CPT Code |
CPT Code Description |
Charge Amount |
0202U |
COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing |
$1,500.00 |
10060 |
INCISION/DRAINAGE ABSCESS |
$1,243.38 |
10061 |
INS/DRAIN ABSCESS COMPL |
$1,566.72 |
10080 |
INCISION & DRAINAGE PILONIDAL CYST SIMPLE |
$1,216.00 |
10081 |
I&D PILONIDAL CST COMP |
$590.00 |
10120 |
I & RMVL SUB-CUT SIMPLE |
$3,376.43 |
10121 |
I & RMVL FB, SUB-CUT,COMP |
$583.00 |
10160 |
PUNCTURE ASP OF ABSCESS |
$328.00 |
10180 |
Incision and drainage, complex, postoperative wound infecti… |
$1,950.00 |
11011 |
DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC |
$263.00 |
11040 |
DBRDMT, SKIN, PARTIAL THICK |
$205.00 |
11042 |
DBRD SKN SUBQ TISSUE |
$1,455.00 |
11200 |
RMVL SKIN TAGS |
$443.74 |
11404 |
EXC BGN LSN TRUNK 3.1-4.0 |
$833.00 |
11719 |
TRIMMING NONDYSTROPHIC NAILS ANY NUMBER |
$360.00 |
11730 |
AVULSION/1-NAIL PLATE |
$1,540.00 |
11740 |
EVAC SUBUNGUAL HEMATOMA |
$1,180.00 |
11750 |
EXC NAIL PART/COMP |
$1,404.00 |
11760 |
REPAIR NAIL BED |
$531.00 |
11765 |
WEDGE EXC SKIN/NAIL BED |
$341.00 |
11771 |
EXCISION PILONIDAL CYST SINUS EXTENSIVE |
$297.00 |
11982 |
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT |
$895.00 |
12001 |
LACERATION REPAIR |
$290.54 |
12002 |
REPAIR LAC SCALP 2.6-7.5 |
$326.36 |
12004 |
REPAIR LAC SCALP 7.6-12.5 |
$356.21 |
12005 |
REPAIR LAC,SCALP 12.6-20C |
$902.50 |
12011 |
REPAIR LAC FACE LESS THAN 2.5 CM |
$812.92 |
12013 |
REPAIR LAC FACE 2.6-5.0CM |
$854.70 |
12014 |
REPAIR LAC FACE 5.1-7.5CM |
$1,258.00 |
12015 |
SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM |
$1,235.00 |
12020 |
TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE |
$320.00 |
12031 |
LYR CLSR S/A/T/E 2.5CM |
$504.00 |
12032 |
REPAIR-INT SCALP 2.6-7.5 |
$344.27 |
12034 |
INTERM RPR SCLP/TRNK/EXTR |
$707.00 |
12035 |
REPAIR INTERM S/A/T/E 12. |
$1,226.55 |
12036 |
REPAIR INTERM S/A/T/E 20.1-30.0 CM |
$762.00 |
12041 |
LAYER CLSR NECK/HAND 2.6 |
$292.53 |
12042 |
REPAIR LAC HAND/FOOT 2.6- |
$883.00 |
12044 |
LYR CLSR N/H/F/ETRNL GENT |
$762.00 |
12045 |
REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM |
$760.00 |
12051 |
LAYER CLSR OF WND NCK/HND |
$1,540.00 |
12052 |
LYR CLSR WOUND 2.6-5.0FAC |
$1,180.00 |
12053 |
LYR CLSR F/E/E/N/L/M&/MUC |
$957.00 |
12054 |
REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM |
$1,404.00 |
13120 |
REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM |
$2,023.03 |
13121 |
RPR CMPX SCALP ARM2.6-7.5 |
$1,236.00 |
13122 |
CMPLX RPR ADD 5 CM OR LES |
$531.00 |
13132 |
RPR CMPX FOREHEAD/CHECK/C |
$1,462.00 |
13151 |
CMPX RPR EYE NOSE 1.1-2.5 |
$1,055.00 |
13152 |
RPR CPLX E/N/E/L 2.6-7.5 |
$2,618.93 |
13153 |
REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< |
$669.00 |
15850 |
SUTURE RMVL W/ANESTHESIA |
$895.00 |
16000 |
BURN, INITIAL TREATMENT |
$1,350.00 |
16020 |
BURN, DRESSING/DBRDMNT-SM |
$284.57 |
17250 |
UMBILICAL CAUTERIZATION |
$368.15 |
19000 |
PUNCTURE ASPIRATION CYST BREAST |
$2,521.33 |
19100 |
BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX |
$779.08 |
20552 |
TRIGGER POINT INJ 1-2 MUS |
$805.95 |
20600 |
ARTHROCENTESIS, SML JOINT |
$1,523.75 |
20605 |
ARTHROCENTESIS, MED JOINT |
$1,412.50 |
20610 |
ARTHROCENTESIS, LG JOINT |
$1,523.00 |
20611 |
Arthrocentesis, aspiration and/or injection, major joint or… |
$1,922.00 |
21310 |
CLTX NSL B1 FX W/O MNPJ |
$498.00 |
21480 |
CLDS TX TEMP DISLOCATION |
$452.00 |
21800 |
CLTX RIB FX UNCOMP EA |
$425.00 |
23500 |
CLTX CLAVICULAR FX WO MNP |
$814.00 |
23550 |
OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC |
$890.00 |
23570 |
CLSD TX SCAPULAR FX WO MA |
$839.00 |
23600 |
CLTX PROX HUMRL FX WO MAN |
$381.00 |
23605 |
CLTX PRX HMRL FX MNPJ+-TRACT |
$3,328.28 |
23650 |
SHOULDER DISLOCATION TRMT |
$1,100.00 |
23665 |
CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ |
$1,320.00 |
24075 |
EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM |
$1,000.00 |
24500 |
CLTX HUMRL SHFT FX W/O MN |
$378.00 |
24530 |
CLTX SPRCNDYLR/TRANSCNDYL |
$1,392.00 |
24576 |
CLTX HUMRL CNDLYR FX MEDI |
$381.00 |
24600 |
CLSD TX ELBOW DISLOCAT |
$1,000.00 |
24605 |
Treatment of closed elbow dislocation; requiring anesthesia |
$5,318.00 |
24640 |
RADIAL HEAD SUBLUX. CHILD |
$1,100.00 |
24650 |
CLTX RDL HEAD FX WO MANP |
$959.00 |
24670 |
CLTX ULNR FX PROX END WO |
$942.00 |
25066 |
BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP |
$1,000.00 |
25500 |
CLTX RDL SHFT FX WO MANP |
$650.00 |
25505 |
CLSD TX RAD SHAFT W/MANIP |
$2,213.00 |
25530 |
CLSD TX ULNAR SHFT FX NO |
$1,452.00 |
25535 |
CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION |
$715.00 |
25560 |
CLTX RDL&UR SHFT FXS W/O |
$378.00 |
25600 |
CLSD TX DISTAL RAD FX WO |
$1,045.00 |
25605 |
CLSD TX DISTAL RAD FX |
$1,992.00 |
25622 |
CLSD TX NAVICULAR FX WO M |
$650.00 |
25635 |
CLTTX CARPL B1 FX W/MNPJ EA B1 |
$1,085.00 |
25650 |
CLTX UR SYLOID FX |
$1,097.00 |
26010 |
I & D FINGER ABSCESS,SIMP |
$999.00 |
26600 |
CLSD TX METACARPAL FX |
$909.00 |
26605 |
CLSD TX MEDICARPAL FX |
$1,200.00 |
26607 |
CLTX MTCRPL FX W/MNP W/XT |
$1,670.00 |
26700 |
CLS TX MCP DISLOCATION |
$381.00 |
26705 |
Closed treatment of metacarpophalangeal dislocation, single… |
$4,322.00 |
26720 |
CLSD TX PHALANGEAL SHFTFX |
$628.00 |
26725 |
CLTX PHLNGL FX PROX/MIDDL |
$1,027.00 |
26750 |
CLS TX FX FINGER/THUMB |
$1,080.00 |
26755 |
CLTX DSTL PHLNGL FX FNGR/ |
$1,259.00 |
26770 |
TREAT FINGER DISLOC FINGE |
$560.00 |
26775 |
Closed treatment of interphalangeal joint dislocation, sing… |
$985.00 |
27220 |
CLTX ACETABULUM HIP/SOCKT FX W/O MNP |
$635.00 |
27372 |
REMOVAL FOREIGN BODY DEEP THIGH/KNEE |
$350.00 |
27508 |
CLTX FEM FX DSTAL END MED |
$381.00 |
27520 |
CLTX PATELLAR FX W/O MNPJ |
$1,205.00 |
27530 |
CLTX TIBL FX PROX W/O MNPJ |
$507.00 |
27550 |
CLOSED TX KNEE DISLOCATION W/O ANESTHESIA |
$1,366.00 |
27560 |
CLTX PATELLAR DISLC W/O A |
$381.00 |
27752 |
CLTX TIBL SFT FX W/MANP |
$1,968.00 |
27760 |
CLTX MEDIAL MALLS FX W/O |
$1,153.00 |
27780 |
CLTX PROX FIVULA/SHFT FX |
$1,055.00 |
27786 |
CLSD TX DISTAL FIBULAR FX |
$993.00 |
27792 |
Open treatment of distal fibular fracture (lateral malleolu… |
$8,700.00 |
27808 |
CLOSED TX BIMALLEOLAR ANK |
$507.00 |
27810 |
CLTX BIMAL ANKLE FX W/POT |
$1,704.00 |
27840 |
CLOSED TX ANKLE DISLOCATI |
$100.00 |
28190 |
RMVL FB BODY FOOT SUBQ |
$1,320.00 |
28192 |
RMVL FB FOOT DEEP |
$1,373.00 |
28400 |
CLSD TX CLAVICLE FX WO MA |
$650.00 |
28430 |
CLTX TALUS FX W/O MNPJ |
$106.00 |
28450 |
TX TARSAL B1 FX XCP TALUS |
$635.00 |
28470 |
CLTX METAR FX WO MNP |
$840.00 |
28490 |
CLTX FX GRT TOE W/O MNLJ |
$594.00 |
28510 |
CLSD TX FX PLALANX/PHALAN |
$850.00 |
28515 |
FX CARE PHALANX NOT GREAT |
$622.00 |
28635 |
Closed treatment of metatarsophalangeal joint dislocation; … |
$3,824.78 |
28660 |
CLSD TX PIP JNT DISLOCATI |
$1,000.00 |
29075 |
APPLICATION CAST ELBOW FINGER SHORT ARM |
$950.00 |
29085 |
CAST HAND/LOWER FOREARM GAUNTLET |
$176.00 |
29086 |
APPLICATION CAST FINGER |
$920.00 |
29105 |
LONG ARM SPLINT |
$829.18 |
29125 |
SHORT ARM SPLINT |
$725.36 |
29126 |
SHORT ARM SPLINT DYNAMIC |
$176.00 |
29130 |
APPLICATION FINGER SPLINT |
$542.74 |
29131 |
APPLICATION FINGER SPLINT DYNAMIC |
$733.20 |
29240 |
STRPG SHO |
$723.36 |
29280 |
