| Sr. # | CPT Codes | Description | Billing Charge Price |
|---|---|---|---|
| 1 | 10060 | INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE | $1,263.00 |
| 2 | 10061 | INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE | $1,263.00 |
| 3 | 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $1,263.00 |
| 4 | 10120 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE | $1,263.00 |
| 5 | 10121 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL | $1,260.00 |
| 6 | 10160 | PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST | $600.00 |
| 7 | 11000 | DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF | $1,260.00 |
| 8 | 11042 | DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< | $1,260.00 |
| 9 | 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $420.00 |
| 10 | 11730 | AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 | $1,365.00 |
| 11 | 11740 | EVACUATION SUBUNGUAL HEMATOMA | $648.00 |
| 12 | 11750 | EXCISION NAIL MATRIX PERMANENT REMOVAL | $1,260.00 |
| 13 | 11982 | REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT | $1,362.00 |
| 14 | 12001 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK | $738.00 |
| 15 | 12002 | SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM | $738.00 |
| 16 | 12004 | SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM | $714.00 |
| 17 | 12005 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM | $714.00 |
| 18 | 12011 | SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< | $1,362.00 |
| 19 | 12013 | SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM | $1,260.00 |
| 20 | 12014 | SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM | $1,260.00 |
| 21 | 12015 | SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM | $1,512.00 |
| 22 | 12032 | REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM | $1,200.00 |
| 23 | 12041 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< | $1,764.00 |
| 24 | 12042 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM | $1,890.00 |
| 25 | 12044 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM | $1,260.00 |
| 26 | 12051 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< | $1,764.00 |
| 27 | 12052 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM | $1,362.00 |
| 28 | 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $1,362.00 |
| 29 | 13152 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM | $1,362.00 |
| 30 | 15850 | REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON | $1,026.00 |
| 31 | 16000 | INITIAL TX 1ST DEGREE BURN LOCAL TX | $1,512.00 |
| 32 | 16020 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL | $1,362.00 |
| 33 | 16030 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE | $1,152.00 |
| 34 | 19000 | PUNCTURE ASPIRATION CYST BREAST | $3,024.00 |
| 35 | 19100 | BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX | $3,024.00 |
| 36 | 20550 | INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS | $1,020.00 |
| 37 | 20551 | INJECTION SINGLE TENDON ORIGIN/INSERTION | $1,020.00 |
| 38 | 20552 | INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES | $1,020.00 |
| 39 | 20553 | INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES | $1,020.00 |
| 40 | 20600 | ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US | $1,200.00 |
| 41 | 20605 | ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US | $1,260.00 |
| 42 | 20610 | ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US | $1,260.00 |
| 43 | 20611 | ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US | $1,152.00 |
| 44 | 20612 | ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ | $540.00 |
| 45 | 23550 | OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC | $1,020.00 |
| 46 | 23650 | CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES | $1,260.00 |
| 47 | 23665 | CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ | $1,512.00 |
| 48 | 24105 | EXCISION OLECRANON BURSA | $1,140.00 |
| 49 | 24640 | CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ | $1,260.00 |
| 50 | 25600 | CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ | $1,152.00 |
| 51 | 25605 | CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF | $1,152.00 |
| 52 | 26010 | DRAINAGE FINGER ABSCESS SIMPLE | $1,260.00 |
| 53 | 26725 | CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA | $1,260.00 |
| 54 | 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $540.00 |
| 55 | 28190 | REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS | $1,512.00 |
| 56 | 28192 | REMOVAL FOREIGN BODY FOOT DEEP | $1,260.00 |
| 57 | 28470 | CLOSED TX METATARSAL FRACTURE W/O MANIPULATION | $2,400.00 |
| 58 | 28490 | CLTX FX GRT TOE PHLX/PHLG W/O MANJ | $1,152.00 |
| 59 | 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $1,098.00 |
| 60 | 29086 | APPLICATION CAST FINGER | $1,062.00 |
| 61 | 29105 | APPLICATION LONG ARM SPLINT SHOULDER HAND | $1,188.00 |
| 62 | 29125 | APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC | $1,014.00 |
| 63 | 29126 | APPLICATION SHORT ARM SPLINT DYNAMIC | $1,079.00 |
| 64 | 29130 | APPLICATION FINGER SPLINT STATIC | $583.00 |
| 65 | 29131 | APPLICATION FINGER SPLINT DYNAMIC | $655.00 |
| 66 | 29240 | STRAPPING SHOULDER | $1,260.00 |
| 67 | 29280 | STRAPPING HAND/FINGER | $1,260.00 |
| 68 | 29450 | APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG | $1,260.00 |
| 69 | 29505 | APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES | $941.00 |
| 70 | 29515 | APPLICATION SHORT LEG SPLINT CALF FOOT | $1,019.00 |
| 71 | 29530 | STRAPPING KNEE | $2,040.00 |
| 72 | 29540 | STRAPPING ANKLE &/FOOT | $1,362.00 |
| 73 | 29550 | STRAPPING TOES | $1,362.00 |
| 74 | 29700 | REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST | $1,260.00 |
| 75 | 30300 | REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE | $1,512.00 |
| 76 | 30901 | CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE | $1,512.00 |
| 77 | 30903 | CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX | $1,200.00 |
| 78 | 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $1,512.00 |
| 79 | 3120F | 12-LEAD ECG PERFORMED | $276.00 |
| 80 | 31541 | LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP | $1,200.00 |
| 81 | 33512 | CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS | $3,024.00 |
| 82 | 36000 | INTRODUCTION NEEDLE/INTRACATHETER VEIN | $204.00 |
| 83 | 36010 | INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA | $684.00 |
| 84 | 36410 | NON-ROUTINE BL DRAW 3/> YRS | $378.00 |
| 85 | 36415 | ROUTINE VENIPUNCTURE | $456.00 |
| 86 | 36416 | COLLECTION CAPILLARY BLOOD SPECIMEN | $684.00 |
| 87 | 36555 | INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y | $900.00 |
| 88 | 36558 | INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> | $1,500.00 |
| 89 | 36569 | INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/> | $1,152.00 |
