CPT Codes,Description,Gross Charge,De-Identified minimum negotiated charge,De-identified maximum negotiated charge,Discounted Cash Price
10060,INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE,"$1,263.00 ",#N/A,#N/A,N/A
10061,INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE,"$1,263.00 ",#N/A,#N/A,N/A
10080,INCISION & DRAINAGE PILONIDAL CYST SIMPLE,"$1,263.00 ",#N/A,#N/A,N/A
10120,INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,"$1,263.00 ",#N/A,#N/A,N/A
10121,INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL,"$1,260.00 ",#N/A,#N/A,N/A
10160,PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST,$600.00 ,#N/A,#N/A,N/A
11000,DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF,"$1,260.00 ",#N/A,#N/A,N/A
11042,DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,"$1,260.00 ",#N/A,#N/A,N/A
11719,TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,$420.00 ,#N/A,#N/A,N/A
11730,AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1,"$1,365.00 ",#N/A,#N/A,N/A
11740,EVACUATION SUBUNGUAL HEMATOMA,$648.00 ,#N/A,#N/A,N/A
11750,EXCISION NAIL MATRIX PERMANENT REMOVAL,"$1,260.00 ",#N/A,#N/A,N/A
11982,REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,"$1,362.00 ",#N/A,#N/A,N/A
12001,SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK,$738.00 ,#N/A,#N/A,N/A
12002,SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM,$738.00 ,#N/A,#N/A,N/A
12004,SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,$714.00 ,#N/A,#N/A,N/A
12005,SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM,$714.00 ,#N/A,#N/A,N/A
12011,SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,"$1,362.00 ",#N/A,#N/A,N/A
12013,SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,"$1,260.00 ",#N/A,#N/A,N/A
12014,SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM,"$1,260.00 ",#N/A,#N/A,N/A
12015,SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM,"$1,512.00 ",#N/A,#N/A,N/A
12032,REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,"$1,200.00 ",#N/A,#N/A,N/A
12041,REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,"$1,764.00 ",#N/A,#N/A,N/A
12042,REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,"$1,890.00 ",#N/A,#N/A,N/A
12044,REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM,"$1,260.00 ",#N/A,#N/A,N/A
12051,REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<,"$1,764.00 ",#N/A,#N/A,N/A
12052,REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM,"$1,362.00 ",#N/A,#N/A,N/A
13120,REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM,"$1,362.00 ",#N/A,#N/A,N/A
13152,REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM,"$1,362.00 ",#N/A,#N/A,N/A
15850,REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON,"$1,026.00 ",#N/A,#N/A,N/A
16000,INITIAL TX 1ST DEGREE BURN LOCAL TX,"$1,512.00 ",#N/A,#N/A,N/A
16020,DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,"$1,362.00 ",#N/A,#N/A,N/A
16030,DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE,"$1,152.00 ",#N/A,#N/A,N/A
19000,PUNCTURE ASPIRATION CYST BREAST,"$3,024.00 ",#N/A,#N/A,N/A
19100,BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX,"$3,024.00 ",#N/A,#N/A,N/A
20550,INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS,"$1,020.00 ",#N/A,#N/A,N/A
20551,INJECTION SINGLE TENDON ORIGIN/INSERTION,"$1,020.00 ",#N/A,#N/A,N/A
20552,INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES,"$1,020.00 ",#N/A,#N/A,N/A
20553,INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES,"$1,020.00 ",#N/A,#N/A,N/A
20600,ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US,"$1,200.00 ",#N/A,#N/A,N/A
20605,ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US,"$1,260.00 ",#N/A,#N/A,N/A
20610,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US,"$1,260.00 ",#N/A,#N/A,N/A
20611,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,"$1,152.00 ",#N/A,#N/A,N/A
20612,ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ,$540.00 ,#N/A,#N/A,N/A
23550,OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC,"$1,020.00 ",#N/A,#N/A,N/A
23650,CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,"$1,260.00 ",#N/A,#N/A,N/A
23665,CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ,"$1,512.00 ",#N/A,#N/A,N/A
24105,EXCISION OLECRANON BURSA,"$1,140.00 ",#N/A,#N/A,N/A
24640,CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,"$1,260.00 ",#N/A,#N/A,N/A
25600,CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ,"$1,152.00 ",#N/A,#N/A,N/A
25605,CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,"$1,152.00 ",#N/A,#N/A,N/A
26010,DRAINAGE FINGER ABSCESS SIMPLE,"$1,260.00 ",#N/A,#N/A,N/A
26725,CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA,"$1,260.00 ",#N/A,#N/A,N/A
27372,REMOVAL FOREIGN BODY DEEP THIGH/KNEE,$540.00 ,#N/A,#N/A,N/A
28190,REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS,"$1,512.00 ",#N/A,#N/A,N/A
28192,REMOVAL FOREIGN BODY FOOT DEEP,"$1,260.00 ",#N/A,#N/A,N/A
28470,CLOSED TX METATARSAL FRACTURE W/O MANIPULATION,"$2,400.00 ",#N/A,#N/A,N/A
28490,CLTX FX GRT TOE PHLX/PHLG W/O MANJ,"$1,152.00 ",#N/A,#N/A,N/A
29075,APPLICATION CAST ELBOW FINGER SHORT ARM,"$1,098.00 ",#N/A,#N/A,N/A
29086,APPLICATION CAST FINGER,"$1,062.00 ",#N/A,#N/A,N/A
29105,APPLICATION LONG ARM SPLINT SHOULDER HAND,"$1,188.00 ",#N/A,#N/A,N/A
29125,APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC,"$1,014.00 ",#N/A,#N/A,N/A
29126,APPLICATION SHORT ARM SPLINT DYNAMIC,"$1,079.00 ",#N/A,#N/A,N/A
29130,APPLICATION FINGER SPLINT STATIC,$583.00 ,#N/A,#N/A,N/A
29131,APPLICATION FINGER SPLINT DYNAMIC,$655.00 ,#N/A,#N/A,N/A
29240,STRAPPING SHOULDER,"$1,260.00 ",#N/A,#N/A,N/A
29280,STRAPPING HAND/FINGER,"$1,260.00 ",#N/A,#N/A,N/A
29450,APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG,"$1,260.00 ",#N/A,#N/A,N/A
29505,APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES,$941.00 ,#N/A,#N/A,N/A
29515,APPLICATION SHORT LEG SPLINT CALF FOOT,"$1,019.00 ",#N/A,#N/A,N/A
29530,STRAPPING KNEE,"$2,040.00 ",#N/A,#N/A,N/A
29540,STRAPPING ANKLE &/FOOT,"$1,362.00 ",#N/A,#N/A,N/A
29550,STRAPPING TOES,"$1,362.00 ",#N/A,#N/A,N/A
29700,REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST,"$1,260.00 ",#N/A,#N/A,N/A
30300,REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE,"$1,512.00 ",#N/A,#N/A,N/A
30901,CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,"$1,512.00 ",#N/A,#N/A,N/A
30903,CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,"$1,200.00 ",#N/A,#N/A,N/A
30905,CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,"$1,512.00 ",#N/A,#N/A,N/A
3120F,12-LEAD ECG PERFORMED,$276.00 ,#N/A,#N/A,N/A
31541,LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP,"$1,200.00 ",#N/A,#N/A,N/A
33512,CORONARY ARTERY BYPASS 3 CORONARY VENOUS GRAFTS,"$3,024.00 ",#N/A,#N/A,N/A
36000,INTRODUCTION NEEDLE/INTRACATHETER VEIN,$204.00 ,#N/A,#N/A,N/A
36010,INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA,$684.00 ,#N/A,#N/A,N/A
36410,NON-ROUTINE BL DRAW 3/> YRS,$378.00 ,#N/A,#N/A,N/A
36415,ROUTINE VENIPUNCTURE,$456.00 ,#N/A,#N/A,N/A
36416,COLLECTION CAPILLARY BLOOD SPECIMEN,$684.00 ,#N/A,#N/A,N/A
36555,INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y,$900.00 ,#N/A,#N/A,N/A
36558,INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/>,"$1,500.00 ",#N/A,#N/A,N/A