STRAPPING HAND/FINGER |
$605.96 |
29450 |
APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG |
$1,150.00 |
29505 |
LONG LEG SPLINT |
$935.75 |
29515 |
SHORT LEG SPLINT |
$890.00 |
29530 |
STRAPPING KNEE |
$492.52 |
29540 |
STRAPPING ANKLE/FOOT |
$465.66 |
29550 |
STRAPPING TOES |
$505.46 |
29580 |
STRAPPING UNNA BOOT |
$220.00 |
29700 |
RMVL/BIVALV GAUNTLET BOOT |
$1,100.00 |
30300 |
RMVL FOREIGN BODY NASAL |
$1,300.00 |
30901 |
NASAL PACKING |
$1,440.39 |
30903 |
CTRL NSL HEMRRG ANT CPLX |
$443.00 |
30905 |
CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST |
$1,325.00 |
3120F |
12-LEAD ECG PERFORMED |
$250.00 |
31500 |
INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE |
$571.00 |
31502 |
TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT |
$891.00 |
31515 |
LARYNGOSCOPY +- TRACHEOSCOPY ASPIRATION |
$670.00 |
31525 |
LARGSC +-TRACHEOSCOPY DX |
$198.00 |
32551 |
TUBE THORACOSTOMY INCLUDES WATER SEAL |
$1,197.00 |
33415 |
RESCJ/INC SUBVALVULAR TISSUE |
$980.00 |
33512 |
CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS |
$2,700.00 |
36000 |
INTRODUCTION OF NEEDLE/IN |
$76.32 |
36005 |
NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH |
$604.79 |
36010 |
INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA |
$590.00 |
36410 |
VENIPUNCTURE, 3 YRS OR OLDER |
$68.00 |
36415 |
VENIPUNCTURE |
$75.22 |
36416 |
COLL CAPILLARY BLG SPEC |
$595.00 |
36556 |
Insertion of non-tunneled centrally inserted central venous… |
$3,150.00 |
36558 |
INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR |
$2,156.00 |
36589 |
RMVL TUN CVC W/O SUBQ PORT/PMP |
$1,912.75 |
36591 |
COLLECT BLOOD FROM IMPLAN |
$146.00 |
38300 |
DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL |
$303.00 |
40650 |
RPR LIP FULL THICKNESS |
$2,990.00 |
41252 |
Repair Procedures on the Tongue and Floor of Mouth |
$2,423.28 |
41800 |
DRNG ABSC DENTOALVEOLAR S |
$480.00 |
42700 |
I&D ABSC PRITONSILLAR |
$857.00 |
43752 |
NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE |
$2,050.00 |
43753 |
GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … |
$128.00 |
45900 |
Manipulation Procedures on the Colon and Rectum |
$800.00 |
46040 |
I&D ISCHIOR/PRIRC ABSC SP |
$1,957.00 |
46050 |
INC/DRAIN PERIANAL ABS SU |
$1,111.00 |
46083 |
INCISION THROM HEMORRHOID |
$491.00 |
46320 |
ENULEATION EXCC OF EXT HE |
$612.00 |
51700 |
BLDR IRR SMPL LVG&/INSTLJ |
$97.00 |
51701 |
INSR NONDWELLING BLDR CAT |
$231.00 |
51702 |
INSERTION BLADDER CATH |
$989.03 |
51703 |
INSERT BLADDER CATH COMPL |
$1,110.00 |
56405 |
INC/DRAIN VULVA/PERINEAL |
$259.00 |
56420 |
I & D BARTHOLIN ABSCESS |
$100.00 |
57415 |
REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL |
$1,115.00 |
59025 |
FTL NON-STRS TST |
$950.00 |
59409 |
VAG DLVR ONLY |
$3,960.00 |
62270 |
SPINAL PUNCTURE,LUMBAR |
$554.00 |
64400 |
NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH |
$1,000.00 |
64402 |
INJ ANESTHETIC FACIAL NRV |
$640.00 |
64450 |
INJ ANESTHETIC AGENT |
$1,432.80 |
64640 |
DSTRJ NULYT OTH PRPH NVR/BRANCH |
$1,220.00 |
65205 |
REMOVAL FB EYE-SUPERFCL |
$1,300.00 |
65220 |
RMVL FB EYE W/O SLIT LAMP |
$1,190.00 |
65222 |
RMVL FB EYE |
$1,320.00 |
65435 |
RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION |
$1,190.00 |
67700 |
I&D ABSCESS EYELID |
$773.00 |
69005 |
DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED |
$363.00 |
69200 |
RMVL FOREIGN BODY EAR |
$1,190.00 |
69205 |
RMVL FB XTRNL AUD CANAL A |
$409.00 |
69209 |
REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL |
$1,190.00 |
69210 |
RMVL IMPACTED CERUMEN |
$202.98 |
69399 |
Under Other Procedures of the External Ear |
$1,200.00 |
70030 |
RADEX EYE DETCJ FB |
$636.80 |
70100 |
XRAY MANDIBLE LESS THAN 4 VIEWS |
$913.41 |
70110 |
XRAY MANDIBLE MIN 4 VIEWS |
$1,480.56 |
70120 |
RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE |
$157.00 |
70130 |
RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE |
$1,355.19 |
70140 |
XRAY FACIAL BONES LESS THAN 3 VIEW |
$1,148.53 |
70150 |
XRAY FACIAL BONES GREATER THAN 3 VIEW |
$1,816.13 |
70160 |
Radiologic examination, nasal bones, complete, minimum of 3… |
$1,165.14 |
70200 |
RAD EXAM ORBIT COMP. |
$1,801.94 |
70210 |
RADEX SINUSES PARANASAL <3 VIEWS |
$1,694.48 |
70220 |
RAD EXAM SINUS COMPLETE |
$1,276.68 |
70250 |
SKULL LESS THAN 4 VIEWS |
$1,675.08 |
70260 |
RAD EXAM SKULL COMPLETE |
$2,371.39 |
70328 |
RADEX TMPRMAND JT OPN&CLSD MOUTH UNI |
$351.00 |
70330 |
RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT |
$1,215.89 |
70350 |
CEPHALOGRAM ORTHODONTIC |
$257.00 |
70360 |
RAD EXAM NECK,SOFT TISSUE |
$645.66 |
70450 |
COMPUTED TOMOGRAPHY HD/BR |
$5,538.75 |
70460 |
TOMOGRAPHY HEAD/BRAIN WIT |
$6,331.50 |
70470 |
COMPUTED TOMOGRAPHY HEAD/ |
$7,147.88 |
70480 |
CT ORBIT SELLA/POST FOSSA |
$5,801.25 |
70481 |
CT ORBIT SELLA/POST FOSSA |
$6,365.90 |
70482 |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
$7,103.52 |
70486 |
CT MAXLFCL AREA C-MATRL |
$5,858.95 |
70487 |
CT MAXLFCL AREA C+ MATRL |
$6,703.15 |
70488 |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
$7,092.00 |
70490 |
CT NECK WO CONTRAST |
$5,911.50 |
70491 |
CT SOFT TISS NCK C+MATRL |
$6,395.38 |
70492 |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
$6,801.53 |
70496 |
CTA HEAD C-/C+ |
$5,991.19 |
70498 |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
$6,306.75 |
70544 |
MRA HEAD C-MATRL |
$3,150.00 |
70547 |
MRA NECK C-MATRL |
$2,772.00 |
70551 |
MRI BRN BRN STEM C-MATRL |
$2,772.00 |
70553 |
MRI BRN BRN STEM C-/C+ |
$3,268.00 |
71035 |
RADEX CHEST SPECIAL VIEWS |
$2,393.97 |
71045 |
Radiologic examination, chest ; single view |
$1,385.24 |
71046 |
CHEST XRAY 2 VIEWS |
$1,526.53 |
71047 |
Radiologic examination, chest ; 3 views |
$2,039.75 |
71048 |
(Radiologic examination, chest ; 4 or more |
$1,895.92 |
71060 |
BRONCHOGRAPHY BI RS&I |
$537.00 |
71100 |
RIBS UNILATERAL 2 VIEWS |
$1,552.20 |
71101 |
RIB UNILATERAL W CHEST |
$1,313.40 |
71110 |
RIBS BILATERAL 3 VIEWS |
$2,085.02 |
71111 |
RIBS BILATERAL W/CHEST |
$1,596.38 |
71120 |
Radiologic examination; sternum, minimum of 2 views |
$1,345.84 |
71250 |
CT CHEST W/O CONTRAST |
$6,450.65 |
71260 |
CT THORAX W/CONTRAST |
$6,947.90 |
71270 |
CT THORAX WO CONTRAST |
$7,342.40 |
71275 |
CT ANGIOGRAPHY |
$7,164.50 |
71550 |
MRI CH C-MATRL |
$2,771.00 |
72020 |
Radiologic examination, spine, single view, specify level |
$1,155.20 |
72040 |
SPINE, CERVICAL 2/3 VIEWS |
$1,458.67 |
72050 |
SPINE, CERVICAL MIN 4VIEW |
$2,220.39 |
72052 |
SPINE CERV. COMP FLEX/EXT |
$2,503.42 |
72069 |
RADEX SPI THORACOLMBR STANDING SCOLIOSIS |
$374.00 |
72070 |
SPINE THORACIC 2 VIEWS |
$1,603.94 |
72072 |
SPINE THORACIC 3 VIEWS |
$1,895.48 |
72074 |
RAD EXAN SPINE THROAC 4 V |
$2,044.92 |
72080 |
RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS |
$1,580.06 |
72082 |
RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW |
$1,373.10 |
72100 |
SPINE LUMBO. MIN 4 VIEWS |
$1,566.13 |
72110 |
LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS |
$2,435.76 |
72114 |
RAD EXAM SPINE LUMBO COMP |
$1,746.82 |
72120 |
SPINE LUMBAR AP & LAT W F |
$1,855.68 |
72125 |
COMPUTED TOMOGRAPHY CERVI |
$6,227.92 |
72126 |
CT CRV SPI C+MATRL |
$6,944.93 |
72127 |
CT CRV SPI C-/C+ |
$7,326.08 |
72128 |
