The median cost of healthcare in Charlotte ranges from $1 for a 5fr obturator to $352,263 for a aicd generator procedures across 48 reporting Charlotte hospitals. ProcedureRadar scans federally mandated Machine-Readable Files every month to show exactly what Charlotte hospitals charge for 2288 shoppable procedures. The most affordable Charlotte hospital in our data is Carolinas Rehabilitation, currently running about 61% below the metro median.
Every shoppable procedure in Charlotte, plotted by median price against how much prices vary across hospitals. Hover any point to see the procedure, median, and hospital spread. Click to view hospitals.
| Procedure | Category | Median Price | Low | High | Hospitals |
|---|---|---|---|---|---|
| 5fr Obturator | other | $1 | $1 | $1 | 1 |
| 6fr Obturator | other | $1 | $1 | $1 | 1 |
| 7fr Obturator | other | $1 | $1 | $1 | 1 |
| Acetaminophen 650mg/20.3ml Cup | other | $1 | $1 | $1 | 1 |
| Acetylcysteine, Inhalation Solution, Fda-approved Final Product, Non-compound... | other | $1 | $1 | $1 | 1 |
| Adaptor Meconium Aspiration #n0101 40ea/bx | other | $1 | $1 | $1 | 1 |
| Adhesive, Liquid OR Equal, Any Type, Per Oz | other | $1 | $1 | $1 | 1 |
| Airway Ovassapian #bd6075 5/cs | other | $1 | $1 | $1 | 1 |
| Albuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded, A... | other | $1 | $1 | $1 | 2 |
| Aliskiren 150 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Allegra-d 24 Hour Tablet | other | $1 | $1 | $1 | 1 |
| Amox-clav 200-28.5 Mg/5 Ml Sus | other | $1 | $1 | $1 | 1 |
| Amox-clav 400-57 Mg/5 Ml Susp | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphet ER 10 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphet ER 15 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphetamine 10 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphetamine 15 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Anes Breathing Circuit Adult 3l #a4y520xxf | other | $1 | $1 | $1 | 1 |
| Anesthesia for Other Repair of Upper Abdomen Hernia | surgery | $1 | $1 | $1 | 1 |
| Anesthesia for Procedure On Veins in Upper Leg | other | $1 | $1 | $1 | 1 |
| Arformoterol, Inhalation Solution, Fda Approved Final Product, Non-compounded... | other | $1 | $1 | $1 | 1 |
| Aripiprazole 5 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Aripiprazole 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Arnuity Ellipta 100 Mcg Inh | other | $1 | $1 | $1 | 1 |
| Aspirin 300 Mg Suppository | other | $1 | $1 | $1 | 1 |
| Aspirin-dipyridam ER 25-200 Mg | other | $1 | $1 | $1 | 1 |
| Aspirin-dipyridamole ER 25-200 Mg Po Cp12 | other | $1 | $1 | $1 | 1 |
| Assessment By Trained Clinical Staff of Implant And/or Foreign Body for Mr Sa... | surgery | $1 | $1 | $1 | 1 |
| Atazanavir Sulfate 200 Mg Cap | other | $1 | $1 | $1 | 1 |
| Azithromycin 500 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Azithromycin 500 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Bacitracin 500 Unit/gm Ointmnt | other | $1 | $1 | $1 | 1 |
| Bactine Max 0.13% Solution | other | $1 | $1 | $1 | 1 |
| Bag Phlebotomy Set 25/bx #bk-64a | other | $1 | $1 | $1 | 1 |
| Banatrol Plus Powder Packet | other | $1 | $1 | $1 | 1 |
| Belt Gait W/ Buckle 72" #655702 | other | $1 | $1 | $1 | 1 |
| Benadryl Itch Stop 1%-0.1% Crm | other | $1 | $1 | $1 | 1 |
| Blade Laryngoscope Disp Led Millr Sz00 1039.c | other | $1 | $1 | $1 | 1 |
| Blade Laryngoscope Dispo Robert Shaw 1 2011.c | other | $1 | $1 | $1 | 1 |
| Boot Cast Extra Large 1ea | other | $1 | $1 | $1 | 1 |
| Boot Cast Gelo Unna's 12ea/1cs | other | $1 | $1 | $1 | 1 |
| Boot Cast Small #2035-02 1ea | other | $1 | $1 | $1 | 1 |
| Boot Cast-large | other | $1 | $1 | $1 | 1 |
| Boot Cast-medium | other | $1 | $1 | $1 | 1 |
| Boudreauxs Butt Paste | other | $1 | $1 | $1 | 1 |
| Brace Thumb Splint Universal #5026 | other | $1 | $1 | $1 | 1 |
| Brace Wrist Right Small #79 | other | $1 | $1 | $1 | 1 |
| Brimonidine 0.2% Eye Drop | other | $1 | $1 | $1 | 1 |
| Bromocriptine 2.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Bss Eye Solution | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 75 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 75 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl ER (xl) 150 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl Xl 150 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Butalb-acetamin-caff 50-325 | other | $1 | $1 | $1 | 1 |
| Butalbital-apap-caffeine 50-325-40 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Azathioprine, Oral, 50 Mg | other | $1 | $1 | $1 | 1 |
| Bacitracin Oint 0.9gm | other | $1 | $1 | $1 | 1 |
| Hyoscyamine Sulfate 120 Ml Dos | other | $1 | $1 | $1 | 1 |
| Injection, Fosphenytoin, 50 Mg Phenytoin Equivalent | other | $1 | $1 | $1 | 1 |
| Injection, Heparin Sodium, (heparin Lock Flush), Per 10 Units | other | $1 | $1 | $1 | 1 |
| Injection, Ondansetron Hydrochloride, Per 1 Mg | other | $1 | $1 | $1 | 1 |
| Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg | other | $1 | $1 | $1 | 1 |
| Mycophenolate Mofetil, Oral, 250 Mg | other | $1 | $1 | $1 | 1 |
| No Charge Item | other | $1 | $1 | $1 | 1 |
| Noc Drugs, Inhalation Solution Administered Through DME | other | $1 | $1 | $1 | 1 |
| Flowcytometry/tc Add-on | other | $1 | $1 | $1 | 1 |
| **discontinued** Endotrach Tube 2.0 Uncuffed 10ea/1bx | other | $2 | $2 | $2 | 1 |
| 1/2 Circle Rev Cut Richard Allen #209106 | other | $2 | $2 | $2 | 1 |
| 20fr Y Ports #m00580641 10ea/bx | other | $2 | $2 | $2 | 1 |
| 24fr Y Ports #m00580651 10ea/bx | other | $2 | $2 | $2 | 1 |
| 6 Fr Cas 1 | other | $2 | $2 | $2 | 1 |
| 6 Fr Ultimate 4-t40 | other | $2 | $2 | $2 | 1 |
| Abdominal Support 9in 1ea | other | $2 | $2 | $2 | 1 |
| Acetaminophen 120 Mg Re Supp | other | $2 | $2 | $2 | 1 |
| Adaptic Finger Dressing Large 1-1/8" #mad023u Case=17bx=170each | other | $2 | $2 | $2 | 1 |
| Adaptic Finger Dressing Small 3/4" #mad003u Case=17bx=170each | other | $2 | $2 | $2 | 1 |
| Adaptic Toe Dressing 1-1/8" Size Lg #mad062u 10ea/bx | other | $2 | $2 | $2 | 1 |
| Adderall Xr 20 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 25 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 30 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 5 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Addition to Ctlso OR Scoliosis Orthosis, Kyphosis Pad | other | $2 | $2 | $2 | 1 |
| Alaris Pump Module Admin Set 10942011 20ea/cs | other | $2 | $2 | $2 | 1 |
| Alginate OR Other Fiber Gelling Dressing, Wound Filler, Sterile, Per 6 Inches | other | $2 | $2 | $2 | 1 |
| Ammonium Lactate 12% Lotion | other | $2 | $2 | $2 | 1 |
| Amox-clav 250-62.5 Mg/5 Ml Sus | other | $2 | $2 | $2 | 1 |
| Amoxicillin 125 Mg/5ml Po Susr | other | $2 | $2 | $2 | 1 |
| Amoxicillin 200 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Amoxicillin 250 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Amoxicillin 400 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Anes Breathing Circuit Ped 1l 20/cs B1554xx4 | other | $2 | $2 | $2 | 1 |
| Anes Breathing Circuit Ped 2l W/mask B1557xx4 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Access to Central Vein | other | $2 | $2 | $2 | 1 |
| Anesthesia for Amputation On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Lower Leg, Ankle, and Foot | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Knee Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Shoulder Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Uterus Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Partial Removal of Rib | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Procedure On Perineum | other | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Removal of Prostate | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Fragmenting, Manipulation And/or Removal of Kidney Stone Inclu... | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Heart Artery Bypass Grafting | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Heart Artery Bypass Grafting On Heart-lung Machine | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion of Penile Prosthesis | other | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion of Permanent Heart Pacemaker | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion OR Replace of Pacing Heart Defibrillator | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Lens Surgery | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Open Amputation Below the Knee | other | $2 | $2 | $2 | 1 |
| Anesthesia for Open OR Endoscopic Total Shoulder Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Arteries of Upper Arm and Elbow | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Artery of Knee | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Artery of Upper Leg | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Collar Bone and Shoulder Blade | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Elbow | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Esophagus, Stomach, OR Upper Small Bowel Us... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On External Middle and Inner Ear | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Face Bones OR Skull | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Female Genitals | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Hip Joint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Large Blood Vessel of Neck | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Large Bowel Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Abdomen Outside Abdominal Cavity | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Front Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Leg, Ankle, and Foot Bones | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Spine | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Male Genitals | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Mouth | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Neck Area | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Nerves, Muscles, Tendons, and Tissue of Low... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Nose and Sinuses | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Skin of Arms, Legs, and Front Body | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Skin, Muscles, OR Nerves of Head, Neck, and... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Front Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Spine | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Urinary System Through Urethra | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure OR Exam of Knee Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedures On Nerves, Muscles, Tendons, and Tissue of Up... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Repair of Lower Abdomen Hernia | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure for Total Knee Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Ankle OR Foot Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Anus and Rectum | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Chest with 1 Lung Inflated | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Eye for Corneal Transplant | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Gallbladder, Pancreas, OR Liver Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Kneecap And/or Upper Part of Lower Leg Bones | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Lower Rear Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Knee | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Upper Leg | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, Fascia, and Bursae of S... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Saliva Gland | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Tendon of Elbow to Shoulder | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Tendon of Upper Arm Muscle | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Upper Urinary Tubes OR Removal of Kidney for Tran... | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Control Urinary System Bleeding Including Use of ... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Correct Abnormal Heart Rhythm | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Repair Upper Abdominal Incisional Hernia And/or W... | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Reconstruction of Breast | other | $2 | $2 | $2 | 1 |
| Anesthesia for Relocation of Undescended Testicle Into Scrotum | other | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of All OR Part of Breast | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Breast Bone Tissue | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Prostate Including Use of an Endoscope | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Testicle Through Groin | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Tissue From Around Lung | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Urinary Bladder Tumors Including Use of an Endoscope | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Abdominal Wall Hernia | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Achilles Tendon | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Bulging (aneurysm) Defect in Knee Artery | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Calf Muscle | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Elbow to Shoulder Tendon | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair OR Removal of Vagina and Urinary Procedure | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Total Elbow Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Vaginal Removal of Uterus | surgery | $2 | $2 | $2 | 1 |
| Ankle Gel Splint #79 | other | $2 | $2 | $2 | 1 |
| Aquacel Adhesive Foam Dressing 4 X 10 #421153 140ea/case | other | $2 | $2 | $2 | 1 |
| Aripiprazole 2 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Arnuity Ellipta 200 Mcg Inh | other | $2 | $2 | $2 | 1 |
| Arthritis Hot 15%-10% Cream | other | $2 | $2 | $2 | 1 |
| Atomizer Mucosal Atomization Device | other | $2 | $2 | $2 | 1 |
| Auryxia 210 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Azelastine 0.1% (137 Mcg) Spry | other | $2 | $2 | $2 | 1 |
| Azithromycin 250 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Bandage Comprilan 10cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Bandage Comprilan 6cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Bandage Comprilan 8cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Benzoyl Peroxide 5 % Ex Gel | other | $2 | $2 | $2 | 1 |
| Bile Bag with Straps 0015850 12ea/case | other | $2 | $2 | $2 | 1 |
| Binder Abdominal 10" 27"-48" #ort21200 | other | $2 | $2 | $2 | 1 |
| Binder Abdominal 12" 27"-48" #ort21300 | other | $2 | $2 | $2 | 1 |
| Biofreeze W/ilex 4oz Tube 1ea | other | $2 | $2 | $2 | 1 |
| Biotene Moisturizing Mouth Spr | other | $2 | $2 | $2 | 1 |
| Blade Beaver #bb365r Aesculap | other | $2 | $2 | $2 | 1 |
| Blood Count, Hemoglobin | other | $2 | $2 | $2 | 2 |
| Bra Compression White 34 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 36 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 38 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 40 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 42 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 44 #e5001 | other | $2 | $2 | $2 | 1 |
| Brace Ankle Air Gel 8.5in Med #79 | other | $2 | $2 | $2 | 1 |
| Brace Ankle Air Gel 9in Small #79 | other | $2 | $2 | $2 | 1 |
| Brace Wrist Elastic Right Sm #79 | other | $2 | $2 | $2 | 1 |
| Brace Wrist/forearm Support Left #79 | other | $2 | $2 | $2 | 1 |
| Brilinta 60 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Brilinta 90 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Analysis of Urine, Except Immunoassays | other | $2 | $2 | $2 | 1 |
| Buprenorphine, Oral, 1 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Lorazepam, 2 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Meperidine Hydrochloride, Per 100 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Metronidazole, 10 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Morphine Sulfate (fresenius Kabi), Not Therapeutically Equivalent ... | other | $2 | $2 | $2 | 1 |
| Injection, Phenytoin Sodium, Per 50 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Promethazine Hcl, Up to 50 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Prothrombin Complex Concentrate, Human-lans, Per I.u. of Factor Ix... | other | $2 | $2 | $2 | 1 |
| Injection, Zidovudine, 10 Mg | other | $2 | $2 | $2 | 1 |
| Loperamide Hcl 1mg/7.5 Ml Ud | other | $2 | $2 | $2 | 1 |
| Methylprednisolone Oral, Per 4 Mg | other | $2 | $2 | $2 | 1 |
| **discontinued** Filter Line H Set M1920a 25ea/1cs | other | $3 | $3 | $3 | 1 |
| 12 Ga Sertera Introducer5ea/bx #sertera Intro | other | $3 | $3 | $3 | 1 |
| Abdominal Support 10in 1ea | other | $3 | $3 | $3 | 1 |
| Acuvail 0.45% Ophth Solution | other | $3 | $3 | $3 | 1 |
| Adaptive Mug Alimed #2970010571 Pk/20ea | other | $3 | $3 | $3 | 1 |
| Administration and Interpretation of Caregiver-focused Health Risk Assessment | other | $3 | $3 | $3 | 1 |
| Administration and Interpretation of Patient-focused Health Risk Assessment | other | $3 | $3 | $3 | 1 |
| Alginate OR Other Fiber Gelling Dressing, Wound Cover, Sterile, Pad Size 16 S... | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Exam of Chest Using an Endoscope with 1 Lung Inflated | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Procedure On Hip Joint | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Procedure On Knee Joint | other | $3 | $3 | $3 | 1 |
| Anesthesia for Exam of Colon Using an Endoscope | other | $3 | $3 | $3 | 1 |
| Anesthesia for Extensive Surgery On Spine | surgery | $3 | $3 | $3 | 1 |
| Anesthesia for Other Procedure On Eye | other | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure On Eyelid | other | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure On Heart and Large Blood Vessels Using Heart-lung Ma... | cardiac | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure to Assess Heart Electrical Activity | cardiac | $3 | $3 | $3 | 1 |
| Anesthesia for Retinal Surgery | surgery | $3 | $3 | $3 | 1 |
| Angiocath 16ga 3-1/4 Bd #382258 | other | $3 | $3 | $3 | 1 |
| Ankle Brace-air/gel 10" Universal | other | $3 | $3 | $3 | 1 |
| Anucort-hc 25 Mg Suppository | other | $3 | $3 | $3 | 1 |
| Aspirin 1 Mg/1 Ml Po Suspension | other | $3 | $3 | $3 | 1 |
| Automated White Blood Cell Count | other | $3 | $3 | $3 | 2 |
| Bandage Comprilan 12cm 20ea/1cs | other | $3 | $3 | $3 | 1 |
| Bard Foley Drainage Syestem #a304400a | other | $3 | $3 | $3 | 1 |
| Bcg Live Intravesical Instillation, 1 Mg | other | $3 | $3 | $3 | 1 |
| Belt Gait W/buckle 48" 1ea | other | $3 | $3 | $3 | 1 |
| Belt Gait W/buckle 60" 1ea | other | $3 | $3 | $3 | 1 |
| Betamethasone Va 0.1% Cream | other | $3 | $3 | $3 | 1 |
| Blm Mouthwash - 10 Ml - Compounded | other | $3 | $3 | $3 | 1 |
| Blood Glucose (sugar) Test Performed By Hand-held Instrument | other | $3 | $3 | $3 | 1 |
| Blood Group Typing | other | $3 | $3 | $3 | 2 |
| Blood Typing for Rh (d) Antigen | other | $3 | $3 | $3 | 2 |
| Bone Wax 2.5 Gram Non-absorbable #bw25g | other | $3 | $3 | $3 | 1 |
| Boots Sta-dri Knee-hi #kh | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Large #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Medium #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Small #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Xlarge #ab2900 | other | $3 | $3 | $3 | 1 |
| Breast Comfort Gel Pads #17264 50ea/1cs | other | $3 | $3 | $3 | 1 |
| Budesonide, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $3 | $3 | $3 | 1 |
| Glutose 15 Gel | other | $3 | $3 | $3 | 1 |
| Injection, Ciprofloxacin for Intravenous Infusion, 200 Mg | surgery | $3 | $3 | $3 | 1 |
| Injection, Dexamethasone Sodium Phosphate, 1 Mg | imaging | $3 | $3 | $3 | 1 |
| Injection, Diphenhydramine Hcl, Up to 50 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Hydromorphone, 0.1 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Metoclopramide Hcl, Up to 10 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Midazolam Hydrochloride, Per 1 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Midazolam in 0.9% Sodium Chloride, Intravenous, Not Therapeuticall... | other | $3 | $3 | $3 | 1 |
| Injection, Morphine Sulfate, Up to 10 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Sterile Cefuroxime Sodium, Per 750 Mg | other | $3 | $3 | $3 | 1 |
| Injection, Ziprasidone Mesylate, 10 Mg | other | $3 | $3 | $3 | 1 |
| Methotrexate; Oral, 2.5 Mg | other | $3 | $3 | $3 | 1 |
| 25-40cc Iabp Adaptor#0684-00-0510-01 5ea/pk | other | $4 | $4 | $4 | 1 |
| 4fr Simmons 1 | other | $4 | $4 | $4 | 1 |
| 4fr Sos 1 | other | $4 | $4 | $4 | 1 |
| 5 Fr Barbeau | other | $4 | $4 | $4 | 1 |
| 5 Fr IM | other | $4 | $4 | $4 | 1 |
| 5 Fr Jr 3.5 | other | $4 | $4 | $4 | 1 |
| 5fr Simmons 2 | other | $4 | $4 | $4 | 1 |
| 5fr Sos 2 | other | $4 | $4 | $4 | 1 |
| Abdominal Support 12in 1ea | other | $4 | $4 | $4 | 1 |
| Antithrombin Iii (human), Per I.u. | other | $4 | $4 | $4 | 1 |
| Application of Hot OR Cold Packs | other | $4 | $4 | $4 | 1 |
| Arch Support Medium #mdy10520 | other | $4 | $4 | $4 | 1 |
| Atovaquone 750 Mg/5ml Susp Cup | other | $4 | $4 | $4 | 1 |
| Binder Abdominal 12" 46-62" #13982000 | other | $4 | $4 | $4 | 1 |
| Blanket-nsy Disp Therm Med #37.09.15 | other | $4 | $4 | $4 | 1 |
| Blanket-nsy Disp Therm Sm #37.09.14 | other | $4 | $4 | $4 | 1 |
| Blood Glucose (sugar) Level | other | $4 | $4 | $4 | 2 |
| Blood Glucose (sugar) Tolerance Test, Each Additional Beyond 3 Specimens | lab | $4 | $4 | $4 | 2 |
| Blood Typing for Red Blood Cell Antigens | other | $4 | $4 | $4 | 2 |
| Body Fluid Ph Level | other | $4 | $4 | $4 | 1 |