36569,INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/>,"$1,152.00 ",#N/A,#N/A,N/A
36572,INSERTION PICC W/RS&I < 5 YR,$600.00 ,#N/A,#N/A,N/A
36600,ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX,$900.00 ,#N/A,#N/A,N/A
43752,NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE,"$2,332.00 ",#N/A,#N/A,N/A
43753,GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE,"$1,500.00 ",#N/A,#N/A,N/A
51702,INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE,"$1,260.00 ",#N/A,#N/A,N/A
51703,INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED,"$1,260.00 ",#N/A,#N/A,N/A
57415,REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL,"$1,260.00 ",#N/A,#N/A,N/A
58301,REMOVAL INTRAUTERINE DEVICE IUD,"$1,260.00 ",#N/A,#N/A,N/A
64450,INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH,"$1,362.00 ",#N/A,#N/A,N/A
64451,"Injection(s), anesthetic agent(s) and/or steroid;",$600.00 ,#N/A,#N/A,N/A
65205,REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,"$1,512.00 ",#N/A,#N/A,N/A
65210,RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR,"$1,260.00 ",#N/A,#N/A,N/A
65220,RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP,"$1,362.00 ",#N/A,#N/A,N/A
65222,RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP,"$1,512.00 ",#N/A,#N/A,N/A
65435,RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION,"$1,362.00 ",#N/A,#N/A,N/A
69200,RMVL FB XTRNL AUDITORY CANAL W/O ANES,"$1,362.00 ",#N/A,#N/A,N/A
69209,REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT,"$1,362.00 ",#N/A,#N/A,N/A
69210,REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,"$1,512.00 ",#N/A,#N/A,N/A
70030,RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY,"$2,190.00 ",#N/A,#N/A,N/A
70110,RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS,"$2,538.00 ",#N/A,#N/A,N/A
70130,RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE,"$1,824.00 ",#N/A,#N/A,N/A
70140,RADEX FACIAL BONES < 3 VIEWS,"$2,394.00 ",#N/A,#N/A,N/A
70150,RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS,"$2,394.00 ",#N/A,#N/A,N/A
70160,RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
70200,RADEX ORBITS COMPLETE MINIMUM 4 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
70210,RADEX SINUSES PARANASAL <3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
70220,RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
70250,RADIOLOGIC EXAMINATION SKULL 4/> VIEWS,"$2,724.00 ",#N/A,#N/A,N/A
70260,RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS,"$2,724.00 ",#N/A,#N/A,N/A
70330,RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT,"$3,024.00 ",#N/A,#N/A,N/A
70360,RADIOLOGIC EXAMINATION NECK SOFT TISSUE,"$3,024.00 ",#N/A,#N/A,N/A
70450,CT HEAD/BRAIN W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70460,CT HEAD/BRAIN W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70470,CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70480,CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL,"$6,804.00 ",#N/A,#N/A,N/A
70481,CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL,"$6,804.00 ",#N/A,#N/A,N/A
70482,CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR,"$6,804.00 ",#N/A,#N/A,N/A
70486,CT MAXILLOFACIAL W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70487,CT MAXILLOFACIAL W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70488,CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL,"$6,048.00 ",#N/A,#N/A,N/A
70490,CT SOFT TISSUE NECK W/O CONTRAST MATERIAL,"$6,048.00 ",#N/A,#N/A,N/A
70491,CT SOFT TISSUE NECK W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
70492,CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL,"$6,048.00 ",#N/A,#N/A,N/A
70496,CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST,"$6,048.00 ",#N/A,#N/A,N/A
70498,CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST,"$6,048.00 ",#N/A,#N/A,N/A
71010,RADIOLOGIC EXAMINATION CHEST SINGLE VIEW FRONTAL,"$2,724.00 ",#N/A,#N/A,N/A
71020,RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL,"$2,724.00 ",#N/A,#N/A,N/A
71035,RADEX CHEST SPECIAL VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
71045,"Radiologic examination, chest ; single view","$2,370.00 ",#N/A,#N/A,N/A
71046,"Radiologic examination, chest ; 2 views","$3,024.00 ",#N/A,#N/A,N/A
71047,"Radiologic examination, chest ; 3 views","$3,024.00 ",#N/A,#N/A,N/A
71048,"(Radiologic examination, chest ; 4 or more","$3,024.00 ",#N/A,#N/A,N/A
71100,RADEX RIBS UNILATERAL 2 VIEWS,"$2,274.00 ",#N/A,#N/A,N/A
71101,RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS,"$2,634.00 ",#N/A,#N/A,N/A
71110,RADEX RIBS BILATERAL 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
71111,RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
71120,RADEX STERNUM MINIMUM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
71250,CT THORAX W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
71260,CT THORAX W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
71270,CT THORAX W/O & W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
71275,CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST,"$6,804.00 ",#N/A,#N/A,N/A
72020,RADEX SPINE 1 VIEW SPECIFY LEVEL,"$3,024.00 ",#N/A,#N/A,N/A
72040,RADEX SPINE CERVICAL 2 OR 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72050,RADEX SPINE CERVICAL 4 OR 5 VIEWS,"$3,025.00 ",#N/A,#N/A,N/A
72052,RADEX SPINE CERVICAL 6 OR MORE VIEWS,"$3,025.00 ",#N/A,#N/A,N/A
72070,RADEX SPINE THORACIC 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72072,RADEX SPINE THORACIC 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72074,RADEX SPINE THORACIC MINIMUM 4 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72080,RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72082,RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW,"$3,024.00 ",#N/A,#N/A,N/A
72100,RADEX SPINE LUMBOSACRAL 2/3 VIEWS,"$3,258.00 ",#N/A,#N/A,N/A
72110,RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS,"$3,571.00 ",#N/A,#N/A,N/A
72114,RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6,"$3,024.00 ",#N/A,#N/A,N/A
72120,RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72125,CT CERVICAL SPINE W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72126,CT CERVICAL SPINE W/CONTRAST MATERIAL,"$6,048.00 ",#N/A,#N/A,N/A
72127,CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL,"$6,930.00 ",#N/A,#N/A,N/A
72128,CT THORACIC SPINE W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72129,CT THORACIC SPINE W/CONTRAST MATERIAL,"$6,048.00 ",#N/A,#N/A,N/A
72130,CT THORACIC SPINE W/O & W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72131,CT LUMBAR SPINE W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72132,CT LUMBAR SPINE W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72133,CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72170,RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS,"$2,111.00 ",#N/A,#N/A,N/A
72190,RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS,"$2,214.00 ",#N/A,#N/A,N/A
72192,CT PELVIS W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
72193,CT PELVIS W/CONTRAST MATERIAL,"$6,827.00 ",#N/A,#N/A,N/A
72220,RADEX SACRUM & COCCYX MINIMUM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
72270,MYELOGRAPY 2/MORE REGIONS RS&I,"$3,024.00 ",#N/A,#N/A,N/A
