Charge Master 05 09 2025

CPT Code

CPT Code Description

Charge Amount

0202U

COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing

$1,989.31

0241U

Infectious disease (viral respiratory tract infection), pat…

$758.89

10021

FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE

$4,641.31

10060

INCISION/DRAINAGE ABSCESS

$2,286.00

10061

INS/DRAIN ABSCESS COMPL

$3,124.00

10080

INCISION & DRAINAGE PILONIDAL CYST SIMPLE

$2,960.35

10081

I&D PILONIDAL CST COMP

$6,936.97

10120

I & RMVL SUB-CUT SIMPLE

$9,595.88

10121

I & RMVL FB, SUB-CUT,COMP

$10,100.00

10140

I&D HEMATOMA SEROMA/FLUID COLLECTION

$16,133.10

10160

PUNCTURE ASP OF ABSCESS

$2,376.65

10180

Incision and drainage, complex, postoperative wound infecti…

$20,219.00

11000

DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF

$333.96

11010

DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS

$12,186.00

11011

DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC

$22,069.41

11042

DBRD SKN SUBQ TISSUE

$9,761.39

11043

DEBRIDEMENT SUBCUTANEOUS TISSUE&MUSCLE

$14,693.47

11045

Deb subq tissue add-on

$4,434.64

11055

PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1

$649.29

11056

PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4

$1,021.17

11200

RMVL SKIN TAGS

$10,474.13

11402

EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM

$13,139.00

11403

EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM

$23,908.58

11404

EXC BGN LSN TRUNK 3.1-4.0

$14,995.13

11406

EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM

$12,815.95

11420

EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<

$16,381.22

11421

EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM

$8,647.10

11422

EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM

$13,163.65

11423

EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM

$11,349.41

11440

Excision, other benign lesion including margins, except ski…

$15,568.25

11441

EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM

$10,861.67

11443

EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM

$19,091.71

11719

TRIMMING NONDYSTROPHIC NAILS ANY NUMBER

$310.00

11720

DEBRIDE NAIL 1-5

$486.17

11730

AVULSION/1-NAIL PLATE

$3,172.29

11732

Avulsion of nail plate, partial or complete, simple; each a…

$1,125.07

11740

EVAC SUBUNGUAL HEMATOMA

$1,381.34

11750

EXC NAIL PART/COMP

$10,149.71

11760

REPAIR NAIL BED

$6,346.00

11765

WEDGE EXC SKIN/NAIL BED

$5,403.55

11771

EXCISION PILONIDAL CYST SINUS EXTENSIVE

$22,279.64

11900

Injection, intralesional; up to and including 7 lesions

$5,324.64

11982

REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT

$13,668.99

12001

LACERATION REPAIR

$1,489.84

12002

REPAIR LAC SCALP 2.6-7.5

$1,742.63

12004

REPAIR LAC SCALP 7.6-12.5

$1,556.87

12005

REPAIR LAC,SCALP 12.6-20C

$2,016.99

12006

SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM

$2,110.17

12007

SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM

$2,305.00

12011

REPAIR LAC FACE LESS THAN 2.5 CM

$1,521.30

12013

REPAIR LAC FACE 2.6-5.0CM

$1,416.77

12014

REPAIR LAC FACE 5.1-7.5CM

$1,639.40

12015

Rpr f/e/e/n/l/m 7.6-12.5 cm

$1,789.21

12016

SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM

$2,342.32

12017

SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM

$3,114.00

12020

TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE

$8,522.87

12021

TX SUPERFICIAL WOUND DEHISCENCE W/PACKING

$9,614.19

12031

LYR CLSR S/A/T/E 2.5CM

$2,470.88

12032

REPAIR-INT SCALP 2.6-7.5

$2,846.00

12034

INTERM RPR SCLP/TRNK/EXTR

$2,772.78

12035

REPAIR INTERM S/A/T/E 12.