| Bovie High Temp Fine Tip Cautery Surgical Disposable Aspen # Aa01 10ea/1bx | surgery | $4 | $4 | $4 | 1 |
| Breast Pump One-hand Manual #17161 | other | $4 | $4 | $4 | 1 |
| 5% Dextrose and 0.45% Normal Saline, 1000 Ml | other | $4 | $4 | $4 | 1 |
| Cholesterol Level | other | $4 | $4 | $4 | 1 |
| Cryoglobulin (protein) Measurement | other | $4 | $4 | $4 | 1 |
| Dexamethasone, Oral, 0.25 Mg | imaging | $4 | $4 | $4 | 1 |
| Glucose (sugar) Level On Body Fluid | other | $4 | $4 | $4 | 1 |
| Injection, Acetylcysteine, 100 Mg | other | $4 | $4 | $4 | 1 |
| Injection, Amiodarone Hydrochloride, 30 Mg | other | $4 | $4 | $4 | 1 |
| Injection, Labetalol Hydrochloride, 5 Mg | other | $4 | $4 | $4 | 1 |
| Injection, Nalbuphine Hydrochloride, Per 10 Mg | other | $4 | $4 | $4 | 1 |
| Injection, Terbutaline Sulfate, Up to 1 Mg | other | $4 | $4 | $4 | 1 |
| Microscopic Examination for White Blood Cells with Manual Cell Count | other | $4 | $4 | $4 | 1 |
| Urinalysis | lab | $5 | $1 | $61 | 34 |
| **discontinued** Catheter Imager Ii Cobra 5fr M0064003011 5/bx | cardiac | $5 | $5 | $5 | 1 |
| 4fr Sos Mini Omni 65cm - Must Be Ordered in Qty's of 5 Ea | other | $5 | $5 | $5 | 1 |
| 5fr Sos 80cm | other | $5 | $5 | $5 | 1 |
| Akten 3.5% Gel Drops | other | $5 | $5 | $5 | 1 |
| Albumin (protein) Level | other | $5 | $5 | $5 | 2 |
| Ambien 10 Mg Tablet | other | $5 | $5 | $5 | 1 |
| Anesthesia for Exam of Ear Using an Endoscope | other | $5 | $5 | $5 | 1 |
| Anesthesia for Incision of Ear Drum | other | $5 | $5 | $5 | 1 |
| Anesthesia for Procedure On Small and Large Bowel Using an Endoscope | other | $5 | $5 | $5 | 1 |
| Angiographic Catheter 5f (1.8mm) X 90cm Cobra 2 #10719711 5ea/bx | imaging | $5 | $5 | $5 | 1 |
| Arch Support Large #mdy10530 | other | $5 | $5 | $5 | 1 |
| Avitene Ultrafoam Collagen Hemostatic Sponge 3/4 X 2-1/2 X 1/4 12 Ea/bx 1050020 | other | $5 | $5 | $5 | 1 |
| Bilirubin Level, Direct | other | $5 | $5 | $5 | 2 |
| Bilirubin Level, Total | other | $5 | $5 | $5 | 2 |
| Bleeding Time | other | $5 | $5 | $5 | 2 |
| Blood Chloride Level | other | $5 | $5 | $5 | 2 |
| Blood Creatinine Level | other | $5 | $5 | $5 | 2 |
| Blood Glucose (sugar) Level After Receiving Dose of Glucose | other | $5 | $5 | $5 | 2 |
| Blood Glucose (sugar) Measurement Using Reagent Strip | other | $5 | $5 | $5 | 1 |
| Blood Potassium Level | other | $5 | $5 | $5 | 2 |
| Blood Sodium Level | other | $5 | $5 | $5 | 2 |
| Body Fluid Cell Count | other | $5 | $5 | $5 | 2 |
| Brace Elbow 11 Inch Adult #79 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Large Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Medium Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Small Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Xlarge Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Xsmall Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Large Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Medium Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Small Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Xlarge Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Xsmall Ab2801 | other | $5 | $5 | $5 | 1 |
| Blocking Needle | other | $5 | $5 | $5 | 1 |
| Calcium Level, Total | other | $5 | $5 | $5 | 1 |
| Carbon Dioxide (bicarbonate) Level | other | $5 | $5 | $5 | 1 |
| Cath Ua Collection | other | $5 | $5 | $5 | 1 |
| Cerebrospinal Fluid, OR Amniotic Fluid Albumin (protein) Level | other | $5 | $5 | $5 | 1 |
| Chlorhexidine Gluconate 4% Liq | other | $5 | $5 | $5 | 1 |
| Chloride Level | other | $5 | $5 | $5 | 1 |
| Creatinine Level to Test for Kidney Function OR Muscle Injury | other | $5 | $5 | $5 | 1 |
| Detection of Antimicrobial Drug | other | $5 | $5 | $5 | 1 |
| Fern Test | other | $5 | $5 | $5 | 1 |
| G6pd (enzyme) Level | other | $5 | $5 | $5 | 1 |
| Infusion, Normal Saline Solution, 250 Cc | surgery | $5 | $5 | $5 | 1 |
| Injection, Digoxin, Up to 0.5 Mg | other | $5 | $5 | $5 | 1 |
| Injection, Droperidol, Up to 5 Mg | other | $5 | $5 | $5 | 1 |
| Injection, Furosemide, 1 Mg | other | $5 | $5 | $5 | 1 |
| Injection, Lidocaine Hcl with Epinephrine, 1 Mg | other | $5 | $5 | $5 | 1 |
| Injection, Meropenem, 100 Mg | other | $5 | $5 | $5 | 1 |
| Insertion of Needle Into Vein for Collection of Blood Sample | other | $5 | $5 | $5 | 1 |
| Ketone Bodies Analysis, Qualitative | other | $5 | $5 | $5 | 1 |
| Liver Enzyme (sgot), Level | other | $5 | $5 | $5 | 1 |
| Liver Enzyme (sgpt), Level | other | $5 | $5 | $5 | 1 |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation | other | $5 | $5 | $5 | 1 |
| Measurement of Antibody (ige) to Allergic Substance, Crude Allergen Extract, ... | other | $5 | $5 | $5 | 1 |
| Abreva 10% Cream | other | $6 | $6 | $6 | 1 |
| Albuterol Hfa 90 Mcg Inhaler | other | $6 | $6 | $6 | 1 |
| Albuterol Sulfate Hfa 108 (90 Base) Mcg/act in Aers | other | $6 | $6 | $6 | 1 |
| All Potassium Hydroxide (koh) Preparations | other | $6 | $6 | $6 | 1 |
| Amerigel Wound Dressing Gel | other | $6 | $6 | $6 | 1 |
| Amylase (enzyme) Level | other | $6 | $6 | $6 | 2 |
| Application of Hot Wax Bath | other | $6 | $6 | $6 | 2 |
| Bacitracin-polymyxin Eye Oint | other | $6 | $6 | $6 | 1 |
| Benzocaine 20 % Gel | other | $6 | $6 | $6 | 1 |
| Body Fluid Cell Count with Cell Identification | other | $6 | $6 | $6 | 1 |
| Chlorpromazine Hydrochloride, 5 Mg, Oral, Fda Approved Prescription Anti-emet... | other | $6 | $6 | $6 | 1 |
| Complete Blood Cell Count (red Cells, White Blood Cell, Platelets), Automated... | other | $6 | $6 | $6 | 1 |
| Concentration of Specimen for Infectious Agents | lab | $6 | $6 | $6 | 1 |
| Confirmation Test for Antibody to Borrelia Burgdorferi | other | $6 | $6 | $6 | 1 |
| Dextrose 10%-water IV Solution | other | $6 | $6 | $6 | 1 |
| G6pd (enzyme) Screening Test | preventive | $6 | $6 | $6 | 1 |
| Hypertonic Saline Solution, 1 Ml | other | $6 | $6 | $6 | 1 |
| Injection, Adenosine, 1 Mg | other | $6 | $6 | $6 | 1 |
| Injection, Azithromycin, 500 Mg | other | $6 | $6 | $6 | 1 |
| Injection, Gadolinium-based Magnetic Resonance Contrast Agent, Not Otherwise ... | other | $6 | $6 | $6 | 1 |
| Injection, Haloperidol, Up to 5 Mg | other | $6 | $6 | $6 | 1 |
| Injection, Levofloxacin, 250 Mg | other | $6 | $6 | $6 | 1 |
| Injection, Octreotide, Non-depot Form for Subcutaneous OR Intravenous Injecti... | other | $6 | $6 | $6 | 1 |
| Injection, Prochlorperazine, Up to 10 Mg | other | $6 | $6 | $6 | 1 |
| Iron Level | other | $6 | $6 | $6 | 1 |
| Lactate Dehydrogenase (enzyme) Level | other | $6 | $6 | $6 | 1 |
| Lidocaine Jell Ur | other | $6 | $6 | $6 | 1 |
| Measurement of Range of Motion in Arm, Leg OR Each Spine Section | other | $6 | $6 | $6 | 1 |
| Nasal Smear for Eosinophils | other | $6 | $6 | $6 | 1 |
| Complete Blood Count (CBC) | lab | $7 | $5 | $169 | 14 |
| Adapter Connecting Ureteral Cath #uca5 | other | $7 | $7 | $7 | 1 |
| Adapter Tuohy-borst #g18813 | other | $7 | $7 | $7 | 1 |
| Antimicrobial Study, Mycobacteria | other | $7 | $7 | $7 | 1 |
| Antivenin (latrodectus) Vial | other | $7 | $7 | $7 | 1 |
| Arch Support Xlarge #mdy10540 | other | $7 | $7 | $7 | 1 |
| Aztreonam 1 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $7 | $7 | $7 | 1 |
| Ball Electrode 3mm Vaginal #e1563 | other | $7 | $7 | $7 | 1 |
| Ball Electrode 5mm Vaginal #e1564 | other | $7 | $7 | $7 | 1 |
| Blood Osmolality (concentration) Measurement | other | $7 | $7 | $7 | 2 |
| Catheter, Ureteral | cardiac | $7 | $7 | $7 | 1 |
| Creatine Kinase (cardiac Enzyme) Level, Total | cardiac | $7 | $7 | $7 | 1 |
| Crystal Identification From Tissue OR Body Fluid | other | $7 | $7 | $7 | 1 |
| Evaluation of Antimicrobial Drug | other | $7 | $7 | $7 | 1 |
| Glutamyltransferase (liver Enzyme) Level | other | $7 | $7 | $7 | 1 |
| Injection, Ampicillin Sodium, 500 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Bupivicaine, Not Otherwise Specified, 0.5 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Cefoxitin Sodium, 1 Gm | other | $7 | $7 | $7 | 1 |
| Injection, Ceftriaxone Sodium, Per 250 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Heparin Sodium (pfizer), Not Therapeutically Equivalent to J1644, ... | other | $7 | $7 | $7 | 1 |
| Injection, Lidocaine Hcl in 5% Dextrose, 1 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Lidocaine Hydrochloride, 1 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Remdesivir, 1 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Vitamin B-12 Cyanocobalamin, Up to 1000 Mcg | other | $7 | $7 | $7 | 1 |
| Lipase (fat Enzyme) Level | other | $7 | $7 | $7 | 1 |
| Lithium Level | other | $7 | $7 | $7 | 1 |
| Magnesium Level | other | $7 | $7 | $7 | 1 |
| Measurement for Strep Antibody | other | $7 | $7 | $7 | 1 |
| Measurement of Antibody to Infectious Organism | other | $7 | $7 | $7 | 1 |
| Liver Function Panel | lab | $8 | $4 | $39 | 14 |
| Administration of Vaccine OR Toxoid Component with Counseling (18 Years OR Yo... | therapy | $8 | $8 | $8 | 1 |
| Administration of Vaccine, Each Additional Vaccine | preventive | $8 | $8 | $8 | 1 |
| Albuterol, Up to 2.5 Mg and Ipratropium Bromide, Up to 0.5 Mg, Fda-approved F... | other | $8 | $1 | $15 | 2 |
| Algicell 4 X 4 #88044 4ea/1cs | other | $8 | $8 | $8 | 1 |
| Anesthesia for Removal of Blood Clot From Upper Arm OR Elbow Artery | surgery | $8 | $8 | $8 | 1 |
| Bacterial Colony Count, Urine | other | $8 | $8 | $8 | 1 |
| Blood Typing Rh Phenotyping | other | $8 | $8 | $8 | 1 |
| Boot Prevalon Heel Protector I #7305 8/cs | other | $8 | $8 | $8 | 1 |
| Analysis for Antibody to Brucella | other | $8 | $8 | $8 | 1 |
| Chemical Analysis Using Spectrophotometry | other | $8 | $8 | $8 | 1 |
| Cholinesterase (enzyme) Level, to Test for Exposure to Chemical OR Liver Disease | other | $8 | $8 | $8 | 1 |
| Clotting Factor X Assessment Test, Diluted | other | $8 | $8 | $8 | 1 |
| Detection Test By Immunoassay Technique for Histoplasma Capsulatum | other | $8 | $8 | $8 | 1 |
| Fetal Hemoglobin Analysis | other | $8 | $8 | $8 | 1 |
| Fungal Culture | lab | $8 | $8 | $8 | 1 |
| Fungal Culture (mold OR Yeast) of Skin, Hair, OR Nail | lab | $8 | $8 | $8 | 1 |
| Gonadotropin (reproductive Hormone) Analysis | other | $8 | $8 | $8 | 1 |
| Guide Wire | other | $8 | $8 | $8 | 1 |
| Hdl Cholesterol Level | other | $8 | $8 | $8 | 1 |
| Injection, Ampicillin Sodium/sulbactam Sodium, Per 1.5 Gm | other | $8 | $8 | $8 | 1 |
| Ketone Bodies Analysis, Quantitative | other | $8 | $8 | $8 | 1 |
| Measurement of Cold Agglutinin (protein) to Screen for Infection OR Disease | other | $8 | $8 | $8 | 1 |
| Measurement of Hepatitis a Antibody | other | $8 | $8 | $8 | 1 |
| Methemoglobin (hemoglobin) Analysis, Quantitative | other | $8 | $8 | $8 | 1 |
| Blood Draw (Venipuncture) | lab | $9 | $1 | $73 | 14 |
| 0.054 Wire Ws-1407st | other | $9 | $9 | $9 | 1 |
| 5% Dextrose/normal Saline | other | $9 | $5 | $13 | 2 |
| 6/7 Glidesheath Slender #50-1070 10ea/box | other | $9 | $9 | $9 | 1 |
| Administration of Nasal OR Oral Vaccine, Each Additional Vaccine | preventive | $9 | $9 | $9 | 1 |
| Annual, Face-to-face Intensive Behavioral Therapy for Cardiovascular Disease,... | cardiac | $9 | $9 | $9 | 1 |
| Application of Electrical Stimulation | other | $9 | $9 | $9 | 1 |
| Bacterial Culture | lab | $9 | $8 | $53 | 3 |
| Biopsy Inst Max-core Disposable Core #mc1820 | lab | $9 | $9 | $9 | 1 |
| Butorphanol 10 Mg/ml Spray | other | $9 | $9 | $9 | 1 |
| Button Cannula 10mm Idx4 #ar-6592-10 | other | $9 | $9 | $9 | 1 |
| Button Cannula 10mm Idx5 #ar-6592-10 | other | $9 | $9 | $9 | 1 |
| Analysis for Antibody to HIV -1 Virus | other | $9 | $9 | $9 | 1 |
| Benzocaine 20% 60 Ml Spray | other | $9 | $9 | $9 | 1 |
| Carotene Level | other | $9 | $9 | $9 | 1 |
| Creatinine Clearance Measurement to Test for Kidney Function | other | $9 | $9 | $9 | 1 |
| Evaluation of Antimicrobial Drug (antibiotic, Antifungal, Antiviral), Microdi... | other | $9 | $9 | $9 | 1 |
| Fetal Hemoglobin OR Red Blood Cells Measurement for Assessment of Fetal-mater... | other | $9 | $9 | $9 | 1 |
| Gammaglobulin (immune System Protein) Measurement | other | $9 | $9 | $9 | 1 |
| Injection, Butorphanol Tartrate, 1 Mg | other | $9 | $9 | $9 | 1 |
| Injection, Epinephrine (international Medication Systems), Not Therapeuticall... | other | $9 | $9 | $9 | 1 |
| Injection, Epoetin Alfa, (for Non-esrd Use), 1000 Units | other | $9 | $9 | $9 | 1 |
| Injection, Non-radioactive, Non-contrast, Visualization Adjunct (e.g., Methyl... | other | $9 | $9 | $9 | 1 |
| Injection, Phenylephrine Hydrochloride, 20 Micrograms | other | $9 | $9 | $9 | 1 |
| Injection, Piperacillin Sodium/tazobactam Sodium, 1 Gram/0.125 Grams | other | $9 | $9 | $9 | 1 |
| Iron Binding Capacity | other | $9 | $9 | $9 | 1 |
| Non-covered Item OR Service | other | $9 | $9 | $9 | 1 |
| Hemoglobin A1C | lab | $10 | $7 | $900 | 21 |
| 5% Dextrose in Lactated Ringers Infusion, Up to 1000 Cc | surgery | $10 | $6 | $13 | 2 |
| 5% Dextrose/water | other | $10 | $6 | $13 | 2 |
| Aldolase (enzyme) Level | other | $10 | $10 | $10 | 2 |
| Analysis for Antibody to Bartonella | other | $10 | $10 | $10 | 2 |
| Analysis for Antibody to Coccidioides | other | $10 | $8 | $11 | 2 |
| Analysis for Antibody to Ehrlichia | other | $10 | $10 | $10 | 1 |
| Aortical Surgical Flat 4.0 Punch #080-401 6ea/box | surgery | $10 | $10 | $10 | 1 |
| Ascorbic Acid (vitamin C) Level, Blood | other | $10 | $10 | $10 | 2 |
| Betamethasone Dp 0.05% Lot | other | $10 | $10 | $10 | 1 |
| Bra Compression Pink Post Surgery Large #042l | surgery | $10 | $10 | $10 | 1 |
| Bra Compression Pink Post Surgery Medium #042m | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression 2xl #0422xl | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression 3xl #0423xl | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression Xl #042xl | surgery | $10 | $10 | $10 | 1 |
| Breather/speech/rehab 1ea | other | $10 | $10 | $10 | 1 |
| Cholangiogram Catheter | cardiac | $10 | $10 | $10 | 1 |
| Coagulation Function Measurement, D-dimer; Quantitative | other | $10 | $10 | $10 | 1 |
| Detection Test By Immunoassay Technique for Hepatitis B Surface Antigen | other | $10 | $10 | $10 | 1 |
| Detection Test By Immunoassay with Direct Visual Observation for Other Organism | other | $10 | $10 | $10 | 1 |
| Detection Test By Immunoassay with Direct Visual Observation for Streptococcu... | other | $10 | $10 | $10 | 1 |
| Dextrose 5%-0.45% Nacl IV Soln | other | $10 | $10 | $10 | 1 |
| Fibrinogen (factor 1) Activity Measurement | other | $10 | $10 | $10 | 1 |
| Injection, Acyclovir, 5 Mg | other | $10 | $10 | $10 | 1 |
| Injection, Cefepime Hydrochloride, 500 Mg | other | $10 | $10 | $10 | 1 |
| Injection, Ceftazidime, Per 500 Mg | other | $10 | $10 | $10 | 1 |
| Injection, Pantoprazole Sodium, 40 Mg | other | $10 | $10 | $10 | 1 |
| Injection, Potassium Chloride, Per 2 Meq | other | $10 | $10 | $10 | 1 |
| Injection, Thiamine Hcl, 100 Mg | other | $10 | $10 | $10 | 1 |
| Injection, Vancomycin Hcl (mylan), Not Therapeutically Equivalent to J3370, 5... | other | $10 | $10 | $10 | 1 |
| Low Osmolar Contrast Material, 300-399 Mg/ml Iodine Concentration, Per Ml | other | $10 | $10 | $10 | 1 |
| **obsolete** Suture 0 Poly Prolene #833 | other | $11 | $11 | $11 | 1 |
| 5fr Sos Omni (0) 80cm H787107120085 | other | $11 | $11 | $11 | 1 |
| 5fr Sos Omni (3) 80cm | other | $11 | $11 | $11 | 1 |
| Aminocaproic Acid 500 Mg Tab | other | $11 | $11 | $11 | 1 |
| Butrans 5 Mcg/hr Patch | other | $11 | $11 | $11 | 1 |
| Analysis for Antibody to Hiv-1 and Hiv-2 Virus | other | $11 | $11 | $11 | 1 |
| Analysis for Antibody to Zika Virus | other | $11 | $11 | $11 | 1 |
| Antithrombin Iii Antigen (clotting Inhibitor) Level | other | $11 | $11 | $11 | 1 |
| Blood Ph Level | other | $11 | $11 | $11 | 1 |
| Ceruloplasmin (protein) Level | other | $11 | $11 | $11 | 1 |
| Culture for Acid-fast Bacilli | lab | $11 | $11 | $11 | 1 |
| Detection Test By Immunoassay Technique for Helicobacter Pylori (gi Tract Bac... | other | $11 | $11 | $11 | 1 |
| Diclofenac Sodium 1% Gel | other | $11 | $11 | $11 | 1 |
| Flector Patch | other | $11 | $11 | $11 | 1 |
| Hepatitis B Surface Antibody Measurement | other | $11 | $11 | $11 | 1 |
| Infusion, Albumin (human), 5%, 50 Ml | surgery | $11 | $11 | $11 | 1 |
| Injection, Betamethasone Acetate 3 Mg and Betamethasone Sodium Phosphate 3 Mg | other | $11 | $11 | $11 | 1 |
| Injection, Methylprednisolone Acetate, 1 Mg | other | $11 | $11 | $11 | 1 |
| Injection, Sumatriptan Succinate, 6 Mg | other | $11 | $11 | $11 | 1 |
| Insulin Measurement, Total | other | $11 | $11 | $11 | 1 |
| Ldl Cholesterol Level | other | $11 | $11 | $11 | 1 |
| Administration of Hepatitis B Vaccine | preventive | $12 | $12 | $12 | 1 |
| Administration of Influenza Virus Vaccine | preventive | $12 | $12 | $12 | 1 |
| Administration of Pneumococcal Vaccine | preventive | $12 | $12 | $12 | 1 |
| Analysis for Antibody to Blastomyces | other | $12 | $10 | $13 | 2 |
| Analysis for Antibody to Histoplasma | other | $12 | $10 | $14 | 2 |
| Analysis for Antibody to Virus | other | $12 | $11 | $13 | 2 |
| Analysis of Substance Using Immunoassay Technique, Multiple Step Method | other | $12 | $12 | $12 | 2 |
| Antithrombin Iii Antigen (clotting Inhibitor) Activity | other | $12 | $12 | $12 | 2 |
| Application of Blood Vessel Compression Device | other | $12 | $11 | $12 | 2 |
| Assessment of Emotional OR Behavioral Problems | other | $12 | $12 | $12 | 1 |
| Betamethasone Dp 0.05% Oint | other | $12 | $12 | $12 | 1 |
| Blood Viscosity Measurement | other | $12 | $12 | $12 | 2 |
| Brexpiprazole 2 Mg Po Tabs | other | $12 | $12 | $12 | 1 |
| Analysis for Antibody to Chlamydia | other | $12 | $12 | $12 | 1 |
| Analysis for Antibody to Parvovirus | other | $12 | $12 | $12 | 1 |
| Antibody Identification Test, Platelet Associated Immunoglobulin Assay | other | $12 | $12 | $12 | 1 |
| Carboxyhemoglobin (protein) Level | other | $12 | $12 | $12 | 1 |
| Copper Level | other | $12 | $12 | $12 | 1 |
| Creatine Kinase (cardiac Enzyme) Level, Mb Fraction Only | cardiac | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Giardia | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Hepatitis Be Surface Antigen | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Other Organism | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Rotavirus | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Shiga-like Toxin | other | $12 | $12 | $12 | 1 |
| Electrical Stimulation (unattended), to One OR More Areas for Indication(s) O... | other | $12 | $12 | $12 | 1 |
| Hepatitis B Core Antibody (igm) Measurement | other | $12 | $12 | $12 | 1 |
| Hepatitis Be Antibody Measurement | other | $12 | $12 | $12 | 1 |
| Injection, Amikacin Sulfate, 100 Mg | other | $12 | $12 | $12 | 1 |
| Injection, Atropine Sulfate, 0.01 Mg | other | $12 | $12 | $12 | 1 |
| Injection, Succinylcholine Chloride, Up to 20 Mg | other | $12 | $12 | $12 | 1 |
| Islet Cell (pancreas) Antibody Measurement | other | $12 | $12 | $12 | 1 |
| Lactic Acid Level | other | $12 | $12 | $12 | 1 |
| Lead Level | other | $12 | $12 | $12 | 1 |
| Measurement of Antibody to Noninfectious Agent | other | $12 | $12 | $12 | 1 |
| Measurement of Complement (immune System Proteins), Antigen | other | $12 | $12 | $12 | 1 |
| Measurement of Complement Function | other | $12 | $12 | $12 | 1 |
| Nephelometry, Test Method Using Light | other | $12 | $12 | $12 | 1 |
| Hematocrit | other | $12 | $12 | $12 | 1 |
| Cholesterol Management | cardiac | $13 | $2 | $65 | 35 |
| Adenovirus Type 4 Vaccine | preventive | $13 | $13 | $13 | 1 |
| Administration of First Vaccine OR Toxoid Component with Counseling | therapy | $13 | $13 | $13 | 1 |
| Administration of Nasal OR Oral Vaccine, 1 Vaccine | preventive | $13 | $13 | $13 | 1 |
| Administration of Vaccine | preventive | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Aspergillus | other | $13 | $10 | $15 | 2 |
| Analysis for Antibody to Cytomegalovirus | other | $13 | $12 | $14 | 2 |
| Analysis for Antibody to Enterovirus | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Early Antigen | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Mumps Virus | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Mycoplasma | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Rubeola | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Varicella-zoster Virus | other | $13 | $13 | $13 | 2 |
| Avitene Ultrafoam Collagen Sponge 100 SQ Cm 8cm X 12.5cm 3-1/18" X 5" 1050040 | other | $13 | $13 | $13 | 1 |
| Bacteriostatic Saline Vial | other | $13 | $13 | $13 | 1 |
| Blood Glucose (sugar) Tolerance Test, 3 Specimens | lab | $13 | $13 | $13 | 2 |
| Boot Prevalon Iii W/wedge #7355 8ea/cs | other | $13 | $13 | $13 | 1 |
| Bupivacaine-epinephrine (pf) 0.5% -1:200000 Ij Soln | other | $13 | $13 | $13 | 1 |
| Buprenorphine 10 Mcg/hr Patch | other | $13 | $13 | $13 | 1 |
| Activated Charcoal 25gm Oral | other | $13 | $13 | $13 | 1 |
| Activated Charcoal; 25gm Water | other | $13 | $13 | $13 | 1 |
| Amino Acid Level, 6 OR More Amino Acids, Quantitative, Each Specimen | lab | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Herpes Simplex Virus, Type 1 | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Salmonella | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody, Treponema Pallidum | other | $13 | $13 | $13 | 1 |
| Breathing Bag OR Tube | other | $13 | $13 | $13 | 1 |
| Chemical Analysis of Stone | other | $13 | $13 | $13 | 1 |
| Creatine Kinase (cardiac Enzyme) Level, Isoenzymes | cardiac | $13 | $13 | $13 | 1 |
| Cyanocobalamin (vitamin B-12) Level | other | $13 | $13 | $13 | 1 |
| Detection Test By Immunoassay Technique for Escherichia Coli 0157 | other | $13 | $13 | $13 | 1 |
