| CPT Code | CPT Short Description | CPT Default Price |
| 0202U | COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing | $1,500.00 |
| 10060 | INCISION/DRAINAGE ABSCESS | $748.24 |
| 10061 | INS/DRAIN ABSCESS COMPL | $444.00 |
| 10081 | I&D PILONIDAL CST COMP | $590.00 |
| 10120 | I & RMVL SUB-CUT SIMPLE | $200.00 |
| 10121 | I & RMVL FB, SUB-CUT,COMP | $583.00 |
| 10160 | PUNCTURE ASP OF ABSCESS | $328.00 |
| 11011 | DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC | $263.00 |
| 11040 | DBRDMT, SKIN, PARTIAL THICK | $205.00 |
| 11042 | DBRD SKN SUBQ TISSUE | $1,098.00 |
| 11200 | RMVL SKIN TAGS | $294.00 |
| 11404 | EXC BGN LSN TRUNK 3.1-4.0 | $833.00 |
| 11730 | AVULSION/1-NAIL PLATE | $290.00 |
| 11740 | EVAC SUBUNGUAL HEMATOMA | $303.00 |
| 11750 | EXC NAIL PART/COMP | $619.00 |
| 11760 | REPAIR NAIL BED | $531.00 |
| 11765 | WEDGE EXC SKIN/NAIL BED | $341.00 |
| 11771 | EXCISION PILONIDAL CYST SINUS EXTENSIVE | $297.00 |
| 12001 | LACERATION REPAIR | $352.23 |
| 12002 | REPAIR LAC SCALP 2.6-7.5 | $430.00 |
| 12004 | REPAIR LAC SCALP 7.6-12.5 | $496.00 |
| 12005 | REPAIR LAC,SCALP 12.6-20C | $658.00 |
| 12011 | REPAIR LAC FACE LESS THAN 2.5 CM | $759.00 |
| 12013 | REPAIR LAC FACE 2.6-5.0CM | $526.00 |
| 12014 | REPAIR LAC FACE 5.1-7.5CM | $729.00 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $320.00 |
| 12031 | LYR CLSR S/A/T/E 2.5CM | $504.00 |
| 12032 | REPAIR-INT SCALP 2.6-7.5 | $761.00 |
| 12034 | INTERM RPR SCLP/TRNK/EXTR | $707.00 |
| 12035 | REPAIR INTERM S/A/T/E 12. | $318.00 |
| 12036 | REPAIR INTERM S/A/T/E 20.1-30.0 CM | $762.00 |
| 12041 | LAYER CLSR NECK/HAND 2.6 | $524.00 |
| 12042 | REPAIR LAC HAND/FOOT 2.6- | $883.00 |
| 12044 | LYR CLSR N/H/F/ETRNL GENT | $762.00 |
| 12045 | REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM | $760.00 |
| 12051 | LAYER CLSR OF WND NCK/HND | $594.00 |
| 12052 | LYR CLSR WOUND 2.6-5.0FAC | $708.00 |
| 12053 | LYR CLSR F/E/E/N/L/M&/MUC | $957.00 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM | $865.00 |
| 13121 | RPR CMPX SCALP ARM2.6-7.5 | $1,236.00 |
| 13122 | CMPLX RPR ADD 5 CM OR LES | $531.00 |
| 13132 | RPR CMPX FOREHEAD/CHECK/C | $1,462.00 |
| 13151 | CMPX RPR EYE NOSE 1.1-2.5 | $1,055.00 |
| 13152 | RPR CPLX E/N/E/L 2.6-7.5 | $1,830.00 |
| 13153 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< | $669.00 |
| 15850 | SUTURE RMVL W/ANESTHESIA | $653.00 |
| 16000 | BURN, INITIAL TREATMENT | $274.00 |
| 16020 | BURN, DRESSING/DBRDMNT-SM | $270.00 |
| 20552 | TRIGGER POINT INJ 1-2 MUS | $176.00 |
| 20600 | ARTHROCENTESIS, SML JOINT | $640.00 |
| 20605 | ARTHROCENTESIS, MED JOINT | $154.00 |
| 20610 | ARTHROCENTESIS, LG JOINT | $361.00 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $1,009.00 |
| 21310 | CLTX NSL B1 FX W/O MNPJ | $498.00 |
| 21480 | CLDS TX TEMP DISLOCATION | $452.00 |
| 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 | $381.00 |
| 23650 | SHOULDER DISLOCATION TRMT | $934.00 |
| 24500 | CLTX HUMRL SHFT FX W/O MN | $378.00 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYL | $1,392.00 |
| 24576 | CLTX HUMRL CNDLYR FX MEDI | $381.00 |
| 24600 | CLSD TX ELBOW DISLOCAT | $650.00 |
| 24640 | RADIAL HEAD SUBLUX. CHILD | $519.00 |
| 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 | $2,213.00 |
| 25530 | CLSD TX ULNAR SHFT FX NO | $378.00 |
| 25535 | CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION | $715.00 |
| 25560 | CLTX RDL&UR SHFT FXS W/O | $378.00 |
| 25600 | CLSD TX DISTAL RAD FX WO | $1,045.00 |
| 25605 | CLSD TX DISTAL RAD FX | $1,992.00 |
| 25622 | CLSD TX NAVICULAR FX WO M | $650.00 |
| 25635 | CLTTX CARPL B1 FX W/MNPJ EA B1 | $1,085.00 |
| 25650 | CLTX UR SYLOID FX | $1,097.00 |
| 26010 | I & D FINGER ABSCESS,SIMP | $298.00 |
| 26600 | CLSD TX METACARPAL FX | $909.00 |
| 26605 | CLSD TX MEDICARPAL FX | $1,053.00 |
| 26607 | CLTX MTCRPL FX W/MNP W/XT | $1,670.00 |
| 26700 | CLS TX MCP DISLOCATION | $381.00 |
| 26720 | CLSD TX PHALANGEAL SHFTFX | $628.00 |
| 26725 | CLTX PHLNGL FX PROX/MIDDL | $1,027.00 |
| 26750 | CLS TX FX FINGER/THUMB | $618.00 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/ | $792.00 |
| 26770 | TREAT FINGER DISLOC FINGE | $560.00 |
| 27220 | CLTX ACETABULUM HIP/SOCKT FX W/O MNP | $635.00 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $350.00 |
| 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 | $1,366.00 |
| 27560 | CLTX PATELLAR DISLC W/O A | $381.00 |
| 27752 | CLTX TIBL SFT FX W/MANP | $1,968.00 |
| 27760 | CLTX MEDIAL MALLS FX W/O | $1,153.00 |
| 27780 | CLTX PROX FIVULA/SHFT FX | $1,055.00 |
| 27786 | CLSD TX DISTAL FIBULAR FX | $993.00 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $5,342.00 |
| 27808 | CLOSED TX BIMALLEOLAR ANK | $507.00 |
| 27810 | CLTX BIMAL ANKLE FX W/POT | $1,704.00 |
| 27840 | CLOSED TX ANKLE DISLOCATI | $100.00 |
| 28190 | RMVL FB BODY FOOT SUBQ | $745.00 |
| 28192 | RMVL FB FOOT DEEP | $1,373.00 |
| 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 | $840.00 |
| 28490 | CLTX FX GRT TOE W/O MNLJ | $594.00 |
| 28510 | CLSD TX FX PLALANX/PHALAN | $523.00 |
| 28515 | FX CARE PHALANX NOT GREAT | $622.00 |
| 28660 | CLSD TX PIP JNT DISLOCATI | $622.00 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $610.93 |
| 29085 | CAST HAND/LOWER FOREARM GAUNTLET | $176.00 |
| 29105 | LONG ARM SPLINT | $176.00 |
| 29125 | SHORT ARM SPLINT | $532.80 |
| 29126 | SHORT ARM SPLINT DYNAMIC | $176.00 |
| 29130 | APPLICATION FINGER SPLINT | $176.00 |
| 29131 | APPLICATION FINGER SPLINT DYNAMIC | $364.17 |
| 29240 | STRPG SHO | $260.00 |
| 29280 | STRAPPING HAND/FINGER | $239.00 |
| 29505 | LONG LEG SPLINT | $176.00 |
| 29515 | SHORT LEG SPLINT | $176.00 |
| 29540 | STRAPPING ANKLE/FOOT | $220.00 |
| 29550 | STRAPPING TOES | $176.00 |
| 29580 | STRAPPING UNNA BOOT | $220.00 |
| 29700 | RMVL/BIVALV GAUNTLET BOOT | $127.00 |
| 30300 | RMVL FOREIGN BODY NASAL | $496.00 |
| 30901 | NASAL PACKING | $131.00 |
| 30903 | CTRL NSL HEMRRG ANT CPLX | $443.00 |
