| CPT Code |
CPT Code Description |
Charge Amount |
| 0202U | COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing | $3,071.59 |
| 0240U | Infectious disease (viral respiratory tract infection), pat… | $1,385.84 |
| 0241U | Infectious disease (viral respiratory tract infection), pat… | $1,266.75 |
| 10021 | FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE | $3,336.10 |
| 10060 | INCISION/DRAINAGE ABSCESS | $1,828.00 |
| 10061 | INS/DRAIN ABSCESS COMPL | $4,538.00 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $1,530.00 |
| 10081 | I&D PILONIDAL CST COMP | $6,644.71 |
| 10120 | I & RMVL SUB-CUT SIMPLE | $3,454.67 |
| 10121 | I & RMVL FB, SUB-CUT,COMP | $24,158.89 |
| 10140 | I&D HEMATOMA SEROMA/FLUID COLLECTION | $22,973.00 |
| 10160 | PUNCTURE ASP OF ABSCESS | $1,424.00 |
| 10180 | Incision and drainage, complex, postoperative wound infecti… | $23,343.00 |
| 11000 | DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF | $29,391.88 |
| 11010 | DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS | $15,400.00 |
| 11011 | DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC | $23,707.83 |
| 11042 | DBRD SKN SUBQ TISSUE | $5,033.92 |
| 11043 | DEBRIDEMENT SUBCUTANEOUS TISSUE&MUSCLE | $8,119.72 |
| 11045 | Deb subq tissue add-on | $12,378.25 |
| 11055 | PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 | $9,250.91 |
| 11200 | RMVL SKIN TAGS | $10,567.27 |
| 11402 | EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM | $8,847.27 |
| 11403 | EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM | $10,099.26 |
| 11404 | EXC BGN LSN TRUNK 3.1-4.0 | $10,354.64 |
| 11406 | EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM | $16,666.00 |
| 11420 | EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< | $12,089.00 |
| 11421 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM | $19,406.21 |
| 11422 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM | $12,128.00 |
| 11423 | EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM | $10,284.09 |
| 11440 | Excision, other benign lesion including margins, except ski… | $5,536.00 |
| 11441 | EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM | $6,014.00 |
| 11443 | EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM | $18,258.92 |
| 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $517.99 |
| 11730 | AVULSION/1-NAIL PLATE | $2,794.98 |
| 11732 | AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL | $1,166.24 |
| 11740 | EVAC SUBUNGUAL HEMATOMA | $671.00 |
| 11750 | EXC NAIL PART/COMP | $8,288.00 |
| 11760 | REPAIR NAIL BED | $9,302.00 |
| 11765 | WEDGE EXC SKIN/NAIL BED | $1,539.00 |
| 11771 | EXCISION PILONIDAL CYST SINUS EXTENSIVE | $20,623.00 |
| 11900 | Injection, intralesional; up to and including 7 lesions | $9,483.13 |
| 11982 | REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT | $3,885.00 |
| 12001 | LACERATION REPAIR | $1,228.00 |
| 12002 | REPAIR LAC SCALP 2.6-7.5 | $1,322.00 |
| 12004 | REPAIR LAC SCALP 7.6-12.5 | $1,395.00 |
| 12005 | REPAIR LAC,SCALP 12.6-20C | $3,438.00 |
| 12006 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM | $2,232.00 |
| 12007 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM | $2,913.00 |
| 12011 | REPAIR LAC FACE LESS THAN 2.5 CM | $1,227.00 |
| 12013 | REPAIR LAC FACE 2.6-5.0CM | $1,322.00 |
| 12014 | REPAIR LAC FACE 5.1-7.5CM | $1,622.00 |
| 12015 | SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM | $1,879.00 |
| 12016 | SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0CM | $2,384.00 |
| 12017 | SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0CM | $3,935.00 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $7,687.00 |
| 12031 | LYR CLSR S/A/T/E 2.5CM | $4,936.00 |
| 12032 | REPAIR-INT SCALP 2.6-7.5 | $3,215.00 |
| 12034 | INTERM RPR SCLP/TRNK/EXTR | $4,487.40 |
| 12035 | REPAIR INTERM S/A/T/E 12. | $4,509.00 |
| 12036 | REPAIR INTERM S/A/T/E 20.1-30.0 CM | $8,457.00 |
| 12037 | REPAIR INTERMEDIATE S/A/T/E > 30.0 CM | $16,421.00 |
| 12041 | LAYER CLSR NECK/HAND 2.6 | $3,720.00 |
| 12042 | REPAIR LAC HAND/FOOT 2.6- | $3,216.64 |
| 12044 | LYR CLSR N/H/F/ETRNL GENT | $5,507.00 |
| 12045 | REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM | $4,388.00 |
| 12051 | LAYER CLSR OF WND NCK/HND | $1,951.00 |
| 12052 | LYR CLSR WOUND 2.6-5.0FAC | $1,692.00 |
| 12053 | LYR CLSR F/E/E/N/L/M&/MUC | $2,509.00 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM | $3,006.00 |
| 12055 | REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM | $3,152.00 |
| 13101 | REPAIR COMPLEX TRUNK 2.6 CM-7.5 CM | $7,717.00 |
| 13102 | REPAIR COMPLEX TRUNK EA 5 CM/< | $8,771.81 |
| 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $6,210.00 |
| 13121 | RPR CMPX SCALP ARM2.6-7.5 | $5,463.00 |
| 13122 | CMPLX RPR ADD 5 CM OR LES | $4,533.15 |
| 13131 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1 CM-2.5 CM | $3,247.00 |
| 13132 | RPR CMPX FOREHEAD/CHECK/C | $4,515.00 |
| 13133 | Repair, complex, forehead, cheeks, chin, mouth, neck, axill… | $3,175.00 |
| 13151 | CMPX RPR EYE NOSE 1.1-2.5 | $4,687.00 |
| 13152 | RPR CPLX E/N/E/L 2.6-7.5 | $5,861.63 |
| 15851 | REMOVAL SUTR/STAPLE REQ ANES | $15,609.64 |
| 15853 | REMOVAL SUTR/STAPL XREQ ANES | $106.00 |
| 16000 | BURN, INITIAL TREATMENT | $1,869.00 |
| 16020 | BURN, DRESSING/DBRDMNT-SM | $1,891.00 |
| 16025 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM | $2,042.00 |
| 17000 | DESTRUCTION PREMALIGNANT LESION 1ST | $1,443.04 |
| 17110 | DESTRUCTION BENIGN LESIONS UP TO 14 | $39,187.40 |
| 17250 | UMBILICAL CAUTERIZATION | $1,028.04 |
| 19000 | PUNCTURE ASPIRATION CYST BREAST | $2,989.48 |
| 19020 | MASTOTOMY W/EXPL/DRAINAGE ABSCESS DEEP | $23,189.00 |
| 20102 | EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK | $30,841.00 |
| 20103 | EXPLORATION PENETRATING WOUND SPX EXTREMITY | $18,002.36 |
| 20520 | REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE | $26,006.72 |
| 20525 | RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP | $22,020.07 |
| 20550 | INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS | $9,213.93 |
| 20551 | INJ TENDON ORIGIN/INSERTION | $4,413.64 |
| 20552 | TRIGGER POINT INJ 1-2 MUS | $8,642.39 |
| 20553 | Injection(s); single or multiple trigger point(s), 3 or mor… | $14,786.97 |
| 20600 | ARTHROCENTESIS, SML JOINT | $10,824.00 |
| 20605 | ARTHROCENTESIS, MED JOINT | $3,778.76 |
| 20610 | ARTHROCENTESIS, LG JOINT | $5,655.00 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $6,836.37 |
| 20612 | Aspiration and/or injection of ganglion cyst any location | $11,167.94 |
| 21315 | CLOSED TX NASAL FRACTURE W/O STABILIZATION | $14,760.00 |
| 21320 | Closed treatment of nasal bone fracture; with stabilization | $10,976.00 |
| 21337 | CLOSED TX NASAL SEPTAL FRACTURE +-STABILIZATION | $42,751.83 |
| 21451 | Treat lower jaw fracture | $20,142.00 |
| 21480 | CLDS TX TEMP DISLOCATION | $2,243.03 |
| 21501 | I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX | $27,512.00 |
| 23075 | EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM | $14,178.81 |
| 23505 | CLSD TX CLAVICULAR FRACTURE W/MANIPULATION | $13,049.00 |
