CHARGE CODE     DESCRIPTION CURRENT FEE
10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE $1,100.00
10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE $1,100.00
10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE $1,100.00
10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE $1,100.00
10180 Incision and drainage, complex, postoperative wound infectio… $1,800.00
11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< $1,100.00
11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER $360.00
11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 $1,150.00
11740 EVACUATION SUBUNGUAL HEMATOMA $560.00
11750 EXCISION NAIL MATRIX PERMANENT REMOVAL $1,100.00
11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $1,150.00
12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< $645.00
12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM $645.00
12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM $625.00
12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM $625.00
12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< $1,180.00
12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM $1,100.00
12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM $1,100.00
12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM $1,050.00
12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< $1,540.00
12051 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< $1,540.00
12052 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM $1,180.00
13120 REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM $1,185.00
13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM $1,190.00
15850 REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON $895.00
16000 INITIAL TX 1ST DEGREE BURN LOCAL TX $1,350.00
16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL $1,190.00
19000 PUNCTURE ASPIRATION CYST BREAST $2,600.00
19100 BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX $2,500.00
20600 arthrocentesis of a small joint or bursa $1,000.00
20605 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US $1,100.00
20610 aspiration (removal of fluid) from, or injection into, a maj… $1,120.00
23550 OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC $890.00
23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES $1,100.00
23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ $1,320.00
24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ $1,100.00
26010 DRAINAGE FINGER ABSCESS SIMPLE $999.00
26605 CLTX METACARPAL FX W/MANIPULATION EACH BONE $1,200.00
26750 CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA $1,080.00
27252 CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA $1,500.00
28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS $1,320.00
28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ $850.00
28660 CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES $1,000.00
29075 APPLICATION CAST ELBOW FINGER SHORT ARM $950.00
29086 APPLICATION CAST FINGER $920.00
29105 APPLICATION LONG ARM SPLINT SHOULDER HAND $1,020.00
29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC $880.00
29130 APPLICATION FINGER SPLINT STATIC $500.00
29131 APPLICATION FINGER SPLINT DYNAMIC $560.00
29240 STRAPPING SHOULDER $1,100.00
29280 STRAPPING HAND/FINGER $1,000.00
29450 APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG $1,150.00
29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES $820.00
29515 APPLICATION SHORT LEG SPLINT CALF FOOT $890.00
29530 STRAPPING KNEE $1,600.00
29540 STRAPPING ANKLE &/FOOT $1,190.00
29550 STRAPPING TOES $1,200.00
29700 REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST $1,100.00
30300 REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE $1,300.00
30901 CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE $1,320.00
30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST $1,325.00
3120F 12-LEAD ECG PERFORMED $250.00
33512 CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS $2,700.00
36000 INTRODUCTION NEEDLE/INTRACATHETER VEIN $200.00
36010 INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA $590.00
36415 COLLECTION VENOUS BLOOD VENIPUNCTURE $390.00
36416 COLLECTION CAPILLARY BLOOD SPECIMEN $595.00
43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE $2,050.00
51702 INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE $1,100.00
51703 INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED $1,110.00
57415 REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL $1,115.00
64400 NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH $1,000.00
64405 INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV $1,200.00
64450 INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH $1,180.00
65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL $1,300.00
65220 RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP $1,190.00
65222 RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP $1,320.00
65435 RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION $1,190.00
