Charge Code Description Fee 116561 18 G IV Cath needle, sterile $5.00 116577 20 G IV Cath needle, sterile $5.00 116588 22 G IV Cath needle, sterile $5.00 118216 5% dextrose/NS (500 ml = 1 unit) $75.00 118237 5% Dextrose/Water, 250 ml $10.00 118229 5% Dextrose/Water, 500 ml $10.00 117453 Acet/Tylenol #3 with Codeine, 300mg, Oral $7.88 117515 Acet/Tylenol drops, 80mg $7.88 117525 Acet/Tylenol w/ Codeine, 12.5mg, Elixer $7.88 117467 Acet/Tylenol, 120mg, Suppository $7.88 117493 Acet/Tylenol, 325 mg, PO $7.88 117523 Acetaminophen/Tylenol Elixir, 160mg $7.88 117483 Acetaminophen/Tylenol, 160 mg, chewable tablet $7.88 117498 Acetaminophen/Tylenol, 500 mg tablet $7.88 117514 Acetaminophen/Tylenol, 60mg suppository $7.88 117528 Activated Charcoal, 25mg with Sorbital, Suspension $25.00 116826 Adaptic / Gel sheet / Kling for dermal or epidermal application, each $23.63 117046 Adenosine for therapeutic use, 6 mg (vial), IV $490.35 116958 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable $35.00 117061 Adrenalin, Epinephrine, 0.1 mg, IV/IM/SC $42.00 117715 Adult-Fleet Enema $10.00 116967 Aerosol mask, used with DME nebulizer $15.00 117535 Afrin Nasal Spray (Oxymetazoline) $7.88 115336 Albumin; serum, plasma or whole blood $71.00 118279 Albuterol, inhalation solution, unit dose (per vial) $20.00 118293 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, $40.00 115301 Alcohol Level, Blood (ETOH) $36.00 116615 Alcohol or peroxide, per pint $2.00 116076 Alligator Forceps $137.81 117538 Amidate / Etomidate 2mg, IV $10.00 117077 Amiodarone HCl, 30 mg, IV $168.00 117086 Ampicillin Sodium, 500 mg, IV/IM $101.06 115342 Amylase $136.50 115310 Analgesics, non-opioid; 1 or 2 (Tylenol, Salicylate) Level $363.38 117154 Ancef/Cefazolin Sodium, up to 500 mg, IV/IM $50.00 118391 Ankle Brace / Air Gel Cast - size L $100.00 118405 Ankle Brace / Air Gel Cast - size M $100.00 118599 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease $327.31 [COVID-19]) 114173 Application of finger splint; static (foam) $129.94 114152 Application of long arm splint (shoulder to hand) $129.94 114187 Application of long leg splint (thigh to ankle or toes) $129.94 114163 Application of short arm splint (forearm to hand); static $129.94 114197 Application of short leg splint (calf to foot) $129.94 116086 Arm board, for IV stabilization $27.56 117554 Aspirin Tablet, 81mg PO $7.88 117544 Aspirin, 325mg, PO $7.88 117292 Ativan/Lorazepam, 2 mg/mL, IV/IM $98.44 118307 Atrovent/Ipratropium bromide, inhalation solution, unit dose form, per mg $25.00 113831 Avulsion of nail plate, partial or complete, simple; single $404.88 117561 Bactroban/ Mupirocin $20.00 115237 Basic metabolic panel $252.00 115226 Basic metabolic panel; CHEM8; (Calcium, ionized) Must include 82330, 82374, 82435, 82565, 82947, $279.71 84132, 84295 & 84520 117579 Benadryl / Diphenhydramine Elixir $7.88 117232 Benadryl/Diphenhydramine HCl, up to 50 mg, IV/IM $20.00 117573 Benadryl/Diphenhydramine, 25 mg, PO $7.88 117115 Bentyl, up to 20 mg, IM $145.69 116619 Betadine, 4 ounce bottle $5.00 117122 Bicillin / Penicillin G Benzathine 1.2 ml , Injection (Per Dose/Vial) $144.38 115343 Bilirubin; direct $139.01 116787 Blades, surgical supplies $13.13 115579 Blood count; complete (CBC) $127.31 115642 Blood typing, serologic; ABO $27.50 115644 Blood typing, serologic; Rh (D) $27.50 115351 Blood, occult, by peroxidase activity (eg, guaiac), qualitative $36.75 115367 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, single specimen $36.75 117124 Calcium gluconate, per 10 ml, Injection, IV $20.00 115371 Calcium; total $38.04 116782 Cannula, nasal $44.63 117599 Cardene, PGBCK IV PREMIX SOD CHLORIDE 20 MG/200ML $165.00 116102 Cardiac Monitoring/Telemetry $351.75 115841 Cardioversion, elective, electrical conversion of arrhythmia; external $758.63 117618 Cardizem / Diltiazem 25mg/5ml vial, IV $15.00 117603 Cardizem/Diltiazem 5mg per vial, IV $10.00 117641 Catapres/Clonidine, 0.1mg PO $6.00 118414 Catheterization for collection of specimen, single patient, all places of service $10.00 116105 Cautery, Micro-temp Fine Tip / Bovie $51.19 117623 Cephalexin / Keflex 500MG PO $5.00 118428 Cerebyx/Fosphenytoin, 50 mg, Injection, IM/IV $20.00 118342 Cervical, collar, semi-rigid thermoplastic foam, 2 piece $20.00 118337 Cervical, flexible, nonadjustable (foam collar) $50.00 118339 Cervical, flexible, thermoplastic collar $20.00 116622 Chlorhexidine Antiseptic $6.00 116109 Chromic sutures (Gut) $90.56 117632 Cipro Ophthalmic Drops $25.00 117635 Clindamycin/Cleocin phosphate, 150 mg, IV/IM $6.00 118570 Clindamycin/Cleocin phosphate, 300 mg, IV/IM $50.00 114086 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation $129.94 114035 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or $2,222.29 without fracture of ulnar styloid; with manipulation 114029 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or $129.94 without fracture of ulnar styloid; without manipulation 114115 Closed treatment of fracture great toe, phalanx or phalanges; with manipulation $129.94 114128 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each $129.94

