5% dextrose/normal saline (500 ml = 1 unit) $ 0.01 5% … · analysis for detection of tumor marker...

Transparency Description 2019 Price

3D radiographic procedure with computerized image postprocessing 394.00$

5% dextrose/normal saline (500 ml = 1 unit) 0.01$

5% dextrose/water (500 ml = 1 unit) 0.12$

Abdominal ultrasound of pregnant uterus 412.75$

Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 414.25$

Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) 412.75$

Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus 631.50$

Abdominal ultrasound of pregnant uterus single or first fetus 631.50$

ACEBUTOLOL 200 MG CAPSULE [6512] 1.05$

ACEBUTOLOL 400 MG CAPSULE [6513] 1.39$

ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [6427] 0.83$

ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [114834] 0.21$

ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET [39227] 0.37$

ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION [134214] 0.15$


ACETAMINOPHEN 325 MG TABLET [2671] 0.03$

ACETAMINOPHEN 500 MG TABLET [2672] 0.01$


ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [114839] 0.12$

ACETAZOLAMIDE 250 MG TABLET [7412] 2.99$

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [44772] 4.45$

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [47973] 117.30$

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [2549] 0.41$

Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 0.42$

ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [56187] 0.26$

Activated protein resistance assay 132.00$

Acute digestive tract blood loss imaging 2,138.25$

Acute hepatitis panel 588.25$

ACYCLOVIR 200 MG CAPSULE [5086] 1.01$

ADH (antidiuretic hormone) level 241.75$

Administration of 1 vaccine 128.25$

Administration of first vaccine or toxoid component through 18 years of age with counseling 30.00$

Administration of hepatitis b vaccine 53.00$

Administration of influenza virus vaccine 54.50$

Administration of pneumococcal vaccine 61.74$

Administration of vaccine 97.75$

Administration of vaccine or toxoid component through 18 years of age with counseling 30.00$

Adrenocorticotropic hormone (ACTH) level 397.25$

Air and bone conduction assessment of hearing loss and speech recognition 162.00$

Air tone conduction hearing assessment screening 115.00$

Albumin (protein) level 73.00$

ALBUTEROL INHLTN SOL PER 1MG 10.00$

ALBUTEROL SULFATE 2 MG TABLET [647] 7.32$

ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER (PED) [613117] 3.33$

Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg 0.28$

Aldolase (enzyme) level 207.50$

Aldosterone hormone level 436.75$

ALENDRONATE 70 MG TABLET [45120] 21.24$

Alkaloids levels 59.75$

Allergy testing with drugs or biologicals into or within the skin, immediate type reaction, including test interpretation and report 106.00$

Allergy testing with venoms into or within skin, immediate type reaction, including test interpretation and report 38.00$

ALLOPURINOL 100 MG TABLET [6395] 0.28$

ALLOPURINOL 300 MG TABLET [6396] 0.76$

Alpha-1-antitrypsin (protein) blood test 197.50$

Alpha-fetoprotein (AFP) level, amniotic fluid 279.50$

Alpha-fetoprotein (AFP) level, serum 100.00$

ALPRAZOLAM 0.25 MG TABLET [668] 0.68$

ALPRAZOLAM 0.5 MG TABLET [669] 0.79$

Aluminum level 235.75$

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [35974] 0.10$

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [42579] 0.10$

Amantadine hydrochloride, oral, per 100 mg (for use in a medicare-approved demonstration project) 2.10$

Ambulatory continuous glucose (sugar) monitoring for a minimum of 72 hours 241.50$

AMI ACID 4.25% D5W SOL,1000ML 443.00$

AMI ACID 4.25% D5W SOL,2000ML 443.00$

Amikacin (antibiotic) level 293.50$

AMILORIDE 5 MG TABLET [6466] 0.28$

AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION [49112] 0.05$

Amino acid level, multiple amino acids 364.50$

Aminolevulinic acid (protein) level 197.50$

AMIODARONE 200 MG TABLET [5218] 0.37$

AMITRIPTYLINE 10 MG TABLET [6289] 0.33$

AMITRIPTYLINE 25 MG TABLET [6290] 0.66$

AMLODIPINE 10 MG TABLET [47061] 0.59$

AMLODIPINE 2.5 MG TABLET [45715] 0.41$

AMLODIPINE 5 MG TABLET [45846] 3.61$

AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION [7948] 0.53$

Ammonia level 168.75$

AMMONIUM LACTATE 12 % LOTION [20296] 0.04$

AMOXICILLIN 250 MG CAPSULE [2352] 0.13$

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [2366] 0.07$

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [45621] 2.97$

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION [44887] 0.90$

AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [38060] 0.72$

AMOXICILLIN 500 MG CAPSULE [2353] 0.21$


AMOXICILLIN 875 MG TABLET [28148] 0.95$


Amputation of foot 1,745.00$

Amylase (enzyme) level 146.75$

Analysis for antibody (IgM) to Cytomegalovirus (CMV) 196.25$

Analysis for antibody (IgM) to Toxoplasma (parasite) 219.50$

Analysis for antibody (IgM) to West Nile virus 128.00$

Analysis for antibody bacteria 366.25$

Analysis for antibody bordetella (respiratory bacteria) 49.50$

Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 53.75$

Analysis for antibody to aspergillus (fungus) 98.25$

Analysis for antibody to blastomyces (fungus) 98.25$

Analysis for antibody to Brucella (bacteria) 31.75$

Analysis for antibody to Coccidioides (bacteria) 98.25$

Analysis for antibody to Cytomegalovirus (CMV) 214.25$

Analysis for antibody to Diphtheria (bacteria) 214.25$

Analysis for antibody to Enterovirus (gastrointestinal virus) 246.75$

Analysis for antibody to Epstein-Barr virus (mononucleosis virus) 163.75$

Analysis for antibody to Giardia lamblia (intestinal parasite) 148.25$

Analysis for antibody to Helicobacter pylori (gastrointestinal bacteria) 56.25$

Analysis for antibody to helminth (intestinal worm) 200.00$

Analysis for antibody to Hepatitis D virus 219.50$

Analysis for antibody to Herpes simplex virus 110.75$

Analysis for antibody to Herpes simplex virus, type 1 83.00$

Analysis for antibody to Herpes simplex virus, type 2 51.25$

Analysis for antibody to histoplasma (fungus) 98.25$

Analysis for antibody to HIV -1 virus 100.75$

Analysis for antibody to Influenza virus 250.75$

Analysis for antibody to Leptospira 196.50$

Analysis for antibody to mumps virus 43.75$

Analysis for antibody to Mycoplasma (bacteria) 207.50$

Analysis for antibody to Rickettsia (bacteria) 67.75$

Analysis for antibody to Rubella (German measles virus) 145.25$

Analysis for antibody to Rubeola (measles virus) 43.75$

Analysis for antibody to Salmonella (intestinal bacteria) 46.00$

Analysis for antibody to tetanus bacteria (Clostridium tetanus) 231.50$

Analysis for antibody to Toxoplasma (parasite) 261.25$

Analysis for antibody to varicella-zoster virus (chicken pox) 105.00$

Analysis for antibody to virus 197.50$

Analysis for antibody to West Nile virus 128.00$

Analysis for antibody, Treponema pallidum 217.25$

Analysis for detection of tumor marker 234.25$

Analysis of substance using immunoassay technique 310.50$

Analysis using chemiluminescent technique (light and chemical )reaction 53.50$

Anastrozole, oral, 1 mg 4.20$

Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) 3,440.25$

Androstenedione (hormone) level 108.25$

ANES-BIER BLOCK 15 MIN 539.00$

ANES-GENERAL 15 MIN 539.00$

ANES-MAC 15MIN 319.75$

ANES-PARAVERT BLOCK 15 MIN 319.75$

ANES-REGIONAL BLOCK 15 MIN 319.75$

ANES-SPINAL 15MIN 319.75$

ANESTH GENERAL 1ST 15 MIN 539.00$

ANESTH GENRAL ADD 15 MIN 539.00$

ANES-WPIDURAL 15MIN 319.75$

Angiotensin l - converting enzyme (ACE) level 253.75$

Antibody evaluation 304.25$

Antibody identification test for platelet antibodies 419.50$

Antibody identification test for white blood cell antibodies 344.25$

Anti-inhibitor, per i.u. 2.69$

Antimicrobial study, mycobacteria (TB organism family) 215.50$

Antithrombin III antigen (clotting inhibitor) activity 201.75$

Antithrombin III antigen (clotting inhibitor) level 196.25$

APIXABAN 5 MG TABLET [135092] 8.70$

Apligraf, per square centimeter 114.75$

Apolipoprotein level 211.75$

Application of blood vessel compression or decompression device to 1 or more areas 67.50$

Application of cast to hand and lower forearm 260.00$

Application of cast, elbow to finger (short arm) 260.00$

Application of cast, shoulder to hand (long arm) 260.00$

Application of chemical agent to excessive wound tissue 372.75$

Application of electrical stimulation to 1 or more areas, each 15 minutes 77.00$

Application of hot or cold packs to 1 or more areas 67.50$

Application of hot wax bath to 1 or more areas 30.75$

Application of long arm splint (shoulder to hand) 254.25$

Application of long leg cast (thigh to toes) 210.00$

Application of long leg splint (thigh to ankle or toes) 384.75$

Application of mechanical traction to 1 or more areas 72.00$

Application of medication through skin using electrical current, each 15 minutes 98.75$

Application of moveable, hinged short arm splint (forearm to hand) 369.75$

Application of nerve stimulator electrodes to skin surface 240.50$

Application of non-moveable, hinged finger splint 254.25$

Application of non-moveable, short arm splint (forearm to hand) 281.75$

Application of rigid total contact leg cast 492.00$

Application of short leg cast (below knee to toes) 260.00$

Application of short leg splint (calf to foot) 254.00$

Application of skin substitute (wound surface up to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes193.00$

Application of skin substitute (wound surface up to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 25 sq cm or less)2,361.50$

Application of skin substitute (wound surface up to 100 sq cm) to trunk, arms, or legs 846.00$

Application of skin substitute (wound surface up to 100 sq cm) to trunk, arms, or legs (first 25 sq cm or less) 2,361.50$

Application of ultrasound to 1 or more areas, each 15 minutes 79.00$

Application of vein wound compression system lower leg below knee including ankle and foot 253.25$

APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE [49077] 34.53$

APREPITANT 40 MG CAPSULE [87882] 147.01$

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [90429] 10.08$

ARGON FOCAL LASER 1,902.50$

ARIPIPRAZOLE 10 MG TABLET [52490] 33.29$





ARMSTRONG BEVELED VENT 140242 114.50$

Arsenic level 299.00$

Arterial puncture withdrawal of blood for diagnosis 113.50$

ASCORBIC ACID (VITAMIN C) 500 MG TABLET [5289] 0.04$

ASENAPINE 5 MG SUBLINGUAL TABLET [113444] 24.92$

ASP/INJ RENAL CYST/PELVIS 1,332.75$

Aspiration and/or injection of cysts 304.50$

Aspiration and/or injection of intermediate joint or joint capsule with recording and reporting using ultrasound guidance 450.00$

Aspiration and/or injection of large joint or joint capsule 582.75$

Aspiration and/or injection of major joint or joint capsule with recording and reporting using ultrasound guidance 450.00$

Aspiration and/or injection of medium joint or joint capsule 370.50$

Aspiration and/or injection of small joint or joint capsule 520.75$

Aspiration and/or injection of small joint or joint capsule with recording and reporting using ultrasound guidance 450.00$

Aspiration and/or injection of thyroid cyst 892.00$

Aspiration of abscess, blood accumulation, blister, or cyst 285.00$

Aspiration of bladder with insertion of bladder tube to skin surface 4,785.75$

Aspiration of fluid from sac that covers the heart 1,543.50$

ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE [44176] 10.84$

ASPIRIN 300 MG RECTAL SUPPOSITORY [10039] 1.51$

ASPIRIN 325 MG TABLET [5278] 0.06$

ASPIRIN 325 MG TABLET,DELAYED RELEASE [5455] 0.01$

ASPIRIN 81 MG CHEWABLE TABLET [31359] 0.02$

ASPIRIN 81 MG TABLET,DELAYED RELEASE [30082] 0.01$

ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TABLET [49371] 0.03$

Assessment and recording of balance system during hot and cold irrigation of both ears 440.00$

Assessment of eardrum and muscle function 162.00$

Assessment of hearing loss and speech recognition 38.00$

Assessment of hearing loss with placement of probe in ear to assess ear bone contraction 38.00$

Assessment of speech hearing loss 38.00$

ATENOLOL 25 MG TABLET [656] 0.83$

ATENOLOL 50 MG TABLET [657] 0.93$

ATOMOXETINE 40 MG CAPSULE [52510] 17.83$

ATOMOXETINE 60 MG CAPSULE [52511] 17.83$

ATORVASTATIN 10 MG TABLET [44642] 0.31$




ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION [4124] 2.05$

ATROPINE 1 % EYE DROPS [2911] 15.96$

Attempt to restart heart and lungs 641.00$

Attention functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Attention functional limitation, discharge status at discharge from therapy or to end reporting 0.25$

Attention functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

Automated urinalysis test 38.25$

Automated white blood cell count 75.25$

Azathioprine, oral, 50 mg 2.43$

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [48640] 3.64$

AZITHROMYCIN 1 GRAM ORAL PACKET [49573] 30.23$

AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [48236] 2.41$

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [48737] 2.41$

AZITHROMYCIN 250 MG TABLET [44705] 7.67$

AZITHROMYCIN 500 MG TABLET [52022] 16.16$

AZTREONAM 1 GRAM SOLUTION FOR INJECTION [48634] 41.04$

AZTREONAM 2 GRAM SOLUTION FOR INJECTION [47326] 83.38$

BACITRACIN 50,000 UNIT INTRAMUSCULAR SOLUTION [1180] 13.81$

BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [5858] 0.18$

BACITRACIN ZINC 500 UNIT/GRAM TOPICAL PACKET [53345] 0.11$

BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [8855] 7.62$

BACLOFEN 10 MG TABLET [5192] 0.48$

Bacterial blood culture 243.25$

Bacterial colony count, urine 125.50$

Bacterial culture 243.25$

Bacterial culture for aerobic isolates 87.25$

Bacterial culture for anaerobic isolates 145.25$

Bacterial urine culture 177.00$

BAG LEG DISP LARGE 8.75$

BAG LEG DISP SM 8.75$

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [55404] 0.57$

BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH [55538] 0.76$

Balloon dilation of arteries in one leg, endovascular, accessed through the skin or open procedure 13,961.75$

Balloon dilation of artery in one leg, endovascular, accessed through the skin or open procedure 8,040.75$

Balloon dilation of artery in one side of groin, endovascular, accessed through the skin or open procedure 11,892.50$

Balloon dilation of artery of one leg, endovascular, accessed through the skin or open procedure 13,962.75$

Balloon dilation of groin artery, endovascular, open, or percutaneous approach 13,086.25$

Balloon dilation of pancreatic or bile duct using an endoscope 4,152.00$

BALSAM PERU-CASTOR OIL 87 MG-788 MG/GRAM TOPICAL OINTMENT [114689] 0.65$

Bcg (intravesical) per instillation 195.62$

B-COMPLEX WITH VITAMIN C TABLET [38958] 0.05$

BECLOMETHASONE DIPROP 80 MCG/ACTUATION HFA BREATH ACTIVATED AEROSOL [159341] 26.63$

Behavioral and qualitative analysis of voice and resonance 226.25$

BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [49308] 34.72$

BENAZEPRIL 10 MG TABLET [41881] 0.99$

BENZOCAINE 20 % MUCOSAL GEL [20266] 0.82$

BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL [44713] 0.10$

BENZOIN-ALOE VERA-STORAX-TOLU BALSAM 10 %-2 %-8 %-4 % TOPICAL TINCTURE [97758] 0.10$

BENZONATATE 100 MG CAPSULE [2339] 0.29$

BENZTROPINE 1 MG TABLET [6435] 0.61$

Beta-2 microglobulin (protein) level 166.25$

BETHANECHOL CHLORIDE 10 MG TABLET [41387] 2.08$

BICALUTAMIDE 50 MG TABLET [44166] 19.26$

Bilirubin level 87.25$

Biofeedback training, perineal muscles, anorectal or urethral sphincter 162.00$

BIOFIX 121560 1.5X 60 604.00$

Biopsy and scraping of the cervix using an endoscope 314.00$

Biopsy of breast accessed through the skin with stereotactic guidance 2,045.25$

Biopsy of breast accessed through the skin with ultrasound guidance 2,726.50$

Biopsy of cervix or excision of local growths 100.00$

Biopsy of cervix using an endoscope 2,326.00$

Biopsy of each additional growth of skin and/or tissue 80.00$

Biopsy of external female genitals 314.00$

Biopsy of eyelid 326.00$

Biopsy of one lobe of lung using an endoscope 4,020.75$

Biopsy of prostate gland 2,719.75$

Biopsy of rectum and large bowel using an endoscope 1,916.25$

Biopsy of roof of mouth 2,080.00$

Biopsy of single growth of skin and/or tissue 372.75$

Biopsy of small bowel using an endoscope 2,012.00$

Biopsy of tongue 550.00$

Biopsy of uterine lining 176.00$

Biopsy or removal of nasal polyp or tissue using an endoscope 1,490.00$

BISACODYL 10 MG RECTAL SUPPOSITORY [26910] 0.09$

BISACODYL 5 MG TABLET,DELAYED RELEASE [5759] 0.03$

BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION [47305] 0.01$

BISOPROLOL FUMARATE 5 MG TABLET [28177] 2.34$

BISOPROLOL-HYDROCHLOROTHIAZIDE 7.26$

Bladder instillation of cancer preventive, inhibiting, or suppressive agent 1,002.75$

Bladder irrigation and/or instillation 258.00$

Blood chloride level 95.25$

Blood creatinine level 79.00$

Blood gases measurement 310.50$

Blood glucose (sugar) level 65.25$

Blood glucose (sugar) level after receiving dose of glucose 88.75$

Blood glucose (sugar) measurement using reagent strip 59.25$

Blood glucose (sugar) test performed by hand-held instrument 15.00$

Blood glucose (sugar) tolerance test 189.50$

Blood group typing (ABO) 68.75$

Blood osmolality (concentration) measurement 110.75$

Blood pH level 75.25$

Blood potassium level 75.25$

Blood sodium level 65.25$

Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide) 136.00$

Blood test, basic group of blood chemicals 158.25$

Blood test, clotting time 49.00$

Blood test, comprehensive group of blood chemicals 230.00$

Blood test, lipids (cholesterol and triglycerides) 186.50$

Blood test, thyroid stimulating hormone (TSH) 136.00$

Blood typing for red blood cell antigens 304.25$

Blood typing for Rh (D) antigen 49.00$

Blood unit compatibility test 138.75$

Blood viscosity measurement 88.75$

Body fluid cell count with cell identification 138.75$

Body fluid pH level 24.25$

Bone and/or joint imaging, 3 phase study 2,597.50$

Bone and/or joint imaging, whole body 2,104.50$

Bone density measurement using dedicated X-ray machine 466.75$

Bone marrow biopsy 2,045.25$

BRAVO PH CAPSULE 703.75$

Breast pump, hospital grade, electric (ac and / or dc), any type 293.50$

BREXPIPRAZOLE 0.5 MG TABLET [147953] 46.06$

BREXPIPRAZOLE 1 MG TABLET [147954] 46.06$

BREXPIPRAZOLE 4 MG TABLET [147957] 46.06$

BRIMONIDINE 0.1 % EYE DROPS [86277] 36.39$



BRINZOLAMIDE 1% OPHTH DPS, 10M 406.83$

BROMOCRIPTINE 2.5MG TAB 7.26$

BRONCHOSCOPY DIAGNOSTIC 4,020.75$

BRONCHOSCOPY FLEX W/BIOPSY 4,020.75$

BRONCHOSCOPY FLEX W/BRUSHING 4,020.75$

BRONCHOSCOPY W/NEEDLE ASP/BX 4,020.75$

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [48023] 4.89$

Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 0.5 mg 5.75$

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [3333] 0.84$

BUMETANIDE 1 MG TABLET [5999] 0.42$

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [3287] 0.07$

BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [3290] 0.23$

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [3292] 0.26$

BUPIVACAINE 0.0625%-FENTANYL 2 MCG/ML-EPINEPHRINE 1.25 MCG/ML EPIDURAL INTERMITTENT DOSING IN NS 150 ML PYXIS (AC) [614835] 0.04$

