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| CPT Code | CPT Code Description | Charge Amount |
| 0001A | Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose | $178.51 |
| 0202U | Infectious disease (bacterial or viral respiratory tract in… | $420.78 |
| 10021 | FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION | $2,492.00 |
| 10060 | INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE | $1,323.00 |
| 10061 | INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE | $2,323.00 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $2,085.72 |
| 10081 | INCISION & DRAINAGE PILONIDAL CYST COMPLICATED | $3,013.19 |
| 10120 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE | $1,947.99 |
| 10121 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL | $9,189.00 |
| 10140 | I&D HEMATOMA SEROMA/FLUID COLLECTION | $7,345.00 |
| 10160 | PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST | $1,427.82 |
| 10180 | INCISION & DRAINAGE COMPLEX PO WOUND INFECTION | $7,715.00 |
| 11010 | DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS | $3,896.00 |
| 11011 | DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC | $8,652.75 |
| 11042 | DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< | $6,638.12 |
| 11043 | DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< | $5,488.25 |
| 11045 | DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM | $3,801.85 |
| 11055 | PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 | $1,721.85 |
| 11200 | REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 | $5,567.00 |
| 11402 | EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM | $5,485.00 |
| 11420 | EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< | $10,133.00 |
| 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $1,069.00 |
| 11720 | DEBRIDEMENT NAIL ANY METHOD 1-5 | $228.35 |
| 11730 | AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 | $1,196.86 |
| 11732 | AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL | $376.95 |
| 11740 | EVACUATION SUBUNGUAL HEMATOMA | $673.39 |
| 11750 | EXCISION NAIL MATRIX PERMANENT REMOVAL | $4,277.00 |
| 11760 | REPAIR NAIL BED | $2,212.00 |
| 11765 | WEDGE EXCISION SKIN NAIL FOLD | $3,953.99 |
| 11771 | EXCISION PILONIDAL CYST/SINUS EXTENSIVE | $8,996.00 |
| 11900 | INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS | $1,623.75 |
| 11982 | REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT | $1,375.09 |
| 12001 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< | $1,088.26 |
| 12002 | SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM | $1,154.70 |
| 12004 | SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM | $1,176.31 |
| 12005 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM | $1,758.37 |
| 12006 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM | $1,688.00 |
| 12007 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM | $2,203.00 |
| 12011 | SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< | $1,082.99 |
| 12013 | SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM | $1,173.49 |
| 12014 | SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM | $1,350.52 |
| 12015 | SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM | $1,228.80 |
| 12016 | SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM | $1,803.00 |
| 12017 | SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM | $2,300.00 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $3,283.00 |
| 12021 | TX SUPERFICIAL WOUND DEHISCENCE W/PACKING | $2,226.00 |
| 12031 | REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< | $1,678.85 |
| 12032 | REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM | $1,789.92 |
| 12034 | REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM | $2,017.16 |
| 12035 | REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM | $2,494.00 |
| 12036 | REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM | $6,519.16 |
| 12037 | REPAIR INTERMEDIATE S/A/T/E >30.0 CM | $6,835.00 |
| 12041 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< | $1,370.35 |
| 12042 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM | $1,589.00 |
| 12044 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM | $1,827.00 |
| 12045 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM | $2,565.00 |
| 12051 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< | $1,547.77 |
| 12052 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM | $1,612.40 |
| 12053 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM | $2,309.00 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM | $1,673.19 |
| 12055 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM | $1,744.43 |
| 12056 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM | $2,582.45 |
| 13100 | REPAIR COMPLEX TRUNK 1.1-2.5 CM | $3,522.30 |
| 13101 | REPAIR COMPLEX TRUNK 2.6-7.5 CM | $3,768.97 |
| 13102 | REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/< | $5,076.35 |
| 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $2,350.17 |
| 13121 | REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM | $3,074.00 |
| 13122 | REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/< | $3,074.00 |
| 13131 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM | $2,209.83 |
| 13132 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM | $3,760.25 |
| 13133 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< | $2,500.93 |
| 13151 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM | $2,740.00 |
| 13152 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM | $3,398.42 |
| 13153 | REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/< | $2,957.08 |
| 16000 | INITIAL TX 1ST DEGREE BURN LOCAL TX | $1,127.89 |
| 16020 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL | $1,170.16 |
| 16025 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM | $1,627.36 |
| 16030 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE | $1,112.36 |
| 17000 | DESTRUCTION PREMALIGNANT LESION 1ST | $887.00 |
| 17110 | DESTRUCTION BENIGN LESIONS UP TO 14 | $1,064.00 |
| 17111 | DESTRUCTION BENIGN LESIONS 15/> | $1,225.13 |
| 17250 | CHEMICAL CAUTERIZATION OF GRANULATION TISSUE | $819.30 |
| 19000 | PUNCTURE ASPIRATION CYST BREAST | $1,908.29 |
| 19020 | MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP | $11,088.00 |
| 20102 | EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK | $9,643.00 |
| 20103 | EXPLORATION PENETRATING WOUND SPX EXTREMITY | $6,881.00 |
| 20520 | REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE | $9,411.00 |
| 20525 | RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP | $10,040.00 |
| 20550 | INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS | $1,347.00 |
| 20552 | INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES | $1,628.97 |
| 20553 | INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES | $1,885.86 |
| 20600 | ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US | $1,778.14 |
| 20605 | ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US | $1,448.71 |
| 20610 | ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US | $1,893.67 |
| 20611 | ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US | $2,514.34 |
| 20650 | INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX | $16,771.00 |
| 21315 | CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION | $7,064.33 |
| 21320 | CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION | $7,097.00 |
| 21337 | CLOSED TX NASAL SEPTAL FRACT W/WO STABILIZATION | $7,284.00 |
| 21451 | CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION | $12,884.57 |
| 21480 | CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ | $1,718.31 |
| 21485 | CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ | $9,258.21 |
| 21501 | I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX | $14,086.00 |