| 90 | 36572 | INSERTION PICC W/RS&I < 5 YR | $600.00 |
| 91 | 36600 | ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX | $900.00 |
| 92 | 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $2,332.00 |
| 93 | 43753 | GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE | $1,500.00 |
| 94 | 51702 | INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE | $1,260.00 |
| 95 | 51703 | INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED | $1,260.00 |
| 96 | 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $1,260.00 |
| 97 | 58301 | REMOVAL INTRAUTERINE DEVICE IUD | $1,260.00 |
| 98 | 64450 | INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH | $1,362.00 |
| 99 | 64451 | Injection(s), anesthetic agent(s) and/or steroid; | $600.00 |
| 100 | 65205 | REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL | $1,512.00 |
| 101 | 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $1,260.00 |
| 102 | 65220 | RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP | $1,362.00 |
| 103 | 65222 | RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP | $1,512.00 |
| 104 | 65435 | RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION | $1,362.00 |
| 105 | 69200 | RMVL FB XTRNL AUDITORY CANAL W/O ANES | $1,362.00 |
| 106 | 69209 | REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT | $1,362.00 |
| 107 | 69210 | REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT | $1,512.00 |
| 108 | 70030 | RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY | $2,190.00 |
| 109 | 70110 | RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS | $2,538.00 |
| 110 | 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $1,824.00 |
| 111 | 70140 | RADEX FACIAL BONES < 3 VIEWS | $2,394.00 |
| 112 | 70150 | RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS | $2,394.00 |
| 113 | 70160 | RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS | $3,024.00 |
| 114 | 70200 | RADEX ORBITS COMPLETE MINIMUM 4 VIEWS | $3,024.00 |
| 115 | 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $3,024.00 |
| 116 | 70220 | RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS | $3,024.00 |
| 117 | 70250 | RADIOLOGIC EXAMINATION SKULL 4/> VIEWS | $2,724.00 |
| 118 | 70260 | RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS | $2,724.00 |
| 119 | 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $3,024.00 |
| 120 | 70360 | RADIOLOGIC EXAMINATION NECK SOFT TISSUE | $3,024.00 |
| 121 | 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $6,804.00 |
| 122 | 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $6,804.00 |
| 123 | 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $6,804.00 |
| 124 | 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $6,804.00 |
| 125 | 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $6,804.00 |
| 126 | 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $6,804.00 |
| 127 | 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $6,804.00 |
| 128 | 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $6,804.00 |
| 129 | 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $6,048.00 |
| 130 | 70490 | CT SOFT TISSUE NECK W/O CONTRAST MATERIAL | $6,048.00 |
| 131 | 70491 | CT SOFT TISSUE NECK W/CONTRAST MATERIAL | $6,804.00 |
| 132 | 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $6,048.00 |
| 133 | 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $6,048.00 |
| 134 | 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $6,048.00 |
| 135 | 71010 | RADIOLOGIC EXAMINATION CHEST SINGLE VIEW FRONTAL | $2,724.00 |
| 136 | 71020 | RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL | $2,724.00 |
| 137 | 71035 | RADEX CHEST SPECIAL VIEWS | $3,024.00 |
| 138 | 71045 | Radiologic examination, chest ; single view | $2,370.00 |
| 139 | 71046 | Radiologic examination, chest ; 2 views | $3,024.00 |
| 140 | 71047 | Radiologic examination, chest ; 3 views | $3,024.00 |
| 141 | 71048 | (Radiologic examination, chest ; 4 or more | $3,024.00 |
| 142 | 71100 | RADEX RIBS UNILATERAL 2 VIEWS | $2,274.00 |
| 143 | 71101 | RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS | $2,634.00 |
| 144 | 71110 | RADEX RIBS BILATERAL 3 VIEWS | $3,024.00 |
| 145 | 71111 | RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS | $3,024.00 |
| 146 | 71120 | RADEX STERNUM MINIMUM 2 VIEWS | $3,024.00 |
| 147 | 71250 | CT THORAX W/O CONTRAST MATERIAL | $6,804.00 |
| 148 | 71260 | CT THORAX W/CONTRAST MATERIAL | $6,804.00 |
| 149 | 71270 | CT THORAX W/O & W/CONTRAST MATERIAL | $6,804.00 |
| 150 | 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $6,804.00 |
| 151 | 72020 | RADEX SPINE 1 VIEW SPECIFY LEVEL | $3,024.00 |
| 152 | 72040 | RADEX SPINE CERVICAL 2 OR 3 VIEWS | $3,024.00 |
| 153 | 72050 | RADEX SPINE CERVICAL 4 OR 5 VIEWS | $3,025.00 |
| 154 | 72052 | RADEX SPINE CERVICAL 6 OR MORE VIEWS | $3,025.00 |
| 155 | 72070 | RADEX SPINE THORACIC 2 VIEWS | $3,024.00 |
| 156 | 72072 | RADEX SPINE THORACIC 3 VIEWS | $3,024.00 |
| 157 | 72074 | RADEX SPINE THORACIC MINIMUM 4 VIEWS | $3,024.00 |
| 158 | 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $3,024.00 |
| 159 | 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $3,024.00 |
| 160 | 72100 | RADEX SPINE LUMBOSACRAL 2/3 VIEWS | $3,258.00 |
| 161 | 72110 | RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS | $3,571.00 |
| 162 | 72114 | RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 | $3,024.00 |
| 163 | 72120 | RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS | $3,024.00 |
| 164 | 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $6,804.00 |
| 165 | 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $6,048.00 |
| 166 | 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $6,930.00 |
| 167 | 72128 | CT THORACIC SPINE W/O CONTRAST MATERIAL | $6,804.00 |
| 168 | 72129 | CT THORACIC SPINE W/CONTRAST MATERIAL | $6,048.00 |
| 169 | 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $6,804.00 |
| 170 | 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $6,804.00 |
| 171 | 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $6,804.00 |
| 172 | 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $6,804.00 |
| 173 | 72170 | RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS | $2,111.00 |
| 174 | 72190 | RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS | $2,214.00 |
| 175 | 72192 | CT PELVIS W/O CONTRAST MATERIAL | $6,804.00 |
| 176 | 72193 | CT PELVIS W/CONTRAST MATERIAL | $6,827.00 |
| 177 | 72220 | RADEX SACRUM & COCCYX MINIMUM 2 VIEWS | $3,024.00 |
| 178 | 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $3,024.00 |
| 179 | 73000 | RADEX CLAVICLE COMPLETE | $3,024.00 |
| 180 | 73010 | RADEX SCAPULA COMPLETE | $3,024.00 |
| 181 | 73020 | RADEX SHOULDER 1 VIEW | $2,279.00 |
| 182 | 73030 | RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS | $3,235.00 |
| 183 | 73050 | RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ | $3,024.00 |