$5,486.18

12036

REPAIR INTERM S/A/T/E 20.1-30.0 CM

$6,692.00

12037

REPAIR INTERMEDIATE S/A/T/E > 30.0 CM

$9,290.00

12041

LAYER CLSR NECK/HAND 2.6

$2,200.64

12042

REPAIR LAC HAND/FOOT 2.6-

$2,577.00

12044

LYR CLSR N/H/F/ETRNL GENT

$4,358.00

12045

REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM

$3,472.00

12046

RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM

$1,682.55

12047

REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM

$4,774.16

12051

LAYER CLSR OF WND NCK/HND

$2,858.04

12052

LYR CLSR WOUND 2.6-5.0FAC

$2,179.92

12053

LYR CLSR F/E/E/N/L/M&/MUC

$2,085.93

12054

REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM

$2,379.00

12055

REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM

$2,494.00

12056

REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 20.1-30.0CM

$5,622.60

13100

REPAIR COMPLEX TRUNK 1.1 CM-2.5 CM

$9,620.10

13101

REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM

$7,300.07

13102

REPAIR COMPLEX TRUNK EA 5 CM/<

$5,548.00

13120

REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM

$6,502.19

13121

RPR CMPX SCALP ARM2.6-7.5

$7,267.00

13122

CMPLX RPR ADD 5 CM OR LES

$6,593.00

13131

REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM

$4,667.20

13132

RPR CMPX FOREHEAD/CHECK/C

$4,196.00

13133

Repair, complex, forehead, cheeks, chin, mouth, neck, axill…

$3,343.23

13151

CMPX RPR EYE NOSE 1.1-2.5

$8,624.88

13152

RPR CPLX E/N/E/L 2.6-7.5

$4,508.00

13153

REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM<

$3,197.00

15851

REMOVAL SUTR/STAPLE REQ ANES

$11,353.34

15853

REMOVAL SUTR/STAPL XREQ ANES

$1,321.91

15854

REMOVAL SUTR&STAPL XREQ ANES

$2,383.13

16000

BURN, INITIAL TREATMENT

$1,479.00

16020

BURN, DRESSING/DBRDMNT-SM

$1,352.05

16025

DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM

$1,844.18

16030

Dressings and/or debridement of partial-thickness burns, in…

$2,057.68

17000

DESTRUCTION PREMALIGNANT LESION 1ST

$2,368.43

17110

DESTRUCTION BENIGN LESIONS UP TO 14

$1,913.39

17250

Destruction Procedures on Benign or Premalignant Lesions of…

$1,834.29

19000

PUNCTURE ASPIRATION CYST BREAST

$3,044.88

19020

MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP

$13,120.00

19100

BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX

$9,171.37

20102

EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK

$20,929.00

20103

EXPLORATION PENETRATING WOUND SPX EXTREMITY

$7,090.00

20520

REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE

$16,267.56

20525

RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP

$14,055.00

20550

INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS

$6,708.57

20551

INJ TENDON ORIGIN/INSERTION

$1,848.89

20552

TRIGGER POINT INJ 1-2 MUS

$5,238.25

20553

Injection(s); single or multiple trigger point(s), 3 or mor…

$7,713.66

20600

ARTHROCENTESIS, SML JOINT

$2,869.17

20605

ARTHROCENTESIS, MED JOINT

$5,502.53

20610

ARTHROCENTESIS, LG JOINT

$6,668.92

20611

Arthrocentesis, aspiration and/or injection, major joint or…

$5,567.92

20612

Aspiration and/or injection of ganglion cyst any location

$3,641.57

20650

INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX

$20,971.00

21315

CLOSED TX NASAL FRACTURE W/O STABILIZATION

$13,611.00

21320

Closed treatment of nasal bone fracture; with stabilization

$16,066.38

21337

CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION

$9,109.00

21450

CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION

$17,732.39

21451

Treat lower jaw fracture

$18,574.00

21480

CLDS TX TEMP DISLOCATION

$2,168.91

21485

CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ

$11,470.00

21501

I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX

$18,671.00

21705

DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB

$17,150.50

23075

EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM

$12,321.28

23500

CLTX CLAVICULAR FX WO MNP

$1,110.00

23505

CLSD TX CLAVICULAR FRACTURE W/MANIPULATION

$8,855.00

23545

CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION

$2,354.00

23550

OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC

$26,613.59

23600

CLTX PROX HUMRL FX WO MAN

$1,835.00

23620

CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ

$1,511.00

23650

SHOULDER DISLOCATION TRMT

$1,898.00

23655

lllClosed treatment of shoulder dislocation, with manipulatio…

$5,867.55

23665

Closed treatment of dislocation with fracture with manipula…

$4,893.00

23930

I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA

$16,749.00

23931

I&D, upper arm or elbow area; bursa

$13,519.00

24075

Exc arm/elbow les sc < 3 cm

$12,071.19

24200

RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS

$10,398.00

24357

Tenotomy, elbow, lateral or medial (eg, epicondylitis, tenn…

$32,617.83

24500

CLTX HUMRL SHFT FX W/O MN

$2,101.00

24505

CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ

$4,973.00

24530

CLTX SPRCNDYLR/TRANSCNDYL

$2,019.97

24535

CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ

$8,458.00

24565

CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MNPJ

$7,155.00

24586

Open treatment of periarticular fracture and/or dislocation…

$39,223.00

24600

CLSD TX ELBOW DISLOCAT

$2,059.00

24605

Treatment of closed elbow dislocation; requiring anesthesia

$8,414.43

24615

OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION

$10,177.39

24620

CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ

$8,618.99

24640

RADIAL HEAD SUBLUX. CHILD

$1,938.79

24650

CLTX RDL HEAD FX WO MANP

$6,969.49

24655

CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION

$8,185.61

24670

CLTX ULNR FX PROX END WO

$8,430.27

24675

CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ

$7,023.00

25028

Drainage of forearm lesion

$10,851.00

25066

Biopsy forearm soft tissues

$10,127.42

25111

Excision of Ganglion, wrist (dorsal or volar); primary

$19,536.33

25500

CLTX RDL SHFT FX WO MANP

$1,768.00

25505

CLSD TX RAD SHAFT W/MANIP

$9,227.21

25520

CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT

$6,985.00

25530

CLSD TX ULNAR SHFT FX NO

$1,545.00

25535

CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION

$7,488.87

25565

CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ

$8,954.73

25574

OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA

$6,824.26

25600

CLSD TX DISTAL RAD FX WO

$9,201.69

25605

CLSD TX DISTAL RAD FX

$5,622.26

25607

Open treatment of distal radial extra-articular fracture or…

$27,757.32

25622

CLSD TX NAVICULAR FX WO M

$711.34

25635

CLTTX CARPL B1 FX W/MNPJ EA B1

$7,513.00

25650

CLTX UR SYLOID FX

$4,744.49

25652

OPEN TREATMENT ULNAR STYLOID FRACTURE

$18,075.00

25660

Closed treatment of radiocarpal or intercarpal dislocation,…

$1,283.00

25675

CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH MANI…

$2,695.39

25690

Closed treatment of lunate dislocation, with manipulation

$8,508.00

26010

I & D FINGER ABSCESS,SIMP

$3,416.76

26011

DRAINAGE OF FINGER ABCESS

$8,847.00

26567

Osteotomy; phalanx of finger, each

$7,662.12

26600

CLSD TX METACARPAL FX

$4,656.23

26605

CLSD TX MEDICARPAL FX

$3,361.74

26615

OPEN TX METACARPAL FRACTURE SINGLE EA BONE

$19,438.50

26641

Closed treatment of carpometacarpal dislocation, thumb, wit…

$2,323.95

26670

CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES;  Closed …

$1,914.00

26675

Closed treatment of carpometacarpal dislocation, other than…

$5,266.00

26700

CLS TX MCP DISLOCATION

$1,891.91

26705

TREAT KNUCKLE DISLOCATION

$3,807.00

26720

CLSD TX PHALANGEAL SHFTFX

$1,389.00

26725

CLTX PHLNGL FX PROX/MIDDL

$2,155.90

26735

OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA

$28,194.70

26740

Closed treatment of articular fracture, involving metacarpo…

$256.17

26742

CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ

$6,051.30

26746

OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA

$16,976.67

26750

CLS TX FX FINGER/THUMB

$3,719.89

26755

CLTX DSTL PHLNGL FX FNGR/

$2,022.00

26765

OPEN TX DISTAL PHALANGEAL FRACTURE EACH

$17,612.77

26770

TREAT FINGER DISLOC FINGE

$1,792.51

26775

Treat finger dislocation

$3,610.00

26952

AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP

$18,008.66

27096

INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA

$9,489.39

27301

I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION

$19,128.00

27372

REMOVAL FOREIGN BODY DEEP THIGH/KNEE

$21,544.09

27502

CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ

$10,941.00

27520

CLTX PATELLAR FX W/O MNPJ

$1,777.00

27530

CLTX TIBL FX PROX W/O MNPJ

$1,076.48

27550

CLOSED TX KNEE DISLOCATION W/O ANESTHESIA

$3,375.71

27560

CLTX PATELLAR DISLC W/O A

$1,946.58

27750

CLTX TIBL SHFT FX W/O MNPJ

$999.34

27752

CLTX TIBL SFT FX W/MANP

$6,573.33

27760

CLTX MEDIAL MALLS FX W/O

$8,843.44

27762

CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ

$6,355.57

27780

CLTX PROX FIVULA/SHFT FX

$1,603.00

27786

CLSD TX DISTAL FIBULAR FX

$12,818.22

27788

CLTX DSTL FIBULAR FX LAT MALLS W/MANJ

$3,638.46

27792

Open treatment of distal fibular fracture (lateral malleolu…

$21,656.74

27808

CLOSED TX BIMALLEOLAR ANK

$2,469.53

27810

CLTX BIMAL ANKLE FX W/POT

$5,073.48

27818

Treatment of ankle fracture

$8,273.30

27824

Closed treatment of fracture of weight bearing articular po…

$858.47

27840

CLOSED TX ANKLE DISLOCATI

$2,233.00

27842

Closed treatment of ankle dislocation; requiring anesthesia…

$8,221.99

28001

INCISION&DRAINAGE BURSA FOOT

$7,605.56

28024

Arthrotomy, including exploration, drainage, or removal of …

$4,502.90

28190

RMVL FB BODY FOOT SUBQ

$5,561.51

28192

RMVL FB FOOT DEEP

$15,469.00

28193

Removal of foreign body, foot; complicated

$10,905.21

28400

CLSD TX CLAVICLE FX WO MA

$438.86

28430

CLTX TALUS FX W/O MNPJ

$838.04

28450

TX TARSAL B1 FX XCP TALUS

$1,303.00

28470

CLTX METAR FX WO MNP

$3,545.12

28475

Treat metatarsal fracture

$5,808.91

28490

CLTX FX GRT TOE W/O MNLJ

$1,495.29

28495

CLTX FX GRT TOE PHLX/PHLG W/MNPJ

$2,281.00

28505

OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES

$19,402.00

28510

CLSD TX FX PLALANX/PHALAN

$1,972.69

28515

FX CARE PHALANX NOT GREAT

$2,321.00

28600

CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES

$1,194.00

28630

CLTX METATARSOPHLNGL JT DISLC W/O ANES

$1,301.00

28660

CLSD TX PIP JNT DISLOCATI

$2,924.97

29065

Application, cast; shoulder to hand (long arm)

$1,921.57

29075

APPLICATION CAST ELBOW FINGER SHORT ARM

$753.87

29085

CAST HAND/LOWER FOREARM GAUNTLET

$2,284.64

29086

APPLICATION CAST FINGER

$559.71

29105

LONG ARM SPLINT

$1,952.91

29125

SHORT ARM SPLINT

$1,055.34

29126

SHORT ARM SPLINT DYNAMIC

$1,586.90

29130

APPLICATION FINGER SPLINT

$815.12

29131

APPLICATION FINGER SPLINT DYNAMIC

$940.12

29240

STRPG SHO

$2,067.66

29260

Strapping Of Elbow Or Wrist

$814.80

29280

STRAPPING HAND/FINGER

$840.92

29355

Application of long leg cast

$1,423.00

29405

Application of short leg cast (below knee to toes)