| 22310 | CLTX VRT BDY FX W/O MANJ REQ&W/CSTING/BRACING | $1,772.55 |
| 23330 | REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS | $4,642.80 |
| 23500 | CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION | $1,077.00 |
| 23505 | CLSD TX CLAVICULAR FRACTURE W/MANIPULATION | $8,392.49 |
| 23540 | CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION | $2,048.58 |
| 23545 | CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION | $2,339.00 |
| 23550 | OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC | $18,172.00 |
| 23600 | CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION | $3,216.53 |
| 23620 | CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ | $1,144.77 |
| 23650 | CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES | $1,897.00 |
| 23655 | CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES | $5,016.41 |
| 23665 | CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MNPJ | $3,094.75 |
| 23930 | I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA | $9,241.00 |
| 23931 | INCISION&DRAINAGE UPPER ARM/ELBOW BURSA | $12,157.37 |
| 24200 | RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS | $7,428.00 |
| 24500 | CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION | $2,398.75 |
| 24505 | CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ | $4,224.71 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ | $1,878.50 |
| 24535 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ | $8,305.30 |
| 24565 | CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ | $6,565.53 |
| 24586 | OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO | $24,064.00 |
| 24600 | TREATMENT CLOSED ELBOW DISLOCATION W/O ANES | $1,512.71 |
| 24605 | TREATMENT CLOSED ELBOW DISLOCATION REQ ANES | $5,346.87 |
| 24620 | CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ | $7,073.35 |
| 24640 | CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ | $1,600.45 |
| 24650 | CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION | $1,066.00 |
| 24655 | CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION | $8,078.76 |
| 24675 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ | $5,017.00 |
| 25028 | I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA | $9,808.88 |
| 25111 | EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY | $9,084.85 |
| 25500 | CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION | $2,072.08 |
| 25505 | CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION | $5,291.93 |
| 25520 | CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT | $7,566.07 |
| 25530 | CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION | $1,318.62 |
| 25535 | CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION | $4,437.41 |
| 25560 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN | $2,031.17 |
| 25565 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ | $3,494.76 |
| 25600 | CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ | $1,587.22 |
| 25605 | CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF | $3,724.34 |
| 25607 | OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP | $16,929.46 |
| 25635 | CLTX CARPAL BONE FX W/MANJ EACH BONE | $7,293.00 |
| 25650 | CLOSED TREATMENT ULNAR STYLOID FRACTURE | $2,002.00 |
| 25652 | OPEN TREATMENT ULNAR STYLOID FRACTURE | $17,544.00 |
| 25660 | CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MANJ | $1,245.00 |
| 25675 | CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ | $2,513.64 |
| 25690 | CLOSED TX LUNATE DISLOCATION W/MANIPULATION | $8,117.33 |
| 26010 | DRAINAGE FINGER ABSCESS SIMPLE | $1,421.08 |
| 26011 | DRAINAGE FINGER ABSCESS COMPLICATED | $4,597.00 |
| 26600 | CLTX METACARPAL FX W/O MANIPULATION EACH BONE | $1,473.45 |
| 26605 | CLTX METACARPAL FX W/MANIPULATION EACH BONE | $1,935.67 |
| 26607 | CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE | $4,599.00 |
| 26615 | OPEN TX METACARPAL FRACTURE SINGLE EA BONE | $14,905.00 |
| 26641 | CLTX CARPO/METACARPAL DISLOCATION THUMB W/MANJ | $1,798.38 |
| 26670 | CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES | $2,400.01 |
| 26675 | CLTX CARPO/MTCRPL DISLC THUMB MANJ EA JT W/ANES | $5,111.00 |
| 26700 | CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES | $1,575.89 |
| 26705 | CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES | $3,695.00 |
| 26720 | CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA | $1,867.00 |
| 26725 | CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA | $1,896.13 |
| 26735 | OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA | $11,705.00 |
| 26742 | CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ | $4,724.00 |
| 26746 | OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA | $11,669.00 |
| 26750 | CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA | $1,726.45 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA | $2,009.00 |
| 26765 | OPEN TX DISTAL PHALANGEAL FRACTURE EACH | $9,370.56 |
| 26770 | CLTX IPHAL JT DISLC W/MANJ W/O ANES | $1,485.59 |
| 26775 | CLTX IPHAL JT DISLC W/MANJ REQ ANES | $3,824.32 |
| 26952 | AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP | $14,338.14 |
| 27301 | I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION | $14,322.00 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $16,859.00 |
| 27502 | CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ | $10,922.74 |
| 27508 | CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MANJ | $1,724.00 |
| 27520 | CLOSED TX PATELLAR FRACTURE W/O MANIPULATION | $3,322.16 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $2,254.00 |
| 27560 | CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA | $1,440.94 |
| 27752 | CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ | $5,028.61 |
| 27760 | CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION | $1,284.55 |
| 27762 | CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ | $4,707.20 |
| 27780 | CLTX PROX FIBULA/SHFT FX W/O MANJ | $1,592.00 |
| 27786 | CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ | $1,189.00 |
| 27788 | CLTX DSTL FIBULAR FX LAT MALLS W/MANJ | $1,786.83 |
| 27792 | OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS | $23,734.72 |
| 27808 | CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ | $2,105.56 |
| 27810 | CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ | $4,329.57 |
| 27818 | CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION | $3,704.75 |
| 27840 | CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA | $1,805.48 |
| 27842 | CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ | $4,227.85 |
| 28190 | REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS | $3,711.38 |
| 28192 | REMOVAL FOREIGN BODY FOOT DEEP | $6,787.27 |
| 28470 | CLOSED TX METATARSAL FRACTURE W/O MANIPULATION | $1,076.00 |
| 28475 | CLTX METAR FX W/MANJ | $2,617.81 |
| 28490 | CLTX FX GRT TOE PHLX/PHLG W/O MANJ | $912.00 |
| 28495 | CLTX FX GRT TOE PHLX/PHLG W/MANJ | $2,523.16 |
| 28505 | OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES | $16,243.00 |
| 28510 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ | $4,017.85 |
| 28515 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ | $2,001.51 |
| 28630 | CLTX METATARSOPHLNGL JT DISLC W/O ANES | $1,263.00 |
| 28660 | CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES | $1,508.08 |
| 29065 | APPLICATION CAST SHOULDER HAND LONG ARM | $1,716.90 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $1,449.27 |
| 29085 | APPLICATION CAST HAND & LOWER FOREARM GAUNTLET | $771.13 |
| 29105 | APPLICATION LONG ARM SPLINT SHOULDER HAND | $937.92 |
| 29125 | APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC | $818.00 |
| 29126 | APPLICATION SHORT ARM SPLINT DYNAMIC | $884.89 |
| 29130 | APPLICATION FINGER SPLINT STATIC | $568.93 |
