| CPT Code | CPT Code Description | Charge Amount |
| 0001A | Immunization administration by intramuscular injection of (… | $100.00 |
| 0202U | COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing | $1,500.00 |
| 10060 | INCISION/DRAINAGE ABSCESS | $1,970.53 |
| 10061 | INS/DRAIN ABSCESS COMPL | $2,215.83 |
| 10081 | I&D PILONIDAL CST COMP | $2,816.73 |
| 10120 | I & RMVL SUB-CUT SIMPLE | $3,510.46 |
| 10121 | I & RMVL FB, SUB-CUT,COMP | $4,299.89 |
| 10160 | PUNCTURE ASP OF ABSCESS | $1,281.01 |
| 11011 | DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC | $1,640.89 |
| 11040 | DBRDMT, SKIN, PARTIAL THICK | $205.00 |
| 11042 | DBRD SKN SUBQ TISSUE | $3,088.37 |
| 11200 | RMVL SKIN TAGS | $4,554.95 |
| 11404 | EXC BGN LSN TRUNK 3.1-4.0 | $6,302.06 |
| 11720 | DEBRIDE NAIL 1-5 | $353.00 |
| 11730 | AVULSION/1-NAIL PLATE | $982.41 |
| 11732 | Avulsion of nail plate, partial or complete, simple; each a… | $265.00 |
| 11740 | EVAC SUBUNGUAL HEMATOMA | $588.97 |
| 11750 | EXC NAIL PART/COMP | $1,738.04 |
| 11760 | REPAIR NAIL BED | $1,615.96 |
| 11765 | WEDGE EXC SKIN/NAIL BED | $1,095.63 |
| 11771 | EXCISION PILONIDAL CYST SINUS EXTENSIVE | $7,234.13 |
| 12001 | LACERATION REPAIR | $896.21 |
| 12002 | REPAIR LAC SCALP 2.6-7.5 | $1,013.45 |
| 12004 | REPAIR LAC SCALP 7.6-12.5 | $1,442.44 |
| 12005 | REPAIR LAC,SCALP 12.6-20C | $1,261.16 |
| 12011 | REPAIR LAC FACE LESS THAN 2.5 CM | $941.45 |
| 12013 | REPAIR LAC FACE 2.6-5.0CM | $1,114.56 |
| 12014 | REPAIR LAC FACE 5.1-7.5CM | $1,435.78 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $4,340.93 |
| 12031 | LYR CLSR S/A/T/E 2.5CM | $1,329.73 |
| 12032 | REPAIR-INT SCALP 2.6-7.5 | $1,598.10 |
| 12034 | INTERM RPR SCLP/TRNK/EXTR | $1,741.77 |
| 12035 | REPAIR INTERM S/A/T/E 12. | $1,560.38 |
| 12036 | REPAIR INTERM S/A/T/E 20.1-30.0 CM | $2,054.03 |
| 12041 | LAYER CLSR NECK/HAND 2.6 | $1,602.70 |
| 12042 | REPAIR LAC HAND/FOOT 2.6- | $1,724.30 |
| 12044 | LYR CLSR N/H/F/ETRNL GENT | $1,299.80 |
| 12045 | REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM | $2,110.64 |
| 12051 | LAYER CLSR OF WND NCK/HND | $1,136.14 |
| 12052 | LYR CLSR WOUND 2.6-5.0FAC | $1,575.97 |
| 12053 | LYR CLSR F/E/E/N/L/M&/MUC | $2,666.56 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM | $1,465.67 |
| 13121 | RPR CMPX SCALP ARM2.6-7.5 | $2,510.06 |
| 13122 | CMPLX RPR ADD 5 CM OR LES | $1,557.49 |
| 13132 | RPR CMPX FOREHEAD/CHECK/C | $3,241.75 |
| 13151 | CMPX RPR EYE NOSE 1.1-2.5 | $2,617.61 |
| 13152 | RPR CPLX E/N/E/L 2.6-7.5 | $2,752.93 |
| 13153 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< | $1,721.22 |
| 15850 | SUTURE RMVL W/ANESTHESIA | $4,805.95 |
| 16000 | BURN, INITIAL TREATMENT | $919.87 |
| 16020 | BURN, DRESSING/DBRDMNT-SM | $1,054.15 |
| 20552 | TRIGGER POINT INJ 1-2 MUS | $2,634.28 |
| 20600 | ARTHROCENTESIS, SML JOINT | $1,279.81 |
| 20605 | ARTHROCENTESIS, MED JOINT | $1,820.47 |
| 20610 | ARTHROCENTESIS, LG JOINT | $2,459.82 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $3,345.86 |
| 21310 | CLTX NSL B1 FX W/O MNPJ | $498.00 |
| 21480 | CLDS TX TEMP DISLOCATION | $1,008.34 |
| 21800 | CLTX RIB FX UNCOMP EA | $425.00 |
| 23500 | CLTX CLAVICULAR FX WO MNP | $814.00 |
| 23570 | CLSD TX SCAPULAR FX WO MA | $839.00 |
| 23600 | CLTX PROX HUMRL FX WO MAN | $1,314.84 |
| 23650 | SHOULDER DISLOCATION TRMT | $1,576.39 |
| 23655 | Closed treatment of shoulder dislocation, with manipulatio… | $4,245.00 |
| 24500 | CLTX HUMRL SHFT FX W/O MN | $1,030.50 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYL | $2,993.75 |
| 24576 | CLTX HUMRL CNDLYR FX MEDI | $381.00 |
| 24600 | CLSD TX ELBOW DISLOCAT | $1,036.44 |
| 24605 | Treatment of closed elbow dislocation; requiring anesthesia | $4,200.00 |
| 24640 | RADIAL HEAD SUBLUX. CHILD | $1,393.15 |
| 24650 | CLTX RDL HEAD FX WO MANP | $959.00 |
| 24670 | CLTX ULNR FX PROX END WO | $942.00 |
| 25500 | CLTX RDL SHFT FX WO MANP | $650.00 |
| 25505 | CLSD TX RAD SHAFT W/MANIP | $3,373.00 |
| 25530 | CLSD TX ULNAR SHFT FX NO | $657.34 |
| 25535 | CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION | $2,827.19 |
| 25560 | CLTX RDL&UR SHFT FXS W/O | $378.00 |
| 25600 | CLSD TX DISTAL RAD FX WO | $1,497.81 |
| 25605 | CLSD TX DISTAL RAD FX | $3,120.90 |
| 25622 | CLSD TX NAVICULAR FX WO M | $650.00 |
| 25635 | CLTTX CARPL B1 FX W/MNPJ EA B1 | $1,898.28 |
| 25650 | CLTX UR SYLOID FX | $904.12 |
| 26010 | I & D FINGER ABSCESS,SIMP | $1,057.79 |
| 26600 | CLSD TX METACARPAL FX | $1,314.17 |
| 26605 | CLSD TX MEDICARPAL FX | $1,541.68 |
| 26607 | CLTX MTCRPL FX W/MNP W/XT | $1,670.00 |
| 26700 | CLS TX MCP DISLOCATION | $1,565.76 |
| 26720 | CLSD TX PHALANGEAL SHFTFX | $628.00 |
| 26725 | CLTX PHLNGL FX PROX/MIDDL | $1,675.91 |
| 26750 | CLS TX FX FINGER/THUMB | $2,805.78 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/ | $1,757.40 |
| 26770 | TREAT FINGER DISLOC FINGE | $1,237.40 |
| 26775 | Treat finger dislocation | $1,852.04 |
| 27220 | CLTX ACETABULUM HIP/SOCKT FX W/O MNP | $635.00 |
| 27301 | I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION | $11,571.00 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $3,398.36 |
| 27508 | CLTX FEM FX DSTAL END MED | $381.00 |
| 27520 | CLTX PATELLAR FX W/O MNPJ | $1,205.00 |
| 27530 | CLTX TIBL FX PROX W/O MNPJ | $507.00 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $1,759.63 |
| 27560 | CLTX PATELLAR DISLC W/O A | $1,081.07 |
| 27752 | CLTX TIBL SFT FX W/MANP | $6,933.56 |
| 27760 | CLTX MEDIAL MALLS FX W/O | $1,153.00 |
| 27780 | CLTX PROX FIVULA/SHFT FX | $2,589.00 |
| 27786 | CLSD TX DISTAL FIBULAR FX | $638.79 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $12,607.88 |
| 27808 | CLOSED TX BIMALLEOLAR ANK | $507.00 |
| 27810 | CLTX BIMAL ANKLE FX W/POT | $2,491.37 |
| 27840 | CLOSED TX ANKLE DISLOCATI | $846.39 |
| 28190 | RMVL FB BODY FOOT SUBQ | $2,681.82 |
| 28192 | RMVL FB FOOT DEEP | $4,902.95 |
| 28400 | CLSD TX CLAVICLE FX WO MA | $650.00 |
| 28430 | CLTX TALUS FX W/O MNPJ | $106.00 |
| 28450 | TX TARSAL B1 FX XCP TALUS | $635.00 |
| 28470 | CLTX METAR FX WO MNP | $945.38 |
| 28490 | CLTX FX GRT TOE W/O MNLJ | $594.00 |
| 28510 | CLSD TX FX PLALANX/PHALAN | $1,026.57 |
| 28515 | FX CARE PHALANX NOT GREAT | $1,773.00 |
| 28660 | CLSD TX PIP JNT DISLOCATI | $1,364.00 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $1,036.39 |
| 29085 | CAST HAND/LOWER FOREARM GAUNTLET | $597.31 |
| 29105 | LONG ARM SPLINT | $880.60 |
| 29125 | SHORT ARM SPLINT | $789.85 |
| 29126 | SHORT ARM SPLINT DYNAMIC | $703.95 |
| 29130 | APPLICATION FINGER SPLINT | $538.88 |
| 29131 | APPLICATION FINGER SPLINT DYNAMIC | $504.73 |
| 29240 | STRPG SHO | $560.21 |
| 29280 | STRAPPING HAND/FINGER | $572.08 |
| 29505 | LONG LEG SPLINT | $845.33 |
| 29515 | SHORT LEG SPLINT | $838.98 |
| 29540 | STRAPPING ANKLE/FOOT | $488.47 |
| 29550 | STRAPPING TOES | $176.00 |
| 29580 | STRAPPING UNNA BOOT | $691.49 |
