Richmond Charge Master 04.09.21

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 $1,243.38
10061 INS/DRAIN ABSCESS COMPL $1,566.72
10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE $1,216.00
10081 I&D PILONIDAL CST COMP $590.00
10120 I & RMVL SUB-CUT SIMPLE $3,376.43
10121 I & RMVL FB, SUB-CUT,COMP $583.00
10160 PUNCTURE ASP OF ABSCESS $328.00
10180 Incision and drainage, complex, postoperative wound infecti… $1,950.00
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 $1,455.00
11200 RMVL SKIN TAGS $443.74
11404 EXC BGN LSN TRUNK 3.1-4.0 $833.00
11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER $360.00
11730 AVULSION/1-NAIL PLATE $1,540.00
11740 EVAC SUBUNGUAL HEMATOMA $1,180.00
11750 EXC NAIL PART/COMP $1,404.00
11760 REPAIR NAIL BED $531.00
11765 WEDGE EXC SKIN/NAIL BED $341.00
11771 EXCISION PILONIDAL CYST SINUS EXTENSIVE $297.00
11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $895.00
12001 LACERATION REPAIR $290.54
12002 REPAIR LAC SCALP 2.6-7.5 $326.36
12004 REPAIR LAC SCALP 7.6-12.5 $356.21
12005 REPAIR LAC,SCALP 12.6-20C $902.50
12011 REPAIR LAC FACE LESS THAN 2.5 CM $812.92
12013 REPAIR LAC FACE 2.6-5.0CM $854.70
12014 REPAIR LAC FACE 5.1-7.5CM $1,258.00
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 $344.27
12034 INTERM RPR SCLP/TRNK/EXTR $707.00
12035 REPAIR INTERM S/A/T/E 12. $1,226.55
12036 REPAIR INTERM S/A/T/E 20.1-30.0 CM $762.00
12041 LAYER CLSR NECK/HAND 2.6 $292.53
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 $1,540.00
12052 LYR CLSR WOUND 2.6-5.0FAC $1,180.00
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 $1,404.00
13120 REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM $2,023.03
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 $2,618.93
13153 REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< $669.00
15850 SUTURE RMVL W/ANESTHESIA $895.00
16000 BURN, INITIAL TREATMENT $1,350.00
16020 BURN, DRESSING/DBRDMNT-SM $284.57
17250 UMBILICAL CAUTERIZATION $368.15
19000 PUNCTURE ASPIRATION CYST BREAST $2,521.33
19100 BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX $779.08
20552 TRIGGER POINT INJ 1-2 MUS $805.95
20600 ARTHROCENTESIS, SML JOINT $1,523.75
20605 ARTHROCENTESIS, MED JOINT $1,412.50
20610 ARTHROCENTESIS, LG JOINT $1,523.00
20611 Arthrocentesis, aspiration and/or injection, major joint or… $1,922.00
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
23550 OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC $890.00
23570 CLSD TX SCAPULAR FX WO MA $839.00
23600 CLTX PROX HUMRL FX WO MAN $381.00
23650 SHOULDER DISLOCATION TRMT $1,100.00
23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ $1,320.00
24075 EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM $1,000.00
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 $1,000.00
24640 RADIAL HEAD SUBLUX. CHILD $1,100.00
24650 CLTX RDL HEAD FX WO MANP $959.00
24670 CLTX ULNR FX PROX END WO $942.00
25066 BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP $1,000.00
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 $999.00
26600 CLSD TX METACARPAL FX $909.00
26605 CLSD TX MEDICARPAL FX $1,200.00
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 $1,080.00
26755 CLTX DSTL PHLNGL FX FNGR/ $1,259.00
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… $8,700.00
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 $1,320.00
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 $850.00
28515 FX CARE PHALANX NOT GREAT $622.00
28660 CLSD TX PIP JNT DISLOCATI $1,000.00
29075 APPLICATION CAST ELBOW FINGER SHORT ARM $950.00
29085 CAST HAND/LOWER FOREARM GAUNTLET $176.00
29086 APPLICATION CAST FINGER $920.00
29105 LONG ARM SPLINT $829.18
29125 SHORT ARM SPLINT $725.36
29126 SHORT ARM SPLINT DYNAMIC $176.00
29130 APPLICATION FINGER SPLINT $542.74
29131 APPLICATION FINGER SPLINT DYNAMIC $733.20
29240 STRPG SHO $723.36
29280 STRAPPING HAND/FINGER $605.96
29450 APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG $1,150.00
29505 LONG LEG SPLINT $935.75
29515 SHORT LEG SPLINT $890.00
29530 STRAPPING KNEE $492.52
29540 STRAPPING ANKLE/FOOT $465.66
29550 STRAPPING TOES $505.46
29580 STRAPPING UNNA BOOT $220.00
29700 RMVL/BIVALV GAUNTLET BOOT $1,100.00
30300 RMVL FOREIGN BODY NASAL $1,300.00
30901 NASAL PACKING $1,440.39
30903 CTRL NSL HEMRRG ANT CPLX $443.00
30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST $1,325.00
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 $1,197.00
33415 RESCJ/INC SUBVALVULAR TISSUE $980.00
33512 CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS $2,700.00
36000 INTRODUCTION OF NEEDLE/IN $76.32
36005 NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH $604.79
36010 INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA $590.00
36410 VENIPUNCTURE, 3 YRS OR OLDER $68.00
36415 VENIPUNCTURE $75.22
36416 COLL CAPILLARY BLG SPEC $595.00
36556 Insertion of non-tunneled centrally inserted central venous… $3,150.00
36558 INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR $2,156.00
36589 RMVL TUN CVC W/O SUBQ PORT/PMP $1,912.75
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
43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE $2,050.00
43753 GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … $128.00
45900 Manipulation Procedures on the Colon and Rectum $800.00
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 $989.03
51703 INSERT BLADDER CATH COMPL $1,110.00
56405 INC/DRAIN VULVA/PERINEAL $259.00
56420 I & D BARTHOLIN ABSCESS $100.00
57415 REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL $1,115.00
59025 FTL NON-STRS TST $950.00
59409 VAG DLVR ONLY $3,960.00
62270 SPINAL PUNCTURE,LUMBAR $554.00
64400 NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH $1,000.00
64402 INJ ANESTHETIC FACIAL NRV $640.00
64450 INJ ANESTHETIC AGENT $1,432.80
64640 DSTRJ NULYT OTH PRPH NVR/BRANCH $1,220.00