| 184 | 73060 | RADEX HUMERUS MINIMUM 2 VIEWS | $3,024.00 |
| 185 | 73070 | RADEX ELBOW 2 VIEWS | $3,024.00 |
| 186 | 73080 | RADEX ELBOW COMPLETE MINIMUM 3 VIEWS | $3,024.00 |
| 187 | 73090 | RADEX FOREARM 2 VIEWS | $3,024.00 |
| 188 | 73100 | RADEX WRIST 2 VIEWS | $3,024.00 |
| 189 | 73110 | RADEX WRIST COMPLETE MINIMUM 3 VIEWS | $3,164.00 |
| 190 | 73120 | RADEX HAND 2 VIEWS | $2,584.00 |
| 191 | 73130 | RADEX HAND MINIMUM 3 VIEWS | $3,024.00 |
| 192 | 73140 | RADEX FINGR MINIMUM 2 VIEWS | $2,274.00 |
| 193 | 73200 | CT UPPER EXTREMITY W/O CONTRAST MATERIAL | $6,804.00 |
| 194 | 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $6,804.00 |
| 195 | 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $6,804.00 |
| 196 | 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $2,100.00 |
| 197 | 73502 | RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS | $3,024.00 |
| 198 | 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $3,024.00 |
| 199 | 73510 | X-RAY HIP UNILATERAL 2 VIEWS | $2,154.00 |
| 200 | 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $3,024.00 |
| 201 | 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $1,320.00 |
| 202 | 73552 | RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS | $2,382.00 |
| 203 | 73560 | RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS | $2,016.00 |
| 204 | 73562 | RADIOLOGIC EXAMINATION KNEE 3 VIEWS | $3,300.00 |
| 205 | 73564 | RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS | $3,024.00 |
| 206 | 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $3,024.00 |
| 207 | 73590 | RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS | $3,024.00 |
| 208 | 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $3,024.00 |
| 209 | 73600 | RADIOLOGIC EXAMINATION ANKLE 2 VIEWS | $3,024.00 |
| 210 | 73610 | RADEX ANKLE COMPLETE MINIMUM 3 VIEWS | $3,024.00 |
| 211 | 73620 | RADIOLOGIC EXAMINATION FOOT 2 VIEWS | $2,538.00 |
| 212 | 73630 | RADEX FOOT COMPLETE MINIMUM 3 VIEWS | $2,700.00 |
| 213 | 73650 | RADEX CALCANEUS MINIMUM 2 VIEWS | $3,024.00 |
| 214 | 73660 | RADEX TOE MINIMUM 2 VIEWS | $1,760.00 |
| 215 | 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $8,004.00 |
| 216 | 73701 | CT LOWER EXTREMITY W/CONTRAST MATERIAL | $7,770.00 |
| 217 | 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $7,814.00 |
| 218 | 74000 | RADEX ABDOMEN 1 ANTEROPOSTERIOR VIEW | $3,024.00 |
| 219 | 74018 | Radiologic examination, abdomen; 1 view | $2,142.00 |
| 220 | 74019 | Radiologic examination, abdomen; 2 views | $2,058.00 |
| 221 | 74020 | RADEX ABDOMEN COMPL W/DCBTS&/ERC VIEWS | $3,024.00 |
| 222 | 74021 | Radiologic examination, abdomen; 3 or more views | $2,389.00 |
| 223 | 74022 | RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH | $2,275.00 |
| 224 | 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $7,177.00 |
| 225 | 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $7,177.00 |
| 226 | 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $6,804.00 |
| 227 | 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $7,170.00 |
| 228 | 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $6,804.00 |
| 229 | 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $6,804.00 |
| 230 | 74178 | CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE | $6,810.00 |
| 231 | 74190 | PERITONEOGRAM RS&I | $3,024.00 |
| 232 | 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $3,024.00 |
| 233 | 74241 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB | $3,024.00 |
| 234 | 74245 | RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES | $3,024.00 |
| 235 | 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $3,024.00 |
| 236 | 74251 | RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE | $3,024.00 |
| 237 | 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $4,282.00 |
| 238 | 74329 | ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I | $3,024.00 |
| 239 | 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $3,286.00 |
| 240 | 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $1,500.00 |
| 241 | 74440 | VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I | $3,024.00 |
| 242 | 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $6,804.00 |
| 243 | 76536 | US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM | $3,024.00 |
| 244 | 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $2,724.00 |
| 245 | 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,884.00 |
| 246 | 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $1,194.00 |
| 247 | 76700 | US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION | $3,224.00 |
| 248 | 76705 | US ABDOMINAL REAL TIME W/IMAGE LIMITED | $4,003.00 |
| 249 | 76770 | US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE | $2,153.00 |
| 250 | 76775 | US RETROPERITONEAL REAL TIME W/IMAGE LIMITED | $3,024.00 |
| 251 | 76801 | US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT | $2,724.00 |
| 252 | 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $1,170.00 |
| 253 | 76805 | US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION | $3,024.00 |
| 254 | 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $3,024.00 |
| 255 | 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $1,854.00 |
| 256 | 76817 | US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG | $3,024.00 |
| 257 | 76830 | US TRANSVAGINAL | $3,208.00 |
| 258 | 76856 | US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE | $3,024.00 |
| 259 | 76857 | US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U | $2,724.00 |
| 260 | 76870 | US SCROTUM & CONTENTS | $3,654.00 |
| 261 | 76881 | US EXTREMITY NON-VASC REAL-TIME IMG COMPL | $3,024.00 |
| 262 | 76882 | US EXTREMITY NON-VASC REAL-TIME IMG LMTD | $1,380.00 |
| 263 | 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $1,554.00 |
| 264 | 80048 | BASIC METABOLIC PANEL CALCIUM TOTAL | $1,430.00 |
| 265 | 80051 | ELECTROLYTE PANEL | $540.00 |
| 266 | 80053 | COMPREHENSIVE METABOLIC PANEL | $1,794.00 |
| 267 | 80061 | LIPID PANEL | $1,512.00 |
| 268 | 80074 | ACUTE HEPATITIS PANEL | $1,440.00 |
| 269 | 80076 | HEPATIC FUNCTION PANEL | $1,458.00 |
| 270 | 80102 | Drug confirmation, each procedure | $276.00 |
| 271 | 80299 | QUANTITATION DRUG NOT ELSEWHERE SPECIFIED | $1,020.00 |
| 272 | 80305 | DRUG TEST PRSMV QUAL DIR OPTICAL OBS PER DAY | $493.00 |
| 273 | 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $756.00 |
| 274 | 80320 | DRUG SCREEN QUANTITATIVE ALCOHOLS | $684.00 |
| 275 | 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $756.00 |
| 276 | 80329 | DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2 | $684.00 |
| 277 | 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $276.00 |
| 278 | 80345 | DRUG SCREENING BARBITURATES | $756.00 |
| 279 | 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $756.00 |
