Charge Master – Frontline ER Dallas – 4/29/21

CPT Code CPT Short Description CPT Default Price
0202U COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing $1,500.00
10060 INCISION/DRAINAGE ABSCESS $748.24
10061 INS/DRAIN ABSCESS COMPL $444.00
10081 I&D PILONIDAL CST COMP $590.00
10120 I & RMVL SUB-CUT SIMPLE $200.00
10121 I & RMVL FB, SUB-CUT,COMP $583.00
10160 PUNCTURE ASP OF ABSCESS $328.00
11011 DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC $263.00
11040 DBRDMT, SKIN, PARTIAL THICK $205.00
11042 DBRD SKN SUBQ TISSUE $1,098.00
11200 RMVL SKIN TAGS $294.00
11404 EXC BGN LSN TRUNK 3.1-4.0 $833.00
11730 AVULSION/1-NAIL PLATE $290.00
11740 EVAC SUBUNGUAL HEMATOMA $303.00
11750 EXC NAIL PART/COMP $619.00
11760 REPAIR NAIL BED $531.00
11765 WEDGE EXC SKIN/NAIL BED $341.00
11771 EXCISION PILONIDAL CYST SINUS EXTENSIVE $297.00
12001 LACERATION REPAIR $352.23
12002 REPAIR LAC SCALP 2.6-7.5 $430.00
12004 REPAIR LAC SCALP 7.6-12.5 $496.00
12005 REPAIR LAC,SCALP 12.6-20C $658.00
12011 REPAIR LAC FACE LESS THAN 2.5 CM $759.00
12013 REPAIR LAC FACE 2.6-5.0CM $526.00
12014 REPAIR LAC FACE 5.1-7.5CM $729.00
12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE $320.00
12031 LYR CLSR S/A/T/E 2.5CM $504.00
12032 REPAIR-INT SCALP 2.6-7.5 $761.00
12034 INTERM RPR SCLP/TRNK/EXTR $707.00
12035 REPAIR INTERM S/A/T/E 12. $318.00
12036 REPAIR INTERM S/A/T/E 20.1-30.0 CM $762.00
12041 LAYER CLSR NECK/HAND 2.6 $524.00
12042 REPAIR LAC HAND/FOOT 2.6- $883.00
12044 LYR CLSR N/H/F/ETRNL GENT $762.00
12045 REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM $760.00
12051 LAYER CLSR OF WND NCK/HND $594.00
12052 LYR CLSR WOUND 2.6-5.0FAC $708.00
12053 LYR CLSR F/E/E/N/L/M&/MUC $957.00
12054 REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM $865.00
13121 RPR CMPX SCALP ARM2.6-7.5 $1,236.00
13122 CMPLX RPR ADD 5 CM OR LES $531.00
13132 RPR CMPX FOREHEAD/CHECK/C $1,462.00
13151 CMPX RPR EYE NOSE 1.1-2.5 $1,055.00
13152 RPR CPLX E/N/E/L 2.6-7.5 $1,830.00
13153 REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< $669.00
15850 SUTURE RMVL W/ANESTHESIA $653.00
16000 BURN, INITIAL TREATMENT $274.00
16020 BURN, DRESSING/DBRDMNT-SM $270.00
20552 TRIGGER POINT INJ 1-2 MUS $176.00
20600 ARTHROCENTESIS, SML JOINT $640.00
20605 ARTHROCENTESIS, MED JOINT $154.00
20610 ARTHROCENTESIS, LG JOINT $361.00
20611 Arthrocentesis, aspiration and/or injection, major joint or… $1,009.00
21310 CLTX NSL B1 FX W/O MNPJ $498.00
21480 CLDS TX TEMP DISLOCATION $452.00
21800 CLTX RIB FX UNCOMP EA $425.00
23500 CLTX CLAVICULAR FX WO MNP $814.00
23570 CLSD TX SCAPULAR FX WO MA $839.00
23600 CLTX PROX HUMRL FX WO MAN $381.00
23650 SHOULDER DISLOCATION TRMT $934.00
24500 CLTX HUMRL SHFT FX W/O MN $378.00
24530 CLTX SPRCNDYLR/TRANSCNDYL $1,392.00
24576 CLTX HUMRL CNDLYR FX MEDI $381.00
24600 CLSD TX ELBOW DISLOCAT $650.00
24640 RADIAL HEAD SUBLUX. CHILD $519.00
24650 CLTX RDL HEAD FX WO MANP $959.00
24670 CLTX ULNR FX PROX END WO $942.00
25500 CLTX RDL SHFT FX WO MANP $650.00
25505 CLSD TX RAD SHAFT W/MANIP $2,213.00
25530 CLSD TX ULNAR SHFT FX NO $378.00
25535 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION $715.00
25560 CLTX RDL&UR SHFT FXS W/O $378.00
25600 CLSD TX DISTAL RAD FX WO $1,045.00
25605 CLSD TX DISTAL RAD FX $1,992.00
25622 CLSD TX NAVICULAR FX WO M $650.00
25635 CLTTX CARPL B1 FX W/MNPJ EA B1 $1,085.00
25650 CLTX UR SYLOID FX $1,097.00
26010 I & D FINGER ABSCESS,SIMP $298.00
26600 CLSD TX METACARPAL FX $909.00
26605 CLSD TX MEDICARPAL FX $1,053.00
26607 CLTX MTCRPL FX W/MNP W/XT $1,670.00
26700 CLS TX MCP DISLOCATION $381.00
26720 CLSD TX PHALANGEAL SHFTFX $628.00
26725 CLTX PHLNGL FX PROX/MIDDL $1,027.00
26750 CLS TX FX FINGER/THUMB $618.00
26755 CLTX DSTL PHLNGL FX FNGR/ $792.00
26770 TREAT FINGER DISLOC FINGE $560.00
27220 CLTX ACETABULUM HIP/SOCKT FX W/O MNP $635.00
27372 REMOVAL FOREIGN BODY DEEP THIGH/KNEE $350.00
27508 CLTX FEM FX DSTAL END MED $381.00
27520 CLTX PATELLAR FX W/O MNPJ $1,205.00
27530 CLTX TIBL FX PROX W/O MNPJ $507.00
27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA $1,366.00
27560 CLTX PATELLAR DISLC W/O A $381.00
27752 CLTX TIBL SFT FX W/MANP $1,968.00
27760 CLTX MEDIAL MALLS FX W/O $1,153.00
27780 CLTX PROX FIVULA/SHFT FX $1,055.00
27786 CLSD TX DISTAL FIBULAR FX $993.00
27792 Open treatment of distal fibular fracture (lateral malleolu… $5,342.00
27808 CLOSED TX BIMALLEOLAR ANK $507.00
27810 CLTX BIMAL ANKLE FX W/POT $1,704.00
27840 CLOSED TX ANKLE DISLOCATI $100.00
28190 RMVL FB BODY FOOT SUBQ $745.00
28192 RMVL FB FOOT DEEP $1,373.00
28400 CLSD TX CLAVICLE FX WO MA $650.00
28430 CLTX TALUS FX W/O MNPJ $106.00
28450 TX TARSAL B1 FX XCP TALUS $635.00
28470 CLTX METAR FX WO MNP $840.00
28490 CLTX FX GRT TOE W/O MNLJ $594.00
28510 CLSD TX FX PLALANX/PHALAN $523.00
28515 FX CARE PHALANX NOT GREAT $622.00
28660 CLSD TX PIP JNT DISLOCATI $622.00
29075 APPLICATION CAST ELBOW FINGER SHORT ARM $610.93
29085 CAST HAND/LOWER FOREARM GAUNTLET $176.00
29105 LONG ARM SPLINT $176.00
29125 SHORT ARM SPLINT $532.80
29126 SHORT ARM SPLINT DYNAMIC $176.00
29130 APPLICATION FINGER SPLINT $176.00
29131 APPLICATION FINGER SPLINT DYNAMIC $364.17
29240 STRPG SHO $260.00
29280 STRAPPING HAND/FINGER $239.00
29505 LONG LEG SPLINT $176.00
29515 SHORT LEG SPLINT $176.00
29540 STRAPPING ANKLE/FOOT $220.00
29550 STRAPPING TOES $176.00
29580 STRAPPING UNNA BOOT $220.00
29700 RMVL/BIVALV GAUNTLET BOOT $127.00
30300 RMVL FOREIGN BODY NASAL $496.00
30901 NASAL PACKING $131.00
30903 CTRL NSL HEMRRG ANT CPLX $443.00
