Houston Medical ER Facility Fee Schedule (updated 6.1.2021) CPT Description Fee J8540 Dexamethasone, oral, 0.25 mg $0.51 J7510 Prednisolone oral, per 5 mg $0.69 J2250 Injection, midazolam hydrochloride, per 1 mg $0.76 Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.81 J7613 Albuterol, inhalation solution, unit dose, 1 mg (Accuneb) $1.00 Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $2.30 J1756 Injection, iron sucrose, 1 mg $3.51 J3475 Injection, magnesium sulfate, per 500 mg $3.86 A9150 Aceaminopen (Tylenol) 500mg Tab po $5.00 J849 ACETAMINOPHEN (TYLENOL) 120/12 MG PO $5.00 J8499 ACETAMINOPHEN (TYLENOL) 160MG/5ML SUSP $5.00 J8499 ACETAMINOPHEN (TYLENOL) 500MG TAB $5.00 J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg (Duoneb) $5.00 A9150 ASPIRIN 325MG TAB $5.00 A4246 Betadine or phisohex solution, per pint $5.00 A4248 Chlorhexidine containing antiseptic, 1 ml $5.00 J7515 Cyclosporine, oral, 25 mg $5.00 A9150 Dextromethorphen Polistirex DELYSM Susp 30 mg PO $5.00 A9150 Diphenhydramine(Benadryl) 25MG CAP PO $5.00 A9150 FAMOTIDINE (PEPCID) 20MG TAB $5.00 A4930 Gloves, sterile, per pair $5.00 A9150 IBUPROFEN (ADVIL, MOTRIN) 200MG TAB $5.00 J0461 Injection, atropine sulfate, 0.01 mg $5.00 J1100 Injection, dexamethasone sodium phosphate, 1 mg $5.00 J1265 Injection, dopamine hcl, 40 mg $5.00 J2001 Injection, lidocaine hcl for intravenous infusion, 10 mg $5.00 J3480 Injection, potassium chloride, per 2 meq $5.00 A4259 Lancets, per box of 100 $5.00 A9150 METOPROLOL (LOPRESSOR) 25MG Tablet $5.00 J8499 Tetracaine HCl 0.5 % occular $5.00 A9150 Tylenol Liquid 225ml po $5.00 A6260 Wound cleansers, any type, any size $5.00 J3010 Injection, fentanyl citrate, 0.1 mg $5.54 J2185 Injection, meropenem, 100 mg $5.65 J1165 Injection, phenytoin sodium, per 50 mg $5.83 S0028 Injection, famotidine, 20 mg $6.16 J8499 ACETAMINOPHEN (TYLENOL) 325MG TAB $8.00 S5000 Prescription drug, generic $8.00 A4218 Sterile saline or water, metered dose dispenser, 10 ml $8.00 A4215 Needle, sterile, any size, each $8.40 A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml $8.61 J2765 Injection, metoclopramide hcl, up to 10 mg (Reglan) $8.69 J8499 PSUEDOPHEDRINE HCL (SUDAFED) 30MG TAB $9.88 A9150 Acetaminophen (Tylenol) Pediatrics $10.00 A4364 Adhesive, liquid or equal, any type, per oz $10.00 J7610 Albuterol, inhalation solution, compounded product, administered through dme, concentrated form, 1 mg $10.00 J8499 Anthihistamine Diphenhydramine(Benadryl) Susp 12.5 mg PO $10.00 A9150 Aspirin 81 Mg $10.00 A9150 Aspirin 81 tab Sub $10.00 A9150 BENZONATATE (TESSALON PERLES) 100MG CAP $10.00 J8499 ciprofloxacin 500 mg tablets $10.00 A9150 Clindamycin 150 mg PO Tab $10.00 A9150 Dicyclomine 10 Mg Cap $10.00 J8499 DIPHENOXYLATE HCL/ATROPINE SULFATE (LOMOTIL) 2.5MG/0.025MG TAB $10.00 J1756 Iron Sucrose (Venofer) 200 mg in 100 ml NS $10.00 A4322 Irrigation syringe, bulb or piston, each $10.00 J8499 IVERMECTIN 3mg $10.00 A9150 MAG-AL-PLUS (Magnesium Hydroxide, Aluminum Hydroxide Simethicon) SUSP 30ml PO $10.00 J8499 Magnesium Citrate $10.00 A9150 MECLIZINE HCL (ANTIVERT) 25MG TAB $10.00 J8499 Metoclopramide (Reglan) 10mg PO $10.00 J8499 METOPROLOL TARTRATE (LOPRESSOR) 25MG TAB $10.00 J8499 METRONIDAZOLE (FLAGYL) 250MG TAB $10.00 A9150 Multivitamin (Infuvite) $10.00 J8499 Promethazine HCL 25 Tab $10.00 J7699 Racepinephrine 2.25 % INH $10.00 A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard $10.00 A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size $10.00 A4657 Syringe, with or without needle, each $10.00 A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each $10.00 S5001 Prescription drug, brand name $12.00 J7626 Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 0.5 mg $12.19 J0692 Injection, cefepime hydrochloride, 500 mg $12.77 J7060 5% dextrose/water (500 ml = 1 unit) $13.32 A6257 Transparent film, sterile, 16 sq. in. or less, each dressing $13.93 J8499 Activated Charcoal 25g $14.49 J8499 Amlodipine 5mg po $15.00 J8499 Amoxicillin 250mg po $15.00 J8499 Amoxicillin 875/125MG PO $15.00 J8499 Augmentin 875mg po $15.00 J8499 Azithromycin 250mg po $15.00 J8499 Azithromycin 500mg po (Zithromax) $15.00 J8499 Cephalexin 500mg po (Keflex) $15.00 J8499 Cyclobenazapline 10 mg po (Flexeril) $15.00 J8499 Donnatal (Phenobarbital,Hyoscyamine Sulfate, Atropine Sulfate, Scopolamine Hydrobromid) Susp 10ml po $15.00 J8499 Doxycycline 100 mg PO $15.00 J8499 Erythromycin Ophthalmic Ointment $15.00 A6410 Eye pad, sterile, each $15.00 A6412 Eye patch, occlusive, each $15.00 J8499 Flagyl 500 mg PO $15.00 A9150 IBUPROFEN (MOTRIN) 600MG TAB $15.00 J8499 Ibuprofen 600mg table po (Motrin) $15.00 