Charge Master 2023

CodeDescriptionPrice
10021FNA BX W/O IMG GDN 1ST LES$1,310.00
10060DRAINAGE OF SKIN ABSCESS$1,970.53
10061DRAINAGE OF SKIN ABSCESS$2,215.83
10080DRAINAGE OF PILONIDAL CYST$1,355.00
10081DRAINAGE OF PILONIDAL CYST$2,816.73
10120REMOVE FOREIGN BODY$3,510.46
10121REMOVE FOREIGN BODY$4,299.89
10140DRAINAGE OF HEMATOMA/FLUID$1,255.00
10160PUNCTURE DRAINAGE OF LESION$1,281.01
10180COMPLEX DRAINAGE WOUND$1,066.53
11010DEBRIDE SKIN AT FX SITE$3,241.30
11011DEBRIDE SKIN MUSC AT FX SITE$1,640.89
11040DBRDMT, SKIN, PARTIAL THI$1,270.57
11042DEB SUBQ TISSUE 20 SQ CM/<$3,088.37
11055TRIM SKIN LESION$1,191.52
11056TRIM SKIN LESIONS 2 TO 4$1,165.00
11200REMOVAL OF SKIN TAGS $4,554.95
11403EXC TR EXT B9+MARG 2.1 3CM$1,510.00
11404EXC TR EXT B9+MARG 3.1 4 CM$6,302.06
11406EXC TR EXT B9+MARG >4.0 CM$2,802.80
11420EXC H F NK SP B9+MARG 0.5/<$1,965.68
11422EXC H F NK SP B9+MARG 1.1$1,765.60
11423EXC H F NK SP B9+MARG 2.1$1,892.07
11441EXC FACE MM B9+MARG 0.6 1 CM$1,556.94
11720DEBRIDE NAIL 1 5$1,165.00
11730REMOVAL OF NAIL PLATE$1,982.41
11732REMOVE NAIL PLATE ADD ON$1,202.70
11740DRAIN BLOOD FROM UNDER NAIL$1,588.97
11750REMOVAL OF NAIL BED$1,738.04
11760REPAIR OF NAIL BED$1,615.96
11765EXCISION OF NAIL FOLD TOE$1,095.63
11771REMOVE PILONIDAL CYST EXTEN$7,234.13
11982REMOVE DRUG IMPLANT DEVICE$1,601.82
12001RPR S/N/AX/GEN/TRNK 2.5CM/<$1,896.21
12002RPR S/N/AX/GEN/TRNK2.6 7.5CM$1,013.45
12004RPR S/N/AX/GEN/TRK7.6 12.5CM$1,442.44
12005RPR S/N/A/GEN/TRK12.6 20.0CM$1,261.16
12006RPR S/N/A/GEN/TRK20.1 30.0CM$1,640.00
12007RPR S/N/AX/GEN/TRNK >30.0 CM$1,792.10
12011RPR F/E/E/N/L/M 2.5 CM/<$1,941.45
12013RPR F/E/E/N/L/M 2.6 5.0 CM$1,114.56
12014RPR F/E/E/N/L/M 5.1 7.5 CM$1,435.78
12015RPR F/E/E/N/L/M 7.6 12.5 CM$1,575.00
12016RPR FE/E/EN/L/M 12.6 20.0 CM$1,595.00
12017RPR FE/E/EN/L/M 20.1 30.0 CM$1,750.00
12018RPR F/E/E/N/L/M >30.0 CM$2,091.82
12020CLOSURE OF SPLIT WOUND$4,340.93
12021CLOSURE OF SPLIT WOUND$1,657.08
12031INTMD RPR S/A/T/EXT 2.5 CM/<$1,329.73
12032INTMD RPR S/A/T/EXT 2.6 7.5$1,598.10
12034INTMD RPR S/TR/EXT 7.6 12.5$1,741.77
12035INTMD RPR S/A/T/EXT 12.6 20$1,560.38
12036INTMD RPR S/A/T/EXT 20.1 30$2,054.03
12037INTMD RPR S/TR/EXT >30.0 CM$3,932.84
12041INTMD RPR N HF/GENIT 2.5CM/<$1,602.70
12042INTMD RPR N HF/GENIT2.6 7.5$1,724.30
12044INTMD RPR N HF/GENIT7.6 12.5$1,299.80
12045INTMD RPR N HF/GENIT12.6 20$2,110.64
12046INTMD RPR N HF/GENIT20.1 30$1,755.00
12047INTMD RPR N HF/GENIT >30.0CM$4,495.72
12051INTMD RPR FACE/MM 2.5 CM/<$1,136.14
12052INTMD RPR FACE/MM 2.6 5.0 CM$1,575.97
12053INTMD RPR FACE/MM 5.1 7.5 CM$2,666.56
12054INTMD RPR FACE/MM 7.6 12.5CM$1,465.67
12055INTMD RPR FACE/MM 12.6 20 CM$1,050.00
12056INTMD RPR FACE/MM 20.1 30$1,035.00
12057INTMD RPR FACE/MM >30.0 CM$4,518.71
13100CMPLX RPR TRUNK 1.1 2.5 CM$1,445.00
13101CMPLX RPR TRUNK 2.6 7.5 CM$1,555.00
13102CMPLX RPR TRUNK ADDL 5CM/<$1,423.37
13120CMPLX RPR S/A/L 1.1 2.5 CM$1,475.00
13121CMPLX RPR S/A/L 2.6 7.5 CM$2,510.06
13122CMPLX RPR S/A/L ADDL 5 CM/>$1,557.49
13131CMPLX RPR F/C/C/M/N/AX/G/H/F$1,710.00
13132CMPLX RPR F/C/C/M/N/AX/G/H/F$3,241.75
13133CMPLX RPR F/C/C/M/N/AX/G/H/F$1,004.34
13150RPR CMPLX EYE NOSE LESS T$1,625.00
13151CMPLX RPR E/N/E/L 1.1 2.5 CM$2,617.61
13152CMPLX RPR E/N/E/L 2.6 7.5 CM$2,752.93
13153CMPLX RPR E/N/E/L ADDL 5CM/<$1,721.22
14040TIS TRNFR F/C/C/M/N/A/G/H/F$1,770.00
15850Remove sutures same surgeon$4,805.95
16000INITIAL TREATMENT OF BURN(S)$1,919.87
16020DRESS/DEBRID P THICK BURN S$1,054.15
16025DRESS/DEBRID P THICK BURN M$1,275.00
16030DRESS/DEBRID P THICK BURN L$1,749.83
17000DESTRUCT PREMALG LESION$1,633.75
17110DESTRUCT B9 LESION 1 14$1,145.00
17340CRYOTHERAPY OF SKIN$1,555.00
19020INCISION OF BREAST LESION$1,812.77
20520REMOVAL OF FOREIGN BODY$1,663.10
20525REMOVAL OF FOREIGN BODY$2,959.53
20550INJ TENDON SHEATH/LIGAMENT$1,500.69
20551INJ TENDON ORIGIN/INSERTION$1,160.04
20552INJ TRIGGER POINT 1/2 MUSCL$2,634.28
20553INJECT TRIGGER POINTS 3/>$1,475.00
20600DRAIN/INJ JOINT/BURSA W/O US$1,279.81
20605DRAIN/INJ JOINT/BURSA W/O US$1,820.47
20606DRAIN/INJ JOINT/BURSA W/US$1,245.00
20610DRAIN/INJ JOINT/BURSA W/O US$2,459.82
20611DRAIN/INJ JOINT/BURSA W/US$3,345.86
20612ASPIRATE/INJ GANGLION CYST$1,237.70
21310CLOSED TX NOSE FX W/O MANJ$1,345.00
21315CLOSED TX NOSE FX W/O STABLJ$1,625.00
21480RESET DISLOCATED JAW$1,008.34
21485RESET DISLOCATED JAW$3,539.79
21705REVISION OF NECK MUSCLE/RIB$1,768.65
21800CLTX RIB FX UNCOMP EA$1,559.58
23330REMOVE SHOULDER FOREIGN BODY$1,758.60
23500TREAT CLAVICLE FRACTURE$1,645.00
23540TREAT CLAVICLE DISLOCATION$1,615.00
23545TREAT CLAVICLE DISLOCATION$1,820.00
23570TREAT SHOULDER BLADE FX$1,405.00
23575TREAT SHOULDER BLADE FX$1,624.00
23600TREAT HUMERUS FRACTURE$1,314.84
23605TREAT HUMERUS FRACTURE$1,405.00
23620TREAT HUMERUS FRACTURE$3,019.80
23650TREAT SHOULDER DISLOCATION$1,576.39
23655TREAT SHOULDER DISLOCATION$1,746.38
23665TREAT DISLOCATION/FRACTURE$2,348.35
23930DRAINAGE OF ARM LESION$1,170.17
23931DRAINAGE OF ARM BURSA$1,043.14
24200REMOVAL OF ARM FOREIGN BODY$1,796.78
24357REPAIR ELBOW PERC$2,447.62
24500TREAT HUMERUS FRACTURE$1,030.50
24505TREAT HUMERUS FRACTURE$1,580.00
24530TREAT HUMERUS FRACTURE$2,993.75
24535TREAT HUMERUS FRACTURE$1,875.00
24560TREAT HUMERUS FRACTURE$1,861.69
24565TREAT HUMERUS FRACTURE$2,769.29
24576TREAT HUMERUS FRACTURE$3,437.50
24600TREAT ELBOW DISLOCATION$1,036.44
24605TREAT ELBOW DISLOCATION$5,306.00
24615TREAT ELBOW DISLOCATION$8,461.84
24620TREAT ELBOW FRACTURE$3,087.49
24640TREAT ELBOW DISLOCATION$1,393.15
24650TREAT RADIUS FRACTURE$1,580.00
24655TREAT RADIUS FRACTURE$1,275.00
24670TREAT ULNAR FRACTURE$1,501.47
25111REMOVE WRIST TENDON LESION$1,807.75
25505TREAT FRACTURE OF RADIUS$3,373.00
25530TREAT FRACTURE OF ULNA$1,657.34
25535Treat fracture of ulna$2,827.19
25560TREAT FRACTURE RADIUS & ULNA$2,697.03
25565TREAT FRACTURE RADIUS & ULNA$1,615.00
25574TREAT FRACTURE RADIUS & ULNA$7,976.96
25600TREAT FRACTURE RADIUS/ULNA$1,497.81
25605TREAT FRACTURE RADIUS/ULNA$3,120.90
25607TREAT FX RAD EXTRA ARTICUL$8,335.30
25622TREAT WRIST BONE FRACTURE$1,553.36
25635TREAT WRIST BONE FRACTURE$1,898.28
25650Treat wrist bone fracture$1,904.12
25652TREAT FRACTURE ULNAR STYLOID$7,069.50
25660TREAT WRIST DISLOCATION$1,849.02
25675TREAT WRIST DISLOCATION$1,844.77
26010DRAINAGE OF FINGER ABSCESS$1,057.79
26011DRAINAGE OF FINGER ABSCESS$1,843.71
26418REPAIR FINGER TENDON$1,965.00
26540UNDER REPAIR, REVISION, AND/OR RECONSTRU$3,548.21
26567CORRECT FINGER DEFORMITY$3,785.55
26600TREAT METACARPAL FRACTURE$1,314.17
26605TREAT METACARPAL FRACTURE$1,541.68
26607TREAT METACARPAL FRACTURE$2,199.89
26615TREAT METACARPAL FRACTURE$6,521.50
26641TREAT THUMB DISLOCATION$1,010.00
26645TREAT THUMB FRACTURE$2,285.85
26670TREAT HAND DISLOCATION$1,745.00
26675TREAT HAND DISLOCATION$2,488.68
26700TREAT KNUCKLE DISLOCATION$1,565.76
26705TREAT KNUCKLE DISLOCATION$1,849.02
26720TREAT FINGER FRACTURE EACH$1,520.00
26725TREAT FINGER FRACTURE EACH$1,675.91
26740TREAT FINGER FRACTURE EACH$1,670.00
26742TREAT FINGER FRACTURE EACH$2,590.57
26746TREAT FINGER FRACTURE EACH$4,425.27
26750TREAT FINGER FRACTURE EACH$2,805.78
26755TREAT FINGER FRACTURE EACH$1,757.40
26765TREAT FINGER FRACTURE EACH$3,270.70
26770TREAT FINGER DISLOCATION$1,237.40
26775TREAT FINGER DISLOCATION$1,141.05
26952AMPUTATION OF FINGER/THUMB$7,187.30
27096INJECT SACROILIAC JOINT$1,009.26
27372REMOVAL OF FOREIGN BODY$3,398.36
27502TREATMENT OF THIGH FRACTURE$2,206.14
27520TREAT KNEECAP FRACTURE$1,586.50
27532TREAT KNEE FRACTURE$2,135.00
27550TREAT KNEE DISLOCATION$1,759.63
27560TREAT KNEECAP DISLOCATION$1,081.07
27750TREATMENT OF TIBIA FRACTURE$2,470.00
27752TREATMENT OF TIBIA FRACTURE$6,933.56
27760CLTX MEDIAL ANKLE FX$1,517.32
27762CLTX MED ANKLE FX W/MNPJ$2,562.37
27780TREATMENT OF FIBULA FRACTURE$2,589.00
27786TREATMENT OF ANKLE FRACTURE$1,638.79
27788TREATMENT OF ANKLE FRACTURE$1,385.00
27792Treatment of ankle fracture$12,607.88
27808TREATMENT OF ANKLE FRACTURE$2,000.00
27810TREATMENT OF ANKLE FRACTURE$2,491.37
27818TREATMENT OF ANKLE FRACTURE$1,655.00
27824TREAT LOWER LEG FRACTURE$1,849.02
