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 |