| 29131 | APPLICATION FINGER SPLINT DYNAMIC | $1,000.64 |
| 29240 | STRAPPING SHOULDER | $782.04 |
| 29260 | STRAPPING ELBOW/WRIST | $636.64 |
| 29280 | STRAPPING HAND/FINGER | $695.11 |
| 29355 | APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE | $1,600.00 |
| 29405 | APPLICATION SHORT LEG CAST BELOW KNEE-TOE | $1,014.13 |
| 29505 | APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES | $948.37 |
| 29515 | APPLICATION SHORT LEG SPLINT CALF FOOT | $859.46 |
| 29530 | STRAPPING KNEE | $618.52 |
| 29540 | STRAPPING ANKLE &/FOOT | $646.65 |
| 29550 | STRAPPING TOES | $588.00 |
| 29580 | STRAPPING UNNA BOOT | $565.49 |
| 30300 | REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE | $767.78 |
| 30901 | CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE | $922.14 |
| 30903 | CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX | $933.50 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $1,340.00 |
| 30906 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ | $1,062.75 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,297.91 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $4,044.00 |
| 31525 | LARYNGOSCOPY W/WO TRACHEOSCOPY DX EXCEPT NEWBORN | $11,950.00 |
| 31541 | LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP | $10,022.00 |
| 31575 | LARYNGOSCOPY FLEXIBLE DIAGNOSTIC | $1,090.18 |
| 31605 | TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE | $2,831.69 |
| 32550 | INSERTION INDWELLING TUNNELED PLEURAL CATHETER | $11,312.30 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $3,501.00 |
| 32556 | PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING | $9,427.26 |
| 36000 | INTRODUCTION NEEDLE/INTRACATHETER VEIN | $1,069.00 |
| 36005 | NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH | $3,058.77 |
| 36010 | INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA | $3,804.22 |
| 36011 | SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH | $6,860.00 |
| 36410 | VNPNXR 3 YEARS/> PHYS/QHP SKILL | $2,309.05 |
| 36415 | COLLECTION VENOUS BLOOD VENIPUNCTURE | $76.46 |
| 36416 | COLLECTION CAPILLARY BLOOD SPECIMEN | $123.30 |
| 36556 | INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> | $6,066.00 |
| 36558 | INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> | $11,312.42 |
| 36569 | INSERTION PICC W/O IMG GDN 5 YR/> | $5,582.76 |
| 36573 | INSERTION PICC W/RS&I 5 YR/> | $7,172.57 |
| 36575 | RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP | $2,830.14 |
| 36589 | RMVL TUN CVC W/O SUBQ PORT/PMP | $7,338.00 |
| 36591 | COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE | $339.09 |
| 36592 | COLLECT BLOOD FROM CATHETER VENOUS NOS | $408.56 |
| 36680 | PLACEMENT NEEDLE INTRAOSSEOUS INFUSION | $999.97 |
| 37785 | LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG | $13,216.00 |
| 40650 | RPR LIP FULL THICKNESS VERMILION ONLY | $3,650.91 |
| 40800 | DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL | $2,087.09 |
| 40801 | DRG ABSC CST HMTMA VESTIBULE MOUTH COMP | $6,465.00 |
| 40804 | RMVL EMBEDDED FB VESTIBULE MOUTH SMPL | $2,758.00 |
| 40830 | CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/< | $2,893.80 |
| 40831 | CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL | $3,038.57 |
| 41008 | INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE | $9,867.00 |
| 41250 | RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG | $1,200.05 |
| 41252 | RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX | $2,671.00 |
| 41800 | DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS | $1,088.59 |
| 42700 | I&D ABSCESS PERITONSILLAR | $2,011.17 |
| 42809 | REMOVAL FOREIGN BODY PHARYNX | $2,341.47 |
| 43215 | ESOPHAGOSCOPY FLEXIBLE REMOVAL FOREIGN BODY | $9,194.89 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $7,610.56 |
| 43753 | GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE | $1,600.36 |
| 45900 | RDCTJ PROCIDENTIA UNDER ANES SEPARATE PROCEDURE | $5,736.72 |
| 45915 | RMVL FECAL IMPACTION/FB SPX UNDER ANES | $12,632.58 |
| 46040 | I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX | $8,599.00 |
| 46050 | I&D PERIANAL ABSCESS SUPERFICIAL | $4,456.40 |
| 46083 | INCISION THROMBOSED HEMORRHOID EXTERNAL | $1,538.00 |
| 46221 | HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS | $2,372.08 |
| 46320 | EXC THROMBOSED HEMORRHOID XTRNL | $11,547.93 |
| 46608 | ANOSCOPY W/RMVL FOREIGN BODY | $4,075.52 |
| 49083 | ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE | $3,910.36 |
| 49505 | RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE | $15,387.60 |
| 51700 | BLDR IRRIGATION SMPL LAVAGE &/INSTLJ | $3,194.71 |
| 51701 | INSJ NON-NDWELLG BLADDER CATHETER | $887.11 |
| 51702 | INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE | $945.34 |
| 51703 | INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED | $2,296.93 |
| 54001 | SLITTING PREPUCE DORSAL/LAT SPX XCP NEWBORN | $14,646.83 |
| 54015 | I&D PENIS DEEP | $5,352.11 |
| 54163 | REPAIR INCOMPLETE CIRCUMCISION | $8,002.00 |
| 54220 | IRRIGATION CORPORA CAVERNOSA PRIAPISM | $939.00 |
| 54235 | NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT | $2,989.65 |
| 54437 | REPAIR OF TRAUMATIC CORPOREAL TEAR(S) | $12,227.07 |
| 54450 | FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING | $1,619.65 |
| 55100 | DRAINAGE SCROTAL WALL ABSCESS | $6,714.97 |
| 56405 | I&D VULVA/PERINEAL ABSCESS | $1,700.77 |
| 56420 | I&D OF BARTHOLINS GLAND ABSCESS | $1,383.01 |
| 56440 | MARSUPIALIZATION BARTHOLINS GLAND CYST | $14,649.00 |
| 57410 | PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL | $10,921.00 |
| 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $14,721.00 |
| 58301 | REMOVAL INTRAUTERINE DEVICE IUD | $2,124.00 |
| 59025 | FETAL NONSTRESS TEST | $2,206.31 |
| 59409 | VAGINAL DELIVERY ONLY | $9,990.00 |
| 62270 | DIAGNOSTIC LUMBAR SPINAL PUNCTURE | $2,273.03 |
| 62272 | THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF | $2,849.65 |
| 64400 | INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH | $2,119.00 |
| 64405 | INJECTION AA&/STRD GREATER OCCIPITAL NERVE | $2,049.25 |
| 64415 | INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN | $6,351.34 |
| 64447 | INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN | $5,104.00 |
| 64450 | INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH | $2,977.20 |
| 64455 | NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES | $1,456.82 |
| 64640 | DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE | $3,869.56 |
| 65205 | REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL | $823.16 |
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $1,261.83 |
| 65220 | RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP | $1,224.67 |
| 65222 | RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP | $1,121.00 |
| 65235 | RMVL FB INTRAOCULAR ANT CHAMBER EYE/LENS | $6,059.10 |
| 67700 | BLEPHAROTOMY DRAINAGE ABSCESS EYELID | $2,162.59 |
| 67938 | REMOVAL EMBEDDED FOREIGN BODY EYELID | $1,244.35 |
| 69000 | DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE | $1,888.67 |
| 69005 | DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX | $6,055.62 |
| 69020 | DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS | $1,612.14 |
| 69200 | RMVL FB XTRNL AUDITORY CANAL W/O ANES | $792.20 |
| 69205 | RMVL FB XTRNL AUDITORY CANAL ANES | $4,650.00 |
| 69209 | REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT | $689.53 |
| 69210 | REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT | $671.24 |
| 70030 | RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY | $755.54 |
| 70100 | RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS | $1,014.05 |
| 70110 | RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS | $1,144.38 |
| 70140 | RADEX FACIAL BONES < 3 VIEWS | $900.30 |