27840TREAT ANKLE DISLOCATION$1,846.39
27842TREAT ANKLE DISLOCATION$3,244.97
28001DRAINAGE OF BURSA OF FOOT$2,022.40
28024EXPLORATION OF TOE JOINT$1,743.47
28190REMOVAL OF FOOT FOREIGN BODY$2,681.82
28192Removal of foot foreign body$4,902.95
28193Removal of foreign body, foot; complicated$4,860.10
28400TREATMENT OF HEEL FRACTURE$1,808.53
28430TREATMENT OF ANKLE FRACTURE$1,580.00
28470TREAT METATARSAL FRACTURE$1,945.38
28475TREAT METATARSAL FRACTURE$2,710.58
28490TREAT BIG TOE FRACTURE$1,420.00
28495TREAT BIG TOE FRACTURE$1,515.00
28505TREAT BIG TOE FRACTURE$3,329.17
28510TREATMENT OF TOE FRACTURE$1,026.57
28515TREATMENT OF TOE FRACTURE$1,773.00
28600TREAT FOOT DISLOCATION$1,062.02
28630TREAT TOE DISLOCATION$1,306.30
28660TREAT TOE DISLOCATION$1,364.00
28665TREAT TOE DISLOCATION$1,600.00
29049APPLICATION OF FIGURE EIGHT$1,230.60
29065APPLICATION OF LONG ARM CAST$1,406.79
29075APPLICATION OF FOREARM CAST$1,036.39
29085APPLY HAND/WRIST CAST$1,597.31
29105APPLY LONG ARM SPLINT$1,880.60
29125APPLY FOREARM SPLINT$1,789.85
29126APPLY FOREARM SPLINT$1,703.95
29130APPLICATION OF FINGER SPLINT$1,538.88
29131APPLICATION OF FINGER SPLINT$1,504.73
29240STRAPPING OF SHOULDER$1,560.21
29260STRAPPING OF ELBOW OR WRIST$1,225.00
29280STRAPPING OF HAND OR FINGER$1,572.08
29355APPLICATION OF LONG LEG CAST$1,606.90
29505APPLICATION LONG LEG SPLINT$1,845.33
29515APPLICATION LOWER LEG SPLINT$1,838.98
29530STRAPPING OF KNEE$1,125.00
29540STRAPPING OF ANKLE AND/OR FT$1,488.47
29550STRAPPING OF TOES$1,180.00
29580APPLICATION OF PASTE BOOT$1,691.49
29700REMOVAL/REVISION OF CAST$1,167.57
30300REMOVE NASAL FOREIGN BODY$1,706.42
30802ABLATE INF TURBINATE SUBMUC$2,133.90
30901CONTROL OF NOSEBLEED$1,045.95
30903CONTROL OF NOSEBLEED$1,692.51
30905CONTROL OF NOSEBLEED$1,600.37
30906REPEAT CONTROL OF NOSEBLEED$1,858.69
31231NASAL ENDOSCOPY DX$1,736.90
31500INSERT EMERGENCY AIRWAY$1,274.88
31502CHANGE OF WINDPIPE AIRWAY$2,395.75
31505DIAGNOSTIC LARYNGOSCOPY$1,210.00
31515Laryngoscopy for aspiration$1,101.50
31525DX LARYNGOSCOPY EXCL NB$4,184.03
31575DIAGNOSTIC LARYNGOSCOPY$1,915.92
31600INCISION OF WINDPIPE$5,426.68
31603INCISION OF WINDPIPE$6,501.46
31605INCISION OF WINDPIPE$1,052.55
32550INSERT PLEURAL CATH$2,396.00
32551INSERTION OF CHEST TUBE$3,693.36
33415REVISION SUBVALVULAR TISSUE$1,291.33
36000PLACE NEEDLE IN VEIN$1,019.62
36010PLACE CATHETER IN VEIN$1,745.85
36011PLACE CATHETER IN VEIN$1,167.46
36410NON ROUTINE BL DRAW 3/> YRS$727.00
36415ROUTINE VENIPUNCTURE$579.35
36416CAPILLARY BLOOD DRAW$584.51
36556INSERT NON TUNNEL CV CATH$4,819.77
36558INSERT TUNNELED CV CATH$7,040.12
36561INSERT TUNNELED CV CATH$9,025.40
36569INSERT PICC CATH$1,265.00
36575REPAIR TUNNELED CV CATH$1,423.15
36589Removal tunneled cv cath$6,652.10
36591DRAW BLOOD OFF VENOUS DEVICE$1,431.58
36592COLLECT BLOOD FROM PICC$1,153.68
36600WITHDRAWAL OF ARTERIAL BLOOD$1,100.00
36680INSERT NEEDLE BONE CAVITY$1,365.90
37195THROMBOLYTIC THERAPY STROKE$3,045.00
37785LIGATE/DIVIDE/EXCISE VEIN$6,442.46
38300DRAINAGE LYMPH NODE LESION$1,398.56
40650REPAIR LIP$2,975.92
40652REPAIR LIP$1,485.00
40654REPAIR LIP$1,970.00
40804REMOVAL FOREIGN BODY MOUTH$1,420.23
40830REPAIR MOUTH LACERATION$1,520.00
40831REPAIR MOUTH LACERATION$1,725.00
41250REPAIR TONGUE LACERATION$1,855.88
41251REPAIR TONGUE LACERATION$2,234.20
41252REPAIR TONGUE LACERATION$2,439.10
41800DRAINAGE OF GUM LESION$1,003.03
42330REMOVAL OF SALIVARY STONE$1,996.68
42700DRAINAGE OF TONSIL ABSCESS$2,148.80
42809REMOVE PHARYNX FOREIGN BODY$1,485.00
43752NASAL/OROGASTRIC W/TUBE PLMT$1,520.00
43753TX GASTRO INTUB W/ASP$1,897.64
43760CHANGE GASTROSTOMY TUBE$1,564.06
45915REMOVE RECTAL OBSTRUCTION$2,324.70
46040INCISION OF RECTAL ABSCESS$5,286.10
46050INCISION OF ANAL ABSCESS$3,180.76
46083INCISE EXTERNAL HEMORRHOID$1,275.12
46320REMOVAL OF HEMORRHOID CLOT$6,631.35
46600DIAGNOSTIC ANOSCOPY SPX$1,210.00
46608ANOSCOPY REMOVE FOR BODY$1,450.00
49082ABD PARACENTESIS$1,465.00
49083ABD PARACENTESIS W/IMAGING$1,441.56
49505PRP I/HERN INIT REDUC >5 YR$2,130.00
51700IRRIGATION OF BLADDER$1,816.73
51701INSERT BLADDER CATHETER$1,438.62
51702INSERT TEMP BLADDER CATH$1,752.97
51703INSERT BLADDER CATH COMPLEX$2,228.70
54001SLITTING OF PREPUCE$1,788.52
54015DRAIN PENIS LESION$2,011.43
54220TREATMENT OF PENIS LESION$1,670.00
54235PENILE INJECTION$1,840.60
54450PREPUTIAL STRETCHING$1,327.27
55100DRAINAGE OF SCROTUM ABSCESS$1,981.35
55175REVISION OF SCROTUM$4,318.76
56405I & D OF VULVA/PERINEUM$1,375.13
56420DRAINAGE OF GLAND ABSCESS$1,002.34
57410PELVIC EXAMINATION$1,064.10
57415REMOVE VAGINAL FOREIGN BODY$1,807.30
58301REMOVE INTRAUTERINE DEVICE$1,911.60
59025FETAL NON STRESS TEST$1,141.42
59409OBSTETRICAL CARE$5,641.48
62270SPINAL FLUID TAP DIAGNOSTIC$2,201.61
62272DRAIN CEREBRO SPINAL FLUID$1,685.00
64400N BLOCK INJ TRIGEMINAL$1,745.26
64402N BLOCK INJ FACIAL$1,919.03
64405N BLOCK INJ OCCIPITAL$1,753.06
64413N BLOCK INJ CERVICAL PLEXUS$1,535.00
64415N BLOCK INJ BRACHIAL PLEXUS$1,940.00
64450N BLOCK OTHER PERIPHERAL$2,398.50
64455N BLOCK INJ PLANTAR DIGIT$1,040.81
64640INJECTION TREATMENT OF NERVE$2,861.75
65205REMOVE FOREIGN BODY FROM EYE$1,600.16
65210REMOVE FOREIGN BODY FROM EYE$1,299.61
65220REMOVE FOREIGN BODY FROM EYE$1,113.23
65222REMOVE FOREIGN BODY FROM EYE$1,964.40
65265REMOVE FOREIGN BODY FROM EYE$3,380.00
65435CURETTE/TREAT CORNEA$1,235.00
67700DRAINAGE OF EYELID ABSCESS$1,917.89
67938REMOVE EYELID FOREIGN BODY$1,360.70
69000DRAIN EXTERNAL EAR LESION$1,796.93
69005DRAIN EXTERNAL EAR LESION$1,876.77
69200CLEAR OUTER EAR CANAL$1,692.53
69205CLEAR OUTER EAR CANAL$3,169.73
69209REMOVE IMPACTED EAR WAX UNI$1,441.90
69210REMOVE IMPACTED EAR WAX UNI$1,769.28
69220CLEAN OUT MASTOID CAVITY$1,545.35
70030X RAY EYE FOR FOREIGN BODY$1,575.64
70100X RAY EXAM OF JAW <4VIEWS$1,790.30
70110X RAY EXAM OF JAW 4/> VIEWS$1,096.68
70120X-ray exam of mastoids$1,517.93
70130X-ray exam of mastoids$1,706.12
70140X RAY EXAM OF FACIAL BONES$1,973.66
70150X RAY EXAM OF FACIAL BONES$1,170.86
70160X RAY EXAM OF NASAL BONES$1,983.20
70200X RAY EXAM OF EYE SOCKETS$1,121.74
70210X RAY EXAM OF SINUSES$1,647.33
70220X RAY EXAM OF SINUSES$1,268.49
70250X RAY EXAM OF SKULL$1,061.46
70260X RAY EXAM OF SKULL$1,719.91
70328X RAY EXAM OF JAW JOINT$1,396.01
70330X RAY EXAM OF JAW JOINTS$1,928.88
70350X RAY HEAD FOR ORTHODONTIA$1,458.85
70360X RAY EXAM OF NECK$1,855.44
70450CT HEAD/BRAIN W/O DYE$9,250.43
70460CT HEAD/BRAIN W/DYE$9,413.03
70470CT HEAD/BRAIN W/O & W/DYE$10,306.83
70480CT ORBIT/EAR/FOSSA W/O DYE$6,944.58
70481CT ORBIT/EAR/FOSSA W/DYE$6,883.52
70482CT ORBIT/EAR/FOSSA W/O&W/DYE$7,421.20
70486CT MAXILLOFACIAL W/O DYE$6,760.58
70487CT MAXILLOFACIAL W/DYE$6,456.83
70488CT MAXILLOFACIAL W/O & W/DYE$7,850.44
70490CT SOFT TISSUE NECK W/O DYE$5,613.27
70491CT SOFT TISSUE NECK W/DYE$7,446.03
70492CT SFT TSUE NCK W/O & W/DYE$5,100.00
70496CT ANGIOGRAPHY HEAD$8,748.82
70498CT ANGIOGRAPHY NECK$8,724.82
70544MR ANGIOGRAPHY HEAD W/O DYE$7,387.90
70547MR ANGIOGRAPHY NECK W/O DYE$7,254.81
70551MRI BRAIN STEM W/O DYE$7,892.81
70553MRI BRAIN STEM W/O & W/DYE$10,284.54
71010CHEST X RAY 1 VIEW FRONTAL$1,299.00
71020CHEST X RAY 2VW FRONTAL&LATL$1,464.00
71022CHEST X RAY FRNT LAT OBLIQUE$1,583.20
71030CHEST X RAY 4/> VIEWS$1,524.00
71045X RAY EXAM CHEST 1 VIEW$1,069.10
71046X RAY EXAM CHEST 2 VIEWS$1,566.18
71047RADIOLOGIC EXAMINATION, CHEST$1,508.97
71048X-ray exam chest 4+ views$1,505.13
71100X RAY EXAM RIBS UNI 2 VIEWS$1,046.72
71101X RAY EXAM UNILAT RIBS/CHEST$1,292.21
71110X RAY EXAM RIBS BIL 3 VIEWS$1,247.46
71111X RAY EXAM RIBS/CHEST4/> VWS$1,480.42
71120X RAY EXAM BREASTBONE 2/>VWS$1,886.55
71130X RAY STRENOCLAVIC JT 3/>VWS$5,636.25
71250CT THORAX W/O DYE$9,663.17
71260CT THORAX W/DYE$9,772.46
71270CT THORAX W/O & W/DYE$9,637.36
71275CT ANGIOGRAPHY CHEST$9,820.46
71550MRI CHEST W/O DYE$6,937.29
72020X RAY EXAM OF SPINE 1 VIEW$1,893.78
72040X RAY EXAM NECK SPINE 2 3 VW$1,169.60
72050X RAY EXAM NECK SPINE 4/5VWS$1,748.58
72052X RAY EXAM NECK SPINE 6/>VWS$1,753.81
72069RADEX SPI THORACOLMBR STA$1,374.00
72070X RAY EXAM THORAC SPINE 2VWS$1,379.90