69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES $1,190.00
69209 REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT $1,190.00
69210 REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT $1,320.00
70030 RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY $1,900.00
70110 RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS $2,220.00
70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE $1,590.00
70150 RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS $2,050.00
70160 RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS $2,640.00
70200 RADEX ORBITS COMPLETE MINIMUM 4 VIEWS $2,645.00
70210 RADEX SINUSES PARANASAL <3 VIEWS $2,500.00
70220 RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS $2,600.00
70250 RADIOLOGIC EXAMINATION SKULL 4/> VIEWS $2,350.00
70260 RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS $2,300.00
70330 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT $2,600.00
70360 RADIOLOGIC EXAMINATION NECK SOFT TISSUE $2,500.00
70450 CT HEAD/BRAIN W/O CONTRAST MATERIAL $4,800.00
70460 CT HEAD/BRAIN W/CONTRAST MATERIAL $5,200.00
70470 CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL $5,500.00
70480 CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL $5,600.00
70481 CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL $5,700.00
70482 CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR $5,800.00
70486 CT MAXILLOFACIAL W/O CONTRAST MATERIAL $5,500.00
70487 CT MAXILLOFACIAL W/CONTRAST MATERIAL $5,600.00
70488 CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL $5,100.00
70490 CT SOFT TISSUE NECK W/O CONTRAST MATERIAL $5,200.00
70491 CT SOFT TISSUE NECK W/CONTRAST MATERIAL $5,600.00
70492 CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL $5,100.00
70496 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST $5,200.00
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST $5,250.00
71010 RADIOLOGIC EXAMINATION CHEST SINGLE VIEW FRONTAL $2,250.00
71020 RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL $2,300.00
71035 RADEX CHEST SPECIAL VIEWS $2,600.00
71045 Radiologic examination, chest ; single view $2,050.00
71046 Radiologic examination, chest ; 2 views $2,550.00
71047 Radiologic examination, chest ; 3 views $2,600.00
71048 (Radiologic examination, chest ; 4 or more $2,600.00
71100 RADEX RIBS UNILATERAL 2 VIEWS $1,950.00
71101 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS $2,300.00
71110 RADEX RIBS BILATERAL 3 VIEWS $2,500.00
71111 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS $2,600.00
71120 RADEX STERNUM MINIMUM 2 VIEWS $2,450.00
71250 CT THORAX W/O CONTRAST MATERIAL $5,200.00
71260 CT THORAX W/CONTRAST MATERIAL $5,500.00
71270 CT THORAX W/O & W/CONTRAST MATERIAL $5,600.00
71275 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST $5,400.00
72020 RADEX SPINE 1 VIEW SPECIFY LEVEL $2,200.00
72040 RADEX SPINE CERVICAL 2 OR 3 VIEWS $2,300.00
72050 RADEX SPINE CERVICAL 4 OR 5 VIEWS $2,400.00
72052 RADEX SPINE CERVICAL 6 OR MORE VIEWS $2,500.00
72070 RADEX SPINE THORACIC 2 VIEWS $2,200.00
72072 RADEX SPINE THORACIC 3 VIEWS $2,400.00
72074 RADEX SPINE THORACIC MINIMUM 4 VIEWS $2,300.00
72080 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS $2,100.00
72082 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW $2,250.00
72100 RADEX SPINE LUMBOSACRAL 2/3 VIEWS $2,500.00
72110 RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS $2,800.00
72114 RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 $2,400.00
72120 RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS $2,500.00
72125 CT CERVICAL SPINE W/O CONTRAST MATERIAL $5,500.00
72126 CT CERVICAL SPINE W/CONTRAST MATERIAL $5,000.00
72127 CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL $5,800.00
72128 CT THORACIC SPINE W/O CONTRAST MATERIAL $5,450.00
72129 CT THORACIC SPINE W/CONTRAST MATERIAL $5,200.00
72130 CT THORACIC SPINE W/O & W/CONTRAST MATERIAL $5,500.00
72131 CT LUMBAR SPINE W/O CONTRAST MATERIAL $5,600.00
72132 CT LUMBAR SPINE W/CONTRAST MATERIAL $5,550.00
72133 CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL $5,500.00
72141 MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL $4,000.00
72170 RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS $1,750.00
72190 RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS $1,800.00
72192 CT PELVIS W/O CONTRAST MATERIAL $5,200.00
72193 CT PELVIS W/CONTRAST MATERIAL $5,500.00
72220 RADEX SACRUM & COCCYX MINIMUM 2 VIEWS $2,400.00
72270 MYELOGRAPY 2/MORE REGIONS RS&I $2,450.00
73000 RADEX CLAVICLE COMPLETE $2,400.00
73010 RADEX SCAPULA COMPLETE $2,450.00
73020 RADEX SHOULDER 1 VIEW $1,800.00
73030 RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS $2,600.00
73050 RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ $2,400.00
73060 RADEX HUMERUS MINIMUM 2 VIEWS $2,450.00
73070 RADEX ELBOW 2 VIEWS $2,500.00
73080 RADEX ELBOW COMPLETE MINIMUM 3 VIEWS $2,500.00
73090 RADEX FOREARM 2 VIEWS $2,300.00
73100 RADEX WRIST 2 VIEWS $2,200.00
73110 RADEX WRIST COMPLETE MINIMUM 3 VIEWS $2,500.00