65205 REMOVAL FB EYE-SUPERFCL $1,300.00
65220 RMVL FB EYE W/O SLIT LAMP $1,190.00
65222 RMVL FB EYE $1,320.00
65435 RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION $1,190.00
67700 I&D ABSCESS EYELID $773.00
69005 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED $363.00
69200 RMVL FOREIGN BODY EAR $1,190.00
69205 RMVL FB XTRNL AUD CANAL A $409.00
69209 REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL $1,190.00
69210 RMVL IMPACTED CERUMEN $202.98
69399 Under Other Procedures of the External Ear $1,200.00
70030 RADEX EYE DETCJ FB $636.80
70100 XRAY MANDIBLE LESS THAN 4 VIEWS $913.41
70110 XRAY MANDIBLE MIN 4 VIEWS $1,480.56
70120 RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE $157.00
70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE $1,355.19
70140 XRAY FACIAL BONES LESS THAN 3 VIEW $1,148.53
70150 XRAY FACIAL BONES GREATER THAN 3 VIEW $1,816.13
70160 Radiologic examination, nasal bones, complete, minimum of 3… $1,165.14
70200 RAD EXAM ORBIT COMP. $1,801.94
70210 RADEX SINUSES PARANASAL <3 VIEWS $1,694.48
70220 RAD EXAM SINUS COMPLETE $1,276.68
70250 SKULL LESS THAN 4 VIEWS $1,675.08
70260 RAD EXAM SKULL COMPLETE $2,371.39
70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI $351.00
70330 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT $1,215.89
70350 CEPHALOGRAM ORTHODONTIC $257.00
70360 RAD EXAM NECK,SOFT TISSUE $645.66
70450 COMPUTED TOMOGRAPHY HD/BR $5,538.75
70460 TOMOGRAPHY HEAD/BRAIN WIT $6,331.50
70470 COMPUTED TOMOGRAPHY HEAD/ $7,147.88
70480 CT ORBIT SELLA/POST FOSSA $5,801.25
70481 CT ORBIT SELLA/POST FOSSA $6,365.90
70482 CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR $7,103.52
70486 CT MAXLFCL AREA C-MATRL $5,858.95
70487 CT MAXLFCL AREA C+ MATRL $6,703.15
70488 CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL $7,092.00
70490 CT NECK WO CONTRAST $5,911.50
70491 CT SOFT TISS NCK C+MATRL $6,395.38
70492 CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL $6,801.53
70496 CTA HEAD C-/C+ $5,991.19
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST $6,306.75
70544 MRA HEAD C-MATRL $3,150.00
70547 MRA NECK C-MATRL $2,772.00
70551 MRI BRN BRN STEM C-MATRL $2,772.00
70553 MRI BRN BRN STEM C-/C+ $3,268.00
71035 RADEX CHEST SPECIAL VIEWS $2,393.97
71045 Radiologic examination, chest ; single view $1,385.24
71046 CHEST XRAY 2 VIEWS $1,526.53
71047 Radiologic examination, chest ; 3 views $2,039.75
71048 (Radiologic examination, chest ; 4 or more $1,895.92
71060 BRONCHOGRAPHY BI RS&I $537.00
71100 RIBS UNILATERAL 2 VIEWS $1,552.20
71101 RIB UNILATERAL W CHEST $1,313.40
71110 RIBS BILATERAL 3 VIEWS $2,085.02
71111 RIBS BILATERAL W/CHEST $1,596.38
71120 Radiologic examination; sternum, minimum of 2 views $1,345.84
71250 CT CHEST W/O CONTRAST $6,450.65
71260 CT THORAX W/CONTRAST $6,947.90
71270 CT THORAX WO CONTRAST $7,342.40
71275 CT ANGIOGRAPHY $7,164.50
71550 MRI CH C-MATRL $2,771.00
72020 Radiologic examination, spine, single view, specify level $1,155.20
72040 SPINE, CERVICAL 2/3 VIEWS $1,458.67
72050 SPINE, CERVICAL MIN 4VIEW $2,220.39
72052 SPINE CERV. COMP FLEX/EXT $2,503.42
72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS $374.00
72070 SPINE THORACIC 2 VIEWS $1,603.94
72072 SPINE THORACIC 3 VIEWS $1,895.48
72074 RAD EXAN SPINE THROAC 4 V $2,044.92
72080 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS $1,580.06
72082 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW $1,373.10
72100 SPINE LUMBO. MIN 4 VIEWS $1,566.13
72110 LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS $2,435.76
72114 RAD EXAM SPINE LUMBO COMP $1,746.82
72120 SPINE LUMBAR AP & LAT W F $1,855.68
72125 COMPUTED TOMOGRAPHY CERVI $6,227.92
72126 CT CRV SPI C+MATRL $6,944.93
72127 CT CRV SPI C-/C+ $7,326.08
72128 CT THRC SPI C-MATRL $6,248.82
72129 CT THRC SPI C+ MATRL $6,723.90
72130 CT THORACIC SPINE W/O & W/CONTRAST MATERIAL $7,033.50
72131 CT L SPINE WO CONTRST $6,378.00
72132 CT LMBR SPI C+ MATRL $6,946.84
72133 CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL $6,928.82
72141 MRI SPI CANAL&CNTS CRV C-MATRL $1,867.00
72146 MRI SPI CANAL&CNTS THRC C-MATRL $2,772.00
72148 MRI SPI CANAL&CNTS LMBR C-MATRL $2,772.00
72156 MRI SPI CANAL&CNTS C-/C+ CRV $3,268.00
72157 MRI SPI CANAL&CNTS C-/C+ $2,772.00
72158 MRI SPI CANAL&CNTS C-/C+ LMBR $2,801.00
72170 RAD EXAM PELVIS 1/2 VEIW $1,284.54
72190 RADEX PELVIS COMPL MIN 3 $1,573.10
72191 CTA PELVIS C-/C+ POST-PXE $7,154.61
72192 CT PELVIS WO CONTRAST $5,718.08
72193 TOMOGRAPHY PELVIS WCONTRS $6,255.48
72194 CT PELVIS W OR WO CONTRST $9,776.87
72195 MRI PELVIS C-MATRL $2,772.00
72196 MRI PELVIS C+ MATRL $3,735.00
72220 XRAY COCCYX/SACRUM $1,628.82
72270 MYELOGRAPY 2/MORE REGIONS RS&I $2,450.00
73000 XRAY CLAVICLE 2 VIEWS $1,301.46
73010 SCAPULA COMPLETE $1,641.75
73020 RADEX SHO 1 VIEW $1,032.81
73030 SHOULDR COMPLETE 2 VIEWS $1,720.36
73050 XRAY AC JOINTS-BILAT $841.77
73060 XRAY HUMERUS MIN 2 VIEWS $1,337.28
73070 XRAY ELBOW 2 VIEWS $1,206.94
73080 XRAY ELBOW GREATER THAN 3 VIEWS-COMP $1,590.01
73090 XRAY FOREARM AP & LAT $1,278.58
73100 XRAY WRIST AP & LAT VIEW $1,019.88
73110 XRAY WRIST/COMP MIN 3 VIE $1,445.24
73120 XRAY HAND AP & LAT $1,026.84
73130 XRAY HAND MIN 3 VIEWS $1,415.88
73140 XRAY FINGER MIN 2 VIEWS $1,029.82
73200 CT UPPR EXTR WO CNTRS $5,749.44
73201 CT UPPER EXTREMITY W/CONTRAST MATERIAL $6,270.61
73202 CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL $6,710.40
73220 MRI UXTR OTH/THN JT C-/C+ $3,268.00
73221 MRI ANY JT UXTR C-MATRL $2,772.00
73500 RADIOLOGIC EXAM HIP UNILAT 1 VIEW $380.00
73501 RADEX HIP UNILATERAL WITH PELVIS 1 VIEW $966.14
73502 RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… $881.57
73503 RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS $1,749.21
73510 XRAY HIP MIN 2 VIEWS $1,371.11
