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 |
| CHARGE CODE | DESCRIPTION | CURRENT FEE |
| 10060 | INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE | $1,715.89 |
| 10061 | INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE | $2,452.29 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $5,028.25 |
| 10120 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE | $1,993.99 |
| 10180 | Incision and drainage, complex, postoperative wound infectio… | $7,063.88 |
| 11042 | DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< | $2,104.73 |
| 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $326.63 |
| 11730 | AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 | $1,176.21 |
| 11740 | EVACUATION SUBUNGUAL HEMATOMA | $1,206.22 |
| 11750 | EXCISION NAIL MATRIX PERMANENT REMOVAL | $2,734.11 |
| 11982 | REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT | $1,150.00 |
| 12001 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< | $1,525.60 |
| 12002 | SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM | $1,574.74 |
| 12004 | SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM | $1,722.89 |
| 12005 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM | $3,150.11 |
| 12011 | SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< | $2,024.57 |
| 12013 | SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM | $1,773.53 |
| 12014 | SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM | $2,182.75 |
| 12032 | REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM | $2,635.47 |
| 12041 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< | $1,928.71 |
| 12051 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< | $2,406.48 |
| 12052 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM | $2,677.12 |
| 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $3,749.15 |
| 13152 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM | $5,827.26 |
| 15850 | REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON | $895.00 |
| 16000 | INITIAL TX 1ST DEGREE BURN LOCAL TX | $1,292.07 |
| 16020 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL | $1,412.14 |
| 19000 | PUNCTURE ASPIRATION CYST BREAST | $1,584.13 |
| 19100 | BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX | $1,829.10 |
| 20600 | arthrocentesis of a small joint or bursa | $1,898.64 |
| 20605 | ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US | $1,644.09 |
| 20610 | aspiration (removal of fluid) from, or injection into, a maj… | $1,979.30 |
| 23550 | OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC | $890.00 |
| 23650 | CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES | $2,870.13 |
| 23665 | CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ | $4,875.00 |
| 24640 | CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ | $2,846.22 |
| 26010 | DRAINAGE FINGER ABSCESS SIMPLE | $1,698.37 |
| 26605 | CLTX METACARPAL FX W/MANIPULATION EACH BONE | $3,022.34 |
| 26750 | CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA | $2,179.47 |
| 27252 | CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA | $11,582.84 |
| 28190 | REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS | $2,725.67 |
| 28510 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MNPJ | $1,337.17 |
| 28660 | CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES | $1,926.60 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $852.15 |
| 29086 | APPLICATION CAST FINGER | $920.00 |
| 29105 | APPLICATION LONG ARM SPLINT SHOULDER HAND | $1,503.79 |
| 29125 | APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC | $573.17 |
| 29130 | APPLICATION FINGER SPLINT STATIC | $586.82 |
| 29131 | APPLICATION FINGER SPLINT DYNAMIC | $560.00 |
| 29240 | STRAPPING SHOULDER | $989.88 |
| 29280 | STRAPPING HAND/FINGER | $611.89 |
| 29450 | APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG | $1,150.00 |
| 29505 | APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES | $434.12 |
| 29515 | APPLICATION SHORT LEG SPLINT CALF FOOT | $469.17 |
| 29530 | STRAPPING KNEE | $841.29 |
| 29540 | STRAPPING ANKLE &/FOOT | $561.13 |
| 29550 | STRAPPING TOES | $561.13 |
| 29700 | REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST | $325.34 |
| 30300 | REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE | $1,453.58 |
| 30901 | CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE | $1,332.03 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $2,334.96 |
| 3120F | 12-LEAD ECG PERFORMED | $250.00 |
| 33512 | CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS | $2,700.00 |
| 36000 | INTRODUCTION NEEDLE/INTRACATHETER VEIN | $945.10 |
| 36010 | INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA | $3,325.72 |
| 36415 | COLLECTION VENOUS BLOOD VENIPUNCTURE | $221.83 |
| 36416 | COLLECTION CAPILLARY BLOOD SPECIMEN | $121.89 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $2,375.15 |
| 51702 | INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE | $858.63 |
| 51703 | INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED | $1,550.24 |
| 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $35,455.21 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $2,697.24 |
| 64405 | INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV | $1,544.40 |
| 64450 | INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH | $3,471.51 |
| 65205 | REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL | $1,132.72 |
| 65220 | RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP | $933.77 |
| 65222 | RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP | $1,392.39 |
| 65435 | RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION | $7,013.14 |
| 69200 | RMVL FB XTRNL AUDITORY CANAL W/O ANES | $1,012.26 |
| 69209 | REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT | $582.74 |
| 69210 | REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT | $738.94 |