BUPIVACAINE 0.1%-FENTANYL 2 MCG/ML EPIDURAL CLINICIAN DOSE [616277] 0.04$

BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [53067] 0.50$

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [53065] 0.29$

BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [4267] 0.32$

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM [118317] 5.66$

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [52705] 4.30$

BUPROPION HCL 100 MG TABLET [5119] 2.04$

BUPROPION HCL 75 MG TABLET [5118] 1.61$

BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [41898] 1.75$

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [41899] 1.88$

BUPROPION XL 150 MG TAB [53708] 4.83$

BUSPIRONE 10 MG TABLET [28850] 1.41$

BUSPIRONE 5 MG TABLET [28849] 0.81$

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET [5165] 1.75$

BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE [41145] 1.76$

BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY [45401] 1.46$

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [9080] 10.90$

Calcitonin (hormone) level 326.25$

CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [46963] 33.25$

CALCITRIOL 0.25 MCG CAPSULE [29853] 1.33$

CALCIUM ACETATE 667 MG TABLET [45815] 0.16$

CALCIUM ACETATE 667MG TAB 7.26$

CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET [9859] 0.07$

CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET [82334] 0.05$

CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABLET [32875] 0.04$

CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [3903] 0.84$

CALCIUM CITRATE-VITAMIN D 315M 7.26$

Calcium level 178.25$

CALCIUM POLYCARBOPHIL 625 MG TABLET [47666] 0.13$

Capecitabine, oral, 500 mg 56.27$

CAPSULAR TENSION RING 681.50$

CAPTOPRIL 12.5 MG TABLET [5092] 1.26$

CAPTOPRIL 50 MG TABLET [5094] 2.11$

CARBACHOL 0.01 % INTRAOCULAR SOLUTION [47535] 24.46$

CARBAMAZEPINE 100 MG CHEWABLE TABLET [5152] 0.68$

CARBAMAZEPINE 200 MG TABLET [5099] 1.66$

CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [81365] 1.85$

Carbamazepine level 257.25$

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [23259] 0.10$

CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [5120] 1.26$



CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [42932] 0.87$

Carbohydrate deficient transferrin (protein) level 479.00$

Carbon dioxide (bicarbonate) level 93.00$

CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [49618] 441.41$

Carboxyhemoglobin (protein) level 170.00$

CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [49604] 0.65$

Carcinoembryonic antigen (CEA) protein level 239.00$

Cardiac output measurements 232.50$

Cardiolipin antibody (tissue antibody) measurement 250.75$

Cardioverter-defibrillator, dual chamber (implantable) 63,526.50$

Cardioverter-defibrillator, other than single or dual chamber (implantable) 101,805.75$

Cardioverter-defibrillator, single chamber (implantable) 52,939.25$

CARISOPRODOL 350 MG TABLET [7375] 0.23$

Carnitine level 67.00$

Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

CARVEDILOL 12.5 MG TABLET [44354] 2.21$

CARVEDILOL 25 MG TABLET [44195] 2.21$



Cast supplies, long arm cast, pediatric (0-10 years), fiberglass 25.00$

Cast supplies, short arm cast, adult (11 years +), fiberglass 30.00$

Cast supplies, short leg cast, pediatric (0-10 years), fiberglass 45.00$

Catecholamines (organic nitrogen) level 350.00$

CATH FOLEY SIL 2 WAY 14 FR 5CC 15.25$

CATH KIT MAN 10 FR. 19.5 466.75$

CATHETER 12 FR 22.25$

Catheter, electrophysiology, diagnostic, other than 3d mapping (19 or fewer electrodes) 1,557.00$

Catheter, guiding (may include infusion/perfusion capability) 122.00$

Catheter, hemodialysis/peritoneal, long-term 618.75$

Catheter, hemodialysis/peritoneal, short-term 230.00$

Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis) 723.50$

Catheter, thrombectomy/embolectomy 3,868.75$

Catheter, transluminal angioplasty, drug-coated, non-laser 5,904.00$

Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion capability) 1,018.50$

Catheter, transluminal atherectomy, directional 6,700.25$

CEFDINIR 250 MG/5 ML ORAL SUSPENSION [56375] 1.72$

CEFDINIR 300 MG CAPSULE [49074] 5.31$

CEFUROXIME AXETIL 250 MG TABLET [30665] 4.57$

CELECOXIB 200 MG CAPSULE [40379] 15.02$

Cell examination of body fluid 214.25$

Cell examination of specimen 201.75$

CELLSAVER REPROFUSION PROCEDUR 2,753.25$

CEPACOL (MENTHOL)3MG LOZENGE 1.04$

CEPHALEXIN 250 MG CAPSULE [209] 0.72$

CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [384] 0.30$

CEPHALEXIN 500 MG CAPSULE [227] 1.43$

Cerebrospinal fluid, or amniotic fluid albumin (protein) level 146.75$

Ceruloplasmin (protein) level 113.50$

Cervicovaginal secretion of placenta protein 202.75$

Cesarean delivery 2,728.50$

CHANGE NEPHROSTOMY TUBE 2,595.25$

Change of breathing tube of windpipe in neck 260.00$

Change of stomach feeding, accessed through the skin 1,076.75$

Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

Chemical analysis using chromatography technique 218.75$

Chemical analysis using spectrophotometry (light) 203.50$

Chemical receptor analysis 652.50$

Chemical test for genetic disorder 67.00$

Chest ultrasound examination of heart 949.75$

Childbirth preparation/lamaze classes, non-physician provider, per session 20.25$

CHLORDIAZEPOXIDE 25 MG CAPSULE [9168] 0.44$

CHLORDIAZEPOXIDE 5 MG CAPSULE [9167] 0.37$

CHLORDIAZEPOXIDE-CLIDINIUM 5 MG-2.5 MG CAPSULE [6756] 5.34$

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [84608] 0.03$

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [8511] 0.02$

Chloride level 67.50$

CHLORPROMAZINE 25 MG TABLET [7440] 9.92$

CHLORTHALIDONE 25 MG TABLET [5966] 2.38$

CHLORZOXAZONE 500 MG TABLET [30935] 1.12$

CHOLECALCIFEROL (VITAMIN D3) 1,000 UNIT TABLET [88837] 0.05$

CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET [49223] 0.29$

CHOLECALCIFEROL (VITAMIN D3) 5,000 UNIT TABLET [112436] 0.34$

Cholesterol level 122.25$

CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET [53595] 3.48$

Cholinesterase (enzyme) level 168.75$

CHONDROITIN-SOD HYALURON 3 %-4 %(0.5 ML)1 %(0.55 ML)INTRAOCULAR SYRING [44754] 207.32$

Chromium level to test for poisoning or deficiency 276.50$

Chromosome analysis for genetic defects 882.25$

CH-SODIUM CHLORIDE 0.9%IV SOL 32.95$

CH-SODIUM CHLORIDE/0.9% IV SOL 32.95$

CILOSTAZOL 100 MG TABLET [43441] 1.89$

CINACALCET 30 MG TABLET [55310] 33.49$

CIPROFLOXACIN 0.3 % EYE DROPS [42747] 10.39$

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [53566] 36.30$

CIPROFLOXACIN 250 MG TABLET [39995] 5.67$

CIPROFLOXACIN 500 MG TABLET [39996] 3.30$

CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [47334] 3.91$

CITALOPRAM 20 MG TABLET [43432] 2.65$

Citrate level 406.00$

CLARITHROMYCIN 500 MG TABLET [44878] 6.24$

CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [3755] 0.90$

CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [30476] 0.43$

CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [30477] 0.53$

CLINDAMYCIN HCL 150 MG CAPSULE [5201] 1.19$

CLOBETASOL 0.05 % TOPICAL CREAM [5904] 8.87$

CLOMIPRAMINE 25 MG CAPSULE [5170] 11.67$

CLONAZEPAM 0.5 MG TABLET [5159] 0.07$

CLONAZEPAM 1 MG TABLET [5160] 0.94$

CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [44448] 34.41$



CLONIDINE HCL 0.1 MG TABLET [653] 0.24$

CLONIDINE HCL 0.2 MG TABLET [654] 0.09$

CLOPIDOGREL 300 MG TABLET [102007] 28.90$

CLOPIDOGREL 75 MG TABLET [45777] 8.03$

Closed treatment of ankle dislocation 1,250.50$

Closed treatment of broke forearm bone at elbow 215.00$

Closed treatment of broken ankle 297.00$

Closed treatment of broken ankle joint bone 215.00$

Closed treatment of broken ankle with manipulation 1,701.75$

Closed treatment of broken chest bone 150.00$

Closed treatment of broken finger or thumb 382.00$

Closed treatment of broken finger or thumb with manipulation 396.00$

Closed treatment of broken foot bone 215.00$

Closed treatment of broken forearm bone 215.00$

Closed treatment of broken forearm bone at elbow 215.00$

Closed treatment of broken forearm bone at elbow with manipulation 2,013.00$

Closed treatment of broken forearm bones 297.00$

Closed treatment of broken forearm bones with manipulation 1,441.25$

Closed treatment of broken great toe 215.00$

Closed treatment of broken heel bone 297.00$

Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 1,441.25$

Closed treatment of broken shin bone 297.00$

Closed treatment of broken shin bone with manipulation 2,835.00$

Closed treatment of broken spine bones with casting or bracing 430.00$

Closed treatment of broken toe 345.00$

Closed treatment of broken toe with manipulation 727.75$

Closed treatment of broken upper arm bone at shoulder 215.00$

Closed treatment of broken upper arm bone with manipulation 4,798.50$

Closed treatment of broken wrist bone 215.00$

Closed treatment of collar bone broken with manipulation 2,835.00$

Closed treatment of collar bone fracture 215.00$

Closed treatment of dislocated finger joint with manipulation 374.75$

Closed treatment of dislocated foot joint 374.75$

Closed treatment of dislocated forearm bone of elbow, child 1,190.75$

Closed treatment of dislocated hand joint with manipulation 374.50$

Closed treatment of dislocated hip prosthesis 550.00$

Closed treatment of dislocation of joint between collar and chest bones with manipulation 420.00$

Closed treatment of dislocation of knee cap 727.75$

Closed treatment of fracture and/or dislocation of pelvis and/or sacrum 400.00$

Closed treatment of fracture hand bone 215.00$

Closed treatment of fracture of bone of hand with manipulation 1,190.75$

Closed treatment of fracture of shin bone 215.00$

Closed treatment of fracture of upper arm bone at shoulder joint 297.00$

Closed treatment of growth plate or broken upper arm bone at elbow 297.00$

Closed treatment of hip socket fractures 150.00$

Closed treatment of jaw temporomandibular joint (TMJ) dislocation 727.75$

Closed treatment of knee cap fracture 215.00$

Closed treatment of shoulder dislocation and broken of upper arm bone with manipulation 1,440.25$

Closed treatment of shoulder dislocation with manipulation 727.75$

Closed treatment of shoulder dislocation with manipulation under anesthesia 3,646.25$

Closed treatment of upper arm fracture 215.00$

Closure device, vascular (implantable/insertable) 814.75$

Closure of tear duct opening using plug 392.00$

CLOTRIMAZOLE 1 % TOPICAL CREAM [6666] 0.59$

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [41550] 1.40$

Clotting factor II prothrombin, measurement 237.50$

Clotting factor inhibitor test 237.50$

Clotting factor IX (PTC or Christmas) measurement 187.75$

Clotting factor V (AcG or proaccelerin) measurement 435.25$

Clotting factor VIII (AHG) measurement 478.00$

Clotting factor VIII (von Willebrand factor) measurement 301.25$

Clotting factor VIII (VW factor) antigen 435.25$

Clotting factor VIII (VW factor) measurement 591.75$

Clotting factor X (Stuart-Prower) measurement 145.25$

Clotting factor X assessment test 280.50$

Clotting factor XI (PTA) measurement 180.00$

Clotting factor XII (Hageman) measurement 178.25$

Clotting factor XIII (fibrin stabilizing) measurement 141.50$

CLOZAPINE 100 MG TABLET [6014] 3.56$

Clozapine level 324.50$

Clozapine, 25 mg 1.37$

Coagulation assessment blood test 158.25$

Coagulation function measurement 178.25$

Coagulation function screening test with interpretation and report 20.00$

Coagulation time measurement 14.50$

COCAINE 4 % TOPICAL SOLUTION [2556] 57.89$

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [39878] 0.13$

CODEINE SULFATE 30 MG TABLET [2165] 1.07$

COLCHICINE 0.6 MG TABLET [3725] 6.99$

COLESEVELAM 625 MG TABLET [47047] 4.32$

Collagen cross links test, (urine test to evaluate bone health) 465.25$

Collection of blood specimen from a completely implantable venous access device 191.25$

Collection of blood specimen from central or peripheral venous catheter 236.25$

COLONOSCOPY 1,796.75$

COLONOSCOPY W/ BIOPSY 2,158.50$

Community or work reintegration training, each 15 minutes 132.50$

Complete blood cell count (red cells, white blood cell, platelets), automated test 79.00$

Complex control of nose bleed 727.75$

Computerized mapping of corneal curvature 70.00$

Concentration of specimen for infectious agents 105.00$

Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 148.75$

Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 326.25$

Connective tissue, human (includes fascia lata) 5,171.00$

Control of bleeding in large bowel using an endoscope 2,514.25$

Control of bleeding in small bowel using an endoscope 3,109.50$

Control of nasal bleeding using an endoscope 1,490.00$

Control of nose bleed and insertion of packing 727.75$

Conversion to two chamber pacemaker system 35,412.00$

Copper level 199.25$

Cortisol (hormone) measurement 308.25$

C-peptide (protein) level 271.25$

Creatine kinase (cardiac enzyme) level 166.25$

Creatinine clearance measurement to test for kidney function 158.25$

Creatinine level to test for kidney function or muscle injury 95.25$

Critical care delivery critically ill or injured patient 719.25$

Critical care delivery critically ill or injured patient, first 30-74 minutes 1,870.50$

Cryoglobulin (protein) measurement 119.50$

Crystal identification from tissue or body fluid 98.75$

CT scan abdomen 1,898.25$

CT scan abdomen before and after contrast 2,940.25$

CT scan abdomen with contrast 2,352.00$

CT scan chest 1,894.75$

CT scan chest with contrast 2,401.50$

CT scan head or brain 1,941.25$

CT scan head or brain before and after contrast 1,102.50$

CT scan head or brain with contrast 2,431.50$

CT scan leg 1,876.50$

CT scan leg with contrast injection 2,199.75$

CT scan of abdomen and pelvis 716.75$

CT scan of abdomen and pelvis before and after contrast 2,042.25$

CT scan of abdomen and pelvis with contrast 2,042.00$

CT scan of abdominal and pelvic blood vessels with contrast 1,633.50$

CT scan of abdominal aorta and both leg arteries with contrast 4,970.00$

CT scan of abdominal blood vessels with contrast 3,087.00$

CT scan of arm 1,835.50$

CT scan of arm blood vessels with contrast 2,441.50$

CT scan of arm with contrast 2,017.75$

CT scan of blood vessel of head with contrast 1,102.50$

CT scan of blood vessels in chest with contrast 2,621.75$

CT scan of cranial cavity 1,788.25$

CT scan of cranial cavity before and after contrast 2,095.00$

CT scan of cranial cavity with contrast 1,965.75$

CT scan of face 1,720.75$

CT scan of face before and after contrast 2,670.25$

CT scan of face with contrast 2,136.75$

CT scan of heart blood vessels and grafts with contrast dye 1,411.50$

CT scan of heart structure with contrast 447.50$

CT scan of lower leg blood vessels with contrast 3,437.75$

CT scan of lower spine 2,639.50$

CT scan of lower spine before and after contrast 3,193.50$

CT scan of lower spine with contrast 2,901.75$

CT scan of middle spine 1,991.75$

CT scan of middle spine with contrast 2,189.25$

CT scan of neck 2,150.00$

CT scan of neck before and after contrast 2,624.50$

CT scan of neck blood vessels with contrast 1,102.50$

CT scan of neck with contrast 2,387.25$

CT scan of pelvic blood vessels with contrast 2,878.75$

CT scan of pelvis before and after contrast 2,617.25$

CT scan of upper spine 1,997.75$

CT scan of upper spine with contrast 2,498.25$

CT scan pelvis 1,857.25$

CT scan pelvis with contrast 2,229.25$

Culture for acid-fast bacilli 239.00$

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [26173] 0.05$

CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET [5291] 0.02$

Cyanocobalamin (vitamin B-12) level 185.00$

CYCLOBENZAPRINE 10 MG TABLET [6480] 1.01$

CYCLOPENTOLATE 2 % EYE DROPS [47437] 10.13$

Cyclophosphamide, 100 mg 1,710.49$

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [52797] 10.57$

Cyclosporine level 288.50$

CYCLOSPORINE PER 25MG, 25MG CA 7.26$

CYPROHEPTADINE 4 MG TABLET [5816] 1.11$

DABIGATRAN ETEXILATE 150 MG CAPSULE [119046] 8.31$

DABIGATRAN ETEXILATE 75 MG CAPSULE [119358] 8.31$

Dacarbazine, 100 mg 14.94$

DANTROLENE 25 MG CAPSULE [44539] 2.01$

DBX MIX 10CC 3,590.25$

DBX MIX 5CC 2,291.75$

DBX PUTTY 2.5CC 1,026.00$

DBX PUTTY 5CC 1,872.25$

Declotting infusion of implanted central venous access device or catheter 867.00$

Dehydroepiandrosterone (DHEA) hormone level 203.50$

Dehydroepiandrosterone (DHEA-S) hormone level 207.50$

Demonstration and/or evaluation of manual maneuvers to chest wall to assist movement of lung secretions 250.75$

Demonstration and/or evaluation of patient use of aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device187.00$

DEPUY 1 GENTAMICIN BN CMNT 40G 829.25$

DESMOPRESSIN 0.2 MG TABLET [45242] 7.90$

Destruction of 15 or more skin growths 282.00$

Destruction of 2-14 skin growths 35.00$

Destruction of extensive growths of external female genitals 2,672.00$

Destruction of external female genital growths 1,764.00$

Destruction of growths on esophagus, stomach, and/or upper small bowel using an endoscope 2,385.00$

Destruction of peripheral nerve or branch 1,028.00$

Destruction of skin growth 206.00$

Destruction of up to 14 skin growths 147.00$

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [102745] 12.40$

Detection of infectious agent antibody 229.75$

Detection test for candida species (yeast) 67.00$

Detection test for chlamydia 162.00$

Detection test for clostridium difficile 129.50$

Detection test for cryptosporidium (parasite) 125.50$

Detection test for Cytomegalovirus (CMV) 352.25$

Detection test for cytomegalovirus, quantification 356.50$

Detection test for entamoeba histolytica group (parasite) 59.25$

Detection test for enterovirus (intestinal virus) 559.25$

Detection test for gardnerella vaginalis (bacteria) 67.00$

Detection test for Hepatitis B surface antigen 47.25$

Detection test for Hepatitis B virus 755.25$

Detection test for Hepatitis Be surface antigen 171.75$

Detection test for Hepatitis C virus 694.50$

Detection test for herpes simplex virus 802.50$

Detection test for histoplasma capsulatum (parasite) 241.50$

Detection test for HIV-1 virus 637.50$

Detection test for identification of organism 42.25$

Detection test for influenza A virus 73.00$

Detection test for influenza B virus 73.00$

Detection test for multiple types influenza virus 257.50$

Detection test for multiple types of respiratory virus 1,454.75$

Detection test for Neisseria gonorrhoeae (gonorrhoeae bacteria) 129.50$

Detection test for organism 505.50$

Detection test for respiratory syncytial virus 181.75$

Detection test for Rotavirus 399.50$

Detection test for Strep (Streptococcus, group A) 152.75$

Detection test for Streptococcus, group B (bacteria) 113.50$

Detection test for Trichomonas vaginalis (genital parasite) 162.00$

Determination of lung volumes using gas dilution or washout 409.25$

Determination of lung volumes using plethysmography 383.75$

DEXAMETHASONE 4 MG TABLET [2624] 1.25$

Dexamethasone, oral, 0.25 mg 0.21$

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [136578] 1.05$

DEXTRAN 70-HYPROMELLOSE 0.1 %-0.3 % EYE DROPS [122778] 0.16$

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET [30497] 1.78$

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP [5559] 0.37$

DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [6297] 0.58$

DEXTROSE 1.5% PERITONEAL SOLN, 241.00$

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [3922] 0.01$

DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [4189] 1.04$

DEXTROSE 40 % ORAL GEL [45232] 0.11$

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [31255] 0.20$

DEXTRSE 2.5% PERIT SOLN,2500ML 369.25$

DEXTRSE 4.25% PERITSOLN,2500ML 443.00$

Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes 75.00$

Diabetes outpatient self-management training services, individual, per 30 minutes 72.75$

Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) 90.25$

Diagnostic examination of ear and nose 27.00$

Diagnostic examination of nasal passages using an endoscope 247.00$

Diagnostic examination of the bladder and bladder canal (urethra) using an endoscope 560.00$

Diagnostic examination of voice box using flexible endoscope 247.00$

Diagnostic imaging of optic nerve of eye 70.00$

Diagnostic imaging of retina 70.00$

Diagnostic test for sleep disorder 3,763.50$

Diagnostic testing in a pulmonary function lab 364.50$

DIAZEPAM 10 MG TABLET [652] 0.44$


DIAZEPAM 2.5 MG RECTAL KIT [48418] 292.24$


DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT [84557] 346.68$

DICLOFENAC 1 % TOPICAL GEL [102842] 0.57$

DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE [2631] 1.53$

DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE [2632] 1.84$

DICYCLOMINE 10 MG CAPSULE [5721] 0.62$

DICYCLOMINE 20 MG TABLET [5702] 0.62$

DIGOXIN 125 MCG TABLET [10285] 15.47$

Digoxin level 206.00$

Dihydroxyvitamin D, 1, 25 level 316.50$

Dilation of kidney and/or urinary duct (ureter) with creation of drainage tract, accessed through the skin 5,105.00$

Dilation of tear-drainage opening 114.00$

DILTIAZEM 30 MG TABLET [479] 0.47$

DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [3294] 0.39$

DILTIAZEM 60 MG TABLET [480] 0.75$

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [5082] 4.12$

DILTIAZEM SR 120 MG 24 HR CAP [42210] 1.24$



DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [47783] 381.43$

DIPHENHYDRAMINE - MYLANTA DS - LIDOCAINE VISCOUS [612717] 0.03$

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [47470] 0.19$

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [5549] 0.01$

Diphenhydramine hydrochloride, 50 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen0.09$

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [40864] 0.50$

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2566] 1.45$

DIPYRIDAMOLE 25 MG TABLET [686] 0.40$

Direct admission of patient for hospital observation care 808.25$

DISCISSION 2ND CATARACT 1,662.00$

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [49173] 1.47$

DIVALPROEX 125 MG TABLET,DELAYED RELEASE [47640] 0.92$



DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [52500] 2.54$

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [47489] 3.98$

DOCOSANOL 10 % TOPICAL CREAM [44106] 9.63$

DOCUSATE SODIUM 100 MG CAPSULE [6249] 0.18$

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [5553] 0.07$

DOFETILIDE 125 MCG CAPSULE [45509] 8.89$



DONEPEZIL 10 MG TABLET [45035] 8.08$

DONEPEZIL 5 MG TABLET [44390] 8.08$

Doppler ultrasound study of color-directed heart blood flow, rate, and valve function 436.75$

Doppler ultrasound study of heart blood flow, valves, and chambers 436.75$

DORZOLAMIDE 2 % EYE DROPS [49581] 4.76$

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [48286] 12.72$

DOXAZOSIN 2 MG TABLET [28152] 0.96$

DOXAZOSIN 4 MG TABLET [28153] 4.09$

DOXEPIN 10 MG CAPSULE [8474] 0.66$



DOXYCYCLINE HYCLATE 100 MG CAPSULE [2354] 1.49$

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [26741] 15.07$

Drainage of abscess 346.25$

Drainage of abscess, cyst, or blood accumulation of dental bone 727.75$

Drainage of blood or fluid accumulation 3,027.75$

Drainage of finger abscess 331.00$

Drainage of fluid from abdominal cavity using imaging guidance 1,543.50$

Drainage of fluid-filled sac (bursa) of upper arm or elbow 2,102.75$

Drainage of multiple abscess 347.25$

Drainage of rectal abscess 5,429.50$

Drainage of tailbone cyst 2,949.75$

Drainage of tonsil abscess 377.00$

Dressing change and/or removal of burn tissue (5% to 10% total body surface) 355.00$

Dressing change and/or removal of burn tissue (less than 5% total body surface) 355.00$

Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen6.12$

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed162.00$

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [56270] 8.87$



DUO NEB 10.00$

DUTASTERIDE 0.5 MG CAPSULE [52424] 6.28$

Eardrum testing using ear probe 46.00$

Education and training for patient self-management, each 30 minutes 73.75$

EGD 1,262.00$

EGD W/ BIOPSY 1,721.00$

EGD W/DILATATION 1,439.75$

Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care 68.75$

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination16.00$

Electronic analysis and programming of implanted complex spinal cord or peripheral neurostimulator generator system during or after surgery, first hour 133.00$

Electronic assessment of bladder emptying 162.00$

Emergency department visit, low to moderately severe problem 319.50$

Emergency department visit, moderately severe problem 498.50$

Emergency department visit, problem of high severity 786.75$

Emergency department visit, problem with significant threat to life or function 1,543.50$

Emergency department visit, self limited or minor problem 200.75$

EMERGENCY HEMODIALYSIS 959.00$

Emergent insertion of breathing tube into windpipe cartilage using an endoscope 1,372.25$

EMPAGLIFLOZIN 10 MG TABLET [143841] 19.30$

EMPAGLIFLOZIN 25 MG TABLET [143840] 19.30$

EMPTY CONTAINER, PLASTIC BAG 250 ML [4216] 6.80$

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [56267] 69.57$

ENALAPRIL MALEATE 10 MG TABLET [28143] 2.02$

ENALAPRIL MALEATE 5 MG TABLET [28142] 1.92$

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [28112] 3.83$

ENDOVIVE REPLACEMENT PEG TUBE 95.75$

ENDURANCE 40MG BONE CEMENT 206.00$

ENTACAPONE 200 MG TABLET [46529] 4.10$

Enzyme activity measurement 191.25$

EPHEDRINE 50MG/ML INJ, 1ML 7.26$

Episiotomy or vaginal repair 2,327.75$

EPLERENONE 25 MG TABLET [52307] 4.25$

ERCP 1,923.00$

ERGOCALCIFEROL (VITAMIN D2) 50,000 UNIT CAPSULE [48547] 2.05$

ERYTHROMYCIN 250MG BASE TAB 7.26$

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [5890] 10.60$

Erythropoietin (protein) level 239.00$

ESCITALOPRAM 10 MG TABLET [52180] 9.47$

ESCITALOPRAM 20 MG TABLET [52181] 9.89$

ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [40010] 0.65$

ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [45178] 2.33$

Established patient office or other outpatient visit, typically 5 minutes 114.50$

Established patient periodic preventive medicine examination age 18-39 years 70.00$

Established patient periodic preventive medicine examination infant younger than 1 year 250.00$

Established patient periodic preventive medicine examination, age 1 through 4 years 70.00$



Estradiol (hormone) level 211.75$

ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [48776] 9.23$

ESTRADIOL 1 MG TABLET [6528] 0.71$

Estriol (hormone) level 185.00$

Estrogen analysis 544.75$

Estrone (hormone) level 178.00$

Ethosuximide level 219.50$

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [24641] 0.69$

Etonogestrel (contraceptive) implant system, including implant and supplies 1,108.78$

Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) 132.50$

Evaluation of fine needle aspirate 304.25$

Evaluation of occupational therapy established plan of care, typically 60 minutes 291.00$

Evaluation of occupational therapy, typically 30 minutes 269.00$

Evaluation of occupational therapy, typically 45 minutes 280.00$

Evaluation of physical therapy, typically 20 minutes 202.75$



Evaluation of single or dual chamber pacing cardioverter-defibrillator and generator at time of implantation or replacement 2,036.00$

Evaluation of single or dual chamber pacing cardioverter-defibrillator at time of implantation or replacement 270.00$

Evaluation of single or dual chamber pacing cardioverter-defibrillator with programming or reprogramming 1,968.00$

Evaluation of speech fluency 266.50$

Evaluation of speech sound production 199.25$

Evaluation of speech sound production with evaluation of language comprehension and expression 450.00$

Evaluation of swallowing function 412.75$

Event recorder, cardiac (implantable) 13,845.50$

EVIDENCE COLLECTION 1.00$

Examination of cornea and iris using lens device and slit lamp 114.00$

Examination of small bowel using an endoscope 2,061.50$

Examination of the vagina and cervix using an endoscope 176.00$

Exchange of abdominal cavity drainage catheter using imaging guidance 2,089.25$

Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring 1,395.50$

Exploration of penetrating wound of abdomen, flank, or back 3,150.00$

External shock to heart to regulate heart beat 2,091.25$

Eye and medical examination for diagnosis and treatment, established patient 128.00$

Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits 128.00$

Eye and medical examination for diagnosis and treatment, new patient, 1 or more visits 128.00$

EZETIMIBE 10 MG TABLET [52412] 11.72$

Family psychotherapy including patient, 50 minutes 315.00$

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION [28904] 0.56$

FAMOTIDINE 20 MG TABLET [28881] 1.80$

FAT EMULSION 20% IV SOLN, 250M 50.75$

FEBUXOSTAT 40 MG TABLET [110835] 13.30$

FENOFIBRATE 160 MG TABLET [82238] 2.47$

FENOFIBRATE 54 MG TABLET [108488] 0.82$

FENTANYL 100 MCG/HR TRANSDERMAL PATCH [46753] 81.69$





Ferritin (blood protein) level 158.25$

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET [89134] 0.11$

FERROUS SULFATE 325 MG (65 MG IRON) TABLET [6239] 0.03$

Fetal contraction stress test 607.50$

Fetal hemoglobin level 160.75$

Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation 68.75$

Fetal monitoring during labor by consulting physician 240.50$

Fetal non-stress test 374.75$

Fibrinogen (factor 1) activity measurement 131.50$

FIDAXOMICIN 200 MG TABLET [122738] 229.25$

FILSHIE CLIP 134.00$

FINASTERIDE 5 MG TABLET [49340] 3.46$

Fine needle aspiration 282.00$

Fine needle aspiration using imaging guidance 1,086.50$

First degree burn treatment 193.75$

Fitting and insertion of vaginal support device 176.00$

Fitting of contact lens for treatment of ocular surface disease 20.00$

FLECAINIDE 100 MG TABLET [30587] 3.72$

FLEX SIGMOID W/BIOPSY 1,815.25$

FLOSEAL HEMOSTATIC MATRIX 5 ML KIT [613283] 247.91$

Flow cytometry technique for DNA or cell analysis 304.25$

FLUCONAZOLE 100 MG TABLET [43062] 9.09$

FLUCONAZOLE 150 MG TABLET [43064] 14.54$

FLUDROCORTISONE 0.1 MG TABLET [30479] 0.78$

Fluid collection drainage by catheter using imaging guidance, accessed through the skin 1,850.75$

FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION [43498] 1.69$

FLUOCINOLONE 0.025 % TOPICAL CREAM [5886] 2.34$

FLUOCINOLONE 0.025 % TOPICAL OINTMENT [5887] 2.34$

FLUORESCEIN 0.6 MG EYE STRIPS [46801] 0.16$

FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [45406] 5.76$

FLUORESCEIN SODIUM 1MG OPHTH S 7.26$

Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries 990.50$

Fluoroscopic and video recorded motion evaluation of swallowing function 497.00$

Fluoroscopic guidance for injection into spine or muscle next to spine 649.75$

Fluoroscopic guidance for insertion of needle 788.75$

Fluoroscopic guidance for insertion, replacement or removal of central venous access device 230.50$

FLUOXETINE 10 MG CAPSULE [29111] 0.11$

FLUOXETINE 20 MG CAPSULE [29095] 0.12$

FLUPHENAZINE 1 MG TABLET [6354] 0.60$

FLUPHENAZINE 2.5 MG TABLET [6355] 0.72$

FLURBIPROFEN 0.03 % EYE DROPS [18439] 3.62$

FLUTICASONE 100 MCG-VILANTEROL 25 MCG/DOSE POWDER FOR INHALATION [137895] 5.84$

FLUTICASONE 200 MCG-VILANTEROL 25 MCG/DOSE POWDER FOR INHALATION [147454] 5.84$

FLUTICASONE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [49145] 5.47$

FLUTICASONE-SALMETEROL 115 MCG-21 MCG/ACTUATION HFA AEROSOL INHALER [88375] 33.08$

FLUTICASONE-SALMETEROL 230 MCG-21 MCG/ACTUATION HFA AEROSOL INHALER [88376] 49.06$

FOLIC ACID 1 MG TABLET [5703] 0.38$

FOLIC ACID 5 MG/ML INJECTION SOLUTION [24635] 5.62$

Folic acid level 245.25$

Follow-up or limited ultrasound examination of heart 838.00$

FREEZE DRIED CRUSHED BONE 2,492.50$

Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit 191.25$

Fungal blood culture (mold or yeast) 209.25$

Fungal culture (mold or yeast) 191.25$

Fungal culture (mold or yeast) of skin, hair, or nail 214.25$

Fungal culture, yeast 140.25$

FUROSEMIDE 20 MG TABLET [684] 0.15$



G6PD (enzyme) level 219.50$

GABAPENTIN 100 MG CAPSULE [43401] 0.61$



Gabapentin level 178.25$

GALANTAMINE 4 MG TABLET [45391] 4.38$

Gallium ga-67 citrate, diagnostic, per millicurie 84.50$

Gammaglobulin (immune system protein) measurement 301.50$

Gastrin (GI tract hormone) level 214.25$

GASTROVIEW CONTRAST AGENT 187.50$

GASTROVIEW MO 139.25$

GB CHEM PROFILE 38.25$

GB HCG 100.00$

GEL DRESSING TOPICAL [50553] 0.22$

GELATIN ABSORBABLE 100 TOPICAL SPONGE [45780] 51.88$

GELATIN ABSORBABLE 12 MM-7 MM TOPICAL SPONGE [48556] 10.70$

GELATIN ABSORBABLE 50 TOPICAL SPONGE [48059] 34.71$

GELATIN ABSORBABLE 8 CM X 3 CM TOPICAL SPONGE [56427] 34.14$

GEMFIBROZIL 600 MG TABLET [2340] 1.13$

Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants 200.75$

Gene analysis (coagulation factor V) Leiden variant 187.50$

Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 1,100.50$

Gene analysis (hemochromatosis) common variants 268.00$

Gene analysis (Janus kinase 2) variant 536.00$

Gene analysis (prothrombin, coagulation factor II) A variant 140.50$

Gene analysis (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) common variants 145.75$

Generator, neurostimulator (implantable), with rechargeable battery and charging system 36,182.50$

Gentamicin (antibiotic) level 293.50$

GENTAMICIN 0.1 % TOPICAL CREAM [5891] 3.42$

GENTAMICIN 0.1 % TOPICAL OINTMENT [5892] 0.25$

GENTAMICIN 0.3 % EYE DROPS [6434] 8.89$

GLENBEIGH THYROID PANEL 63.00$

GLIMEPIRIDE 1 MG TABLET [46189] 1.12$



GLIPIZIDE 5 MG TABLET [2345] 0.39$

GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [41777] 0.42$

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [41560] 0.75$

Glucose (sugar) level on body fluid 63.00$

Glutamyltransferase (liver enzyme) level 98.75$

GLYBURIDE 2.5 MG TABLET [6525] 0.48$

GLYBURIDE 5 MG TABLET [6526] 0.55$

GLYBURIDE MICRONIZED 3 MG TABLET [8565] 0.06$

Glycated protein level 78.75$

GLYCERIN (ADULT) RECTAL SUPPOSITORY [6248] 0.45$

GLYCERIN (CHILD) RECTAL SUPPOSITORY [6247] 0.13$

GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS [83775] 0.06$

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [1962] 8.72$

GLYCOPYRROLATE 1 MG TABLET [40412] 1.10$

Gonadotropin (reproductive hormone) analysis 113.50$

Gonadotropin, chorionic (reproductive hormone) level 100.00$

Gonadotropin, follicle stimulating (reproductive hormone) level 227.25$

Gonadotropin, luteinizing (reproductive hormone) level 225.75$

GORETEX PATCH 1,412.50$

Goserelin acetate implant, per 3.6 mg 753.47$

Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter 653.84$

Graft, vascular 6,789.75$

Graftjacket, per square centimeter 1,085.06$

Group psychotherapy 256.00$

Group treatment of speech, language, voice, communication, and/or hearing processing disorder 140.25$

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [46030] 0.07$

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [142544] 1.04$

Guide wire 403.25$

HALOPERIDOL 1 MG TABLET [6336] 0.51$

HALOPERIDOL 2MG/ML ORAL CONC 1.19$

HALOPERIDOL 5 MG TABLET [6338] 1.13$

Haptoglobin (serum protein) level 158.25$

HDL cholesterol level 237.25$

Hearing test for children 162.00$

Heart rhythm analysis, interpretation and report of 48-hour EKG 462.00$

Heart rhythm tracing of 48-hour EKG 436.75$

Heavy metal level 128.00$

HELICAL BLADE 80MM-120MM 1,377.50$

Hemoglobin A1C level 146.75$

Hemoglobin analysis and measurement 344.25$

Hemoglobin measurement 51.25$

Hemosiderin (hemoglobin breakdown product) analysis 87.25$

HEMOSPLIT 5744420 1,379.50$

Heparin assay 155.50$

Hepatitis B core antibody (IgM) measurement 235.75$

Hepatitis B core antibody measurement 57.75$

Hepatitis B immune globulin for injection into muscle 190.64$

Hepatitis B surface antibody measurement 103.00$

Hepatitis Be antibody measurement 84.75$

Hepatitis C antibody measurement 68.25$

HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [4113] 0.04$

High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml 32.17$

HLA class I typing, low resolution one antigen equivalent 569.25$

HLA class II typing high resolution one locus 325.50$

HOLTER MONITOR 48 HRS 924.25$

Homocysteine (amino acid) level 230.00$

HONEY 80 % TOPICAL GEL [135106] 0.41$

Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle 138.00$

Hospital Observation Care 808.25$

Hospital observation care, typically 30 minutes 52.75$

Hospital observation service, per hour 808.25$

Hospital outpatient clinic visit for assessment and management of a patient 334.00$

Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose 311.35$

Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 8.30$

Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose 238.70$

Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg 207.57$

HYDRALAZINE 10 MG TABLET [5823] 0.43$



Hydration infusion into a vein 98.00$

Hydration infusion into a vein 31 minutes to 1 hour 529.25$

HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE [8563] 0.44$

HYDROCHLOROTHIAZIDE 25 MG TABLET [687] 0.15$

HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7513] 1.14$

HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [39038] 0.49$

HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET [39037] 0.92$

HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML SYRUP [10205] 0.19$

HYDROCORTISONE 1 % TOPICAL CREAM [28698] 0.06$

HYDROCORTISONE 2.5 % TOPICAL CREAM [5894] 0.43$

HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR [11288] 3.20$

HYDROCORTISONE 2.5 % TOPICAL OINTMENT [5900] 0.15$

HYDROCORTISONE 5 MG TABLET [40397] 0.35$

HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [6736] 14.97$

HYDROMORPHONE 2 MG TABLET [2635] 0.74$

HYDROMORPHONE 4 MG TABLET [2636] 0.74$

HYDROXYCHLOROQUINE 200 MG TABLET [5245] 4.56$

Hydroxycorticosteroids, 17 (adrenal gland hormone) level 250.75$

Hydroxyindolacetic acid (product of metabolism) level 233.75$

Hydroxyprogesterone, 17-D (synthetic hormone) level 376.00$

Hydroxyurea, oral, 500 mg 1.15$

HYDROXYZINE HCL 10 MG TABLET [6397] 0.29$

HYDROXYZINE HCL 25 MG TABLET [6398] 0.41$

HYDROXYZINE PAMOATE 50 MG CAPSULE [5961] 0.33$

Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen0.31$

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [47479] 0.88$

HYOSCYAMINE 0.125 SL TAB 7.26$

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval 382.25$

Hypertonic saline solution, 1 ml 0.19$

HYPROMELLOSE 2.5 % EYE DROPS [42330] 0.77$

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [8877] 0.18$

IBUPROFEN 200 MG TABLET [5479] 0.04$




Identification of mycobacteria (TB or TB like organism) 263.00$

Identification of organisms by genetic analysis 46.25$

Identification of red blood cell antibodies 310.50$

IgE (immune system protein) level 191.25$

Iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure)105.00$

ILOPERIDONE 2 MG TABLET [114883] 22.62$



Imaging for abscess or abnormal drainage tract procedure 814.00$

Imaging for bone age assessment 232.50$

Imaging for bone length assessment 422.75$

Imaging for evaluation of swallowing function 699.25$

Imaging from nose to rectum, single view, child 444.75$

Imaging guidance for procedure, up to 1 hour 550.00$

Imaging of 2 or more joints, single view 349.50$

Imaging of abdomen and chest 582.50$

Imaging of blood vessels in back of eye using fluorescein dye 439.50$

Imaging of bone marrow limited area 1,020.75$

Imaging of bone marrow multiple areas 589.00$

Imaging of bone marrow whole body 735.25$

Imaging of colon using enema 257.25$

Imaging of digestive tract done from the inside of the digestive tract 1,155.00$

Imaging of liver and bile duct system 735.25$

Imaging of liver and bile duct system with use of drugs 2,809.25$

Imaging of liver and spleen 1,215.50$

Imaging of lymphatic tissue and lymph node 712.25$

Imaging of parathyroid 1,538.25$

Imaging of parathyroid with nuclear medicine study 735.25$

Imaging of surgical specimen 814.00$

Imaging of urinary tract 1,745.00$

Imaging of urinary tract with injection of contrast into a vein 864.50$

IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [44933] 12.09$

Immunologic analysis for autoimmune disease 113.50$

Immunologic analysis for detection of organism 246.75$

Immunologic analysis for detection of tumor antigen 368.25$

Immunologic analysis technique on body fluid 320.00$

Immunologic analysis technique on serum 320.00$

Implantation of lower leg neurostimulator electrode, accessed through the skin 280.00$