| 280 | 80347 | DRUG SCREENING BENZODIAZEPINES 13 OR MORE | $630.00 |
| 281 | 80348 | DRUG SCREENING BUPRENORPHINE | $630.00 |
| 282 | 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $480.00 |
| 283 | 80351 | DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 | $756.00 |
| 284 | 80352 | DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE | $204.00 |
| 285 | 80353 | DRUG SCREENING COCAINE | $756.00 |
| 286 | 80356 | DRUG SCREENING HEROIN METABOLITE | $138.00 |
| 287 | 80358 | DRUG SCREENING METHADONE | $756.00 |
| 288 | 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $756.00 |
| 289 | 80361 | DRUG SCREENING OPIATES 1 OR MORE | $756.00 |
| 290 | 80362 | DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 | $684.00 |
| 291 | 80365 | DRUG SCREENING OXYCODONE | $756.00 |
| 292 | 80366 | DRUG SCREENING PREGABALIN | $342.00 |
| 293 | 80367 | DRUG SCREENING PROPOXYPHENE | $276.00 |
| 294 | 80373 | DRUG SCREENING TRAMADOL | $684.00 |
| 295 | 80374 | DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS | $684.00 |
| 296 | 81000 | URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY | $510.00 |
| 297 | 81001 | URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY | $690.00 |
| 298 | 81002 | URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP | $300.00 |
| 299 | 81003 | URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY | $545.00 |
| 300 | 81025 | URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS | $684.00 |
| 301 | 82010 | KETONE BODIES SERUM QUANTITATIVE | $382.00 |
| 302 | 82040 | ALBUMIN SERUM PLASMA/WHOLE BLOOD | $204.00 |
| 303 | 82075 | ASSAY OF ALCOHOL BREATH | $600.00 |
| 304 | 82140 | ASSAY OF AMMONIA | $1,020.00 |
| 305 | 82150 | ASSAY OF AMYLASE | $572.00 |
| 306 | 82247 | BILIRUBIN TOTAL | $366.00 |
| 307 | 82248 | BILIRUBIN DIRECT | $450.00 |
| 308 | 82270 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER | $1,512.00 |
| 309 | 82272 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC | $1,512.00 |
| 310 | 82310 | CALCIUM TOTAL | $504.00 |
| 311 | 82330 | CALCIUM IONIZED | $504.00 |
| 312 | 82374 | CARBON DIOXIDE BICARBONATE | $360.00 |
| 313 | 82435 | CHLORIDE BLD | $300.00 |
| 314 | 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $540.00 |
| 315 | 82533 | CORTISOL TOTAL | $408.00 |
| 316 | 82550 | CREATINE KINASE TOTAL | $468.00 |
| 317 | 82553 | CREATINE KINASE MB FRACTION ONLY | $780.00 |
| 318 | 82565 | CREATININE BLOOD | $468.00 |
| 319 | 82668 | ASSAY OF ERYTHROPOIETIN | $780.00 |
| 320 | 82728 | ASSAY OF FERRITIN | $660.00 |
| 321 | 82747 | ASSAY OF FOLIC ACID RBC | $358.00 |
| 322 | 82784 | ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH | $810.00 |
| 323 | 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $649.00 |
| 324 | 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $474.00 |
| 325 | 82947 | GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP | $276.00 |
| 326 | 82948 | GLUCOSE BLOOD REAGENT STRIP | $684.00 |
| 327 | 82962 | GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE | $276.00 |
| 328 | 82977 | ASSAY OF GLUTAMYLTRASE GAMMA | $600.00 |
| 329 | 83009 | HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE | $606.00 |
| 330 | 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $684.00 |
| 331 | 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $330.00 |
| 332 | 83525 | ASSAY OF INSULIN TOTAL | $342.00 |
| 333 | 83605 | ASSAY OF LACTATE | $570.00 |
| 334 | 83615 | LACTATE DEHYDROGENASE LDH | $600.00 |
| 335 | 83690 | ASSAY OF LIPASE | $556.00 |
| 336 | 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $420.00 |
| 337 | 83735 | ASSAY OF MAGNESIUM | $600.00 |
| 338 | 83835 | METANEPHRINES | $780.00 |
| 339 | 83874 | MYOGLOBIN | $780.00 |
| 340 | 83880 | NATRIURETIC PEPTIDE | $1,056.00 |
| 341 | 83992 | ASSAY OF PHENCYCLIDINE | $540.00 |
| 342 | 84075 | ASSAY OF PHOSPHATASE ALKALINE | $306.00 |
| 343 | 84100 | ASSAY OF PHOSPHORUS INORGANIC | $292.00 |
| 344 | 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $300.00 |
| 345 | 84145 | PROCALCITONIN (PCT) | $1,020.00 |
| 346 | 84155 | PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD | $347.00 |
| 347 | 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $425.00 |
| 348 | 84295 | SODIUM SERUM PLASMA OR WHOLE BLOOD | $240.00 |
| 349 | 84436 | ASSAY OF THYROXINE TOTAL | $438.00 |
| 350 | 84439 | ASSAY OF FREE THYROXINE | $538.00 |
| 351 | 84443 | ASSAY OF THYROID STIMULATING HORMONE TSH | $774.00 |
| 352 | 84450 | TRANSFERASE ASPARTATE AMINO AST SGOT | $356.00 |
| 353 | 84460 | TRANSFERASE ALANINE AMINO ALT SGPT | $300.00 |
| 354 | 84478 | ASSAY OF TRIGLYCERIDES | $858.00 |
| 355 | 84479 | THYROID HORM UPTK/THYROID HORMONE BINDING RATIO | $402.00 |
| 356 | 84480 | ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3 | $684.00 |
| 357 | 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $570.00 |
| 358 | 84484 | ASSAY OF TROPONIN QUANTITATIVE | $1,055.00 |
| 359 | 84512 | ASSAY OF TROPONIN QUALITATIVE | $408.00 |
| 360 | 84520 | ASSAY OF UREA NITROGEN QUANTITATIVE | $431.00 |
| 361 | 84550 | ASSAY OF BLOOD/URIC ACID | $684.00 |
| 362 | 84702 | GONADOTROPIN CHORIONIC QUANTITATIVE | $1,176.00 |
| 363 | 84703 | GONADOTROPIN CHORIONIC QUALITATIVE | $1,020.00 |
| 364 | 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $1,512.00 |
| 365 | 85027 | BLOOD COUNT COMPLETE AUTOMATED | $408.00 |
| 366 | 85379 | FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE | $1,050.00 |
| 367 | 85610 | PROTHROMBIN TIME | $934.00 |
| 368 | 85651 | SEDIMENTATION RATE RBC NON-AUTOMATED | $684.00 |
| 369 | 85652 | SEDIMENTATION RATE RBC AUTOMATED | $168.00 |
| 370 | 85730 | THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD | $359.00 |
| 371 | 86038 | ANTINUCLEAR ANTIBODIES ANA | $411.00 |
| 372 | 86039 | ANTINUCLEAR ANTIBODIES ANA TITER | $521.00 |
| 373 | 86060 | ANTISTREPTOLYSIN O TITER | $186.00 |
| 374 | 86140 | C-REACTIVE PROTEIN | $504.00 |
| 375 | 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $684.00 |
| 376 | 86308 | HETEROPHILE ANTIBODIES SCREEN | $524.00 |
| 377 | 86328 | IA INFECTIOUS AGT ANTIBODY SARS-COV-2 COVID-19 | $360.00 |
| 378 | 86431 | RHEUMATOID FACTOR QUANTITATIVE | $307.00 |
| 379 | 86592 | SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL | $384.00 |
| 380 | 86593 | SYPHILIS TEST QUANTITATIVE | $756.00 |
| 381 | 86677 | ANTIBODY HELICOBACTER PYLORI | $684.00 |
| 382 | 86689 | ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST | $465.00 |
| 383 | 86695 | ANTIBODY HERPES SMPLX TYPE 1 | $408.00 |
| 384 | 86696 | ANTIBODY HERPES SMPLX TYPE 2 | $480.00 |
| 385 | 86701 | ANTIBODY HIV-1 | $480.00 |
| 386 | 86735 | ANTIBODY MUMPS | $720.00 |
| 387 | 86757 | ANTIBODY RICKETTSIA | $1,020.00 |
| 388 | 86762 | ANTIBODY RUBELLA | $480.00 |
| 389 | 86765 | ANTIBODY RUBEOLA | $600.00 |
| 390 | 86769 | SARS-COV-2 COVID-19 ANTIBODY | $1,020.00 |