3120F 12-LEAD ECG PERFORMED $250.00
31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE $571.00
31502 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT $891.00
31515 LARYNGOSCOPY +- TRACHEOSCOPY ASPIRATION $670.00
31525 LARGSC +-TRACHEOSCOPY DX $198.00
32551 TUBE THORACOSTOMY INCLUDES WATER SEAL $1,342.00
33415 RESCJ/INC SUBVALVULAR TISSUE $980.00
36000 INTRODUCTION OF NEEDLE/IN $244.00
36410 VENIPUNCTURE, 3 YRS OR OLDER $68.00
36415 VENIPUNCTURE $28.00
36416 COLL CAPILLARY BLG SPEC $41.00
36556 Insertion of non-tunneled centrally inserted central venous… $3,816.00
36558 INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR $2,156.00
36591 COLLECT BLOOD FROM IMPLAN $146.00
38300 DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL $303.00
40650 RPR LIP FULL THICKNESS $2,990.00
41800 DRNG ABSC DENTOALVEOLAR S $480.00
42700 I&D ABSC PRITONSILLAR $857.00
43753 GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … $128.00
46040 I&D ISCHIOR/PRIRC ABSC SP $1,957.00
46050 INC/DRAIN PERIANAL ABS SU $1,111.00
46083 INCISION THROM HEMORRHOID $491.00
46320 ENULEATION EXCC OF EXT HE $612.00
51700 BLDR IRR SMPL LVG&/INSTLJ $97.00
51701 INSR NONDWELLING BLDR CAT $231.00
51702 INSERTION BLADDER CATH $361.00
51703 INSERT BLADDER CATH COMPL $569.00
56405 INC/DRAIN VULVA/PERINEAL $259.00
56420 I & D BARTHOLIN ABSCESS $100.00
59025 FTL NON-STRS TST $600.00
59409 VAG DLVR ONLY $3,960.00
62270 SPINAL PUNCTURE,LUMBAR $554.00
64400 NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH $2,743.00
64402 INJ ANESTHETIC FACIAL NRV $640.00
64450 INJ ANESTHETIC AGENT $1,312.50
64640 DSTRJ NULYT OTH PRPH NVR/BRANCH $1,220.00
65205 REMOVAL FB EYE-SUPERFCL $244.00
65220 RMVL FB EYE W/O SLIT LAMP $380.00
65222 RMVL FB EYE $449.00
67700 I&D ABSCESS EYELID $773.00
69005 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED $363.00
69200 RMVL FOREIGN BODY EAR $381.00
69205 RMVL FB XTRNL AUD CANAL A $409.00
69209 REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL $340.00
69210 RMVL IMPACTED CERUMEN $196.00
70030 RADEX EYE DETCJ FB $396.01
70100 XRAY MANDIBLE LESS THAN 4 VIEWS $396.01
70110 XRAY MANDIBLE MIN 4 VIEWS $550.80
70120 RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE $459.00
70130 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE $396.01
70140 XRAY FACIAL BONES LESS THAN 3 VIEW $396.01
70150 XRAY FACIAL BONES GREATER THAN 3 VIEW $769.50
70160 NASAL BONE X-RAY $396.01
70200 RAD EXAM ORBIT COMP. $641.25
70210 RADEX SINUSES PARANASAL <3 VIEWS $523.37
70220 RAD EXAM SINUS COMPLETE $622.50
70250 SKULL LESS THAN 4 VIEWS $515.41
70260 RAD EXAM SKULL COMPLETE $970.20
70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI $396.01
70330 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT $396.01
70350 CEPHALOGRAM ORTHODONTIC $257.00
70360 RAD EXAM NECK,SOFT TISSUE $493.52
70450 CT HEAD/BRAIN W/O CONTRAST MATERIAL $4,022.10
70460 CT HEAD/BRAIN W/CONTRAST MATERIAL $5,317.20
70470 CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL $6,624.71
70480 CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL $2,718.75
70481 CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL $4,801.50
70482 CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR $6,740.13
70486 CT MAXILLOFACIAL W/O CONTRAST MATERIAL $3,129.30
70487 CT MAXILLOFACIAL W/CONTRAST MATERIAL $3,352.50
70488 CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL $6,586.13
70490 CT NECK WO CONTRAST $3,020.00
70491 CT SOFT TISS NCK C+MATRL $3,502.00
70496 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST $4,026.60
70498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST $6,792.87
70544 MRA HEAD C-MATRL $5,975.25
70547 MRA NECK C-MATRL $5,178.55
70551 MRI BRN BRN STEM C-MATRL $4,780.20
70553 MRI BRN BRN STEM C-/C+ $6,492.28
71045 RADIOLOGIC EXAM CHEST SINGLE VIEW $583.20
71046 CHEST XRAY 2 VIEWS $563.25
71047 RADIOLOGIC EXAM CHEST 3 VIEWS $818.89
71048 RADIOLOGIC EXAM CHEST 4+ VIEWS $899.48
71060 BRONCHOGRAPHY BI RS&I $537.00
71100 RIBS UNILATERAL 2 VIEWS $505.50
71101 RIB UNILATERAL W CHEST $848.25
71110 RIBS BILATERAL 3 VIEWS $689.25
71111 RIBS BILATERAL W/CHEST $509.25
71120 Radiologic examination; sternum, minimum of 2 views $511.50
71250 CT CHEST W/O CONTRAST $3,519.00
71260 CT THORAX W/CONTRAST $5,201.25
71270 CT THORAX WO CONTRAST $5,636.25
71275 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST $3,605.88
71550 MRI CH C-MATRL $4,454.40
72020 SPINE SINGLE VIEW $428.25
72040 SPINE, CERVICAL 2/3 VIEWS $541.50
72050 SPINE, CERVICAL MIN 4VIEW $733.50
72052 SPINE CERV. COMP FLEX/EXT $608.94
72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS $374.00
72070 SPINE THORACIC 2 VIEWS $649.80
72072 SPINE THORACIC 3 VIEWS $797.40
72074 RAD EXAN SPINE THROAC 4 V $396.01
72080 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS $515.41
72082 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW $1,086.54
72100 SPINE LUMBO. MIN 4 VIEWS $649.80
72110 LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS $961.17
72114 RAD EXAM SPINE LUMBO COMP $608.94
72120 SPINE LUMBAR AP & LAT W F $608.94
72125 CT CERVICAL SPINE W/O CONTRAST MATERIAL $4,072.90
72126 CT CERVICAL SPINE W/CONTRAST MATERIAL $5,183.75
72127 CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL $5,523.70
72128 CT THRC SPI C-MATRL $4,683.75
72129 CT THRC SPI C+ MATRL $3,564.00
72130 CT THORACIC SPINE W/O & W/CONTRAST MATERIAL $6,373.50
72131 CT LUMBAR SPINE W/O CONTRAST MATERIAL $5,620.50
72132 CT LUMBAR SPINE W/CONTRAST MATERIAL $7,483.40