| 70150 | RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS | $1,148.66 |
| 70160 | RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS | $1,019.78 |
| 70200 | RADEX ORBITS COMPLETE MINIMUM 4 VIEWS | $1,274.20 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $945.49 |
| 70220 | RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS | $1,458.42 |
| 70250 | RADIOLOGIC EXAMINATION SKULL 4< VIEWS | $1,023.12 |
| 70260 | RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS | $2,216.70 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $1,125.35 |
| 70360 | RADIOLOGIC EXAMINATION NECK SOFT TISSUE | $744.85 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $5,406.62 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $6,851.48 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $7,018.11 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $5,029.12 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $6,863.16 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $7,800.71 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $5,071.38 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $6,152.12 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $8,746.32 |
| 70490 | CT SOFT TISSUE NECK W/O CONTRAST MATERIAL | $6,134.14 |
| 70491 | CT SOFT TISSUE NECK W/CONTRAST MATERIAL | $7,053.79 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $8,205.14 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $8,610.72 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $8,224.80 |
| 71045 | RADIOLOGIC EXAM CHEST SINGLE VIEW | $964.25 |
| 71046 | RADIOLOGIC EXAM CHEST 2 VIEWS | $1,154.31 |
| 71047 | RADIOLOGIC EXAM CHEST 3 VIEWS | $1,529.42 |
| 71048 | RADIOLOGIC EXAM CHEST 4+ VIEWS | $1,374.85 |
| 71100 | RADEX RIBS UNILATERAL 2 VIEWS | $936.38 |
| 71101 | RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS | $1,151.18 |
| 71110 | RADEX RIBS BILATERAL 3 VIEWS | $1,306.19 |
| 71111 | RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS | $1,844.26 |
| 71120 | RADEX STERNUM MINIMUM 2 VIEWS | $747.43 |
| 71250 | DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST | $5,853.65 |
| 71260 | DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/CONTRAST | $7,331.27 |
| 71270 | DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+ | $8,779.46 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $9,162.07 |
| 72020 | RADEX SPINE 1 VIEW SPECIFY LEVEL | $882.28 |
| 72040 | RADEX SPINE CERVICAL 2 OR 3 VIEWS | $1,079.17 |
| 72050 | RADEX SPINE CERVICAL 4 OR 5 VIEWS | $1,694.93 |
| 72052 | RADEX SPINE CERVICAL 6 OR MORE VIEWS | $1,358.40 |
| 72070 | RADEX SPINE THORACIC 2 VIEWS | $1,190.08 |
| 72072 | RADEX SPINE THORACIC 3 VIEWS | $1,452.84 |
| 72074 | RADEX SPINE THORACIC MINIMUM 4 VIEWS | $1,415.89 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $1,223.77 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $1,123.36 |
| 72100 | RADEX SPINE LUMBOSACRAL 2/3 VIEWS | $1,256.92 |
| 72110 | RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS | $1,859.14 |
| 72114 | RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 | $1,457.16 |
| 72120 | RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS | $1,405.63 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $6,657.18 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $8,031.19 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $10,077.00 |
| 72128 | CT THORACIC SPINE W/O CONTRAST MATERIAL | $6,488.48 |
| 72129 | CT THORACIC SPINE W/CONTRAST MATERIAL | $6,801.41 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $10,864.58 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $6,635.12 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $8,112.87 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $8,615.06 |
| 72170 | RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS | $915.25 |
| 72190 | RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS | $1,098.38 |
| 72191 | CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST | $7,519.99 |
| 72192 | CT PELVIS W/O CONTRAST MATERIAL | $5,676.97 |
| 72193 | CT PELVIS W/CONTRAST MATERIAL | $6,984.65 |
| 72194 | CT PELVIS W/O & W/CONTRAST MATERIAL | $7,910.23 |
| 72220 | RADEX SACRUM & COCCYX MINIMUM 2 VIEWS | $948.93 |
| 72270 | MYELOGRAPY 2/MORE REGIONS RS&I | $5,862.05 |
| 73000 | RADEX CLAVICLE COMPLETE | $1,000.30 |
| 73010 | RADEX SCAPULA COMPLETE | $996.64 |
| 73020 | RADEX SHOULDER 1 VIEW | $924.14 |
| 73030 | RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS | $1,170.82 |
| 73050 | RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ | $1,197.91 |
| 73060 | RADEX HUMERUS MINIMUM 2 VIEWS | $982.16 |
| 73070 | RADEX ELBOW 2 VIEWS | $928.80 |
| 73080 | RADEX ELBOW COMPLETE MINIMUM 3 VIEWS | $1,111.54 |
| 73090 | RADEX FOREARM 2 VIEWS | $1,133.85 |
| 73092 | RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,031.69 |
| 73100 | RADEX WRIST 2 VIEWS | $975.14 |
| 73110 | RADEX WRIST COMPLETE MINIMUM 3 VIEWS | $1,272.53 |
| 73120 | RADEX HAND 2 VIEWS | $1,107.91 |
| 73130 | RADEX HAND MINIMUM 3 VIEWS | $1,155.55 |
| 73140 | RADEX FINGR MINIMUM 2 VIEWS | $882.14 |
| 73200 | CT UPPER EXTREMITY W/O CONTRAST MATERIAL | $4,621.26 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $5,712.04 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $9,059.37 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $905.44 |
| 73502 | RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS | $1,101.03 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $1,094.94 |
| 73521 | RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS | $1,639.23 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $1,588.93 |
| 73523 | RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS | $1,328.53 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $750.82 |
| 73552 | RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS | $1,052.05 |
| 73560 | RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS | $938.22 |
| 73562 | RADIOLOGIC EXAMINATION KNEE 3 VIEWS | $973.14 |
| 73564 | RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS | $1,524.60 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $866.90 |
| 73590 | RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS | $1,122.07 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,259.44 |
| 73600 | RADIOLOGIC EXAMINATION ANKLE 2 VIEWS | $892.84 |
| 73610 | RADEX ANKLE COMPLETE MINIMUM 3 VIEWS | $1,110.18 |
| 73620 | RADIOLOGIC EXAMINATION FOOT 2 VIEWS | $955.23 |
| 73630 | RADEX FOOT COMPLETE MINIMUM 3 VIEWS | $1,104.36 |
| 73650 | RADEX CALCANEUS MINIMUM 2 VIEWS | $907.78 |
| 73660 | RADEX TOE MINIMUM 2 VIEWS | $872.90 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $5,663.70 |
| 73701 | CT LOWER EXTREMITY W/CONTRAST MATERIAL | $6,029.99 |
| 73702 | CT LOWER EXTREMITY W/O & W/CONTRAST MATRL | $9,008.23 |
| 73706 | CT ANGIOGRAPHY LOWER EXTREMITY | $8,059.05 |
| 74018 | RADIOLOGIC EXAM ABDOMEN 1 VIEW | $930.95 |
| 74019 | RADIOLOGIC EXAM ABDOMEN 2 VIEWS | $1,231.86 |
| 74021 | RADIOLOGIC EXAM ABDOMEN 3+ VIEWS | $1,540.13 |
| 74022 | RADIOLOGIC EXAM COMPLETE ACUTE ABDOMEN SERIES | $1,442.96 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $6,045.98 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $7,665.56 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $9,055.00 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $13,001.14 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $8,484.67 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $9,840.13 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $12,367.58 |
| 74178 | CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE | $16,009.22 |
| 74190 | PERITONEOGRAM RS&I | $2,163.13 |
| 74220 | RADIOLOGIC EXAM ESOPHAGUS SINGLE CONTRAST STUDY | $1,583.10 |
| 74240 | RADIOLOGIC EXAM UPR GI TRC SINGLE CONTRAST STUDY | $2,004.07 |