| 70030 | RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY | $798.82 |
| 70110 | RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS | $1,185.49 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $1,153.43 |
| 70150 | RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS | $1,200.74 |
| 70160 | RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS | $705.74 |
| 70200 | RADEX ORBITS COMPLETE MINIMUM 4 VIEWS | $1,074.34 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $816.18 |
| 70220 | RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS | $1,029.30 |
| 70250 | RADIOLOGIC EXAMINATION SKULL 4/> VIEWS | $1,020.02 |
| 70260 | RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS | $1,217.86 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $895.30 |
| 70360 | RADIOLOGIC EXAMINATION NECK SOFT TISSUE | $1,036.35 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $5,910.04 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $7,411.15 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $10,845.56 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $6,428.14 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $6,428.14 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $7,826.81 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $5,315.01 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $6,549.27 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $6,601.40 |
| 70490 | CT SOFT TISSUE NECK W/O CONTRAST MATERIAL | $4,316.91 |
| 70491 | CT SOFT TISSUE NECK W/CONTRAST MATERIAL | $6,370.33 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $6,635.41 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $10,507.76 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $6,669.75 |
| 71010 | RADIOLOGIC EXAMINATION CHEST SINGLE VIEW FRONTAL | $797.27 |
| 71020 | RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL | $758.38 |
| 71035 | RADEX CHEST SPECIAL VIEWS | $932.10 |
| 71045 | Radiologic examination, chest ; single view | $1,019.91 |
| 71046 | Radiologic examination, chest ; 2 views | $1,339.50 |
| 71047 | Radiologic examination, chest ; 3 views | $1,477.06 |
| 71048 | (Radiologic examination, chest ; 4 or more | $1,196.19 |
| 71100 | RADEX RIBS UNILATERAL 2 VIEWS | $968.49 |
| 71101 | RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS | $1,900.03 |
| 71110 | RADEX RIBS BILATERAL 3 VIEWS | $1,319.95 |
| 71111 | RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS | $1,847.46 |
| 71120 | RADEX STERNUM MINIMUM 2 VIEWS | $758.38 |
| 71250 | CT THORAX W/O CONTRAST MATERIAL | $7,275.20 |
| 71260 | CT THORAX W/CONTRAST MATERIAL | $9,044.06 |
| 71270 | CT THORAX W/O & W/CONTRAST MATERIAL | $9,375.23 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $10,507.76 |
| 72020 | RADEX SPINE 1 VIEW SPECIFY LEVEL | $718.19 |
| 72040 | RADEX SPINE CERVICAL 2 OR 3 VIEWS | $1,100.87 |
| 72050 | RADEX SPINE CERVICAL 4 OR 5 VIEWS | $1,432.18 |
| 72052 | RADEX SPINE CERVICAL 6 OR MORE VIEWS | $1,933.59 |
| 72070 | RADEX SPINE THORACIC 2 VIEWS | $1,327.95 |
| 72072 | RADEX SPINE THORACIC 3 VIEWS | $1,549.34 |
| 72074 | RADEX SPINE THORACIC MINIMUM 4 VIEWS | $1,315.20 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $656.24 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $975.00 |
| 72100 | RADEX SPINE LUMBOSACRAL 2/3 VIEWS | $1,409.52 |
| 72110 | RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS | $1,714.43 |
| 72114 | RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 | $1,707.67 |
| 72120 | RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS | $1,371.33 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $6,634.01 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $8,579.66 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $10,688.78 |
| 72128 | CT THORACIC SPINE W/O CONTRAST MATERIAL | $6,310.15 |
| 72129 | CT THORACIC SPINE W/CONTRAST MATERIAL | $7,630.65 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $6,469.13 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $7,105.53 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $9,275.15 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $18,354.25 |
| 72141 | MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL | $6,169.08 |
| 72170 | RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS | $1,082.08 |
| 72190 | RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS | $1,183.52 |
| 72192 | CT PELVIS W/O CONTRAST MATERIAL | $5,453.51 |
| 72193 | CT PELVIS W/CONTRAST MATERIAL | $5,062.28 |
| 72220 | RADEX SACRUM & COCCYX MINIMUM 2 VIEWS | $854.69 |
| 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $4,862.81 |
| 73000 | RADEX CLAVICLE COMPLETE | $798.45 |
| 73010 | RADEX SCAPULA COMPLETE | $1,036.64 |
| 73020 | RADEX SHOULDER 1 VIEW | $583.29 |
| 73030 | RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS | $1,109.37 |
| 73050 | RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ | $905.42 |
| 73060 | RADEX HUMERUS MINIMUM 2 VIEWS | $1,061.68 |
| 73070 | RADEX ELBOW 2 VIEWS | $1,012.86 |
| 73080 | RADEX ELBOW COMPLETE MINIMUM 3 VIEWS | $1,590.41 |
| 73090 | RADEX FOREARM 2 VIEWS | $1,090.58 |
| 73100 | RADEX WRIST 2 VIEWS | $933.46 |
| 73110 | RADEX WRIST COMPLETE MINIMUM 3 VIEWS | $1,087.00 |
| 73120 | RADEX HAND 2 VIEWS | $1,239.75 |
| 73130 | RADEX HAND MINIMUM 3 VIEWS | $1,084.93 |
| 73140 | RADEX FINGR MINIMUM 2 VIEWS | $742.37 |
| 73200 | CT UPPER EXTREMITY W/O CONTRAST MATERIAL | $4,552.08 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $4,430.00 |
| 64640 | DSTRJ NULYT OTH PRPH NVR/BRANCH | $5,389.86 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $1,132.72 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $1,392.39 |
| 65222 | RMVL FB EYE | $ 919.00 |
| 67700 | I&D ABSCESS EYELID | $3,077.20 |
| 69200 | RMVL FOREIGN BODY EAR | $1,012.26 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $1,278.70 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRAGATION/LAVAGE, UNILATERAL | $582.74 |