$8,651.75

29450

APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG

$3,812.14

29505

LONG LEG SPLINT

$1,269.00

29515

SHORT LEG SPLINT

$1,192.32

29530

STRAPPING KNEE

$793.00

29540

STRAPPING ANKLE/FOOT

$838.72

29550

STRAPPING TOES

$606.00

29580

STRAPPING UNNA BOOT

$828.77

29700

RMVL/BIVALV GAUNTLET BOOT

$1,185.91

29705

Removal or bivalving; full arm or full leg cast

$507.09

29799

Unlisted px casting/strpg

$26,166.00

29840

Arthroscopy, wrist, diagnostic, with or without synovial bi…

$16,744.00

30020

Drainage of nose lesion

$13,586.45

30300

RMVL FOREIGN BODY NASAL

$1,283.00

30802

ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL

$4,583.19

30901

NASAL PACKING

$1,473.04

30903

CTRL NSL HEMRRG ANT CPLX

$1,191.58

30905

Control nasal hemorrhage, posterior, with posterior nasal p…

$1,458.13

30906

Cntrl nasal hemorrhage, posterior,w/ posterior nasal packs …

$1,373.00

31500

INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE

$1,790.79

31502

TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT

$7,598.00

31505

LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX

$4,868.47

31525

LARGSC +-TRACHEOSCOPY DX

$12,685.00

31541

LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP

$12,639.01

31575

LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC

$2,197.47

31600

TRACHEOSTOMY PLANNED SPX

$10,241.71

31605

TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE

$3,323.98

32550

INSERT PLEURAL CATH

$16,651.44

32551

TUBE THORACOSTOMY INCLUDES WATER SEAL

$4,876.00

32556

Pleural drainage, percutaneous, with insertion of indwellin…

$7,307.00

36000

INTRODUCTION OF NEEDLE/IN

$1,101.00

36005

OPERATING ROOM SERVICES – GENERAL CLASSIFICATION

$6,155.60

36010

INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA

$7,983.80

36011

Place catheter in vein

$10,340.57

36410

VENIPUNCTURE, 3 YRS OR OLDER

$2,251.92

36415

VENIPUNCTURE

$108.33

36416

COLL CAPILLARY BLG SPEC

$104.63

36556

Insertion of non-tunneled centrally inserted central venous…

$12,572.19

36558

INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR

$11,529.20

36569

IV cather

$6,756.18

36573

Insertion through the skin of a thin tube (catheter) into a…

$7,349.83

36575

RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP

$3,447.36

36589

Removal of tunneled central venous catheter, without subcut…

$8,636.00

36591

COLLECT BLOOD FROM IMPLAN

$800.95

36592

Collect blood from picc

$851.48

36680

Placement of needle for intraosseous infusion

$1,295.87

37785

LIGATION, DIVISION, ANDOR EXCISION OF VARICOSE VEIN CLUSTERS

$15,248.88

40650

RPR LIP FULL THICKNESS

$5,180.92

40800

DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL

$2,711.29

40801

Drainage of mouth lesion

$8,084.00

40804

RMVL EMBEDDED FB VESTIBULE MOUTH SMPL

$2,841.00

40830

Closure of laceration, vestibule of mouth; 2.5 cm or less

$3,516.38

40831

CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL

$3,996.00

41008

Intraoral incision and drainage of abscess, cyst, or hemato…

$10,165.00

41250

REPAIR TONGUE LACERATION

$1,417.96

41252

Repair tongue laceration

$2,752.00

41800

DRNG ABSC DENTOALVEOLAR S

$1,665.88

41899

Unlisted procedure, dentoalveolar structures

$8,737.32

42330

REMOVAL OF SALIVARY STONE

$18,955.00

42700

I&D ABSC PRITONSILLAR

$3,485.00

42809

REMOVAL FOREIGN BODY PHARYNX

$1,768.00

43215

Esophagoscopy, flexible, transoral; with removal of foreign…

$16,110.01

43752

NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE

$4,455.69

43753

GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING …

$1,524.27

45915

RMVL FECAL IMPACTION/FB SPX UNDER ANES

$16,218.00

46040

I&D ISCHIOR/PRIRC ABSC SP

$13,009.00

46050

INC/DRAIN PERIANAL ABS SU

$8,955.00

46083

INCISION THROM HEMORRHOID

$1,548.00

46221

Hemorrhoidectomy, internal, by rubber band ligation(s)

$24,637.53

46320

ENULEATION EXCC OF EXT HE

$10,291.00

46608

ANOSC RMVL FB

$10,924.00

49083

Abdominal paracentesis (diagnostic or therapeutic); w/ imag…

$5,664.07

49505

Prp i/hern init reduc >5 yr

$23,433.92

51700

BLDR IRR SMPL LVG&/INSTLJ

$3,474.67

51701

INSR NONDWELLING BLDR CAT

$1,163.02

51702

INSERTION BLADDER CATH

$1,155.21

51703

INSERT BLADDER CATH COMPL

$3,536.66

54001

SLITTING PREPUCE DORSAL/LAT SPX XCP NB

$19,822.88

54015

Incision and drainage of penis, deep

$7,571.37

54163

REPAIR INCOMPLETE CIRCUMCISION

$14,149.65

54220

IRRIGATION CORPORA CAVERNOSA PRIAPISM

$1,569.00

54235

NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT

$3,442.44

54437

REPAIR OF TRAUMATIC CORPOREAL TEAR(S)

$14,331.00

54450

FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING

$2,577.00

55100

DRAINAGE SCROTAL WALL ABSCESS

$6,738.00

55175

Scrotoplasty; simple

$9,832.60

56405

INC/DRAIN VULVA/PERINEAL

$2,272.03

56420

I & D BARTHOLIN ABSCESS

$1,679.48

56440

Surgery for vulva lesion

$21,416.00

57410

Pelvic examination

$17,877.00

57415

REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL

$21,521.00

58301

REMOVAL INTRAUTERINE DEVICE IUD

$5,981.02

59025

FTL NON-STRS TST

$1,976.74

59409

VAG DLVR ONLY

$14,605.00

62270

SPINAL PUNCTURE,LUMBAR

$4,050.94

62272

Drain cerebro spinal fluid

$4,181.00

64400

NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH

$2,159.00

64405

N BLOCK INJ OCCIPITAL

$4,888.27

64415

N block inj brachial plexus

$6,112.90

64447

INJECTION ANESTHETIC AGENT FEMORAL NERVE SINGLE

$10,044.96

64450

INJ ANESTHETIC AGENT

$4,448.31

64454

Injection(s), anesthetic agent(s) and/or steroid; genicular…

$6,303.44

64455

Inj, anesthetic agent a/o steroid, plantar common digital n…

$2,189.89

64640

DSTRJ NULYT OTH PRPH NVR/BRANCH

$9,090.76

65205

REMOVAL FB EYE-SUPERFCL

$1,176.50

65210

RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR

$1,208.98

65220

RMVL FB EYE W/O SLIT LAMP

$1,973.88

65222

RMVL FB EYE

$1,129.00

65235

Remove foreign body from eye

$7,479.00

65435

Removal of corneal epithelium; with or without chemocauteri…

$2,873.86

67700

I&D ABSCESS EYELID

$2,510.38

67938

Removal of embedded foreign body, eyelid

$1,605.00

69000

Drainage external ear, abscess or hematoma

$2,455.38

69005

DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED

$8,679.07

69020

DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS

$4,475.67

69200

RMVL FOREIGN BODY EAR

$1,084.34

69205

RMVL FB XTRNL AUD CANAL A

$8,108.40

69209

REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL

$941.00

69210

RMVL IMPACTED CERUMEN

$1,520.57

69220

DBRDMT MSTDC CAVITY SMPL

$6,057.10

69399

Unlisted procedure, external ear

$10,124.51

70030

RADEX EYE DETCJ FB

$761.21

70100

XRAY MANDIBLE LESS THAN 4 VIEWS

$883.00

70110

XRAY MANDIBLE MIN 4 VIEWS

$1,065.77

70130

RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE

$446.04

70140

XRAY FACIAL BONES LESS THAN 3 VIEW

$966.45

70150

XRAY FACIAL BONES GREATER THAN 3 VIEW

$1,518.74

70160

NASAL BONE X-RAY

$1,171.43

70200

RAD EXAM ORBIT COMP.

