List of Charges
| Facility Fee | |
| The Median facility fee for Ascent Emergency Medical Center is $ 2592.00 | |
| Level Of Service | Facility Fee |
| Emergency Dept Visit Level 1 | $767.60 |
| Emergency Dept Visit Level 2 | $1,200.00 |
| Emergency Dept Visit Level3 | $2,350.00 |
| Emergency Dept Visit Level 4 | $3,645.00 |
| Emergency Dept Visit Level 5 | $5,000.00 |
| Level Of Service | Range of Possible Fees |
| Emergency Dept Visit Level 1 | Less than $800.00 |
| Emergency Dept Visit Level 2 | Less than $1500.00 |
| Emergency Dept Visit Level3 | Less than $2500.00 |
| Emergency Dept Visit Level 4 | Less than $4000.00 |
| Emergency Dept Visit Level 5 | Less than $6000.00 |
| Observation Fees | |
| Median Observation Fee | $2,000.00 |
| Range of Observation Fees | More Than $2000.00 |
| Observation Fee for Level of Service | $2,000.00 |
| CPT Code | CPT Short Description | CPT Default Price |
| 0097U | Gastrointestinal pathogen, multiplex reverse transcription … | $1,270.64 |
| 0202U | Infectious disease (bacterial or viral respiratory tract in… | $1,500.00 |
| 10060 | INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE | $1,100.00 |
| 10061 | INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE | $1,350.00 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $1,100.00 |
| 10120 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE | $1,100.00 |
| 10121 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL | $1,350.00 |
| 10180 | Incision and drainage, complex, postoperative wound infecti… | $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 | $436.00 |
| 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 |
| 12034 | Repair, intermediate, wounds of scalp, axillae, trunk and/o… | $2,062.00 |
| 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 |
| 13121 | REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5 CM | $1,872.74 |
| 13122 | REPAIR COMPLEX SCALP/ARM/LEG EA 5 CM/< | $804.92 |
| 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axill… | $2,247.00 |
| 13151 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM | $1,598.18 |
| 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 | $504.00 |
| 16020 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL | $995.00 |
| 17250 | Chemical cauterization of granulation tissue | $656.00 |
| 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 ma… | $1,120.00 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $3,016.00 |
| 21320 | Closed treatment of nasal bone fracture; with stabilization | $9,964.00 |
| 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 |
| 24675 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ | $4,670.38 |
| 25600 | Closed treatment of distal radial fracture (eg, Colles or S… | $1,133.00 |
| 25605 | CLOSED TREATMENT OF DISTAL RADIUS OR EPIPHYSEAL SEPARATION | $2,843.84 |
| 26010 | DRAINAGE FINGER ABSCESS SIMPLE | $999.00 |
| 26605 | CLTX METACARPAL FX W/MANIPULATION EACH BONE | $1,200.00 |
| 26641 | Closed treatment of carpometacarpal dislocation, thumb, wit… | $1,081.00 |
| 26720 | CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR … | $951.13 |
| 26750 | CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA | $1,080.00 |
| 26755 | Closed treatment of distal phalangeal fracture, finger or t… | $1,488.00 |
| 26775 | Closed treatment of interphalangeal joint dislocation, sing… | $2,657.00 |
| 27252 | CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA | $1,500.00 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $4,500.00 |
| 28190 | REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS | $1,320.00 |
| 28470 | closed treatment of metatarsal fracture;without manipulatio… | $1,272.89 |
| 28510 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ | $850.00 |
| 28630 | CLTX METATARSOPHLNGL JT DISLC W/O ANES | $1,428.60 |
| 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 |
| 29260 | Strapping Of Elbow Or Wrist | $400.00 |
| 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 |
| 29705 | Removal or bivalving; full arm or full leg cast | $708.00 |
| 29840 | Arthroscopy, wrist, diagnostic, with or without synovial bi… | $6,319.00 |
| 30300 | REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE | $1,300.00 |
| 30901 | CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE | $872.00 |
| 30903 | Control nasal hemorrhage, anterior, complex (extensive caut… | $1,098.00 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $1,325.00 |
| 3120F | 12-LEAD ECG PERFORMED | $250.00 |
| 31500 | Intubation, endotracheal, emergency procedure | $388.00 |
| 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 | $100.00 |
| 36416 | COLLECTION CAPILLARY BLOOD SPECIMEN | $595.00 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $1,318.48 |
| 43215 | Esophagoscopy, flexible, transoral; with removal of foreign… | $4,588.00 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $2,050.00 |
| 46040 | Incision and drainage of ischiorectal and/or perirectal abs… | $5,901.00 |
| 46083 | INCISION THROMBOSED HEMORRHOID EXTERNAL | $653.00 |
| 51702 | INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE | $1,100.00 |
| 51703 | INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED | $1,110.00 |