J8499 Ibuprofen 800mg po $15.00 J0290 Injection, ampicillin sodium, 500 mg $15.00 J0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm (Unasyn) $15.00 J3360 Injection, diazepam, up to 5 mg (Valium) $15.00 J1815 Injection, insulin, per 5 units $15.00 J8499 Keflex 500 mg PO $15.00 J8499 Levofloxacin 500mg po (Levaquin) $15.00 J8499 Lidocaine Hydrochloride 2% oral solution 10ml $15.00 A6448 Light compression bandage, elastic, knitted/woven, width less than three inches, per yard $15.00 J8499 Lisinopril 20 mg PO $15.00 J8499 LOPERAMIDE HCL (IMMODIUM) 2MG CAP $15.00 J8499 Lortab 5 mg Tablets $15.00 J8499 Meclizine Hcl 25mg (Antivert) $15.00 J7509 Methylprednisolone oral, per 4 mg $15.00 J8499 Motrin (Iburprofen) 600 mg PO $15.00 A9150 Nifedipine (Procardia) 10mg cap po $15.00 J8499 Nifedipine 20 mg $15.00 J8499 Potassium Chloride 10 meq $15.00 J8499 Prednisone 20mg po $15.00 A4565 Sling $15.00 J8499 Sucralfate Suspension 1g/10ml po (Carafate) $15.00 J8499 Sulfamethoxazole and Trimethoprim 800/160 mg PO (Bactrim DS) $15.00 J8499 Tamiflu 75 mg PO $15.00 J8499 Tamsulosin Hydrochloride (Flomax) 0.4 mg PO $15.00 J8499 Tessalon Perles 100 mg po $15.00 J8499 Tylenol with Codeine 5ml po $15.00 J8499 Zantac 150mg po $15.00 A9150 Zyrtec 10 mg $15.00 81005 Urinalysis; qualitative or semiquantitative, except immunoassays $15.19 J7042 5% dextrose/normal saline (500 ml = 1 unit) $15.32 J0171 Injection, adrenalin, epinephrine, 0.1 mg $16.80 J7120 Ringers lactate infusion, up to 1000 cc $16.89 J2550 Injection, promethazine hcl, up to 50 mg (Phenergan $17.47 J7502 Cyclosporine, oral, 100 mg $18.07 J0690 Injection, cefazolin sodium, 500 mg $19.34 J2270 Injection, morphine sulfate, up to 10 mg $19.45 J7042 5% DEXTROSE AND 0.45% SODIUM CHLORIDE (D51/2 NS) 250 ML IV SOLN $20.00 A9150 IBUPROFEN (MOTRIN CHILDRENS) 100MG/5ML SUSP $20.00 J7030 Infusion, normal saline solution , 1000 cc $20.00 J0132 Injection, acetylcysteine, 100 mg $20.00 A6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard $20.00 A9150 MAGNESIUM CHLORIDE 200 MG/ML INJ $20.00 J8499 Potassium Chloride ER 20mEq po $20.00 J8499 POTASSIUM CHLORIDE ER (KDUR) 20MEQ TAB $21.06 J3411 Injection, thiamine hcl, 100 mg $21.26 J8499 HYDROXYZINE PAMOATE (VISTIRIL) 50MG CAP $21.80 J1650 Injection, enoxaparin sodium, 10 mg (Lovenox) $21.93 A9273 Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type $22.00 Q4049 Finger splint, static $24.00 J1020 Injection, methylprednisolone acetate, 20 mg $24.07 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without $24.36 A6413 Adhesive bandage, first-aid type, any size, each $25.00 A9150 BENZOCAINE SPRAY (HURRICANE SPRAY) $25.00 J7633 Budesonide, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, per 0.25 milligram $25.00 A9150 DEXTROMETHORPHEN POLISTIREX (DELYSM) SUSP $25.00 J8499 Diazepam 5 MG Tablets $25.00 A9150 ERTHROMYCIN OPTHALMIC OINTMENT $25.00 J8499 FLUCONAZOLE (DIFLUCAN) 150MG TAB $25.00 A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing $25.00 A6223 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing $25.00 A6228 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing $25.00 A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing $25.00 A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing $25.00 A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing $25.00 J8499 Hyoscyamine Sulfate 0.125 mg tablet $25.00 J7050 Infusion, normal saline solution, 250 cc $25.00 J0696 Injection, ceftriaxone sodium, per 250 mg (Rocephin) $25.00 J1200 Injection, diphenhydramine hcl, up to 50 mg (Benadryl) $25.00 J1940 Injection, furosemide, up to 40 mg (Lasix) $25.00 J1580 Injection, garamycin, gentamicin, up to 80 mg $25.00 S0030 Injection, metronidazole, 500 mg $25.00 J2405 Injection, ondansetron hydrochloride, per 1 mg (Zofran) $25.00 J3370 Injection, vancomycin hcl, 500 mg (Vancocin) $25.00 J3490 Labetelol HCL 5MG INJ $25.00 J7607 Levalbuterol, inhalation solution, compounded product, administered through dme, concentrated form, 0.5 mg $25.00 J8499 LISINOPRIL (ZESTRIL) 10MG TAB $25.00 A9150 Milk Of Magnesia 1200 mg/15ml suspension 30 ml PO $25.00 A9150 MILK OF MAGNESIA 1200MG/15ML SUSP 355ML $25.00 J8499 Nitroglycerin Sublingual Table 0.4mg SL $25.00 J8499 OSELTAMIVIR PHOSPHATE (TAMIFLU) 75MG CAP $25.00 A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard $25.00 J3490 Pantoprazole Sodium 40mg po (Protonix) $25.00 A9150 Pedia-Lax Glycerin Suppositories $25.00 J8499 Phenazopyridine HCI (pyridium) 200mg PO $25.00 A4802 Protamine sulfate, for hemodialysis, per 50 mg $25.00 A4450 Tape, non-waterproof, per 18 square inches $25.00 J3490 Vitamin C 500 mg/ml $25.00 J3490 