114117 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, $129.94 each 114076 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia $129.94

114048 Closed treatment of metacarpal fracture, single; with manipulation, each bone $129.94 114046 Closed treatment of metacarpal fracture, single; without manipulation, each bone $129.94 114059 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without $852.72 anesthesia 114104 Closed treatment of metatarsal fracture; without manipulation, each $129.94 114142 Closed treatment of metatarsophalangeal joint dislocation; without anesthesia $902.13 114068 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with $129.94 manipulation, with or without skin or skeletal traction, each 114023 Closed treatment of radial and ulnar shaft fractures; with manipulation $3,790.67 114005 Closed treatment of radial head or neck fracture; without manipulation $129.94 114000 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation $129.94 114018 Closed treatment of radial shaft fracture; with manipulation $129.94 113977 Closed treatment of shoulder dislocation, with manipulation; without anesthesia $129.94 113967 Closed treatment of temporomandibular dislocation; initial or subsequent $1,375.15 116123 Coban/ Co-Flex Bandage $11.81 114265 Collection of capillary blood specimen (eg, finger, heel, ear stick) $17.06 114252 Collection of venous blood by venipuncture $42.00 117204 Compazine/Prochlorperazine, up to 10 mg, injection, IM/IV $81.38 115256 Comprehensive metabolic panel; CHEM13 $363.56 114863 Computed tomography, upper extremity; with contrast material(s) $2,539.94 116899 Conforming bandage, nonelastic, knitted/woven, nonsterile, width 3" to 4.9", per yd. $9.19 116894 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard $4.51

118542 Contrast media / Omnipaque / Low osmolar contrast material, 300-399 mg/ml iodine concentration, $15.60 per ml 114224 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method $783.96 118597 COVID-19 $427.31 115626 C-reactive protein; $95.55 115387 Creatine kinase (CK), (CPK); MB fraction only (CKMB) $173.25 115374 Creatine kinase (CK), (CPK); total $242.81 115396 Creatinine; blood $132.56 116548 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 $5,300.00 minutes 116999 Crutches, underarm, pair, with pads, tips and handgrips $103.69 114482 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST #N/A 114498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST #N/A 114599 CT angiography, chest, without and with contrast $2,401.88 116129 CT Injector Kit $87.94 114452 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL $2,352.00 115089 CT, abdomen and pelvis; with contrast material(s) $2,425.58 115077 CT, abdomen and pelvis; without contrast material $2,729.43 115100 CT, abdomen and pelvis; without contrast material in one or both body regions, followed by $3,065.90 contrast material(s) and further sections in one or both body regions 115063 CT, abdomen; with contrast material(s) $2,079.00 114671 CT, cervical spine; without contrast material $2,079.00 114426 CT, head or brain; with contrast material(s) $1,813.88 114419 CT, head or brain; without contrast material $2,310.00 114434 CT, head or brain; without contrast material, followed by contrast material(s) and further sections $2,352.00