| 391 | 86787 | ANTIBODY VARICELLA-ZOSTER | $300.00 |
| 392 | 86900 | BLOOD TYPING SEROLOGIC ABO | $1,020.00 |
| 393 | 86901 | BLOOD TYPING SEROLOGIC RH (D) | $1,020.00 |
| 394 | 87015 | CONCENTRATION INFECTIOUS AGENTS | $344.00 |
| 395 | 87040 | CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES | $463.00 |
| 396 | 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $953.00 |
| 397 | 87070 | CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL | $612.00 |
| 398 | 87071 | CUL BACT QUAN AEROBIC ISOL XCPT UR BLOOD/STOOL | $1,020.00 |
| 399 | 87075 | CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID | $684.00 |
| 400 | 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $516.00 |
| 401 | 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $684.00 |
| 402 | 87081 | CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ | $684.00 |
| 403 | 87086 | CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE | $465.00 |
| 404 | 87088 | CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE | $344.00 |
| 405 | 87106 | CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST | $1,020.00 |
| 406 | 87184 | SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD | $780.00 |
| 407 | 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $420.00 |
| 408 | 87210 | SMR PRIM SRC WET MOUNT NFCT AGT | $1,020.00 |
| 409 | 87230 | TOXIN/ANTITOXIN ASSAY TISSUE CULTURE | $1,140.00 |
| 410 | 87255 | VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC | $480.00 |
| 411 | 87338 | IAAD IA HPYLORI STOOL | $756.00 |
| 412 | 87389 | IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE | $720.00 |
| 413 | 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $570.00 |
| 414 | 87426 | SARSCOV CORONAVIRUS AG IA | $360.00 |
| 415 | 87428 | IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B | $480.00 |
| 416 | 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $480.00 |
| 417 | 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $756.00 |
| 418 | 87493 | INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE | $1,020.00 |
| 419 | 87529 | IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ | $1,020.00 |
| 420 | 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $360.00 |
| 421 | 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $408.00 |
| 422 | 87631 | IADNA RESPIRATRY PROBE & REV TRNSCR 3-5 TARGETS | $660.00 |
| 423 | 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $720.00 |
| 424 | 87635 | SARS-COV-2 COVID-19 AMP PRB | $600.00 |
| 425 | 87637 | SARSCOV2&INF A&B&RSV AMP PRB | $600.00 |
| 426 | 87640 | IADNA S AUREUS AMPLIFIED PROBE TQ | $1,200.00 |
| 427 | 87651 | IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ | $480.00 |
| 428 | 87653 | IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ | $480.00 |
| 429 | 87660 | IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ | $780.00 |
| 430 | 87661 | Infectious agent detection by nucleic acid (DNA or RNA) | $480.00 |
| 431 | 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $480.00 |
| 432 | 87799 | IADNA NOS QUANTIFICATION EACH ORGANISM | $720.00 |
| 433 | 87801 | Infectious agent detection by nucleic acid (DNA or RNA) | $480.00 |
| 434 | 87804 | IAADIADOO INFLUENZA | $575.00 |
| 435 | 87806 | IAADIADOO HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES | $1,260.00 |
| 436 | 87807 | IAADIADOO RESPIRATORY SYNCTIAL VIRUS | $756.00 |
| 437 | 87880 | IAADIADOO STREPTOCOCCUS GROUP A | $1,038.00 |
| 438 | 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $497.00 |
| 439 | 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $684.00 |
| 440 | 89240 | UNLIS MISC | $246.00 |
| 441 | 90471 | IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE | $303.00 |
| 442 | 90472 | IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE | $420.00 |
| 443 | 90714 | TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE | $806.00 |
| 444 | 90715 | TDAP VACCINE 7 YRS/> IM | $756.00 |
| 445 | 93000 | ECG ROUTINE ECG W/LEAST 12 LDS W/I&R | $756.00 |
| 446 | 93005 | ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R | $960.00 |
| 447 | 93010 | ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY | $240.00 |
| 448 | 93040 | RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT | $960.00 |
| 449 | 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $756.00 |
| 450 | 93224 | XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I | $1,212.00 |
| 451 | 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $2,880.00 |
| 452 | 93631 | INTRAOP EPICAR& ENDOCAR PACG& MAPG | $912.00 |
| 453 | 93880 | DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY | $2,461.00 |
| 454 | 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $2,921.00 |
| 455 | 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $3,024.00 |
| 456 | 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $3,570.00 |
| 457 | 93926 | DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,724.00 |
| 458 | 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $3,280.00 |
| 459 | 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,976.00 |
| 460 | 93970 | DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY | $3,455.00 |
| 461 | 93971 | DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY | $3,024.00 |
| 462 | 93975 | DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM | $3,815.00 |
| 463 | 93980 | DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL | $2,080.00 |
| 464 | 94640 | PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT | $347.00 |
| 465 | 94760 | NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER | $457.00 |
| 466 | 94761 | NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER | $408.00 |
| 467 | 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $684.00 |
| 468 | 96360 | IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR | $1,512.00 |
| 469 | 96361 | IV INFUSION HYDRATION EACH ADDITIONAL HOUR | $714.00 |
| 470 | 96365 | IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | $1,512.00 |
| 471 | 96366 | IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR | $937.00 |
| 472 | 96367 | IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR | $1,247.00 |
| 473 | 96368 | IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS | $960.00 |
| 474 | 96372 | THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM | $1,512.00 |
| 475 | 96374 | THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG | $1,236.00 |
| 476 | 96375 | THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG | $847.00 |
| 477 | 96376 | THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC | $853.00 |
| 478 | 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $960.00 |
| 479 | 97010 | APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS | $171.00 |
| 480 | 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR | $780.00 |
| 481 | 97542 | WHEELCHAIR MGMT EA 15 MIN | $615.00 |