| 69210 | RMVL IMPACTED CERUMEN | $738.94 |
| 70030 | RADEX EYE DETCJ FB | $798.82 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $756.15 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $1,185.49 |
| 70120 | RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE | $ 1,039.00 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $933.28 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $1,200.74 |
| 70160 | NASAL BONE X-RAY | $705.74 |
| 70200 | RAD EXAM ORBIT COMP. | $ 1,074.34 |
| 70220 | RAD EXAM SINUS COMPLETE | $1,029.30 |
| 70250 | SKULL LESS THAN 4 VIEWS | $1,020.02 |
| 70260 | RAD EXAM SKULL COMPLETE | $1,217.86 |
| 70328 | RADEX TMPRMAND JT OPN&CLSD MOUTH UNI | $ 933.37 |
| 70350 | CEPHALOGRAM ORTHODONTIC | $812.86 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $ 1,036.35 |
| 70450 | CT HEAD/BRAIN WO CONTRAST | $ 5,910.04 |
| 70460 | CT HEAD W/CONTRAST | $ 7,411.15 |
| 70470 | CT HEAD/BRAIN W & WO CONTRAST | $ 10,845.56 |
| 70480 | CT ORBIT SELLA/POST FOSSA | $ 4,581.66 |
| 70481 | CT ORBIT SELLA/POST FOSSA | $ 3,700.00 |
| 70486 | CT MAXLFCL AREA C-MATRL | $5,315.01 |
| 70487 | CT MAXLFCL AREA C+ MATRL | $6,549.27 |
| 70490 | CT NECK WO CONTRAST | $4,316.91 |
| 70491 | CT SOFT TISS NCK C+MATRL | $6,370.33 |
| 70496 | CTA HEAD C-/C+ | $7,520.32 |
| 70498 | CT ANGIOGRAPHY NECK WITH CON | $6,669.75 |
| 70544 | MRA HEAD C-MATRL | $5,615.38 |
| 70547 | MRA NECK C-MATRL | $5,576.30 |
| 70551 | MRI BRN BRN STEM C-MATRL | $ 7,251.72 |
| 70553 | MRI BRN BRN STEM C-/C+ | $10,176.94 |
| 71010 | XRAY CHEST AP | $797.27 |
| 71020 | XRAY CHEST PA & LATERAL | $1,084.56 |
| 71030 | RADEX CH COMPL MIN 4 VIEW | $ 1,223.88 |
| 71045 | RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW | $ 1,019.91 |
| 71046 | RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS | $1,339.50 |
| 71047 | RADIOLOGIC EXAMINATION, CHEST; 3 VIEWS | $1,477.06 |
| 71048 | RADIOLOGIC EXAMINATION, CHEST; 4 OR MORE VIEWS | $1,196.19 |
| 71060 | BRONCHOGRAPHY BI RS&I | $ 723.00 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $ 544.00 |
| 71101 | RIB UNILATERAL W CHEST | $ 1,900.03 |
| 71110 | RIBS BILATERAL 3 VIEWS | $1,319.95 |
| 71111 | RIBS BILATERAL W/CHEST | $1,847.46 |
| 71120 | CHEST 2 VIEWS | $ 943.00 |
| 71250 | CT CHEST W/O CONTRAST | $7,275.20 |
| 71260 | CT THORAX W/CONTRAST | $ 2,211.00 |
| 71270 | CT THORAX WO CONTRAST | $9,375.23 |
| 71275 | CT ANGIOGRAPHY | $ 2,211.00 |
| 71550 | MRI CH C-MATRL | $ 6,635.26 |
| 72020 | SPINE SINGLE VIEW | $718.19 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $1,100.87 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $1,432.18 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $ 1,933.59 |
| 72069 | RADEX SPI THORACOLMBR STANDING SCOLIOSIS | $1,380.90 |
| 72070 | SPINE THORACIC 2 VIEWS | $ 1,039.00 |
| 72072 | SPINE THORACIC 3 VIEWS | $ 1,039.00 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $1,315.20 |
| 72100 | SPINE LUMBO. MIN 4 VIEWS | $1,409.52 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $ 1,714.43 |
| 72114 | RAD EXAM SPINE LUMBO COMP | $1,707.67 |
| 72120 | SPINE LUMBAR AP & LAT W F | $ 1,039.00 |
| 72125 | COMPUTED TOMOGRAPHY CERVI | $6,634.01 |
| 72126 | CT CRV SPI C+MATRL | $8,579.66 |
| 72127 | CT CRV SPI C-/C+ | $10,688.78 |
| 72128 | CT THRC SPI C-MATRL | $6,310.15 |
| 72129 | CT THRC SPI C+ MATRL | $7,630.65 |
| 72131 | CT L SPINE WO CONTRST | $7,105.53 |
| 72132 | CT LMBR SPI C+ MATRL | $9,275.15 |
| 72141 | MRI SPI CANAL&CNTS CRV C-MATRL | $6,169.08 |
| 72146 | MRI SPI CANAL&CNTS THRC C-MATRL | $ 6,709.62 |
| 72148 | MRI SPI CANAL&CNTS LMBR C-MATRL | $ 6,753.49 |
| 72156 | MRI SPI CANAL&CNTS C-/C+ CRV | $10,154.64 |
| 72157 | MRI SPI CANAL&CNTS C-/C+ | $9,518.34 |
| 72158 | MRI SPI CANAL&CNTS C-/C+ LMBR | $9,798.15 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $1,082.08 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $1,183.52 |
| 72191 | CTA PELVIS C-/C+ POST-PXE | $5,514.70 |
| 72192 | CT PELVIS WO CONTRAST | $5,453.51 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $5,062.28 |
| 72194 | CT PELVIS W OR WO CONTRST | $8,292.81 |
| 72195 | MRI PELVIS C-MATRL | $ 6,714.98 |
| 72196 | MRI PELVIS C+ MATRL | $ 8,563.44 |
| 72220 | XRAY COCCYX/SACRUM | $ 854.69 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $798.45 |
| 73010 | SCAPULA COMPLETE | $ 1,039.00 |
| 73020 | RADEX SHO 1 VIEW | $583.29 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $1,109.37 |
| 73050 | XRAY AC JOINTS-BILAT | $ 905.42 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $ 1,061.68 |
| 73070 | XRAY ELBOW 2 VIEWS | $ 1,012.86 |
| 73080 | XRAY ELBOW LESS THAN 3 VIEWS-COMP | $1,590.41 |
| 73090 | XRAY FOREARM AP & LAT | $1,090.58 |
| 73100 | XRAY WRIST AP & LAT VIEW | $ 933.46 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $1,087.00 |
| 73120 | XRAY HAND AP & LAT | $1,239.75 |
| 73130 | XRAY HAND MIN 3 VIEWS | $ 1,084.93 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $742.37 |
| 73200 | CT UPPR EXTR WO CNTRS | $4,552.08 |
| 73206 | CT ANGIOGRAPHY, UPPER EXT, W/CONTRAST | $5,331.30 |
| 73220 | MRI UXTR OTH/THN JT C-/C+ | $8,890.43 |
| 73221 | MRI ANY JT UXTR C-MATRL | $ 6,225.17 |
| 73500 | RADIOLOGIC EXAM HIP UNILAT 1 VIEW | $812.66 |
| 73502 | RADIOLOGIC EXAM, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED, 2-3VIEWS | $ 1,049.84 |
| 73510 | XRAY HIP MIN 2 VIEWS | $1,088.33 |
| 73520 | HIPS BILAT MIN 2 VIEW INC | $1,519.41 |
| 73550 | XRAY FEMUR AP & LAT VIEW | $1,070.55 |
| 73552 | FEMUR, MINIMUM 2 VIEWS | $1,112.41 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $ 1,020.45 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $1,404.39 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $1,230.74 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $1,105.76 |