Vitamin D 1mcg $25.00 J3490 Vitamin D3 100,000 Unit/GM PWD 1ml IV $25.00 J3490 Zinc Sulphate 1 mg / ml vial $25.00 J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $25.22 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination $25.40 A9150 Maalox 30ml PO $26.25 A9150 Mag-Al-Plus (Magnesium Hydroxide, Aluminum Hydroxide, Simethicone) Susp 30ml po $26.25 J8499 Activated Charcoal 50g $26.40 J3420 Injection, Vitamin B-12 cyanocobalamin, up to 1000 mcg $28.82 J1885 Injection, ketorolac tromethamine, per 15 mg (Toradol) $30.00 J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $30.00 J0561 Injection, penicillin g benzathine, 100,000 units $30.00 A4208 Syringe with needle, sterile 3 cc, each $30.00 85610 Prothrombin time; $30.03 86593 Syphilis test, non-treponemal antibody; quantitative $30.80 A4615 Cannula, nasal $31.50 J2930 Injection, methylprednisolone sodium succinate, up to 125 mg (Solu-medrol) $34.36 82728 Ferritin $35.00 83020 Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) $35.00 J7614 Levalbuterol, inhalation solution,unit dose, 0.5 mg (Xopenex) $35.00 A4209 Syringe with needle, sterile 5 cc or greater, each $35.00 A4213 Syringe, sterile, 20 cc or greater, each $35.00 A9150 Zofran 4mg PO $35.00 J1170 Injection, hydromorphone, up to 4 mg (Dilaudid) $39.77 J1030 Injection, methylprednisolone acetate, 40 mg $39.95 83540 Iron $40.00 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) $40.74 85730 Thromboplastin time, partial (PTT); plasma or whole blood $42.07 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use $42.94 83010 Haptoglobin; quantitative $45.00 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy $45.00 82150 Amylase $45.36 J0456 Injection, azithromycin, 500 mg (Zithromax) $47.05 36415 Collection of venous blood by venipuncture $48.50 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report $48.61 S0164 Injection, pantoprazole sodium, 40 mg $48.81 J8499 Ammonia Inhalant $50.00 82550 Creatine kinase (CK), (CPK); total $50.00 A9150 DIPHENHYDRAMINE (BENADRYL) 50 MG INJ $50.00 82947 Glucose; quantitative, blood (except reagent strip) $50.00 J3490 GLUTATHIONE 200MG/ML INJ $50.00 J8499 Hydrocodone Bitartrate and Acetaminophen (Norco) 5 /325 mg po $50.00 S0020 Injection, bupivacaine hydrochloride, 30 ml $50.00 S0077 Injection, clindamycin phosphate, 300 mg $50.00 J2060 Injection, lorazepam, 2 mg (Ativan) $50.00 J0780 Injection, prochlorperazine, up to 10 mg $50.00 J1756 IRON SUCROSE (VENOFER) 200 MG INFUSION $50.00 J1756 Iron Sucrose (Venofer) 300 mg in 250 ml NS $50.00 J1756 IRON SUCROSE (VENOFOR) 300 MG INFUSION $50.00 J3490 Ketamine Hydrochloride 1000MG INJ $50.00 J3490 Lidocaine Hcl 1% $50.00 A9150 Tramadol 50mg PO $50.00 84520 Urea nitrogen; quantitative $50.00 82977 Glutamyltransferase, gamma (GGT) $50.40 84485 Trypsin; duodenal fluid $50.40 82565 Creatinine; blood $55.00 J2310 Injection, naloxone hydrochloride, per 1 mg $55.00 87077 Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate $56.56 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy $58.02 99070 Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, $59.37 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates $60.34 87177 Ova and parasites, direct smears, concentration and identification $62.30 85652 Sedimentation rate, erythrocyte; automated $65.00 81025 Urine pregnancy test, by visual color comparison methods $65.00 87075 Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates $66.29 J1956 Injection, levofloxacin, 250 mg (Levaquin) $70.00 S0119 Ondansetron, oral, 4 mg $70.00 86592 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) $70.00 87341 HEPATITIS B SURFACE AG IA, Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) $72.31 J1817 Insulin for administration through dme (i.e., insulin pump) per 50 units $74.65 S0077 CLINDAMYCIN (CLEOCIN) 600MG/4ML VIAL INJ $75.00 J8499 Racepinerine 2.25% INHph $75.00 J0558 Injection, penicillin g benzathine and penicillin g procaine, 100,000 units (Bicillin CR) $75.66 S0630 Removal of sutures; by a physician other than the physician who originally closed the wound $77.46 87086 Culture, bacterial; quantitative colony count, urine $80.01 J2543 Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) (Zosyn) $80.67 82570 Creatinine; other source $85.00 90461 IM ADMIN EACH ADDL COMPONENT, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional $90.37 99173 Screening test of visual acuity, quantitative, bilateral $95.00 86703 Antibody; HIV-1 and HIV-2, single result $95.97 E0114 Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips $100.00 A4310 Insertion tray without drainage bag and without catheter (accessories only) $100.00 36000 Introduction of needle or intracatheter, vein $100.00 86694 Antibody; herpes simplex, non-specific type test $100.73 82140 Ammonia $101.00 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only $101.85 J0735 Injection, clonidine hydrochloride, 1 mg $105.00 85370 Fibrin(ogen) degradation (split) products (FDP) (FSP); quantitative $107.01 J0153 Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) $111.55 82135 Aminolevulinic acid, delta (ALA) $115.00 82533 Cortisol; total $115.00 84703 Gonadotropin, chorionic (hCG); qualitative $116.03 80306 DRUG TEST PRSMV INSTRMNT, Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, $119.18 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid $119.70 J8499 Clonidine 0.1mg po $120.00 J3490 Immuno Meds $125.00 L3215 Orthopedic footwear, ladies shoe, oxford, each $125.00 87798 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism $130.00 87486 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique $130.00 87581 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique $130.00 80179 Salicylate $130.48 85379 Fibrin degradation products, D-dimer; quantitative $130.84 J0360 Injection, hydralazine hcl, up to 20 mg $134.44 97605 NEG PRESS WOUND TX <=50 CM, Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and $135.80 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for $136.26 90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) $136.26 87480 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique $140.35 87510 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique $140.35 J2360 Injection, orphenadrine citrate, up to 60 mg $146.98 J3490 MULTI TRACE-5 INJ $150.00 J3490 MULTI-MINERAL INJ $150.00 A4590 Special casting material (e.g., fiberglass) $150.00 L3260 Surgical boot/shoe, each $150.00 A9150 SURGICAL RECOVERY INFUSION $150.00 J3490 TRI-AMINO ACID INJ $150.00 V2799 Vision item or service, miscellaneous $150.00 87534 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique $153.44 E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or without shock absorber, each $154.00 J3490 ASCORBIC ACID (VITAMIN C) 500 MG/ML INJ $154.93 J3490 Ascorbic Acid with Preservative 500mg/ml $154.93 J3490 B Complex Injection $154.93 J3490 DEXPANTHENOL (B-5) 250 MG/ML INJ $154.93 J3490 Injection, 50% Dextrose Carpuject 25 gms in 50ml $154.93 J3490 Injection, bupivicaine hydrochloride, 30 ml $154.93 J3490 Injection, Clindamycin Phosphate 300mg $154.93 J3490 Lidocaine 1% with epinephrine $154.93 J3490 Magnesium Chloride Injection 200mg/ml $154.93 J3490 Metoprolol Tartrate 1mg $154.93 J8499 Nitroglycerin ointment 2% topical $154.93 J3490 Sodium Selenite (Selenium) 200 mcg/ml $154.93 J3490 Zinc 5mg/ml add 2.5ml to 1000 ml $154.93 L3908 Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf $163.29 99000 Handling and/or conveyance of specimen for transfer from the office to a laboratory $164.00 C9803 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source $164.22 83874 Myoglobin $166.84 87389 HIV-1 AG W/HIV-1 & HIV-2 AB, Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay $168.56 82627 Dehydroepiandrosterone-sulfate (DHEA-S) $170.23 J0744 Injection, ciprofloxacin for intravenous infusion, 200 mg $170.72 U0005 Infec agen detec ampli probe $175.00 84402 Testosterone; free $178.29 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) $181.68 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) $181.68 99211 OFFICE/OUTPATIENT VISIT EST, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care $182.98 84702 Gonadotropin, chorionic (hCG); quantitative $185.35 86356 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen $187.46 80178 Lithium $210.00 87880 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A $219.94 11740 Evacuation of subungual hematoma $225.00 29280 Strapping; hand or finger $234.01 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use $240.00 83735 Magnesium $240.00 L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment $243.00 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report $245.41 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique $245.63 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique $245.63 L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf $250.00 82553 Creatine kinase (CK), (CPK); MB fraction only $255.11 84484 Troponin, quantitative $255.11 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count $258.21 94640 AIRWAY INHALATION TREATMENT, Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an $258.88 87807 Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus $260.00 87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza $264.62 S0039 Injection, sulfamethoxazole and trimethoprim, 10 ml $265.31 80051 Electrolyte panel This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295) $268.69 83921 Organic acid, single, quantitative $270.00 82670 Estradiol $270.40 A4566 Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment $275.00 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple $283.09 86308 Heterophile antibodies; screening $283.09 76380 Computed tomography, limited or localized follow-up study $291.00 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) $291.16 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) $294.49 84075 Phosphatase, alkaline; $296.82 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) $300.09 96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for $300.09 90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use $301.57 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) $313.70 80074 Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) $315.40 69209 Removal impacted cerumen using irrigation/lavage, unilateral $318.00 J0500 Injection, dicyclomine hcl, up to 20 mg $321.01 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular $345.71 99201 OFFICE/OUTPATIENT VISIT NEW, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused $357.56 U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique $359.19 51020 Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material $383.00 A4550 Surgical trays $385.00 A4606 Oxygen probe for use with oximeter device, replacement $386.82 82310 Calcium; total $390.00 86328 COVID 19 Antibody; Single Step Method $390.00 87328 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or $390.00 76937 US GUIDE VASCULAR ACCESS, Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound $390.80 80076 HEPATIC FUNCTION PANEL, Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) $399.06 87426 Covid 19/Sofia 2 SARS Antigen FIA $410.00 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations $415.80 J3030 Injection, sumatriptan succinate, 6 mg (Imitrex) $425.00 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary $427.60 80320 Alcohols $430.00 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses $430.84 80307 DRUG TEST PRSMV CHEM ANLYZR, Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, $434.98 99360 Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG) $442.12 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use $450.79 76882 Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image $451.94 80305 DRUG TEST PRSMV DIR OPT OBS, Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay $485.00 87301 ADENOVIRUS AG IA, Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) $490.00 80329 Analgesics, non-opioid; 1 or 2 $490.00 Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies) $500.00 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report $503.62 L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf $507.43 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay $514.43 83002 Gonadotropin; luteinizing hormone (LH) $550.00 83001 Gonadotropin; follicle stimulating hormone (FSH) $550.53 29130 Application of finger splint; static $558.30 30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method $572.20 L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf $573.65 70360 Radiologic examination; neck, soft tissue $577.46 84443 Thyroid stimulating hormone (TSH) $590.00 99281 EMERGENCY DEPT VISIT, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and $590.11 73140 Radiologic examination, finger(s), minimum of 2 views $597.48 10120 Incision and removal of foreign body, subcutaneous tissues; simple $621.00 83880 Natriuretic peptide $622.32 E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips $630.98 73600 Radiologic examination, ankle; 2 views $640.88 64450 Injection, anesthetic agent; other peripheral nerve or branch $674.64 74018 Radiologic examination, abdomen; 1 view $677.33 70160 Radiologic examination, nasal bones, complete, minimum of 3 views $680.04 74022 Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect, decubitus), and a single view chest $687.89 80053 COMPREHEN METABOLIC PANEL, Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) $690.35 A4222 Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) $700.14 65222 Removal of foreign body, external eye; corneal, with slit lamp $710.40 73610 Radiologic examination, ankle; complete, minimum of 3 views $739.91 L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf $759.34 69210 Removal impacted cerumen requiring instrumentation, unilateral $760.00 51702 Insertion of temporary indwelling bladder catheter; simple (eg, Foley) $763.21 