| CPT Code | Description | Charge Amount |
| 0202U | COVID-19 BioFire Respiratory Panel 2.1 (RP2.1) Testing | $2,550.77 |
| 10060 | INCISION/DRAINAGE ABSCESS | $1,662.80 |
| 10061 | INS/DRAIN ABSCESS COMPL | $2,634.00 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $2,042.91 |
| 10081 | I&D PILONIDAL CST COMP | $6,514.99 |
| 10120 | I & RMVL SUB-CUT SIMPLE | $2,763.00 |
| 10121 | I & RMVL FB, SUB-CUT,COMP | $13,253.00 |
| 10140 | I&D HEMATOMA SEROMA/FLUID COLLECTION | $16,139.30 |
| 10160 | PUNCTURE ASP OF ABSCESS | $1,565.00 |
| 10180 | Incision and drainage, complex, postoperative wound infecti… | $13,429.00 |
| 11010 | DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS | $9,150.60 |
| 11042 | DBRD SKN SUBQ TISSUE | $5,214.02 |
| 11043 | DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< | $6,821.00 |
| 11045 | DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM | $1,943.00 |
| 11200 | RMVL SKIN TAGS | $2,138.17 |
| 11730 | AVULSION/1-NAIL PLATE | $1,701.14 |
| 11732 | AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL | $528.00 |
| 11740 | EVAC SUBUNGUAL HEMATOMA | $760.00 |
| 11750 | EXC NAIL PART/COMP | $6,767.00 |
| 11760 | REPAIR NAIL BED | $8,549.00 |
| 12001 | LACERATION REPAIR | $1,143.98 |
| 12002 | REPAIR LAC SCALP 2.6-7.5 | $1,150.81 |
| 12004 | REPAIR LAC SCALP 7.6-12.5 | $1,170.04 |
| 12005 | REPAIR LAC,SCALP 12.6-20C | $1,176.00 |
| 12006 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM | $1,946.00 |
| 12007 | SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM | $2,540.00 |
| 12011 | REPAIR LAC FACE LESS THAN 2.5 CM | $1,119.40 |
| 12013 | REPAIR LAC FACE 2.6-5.0CM | $1,151.40 |
| 12014 | REPAIR LAC FACE 5.1-7.5CM | $1,558.00 |
| 12015 | SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM | $1,638.00 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $3,785.00 |
| 12031 | LYR CLSR S/A/T/E 2.5CM | $1,915.00 |
| 12032 | REPAIR-INT SCALP 2.6-7.5 | $2,273.00 |
| 12034 | INTERM RPR SCLP/TRNK/EXTR | $3,165.00 |
| 12035 | REPAIR INTERM S/A/T/E 12. | $3,932.00 |
| 12041 | LAYER CLSR NECK/HAND 2.6 | $1,456.64 |
| 12042 | REPAIR LAC HAND/FOOT 2.6- | $1,546.44 |
| 12044 | LYR CLSR N/H/F/ETRNL GENT | $2,725.00 |
| 12051 | LAYER CLSR OF WND NCK/HND | $1,868.08 |
| 12052 | LYR CLSR WOUND 2.6-5.0FAC | $1,915.00 |
| 12053 | LYR CLSR F/E/E/N/L/M&/MUC | $2,188.00 |
| 12054 | REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM | $2,621.00 |
| 13101 | REPAIR COMPLEX TRUNK 2.6-7.5 CM | $11,504.00 |
| 13121 | RPR CMPX SCALP ARM2.6-7.5 | $4,622.00 |
| 13122 | CMPLX RPR ADD 5 CM OR LES | $1,846.73 |
| 13131 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM | $2,831.00 |
| 13132 | RPR CMPX FOREHEAD/CHECK/C | $3,937.00 |
| 13133 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< | $3,256.41 |
| 13151 | CMPX RPR EYE NOSE 1.1-2.5 | $4,087.00 |
| 13152 | RPR CPLX E/N/E/L 2.6-7.5 | $4,967.00 |
| 16000 | BURN, INITIAL TREATMENT | $1,631.80 |
| 16020 | BURN, DRESSING/DBRDMNT-SM | $1,510.00 |
| 16030 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE | $3,353.15 |
| 17250 | UMBILICAL CAUTERIZATION | $1,454.69 |
| 19020 | MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP | $15,871.14 |
| 20103 | EXPLORATION PENETRATING WOUND SPX EXTREMITY | $9,778.00 |
| 20520 | REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE | $6,102.00 |
| 20525 | RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP | $14,267.00 |
| 20552 | TRIGGER POINT INJ 1-2 MUS | $7,891.00 |
| 20605 | ARTHROCENTESIS, MED JOINT | $4,695.00 |
| 20610 | ARTHROCENTESIS, LG JOINT | $5,568.00 |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or… | $3,964.00 |
| 21320 | CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION | $10,273.00 |
| 21480 | CLDS TX TEMP DISLOCATION | $1,842.00 |
| 21485 | CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ | $11,643.00 |
| 23600 | CLTX PROX HUMRL FX WO MAN | $2,165.12 |
| 23605 | CLTX PRX HMRL FX MNPJ+-TRACT | $6,012.00 |
| 23650 | SHOULDER DISLOCATION TRMT | $1,815.67 |
| 23655 | CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES | $8,747.56 |
| 23665 | CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ | $3,471.00 |
| 23931 | INCISION&DRAINAGE UPPER ARM/ELBOW BURSA | $7,329.00 |
| 24505 | CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ | $5,048.00 |
| 24535 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ | $8,585.00 |
| 24565 | CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ | $7,263.00 |
| 24600 | CLSD TX ELBOW DISLOCAT | $1,342.06 |
| 24605 | Treatment of closed elbow dislocation; requiring anesthesia | $7,607.77 |
| 24620 | CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ | $5,184.95 |
| 24640 | RADIAL HEAD SUBLUX. CHILD | $1,247.63 |
| 24650 | CLTX RDL HEAD FX WO MANP | $2,565.91 |
| 24655 | CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION | $6,529.00 |
| 24675 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ | $7,129.00 |