CT THRC SPI C-MATRL |
$6,248.82 |
72129 |
CT THRC SPI C+ MATRL |
$6,723.90 |
72130 |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
$7,033.50 |
72131 |
CT L SPINE WO CONTRST |
$6,378.00 |
72132 |
CT LMBR SPI C+ MATRL |
$6,946.84 |
72133 |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
$6,928.82 |
72141 |
MRI SPI CANAL&CNTS CRV C-MATRL |
$1,867.00 |
72146 |
MRI SPI CANAL&CNTS THRC C-MATRL |
$2,772.00 |
72148 |
MRI SPI CANAL&CNTS LMBR C-MATRL |
$2,772.00 |
72156 |
MRI SPI CANAL&CNTS C-/C+ CRV |
$3,268.00 |
72157 |
MRI SPI CANAL&CNTS C-/C+ |
$2,772.00 |
72158 |
MRI SPI CANAL&CNTS C-/C+ LMBR |
$2,801.00 |
72170 |
RAD EXAM PELVIS 1/2 VEIW |
$1,284.54 |
72190 |
RADEX PELVIS COMPL MIN 3 |
$1,573.10 |
72191 |
CTA PELVIS C-/C+ POST-PXE |
$7,154.61 |
72192 |
CT PELVIS WO CONTRAST |
$5,718.08 |
72193 |
TOMOGRAPHY PELVIS WCONTRS |
$6,255.48 |
72194 |
CT PELVIS W OR WO CONTRST |
$9,776.87 |
72195 |
MRI PELVIS C-MATRL |
$2,772.00 |
72196 |
MRI PELVIS C+ MATRL |
$3,735.00 |
72220 |
XRAY COCCYX/SACRUM |
$1,628.82 |
72270 |
MYELOGRAPY 2/MORE REGIONS RS&I |
$2,450.00 |
73000 |
XRAY CLAVICLE 2 VIEWS |
$1,301.46 |
73010 |
SCAPULA COMPLETE |
$1,641.75 |
73020 |
RADEX SHO 1 VIEW |
$1,032.81 |
73030 |
SHOULDR COMPLETE 2 VIEWS |
$1,720.36 |
73050 |
XRAY AC JOINTS-BILAT |
$841.77 |
73060 |
XRAY HUMERUS MIN 2 VIEWS |
$1,337.28 |
73070 |
XRAY ELBOW 2 VIEWS |
$1,206.94 |
73080 |
XRAY ELBOW GREATER THAN 3 VIEWS-COMP |
$1,590.01 |
73090 |
XRAY FOREARM AP & LAT |
$1,278.58 |
73092 |
Radiologic examination; upper extremity, infant, minimum of… |
$720.00 |
73100 |
XRAY WRIST AP & LAT VIEW |
$1,019.88 |
73110 |
XRAY WRIST/COMP MIN 3 VIE |
$1,445.24 |
73120 |
XRAY HAND AP & LAT |
$1,026.84 |
73130 |
XRAY HAND MIN 3 VIEWS |
$1,415.88 |
73140 |
XRAY FINGER MIN 2 VIEWS |
$1,029.82 |
73200 |
CT UPPR EXTR WO CNTRS |
$5,749.44 |
73201 |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
$6,270.61 |
73202 |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
$6,710.40 |
73220 |
MRI UXTR OTH/THN JT C-/C+ |
$3,268.00 |
73221 |
MRI ANY JT UXTR C-MATRL |
$2,772.00 |
73500 |
RADIOLOGIC EXAM HIP UNILAT 1 VIEW |
$380.00 |
73501 |
RADEX HIP UNILATERAL WITH PELVIS 1 VIEW |
$966.14 |
73502 |
RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… |
$881.57 |
73503 |
RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS |
$1,749.21 |
73510 |
XRAY HIP MIN 2 VIEWS |
$1,371.11 |
73520 |
HIPS BILAT MIN 2 VIEW INC |
$507.00 |
73521 |
Radiologic examination, hips, bilateral, with pelvis when p… |
$1,393.00 |
73522 |
RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS |
$2,594.49 |
73523 |
Radiologic examination, hips, bilateral, with pelvis when p… |
$2,633.00 |
73550 |
XRAY FEMUR AP & LAT VIEW |
$311.00 |
73551 |
RADIOLOGIC EXAMINATION FEMUR 1 VIEW |
$1,422.34 |
73552 |
FEMUR; MIN 2 VIEWS |
$1,287.63 |
73560 |
XRAY KNEE, SUNRISE VIEW |
$1,287.63 |
73562 |
XRAY KNEE MIN 3 VIEWS |
$1,508.42 |
73564 |
RAD EXAM KNEE 4 OR MORE |
$1,815.88 |
73565 |
RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOSTC |
$770.13 |
73580 |
X-RAY KNEE.BILATERAL STANDING |
$3,065.12 |
73590 |
XRAY TIBIA/FIBULA AP/LAT |
$796.00 |
73592 |
RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS |
$829.73 |
73600 |
XRAY ANKLE 2 VIEWS |
$1,009.38 |
73610 |
XRAY ANKLE 3 VIEWS/COMPLE |
$1,514.39 |
73620 |
XRAY FOOT MIN 2 VIEWS |
$1,257.68 |
73630 |
XRAY FOOT MIN 3 VIEWS |
$1,516.88 |
73650 |
RAD EXAN HEEL MIN 2 VIEWS |
$756.20 |
73660 |
XRAY TOES, MIN 2 VIEWS |
$993.01 |
73700 |
CT LWR EXTR WO CONTRAST |
$5,335.19 |
73701 |
CT LWR EXT W CONT |
$7,574.00 |
73702 |
CT LXTR C-/C+ |
$4,403.00 |
73718 |
MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL |
$6,901.12 |
73721 |
MRI ANY JT LXTR C-MATRL |
$2,772.00 |
73722 |
MRI ANY JT LXTR C+ MATRL |
$3,076.00 |
73723 |
MRI ANY JT LXTR C-/C+ |
$5,049.00 |
73725 |
MRA LXTR C+-MATRL |
$3,735.00 |
74010 |
RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS |
$426.00 |
74018 |
Radiologic examination, abdomen; 1 view |
$1,098.48 |
74019 |
Radiologic examination, abdomen; 2 views |
$1,128.33 |
74020 |
RAD EXAM ABDOMEN COMPL |
$2,500.00 |
74021 |
Radiologic examination, abdomen; 3 or more views |
$1,317.38 |
74022 |
RAD EXAM COMPLETE ABD |
$1,871.60 |
74150 |
COMPUTED TOMOGRAPHY ABD |
$6,892.88 |
74160 |
TOMOGRAPHY ABD W/CONTRAST |
$7,306.24 |
74170 |
TOMOGRAPHY ABD W/OCONTRAS |
$8,060.85 |
74174 |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
$7,619.70 |
74175 |
CT ANGIO ABDOMEN W/CONTRA |
$7,362.99 |
74176 |
COMP TOMOG AB/PEL W/O CON |
$7,973.35 |
74177 |
COMP TOMO AB/PELV W/OCONT |
$8,656.42 |
74178 |
CT ABD & PELVIS 1 PLUS SECTION/REGNS |
$10,859.59 |
74181 |
MRI ABD C-MATRL |
$2,772.00 |
74183 |
MRI ABD C-/C+ |
$3,268.00 |
74190 |
PERITONEOGRAM RS&I |
$3,174.50 |
74240 |
RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB |
$3,543.03 |
74241 |
RADEX GI TRC UPR +-DLYD FLMS W/KUB |
$2,665.65 |
74245 |
RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES |
$3,014.76 |
74246 |
Radiologic examination, gastrointestinal tract, upper, air … |
$2,131.50 |
74247 |
RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB |
$1,010.00 |
74250 |
RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES |
$2,349.75 |
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 |
$3,732.00 |
74340 |
INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I |
$1,409.85 |
74440 |
VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I |
$2,300.00 |
75574 |
CT CORONARY |
$3,245.00 |
76376 |
3D RNDR I&R CT MRI US/OTH |
$964.00 |
76380 |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
$2,924.30 |
76536 |
ULTRASOUND, SOFT TISSUES OF HEAD AND NECK |
$2,120.25 |
76604 |
US CHEST REAL TIME W/IMAGE DOCUMENTATION |
$2,017.61 |
76641 |
US BREAST UNI REAL TIME WITH IMAGE COMPLETE |
$2,279.50 |
76642 |
US BREAST UNI REAL TIME WITH IMAGE LIMITED |
$2,007.21 |
76645 |
US BREAST R-T W/IMAGE DOCUMENTATION |
$719.00 |
76700 |
US ABDOMINAL R-T W/IMAGE |
$3,158.36 |
76705 |
US ABDOMINAL |
$3,251.16 |
76770 |
US RETROPERITONEAL R-T W/ |
$3,237.75 |
76775 |
US RPR B-SCAN&/R-T IMG LMTD |
$1,399.96 |
76801 |
ULTRASOUND 14 WK TABDL 1/1ST GESTATION |
$2,767.39 |
76802 |
US PREG UTERUS 14 WK TRANSABDL EACH GESTATION |
$2,145.00 |
76805 |
US PG UTER F&MAT AFTER 1S |
$2,751.88 |
76810 |
US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO |
$2,911.21 |
76815 |
ULTRASND PG UTER |
$356.00 |
76816 |
US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS |
$1,862.95 |
76817 |
UT PG UTER R-T IMG TRVG |
$2,224.82 |
76830 |
TRANSVAGINAL ULTRASOUND |
$2,135.27 |
76856 |
US PELVIC NONOB REAL-TIME |
$2,992.95 |
76857 |
PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 |
$1,777.07 |
76870 |
US SCROTUM&CNTS |
$2,807.64 |
76881 |
US EXTREMITY NON-VASC REAL-TIME IMG COMPL |
$2,930.24 |
76882 |
ULTRASOUND, EXTREMITY, NON VASCULAR |
$1,829.62 |
76937 |
Us guide vascular access |
$1,619.15 |
76942 |
ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… |
$495.00 |
77777 |
SHORTNESS OF BREATH PANEL |
$12.00 |
78075 |
ADRNL IMG CORTEX&/MEDULLA |
$3,618.00 |
78223 |
HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR |
$2,509.00 |
78306 |
B1&/JT IMG WHBDY |
$1,440.00 |
78315 |
B1&/JT IMG 3 PHASE STD |
$1,440.00 |
78320 |
B1&/JT IMG TOMOG SPECT |
$923.00 |
