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
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