Implantation patient-activated heart monitoring device 17,904.50$

Incision and drainage of abscess in scrotal sac of testicle 1,945.75$

Incision and drainage of external ear abscess or blood accumulation 1,100.00$

Incision and drainage of eyelid abscess 326.00$

Incision and drainage of female genital gland abscess 363.75$

Incision and drainage of female genitals abscess 1,190.75$

Incision and drainage of roof of mouth or its soft tissue projection 1,190.75$

Incision of abscess, cyst, or blood accumulation in mouth 892.00$

Incision of eardrum with insertion of eardrum tube under local or topical anesthesia 630.00$

Incision of elbow with exploration, drainage, or removal of foreign body 5,556.50$

Incision of engorged external hemorrhoid 727.75$

Incision of pancreatic outlet muscle using an endoscope 5,909.75$

Incision of penile foreskin 90.00$

Incision of tissue connecting tongue and floor of mouth 550.00$

Incision, aspiration, and/or inflation of eardrum 391.00$

INDAPAMIDE 1.25 MG TABLET [3141] 1.47$

Indium in-111 labeled autologous white blood cells, diagnostic, per study dose 3,821.00$

Indium in-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries 1,293.25$

INDOCYANINE 25MG INJ KIT 348.45$

INDOMETHACIN 25 MG CAPSULE [5986] 0.40$

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [30358] 105.86$

Infrared analysis of stone 211.75$

Infusion into a vein for therapy prevention or diagnosis additional sequential infusion up to 1 hour 138.00$

Infusion into a vein for therapy, prevention, or diagnosis 98.00$

Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour 529.25$

Infusion into a vein for therapy, prevention, or diagnosis, concurrent with another infusion 138.00$

Infusion of chemotherapy into a vein 138.00$

Infusion of chemotherapy into a vein up to 1 hour 350.00$

Infusion of chemotherapy into a vein using push technique 475.75$

Infusion of different chemotherapy drug or substance into a vein 280.50$

Infusion of different chemotherapy drug or substance into a vein up to 1 hour 280.50$

Infusion pump, programmable (implantable) 29,267.50$

Infusion, albumin (human), 25%, 50 ml 1.44$

Infusion, d5w, 1000 cc 0.01$

Infusion, normal saline solution , 1000 cc 0.01$

Infusion, normal saline solution, 250 cc 0.12$

Infusion, normal saline solution, sterile (500 ml = 1 unit) 0.08$

Ingestion of test items for allergies, 120 minutes 496.00$

Inhibin A (reproductive organ hormone) measurement 100.00$

Initial new patient preventive medicine evaluation age 18-39 years 70.00$

Initial new patient preventive medicine evaluation infant younger than 1 year 70.00$

Initial new patient preventive medicine evaluation, age 1 through 4 years 70.00$



Initiation and management of continued pressured respiratory assistance by mask or breathing tube 1,263.75$

Injection beneath the skin or into muscle for therapy, diagnosis, or prevention 148.25$

Injection fluconazole, 200 mg 0.23$

Injection of allergenic extracts into skin for immediate reaction analysis 70.00$

Injection of allergenic extracts into skin with delayed reaction analysis 38.00$

Injection of allergenic extracts into skin, accessed through the skin 114.00$

Injection of anesthetic agent, facial nerve 610.00$

Injection of anesthetic agent, other peripheral nerve or branch 855.00$

Injection of bile duct for X-ray imaging procedure accessed through the skin using imaging guidance including radiological supervision and interpretation 4,734.25$

Injection of blood or blood clot into spinal canal 855.00$

Injection of carpal tunnel 336.00$

Injection of chemical for destruction of facial and neck nerve muscles on both sides of face 450.00$

Injection of chemical for destruction of nerve muscles on arm or leg, 1-4 muscles 1,170.00$

Injection of chemical for destruction of nerve muscles on arm or leg, 5 or more muscles 1,170.00$

Injection of chemical for destruction of nerve muscles on one side of face 280.00$

Injection of chemical for destruction of nerve muscles on one side of neck excluding voice box accessed through the skin 450.00$

Injection of chemical for destruction of nerve muscles on trunk, 5 or more muscles 460.00$

Injection of chemical for destruction of salivary glands on both sides of the mouth 450.00$

Injection of different drug or substance into a vein for therapy, diagnosis, or prevention 138.00$

Injection of drug into erectile tissue at sides and back of penis 727.75$

Injection of drug into eye 350.00$

Injection of drug or substance into a vein for therapy, diagnosis, or prevention 219.50$

Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility 166.75$

Injection of dye for X-ray imaging and/or CT of lower spinal canal 1,209.00$

Injection of dye for X-ray imaging of elbow joint 520.75$

Injection of dye for X-ray imaging of hip joint 2,065.50$

Injection of dye for X-ray imaging of shoulder joint 520.75$

Injection of dye for X-ray imaging of wrist joint 1,190.75$

Injection of incremental dosages of allergen 127.00$

Injection of incremental dosages of allergen, 2 or more injections 39.00$

Injection of medication or substance into membrane covering eyeball 50.00$

Injection of up to 7 skin growths 147.00$

Injection procedure for X-ray imaging of the bladder or during voiding 522.50$

Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)1,303.00$

Injection, acetaminophen, 10 mg 42.81$

Injection, acetylcysteine, 100 mg 8.95$

Injection, acyclovir, 5 mg 2.34$

Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 3.89$

Injection, ado-trastuzumab emtansine, 1 mg 3,721.16$

Injection, adrenalin, epinephrine, 0.1 mg 378.98$

Injection, aflibercept, 1 mg 2,054.92$

Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 0.62$

Injection, alteplase recombinant, 1 mg 10,960.01$

Injection, amikacin sulfate, 100 mg 1.72$

Injection, aminophyllin, up to 250 mg 0.44$

Injection, amiodarone hydrochloride, 30 mg 1.51$

Injection, ampicillin sodium, 500 mg 9.89$

Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 30.62$

Injection, argatroban, 1 mg (for non-esrd use) 654.34$

Injection, aripiprazole, extended release, 1 mg 5.19$

Injection, atezolizumab, 10 mg 552.99$

Injection, atropine sulfate, 0.01 mg 13.70$

Injection, azacitidine, 1 mg 640.99$

Injection, azithromycin, 500 mg 80.43$

Injection, bendamustine hcl (bendeka), 1 mg 770.22$

Injection, benztropine mesylate, per 1 mg 34.25$

Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 12.31$

Injection, bevacizumab, 0.25 mg 25.95$

Injection, bevacizumab, 10 mg 248.13$

Injection, bleomycin sulfate, 15 units 91.20$

Injection, bortezomib (velcade), 0.1 mg 1,996.38$

Injection, bumetanide, 0.5 mg 0.31$

Injection, bupivicaine hydrochloride, 30 ml 0.06$

Injection, buprenorphine hydrochloride, 0.1 mg 18.89$

Injection, calcitonin salmon, up to 400 units 1,421.94$

Injection, calcium gluconate, per 10 ml 1.14$

Injection, carboplatin, 50 mg 49.30$

Injection, carfilzomib, 1 mg 2,807.19$

Injection, cefazolin sodium, 500 mg 14.27$

Injection, cefepime hydrochloride, 500 mg 41.88$

Injection, cefotaxime sodium, per gm 45.66$

Injection, cefoxitin sodium, 1 gm 11.65$

Injection, ceftaroline fosamil, 10 mg 218.51$

Injection, ceftazidime, per 500 mg 13.70$

Injection, ceftriaxone sodium, per 250 mg 94.87$

Injection, cetuximab, 10 mg 15.11$

Injection, chlorpromazine hcl, up to 50 mg 15.05$

Injection, ciprofloxacin for intravenous infusion, 200 mg 0.15$

Injection, cisplatin, powder or solution, 10 mg 0.50$

Injection, colistimethate sodium, up to 150 mg 34.86$

Injection, cosyntropin, 0.25 mg 132.74$

Injection, dalbavancin, 5 mg 1,911.32$

Injection, daptomycin, 1 mg 554.82$

Injection, daratumumab, 10 mg 126.99$

Injection, darbepoetin alfa, 1 microgram (non-esrd use) 4,819.72$

Injection, decitabine, 1 mg 1,183.13$

Injection, deferoxamine mesylate, 500 mg 11.72$

Injection, degarelix, 1 mg 608.32$

Injection, denosumab, 1 mg 1,624.32$

Injection, desmopressin acetate, per 1 mcg 73.22$

Injection, dexamethasone sodium phosphate, 1 mg 3.11$

Injection, diazepam, up to 5 mg 17.03$

Injection, dicyclomine hcl, up to 20 mg 49.90$

Injection, digoxin, up to 0.5 mg 3.42$

Injection, dihydroergotamine mesylate, per 1 mg 163.58$

Injection, diphenhydramine hcl, up to 50 mg 5.19$

Injection, dobutamine hydrochloride, per 250 mg 0.12$

Injection, docetaxel, 1 mg 135.75$

Injection, dopamine hcl, 40 mg 0.08$

Injection, doxercalciferol, 1 mcg 7.78$

Injection, doxorubicin hydrochloride, 10 mg 2.76$

Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg 146.19$

Injection, elotuzumab, 1 mg 2,211.84$

Injection, enoxaparin sodium, 10 mg 154.71$

Injection, epoetin alfa, (for non-esrd use), 1000 units 1,281.35$

Injection, ertapenem sodium, 500 mg 160.23$

Injection, erythromycin lactobionate, per 500 mg 92.66$

Injection, estrogen conjugated, per 25 mg 369.64$

Injection, etoposide, 10 mg 3.10$

Injection, fentanyl citrate, 0.1 mg 1.82$

Injection, ferric carboxymaltose, 1 mg 82.42$

Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 392.10$

Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram 686.62$

Injection, fludarabine phosphate, 50 mg 117.69$

Injection, fluorouracil, 500 mg 0.37$

Injection, fondaparinux sodium, 0.5 mg 36.06$

Injection, fosaprepitant, 1 mg 398.80$

Injection, fosphenytoin, 50 mg phenytoin equivalent 2.99$

Injection, fulvestrant, 25 mg 237.92$

Injection, furosemide, up to 20 mg 1.37$

Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 14.01$

Injection, gadoterate meglumine, 0.1 ml 0.26$

Injection, garamycin, gentamicin, up to 80 mg 2.45$

Injection, gemcitabine hydrochloride, 200 mg 427.33$

Injection, glucagon hydrochloride, per 1 mg 349.71$

Injection, golimumab, 1 mg, for intravenous use 539.75$

Injection, haloperidol decanoate, per 50 mg 32.24$

Injection, haloperidol, up to 5 mg 7.46$

Injection, heparin sodium, (heparin lock flush), per 10 units 0.77$

Injection, heparin sodium, per 1000 units 5.87$

Injection, hepatitis b immune globulin (hepagam b), intravenous, 0.5 ml 176.43$

Injection, hyaluronidase, up to 150 units 69.49$

Injection, hydralazine hcl, up to 20 mg 14.94$

Injection, hydrocortisone sodium succinate, up to 100 mg 16.73$

Injection, hydromorphone, up to 4 mg 8.22$

Injection, hydroxyzine hcl, up to 25 mg 26.60$

Injection, ibandronate sodium, 1 mg 218.94$

Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg 16.59$

Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg 13.99$

Injection, infliximab, excludes biosimilar, 10 mg 1,454.41$

Injection, insulin, per 5 units 46.40$

Injection, irinotecan, 20 mg 7.68$

Injection, iron dextran, 50 mg 16.52$

Injection, iron sucrose, 1 mg 11.96$

Injection, ketorolac tromethamine, per 15 mg 20.76$

Injection, lacosamide, 1 mg 4.40$

Injection, leucovorin calcium, per 50 mg 23.60$

Injection, levetiracetam, 10 mg 1.54$

Injection, levofloxacin, 250 mg 0.27$

Injection, lidocaine hcl for intravenous infusion, 10 mg 1.59$

Injection, linezolid, 200 mg 0.25$

Injection, lorazepam, 2 mg 3.33$

Injection, magnesium sulfate, per 500 mg 0.70$

Injection, mannitol, 25% in 50 ml 0.06$

Injection, medroxyprogesterone acetate, 1 mg 101.55$

Injection, meperidine hydrochloride, per 100 mg 7.66$

Injection, mepivacaine hydrochloride, per 10 ml 0.31$

Injection, mepolizumab, 1 mg 3,572.66$

Injection, meropenem, 100 mg 36.29$

Injection, methylergonovine maleate, up to 0.2 mg 8.90$

Injection, methylnaltrexone, 0.1 mg 95.48$

Injection, methylprednisolone acetate, 40 mg 25.95$

Injection, methylprednisolone acetate, 80 mg 51.89$

Injection, methylprednisolone sodium succinate, up to 125 mg 52.17$

Injection, methylprednisolone sodium succinate, up to 40 mg 7.49$

Injection, metoclopramide hcl, up to 10 mg 0.69$

Injection, micafungin sodium, 1 mg 232.89$

Injection, midazolam hydrochloride, per 1 mg 0.84$

Injection, milrinone lactate, 5 mg 83.81$

Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 3.28$

Injection, morphine sulfate, up to 10 mg 2.39$

Injection, nalbuphine hydrochloride, per 10 mg 7.75$

Injection, naloxone hydrochloride, per 1 mg 20.55$

Injection, naltrexone, depot form, 1 mg 1,630.24$

Injection, natalizumab, 1 mg 513.11$

Injection, neostigmine methylsulfate, up to 0.5 mg 2.29$

Injection, nivolumab, 1 mg 326.56$

Injection, non-radioactive, non-contrast, visualization adjunct (e.g., methylene blue, isosulfan blue), 1 mg 22.29$

Injection, obinutuzumab, 10 mg 200.95$

Injection, octafluoropropane microspheres, per ml 58.28$

Injection, octreotide, depot form for intramuscular injection, 1 mg 7,610.84$

Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25.41$

Injection, olanzapine, long-acting, 1 mg 41.10$

Injection, omalizumab, 5 mg 1,350.84$

Injection, onabotulinumtoxina, 1 unit 748.49$

Injection, ondansetron hydrochloride, per 1 mg 0.49$

Injection, oritavancin, 10 mg 1,203.89$

Injection, orphenadrine citrate, up to 60 mg 11.52$

Injection, oxaliplatin, 0.5 mg 1,712.43$

Injection, oxytocin, up to 10 units 1.86$

Injection, paclitaxel protein-bound particles, 1 mg 1,658.14$

Injection, paclitaxel, 1 mg 4.25$

Injection, paliperidone palmitate extended release, 1 mg 2,077.14$

Injection, pamidronate disodium, per 30 mg 3.84$

Injection, panitumumab, 10 mg 295.77$

Injection, pantoprazole sodium, per vial 6.23$

Injection, papaverine hcl, up to 60 mg 21.38$

Injection, pegfilgrastim, 6 mg 12,933.66$

Injection, pembrolizumab, 1 mg 1,447.67$

Injection, pemetrexed, 10 mg 4,212.71$

Injection, penicillin g benzathine, 100,000 units 113.16$

Injection, penicillin g potassium, up to 600,000 units 15.76$

Injection, pertuzumab, 1 mg 445.90$

Injection, phenobarbital sodium, up to 120 mg 25.91$

Injection, phenylephrine hcl, up to 1 ml 3.09$

Injection, phenytoin sodium, per 50 mg 0.45$

Injection, phytonadione (vitamin k), per 1 mg 60.08$

Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 24.65$

Injection, potassium chloride, per 2 meq 0.37$

Injection, prochlorperazine, up to 10 mg 11.52$

Injection, promethazine hcl, up to 50 mg 8.30$

Injection, propofol, 10 mg 0.39$

Injection, protamine sulfate, per 10 mg 3.06$

Injection, pyridoxine hcl, 100 mg 18.93$

Injection, regadenoson, 0.1 mg 60.52$

Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 106.90$

Injection, rituximab, 100 mg 117.01$

Injection, sincalide, 5 micrograms 211.46$

Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 7.92$

Injection, succinylcholine chloride, up to 20 mg 2.39$

Injection, sumatriptan succinate, 6 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)64.76$

Injection, tedizolid phosphate, 1 mg 344.68$

Injection, telavancin, 10 mg 537.90$

Injection, terbutaline sulfate, up to 1 mg 4.98$

Injection, testosterone cypionate, 1 mg 24.91$

Injection, tetracycline, up to 250 mg 10.34$

Injection, thiamine hcl, 100 mg 6.20$

Injection, tigecycline, 1 mg 194.28$

Injection, tirofiban hcl, 0.25 mg 2.58$

Injection, tobramycin sulfate, up to 80 mg 1.51$

Injection, tocilizumab, 1 mg 136.00$

Injection, trastuzumab, 10 mg 1,940.86$

Injection, triamcinolone acetonide, not otherwise specified, 10 mg 11.66$

Injection, triamcinolone acetonide, preservative free, 1 mg 187.32$

Injection, vancomycin hcl, 500 mg 264.65$

Injection, vedolizumab, 1 mg 7,593.94$

Injection, vinblastine sulfate, 1 mg 5.36$

Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 10.38$

Injection, voriconazole, 10 mg 185.80$

Injection, ziprasidone mesylate, 10 mg 61.87$

Injection, zoledronic acid, 1 mg 44.83$

Injections into large bowel using an endoscope 1,404.00$

Injections of anesthetic and/or steroid drug into nerve of foot 280.00$

Injections of tendon attachment to bone 280.00$

Injections of tendon sheath, ligament, or muscle membrane 336.00$

Injections of trigger points in 1 or 2 muscles 280.00$

Injections of trigger points in 3 or more muscles 509.25$

Insertion dilator device into cervix 620.75$

Insertion of arterial catheter for blood sampling or infusion, accessed through the skin 1,098.75$

Insertion of assistive heart blood flow device into aorta, accessed through the skin 121.50$

Insertion of catheter for diagnostic evaluation of right heart structures 10,076.25$

Insertion of catheter for suction of secretions 727.75$

Insertion of catheter in left heart for imaging of blood vessels or grafts and left lower heart 10,076.25$

Insertion of catheter in right heart for imaging of blood vessels or grafts 4,685.75$

Insertion of catheter into abdominal pelvic or leg artery 2,171.75$

Insertion of catheter into aorta 631.50$

Insertion of catheter into artery for drug infusion for blood clot including radiological supervision and interpretation 6,489.25$

Insertion of catheter into right and left heart for diagnosis 10,076.25$

Insertion of catheter into right upper heart chamber and pulmonary (lung) artery for monitoring purposes 3,922.75$

Insertion of catheter into vein for drug infusion for blood clot including radiological supervision and interpretation 3,904.00$