73120 RADEX HAND 2 VIEWS $2,100.00
73130 RADEX HAND MINIMUM 3 VIEWS $2,400.00
73140 RADEX FINGR MINIMUM 2 VIEWS $1,800.00
73200 CT UPPER EXTREMITY W/O CONTRAST MATERIAL $5,400.00
73201 CT UPPER EXTREMITY W/CONTRAST MATERIAL $5,500.00
64640 DSTRJ NULYT OTH PRPH NVR/BRANCH $ 1,645.00
65205 REMOVAL FB EYE-SUPERFCL $ 919.00
65220 RMVL FB EYE W/O SLIT LAMP $ 2,888.00
65222 RMVL FB EYE $ 919.00
67700 I&D ABSCESS EYELID $ 2,343.00
69200 RMVL FOREIGN BODY EAR $ 919.00
69205 RMVL FB XTRNL AUD CANAL A $ 551.00
69209 REMOVAL IMPACTED CERUMEN USING IRRAGATION/LAVAGE, UNILATERAL $ 490.00
69210 RMVL IMPACTED CERUMEN $ 490.00
70030 RADEX EYE DETCJ FB $ 355.00
70100 XRAY MANDIBLE LESS THAN 4 VIEWS $ 544.00
70110 XRAY MANDIBLE MIN 4 VIEWS $ 1,039.00
70120 RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE $ 1,039.00
70140 XRAY FACIAL BONES LESS THAN 3 VIEW $ 544.00
70150 XRAY FACIAL BONES GREATER THAN 3 VIEW $ 1,039.00
70160 NASAL BONE X-RAY $ 544.00
70200 RAD EXAM ORBIT COMP. $ 631.00
70220 RAD EXAM SINUS COMPLETE $ 664.00
70250 SKULL LESS THAN 4 VIEWS $ 1,039.00
70260 RAD EXAM SKULL COMPLETE $ 520.00
70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI $ 474.00
70350 CEPHALOGRAM ORTHODONTIC $ 345.00
70360 RAD EXAM NECK,SOFT TISSUE $ 544.00
70450 CT HEAD/BRAIN WO CONTRAST $ 3,342.00
70460 CT HEAD W/CONTRAST $ 4,070.00
70470 CT HEAD/BRAIN W & WO CONTRAST $ 5,480.00
70480 CT ORBIT SELLA/POST FOSSA $ 2,841.00
70481 CT ORBIT SELLA/POST FOSSA $ 3,700.00
70486 CT MAXLFCL AREA C-MATRL $ 3,878.00
70487 CT MAXLFCL AREA C+ MATRL $ 4,475.00
70490 CT NECK WO CONTRAST $ 1,039.00
70491 CT SOFT TISS NCK C+MATRL $ 2,211.00
70496 CTA HEAD C-/C+ $ 2,211.00
70498 CT ANGIOGRAPHY NECK WITH CON $ 2,211.00
70544 MRA HEAD C-MATRL $ 4,249.00
70547 MRA NECK C-MATRL $ 3,739.00
70551 MRI BRN BRN STEM C-MATRL $ 3,739.00
70553 MRI BRN BRN STEM C-/C+ $ 4,408.00
71010 XRAY CHEST AP $ 309.00
71020 XRAY CHEST PA & LATERAL $ 455.00
71030 RADEX CH COMPL MIN 4 VIEW $ 706.00
71045 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW $ 544.00
71046 RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS $ 943.00
71047 RADIOLOGIC EXAMINATION, CHEST; 3 VIEWS $ 706.00
71048 RADIOLOGIC EXAMINATION, CHEST; 4 OR MORE VIEWS $ 900.00
71060 BRONCHOGRAPHY BI RS&I $ 723.00
71100 RIBS UNILATERAL 2 VIEWS $ 544.00
71101 RIB UNILATERAL W CHEST $ 1,039.00
71110 RIBS BILATERAL 3 VIEWS $ 1,039.00
71111 RIBS BILATERAL W/CHEST $ 418.00
71120 CHEST 2 VIEWS $ 943.00
71250 CT CHEST W/O CONTRAST $ 1,039.00
71260 CT THORAX W/CONTRAST $ 2,211.00
71270 CT THORAX WO CONTRAST $ 3,898.00
71275 CT ANGIOGRAPHY $ 2,211.00
71550 MRI CH C-MATRL $ 3,739.00
72020 SPINE SINGLE VIEW $ 544.00
72040 SPINE, CERVICAL 2/3 VIEWS $ 544.00
72050 SPINE, CERVICAL MIN 4VIEW $ 1,039.00
72052 SPINE CERV. COMP FLEX/EXT $ 1,039.00
72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS $ 505.00
72070 SPINE THORACIC 2 VIEWS $ 1,039.00
72072 SPINE THORACIC 3 VIEWS $ 1,039.00
72074 RAD EXAN SPINE THROAC 4 V $ 1,039.00
72100 SPINE LUMBO. MIN 4 VIEWS $ 1,039.00
72110 LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS $ 1,039.00
72114 RAD EXAM SPINE LUMBO COMP $ 630.00
72120 SPINE LUMBAR AP & LAT W F $ 1,039.00
72125 COMPUTED TOMOGRAPHY CERVI $ 1,039.00
72126 CT CRV SPI C+MATRL $ 3,993.00
72127 CT CRV SPI C-/C+ $ 4,049.00
72128 CT THRC SPI C-MATRL $ 1,039.00
72129 CT THRC SPI C+ MATRL $ 2,211.00
72131 CT L SPINE WO CONTRST $ 1,039.00
72132 CT LMBR SPI C+ MATRL $ 3,993.00
72141 MRI SPI CANAL&CNTS CRV C-MATRL $ 2,516.00
72146 MRI SPI CANAL&CNTS THRC C-MATRL $ 3,739.00
72148 MRI SPI CANAL&CNTS LMBR C-MATRL $ 3,739.00
72156 MRI SPI CANAL&CNTS C-/C+ CRV $ 4,408.00
72157 MRI SPI CANAL&CNTS C-/C+ $ 3,739.00
72158 MRI SPI CANAL&CNTS C-/C+ LMBR $ 3,778.00
72170 RAD EXAM PELVIS 1/2 VEIW $ 1,039.00
72190 RADEX PELVIS COMPL MIN 3 $ 585.00
72191 CTA PELVIS C-/C+ POST-PXE $ 2,036.00
72192 CT PELVIS WO CONTRAST $ 1,039.00
72193 TOMOGRAPHY PELVIS WCONTRS $ 2,211.00
72194 CT PELVIS W OR WO CONTRST $ 5,447.00
72195 MRI PELVIS C-MATRL $ 3,739.00
72196 MRI PELVIS C+ MATRL $ 5,035.00
72220 XRAY COCCYX/SACRUM $ 544.00
73000 XRAY CLAVICLE 2 VIEWS $ 544.00
73010 SCAPULA COMPLETE $ 1,039.00
73020 RADEX SHO 1 VIEW $ 544.00
73030 SHOULDR COMPLETE 2 VIEWS $ 544.00
73050 XRAY AC JOINTS-BILAT $ 501.00
73060 XRAY HUMERUS MIN 2 VIEWS $ 544.00
73070 XRAY ELBOW 2 VIEWS $ 544.00
73080 XRAY ELBOW LESS THAN 3 VIEWS-COMP $ 544.00
73090 XRAY FOREARM AP & LAT $ 544.00
73100 XRAY WRIST AP & LAT VIEW $ 544.00
73110 XRAY WRIST/COMP MIN 3 VIE $ 544.00
73120 XRAY HAND AP & LAT $ 1,039.00
73130 XRAY HAND MIN 3 VIEWS $ 544.00
73140 XRAY FINGER MIN 2 VIEWS $ 544.00
73200 CT UPPR EXTR WO CNTRS $ 1,039.00
73206 CT ANGIOGRAPHY, UPPER EXT, W/CONTRAST $ 3,575.00
73220 MRI UXTR OTH/THN JT C-/C+ $ 4,408.00
73221 MRI ANY JT UXTR C-MATRL $ 3,739.00
73500 RADIOLOGIC EXAM HIP UNILAT 1 VIEW $ 356.00
73502 RADIOLOGIC EXAM, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED, 2-3VIEWS $ 544.00
73510 XRAY HIP MIN 2 VIEWS $ 486.00