73520 HIPS BILAT MIN 2 VIEW INC $507.00
73522 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS $2,594.49
73550 XRAY FEMUR AP & LAT VIEW $311.00
73551 RADIOLOGIC EXAMINATION FEMUR 1 VIEW $1,422.34
73552 FEMUR; MIN 2 VIEWS $1,287.63
73560 XRAY KNEE, SUNRISE VIEW $1,287.63
73562 XRAY KNEE MIN 3 VIEWS $1,508.42
73564 RAD EXAM KNEE 4 OR MORE $1,815.88
73565 RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOSTC $770.13
73580 X-RAY KNEE.BILATERAL STANDING $3,065.12
73590 XRAY TIBIA/FIBULA AP/LAT $796.00
73592 RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS $829.73
73600 XRAY ANKLE 2 VIEWS $1,009.38
73610 XRAY ANKLE 3 VIEWS/COMPLE $1,514.39
73620 XRAY FOOT MIN 2 VIEWS $1,257.68
73630 XRAY FOOT MIN 3 VIEWS $1,516.88
73650 RAD EXAN HEEL MIN 2 VIEWS $756.20
73660 XRAY TOES, MIN 2 VIEWS $993.01
73700 CT LWR EXTR WO CONTRAST $5,335.19
73701 CT LWR EXT W CONT $7,574.00
73702 CT LXTR C-/C+ $4,403.00
73718 MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL $6,901.12
73721 MRI ANY JT LXTR C-MATRL $2,772.00
73722 MRI ANY JT LXTR C+ MATRL $3,076.00
73723 MRI ANY JT LXTR C-/C+ $5,049.00
73725 MRA LXTR C+-MATRL $3,735.00
74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS $426.00
74018 Radiologic examination, abdomen; 1 view $1,098.48
74019 Radiologic examination, abdomen; 2 views $1,128.33
74020 RAD EXAM ABDOMEN COMPL $2,500.00
74021 Radiologic examination, abdomen; 3 or more views $1,317.38
74022 RAD EXAM COMPLETE ABD $1,871.60
74150 COMPUTED TOMOGRAPHY ABD $6,892.88
74160 TOMOGRAPHY ABD W/CONTRAST $7,306.24
74170 TOMOGRAPHY ABD W/OCONTRAS $8,060.85
74174 CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG $7,619.70
74175 CT ANGIO ABDOMEN W/CONTRA $7,362.99
74176 COMP TOMOG AB/PEL W/O CON $7,973.35
74177 COMP TOMO AB/PELV W/OCONT $8,656.42
74178 CT ABD & PELVIS 1 PLUS SECTION/REGNS $10,859.59
74181 MRI ABD C-MATRL $2,772.00
74183 MRI ABD C-/C+ $3,268.00
74190 PERITONEOGRAM RS&I $3,174.50
74240 RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB $3,543.03
74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB $2,665.65
74245 RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES $3,014.76
74246 Radiologic examination, gastrointestinal tract, upper, air … $2,131.50
74247 RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB $1,010.00
74250 RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES $2,349.75
74251 RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE $2,300.00
74328 ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I $3,200.00
74329 ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I $2,450.00
74330 CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I $3,732.00
74340 INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I $1,409.85
74440 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I $2,300.00
75574 CT CORONARY $3,245.00
76376 3D RNDR I&R CT MRI US/OTH $964.00
76380 CT LIMITED/LOCALIZED FOLLOW UP STUDY $2,924.30
76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK $2,120.25
76604 US CHEST REAL TIME W/IMAGE DOCUMENTATION $2,017.61
76641 US BREAST UNI REAL TIME WITH IMAGE COMPLETE $2,279.50
76642 US BREAST UNI REAL TIME WITH IMAGE LIMITED $2,007.21
76645 US BREAST R-T W/IMAGE DOCUMENTATION $719.00
76700 US ABDOMINAL R-T W/IMAGE $3,158.36
76705 US ABDOMINAL $3,251.16
76770 US RETROPERITONEAL R-T W/ $3,237.75
76775 US RPR B-SCAN&/R-T IMG LMTD $1,399.96
76801 ULTRASOUND 14 WK TABDL 1/1ST GESTATION $2,767.39
76802 US PREG UTERUS 14 WK TRANSABDL EACH GESTATION $2,145.00
76805 US PG UTER F&MAT AFTER 1S $2,751.88
76810 US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO $2,911.21
76815 ULTRASND PG UTER $356.00
76816 US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS $1,862.95
76817 UT PG UTER R-T IMG TRVG $2,224.82
76830 TRANSVAGINAL ULTRASOUND $2,135.27
76856 US PELVIC NONOB REAL-TIME $2,992.95
76857 PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 $1,777.07
76870 US SCROTUM&CNTS $2,807.64
76881 US EXTREMITY NON-VASC REAL-TIME IMG COMPL $2,930.24
76882 ULTRASOUND, EXTREMITY, NON VASCULAR $1,829.62
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… $495.00
77777 SHORTNESS OF BREATH PANEL $12.00
78075 ADRNL IMG CORTEX&/MEDULLA $3,618.00
78223 HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR $2,509.00
78306 B1&/JT IMG WHBDY $1,440.00
78315 B1&/JT IMG 3 PHASE STD $1,440.00
78320 B1&/JT IMG TOMOG SPECT $923.00
78472 CARD BPI GTD=BRM PLNR 1 STD REST/STRS $2,039.00
80047 BASIC METABOLIC PANEL CALCIUM IONIZED $766.00
80048 METABOLIC PANEL BASIC $918.86
80051 ELECTROLYTE PANEL $614.65
80053 METABOLIC COMPRE PANEL $1,085.42
80061 LIPID PROFILE III $648.74
80074 HEPATITIS PANEL $1,087.50
80076 HEPATIC FUNCTION PANEL $843.50
80100 DRUG ABUSE PANEL II $230.00
80102 Drug confirmation, each procedure $435.94
80104 DRUG SCREEN $172.00
80143 Acetaminophen $533.28
80178 LITHIUM $59.00
80179 Salicylate $324.00
80196 SALICYLATE $270.00
80197 TACROLIMUS $350.00
80202 VANCOMYCIN PEAK $229.00
80300 DRUG SCREEN $221.00
80304 DRUG SCREEN $211.00
80305 DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… $532.50
80307 DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS $351.50
80320 DRUG SCREEN $155.22
80324 DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 $665.00
80329 DRUG SCREEN $464.07
80335 ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 $143.28
80345 DRUG SCREENING BARBITURATES $228.85
80346 DRUG SCREENING BENZODIAZEPINES 1-12 $173.13
80347 DRUG SCREENING BENZODIAZEPINES 13 OR MORE $450.00
80349 DRUG SCREENING CANNABINOIDS NATURAL $272.63
80351 DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 $338.30
80352 DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE $280.00
80353 DRUG SCREENING COCAINE $240.79
80356 DRUG SCREENING HEROIN METABOLITE $148.20
80358 DRUG SCREENING METHADONE $177.11
80359 DRUG SCREENING METHYLENEDIOXYAMPHETAMINES $560.00