| 23545 | CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION | $2,869.79 |
| 23550 | OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC | $34,448.88 |
| 23600 | CLTX PROX HUMRL FX WO MAN | $3,862.01 |
| 23605 | CLTX PRX HMRL FX MNPJ+-TRACT | $11,421.00 |
| 23620 | CLTX GREATER HUMERAL TUBEROSITY FX W/O MNPJ | $9,267.30 |
| 23650 | SHOULDER DISLOCATION TRMT | $2,413.00 |
| 23655 | Closed treatment of shoulder dislocation, with manipulation… | $5,906.35 |
| 23665 | CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ | $7,211.00 |
| 23930 | I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA | $24,680.00 |
| 24075 | EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM | $8,987.00 |
| 24200 | RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS | $11,276.00 |
| 24357 | repair, revision, or reconstruction of the upper arm and el… | $15,438.00 |
| 24500 | CLTX HUMRL SHFT FX W/O MN | $2,278.00 |
| 24505 | CLTX HUMERAL SHFT FX W/MANIPULATION +-SKEL TRACJ | $5,393.00 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYL | $17,780.87 |
| 24535 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MNPJ | $9,172.00 |
| 24586 | Open treatment of periarticular fracture and/or dislocation… | $66,817.00 |
| 24600 | CLSD TX ELBOW DISLOCAT | $2,233.00 |
| 24605 | Treatment of closed elbow dislocation; requiring anesthesia | $9,582.00 |
| 24615 | OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION | $24,671.00 |
| 24620 | CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MNPJ | $7,262.00 |
| 24640 | RADIAL HEAD SUBLUX. CHILD | $1,671.00 |
| 24650 | CLTX RDL HEAD FX WO MANP | $2,624.33 |
| 24655 | CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION | $7,081.54 |
| 24675 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ | $7,616.00 |
| 25028 | Drainage of forearm lesion | $15,990.00 |
| 25111 | Excision of Ganglion, wrist (dorsal or volar); primary | $19,964.10 |
| 25505 | CLSD TX RAD SHAFT W/MANIP | $6,206.00 |
| 25520 | CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT | $7,575.00 |
| 25530 | CLSD TX ULNAR SHFT FX NO | $2,325.00 |
| 25535 | CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION | $6,932.00 |
| 25560 | CLTX RDL&UR SHFT FXS W/O | $3,670.83 |
| 25565 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MNPJ | $14,318.06 |
| 25574 | OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA | $33,613.00 |
| 25600 | CLSD TX DISTAL RAD FX WO | $2,436.00 |
| 25605 | CLSD TX DISTAL RAD FX | $3,030.00 |
| 25607 | Open treatment of distal radial extra-articular fracture or… | $32,920.00 |
| 25650 | CLTX UR SYLOID FX | $3,039.00 |
| 25652 | OPEN TREATMENT ULNAR STYLOID FRACTURE | $27,558.46 |
| 25660 | Closed treatment of radiocarpal or intercarpal dislocation,… | $3,014.30 |
| 25675 | CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH MANI… | $3,416.00 |
| 25690 | Closed treatment of lunate dislocation, with manipulation | $21,075.68 |
| 26010 | I & D FINGER ABSCESS,SIMP | $1,071.00 |
| 26011 | DRAINAGE OF FINGER ABCESS | $13,036.00 |
| 26567 | Osteotomy; phalanx of finger, each | $51,110.59 |
| 26600 | CLSD TX METACARPAL FX | $2,494.68 |
| 26605 | CLSD TX MEDICARPAL FX | $3,035.00 |
| 26615 | OPEN TX METACARPAL FRACTURE SINGLE EA BONE | $29,042.00 |
| 26641 | Closed treatment of carpometacarpal dislocation, thumb, wit… | $2,914.00 |
| 26700 | CLS TX MCP DISLOCATION | $2,511.00 |
| 26720 | CLSD TX PHALANGEAL SHFTFX | $2,356.28 |
| 26725 | CLTX PHLNGL FX PROX/MIDDL | $2,772.01 |
| 26735 | OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA | $33,542.08 |
| 26742 | CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ | $7,171.00 |
| 26746 | OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA | $21,997.63 |
| 26750 | CLS TX FX FINGER/THUMB | $2,183.36 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/ | $2,193.00 |
| 26765 | OPEN TX DISTAL PHALANGEAL FRACTURE EACH | $17,662.19 |
| 26770 | TREAT FINGER DISLOC FINGE | $1,771.00 |
| 26775 | Closed treatment of interphalangeal joint dislocation, sing… | $11,629.66 |
| 26952 | AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP | $26,158.00 |
| 27096 | INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA | $9,281.94 |
| 27301 | Drain thigh/knee lesion | $30,416.76 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $25,595.00 |
| 27502 | CLTX FEM SHFT FX W/MNPJ +-SKN/SKEL TRACJ | $11,865.00 |
| 27508 | CLTX FEM FX DSTAL END MED | $6,818.14 |
| 27520 | CLTX PATELLAR FX W/O MNPJ | $34,891.32 |
| 27530 | CLTX TIBL FX PROX W/O MNPJ | $8,846.40 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $2,461.00 |
| 27560 | CLTX PATELLAR DISLC W/O A | $2,534.53 |
| 27750 | CLTX TIBL SHFT FX W/O MNPJ | $3,134.00 |
| 27752 | CLTX TIBL SFT FX W/MANP | $8,616.00 |
| 27762 | CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ | $7,524.00 |
| 27786 | CLSD TX DISTAL FIBULAR FX | $9,858.49 |
| 27788 | CLTX DSTL FIBULAR FX LAT MALLS W/MANJ | $3,327.00 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $26,336.00 |
| 27810 | CLTX BIMAL ANKLE FX W/POT | $5,255.00 |
| 27818 | Treatment of ankle fracture | $4,165.00 |
| 27840 | CLOSED TX ANKLE DISLOCATI | $3,361.00 |
| 27842 | Closed treatment of ankle dislocation; requiring anesthesia… | $16,253.00 |
| 28001 | INCISION&DRAINAGE BURSA FOOT | $10,644.00 |
| 28190 | RMVL FB BODY FOOT SUBQ | $7,325.00 |
| 28192 | RMVL FB FOOT DEEP | $22,795.00 |
| 28450 | TX TARSAL B1 FX XCP TALUS | $13,933.89 |
| 28470 | CLTX METAR FX WO MNP | $4,486.03 |
| 28475 | Treat metatarsal fracture | $12,213.03 |
| 28495 | CLTX FX GRT TOE PHLX/PHLG W/MNPJ | $2,871.83 |
| 28505 | OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES | $21,040.00 |
| 28515 | FX CARE PHALANX NOT GREAT | $2,517.00 |
| 28630 | CLTX METATARSOPHLNGL JT DISLC W/O ANES | $1,918.00 |
| 28635 | Closed treatment of metatarsophalangeal joint dislocation; … | $22,576.85 |
| 28660 | CLSD TX PIP JNT DISLOCATI | $1,779.43 |
| 29065 | Application, cast; shoulder to hand (long arm) | $1,220.17 |
| 29075 | APPLICATION CAST ELBOW FINGER SHORT ARM | $1,030.00 |
| 29086 | APPLICATION CAST FINGER | $9,768.79 |
| 29105 | LONG ARM SPLINT | $979.00 |
| 29125 | SHORT ARM SPLINT | $968.41 |
| 29130 | APPLICATION FINGER SPLINT | $735.00 |
| 29240 | STRPG SHO | $851.00 |
| 29405 | Application of short leg cast (below knee to toes) | $1,800.76 |
| 29505 | LONG LEG SPLINT | $1,367.00 |
| 29515 | SHORT LEG SPLINT | $1,372.85 |
| 29550 | STRAPPING TOES | $893.00 |
| 29580 | STRAPPING UNNA BOOT | $1,476.36 |
| 30300 | RMVL FOREIGN BODY NASAL | $744.84 |
| 30802 | ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL | $15,578.86 |
| 30901 | NASAL PACKING | $1,312.00 |
| 30903 | CTRL NSL HEMRRG ANT CPLX | $2,044.42 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $2,027.55 |
| 30906 | Cntrl nasal hemorrhage, posterior,w/ posterior nasal packs … | $2,083.18 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,500.88 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $2,075.00 |
| 31541 | LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP | $24,103.97 |
| 31575 | LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC | $2,380.24 |