73520 HIPS BILAT MIN 2 VIEW INC $ 530.00
73550 XRAY FEMUR AP & LAT VIEW $ 421.00
73552 FEMUR, MINIMUM 2 VIEWS $ 544.00
73560 XRAY KNEE, SUNRISE VIEW $ 544.00
73562 XRAY KNEE MIN 3 VIEWS $ 544.00
73564 RAD EXAM KNEE 4 OR MORE $ 1,039.00
73590 XRAY TIBIA/FIBULA AP/LAT $ 544.00
73600 XRAY ANKLE 2 VIEWS $ 544.00
73610 XRAY ANKLE 3 VIEWS/COMPLE $ 544.00
73620 XRAY FOOT MIN 2 VIEWS $ 544.00
73630 XRAY FOOT MIN 3 VIEWS $ 544.00
73650 RAD EXAN HEEL MIN 2 VIEWS $ 544.00
73660 XRAY TOES, MIN 2 VIEWS $ 544.00
73700 CT LWR EXTR WO CONTRAST $ 1,039.00
73701 CT LWR EXT W CONT $ 3,015.00
73702 CT LXTR C-/C+ $ 2,965.00
73721 MRI ANY JT LXTR C-MATRL $ 3,739.00
73722 MRI ANY JT LXTR C+ MATRL $ 4,148.00
73723 MRI ANY JT LXTR C-/C+ $ 5,447.00
73725 MRA LXTR C+-MATRL $ 5,035.00
74000 RAD EXAM ABD SINGL ANTER $ 399.00
74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS $ 575.00
74018 RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW $ 544.00
74019 RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS $ 1,039.00
74020 RAD EXAM ABDOMEN COMPL $ 473.00
74021 RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS $ 575.00
74022 RAD EXAM COMPLETE ABD $ 1,039.00
74150 COMPUTED TOMOGRAPHY ABD $ 2,936.00
74160 TOMOGRAPHY ABD W/CONTRAST $ 3,451.00
74170 TOMOGRAPHY ABD W/OCONTRAS $ 2,211.00
74174 CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST, INC NONCONTRAST IMAGES $ 2,211.00
74175 CT ANGIO ABDOMEN W/CONTRA $ 4,358.00
74176 COMP TOMOG AB/PEL W/O CON $ 2,146.00
74177 COMP TOMO AB/PELV W/OCONT $ 2,211.00
74178 CT ABD & PELVIS 1 PLUS SECTION/REGNS $ 2,211.00
74181 MRI ABD C-MATRL $ 3,739.00
74183 MRI ABD C-/C+ $ 4,408.00
74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB $ 1,348.00
74247 RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB $ 1,361.00
74420 UROGRAPHY, RETROGRADE, W OR W/O KUB $ 3,993.00
76000 FLUOROSCOPY $ 1,094.00
76376 3D RNDR I&R CT MRI US/OTH $ 938.00
76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK $ 1,094.00
76642 ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION $ 1,039.00
76645 US BREAST R-T W/IMAGE DOCUMENTATION $ 1,039.00
76700 US ABDOMINAL R-T W/IMAGE $ 1,094.00
76705 US ABDOMINAL $ 1,094.00
76770 US RETROPERITONEAL R-T W/ $ 1,156.00
76775 US RPR B-SCAN&/R-T IMG LMTD $ 1,094.00
76801 ULTRASOUND 14 WK TABDL 1/1ST GESTATION $ 1,094.00
76815 ULTRASND PG UTER $ 1,094.00
76817 UT PG UTER R-T IMG TRVG $ 1,094.00
76830 TRANSVAGINAL ULTRASOUND $ 1,094.00
76856 US PELVIC NONOB REAL-TIME $ 1,094.00
76857 PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 $ 1,094.00
76870 US SCROTUM&CNTS $ 1,094.00
76880 US EXTREMITY $ 1,113.00
76882 ULTRASOUND, EXTREMITY, NONVASCULAR $ 1,094.00
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT $ 469.00
77079 CT BONE MINERAL DENSITY STUDY 1+SITS APPND $ 551.00
77777 SHORTNESS OF BREATH PANEL $ 1,626.00
78075 ADRNL IMG CORTEX&/MEDULLA $ 4,879.00
78223 HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR $ 3,384.00
78306 B1&/JT IMG WHBDY $ 1,941.00
78315 B1&/JT IMG 3 PHASE STD $ 1,941.00
78320 B1&/JT IMG TOMOG SPECT $ 1,245.00
78472 CARD BPI GTD=BRM PLNR 1 STD REST/STRS $ 2,750.00
78630 CEREBROSPINAL FLUID SCAN $ 1,500.00
80047 BASIC METABOLIC PANEL CALCIUM IONIZED $ 144.00
80048 METABOLIC PANEL BASIC $ 113.00
80051 ELECTROLYTE PANEL $ 100.00
80053 METABOLIC COMPRE PANEL $ 125.00
80061 LIPID PROFILE III $ 156.00
80074 HEPATITIS PANEL $ 563.00
80076 HEPATIC FUNCTION PANEL $ 438.00
80100 DRUG ABUSE PANEL II $ 406.00
80102 DRUG CONFIRMATION, EACH PROCEDURE $ 188.00
80104 DRUG SCREEN $ 188.00
80178 LITHIUM $ 143.00
80185 PHENYTOIN LEVEL $ 144.00
80196 SALICYLATE $ 151.00
80197 TACROLIMUS $ 473.00
80202 VANCOMYCIN PEAK $ 309.00
80304 DRUG SCREEN $ 188.00
80305 DRUG SCREENING $ 188.00
80306 DRUG TEST, PRESUMPTIVE, ANY NUMBER DRUG CLASSES, DEVICES, PROCEDURES $ 125.00
80320 DRUG SCREEN $ 313.00
80329 ANALGESICS, NON OPIOID 1&2 $ 244.00
81000 U/A DIPSTICK $ 126.00
81001 U/A DIP STICK $ 125.00
81002 URNLS DIP STICK/TABLET RG $ 43.00
81003 U/A W/O MICRO DIPSTICK $ 24.00
81025 PREG.TST URINE VISUAL $ 75.00
82003 ACETAMINOPHEN $ 309.00
82009 KETONES-SERUM $ 79.00
82010 KETONE BODY $ 89.00
82040 ASSAY OF SERUM ALBUMIN $ 54.00
82055 ALCOHOL-BLOOD $ 409.00
82150 AMYLASE $ 70.00
82247 BILIRUBIN TOTAL $ 54.00
82253 MB FRACTION $ 209.00
82270 OCCULT BLOOD $ 39.00
82272 BLD OCLT PEROXIDASE ACTV $ 38.00
82274 BLD OCLT FECAL HGB DETER $ 171.00
82306 VITAMIN D HYDROXY $ 275.00
82310 CALCIUM, SERUM $ 69.00
82375 CARBOXYHEMOGLOBIN, QUANTITATIVE $ 148.00
82540 CREATINE $ 75.00
82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE $ 164.00
82550 CREATINE CK-TOTAL $ 83.00
82553 CREATINE CKMB $ 156.00
82565 CREATININE $ 63.00
82657 ENZYME CELL ACTIVITY $ 79.00
82800 GASES BLD PH ONLY $ 96.00
82803 GASES, BLOOD $ 228.00
82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD $ 63.00
82947 GLUCOSE $ 63.00
82948 GLUCOSE BLOOD REAGET STR $ 44.00
82962 GLUCOSE FINGER STICK $ 70.00
82977 GLUTAMYLTRANSFERASE-GTT $ 78.00