| 74246 | RADIOLOGIC EXAM UPR GI TRC DOUBLE CONTRAST STUDY | $2,055.44 |
| 74250 | RADIOLOGIC EXAM SMALL INT SINGLE CONTRAST STUDY | $2,403.64 |
| 74251 | RADIOLOGIC EXAM SMALL INT DOUBLE CONTRAST STUDY | $5,533.24 |
| 74283 | THERAPEUTIC ENEMA RDCTJ INTUSSUSCEPTION/OBSTRCJ | $3,964.07 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $2,303.35 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $2,833.29 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $1,523.00 |
| 75574 | CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST | $3,597.31 |
| 75635 | CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP | $8,115.27 |
| 76010 | RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD | $812.04 |
| 76376 | 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION | $1,867.37 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $3,178.00 |
| 76512 | OPHTHALMIC US DX B-SCAN W/WO NON-QUAN A-SCAN | $713.88 |
| 76536 | US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM | $2,035.13 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $1,315.25 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,192.45 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $1,393.08 |
| 76700 | US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION | $2,570.19 |
| 76705 | US ABDOMINAL REAL TIME W/IMAGE LIMITED | $1,945.21 |
| 76706 | US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA | $1,295.58 |
| 76770 | US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE | $2,123.43 |
| 76775 | US RETROPERITONEAL REAL TIME W/IMAGE LIMITED | $1,824.36 |
| 76801 | US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT | $1,861.43 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $1,484.37 |
| 76805 | US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION | $2,168.57 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,255.98 |
| 76815 | US PREGNANT UTERUS LIMITED 1/> FETUSES | $1,543.33 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $1,289.61 |
| 76817 | US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG | $1,504.93 |
| 76830 | US TRANSVAGINAL | $1,876.10 |
| 76856 | US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE | $2,550.92 |
| 76857 | US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U | $1,485.78 |
| 76870 | US SCROTUM & CONTENTS | $2,040.92 |
| 76881 | US COMPL JOINT R-T W/IMAGE DOCUMENTATION | $1,785.23 |
| 76882 | US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG | $1,150.92 |
| 76937 | US VASC ACCESS SITS VSL PATENCY NDL ENTRY | $1,856.00 |
| 76942 | US GUIDANCE NEEDLE PLACEMENT IMG S&I | $2,599.69 |
| 77076 | RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT | $1,846.72 |
| 78306 | BONE &/JOINT IMAGING WHOLE BODY | $5,016.38 |
| 78315 | BONE &/JOINT IMAGING 3 PHASE STUDY | $4,810.29 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $694.23 |
| 80048 | BASIC METABOLIC PANEL CALCIUM TOTAL | $845.83 |
| 80050 | GENERAL HEALTH PANEL | $1,754.89 |
| 80051 | ELECTROLYTE PANEL | $699.71 |
| 80053 | COMPREHENSIVE METABOLIC PANEL | $1,093.49 |
| 80061 | LIPID PANEL | $825.19 |
| 80074 | ACUTE HEPATITIS PANEL | $1,984.00 |
| 80076 | HEPATIC FUNCTION PANEL | $1,308.00 |
| 80143 | DRUG ASSAY ACETAMINOPHEN | $617.90 |
| 80175 | DRUG SCREEN QUANTITATIVE LAMOTRIGINE | $308.97 |
| 80177 | DRUG SCREEN QUANTITATIVE LEVETIRACETAM | $464.27 |
| 80178 | DRUG SCREEN QUANTITATIVE LITHIUM | $616.36 |
| 80179 | DRUG ASSAY SALICYLATE | $390.84 |
| 80197 | DRUG SCREEN QUANTITATIVE TACROLIMUS | $1,435.00 |
| 80202 | DRUG SCREEN QUANTITATIVE VANCOMYCIN | $799.00 |
| 80305 | DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE | $552.00 |
| 80307 | DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE | $1,317.95 |
| 80320 | DRUG SCREEN QUANTITATIVE ALCOHOLS | $604.00 |
| 80324 | DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 | $606.07 |
| 80329 | DRUG SCREEN ANALGESICS 1 OR 2 | $777.52 |
| 80335 | ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 | $427.00 |
| 80345 | DRUG SCREENING BARBITURATES | $412.83 |
| 80346 | DRUG SCREENING BENZODIAZEPINES 1-12 | $346.82 |
| 80348 | DRUG SCREENING | $331.00 |
| 80349 | DRUG SCREENING CANNABINOIDS NATURAL | $209.70 |
| 80352 | DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE | $619.00 |
| 80353 | DRUG SCREENING | $243.00 |
| 80358 | DRUG SCREENING METHADONE | $462.00 |
| 80359 | DRUG SCREENING METHYLENEDIOXYAMPHETAMINES | $42.29 |
| 80361 | $804.37 | |
| 80365 | $45.02 | |
| 80373 | DRUG SCREENING TRAMADOL | $246.26 |
| 81001 | URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY | $365.85 |
| 81002 | URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP | $124.77 |
| 81003 | URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY | $291.00 |
| 81007 | URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK | $354.00 |
| 81015 | URINALYSIS MICROSCOPIC ONLY | $236.74 |
| 81025 | URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS | $402.80 |
| 81240 | F2 GENE ANALYSIS 20210G >A VARIANT | $645.18 |
| 82009 | KETONE BODIES SERUM QUALITATIVE | $175.00 |
| 82010 | KETONE BODIES SERUM QUANTITATIVE | $420.69 |
| 82040 | ALBUMIN SERUM PLASMA/WHOLE BLOOD | $335.90 |
| 82140 | ASSAY OF AMMONIA | $542.53 |
| 82150 | ASSAY OF AMYLASE | $585.03 |
| 82247 | BILIRUBIN TOTAL | $496.39 |
| 82248 | BILIRUBIN DIRECT | $344.31 |
| 82270 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER | $261.92 |
| 82271 | BLOOD OCCULT PEROXIDASE ACTV QUAL OTHER SOURCES | $179.35 |
| 82272 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC | $156.00 |
| 82274 | BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 | $218.66 |
| 82310 | CALCIUM TOTAL | $352.77 |
| 82330 | CALCIUM IONIZED | $721.37 |
| 82374 | CARBON DIOXIDE BICARBONATE | $255.00 |
| 82375 | CARBOXYHEMOGLOBIN QUANTITATIVE | $343.82 |
| 82435 | CHLORIDE BLD | $218.95 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $339.15 |
| 82533 | CORTISOL TOTAL | $808.99 |
| 82550 | CREATINE KINASE TOTAL | $471.36 |
| 82553 | CREATINE KINASE MB FRACTION ONLY | $643.69 |
| 82565 | CREATININE BLOOD | $369.58 |
| 82607 | CYANOCOBALAMIN VITAMIN B-12 | $526.51 |
| 82693 | ASSAY OF ETHYLENE GLYCOL | $410.00 |
| 82728 | ASSAY OF FERRITIN | $672.80 |
| 82746 | ASSAY OF FOLIC ACID SERUM | $570.82 |
| 82747 | ASSAY OF FOLIC ACID RBC | $155.00 |
| 82784 | ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH | $432.62 |
| 82785 | ASSAY OF GAMMAGLOBULIN IGE | $472.76 |
| 82800 | GASES BLOOD PH ONLY | $350.64 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $1,357.15 |
| 82805 | GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY | $1,979.10 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $337.86 |
| 82947 | GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP | $317.03 |
| 82948 | GLUCOSE BLOOD REAGENT STRIP | $162.24 |
| 82962 | GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE | $91.85 |
| 82977 | ASSAY OF GLUTAMYLTRASE GAMMA | $436.25 |
| 83013 | HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE | $604.46 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $446.81 |
| 83050 | HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE | $272.54 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITATIVE NOS | $750.86 |
| 83525 | ASSAY OF INSULIN TOTAL | $374.16 |
| 83540 | ASSAY OF IRON | $505.96 |
| 83550 | IRON BINDING CAPACITY | $537.90 |
| 83605 | ASSAY OF LACTATE | $579.34 |
| 83615 | LACTATE DEHYDROGENASE LDH | $469.21 |
| 83690 | ASSAY OF LIPASE | $509.18 |
| 83718 | LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL | $330.00 |
| 83735 | ASSAY OF MAGNESIUM | $427.01 |
| 83874 | MYOGLOBIN | $539.00 |
| 83880 | NATRIURETIC PEPTIDE | $868.55 |
| 83992 | ASSAY OF PHENCYCLIDINE | $232.00 |
| 84075 | ASSAY OF PHOSPHATASE ALKALINE | $516.01 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $336.00 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $327.69 |