| 32550 | INSERT PLEURAL CATH | $21,791.71 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $7,185.00 |
| 32556 | Pleural drainage, percutaneous, with insertion of indwellin… | $10,999.00 |
| 36000 | INTRODUCTION OF NEEDLE/IN | $417.90 |
| 36005 | NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH | $8,659.00 |
| 36010 | INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA | $6,462.82 |
| 36011 | SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH | $11,641.61 |
| 36410 | VENIPUNCTURE, 3 YRS OR OLDER | $4,346.44 |
| 36415 | VENIPUNCTURE | $85.16 |
| 36416 | COLL CAPILLARY BLG SPEC | $70.65 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $7,580.84 |
| 36558 | INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR | $23,422.00 |
| 36569 | IV cather | $9,400.43 |
| 36589 | RMVL TUN CVC W/O SUBQ PORT/PMP | $10,342.00 |
| 36591 | COLLECT BLOOD FROM IMPLAN | $874.68 |
| 36592 | Collect blood from picc | $634.47 |
| 36680 | Placement of needle for intraosseous infusion | $1,173.00 |
| 37785 | LIGATION, DIVISION, ANDOR EXCISION OF VARICOSE VEIN CLUSTERS | $25,826.96 |
| 38300 | DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL | $12,127.00 |
| 40650 | RPR LIP FULL THICKNESS | $5,409.00 |
| 40800 | DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL | $3,524.00 |
| 40804 | RMVL EMBEDDED FB VESTIBULE MOUTH SMPL | $4,187.00 |
| 40830 | Closure of laceration, vestibule of mouth; 2.5 cm or less | $1,782.00 |
| 41008 | Intraoral incision and drainage of abscess, cyst, or hemato… | $14,979.00 |
| 41250 | REPAIR TONGUE LACERATION | $1,706.00 |
| 41252 | Repair Procedures on the Tongue and Floor of Mouth | $4,055.00 |
| 41800 | DRNG ABSC DENTOALVEOLAR S | $1,664.00 |
| 41899 | Unlisted procedure, dentoalveolar structures | $16,397.04 |
| 42700 | I&D ABSC PRITONSILLAR | $3,129.00 |
| 42809 | Remove pharynx foreign body | $1,918.00 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $2,384.64 |
| 43753 | GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … | $1,043.00 |
| 45900 | Manipulation Procedures on the Colon and Rectum | $8,051.00 |
| 45915 | RMVL FECAL IMPACTION/FB SPX UNDER ANES | $17,587.00 |
| 46040 | I&D ISCHIOR/PRIRC ABSC SP | $19,170.00 |
| 46050 | INC/DRAIN PERIANAL ABS SU | $12,169.00 |
| 46083 | INCISION THROM HEMORRHOID | $4,349.20 |
| 46320 | ENULEATION EXCC OF EXT HE | $14,637.42 |
| 49083 | Abdominal paracentesis (diagnostic or therapeutic); w/ imag… | $7,268.00 |
| 49505 | Prp i/hern init reduc >5 yr | $25,487.00 |
| 51700 | BLDR IRR SMPL LVG&/INSTLJ | $1,852.00 |
| 51701 | INSR NONDWELLING BLDR CAT | $1,311.77 |
| 51702 | INSERTION BLADDER CATH | $829.76 |
| 51703 | INSERT BLADDER CATH COMPL | $1,130.42 |
| 54001 | SLITTING PREPUCE DORSAL/LAT SPX XCP NB | $18,664.00 |
| 54220 | IRRIGATION CORPORA CAVERNOSA PRIAPISM | $2,473.00 |
| 54450 | FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING | $4,062.00 |
| 55100 | DRAINAGE SCROTAL WALL ABSCESS | $10,664.00 |
| 55175 | Scrotoplasty; simple | $32,517.30 |
| 56405 | INC/DRAIN VULVA/PERINEAL | $5,172.05 |
| 56420 | I & D BARTHOLIN ABSCESS | $2,329.00 |
| 57410 | Pelvic examination | $19,468.00 |
| 57415 | REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL | $14,917.00 |
| 58301 | REMOVAL INTRAUTERINE DEVICE IUD | $17,981.00 |
| 59025 | FTL NON-STRS TST | $2,049.78 |
| 62270 | SPINAL PUNCTURE,LUMBAR | $2,672.00 |
| 62272 | Drain cerebro spinal fluid | $6,887.00 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $2,597.18 |
| 64405 | N BLOCK INJ OCCIPITAL | $3,995.00 |
| 64415 | N block inj brachial plexus | $6,291.19 |
| 64447 | INJECTION ANESTHETIC AGENT FEMORAL NERVE SINGLE | $10,149.94 |
| 64450 | INJ ANESTHETIC AGENT | $3,991.21 |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular… | $9,723.13 |
| 64455 | Inj, anesthetic agent a/o steroid, plantar common digital n… | $9,166.70 |
| 64640 | DSTRJ NULYT OTH PRPH NVR/BRANCH | $9,922.90 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $1,289.00 |
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $1,752.00 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $2,050.00 |
| 65222 | RMVL FB EYE | $1,699.00 |
| 67938 | Removal of embedded foreign body, eyelid | $2,365.00 |
| 69000 | Drainage external ear | $3,571.00 |
| 69200 | RMVL FOREIGN BODY EAR | $930.70 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $10,603.00 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL | $924.00 |
| 69210 | RMVL IMPACTED CERUMEN | $2,521.64 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $2,260.80 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $1,955.82 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $1,520.00 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $1,515.02 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $2,214.19 |
| 70160 | Radiologic examination, nasal bones, complete, minimum of 3… | $1,437.91 |
| 70200 | RAD EXAM ORBIT COMP. | $2,371.28 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $1,393.00 |
| 70220 | RAD EXAM SINUS COMPLETE | $2,387.42 |
| 70250 | SKULL LESS THAN 4 VIEWS | $2,225.09 |
| 70260 | RAD EXAM SKULL COMPLETE | $2,295.49 |
| 70328 | RADEX TMPRMAND JT OPN&CLSD MOUTH UNI | $1,018.00 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $2,481.51 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $1,205.47 |
| 70450 | COMPUTED TOMOGRAPHY HD/BR | $6,595.57 |
| 70460 | TOMOGRAPHY HEAD/BRAIN WIT | $7,235.10 |
| 70470 | COMPUTED TOMOGRAPHY HEAD/ | $7,556.60 |
| 70480 | CT ORBIT SELLA/POST FOSSA | $5,483.30 |
| 70481 | CT ORBIT SELLA/POST FOSSA | $8,041.72 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $8,906.00 |
| 70486 | CT MAXLFCL AREA C-MATRL | $6,896.66 |
| 70487 | CT MAXLFCL AREA C+ MATRL | $8,126.16 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $8,172.70 |
| 70490 | CT NECK WO CONTRAST | $6,793.15 |
| 70491 | CT SOFT TISS NCK C+MATRL | $8,525.95 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $8,750.12 |
| 70496 | CTA HEAD C-/C+ | $7,787.42 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $7,683.28 |
| 70544 | MRA HEAD C-MATRL | $6,715.92 |
| 70547 | MRA NECK C-MATRL | $7,934.75 |
| 70551 | MRI BRN BRN STEM C-MATRL | $7,116.97 |
| 70553 | MRI BRN BRN STEM C-/C+ | $12,214.02 |
| 71045 | Radiologic examination, chest ; single view | $1,491.00 |
| 71046 | CHEST XRAY 2 VIEWS | $1,734.00 |
| 71047 | Radiologic examination, chest ; 3 views | $1,888.77 |
| 71048 | (Radiologic examination, chest ; 4 or more | $3,120.14 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $1,876.79 |
| 71101 | RIB UNILATERAL W CHEST | $1,874.08 |
| 71110 | RIBS BILATERAL 3 VIEWS | $3,658.29 |
| 71111 | RIBS BILATERAL W/CHEST | $2,915.73 |
| 71120 | Radiologic examination; sternum, minimum of 2 views | $1,395.88 |
| 71250 | CT CHEST W/O CONTRAST | $6,077.93 |
| 71260 | CT THORAX W/CONTRAST | $7,871.28 |
| 71270 | CT THORAX WO CONTRAST | $7,397.54 |
| 71271 | CT THORAX LUNG CANCER SCR C- | $4,861.07 |
| 71275 | CT ANGIOGRAPHY | $8,359.09 |
| 71550 | MRI CH C-MATRL | $7,978.00 |