| 3120F | 12-LEAD ECG PERFORMED | $250.00 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $571.00 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $891.00 |
| 31515 | LARYNGOSCOPY +- TRACHEOSCOPY ASPIRATION | $670.00 |
| 31525 | LARGSC +-TRACHEOSCOPY DX | $198.00 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $1,342.00 |
| 33415 | RESCJ/INC SUBVALVULAR TISSUE | $980.00 |
| 36000 | INTRODUCTION OF NEEDLE/IN | $244.00 |
| 36410 | VENIPUNCTURE, 3 YRS OR OLDER | $68.00 |
| 36415 | VENIPUNCTURE | $28.00 |
| 36416 | COLL CAPILLARY BLG SPEC | $41.00 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $3,816.00 |
| 36558 | INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR | $2,156.00 |
| 36591 | COLLECT BLOOD FROM IMPLAN | $146.00 |
| 38300 | DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL | $303.00 |
| 40650 | RPR LIP FULL THICKNESS | $2,990.00 |
| 41800 | DRNG ABSC DENTOALVEOLAR S | $480.00 |
| 42700 | I&D ABSC PRITONSILLAR | $857.00 |
| 43753 | GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … | $128.00 |
| 46040 | I&D ISCHIOR/PRIRC ABSC SP | $1,957.00 |
| 46050 | INC/DRAIN PERIANAL ABS SU | $1,111.00 |
| 46083 | INCISION THROM HEMORRHOID | $491.00 |
| 46320 | ENULEATION EXCC OF EXT HE | $612.00 |
| 51700 | BLDR IRR SMPL LVG&/INSTLJ | $97.00 |
| 51701 | INSR NONDWELLING BLDR CAT | $231.00 |
| 51702 | INSERTION BLADDER CATH | $361.00 |
| 51703 | INSERT BLADDER CATH COMPL | $569.00 |
| 56405 | INC/DRAIN VULVA/PERINEAL | $259.00 |
| 56420 | I & D BARTHOLIN ABSCESS | $100.00 |
| 59025 | FTL NON-STRS TST | $600.00 |
| 59409 | VAG DLVR ONLY | $3,960.00 |
| 62270 | SPINAL PUNCTURE,LUMBAR | $554.00 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $2,743.00 |
| 64402 | INJ ANESTHETIC FACIAL NRV | $640.00 |
| 64450 | INJ ANESTHETIC AGENT | $1,312.50 |
| 64640 | DSTRJ NULYT OTH PRPH NVR/BRANCH | $1,220.00 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $244.00 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $380.00 |
| 65222 | RMVL FB EYE | $449.00 |
| 67700 | I&D ABSCESS EYELID | $773.00 |
| 69005 | DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED | $363.00 |
| 69200 | RMVL FOREIGN BODY EAR | $381.00 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $409.00 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL | $340.00 |
| 69210 | RMVL IMPACTED CERUMEN | $196.00 |
| 70030 | RADEX EYE DETCJ FB | $396.01 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $396.01 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $550.80 |
| 70120 | RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE | $459.00 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $396.01 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $396.01 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $769.50 |
| 70160 | NASAL BONE X-RAY | $396.01 |
| 70200 | RAD EXAM ORBIT COMP. | $641.25 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $523.37 |
| 70220 | RAD EXAM SINUS COMPLETE | $622.50 |
| 70250 | SKULL LESS THAN 4 VIEWS | $515.41 |
| 70260 | RAD EXAM SKULL COMPLETE | $970.20 |
| 70328 | RADEX TMPRMAND JT OPN&CLSD MOUTH UNI | $396.01 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $396.01 |
| 70350 | CEPHALOGRAM ORTHODONTIC | $257.00 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $493.52 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $4,022.10 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $5,317.20 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $6,624.71 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $2,718.75 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $4,801.50 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $6,740.13 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $3,129.30 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $3,352.50 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $6,586.13 |
| 70490 | CT NECK WO CONTRAST | $3,020.00 |
| 70491 | CT SOFT TISS NCK C+MATRL | $3,502.00 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $4,026.60 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $6,792.87 |
| 70544 | MRA HEAD C-MATRL | $5,975.25 |
| 70547 | MRA NECK C-MATRL | $5,178.55 |
| 70551 | MRI BRN BRN STEM C-MATRL | $4,780.20 |
| 70553 | MRI BRN BRN STEM C-/C+ | $6,492.28 |
| 71045 | RADIOLOGIC EXAM CHEST SINGLE VIEW | $583.20 |
| 71046 | CHEST XRAY 2 VIEWS | $563.25 |
| 71047 | RADIOLOGIC EXAM CHEST 3 VIEWS | $818.89 |
| 71048 | RADIOLOGIC EXAM CHEST 4+ VIEWS | $899.48 |
| 71060 | BRONCHOGRAPHY BI RS&I | $537.00 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $505.50 |
| 71101 | RIB UNILATERAL W CHEST | $848.25 |
| 71110 | RIBS BILATERAL 3 VIEWS | $689.25 |
| 71111 | RIBS BILATERAL W/CHEST | $509.25 |
| 71120 | Radiologic examination; sternum, minimum of 2 views | $511.50 |
| 71250 | CT CHEST W/O CONTRAST | $3,519.00 |
| 71260 | CT THORAX W/CONTRAST | $5,201.25 |
| 71270 | CT THORAX WO CONTRAST | $5,636.25 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $3,605.88 |
| 71550 | MRI CH C-MATRL | $4,454.40 |
| 72020 | SPINE SINGLE VIEW | $428.25 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $541.50 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $733.50 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $608.94 |
| 72069 | RADEX SPI THORACOLMBR STANDING SCOLIOSIS | $374.00 |
| 72070 | SPINE THORACIC 2 VIEWS | $649.80 |
| 72072 | SPINE THORACIC 3 VIEWS | $797.40 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $396.01 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $515.41 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $1,086.54 |
| 72100 | SPINE LUMBO. MIN 4 VIEWS | $649.80 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $961.17 |
| 72114 | RAD EXAM SPINE LUMBO COMP | $608.94 |
| 72120 | SPINE LUMBAR AP & LAT W F | $608.94 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $4,072.90 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $5,183.75 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $5,523.70 |