73000,RADEX CLAVICLE COMPLETE,"$3,024.00 ",#N/A,#N/A,N/A
73010,RADEX SCAPULA COMPLETE,"$3,024.00 ",#N/A,#N/A,N/A
73020,RADEX SHOULDER 1 VIEW,"$2,279.00 ",#N/A,#N/A,N/A
73030,RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS,"$3,235.00 ",#N/A,#N/A,N/A
73050,RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ,"$3,024.00 ",#N/A,#N/A,N/A
73060,RADEX HUMERUS MINIMUM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73070,RADEX ELBOW 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73080,RADEX ELBOW COMPLETE MINIMUM 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73090,RADEX FOREARM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73100,RADEX WRIST 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73110,RADEX WRIST COMPLETE MINIMUM 3 VIEWS,"$3,164.00 ",#N/A,#N/A,N/A
73120,RADEX HAND 2 VIEWS,"$2,584.00 ",#N/A,#N/A,N/A
73130,RADEX HAND MINIMUM 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73140,RADEX FINGR MINIMUM 2 VIEWS,"$2,274.00 ",#N/A,#N/A,N/A
73200,CT UPPER EXTREMITY W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
73201,CT UPPER EXTREMITY W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
73202,CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
73501,RADEX HIP UNILATERAL WITH PELVIS 1 VIEW,"$2,100.00 ",#N/A,#N/A,N/A
73502,RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73503,RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73510,X-RAY HIP UNILATERAL 2 VIEWS,"$2,154.00 ",#N/A,#N/A,N/A
73522,RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73551,RADIOLOGIC EXAMINATION FEMUR 1 VIEW,"$1,320.00 ",#N/A,#N/A,N/A
73552,RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,"$2,382.00 ",#N/A,#N/A,N/A
73560,RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS,"$2,016.00 ",#N/A,#N/A,N/A
73562,RADIOLOGIC EXAMINATION KNEE 3 VIEWS,"$3,300.00 ",#N/A,#N/A,N/A
73564,RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73565,RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST,"$3,024.00 ",#N/A,#N/A,N/A
73590,RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73592,RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73600,RADIOLOGIC EXAMINATION ANKLE 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73610,RADEX ANKLE COMPLETE MINIMUM 3 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73620,RADIOLOGIC EXAMINATION FOOT 2 VIEWS,"$2,538.00 ",#N/A,#N/A,N/A
73630,RADEX FOOT COMPLETE MINIMUM 3 VIEWS,"$2,700.00 ",#N/A,#N/A,N/A
73650,RADEX CALCANEUS MINIMUM 2 VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
73660,RADEX TOE MINIMUM 2 VIEWS,"$1,760.00 ",#N/A,#N/A,N/A
73700,CT LOWER EXTREMITY W/O CONTRAST MATERIAL,"$8,004.00 ",#N/A,#N/A,N/A
73701,CT LOWER EXTREMITY W/CONTRAST MATERIAL,"$7,770.00 ",#N/A,#N/A,N/A
73718,MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL,"$7,814.00 ",#N/A,#N/A,N/A
74000,RADEX ABDOMEN 1 ANTEROPOSTERIOR VIEW,"$3,024.00 ",#N/A,#N/A,N/A
74018,"Radiologic examination, abdomen; 1 view","$2,142.00 ",#N/A,#N/A,N/A
74019,"Radiologic examination, abdomen; 2 views","$2,058.00 ",#N/A,#N/A,N/A
74020,RADEX ABDOMEN COMPL W/DCBTS&/ERC VIEWS,"$3,024.00 ",#N/A,#N/A,N/A
74021,"Radiologic examination, abdomen; 3 or more views","$2,389.00 ",#N/A,#N/A,N/A
74022,RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH,"$2,275.00 ",#N/A,#N/A,N/A
74150,CT ABDOMEN W/O CONTRAST MATERIAL,"$7,177.00 ",#N/A,#N/A,N/A
74160,CT ABDOMEN W/CONTRAST MATERIAL,"$7,177.00 ",#N/A,#N/A,N/A
74174,CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG,"$6,804.00 ",#N/A,#N/A,N/A
74175,CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST,"$7,170.00 ",#N/A,#N/A,N/A
74176,CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
74177,CT ABDOMEN & PELVIS W/CONTRAST MATERIAL,"$6,804.00 ",#N/A,#N/A,N/A
74178,CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE,"$6,810.00 ",#N/A,#N/A,N/A
74190,PERITONEOGRAM RS&I,"$3,024.00 ",#N/A,#N/A,N/A
74240,RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB,"$3,024.00 ",#N/A,#N/A,N/A
74241,RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB,"$3,024.00 ",#N/A,#N/A,N/A
74245,RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES,"$3,024.00 ",#N/A,#N/A,N/A
74250,RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES,"$3,024.00 ",#N/A,#N/A,N/A
74251,RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE,"$3,024.00 ",#N/A,#N/A,N/A
74328,ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I,"$4,282.00 ",#N/A,#N/A,N/A
74329,ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I,"$3,024.00 ",#N/A,#N/A,N/A
74330,CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I,"$3,286.00 ",#N/A,#N/A,N/A
74340,INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I,"$1,500.00 ",#N/A,#N/A,N/A
74440,VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I,"$3,024.00 ",#N/A,#N/A,N/A
76380,CT LIMITED/LOCALIZED FOLLOW UP STUDY,"$6,804.00 ",#N/A,#N/A,N/A
76536,US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM,"$3,024.00 ",#N/A,#N/A,N/A
76604,US CHEST REAL TIME W/IMAGE DOCUMENTATION,"$2,724.00 ",#N/A,#N/A,N/A
76641,US BREAST UNI REAL TIME WITH IMAGE COMPLETE,"$1,884.00 ",#N/A,#N/A,N/A
76642,US BREAST UNI REAL TIME WITH IMAGE LIMITED,"$1,194.00 ",#N/A,#N/A,N/A
76700,US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION,"$3,224.00 ",#N/A,#N/A,N/A
76705,US ABDOMINAL REAL TIME W/IMAGE LIMITED,"$4,003.00 ",#N/A,#N/A,N/A
76770,US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE,"$2,153.00 ",#N/A,#N/A,N/A
76775,US RETROPERITONEAL REAL TIME W/IMAGE LIMITED,"$3,024.00 ",#N/A,#N/A,N/A
76801,US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT,"$2,724.00 ",#N/A,#N/A,N/A
76802,US PREG UTERUS 14 WK TRANSABDL EACH GESTATION,"$1,170.00 ",#N/A,#N/A,N/A
76805,US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION,"$3,024.00 ",#N/A,#N/A,N/A
76810,US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO,"$3,024.00 ",#N/A,#N/A,N/A
76816,US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS,"$1,854.00 ",#N/A,#N/A,N/A
76817,US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG,"$3,024.00 ",#N/A,#N/A,N/A
76830,US TRANSVAGINAL,"$3,208.00 ",#N/A,#N/A,N/A
76856,US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE,"$3,024.00 ",#N/A,#N/A,N/A
76857,US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U,"$2,724.00 ",#N/A,#N/A,N/A
76870,US SCROTUM & CONTENTS,"$3,654.00 ",#N/A,#N/A,N/A
76881,US EXTREMITY NON-VASC REAL-TIME IMG COMPL,"$3,024.00 ",#N/A,#N/A,N/A
76882,US EXTREMITY NON-VASC REAL-TIME IMG LMTD,"$1,380.00 ",#N/A,#N/A,N/A
80047,BASIC METABOLIC PANEL CALCIUM IONIZED,"$1,554.00 ",#N/A,#N/A,N/A
80048,BASIC METABOLIC PANEL CALCIUM TOTAL,"$1,430.00 ",#N/A,#N/A,N/A
80051,ELECTROLYTE PANEL,$540.00 ,#N/A,#N/A,N/A
80053,COMPREHENSIVE METABOLIC PANEL,"$1,794.00 ",#N/A,#N/A,N/A
80061,LIPID PANEL,"$1,512.00 ",#N/A,#N/A,N/A
80074,ACUTE HEPATITIS PANEL,"$1,440.00 ",#N/A,#N/A,N/A
80076,HEPATIC FUNCTION PANEL,"$1,458.00 ",#N/A,#N/A,N/A
80102,"Drug confirmation, each procedure",$276.00 ,#N/A,#N/A,N/A
80299,QUANTITATION DRUG NOT ELSEWHERE SPECIFIED,"$1,020.00 ",#N/A,#N/A,N/A
80305,DRUG TEST PRSMV QUAL DIR OPTICAL OBS PER DAY,$493.00 ,#N/A,#N/A,N/A
80307,DRUG TEST PRSMV INSTRMNT CHEMISTRY ANALYZERS,$756.00 ,#N/A,#N/A,N/A
