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 &#60;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
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