115019 CT, lower extremity; with contrast material(s) $1,601.25 115005 CT, lower extremity; without contrast material $1,392.56 114702 CT, lumbar spine; without contrast material $2,079.00 114460 CT, maxillofacial area; with contrast material(s) $2,361.19 114456 CT, maxillofacial area; without contrast material $1,568.44 114443 CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material $2,079.00 114724 CT, pelvis; with contrast material(s) $1,813.88 114720 CT, pelvis; without contrast material $1,568.44 114471 CT, soft tissue neck; with contrast material(s) $2,079.00 114462 CT, soft tissue neck; without contrast material $1,813.88 114687 CT, thoracic spine; without contrast material $2,079.00 114594 CT, thorax/chest; with contrast material $2,743.13 114588 CT, thorax/chest; without contrast material $1,813.88 114598 CT, thorax/chest; without contrast material, followed by contrast material(s) and further sections $2,021.25

115679 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and $118.13 presumptive identification of isolates 115691 Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification $283.50 of isolates 115658 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes $118.13 anaerobic culture, if appropriate) 115707 Culture, bacterial; quantitative colony count, urine $59.90 115668 Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), $118.13 Salmonella and Shigella species 115697 Culture, presumptive, pathogenic organisms, screening only (throat swab) $118.13 117647 Cyclogyl opthamalgic drops, 1% $35.00 113830 Debridement; skin and subcutaneous tissue; wound superficial $129.94 117658 Debrox, Earwax Removal Kit $15.00 117214 Decadron/Dexamethasone sodium phosphate, 1 mg, IM/IV & Oral $6.19 118325 Decadron/Dexamethasone, oral, 0.25 mg $6.19 116702 Dermabond Adhesive, liquid or equal, any type, per oz $55.00 118319 Dexamethasone .25 mg PO $6.19 117659 Dextrose 50%, 50 ml $10.00 117587 Dicyclomine/ Bentyl 10mg (PO Med) $7.88 115279 Digoxin; total $418.46 117217 Dilantin/Phenytoin sodium, per 50 mg, IV/IM $18.38 117223 Dilaudid/Hydromorphone, up to 4 mg, IV/IM/SC $85.31 117667 Donnatal Elixir, 16.2mg $36.00 116136 Dressing Change Tray, Sterile $79.41 113959 Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium $129.94 113954 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small $129.94 115299 Drug Screen, any number of drug classes from Drug Class List A (eg, dipsticks, cups, cards, $388.13 cartridges) 115887 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or $1,174.69 retroperitoneal organs; limited study 115884 Duplex scan of extremity veins including responses to compression and other maneuvers; complete $1,187.81 bilateral study 115886 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral $868.88 or limited study 115883 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study $1,123.50

116145 Ear Curette $39.38 116146 Ear Wick $34.13 116734 EENT Tray (Ear, Eye, Nose, Throat) $204.75 115854 EKG/ECG with at least 12 leads; tracing only, without interpretation and report $179.81 116152 Electrodes for EKG $32.81 115244 Electrolyte panel $233.63 116162 Emesis Basin $19.69 116173 Epistat Balloon $65.63 117669 Erythromycin Eye Ointment $18.00 116186 Ethilon 3.0 sutures $51.19 116194 Ethilon 4.0 sutures $51.19 116204 Ethilon 5.0 sutures $57.75 116205 Ethilon 6.0 sutures $57.75 113832 Evacuation of subungual hematoma $202.16 113848 Excision of nail and nail matrix, partial or complete, for permanent removal $738.28 117679 Eye Wash $10.00 116517 Facility - Emergency department visit, level 1 $404.78 116524 Facility - Emergency department visit, level 2 $812.50 116527 Facility - Emergency department visit, level 3 $1,400.00 116533 Facility - Emergency department visit, level 4 $3,500.00 116545 Facility - Emergency department visit, level 5 $4,600.00 117997 Famotidine/Pepcid, 10 mg, oral $9.19 118006 Famotidine/Pepcid, 20 mg, oral $10.00 118550 Famotidine/Pepcid, up to 20 mg, IV $50.00 117394 Fentanyl Citrate / Sublimaze, 0.1 mg, IM/IV $55.00 117690 Fentanyl, 25 mg, IV $10.00 117683 Fentanyl, 50mg, IV $10.00 115591 Fibrin degradation products, D-dimer; quantitative $148.31 118509 Finger splint, aluminum/static $14.44 118564 Flagyl / Metronidazole, 500 mg, Injection, IV $100.00 117702 Flagyl / Metronidazole, 500mg, PO $10.00 117718 Flexerill/Cyclobenzaprine HCI, 10 mg PO $10.00 117733 Fluor-I-Strip, 9mg, for dialation of the eye $9.19 118537 Gastrografin Oral Contrast $150.41 116840 Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less, $11.81 without adhesive border, each dressing (Xeroform) 116879 Gauze, nonimpregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing $14.44