80320,DRUG SCREEN QUANTITATIVE ALCOHOLS,$684.00 ,#N/A,#N/A,N/A
80324,DRUG SCREEN QUANT AMPHETAMINES 1 OR 2,$756.00 ,#N/A,#N/A,N/A
80329,DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2,$684.00 ,#N/A,#N/A,N/A
80335,ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,$276.00 ,#N/A,#N/A,N/A
80345,DRUG SCREENING BARBITURATES,$756.00 ,#N/A,#N/A,N/A
80346,DRUG SCREENING BENZODIAZEPINES 1-12,$756.00 ,#N/A,#N/A,N/A
80347,DRUG SCREENING BENZODIAZEPINES 13 OR MORE,$630.00 ,#N/A,#N/A,N/A
80348,DRUG SCREENING BUPRENORPHINE,$630.00 ,#N/A,#N/A,N/A
80349,DRUG SCREENING CANNABINOIDS NATURAL,$480.00 ,#N/A,#N/A,N/A
80351,DRUG SCREENING CANNABINOIDS SYNTHETIC 4-6,$756.00 ,#N/A,#N/A,N/A
80352,DRUG SCREENING CANNABINOIDS SYNTHETIC 7/MORE,$204.00 ,#N/A,#N/A,N/A
80353,DRUG SCREENING COCAINE,$756.00 ,#N/A,#N/A,N/A
80356,DRUG SCREENING HEROIN METABOLITE,$138.00 ,#N/A,#N/A,N/A
80358,DRUG SCREENING METHADONE,$756.00 ,#N/A,#N/A,N/A
80359,DRUG SCREENING METHYLENEDIOXYAMPHETAMINES,$756.00 ,#N/A,#N/A,N/A
80361,DRUG SCREENING OPIATES 1 OR MORE,$756.00 ,#N/A,#N/A,N/A
80362,DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2,$684.00 ,#N/A,#N/A,N/A
80365,DRUG SCREENING OXYCODONE,$756.00 ,#N/A,#N/A,N/A
80366,DRUG SCREENING PREGABALIN,$342.00 ,#N/A,#N/A,N/A
80367,DRUG SCREENING PROPOXYPHENE,$276.00 ,#N/A,#N/A,N/A
80373,DRUG SCREENING TRAMADOL,$684.00 ,#N/A,#N/A,N/A
80374,DRUG SCREEN STEREOISOMER ANALYSIS 1 DRUG CLASS,$684.00 ,#N/A,#N/A,N/A
81000,URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY,$510.00 ,#N/A,#N/A,N/A
81001,URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY,$690.00 ,#N/A,#N/A,N/A
81002,URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP,$300.00 ,#N/A,#N/A,N/A
81003,URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY,$545.00 ,#N/A,#N/A,N/A
81025,URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS,$684.00 ,#N/A,#N/A,N/A
82010,KETONE BODIES SERUM QUANTITATIVE,$382.00 ,#N/A,#N/A,N/A
82040,ALBUMIN SERUM PLASMA/WHOLE BLOOD,$204.00 ,#N/A,#N/A,N/A
82075,ASSAY OF ALCOHOL BREATH,$600.00 ,#N/A,#N/A,N/A
82140,ASSAY OF AMMONIA,"$1,020.00 ",#N/A,#N/A,N/A
82150,ASSAY OF AMYLASE,$572.00 ,#N/A,#N/A,N/A
82247,BILIRUBIN TOTAL,$366.00 ,#N/A,#N/A,N/A
82248,BILIRUBIN DIRECT,$450.00 ,#N/A,#N/A,N/A
82270,BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER,"$1,512.00 ",#N/A,#N/A,N/A
82272,BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC,"$1,512.00 ",#N/A,#N/A,N/A
82310,CALCIUM TOTAL,$504.00 ,#N/A,#N/A,N/A
82330,CALCIUM IONIZED,$504.00 ,#N/A,#N/A,N/A
82374,CARBON DIOXIDE BICARBONATE,$360.00 ,#N/A,#N/A,N/A
82435,CHLORIDE BLD,$300.00 ,#N/A,#N/A,N/A
82465,CHOLESTEROL SERUM/WHOLE BLOOD TOTAL,$540.00 ,#N/A,#N/A,N/A
82533,CORTISOL TOTAL,$408.00 ,#N/A,#N/A,N/A
82550,CREATINE KINASE TOTAL,$468.00 ,#N/A,#N/A,N/A
82553,CREATINE KINASE MB FRACTION ONLY,$780.00 ,#N/A,#N/A,N/A
82565,CREATININE BLOOD,$468.00 ,#N/A,#N/A,N/A
82668,ASSAY OF ERYTHROPOIETIN,$780.00 ,#N/A,#N/A,N/A
82728,ASSAY OF FERRITIN,$660.00 ,#N/A,#N/A,N/A
82747,ASSAY OF FOLIC ACID RBC,$358.00 ,#N/A,#N/A,N/A
82784,ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH,$810.00 ,#N/A,#N/A,N/A
82803,BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3,$649.00 ,#N/A,#N/A,N/A
82945,GLUCOSE BODY FLUID OTHER THAN BLOOD,$474.00 ,#N/A,#N/A,N/A
82947,GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP,$276.00 ,#N/A,#N/A,N/A
82948,GLUCOSE BLOOD REAGENT STRIP,$684.00 ,#N/A,#N/A,N/A
82962,GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE,$276.00 ,#N/A,#N/A,N/A
82977,ASSAY OF GLUTAMYLTRASE GAMMA,$600.00 ,#N/A,#N/A,N/A
83009,HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE,$606.00 ,#N/A,#N/A,N/A
83013,HPYLORI BREATH ANAL UREASE ACT NON-RADACT ISTOPE,$684.00 ,#N/A,#N/A,N/A
83036,HEMOGLOBIN GLYCOSYLATED A1C,$330.00 ,#N/A,#N/A,N/A
83525,ASSAY OF INSULIN TOTAL,$342.00 ,#N/A,#N/A,N/A
83605,ASSAY OF LACTATE,$570.00 ,#N/A,#N/A,N/A
83615,LACTATE DEHYDROGENASE LDH,$600.00 ,#N/A,#N/A,N/A
83690,ASSAY OF LIPASE,$556.00 ,#N/A,#N/A,N/A
83718,LIPOPROTEIN DIR MEAS HIGH DENSITY CHOLESTEROL,$420.00 ,#N/A,#N/A,N/A
83735,ASSAY OF MAGNESIUM,$600.00 ,#N/A,#N/A,N/A
83835,METANEPHRINES,$780.00 ,#N/A,#N/A,N/A
83874,MYOGLOBIN,$780.00 ,#N/A,#N/A,N/A
83880,NATRIURETIC PEPTIDE,"$1,056.00 ",#N/A,#N/A,N/A
83992,ASSAY OF PHENCYCLIDINE,$540.00 ,#N/A,#N/A,N/A
84075,ASSAY OF PHOSPHATASE ALKALINE,$306.00 ,#N/A,#N/A,N/A
84100,ASSAY OF PHOSPHORUS INORGANIC,$292.00 ,#N/A,#N/A,N/A
84132,POTASSIUM SERUM PLASMA/WHOLE BLOOD,$300.00 ,#N/A,#N/A,N/A
84145,PROCALCITONIN (PCT),"$1,020.00 ",#N/A,#N/A,N/A
84155,PROTEIN XCPT REFRACTOMETRY SERUM PLASMA/WHL BLD,$347.00 ,#N/A,#N/A,N/A
84157,PROTEIN TOTAL XCPT REFRACTOMETRY OTH SRC,$425.00 ,#N/A,#N/A,N/A
84295,SODIUM SERUM PLASMA OR WHOLE BLOOD,$240.00 ,#N/A,#N/A,N/A
84436,ASSAY OF THYROXINE TOTAL,$438.00 ,#N/A,#N/A,N/A
84439,ASSAY OF FREE THYROXINE,$538.00 ,#N/A,#N/A,N/A
84443,ASSAY OF THYROID STIMULATING HORMONE TSH,$774.00 ,#N/A,#N/A,N/A
84450,TRANSFERASE ASPARTATE AMINO AST SGOT,$356.00 ,#N/A,#N/A,N/A
84460,TRANSFERASE ALANINE AMINO ALT SGPT,$300.00 ,#N/A,#N/A,N/A
84478,ASSAY OF TRIGLYCERIDES,$858.00 ,#N/A,#N/A,N/A
84479,THYROID HORM UPTK/THYROID HORMONE BINDING RATIO,$402.00 ,#N/A,#N/A,N/A
84480,ASSAY OF TRIIODOTHYRONINE T3 TOTAL TT3,$684.00 ,#N/A,#N/A,N/A
84481,ASSAY OF TRIIODOTHYRONINE T3 FREE,$570.00 ,#N/A,#N/A,N/A
84484,ASSAY OF TROPONIN QUANTITATIVE,"$1,055.00 ",#N/A,#N/A,N/A
84512,ASSAY OF TROPONIN QUALITATIVE,$408.00 ,#N/A,#N/A,N/A
84520,ASSAY OF UREA NITROGEN QUANTITATIVE,$431.00 ,#N/A,#N/A,N/A
84550,ASSAY OF BLOOD/URIC ACID,$684.00 ,#N/A,#N/A,N/A
84702,GONADOTROPIN CHORIONIC QUANTITATIVE,"$1,176.00 ",#N/A,#N/A,N/A
84703,GONADOTROPIN CHORIONIC QUALITATIVE,"$1,020.00 ",#N/A,#N/A,N/A
85025,BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC,"$1,512.00 ",#N/A,#N/A,N/A
85027,BLOOD COUNT COMPLETE AUTOMATED,$408.00 ,#N/A,#N/A,N/A
85379,FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE,"$1,050.00 ",#N/A,#N/A,N/A
85610,PROTHROMBIN TIME,$934.00 ,#N/A,#N/A,N/A
85651,SEDIMENTATION RATE RBC NON-AUTOMATED,$684.00 ,#N/A,#N/A,N/A
85652,SEDIMENTATION RATE RBC AUTOMATED,$168.00 ,#N/A,#N/A,N/A
85730,THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD,$359.00 ,#N/A,#N/A,N/A
86038,ANTINUCLEAR ANTIBODIES ANA,$411.00 ,#N/A,#N/A,N/A
86039,ANTINUCLEAR ANTIBODIES ANA TITER,$521.00 ,#N/A,#N/A,N/A
86060,ANTISTREPTOLYSIN O TITER,$186.00 ,#N/A,#N/A,N/A
86140,C-REACTIVE PROTEIN,$504.00 ,#N/A,#N/A,N/A
86235,EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY ANY METHOD,$684.00 ,#N/A,#N/A,N/A
86308,HETEROPHILE ANTIBODIES SCREEN,$524.00 ,#N/A,#N/A,N/A
86328,IA INFECTIOUS AGT ANTIBODY SARS-COV-2 COVID-19,$360.00 ,#N/A,#N/A,N/A
86431,RHEUMATOID FACTOR QUANTITATIVE,$307.00 ,#N/A,#N/A,N/A
86592,SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL,$384.00 ,#N/A,#N/A,N/A
86593,SYPHILIS TEST QUANTITATIVE,$756.00 ,#N/A,#N/A,N/A
86677,ANTIBODY HELICOBACTER PYLORI,$684.00 ,#N/A,#N/A,N/A
86689,ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST,$465.00 ,#N/A,#N/A,N/A
86695,ANTIBODY HERPES SMPLX TYPE 1,$408.00 ,#N/A,#N/A,N/A
86696,ANTIBODY HERPES SMPLX TYPE 2,$480.00 ,#N/A,#N/A,N/A
86701,ANTIBODY HIV-1,$480.00 ,#N/A,#N/A,N/A
86735,ANTIBODY MUMPS,$720.00 ,#N/A,#N/A,N/A
86757,ANTIBODY RICKETTSIA,"$1,020.00 ",#N/A,#N/A,N/A