$1,404.67

70210

RADEX SINUSES PARANASAL <3 VIEWS

$854.03

70220

RAD EXAM SINUS COMPLETE

$1,652.60

70250

SKULL LESS THAN 4 VIEWS

$1,255.69

70260

RAD EXAM SKULL COMPLETE

$2,547.01

70328

RADEX TMPRMAND JT OPN&CLSD MOUTH UNI

$782.58

70330

RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT

$1,472.90

70350

CEPHALOGRAM ORTHODONTIC

$1,007.48

70360

RAD EXAM NECK,SOFT TISSUE

$916.40

70450

CT HEAD/BRAIN W/O CONTRAST MATERIAL

$6,039.17

70460

CT HEAD/BRAIN W/CONTRAST MATERIAL

$7,594.69

70470

CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL

$8,772.99

70480

CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL

$6,317.97

70481

CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL

$7,136.61

70482

CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR

$9,167.21

70486

CT MAXILLOFACIAL W/O CONTRAST MATERIAL

$6,319.26

70487

CT MAXILLOFACIAL W/CONTRAST MATERIAL

$7,129.56

70488

CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL

$8,472.13

70490

CT NECK WO CONTRAST

$6,504.29

70491

CT SOFT TISS NCK C+MATRL

$7,506.08

70492

CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL

$8,859.04

70496

CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST

$10,036.36

70498

CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST

$9,863.34

70544

MRA HEAD C-MATRL

$8,078.36

70547

MRA NECK C-MATRL

$8,454.05

70551

MRI BRN BRN STEM C-MATRL

$8,670.45

70553

MRI BRN BRN STEM C-/C+

$12,192.48

71045

RADIOLOGIC EXAM CHEST SINGLE VIEW

$987.60

71046

CHEST XRAY 2 VIEWS

$1,228.76

71047

RADIOLOGIC EXAM CHEST 3 VIEWS

$1,376.41

71048

RADIOLOGIC EXAM CHEST 4+ VIEWS

$1,270.54

71100

RIBS UNILATERAL 2 VIEWS

$1,147.70

71101

RIB UNILATERAL W CHEST

$1,526.84

71110

RIBS BILATERAL 3 VIEWS

$1,723.28

71111

RIBS BILATERAL W/CHEST

$2,027.13

71120

Radiologic examination; sternum, minimum of 2 views

$1,259.82

71250

CT CHEST W/O CONTRAST

$6,101.29

71260

CT THORAX W/CONTRAST

$7,793.36

71270

CT THORAX WO CONTRAST

$9,932.36

71271

CT THORAX LUNG CANCER SCR C-

$730.02

71275

CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST

$9,828.86

71550

MRI CH C-MATRL

$7,386.46

72020

SPINE SINGLE VIEW

$875.81

72040

SPINE, CERVICAL 2/3 VIEWS

$1,294.21

72050

SPINE, CERVICAL MIN 4VIEW

$1,968.72

72052

SPINE CERV. COMP FLEX/EXT

$2,299.63

72070

SPINE THORACIC 2 VIEWS

$1,410.89

72072

SPINE THORACIC 3 VIEWS

$1,958.55

72074

RAD EXAN SPINE THROAC 4 V

$1,698.56

72080

RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS

$1,542.94

72082

RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW

$1,816.53

72100

Radiologic examination, spine, lumbosacral; 2 or 3 views

$1,484.58

72110

LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS

$2,059.48

72114

RAD EXAM SPINE LUMBO COMP

$2,765.24

72120

SPINE LUMBAR AP & LAT W F

$1,692.58

72125

CT CERVICAL SPINE W/O CONTRAST MATERIAL

$7,253.85

72126

CT CERVICAL SPINE W/CONTRAST MATERIAL

$9,206.55

72127

CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL

$8,843.31

72128

CT THRC SPI C-MATRL

$7,412.06

72129

CT THRC SPI C+ MATRL

$8,169.76

72130

CT THORACIC SPINE W/O & W/CONTRAST MATERIAL

$9,579.06

72131

CT LUMBAR SPINE W/O CONTRAST MATERIAL

$7,133.37

72132

CT LUMBAR SPINE W/CONTRAST MATERIAL

$9,853.24

72133

CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL

$6,982.00

72141

MRI SPI CANAL&CNTS CRV C-MATRL

$8,933.86

72146

MRI SPI CANAL&CNTS THRC C-MATRL

$9,097.74

72148

MRI SPI CANAL&CNTS LMBR C-MATRL

$9,174.67

72156

MRI SPI CANAL&CNTS C-/C+ CRV

$12,818.34

72157

MRI SPI CANAL&CNTS C-/C+

$12,891.47

72158

MRI SPI CANAL&CNTS C-/C+ LMBR

$13,004.83

72170

RAD EXAM PELVIS 1/2 VEIW

$1,139.17

72190

RADEX PELVIS COMPL MIN 3

$1,809.31

72191

CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST

$10,177.15

72192

CT PELVIS WO CONTRAST

$6,075.46

72193

TOMOGRAPHY PELVIS WCONTRS

$7,613.50

72194

CT PELVIS W OR WO CONTRST

$9,112.91

72195

MRI PELVIS C-MATRL

$7,947.05

72196

MRI PELVIS C+ MATRL

$7,704.21

72220

XRAY COCCYX/SACRUM

$1,119.18

72255

MYELOGRAPY THRC RS&I

$6,277.09

72265

MYELOGRAPY LUMBOSAC RS&I

$4,574.24

72270

MYELOGRAPY 2/MORE REGIONS RS&I

$6,767.60

73000

XRAY CLAVICLE 2 VIEWS

$1,212.67

73010

SCAPULA COMPLETE

$1,245.91

73020

RADEX SHO 1 VIEW

$1,075.85

73030

SHOULDR COMPLETE 2 VIEWS

$1,393.67

73050

XRAY AC JOINTS-BILAT

$896.00

73060

XRAY HUMERUS MIN 2 VIEWS

$1,216.09

73070

XRAY ELBOW 2 VIEWS

$1,161.43

73080

XRAY ELBOW GREATER THAN 3 VIEWS-COMP

$1,279.07

73090

XRAY FOREARM AP & LAT

$1,378.62

73092

Radiologic examination; upper extremity, infant, minimum of…

$1,216.91

73100

XRAY WRIST AP & LAT VIEW

$1,217.17

73110

XRAY WRIST/COMP MIN 3 VIE

$1,497.65

73120

XRAY HAND AP & LAT

$1,377.30

73130

XRAY HAND MIN 3 VIEWS

$1,383.98

73140

XRAY FINGER MIN 2 VIEWS

$1,134.73

73200

CT UPPR EXTR WO CNTRS

$5,409.46

73201

CT UPPER EXTREMITY W/CONTRAST MATERIAL

$7,264.47

73202

CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL

$9,222.34

73218

MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL

$7,442.47

73220

MRI UXTR OTH/THN JT C-/C+

$12,039.09

73221

MRI ANY JT UXTR C-MATRL

$9,054.55

73223

MRI ANY JT UXTR C-/C+

$13,561.03

73501

RADEX HIP UNILATERAL WITH PELVIS 1 VIEW

$960.80

73502

RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P…

$1,232.13

73503

RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS

$1,613.13

73521

X-ray exam hips bi 2 views

$1,934.89

73522

RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS

$1,688.58

73523

RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS

$1,636.89

73551

RADIOLOGIC EXAMINATION FEMUR 1 VIEW

$844.66

73552

FEMUR; MIN 2 VIEWS

$1,259.22

73560

XRAY KNEE, SUNRISE VIEW

$1,144.02

73562

XRAY KNEE MIN 3 VIEWS

$1,236.77

73564

RAD EXAM KNEE 4 OR MORE

$1,722.63

73565

RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST

$1,036.17

73580

X-RAY KNEE.BILATERAL STANDING

$2,395.45

73590

XRAY TIBIA/FIBULA AP/LAT

$1,393.40

73592

RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS

$1,315.08

73600

XRAY ANKLE 2 VIEWS

$1,105.64

73610

XRAY ANKLE 3 VIEWS/COMPLE

$1,383.97

73620

XRAY FOOT MIN 2 VIEWS

$1,139.00

73630

XRAY FOOT MIN 3 VIEWS

$1,385.40

73650

RAD EXAN HEEL MIN 2 VIEWS

$1,206.54

73660

XRAY TOES, MIN 2 VIEWS

$1,079.35

73700

CT LOWER EXTREMITY W/O CONTRAST MATERIAL

$6,015.94

73701

CT LWR EXT W CONT

$7,372.44

73702

CT LXTR C-/C+

$9,307.04

73706

Computed tomographic angiography, lower extremity, with con…

$9,402.39

73718

MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL

$8,807.18

73721

MRI ANY JT LXTR C-MATRL

$9,403.53

73722

MRI ANY JT LXTR C+ MATRL

$9,178.91

73723

MRI ANY JT LXTR C-/C+

$11,505.98

73725

MRA LXTR C+-MATRL

$8,082.34

74018

RADIOLOGIC EXAM ABDOMEN 1 VIEW

$995.64

74019

RADIOLOGIC EXAM ABDOMEN 2 VIEWS

$1,507.44

74021

RADIOLOGIC EXAM ABDOMEN 3+ VIEWS

$1,423.00

74022

RAD EXAM COMPLETE ABD

$1,686.10

74150

CT ABDOMEN W/O CONTRAST MATERIAL

$7,132.29

74160

CT ABDOMEN W/CONTRAST MATERIAL

$8,383.20

74170

CT ABDOMEN W/O & W/CONTRAST MATERIAL

$10,080.65

74174

CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG

$13,719.94

74175

CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST

$10,454.48

74176

CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL

$10,675.50

74177

CT ABDOMEN & PELVIS W/CONTRAST MATERIAL

$13,099.89

74178

CT ABD & PELVIS 1 PLUS SECTION/REGNS

$16,560.16