| 56420 | I&D OF BARTHOLINS GLAND ABSC | $1,282.00 |
| 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $1,115.00 |
| 59025 | FETAL NON-STRESS TEST | $950.00 |
| 62270 | Spinal puncture, lumbar, diagnostic; | $1,502.00 |
| 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 | $3,378.00 |
| 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 | $5,500.00 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $5,729.50 |
| 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 | $5,270.00 |
| 70491 | CT SOFT TISSUE NECK W/CONTRAST MATERIAL | $6,065.00 |
| 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 | $6,620.00 |
| 70551 | MRI BRN BRN STEM C-MATRL | $403.10 |
| 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 | $1,215.00 |
| 71046 | Radiologic examination, chest ; 2 views | $1,575.00 |
| 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 | $1,225.00 |
| 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 | $6,224.00 |
| 71260 | CT THORAX W/CONTRAST MATERIAL | $6,517.00 |
| 71270 | CT THORAX W/O & W/CONTRAST MATERIAL | $5,600.00 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $6,300.00 |
| 72020 | RADEX SPINE 1 VIEW SPECIFY LEVEL | $2,200.00 |
| 72040 | RADEX SPINE CERVICAL 2 OR 3 VIEWS | $1,040.00 |
| 72050 | RADEX SPINE CERVICAL 4 OR 5 VIEWS | $1,950.65 |
| 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 | $1,165.00 |
| 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 | $6,421.00 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $6,963.00 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $5,800.00 |
| 72128 | CT THORACIC SPINE W/O CONTRAST MATERIAL | $5,834.00 |
| 72129 | CT THORACIC SPINE W/CONTRAST MATERIAL | $6,044.00 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $5,500.00 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $6,479.00 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $7,000.00 |
| 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 | $1,700.21 |
| 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 |
| 73092 | Radiologic examination; upper extremity, infant, minimum of… | $646.00 |
| 73100 | RADEX WRIST 2 VIEWS | $755.00 |
| 73110 | RADEX WRIST COMPLETE MINIMUM 3 VIEWS | $2,500.00 |
| 73120 | RADEX HAND 2 VIEWS | $2,100.00 |
| 73130 | RADEX HAND MINIMUM 3 VIEWS | $1,515.33 |
| 73140 | RADEX FINGR MINIMUM 2 VIEWS | $825.78 |
| 73200 | CT UPPER EXTREMITY W/O CONTRAST MATERIAL | $5,400.00 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $5,500.00 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $5,600.00 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $775.00 |
| 73502 | RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS | $1,375.81 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $2,400.00 |
| 73510 | X-RAY HIP UNILATERAL 2 VIEWS | $1,650.00 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $2,500.00 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $1,100.00 |
| 73552 | RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS | $1,950.00 |
| 73560 | RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS | $1,260.00 |
| 73562 | RADIOLOGIC EXAMINATION KNEE 3 VIEWS | $1,425.00 |
| 73564 | RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS | $2,500.00 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOSTC | $2,650.00 |
| 73590 | RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS | $2,300.00 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $2,400.00 |
| 73600 | RADIOLOGIC EXAMINATION ANKLE 2 VIEWS | $2,400.00 |
| 73610 | RADEX ANKLE COMPLETE MINIMUM 3 VIEWS | $2,500.00 |
| 73620 | RADIOLOGIC EXAMINATION FOOT 2 VIEWS | $2,100.00 |
| 73630 | RADEX FOOT COMPLETE MINIMUM 3 VIEWS | $1,535.97 |
| 73650 | RADEX CALCANEUS MINIMUM 2 VIEWS | $2,300.00 |
| 73660 | RADEX TOE MINIMUM 2 VIEWS | $835.75 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $6,500.00 |
| 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $6,490.00 |
| 73721 | MRI right knee without contrast | $7,405.00 |
| 74000 | RADEX ABDOMEN 1 ANTEROPOSTERIOR VIEW | $2,250.00 |
| 74018 | Radiologic examination, abdomen; 1 view | $825.00 |
| 74019 | Radiologic examination, abdomen; 2 views | $1,130.00 |
| 74020 | RADEX ABDOMEN COMPL W/DCBTS&/ERC VIEWS | $2,500.00 |
| 74021 | Radiologic examination, abdomen; 3 or more views | $2,000.00 |
| 74022 | RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH | $1,900.00 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $5,785.00 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $6,457.00 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $7,550.00 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $8,500.00 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $6,395.00 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $9,500.00 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $10,500.00 |
| 74178 | CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE | $5,700.00 |
| 74190 | PERITONEOGRAM RS&I | $2,400.00 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $2,300.00 |
| 74241 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB | $2,400.00 |
| 74245 | RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES | $2,250.00 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $2,200.00 |