117237 Glucagon HCl/GlucaGen Diagnostic Kit, per 1 mg, SC/IM/IV $595.01 115408 Glucose; blood, reagent strip (Accucheck) $39.38 115403 Glucose; quantitative, blood (except reagent strip) $108.94 115415 Glutamyltransferase, gamma (GGT) $133.88 115572 Gonadotropin, chorionic (hCG); qualitative $206.06 115558 Gonadotropin, chorionic (hCG); quantitative $152.25 117245 Haldol/Haloperidol, up to 5 mg, IV/IM $40.00 116041 Handling and/or conveyance of specimen (Send Out Lab) $87.94 115424 Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) $127.04 115436 Hemoglobin; glycosylated (A1C) $72.00 115272 Hepatic function panel; LFT $280.88 115641 Heterophile antibodies; screening; Monospot $105.00 117034 Hospital Observation Service, per 1 hour $1,600.00 117749 Hyoscyamine Sulfate 0.125 mg tablet.125mg/5ml, PO $10.00 113812 I & D of abscess; complicated or multiple $845.20 113810 I & D of abscess; simple or single $479.64 116229 Ice/Cold Pack $5.25 117406 Imitrex / Sumatriptan Succinate, 6 mg, SC $416.06 115818 Immunization administration; one vaccine $69.56 118598 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method $94.58 (eg, reagent strip); severe acute respiratory 117753 Imodium/ Loperamide PO $7.88 113826 Incision and drainage of hematoma, seroma or fluid collection $667.12 113814 Incision and removal of foreign body, subcutaneous tissues; simple $620.76 116681 Indwelling catheter; Foley type, 2-way latex with coating (Teflon, silicone, silicone elastomer, or $5.00 hydrophilic, etc.), each 115735 Infectious agent antigen detection by enzyme immunoassay technique, Influenza A $115.50 115738 Infectious agent antigen detection by enzyme immunoassay technique, Influenza B $115.50 115804 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, $141.75 group A 115748 Infectious agent antigen detection; respiratory syncytial virus $141.75 115761 Infectious agent antigen detection; Streptococcus, group A $141.75 115792 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) $245.44 technique 115774 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe $258.40 technique 115788 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe $258.40 technique 117045 Injection, Acetylcysteine, 100 mg $5.24 114313 Injection, anesthetic agent; other peripheral nerve or branch $129.94 117250 Injection, heparin sodium, (heparin lock flush), per 10 units $7.88 117253 Injection, Heparin sodium, per 1000 units $17.06 117138 Injection, mepivacaine hydrochloride, per 10 ml $13.87 117429 Injection, thiamine hcl, 100 mg $15.00 114291 Insertion of non-indwelling bladder catheter $254.63 114299 Insertion of temporary indwelling bladder catheter; simple (eg, Foley) $252.00 116634 Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating $75.00 (Teflon, silicone, silicone elastomer or hydrophilic, etc.) 117280 Insulin HUM-R-100U, per 5 units, SC/IV $9.19 116213 Intranasal Fentanyl Kit $30.00 115973 Intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion, up to 1 $261.19 hour 115985 Intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion $194.25 115967 Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour $253.31 115951 Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour $518.44 115935 Intravenous infusion, hydration; each additional hour $127.31 115924 Intravenous infusion, hydration; initial, 31 minutes to 1 hour $427.88 116665 Irrigation syringe, bulb or piston, each $15.75 116649 Irrigation tray with bulb or piston syringe, any purpose $16.00 116241 IV Pump $118.13 116560 IV start kit $50.00 117761 KDur / Potassium, 40 meq, oral $10.00 116798 Kerlix, miscellaneous surgical supplies $9.19 117773 Ketamine 10 mg IV/IM $15.00 117787 Ketamine 5 mg IV/IM $15.00 117800 Ketamine, 100 mg/ml, IV/IM $30.00 117776 Ketamine, 20 mg, for sedation, IV/IM $15.00 117782 Ketamine, 40 mg, IV/IM $15.00 118349 KO, immobilizer, canvas longitudinal, prefabricated (knee splint) $133.88 117812 Labetalol HCI, 5mg/ml, IV $10.00 115440 Lactate (lactic acid) $78.76 117285 Lasix/Furosemide, up to 20 mg, IV/IM $20.00 113923 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less $1,054.92