72072X RAY EXAM THORAC SPINE 3VWS$1,616.62
72074X RAY EXAM THORAC SPINE4/>VW$1,984.58
72080X RAY EXAM THORACOLMB 2/> VW$1,847.78
72082X-ray exam entire spi 2/3 vw$1,390.34
72100X RAY EXAM L S SPINE 2/3 VWS$1,466.45
72110X RAY EXAM L 2 SPINE 4/>VWS$1,769.62
72114X RAY EXAM L S SPINE BENDING$1,674.05
72120X RAY BEND ONLY L S SPINE$1,150.72
72125CT NECK SPINE W/O DYE$6,899.72
72126CT NECK SPINE W/DYE$7,261.86
72127CT NECK SPINE W/O & W/DYE$8,241.83
72128CT CHEST SPINE W/O DYE$6,993.51
72129CT CHEST SPINE W/DYE$6,608.08
72130CT CHEST SPINE W/O & W/DYE$7,543.10
72131CT LUMBAR SPINE W/O DYE$6,857.74
72132CT LUMBAR SPINE W/DYE$7,650.90
72133CT LUMBAR SPINE W/O & W/DYE$8,524.60
72141MRI NECK SPINE W/O DYE$7,109.20
72146MRI CHEST SPINE W/O DYE$6,861.20
72148MRI LUMBAR SPINE W/O DYE$6,896.90
72156MRI NECK SPINE W/O & W/DYE$10,073.46
72157MRI CHEST SPINE W/O & W/DYE$9,931.72
72158MRI LUMBAR SPINE W/O & W/DYE$9,630.29
72170X RAY EXAM OF PELVIS$1,052.68
72175CTA CHEST (NONCORONARY)$6,816.50
72190X RAY EXAM OF PELVIS$1,357.91
72191CT ANGIOGRAPH PELV W/O&W/DYE$7,419.44
72192CT PELVIS W/O DYE$6,035.36
72193CT PELVIS W/DYE$6,635.61
72194CT PELVIS W/O & W/DYE$7,635.46
72195MRI PELVIS W/O DYE$7,039.42
72196MRI PELVIS W/DYE$8,207.89
72200X RAY EXAM SI JOINTS$1,612.90
72202X RAY EXAM SI JOINTS 3/> VWS$1,396.01
72220X RAY EXAM SACRUM TAILBONE$1,951.99
72255MYELOGRAPHY THORACIC SPINE$1,598.00
72265MYELOGRAPHY L S SPINE$1,388.05
72270Myelogphy 2/> spine regions$4,893.71
73000X RAY EXAM OF COLLAR BONE$1,986.84
73010X RAY EXAM OF SHOULDER BLADE$1,014.48
73020X RAY EXAM OF SHOULDER$1,847.88
73030X RAY EXAM OF SHOULDER$1,275.51
73050X RAY EXAM OF SHOULDERS$1,995.85
73060X RAY EXAM OF HUMERUS$1,103.34
73070X RAY EXAM OF ELBOW$1,827.70
73080X RAY EXAM OF ELBOW$1,981.15
73090X RAY EXAM OF FOREARM$1,078.84
73092X RAY EXAM OF ARM INFANT$1,566.00
73100X RAY EXAM OF WRIST$1,866.46
73110X RAY EXAM OF WRIST$1,220.02
73120X RAY EXAM OF HAND$1,887.55
73130X RAY EXAM OF HAND$1,120.38
73140X RAY EXAM OF FINGER(S)$1,838.86
73200CT UPPER EXTREMITY W/O DYE$6,804.57
73201CT UPPER EXTREMITY W/DYE$6,243.23
73202CT UPPR EXTREMITY W/O&W/DYE$7,150.91
73206CT ANGIO UPR EXTRM W/O&W/DYE$1,523.37
73220MRI UPPR EXTREMITY W/O&W/DYE$8,670.35
73221MRI JOINT UPR EXTREM W/O DYE$7,281.36
73223MRI JOINT UPR EXTR W/O&W/DYE$7,543.27
73501X RAY EXAM HIP UNI 1 VIEW$1,868.27
73502X RAY EXAM HIP UNI 2 3 VIEWS$1,198.14
73503X RAY EXAM HIP UNI 4/> VIEWS$2,248.12
73510XRAY HIP MIN 2 VIEWS$1,476.00
73520HIPS BILAT MIN 2 VIEW INC$1,507.00
73521X RAY EXAM HIPS BI 2 VIEWS$1,685.80
73522X RAY EXAM HIPS BI 3 4 VIEWS$1,573.84
73540X RAY EXAM OF PELVIS & HI$1,691.53
73550XRAY FEMUR AP & LAT VIEW$1,311.00
73551X RAY EXAM OF FEMUR 1$1,655.45
73552X RAY EXAM OF FEMUR 2/>$1,939.64
73560X RAY EXAM OF KNEE 1 OR 2$1,813.35
73562X RAY EXAM OF KNEE 3$1,906.80
73564X RAY EXAM KNEE 4 OR MORE$1,288.74
73565X RAY EXAM OF KNEES$1,803.84
73580Contrast x-ray of knee joint$2,724.00
73590X RAY EXAM OF LOWER LEG$1,079.10
73592X RAY EXAM OF LEG INFANT$1,394.22
73600X RAY EXAM OF ANKLE$1,847.40
73610X RAY EXAM OF ANKLE$1,058.35
73620X RAY EXAM OF FOOT$1,937.41
73630X RAY EXAM OF FOOT$1,035.55
73650X RAY EXAM OF HEEL$1,838.01
73660X RAY EXAM OF TOE(S)$1,923.80
73700CT LOWER EXTREMITY W/O DYE$5,595.48
73701CT LOWER EXTREMITY W/DYE$6,122.83
73702CT LWR EXTREMITY W/O&W/DYE$7,134.98
73706CT ANGIO LWR EXTR W/O&W/DYE$5,528.25
73718Mri lower extremity w/o dye$5,271.95
73720MRI LWR EXTREMITY W/O&W/DYE$7,019.00
73721MRI JNT OF LWR EXTRE W/O DYE$6,044.10
73722MRI JOINT OF LWR EXTR W/DYE$5,399.08
73723MRI JOINT LWR EXTR W/O&W/DYE$7,865.38
73725MR ANG LWR EXT W OR W/O DYE$3,945.60
74000X RAY EXAM OF ABDOMEN$1,759.00
74010X RAY EXAM OF ABDOMEN$1,426.00
74018X RAY EXAM ABDOMEN 1 VIEW$1,906.51
74019X RAY EXAM ABDOMEN 2 VIEWS$1,045.13
74020X RAY EXAM OF ABDOMEN$1,454.00
74021X RAY EXAM ABDOMEN 3+ VIEWS$1,141.96
74022X RAY EXAM SERIES ABDOMEN$1,631.74
74150CT ABDOMEN W/O DYE$6,755.36
74160CT ABDOMEN W/DYE$6,827.85
74170CT ABDOMEN W/O & W/DYE$7,789.34
74174CT ANGIO ABD&PELV W/O&W/DYE$9,920.02
74175CT ANGIO ABDOM W/O & W/DYE$7,492.15
74176CT ABD & PELVIS W/O CONTRAST$9,556.67
74177CT ABD & PELV W/CONTRAST$10,615.21
74178CT ABD & PELV 1/> REGNS$12,514.63
74181MRI ABDOMEN W/O DYE$6,118.29
74183MRI ABDOMEN W/O & W/DYE$7,163.23
74190X-ray exam of peritoneum$2,295.23
74210CONTRST X RAY EXAM OF THROAT$1,700.48
74220CONTRAST X RAY ESOPHAGUS$1,881.57
74240X-ray upper gi delay w/o kub$1,447.65
74241X RAY UPPER GI DELAY W/KUB$1,998.00
74246Contrst x-ray uppr gi tract$1,910.17
74247CONTRST X RAY UPPR GI TRACT$1,010.00
74250X-ray exam of small bowel$1,615.90
74251X-ray exam of small bowel$2,605.80
74283Contrast x-ray exam of colon$2,038.49
74328X-ray bile duct endoscopy$3,597.46
74329X-ray for pancreas endoscopy$2,720.52
74330X-ray bile/panc endoscopy$1,749.01
74340X-ray guide for gi tube$1,999.91
74400CONTRST X RAY URINARY TRACT$1,581.08
75574CT ANGIO HRT W/3D IMAGE$3,340.10
75635CT ANGIO ABDOMINAL ARTERIES$1,624.00
75741ARTERY X RAYS LUNG$1,004.40
76010X RAY NOSE TO RECTUM$1,913.00
763763D RENDER W/INTRP POSTPROCES$1,642.09
76380CAT SCAN FOLLOW UP STUDY$1,974.35
76512OPHTH US B W/NON QUANT A$1,550.00
76536US EXAM OF HEAD AND NECK$4,994.75
76604US EXAM CHEST$4,253.43
76641ULTRASOUND BREAST COMPLETE$4,517.90
76642ULTRASOUND BREAST LIMITED$4,031.54
76645US EXAM, BREASTS$3,784.06
76700US EXAM ABDOM COMPLETE$5,693.25
76705ECHO EXAM OF ABDOMEN$4,173.92
76706Us abdl aorta screen aaa$4,445.50
76770US EXAM ABDO BACK WALL COMP$4,043.71
76775US EXAM ABDO BACK WALL LIM$4,696.82
76800US EXAM SPINAL CANAL$4,571.13
76801OB US < 14 WKS SINGLE FETUS$4,942.32
76802OB US < 14 WKS ADDL FETUS$4,335.27
76805OB US >/= 14 WKS SNGL FETUS$4,307.09
76810OB US >/= 14 WKS ADDL FETUS$4,243.69
76813OB US NUCHAL MEAS 1 GEST$3,508.94
76814OB US NUCHAL MEAS ADD ON$3,484.57
76815OB US LIMITED FETUS(S)$3,575.00
76816Ob us follow-up per fetus$3,124.10
76817TRANSVAGINAL US OBSTETRIC$3,611.41
76819DIAGNOSTIC ULTRASOUND PROCEDURES OF THE$4,456.71
76827ECHO EXAM OF FETAL HEART$3,332.33
76830TRANSVAGINAL US NON OB$3,492.21
76856US EXAM PELVIC COMPLETE$4,482.38
76857US EXAM PELVIC LIMITED$4,352.35
76870US EXAM SCROTUM$4,996.83
76880US EXTREMITY$3,913.00
76881US XTR NON VASC COMPLETE$4,010.16
76882US XTR NON VASC LMTD$3,071.43
76932ECHO GUIDE FOR HEART BIOPSY$3,151.24
76937US GUIDE VASCULAR ACCESS$3,550.00
76942ECHO GUIDE FOR BIOPSY$3,812.96
77076X RAYS BONE SURVEY INFANT$1,235.20
77077JOINT SURVEY SINGLE VIEW$1,337.81
77079CT BONE MINERAL DENSITY S$3,613.00
78070PARATHYROID PLANAR IMAGING$1,336.00
78075ADRENAL CORTEX & MEDULLA IMG$3,618.00
78223HIDA SCAN HEPATBL DUX S$3,509.00
78305Bone and/or joint imaging; multiple areas$3,285.43
78306BONE IMAGING WHOLE BODY$3,893.49
78315BONE IMAGING 3 PHASE$4,373.79
78320BONE IMAGING (3D)$3,891.25
78472GATED HEART PLANAR SINGLE$3,518.15
78808IV INJ RA DRUG DX STUDY$2,102.49
80047METABOLIC PANEL IONIZED CA$999.70
80048METABOLIC PANEL TOTAL CA$699.69
80050GENERAL HEALTH PANEL$674.13
80051ELECTROLYTE PANEL$556.19
80053COMPREHEN METABOLIC PANEL$985.40
80061LIPID PANEL$755.70
80069RENAL FUNCTION PANEL$588.80
80074ACUTE HEPATITIS PANEL$1,368.96
80076HEPATIC FUNCTION PANEL$862.28
80100DRUG ABUSE PANEL II$591.04
80143Acetaminophen$764.20
80156ASSAY CARBAMAZEPINE TOTAL$433.82
80162ASSAY OF DIGOXIN TOTAL$421.00
80164ASSAY DIPROPYLACETIC ACD TOT$471.64
80175DRUG SCREEN QUAN LAMOTRIGINE$407.69
80177DRUG SCRN QUAN LEVETIRACETAM$494.03
80178ASSAY OF LITHIUM$543.44
80179Salicylate$764.20
80184ASSAY OF PHENOBARBITAL$458.45
80185ASSAY OF PHENYTOIN TOTAL$499.00
80196SALICYLATE$332.33
80197ASSAY OF TACROLIMUS$1,091.40
80201ASSAY OF TOPIRAMATE$384.33
80202ASSAY OF VANCOMYCIN$674.67
80300DRUG SCREEN NON TLC DEVIC$421.00
80301UDS URINE DRUG SCREEN Q$889.10
80304DRUG SCREEN ONE/MULT CLAS$411.00
80305DRUG TEST PRSMV DIR OPT OBS$412.79
80307DRUG TEST PRSMV CHEM ANLYZR$1,162.55
80320DRUG SCREEN QUANTALCOHOLS$501.12
80324Drug screen amphetamines 1/2$534.65
80329ANALGESICS NON OPIOID 1 OR 2$621.61
80335Antidepressant tricyclic 1/2$405.00
