| CPT Code | CPT Code Description | Charge Amount |
| 0202U | COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing | $1,989.31 |
| 0241U | Infectious disease (viral respiratory tract infection), pat… | $758.89 |
| 10021 | FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE | $4,641.31 |
| 10060 | INCISION/DRAINAGE ABSCESS | $2,286.00 |
| 10061 | INS/DRAIN ABSCESS COMPL | $3,124.00 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $2,960.35 |
| 10081 | I&D PILONIDAL CST COMP | $6,936.97 |
| 10120 | I & RMVL SUB-CUT SIMPLE | $9,595.88 |
| 10121 | I & RMVL FB, SUB-CUT,COMP | $10,100.00 |
| 10140 | I&D HEMATOMA SEROMA/FLUID COLLECTION | $16,133.10 |
| 10160 | PUNCTURE ASP OF ABSCESS | $2,376.65 |
| 10180 | Incision and drainage, complex, postoperative wound infecti… | $20,219.00 |
| 11000 | DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF | $333.96 |
| 11010 | DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS | $12,186.00 |
| 11011 | DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC | $22,069.41 |
| 11042 | DBRD SKN SUBQ TISSUE | $9,761.39 |
| 11043 | DEBRIDEMENT SUBCUTANEOUS TISSUE&MUSCLE | $14,693.47 |
| 11045 | Deb subq tissue add-on | $4,434.64 |
| 11055 | PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 | $649.29 |
| 11056 | PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4 | $1,021.17 |
| 11200 | RMVL SKIN TAGS | $10,474.13 |
| 11402 | EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM | $13,139.00 |
| 11403 | EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM | $23,908.58 |
| 11404 | EXC BGN LSN TRUNK 3.1-4.0 | $14,995.13 |
| 11406 | EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM | $12,815.95 |
| 11420 | EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< | $16,381.22 |
| 11421 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM | $8,647.10 |
| 11422 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM | $13,163.65 |
| 11423 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM | $11,349.41 |
| 11440 | Excision, other benign lesion including margins, except ski… | $15,568.25 |
| 11441 | EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM | $10,861.67 |
| 11443 | EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM | $19,091.71 |
| 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $310.00 |
| 11720 | DEBRIDE NAIL 1-5 | $486.17 |
| 11730 | AVULSION/1-NAIL PLATE | $3,172.29 |
| 11732 | Avulsion of nail plate, partial or complete, simple; each a… | $1,125.07 |
| 11740 | EVAC SUBUNGUAL HEMATOMA | $1,381.34 |
| 11750 | EXC NAIL PART/COMP | $10,149.71 |
| 11760 | REPAIR NAIL BED | $6,346.00 |
| 11765 | WEDGE EXC SKIN/NAIL BED | $5,403.55 |
| 11771 | EXCISION PILONIDAL CYST SINUS EXTENSIVE | $22,279.64 |
| 11900 | Injection, intralesional; up to and including 7 lesions | $5,324.64 |
| 11982 | REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT | $13,668.99 |
| 12001 | LACERATION REPAIR | $1,489.84 |
| 12002 | REPAIR LAC SCALP 2.6-7.5 | $1,742.63 |
| 12004 | REPAIR LAC SCALP 7.6-12.5 | $1,556.87 |
| 12005 | REPAIR LAC,SCALP 12.6-20C | $2,016.99 |
| 12006 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM | $2,110.17 |
| 12007 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM | $2,305.00 |
| 12011 | REPAIR LAC FACE LESS THAN 2.5 CM | $1,521.30 |
| 12013 | REPAIR LAC FACE 2.6-5.0CM | $1,416.77 |
| 12014 | REPAIR LAC FACE 5.1-7.5CM | $1,639.40 |
| 12015 | Rpr f/e/e/n/l/m 7.6-12.5 cm | $1,789.21 |
| 12016 | SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM | $2,342.32 |
| 12017 | SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM | $3,114.00 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $8,522.87 |
| 12021 | TX SUPERFICIAL WOUND DEHISCENCE W/PACKING | $9,614.19 |
| 12031 | LYR CLSR S/A/T/E 2.5CM | $2,470.88 |
| 12032 | REPAIR-INT SCALP 2.6-7.5 | $2,846.00 |
| 12034 | INTERM RPR SCLP/TRNK/EXTR | $2,772.78 |
| 12035 | REPAIR INTERM S/A/T/E 12. | $5,486.18 |
| 12036 | REPAIR INTERM S/A/T/E 20.1-30.0 CM | $6,692.00 |
| 12037 | REPAIR INTERMEDIATE S/A/T/E > 30.0 CM | $9,290.00 |
| 12041 | LAYER CLSR NECK/HAND 2.6 | $2,200.64 |
| 12042 | REPAIR LAC HAND/FOOT 2.6- | $2,577.00 |
| 12044 | LYR CLSR N/H/F/ETRNL GENT | $4,358.00 |
| 12045 | REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM | $3,472.00 |
| 12046 | RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM | $1,682.55 |
| 12047 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM | $4,774.16 |
| 12051 | LAYER CLSR OF WND NCK/HND | $2,858.04 |
| 12052 | LYR CLSR WOUND 2.6-5.0FAC | $2,179.92 |
| 12053 | LYR CLSR F/E/E/N/L/M&/MUC | $2,085.93 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM | $2,379.00 |
| 12055 | REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM | $2,494.00 |
| 12056 | REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 20.1-30.0CM | $5,622.60 |
| 13100 | REPAIR COMPLEX TRUNK 1.1 CM-2.5 CM | $9,620.10 |
| 13101 | REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM | $7,300.07 |
| 13102 | REPAIR COMPLEX TRUNK EA 5 CM/< | $5,548.00 |
| 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $6,502.19 |
| 13121 | RPR CMPX SCALP ARM2.6-7.5 | $7,267.00 |
| 13122 | CMPLX RPR ADD 5 CM OR LES | $6,593.00 |
| 13131 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM | $4,667.20 |
| 13132 | RPR CMPX FOREHEAD/CHECK/C | $4,196.00 |
| 13133 | Repair, complex, forehead, cheeks, chin, mouth, neck, axill… | $3,343.23 |
| 13151 | CMPX RPR EYE NOSE 1.1-2.5 | $8,624.88 |
| 13152 | RPR CPLX E/N/E/L 2.6-7.5 | $4,508.00 |
| 13153 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< | $3,197.00 |
| 15851 | REMOVAL SUTR/STAPLE REQ ANES | $11,353.34 |
| 15853 | REMOVAL SUTR/STAPL XREQ ANES | $1,321.91 |
| 15854 | REMOVAL SUTR&STAPL XREQ ANES | $2,383.13 |
| 16000 | BURN, INITIAL TREATMENT | $1,479.00 |
| 16020 | BURN, DRESSING/DBRDMNT-SM | $1,352.05 |
| 16025 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM | $1,844.18 |
| 16030 | Dressings and/or debridement of partial-thickness burns, in… | $2,057.68 |
| 17000 | DESTRUCTION PREMALIGNANT LESION 1ST | $2,368.43 |
| 17110 | DESTRUCTION BENIGN LESIONS UP TO 14 | $1,913.39 |
| 17250 | Destruction Procedures on Benign or Premalignant Lesions of… | $1,834.29 |
| 19000 | PUNCTURE ASPIRATION CYST BREAST | $3,044.88 |
| 19020 | MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP | $13,120.00 |
| 19100 | BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX | $9,171.37 |
| 20102 | EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK | $20,929.00 |
| 20103 | EXPLORATION PENETRATING WOUND SPX EXTREMITY | $7,090.00 |
| 20520 | REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE | $16,267.56 |
| 20525 | RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP | $14,055.00 |
| 20550 | INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS | $6,708.57 |
| 20551 | INJ TENDON ORIGIN/INSERTION | $1,848.89 |
| 20552 | TRIGGER POINT INJ 1-2 MUS | $5,238.25 |
| 20553 | Injection(s); single or multiple trigger point(s), 3 or mor… | $7,713.66 |
| 20600 | ARTHROCENTESIS, SML JOINT | $2,869.17 |
| 20605 | ARTHROCENTESIS, MED JOINT | $5,502.53 |
| 20610 | ARTHROCENTESIS, LG JOINT | $6,668.92 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $5,567.92 |
| 20612 | Aspiration and/or injection of ganglion cyst any location | $3,641.57 |
| 20650 | INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX | $20,971.00 |
| 21315 | CLOSED TX NASAL FRACTURE W/O STABILIZATION | $13,611.00 |
| 21320 | Closed treatment of nasal bone fracture; with stabilization | $16,066.38 |
| 21337 | CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION | $9,109.00 |
| 21450 | CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION | $17,732.39 |
| 21451 | Treat lower jaw fracture | $18,574.00 |
| 21480 | CLDS TX TEMP DISLOCATION | $2,168.91 |
| 21485 | CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ | $11,470.00 |
| 21501 | I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX | $18,671.00 |
| 21705 | DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB | $17,150.50 |
| 23075 | EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM | $12,321.28 |
| 23500 | CLTX CLAVICULAR FX WO MNP | $1,110.00 |
| 23505 | CLSD TX CLAVICULAR FRACTURE W/MANIPULATION | $8,855.00 |
| 23545 | CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION | $2,354.00 |
| 23550 | OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC | $26,613.59 |
| 23600 | CLTX PROX HUMRL FX WO MAN | $1,835.00 |
| 23620 | CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ | $1,511.00 |
| 23650 | SHOULDER DISLOCATION TRMT | $1,898.00 |
| 23655 | lllClosed treatment of shoulder dislocation, with manipulatio… | $5,867.55 |
| 23665 | Closed treatment of dislocation with fracture with manipula… | $4,893.00 |
| 23930 | I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA | $16,749.00 |
| 23931 | I&D, upper arm or elbow area; bursa | $13,519.00 |
| 24075 | Exc arm/elbow les sc < 3 cm | $12,071.19 |
| 24200 | RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS | $10,398.00 |
| 24357 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tenn… | $32,617.83 |