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug $767.97 74019 Radiologic examination, abdomen; 2 views $778.85 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour $781.58 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study $784.56 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) $784.56 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation $784.56 65205 Removal of foreign body, external eye; conjunctival superficial $793.98 L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise $803.04 73060 Radiologic examination; humerus, minimum of 2 views $829.59 73590 Radiologic examination; tibia and fibula, 2 views $840.76 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less $850.00 10080 Incision and drainage of pilonidal cyst; simple $858.00 24640 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation $873.00 71045 Radiologic examination, chest; single view $890.11 29125 Application of short arm splint (forearm to hand); static $898.05 28160 Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each $910.30 29540 Strapping; ankle and/or foot $936.18 L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) $944.79 65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating $953.23 83690 Lipase $963.50 99282 EMERGENCY DEPT VISIT, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem $980.76 99212 OFFICE/OUTPATIENT VISIT EST, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A $980.76 99202 OFFICE/OUTPATIENT VISIT NEW, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded $980.76 29515 Application of short leg splint (calf to foot) $989.90 71046 Radiologic examination, chest; 2 views $990.13 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour $1,008.98 62270 Spinal puncture, lumbar, diagnostic $1,017.00 70110 Radiologic examination, mandible; complete, minimum of 4 views $1,025.97 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less $1,029.42 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance $1,043.10 29126 Application of short arm splint (forearm to hand); dynamic $1,084.27 28190 Removal of foreign body, foot; subcutaneous $1,094.94 29505 Application of long leg splint (thigh to ankle or toes) $1,153.16 72170 Radiologic examination, pelvis; 1 or 2 views $1,160.77 29131 Application of finger splint; dynamic $1,193.88 29105 Application of long arm splint (shoulder to hand) $1,207.17 11730 Avulsion of nail plate, partial or complete, simple; single $1,223.11 16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) $1,223.11 12013 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm $1,223.11 12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less $1,229.62 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm $1,234.38 87040 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) $1,250.00 29240 Strapping; shoulder (eg, Velpeau) $1,263.21 73070 Radiologic examination, elbow; 2 views $1,269.44 71100 Radiologic examination, ribs, unilateral; 2 views $1,290.44 73660 Radiologic examination; toe(s), minimum of 2 views $1,337.63 73560 Radiologic examination, knee; 1 or 2 views $1,380.00 71047 Radiologic examination, chest; 3 views $1,390.11 73030 Radiologic examination, shoulder; complete, minimum of 2 views $1,390.85 73501 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view $1,470.11 71048 Radiologic examination, chest; 4 or more views $1,470.99 72120 Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views $1,478.69 99217 OBSERVATION CARE DISCHARGE, Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the $1,500.00 26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each $1,509.48 99213 OFFICE/OUTPATIENT VISIT EST, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused $1,563.38 99203 OFFICE/OUTPATIENT VISIT NEW, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical $1,563.38 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single $1,577.29 73502 Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views $1,585.95 76816 OB US FOLLOW-UP PER FETUS, Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re- $1,595.84 29365 Application of cylinder cast (thigh to ankle) $1,608.74 29405 Application of short leg cast (below knee to toes); $1,608.74 29425 Application of short leg cast (below knee to toes); walking or ambulatory type $1,608.74 46050 Incision and drainage, perianal abscess, superficial $1,611.12 80048 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) $1,634.64 71101 Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views $1,690.41 L3915 Who nontorsion jnts pre cst, Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, $1,735.32 73552 Radiologic examination, femur; minimum 