80339ANTIEPILEPTICS NOS 1 3$495.02
80345Drug screening barbiturates$437.80
80346Benzodiazepines1-12$326.38
80349Cannabinoids natural$475.05
80352Cannabinoid synthetic 7/more$451.07
80353Drug screening cocaine$422.95
80358Drug screening methadone$349.24
80359Methylenedioxyamphetamines$354.06
80361Opiates 1 or more$355.54
80362Opioids & opiate analogs 1/2$378.24
80365Drug screening oxycodone$357.76
80373Drug screening tramadol$246.26
81000URINALYSIS NONAUTO W/SCOPE$315.42
81001URINALYSIS AUTO W/SCOPE$411.11
81002URINALYSIS NONAUTO W/O SCOPE$404.29
81003URINALYSIS AUTO W/O SCOPE$482.92
81007Urine screen for bacteria$492.30
81015MICROSCOPIC EXAM OF URINE$496.44
81025URINE PREGNANCY TEST$560.94
81257HBA1/HBA2 GENE$1,022.60
81374HLA I TYPING 1 ANTIGEN LR$341.79
82009TEST FOR ACETONE/KETONES$362.42
82010ACETONE ASSAY$313.93
82040ASSAY OF SERUM ALBUMIN$343.19
82075ASSAY OF BREATH ETHANOL$375.12
82088ASSAY OF ALDOSTERONE$380.10
82105ALPHA FETOPROTEIN SERUM$409.95
82135ASSAY AMINOLEVULINIC ACID$366.17
82140ASSAY OF AMMONIA$495.41
82150ASSAY OF AMYLASE$505.61
82190ATOMIC ABSORPTION$413.18
82247BILIRUBIN TOTAL$415.51
82248BILIRUBIN DIRECT$485.34
82252FECAL BILIRUBIN TEST$587.05
82270OCCULT BLOOD FECES$426.28
82271OCCULT BLOOD OTHER SOURCES$391.54
82272OCCULT BLD FECES 1 3 TESTS$431.58
82274ASSAY TEST FOR BLOOD FECAL$450.45
82306VITAMIN D 25 HYDROXY$455.72
82310ASSAY OF CALCIUM$406.94
82330ASSAY OF CALCIUM$625.21
82355CALCULUS ANALYSIS QUAL$428.40
82374ASSAY BLOOD CARBON DIOXIDE$425.75
82375ASSAY CARBOXYHB QUANT$455.34
82390ASSAY OF CERULOPLASMIN$367.16
82397CHEMILUMINESCENT ASSAY$349.25
82435ASSAY OF BLOOD CHLORIDE$401.16
82441TEST FOR CHLOROHYDROCARBONS$381.59
82465ASSAY BLD/SERUM CHOLESTEROL$413.05
82491PORPHYRINS, PLASMA$425.37
82530CORTISOL FREE$352.00
82533TOTAL CORTISOL$613.18
82540ASSAY OF CREATINE$498.50
82541COL CHR/MS QUAL 1 STATION$421.00
82550ASSAY OF CK (CPK)$384.08
82552ASSAY OF CPK IN BLOOD$400.00
82553CREATINE MB FRACTION$583.33
82554CREATINE ISOFORMS$377.11
82565ASSAY OF CREATININE$349.61
82607VITAMIN B 12$508.19
82627DEHYDROEPIANDROSTERONE$486.56
82657ENZYME CELL ACTIVITY$477.60
82664ELECTROPHORETIC TEST$391.54
82670ASSAY OF ESTRADIOL$399.99
82672ASSAY OF ESTROGEN$463.67
82693ASSAY OF ETHYLENE GLYCOL$388.96
82728ASSAY OF FERRITIN$499.00
82746ASSAY OF FOLIC ACID SERUM$547.00
82747ASSAY OF FOLIC ACID RBC$476.55
82784ASSAY IGA/IGD/IGG/IGM EACH$329.82
82785Assay of ige$379.38
82800BLOOD PH$352.39
82803BLOOD GASES ANY COMBINATION$998.98
82805BLOOD GASES W/O2 SATURATION$1,137.03
82941ASSAY OF GASTRIN$365.67
82945GLUCOSE OTHER FLUID$306.91
82947ASSAY GLUCOSE BLOOD QUANT$372.05
82948REAGENT STRIP/BLOOD GLUCOSE$328.11
82951GLUCOSE TOLERANCE TEST (GTT)$450.74
82952GTT ADDED SAMPLES$406.46
82960TEST FOR G6PD ENZYME$454.72
82962GLUCOSE BLOOD TEST$390.49
82963ASSAY OF GLUCOSIDASE$300.00
82977ASSAY OF GGT$465.98
83001ASSAY OF GONADOTROPIN (FSH)$536.25
83002ASSAY OF GONADOTROPIN (LH)$505.46
83010ASSAY OF HAPTOGLOBIN QUANT$455.40
83013H pylori (c-13) breath$635.04
83020HEMOGLOBIN ELECTROPHORESIS$359.20
83036GLYCOSYLATED HEMOGLOBIN TEST$404.62
83050Blood methemoglobin assay$422.64
83516IMMUNOASSAY NONANTIBODY$313.18
83519RIA NONANTIBODY$450.74
83520IMMUNOASSAY QUANT NOS NONAB$526.79
83525ASSAY OF INSULIN$462.59
83540ASSAY OF IRON$439.93
83550IRON BINDING TEST$342.21
83605ASSAY OF LACTIC ACID$516.66
83615LACTATE (LD) (LDH) ENZYME$397.33
83630LACTOFERRIN FECAL (QUAL)$398.01
83690ASSAY OF LIPASE$431.40
83695ASSAY OF LIPOPROTEIN(A)$367.16
83718Assay of lipoprotein$300.17
83721ASSAY OF BLOOD LIPOPROTEIN$485.10
83735ASSAY OF MAGNESIUM$334.53
83873ASSAY OF CSF PROTEIN$355.22
83874ASSAY OF MYOGLOBIN$524.65
83880ASSAY OF NATRIURETIC PEPTIDE$801.46
83930ASSAY OF BLOOD OSMOLALITY$361.69
83935ASSAY OF URINE OSMOLALITY$351.24
83986ASSAY PH BODY FLUID NOS$359.70
83992Assay for phencyclidine$319.40
84075ASSAY ALKALINE PHOSPHATASE$352.13
84100ASSAY OF PHOSPHORUS$381.09
84110ASSAY OF PORPHOBILINOGEN$389.05
84119TEST URINE FOR PORPHYRINS$362.68
84120ASSAY OF URINE PORPHYRINS$383.58
84132ASSAY OF SERUM POTASSIUM$395.29
84133ASSAY OF URINE POTASSIUM$432.83
84134ASSAY OF PREALBUMIN$320.89
84144ASSAY OF PROGESTERONE$320.89
84145PROCALCITONIN (PCT)$332.33
84146ASSAY OF PROLACTIN$467.65
84152ASSAY OF PSA COMPLEXED$395.52
84153ASSAY OF PSA TOTAL$987.78
84154ASSAY OF PSA FREE$389.05
84155ASSAY OF PROTEIN SERUM$365.08
84157ASSAY OF PROTEIN OTHER$358.64
84165Protein e-phoresis serum$503.22
84166PROTEIN E PHORESIS/URINE/CSF$320.89
84244ASSAY OF RENIN$331.84
84270ASSAY OF SEX HORMONE GLOBUL$300.00
84295ASSAY OF SERUM SODIUM$363.84
84300ASSAY OF URINE SODIUM$403.28
84378SUGARS SINGLE QUANT$3,998.40
84402ASSAY OF FREE TESTOSTERONE$350.00
84403ASSAY OF TOTAL TESTOSTERONE$684.51
84425ASSAY OF VITAMIN B 1$429.17
84436ASSAY OF TOTAL THYROXINE$360.99
84439ASSAY OF FREE THYROXINE$483.87
84443ASSAY THYROID STIM HORMONE$709.66
84450TRANSFERASE (AST) (SGOT)$398.09
84460ALANINE AMINO (ALT) (SGPT)$350.99
84466ASSAY OF TRANSFERRIN$702.00
84478ASSAY OF TRIGLYCERIDES$417.21
84479ASSAY OF THYROID (T3 OR T4)$392.77
84480ASSAY TRIIODOTHYRONINE (T3)$499.84
84481FREE ASSAY (FT 3)$512.06
84482T3 REVERSE$300.99
84484ASSAY OF TROPONIN QUANT$643.09
84510ASSAY OF TYROSINE$334.33
84512ASSAY OF TROPONIN QUAL$549.24
84520ASSAY OF UREA NITROGEN$339.11
84550ASSAY OF BLOOD/URIC ACID$324.15
84560ASSAY OF URINE/URIC ACID$374.58
84600ASSAY OF VOLATILES$354.23
84681ASSAY OF C PEPTIDE$370.00
84702CHORIONIC GONADOTROPIN TEST$648.05
84703CHORIONIC GONADOTROPIN ASSAY$409.33
84704HCG FREE BETACHAIN TEST$374.32
84999Clinical chemistry test$363.60
85004AUTOMATED DIFF WBC COUNT$397.01
85007BL SMEAR W/DIFF WBC COUNT$352.00
85009MANUAL DIFF WBC COUNT B COAT$395.70
85014HEMATOCRIT$338.64
85018HEMOGLOBIN$353.28
85025COMPLETE CBC W/AUTO DIFF WBC$319.06
85027COMPLETE CBC AUTOMATED$433.25
85032MANUAL CELL COUNT EACH$352.00
85044MANUAL RETICULOCYTE COUNT$450.15
85045AUTOMATED RETICULOCYTE COUNT$459.69
85048AUTOMATED LEUKOCYTE COUNT$346.00
85060BLOOD SMEAR INTERPRETATION$340.29
85210CLOT FACTOR II PROTHROM SPEC$349.00
85270CLOT FACTOR XI PTA$2,795.40
85345COAGULATION TIME LEE & WHITE$2,626.00
85347COAGULATION TIME ACTIVATED$494.08
85378FIBRIN DEGRADE SEMIQUANT$468.06
85379FIBRIN DEGRADATION QUANT$586.24
85380FIBRIN DEGRADJ D DIMER$726.35
85384FIBRINOGEN ACTIVITY$300.00
85576BLOOD PLATELET AGGREGATION$845.75
85598HEXAGNAL PHOSPH PLTLT NEUTRL$923.36
85610PROTHROMBIN TIME$301.03
85613RUSSELL VIPER VENOM DILUTED$923.36
85651RBC SED RATE NONAUTOMATED$340.20
85652RBC SED RATE AUTOMATED$336.85
85730THROMBOPLASTIN TIME PARTIAL$344.03
86000AGGLUTININS FEBRILE ANTIGEN$756.60
86021WBC ANTIBODY IDENTIFICATION$1,207.50
86038ANTINUCLEAR ANTIBODIES$513.72
86039ANTINUCLEAR ANTIBODIES (ANA)$562.17
86060ANTISTREPTOLYSIN O TITER$336.22
86140C REACTIVE PROTEIN$427.25
86141C REACTIVE PROTEIN HS$360.20
86146BETA 2 GLYCOPROTEIN ANTIBODY$325.87
86157COLD AGGLUTININ TITER$338.00
86160COMPLEMENT ANTIGEN$634.50
86162COMPLEMENT TOTAL (CH50)$356.21
86200CCP ANTIBODY$356.21
86225DNA ANTIBODY NATIVE$470.64
86235NUCLEAR ANTIGEN ANTIBODY$437.03
86255FLUORESCENT ANTIBODY SCREEN$387.56
86256FLUORESCENT ANTIBODY TITER$447.63
86308HETEROPHILE ANTIBODY SCREEN$322.12
86317IMMUNOASSAY INFECTIOUS AGENT$402.98
86320Serum immunoelectrophoresis$1,094.54
86325OTHER IMMUNOELECTROPHORESIS$388.05
86328IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBOD$346.72
86337INSULIN ANTIBODIES$301.49
86341ISLET CELL ANTIBODY$302.48
86343LEUKOCYTE HISTAMINE RELEASE$638.79
86356MONONUCLEAR CELL ANTIGEN$318.00
86359T CELLS TOTAL COUNT$341.00
86360T CELL ABSOLUTE COUNT/RATIO$590.57
86376MICROSOMAL ANTIBODY EACH$439.00
86403PARTICLE AGGLUT ANTBDY SCRN$366.70
86430RHEUMATOID FACTOR TEST QUAL$355.72
86431RHEUMATOID FACTOR QUANT$372.77
86480TB TEST CELL IMMUN MEASURE$857.69
86580TB INTRADERMAL TEST$646.50
86592SYPHILIS TEST NON TREP QUAL$306.95
86593SYPHILIS TEST NON TREP QUANT$361.59
86611BARTONELLA ANTIBODY$975.10
86615BORDETELLA ANTIBODY$387.06
86617LYME DISEASE ANTIBODY$957.00
86618LYME DISEASE ANTIBODY$1,800.00
86622BRUCELLA ANTIBODY$334.52