| 24500 | CLTX HUMRL SHFT FX W/O MN | $2,101.00 |
| 24505 | CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ | $4,973.00 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYL | $2,019.97 |
| 24535 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ | $8,458.00 |
| 24565 | CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MNPJ | $7,155.00 |
| 24586 | Open treatment of periarticular fracture and/or dislocation… | $39,223.00 |
| 24600 | CLSD TX ELBOW DISLOCAT | $2,059.00 |
| 24605 | Treatment of closed elbow dislocation; requiring anesthesia | $8,414.43 |
| 24615 | OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION | $10,177.39 |
| 24620 | CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ | $8,618.99 |
| 24640 | RADIAL HEAD SUBLUX. CHILD | $1,938.79 |
| 24650 | CLTX RDL HEAD FX WO MANP | $6,969.49 |
| 24655 | CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION | $8,185.61 |
| 24670 | CLTX ULNR FX PROX END WO | $8,430.27 |
| 24675 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ | $7,023.00 |
| 25028 | Drainage of forearm lesion | $10,851.00 |
| 25066 | Biopsy forearm soft tissues | $10,127.42 |
| 25111 | Excision of Ganglion, wrist (dorsal or volar); primary | $19,536.33 |
| 25500 | CLTX RDL SHFT FX WO MANP | $1,768.00 |
| 25505 | CLSD TX RAD SHAFT W/MANIP | $9,227.21 |
| 25520 | CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT | $6,985.00 |
| 25530 | CLSD TX ULNAR SHFT FX NO | $1,545.00 |
| 25535 | CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION | $7,488.87 |
| 25565 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ | $8,954.73 |
| 25574 | OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA | $6,824.26 |
| 25600 | CLSD TX DISTAL RAD FX WO | $9,201.69 |
| 25605 | CLSD TX DISTAL RAD FX | $5,622.26 |
| 25607 | Open treatment of distal radial extra-articular fracture or… | $27,757.32 |
| 25622 | CLSD TX NAVICULAR FX WO M | $711.34 |
| 25635 | CLTTX CARPL B1 FX W/MNPJ EA B1 | $7,513.00 |
| 25650 | CLTX UR SYLOID FX | $4,744.49 |
| 25652 | OPEN TREATMENT ULNAR STYLOID FRACTURE | $18,075.00 |
| 25660 | Closed treatment of radiocarpal or intercarpal dislocation,… | $1,283.00 |
| 25675 | CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH MANI… | $2,695.39 |
| 25690 | Closed treatment of lunate dislocation, with manipulation | $8,508.00 |
| 26010 | I & D FINGER ABSCESS,SIMP | $3,416.76 |
| 26011 | DRAINAGE OF FINGER ABCESS | $8,847.00 |
| 26567 | Osteotomy; phalanx of finger, each | $7,662.12 |
| 26600 | CLSD TX METACARPAL FX | $4,656.23 |
| 26605 | CLSD TX MEDICARPAL FX | $3,361.74 |
| 26615 | OPEN TX METACARPAL FRACTURE SINGLE EA BONE | $19,438.50 |
| 26641 | Closed treatment of carpometacarpal dislocation, thumb, wit… | $2,323.95 |
| 26670 | CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES; Closed … | $1,914.00 |
| 26675 | Closed treatment of carpometacarpal dislocation, other than… | $5,266.00 |
| 26700 | CLS TX MCP DISLOCATION | $1,891.91 |
| 26705 | TREAT KNUCKLE DISLOCATION | $3,807.00 |
| 26720 | CLSD TX PHALANGEAL SHFTFX | $1,389.00 |
| 26725 | CLTX PHLNGL FX PROX/MIDDL | $2,155.90 |
| 26735 | OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA | $28,194.70 |
| 26740 | Closed treatment of articular fracture, involving metacarpo… | $256.17 |
| 26742 | CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ | $6,051.30 |
| 26746 | OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA | $16,976.67 |
| 26750 | CLS TX FX FINGER/THUMB | $3,719.89 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/ | $2,022.00 |
| 26765 | OPEN TX DISTAL PHALANGEAL FRACTURE EACH | $17,612.77 |
| 26770 | TREAT FINGER DISLOC FINGE | $1,792.51 |
| 26775 | Treat finger dislocation | $3,610.00 |
| 26952 | AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP | $18,008.66 |
| 27096 | INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA | $9,489.39 |
| 27301 | I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION | $19,128.00 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $21,544.09 |
| 27502 | CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ | $10,941.00 |
| 27520 | CLTX PATELLAR FX W/O MNPJ | $1,777.00 |
| 27530 | CLTX TIBL FX PROX W/O MNPJ | $1,076.48 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $3,375.71 |
| 27560 | CLTX PATELLAR DISLC W/O A | $1,946.58 |
| 27750 | CLTX TIBL SHFT FX W/O MNPJ | $999.34 |
| 27752 | CLTX TIBL SFT FX W/MANP | $6,573.33 |
| 27760 | CLTX MEDIAL MALLS FX W/O | $8,843.44 |
| 27762 | CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ | $6,355.57 |
| 27780 | CLTX PROX FIVULA/SHFT FX | $1,603.00 |
| 27786 | CLSD TX DISTAL FIBULAR FX | $12,818.22 |
| 27788 | CLTX DSTL FIBULAR FX LAT MALLS W/MANJ | $3,638.46 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $21,656.74 |
| 27808 | CLOSED TX BIMALLEOLAR ANK | $2,469.53 |
| 27810 | CLTX BIMAL ANKLE FX W/POT | $5,073.48 |
| 27818 | Treatment of ankle fracture | $8,273.30 |
| 27824 | Closed treatment of fracture of weight bearing articular po… | $858.47 |
| 27840 | CLOSED TX ANKLE DISLOCATI | $2,233.00 |
| 27842 | Closed treatment of ankle dislocation; requiring anesthesia… | $8,221.99 |
| 28001 | INCISION&DRAINAGE BURSA FOOT | $7,605.56 |
| 28024 | Arthrotomy, including exploration, drainage, or removal of … | $4,502.90 |
| 28190 | RMVL FB BODY FOOT SUBQ | $5,561.51 |
| 28192 | RMVL FB FOOT DEEP | $15,469.00 |
| 28193 | Removal of foreign body, foot; complicated | $10,905.21 |
| 28400 | CLSD TX CLAVICLE FX WO MA | $438.86 |
| 28430 | CLTX TALUS FX W/O MNPJ | $838.04 |
| 28450 | TX TARSAL B1 FX XCP TALUS | $1,303.00 |
| 28470 | CLTX METAR FX WO MNP | $3,545.12 |
| 28475 | Treat metatarsal fracture | $5,808.91 |
| 28490 | CLTX FX GRT TOE W/O MNLJ | $1,495.29 |
| 28495 | CLTX FX GRT TOE PHLX/PHLG W/MNPJ | $2,281.00 |
| 28505 | OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES | $19,402.00 |
| 28510 | CLSD TX FX PLALANX/PHALAN | $1,972.69 |
| 28515 | FX CARE PHALANX NOT GREAT | $2,321.00 |
| 28600 | CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES | $1,194.00 |
| 28630 | CLTX METATARSOPHLNGL JT DISLC W/O ANES | $1,301.00 |
| 28660 | CLSD TX PIP JNT DISLOCATI | $2,924.97 |
| 29065 | Application, cast; shoulder to hand (long arm) | $1,921.57 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $753.87 |
| 29085 | CAST HAND/LOWER FOREARM GAUNTLET | $2,284.64 |
| 29086 | APPLICATION CAST FINGER | $559.71 |
| 29105 | LONG ARM SPLINT | $1,952.91 |
| 29125 | SHORT ARM SPLINT | $1,055.34 |
| 29126 | SHORT ARM SPLINT DYNAMIC | $1,586.90 |
| 29130 | APPLICATION FINGER SPLINT | $815.12 |
| 29131 | APPLICATION FINGER SPLINT DYNAMIC | $940.12 |
| 29240 | STRPG SHO | $2,067.66 |
| 29260 | Strapping Of Elbow Or Wrist | $814.80 |
| 29280 | STRAPPING HAND/FINGER | $840.92 |
| 29355 | Application of long leg cast | $1,423.00 |
| 29405 | Application of short leg cast (below knee to toes) | $8,651.75 |
| 29450 | APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG | $3,812.14 |
| 29505 | LONG LEG SPLINT | $1,269.00 |
| 29515 | SHORT LEG SPLINT | $1,192.32 |
| 29530 | STRAPPING KNEE | $793.00 |
| 29540 | STRAPPING ANKLE/FOOT | $838.72 |
| 29550 | STRAPPING TOES | $606.00 |
| 29580 | STRAPPING UNNA BOOT | $828.77 |
| 29700 | RMVL/BIVALV GAUNTLET BOOT | $1,185.91 |
| 29705 | Removal or bivalving; full arm or full leg cast | $507.09 |
| 29799 | Unlisted px casting/strpg | $26,166.00 |
| 29840 | Arthroscopy, wrist, diagnostic, with or without synovial bi… | $16,744.00 |
| 30020 | Drainage of nose lesion | $13,586.45 |
| 30300 | RMVL FOREIGN BODY NASAL | $1,283.00 |
| 30802 | ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL | $4,583.19 |
| 30901 | NASAL PACKING | $1,473.04 |
| 30903 | CTRL NSL HEMRRG ANT CPLX | $1,191.58 |
| 30905 | Control nasal hemorrhage, posterior, with posterior nasal p… | $1,458.13 |
| 30906 | Cntrl nasal hemorrhage, posterior,w/ posterior nasal packs … | $1,373.00 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,790.79 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $7,598.00 |
| 31505 | LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX | $4,868.47 |
| 31525 | LARGSC +-TRACHEOSCOPY DX | $12,685.00 |
| 31541 | LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP | $12,639.01 |
| 31575 | LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC | $2,197.47 |
| 31600 | TRACHEOSTOMY PLANNED SPX | $10,241.71 |
| 31605 | TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE | $3,323.98 |
| 32550 | INSERT PLEURAL CATH | $16,651.44 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $4,876.00 |
| 32556 | Pleural drainage, percutaneous, with insertion of indwellin… | $7,307.00 |
| 36000 | INTRODUCTION OF NEEDLE/IN | $1,101.00 |
| 36005 | OPERATING ROOM SERVICES – GENERAL CLASSIFICATION | $6,155.60 |
| 36010 | INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA | $7,983.80 |
| 36011 | Place catheter in vein | $10,340.57 |
| 36410 | VENIPUNCTURE, 3 YRS OR OLDER | $2,251.92 |
| 36415 | VENIPUNCTURE | $108.33 |
| 36416 | COLL CAPILLARY BLG SPEC | $104.63 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $12,572.19 |
| 36558 | INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR | $11,529.20 |
