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 RECTAL SUPPOSITORY [6725] $ 0.83 ACETAMINOPHEN 325 MG TABLET [2671] $ 0.03 ACETAMINOPHEN 500 MG TABLET [2672] $ 0.01 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [6312] $ 0.45 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 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [38056] $ 3.81 AMOXICILLIN 875 MG TABLET [28148] $ 0.95 AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [38057] $ 5.09 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 193.00 or toes 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$ 2,361.50fingers or toes (first 25 sq cm or less) 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 ARIPIPRAZOLE 15 MG TABLET [52491] $ 37.03 ARIPIPRAZOLE 2 MG TABLET [85655] $ 37.03 ARIPIPRAZOLE 30 MG TABLET [52493] $ 52.36 ARIPIPRAZOLE 5 MG TABLET [53505] $ 33.21 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 ATORVASTATIN 20 MG TABLET [44341] $ 0.38 ATORVASTATIN 40 MG TABLET [44070] $ 0.40 ATORVASTATIN 80 MG TABLET [44182] $ 0.54 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 BRIMONIDINE 0.15 % EYE DROPS [49362] $ 38.79 BRIMONIDINE 0.2 % EYE DROPS [40132] $ 3.76 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 25 MG-LEVODOPA 100 MG TABLET [42527] $ 0.83 CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [5122] $ 1.68 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 CARVEDILOL 3.125 MG TABLET [46124] $ 2.21 CARVEDILOL 6.25 MG TABLET [44249] $ 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 reporting 0.25 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 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [44707] $ 57.94 CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [48421] $ 80.38 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)$ device 187.00 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 MG TABLET [650] $ 0.25 DIAZEPAM 2.5 MG RECTAL KIT [48418] $ 292.24 DIAZEPAM 5 MG TABLET [651] $ 0.33 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 DILTIAZEM SR 180 MG 24 HR CAP [28893] $ 0.53 DILTIAZEM SR 240 MG 24 HR CAP [5207] $ 2.13 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 chemotherapy0.09 treatment not to exceed a 48 hour dosage regimen 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 250 MG TABLET,DELAYED RELEASE [44568] $ 1.83 DIVALPROEX 500 MG TABLET,DELAYED RELEASE [45891] $ 3.35 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 DOFETILIDE 250 MCG CAPSULE [45380] $ 8.89 DOFETILIDE 500 MCG CAPSULE [49237] $ 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 DOXEPIN 100 MG CAPSULE [7433] $ 2.07 DOXEPIN 25 MG CAPSULE [7479] $ 0.87 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, 6.12 not to exceed a 48 hour dosage regimen Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily$ 162.00 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 performed DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [56270] $ 8.87 DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [56271] $ 1.79 DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [56272] $ 1.79 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 $examination 16.00 Electronic analysis and programming of implanted complex spinal cord or peripheral neurostimulator generator system during or after surgery, first hour$ 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 Established patient periodic preventive medicine examination, age 12 through 17 years $ 70.00 Established patient periodic preventive medicine examination, age 5 through 11 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 physical therapy, typically 30 minutes $ 213.25 Evaluation of physical therapy, typically 45 minutes $ 223.75 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 FENTANYL 12 MCG/HR TRANSDERMAL PATCH [82230] $ 21.07 FENTANYL 25 MCG/HR TRANSDERMAL PATCH [48755] $ 22.07 FENTANYL 50 MCG/HR TRANSDERMAL PATCH [44096] $ 27.36 FENTANYL 75 MCG/HR TRANSDERMAL PATCH [49029] $ 61.55 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 FUROSEMIDE 40 MG TABLET [685] $ 0.06 FUROSEMIDE 80 MG TABLET [649] $ 0.47 G6PD (enzyme) level $ 219.50 GABAPENTIN 100 MG CAPSULE [43401] $ 0.61 GABAPENTIN 300 MG CAPSULE [43402] $ 1.50 GABAPENTIN 400 MG CAPSULE [43403] $ 1.27 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 GLIMEPIRIDE 2 MG TABLET [46122] $ 1.28 GLIMEPIRIDE 4 MG TABLET [47454] $ 1.28 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 HYDRALAZINE 25 MG TABLET [682] $ 0.53 HYDRALAZINE 