86762,ANTIBODY RUBELLA,$480.00 ,#N/A,#N/A,N/A
86765,ANTIBODY RUBEOLA,$600.00 ,#N/A,#N/A,N/A
86769,SARS-COV-2 COVID-19 ANTIBODY,"$1,020.00 ",#N/A,#N/A,N/A
86787,ANTIBODY VARICELLA-ZOSTER,$300.00 ,#N/A,#N/A,N/A
86900,BLOOD TYPING SEROLOGIC ABO,"$1,020.00 ",#N/A,#N/A,N/A
86901,BLOOD TYPING SEROLOGIC RH (D),"$1,020.00 ",#N/A,#N/A,N/A
87015,CONCENTRATION INFECTIOUS AGENTS,$344.00 ,#N/A,#N/A,N/A
87040,CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES,$463.00 ,#N/A,#N/A,N/A
87045,CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL,$953.00 ,#N/A,#N/A,N/A
87070,CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL,$612.00 ,#N/A,#N/A,N/A
87071,CUL BACT QUAN AEROBIC ISOL XCPT UR BLOOD/STOOL,"$1,020.00 ",#N/A,#N/A,N/A
87075,CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID,$684.00 ,#N/A,#N/A,N/A
87076,CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL,$516.00 ,#N/A,#N/A,N/A
87077,CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL,$684.00 ,#N/A,#N/A,N/A
87081,CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ,$684.00 ,#N/A,#N/A,N/A
87086,CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE,$465.00 ,#N/A,#N/A,N/A
87088,CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE,$344.00 ,#N/A,#N/A,N/A
87106,CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST,"$1,020.00 ",#N/A,#N/A,N/A
87184,SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD,$780.00 ,#N/A,#N/A,N/A
87205,SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL,$420.00 ,#N/A,#N/A,N/A
87210,SMR PRIM SRC WET MOUNT NFCT AGT,"$1,020.00 ",#N/A,#N/A,N/A
87230,TOXIN/ANTITOXIN ASSAY TISSUE CULTURE,"$1,140.00 ",#N/A,#N/A,N/A
87255,VIRUS ID NON-IMMUNOLOGIC OTH/THN CYTOPATHIC,$480.00 ,#N/A,#N/A,N/A
87338,IAAD IA HPYLORI STOOL,$756.00 ,#N/A,#N/A,N/A
87389,IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE,$720.00 ,#N/A,#N/A,N/A
87420,IAAD IA RESPIRATORY SYNCTIAL VIRUS,$570.00 ,#N/A,#N/A,N/A
87426,SARSCOV CORONAVIRUS AG IA,$360.00 ,#N/A,#N/A,N/A
87428,IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B,$480.00 ,#N/A,#N/A,N/A
87486,IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ,$480.00 ,#N/A,#N/A,N/A
87491,IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ,$756.00 ,#N/A,#N/A,N/A
87493,INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE,"$1,020.00 ",#N/A,#N/A,N/A
87529,IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ,"$1,020.00 ",#N/A,#N/A,N/A
87581,IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ,$360.00 ,#N/A,#N/A,N/A
87591,IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ,$408.00 ,#N/A,#N/A,N/A
87631,IADNA RESPIRATRY PROBE & REV TRNSCR 3-5 TARGETS,$660.00 ,#N/A,#N/A,N/A
87633,IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET,$720.00 ,#N/A,#N/A,N/A
87635,SARS-COV-2 COVID-19 AMP PRB,$600.00 ,#N/A,#N/A,N/A
87637,SARSCOV2&INF A&B&RSV AMP PRB,$600.00 ,#N/A,#N/A,N/A
87640,IADNA S AUREUS AMPLIFIED PROBE TQ,"$1,200.00 ",#N/A,#N/A,N/A
87651,IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ,$480.00 ,#N/A,#N/A,N/A
87653,IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ,$480.00 ,#N/A,#N/A,N/A
87660,IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ,$780.00 ,#N/A,#N/A,N/A
87661,Infectious agent detection by nucleic acid (DNA or RNA),$480.00 ,#N/A,#N/A,N/A
87798,IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,$480.00 ,#N/A,#N/A,N/A
87799,IADNA NOS QUANTIFICATION EACH ORGANISM,$720.00 ,#N/A,#N/A,N/A
87801,Infectious agent detection by nucleic acid (DNA or RNA),$480.00 ,#N/A,#N/A,N/A
87804,IAADIADOO INFLUENZA,$575.00 ,#N/A,#N/A,N/A
87806,IAADIADOO HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES,"$1,260.00 ",#N/A,#N/A,N/A
87807,IAADIADOO RESPIRATORY SYNCTIAL VIRUS,$756.00 ,#N/A,#N/A,N/A
87880,IAADIADOO STREPTOCOCCUS GROUP A,"$1,038.00 ",#N/A,#N/A,N/A
89051,CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT,$497.00 ,#N/A,#N/A,N/A
89055,LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE,$684.00 ,#N/A,#N/A,N/A
89240,UNLIS MISC,$246.00 ,#N/A,#N/A,N/A
90471,IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,$303.00 ,#N/A,#N/A,N/A
90472,IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE,$420.00 ,#N/A,#N/A,N/A
90714,TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE,$806.00 ,#N/A,#N/A,N/A
90715,TDAP VACCINE 7 YRS/> IM,$756.00 ,#N/A,#N/A,N/A
93000,ECG ROUTINE ECG W/LEAST 12 LDS W/I&R,$756.00 ,#N/A,#N/A,N/A
93005,ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R,$960.00 ,#N/A,#N/A,N/A
93010,ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY,$240.00 ,#N/A,#N/A,N/A
93040,RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT,$960.00 ,#N/A,#N/A,N/A
93042,RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON,$756.00 ,#N/A,#N/A,N/A
93224,XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I,"$1,212.00 ",#N/A,#N/A,N/A
93307,ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP,"$2,880.00 ",#N/A,#N/A,N/A
93631,INTRAOP EPICAR& ENDOCAR PACG& MAPG,$912.00 ,#N/A,#N/A,N/A
93880,DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY,"$2,461.00 ",#N/A,#N/A,N/A
93922,NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL,"$2,921.00 ",#N/A,#N/A,N/A
93923,NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS,"$3,024.00 ",#N/A,#N/A,N/A
93925,DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY,"$3,570.00 ",#N/A,#N/A,N/A
93926,DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY,"$2,724.00 ",#N/A,#N/A,N/A
93930,DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY,"$3,280.00 ",#N/A,#N/A,N/A
93931,DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY,"$2,976.00 ",#N/A,#N/A,N/A
93970,DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY,"$3,455.00 ",#N/A,#N/A,N/A
93971,DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY,"$3,024.00 ",#N/A,#N/A,N/A
93975,DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM,"$3,815.00 ",#N/A,#N/A,N/A
93980,DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL,"$2,080.00 ",#N/A,#N/A,N/A
94640,PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT,$347.00 ,#N/A,#N/A,N/A
94760,NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER,$457.00 ,#N/A,#N/A,N/A
94761,NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER,$408.00 ,#N/A,#N/A,N/A
94762,NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR,$684.00 ,#N/A,#N/A,N/A
96360,IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR,"$1,512.00 ",#N/A,#N/A,N/A
96361,IV INFUSION HYDRATION EACH ADDITIONAL HOUR,$714.00 ,#N/A,#N/A,N/A
96365,IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR,"$1,512.00 ",#N/A,#N/A,N/A
96366,IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR,$937.00 ,#N/A,#N/A,N/A
96367,IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,"$1,247.00 ",#N/A,#N/A,N/A
96368,IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS,$960.00 ,#N/A,#N/A,N/A
96372,THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM,"$1,512.00 ",#N/A,#N/A,N/A
96374,THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,"$1,236.00 ",#N/A,#N/A,N/A
96375,THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG,$847.00 ,#N/A,#N/A,N/A
96376,THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC,$853.00 ,#N/A,#N/A,N/A