| 73600 | XRAY ANKLE 2 VIEWS | $669.42 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $ 1,048.10 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $ 915.19 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $ 1,051.45 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $792.13 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $712.04 |
| 73700 | CT LWR EXTR WO CONTRAST | $4,204.67 |
| 73701 | CT LWR EXT W CONT | $ 4,740.91 |
| 73702 | CT LXTR C-/C+ | $ 4,662.90 |
| 73721 | MRI ANY JT LXTR C-MATRL | $ 6,452.71 |
| 73722 | MRI ANY JT LXTR C+ MATRL | $8,735.06 |
| 73723 | MRI ANY JT LXTR C-/C+ | $ 10,390.09 |
| 73725 | MRA LXTR C+-MATRL | $ 8,772.97 |
| 74000 | RAD EXAM ABD SINGL ANTER | $1,347.37 |
| 74010 | RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS | $ 1,089.45 |
| 74018 | RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW | $ 894.06 |
| 74019 | RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS | $1,366.06 |
| 74020 | RAD EXAM ABDOMEN COMPL | $1,184.06 |
| 74021 | RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS | $1,361.80 |
| 74022 | RAD EXAM COMPLETE ABD | $1,347.83 |
| 74150 | COMPUTED TOMOGRAPHY ABD | $6,358.08 |
| 74160 | TOMOGRAPHY ABD W/CONTRAST | $7,063.45 |
| 74170 | TOMOGRAPHY ABD W/OCONTRAS | $7,829.10 |
| 74174 | CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST, INC NONCONTRAST IMAGES | $9,183.43 |
| 74175 | CT ANGIO ABDOMEN W/CONTRA | $6,665.36 |
| 74176 | COMP TOMOG AB/PEL W/O CON | $8,805.94 |
| 74177 | COMP TOMO AB/PELV W/OCONT | $11,219.23 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $14,313.08 |
| 74181 | MRI ABD C-MATRL | $ 6,909.98 |
| 74183 | MRI ABD C-/C+ | $9,593.41 |
| 74241 | RADEX GI TRC UPR +-DLYD FLMS W/KUB | $3,247.44 |
| 74247 | RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB | $3,031.85 |
| 74420 | UROGRAPHY, RETROGRADE, W OR W/O KUB | $2,366.57 |
| 76000 | FLUOROSCOPY | $1,091.03 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $ 1,692.89 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $ 1,955.96 |
| 76642 | ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION | $2,436.50 |
| 76645 | US BREAST R-T W/IMAGE DOCUMENTATION | $1,339.14 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $2,285.31 |
| 76705 | US ABDOMINAL | $ 1,094.00 |
| 76770 | US RETROPERITONEAL R-T W/ | $1,806.06 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $1,169.73 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $1,668.46 |
| 76815 | ULTRASND PG UTER | $1,192.88 |
| 76817 | UT PG UTER R-T IMG TRVG | $1,630.17 |
| 76830 | TRANSVAGINAL ULTRASOUND | $ 1,764.89 |
| 76856 | US PELVIC NONOB REAL-TIME | $ 1,848.95 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $1,295.86 |
| 76870 | US SCROTUM&CNTS | $1,713.17 |
| 76880 | US EXTREMITY | $2,334.58 |
| 76882 | ULTRASOUND, EXTREMITY, NONVASCULAR | $1,333.08 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT | $1,403.17 |
| 77079 | CT BONE MINERAL DENSITY STUDY 1+SITS APPND | $ 1,044.67 |
| 77777 | SHORTNESS OF BREATH PANEL | $ 1,626.00 |
| 78075 | ADRNL IMG CORTEX&/MEDULLA | $11,591.10 |
| 78223 | HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR | $ 6,417.26 |
| 78306 | B1&/JT IMG WHBDY | $4,248.36 |
| 78315 | B1&/JT IMG 3 PHASE STD | $4,337.60 |
| 78320 | B1&/JT IMG TOMOG SPECT | $4,471.32 |
| 78472 | CARD BPI GTD=BRM PLNR 1 STD REST/STRS | $ 4,624.67 |
| 78630 | CEREBROSPINAL FLUID SCAN | $4,287.07 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $790.64 |
| 80048 | METABOLIC PANEL BASIC | $819.66 |
| 80051 | ELECTROLYTE PANEL | $832.21 |
| 80053 | METABOLIC COMPRE PANEL | $1,797.93 |
| 80061 | LIPID PROFILE III | $539.79 |
| 80074 | HEPATITIS PANEL | $1,857.53 |
| 80076 | HEPATIC FUNCTION PANEL | $ 832.53 |
| 80100 | DRUG ABUSE PANEL II | $587.98 |
| 80102 | DRUG CONFIRMATION, EACH PROCEDURE | $434.85 |
| 80104 | DRUG SCREEN | $940.21 |
| 80178 | LITHIUM | $ 256.57 |
| 80185 | PHENYTOIN LEVEL | $321.93 |
| 80196 | SALICYLATE | $370.50 |
| 80197 | TACROLIMUS | $ 798.25 |
| 80202 | VANCOMYCIN PEAK | $ 528.58 |
| 80304 | DRUG SCREEN | $ 188.00 |
| 80305 | DRUG SCREENING | $729.46 |
| 80306 | DRUG TEST, PRESUMPTIVE, ANY NUMBER DRUG CLASSES, DEVICES, PROCEDURES | $536.25 |
| 80320 | DRUG SCREEN | $ 313.00 |
| 80329 | ANALGESICS, NON OPIOID 1&2 | $626.27 |
| 81000 | U/A DIPSTICK | $383.03 |
| 81001 | U/A DIP STICK | $ 246.04 |
| 81002 | URNLS DIP STICK/TABLET RG | $298.90 |
| 81003 | U/A W/O MICRO DIPSTICK | $331.37 |
| 81025 | PREG.TST URINE VISUAL | $186.05 |
| 82003 | ACETAMINOPHEN | $ 546.00 |
| 82009 | KETONES-SERUM | $71.29 |
| 82010 | KETONE BODY | $302.31 |
| 82040 | ASSAY OF SERUM ALBUMIN | $75.60 |
| 82055 | ALCOHOL-BLOOD | $ 663.00 |
| 82150 | AMYLASE | $486.47 |
| 82247 | BILIRUBIN TOTAL | $146.94 |
| 82253 | MB FRACTION | $ 209.00 |
| 82270 | OCCULT BLOOD | $360.30 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $348.21 |
| 82274 | BLD OCLT FECAL HGB DETER | $361.65 |
| 82306 | VITAMIN D HYDROXY | $256.67 |
| 82310 | CALCIUM, SERUM | $161.37 |
| 82375 | CARBOXYHEMOGLOBIN, QUANTITATIVE | $480.95 |
| 82540 | CREATINE | $203.77 |
| 82541 | COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE | $481.00 |
| 82550 | CREATINE CK-TOTAL | $474.41 |
| 82553 | CREATINE CKMB | $703.44 |
| 82565 | CREATININE | $299.95 |
| 82657 | ENZYME CELL ACTIVITY | $754.65 |
| 82800 | GASES BLD PH ONLY | $299.83 |
| 82803 | GASES, BLOOD | $1,177.68 |
| 82945 | GLUCOSE, BODY FLUID, OTHER THAN BLOOD | $263.89 |
| 82947 | GLUCOSE | $ 63.00 |
| 82948 | GLUCOSE BLOOD REAGET STR | $230.40 |
| 82962 | GLUCOSE FINGER STICK | $205.44 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $177.60 |
| 83036 | HEMOGLOBIN, GLYCOSYLATED(A1C) | $313.88 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $577.89 |
| 83605 | LACTATE(LACTIC ACID) | $327.44 |
| 83615 | LDH | $ 165.32 |
| 83630 | LACTOFERRIN FECAL QUAL | $ 374.40 |