Insertion of catheter into vein of navel, newborn 823.00$

Insertion of central venous catheter for infusion, patient 5 years or older 3,817.00$

Insertion of central venous catheter for infusion, patient younger than 5 years 2,591.75$

Insertion of device into the abdomen with measurement of pressure and urine flow rate 315.00$

Insertion of drug delivery implant into tissue 114.00$

Insertion of electrodes for permanent pacemaker or pacing defibrillator device 12,415.75$

Insertion of electronic device into bladder with voiding pressure studies 656.00$

Insertion of indwelling bladder catheter 727.75$

Insertion of intravascular stents in vein, open or accessed through the skin, with radiological supervision and interpretation 22,688.00$

Insertion of left heart electrode for pacing defibrillator device 53,232.75$

Insertion of needle and/or catheter into dialysis circuit and balloon dilation of dialysis segment, with imaging including radiological supervision and interpretation10,639.25$

Insertion of needle and/or catheter into dialysis circuit and insertion of stent in dialysis segment, with imaging including radiological supervision and interpretation21,498.75$

Insertion of needle and/or catheter into dialysis circuit, with imaging including radiological supervision and interpretation 1,510.50$

Insertion of needle for infusion into bone 335.50$

Insertion of needle into scalp vein, patient younger than 3 years 128.25$

Insertion of needle into vein for collection of blood sample 33.75$

Insertion of needle into vein, patient 3 years or older 16.00$

Insertion of new or replacement of permanent pacemaker including upper and lower chamber electrodes 35,412.00$

Insertion of pacemaker pulse generator with existing dual leads 12,668.00$

Insertion of pacemaker pulse generator with existing multiple leads 25,525.50$

Insertion of pacing defibrillator pulse generator with existing dual leads 57,432.75$

Insertion of pacing defibrillator pulse generator with existing multiple leads 44,669.75$

Insertion of pacing defibrillator pulse generator with existing single lead 78,701.75$

Insertion of probe in esophagus for heart ultrasound examination including interpretation and report 1,548.25$

Insertion of stent in urinary duct (ureter) using an endoscope 131.02$

Insertion of stents in artery in one side of groin, endovascular, accessed through the skin or open procedure 22,795.00$

Insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure 29,643.25$

Insertion of stomach tube and aspirations of gastric contents 383.75$

Insertion of temporary bladder catheter 255.25$

Insertion of vena cava filter by endovascular approach, including radiological supervision and interpretation 12,060.75$

Insertion or replacement of permanent pacemaker and lower chamber electrodes 28,957.25$

Insertion or replacement of single or dual chamber pacing defibrillator leads 40,111.50$

Insulin antibody measurement 94.00$

Insulin measurement 138.75$

INT SCALP ELECTRODE 210.00$

Intestine imaging 651.50$

INTRAUTERINE PRESSURE CATH 247.00$

Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump 773.50$

Intrinsic factor (stomach protein) antibody measurement 178.25$

Introducer/sheath, guiding, intracardiac electrophysiological, fixed-curve, other than peel-away 541.00$

Introducer/sheath, guiding, intracardiac electrophysiological, fixed-curve, peel-away 308.75$

Introducer/sheath, guiding, intracardiac electrophysiological, steerable, other than peel-away 178.75$

Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser 569.75$

Introduction of saline or X-ray contrast material for X-ray imaging of the uterus and tubes 251.75$

Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries 10,542.09$

Iodine i-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries 133.25$

IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [44322] 2.22$

IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [2683] 0.55$

IPRATROPIUM BROMIDE 0.03 % NASAL SPRAY [39164] 1.58$

IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY [39165] 6.62$

IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML NEBULIZATION SOLN [44387] 0.76$

IRBESARTAN 150 MG TABLET [48608] 3.19$

IRIDECTOMY FOR GLAUCOMA 1,940.50$

Iron binding capacity 145.25$

Iron level 103.00$

Irradiation of blood product, each unit 96.75$

Irrigation of implanted venous access drug delivery device 162.25$

Islet cell (pancreas) antibody measurement 174.25$

ISOFLURANE 99.9 % INHALATION LIQUID [129667] 0.29$

ISOSORBIDE DINITRATE 10 MG TABLET [5715] 1.13$



ISOSORBIDE MONONITRATE 20 MG TABLET [5088] 0.43$

ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [7312] 0.54$

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [7311] 0.56$

JELCO ALL SIZES 20 22 24 16.50$

JELCO NEXIVA 20X 1 13.75$

JELCO NEXIVA 22 X 1 13.75$

Joint device (implantable) 3,939.75$

KERLIX ROLL ST 8.75$

KETAMINE 50 MG/ML INJECTION SOLUTION [3542] 0.82$

Ketone bodies analysis 88.75$

KETOROLAC 0.5 % EYE DROPS [46278] 21.90$

KETOROLAC 10 MG TABLET [5127] 2.24$

Ketosteroids, 17 (hormone) measurement 439.50$

Kidney function blood test panel 230.00$

KIT CATH TRIPLE LUMEN 16CM 106.50$

KIT DRESSING CHG 22.25$

KIT IV START DISP 8.75$

KIT STAPLER SK REM 8.75$

L.ACIDOPHIL,SALIVARI-BIFIDO BIFIDUM-STREP THERMOPH 175 MG CAPSULE [103278] 0.10$

LABETALOL 100 MG TABLET [5096] 0.57$

LABETALOL 200 MG TABLET [5097] 0.71$

LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [3551] 0.21$

LACOSAMIDE 100 MG TABLET [111128] 16.77$

Lactate dehydrogenase (enzyme) level 113.50$

Lactic acid level 93.25$

LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET [53589] 0.89$

LACTOBACILLUS ACIDOPHILUS100MG 0.26$

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [126158] 0.03$

LAMOTRIGINE 100 MG TABLET [49320] 0.24$

LAMOTRIGINE 25 MG TABLET [46191] 0.23$

Lamotrigine level 324.50$

Laser vaporization of prostate including control of bleeding using an endoscope 11,348.50$

LATANOPROST 0.005 % EYE DROPS [40543] 39.44$

Lead level 128.25$

Lead, cardioverter-defibrillator, endocardial dual coil (implantable) 8,168.25$

Lead, cardioverter-defibrillator, endocardial single coil (implantable) 14,659.75$

Lead, left ventricular coronary venous system 3,828.75$

Lead, neurostimulator (implantable) 5,092.50$

Lead, pacemaker, other than transvenous vdd single pass 1,084.75$

Lead, pacemaker, transvenous vdd single pass 1,746.75$

LEFLUNOMIDE 10 MG TABLET [45618] 17.05$

Lens, intraocular (new technology) 1,347.25$

LET INJ 3CC 66.16$

LETROZOLE 2.5 MG TABLET [48801] 18.74$

LEUCOVORIN 25MG TAB 37.62$

LEUCOVORIN CALCIUM 5 MG TABLET [2638] 2.91$

Leuprolide acetate (for depot suspension), 7.5 mg 10,903.40$

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [53723] 0.68$

LEVETIRACETAM 250 MG TABLET [46871] 0.62$

LEVETIRACETAM 500 MG TABLET [44833] 0.75$

Levetiracetam level 229.75$

LEVOFLOXACIN 250 MG TABLET [45823] 17.12$



LEVONORGESTREL 1.5 MG TABLET [113026] 37.94$

LEVOTHYROXINE 100 MCG INTRAVENOUS SOLUTION [125998] 131.49$

LEVOTHYROXINE 100 MCG TABLET [7400] 0.58$








LIDOCAINE (PF) 3.5 % EYE GEL [109597] 27.56$

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [3657] 0.13$

LIDOCAINE 2 % MUCOSAL JELLY [7460] 1.62$

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [108584] 0.72$

LIDOCAINE 2 % MUCOSAL SOLUTION [48036] 0.14$

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [3661] 0.19$

LIDOCAINE 4 % (40 MG/ML) MUCOSAL SOLUTION [2577] 1.34$

LIDOCAINE 4 % TOPICAL CREAM [45297] 1.25$

LIDOCAINE 5 % TOPICAL PATCH [47492] 19.68$

LINEZOLID 600 MG TABLET [46868] 211.80$

LIOTHYRONINE 25 MCG TABLET [44830] 1.09$

LIOTHYRONINE 5 MCG TABLET [45974] 0.83$

Lipase (fat enzyme) level 166.25$

LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [112665] 3.65$

Lipoprotein (A) level 46.00$

Lipoprotein level 184.50$

Lipoprotein measurement 237.25$

LISINOPRIL 10 MG TABLET [38031] 0.43$



LITHIUM CARBONATE 150 MG CAPSULE [2535] 0.15$

LITHIUM CARBONATE 300 MG CAPSULE [2536] 0.22$

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [39730] 0.48$

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE [40708] 0.56$

Lithium level 132.50$

LITHOTRIPSY 3,675.00$

Liver enzyme (SGOT), level 59.25$

Liver enzyme (SGPT), level 65.25$

Liver function blood test panel 230.00$

LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [83576] 0.03$

LOPERAMIDE 2 MG CAPSULE [5126] 0.91$

LORATADINE 10 MG TABLET [39351] 0.89$

LORATADINE 5 MG-PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE,12HR [47707] 0.73$

LORAZEPAM 0.5 MG TABLET [6461] 0.72$

LORAZEPAM 1 MG TABLET [6462] 0.94$

LORAZEPAM 2 MG/ML ORAL CONCENTRATE [49260] 1.66$

LOSARTAN 25 MG TABLET [47616] 1.75$

LOSARTAN 50 MG TABLET [40349] 2.35$

Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 37.10$

LUBIPROSTONE 24 MCG CAPSULE [86287] 7.70$

LURASIDONE 40 MG TABLET [119959] 50.79$

Macroscopic examination (visual inspection) of parasite 26.75$

MAGNESIUM CITRATE ORAL SOLUTION [40288] 0.01$

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [46732] 0.08$

Magnesium level 109.00$

MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [11204] 0.15$

Magnetic resonance angiography with contrast, abdomen 1,870.50$

Magnetic resonance angiography without contrast, abdomen 4,450.50$

Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral 1,663.25$

MAJOR SUTURE CHARGE 937.50$

Mammography of both breasts 353.75$

Mammography of one breast 277.75$

Manganese (heavy metal) level 140.25$

MANNITOL 20% (200MG/ML) IV SOL 97.30$

Manual (physical) therapy techniques to 1 or more regions, each 15 minutes 128.25$

Manual maneuvers to chest wall to assist movement of lung secretions 152.25$

Manual muscle testing of arm, leg or trunk 135.00$

Mass spectrometry (laboratory testing method) 378.00$

Maternity care and delivery procedure 191.25$

Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration 754.25$

Measurement and graphic recording of total and timed exhaled air capacity 316.75$

Measurement and recording of brain wave (EEG) activity, awake and drowsy 587.00$

Measurement C-reactive protein for detection of infection or inflammation 171.75$

Measurement for Strep antibody (strep throat) 145.25$

Measurement of antibody (IgE) to allergic substance 79.00$

Measurement of antibody for assessment of autoimmune disorder 233.25$

Measurement of antibody for rheumatoid arthritis assessment 159.75$

Measurement of antibody to noninfectious agent 59.50$

Measurement of bilirubin 35.00$

Measurement of cold agglutinin (protein) to detect infection or disease 145.25$

Measurement of complement (immune system proteins) 268.75$

Measurement of complement function (immune system proteins) 178.25$

Measurement of corneal curvature and depth of eye 114.00$

Measurement of DNA antibody 535.00$

Measurement of eye muscles to detect deviation of eyeball 114.00$

Measurement of field of vision during daylight conditions 114.00$

Measurement of Hepatitis A antibody 134.50$

Measurement of Hepatitis A antibody (IgM) 42.00$

Measurement of hydrogen in breath to test for GI symptoms 162.00$

Measurement of immune substance (oligoclonal bands) 209.25$

Measurement of largest amount of air breathed in an out of lungs over one minute 274.75$

Measurement of lung diffusing capacity 374.75$

Measurement of oxygen saturation in blood using ear or finger device 243.50$

Measurement of substance using immunoassay technique 1,101.50$

Mechanical chest wall manipulation for improvement in lung function 357.25$

MECLIZINE 12.5 MG TABLET [5810] 0.74$

MECLIZINE 25 MG TABLET [5804] 0.42$

MECOBALAMIN-LEVOMEFOLATE CALCIUM-PYRIDOXAL PHOS 3 MG-35 MG-2 MG TABLET [115659] 1.50$

MECONIUM ASPIRATOR 24.50$

Medical nutrition therapy performed in a group setting, each 30 minutes 49.50$

Medical nutrition therapy re-assessment and intervention, each 15 minutes 80.50$

Medical nutrition therapy, assessment and intervention, each 15 minutes 105.50$

MEDICATION, NON-DATABASE [600098] -$

MEDROXYPROGESTERONE 5 MG TABLET [7434] 0.49$

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [133949] 0.44$

Megestrol acetate, oral, 20 mg 0.29$

MELATONIN 1 MG TAB 6.23$

MELATONIN 3 MG TABLET [9851] 0.07$

MELOXICAM 7.5 MG TABLET [46391] 3.25$

MEMANTINE 10 MG TABLET [54725] 9.23$

MEMANTINE 5 MG TABLET [54728] 9.23$

Memory functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Memory functional limitation, discharge status at discharge from therapy or to end reporting 0.25$

Memory functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [114617] 0.09$

MENTHOL 3.3 MG LOZENGES [122655] 0.61$

Mercury level 235.75$

MESALAMINE ER 0.375 GRAM CAPSULE,EXTENDED RELEASE 24 HR [110454] 5.00$

Mesh (implantable) 2,814.75$

Metanephrines level 441.75$

METAXALONE 800 MG TABLET [52328] 5.08$

METFORMIN 500 MG TABLET [30139] 0.73$

METFORMIN 850 MG TABLET [30140] 1.25$

METFORMIN ER 1000MG TAB 6.23$

METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR [41543] 0.12$

Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg 83.44$

METHADONE 10 MG TABLET [2645] 0.45$

Methadone, oral, 5 mg 0.40$

METHIMAZOLE 10 MG TABLET [21513] 0.80$

METHIMAZOLE 5 MG TABLET [21512] 0.46$

METHOCARBAMOL 500 MG TABLET [680] 0.44$

METHOCARBAMOL 750 MG TABLET [681] 0.61$

Methotrexate sodium, 50 mg 17.38$

Methotrexate; oral, 2.5 mg 6.47$

METHYL SALICYLATE-MENTHOL 30 %-10 % TOPICAL CREAM [88548] 0.06$

METHYL SALICYLATE-MENTHOL TOPICAL OINTMENT [48520] 0.07$

METHYLDOPA 250 MG TABLET [694] 0.38$

METHYLDOPA 500 MG TABLET [695] 0.70$

METHYLPHENIDATE 10 MG TABLET [5731] 1.08$

Methylprednisolone oral, per 4 mg 1.71$

METOCLOPRAMIDE 10 MG TABLET [5187] 0.31$

METOCLOPRAMIDE 5 MG TABLET [5188] 0.42$

METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [2586] 0.70$

METOLAZONE 2.5 MG TABLET [40990] 3.41$

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [45229] 2.24$



METOPROLOL TARTRATE 25 MG TABLET [41907] 0.25$

METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [3554] 0.37$

METOPROLOL TARTRATE 50 MG TABLET [5142] 0.59$

METRONIDAZOLE 250 MG TABLET [5163] 0.50$

METRONIDAZOLE 50 MG/ML ORAL LIQUID (CCF) [600748] 0.10$

METRONIDAZOLE 500 MG TABLET [5164] 0.95$

METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [4177] 0.02$

MEXILETINE 150 MG CAPSULE [2541] 2.63$

MICONAZOLE NITRATE 2 % TOPICAL OINTMENT [47001] 0.12$

MICONAZOLE NITRATE 2 % TOPICAL POWDER [45370] 0.10$

MICONAZOLE NITRATE 2 % VAGINAL CREAM [5490] 0.26$

MICONAZOLE2% PDR,85GM=1 BLG UN 24.91$

MICROFIBRILLAR COLLAGEN HEMOSTAT 70 MM X 35 MM SHEETS [112671] 236.63$

MICROFIBRILLAR COLLAGEN HEMOSTAT TOPICAL POWDER IN PACKET [130476] 117.07$

Microsomal antibodies (autoantibody) measurement 150.00$

MIDODRINE 10 MG TABLET [41133] 5.17$

MIDODRINE 5 MG TABLET [41132] 2.51$

MINERAL OIL [31523] 1.73$

MINERAL OIL ENEMA [29934] 0.02$

MINERAL OIL ORAL [185] 0.03$

MINOXIDIL 2.5 MG TABLET [8481] 0.61$

MIRTAZAPINE 15 MG DISINTEGRATING TABLET [41555] 2.70$

MIRTAZAPINE 15 MG TABLET [39181] 2.82$

MIRTAZAPINE 30 MG TABLET [39182] 1.34$

MISC SURGERY SUPPLIES -$

MISOPROSTOL 100 MCG TABLET [38037] 4.71$

MITEK QUICK ANCHOR 1,596.50$

Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

MODAFINIL 100 MG TABLET [49666] 30.45$

Moderate sedation services by physician also performing a procedure, additional 15 minutes 16.50$

Moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes 55.25$

Moderate sedation services by physician also performing a procedure, patient younger than 5 years of age, first 15 minutes 55.25$

MODIFIED LANOLIN TOPICAL OINTMENT [81469] 2.74$

Molecular pathology procedure 1,238.25$

Molecular pathology procedure level 1 1,206.00$

Molecular pathology procedure level 2 562.75$

MOMETASONE 220 MCG (14 DOSES) BREATH ACTIVATED POWDER INHALER [83460] 92.11$

Monitoring and recording of gastroesophageal reflux with pH electrode insertion including analysis and interpretation 802.50$

MONTELUKAST 10 MG TABLET [48315] 5.87$

MONTELUKAST 5 MG CHEWABLE TABLET [44062] 5.87$

MORPHINE 10 MG/5 ML ORAL SOLUTION [2607] 0.18$

MORPHINE 15 MG IMMEDIATE RELEASE TABLET [25285] 0.94$

MORPHINE 30 MG IMMEDIATE RELEASE TABLET [2647] 1.60$

MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION [6879] 0.87$

MORPHINE ER 100 MG TABLET,EXTENDED RELEASE [26214] 7.92$



Motor speech functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Motor speech functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Motor speech functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

MOXIFLOXACIN 0.5 % EYE DROPS [52985] 68.19$

MRA scan of head blood vessels 3,356.00$

MRA scan of head blood vessels before and after contrast 3,773.00$

MRA scan of neck blood vessels 3,356.00$

MRA scan of neck blood vessels before and after contrast 3,773.00$

MRI scan bones of the eye, face, and/or neck 2,948.25$

MRI scan bones of the eye, face, and/or neck before and after contrast 4,481.00$

MRI scan brain 3,537.75$

MRI scan of abdomen 3,249.25$

MRI scan of abdomen before and after contrast 4,047.00$

MRI scan of arm 2,642.75$

MRI scan of arm before and after contrast 3,819.00$

MRI scan of arm joint 4,011.25$

MRI scan of arm joint before and after contrast 5,179.75$

MRI scan of arm joint with contrast 4,211.25$

MRI scan of arm with contrast 3,472.50$

MRI scan of brain before and after contrast 5,672.25$

MRI scan of brain with contrast 3,888.25$

MRI scan of chest 2,855.00$

MRI scan of chest before and after contrast 3,193.50$

MRI scan of jaw joints 3,140.50$

MRI scan of leg 2,642.75$

MRI scan of leg before and after contrast 4,403.75$

MRI scan of leg joint 4,048.00$

MRI scan of leg joint before and after contrast 4,462.25$

MRI scan of leg joint with contrast 4,252.75$

MRI scan of leg with contrast 2,872.75$

MRI scan of lower spinal canal 4,199.25$

MRI scan of lower spinal canal before and after contrast 5,664.50$

MRI scan of lower spinal canal with contrast 4,618.75$

MRI scan of middle spinal canal 3,443.50$

MRI scan of middle spinal canal before and after contrast 4,849.00$

MRI scan of pelvis 3,270.75$

MRI scan of pelvis before and after contrast 4,310.00$

MRI scan of pelvis with contrast 3,611.25$

MRI scan of upper spinal canal 1,190.75$

MRI scan of upper spinal canal before and after contrast 5,071.00$

MRI scan of upper spinal canal with contrast 4,609.00$

Multiple measurements and graphic recordings of the amount and speed of breathed air, before and following medication administration 1,969.75$