113932 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 $1,202.36 cm 113939 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 $1,410.04 cm 113906 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 $1,238.08 cm to 7.5 cm 113907 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 $1,272.76 cm to 12.5 cm 117291 Levaquin/Levofloxacin, 250 mg, IV $156.19 117821 Lidocaine 1% with EPI, 20ml, IV $10.00 117853 Lidocaine 2% with EPI $13.13 117836 Lidocaine 2%, 10ml, IV $7.88 117850 Lidocaine 2%, 20ml $30.19 117858 Lidocaine 4%, 50ml, topical solution $34.13 117833 Lidocaine HCL, MDV 1%, 10ml $7.88 116910 Light compression bandage, elastic, ace bandage, 2" $22.31 116911 Light compression bandage, elastic, knitted/woven, ace bandage, 4" $22.31 116920 Light compression bandage, elastic, knitted/woven, ace bandage, 6" $22.31 115452 Lipase $84.00 115264 Lipid panel $274.31 117865 Lopressor/Metoprolol Tartrate 25 mg oral $11.81 117877 Lopressor/Metoprolol Tartrate 50 mg oral $17.06 117266 Lovenox/Enoxaparin sodium, 10 mg, SC $100.00 116737 Lumbar Puncture Tray $124.69 115463 Magnesium $49.40 117884 Magnesium citrate, 1 bottle $10.00 118585 Magnesium Oxide 250 mg PO $6.25 117442 Magnesium sulphate, per 500 mg, IM/IV $75.00 116062 Marcain 0.5%, 50 ml, single vial $34.13 116071 Marcaine / Bupivicaine 0.25% 10 ml SDV $32.81 117163 Maxipime / Cefepime HCl, 500 mg , IV/IM $105.00 117888 Meclizine / Dramamine / Antivert, 25 mg, oral $7.88 117177 Mefoxin / Cefoxitin Sodium, 1 g, IV/IM $50.00 117892 Metoprolol Tartrate / Lopressor, 1mg/ml, IV $10.00 116487 Mod sed same phys/qhp <5 yrs $773.30 116493 Mod sed same phys/qhp 5/>yrs $626.28 116508 Mod sed same phys/qhp each additional 15 minutes $109.10 116243 Morgan Lens Medi Flow $283.90 117304 Morphine sulfate, up to 10 mg, IM/IV/SC $168.00 117314 Morphine sulfate, up to 5 mg, IM/IV/SC $84.00 117914 Motrin / Ibuprofen, Children's Elixir $10.00 117902 Motrin/Ibuprofen tablet, 200mg, coated (oral) $7.88 117918 Mylanta/Maalox (oral) $7.88 115466 Myoglobin $168.00 117317 Narcan/Naloxone HCl, per 1 mg, IM/IV/SC $40.00 116344 Nasal rapid rhino rocket (supplies) $63.00 116972 Nasogastric (NG) tubing without stylet, any size $32.81 115471 Natriuretic peptide; BNP $288.75 115899 Nebulizer treatment $165.38 117919 Neomycin Hydrocortisone Otic Drops $168.00 117451 Neosporin Antibiotic Ointment foil packs $7.88 117924 Neo-Synephrine $10.00 117939 Nitro-Bid, ointment 2%, 1gm $10.00 117943 Nitroglycerin, 0.2mg/250ml, IV $40.00 117955 Nitroquick SL, 0.4mg tablet $7.88 116244 Nonrebreather oxygen mask $53.81 118181 Norco / Vicodin / Hydrocodone 5/500mg (oral); 5 mg tablet $10.00 117966 Norco 5/325 mg $16.15 117327 Norflex/Orphenadrine citrate, up to 60 mg, IM/IV $75.00 117979 Normal saline 0.9%, 250 ml bottle, for irrigation $10.00 117968 Normal saline solution / Sodium Chloride, 100 ml $10.00 118222 Normal saline solution / Sodium Chloride, 250 cc, IV $25.00 118211 Normal Saline Solution / Sodium Cholride, 1000 cc, IV $50.00 116612 Normal Saline Solution, 10 ml $5.00 118213 Normal saline solution, sterile (500 ml = 1 unit), IV $35.00 118422 Ondansetron 1 mg, oral, not to exceed a 48 hour dosage regimen $5.00 118578 Ondansetron, Zofran ODT oral, Up to 4 mg given (for circumstances falling under the Medicare $75.00 statute, use HCPCS Q code) 117993 Orapred / Oral Prednisone, for kids $15.00 116254 Oxygen each additional hour $140.44 116268 Oxygen First Hour $210.00 116863 Packing Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear $20.00 yd./ Iodoform gauze 116270 Paper tape $5.25 116770 Peak expiratory flow rate meter, hand held $59.06 116279 Pelvic Tray (for Female Pelvic Exams) $48.56 116877 Petroleum/ Vasoline gauze $7.88 118103 Phenazopyridine HCl 95mg $5.50 117366 Phenergan/Promethazine HCl, up to 50 mg, IM/IV $30.00 118017 Phenergan/Promethazine Suppository 50 mg each $20.00 115487 Phosphorus inorganic (phosphate); $34.96 118027 Plavix / Clopidogrel, 75mg, oral $15.00 116057 Post-operative follow-up visit $0.00 118032 Potassium 60mg PO $17.06 118057 Potassium Chloride ER, 20 mg, oral $7.88 118045 Potassium Chloride, 10 meq, oral $7.88 117446 Potassium chloride, per 2 meq, IV $10.00 118277 Prednisone, oral, per 1 mg $0.60 118266 Prelone/Prednisolone, oral, per 5 mg, Oral $7.88 116287 Primary tubing for IV $24.94 116290 Prolene 3.0 sutures $51.19 116291 Prolene 4.0 sutures $63.00 116302 Prolene 5.0 sutures $51.19 116316 Prolene 6.0 sutures $66.94 118069 Proparacaine HCl / Alcaine Opth Drops $7.88 115493 Prostate specific