| Digoxin Level, Total | other | $13 | $13 | $13 | 1 |
| Haptoglobin (serum Protein) Level | other | $13 | $13 | $13 | 1 |
| Hemoglobin Analysis and Measurement, Electrophoresis | other | $13 | $13 | $13 | 1 |
| Hydroxyindolacetic Acid (product of Metabolism) Level | other | $13 | $13 | $13 | 1 |
| Ige (immune System Protein) Level | other | $13 | $13 | $13 | 1 |
| Inhibin a (reproductive Organ Hormone) Measurement | other | $13 | $13 | $13 | 1 |
| Injection, Cefazolin Sodium, 500 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Magnesium Sulfate, Per 500 Mg | other | $13 | $13 | $13 | 1 |
| Ketosteroids, 17 (hormone) Measurement, Total | other | $13 | $13 | $13 | 1 |
| Lactate Dehydrogenase (enzyme) Measurement | other | $13 | $13 | $13 | 1 |
| Lamotrigine Level | other | $13 | $13 | $13 | 1 |
| Levetiracetam Level | other | $13 | $13 | $13 | 1 |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation, Hi... | other | $13 | $13 | $13 | 1 |
| Measurement of Antibody for Rheumatoid Arthritis Assessment | other | $13 | $13 | $13 | 1 |
| Measurement of Dna Antibody, Native OR Double Stranded | other | $13 | $13 | $13 | 1 |
| Measurement of Substance Using Immunoassay Technique | other | $13 | $13 | $13 | 1 |
| Myoglobin (muscle Protein) Level | other | $13 | $13 | $13 | 1 |
| Emergency Room Visit | emergency | $14 | $1 | $1,749 | 32 |
| Addition to Lower Extremity Orthosis, Drop Lock Retainer, Each | other | $14 | $14 | $14 | 1 |
| Addition to Upper Extremity Orthosis, Sock, Fracture OR Equal, Each | other | $14 | $14 | $14 | 1 |
| Analysis for Antibody to Cryptococcus | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Herpes Simplex Virus | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Hiv-2 Virus | other | $14 | $14 | $14 | 1 |
| Analysis for Antibody to Rubella | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Toxoplasma | other | $14 | $14 | $14 | 2 |
| Analysis Using Chemiluminescent Technique (light and Chemical )reaction | other | $14 | $14 | $14 | 2 |
| Benzoyl Peroxide-erythromycin 5-3 % Ex Gel | other | $14 | $14 | $14 | 1 |
| Boot Prevalon Heel Protector Petite #7310 | other | $14 | $14 | $14 | 1 |
| Bowl Cement Smart Mix #5401-76 | other | $14 | $14 | $14 | 1 |
| Amino Acid Analysis, Multiple Amino Acids, Qualitative, Each Specimen | lab | $14 | $14 | $14 | 1 |
| Analysis for Antibody to West Nile Virus | other | $14 | $14 | $14 | 1 |
| Application of Electrical Stimulation with Therapist Present, Each 15 Minutes | other | $14 | $14 | $14 | 1 |
| Application of Mechanical Traction | other | $14 | $14 | $14 | 1 |
| Application of Ultrasound, Each 15 Minutes | imaging | $14 | $14 | $14 | 1 |
| Calcium Level, Ionized | other | $14 | $14 | $14 | 1 |
| Detection Test By Immunoassay Technique for Influenza Virus | other | $14 | $14 | $14 | 1 |
| Detection Test By Immunoassay Technique for Respiratory Syncytial Virus | other | $14 | $14 | $14 | 1 |
| Detection Test By Immunoassay with Direct Visual Observation for Influenza Virus | other | $14 | $14 | $14 | 1 |
| Ferritin (blood Protein) Level | other | $14 | $14 | $14 | 1 |
| Hepatitis C Antibody Measurement | other | $14 | $14 | $14 | 1 |
| Injection, Clindamycin Phosphate, 300 Mg | other | $14 | $14 | $14 | 1 |
| Injection, Heparin Sodium, Per 1000 Units | other | $14 | $14 | $14 | 1 |
| Injection, Hydralazine Hcl, Up to 20 Mg | other | $14 | $14 | $14 | 1 |
| Nacl 0.45 500 | other | $14 | $14 | $14 | 1 |
| Rbc Sed Rate Nonautomated | other | $14 | $14 | $14 | 1 |
| Venipuncture | lab | $15 | $1 | $22 | 6 |
| 4fr Pigtail | other | $15 | $15 | $15 | 1 |
| Amikacin (antibiotic) Level | other | $15 | $15 | $15 | 2 |
| Ammonia Level | other | $15 | $15 | $15 | 2 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Nuclear An... | imaging | $15 | $15 | $15 | 2 |
| Analysis for Antibody to Legionella | other | $15 | $15 | $15 | 2 |
| Angiotensin L - Converting Enzyme (ace) Level | other | $15 | $15 | $15 | 2 |
| Bile Acids Level, Total | other | $15 | $13 | $17 | 2 |
| Blower Mister Kit Clearview #22150 | other | $15 | $15 | $15 | 1 |
| Brachytherapy Needle | other | $15 | $15 | $15 | 1 |
| Brachytherapy Source, Non-stranded, Iodine-125, Per Source | other | $15 | $15 | $15 | 1 |
| Application of Whirlpool Therapy | other | $15 | $15 | $15 | 1 |
| Carbamazepine Level, Total | other | $15 | $15 | $15 | 1 |
| Folic Acid Level, Serum | other | $15 | $15 | $15 | 1 |
| Gonadotropin, Chorionic (reproductive Hormone) Level | other | $15 | $15 | $15 | 1 |
| Hemoglobin Analysis and Measurement, Chromatography | other | $15 | $15 | $15 | 1 |
| Inhalation Treatment for Acute Airway Obstruction, Each Additional Hour | other | $15 | $15 | $15 | 1 |
| Injection, Neostigmine Methylsulfate, Up to 0.5 Mg | other | $15 | $15 | $15 | 1 |
| Lidocaine Level | other | $15 | $15 | $15 | 1 |
| Microsomal Antibodies (autoantibody) Measurement | other | $15 | $15 | $15 | 1 |
| 10.0mm Shiley Flex Cuffless Reus Trach 10un10r | other | $16 | $16 | $16 | 1 |
| 20fr Standard Peg Kit Push Box of 2 #m00568211 | other | $16 | $16 | $16 | 1 |
| 24fr Standard Peg Kit Pull with Enfit M00509061 | other | $16 | $16 | $16 | 1 |
| Aminolevulinic Acid (protein) Level | other | $16 | $16 | $16 | 1 |
| Anesthesia for Electroshock Therapy | other | $16 | $16 | $16 | 1 |
| Aveta Waste Management Accessory 3.0 #205-2036 6ea/ct | other | $16 | $16 | $16 | 1 |
| Beta-2 Microglobulin (protein) Level | other | $16 | $16 | $16 | 2 |
| Breast Prosthesis, Mastectomy Bra, without Integrated Breast Prosthesis Form,... | other | $16 | $16 | $16 | 1 |
| Cell Examination of Specimen, Concentration Technique | lab | $16 | $16 | $16 | 1 |
| Cement Mixer Optivac Triple Mi | other | $16 | $16 | $16 | 1 |
| Cortisol (hormone) Measurement, Total | other | $16 | $16 | $16 | 1 |
| Gentamicin (antibiotic) Level | other | $16 | $16 | $16 | 1 |
| Haloperidol Level | other | $16 | $16 | $16 | 1 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 15 | other | $16 | $16 | $16 | 1 |
| Injection, Aminophyllin, Up to 250 Mg | other | $16 | $16 | $16 | 1 |
| L.e.t. (lido-epineph-tetra) Ge | other | $16 | $16 | $16 | 1 |
| Mercury Level | other | $16 | $16 | $16 | 1 |
| Assay of Urea Nitrogen | other | $16 | $16 | $16 | 1 |
| Glucose Blood Test | lab | $16 | $16 | $16 | 1 |
| Prothrombin Time | lab | $16 | $16 | $16 | 1 |
| Rbc Sed Rate Automated | other | $16 | $16 | $16 | 1 |
| Addition to Lower Extremity, Below Knee, Fork Strap | other | $17 | $17 | $17 | 1 |
| Alpha-fetoprotein (afp) Level, Serum | other | $17 | $17 | $17 | 2 |
| Analysis for Antibody | other | $17 | $17 | $17 | 2 |
| Analysis for Antibody Borrelia Burgdorferi | other | $17 | $17 | $17 | 2 |
| Analysis for Antibody to Helicobacter Pylori | other | $17 | $17 | $17 | 2 |
| Analysis for Antibody to Hepatitis D Virus | other | $17 | $17 | $17 | 1 |
| Aprepitant, Oral, 5 Mg | other | $17 | $17 | $17 | 1 |
| Balloon Armada 35 Wh 12x80x135cm #b2120 | other | $17 | $17 | $17 | 1 |
| Bellaire Comfort Lso Universal Fits Waist Circumference: 25-60inch (64-152cm)... | other | $17 | $17 | $17 | 1 |
| Analysis for Antibody (igm) to West Nile Virus | other | $17 | $17 | $17 | 1 |
| Aspiration of Cyst of Breast, Each Additional Cyst | other | $17 | $17 | $17 | 1 |
| Carnitine Level | other | $17 | $17 | $17 | 1 |
| Catheter, Intradiscal | cardiac | $17 | $17 | $17 | 1 |
| Cortisol (hormone) Measurement, Free | other | $17 | $17 | $17 | 1 |
| D-5 Lr 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5- 1/2 500cc | other | $17 | $17 | $17 | 1 |
| D-5- 1/4 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5- Lr 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-1/2 Ns 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-1/4 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-s 100o Cc | other | $17 | $17 | $17 | 1 |
| D-5-s 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5-w 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-w 500 Cc | other | $17 | $17 | $17 | 1 |
| Detection Test By Immunoassay Technique for Streptococcus, Group a | other | $17 | $17 | $17 | 1 |
| Estrogen Analysis, Total | other | $17 | $17 | $17 | 1 |
| Glycated Protein Level | other | $17 | $17 | $17 | 1 |
| Injection, Glycopyrrolate, 0.1 Mg | other | $17 | $17 | $17 | 1 |
| Lactated Ringers 500 Cc | other | $17 | $17 | $17 | 1 |
| Lactated Ringers-1000cc | other | $17 | $17 | $17 | 1 |
| Measurement of Antibody for Assessment of Autoimmune Disorder, Any Method | other | $17 | $17 | $17 | 1 |
| Metanephrines Level | other | $17 | $17 | $17 | 1 |
| Nacl 0.45 1000 Cc | other | $17 | $17 | $17 | 1 |
| Active Wound Care >20 Cm | other | $17 | $17 | $17 | 1 |
| Assay of Protein Urine | other | $17 | $17 | $17 | 1 |
| Assay of Urine Sodium | other | $17 | $17 | $17 | 1 |
| 10.0mm Shiley Flex Cuffed Reus Trach 10cn10r | other | $18 | $18 | $18 | 1 |
| 14fr Entuit Gastrostomy Tube #g35615 | other | $18 | $18 | $18 | 1 |
| 6.5mm Shiley Flex Cuffed Reus Trach 4cn65r | other | $18 | $18 | $18 | 1 |
| 7.5mm Shiley Flex Cuffed Reus Trach 6cn75r | other | $18 | $18 | $18 | 1 |
| 8.5mm S Shiley Flex Cuffed Reus Trach 8cn85r | other | $18 | $18 | $18 | 1 |
| Amino Acid Analysis, Quantitative, Each Specimen | lab | $18 | $13 | $23 | 2 |
| Amox-clav 600-42.9 Mg/5 Ml Sus | other | $18 | $18 | $18 | 1 |
| Amoxicillin-pot Clavulanate 600-42.9 Mg/5ml Po Susr | other | $18 | $18 | $18 | 1 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Viral Capsid | other | $18 | $18 | $18 | 2 |
| Antibody Identification Test, Platelet Antibodies | other | $18 | $18 | $18 | 2 |
| Auto Effluent Set #115370 Ca/ 8ea | other | $18 | $18 | $18 | 1 |
| Aztreonam 2 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $18 | $18 | $18 | 1 |
| Abreva 2 Gm Tube | other | $18 | $18 | $18 | 1 |
| Application of Medication Using Electrical Current, Each 15 Minutes | other | $18 | $18 | $18 | 1 |
| C-peptide (protein) Level | other | $18 | $18 | $18 | 1 |
| Cyclosporine Level | other | $18 | $18 | $18 | 1 |
| Folic Acid Level, Rbc | other | $18 | $18 | $18 | 1 |
| Gastrin (gi Tract Hormone) Level | other | $18 | $18 | $18 | 1 |
| Glycine Sol.1.5%-3000cc | other | $18 | $18 | $18 | 1 |
| Homocysteine (amino Acid) Level | other | $18 | $18 | $18 | 1 |
| Hydroxycorticosteroids, 17 (adrenal Gland Hormone) Level | other | $18 | $18 | $18 | 1 |
| Injection, Dopamine Hcl, 40 Mg | other | $18 | $18 | $18 | 1 |
| Injection, Iron Dextran, 50 Mg | other | $18 | $18 | $18 | 1 |
| Injection, Levetiracetam, 10 Mg | other | $18 | $18 | $18 | 1 |
| Hc Sars-cov-2 Cdc | other | $18 | $18 | $18 | 1 |
| ABO Blood Type | lab | $18 | $18 | $18 | 1 |
| Assay of Blood Chloride | other | $18 | $18 | $18 | 1 |
| Assay of Serum Potassium | other | $18 | $18 | $18 | 1 |
| Blood Typing Serologic Rh | other | $18 | $18 | $18 | 1 |
| 4fr Pedal Access Set Micropuncture Transitionless #g02972 | other | $19 | $19 | $19 | 1 |
| 5fr Pedal Access Set Micropuncture Transitionless #g02988 | other | $19 | $19 | $19 | 1 |
| Analysis for Antibody to Rickettsia | other | $19 | $19 | $19 | 2 |
| Arsenic Level | other | $19 | $19 | $19 | 2 |
| Barron Vacuum Punch 9.0mm | other | $19 | $19 | $19 | 1 |
| Bivona Uncuffed Tracheostomy Tube Flextend Size 8.0 Pediatric #60pfs55 | other | $19 | $19 | $19 | 1 |
| Blood Smear Interpretation By Physician with Written Report | other | $19 | $19 | $19 | 1 |
| Alcohol 5%&dextr.5%in Water 10 | other | $19 | $19 | $19 | 1 |
| Analysis for Antibody to Herpes Simplex Virus, Type 2 | other | $19 | $19 | $19 | 1 |
| Carcinoembryonic Antigen (cea) Protein Level | other | $19 | $19 | $19 | 1 |
| Collagen Cross Links Test | other | $19 | $19 | $19 | 1 |
| D-10-w 500ml | other | $19 | $19 | $19 | 1 |
| D-5-0.2% Sodium Chloride(250cc | other | $19 | $19 | $19 | 1 |
| D-5-r 1000 Cc | other | $19 | $19 | $19 | 1 |
| Detection Test By Immunoassay Technique for Hiv-1 Antigen and Hiv-1 and Hiv-2... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Chlamydia Trachomatis, Amplified Probe Tec... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Clostridium Difficile, Amplified Probe Tec... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Cytomegalovirus (cmv), Amplified Probe Tec... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Neisseria Gonorrhoeae (gonorrhoeae Bacteri... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Trichomonas Vaginalis (genital Parasite), ... | other | $19 | $19 | $19 | 1 |
| Dextrose 10%in Saline(d-10-s)1 | other | $19 | $19 | $19 | 1 |
| Dextrose 2.5% Strength Saline | other | $19 | $19 | $19 | 1 |
| Dextrose 5.5%in Salinec\20meq5 | other | $19 | $19 | $19 | 1 |
| Dextrose 5.5%in Salinec\meq 10 | other | $19 | $19 | $19 | 1 |
| Dextrose 5%inh2o(d5w)1000cc | other | $19 | $19 | $19 | 1 |
| Dextrose 5%inwatr(d5w)500cc | other | $19 | $19 | $19 | 1 |
| Dextrose 5%ring.inj.500cc | other | $19 | $19 | $19 | 1 |
| Diagnostic Digital Breast Tomosynthesis, Unilateral OR Bilateral | other | $19 | $19 | $19 | 1 |
| Erythropoietin (protein) Level | other | $19 | $19 | $19 | 1 |
| Evaluation for Wheelchair, Each 15 Minutes | other | $19 | $19 | $19 | 1 |
| Gonadotropin, Follicle Stimulating (reproductive Hormone) Level | other | $19 | $19 | $19 | 1 |
| Gonadotropin, Luteinizing (reproductive Hormone) Level | other | $19 | $19 | $19 | 1 |
| Injection Fluconazole, 200 Mg | other | $19 | $19 | $19 | 1 |
| Microbial Toxin OR Antitoxin Assay | other | $19 | $19 | $19 | 1 |
| Automated Reticulocyte Count | other | $19 | $19 | $19 | 1 |
| Blood Test | lab | $20 | $2 | $547 | 26 |
| Flu Vaccination | preventive | $20 | $12 | $69 | 24 |
| Pap Smear | preventive | $20 | $4 | $208 | 30 |
| 3d Ultrasound Imaging of Heart for Evaluation of Heart Structure Performed Du... | imaging | $20 | $20 | $20 | 1 |
| Addition to Lower Extremity, Limited Ankle Motion, Each Joint | other | $20 | $20 | $20 | 1 |
| Aerotech I Aerosol Unit Ca-1124 | other | $20 | $20 | $20 | 1 |
| Beta 2 Glycoprotein 1 Antibody (autoantibody) Measurement | other | $20 | $19 | $21 | 2 |
| Blake Drain 19fr R/f #2230 Case/10ea | other | $20 | $20 | $20 | 1 |
| Blood Culture | lab | $20 | $10 | $64 | 3 |
| Bone Hemostasis 2.5gm #bw012 Ostene | other | $20 | $20 | $20 | 1 |
| Bowl and Spatula Bone Cement Mixing Universal System Vacuum Rotor without Noz... | other | $20 | $20 | $20 | 1 |
| Brace Knee Post Op Warrior Kb9000 | other | $20 | $20 | $20 | 1 |
| Astelin | other | $20 | $20 | $20 | 1 |
| Culture for Chlamydia | lab | $20 | $20 | $20 | 1 |
| Detection Test By Nucleic Acid for Chlamydia, Direct Probe Technique | other | $20 | $20 | $20 | 1 |
| Detection Test By Nucleic Acid for Enterovirus (intestinal Virus), Amplified ... | other | $20 | $20 | $20 | 1 |
| Estriol (hormone) Level | other | $20 | $20 | $20 | 1 |
| Hydroxyprogesterone, 17-d (synthetic Hormone) Level | other | $20 | $20 | $20 | 1 |
| Infectious Agent Detection By Nucleic Acid (dna OR Rna); Human Papillomavirus... | other | $20 | $20 | $20 | 1 |
| Injection, Fentanyl Citrate, 0.1 Mg | other | $20 | $20 | $20 | 1 |
| Injection, Methocarbamol, Up to 10 Ml | other | $20 | $20 | $20 | 1 |
| Injection, Nitroglycerin, 5 Mg | other | $20 | $20 | $20 | 1 |
| Injection, Regadenoson, 0.1 Mg | other | $20 | $20 | $20 | 1 |
| Measurement of Complement (immune System Proteins), Total Hemolytic | other | $20 | $20 | $20 | 1 |
| Assay Blood Carbon Dioxide | other | $20 | $20 | $20 | 1 |
| 45 Degree Kelman Mini-flare Tip | other | $21 | $21 | $21 | 1 |
| Acclarent Balloon Inflation Device 5 Ea/bxdib30 | other | $21 | $21 | $21 | 1 |
| Addition to Lower Extremity, Below Knee, Waist Belt, Webbing | other | $21 | $21 | $21 | 1 |
| Analysis for Detection of Tumor Marker | other | $21 | $21 | $21 | 1 |
| Bio-medicus Venous Insertion Kit 5 Ea/pk 96551 | other | $21 | $21 | $21 | 1 |
| Brace Rcai Contour Fit Lso Med 451-cf-lso-m | other | $21 | $21 | $21 | 1 |
| Brace Rcai Control Fit Lso Large 451-cf-lso-l | other | $21 | $21 | $21 | 1 |
| Abo & Rh Blood Type | other | $21 | $21 | $21 | 1 |
| Analysis of Female Reproductive Genetic Marker | other | $21 | $21 | $21 | 1 |
| Cell Examination of Body Fluid, Smears | other | $21 | $21 | $21 | 1 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 125 | other | $21 | $21 | $21 | 1 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 19 | other | $21 | $21 | $21 | 1 |
| Influenza Vaccine, Quadrivalent, Preservative Free, 0.5 Ml Dosage | preventive | $21 | $21 | $21 | 1 |
| Injection, Esmolol Hydrochloride, 10 Mg | other | $21 | $21 | $21 | 1 |
| Insulin Antibody Measurement | other | $21 | $21 | $21 | 1 |
| Muri-lube Mineral Oil Vial | other | $21 | $21 | $21 | 1 |
| Assay of Creatinine | other | $21 | $21 | $21 | 1 |
| 4.2mm Trocar 210mm 03.010.070 | other | $22 | $22 | $22 | 1 |
| Addition to Lower Extremity, Extended Steel Shank | other | $22 | $22 | $22 | 1 |
| Dehydroepiandrosterone (dhea-s) Hormone Level | other | $22 | $22 | $22 | 1 |
| Fetal Lung Maturity Assessment, Lecithin Sphingomyelin (l/s) Ratio | other | $22 | $22 | $22 | 1 |
| Gabapentin Level | other | $22 | $22 | $22 | 1 |
| Hemoglobin & Hematocrit | other | $22 | $22 | $22 | 1 |
| Immunologic Analysis Technique On Serum | other | $22 | $22 | $22 | 1 |
| Injection, Hydrocortisone Sodium Succinate, Up to 100 Mg | other | $22 | $22 | $22 | 1 |
| Injection, Ropivacaine Hydrochloride, 1 Mg | other | $22 | $22 | $22 | 1 |
| Assay of Protein Serum | other | $22 | $22 | $22 | 1 |
| Addition to Lower Extremity, Varus/valgus Correction ('t') Strap, Padded/line... | other | $23 | $23 | $23 | 1 |
| Alcohol And/or Substance (other Than Tobacco) Misuse Structured Assessment (e... | other | $23 | $23 | $23 | 1 |
| Alcohol And/or Substance Abuse Screening and Intervention, 15-30 Minutes | preventive | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 7.5mm | other | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 8.0mm | other | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 8.25mm | other | $23 | $23 | $23 | 1 |
| Brace Knee T-scope Post Op #08814 | other | $23 | $23 | $23 | 1 |
| Brush Biopsy Deflection 3.2frx115cm #g15045 | lab | $23 | $23 | $23 | 1 |
| Immunologic Analysis Technique On Body Fluid | other | $23 | $23 | $23 | 1 |
| Injection, Calcium Gluconate (wg Critical Care), Not Therapeutically Equivale... | other | $23 | $23 | $23 | 1 |
| Injection, Ketorolac Tromethamine, Per 15 Mg | other | $23 | $23 | $23 | 1 |
| Lipoprotein Level, Quantitation of Lipoprotein Particle Number | other | $23 | $23 | $23 | 1 |
| Antibody Screen | lab | $23 | $23 | $23 | 1 |
| Complete Blood Count (CBC) | lab | $24 | $5 | $47 | 6 |
| Hepatic Function Panel | lab | $24 | $4 | $49 | 6 |
| 1.5mm Quick Release Drill Msdc15 Ms-dc15 | other | $24 | $24 | $24 | 1 |
| 16fr Entuit Gastrostomy Tube #g35616 | other | $24 | $24 | $24 | 1 |
| 3d Radiographic Procedure | imaging | $24 | $24 | $24 | 2 |
| 9986-21-20 Flexible Osteotome Short 8 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-21 Flexible Osteotome Short 10 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-22 Flexible Osteotome Short 12 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-24 Flexible Osteotome Short Curved | other | $24 | $24 | $24 | 1 |
| 9986-21-26 Flexible Osteotome Long 10 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-27 Flexible Osteotome Long 8 Mm | other | $24 | $24 | $24 | 1 |
| Addition to Lower Extremity, Below Knee, Cuff Suspension | other | $24 | $24 | $24 | 1 |
| Application of Nonmoveable Finger Splint | other | $24 | $24 | $24 | 1 |
| Bard Single Lumen Picc 5fr #3195335 | other | $24 | $24 | $24 | 1 |
| Bra Cardiac Surgery Sz-40b-52dd 1ea | surgery | $24 | $24 | $24 | 1 |
| Chemical Analysis Using Chromatography Technique | other | $24 | $24 | $24 | 1 |
| Icd-s/d/m In/cl-chec | other | $24 | $24 | $24 | 1 |
| Injection, Vancomycin Hydrochloride, 10 Mg | other | $24 | $24 | $24 | 1 |
| Iodine I-131 Sodium Iodide Capsule(s), Therapeutic, Per Millicurie | other | $24 | $24 | $24 | 1 |
| Smear Gram Stain | other | $24 | $24 | $24 | 1 |
| 5.5x85mm Rod Ti Alloy Curved Vitality #07.02015.014 | other | $25 | $25 | $25 | 1 |
| Adapter/extension, Pacing Lead OR Neurostimulator Lead | other | $25 | $25 | $25 | 1 |
| Aplisol 5t Unit/0.1 Ml Vial | other | $25 | $25 | $25 | 1 |
| Basket Retrieval 2.5x230cm Disp Roth 00711050 | other | $25 | $25 | $25 | 1 |
| Aluminum Level | other | $25 | $25 | $25 | 1 |
| Cardiolipin Antibody (tissue Antibody) Measurement | other | $25 | $25 | $25 | 1 |
| Catecholamines (organic Nitrogen) Level | imaging | $25 | $25 | $25 | 1 |
| Detection Test By Immunoassay Technique for Severe Acute Respiratory Syndrome... | other | $25 | $25 | $25 | 1 |
| Detection Test By Nucleic Acid for Organism, Quantification | other | $25 | $25 | $25 | 1 |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, Each Additional Growth | imaging | $25 | $25 | $25 | 1 |
| Injection, Enoxaparin Sodium, 10 Mg | other | $25 | $25 | $25 | 1 |
| Measure of Severe Acute Respiratory Syndrome Coronavirus 2 (covid-19) Antibody | other | $25 | $25 | $25 | 1 |
| Addition to Lower Extremity Orthosis, Knee Control, Full Kneecap | other | $26 | $26 | $26 | 1 |
| Adhesion Barrier | other | $26 | $26 | $26 | 1 |
| Anticoagulant Management for an Outpatient Taking Warfarin, Physician Review ... | other | $26 | $26 | $26 | 1 |
| Blood Gases Measurement | other | $26 | $26 | $26 | 2 |
| Bone Marrow Asp Sys Dstl Hole 11g 710.150.97s | other | $26 | $26 | $26 | 1 |
| Catheter, Suprapubic/cystoscopic | cardiac | $26 | $26 | $26 | 1 |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Quantification | other | $26 | $26 | $26 | 1 |