| 83690 | LIPASE | $330.26 |
| 83735 | SERUM MAGNESIUM | $370.70 |
| 83874 | MYOGLOBIN | $745.88 |
| 83880 | B-TYPE NATRIURETIC | $978.39 |
| 84075 | ASSAY OF ALKALINE PHOSPHATE | $151.39 |
| 84146 | ASSAY OF PROLACTIN | $374.79 |
| 84153 | PSA SCREEN TOTAL | $ 313.19 |
| 84155 | ASSAY OF PROTEIN SERUM | $135.42 |
| 84165 | PROTEIN ELECTROPHORESIS | $165.75 |
| 84166 | PROTEIN, ELECTROPHORETIC FRACTIONATION AND QUANTITATION | $ 317.85 |
| 84436 | THYRIXINE TOTAL | $405.31 |
| 84439 | LAB FOR ASSAY OF FREE THYROXINE | $405.40 |
| 84443 | TSH | TSH $523.55 |
| 84450 | TRANSFERASE (AST) | $362.67 |
| 84460 | ALANINE AMINO (ALT) | $339.27 |
| 84479 | THYROID HORMONE | $495.64 |
| 84480 | ASSAY TRIIODOTHYRONINE | $412.96 |
| 84484 | TROPONIN I | $885.53 |
| 84512 | TROPONIN QUAL | $460.54 |
| 84520 | BUN | $349.60 |
| 84550 | URIC ACID | $309.22 |
| 84560 | URIC ACID OTH SRC | $371.74 |
| 84702 | HCG QUANTATIVE | $617.37 |
| 84703 | GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE | $432.26 |
| 85014 | HEMATOCRIT | $250.76 |
| 85018 | HEMOGLOBIN | $206.59 |
| 85025 | CBC | $482.60 |
| 85027 | CBC W/O DIFF | $365.43 |
| 85032 | BLD# MNL C-CNT RBC/PLTLT EA | $371.52 |
| 85045 | AUTOMATED RETICULOCYTE COUNT | $259.43 |
| 85048 | AUTOMATED LEUKOCYTE COUNT | $44.85 |
| 85347 | COAGJ TM ACTIVATED | $105.37 |
| 85378 | FIBRIN DEGRADATION PROD | $448.54 |
| 85379 | D-DIMER | $585.64 |
| 85610 | PROTHROMBIN TIME | $307.13 |
| 85651 | SEDIMENTATION RATE NONAUT | $309.79 |
| 85652 | SED RATE ERYTHROCYTE NON | $198.63 |
| 85730 | THROMBOPLASTIN TIME PART | $286.32 |
| 86140 | C REACTIVE PROTEIN | $174.83 |
| 86256 | SMOOTH MUSCLE AB TITER | $1,051.54 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $341.41 |
| 86320 | IMMUNOELECTROPHORESIS | $653.25 |
| 86403 | MONO SPOT | $444.42 |
| 86430 | RHEUMATOID FACTOR | $271.01 |
| 86490 | SKN TST COCCIDIOIDOMYCOSI | $ 89.00 |
| 86510 | SKN TST HISTOPLASMOSIS | $ 85.00 |
| 86580 | TB INTRADERMAL | $158.66 |
| 86592 | RPR RAPID REGAIN TEST | $110.84 |
| 86631 | ANTB CHLAMYDIA | $444.88 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $ 519.62 |
| 86701 | HIV SERUM | $433.45 |
| 86702 | ANTB HIV-2 | $525.52 |
| 86703 | SINGLE LAB TEST RESULT | $ 268.81 |
| 86735 | MUMPS ANTIBODY | $117.31 |
| 86756 | ANTB RSV | $ 338.17 |
| 86788 | WEST NILE, IGM | $511.74 |
| 86789 | ANTIBODY, WEST NILE VIRUS | $ 306.16 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $548.81 |
| 86901 | RH FACTOR-BLOOD | $317.76 |
| 86906 | BLD TYPING RH PHEXYPING COMPL | $298.58 |
| 87040 | BLOOD CULTURE | $555.23 |
| 87045 | FECES CULTURE, BACTERIA | $530.21 |
| 87046 | STOOL CULTURE, BACTERIA | $274.78 |
| 87070 | CULTURE BODY FLUID | $483.69 |
| 87075 | CULTURE ANAEROBIC | $473.86 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $539.13 |
| 87086 | URINE CULTURE | $460.54 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $ 118.00 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $473.12 |
| 87110 | CHLAMYDIA CULTURE | $622.67 |
| 87177 | OVA AND PARASITES SMEAR | $ 177.59 |
| 87205 | SMEAR, PRIMARY SOURCE WITH INTERP, WET MOUNT FOR INFECTIOUS AGENTS | $313.27 |
| 87207 | SMR PRIM SRC SPEC STAIN | $ 284.82 |
| 87210 | WET SMEAR | $235.18 |
| 87230 | TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE | $ 341.25 |
| 87252 | HSV 1 AND 2 CULTURES | $200.73 |
| 87274 | INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLORESCENT TECHNIQUE | $238.08 |
| 87275 | IAADI INF B VIRUS | $ 138.00 |
| 87400 | INFLUENZA A&B | $535.70 |
| 87425 | INFECTIOUS AGENT DETECTION BY ENZYME IMMUNOSSAY TECHNIQUE STEP METHOD; ROTAVIRU | $608.15 |
| 87430 | INF AGT IMMUNO STREP A | $637.20 |
| 87480 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA);CANDIDA SPECIES,DIRECT | $220.35 |
| 87491 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID;CHLAMYDIA TRACHOMATIS,AMP PROBE | $364.10 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $ 536.89 |
| 87502 | INFLUENZA DNA AMP PROBE | $1,355.78 |
| 87510 | INFECTIOUS AGENT BY NUCLEIC ACID | $220.35 |
| 87529 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID(DNA OR RNA) | $546.16 |
| 87591 | INF AGENT DETECION BY NUCLEIC ACID(DNA OR RNA) NEISSERIA GONORRHOEAE, AMPLIFIED | $344.91 |
| 87660 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID ( DNA OR RNA);TRICHOMONAS VAG, DIRECT | $418.27 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $324.68 |
| 87807 | INF AGT DET IMNAS OPT RSV | $ 248.55 |
| 87808 | INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OBSERVATION | $92.66 |
| 87847 | NO DESCRIPTION | $ 551.00 |
| 87850 | NEISSERIA GONORRHOEAE DET | $ 341.25 |
| 87880 | RAPID STREP-BETA STREP | $381.74 |
| 88300 | PATH LEVEL 1 | $ 258.62 |
| 88304 | PATH LEVEL III | $ 541.37 |
| 88305 | PATH SURG LEVEL IV | $ 919.42 |
| 88313 | STAIN TRICHOME | $629.85 |
| 89050 | CELL COUNT, MISC BODY FLUIDS | $305.14 |
| 89055 | LEUKOCYTE ASSESSMENT, FECAL | $192.27 |
| 89060 | CRYSTAL INDENTIFICATION | $ 132.16 |
| 89220 | SPTM OBTG SPEC AERSL INDUCED SPX | $ 249.23 |
| 89947 | GLUCOSE TEST IN MET 8 PANEL | $188.44 |
| 90471 | IMMUN ADM 1 VAC | $355.68 |
| 90472 | IMADM PRQ ID SUBQ/IM NJXS | $86.50 |
| 90658 | INFLUENZA VIRUS VACCINE, SPLIT VIRUS, H1N1 | $402.93 |
| 90660 | INFLUENZA VIRUS INTRANASA | $208.96 |
| 90703 | TETANUS TOXID | $ 387.91 |
| 90714 | TETANUS DIPTHERIA TOXOID | $428.77 |
| 90715 | TDAP VACCINE | $439.81 |
| 90718 | TETANUS & DIPTHERIA | $ 387.91 |
| 90746 | HEPATITIS B VACCINE/ADULT | $236.71 |
| 90765 | IV NFS THER PROPH/DX 1ST | $ 253.00 |
| 90997 | HEMOPERFUSION | $3,184.38 |
| 91105 | GASTRIC INTUBATION/ASPER | $ 806.00 |
| 92002 | OPH MEDICAL XM&EVAL INTRM | $ 398.00 |
| 92081 | VIS FLD XM UNI/BI I&R LMT | $399.75 |
| 92551 | AUDIO SCREENING | $154.05 |
| 92552 | PURE TONE AUDIOMTRY AIR O | $327.60 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $4,268.84 |