antigen (PSA); total $171.98 115601 Prothrombin time $132.56 118078 Protonix / Pantoprazole Sodium 40 mg, oral $7.88 116983 Protonix/Pantoprazole sodium, per vial (40mg), IV/IM $191.63 115916 Pulse oximetry for oxygen saturation; multiple determinations $152.25 115914 Pulse oximetry for oxygen saturation; single determination $110.25 116330 Pump tubing for IV $185.06 118087 Pyridium/Phenazopyridine, 200MG PO $9.04 118111 Racemic EPI, 2.25%, inhalation $10.00 114514 RADEX CH 2 VIEWS FRNT&LAT $305.81 114926 Radiologic exam knee; complete, four or more views $389.81 115051 Radiologic exam, abdomen; complete acute abdomen series $467.25 114960 Radiologic exam, ankle; complete, minimum of three views $333.38 114955 Radiologic exam, ankle; two views $211.31 114538 Radiologic exam, chest, two views, frontal and lateral; $305.81 114526 Radiologic exam, chest; single view, frontal $233.63 114786 Radiologic exam, elbow; complete, minimum of three views $267.75 114778 Radiologic exam, elbow; two views $240.19 114400 Radiologic exam, facial bones; complete, minimum of three views $401.63 114853 Radiologic exam, finger(s), minimum of two views $227.06 114980 Radiologic exam, foot; complete, minimum of three views $531.56 114971 Radiologic exam, foot; two views $232.31 114851 Radiologic exam, hand; minimum of three views $412.13 114848 Radiologic exam, hand; two views $232.31 114911 Radiologic exam, knee; one or two views $257.25 114912 Radiologic exam, knee; three views $257.25 114392 Radiologic exam, mandible; complete, minimum of four views $401.63 114380 Radiologic exam, mandible; partial, less than four views $347.81 114402 Radiologic exam, nasal bones, complete, minimum of three views $232.31 114717 Radiologic exam, pelvis; one or two views $228.38 114576 Radiologic exam, ribs, bilateral; including posteroanterior chest, minimum of four views $430.50 114566 Radiologic exam, ribs, bilateral; three views $261.19 114551 Radiologic exam, ribs, unilateral; including posteroanterior chest, minimum of three views $345.19 114539 Radiologic exam, ribs, unilateral; two views $300.56 114739 Radiologic exam, sacrum and coccyx, minimum of two views $292.69 114772 Radiologic exam, shoulder; complete, minimum of two views $252.00 114761 Radiologic exam, shoulder; one view $191.63 114414 Radiologic exam, sinuses, paranasal, less than three views $313.69 114629 Radiologic exam, spine, cervical; 4 or 5 views $485.63 114614 Radiologic exam, spine, cervical; two or three views $267.75 114668 Radiologic exam, spine, lumbosacral; minimum of four views $467.25 114657 Radiologic exam, spine, lumbosacral; two or three views $467.25 114632 Radiologic exam, spine; thoracic, 2 views $311.06 114644 Radiologic exam, spine; thoracic, 3 views $467.25 114834 Radiologic exam, wrist; complete, minimum of three views $228.38 114818 Radiologic exam, wrist; two views $195.56 114993 Radiologic exam; calcaneus, minimum of two views $228.38 114740 Radiologic exam; clavicle, complete $276.94 114799 Radiologic exam; forearm, two views $258.56 114777 Radiologic exam; humerus, minimum of two views $267.75 114416 Radiologic exam; neck, soft tissue $267.75 114755 Radiologic exam; scapula, complete $232.31 114577 Radiologic exam; sternum, minimum of two views $252.00 114941 Radiologic exam; tibia and fibula, two views $258.56 114994 Radiologic exam; toe(s), minimum of two views $211.31 114807 Radiologic exam; upper extremity, infant, minimum of two views $276.94 114906 Radiologic examination femur minimum of 2 views $328.50 114876 Radiologic examination hip unilateral with pelvis when performed 1 view $320.25 114890 Radiologic examination hip unilateral with pelvis when performed 2-3 views $418.00 114896 Radiologic examination hips, bilateral, with pelvis when performed, 2 views $400.43 115034 Radiologic examination, abdomen; 1 view $246.75 115035 Radiologic examination, abdomen; 2 views $355.69 115049 Radiologic examination, abdomen; 3 or more views $320.56 117374 Reglan/Metoclopramide HCl, up to 10 mg, IV/IM $35.00 114337 Removal foreign body from external auditory canal; without general anesthesia $337.09 114350 Removal impacted cerumen using irrigation/lavage, unilateral $69.30 114331 Removal of foreign body, external eye; corneal, with slit lamp $630.24 114320 Removal of foreign body, external eye; corneal, without slit lamp $497.47 114095 Removal of foreign body, foot; subcutaneous $1,328.97 114365 Removal of impacted cerumen requiring instrumentation, Unilateral (apply -50 mod for Bilat Ears) $86.63