| 72020 | Radiologic examination, spine, single view, specify level | $1,572.59 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $1,743.76 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $2,478.15 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $3,048.74 |
| 72070 | SPINE THORACIC 2 VIEWS | $2,032.13 |
| 72072 | SPINE THORACIC 3 VIEWS | $2,194.65 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $2,604.82 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $1,712.44 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $2,721.92 |
| 72100 | Radiologic examination, spine, lumbosacral; 2 or 3 views | $1,946.68 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $3,107.07 |
| 72114 | RAD EXAM SPINE LUMBO COMP | $3,078.37 |
| 72120 | SPINE LUMBAR AP & LAT W F | $2,352.60 |
| 72125 | COMPUTED TOMOGRAPHY CERVI | $6,662.40 |
| 72126 | CT CRV SPI C+MATRL | $7,210.38 |
| 72127 | CT CRV SPI C-/C+ | $13,362.97 |
| 72128 | CT THRC SPI C-MATRL | $9,202.66 |
| 72129 | CT THRC SPI C+ MATRL | $8,993.24 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $9,704.61 |
| 72131 | CT L SPINE WO CONTRST | $8,660.12 |
| 72132 | CT LMBR SPI C+ MATRL | $7,453.39 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $10,575.62 |
| 72141 | MRI SPI CANAL&CNTS CRV C-MATRL | $9,140.27 |
| 72146 | MRI SPI CANAL&CNTS THRC C-MATRL | $8,142.64 |
| 72148 | MRI SPI CANAL&CNTS LMBR C-MATRL | $9,606.13 |
| 72156 | MRI SPI CANAL&CNTS C-/C+ CRV | $13,001.35 |
| 72157 | MRI SPI CANAL&CNTS C-/C+ | $10,244.60 |
| 72158 | MRI SPI CANAL&CNTS C-/C+ LMBR | $11,200.95 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $1,401.71 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $1,488.68 |
| 72191 | CTA PELVIS C-/C+ POST-PXE | $8,086.00 |
| 72192 | CT PELVIS WO CONTRAST | $8,479.45 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $7,875.21 |
| 72194 | CT PELVIS W OR WO CONTRST | $7,402.44 |
| 72195 | MRI PELVIS C-MATRL | $8,037.12 |
| 72196 | MRI PELVIS C+ MATRL | $12,582.31 |
| 72220 | XRAY COCCYX/SACRUM | $1,480.72 |
| 72265 | MYELOGRAPY LUMBOSAC RS&I | $5,753.00 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $1,635.00 |
| 73010 | SCAPULA COMPLETE | $1,797.50 |
| 73020 | RADEX SHO 1 VIEW | $1,406.68 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $1,990.09 |
| 73050 | XRAY AC JOINTS-BILAT | $1,950.85 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $1,574.47 |
| 73070 | XRAY ELBOW 2 VIEWS | $1,532.23 |
| 73080 | XRAY ELBOW GREATER THAN 3 VIEWS-COMP | $1,819.11 |
| 73090 | XRAY FOREARM AP & LAT | $1,550.61 |
| 73092 | Radiologic examination; upper extremity, infant, minimum of… | $1,160.00 |
| 73100 | XRAY WRIST AP & LAT VIEW | $1,450.09 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $1,793.21 |
| 73120 | XRAY HAND AP & LAT | $1,486.03 |
| 73130 | XRAY HAND MIN 3 VIEWS | $1,864.90 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $1,236.26 |
| 73200 | CT UPPR EXTR WO CNTRS | $6,642.01 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $7,385.60 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $9,384.62 |
| 73218 | MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL | $8,933.84 |
| 73220 | MRI UXTR OTH/THN JT C-/C+ | $11,764.36 |
| 73221 | MRI ANY JT UXTR C-MATRL | $8,434.52 |
| 73223 | MRI ANY JT UXTR C-/C+ | $10,229.46 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $1,034.12 |
| 73502 | RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… | $1,694.37 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $3,136.14 |
| 73521 | Radiologic examination, hips, bilateral, with pelvis when p… | $2,625.86 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $2,947.26 |
| 73523 | Radiologic examination, hips, bilateral, with pelvis when p… | $5,883.71 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $2,112.32 |
| 73552 | FEMUR; MIN 2 VIEWS | $1,905.93 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $1,632.05 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $2,054.93 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $2,175.82 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOSTC | $1,757.60 |
| 73580 | X-RAY KNEE.BILATERAL STANDING | $4,174.25 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $1,825.15 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,685.64 |
| 73600 | XRAY ANKLE 2 VIEWS | $1,441.03 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $1,805.13 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $1,521.92 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $2,350.00 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $1,288.26 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $1,409.00 |
| 73700 | CT LWR EXTR WO CONTRAST | $5,884.77 |
| 73701 | CT LWR EXT W CONT | $7,768.63 |
| 73702 | CT LXTR C-/C+ | $7,836.47 |
| 73706 | Computed tomographic angiography, lower extremity, with con… | $13,799.39 |
| 73718 | MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL | $8,456.53 |
| 73721 | MRI ANY JT LXTR C-MATRL | $7,963.20 |
| 73722 | MRI ANY JT LXTR C+ MATRL | $10,453.70 |
| 73723 | MRI ANY JT LXTR C-/C+ | $9,947.03 |
| 74018 | Radiologic examination, abdomen; 1 view | $1,357.29 |
| 74019 | Radiologic examination, abdomen; 2 views | $1,971.50 |
| 74021 | Radiologic examination, abdomen; 3 or more views | $2,130.98 |
| 74022 | RAD EXAM COMPLETE ABD | $2,149.63 |
| 74150 | COMPUTED TOMOGRAPHY ABD | $6,409.08 |
| 74160 | TOMOGRAPHY ABD W/CONTRAST | $10,695.95 |
| 74170 | TOMOGRAPHY ABD W/OCONTRAS | $10,341.03 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $14,994.47 |
| 74175 | CT ANGIO ABDOMEN W/CONTRA | $10,262.52 |
| 74176 | COMP TOMOG AB/PEL W/O CON | $12,666.04 |
| 74177 | COMP TOMO AB/PELV W/OCONT | $14,870.50 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $16,905.92 |
| 74181 | MRI ABD C-MATRL | $7,797.03 |
| 74183 | MRI ABD C-/C+ | $12,530.44 |
| 74190 | PERITONEOGRAM RS&I | $2,630.00 |
| 74220 | Radiologic examination; esophagus | $2,819.86 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $3,402.96 |
| 74246 | Radiologic examination, gastrointestinal tract, upper, air … | $3,622.31 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $3,018.91 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $2,921.18 |
| 74329 | ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I | $4,794.18 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $5,260.00 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $2,610.00 |
| 74400 | Urography (pyelography), intravenous, with or without KUB, … | $6,348.15 |
| 75574 | CT CORONARY | $5,283.23 |
| 75635 | CT ANGIO ABDOMINAL ARTERIES | $10,243.33 |
| 76010 | RADEX FROM NOSE RECTUM FB 1 VIEW CHLD | $1,160.13 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $2,088.49 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | $2,518.96 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $3,365.97 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $2,379.20 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $3,298.00 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $3,194.77 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $5,055.33 |
| 76705 | US ABDOMINAL | $3,580.20 |
| 76706 | Ultrasound, abdominal aorta, real time with image documenta… | $3,341.44 |