78472 |
CARD BPI GTD=BRM PLNR 1 STD REST/STRS |
$2,039.00 |
80047 |
BASIC METABOLIC PANEL CALCIUM IONIZED |
$766.00 |
80048 |
METABOLIC PANEL BASIC |
$918.86 |
80050 |
General health panel This panel must include the following:… |
$1,114.51 |
80051 |
ELECTROLYTE PANEL |
$614.65 |
80053 |
METABOLIC COMPRE PANEL |
$1,085.42 |
80061 |
LIPID PROFILE III |
$648.74 |
80074 |
HEPATITIS PANEL |
$1,087.50 |
80076 |
HEPATIC FUNCTION PANEL |
$843.50 |
80100 |
DRUG ABUSE PANEL II |
$230.00 |
80102 |
Drug confirmation, each procedure |
$435.94 |
80104 |
DRUG SCREEN |
$172.00 |
80143 |
Acetaminophen |
$533.28 |
80178 |
LITHIUM |
$59.00 |
80179 |
Salicylate |
$324.00 |
80196 |
SALICYLATE |
$270.00 |
80197 |
TACROLIMUS |
$350.00 |
80202 |
VANCOMYCIN PEAK |
$229.00 |
80300 |
DRUG SCREEN |
$221.00 |
80304 |
DRUG SCREEN |
$211.00 |
80305 |
DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… |
$532.50 |
80307 |
DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS |
$351.50 |
80320 |
DRUG SCREEN |
$155.22 |
80324 |
DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 |
$665.00 |
80329 |
DRUG SCREEN |
$464.07 |
80335 |
ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 |
$143.28 |
80345 |
DRUG SCREENING BARBITURATES |
$228.85 |
80346 |
DRUG SCREENING BENZODIAZEPINES 1-12 |
$173.13 |
80347 |
DRUG SCREENING BENZODIAZEPINES 13 OR MORE |
$450.00 |
80349 |
DRUG SCREENING CANNABINOIDS NATURAL |
$272.63 |
80351 |
DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 |
$338.30 |
80352 |
DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE |
$280.00 |
80353 |
DRUG SCREENING COCAINE |
$240.79 |
80356 |
DRUG SCREENING HEROIN METABOLITE |
$148.20 |
80358 |
DRUG SCREENING METHADONE |
$177.11 |
80359 |
DRUG SCREENING METHYLENEDIOXYAMPHETAMINES |
$560.00 |
80361 |
DRUG SCREENING OPIATES 1 OR MORE |
$447.75 |
80362 |
DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 |
$500.00 |
80365 |
DRUG SCREENING OXYCODONE |
$550.00 |
80366 |
DRUG SCREENING PREGABALIN |
$179.10 |
80367 |
DRUG SCREENING PROPOXYPHENE |
$343.00 |
80373 |
DRUG SCREENING TRAMADOL |
$400.00 |
80374 |
DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS |
$420.00 |
81000 |
U/A DIPSTICK |
$240.34 |
81001 |
U/A DIP STICK |
$384.52 |
81002 |
URNLS DIP STICK/TABLET RG |
$231.00 |
81003 |
U/A W/O MICRO DIPSTICK |
$205.17 |
81005 |
Urinalysis; qualitative or semiquantitative, except immunoa… |
$92.00 |
81007 |
URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK |
$500.00 |
81025 |
PREG.TST URINE VISUAL |
$339.30 |
82003 |
ACETAMINOPHEN |
$229.00 |
82009 |
KETONES-SERUM |
$36.00 |
82040 |
ALBUMIN; SERUM |
$182.52 |
82055 |
ALCOHOL-BLOOD |
$201.00 |
82075 |
ALCOHOL BREATH TEST |
$84.00 |
82140 |
Ammonia |
$330.19 |
82150 |
AMYLASE |
$429.84 |
82247 |
BILIRUBIN TOTAL |
$200.59 |
82248 |
BILIRUBIN DIRECT |
$286.56 |
82253 |
MB FRACTION |
$154.00 |
82270 |
OCCULT BLOOD |
$750.00 |
82272 |
BLD OCLT PEROXIDASE ACTV |
$141.29 |
82274 |
blood, occult by fecal hemoglobin determination by immunoas… |
$153.30 |
82310 |
CALCIUM |
$233.48 |
82330 |
CALCIUM IONIZED |
$293.52 |
82374 |
CARBON DIOXIDE BICARBONATE |
$99.50 |
82375 |
Under Chemistry Procedures |
$400.00 |
82435 |
CHLORIDE BLD |
$152.68 |
82465 |
CHOLESTEROL SERUM/WHOLE BLOOD TOTAL |
$159.20 |
82533 |
CORTISOL TOTAL |
$365.25 |
82540 |
CREATINE |
$68.00 |
82541 |
COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE |
$121.00 |
82550 |
CREATINE CK-TOTAL |
$195.02 |
82553 |
CREATINE CKMB |
$257.01 |
82565 |
CREATININE |
$257.70 |
82607 |
VITAMIN B-12 |
$72.00 |
82747 |
ASSAY OF FOLIC ACID RBC |
$310.20 |
82784 |
IGC IMMUNOGLOBULIN |
$403.97 |
82785 |
GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE |
$182.00 |
82800 |
GASES BLD PH ONLY |
$130.00 |
82803 |
BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 |
$529.80 |
82805 |
Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (… |
$569.62 |
82945 |
GLUCOSE BODY FLUID OTHER THAN BLOOD |
$299.25 |
82947 |
GLUCOSE |
$163.43 |
82948 |
GLUCOSE BLOOD REAGET STR |
$409.94 |
82962 |
GLUCOSE FINGER STICK |
$155.63 |
82977 |
GLUTAMYLTRANSFERASE-GTT |
$296.97 |
83009 |
HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE |
$490.00 |
83013 |
HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE |
$439.79 |
83036 |
HEMOGLOBIN GLYCOSYLATED A1C |
$278.64 |
83037 |
Hemoglobin, glycosylated |
$117.00 |
83050 |
Under Chemistry Procedures |
$350.00 |
83520 |
IMMUNOASSAY ANALYTE QUANTITIATIVE NOS |
$144.00 |
83525 |
ASSAY OF INSULIN TOTAL |
$172.14 |
83540 |
IRON-TOTAL |
$102.00 |
83605 |
ASSAY OF LACTATE |
$210.00 |
83615 |
Lactate dehydrogenase (LD), (LDH); |
$265.66 |
83690 |
LIPASE |
$409.50 |
83718 |
LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL |
$356.12 |
83735 |
MAGNESIUM |
$391.18 |
83874 |
MYOGLOBIN |
$180.10 |
83880 |
B-TYPE NATRIURETIC |
$555.21 |
83992 |
ASSAY OF PHENCYCLIDINE |
$455.00 |
84075 |
ALK PHOS/PROFILE OR PANEL |
$225.22 |
84100 |
ASSAY OF PHOSPHORUS INORGANIC |
$234.49 |
84132 |
POTASSIUM SERUM PLASMA/WHOLE BLOOD |
$219.90 |
84153 |
Prostate specific antigen (PSA); total |
$288.00 |
84155 |
PROTEIN,TOTAL,EXCEPT REFR |
$77.31 |
84157 |
PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC |
$211.04 |
84165 |
PROTEIN ELECTROPHORESIS |
$1.00 |
84295 |
SODIUM; SERUM |
$180.59 |
84403 |
Testosterone; total |
$335.32 |
84436 |
THYRIXINE TOTAL |
$243.23 |
84439 |
THYROXINE-FREE |
$200.99 |
84443 |
Thyroid stimulating hormone (TSH) |
$263.00 |
84450 |
Transferase; aspartate amino (AST) (SGOT) |
$95.52 |
84460 |
ALT-TRANSFERASE;ALANINE |
$385.55 |
84478 |
ASSAY OF TRIGLYCERIDES |
$244.52 |
84479 |
THYROID HORMONE |
$224.87 |
84480 |
T3 TOTAL |
$601.80 |
84481 |
ASSAY OF TRIIODOTHYRONINE T3 FREE |
$123.38 |
84484 |
TROPONIN I |
$436.80 |
84512 |
TROPONIN QUAL |
$379.35 |
84520 |
Urea nitrogen; quantitative |
$194.27 |
84550 |
URIC ACID |
$93.53 |
84560 |
URIC ACID OTH SRC |
$138.00 |
84702 |
HCG QUANTATIVE |
$324.37 |
84703 |
PREGNANCY TEST BLOOD |
$419.34 |
84999 |
UNLISTED CHEMISTRY PROCEDURE |
$435.56 |
85014 |
HEMATOCRIT |
$102.00 |
85018 |
HEMOGLOBIN |
$326.81 |
85025 |
Blood count; complete (CBC) |
$256.76 |
85027 |
CBC W/O DIFF |
$236.11 |
85032 |
BLD# MNL C-CNT RBC/PLTLT EA |
$152.00 |
85044 |
RETICULOCYTE COUNT |
$21.00 |
85347 |
COAGJ TM ACTIVATED |
$35.00 |
85378 |
FIBRIN DEGRADATION PROD |
$151.24 |
85379 |
D-DIMER |
$267.46 |
85397 |
Coagulation and fibrinolysis, functional activity, not othe… |
$591.00 |
85610 |
PROTHROMBIN TIME |
$297.90 |
85651 |
SEDIMENTATION RATE NONAUT |
$189.05 |
85652 |
SED RATE ERYTHROCYTE NON |
$179.40 |
85730 |
THROMBOPLASTIN TIME PART |
$393.00 |
86038 |
ANTINUCLEAR AB |
$117.01 |
86039 |
ANTINUCLEAR AB TITER |
$409.50 |
86060 |
ANTISTREPTOLYSIN O TITER |
$108.65 |
86140 |
C REACTIVE PROTEIN |
$274.62 |
86235 |
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD |
$317.90 |
86256 |
SMOOTH MUSCLE AB TITER |
$1.00 |
86308 |
MONO,HETEROPHILE ANTIBODI |
$328.69 |
86318 |
Immunoassay for infectious agent antibodies, qualitative or… |
$125.00 |
86320 |
IMMUNOELECTROPHORESIS |
$1.00 |
86328 |
COVID-19 RAPID ANTIBODY TEST SINGLE METHOD |
$100.00 |
86360 |
T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO |
$627.00 |
86376 |
Microsomal antibodies (eg, thyroid or liver-kidney), each |
$140.00 |