| 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 | $2,600.00 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $1,200.00 |
| 74440 | VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I | $2,300.00 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $5,500.00 |
| 76536 | US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM | $2,300.00 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $2,100.00 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,500.00 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $1,000.00 |
| 76700 | US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION | $2,500.00 |
| 76705 | US ABDOMINAL REAL TIME W/IMAGE LIMITED | $3,250.00 |
| 76770 | US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE | $1,650.00 |
| 76775 | US RETROPERITONEAL REAL TIME W/IMAGE LIMITED | $2,350.00 |
| 76801 | US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT | $2,100.00 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $980.00 |
| 76805 | US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION | $2,200.00 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,400.00 |
| 76815 | US PG UTER R-T IMG LMTD 1+ FETUSES | $175.02 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $1,500.00 |
| 76817 | US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG | $2,400.00 |
| 76830 | US TRANSVAGINAL | $2,600.00 |
| 76856 | US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE | $2,500.00 |
| 76857 | US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U | $2,200.00 |
| 76870 | US SCROTUM & CONTENTS | $2,800.00 |
| 76881 | US EXTREMITY NON-VASC REAL-TIME IMG COMPL | $2,400.00 |
| 76882 | US EXTREMITY NON-VASC REAL-TIME IMG LMTD | $800.00 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $850.00 |
| 80048 | BASIC METABOLIC PANEL CALCIUM TOTAL | $810.00 |
| 80051 | ELECTROLYTE PANEL | $487.55 |
| 80053 | COMPREHENSIVE METABOLIC PANEL | $1,250.00 |
| 80061 | LIPID PANEL | $750.00 |
| 80074 | Hepatitis Panel, Acute | $540.00 |
| 80076 | HEPATIC FUNCTION PANEL | $804.00 |
| 80084 | PITUITARY PANEL | $1,000.00 |
| 80102 | Drug confirmation, each procedure | $250.00 |
| 80165 | DRUG SCREEN QUANT DIPROPYLACETIC ACID FREE | $192.28 |
| 80305 | DRUG TEST PRSMV QUAL DIR OPTICAL OBS PER DAY | $400.00 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $360.45 |
| 80320 | DRUG SCREEN QUANTITATIVE ALCOHOLS | $545.00 |
| 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $580.00 |
| 80329 | DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2 | $550.00 |
| 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $230.00 |
| 80345 | DRUG SCREENING BARBITURATES | $580.00 |
| 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $580.00 |
| 80347 | DRUG SCREENING BENZODIAZEPINES 13 OR MORE | $450.00 |
| 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $420.00 |
| 80351 | DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 | $600.00 |
| 80352 | DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE | $178.00 |
| 80353 | DRUG SCREENING COCAINE | $625.00 |
| 80356 | DRUG SCREENING HEROIN METABOLITE | $110.00 |
| 80358 | DRUG SCREENING METHADONE | $550.00 |
| 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $560.00 |
| 80361 | DRUG SCREENING OPIATES 1 OR MORE | $570.00 |
| 80362 | DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 | $500.00 |
| 80365 | DRUG SCREENING OXYCODONE | $550.00 |
| 80366 | DRUG SCREENING PREGABALIN | $250.00 |
| 80367 | DRUG SCREENING PROPOXYPHENE | $225.00 |
| 80373 | DRUG SCREENING TRAMADOL | $400.00 |
| 80374 | DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS | $420.00 |
| 81000 | URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY | $38.00 |
| 81001 | URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY | $430.00 |
| 81002 | URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP | $210.00 |
| 81003 | URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY | $375.00 |
| 81007 | Urinalysis; bacteriuria screen, except by culture or dipsti… | $111.88 |
| 81025 | URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS | $325.00 |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hyp… | $313.00 |
| 81400 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 | $706.00 |
| 82040 | ALBUMIN SERUM PLASMA/WHOLE BLOOD | $105.65 |
| 82075 | ASSAY OF ALCOHOL BREATH | $84.00 |
| 82077 | Alcohol (ethanol); any specimen except urine and breath, im… | $215.90 |
| 82150 | ASSAY OF AMYLASE | $265.00 |
| 82247 | BILIRUBIN TOTAL | $280.00 |
| 82248 | BILIRUBIN DIRECT | $300.00 |
| 82270 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER | $750.00 |
| 82271 | Blood, occult, by peroxidase activity (eg, guaiac), qualita… | $243.00 |
| 82272 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC | $850.00 |
| 82310 | CALCIUM TOTAL | $350.00 |
| 82330 | CALCIUM IONIZED | $360.00 |
| 82374 | CARBON DIOXIDE BICARBONATE | $370.00 |
| 82435 | CHLORIDE BLD | $295.00 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $330.00 |
| 82533 | CORTISOL TOTAL | $295.00 |
| 82550 | CREATINE KINASE TOT | $265.19 |
| 82553 | CREATINE KINASE MB FRACTION ONLY | $448.89 |
| 82565 | CREATININE BLOOD | $222.58 |
| 82747 | ASSAY OF FOLIC ACID RBC | $275.00 |