| 25505 | CLSD TX RAD SHAFT W/MANIP | $5,809.00 |
| 25520 | CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT | $7,090.00 |
| 25535 | CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION | $6,488.00 |
| 25565 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ | $3,153.55 |
| 25600 | CLSD TX DISTAL RAD FX WO | $4,425.76 |
| 25605 | CLSD TX DISTAL RAD FX | $2,551.27 |
| 25607 | OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP | $25,284.00 |
| 25652 | OPEN TREATMENT ULNAR STYLOID FRACTURE | $18,687.50 |
| 25675 | CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ | $3,542.20 |
| 26010 | I & D FINGER ABSCESS,SIMP | $1,022.78 |
| 26011 | DRAINAGE FINGER ABSCESS COMPLICATED | $7,507.16 |
| 26600 | CLSD TX METACARPAL FX | $1,843.74 |
| 26605 | CLSD TX MEDICARPAL FX | $2,841.00 |
| 26700 | CLS TX MCP DISLOCATION | $1,990.00 |
| 26725 | CLTX PHLNGL FX PROX/MIDDL | $2,191.26 |
| 26735 | OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA | $25,284.00 |
| 26742 | CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ | $6,712.00 |
| 26746 | OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA | $16,463.00 |
| 26750 | CLS TX FX FINGER/THUMB | $1,552.20 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/ | $2,085.52 |
| 26765 | OPEN TX DISTAL PHALANGEAL FRACTURE EACH | $13,312.00 |
| 26770 | TREAT FINGER DISLOC FINGE | $1,535.83 |
| 26775 | Closed treatment of interphalangeal joint dislocation, sing… | $3,665.00 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $2,303.00 |
| 27560 | CLTX PATELLAR DISLC W/O A | $1,917.56 |
| 27750 | Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation | $4,062.50 |
| 27752 | CLTX TIBL SFT FX W/MANP | $8,065.00 |
| 27762 | CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ | $7,043.00 |
| 27788 | CLTX DSTL FIBULAR FX LAT MALLS W/MANJ | $3,198.93 |
| 27792 | Open treatment of distal fibular fracture (lateral malleolu… | $25,063.00 |
| 27810 | CLTX BIMAL ANKLE FX W/POT | $4,919.00 |
| 27818 | CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION | $3,435.14 |
| 27840 | CLOSED TX ANKLE DISLOCATI | $3,642.60 |
| 27842 | CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ | $15,556.02 |
| 28190 | RMVL FB BODY FOOT SUBQ | $6,856.00 |
| 28192 | RMVL FB FOOT DEEP | $16,549.65 |
| 28495 | CLTX FX GRT TOE PHLX/PHLG W/MANJ | $2,652.67 |
| 28515 | FX CARE PHALANX NOT GREAT | $2,356.00 |
| 28660 | CLSD TX PIP JNT DISLOCATI | $1,636.18 |
| 29105 | LONG ARM SPLINT | $829.00 |
| 29125 | SHORT ARM SPLINT | $753.22 |
| 29126 | SHORT ARM SPLINT DYNAMIC | $1,071.00 |
| 29130 | APPLICATION FINGER SPLINT | $625.00 |
| 29240 | STRPG SHO | $797.00 |
| 29280 | STRAPPING HAND/FINGER | $646.00 |
| 29505 | LONG LEG SPLINT | $1,099.00 |
| 29515 | SHORT LEG SPLINT | $1,026.37 |
| 29530 | STRAPPING KNEE | $805.00 |
| 29550 | STRAPPING TOES | $836.00 |
| 30300 | RMVL FOREIGN BODY NASAL | $685.91 |
| 30901 | NASAL PACKING | $1,023.89 |
| 30903 | CTRL NSL HEMRRG ANT CPLX | $3,209.00 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $1,370.00 |
| 30906 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ | $1,791.00 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,213.09 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $1,942.00 |
| 32550 | INSERTION INDWELLING TUNNELED PLEURAL CATHETER | $20,534.31 |
| 32551 | TUBE THORACOSTOMY INCLUDES WATER SEAL | $3,465.00 |
| 32556 | PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING | $8,060.39 |
| 36000 | INTRODUCTION OF NEEDLE/IN | $350.26 |
| 36005 | NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH | $4,393.00 |
| 36410 | VENIPUNCTURE, 3 YRS OR OLDER | $765.01 |
| 36415 | VENIPUNCTURE | $74.85 |
| 36416 | COLL CAPILLARY BLG SPEC | $82.50 |
| 36556 | Insertion of non-tunneled centrally inserted central venous… | $6,684.99 |
| 36558 | INSERT TUNNELED CV CATH – INSJ TUN CTR CVC W/O SUBQ POR | $13,386.49 |
| 36569 | INSERTION PICC W/O IMG GDN 5 YR/> | $8,161.08 |
| 36589 | RMVL TUN CVC W/O SUBQ PORT/PMP | $7,102.88 |
| 36591 | COLLECT BLOOD FROM IMPLAN | $735.89 |
| 36592 | COLLECT BLOOD FROM CATHETER VENOUS NOS | $702.84 |
| 36680 | PLACEMENT NEEDLE INTRAOSSEOUS INFUSION | $1,091.83 |
| 40650 | RPR LIP FULL THICKNESS | $5,063.00 |
| 40800 | DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL | $3,008.19 |
| 41250 | RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG | $1,653.69 |
| 41800 | DRNG ABSC DENTOALVEOLAR S | $1,558.00 |
| 42700 | I&D ABSC PRITONSILLAR | $2,929.00 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $2,787.02 |
| 43753 | GASTRIC INTUBATION AND ASPIRATION THERAPUETIC, NECESSATING … | $976.00 |
| 45915 | RMVL FECAL IMPACTION/FB SPX UNDER ANES | $9,348.00 |
| 46040 | I&D ISCHIOR/PRIRC ABSC SP | $12,172.00 |
| 46050 | INC/DRAIN PERIANAL ABS SU | $5,126.00 |
| 46083 | INCISION THROM HEMORRHOID | $1,571.00 |
| 49083 | ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE | $6,502.68 |