83036 HEMOGLOBIN, GLYCOSYLATED(A1C) $ 105.00
83520 IMMUNOASSAY ANALYTE QUANTITIATIVE NOS $ 193.00
83605 LACTATE(LACTIC ACID) $ 128.00
83615 LDH $ 88.00
83630 LACTOFERRIN FECAL QUAL $ 213.00
83690 LIPASE $ 100.00
83735 SERUM MAGNESIUM $ 102.00
83874 MYOGLOBIN $ 140.00
83880 B-TYPE NATRIURETIC $ 366.00
84075 ASSAY OF ALKALINE PHOSPHATE $ 56.00
84146 ASSAY OF PROLACTIN $ 118.00
84153 PSA SCREEN TOTAL $ 199.00
84155 ASSAY OF PROTEIN SERUM $ 40.00
84165 PROTEIN ELECTROPHORESIS $ 266.00
84166 PROTEIN, ELECTROPHORETIC FRACTIONATION AND QUANTITATION $ 193.00
84436 THYRIXINE TOTAL $ 181.00
84439 LAB FOR ASSAY OF FREE THYROXINE $ 98.00
84443 TSH $ 181.00
84450 TRANSFERASE (AST) $ 56.00
84460 ALANINE AMINO (ALT) $ 58.00
84479 THYROID HORMONE $ 70.00
84480 ASSAY TRIIODOTHYRONINE $ 92.00
84484 TROPONIN I $ 109.00
84512 TROPONIN QUAL $ 209.00
84520 BUN $ 55.00
84550 URIC ACID $ 49.00
84560 URIC ACID OTH SRC $ 185.00
84702 HCG QUANTATIVE $ 163.00
84703 GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE $ 81.00
85014 HEMATOCRIT $ 70.00
85018 HEMOGLOBIN $ 85.00
85025 CBC $ 155.00
85027 CBC W/O DIFF $ 85.00
85032 BLD# MNL C-CNT RBC/PLTLT EA $ 46.00
85045 AUTOMATED RETICULOCYTE COUNT $ 118.00
85048 AUTOMATED LEUKOCYTE COUNT $ 141.00
85347 COAGJ TM ACTIVATED $ 125.00
85378 FIBRIN DEGRADATION PROD $ 203.00
85379 D-DIMER $ 123.00
85610 PROTHROMBIN TIME $ 43.00
85651 SEDIMENTATION RATE NONAUT $ 39.00
85652 SED RATE ERYTHROCYTE NON $ 29.00
85730 THROMBOPLASTIN TIME PART $ 65.00
86140 C REACTIVE PROTEIN $ 56.00
86256 SMOOTH MUSCLE AB TITER $ 258.00
86308 MONO,HETEROPHILE ANTIBODI $ 56.00
86320 IMMUNOELECTROPHORESIS $ 258.00
86403 MONO SPOT $ 188.00
86430 RHEUMATOID FACTOR $ 100.00
86490 SKN TST COCCIDIOIDOMYCOSI $ 89.00
86510 SKN TST HISTOPLASMOSIS $ 85.00
86580 TB INTRADERMAL $ 109.00
86592 RPR RAPID REGAIN TEST $ 46.00
86631 ANTB CHLAMYDIA $ 128.00
86689 ANTB HTLV/HIV ANTB CONFIRMATION TST $ 290.00
86701 HIV SERUM $ 96.00
86702 ANTB HIV-2 $ 221.00
86703 SINGLE LAB TEST RESULT $ 148.00
86735 MUMPS ANTIBODY $ 141.00
86756 ANTB RSV $ 191.00
86788 WEST NILE, IGM $ 183.00
86789 ANTIBODY, WEST NILE VIRUS $ 155.00
86850 ANTB SCR RBC EA SERUM TQ $ 255.00
86901 RH FACTOR-BLOOD $ 279.00
86906 BLD TYPING RH PHEXYPING COMPL $ 279.00
87040 BLOOD CULTURE $ 111.00
87045 FECES CULTURE, BACTERIA $ 103.00
87046 STOOL CULTURE, BACTERIA $ 103.00
87070 CULTURE BODY FLUID $ 93.00
87075 CULTURE ANAEROBIC $ 103.00
87081 CULTURE, BACTERIAL-SCREEN $ 179.00
87086 URINE CULTURE $ 88.00
87088 CULTURE BCT ISOL&PRSMPTV $ 118.00
87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST $ 115.00
87110 CHLAMYDIA CULTURE $ 211.00
87177 OVA AND PARASITES SMEAR $ 96.00
87205 SMEAR, PRIMARY SOURCE WITH INTERP, WET MOUNT FOR INFECTIOUS AGENTS $ 46.00
87207 SMR PRIM SRC SPEC STAIN $ 178.00
87210 WET SMEAR $ 51.00
87230 TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE $ 214.00
87252 HSV 1 AND 2 CULTURES $ 225.00
87274 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLORESCENT TECHNIQUE $ 390.00
87275 IAADI INF B VIRUS $ 138.00
87400 INFLUENZA A&B $ 156.00
87425 INFECTIOUS AGENT DETECTION BY ENZYME IMMUNOSSAY TECHNIQUE STEP METHOD; ROTAVIRU $ 130.00
87430 INF AGT IMMUNO STREP A $ 238.00
87480 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA);CANDIDA SPECIES,DIRECT $ 203.00
87491 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID;CHLAMYDIA TRACHOMATIS,AMP PROBE $ 379.00
87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE $ 313.00
87502 INFLUENZA DNA AMP PROBE $ 141.00
87510 INFECTIOUS AGENT BY NUCLEIC ACID $ 78.00
87529 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID(DNA OR RNA) $ 379.00
87591 INF AGENT DETECION BY NUCLEIC ACID(DNA OR RNA) NEISSERIA GONORRHOEAE, AMPLIFIED $ 379.00
87660 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID ( DNA OR RNA);TRICHOMONAS VAG, DIRECT $ 178.00
87804 INFLUENZA IMMUNOASSAY OPT $ 145.00
87807 INF AGT DET IMNAS OPT RSV $ 130.00
87808 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OBSERVATION $ 134.00
87847 NO DESCRIPTION $ 551.00
87850 NEISSERIA GONORRHOEAE DET $ 215.00
87880 RAPID STREP-BETA STREP $ 145.00
88300 PATH LEVEL 1 $ 133.00
88304 PATH LEVEL III $ 343.00
88305 PATH SURG LEVEL IV $ 569.00
88313 STAIN TRICHOME $ 413.00
89050 CELL COUNT, MISC BODY FLUIDS $ 51.00
89055 LEUKOCYTE ASSESSMENT, FECAL $ 46.00
89060 CRYSTAL INDENTIFICATION $ 78.00
89220 SPTM OBTG SPEC AERSL INDUCED SPX $ 131.00
89947 GLUCOSE TEST IN MET 8 PANEL $ 141.00
90471 IMMUN ADM 1 VAC $ 509.00
90472 IMADM PRQ ID SUBQ/IM NJXS $ 65.00
90658 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, H1N1 $ 118.00
90660 INFLUENZA VIRUS INTRANASA $ 93.00
90703 TETANUS TOXID $ 204.00
90714 TETANUS DIPTHERIA TOXOID $ 211.00
90715 TDAP VACCINE $ 283.00
90718 TETANUS & DIPTHERIA $ 204.00
90746 HEPATITIS B VACCINE/ADULT $ 109.00
90765 IV NFS THER PROPH/DX 1ST $ 253.00
90997 HEMOPERFUSION $ 551.00
91105 GASTRIC INTUBATION/ASPER $ 806.00
92002 OPH MEDICAL XM&EVAL INTRM $ 398.00
92081 VIS FLD XM UNI/BI I&R LMT $ 185.00