| 82784 | ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH | $590.00 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $510.00 |
| 82805 | Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (… | $400.00 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $395.00 |
| 82947 | GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP | $90.03 |
| 82948 | GLUCOSE BLOOD REAGENT STRIP | $490.00 |
| 82962 | GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE | $157.21 |
| 82977 | GGT – GLUTAMYLTRASE GAMMA | $116.97 |
| 83009 | HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE | $490.00 |
| 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $495.00 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $220.00 |
| 83037 | Hemoglobin; glycosylated (A1C) by device cleared by FDA for… | $95.00 |
| 83519 | IMMUNOASSAY ANALYTE QUANT RADIOIMMUNOASSAY | $213.10 |
| 83525 | ASSAY OF INSULIN TOTAL | $225.00 |
| 83690 | ASSAY OF LIPASE | $380.00 |
| 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $295.00 |
| 83874 | MYOGLOBIN | $195.97 |
| 83880 | NATRIURETIC PEPTIDE | $362.45 |
| 83992 | ASSAY OF PHENCYCLIDINE | $398.00 |
| 84075 | ASSAY OF PHOSPHATASE ALKALINE | $210.00 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $200.00 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $305.00 |
| 84155 | PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD | $265.00 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $280.00 |
| 84295 | SODIUM SERUM PLASMA OR WHOLE BLOOD | $265.00 |
| 84379 | Sugars (mono-, di-, and oligosaccharides); multiple quantit… | $90.00 |
| 84403 | Testosterone; total | $530.00 |
| 84436 | ASSAY OF THYROXINE TOTAL | $290.00 |
| 84439 | ASSAY OF FREE THYROXINE | $390.00 |
| 84450 | TRANSFERASE ASPARTATE AMINO AST SGOT | $255.00 |
| 84460 | TRANSFERASE ALANINE AMINO ALT SGPT | $200.00 |
| 84478 | ASSAY OF TRIGLYCERIDES | $600.00 |
| 84479 | THYROID HORM UPTK/THYROID HORMONE BINDING RATIO | $280.00 |
| 84480 | ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3 | $495.00 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $395.00 |
| 84484 | ASSAY OF TROPONIN QUANTITATIVE | $384.18 |
| 84512 | ASSAY OF TROPONIN QUALITATIVE | $275.00 |
| 84520 | ASSAY OF UREA NITROGEN QUANTITATIVE | $275.00 |
| 84550 | ASSAY OF BLOOD/URIC ACID | $390.00 |
| 84702 | GONADOTROPIN CHORIONIC QUANTITATIVE | $490.00 |
| 84703 | Gonadotropin, chorionic (hCG); qualitative | $315.00 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $250.00 |
| 85027 | BLOOD COUNT COMPLETE AUTOMATED | $280.00 |
| 85378 | D-DIMER – FIBRIN DGRADJ PRODUXS D-DIMER QUAL/SEMIQUAN | $450.00 |
| 85379 | FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE | $805.00 |
| 85610 | PROTHROMBIN TIME | $710.00 |
| 85651 | SEDIMENTATION RATE RBC NON-AUTOMATED | $490.00 |
| 85652 | SEDIMENTATION RATE RBC AUTOMATED | $110.00 |
| 85730 | THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD | $240.00 |
| 86038 | ANTINUCLEAR ANTIBODIES ANA | $250.00 |
| 86039 | ANTINUCLEAR ANTIBODIES ANA TITER | $350.00 |
| 86060 | ANTISTREPTOLYSIN O TITER | $120.00 |
| 86140 | C-REACTIVE PROTEIN | $340.00 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $480.00 |
| 86255 | FLUORESCENT NONNFCT AGT ANTB SCREEN EA ANTIBODY | $190.10 |
| 86308 | HETEROPHILE ANTIBODIES SCREEN | $325.00 |
| 86318 | Immunoassay for infectious agent antibodies, qualitative or… | $275.00 |
| 86328 | Immunoassay for infectious agent antibody(ies), qualitative… | $275.00 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $180.00 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $96.00 |
| 86593 | Syphilis test, non-treponemal antibody; quantitative | $44.21 |
| 86631 | Antibody; Chlamydia | $121.00 |
| 86664 | ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA | $241.27 |
| 86665 | ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA | $286.24 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $420.00 |
| 86689 | ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST | $300.00 |
| 86695 | ANTIBODY HERPES SMPLX TYPE 1 | $216.98 |
| 86696 | ANTIBODY HERPES SMPLX TYPE 2 | $80.00 |
| 86701 | Under Qualitative or Semiquantitative Immunoassays-Antibody | $450.00 |
| 86703 | ANTIBODY HIV-1&HIV-2 SINGLE RESULT | $225.45 |
| 86769 | Antibody; severe acute respiratory syndrome coronavirus 2 (… | $125.00 |
| 86780 | Antibody; Treponema pallidum | $33.00 |
| 86900 | Blood typing, serologic; ABO | $49.15 |
| 86901 | Blood typing, serologic; Rh (D) | $44.00 |
| 87040 | CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES | $320.00 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $620.00 |
| 87070 | CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL | $430.00 |
| 87075 | CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID | $490.00 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $350.00 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $480.00 |
| 87081 | CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ | $490.00 |
| 87086 | CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE | $300.00 |
| 87088 | CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE | $210.00 |
| 87110 | Culture, chlamydia, any source | $80.00 |
| 87169 | Macroscopic examination; parasite | $102.00 |
