| 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 |