72133 CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL $8,455.51
72141 MRI SPI CANAL&CNTS CRV C-MATRL $4,780.20
72146 MRI SPI CANAL&CNTS THRC C-MATRL $4,780.20
72148 MRI SPI CANAL&CNTS LMBR C-MATRL $4,780.20
72156 MRI SPI CANAL&CNTS C-/C+ CRV $6,047.38
72157 MRI SPI CANAL&CNTS C-/C+ $4,402.50
72158 MRI SPI CANAL&CNTS C-/C+ LMBR $6,047.38
72170 RAD EXAM PELVIS 1/2 VEIW $793.80
72190 RADEX PELVIS COMPL MIN 3 $396.01
72191 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST $4,743.70
72192 CT PELVIS WO CONTRAST $4,168.00
72193 TOMOGRAPHY PELVIS WCONTRS $2,750.00
72194 CT PELVIS W OR WO CONTRST $7,574.00
72195 MRI PELVIS C-MATRL $4,454.40
72196 MRI PELVIS C+ MATRL $5,194.80
72220 XRAY COCCYX/SACRUM $396.01
72270 MYELOGRAPY 2/MORE REGIONS RS&I $4,354.12
73000 XRAY CLAVICLE 2 VIEWS $396.01
73010 SCAPULA COMPLETE $396.01
73020 RADEX SHO 1 VIEW $598.00
73030 SHOULDR COMPLETE 2 VIEWS $612.90
73050 XRAY AC JOINTS-BILAT $396.01
73060 XRAY HUMERUS MIN 2 VIEWS $550.80
73070 XRAY ELBOW 2 VIEWS $598.00
73080 XRAY ELBOW GREATER THAN 3 VIEWS-COMP $388.05
73090 XRAY FOREARM AP & LAT $594.90
73100 XRAY WRIST AP & LAT VIEW $534.60
73110 XRAY WRIST/COMP MIN 3 VIE $396.01
73120 XRAY HAND AP & LAT $488.70
73130 XRAY HAND MIN 3 VIEWS $550.80
73140 XRAY FINGER MIN 2 VIEWS $461.68
73200 CT UPPR EXTR WO CNTRS $3,309.75
73201 CT UPPER EXTREMITY W/CONTRAST MATERIAL $5,778.90
73202 CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL $6,740.13
73220 MRI UXTR OTH/THN JT C-/C+ $4,402.50
73221 MRI ANY JT UXTR C-MATRL $4,365.00
73501 RADEX HIP UNILATERAL WITH PELVIS 1 VIEW $545.30
73502 RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… $894.90
73503 RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS $1,142.26
73520 HIPS BILAT MIN 2 VIEW INC $507.00
73522 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS $1,286.54
73551 RADIOLOGIC EXAMINATION FEMUR 1 VIEW $523.37
73552 FEMUR; MIN 2 VIEWS $610.50
73560 XRAY KNEE, SUNRISE VIEW $424.87
73562 XRAY KNEE MIN 3 VIEWS $543.27
73564 RAD EXAM KNEE 4 OR MORE $585.90
73565 RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST $396.01
73580 X-RAY KNEE.BILATERAL STANDING $2,563.12
73590 XRAY TIBIA/FIBULA AP/LAT $396.01
73592 RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS $396.01
73600 XRAY ANKLE 2 VIEWS $547.25
73610 XRAY ANKLE 3 VIEWS/COMPLE $685.80
73620 XRAY FOOT MIN 2 VIEWS $498.50
73630 XRAY FOOT MIN 3 VIEWS $691.53
73650 RAD EXAN HEEL MIN 2 VIEWS $396.01
73660 XRAY TOES, MIN 2 VIEWS $467.10
73700 CT LOWER EXTREMITY W/O CONTRAST MATERIAL $4,390.94
73701 CT LWR EXT W CONT $6,388.90
73702 CT LXTR C-/C+ $5,080.50
73718 MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL $4,678.49
73721 MRI ANY JT LXTR C-MATRL $4,365.00
73722 MRI ANY JT LXTR C+ MATRL $5,106.00
73723 MRI ANY JT LXTR C-/C+ $6,503.75
73725 MRA LXTR C+-MATRL $6,163.30
74000 RAD EXAM ABD SINGL ANTER $759.00
74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS $426.00
74018 RADIOLOGIC EXAM ABDOMEN 1 VIEW $588.60
74019 RADIOLOGIC EXAM ABDOMEN 2 VIEWS $725.25
74020 RAD EXAM ABDOMEN COMPL $454.00
74021 RADIOLOGIC EXAM ABDOMEN 3+ VIEWS $688.80
74022 RAD EXAM COMPLETE ABD $1,360.80
74150 CT ABDOMEN W/O CONTRAST MATERIAL $3,407.20
74160 CT ABDOMEN W/CONTRAST MATERIAL $4,816.50
74170 CT ABDOMEN W/O & W/CONTRAST MATERIAL $5,528.25
74174 CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG $7,019.00
74175 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST $5,196.80
74176 CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL $4,588.65
74177 CT ABDOMEN & PELVIS W/CONTRAST MATERIAL $5,702.97
74178 CT ABD & PELVIS 1 PLUS SECTION/REGNS $6,905.88
74181 MRI ABD C-MATRL $4,780.20
74183 MRI ABD C-/C+ $6,047.38
74190 PERITONEOGRAM RS&I $2,192.98
74240 RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB $718.39
74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB $998.00
74245 RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES $3,871.50
74246 Radiologic examination, gastrointestinal tract, upper, air … $1,108.43
74247 RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB $1,010.00
74250 RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES $768.14
74251 RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE $1,430.81
74283 Therapeutic enema, contrast or air, for reduction of intuss… $1,408.00
74328 ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I $3,320.40
74329 ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I $2,701.60
74330 CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I $386.06
74340 INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I $228.85
74440 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I $2,857.80
75574 CT CORONARY $3,360.60
76376 3D RNDR I&R CT MRI US/OTH $543.27
76380 CT LIMITED/LOCALIZED FOLLOW UP STUDY $1,293.50
76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK $1,133.10
76604 US CHEST REAL TIME W/IMAGE DOCUMENTATION $769.14
76641 US BREAST UNI REAL TIME WITH IMAGE COMPLETE $893.51
76642 US BREAST UNI REAL TIME WITH IMAGE LIMITED $648.74
76645 US BREAST R-T W/IMAGE DOCUMENTATION $784.06
76700 US ABDOMINAL R-T W/IMAGE $1,504.80
76705 US ABDOMINAL $1,151.10
76706 Ultrasound, abdominal aorta, real time with image documenta… $901.00
76770 US RETROPERITONEAL R-T W/ $1,174.50
76775 US RPR B-SCAN&/R-T IMG LMTD $1,089.90
76801 ULTRASOUND 14 WK TABDL 1/1ST GESTATION $700.48
76802 US PREG UTERUS 14 WK TRANSABDL EACH GESTATION $700.48
76805 US PG UTER F&MAT AFTER 1S $881.57
76810 $894.51
76815 ULTRASND PG UTER $525.36