| 72128 | CT THRC SPI C-MATRL | $4,683.75 |
| 72129 | CT THRC SPI C+ MATRL | $3,564.00 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $6,373.50 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $5,620.50 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $7,483.40 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $8,455.51 |
| 72141 | MRI SPI CANAL&CNTS CRV C-MATRL | $4,780.20 |
| 72146 | MRI SPI CANAL&CNTS THRC C-MATRL | $4,780.20 |
| 72148 | MRI SPI CANAL&CNTS LMBR C-MATRL | $4,780.20 |
| 72156 | MRI SPI CANAL&CNTS C-/C+ CRV | $6,047.38 |
| 72157 | MRI SPI CANAL&CNTS C-/C+ | $4,402.50 |
| 72158 | MRI SPI CANAL&CNTS C-/C+ LMBR | $6,047.38 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $793.80 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $396.01 |
| 72191 | CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST | $4,743.70 |
| 72192 | CT PELVIS WO CONTRAST | $4,168.00 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $2,750.00 |
| 72194 | CT PELVIS W OR WO CONTRST | $7,574.00 |
| 72195 | MRI PELVIS C-MATRL | $4,454.40 |
| 72196 | MRI PELVIS C+ MATRL | $5,194.80 |
| 72220 | XRAY COCCYX/SACRUM | $396.01 |
| 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $4,354.12 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $396.01 |
| 73010 | SCAPULA COMPLETE | $396.01 |
| 73020 | RADEX SHO 1 VIEW | $598.00 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $612.90 |
| 73050 | XRAY AC JOINTS-BILAT | $396.01 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $550.80 |
| 73070 | XRAY ELBOW 2 VIEWS | $598.00 |
| 73080 | XRAY ELBOW GREATER THAN 3 VIEWS-COMP | $388.05 |
| 73090 | XRAY FOREARM AP & LAT | $594.90 |
| 73100 | XRAY WRIST AP & LAT VIEW | $534.60 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $396.01 |
| 73120 | XRAY HAND AP & LAT | $488.70 |
| 73130 | XRAY HAND MIN 3 VIEWS | $550.80 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $461.68 |
| 73200 | CT UPPR EXTR WO CNTRS | $3,309.75 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $5,778.90 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $6,740.13 |
| 73220 | MRI UXTR OTH/THN JT C-/C+ | $4,402.50 |
| 73221 | MRI ANY JT UXTR C-MATRL | $4,365.00 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $545.30 |
| 73502 | RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… | $894.90 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $1,142.26 |
| 73520 | HIPS BILAT MIN 2 VIEW INC | $507.00 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $1,286.54 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $523.37 |
| 73552 | FEMUR; MIN 2 VIEWS | $610.50 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $424.87 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $543.27 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $585.90 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $396.01 |
| 73580 | X-RAY KNEE.BILATERAL STANDING | $2,563.12 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $396.01 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $396.01 |
| 73600 | XRAY ANKLE 2 VIEWS | $547.25 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $685.80 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $498.50 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $691.53 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $396.01 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $467.10 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $4,390.94 |
| 73701 | CT LWR EXT W CONT | $6,388.90 |
| 73702 | CT LXTR C-/C+ | $5,080.50 |
| 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $4,678.49 |
| 73721 | MRI ANY JT LXTR C-MATRL | $4,365.00 |
| 73722 | MRI ANY JT LXTR C+ MATRL | $5,106.00 |
| 73723 | MRI ANY JT LXTR C-/C+ | $6,503.75 |
| 73725 | MRA LXTR C+-MATRL | $6,163.30 |
| 74000 | RAD EXAM ABD SINGL ANTER | $759.00 |
| 74010 | RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS | $426.00 |
| 74018 | RADIOLOGIC EXAM ABDOMEN 1 VIEW | $588.60 |
| 74019 | RADIOLOGIC EXAM ABDOMEN 2 VIEWS | $725.25 |
| 74020 | RAD EXAM ABDOMEN COMPL | $454.00 |
| 74021 | RADIOLOGIC EXAM ABDOMEN 3+ VIEWS | $688.80 |
| 74022 | RAD EXAM COMPLETE ABD | $1,360.80 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $3,407.20 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $4,816.50 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $5,528.25 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $7,019.00 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $5,196.80 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $4,588.65 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $5,702.97 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $6,905.88 |
| 74181 | MRI ABD C-MATRL | $4,780.20 |
| 74183 | MRI ABD C-/C+ | $6,047.38 |
| 74190 | PERITONEOGRAM RS&I | $2,192.98 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $718.39 |
| 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 … | $1,108.43 |
| 74247 | RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB | $1,010.00 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $768.14 |
| 74251 | RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE | $1,430.81 |
| 74283 | Therapeutic enema, contrast or air, for reduction of intuss… | $1,408.00 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $3,320.40 |
| 74329 | ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I | $2,701.60 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $386.06 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $228.85 |
| 74440 | VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I | $2,857.80 |
| 75574 | CT CORONARY | $3,360.60 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $543.27 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $1,293.50 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $1,133.10 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $769.14 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $893.51 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $648.74 |