74181

MRI ABD C-MATRL

$8,800.32

74183

MRI ABD C-/C+

$12,268.04

74190

PERITONEOGRAM RS&I

$3,020.85

74220

Radiologic examination; esophagus

$2,042.67

74240

RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB

$2,312.75

74241

RADEX GI TRC UPR +-DLYD FLMS W/KUB

$2,717.14

74246

Radiologic examination, gastrointestinal tract, upper, air …

$2,798.28

74250

RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES

$2,401.09

74251

RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE

$4,154.65

74283

Therapeutic enema, contrast or air, for reduction of intuss…

$4,881.53

74328

ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I

$5,450.02

74329

ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I

$6,650.22

74330

CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I

$5,317.27

74340

INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I

$2,072.45

74400

Urography (pyelography), intravenous, with or without KUB, …

$2,337.38

75574

CT CORONARY

$4,524.62

75635

CT ANGIO ABDOMINAL ARTERIES

$7,902.18

76010

X-ray nose to rectum

$1,066.97

76376

3D RNDR I&R CT MRI US/OTH

$1,774.00

76380

CT LIMITED/LOCALIZED FOLLOW UP STUDY

$3,109.04

76512

OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN

$945.90

76536

ULTRASOUND, SOFT TISSUES OF HEAD AND NECK

$2,431.28

76604

US CHEST REAL TIME W/IMAGE DOCUMENTATION

$1,622.73

76641

US BREAST UNI REAL TIME WITH IMAGE COMPLETE

$1,634.53

76642

US BREAST UNI REAL TIME WITH IMAGE LIMITED

$1,228.56

76700

US ABDOMINAL R-T W/IMAGE

$2,992.07

76705

US ABDOMINAL

$2,216.05

76706

Ultrasound, abdominal aorta, real time with image documenta…

$1,449.39

76770

US RETROPERITONEAL R-T W/

$2,582.18

76775

US RPR B-SCAN&/R-T IMG LMTD

$2,022.35

76801

ULTRASOUND 14 WK TABDL 1/1ST GESTATION

$2,015.85

76802

US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

$1,866.19

76805

US PG UTER F&MAT AFTER 1S

$2,482.71

76810

US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO

$2,657.06

76815

ULTRASND PG UTER

$1,608.77

76816

US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS

$1,440.45

76817

UT PG UTER R-T IMG TRVG

$1,705.99

76830

TRANSVAGINAL ULTRASOUND

$2,184.64

76856

US PELVIC NONOB REAL-TIME

$2,825.56

76857

PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97

$1,834.67

76870

US SCROTUM&CNTS

$2,268.29

76872

US TRANSRECTAL

$2,183.40

76881

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

$2,105.33

76882

ULTRASOUND, EXTREMITY, NON VASCULAR

$1,174.71

76937

Us guide vascular access

$2,352.39

76942

ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I…

$3,198.72

77076

RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT

$2,016.83

78306

B1&/JT IMG WHBDY

$6,363.90

78315

B1&/JT IMG 3 PHASE STD

$7,310.12

78472

CARD BPI GTD=BRM PLNR 1 STD REST/STRS

$5,557.96

78808

NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS

$1,542.56

80047

BASIC METABOLIC PANEL CALCIUM IONIZED

$1,050.10

80048

METABOLIC PANEL BASIC

$1,000.50

80050

General health panel

$1,601.85

80051

ELECTROLYTE PANEL

$674.70

80053

METABOLIC COMPRE PANEL

$1,245.31

80061

LIPID PROFILE III

$840.29

80069

RENAL FUNCTION PANEL

$2,057.00

80074

HEPATITIS PANEL

$1,910.77

80076

HEPATIC FUNCTION PANEL

$1,120.95

80143

Therapeutic Drug Assays

$749.31

80175

DRUG SCREEN QUANTITATIVE LAMOTRIGINE

$392.87

80177

Levetiracetam

$584.75

80178

LITHIUM

$786.23

80179

Therapeutic Drug Assays

$672.50

80197

TACROLIMUS

$1,607.00

80202

VANCOMYCIN PEAK

$822.23

80305

DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM…

$702.00

80306

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample

validation when performed, per date of service

$610.59

80307

DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS

$1,356.00

80320

DRUG SCREEN

$752.61

80324

DRUG SCREEN QUANT AMPHETAMINES 1 OR 2

$497.00

80329

DRUG SCREEN

$867.21

80335

ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2

$447.00

80345

DRUG SCREENING BARBITURATES

$288.00

80346

DRUG SCREENING BENZODIAZEPINES 1-12

$573.68

80347

DRUG SCREENING BENZODIAZEPINES 13 OR MORE

$200.21

80348

DRUG SCREENING BUPRENORPHINE

$346.00

80349

DRUG SCREENING CANNABINOIDS NATURAL

$272.77

80353

DRUG SCREENING COCAINE

$298.00

80356

DRUG SCREENING HEROIN METABOLITE

$228.73

80358

DRUG SCREENING METHADONE

$483.00

80359

DRUG SCREENING METHYLENEDIOXYAMPHETAMINES

$379.00

80361

DRUG SCREENING OPIATES 1 OR MORE

$604.00

80365

DRUG SCREENING OXYCODONE

$415.00

80373

DRUG SCREENING TRAMADOL

$250.00

81001

U/A DIP STICK

$418.50

81002

URNLS DIP STICK/TABLET RG

$233.98

81003

U/A W/O MICRO DIPSTICK

$333.00

81015

Urinalysis Microscopic Olny

$262.01

81025

PREG.TST URINE VISUAL

$435.10

81240

F2 (prothrombin, coagulation factor II) (eg, hereditary hyp…

$1,403.24

82009

KETONES-SERUM

$184.00

82010

KETONE BODIES SERUM QUANTITATIVE

$598.82

82040

ALBUMIN; SERUM

$429.03

82077

Alcohol (ethanol); any specimen except urine and breath, im…

$449.00

82140

Ammonia

$666.33

82150

AMYLASE

$612.90

82247

BILIRUBIN TOTAL

$596.25

82248

BILIRUBIN DIRECT

$455.86

82270

OCCULT BLOOD

$311.00

82271

Occult blood other sources

$346.90

82272

BLD OCLT PEROXIDASE ACTV

$172.00

82274

BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3

$286.63

82310

CALCIUM

$415.24

82330

CALCIUM IONIZED

$771.55

82374

CARBON DIOXIDE BICARBONATE

$339.00

82375

Under Chemistry Procedures

$442.82

82435

CHLORIDE BLD

$249.79

82465

CHOLESTEROL SERUM/WHOLE BLOOD TOTAL

$487.96

82533

CORTISOL TOTAL

$916.37

82550

CREATINE CK-TOTAL

$542.88

82553

CREATINE CKMB

$809.00

82565

CREATININE

$452.40

82607

VITAMIN B-12

$737.86

82693

ASSAY OF ETHYLENE GLYCOL

$640.06

82728

Ferritin

$758.14

82746

Folic acid; serum

$789.70

82747

ASSAY OF FOLIC ACID RBC

$173.00

82784

IGC IMMUNOGLOBULIN

$519.30

82785

GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE

$527.36

82800

GASES BLD PH ONLY

$295.13

82803

BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3

$1,779.79

82805

GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY

$2,697.00

82945

GLUCOSE BODY FLUID OTHER THAN BLOOD

$453.62

82947

GLUCOSE

$333.78

82948

GLUCOSE BLOOD REAGET STR

$191.15

82962

GLUCOSE FINGER STICK

$110.62

82977

GLUTAMYLTRANSFERASE-GTT

$585.40

83013

HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE

$534.00

83036

HEMOGLOBIN GLYCOSYLATED A1C

$494.12

83050

HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE

$293.51

83520

IMMUNOASSAY ANALYTE QUANTITIATIVE NOS

$950.92

83525

ASSAY OF INSULIN TOTAL

$610.72

83540

IRON-TOTAL

$587.57

83550

Total IRON BNDNG CAP

$648.34

83605

ASSAY OF LACTATE

$697.26

83615

Lactate dehydrogenase (LD), (LDH);

$586.46

83690

LIPASE

$622.68

83718

LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL

$619.92

83735

MAGNESIUM

$505.53

83874

MYOGLOBIN

$1,010.00

83880

B-TYPE NATRIURETIC

$1,093.06

83992

ASSAY OF PHENCYCLIDINE

$242.00

84075

ALK PHOS/PROFILE OR PANEL

$410.74

84100

ASSAY OF PHOSPHORUS INORGANIC

$378.54

84132

POTASSIUM SERUM PLASMA/WHOLE BLOOD

$383.65

84155

PROTEIN,TOTAL,EXCEPT REFR

$289.88

84157

PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC

$473.86

84165

PROTEIN ELECTROPHORESIS

$930.14

84295

SODIUM; SERUM

$316.19

84403

ASSAY OF TESTOSTERONE TOTAL

$799.63

84436

THYRIXINE TOTAL

$668.92

84439

THYROXINE-FREE

$713.67

84443

Thyroid stimulating hormone (TSH)