92551 AUDIO SCREENING $ 59.00
92552 PURE TONE AUDIOMTRY AIR O $ 120.00
92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL $ 4,485.00
93000 EKG W/INTREP AND REPORT $ 313.00
93005 EKG $ 156.00
93010 RTN ECG 12 LEADS INTRP/RP $ 203.00
93040 RHYTHM ECG 1-3 LDS W/I&R $ 126.00
93041 RHYTHEM ECG 1-3 LDS $ 490.00
93042 RHYTHM ECG 1-3 LDS I&R ON $ 98.00
93224 WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I $ 309.00
93306 TRANSTHORACIC ECHOCARDIOGRAPHY $ 1,800.00
93313 TEE R-T IMG 2D W/PROBE PLMT ONLY $ 2,605.00
93351 ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG $ 2,105.00
93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD $ 1,133.00
93880 DUP-SCAN XTRC ART COMPL B $ 1,218.00
93882 DUP-SCAN XTRC ART UNI/LMTD STD $ 1,218.00
93922 N-INVAS PHYSIOLOGIC STD $ 754.00
93926 DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD $ 1,184.00
93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD $ 785.00
93965 QUANT VENOUS FLOW ST $ 1,565.00
93970 DUP-SCAN XTR VEINS COMPL $ 2,146.00
93971 DPLX SCN EXTRM VEINS $ 1,039.00
93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, PELVIC, SCROTAL $ 1,495.00
93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW ABDOMEN, PELVIS, OR SCROTUM $ 1,039.00
93990 DOPPLER FLOW TESTING $ 724.00
94010 SPIROMETRY W/RECORD $ 213.00
94060 BRNCDILAT RSPSE SPMTRY PR $ 653.00
94150 VC TOT SPX $ 150.00
94375 RESPIR FLO VOL LOOP $ 556.00
94621 PULM STRS TSTG CPLX $ 1,388.00
94640 NEBULIZER TREATMENT $ 189.00
94644 INHALATION TREATMENT – CONTINUOUS 1ST HR $ 735.00
94664 DEMO&/EVAL OF PT UTILIZ $ 93.00
94750 PULM COMPLIANCE STD $ 458.00
94760 EAR OR PULSE OXIMETRY $ 103.00
94761 N-INVAS EAR/PLS OXIMTRY F $ 259.00
95115 ALLERGY INJ SRVC; SINGLE $ 64.00
95117 ALLERGY INJ SRVC; 2 OR MO $ 79.00
96360 IV INFUS INIT 31 MIN 1 HR $ 1,140.00
96361 IV INFUS HYDR EA ADD’T HR $ 1,002.00
96365 IV INFUSION THERAPY/PROPH $ 719.00
96366 IV INFUS THER PROPH/DX EA $ 324.00
96367 IV NFS THER PROPH/DX ADDL $ 509.00
96368 IV NFS TX PROPHYLAXIS/DX $ 355.00
96370 SUB INFUS EA ADD HR $ 188.00
96372 THERAPEUTIC PROPHYLACTIC/ $ 509.00
96373 INJECTION, INTRA-ARTERIAL $ 308.00
96374 THER PROPH/DX NJX IV PUSH $ 423.00
96375 THER PROPH/DX NJX EA SEQL $ 324.00
96376 SUB INFU EA ADD IV PUSH $ 299.00
96379 INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS $ 289.00
97810 ACUPUNCTURE, 1 OR MORE NEEDLES, W/OUT ELECTRICAL STIM, INITIAL 15 MINS $ 76.00
99000 SPECIMEN HANDLING $ 84.00
99001 COC COLLECITON ONLY $ 55.00
99050 BLUE CROSS RQRD LVL3 $ 119.00
99053 SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY $ 198.00
99080 MEDICAL RECORDS $ 33.00
99143 MOD SEDATION &#60;5YRS 30 $ 724.00
99144 MOD SEDATION SERV UNDER 5 $ 716.00
99145 M-SEDAJ BY SM PHY 15 MIN $ 283.00
99149 MOD SEDATION $ 600.00
99173 SCREENING TEST OF VISION $ 393.00
99281 FACILITY CHG LEVEL 1 $ 495.00
99282 FACILITY CHG LEVEL 2 $ 841.00
99283 FACILITY CHG LEVEL 3 $ 1,577.00
99284 FACILITY CHG LEVEL 4 $ 2,685.00
99285 FACILITY CHG LEVEL 5 $ 3,633.00
99291 CRITICAL CARE 30-74 MIN $ 5,310.00
99292 CRITICAL CARE ADD 30 MIN $ 895.00
99406 SMOKING CESSATION 3-10 $ 266.00
99407 SMOKING CESSATION 10 MIN $ 126.00
A0394 ALS IV DRUG THERAPY SUPPLIES $ 53.00
A0396 ALS ESPOHAGEAL INTUB SUPPLIES $ 55.00
A1234 SURGICAL TRAY- PNEUMOTHORAX/CHEST KIT $ 586.00
A4208 3 CC STERILE SYRINGE & NEEDLE $ 26.00
A4209 5+ CC STERILE SYRINGE & NEEDLE $ 33.00
A4213 20+ CC SYRINGE ONLY $ 9.00
A4215 NEEDLE STERILE, ANY SIZE, EACH $ 9.00
A4216 STERILE WATER/SALINE, FLUSH 10ML $ 6.00
A4217 STERILE SALINE WATER PER 500 ML $ 36.00
A4218 STERILE SALINE OR WATER $ 35.00
A4222 EXT UNFU PMP PER CASS/BAG $ 236.00
A4224 ALOCHOL OR PEROXIDE PER PINT $ 6.00
A4246 BETADINE/PHISOHEX SOLUTION $ 34.00
A4247 BETADINE/IODINE SWABS/WIPES $ 19.00
A4252 GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP $ 8.00
A4311 CATHETER W/O BAG 2 WAY LATEX $ 33.00
A4314 INSRT TRAY W/DRAINAGE BAG $ 34.00
A4320 IRR TRAY W/BULB/PISTON SY $ 11.00
A4322 IRRIGATION SYRINGE, BULB $ 13.00
A4327 URIN CUP FEMALE COLLECT DEV CUP $ 4.00
A4332 LUBE STERILE PACKET $ 4.00
A4335 INCONTINENCE SUPPLY MISC $ 4.00
A4338 INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING $ 46.00
A4344 INDWELLING CATH FOLEY TYP $ 34.00
A4351 STRAIGHT TIP URINE CATHETER $ 8.00
A4353 INTERMIT URINARY CATHETER $ 33.00
A4358 URINARY DRAINAGE BAG $ 11.00
A4364 DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ $ 76.00
A4450 TAPE NO WATERPROOF $ 8.00
A4452 TAPE WATERPROOF 18 SQ IN $ 8.00
A4550 LACERATION- SURGICAL KIT $ 254.00
A4554 DISPOSABLE UNDERPADS $ 8.00
A4565 SLING $ 41.00
A4570 SPECIAL CASTING MATERIAL $ 44.00
A4580 CAST SUPPLIES $ 69.00
A4590 3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL $ 53.00
A4595 TENS SUPPL 2 LEAD PER MONTH $ 63.00
A4606 OXYGEN PROBE USED W OXIMETER $ 48.00
A4614 PEAK FLOW SUPPLY $ 63.00
A4615 CANNULA NASAL $ 15.00
A4616 TUBING (OXYGEN) PER FOOT $ 1.00
A4617 MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT $ 43.00