80361 DRUG SCREENING OPIATES 1 OR MORE $447.75
80362 DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 $500.00
80365 DRUG SCREENING OXYCODONE $550.00
80366 DRUG SCREENING PREGABALIN $179.10
80367 DRUG SCREENING PROPOXYPHENE $343.00
80373 DRUG SCREENING TRAMADOL $400.00
80374 DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS $420.00
81000 U/A DIPSTICK $240.34
81001 U/A DIP STICK $384.52
81002 URNLS DIP STICK/TABLET RG $231.00
81003 U/A W/O MICRO DIPSTICK $205.17
81005 Urinalysis; qualitative or semiquantitative, except immunoa… $92.00
81007 URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK $500.00
81025 PREG.TST URINE VISUAL $339.30
82003 ACETAMINOPHEN $229.00
82009 KETONES-SERUM $36.00
82040 ALBUMIN; SERUM $182.52
82055 ALCOHOL-BLOOD $201.00
82075 ALCOHOL BREATH TEST $84.00
82140 Ammonia $330.19
82150 AMYLASE $429.84
82247 BILIRUBIN TOTAL $200.59
82248 BILIRUBIN DIRECT $286.56
82253 MB FRACTION $154.00
82270 OCCULT BLOOD $750.00
82272 BLD OCLT PEROXIDASE ACTV $141.29
82274 blood, occult by fecal hemoglobin determination by immunoas… $153.30
82310 CALCIUM $233.48
82330 CALCIUM IONIZED $293.52
82374 CARBON DIOXIDE BICARBONATE $99.50
82375 Under Chemistry Procedures $400.00
82435 CHLORIDE BLD $152.68
82465 CHOLESTEROL SERUM/WHOLE BLOOD TOTAL $159.20
82533 CORTISOL TOTAL $365.25
82540 CREATINE $68.00
82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE $121.00
82550 CREATINE CK-TOTAL $195.02
82553 CREATINE CKMB $257.01
82565 CREATININE $257.70
82607 VITAMIN B-12 $72.00
82747 ASSAY OF FOLIC ACID RBC $310.20
82784 IGC IMMUNOGLOBULIN $403.97
82785 GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE $182.00
82800 GASES BLD PH ONLY $130.00
82803 BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 $529.80
82805 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (… $569.62
82945 GLUCOSE BODY FLUID OTHER THAN BLOOD $299.25
82947 GLUCOSE $163.43
82948 GLUCOSE BLOOD REAGET STR $409.94
82962 GLUCOSE FINGER STICK $155.63
82977 GLUTAMYLTRANSFERASE-GTT $296.97
83009 HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE $490.00
83013 HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE $439.79
83036 HEMOGLOBIN GLYCOSYLATED A1C $278.64
83050 Under Chemistry Procedures $350.00
83520 IMMUNOASSAY ANALYTE QUANTITIATIVE NOS $144.00
83525 ASSAY OF INSULIN TOTAL $172.14
83540 IRON-TOTAL $102.00
83605 ASSAY OF LACTATE $210.00
83615 Lactate dehydrogenase (LD), (LDH); $265.66
83690 LIPASE $409.50
83718 LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL $356.12
83735 MAGNESIUM $391.18
83874 MYOGLOBIN $180.10
83880 B-TYPE NATRIURETIC $555.21
83992 ASSAY OF PHENCYCLIDINE $455.00
84075 ALK PHOS/PROFILE OR PANEL $225.22
84100 ASSAY OF PHOSPHORUS INORGANIC $234.49
84132 POTASSIUM SERUM PLASMA/WHOLE BLOOD $219.90
84155 PROTEIN,TOTAL,EXCEPT REFR $77.31
84157 PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC $211.04
84165 PROTEIN ELECTROPHORESIS $1.00
84295 SODIUM; SERUM $180.59
84403 Testosterone; total $335.32
84436 THYRIXINE TOTAL $243.23
84439 THYROXINE-FREE $200.99
84443 Thyroid stimulating hormone (TSH) $263.00
84450 Transferase; aspartate amino (AST) (SGOT) $95.52
84460 ALT-TRANSFERASE;ALANINE $385.55
84478 ASSAY OF TRIGLYCERIDES $244.52
84479 THYROID HORMONE $224.87
84480 T3 TOTAL $601.80
84481 ASSAY OF TRIIODOTHYRONINE T3 FREE $123.38
84484 TROPONIN I $436.80
84512 TROPONIN QUAL $379.35
84520 Urea nitrogen; quantitative $194.27
84550 URIC ACID $93.53
84560 URIC ACID OTH SRC $138.00
84702 HCG QUANTATIVE $324.37
84703 PREGNANCY TEST BLOOD $419.34
84999 UNLISTED CHEMISTRY PROCEDURE $435.56
85014 HEMATOCRIT $102.00
85018 HEMOGLOBIN $326.81
85025 Blood count; complete (CBC) $256.76
85027 CBC W/O DIFF $236.11
85032 BLD# MNL C-CNT RBC/PLTLT EA $152.00
85044 RETICULOCYTE COUNT $21.00
85347 COAGJ TM ACTIVATED $35.00
85378 FIBRIN DEGRADATION PROD $151.24
85379 D-DIMER $267.46
85610 PROTHROMBIN TIME $297.90
85651 SEDIMENTATION RATE NONAUT $189.05
85652 SED RATE ERYTHROCYTE NON $179.40
85730 THROMBOPLASTIN TIME PART $393.00
86038 ANTINUCLEAR AB $117.01
86039 ANTINUCLEAR AB TITER $409.50
86060 ANTISTREPTOLYSIN O TITER $108.65
86140 C REACTIVE PROTEIN $274.62
86235 EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD $317.90
86256 SMOOTH MUSCLE AB TITER $1.00
86308 MONO,HETEROPHILE ANTIBODI $328.69
86318 Immunoassay for infectious agent antibodies, qualitative or… $125.00
86320 IMMUNOELECTROPHORESIS $1.00
86328 COVID-19 RAPID ANTIBODY TEST SINGLE METHOD $100.00
86360 T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO $627.00
86403 MONO SPOT $134.00
86430 RHEUMATOID FACTOR $74.00
86431 RHEUMATOID FACTOR QUANTITATIVE $321.00
86592 Syphilis test, non-treponemal antibody; qualitative (eg, VD… $77.00
86593 Syphilis test, non-treponemal antibody; quantitative $349.00
86631 ANTB CHLAMYDIA $130.00
86644 ANTIBODY CYTOMEGALOVIRUS CMV $650.00
86645 ANTIBODY CYTOMEGALOVIRUS CMV IGM $150.00
86664 EPSTEIN-BARR VIRUS EBNA $133.00
86677 ANTIBODY HELICOBACTER PYLORI $700.00
86689 ANTB HTLV/HIV ANTB CONFIRMATION TST $481.59
86701 HIV SERUM $523.55
86702 ANTB HIV-2 $164.00
86705 HEPATITIS B CORE IGM $187.00
86713 LEGIONELLA PNEUMONPILA AB $88.00
86756 ANTB RSV $143.00
86769 COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD $100.00
86780 TP-Under Qualitative or Semi quantitative Immunologists- $87.56
86803 HEPATITIS C ANTIBODY $402.75
86850 ANTB SCR RBC EA SERUM TQ $189.00
86900 Blood typing, serologic; ABO $131.78
86901 RH FACTOR-BLOOD $164.50
86906 BLD TYPING RH PHEXYPING COMPL $86.00
87040 BLOOD CULTURE $480.31
87045 CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL $571.13
87070 CULTURE BODY FLUID $508.50
87075 CULTURE ANAEROBIC $346.26
87076 CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL $510.00
87077 CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL $197.01