| Follow-up Therapy Service to Facilitate Lung Function | other | $26 | $26 | $26 | 1 |
| Immunologic Analysis for Autoimmune Disease, A, B, OR C, Single Antigen | other | $26 | $26 | $26 | 1 |
| Injection, Haloperidol Decanoate, Per 50 Mg | other | $26 | $26 | $26 | 1 |
| Injection, Phenobarbital Sodium, Up to 120 Mg | other | $26 | $26 | $26 | 1 |
| Iodine I-123 Sodium Iodide, Diagnostic, Per Millicurie | other | $26 | $26 | $26 | 1 |
| 3.0mm Round Diamond 5820-012-030d | other | $27 | $27 | $27 | 1 |
| 4.0mm Round Diamond 5820-012-040d | other | $27 | $27 | $27 | 1 |
| Addition to Lower Extremity Orthosis, Femoral Length Sock, Fracture OR Equal,... | other | $27 | $27 | $27 | 1 |
| Albendazole 200 Mg Po Tabs | other | $27 | $27 | $27 | 1 |
| Alkaloids Levels | other | $27 | $27 | $27 | 1 |
| Balloon Wedge Pressure Catheter 5fr 110cm | cardiac | $27 | $27 | $27 | 1 |
| Belt, Strap, Sleeve, Garment, OR Covering, Any Type | other | $27 | $27 | $27 | 1 |
| Hepatitis B Vaccine, Pediatric OR Adolescent Dosage | preventive | $27 | $27 | $27 | 1 |
| Initial Oxygen 30 Min | other | $27 | $27 | $27 | 1 |
| Injection, Infliximab-abda, Biosimilar, (renflexis), 10 Mg | other | $27 | $27 | $27 | 1 |
| Injection, Medroxyprogesterone Acetate, 1 Mg | other | $27 | $27 | $27 | 1 |
| Assay of Blood/uric Acid | other | $27 | $27 | $27 | 1 |
| Automated Platelet Count | other | $27 | $27 | $27 | 1 |
| Blood,occult By Peroxidase Act | other | $27 | $27 | $27 | 1 |
| 2.2mm Match Head 5820-107 | other | $28 | $28 | $28 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Drop Lock Knee Joint | other | $28 | $28 | $28 | 1 |
| Citrate Level | other | $28 | $28 | $28 | 1 |
| Evaluation of Fine Needle Aspirate with Interpretation and Report | other | $28 | $28 | $28 | 1 |
| Impersol 1.5% 2000cc | other | $28 | $28 | $28 | 1 |
| Impersol 4.25% 2000 Cc | other | $28 | $28 | $28 | 1 |
| Injection, Hydroxyzine Hcl, Up to 25 Mg | other | $28 | $28 | $28 | 1 |
| Injection, Propofol, 10 Mg | other | $28 | $28 | $28 | 1 |
| Lokelma 10 Gm Powder Packet | other | $28 | $28 | $28 | 1 |
| Measurement of Total Estradiol | other | $28 | $28 | $28 | 1 |
| Assay of Phosphorus | other | $28 | $28 | $28 | 1 |
| Decalcification of Tissue | other | $28 | $28 | $28 | 1 |
| Urine Pregnancy Test | other | $28 | $28 | $28 | 1 |
| Mammogram | preventive | $29 | $4 | $1,356 | 32 |
| Allergy Testing Panel | diagnostic | $29 | $19 | $357 | 11 |
| 7fr Single Sensor W/lumen/coude Tip | other | $29 | $29 | $29 | 1 |
| Application of Hinged Finger Splint | other | $29 | $29 | $29 | 1 |
| Detection Test By Nucleic Acid for Cytomegalovirus, Quantification | other | $29 | $29 | $29 | 1 |
| Immunologic Analysis Technique On Body Fluid, Other Fluids with Concentration | other | $29 | $29 | $29 | 1 |
| Injection, Meropenem (b. Braun), Not Therapeutically Equivalent to J2185, 100 Mg | other | $29 | $29 | $29 | 1 |
| Injection, Oxytocin, Up to 10 Units | other | $29 | $29 | $29 | 1 |
| Assay of Serum Sodium | other | $29 | $29 | $29 | 1 |
| Vitamin D Test | lab | $30 | $13 | $367 | 14 |
| 2.3mm Tapered Router5407-fa2 | other | $30 | $30 | $30 | 1 |
| 3.0mm Tapered Router5407-fa3 | other | $30 | $30 | $30 | 1 |
| Amplifed Dna OR Rna Probe Detection of Severe Acute Respiratory Syndrome Coro... | other | $30 | $25 | $35 | 2 |
| Ankle Orthosis, Ankle Gauntlet OR Similar, with OR without Joints, Prefabrica... | other | $30 | $30 | $30 | 1 |
| Antibody Evaluation, Each Additional Single Antibody Stain Procedure | other | $30 | $30 | $30 | 1 |
| Detection Test By Nucleic Acid for Organism, Amplified Probe Technique | other | $30 | $30 | $30 | 1 |
| Detection Test By Nucleic Acid for Zika Virus, Amplified Probe Technique | other | $30 | $30 | $30 | 1 |
| Dxa Bone Density Measurement of Forearm, Finger, Hand, OR Foot | other | $30 | $30 | $30 | 1 |
| Injection, Cefepime Hydrochloride (b Braun), Not Therapeutically Equivalent t... | other | $30 | $30 | $30 | 1 |
| Injection, Daptomycin, 1 Mg | other | $30 | $30 | $30 | 1 |
| Injection, Methylergonovine Maleate, Up to 0.2 Mg | other | $30 | $30 | $30 | 1 |
| Injection, Penicillin G Benzathine, 100,000 Units | other | $30 | $30 | $30 | 1 |
| Assay of Serum Albumin | other | $30 | $30 | $30 | 1 |
| Bilirubin Direct | other | $30 | $30 | $30 | 1 |
| Bilirubin Total | other | $30 | $30 | $30 | 1 |
| Smear Fluorescent/acid Stai | other | $30 | $30 | $30 | 1 |
| 12.6mm X 10.4mm Boring Toolstryker #5130-123 | other | $31 | $31 | $31 | 1 |
| 9.5mm X 10.4mm Boring Tool 5130-123 | other | $31 | $31 | $31 | 1 |
| Addition to Lower Extremity Orthosis, Non-corrosive Finish, Per Bar | other | $31 | $31 | $31 | 1 |
| Follow-up Training in the Use of Orthopedic Device OR Artificial Arm, Leg And... | other | $31 | $31 | $31 | 1 |
| Fracture Assessment of Spine Bones Using Dxa | other | $31 | $31 | $31 | 1 |
| Injection, Infliximab, Excludes Biosimilar, 10 Mg | other | $31 | $31 | $31 | 1 |
| Aspartate Aminotransferase | other | $31 | $31 | $31 | 1 |
| Assay Alkaline Phosphatase | other | $31 | $31 | $31 | 1 |
| Assay of Urine Creatinine | other | $31 | $31 | $31 | 1 |
| C-reactive Protein | other | $31 | $31 | $31 | 1 |
| Fibrinogen | other | $31 | $31 | $31 | 1 |
| Avitene Microfibril Collagen Hemostat 1010020 | other | $32 | $32 | $32 | 1 |
| Basket Roth Net Pedia Foreign Body Bx00711057 | other | $32 | $32 | $32 | 1 |
| Blood Gases Measurement, with O2 Saturation | other | $32 | $32 | $32 | 1 |
| Button Replacement 24fr X 2.4cm Low Profile | surgery | $32 | $32 | $32 | 1 |
| Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 Mg | other | $32 | $32 | $32 | 1 |
| Alanine Amino | other | $32 | $32 | $32 | 1 |
| Cortisol, Serum | other | $32 | $32 | $32 | 1 |
| Rbc Pretreatment with Enzymes | other | $32 | $32 | $32 | 1 |
| Rheumatoid Factor Quant | other | $32 | $32 | $32 | 1 |
| 2.0mm Round Diamond 5820-012-020d | other | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity Orthosis, Rocker Bottom for Total Contact Ankle F... | other | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity, Dorsiflexion Assist (plantar Flexion Resist), Ea... | other | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity, Split Flat Caliper Stirrups and Plate Attachment | other | $33 | $33 | $33 | 1 |
| Ankle Control Orthosis, Stirrup Style, Rigid, Includes Any Type Interface (e.... | other | $33 | $33 | $33 | 1 |
| Injection, Chlorpromazine Hcl, Up to 50 Mg | other | $33 | $33 | $33 | 1 |
| Injection, Diazepam, Up to 5 Mg | other | $33 | $33 | $33 | 1 |
| Injection, Garamycin, Gentamicin, Up to 80 Mg | other | $33 | $33 | $33 | 1 |
| Lipoprotein-associated Phospholipase A2 (enzyme) Level | other | $33 | $33 | $33 | 1 |
| Newborn Metabolic Screening Panel, Includes Test Kit, Postage and the Laborat... | lab | $33 | $33 | $33 | 1 |
| Assay of Triglycerides | other | $33 | $33 | $33 | 1 |
| Coombs Test Direct | other | $33 | $33 | $33 | 1 |
| Deb Bone Add-on | other | $33 | $33 | $33 | 1 |
| Addition to Knee Joint, Lift Loop for Drop Lock Ring | other | $34 | $34 | $34 | 1 |
| Adh (antidiuretic Hormone) Level | other | $34 | $34 | $34 | 1 |
| Biktarvy 50-200-25 Mg Tablet | other | $34 | $34 | $34 | 1 |
| 3d/4d Prenatal Ultrasound | imaging | $34 | $34 | $34 | 1 |
| Injection, Amiodarone Hydrochloride (nexterone), 30 Mg | other | $34 | $34 | $34 | 1 |
| Injection, Caffeine Citrate, 5 Mg | other | $34 | $34 | $34 | 1 |
| Deb Subq Tissue Add-on | other | $34 | $34 | $34 | 1 |
| Prostate Cancer Screening | other | $35 | $8 | $912 | 33 |
| PSA (Prostate-Specific Antigen) | lab | $35 | $18 | $912 | 17 |
| Lipid Panel | lab | $35 | $2 | $76 | 14 |
| Addition to Lower Extremity, Torsion Control, Ankle Joint and Half Solid Stirrup | other | $35 | $35 | $35 | 1 |
| Alvimopan 12 Mg Capsule | other | $35 | $35 | $35 | 1 |
| Application of Lower and Upper Arm Splint | other | $35 | $35 | $35 | 1 |
| Aveta Fluid Management Accessory #205-212 3/ctn | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Herpes Simplex Virus, Amplified Probe Tech... | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Amplified Probe Technique | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Multiple Organisms, Direct Probe(s) Technique | other | $35 | $35 | $35 | 1 |
| Initial Aerosol O2 - 30 Min | other | $35 | $35 | $35 | 1 |
| Injection, Acetaminophen, Not Otherwise Specified,10 Mg | other | $35 | $35 | $35 | 1 |
| Injection, Insulin, Per 5 Units | other | $35 | $35 | $35 | 1 |
| Introducer/sheath, Other Than Guiding, Other Than Intracardiac Electrophysiol... | cardiac | $35 | $35 | $35 | 1 |
| Antibody Id/eash Sel Reagent C | other | $35 | $35 | $35 | 1 |
| Gait Training Therapy | other | $35 | $35 | $35 | 1 |
| Microalbumin, Urine | other | $35 | $35 | $35 | 1 |
| Physical Therapy Session | therapy | $35 | $35 | $35 | 1 |
| Self Care Mngment Training | other | $35 | $35 | $35 | 1 |
| Therapeutic Activities | therapy | $35 | $35 | $35 | 1 |
| Application of Long Leg Splint From Thigh to Ankle OR Toe | other | $36 | $36 | $36 | 1 |
| Application of Nonmoveable Forearm to Hand Splint | other | $36 | $36 | $36 | 1 |
| Application of Short Leg Splint From Calf to Foot | other | $36 | $36 | $36 | 1 |
| Biopsy of Ear | lab | $36 | $36 | $36 | 1 |
| Bonopty Biopsy Set 16cm #10 | lab | $36 | $36 | $36 | 1 |
| Bonopty Penetration Set 9.5cms #10 | other | $36 | $36 | $36 | 1 |
| Atropine Sulf Opth Sol | other | $36 | $36 | $36 | 1 |
| Inhalational Anesth Ea 30min | other | $36 | $36 | $36 | 1 |
| Injection, Aztreonam, 100 Mg | other | $36 | $36 | $36 | 1 |
| Irradiation of Blood Product, Each Unit | other | $36 | $36 | $36 | 1 |
| Lactate (ld) (ldh) Enzyme | other | $36 | $36 | $36 | 1 |
| Partial Thromboplastin Time | lab | $36 | $36 | $36 | 1 |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Belo... | other | $37 | $37 | $37 | 1 |
| Ball 24fr Monopolar Coag 3mm 27050n-s Cysview | other | $37 | $37 | $37 | 1 |
| 17 Ketogenicsteroids | other | $37 | $37 | $37 | 1 |
| Initial Oxy Hood 30 Min | other | $37 | $37 | $37 | 1 |
| Injection for X-ray of Hinged Joint of Upper and Lower Jaw Bones | imaging | $37 | $37 | $37 | 1 |
| Assay of Iron | other | $37 | $37 | $37 | 1 |
| Thyroid Test (TSH) | lab | $38 | $14 | $84 | 14 |
| 1203105 9.0 Uniblocker 1/ea | other | $38 | $38 | $38 | 1 |
| Addition to Lower Extremity, Dorsiflexion and Plantar Flexion Assist/resist, ... | other | $38 | $38 | $38 | 1 |
| Addition to Lower Extremity, Torsion Control, Straight Knee Joint, Each Joint | other | $38 | $38 | $38 | 1 |
| Application of Vein Wound Compression Bandages On Lower Leg, Ankle, and Foot | other | $38 | $23 | $52 | 2 |
| Aspiration And/or Injection of Fluid From Small Joint Using Ultrasound Guidance | imaging | $38 | $38 | $38 | 1 |
| Blood Unit Compatibility Test, Incubation Technique | other | $38 | $38 | $38 | 1 |
| Adrenocorticotropic Hormone (acth) Level | other | $39 | $39 | $39 | 2 |
| Blood Bank Physician Services for Cross Match And/or Evaluation and Written R... | other | $39 | $39 | $39 | 1 |
| Dihydroxyvitamin D, 1, 25 Level | other | $39 | $39 | $39 | 1 |
| Fresh Frozen Plasma (single Donor), Frozen Within 8 Hours of Collection, Each... | other | $39 | $39 | $39 | 1 |
| Fresh Frozen Plasma Between 8-24 Hours of Collection, Each Unit | other | $39 | $39 | $39 | 1 |
| Natriuretic Peptide (heart and Blood Vessel Protein) Level | cardiac | $39 | $39 | $39 | 1 |
| Assay of Amylase | other | $39 | $39 | $39 | 1 |
| Assay of Ck | other | $39 | $39 | $39 | 1 |
| Assay of Thyroid | other | $39 | $39 | $39 | 1 |
| Ccp Antibodies | other | $39 | $39 | $39 | 1 |
| Comprehensive Metabolic Panel | lab | $40 | $2 | $499 | 16 |
| Addition to Knee Joint, Drop Lock, Each | other | $40 | $40 | $40 | 1 |
| Alcohols Levels, 1 OR 2 | other | $40 | $40 | $40 | 1 |
| Aspiration And/or Injection of Cyst of Thyroid | other | $40 | $40 | $40 | 1 |
| Barbiturates Levels | other | $40 | $40 | $40 | 1 |
| Budesonide 32 Mcg/act Na Susp | other | $40 | $40 | $40 | 1 |
| Limited OR Follow-up CT Scan | imaging | $40 | $40 | $40 | 1 |
| New Patient Office OR Other Outpatient Visit with Straightforward Medical Dec... | other | $40 | $40 | $40 | 1 |
| Assay of Magnesium | other | $40 | $40 | $40 | 1 |
| Pathology (Surgical Specimen) | lab | $41 | $3 | $949 | 19 |
| Aldosterone Hormone Level | other | $41 | $41 | $41 | 2 |
| Anesthesia for Procedure to Drain Brain and Spinal Cord Fluid | other | $41 | $41 | $41 | 1 |
| Assay of Lipase | other | $41 | $41 | $41 | 1 |
| Assay of Total Thyroxine | other | $41 | $41 | $41 | 1 |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Abov... | other | $42 | $42 | $42 | 1 |
| Addition to Lower Extremity, Straight Knee Joint, Heavy Duty, Each Joint | other | $42 | $42 | $42 | 1 |
| Antipsychotics Levels, 1 | other | $42 | $42 | $42 | 1 |
| Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $42 | $42 | $42 | 1 |
| Electrolyte Panel | lab | $42 | $42 | $42 | 1 |
| 25 Left Quick Pass Lasso #ar-6068-25tl | other | $43 | $43 | $43 | 1 |
| 25 Right Quick Pass Lasso #ar-6068-25tr | other | $43 | $43 | $43 | 1 |
| 45 Left Quick Pass Lasso #ar-6068-45l | other | $43 | $43 | $43 | 1 |
| 45 Right Quick Pass Lasso #ar-6068-45r | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Left Quick Pass Lasso #ar-6068-90l | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Right Quick Pass Lasso #ar-6068-90r | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Straight Quick Pass Lasso #ar-6068 | other | $43 | $43 | $43 | 1 |
| Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-the-s... | other | $43 | $43 | $43 | 1 |
| Application of Moveable OR Hinged Forearm to Hand Splint | other | $43 | $43 | $43 | 1 |
| Bonopty Biopsy Set 16.5cm #12 | lab | $43 | $43 | $43 | 1 |
| Bonopty Penetration Set 10cm #12 | other | $43 | $43 | $43 | 1 |
| Exam Synovial Fluid Crystals | other | $43 | $43 | $43 | 1 |
| Microbe Susceptible Disk | other | $43 | $43 | $43 | 1 |
| Addition to Knee Lock with Integrated Release Mechanism (bail, Cable, OR Equa... | other | $44 | $44 | $44 | 1 |
| Application of Finger Cast | other | $44 | $44 | $44 | 1 |
| Absorb.gelantin Sponge | other | $44 | $44 | $44 | 1 |
| Injection, Acetazolamide Sodium, Up to 500 Mg | other | $44 | $44 | $44 | 1 |
| Drug Test Prsmv Dir Opt Obs | other | $44 | $44 | $44 | 1 |
| Istat Chem 8-clia Waived | other | $44 | $44 | $44 | 1 |
| Alpena Contour Lso Universal Fits Waist Circumference: 25-60inch (64-152cm) #... | other | $45 | $45 | $45 | 1 |
| Application of On-body Injector for Under Skin Injection | other | $45 | $45 | $45 | 1 |
| Aspiration Tubing Kit #72-00114 | other | $45 | $45 | $45 | 1 |
| Application of Vein Wound Compression Bandages On Upper Arm, Forearm, Hand, a... | other | $45 | $45 | $45 | 1 |
| Diphtheria, Tetanus, and Acellular Pertussis Vaccine | preventive | $45 | $45 | $45 | 1 |
| Injection of Ureter for Imaging | other | $45 | $45 | $45 | 1 |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Un... | other | $46 | $46 | $46 | 1 |
| 3 Hour Gtt | other | $46 | $46 | $46 | 1 |
| Evaluation for Work Hardening OR Conditioning, Each Additional Hour | other | $46 | $46 | $46 | 1 |
| Gene Analysis (coagulation Factor V) Leiden Variant | other | $46 | $46 | $46 | 1 |
| Injection, Penicillin G Potassium, Up to 600,000 Units | other | $46 | $46 | $46 | 1 |
| Compatibility Test Spin | other | $46 | $46 | $46 | 1 |
| Fungal Culture Hair,skin,nails | lab | $46 | $46 | $46 | 1 |
| Barone Jejunostomy Set | other | $47 | $47 | $47 | 1 |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine Including Spine Fracture A... | other | $47 | $47 | $47 | 1 |
| Injection, Vancomycin Hydrochloride (mylan) Not Therapeutically Equivalent to... | other | $47 | $47 | $47 | 1 |
| Limited Ultrasound Scan of Pelvis | imaging | $47 | $47 | $47 | 1 |
| Rbc Pretreatment | other | $47 | $47 | $47 | 1 |
| 2.5mm Mtch Hd 16cm Stryker #8470-107 | other | $48 | $48 | $48 | 1 |
| Acute Hepatitis Panel | lab | $48 | $48 | $48 | 2 |
| Advance Care Planning, Each Additional 30 Minutes | other | $48 | $48 | $48 | 1 |
| Cervicovaginal Secretion of Placenta Protein | other | $48 | $48 | $48 | 1 |
| Gentran 10%-5% Dextrose | other | $48 | $48 | $48 | 1 |
| Gentran 10%-saline 0.9% | other | $48 | $48 | $48 | 1 |
| Ag Detect Nos Ia Mult | other | $48 | $48 | $48 | 1 |
| Bld Typing Serologic Rh Phnt | other | $48 | $48 | $48 | 1 |
| Blood Typing Rbc Antigens | other | $48 | $48 | $48 | 1 |
| Clostridium Ag Ia | other | $48 | $48 | $48 | 1 |
| Application of Elbow to Finger Cast | other | $49 | $49 | $49 | 1 |
| Application of Walking Cast Covering Below Knee to Toe | other | $49 | $49 | $49 | 1 |
| Collection of Blood Sample From Implanted Device | surgery | $49 | $49 | $49 | 1 |
| Injection, Phytonadione (vitamin K), Per 1 Mg | other | $49 | $49 | $49 | 1 |
| Insertion of Tube and Introduction of Contrast for X-ray of Uterus and Fallop... | imaging | $49 | $49 | $49 | 1 |
| Iron Binding Test | other | $49 | $49 | $49 | 1 |
| Basic Metabolic Panel (BMP) | lab | $50 | $7 | $5,621 | 27 |
| Addition to Lower Extremity Fracture Orthosis, Plastic Shoe Insert with Ankle... | other | $50 | $50 | $50 | 1 |
| Flow Cytometry Technique for Dna OR Cell Analysis | other | $50 | $50 | $50 | 1 |
| Injection, Mannitol, 25% in 50 Ml | other | $50 | $50 | $50 | 1 |
| Drug Screen Quantalcohols | other | $50 | $50 | $50 | 1 |
| Urine Bacteria Culture | lab | $50 | $50 | $50 | 1 |
| Thyroid Panel (TSH) | lab | $51 | $17 | $101 | 6 |
| Addition to Lower Extremity Prosthesis, Below Knee, Suspension/sealing Sleeve... | other | $51 | $51 | $51 | 1 |
| Addition to Lower Extremity, Long Tongue Stirrup | other | $51 | $51 | $51 | 1 |
| Antidepressants Levels, 1 OR 2 | other | $51 | $51 | $51 | 1 |
| Anterior Chamber Intraocular Lens | other | $51 | $51 | $51 | 1 |
| Insertion of Temporary Bladder Tube | other | $51 | $51 | $51 | 1 |
| Low Dose CT Scan of Chest for Lung Cancer Screening | imaging | $51 | $51 | $51 | 1 |
| Addition to Lower Extremity, Below Knee, Molded Distal Cushion | other | $52 | $52 | $52 | 1 |
| Application of Hand and Lower Forearm Cast | other | $52 | $52 | $52 | 1 |
| Arc Smart Argon Probe 2.3/220 G1140001 | other | $52 | $52 | $52 | 1 |
| Basket Nitinol 1.9 #390 | other | $52 | $52 | $52 | 1 |
| Blood Bank Physician Services for Investigation of Transfusion Reaction with ... | surgery | $52 | $39 | $65 | 2 |
| Blood Unit Compatibility Test, Antiglobulin Technique | other | $52 | $42 | $62 | 2 |
| Fungus Isolation Culture | lab | $52 | $52 | $52 | 1 |
| Application of Short Leg Cast | other | $53 | $53 | $53 | 1 |
| Diffcult Airway-video-larygeo | other | $53 | $53 | $53 | 1 |
| Drug Test(s), Definitive, Utilizing (1) Drug Identification Methods Able to I... | other | $53 | $53 | $53 | 1 |
| Evaluation and Recording of Swallowing Using an Endoscope | other | $53 | $53 | $53 | 1 |
| Gene Analysis (prothrombin, Coagulation Factor Ii) a Variant | other | $53 | $53 | $53 | 1 |
| Infusion, Albumin (human), 25%, 50 Ml | surgery | $53 | $53 | $53 | 1 |
| Injection Procedure Through Bladder and Urethra for X-ray Imaging | imaging | $53 | $53 | $53 | 1 |
| Alcohol And/or Substance Abuse Screening and Intervention, More Than 30 Minutes | preventive | $54 | $54 | $54 | 1 |
| Biopsy of Ear Canal | lab | $54 | $54 | $54 | 1 |
| Biopsy of Lip | lab | $54 | $54 | $54 | 1 |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Ea... | imaging | $54 | $54 | $54 | 1 |
| Assay of Free Thyroxine | other | $54 | $54 | $54 | 1 |
| Influenza Rapid Test | lab | $54 | $54 | $54 | 1 |
| Application of Stress By Physician for Joint Imaging | other | $55 | $55 | $55 | 1 |
| Arista Surgical Hemostatic Powder 5 Gm Polysaccharide Hemospheres Absorbable ... | surgery | $55 | $55 | $55 | 1 |
| Antibody; HIV 1&2 Single Assay | other | $55 | $55 | $55 | 1 |
| Assay of Calcium | other | $55 | $55 | $55 | 1 |
| Acu-dispo-cautery2 Fine Tip-s #dcft2 | other | $56 | $56 | $56 | 1 |
| Addition to Lower Extremity, Varus/valgus Correction, Plastic Modification, P... | other | $56 | $56 | $56 | 1 |
| Annual Wellness Visit; Includes a Personalized Prevention Plan of Service (pp... | preventive | $56 | $56 | $56 | 1 |
| Drawing of Blood for a Medical Problem | other | $56 | $56 | $56 | 1 |
| Established Patient Office OR Other Outpatient Visit with Low Level of Decisi... | other | $56 | $56 | $56 | 1 |
| EKG (Electrocardiogram) | cardiac | $57 | $8 | $352 | 34 |
| Advance Care Planning, First 30 Minutes | other | $57 | $57 | $57 | 1 |
| Blood Unit Compatibility Test, Immediate Spin Technique | other | $57 | $51 | $62 | 2 |
| Evaluation of Swallowing Function | other | $57 | $57 | $57 | 1 |
| Compatibility Test Antiglob | other | $57 | $57 | $57 | 1 |
| Rbc Pretreatment Serum | other | $57 | $57 | $57 | 1 |
| Occupational Therapy | therapy | $58 | $20 | $660 | 34 |
| Physical Therapy Evaluation | therapy | $58 | $21 | $262 | 15 |
| Amplatz Grad Renal Dilation Set | other | $58 | $58 | $58 | 1 |
| Arc Smart Argon Probe 2.3/330 G1140002 | other | $58 | $58 | $58 | 1 |
| Biopsy of Lining of Nose | lab | $58 | $58 | $58 | 1 |
| Blade Shave Biopsy Flex Dermablade 8ea/1cs | lab | $58 | $58 | $58 | 1 |
| A-scope 4 Rhinolaryngo Slim 510001000 5ea/1bx | other | $59 | $59 | $59 | 1 |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Knee Extens... | other | $59 | $59 | $59 | 1 |
| 4 Hour Gtt | other | $59 | $59 | $59 | 1 |
| Atb45mm Standard Artic Cutter | other | $59 | $59 | $59 | 1 |
| Injection of Bladder and Ureter for Imaging | other | $59 | $59 | $59 | 1 |
| Assay of Troponin Quant | other | $59 | $59 | $59 | 1 |
| Cultr Bacteria Except Blood | other | $59 | $59 | $59 | 1 |