A4627 SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR METERED DOSE INHALER $ 55.00
A4649 SURGICAL SUPPLY MISC $ 30.00
A4653 PD CATHERTER ANCHOR BELT $ 19.00
A4657 SYRINGE W OR WO NEEDLE $ 4.00
A4670 AUTOMATIC BP MONITOR #11 $ 49.00
A4673 SALINE BLADE #11 $ 9.00
A4930 GLOVES STERILE PER PAIR $ 4.00
A5120 SWAB OR WIPE SKIN BARRIER $ 4.00
A5200 PERCUTANEOUS CATHETER ANCHOR $ 96.00
A6021 COLLAGEN DRESSING STERIL $ 24.00
A6205 COMPOSITE DRSG LESS THAN 48 SQ IN $ 29.00
A6210 FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER $ 38.00
A6211 FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER $ 43.00
A6213 FOAM DRG 16-48 SQ IN W/BRDR $ 48.00
A6216 GAUZE NONIMPREG 16 SQ IN $ 20.00
A6217 GAUZE NON STERILE $ 20.00
A6218 GAUZE, NON STERILE $ 20.00
A6219 GAUZE- STERILE $ 20.00
A6222 GAUZE IMPREGNATED WITH ME $ 11.00
A6228 GAUZE GREATER THAN 16 SQ IN $ 10.00
A6231 GAUZE, 16 LESS THAN SQ IN, EACH $ 18.00
A6250 SKIN SEAL PROTECT MOISTURIZER OINTMENT $ 30.00
A6260 WOUND CLEANSER $ 41.00
A6261 WOUND FILLER $ 41.00
A6266 GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE $ 11.00
A6402 STERILE GUAZE LESS THAN 16 INCHES $ 8.00
A6407 PACK STRIPS NON-IMPREGNTD $ 40.00
A6410 STERILE EYE PAD OR STRIP $ 8.00
A6412 EYE PATCH $ 8.00
A6413 ADHESIVE BANDAGE FIRST AI $ 8.00
A6446 CONFORMING BANDAGE, > THAN 3 INCHES $ 16.00
A6448 LT COMP BANDAGE LESS THAN 3IN $ 15.00
A6449 LIGHT COMP BANDAGE $ 15.00
A6450 LT COMPRS BANDAGE ELAST $ 24.00
A6453 BANDAGE SELF ADHER BAND W LESS THAN 3 $ 3.00
A6454 SELF ADHER BANDAGE $ 19.00
A6455 SELF ADHER BANDAGE $ 19.00
A6457 TUBULAR DRESSING $ 40.00
A7002 SUCTION TUBING USED W PUMP $ 34.00
A7003 ADMN SET SM VOL NONFILTER $ 76.00
A7011 NONDISPOS CORRUGATED TUBING $ 18.00
A7015 NEBULIZER MASK USED W NEBULIZER $ 33.00
A7016 DOME/MOUTHPIECE NEB $ 155.00
A7017 NEBULIZER MASK NOT USED W/ OXYGEN $ 33.00
A7520 TRACH LARYN TUBE NON CUFFED $ 35.00
A9150 NON PRESCRIPTION DRUG $ 30.00
A9273 HOT/COLD H2OBOT/CAP/COL/WRAP $ 33.00
A9284 NON-ELECTRONIC SPIROMETER $ 341.00
A9579 GAD-BASE MR CONTRAST NOS,1ML $ 21.00
CASH XRAY DISC $ 15.00
E0114 CRUTCHES UNDERARM $ 79.00
E0116 CRTCH UNDARM NOT WOOD ADJ $ 79.00
E0220 HOT WATER BOTTLE $ 18.00
E0230 ICE CAP OR COLLAR $ 18.00
E0275 BED PAN STANDARD $ 10.00
E0325 URINAL MALE JUG-TYPE $ 10.00
E0352 DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) $ 238.00
E0445 OXIMETER NON-INVASIVE $ 779.00
E0570 NEBULIZER WITH COMPRESSION $ 195.00
E0580 NEBULIZER FOR USE W/ REGULAT $ 393.00
G0009 ADM PNEUMOCOCCAL VACCINE $ 123.00
G0168 WND CLS TISSUE ADHESIVE $ 204.00
G0378 HOSPITAL OBSERVATION SERVICES PER HOUR $ 1,000.00
G0434 DRUG ABUSE PANEL II $ 310.00
J0131 INJECTION, ACETAMINOPHEN, 10MG $ 5.00
J0150 ADENOSINE INJ 6MG VIAL $ 46.00
J0153 INJECTION, ADENOSINE, 1 MG $ 8.00
J0170 EPINEPHRINE 3 1/2 NDL 10M $ 51.00
J0171 ADRENALIN EPINEPHRINE INJECT $ 8.00
J0282 INJ AMIODARONE HYDROCHLOR $ 19.00
J0290 AMPICILLIN 500 MG INJ $ 44.00
J0295 INJ AMPCLLN SODIUM/SULBA $ 21.00
J0330 SUCCINYLCHOLINE CHLO 20MG $ 171.00
J0360 HYDRALAZINE HCL INJ UP TO 20MG $ 30.00
J0456 INJ AZITHROMYCIN 500MG $ 25.00
J0461 INJ ATROPINE SULFATE 0.01 $ 35.00
J0500 DICYCLOMINE HCL 20MG $ 660.00
J0550 BICILLIN – PENICILLIN G BENZATHINE INJ $ 244.00
J0559 BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS $ 244.00
J0560 BICILLIN 600,000 $ 221.00
J0561 INJECTION PENICILLIN G BENZATHINE 100,000 UNITS $ 104.00
J0570 BICILLIN 1,200,000 $ 304.00
J0595 STADOL $ 19.00
J0610 INJECTION CALCIUM GLUCONATE $ 33.00
J0641 LEVOLEUCOVORIN INJECTION $ 5.00
J0690 KEFZOL 1 GR VIAL $ 10.00
J0692 INJ CEFEPIME HCI 500MG $ 93.00
J0694 MEFOXIN 1 GM INJECTION $ 55.00
J0696 ROCEPHIN 250 MG $ 9.00
J0698 INJECTION, CEFOTAXIME SODIUM, PER G $ 23.00
J0708 J0708 $ 29.00
J0735 CLONIDINE 1MG $ 115.00
J0744 INJECTION, CIPROFLAXIN FOR IV INFUSION $ 11.00
J0760 COLCHICINE INJECTION $ 30.00
J0780 COMPAZINE 10 MG $ 88.00
J1020 INJ METHYLPREDNISOLONE AC $ 43.00
J1030 DEPO MEDROL 40 MG/ML $ 58.00
J1040 METHYLPREDNISOLONE 80MG $ 36.00
J1094 DECADRON DEXAMETHASONE ACETATE 1MG $ 29.00
J1100 DECADRON 4 MG VIAL $ 3.00
J1165 DILANTIN 100 MG VIAL $ 40.00
J1170 DILAUDID 4 MG $ 14.00
J1200 BENADRYL 50MG $ 8.00
J1240 ANTIVERT – DIMENHYDRINATE INJECTION 50MG $ 44.00
J1265 DOPAMINE HCL, 40MG $ 8.00
J1335 ERTAPENEM INJECTION $ 495.00
J1580 GARAMYCIN,GENTAMICIN 80MG $ 13.00
J1610 GLUCOGAN 1 MG VIAL $ 1,439.00
J1630 HALOPERIDOL INJECTION, 5MG $ 10.00
J1631 INJECTION, HALOPERIDOL DECANOATE, 50 MG $ 154.00
J1642 HEPARIN SODIUM PER 10 UNI $ 3.00
J1650 ENOXAPARIN SODIUM 10MG $ 8.00
J1670 TETANUS INJECTION $ 119.00
J1710 INJECTIONS, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG $ 19.00
J1815 INJ INSULIN PER 5 UNITS $ 10.00
J1817 INSULIN FOR INSULIN PUMP USE $ 29.00
J1885 TORADOL INJ 15 MG $ 8.00
J1940 LASIX 40 MG IV VIAL $ 13.00
J1956 LEVOFLOXACIN 250 MG $ 14.00
J2001 LIDOCAINE HCI 10MG $ 43.00
J2060 ATIVAN 2ML SYRUP $ 10.00
J2150 MANNITOL INJECTION $ 35.00
J2175 DEMEROL 50 MG SYRINGE $ 36.00
J2250 MIDAZOLAM HCI PER 1 MG $ 3.00
J2270 INJ MORPHINE SULFATE 10 M $ 11.00