| 29700 | RMVL/BIVALV GAUNTLET BOOT | $127.00 |
| 30300 | RMVL FOREIGN BODY NASAL | $706.42 |
| 30901 | NASAL PACKING | $1,045.95 |
| 30903 | CTRL NSL HEMRRG ANT CPLX | $1,692.51 |
| 30905 | Control nasal hemorrhage, posterior, with posterior nasal p… | $1,755.81 |
| 3120F | 12-LEAD ECG PERFORMED | $250.00 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,274.88 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $2,395.75 |
| 31515 | LARYNGOSCOPY +- TRACHEOSCOPY ASPIRATION | $1,101.50 |
| 31525 | LARGSC +-TRACHEOSCOPY DX | $4,184.03 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $3,693.36 |
| 33415 | RESCJ/INC SUBVALVULAR TISSUE | $980.00 |
| 36000 | INTRODUCTION OF NEEDLE/IN | $1,019.62 |
| 36011 | Place catheter in vein | $4,767.33 |
| 36410 | VENIPUNCTURE, 3 YRS OR OLDER | $1,727.00 |
| 36415 | VENIPUNCTURE | $79.35 |
| 36416 | COLL CAPILLARY BLG SPEC | $84.51 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $4,819.77 |
| 36558 | INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR | $7,040.12 |
| 36573 | Insertion through the skin of a thin tube (catheter) into a… | $6,202.81 |
| 36589 | Removal of tunneled central venous catheter, without subcut… | $6,652.10 |
| 36591 | COLLECT BLOOD FROM IMPLAN | $431.58 |
| 38300 | DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL | $303.00 |
| 40650 | RPR LIP FULL THICKNESS | $2,975.92 |
| 41800 | DRNG ABSC DENTOALVEOLAR S | $1,003.03 |
| 42700 | I&D ABSC PRITONSILLAR | $2,148.80 |
| 42809 | REMOVAL FOREIGN BODY PHARYNX | $945.00 |
| 43753 | GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … | $1,897.64 |
| 46040 | I&D ISCHIOR/PRIRC ABSC SP | $5,286.10 |
| 46050 | INC/DRAIN PERIANAL ABS SU | $3,180.76 |
| 46083 | INCISION THROM HEMORRHOID | $1,275.12 |
| 46221 | Hemorrhoidectomy, internal, by rubber band ligation(s) | $701.00 |
| 46320 | ENULEATION EXCC OF EXT HE | $6,631.35 |
| 51700 | BLDR IRR SMPL LVG&/INSTLJ | $1,816.73 |
| 51701 | INSR NONDWELLING BLDR CAT | $438.62 |
| 51702 | INSERTION BLADDER CATH | $752.97 |
| 51703 | INSERT BLADDER CATH COMPL | $2,228.70 |
| 56405 | INC/DRAIN VULVA/PERINEAL | $1,375.13 |
| 56420 | I & D BARTHOLIN ABSCESS | $1,002.34 |
| 56440 | Surgery for vulva lesion | $5,784.61 |
| 59025 | FTL NON-STRS TST | $1,141.42 |
| 59409 | VAG DLVR ONLY | $5,641.48 |
| 62200 | Establish brain cavity shunt | $15,151.65 |
| 62270 | SPINAL PUNCTURE,LUMBAR | $2,201.61 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $1,745.26 |
| 64402 | INJ ANESTHETIC FACIAL NRV | $919.03 |
| 64450 | INJ ANESTHETIC AGENT | $2,398.50 |
| 64640 | DSTRJ NULYT OTH PRPH NVR/BRANCH | $2,861.75 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $600.16 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $1,113.23 |
| 65222 | RMVL FB EYE | $964.40 |
| 67700 | I&D ABSCESS EYELID | $917.89 |
| 69005 | DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED | $363.00 |
| 69200 | RMVL FOREIGN BODY EAR | $692.53 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $3,169.73 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL | $441.90 |
| 69210 | RMVL IMPACTED CERUMEN | $769.28 |
| 70030 | RADEX EYE DETCJ FB | $575.64 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $790.30 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $1,096.68 |
| 70120 | RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE | $517.93 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $706.12 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $973.66 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $1,170.86 |
| 70160 | NASAL BONE X-RAY | $983.20 |
| 70200 | RAD EXAM ORBIT COMP. | $1,121.74 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $647.33 |
| 70220 | RAD EXAM SINUS COMPLETE | $1,268.49 |
| 70250 | SKULL LESS THAN 4 VIEWS | $1,061.46 |
| 70260 | RAD EXAM SKULL COMPLETE | $1,719.91 |
| 70328 | RADEX TMPRMAND JT OPN&CLSD MOUTH UNI | $396.01 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $928.88 |
| 70350 | CEPHALOGRAM ORTHODONTIC | $458.85 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $855.44 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $6,250.43 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $6,413.03 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $7,306.83 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $4,944.58 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $6,883.52 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $7,421.20 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $5,760.58 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $6,456.83 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $7,850.44 |
| 70490 | CT NECK WO CONTRAST | $5,613.27 |
| 70491 | CT SOFT TISS NCK C+MATRL | $7,446.03 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $8,748.82 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $8,724.82 |
| 70544 | MRA HEAD C-MATRL | $7,387.90 |
| 70547 | MRA NECK C-MATRL | $7,254.81 |
| 70551 | MRI BRN BRN STEM C-MATRL | $7,892.81 |
| 70553 | MRI BRN BRN STEM C-/C+ | $10,284.54 |
| 71045 | RADIOLOGIC EXAM CHEST SINGLE VIEW | $1,069.10 |
| 71046 | CHEST XRAY 2 VIEWS | $1,166.18 |
| 71047 | RADIOLOGIC EXAM CHEST 3 VIEWS | $1,208.97 |
| 71048 | RADIOLOGIC EXAM CHEST 4+ VIEWS | $1,505.13 |
| 71060 | BRONCHOGRAPHY BI RS&I | $537.00 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $1,046.72 |
| 71101 | RIB UNILATERAL W CHEST | $1,292.21 |
| 71110 | RIBS BILATERAL 3 VIEWS | $1,247.46 |
| 71111 | RIBS BILATERAL W/CHEST | $1,480.42 |
| 71120 | Radiologic examination; sternum, minimum of 2 views | $886.55 |
| 71250 | CT CHEST W/O CONTRAST | $5,663.17 |
| 71260 | CT THORAX W/CONTRAST | $7,072.46 |
| 71270 | CT THORAX WO CONTRAST | $7,637.36 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $8,820.46 |
| 71550 | MRI CH C-MATRL | $6,937.29 |
| 72020 | SPINE SINGLE VIEW | $893.78 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $1,169.60 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $1,748.58 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $1,753.81 |
| 72069 | RADEX SPI THORACOLMBR STANDING SCOLIOSIS | $374.00 |
| 72070 | SPINE THORACIC 2 VIEWS | $1,379.90 |
| 72072 | SPINE THORACIC 3 VIEWS | $1,616.62 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $984.58 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $847.78 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $1,390.34 |
| 72100 | SPINE LUMBO. MIN 4 VIEWS | $1,466.45 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $1,769.62 |
| 72114 | RAD EXAM SPINE LUMBO COMP | $1,674.05 |
| 72120 | SPINE LUMBAR AP & LAT W F | $1,150.72 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $6,899.72 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $7,261.86 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $8,241.83 |
| 72128 | CT THRC SPI C-MATRL | $5,993.51 |