| 76645 | US BREAST R-T W/IMAGE DOCUMENTATION | $784.06 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $1,504.80 |
| 76705 | US ABDOMINAL | $1,151.10 |
| 76706 | Ultrasound, abdominal aorta, real time with image documenta… | $901.00 |
| 76770 | US RETROPERITONEAL R-T W/ | $1,174.50 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $1,089.90 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $700.48 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $700.48 |
| 76805 | US PG UTER F&MAT AFTER 1S | $881.57 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $894.51 |
| 76815 | ULTRASND PG UTER | $525.36 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $851.72 |
| 76817 | UT PG UTER R-T IMG TRVG | $581.08 |
| 76830 | TRANSVAGINAL ULTRASOUND | $487.50 |
| 76856 | US PELVIC NONOB REAL-TIME | $1,089.75 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $624.00 |
| 76870 | US SCROTUM&CNTS | $1,004.40 |
| 76880 | US EXTREMITY | $913.00 |
| 76881 | US COMPL JOINT R-T W/IMAGE DOCUMENTATION | $801.97 |
| 76882 | ULTRASOUND, EXTREMITY, NON VASCULAR | $155.22 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… | $1,485.00 |
| 77076 | RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT | $275.00 |
| 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 | $1,701.00 |
| 78315 | B1&/JT IMG 3 PHASE STD | $2,022.00 |
| 78320 | B1&/JT IMG TOMOG SPECT | $923.00 |
| 78472 | CARD BPI GTD=BRM PLNR 1 STD REST/STRS | $2,047.71 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $571.13 |
| 80048 | METABOLIC PANEL BASIC | $163.18 |
| 80051 | ELECTROLYTE PANEL | $414.92 |
| 80053 | METABOLIC COMPRE PANEL | $689.54 |
| 80061 | LIPID PROFILE III | $452.73 |
| 80074 | HEPATITIS PANEL | $508.94 |
| 80076 | HEPATIC FUNCTION PANEL | $484.57 |
| 80100 | DRUG ABUSE PANEL II | $191.04 |
| 80102 | Drug confirmation, each procedure | $523.13 |
| 80104 | DRUG SCREEN | $172.00 |
| 80178 | LITHIUM | $456.71 |
| 80196 | SALICYLATE | $332.33 |
| 80197 | TACROLIMUS | $452.70 |
| 80202 | VANCOMYCIN PEAK | $390.04 |
| 80300 | DRUG SCREEN | $221.00 |
| 80304 | DRUG SCREEN | $211.00 |
| 80305 | DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… | $143.00 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $763.20 |
| 80320 | DRUG SCREEN | $143.28 |
| 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $407.70 |
| 80329 | DRUG SCREEN | $151.24 |
| 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $165.17 |
| 80345 | DRUG SCREENING BARBITURATES | $286.20 |
| 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $246.26 |
| 80347 | DRUG SCREENING BENZODIAZEPINES 13 OR MORE | $525.00 |
| 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $298.06 |
| 80351 | DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 | $829.80 |
| 80352 | DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE | $655.20 |
| 80353 | DRUG SCREENING COCAINE | $302.10 |
| 80356 | DRUG SCREENING HEROIN METABOLITE | $212.68 |
| 80358 | DRUG SCREENING METHADONE | $362.18 |
| 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $88.06 |
| 80361 | DRUG SCREENING OPIATES 1 OR MORE | $298.50 |
| 80362 | DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 | $296.51 |
| 80365 | DRUG SCREENING OXYCODONE | $37.56 |
| 80366 | DRUG SCREENING PREGABALIN | $227.86 |
| 80367 | DRUG SCREENING PROPOXYPHENE | $233.83 |
| 80373 | DRUG SCREENING TRAMADOL | $256.71 |
| 80374 | DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS | $420.00 |
| 81000 | U/A DIPSTICK | $115.42 |
| 81001 | U/A DIP STICK | $176.12 |
| 81002 | URNLS DIP STICK/TABLET RG | $37.81 |
| 81003 | U/A W/O MICRO DIPSTICK | $37.81 |
| 81007 | URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK | $288.55 |
| 81025 | PREG.TST URINE VISUAL | $95.52 |
| 82003 | ACETAMINOPHEN | $624.60 |
| 82009 | KETONES-SERUM | $36.00 |
| 82040 | ALBUMIN; SERUM | $133.33 |
| 82055 | ALCOHOL-BLOOD | $330.34 |
| 82075 | ALCOHOL BREATH TEST | $175.12 |
| 82140 | Ammonia | $278.60 |
| 82150 | AMYLASE | $220.89 |
| 82247 | BILIRUBIN TOTAL | $311.44 |
| 82248 | BILIRUBIN DIRECT | $179.10 |
| 82250 | direct bilirubin | $260.69 |
| 82253 | MB FRACTION | $154.00 |
| 82270 | OCCULT BLOOD | $102.49 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $47.76 |
| 82274 | BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 | $177.11 |
| 82310 | CALCIUM | $174.13 |
| 82330 | CALCIUM IONIZED | $476.61 |
| 82355 | CALCULUS QUALITATIVE ANALYSIS | $428.40 |
| 82374 | CARBON DIOXIDE BICARBONATE | $185.07 |
| 82375 | Under Chemistry Procedures | $188.80 |
| 82435 | CHLORIDE BLD | $178.11 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $197.01 |
| 82533 | CORTISOL TOTAL | $243.03 |
| 82540 | CREATINE | $433.82 |
| 82541 | COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE | $121.00 |
| 82550 | CREATINE CK-TOTAL | $71.64 |
| 82553 | CREATINE CKMB | $149.25 |
| 82565 | CREATININE | $194.03 |
| 82607 | VITAMIN B-12 | $297.51 |
| 82693 | ASSAY OF ETHYLENE GLYCOL | $158.45 |
| 82747 | ASSAY OF FOLIC ACID RBC | $372.13 |
| 82784 | IGC IMMUNOGLOBULIN | $84.33 |
| 82785 | GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE | $152.73 |
| 82800 | GASES BLD PH ONLY | $130.00 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $284.57 |
| 82805 | GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY | $889.10 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $169.15 |
| 82947 | GLUCOSE | $169.15 |
| 82948 | GLUCOSE BLOOD REAGET STR | $166.66 |
| 82962 | GLUCOSE FINGER STICK | $47.76 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $391.04 |
| 83009 | HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE | $754.60 |
| 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $742.50 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $195.02 |
| 83050 | HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE | $107.46 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $570.00 |