Multiple measurements of eye fluid pressure over an extended time period, same day 50.00$

Multiple measurements of oxygen saturation in blood using ear or finger device 324.75$

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [111870] 0.06$

MUPIROCIN 2 % TOPICAL CREAM [47938] 8.64$

MUPIROCIN 2 % TOPICAL OINTMENT [41535] 0.53$

MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [133542] 5.04$

Mycophenolate (mycophenolic acid) level 202.25$

Mycophenolate mofetil, oral, 250 mg 8.23$

Myelin basic protein (nerve protein) level, spinal fluid 159.75$

Myoglobin (muscle protein) level 206.00$

NABUMETONE 500 MG TABLET [29026] 1.34$

NABUMETONE 750 MG TABLET [29855] 1.69$

NADOLOL 40 MG TABLET [6002] 7.50$

NAIL TROCHANTERIC 340-400MM LH 4,088.75$

NALBUPHINE 10 MG/ML INJECTION SOLUTION [3336] 4.38$

NALTREXONE 50 MG TABLET [8908] 4.44$

NAPROXEN 250 MG TABLET [665] 0.80$

NAPROXEN 500 MG TABLET [667] 1.34$

Nasal procedure 367.50$

Nasal smear for eosinophils (allergy related white blood cells) 37.50$

NATEGLINIDE 120 MG TABLET [40628] 1.79$

Natriuretic peptide (heart and blood vessel protein) level 171.75$

NEBIVOLOL 10 MG TABLET [101886] 5.43$

NEBIVOLOL 2.5 MG TABLET [101885] 5.43$

Needle biopsy of abdominal cavity growth, accessed through the skin 3,009.25$

Needle biopsy of breast 1,177.00$

Needle biopsy of kidney, accessed through the skin 1,471.50$

Needle biopsy of liver, accessed through the skin 2,482.25$

Needle biopsy of lung or chest tissue, accessed through the skin 1,912.75$

Needle biopsy of thyroid, accessed through the skin 892.00$

NEEDLE HUBER 20G 1 1/2 RA 27.75$

NEEDLE HUBER 22G 1 1/2 RA 27.75$

NEEDLE HUBER SAFETY 20X1 28.25$

Needle measurement and recording of electrical activity of head or trunk muscles 70.00$

Needle measurement and recording of electrical activity of middle spine muscles 162.00$

Needle measurement and recording of electrical activity of muscles of arm or leg complete study 70.00$

Needle measurement and recording of electrical activity of muscles of arm or leg limited study 95.00$

Needle measurement and recording of electrical activity of muscles of arms or legs 114.00$

NEEDLE, HUBER 36.25$

NEEDLE,BIOPSY TYPE 1 177.00$

NEEDLE,BIOPSY TYPE 2 59.25$

Negative pressure wound therapy, surface area greater than 50 square centimeters, per session 484.00$

Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session 203.50$

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [5917] 13.05$

NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT [6411] 16.89$

NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [88672] 0.24$

NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [6731] 4.12$

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [8818] 10.45$

NEOSPORIN OINT, 30GM 12.71$

Nephelometry, test method using light 168.00$

Nerve transmission studies, 11-12 studies 496.00$





Neurobehavioral status examination, interpretation, and report by psychologist or physician per hour 377.50$

NIACIN 250 MG TABLET [6619] 0.04$

NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR [31585] 6.44$

NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION [45909] 26.25$

NICOTINE (POLACRILEX) 2 MG GUM [9770] 0.29$

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [8499] 2.22$



NIFEDIPINE 10 MG CAPSULE [6408] 3.42$

NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [5176] 1.38$

NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [8578] 2.38$

NITROFURANTOIN MONOHYDRATE & MACROCRYSTAL 100 MG ORAL CAP [41908] 3.66$

NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH [8585] 1.93$


NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [24864] 1.55$


NITROGLYCERIN 0.6 MG SUBLINGUAL TABLET [24865] 0.71$

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [23994] 2.86$

NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [110223] 0.09$

NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [111991] 1.62$

NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [3341] 0.10$

Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle 138.00$

Non-needle measurement and recording of electrical activity of muscles at bladder and bowel openings 200.00$

NON-ROUTINE HEMODIALYSIS 959.00$

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [39256] 6.30$

NORTRIPTYLINE 10 MG CAPSULE [5155] 0.46$

NORTRIPTYLINE 25 MG CAPSULE [5156] 0.92$

Nuclear medicine imaging for thyroid uptake measurements 1,518.50$

Nuclear medicine imaging from skull base to mid-thigh 4,356.25$

Nuclear medicine study of blood circulation in the lungs 1,199.25$

Nuclear medicine study of bone and/or joint 2,188.25$

Nuclear medicine study of heart wall motion at rest or stress with evaluation of blood ejection from heart, single study 1,548.25$

Nuclear medicine study of kidney with assessment of blood flow and function 1,837.50$

Nuclear medicine study of liver 2,419.25$

Nuclear medicine study of liver with blood flow 982.75$

Nuclear medicine study of lung ventilation 1,123.00$

Nuclear medicine study of lung ventilation and blood circulation in the lungs 1,704.25$

Nuclear medicine study of radioactive material distribution 1,984.00$

Nuclear medicine study of radioactive material distribution at site of inflammation 2,943.00$

Nuclear medicine study of radioactive material distribution at sites of inflammation in whole body 2,676.00$

Nuclear medicine study of radioactive material distribution at tumor locations in whole body, single day imaging 2,513.75$

Nuclear medicine study of radioactive material distribution of whole body, requiring 2 or more days imaging 3,726.25$

Nuclear medicine study of vessels of heart using drugs or exercise multiple studies 2,749.00$

Nuclear medicine study of vessels of heart using drugs or exercise single study 2,749.00$

Nuclear medicine study with CT imaging skull base to mid-thigh 5,892.50$

Nuclear medicine study with CT imaging whole body 5,892.50$

Nuclear medicine study with measurement of blood circulation in the lungs 2,204.00$

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5881] 1.21$

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [2687] 0.29$

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [42135] 7.75$

Observation, testing, and recording of abnormal eye movement 275.00$

OLANZAPINE 5 MG DISINTEGRATING TABLET [49664] 14.81$

OLANZAPINE 5 MG TABLET [45302] 13.72$

OLANZAPINE 7.5 MG TABLET [45957] 16.69$

OLMESARTAN 20 MG TABLET [50462] 6.04$

OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [28284] 0.08$

OMEGA-3 FISH OIL 1 G CAP 7.26$

OMEPRAZOLE 10 MG CAPSULE,DELAYED RELEASE [40725] 3.84$

OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE [38954] 4.05$

ONDANSETRON 4 MG DISINTEGRATING TABLET [49063] 1.33$

ONDANSETRON HCL 4 MG TABLET [45094] 25.72$

OR MAJOR 1ST 1/2 HOUR 2,066.25$

Organic acids level 691.00$

ORTHOPEDIC IMPLANT -$

OSELTAMIVIR 30 MG CAPSULE [100574] 14.72$

OSELTAMIVIR 45 MG CAPSULE [100575] 14.72$

Oseltamivir phosphate, oral, brand, per 75 mg (for use in a medicare-approved demonstration project) 378.55$

Osteocalcin (bone protein) level 186.50$

Osteopathic manipulative treatment to 1-2 body regions 15.00$

OSTEOSET MINI BEAD KIT 1,684.00$

Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

Other speech language pathology functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Other speech language pathology functional limitation, discharge status at discharge from therapy or to end reporting 0.25$

Other speech language pathology functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

Overnight measurement of oxygen saturation in blood using ear or finger device 447.50$

Oxalate level 136.00$

OXCARBAZEPINE 150 MG TABLET [44190] 1.57$

OXCARBAZEPINE 300 MG TABLET [45738] 2.86$

Oxcarbazepine level 324.50$

OXYBUTYNIN CHLORIDE 5 MG TABLET [6340] 0.75$

OXYCODONE 15 MG TABLET [42173] 1.94$



OXYCODONE 5 MG/5 ML ORAL SOLUTION [30157] 1.79$

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [145882] 4.70$



Oxycodone levels 87.00$

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [6388] 1.42$

OXYGEN SUPPLY/DAY 178.25$

OXYMETAZOLINE 0.05 % NASAL SPRAY [8816] 0.06$

Pacemaker, dual chamber, rate-responsive (implantable) 16,940.50$

Pacemaker, other than single or dual chamber (implantable) 13,370.50$

Pacemaker, single chamber, rate-responsive (implantable) 13,031.00$

PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [89881] 45.98$

PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR [89882] 45.98$

PANCRELIPASE DR(27K-5K-17K)UNI 7.26$

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [46266] 5.47$

PANTOPRAZOLE 40 MG GRANULES FOR ORAL SUSP, DELAYED RELEASE [102486] 16.33$

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [47191] 0.48$

Parathormone (parathyroid hormone) level 540.50$

PAROXETINE 10 MG TABLET [40192] 2.92$

PAROXETINE 20 MG TABLET [40193] 2.89$

Pathology examination of specimen during surgery 273.50$

Pathology examination of tissue during surgery 556.00$

Pathology examination of tissue using a microscope 217.25$

Pathology examination of tissue using a microscope, high complexity 733.00$

Pathology examination of tissue using a microscope, intermediate complexity 332.50$

Pathology examination of tissue using a microscope, limited examination 131.50$

Pathology examination of tissue using a microscope, moderately high complexity 544.75$

Pathology examination of tissue using a microscope, moderately low complexity 263.00$

Patient education, not otherwise classified, non-physician provider, individual, per session 82.00$

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [53045] 0.72$

PEG TUBES 985.50$

PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [45950] 0.01$

PEN SURG MARKING 8.75$

PENICILLIN V POTASSIUM 250 MG TABLET [2348] 1.24$

PENICILLIN V POTASSIUM 500 MG TABLET [5182] 1.21$

Pentamidine isethionate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 300 mg 207.85$

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [5205] 1.55$

Percutaneous insertion of small bowel tube (accessed through the skin) using fluoroscopic guidance with contrast 1,517.25$

PERMETHRIN 1 % TOPICAL LIQUID [28216] 0.18$

PERMETHRIN 5 % TOPICAL CREAM [9387] 2.05$

PERPHENAZINE 2 MG TABLET [5978] 2.04$

PERPHENAZINE 8 MG TABLET [5980] 3.38$

Perphenazine, 4 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen2.79$

Pessary, non rubber, any type 75.00$

PHASE 1 RECOVERY PER MIN 7.00$

PHENAZOPYRIDINE 100 MG TABLET [5760] 2.80$

PHENAZOPYRIDINE 200 MG TABLET [5761] 4.15$

PHENOBARBITAL 32.4 MG TABLET [7516] 0.88$

Phenobarbital level 171.75$

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [49548] 0.02$

Phenylalanine, PKU (amino acid) level 125.50$

PHENYLEPHRINE 1 % NASAL SPRAY [47141] 0.45$

PHENYLEPHRINE 10 % EYE DROPS [42331] 9.96$

PHENYLEPHRINE 2.5 % EYE DROPS [7373] 7.05$

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [103820] 2.24$

PHENYTOIN 50 MG CHEWABLE TABLET [45771] 0.81$

Phenytoin level 178.25$

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [8567] 0.71$

PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [49318] 1.33$

Phosphatase (enzyme) level 290.25$

Phosphatase (enzyme) measurement 185.00$

Phosphate level 103.00$

Phospholipid antibody (autoimmune antibody) measurement 163.50$

Photography of content of eyes 114.00$

Photography of the retina 266.00$

Phototherapy (bilirubin) light with photometer 261.75$

Physical performance test or measurement with report, each 15 minutes 145.25$

Physician services for outpatient heart cardiac rehabilitation per session 173.25$

Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session 241.00$

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [49647] 12.80$

PHYTONADIONE 1 MG/ML ORAL LIQUID (CCF) [614329] 6.01$

PILOCARPINE 2 % EYE DROPS [2914] 7.90$

PILOCARPINE 5 MG TABLET [43501] 1.88$

PIN STEINMAN AND GUIDEWIRE 75.25$

Pinworm test 125.50$

PIOGLITAZONE 15 MG TABLET [44066] 5.90$

PIOGLITAZONE 30 MG TABLET [48922] 9.01$

PIPERACILLIN/TAZOBACTAM PER 1G 31.14$

PIPERACILLIN-TAZOBACTAM PER 1G 31.14$

Placement of breast localization devices accessed through the skin with mammographic guidance 240.50$

Placement of breast localization devices accessed through the skin with stereotactic guidance 1,112.50$

Placement of breast localization devices accessed through the skin with ultrasound guidance 1,190.75$

Placement of catheter of gallbladder and pancreas under imaging using an endoscope 1,088.25$

Placement of catheter of kidney, accessed through the skin using imaging guidance with radiological supervision and interpretation 3,501.75$

Placement of ear probe for computerized cochlear assessment of repeated sounds with interpretation and report 275.00$

Placement of ear probe for computerized measurement of sound with interpretation and report 275.00$

Placement of intra-uterine device (IUD) for pregnancy prevention 100.00$

Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure (e.g., angioseal plug, vascular plug) 105.00$

Placement of stent pancreatic or bile duct using an endoscope 6,516.75$

Placement of temporary pacemaker leads 15,801.50$

Platelet count, automated test 95.25$

Platelet function test 147.25$

Platelets, pheresis, each unit 2,150.00$

Pneumococcal vaccine for injection into muscle 300.00$

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [44609] 1.94$

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [24627] 14.01$

POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE [10442] 0.13$

POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE [52439] 0.36$

PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [85155] 337.95$

PORT A CATH LOW PROFILE 1,081.00$

Post-delivery care 100.00$

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [3680] 0.21$

POTASSIUM BICARBONATE AND CHLORIDE 25 MEQ EFFERVESCENT TABLET [44058] 0.51$

POTASSIUM BICARBONATE-CITRIC ACID 25 MEQ EFFERVESCENT TABLET [6400] 0.25$

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [2596] 0.84$

POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE [4170] 0.67$

POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [30045] 0.71$

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [4114] 0.71$

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [101488] 0.54$

POVIDONE-IODINE 10 % TOPICAL OINTMENT [6747] 0.07$

POVIDONE-IODINE 5 % EYE SOLUTION [47507] 0.47$

POWER PORT 1,070.50$

PRAMIPEXOLE 0.25 MG TABLET [47991] 3.06$

PRAMIPEXOLE 1 MG TABLET [40492] 3.47$

PRASUGREL 10 MG TABLET [112844] 19.05$

PRAVASTATIN 10 MG TABLET [46693] 0.49$

PRAVASTATIN 20 MG TABLET [48414] 3.39$

PRAZOSIN 1 MG CAPSULE [671] 1.88$

Prealbumin (protein) level 158.25$

Predelivery care 4-6 visits 200.00$

PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION [23260] 11.48$

Prednisolone oral, per 5 mg 7.26$

PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [38180] 0.33$

Prednisone, immediate release or delayed release, oral, 1 mg 0.77$

PREGABALIN 25 MG CAPSULE [83700] 9.26$



Pregnenolone (reproductive hormone) level 163.75$

PRENATAL VIT NO.136-FERROUS FUMARATE 27 MG IRON-FOLIC ACID 1 MG TABLET [49454] 0.27$

Preparation and provision of single or multiple antigens for allergen immunotherapy 39.00$

Preparation of tissue for examination by removing any calcium present 211.75$

Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement 304.25$

Pretreatment of serum for use in red blood cell antibody analysis and measurement 113.50$

PRIMIDONE 50 MG TABLET [29089] 0.52$

Primidone level 201.75$

PROBENECID 500 MG TABLET [5953] 1.19$

Procalcitonin (hormone) level 266.25$

PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [10542] 13.06$

Prochlorperazine maleate, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen1.01$

Progesterone (reproductive hormone) level 231.50$

Prolactin (milk producing hormone) level 344.25$

Prolonged chemotherapy infusion into a vein by portable or implanted pump more than 8 hours 760.75$

Prolonged office or other outpatient service first hour 40.00$

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [39731] 18.37$

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [38990] 18.37$

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [38455] 0.19$

Promethazine hydrochloride, 12.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen0.55$

PROPARACAINE 0.5 % EYE DROPS [8851] 3.04$

PROPRANOLOL 10 MG TABLET [6447] 0.21$



PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE [24304] 2.26$

PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED RELEASE [23235] 2.48$

PROPYLTHIOURACIL 50 MG TABLET [714] 2.70$

Prostate cancer screening; prostate specific antigen test (psa) 217.25$

Protein C, (clotting inhibitor) activity 471.25$

Protein measurement 290.25$

Protein measurement, body fluid 191.25$

Protein measurement, serum 191.25$

Protein S (clotting inhibitor) measurement 348.50$

Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity 2.88$

PSA (prostate specific antigen) measurement 447.50$

PSEUDOEPHEDRINE 30 MG TABLET [2661] 0.06$

Psychiatric diagnostic evaluation 402.25$

Psychotherapy, 30 minutes 262.50$

Psychotherapy, 60 minutes 283.50$

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [142080] 0.53$

PT WORK CONDITION PER 15 MIN 52.50$

Pulmonary service or operation 275.75$

Pure tone air conduction threshold hearing assessment 114.00$

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [39241] 1.54$

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [7391] 0.03$

Pyruvate kinase (enzyme) level 237.50$

Qualitative or semiquantitative detection test for helicobacter pylori in stool, multiple-step method 189.50$

Quantitation of therapeutic drug 324.50$

QUETIAPINE 100 MG TABLET [46007] 8.30$




QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR [110511] 16.53$

QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [110510] 9.20$

QUINAPRIL 20 MG TABLET [48402] 1.27$

QUINAPRIL 5 MG TABLET [47912] 1.27$

Rabies immune globulin for injection beneath the skin and/or into muscle 1,197.92$

RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [56042] 1.30$

Radiological supervision and interpretation of CT guidance for needle insertion 1,969.75$

Radiological supervision and interpretation of imaging of arteries of both arms or legs 6,030.50$

Radiological supervision and interpretation of imaging of artery of one arm or leg 7,275.75$

Radiological supervision and interpretation of imaging of previous placed shunt 232.50$

Radiological supervision and interpretation of imaging of vein of one arm or leg 2,066.50$

Radiological supervision and interpretation of imaging of vein system of head 2,655.00$

Radiological supervision and interpretation of placement of catheter with drainage (accessed through the skin) procedure 126.75$

Radiological supervision and interpretation X-ray of abdominal aorta 7,275.75$

Radiological supervision and interpretation X-ray of abdominal aorta and both leg arteries 7,275.75$

Radiological supervision and interpretation X-ray of bile and/or pancreatic ducts during surgery 813.75$

Radiological supervision and interpretation X-ray of elbow 497.00$

Radiological supervision and interpretation X-ray of hip joint 625.50$

Radiological supervision and interpretation X-ray of knee joint 676.75$

Radiological supervision and interpretation X-ray of lower spinal canal 1,634.75$

Radiological supervision and interpretation X-ray of middle spinal canal 1,283.00$

Radiological supervision and interpretation X-ray of shoulder joint 751.25$

Radiological supervision and interpretation X-ray of spinal canal, 2 or more spinal regions 1,842.50$

Radiological supervision and interpretation X-ray of upper spinal canal 1,261.00$

Radiological supervision and interpretation X-ray of urinary bladder and urethra 814.00$

Radiological supervision and interpretation X-ray of urinary bladder, minimum of 3 views 502.00$

Radiological supervision and interpretation X-ray of urinary tract 553.25$

Radiological supervision and interpretation X-ray of uterine tubes and ovaries 542.25$

Radiological supervision and interpretation X-ray of wrist joint 497.00$

RALOXIFENE 60 MG TABLET [48127] 8.22$

RALTEGRAVIR 400 MG TABLET [100667] 31.14$

RAMIPRIL 1.25 MG CAPSULE [49346] 1.97$

RANITIDINE 150MG TAB 7.26$

RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [86285] 7.41$

RECOVERY L/D PER MINUTE 7.00$

RECOVERY ROOM/ MINUTE 7.00$

RECOVERY-ENDO 56.75$

Red blood cell antibody detection test 172.00$

Red blood cell antibody level 166.25$

Red blood cell concentration measurement 39.50$

Red blood cell sedimentation rate, to detect inflammation 57.25$

Red blood cell sickling measurement 80.75$

Red blood cells, each unit 618.00$

Red blood cells, leukocytes reduced, each unit 618.00$

Red blood count automated, with additional calculations 33.00$

Re-evaluation of occupational therapy established plan of care, typically 30 minutes 162.00$