| 482 | 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $1,195.00 |
| 483 | 98925 | OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS | $240.00 |
| 484 | 99000 | HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB | $1,020.00 |
| 485 | 99024 | POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX | $912.00 |
| 486 | 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $300.00 |
| 487 | 99072 | “Miscellaneous Medicine Services | |
| “ | $150.00 | ||
| 488 | 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $630.00 |
| 489 | 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $1,500.00 |
| 490 | 99173 | SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT | $1,812.00 |
| 491 | 99217 | OBSERVATION CARE DISCHARGE MANAGEMENT | $1,434.00 |
| 492 | 99218 | INITIAL OBSERVATION CARE/DAY 30 MINUTES | $1,500.00 |
| 493 | 99219 | INITIAL OBSERVATION CARE/DAY 50 MINUTES | $1,710.00 |
| 494 | 99220 | INITIAL OBSERVATION CARE/DAY 70 MINUTES | $1,950.00 |
| 495 | 99224 | SBSQ OBSERVATION CARE/DAY 15 MINUTES | $1,500.00 |
| 496 | 99225 | SBSQ OBSERVATION CARE/DAY 25 MINUTES | $1,710.00 |
| 497 | 99226 | SBSQ OBSERVATION CARE/DAY 35 MINUTES | $1,950.00 |
| 498 | 99234 | OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES | $1,560.00 |
| 499 | 99235 | OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES | $1,800.00 |
| 500 | 99236 | OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES | $2,160.00 |
| 501 | 99281 | EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB | $1,199.00 |
| 502 | 99282 | EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY | $2,400.00 |
| 503 | 99283 | EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY | $5,040.00 |
| 504 | 99283CP | EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY | $2,400.00 |
| 505 | 99284 | EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY | $5,400.00 |
| 506 | 99285 | EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ | $6,000.00 |
| 507 | 99291 | CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN | $2,400.00 |
| 508 | 99292 | CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN | $1,200.00 |
| 509 | A0382 | BASIC SUPPORT ROUTINE SUPPLS | $83.00 |
| 510 | A0394 | ALS IV DRUG THERAPY SUPPLIES | $83.00 |
| 511 | A4206 | 1 CC STERILE SYRINGE&NEEDLE | $138.00 |
| 512 | A4207 | 2 CC STERILE SYRINGE&NEEDLE | $99.00 |
| 513 | A4208 | STERILE SYRINGE&NEEDLE | $138.00 |
| 514 | A4209 | FIVE PLUS CC STERILE SYRINGE&NEEDLE | $138.00 |
| 515 | A4210 | NONNEEDLE INJECTION DEVICE | $138.00 |
| 516 | A4211 | SUPP FOR SELF-ADM INJECTIONS | $99.00 |
| 517 | A4212 | NON CORING NEEDLE OR STYLET | $138.00 |
| 518 | A4213 | 20+ CC SYRINGE ONLY | $138.00 |
| 519 | A4215 | STERILE NEEDLE | $138.00 |
| 520 | A4216 | STERILE WATER/SALINE, 10 ML | $138.00 |
| 521 | A4217 | STERILE WATER/SALINE, 500 ML | $99.00 |
| 522 | A4218 | STERILE SALINE OR WATER | $138.00 |
| 523 | A4221 | SUPP NON-INSULIN INF CATH/WK | $138.00 |
| 524 | A4224 | SUPPLY INSULIN INF CATH/WK | $138.00 |
| 525 | A4232 | SYRINGE W/NEEDLE INSULIN 3CC | $99.00 |
| 526 | A4244 | ALCOHOL OR PEROXIDE PER PINT | $138.00 |
| 527 | A4245 | ALCOHOL WIPES PER BOX | $138.00 |
| 528 | A4246 | BETADINE/PHISOHEX SOLUTION | $138.00 |
| 529 | A4247 | BETADINE/IODINE SWABS/WIPES | $83.00 |
| 530 | A4248 | CHLORHEXIDINE ANTISEPT | $138.00 |
| 531 | A4250 | URINE REAGENT STRIPS/TABLETS | $138.00 |
| 532 | A4253 | BLOOD GLUCOSE/REAGENT STRIPS | $83.00 |
| 533 | A4281 | REPLACEMENT BREASTPUMP TUBE | $138.00 |
| 534 | A4283 | REPLACEMENT BREASTPUMP CAP | $138.00 |
| 535 | A4300 | CATH IMPL VASC ACCESS PORTAL | $99.00 |
| 536 | A4310 | INSERT TRAY W/O BAG/CATH | $138.00 |
| 537 | A4311 | CATHETER W/O BAG 2-WAY LATEX | $138.00 |
| 538 | A4313 | CATHETER W/BAG 3-WAY | $138.00 |
| 539 | A4314 | CATH W/DRAINAGE 2-WAY LATEX | $138.00 |
| 540 | A4315 | CATH W/DRAINAGE 2-WAY SILCNE | $99.00 |
| 541 | A4322 | IRRIGATION SYRINGE | $127.00 |
| 542 | A4327 | FEM URINARY COLLECT DEV CUP | $138.00 |
| 543 | A4332 | LUBE STERILE PACKET | $83.00 |
| 544 | A4338 | INDWELLING CATHETER LATEX | $127.00 |
| 545 | A4352 | COUDE TIP URINARY CATHETER | $99.00 |
| 546 | A4353 | INTERMITTENT URINARY CATH | $138.00 |
| 547 | A4358 | URINARY LEG OR ABDOMEN BAG | $138.00 |
| 548 | A4369 | SKIN BARRIER LIQUID PER OZ | $138.00 |
| 549 | A4402 | LUBRICANT PER OUNCE | $99.00 |
| 550 | A4406 | PECTIN BASED OSTOMY PASTE | $99.00 |
| 551 | A4450 | NON-WATERPROOF TAPE | $138.00 |
| 552 | A4452 | WATERPROOF TAPE | $138.00 |
| 553 | A4458 | REUSABLE ENEMA BAG | $127.00 |
| 554 | A4461 | SURGICL DRESS HOLD NON-REUSE | $138.00 |
| 555 | A4465 | NON-ELASTIC EXTREMITY BINDER | $99.00 |
| 556 | A4470 | GRAVLEE JET WASHER | $83.00 |
| 557 | A4550 | SURGICAL TRAYS | $138.00 |
| 558 | A4554 | DISPOSABLE UNDERPADS | $83.00 |
| 559 | A4556 | ELECTRODES, PAIR | $138.00 |
| 560 | A4558 | CONDUCTIVE GEL OR PASTE | $127.00 |
| 561 | A4562 | PESSARY, NON RUBBER,ANY TYPE | $99.00 |
| 562 | A4565 | SLINGS | $138.00 |
| 563 | A4566 | SHOULD SLING/VEST/ABRESTRAIN | $99.00 |
| 564 | A4570 | SPLINT | $413.00 |
| 565 | A4580 | CAST SUPPLIES (PLASTER) | $127.00 |
| 566 | A4606 | OXYGEN PROBE USED W OXIMETER | $138.00 |
| 567 | A4613 | BATTERY CHARGER | $138.00 |
| 568 | A4615 | CANNULA NASAL | $138.00 |
| 569 | A4616 | TUBING (OXYGEN) PER FOOT | $99.00 |
| 570 | A4619 | FACE TENT | $138.00 |
| 571 | A4620 | VARIABLE CONCENTRATION MASK | $138.00 |
| 572 | A4628 | OROPHARYNGEAL SUCTION CATH | $138.00 |
| 573 | A4629 | TRACHEOSTOMY CARE KIT | $83.00 |
| 574 | A4635 | UNDERARM CRUTCH PAD | $550.00 |
| 575 | A4649 | SURGICAL SUPPLIES | $138.00 |
| 576 | A4653 | PD CATHETER ANCHOR BELT | $83.00 |
| 577 | A4657 | SYRINGE W/WO NEEDLE | $138.00 |
| 578 | A4670 | AUTOMATIC BP MONITOR, DIAL | $138.00 |
| 579 | A4673 | EXT LINE W EASY LOCK CONNECT | $138.00 |
| 580 | A4750 | ART OR VENOUS BLOOD TUBING | $83.00 |
| 581 | A4770 | BLOOD COLLECTION TUBE/VACUUM | $138.00 |
| 582 | A4927 | NON-STERILE GLOVES | $50.00 |
| 583 | A4930 | STERILE, GLOVES PER PAIR | $50.00 |
| 584 | A5112 | URINARY LEG BAG | $138.00 |
| 585 | A5120 | SKIN BARRIER, WIPE OR SWAB | $138.00 |
| 586 | A5126 | DISK/FOAM PAD +OR- ADHESIVE | $138.00 |
| 587 | A6021 | COLLAGEN DRESSING <=16 SQ IN | $127.00 |
| 588 | A6196 | ALGINATE DRESSING <=16 SQ IN | $138.00 |
| 589 | A6203 | COMPOSITE DRSG <= 16 SQ IN | $138.00 |
| 590 | A6208 | CONTACT LAYER > 48 SQ IN | $138.00 |
| 591 | A6209 | FOAM DRSG <=16 SQ IN W/O BDR | $138.00 |
| 592 | A6212 | FOAM DRG <=16 SQ IN W/BORDER | $99.00 |
| 593 | A6216 | NON-STERILE GAUZE<=16 SQ IN | $138.00 |
| 594 | A6217 | NON-STERILE GAUZE>16<=48 SQ | $138.00 |
| 595 | A6218 | NON-STERILE GAUZE > 48 SQ IN | $99.00 |
| 596 | A6219 | GAUZE <= 16 SQ IN W/BORDER | $99.00 |
| 597 | A6220 | GAUZE >16 <=48 SQ IN W/BORDR | $99.00 |
| 598 | A6221 | GAUZE > 48 SQ IN W/BORDER | $83.00 |
| 599 | A6222 | GAUZE <=16 IN NO W/SAL W/O B | $99.00 |