$930.80

84450

Aspartate Aminotransferase

$431.01

84460

ALT-TRANSFERASE;ALANINE

$410.02

84478

ASSAY OF TRIGLYCERIDES

$754.57

84479

THYROID HORMONE

$415.71

84480

T3 TOTAL

$873.52

84481

ASSAY OF TRIIODOTHYRONINE T3 FREE

$917.39

84484

TROPONIN I

$845.34

84520

Urea nitrogen

$407.73

84550

URIC ACID

$463.57

84560

URIC ACID OTH SRC

$467.05

84702

HCG QUANTATIVE

$951.33

84703

PREGNANCY TEST BLOOD

$547.96

84999

UNLISTED CHEMISTRY PROCEDURE

$196.42

85014

HEMATOCRIT

$215.94

85018

HEMOGLOBIN

$239.74

85025

BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC

$375.84

85027

CBC W/O DIFF

$1,054.00

85032

BLD# MNL C-CNT RBC/PLTLT EA

$329.04

85044

RETICULOCYTE COUNT

$839.82

85045

Blood count

$301.90

85270

hematology and coagulation

$1,166.45

85347

COAGJ TM ACTIVATED

$503.01

85378

FIBRIN DEGRADATION PROD

$923.26

85379

D-DIMER

$730.49

85384

Fibrinogen; activity

$518.21

85610

PROTHROMBIN TIME

$418.45

85651

SEDIMENTATION RATE NONAUT

$335.81

85652

SED RATE ERYTHROCYTE NON

$266.05

85730

THROMBOPLASTIN TIME PART

$520.24

86038

ANTINUCLEAR AB

$562.08

86039

ANTINUCLEAR AB TITER

$671.23

86060

ANTISTREPTOLYSIN O TITER

$938.08

86140

C REACTIVE PROTEIN

$553.64

86235

EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD

$448.08

86256

SMOOTH MUSCLE AB TITER

$368.97

86308

MONO,HETEROPHILE ANTIBODI

$442.97

86320

IMMUNOELECTROPHORESIS

$757.14

86328

COVID-19 RAPID ANTIBODY TEST SINGLE METHOD

$3,052.97

86360

T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO

$1,020.77

86403

MONO SPOT

$322.00

86430

RHEUMATOID FACTOR

$332.09

86431

RHEUMATOID FACTOR QUANTITATIVE

$609.39

86580

TB tests

$78.87

86592

Syphilis test, non-treponemal antibody; qualitative (eg, VD…

$365.01

86593

SYPHILIS TEST, NON- TREPONEMAL ANTIBODY; QUANTITATIVE

$531.53

86617

Antibody; Borrelia burgdorferi (Lyme disease) confirmatory …

$190.45

86618

LYME DISEASE ANTIBODY

$316.64

86622

Antibody; Brucella

$263.00

86631

ANTB CHLAMYDIA

$245.00

86644

ANTIBODY CYTOMEGALOVIRUS CMV

$762.47

86645

ANTIBODY CYTOMEGALOVIRUS CMV IGM

$1,073.00

86664

EPSTEIN-BARR VIRUS EBNA

$522.83

86677

ANTIBODY HELICOBACTER PYLORI

$1,074.79

86689

ANTB HTLV/HIV ANTB CONFIRMATION TST

$571.00

86695

Antibody; herpes simplex, type 1

$443.72

86696

Antibody; herpes simplex, type 2

$484.85

86701

HIV SERUM

$823.24

86702

ANTB HIV-2

$742.66

86703

Antibody; HIV-1 and HIV-2, single result

$534.68

86704

HEPATITIS B CORE ANTIBODY HBCAB TOTAL

$699.63

86705

HEPATITIS B CORE IGM

$682.84

86706

HEPATITIS B SURF ANTIBODY HBSAB

$705.23

86708

Hepatitis a antibody

$550.20

86709

Hepatitis A antibody (HAAb), IgM antibody

$620.36

86757

Antibody; Rickettsia

$272.04

86768

Antibody; Salmonella

$289.00

86769

COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD

$317.49

86780

ANTIBODY TREPONEMA PALLIDUM

$458.54

86787

Antibody; varicella-zoster

$346.91

86803

HEPATITIS C ANTIBODY

$914.43

86850

ANTB SCR RBC EA SERUM TQ

$648.65

86900

Blood typing, serologic; ABO

$449.00

86901

RH FACTOR-BLOOD

$381.31

86906

BLD TYPING RH PHEXYPING COMPL

$436.00

87015

CONCENTRATION INFECTIOUS AGENTS

$210.98

87040

BLOOD CULTURE

$865.88

87045

CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL

$874.65

87046

CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA

$376.03

87070

CULTURE BODY FLUID

$1,004.00

87075

CULTURE ANAEROBIC

$1,025.02

87076

CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL

$446.34

87077

CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL

$452.50

87081

CULTURE, BACTERIAL-SCREEN

$526.38

87086

URINE CULTURE

$855.96

87088

CULTURE BCT ISOL&PRSMPTV

$351.03

87103

Under Microbiology Culture and Typing Procedures

$689.90

87106

CUL FNGI DEFINITIVE ID EA ORGANISM YEAST

$483.70

87110

CHLAMYDIA CULTURE

$982.50

87169

Macroscopic examination; parasite

$102.03

87177

OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID

$575.87

87186

Susceptibility studies, antimicrobial agent

$813.02

87205

SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL

$340.60

87207

SMR PRIM SRC SPEC STAIN

$460.29

87209

SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS

$317.76

87210

WET SMEAR

$482.08

87252

VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT

$919.97

87255

Herpes Simplex Virus Culture with Reflex Typing

$897.50

87275

IAADI INF B VIRUS

$303.44

87324

Infectious agent antigen detection by immunoassay technique…

$880.31

87328

Infectious agent antigen detection by immunoassay technique…

$238.47

87338

IAAD IA HPYLORI STOOL

$641.98

87340

IAAD IA HEPATITIS B SURFACE ANTIGEN

$530.02

87341

IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION

$352.45

87389

HIV-1 AG W/HIV-1 & HIV-S AB

$629.98

87400

INFLUENZA A&B

$380.05

87420

IAAD IA RESPIRATORY SYNCTIAL VIRUS

$801.00

87425

ROTAVIRUS AG EIA

$445.47

87426

COVID-19 RAPID ANTIGEN TESTING

$365.00

87427

IAAD IA SHIGA-LIKE TOXIN

$511.28

87428

Multiplex viral pathogen panel using Antigen technique for …

$719.00

87430

INF AGT IMMUNO STREP A

$418.72

87471

Infectious agent detection by nucleic acid (DNA or RNA); Ba…

$1,238.00

87480

IADNA CANDIDA SPECIES DIRECT PROBE TQ

$152.65

87481

Infectious agent detection by nucleic acid (DNA or RNA); Candida species,

amplified probe technique

$412.85

87486

IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ

$785.74

87491

IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ

$676.34

87493

INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE

$826.23

87506

Infectious agent detection by nucleic acid (DNA or RNA); ga…

$2,053.46

87507

IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25

$2,276.72

87510

Infectious agent detection by nucleic acid (DNA or RNA); Ga…

$152.65

87529

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA &RNA)

$1,179.12

87581

IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ

$838.67

87591

IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ

$641.86

87624

HPV HIGH-RISK TYPES

$584.71

87633

IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET

$3,739.69

87635

IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ

$353.55

87636

“severe acute respiratory syndrome coronavirus 2 (SARSCoV-2…

$978.00

87660

Infectious agent detection by nucleic acid (DNA or RNA); Tr…

$427.42

87661

INF AGENT DETECTED NUCLEIC ACID; TRICHMONAS VAGINALIS AMP P…

$386.83

87798

O&P SMEAR W/AMPLIFIC

$1,205.68

87801

Illlnfectious agent detection by nucleic acid (DNA or RNA), multiple organisms;

amplified probe(s) technique

$1,717.40

87804

INFLUENZA IMMUNOASSAY OPT

$480.73

87806

Infectious agent antigen detection by immunoassay with dire…

$549.56

87807

INF AGT DET IMNAS OPT RSV

$943.55

87808

Infectious agent antigen detection by immunoassay with dire…

$208.69

87880

RAPID STREP-BETA STREP

$1,087.00

88161

Cytopathology, smears, any other source; preparation, scree…

$362.47

88233

Under Cytogenetic Studies

$2,348.57

88262

Under Cytogenetic Studies

$1,607.85

88291

Under Cytogenetic Studies

$1,047.67

88305

PATH SURG LEVEL IV

$1,006.81

89050

CELL COUNT MISCELLANEOUS BODY FLUIDS

$354.91

89051

CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT

$546.48

89055

LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE

$319.92

89060

CRYSTAL INDENTIFICATION

$419.12

89220

SPTM OBTG SPEC AERSL INDUCED SPX

$624.00

89240

UNLIS MISC

$250.00

90471

IMMUN ADM 1 VAC

$345.43

90472

Immunization admin, each add

$263.73

90658

Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for

intramuscular use

$1,441.00

90688

Influenza virus vaccine, quadrivalent (IIV4), split virus, …

$220.28

90700

DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM

$303.30

90707

Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

$934.00

90714

TETANUS DIPHTHERIA TOXOID

$390.61

90715

TDAP VACCINE

$505.39

90746

HEPATITIS B VACCINE/ADULT

$598.20

92552

PURE TONE AUDIOMTRY AIR O

$459.98

92950

cardiopulmonary resuscitation

$3,288.65

92960

CARDIOVERSION ELECTIVE ARRHYT XTRNL

$5,474.39

93000

EKG W/INTREP AND REPORT

$1,305.65

93005

Electrocardiogram, routine ECG

$1,051.55

93016

CV STRS TST XERS&/OR RX CONT ECG W/O I&R

$12,862.68

93017

CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY

$4,997.90

93018

CV STRS TST XERS&/OR RX CONT ECG I&R ONLY

$4,125.58

93041

RHYTHEM ECG 1-3 LDS

$558.73

93225

XTRNL ECG & 48 HR RECORDING

$2,567.57

93226

EXTERNAL ECG SCANNING ANALYSIS REPORT

$2,725.52

93246

External electrocardiographic recording for more than 7 day…

$807.02

93303

COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY

$9,841.14

93306

ECHO TEST

$8,952.74

93307

ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP

$5,330.77

93308

ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD

$3,803.20

93313

TEE R-T IMG 2D W/PROBE PLMT ONLY

$1,701.52

93314

TEE R-T IMG 2D IMG ACQUISJ I&R ONLY

$9,523.20

93320

DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY

$3,807.54

93325

DOP ECHOCARD COLOR FLOW VELOCITY MAPPING

$3,439.17

93350

ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST

$6,028.86

93351

ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG

$11,915.66

93623

Programmed stimulation and pacing after intravenous drug infusion (List

separately in addition to code for primary procedure)