| 72129 | CT THRC SPI C+ MATRL | $6,608.08 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $7,543.10 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $6,857.74 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $7,650.90 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $8,524.60 |
| 72141 | MRI SPI CANAL&CNTS CRV C-MATRL | $7,109.20 |
| 72146 | MRI SPI CANAL&CNTS THRC C-MATRL | $6,861.20 |
| 72148 | MRI SPI CANAL&CNTS LMBR C-MATRL | $6,896.90 |
| 72150 | Diagnostic Radiology (Diagnostic Imaging) Procedures of the… | $10,217.87 |
| 72156 | MRI SPI CANAL&CNTS C-/C+ CRV | $10,073.46 |
| 72157 | MRI SPI CANAL&CNTS C-/C+ | $9,931.72 |
| 72158 | MRI SPI CANAL&CNTS C-/C+ LMBR | $9,630.29 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $1,052.68 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $1,357.91 |
| 72191 | CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST | $7,419.44 |
| 72192 | CT PELVIS WO CONTRAST | $6,035.36 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $6,635.61 |
| 72194 | CT PELVIS W OR WO CONTRST | $7,635.46 |
| 72195 | MRI PELVIS C-MATRL | $7,039.42 |
| 72196 | MRI PELVIS C+ MATRL | $8,207.89 |
| 72220 | XRAY COCCYX/SACRUM | $951.99 |
| 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $4,893.71 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $986.84 |
| 73010 | SCAPULA COMPLETE | $1,014.48 |
| 73020 | RADEX SHO 1 VIEW | $847.88 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $1,275.51 |
| 73050 | XRAY AC JOINTS-BILAT | $995.85 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $1,103.34 |
| 73070 | XRAY ELBOW 2 VIEWS | $827.70 |
| 73080 | XRAY ELBOW GREATER THAN 3 VIEWS-COMP | $981.15 |
| 73090 | XRAY FOREARM AP & LAT | $1,078.84 |
| 73100 | XRAY WRIST AP & LAT VIEW | $866.46 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $1,220.02 |
| 73120 | XRAY HAND AP & LAT | $887.55 |
| 73130 | XRAY HAND MIN 3 VIEWS | $1,120.38 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $838.86 |
| 73200 | CT UPPR EXTR WO CNTRS | $4,804.57 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $6,243.23 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $7,150.91 |
| 73220 | MRI UXTR OTH/THN JT C-/C+ | $8,670.35 |
| 73221 | MRI ANY JT UXTR C-MATRL | $7,281.36 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $868.27 |
| 73502 | RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… | $1,198.14 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $2,248.12 |
| 73520 | HIPS BILAT MIN 2 VIEW INC | $507.00 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $1,573.84 |
| 73523 | RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS | $2,405.00 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $655.45 |
| 73552 | FEMUR; MIN 2 VIEWS | $939.64 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $813.35 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $906.80 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $1,288.74 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $803.84 |
| 73580 | X-RAY KNEE.BILATERAL STANDING | $2,724.00 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $1,079.10 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,394.22 |
| 73600 | XRAY ANKLE 2 VIEWS | $847.40 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $1,058.35 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $937.41 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $1,035.55 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $838.01 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $923.80 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $5,595.48 |
| 73701 | CT LWR EXT W CONT | $6,122.83 |
| 73702 | CT LXTR C-/C+ | $7,134.98 |
| 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $5,271.95 |
| 73721 | MRI ANY JT LXTR C-MATRL | $6,044.10 |
| 73722 | MRI ANY JT LXTR C+ MATRL | $5,399.08 |
| 73723 | MRI ANY JT LXTR C-/C+ | $7,865.38 |
| 73725 | MRA LXTR C+-MATRL | $3,945.60 |
| 74000 | RAD EXAM ABD SINGL ANTER | $759.00 |
| 74010 | RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS | $426.00 |
| 74018 | RADIOLOGIC EXAM ABDOMEN 1 VIEW | $906.51 |
| 74019 | RADIOLOGIC EXAM ABDOMEN 2 VIEWS | $1,045.13 |
| 74020 | RAD EXAM ABDOMEN COMPL | $454.00 |
| 74021 | RADIOLOGIC EXAM ABDOMEN 3+ VIEWS | $1,141.96 |
| 74022 | RAD EXAM COMPLETE ABD | $1,631.74 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $5,755.36 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $6,827.85 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $7,789.34 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $9,920.02 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $7,492.15 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $9,556.67 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $10,615.21 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $12,514.63 |
| 74181 | MRI ABD C-MATRL | $6,118.29 |
| 74183 | MRI ABD C-/C+ | $7,163.23 |
| 74190 | PERITONEOGRAM RS&I | $2,295.23 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $1,447.65 |
| 74241 | RADEX GI TRC UPR +-DLYD FLMS W/KUB | $998.00 |
| 74245 | RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES | $3,871.50 |
| 74246 | Radiologic examination, gastrointestinal tract, upper, air … | $1,910.17 |
| 74247 | RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB | $1,010.00 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $1,615.90 |
| 74251 | RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE | $2,605.80 |
| 74283 | Therapeutic enema, contrast or air, for reduction of intuss… | $2,038.49 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $3,597.46 |
| 74329 | ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I | $2,720.52 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $1,749.01 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $999.91 |
| 74440 | VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I | $2,857.80 |
| 75574 | CT CORONARY | $3,340.10 |
| 76010 | X-ray nose to rectum | $928.99 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $1,642.09 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $1,974.35 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $1,994.75 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $1,253.43 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,517.90 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $1,031.54 |
| 76645 | US BREAST R-T W/IMAGE DOCUMENTATION | $784.06 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $2,693.25 |
| 76705 | US ABDOMINAL | $2,173.92 |
| 76706 | Ultrasound, abdominal aorta, real time with image documenta… | $1,445.50 |
| 76770 | US RETROPERITONEAL R-T W/ | $2,043.71 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $1,696.82 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $1,942.32 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $1,335.27 |
| 76805 | US PG UTER F&MAT AFTER 1S | $2,307.09 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,243.69 |
| 76815 | ULTRASND PG UTER | $1,575.00 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $1,124.10 |