| 83525 | ASSAY OF INSULIN TOTAL | $167.16 |
| 83540 | IRON-TOTAL | $133.33 |
| 83605 | ASSAY OF LACTATE | $548.74 |
| 83615 | Lactate dehydrogenase (LD), (LDH); | $275.62 |
| 83690 | LIPASE | $241.79 |
| 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $71.89 |
| 83735 | MAGNESIUM | $258.70 |
| 83874 | MYOGLOBIN | $113.93 |
| 83880 | B-TYPE NATRIURETIC | $549.75 |
| 83992 | ASSAY OF PHENCYCLIDINE | $225.00 |
| 84075 | ALK PHOS/PROFILE OR PANEL | $99.50 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $180.10 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $209.95 |
| 84155 | PROTEIN,TOTAL,EXCEPT REFR | $166.17 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $425.86 |
| 84165 | PROTEIN ELECTROPHORESIS | $120.40 |
| 84295 | SODIUM; SERUM | $208.95 |
| 84403 | ASSAY OF TESTOSTERONE TOTAL | $213.18 |
| 84436 | THYRIXINE TOTAL | $133.33 |
| 84439 | THYROXINE-FREE | $319.40 |
| 84443 | Thyroid stimulating hormone (TSH) | $587.05 |
| 84450 | Aspartate Aminotransferase | $99.50 |
| 84460 | ALT-TRANSFERASE;ALANINE | $91.54 |
| 84478 | ASSAY OF TRIGLYCERIDES | $351.24 |
| 84479 | THYROID HORMONE | $209.95 |
| 84480 | T3 TOTAL | $155.72 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $356.21 |
| 84484 | TROPONIN I | $369.15 |
| 84512 | TROPONIN QUAL | $549.24 |
| 84520 | Urea nitrogen | $178.11 |
| 84550 | URIC ACID | $166.17 |
| 84560 | URIC ACID OTH SRC | $167.16 |
| 84702 | HCG QUANTATIVE | $492.30 |
| 84703 | PREGNANCY TEST BLOOD | $149.25 |
| 84999 | UNLISTED CHEMISTRY PROCEDURE | $179.10 |
| 85014 | HEMATOCRIT | $81.59 |
| 85018 | HEMOGLOBIN | $81.59 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $268.65 |
| 85027 | CBC W/O DIFF | $125.37 |
| 85032 | BLD# MNL C-CNT RBC/PLTLT EA | $152.00 |
| 85044 | RETICULOCYTE COUNT | $248.75 |
| 85347 | COAGJ TM ACTIVATED | $83.58 |
| 85378 | FIBRIN DEGRADATION PROD | $93.53 |
| 85379 | D-DIMER | $140.54 |
| 85610 | PROTHROMBIN TIME | $182.09 |
| 85651 | SEDIMENTATION RATE NONAUT | $177.11 |
| 85652 | SED RATE ERYTHROCYTE NON | $51.74 |
| 85730 | THROMBOPLASTIN TIME PART | $117.41 |
| 86038 | ANTINUCLEAR AB | $486.56 |
| 86039 | ANTINUCLEAR AB TITER | $477.60 |
| 86060 | ANTISTREPTOLYSIN O TITER | $291.54 |
| 86140 | C REACTIVE PROTEIN | $399.99 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $463.67 |
| 86256 | SMOOTH MUSCLE AB TITER | $251.24 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $99.50 |
| 86320 | IMMUNOELECTROPHORESIS | $48.76 |
| 86328 | COVID-19 RAPID ANTIBODY TEST SINGLE METHOD | $297.00 |
| 86360 | T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO | $300.49 |
| 86403 | MONO SPOT | $221.89 |
| 86430 | RHEUMATOID FACTOR | $300.49 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $219.90 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $281.59 |
| 86593 | SYPHILIS TEST, NON- TREPONEMAL ANTIBODY; QUANTITATIVE | $65.67 |
| 86631 | ANTB CHLAMYDIA | $111.94 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $408.60 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $450.74 |
| 86664 | EPSTEIN-BARR VIRUS EBNA | $133.00 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $454.72 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $820.88 |
| 86701 | HIV SERUM | $131.34 |
| 86702 | ANTB HIV-2 | $536.25 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $505.46 |
| 86705 | HEPATITIS B CORE IGM | $455.40 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $359.20 |
| 86713 | LEGIONELLA PNEUMONPILA AB | $133.33 |
| 86756 | ANTB RSV | $143.00 |
| 86769 | COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD | $325.00 |
| 86780 | ANTIBODY TREPONEMA PALLIDUM | $113.18 |
| 86787 | Antibody; varicella-zoster | $450.74 |
| 86803 | HEPATITIS C ANTIBODY | $517.40 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $248.75 |
| 86900 | Blood typing, serologic; ABO | $141.29 |
| 86901 | RH FACTOR-BLOOD | $135.32 |
| 86906 | BLD TYPING RH PHEXYPING COMPL | $86.00 |
| 87040 | BLOOD CULTURE | $400.99 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $198.01 |
| 87046 | CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA | $198.01 |
| 87070 | CULTURE BODY FLUID | $167.16 |
| 87075 | CULTURE ANAEROBIC | $485.10 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $523.37 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $155.22 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $81.59 |
| 87086 | URINE CULTURE | $99.00 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $61.69 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $151.24 |
| 87110 | CHLAMYDIA CULTURE | $259.70 |
| 87177 | OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID | $206.46 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $100.74 |
| 87207 | SMR PRIM SRC SPEC STAIN | $189.05 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $262.68 |
| 87210 | WET SMEAR | $83.58 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $394.02 |
| 87255 | Herpes Simplex Virus Culture with Reflex Typing | $432.83 |
| 87275 | IAADI INF B VIRUS | $220.89 |
| 87338 | IAAD IA HPYLORI STOOL | $220.89 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $332.33 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $501.60 |
| 87389 | HIV-1 AG W/HIV-1 & HIV-S AB | $467.65 |
| 87400 | INFLUENZA A&B | $95.52 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $987.78 |
| 87425 | ROTAVIRUS AG EIA | $389.05 |
| 87426 | COVID-19 RAPID ANTIGEN TESTING | $353.00 |
| 87427 | IAAD IA SHIGA-LIKE TOXIN | $447.60 |
| 87428 | Multiplex viral pathogen panel using Antigen technique for … | $700.00 |
| 87430 | INF AGT IMMUNO STREP A | $220.89 |
| 87480 | IADNA CANDIDA SPECIES DIRECT PROBE TQ | $231.84 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $579.60 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $403.28 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $497.50 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $3,998.40 |