$12,625.92

93880

DUP-SCAN XTRC ART COMPL B

$5,085.37

93882

DUP-SCAN XTRC ART UNI/LMTD STD

$2,633.87

93886

TCD STD ICRA ART COMPL STD

$3,910.71

93922

NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL

$2,148.22

93923

NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS

$3,432.28

93925

DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY

$4,390.92

93926

DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD

$2,784.34

93930

DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY

$3,463.23

93931

DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD

$3,244.86

93970

DUP-SCAN XTR VEINS COMPL

$4,343.97

93971

DPLX SCN EXTRM VEINS

$2,803.74

93975

DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P…

$4,575.16

93976

DUPLEX SCAN- LIMITED

$3,189.05

93980

DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL

$2,674.77

94010

SPIROMETRY W/RECORD

$978.31

94060

BRNCDILAT RSPSE SPMTRY PR

$2,065.37

94621

PULM STRS TSTG CPLX

$4,556.43

94640

NEBULIZER TREATMENT

$946.14

94644

INHALATION TREATMENT – CONTINUOUS 1ST HR

$1,214.97

94660

CPAP VENTILATION CPAP INITIATION&MGMT

$5,258.84

94664

DEMO&/EVAL OF PT UTILIZ

$943.86

94760

EAR OR PULSE OXIMETRY

$294.00

94761

N-INVAS EAR/PLS OXIMTRY F

$729.00

94762

NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR

$1,232.54

95811

POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

$11,551.65

96360

IV INFUS INIT 31 MIN 1 HR

$1,631.70

96361

IV INFUS HYDR EA ADD’T HR

$613.68

96365

IV INFUSION THERAPY/PROPH

$1,565.14

96366

IV INFUS THER PROPH/DX EA

$678.27

96367

IV NFS THER PROPH/DX ADDL

$827.25

96368

IV NFS TX PROPHYLAXIS/DX

$611.94

96372

THERAPEUTIC PROPHYLACTIC/

$687.46

96373

INJECTION, INTRA-ARTERIAL

$584.99

96374

THER PROPH/DX NJX IV PUSH

$964.22

96375

THER PROPH/DX NJX EA SEQL

$705.75

96376

SUB INFU EA ADD IV PUSH

$696.68

96377

APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION

$567.61

96379

INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS

$2,321.55

97110

Therapeutic procedure, 1 or more areas, each 15 minutes; th…

$423.74

97116

THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR

$413.79

97140

MANUAL THERAPY 1/> REGIONS

$449.62

97166

Occupational therapy evaluation, moderate complexity, requi…

$1,246.65

97542

WHEELCHAIR MGMT EA 15 MIN

$328.18

97597

DEBRIDEMENT OPEN WOUND 20 SQ CM/<

$3,017.36

99000

SPECIMEN HANDLING

$63.50

99001

COC COLLECITON ONLY

$427.32

99024

POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX

$1,364.88

99050

BLUE CROSS RQRD LVL3

$207.00

99070

SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP

$1,102.63

99151

MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS

$954.61

99152

MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS

$853.36

99153

MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

$490.83

99155

MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

$1,247.00

99156

MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

$1,033.00

99157

MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS

$798.00

99173

SCREENING TEST OF VISION

$312.76

99281

E/M VISIT LEVEL 1 TECH COMP

$1,044.66

99282

E/M VISIT LEVEL 2 TECH COMP

$1,927.37

99283

E/M VISIT LEVEL 3 TECH COMP

$3,377.98

99284

E/M VISIT LEVEL 4 TECH COMP

$5,520.81

99285

E/M VISIT LEVEL 5 TECH COMP

$8,202.90

99291

CRITICAL CARE 30-74 MIN

$8,113.46

99292

CRITICAL CARE ADD 30 MIN

$4,765.37

99384

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12

through 17 years)