2 views $1,742.12 24650 Closed treatment of radial head or neck fracture; without manipulation $1,778.14 72070 Radiologic examination, spine; thoracic, 2 views $1,790.78 72040 Radiologic examination, spine, cervical; 2 or 3 views $1,790.85 73620 Radiologic examination, foot; 2 views $1,821.44 74240 Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study $1,822.00 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance $1,828.19 64405 Injection, anesthetic agent; greater occipital nerve $1,828.19 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) $1,832.39 64999 Unlisted procedure, nervous system $1,832.39 G0378 Hospital observation service, per hour $1,850.00 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm $1,875.00 70140 Radiologic examination, facial bones; less than 3 views $1,890.48 43752 Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) $1,891.54 73521 Radiologic examination, hips, bilateral, with pelvis when performed; 2 views $1,899.44 11772 Excision of pilonidal cyst or sinus; complicated $1,905.12 69200 Removal foreign body from external auditory canal; without general anesthesia $1,926.61 72072 Radiologic examination, spine; thoracic, 3 views $1,968.13 99220 INITIAL OBSERVATION CARE, Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and $1,970.00 70150 Radiologic examination, facial bones; complete, minimum of 3 views $1,995.00 99234 OBSERV/HOSP SAME DATE, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A $2,030.45 23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia $2,035.18 72050 Radiologic examination, spine, cervical; 4 or 5 views $2,084.53 10121 Incision and removal of foreign body, subcutaneous tissues; complicated $2,085.18 73000 Radiologic examination; clavicle, complete $2,090.00 99235 OBSERV/HOSP SAME DATE, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A $2,090.12 97597 RMVL DEVITAL TIS 20 CM/<, Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or $2,093.36 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) $2,094.00 73100 Radiologic examination, wrist; 2 views $2,189.47 73020 Radiologic examination, shoulder; 1 view $2,190.22 73120 Radiologic examination, hand; 2 views $2,190.44 99236 OBSERV/HOSP SAME DATE, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A $2,195.85 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst $2,236.57 73650 Radiologic examination; calcaneus, minimum of 2 views $2,250.00 70260 Radiologic examination, skull; complete, minimum of 4 views $2,265.92 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study $2,343.28 72100 Radiologic examination, spine, lumbosacral; 2 or 3 views $2,375.53 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal $2,380.44 L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific $2,420.81 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less $2,420.88 12053 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm $2,481.64 73130 Radiologic examination, hand; minimum of 3 views $2,490.75 99283 EMERGENCY DEPT VISIT, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem $2,490.93 73080 Radiologic examination, elbow; complete, minimum of 3 views $2,520.00 73503 Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views $2,520.00 73562 Radiologic examination, knee; 3 views $2,520.00 71111 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views $2,520.00 73110 Radiologic examination, wrist; complete, minimum of 3 views $2,520.00 73090 Radiologic examination; forearm, 2 views $2,520.00 72110 Radiologic examination, spine, lumbosacral; minimum of 4 views $2,590.44 10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple $2,597.68 73630 Radiologic examination, foot; complete, minimum of 3 views $2,610.70 76830 Ultrasound, transvaginal $2,684.42 76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) $2,687.67 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete $2,710.91 76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation $2,720.00 12044 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm $2,724.00 73564 Radiologic examination, knee; complete, 4 or more views $2,750.00 76870 Ultrasound, scrotum and contents $2,845.20 23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia $2,864.54 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study $2,970.44 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study $2,975.33 0223U NFCT DS 22 TRGT SARS-COV-2, Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 $3,000.00 87633 RESP VIRUS 12-25 TARGETS, Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, $3,000.00 76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation $3,053.68 72052 Radiologic examination, spine, cervical; 