87081 CULTURE, BACTERIAL-SCREEN $493.02
87086 URINE CULTURE $277.90
87088 CULTURE BCT ISOL&PRSMPTV $286.90
87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST $85.00
87110 CHLAMYDIA CULTURE $260.00
87177 Ova and parasites, direct smears, concentration and identif… $217.31
87205 SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL $173.43
87207 SMR PRIM SRC SPEC STAIN $1.00
87210 WET SMEAR $91.00
87252 VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT $240.79
87255 Herpes Simplex Virus Culture with Reflex Typing $309.00
87275 IAADI INF B VIRUS $55.00
87338 IAAD IA HPYLORI STOOL $66.86
87341 IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION $474.12
87389 infection agent etc $203.50
87400 INFLUENZA A&B $174.00
87420 IAAD IA RESPIRATORY SYNCTIAL VIRUS $578.02
87426 COVID-19 RAPID ANTIGEN TESTING $349.00
87428 Multiplex viral pathogen panel using Antigen technique for … $843.00
87430 INF AGT IMMUNO STREP A $234.00
87480 IADNA CANDIDA SPECIES DIRECT PROBE TQ $500.00
87486 IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ $640.78
87491 IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ $501.48
87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE $197.00
87507 IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 $500.00
87581 IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ $700.00
87591 IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ $370.70
87633 IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET $1,500.00
87635 Infectious agent detection by nucleic acid (DNA or RNA); se… $150.00
87636 severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)… $700.00
87661 IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH $546.00
87798 IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM $700.00
87801 Infectious agent detection by nucleic acid $500.00
87804 INFLUENZA IMMUNOASSAY OPT $346.50
87807 INF AGT DET IMNAS OPT RSV $201.39
87808 Infectious agent antigen detection by immunoassay with dire… $253.75
87847 NO DESCRIPTION $409.00
87850 NEISSERIA GONORRHOEAE DET $130.00
87880 RAPID STREP-BETA STREP $820.00
87905 Infectious agent enzymatic activity other than virus eg, si… $172.00
88305 PATH SURG LEVEL IV $1.00
89051 CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT $325.00
89055 LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE $185.07
89060 CRYSTAL INDENTIFICATION $277.60
89220 SPTM OBTG SPEC AERSL INDUCED SPX $98.00
90471 IMMUN ADM 1 VAC $203.05
90660 INFLUENZA VIRUS INTRANASA $70.00
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, … $480.00
90700 DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM $72.52
90703 TETANUS TOXID $152.00
90714 TETANUS DIPHTHERIA TOXOID $302.98
90715 TDAP VACCINE $292.53
90718 TETANUS & DIPTHERIA $229.76
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 (eg, in cardiac arrest) $1,906.00
92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL $1,089.00
93000 EKG W/INTREP AND REPORT $335.81
93005 Electrocardiogram, routine ECG with at least 12 leads; trac… $752.95
93010 RTN ECG 12 LEADS INTRP/RP $213.75
93018 CV STRS TST XERS&/OR RX CONT ECG I&R ONLY $1,000.00
93040 RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT $335.81
93041 RHYTHEM ECG 1-3 LDS $146.00
93042 RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON $550.00
93224 WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I $924.00
93306 ECHO TEST $3,658.22
93307 ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP $2,967.50
93308 ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD $3,794.06
93313 TEE R-T IMG 2D W/PROBE PLMT ONLY $2,626.00
93320 DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY $1,417.50
93325 DOP ECHOCARD COLOR FLOW VELOCITY MAPPING $1,485.00
93351 ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG $1,000.00
93631 INTRAOP EPICAR& ENDOCAR PACG& MAPG $650.00
93784 Ambulatory blood pressure monitoring, $500.00
93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD $840.00
93880 DUP-SCAN XTRC ART COMPL B $2,508.98
93882 DUP-SCAN XTRC ART UNI/LMTD STD $903.00
93922 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL $1,643.74
93923 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS $3,155.00
93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY $2,342.23
93926 DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD $2,351.97
93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY $2,379.04
93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD $2,599.96
93965 QUANT VENOUS FLOW ST $1,806.00
93970 DUP-SCAN XTR VEINS COMPL $3,938.65
93971 DPLX SCN EXTRM VEINS $2,716.05
93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… $4,000.50
93976 DUPLEX SCAN- LIMITED $466.00
94010 SPIROMETRY W/RECORD $922.50
94060 BRNCDILAT RSPSE SPMTRY PR $385.00
94621 PULM STRS TSTG CPLX $1,029.00
94640 NEBULIZER TREATMENT $277.77
94644 INHALATION TREATMENT – CONTINUOUS 1ST HR $157.00
94664 DEMO&/EVAL OF PT UTILIZ $1.00
94760 EAR OR PULSE OXIMETRY $333.38
94761 N-INVAS EAR/PLS OXIMTRY F $458.96
94762 NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR $734.25
96360 IV INFUS INIT 31 MIN 1 HR $784.50
96361 IV INFUS HYDR EA ADD’T HR $242.78
96365 IV INFUSION THERAPY/PROPH $904.22
96366 IV INFUS THER PROPH/DX EA $811.12
96367 IV NFS THER PROPH/DX ADDL $1,029.94
96368 IV NFS TX PROPHYLAXIS/DX $749.14
96372 THERAPEUTIC PROPHYLACTIC/ $503.55
96373 INJECTION, INTRA-ARTERIAL $228.00
96374 THER PROPH/DX NJX IV PUSH $790.12
96375 THER PROPH/DX NJX EA SEQL $532.88
96376 SUB INFU EA ADD IV PUSH $578.93
96377 APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION $720.00
96379 INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS $213.00
97010 APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS $183.21
97116 THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR $197.01
97542 WHEELCHAIR MGMT EA 15 MIN $320.39