| 2.0 Mm Drive Shaft for Quickfix Screw System Ar-8930d | other | $60 | $60 | $60 | 1 |
| 2.0mm Carbide Round 5820-110-020c | other | $60 | $60 | $60 | 1 |
| 2.5mm Prcsn Mtch Hd 13cm8450-107 | other | $60 | $60 | $60 | 1 |
| 3.0 Drive Shft for Quickfix Screw System Ar-8930d | other | $60 | $60 | $60 | 1 |
| 3.0mm Carbide Round5820-110-030c | other | $60 | $60 | $60 | 1 |
| 4.0mm Carbide Round 5820-110-040c | other | $60 | $60 | $60 | 1 |
| Application of Shoulder to Hand Cast | other | $60 | $60 | $60 | 1 |
| Gene Analysis (survival of Motor Neuron 1, Telomeric) for Dosage/deletion | other | $60 | $60 | $60 | 1 |
| Injection, Benztropine Mesylate, Per 1 Mg | other | $60 | $60 | $60 | 1 |
| Addition to Lower Extremity Orthosis, High Strength, Lightweight Material, Al... | other | $61 | $61 | $61 | 1 |
| Alcohols Levels | other | $61 | $61 | $61 | 1 |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Bi... | other | $61 | $61 | $61 | 1 |
| Anesthesia Facility Charge | other | $61 | $61 | $61 | 1 |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine | other | $61 | $61 | $61 | 1 |
| Evaluation for Use of Voice Artificial Device to Supplement Oral Speech | other | $61 | $61 | $61 | 1 |
| 2.0 Cann Driver Tip Ht | other | $62 | $62 | $62 | 1 |
| Arndt Endobronchial Blocker Set 7fr G44114 | other | $62 | $62 | $62 | 1 |
| Insertion of Tube Into Vena Cava | other | $62 | $62 | $62 | 1 |
| Hepatitis B Surface Ag Ia | other | $62 | $62 | $62 | 1 |
| Physical Therapy | therapy | $63 | $7 | $701 | 34 |
| 3.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 4.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 5.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 6.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| Biopsy of Lower Large Bowel Using a Flexible Endoscope | lab | $63 | $63 | $63 | 1 |
| Evaluation of Speech Sound Production | other | $63 | $63 | $63 | 1 |
| Assay Triiodothyronine | other | $63 | $63 | $63 | 1 |
| DEXA Bone Density Scan | imaging | $64 | $22 | $249 | 15 |
| Assay of Lactic Acid | other | $64 | $64 | $64 | 1 |
| Spirometry (Pulmonary Function) | diagnostic | $65 | $3 | $370 | 11 |
| Balloon Oval Kidney Shape Str #omspdbs2 | other | $65 | $65 | $65 | 1 |
| Biopsies of Rectum And/or Lower Large Bowel Using a Rigid Endoscope | other | $65 | $65 | $65 | 1 |
| Biopsy of Small Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $65 | $65 | $65 | 1 |
| Analysis of Voice and Resonance Production | other | $65 | $65 | $65 | 1 |
| Artery Puncture Collection of Blood Sample | other | $65 | $65 | $65 | 1 |
| Catheter, Balloon Dilatation, Non-vascular | cardiac | $65 | $65 | $65 | 1 |
| Imaging for Evaluation of Swallowing Function | other | $65 | $65 | $65 | 1 |
| Inhalation Treatment for Acute Airway Obstruction, First Hour | other | $65 | $65 | $65 | 1 |
| Injection, Lacosamide, 1 Mg | other | $65 | $65 | $65 | 1 |
| Assay of Vitamin B | other | $65 | $65 | $65 | 1 |
| Occupational Therapy Evaluation | therapy | $66 | $29 | $660 | 5 |
| Adapalene 0.3% Gel | other | $66 | $66 | $66 | 1 |
| Low Osmolar Contrast Material, 200-299 Mg/ml Iodine Concentration, Per Ml | other | $66 | $66 | $66 | 1 |
| Therapeutic Injection | preventive | $67 | $7 | $181 | 15 |
| Administration of Hormonal Anti-neoplastic Chemotherapy Under Skin OR Into Mu... | other | $67 | $67 | $67 | 1 |
| Alvarado Traction Boot #00132021000 | other | $67 | $67 | $67 | 1 |
| Assistive Listening Device, Television Amplifier, Any Type | other | $67 | $67 | $67 | 1 |
| Aveta Coral Disposable Hysteroscope 4.6mm #214 | other | $67 | $67 | $67 | 1 |
| Aveta Pearl Disposable Hysteroscope 5.7mm #214 | other | $67 | $67 | $67 | 1 |
| Biopsy of Anus Using an Endoscope | lab | $67 | $67 | $67 | 1 |
| Bypass of Diseased OR Blocked Artery with Prosthetic and Vein | other | $67 | $67 | $67 | 1 |
| High Osmolar Contrast Material, 350-399 Mg/ml Iodine Concentration, Per Ml | other | $67 | $67 | $67 | 1 |
| Mycobacteria Culture | lab | $67 | $67 | $67 | 1 |
| Bone Density Scan | imaging | $68 | $9 | $180 | 35 |
| 8813e Suture Kit Dr Dumicz Oh Only 5kt/bx | other | $68 | $68 | $68 | 1 |
| Administration of Non-hormonal Anti-neoplastic Chemotherapy Under Skin OR Int... | other | $68 | $68 | $68 | 1 |
| Amnioexcel, Amnioexcel Plus OR Biodexcel, Per Square Centimeter | other | $68 | $68 | $68 | 1 |
| Antibody Evaluation, Initial Single Antibody Stain Procedure | other | $68 | $68 | $68 | 1 |
| Back Brace Aspen Summit 637 X-large 992380 | other | $68 | $68 | $68 | 1 |
| Antinuclear Antibodies | imaging | $68 | $68 | $68 | 1 |
| Free Assay | other | $68 | $68 | $68 | 1 |
| **discontinued 2/19/2021** Percut Kit 19fr X 18cm Femoral Arterial | other | $69 | $69 | $69 | 1 |
| 8815e Suture Dr Halligan CABG 1ea=1kt 5kt/1bx | other | $69 | $69 | $69 | 1 |
| Administration of Additional New Drug OR Substance Into Vein Using Push Techn... | other | $69 | $69 | $69 | 1 |
| Administration of Additional New Drug OR Substance Into Vein, 1 Hour OR Less | other | $69 | $69 | $69 | 1 |
| Administration of Chemotherapy Into Vein, Each Additional Hour | other | $69 | $69 | $69 | 1 |
| Balloon Dilation of Lower Large Bowel Using a Flexible Endoscope | other | $69 | $69 | $69 | 1 |
| Basket Trapezoid 3cm #m00510890 | other | $69 | $69 | $69 | 1 |
| Basket Wireguided Retrieval 2.0 X .035 | other | $69 | $69 | $69 | 1 |
| Basket Wireguided Retrieval 2.5 X .035 | other | $69 | $69 | $69 | 1 |
| Complete Ultrasound Scan of 1 Breast | imaging | $69 | $69 | $69 | 1 |
| Hormone Receptor Analysis | other | $69 | $69 | $69 | 1 |
| Injection of Contrast for Imaging of Lower Spinal Canal | other | $69 | $69 | $69 | 1 |
| Monurol 3 Gm Sacet | other | $69 | $69 | $69 | 1 |
| New Patient Office OR Other Outpatient Visit with Low Level of Medical Decisi... | other | $69 | $69 | $69 | 1 |
| Clot Factor Viii Vw Ristoctn | other | $69 | $69 | $69 | 1 |
| Creatine Mb Fraction | other | $69 | $69 | $69 | 1 |
| Sars Antigen Fia | other | $69 | $69 | $69 | 1 |
| Assessment for Hearing Aid | other | $70 | $70 | $70 | 1 |
| Albuterol Inhaler | other | $70 | $70 | $70 | 1 |
| Bflex 2 Slim 3.8 Single-use Bronchoscope 0570-0448 Bx=pk/5ea | other | $71 | $71 | $71 | 1 |
| Addition to Knee Joint, Disc OR Dial Lock for Adjustable Knee Flexion, Each J... | other | $72 | $72 | $72 | 1 |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Quantification | other | $72 | $72 | $72 | 1 |
| Limited Ultrasound Scan of 1 Breast | imaging | $72 | $72 | $72 | 1 |
| Gross Exam Only By Pathologist | other | $72 | $72 | $72 | 1 |
| Hypertension Management | cardiac | $73 | $22 | $303 | 31 |
| Acp Max Prp System W/acda Abs | other | $73 | $73 | $73 | 1 |
| Anesthesia for Tying OR Incision of Fallopian Tubes Using an Endoscope | other | $73 | $73 | $73 | 1 |
| Biopsy of Breast and Placement of Locating Device Using Mri, Each Additional ... | imaging | $73 | $73 | $73 | 1 |
| Levalbuterol, Inhalation Solution, Compounded Product, Administered Through D... | other | $73 | $73 | $73 | 1 |
| Urgent Care Visit | other | $74 | $2 | $304 | 26 |
| 5 Hour Gtt | other | $74 | $74 | $74 | 1 |
| IV Push Inj Each New Drug | other | $75 | $23 | $122 | 6 |
| 3d Radiographic Procedure with Computerized Image Postprocessing | imaging | $75 | $75 | $75 | 1 |
| Benzodiazepines Levels, 1 | other | $75 | $75 | $75 | 1 |
| Blood (whole), for Transfusion, Per Unit | surgery | $75 | $75 | $75 | 1 |
| 11mm Mcglamry Metatarsal Elevator Ar-8930m | other | $76 | $76 | $76 | 1 |
| All Lower Extremity Prosthesis, Solid Ankle Cushion Heel (sach) Foot, Replace... | other | $77 | $77 | $77 | 1 |
| Biopsy of Small Bowel Pouch Using an Endoscope | lab | $77 | $77 | $77 | 1 |
| Bone Mill #bm210 Fine | other | $77 | $77 | $77 | 1 |
| Contrast Injection for X-ray Imaging Through Existing Tube in Stomach, Small ... | imaging | $77 | $77 | $77 | 1 |
| Evaluation of Speech Continuity, Smoothness, Rate, and Effort | other | $77 | $77 | $77 | 1 |
| Molecular Pathology Procedure | lab | $77 | $77 | $77 | 1 |
| Assay of Ferritin | other | $77 | $77 | $77 | 1 |
| Culture Screen Only | lab | $77 | $77 | $77 | 1 |
| Rubeola Antibody | other | $77 | $77 | $77 | 1 |
| Balloon Cre Rx Biliary 10-11-12mm #m00558930 | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary 6-7-8mmx5.5 #m00558860 | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary 8-9-10mm #m00558920 | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary12-13.5-15mm #m00558940 | other | $78 | $78 | $78 | 1 |
| Bio-tenodesis Disp Kit #ar-1530ds | other | $78 | $78 | $78 | 1 |
| Biopsy of Mouth | lab | $78 | $78 | $78 | 1 |
| Complete X-ray of Body Bones | imaging | $78 | $78 | $78 | 1 |
| Limited X-ray of Body Bones | imaging | $78 | $78 | $78 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Adjustable Motion Knee Joint, ... | other | $79 | $79 | $79 | 1 |
| Biopsy of Floor of Mouth | lab | $79 | $79 | $79 | 1 |
| Balloon Seeker 6x17mm Em Sphn #1830617sph | other | $80 | $80 | $80 | 1 |
| Fluoroscopic Guidance for Insertion OR Removal of Central Vein Access Device | surgery | $80 | $80 | $80 | 1 |
| Injection, Linezolid, 200 Mg | other | $80 | $80 | $80 | 1 |
| Assay of Digoxin | other | $80 | $80 | $80 | 1 |
| Initial Therapy Service to Facilitate Lung Function | other | $81 | $81 | $81 | 1 |
| Injection, Desmopressin Acetate, Per 1 Mcg | other | $81 | $81 | $81 | 1 |
| Assay of Vancomycin | other | $81 | $81 | $81 | 1 |
| Cryoprecipitate, Each Unit | other | $82 | $12 | $151 | 2 |
| Imaging of Gallbladder with Contrast | other | $82 | $82 | $82 | 1 |
| Injection, Vasopressin, 1 Unit | other | $82 | $82 | $82 | 1 |
| Lyme Disease Antibody | other | $82 | $82 | $82 | 1 |
| Asthma Management | other | $83 | $3 | $370 | 31 |
| Breast Prosthesis, Mastectomy Form | other | $83 | $83 | $83 | 1 |
| CT Scan for Measuring Calcium and Other Minerals in Bone | imaging | $83 | $83 | $83 | 1 |
| Assay of Folic Acid Serum | other | $83 | $83 | $83 | 1 |
| Flu Vaccine Administration | preventive | $84 | $84 | $84 | 1 |
| Brav0 Cf Capsule Delivery Dev 5-pk #fgs | obstetric | $85 | $85 | $85 | 1 |
| Vitamin B | other | $85 | $85 | $85 | 1 |
| Vitamin D Level | lab | $86 | $13 | $178 | 6 |
| 10.5mm Short Flipcutter #ar-1204as | other | $86 | $86 | $86 | 1 |
| Application of Long Leg Cast From Thigh to Toe | other | $86 | $86 | $86 | 1 |
| Bflex 2 Ultraslim 2.8 Single-use Bronchoscope 0570-0447 Bx=pk/5ea | other | $86 | $86 | $86 | 1 |
| 6 Hour Gtt | other | $86 | $86 | $86 | 1 |
| Hepatitis C Ab Test | other | $86 | $86 | $86 | 1 |
| Foot X-Ray | imaging | $87 | $71 | $325 | 19 |
| Shoulder X-Ray | imaging | $87 | $58 | $288 | 14 |
| Aspiration And/or Injection of Fluid Large Joint Using Ultrasound Guidance | imaging | $87 | $87 | $87 | 1 |
| Carcinoembryonic Antigen | other | $87 | $87 | $87 | 1 |
| Chest X-Ray 1 View | imaging | $88 | $22 | $204 | 15 |
| Acyclovir 200 Mg/5 Ml Susp | other | $88 | $88 | $88 | 1 |
| Assay of Prealbumin | other | $88 | $88 | $88 | 1 |
| Diabetes Management | other | $89 | $6 | $535 | 27 |
| Arthrex Acl Fibertag Tightrope Abs Implant #ar-1588tnt | surgery | $89 | $89 | $89 | 1 |
| Inhalation Treatment for Airway Obstruction OR Sputum Production | other | $89 | $89 | $89 | 1 |
| Insertion of Tube Into Airway for Aspiration of Secretions | other | $89 | $89 | $89 | 1 |
| Feces Culture Aerobic Bact | lab | $89 | $89 | $89 | 1 |
| Ankle X-Ray | imaging | $90 | $71 | $370 | 19 |
| Cardiac Stress Test | cardiac | $90 | $5 | $741 | 12 |
| Identification of Red Blood Cell Antibodies | other | $90 | $90 | $90 | 1 |
| 2.3mm X 30.0mm Tapered Routerstryker# 5130-071-223s1 | other | $91 | $91 | $91 | 1 |
| Application of Walking Cast Covering Thigh to Toe | other | $91 | $91 | $91 | 1 |
| Catheter, Intraspinal | cardiac | $91 | $91 | $91 | 1 |
| IV Hydration | therapy | $92 | $10 | $604 | 14 |
| Biopsy of Front 2/3 of Tongue | lab | $92 | $92 | $92 | 1 |
| Injection, Dobutamine Hydrochloride, Per 250 Mg | other | $92 | $92 | $92 | 1 |
| Injection, Naloxone Hydrochloride, Not Otherwise Specified, 0.01 Mg | other | $92 | $92 | $92 | 1 |
| Angiojet Power Pulse Kit #104834 | other | $94 | $94 | $94 | 1 |
| Biocomposite Corkscrew Ft Suture Anchor 4.75 Mm X 14 Mm W/two 1.3 Mm Sutureta... | other | $94 | $94 | $94 | 1 |
| Injection, Alteplase Recombinant, 1 Mg | other | $94 | $94 | $94 | 1 |
| IV Drug Infusion | therapy | $95 | $30 | $661 | 14 |
| Stress Test | cardiac | $95 | $5 | $1,673 | 32 |
| Biopsy of Back 1/3 of Tongue | lab | $95 | $95 | $95 | 1 |
| Brachytherapy Source, Non-stranded, Non-high Dose Rate Iridium-192, Per Source | other | $95 | $95 | $95 | 1 |
| Double Contrast X-ray of Small Intestine | imaging | $95 | $95 | $95 | 1 |
| Fluoroscopic Guidance for Needle Placement | other | $95 | $95 | $95 | 1 |
| Biopsy of Roof of Mouth | lab | $96 | $96 | $96 | 1 |
| Alfuria 60 Mcg/0.5 Ml Flu Vacc | other | $96 | $96 | $96 | 1 |
| Arterial Cannula 19fr 96530 | other | $97 | $97 | $97 | 1 |
| Complete Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $97 | $97 | $97 | 1 |
| Evaluation of Fine Needle Aspirate | other | $97 | $97 | $97 | 1 |
| Incision of Sperm Duct for X-ray Procedure | imaging | $97 | $97 | $97 | 1 |
| Microscopic Genetic Analysis of Tissue, Computer-assisted Technology, Initial... | other | $97 | $97 | $97 | 1 |
| Biopsy of Voice Box Using a Flexible Endoscope | lab | $98 | $98 | $98 | 1 |
| Fluoroscopic Guidance for Spine OR Back Muscle Injection | other | $98 | $98 | $98 | 1 |
| Imaging Guidance for Procedure, 60 Minutes OR Less | other | $98 | $98 | $98 | 1 |
| Hc 2019 Novel Coronavirus Naa | other | $98 | $41 | $154 | 2 |
| Basket Memory 2x4cm Eight Wire ERCP G21538 | other | $99 | $99 | $99 | 1 |
| Cortisone Shot (Joint Injection) | surgery | $100 | $7 | $4,007 | 28 |
| 3d Breast Mammography of Both Breasts | imaging | $100 | $100 | $100 | 1 |
| Biopsy of Back of Throat | lab | $100 | $100 | $100 | 1 |
| 2d Ultrasound Scan of Eye Tissue and Structures | imaging | $100 | $100 | $100 | 1 |
| Complete Ultrasound Scan Behind Abdominal Cavity | imaging | $100 | $100 | $100 | 1 |
| Complete Ultrasound Scan of Abdomen | imaging | $100 | $100 | $100 | 1 |
| Complete Ultrasound Scan of Pelvis | imaging | $100 | $100 | $100 | 1 |
| Contrast Injection for Imaging to Evaluate Central Venous Access Device | other | $100 | $100 | $100 | 1 |
| CT Scan Head OR Brain without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Abdomen without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Arm without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Chest without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Cranial Cavity without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Face without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Leg without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Lower Spine without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Middle Spine without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Pelvis without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Soft Tissue of Neck without Contrast | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Upper Spine without Contrast | imaging | $100 | $100 | $100 | 1 |
| Follow-up Ultrasound Scan of Pregnant Uterus | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound of Pregnant Uterus | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound Scan Behind Abdominal Cavity | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound Scan of Abdomen | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound Scan of Joint OR Other Extremity Structure Except Blood Ve... | imaging | $100 | $100 | $100 | 1 |
| COVID-19 Vaccination | preventive | $101 | $39 | $163 | 2 |
| 6' Dx Cable 10 Pin #c6tmrmst10sa | other | $101 | $101 | $101 | 1 |
| Administration of Prolonged Chemotherapy Into Vein | other | $101 | $101 | $101 | 1 |
| Balloon Seeker 6x7mm Em Maxl #1830607max | other | $101 | $101 | $101 | 1 |
| Injection, Nicardipine, 0.1 Mg | other | $101 | $101 | $101 | 1 |
| Microscopic Genetic Analysis of Tumor, Using Computer-assisted Technology | other | $101 | $101 | $101 | 1 |
| Shoulder X-Ray | imaging | $102 | $83 | $200 | 6 |
| Alexis Extraction System #gtk17 | other | $102 | $102 | $102 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material, Prefabricated, Includes Fitti... | other | $102 | $102 | $102 | 1 |
| Aztreonam 1 G/3ml Ij | other | $102 | $102 | $102 | 1 |
| Aztreonam 1 Gm Vial | other | $102 | $102 | $102 | 1 |
| Bacillus Calmette-guerin Vaccine for Bladder Cancer | preventive | $102 | $102 | $102 | 1 |
| Blind Obt 22.5fr for A20914a #a20906a | other | $102 | $102 | $102 | 1 |
| Blind Obturator for A20931a 17fr #a20909a | other | $102 | $102 | $102 | 1 |
| Ambulatory Infusion Pump, Single OR Multiple Channels, Electric OR Battery Op... | surgery | $104 | $104 | $104 | 1 |
| Emergency Surgery Fee | surgery | $104 | $104 | $104 | 1 |
| Abdominal Ultrasound | imaging | $106 | $20 | $1,120 | 34 |
| Ultrasound of the Abdomen | imaging | $106 | $22 | $550 | 15 |
| 3d Breast Mammography of 1 Breast | imaging | $106 | $106 | $106 | 1 |
| Injection, Cosyntropin, 0.25 Mg | other | $106 | $106 | $106 | 1 |
| All Lower Extremity Prostheses, Foot, Single Axis Ankle/foot | other | $107 | $107 | $107 | 1 |
| Injection, Epinephrine (adrenalin), Not Therapeutically Equivalent to J0165, ... | other | $107 | $107 | $107 | 1 |
| Mesh | other | $107 | $107 | $107 | 1 |
| IV Infusion, Ea Add Hr | surgery | $107 | $107 | $107 | 1 |
| Hand/Wrist X-Ray | imaging | $108 | $58 | $284 | 19 |
| Injection, Methylprednisolone Sodium Succinate, 5 Mg | other | $108 | $108 | $108 | 1 |
| Adult Venous Cannula 25fr 96600 | other | $109 | $109 | $109 | 1 |
| Adult Venous Cannula 96600 | other | $109 | $109 | $109 | 1 |
| Adapalene 0.1 % Ex Gel | other | $111 | $111 | $111 | 1 |
| New Patient Office OR Other Outpatient Visit with Moderate Level of Medical D... | other | $111 | $111 | $111 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Hip Joint, Pelvic Band, Thigh ... | other | $112 | $112 | $112 | 1 |
| Assistant W/stable Soft 3l #401-209s | other | $112 | $112 | $112 | 1 |
| Surgical Pathology | lab | $112 | $112 | $112 | 1 |
| Chest X-Ray | imaging | $115 | $10 | $486 | 24 |
| **discontinued**laser Fiber 200 Ball Tip #m0068403961 | other | $116 | $116 | $116 | 1 |
| Atrovent 17 Mcg Hfa Inhaler | other | $116 | $116 | $116 | 1 |
| Blood Gases Any Combination | other | $116 | $116 | $116 | 1 |
| X-Ray of the Knee | imaging | $117 | $78 | $365 | 15 |
| Lumbar Spine X-Ray | imaging | $118 | $64 | $469 | 14 |
| Bss Plus Eye Irrig Solution | other | $118 | $118 | $118 | 1 |
| Catheter, Drainage | cardiac | $118 | $118 | $118 | 1 |
| Apligraf | other | $118 | $118 | $118 | 1 |
| Tx/pro/dx Inj Same Drug Add On | other | $118 | $118 | $118 | 1 |
| Arthroflex, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Fetal Test | other | $119 | $119 | $119 | 1 |
| Injection, Esmolol Hydrochloride (wg Critical Care), Not Therapeutically Equi... | other | $119 | $119 | $119 | 1 |
| Allograft Mis Dispenser Bl-1900-gun | other | $120 | $120 | $120 | 1 |
| Aspiration of Bladder with Insertion of Bladder Tube to Skin | other | $120 | $120 | $120 | 1 |
| Breast Prosthesis, Silicone OR Equal, with Integral Adhesive | other | $120 | $120 | $120 | 1 |
| Breast Prosthesis, Silicone OR Equal, without Integral Adhesive | other | $120 | $120 | $120 | 1 |
| Cold Agglutinin Screen | other | $120 | $120 | $120 | 1 |
| IV Infusion, 1st Hr | surgery | $121 | $44 | $568 | 6 |
| Balloon Dilation of Vein with Review By Radiologist, Each Additional Vein | other | $121 | $121 | $121 | 1 |
| Aspiration of Subsequent Secretions of Lung Airway Using an Endoscope During ... | other | $124 | $124 | $124 | 1 |
| Annual Wellness Visit (Established) | preventive | $125 | $28 | $374 | 10 |
| All Lower Extremity Prostheses, Foot, Flexible Keel | other | $125 | $125 | $125 | 1 |
| Chromosome Analysis for Genetic Defects, Count 15-20 Cells | other | $125 | $125 | $125 | 1 |
| Addition to Lower Extremity, Test Socket, Below Knee | other | $127 | $127 | $127 | 1 |
| Dental Cleaning | other | $127 | $127 | $127 | 1 |
| Injection, Ertapenem Sodium, 500 Mg | other | $128 | $128 | $128 | 1 |
| Knee X-Ray | imaging | $129 | $100 | $200 | 6 |
| X-Ray of the Chest | imaging | $129 | $84 | $204 | 6 |
| Addition to Lower Extremity, Socket Insert, Below Knee | other | $129 | $129 | $129 | 1 |
| Evaluation of Speech Sound Production with Evaluation of Language Comprehensi... | other | $129 | $129 | $129 | 1 |
| Bone Dowel Revision Kit 10 Mm #abs-2850 | other | $130 | $130 | $130 | 1 |
| Injection of Radioactive Material for X-ray Identification of Lymph Node | imaging | $130 | $130 | $130 | 1 |
| Addition to Lower Extremity, Below Knee, Total Contact | other | $132 | $132 | $132 | 1 |
| Addition to Lower Extremity, Lacer Molded to Patient Model, for Custom Fabric... | other | $132 | $132 | $132 | 1 |
| Biopsy of Wedge of Lung Tissue Followed By Partial Removal of Lung | surgery | $132 | $132 | $132 | 1 |
| Blade Kahook Dual#kdb Glide | other | $132 | $132 | $132 | 1 |
| Emergent Insertion of Breathing Tube Into Windpipe Using an Endoscope | other | $132 | $132 | $132 | 1 |
| 12x11x14mm 7 Degree Vista-s Dev #06-401 | other | $133 | $133 | $133 | 1 |
| 5x11x14mm Vista-s Dev #06-401 | other | $133 | $133 | $133 | 1 |
| Administration of Chemotherapy Into Vein Using Push Technique | other | $133 | $133 | $133 | 1 |
| CT Scan of the Head | imaging | $134 | $22 | $3,570 | 16 |
| Bear Claw Otsc Sys Set 11/6t 165cm #100.10 | other | $135 | $135 | $135 | 1 |
| Bear Claw Otsc Sys Set 12/6t 220cm #100.31 | other | $135 | $135 | $135 | 1 |