| 76770 | US RETROPERITONEAL R-T W/ | $4,055.51 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $3,977.79 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $3,679.72 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $2,163.03 |
| 76805 | US PG UTER F&MAT AFTER 1S | $4,025.14 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,921.35 |
| 76815 | ULTRASND PG UTER | $3,234.10 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $3,244.29 |
| 76817 | UT PG UTER R-T IMG TRVG | $3,658.94 |
| 76830 | TRANSVAGINAL ULTRASOUND | $3,170.23 |
| 76856 | US PELVIC NONOB REAL-TIME | $4,050.85 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $2,520.37 |
| 76870 | US SCROTUM&CNTS | $3,421.63 |
| 76881 | US EXTREMITY NON-VASC REAL-TIME IMG COMPL | $3,398.00 |
| 76882 | ULTRASOUND, EXTREMITY, NON VASCULAR | $3,762.28 |
| 76937 | Us guide vascular access | $2,820.61 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… | $4,209.59 |
| 78306 | B1&/JT IMG WHBDY | $7,330.77 |
| 78315 | B1&/JT IMG 3 PHASE STD | $9,668.10 |
| 78472 | CARD BPI GTD=BRM PLNR 1 STD REST/STRS | $7,725.71 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $829.49 |
| 80048 | METABOLIC PANEL BASIC | $1,111.03 |
| 80050 | General health panel This panel must include the following:… | $2,069.58 |
| 80051 | ELECTROLYTE PANEL | $1,066.54 |
| 80053 | METABOLIC COMPRE PANEL | $1,542.33 |
| 80061 | LIPID PROFILE III | $1,082.95 |
| 80074 | HEPATITIS PANEL | $1,624.58 |
| 80076 | HEPATIC FUNCTION PANEL | $1,038.43 |
| 80143 | Acetaminophen | $928.20 |
| 80175 | Lamotrigine | $137.99 |
| 80177 | Levetiracetam | $349.00 |
| 80178 | LITHIUM | $497.44 |
| 80179 | Salicylate | $508.41 |
| 80197 | TACROLIMUS | $1,111.61 |
| 80202 | VANCOMYCIN PEAK | $448.68 |
| 80305 | DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… | $745.17 |
|
80306 |
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation
when performed, per date of service |
$604.71 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $1,015.00 |
| 80320 | DRUG SCREEN | $538.91 |
| 80329 | DRUG SCREEN | $805.00 |
| 81001 | U/A DIP STICK | $556.44 |
| 81003 | U/A W/O MICRO DIPSTICK | $333.24 |
| 81005 | Urinalysis; qualitative or semiquantitative, except immunoa… | $190.00 |
| 81025 | PREG.TST URINE VISUAL | $613.75 |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hyp… | $5,403.00 |
| 82010 | KETONE BODIES SERUM QUANTITATIVE | $447.10 |
| 82040 | ALBUMIN; SERUM | $220.00 |
| 82075 | ALCOHOL BREATH TEST | $378.00 |
| 82077 | Alcohol (ethanol); any specimen except urine and breath, im… | $1,010.88 |
| 82140 | Ammonia | $440.00 |
| 82150 | AMYLASE | $628.68 |
| 82247 | BILIRUBIN TOTAL | $299.26 |
| 82248 | BILIRUBIN DIRECT | $414.86 |
| 82270 | OCCULT BLOOD | $161.47 |
| 82271 | Blood, occult, by peroxidase activity (eg, guaiac), qualita… | $252.38 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $143.19 |
| 82274 | blood, occult by fecal hemoglobin determination by immunoas… | $306.12 |
| 82310 | CALCIUM | $276.82 |
| 82330 | CALCIUM IONIZED | $459.10 |
| 82374 | CARBON DIOXIDE BICARBONATE | $372.46 |
| 82375 | Under Chemistry Procedures | $608.11 |
| 82435 | CHLORIDE BLD | $167.25 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $578.12 |
| 82533 | CORTISOL TOTAL | $611.00 |
| 82550 | CREATINE CK-TOTAL | $462.02 |
| 82553 | CREATINE CKMB | $712.95 |
| 82565 | CREATININE | $356.43 |
| 82607 | VITAMIN B-12 | $336.84 |
| 82728 | Ferritin | $605.00 |
| 82746 | Folic acid; serum | $365.67 |
| 82747 | ASSAY OF FOLIC ACID RBC | $433.95 |
| 82784 | IGC IMMUNOGLOBULIN | $500.60 |
| 82785 | GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE | $417.56 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $888.31 |
| 82805 | Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (… | $827.61 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $392.13 |
| 82947 | GLUCOSE | $247.13 |
| 82948 | GLUCOSE BLOOD REAGET STR | $203.12 |
| 82962 | GLUCOSE FINGER STICK | $167.30 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $305.00 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $406.75 |
| 83050 | Under Chemistry Procedures | $726.26 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $603.09 |
| 83525 | ASSAY OF INSULIN TOTAL | $396.43 |
| 83540 | IRON-TOTAL | $318.00 |
| 83550 | Total IRON BNDNG CAP | $393.00 |
| 83605 | ASSAY OF LACTATE | $331.17 |
| 83615 | Lactate dehydrogenase (LD), (LDH); | $380.00 |
| 83690 | LIPASE | $613.49 |
| 83735 | MAGNESIUM | $411.00 |
| 83874 | MYOGLOBIN | $207.00 |
| 83880 | B-TYPE NATRIURETIC | $627.90 |
| 84075 | ALK PHOS/PROFILE OR PANEL | $339.00 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $311.00 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $389.00 |
| 84153 | Prostate specific antigen (PSA); total | $443.00 |
| 84155 | PROTEIN,TOTAL,EXCEPT REFR | $312.01 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $343.66 |
| 84165 | PROTEIN ELECTROPHORESIS | $629.59 |
| 84295 | SODIUM; SERUM | $194.00 |
| 84403 | Testosterone; total | $548.35 |
| 84436 | THYRIXINE TOTAL | $425.38 |
| 84439 | THYROXINE-FREE | $490.16 |
| 84443 | Thyroid stimulating hormone (TSH) | $592.47 |
| 84450 | Transferase; aspartate amino (AST) (SGOT) | $430.73 |
| 84460 | ALT-TRANSFERASE;ALANINE | $467.72 |
| 84478 | ASSAY OF TRIGLYCERIDES | $370.40 |
| 84479 | THYROID HORMONE | $769.76 |
| 84480 | T3 TOTAL | $500.54 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $557.09 |
| 84484 | TROPONIN I | $820.39 |
| 84520 | Urea nitrogen; quantitative | $352.77 |
| 84550 | URIC ACID | $470.48 |
| 84560 | URIC ACID OTH SRC | $334.30 |
| 84702 | HCG QUANTATIVE | $700.02 |
| 84703 | PREGNANCY TEST BLOOD | $723.15 |
| 85014 | HEMATOCRIT | $154.93 |
| 85018 | HEMOGLOBIN | $157.57 |
| 85025 | Blood count; complete (CBC) | $538.21 |
| 85027 | CBC W/O DIFF | $353.20 |
| 85347 | COAGJ TM ACTIVATED | $308.69 |
| 85379 | D-DIMER | $786.78 |
| 85384 | Fibrinogen; activity | $536.32 |
| 85397 | Coagulation and fibrinolysis, functional activity, not othe… | $1,141.00 |
| 85610 | PROTHROMBIN TIME | $370.50 |
| 85651 | SEDIMENTATION RATE NONAUT | $246.01 |
| 85652 | SED RATE ERYTHROCYTE NON | $267.12 |
| 85730 | THROMBOPLASTIN TIME PART | $420.10 |
| 86038 | ANTINUCLEAR AB | $484.46 |
| 86039 | ANTINUCLEAR AB TITER | $595.00 |
| 86060 | ANTISTREPTOLYSIN O TITER | $523.08 |
| 86140 | C REACTIVE PROTEIN | $352.49 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $521.84 |
| 86256 | SMOOTH MUSCLE AB TITER | $589.74 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $402.14 |
| 86317 | IMMUNOASSAY INFECTIOUS AGENT | $386.01 |
| 86360 | T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO | $889.00 |
| 86376 | Microsomal antibodies (eg, thyroid or liver-kidney), each | $407.97 |
| 86403 | MONO SPOT | $427.08 |
| 86430 | RHEUMATOID FACTOR | $179.75 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $432.57 |
| 86580 | Skin test; tuberculosis, intradermal | $73.27 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $377.82 |
| 86593 | Syphilis test, non-treponemal antibody; quantitative | $344.05 |
| 86622 | Antibody; Brucella | $380.00 |