86625CAMPYLOBACTER ANTIBODY$479.59
86631CHLAMYDIA ANTIBODY$368.00
86638Q FEVER ANTIBODY$2,055.67
86644CMV ANTIBODY$472.84
86645CMV ANTIBODY IGM$520.96
86652ENCEPHALTIS EAST EQNE ANBDY$4,779.00
86654ENCEPHALTIS WEST EQNE ANTBDY$1,365.14
86663EPSTEIN BARR ANTIBODY$323.52
86664EPSTEIN BARR NUCLEAR ANTIGEN$406.28
86665EPSTEIN BARR CAPSID VCA$370.00
86666EHRLICHIA ANTIBODY$328.67
86668FRANCISELLA TULARENSIS$348.78
86674GIARDIA LAMBLIA ANTIBODY$315.00
86677HELICOBACTER PYLORI ANTIBODY$533.88
86689HTLV/HIV CONFIRMJ ANTIBODY$587.05
86694HERPES SIMPLEX NES ANTBDY$315.00
86695HERPES SIMPLEX TYPE 1 TEST$300.00
86696HERPES SIMPLEX TYPE 2 TEST$390.00
86701HIV 1ANTIBODY$435.76
86702HIV 2 ANTIBODY$538.40
86703HIV 1/HIV 2 1 RESULT ANTBDY$375.00
86704HEP B CORE ANTIBODY TOTAL$539.59
86705HEP B CORE ANTIBODY IGM$521.56
86706HEP B SURFACE ANTIBODY$512.28
86707HEPATITIS BE ANTIBODY$390.00
86708HEPATITIS A ANTIBODY$390.00
86709HEPATITIS A IGM ANTIBODY$385.00
86710INFLUENZA VIRUS ANTIBODY$388.33
86713Legionella antibody$388.66
86717LEISHMANIA ANTIBODY$316.97
86720LEPTOSPIRA ANTIBODY$316.97
86735MUMPS ANTIBODY$380.00
86750MALARIA ANTIBODY$395.00
86753PROTOZOA ANTIBODY NOS$390.00
86756Respiratory virus antibody$324.52
86757RICKETTSIA ANTIBODY$350.26
86759ROTAVIRUS ANTIBODY$315.17
86762RUBELLA ANTIBODY$305.00
86765RUBEOLA ANTIBODY$335.00
86769Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])$401.71
86777TOXOPLASMA ANTIBODY$305.00
86780TREPONEMA PALLIDUM$323.90
86787VARICELLA ZOSTER ANTIBODY$309.55
86788WEST NILE VIRUS AB IGM$335.00
86789WEST NILE VIRUS ANTIBODY$310.00
86790VIRUS ANTIBODY NOS$390.00
86800THYROGLOBULIN ANTIBODY$345.00
86803HEPATITIS C AB TEST$563.61
86812HLA TYPING A B OR C$354.00
86850RBC ANTIBODY SCREEN$453.84
86880COOMBS TEST DIRECT$315.00
86886COOMBS TEST INDIRECT TITER$374.02
86900BLOOD TYPING SEROLOGIC ABO$384.77
86901BLOOD TYPING SEROLOGIC RH(D)$330.38
86905BLOOD TYPING RBC ANTIGENS$300.00
86906BLD TYPING SEROLOGIC RH PHNT$309.04
87015SPECIMEN INFECT AGNT CONCNTJ$300.00
87040BLOOD CULTURE FOR BACTERIA$664.25
87045FECES CULTURE AEROBIC BACT$533.49
87046STOOL CULTR AEROBIC BACT EA$378.14
87070CULTURE OTHR SPECIMN AEROBIC$549.73
87075CULTR BACTERIA EXCEPT BLOOD$741.98
87076CULTURE ANAEROBE IDENT EACH$356.89
87077CULTURE AEROBIC IDENTIFY$382.06
87081CULTURE SCREEN ONLY$384.80
87084CULTURE OF SPECIMEN BY KIT$300.00
87086URINE CULTURE/COLONY COUNT$573.69
87088URINE BACTERIA CULTURE$342.71
87102FUNGUS ISOLATION CULTURE$330.00
87103Blood fungus culture$402.31
87106FUNGI IDENTIFICATION YEAST$371.54
87110CHLAMYDIA CULTURE$496.58
87140CULTURE TYPE IMMUNOFLUORESC$379.70
87177OVA AND PARASITES SMEARS$339.31
87181MICROBE SUSCEPTIBLE DIFFUSE$375.00
87185MICROBE SUSCEPTIBLE ENZYME$375.00
87186MICROBE SUSCEPTIBLE MIC$320.00
87205SMEAR GRAM STAIN$334.38
87207SMEAR SPECIAL STAIN$301.54
87209SMEAR COMPLEX STAIN$368.63
87210SMEAR WET MOUNT SALINE/INK$371.40
87220TISSUE EXAM FOR FUNGI$365.00
87230ASSAY TOXIN OR ANTITOXIN$360.00
87252VIRUS INOCULATION TISSUE$611.29
87254Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus$449.80
87255GENET VIRUS ISOLATE HSV$387.00
87265PERTUSSIS AG IF$350.00
87272CRYPTOSPORIDIUM AG IF$364.40
87273HERPES SIMPLEX 2 AG IF$345.00
87274HERPES SIMPLEX 1 AG IF$340.00
87275INFLUENZA B AG IF$318.67
87276INFLUENZA A AG IF$320.00
87278LEGION PNEUMOPHILIA AG IF$364.40
87280RESPIRATORY SYNCYTIAL AG IF$345.00
87324CLOSTRIDIUM AG IA$370.00
87327CRYPTOCOCCUS NEOFORM AG IA$393.84
87328CRYPTOSPORIDIUM AG IA$360.00
87329GIARDIA AG IA$380.00
87338HPYLORI STOOL IA$407.93
87339Infectious agent antigen detection by immunoassay technique, Helicobacter pylori$483.33
87340HEPATITIS B SURFACE AG IA$378.05
87341Hepatitis b surface ag ia$344.68
87350HEPATITIS BE AG IA$385.00
87389HIV 1 AG W/HIV 1 & HIV 2 AB$431.33
87400INFLUENZA A/B AG IA$347.02
87420RESP SYNCYTIAL AG IA$452.33
87425ROTAVIRUS AG IA$485.07
87426INFECTIOUS AGENT ANTIGEN DETECTION BY IM$988.56
87427SHIGA LIKE TOXIN AG IA$349.27
87430STREP A AG IA$560.23
87472BARTONELLA DNA QUANT$535.00
87480CANDIDA DNA DIR PROBE$363.68
87481CANDIDA DNA AMP PROBE$300.00
87483CNS DNA AMP PROBE TYPE 12 25$2,858.60
87486INFECTIOUS AGENT DETECTION BY NUCLEIC AC$642.05
87490CHYLMD TRACH DNA DIR PROBE$330.00
87491CHYLMD TRACH DNA AMP PROBE$551.85
87493C DIFF AMPLIFIED PROBE$634.41
87498ENTEROVIRUS PROBE&REVRS TRNS$481.40
87507IADNA DNA/RNA PROBE TQ 12 25$4,327.29
87510GARDNER VAG DNA DIR PROBE$350.00
87522HEPATITIS C REVRS TRNSCRPJ$405.82
87528HSV DNA DIR PROBE$335.00
87529HSV DNA AMP PROBE$685.64
87530HSV DNA QUANT$510.00
87536HIV 1 QUANT&REVRSE TRNSCRPJ$1,100.00
87581INFECTIOUS AGENT DETECTION BY NUCLEIC AC$617.89
87590N.GONORRHOEAE DNA DIR PROB$330.00
87591N.GONORRHOEAE DNA AMP PROB$483.52
87592N.GONORRHOEAE DNA QUANT$490.00
87621HPB LAB$327.49
87632INFECTIOUS AGENT DETECTION BY NUCLEIC AC$1,155.00
87633RESP VIRUS 12 25 TARGETS$1,342.03
87634Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe
technique		$1,542.53
87635INFECTIOUS AGENT DETECTION BY NUCLEIC AC$1,751.58
87636Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique$1,290.87
87637Infectious agent detection by nucleic acid (DNA or RNA); COVID 19, RSV and FLU A&B PCR, multiplex amplified probe technique$1,993.87
87641MR STAPH DNA AMP PROBE$405.00
87651STREP A DNA AMP PROBE$345.00
87653STREP B DNA AMP PROBE$345.00
87660TRICHOMONAS VAGIN DIR PROBE$300.00
87661TRICHOMONAS VAGINALIS AMPLIF$342.97
87798DETECT AGENT NOS DNA AMP$843.84
87800DETECT AGNT MULT DNA DIREC$455.00
87801DETECT AGNT MULT DNA AMPLI$762.17
87802STREP B ASSAY W/OPTIC$345.00
87803CLOSTRIDIUM TOXIN A W/OPTIC$350.00
87804INFLUENZA ASSAY W/OPTIC$342.53
87806HIV ANTIGEN W/HIV ANTIBODIES$344.40
87807RSV ASSAY W/OPTIC$403.74
87810CHYLMD TRACH ASSAY W/OPTIC$364.40
87850N. GONORRHOEAE ASSAY W/OPTIC$369.65
87880STREP A ASSAY W/OPTIC$538.66
87899AGENT NOS ASSAY W/OPTIC$345.00
88141CYTOPATH C/V INTERPRET$396.51
88142CYTOPATH C/V THIN LAYER$310.00
88233TISSUE CULTURE SKIN/BIOPSY$1,495.00
88262CHROMOSOME ANALYSIS 15 20$1,709.80
88291CYTO/MOLECULAR REPORT$365.70
88304TISSUE EXAM BY PATHOLOGIST$430.00
88305TISSUE EXAM BY PATHOLOGIST$835.74
88346IMMUNOFLUOR ANTB 1ST STAIN$1,059.00
89050BODY FLUID CELL COUNT$388.09
89051BODY FLUID CELL COUNT$350.71
89055LEUKOCYTE ASSESSMENT FECAL$340.82
89060EXAM SYNOVIAL FLUID CRYSTALS$374.10
89220SPUTUM SPECIMEN COLLECTION$370.00
90460IM ADMIN 1ST/ONLY COMPONENT$362.82
90471IMMUNIZATION ADMIN$367.82
90472IMMUNIZATION ADMIN EACH ADD$355.00
90656IIV3 VACC NO PRSV 0.5 ML IM$353.81
90658IIV3 VACCINE SPLT 0.5 ML IM$380.00
90660LAIV3 VACCINE INTRANASAL$370.00
90661CCIIV3 VAC NO PRSV 0.5 ML IM$377.87
90688Iiv4 vaccine splt 0.5 ml im$371.66
90700DTAP VACCINE < 7 YRS IM$317.72
90702DT VACCINE UNDER 7 YRS IM$365.00
90703TETANUS TOXID$393.03
90707MMR VACCINE SC$350.19
90714TD VACC NO PRESV 7 YRS+ IM$326.81
90715TDAP VACCINE 7 YRS/> IM$372.31
90718TETANUS & DIPTHERIA$352.00
90732PPSV23 VACC 2 YRS+ SUBQ/IM$395.00
90733MPSV4 VACCINE SUBQ$425.00
90746HEPB VACCINE 3 DOSE ADULT IM$376.20
90997HEMOPERFUSION$409.00
92100SERIAL TONOMETRY EXAM(S)$360.00
92235FLUORESCEIN ANGRPH UNI/BI$580.00
92950HEART/LUNG RESUSCITATION CPR$1,833.48
92960CARDIOVERSION ELECTRIC EXT$2,730.97
93000ELECTROCARDIOGRAM COMPLETE$624.00
93005ELECTROCARDIOGRAM TRACING$893.06
93010ELECTROCARDIOGRAM REPORT$346.88
93040RHYTHM ECG WITH REPORT$459.69
93041RHYTHM ECG TRACING$400.74
93042RHYTHM ECG REPORT$318.40
93224ECG MONIT/REPRT UP TO 48 HRS$1,749.00
93225ECG MONIT/REPRT UP TO 48 HRS$2,596.50
93226ECG MONIT/REPRT UP TO 48 HRS$2,423.10
93227ECG MONIT/REPRT UP TO 48 HRS$2,902.40
93303ECHO TRANSTHORACIC$3,085.28
93306Tte w/doppler complete$4,090.66
93307Tte w/o doppler complete$4,864.69
93308TTE F UP OR LMTD$4,013.64
93313ECHO TRANSESOPHAGEAL$2,934.28
93314ECHO TRANSESOPHAGEAL$3,689.53
93320Doppler echo exam heart$3,578.72
93325Doppler color flow add-on$3,596.69
93351STRESS TTE COMPLETE$5,182.32
93623STIMULATION PACING HEART$3,899.56
93875N INVAS PHYSIOLOGIC STD X$4,086.20
93880EXTRACRANIAL BILAT STUDY$4,396.12
93882EXTRACRANIAL UNI/LTD STUDY$4,996.50