| 36569 | IV cather | $6,756.18 |
| 36573 | Insertion through the skin of a thin tube (catheter) into a… | $7,349.83 |
| 36575 | RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP | $3,447.36 |
| 36589 | Removal of tunneled central venous catheter, without subcut… | $8,636.00 |
| 36591 | COLLECT BLOOD FROM IMPLAN | $800.95 |
| 36592 | Collect blood from picc | $851.48 |
| 36680 | Placement of needle for intraosseous infusion | $1,295.87 |
| 37785 | LIGATION, DIVISION, ANDOR EXCISION OF VARICOSE VEIN CLUSTERS | $15,248.88 |
| 40650 | RPR LIP FULL THICKNESS | $5,180.92 |
| 40800 | DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL | $2,711.29 |
| 40801 | Drainage of mouth lesion | $8,084.00 |
| 40804 | RMVL EMBEDDED FB VESTIBULE MOUTH SMPL | $2,841.00 |
| 40830 | Closure of laceration, vestibule of mouth; 2.5 cm or less | $3,516.38 |
| 40831 | CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL | $3,996.00 |
| 41008 | Intraoral incision and drainage of abscess, cyst, or hemato… | $10,165.00 |
| 41250 | REPAIR TONGUE LACERATION | $1,417.96 |
| 41252 | Repair tongue laceration | $2,752.00 |
| 41800 | DRNG ABSC DENTOALVEOLAR S | $1,665.88 |
| 41899 | Unlisted procedure, dentoalveolar structures | $8,737.32 |
| 42330 | REMOVAL OF SALIVARY STONE | $18,955.00 |
| 42700 | I&D ABSC PRITONSILLAR | $3,485.00 |
| 42809 | REMOVAL FOREIGN BODY PHARYNX | $1,768.00 |
| 43215 | Esophagoscopy, flexible, transoral; with removal of foreign… | $16,110.01 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $4,455.69 |
| 43753 | GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … | $1,524.27 |
| 45915 | RMVL FECAL IMPACTION/FB SPX UNDER ANES | $16,218.00 |
| 46040 | I&D ISCHIOR/PRIRC ABSC SP | $13,009.00 |
| 46050 | INC/DRAIN PERIANAL ABS SU | $8,955.00 |
| 46083 | INCISION THROM HEMORRHOID | $1,548.00 |
| 46221 | Hemorrhoidectomy, internal, by rubber band ligation(s) | $24,637.53 |
| 46320 | ENULEATION EXCC OF EXT HE | $10,291.00 |
| 46608 | ANOSC RMVL FB | $10,924.00 |
| 49083 | Abdominal paracentesis (diagnostic or therapeutic); w/ imag… | $5,664.07 |
| 49505 | Prp i/hern init reduc >5 yr | $23,433.92 |
| 51700 | BLDR IRR SMPL LVG&/INSTLJ | $3,474.67 |
| 51701 | INSR NONDWELLING BLDR CAT | $1,163.02 |
| 51702 | INSERTION BLADDER CATH | $1,155.21 |
| 51703 | INSERT BLADDER CATH COMPL | $3,536.66 |
| 54001 | SLITTING PREPUCE DORSAL/LAT SPX XCP NB | $19,822.88 |
| 54015 | Incision and drainage of penis, deep | $7,571.37 |
| 54163 | REPAIR INCOMPLETE CIRCUMCISION | $14,149.65 |
| 54220 | IRRIGATION CORPORA CAVERNOSA PRIAPISM | $1,569.00 |
| 54235 | NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT | $3,442.44 |
| 54437 | REPAIR OF TRAUMATIC CORPOREAL TEAR(S) | $14,331.00 |
| 54450 | FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING | $2,577.00 |
| 55100 | DRAINAGE SCROTAL WALL ABSCESS | $6,738.00 |
| 55175 | Scrotoplasty; simple | $9,832.60 |
| 56405 | INC/DRAIN VULVA/PERINEAL | $2,272.03 |
| 56420 | I & D BARTHOLIN ABSCESS | $1,679.48 |
| 56440 | Surgery for vulva lesion | $21,416.00 |
| 57410 | Pelvic examination | $17,877.00 |
| 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $21,521.00 |
| 58301 | REMOVAL INTRAUTERINE DEVICE IUD | $5,981.02 |
| 59025 | FTL NON-STRS TST | $1,976.74 |
| 59409 | VAG DLVR ONLY | $14,605.00 |
| 62270 | SPINAL PUNCTURE,LUMBAR | $4,050.94 |
| 62272 | Drain cerebro spinal fluid | $4,181.00 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $2,159.00 |
| 64405 | N BLOCK INJ OCCIPITAL | $4,888.27 |
| 64415 | N block inj brachial plexus | $6,112.90 |
| 64447 | INJECTION ANESTHETIC AGENT FEMORAL NERVE SINGLE | $10,044.96 |
| 64450 | INJ ANESTHETIC AGENT | $4,448.31 |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular… | $6,303.44 |
| 64455 | Inj, anesthetic agent a/o steroid, plantar common digital n… | $2,189.89 |
| 64640 | DSTRJ NULYT OTH PRPH NVR/BRANCH | $9,090.76 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $1,176.50 |
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $1,208.98 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $1,973.88 |
| 65222 | RMVL FB EYE | $1,129.00 |
| 65235 | Remove foreign body from eye | $7,479.00 |
| 65435 | Removal of corneal epithelium; with or without chemocauteri… | $2,873.86 |
| 67700 | I&D ABSCESS EYELID | $2,510.38 |
| 67938 | Removal of embedded foreign body, eyelid | $1,605.00 |
| 69000 | Drainage external ear, abscess or hematoma | $2,455.38 |
| 69005 | DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED | $8,679.07 |
| 69020 | DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS | $4,475.67 |
| 69200 | RMVL FOREIGN BODY EAR | $1,084.34 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $8,108.40 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL | $941.00 |
| 69210 | RMVL IMPACTED CERUMEN | $1,520.57 |
| 69220 | DBRDMT MSTDC CAVITY SMPL | $6,057.10 |
| 69399 | Unlisted procedure, external ear | $10,124.51 |
| 70030 | RADEX EYE DETCJ FB | $761.21 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $883.00 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $1,065.77 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $446.04 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $966.45 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $1,518.74 |
| 70160 | NASAL BONE X-RAY | $1,171.43 |
| 70200 | RAD EXAM ORBIT COMP. | $1,404.67 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $854.03 |
| 70220 | RAD EXAM SINUS COMPLETE | $1,652.60 |
| 70250 | SKULL LESS THAN 4 VIEWS | $1,255.69 |
| 70260 | RAD EXAM SKULL COMPLETE | $2,547.01 |
| 70328 | RADEX TMPRMAND JT OPN&CLSD MOUTH UNI | $782.58 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $1,472.90 |
| 70350 | CEPHALOGRAM ORTHODONTIC | $1,007.48 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $916.40 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $6,039.17 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $7,594.69 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $8,772.99 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $6,317.97 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $7,136.61 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $9,167.21 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $6,319.26 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $7,129.56 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $8,472.13 |
| 70490 | CT NECK WO CONTRAST | $6,504.29 |
| 70491 | CT SOFT TISS NCK C+MATRL | $7,506.08 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $8,859.04 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $10,036.36 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $9,863.34 |
| 70544 | MRA HEAD C-MATRL | $8,078.36 |
| 70547 | MRA NECK C-MATRL | $8,454.05 |
| 70551 | MRI BRN BRN STEM C-MATRL | $8,670.45 |
| 70553 | MRI BRN BRN STEM C-/C+ | $12,192.48 |
| 71045 | RADIOLOGIC EXAM CHEST SINGLE VIEW | $987.60 |
| 71046 | CHEST XRAY 2 VIEWS | $1,228.76 |
| 71047 | RADIOLOGIC EXAM CHEST 3 VIEWS | $1,376.41 |
| 71048 | RADIOLOGIC EXAM CHEST 4+ VIEWS | $1,270.54 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $1,147.70 |
| 71101 | RIB UNILATERAL W CHEST | $1,526.84 |
| 71110 | RIBS BILATERAL 3 VIEWS | $1,723.28 |
| 71111 | RIBS BILATERAL W/CHEST | $2,027.13 |
| 71120 | Radiologic examination; sternum, minimum of 2 views | $1,259.82 |
| 71250 | CT CHEST W/O CONTRAST | $6,101.29 |
| 71260 | CT THORAX W/CONTRAST | $7,793.36 |
| 71270 | CT THORAX WO CONTRAST | $9,932.36 |
| 71271 | CT THORAX LUNG CANCER SCR C- | $730.02 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $9,828.86 |
| 71550 | MRI CH C-MATRL | $7,386.46 |
| 72020 | SPINE SINGLE VIEW | $875.81 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $1,294.21 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $1,968.72 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $2,299.63 |
| 72070 | SPINE THORACIC 2 VIEWS | $1,410.89 |
| 72072 | SPINE THORACIC 3 VIEWS | $1,958.55 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $1,698.56 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $1,542.94 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $1,816.53 |
| 72100 | Radiologic examination, spine, lumbosacral; 2 or 3 views | $1,484.58 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $2,059.48 |
| 72114 | RAD EXAM SPINE LUMBO COMP | $2,765.24 |
| 72120 | SPINE LUMBAR AP & LAT W F | $1,692.58 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $7,253.85 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $9,206.55 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $8,843.31 |
| 72128 | CT THRC SPI C-MATRL | $7,412.06 |
| 72129 | CT THRC SPI C+ MATRL | $8,169.76 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $9,579.06 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $7,133.37 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $9,853.24 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $6,982.00 |
| 72141 | MRI SPI CANAL&CNTS CRV C-MATRL | $8,933.86 |
| 72146 | MRI SPI CANAL&CNTS THRC C-MATRL | $9,097.74 |
| 72148 | MRI SPI CANAL&CNTS LMBR C-MATRL | $9,174.67 |
| 72156 | MRI SPI CANAL&CNTS C-/C+ CRV | $12,818.34 |