76816 US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS $851.72
76817 UT PG UTER R-T IMG TRVG $581.08
76830 TRANSVAGINAL ULTRASOUND $487.50
76856 US PELVIC NONOB REAL-TIME $1,089.75
76857 PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 $624.00
76870 US SCROTUM&CNTS $1,004.40
76880 US EXTREMITY $913.00
76881 US COMPL JOINT R-T W/IMAGE DOCUMENTATION $801.97
76882 ULTRASOUND, EXTREMITY, NON VASCULAR $155.22
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… $1,485.00
77076 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT $275.00
77079 CT BONE MINERAL DENSITY STUDY 1+SITS APPND $613.00
78075 ADRNL IMG CORTEX&/MEDULLA $3,618.00
78223 HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR $2,509.00
78306 B1&/JT IMG WHBDY $1,701.00
78315 B1&/JT IMG 3 PHASE STD $2,022.00
78320 B1&/JT IMG TOMOG SPECT $923.00
78472 CARD BPI GTD=BRM PLNR 1 STD REST/STRS $2,047.71
80047 BASIC METABOLIC PANEL CALCIUM IONIZED $571.13
80048 METABOLIC PANEL BASIC $163.18
80051 ELECTROLYTE PANEL $414.92
80053 METABOLIC COMPRE PANEL $689.54
80061 LIPID PROFILE III $452.73
80074 HEPATITIS PANEL $508.94
80076 HEPATIC FUNCTION PANEL $484.57
80100 DRUG ABUSE PANEL II $191.04
80102 Drug confirmation, each procedure $523.13
80104 DRUG SCREEN $172.00
80178 LITHIUM $456.71
80196 SALICYLATE $332.33
80197 TACROLIMUS $452.70
80202 VANCOMYCIN PEAK $390.04
80300 DRUG SCREEN $221.00
80304 DRUG SCREEN $211.00
80305 DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… $143.00
80307 DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS $763.20
80320 DRUG SCREEN $143.28
80324 DRUG SCREEN QUANT AMPHETAMINES 1 OR 2 $407.70
80329 DRUG SCREEN $151.24
80335 ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2 $165.17
80345 DRUG SCREENING BARBITURATES $286.20
80346 DRUG SCREENING BENZODIAZEPINES 1-12 $246.26
80347 DRUG SCREENING BENZODIAZEPINES 13 OR MORE $525.00
80349 DRUG SCREENING CANNABINOIDS NATURAL $298.06
80351 DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6 $829.80
80352 DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE $655.20
80353 DRUG SCREENING COCAINE $302.10
80356 DRUG SCREENING HEROIN METABOLITE $212.68
80358 DRUG SCREENING METHADONE $362.18
80359 DRUG SCREENING METHYLENEDIOXYAMPHETAMINES $88.06
80361 DRUG SCREENING OPIATES 1 OR MORE $298.50
80362 DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2 $296.51
80365 DRUG SCREENING OXYCODONE $37.56
80366 DRUG SCREENING PREGABALIN $227.86
80367 DRUG SCREENING PROPOXYPHENE $233.83
80373 DRUG SCREENING TRAMADOL $256.71
80374 DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS $420.00
81000 U/A DIPSTICK $115.42
81001 U/A DIP STICK $176.12
81002 URNLS DIP STICK/TABLET RG $37.81
81003 U/A W/O MICRO DIPSTICK $37.81
81007 URINALYSIS BACTERIURIA SCR XCPT CULTURE/DIPSTICK $288.55
81025 PREG.TST URINE VISUAL $95.52
82003 ACETAMINOPHEN $624.60
82009 KETONES-SERUM $36.00
82040 ALBUMIN; SERUM $133.33
82055 ALCOHOL-BLOOD $330.34
82075 ALCOHOL BREATH TEST $175.12
82140 Ammonia $278.60
82150 AMYLASE $220.89
82247 BILIRUBIN TOTAL $311.44
82248 BILIRUBIN DIRECT $179.10
82250 direct bilirubin $260.69
82253 MB FRACTION $154.00
82270 OCCULT BLOOD $102.49
82272 BLD OCLT PEROXIDASE ACTV $47.76
82274 BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 $177.11
82310 CALCIUM $174.13
82330 CALCIUM IONIZED $476.61
82355 CALCULUS QUALITATIVE ANALYSIS $428.40
82374 CARBON DIOXIDE BICARBONATE $185.07
82375 Under Chemistry Procedures $188.80
82435 CHLORIDE BLD $178.11
82465 CHOLESTEROL SERUM/WHOLE BLOOD TOTAL $197.01
82533 CORTISOL TOTAL $243.03
82540 CREATINE $433.82
82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE $121.00
82550 CREATINE CK-TOTAL $71.64
82553 CREATINE CKMB $149.25
82565 CREATININE $194.03
82607 VITAMIN B-12 $297.51
82693 ASSAY OF ETHYLENE GLYCOL $158.45
82747 ASSAY OF FOLIC ACID RBC $372.13
82784 IGC IMMUNOGLOBULIN $84.33
82785 GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE $152.73
82800 GASES BLD PH ONLY $130.00
82803 BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 $284.57
82805 GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY $889.10
82945 GLUCOSE BODY FLUID OTHER THAN BLOOD $169.15
82947 GLUCOSE $169.15
82948 GLUCOSE BLOOD REAGET STR $166.66
82962 GLUCOSE FINGER STICK $47.76
82977 GLUTAMYLTRANSFERASE-GTT $391.04
83009 HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE $754.60
83013 HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE $742.50
83036 HEMOGLOBIN GLYCOSYLATED A1C $195.02
83050 HEMOGLOBIN METHEMOGLOBIN QUANTITATIVE $107.46
83520 IMMUNOASSAY ANALYTE QUANTITIATIVE NOS $570.00
83525 ASSAY OF INSULIN TOTAL $167.16
83540 IRON-TOTAL $133.33
83605 ASSAY OF LACTATE $548.74
83615 Lactate dehydrogenase (LD), (LDH); $275.62
83690 LIPASE $241.79
83718 LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL $71.89
83735 MAGNESIUM $258.70
83874 MYOGLOBIN $113.93
83880 B-TYPE NATRIURETIC $549.75
83992 ASSAY OF PHENCYCLIDINE $225.00
84075 ALK PHOS/PROFILE OR PANEL $99.50
84100 ASSAY OF PHOSPHORUS INORGANIC $180.10
84132 POTASSIUM SERUM PLASMA/WHOLE BLOOD $209.95
84155 PROTEIN,TOTAL,EXCEPT REFR $166.17
84157 PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC $425.86
84165 PROTEIN ELECTROPHORESIS $120.40
84295 SODIUM; SERUM $208.95
84403 ASSAY OF TESTOSTERONE TOTAL $213.18
84436 THYRIXINE TOTAL $133.33
84439 THYROXINE-FREE $319.40
84443 Thyroid stimulating hormone (TSH) $587.05
84450 Aspartate Aminotransferase $99.50
84460 ALT-TRANSFERASE;ALANINE $91.54
84478 ASSAY OF TRIGLYCERIDES $351.24
84479 THYROID HORMONE $209.95