| 86631 | ANTB CHLAMYDIA | $456.67 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $589.20 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $718.58 |
| 86664 | EPSTEIN-BARR VIRUS EBNA | $399.45 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $716.43 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $763.00 |
| 86695 | Antibody; herpes simplex, type 1 | $404.85 |
| 86696 | Antibody; herpes simplex, type 2 | $435.78 |
| 86701 | HIV SERUM | $799.00 |
| 86702 | ANTB HIV-2 | $535.00 |
| 86704 | Hepatitis B core antibody (HBcAb); total | $578.00 |
| 86705 | HEPATITIS B CORE IGM | $362.00 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $491.00 |
| 86708 | Hepatitis A antibody (HAAb) | $505.78 |
| 86709 | Hepatitis A antibody (HAAb), IgM antibody | $321.21 |
| 86757 | Antibody; Rickettsia | $270.80 |
| 86769 | COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD | $630.00 |
| 86780 | TP-Under Qualitative or Semi quantitative Immunologists- | $235.68 |
| 86787 | VARICELLA-ZOSTER ANTIBODY | $202.06 |
| 86803 | HEPATITIS C ANTIBODY | $455.17 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $442.41 |
| 86900 | Blood typing, serologic; ABO | $441.83 |
| 86901 | RH FACTOR-BLOOD | $304.54 |
| 87015 | CONCENTRATION INFECTIOUS AGENTS | $223.57 |
| 87040 | BLOOD CULTURE | $710.76 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $684.59 |
| 87046 | Culture, bacterial; stool, aerobic, additional pathogens, i… | $537.12 |
| 87070 | CULTURE BODY FLUID | $553.00 |
| 87075 | CULTURE ANAEROBIC | $846.00 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $465.69 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $389.96 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $913.00 |
| 87086 | URINE CULTURE | $601.71 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $754.27 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $421.16 |
| 87110 | CHLAMYDIA CULTURE | $723.00 |
| 87177 | Ova and parasites, direct smears, concentration and identif… | $584.30 |
| 87186 | Susceptibility studies, antimicrobial agent | $445.94 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $371.70 |
| 87207 | SMR PRIM SRC SPEC STAIN | $656.62 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $731.70 |
| 87210 | WET SMEAR | $402.72 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $683.00 |
| 87255 | Herpes Simplex Virus Culture with Reflex Typing | $878.00 |
| 87324 | Infectious agent antigen detection by immunoassay technique… | $514.43 |
| 87328 | Infectious agent antigen detection by immunoassay technique… | $415.00 |
| 87338 | IAAD IA HPYLORI STOOL | $380.65 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $525.00 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $533.72 |
| 87389 | infection agent etc | $561.42 |
| 87400 | INFLUENZA A&B | $709.07 |
| 87426 | COVID-19 RAPID ANTIGEN TESTING | $460.34 |
| 87430 | INF AGT IMMUNO STREP A | $201.50 |
| 87480 | IADNA CANDIDA SPECIES DIRECT PROBE TQ | $438.06 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $815.00 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $632.15 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $936.24 |
| 87506 | Infectious agent detection by nucleic acid (DNA or RNA); ga… | $2,392.85 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $4,565.95 |
| 87510 | Infectious agent detection by nucleic acid (DNA or RNA); Ga… | $438.06 |
| 87522 | Infectious agent detection by nucleic acid (DNA or RNA); he… | $2,163.08 |
| 87529 | IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ | $1,192.86 |
| 87535 | HIV-1 PROBE&REVERSE TRNSCRPJ | $1,581.81 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $1,524.56 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $633.45 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $4,939.71 |
| 87635 | Infectious agent detection by nucleic acid (DNA or RNA); se… | $468.71 |
| 87660 | Infectious agent detection by nucleic acid (DNA or RNA); Tr… | $574.00 |
| 87661 | IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH | $782.49 |
| 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $969.86 |
| 87801 | Infectious agent detection by nucleic acid | $1,369.33 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $500.00 |
| 87807 | INF AGT DET IMNAS OPT RSV | $450.08 |
| 87880 | RAPID STREP-BETA STREP | $402.10 |
| 88305 | PATH SURG LEVEL IV | $1,531.00 |
| 89050 | Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except
blood; |
$614.46 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $606.42 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $397.99 |
| 89060 | CRYSTAL INDENTIFICATION | $319.82 |
| 90471 | IMMUN ADM 1 VAC | $343.55 |
| 90472 | Immunization admin, each add | $239.48 |
| 90714 | TETANUS DIPHTHERIA TOXOID | $1,073.00 |
| 90715 | TDAP VACCINE | $672.00 |
| 92950 | Cardiopulmonary resuscitation (eg, in cardiac arrest) | $3,202.00 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $4,655.00 |
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; trac… | $1,252.00 |
| 93017 | CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY | $6,895.32 |
| 93041 | RHYTHEM ECG 1-3 LDS | $652.47 |
| 93225 | XTRNL ECG & 48 HR RECORDING | $2,462.73 |
| 93226 | EXTERNAL ECG SCANNING ANALYSIS REPORT | $9,531.71 |
| 93303 | COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY | $7,109.76 |
| 93306 | ECHO TEST | $10,323.95 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $6,163.00 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $2,558.21 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $3,465.34 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $1,937.16 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $10,772.00 |
| 93623 | Programmed stimulation and pacing after intravenous drug infusion (List separately
in addition to code for primary procedure) |
$19,712.48 |
| 93880 | DUP-SCAN XTRC ART COMPL B | $4,255.00 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $3,073.00 |
| 93886 | TCD STD ICRA ART COMPL STD | $4,521.00 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $7,231.00 |
| 93923 | NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS | $7,372.44 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $4,071.00 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $3,028.51 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $4,635.94 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $2,892.89 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $5,121.00 |
| 93971 | DPLX SCN EXTRM VEINS | $3,736.13 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… | $5,162.39 |
| 93976 | DUPLEX SCAN- LIMITED | $3,021.00 |
| 94010 | SPIROMETRY W/RECORD | $2,456.51 |
| 94060 | BRNCDILAT RSPSE SPMTRY PR | $2,714.80 |
| 94150 | Vital capacity test | $1,215.00 |
| 94640 | NEBULIZER TREATMENT | $1,067.00 |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $1,124.75 |
| 94660 | CPAP VENTILATION CPAP INITIATION&MGMT | $2,316.84 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $796.48 |
| 94760 | EAR OR PULSE OXIMETRY | $991.00 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $560.78 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $1,718.82 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $1,470.76 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $738.55 |