96377,APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION,$960.00 ,#N/A,#N/A,N/A
97010,APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS,$171.00 ,#N/A,#N/A,N/A
97116,THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR,$780.00 ,#N/A,#N/A,N/A
97542,WHEELCHAIR MGMT EA 15 MIN,$615.00 ,#N/A,#N/A,N/A
97597,DEBRIDEMENT OPEN WOUND 20 SQ CM/<,"$1,195.00 ",#N/A,#N/A,N/A
98925,OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS,$240.00 ,#N/A,#N/A,N/A
99000,HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB,"$1,020.00 ",#N/A,#N/A,N/A
99024,POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX,$912.00 ,#N/A,#N/A,N/A
99070,SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP,$300.00 ,#N/A,#N/A,N/A
99072,“Miscellaneous Medicine Services,,#N/A,#N/A,N/A
$150.00 ,,,#N/A,#N/A,N/A
99151,MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,$630.00 ,#N/A,#N/A,N/A
99152,MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,"$1,500.00 ",#N/A,#N/A,N/A
99173,SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT,"$1,812.00 ",#N/A,#N/A,N/A
99217,OBSERVATION CARE DISCHARGE MANAGEMENT,"$1,434.00 ",#N/A,#N/A,N/A
99218,INITIAL OBSERVATION CARE/DAY 30 MINUTES,"$1,500.00 ",#N/A,#N/A,N/A
99219,INITIAL OBSERVATION CARE/DAY 50 MINUTES,"$1,710.00 ",#N/A,#N/A,N/A
99220,INITIAL OBSERVATION CARE/DAY 70 MINUTES,"$1,950.00 ",#N/A,#N/A,N/A
99224,SBSQ OBSERVATION CARE/DAY 15 MINUTES,"$1,500.00 ",#N/A,#N/A,N/A
99225,SBSQ OBSERVATION CARE/DAY 25 MINUTES,"$1,710.00 ",#N/A,#N/A,N/A
99226,SBSQ OBSERVATION CARE/DAY 35 MINUTES,"$1,950.00 ",#N/A,#N/A,N/A
99234,OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES,"$1,560.00 ",#N/A,#N/A,N/A
99235,OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES,"$1,800.00 ",#N/A,#N/A,N/A
99236,OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES,"$2,160.00 ",#N/A,#N/A,N/A
99281,EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB,"$1,199.00 ",#N/A,#N/A,N/A
99282,EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY,"$2,400.00 ",#N/A,#N/A,N/A
99283,EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY,"$5,040.00 ",#N/A,#N/A,N/A
99283CP,EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY,"$2,400.00 ",#N/A,#N/A,N/A
99284,EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY,"$5,400.00 ",#N/A,#N/A,N/A
99285,EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ,"$6,000.00 ",#N/A,#N/A,N/A
99291,CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN,"$2,400.00 ",#N/A,#N/A,N/A
99292,CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN,"$1,200.00 ",#N/A,#N/A,N/A
A0382,BASIC SUPPORT ROUTINE SUPPLS,$83.00 ,#N/A,#N/A,N/A
A0394,ALS IV DRUG THERAPY SUPPLIES,$83.00 ,#N/A,#N/A,N/A
A4206,1 CC STERILE SYRINGE&NEEDLE,$138.00 ,#N/A,#N/A,N/A
A4207,2 CC STERILE SYRINGE&NEEDLE,$99.00 ,#N/A,#N/A,N/A
A4208,STERILE SYRINGE&NEEDLE,$138.00 ,#N/A,#N/A,N/A
A4209,FIVE PLUS CC STERILE SYRINGE&NEEDLE,$138.00 ,#N/A,#N/A,N/A
A4210,NONNEEDLE INJECTION DEVICE,$138.00 ,#N/A,#N/A,N/A
A4211,SUPP FOR SELF-ADM INJECTIONS,$99.00 ,#N/A,#N/A,N/A
A4212,NON CORING NEEDLE OR STYLET,$138.00 ,#N/A,#N/A,N/A
A4213,20+ CC SYRINGE ONLY,$138.00 ,#N/A,#N/A,N/A
A4215,STERILE NEEDLE,$138.00 ,#N/A,#N/A,N/A
A4216,"STERILE WATER/SALINE, 10 ML",$138.00 ,#N/A,#N/A,N/A
A4217,"STERILE WATER/SALINE, 500 ML",$99.00 ,#N/A,#N/A,N/A
A4218,STERILE SALINE OR WATER,$138.00 ,#N/A,#N/A,N/A
A4221,SUPP NON-INSULIN INF CATH/WK,$138.00 ,#N/A,#N/A,N/A
A4224,SUPPLY INSULIN INF CATH/WK,$138.00 ,#N/A,#N/A,N/A
A4232,SYRINGE W/NEEDLE INSULIN 3CC,$99.00 ,#N/A,#N/A,N/A
A4244,ALCOHOL OR PEROXIDE PER PINT,$138.00 ,#N/A,#N/A,N/A
A4245,ALCOHOL WIPES PER BOX,$138.00 ,#N/A,#N/A,N/A
A4246,BETADINE/PHISOHEX SOLUTION,$138.00 ,#N/A,#N/A,N/A
A4247,BETADINE/IODINE SWABS/WIPES,$83.00 ,#N/A,#N/A,N/A
A4248,CHLORHEXIDINE ANTISEPT,$138.00 ,#N/A,#N/A,N/A
A4250,URINE REAGENT STRIPS/TABLETS,$138.00 ,#N/A,#N/A,N/A
A4253,BLOOD GLUCOSE/REAGENT STRIPS,$83.00 ,#N/A,#N/A,N/A
A4281,REPLACEMENT BREASTPUMP TUBE,$138.00 ,#N/A,#N/A,N/A
A4283,REPLACEMENT BREASTPUMP CAP,$138.00 ,#N/A,#N/A,N/A
A4300,CATH IMPL VASC ACCESS PORTAL,$99.00 ,#N/A,#N/A,N/A
A4310,INSERT TRAY W/O BAG/CATH,$138.00 ,#N/A,#N/A,N/A
A4311,CATHETER W/O BAG 2-WAY LATEX,$138.00 ,#N/A,#N/A,N/A
A4313,CATHETER W/BAG 3-WAY,$138.00 ,#N/A,#N/A,N/A
A4314,CATH W/DRAINAGE 2-WAY LATEX,$138.00 ,#N/A,#N/A,N/A
A4315,CATH W/DRAINAGE 2-WAY SILCNE,$99.00 ,#N/A,#N/A,N/A
A4322,IRRIGATION SYRINGE,$127.00 ,#N/A,#N/A,N/A
A4327,FEM URINARY COLLECT DEV CUP,$138.00 ,#N/A,#N/A,N/A
A4332,LUBE STERILE PACKET,$83.00 ,#N/A,#N/A,N/A
A4338,INDWELLING CATHETER LATEX,$127.00 ,#N/A,#N/A,N/A
A4352,COUDE TIP URINARY CATHETER,$99.00 ,#N/A,#N/A,N/A
A4353,INTERMITTENT URINARY CATH,$138.00 ,#N/A,#N/A,N/A
A4358,URINARY LEG OR ABDOMEN BAG,$138.00 ,#N/A,#N/A,N/A
A4369,SKIN BARRIER LIQUID PER OZ,$138.00 ,#N/A,#N/A,N/A
A4402,LUBRICANT PER OUNCE,$99.00 ,#N/A,#N/A,N/A
A4406,PECTIN BASED OSTOMY PASTE,$99.00 ,#N/A,#N/A,N/A
A4450,NON-WATERPROOF TAPE,$138.00 ,#N/A,#N/A,N/A
A4452,WATERPROOF TAPE,$138.00 ,#N/A,#N/A,N/A
A4458,REUSABLE ENEMA BAG,$127.00 ,#N/A,#N/A,N/A
A4461,SURGICL DRESS HOLD NON-REUSE,$138.00 ,#N/A,#N/A,N/A
A4465,NON-ELASTIC EXTREMITY BINDER,$99.00 ,#N/A,#N/A,N/A
A4470,GRAVLEE JET WASHER,$83.00 ,#N/A,#N/A,N/A
A4550,SURGICAL TRAYS,$138.00 ,#N/A,#N/A,N/A
A4554,DISPOSABLE UNDERPADS,$83.00 ,#N/A,#N/A,N/A
A4556,"ELECTRODES, PAIR",$138.00 ,#N/A,#N/A,N/A
A4558,CONDUCTIVE GEL OR PASTE,$127.00 ,#N/A,#N/A,N/A
A4562,"PESSARY, NON RUBBER,ANY TYPE",$99.00 ,#N/A,#N/A,N/A
A4565,SLINGS,$138.00 ,#N/A,#N/A,N/A
A4566,SHOULD SLING/VEST/ABRESTRAIN,$99.00 ,#N/A,#N/A,N/A
A4570,SPLINT,$413.00 ,#N/A,#N/A,N/A
A4580,CAST SUPPLIES (PLASTER),$127.00 ,#N/A,#N/A,N/A
A4606,OXYGEN PROBE USED W OXIMETER,$138.00 ,#N/A,#N/A,N/A
A4613,BATTERY CHARGER,$138.00 ,#N/A,#N/A,N/A
A4615,CANNULA NASAL,$138.00 ,#N/A,#N/A,N/A
A4616,TUBING (OXYGEN) PER FOOT,$99.00 ,#N/A,#N/A,N/A
A4619,FACE TENT,$138.00 ,#N/A,#N/A,N/A
A4620,VARIABLE CONCENTRATION MASK,$138.00 ,#N/A,#N/A,N/A
A4628,OROPHARYNGEAL SUCTION CATH,$138.00 ,#N/A,#N/A,N/A
A4629,TRACHEOSTOMY CARE KIT,$83.00 ,#N/A,#N/A,N/A
A4635,UNDERARM CRUTCH PAD,$550.00 ,#N/A,#N/A,N/A
A4649,SURGICAL SUPPLIES,$138.00 ,#N/A,#N/A,N/A
A4653,PD CATHETER ANCHOR BELT,$83.00 ,#N/A,#N/A,N/A
A4657,SYRINGE W/WO NEEDLE,$138.00 ,#N/A,#N/A,N/A
A4670,"AUTOMATIC BP MONITOR, DIAL",$138.00 ,#N/A,#N/A,N/A
A4673,EXT LINE W EASY LOCK CONNECT,$138.00 ,#N/A,#N/A,N/A
A4750,ART OR VENOUS BLOOD TUBING,$83.00 ,#N/A,#N/A,N/A
A4770,BLOOD COLLECTION TUBE/VACUUM,$138.00 ,#N/A,#N/A,N/A
A4927,NON-STERILE GLOVES,$50.00 ,#N/A,#N/A,N/A
A4930,"STERILE, GLOVES PER PAIR",$50.00 ,#N/A,#N/A,N/A
A5112,URINARY LEG BAG,$138.00 ,#N/A,#N/A,N/A
A5120,"SKIN BARRIER, WIPE OR SWAB",$138.00 ,#N/A,#N/A,N/A
A5126,DISK/FOAM PAD +OR- ADHESIVE,$138.00 ,#N/A,#N/A,N/A
A6021,COLLAGEN DRESSING <=16 SQ IN,$127.00 ,#N/A,#N/A,N/A
A6196,ALGINATE DRESSING <=16 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6203,COMPOSITE DRSG <= 16 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6208,CONTACT LAYER > 48 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6209,FOAM DRSG <=16 SQ IN W/O BDR,$138.00 ,#N/A,#N/A,N/A
A6212,FOAM DRG <=16 SQ IN W/BORDER,$99.00 ,#N/A,#N/A,N/A
A6216,NON-STERILE GAUZE<=16 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6217,NON-STERILE GAUZE>16<=48 SQ,$138.00 ,#N/A,#N/A,N/A