84480 T3 TOTAL $155.72
84481 ASSAY OF TRIIODOTHYRONINE T3 FREE $356.21
84484 TROPONIN I $369.15
84512 TROPONIN QUAL $549.24
84520 Urea nitrogen $178.11
84550 URIC ACID $166.17
84560 URIC ACID OTH SRC $167.16
84702 HCG QUANTATIVE $492.30
84703 PREGNANCY TEST BLOOD $149.25
84999 UNLISTED CHEMISTRY PROCEDURE $179.10
85014 HEMATOCRIT $81.59
85018 HEMOGLOBIN $81.59
85025 BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC $268.65
85027 CBC W/O DIFF $125.37
85032 BLD# MNL C-CNT RBC/PLTLT EA $152.00
85044 RETICULOCYTE COUNT $248.75
85347 COAGJ TM ACTIVATED $83.58
85378 FIBRIN DEGRADATION PROD $93.53
85379 D-DIMER $140.54
85610 PROTHROMBIN TIME $182.09
85651 SEDIMENTATION RATE NONAUT $177.11
85652 SED RATE ERYTHROCYTE NON $51.74
85730 THROMBOPLASTIN TIME PART $117.41
86038 ANTINUCLEAR AB $486.56
86039 ANTINUCLEAR AB TITER $477.60
86060 ANTISTREPTOLYSIN O TITER $291.54
86140 C REACTIVE PROTEIN $399.99
86235 EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD $463.67
86256 SMOOTH MUSCLE AB TITER $251.24
86308 MONO,HETEROPHILE ANTIBODI $99.50
86320 IMMUNOELECTROPHORESIS $48.76
86328 COVID-19 RAPID ANTIBODY TEST SINGLE METHOD $297.00
86360 T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO $300.49
86403 MONO SPOT $221.89
86430 RHEUMATOID FACTOR $300.49
86431 RHEUMATOID FACTOR QUANTITATIVE $219.90
86592 Syphilis test, non-treponemal antibody; qualitative (eg, VD… $281.59
86593 SYPHILIS TEST, NON- TREPONEMAL ANTIBODY; QUANTITATIVE $65.67
86631 ANTB CHLAMYDIA $111.94
86644 ANTIBODY CYTOMEGALOVIRUS CMV $408.60
86645 ANTIBODY CYTOMEGALOVIRUS CMV IGM $450.74
86664 EPSTEIN-BARR VIRUS EBNA $133.00
86677 ANTIBODY HELICOBACTER PYLORI $454.72
86689 ANTB HTLV/HIV ANTB CONFIRMATION TST $820.88
86701 HIV SERUM $131.34
86702 ANTB HIV-2 $536.25
86704 HEPATITIS B CORE ANTIBODY HBCAB TOTAL $505.46
86705 HEPATITIS B CORE IGM $455.40
86706 HEPATITIS B SURF ANTIBODY HBSAB $359.20
86713 LEGIONELLA PNEUMONPILA AB $133.33
86756 ANTB RSV $143.00
86769 COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD $325.00
86780 ANTIBODY TREPONEMA PALLIDUM $113.18
86787 Antibody; varicella-zoster $450.74
86803 HEPATITIS C ANTIBODY $517.40
86850 ANTB SCR RBC EA SERUM TQ $248.75
86900 Blood typing, serologic; ABO $141.29
86901 RH FACTOR-BLOOD $135.32
86906 BLD TYPING RH PHEXYPING COMPL $86.00
87040 BLOOD CULTURE $400.99
87045 CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL $198.01
87046 CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA $198.01
87070 CULTURE BODY FLUID $167.16
87075 CULTURE ANAEROBIC $485.10
87076 CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL $523.37
87077 CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL $155.22
87081 CULTURE, BACTERIAL-SCREEN $81.59
87086 URINE CULTURE $99.00
87088 CULTURE BCT ISOL&PRSMPTV $61.69
87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST $151.24
87110 CHLAMYDIA CULTURE $259.70
87177 OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID $206.46
87205 SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL $100.74
87207 SMR PRIM SRC SPEC STAIN $189.05
87209 SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS $262.68
87210 WET SMEAR $83.58
87252 VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT $394.02
87255 Herpes Simplex Virus Culture with Reflex Typing $432.83
87275 IAADI INF B VIRUS $220.89
87338 IAAD IA HPYLORI STOOL $220.89
87340 IAAD IA HEPATITIS B SURFACE ANTIGEN $332.33
87341 IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION $501.60
87389 HIV-1 AG W/HIV-1 & HIV-S AB $467.65
87400 INFLUENZA A&B $95.52
87420 IAAD IA RESPIRATORY SYNCTIAL VIRUS $987.78
87425 ROTAVIRUS AG EIA $389.05
87426 COVID-19 RAPID ANTIGEN TESTING $353.00
87427 IAAD IA SHIGA-LIKE TOXIN $447.60
87428 Multiplex viral pathogen panel using Antigen technique for … $700.00
87430 INF AGT IMMUNO STREP A $220.89
87480 IADNA CANDIDA SPECIES DIRECT PROBE TQ $231.84
87486 IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ $579.60
87491 IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ $403.28
87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE $497.50
87507 IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 $3,998.40
87529 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA &RNA) $601.50
87581 IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ $429.17
87591 IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ $289.05
87633 IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET $2,061.60
87635 IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ $301.00
87636 “severe acute respiratory syndrome coronavirus 2 (SARSCoV-2… $800.00
87661 INF AGENT DETECTED NUCLEIC ACID; TRICHMONAS VAGINALIS AMP P… $460.80
87798 O&P SMEAR W/AMPLIFIC $702.00
87800 IAADIADOO NEISSERIA GONORRHOEAE $197.23
87804 INFLUENZA IMMUNOASSAY OPT $168.00
87807 INF AGT DET IMNAS OPT RSV $42.00
87847 NO DESCRIPTION $409.00
87850 NEISSERIA GONORRHOEAE DET $169.65
87880 RAPID STREP-BETA STREP $200.99
87905 INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS $394.50
88305 PATH SURG LEVEL IV $405.96
89050 CELL COUNT MISCELLANEOUS BODY FLUIDS $134.33
89051 CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT $127.36
89055 LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE $98.51
89060 CRYSTAL INDENTIFICATION $105.47
89220 SPTM OBTG SPEC AERSL INDUCED SPX $98.00
90471 IMMUN ADM 1 VAC $154.23
90660 INFLUENZA VIRUS INTRANASA $70.00
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, … $525.30
90700 DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM $231.60