| 93000 | EKG W/INTREP AND REPORT | $738.21 |
| 93005 | EKG | $784.50 |
| 93010 | RTN ECG 12 LEADS INTRP/RP | $257.21 |
| 93040 | RHYTHM ECG 1-3 LDS W/I&R | $ 126.00 |
| 93041 | RHYTHEM ECG 1-3 LDS | $623.04 |
| 93042 | RHYTHM ECG 1-3 LDS I&R ON | $214.50 |
| 93224 | WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I | $442.64 |
| 93306 | TRANSTHORACIC ECHOCARDIOGRAPHY | $6,310.13 |
| 93313 | TEE R-T IMG 2D W/PROBE PLMT ONLY | $7,153.00 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $5,791.35 |
| 93875 | N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD | $ 2,149.04 |
| 93880 | DUP-SCAN XTRC ART COMPL B | $3,071.36 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $1,276.47 |
| 93922 | N-INVAS PHYSIOLOGIC STD | $1,089.32 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $ 2,105.14 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $ 1,529.38 |
| 93965 | QUANT VENOUS FLOW ST | $4,278.74 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $3,174.02 |
| 93971 | DPLX SCN EXTRM VEINS | $ 1,895.20 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, PELVIC, SCROTAL | $4,606.71 |
| 93976 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW ABDOMEN, PELVIS, OR SCROTUM | $1,598.79 |
| 93990 | DOPPLER FLOW TESTING | $1,734.28 |
| 94010 | SPIROMETRY W/RECORD | $1,849.09 |
| 94060 | BRNCDILAT RSPSE SPMTRY PR | $1,553.17 |
| 94150 | VC TOT SPX | $885.27 |
| 94375 | RESPIR FLO VOL LOOP | $ 556.00 |
| 94621 | PULM STRS TSTG CPLX | $ 2,694.49 |
| 94640 | NEBULIZER TREATMENT | NEBULIZER TREATMENT |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $889.67 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $563.55 |
| 94750 | PULM COMPLIANCE STD | $ 458.00 |
| 94760 | EAR OR PULSE OXIMETRY | $274.92 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $550.32 |
| 95115 | ALLERGY INJ SRVC; SINGLE | $ 64.00 |
| 95117 | ALLERGY INJ SRVC; 2 OR MO | $ 79.00 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $1,553.53 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $774.29 |
| 96365 | IV INFUSION THERAPY/PROPH | $ 1,430.47 |
| 96366 | IV INFUS THER PROPH/DX EA | $442.42 |
| 96367 | IV NFS THER PROPH/DX ADDL | $651.79 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $779.08 |
| 96370 | SUB INFUS EA ADD HR | $ 188.00 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $531.08 |
| 96373 | INJECTION, INTRA-ARTERIAL | $1,781.86 |
| 96374 | THER PROPH/DX NJX IV PUSH | $923.69 |
| 96375 | THER PROPH/DX NJX EA SEQL | $ 520.72 |
| 96376 | SUB INFU EA ADD IV PUSH | $ 496.36 |
| 96379 | INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS | $ 560.90 |
| 97810 | ACUPUNCTURE, 1 OR MORE NEEDLES, W/OUT ELECTRICAL STIM, INITIAL 15 MINS | $438.75 |
| 99000 | SPECIMEN HANDLING | $58.56 |
| 99001 | COC COLLECITON ONLY | $128.15 |
| 99050 | BLUE CROSS RQRD LVL3 | $ 119.00 |
| 99053 | SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY | $ 323.13 |
| 99080 | MEDICAL RECORDS | $ 33.00 |
| 99143 | MOD SEDATION <5YRS 30 | $1,122.28 |
| 99144 | MOD SEDATION SERV UNDER 5 | $ 1,333.21 |
| 99145 | M-SEDAJ BY SM PHY 15 MIN | $432.80 |
| 99149 | MOD SEDATION | $928.26 |
| 99173 | SCREENING TEST OF VISION | $870.58 |
| 99281 | FACILITY CHG LEVEL 1 | $748.96 |
| 99282 | FACILITY CHG LEVEL 2 | $ 1,372.98 |
| 99283 | FACILITY CHG LEVEL 3 | $2,258.04 |
| 99284 | FACILITY CHG LEVEL 4 | $ 4,419.67 |
| 99285 | FACILITY CHG LEVEL 5 | $ 5,975.11 |
| 99291 | CRITICAL CARE 30-74 MIN | $8,054.65 |
| 99292 | CRITICAL CARE ADD 30 MIN | $ 1,610.42 |
| 99406 | SMOKING CESSATION 3-10 | $341.05 |
| 99407 | SMOKING CESSATION 10 MIN | $ 126.00 |
| A0394 | ALS IV DRUG THERAPY SUPPLIES | $7.89 |
| A0396 | ALS ESPOHAGEAL INTUB SUPPLIES | $74.63 |
| A1234 | SURGICAL TRAY- PNEUMOTHORAX/CHEST KIT | $ 586.00 |
| A4208 | 3 CC STERILE SYRINGE & NEEDLE | $53.18 |
| A4209 | 5+ CC STERILE SYRINGE & NEEDLE | $ 57.80 |
| A4213 | 20+ CC SYRINGE ONLY | $20.86 |
| A4215 | NEEDLE STERILE, ANY SIZE, EACH | $38.36 |
| A4216 | STERILE WATER/SALINE, FLUSH 10ML | $ 10.72 |
| A4217 | STERILE SALINE WATER PER 500 ML | $ 68.06 |
| A4218 | STERILE SALINE OR WATER | $30.73 |
| A4222 | EXT UNFU PMP PER CASS/BAG | $716.41 |
| A4224 | ALOCHOL OR PEROXIDE PER PINT | $ 6.00 |
| A4246 | BETADINE/PHISOHEX SOLUTION | $75.18 |
| A4247 | BETADINE/IODINE SWABS/WIPES | $64.41 |
| A4252 | GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP | $19.50 |
| A4311 | CATHETER W/O BAG 2 WAY LATEX | $89.54 |
| A4314 | INSRT TRAY W/DRAINAGE BAG | $38.34 |
| A4320 | IRR TRAY W/BULB/PISTON SY | $46.15 |
| A4322 | IRRIGATION SYRINGE, BULB | $46.15 |
| A4327 | URIN CUP FEMALE COLLECT DEV CUP | $8.95 |
| A4332 | LUBE STERILE PACKET | $17.92 |
| A4335 | INCONTINENCE SUPPLY MISC | $8.95 |
| A4338 | INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING | $34.82 |
| A4344 | INDWELLING CATH FOLEY TYP | $32.84 |
| A4351 | STRAIGHT TIP URINE CATHETER | $47.31 |
| A4353 | INTERMIT URINARY CATHETER | $ 59.69 |
| A4358 | URINARY DRAINAGE BAG | $39.27 |
| A4364 | DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ | $99.50 |
| A4450 | TAPE NO WATERPROOF | $31.25 |
| A4452 | TAPE WATERPROOF 18 SQ IN | $26.77 |
| A4550 | LACERATION- SURGICAL KIT | $586.76 |
| A4554 | DISPOSABLE UNDERPADS | $74.49 |
| A4565 | SLING | $359.75 |
| A4570 | SPECIAL CASTING MATERIAL | $303.02 |
| A4580 | CAST SUPPLIES | $213.15 |
| A4590 | 3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL | $320.87 |
| A4595 | TENS SUPPL 2 LEAD PER MONTH | $ 63.00 |
| A4606 | OXYGEN PROBE USED W OXIMETER | $325.34 |
| A4614 | PEAK FLOW SUPPLY | $153.50 |
| A4615 | CANNULA NASAL | $17.45 |
| A4616 | TUBING (OXYGEN) PER FOOT | $6.73 |
| 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 | $ 57.71 |
| A4653 | PD CATHERTER ANCHOR BELT | $ 19.00 |
| A4657 | SYRINGE W OR WO NEEDLE | $17.84 |
| A4670 | AUTOMATIC BP MONITOR #11 | $ 91.34 |