| 87529 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA &RNA) | $601.50 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $429.17 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $289.05 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $2,061.60 |
| 87635 | IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ | $301.00 |
| 87636 | “severe acute respiratory syndrome coronavirus 2 (SARSCoV-2… | $800.00 |
| 87661 | INF AGENT DETECTED NUCLEIC ACID; TRICHMONAS VAGINALIS AMP P… | $460.80 |
| 87798 | O&P SMEAR W/AMPLIFIC | $702.00 |
| 87800 | IAADIADOO NEISSERIA GONORRHOEAE | $197.23 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $168.00 |
| 87807 | INF AGT DET IMNAS OPT RSV | $42.00 |
| 87847 | NO DESCRIPTION | $409.00 |
| 87850 | NEISSERIA GONORRHOEAE DET | $169.65 |
| 87880 | RAPID STREP-BETA STREP | $200.99 |
| 87905 | INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS | $394.50 |
| 88305 | PATH SURG LEVEL IV | $405.96 |
| 89050 | CELL COUNT MISCELLANEOUS BODY FLUIDS | $134.33 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $127.36 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $98.51 |
| 89060 | CRYSTAL INDENTIFICATION | $105.47 |
| 89220 | SPTM OBTG SPEC AERSL INDUCED SPX | $98.00 |
| 90471 | IMMUN ADM 1 VAC | $154.23 |
| 90660 | INFLUENZA VIRUS INTRANASA | $70.00 |
| 90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, … | $525.30 |
| 90700 | DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM | $231.60 |
| 90703 | TETANUS TOXID | $152.00 |
| 90714 | TETANUS DIPHTHERIA TOXOID | $374.32 |
| 90715 | TDAP VACCINE | $116.00 |
| 90718 | TETANUS & DIPTHERIA | $152.00 |
| 90746 | HEPATITIS B VACCINE/ADULT | $79.00 |
| 90765 | IV NFS THER PROPH/DX 1ST | $210.00 |
| 90997 | HEMOPERFUSION | $409.00 |
| 91105 | GASTRIC INTUBATION/ASPER | $596.00 |
| 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 | $1,301.00 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $1,089.00 |
| 93000 | EKG W/INTREP AND REPORT | $248.00 |
| 93005 | Electrocardiogram, routine ECG | $534.00 |
| 93010 | RTN ECG 12 LEADS INTRP/RP | $624.00 |
| 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 | $146.00 |
| 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $340.29 |
| 93224 | WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I | $149.00 |
| 93306 | ECHO TEST | $1,367.00 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $3,524.29 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $2,795.40 |
| 93313 | TEE R-T IMG 2D W/PROBE PLMT ONLY | $2,626.00 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $1,457.30 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $1,480.10 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $1,560.00 |
| 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 | $903.00 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $903.00 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $557.20 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $845.75 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $923.36 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $878.00 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $923.36 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $466.00 |
| 93965 | QUANT VENOUS FLOW ST | $1,806.00 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $1,201.96 |
| 93971 | DPLX SCN EXTRM VEINS | $645.00 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… | $514.00 |
| 93976 | DUPLEX SCAN- LIMITED | $466.00 |
| 94010 | SPIROMETRY W/RECORD | $150.00 |
| 94060 | BRNCDILAT RSPSE SPMTRY PR | $385.00 |
| 94621 | PULM STRS TSTG CPLX | $1,029.00 |
| 94640 | NEBULIZER TREATMENT | $873.65 |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $157.00 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $1.00 |
| 94760 | EAR OR PULSE OXIMETRY | $25.87 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $238.00 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $644.76 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $634.50 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $356.21 |
| 96365 | IV INFUSION THERAPY/PROPH | $497.50 |
| 96366 | IV INFUS THER PROPH/DX EA | $356.21 |
| 96367 | IV NFS THER PROPH/DX ADDL | $470.64 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $263.00 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $87.56 |
| 96373 | INJECTION, INTRA-ARTERIAL | $228.00 |
| 96374 | THER PROPH/DX NJX IV PUSH | $441.78 |
| 96375 | THER PROPH/DX NJX EA SEQL | $402.98 |
| 96376 | SUB INFU EA ADD IV PUSH | $388.05 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $232.83 |
| 96379 | INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS | $213.00 |
| 97010 | APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS | $101.49 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR | $302.48 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $278.60 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $638.79 |
| 99000 | SPECIMEN HANDLING | $54.00 |
| 99001 | COC COLLECITON ONLY | $41.00 |
| 99024 | POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX | $789.00 |
| 99050 | BLUE CROSS RQRD LVL3 | $87.00 |
| 99053 | SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY | $146.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $183.08 |
| 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 | $857.69 |
| 99173 | SCREENING TEST OF VISION | $293.00 |
| 99217 | OBSERVATION CARE DISCHARGE MANAGEMENT | $975.10 |
| 99218 | INITIAL OBSERVATION CARE/DAY 30 MINUTES | $187.06 |
| 99219 | INITIAL OBSERVATION CARE/DAY 50 MINUTES | $957.19 |
| 99220 | INITIAL OBSERVATION CARE/DAY 70 MINUTES | $957.19 |
| 99234 | OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES | $1,066.64 |
| 99235 | OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES | $1,852.69 |
| 99236 | OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES | $2,454.80 |
| 99281 | E/M VISIT LEVEL 1 TECH COMP | $479.59 |
| 99282 | E/M VISIT LEVEL 2 TECH COMP | $1,035.80 |
| 99283 | E/M VISIT LEVEL 3 TECH COMP | $2,055.67 |