90703 TETANUS TOXID $152.00
90714 TETANUS DIPHTHERIA TOXOID $374.32
90715 TDAP VACCINE $116.00
90718 TETANUS & DIPTHERIA $152.00
90746 HEPATITIS B VACCINE/ADULT $79.00
90765 IV NFS THER PROPH/DX 1ST $210.00
90997 HEMOPERFUSION $409.00
91105 GASTRIC INTUBATION/ASPER $596.00
92002 OPH MEDICAL XM&EVAL INTRM $1.00
92081 VIS FLD XM UNI/BI I&R LMT $1.00
92552 PURE TONE AUDIOMTRY AIR O $1.00
92950 cardiopulmonary resuscitation $1,301.00
92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL $1,089.00
93000 EKG W/INTREP AND REPORT $248.00
93005 Electrocardiogram, routine ECG $534.00
93010 RTN ECG 12 LEADS INTRP/RP $624.00
93018 CV STRS TST XERS&/OR RX CONT ECG I&R ONLY $475.61
93040 RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT $459.69
93041 RHYTHEM ECG 1-3 LDS $146.00
93042 RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON $340.29
93224 WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I $149.00
93306 ECHO TEST $1,367.00
93307 ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP $3,524.29
93308 ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD $2,795.40
93313 TEE R-T IMG 2D W/PROBE PLMT ONLY $2,626.00
93320 DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY $1,457.30
93325 DOP ECHOCARD COLOR FLOW VELOCITY MAPPING $1,480.10
93351 ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG $1,560.00
93631 INTRAOP EPICAR& ENDOCAR PACG& MAPG $10,386.84
93784 Orthostatic $387.84
93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD $840.00
93880 DUP-SCAN XTRC ART COMPL B $903.00
93882 DUP-SCAN XTRC ART UNI/LMTD STD $903.00
93922 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL $557.20
93923 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS $845.75
93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY $923.36
93926 DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD $878.00
93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY $923.36
93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD $466.00
93965 QUANT VENOUS FLOW ST $1,806.00
93970 DUP-SCAN XTR VEINS COMPL $1,201.96
93971 DPLX SCN EXTRM VEINS $645.00
93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… $514.00
93976 DUPLEX SCAN- LIMITED $466.00
94010 SPIROMETRY W/RECORD $150.00
94060 BRNCDILAT RSPSE SPMTRY PR $385.00
94621 PULM STRS TSTG CPLX $1,029.00
94640 NEBULIZER TREATMENT $873.65
94644 INHALATION TREATMENT – CONTINUOUS 1ST HR $157.00
94664 DEMO&/EVAL OF PT UTILIZ $1.00
94760 EAR OR PULSE OXIMETRY $25.87
94761 N-INVAS EAR/PLS OXIMTRY F $238.00
94762 NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR $644.76
96360 IV INFUS INIT 31 MIN 1 HR $634.50
96361 IV INFUS HYDR EA ADD’T HR $356.21
96365 IV INFUSION THERAPY/PROPH $497.50
96366 IV INFUS THER PROPH/DX EA $356.21
96367 IV NFS THER PROPH/DX ADDL $470.64
96368 IV NFS TX PROPHYLAXIS/DX $263.00
96372 THERAPEUTIC PROPHYLACTIC/ $87.56
96373 INJECTION, INTRA-ARTERIAL $228.00
96374 THER PROPH/DX NJX IV PUSH $441.78
96375 THER PROPH/DX NJX EA SEQL $402.98
96376 SUB INFU EA ADD IV PUSH $388.05
96377 APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION $232.83
96379 INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS $213.00
97010 $101.49
97116 $302.48
97542 WHEELCHAIR MGMT EA 15 MIN $278.60
97597 DEBRIDEMENT OPEN WOUND 20 SQ CM/< $638.79
99000 SPECIMEN HANDLING $54.00
99001 COC COLLECITON ONLY $41.00
99024 POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX $789.00
99050 BLUE CROSS RQRD LVL3 $87.00
99053 SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY $146.00
99070 SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP $183.08
99080 MEDICAL RECORDS $46.00
99143 MOD SEDATION &#60;5YRS 30 $439.00
99144 MOD SEDATION SERV UNDER 5 $433.00
99145 M-SEDAJ BY SM PHY 15 MIN $168.00
99149 MOD SEDATION $363.00
99151 MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS $857.69
99173 SCREENING TEST OF VISION $293.00
99217 OBSERVATION CARE DISCHARGE MANAGEMENT $975.10
99218 INITIAL OBSERVATION CARE/DAY 30 MINUTES $187.06
99219 INITIAL OBSERVATION CARE/DAY 50 MINUTES $957.19
99220 INITIAL OBSERVATION CARE/DAY 70 MINUTES $957.19
99234 OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES $1,066.64
99235 OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES $1,852.69
99236 OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES $2,454.80
99281 E/M VISIT LEVEL 1 TECH COMP $479.59
99282 E/M VISIT LEVEL 2 TECH COMP $1,035.80
99283 E/M VISIT LEVEL 3 TECH COMP $2,055.67
99284 E/M VISIT LEVEL 4 TECH COMP $2,692.47
99285 E/M VISIT LEVEL 5 TECH COMP $3,770.06
99291 CRITICAL CARE 30-74 MIN $4,779.00
99292 CRITICAL CARE ADD 30 MIN $1,365.14
99406 SMOKING CESSATION 3-10 $81.00
99407 SMOKING CESSATION 10 MIN $94.00
A0394 ALS IV DRUG THERAPY SUPPLIES $1.00
A0396 ALS ESPOHAGEAL INTUB SUPPLIES $30.00
A4208 3 CC STERILE SYRINGE & NEEDLE $32.00
A4209 5+ CC STERILE SYRINGE & NEEDLE $35.00
A4213 20+ CC SYRINGE ONLY $7.00
A4215 NEEDLE STERILE, ANY SIZE, EACH $12.00
A4216 STERILE WATER/SALINE, FLUSH 10ML $3.00
A4217 STERILE SALINE WATER PER 500 ML $26.00
A4218 STERILE SALINE OR WATER $26.00
A4222 EXT UNFU PMP PER CASS/BAG $176.00
A4224 ALOCHOL OR PEROXIDE PER PINT $4.00
A4246 BETADINE/PHISOHEX SOLUTION $25.00
A4247 BETADINE/IODINE SWABS/WIPES $25.00
A4252 GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP $6.00
A4270 DISPOSABLE ENDO CODE SHEATH $24.00
A4311 CATHETER W/O BAG 2 WAY LATEX $35.00
A4314 INSRT TRAY W/DRAINAGE BAG $12.00
A4315 Insertion tray with drainage bag with indwelling catheter, … $15.00
A4316 CATH W DRAINAGE 3 WAY $90.00