| 76817 | UT PG UTER R-T IMG TRVG | $1,611.41 |
| 76830 | TRANSVAGINAL ULTRASOUND | $1,492.21 |
| 76856 | US PELVIC NONOB REAL-TIME | $2,482.38 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $1,352.35 |
| 76870 | US SCROTUM&CNTS | $1,996.83 |
| 76880 | US EXTREMITY | $913.00 |
| 76881 | US COMPL JOINT R-T W/IMAGE DOCUMENTATION | $2,010.16 |
| 76882 | ULTRASOUND, EXTREMITY, NON VASCULAR | $1,071.43 |
| 76937 | Us guide vascular access | $1,619.15 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… | $2,812.96 |
| 77076 | RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT | $1,235.20 |
| 77079 | CT BONE MINERAL DENSITY STUDY 1+SITS APPND | $613.00 |
| 78075 | ADRNL IMG CORTEX&/MEDULLA | $3,618.00 |
| 78223 | HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR | $2,509.00 |
| 78306 | B1&/JT IMG WHBDY | $3,893.49 |
| 78315 | B1&/JT IMG 3 PHASE STD | $4,373.79 |
| 78320 | B1&/JT IMG TOMOG SPECT | $3,891.25 |
| 78472 | CARD BPI GTD=BRM PLNR 1 STD REST/STRS | $3,518.15 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $999.70 |
| 80048 | METABOLIC PANEL BASIC | $699.69 |
| 80050 | General health panel | $1,114.51 |
| 80051 | ELECTROLYTE PANEL | $556.19 |
| 80053 | METABOLIC COMPRE PANEL | $985.40 |
| 80061 | LIPID PROFILE III | $755.70 |
| 80074 | HEPATITIS PANEL | $1,368.96 |
| 80076 | HEPATIC FUNCTION PANEL | $862.28 |
| 80100 | DRUG ABUSE PANEL II | $191.04 |
| 80102 | Drug confirmation, each procedure | $523.13 |
| 80104 | DRUG SCREEN | $172.00 |
| 80175 | DRUG SCREEN QUANTITATIVE LAMOTRIGINE | $168.00 |
| 80178 | LITHIUM | $543.44 |
| 80196 | SALICYLATE | $332.33 |
| 80197 | TACROLIMUS | $1,091.40 |
| 80202 | VANCOMYCIN PEAK | $674.67 |
| 80300 | DRUG SCREEN | $221.00 |
| 80304 | DRUG SCREEN | $211.00 |
| 80305 | DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… | $312.79 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $1,162.55 |
| 80320 | DRUG SCREEN | $501.12 |
| 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $534.65 |
| 80329 | DRUG SCREEN | $621.61 |
| 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $305.00 |
| 80345 | DRUG SCREENING BARBITURATES | $237.80 |
| 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $326.38 |
| 80347 | DRUG SCREENING BENZODIAZEPINES 13 OR MORE | $525.00 |
| 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $275.05 |
| 80351 | DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 | $829.80 |
| 80352 | DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE | $451.07 |
| 80353 | DRUG SCREENING COCAINE | $222.95 |
| 80356 | DRUG SCREENING HEROIN METABOLITE | $212.68 |
| 80358 | DRUG SCREENING METHADONE | $349.24 |
| 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $54.06 |
| 80361 | DRUG SCREENING OPIATES 1 OR MORE | $255.54 |
| 80362 | DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 | $378.24 |
| 80365 | DRUG SCREENING OXYCODONE | $57.76 |
| 80366 | DRUG SCREENING PREGABALIN | $227.86 |
| 80367 | DRUG SCREENING PROPOXYPHENE | $233.83 |
| 80373 | DRUG SCREENING TRAMADOL | $246.26 |
| 80374 | DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS | $420.00 |
| 81000 | U/A DIPSTICK | $115.42 |
| 81001 | U/A DIP STICK | $311.11 |
| 81002 | URNLS DIP STICK/TABLET RG | $104.29 |
| 81003 | U/A W/O MICRO DIPSTICK | $182.92 |
| 81007 | URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK | $292.30 |
| 81015 | Urinalysis Microscopic Olny | $196.44 |
| 81025 | PREG.TST URINE VISUAL | $360.94 |
| 82003 | ACETAMINOPHEN | $624.60 |
| 82009 | KETONES-SERUM | $162.42 |
| 82040 | ALBUMIN; SERUM | $243.19 |
| 82055 | ALCOHOL-BLOOD | $330.34 |
| 82075 | ALCOHOL BREATH TEST | $175.12 |
| 82140 | Ammonia | $495.41 |
| 82150 | AMYLASE | $505.61 |
| 82247 | BILIRUBIN TOTAL | $415.51 |
| 82248 | BILIRUBIN DIRECT | $285.34 |
| 82250 | direct bilirubin | $260.69 |
| 82253 | MB FRACTION | $154.00 |
| 82270 | OCCULT BLOOD | $226.28 |
| 82271 | Occult blood other sources | $190.95 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $131.58 |
| 82274 | BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 | $250.45 |
| 82310 | CALCIUM | $306.94 |
| 82330 | CALCIUM IONIZED | $625.21 |
| 82355 | CALCULUS QUALITATIVE ANALYSIS | $428.40 |
| 82374 | CARBON DIOXIDE BICARBONATE | $225.75 |
| 82375 | Under Chemistry Procedures | $355.34 |
| 82435 | CHLORIDE BLD | $201.16 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $413.05 |
| 82533 | CORTISOL TOTAL | $613.18 |
| 82540 | CREATINE | $298.50 |
| 82541 | COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE | $121.00 |
| 82550 | CREATINE CK-TOTAL | $384.08 |
| 82553 | CREATINE CKMB | $583.33 |
| 82565 | CREATININE | $349.61 |
| 82607 | VITAMIN B-12 | $508.19 |
| 82693 | ASSAY OF ETHYLENE GLYCOL | $388.96 |
| 82747 | ASSAY OF FOLIC ACID RBC | $276.55 |
| 82784 | IGC IMMUNOGLOBULIN | $329.82 |
| 82785 | GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE | $279.38 |
| 82800 | GASES BLD PH ONLY | $152.39 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $998.98 |
| 82805 | GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY | $1,137.03 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $306.91 |
| 82947 | GLUCOSE | $272.05 |
| 82948 | GLUCOSE BLOOD REAGET STR | $128.11 |
| 82962 | GLUCOSE FINGER STICK | $90.49 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $465.98 |
| 83009 | HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE | $754.60 |
| 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $635.04 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $404.62 |
| 83050 | HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE | $222.64 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $526.79 |
| 83525 | ASSAY OF INSULIN TOTAL | $462.59 |
| 83540 | IRON-TOTAL | $439.93 |
| 83605 | ASSAY OF LACTATE | $516.66 |
| 83615 | Lactate dehydrogenase (LD), (LDH); | $397.33 |
| 83690 | LIPASE | $431.40 |
| 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $200.17 |
| 83735 | MAGNESIUM | $334.53 |
| 83874 | MYOGLOBIN | $524.65 |
| 83880 | B-TYPE NATRIURETIC | $801.46 |
| 83992 | ASSAY OF PHENCYCLIDINE | $119.40 |
| 84075 | ALK PHOS/PROFILE OR PANEL | $352.13 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $281.09 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $295.29 |
| 84155 | PROTEIN,TOTAL,EXCEPT REFR | $265.08 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $358.64 |
| 84165 | PROTEIN ELECTROPHORESIS | $503.22 |
| 84295 | SODIUM; SERUM | $263.84 |
| 84403 | ASSAY OF TESTOSTERONE TOTAL | $684.51 |
| 84436 | THYRIXINE TOTAL | $360.99 |
| 84439 | THYROXINE-FREE | $483.87 |
| 84443 | Thyroid stimulating hormone (TSH) | $709.66 |
| 84450 | Aspartate Aminotransferase | $398.09 |
| 84460 | ALT-TRANSFERASE;ALANINE | $350.99 |
| 84478 | ASSAY OF TRIGLYCERIDES | $417.21 |
| 84479 | THYROID HORMONE | $192.77 |
| 84480 | T3 TOTAL | $499.84 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $512.06 |