| 49505 | RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE | $25,524.60 |
| 51700 | BLDR IRR SMPL LVG&/INSTLJ | $1,902.92 |
| 51701 | INSR NONDWELLING BLDR CAT | $680.91 |
| 51702 | INSERTION BLADDER CATH | $664.00 |
| 51703 | INSERT BLADDER CATH COMPL | $844.76 |
| 54220 | IRRIGATION CORPORA CAVERNOSA PRIAPISM | $2,403.92 |
| 54235 | NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT | $1,419.87 |
| 54437 | REPAIR OF TRAUMATIC CORPOREAL TEAR(S) | $25,072.78 |
| 54450 | FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING | $4,025.00 |
| 55100 | DRAINAGE SCROTAL WALL ABSCESS | $6,504.55 |
| 56405 | INC/DRAIN VULVA/PERINEAL | $2,036.47 |
| 56420 | I & D BARTHOLIN ABSCESS | $1,694.00 |
| 57410 | PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL | $13,698.75 |
| 58301 | REMOVAL INTRAUTERINE DEVICE IUD | $14,504.00 |
| 59025 | FTL NON-STRS TST | $1,670.13 |
| 62270 | SPINAL PUNCTURE,LUMBAR | $3,147.32 |
| 62272 | THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF | $3,759.11 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $2,474.37 |
| 64405 | INJECTION AA&/STRD GREATER OCCIPITAL NERVE | $4,308.53 |
| 64450 | INJ ANESTHETIC AGENT | $2,131.06 |
| 65205 | REMOVAL FB EYE-SUPERFCL | $1,275.00 |
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $2,119.65 |
| 65220 | RMVL FB EYE W/O SLIT LAMP | $1,561.00 |
| 65222 | RMVL FB EYE | $1,681.00 |
| 67700 | I&D ABSCESS EYELID | $1,658.00 |
| 69000 | Drainage external ear | $3,343.00 |
| 69200 | RMVL FOREIGN BODY EAR | $826.00 |
| 69205 | RMVL FB XTRNL AUD CANAL A | $9,924.00 |
| 69209 | REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL | $766.00 |
| 69210 | RMVL IMPACTED CERUMEN | $671.70 |
| 70100 | XRAY MANDIBLE LESS THAN 4 VIEWS | $1,716.86 |
| 70110 | XRAY MANDIBLE MIN 4 VIEWS | $1,709.01 |
| 70130 | RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE | $1,335.29 |
| 70140 | XRAY FACIAL BONES LESS THAN 3 VIEW | $1,838.76 |
| 70150 | XRAY FACIAL BONES GREATER THAN 3 VIEW | $1,699.89 |
| 70160 | Radiologic examination, nasal bones, complete, minimum of 3… | $1,286.15 |
| 70200 | RAD EXAM ORBIT COMP. | $2,352.18 |
| 70210 | RADEX SINUSES PARANASAL <3 VIEWS | $1,100.47 |
| 70220 | RAD EXAM SINUS COMPLETE | $1,324.00 |
| 70250 | SKULL LESS THAN 4 VIEWS | $1,542.89 |
| 70260 | RAD EXAM SKULL COMPLETE | $1,988.00 |
| 70330 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT | $1,415.89 |
| 70360 | RAD EXAM NECK,SOFT TISSUE | $986.98 |
| 70450 | COMPUTED TOMOGRAPHY HD/BR | $6,000.35 |
| 70460 | TOMOGRAPHY HEAD/BRAIN WIT | $6,473.78 |
| 70470 | COMPUTED TOMOGRAPHY HEAD/ | $7,290.89 |
| 70480 | CT ORBIT SELLA/POST FOSSA | $5,449.04 |
| 70481 | CT ORBIT SELLA/POST FOSSA | $6,918.53 |
| 70482 | CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR | $8,800.75 |
| 70486 | CT MAXLFCL AREA C-MATRL | $6,491.00 |
| 70487 | CT MAXLFCL AREA C+ MATRL | $8,034.29 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $7,129.51 |
| 70490 | CT NECK WO CONTRAST | $5,581.92 |
| 70491 | CT SOFT TISS NCK C+MATRL | $6,970.56 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $6,402.00 |
| 70496 | CTA HEAD C-/C+ | $6,569.35 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $6,650.72 |
| 71045 | Radiologic examination, chest ; single view | $1,119.00 |
| 71046 | CHEST XRAY 2 VIEWS | $1,410.15 |
| 71047 | Radiologic examination, chest ; 3 views | $1,428.00 |
| 71100 | RIBS UNILATERAL 2 VIEWS | $1,689.49 |
| 71101 | RIB UNILATERAL W CHEST | $1,643.78 |
| 71110 | RIBS BILATERAL 3 VIEWS | $2,887.49 |
| 71111 | RIBS BILATERAL W/CHEST | $3,412.26 |
| 71120 | Radiologic examination; sternum, minimum of 2 views | $1,314.73 |
| 71250 | CT CHEST W/O CONTRAST | $5,793.47 |
| 71260 | CT THORAX W/CONTRAST | $7,325.61 |
| 71270 | CT THORAX WO CONTRAST | $8,569.40 |
| 71275 | CT ANGIOGRAPHY | $7,192.43 |
| 72020 | Radiologic examination, spine, single view, specify level | $714.00 |
| 72040 | SPINE, CERVICAL 2/3 VIEWS | $1,387.03 |
| 72050 | SPINE, CERVICAL MIN 4VIEW | $2,298.95 |
| 72052 | SPINE CERV. COMP FLEX/EXT | $2,879.53 |
| 72070 | SPINE THORACIC 2 VIEWS | $1,864.83 |
| 72072 | SPINE THORACIC 3 VIEWS | $2,042.75 |
| 72074 | RAD EXAN SPINE THROAC 4 V | $1,605.93 |
| 72080 | RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS | $1,490.51 |
| 72082 | RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW | $2,390.99 |
| 72100 | SPINE LUMBO. MIN 4 VIEWS | $1,655.93 |
| 72110 | LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS | $2,484.48 |
| 72125 | COMPUTED TOMOGRAPHY CERVI | $5,904.47 |
| 72126 | CT CRV SPI C+MATRL | $7,249.92 |
| 72127 | CT CRV SPI C-/C+ | $8,780.00 |
| 72128 | CT THRC SPI C-MATRL | $7,830.72 |
| 72129 | CT THRC SPI C+ MATRL | $7,320.41 |
| 72131 | CT L SPINE WO CONTRST | $7,131.83 |
| 72132 | CT LMBR SPI C+ MATRL | $7,215.83 |
| 72133 | CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL | $7,493.00 |
| 72170 | RAD EXAM PELVIS 1/2 VEIW | $1,155.29 |
| 72190 | RADEX PELVIS COMPL MIN 3 | $1,417.68 |