| 99284 | E/M VISIT LEVEL 4 TECH COMP | $2,692.47 |
| 99285 | E/M VISIT LEVEL 5 TECH COMP | $3,770.06 |
| 99291 | CRITICAL CARE 30-74 MIN | $4,779.00 |
| 99292 | CRITICAL CARE ADD 30 MIN | $1,365.14 |
| 99406 | SMOKING CESSATION 3-10 | $81.00 |
| 99407 | SMOKING CESSATION 10 MIN | $94.00 |
| 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 | $12.00 |
| A4216 | STERILE WATER/SALINE, FLUSH 10ML | $3.00 |
| A4217 | STERILE SALINE WATER PER 500 ML | $26.00 |
| A4218 | STERILE SALINE OR WATER | $26.00 |
| A4222 | EXT UNFU PMP PER CASS/BAG | $176.00 |
| A4224 | ALOCHOL OR PEROXIDE PER PINT | $4.00 |
| A4246 | BETADINE/PHISOHEX SOLUTION | $25.00 |
| A4247 | BETADINE/IODINE SWABS/WIPES | $25.00 |
| 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 | $12.00 |
| A4315 | Insertion tray with drainage bag with indwelling catheter, … | $15.00 |
| 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 | $3.00 |
| A4338 | INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING | $53.00 |
| A4344 | INDWELLING CATH FOLEY TYP | $12.00 |
| A4353 | INTERMIT URINARY CATHETER | $24.00 |
| A4358 | URINARY DRAINAGE BAG | $14.00 |
| A4364 | DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ | $33.00 |
| 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 |
| A4565 | SLING | $146.00 |
| 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 | $127.00 |
| A4614 | HAND HELD PEFR METER | $50.00 |
| A4615 | CANNULA NASAL | $6.00 |
| A4616 | TUBING (OXYGEN) PER FOOT | $1.00 |
| A4617 | MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT | $55.00 |
| A4649 | SURGICAL SUPPLY MISC | $23.00 |
| 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 | $117.00 |
| A6021 | COLLAGEN DRESSING STERIL | $17.00 |
| A6205 | COMPOSITE DRSG LESS THAN 48 SQ IN | $22.00 |
| A6210 | FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER | $98.00 |
| A6211 | FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER | $31.00 |
| A6212 | FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ IN OR LESS, EACH… | $7.00 |
| A6213 | FOAM DRG 16-48 SQ IN W/BRDR | $11.00 |
| A6216 | GAUZE NONIMPREG 16 SQ IN | $13.00 |
| A6217 | GAUZE NON STERILE | $13.00 |
| A6218 | GAUZE, NON STERILE | $13.00 |
| A6219 | GAUZE- STERILE | $13.00 |
| A6220 | GAUZE, NON IMP, STERILE, PAD SIZE >16 SQ < OR = 48SQ IN | $11.00 |
| A6222 | GAUZE IMPREGNATED WITH ME | $8.00 |
| A6231 | GAUZE, 16<SQ IN, EACH | $70.00 |
| A6250 | SKIN SEAL PROTECT MOISTURIZER OINTMENT | $34.00 |
| A6260 | WOUND CLEANSER | $100.00 |
| A6261 | WOUND FILLER | $100.00 |
| A6402 | GAUZE NON-IMPREG STERL 16 | $7.00 |
| A6407 | PACK STRIPS NON-IMPREGNTD | $29.00 |
| 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 |
| 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 | $2.00 |
| A6454 | SELF ADHER BANDAGE | $13.00 |
| A6455 | SELF ADHER BANDAGE | $13.00 |
| A6457 | TUBULAR DRESSING | $41.00 |
| A7002 | SUCTION TUBING USED W PUMP | $94.00 |
| 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 | $37.00 |
| A9150 | NON PERSCRIPTION DRUG | $23.00 |
| A9273 | HOT/COLD H2OBOT/CAP/COL/WRAP | $32.00 |
| A9284 | NON-ELECTRONIC SPIROMETER | $254.00 |
| A9579 | GAD-BASE MR CONTRAST NOS,1ML | $15.00 |
| C9399 | ORBACTIV 1200 MG IV | $10,153.00 |
| CASH | XRAY DISC | $17.00 |
| E0110 | CRUTCH FOREARM PAIR | $225.00 |
| E0114 | CRUTCHES UNDERARM | $59.00 |
| 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 | $90.00 |
| G0168 | WND CLS TISSUE ADHESIVE | $152.00 |
| 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 | $3.00 |
| J0150 | ADENOSINE INJ 6MG VIAL | $65.00 |
| J0153 | ADENOSINE INJ 1MG | $8.00 |
| J0170 | EPINEPHRINE 3 1/2 NDL 10M | $8.00 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $23.00 |
| J0210 | METHYLDOPATE HCL INJECTION | $40.00 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $13.00 |
| J0290 | AMPICILLIN 500 MG INJ | $22.00 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $20.00 |
| J0330 | SUCCINYLCHOLINE CHLO 20MG | $173.00 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $173.00 |
| J0456 | INJ AZITHROMYCIN 500MG | $81.00 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $1.00 |
| J0500 | DICYCLOMINE HCL 20MG | $22.00 |
| J0550 | BICILLIN – PENICILLIN G BENZATHINE INJ | $65.00 |
| J0558 | PENG BENZATHINE/PROCAINE INJ | $90.00 |
| J0559 | BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS | $65.00 |
| J0560 | BICILLIN 600,000 | $50.00 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $55.00 |
| J0570 | BICILLIN 1,200,000 | $110.00 |
| J0595 | STADOL | $13.00 |
| J0610 | CALCIUM GLUCONATE INJECTION | $79.80 |
| J0641 | LEVOLEUCOVORIN INJECTION | $2.00 |
| J0690 | KEFZOL 1 GR VIAL | $22.00 |
| J0692 | INJ CEFEPIME HCI 500MG | $46.00 |
| J0696 | ROCEPHIN 250 MG | $52.00 |
| J0697 | STERILE CEFUROXIME INJECTION | $25.00 |
| J0698 | CLAFORAN 1 GR VIAL | $63.00 |
| J0735 | CLONIDINE 1MG | $8.00 |
| J0744 | CIPRO 200MG | $176.00 |
| J0760 | COLCHICINE INJECTION | $23.00 |
| J0780 | COMPAZINE 10 MG | $12.00 |
| J1020 | INJ METHYLPREDNISOLONE AC | $2.00 |
| J1030 | DEPO MEDROL 40 MG/ML | $75.64 |
| J1040 | METHYLPREDNISOLONE 80MG | $10.00 |
| J1094 | DECADRON DEXAMETHASONE ACETATE 1MG | $22.00 |
| J1100 | DECADRON 4 MG VIAL | $22.00 |
| J1110 | INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG | $70.00 |
| J1165 | DILANTIN 100 MG VIAL | $41.00 |
| J1170 | DILAUDID 4 MG | $41.00 |
| J1200 | BENADRYL 50MG | $22.00 |
| J1240 | ANTIVERT – DIMENHYDRINATE INJECTION 50MG | $33.00 |
| J1335 | ERTAPENEM INJECTION | $21.00 |
| J1580 | GARAMYCIN,GENTAMICIN 80MG | $50.00 |
| J1610 | GLUCOGAN 1 MG VIAL | $68.00 |
| J1630 | HALOPERIDOL INJECTION | $39.70 |
| J1631 | HALOPERIDOL DECANOATE INJ PER 50 MG | $83.00 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $13.00 |
| J1644 | INJ HEPARIN SOD PER 1000 | $87.00 |
| J1650 | ENOXAPARIN SODIUM 10MG | $37.00 |
| J1670 | TETANUS INJECTION | $41.00 |
| J1741 | IBUPROFEN INJECTION | $22.00 |
| J1810 | DROPERIDOL/FENTANYL INJ | $25.00 |