| 84484 | TROPONIN I | $643.09 |
| 84512 | TROPONIN QUAL | $549.24 |
| 84520 | Urea nitrogen | $239.11 |
| 84550 | URIC ACID | $324.15 |
| 84560 | URIC ACID OTH SRC | $274.58 |
| 84702 | HCG QUANTATIVE | $648.05 |
| 84703 | PREGNANCY TEST BLOOD | $409.33 |
| 84999 | UNLISTED CHEMISTRY PROCEDURE | $263.60 |
| 85014 | HEMATOCRIT | $138.64 |
| 85018 | HEMOGLOBIN | $153.28 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $319.06 |
| 85027 | CBC W/O DIFF | $433.25 |
| 85032 | BLD# MNL C-CNT RBC/PLTLT EA | $152.00 |
| 85044 | RETICULOCYTE COUNT | $450.15 |
| 85347 | COAGJ TM ACTIVATED | $294.08 |
| 85378 | FIBRIN DEGRADATION PROD | $468.06 |
| 85379 | D-DIMER | $586.24 |
| 85610 | PROTHROMBIN TIME | $301.03 |
| 85651 | SEDIMENTATION RATE NONAUT | $240.20 |
| 85652 | SED RATE ERYTHROCYTE NON | $236.85 |
| 85730 | THROMBOPLASTIN TIME PART | $344.03 |
| 86038 | ANTINUCLEAR AB | $513.72 |
| 86039 | ANTINUCLEAR AB TITER | $562.17 |
| 86060 | ANTISTREPTOLYSIN O TITER | $336.22 |
| 86140 | C REACTIVE PROTEIN | $427.25 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $437.03 |
| 86256 | SMOOTH MUSCLE AB TITER | $447.63 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $322.12 |
| 86320 | IMMUNOELECTROPHORESIS | $1,094.54 |
| 86328 | COVID-19 RAPID ANTIBODY TEST SINGLE METHOD | $346.72 |
| 86360 | T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO | $590.57 |
| 86403 | MONO SPOT | $266.70 |
| 86430 | RHEUMATOID FACTOR | $255.72 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $372.77 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $306.95 |
| 86593 | SYPHILIS TEST, NON- TREPONEMAL ANTIBODY; QUANTITATIVE | $261.59 |
| 86631 | ANTB CHLAMYDIA | $168.00 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $472.84 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $520.96 |
| 86664 | EPSTEIN-BARR VIRUS EBNA | $406.28 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $533.88 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $587.05 |
| 86695 | Antibody; herpes simplex, type 1 | $217.00 |
| 86696 | Antibody; herpes simplex, type 2 | $148.00 |
| 86701 | HIV SERUM | $435.76 |
| 86702 | ANTB HIV-2 | $538.40 |
| 86703 | Antibody; HIV-1 and HIV-2, single result | $520.00 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $539.59 |
| 86705 | HEPATITIS B CORE IGM | $521.56 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $512.28 |
| 86708 | Hepatitis a antibody | $339.70 |
| 86713 | LEGIONELLA PNEUMONPILA AB | $188.66 |
| 86756 | ANTB RSV | $224.52 |
| 86769 | COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD | $401.71 |
| 86780 | ANTIBODY TREPONEMA PALLIDUM | $323.90 |
| 86787 | Antibody; varicella-zoster | $309.55 |
| 86803 | HEPATITIS C ANTIBODY | $563.61 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $453.84 |
| 86900 | Blood typing, serologic; ABO | $284.77 |
| 86901 | RH FACTOR-BLOOD | $230.38 |
| 86906 | BLD TYPING RH PHEXYPING COMPL | $309.04 |
| 87040 | BLOOD CULTURE | $664.25 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $533.49 |
| 87046 | CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA | $278.14 |
| 87070 | CULTURE BODY FLUID | $549.73 |
| 87075 | CULTURE ANAEROBIC | $741.98 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $356.89 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $382.06 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $284.80 |
| 87086 | URINE CULTURE | $573.69 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $242.71 |
| 87103 | Under Microbiology Culture and Typing Procedures | $402.31 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $271.54 |
| 87110 | CHLAMYDIA CULTURE | $496.58 |
| 87177 | OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID | $339.31 |
| 87186 | Susceptibility studies, antimicrobial agent | $254.00 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $234.38 |
| 87207 | SMR PRIM SRC SPEC STAIN | $301.54 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $268.63 |
| 87210 | WET SMEAR | $271.40 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $611.29 |
| 87255 | Herpes Simplex Virus Culture with Reflex Typing | $387.00 |
| 87275 | IAADI INF B VIRUS | $218.67 |
| 87338 | IAAD IA HPYLORI STOOL | $407.93 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $378.05 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $344.68 |
| 87389 | HIV-1 AG W/HIV-1 & HIV-S AB | $431.33 |
| 87400 | INFLUENZA A&B | $347.02 |
| 87403 | Particle agglutination; screen, each antibody | $350.00 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $452.33 |
| 87425 | ROTAVIRUS AG EIA | $485.07 |
| 87426 | COVID-19 RAPID ANTIGEN TESTING | $488.56 |
| 87427 | IAAD IA SHIGA-LIKE TOXIN | $349.27 |
| 87428 | Multiplex viral pathogen panel using Antigen technique for … | $700.00 |
| 87430 | INF AGT IMMUNO STREP A | $260.23 |
| 87480 | IADNA CANDIDA SPECIES DIRECT PROBE TQ | $63.68 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $642.05 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $551.85 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $634.41 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $4,327.29 |
| 87529 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA &RNA) | $685.64 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $617.89 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $483.52 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $2,842.03 |
| 87635 | IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ | $351.58 |
| 87636 | “severe acute respiratory syndrome coronavirus 2 (SARSCoV-2… | $800.00 |
| 87661 | INF AGENT DETECTED NUCLEIC ACID; TRICHMONAS VAGINALIS AMP P… | $342.97 |
| 87798 | O&P SMEAR W/AMPLIFIC | $843.84 |
| 87800 | IAADIADOO NEISSERIA GONORRHOEAE | $197.23 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $342.53 |
| 87806 | Infectious agent antigen detection by immunoassay with dire… | $271.00 |
| 87807 | INF AGT DET IMNAS OPT RSV | $403.74 |
| 87847 | NO DESCRIPTION | $409.00 |
| 87850 | NEISSERIA GONORRHOEAE DET | $169.65 |
| 87880 | RAPID STREP-BETA STREP | $538.66 |
| 87905 | INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS | $394.50 |
| 88305 | PATH SURG LEVEL IV | $835.74 |
| 89050 | CELL COUNT MISCELLANEOUS BODY FLUIDS | $288.09 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $350.71 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $240.82 |
| 89060 | CRYSTAL INDENTIFICATION | $274.10 |
| 89220 | SPTM OBTG SPEC AERSL INDUCED SPX | $170.00 |
| 90471 | IMMUN ADM 1 VAC | $267.82 |
| 90660 | INFLUENZA VIRUS INTRANASA | $70.00 |
| 90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, … | $171.66 |
| 90700 | DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM | $217.72 |
| 90703 | TETANUS TOXID | $152.00 |
| 90714 | TETANUS DIPHTHERIA TOXOID | $326.81 |
| 90715 | TDAP VACCINE | $372.31 |
| 90718 | TETANUS & DIPTHERIA | $152.00 |
| 90746 | HEPATITIS B VACCINE/ADULT | $376.20 |