| 600 | A6223 | GAUZE >16<=48 NO W/SAL W/O B | $83.00 |
| 601 | A6224 | GAUZE > 48 IN NO W/SAL W/O B | $138.00 |
| 602 | A6231 | HYDROGEL DSG<=16 SQ IN | $138.00 |
| 603 | A6233 | HYDROGEL DRESSING >48 SQ IN | $138.00 |
| 604 | A6235 | HYDROCOLLD DRG >16<=48 W/O B | $83.00 |
| 605 | A6238 | HYDROCOLLD DRG >16<=48 W/BDR | $83.00 |
| 606 | A6239 | HYDROCOLLD DRG > 48 IN W/BDR | $99.00 |
| 607 | A6246 | HYDROGEL DRG >16<=48 IN W/B | $138.00 |
| 608 | A6248 | HYDROGEL DRSG GEL FILLER | $138.00 |
| 609 | A6250 | SKIN SEAL PROTECT MOISTURIZR | $138.00 |
| 610 | A6251 | ABSORPT DRG <=16 SQ IN W/O B | $138.00 |
| 611 | A6252 | ABSORPT DRG >16 <=48 W/O BDR | $138.00 |
| 612 | A6253 | ABSORPT DRG > 48 SQ IN W/O B | $138.00 |
| 613 | A6254 | ABSORPT DRG <=16 SQ IN W/BDR | $138.00 |
| 614 | A6255 | ABSORPT DRG >16<=48 IN W/BDR | $99.00 |
| 615 | A6257 | TRANSPARENT FILM <= 16 SQ IN | $138.00 |
| 616 | A6258 | TRANSPARENT FILM >16<=48 IN | $138.00 |
| 617 | A6260 | WOUND CLEANSER ANY TYPE/SIZE | $138.00 |
| 618 | A6266 | IMPREG GAUZE NO H20/SAL/YARD | $138.00 |
| 619 | A6402 | MEDICAL/SURGICAL SUPPLIES AND DEVICES (ALSO SEE 062X AN EXTENSION OF STE | $138.00 |
| 620 | A6403 | STERILE GAUZE>16 <= 48 SQ IN | $99.00 |
| 621 | A6404 | STERILE GAUZE > 48 SQ IN | $138.00 |
| 622 | A6407 | PACKING STRIPS, NON-IMPREG | $99.00 |
| 623 | A6412 | OCCLUSIVE EYE PATCH | $83.00 |
| 624 | A6413 | ADHESIVE BANDAGE, FIRST-AID | $138.00 |
| 625 | A6441 | PAD BAND W>=3 <5/YD | $99.00 |
| 626 | A6442 | CONFORM BAND N/S W<3/YD | $127.00 |
| 627 | A6445 | CONFORM BAND S W <3/YD | $138.00 |
| 628 | A6446 | CONFORM BAND S W>=3 <5/YD | $138.00 |
| 629 | A6447 | CONFORM BAND S W >=5/YD | $83.00 |
| 630 | A6448 | LT COMPRES BAND <3/YD | $138.00 |
| 631 | A6449 | LT COMPRES BAND >=3 <5/YD | $127.00 |
| 632 | A6450 | LT COMPRES BAND >=5/YD | $99.00 |
| 633 | A6453 | SELF-ADHER BAND W <3/YD | $138.00 |
| 634 | A6454 | SELF-ADHER BAND W>=3 <5/YD | $99.00 |
| 635 | A6455 | SELF-ADHER BAND >=5/YD | $138.00 |
| 636 | A6456 | ZINC PASTE BAND W >=3<5/YD | $138.00 |
| 637 | A6457 | TUBULAR DRESSING | $150.00 |
| 638 | A6530 | COMPRESSION STOCKING BK18-30 | $90.00 |
| 639 | A6545 | GRAD COMP NON-ELASTIC BK | $108.00 |
| 640 | A7000 | DISPOSABLE CANISTER FOR PUMP | $150.00 |
| 641 | A7001 | NONDISPOSABLE PUMP CANISTER | $150.00 |
| 642 | A7002 | TUBING USED W SUCTION PUMP | $150.00 |
| 643 | A7003 | NEBULIZER ADMINISTRATION SET | $150.00 |
| 644 | A7004 | DISPOSABLE NEBULIZER SML VOL | $150.00 |
| 645 | A7005 | NONDISPOSABLE NEBULIZER SET | $150.00 |
| 646 | A7006 | FILTERED NEBULIZER ADMIN SET | $90.00 |
| 647 | A7015 | AEROSOL MASK USED W NEBULIZE | $108.00 |
| 648 | A7030 | CPAP FULL FACE MASK | $108.00 |
| 649 | A7031 | REPLACEMENT FACEMASK INTERFA | $150.00 |
| 650 | A7046 | REPL WATER CHAMBER, PAP DEV | $150.00 |
| 651 | A7047 | RESP SUCTION ORAL INTERFACE | $150.00 |
| 652 | A9150 | MISC/EXPER NON-PRESCRIPT DRU | $90.00 |
| 653 | A9270 | NON-COVERED ITEM OR SERVICE | $108.00 |
| 654 | A9273 | HOT/COLD H2OBOT/CAP/COL/WRAP | $150.00 |
| 655 | A9281 | REACHING/GRABBING DEVICE | $150.00 |
| 656 | B4082 | ENTERAL NG TUBING W/O STYLET | $300.00 |
| 657 | C1722 | AICD, SINGLE CHAMBER | $2,580.00 |
| 658 | C1751 | CATH, INF, PER/CENT/MIDLINE | $2,544.00 |
| 659 | C1781 | MESH (IMPLANTABLE) | $1,849.00 |
| 660 | C2618 | PROBE/NEEDLE, CRYO | $408.00 |
| 661 | C9285 | PATCH, LIDOCAINE/TETRACAINE | $102.00 |
| 662 | E0110 | CRUTCH FOREARM PAIR | $840.00 |
| 663 | E0114 | CRUTCH UNDERARM PAIR NO WOOD | $955.00 |
| 664 | E0116 | CRUTCH UNDERARM EACH NO WOOD | $720.00 |
| 665 | E0168 | HEAVYDUTY/WIDE COMMODE CHAIR | $456.00 |
| 666 | E0240 | BATH/SHOWER CHAIR | $138.00 |
| 667 | E0275 | BED PAN STANDARD | $276.00 |
| 668 | E0325 | URINAL MALE JUG-TYPE | $174.00 |
| 669 | E0326 | URINAL FEMALE JUG-TYPE | $174.00 |
| 670 | E0487 | ELECTRONIC SPIROMETER | $420.00 |
| 671 | E0570 | NEBULIZER WITH COMPRESSION | $1,092.00 |
| 672 | E0607 | BLOOD GLUCOSE MONITOR HOME | $684.00 |
| 673 | E0625 | PATIENT LIFT BATHROOM OR TOI | $546.00 |
| 674 | G0168 | WOUND CLOSURE BY ADHESIVE | $456.00 |
| 675 | G0378 | HOSPITAL OBSERVATION PER HR | $3,024.00 |
| 676 | G0402 | INITIAL PREVENTIVE EXAM | $2,520.00 |
| 677 | G0481 | DRUG TEST DEF 8-14 CLASSES | $600.00 |
| 678 | G6058 | Drug confirmation, each procedure | $684.00 |
| 679 | G8598 | ASA/ANTIPLAT THER USED | $72.00 |
| 680 | G8601 | NO ELIG TPA INIT W/IN 3 HRS | $1,362.00 |
| 681 | G8602 | NO TPA INIT W/IN 3 HRS | $1,362.00 |
| 682 | J0120 | TETRACYCLIN INJECTION | $228.00 |
| 683 | J0129 | ABATACEPT INJECTION | $228.00 |
| 684 | J0131 | ACETAMINOPHEN INJECTION | $36.00 |
| 685 | J0153 | ADENOSINE INJ 1MG | $138.00 |
| 686 | J0171 | ADRENALIN EPINEPHRINE INJECT | $228.00 |
| 687 | J0282 | AMIODARONE HCL | $138.00 |
| 688 | J0290 | AMPICILLIN 500 MG INJ | $60.00 |
| 689 | J0295 | AMPICILLIN SODIUM PER 1.5 GM | $300.00 |
| 690 | J0360 | HYDRALAZINE HCL INJECTION | $228.00 |
| 691 | J0456 | AZITHROMYCIN | $228.00 |
| 692 | J0461 | ATROPINE SULFATE INJECTION | $72.00 |
| 693 | J0500 | DICYCLOMINE INJECTION | $271.00 |
| 694 | J0561 | PENICILLIN G BENZATHINE INJ | $228.00 |
| 695 | J0610 | CALCIUM GLUCONATE INJECTION | $36.00 |
| 696 | J0690 | CEFAZOLIN SODIUM INJECTION | $228.00 |
| 697 | J0696 | CEFTRIAXONE SODIUM INJECTION | $228.00 |
| 698 | J0697 | STERILE CEFUROXIME INJECTION | $138.00 |
| 699 | J0735 | CLONIDINE HYDROCHLORIDE | $138.00 |
| 700 | J0744 | CIPROFLOXACIN IV | $228.00 |
| 701 | J0780 | PROCHLORPERAZINE INJECTION | $228.00 |
| 702 | J1020 | METHYLPREDNISOLONE 20 MG INJ | $108.00 |
| 703 | J1030 | METHYLPREDNISOLONE 40 MG INJ | $120.00 |
| 704 | J1040 | METHYLPREDNISOLONE 80 MG INJ | $120.00 |
| 705 | J1100 | DEXAMETHASONE SODIUM PHOS | $24.00 |
| 706 | J1170 | HYDROMORPHONE INJECTION | $228.00 |
| 707 | J1200 | DIPHENHYDRAMINE HCL INJECTIO | $60.00 |
| 708 | J1265 | DOPAMINE INJECTION | $48.00 |
| 709 | J1550 | Injection, gamma globulin, intramuscular, 10 cc | $36.00 |
| 710 | J1610 | GLUCAGON HYDROCHLORIDE/1 MG | $589.00 |
| 711 | J1631 | HALOPERIDOL DECANOATE INJ | $378.00 |
| 712 | J1642 | INJ HEPARIN SODIUM PER 10 U | $35.00 |
| 713 | J1644 | INJ HEPARIN SODIUM PER 1000U | $228.00 |
| 714 | J1650 | INJ ENOXAPARIN SODIUM | $170.00 |
| 715 | J1741 | IBUPROFEN INJECTION | $138.00 |
| 716 | J1810 | DROPERIDOL/FENTANYL INJ | $138.00 |
| 717 | J1815 | INSULIN INJECTION | $60.00 |
| 718 | J1817 | INSULIN FOR INSULIN PUMP USE | $138.00 |
| 719 | J1885 | KETOROLAC TROMETHAMINE INJ | $114.00 |
| 720 | J1930 | LANREOTIDE INJECTION | $349.00 |
| 721 | J1940 | FUROSEMIDE INJECTION | $198.00 |
| 722 | J1956 | LEVOFLOXACIN INJECTION | $228.00 |
| 723 | J2001 | Injection, lidocaine hcl for intravenous infusion | $155.00 |
| 724 | J2060 | LORAZEPAM INJECTION | $228.00 |
| 725 | J2175 | MEPERIDINE HYDROCHL /100 MG | $138.00 |