| 72157 | MRI SPI CANAL&CNTS C-/C+ | $12,891.47 |
| 72158 | MRI SPI CANAL&CNTS C-/C+ LMBR | $13,004.83 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $1,139.17 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $1,809.31 |
| 72191 | CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST | $10,177.15 |
| 72192 | CT PELVIS WO CONTRAST | $6,075.46 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $7,613.50 |
| 72194 | CT PELVIS W OR WO CONTRST | $9,112.91 |
| 72195 | MRI PELVIS C-MATRL | $7,947.05 |
| 72196 | MRI PELVIS C+ MATRL | $7,704.21 |
| 72220 | XRAY COCCYX/SACRUM | $1,119.18 |
| 72255 | MYELOGRAPY THRC RS&I | $6,277.09 |
| 72265 | MYELOGRAPY LUMBOSAC RS&I | $4,574.24 |
| 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $6,767.60 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $1,212.67 |
| 73010 | SCAPULA COMPLETE | $1,245.91 |
| 73020 | RADEX SHO 1 VIEW | $1,075.85 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $1,393.67 |
| 73050 | XRAY AC JOINTS-BILAT | $896.00 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $1,216.09 |
| 73070 | XRAY ELBOW 2 VIEWS | $1,161.43 |
| 73080 | XRAY ELBOW GREATER THAN 3 VIEWS-COMP | $1,279.07 |
| 73090 | XRAY FOREARM AP & LAT | $1,378.62 |
| 73092 | Radiologic examination; upper extremity, infant, minimum of… | $1,216.91 |
| 73100 | XRAY WRIST AP & LAT VIEW | $1,217.17 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $1,497.65 |
| 73120 | XRAY HAND AP & LAT | $1,377.30 |
| 73130 | XRAY HAND MIN 3 VIEWS | $1,383.98 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $1,134.73 |
| 73200 | CT UPPR EXTR WO CNTRS | $5,409.46 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $7,264.47 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $9,222.34 |
| 73218 | MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL | $7,442.47 |
| 73220 | MRI UXTR OTH/THN JT C-/C+ | $12,039.09 |
| 73221 | MRI ANY JT UXTR C-MATRL | $9,054.55 |
| 73223 | MRI ANY JT UXTR C-/C+ | $13,561.03 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $960.80 |
| 73502 | RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… | $1,232.13 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $1,613.13 |
| 73521 | X-ray exam hips bi 2 views | $1,934.89 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $1,688.58 |
| 73523 | RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS | $1,636.89 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $844.66 |
| 73552 | FEMUR; MIN 2 VIEWS | $1,259.22 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $1,144.02 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $1,236.77 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $1,722.63 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $1,036.17 |
| 73580 | X-RAY KNEE.BILATERAL STANDING | $2,395.45 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $1,393.40 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,315.08 |
| 73600 | XRAY ANKLE 2 VIEWS | $1,105.64 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $1,383.97 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $1,139.00 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $1,385.40 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $1,206.54 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $1,079.35 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $6,015.94 |
| 73701 | CT LWR EXT W CONT | $7,372.44 |
| 73702 | CT LXTR C-/C+ | $9,307.04 |
| 73706 | Computed tomographic angiography, lower extremity, with con… | $9,402.39 |
| 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $8,807.18 |
| 73721 | MRI ANY JT LXTR C-MATRL | $9,403.53 |
| 73722 | MRI ANY JT LXTR C+ MATRL | $9,178.91 |
| 73723 | MRI ANY JT LXTR C-/C+ | $11,505.98 |
| 73725 | MRA LXTR C+-MATRL | $8,082.34 |
| 74018 | RADIOLOGIC EXAM ABDOMEN 1 VIEW | $995.64 |
| 74019 | RADIOLOGIC EXAM ABDOMEN 2 VIEWS | $1,507.44 |
| 74021 | RADIOLOGIC EXAM ABDOMEN 3+ VIEWS | $1,423.00 |
| 74022 | RAD EXAM COMPLETE ABD | $1,686.10 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $7,132.29 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $8,383.20 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $10,080.65 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $13,719.94 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $10,454.48 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $10,675.50 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $13,099.89 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $16,560.16 |
| 74181 | MRI ABD C-MATRL | $8,800.32 |
| 74183 | MRI ABD C-/C+ | $12,268.04 |
| 74190 | PERITONEOGRAM RS&I | $3,020.85 |
| 74220 | Radiologic examination; esophagus | $2,042.67 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $2,312.75 |
| 74241 | RADEX GI TRC UPR +-DLYD FLMS W/KUB | $2,717.14 |
| 74246 | Radiologic examination, gastrointestinal tract, upper, air … | $2,798.28 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $2,401.09 |
| 74251 | RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE | $4,154.65 |
| 74283 | Therapeutic enema, contrast or air, for reduction of intuss… | $4,881.53 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $5,450.02 |
| 74329 | ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I | $6,650.22 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $5,317.27 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $2,072.45 |
| 74400 | Urography (pyelography), intravenous, with or without KUB, … | $2,337.38 |
| 75574 | CT CORONARY | $4,524.62 |
| 75635 | CT ANGIO ABDOMINAL ARTERIES | $7,902.18 |
| 76010 | X-ray nose to rectum | $1,066.97 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $1,774.00 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $3,109.04 |
| 76512 | OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN | $945.90 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $2,431.28 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $1,622.73 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,634.53 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $1,228.56 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $2,992.07 |
| 76705 | US ABDOMINAL | $2,216.05 |
| 76706 | Ultrasound, abdominal aorta, real time with image documenta… | $1,449.39 |
| 76770 | US RETROPERITONEAL R-T W/ | $2,582.18 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $2,022.35 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $2,015.85 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $1,866.19 |
| 76805 | US PG UTER F&MAT AFTER 1S | $2,482.71 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,657.06 |
| 76815 | ULTRASND PG UTER | $1,608.77 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $1,440.45 |
| 76817 | UT PG UTER R-T IMG TRVG | $1,705.99 |
| 76830 | TRANSVAGINAL ULTRASOUND | $2,184.64 |
| 76856 | US PELVIC NONOB REAL-TIME | $2,825.56 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $1,834.67 |
| 76870 | US SCROTUM&CNTS | $2,268.29 |
| 76872 | US TRANSRECTAL | $2,183.40 |
| 76881 | US COMPL JOINT R-T W/IMAGE DOCUMENTATION | $2,105.33 |
| 76882 | ULTRASOUND, EXTREMITY, NON VASCULAR | $1,174.71 |
| 76937 | Us guide vascular access | $2,352.39 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… | $3,198.72 |
| 77076 | RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT | $2,016.83 |
| 78306 | B1&/JT IMG WHBDY | $6,363.90 |
| 78315 | B1&/JT IMG 3 PHASE STD | $7,310.12 |
| 78472 | CARD BPI GTD=BRM PLNR 1 STD REST/STRS | $5,557.96 |
| 78808 | NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS | $1,542.56 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $1,050.10 |
| 80048 | METABOLIC PANEL BASIC | $1,000.50 |
| 80050 | General health panel | $1,601.85 |
| 80051 | ELECTROLYTE PANEL | $674.70 |
| 80053 | METABOLIC COMPRE PANEL | $1,245.31 |
| 80061 | LIPID PROFILE III | $840.29 |
| 80069 | RENAL FUNCTION PANEL | $2,057.00 |
| 80074 | HEPATITIS PANEL | $1,910.77 |
| 80076 | HEPATIC FUNCTION PANEL | $1,120.95 |
| 80143 | Therapeutic Drug Assays | $749.31 |
| 80175 | DRUG SCREEN QUANTITATIVE LAMOTRIGINE | $392.87 |
| 80177 | Levetiracetam | $584.75 |
| 80178 | LITHIUM | $786.23 |
| 80179 | Therapeutic Drug Assays | $672.50 |
| 80197 | TACROLIMUS | $1,607.00 |
| 80202 | VANCOMYCIN PEAK | $822.23 |
| 80305 | DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… | $702.00 |
|
80306 |
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample
validation when performed, per date of service |
$610.59 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $1,356.00 |
| 80320 | DRUG SCREEN | $752.61 |
| 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $497.00 |
| 80329 | DRUG SCREEN | $867.21 |
| 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $447.00 |
| 80345 | DRUG SCREENING BARBITURATES | $288.00 |
| 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $573.68 |
| 80347 | DRUG SCREENING BENZODIAZEPINES 13 OR MORE | $200.21 |
| 80348 | DRUG SCREENING BUPRENORPHINE | $346.00 |
| 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $272.77 |
| 80353 | DRUG SCREENING COCAINE | $298.00 |
| 80356 | DRUG SCREENING HEROIN METABOLITE | $228.73 |
| 80358 | DRUG SCREENING METHADONE | $483.00 |