93886INTRACRANIAL COMPLETE STUDY$4,189.04
93922UPR/L XTREMITY ART 2 LEVELS$4,329.03
93923UPR/LXTR ART STDY 3+ LVLS$4,863.04
93925LOWER EXTREMITY STUDY$4,688.18
93926LOWER EXTREMITY STUDY$4,959.69
93930UPPER EXTREMITY STUDY$4,740.94
93931UPPER EXTREMITY STUDY$4,032.09
93965EXTREMITY STUDY$4,806.00
93970EXTREMITY STUDY$4,622.27
93971EXTREMITY STUDY$4,043.21
93975VASCULAR STUDY$4,484.59
93976VASCULAR STUDY$4,939.05
93980PENILE VASCULAR STUDY$2,982.99
94010BREATHING CAPACITY TEST$2,665.33
94060Evaluation of wheezing$2,279.67
94150VITAL CAPACITY TEST$1,280.70
94621PULM STRESS TEST/COMPLEX$2,408.02
94640AIRWAY INHALATION TREATMENT$1,694.72
94644CBT 1ST HOUR$1,597.20
94645CBT EACH ADDL HOUR$1,177.64
94664Evaluate pt use of inhaler$1,193.11
94760MEASURE BLOOD OXYGEN LEVEL$244.35
94761MEASURE BLOOD OXYGEN LEVEL$376.62
94762Measure blood oxygen level$1,102.92
95921AUTONOMIC NRV PARASYM INERVJ$1,011.88
95971ANALYZE NEUROSTIM SIMPLE$661.59
96000MOTION ANALYSIS VIDEO/3D$1,424.08
96116NUBHVL XM PHYS/QHP 1ST HR$530.00
96360HYDRATION IV INFUSION INIT$1,533.08
96361HYDRATE IV INFUSION ADD ON$957.51
96365THER/PROPH/DIAG IV INF INIT$1,563.01
96366THER/PROPH/DIAG IV INF ADDON$942.96
96367TX/PROPH/DG ADDL SEQ IV INF$721.25
96368THER/DIAG CONCURRENT INF$771.98
96369SC THER INFUSION UP TO 1 HR$810.00
96371SC THER INFUSION RESET PUMP$543.25
96372THER/PROPH/DIAG INJ SC/IM$969.53
96373THER/PROPH/DIAG INJ IA$933.44
96374THER/PROPH/DIAG INJ IV PUSH$1,508.09
96375TX/PRO/DX INJ NEW DRUG ADDON$938.26
96376TX/PRO/DX INJ SAME DRUG ADON$778.76
96377Applicaton on-body injector$731.69
96379THER/PROP/DIAG INJ/INF PROC$1,641.63
97010HOT OR COLD PACKS THERAPY$101.49
97116GAIT TRAINING THERAPY$432.70
97140MANUAL THERAPY 1/> REGIONS$349.12
97542Wheelchair mngment training$214.92
97597RMVL DEVITAL TIS 20 CM/<$2,528.74
98925OSTEOPATH MANJ 1 2 REGIONS$278.67
99000SPECIMEN HANDLING OFFICE LAB$167.90
99001SPECIMEN HANDLING PT LAB$183.33
99024Postop follow-up visit$298.50
99050Medical services after hrs$177.61
99070SPECIAL SUPPLIES PHYS/QHP$258.10
99072ADDITIONAL SUPPLIES, MATERIALS, AND CLI$197.14
99143MOD SEDAT PHYS/QHP <5 YRS$439.00
99144MOD SEDAT PHYS/QHP 5YRS/>$433.00
99145MOD SEDAT PHYS/QHP EA 15$168.00
99148MOD SED DIFF PHYS/QHP<5 Y$575.00
99149MOD SED DIFF PHYS/QHP 5/>$363.00
99150MOD SED DIFF PHYS/QHP ADD$165.00
99151MOD SED SAME PHYS/QHP <5 YRS$694.07
99152MOD SED SAME PHYS/QHP 5/>YRS$646.50
99153MOD SED SAME PHYS/QHP EA$382.08
99156MOD SED OTH PHYS/QHP 5/>YRS$473.00
99157MOD SED OTHER PHYS/QHP EA$326.00
99173VISUAL ACUITY SCREEN$293.00
99175INDUCTION OF VOMITING$184.47
99201OFFICE/OUTPATIENT VISIT NEW$250.00
99217OBSERVATION CARE DISCHARGE$1,942.81
99218INITIAL OBSERVATION CARE$2,320.93
99219Initial observation care$2,400.49
99220INITIAL OBSERVATION CARE$2,499.22
992211ST HOSP IP/OBS SF/LOW 40$3,994.72
992221ST HOSP IP/OBS MODERATE 55$4,957.82
992231ST HOSP IP/OBS HIGH 75$5,992.84
99225Subsequent observation care$2,865.80
99226SUBSEQUENT OBSERVATION CARE$3,226.49
99231SBSQ HOSP IP/OBS SF/LOW 25$2,865.80
99232SBSQ HOSP IP/OBS MODERATE 35$3,226.49
99233SBSQ HOSP IP/OBS HIGH 50$4,226.49
99234Observ/hosp same date$2,676.60
99235OBSERV/HOSP SAME DATE$2,800.00
99236OBSERV/HOSP SAME DATE$2,454.80
99238HOSP IP/OBS DSCHRG MGMT 30/<$4,957.82
99239HOSP IP/OBS DSCHRG MGMT >30$5,992.84
99281EMERGENCY DEPT VISIT$825.67
99282EMERGENCY DEPT VISIT$1,871.99
99283EMERGENCY DEPT VISIT$3,994.72
99284EMERGENCY DEPT VISIT$4,957.82
99285EMERGENCY DEPT VISIT$5,992.84
99291CRITICAL CARE FIRST HOUR$6,905.16
99292CRITICAL CARE ADDL 30 MIN$2,979.23
99374HOME HEALTH CARE SUPERVISION$1,315.89
99406BEHAV CHNG SMOKING 3 10 MIN$1,109.98
99407Behav chng smoking > 10 min$576.94
0202UNFCT DS 22 TRGT SARS COV 2$3,751.50
2010FVITAL SIGNS RECORDED$105.27
2014FMENTAL STATUS ASSESS$105.40
3028FO2 SATURATION DOC REV$169.18
3293FABO RH BLOOD TYPING DOCD$215.22
A0394ALS SPCLIZED SRVC DISPBL SPL; IV RX$105.56
A0396ALS SPCLIZD SRVC DISPBL SPL;INTUBAT$138.44
A4208SYRINGE W/NEEDLE STERILE 3 CC EACH$141.36
A4209SYRINGE W/NEEDLE STERILE 5 CC/> EA$146.12
A4213SYRINGE STERILE 20 CC/GREATER EACH$109.20
A4215NEEDLE STERILE ANY SIZE EACH$371.44
A4216STERL H2O SALINE & OR DXT DIL 10 ML (Saline Lock)
$139.30
A4217STERILE WATER/SALINE 500 ML$133.39
A4218STERILE SALINE OR WATER$104.61
A4221SUPS MAINT NON INS RX INFUS CATH PW$185.88
A4222INFUS SPL EXT RX INFUS PUMP CAS/BAG$368.99
A4244ALCOHOL OR PEROXIDE PER PINT$106.14
A4245Alcohol wipes, per box$179.00
A4246BETADINE/PHISOHEX SOLUTION PER PINT$133.17
A4247BETADINE/IODINE SWABS/WIPES PER BOX$378.30
A4248CHLORHEXIDINE CONTAINING ANTISEPTIC$176.87
A4252BLOOD KETONE TEST/REAGENT STRIP EA$107.95
A4311INSRTION TRAY W/O BAG 2 WAY LATEX$146.12
A4313INSRT TRAY W/O BAG 3 WAY CNT IRRIG$136.89
A4314INSRTION TRAY W/BAG 2 WAY LATEX$319.21
A4315Cath w/drainage 2-way silcne$445.36
A4320IRRIG TRAY W/BULB/PISTON SYRINGE$120.37
A4322IRRIGATION SYRINGE BULB/PISTON EACH$120.37
A4327FE EXT URIN CLCT DEVC; METL CUP EA$144.61
A4328FE EXT URIN CLCT DEVICE; POUCH EA$105.76
A4332LUBRICNT INDIVIDUAL STERL PACKET EA$109.23
A4335INCONTINENCE SUPPLY; MISCELLANEOUS$111.94
A4338INDWLL CATH; 2 WAY LATEX W/COAT EA$142.51
A4344INDWLL CATH FOLEY 2 WAY SILCON EA$860.51
A4351INTERMIT URIN CATH; STRAIT TIP EA$114.98
A4352INTERMIT URIN CATH; COUDE TIP EA$130.94
A4353INTERMIT URIN CATH W/INSERTION SPL$164.51
A4354INSRTION TRAY W/DRN BAG W/O CATH$145.24
A4356EXT URETHRAL CLAMP/COMPRS DEVICE EA$358.98
A4358URINARY LEG BAG; VINYL W/WO TUBE EA$150.34
A4364ADHES LIQUID/EQUAL ANY TYPE OUNCE$255.12
A4369SKIN BARRIER LIQUID PER OZ$109.69
A4450TAPE NON WATERPROOF 18 SQUARE IN$113.79
A4452TAPE WATERPROOF PER 18 SQUARE IN$113.79
A4550SURGICAL TRAYS$905.30
A4554DISPOSABLE UNDERPADS ALL SIZES$138.37
A4556ELECTRODES PER PAIR$197.93
A4559COUPLING GEL OR PASTE$149.30
A4565SLINGS$145.63
A4566SHOULDR SLING/VEST ABD RSTRN PREFAB$158.81
A4570SPLINTS$165.27
A4590SPECIAL CASTING MATERIAL$165.27
A4606O2 PROBE W/OXIMETER DEVICE REPLCMT$208.95
A4615CANNULA NASAL$124.77
A4616TUBING PER FOOT$101.73
A4620VARIABLE CONCENTRATION MASK$172.50
A4649SURGICAL SUPPLIES - MISCELLANEOUS$1,352.32
A4657SYRINGE WITH OR WITHOUT NEEDLE EACH$109.20
A4670AUTOMATIC BLOOD PRESSURE MONITOR$147.04
A4673EXT LINE W/EASY LOCK CNCTR DIALYSIS$118.45
A4770BLD COLLECTION TUBE VAC DIALYSIS 50$107.86
A4927GLOVES NON STERILE PER 100$105.53
A4929TOURNIQUET FOR DIALYSIS EACH$138.12
A4930GLOVES STERILE PER PAIR$104.61
A5120SKIN BARRIER WIPES OR SWABS EACH$107.70
A5200PERQ CATH/TUBE ANCHR DEVC ADHES SKN$137.81
A6000NON CNTC WND WARMING COVR W/DEVC$148.24
A6021COLL DRESS PAD SIZE 16 SQ/LESS EA$133.67
A6198ALGINAT/OTH FIBR GELL PAD >48 SQ EA$147.90
A6203COMPOSITE DRSG <= 16 SQ IN$127.68
A6205COMPOS DRESS >48SQ W/ADHES BORDR EA$127.68
A6209FOAM DRSG <=16 SQ IN W/O BDR$150.00
A6210Foam drg >16<=48 sq in w/o b$101.92
A6211FOAM DRESS STERL > 48 SQ NO ADHES$580.27
A6212Foam drg <=16 sq in w/border$199.18
A6213FOAM DRESS >16 <= 48 SQ W/ADHES EA$187.24
A6216GAUZE NON IMPREG NONSTERL 16 SQ/<$118.60
A6217GAUZE NON IMPREG NONSTRL >16<=48SQ$188.12
A6218GAUZE NON IMPREG NONSTERL > 48 SQ$149.37
A6219GAUZE NON IMPREG STERL 16 SQ/$142.36
A6220Gauze >16 <=48 sq in w/bordr$134.39
A6222GAUZ IMPREG NOT H2O/HYDRGEL 16 SQ/<$115.35
A6223GAUZ IMPREG NOT H2O/HYDRGL >16<=48$119.54
A6224GAUZ IMPREG NOT H2O/HYDROGEL >48 SQ$120.94
A6231GAUZ IMPREG HYDRGEL DIR WND 16 SQ/<$192.85
A6250SKN SEALNT PROTCT MOISTURZR OINTMNT$198.03
A6260WOUND CLEANSERS ANY TYPE ANY SIZE$196.95
A6261WOUND FILLR GEL/PASTE PER FL OZ NOS$423.60
A6266GAUZ IMPRG NOT H2O SAL/ZINC LINR YD$113.28
A6402GAUZ NON IMPREG STERL 16 SQ/< NO AD$140.83
A6407PACK STRIPS NON IMPREGNTD UP 2 IN$189.35
A6410EYE PAD STERILE EACH$147.70
A6412EYE PATCH OCCLUSIVE EACH$103.57
A6413ADHESIVE BANDAGE FIRST AID TYPE EA$106.93
A6441PAD BAND W>=3" <5"/YD$138.89
A6442CONFORM BAND N/S W<3"/YD$118.45
A6443CONFORM BAND N/S W>=3"<5"/YD$104.85
A6446CONFORMING BANDGE NON ELAST KNITTED$102.49
A6448LT COMPRS BANDGE ELAST WDTH < 3 IN$115.08
A6449LT COMPRS BANDGE WDTH >/= 3 & <5 IN$115.37
A6450LT COMPRS BANDGE WDTH >/= 5 IN$123.07