| New Patient Office OR Other Outpatient Visit with a High Level of Medical Dec... | other | $135 | $135 | $135 | 1 |
| Obstetric Ultrasound | imaging | $137 | $100 | $550 | 19 |
| Bone Marrow, Smear Interpretation | other | $137 | $38 | $236 | 2 |
| Arexvy Vial Kit | other | $139 | $139 | $139 | 1 |
| Chemotherapy Administration | other | $140 | $4 | $888 | 28 |
| 3.0 Knotless Suture Tak Anchor #ar-8934bck | other | $140 | $140 | $140 | 1 |
| Arthrex Acl Fibertag Tightrope Implant #ar-1588rtt | surgery | $140 | $140 | $140 | 1 |
| Autoinjector Endologix #tv-a101-n | other | $141 | $141 | $141 | 1 |
| Balloon Dilation of Artery with Review By Radiologist, Each Additional Artery | other | $143 | $143 | $143 | 1 |
| Evaluation for Work Hardening OR Conditioning, Initial 2 Hours | other | $144 | $144 | $144 | 1 |
| Lumbar Spine X-Ray | imaging | $145 | $81 | $376 | 6 |
| Biopsy of Prostate Gland | lab | $145 | $145 | $145 | 1 |
| Fetal Congenital Abnormalities, Biochemical Assays of Four Analytes (afp, Ue3... | other | $145 | $145 | $145 | 1 |
| Addition to Lower Extremity, Below Knee, Acrylic Socket | other | $146 | $146 | $146 | 1 |
| Imaging of Urinary Tract Following Injection of a Contrast Agent | other | $146 | $146 | $146 | 1 |
| Blood Pressure Monitoring | other | $147 | $18 | $214 | 25 |
| Acutrak 2 Drill Acumed #at2-m1813 | other | $148 | $148 | $148 | 1 |
| Atrial Depressor W/quick Connect Clearview Mv | other | $148 | $148 | $148 | 1 |
| Amputation of Toe At Toe Joint | other | $149 | $149 | $149 | 1 |
| Balloon Dilation Treatment of Stricture of Ureter Using Imaging Guidance with... | other | $149 | $149 | $149 | 1 |
| Bipolar Sealer 2.3 Neuro Aquamantys | other | $150 | $150 | $150 | 1 |
| Phytonadione Inj 1 Mg/0.5 Ml C | other | $150 | $150 | $150 | 1 |
| Emergency Room Visit (Level 3) | emergency | $151 | $1 | $495 | 5 |
| Mental Health Evaluation | therapy | $153 | $53 | $367 | 18 |
| 8mm Blunt Xi #470008 | other | $154 | $154 | $154 | 1 |
| Amputation of Toe At Joint Between Forefoot and Toes | other | $154 | $154 | $154 | 1 |
| Biopsy of Voice Box Using an Endoscope | lab | $154 | $154 | $154 | 1 |
| Magnetic Resonance Angiography without Contrast, Chest | imaging | $154 | $154 | $154 | 1 |
| 2019-ncovid Any Technq-non-cdc | other | $154 | $154 | $154 | 1 |
| Addition to Lower Extremity, Suction Suspension, Above Knee OR Knee Disarticu... | other | $156 | $156 | $156 | 1 |
| Complete Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $157 | $157 | $157 | 1 |
| Astigmatism Correcting Function of Intraocular Lens | other | $158 | $158 | $158 | 1 |
| Hydrate IV Infusion Add-on | surgery | $160 | $58 | $201 | 6 |
| Aveta Smol Disposable Resecting Device 2.9mm #210-100 3/ctn | other | $160 | $160 | $160 | 1 |
| Pelvic Ultrasound | imaging | $161 | $100 | $839 | 19 |
| Auto-id Quad Cable; Vizigo Cable #cy1212ct | other | $161 | $161 | $161 | 1 |
| Injection, Methylnaltrexone, 0.1 Mg | other | $162 | $162 | $162 | 1 |
| Fdp,fibrinogen Degradation Pro | other | $162 | $162 | $162 | 1 |
| Irrig Drug Delivery Device | obstetric | $162 | $162 | $162 | 1 |
| Meas Post-voiding Residl Urine | other | $162 | $162 | $162 | 1 |
| Anchor/screw for Opposing Bone-to-bone OR Soft Tissue-to-bone | other | $164 | $90 | $238 | 2 |
| Double Contrast X-ray of Upper Digestive Tract | imaging | $164 | $164 | $164 | 1 |
| Addition, Endoskeletal System, Below Knee, Alignable System | other | $166 | $166 | $166 | 1 |
| Injection, Rho(d) Immune Globulin (human), (rhophylac), Intramuscular OR Intr... | other | $166 | $166 | $166 | 1 |
| Addition to Lower Extremity, Test Socket, Above Knee | other | $167 | $167 | $167 | 1 |
| CT Head | imaging | $168 | $99 | $3,570 | 33 |
| CT Scan Head OR Brain with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Abdomen Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Abdomen with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Arm Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Abdomen with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Arm with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Chest with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Head with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Lower Leg with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Neck with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Pelvis with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Chest Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Chest with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Cranial Cavity Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Cranial Cavity with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Face Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Face with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Head OR Brain Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Leg Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Leg with Contrast Material | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Lower Spine Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Middle Spine Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Middle Spine with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Pelvis Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Pelvis with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Soft Tissue of Neck Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Soft Tissue of Neck with Contrast | imaging | $168 | $168 | $168 | 1 |
| CT Scan of Upper Spine Before and After Contrast | imaging | $168 | $168 | $168 | 1 |
| Double Contrast X-ray of Large Intestine | imaging | $168 | $168 | $168 | 1 |
| Imaging of Urinary Tract Using Infusion Technique | surgery | $168 | $168 | $168 | 1 |
| Imaging of Urinary Tract Using Infusion Technique with Kidney Section Filming | surgery | $168 | $168 | $168 | 1 |
| Imaging of Urinary Tract with Injection of Contrast Into a Vein | other | $168 | $168 | $168 | 1 |
| Azactam 2 Gm Vial | other | $169 | $169 | $169 | 1 |
| Biopsy of Large Bowel Using a Flexible Endoscope | lab | $169 | $169 | $169 | 1 |
| Special Stains Group 1 | other | $169 | $169 | $169 | 1 |
| Biopsy of Voice Box Using an Endoscope with Operating Microscope OR Telescope | lab | $170 | $170 | $170 | 1 |
| Injection, Tenecteplase, 1 Mg | other | $172 | $172 | $172 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material with Ankle Joint, Prefabricate... | other | $173 | $173 | $173 | 1 |
| Psychotherapy Session (45 min) | therapy | $176 | $22 | $367 | 7 |
| Pt Re-eval Est Plan Care | other | $177 | $177 | $177 | 1 |
| Tx/proph/dg Addl Seq IV Inf | other | $178 | $178 | $178 | 1 |
| Addition to Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, E... | other | $179 | $179 | $179 | 1 |
| Analysis Test By Nucleic Acid for Hepatitis C Virus | other | $179 | $179 | $179 | 1 |
| Balloon Dilation of Large Bowel Using a Flexible Endoscope | other | $179 | $179 | $179 | 1 |
| 000-030 Min - Anesthesia | other | $179 | $179 | $179 | 1 |
| Add'l 30 Min Anesthesia | other | $179 | $179 | $179 | 1 |
| Convalescent Plasma | other | $179 | $179 | $179 | 1 |
| Injection, Zoledronic Acid, 1 Mg | other | $179 | $179 | $179 | 1 |
| Nuclear Medicine Study of Bone And/or Joint Limited Area | imaging | $179 | $179 | $179 | 1 |
| Hip/Pelvis X-Ray | imaging | $180 | $78 | $338 | 14 |
| X-ray Exam Hip Uni 1 View | imaging | $182 | $100 | $200 | 6 |
| Biomed Fiber Optic Probe Assembly Pteye | other | $182 | $182 | $182 | 1 |
| Injection, Glucagon Hydrochloride, Per 1 Mg | other | $182 | $182 | $182 | 1 |
| All Lower Extremity Prostheses, Energy Storing Foot | other | $184 | $184 | $184 | 1 |
| Special Stains Group 2 | other | $184 | $184 | $184 | 1 |
| Td Vacc No Presv 7 Yrs+ IM | other | $184 | $184 | $184 | 1 |
| Injection, Micafungin Sodium, 1 Mg | other | $186 | $186 | $186 | 1 |
| Tb Test Cell Immun Measure | other | $186 | $186 | $186 | 1 |
| Hospital Observation | other | $189 | $3 | $890 | 18 |
| Biopsy of Saliva Gland | lab | $191 | $191 | $191 | 1 |
| Vaccine Administration | preventive | $191 | $191 | $191 | 1 |
| Foot X-Ray | imaging | $194 | $194 | $194 | 1 |
| Forearm X-Ray | imaging | $194 | $194 | $194 | 1 |
| Humerus X-Ray | imaging | $194 | $194 | $194 | 1 |
| Wrist X-Ray | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Ankle | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Clavicle Left | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Femur 1 | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Femur 2/> | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Finger | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Lower Leg | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Toe | imaging | $194 | $194 | $194 | 1 |
| X-Ray of the Hand | imaging | $194 | $194 | $194 | 1 |
| Ankle Orthosis, Supramalleolar with Straps, with OR without Interface/pads, C... | other | $196 | $196 | $196 | 1 |
| Moderate Sedation | other | $197 | $66 | $10,074 | 19 |
| All Endoskeletal Lower Extremity Prosthesis, Axial Rotation Unit, with OR wit... | other | $200 | $200 | $200 | 1 |
| Bactisure Wound Lavage #00888700200(qtys of 6 | other | $200 | $200 | $200 | 1 |
| Hip X-Ray | imaging | $200 | $200 | $200 | 1 |
| X-ray Exam of Elbow | imaging | $200 | $200 | $200 | 1 |
| X-ray Exam of Shoulder | imaging | $200 | $200 | $200 | 1 |
| Addition to Lower Extremity, Above Knee OR Knee Disarticulation, Acrylic Socket | other | $202 | $202 | $202 | 1 |
| Ankle Foot Orthosis, Double Upright Free Plantar Dorsiflexion, Solid Stirrup,... | other | $203 | $203 | $203 | 1 |
| Aspiration And/or Injection of Fluid From Medium Joint Using Ultrasound Guidance | imaging | $203 | $203 | $203 | 1 |
| Aortic Balloon Pump Cath 7.5fr 34cc 0684-00-0479-01u | other | $205 | $205 | $205 | 1 |
| X-ray Exam Abdomen 1 View | imaging | $206 | $206 | $206 | 1 |
| X-ray Exam Neck Spine 2-3 Vw | imaging | $206 | $206 | $206 | 1 |
| Balloon Seeker 70dg Frt 6x17 #1830617frt0 | other | $207 | $207 | $207 | 1 |
| Fine Needle Aspiration Biopsy Using Fluoroscopic Guidance, First Growth | lab | $208 | $208 | $208 | 1 |
| Intravenous Infusion OR Subcutaneous Injection, Casirivimab and Imdevimab Inc... | surgery | $208 | $208 | $208 | 1 |
| Intravenous Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post... | surgery | $208 | $208 | $208 | 1 |
| Immunihistology-additional Sli | other | $211 | $211 | $211 | 1 |
| Aveta Flex Disposable Resecting Device 2.9mm #210-080 3/ctn | other | $213 | $213 | $213 | 1 |
| Echo Limit | imaging | $213 | $213 | $213 | 1 |
| Annual Wellness Visit (New) | preventive | $214 | $39 | $476 | 9 |
| Amniotic Membrane for Surgical Reconstruction, Per Procedure | surgery | $215 | $215 | $215 | 1 |
| Hospital Follow-up Care | other | $219 | $31 | $346 | 8 |
| Addition, Endoskeletal System, Below Knee, Flexible Protective Outer Surface ... | other | $223 | $223 | $223 | 1 |
| Biopsy of Lung Lining Using an Endoscope | lab | $223 | $223 | $223 | 1 |
| Hla B27 | other | $223 | $223 | $223 | 1 |
| Additions to Lower Extremity, Total Contact, Above Knee OR Knee Disarticulati... | other | $224 | $224 | $224 | 1 |
| Fresh Frozen Plasma | other | $224 | $224 | $224 | 1 |
| Nuclear Medicine Studies of Kidney, Blood Flow, and Function | imaging | $226 | $226 | $226 | 1 |
| Biopsy OR Removal of Lymph Nodes | surgery | $228 | $228 | $228 | 1 |
| CT Scan of Abdomen and Pelvis without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Abdomen without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Arm Joint without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Arm without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Blood Vessels of Head without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Blood Vessels of Neck without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Brain without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Chest without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Jaw Joint | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Leg Joint without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Leg without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Lower Spinal Canal without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Middle Spinal Canal without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Pelvis without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of Upper Spinal Canal without Contrast | imaging | $228 | $228 | $228 | 1 |
| Magnetic Resonance Angiography with Contrast, Chest | imaging | $229 | $229 | $229 | 1 |
| Addition, Endoskeletal System, Below Knee, Ultra-light Material | other | $230 | $230 | $230 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material, Custom Fabricated | other | $230 | $230 | $230 | 1 |
| CT Scan of the Chest | imaging | $233 | $22 | $1,316 | 13 |
| Addition to Lower Extremity, Pre-tibial Shell, Molded to Patient Model | other | $235 | $235 | $235 | 1 |
| Administration of Chemotherapy Into Vein, 1 Hour OR Less | other | $235 | $235 | $235 | 1 |
| X-ray Ac Joints Bi W/wo Weight | imaging | $235 | $235 | $235 | 1 |
| Dilation of Stomach And/or Small Bowel Using Long Gastrointestinal Tube | other | $236 | $236 | $236 | 1 |
| Weight Management Program | preventive | $238 | $37 | $238 | 7 |
| Fibrin Degradation Quant | other | $238 | $238 | $238 | 1 |
| Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom Fabricated | other | $239 | $239 | $239 | 1 |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Alignable S... | other | $243 | $243 | $243 | 1 |
| Joint Device | other | $244 | $244 | $244 | 1 |
| Assay of Parathormone | other | $248 | $248 | $248 | 1 |
| Newborn Care | obstetric | $249 | $35 | $371 | 8 |
| Biopsy of Small Bowel Using an Endoscope | lab | $249 | $249 | $249 | 1 |
| ICU Nursing Increment | other | $249 | $249 | $249 | 1 |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth | imaging | $251 | $251 | $251 | 1 |
| Bupivacaine, Collagen-matrix Implant, 1 Mg | surgery | $255 | $255 | $255 | 1 |
| Ahmed Valve | other | $255 | $255 | $255 | 1 |
| Blood Gases W/o2 Saturation | other | $255 | $255 | $255 | 1 |
| Hospital Discharge | other | $256 | $58 | $354 | 8 |
| Trigger Point Injection | therapy | $259 | $8 | $10,074 | 18 |
| Addition, Endoskeletal Knee-shin System, Single Axis, Friction Swing and Stan... | other | $259 | $259 | $259 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Chest | imaging | $259 | $259 | $259 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Sp... | imaging | $259 | $259 | $259 | 1 |
| Aveta Wave+ Disposable Resecting Device 3.9mm #210-2005 3/ctn | other | $263 | $263 | $263 | 1 |
| Addition to Lower Extremity, Below Knee / Above Knee Suspension Locking Mecha... | other | $264 | $264 | $264 | 1 |
| Drainage of Fluid From Abdominal Cavity Using Imaging Guidance | other | $264 | $264 | $264 | 1 |
| Blood Platelet Aggregation | other | $264 | $264 | $264 | 1 |
| Brevital Sodium 500 Mg Vial | other | $265 | $265 | $265 | 1 |
| Application of Walking Cast Covering Foot, Ankle, and Lower Leg | other | $268 | $268 | $268 | 1 |
| Biopsy of Anal And/or Rectal Wall Through Anus | lab | $268 | $268 | $268 | 1 |
| Injection, Epinephrine, Not Otherwise Specified, 0.1 Mg | other | $268 | $268 | $268 | 1 |
| Graft Applic<100cm,add-on 25cm | other | $268 | $268 | $268 | 1 |
| Biopsy of Fluid Collection of Lung Using an Endoscope | lab | $269 | $269 | $269 | 1 |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated From Ex... | other | $272 | $272 | $272 | 1 |
| Bronchospam Complete | other | $273 | $273 | $273 | 1 |
| All Lower Extremity Prostheses, Multi-axial Rotation Unit | other | $274 | $274 | $274 | 1 |
| Small Joint Injection | surgery | $277 | $62 | $10,074 | 18 |
| Follow-up Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 | $277 | 1 |
| Initial Hospital Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 | $277 | 1 |
| Ankle Foot Orthosis, Spiral, (institute of Rehabilitative Medicine Type), Pla... | other | $280 | $280 | $280 | 1 |
| Gastrografin 66-10 Sol 120 Ml | other | $283 | $283 | $283 | 1 |
| Addition to Lower Extremity, Below Knee Suction Socket | other | $284 | $284 | $284 | 1 |
| Tubal Ligation | surgery | $288 | $241 | $10,074 | 9 |
| Afo, Rigid Anterior Tibial Section, Total Carbon Fiber OR Equal Material, Pre... | other | $293 | $293 | $293 | 1 |
| CT Abdomen and Pelvis without Contrast | imaging | $294 | $22 | $5,912 | 12 |
| Application of Paste Boot | other | $296 | $296 | $296 | 1 |
| Alexis Ces W/gel Point Mini #gtm14 | other | $297 | $297 | $297 | 1 |
| Accessory Kit Ams 700 #72401850 | other | $299 | $299 | $299 | 1 |
| Bridion 200 Mg/2 Ml Vial | other | $301 | $301 | $301 | 1 |
| Apply Multlay Comprs Lwr Leg | other | $305 | $305 | $305 | 1 |
| Biopsy of Abdomen Using an Endoscope | lab | $307 | $307 | $307 | 1 |
| Allopatch Human Dermis 5x5 Cm | other | $311 | $311 | $311 | 1 |
| Assay of Natriuretic Peptide | other | $312 | $312 | $312 | 1 |
| Bone And/or Joint Imaging; Tomographic | other | $315 | $315 | $315 | 1 |
| Injection, Amphotericin B, 50 Mg | other | $316 | $316 | $316 | 1 |
| Hemabate 250 Mcg IM | other | $317 | $317 | $317 | 1 |
| Mitomycin Pyelocalyceal Instillation, 1 Mg | other | $319 | $319 | $319 | 1 |
| X-ray Exam Entire Spi 2/3 Vw | imaging | $320 | $320 | $320 | 1 |
| Puraply Am 1 SQ Cm | other | $323 | $323 | $323 | 1 |
| Biopsy of Growth of Lung Using an Endoscope | lab | $328 | $328 | $328 | 1 |
| Dialysis | other | $330 | $2 | $114,715 | 31 |
| MRI of the Lower Back (Lumbar) | imaging | $331 | $22 | $3,490 | 12 |
| CT Scan of Arm with Contrast | imaging | $332 | $332 | $332 | 1 |
| CT Scan of Abdomen and Pelvis Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| CT Scan of Abdomen and Pelvis with Contrast | imaging | $333 | $333 | $333 | 1 |
| CT Scan of Blood Vessels of Abdomen and Pelvis with Contrast | imaging | $333 | $333 | $333 | 1 |
| CT Scan of Lower Spine with Contrast | imaging | $333 | $333 | $333 | 1 |
| CT Scan of Upper Spine with Contrast | imaging | $333 | $333 | $333 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Ab... | imaging | $333 | $333 | $333 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Pe... | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Abdomen Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Abdomen with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Arm Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Arm Joint Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Arm with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Head Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Head with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Neck Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Neck with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Brain Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Brain with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Chest Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Leg Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Leg Joint Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Leg with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Lower Spinal Canal Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Lower Spinal Canal with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Middle Spinal Canal Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Middle Spinal Canal with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Pelvis Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Pelvis with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Upper Spinal Canal Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Upper Spinal Canal with Contrast | imaging | $333 | $333 | $333 | 1 |
| Dress/debrid P-thick Burn S | other | $334 | $334 | $334 | 1 |
| Neg Press Wound Tx <=50 Cm | other | $334 | $334 | $334 | 1 |
| Thyroid Ultrasound | imaging | $334 | $334 | $334 | 1 |
| MRI Spine | imaging | $335 | $227 | $4,605 | 31 |
| Implantable Surgical Supplies | surgery | $339 | $339 | $339 | 1 |
| MRI of the Shoulder | imaging | $340 | $7 | $4,594 | 31 |
| Accessory Kit Ams 800 #720066 | other | $340 | $340 | $340 | 1 |
| Insert Temp Bladder Cath | other | $342 | $342 | $342 | 1 |
| Intermediate Joint Injection | surgery | $345 | $10 | $10,074 | 19 |
| Active Wound Care/20 Cm OR < | other | $345 | $345 | $345 | 1 |
| Chem Caut of Granltj Tissue | other | $345 | $345 | $345 | 1 |
| Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Custom... | other | $346 | $346 | $346 | 1 |
| Skin Tag Removal | other | $347 | $19 | $10,074 | 16 |
| Carotid Ultrasound | imaging | $348 | $227 | $1,484 | 14 |
| MRI of the Knee | imaging | $351 | $22 | $4,326 | 31 |
| Ankle Foot Orthosis, Plastic with Ankle Joint, Custom Fabricated | other | $353 | $353 | $353 | 1 |
| Biopsy OR Removal of Deep Lymph Nodes of Neck | surgery | $355 | $355 | $355 | 1 |
| MRI of the Brain | imaging | $357 | $22 | $4,610 | 31 |
| Biopsy OR Removal of Deep Lymph Nodes of Underarm | surgery | $359 | $359 | $359 | 1 |
| Addition, Endoskeletal System, Above Knee, Ultra-light Material | other | $360 | $360 | $360 | 1 |
| Hbo Therapy Per 30 Min Session | other | $364 | $364 | $364 | 1 |
| Breast Ultrasound Complete | imaging | $365 | $365 | $365 | 1 |
| CT Lower Extremity | imaging | $365 | $365 | $365 | 1 |
| Hip Bilateral 2 V | other | $365 | $365 | $365 | 1 |
| Lower Extremity Study | other | $365 | $365 | $365 | 1 |
| Thoracic Spine X-Ray | imaging | $365 | $365 | $365 | 1 |
| Ultrasound Breast Limited | imaging | $365 | $365 | $365 | 1 |
| Us Compl Joint R-t W/img | other | $365 | $365 | $365 | 1 |