| 87177 | Ova and parasites, direct smears, concentration and identif… | $240.00 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $250.00 |
| 87210 | SMR PRIM SRC WET MOUNT NFCT AGT | $139.32 |
| 87324 | CLOSTRIDIUM AG EIA | $13.32 |
| 87328 | Infectious agent antigen detection by immunoassay technique… | $106.00 |
| 87338 | IAAD IA HPYLORI STOOL | $560.00 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $500.00 |
| 87389 | Infectious agent antigen detection by enzyme immunoassay te… | $225.81 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $380.00 |
| 87426 | Infectious agent antigen detection by immunoassay technique… | $275.00 |
| 87428 | severe acute respiratory syndrome coronavirus (eg,SARS-CoV,… | $875.00 |
| 87471 | Infectious agent detection by nucleic acid (DNA or RNA); Ba… | $800.00 |
| 87480 | Infectious agent detection by nucleic acid (DNA or RNA); Ca… | $60.00 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $68.75 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $525.00 |
| 87510 | Infectious agent detection by nucleic acid (DNA or RNA); Ga… | $90.00 |
| 87529 | IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ | $38.99 |
| 87581 | Infectious agent detection by nucleic acid (DNA or RNA) | $68.75 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $225.00 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $68.75 |
| 87635 | Infectious agent detection by nucleic acid (DNA or RNA); se… | $275.00 |
| 87636 | severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)… | $875.00 |
| 87660 | Infectious agent detection by nucleic acid (DNA or RNA); Tr… | $180.00 |
| 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $68.75 |
| 87804 | IAADIADOO INFLUENZA | $300.00 |
| 87806 | IAADIADOO HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES | $639.00 |
| 87807 | IAADIADOO RESPIRATORY SYNCTIAL VIRUS | $550.00 |
| 87808 | Infectious agent antigen detection by immunoassay with dire… | $147.00 |
| 87850 | Infectious agent antigen detection by immunoassay with dire… | $180.00 |
| 87880 | IAADIADOO STREPTOCOCCUS GROUP A | $820.00 |
| 87905 | Infectious agent enzymatic activity other than virus (eg, s… | $864.00 |
| 88161 | Cytopathology, smears, any other source; preparation, scree… | $270.00 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $325.00 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $490.00 |
| 90471 | IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE | $160.00 |
| 90658 | Influenza virus vaccine, trivalent, split virus, when admin… | $204.55 |
| 90700 | DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM | $72.52 |
| 90714 | TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE | $580.00 |
| 90715 | TDAP VACCINE 7 YRS/> IM | $540.00 |
| 90718 | TD – TETANUS & DIPHTHERIA TOXOIDS ADSORBED 7 YR + IM | $227.83 |
| 90756 | Influenza virus vaccine | $223.30 |
| 92950 | Cardiopulmonary resuscitation (eg, in cardiac arrest) | $1,928.00 |
| 92960 | Cardioversion, elective, electrical conversion of arrhythmi… | $4,069.00 |
| 93000 | ECG ROUTINE ECG W/LEAST 12 LDS W/I&R | $530.00 |
| 93005 | ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R | $690.00 |
| 93010 | ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY | $100.00 |
| 93040 | RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT | $710.00 |
| 93041 | RHYTHM ECG 1-3 LDS TRCG ONLY W/O I&R | $221.00 |
| 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $550.00 |
| 93224 | XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I | $800.00 |
| 93306 | ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLRD | $2,721.82 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $2,200.00 |
| 93631 | INTRAOP EPICAR& ENDOCAR PACG& MAPG | $650.00 |
| 93880 | DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY | $2,000.00 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $2,400.00 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $2,500.00 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $2,900.00 |
| 93926 | DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,150.00 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $2,650.00 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,550.00 |
| 93970 | DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY | $2,800.00 |
| 93971 | DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY | $2,500.00 |
| 93975 | DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM | $3,200.00 |
| 93976 | Duplex scan of arterial inflow and venous outflow of abdomi… | $1,130.44 |
| 94010 | Spirometry, including graphic record, total and timed vital… | $458.00 |
| 94014 | Patient-initiated spirometric recording per 30-day period o… | $385.00 |
| 94640 | PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT | $220.00 |
| 94760 | NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER | $280.00 |
| 94761 | NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER | $225.00 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $480.00 |
| 96360 | IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR | $725.25 |
| 96361 | IV INFUSION HYDRATION EACH ADDITIONAL HOUR | $449.00 |
| 96365 | IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | $711.00 |