| 84155 | PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD | $293.03 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $363.46 |
| 84165 | PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM | $666.15 |
| 84295 | SODIUM SERUM PLASMA OR WHOLE BLOOD | $283.98 |
| 84403 | ASSAY OF TESTOSTERONE TOTAL | $752.78 |
| 84436 | ASSAY OF THYROXINE TOTAL | $566.39 |
| 84439 | ASSAY OF FREE THYROXINE | $577.67 |
| 84443 | ASSAY OF THYROID STIMULATING HORMONE TSH | $869.43 |
| 84450 | TRANSFERASE ASPARTATE AMINO AST SGOT | $465.45 |
| 84460 | TRANSFERASE ALANINE AMINO ALT SGPT | $419.20 |
| 84478 | ASSAY OF TRIGLYCERIDES | $574.50 |
| 84479 | THYROID HORM UPTK/THYROID HORMONE BINDING RATIO | $196.31 |
| 84480 | ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3 | $657.18 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $601.65 |
| 84484 | ASSAY OF TROPONIN QUANTITATIVE | $741.50 |
| 84520 | ASSAY OF UREA NITROGEN QUANTITATIVE | $330.87 |
| 84550 | ASSAY OF BLOOD/URIC ACID | $387.66 |
| 84560 | ASSAY OF URIC ACID OTHER SOURCE | $426.25 |
| 84702 | GONADOTROPIN CHORIONIC QUANTITATIVE | $776.01 |
| 84703 | GONADOTROPIN CHORIONIC QUALITATIVE | $461.38 |
| 84999 | UNLISTED CHEMISTRY PROCEDURE | $383.33 |
| 85014 | BLOOD COUNT HEMATOCRIT | $183.58 |
| 85018 | BLOOD COUNT HEMOGLOBIN | $183.91 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $347.30 |
| 85027 | BLOOD COUNT COMPLETE AUTOMATED | $917.00 |
| 85044 | BLOOD COUNT RETICULOCYTE MANUAL | $506.56 |
| 85045 | BLOOD COUNT RETICULOCYTE AUTOMATED | $259.12 |
| 85270 | CLOTTING FACTOR XI PTA | $1,230.90 |
| 85347 | COAGULATION TIME ACTIVATED | $353.70 |
| 85378 | FIBRIN DGRADJ PRODUCTS D-DIMER QUAL/SEMIQUAN | $568.56 |
| 85379 | FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE | $710.85 |
| 85384 | FIBRINOGEN ACTIVITY | $429.15 |
| 85610 | PROTHROMBIN TIME | $362.40 |
| 85651 | SEDIMENTATION RATE RBC NON-AUTOMATED | $276.87 |
| 85652 | SEDIMENTATION RATE RBC AUTOMATED | $277.53 |
| 85730 | THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD | $430.03 |
| 86038 | ANTINUCLEAR ANTIBODIES ANA | $652.31 |
| 86039 | ANTINUCLEAR ANTIBODIES ANA TITER | $733.28 |
| 86060 | ANTISTREPTOLYSIN O TITER | $427.44 |
| 86140 | C-REACTIVE PROTEIN | $488.06 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $318.80 |
| 86256 | FLUORESCENT NONNFCT AGT ANTB TITER EA ANTIBODY | $376.08 |
| 86308 | HETEROPHILE ANTIBODIES SCREEN | $403.01 |
| 86328 | IA INFECTIOUS AGT ANTIBODY SARS-COV-2 COVID-19 | $393.40 |
| 86360 | T CELLS ABSOLUTE CD4&CD8 COUNT RATIO | $337.48 |
| 86403 | PARTICLE AGGLUTINATION SCREEN EACH ANTIBODY | $244.31 |
| 86430 | RHEUMATOID FACTOR QUALITATIVE | $271.72 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $508.29 |
| 86580 | SKIN TEST TUBERCULOSIS INTRADERMAL | $45.77 |
| 86592 | SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL | $272.11 |
| 86593 | SYPHILIS TEST QUANTITATIVE | $434.50 |
| 86617 | ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST | $279.00 |
| 86622 | ANTIBODY BRUCELLA | $120.54 |
| 86631 | ANTIBODY CHLAMYDIA | $202.00 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $674.21 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $668.76 |
| 86664 | ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA | $347.17 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $610.34 |
| 86689 | ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST | $513.06 |
| 86695 | ANTIBODY HERPES SMPLX TYPE 1 | $312.04 |
| 86696 | ANTIBODY HERPES SMPLX TYPE 2 | $410.34 |
| 86701 | ANTIBODY HIV-1 | $513.63 |
| 86702 | ANTIBODY HIV-2 | $528.78 |
| 86703 | ANTIBODY HIV-1&HIV-2 SINGLE RESULT | $474.56 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $471.70 |
| 86705 | HEPATITIS B CORE ANTIBODY HBCAB IGM ANTIBODY | $540.54 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $557.90 |
| 86708 | HEPATITIS A ANTIBODY HAAB | $438.70 |
| 86709 | HEPATITIS ANTIBODY HAAB IGM ANTIBODY | $525.83 |
| 86756 | ANTIBODY RESPIRATORY SYNCTIAL VIRUS | $235.24 |
| 86757 | ANTIBODY RICKETTSIA | $254.13 |
| 86768 | ANTIBODY SALMONELLA | $184.00 |
| 86769 | ANTB SEVERE AQT RESPIR SYND SARS-COV-2 COVID-19 | $444.41 |
| 86780 | ANTIBODY TREPONEMA PALLIDUM | $394.78 |
| 86787 | ANTIBODY VARICELLA-ZOSTER | $228.11 |
| 86803 | HEPATITIS C ANTIBODY | $679.05 |
| 86850 | ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE | $563.28 |
| 86900 | BLOOD TYPING SEROLOGIC ABO | $355.37 |
| 86901 | BLOOD TYPING SEROLOGIC RH (D) | $342.26 |
| 86906 | BLOOD TYPING SEROLOGIC RH PHENOTYPING COMPLETE | $356.81 |
| 87015 | CONCENTRATION INFECTIOUS AGENTS | $164.06 |
| 87040 | CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES | $765.46 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $683.14 |
| 87046 | CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA | $292.53 |
| 87070 | CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL | $867.00 |
| 87075 | CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID | $867.43 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $374.07 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $481.69 |
| 87081 | CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ | $455.06 |
| 87086 | CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE | $744.71 |
| 87088 | CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE | $256.12 |
| 87103 | CULTURE FNGI MOLD/YEAST ISOL PRSMPTV ISOL BLOOD | $407.75 |
| 87106 | CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST | $396.63 |
| 87110 | CULTURE CHLAMYDIA ANY SOURCE | $753.91 |
| 87177 | OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID | $375.58 |
| 87186 | SUSCEPTIBLTY STDY ANTIMICRBIAL MICRO/AGAR DILUTJ | $688.77 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $397.00 |
| 87207 | SMR PRIM SRC SPEC STAIN BODIES/PARASITS | $438.87 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $262.81 |
| 87210 | SMR PRIM SRC WET MOUNT NFCT AGT | $378.06 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $728.61 |
| 87255 | VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC | $665.03 |
| 87275 | IAADI INFLUENZA B VIRUS | $220.89 |
| 87324 | IAAD IA CLOSTRIDIUM DIFFICILE TOXIN | $740.53 |
| 87328 | IAAD IA CRYPTOSPORIDIUM | $165.75 |
| 87338 | IAAD IA HPYLORI STOOL | $492.87 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $427.64 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $346.18 |
| 87389 | IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE | $492.06 |
| 87400 | IAAD IA INFLUENZA A/B EACH | $477.36 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $540.92 |
| 87425 | IAAD IA ROTAVIRUS | $606.84 |
| 87426 | IAAD IA SEVERE AQT RESPIR SYND CORONAVIRUS | $355.08 |
| 87427 | IAAD IA SHIGA-LIKE TOXIN | $395.11 |
| 87428 | IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B | $507.45 |
| 87430 | IAAD IA STREPTOCOCCUS GROUP A | $331.17 |
| 87471 | IADNA BARTONELLA AMPLIFIED PROBE TECHNIQUE | $1,093.08 |
| 87481 | IADNA CANDIDA SPECIES AMPLIFIED PROBE TQ | $347.00 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $765.74 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $627.98 |
| 87493 | INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE | $744.85 |
| 87506 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11 | $1,550.70 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $3,707.75 |
| 87529 | IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ | $823.26 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $567.63 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $507.38 |
| 87624 | IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES | $410.93 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $3,927.97 |
| 87635 | IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ | $365.47 |
| 87636 | IADNA SARSCOV2& INF A&B MULT AMPLIFIED PROBE TQ | $679.25 |