| Us Exam Abdo Back Wall Lim | other | $365 | $365 | $365 | 1 |
| Us Exam Scrotum | other | $365 | $365 | $365 | 1 |
| Us Extremity Non Vascular Lt | other | $365 | $365 | $365 | 1 |
| X-ray Exam of Jaw 4/> Views | imaging | $365 | $365 | $365 | 1 |
| Banding of Hemorrhoids Using a Flexible Endoscope | other | $367 | $367 | $367 | 1 |
| CT Chest without Contrast | imaging | $368 | $368 | $368 | 1 |
| Pelvic Ultrasound Complete | imaging | $372 | $372 | $372 | 1 |
| X-ray Exam Abdomen 3+ Views | imaging | $372 | $372 | $372 | 1 |
| Skin Biopsy | other | $374 | $19 | $10,074 | 23 |
| Er-o.v.-established Level 3 | other | $374 | $374 | $374 | 1 |
| Laceration Repair | emergency | $375 | $104 | $10,074 | 19 |
| Amputation of Toe and Midfoot Bone | other | $375 | $375 | $375 | 1 |
| CT Upper Ext Left W/o Contrast | other | $376 | $376 | $376 | 1 |
| Extremity Study | other | $376 | $376 | $376 | 1 |
| Retroperitoneal Ultrasound | imaging | $376 | $376 | $376 | 1 |
| X-ray Exam Abdomen 2 Views | imaging | $376 | $376 | $376 | 1 |
| X-ray Exam of Pelvis | imaging | $376 | $376 | $376 | 1 |
| Nuclear Medicine Study of Bone And/or Joint Multiple Areas | imaging | $379 | $379 | $379 | 1 |
| CT Orbit/ear/fossa W/o Dye | other | $381 | $381 | $381 | 1 |
| Needle Biopsy of Lining of Lung | lab | $382 | $382 | $382 | 1 |
| Skin Lesion Destruction | other | $387 | $2 | $10,074 | 17 |
| Intensive Care Unit - General Classification | other | $388 | $388 | $388 | 1 |
| Toenail Removal | surgery | $389 | $63 | $10,074 | 19 |
| Vision Exam | other | $389 | $23 | $419 | 10 |
| Addition, Endoskeletal Knee-shin System, Polycentric, Mechanical Stance Phase... | other | $392 | $392 | $392 | 1 |
| CT Abdomen without Contrast | imaging | $393 | $393 | $393 | 1 |
| ERCP (Gallstone Removal) | other | $395 | $22 | $3,569 | 28 |
| CT Contrast Low Osmolar 200-299ml | imaging | $397 | $397 | $397 | 1 |
| Biopsy of Tissue of Chest Using an Endoscope | lab | $398 | $398 | $398 | 1 |
| Graft Jacket | other | $399 | $399 | $399 | 1 |
| Bexsero Prefilled Syringe | other | $401 | $401 | $401 | 1 |
| Drainage of Skin Abscess | other | $404 | $404 | $404 | 1 |
| Biopsy OR Removal of Lymph Nodes of Neck with Removal of Fat Pad | surgery | $406 | $406 | $406 | 1 |
| Aspiration of Fluid From Cyst of Spinal Cord OR Fluid-filled Cavity | other | $406 | $406 | $406 | 1 |
| Aspiration And/or Injection of Cyst of Kidney | other | $416 | $382 | $449 | 2 |
| Aspiration of Fluid From Chest Cavity Using Imaging Guidance | other | $424 | $424 | $424 | 1 |
| Path Consult Intraop Frozen Se | other | $425 | $425 | $425 | 1 |
| Nervous System Surgery | surgery | $432 | $432 | $432 | 1 |
| Aspiration of Initial Secretion of Lung Airway Using an Endoscope | other | $440 | $408 | $472 | 2 |
| Echocardiogram | imaging | $442 | $7 | $8,078 | 32 |
| Gene Analysis (cystic Fibrosis Transmembrane Conductance Regular) Common Vari... | other | $446 | $446 | $446 | 1 |
| Biopsy and Removal of Lymph Nodes of Abdominal Cavity Using an Endoscope | surgery | $450 | $450 | $450 | 1 |
| Anti-xa | other | $454 | $454 | $454 | 1 |
| Bydureon Bcise 2 Mg Autoinject | other | $456 | $456 | $456 | 1 |
| Biopsy of Esophagus Using a Flexible Endoscope Through Mouth | lab | $461 | $461 | $461 | 1 |
| Balloon Dilation of Esophagus Using a Flexible Endoscope, Less Than 3.0 Cm | other | $464 | $464 | $464 | 1 |
| Pretreatment of Rbc By Density | other | $465 | $465 | $465 | 1 |
| Albumin (human) 5% Glass Bottl | other | $472 | $472 | $472 | 1 |
| Biopsy of Lung Airway Using an Endoscope | lab | $473 | $473 | $473 | 1 |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated Socket ... | other | $475 | $475 | $475 | 1 |
| Amniomatrix OR Biodmatrix, Injectable, 1 Cc | other | $479 | $479 | $479 | 1 |
| Biopsy OR Removal of Lymph Nodes of Breast | surgery | $496 | $496 | $496 | 1 |
| Laryngoscopy | other | $498 | $22 | $5,405 | 27 |
| 23x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 | $505 | 1 |
| 41x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 | $505 | 1 |
| Balloon Dilation of Pulmonary Artery, Single Vessel | other | $514 | $514 | $514 | 1 |
| Punch Bx Skin Single Lesion | other | $515 | $515 | $515 | 1 |
| Labor Room/delivery - General Classification | obstetric | $519 | $519 | $519 | 1 |
| Carotid Duplex Ultrasound | imaging | $527 | $227 | $740 | 6 |
| Addition to Lower Extremity, Endoskeletal System, Above Knee - Knee Disarticu... | other | $529 | $529 | $529 | 1 |
| Ankle Foot Orthosis, Walking Boot Type, Varus/valgus Correction, Rocker Botto... | other | $538 | $538 | $538 | 1 |
| Airway Inhalation Treatment | other | $542 | $542 | $542 | 1 |
| Pos Airway Pressure CPAP | other | $542 | $542 | $542 | 1 |
| Epifix 1 SQ Cm | other | $549 | $549 | $549 | 1 |
| Addition to Lower Extremity, Above Knee, Flexible Inner Socket, External Frame | other | $551 | $551 | $551 | 1 |
| Addition to Lower Extremity, Below Knee, Flexible Inner Socket, External Frame | other | $551 | $551 | $551 | 1 |
| IOL Akreos Lens B&l | other | $551 | $551 | $551 | 1 |
| Injection, Tetanus Immune Globulin, Human, Up to 250 Units | other | $557 | $557 | $557 | 1 |
| Lymph OR Ln Nm Scan | other | $558 | $558 | $558 | 1 |
| Neg Press Wnd Tx <=50 SQ Cm | other | $558 | $558 | $558 | 1 |
| IUD Insertion | other | $559 | $22 | $4,962 | 32 |
| Biopsy of Small Bowel (except Ileum) Using an Endoscope | lab | $561 | $561 | $561 | 1 |
| CT Pelvis W/o Dye | other | $562 | $562 | $562 | 1 |
| CT Soft Tissue Neck W/o Dye | other | $562 | $562 | $562 | 1 |
| CT Sinus without Contrast | imaging | $563 | $563 | $563 | 1 |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Fi... | imaging | $564 | $564 | $564 | 1 |
| Insertion of Stomach Tube Using Fluoroscopic Guidance with Contrast | other | $570 | $570 | $570 | 1 |
| 8x21x32mm 7 Degree Tm-400 Dev #06-131 | other | $572 | $572 | $572 | 1 |
| Hydration IV Infusion Init | surgery | $573 | $573 | $573 | 1 |
| Amputation of Foot Across Instep | other | $574 | $574 | $574 | 1 |
| Biopsy of Large Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $578 | $578 | $578 | 1 |
| CT Cervical Spine without Contrast | imaging | $579 | $579 | $579 | 1 |
| Thoracentesis | other | $580 | $362 | $2,948 | 19 |
| CT Lumbar Spine without Contrast | imaging | $580 | $580 | $580 | 1 |
| Lumbar Puncture (Spinal Tap) | other | $581 | $23 | $2,476 | 19 |
| Amputation of Thigh Through Thigh Bone Leaving Wound | other | $585 | $585 | $585 | 1 |
| MRI Scan of Chest with Contrast | imaging | $588 | $588 | $588 | 1 |
| Mole Removal | other | $605 | $22 | $10,074 | 23 |
| Adhesion of Linings of Lung Using an Endoscope | other | $605 | $605 | $605 | 1 |
| Apply Rigid Leg Cast | other | $609 | $609 | $609 | 1 |
| CT Chest | imaging | $612 | $99 | $3,650 | 31 |
| MRI Scan of Arm Joint with Contrast | imaging | $613 | $613 | $613 | 1 |
| Anchoring of Flexing Tendon of Fingers to Wrist Bone | other | $614 | $614 | $614 | 1 |
| Abscess Drainage (I&D) | emergency | $617 | $32 | $2,550 | 19 |
| Amputation of Finger OR Thumb with Direct Closure | other | $620 | $620 | $620 | 1 |
| Ther/proph/diag Inj IV Push | other | $628 | $628 | $628 | 1 |
| Annuloplasty Ring 25mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 29mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 31mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 33mm #tarp | other | $637 | $637 | $637 | 1 |
| Aspiration of Bone Marrow Sample for Diagnosis | other | $637 | $637 | $637 | 1 |
| Misc Implant | surgery | $637 | $637 | $637 | 1 |
| Anjeso (meloxicam) Inj 30 Mg | other | $652 | $652 | $652 | 1 |
| Rbc Leukocytes Reduced | other | $659 | $659 | $659 | 1 |
| MRI Scan of Leg Joint with Contrast | imaging | $661 | $661 | $661 | 1 |
| Critical Care | emergency | $666 | $2 | $3,727 | 18 |
| Addition to Lower Limb Prosthesis, Vertical Shock Reducing Pylon Feature | other | $668 | $668 | $668 | 1 |
| Amputation of Thigh Through Thigh Bone | other | $670 | $670 | $670 | 1 |
| Biopsy of Lung Lining | lab | $671 | $671 | $671 | 1 |
| Deb Subq Tissue 20 SQ Cm/< | other | $675 | $675 | $675 | 1 |
| Biopsy of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible Endos... | lab | $684 | $684 | $684 | 1 |
| Hosp Obs Direct Referral | other | $685 | $685 | $685 | 1 |
| Tumor Immunohistochem/comput | other | $687 | $687 | $687 | 1 |
| Balloon Dilation of Groin Artery, Each Additional Vessel | other | $692 | $692 | $692 | 1 |
| Amputation of Finger OR Thumb | other | $693 | $693 | $693 | 1 |
| Immunohisto Antb 1st Stain | other | $708 | $708 | $708 | 1 |
| Flowcytometry/ Tc 1 Marker | other | $709 | $709 | $709 | 1 |
| Rbc Antibody Identification | other | $709 | $709 | $709 | 1 |
| Biopsy of Fluid Collection of Lung | lab | $710 | $710 | $710 | 1 |
| Biopsy of Growth of Lung | lab | $716 | $716 | $716 | 1 |
| Deep Biopsy of Bone Using Needle OR Trocar | lab | $718 | $718 | $718 | 1 |
| Upper Extremity Study | other | $740 | $740 | $740 | 1 |
| Prostate Biopsy | other | $741 | $22 | $10,074 | 23 |
| Byfavo 20 Mg Vial | other | $752 | $752 | $752 | 1 |
| Amputation of Both Lower Leg Bones | other | $765 | $765 | $765 | 1 |
| Biopsy and Aspiration of Bone Marrow Sample for Diagnosis | lab | $772 | $772 | $772 | 1 |
| Drain/inj Joint/bursa W/us | other | $795 | $795 | $795 | 1 |
| Balloon Dilation of Artery of Leg, Each Additional Vessel | other | $807 | $807 | $807 | 1 |
| Graft Applic <100cm, 1st 25 Cm | other | $810 | $810 | $810 | 1 |
| Graft Applic <100cm, 1st 25cm | other | $810 | $810 | $810 | 1 |
| Addition, Endoskeletal, Knee-shin System, Stance Flexion Feature, Adjustable | other | $831 | $831 | $831 | 1 |
| Insertion of Indwelling Tube for Drainage of Lung Fluid | other | $831 | $831 | $831 | 1 |
| Sleep Study (Polysomnography) | diagnostic | $839 | $8 | $2,274 | 31 |
| Biopsy OR Removal of Foreign Body in Large Bowel | surgery | $855 | $855 | $855 | 1 |
| CT Lower Ext Left W/wo Contras | other | $859 | $859 | $859 | 1 |
| CT Upper Ext Left W/contrast | other | $859 | $859 | $859 | 1 |
| CT Upper Ext Left W/wo Contras | other | $859 | $859 | $859 | 1 |
| Platelet Pheres Leuko-storage& | other | $859 | $859 | $859 | 1 |
| N Block, Other Peripheral | other | $866 | $866 | $866 | 1 |
| Paracentesis | diagnostic | $867 | $40 | $1,317 | 19 |
| Injection, Tbo-filgrastim, 1 Microgram | other | $875 | $875 | $875 | 1 |
| Balloon Dilation of Coronary Artery OR Branch, Each Additional Artery OR Branch | cardiac | $880 | $880 | $880 | 1 |
| Hip Arthroscopy | other | $884 | $783 | $10,074 | 12 |
| Bypass of Diseased OR Blocked Chest to Opposite Chest Artery with Other Than ... | other | $884 | $884 | $884 | 1 |
| CT Lower Ext Left W/contrast | other | $884 | $884 | $884 | 1 |
| Postpartum Care | obstetric | $898 | $22 | $10,074 | 15 |
| Deb Musc/fascia 20 SQ Cm/< | other | $902 | $251 | $12,544 | 7 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Thigh Artery with Other Than... | other | $902 | $902 | $902 | 1 |
| Argatroban Non-esrd 1mg | other | $906 | $906 | $906 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Oth... | other | $911 | $911 | $911 | 1 |
| Intravitreal Injection | surgery | $912 | $912 | $912 | 1 |
| Injection, Crotalidae Immune F(ab')2 (equine), 120 Mg | other | $918 | $918 | $918 | 1 |
| Bypass of Diseased OR Blocked Arm to Chest Artery with Other Than Vein | other | $919 | $919 | $919 | 1 |
| Bypass of Diseased OR Blocked Upper Arm to Opposite Arm Artery with Vein | other | $928 | $928 | $928 | 1 |
| Central Line Insertion | other | $937 | $7 | $1,976 | 20 |
| Balloon Viabahn Bx 7mmx59mm 7fr Bxa075902a | other | $948 | $948 | $948 | 1 |
| Bypass of Diseased OR Blocked Knee to Lower Leg Arteries with Other Than Vein | other | $954 | $954 | $954 | 1 |
| CT Lumbar Spine W/dye | other | $962 | $962 | $962 | 1 |
| CT Abdomen with Contrast | imaging | $963 | $963 | $963 | 1 |
| CT Pelvis W/dye | other | $963 | $963 | $963 | 1 |
| ACL Reconstruction | surgery | $987 | $8 | $46,499 | 22 |
| Bypass of Diseased OR Blocked Under Arm to Arm Artery with Vein | other | $987 | $987 | $987 | 1 |
| Bypass of Diseased OR Blocked Neck to Chest Artery with Other Than Vein | other | $988 | $988 | $988 | 1 |
| Bypass of Diseased OR Blocked Groin to Upper Leg Artery with Other Than Vein | other | $989 | $989 | $989 | 1 |
| CT Neck with Contrast | imaging | $992 | $992 | $992 | 1 |
| Bronchoscopy | diagnostic | $1,000 | $79 | $3,260 | 17 |
| Circumcision | surgery | $1,000 | $199 | $2,550 | 17 |
| Cystoscopy | diagnostic | $1,005 | $22 | $7,901 | 23 |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Vein | other | $1,024 | $1,024 | $1,024 | 1 |
| Epidural Steroid Injection | other | $1,025 | $215 | $10,074 | 19 |
| Njx Interlaminar Lmbr/sac | other | $1,025 | $22 | $2,550 | 11 |
| MRI of the Abdomen | imaging | $1,027 | $333 | $3,752 | 18 |
| CT Spine | imaging | $1,028 | $101 | $4,945 | 19 |
| Bypass of Diseased OR Blocked Upper Arm to Arm Artery with Vein | other | $1,038 | $1,038 | $1,038 | 1 |
| Tissue Exam By Pathologist | other | $1,039 | $1,039 | $1,039 | 1 |
| CT Angiography Chest | imaging | $1,040 | $167 | $1,316 | 6 |
| Inj Paravert F Jnt L/s 2 Lev | other | $1,041 | $1,041 | $1,041 | 1 |
| Inj Paravert F Jnt L/s 3 Lev | other | $1,041 | $1,041 | $1,041 | 1 |
| Inj Paravert F Jnt C/t 2 Lev | other | $1,061 | $1,061 | $1,061 | 1 |
| **obsolete** Valve Mitral 25mm Bicor #b100-25m | other | $1,064 | $1,064 | $1,064 | 1 |
| CT Abdomen with and without Contrast | imaging | $1,067 | $1,067 | $1,067 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Other Than Vein | other | $1,083 | $1,083 | $1,083 | 1 |
| Addition to Lower Extremity, Ischial Containment/narrow M-l Socket | other | $1,094 | $1,094 | $1,094 | 1 |
| CT Angio Abdom W/o & W/dye | other | $1,099 | $1,099 | $1,099 | 1 |
| CT Angiography Head | imaging | $1,099 | $1,099 | $1,099 | 1 |
| CT Angiography Neck | imaging | $1,099 | $1,099 | $1,099 | 1 |
| Digital Nerve Block | other | $1,110 | $1,110 | $1,110 | 1 |
| Bypass of Diseased OR Blocked Lower Leg to Lower Leg Artery with Vein | other | $1,113 | $1,113 | $1,113 | 1 |
| Colonoscopy with Polypectomy | other | $1,123 | $310 | $2,894 | 19 |
| Biopsy of Gallbladder, Pancreatic, Liver, and Bile Ducts Using a Flexible End... | lab | $1,134 | $1,134 | $1,134 | 1 |
| Biopsy of Lobe of Lung Using an Endoscope, 1 Lobe | lab | $1,147 | $1,147 | $1,147 | 1 |
| Bypass of Diseased OR Blocked Arm to Both Lower Thigh Arteries with Other Tha... | other | $1,147 | $1,147 | $1,147 | 1 |
| Destr L/s Facet Jnt Addtl | other | $1,160 | $1,160 | $1,160 | 1 |
| Destr Paravertebrl N Add-on | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Foramen Epidural Add-on | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Foramen Epidural L/s | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Paravert F Jnt C/t 1 Lev | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Paravert F Jnt L/s 1 Lev | other | $1,160 | $1,160 | $1,160 | 1 |
| N Block Stellate Ganglion | other | $1,160 | $1,160 | $1,160 | 1 |
| Bypass of Diseased OR Blocked Upper to Lower Leg Artery with Vein | other | $1,171 | $1,171 | $1,171 | 1 |
| Hospital Admission | other | $1,172 | $83 | $10,074 | 12 |
| Bypass of Diseased OR Blocked Neck to Opposite Neck Artery with Vein | other | $1,191 | $1,191 | $1,191 | 1 |
| Angiojet Solent Dista Set #111303 | other | $1,202 | $1,202 | $1,202 | 1 |
| Bypass of Diseased OR Blocked Thigh to Knee Artery with Vein Graft | other | $1,208 | $1,208 | $1,208 | 1 |
| Cardiac Catheterization | cardiac | $1,225 | $7 | $49,200 | 34 |
| Addition to Lower Limb Prosthesis, Multiaxial Ankle with Swing Phase Active D... | other | $1,229 | $1,229 | $1,229 | 1 |
| Blood Transfusion Service | surgery | $1,233 | $1,233 | $1,233 | 1 |
| CT Abdomen and Pelvis | imaging | $1,234 | $213 | $6,606 | 23 |
| Nuclear Medicine Studies of Heart Muscle At Rest and with Stress and SPECT | imaging | $1,237 | $1,237 | $1,237 | 1 |
| Bypass of Diseased OR Blocked Aorta to Upper Leg Artery with Other Than Vein | other | $1,260 | $1,260 | $1,260 | 1 |
| Below Knee, Molded Socket, Shin, Sach Foot, Endoskeletal System | other | $1,261 | $1,261 | $1,261 | 1 |
| Radiation Therapy | other | $1,284 | $22 | $33,804 | 31 |
| Addition, Endoskeletal System, High Activity Knee Control Frame | other | $1,293 | $1,293 | $1,293 | 1 |
| Addition, Endoskeletal Knee-shin System, Single Axis, Fluid Swing and Stance ... | other | $1,295 | $1,295 | $1,295 | 1 |
| Addition, Endoskeletal Knee-shin System, Polycentric, Hydraulic Swing Phase C... | other | $1,342 | $1,342 | $1,342 | 1 |
| 25mj-501 Valve Mitral Size 25 Mm Rotatable Standard Cuff Mechanical | other | $1,357 | $1,357 | $1,357 | 1 |
| Biopsy of Breast and Placement of Locating Device Using Mri, First Growth | imaging | $1,357 | $1,357 | $1,357 | 1 |
| All Lower Extremity Prostheses, Flex-walk System OR Equal | other | $1,373 | $1,373 | $1,373 | 1 |
| Bypass of Diseased OR Blocked Arm to Lower Thigh OR Leg Artery with Other Tha... | other | $1,376 | $1,376 | $1,376 | 1 |
| Bypass of Diseased OR Blocked Major Upper to Lower Leg Artery with Vein | other | $1,393 | $1,393 | $1,393 | 1 |
| Bypass of Diseased OR Blocked Aorta to Groin Artery with Other Than Vein | other | $1,398 | $1,398 | $1,398 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Vein Graft | other | $1,398 | $1,398 | $1,398 | 1 |
| Bypass of Diseased OR Blocked Artery Aorta to Upper Leg and Opposite Upper Le... | other | $1,431 | $1,431 | $1,431 | 1 |
| Atricure Isolator Synergy Encompass Long #olh | other | $1,436 | $1,436 | $1,436 | 1 |
| Addition to Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Manageme... | other | $1,446 | $1,446 | $1,446 | 1 |
| CT Scan of the Abdomen and Pelvis | imaging | $1,461 | $230 | $5,912 | 6 |
| Atriclip Pro-v Device 35mm #prov35 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Pro-v Device 45mm #prov45 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Pro-v Device 50mm #prov50 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Prov-5 Device 40mm #prov40 | other | $1,463 | $1,463 | $1,463 | 1 |
| Bypass of Diseased OR Blocked Aorta to Groin to Opposite Groin Artery with Ot... | other | $1,467 | $1,467 | $1,467 | 1 |
| Normal Newborn | other | $1,469 | $1,469 | $1,469 | 1 |
| Byetta 10 Mcg Dose Pen Inj | other | $1,487 | $1,487 | $1,487 | 1 |
| Byetta 5 Mcg Dose Pen Inj | other | $1,487 | $1,487 | $1,487 | 1 |
| Acute Myocardial Infarction, Expired without Cc/mcc | other | $1,497 | $1,497 | $1,497 | 1 |
| Bypass of Diseased OR Blocked Artery Aorta to Abdominal OR Kidney Artery with... | other | $1,553 | $1,553 | $1,553 | 1 |
| Alcohol, Drug Abuse OR Dependence, Left Ama | other | $1,554 | $1,427 | $1,681 | 2 |
| CT Abdomen and Pelvis with and without Contrast | imaging | $1,564 | $1,564 | $1,564 | 1 |
| Colonoscopy | preventive | $1,589 | $1 | $5,345 | 24 |
| Acute Leukemia with Cc | other | $1,598 | $1,598 | $1,598 | 1 |
| Cardiac Congenital and Valvular Disorders without Mcc | cardiac | $1,598 | $1,598 | $1,598 | 1 |
| Complications of Treatment with Mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Connective Tissue Disorders with Cc | other | $1,598 | $1,598 | $1,598 | 1 |
| Endocrine Disorders without Cc/mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Fever and Inflammatory Conditions | other | $1,598 | $1,598 | $1,598 | 1 |
| Headaches without Mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Heart Failure and Shock without CC/MCC | cardiac | $1,598 | $1,598 | $1,598 | 1 |
| Inborn and Other Disorders of Metabolism | other | $1,598 | $1,598 | $1,598 | 1 |
| Inflammation of the Male Reproductive System with Mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Major Chest Trauma without Cc/mcc | emergency | $1,598 | $1,598 | $1,598 | 1 |
| Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and... | other | $1,598 | $1,598 | $1,598 | 1 |
| Malignancy, Male Reproductive System with Cc | other | $1,598 | $1,598 | $1,598 | 1 |
| Neonates, Died OR Transferred to Another Acute Care Facility | other | $1,598 | $1,598 | $1,598 | 1 |
| Nervous System Neoplasms with Mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Addition, Endoskeletal Knee/shin System, 4-bar Linkage OR Multiaxial, Pneumat... | other | $1,609 | $1,609 | $1,609 | 1 |
| CT Angio Abd&pelv W/o&w/dye | other | $1,610 | $1,610 | $1,610 | 1 |
| Vasectomy | surgery | $1,663 | $22 | $2,894 | 30 |
| Colonoscopy (Diagnostic) | diagnostic | $1,673 | $22 | $2,550 | 10 |
| Balloon Dilation of Groin Artery, Initial Vessel | other | $1,687 | $1,687 | $1,687 | 1 |
| All Lower Extremity Prostheses, Flex Foot System | other | $1,700 | $1,700 | $1,700 | 1 |
| Lithotripsy-s/w | other | $1,704 | $1,704 | $1,704 | 1 |
| Anesthesia for Procedure On Esophagus | other | $1,722 | $1,722 | $1,722 | 1 |
| Intraop Cyto Path Consult 1 | other | $1,726 | $1,726 | $1,726 | 1 |
| Astigmatism-correct Function | other | $1,746 | $1,746 | $1,746 | 1 |
| LASIK Eye Surgery | other | $1,750 | $168 | $2,894 | 8 |
| Balloon Dilation of Artery of Leg | other | $1,786 | $1,786 | $1,786 | 1 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis without Cc/mcc | other | $1,800 | $1,800 | $1,800 | 1 |
| Hernia Procedures Except Inguinal and Femoral without Cc/mcc | other | $1,800 | $1,800 | $1,800 | 1 |
| Minor Bladder Procedures with Mcc | other | $1,800 | $1,800 | $1,800 | 1 |
| Minor Small and Large Bowel Procedures without Cc/mcc | other | $1,800 | $1,800 | $1,800 | 1 |
| Deb Bone 20 SQ Cm/< | other | $1,825 | $1,825 | $1,825 | 1 |
| Above Knee, Molded Socket, Open End, Sach Foot, Endoskeletal System, Single A... | other | $1,828 | $1,828 | $1,828 | 1 |