114277 Repair of laceration 2.5 cm or less; posterior one-third of tongue $1,872.57 115870 Rhythm ECG, one to three leads; tracing only without interpretation and report $101.06 118252 Ringers lactate infusion, up to 1000 cc $10.00 117190 Rocephin/Ceftriaxone Sodium, up to 250 mg, IV/IM $126.00 115289 Salicylate Lab $313.63 116352 Saline locks for IV $9.19 116516 Screening test of visual acuity, quantitative, bilateral $55.28 116366 Secondary Tubing for IV $6.56 115621 Sedimentation rate, erythrocyte; automated $112.88 115613 Sedimentation rate, erythrocyte; non-automated $42.50 118377 Shoulder orthotic (SO), figure of eight design abduction restrainer, canvas and webbing, $100.00 prefabricated, includes fitting and adjustment 116757 Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, $16.00 includes fitting and adjustment 118121 Silvadene Cream 1%, 20gm $20.00 118127 Silver Nitrate $10.00 113872 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 $446.08 cm or less 113888 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 $466.40 cm to 5.0 cm 113889 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 $545.92 cm to 7.5 cm 113899 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 $661.52 cm to 12.5 cm 113854 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or $363.84 extremities; 2.5 cm or less 113856 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or $440.20 extremities; 2.6 cm to 7.5 cm 113862 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or $522.76 extremities; 7.6 cm to 12.5 cm 116852 Skin sealants, protectants, moisturizers, ointments, any type, any size $23.70 116749 Slings, arm $35.44 115722 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, $51.19 KOH preps) 118366 SO, sling & swath, figure of eight design abduction restrainer, prefabricated, includes fitting and $100.00 adjustment 118138 Sodium Bicarbonate, 8.4%, 50 ml, 1meq/mL $20.00 117379 Solu-Medrol/Methylprednisolone Sodium Succinate, up to 125 mg, IM/IV $50.00 118596 Splint ankle or wrist (Pre-fabricated) $100.00 118511 Splint supplies / 2" Webril $7.88 118517 Splint supplies / 3" Webril $7.88 118530 Splint supplies / 4" Webril $7.88 118441 Splint supply, long arm, adult (11 years +), fiberglass (Orthoglass) $148.05 118449 Splint supply, long arm, pediatric (0-10 years), fiberglass (Orthoglass) $121.80 118470 Splint supply, long leg, adult (11 years +), fiberglass (Orthoglass) $148.05 118477 Splint supply, long leg, pediatric (0-10 years), fiberglass (Orthoglass) $121.80 118450 Splint supply, short arm, adult (11 years +), fiberglass (Orthoglass) $121.80 118456 Splint supply, short arm, pediatric (0-10 years), fiberglass (Orthoglass) $100.80 118487 Splint supply, short leg, adult (11 years +), fiberglass (Orthoglass) $121.80 118502 Splint supply, short leg, pediatric (0-10 years), fiberglass (Orthoglass) $100.80 116387 Staples $49.88 116389 Steri Strips 1/2" $11.81 116379 Sterile surgical gloves, 1 pair $7.88 116604 Sterile Water per 10 ml $5.00 114222 Strapping; ankle and or foot $75.44 114179 Strapping; elbow or wrist $387.42 114213 Strapping; knee $206.08 116942 Suction Canister $7.88 116949 Suction Tubing $7.88 118356 Surgical boot/shoe, each $278.25 116719 Surgical trays (Lac tray/ I&D tray/ Sut Removal) $168.00 116414 Surgicel $38.06 116714 Tape, non-waterproof, per 18 sqare inches $2.50 116880 Telfa pad $7.88 115830 Tetanus and diphtheria toxoids (Td) adsorbed, individuals 7 years or older, for intramuscular use $93.75