| 87660 | IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ | $386.75 |
| 87661 | IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH | $341.91 |
| 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $959.00 |
| 87801 | IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ | $1,906.34 |
| 87804 | IAADIADOO INFLUENZA | $358.53 |
| 87806 | IAADIADOO HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES | $526.52 |
| 87807 | IAADIADOO RESPIRATORY SYNCTIAL VIRUS | $755.79 |
| 87808 | IAADIADOO TRICHOMONAS VAGINALIS | $189.43 |
| 87880 | IAADIADOO STREPTOCOCCUS GROUP A | $670.51 |
| 88141 | CYTP CERVICAL/VAGINAL REQ INTERP PHYSICIAN | $222.40 |
| 88233 | TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX | $1,160.45 |
| 88262 | CHRMSM COUNT 15-20 CLL 2KARYOTYP BANDING | $1,464.42 |
| 88291 | CYTOGENETICS&MOLEC CYTOGENETICS INTERP&REP | $749.08 |
| 88305 | LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM | $972.35 |
| 89050 | CELL COUNT MISCELLANEOUS BODY FLUIDS | $335.51 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $402.27 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $296.43 |
| 89060 | CRYSTAL ID LIGHT MICROSCOPY ALYS TISS/ANY FLUID | $331.10 |
| 89220 | SPUTUM OBTAINING SPEC AEROSOL INDUCED TX SPX | $571.46 |
| 89240 | UNLISTED MISCELLANEOUS PATHOLOGY TEST | $218.90 |
| 90471 | IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE | $285.62 |
| 90472 | IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE | $206.82 |
| 90658 | IIV3 VACCINE SPLIT VIRUS 0.5 ML DOSAGE IM USE | $99.50 |
| 90688 | IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR IM USE | $448.18 |
| 90700 | DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM | $229.74 |
| 90707 | MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ | $815.67 |
| 90714 | TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE | $319.80 |
| 90715 | TDAP VACCINE 7 YRS/> IM | $441.00 |
| 90746 | HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE | $481.16 |
| 91300 | SARSCOV2 VACCINE DIL RECON 30 MCG/0.3 ML IM USE | $0.02 |
| 92002 | OPHTH MEDICAL XM&EVAL INTERMEDIATE NEW PT | $544.05 |
| 92552 | PURE TONE AUDIOMETRY AIR ONLY | $458.25 |
| 92950 | CARDIOPULMONARY RESUSCITATION | $2,722.70 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL | $3,811.56 |
| 93005 | ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R | $942.78 |
| 93016 | CV STRS TST XERS&/OR RX CONT ECG W/O I&R | $378.10 |
| 93017 | CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY | $4,356.39 |
| 93041 | RHYTHM ECG 1-3 LEADS TRACING ONLY W/O I&R | $472.06 |
| 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $142.78 |
| 93225 | XTRNL ECG & 48 HR RECORDING | $2,578.24 |
| 93226 | EXTERNAL ECG SCANNING ANALYSIS REPORT | $2,740.23 |
| 93303 | COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY | $5,799.42 |
| 93306 | ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D | $7,339.06 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $5,257.71 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $3,458.90 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $4,003.28 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $3,454.75 |
| 93350 | ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST | $6,557.57 |
| 93351 | ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG | $8,541.79 |
| 93623 | PROGRAMMED STIMJ & PACG AFTER IV DRUG NFS | $6,364.25 |
| 93880 | DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY | $4,315.98 |
| 93882 | DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY | $2,732.15 |
| 93886 | TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL | $2,142.08 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $1,840.58 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $2,555.72 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $3,728.25 |
| 93926 | DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,341.06 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $3,723.78 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY | $2,705.41 |
| 93970 | DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY | $3,677.92 |
| 93971 | DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY | $2,434.34 |
| 93975 | DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM | $3,404.42 |
| 93976 | DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT | $2,168.36 |
| 93980 | DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL | $2,183.69 |
| 94010 | SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ | $1,033.48 |
| 94060 | BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN | $1,205.87 |
| 94621 | CARDIOPULMONARY EXERCISE TESTING | $2,200.00 |
| 94640 | PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT | $746.55 |
| 94644 | CONTINUOUS INHALATION TREATMENT 1ST HR | $932.24 |
| 94660 | CPAP VENTILATION CPAP INITIATION&MGMT | $4,561.29 |
| 94664 | DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IP | $609.62 |
| 94760 | NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER | $257.45 |
| 94761 | NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER | $381.91 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $1,335.38 |
| 95811 | POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND | $6,415.76 |
| 96360 | IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR | $1,367.57 |
| 96361 | IV INFUSION HYDRATION EACH ADDITIONAL HOUR | $474.26 |
| 96365 | IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | $1,466.94 |
| 96366 | IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR | $474.23 |
| 96367 | IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR | $789.44 |
| 96368 | IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS | $527.76 |
| 96372 | THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM | $558.96 |
| 96373 | THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL | $1,336.45 |
| 96374 | THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG | $789.93 |
| 96375 | THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG | $637.64 |
| 96376 | THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC | $613.26 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $530.34 |
| 96379 | UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS | $515.41 |
| 97110 | THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES | $345.30 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR | $357.12 |
| 97140 | MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES | $341.65 |
| 97166 | OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS | $940.17 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $296.36 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $1,295.55 |
| 99001 | HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB | $175.12 |
| 99050 | SERVICES PROVIDED OFFICE OTH/THN REG SCHED HOURS | $161.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $369.80 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $562.93 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $668.12 |
| 99153 | MOD SED SAME PHYS/QHP EACH ADDL 15 MINS | $383.11 |
| 99155 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS | $1,190.00 |
| 99156 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS | $588.86 |
| 99157 | MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS | $779.00 |
| 99282 | EMERGENCY DEPARTMENT VISIT STRAIGHTFORWARD MDM | $2,065.14 |
| 99283 | EMERGENCY DEPARTMENT VISIT LOW MDM | $3,796.82 |
| 99284 | EMERGENCY DEPARTMENT VISIT MODERATE MDM | $5,891.67 |
| 99285 | EMERGENCY DEPARTMENT VISIT HIGH MDM | $8,139.58 |
| 99291 | CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN | $11,436.47 |
| 99292 | CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN | $3,357.76 |
| 99406 | TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES | $156.24 |
| 99407 | TOBACCO USE CESSATION INTENSIVE >10 MINUTES | $183.00 |