| 72192 | CT PELVIS WO CONTRAST | $6,238.31 |
| 72193 | TOMOGRAPHY PELVIS WCONTRS | $7,003.32 |
| 72220 | XRAY COCCYX/SACRUM | $1,341.14 |
| 73000 | XRAY CLAVICLE 2 VIEWS | $1,342.35 |
| 73010 | SCAPULA COMPLETE | $1,508.15 |
| 73020 | RADEX SHO 1 VIEW | $1,044.62 |
| 73030 | SHOULDR COMPLETE 2 VIEWS | $1,605.00 |
| 73060 | XRAY HUMERUS MIN 2 VIEWS | $1,305.02 |
| 73070 | XRAY ELBOW 2 VIEWS | $1,451.65 |
| 73080 | XRAY ELBOW GREATER THAN 3 VIEWS-COMP | $1,505.02 |
| 73090 | XRAY FOREARM AP & LAT | $1,232.77 |
| 73092 | Radiologic examination; upper extremity, infant, minimum of… | $997.00 |
| 73100 | XRAY WRIST AP & LAT VIEW | $1,236.77 |
| 73110 | XRAY WRIST/COMP MIN 3 VIE | $1,514.00 |
| 73120 | XRAY HAND AP & LAT | $1,236.00 |
| 73130 | XRAY HAND MIN 3 VIEWS | $1,421.75 |
| 73140 | XRAY FINGER MIN 2 VIEWS | $1,096.72 |
| 73200 | CT UPPR EXTR WO CNTRS | $6,051.50 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $6,125.59 |
| 73202 | CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL | $8,139.25 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $899.68 |
| 73502 | RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN P… | $1,331.50 |
| 73503 | RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS | $3,029.65 |
| 73521 | Radiologic examination, hips, bilateral, with pelvis when p… | $2,996.00 |
| 73522 | RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS | $2,699.97 |
| 73523 | Radiologic examination, hips, bilateral, with pelvis when p… | $3,139.00 |
| 73551 | RADIOLOGIC EXAMINATION FEMUR 1 VIEW | $1,650.00 |
| 73552 | FEMUR; MIN 2 VIEWS | $1,720.31 |
| 73560 | XRAY KNEE, SUNRISE VIEW | $1,151.00 |
| 73562 | XRAY KNEE MIN 3 VIEWS | $1,668.26 |
| 73564 | RAD EXAM KNEE 4 OR MORE | $2,035.51 |
| 73590 | XRAY TIBIA/FIBULA AP/LAT | $1,407.38 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,182.06 |
| 73600 | XRAY ANKLE 2 VIEWS | $1,177.62 |
| 73610 | XRAY ANKLE 3 VIEWS/COMPLE | $1,412.56 |
| 73620 | XRAY FOOT MIN 2 VIEWS | $1,321.00 |
| 73630 | XRAY FOOT MIN 3 VIEWS | $1,883.00 |
| 73650 | RAD EXAN HEEL MIN 2 VIEWS | $1,057.85 |
| 73660 | XRAY TOES, MIN 2 VIEWS | $1,088.51 |
| 73700 | CT LWR EXTR WO CONTRAST | $5,608.28 |
| 73701 | CT LWR EXT W CONT | $7,054.52 |
| 73702 | CT LXTR C-/C+ | $7,201.81 |
| 73706 | CT ANGIOGRAPHY LOWER EXTREMITY | $13,771.00 |
| 74018 | Radiologic examination, abdomen; 1 view | $1,063.05 |
| 74019 | Radiologic examination, abdomen; 2 views | $1,484.30 |
| 74021 | Radiologic examination, abdomen; 3 or more views | $1,639.76 |
| 74022 | RAD EXAM COMPLETE ABD | $1,705.16 |
| 74150 | COMPUTED TOMOGRAPHY ABD | $7,791.41 |
| 74160 | TOMOGRAPHY ABD W/CONTRAST | $8,410.50 |
| 74170 | TOMOGRAPHY ABD W/OCONTRAS | $9,068.43 |
| 74174 | CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG | $15,775.03 |
| 74175 | CT ANGIO ABDOMEN W/CONTRA | $9,171.00 |
| 74176 | COMP TOMOG AB/PEL W/O CON | $9,914.62 |
| 74177 | COMP TOMO AB/PELV W/OCONT | $10,986.69 |
| 74178 | CT ABD & PELVIS 1 PLUS SECTION/REGNS | $13,343.04 |
| 74220 | RADIOLOGIC EXAM ESOPHAGUS SINGLE CONTRAST STUDY | $2,001.14 |
| 74240 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB | $3,088.48 |
| 74246 | Radiologic examination, gastrointestinal tract, upper, air … | $2,527.30 |
| 74250 | RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES | $2,411.38 |
| 74328 | ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I | $2,853.66 |
| 74330 | CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I | $5,004.85 |
| 74340 | INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I | $2,242.00 |
| 75574 | CT CORONARY | $6,053.46 |
| 75635 | CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP | $7,566.54 |
| 76010 | RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD | $979.00 |
| 76376 | 3D RNDR I&R CT MRI US/OTH | $1,871.83 |
| 76536 | ULTRASOUND, SOFT TISSUES OF HEAD AND NECK | $2,623.06 |
| 76604 | US CHEST REAL TIME W/IMAGE DOCUMENTATION | $1,716.51 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $2,739.00 |
| 76642 | US BREAST UNI REAL TIME WITH IMAGE LIMITED | $2,766.31 |
| 76700 | US ABDOMINAL R-T W/IMAGE | $3,749.11 |
| 76705 | US ABDOMINAL | $2,913.68 |
| 76770 | US RETROPERITONEAL R-T W/ | $3,104.40 |
| 76775 | US RPR B-SCAN&/R-T IMG LMTD | $2,902.50 |
| 76801 | ULTRASOUND 14 WK TABDL 1/1ST GESTATION | $2,905.05 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $1,469.12 |
| 76805 | US PG UTER F&MAT AFTER 1S | $3,004.33 |
| 76810 | US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO | $2,164.13 |
| 76815 | ULTRASND PG UTER | $2,534.91 |
| 76816 | US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS | $2,425.15 |
| 76817 | UT PG UTER R-T IMG TRVG | $2,833.44 |
| 76830 | TRANSVAGINAL ULTRASOUND | $2,491.27 |
| 76856 | US PELVIC NONOB REAL-TIME | $3,110.49 |
| 76857 | PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 | $2,144.27 |
| 76870 | US SCROTUM&CNTS | $2,692.89 |