A6453SELF ADHERENT BANDGE WDTH $113.73
A6454SLF ADHERNT BANDGE WD >/= 3 & <5 IN$150.26
A6455Self-adher band >=5"/yd$130.50
A6457TUBULR DRSG W/WO ELAST WDTH LINR YD$176.44
A7001CANISTR NONDISPBL USED W/SUCTN PUMP$113.07
A7002TUBING USED WITH SUCTION PUMP EACH$175.62
A7003ADMN SET SM VOL NONFILTR NEB DISPBL$174.25
A7006FILTERED NEBULIZER ADMIN SET$199.93
A7011NONDISPOS CORRUGATED TUBI$116.90
A7015AREO MASK USED W/ DME NEB$174.25
A7016DOME&MOUTHPECE W/SM VOL US NEBULIZR$130.74
A7017NEB GLASS/AUTOCLAV NOT USE W/O2$174.25
A7018WATER DISTILLED W/NEBULIZER$166.77
A7520TRACHEOST/LARYNGECT TUBE NON CUFFED$563.31
A9150GENERIC DRUG$121.55
A9150ANONPRESCRIPTION DRUG$28.82
A9150AAMUCINEX 600 MG PO (GUAIFENESIN)$28.82
A9150ABCHERATUSSIN SYRUP 5M$28.82
A9150ACCLARITIN (LORATADINE) 10 MG$28.82
A9150ADSIMETHICONE 125 MG PO$28.82
A9150AEMIRALAX POWDER$28.82
A9150AFDEXTROMETHORPHAN (DELSYM) 30 MG/5 ML$28.82
A9150AGZINC SULFATE 220 MG CAPSULE$28.82
A9150AHACTIVATED CHARCOAL (ACTIDOSE AQUA) 75 MG$28.82
A9150BMISC/EXPER NON PRESCRIPT$28.82
A9150CMISC/EXPER NON PRESCRIPT$28.82
A9150DNONPRESCRIPTION DRUG$28.82
A9150ENONPRESCRIPTION DRUG$28.82
A9150FZANTAC 75MG$28.82
A9150GACETAMINOPHEN 650 MG$28.82
A9150HNONPRESCRIPTION DRUG$28.82
A9150IBENADRYL PEDIATRIC SYRUP$28.82
A9150KCETIRIZINE HCL 10 MG$28.82
A9150LCHERATUSSIN SYRUP 5ML$28.82
A9150MIBUPROFEN 100$28.82
A9150NMYLANTA 10ML$28.82
A9150QACETAMINOPHEN 100$28.82
A9150RMAGNESIUM CITRATE ORAL$28.82
A9150TMAALOX$28.82
A9150VASPIRIN$28.82
A9150WACETAMINOPHEN 325 MG$28.82
A9150XMILK OF MAGNESIA 10ML$28.82
A9150YPSEUDOPHEDRINE 30 MG$28.82
A9150ZGUAIFENESIN 600MG PO$28.82
A9152SINGLE VITAMIN NOS$105.91
A9273HOT WATER BOTTLE ICE CAP/COLLAR ANY$116.90
A9284NON ELECTRONIC SPIROMETER$141.79
A9530I131 IODIDE SOL, RX$101.12
A9579INJ GADOLINIUM MR CONTRAST NOS ML$137.01
A9900DME SUP/ACCESS/SRV COMPON/OTH HCPCS$108.88
C9285LIDO 70 MG/TETRACAINE 70 MG PATCH$101.47
C9399Unclassified drugs or biolog$3,744.41
E0110Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips$1,590.32
E0112CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR F$1,227.62
E0114CRTCHES UNDARM OTH THAN WOOD PAIR$1,397.93
E0116CRTCH UNDARM OTH THAN WOOD ADJ/FIX$1,376.87
E0117CRUTCH, UNDERARM, ARTICULATING, SPRING A$1,158.95
E0144WALKER ENCLOS 4 SIDE WHL POST SEAT$1,887.84
E0220HOT WATER BOTTLE$546.12
E0230ICE CAP OR COLLAR$530.00
E0275BED PAN STANDARD METAL OR PLASTIC$515.37
E0325URINAL; MALE JUG TYPE ANY MATERIAL$510.00
E0352DISPBL PACK W/ELEC BOWEL IRRIG/EVAC$532.61
E0445OXIMETER MSR BLD O2 LEVL NON INVASV$760.98
E0570NEBULIZER WITH COMPRESSOR$594.97
E0580NEBULIZR GLASS/AUTOCLVBL PLST BOTTL$584.33
E0691ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUD$7,272.54
E1399DURABLE MEDICAL EQUIPMENT, MISCELLANEOU$580.00
G0009Admin pneumococcal vaccine$585.38
G0168WOUND CLOS UTIL TISSUE ADHES ONLY$570.55
G0268REMV IMP CERUMN SAME DATE FUNCT TST$539.56
G0378HOSPITAL OBSERVATN SERVICE PER HOUR$2,000.00
G0379DIRECT REFER HOSPITAL OBSERV$8,675.00
G0434DRUG ABUSE PANEL II$555.00
G0479UDS URINE DRUG SCREEN Q$519.28
G0480DR TST DEFIN DR ID M P D 1 7 DR CL$595.42
G6038SALICYLATE$511.57
G6039ACETAMINOPHEN$559.04
G8895ANTROM PRESCRIBE$106.35
G8950PRE HTN OR HTN DOC, F/U INDC$105.00
G9019ORAL MED ADM DIRECT OBSERVE$150.00
H0033ORAL MED ADM DIRECT OBSERVE$144.01
H0048SPEC COLL NON BLOOD:A/D TEST$180.00
J0129Abatacept injection$179.48
J0131INJECTION ACETAMINOPHEN 10 MG$390.00
J0132ACETYLCYSTEINE INJECTION$325.00
J0133INJECTION ACYCLOVIR 5 MG$224.25
J0150ADENOSINE INJ 6MG VIAL$75.00
J0153ADENOSINE INJ 1MG$55.95
J0170EPINEPHRINE 3 1/2 NDL 10M$50.82
J0171INJ ADRENALIN EPINEPHRINE 0.1 MG$56.65
J0248Injection, Remdesivir, 1 mg$55.12
J0282INJ AMIODARONE HYDROCHLORIDE 30 MG$58.51
J0290INJECTION AMPICILLIN SODIUM 500 MG$55.70
J0295INJ AMPCLLN SODIM/SULBACTAM 1.5 G$62.90
J0330INJ SUCCINYLCHOLINE CHLORID UP 20MG$72.12
J0360INJECTION HYDRALAZINE HCL UP 20 MG$187.10
J0456INJECTION AZITHROMYCIN 500 MG$82.41
J0461INJECTION ATROPINE SULFATE 0.01 MG$59.46
J0500INJECTION DICYCLOMINE HCL UP 20 MG$264.25
J0540INJECTION, PENICILLIN G BENZATHINE AND P$86.58
J0550BICILLIN PENICILLIN G B$85.78
J0558INJ PCN G BENZ & PROCAINE 100000 U$91.97
J0559BICILLIN PENICILLIN G B$85.78
J0561INJECTION PCN G BENZ 100000 UNITS$108.27
J0595INJECTION BUTORPHANOL TARTRATE 1 MG$59.18
J0610INJECTION CALCM GLUCONATE PER 10 ML$84.19
J0641INJ LEVOLEUCOVORIN CALCIUM 0.5 MG$53.08
J0670INJ MEPIVACAINE HCL/10 ML$55.00
J0690INJECTION CEFAZOLIN SODIUM 500 MG$53.22
J0692INJ CEFEPIME HYDROCHLORID 500 MG$57.21
J0694INJ CEFOXITIN SODIUM 1 GM$105.00
J0696INJ CEFTRIAXONE SODIUM PER 250 MG$52.71
J0697Sterile cefuroxime injection$58.36
J0698INJECTION CEFOTAXIME SODIUM PER G$50.00
J0702INJ BETAMETHASONE AC & PHOS 3 MG$478.50
J0708Injection, daptomycin (hospira), not therapeutically 1 MG$58.29
J0735INJ CLONIDINE HYDROCHLORID 1 MG$147.94
J0744INJ CIPROFLOXACIN IV INFUS 200 MG$159.10
J0780INJ PROCHLORPERAZINE TO 10 MG$112.70
J1020INJ METHYLPRDNISOLONE ACTAT 20 MG$53.58
J1030INJ METHYLPRDNISOLONE ACTAT 40 MG$78.34
J1040INJ METHYLPRDNISOLONE ACTAT 80 MG$115.22
J1050INJ MEDROXYPROGESTERNE ACETATE 1 MG$58.29
J1055TRAMADOL$58.29
J1070INJ TESTOSTERONE TO 100MG$58.29
J1094INJECTION DEXAMETHASONE ACTAT 1 MG$58.29
J1100INJ DEXMETHOSON SODIM PHOSHATE 1 MG$51.07
J1110INJ DIHYDROERGOTAMINE MESYLATE 1 MG$616.55
J1165INJ PHENYTOIN SODIUM PER 50 MG$53.88
J1170INJECTION HYDROMORPHONE UP TO 4 MG$53.56
J1200INJ DIPHENHYDRAMINE HCL TO 50 MG$58.06
J1240INJECTION DIMENHYDRINATE TO 50 MG$53.34
J1265INJECTION DOPAMINE HCL 40 MG$50.00
J1327EPTIFIBATIDE INJECTION$54.76
J1335INJECTION ERTAPENEM SODIUM 500 MG$288.40
J1364ERYTHRO LACTOBIONATE /500 MG$278.74
J1450FLUCONAZOLE$50.00
J1580INJ GARAMYCIN GENTAMICIN UP 80 MG$50.73
J1610INJ GLUCAGON HYDROCHLORIDE PER 1 MG$891.43
J1630INJECTION HALOPERIDOL UP TO 5 MG$56.40
J1631INJ HALOPERIDOL DECANOATE PER 50 MG$140.95
J1642INJECTION HEPARIN SODIUM 10 UNITS$58.32
J1644INJ HEPARIN SODIUM PER 1000 UNITS$66.80
J1650INJECTION ENOXAPARIN SODIUM 10 MG$76.51
J1670INJ TETNS IMMUN GLOB HUMN TO 250 U$2,302.39
J1720INJ HYDROCORTSON SOD SUCC TO 100 MG$50.00
J1741Ibuprofen injection$57.35
J1756IRON SUCROSE INJECTION$53.65
J1790INJECTION DROPERIDOL UP TO 5 MG$50.00
J1815INJECTION INSULIN PER 5 UNITS$50.65
J1817Insulin for insulin pump use$52.76
J1885INJ KETOROLAC TROMETHAMINE 15 MG$53.67
J1890INJECTION, CEPHALOTHIN SODIUM, UP TO 1 G$59.54
J1930INJECTION LANREOTIDE 1 MG$244.18
J1940INJECTION FUROSEMIDE UP TO 20 MG$54.68
J1950INJ LEUPROLIDE ACETATE PER 3.75 MG$3,969.47
J1953INJECTION LEVETIRACETAM 10 MG$50.00
J1956INJECTION LEVOFLOXACIN 250 MG$123.32
J1980INJ HYOSCYAMINE SULFATE TO 0.25 MG$787.50
J2001INJECTION LIDO HCL IV INFUS 10 MG$57.51
J2020INJECTION LINEZOLID 200 MG$290.00
J2060INJECTION LORAZEPAM 2 MG$82.49
J2150INJECTION MANNITOL 25% IN 50 ML$58.37
J2175INJECTION MEPERIDINE HCL PER 100 MG$53.82
J2180MEPERIDINE/PROMETHAZINE INJ$50.00
J2250INJECTION MIDAZOLAM HCL PER 1 MG$53.76
J2270INJ MORPHINE SULFATE UP TO 10 MG$50.76
J2274Inj morphine pf epid ithc$88.41
J2300INJECTION NALBUPHINE HCL PER 10 MG$65.52
J2310INJECTION NALOXONE HCL PER 1 MG$99.62
J2315INJ NALTREXONE DEPOT FORM 1 MG$57.99
J2354OCTREOTIDE INJ, NON DEPOT$58.85
J2358OLANZAPINE LONG ACTING INJ$50.00
J2360INJ ORPHENADRINE CITRATE TO 60 MG$128.30
J2370INJECTION PHENYLEPHRINE HCL TO 1 ML$88.06
J2405INJECTION ONDANSETRON HCL PER 1 MG$55.09
J2510PENICILLIN G PROCAINE INJ$1,371.25
J2540INJECTION PCN G K+ TO 600000 UNITS$65.42
J2543INJ PIP SOD/TZ SOD 1 G/0.125 G$66.90
J2550INJECTION PROMETHAZINE HCL TO 50 MG$50.00
J2650INJ PREDNISOLONE ACETATE TO 1 ML$47.99
J2690INJ PROCAINAMIDE HCL TO 1 GM$420.79
J2704INJECTION PROPOFOL 10 MG$54.84
J2730INJ PRALIDOXIME CHLORIDE TO 1 GM$58.29
J2765INJ METOCLOPRAMIDE HCL TO 10 MG$58.82
J2770INJ QUINUPRISTIN/DALFOPRISTN 500 MG$214.84
J2780INJ RANITIDINE HYDROCHLORIDE 25 MG$55.66
J2790INJ RHO D IG HUMN FULL DOSE 300 MCG$385.42
J2800INJECTION METHOCARBAMOL UP TO 10 ML$201.28
J2805INJECTION SINCALIDE 5 MICROGRAMS$69.18
J2920INJ METHYLPRDNISOLON SODIM TO 40 MG$59.72
J2930INJ METHYLPRDNISLN SODIM TO 125 MG$76.90