A4320 IRR TRAY W/BULB/PISTON SY $9.00
A4322 IRRIGATION SYRINGE, BULB $15.00
A4327 URIN CUP FEMALE COLLECT DEV CUP $3.00
A4332 LUBE STERILE PACKET $7.00
A4335 INCONTINENCE SUPPLY MISC $3.00
A4338 INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING $53.00
A4344 INDWELLING CATH FOLEY TYP $12.00
A4353 INTERMIT URINARY CATHETER $24.00
A4358 URINARY DRAINAGE BAG $14.00
A4364 DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ $33.00
A4450 TAPE NO WATERPROOF $10.00
A4452 TAPE WATERPROOF 18 SQ IN $10.00
A4550 LACERATION- SURGICAL KIT $409.00
A4554 DISPOSABLE UNDERPADS $30.00
A4565 SLING $146.00
A4570 SPECIAL CASTING MATERIAL $125.00
A4590 3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL $84.00
A4595 TENS SUPPL 2 LEAD PER MONTH $46.00
A4606 OXYGEN PROBE USED W OXIMETER $127.00
A4614 HAND HELD PEFR METER $50.00
A4615 CANNULA NASAL $6.00
A4616 TUBING (OXYGEN) PER FOOT $1.00
A4617 MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT $55.00
A4649 SURGICAL SUPPLY MISC $23.00
A4653 PD CATHERTER ANCHOR BELT $13.00
A4657 SYRINGE W OR WO NEEDLE $7.00
A4670 AUTOMATIC BP MONITOR #11 $36.00
A4673 SALINE BLADE #11 $13.00
A4927 GLOVES NON STERILE $1.00
A4930 GLOVES STERILE PER PAIR $3.00
A5120 SWAB OR WIPE SKIN BARRIER $6.00
A5200 PERCUTANEOUS CATHETER ANCHOR $117.00
A6021 COLLAGEN DRESSING STERIL $17.00
A6205 COMPOSITE DRSG LESS THAN 48 SQ IN $22.00
A6210 FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER $98.00
A6211 FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER $31.00
A6212 FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ IN OR LESS, EACH… $7.00
A6213 FOAM DRG 16-48 SQ IN W/BRDR $11.00
A6216 GAUZE NONIMPREG 16 SQ IN $13.00
A6217 GAUZE NON STERILE $13.00
A6218 GAUZE, NON STERILE $13.00
A6219 GAUZE- STERILE $13.00
A6220 GAUZE, NON IMP, STERILE, PAD SIZE >16 SQ < OR = 48SQ IN $11.00
A6222 GAUZE IMPREGNATED WITH ME $8.00
A6231 GAUZE, 16<SQ IN, EACH $70.00
A6250 SKIN SEAL PROTECT MOISTURIZER OINTMENT $34.00
A6260 WOUND CLEANSER $100.00
A6261 WOUND FILLER $100.00
A6402 GAUZE NON-IMPREG STERL 16 $7.00
A6407 PACK STRIPS NON-IMPREGNTD $29.00
A6410 STERILE EYE PAD OR STRIP $6.00
A6412 OCCLUSIVE EYE PATCH $30.00
A6413 ADHESIVE BANDAGE FIRST AI $6.00
A6446 CONFORMING BANDAGE NON-EL $19.00
A6448 LT COMP BANDAGE LESS THAN 3IN $11.00
A6449 LIGHT COMP BANDAGE $11.00
A6450 LT COMPRS BANDAGE ELAST $17.00
A6453 BANDAGE SELF ADHER BAND W LESS THAN 3 $2.00
A6454 SELF ADHER BANDAGE $13.00
A6455 SELF ADHER BANDAGE $13.00
A6457 TUBULAR DRESSING $41.00
A7002 SUCTION TUBING USED W PUMP $94.00
A7003 ADMN SET SM VOL NONFILTER $57.00
A7011 NONDISPOS CORRUGATED TUBING $12.00
A7015 NEBULIZER MASK USED W NEBULIZER $57.00
A7016 DOME/MOUTHPEICE NEB $161.00
A7017 NEBULIZER MASK NOT USED W/ OXYGEN $57.00
A7520 TRACH LARYN TUBE NON CUFFED $37.00
A9150 NON PERSCRIPTION DRUG $23.00
A9273 HOT/COLD H2OBOT/CAP/COL/WRAP $32.00
A9284 NON-ELECTRONIC SPIROMETER $254.00
A9579 GAD-BASE MR CONTRAST NOS,1ML $15.00
C9399 ORBACTIV 1200 MG IV $10,153.00
CASH XRAY DISC $17.00
E0110 CRUTCH FOREARM PAIR $225.00
E0114 CRUTCHES UNDERARM $59.00
E0116 CRTCH UNDARM NOT WOOD ADJ $59.00
E0220 HOT WATER BOTTLE $35.00
E0230 ICE CAP OR COLLAR $12.00
E0275 BED PAN STANDARD $11.00
E0325 URINAL MALE JUG-TYPE $7.00
E0352 DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) $177.00
E04114 E04114 $41.00
E0445 OXIMETER NON-INVASIVE $578.00
E0570 NEBULIZER WITH COMPRESSION $677.00
E0580 NEBULIZER FOR USE W/ REGULAT $293.00
G0009 ADM PNEUMOCOCCAL VACCINE $90.00
G0168 WND CLS TISSUE ADHESIVE $152.00
G0378 HOSPITAL OBSERVATION SERVICES PER HOUR $2,000.00
G0434 DRUG ABUSE PANEL II $230.00
G2023 COVID-19 Testing specimen collection for severe acute respi… $30.00
J0120 TETRACYCLIN INJECTION $30.00
J0129 ABATACEPT INJECTION $25.00
J0131 INJECTION, ACETAMINOPHEN, 10 MG $3.00
J0150 ADENOSINE INJ 6MG VIAL $65.00
J0153 ADENOSINE INJ 1MG $8.00
J0170 EPINEPHRINE 3 1/2 NDL 10M $8.00
J0171 ADRENALIN EPINEPHRINE INJECT $23.00
J0210 METHYLDOPATE HCL INJECTION $40.00
J0282 INJ AMIODARONE HYDROCHLOR $13.00
J0290 AMPICILLIN 500 MG INJ $22.00
J0295 INJ AMPCLLN SODIUM/SULBA $20.00
J0330 SUCCINYLCHOLINE CHLO 20MG $173.00
J0360 HYDRALAZINE HCL INJ UP TO 20MG $173.00
J0456 INJ AZITHROMYCIN 500MG $81.00
J0461 INJ ATROPINE SULFATE 0.01 $1.00
J0500 DICYCLOMINE HCL 20MG $22.00
J0550 BICILLIN – PENICILLIN G BENZATHINE INJ $65.00
J0558 PENG BENZATHINE/PROCAINE INJ $90.00
J0559 BICILLIN – PENICILLIN G BENZATHINE INJ 2500 UNITS $65.00
J0560 BICILLIN 600,000 $50.00
J0561 INJECTION PENICILLIN G BENZATHINE 100,000 UNITS $55.00
J0570 BICILLIN 1,200,000 $110.00
J0595 STADOL $13.00
J0610 CALCIUM GLUCONATE INJECTION $79.80
J0641 LEVOLEUCOVORIN INJECTION $2.00
J0690 KEFZOL 1 GR VIAL $22.00
J0692 INJ CEFEPIME HCI 500MG $46.00
J0696 ROCEPHIN 250 MG $52.00
J0697 STERILE CEFUROXIME INJECTION $25.00
J0698 CLAFORAN 1 GR VIAL $63.00
J0735 CLONIDINE 1MG $8.00
J0744 CIPRO 200MG $176.00
J0760 COLCHICINE INJECTION $23.00
J0780 COMPAZINE 10 MG $12.00
J1020 INJ METHYLPREDNISOLONE AC $2.00
J1030 DEPO MEDROL 40 MG/ML $75.64
J1040 METHYLPREDNISOLONE 80MG $10.00
J1094 DECADRON DEXAMETHASONE ACETATE 1MG $22.00
J1100 DECADRON 4 MG VIAL $22.00
J1110 INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG $70.00
J1165 DILANTIN 100 MG VIAL $41.00
J1170 DILAUDID 4 MG $41.00
J1200 BENADRYL 50MG $22.00
J1240 ANTIVERT – DIMENHYDRINATE INJECTION 50MG $33.00
J1335 ERTAPENEM INJECTION $21.00
J1580 GARAMYCIN,GENTAMICIN 80MG $50.00
J1610 GLUCOGAN 1 MG VIAL $68.00
J1630 HALOPERIDOL INJECTION $39.70