Re-evaluation of physical therapy, typically 20 minutes 154.25$

Refilling and maintenance of portable pump 475.75$

Relocation of mouth tissue to gum surface 2,050.75$

Relocation of pacemaker generator skin pocket 3,928.50$

Removal (1.5 centimeters or greater) tissue growth beneath the skin of foot or toe 3,000.00$

Removal (3.1 to 4.0 centimeters) growth of face, ears, eyelids, nose, lips, or mouth 645.00$

Removal (over 4.0 centimeters) growth of the face, ears, eyelids, nose, lips, or mouth 1,830.00$

Removal and replacement of defibrillator pulse generator 47,860.50$

Removal and replacement of dual lead permanent pacemaker pulse generator 21,441.50$

Removal and replacement of multiple lead permanent pacemaker pulse generator 21,441.50$

Removal and replacement of single lead permanent pacemaker pulse generator 18,633.50$

Removal of antibodies from surface of red blood cell 180.00$

Removal of blood accumulation between nail and nail bed 240.50$

Removal of blood clot and injections (accessed through the skin) to dissolve blood clot from veins using fluoroscopic guidance 7,900.75$

Removal of blood clot and injections to dissolve blood clot from artery or arterial graft using fluoroscopic guidance, accessed through the skin 7,900.75$

Removal of central venous catheter for infusion 6,284.25$

Removal of deep foreign body in muscle or tendon 1,830.00$

Removal of defibrillator pulse generator 2,964.25$

Removal of drug delivery implant from tissue 114.00$

Removal of electrode from right heart 5,712.75$

Removal of eyelashes by forceps 114.00$

Removal of eyelid growth 1,618.00$

Removal of fluid from between lung and chest cavity, open procedure 1,249.75$

Removal of fluid from chest cavity with imaging guidance 1,244.50$

Removal of fluid from chest cavity with insertion of indwelling catheter and imaging guidance, accessed through the skin 2,077.00$

Removal of fluid from chest cavity with insertion of indwelling catheter, accessed through the skin 2,950.50$

Removal of foreign body from ear canal 165.50$

Removal of foreign body from inside the eye or lens 3,920.50$

Removal of foreign body from tissue, accessed beneath the skin 3,800.50$

Removal of foreign body in external eye, conjunctiva 219.00$

Removal of foreign body in external eye, conjunctiva or sclera 114.00$

Removal of foreign body in nose 165.50$

Removal of foreign body of foot tissue, accessed beneath the skin 1,934.25$

Removal of foreign body or stent from pancreatic or bile duct using an endoscope 4,152.00$

Removal of foreign body, external eye, cornea 855.00$

Removal of foreign body, external eye, cornea with slit lamp examination 219.00$

Removal of foreskin of using clamp or device 5,155.50$

Removal of growth (0.5 centimeters or less) of the face, ears, eyelids, nose, lips, or mouth 601.00$

Removal of growth (0.5 centimeters or less) of the scalp, neck, hands, feet, or genitals 1,177.00$

Removal of growth (0.5 centimeters or less) of the trunk, arms or legs 601.00$

Removal of growth (0.6 to 1.0 centimeters) of the face, ears, eyelids, nose, lips, or mouth 601.00$

Removal of growth (0.6 to 1.0 centimeters) of the scalp, neck, hands, feet, or genitals 1,177.00$

Removal of growth (0.6 to 1.0 centimeters) of the trunk, arms, or legs 601.00$

Removal of growth (1.1 to 2.0 centimeters) of the face, ears, eyelids, nose, lips, or mouth 1,177.00$


Removal of growth (1.1 to 2.0 centimeters) of the trunk, arms, or legs 601.00$


Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs 1,177.00$

Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs 1,413.00$

Removal of growth (4.0 centimeters) of the trunk, arms, or legs 1,768.00$

Removal of growth (over 4.0 centimeters) of the scalp, neck, hands, feet, or genitals 1,830.00$

Removal of hemorrhoid by rubber banding 1,097.75$

Removal of impact ear wax, one ear 240.50$

Removal of impacted ear wax by washing 240.50$

Removal of implantable patient-activated heart monitoring device 2,031.00$

Removal of intra-uterine device (IUD) for pregnancy prevention 314.00$

Removal of malignant growth (0.5 centimeters or less) of the scalp, neck, hands, feet, or genitals 645.00$

Removal of malignant growth (0.5 centimeters or less) of the trunk, arms, or legs 1,177.00$

Removal of malignant growth (0.6 to 1.0 centimeters) of the face, ears, eyelids, nose, or lips 601.00$

Removal of malignant growth (0.6 to 1.0 centimeters) of the trunk, arms, or legs 601.00$

Removal of malignant growth (1.1 to 2.0 centimeters) of the face, ears, eyelids, nose, or lips 601.00$

Removal of malignant growth (1.1 to 2.0 centimeters) of the scalp, neck, hands, feet, or genitals 1,177.00$

Removal of malignant growth (1.1 to 2.0 centimeters) of the trunk, arms, or legs 601.00$

Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips 1,177.00$

Removal of malignant growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals 1,177.00$

Removal of malignant growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs 1,177.00$

Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs 645.00$

Removal of malignant growth (over 4.0 centimeters) of the trunk, arms, or legs 1,768.00$

Removal of multiple growths of different eyelids 326.00$

Removal of multiple growths of same eyelid 48.00$

Removal of nail 399.00$

Removal of outer layer of cornea 1,393.00$

Removal of permanent pacemaker pulse generator 7,350.00$

Removal of plaque and insertion of stents into arteries in one leg, endovascular, accessed through the skin or open procedure 25,641.25$

Removal of plaque in arteries in one leg, endovascular, accessed through the skin or open procedure 22,781.50$

Removal of polyps or growths of esophagus, stomach, and/or upper small bowel using an endoscope 3,517.75$

Removal of single thickened skin growth 203.50$

Removal of skin and bone first 20 sq cm or less 1,776.75$

Removal of skin and tissue 701.75$

Removal of skin and tissue first 20 sq cm or less 1,190.75$

Removal of skin and/or muscle 701.75$

Removal of skin and/or muscle first 20 sq cm or less 670.75$

Removal of skin debris and drainage of mastoid cavity 147.00$

Removal of skin of finger or toe nail 147.00$

Removal of skin suture with change of bladder tube 493.75$

Removal of skin tags 80.00$

Removal of tailbone cyst 3,241.25$

Removal of tissue from 1 to 5 finger or toe nails 121.25$

Removal of tissue from 6 or more finger or toe nails 121.25$

Removal of tissue from wounds per session 372.75$

Removal of up to and including 15 skin tags 147.00$

Renin (kidney enzyme) level 250.75$

REPAGLINIDE 2 MG TABLET [44293] 7.79$

Repair device, urinary, incontinence, with sling graft 3,769.75$

Repair of blood vessel of arm 5,360.25$

Repair of blood vessel of leg 2,139.50$

Repair of finger or toe nail bed 807.00$

Repair of toe tendon, accessed through the skin 1,740.00$

Repair of wound (1.1 to 2.5 centimeters) of scalp, arms, and/or legs 806.50$

Repair of wound (12.6 to 20.0 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs 1,190.75$

Repair of wound (12.6 to 20.0 centimeters) of the scalp, underarms, trunk, arms, and/or legs 1,190.75$

Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, and/or mucous membranes 308.00$

Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs 308.00$

Repair of wound (2.5 centimeters or less) of the scalp, underarms, trunk, arms, and/or legs 484.00$

Repair of wound (2.6 to 5.0 centimeters) of face, ears, eyelids, nose, lips, and/or mouth 630.00$

Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes 308.00$

Repair of wound (2.6 to 7.5 centimeters) of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, and/or feet 2,050.75$

Repair of wound (2.6 to 7.5 centimeters) of scalp, arms, and/or legs 2,050.75$

Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs 308.00$

Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs 806.25$

Repair of wound (2.6 to 7.5 centimeters) of trunk 2,050.75$

Repair of wound (20.1 to 30.0 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs 1,190.75$


Repair of wound (7.6 to 12.5 centimeters) of neck, hands, feet, and/or genitals 1,190.75$


Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs 308.00$

Repair of wound (7.6 to 12.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs 1,190.75$

Repair of wound of scalp, arms, and/or legs 1,190.75$

Replacement of kidney drainage catheter accessed through the skin with imaging and radiological supervision and interpretation 2,100.00$

Replacement of peripheral venous catheter 2,100.00$

Repositioning maneuvers for treatment of vertigo, per day 155.00$

Repositioning of implanted pacemaker or defibrillator device 5,442.25$

RESOLUTION CLIPS 370.50$

Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen 341.75$

Reviving newborn at delivery 885.50$

Rheumatoid factor level 138.75$

RIFAMPIN 300 MG CAPSULE [6769] 1.38$

RIFAXIMIN 550 MG TABLET [116444] 45.56$

Ringers lactate infusion, up to 1000 cc 0.01$

RISPERIDONE 0.5 MG TABLET [49430] 4.43$

RISPERIDONE 1 MG TABLET [49198] 4.71$

RISPERIDONE 2 MG TABLET [46376] 4.08$

RIVAROXABAN 10 MG TABLET [123504] 17.40$



RIVASTIGMINE 1.5 MG CAPSULE [40539] 4.40$

RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [99231] 26.87$

RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH [99232] 26.87$

RIZATRIPTAN 10 MG DISINTEGRATING TABLET [47090] 45.54$

RIZATRIPTAN 5 MG DISINTEGRATING TABLET [48921] 37.75$

ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [45675] 0.91$

ROFLUMILAST 500 MCG TABLET [122215] 14.55$

Room and Board Intensive Care Unit General 2,941.00$

Room and Board Intermediate Intensive Care Unit 2,056.00$

Room and Board Nursery 1,004.00$

Room and Board Semiprivate Hospice 1,376.00$

Room and Board Semiprivate Medical/Surgical/GYN 1,376.00$

Room and Board Semiprivate Psychiatric 1,877.00$

Room and Board Semiprivate Skilled Nursing 1,180.00$

ROPINIROLE 0.25 MG TABLET [46912] 2.60$

ROPINIROLE 1 MG TABLET [44378] 2.60$

ROPINIROLE 4 MG TABLET [49629] 2.59$

ROSUVASTATIN 10 MG TABLET [53606] 1.50$

ROSUVASTATIN 20 MG TABLET [53607] 1.50$

Routine electrocardiogram (EKG) with tracing using at least 12 leads 308.75$

ROUTINE HEMODIALYSIS 959.00$

SACCHAROMYCES BOULARDII 250 MG CAPSULE [54687] 0.97$

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [147927] 9.62$

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [147928] 9.62$

SALIVA SUBSTITUTE COMBO NO.9 MOUTHWASH [142575] 0.02$

SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION [47762] 9.88$

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [48815] 19.99$

Screening digital tomography of both breasts 90.25$

Screening examination of specimen cells 168.75$

Screening test for antibody to noninfectious agent 162.00$

Screening test for autoimmune disorder 189.50$

Screening test for compatible blood unit 304.25$

Screening test for mononucleosis (mono) 87.25$

Screening test for pathogenic organisms 105.00$

Screening test for presence of antibody 219.50$

Screening test for red blood cell antibodies 140.25$

SCRW 4.0CNCLS PTL THRD 10-50MM 43.00$

SCRW 5.0 LCKG/IM NAIL 26-100MM 409.25$

SCRW 5.0MM CNLTD LCKNG 25-95MM 445.25$

Selenium (vitamin) level 138.75$

Self care functional limitation, current status, at therapy episode outset and at reporting intervals 0.25$

Self care functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

Self-care or home management training, each 15 minutes 145.25$

Semen analysis for sperm presence 154.25$

Semen evaluation volume, sperm count, motility and analysis 231.50$

SENNOSIDES 8.6 MG TABLET [24585] 0.08$

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [43603] 0.04$

Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes 93.00$

Separation of nail plate from nail bed 193.75$

Serotonin (hormone) level 520.75$

SERTRALINE 100 MG TABLET [45246] 0.42$



SET BUTTERFLY 24 X 3/4 13.75$

SET EXT W/TCONNECTOR 20.25$

SET FILTER & AXALL FIONCO 34.25$

SEVELAMER CARBONATE 800 MG TABLET [101881] 7.03$

Sex hormone binding globulin (protein) level 145.75$

Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth 282.00$

Shaving of 0.5 centimeters or less skin growth of scalp, neck, hands, feet, or genitals 147.00$

Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs 147.00$

Shaving of 0.6 centimeters to 1.0 centimeters skin growth of face, ears, eyelids, nose, lips, or mouth 282.00$

Shaving of 0.6 centimeters to 1.0 centimeters skin growth of scalp, neck, hands, feet, or genitals 147.00$

Shaving of 0.6 centimeters to 1.0 centimeters skin growth of the trunk, arms, or legs 147.00$

Shaving of 1.1 to 2.0 centimeters skin growth of face, ears, eyelids, nose, lips, or mouth 282.00$

Shaving of 1.1 to 2.0 centimeters skin growth of the trunk, arms, or legs 147.00$

Shaving of over 2.0 centimeters skin growth of face, ears, eyelids, nose, lips, or mouth 282.00$

SHEEHY COLLR EAR TUBE 23-40300 19.75$

SIGMOIDOSCOPY 1,604.00$

SIGMOIDOSCOPY W/POLYP REM 2,237.50$

SILVER ER TOPICAL GEL,EXTENDED RELEASE [56063] 0.71$

SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK [90041] 0.25$

SILVER SULFADIAZINE 1 % TOPICAL CREAM [8861] 0.17$

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [5365] 0.21$

SIMETHICONE 80 MG CHEWABLE TABLET [6749] 0.09$

Simple control of nose bleed 237.00$

SIMVASTATIN 20MG TAB 16.61$

Sirolimus level 265.75$

SITAGLIPTIN 100 MG TABLET [88990] 17.83$

SITAGLIPTIN 25 MG TABLET [88987] 17.83$

Skin barrier, wipes or swabs, each 28.50$

Skin test for tuberculosis 16.00$

Skin, mucus membrane and beneath the skin procedure 384.75$

Sleep monitoring of patient (6 years or older) in sleep lab 4,509.75$

Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube 4,880.75$

Sleep monitoring of patient (younger than 6 years) in sleep lab 1,531.75$

Smear for infectious agents 100.75$

Smoking and tobacco use intensive counseling, greater than 10 minutes 34.00$

Smoking and tobacco use intermediate counseling, greater than 3 minutes up to 10 minutes 34.00$

SOD CHL 0.9% PF LUSH INJ 10 ML 7.50$

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [3684] 0.20$

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [4053] 0.24$

SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE [132536] 1.75$

SODIUM BICARBONATE 650 MG TABLET [16] 0.07$

SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL [24003] 0.02$

SODIUM CHLORIDE 0.9 % FOR NEBULIZATION [2688] 0.04$

SODIUM CHLORIDE 0.9 % INJECTION SYRINGE [1028] 0.88$

SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION [3346] 0.05$

SODIUM CHLORIDE 1 GRAM TABLET [15] 0.10$

SODIUM CHLORIDE 2 % EYE DROPS [49623] 1.19$

SODIUM CHLORIDE 3 % FOR NEBULIZATION [21221] 0.10$

SODIUM CHLORIDE 5 % EYE OINTMENT [6657] 3.70$

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [5555] 0.07$

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [48260] 0.53$

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [47065] 227.99$

SODIUM HYPOCHLORITE 0.25 % SOLUTION [50104] 0.03$

Sodium level 68.75$

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [10511] 29.73$

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [31251] 1.21$

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [47846] 0.01$

SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [90717] 0.02$

SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP [152071] 0.20$

SOL .45% SC 1000 ML 2.25$

SOL SOD CHOL 0.9% IRR 5.25$

SOLIFENACIN 5 MG TABLET [56684] 15.10$

Somatomedin (growth factor) level 295.75$

SORBITOL 70 % SOLUTION [5564] 0.12$

SOTALOL 120 MG TABLET [5178] 3.25$

SOTALOL 80 MG TABLET [5179] 2.44$

Special stain for microorganism 73.00$

Special stained specimen slides to examine tissue 103.50$

Special stained specimen slides to examine tissue including interpretation and report 173.50$

Special stained specimen slides to identify organisms including interpretation and report 156.00$

Specimen analysis for blood 41.25$

Speical Charge General Admission - IV Board 20.25$

Spinal tap for diagnosis 1,354.50$

SPIRONOLACTONE 25 MG TABLET [8568] 0.44$

SPIRONOLACTONE 50 MG TABLET [7309] 0.91$

Spoken language comprehension functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Spoken language comprehension functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Spoken language comprehension functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting0.25$

Spoken language expression functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Spoken language expression functional limitation, discharge status at discharge from therapy or to end reporting 0.25$

Spoken language expression functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

SPONGE 4X4 ST RAYTEC 8.75$

Standardized thought processing testing, interpretation, and report per hour 401.75$

Stent, non-coated/non-covered, with delivery system 3,664.75$

Stent, non-coronary, temporary, without delivery system 576.50$

Sterile water, saline and/or dextrose, diluent/flush, 10 ml 0.11$

Sterile water/saline, 500 ml 0.01$

Stomach emptying study 1,639.50$

Stool analysis for blood 59.25$

Stool analysis for blood to screen for colon tumors 18.50$

Stool culture 217.25$

Stool porphyrins (metabolism substance) level 467.25$

Strapping of ankle and/or foot 281.75$

Strapping of knee 281.75$

Strapping of shoulder 281.75$

Strapping, Unna boot 268.00$

Strep test (Streptococcus, group A) 35.00$

Study of sleep patterns 468.75$

SUCRALFATE 1 GRAM TABLET [5189] 0.39$

SUCRALFATE 100 MG/ML ORAL SUSPENSION [44976] 0.98$

SUCROSE IN WATER 24% CUP [600870] 0.07$

SULFACETAMIDE SODIUM 10 % EYE DROPS [5916] 3.85$

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [5133] 0.47$

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [5089] 0.81$

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [10348] 1.56$

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [5090] 0.23$

SULFASALAZINE 500 MG TABLET [6287] 0.25$

SUMATRIPTAN 100 MG TABLET [44895] 2.21$



SUPER QUICK ANCHOR 1,596.50$

SURG LEVEL 1 EA ADD 30 MIN 1,771.25$





SURGERY LEVEL 1 1ST 30 MIN 2,400.25$





SURGIFLO HEMOSTATIC MATRIX 12 ML KIT [613282] 252.31$

SUTURLYSIS FOR SUTURE REMOVAL 3,475.00$

Swallowing functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting 0.25$

Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

Sweat collection 178.25$

SYNTH CIRC WIRE W/EYE 10.75$

Syphilis detection test 38.25$

Syphilis test 93.00$

SYR 10 ML PREFILL 7.50$

T cell count and ratio 227.25$

T cells count, total 180.75$

Tacrolimus level 265.75$

Tacrolimus, immediate release, oral, 1 mg 4.63$

Tamoxifen citrate, oral, 10 mg 2.46$

TAMSULOSIN 0.4 MG CAPSULE [46859] 4.37$

Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose 21.00$

Technetium tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries 375.00$

Technetium tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries 83.25$

Technetium tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries 183.00$

Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries 116.25$

Technetium tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries 779.00$

Technetium tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries 103.75$

Technetium tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries 180.50$

Technetium tc-99m pertechnetate, diagnostic, per millicurie 2.75$

Technetium tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries 134.00$

Technetium tc-99m sestamibi, diagnostic, per study dose 1,091.50$

Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries 87.50$

Technetium tc-99m tetrofosmin, diagnostic, per study dose 305.75$

TELMISARTAN 80 MG TABLET [47538] 8.29$

TEMAZEPAM 15 MG CAPSULE [7304] 0.74$

TEMAZEPAM 7.5MG CAP 27.76$

TENCKHOFF CATHETER 88.50$

TERAZOSIN 1 MG CAPSULE [5148] 1.67$

TERAZOSIN 2 MG CAPSULE [5149] 1.67$

TERBINAFINE HCL 250 MG TABLET [46506] 13.52$

TESIO CATHETER 2,053.75$

Test for exercise-induced lung stress 220.00$

Testing for presence of drug 491.25$

Testing with stimulation for assessment of function at muscle-nerve junction 162.00$