| 90765 | IV NFS THER PROPH/DX 1ST | $210.00 |
| 90997 | HEMOPERFUSION | $409.00 |
| 91105 | GASTRIC INTUBATION/ASPER | $596.00 |
| 91300 | Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2… | $0.01 |
| 92002 | OPH MEDICAL XM&EVAL INTRM | $1.00 |
| 92081 | VIS FLD XM UNI/BI I&R LMT | $1.00 |
| 92552 | PURE TONE AUDIOMTRY AIR O | $1.00 |
| 92950 | cardiopulmonary resuscitation | $1,833.48 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $2,730.97 |
| 93000 | EKG W/INTREP AND REPORT | $248.00 |
| 93005 | Electrocardiogram, routine ECG | $893.06 |
| 93010 | RTN ECG 12 LEADS INTRP/RP | $146.88 |
| 93018 | CV STRS TST XERS&/OR RX CONT ECG I&R ONLY | $475.61 |
| 93040 | RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT | $459.69 |
| 93041 | RHYTHEM ECG 1-3 LDS | $400.74 |
| 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $118.40 |
| 93224 | WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I | $149.00 |
| 93306 | ECHO TEST | $4,090.66 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $4,864.69 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $3,013.64 |
| 93313 | TEE R-T IMG 2D W/PROBE PLMT ONLY | $1,934.28 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $2,578.72 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $2,596.69 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $5,182.32 |
| 93631 | INTRAOP EPICAR& ENDOCAR PACG& MAPG | $10,386.84 |
| 93784 | Orthostatic | $387.84 |
| 93875 | N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD | $840.00 |
| 93880 | DUP-SCAN XTRC ART COMPL B | $2,396.12 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $1,996.50 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $1,329.03 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $1,863.04 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $2,688.18 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $1,959.69 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $2,740.94 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $2,032.09 |
| 93965 | QUANT VENOUS FLOW ST | $1,806.00 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $2,622.27 |
| 93971 | DPLX SCN EXTRM VEINS | $2,043.21 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… | $2,484.59 |
| 93976 | DUPLEX SCAN- LIMITED | $1,939.05 |
| 94010 | SPIROMETRY W/RECORD | $665.33 |
| 94060 | BRNCDILAT RSPSE SPMTRY PR | $1,279.67 |
| 94621 | PULM STRS TSTG CPLX | $2,408.02 |
| 94640 | NEBULIZER TREATMENT | $694.72 |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $597.20 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $193.11 |
| 94760 | EAR OR PULSE OXIMETRY | $500.00 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $376.62 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $1,102.92 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $1,133.08 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $457.51 |
| 96365 | IV INFUSION THERAPY/PROPH | $1,163.01 |
| 96366 | IV INFUS THER PROPH/DX EA | $442.96 |
| 96367 | IV NFS THER PROPH/DX ADDL | $721.25 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $471.98 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $509.53 |
| 96373 | INJECTION, INTRA-ARTERIAL | $833.44 |
| 96374 | THER PROPH/DX NJX IV PUSH | $708.09 |
| 96375 | THER PROPH/DX NJX EA SEQL | $538.26 |
| 96376 | SUB INFU EA ADD IV PUSH | $578.76 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $431.69 |
| 96379 | INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS | $1,641.63 |
| 97010 | APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS | $101.49 |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; th… | $97.00 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR | $432.70 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $214.92 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $2,028.74 |
| 99000 | SPECIMEN HANDLING | $67.90 |
| 99001 | COC COLLECITON ONLY | $183.33 |
| 99024 | POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX | $298.50 |
| 99050 | BLUE CROSS RQRD LVL3 | $77.61 |
| 99053 | SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY | $150.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $258.10 |
| 99080 | MEDICAL RECORDS | $46.00 |
| 99143 | MOD SEDATION <5YRS 30 | $439.00 |
| 99144 | MOD SEDATION SERV UNDER 5 | $433.00 |
| 99145 | M-SEDAJ BY SM PHY 15 MIN | $168.00 |
| 99149 | MOD SEDATION | $363.00 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $694.07 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $12.13 |
| 99153 | MOD SED SAME PHYS/QHP EACH ADDL 15 MINS | $10.20 |
| 99173 | SCREENING TEST OF VISION | $293.00 |
| 99217 | OBSERVATION CARE DISCHARGE MANAGEMENT | $942.81 |
| 99218 | INITIAL OBSERVATION CARE/DAY 30 MINUTES | $5,520.93 |
| 99219 | INITIAL OBSERVATION CARE/DAY 50 MINUTES | $1,400.49 |
| 99220 | INITIAL OBSERVATION CARE/DAY 70 MINUTES | $499.22 |
| 99224 | SBSQ OBSERVATION CARE/DAY 15 MINUTES | $107.00 |
| 99225 | Subsequent observation care, per day, for the evaluation an… | $865.80 |
| 99234 | OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES | $676.60 |
| 99235 | OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES | $1,800.00 |
| 99236 | OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES | $2,400.00 |
| 99281 | E/M VISIT LEVEL 1 TECH COMP | $0.01 |
| 99282 | E/M VISIT LEVEL 2 TECH COMP | $1,371.99 |
| 99283 | E/M VISIT LEVEL 3 TECH COMP | $2,694.72 |
| 99284 | E/M VISIT LEVEL 4 TECH COMP | $3,957.82 |
| 99285 | E/M VISIT LEVEL 5 TECH COMP | $5,492.84 |
| 99291 | CRITICAL CARE 30-74 MIN | $6,405.16 |
| 99292 | CRITICAL CARE ADD 30 MIN | $2,779.23 |
| 99406 | SMOKING CESSATION 3-10 | $109.98 |
| 99407 | SMOKING CESSATION 10 MIN | $176.94 |
| A0394 | ALS IV DRUG THERAPY SUPPLIES | $1.00 |
| A0396 | ALS ESPOHAGEAL INTUB SUPPLIES | $30.00 |
| A4208 | 3 CC STERILE SYRINGE & NEEDLE | $32.00 |
| A4209 | 5+ CC STERILE SYRINGE & NEEDLE | $35.00 |
| A4213 | 20+ CC SYRINGE ONLY | $7.00 |
| A4215 | NEEDLE STERILE, ANY SIZE, EACH | $371.44 |
| A4216 | STERILE WATER/SALINE, FLUSH 10ML | $139.30 |
| A4217 | STERILE SALINE WATER PER 500 ML | $133.39 |
| A4218 | STERILE SALINE OR WATER | $26.00 |
| A4222 | EXT UNFU PMP PER CASS/BAG | $176.00 |
| A4224 | ALOCHOL OR PEROXIDE PER PINT | $4.00 |
| A4244 | Alcohol or peroxide, per pint | $13.98 |
| A4245 | Alcohol wipes, per box | $13.98 |
| A4246 | BETADINE/PHISOHEX SOLUTION | $25.00 |
| A4247 | BETADINE/IODINE SWABS/WIPES | $378.30 |
| A4248 | Chlorhexidine containing antiseptic, 1 ml | $5.00 |
| A4252 | GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP | $6.00 |
| A4270 | DISPOSABLE ENDO CODE SHEATH | $24.00 |
| A4311 | CATHETER W/O BAG 2 WAY LATEX | $35.00 |
| A4314 | INSRT TRAY W/DRAINAGE BAG | $319.21 |
| A4315 | Insertion tray with drainage bag with indwelling catheter, … | $445.36 |
| A4316 | CATH W DRAINAGE 3 WAY | $90.00 |
| A4320 | IRR TRAY W/BULB/PISTON SY | $9.00 |
| A4322 | IRRIGATION SYRINGE, BULB | $15.00 |