| 76881 | US EXTREMITY NON-VASC REAL-TIME IMG COMPL | $2,977.21 |
| 76882 | ULTRASOUND, EXTREMITY, NON VASCULAR | $2,783.68 |
| 76937 | Us guide vascular access | $2,026.00 |
| 76942 | ULTRASONIC GUIDANCE FOR NEEDLE PLCMNT, IMGNG SUPERVSN AND I… | $3,311.72 |
| 78315 | B1&/JT IMG 3 PHASE STD | $5,640.00 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $417.90 |
| 80048 | METABOLIC PANEL BASIC | $839.17 |
| 80051 | ELECTROLYTE PANEL | $781.42 |
| 80053 | METABOLIC COMPRE PANEL | $1,187.55 |
| 80061 | LIPID PROFILE III | $798.10 |
| 80074 | HEPATITIS PANEL | $1,262.45 |
| 80076 | HEPATIC FUNCTION PANEL | $792.48 |
| 80143 | Acetaminophen | $616.04 |
| 80175 | DRUG SCREEN QUANTITATIVE LAMOTRIGINE | $116.22 |
| 80177 | DRUG SCREEN QUANTITATIVE LEVETIRACETAM | $351.00 |
| 80178 | LITHIUM | $330.30 |
| 80197 | TACROLIMUS | $754.71 |
| 80202 | VANCOMYCIN PEAK | $408.10 |
| 80305 | DRUG TEST, PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUM… | $728.58 |
| 80307 | DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS | $935.00 |
| 80320 | DRUG SCREEN | $526.91 |
| 80329 | DRUG SCREEN | $356.69 |
| 80349 | DRUG SCREENING | $853.71 |
| 80353 | DRUG SCREENING | $853.71 |
| 80361 | DRUG SCREENING | $853.71 |
| 81001 | U/A DIP STICK | $485.32 |
| 81003 | U/A W/O MICRO DIPSTICK | $255.32 |
| 81005 | Urinalysis; qualitative or semiquantitative, except immunoa… | $65.67 |
| 81025 | PREG.TST URINE VISUAL | $491.11 |
| 81240 | F2 GENE ANALYSIS 20210G >A VARIANT | $786.05 |
| 82010 | KETONE BODIES SERUM QUANTITATIVE | $288.04 |
| 82040 | ALBUMIN; SERUM | $201.28 |
| 82075 | ALCOHOL BREATH TEST | $262.92 |
| 82140 | Ammonia | $365.00 |
| 82150 | AMYLASE | $523.51 |
| 82247 | BILIRUBIN TOTAL | $256.60 |
| 82248 | BILIRUBIN DIRECT | $306.65 |
| 82270 | OCCULT BLOOD | $240.31 |
| 82271 | BLOOD OCCULT PEROXIDASE ACTV QUAL OTHER SOURCES | $148.87 |
| 82272 | BLD OCLT PEROXIDASE ACTV | $114.93 |
| 82310 | CALCIUM | $212.00 |
| 82330 | CALCIUM IONIZED | $339.21 |
| 82374 | CARBON DIOXIDE BICARBONATE | $199.00 |
| 82375 | Under Chemistry Procedures | $455.11 |
| 82435 | CHLORIDE BLD | $168.82 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $175.12 |
| 82533 | CORTISOL TOTAL | $454.90 |
| 82550 | CREATINE CK-TOTAL | $343.57 |
| 82553 | CREATINE CKMB | $541.53 |
| 82565 | CREATININE | $314.93 |
| 82607 | VITAMIN B-12 | $268.08 |
| 82728 | ASSAY OF FERRITIN | $555.00 |
| 82746 | ASSAY OF FOLIC ACID SERUM | $294.42 |
| 82747 | ASSAY OF FOLIC ACID RBC | $470.56 |
| 82784 | IGC IMMUNOGLOBULIN | $433.13 |
| 82785 | GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE | $262.68 |
| 82800 | GASES BLD PH ONLY | $163.18 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $659.49 |
| 82805 | Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (… | $824.41 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $311.95 |
| 82947 | GLUCOSE | $284.83 |
| 82948 | GLUCOSE BLOOD REAGET STR | $203.32 |
| 82977 | GLUTAMYLTRANSFERASE-GTT | $216.42 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $291.00 |
| 83050 | Under Chemistry Procedures | $550.24 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITIATIVE NOS | $461.34 |
| 83525 | ASSAY OF INSULIN TOTAL | $360.19 |
| 83540 | IRON-TOTAL | $241.98 |
| 83550 | IRON BINDING CAPACITY | $356.00 |
| 83605 | ASSAY OF LACTATE | $259.81 |
| 83615 | Lactate dehydrogenase (LD), (LDH); | $293.00 |
| 83690 | LIPASE | $469.00 |
| 83735 | MAGNESIUM | $340.00 |
| 83874 | MYOGLOBIN | $309.47 |
| 83880 | B-TYPE NATRIURETIC | $542.32 |
| 83992 | ASSAY OF PHENCYCLIDINE | $459.69 |
| 84075 | ALK PHOS/PROFILE OR PANEL | $270.00 |
| 84100 | ASSAY OF PHOSPHORUS INORGANIC | $239.00 |
| 84132 | POTASSIUM SERUM PLASMA/WHOLE BLOOD | $298.00 |
| 84153 | Prostate specific antigen (PSA); total | $368.00 |
| 84155 | PROTEIN,TOTAL,EXCEPT REFR | $223.80 |
| 84157 | PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC | $256.54 |
| 84165 | PROTEIN ELECTROPHORESIS | $468.95 |
| 84295 | SODIUM; SERUM | $153.00 |
| 84403 | Testosterone; total | $560.52 |
| 84436 | THYRIXINE TOTAL | $278.07 |
| 84439 | THYROXINE-FREE | $389.05 |
| 84443 | Thyroid stimulating hormone (TSH) | $440.69 |
| 84450 | Transferase; aspartate amino (AST) (SGOT) | $343.09 |
| 84460 | ALT-TRANSFERASE;ALANINE | $355.77 |
| 84478 | ASSAY OF TRIGLYCERIDES | $287.37 |
| 84479 | THYROID HORMONE | $541.28 |
| 84480 | T3 TOTAL | $482.60 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $618.77 |
| 84484 | TROPONIN I | $583.78 |
| 84520 | Urea nitrogen; quantitative | $233.22 |
| 84550 | URIC ACID | $343.51 |
| 84560 | URIC ACID OTH SRC | $248.16 |
| 84702 | HCG QUANTATIVE | $554.98 |
| 84703 | PREGNANCY TEST BLOOD | $527.57 |
| 85014 | HEMATOCRIT | $121.51 |
| 85018 | HEMOGLOBIN | $116.93 |
| 85025 | Blood count; complete (CBC) | $361.01 |
| 85027 | CBC W/O DIFF | $258.71 |
| 85044 | RETICULOCYTE COUNT | $71.64 |
| 85347 | COAGJ TM ACTIVATED | $326.63 |
| 85379 | D-DIMER | $593.59 |