Testosterone (hormone) level 296.25$

TETRACAINE 0.5 % VISCOUS EYE DROPS IN A DROPPERETTE [114968] 10.34$

TETRACAINE HCL (PF) 0.5 % EYE DROPS [120375] 3.18$

THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [49016] 3.42$

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [6365] 4.46$

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [44813] 1.41$

THEOPHYLLINE ER 600 MG TABLET,EXTENDED RELEASE 24 HR [47402] 2.04$

Theophylline level 177.00$

Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes 141.75$

Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes 135.00$

THERAPEUTIC MULTIVITAMIN TABLET [7355] 0.05$

Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes 145.25$

Therapeutic procedures in a group setting 83.50$

Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)247.50$

Therapeutic removal of whole blood to correct blood level imbalance 233.75$

THIAMINE 100 MG TABLET 6.23$

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [33349] 0.02$

Thiocyanate (organic sulfur substance) level 197.50$

THIOTHIXENE 5 MG CAPSULE [8479] 3.76$

THORACENTESIS TRAY 60.00$

THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY SYRINGE [131920] 370.13$

THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION [100271] 89.38$

Thrombin time, fibrinogen screening test 91.25$

Thyroglobulin (thyroid protein) antibody measurement 177.00$

Thyroglobulin (thyroid related hormone) level 179.00$

THYROID (PORK) 30 MG TABLET [113861] 0.86$

THYROID (PORK) 60 MG TABLET [113862] 0.95$

Thyroid hormone evaluation 120.75$

Thyroid hormone, T3 measurement 296.25$

Thyroid stimulating immune globulins (thyroid related protein) level 366.25$

Thyroxine (thyroid chemical) measurement 266.00$

TICAGRELOR 90 MG TABLET [123691] 7.33$

TIMOLOL MALEATE 0.25 % EYE DROPS [5907] 3.63$

TIMOLOL MALEATE 0.5 % EYE DROPS [5908] 3.53$

TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [55359] 19.62$

TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [144777] 57.78$

Tissue culture for tumor disorders of bone marrow and blood cells 1,067.25$

Tissue culture for virus isolation 323.50$

Tissue culture to identify white blood cell disorders 1,500.25$

Tissue fungi or parasites 84.75$

Tissue or cell analysis by immunologic technique 644.75$

TIZANIDINE 4 MG TABLET [37867] 1.53$

Tobramycin (antibiotic) level 237.25$

TOBRAMYCIN 0.3 % EYE DROPS [6738] 3.02$

TOBRAMYCIN 0.3 % EYE OINTMENT [48028] 76.28$

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [49657] 30.12$

TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [45613] 76.61$

TOLTERODINE 1 MG TABLET [44973] 3.43$

TOLTERODINE 2 MG TABLET [46652] 3.53$

TOLVAPTAN 15 MG TABLET [112266] 534.69$

TOLVAPTAN 7.5 MG PRE-SPLIT TABLET [612577] 222.81$

TOPIRAMATE 100 MG TABLET [49087] 6.43$

TOPIRAMATE 25 MG TABLET [45657] 2.18$

Topiramate level 148.25$

TORSEMIDE 100 MG TABLET [37863] 3.16$

TORSEMIDE 20 MG TABLET [37862] 0.85$

Total cell count for B cells (white blood cells) 183.00$

Total cell count for natural killer cells (white blood cell) 180.75$

Total protein level, blood 95.25$

Total protein level, body fluid 95.25$

Total protein level, urine 95.25$

TRABECULOPASTY 65855 4,294.25$

TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN [40547] 9.96$

Tracing of electrical activity of the heart using 1-3 leads 237.25$

Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes 148.25$

Training in use of prosthesis for arms and/or legs, per 15 minutes 135.00$

TRAMADOL 50 MG TABLET [37859] 0.83$

TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [125934] 9.01$

TRANEXAMIC ACID 650 MG TABLET [116660] 5.42$

Transferrin (iron binding protein) level 134.50$

Transfusion of blood or blood products 949.75$

Transitional care management services, highly complexity, requiring face-to-face visits within 7 days of discharge 128.00$

Transitional care management services, moderately complexity, requiring face-to-face visits within 14 days of discharge 128.00$

Translocation analysis (BCR/ABL1) minor breakpoint 602.75$

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography2,475.50$

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, follow-up or limited study918.75$

Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge12.25$

TRAVOPROST 0.004% OPHTH DPS, 2 408.13$

TRAY LUMBAR DISP 87.00$

TRAY SCRUB SKIN DISP 24.50$

TRAZODONE 100 MG TABLET [5135] 0.81$



Treatment of broken foot bone 297.00$

Treatment of elbow dislocation 727.75$

Treatment of hip dislocation 727.75$

Treatment of speech, language, voice, communication, and/or hearing processing disorder 296.25$

Treatment of swallowing and/or oral feeding function 379.50$

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [6646] 16.73$

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [5852] 0.27$

TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM [5850] 0.77$

TRIAMETERENE-HYDROCHLOROTHIAZI 7.26$

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [6478] 0.41$

TRIFLUOPERAZINE 5 MG TABLET [8571] 2.64$

Triglycerides level 88.75$

TRIHEXYPHENIDYL 2 MG TABLET [5711] 0.28$

TRIHEXYPHENIDYL 5 MG TABLET [5710] 0.69$

TROLAMINE 10% CRM, 90GM 16.35$

TROPICAMIDE 0.5 % EYE DROPS [18451] 1.85$

TROPICAMIDE 1 % EYE DROPS [18450] 5.19$

Troponin (protein) analysis 204.25$

TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [85027] 140.23$

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [44141] 96.52$

Tuberculosis test 224.50$

TUBING IV 20" EXT 7.00$

TUBING IV PRIM PUMP 20.25$

Turning of fetus from breech to presenting position 2,590.00$

Tying of dilated veins of stomach and/or esophagus using an endoscope 2,546.25$

Tying or incision of fallopian tubes at time of cesarean delivery or other abdominal surgery 239.00$

Ultrasonic guidance imaging supervision and interpretation for insertion of needle 1,061.00$

Ultrasound and monitoring of heart of fetus 649.75$

Ultrasound behind abdominal cavity 551.25$

Ultrasound behind abdominal cavity, limited 716.75$

Ultrasound evaluation of abdominal aorta to detect bulging (aneurysm) 154.25$

Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function 949.75$

Ultrasound examination of the heart performed during rest, exercise, and/or drug-induced stress with interpretation and report 828.50$

Ultrasound measurement of bladder capacity after voiding 114.00$

Ultrasound of abdomen 1,231.75$

Ultrasound of arm or leg 444.50$

Ultrasound of brain 425.25$

Ultrasound of chest 675.25$

Ultrasound of corneal structure and measurement 38.00$

Ultrasound of dialysis access 414.25$

Ultrasound of eye disease, growth, or structure 115.00$

Ultrasound of eye for determination of lens power 115.00$

Ultrasound of fetal umbilical artery flow rate 222.25$

Ultrasound of fetus 257.25$

Ultrasound of head and neck 663.00$

Ultrasound of hips with manipulation, infant 849.50$

Ultrasound of hips, infant 132.25$

Ultrasound of one breast 158.00$

Ultrasound of pelvis 821.75$

Ultrasound of pregnant uterus, 1 or more fetus(es) 605.50$

Ultrasound of rectum 940.25$

Ultrasound of scrotum 610.25$

Ultrasound of spinal canal 359.75$

Ultrasound of uterus 562.75$

Ultrasound pelvis through vagina 699.25$

Ultrasound scan of abdominal, pelvic, and/or scrotal arterial inflow and venous outflow 666.25$

Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers 666.25$

Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers 414.25$

Ultrasound scan of vena cava or groin graft or vessel blood flow 414.25$

Ultrasound scanning of blood flow (outside of brain) on one side of head and neck or limited 806.75$

Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck 666.25$

Ultrasound study of arteries and arterial grafts of both arms 864.50$

Ultrasound study of arteries and arterial grafts of both legs 666.25$

Ultrasound study of arteries and arterial grafts of one arm or limited 414.25$

Ultrasound study of arteries and arterial grafts of one leg or limited 414.25$

Ultrasound study of arteries of both arms and legs 417.00$

Ultrasound with elastography 152.00$

UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION [145547] 12.22$

UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION [141476] 8.50$

Unattended sleep study with recording of heart rate, oxygen, respiratory airflow and effort 468.75$

Unclassified drugs 15.15$

Unclassified drugs or biologicals 43.59$

Urea nitrogen level to assess kidney function 98.75$

Uric acid level 96.75$

Uric acid level, blood 67.50$

Urinalysis, manual test 57.25$

Urine calcium level 96.75$

Urine chloride level 46.25$

Urine microalbumin (protein) level 166.25$

Urine osmolality (concentration) measurement 100.75$

Urine phosphate level 96.75$

Urine porphyrins (metabolism substance) measurement 280.50$

Urine potassium level 73.00$

Urine pregnancy test 103.00$

Urine sodium level 68.75$

Urine vanillylmandelic acid 196.25$

URSODIOL 300 MG CAPSULE [5230] 7.63$

Vaccine for diphtheria, tetanus toxoids, acellular pertussis (whooping cough), and polio for injection into muscle, patient 4 through 6 years of age 11.00$

Vaccine for diphtheria, tetanus toxoids, acellular pertussis (whooping cough), haemophilus influenza type B, and polio for injection into muscle 170.00$

Vaccine for diphtheria, tetanus toxoids, acellular pertussis (whooping cough), Hepatitis B, and polio for injection into muscle 11.00$

Vaccine for diphtheria, tetanus, and acellular pertussis (whooping cough) injection into muscle, child younger than 7 years 25.00$

Vaccine for Hemophilus influenza B (4 dose schedule) injection into muscle 55.00$

Vaccine for Hepatitis A (2 dose schedule) injection into muscle, pediatric or adolescent dosage 120.00$

Vaccine for Hepatitis A injection into muscle, adult dosage 120.00$

Vaccine for Hepatitis B (3 dose schedule) for injection into muscle, pediatric and adolescent patients 65.00$

Vaccine for Hepatitis B adult dosage (3 dose schedule) injection into muscle 110.00$

Vaccine for Hepatitis B and Hemophilus influenza B for injection into muscle 85.00$

Vaccine for human papilloma virus (3 dose schedule) injection into muscle 400.00$

Vaccine for influenza for administration into muscle, 0.25 ml dosage 50.00$

Vaccine for influenza for administration into muscle, 0.5 ml dosage 50.00$

Vaccine for influenza for injection into muscle 151.01$

Vaccine for influenza for nasal administration 50.00$

Vaccine for measles, mumps, and rubella (German measles) injection beneath skin 120.00$

Vaccine for measles, mumps, rubella (German measles), and varicella (chicken pox) injection beneath skin 350.00$

Vaccine for meningococcus for administration into muscle 200.00$

Vaccine for meningococcus for injection into muscle 153.00$

Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older 235.42$

Vaccine for rabies injection into muscle 422.67$

Vaccine for Rotavirus (2 dose schedule) for oral administration 190.00$

Vaccine for Rotavirus (3 dose schedule) for oral administration 11.00$

Vaccine for tetanus and diphtheria toxoids injection into muscle, patient 7 years or older 59.59$

Vaccine for tetanus, diphtheria toxoids and acellular pertussis (whooping cough) for injection into muscle, patient 7 years or older 120.00$

Vaccine for varicella (chicken pox) injection beneath skin 200.00$

VACUUM EXTRACTOR 73.00$

VAD DRESSING KIT 20.25$

Vaginal delivery 2,590.00$

Vaginal delivery after prior cesarean delivery 2,590.00$

Vaginal ultrasound of pregnant uterus 699.25$

VALACYCLOVIR 500 MG TABLET [45916] 7.50$

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [39763] 0.90$

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [126161] 0.12$

VALPROIC ACID 250 MG CAPSULE [6446] 1.04$

Valproic acid level 187.75$

VALSARTAN 160 MG TABLET [49674] 5.19$



Vancomycin (antibiotic) level 290.25$

VANCOMYCIN 25 MG/ML ORAL LIQUID (CCF) [612850] 0.67$

VASCULAR GRAFT ARTEGRAFT 3,904.75$

VASCULAR GRAFT RRT06030040L 3,197.25$

VASCULART GRAFT V4604DKL 954.00$

VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION [145182] 208.29$

VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION [3389] 10.59$

Vena cava filter 2,036.00$

VENLAFAXINE 25 MG TABLET [45062] 2.02$

VENLAFAXINE 37.5 MG TABLET [47199] 2.08$

VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [45480] 5.27$

VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [44220] 4.32$

VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [44254] 4.84$

Ventilation assistance and management, hospital inpatient or observation 1,263.75$

VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [3284] 9.06$

VERAPAMIL 80 MG TABLET [6343] 0.55$

VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE [6010] 1.49$

VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [6008] 2.63$

VILAZODONE 10 MG TABLET [122286] 10.32$



Vincristine sulfate, 1 mg 7.16$

VIT A 1,000 UNIT-C 200 MG-E 60 UNIT-LUTEIN 2 MG AND MINERALS TABLET [87871] 0.14$

Vitamin A level 109.50$

VITAMIN B COMPLEX AND VITAMIN C NO.20-FOLIC ACID 1 MG CAPSULE [48691] 0.97$

Vitamin B-1 (thiamine) level 74.00$

Vitamin B-6 level 229.75$

Vitamin D-3 level 266.50$

VITAMIN E 400 UNIT CAPSULE [10601] 0.07$

Vitamin E level 51.00$

Vitamin K level 377.50$

Voice functional limitation, current status at therapy episode outset and at reporting intervals 0.25$

Voice functional limitation, discharge status at discharge from therapy or to end reporting 0.25$

Voice functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting 0.25$

Volatile chemical measurement 145.25$

VORTIOXETINE 10 MG 26.98$

Walking training to 1 or more areas, each 15 minutes 119.50$

WARFARIN 1 MG TABLET [6534] 2.57$



WARFARIN 2.5 MG TABLET [6536] 2.76$





WARFARIN 7.5 MG TABLET [6541] 3.84$

WARMING BLANKET 227.25$

WASHER 7MM-10MM-13MM 58.25$

WATER FOR INJECTION, STERILE INJECTION SOLUTION [3750] 0.11$

Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes 155.00$

Wheelchair management, each 15 minutes 94.50$

White blood cell enzyme activity measurement 105.75$

White blood cell function measurement 172.25$

White blood cell measure, stool specimen 67.50$

WHITE PETROLATUM TOPICAL OINTMENT IN PACKET [132620] 0.06$

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [101808] 3.48$

WIRE,KIRSCHNER .045X4 42.00$

WIRE,KIRSCHNER .062X4 34.25$

XENOSURE BIOLOGICAL GRAFT 238.00$

X-ray lower and sacral spine including bending views minimum 6 views 582.50$

X-ray of abdomen, 1 view 352.00$

X-ray of abdomen, 2 views 422.75$

X-ray of ankle, 2 views 210.50$

X-ray of ankle, minimum of 3 views 352.00$

X-ray of bones 232.50$

X-ray of bones of face, less than 3 views 141.25$

X-ray of bones of face, minimum of 3 views 232.50$

X-ray of bones of nose, minimum of 3 views 141.25$

X-ray of both collar bones 141.25$

X-ray of both hips with pelvis, 2 views 232.50$

X-ray of both hips with pelvis, 3-4 views 232.50$

X-ray of both hips with pelvis, minimum of 5 views 463.00$

X-ray of both knees, standing, front to back view 141.25$

X-ray of both sides of the ribs including the chest, minimum of 4 views 232.50$

X-ray of breast bone, minimum of 2 views 141.25$

X-ray of chest, 1 view 352.00$

X-ray of chest, 2 views 422.75$

X-ray of chest, 3 views 141.25$

X-ray of chest, minimum of 4 views 141.25$

X-ray of collar bone 210.50$

X-ray of elbow, 2 views 210.50$

X-ray of elbow, minimum of 3 views 352.00$

X-ray of esophagus 367.50$

X-ray of eye 141.25$

X-ray of eye bones, minimum of 4 views 232.50$

X-ray of femur, 1 view 141.25$

X-ray of femur, minimum 2 views 422.75$

X-ray of fingers, minimum of 2 views 352.00$

X-ray of foot, 2 views 210.50$

X-ray of foot, minimum of 3 views 352.00$

X-ray of forearm, 2 views 281.50$

X-ray of hand, 2 views 232.50$

X-ray of hand, minimum of 3 views 352.00$

X-ray of heel, minimum of 2 views 210.50$

X-ray of hip with pelvis, 1 view 141.25$

X-ray of hip with pelvis, 2-3 views 422.75$

X-ray of jaw joints on both sides of the face 141.25$

X-ray of junction of breast and collar bones, minimum of 2 views 352.00$

X-ray of knee, 1 or 2 views 352.00$

X-ray of knee, 3 views 422.75$

X-ray of knee, 4 or more views 466.75$

X-ray of large bowel with contrast 666.75$

X-ray of lower and sacral spine, 2 or 3 views 466.75$

X-ray of lower and sacral spine, minimum of 4 views 582.50$

X-ray of lower leg, 2 views 352.00$

X-ray of mandible, less than 4 views 141.25$

X-ray of mandible, minimum of 4 views 232.50$

X-ray of mastoid, minimum of 3 views per side 232.50$

X-ray of middle and lower spine, 2 views 141.25$

X-ray of middle spine, 3 views 466.75$

X-ray of middle spine, minimum of 4 views 232.50$

X-ray of paranasal sinus, complete, minimum of 3 views 141.25$

X-ray of paranasal sinus, less than 3 views 141.25$

X-ray of pelvis, 1 or 2 views 349.50$

X-ray of pelvis, minimum of 2 views 210.50$

X-ray of pelvis, minimum of 3 views 232.50$

X-ray of ribs of one side of body, 2 views 141.25$

X-ray of ribs on one side of body including the chest, minimum of 3 views 466.75$

X-ray of sacroiliac joints, 3 or more views 248.00$

X-ray of sacroiliac joints, less than 3 views 232.50$

X-ray of shoulder blade 141.25$

X-ray of shoulder, 1 view 141.25$

X-ray of shoulder, minimum of 2 views 422.75$

X-ray of skull, complete, minimum of 4 views 232.50$

X-ray of skull, less than 4 views 349.50$

X-ray of small intestine 232.50$

X-ray of soft tissue of neck 352.00$

X-ray of spine of neck, 2 or 3 views 349.50$

X-ray of spine, 1 view 141.25$

X-ray of spine, 2 or 3 views 232.50$

X-ray of spine, 4 or 5 views 463.00$

X-ray of toes, minimum of 2 views 210.50$

X-ray of upper arm, minimum of 2 views 141.25$

X-ray of upper digestive tract 349.50$

X-ray of upper digestive tract with contrast 367.50$

X-ray of upper digestive tract, kidneys, urinary ducts (ureters), and bladder 367.50$

X-ray of upper spine, 4 or 5 views 582.50$

X-ray of upper spine, 6 or more views 349.50$

X-ray of voice box and/or esophagus 349.50$

X-ray of wrist, 2 views 352.00$

X-ray of wrist, minimum of 3 views 352.00$

X-ray survey of bones, infant 232.50$

X-ray survey of forearm or wrist bone density 232.50$

X-ray upper GI series, with small bowel films 1,007.75$

YAG LASER SECONDARY 4,294.25$

ZAFIRLUKAST 20 MG TABLET [47881] 2.13$

ZALEPLON 10 MG CAPSULE [48467] 3.93$

ZALEPLON 5 MG CAPSULE [48636] 3.83$

Zinc level 61.75$

ZINC OXIDE 3" X 10 YARD BANDAGE [53184] 12.68$

ZINC SULFATE 220 MG (50 MG) CAPSULE [88464] 0.03$

ZIPRASIDONE 20 MG CAPSULE [46617] 23.95$




ZOLPIDEM 10 MG TABLET [48810] 19.89$

ZOLPIDEM 5MG TAB 15.83$

ZOLPIDEM ER 6.25 MG TABLET,EXTENDED RELEASE,MULTIPHASE [83869] 6.35$

ZONISAMIDE 100 MG CAPSULE [46358] 2.05$

5% dextrose/normal saline (500 ml = 1 unit) $ 0.01 5% … · analysis for detection of tumor marker...

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