| A4327 | URIN CUP FEMALE COLLECT DEV CUP | $3.00 |
| A4332 | LUBE STERILE PACKET | $7.00 |
| A4335 | INCONTINENCE SUPPLY MISC | $11.94 |
| A4338 | INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING | $142.51 |
| A4344 | INDWELLING CATH FOLEY TYP | $860.51 |
| A4353 | INTERMIT URINARY CATHETER | $164.51 |
| A4358 | URINARY DRAINAGE BAG | $50.34 |
| A4364 | DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ | $255.12 |
| A4450 | TAPE NO WATERPROOF | $10.00 |
| A4452 | TAPE WATERPROOF 18 SQ IN | $10.00 |
| A4550 | LACERATION- SURGICAL KIT | $409.00 |
| A4554 | DISPOSABLE UNDERPADS | $30.00 |
| A4556 | ELECTRODES, (E.G., APNEA MONITOR), PER PAIR | $60.00 |
| A4565 | SLING | $45.63 |
| A4566 | Shoulder sling or vest design, abduction restrainer, with o… | $40.00 |
| A4570 | SPECIAL CASTING MATERIAL | $125.00 |
| A4590 | 3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL | $84.00 |
| A4595 | TENS SUPPL 2 LEAD PER MONTH | $46.00 |
| A4606 | OXYGEN PROBE USED W OXIMETER | $208.95 |
| A4614 | HAND HELD PEFR METER | $50.00 |
| A4615 | CANNULA NASAL | $124.77 |
| A4616 | TUBING (OXYGEN) PER FOOT | $1.00 |
| A4617 | MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT | $55.00 |
| A4649 | SURGICAL SUPPLY MISC | $6,352.32 |
| A4653 | PD CATHERTER ANCHOR BELT | $13.00 |
| A4657 | SYRINGE W OR WO NEEDLE | $7.00 |
| A4670 | AUTOMATIC BP MONITOR #11 | $36.00 |
| A4673 | SALINE BLADE #11 | $13.00 |
| A4927 | GLOVES NON STERILE | $1.00 |
| A4930 | GLOVES STERILE PER PAIR | $3.00 |
| A5120 | SWAB OR WIPE SKIN BARRIER | $6.00 |
| A5200 | PERCUTANEOUS CATHETER ANCHOR | $37.81 |
| A6021 | COLLAGEN DRESSING STERIL | $133.67 |
| A6203 | Composite dressing, sterile, pad size 16 sq. in. or less, w… | $16.17 |
| A6205 | COMPOSITE DRSG LESS THAN 48 SQ IN | $22.00 |
| A6210 | FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER | $101.92 |
| A6211 | FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER | $580.27 |
| A6212 | FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ IN OR LESS, EACH… | $99.18 |
| A6213 | FOAM DRG 16-48 SQ IN W/BRDR | $187.24 |
| A6216 | GAUZE NONIMPREG 16 SQ IN | $13.00 |
| A6217 | GAUZE NON STERILE | $88.12 |
| A6218 | GAUZE, NON STERILE | $149.37 |
| A6219 | GAUZE- STERILE | $42.36 |
| A6220 | GAUZE, NON IMP, STERILE, PAD SIZE >16 SQ < OR = 48SQ IN | $34.39 |
| A6222 | GAUZE IMPREGNATED WITH ME | $15.35 |
| A6231 | GAUZE, 16<SQ IN, EACH | $70.00 |
| A6250 | SKIN SEAL PROTECT MOISTURIZER OINTMENT | $98.03 |
| A6260 | WOUND CLEANSER | $96.95 |
| A6261 | WOUND FILLER | $423.60 |
| A6402 | GAUZE NON-IMPREG STERL 16 | $40.83 |
| A6407 | PACK STRIPS NON-IMPREGNTD | $89.35 |
| A6410 | STERILE EYE PAD OR STRIP | $6.00 |
| A6412 | OCCLUSIVE EYE PATCH | $30.00 |
| A6413 | ADHESIVE BANDAGE FIRST AI | $6.00 |
| A6446 | CONFORMING BANDAGE NON-EL | $19.00 |
| A6447 | Conforming bandage, non-elastic, knitted/woven, sterile, wi… | $26.57 |
| A6448 | LT COMP BANDAGE LESS THAN 3IN | $11.00 |
| A6449 | LIGHT COMP BANDAGE | $11.00 |
| A6450 | LT COMPRS BANDAGE ELAST | $17.00 |
| A6453 | BANDAGE SELF ADHER BAND W LESS THAN 3 | $13.73 |
| A6454 | SELF ADHER BANDAGE | $150.26 |
| A6455 | SELF ADHER BANDAGE | $30.50 |
| A6457 | TUBULAR DRESSING | $176.44 |
| A7002 | SUCTION TUBING USED W PUMP | $75.62 |
| A7003 | ADMN SET SM VOL NONFILTER | $57.00 |
| A7011 | NONDISPOS CORRUGATED TUBING | $12.00 |
| A7015 | NEBULIZER MASK USED W NEBULIZER | $57.00 |
| A7016 | DOME/MOUTHPEICE NEB | $161.00 |
| A7017 | NEBULIZER MASK NOT USED W/ OXYGEN | $57.00 |
| A7520 | TRACH LARYN TUBE NON CUFFED | $563.31 |
| A9150 | NON PERSCRIPTION DRUG | $21.55 |
| A9273 | HOT/COLD H2OBOT/CAP/COL/WRAP | $32.00 |
| A9284 | NON-ELECTRONIC SPIROMETER | $254.00 |
| A9579 | GAD-BASE MR CONTRAST NOS,1ML | $137.01 |
| C1751 | Catheter, infusion, inserted peripherally, centrally or mid… | $558.25 |
| C9399 | ORBACTIV 1200 MG IV | $6,744.41 |
| CASH | XRAY DISC | $17.00 |
| E0110 | CRUTCH FOREARM PAIR | $225.00 |
| E0114 | CRUTCHES UNDERARM | $97.93 |
| E0116 | CRTCH UNDARM NOT WOOD ADJ | $59.00 |
| E0220 | HOT WATER BOTTLE | $35.00 |
| E0230 | ICE CAP OR COLLAR | $12.00 |
| E0275 | BED PAN STANDARD | $11.00 |
| E0325 | URINAL MALE JUG-TYPE | $7.00 |
| E0352 | DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) | $177.00 |
| E04114 | E04114 | $41.00 |
| E0445 | OXIMETER NON-INVASIVE | $578.00 |
| E0570 | NEBULIZER WITH COMPRESSION | $677.00 |
| E0580 | NEBULIZER FOR USE W/ REGULAT | $293.00 |
| G0009 | ADM PNEUMOCOCCAL VACCINE | $185.38 |
| G0168 | WND CLS TISSUE ADHESIVE | $270.55 |
| G0378 | HOSPITAL OBSERVATION SERVICES PER HOUR | $2,000.00 |
| G0434 | DRUG ABUSE PANEL II | $230.00 |
| G2023 | COVID-19 Testing specimen collection for severe acute respi… | $30.00 |
| J0120 | TETRACYCLIN INJECTION | $30.00 |
| J0129 | ABATACEPT INJECTION | $25.00 |
| J0131 | INJECTION, ACETAMINOPHEN, 10 MG | $30.00 |
| J0153 | ADENOSINE INJ 1MG | $40.00 |
| J0170 | EPINEPHRINE 3 1/2 NDL 10M | $12.44 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $30.00 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $25.00 |
| J0290 | AMPICILLIN 500 MG INJ | $50.00 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $53.55 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $30.00 |
| J0456 | INJ AZITHROMYCIN 500MG | $25.00 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $20.00 |
| J0500 | DICYCLOMINE HCL 20MG | $45.00 |
| J0515 | INJ BENZTROPINE MESYLATE | $19.02 |
| J0558 | PENG BENZATHINE/PROCAINE INJ | $85.00 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $30.00 |
| J0610 | CALCIUM GLUCONATE INJECTION | $30.00 |
| J0690 | KEFZOL 1 GR VIAL | $25.00 |
| J0692 | INJ CEFEPIME HCI 500MG | $55.60 |
| J0696 | ROCEPHIN 250 MG | $30.00 |
| J0697 | STERILE CEFUROXIME INJECTION | $25.00 |
| J0735 | CLONIDINE 1MG | $25.00 |
| J0744 | CIPRO 200MG | $30.00 |
| J0760 | COLCHICINE INJECTION | $23.00 |
| J0780 | COMPAZINE 10 MG | $20.00 |
| J0840 | Injection, crotalidae polyvalent immune fab (ovine), up to … | $25.00 |
| J1020 | INJ METHYLPREDNISOLONE AC | $20.00 |
| J1030 | DEPO MEDROL 40 MG/ML | $22.00 |
| J1040 | METHYLPREDNISOLONE 80MG | $25.00 |
| J1094 | DECADRON DEXAMETHASONE ACETATE 1MG | $32.53 |
| J1100 | DECADRON 4 MG VIAL | $21.00 |
| J1110 | INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG | $240.00 |
| J1170 | DILAUDID 4 MG | $35.00 |
| J1200 | BENADRYL 50MG | $20.00 |
| J1610 | GLUCOGAN 1 MG VIAL | $50.00 |
| J1630 | HALOPERIDOL INJECTION | $39.70 |
| J1631 | HALOPERIDOL DECANOATE INJ PER 50 MG | $45.00 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $20.00 |
| J1644 | INJ HEPARIN SOD PER 1000 | $30.00 |
| J1650 | ENOXAPARIN SODIUM 10MG | $25.00 |
| J1741 | IBUPROFEN INJECTION | $22.00 |
| J1810 | DROPERIDOL/FENTANYL INJ | $25.00 |
| J1815 | INJ INSULIN PER 5 UNITS | $20.00 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $22.00 |
| J1885 | TORADOL INJ 15 MG | $20.00 |