A6218,NON-STERILE GAUZE > 48 SQ IN,$99.00 ,#N/A,#N/A,N/A
A6219,GAUZE <= 16 SQ IN W/BORDER,$99.00 ,#N/A,#N/A,N/A
A6220,GAUZE >16 <=48 SQ IN W/BORDR,$99.00 ,#N/A,#N/A,N/A
A6221,GAUZE > 48 SQ IN W/BORDER,$83.00 ,#N/A,#N/A,N/A
A6222,GAUZE <=16 IN NO W/SAL W/O B,$99.00 ,#N/A,#N/A,N/A
A6223,GAUZE >16<=48 NO W/SAL W/O B,$83.00 ,#N/A,#N/A,N/A
A6224,GAUZE > 48 IN NO W/SAL W/O B,$138.00 ,#N/A,#N/A,N/A
A6231,HYDROGEL DSG<=16 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6233,HYDROGEL DRESSING >48 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6235,HYDROCOLLD DRG >16<=48 W/O B,$83.00 ,#N/A,#N/A,N/A
A6238,HYDROCOLLD DRG >16<=48 W/BDR,$83.00 ,#N/A,#N/A,N/A
A6239,HYDROCOLLD DRG > 48 IN W/BDR,$99.00 ,#N/A,#N/A,N/A
A6246,HYDROGEL DRG >16<=48 IN W/B,$138.00 ,#N/A,#N/A,N/A
A6248,HYDROGEL DRSG GEL FILLER,$138.00 ,#N/A,#N/A,N/A
A6250,SKIN SEAL PROTECT MOISTURIZR,$138.00 ,#N/A,#N/A,N/A
A6251,ABSORPT DRG <=16 SQ IN W/O B,$138.00 ,#N/A,#N/A,N/A
A6252,ABSORPT DRG >16 <=48 W/O BDR,$138.00 ,#N/A,#N/A,N/A
A6253,ABSORPT DRG > 48 SQ IN W/O B,$138.00 ,#N/A,#N/A,N/A
A6254,ABSORPT DRG <=16 SQ IN W/BDR,$138.00 ,#N/A,#N/A,N/A
A6255,ABSORPT DRG >16<=48 IN W/BDR,$99.00 ,#N/A,#N/A,N/A
A6257,TRANSPARENT FILM <= 16 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6258,TRANSPARENT FILM >16<=48 IN,$138.00 ,#N/A,#N/A,N/A
A6260,WOUND CLEANSER ANY TYPE/SIZE,$138.00 ,#N/A,#N/A,N/A
A6266,IMPREG GAUZE NO H20/SAL/YARD,$138.00 ,#N/A,#N/A,N/A
A6402,MEDICAL/SURGICAL SUPPLIES AND DEVICES (ALSO SEE 062X AN EXTENSION OF STE,$138.00 ,#N/A,#N/A,N/A
A6403,STERILE GAUZE>16 <= 48 SQ IN,$99.00 ,#N/A,#N/A,N/A
A6404,STERILE GAUZE > 48 SQ IN,$138.00 ,#N/A,#N/A,N/A
A6407,"PACKING STRIPS, NON-IMPREG",$99.00 ,#N/A,#N/A,N/A
A6412,OCCLUSIVE EYE PATCH,$83.00 ,#N/A,#N/A,N/A
A6413,"ADHESIVE BANDAGE, FIRST-AID",$138.00 ,#N/A,#N/A,N/A
A6441,PAD BAND W>=3 <5/YD,$99.00 ,#N/A,#N/A,N/A
A6442,CONFORM BAND N/S W<3/YD,$127.00 ,#N/A,#N/A,N/A
A6445,CONFORM BAND S W <3/YD,$138.00 ,#N/A,#N/A,N/A
A6446,CONFORM BAND S W>=3 <5/YD,$138.00 ,#N/A,#N/A,N/A
A6447,CONFORM BAND S W >=5/YD,$83.00 ,#N/A,#N/A,N/A
A6448,LT COMPRES BAND <3/YD,$138.00 ,#N/A,#N/A,N/A
A6449,LT COMPRES BAND >=3 <5/YD,$127.00 ,#N/A,#N/A,N/A
A6450,LT COMPRES BAND >=5/YD,$99.00 ,#N/A,#N/A,N/A
A6453,SELF-ADHER BAND W <3/YD,$138.00 ,#N/A,#N/A,N/A
A6454,SELF-ADHER BAND W>=3 <5/YD,$99.00 ,#N/A,#N/A,N/A
A6455,SELF-ADHER BAND >=5/YD,$138.00 ,#N/A,#N/A,N/A
A6456,ZINC PASTE BAND W >=3<5/YD,$138.00 ,#N/A,#N/A,N/A
A6457,TUBULAR DRESSING,$150.00 ,#N/A,#N/A,N/A
A6530,COMPRESSION STOCKING BK18-30,$90.00 ,#N/A,#N/A,N/A
A6545,GRAD COMP NON-ELASTIC BK,$108.00 ,#N/A,#N/A,N/A
A7000,DISPOSABLE CANISTER FOR PUMP,$150.00 ,#N/A,#N/A,N/A
A7001,NONDISPOSABLE PUMP CANISTER,$150.00 ,#N/A,#N/A,N/A
A7002,TUBING USED W SUCTION PUMP,$150.00 ,#N/A,#N/A,N/A
A7003,NEBULIZER ADMINISTRATION SET,$150.00 ,#N/A,#N/A,N/A
A7004,DISPOSABLE NEBULIZER SML VOL,$150.00 ,#N/A,#N/A,N/A
A7005,NONDISPOSABLE NEBULIZER SET,$150.00 ,#N/A,#N/A,N/A
A7006,FILTERED NEBULIZER ADMIN SET,$90.00 ,#N/A,#N/A,N/A
A7015,AEROSOL MASK USED W NEBULIZE,$108.00 ,#N/A,#N/A,N/A
A7030,CPAP FULL FACE MASK,$108.00 ,#N/A,#N/A,N/A
A7031,REPLACEMENT FACEMASK INTERFA,$150.00 ,#N/A,#N/A,N/A
A7046,"REPL WATER CHAMBER, PAP DEV",$150.00 ,#N/A,#N/A,N/A
A7047,RESP SUCTION ORAL INTERFACE,$150.00 ,#N/A,#N/A,N/A
A9150,MISC/EXPER NON-PRESCRIPT DRU,$90.00 ,#N/A,#N/A,N/A
A9270,NON-COVERED ITEM OR SERVICE,$108.00 ,#N/A,#N/A,N/A
A9273,HOT/COLD H2OBOT/CAP/COL/WRAP,$150.00 ,#N/A,#N/A,N/A
A9281,REACHING/GRABBING DEVICE,$150.00 ,#N/A,#N/A,N/A
B4082,ENTERAL NG TUBING W/O STYLET,$300.00 ,#N/A,#N/A,N/A
C1722,"AICD, SINGLE CHAMBER","$2,580.00 ",#N/A,#N/A,N/A
C1751,"CATH, INF, PER/CENT/MIDLINE","$2,544.00 ",#N/A,#N/A,N/A
C1781,MESH (IMPLANTABLE),"$1,849.00 ",#N/A,#N/A,N/A
C2618,"PROBE/NEEDLE, CRYO",$408.00 ,#N/A,#N/A,N/A
C9285,"PATCH, LIDOCAINE/TETRACAINE",$102.00 ,#N/A,#N/A,N/A
E0110,CRUTCH FOREARM PAIR,$840.00 ,#N/A,#N/A,N/A
E0114,CRUTCH UNDERARM PAIR NO WOOD,$955.00 ,#N/A,#N/A,N/A
E0116,CRUTCH UNDERARM EACH NO WOOD,$720.00 ,#N/A,#N/A,N/A
E0168,HEAVYDUTY/WIDE COMMODE CHAIR,$456.00 ,#N/A,#N/A,N/A
E0240,BATH/SHOWER CHAIR,$138.00 ,#N/A,#N/A,N/A
E0275,BED PAN STANDARD,$276.00 ,#N/A,#N/A,N/A
E0325,URINAL MALE JUG-TYPE,$174.00 ,#N/A,#N/A,N/A
E0326,URINAL FEMALE JUG-TYPE,$174.00 ,#N/A,#N/A,N/A
E0487,ELECTRONIC SPIROMETER,$420.00 ,#N/A,#N/A,N/A
E0570,NEBULIZER WITH COMPRESSION,"$1,092.00 ",#N/A,#N/A,N/A
E0607,BLOOD GLUCOSE MONITOR HOME,$684.00 ,#N/A,#N/A,N/A
E0625,PATIENT LIFT BATHROOM OR TOI,$546.00 ,#N/A,#N/A,N/A
G0168,WOUND CLOSURE BY ADHESIVE,$456.00 ,#N/A,#N/A,N/A
G0378,HOSPITAL OBSERVATION PER HR,"$3,024.00 ",#N/A,#N/A,N/A
G0402,INITIAL PREVENTIVE EXAM,"$2,520.00 ",#N/A,#N/A,N/A
G0481,DRUG TEST DEF 8-14 CLASSES,$600.00 ,#N/A,#N/A,N/A
G6058,"Drug confirmation, each procedure",$684.00 ,#N/A,#N/A,N/A
G8598,ASA/ANTIPLAT THER USED,$72.00 ,#N/A,#N/A,N/A
G8601,NO ELIG TPA INIT W/IN 3 HRS,"$1,362.00 ",#N/A,#N/A,N/A
G8602,NO TPA INIT W/IN 3 HRS,"$1,362.00 ",#N/A,#N/A,N/A
J0120,TETRACYCLIN INJECTION,$228.00 ,#N/A,#N/A,N/A
J0129,ABATACEPT INJECTION,$228.00 ,#N/A,#N/A,N/A
J0131,ACETAMINOPHEN INJECTION,$36.00 ,#N/A,#N/A,N/A
J0153,ADENOSINE INJ 1MG,$138.00 ,#N/A,#N/A,N/A
J0171,ADRENALIN EPINEPHRINE INJECT,$228.00 ,#N/A,#N/A,N/A
J0282,AMIODARONE HCL,$138.00 ,#N/A,#N/A,N/A
J0290,AMPICILLIN 500 MG INJ,$60.00 ,#N/A,#N/A,N/A
J0295,AMPICILLIN SODIUM PER 1.5 GM,$300.00 ,#N/A,#N/A,N/A
J0360,HYDRALAZINE HCL INJECTION,$228.00 ,#N/A,#N/A,N/A
J0456,AZITHROMYCIN,$228.00 ,#N/A,#N/A,N/A
J0461,ATROPINE SULFATE INJECTION,$72.00 ,#N/A,#N/A,N/A
J0500,DICYCLOMINE INJECTION,$271.00 ,#N/A,#N/A,N/A
J0561,PENICILLIN G BENZATHINE INJ,$228.00 ,#N/A,#N/A,N/A
J0610,CALCIUM GLUCONATE INJECTION,$36.00 ,#N/A,#N/A,N/A
J0690,CEFAZOLIN SODIUM INJECTION,$228.00 ,#N/A,#N/A,N/A
J0696,CEFTRIAXONE SODIUM INJECTION,$228.00 ,#N/A,#N/A,N/A
J0697,STERILE CEFUROXIME INJECTION,$138.00 ,#N/A,#N/A,N/A
J0735,CLONIDINE HYDROCHLORIDE,$138.00 ,#N/A,#N/A,N/A
J0744,CIPROFLOXACIN IV,$228.00 ,#N/A,#N/A,N/A
J0780,PROCHLORPERAZINE INJECTION,$228.00 ,#N/A,#N/A,N/A
J1020,METHYLPREDNISOLONE 20 MG INJ,$108.00 ,#N/A,#N/A,N/A
J1030,METHYLPREDNISOLONE 40 MG INJ,$120.00 ,#N/A,#N/A,N/A
J1040,METHYLPREDNISOLONE 80 MG INJ,$120.00 ,#N/A,#N/A,N/A
J1100,DEXAMETHASONE SODIUM PHOS,$24.00 ,#N/A,#N/A,N/A
J1170,HYDROMORPHONE INJECTION,$228.00 ,#N/A,#N/A,N/A
J1200,DIPHENHYDRAMINE HCL INJECTIO,$60.00 ,#N/A,#N/A,N/A
J1265,DOPAMINE INJECTION,$48.00 ,#N/A,#N/A,N/A
J1550,"Injection, gamma globulin, intramuscular, 10 cc",$36.00 ,#N/A,#N/A,N/A
J1610,GLUCAGON HYDROCHLORIDE/1 MG,$589.00 ,#N/A,#N/A,N/A
J1631,HALOPERIDOL DECANOATE INJ,$378.00 ,#N/A,#N/A,N/A
J1642,INJ HEPARIN SODIUM PER 10 U,$35.00 ,#N/A,#N/A,N/A
J1644,INJ HEPARIN SODIUM PER 1000U,$228.00 ,#N/A,#N/A,N/A
J1650,INJ ENOXAPARIN SODIUM,$170.00 ,#N/A,#N/A,N/A
J1741,IBUPROFEN INJECTION,$138.00 ,#N/A,#N/A,N/A
J1810,DROPERIDOL/FENTANYL INJ,$138.00 ,#N/A,#N/A,N/A
J1815,INSULIN INJECTION,$60.00 ,#N/A,#N/A,N/A
J1817,INSULIN FOR INSULIN PUMP USE,$138.00 ,#N/A,#N/A,N/A
J1885,KETOROLAC TROMETHAMINE INJ,$114.00 ,#N/A,#N/A,N/A
J1930,LANREOTIDE INJECTION,$349.00 ,#N/A,#N/A,N/A
J1940,FUROSEMIDE INJECTION,$198.00 ,#N/A,#N/A,N/A
J1956,LEVOFLOXACIN INJECTION,$228.00 ,#N/A,#N/A,N/A