| 96366 | IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR | $700.00 |
| 96367 | IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR | $990.00 |
| 96368 | IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS | $710.00 |
| 96372 | THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM | $341.95 |
| 96374 | THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG | $357.00 |
| 96375 | THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG | $374.00 |
| 96376 | THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC | $289.00 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $720.00 |
| 97010 | APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS | $120.00 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR | $580.00 |
| 97166 | Occupational therapy evaluation, moderate complexity, requi… | $657.00 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $430.00 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $920.00 |
| 99000 | Handling and/or conveyance of specimen for transfer from th… | $35.00 |
| 99001 | HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB | $61.88 |
| 99024 | POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX | $650.00 |
| 99053 | Service(s) provided between 10:00 PM and 8:00 AM at 24-hour… | $303.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $160.00 |
| 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 VISUAL ACUITY QUANTITATIVE BILAT | $1,300.00 |
| 99217 | OBSERVATION CARE DISCHARGE MANAGEMENT | $1,200.00 |
| 99218 | INITIAL OBSERVATION CARE/DAY 30 MINUTES | $1,800.00 |
| 99219 | INITIAL OBSERVATION CARE/DAY 50 MINUTES | $1,800.00 |
| 99220 | INITIAL OBSERVATION CARE/DAY 70 MINUTES | $1,800.00 |
| 99234 | OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES | $1,800.00 |
| 99235 | OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES | $2,763.06 |
| 99236 | OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES | $2,200.00 |
| 99281 | EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB | $767.60 |
| 99282 | EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY | $1,200.00 |
| 99283 | EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY | $2,350.00 |
| 99284 | EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY | $3,645.00 |
| 99285 | EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ | $5,000.00 |
| 99291 | CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN | $2,000.00 |
| 99292 | CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN | $762.00 |
| 99406 | TOBACCO USE CESSATION INTERMEDIATE 3-10 | $69.54 |
| A0382 | BASIC SUPPORT ROUTINE SUPPLS | $18.00 |
| A0394 | ALS IV DRUG THERAPY SUPPLIES | $1.02 |
| A0396 | ALS ESOPHAGEAL INTUB SUPPLS | $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 | STERILE NEEDLE | $10.75 |
| A4216 | STERILE WATER/SALINE, 10 ML | $3.00 |
| A4217 | STERILE WATER/SALINE, 500 ML | $22.80 |
| A4221 | SUPP NON-INSULIN INF CATH/WK | $20.00 |
| A4223 | INFUSION SUPPLIES W/O PUMP | $40.00 |
| A4224 | SUPPLY INSULIN INF CATH/WK | $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 | $10.00 |
| A4253 | BLOOD GLUCOSE/REAGENT STRIPS | $10.00 |
| 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 | CATH W/DRAINAGE 2-WAY LATEX | $44.00 |
| A4315 | CATH W/DRAINAGE 2-WAY SILCNE | $18.00 |
| A4322 | IRRIGATION SYRINGE | $15.00 |
| A4327 | FEM URINARY COLLECT DEV CUP | $10.00 |
| A4332 | LUBE STERILE PACKET | $12.00 |
| A4335 | INCONTINENCE SUPPLY | $3.00 |
| A4338 | INDWELLING CATHETER LATEX | $15.00 |
| A4344 | CATH INDW FOLEY 2 WAY SILICN | $146.00 |
| A4352 | COUDE TIP URINARY CATHETER | $20.00 |
| A4353 | INTERMITTENT URINARY CATH | $120.00 |
| A4358 | URINARY LEG OR ABDOMEN BAG | $12.50 |
| A4364 | ADHESIVE, LIQUID OR EQUAL | $12.61 |
| A4369 | SKIN BARRIER LIQUID PER OZ | $10.00 |
| A4402 | LUBRICANT PER OUNCE | $10.00 |
| A4406 | PECTIN BASED OSTOMY PASTE | $12.00 |
| A4450 | NON-WATERPROOF TAPE | $10.00 |
| A4452 | WATERPROOF TAPE | $12.00 |
| A4458 | REUSABLE ENEMA BAG | $25.00 |
| A4465 | NON-ELASTIC EXTREMITY BINDER | $20.00 |
| A4470 | GRAVLEE JET WASHER | $15.00 |
| A4550 | SURGICAL TRAYS | $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 | SLINGS | $20.00 |
| A4566 | SHOULD SLING/VEST/ABRESTRAIN | $25.00 |
| A4570 | SPLINT | $50.00 |
| A4580 | CAST SUPPLIES (PLASTER) | $35.00 |
| A4590 | SPECIAL CASTING MATERIAL | $40.00 |
| A4606 | OXYGEN PROBE USED W OXIMETER | $20.00 |
| A4613 | BATTERY CHARGER | $60.00 |
| A4615 | CANNULA NASAL | $20.00 |
| A4616 | TUBING (OXYGEN) PER FOOT | $25.00 |
| A4620 | VARIABLE CONCENTRATION MASK | $15.00 |
| A4628 | OROPHARYNGEAL SUCTION CATH | $20.00 |
| A4629 | TRACHEOSTOMY CARE KIT | $35.00 |
| A4649 | SURGICAL SUPPLIES | $40.00 |
| A4653 | PD CATHETER ANCHOR BELT | $20.00 |
| A4657 | SYRINGE W/WO NEEDLE | $10.00 |
| A4670 | AUTOMATIC BP MONITOR, DIAL | $30.00 |
| A4673 | EXT LINE W EASY LOCK CONNECT | $15.00 |
| A4750 | ART OR VENOUS BLOOD TUBING | $20.00 |
| A4770 | BLOOD COLLECTION TUBE/VACUUM | $25.00 |
| A4927 | NON-STERILE GLOVES | $10.00 |
| A4930 | STERILE, GLOVES PER PAIR | $12.00 |
| A5112 | URINARY LEG BAG | $20.00 |
| A5120 | SKIN BARRIER, WIPE OR SWAB | $12.00 |
| A5126 | DISK/FOAM PAD +OR- ADHESIVE | $15.00 |