| 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $379.00 |
| 80361 | DRUG SCREENING OPIATES 1 OR MORE | $604.00 |
| 80365 | DRUG SCREENING OXYCODONE | $415.00 |
| 80373 | DRUG SCREENING TRAMADOL | $250.00 |
| 81001 | U/A DIP STICK | $418.50 |
| 81002 | URNLS DIP STICK/TABLET RG | $233.98 |
| 81003 | U/A W/O MICRO DIPSTICK | $333.00 |
| 81015 | Urinalysis Microscopic Olny | $262.01 |
| 81025 | PREG.TST URINE VISUAL | $435.10 |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hyp… | $1,403.24 |
| 82009 | KETONES-SERUM | $184.00 |
| 82010 | KETONE BODIES SERUM QUANTITATIVE | $598.82 |
| 82040 | ALBUMIN; SERUM | $429.03 |
| 82077 | Alcohol (ethanol); any specimen except urine and breath, im… | $449.00 |
| 82140 | Ammonia | $666.33 |
| 82150 | AMYLASE | $612.90 |
| 82247 | BILIRUBIN TOTAL | $596.25 |
| 82248 | BILIRUBIN DIRECT | $455.86 |
| 82270 | OCCULT BLOOD | $311.00 |
| 82271 | Occult blood other sources | $346.90 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $172.00 |
| 82274 | BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 | $286.63 |
| 82310 | CALCIUM | $415.24 |
| 82330 | CALCIUM IONIZED | $771.55 |
| 82374 | CARBON DIOXIDE BICARBONATE | $339.00 |
| 82375 | Under Chemistry Procedures | $442.82 |
| 82435 | CHLORIDE BLD | $249.79 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $487.96 |
| 82533 | CORTISOL TOTAL | $916.37 |
| 82550 | CREATINE CK-TOTAL | $542.88 |
| 82553 | CREATINE CKMB | $809.00 |
| 82565 | CREATININE | $452.40 |
| 82607 | VITAMIN B-12 | $737.86 |
| 82693 | ASSAY OF ETHYLENE GLYCOL | $640.06 |
| 82728 | Ferritin | $758.14 |
| 82746 | Folic acid; serum | $789.70 |
| 82747 | ASSAY OF FOLIC ACID RBC | $173.00 |
| 82784 | IGC IMMUNOGLOBULIN | $519.30 |
| 82785 | GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE | $527.36 |
| 82800 | GASES BLD PH ONLY | $295.13 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $1,779.79 |
| 82805 | GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY | $2,697.00 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $453.62 |
| 82947 | GLUCOSE | $333.78 |
| 82948 | GLUCOSE BLOOD REAGET STR | $191.15 |
| 82962 | GLUCOSE FINGER STICK | $110.62 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $585.40 |
| 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $534.00 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $494.12 |
| 83050 | HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE | $293.51 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $950.92 |
| 83525 | ASSAY OF INSULIN TOTAL | $610.72 |
| 83540 | IRON-TOTAL | $587.57 |
| 83550 | Total IRON BNDNG CAP | $648.34 |
| 83605 | ASSAY OF LACTATE | $697.26 |
| 83615 | Lactate dehydrogenase (LD), (LDH); | $586.46 |
| 83690 | LIPASE | $622.68 |
| 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $619.92 |
| 83735 | MAGNESIUM | $505.53 |
| 83874 | MYOGLOBIN | $1,010.00 |
| 83880 | B-TYPE NATRIURETIC | $1,093.06 |
| 83992 | ASSAY OF PHENCYCLIDINE | $242.00 |
| 84075 | ALK PHOS/PROFILE OR PANEL | $410.74 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $378.54 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $383.65 |
| 84155 | PROTEIN,TOTAL,EXCEPT REFR | $289.88 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $473.86 |
| 84165 | PROTEIN ELECTROPHORESIS | $930.14 |
| 84295 | SODIUM; SERUM | $316.19 |
| 84403 | ASSAY OF TESTOSTERONE TOTAL | $799.63 |
| 84436 | THYRIXINE TOTAL | $668.92 |
| 84439 | THYROXINE-FREE | $713.67 |
| 84443 | Thyroid stimulating hormone (TSH) | $930.80 |
| 84450 | Aspartate Aminotransferase | $431.01 |
| 84460 | ALT-TRANSFERASE;ALANINE | $410.02 |
| 84478 | ASSAY OF TRIGLYCERIDES | $754.57 |
| 84479 | THYROID HORMONE | $415.71 |
| 84480 | T3 TOTAL | $873.52 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $917.39 |
| 84484 | TROPONIN I | $845.34 |
| 84520 | Urea nitrogen | $407.73 |
| 84550 | URIC ACID | $463.57 |
| 84560 | URIC ACID OTH SRC | $467.05 |
| 84702 | HCG QUANTATIVE | $951.33 |
| 84703 | PREGNANCY TEST BLOOD | $547.96 |
| 84999 | UNLISTED CHEMISTRY PROCEDURE | $196.42 |
| 85014 | HEMATOCRIT | $215.94 |
| 85018 | HEMOGLOBIN | $239.74 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $375.84 |
| 85027 | CBC W/O DIFF | $1,054.00 |
| 85032 | BLD# MNL C-CNT RBC/PLTLT EA | $329.04 |
| 85044 | RETICULOCYTE COUNT | $839.82 |
| 85045 | Blood count | $301.90 |
| 85270 | hematology and coagulation | $1,166.45 |
| 85347 | COAGJ TM ACTIVATED | $503.01 |
| 85378 | FIBRIN DEGRADATION PROD | $923.26 |
| 85379 | D-DIMER | $730.49 |
| 85384 | Fibrinogen; activity | $518.21 |
| 85610 | PROTHROMBIN TIME | $418.45 |
| 85651 | SEDIMENTATION RATE NONAUT | $335.81 |
| 85652 | SED RATE ERYTHROCYTE NON | $266.05 |
| 85730 | THROMBOPLASTIN TIME PART | $520.24 |
| 86038 | ANTINUCLEAR AB | $562.08 |
| 86039 | ANTINUCLEAR AB TITER | $671.23 |
| 86060 | ANTISTREPTOLYSIN O TITER | $938.08 |
| 86140 | C REACTIVE PROTEIN | $553.64 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $448.08 |
| 86256 | SMOOTH MUSCLE AB TITER | $368.97 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $442.97 |
| 86320 | IMMUNOELECTROPHORESIS | $757.14 |
| 86328 | COVID-19 RAPID ANTIBODY TEST SINGLE METHOD | $3,052.97 |
| 86360 | T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO | $1,020.77 |
| 86403 | MONO SPOT | $322.00 |
| 86430 | RHEUMATOID FACTOR | $332.09 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $609.39 |
| 86580 | TB tests | $78.87 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $365.01 |
| 86593 | SYPHILIS TEST, NON- TREPONEMAL ANTIBODY; QUANTITATIVE | $531.53 |
| 86617 | Antibody; Borrelia burgdorferi (Lyme disease) confirmatory … | $190.45 |
| 86618 | LYME DISEASE ANTIBODY | $316.64 |
| 86622 | Antibody; Brucella | $263.00 |
| 86631 | ANTB CHLAMYDIA | $245.00 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $762.47 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $1,073.00 |
| 86664 | EPSTEIN-BARR VIRUS EBNA | $522.83 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $1,074.79 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $571.00 |
| 86695 | Antibody; herpes simplex, type 1 | $443.72 |
| 86696 | Antibody; herpes simplex, type 2 | $484.85 |
| 86701 | HIV SERUM | $823.24 |
| 86702 | ANTB HIV-2 | $742.66 |
| 86703 | Antibody; HIV-1 and HIV-2, single result | $534.68 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $699.63 |
| 86705 | HEPATITIS B CORE IGM | $682.84 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $705.23 |
| 86708 | Hepatitis a antibody | $550.20 |
| 86709 | Hepatitis A antibody (HAAb), IgM antibody | $620.36 |
| 86757 | Antibody; Rickettsia | $272.04 |
| 86768 | Antibody; Salmonella | $289.00 |
| 86769 | COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD | $317.49 |
| 86780 | ANTIBODY TREPONEMA PALLIDUM | $458.54 |
| 86787 | Antibody; varicella-zoster | $346.91 |
| 86803 | HEPATITIS C ANTIBODY | $914.43 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $648.65 |
| 86900 | Blood typing, serologic; ABO | $449.00 |
| 86901 | RH FACTOR-BLOOD | $381.31 |
| 86906 | BLD TYPING RH PHEXYPING COMPL | $436.00 |
| 87015 | CONCENTRATION INFECTIOUS AGENTS | $210.98 |
| 87040 | BLOOD CULTURE | $865.88 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $874.65 |
| 87046 | CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA | $376.03 |
| 87070 | CULTURE BODY FLUID | $1,004.00 |
| 87075 | CULTURE ANAEROBIC | $1,025.02 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $446.34 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $452.50 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $526.38 |
| 87086 | URINE CULTURE | $855.96 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $351.03 |
| 87103 | Under Microbiology Culture and Typing Procedures | $689.90 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $483.70 |
| 87110 | CHLAMYDIA CULTURE | $982.50 |
| 87169 | Macroscopic examination; parasite | $102.03 |
| 87177 | OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID | $575.87 |
| 87186 | Susceptibility studies, antimicrobial agent | $813.02 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $340.60 |
| 87207 | SMR PRIM SRC SPEC STAIN | $460.29 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $317.76 |
| 87210 | WET SMEAR | $482.08 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $919.97 |
| 87255 | Herpes Simplex Virus Culture with Reflex Typing | $897.50 |
| 87275 | IAADI INF B VIRUS | $303.44 |
| 87324 | Infectious agent antigen detection by immunoassay technique… | $880.31 |
| 87328 | Infectious agent antigen detection by immunoassay technique… | $238.47 |
| 87338 | IAAD IA HPYLORI STOOL | $641.98 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $530.02 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $352.45 |
| 87389 | HIV-1 AG W/HIV-1 & HIV-S AB | $629.98 |
| 87400 | INFLUENZA A&B | $380.05 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $801.00 |
| 87425 | ROTAVIRUS AG EIA | $445.47 |
| 87426 | COVID-19 RAPID ANTIGEN TESTING | $365.00 |
| 87427 | IAAD IA SHIGA-LIKE TOXIN | $511.28 |
| 87428 | Multiplex viral pathogen panel using Antigen technique for … | $719.00 |
| 87430 | INF AGT IMMUNO STREP A | $418.72 |