| 85384 | FIBRINOGEN ACTIVITY | $412.13 |
| 85397 | Coagulation and fibrinolysis, functional activity, not othe… | $777.10 |
| 85610 | PROTHROMBIN TIME | $306.02 |
| 85651 | SEDIMENTATION RATE NONAUT | $202.85 |
| 85652 | SED RATE ERYTHROCYTE NON | $215.19 |
| 85730 | THROMBOPLASTIN TIME PART | $317.85 |
| 86038 | ANTINUCLEAR AB | $410.17 |
| 86039 | ANTINUCLEAR AB TITER | $616.32 |
| 86060 | ANTISTREPTOLYSIN O TITER | $373.13 |
| 86140 | C REACTIVE PROTEIN | $259.98 |
| 86235 | EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD | $472.85 |
| 86256 | SMOOTH MUSCLE AB TITER | $568.46 |
| 86308 | MONO,HETEROPHILE ANTIBODI | $342.87 |
| 86328 | COVID-19 RAPID ANTIBODY TEST SINGLE METHOD | $100.00 |
| 86360 | T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO | $1,301.46 |
| 86376 | Microsomal antibodies (eg, thyroid or liver-kidney), each | $325.78 |
| 86403 | MONO SPOT | $362.35 |
| 86430 | RHEUMATOID FACTOR | $157.87 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $376.55 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VD… | $290.05 |
| 86593 | Syphilis test, non-treponemal antibody; quantitative | $276.11 |
| 86617 | Antibody; Borrelia burgdorferi (Lyme disease) confirmatory … | $546.00 |
| 86631 | ANTB CHLAMYDIA | $183.00 |
| 86644 | ANTIBODY CYTOMEGALOVIRUS CMV | $501.81 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $613.92 |
| 86664 | EPSTEIN-BARR VIRUS EBNA | $350.11 |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $387.83 |
| 86689 | ANTB HTLV/HIV ANTB CONFIRMATION TST | $593.00 |
| 86695 | Antibody; herpes simplex, type 1 | $347.98 |
| 86696 | Antibody; herpes simplex, type 2 | $408.32 |
| 86701 | HIV SERUM | $767.00 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $529.00 |
| 86705 | HEPATITIS B CORE IGM | $306.46 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $447.00 |
| 86708 | HEPATITIS A ANTIBODY HAAB | $312.00 |
| 86709 | HEPATITIS ANTIBODY HAAB IGM ANTIBODY | $323.87 |
| 86757 | ANTIBODY RICKETTSIA | $288.05 |
| 86769 | COVID-19 RAPID ANTIBODY TEST MULTIPLE STEP METHOD | $100.00 |
| 86780 | TP-Under Qualitative or Semi quantitative Immunologists- | $187.31 |
| 86803 | HEPATITIS C ANTIBODY | $439.00 |
| 86850 | ANTB SCR RBC EA SERUM TQ | $315.78 |
| 86900 | Blood typing, serologic; ABO | $310.13 |
| 86901 | RH FACTOR-BLOOD | $236.89 |
| 87015 | CONCENTRATION INFECTIOUS AGENTS | $162.82 |
| 87040 | BLOOD CULTURE | $631.00 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $570.47 |
| 87046 | Culture, bacterial; stool, aerobic, additional pathogens, i… | $377.36 |
| 87070 | CULTURE BODY FLUID | $467.00 |
| 87075 | CULTURE ANAEROBIC | $701.00 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $393.03 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $326.00 |
| 87081 | CULTURE, BACTERIAL-SCREEN | $357.89 |
| 87086 | URINE CULTURE | $449.32 |
| 87088 | CULTURE BCT ISOL&PRSMPTV | $505.99 |
| 87106 | CUL FNGI DEFINITIVE ID EA ORGANISM YEAST | $302.06 |
| 87110 | CHLAMYDIA CULTURE | $562.00 |
| 87140 | Culture, typing; immunofluorescent method, each antiserum | $194.00 |
| 87177 | Ova and parasites, direct smears, concentration and identif… | $498.48 |
| 87186 | Susceptibility studies, antimicrobial agent | $307.46 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $282.00 |
| 87207 | SMR PRIM SRC SPEC STAIN | $310.44 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $468.89 |
| 87210 | WET SMEAR | $263.25 |
| 87252 | VIRUS TISS CUL INOCULATION CYTOPATHIC EFFECT | $359.53 |
| 87255 | Herpes Simplex Virus Culture with Reflex Typing | $689.85 |
| 87324 | IAAD IA CLOSTRIDIUM DIFFICILE TOXIN | $274.91 |
| 87338 | IAAD IA HPYLORI STOOL | $302.04 |
| 87340 | IAAD IA HEPATITIS B SURFACE ANTIGEN | $451.00 |
| 87341 | IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION | $476.27 |
| 87389 | infection agent etc | $279.65 |
| 87400 | INFLUENZA A&B | $405.86 |
| 87420 | IAAD IA RESPIRATORY SYNCTIAL VIRUS | $522.54 |
| 87425 | IAAD IA ROTAVIRUS | $491.75 |
| 87426 | COVID-19 RAPID ANTIGEN TESTING | $446.62 |
| 87430 | INF AGT IMMUNO STREP A | $221.00 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $285.00 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $477.19 |
| 87493 | INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE | $556.31 |
| 87506 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11 | $1,498.51 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $3,160.95 |
| 87522 | Infectious agent detection by nucleic acid (DNA or RNA); he… | $1,416.35 |
| 87529 | IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ | $1,150.41 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $1,665.64 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $447.57 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $3,757.00 |
| 87635 | Infectious agent detection by nucleic acid (DNA or RNA); se… | $275.00 |
| 87660 | IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ | $471.63 |