| J1930 | LANREOTIDE INJECTION | $45.00 |
| J1940 | LASIX 40 MG IV VIAL | $35.00 |
| J1956 | LEVOFLOXACIN 250 MG | $45.00 |
| J2001 | LIDOCAINE HCI 10MG | $30.00 |
| J2060 | ATIVAN 2ML SYRUP | $35.00 |
| J2175 | DEMEROL 50 MG SYRINGE | $25.00 |
| J2180 | MEPERIDINE/PROMETHAZINE INJ | $30.00 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $30.00 |
| J2270 | INJ MORPHINE SULFATE 10 M | $30.00 |
| J2274 | INJ MORPHINE PF EPID ITHC | $30.00 |
| J2360 | ORPHENADRINE CITRATE 60MG | $30.00 |
| J2405 | ONDANSETRON HCI, PER MG | $21.00 |
| J2410 | OXYMORPHONE HCL INJECTION | $25.00 |
| J2425 | PALIFERMIN INJECTION | $25.00 |
| J2504 | PEGADEMASE BOVINE, 25 IU | $25.00 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $30.00 |
| J2550 | PHENERGAN 50 MG | $35.00 |
| J2704 | INJECTION PROPOFOL 10 MG | $22.00 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $30.00 |
| J2770 | QUINUPRISTIN/DALFOPRISTIN | $405.68 |
| J2780 | INJ RANITIDINE 25 MG | $20.00 |
| J2800 | METHOCARBAMOL INJECTION | $50.00 |
| J2920 | SOLU-MEDROL 40MG | $32.00 |
| J2930 | SOLU-MEDROL 125 MG | $35.00 |
| J3010 | INJ FENTANYL CITRATE .1MG | $33.00 |
| J3030 | IMITREX 6MG VIAL | $50.00 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $50.00 |
| J3360 | VALIUM INJ 5 MG | $25.00 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $30.00 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $50.00 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $20.00 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $125.00 |
| J3490 | UNCLASSIFIED DRUGS | $31.00 |
| J7030 | INFUS NORM SALINE 1000CC | $45.00 |
| J7040 | INFUS NORM SALINE 500ML | $40.00 |
| J7042 | 5% DEXTROSE | $45.00 |
| J7050 | INFS NORM SALINE 250CC | $48.00 |
| J7070 | INFUSION D5W 1000ML | $20.00 |
| J7120 | RINGER’S LACTATE INFUS | $50.00 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $50.00 |
| J7131 | HYPERTONIC SALINE SOL | $20.00 |
| J7192 | FACTOR VIII RECOMBINANT NOS | $20.00 |
| J7313 | FLUOCINOL ACET INTRAVIT IMP | $20.00 |
| J7506 | PREDNISONE ORAL 5 MG | $8.00 |
| J7510 | PREDNISOLONE ORAL 5 MG | $15.00 |
| J7611 | ALBUTEROL 1MG CONC INHALA | $35.00 |
| J7613 | ALBUT INHAL NON-CP 1MG | $35.00 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $35.00 |
| J7615 | LEVALBTERAL INHALATION SO | $35.00 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $35.00 |
| J7631 | CROMOLYN SODIUM NONCOMP UNIT | $20.00 |
| J7637 | DEXAMETHASONE COMP CON | $20.00 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $50.00 |
| J7682 | TOBRAMYCIN NON-COMP UNIT | $25.00 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $25.00 |
| J8498 | ENEMA SUPPOSITORY, ANTIEMETIC RECTAL | $25.00 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $25.00 |
| J9206 | IRINOTECAN INJECTION | $25.00 |
| L0120 | CERVICAL FLEX NONADJ COLL | $142.78 |
| L0172 | CLAVICAL COLLAR 2 PC | $139.39 |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam, two piece… | $382.86 |
| L1630 | ABDUCT CONTROL HIP SEMI FLEX | $41.00 |
| L1812 | Knee orthosis (KO), elastic with joints, prefabricated, off… | $143.01 |
| L1830 | KNEE IMMOBOLIZER | $180.48 |
| L1906 | ANKLE SUPPORT | $163.75 |
| L1960 | Ankle foot orthosis (AFO), posterior solid ankle, plastic, … | $2,358.00 |
| L2116 | Ankle foot orthosis (AFO), fracture orthosis, tibial fractu… | $1,978.68 |
| L2136 | Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral… | $1,720.92 |
| L3260 | SURGICAL BOOT/SHOE | $413.25 |
| L3650 | SO FIGURE EIGHT ABDUCTION | $158.72 |
| L3670 | SO ACROMIO/CLAVICULAR | $351.28 |
| L3762 | Elbow orthosis (EO), rigid, without joints, includes soft i… | $954.21 |
| L3809 | Wrist-hand-finger orthosis (WHFO), without joint(s), prefab… | $824.25 |
| L3908 | WRIST EXTN CONTROL COCKUP | $197.41 |
| L3924 | Hand finger orthosis (HFO), without joints, | $158.50 |
| L3930 | HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT… | $405.96 |
| L3999 | UPPER LIMB ORTHOSIS NOS | $176.00 |
| L4350 | AIR SPLINT | $203.01 |
| L4360 | WALK BOOT PNEUMATIC | $388.31 |
| L4380 | PNEUMATIC KNEE SPLINT | $125.00 |
| L4386 | WALKING BOOT NON PNEUMATIC | $420.80 |
| L4387 | NON-PNEUM WALK BOOT PRE OTS | $305.30 |
| L4631 | Ankle foot orthosis (AFO) | $1,399.17 |
| M0239 | Intravenous infusion, bamlanivimab-xxxx, includes infusion … | $1,200.00 |
| M0243 | Intravenous infusion, casirivimab and imdevimab includes in… | $1,200.00 |
| M0245 | intravenous infusion, bamlanivimab and etesevimab, includes… | $1,200.00 |
| P7001 | CULTURE BACTERIAL URINE | $89.00 |
| P9612 | CATHETERIZE FOR URINE | $186.02 |
| Q0144 | AZITH DIHY ORAL CAP/POWD | $172.69 |
| Q0179 | ONDANESTRONG HCL 8MG ORL | $4.00 |
| Q0239 | Injection, bamlanivimab, 700 mg | $0.01 |
| Q0243 | Injection, casirivimab and imdevimab, 2400 mg | $0.01 |
| Q0244 | Injection, casirivimab and imdevimab, 1200 mg | $0.01 |
| Q0245 | Injection, bamlanivimab and etesevimab, 2100 mg | $0.01 |
| Q4006 | LONG ARM CAST ADULT | $92.00 |
| Q4007 | CAST SUPPLIES LONG ARM CA | $15.00 |
| Q4008 | CAST SUPPLIES LONG ARM | $40.00 |
| Q4009 | CAST SUPPLIES SHORT ARM | $140.00 |
| Q4010 | SHORT ARM CAST ADULT | $55.00 |
| Q4012 | CAST SUPPLIES SHORT ARM | $87.00 |
| Q4020 | LNG ARM SPLNT 0-10 YRS | $39.00 |
| Q4022 | SHRT ARM SPLNT 11 YRS + | $805.00 |
| Q4034 | CAST SUP LNG LEG CYLINDER FB | $176.00 |
| Q4037 | CAST SUPPLIES SHORT LEG | $146.00 |
| Q4038 | CAST SUP SHRT LEG FIBERGLASS | $1,513.23 |
| Q4039 | CAST SUPPLIES SHORT LEG C | $146.00 |
| Q4042 | LNG ARM SPLNT 11 YRS + | $117.00 |
| Q4046 | SHRT LG SPLNT 11 YRS + | $249.00 |
| Q4049 | FINGER SPLNT STATIC | $206.00 |
| Q4051 | SPLINT SUPPLIES MISC | $198.00 |
| Q9954 | ORAL MR CONTRAST, 100ML | $193.03 |
| Q9963 | HI OSM CONTRST MATL 350-3 | $51.73 |
| Q9965 | LOW OSMOLAR CON MAT PER M | $34.49 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $64.36 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $15.00 |
| S0020 | INJ, BUPIVICAINE, 30ML | $216.80 |
| S0028 | INJECT FAMOTIDINE 20 MG | $85.34 |
| S0030 | METRONIDAZOLE 500 MG INJ | $193.46 |
| S0077 | CLANDAMYCIN PHOSPHATE 300 | $57.93 |
| S0119 | ZOFRAN, 4MG, ORAL | $96.22 |
| S0164 | PROTONIX PANTROPRAZOLE 40MG | $137.54 |
| S0622 | PHYS EXAM FOR COLLEGE | $87.00 |
| S0630 | RMV SUTURES; PHYS NOT PHY | $179.78 |
| S3000 | BILAT DIL RETINAL EXAM | $11.00 |
| S5000 | PRESCRIPTION DRUG GENERIC | $10.00 |
| S5001 | PRESCRIPTION DRUG BAND NM | $15.00 |
| S5010 | STERILE SALINE 5% DEXTROSE AND 0.45% SALINE | $243.48 |
| S5011 | 5% DEXTROSE 1000 ML | $1.00 |
| S5550 | INSULIN RAPID 5 U | $16.98 |
| S8037 | MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY | $1,284.00 |
| S8100 | SPACER WITHOUT MASK | $52.00 |
| S8101 | MASK NEBULIZER MASK SPACER WITH MASK | $59.00 |
| S8450 | SPLINT | $84.00 |
| S8451 | Splint, prefabricated, wrist or ankle | $33.00 |
| U0002 | COVID-19 PCR Testing | $327.39 |
| V2799 | Vision item or service, miscellaneous | $25.00 |