| Carpal Tunnel Release | surgery | $1,832 | $196 | $10,074 | 22 |
| Inject Epidural Patch | other | $1,843 | $1,843 | $1,843 | 1 |
| Injection, Calcitonin Salmon, Up to 400 Units | other | $1,917 | $1,917 | $1,917 | 1 |
| Glucagon Emergency Kit 1 Mg | emergency | $1,943 | $1,943 | $1,943 | 1 |
| Destr Paravertebrl Nerve | other | $1,944 | $1,944 | $1,944 | 1 |
| Destr L/s Facet Jnt | other | $1,947 | $1,947 | $1,947 | 1 |
| PET Scan | imaging | $1,966 | $1,368 | $13,340 | 12 |
| Neonate with Other Significant Problems | other | $1,990 | $1,990 | $1,990 | 1 |
| Hysteroscopy | other | $2,068 | $22 | $4,950 | 25 |
| Knee Arthroscopy | other | $2,100 | $161 | $12,272 | 21 |
| Balloon Dilation of Artery with Review By Radiologist, Initial Artery | other | $2,101 | $2,101 | $2,101 | 1 |
| Wound Debridement | surgery | $2,107 | $251 | $66,385 | 18 |
| Balloon Dilation of Artery of Leg, Initial Vessel | other | $2,179 | $2,179 | $2,179 | 1 |
| Injection, Ferumoxytol, for Treatment of Iron Deficiency Anemia, 1 Mg | other | $2,208 | $2,208 | $2,208 | 1 |
| Bronchitis and Asthma without Cc/mcc | other | $2,226 | $1,292 | $3,160 | 2 |
| Zynrelef Implant (bupivacaine | surgery | $2,228 | $2,228 | $2,228 | 1 |
| Anesthesia for Closed Drainage of Lung Fluid | other | $2,245 | $2,245 | $2,245 | 1 |
| Abortion without D&c | other | $2,318 | $1,598 | $3,038 | 2 |
| Cardiac Ablation | other | $2,334 | $17 | $50,861 | 17 |
| Hernia Repair (Inguinal) | surgery | $2,347 | $22 | $4,950 | 9 |
| Njx Aa&/strd Brach Plexus | other | $2,394 | $2,394 | $2,394 | 1 |
| Hernia Repair | surgery | $2,454 | $13 | $9,094 | 23 |
| N Block Inj Fem Cont Inf | other | $2,455 | $2,455 | $2,455 | 1 |
| Balloon Dilation of Vein with Review By Radiologist, Initial Vein | other | $2,481 | $2,481 | $2,481 | 1 |
| Cataract Surgery | surgery | $2,550 | $671 | $10,074 | 20 |
| Endoscopy | preventive | $2,550 | $454 | $3,743 | 24 |
| Prenatal Care | obstetric | $2,550 | $22 | $10,074 | 15 |
| Tonsillectomy | surgery | $2,550 | $22 | $9,094 | 15 |
| Upper GI Endoscopy (EGD) | diagnostic | $2,550 | $22 | $3,743 | 10 |
| Ascending Aorta Graft, with Cardiopulmonary Bypass, Includes Valve Suspension... | other | $2,568 | $2,568 | $2,568 | 1 |
| Shoulder Surgery | surgery | $2,589 | $92 | $46,499 | 21 |
| Breast Biopsy | other | $2,686 | $18 | $139,721 | 34 |
| Drainage of Hematoma/fluid | other | $2,751 | $2,751 | $2,751 | 1 |
| Ankle Surgery | other | $2,797 | $400 | $5,141 | 12 |
| Insert Picc Cath - OR | other | $2,836 | $2,836 | $2,836 | 1 |
| Dexametha Opth Insert 0.1 Mg | imaging | $2,867 | $2,867 | $2,867 | 1 |
| Allergic Reactions without Mcc | other | $2,868 | $2,868 | $2,868 | 1 |
| Acute Myocardial Infarction, Expired with Cc | other | $2,933 | $2,933 | $2,933 | 1 |
| Septoplasty | surgery | $3,042 | $382 | $9,094 | 11 |
| Bunionectomy | other | $3,044 | $601 | $4,950 | 15 |
| Hosp Obs Hrs 8 & Above | other | $3,091 | $3,091 | $3,091 | 1 |
| Benign Prostatic Hypertrophy without Mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Cardiac Arrhythmia and Conduction Disorders without Cc/mcc | cardiac | $3,196 | $3,196 | $3,196 | 1 |
| Complicated Peptic Ulcer with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| Diabetes without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Digestive Malignancy with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| Disorders of Pancreas Except Malignancy without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Disorders of the Biliary Tract with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with Mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Fractures of Hip and Pelvis with Mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Gastrointestinal Hemorrhage without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Inflammatory Bowel Disease without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Lymphoma and Non-acute Leukemia with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| Malignancy, Female Reproductive System with Cc | other | $3,196 | $3,196 | $3,196 | 1 |
| C-Section (Cesarean Delivery) | obstetric | $3,214 | $17 | $36,823 | 34 |
| Cath, Bal Dil, Non-vascular | other | $3,247 | $3,247 | $3,247 | 1 |
| Alloderm 1518320 | other | $3,248 | $3,248 | $3,248 | 1 |
| IOL Crystalens OR Trulign | other | $3,312 | $3,312 | $3,312 | 1 |
| All Lower Extremity Prosthesis, Shank Foot System with Vertical Loading Pylon | other | $3,336 | $3,336 | $3,336 | 1 |
| Neuragen | other | $3,423 | $3,423 | $3,423 | 1 |
| Propel Mometasone Furoate Sinu | other | $3,497 | $3,497 | $3,497 | 1 |
| Bronchitis and Asthma with Cc/mcc | other | $3,512 | $3,196 | $3,828 | 2 |
| Aftercare without Cc/mcc | other | $3,522 | $3,522 | $3,522 | 1 |
| Gastrointestinal Obstruction without Cc/mcc | other | $3,538 | $3,538 | $3,538 | 1 |
| Vaginal Delivery | obstetric | $3,567 | $22 | $11,589 | 34 |
| Hip and Femur Procedures except Major Joint without CC/MCC | surgery | $3,600 | $3,600 | $3,600 | 1 |
| Inguinal and Femoral Hernia Procedures with Cc | other | $3,600 | $3,600 | $3,600 | 1 |
| Knee Procedures without Principal Diagnosis of Infection with Cc/mcc | other | $3,600 | $3,600 | $3,600 | 1 |
| Laparoscopic Cholecystectomy without CC/MCC | surgery | $3,600 | $3,600 | $3,600 | 1 |
| COPD Management | other | $3,604 | $5 | $19,047 | 38 |
| Lumpectomy (Breast) | surgery | $3,620 | $83 | $4,950 | 16 |
| Dental and Oral Diseases without Cc/mcc | other | $3,665 | $3,665 | $3,665 | 1 |
| Abortion with D&c, Aspiration Curettage OR Hysterotomy | other | $3,739 | $3,600 | $3,878 | 2 |
| Appendectomy (Laparoscopic) | surgery | $3,750 | $3 | $40,890 | 28 |
| Thyroidectomy | surgery | $3,773 | $1,049 | $10,074 | 18 |
| Bifurcated Stent #bea28-90/i16 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Bifurcated Stent #bea28-90/i20 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Bifurcated Stent Bea22-60/i16 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Balloon Dilation Repair of Aortic Valve | surgery | $3,881 | $3,881 | $3,881 | 1 |
| Rotator Cuff Repair | surgery | $3,959 | $92 | $6,805 | 6 |
| Allergic Reactions with Mcc | other | $3,963 | $1,598 | $6,327 | 2 |
| Alcohol/Drug Abuse or Dependence without Rehabilitation without MCC | therapy | $4,059 | $2,521 | $5,597 | 2 |
| Anal and Stomal Procedures with Cc | other | $4,206 | $3,600 | $4,811 | 2 |
| Acute Major Eye Infections with Cc/mcc | other | $4,350 | $4,350 | $4,350 | 1 |
| Gastric Sleeve (Weight Loss Surgery) | other | $4,393 | $1,046 | $10,160 | 14 |
| Atherosclerosis without Mcc | other | $4,466 | $3,196 | $5,736 | 2 |
| Full Term Neonate with Major Problems | other | $4,467 | $4,467 | $4,467 | 1 |
| Gallbladder Removal (Laparoscopic) | surgery | $4,487 | $22 | $57,587 | 37 |
| Kidney and Urinary Tract Signs and Symptoms without Mcc | other | $4,496 | $4,496 | $4,496 | 1 |
| Major Skin Disorders without Mcc | other | $4,522 | $4,522 | $4,522 | 1 |
| Cellulitis without Mcc | other | $4,556 | $4,556 | $4,556 | 1 |
| COPD without CC/MCC | other | $4,627 | $4,627 | $4,627 | 1 |
| Esophagitis and GI Disorders with MCC | other | $4,632 | $4,632 | $4,632 | 1 |
| Inflammation of the Male Reproductive System without Mcc | other | $4,647 | $4,647 | $4,647 | 1 |
| Endometrial Ablation | other | $4,702 | $22 | $19,770 | 21 |
| Kidney and Urinary Tract Infections without MCC | other | $4,748 | $4,748 | $4,748 | 1 |
| Hysterectomy (Laparoscopic) | surgery | $4,755 | $22 | $57,631 | 28 |
| IOL Staar Visian Clearlens Exc | other | $4,755 | $4,755 | $4,755 | 1 |
| Fractures of Femur without Mcc | other | $4,765 | $4,765 | $4,765 | 1 |
| Amplatzer Amulet Laao 16mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 18mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 20mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 22mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 25mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 28mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 31mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 34mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Cardiac Arrhythmia and Conduction Disorders with Cc | cardiac | $4,794 | $4,794 | $4,794 | 1 |
| Cardiac Congenital and Valvular Disorders with Mcc | cardiac | $4,794 | $4,794 | $4,794 | 1 |
| Cranial and Peripheral Nerve Disorders without Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Degenerative Nervous System Disorders without Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Dental and Oral Diseases with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Digestive Malignancy with Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Disorders of the Biliary Tract without Cc/mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh ... | other | $4,794 | $4,794 | $4,794 | 1 |
| Gastrointestinal Obstruction with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Gastrointestinal Obstruction with Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Heart Failure and Shock with CC | cardiac | $4,794 | $4,794 | $4,794 | 1 |
| HIV with Major Related Condition with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Hypertensive Encephalopathy with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Inflammatory Bowel Disease with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Intracranial Hemorrhage or Cerebral Infarction with CC | other | $4,794 | $4,794 | $4,794 | 1 |
| Lymphoma and Non-acute Leukemia with Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Major Esophageal Disorders with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Minor Skin Disorders without Mcc | other | $4,794 | $4,794 | $4,794 | 1 |
| Laminectomy (Back Decompression) | other | $4,950 | $314 | $10,074 | 17 |
| Spinal Fusion (Lumbar) | surgery | $4,950 | $1,700 | $32,341 | 7 |
| Complicated Peptic Ulcer without Cc/mcc | other | $4,967 | $4,967 | $4,967 | 1 |
| Acute and Subacute Endocarditis with Cc | other | $5,035 | $5,035 | $5,035 | 1 |
| Integra Silicone Pip Implant | surgery | $5,150 | $5,150 | $5,150 | 1 |
| Destruction Neurolytic Agt Gen | other | $5,222 | $5,222 | $5,222 | 1 |
| Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes wit... | other | $5,326 | $5,326 | $5,326 | 1 |
| Aftercare, Musculoskeletal System and Connective Tissue without Cc/mcc | other | $5,342 | $4,124 | $6,559 | 2 |
| Kidney Stone Removal | other | $5,366 | $22 | $97,500 | 32 |
| Diabetes with Cc | other | $5,397 | $5,397 | $5,397 | 1 |
| Breast Biopsy, Local Excision and Other Breast Procedures with Cc/mcc | surgery | $5,400 | $5,400 | $5,400 | 1 |
| D&c, Conization, Laparoscopy and Tubal Interruption with Cc/mcc | surgery | $5,400 | $5,400 | $5,400 | 1 |
| Kidney and Ureter Procedures for Non-neoplasm without Cc/mcc | other | $5,400 | $5,400 | $5,400 | 1 |
| Implant Neuroelectrodes | surgery | $5,400 | $5,400 | $5,400 | 1 |
| Nervous System Neoplasms without Mcc | other | $5,452 | $5,452 | $5,452 | 1 |
| Hypertension without Mcc | other | $5,463 | $5,463 | $5,463 | 1 |
| Infectious and Parasitic Diseases with O.r. Procedures with Cc | other | $5,629 | $5,629 | $5,629 | 1 |
| Infectious and Parasitic Diseases with O.r. Procedures with Mcc | other | $5,629 | $5,629 | $5,629 | 1 |
| Prostatectomy | other | $5,732 | $1,592 | $33,079 | 28 |
| Angina Pectoris | other | $5,758 | $5,758 | $5,758 | 1 |
| COPD with CC | other | $5,789 | $5,789 | $5,789 | 1 |
| Appendix Procedures without Cc/mcc | other | $5,901 | $1,800 | $10,001 | 2 |
| Acute Myocardial Infarction Discharged Alive without CC/MCC | cardiac | $6,040 | $5,762 | $6,317 | 2 |
| Endocrine Disorders with Cc | other | $6,164 | $6,164 | $6,164 | 1 |
| Medical Back Problems without Mcc | other | $6,197 | $6,197 | $6,197 | 1 |
| Amputation for Musculoskeletal System and Connective Tissue Disorders without... | other | $6,323 | $6,323 | $6,323 | 1 |
| Disorders of Pancreas Except Malignancy with Cc | other | $6,329 | $6,329 | $6,329 | 1 |
| Major Gastrointestinal Disorders and Peritoneal Infections with Cc | other | $6,358 | $6,358 | $6,358 | 1 |
| Cardiac Arrhythmia and Conduction Disorders with Mcc | cardiac | $6,392 | $6,392 | $6,392 | 1 |
| COPD with MCC | other | $6,392 | $6,392 | $6,392 | 1 |
| Cranial and Peripheral Nerve Disorders with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Degenerative Nervous System Disorders with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Diabetes with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Endocrine Disorders with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Fractures of Hip and Pelvis without Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| GI Hemorrhage with CC | other | $6,392 | $6,392 | $6,392 | 1 |
| Hypertension with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Interstitial Lung Disease with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Intracranial Hemorrhage or Cerebral Infarction | other | $6,392 | $6,392 | $6,392 | 1 |
| Intracranial Hemorrhage OR Cerebral Infarction with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Kidney and Urinary Tract Neoplasms with Cc | other | $6,392 | $6,392 | $6,392 | 1 |
| Major Chest Trauma with Mcc | emergency | $6,392 | $6,392 | $6,392 | 1 |
| Major Gastrointestinal Disorders and Peritoneal Infections with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Multiple Sclerosis and Cerebellar Ataxia with Cc | other | $6,392 | $6,392 | $6,392 | 1 |
| Non-extensive Burns | other | $6,392 | $6,392 | $6,392 | 1 |
| Nontraumatic Stupor and Coma with Mcc | emergency | $6,392 | $6,392 | $6,392 | 1 |
| Acute Myocardial Infarction Discharged Alive with CC | cardiac | $6,412 | $4,794 | $8,030 | 2 |
| Bone Diseases and Arthropathies with Mcc | other | $6,462 | $1,598 | $11,325 | 2 |
| Acute Adjustment Reaction and Psychosocial Dysfunction | other | $6,618 | $5,043 | $8,193 | 2 |
| Multiple Sclerosis and Cerebellar Ataxia without Cc/mcc | other | $6,618 | $6,618 | $6,618 | 1 |
| Bone Diseases and Arthropathies without Mcc | other | $6,792 | $6,331 | $7,252 | 2 |
| Malignancy of Hepatobiliary System OR Pancreas with Cc | other | $6,808 | $6,808 | $6,808 | 1 |
| Aftercare, Musculoskeletal System and Connective Tissue with Cc | other | $6,860 | $6,392 | $7,327 | 2 |
| Aftercare, Musculoskeletal System and Connective Tissue with Mcc | other | $6,931 | $6,839 | $7,023 | 2 |
| Cellulitis with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Cirrhosis and Alcoholic Hepatitis with Cc | other | $7,023 | $7,023 | $7,023 | 1 |
| Cirrhosis and Alcoholic Hepatitis with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Coagulation Disorders | other | $7,023 | $7,023 | $7,023 | 1 |
| Complications of Treatment with Cc | other | $7,023 | $7,023 | $7,023 | 1 |
| Connective Tissue Disorders with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Disorders of Pancreas Except Malignancy with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| GI Hemorrhage with MCC | other | $7,023 | $7,023 | $7,023 | 1 |
| Heart Failure and Shock with MCC | cardiac | $7,023 | $7,023 | $7,023 | 1 |
| HIV with Major Related Condition with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Hypertensive Encephalopathy with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Inflammatory Bowel Disease with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Kidney and Urinary Tract Infections with MCC | other | $7,023 | $7,023 | $7,023 | 1 |
| Malignancy of Hepatobiliary System OR Pancreas with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Aftercare with Cc/mcc | other | $7,058 | $7,058 | $7,058 | 1 |
| Acute Myocardial Infarction Discharged Alive with MCC | cardiac | $7,160 | $4,794 | $9,526 | 2 |
| Foot Procedures with Cc | other | $7,200 | $7,200 | $7,200 | 1 |
| Hand Procedures for Injuries | other | $7,200 | $7,200 | $7,200 | 1 |
| Laparoscopic Cholecystectomy without Common Duct with CC | surgery | $7,200 | $7,200 | $7,200 | 1 |
| Local Excision and Removal of Internal Fixation Devices of Hip and Femur with... | surgery | $7,200 | $7,200 | $7,200 | 1 |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur without Cc/mcc | other | $7,200 | $7,200 | $7,200 | 1 |
| Major Hip and Knee Joint Replacement without MCC | surgery | $7,200 | $7,200 | $7,200 | 1 |
| Major Small and Large Bowel Procedures with MCC | surgery | $7,200 | $7,200 | $7,200 | 1 |
| Major Small and Large Bowel Procedures without CC/MCC | surgery | $7,200 | $7,200 | $7,200 | 1 |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $7,200 | $7,200 | $7,200 | 1 |
| Appendix Procedures with Cc | other | $7,279 | $3,600 | $10,958 | 2 |
| Biliary Tract Procedures Except Only Cholecystectomy with OR without C.d.e. w... | other | $7,393 | $7,200 | $7,586 | 2 |
| Benign Prostatic Hypertrophy with Mcc | other | $7,509 | $4,794 | $10,223 | 2 |
| Alcohol, Drug Abuse OR Dependence without Rehabilitation Therapy with Mcc | therapy | $7,626 | $6,724 | $8,528 | 2 |
| Hernia Repair (Umbilical) | surgery | $7,658 | $358 | $19,770 | 9 |
| Kidney and Ureter Procedures for Non-neoplasm with Cc | other | $7,722 | $7,722 | $7,722 | 1 |
| Angioplasty with Stent (PCI) | other | $7,950 | $22 | $160,325 | 33 |
| Minor Small and Large Bowel Procedures with Cc | other | $8,031 | $8,031 | $8,031 | 1 |
| Biopsies of Musculoskeletal System and Connective Tissue without Cc/mcc | other | $8,406 | $8,406 | $8,406 | 1 |
| Removal Tunneled Cv Cath | surgery | $8,480 | $8,480 | $8,480 | 1 |
| Major Thumb OR Joint Procedures | other | $8,590 | $8,590 | $8,590 | 1 |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures with Cc/mcc | other | $9,000 | $9,000 | $9,000 | 1 |
| Major Small and Large Bowel Procedures with CC | surgery | $9,000 | $9,000 | $9,000 | 1 |
| Acute Myocardial Infarction, Expired with Mcc | other | $9,106 | $1,598 | $16,614 | 2 |
| Adrenal and Pituitary Procedures with CC/MCC | surgery | $9,544 | $9,544 | $9,544 | 1 |
| Cervical Spinal Fusion without CC/MCC | surgery | $9,736 | $9,736 | $9,736 | 1 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $9,736 | $9,736 | $9,736 | 1 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $9,736 | $9,736 | $9,736 | 1 |
| Hernia Procedures Except Inguinal and Femoral with Cc | other | $9,736 | $9,736 | $9,736 | 1 |
| Hip and Femur Procedures except Major Joint with CC | surgery | $9,736 | $9,736 | $9,736 | 1 |
| Hip and Femur Procedures except Major Joint with MCC | surgery | $9,736 | $9,736 | $9,736 | 1 |
| Kidney and Ureter Procedures for Non-neoplasm with Mcc | other | $9,736 | $9,736 | $9,736 | 1 |
| Knee Procedures with Principal Diagnosis of Infection with Mcc | other | $9,736 | $9,736 | $9,736 | 1 |
| Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma | emergency | $9,736 | $9,736 | $9,736 | 1 |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $9,736 | $9,736 | $9,736 | 1 |
| Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders w... | lab | $10,099 | $9,736 | $10,462 | 2 |
| Integra 10x25cm | other | $10,127 | $10,127 | $10,127 | 1 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Cc | other | $10,572 | $7,200 | $13,944 | 2 |
| CABG (Heart Bypass Surgery) | other | $10,639 | $510 | $27,399 | 19 |
| Kcentra 1,000 Unit Injection V | other | $11,591 | $11,591 | $11,591 | 1 |
| Pacemaker Insertion | cardiac | $12,060 | $22 | $55,429 | 28 |
| Anchor Tissue to Bone | other | $12,062 | $12,062 | $12,062 | 1 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe without... | other | $12,095 | $12,095 | $12,095 | 1 |
| Adrenal and Pituitary Procedures without Cc/mcc | other | $12,225 | $12,225 | $12,225 | 1 |
| Biopsies of Musculoskeletal System and Connective Tissue with Cc | other | $12,740 | $9,736 | $15,744 | 2 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Mcc | other | $13,264 | $9,736 | $16,792 | 2 |
| Bilateral or Multiple Major Joint Procedures of Lower Extremity | surgery | $13,799 | $13,799 | $13,799 | 1 |
| Bacterial and Tuberculous Infections of Nervous System without Cc/mcc | other | $13,917 | $7,023 | $20,811 | 2 |
| Appendix Procedures with Mcc | other | $14,062 | $7,200 | $20,923 | 2 |
| Dermacell, Awm, Porous SQ Cm | other | $14,345 | $14,345 | $14,345 | 1 |
| Total Knee Replacement | surgery | $14,400 | $256 | $77,311 | 36 |
| Spinal Fusion | surgery | $14,401 | $1,075 | $352,263 | 31 |
| ERCP Duct Stent Placement | cardiac | $14,520 | $14,520 | $14,520 | 1 |
| Anal and Stomal Procedures with Mcc | other | $14,725 | $14,725 | $14,725 | 1 |
| Total Hip Replacement | surgery | $14,837 | $17 | $75,212 | 36 |
| Corneal Tissue Processing | other | $15,355 | $15,355 | $15,355 | 1 |
| Exactech Total Shoulder | other | $17,020 | $17,020 | $17,020 | 1 |
| Amputation for Musculoskeletal System and Connective Tissue Disorders with Cc | other | $17,022 | $17,022 | $17,022 | 1 |
| Drugs Unclassified Injection | other | $18,095 | $18,095 | $18,095 | 1 |
| Bacterial and Tuberculous Infections of Nervous System with Cc | other | $20,182 | $20,182 | $20,182 | 1 |
| Back and Neck Procedures except Spinal Fusion without CC/MCC | surgery | $20,644 | $20,644 | $20,644 | 1 |
| Heart Valve Replacement | other | $21,532 | $22 | $170,998 | 25 |
| Acute and Subacute Endocarditis with Mcc | other | $23,642 | $23,642 | $23,642 | 1 |
| Lifecell Strattice Tissue 16x2 | other | $26,226 | $26,226 | $26,226 | 1 |
| Aortic and Heart Assist Procedures Except Pulsation Balloon without Mcc | cardiac | $29,028 | $29,028 | $29,028 | 1 |
| Aortic and Heart Assist Procedures Except Pulsation Balloon with Mcc | cardiac | $33,878 | $33,878 | $33,878 | 1 |
| Aicd Generator Procedures | other | $39,859 | $39,859 | $39,859 | 1 |
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