| 726 | J2250 | INJ MIDAZOLAM HYDROCHLORIDE | $228.00 |
| 727 | J2270 | MORPHINE SULFATE INJECTION | $228.00 |
| 728 | J2274 | IN MORPHINE PRESERVATIV FREE | $228.00 |
| 729 | J2360 | ORPHENADRINE INJECTION | $228.00 |
| 730 | J2405 | ONDANSETRON HCL INJECTION | $24.00 |
| 731 | J2410 | OXYMORPHONE HCL INJECTION | $138.00 |
| 732 | J2425 | PALIFERMIN INJECTION | $138.00 |
| 733 | J2504 | PEGADEMASE BOVINE, 25 IU | $138.00 |
| 734 | J2543 | PIPERACILLIN/TAZOBACTAM | $228.00 |
| 735 | J2550 | PROMETHAZINE HCL INJECTION | $173.00 |
| 736 | J2704 | INJ, PROPOFOL, 10 MG | $138.00 |
| 737 | J2765 | METOCLOPRAMIDE HCL INJECTION | $228.00 |
| 738 | J2780 | RANITIDINE HYDROCHLORIDE INJ | $138.00 |
| 739 | J2800 | METHOCARBAMOL INJECTION | $462.00 |
| 740 | J2920 | METHYLPREDNISOLONE INJECTION | $165.00 |
| 741 | J2930 | METHYLPREDNISOLONE INJECTION | $228.00 |
| 742 | J3010 | FENTANYL CITRATE INJECITON | $228.00 |
| 743 | J3030 | SUMATRIPTAN SUCCINATE / 6 MG | $378.00 |
| 744 | J3260 | TOBRAMYCIN SULFATE INJECTION | $528.00 |
| 745 | J3301 | TRIAMCINOLONE ACET INJ NOS | $60.00 |
| 746 | J3360 | DIAZEPAM INJECTION | $184.00 |
| 747 | J3370 | VANCOMYCIN HCL INJECTION | $228.00 |
| 748 | J3430 | VITAMIN K PHYTONADIONE INJ | $359.00 |
| 749 | J3475 | INJ MAGNESIUM SULFATE | $138.00 |
| 750 | J3480 | INJ POTASSIUM CHLORIDE | $150.00 |
| 751 | J3490 | DRUGS UNCLASSIFIED INJECTION | $36.00 |
| 752 | J7030 | NORMAL SALINE SOLUTION INFUS | $296.00 |
| 753 | J7040 | NORMAL SALINE SOLUTION INFUS | $265.00 |
| 754 | J7042 | 5% DEXTROSE/NORMAL SALINE | $312.00 |
| 755 | J7050 | NORMAL SALINE SOLUTION INFUS | $300.00 |
| 756 | J7060 | 5% DEXTROSE/WATER | $300.00 |
| 757 | J7070 | D5W INFUSION | $138.00 |
| 758 | J7120 | RINGERS LACTATE INFUSION | $300.00 |
| 759 | J7121 | 5% DEXTROSE IN LAC RINGERS | $300.00 |
| 760 | J7131 | HYPERTONIC SALINE SOL | $138.00 |
| 761 | J7192 | FACTOR VIII RECOMBINANT NOS | $138.00 |
| 762 | J7313 | FLUOCINOL ACET INTRAVIT IMP | $138.00 |
| 763 | J7510 | PREDNISOLONE ORAL PER 5 MG | $12.00 |
| 764 | J7611 | ALBUTEROL NON-COMP CON | $228.00 |
| 765 | J7613 | ALBUTEROL NON-COMP UNIT | $228.00 |
| 766 | J7614 | LEVALBUTEROL NON-COMP UNIT | $228.00 |
| 767 | J7615 | LEVALBUTEROL COMP UNIT | $228.00 |
| 768 | J7620 | ALBUTEROL IPRATROP NON-COMP | $228.00 |
| 769 | J7631 | CROMOLYN SODIUM NONCOMP UNIT | $138.00 |
| 770 | J7637 | DEXAMETHASONE COMP CON | $138.00 |
| 771 | J7644 | IPRATROPIUM BROMIDE NON-COMP | $228.00 |
| 772 | J7682 | TOBRAMYCIN NON-COMP UNIT | $138.00 |
| 773 | J7699 | INHALATION SOLUTION FOR DME | $138.00 |
| 774 | J8498 | ANTIEMETIC RECTAL/SUPP NOS | $138.00 |
| 775 | J8499 | ORAL PRESCRIP DRUG NON CHEMO | $138.00 |
| 776 | J9206 | IRINOTECAN INJECTION | $138.00 |
| 777 | L0112 | CRANIAL CERVICAL ORTHOSIS | $1,362.00 |
| 778 | L0120 | CERV FLEX N/ADJ FOAM PRE OTS | $774.00 |
| 779 | L0150 | CERV SEMI-RIG ADJ MOLDED CHN | $180.00 |
| 780 | L0170 | CERVICAL COLLAR MOLDED TO PT | $420.00 |
| 781 | L0172 | CERV COL SR FOAM 2PC PRE OTS | $180.00 |
| 782 | L0174 | CERV SR 2PC THOR EXT PRE OTS | $1,512.00 |
| 783 | L0625 | LO FLEX L1-BELOW L5 PRE OTS | $780.00 |
| 784 | L1810 | KO ELASTIC WITH JOINTS | $1,872.00 |
| 785 | L1830 | KO IMMOB CANVAS LONG PRE OTS | $635.00 |
| 786 | L1902 | AFO ANKLE GAUNTLET PRE OTS | $78.00 |
| 787 | L1906 | AFO MULTILIG ANK SUP PRE OTS | $420.00 |
| 788 | L2360 | EXTENDED STEEL SHANK | $564.00 |
| 789 | L3031 | FOOT LAMIN/PREPREG COMPOSITE | $690.00 |
| 790 | L3201 | OXFORD W SUPINAT/PRONAT INF | $510.00 |
| 791 | L3209 | SURGICAL BOOT EACH CHILD | $510.00 |
| 792 | L3250 | CUSTOM MOLD SHOE REMOV PROST | $690.00 |
| 793 | L3260 | AMBULATORY SURGICAL BOOT EAC | $780.00 |
| 794 | L3310 | SHOE LIFT ELEV HEEL/SOLE NEO | $498.00 |
| 795 | L3334 | SHOE LIFTS ELEVATION HEEL /I | $60.00 |
| 796 | L3500 | ORTHO SHOE ADD LEATHER INSOL | $468.00 |
| 797 | L3540 | ORTHO SHOE ADD FULL SOLE | $690.00 |
| 798 | L3650 | SO 8 ABD RESTRAINT PRE OTS | $150.00 |
| 799 | L3660 | SO 8 AB RSTR CAN/WEB PRE OTS | $690.00 |
| 800 | L3670 | SO ACRO/CLAV CAN WEB PRE OTS | $807.00 |
| 801 | L3720 | FOREARM/ARM CUFFS FREE MOTIO | $1,170.00 |
| 802 | L3807 | WHFO W/O JOINTS PRE CST | $600.00 |
| 803 | L3808 | WHFO, RIGID W/O JOINTS | $2,268.00 |
| 804 | L3809 | WHFO W/O JOINTS PRE OTS | $2,268.00 |
| 805 | L3905 | WHO W/NONTORSION JNT(S) CF | $2,268.00 |
| 806 | L3906 | WHO W/O JOINTS CF | $2,268.00 |
| 807 | L3908 | WHO COCK-UP NONMOLDE PRE OTS | $234.00 |
| 808 | L4350 | ANKLE CONTROL ORTHO PRE OTS | $318.00 |
| 809 | L4360 | PNEUMAT WALKING BOOT PRE CST | $330.00 |
| 810 | L4361 | PNEUMA/VAC WALK BOOT PRE OTS | $330.00 |
| 811 | L4386 | NON-PNEUM WALK BOOT PRE CST | $330.00 |
| 812 | L4387 | NON-PNEUM WALK BOOT PRE OTS | $330.00 |
| 813 | L4398 | FOOT DROP SPLINT PRE OTS | $184.00 |
| 814 | L4631 | AFO, WALK BOOT TYPE, CUS FAB | $330.00 |
| 815 | M0243 | CASIRIVI AND IMDEVI INJ | $1,512.00 |
| 816 | P9612 | CATHETERIZE FOR URINE SPEC | $138.00 |
| 817 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL | $68.00 |
| 818 | Q0169 | PROMETHAZINE HCL 12.5MG ORAL | $30.00 |
| 819 | Q4001 | CAST SUP BODY CAST PLASTER | $1,212.00 |
| 820 | Q4006 | CAST SUP LONG ARM ADULT FBRG | $1,212.00 |
| 821 | Q4018 | CAST SUP LNG ARM SPLINT FBRG | $408.00 |
| 822 | Q4019 | CAST SUP LNG ARM SPLNT PED P | $960.00 |
| 823 | Q4020 | CAST SUP LNG ARM SPLNT PED F | $816.00 |
| 824 | Q4021 | CAST SUP SHT ARM SPLINT PLST | $882.00 |
| 825 | Q4022 | CAST SUP SHT ARM SPLINT FBRG | $684.00 |
| 826 | Q4023 | CAST SUP SHT ARM SPLNT PED P | $684.00 |
| 827 | Q4024 | CAST SUP SHT ARM SPLNT PED F | $684.00 |
| 828 | Q4042 | CAST SUP LNG LEG SPLNT FBRGL | $1,212.00 |
| 829 | Q4046 | CAST SUP SHT LEG SPLNT FBRGL | $1,212.00 |
| 830 | Q4049 | FINGER SPLINT, STATIC | $135.00 |
| 831 | Q9962 | HOCM 300-349MG/ML IODINE,1ML | $684.00 |
| 832 | Q9963 | HOCM 350-399MG/ML IODINE,1ML | $276.00 |
| 833 | Q9967 | LOCM 300-399MG/ML IODINE,1ML | $18.00 |
| 834 | S0020 | INJECTION, BUPIVICAINE HYDRO | $210.00 |
| 835 | S0028 | INJECTION, FAMOTIDINE, 20 MG | $150.00 |
| 836 | S0030 | INJECTION, METRONIDAZOLE | $150.00 |
| 837 | S0077 | INJECTION, CLINDAMYCIN PHOSP | $150.00 |
| 838 | S0164 | INJECTION PANTROPRAZOLE | $150.00 |
| 839 | S0630 | REMOVAL OF SUTURES | $408.00 |
| 840 | S1015 | IV TUBING EXTENSION SET | $90.00 |
| 841 | S8100 | SPACER WITHOUT MASK | $138.00 |
| 842 | S8101 | SPACER WITH MASK | $138.00 |
| 843 | S8430 | PADDING FOR COMPRSSN BDG | $83.00 |
| 844 | S8431 | COMPRESSION BANDAGE | $105.00 |
| 845 | S8451 | SPLINT WRIST OR ANKLE | $138.00 |
| 846 | U0001 | Cdc 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel | $300.00 |
| 847 | U0002 | COVID-19 LAB TEST NON-CDC | $360.00 |
| 848 | U0003 | COV-19 AMP PRB HGH THRUPUT | $480.00 |
| 849 | U0004 | COV-19 TEST NON-CDC HGH THRU | $600.00 |
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