| A4673 | SALINE BLADE #11 | $35.82 |
| A4930 | GLOVES STERILE PER PAIR | $10.72 |
| A5120 | SWAB OR WIPE SKIN BARRIER | $14.94 |
| A5200 | PERCUTANEOUS CATHETER ANCHOR | $298.47 |
| A6021 | COLLAGEN DRESSING STERIL | $56.21 |
| A6205 | COMPOSITE DRSG LESS THAN 48 SQ IN | $ 53.72 |
| 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 | $149.65 |
| A6213 | FOAM DRG 16-48 SQ IN W/BRDR | $29.27 |
| A6216 | GAUZE NONIMPREG 16 SQ IN | $ 34.12 |
| A6217 | GAUZE NON STERILE | $ 36.11 |
| A6218 | GAUZE, NON STERILE | $ 36.11 |
| A6219 | GAUZE- STERILE | $ 36.11 |
| A6222 | GAUZE IMPREGNATED WITH ME | $48.13 |
| A6228 | GAUZE GREATER THAN 16 SQ IN | $ 10.00 |
| A6231 | GAUZE, 16 LESS THAN SQ IN, EACH | $180.28 |
| A6250 | SKIN SEAL PROTECT MOISTURIZER OINTMENT | $126.81 |
| A6260 | WOUND CLEANSER | $296.04 |
| A6261 | WOUND FILLER | $ 41.00 |
| A6266 | GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE | $117.77 |
| A6402 | STERILE GUAZE LESS THAN 16 INCHES | $12.41 |
| A6407 | PACK STRIPS NON-IMPREGNTD | $ 71.84 |
| A6410 | STERILE EYE PAD OR STRIP | $ 14.94 |
| A6412 | EYE PATCH | $174.10 |
| A6413 | ADHESIVE BANDAGE FIRST AI | $ 13.46 |
| A6446 | CONFORMING BANDAGE, > THAN 3 INCHES | $23.40 |
| A6448 | LT COMP BANDAGE LESS THAN 3IN | $34.13 |
| A6449 | LIGHT COMP BANDAGE | $34.82 |
| A6450 | LT COMPRS BANDAGE ELAST | $52.27 |
| A6453 | BANDAGE SELF ADHER BAND W LESS THAN 3 | $10.63 |
| A6454 | SELF ADHER BANDAGE | $29.25 |
| A6455 | SELF ADHER BANDAGE | $11.06 |
| A6457 | TUBULAR DRESSING | $122.27 |
| A7002 | SUCTION TUBING USED W PUMP | $279.27 |
| A7003 | ADMN SET SM VOL NONFILTER | $168.17 |
| A7011 | NONDISPOS CORRUGATED TUBING | $ 18.00 |
| A7015 | NEBULIZER MASK USED W NEBULIZER | $168.17 |
| A7016 | DOME/MOUTHPIECE NEB | $59.69 |
| A7017 | NEBULIZER MASK NOT USED W/ OXYGEN | $144.14 |
| A7520 | TRACH LARYN TUBE NON CUFFED | $110.56 |
| A9150 | NON PRESCRIPTION DRUG | $17.24 |
| A9273 | HOT/COLD H2OBOT/CAP/COL/WRAP | $32.84 |
| A9284 | NON-ELECTRONIC SPIROMETER | $ 341.00 |
| A9579 | GAD-BASE MR CONTRAST NOS,1ML | $ 38.15 |
| CASH | XRAY DISC | $ 15.00 |
| E0114 | CRUTCHES UNDERARM | $174.14 |
| E0116 | CRTCH UNDARM NOT WOOD ADJ | $ 149.23 |
| E0220 | HOT WATER BOTTLE | $89.54 |
| E0230 | ICE CAP OR COLLAR | $ 28.31 |
| E0275 | BED PAN STANDARD | $34.82 |
| E0325 | URINAL MALE JUG-TYPE | $ 109.22 |
| E0352 | DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) | $ 451.62 |
| E0445 | OXIMETER NON-INVASIVE | $ 1,477.48 |
| E0570 | NEBULIZER WITH COMPRESSION | $1,731.17 |
| E0580 | NEBULIZER FOR USE W/ REGULAT | $ 746.19 |
| G0009 | ADM PNEUMOCOCCAL VACCINE | $144.30 |
| G0168 | WND CLS TISSUE ADHESIVE | $99.50 |
| G0378 | HOSPITAL OBSERVATION SERVICES PER HOUR | $3,315.00 |
| G0434 | DRUG ABUSE PANEL II | $370.50 |
| J0131 | INJECTION, ACETAMINOPHEN, 10MG | $5.13 |
| J0150 | ADENOSINE INJ 6MG VIAL | $ 46.00 |
| J0153 | INJECTION, ADENOSINE, 1 MG | $39.77 |
| J0170 | EPINEPHRINE 3 1/2 NDL 10M | $ 51.00 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $$246.01 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $40.82 |
| J0290 | AMPICILLIN 500 MG INJ | $64.04 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $91.88 |
| J0330 | SUCCINYLCHOLINE CHLO 20MG | $515.40 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $417.20 |
| J0456 | INJ AZITHROMYCIN 500MG | $242.02 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $12.41 |
| J0500 | DICYCLOMINE HCL 20MG | $299.99 |
| J0550 | BICILLIN – PENICILLIN G BENZATHINE INJ | $ 244.00 |
| J0559 | BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS | $ 244.00 |
| J0560 | BICILLIN 600,000 | $487.50 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $140.87 |
| J0570 | BICILLIN 1,200,000 | $3,894.57 |
| J0595 | STADOL | $41.78 |
| J0610 | INJECTION CALCIUM GLUCONATE | $432.54 |
| J0641 | LEVOLEUCOVORIN INJECTION | $6.73 |
| J0690 | KEFZOL 1 GR VIAL | $63.60 |
| J0692 | INJ CEFEPIME HCI 500MG | $105.11 |
| J0694 | MEFOXIN 1 GM INJECTION | $138.42 |
| J0696 | ROCEPHIN 250 MG | $396.50 |
| J0698 | INJECTION, CEFOTAXIME SODIUM, PER G | $79.58 |
| J0708 | J0708 | $ 47.37 |
| J0735 | CLONIDINE 1MG | $22.12 |
| J0744 | INJECTION, CIPROFLAXIN FOR IV INFUSION | $426.57 |
| J0760 | COLCHICINE INJECTION | $ 30.00 |
| J0780 | COMPAZINE 10 MG | $38.20 |
| J1020 | INJ METHYLPREDNISOLONE AC | $6.96 |
| J1030 | DEPO MEDROL 40 MG/ML | $43.60 |
| J1040 | METHYLPREDNISOLONE 80MG | $26.56 |
| J1094 | DECADRON DEXAMETHASONE ACETATE 1MG | $ 54.91 |
| J1100 | DECADRON 4 MG VIAL | $64.04 |
| J1165 | DILANTIN 100 MG VIAL | $121.89 |
| J1170 | DILAUDID 4 MG | $121.89 |
| J1200 | BENADRYL 50MG | $64.04 |
| J1240 | ANTIVERT – DIMENHYDRINATE INJECTION 50MG | $ 84.16 |
| J1265 | DOPAMINE HCL, 40MG | $53.23 |
| J1335 | ERTAPENEM INJECTION | $542.88 |
| J1580 | GARAMYCIN,GENTAMICIN 80MG | $149.73 |
| J1610 | GLUCOGAN 1 MG VIAL | $1,796.07 |
| J1630 | HALOPERIDOL INJECTION, 5MG | $81.08 |
| J1631 | INJECTION, HALOPERIDOL DECANOATE, 50 MG | $226.59 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $40.10 |
| J1650 | ENOXAPARIN SODIUM 10MG | $647.87 |
| J1670 | TETANUS INJECTION | $104.48 |
| J1710 | INJECTIONS, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG | $ 19.00 |
| J1815 | INJ INSULIN PER 5 UNITS | $92.13 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $ 29.00 |
| J1885 | TORADOL INJ 15 MG | $113.72 |
| J1940 | LASIX 40 MG IV VIAL | $64.04 |
| J1956 | LEVOFLOXACIN 250 MG | $356.94 |
| J2001 | LIDOCAINE HCI 10MG | $ 78.96 |
| J2060 | ATIVAN 2ML SYRUP | $296.34 |
| J2150 | MANNITOL INJECTION | $ 65.21 |
| J2175 | DEMEROL 50 MG SYRINGE | $144.07 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $34.13 |
| J2270 | INJ MORPHINE SULFATE 10 M | $64.04 |
| J2300 | NUBAIN 10MG AMP | $128.33 |
| J2310 | INJ NALOXONE HCL 1MG | $87.08 |
| J2360 | ORPHENADRINE CITRATE 60MG | $366.51 |
| J2370 | NEO-SYNEPHRINE UP TO 1 ML | $ 209.41 |