$442.88

99406

SMOKING CESSATION 3-10

$133.50

99407

SMOKING CESSATION 10 MIN

$233.27

E0114

CRUTCHES UNDERARM

$290.79

E0484

NON-ELEC OSCILLATORY PEP DVC

$327.56

G0378

HOSPITAL OBSERVATION SERVICES PER HOUR

$2,500.00

J0120

TETRACYCLIN INJECTION

$162.00

J0129

ABATACEPT INJECTION

$406.99

J0131

INJECTION, ACETAMINOPHEN, 10 MG

$163.21

J0132

ACETYLCYSTEINE INJECTION

$42.00

J0133

ACYCLOVIR INJECTION

$3.00

J0153

ADENOSINE INJ 1MG

$44.02

J0171

ADRENALIN EPINEPHRINE INJECT

$167.60

J0185

INJ., APREPITANT, 1 MG

$34.35

J0270

ALPROSTADIL FOR INJECTION

$53.00

J0278

AMIKACIN SULFATE INJECTION

$19.67

J0280

AMINOPHYLLIN 250 MG INJ

$177.17

J0282

INJ AMIODARONE HYDROCHLOR

$35.00

J0285

AMPHOTERICIN B

$398.35

J0290

AMPICILLIN 500 MG INJ

$85.00

J0295

INJ AMPCLLN SODIUM/SULBA

$83.00

J0330

SUCCINYLCHOLINE CHLO 20MG

$184.82

J0360

HYDRALAZINE HCL INJ UP TO 20MG

$238.28

J0401

INJ ARIPIPRAZOLE EXT REL 1MG

$82.01

J0456

INJ AZITHROMYCIN 500MG

$181.81

J0461

INJ ATROPINE SULFATE 0.01

$79.65

J0476

BACLOFEN INTRATHECAL TRIAL

$679.00

J0485

BELATACEPT INJECTION

$58.55

J0490

BELIMUMAB INJECTION

$336.22

J0500

DICYCLOMINE HCL 20MG

$522.00

J0515

INJ BENZTROPINE MESYLATE

$384.34

J0558

PENG BENZATHINE/PROCAINE INJ

$159.00

J0561

INJECTION PENICILLIN G BENZATHINE 100,000 UNITS

$213.24

J0571

BUPRENORPHINE ORAL 1MG

$25.35

J0572

BUPREN/NAL UP TO 3MG BUPRENO

$27.00

J0573

BUPREN/NAL 3.1 TO 6MG BUPREN

$65.69

J0574

BUPREN/NAL 6.1 TO 10MG BUPRE

$62.53

J0583

BIVALIRUDIN

$254.88

J0585

INJECTION,ONABOTULINUMTOXINA

$62.85

J0586

ABOBOTULINUMTOXINA

$79.33

J0588

INCOBOTULINUMTOXIN A

$44.01

J0592

BUPRENORPHINE HYDROCHLORIDE

$50.00

J0595

STADOL

$54.05

J0596

INJECTION, RUCONEST

$331.19

J0604

CINACALCET, ESRD ON DIALYSIS

$4.76

J0636

INJ CALCITRIOL PER 0.1 MCG

$64.19

J0640

LEUCOVORIN CALCIUM INJECTION

$120.14

J0670

INJ MEPIVACAINE HCL/10 ML

$167.67

J0690

KEFZOL 1 GR VIAL

$74.14

J0692

INJ CEFEPIME HCI 500MG

$62.87

J0694

CEFOXITIN SODIUM INJECTION

$116.34

J0695

INJ CEFTOLOZANE TAZOBACTAM

$57.96

J0696

ROCEPHIN 250 MG

$60.00

J0697

STERILE CEFUROXIME INJECTION

$49.00

J0702

BETAMETHASONE ACET&SOD PHOSP

$261.37

J0706

CAFFEINE CITRATE INJECTION

$42.31

J0712

CEFTAROLINE FOSAMIL INJ

$37.85

J0713

INJ CEFTAZIDIME PER 500 MG

$169.34

J0735

CLONIDINE 1MG

$270.80

J0736

INJ, CLINDAMYCIN PHOSP 300MG

$110.53

J0743

CILASTATIN SODIUM INJECTION

$173.72

J0744

CIPRO 200MG

$216.73

J0770

COLISTIMETHATE SODIUM INJ

$272.00

J0780

COMPAZINE 10 MG

$273.00

J0875

INJECTION, DALBAVANCIN

$137.88

J0878

DAPTOMYCIN INJECTION

$68.97

J0881

DARBEPOETIN ALFA, NON-ESRD

$72.97

J0882

DARBEPOETIN ALFA, ESRD USE

$80.73

J0885

EPOETIN ALFA, NON-ESRD

$351.84

J0894

DECITABINE INJECTION

$80.45

J0895

DEFEROXAMINE MESYLATE INJ

$463.05

J0897

DENOSUMAB INJECTION

$212.81

J1000

DEPO-ESTRADIOL CYPIONATE INJ

$214.00

J1030

DEPO MEDROL 40 MG/ML

$165.53

J1040

METHYLPREDNISOLONE 80MG

$279.14

J1050

MEDROXYPROGESTERONE ACETATE

$5.57

J1071

INJ TESTOSTERONE CYPIONATE

$1.15

J1100

DECADRON 4 MG VIAL

$46.20

J1110

INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG

$730.00

J1160

DIGOXIN INJECTION

$91.85

J1165

DILANTIN 100 MG VIAL

$67.56

J1170

DILAUDID 4 MG

$89.24

J1200

BENADRYL 50MG

$51.45

J1230

METHADONE INJECTION

$138.64

J1250

INJ DOBUTAMINE HCL/250 MG

$276.73

J1265

DOPAMINE INJECTION

$41.81

J1325

EPOPROSTENOL INJECTION

$117.00

J1327

EPTIFIBATIDE INJECTION

$275.12

J1439

INJ FERRIC CARBOXYMALTOS 1MG

$20.85

J1442

INJ FILGRASTIM EXCL BIOSIMIL

$14.95

J1447

INJ TBO FILGRASTIM 1 MICROG

$12.01

J1450

FLUCONAZOLE

$202.15

J1451

FOMEPIZOLE, 15 MG

$196.83

J1453

FOSAPREPITANT INJECTION

$8.66

J1455

FOSCARNET SODIUM INJECTION

$465.00

J1559

HIZENTRA INJECTION

$379.81

J1561

GAMUNEX-C/GAMMAKED

$496.82

J1571

HEPAGAM B IM INJECTION

$821.00

J1580

GARAMYCIN,GENTAMICIN 80MG

$78.15

J1602

GOLIMUMAB FOR IV USE 1MG

$325.78

J1610

GLUCOGAN 1 MG VIAL

$2,182.74

J1626

GRANISETRON HCL INJECTION

$11.42

J1630

HALOPERIDOL INJECTION

$143.32

J1631

HALOPERIDOL DECANOATE INJ PER 50 MG

$186.21

J1640

HEMIN, 1 MG

$144.44

J1642

HEPARIN SODIUM PER 10 UNI

$23.89

J1644

INJ HEPARIN SOD PER 1000

$70.42

J1650

ENOXAPARIN SODIUM 10MG

$87.59

J1652

FONDAPARINUX SODIUM

$72.23

J1720

HYDROCORTISONE SODIUM SUCC I

$234.94

J1741

IBUPROFEN INJECTION

$38.04

J1744

ICATIBANT INJECTION

$2,053.00

J1750

INJ IRON DEXTRAN

$229.29

J1756

IRON SUCROSE INJECTION

$62.52

J1786

IMUGLUCERASE INJECTION

$336.37

J1790

DROPERIDOL INJECTION

$63.36

J1800

PROPRANOLOL INJECTION

$220.86

J1815

INJ INSULIN PER 5 UNITS

$54.32

J1817

INSULIN FOR INSULIN PUMP USE

$392.87

J1836

Injection, metronidazole, 10 mg

$2.17

J1885

TORADOL INJ 15 MG

$48.38

J1930

LANREOTIDE INJECTION

$579.36

J1931

LARONIDASE INJECTION

$389.87

J1940

LASIX 40 MG IV VIAL

$30.68

J1953

LEVETIRACETAM INJECTION

$29.79

J1955

INJ LEVOCARNITINE PER 1 GM

$411.55

J1956

LEVOFLOXACIN 250 MG

$102.14

J1980

HYOSCYAMINE SULFATE INJ

$278.13

J2001

LIDOCAINE HCI 10MG

$42.31

J2020

LINEZOLID INJECTION

$182.33

J2060

ATIVAN 2ML SYRUP

$45.00

J2150

MANNITOL INJECTION

$133.50

J2175

DEMEROL 50 MG SYRINGE

$161.00

J2182

INJECTION, MEPOLIZUMAB, 1MG

$218.24

J2185

MEROPENEM

$37.51

J2210

METHYLERGONOVIN MALEATE INJ

$319.84

J2212

METHYLNALTREXONE INJECTION

$13.33

J2248

MICAFUNGIN SODIUM INJECTION

$21.17

J2250

MIDAZOLAM HCI PER 1 MG

$36.45

J2260

INJ MILRINONE LACTATE / 5 MG

$56.91

J2270

INJ MORPHINE SULFATE 10 M

$116.00

J2274

INJ MORPHINE PF EPID ITHC

$136.00

J2278

ZICONOTIDE INJECTION

$83.65

J2280

INJ, MOXIFLOXACIN 100 MG

$115.00

J2300

NUBAIN 10MG AMP

$93.41

J2310

INJ NALOXONE HCL 1MG

$189.00

J2315

NALTREXONE, DEPOT FORM

$25.00

J2350

INJECTION, OCRELIZUMAB, 1 MG

$490.44

J2354

OCTREOTIDE INJ, NON-DEPOT

$58.42

J2357

OMALIZUMAB INJECTION

$362.00

J2358

OLANZAPINE LONG-ACTING INJ

$123.49

J2360

ORPHENADRINE CITRATE 60MG

$419.10

J2370

NEO-SYNEPHRINE UP TO 1 ML

$36.58

J2405

ONDANSETRON HCI, PER MG

$16.71

J2426

PALIPERIDONE PALMITATE INJ

$91.00

J2430

PAMIDRONATE DISODIUM /30 MG

$201.71

J2440

PAPAVERIN HCL INJECTION

$479.33

J2469

PALONOSETRON HCL

$290.76

J2501

PARICALCITOL

$81.01

J2540

PENICILLIN G POTASSIUM INJ

$33.67

J2543

ZOSYN – PIPERACILLIN/TAZOBACTAM

$78.82

J2550

PHENERGAN 50 MG

$40.18

J2560

PHENOBARBITAL SODIUM INJ

$359.45

J2562

PLERIXAFOR INJECTION

$2,779.00

J2590

OXYTOCIN INJECTION

$147.00

J2597

INJ DESMOPRESSIN ACETATE

$128.74

J2680

FLUPHENAZINE DECANOATE 25 MG

$292.52

J2700

OXACILLIN SODIUM INJECITON

$79.94

J2704

INJECTION PROPOFOL 10 MG

$31.91

J2710

NEOSTIGMINE METHYLSLFTE INJ

$97.90

J2720

INJ PROTAMINE SULFATE/10 MG

$51.00

J2760

PHENTOLAINE MESYLATE INJ

$2,264.00

J2765

METOCLOPRAMIDE HCL 10MG

$56.99

J2791

RHOPHYLAC INJECTION

$195.14

J2794

RISPERIDONE, LONG ACTING

$143.03

J2795

ROPIVACAINE HCL INJECTION

$32.09

J2800

METHOCARBAMOL INJECTION

$285.81

J2850

INJ SECRETIN SYNTHETIC HUMAN

$299.54

J2916

NA FERRIC GLUCONATE COMPLEX

$141.14

J2919

INJ, METHYLPRED SOD SUCC 5MG

$16.02

J2920

SOLU-MEDROL 40MG

$76.38

J2930

SOLU-MEDROL 125 MG

$100.89

J2941

SOMATROPIN INJECTION

$1,715.00

J3010

INJ FENTANYL CITRATE .1MG

$57.15

J3030

IMITREX 6MG VIAL

$912.29

J3105

INJECTION, TREBUTALINE SULFATE, UP TO 1 MG

$181.35

J3230

THOROZINE 50 MG

$385.08

J3243

TIGECYCLINE INJECTION

$31.47

J3246

TIROFIBAN HCL

$48.38

J3260

TOBRAMYCIN SULFATE INJECTION

$173.15

J3262

TOCILIZUMAB INJECTION

$64.63

J3285

TREPROSTINIL INJECTION

$433.75

J3300

TRIAMCINOLONE A INJ PRS-FREE

$22.00

J3301

TRIAMCINOLONE ACET INJ NOS

$83.71

J3304

INJ TRIAMCINOLONE ACE XR 1MG

$268.06

J3358

USTEKINUMAB, IV INJECT, 1 MG

$109.94

J3360

VALIUM INJ 5 MG

$222.52

J3370

VANCOMYCIN HCI INJ 500MG

$79.52

J3380

INJECTION, VEDOLIZUMAB

$263.23

J3410

VISTERIL INJ 50 MG

$163.12

J3411

INJ THIAMINE 100 MG

$104.00

J3415

PYRIDOXINE HCL 100 MG

$153.59

J3420

VITAMIN B12 INJECTION

$103.50

J3430

INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG

$104.26

J3465

INJECTION, VORICONAZOLE

$79.97

J3471

OVINE, UP TO 999 USP UNITS

$4.86

J3473

HYALURONIDASE RECOMBINANT

$4.41

J3475