97597 DEBRIDEMENT OPEN WOUND 20 SQ CM/< $736.30
99000 SPECIMEN HANDLING $52.00
99001 COC COLLECITON ONLY $41.00
99024 POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX $650.00
99050 BLUE CROSS RQRD LVL3 $87.00
99053 SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY $303.00
99070 SUPPLIES&MATERIALS ABOVE or BEYOND PROV BY PHYS or QHP $93.53
99080 MEDICAL RECORDS $46.00
99143 MOD SEDATION &#60;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 $997.12
99152 MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS $1,480.00
99173 SCREENING TEST OF VISION $1,300.00
99217 OBSERVATION CARE DISCHARGE MANAGEMENT $1,200.00
99218 INITIAL OBSERVATION CARE/DAY 30 MINUTES $242.78
99219 INITIAL OBSERVATION CARE/DAY 50 MINUTES $1,800.00
99220 INITIAL OBSERVATION CARE/DAY 70 MINUTES $3,250.00
99234 OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES $1,800.00
99235 OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES $2,000.00
99236 OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES $2,200.00
99281 E/M VISIT LEVEL 1 TECH COMP $619.45
99282 E/M VISIT LEVEL 2 TECH COMP $1,125.75
99283 E/M VISIT LEVEL 3 TECH COMP $2,012.25
99284 E/M VISIT LEVEL 4 TECH COMP $3,009.75
99285 E/M VISIT LEVEL 5 TECH COMP $4,029.75
99291 CRITICAL CARE 30-74 MIN $5,434.38
99292 CRITICAL CARE ADD 30 MIN $1,430.52
99406 SMOKING CESSATION 3-10 $69.54
99407 SMOKING CESSATION 10 MIN $94.00
A0382 BASIC SUPPORT ROUTINE SUPPLS $18.00
A0394 ALS IV DRUG THERAPY SUPPLIES $1.02
A0396 ALS ESPOHAGEAL INTUB SUPPLIES $25.00
A4206 1 CC STERILE SYRINGE&NEEDLE $15.00
A4207 2 CC STERILE SYRINGE&NEEDLE $18.00
A4208 3 CC STERILE SYRINGE & NEEDLE $26.90
A4209 5+ CC STERILE SYRINGE & NEEDLE $30.00
A4210 NONNEEDLE INJECTION DEVICE $30.00
A4211 SUPP FOR SELF-ADM INJECTIONS $15.00
A4212 NON CORING NEEDLE OR STYLET $15.00
A4213 20+ CC SYRINGE ONLY $5.98
A4215 NEEDLE STERILE, ANY SIZE, EACH $10.75
A4216 STERILE WATER/SALINE, FLUSH 10ML $3.00
A4217 STERILE SALINE WATER PER 500 ML $22.80
A4218 STERILE SALINE OR WATER $26.00
A4221 SUPP NON-INSULIN INF CATH/WK $20.00
A4222 EXT UNFU PMP PER CASS/BAG $176.00
A4223 INFUSION SUPPLIES W/O PUMP $40.00
A4224 ALOCHOL OR PEROXIDE PER PINT $22.00
A4232 SYRINGE W/NEEDLE INSULIN 3CC $15.00
A4244 ALCOHOL OR PEROXIDE PER PINT $4.00
A4245 ALCOHOL WIPES PER BOX $5.00
A4246 BETADINE/PHISOHEX SOLUTION $21.58
A4247 BETADINE/IODINE SWABS/WIPES $21.58
A4248 CHLORHEXIDINE ANTISEPT $42.00
A4252 GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP $6.00
A4253 BLOOD GLUCOSE/REAGENT STRIPS $10.00
A4270 DISPOSABLE ENDO CODE SHEATH $24.00
A4281 REPLACEMENT BREASTPUMP TUBE $15.00
A4283 REPLACEMENT BREASTPUMP CAP $15.00
A4300 CATH IMPL VASC ACCESS PORTAL $10.00
A4310 INSERT TRAY W/O BAG/CATH $15.00
A4311 CATHETER W/O BAG 2 WAY LATEX $139.00
A4314 INSRT TRAY W/DRAINAGE BAG $44.00
A4315 CATH W/DRAINAGE 2-WAY SILCNE $18.00
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 $10.00
A4332 LUBE STERILE PACKET $12.00
A4335 INCONTINENCE SUPPLY MISC $3.00
A4338 INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING $15.00
A4344 INDWELLING CATH FOLEY TYP $19.00
A4352 COUDE TIP URINARY CATHETER $20.00
A4353 INTERMIT URINARY CATHETER $120.00
A4358 URINARY DRAINAGE BAG $12.50
A4364 DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ $33.00
A4369 SKIN BARRIER LIQUID PER OZ $10.00
A4402 LUBRICANT PER OUNCE $10.00
A4406 PECTIN BASED OSTOMY PASTE $12.00
A4450 TAPE NO WATERPROOF $10.00
A4452 TAPE WATERPROOF 18 SQ IN $12.00
A4458 REUSABLE ENEMA BAG $25.00
A4465 NON-ELASTIC EXTREMITY BINDER $20.00
A4470 GRAVLEE JET WASHER $15.00
A4550 LACERATION- SURGICAL KIT $50.00
A4554 DISPOSABLE UNDERPADS $18.00
A4556 ELECTRODES, PAIR $60.00
A4558 CONDUCTIVE GEL OR PASTE $15.00
A4562 PESSARY, NON RUBBER,ANY TYPE $12.00
A4565 SLING $183.82
A4566 SHOULD SLING/VEST/ABRESTRAIN $25.00
A4570 SPECIAL CASTING MATERIAL $50.00
A4580 CAST SUPPLIES (PLASTER) $35.00
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 $20.00
A4613 BATTERY CHARGER $60.00
A4614 HAND HELD PEFR METER $50.00
A4615 CANNULA NASAL $20.00
A4616 TUBING (OXYGEN) PER FOOT $25.00
A4617 MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT $55.00
A4620 VARIABLE CONCENTRATION MASK $15.00
A4628 OROPHARYNGEAL SUCTION CATH $20.00
A4629 TRACHEOSTOMY CARE KIT $35.00
A4649 SURGICAL SUPPLY MISC $40.00
A4653 PD CATHERTER ANCHOR BELT $20.00
A4657 SYRINGE W OR WO NEEDLE $10.00
A4670 AUTOMATIC BP MONITOR #11 $30.00
A4673 SALINE BLADE #11 $15.00
A4750 ART OR VENOUS BLOOD TUBING $20.00
A4770 BLOOD COLLECTION TUBE or VACUUM $25.00
A4927 GLOVES NON STERILE $10.00
A4930 GLOVES STERILE PER PAIR $12.00
A5112 URINARY LEG BAG $20.00
A5120 SWAB OR WIPE SKIN BARRIER $12.00
A5126 DISK/FOAM PAD +OR- ADHESIVE $15.00
A5200 PERCUTANEOUS CATHETER ANCHOR $117.00
A6021 COLLAGEN DRESSING STERIL $15.00
A6196 ALGINATE DRESSING <=16 SQ IN $20.00
A6203 COMPOSITE DRSG <= 16 SQ IN $15.00
A6205 COMPOSITE DRSG LESS THAN 48 SQ IN $22.00
A6208 CONTACT LAYER > 48 SQ IN $20.00
A6209 FOAM DRSG <=16 SQ IN W/O BDR $15.00
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… $15.00
A6213 FOAM DRG 16-48 SQ IN W/BRDR $11.00
A6216 GAUZE NONIMPREG 16 SQ IN $10.00
A6217 GAUZE NON STERILE $12.00
A6218 GAUZE, NON STERILE $15.00
A6219 GAUZE- STERILE $10.00
A6220 GAUZE, NON IMP, STERILE, PAD SIZE >16 SQ < OR = 48SQ IN $12.00
A6221 GAUZE > 48 SQ IN W/BORDER $15.00
A6222 GAUZE IMPREGNATED WITH ME $12.00
A6223 GAUZE >16<=48 NO W/SAL W/O B $15.00
A6224 GAUZE > 48 IN NO W/SAL W/O B $20.00
A6231 GAUZE, 16<SQ IN, EACH $12.00
A6233 HYDROGEL DRESSING >48 SQ IN $15.00
A6235 HYDROCOLLD DRG >16<=48 W/O B $18.00
A6238 HYDROCOLLD DRG >16<=48 W/BDR $20.00
A6239 HYDROCOLLD DRG > 48 IN W/BDR $22.00
A6246 HYDROGEL DRG >16<=48 IN W/B $25.00
A6248 HYDROGEL DRSG GEL FILLER $15.00
A6250 SKIN SEAL PROTECT MOISTURIZER OINTMENT $10.00