| 87471 | Infectious agent detection by nucleic acid (DNA or RNA); Ba… | $1,238.00 |
| 87480 | IADNA CANDIDA SPECIES DIRECT PROBE TQ | $152.65 |
| 87481 | Infectious agent detection by nucleic acid (DNA or RNA); Candida species,
amplified probe technique |
$412.85 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $785.74 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $676.34 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $826.23 |
| 87506 | Infectious agent detection by nucleic acid (DNA or RNA); ga… | $2,053.46 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $2,276.72 |
| 87510 | Infectious agent detection by nucleic acid (DNA or RNA); Ga… | $152.65 |
| 87529 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA &RNA) | $1,179.12 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $838.67 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $641.86 |
| 87624 | HPV HIGH-RISK TYPES | $584.71 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $3,739.69 |
| 87635 | IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ | $353.55 |
| 87636 | “severe acute respiratory syndrome coronavirus 2 (SARSCoV-2… | $978.00 |
| 87660 | Infectious agent detection by nucleic acid (DNA or RNA); Tr… | $427.42 |
| 87661 | INF AGENT DETECTED NUCLEIC ACID; TRICHMONAS VAGINALIS AMP P… | $386.83 |
| 87798 | O&P SMEAR W/AMPLIFIC | $1,205.68 |
| 87801 | Illlnfectious agent detection by nucleic acid (DNA or RNA), multiple organisms;
amplified probe(s) technique |
$1,717.40 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $480.73 |
| 87806 | Infectious agent antigen detection by immunoassay with dire… | $549.56 |
| 87807 | INF AGT DET IMNAS OPT RSV | $943.55 |
| 87808 | Infectious agent antigen detection by immunoassay with dire… | $208.69 |
| 87880 | RAPID STREP-BETA STREP | $1,087.00 |
| 88161 | Cytopathology, smears, any other source; preparation, scree… | $362.47 |
| 88233 | Under Cytogenetic Studies | $2,348.57 |
| 88262 | Under Cytogenetic Studies | $1,607.85 |
| 88291 | Under Cytogenetic Studies | $1,047.67 |
| 88305 | PATH SURG LEVEL IV | $1,006.81 |
| 89050 | CELL COUNT MISCELLANEOUS BODY FLUIDS | $354.91 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $546.48 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $319.92 |
| 89060 | CRYSTAL INDENTIFICATION | $419.12 |
| 89220 | SPTM OBTG SPEC AERSL INDUCED SPX | $624.00 |
| 89240 | UNLIS MISC | $250.00 |
| 90471 | IMMUN ADM 1 VAC | $345.43 |
| 90472 | Immunization admin, each add | $263.73 |
| 90658 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for
intramuscular use |
$1,441.00 |
| 90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, … | $220.28 |
| 90700 | DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM | $303.30 |
| 90707 | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use | $934.00 |
| 90714 | TETANUS DIPHTHERIA TOXOID | $390.61 |
| 90715 | TDAP VACCINE | $505.39 |
| 90746 | HEPATITIS B VACCINE/ADULT | $598.20 |
| 92552 | PURE TONE AUDIOMTRY AIR O | $459.98 |
| 92950 | cardiopulmonary resuscitation | $3,288.65 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $5,474.39 |
| 93000 | EKG W/INTREP AND REPORT | $1,305.65 |
| 93005 | Electrocardiogram, routine ECG | $1,051.55 |
| 93016 | CV STRS TST XERS&/OR RX CONT ECG W/O I&R | $12,862.68 |
| 93017 | CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY | $4,997.90 |
| 93018 | CV STRS TST XERS&/OR RX CONT ECG I&R ONLY | $4,125.58 |
| 93041 | RHYTHEM ECG 1-3 LDS | $558.73 |
| 93225 | XTRNL ECG & 48 HR RECORDING | $2,567.57 |
| 93226 | EXTERNAL ECG SCANNING ANALYSIS REPORT | $2,725.52 |
| 93246 | External electrocardiographic recording for more than 7 day… | $807.02 |
| 93303 | COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY | $9,841.14 |
| 93306 | ECHO TEST | $8,952.74 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $5,330.77 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $3,803.20 |
| 93313 | TEE R-T IMG 2D W/PROBE PLMT ONLY | $1,701.52 |
| 93314 | TEE R-T IMG 2D IMG ACQUISJ I&R ONLY | $9,523.20 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $3,807.54 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $3,439.17 |
| 93350 | ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST | $6,028.86 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $11,915.66 |
| 93623 | Programmed stimulation and pacing after intravenous drug infusion (List
separately in addition to code for primary procedure) |
$12,625.92 |
| 93880 | DUP-SCAN XTRC ART COMPL B | $5,085.37 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $2,633.87 |
| 93886 | TCD STD ICRA ART COMPL STD | $3,910.71 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $2,148.22 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $3,432.28 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $4,390.92 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $2,784.34 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $3,463.23 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $3,244.86 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $4,343.97 |
| 93971 | DPLX SCN EXTRM VEINS | $2,803.74 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… | $4,575.16 |
| 93976 | DUPLEX SCAN- LIMITED | $3,189.05 |
| 93980 | DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL | $2,674.77 |
| 94010 | SPIROMETRY W/RECORD | $978.31 |
| 94060 | BRNCDILAT RSPSE SPMTRY PR | $2,065.37 |
| 94621 | PULM STRS TSTG CPLX | $4,556.43 |
| 94640 | NEBULIZER TREATMENT | $946.14 |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $1,214.97 |
| 94660 | CPAP VENTILATION CPAP INITIATION&MGMT | $5,258.84 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $943.86 |
| 94760 | EAR OR PULSE OXIMETRY | $294.00 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $729.00 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $1,232.54 |
| 95811 | POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND | $11,551.65 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $1,631.70 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $613.68 |
| 96365 | IV INFUSION THERAPY/PROPH | $1,565.14 |
| 96366 | IV INFUS THER PROPH/DX EA | $678.27 |
| 96367 | IV NFS THER PROPH/DX ADDL | $827.25 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $611.94 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $687.46 |
| 96373 | INJECTION, INTRA-ARTERIAL | $584.99 |
| 96374 | THER PROPH/DX NJX IV PUSH | $964.22 |
| 96375 | THER PROPH/DX NJX EA SEQL | $705.75 |
| 96376 | SUB INFU EA ADD IV PUSH | $696.68 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $567.61 |
| 96379 | INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS | $2,321.55 |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; th… | $423.74 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR | $413.79 |
| 97140 | MANUAL THERAPY 1/> REGIONS | $449.62 |
| 97166 | Occupational therapy evaluation, moderate complexity, requi… | $1,246.65 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $328.18 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $3,017.36 |
| 99000 | SPECIMEN HANDLING | $63.50 |
| 99001 | COC COLLECITON ONLY | $427.32 |
| 99024 | POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX | $1,364.88 |
| 99050 | BLUE CROSS RQRD LVL3 | $207.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $1,102.63 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $954.61 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $853.36 |
| 99153 | MOD SED SAME PHYS/QHP EACH ADDL 15 MINS | $490.83 |
| 99155 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS | $1,247.00 |
| 99156 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS | $1,033.00 |
| 99157 | MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS | $798.00 |
| 99173 | SCREENING TEST OF VISION | $312.76 |
| 99281 | E/M VISIT LEVEL 1 TECH COMP | $1,044.66 |
| 99282 | E/M VISIT LEVEL 2 TECH COMP | $1,927.37 |
| 99283 | E/M VISIT LEVEL 3 TECH COMP | $3,377.98 |
| 99284 | E/M VISIT LEVEL 4 TECH COMP | $5,520.81 |
| 99285 | E/M VISIT LEVEL 5 TECH COMP | $8,202.90 |
| 99291 | CRITICAL CARE 30-74 MIN | $8,113.46 |
| 99292 | CRITICAL CARE ADD 30 MIN | $4,765.37 |
|
99384 |
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years) |
$442.88 |
| 99406 | SMOKING CESSATION 3-10 | $133.50 |
| 99407 | SMOKING CESSATION 10 MIN | $233.27 |
| E0114 | CRUTCHES UNDERARM | $290.79 |
| E0484 | NON-ELEC OSCILLATORY PEP DVC | $327.56 |
| G0378 | HOSPITAL OBSERVATION SERVICES PER HOUR | $2,500.00 |
| J0120 | TETRACYCLIN INJECTION | $162.00 |
| J0129 | ABATACEPT INJECTION | $406.99 |
| J0131 | INJECTION, ACETAMINOPHEN, 10 MG | $163.21 |
| J0132 | ACETYLCYSTEINE INJECTION | $42.00 |
| J0133 | ACYCLOVIR INJECTION | $3.00 |
| J0153 | ADENOSINE INJ 1MG | $44.02 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $167.60 |
| J0185 | INJ., APREPITANT, 1 MG | $34.35 |
| J0270 | ALPROSTADIL FOR INJECTION | $53.00 |
| J0278 | AMIKACIN SULFATE INJECTION | $19.67 |
| J0280 | AMINOPHYLLIN 250 MG INJ | $177.17 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $35.00 |
| J0285 | AMPHOTERICIN B | $398.35 |
| J0290 | AMPICILLIN 500 MG INJ | $85.00 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $83.00 |