6 or more views $3,070.05 30300 Removal foreign body, intranasal; office type procedure $3,294.90 24605 Treatment of closed elbow dislocation; requiring anesthesia $3,354.33 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm $3,392.70 46060 Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton $3,420.76 70450 Computed tomography, head or brain; without contrast material $3,532.36 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less $3,536.57 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete $3,539.61 99205 OFFICE/OUTPATIENT VISIT NEW, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive $3,612.00 99284 EMERGENCY DEPT VISIT, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision $3,612.33 99204 OFFICE/OUTPATIENT VISIT NEW, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive $3,612.33 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study $3,652.15 13152 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm $3,669.19 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm $3,669.19 42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical) $3,830.96 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material $3,841.00 76700 Ultrasound, abdominal, real time with image documentation; complete $4,010.68 70460 Computed tomography, head or brain; with contrast material(s) $4,155.95 70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) $4,161.00 71250 Computed tomography, thorax; without contrast material $4,190.08 99285 EMERGENCY DEPT VISIT, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical $4,245.12 10081 Incision and drainage of pilonidal cyst; complicated $4,353.79 72193 Computed tomography, pelvis; with contrast material(s) $4,390.75 71260 Computed tomography, thorax; with contrast material(s) $4,398.72 73700 Computed tomography, lower extremity; without contrast material $4,500.00 72192 Computed tomography, pelvis; without contrast material $4,560.69 70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections $4,890.47 70490 Computed tomography, soft tissue neck; without contrast material $5,040.00 72128 Computed tomography, thoracic spine; without contrast material $5,040.00 71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing $5,476.24 72131 Computed tomography, lumbar spine; without contrast material $5,670.00 70486 Computed tomography, maxillofacial area; without contrast material $5,670.00 72129 Computed tomography, thoracic spine; with contrast material $5,670.00 70491 Computed tomography, soft tissue neck; with contrast material(s) $5,790.41 70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections $5,890.44 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes $5,910.33 72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections $5,989.70 72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections $6,093.34 70498 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing $6,096.44 72125 Computed tomography, cervical spine; without contrast material $6,190.44 70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing $6,360.96 73701 Computed tomography, lower extremity; with contrast material(s) $6,475.00 74150 Computed tomography, abdomen; without contrast material $6,716.77 74160 Computed tomography, abdomen; with contrast material(s) $6,816.44 93880 Duplex scan of extracranial arteries; complete bilateral study $6,970.52 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study $6,980.73 73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material $7,010.44 70482 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections $7,011.44 72132 Computed tomography, lumbar spine; with contrast material $7,072.12 74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing $7,107.00 70487 Computed tomography, maxillofacial area; with contrast material(s) $7,390.56 72126 Computed tomography, cervical spine; with contrast material $7,689.65 72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections $7,904.86 73201 Computed tomography, upper extremity; with contrast material(s) $8,075.42 74177 Computed tomography, abdomen and pelvis; with contrast material(s) $8,090.44 72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections $8,090.46 74176 Computed tomography, abdomen and pelvis; without contrast material $8,208.91 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections $8,490.45 73200 Computed tomography, upper extremity; without contrast material $8,509.63 70492 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections $8,904.85 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions $9,011.26 74175 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing $9,090.44