A6251 ABSORPT DRG <=16 SQ IN W/O B $10.00
A6252 ABSORPT DRG >16 <=48 W/O BDR $15.00
A6253 ABSORPT DRG > 48 SQ IN W/O B $18.00
A6254 ABSORPT DRG <=16 SQ IN W/BDR $10.00
A6255 ABSORPT DRG >16<=48 IN W/BDR $15.00
A6257 TRANSPARENT FILM <= 16 SQ IN $18.00
A6258 TRANSPARENT FILM >16<48 IN $20.00
A6260 WOUND CLEANSER $100.00
A6261 WOUND FILLER $100.00
A6266 IMPREG GAUZE NO H20/SAL/YARD $22.00
A6402 GAUZE NON-IMPREG STERL 16 $15.00
A6403 STERILE GAUZE>16 <= 48 SQ IN $15.00
A6404 STERILE GAUZE > 48 SQ IN $18.00
A6407 PACK STRIPS NON-IMPREGNTD $15.00
A6410 STERILE EYE PAD OR STRIP $6.00
A6412 OCCLUSIVE EYE PATCH $15.00
A6413 ADHESIVE BANDAGE FIRST AI $18.00
A6441 PAD BAND W>=3 <5/YD $15.00
A6442 CONFORM BAND N/S W<3/YD $10.00
A6445 CONFORM BAND S W <3/YD $12.00
A6446 CONFORMING BANDAGE NON-EL $15.00
A6447 CONFORM BAND S W >=5/YD $18.00
A6448 LT COMP BANDAGE LESS THAN 3IN $12.00
A6449 LIGHT COMP BANDAGE $15.00
A6450 LT COMPRS BANDAGE ELAST $18.00
A6453 BANDAGE SELF ADHER BAND W LESS THAN 3 $25.00
A6454 SELF ADHER BANDAGE $12.00
A6455 SELF ADHER BANDAGE $15.00
A6456 ZINC PASTE BAND W >=3<5/YD $15.00
A6457 TUBULAR DRESSING $30.00
A6530 COMPRESSION STOCKING BK18-30 $15.00
A6545 GRAD COMP NON-ELASTIC BK $20.00
A7002 SUCTION TUBING USED W PUMP $40.00
A7003 ADMN SET SM VOL NONFILTER $35.00
A7004 DISPOSABLE NEBULIZER SML VOL $35.00
A7005 NONDISPOSABLE NEBULIZER SET $30.00
A7006 FILTERED NEBULIZER ADMIN SET $25.00
A7011 NONDISPOS CORRUGATED TUBING $12.00
A7015 NEBULIZER MASK USED W NEBULIZER $25.00
A7016 DOME/MOUTHPEICE NEB $161.00
A7017 NEBULIZER MASK NOT USED W/ OXYGEN $57.00
A7030 CPAP FULL FACE MASK $20.00
A7046 REPL WATER CHAMBER, PAP DEV $30.00
A7047 RESP SUCTION ORAL INTERFACE $25.00
A7520 TRACH LARYN TUBE NON CUFFED $37.00
A9150 NON PERSCRIPTION DRUG $35.00
A9270 NON-COVERED ITEM OR SERVICE $50.00
A9273 HOT/COLD H2OBOT/CAP/COL/WRAP $35.00
A9281 REACHING/GRABBING DEVICE $80.00
A9284 NON-ELECTRONIC SPIROMETER $254.00
A9579 GAD-BASE MR CONTRAST NOS,1ML $15.00
C1722 AICD, SINGLE CHAMBER $400.00
C1751 CATH, INF, PER/CENT/MIDLINE $505.75
C1781 MESH (IMPLANTABLE) $475.00
C2618 PROBE/NEEDLE, CRYO $35.00
C9285 PATCH, LIDOCAINE/TETRACAINE $20.00
C9399 ORBACTIV 1200 MG IV $10,153.00
CASH XRAY DISC $17.00
E0110 CRUTCH FOREARM PAIR $225.00
E0114 CRUTCHES UNDERARM $250.00
E0116 CRTCH UNDARM NOT WOOD ADJ $200.00
E0220 HOT WATER BOTTLE $35.00
E0230 ICE CAP OR COLLAR $12.00
E0240 BATH/SHOWER CHAIR $80.00
E0275 BED PAN STANDARD $100.00
E0325 URINAL MALE JUG-TYPE $50.00
E0326 URINAL FEMALE JUG-TYPE $50.00
E0352 DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) $177.00
E04114 E04114 $41.00
E0445 OXIMETER NON-INVASIVE $578.00
E0570 NEBULIZER WITH COMPRESSION $200.00
E0580 NEBULIZER FOR USE W/ REGULAT $293.00
E0607 BLOOD GLUCOSE MONITOR HOME $80.00
E0625 PATIENT LIFT BATHROOM OR TOI $200.00
E2630 MONOSUSPENSION ARM/HAND SUPP $3,379.10
G0009 ADM PNEUMOCOCCAL VACCINE $90.00
G0168 WND CLS TISSUE ADHESIVE $100.00
G0378 HOSPITAL OBSERVATION SERVICES PER HOUR $510.44
G0402 INITIAL PREVENTIVE EXAM $1,500.00
G0434 DRUG ABUSE PANEL II $230.00
G2023 specimen collection for severe acute respiratory syndrome c… $30.00
G2024 specimen collection for severe acute respiratory syndrome c… $200.00
G6039 Acetaminophen or just “Assay of acetaminophen” for shor… $150.00
G6040 Saliva Alcohol Test $131.34
G6058 Drug confirmation, each procedure $250.00
G8598 ASA/ANTIPLAT THER USED $65.00
G8601 NO ELIG TPA INIT W/IN 3 HRS $800.00
G8602 NO TPA INIT W/IN 3 HRS $750.00
J0120 TETRACYCLIN INJECTION $30.00
J0129 ABATACEPT INJECTION $25.00
J0131 INJECTION, ACETAMINOPHEN, 10 MG $30.00
J0150 ADENOSINE INJ 6MG VIAL $65.00
J0153 ADENOSINE INJ 1MG $40.00
J0170 EPINEPHRINE 3 1/2 NDL 10M $12.44
J0171 ADRENALIN EPINEPHRINE INJECT $30.00
J0282 INJ AMIODARONE HYDROCHLOR $25.00
J0290 AMPICILLIN 500 MG INJ $45.77
J0295 INJ AMPCLLN SODIUM/SULBA $20.00
J0330 SUCCINYLCHOLINE CHLO 20MG $173.00
J0360 HYDRALAZINE HCL INJ UP TO 20MG $30.00
J0456 INJ AZITHROMYCIN 500MG $25.00
J0461 INJ ATROPINE SULFATE 0.01 $20.00
J0500 DICYCLOMINE HCL 20MG $45.00
J0550 BICILLIN – PENICILLIN G BENZATHINE INJ $65.00
J0559 BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS $65.00
J0560 BICILLIN 600,000 $50.00
J0561 INJECTION PENICILLIN G BENZATHINE 100,000 UNITS $30.00
J0570 BICILLIN 1,200,000 $110.00
J0595 STADOL $13.00
J0610 CALCIUM GLUCONATE INJECTION $30.00
J0641 LEVOLEUCOVORIN INJECTION $2.00
J0690 KEFZOL 1 GR VIAL $25.00
J0692 INJ CEFEPIME HCI 500MG $46.00
J0696 ROCEPHIN 250 MG $30.00
J0697 STERILE CEFUROXIME INJECTION $25.00
J0698 CLAFORAN 1 GR VIAL $63.00
J0708 J0708 $22.00
J0735 CLONIDINE 1MG $25.00
J0744 CIPRO 200MG $30.00
J0760 COLCHICINE INJECTION $23.00
J0780 COMPAZINE 10 MG $30.00
J1020 INJ METHYLPREDNISOLONE AC $20.00
J1030 DEPO MEDROL 40 MG/ML $22.00
J1040 METHYLPREDNISOLONE 80MG $25.00
J1094 DECADRON DEXAMETHASONE ACETATE 1MG $32.53
J1100 DECADRON 4 MG VIAL $29.02
J1165 DILANTIN 100 MG VIAL $41.00
J1170 DILAUDID 4 MG $35.00
J1200 BENADRYL 50MG $20.00
J1240 ANTIVERT – DIMENHYDRINATE INJECTION 50MG $33.00
J1335 ERTAPENEM INJECTION $21.00
J1580 GARAMYCIN,GENTAMICIN 80MG $50.00
J1610 GLUCOGAN 1 MG VIAL $50.00
J1630 HALOPERIDOL INJECTION $39.70
J1631 HALOPERIDOL DECANOATE INJ $45.00
J1642 HEPARIN SODIUM PER 10 UNI $20.00
J1644 INJ HEPARIN SOD PER 1000 $30.00
J1650 ENOXAPARIN SODIUM 10MG $258.09
J1670 TETANUS INJECTION $41.00
J1741 IBUPROFEN INJECTION $22.00
J1810 DROPERIDOL/FENTANYL INJ $25.00
J1815 INJ INSULIN PER 5 UNITS $20.00
J1817 INSULIN FOR INSULIN PUMP USE $22.00
J1885 TORADOL INJ 15 MG $20.00
J1930 LANREOTIDE INJECTION $45.00
J1940 LASIX 40 MG IV VIAL $35.00
J1956 LEVOFLOXACIN 250 MG $45.00
J2001 LIDOCAINE HCI 10MG $30.00
J2060 ATIVAN 2ML SYRUP $35.00
J2150 MANNITOL INJECTION $26.00
J2175 DEMEROL 50 MG SYRINGE $25.00
J2180 MEPERIDINE/PROMETHAZINE INJ $30.00