| J0330 | SUCCINYLCHOLINE CHLO 20MG | $184.82 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $238.28 |
| J0401 | INJ ARIPIPRAZOLE EXT REL 1MG | $82.01 |
| J0456 | INJ AZITHROMYCIN 500MG | $181.81 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $79.65 |
| J0476 | BACLOFEN INTRATHECAL TRIAL | $679.00 |
| J0485 | BELATACEPT INJECTION | $58.55 |
| J0490 | BELIMUMAB INJECTION | $336.22 |
| J0500 | DICYCLOMINE HCL 20MG | $522.00 |
| J0515 | INJ BENZTROPINE MESYLATE | $384.34 |
| J0558 | PENG BENZATHINE/PROCAINE INJ | $159.00 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $213.24 |
| J0571 | BUPRENORPHINE ORAL 1MG | $25.35 |
| J0572 | BUPREN/NAL UP TO 3MG BUPRENO | $27.00 |
| J0573 | BUPREN/NAL 3.1 TO 6MG BUPREN | $65.69 |
| J0574 | BUPREN/NAL 6.1 TO 10MG BUPRE | $62.53 |
| J0583 | BIVALIRUDIN | $254.88 |
| J0585 | INJECTION,ONABOTULINUMTOXINA | $62.85 |
| J0586 | ABOBOTULINUMTOXINA | $79.33 |
| J0588 | INCOBOTULINUMTOXIN A | $44.01 |
| J0592 | BUPRENORPHINE HYDROCHLORIDE | $50.00 |
| J0595 | STADOL | $54.05 |
| J0596 | INJECTION, RUCONEST | $331.19 |
| J0604 | CINACALCET, ESRD ON DIALYSIS | $4.76 |
| J0636 | INJ CALCITRIOL PER 0.1 MCG | $64.19 |
| J0640 | LEUCOVORIN CALCIUM INJECTION | $120.14 |
| J0670 | INJ MEPIVACAINE HCL/10 ML | $167.67 |
| J0690 | KEFZOL 1 GR VIAL | $74.14 |
| J0692 | INJ CEFEPIME HCI 500MG | $62.87 |
| J0694 | CEFOXITIN SODIUM INJECTION | $116.34 |
| J0695 | INJ CEFTOLOZANE TAZOBACTAM | $57.96 |
| J0696 | ROCEPHIN 250 MG | $60.00 |
| J0697 | STERILE CEFUROXIME INJECTION | $49.00 |
| J0702 | BETAMETHASONE ACET&SOD PHOSP | $261.37 |
| J0706 | CAFFEINE CITRATE INJECTION | $42.31 |
| J0712 | CEFTAROLINE FOSAMIL INJ | $37.85 |
| J0713 | INJ CEFTAZIDIME PER 500 MG | $169.34 |
| J0735 | CLONIDINE 1MG | $270.80 |
| J0736 | INJ, CLINDAMYCIN PHOSP 300MG | $110.53 |
| J0743 | CILASTATIN SODIUM INJECTION | $173.72 |
| J0744 | CIPRO 200MG | $216.73 |
| J0770 | COLISTIMETHATE SODIUM INJ | $272.00 |
| J0780 | COMPAZINE 10 MG | $273.00 |
| J0875 | INJECTION, DALBAVANCIN | $137.88 |
| J0878 | DAPTOMYCIN INJECTION | $68.97 |
| J0881 | DARBEPOETIN ALFA, NON-ESRD | $72.97 |
| J0882 | DARBEPOETIN ALFA, ESRD USE | $80.73 |
| J0885 | EPOETIN ALFA, NON-ESRD | $351.84 |
| J0894 | DECITABINE INJECTION | $80.45 |
| J0895 | DEFEROXAMINE MESYLATE INJ | $463.05 |
| J0897 | DENOSUMAB INJECTION | $212.81 |
| J1000 | DEPO-ESTRADIOL CYPIONATE INJ | $214.00 |
| J1030 | DEPO MEDROL 40 MG/ML | $165.53 |
| J1040 | METHYLPREDNISOLONE 80MG | $279.14 |
| J1050 | MEDROXYPROGESTERONE ACETATE | $5.57 |
| J1071 | INJ TESTOSTERONE CYPIONATE | $1.15 |
| J1100 | DECADRON 4 MG VIAL | $46.20 |
| J1110 | INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG | $730.00 |
| J1160 | DIGOXIN INJECTION | $91.85 |
| J1165 | DILANTIN 100 MG VIAL | $67.56 |
| J1170 | DILAUDID 4 MG | $89.24 |
| J1200 | BENADRYL 50MG | $51.45 |
| J1230 | METHADONE INJECTION | $138.64 |
| J1250 | INJ DOBUTAMINE HCL/250 MG | $276.73 |
| J1265 | DOPAMINE INJECTION | $41.81 |
| J1325 | EPOPROSTENOL INJECTION | $117.00 |
| J1327 | EPTIFIBATIDE INJECTION | $275.12 |
| J1439 | INJ FERRIC CARBOXYMALTOS 1MG | $20.85 |
| J1442 | INJ FILGRASTIM EXCL BIOSIMIL | $14.95 |
| J1447 | INJ TBO FILGRASTIM 1 MICROG | $12.01 |
| J1450 | FLUCONAZOLE | $202.15 |
| J1451 | FOMEPIZOLE, 15 MG | $196.83 |
| J1453 | FOSAPREPITANT INJECTION | $8.66 |
| J1455 | FOSCARNET SODIUM INJECTION | $465.00 |
| J1559 | HIZENTRA INJECTION | $379.81 |
| J1561 | GAMUNEX-C/GAMMAKED | $496.82 |
| J1571 | HEPAGAM B IM INJECTION | $821.00 |
| J1580 | GARAMYCIN,GENTAMICIN 80MG | $78.15 |
| J1602 | GOLIMUMAB FOR IV USE 1MG | $325.78 |
| J1610 | GLUCOGAN 1 MG VIAL | $2,182.74 |
| J1626 | GRANISETRON HCL INJECTION | $11.42 |
| J1630 | HALOPERIDOL INJECTION | $143.32 |
| J1631 | HALOPERIDOL DECANOATE INJ PER 50 MG | $186.21 |
| J1640 | HEMIN, 1 MG | $144.44 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $23.89 |
| J1644 | INJ HEPARIN SOD PER 1000 | $70.42 |
| J1650 | ENOXAPARIN SODIUM 10MG | $87.59 |
| J1652 | FONDAPARINUX SODIUM | $72.23 |
| J1720 | HYDROCORTISONE SODIUM SUCC I | $234.94 |
| J1741 | IBUPROFEN INJECTION | $38.04 |
| J1744 | ICATIBANT INJECTION | $2,053.00 |
| J1750 | INJ IRON DEXTRAN | $229.29 |
| J1756 | IRON SUCROSE INJECTION | $62.52 |
| J1786 | IMUGLUCERASE INJECTION | $336.37 |
| J1790 | DROPERIDOL INJECTION | $63.36 |
| J1800 | PROPRANOLOL INJECTION | $220.86 |
| J1815 | INJ INSULIN PER 5 UNITS | $54.32 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $392.87 |
| J1836 | Injection, metronidazole, 10 mg | $2.17 |
| J1885 | TORADOL INJ 15 MG | $48.38 |
| J1930 | LANREOTIDE INJECTION | $579.36 |
| J1931 | LARONIDASE INJECTION | $389.87 |
| J1940 | LASIX 40 MG IV VIAL | $30.68 |
| J1953 | LEVETIRACETAM INJECTION | $29.79 |
| J1955 | INJ LEVOCARNITINE PER 1 GM | $411.55 |
| J1956 | LEVOFLOXACIN 250 MG | $102.14 |
| J1980 | HYOSCYAMINE SULFATE INJ | $278.13 |
| J2001 | LIDOCAINE HCI 10MG | $42.31 |
| J2020 | LINEZOLID INJECTION | $182.33 |
| J2060 | ATIVAN 2ML SYRUP | $45.00 |
| J2150 | MANNITOL INJECTION | $133.50 |
| J2175 | DEMEROL 50 MG SYRINGE | $161.00 |
| J2182 | INJECTION, MEPOLIZUMAB, 1MG | $218.24 |
| J2185 | MEROPENEM | $37.51 |
| J2210 | METHYLERGONOVIN MALEATE INJ | $319.84 |
| J2212 | METHYLNALTREXONE INJECTION | $13.33 |
| J2248 | MICAFUNGIN SODIUM INJECTION | $21.17 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $36.45 |
| J2260 | INJ MILRINONE LACTATE / 5 MG | $56.91 |
| J2270 | INJ MORPHINE SULFATE 10 M | $116.00 |
| J2274 | INJ MORPHINE PF EPID ITHC | $136.00 |
| J2278 | ZICONOTIDE INJECTION | $83.65 |
| J2280 | INJ, MOXIFLOXACIN 100 MG | $115.00 |
| J2300 | NUBAIN 10MG AMP | $93.41 |
| J2310 | INJ NALOXONE HCL 1MG | $189.00 |
| J2315 | NALTREXONE, DEPOT FORM | $25.00 |
| J2350 | INJECTION, OCRELIZUMAB, 1 MG | $490.44 |
| J2354 | OCTREOTIDE INJ, NON-DEPOT | $58.42 |
| J2357 | OMALIZUMAB INJECTION | $362.00 |
| J2358 | OLANZAPINE LONG-ACTING INJ | $123.49 |
| J2360 | ORPHENADRINE CITRATE 60MG | $419.10 |
| J2370 | NEO-SYNEPHRINE UP TO 1 ML | $36.58 |
| J2405 | ONDANSETRON HCI, PER MG | $16.71 |
| J2426 | PALIPERIDONE PALMITATE INJ | $91.00 |
| J2430 | PAMIDRONATE DISODIUM /30 MG | $201.71 |
| J2440 | PAPAVERIN HCL INJECTION | $479.33 |
| J2469 | PALONOSETRON HCL | $290.76 |
| J2501 | PARICALCITOL | $81.01 |
| J2540 | PENICILLIN G POTASSIUM INJ | $33.67 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $78.82 |
| J2550 | PHENERGAN 50 MG | $40.18 |
| J2560 | PHENOBARBITAL SODIUM INJ | $359.45 |
| J2562 | PLERIXAFOR INJECTION | $2,779.00 |
| J2590 | OXYTOCIN INJECTION | $147.00 |
| J2597 | INJ DESMOPRESSIN ACETATE | $128.74 |
| J2680 | FLUPHENAZINE DECANOATE 25 MG | $292.52 |
| J2700 | OXACILLIN SODIUM INJECITON | $79.94 |
| J2704 | INJECTION PROPOFOL 10 MG | $31.91 |
| J2710 | NEOSTIGMINE METHYLSLFTE INJ | $97.90 |
| J2720 | INJ PROTAMINE SULFATE/10 MG | $51.00 |
| J2760 | PHENTOLAINE MESYLATE INJ | $2,264.00 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $56.99 |
| J2791 | RHOPHYLAC INJECTION | $195.14 |
| J2794 | RISPERIDONE, LONG ACTING | $143.03 |
| J2795 | ROPIVACAINE HCL INJECTION | $32.09 |
| J2800 | METHOCARBAMOL INJECTION | $285.81 |
| J2850 | INJ SECRETIN SYNTHETIC HUMAN | $299.54 |
| J2916 | NA FERRIC GLUCONATE COMPLEX | $141.14 |
| J2919 | INJ, METHYLPRED SOD SUCC 5MG | $16.02 |
| J2920 | SOLU-MEDROL 40MG | $76.38 |
| J2930 | SOLU-MEDROL 125 MG | $100.89 |
| J2941 | SOMATROPIN INJECTION | $1,715.00 |
| J3010 | INJ FENTANYL CITRATE .1MG | $57.15 |
| J3030 | IMITREX 6MG VIAL | $912.29 |
| J3105 | INJECTION, TREBUTALINE SULFATE, UP TO 1 MG | $181.35 |
| J3230 | THOROZINE 50 MG | $385.08 |
| J3243 | TIGECYCLINE INJECTION | $31.47 |
| J3246 | TIROFIBAN HCL | $48.38 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $173.15 |
| J3262 | TOCILIZUMAB INJECTION | $64.63 |
| J3285 | TREPROSTINIL INJECTION | $433.75 |
| J3300 | TRIAMCINOLONE A INJ PRS-FREE | $22.00 |
| J3301 | TRIAMCINOLONE ACET INJ NOS | $83.71 |
| J3304 | INJ TRIAMCINOLONE ACE XR 1MG | $268.06 |
| J3358 | USTEKINUMAB, IV INJECT, 1 MG | $109.94 |
| J3360 | VALIUM INJ 5 MG | $222.52 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $79.52 |
| J3380 | INJECTION, VEDOLIZUMAB | $263.23 |
| J3410 | VISTERIL INJ 50 MG | $163.12 |
| J3411 | INJ THIAMINE 100 MG | $104.00 |
| J3415 | PYRIDOXINE HCL 100 MG | $153.59 |
| J3420 | VITAMIN B12 INJECTION | $103.50 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $104.26 |
| J3465 | INJECTION, VORICONAZOLE | $79.97 |
| J3471 | OVINE, UP TO 999 USP UNITS | $4.86 |
| J3473 | HYALURONIDASE RECOMBINANT | $4.41 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $56.00 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $22.18 |
| J3485 | ZIDOVUDINE | $26.00 |
| J3486 | GEODON – ZIPRASIDONE MESYLATE 10MG | $339.63 |
| J3490 | UNCLASSIFIED DRUGS | $192.22 |
| J7030 | INFUS NORM SALINE 1000CC | $111.00 |
| J7040 | INFUS NORM SALINE 500ML | $130.00 |
| J7042 | 5% DEXTROSE | $172.72 |
| J7050 | INFS NORM SALINE 250CC | $73.53 |
| J7060 | INFUSION D5W 250ML | $163.22 |
| J7070 | INFUSION D5W 1000ML | $158.19 |
| J7100 | DEXTRAN 40 INFUSION | $390.78 |