| J1815 | INJ INSULIN PER 5 UNITS | $31.00 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $22.00 |
| J1885 | TORADOL INJ 15 MG | $22.00 |
| J1930 | LANREOTIDE INJECTION | $45.00 |
| J1940 | LASIX 40 MG IV VIAL | $22.00 |
| J1956 | LEVOFLOXACIN 250 MG | $120.00 |
| J2001 | LIDOCAINE HCI 10MG | $31.00 |
| J2060 | ATIVAN 2ML SYRUP | $100.00 |
| J2150 | MANNITOL INJECTION | $26.00 |
| J2175 | DEMEROL 50 MG SYRINGE | $28.00 |
| J2180 | MEPERIDINE/PROMETHAZINE INJ | $30.00 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $11.00 |
| J2270 | INJ MORPHINE SULFATE 10 M | $22.00 |
| J2274 | INJ MORPHINE PF EPID ITHC | $30.00 |
| J2300 | NUBAIN 10MG AMP | $50.00 |
| J2310 | INJ NALOXONE HCL 1MG | $30.00 |
| J2360 | ORPHENADRINE CITRATE 60MG | $122.00 |
| J2370 | NEO-SYNEPHRINE UP TO 1 ML | $81.00 |
| J2405 | ONDANSETRON HCI, PER MG | $22.00 |
| J2410 | OXYMORPHONE HCL INJECTION | $25.00 |
| J2425 | PALIFERMIN INJECTION | $25.00 |
| J2504 | PEGADEMASE BOVINE, 25 IU | $25.00 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $59.00 |
| J2550 | PHENERGAN 50 MG | $22.00 |
| J2650 | PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML | $6.00 |
| J2690 | PRONESTYL 10 ML | $22.00 |
| J2704 | INJECTION PROPOFOL 10 MG | $32.00 |
| J2730 | PRALIDOXINE CHLORIDE | $22.00 |
| J2760 | PHENTOLAINE MESYLATE INJ | $41.00 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $1.99 |
| J2780 | INJ RANITIDINE 25 MG | $37.00 |
| J2790 | RHOGAM INJECTION | $199.00 |
| J2800 | METHOCARBAMOL INJECTION | $50.00 |
| J2920 | SOLU-MEDROL 40MG | $10.00 |
| J2930 | SOLU-MEDROL 125 MG | $15.00 |
| J3010 | INJ FENTANYL CITRATE .1MG | $1.00 |
| J3030 | IMITREX 6MG VIAL | $216.41 |
| J3105 | INJECTION, TREBUTALINE SULFATE, UP TO 1 MG | $35.00 |
| J3130 | TESTOSTERONE ENANTHATE INJ | $24.00 |
| J3230 | THOROZINE 50 MG | $330.00 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $36.00 |
| J3360 | VALIUM INJ 5 MG | $10.00 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $229.00 |
| J3410 | VISTERIL INJ 50 MG | $22.00 |
| J3411 | INJ THIAMINE 100 MG | $11.00 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $12.00 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $25.00 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $1.99 |
| J3486 | GEODON – ZIPRASIDONE MESYLATE 10MG | $35.00 |
| J3490 | UNCLASSIFIED DRUGS | $36.00 |
| J7030 | INFUS NORM SALINE 1000CC | $53.00 |
| J7040 | INFUS NORM SALINE 500ML | $26.00 |
| J7042 | 5% DEXTROSE | $26.00 |
| J7050 | INFS NORM SALINE 250CC | $26.00 |
| J7060 | INFUSION D5W 250ML | $28.00 |
| J7070 | INFUSION D5W 1000ML | $86.00 |
| J7120 | RINGER’S LACTATE INFUS | $90.00 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $65.27 |
| J7130 | HYPERTONIC SALINE SOLUTION | $76.00 |
| J7131 | HYPERTONIC SALINE SOL | $61.74 |
| 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 | $8.00 |
| J7512 | PREDNISONE 5 MG | $8.00 |
| J7607 | LEVALBUTEROL COMP CON | $13.00 |
| J7610 | ALBUTEROL, THRU DME 1MG | $13.00 |
| J7611 | ALBUTEROL 1MG CONC INHALA | $13.00 |
| J7613 | ALBUT INHAL NON-CP 1MG | $13.00 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $20.00 |
| J7615 | LEVALBTERAL INHALATION SO | $20.00 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $13.00 |
| J7631 | CROMOLYN SODIUM NONCOMP UNIT | $20.00 |
| J7637 | DEXAMETHASONE COMP CON | $20.00 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $31.00 |
| J7682 | TOBRAMYCIN NON-COMP UNIT | $25.00 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $8.00 |
| J8498 | ENEMA SUPPOSITORY, ANTIEMETIC RECTAL | $31.00 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $17.00 |
| J8540 | DEXAMETHASONE, ORAL .25MG | $20.00 |
| J9027 | CLOFARALINE INJECTION | $141.00 |
| J9206 | IRINOTECAN INJECTION | $25.00 |
| L0120 | CERVICAL FLEX NONADJ COLL | $320.00 |
| L0172 | CLAVICAL COLLAR 2 PC | $41.00 |
| L1630 | ABDUCT CONTROL HIP SEMI FLEX | $41.00 |
| L1830 | KNEE IMMOBOLIZER | $24.00 |
| L1906 | ANKLE SUPPORT | $133.00 |
| L3260 | SURGICAL BOOT/SHOE | $87.00 |
| L3650 | SO FIGURE EIGHT ABDUCTION | $251.00 |
| L3670 | SO ACROMIO/CLAVICULAR | $113.00 |
| L3908 | WRIST EXTN CONTROL COCKUP | $87.00 |
| L3999 | UPPER LIMB ORTHOSIS NOS | $176.00 |
| L4350 | AIR SPLINT | $453.00 |
| L4360 | WALK BOOT PNEUMATIC | $117.00 |
| L4380 | PNEUMATIC KNEE SPLINT | $125.00 |
| L4386 | WALKING BOOT NON PNEUMATIC | $168.00 |
| L4387 | NON-PNEUM WALK BOOT PRE OTS | $250.00 |
| P7001 | CULTURE BACTERIAL URINE | $89.00 |
| P9612 | CATHETERIZE FOR URINE | $177.00 |
| Q0144 | AZITH DIHY ORAL CAP/POWD | $161.00 |
| Q0179 | ONDANESTRONG HCL 8MG ORL | $4.00 |
| 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 | $24.00 |
| 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 | $125.00 |
| Q9954 | ORAL MR CONTRAST, 100ML | $416.00 |
| Q9963 | HI OSM CONTRST MATL 350-3 | $23.00 |
| Q9965 | LOW OSMOLAR CON MAT PER M | $25.00 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $22.00 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $20.00 |
| S0020 | INJ, BUPIVICAINE, 30ML | $46.00 |
| S0028 | INJECT FAMOTIDINE 20 MG | $70.00 |
| S0030 | METRONIDAZOLE 500 MG INJ | $188.00 |
| S0077 | CLANDAMYCIN PHOSPHATE 300 | $32.00 |
| S0119 | ZOFRAN, 4MG, ORAL | $8.00 |
| S0164 | PROTONIX PANTROPRAZOLE 40MG | $194.00 |
| S0622 | PHYS EXAM FOR COLLEGE | $87.00 |
| S0630 | RMV SUTURES; PHYS NOT PHY | $65.00 |
| S3000 | BILAT DIL RETINAL EXAM | $11.00 |
| S5000 | PRESCRIPTION DRUG GENERIC | $1.00 |
| S5001 | PRESCRIPTION DRUG BAND NM | $8.00 |
| S5010 | STERILE SALINE 5% DEXTROSE AND 0.45% SALINE | $232.00 |
| S5011 | 5% DEXTROSE 1000 ML | $1.00 |
| S5550 | INSULIN RAPID 5 U | $26.00 |
| 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 |
| U0002 | COVID-19 PCR Testing | $301.00 |
Keeping kids safe on trampolines and at bounce houses
October 27, 2021• By Angela Mattke, M.D., Mayo Clinic Press Editors Trampolines and bounce houses have become staples of backyards, community and family events, and