| 96365 | IV INFUSION THERAPY/PROPH | $1,360.00 |
| 96366 | IV INFUS THER PROPH/DX EA | $814.47 |
| 96367 | IV NFS THER PROPH/DX ADDL | $1,853.95 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $1,294.02 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $569.00 |
| 96374 | THER PROPH/DX NJX IV PUSH | $818.00 |
| 96375 | THER PROPH/DX NJX EA SEQL | $699.08 |
| 96376 | SUB INFU EA ADD IV PUSH | $617.00 |
| 96377 | APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION | $780.42 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR | $477.18 |
| 97140 | MANUAL THERAPY 1/> REGIONS | $592.28 |
| 97166 | Occupational therapy evaluation, moderate complexity, requi… | $1,337.85 |
| 97542 | WHEELCHAIR MGMT EA 15 MIN | $348.90 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $1,282.84 |
| 99000 | SPECIMEN HANDLING | $60.00 |
| 99001 | COC COLLECITON ONLY | $133.00 |
| 99070 | SUPPLIES&MATERIALS ABOVE or BEYOND PROV BY PHYS or QHP | $326.00 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $1,661.50 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $2,379.00 |
| 99153 | Moderate sedation services provided by the same physician o… | $394.03 |
| 99156 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS | $1,766.00 |
| 99157 | MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS | $1,364.00 |
| 99173 | SCREENING TEST OF VISION | $410.03 |
| 99281 | E/M VISIT LEVEL 1 TECH COMP | $918.86 |
| 99282 | E/M VISIT LEVEL 2 TECH COMP | $1,849.01 |
| 99283 | E/M VISIT LEVEL 3 TECH COMP | $3,300.72 |
| 99284 | E/M VISIT LEVEL 4 TECH COMP | $5,953.11 |
| 99285 | E/M VISIT LEVEL 5 TECH COMP | $8,683.96 |
| 99291 | CRITICAL CARE 30-74 MIN | $11,967.27 |
| 99292 | CRITICAL CARE ADD 30 MIN | $1,295.70 |
|
99384 |
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years) |
$682.00 |
| 99407 | SMOKING CESSATION 10 MIN | $293.09 |
| E0114 | CRUTCHES UNDERARM | $171.54 |
| E0135 | WALKER FOLDING ADJUST/FIXED | $383.60 |
| E0141 | RIGID WHEELED WALKER ADJ/FIX | $457.95 |
| E0143 | WALKER FOLDING WHEELED W/O S | $364.32 |
| E0148 | HEAVYDUTY WALKER NO WHEELS | $268.91 |
| G0378 | HOSPITAL OBSERVATION SERVICES PER HOUR | $2,500.00 |
| J0131 | INJECTION, ACETAMINOPHEN, 10 MG | $81.92 |
| J0132 | ACETYLCYSTEINE INJECTION | $133.96 |
| J0133 | ACYCLOVIR INJECTION | $18.22 |
| J0153 | ADENOSINE INJ 1MG | $59.16 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $54.46 |
| J0185 | INJ., APREPITANT, 1 MG | $58.32 |
| J0278 | AMIKACIN SULFATE INJECTION | $66.32 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $49.58 |
| J0290 | AMPICILLIN 500 MG INJ | $91.00 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $83.21 |
| J0330 | SUCCINYLCHOLINE CHLO 20MG | $60.71 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $285.00 |
| J0456 | INJ AZITHROMYCIN 500MG | $169.00 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $17.99 |
| J0500 | DICYCLOMINE HCL 20MG | $583.45 |
| J0515 | Injection, benztropine mesylate, per 1 mg | $518.00 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $529.69 |
| J0571 | BUPRENORPHINE ORAL 1MG | $17.00 |
| J0572 | BUPREN/NAL UP TO 3MG BUPRENO | $90.32 |
| J0574 | BUPREN/NAL 6.1 TO 10MG BUPRE | $231.52 |
| J0583 | BIVALIRUDIN | $9.01 |
| J0595 | STADOL | $133.00 |
| J0604 | CINACALCET, ESRD ON DIALYSIS | $2.77 |
| J0640 | LEUCOVORIN CALCIUM INJECTION | $216.76 |
| J0665 | INJ, BUPIVACAINE, NOS, 0.5MG | $8.82 |
| J0690 | KEFZOL 1 GR VIAL | $38.06 |
| J0692 | INJ CEFEPIME HCI 500MG | $79.44 |
| J0694 | CEFOXITIN SODIUM INJECTION | $147.87 |
| J0696 | ROCEPHIN 250 MG | $49.87 |
| J0697 | STERILE CEFUROXIME INJECTION | $119.00 |
| J0702 | BETAMETHASONE ACET&SOD PHOSP | $129.03 |
| J0712 | CEFTAROLINE FOSAMIL INJ | $65.64 |
| J0713 | INJ CEFTAZIDIME PER 500 MG | $260.00 |
| J0717 | CERTOLIZUMAB PEGOL INJ 1MG | $250.29 |
| J0736 | INJ, CLINDAMYCIN PHOSP 300MG | $268.28 |
| J0744 | CIPRO 200MG | $138.84 |
| J0780 | COMPAZINE 10 MG | $212.00 |
| J0875 | INJECTION, DALBAVANCIN | $311.51 |
| J0878 | DAPTOMYCIN INJECTION | $155.12 |
| J0885 | EPOETIN ALFA, NON-ESRD | $308.99 |
| J0894 | DECITABINE INJECTION | $163.00 |
| J0897 | DENOSUMAB INJECTION | $447.80 |
| J1030 | DEPO MEDROL 40 MG/ML | $151.99 |
| J1040 | METHYLPREDNISOLONE 80MG | $290.58 |
| J1050 | MEDROXYPROGESTERONE ACETATE | $114.94 |
| J1100 | DECADRON 4 MG VIAL | $19.44 |
| J1160 | DIGOXIN INJECTION | $145.00 |
| J1165 | DILANTIN 100 MG VIAL | $25.15 |
| J1170 | DILAUDID 4 MG | $68.00 |
| J1200 | BENADRYL 50MG | $44.51 |
| J1265 | Dopamine | $68.19 |
| J1327 | EPTIFIBATIDE INJECTION | $302.64 |
| J1335 | ERTAPENEM INJECTION | $720.42 |
| J1450 | FLUCONAZOLE | $184.64 |
| J1453 | FOSAPREPITANT INJECTION | $16.00 |
| J1580 | GARAMYCIN,GENTAMICIN 80MG | $60.00 |
| J1610 | GLUCOGAN 1 MG VIAL | $1,944.20 |
| J1630 | HALOPERIDOL INJECTION | $93.34 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $12.10 |
| J1644 | INJ HEPARIN SOD PER 1000 | $161.73 |
| J1650 | ENOXAPARIN SODIUM 10MG | $46.33 |
| J1652 | FONDAPARINUX SODIUM | $132.16 |
| J1670 | TETANUS INJECTION | $6,955.00 |
| J1720 | HYDROCORTISONE SODIUM SUCC I | $274.93 |
| J1750 | INJ IRON DEXTRAN | $479.67 |
| J1756 | IRON SUCROSE INJECTION | $36.00 |
| J1790 | DROPERIDOL INJECTION | $100.25 |
| J1800 | PROPRANOLOL INJECTION | $394.48 |
| J1815 | INJ INSULIN PER 5 UNITS | $20.90 |
| J1836 | Injection, metronidazole, 10 mg | $48.88 |
| J1885 | TORADOL INJ 15 MG | $54.60 |
| J1920 | INJ, LABETALOL HCL, 5MG | $25.47 |
| J1940 | LASIX 40 MG IV VIAL | $50.31 |
| J1953 | INJECTION, LEVETIRACETAM, 10 MG | $3.00 |
| J1956 | LEVOFLOXACIN 250 MG | $108.00 |
| J1980 | HYOSCYAMINE SULFATE INJ | $479.00 |
| J2001 | LIDOCAINE HCI 10MG | $16.25 |
| J2020 | LINEZOLID INJECTION | $271.36 |
| J2060 | ATIVAN 2ML SYRUP | $72.88 |
| J2150 | MANNITOL INJECTION | $69.93 |
| J2175 | DEMEROL 50 MG SYRINGE | $77.25 |
| J2185 | MEROPENEM | $61.26 |
| J2210 | METHYLERGONOVIN MALEATE INJ | $347.38 |
| J2212 | METHYLNALTREXONE INJECTION | $26.83 |
| J2248 | MICAFUNGIN SODIUM INJECTION | $125.78 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $21.24 |
| J2260 | INJ MILRINONE LACTATE / 5 MG | $451.15 |
| J2270 | INJ MORPHINE SULFATE 10 M | $56.60 |
| J2274 | INJ MORPHINE PF EPID ITHC | $367.99 |
| J2310 | INJ NALOXONE HCL 1MG | $238.12 |
| J2354 | OCTREOTIDE INJ, NON-DEPOT | $33.00 |
| J2360 | ORPHENADRINE CITRATE 60MG | $151.13 |
| J2370 | NEO-SYNEPHRINE UP TO 1 ML | $79.38 |
| J2405 | ONDANSETRON HCI, PER MG | $18.29 |
| J2430 | PAMIDRONATE DISODIUM /30 MG | $299.49 |
| J2440 | PAPAVERIN HCL INJECTION | $499.21 |
| J2469 | PALONOSETRON HCL | $66.00 |
| J2540 | PENICILLIN G POTASSIUM INJ | $52.65 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $81.59 |
| J2550 | PHENERGAN 50 MG | $59.63 |
| J2560 | PHENOBARBITAL SODIUM INJ | $403.05 |
| J2590 | OXYTOCIN INJECTION | $99.73 |
| J2597 | INJ DESMOPRESSIN ACETATE | $358.60 |
| J2704 | INJ, PROPOFOL, 10 MG | $18.83 |
| J2710 | NEOSTIGMINE METHYLSLFTE INJ | $62.22 |
| J2720 | INJ PROTAMINE SULFATE/10 MG | $62.00 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $42.00 |