| J7120 | RINGER’S LACTATE INFUS | $57.45 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $134.00 |
| J7131 | HYPERTONIC SALINE SOL | $3.53 |
| J7179 | VONVENDI INJ 1 IU VWF:RCO | $21.53 |
| J7182 | FACTOR VIII RECOMB NOVOEIGHT | $23.00 |
| J7183 | WILATE INJECTION | $18.76 |
| J7186 | ANTIHEMOPHILIC VIII/VWF COMP | $14.12 |
| J7187 | HUMATE-P, INJ | $10.85 |
| J7190 | FACTOR VIII | $13.36 |
| J7192 | FACTOR VIII RECOMBINANT NOS | $13.75 |
| J7193 | FACTOR IX NON-RECOMBINANT | $16.35 |
| J7194 | FACTOR IX COMPLEX | $29.00 |
| J7195 | FACTOR IX RECOMBINANT NOS | $15.49 |
| J7197 | ANTITHROMBIN III INJECTION | $42.74 |
| J7201 | FACTOR IX ALPROLIX RECOMB | $7.00 |
| J7202 | FACTOR IX IDELVION INJ | $23.00 |
| J7207 | FACTOR VIII PEGYLATED RECOMB | $7.65 |
| J7209 | FACTOR VIII NUWIQ RECOMB 1IU | $25.00 |
| J7325 | SYNVISC OR SYNVISC-ONE | $259.05 |
| J7336 | CAPSAICIN 8% PATCH | $48.73 |
| J7500 | AZATHIOPRINE ORAL 50MG | $28.90 |
| J7502 | CYCLOSPORINE ORAL 100 MG | $89.85 |
| J7503 | TACROL ENVARSUS EX REL ORAL | $24.00 |
| J7507 | TACROLIMUS IMME REL ORAL 1MG | $39.44 |
| J7509 | METHYLPREDNISOLONE ORAL | $21.14 |
| J7510 | PREDNISOLONE ORAL 5 MG | $12.00 |
| J7512 | PREDNISONE 5 MG | $2.45 |
| J7515 | CYCLOSPORINE ORAL 25 MG | $47.14 |
| J7517 | MYCOPHENOLATE MOFETIL ORAL | $24.66 |
| J7518 | MYCOPHENOLIC ACID | $43.56 |
| J7520 | SIROLIMUS, ORAL | $184.55 |
| J7527 | ORAL EVEROLIMUS | $185.48 |
| J7599 | IMMUNOSUPPRESSIVE DRUG NOC | $114.44 |
| J7605 | ARFORMOTEROL NON-COMP UNIT | $123.00 |
| J7606 | FORMOTEROL FUMARATE, INH | $179.10 |
| J7608 | ACETYLCYSTEINE NON-COMP UNIT | $272.32 |
| J7610 | ALBUTEROL, THRU DME 1MG | $32.23 |
| J7611 | ALBUTEROL 1MG CONC INHALA | $3.32 |
| J7612 | LEVALBUTEROL NON-COMP CON | $20.67 |
| J7613 | ALBUT INHAL NON-CP 1MG | $8.59 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $26.06 |
| J7615 | LEVALBTERAL INHALATION SO | $61.06 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $38.00 |
| J7626 | BUDESONIDE NON-COMP UNIT | $149.16 |
| J7633 | BUDESONIDE NON-COMP CON | $35.00 |
| J7634 | BUDESONIDE COMP CON | $67.67 |
| J7639 | DORNASE ALFA NON-COMP UNIT | $508.00 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $48.00 |
| J7674 | METHACHOLINE CHLORIDE, NEB | $12.65 |
| J7682 | TOBRAMYCIN NON-COMP UNIT | $312.00 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $4.41 |
| J7799 | NON-INHALATION DRUG FOR DME | $144.39 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $110.86 |
| J8501 | ORAL APREPITANT | $98.45 |
| J8515 | CABERGOLINE, ORAL 0.25MG | $129.81 |
| J8521 | CAPECITABINE, ORAL, 500 MG | $71.62 |
| J8530 | CYCLOPHOSPHAMIDE ORAL 25 MG | $87.25 |
| J8540 | DEXAMETHASONE, ORAL .25MG | $3.32 |
| J8597 | ANTIEMETIC DRUG ORAL NOS | $4.19 |
| J8610 | METHOTREXATE ORAL 2.5 MG | $39.00 |
| J8700 | TEMOZOLOMIDE | $184.68 |
| J8999 | ORAL PRESCRIPTION DRUG CHEMO | $200.81 |
| J9000 | DOXORUBICIN HCL INJECTION | $262.17 |
| J9023 | INJECTION, AVELUMAB, 10 MG | $446.00 |
| J9025 | AZACITIDINE INJECTION | $34.25 |
| J9034 | INJ., BENDEKA 1 MG | $174.20 |
| J9035 | BEVACIZUMAB INJECTION | $705.00 |
| J9041 | INJ., VELCADE 0.1 MG | $192.65 |
| J9043 | CABAZITAXEL INJECTION | $1,403.00 |
| J9045 | CARBOPLATIN INJECTION | $138.31 |
| J9060 | CISPLATIN 10 MG INJECTION | $46.87 |
| J9065 | INJ CLADRIBINE PER 1 MG | $373.27 |
| J9100 | CYTARABINE HCL 100 MG INJ | $187.09 |
| J9130 | DACARBAZINE 100 MG INJ | $111.46 |
| J9155 | DEGARELIX INJECTION | $54.43 |
| J9171 | DOCETAXEL INJECTION | $33.83 |
| J9175 | ELLIOTTS B SOLUTION PER ML | $112.50 |
| J9176 | INJECTION, ELOTUZUMAB, 1MG | $71.32 |
| J9181 | ETOPOSIDE INJECTION | $22.19 |
| J9190 | FLUOROURACIL INJECTION | $50.29 |
| J9208 | IFOSFAMIDE INJECTION | $446.06 |
| J9209 | MESNA INJECTION | $74.04 |
| J9250 | METHOTREXATE SODIUM INJ | $10.27 |
| J9260 | METHOTREXATE SODIUM INJ | $141.39 |
| J9263 | OXALIPLATIN | $4.63 |
| J9264 | PACLITAXEL PROTEIN BOUND | $153.82 |
| J9267 | PACLITAXEL INJECTION | $3.41 |
| J9271 | INJ PEMBROLIZUMAB | $390.74 |
| J9299 | INJECTION, NIVOLUMAB | $264.30 |
| J9306 | INJECTION, PERTUZUMAB, 1 MG | $104.48 |
| J9308 | INJECTION, RAMUCIRUMAB | $355.00 |
| J9328 | TEMOZOLOMIDE INJECTION | $167.20 |
| J9330 | TEMSIROLIMUS INJECTION | $444.87 |
| J9351 | TOPOTECAN INJECTION | $75.64 |
| J9354 | INJ, ADO-TRASTUZUMAB EMT 1MG | $212.16 |
| J9355 | TRASTUZUMAB INJECTION | $660.00 |
| J9360 | VINBLASTINE SULFATE INJ | $82.67 |
| J9390 | VINORELBINE TARTRATE INJ | $302.23 |
| J9395 | INJECTION, FULVESTRANT | $376.67 |
| J9999 | CHEMOTHERAPY DRUG | $9.86 |
| L0120 | CERVICAL FLEX NONADJ COLL | $188.95 |
| L0130 | FLEX THERMOPLASTIC COLLAR MO | $337.39 |
| L0140 | CERVICAL SEMI-RIGID ADJUSTAB | $387.18 |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup (plastic c… | $340.00 |
| L0172 | CLAVICAL COLLAR 2 PC | $446.00 |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam, two piece… | $1,083.00 |
| L0190 | CERV COLLAR SUPP ADJ CERV BA | $1,629.23 |
| L0200 | CERV COL SUPP ADJ BAR & THOR | $1,975.00 |
| L0456 | TLSO FLEX TRNK SJ-SS PRE CST | $3,835.00 |
| L0460 | TLSO 2 SHL SYMPHYS-STERN CST | $3,183.87 |
| L0462 | TLSO 3MOD SACRO-SCAP PRE | $10,290.55 |
| L0464 | TLSO 4MOD SACRO-SCAP PRE | $6,912.00 |
| L0467 | TLSO R FRAM SOFT PRE OTS | $1,054.00 |
| L0625 | LO FLEX L1-BELOW L5 PRE OTS | $1,696.81 |
| L0628 | LSO FLEX NO RI STAYS PRE OTS | $276.00 |
| L0641 | LO RIG POS PNL L1-L5 PRE OTS | $503.13 |
| L0650 | LSO SC R ANT/POS PNL PRE OTS | $5,059.00 |
| L0984 | PROTECT BODY SOCK EA PRE OTS | $307.33 |
| L1210 | LATERAL THORACIC EXTENSION | $985.09 |
| L1240 | LUMBAR DEROTATION PAD | $315.47 |
| L1290 | LATERAL TROCHANTERIC PAD | $297.16 |
| L1499 | SPINAL ORTHOSIS NOS | $109.91 |
| L1660 | HO ABDUCTION STATIC PLASTIC | $856.87 |
| L1686 | HO POST-OP HIP ABDUCTION | $3,873.00 |
| L1810 | KO ELASTIC WITH JOINTS | $498.00 |
| L1830 | KNEE IMMOBOLIZER | $389.00 |
| L1831 | KNEE ORTH POS LOCKING JOINT | $887.72 |
| L1832 | KO ADJ JNT POS R SUP PRE CST | $1,429.68 |
| L1836 | KO RIGID W/O JOINTS PRE OTS | $539.36 |
| L1845 | KO DOUBLE UPRIGHT PRE CST | $2,890.69 |
| L1902 | ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT … | $293.25 |
| L1906 | ANKLE SUPPORT | $305.00 |
| L1930 | AFO PLASTIC | $840.66 |
| L1940 | AFO MOLDED TO PATIENT PLASTI | $1,783.13 |
| L1951 | AFO SPIRAL PREFABRICATED | $3,644.00 |
| L1960 | Ankle foot orthosis (AFO), posterior solid ankle, plastic, … | $2,084.16 |
| L2114 | AFO TIB FX SEMI-RIGID | $2,327.52 |
| L2200 | LIMITED ANKLE MOTION EA JNT | $236.10 |
| L2210 | DORSIFLEXION ASSIST EACH JOI | $265.00 |
| L2270 | VARUS/VALGUS STRAP PADDED/LI | $203.53 |
| L2275 | PLASTIC MOD LOW EXT PAD/LINE | $490.51 |
| L2310 | ABDUCTION BAR-STRAIGHT | $616.70 |
| L2624 | HIP ADJ FLEX EXT ABDUCT CONT | $1,757.00 |
| L2760 | EXTENSION PER EXTENSION PER | $305.30 |
| L2768 | ORTHO SIDEBAR DISCONNECT | $527.15 |
| L2820 | SOFT INTERFACE BELOW KNEE SE | $383.00 |
| L2830 | SOFT INTERFACE ABOVE KNEE SE | $685.00 |
| L3010 | FOOT LONGITUDINAL ARCH SUPPO | $725.94 |
| L3060 | FOOT ARCH SUPP LONGITUD/META | $246.56 |
| L3150 | ABDUCT ROTATION BAR W/O SHOE | $327.69 |
| L3260 | SURGICAL BOOT/SHOE | $303.00 |
| L3310 | SHOE LIFT ELEV HEEL/SOLE NEO | $642.45 |
| L3332 | SHOE LIFTS TAPERED TO ONE-HA | $160.30 |
| L3660 | So 8 ab rstr can/web pre ots | $259.00 |
| L3670 | SO ACROMIO/CLAVICULAR | $453.72 |
| L3764 | EWHO W/JOINT(S) CF | $2,282.00 |
| L3807 | Whfo w/o joints pre cst | $537.00 |
| L3808 | Wrist-hand-finger orthosis (WHFO), rigid without joints, ma… | $958.63 |
| L3809 | Wrist-hand-finger orthosis (WHFO), without joint(s), prefab… | $2,007.63 |
| L3908 | WRIST EXTN CONTROL COCKUP | $207.63 |
| L3925 | FO PIP DIP JNT/SPRNG PRE OTS | $144.00 |
| L3980 | UP EXT FX ORTHOS HUMERAL NOS | $1,792.60 |
| L3995 | SOCK FRACTURE OR EQUAL EACH | $167.91 |
| L4210 | ORTH DEV REPAIR/REPL MINOR P | $254.00 |
| L4350 | AIR SPLINT | $624.00 |
| L4360 | WALK BOOT PNEUMATIC | $540.00 |
| L4386 | WALKING BOOT NON PNEUMATIC | $468.00 |
| L4387 | NON-PNEUM WALK BOOT PRE OTS | $710.33 |
| L4396 | STATIC OR DYNAMI AFO PRE CST | $563.00 |
| L4397 | STATIC OR DYNAMI AFO PRE OTS | $1,480.08 |
| L5628 | TEST SOCKET HEMIPELVECTOMY | $2,735.00 |
| L5658 | SOCKET INSERT ABOVE KNEE | $2,225.00 |
| L5668 | BK MOLDED DISTAL CUSHION | $615.48 |
| L6675 | HARNESS FIGURE OF 8 SING CON | $498.65 |
| L6682 | TEST SOCK ELBW DISART/ABOVE | $2,068.00 |
| L6691 | REMOVABLE INSERT EACH | $1,732.00 |
| L8000 | MASTECTOMY BRA | $210.67 |
| L8002 | BRST PRSTH BRA & BILAT FORM | $360.00 |
| L8420 | PROSTHETIC SOCK MULTI PLY BK | $92.81 |
| L8435 | PROS SOCK MULTI PLY UPPER LM | $105.00 |
| L8470 | PROS SOCK SINGLE PLY BK | $26.87 |
| L8485 | PROS SOCK SINGLE PLY UPPER L | $44.78 |
| L8501 | TRACHEOSTOMY SPEAKING VALVE | $631.88 |
| L8509 | TRACH-ESOPH VOICE PROS MD IN | $2,373.43 |
| Q0144 | AZITH DIHY ORAL CAP/POWD | $436.00 |
| Q9963 | HI OSM CONTRST MATL 350-3 | $96.24 |
| Q9965 | LOW OSMOLAR CON MAT PER M | $40.94 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $48.80 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $109.05 |
| U0002 | COVID-19 PCR Testing | $630.28 |