| E0114 | CRUTCH UNDERARM PAIR NO WOOD | $256.47 |
| E0484 | Oscillatory positive expiratory pressure device, nonelectric, any type, each | $403.65 |
| G0378 | HOSPITAL OBSERVATION PER HR | $2,500.00 |
| J0131 | ACETAMINOPHEN INJECTION | $65.22 |
| J0153 | ADENOSINE INJ 1MG | $55.25 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $40.73 |
| J0282 | AMIODARONE HCL | $37.90 |
| J0290 | AMPICILLIN 500 MG INJ | $64.86 |
| J0295 | AMPICILLIN SULBACTAM 1.5 GM | $72.27 |
| J0360 | HYDRALAZINE HCL INJECTION | $168.44 |
| J0456 | AZITHROMYCIN | $89.54 |
| J0461 | ATROPINE SULFATE INJECTION | $24.86 |
| J0500 | DICYCLOMINE INJECTION | $339.15 |
| J0515 | INJ BENZTROPINE MESYLATE | $184.22 |
| J0558 | PENG BENZATHINE/PROCAINE INJ | $127.93 |
| J0561 | PENICILLIN G BENZATHINE INJ | $137.97 |
| J0610 | CALCIUM GLUCONATE INJECTION | $51.10 |
| J0690 | CEFAZOLIN SODIUM INJECTION | $35.03 |
| J0692 | CEFEPIME HCL FOR INJECTION | $68.60 |
| J0696 | CEFTRIAXONE SODIUM INJECTION | $55.73 |
| J0697 | STERILE CEFUROXIME INJECTION | $51.34 |
| J0735 | CLONIDINE HYDROCHLORIDE | $238.75 |
| J0744 | CIPROFLOXACIN IV | $129.14 |
| J0780 | PROCHLORPERAZINE INJECTION | $167.49 |
| J0840 | CROTALIDAE POLY IMMUNE FAB | $24,660.55 |
| J1030 | METHYLPREDNISOLONE 40 MG INJ | $77.17 |
| J1040 | METHYLPREDNISOLONE 80 MG INJ | $105.36 |
| J1100 | DEXAMETHASONE SODIUM PHOS | $20.28 |
| J1110 | INJ DIHYDROERGOTAMINE MESYLT | $691.60 |
| J1170 | HYDROMORPHONE INJECTION | $69.03 |
| J1200 | DIPHENHYDRAMINE HCL INJECTIO | $34.03 |
| J1610 | GLUCAGON HYDROCHLORIDE/1 MG | $1,014.98 |
| J1630 | HALOPERIDOL INJECTION | $61.76 |
| J1631 | HALOPERIDOL DECANOATE INJ | $159.07 |
| J1642 | INJ HEPARIN SODIUM PER 10 U | $23.44 |
| J1644 | INJ HEPARIN SODIUM PER 1000U | $32.21 |
| J1650 | INJ ENOXAPARIN SODIUM | $73.68 |
| J1741 | IBUPROFEN INJECTION | $28.67 |
| J1815 | INSULIN INJECTION | $27.74 |
| J1817 | INSULIN FOR INSULIN PUMP USE | $26.00 |
| J1885 | KETOROLAC TROMETHAMINE INJ | $30.36 |
| J1930 | LANREOTIDE INJECTION | $441.29 |
| J1940 | FUROSEMIDE INJECTION | $37.74 |
| J1956 | LEVOFLOXACIN INJECTION | $60.71 |
| J2001 | LIDOCAINE INJECTION | $29.36 |
| J2060 | LORAZEPAM INJECTION | $41.01 |
| J2175 | MEPERIDINE HYDROCHL /100 MG | $137.48 |
| J2250 | INJ MIDAZOLAM HYDROCHLORIDE | $21.25 |
| J2270 | MORPHINE SULFATE INJECTION | $54.39 |
| J2274 | INJ MORPHINE PF EPID ITHC | $131.59 |
| J2405 | ONDANSETRON HCL INJECTION | $25.68 |
| J2543 | PIPERACILLIN/TAZOBACTAM | $50.58 |
| J2550 | PROMETHAZINE HCL INJECTION | $53.81 |
| J2704 | INJ, PROPOFOL, 10 MG | $26.69 |
| J2765 | METOCLOPRAMIDE HCL INJECTION | $36.03 |
| J2780 | RANITIDINE HYDROCHLORIDE INJ | $29.72 |
| J2800 | METHOCARBAMOL INJECTION | $309.63 |
| J2920 | METHYLPREDNISOLONE INJECTION | $73.01 |
| J2930 | METHYLPREDNISOLONE INJECTION | $88.81 |
| $40.23 | ||
| J3030 | SUMATRIPTAN SUCCINATE / 6 MG | $416.42 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $119.10 |
| J3360 | DIAZEPAM INJECTION | $120.35 |
| J3370 | VANCOMYCIN HCL INJECTION | $89.09 |
| J3430 | VITAMIN K PHYTONADIONE INJ | $63.81 |
| J3475 | INJ MAGNESIUM SULFATE | $56.79 |
| J3480 | INJ POTASSIUM CHLORIDE | $46.25 |
| J3490 | DRUGS UNCLASSIFIED INJECTION | $250.41 |
| J7030 | NORMAL SALINE SOLUTION INFUS | $104.19 |
| J7040 | NORMAL SALINE SOLUTION INFUS | $83.99 |
| J7042 | 5% DEXTROSE/NORMAL SALINE | $133.67 |
| J7050 | NORMAL SALINE SOLUTION INFUS | $54.57 |
| J7070 | D5W INFUSION | $113.45 |
| J7120 | RINGERS LACTATE INFUSION | $61.77 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $97.97 |
| J7131 | HYPERTONIC SALINE SOL | $1.01 |
| J7192 | FACTOR VIII RECOMBINANT NOS | $17.55 |
| J7510 | PREDNISOLONE ORAL PER 5 MG | $19.90 |
| J7611 | ALBUTEROL NON-COMP CON | $11.23 |
| J7613 | ALBUTEROL NON-COMP UNIT | $14.74 |
| J7614 | LEVALBUTEROL NON-COMP UNIT | $43.61 |
| J7615 | LEVALBUTEROL COMP UNIT | $58.50 |
| J7620 | ALBUTEROL IPRATROP NON-COMP | $40.11 |
| J7644 | IPRATROPIUM BROMIDE NON-COMP | $144.68 |
| J7682 | TOBRAMYCIN NON-COMP UNIT | $953.12 |
| J8499 | ORAL PRESCRIP DRUG NON CHEMO | $136.48 |
| J9206 | IRINOTECAN INJECTION | $116.89 |
| L0120 | CERV FLEX N/ADJ FOAM PRE OTS | $142.29 |
| L0140 | CERVICAL SEMI-RIGID ADJUSTAB | $550.00 |
| L0150 | CERV SEMI-RIG ADJ MOLDED CHN | $353.00 |
| L0172 | CERV COL SR FOAM 2PC PRE OTS | $405.29 |
| L0174 | CERV SR 2PC THOR EXT PRE OTS | $1,396.06 |
| L0180 | CER POST COL OCC/MAN SUP ADJ | $1,200.00 |
| L0190 | CERV COLLAR SUPP ADJ CERV BA | $1,580.00 |
| L0450 | TLSO FLEX TRUNK/THOR PRE OTS | $563.17 |
| L0458 | TLSO 2MOD SYMPHIS-XIPHO PRE | $2,328.30 |
| L0460 | TLSO 2 SHL SYMPHYS-STERN CST | $2,452.69 |
| L0462 | TLSO 3MOD SACRO-SCAP PRE | $8,086.85 |
| L0464 | TLSO 4MOD SACRO-SCAP PRE | $6,819.00 |
| L0467 | TLSO R FRAM SOFT PRE OTS | $1,040.00 |
| L0470 | TLSO RIGID FRAME PRE SUBCLAV | $3,654.75 |
| L0472 | TLSO RIGID FRAME HYPEREX PRE | $2,130.00 |
| L0625 | LO FLEX L1-BELOW L5 PRE OTS | $144.00 |
| L0627 | LO SAG RI AN/POS PNL PRE CST | $2,871.57 |
| L0628 | LSO FLEX NO RI STAYS PRE OTS | $219.70 |
| L0630 | LSO R POST PNL SJ-T9 PRE CST | $435.81 |
| L0631 | LSO SAG R AN/POS PNL PRE CST | $7,038.87 |
| L0635 | LSO SAGIT RIGID PANEL PREFAB | $7,678.00 |
| L0650 | LSO SC R ANT/POS PNL PRE OTS | $4,991.00 |
| L0700 | CTLSO A-P-L CONTROL MOLDED | $8,453.31 |
| L0810 | HALO CERVICAL INTO JCKT VEST | $8,346.06 |
| L0859 | MRI COMPATIBLE SYSTEM | $3,863.34 |
| L0976 | LSO FULL CORSET | $458.50 |
| L1620 | HO FLEX PAVLIK HARNS PRE CST | $545.26 |
| L1686 | HO POST-OP HIP ABDUCTION | $3,076.42 |
| L1810 | KO ELASTIC WITH JOINTS | $452.00 |
| L1820 | KO ELAS W/ CONDYLE PADS & JO | $950.12 |
| L1830 | KO IMMOB CANVAS LONG PRE OTS | $408.99 |
| L1832 | KO ADJ JNT POS R SUP PRE CST | $1,242.00 |
| L1845 | KO DOUBLE UPRIGHT PRE CST | $2,592.97 |
| L1902 | AFO ANKLE GAUNTLET PRE OTS | $260.69 |
| L1930 | AFO PLASTIC | $715.80 |
| L1940 | AFO MOLDED TO PATIENT PLASTI | $1,866.62 |
| L1960 | AFO POS SOLID ANK PLASTIC MO | $1,355.19 |
| L2114 | AFO TIB FX SEMI-RIGID | $1,897.00 |
| L2624 | HIP ADJ FLEX EXT ABDUCT CONT | $855.77 |
| L3650 | SO 8 ABD RESTRAINT PRE OTS | $228.85 |
| L3660 | SO 8 AB RSTR CAN/WEB PRE OTS | $256.00 |
| L3670 | SO ACRO/CLAV CAN WEB PRE OTS | $364.00 |
| L3763 | EWHO RIGID W/O JNTS CF | $1,696.00 |
| L3764 | EWHO W/JOINT(S) CF | $2,251.00 |
| L3807 | WHFO W/O JOINTS PRE CST | $559.00 |
| L3808 | WHFO, RIGID W/O JOINTS | $634.31 |
| L3905 | WHO W/NONTORSION JNT(S) CF | $2,332.00 |
| L3908 | WHO COCK-UP NONMOLDE PRE OTS | $201.00 |
| L3980 | UP EXT FX ORTHOS HUMERAL NOS | $1,098.48 |
| L3984 | UPPER EXT FX ORTHOSIS WRIST | $1,288.38 |
| L3995 | SOCK FRACTURE OR EQUAL EACH | $102.68 |
| L4350 | ANKLE CONTROL ORTHO PRE OTS | $327.00 |
| L4360 | PNEUMAT WALKING BOOT PRE CST | $395.00 |
| L4361 | PNEUMA/VAC WALK BOOT PRE OTS | $444.17 |
| L4386 | NON-PNEUM WALK BOOT PRE CST | $502.76 |
| L4387 | NON-PNEUM WALK BOOT PRE OTS | $513.65 |
| L4396 | STATIC OR DYNAMI AFO PRE CST | $604.79 |
| L4397 | STATIC OR DYNAMI AFO PRE OTS | $1,036.62 |
| L8000 | MASTECTOMY BRA | $212.93 |
| L8020 | MASTECTOMY FORM | $1,409.26 |
| L8509 | TRACH-ESOPH VOICE PROS MD IN | $938.00 |
| L8670 | VASCULAR GRAFT, SYNTHETIC | $7,707.31 |
| M0243 | CASIRIVI AND IMDEVI INJ | $1,567.80 |
| Q0144 | AZITHROMYCIN DIHYDRATE, ORAL | $201.31 |
| Q0243 | CASIRIVIMAB AND IMDEVIMAB | $0.01 |
| Q9963 | HOCM 350-399MG/ML IODINE,1ML | $28.66 |
| Q9965 | LOCM 100-199MG/ML IODINE,1ML | $30.71 |
| Q9966 | LOCM 200-299MG/ML IODINE,1ML | $31.15 |
| Q9967 | LOCM 300-399MG/ML IODINE,1ML | $62.08 |
| S0028 | INJECTION, FAMOTIDINE, 20 MG | $102.67 |
| S0119 | ONDANSETRON 4 MG | $101.13 |
| S0164 | INJECTION PANTROPRAZOLE | $139.76 |
| U0002 | COVID-19 LAB TEST NON-CDC | $416.59 |
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