J1631 HALOPERIDOL DECANOATE INJ PER 50 MG $83.00
J1642 HEPARIN SODIUM PER 10 UNI $13.00
J1644 INJ HEPARIN SOD PER 1000 $87.00
J1650 ENOXAPARIN SODIUM 10MG $37.00
J1670 TETANUS INJECTION $41.00
J1741 IBUPROFEN INJECTION $22.00
J1810 DROPERIDOL/FENTANYL INJ $25.00
J1815 INJ INSULIN PER 5 UNITS $31.00
J1817 INSULIN FOR INSULIN PUMP USE $22.00
J1885 TORADOL INJ 15 MG $22.00
J1930 LANREOTIDE INJECTION $45.00
J1940 LASIX 40 MG IV VIAL $22.00
J1956 LEVOFLOXACIN 250 MG $120.00
J2001 LIDOCAINE HCI 10MG $31.00
J2060 ATIVAN 2ML SYRUP $100.00
J2150 MANNITOL INJECTION $26.00
J2175 DEMEROL 50 MG SYRINGE $28.00
J2180 MEPERIDINE/PROMETHAZINE INJ $30.00
J2250 MIDAZOLAM HCI PER 1 MG $11.00
J2270 INJ MORPHINE SULFATE 10 M $22.00
J2274 INJ MORPHINE PF EPID ITHC $30.00
J2300 NUBAIN 10MG AMP $50.00
J2310 INJ NALOXONE HCL 1MG $30.00
J2360 ORPHENADRINE CITRATE 60MG $122.00
J2370 NEO-SYNEPHRINE UP TO 1 ML $81.00
J2405 ONDANSETRON HCI, PER MG $22.00
J2410 OXYMORPHONE HCL INJECTION $25.00
J2425 PALIFERMIN INJECTION $25.00
J2504 PEGADEMASE BOVINE, 25 IU $25.00
J2543 ZOSYN – PIPERACILLIN/TAZOBACTAM $59.00
J2550 PHENERGAN 50 MG $22.00
J2650 PRELONE – INJECTION PREDNISOLONE ACTATE UP TO 1 ML $6.00
J2690 PRONESTYL 10 ML $22.00
J2704 INJECTION PROPOFOL 10 MG $32.00
J2730 PRALIDOXINE CHLORIDE $22.00
J2760 PHENTOLAINE MESYLATE INJ $41.00
J2765 METOCLOPRAMIDE HCL 10MG $1.99
J2780 INJ RANITIDINE 25 MG $37.00
J2790 RHOGAM INJECTION $199.00
J2800 METHOCARBAMOL INJECTION $50.00
J2920 SOLU-MEDROL 40MG $10.00
J2930 SOLU-MEDROL 125 MG $15.00
J3010 INJ FENTANYL CITRATE .1MG $1.00
J3030 IMITREX 6MG VIAL $216.41
J3105 INJECTION, TREBUTALINE SULFATE, UP TO 1 MG $35.00
J3130 TESTOSTERONE ENANTHATE INJ $24.00
J3230 THOROZINE 50 MG $330.00
J3260 TOBRAMYCIN SULFATE INJECTION $36.00
J3360 VALIUM INJ 5 MG $10.00
J3370 VANCOMYCIN HCI INJ 500MG $229.00
J3410 VISTERIL INJ 50 MG $22.00
J3411 INJ THIAMINE 100 MG $11.00
J3430 INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG $12.00
J3475 MAGNESIUM SULFATE 2CC AMP $25.00
J3480 POTASSIUM CHLORIDE 2 MG $1.99
J3486 GEODON – ZIPRASIDONE MESYLATE 10MG $35.00
J3490 UNCLASSIFIED DRUGS $36.00
J7030 INFUS NORM SALINE 1000CC $53.00
J7040 INFUS NORM SALINE 500ML $26.00
J7042 5% DEXTROSE $26.00
J7050 INFS NORM SALINE 250CC $26.00
J7060 INFUSION D5W 250ML $28.00
J7070 INFUSION D5W 1000ML $86.00
J7120 RINGER’S LACTATE INFUS $90.00
J7121 5% DEXTROSE IN LAC RINGERS $65.27
J7130 HYPERTONIC SALINE SOLUTION $76.00
J7131 HYPERTONIC SALINE SOL $61.74
J7192 FACTOR VIII RECOMBINANT NOS $20.00
J7313 FLUOCINOL ACET INTRAVIT IMP $20.00
J7506 PREDNISONE ORAL 5 MG $8.00
J7510 PREDNISOLONE ORAL 5 MG $8.00
J7512 PREDNISONE 5 MG $8.00
J7607 LEVALBUTEROL COMP CON $13.00
J7610 ALBUTEROL, THRU DME 1MG $13.00
J7611 ALBUTEROL 1MG CONC INHALA $13.00
J7613 ALBUT INHAL NON-CP 1MG $13.00
J7614 ALBUTEROL ALL FOMULATIONS $20.00
J7615 LEVALBTERAL INHALATION SO $20.00
J7620 ALBUTEROL 2.5 MG ATROVENT $13.00
J7631 CROMOLYN SODIUM NONCOMP UNIT $20.00
J7637 DEXAMETHASONE COMP CON $20.00
J7644 IPRATROPIUM BROMIDE INHAL $31.00
J7682 TOBRAMYCIN NON-COMP UNIT $25.00
J7699 NOC DRUGS INHAL SOL ADMIN $8.00
J8498 ENEMA SUPPOSITORY, ANTIEMETIC RECTAL $31.00
J8499 NONCHEMOTHERAPEUTIC ORAL $17.00
J8540 DEXAMETHASONE, ORAL .25MG $20.00
J9027 CLOFARALINE INJECTION $141.00
J9206 IRINOTECAN INJECTION $25.00
L0120 CERVICAL FLEX NONADJ COLL $320.00
L0172 CLAVICAL COLLAR 2 PC $41.00
L1630 ABDUCT CONTROL HIP SEMI FLEX $41.00
L1830 KNEE IMMOBOLIZER $24.00
L1906 ANKLE SUPPORT $133.00
L3260 SURGICAL BOOT/SHOE $87.00
L3650 SO FIGURE EIGHT ABDUCTION $251.00
L3670 SO ACROMIO/CLAVICULAR $113.00
L3908 WRIST EXTN CONTROL COCKUP $87.00
L3999 UPPER LIMB ORTHOSIS NOS $176.00
L4350 AIR SPLINT $453.00
L4360 WALK BOOT PNEUMATIC $117.00
L4380 PNEUMATIC KNEE SPLINT $125.00
L4386 WALKING BOOT NON PNEUMATIC $168.00
L4387 NON-PNEUM WALK BOOT PRE OTS $250.00
P7001 CULTURE BACTERIAL URINE $89.00
P9612 CATHETERIZE FOR URINE $177.00
Q0144 AZITH DIHY ORAL CAP/POWD $161.00
Q0179 ONDANESTRONG HCL 8MG ORL $4.00
Q4006 LONG ARM CAST ADULT $92.00
Q4007 CAST SUPPLIES LONG ARM CA $15.00
Q4008 CAST SUPPLIES LONG ARM $40.00
Q4009 CAST SUPPLIES SHORT ARM $140.00
Q4010 SHORT ARM CAST ADULT $55.00
Q4012 CAST SUPPLIES SHORT ARM $87.00
Q4020 LNG ARM SPLNT 0-10 YRS $39.00
Q4022 SHRT ARM SPLNT 11 YRS + $805.00
Q4034 CAST SUP LNG LEG CYLINDER FB $176.00
Q4037 CAST SUPPLIES SHORT LEG $146.00
Q4038 CAST SUP SHRT LEG FIBERGLASS $24.00
Q4039 CAST SUPPLIES SHORT LEG C $146.00
Q4042 LNG ARM SPLNT 11 YRS + $117.00
Q4046 SHRT LG SPLNT 11 YRS + $249.00
Q4049 FINGER SPLNT STATIC $206.00
Q4051 SPLINT SUPPLIES MISC $125.00
Q9954 ORAL MR CONTRAST, 100ML $416.00
Q9963 HI OSM CONTRST MATL 350-3 $23.00
Q9965 LOW OSMOLAR CON MAT PER M $25.00
Q9966 LOCM 200-299MG ML IODINE, 1ML $22.00
Q9967 LOW OSMOLAR CNTRS MAT $20.00
S0020 INJ, BUPIVICAINE, 30ML $46.00
S0028 INJECT FAMOTIDINE 20 MG $70.00
S0030 METRONIDAZOLE 500 MG INJ $188.00
S0077 CLANDAMYCIN PHOSPHATE 300 $32.00
S0119 ZOFRAN, 4MG, ORAL $8.00
S0164 PROTONIX PANTROPRAZOLE 40MG $194.00
S0622 PHYS EXAM FOR COLLEGE $87.00
S0630 RMV SUTURES; PHYS NOT PHY $65.00
S3000 BILAT DIL RETINAL EXAM $11.00
S5000 PRESCRIPTION DRUG GENERIC $1.00
S5001 PRESCRIPTION DRUG BAND NM $8.00
S5010 STERILE SALINE 5% DEXTROSE AND 0.45% SALINE $232.00
S5011 5% DEXTROSE 1000 ML $1.00
S5550 INSULIN RAPID 5 U $26.00
S8037 MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY $1,284.00
S8100 SPACER WITHOUT MASK $52.00
S8101 MASK NEBULIZER MASK SPACER WITH MASK $59.00
S8450 SPLINT $84.00
U0002 COVID-19 PCR Testing $301.00