| 87661 | IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH | $486.92 |
| 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $672.62 |
| 87804 | INFLUENZA IMMUNOASSAY OPT | $378.23 |
| 87807 | INF AGT DET IMNAS OPT RSV | $348.97 |
| 87880 | RAPID STREP-BETA STREP | $335.45 |
| 88305 | PATH SURG LEVEL IV | $1,222.55 |
| 89050 | CELL COUNT MISCELLANEOUS BODY FLUIDS | $445.15 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $527.00 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $295.32 |
| 89060 | CRYSTAL INDENTIFICATION | $267.06 |
| 90471 | IMMUN ADM 1 VAC | $356.68 |
| 90472 | IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE | $154.56 |
| 90714 | TETANUS DIPHTHERIA TOXOID | $638.00 |
| 90715 | TDAP VACCINE | $547.02 |
| 92950 | Cardiopulmonary resuscitation (eg, in cardiac arrest) | $2,738.00 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYT XTRNL | $4,586.90 |
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; trac… | $1,011.32 |
| 93017 | CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY | $4,759.05 |
| 93041 | RHYTHEM ECG 1-3 LDS | $503.64 |
| 93303 | COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY | $6,128.85 |
| 93306 | ECHO TEST | $7,760.32 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $5,627.00 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $2,277.11 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $2,469.25 |
| 93325 | DOP ECHOCARD COLOR FLOW VELOCITY MAPPING | $1,508.77 |
| 93351 | ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG | $8,973.75 |
| 93880 | DUP-SCAN XTRC ART COMPL B | $3,894.94 |
| 93882 | DUP-SCAN XTRC ART UNI/LMTD STD | $2,806.00 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $6,328.44 |
| 93925 | DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY | $3,347.82 |
| 93926 | DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD | $2,425.62 |
| 93930 | DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY | $3,525.00 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD | $2,203.43 |
| 93970 | DUP-SCAN XTR VEINS COMPL | $4,238.00 |
| 93971 | DPLX SCN EXTRM VEINS | $2,961.51 |
| 93975 | DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, P… | $4,816.86 |
| 93976 | DUPLEX SCAN- LIMITED | $2,686.00 |
| 94010 | SPIROMETRY W/RECORD | $1,742.74 |
| 94150 | Vital capacity test | $1,031.74 |
| 94640 | NEBULIZER TREATMENT | $762.00 |
| 94644 | INHALATION TREATMENT – CONTINUOUS 1ST HR | $757.25 |
| 94660 | CPAP VENTILATION CPAP INITIATION&MGMT | $1,855.11 |
| 94664 | DEMO&/EVAL OF PT UTILIZ | $351.62 |
| 94760 | EAR OR PULSE OXIMETRY | $249.04 |
| 94761 | N-INVAS EAR/PLS OXIMTRY F | $501.00 |
| 94762 | NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR | $1,171.95 |
| 96360 | IV INFUS INIT 31 MIN 1 HR | $1,464.84 |
| 96361 | IV INFUS HYDR EA ADD’T HR | $597.33 |
| 96365 | IV INFUSION THERAPY/PROPH | $1,467.74 |
| 96366 | IV INFUS THER PROPH/DX EA | $688.00 |
| 96367 | IV NFS THER PROPH/DX ADDL | $1,486.18 |
| 96368 | IV NFS TX PROPHYLAXIS/DX | $1,128.35 |
| 96372 | THERAPEUTIC PROPHYLACTIC/ | $583.04 |
| 96374 | THER PROPH/DX NJX IV PUSH | $753.31 |
| 96375 | THER PROPH/DX NJX EA SEQL | $621.20 |
| 96376 | SUB INFU EA ADD IV PUSH | $471.15 |
| 97116 | THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR | $330.24 |
| 97140 | MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES | $450.45 |
| 97166 | OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS | $1,062.60 |
| 97597 | DEBRIDEMENT OPEN WOUND 20 SQ CM/< | $1,053.00 |
| 99000 | SPECIMEN HANDLING | $53.00 |
| 99001 | COC COLLECITON ONLY | $142.88 |
| 99070 | SUPPLIES&MATERIALS ABOVE or BEYOND PROV BY PHYS or QHP | $117.03 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $1,099.00 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $2,852.00 |
| 99153 | Moderate sedation services provided by the same physician o… | $286.59 |
| 99156 | MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS | $756.60 |
| 99157 | MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS | $186.00 |
| 99173 | SCREENING TEST OF VISION | $761.53 |
| 99281 | E/M VISIT LEVEL 1 TECH COMP | $1,000.00 |
| 99282 | E/M VISIT LEVEL 2 TECH COMP | $1,965.24 |
| 99283 | E/M VISIT LEVEL 3 TECH COMP | $3,485.69 |
| 99284 | E/M VISIT LEVEL 4 TECH COMP | $5,681.64 |
| 99285 | E/M VISIT LEVEL 5 TECH COMP | $7,635.21 |
| 99291 | CRITICAL CARE 30-74 MIN | $10,658.97 |
| 99292 | CRITICAL CARE ADD 30 MIN | $2,865.36 |
| G0378 | HOSPITAL OBSERVATION SERVICES PER HOUR | $2,500.00 |
| J0131 | INJECTION, ACETAMINOPHEN, 10 MG | $48.13 |
| J0153 | ADENOSINE INJ 1MG | $50.30 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $50.30 |
| J0282 | INJ AMIODARONE HYDROCHLOR | $32.59 |
| J0290 | AMPICILLIN 500 MG INJ | $79.00 |
| J0295 | INJ AMPCLLN SODIUM/SULBA | $64.62 |
| J0330 | SUCCINYLCHOLINE CHLO 20MG | $121.80 |
| J0360 | HYDRALAZINE HCL INJ UP TO 20MG | $162.55 |
| J0456 | INJ AZITHROMYCIN 500MG | $106.99 |