115837 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or $147.45 older, for intramuscular use 118148 Tetracaine opthalmic drops $25.00 116015 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional $135.19 sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 116026 Therapeutic, prophylactic, or diagnostic injection; each additional sequential intravenous push of $135.19 the same substance/drug provided in a facility 116000 Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance/drug $269.06

115992 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular $210.00 115517 Thyroid stimulating hormone (TSH) $140.44 115502 Thyroxine; free $77.44 118153 Tobramycin Sulfate Opth Drops $40.00 116417 Tono Pen Tip $17.06 117283 Toradol/Ketorolac tromethamine, per 15 mg, IM/IV $50.00 113993 Treatment of closed elbow dislocation; without anesthesia $129.94 115524 Troponin, quantitative $166.69 114233 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, $1,713.32 open 116930 Tubular dressing / Tube gauze with or without elastic, any width, per linear yard $9.19 115123 Ultrasound, abdominal, B-scan and/or real time with image documentation; limited $773.06 115119 Ultrasound, abdominal, real time with image documentation; complete $1,017.19 115113 Ultrasound, breast, unilateral, real time with image documentation, including axilla when $506.10 performed; complete 115213 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific $219.24

115191 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete $561.75 115207 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for $526.31 follicles) 115159 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, $821.63 after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation

115156 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, $618.19 first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

115172 Ultrasound, pregnant uterus, real time with image documentation, limited, one or more fetuses $530.25

115185 Ultrasound, pregnant uterus, real time with image documentation, transvaginal $595.88 115141 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image $530.25 documentation; limited 115134 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; $458.52 complete 115211 Ultrasound, scrotum and contents $829.50 115101 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image $547.31 documentation 115190 Ultrasound, transvaginal $595.88 115532 Urea nitrogen / BUN; quantitative $76.13 115547 Uric acid; blood $33.52 117032 Urinal - Male $5.00 115312 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, $132.56 nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 116688 Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each $25.64 116814 Urinary leg bag; latex $65.63 115328 Urine pregnancy test $51.19 116399 Urine strain cup $17.06 118162 Valium/Diazepam, 10mg tablet (oral) $10.00 118175 Valium/Diazepam, 5mg tablet (oral) $10.00 117411 Valium/Diazepam, up to 5 mg, IM/IV $20.00 117414 Vancomycin HCl, 500 mg, IV/IM $70.00 114243 Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for $275.93 diagnostic or therapeutic purposes (not to be used for routine venipuncture) 117300 Versed / Midazolam HCl, per 1 mg, IM/IV $126.00 116423 Vicryl 3.0 for sutures $52.50 116438 Vicryl 4.0 for sutures $52.50 116454 Vicryl 5.0 for sutures $60.38 116467 Vicryl 6.0 for sutures $52.50 118194 Viscous Lidocaine, 10 ml, PO $17.06 118182 Viscous Lidocaine, for topical use $17.06 117010 Walker, folding (pickup), adjustable or fixed height $50.00 117024 Walker, folding, wheeled, adjustable or fixed height $216.56 118389 WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment $35.00

116857 Wound cleansers, any type, any size / EZ scrub/ Shur-clens/ Hibiclens $14.44 118291 Xopenex / Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, $50.00 administered through DME, unit dose, 0.5 mg 114391 X-RAY EXAM OF EYE SOCKETS, MINIMUM OF 4 VIEWS $305.81 116477 Yankaur Suction $13.13 117099 Zithromax / Azithromycin 500 mg, IV $227.06 118200 Zithromax / Azithromycin dihydrate, oral, up to 500 mg $168.00 117342 Zofran/Ondansetron HCl, per 1 mg, IV/IM $40.00 117351 Zosyn / Piperacillin Sodium / Tazobactam Sodium, 1 g/0.125 g (1.125 g), IV $35.00