| A6021 | COLLAGEN DRESSING <=16 SQ IN | $15.00 |
| A6196 | ALGINATE DRESSING <=16 SQ IN | $20.00 |
| A6203 | COMPOSITE DRSG <=16 SQ IN | $15.00 |
| A6208 | CONTACT LAYER > 48 SQ IN | $20.00 |
| A6209 | FOAM DRSG <=16 SQ IN W/O BDR | $15.00 |
| A6212 | FOAM DRG <=16 SQ IN W/BORDER | $15.00 |
| A6216 | NON-STERILE GAUZE<=16 SQ IN | $10.00 |
| A6217 | NON-STERILE GAUZE>16<=48 SQ | $12.00 |
| A6218 | NON-STERILE GAUZE > 48 SQ IN | $15.00 |
| A6219 | GAUZE <=16 SQ IN W/BORDER | $10.00 |
| A6220 | GAUZE >16 <=48 SQ IN W/BORDR | $12.00 |
| A6221 | GAUZE > 48 SQ IN W/BORDER | $15.00 |
| A6222 | GAUZE <=16 IN NO W/SAL W/O B | $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 | HYDROGEL DSG<=16 SQ IN | $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 MOISTURIZR | $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 ANY TYPE/SIZE | $150.27 |
| A6266 | IMPREG GAUZE NO H20/SAL/YARD | $22.00 |
| A6402 | STERILE GAUZE <=16 SQ IN | $15.00 |
| A6403 | STERILE GAUZE>16 <=48 SQ IN | $15.00 |
| A6404 | STERILE GAUZE > 48 SQ IN | $18.00 |
| A6407 | PACKING STRIPS, NON-IMPREG | $15.00 |
| A6412 | OCCLUSIVE EYE PATCH | $15.00 |
| A6413 | ADHESIVE BANDAGE, FIRST-AID | $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 | CONFORM BAND S W>=3 <5/YD | $15.00 |
| A6447 | CONFORM BAND S W >=5/YD | $18.00 |
| A6448 | LT COMPRES BAND <3/YD | $12.00 |
| A6449 | LT COMPRES BAND >=3 <5/YD | $15.00 |
| A6450 | LT COMPRES BAND >=5/YD | $18.00 |
| A6453 | SELF-ADHER BAND W <3/YD | $25.00 |
| A6454 | SELF-ADHER BAND W>=3 <5/YD | $12.00 |
| A6455 | SELF-ADHER BAND >=5/YD | $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 | TUBING USED W SUCTION PUMP | $40.00 |
| A7003 | NEBULIZER ADMINISTRATION SET | $35.00 |
| A7004 | DISPOSABLE NEBULIZER SML VOL | $35.00 |
| A7005 | NONDISPOSABLE NEBULIZER SET | $30.00 |
| A7006 | FILTERED NEBULIZER ADMIN SET | $25.00 |
| A7015 | AEROSOL MASK USED W NEBULIZE | $25.00 |
| A7030 | CPAP FULL FACE MASK | $20.00 |
| A7046 | REPL WATER CHAMBER, PAP DEV | $30.00 |
| A7047 | RESP SUCTION ORAL INTERFACE | $25.00 |
| A9150 | MISC/EXPER NON-PRESCRIPT DRU | $35.00 |
| A9270 | NON-COVERED ITEM OR SERVICE | $50.00 |
| A9273 | HOT/COLD BOTLE/CAP/COL/WRAP | $35.00 |
| A9281 | REACHING/GRABBING DEVICE | $80.00 |
| C1722 | AICD, SINGLE CHAMBER | $400.00 |
| C1751 | CATH, INF, PER/CENT/MIDLINE | $450.00 |
| C1781 | MESH (IMPLANTABLE) | $200.00 |
| C2618 | PROBE/NEEDLE, CRYO | $35.00 |
| C9285 | PATCH, LIDOCAINE/TETRACAINE | $20.00 |
| E0110 | CRUTCH FOREARM PAIR | $225.00 |
| E0114 | CRUTCH UNDERARM PAIR NO WOOD | $250.00 |
| E0116 | CRUTCH UNDERARM EACH NO WOOD | $200.00 |
| 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 |
| E0445 | OXIMETER NON-INVASIVE | $187.50 |
| E0570 | NEBULIZER WITH COMPRESSION | $200.00 |
| E0607 | BLOOD GLUCOSE MONITOR HOME | $80.00 |
| E0625 | PATIENT LIFT BATHROOM OR TOI | $200.00 |
| E2630 | MONOSUSPENSION ARM/HAND SUPP | $3,379.10 |
| G0168 | WOUND CLOSURE BY ADHESIVE | $20.00 |
| G0378 | HOSPITAL OBSERVATION PER HR | $2,000.00 |
| G0402 | INITIAL PREVENTIVE EXAM | $1,500.00 |
| G2023 | LABORATORY – GENERAL CLASSIFICATION | $30.00 |
| 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 | ACETAMINOPHEN INJECTION | $30.00 |
| J0153 | ADENOSINE INJ 1MG | $40.00 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $30.00 |
| J0282 | AMIODARONE HCL | $25.00 |
| J0290 | AMPICILLIN 500 MG INJ | $50.00 |
| J0360 | HYDRALAZINE HCL INJECTION | $30.00 |
| J0456 | AZITHROMYCIN | $25.00 |
| J0461 | ATROPINE SULFATE INJECTION | $20.00 |
| J0500 | DICYCLOMINE INJECTION | $45.00 |
| J0561 | PENICILLIN G BENZATHINE INJ | $30.00 |
| J0610 | CALCIUM GLUCONATE INJECTION | $30.00 |
| J0690 | CEFAZOLIN SODIUM INJECTION | $25.00 |
| J0696 | CEFTRIAXONE SODIUM INJECTION | $30.00 |
| J0697 | STERILE CEFUROXIME INJECTION | $25.00 |
| J0735 | CLONIDINE HYDROCHLORIDE | $25.00 |
| J0744 | CIPROFLOXACIN IV | $30.00 |
| J1020 | METHYLPREDNISOLONE 20 MG INJ | $20.00 |
| J1030 | METHYLPREDNISOLONE 40 MG INJ | $22.00 |
| J1040 | METHYLPREDNISOLONE 80 MG INJ | $25.00 |
| J1094 | INJ DEXAMETHASONE ACETATE | $32.53 |
| J1100 | DEXAMETHASONE SODIUM PHOS | $21.00 |
| J1170 | HYDROMORPHONE INJECTION | $35.00 |
| J1200 | DIPHENHYDRAMINE HCL INJECTIO | $20.00 |
| J1610 | GLUCAGON HYDROCHLORIDE/1 MG | $50.00 |
| J1630 | HALOPERIDOL INJECTION | $39.70 |
| J1631 | HALOPERIDOL DECANOATE INJ | $45.00 |
| J1642 | INJ HEPARIN SODIUM PER 10 U | $20.00 |
| J1644 | INJ HEPARIN SODIUM PER 1000U | $30.00 |
| J1650 | INJ ENOXAPARIN SODIUM | $25.00 |
| J1741 | IBUPROFEN INJECTION | $22.00 |
| J1810 | DROPERIDOL/FENTANYL INJ | $25.00 |
| J1815 | INSULIN INJECTION | $20.00 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $22.00 |
| J1885 | KETOROLAC TROMETHAMINE INJ | $20.00 |
| J1930 | LANREOTIDE INJECTION | $45.00 |
| J1940 | FUROSEMIDE INJECTION | $35.00 |
| J1956 | LEVOFLOXACIN INJECTION | $45.00 |
| J2001 | LIDOCAINE INJECTION | $30.00 |
| J2060 | LORAZEPAM INJECTION | $35.00 |
| J2175 | MEPERIDINE HYDROCHL /100 MG | $25.00 |
| J2180 | MEPERIDINE/PROMETHAZINE INJ | $30.00 |
| J2250 | INJ MIDAZOLAM HYDROCHLORIDE | $30.00 |
| J2270 | MORPHINE SULFATE INJECTION | $30.00 |
| J2274 | INJ MORPHINE PF EPID ITHC | $30.00 |