| J0461 | INJ ATROPINE SULFATE 0.01 | $22.13 |
| J0500 | DICYCLOMINE HCL 20MG | $557.51 |
| J0515 | Injection, benztropine mesylate, per 1 mg | $390.46 |
| J0561 | INJECTION PENICILLIN G BENZATHINE 100,000 UNITS | $215.93 |
| J0595 | STADOL | $65.00 |
| J0690 | KEFZOL 1 GR VIAL | $34.00 |
| J0692 | INJ CEFEPIME HCI 500MG | $62.78 |
| J0696 | ROCEPHIN 250 MG | $49.21 |
| J0735 | CLONIDINE 1MG | $177.31 |
| J0744 | CIPRO 200MG | $85.77 |
| J0780 | COMPAZINE 10 MG | $156.16 |
| J1030 | DEPO MEDROL 40 MG/ML | $68.63 |
| J1040 | METHYLPREDNISOLONE 80MG | $119.76 |
| J1100 | DECADRON 4 MG VIAL | $21.98 |
| J1110 | dihydroergotamine mesylate | $1,259.92 |
| J1165 | DILANTIN 100 MG VIAL | $20.45 |
| J1170 | DILAUDID 4 MG | $61.48 |
| J1200 | BENADRYL 50MG | $40.82 |
| J1335 | ERTAPENEM INJECTION | $605.36 |
| J1580 | GARAMYCIN,GENTAMICIN 80MG | $61.96 |
| J1610 | GLUCOGAN 1 MG VIAL | $1,555.50 |
| J1630 | HALOPERIDOL INJECTION | $63.94 |
| J1642 | HEPARIN SODIUM PER 10 UNI | $12.11 |
| J1644 | INJ HEPARIN SOD PER 1000 | $78.18 |
| J1650 | ENOXAPARIN SODIUM 10MG | $159.24 |
| J1670 | TETANUS INJECTION | $4,732.95 |
| J1815 | INJ INSULIN PER 5 UNITS | $23.74 |
| J1885 | TORADOL INJ 15 MG | $45.64 |
| J1940 | LASIX 40 MG IV VIAL | $46.86 |
| J1956 | LEVOFLOXACIN 250 MG | $78.35 |
| J2001 | LIDOCAINE HCI 10MG | $19.77 |
| J2060 | ATIVAN 2ML SYRUP | $51.89 |
| J2150 | MANNITOL INJECTION | $45.38 |
| J2175 | DEMEROL 50 MG SYRINGE | $59.82 |
| J2250 | MIDAZOLAM HCI PER 1 MG | $19.19 |
| J2270 | INJ MORPHINE SULFATE 10 M | $46.30 |
| J2274 | INJ MORPHINE PF EPID ITHC | $80.50 |
| J2300 | NUBAIN 10MG AMP | $102.25 |
| J2310 | INJ NALOXONE HCL 1MG | $210.81 |
| J2360 | ORPHENADRINE CITRATE 60MG | $140.03 |
| J2370 | NEO-SYNEPHRINE UP TO 1 ML | $96.16 |
| J2405 | ONDANSETRON HCI, PER MG | $18.94 |
| J2543 | ZOSYN – PIPERACILLIN/TAZOBACTAM | $75.76 |
| J2550 | PHENERGAN 50 MG | $49.68 |
| J2704 | INJ, PROPOFOL, 10 MG | $25.40 |
| J2765 | METOCLOPRAMIDE HCL 10MG | $34.76 |
| J2770 | Quinupristin/dalfopristin | $1,656.91 |
| J2790 | RHOGAM INJECTION | $339.05 |
| J2800 | METHOCARBAMOL INJECTION | $344.59 |
| J2920 | SOLU-MEDROL 40MG | $122.10 |
| J2930 | SOLU-MEDROL 125 MG | $110.69 |
| | | $22.78 |
| J3030 | IMITREX 6MG VIAL | $167.37 |
| J3105 | INJECTION, TREBUTALINE SULFATE, UP TO 1 MG | $72.76 |
| J3230 | THOROZINE 50 MG | $347.06 |
| J3360 | VALIUM INJ 5 MG | $157.22 |
| J3370 | VANCOMYCIN HCI INJ 500MG | $198.77 |
| J3410 | VISTERIL INJ 50 MG | $74.46 |
| J3411 | INJ THIAMINE 100 MG | $89.60 |
| J3430 | INJECTION, (PHYTONADIONE) VITAMIN K, PER 1 MG | $101.43 |
| J3475 | MAGNESIUM SULFATE 2CC AMP | $50.15 |
| J3480 | POTASSIUM CHLORIDE 2 MG | $35.12 |
| J3486 | GEODON – ZIPRASIDONE MESYLATE 10MG | $272.18 |
| J3490 | UNCLASSIFIED DRUGS | $458.39 |
| J7030 | INFUS NORM SALINE 1000CC | $104.54 |
| J7040 | INFUS NORM SALINE 500ML | $92.06 |
| J7042 | 5% DEXTROSE | $74.31 |
| J7050 | INFS NORM SALINE 250CC | $97.51 |
| J7060 | INFUSION D5W 250ML | $93.48 |
| J7070 | INFUSION D5W 1000ML | $62.50 |
| J7120 | RINGER’S LACTATE INFUS | $188.27 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $242.92 |
| J7510 | PREDNISOLONE ORAL 5 MG | $7.72 |
| J7512 | PREDNISONE 5 MG | $6.62 |
| J7607 | LEVALBUTEROL COMP CON | $27.71 |
| J7613 | ALBUT INHAL NON-CP 1MG | $36.89 |
| J7614 | ALBUTEROL ALL FOMULATIONS | $27.52 |
| J7620 | ALBUTEROL 2.5 MG ATROVENT | $36.89 |
| J7644 | IPRATROPIUM BROMIDE INHAL | $53.75 |
| J7699 | NOC DRUGS INHAL SOL ADMIN | $38.19 |
| J8499 | NONCHEMOTHERAPEUTIC ORAL | $73.09 |
| J8540 | DEXAMETHASONE, ORAL .25MG | $14.82 |
| L0120 | CERVICAL FLEX NONADJ COLL | $244.41 |
| L0150 | CERV SEMI-RIG ADJ MOLDED CHN | $368.00 |
| L0464 | TLSO 4MOD SACRO-SCAP PRE | $9,421.00 |
| L1600 | Hip orthosis (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | $234.82 |
| L1830 | KNEE IMMOBOLIZER | $224.00 |
| L3260 | SURGICAL BOOT/SHOE | $228.41 |
| L3620 | Transfer of an orthosis from one shoe to another, solid stirrup, existing | $359.00 |
| L3650 | SO FIGURE EIGHT ABDUCTION | $654.91 |
| L3660 | SO 8 AB RSTR CAN/WEB PRE OTS | $686.43 |
| L3908 | WRIST EXTN CONTROL COCKUP | $228.41 |
| L3913 | Hand-finger orthosis (HFO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | $733.00 |
| L4350 | AIR SPLINT | $888.41 |
| L8501 | Tracheostomy speaking valve | $762.17 |
| M0243 | Intravenous infusion, casirivimab and imdevimab, includes i… | $1,200.00 |
| M0245 | Intravenous infusion, bamlanivimab and etesevimab, includes… | $1,200.00 |
| Q9966 | LOCM 200-299MG ML IODINE, 1ML | $12.63 |
| Q9967 | LOW OSMOLAR CNTRS MAT | $13.00 |
| S0028 | INJECT FAMOTIDINE 20 MG | $62.06 |
| S0119 | ZOFRAN, 4MG, ORAL | $161.73 |
| S0164 | PROTONIX PANTROPRAZOLE 40MG | $256.01 |
| S5000 | PRESCRIPTION DRUG GENERIC | $14.15 |
| S5001 | PRESCRIPTION DRUG BAND NM | $17.93 |
| S8451 | SPLINT WRIST OR ANKLE | $169.68 |
| U0002 | SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple ty… | $150.00 |