J2250 MIDAZOLAM HCI PER 1 MG $30.00
J2270 INJ MORPHINE SULFATE 10 M $30.00
J2274 INJ MORPHINE PF EPID ITHC $30.00
J2300 NUBAIN 10MG AMP $50.00
J2310 INJ NALOXONE HCL 1MG $30.00
J2360 ORPHENADRINE CITRATE 60MG $30.00
J2370 NEO-SYNEPHRINE UP TO 1 ML $81.00
J2405 ONDANSETRON HCI, PER MG $21.00
J2410 OXYMORPHONE HCL INJECTION $25.00
J2425 PALIFERMIN INJECTION $25.00
J2504 PEGADEMASE BOVINE, 25 IU $25.00
J2543 ZOSYN – PIPERACILLIN/TAZOBACTAM $30.00
J2550 PHENERGAN 50 MG $35.00
J2650 PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML $6.00
J2690 PRONESTYL 10 ML $22.00
J2704 INJ, PROPOFOL, 10 MG $22.00
J2730 PRALIDOXINE CHLORIDE $22.00
J2760 PHENTOLAINE MESYLATE INJ $41.00
J2765 METOCLOPRAMIDE HCL 10MG $30.00
J2780 INJ RANITIDINE 25 MG $20.00
J2790 RHOGAM INJECTION $199.00
J2800 METHOCARBAMOL INJECTION $50.00
J2920 SOLU-MEDROL 40MG $32.00
J2930 SOLU-MEDROL 125 MG $35.00
J3010 INJ FENTANYL CITRATE .1MG $33.00
J3030 IMITREX 6MG VIAL $50.00
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 $50.00
J3360 VALIUM INJ 5 MG $25.00
J3370 VANCOMYCIN HCI INJ 500MG $30.00
J3410 VISTERIL INJ 50 MG $22.00
J3411 INJ THIAMINE 100 MG $11.00
J3430 INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG $50.00
J3475 MAGNESIUM SULFATE 2CC AMP $20.00
J3480 POTASSIUM CHLORIDE 2 MG $125.00
J3486 GEODON – ZIPRASIDONE MESYLATE 10MG $35.00
J3490 UNCLASSIFIED DRUGS $31.00
J7030 INFUS NORM SALINE 1000CC $45.00
J7040 INFUS NORM SALINE 500ML $40.00
J7042 5% DEXTROSE $45.00
J7050 INFS NORM SALINE 250CC $48.00
J7060 INFUSION D5W 250ML $28.00
J7070 INFUSION D5W 1000ML $20.00
J7120 RINGER’S LACTATE INFUS $50.00
J7121 5% DEXTROSE IN LAC RINGERS $50.00
J7130 HYPERTONIC SALINE SOLUTION $76.00
J7131 HYPERTONIC SALINE SOL $20.00
J7192 FACTOR VIII RECOMBINANT NOS $20.00
J7313 FLUOCINOL ACET INTRAVIT IMP $20.00
J7506 PREDNISONE ORAL 5 MG $8.00
J7510 PREDNISOLONE ORAL 5 MG $15.00
J7512 PREDNISONE 5 MG $8.00
J7607 LEVALBUTEROL COMP CON $13.00
J7610 ALBUTEROL, THRU DME 1MG $13.00
J7611 ALBUTEROL 1MG CONC INHALA $35.00
J7613 ALBUT INHAL NON-CP 1MG $35.00
J7614 ALBUTEROL ALL FOMULATIONS $35.00
J7615 LEVALBTERAL INHALATION SO $35.00
J7620 ALBUTEROL 2.5 MG ATROVENT $35.00
J7631 CROMOLYN SODIUM NONCOMP UNIT $20.00
J7637 DEXAMETHASONE COMP CON $20.00
J7644 IPRATROPIUM BROMIDE INHAL $50.00
J7682 TOBRAMYCIN NON-COMP UNIT $25.00
J7699 NOC DRUGS INHAL SOL ADMIN $25.00
J8498 ENEMA SUPPOSITORY, ANTIEMETIC RECTAL $25.00
J8499 NONCHEMOTHERAPEUTIC ORAL $25.00
J8540 DEXAMETHASONE, ORAL .25MG $20.00
J9027 CLOFARALINE INJECTION $141.00
J9206 IRINOTECAN INJECTION $25.00
L0112 CRANIAL CERVICAL ORTHOSIS $250.00
L0120 CERVICAL FLEX NONADJ COLL $397.94
L0150 CERV SEMI-RIG ADJ MOLDED CHN $303.00
L0172 CLAVICAL COLLAR 2 PC $303.00
L0174 CERV SR 2PC THOR EXT PRE OTS $300.00
L1630 ABDUCT CONTROL HIP SEMI FLEX $41.00
L1810 KO ELASTIC WITH JOINTS $750.00
L1830 KNEE IMMOBOLIZER $569.33
L1902 AFO ANKLE GAUNTLET PRE OTS $20.00
L1906 ANKLE SUPPORT $133.00
L2360 EXTENDED STEEL SHANK $350.00
L3031 FOOT LAMIN/PREPREG COMPOSITE $450.00
L3201 OXFORD W SUPINAT/PRONAT INF $400.00
L3209 SURGICAL BOOT EACH CHILD $400.00
L3250 CUSTOM MOLD SHOE REMOV PROST $400.00
L3260 SURGICAL BOOT/SHOE $350.00
L3310 SHOE LIFT ELEV HEEL/SOLE NEO $300.00
L3500 ORTHO SHOE ADD LEATHER INSOL $350.00
L3540 ORTHO SHOE ADD FULL SOLE $450.00
L3650 SO FIGURE EIGHT ABDUCTION $204.75
L3660 SO 8 AB RSTR CAN/WEB PRE OTS $375.00
L3670 SO ACROMIO/CLAVICULAR $400.00
L3720 FOREARM/ARM CUFFS FREE MOTIO $550.00
L3808 WHFO, RIGID W/O JOINTS $655.20
L3809 WHFO W/O JOINTS PRE OTS $700.00
L3905 WHO W/NONTORSION JNT(S) CF $1,310.98
L3906 WHO W/O JOINTS CF $658.69
L3908 WRIST EXTN CONTROL COCKUP $85.57
L3999 UPPER LIMB ORTHOSIS NOS $176.00
L4350 AIR SPLINT $358.54
L4360 WALK BOOT PNEUMATIC $250.00
L4361 PNEUMA/VAC WALK BOOT PRE OTS $250.00
L4380 PNEUMATIC KNEE SPLINT $125.00
L4386 WALKING BOOT NON PNEUMATIC $285.65
L4387 NON-PNEUM WALK BOOT PRE OTS $250.00
L4398 FOOT DROP SPLINT PRE OTS $80.00
L4631 AFO, WALK BOOT TYPE, CUS FAB $250.00
M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion … $550.00
P7001 CULTURE BACTERIAL URINE $89.00
P9612 CATHETERIZE FOR URINE $60.00
Q0144 AZITH DIHY ORAL CAP/POWD $15.00
Q0169 PROMETHAZINE HCL 12.5MG ORAL $9.95
Q0179 ONDANESTRONG HCL 8MG ORL $4.00
Q0239 Injection, bamlanivimab-xxxx, 700 mg $0.01
Q4001 CAST SUP BODY CAST PLASTER $900.00
Q4006 LONG ARM CAST ADULT $950.00
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
Q4018 CAST SUP LNG ARM SPLINT FBRG $320.00
Q4019 CAST SUP LNG ARM SPLNT PED P $750.00
Q4020 LNG ARM SPLNT 0-10 YRS $620.00
Q4021 CAST SUP SHT ARM SPLINT PLST $650.00
Q4022 SHRT ARM SPLNT 11 YRS + $500.00
Q4023 CAST SUP SHT ARM SPLNT PED P $525.00
Q4024 CAST SUP SHT ARM SPLNT PED F $550.00
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 + $800.00
Q4046 SHRT LG SPLNT 11 YRS + $850.00
Q4049 FINGER SPLNT STATIC $100.00
Q4051 SPLINT SUPPLIES MISC $125.00
Q9954 ORAL MR CONTRAST, 100ML $416.00
Q9962 HOCM 300-349MG/ML IODINE,1ML $60.00
Q9963 HI OSM CONTRST MATL 350-3 $40.00
Q9965 LOW OSMOLAR CON MAT PER M $25.00
Q9966 LOCM 200-299MG ML IODINE, 1ML $22.00
Q9967 LOW OSMOLAR CNTRS MAT $15.92
S0020 INJ, BUPIVICAINE, 30ML $55.00
S0028 INJECT FAMOTIDINE 20 MG $45.00
S0030 METRONIDAZOLE 500 MG INJ $50.00
S0077 CLANDAMYCIN PHOSPHATE 300 $30.33
S0119 ZOFRAN, 4MG, ORAL $21.44
S0164 PROTONIX PANTROPRAZOLE 40MG $45.00
S0622 PHYS EXAM FOR COLLEGE $87.00
S0630 RMV SUTURES; PHYS NOT PHY $300.00
S1015 IV TUBING EXTENSION SET $30.00
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 $38.00
S8101 MASK NEBULIZER MASK SPACER WITH MASK $40.00
S8430 PADDING FOR COMPRSSN BDG $35.00
S8431 COMPRESSION BANDAGE $45.00
S8450 SPLINT $84.00
S8451 SPLINT WRIST OR ANKLE $125.00
U0002 SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple ty… $150.00

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