J2300 NUBAIN 10MG AMP $ 23.00
J2310 INJ NALOXONE HCL 1MG $ 225.00
J2360 ORPHENADRINE CITRATE 60MG $ 165.00
J2370 NEO-SYNEPHRINE UP TO 1 ML $ 111.00
J2405 ONDANSETRON HCI, PER MG $ 3.00
J2410 INJECTION, OXYMORPHONE HCI, UP TO 1 MG $ 33.00
J2543 ZOSYN – PIPERACILLIN/TAZOBACTAM $ 26.00
J2550 PHENERGAN 50 MG $ 16.00
J2650 PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML $ 8.00
J2690 PRONESTYL 10 ML $ 29.00
J2704 INJECTION, PROPOFOL, 10MG $ 3.00
J2730 PRALIDOXINE CHLORIDE $ 29.00
J2760 PHENTOLAINE MESYLATE INJ $ 55.00
J2765 METOCLOPRAMIDE HCL 10MG $ 10.00
J2780 INJ RANITIDINE 25 MG $ 35.00
J2790 RHOGAM INJECTION $ 660.00
J2920 SOLU-MEDROL 40MG $ 40.00
J2930 SOLU-MEDROL 125 MG $ 59.00
J3010 INJ FENTANYL CITRATE .1MG $ 8.00
J3030 IMITREX 6MG VIAL $ 165.00
J3101 INJECTION, TENECTEPLASE, 1 MG. $ 978.00
J3105 INJECTION, TREBUTALINE SULFATE, UP TO 1 MG $ 48.00
J3130 TESTOSTERONE ENANTHATE INJ $ 33.00
J3260 TOBRAMYCIN SULFATE INJECTION $ 49.00
J3301 INJECTION, TRIAMCINOLONE ACETONIDE 10 MG $ 16.00
J3360 VALIUM INJ 5 MG $ 56.00
J3370 VANCOMYCIN HCI INJ 500MG $ 79.00
J3410 VISTERIL INJ 50 MG $ 56.00
J3411 INJ THIAMINE 100 MG $ 33.00
J3430 INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG $ 18.00
J3475 MAGNESIUM SULFATE 2CC AMP $ 8.00
J3480 POTASSIUM CHLORIDE 2 MG $ 3.00
J3486 GEODON – ZIPRASIDONE MESYLATE 10MG $ 48.00
J3490 UNCLASSIFIED DRUGS $ 49.00
J3535 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER $ 79.00
J7030 INFUS NORM SALINE 1000CC $ 38.00
J7040 INFUS NORM SALINE 500ML $ 20.00
J7042 5% DEXTROSE $ 23.00
J7044 INJECTION, CIPROFLOXACIN FOR IV INFUSION $ 118.00
J7050 INFS NORM SALINE 250CC $ 10.00
J7060 INFUSION D5W 250ML $ 38.00
J7070 INFUSION, D-5W, 1000 CC $ 74.00
J7120 RINGER’S LACTATE INFUS $ 45.00
J7130 HYPERTONIC SALINE SOLUTION $ 200.00
J7506 PREDNISONE ORAL 5 MG $ 10.00
J7510 PREDNISOLONE ORAL 5 MG $ 3.00
J7607 LEVALBUTEROL COMP CON $ 35.00
J7610 ALBUTEROL, THRU DME 1MG $ 20.00
J7611 ALBUTEROL 1MG CONC INHALA $ 20.00
J7614 ALBUTEROL ALL FOMULATIONS $ 3.00
J7615 LEVALBTERAL INHALATION SO $ 25.00
J7620 ALBUTEROL 2.5 MG ATROVENT $ 3.00
J7644 IPRATROPIUM BROMIDE INHAL $ 5.00
J7645 IPRATROPIUM BROMIDE COMP $ 33.00
J7699 NOC DRUGS INHAL SOL ADMIN $ 13.00
J8498 ENEMA SUPPOSITORY, ANTIEMETIC RECTAL $ 25.00
J8499 NONCHEMOTHERAPEUTIC ORAL $ 24.00
J8540 DEXAMETHASONE, ORAL .25MG $ 3.00
J9027 CLOFARALINE INJECTION $ 189.00
L0120 CERVICAL FLEX NONADJ COLL $ 121.00
L0172 CLAVICAL COLLAR 2 PC $ 55.00
L1630 ABDUCT CONTROL HIP SEMI FLEX $ 55.00
L1830 KNEE IMMOBOLIZER $ 111.00
L1906 ANKLE SUPPORT $ 118.00
L3260 SURGICAL BOOT/SHOE $ 56.00
L3650 SO FIGURE EIGHT ABDUCTION $ 104.00
L3660 SHOULDER ORTHOSIS $ 219.00
L3807 WRIST HAND FINGER ORHTOSIS, WITHOUT JOINT COLLES SPLINT $ 76.00
L3908 WRIST EXTN CONTROL COCKUP $ 56.00
L3999 UPPER LIMB ORTHOSIS NOS $ 236.00
L4350 AIR SPLINT $ 489.00
L4360 WALK BOOT PNEUMATIC $ 156.00
L4361 WALKING BOOT, PNEUMATIC AND/OR VACUUM W OR W/O JOINTS, INTERFACE MATERIAL $ 173.00
L4380 PNEUMATIC KNEE SPLINT $ 170.00
L4386 WALKING BOOT NON PNEUMATIC $ 229.00
P7001 CULTURE BACTERIAL URINE $ 121.00
P9612 CATHETERIZE FOR URINE $ 240.00
Q0111 WET MOUNTS WITH PREPARATION $ 174.00
Q0144 AZITH DIHY ORAL CAP/POWD $ 218.00
Q0179 ONDANESTRONG HCL 8MG ORL $ 41.00
Q2009 FOSPHENYTOIN INJECTION $ 93.00
Q4006 LONG ARM CAST ADULT $ 156.00
Q4007 CAST SUPPLIES LONG ARM CA $ 180.00
Q4008 CAST SUPPLIES LONG ARM $ 180.00
Q4009 CAST SUPPLIES SHORT ARM $ 188.00
Q4010 SHORT ARM CAST ADULT $ 180.00
Q4012 CAST SUPPLIES SHORT ARM $ 180.00
Q4020 LNG ARM SPLNT 0-10 YRS $ 169.00
Q4022 SHRT ARM SPLNT 11 YRS + $ 186.00
Q4034 CAST SUP LNG LEG CYLINDER FB $ 236.00
Q4037 CAST SUPPLIES SHORT LEG $ 198.00
Q4038 CAST SUP SHRT LEG FIBERGLASS $ 80.00
Q4039 CAST SUPPLIES SHORT LEG C $ 198.00
Q4042 LNG ARM SPLNT 11 YRS + $ 156.00
Q4046 SHRT LG SPLNT 11 YRS + $ 179.00
Q4049 FINGER SPLNT STATIC $ 123.00
Q4051 SPLINT SUPPLIES MISC $ 170.00
Q9954 ORAL MR CONTRAST, 100ML $ 561.00
Q9963 HI OSM CONTRST MATL 350-3 $ 46.00
Q9965 LOW OSMOLAR CON MAT PER M $ 34.00
Q9966 LOCM 200-299MG ML IODINE, 1ML $ 44.00
Q9967 LOW OSMOLAR CNTRS MAT $ 1.00
S0020 INJ, BUPIVICAINE, 30ML $ 64.00
S0028 INJECT SAMOTIDINE 20 MG $ 96.00
S0030 METRONIDAZOLE 500 MG INJ $ 46.00
S0077 CLANDAMYCIN PHOSPHATE 300 $ 43.00
S0119 ZOFRAN, 4MG, ORAL $ 30.00
S0164 PROTONIX PANTROPRAZOLE 40MG $ 104.00
S0622 PHYS EXAM FOR COLLEGE $ 119.00
S0630 RMV SUTURES; PHYS NOT PHY $ 86.00
S3000 BILAT DIL RETINAL EXAM $ 15.00
S5000 PRESCRIPTION DRUG GENERIC $ 6.00
S5001 PRESCRIPTION DRUG BAND NM $ 10.00
S5010 STERILE SALINE 5% DEXTROSE AND 0.45% SALINE $ 313.00
S5011 5% DEXTROSE 1000 ML $ 13.00
S5550 INSULIN RAPID 5 U $ 36.00
S8037 MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY $ 1,730.00
S8100 SPACER WITHOUT MASK $ 41.00
S8101 MASK NEBULIZER MASK SPACER WITH MASK $ 79.00
S8430 PADDING FOR COMPRESSION BANDAGE, ROLL $ 21.00
S8450 SPLINT $ 114.00
S8451 SPLINT, WRIST OR ANKLE $ 155.00
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