| J2405 | ONDANSETRON HCI, PER MG | $64.04 |
| J2410 | INJECTION, OXYMORPHONE HCI, UP TO 1 MG | $ 33.00 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $208.41 |
| J2550 | PHENERGAN 50 MG | $64.04 |
| J2650 | PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML | $ 15.52 |
| J2690 | PRONESTYL 10 ML | $ 54.91 |
| J2704 | INJECTION, PROPOFOL, 10MG | $286.01 |
| J2730 | PRALIDOXINE CHLORIDE | $ 54.91 |
| J2760 | PHENTOLAINE MESYLATE INJ | $ 55.00 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $77.65 |
| J2780 | INJ RANITIDINE 25 MG | $31.95 |
| J2790 | RHOGAM INJECTION | $594.75 |
| J2920 | SOLU-MEDROL 40MG | $30.99 |
| J2930 | SOLU-MEDROL 125 MG | $146.48 |
| J3010 | INJ FENTANYL CITRATE .1MG | $53.71 |
| J3030 | IMITREX 6MG VIAL | $ 165.00 |
| J3101 | INJECTION, TENECTEPLASE, 1 MG. | $ 978.00 |
| J3105 | INJECTION, TREBUTALINE SULFATE, UP TO 1 MG | $210.19 |
| J3130 | TESTOSTERONE ENANTHATE INJ | $ 59.69 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $ 92.08 |
| J3301 | INJECTION, TRIAMCINOLONE ACETONIDE 10 MG | $51.84 |
| J3360 | VALIUM INJ 5 MG | $32.06 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $682.51 |
| J3410 | VISTERIL INJ 50 MG | $64.04 |
| J3411 | INJ THIAMINE 100 MG | $34.82 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $ 18.00 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $73.96 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $28.90 |
| J3486 | GEODON – ZIPRASIDONE MESYLATE 10MG | $105.35 |
| J3490 | UNCLASSIFIED DRUGS | $682.50 |
| J3535 | DRUG ADMINISTERED THROUGH A METERED DOSE INHALER | $304.43 |
| J7030 | INFUS NORM SALINE 1000CC | $212.59 |
| J7040 | INFUS NORM SALINE 500ML | $79.42 |
| J7042 | 5% DEXTROSE | $103.90 |
| J7044 | INJECTION, CIPROFLOXACIN FOR IV INFUSION | $ 118.00 |
| J7050 | INFS NORM SALINE 250CC | $77.94 |
| J7060 | INFUSION D5W 250ML | $93.83 |
| J7070 | INFUSION, D-5W, 1000 CC | $243.75 |
| J7120 | RINGER’S LACTATE INFUS | $289.75 |
| J7130 | HYPERTONIC SALINE SOLUTION | $194.03 |
| J7506 | PREDNISONE ORAL 5 MG | $ 18.97 |
| J7510 | PREDNISOLONE ORAL 5 MG | $22.12 |
| J7607 | LEVALBUTEROL COMP CON | $48.05 |
| J7610 | ALBUTEROL, THRU DME 1MG | $ 36.11 |
| J7611 | ALBUTEROL 1MG CONC INHALA | $42.16 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $153.58 |
| J7615 | LEVALBTERAL INHALATION SO | $ 48.05 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $121.60 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $130.03 |
| J7645 | IPRATROPIUM BROMIDE COMP | $ 33.00 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $ 20.98 |
| J8498 | ENEMA SUPPOSITORY, ANTIEMETIC RECTAL | $78.96 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $48.75 |
| J8540 | DEXAMETHASONE, ORAL .25MG | $56.64 |
| J9027 | CLOFARALINE INJECTION | $ 358.18 |
| L0120 | CERVICAL FLEX NONADJ COLL | $480.26 |
| L0172 | CLAVICAL COLLAR 2 PC | $121.89 |
| L1630 | ABDUCT CONTROL HIP SEMI FLEX | $ 55.00 |
| L1830 | KNEE IMMOBOLIZER | $163.22 |
| L1906 | ANKLE SUPPORT | $339.83 |
| L3260 | SURGICAL BOOT/SHOE | $300.34 |
| L3650 | SO FIGURE EIGHT ABDUCTION | $518.15 |
| L3660 | SHOULDER ORTHOSIS | $594.02 |
| L3807 | WRIST HAND FINGER ORHTOSIS, WITHOUT JOINT COLLES SPLINT | $1,384.68 |
| L3908 | WRIST EXTN CONTROL COCKUP | $283.46 |
| L3999 | UPPER LIMB ORTHOSIS NOS | $ 435.44 |
| L4350 | AIR SPLINT | $ 822.75 |
| L4360 | WALK BOOT PNEUMATIC | $2,147.32 |
| L4361 | WALKING BOOT, PNEUMATIC AND/OR VACUUM W OR W/O JOINTS, INTERFACE MATERIAL | $861.59 |
| L4380 | PNEUMATIC KNEE SPLINT | $ 320.87 |
| L4386 | WALKING BOOT NON PNEUMATIC | $2,153.97 |
| P7001 | CULTURE BACTERIAL URINE | $ 228.34 |
| P9612 | CATHETERIZE FOR URINE | $501.28 |
| Q0111 | WET MOUNTS WITH PREPARATION | $44.11 |
| Q0144 | AZITH DIHY ORAL CAP/POWD | $494.01 |
| Q0179 | ONDANESTRONG HCL 8MG ORL | $12.17 |
| Q2009 | FOSPHENYTOIN INJECTION | $61.00 |
| Q4006 | LONG ARM CAST ADULT | $160.31 |
| Q4007 | CAST SUPPLIES LONG ARM CA | $88.16 |
| Q4008 | CAST SUPPLIES LONG ARM | $88.16 |
| Q4009 | CAST SUPPLIES SHORT ARM | $ 188.00 |
| Q4010 | SHORT ARM CAST ADULT | $708.34 |
| Q4012 | CAST SUPPLIES SHORT ARM | $ 180.00 |
| Q4020 | LNG ARM SPLNT 0-10 YRS | $1,561.56 |
| Q4022 | SHRT ARM SPLNT 11 YRS + | $1,699.68 |
| Q4034 | CAST SUP LNG LEG CYLINDER FB | $ 236.00 |
| Q4037 | CAST SUPPLIES SHORT LEG | $306.31 |
| Q4038 | CAST SUP SHRT LEG FIBERGLASS | $893.18 |
| Q4039 | CAST SUPPLIES SHORT LEG C | $ 198.00 |
| Q4042 | LNG ARM SPLNT 11 YRS + | $1,390.35 |
| Q4046 | SHRT LG SPLNT 11 YRS + | $740.89 |
| Q4049 | FINGER SPLNT STATIC | $616.40 |
| Q4051 | SPLINT SUPPLIES MISC | $374.39 |
| Q9954 | ORAL MR CONTRAST, 100ML | $568.77 |
| Q9963 | HI OSM CONTRST MATL 350-3 | $49.30 |
| Q9965 | LOW OSMOLAR CON MAT PER M | $ 62.66 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $51.04 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $22.07 |
| S0020 | INJ, BUPIVICAINE, 30ML | $ 119.48 |
| S0028 | INJECT SAMOTIDINE 20 MG | $ 170.24 |
| S0030 | METRONIDAZOLE 500 MG INJ | $455.51 |
| S0077 | CLANDAMYCIN PHOSPHATE 300 | $174.56 |
| S0119 | ZOFRAN, 4MG, ORAL | $211.89 |
| S0164 | PROTONIX PANTROPRAZOLE 40MG | $466.79 |
| S0622 | PHYS EXAM FOR COLLEGE | $ 119.00 |
| S0630 | RMV SUTURES; PHYS NOT PHY | $ 164.17 |
| S3000 | BILAT DIL RETINAL EXAM | $ 15.00 |
| S5000 | PRESCRIPTION DRUG GENERIC | $6.73 |
| S5001 | PRESCRIPTION DRUG BAND NM | $ 18.97 |
| S5010 | STERILE SALINE 5% DEXTROSE AND 0.45% SALINE | $202.94 |
| S5011 | 5% DEXTROSE 1000 ML | $104.23 |
| S5550 | INSULIN RAPID 5 U | $ 67.47 |
| S8037 | MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY | $ 3,283.23 |
| S8100 | SPACER WITHOUT MASK | $134.32 |
| S8101 | MASK NEBULIZER MASK SPACER WITH MASK | $ 149.23 |
| S8430 | PADDING FOR COMPRESSION BANDAGE, ROLL | $43.68 |
| S8450 | SPLINT | $ 203.01 |
| S8451 | SPLINT, WRIST OR ANKLE | $ 287.55 |
| 87088 |
CULTURE BCT ISOL&PRSMPTV | $119.14 |