J2997INJ ALTEPLASE RECOMBINANT 1 MG$230.00
J3010INJECTION FENTANYL CITRATE 0.1 MG$59.80
J3030INJECTION SUMATRIPTAN SUCCNAT 6 MG$372.73
J3101TENECTEPLASE INJECTION$154.00
J3105TERBUTALINE SULFATE INJ$90.73
J3130TESTOSTERONE ENANTHATE IN$50.74
J3230INJ CHLORPROMAZINE HCL TO 50 MG$339.50
J3260INJ TOBRAMYCIN SULFATE TO 80 MG$121.64
J3301INJ TRIAMCINOLON ACETONID NOS 10 MG$50.00
J3320INJ SPCTNOMYCN DHYDROCHLORD TO 2 GM$115.30
J3360INJECTION DIAZEPAM UP TO 5 MG$84.74
J3370INJECTION VANCOMYCIN HCL 500 MG$122.52
J3410INJECTION HYDROXYZINE HCL TO 25 MG$51.26
J3411INJECTION THIAMINE HCL 100 MG$57.42
J3420INJ VIT B 12 CYNOCOBLMN TO 1000 MCG$117.61
J3430INJECTION PHYTONADIONE PER 1 MG$68.79
J3475INJ MAGNESIUM SULFATE PER 500 MG$50.27
J3480INJ POTASSIUM CHLORIDE PER 2 MEQ$50.01
J3486INJ ZIPRASIDONE MESYLATE 10 MG$170.41
J3490UNCLASSIFIED DRUGS$1,033.56
J7030INFUS NORMAL SALINE SOL 1000 CC$59.03
J7040INFUS NORMAL SALINE SOL STERILE$55.94
J70425% DEXTROSE/NORMAL SALINE$96.89
J7050INFUS NORMAL SALINE SOLUTION 250 CC$54.37
J70605% DEXTROSE/WATER$64.71
J7070INFUSION D 5 W 1000 CC$138.67
J7110INFUSION DEXTRAN 75 500 ML$169.01
J7120RINGERS LACTATE INFUSION TO 1000 CC$93.74
J71215% DEXTROSE LR INFUSION TO 1000 CC$116.31
J7130HYPERTONIC SALINE SOLUTIO$99.93
J7131HYPERTONIC SALINE SOL$51.50
J7192Factor viii recombinant nos$56.81
J7506PREDNISONE ORAL 5 MG$50.10
J7509METHYLPREDNISOLONE ORAL PER 4 MG$55.00
J7510PREDNISOLONE ORAL PER 5 MG$50.75
J7512PDN IMMED RLSE/DELAY RLSE ORAL 1 MG$53.65
J7607LEVALBUTERAL INHAL CP DME 0.5 MG$54.75
J7609ALBUTEROL INHAL CP THRU DME 1 MG$55.00
J7610ALBUTEROL INHAL ADMIN THRU DME 1MG$52.43
J7611ALBUTEROL INHAL NON CP CONC 1 MG$59.76
J7612LEVALBUTROL INHL NON CP CONC 0.5 MG$58.75
J7613ALBUTEROL INHAL NON CP U DOSE 1 MG$54.08
J7614LEVALBUTEROL INHAL NON CP U 0.5 MG$57.47
J7615LEVALBUTEROL INHAL DME UNIT 0.5 MG$50.30
J7620ALBUTEROL TO 2.5 MG IPT TO 0.5 MG$56.46
J7626BUDESONIDE NON COMP UNIT$132.00
J7633BUDESONIDE NON-COMP CON$60.46
J7637DEXAMETHASONE INHAL CP CONC PER MG$50.00
J7638DEXAMETHASONE INHAL CP UNIT PER MG$50.00
J7640FORMOTEROL INHAL CP U DOSE 12 MCG$55.10
J7644IPRATROPIUM BROM INHAL NON CP U MG$126.80
J7645IPRATROPIUM BROMIDE COMP$58.00
J7682Tobramycin non-comp unit$507.51
J7699NOC RX INHAL SOL ADMINED THRU DME$120.00
J8498ANTIEMETIC DRUG RECTAL/SUPP NOS$50.67
J8499PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS$130.44
J8540DEXAMETHASONE ORAL 0.25 MG$54.59
J9027INJECTION CLOFARABINE 1 MG$701.71
J9206Irinotecan injection$79.63
J9260METHOTREXATE SODIUM INJ$55.00
L0120CERVICAL FLEX NONADJUSTABLE PREFAB$542.78
L0140CERVICAL, SEMI RIGID, ADJUSTABLE (PLASTI$585.00
L0150CERV SEMI RIGD ADJUST MOLD CHIN CUP$719.37
L0170CERVICAL, COLLAR, MOLDED TO PATIENT MODE$3,793.46
L0172CERV COLLAR SEMI RIGID FOAM PREFAB$539.39
L0978AXILLARY CRUTCH EXTENSION$1,312.55
L1812KNEE ORTHOSIS ELASTIC W/JNTS PREFAB$1,048.90
L1820KNEE ORTHOSIS (KO), ELASTIC WITH CONDYLA$575.00
L1830KNEE ORTHOSIS IMMOBLIZER PREFAB$580.48
L1902ANK ORTH ANK GAUNTLT/SIM PREFAB OTS$590.28
L1906AFO MX LIGAMENT ANK SUPT PREFB OTS$563.75
L3100HALLUS VALGUS NIGHT DYNAMIC SPLINT, PREF$555.00
L3250ORTHOPED FOOTWEAR CSTM MOLD PROSTH$565.88
L3260SURGICAL BOOT/SHOE EACH$413.25
L3540ORTHO SHOE ADD FULL SOLE$560.84
L3580ORTHO SHOE ADD CNVRT INSTP VELC CLO$586.74
L3650SO 8 ABD RESTRAINT PRE OT$558.72
L3660SHOULDER ORTHOS FIG 8 CANVAS PREFAB$535.00
L3670SHOULDER ORTHOS ACROMIO/CLAV PREFAB$551.28
L3671SHOULDER ORTHOSIS (SO), SHOULDER JOINT D$570.00
L3763ELBOW WRIST HAND ORTHOSIS (EWHO), RIGID,$2,600.00
L3807WHF ORTHOS NO JNT PRFAB CUSTOM FIT$530.00
L3809WHF ORTHO NO JOINTS PREFAB ANY TYPE$824.25
L3906WHO W/O JOINTS STRAPS CSTM FAB$1,515.00
L3908WRST HND ORTHOS CNTRL COCK UP PRFAB$597.41
L3923HAND FINGER ORTHOSIS (HFO), WITHOUT JOIN$565.00
L3927FINGER ORTHOSIS (FO), PROXIMAL INTERPHAL$524.44
L3984UP EXTRM FX ORTHOTIC WRST PRFAB$550.00
L3999UPPER LIMB ORTHOSIS NOS$530.60
L4350ANKLE CONTROL ORTHOS STIRRUP PREFAB$503.01
L4360WALK BOOT PNEUMAT&/VAC PREFAB CUSTM$588.31
L4361WALKING BOOT PNEUMATIC AND/OR VAC$550.00
L4380PNEUMATIC KNEE SPLINT$565.27
L4386WALK BOOT NON PNEUMATIC PREFAB CSTM$520.80
L4387WALKING BOOT, NON PNEUMATIC, WITH OR WI$505.30
L4398FOOT DROP SPLINT, RECUMBENT POSITIONING$540.00
L4631AFO WALK BOOT TYP ROCKR BOTTOM CSTM$639.18
M0222Bebtelovimab injection$1,752.50
M0243Intravenous infusion or subcutaneous injection, casirivimab and imdevimab
includes infusion or injection, and post administration monitoring		$2,250.00
M0247SOTROVIMAB INFUSION$2,250.00
P7001CULT BACTERL URINE; QUAN SENS STUDY$117.61
P9612CATH CLCT SPEC 1 PT ALL PLACES SRVC$186.02
Q0091SCR PAP SMER; OBTAIN PREP&CONVY LAB$62.90
Q0092SET UP PORT XRAY EQUIPMENT$293.16
Q0111WET MOUNTS W/PREP VAG CERV/SKN SPEC$61.11
Q0144AZITHROMYCIN ORAL CAP/POWDER 1 GM$172.69
Q0162ONDAN 1 MG ORL NOT EXCEED 48 HR DOS$21.22
Q0163DIPHENHYDRAMINE HCL 50 MG ORAL$5.00
Q0177HYDROXYZINE PAMOATE 25 MG ORAL$10.35
Q0179ONDANESTRONG HCL 8MG ORL$180.00
Q0222Bebtelovimab 175 mg$6,300.00
Q0243CASIRIVIMAB AND IMDEVIMAB$6,300.00
Q0244Injection, casirivimab and imdevimab, 1,200 mg$6,300.00
Q0247SOTROVIMAB$9,576.00
Q2009FOSPHENYTOIN INJ PE$595.00
Q2037FLUVIRIN VACC, 3 YRS & >, IM$65.00
Q4006CAST SPL LONG ARM CAST ADLT FIBRGLS$300.00
Q4008CAST SPL LNG ARM CAST PED FIBRGLS$200.00
Q4009CAST SPL SHORT ARM CAST ADLT PLASTR$120.00
Q4012CAST SPL SHORT ARM CAST PED FIBRGLS$130.00
Q4013CAST SUP GAUNTLET PLASTER$178.60
Q4017CAST SPL LNG ARM SPLINT ADLT PLASTR$103.22
Q4018CAST SPL LNG ARM SPLNT ADLT FIBRGLS$560.00
Q4019CAST SPL LNG ARM SPLINT PED PLASTR$51.76
Q4020CAST SPL LNG ARM SPLINT PED FIBRGLS$360.00
Q4021CAST SPL SHRT ARM SPLINT ADLT PLAST$195.00
Q4022CAST SPL SHRT ARM SPLNT ADLT F GLSS$225.00
Q4023CAST SUP SHT ARM SPLNT PED P$65.00
Q4024CAST SPL SHRT ARM SPLNT PED FIBRGLS$215.00
Q4029CAST SPL LONG LEG CAST ADULT PLASTR$430.00
Q4030CAST SUP LONG LEG FIBERGLASS$115.00
Q4037CAST SPL SHORT LEG CAST ADLT PLASTR$186.27
Q4038CAST SPL SHRT LEG CAST ADLT FIBRGLS$1,513.23
Q4040CAST SPL SHORT LEG CAST PED FIBRGLS$117.99
Q4042CAST SPL LNG LEG SPLNT ADLT FIBRGLS$360.00
Q4044CAST SUP LNG LEG SPLNT PED F$75.00
Q4045CAST SPL SHRT LEG SPLINT ADLT PLAST$131.56
Q4046CAST SPL SHRT LEG SPLNT ADLT F GLSS$280.00
Q4048CAST SPL SHRT LEG SPLNT PED FIBRGLS$275.00
Q4049FINGER SPLINT STATIC$225.00
Q4051SPLINT SUPPLIES MISCELLANEOUS$198.00
Q9954ORAL MR CONTRAST AGENT 100 ML$193.03
Q9957INJ PERFLUTREN LIPID MICROSPHERS ML$167.71
Q9961HOCM 250 299 MG/ML IODINE CONC ML$14.52
Q9963HOCM 350 399 MG/ML IODINE CONC ML$51.73
Q9965LOCM 100 199 MG/ML I CONC PER ML$34.49
Q9966LOCM 200 299 MG/ML I CONC PER ML$64.36
Q9967LOCM 300 399 MG/ML I CONC PER ML$113.61
S0014TACRINE HYDROCHLORIDE 10 MG$50.00
S0020INJ BUPIVICAINE HYDROCHLORIDE 30 ML$216.80
S0028INJECTION FAMOTIDINE 20 MG$85.34
S0030INJECTION METRONIDAZOLE 500 MG$193.46
S0039INJ SULFMETHOXAZL&TRIMETHOPRM 10 ML$51.78
S0077INJ CLINDAMYCIN PHOSPHATE 300 MG$57.93
S0078INJ FOSPHENYTOIN SODIUM 750 MG$147.98
S0081INJ PIPERACILLIN SODIUM 500 MG$53.32
S0119ONDANSETRON ORAL 4 MG$96.22
S0164INJECTION PANTOPRAZOLE SODIUM 40 MG$137.54
S0166INJECTION OLANZAPINE 2.5 MG$60.00
S0181ONDANESTRON HCA, ORAL 4MG$50.00
S0183PROCHLORPERAZINE MALEATE ORAL 5MG$57.65
S0630REMV SUTURS; MD NOT MD WHO CLOS WND$179.78
S1015IV TUBING EXTENSION SET$78.50
S3650SALIVA TEST HORMONE LEVEL;MENOPAUSE$50.43
S4990NICOTINE PATCHES LEGEND$52.40
S5000PRESCRIPTION DRUG GENERIC$296.63
S5001PRESCRIPTION DRUG BRAND NAME$199.78
S50105% DXTROS & 0.45% NL SALINE 1000 ML$243.48
S50115% DEXTROSE 1000 ML$51.82
S50125% DXTROS W/K+ CHLORID 1000 ML$90.91
S5550INSULIN RAPID ONSET; 5 UNITS$56.98
S8037MR CHOLANGIOPANCREATOGRAPHY$1,691.04
S8100HOLD CHAMB W/INHAL/NEBULIZR;NO MASK$69.18
S8101HOLD CHAMB W/INHAL/NEBULIZR; W/MASK$76.87
S8430PADDING COMPRESSION BANDAGE ROLL$52.50
S8450SPLINT PREFABRICATED DIGIT$110.69
S8451SPLINT PREFABRICATED WRIST OR ANKLE$156.81
U00022019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC$1,327.39
V2797VISN SPL ACSS&/SRVC CMPNT OTH HCPCS$54.47
V2799VISION ITEM OR SERVICES, MISCELLANEOUS$154.47