| J2780 | INJ RANITIDINE 25 MG | $56.99 |
| J2790 | RHOGAM INJECTION | $571.24 |
| J2795 | ROPIVACAINE HCL INJECTION | $23.92 |
| J2800 | METHOCARBAMOL INJECTION | $452.00 |
| J2916 | NA FERRIC GLUCONATE COMPLEX | $171.97 |
| J2920 | SOLU-MEDROL 40MG | $156.00 |
| J2930 | SOLU-MEDROL 125 MG | $139.00 |
| J3010 | INJ FENTANYL CITRATE .1MG | $40.00 |
| J3030 | IMITREX 6MG VIAL | $409.00 |
| J3105 | INJECTION, TREBUTALINE SULFATE, UP TO 1 MG | $87.74 |
| J3230 | THOROZINE 50 MG | $357.00 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $82.47 |
| J3301 | TRIAMCINOLONE ACET INJ NOS | $87.53 |
| J3360 | VALIUM INJ 5 MG | $187.27 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $172.80 |
| J3410 | VISTERIL INJ 50 MG | $109.00 |
| J3411 | INJ THIAMINE 100 MG | $110.03 |
| J3415 | PYRIDOXINE HCL 100 MG | $214.00 |
| J3420 | VITAMIN B12 INJECTION | $106.98 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $171.68 |
| J3465 | INJECTION, VORICONAZOLE | $72.02 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $84.63 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $40.67 |
| J3486 | GEODON – ZIPRASIDONE MESYLATE 10MG | $302.58 |
| J3490 | UNCLASSIFIED DRUGS | $273.45 |
| J7030 | INFUS NORM SALINE 1000CC | $158.00 |
| J7040 | INFUS NORM SALINE 500ML | $101.94 |
| J7042 | 5% DEXTROSE | $116.10 |
| J7050 | INFS NORM SALINE 250CC | $196.00 |
| J7060 | INFUSION D5W 250ML | $149.00 |
| J7070 | INFUSION D5W 1000ML | $74.81 |
| J7120 | RINGER’S LACTATE INFUS | $280.00 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $315.00 |
| J7189 | FACTOR VIIA | $22.39 |
| J7325 | SYNVISC OR SYNVISC-ONE | $452.68 |
| J7500 | AZATHIOPRINE ORAL 50MG | $19.00 |
| J7502 | CYCLOSPORINE ORAL 100 MG | $133.06 |
| J7503 | TACROL ENVARSUS EX REL ORAL | $80.77 |
| J7507 | TACROLIMUS IMME REL ORAL 1MG | $21.00 |
| J7509 | METHYLPREDNISOLONE ORAL | $26.97 |
| J7510 | PREDNISOLONE ORAL 5 MG | $12.58 |
| J7512 | PREDNISONE 5 MG | $7.68 |
| J7515 | CYCLOSPORINE ORAL 25 MG | $17.91 |
| J7517 | MYCOPHENOLATE MOFETIL ORAL | $10.00 |
| J7518 | MYCOPHENOLIC ACID | $66.00 |
| J7520 | SIROLIMUS, ORAL | $245.26 |
| J7527 | ORAL EVEROLIMUS | $178.94 |
| J7605 | ARFORMOTEROL NON-COMP UNIT | $192.00 |
| J7608 | ACETYLCYSTEINE NON-COMP UNIT | $391.50 |
| J7611 | ALBUTEROL 1MG CONC INHALA | $18.57 |
| J7613 | ALBUT INHAL NON-CP 1MG | $37.73 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $53.00 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $53.00 |
| J7626 | BUDESONIDE NON-COMP UNIT | $116.22 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $43.00 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $29.25 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $52.70 |
| J8501 | ORAL APREPITANT | $39.35 |
| J8515 | CABERGOLINE, ORAL 0.25MG | $114.88 |
| J8540 | DEXAMETHASONE, ORAL .25MG | $11.57 |
| J8597 | ANTIEMETIC DRUG ORAL NOS | $2.04 |
| J8610 | METHOTREXATE ORAL 2.5 MG | $35.37 |
| J9000 | DOXORUBICIN HCL INJECTION | $94.85 |
| J9025 | AZACITIDINE INJECTION | $12.64 |
| J9034 | INJ., BENDEKA 1 MG | $424.50 |
| J9041 | INJ., VELCADE 0.1 MG | $108.91 |
| J9045 | CARBOPLATIN INJECTION | $113.30 |
| J9060 | CISPLATIN 10 MG INJECTION | $101.38 |
| J9100 | CYTARABINE HCL 100 MG INJ | $57.49 |
| J9130 | DACARBAZINE 100 MG INJ | $275.46 |
| J9171 | DOCETAXEL INJECTION | $45.44 |
| J9181 | ETOPOSIDE INJECTION | $28.90 |
| J9190 | FLUOROURACIL INJECTION | $102.00 |
| J9201 | GEMCITABINE HCL INJECTION | $260.33 |
| J9206 | IRINOTECAN INJECTION | $151.53 |
| J9250 | METHOTREXATE SODIUM INJ | $22.99 |
| J9260 | METHOTREXATE SODIUM INJ | $119.80 |
| J9263 | OXALIPLATIN | $7.90 |
| J9264 | PACLITAXEL PROTEIN BOUND | $256.19 |
| J9267 | PACLITAXEL INJECTION | $6.22 |
| J9299 | INJECTION, NIVOLUMAB | $488.78 |
| J9305 | PEMETREXED INJECTION | $132.00 |
| J9306 | INJECTION, PERTUZUMAB, 1 MG | $146.41 |
| J9351 | TOPOTECAN INJECTION | $96.77 |
| J9360 | VINBLASTINE SULFATE INJ | $124.42 |
| J9370 | VINCRISTINE SULFATE 1 MG INJ | $465.00 |
| L0120 | CERVICAL FLEX NONADJ COLL | $856.79 |
| L0464 | TLSO 4MOD SACRO-SCAP PRE | $10,531.00 |
| L0625 | LO FLEX L1-BELOW L5 PRE OTS | $223.00 |
| L1820 | Knee orthosis | $646.00 |
| L1830 | KNEE IMMOBOLIZER | $416.00 |
| L3260 | SURGICAL BOOT/SHOE | $233.61 |
| L3650 | SO FIGURE EIGHT ABDUCTION | $369.00 |
| L3906 | WHO W/O JOINTS CF | $1,310.00 |
| L3908 | WRIST EXTN CONTROL COCKUP | $233.61 |
| L4350 | AIR SPLINT | $986.52 |
| M0245 | Intravenous infusion, bamlanivimab and etesevimab, includes… | $1,648.60 |
| Q0138 | FERUMOXYTOL, NON-ESRD | $39.54 |
| Q0161 | CHLORPROMAZINE HCL 5MG ORAL | $2.32 |
| Q0162 | ONDANSETRON ORAL | $1.47 |
| Q0163 | DIPHENHYDRAMINE HCL 50MG | $6.96 |
| Q0164 | PROCHLORPERAZINE MALEATE 5MG | $8.00 |
| Q0167 | DRONABINOL 2.5MG ORAL | $12.21 |
| Q0169 | PROMETHAZINE HCL 12.5MG ORAL | $8.00 |
| Q0177 | HYDROXYZINE PAMOATE 25MG | $1.65 |
| Q2009 | FOSPHENYTOIN INJ PE | $281.89 |
| Q2050 | DOXORUBICIN INJ 10MG | $4,402.49 |
| Q3014 | TELEHEALTH FACILITY FEE | $113.01 |
| Q4008 | CAST SUPPLIES LONG ARM | $242.00 |
| Q4018 | CAST SUP LNG ARM SPLINT FBRG | $2,333.23 |
| Q4020 | LNG ARM SPLNT 0-10 YRS | $1,263.65 |
| Q4022 | SHRT ARM SPLNT 11 YRS + | $1,944.41 |
| Q4024 | CAST SUP SHT ARM SPLNT PED F | $1,164.02 |
| Q4042 | LNG ARM SPLNT 11 YRS + | $458.00 |
| Q4046 | SHRT LG SPLNT 11 YRS + | $662.86 |
| Q4048 | CAST SUP SHT LEG SPLNT PED F | $212.00 |
| Q4049 | FINGER SPLNT STATIC | $498.83 |
| Q4051 | SPLINT SUPPLIES MISC | $319.82 |
| Q4081 | EPOETIN ALFA, 100 UNITS ESRD | $47.38 |
| Q4100 | SKIN SUBSTITUTE, NOS | $11,826.71 |
| Q4101 | APLIGRAF | $699.58 |
| Q4102 | OASIS WOUND MATRIX | $35.93 |
| Q4104 | INTEGRA BMWD | $19,047.67 |
| Q4105 | INTEGRA DRT OR OMNIGRAFT | $808.56 |
| Q4107 | GRAFTJACKET | $795.77 |
| Q4118 | MATRISTEM MICROMATRIX | $44.66 |
| Q4124 | OASIS TRI-LAYER WOUND MATRIX | $55.00 |
| Q4125 | ARTHROFLEX | $519.03 |
| Q4132 | GRAFIX CORE, GRAFIXPL CORE | $2,761.11 |
| Q4133 | GRAFIX STRAVIX PRIME PL SQCM | $1,415.16 |
| Q4152 | DERMAPURE 1 SQUARE CM | $21,109.31 |
| Q4158 | KERECIS OMEGA3, PER SQ CM | $393.00 |
| Q4166 | CYTAL, PER SQUARE CENTIMETER | $148.34 |
| Q4186 | EPIFIX 1 SQ CM | $2,194.76 |
| Q5101 | INJECTION, ZARXIO | $15.55 |
| Q5105 | INJ RETACRIT ESRD ON DIALYSI | $17.21 |
| Q5106 | INJ RETACRIT NON-ESRD USE | $310.70 |
| Q5107 | INJ MVASI 10 MG | $1,131.47 |
| Q5108 | INJECTION, FULPHILA | $3,636.64 |
| Q9950 | INJ SULF HEXA LIPID MICROSPH | $270.00 |
| Q9954 | ORAL MR CONTRAST, 100ML | $61.27 |
| Q9956 | INJ OCTAFLUOROPROPANE MIC,ML | $1,013.04 |
| Q9957 | INJ PERFLUTREN LIP MICROS,ML | $1,726.61 |
| Q9958 | HOCM <=149 MG/ML IODINE, 1ML | $6.58 |
| Q9962 | HOCM 300-349MG/ML IODINE,1ML | $20.00 |
| Q9963 | HI OSM CONTRST MATL 350-3 | $427.70 |
| Q9964 | HOCM>= 400MG/ML IODINE, 1ML | $10.66 |
| Q9965 | LOW OSMOLAR CON MAT PER M | $63.03 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $84.24 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $13.00 |
| Q9968 | VISUALIZATION ADJUNCT | $64.53 |
| U0002 | SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple ty… | $393.18 |