J2001,"Injection, lidocaine hcl for intravenous infusion",$155.00 ,#N/A,#N/A,N/A
J2060,LORAZEPAM INJECTION,$228.00 ,#N/A,#N/A,N/A
J2175,MEPERIDINE HYDROCHL /100 MG,$138.00 ,#N/A,#N/A,N/A
J2250,INJ MIDAZOLAM HYDROCHLORIDE,$228.00 ,#N/A,#N/A,N/A
J2270,MORPHINE SULFATE INJECTION,$228.00 ,#N/A,#N/A,N/A
J2274,IN MORPHINE PRESERVATIV FREE,$228.00 ,#N/A,#N/A,N/A
J2360,ORPHENADRINE INJECTION,$228.00 ,#N/A,#N/A,N/A
J2405,ONDANSETRON HCL INJECTION,$24.00 ,#N/A,#N/A,N/A
J2410,OXYMORPHONE HCL INJECTION,$138.00 ,#N/A,#N/A,N/A
J2425,PALIFERMIN INJECTION,$138.00 ,#N/A,#N/A,N/A
J2504,"PEGADEMASE BOVINE, 25 IU",$138.00 ,#N/A,#N/A,N/A
J2543,PIPERACILLIN/TAZOBACTAM,$228.00 ,#N/A,#N/A,N/A
J2550,PROMETHAZINE HCL INJECTION,$173.00 ,#N/A,#N/A,N/A
J2704,"INJ, PROPOFOL, 10 MG",$138.00 ,#N/A,#N/A,N/A
J2765,METOCLOPRAMIDE HCL INJECTION,$228.00 ,#N/A,#N/A,N/A
J2780,RANITIDINE HYDROCHLORIDE INJ,$138.00 ,#N/A,#N/A,N/A
J2800,METHOCARBAMOL INJECTION,$462.00 ,#N/A,#N/A,N/A
J2920,METHYLPREDNISOLONE INJECTION,$165.00 ,#N/A,#N/A,N/A
J2930,METHYLPREDNISOLONE INJECTION,$228.00 ,#N/A,#N/A,N/A
J3010,FENTANYL CITRATE INJECITON,$228.00 ,#N/A,#N/A,N/A
J3030,SUMATRIPTAN SUCCINATE / 6 MG,$378.00 ,#N/A,#N/A,N/A
J3260,TOBRAMYCIN SULFATE INJECTION,$528.00 ,#N/A,#N/A,N/A
J3301,TRIAMCINOLONE ACET INJ NOS,$60.00 ,#N/A,#N/A,N/A
J3360,DIAZEPAM INJECTION,$184.00 ,#N/A,#N/A,N/A
J3370,VANCOMYCIN HCL INJECTION,$228.00 ,#N/A,#N/A,N/A
J3430,VITAMIN K PHYTONADIONE INJ,$359.00 ,#N/A,#N/A,N/A
J3475,INJ MAGNESIUM SULFATE,$138.00 ,#N/A,#N/A,N/A
J3480,INJ POTASSIUM CHLORIDE,$150.00 ,#N/A,#N/A,N/A
J3490,DRUGS UNCLASSIFIED INJECTION,$36.00 ,#N/A,#N/A,N/A
J7030,NORMAL SALINE SOLUTION INFUS,$296.00 ,#N/A,#N/A,N/A
J7040,NORMAL SALINE SOLUTION INFUS,$265.00 ,#N/A,#N/A,N/A
J7042,5% DEXTROSE/NORMAL SALINE,$312.00 ,#N/A,#N/A,N/A
J7050,NORMAL SALINE SOLUTION INFUS,$300.00 ,#N/A,#N/A,N/A
J7060,5% DEXTROSE/WATER,$300.00 ,#N/A,#N/A,N/A
J7070,D5W INFUSION,$138.00 ,#N/A,#N/A,N/A
J7120,RINGERS LACTATE INFUSION,$300.00 ,#N/A,#N/A,N/A
J7121,5% DEXTROSE IN LAC RINGERS,$300.00 ,#N/A,#N/A,N/A
J7131,HYPERTONIC SALINE SOL,$138.00 ,#N/A,#N/A,N/A
J7192,FACTOR VIII RECOMBINANT NOS,$138.00 ,#N/A,#N/A,N/A
J7313,FLUOCINOL ACET INTRAVIT IMP,$138.00 ,#N/A,#N/A,N/A
J7510,PREDNISOLONE ORAL PER 5 MG,$12.00 ,#N/A,#N/A,N/A
J7611,ALBUTEROL NON-COMP CON,$228.00 ,#N/A,#N/A,N/A
J7613,ALBUTEROL NON-COMP UNIT,$228.00 ,#N/A,#N/A,N/A
J7614,LEVALBUTEROL NON-COMP UNIT,$228.00 ,#N/A,#N/A,N/A
J7615,LEVALBUTEROL COMP UNIT,$228.00 ,#N/A,#N/A,N/A
J7620,ALBUTEROL IPRATROP NON-COMP,$228.00 ,#N/A,#N/A,N/A
J7631,CROMOLYN SODIUM NONCOMP UNIT,$138.00 ,#N/A,#N/A,N/A
J7637,DEXAMETHASONE COMP CON,$138.00 ,#N/A,#N/A,N/A
J7644,IPRATROPIUM BROMIDE NON-COMP,$228.00 ,#N/A,#N/A,N/A
J7682,TOBRAMYCIN NON-COMP UNIT,$138.00 ,#N/A,#N/A,N/A
J7699,INHALATION SOLUTION FOR DME,$138.00 ,#N/A,#N/A,N/A
J8498,ANTIEMETIC RECTAL/SUPP NOS,$138.00 ,#N/A,#N/A,N/A
J8499,ORAL PRESCRIP DRUG NON CHEMO,$138.00 ,#N/A,#N/A,N/A
J9206,IRINOTECAN INJECTION,$138.00 ,#N/A,#N/A,N/A
L0112,CRANIAL CERVICAL ORTHOSIS,"$1,362.00 ",#N/A,#N/A,N/A
L0120,CERV FLEX N/ADJ FOAM PRE OTS,$774.00 ,#N/A,#N/A,N/A
L0150,CERV SEMI-RIG ADJ MOLDED CHN,$180.00 ,#N/A,#N/A,N/A
L0170,CERVICAL COLLAR MOLDED TO PT,$420.00 ,#N/A,#N/A,N/A
L0172,CERV COL SR FOAM 2PC PRE OTS,$180.00 ,#N/A,#N/A,N/A
L0174,CERV SR 2PC THOR EXT PRE OTS,"$1,512.00 ",#N/A,#N/A,N/A
L0625,LO FLEX L1-BELOW L5 PRE OTS,$780.00 ,#N/A,#N/A,N/A
L1810,KO ELASTIC WITH JOINTS,"$1,872.00 ",#N/A,#N/A,N/A
L1830,KO IMMOB CANVAS LONG PRE OTS,$635.00 ,#N/A,#N/A,N/A
L1902,AFO ANKLE GAUNTLET PRE OTS,$78.00 ,#N/A,#N/A,N/A
L1906,AFO MULTILIG ANK SUP PRE OTS,$420.00 ,#N/A,#N/A,N/A
L2360,EXTENDED STEEL SHANK,$564.00 ,#N/A,#N/A,N/A
L3031,FOOT LAMIN/PREPREG COMPOSITE,$690.00 ,#N/A,#N/A,N/A
L3201,OXFORD W SUPINAT/PRONAT INF,$510.00 ,#N/A,#N/A,N/A
L3209,SURGICAL BOOT EACH CHILD,$510.00 ,#N/A,#N/A,N/A
L3250,CUSTOM MOLD SHOE REMOV PROST,$690.00 ,#N/A,#N/A,N/A
L3260,AMBULATORY SURGICAL BOOT EAC,$780.00 ,#N/A,#N/A,N/A
L3310,SHOE LIFT ELEV HEEL/SOLE NEO,$498.00 ,#N/A,#N/A,N/A
L3334,SHOE LIFTS ELEVATION HEEL /I,$60.00 ,#N/A,#N/A,N/A
L3500,ORTHO SHOE ADD LEATHER INSOL,$468.00 ,#N/A,#N/A,N/A
L3540,ORTHO SHOE ADD FULL SOLE,$690.00 ,#N/A,#N/A,N/A
L3650,SO 8 ABD RESTRAINT PRE OTS,$150.00 ,#N/A,#N/A,N/A
L3660,SO 8 AB RSTR CAN/WEB PRE OTS,$690.00 ,#N/A,#N/A,N/A
L3670,SO ACRO/CLAV CAN WEB PRE OTS,$807.00 ,#N/A,#N/A,N/A
L3720,FOREARM/ARM CUFFS FREE MOTIO,"$1,170.00 ",#N/A,#N/A,N/A
L3807,WHFO W/O JOINTS PRE CST,$600.00 ,#N/A,#N/A,N/A
L3808,"WHFO, RIGID W/O JOINTS","$2,268.00 ",#N/A,#N/A,N/A
L3809,WHFO W/O JOINTS PRE OTS,"$2,268.00 ",#N/A,#N/A,N/A
L3905,WHO W/NONTORSION JNT(S) CF,"$2,268.00 ",#N/A,#N/A,N/A
L3906,WHO W/O JOINTS CF,"$2,268.00 ",#N/A,#N/A,N/A
L3908,WHO COCK-UP NONMOLDE PRE OTS,$234.00 ,#N/A,#N/A,N/A
L4350,ANKLE CONTROL ORTHO PRE OTS,$318.00 ,#N/A,#N/A,N/A
L4360,PNEUMAT WALKING BOOT PRE CST,$330.00 ,#N/A,#N/A,N/A
L4361,PNEUMA/VAC WALK BOOT PRE OTS,$330.00 ,#N/A,#N/A,N/A
L4386,NON-PNEUM WALK BOOT PRE CST,$330.00 ,#N/A,#N/A,N/A
L4387,NON-PNEUM WALK BOOT PRE OTS,$330.00 ,#N/A,#N/A,N/A
L4398,FOOT DROP SPLINT PRE OTS,$184.00 ,#N/A,#N/A,N/A
L4631,"AFO, WALK BOOT TYPE, CUS FAB",$330.00 ,#N/A,#N/A,N/A
M0243,CASIRIVI AND IMDEVI INJ,"$1,512.00 ",#N/A,#N/A,N/A
P9612,CATHETERIZE FOR URINE SPEC,$138.00 ,#N/A,#N/A,N/A
Q0144,"AZITHROMYCIN DIHYDRATE, ORAL",$68.00 ,#N/A,#N/A,N/A
Q0169,PROMETHAZINE HCL 12.5MG ORAL,$30.00 ,#N/A,#N/A,N/A
Q4001,CAST SUP BODY CAST PLASTER,"$1,212.00 ",#N/A,#N/A,N/A
Q4006,CAST SUP LONG ARM ADULT FBRG,"$1,212.00 ",#N/A,#N/A,N/A
Q4018,CAST SUP LNG ARM SPLINT FBRG,$408.00 ,#N/A,#N/A,N/A
Q4019,CAST SUP LNG ARM SPLNT PED P,$960.00 ,#N/A,#N/A,N/A
Q4020,CAST SUP LNG ARM SPLNT PED F,$816.00 ,#N/A,#N/A,N/A
Q4021,CAST SUP SHT ARM SPLINT PLST,$882.00 ,#N/A,#N/A,N/A
Q4022,CAST SUP SHT ARM SPLINT FBRG,$684.00 ,#N/A,#N/A,N/A
Q4023,CAST SUP SHT ARM SPLNT PED P,$684.00 ,#N/A,#N/A,N/A
Q4024,CAST SUP SHT ARM SPLNT PED F,$684.00 ,#N/A,#N/A,N/A
Q4042,CAST SUP LNG LEG SPLNT FBRGL,"$1,212.00 ",#N/A,#N/A,N/A
Q4046,CAST SUP SHT LEG SPLNT FBRGL,"$1,212.00 ",#N/A,#N/A,N/A
Q4049,"FINGER SPLINT, STATIC",$135.00 ,#N/A,#N/A,N/A
Q9962,"HOCM 300-349MG/ML IODINE,1ML",$684.00 ,#N/A,#N/A,N/A
Q9963,"HOCM 350-399MG/ML IODINE,1ML",$276.00 ,#N/A,#N/A,N/A
Q9967,"LOCM 300-399MG/ML IODINE,1ML",$18.00 ,#N/A,#N/A,N/A
S0020,"INJECTION, BUPIVICAINE HYDRO",$210.00 ,#N/A,#N/A,N/A
S0028,"INJECTION, FAMOTIDINE, 20 MG",$150.00 ,#N/A,#N/A,N/A
S0030,"INJECTION, METRONIDAZOLE",$150.00 ,#N/A,#N/A,N/A
S0077,"INJECTION, CLINDAMYCIN PHOSP",$150.00 ,#N/A,#N/A,N/A
S0164,INJECTION PANTROPRAZOLE,$150.00 ,#N/A,#N/A,N/A
S0630,REMOVAL OF SUTURES,$408.00 ,#N/A,#N/A,N/A
S1015,IV TUBING EXTENSION SET,$90.00 ,#N/A,#N/A,N/A
S8100,SPACER WITHOUT MASK,$138.00 ,#N/A,#N/A,N/A
S8101,SPACER WITH MASK,$138.00 ,#N/A,#N/A,N/A
S8430,PADDING FOR COMPRSSN BDG,$83.00 ,#N/A,#N/A,N/A
S8431,COMPRESSION BANDAGE,$105.00 ,#N/A,#N/A,N/A
S8451,SPLINT WRIST OR ANKLE,$138.00 ,#N/A,#N/A,N/A
U0001,Cdc 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel,$300.00 ,#N/A,#N/A,N/A
U0002,COVID-19 LAB TEST NON-CDC,$360.00 ,#N/A,#N/A,N/A
U0003,COV-19 AMP PRB HGH THRUPUT,$480.00 ,#N/A,#N/A,N/A
U0004,COV-19 TEST NON-CDC HGH THRU,$600.00 ,#N/A,#N/A,N/A