| J2360 | ORPHENADRINE INJECTION | $30.00 |
| J2405 | ONDANSETRON HCL INJECTION | $21.00 |
| J2410 | OXYMORPHONE HCL INJECTION | $25.00 |
| J2425 | PALIFERMIN INJECTION | $25.00 |
| J2504 | PEGADEMASE BOVINE, 25 IU | $25.00 |
| J2543 | PIPERACILLIN/TAZOBACTAM | $30.00 |
| J2550 | PROMETHAZINE HCL INJECTION | $35.00 |
| J2704 | INJ, PROPOFOL, 10 MG | $22.00 |
| J2765 | METOCLOPRAMIDE HCL INJECTION | $30.00 |
| J2780 | RANITIDINE HYDROCHLORIDE INJ | $20.00 |
| J2800 | METHOCARBAMOL INJECTION | $50.00 |
| J2920 | METHYLPREDNISOLONE INJECTION | $32.00 |
| J2930 | METHYLPREDNISOLONE INJECTION | $35.00 |
| J3010 | FENTANYL CITRATE INJECTION | $33.00 |
| J3030 | SUMATRIPTAN SUCCINATE / 6 MG | $50.00 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $50.00 |
| J3360 | DIAZEPAM INJECTION | $25.00 |
| J3370 | VANCOMYCIN HCL INJECTION | $30.00 |
| J3430 | VITAMIN K PHYTONADIONE INJ | $50.00 |
| J3475 | INJ MAGNESIUM SULFATE | $20.00 |
| J3480 | INJ POTASSIUM CHLORIDE | $125.00 |
| J3490 | DRUGS UNCLASSIFIED INJECTION | $31.00 |
| J7030 | NORMAL SALINE SOLUTION INFUS | $45.00 |
| J7040 | NORMAL SALINE SOLUTION INFUS | $40.00 |
| J7042 | 5% DEXTROSE/NORMAL SALINE | $45.00 |
| J7050 | NORMAL SALINE SOLUTION INFUS | $48.00 |
| J7070 | D5W INFUSION | $20.00 |
| J7120 | RINGERS LACTATE INFUSION | $50.00 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $50.00 |
| J7131 | HYPERTONIC SALINE SOL | $20.00 |
| J7192 | FACTOR VIII RECOMBINANT NOS | $20.00 |
| J7313 | FLUOCINOL ACET INTRAVIT IMP | $20.00 |
| J7510 | PREDNISOLONE ORAL PER 5 MG | $15.00 |
| J7512 | PREDNISONE IR OR DR ORAL 1MG | $11.25 |
| J7611 | ALBUTEROL NON-COMP CON | $35.00 |
| J7613 | ALBUTEROL NON-COMP UNIT | $35.00 |
| J7614 | LEVALBUTEROL NON-COMP UNIT | $35.00 |
| J7615 | LEVALBUTEROL COMP UNIT | $35.00 |
| J7620 | ALBUTEROL IPRATROP NON-COMP | $35.00 |
| J7631 | CROMOLYN SODIUM NONCOMP UNIT | $20.00 |
| J7637 | DEXAMETHASONE COMP CON | $20.00 |
| J7644 | IPRATROPIUM BROMIDE NON-COMP | $50.00 |
| J7682 | TOBRAMYCIN NON-COMP UNIT | $25.00 |
| J7699 | INHALATION SOLUTION FOR DME | $25.00 |
| J8498 | ANTIEMETIC RECTAL/SUPP NOS | $25.00 |
| J8499 | ORAL PRESCRIP DRUG NON CHEMO | $25.00 |
| J9206 | IRINOTECAN INJECTION | $25.00 |
| L0112 | CRANIAL CERVICAL ORTHOSIS | $250.00 |
| L0120 | CERV FLEX N/ADJ FOAM PRE OTS | $350.00 |
| L0150 | CERV SEMI-RIG ADJ MOLDED CHN | $150.00 |
| L0172 | CERV COL SR FOAM 2PC PRE OTS | $150.00 |
| L0174 | CERV SR 2PC THOR EXT PRE OTS | $300.00 |
| L1810 | KO ELASTIC WITH JOINTS | $750.00 |
| L1830 | KO IMMOB CANVAS LONG PRE OTS | $500.00 |
| L1902 | AFO ANKLE GAUNTLET PRE OTS | $20.00 |
| L1971 | AFO W/ANKLE JOINT, PREFAB | $473.02 |
| L2134 | KAFO FEM FX CAST SEMI-RIGID | $2,136.66 |
| 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 | AMBULATORY SURGICAL BOOT EAC | $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 8 ABD RESTRAINT PRE OTS | $90.00 |
| L3660 | SO 8 AB RSTR CAN/WEB PRE OTS | $375.00 |
| L3670 | SO ACRO/CLAV CAN WEB PRE OTS | $400.00 |
| L3720 | FOREARM/ARM CUFFS FREE MOTIO | $550.00 |
| L3808 | WHFO, RIGID W/O JOINTS | $600.00 |
| L3809 | WHFO W/O JOINTS PRE OTS | $700.00 |
| L3905 | WHO W/NONTORSION JNT(S) CF | $800.00 |
| L3906 | WHO W/O JOINTS CF | $900.00 |
| L3908 | WHO COCK-UP NONMOLDE PRE OTS | $150.00 |
| L4350 | ANKLE CONTROL ORTHO PRE OTS | $250.00 |
| L4360 | PNEUMAT WALKING BOOT PRE CST | $250.00 |
| L4361 | PNEUMA/VAC WALK BOOT PRE OTS | $250.00 |
| L4386 | NON-PNEUM WALK BOOT PRE CST | $250.00 |
| 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 |
| P9612 | CATHETERIZE FOR URINE SPEC | $60.00 |
| Q0144 | AZITHROMYCIN DIHYDRATE, ORAL | $15.00 |
| Q0169 | PROMETHAZINE HCL 12.5MG ORAL | $10.00 |
| Q4001 | CAST SUP BODY CAST PLASTER | $900.00 |
| Q4006 | CAST SUP LONG ARM ADULT FBRG | $950.00 |
| Q4018 | CAST SUP LNG ARM SPLINT FBRG | $320.00 |
| Q4019 | CAST SUP LNG ARM SPLNT PED P | $750.00 |
| Q4020 | CAST SUP LNG ARM SPLNT PED F | $620.00 |
| Q4021 | CAST SUP SHT ARM SPLINT PLST | $650.00 |
| Q4022 | CAST SUP SHT ARM SPLINT FBRG | $500.00 |
| Q4023 | CAST SUP SHT ARM SPLNT PED P | $525.00 |
| Q4024 | CAST SUP SHT ARM SPLNT PED F | $550.00 |
| Q4042 | CAST SUP LNG LEG SPLNT FBRGL | $800.00 |
| Q4046 | CAST SUP SHT LEG SPLNT FBRGL | $850.00 |
| Q4049 | FINGER SPLINT, STATIC | $100.00 |
| Q9962 | HOCM 300-349MG/ML IODINE,1ML | $60.00 |
| Q9963 | HOCM 350-399MG/ML IODINE,1ML | $40.00 |
| Q9967 | LOCM 300-399MG/ML IODINE,1ML | $30.00 |
| S0020 | INJECTION, BUPIVICAINE HYDRO | $55.00 |
| S0028 | INJECTION, FAMOTIDINE, 20 MG | $45.00 |
| S0030 | INJECTION, METRONIDAZOLE | $50.00 |
| S0077 | INJECTION, CLINDAMYCIN PHOSP | $48.00 |
| S0119 | ONDANSETRON 4 MG | $32.16 |
| S0164 | INJECTION PANTROPRAZOLE | $45.00 |
| S0630 | REMOVAL OF SUTURES | $300.00 |
| S1015 | IV TUBING EXTENSION SET | $30.00 |
| S5000 | PRESCRIPTION DRUG, GENERIC | $2.00 |
| S8100 | SPACER WITHOUT MASK | $38.00 |
| S8101 | SPACER WITH MASK | $40.00 |
| S8430 | PADDING FOR COMPRSSN BDG | $35.00 |
| S8431 | COMPRESSION BANDAGE | $45.00 |
| S8451 | SPLINT WRIST OR ANKLE | $125.00 |
| U0002 | Infectious agent detection by nucleic acid (DNA or RNA); se… | $275.00 |
| V2799 | MISC VISION ITEM OR SERVICE | $25.00 |