86403 |
MONO SPOT |
$134.00 |
86430 |
RHEUMATOID FACTOR |
$74.00 |
86431 |
RHEUMATOID FACTOR QUANTITATIVE |
$321.00 |
86580 |
Skin test; tuberculosis, intradermal |
$122.00 |
86592 |
Syphilis test, non-treponemal antibody; qualitative (eg, VD… |
$77.00 |
86593 |
Syphilis test, non-treponemal antibody; quantitative |
$349.00 |
86631 |
ANTB CHLAMYDIA |
$130.00 |
86644 |
ANTIBODY CYTOMEGALOVIRUS CMV |
$650.00 |
86645 |
ANTIBODY CYTOMEGALOVIRUS CMV IGM |
$150.00 |
86664 |
EPSTEIN-BARR VIRUS EBNA |
$133.00 |
86677 |
ANTIBODY HELICOBACTER PYLORI |
$700.00 |
86689 |
ANTB HTLV/HIV ANTB CONFIRMATION TST |
$481.59 |
86695 |
Antibody; herpes simplex, type 1 |
$177.00 |
86696 |
Antibody; herpes simplex, type 2 |
$458.76 |
86701 |
HIV SERUM |
$523.55 |
86702 |
ANTB HIV-2 |
$164.00 |
86705 |
HEPATITIS B CORE IGM |
$187.00 |
86713 |
LEGIONELLA PNEUMONPILA AB |
$88.00 |
86735 |
Antibody; mumps |
$550.68 |
86756 |
ANTB RSV |
$143.00 |
86769 |
COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD |
$100.00 |
86780 |
TP-Under Qualitative or Semi quantitative Immunologists- |
$87.56 |
86803 |
HEPATITIS C ANTIBODY |
$402.75 |
86850 |
ANTB SCR RBC EA SERUM TQ |
$189.00 |
86900 |
Blood typing, serologic; ABO |
$131.78 |
86901 |
RH FACTOR-BLOOD |
$164.50 |
86906 |
BLD TYPING RH PHEXYPING COMPL |
$86.00 |
87040 |
BLOOD CULTURE |
$480.31 |
87045 |
CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL |
$571.13 |
87046 |
Culture, bacterial; stool, aerobic, additional pathogens, i… |
$187.00 |
87070 |
CULTURE BODY FLUID |
$508.50 |
87075 |
CULTURE ANAEROBIC |
$346.26 |
87076 |
CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL |
$510.00 |
87077 |
CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL |
$197.01 |
87081 |
CULTURE, BACTERIAL-SCREEN |
$493.02 |
87086 |
URINE CULTURE |
$277.90 |
87088 |
CULTURE BCT ISOL&PRSMPTV |
$286.90 |
87106 |
CUL FNGI DEFINITIVE ID EA ORGANISM YEAST |
$85.00 |
87110 |
CHLAMYDIA CULTURE |
$260.00 |
87140 |
Culture, typing; immunofluorescent method, each antiserum |
$85.00 |
87177 |
Ova and parasites, direct smears, concentration and identif… |
$217.31 |
87186 |
Susceptibility studies, antimicrobial agent |
$254.00 |
87205 |
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL |
$173.43 |
87207 |
SMR PRIM SRC SPEC STAIN |
$1.00 |
87210 |
WET SMEAR |
$91.00 |
87252 |
VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT |
$240.79 |
87255 |
Herpes Simplex Virus Culture with Reflex Typing |
$309.00 |
87275 |
IAADI INF B VIRUS |
$55.00 |
87338 |
IAAD IA HPYLORI STOOL |
$66.86 |
87339 |
IAAD IA PYLORI |
$301.00 |
87340 |
IAAD IA HEPATITIS B SURFACE ANTIGEN |
$3.79 |
87341 |
IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION |
$474.12 |
87389 |
infection agent etc |
$203.50 |
87400 |
INFLUENZA A&B |
$174.00 |
87420 |
IAAD IA RESPIRATORY SYNCTIAL VIRUS |
$578.02 |
87426 |
COVID-19 RAPID ANTIGEN TESTING |
$349.00 |
87427 |
Infectious agent antigen detection by immunoassay technique… |
$111.00 |
87428 |
Multiplex viral pathogen panel using Antigen technique for … |
$843.00 |
87430 |
INF AGT IMMUNO STREP A |
$234.00 |
87480 |
IADNA CANDIDA SPECIES DIRECT PROBE TQ |
$500.00 |
87486 |
IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ |
$640.78 |
87491 |
IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ |
$501.48 |
87493 |
INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE |
$197.00 |
87507 |
IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 |
$500.00 |
87522 |
Infectious agent detection by nucleic acid (DNA or RNA); he… |
$142.84 |
87581 |
IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ |
$700.00 |
87591 |
IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ |
$370.70 |
87633 |
IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET |
$1,500.00 |
87635 |
Infectious agent detection by nucleic acid (DNA or RNA); se… |
$275.00 |
87636 |
severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)… |
$700.00 |
87661 |
IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH |
$546.00 |
87798 |
IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM |
$700.00 |
87801 |
Infectious agent detection by nucleic acid |
$500.00 |
87804 |
INFLUENZA IMMUNOASSAY OPT |
$346.50 |
87806 |
Infectious agent antigen detection by immunoassay with dire… |
$230.00 |
87807 |
INF AGT DET IMNAS OPT RSV |
$201.39 |
87808 |
Infectious agent antigen detection by immunoassay with dire… |
$253.75 |
87847 |
NO DESCRIPTION |
$409.00 |
87850 |
NEISSERIA GONORRHOEAE DET |
$130.00 |
87880 |
RAPID STREP-BETA STREP |
$820.00 |
87905 |
Infectious agent enzymatic activity other than virus eg, si… |
$172.00 |
88305 |
PATH SURG LEVEL IV |
$1.00 |
89051 |
CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT |
$325.00 |
89055 |
LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE |
$185.07 |
89060 |
CRYSTAL INDENTIFICATION |
$277.60 |
89220 |
SPTM OBTG SPEC AERSL INDUCED SPX |
$98.00 |
90471 |
IMMUN ADM 1 VAC |
$203.05 |
90660 |
INFLUENZA VIRUS INTRANASA |
$70.00 |
90688 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, … |
$480.00 |
90700 |
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM |
$72.52 |
90703 |
TETANUS TOXID |
$152.00 |
90714 |
TETANUS DIPHTHERIA TOXOID |
$302.98 |
90715 |
TDAP VACCINE |
$292.53 |
90718 |
TETANUS & DIPTHERIA |
$229.76 |
90746 |
HEPATITIS B VACCINE/ADULT |
$79.00 |
90765 |
IV NFS THER PROPH/DX 1ST |
$210.00 |
90997 |
HEMOPERFUSION |
$409.00 |
91105 |
GASTRIC INTUBATION/ASPER |
$596.00 |
92002 |
OPH MEDICAL XM&EVAL INTRM |
$1.00 |
92081 |
VIS FLD XM UNI/BI I&R LMT |
$1.00 |
92552 |
PURE TONE AUDIOMTRY AIR O |
$1.00 |
92950 |
Cardiopulmonary resuscitation (eg, in cardiac arrest) |
$1,906.00 |
92960 |
CARDIOVERSION ELECTIVE ARRHYT XTRNL |
$1,089.00 |
92961 |
Cardioversion, elective, electrical conversion of arrhythmi… |
$2,783.00 |
93000 |
EKG W/INTREP AND REPORT |
$335.81 |
93005 |
Electrocardiogram, routine ECG with at least 12 leads; trac… |
$752.95 |
93010 |
RTN ECG 12 LEADS INTRP/RP |
$213.75 |
93018 |
CV STRS TST XERS&/OR RX CONT ECG I&R ONLY |
$1,000.00 |
93040 |
RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT |
$335.81 |
93041 |
RHYTHEM ECG 1-3 LDS |
$146.00 |
93042 |
RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON |
$550.00 |
93224 |
WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I |
$924.00 |
93306 |
ECHO TEST |
$3,658.22 |
93307 |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
$2,967.50 |
93308 |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
$3,794.06 |
93313 |
TEE R-T IMG 2D W/PROBE PLMT ONLY |
$2,626.00 |
93320 |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
$1,417.50 |
93325 |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
$1,485.00 |
93351 |
ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG |
$1,000.00 |
93631 |
INTRAOP EPICAR& ENDOCAR PACG& MAPG |
$650.00 |
93784 |
Ambulatory blood pressure monitoring, |
$500.00 |
93875 |
N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD |
$840.00 |
93880 |
DUP-SCAN XTRC ART COMPL B |
$2,508.98 |
93882 |
DUP-SCAN XTRC ART UNI/LMTD STD |
$903.00 |
93922 |
NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL |
$1,643.74 |
93923 |
NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS |
$3,155.00 |
93925 |
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY |
$2,342.23 |
93926 |
DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD |
$2,351.97 |
93930 |
DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY |
$2,379.04 |
93931 |
DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD |
$2,599.96 |
93965 |
QUANT VENOUS FLOW ST |
$1,806.00 |
93970 |
DUP-SCAN XTR VEINS COMPL |
$3,938.65 |
93971 |
DPLX SCN EXTRM VEINS |
$2,716.05 |
93975 |
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… |
$4,000.50 |
93976 |
DUPLEX SCAN- LIMITED |
$466.00 |
94010 |
SPIROMETRY W/RECORD |
$922.50 |
94060 |
BRNCDILAT RSPSE SPMTRY PR |
$385.00 |
94150 |
Vital capacity test |
$445.30 |
94621 |
PULM STRS TSTG CPLX |
$1,029.00 |
94640 |
NEBULIZER TREATMENT |
$277.77 |
94644 |
INHALATION TREATMENT – CONTINUOUS 1ST HR |
$157.00 |
94664 |
DEMO&/EVAL OF PT UTILIZ |
$1.00 |
94760 |
EAR OR PULSE OXIMETRY |
$500.00 |
94761 |
N-INVAS EAR/PLS OXIMTRY F |
$458.96 |
94762 |
NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR |
$734.25 |
96360 |
IV INFUS INIT 31 MIN 1 HR |
$784.50 |
96361 |
IV INFUS HYDR EA ADD’T HR |
$242.78 |
96365 |
IV INFUSION THERAPY/PROPH |
$904.22 |
96366 |
IV INFUS THER PROPH/DX EA |
$811.12 |
96367 |
IV NFS THER PROPH/DX ADDL |
$1,029.94 |
96368 |
IV NFS TX PROPHYLAXIS/DX |
$749.14 |
96372 |
THERAPEUTIC PROPHYLACTIC/ |
$503.55 |
96373 |
INJECTION, INTRA-ARTERIAL |
$228.00 |
96374 |
THER PROPH/DX NJX IV PUSH |
$790.12 |
96375 |
THER PROPH/DX NJX EA SEQL |
$532.88 |
96376 |
SUB INFU EA ADD IV PUSH |
$578.93 |
96377 |
APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION |
$720.00 |
96379 |
INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS |
$213.00 |
97010 |
APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS |
$183.21 |
97116 |
THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR |
$197.01 |
97542 |
WHEELCHAIR MGMT EA 15 MIN |
$320.39 |
97597 |
DEBRIDEMENT OPEN WOUND 20 SQ CM/< |
$736.30 |
99000 |
SPECIMEN HANDLING |
$52.00 |
99001 |
COC COLLECITON ONLY |
$41.00 |
99024 |
POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX |
$650.00 |
99050 |
BLUE CROSS RQRD LVL3 |
$87.00 |
99053 |
SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY |
$150.00 |
99070 |
SUPPLIES&MATERIALS ABOVE or BEYOND PROV BY PHYS or QHP |
$93.53 |
99080 |
MEDICAL RECORDS |
$46.00 |
99143 |
MOD SEDATION <5YRS 30 |
$439.00 |
99144 |
MOD SEDATION SERV UNDER 5 |
$433.00 |
99145 |
M-SEDAJ BY SM PHY 15 MIN |
$168.00 |
99149 |
MOD SEDATION |
$363.00 |
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 |
99153 |
Moderate sedation services provided by the same physician o… |
$288.00 |
99173 |
SCREENING TEST OF VISION |
$1,300.00 |
99217 |
OBSERVATION CARE DISCHARGE MANAGEMENT |
$1,200.00 |
99218 |
INITIAL OBSERVATION CARE/DAY 30 MINUTES |
$242.78 |
99219 |
INITIAL OBSERVATION CARE/DAY 50 MINUTES |
$1,800.00 |
99220 |
INITIAL OBSERVATION CARE/DAY 70 MINUTES |
$3,250.00 |
99234 |
OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES |
$1,800.00 |
99235 |
OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES |
$2,000.00 |
99236 |
OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES |
$2,200.00 |
99245 |
OFF/OP CONSLTJ NEW/EST HI 55 |
$406.78 |
99281 |
E/M VISIT LEVEL 1 TECH COMP |
$0.01 |
99282 |
E/M VISIT LEVEL 2 TECH COMP |
$1,125.75 |
99283 |
E/M VISIT LEVEL 3 TECH COMP |
$2,012.25 |
99284 |
E/M VISIT LEVEL 4 TECH COMP |
$3,009.75 |
99285 |
E/M VISIT LEVEL 5 TECH COMP |
$5,000.00 |
99291 |
CRITICAL CARE 30-74 MIN |
$5,434.38 |
99292 |
CRITICAL CARE ADD 30 MIN |
$2,500.00 |
99406 |
SMOKING CESSATION 3-10 |
$69.54 |
99407 |
SMOKING CESSATION 10 MIN |
$94.00 |
A0382 |
BASIC SUPPORT ROUTINE SUPPLS |
$18.00 |
A0394 |
ALS IV DRUG THERAPY SUPPLIES |
$1.02 |
A0396 |
ALS ESPOHAGEAL INTUB SUPPLIES |
$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 |
NEEDLE STERILE, ANY SIZE, EACH |
$10.75 |
A4216 |
STERILE WATER/SALINE, FLUSH 10ML |
$3.00 |
A4217 |
STERILE SALINE WATER PER 500 ML |
$22.80 |
A4218 |
STERILE SALINE OR WATER |
$26.00 |
A4221 |
SUPP NON-INSULIN INF CATH/WK |
$20.00 |
A4222 |
EXT UNFU PMP PER CASS/BAG |
$176.00 |
A4223 |
INFUSION SUPPLIES W/O PUMP |
$40.00 |
A4224 |
ALOCHOL OR PEROXIDE PER PINT |
$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 |
$42.00 |
A4252 |
GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP |
$6.00 |
A4253 |
BLOOD GLUCOSE/REAGENT STRIPS |
$10.00 |
A4270 |
DISPOSABLE ENDO CODE SHEATH |
$24.00 |
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 |
INSRT TRAY W/DRAINAGE BAG |
$44.00 |
A4315 |
CATH W/DRAINAGE 2-WAY SILCNE |
$18.00 |
A4316 |
CATH W DRAINAGE 3 WAY |
$90.00 |
A4320 |
IRR TRAY W/BULB/PISTON SY |
$9.00 |
A4322 |
IRRIGATION SYRINGE, BULB |
$15.00 |
A4327 |
URIN CUP FEMALE COLLECT DEV CUP |
$10.00 |
A4332 |
LUBE STERILE PACKET |
$12.00 |
A4335 |
INCONTINENCE SUPPLY MISC |
$3.00 |
A4338 |
INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING |
$15.00 |
A4344 |
INDWELLING CATH FOLEY TYP |
$19.00 |
A4352 |
COUDE TIP URINARY CATHETER |
$20.00 |
A4353 |
INTERMIT URINARY CATHETER |
$120.00 |
A4358 |
URINARY DRAINAGE BAG |
$12.50 |
A4364 |
DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ |
$33.00 |
A4369 |
SKIN BARRIER LIQUID PER OZ |
$10.00 |
A4402 |
LUBRICANT PER OUNCE |
$10.00 |
A4406 |
PECTIN BASED OSTOMY PASTE |
$12.00 |
A4450 |
TAPE NO WATERPROOF |
$10.00 |
A4452 |
TAPE WATERPROOF 18 SQ IN |
$12.00 |
A4458 |
REUSABLE ENEMA BAG |
$25.00 |
A4465 |
NON-ELASTIC EXTREMITY BINDER |
$20.00 |
A4470 |
GRAVLEE JET WASHER |
$15.00 |
A4550 |
LACERATION- SURGICAL KIT |
$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 |
SLING |
$183.82 |
A4566 |
SHOULD SLING/VEST/ABRESTRAIN |
$25.00 |
A4570 |
SPECIAL CASTING MATERIAL |
$50.00 |
A4580 |
CAST SUPPLIES (PLASTER) |
$35.00 |
A4590 |
3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL |
$84.00 |
A4595 |
TENS SUPPL 2 LEAD PER MONTH |
$46.00 |
A4606 |
OXYGEN PROBE USED W OXIMETER |
$20.00 |
A4613 |
BATTERY CHARGER |
$60.00 |
A4614 |
HAND HELD PEFR METER |
$50.00 |
A4615 |
CANNULA NASAL |
$20.00 |
A4616 |
TUBING (OXYGEN) PER FOOT |
$25.00 |
A4617 |
MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT |
$55.00 |
A4620 |
VARIABLE CONCENTRATION MASK |
$15.00 |
A4628 |
OROPHARYNGEAL SUCTION CATH |
$20.00 |
A4629 |
TRACHEOSTOMY CARE KIT |
$35.00 |
A4649 |
SURGICAL SUPPLY MISC |
$40.00 |
A4653 |
PD CATHERTER ANCHOR BELT |
$20.00 |
A4657 |
SYRINGE W OR WO NEEDLE |
$10.00 |
A4670 |
AUTOMATIC BP MONITOR #11 |
$30.00 |
A4673 |
SALINE BLADE #11 |
$15.00 |
A4750 |
ART OR VENOUS BLOOD TUBING |
$20.00 |
A4770 |
BLOOD COLLECTION TUBE or VACUUM |
$25.00 |
A4927 |
GLOVES NON STERILE |
$10.00 |
A4930 |
GLOVES STERILE PER PAIR |
$12.00 |
A5112 |
URINARY LEG BAG |
$20.00 |
A5120 |
SWAB OR WIPE SKIN BARRIER |
$12.00 |
A5126 |
DISK/FOAM PAD +OR- ADHESIVE |
$15.00 |
A5200 |
PERCUTANEOUS CATHETER ANCHOR |
$117.00 |
A6021 |
COLLAGEN DRESSING STERIL |
$15.00 |
A6196 |
ALGINATE DRESSING <=16 SQ IN |
$20.00 |
A6203 |
COMPOSITE DRSG <= 16 SQ IN |
$15.00 |
A6205 |
COMPOSITE DRSG LESS THAN 48 SQ IN |
$22.00 |
A6208 |
CONTACT LAYER > 48 SQ IN |
$20.00 |
A6209 |
FOAM DRSG <=16 SQ IN W/O BDR |
$15.00 |
A6210 |
FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER |
$98.00 |
A6211 |
FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER |
$31.00 |
A6212 |
FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ IN OR LESS, EACH… |
$15.00 |
A6213 |
FOAM DRG 16-48 SQ IN W/BRDR |
$11.00 |
A6216 |
GAUZE NONIMPREG 16 SQ IN |
$10.00 |
A6217 |
GAUZE NON STERILE |
$12.00 |
A6218 |
GAUZE, NON STERILE |
$15.00 |
A6219 |
GAUZE- STERILE |
$10.00 |
A6220 |
GAUZE, NON IMP, STERILE, PAD SIZE >16 SQ < OR = 48SQ IN |
$12.00 |
A6221 |
GAUZE > 48 SQ IN W/BORDER |
$15.00 |
A6222 |
GAUZE IMPREGNATED WITH ME |
$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 |
GAUZE, 16<SQ IN, EACH |
$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 MOISTURIZER OINTMENT |
$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 |
$100.00 |
A6261 |
WOUND FILLER |
$100.00 |
A6266 |
IMPREG GAUZE NO H20/SAL/YARD |
$22.00 |
A6402 |
GAUZE NON-IMPREG STERL 16 |
$15.00 |
A6403 |
STERILE GAUZE>16 <= 48 SQ IN |
$15.00 |
A6404 |
STERILE GAUZE > 48 SQ IN |
$18.00 |
A6407 |
PACK STRIPS NON-IMPREGNTD |
$15.00 |
A6410 |
STERILE EYE PAD OR STRIP |
$6.00 |
A6412 |
OCCLUSIVE EYE PATCH |
$15.00 |
A6413 |
ADHESIVE BANDAGE FIRST AI |
$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 |
CONFORMING BANDAGE NON-EL |
$15.00 |
A6447 |
CONFORM BAND S W >=5/YD |
$18.00 |
A6448 |
LT COMP BANDAGE LESS THAN 3IN |
$12.00 |
A6449 |
LIGHT COMP BANDAGE |
$15.00 |
A6450 |
LT COMPRS BANDAGE ELAST |
$18.00 |
A6453 |
BANDAGE SELF ADHER BAND W LESS THAN 3 |
$25.00 |
A6454 |
SELF ADHER BANDAGE |
$12.00 |
A6455 |
SELF ADHER BANDAGE |
$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 |
SUCTION TUBING USED W PUMP |
$40.00 |
A7003 |
ADMN SET SM VOL NONFILTER |
$35.00 |
A7004 |
DISPOSABLE NEBULIZER SML VOL |
$35.00 |
A7005 |
NONDISPOSABLE NEBULIZER SET |
$30.00 |
A7006 |
FILTERED NEBULIZER ADMIN SET |
$25.00 |
A7011 |
NONDISPOS CORRUGATED TUBING |
$12.00 |
A7015 |
NEBULIZER MASK USED W NEBULIZER |
$25.00 |
A7016 |
DOME/MOUTHPEICE NEB |
$161.00 |
A7017 |
NEBULIZER MASK NOT USED W/ OXYGEN |
$57.00 |
A7030 |
CPAP FULL FACE MASK |
$20.00 |
A7046 |
REPL WATER CHAMBER, PAP DEV |
$30.00 |
A7047 |
RESP SUCTION ORAL INTERFACE |
$25.00 |
A7520 |
TRACH LARYN TUBE NON CUFFED |
$37.00 |
A9150 |
NON PERSCRIPTION DRUG |
$35.00 |
A9270 |
NON-COVERED ITEM OR SERVICE |
$50.00 |
A9273 |
HOT/COLD H2OBOT/CAP/COL/WRAP |
$35.00 |
A9281 |
REACHING/GRABBING DEVICE |
$80.00 |
A9284 |
NON-ELECTRONIC SPIROMETER |
$254.00 |
A9579 |
GAD-BASE MR CONTRAST NOS,1ML |
$15.00 |
C1722 |
AICD, SINGLE CHAMBER |
$400.00 |
C1751 |
CATH, INF, PER/CENT/MIDLINE |
$505.75 |
C1781 |
MESH (IMPLANTABLE) |
$475.00 |
C2618 |
PROBE/NEEDLE, CRYO |
$35.00 |
C9285 |
PATCH, LIDOCAINE/TETRACAINE |
$20.00 |
C9399 |
ORBACTIV 1200 MG IV |
$10,153.00 |
CASH |
XRAY DISC |
$17.00 |
E0110 |
CRUTCH FOREARM PAIR |
$225.00 |
E0114 |
CRUTCHES UNDERARM |
$250.00 |
E0116 |
CRTCH UNDARM NOT WOOD ADJ |
$200.00 |
E0220 |
HOT WATER BOTTLE |
$35.00 |
E0230 |
ICE CAP OR COLLAR |
$12.00 |
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 |
E0352 |
DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) |
$177.00 |
E04114 |
E04114 |
$41.00 |
E0445 |
OXIMETER NON-INVASIVE |
$578.00 |
E0570 |
NEBULIZER WITH COMPRESSION |
$200.00 |
E0580 |
NEBULIZER FOR USE W/ REGULAT |
$293.00 |
E0607 |
BLOOD GLUCOSE MONITOR HOME |
$80.00 |
E0625 |
PATIENT LIFT BATHROOM OR TOI |
$200.00 |
E2630 |
MONOSUSPENSION ARM/HAND SUPP |
$3,379.10 |
G0009 |
ADM PNEUMOCOCCAL VACCINE |
$90.00 |
G0168 |
WND CLS TISSUE ADHESIVE |
$100.00 |
G0378 |
HOSPITAL OBSERVATION SERVICES PER HOUR |
$2,000.00 |
G0402 |
INITIAL PREVENTIVE EXAM |
$1,500.00 |
G0434 |
DRUG ABUSE PANEL II |
$230.00 |
G2023 |
specimen collection for severe acute respiratory syndrome c… |
$30.00 |
G2024 |
specimen collection for severe acute respiratory syndrome c… |
$200.00 |
G6039 |
Acetaminophen or just “Assay of acetaminophen†for shor… |
$150.00 |
G6040 |
Saliva Alcohol Test |
$131.34 |
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 |
INJECTION, ACETAMINOPHEN, 10 MG |
$30.00 |
J0150 |
ADENOSINE INJ 6MG VIAL |
$65.00 |
J0153 |
ADENOSINE INJ 1MG |
$40.00 |
J0170 |
EPINEPHRINE 3 1/2 NDL 10M |
$12.44 |
J0171 |
ADRENALIN EPINEPHRINE INJECT |
$30.00 |
J0282 |
INJ AMIODARONE HYDROCHLOR |
$25.00 |
J0290 |
AMPICILLIN 500 MG INJ |
$45.77 |
J0295 |
INJ AMPCLLN SODIUM/SULBA |
$20.00 |
J0330 |
SUCCINYLCHOLINE CHLO 20MG |
$173.00 |
J0360 |
HYDRALAZINE HCL INJ UP TO 20MG |
$30.00 |
J0456 |
INJ AZITHROMYCIN 500MG |
$25.00 |
J0461 |
INJ ATROPINE SULFATE 0.01 |
$20.00 |
J0500 |
DICYCLOMINE HCL 20MG |
$45.00 |
J0515 |
Injection, benztropine mesylate, per 1 mg |
$19.02 |
J0550 |
BICILLIN – PENICILLIN G BENZATHINE INJ |
$65.00 |
J0559 |
BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS |
$65.00 |
J0560 |
BICILLIN 600,000 |
$50.00 |
J0561 |
INJECTION PENICILLIN G BENZATHINE 100,000 UNITS |
$30.00 |
J0570 |
BICILLIN 1,200,000 |
$110.00 |
J0595 |
STADOL |
$13.00 |
J0610 |
CALCIUM GLUCONATE INJECTION |
$30.00 |
J0641 |
LEVOLEUCOVORIN INJECTION |
$2.00 |
J0690 |
KEFZOL 1 GR VIAL |
$25.00 |
J0692 |
INJ CEFEPIME HCI 500MG |
$46.00 |
J0696 |
ROCEPHIN 250 MG |
$30.00 |
J0697 |
STERILE CEFUROXIME INJECTION |
$25.00 |
J0698 |
CLAFORAN 1 GR VIAL |
$63.00 |
J0708 |
J0708 |
$22.00 |
J0735 |
CLONIDINE 1MG |
$25.00 |
J0744 |
CIPRO 200MG |
$30.00 |
J0760 |
COLCHICINE INJECTION |
$23.00 |
J0780 |
COMPAZINE 10 MG |
$30.00 |
J1020 |
INJ METHYLPREDNISOLONE AC |
$20.00 |
J1030 |
DEPO MEDROL 40 MG/ML |
$22.00 |
J1040 |
METHYLPREDNISOLONE 80MG |
$25.00 |
J1094 |
DECADRON DEXAMETHASONE ACETATE 1MG |
$32.53 |
J1100 |
DECADRON 4 MG VIAL |
$29.02 |
J1110 |
dihydroergotamine mesylate |
$240.00 |
J1165 |
DILANTIN 100 MG VIAL |
$41.00 |
J1170 |
DILAUDID 4 MG |
$35.00 |
J1200 |
BENADRYL 50MG |
$20.00 |
J1240 |
ANTIVERT – DIMENHYDRINATE INJECTION 50MG |
$33.00 |
J1335 |
ERTAPENEM INJECTION |
$21.00 |
J1580 |
GARAMYCIN,GENTAMICIN 80MG |
$50.00 |
J1610 |
GLUCOGAN 1 MG VIAL |
$50.00 |
J1630 |
HALOPERIDOL INJECTION |
$39.70 |
J1631 |
HALOPERIDOL DECANOATE INJ |
$45.00 |
J1642 |
HEPARIN SODIUM PER 10 UNI |
$20.00 |
J1644 |
INJ HEPARIN SOD PER 1000 |
$30.00 |
J1650 |
ENOXAPARIN SODIUM 10MG |
$258.09 |
J1670 |
TETANUS INJECTION |
$41.00 |
J1741 |
IBUPROFEN INJECTION |
$22.00 |
J1810 |
DROPERIDOL/FENTANYL INJ |
$25.00 |
J1815 |
INJ INSULIN PER 5 UNITS |
$20.00 |
J1817 |
INSULIN FOR INSULIN PUMP USE |
$22.00 |
J1885 |
TORADOL INJ 15 MG |
$20.00 |
J1930 |
LANREOTIDE INJECTION |
$45.00 |
J1940 |
LASIX 40 MG IV VIAL |
$35.00 |
J1956 |
LEVOFLOXACIN 250 MG |
$45.00 |
J2001 |
LIDOCAINE HCI 10MG |
$30.00 |
J2060 |
ATIVAN 2ML SYRUP |
$35.00 |
J2150 |
MANNITOL INJECTION |
$26.00 |
J2175 |
DEMEROL 50 MG SYRINGE |
$25.00 |
J2180 |
MEPERIDINE/PROMETHAZINE INJ |
$30.00 |
J2250 |
MIDAZOLAM HCI PER 1 MG |
$30.00 |
J2270 |
INJ MORPHINE SULFATE 10 M |
$30.00 |
J2274 |
INJ MORPHINE PF EPID ITHC |
$30.00 |
J2300 |
NUBAIN 10MG AMP |
$50.00 |
J2310 |
INJ NALOXONE HCL 1MG |
$30.00 |
J2360 |
ORPHENADRINE CITRATE 60MG |
$30.00 |
J2370 |
NEO-SYNEPHRINE UP TO 1 ML |
$81.00 |
J2405 |
ONDANSETRON HCI, PER MG |
$21.00 |
J2410 |
OXYMORPHONE HCL INJECTION |
$25.00 |
J2425 |
PALIFERMIN INJECTION |
$25.00 |
J2426 |
Injection, paliperidone palmitate extended release, 1 mg |
$13.04 |
J2504 |
PEGADEMASE BOVINE, 25 IU |
$25.00 |
J2543 |
ZOSYN – PIPERACILLIN/TAZOBACTAM |
$30.00 |
J2550 |
PHENERGAN 50 MG |
$35.00 |
J2650 |
PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML |
$6.00 |
J2690 |
PRONESTYL 10 ML |
$22.00 |
J2704 |
INJ, PROPOFOL, 10 MG |
$22.00 |
J2730 |
PRALIDOXINE CHLORIDE |
$22.00 |
J2760 |
PHENTOLAINE MESYLATE INJ |
$41.00 |
J2765 |
METOCLOPRAMIDE HCL 10MG |
$30.00 |
J2770 |
Quinupristin/dalfopristin |
$20.00 |
J2780 |
INJ RANITIDINE 25 MG |
$20.00 |
J2790 |
RHOGAM INJECTION |
$199.00 |
J2800 |
METHOCARBAMOL INJECTION |
$50.00 |
J2920 |
SOLU-MEDROL 40MG |
$32.00 |
J2930 |
SOLU-MEDROL 125 MG |
$35.00 |
J3010 |
INJ FENTANYL CITRATE .1MG |
$33.00 |
J3030 |
IMITREX 6MG VIAL |
$50.00 |
J3105 |
INJECTION, TREBUTALINE SULFATE, UP TO 1 MG |
$35.00 |
J3130 |
TESTOSTERONE ENANTHATE INJ |
$24.00 |
J3230 |
THOROZINE 50 MG |
$330.00 |
J3260 |
TOBRAMYCIN SULFATE INJECTION |
$50.00 |
J3360 |
VALIUM INJ 5 MG |
$25.00 |
J3370 |
VANCOMYCIN HCI INJ 500MG |
$30.00 |
J3410 |
VISTERIL INJ 50 MG |
$22.00 |
J3411 |
INJ THIAMINE 100 MG |
$11.00 |
J3430 |
INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG |
$50.00 |
J3475 |
MAGNESIUM SULFATE 2CC AMP |
$20.00 |
J3480 |
POTASSIUM CHLORIDE 2 MG |
$125.00 |
J3486 |
GEODON – ZIPRASIDONE MESYLATE 10MG |
$35.00 |
J3490 |
UNCLASSIFIED DRUGS |
$31.00 |
J7030 |
INFUS NORM SALINE 1000CC |
$45.00 |
J7040 |
INFUS NORM SALINE 500ML |
$40.00 |
J7042 |
5% DEXTROSE |
$45.00 |
J7050 |
INFS NORM SALINE 250CC |
$48.00 |
J7060 |
INFUSION D5W 250ML |
$28.00 |
J7070 |
INFUSION D5W 1000ML |
$20.00 |
J7120 |
RINGER’S LACTATE INFUS |
$50.00 |
J7121 |
5% DEXTROSE IN LAC RINGERS |
$50.00 |
J7130 |
HYPERTONIC SALINE SOLUTION |
$76.00 |
J7131 |
HYPERTONIC SALINE SOL |
$20.00 |
J7192 |
FACTOR VIII RECOMBINANT NOS |
$20.00 |
J7313 |
FLUOCINOL ACET INTRAVIT IMP |
$20.00 |
J7506 |
PREDNISONE ORAL 5 MG |
$8.00 |
J7510 |
PREDNISOLONE ORAL 5 MG |
$15.00 |
J7512 |
PREDNISONE 5 MG |
$8.00 |
J7607 |
LEVALBUTEROL COMP CON |
$13.00 |
J7610 |
ALBUTEROL, THRU DME 1MG |
$13.00 |
J7611 |
ALBUTEROL 1MG CONC INHALA |
$35.00 |
J7613 |
ALBUT INHAL NON-CP 1MG |
$35.00 |
J7614 |
ALBUTEROL ALL FOMULATIONS |
$35.00 |
J7615 |
LEVALBTERAL INHALATION SO |
$35.00 |
J7620 |
ALBUTEROL 2.5 MG ATROVENT |
$35.00 |
J7631 |
CROMOLYN SODIUM NONCOMP UNIT |
$20.00 |
J7637 |
DEXAMETHASONE COMP CON |
$20.00 |
J7644 |
IPRATROPIUM BROMIDE INHAL |
$50.00 |
J7682 |
TOBRAMYCIN NON-COMP UNIT |
$25.00 |
J7699 |
NOC DRUGS INHAL SOL ADMIN |
$25.00 |
J8498 |
ENEMA SUPPOSITORY, ANTIEMETIC RECTAL |
$25.00 |
J8499 |
NONCHEMOTHERAPEUTIC ORAL |
$25.00 |
J8540 |
DEXAMETHASONE, ORAL .25MG |
$20.00 |
J9027 |
CLOFARALINE INJECTION |
$141.00 |
J9206 |
IRINOTECAN INJECTION |
$25.00 |
L0112 |
CRANIAL CERVICAL ORTHOSIS |
$250.00 |
L0120 |
CERVICAL FLEX NONADJ COLL |
$397.94 |
L0150 |
CERV SEMI-RIG ADJ MOLDED CHN |
$303.00 |
L0172 |
CLAVICAL COLLAR 2 PC |
$303.00 |
L0174 |
CERV SR 2PC THOR EXT PRE OTS |
$300.00 |
L1630 |
ABDUCT CONTROL HIP SEMI FLEX |
$41.00 |
L1810 |
KO ELASTIC WITH JOINTS |
$750.00 |
L1812 |
Knee orthosis (KO), elastic with joints, prefabricated, off… |
$143.01 |
L1830 |
KNEE IMMOBOLIZER |
$569.33 |
L1902 |
AFO ANKLE GAUNTLET PRE OTS |
$20.00 |
L1906 |
ANKLE SUPPORT |
$133.00 |
L1960 |
Ankle foot orthosis (AFO), posterior solid ankle, plastic, … |
$2,358.00 |
L1971 |
Ankle foot orthosis |
$1,454.62 |
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 |
SURGICAL BOOT/SHOE |
$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 FIGURE EIGHT ABDUCTION |
$204.75 |
L3660 |
SO 8 AB RSTR CAN/WEB PRE OTS |
$375.00 |
L3670 |
SO ACROMIO/CLAVICULAR |
$400.00 |
L3720 |
FOREARM/ARM CUFFS FREE MOTIO |
$550.00 |
L3762 |
Elbow orthosis (EO), rigid, without joints, includes soft i… |
$954.21 |
L3808 |
WHFO, RIGID W/O JOINTS |
$655.20 |
L3809 |
WHFO W/O JOINTS PRE OTS |
$700.00 |
L3905 |
WHO W/NONTORSION JNT(S) CF |
$1,310.98 |
L3906 |
WHO W/O JOINTS CF |
$658.69 |
L3908 |
WRIST EXTN CONTROL COCKUP |
$85.57 |
L3999 |
UPPER LIMB ORTHOSIS NOS |
$176.00 |
L4350 |
AIR SPLINT |
$358.54 |
L4360 |
WALK BOOT PNEUMATIC |
$250.00 |
L4361 |
PNEUMA/VAC WALK BOOT PRE OTS |
$250.00 |
L4380 |
PNEUMATIC KNEE SPLINT |
$125.00 |
L4386 |
WALKING BOOT NON PNEUMATIC |
$285.65 |
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 |
M0239 |
Intravenous infusion, bamlanivimab-xxxx, includes infusion … |
$1,200.00 |
M0243 |
Intravenous infusion, casirivimab and imdevimab, includes i… |
$1,200.00 |
M0245 |
Intravenous infusion, bamlanivimab and etesevimab, includes… |
$1,200.00 |
P7001 |
CULTURE BACTERIAL URINE |
$89.00 |
P9612 |
CATHETERIZE FOR URINE |
$60.00 |
Q0144 |
AZITH DIHY ORAL CAP/POWD |
$15.00 |
Q0169 |
PROMETHAZINE HCL 12.5MG ORAL |
$9.95 |
Q0179 |
ONDANESTRONG HCL 8MG ORL |
$4.00 |
Q0239 |
Injection, bamlanivimab-xxxx, 700 mg |
$0.01 |
Q0243 |
Injection, casirivimab and imdevimab, 2400 mg |
$0.01 |
Q0244 |
Q0244 |
$0.01 |
Q0245 |
Injection, bamlanivimab and etesevimab, 2100 mg |
$0.01 |
Q4001 |
CAST SUP BODY CAST PLASTER |
$900.00 |
Q4006 |
LONG ARM CAST ADULT |
$950.00 |
Q4007 |
CAST SUPPLIES LONG ARM CA |
$15.00 |
Q4008 |
CAST SUPPLIES LONG ARM |
$40.00 |
Q4009 |
CAST SUPPLIES SHORT ARM |
$140.00 |
Q4010 |
SHORT ARM CAST ADULT |
$55.00 |
Q4012 |
CAST SUPPLIES SHORT ARM |
$87.00 |
Q4018 |
CAST SUP LNG ARM SPLINT FBRG |
$320.00 |
Q4019 |
CAST SUP LNG ARM SPLNT PED P |
$750.00 |
Q4020 |
LNG ARM SPLNT 0-10 YRS |
$620.00 |
Q4021 |
CAST SUP SHT ARM SPLINT PLST |
$650.00 |
Q4022 |
SHRT ARM SPLNT 11 YRS + |
$500.00 |
Q4023 |
CAST SUP SHT ARM SPLNT PED P |
$525.00 |
Q4024 |
CAST SUP SHT ARM SPLNT PED F |
$550.00 |
Q4034 |
CAST SUP LNG LEG CYLINDER FB |
$176.00 |
Q4037 |
CAST SUPPLIES SHORT LEG |
$146.00 |
Q4038 |
CAST SUP SHRT LEG FIBERGLASS |
$24.00 |
Q4039 |
CAST SUPPLIES SHORT LEG C |
$146.00 |
Q4042 |
LNG ARM SPLNT 11 YRS + |
$800.00 |
Q4046 |
SHRT LG SPLNT 11 YRS + |
$850.00 |
Q4049 |
FINGER SPLNT STATIC |
$100.00 |
Q4051 |
SPLINT SUPPLIES MISC |
$125.00 |
Q9954 |
ORAL MR CONTRAST, 100ML |
$416.00 |
Q9962 |
HOCM 300-349MG/ML IODINE,1ML |
$60.00 |
Q9963 |
HI OSM CONTRST MATL 350-3 |
$40.00 |
Q9965 |
LOW OSMOLAR CON MAT PER M |
$25.00 |
Q9966 |
LOCM 200-299MG ML IODINE, 1ML |
$22.00 |
Q9967 |
LOW OSMOLAR CNTRS MAT |
$15.00 |
S0020 |
INJ, BUPIVICAINE, 30ML |
$55.00 |
S0028 |
INJECT FAMOTIDINE 20 MG |
$45.00 |
S0030 |
METRONIDAZOLE 500 MG INJ |
$50.00 |
S0077 |
CLANDAMYCIN PHOSPHATE 300 |
$30.33 |
S0119 |
ZOFRAN, 4MG, ORAL |
$21.44 |
S0164 |
PROTONIX PANTROPRAZOLE 40MG |
$45.00 |
S0622 |
PHYS EXAM FOR COLLEGE |
$87.00 |
S0630 |
RMV SUTURES; PHYS NOT PHY |
$300.00 |
S1015 |
IV TUBING EXTENSION SET |
$30.00 |
S3000 |
BILAT DIL RETINAL EXAM |
$11.00 |
S5000 |
PRESCRIPTION DRUG GENERIC |
$10.00 |
S5001 |
PRESCRIPTION DRUG BAND NM |
$15.00 |
S5010 |
STERILE SALINE 5% DEXTROSE AND 0.45% SALINE |
$232.00 |
S5011 |
5% DEXTROSE 1000 ML |
$1.00 |
S5550 |
INSULIN RAPID 5 U |
$26.00 |
S8037 |
MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY |
$1,284.00 |
S8100 |
SPACER WITHOUT MASK |
$38.00 |
S8101 |
MASK NEBULIZER MASK SPACER WITH MASK |
$40.00 |
S8430 |
PADDING FOR COMPRSSN BDG |
$35.00 |
S8431 |
COMPRESSION BANDAGE |
$45.00 |
S8450 |
SPLINT |
$84.00 |
S8451 |
SPLINT WRIST OR ANKLE |
$125.00 |
U0002 |
SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple ty… |
$150.00 |
V2797 |
Vision supply, accessory and/or service component of anothe… |
$25.00 |
V2799 |
Vision item or service, miscellaneous |
$25.00 |