50 MG TABLET [683] $ 0.58 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 0.31 treatment, not to exceed a 48 hour dosage regimen 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 IBUPROFEN 400 MG TABLET [5985] $ 0.09 IBUPROFEN 600 MG TABLET [5976] $ 0.11 IBUPROFEN 800 MG TABLET [5977] $ 0.09 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 105.00 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) ILOPERIDONE 2 MG TABLET [114883] $ 22.62 ILOPERIDONE 6 MG TABLET [114885] $ 27.84 ILOPERIDONE 8 MG TABLET [114886] $ 27.84 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 Initial new patient preventive medicine evaluation, age 12 through 17 years $ 70.00 Initial new patient preventive medicine evaluation, age 5 through 11 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 1,303.00 administered) 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 64.76 is self administered) 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 interpretation$ 10,639.25 Insertion of needle and/or catheter into dialysis circuit and insertion of stent in dialysis segment, with imaging including radiological supervision and interpretation$ 21,498.75 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 DINITRATE 20 MG TABLET [5716] $ 2.58 ISOSORBIDE DINITRATE 30 MG TABLET [8380] $ 1.36 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 LEVOFLOXACIN 500 MG TABLET [48762] $ 19.62 LEVOFLOXACIN 750 MG TABLET [48799] $ 36.74 LEVONORGESTREL 1.5 MG TABLET [113026] $ 37.94 LEVOTHYROXINE 100 MCG INTRAVENOUS SOLUTION [125998] $ 131.49 LEVOTHYROXINE 100 MCG TABLET [7400] $ 0.58 LEVOTHYROXINE 112 MCG TABLET [28229] $ 0.67 LEVOTHYROXINE 125 MCG TABLET [7403] $ 0.68 LEVOTHYROXINE 150 MCG TABLET [7401] $ 0.70 LEVOTHYROXINE 25 MCG TABLET [6405] $ 0.45 LEVOTHYROXINE 50 MCG TABLET [6402] $ 0.51 LEVOTHYROXINE 75 MCG TABLET [7399] $ 0.57 LEVOTHYROXINE 88 MCG TABLET [28232] $ 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 LISINOPRIL 20 MG TABLET [38032] $ 0.41 LISINOPRIL 5 MG TABLET [38030] $ 0.90 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 SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [48536] $ 1.16 METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [44824] $ 1.49 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$ reporting 0.25 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 MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [26202] $ 1.94 MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [26203] $ 3.51 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 Nerve transmission studies, 3-4 studies $ 275.00 Nerve transmission studies, 5-6 studies $ 275.00 Nerve transmission studies, 7-8 studies $ 275.00 Nerve transmission studies, 9-10 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 NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [8500] $ 2.61 NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [8498] $ 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 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH [8586] $ 1.97 NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [24864] $ 1.55 NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH [8493] $ 2.26 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 0.25 end reporting 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$ 0.25 or to end reporting 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$ reporting 0.25 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 30 MG TABLET [42174] $ 3.70 OXYCODONE 5 MG TABLET [5526] $ 0.56 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 ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [145884] $ 8.76 OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [145888] $ 14.99 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, 2.79 not to exceed a 48 hour dosage regimen 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 PREGABALIN 50 MG CAPSULE [83701] $ 10.18 PREGABALIN 75 MG CAPSULE [83702] $ 10.18 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 1.01 treatment, not to exceed a 48 hour dosage regimen 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 0.55 chemotherapy treatment, not to exceed a 48 hour dosage regimen PROPARACAINE 0.5 % EYE DROPS [8851] $ 3.04 PROPRANOLOL 10 MG TABLET [6447] $ 0.21 PROPRANOLOL 20 MG TABLET [6448] $ 0.53 PROPRANOLOL 40 MG TABLET [6449] $ 0.43 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 200 MG TABLET [45276] $ 12.68 QUETIAPINE 25 MG TABLET [40359] $ 3.92 QUETIAPINE 300 MG TABLET [44464] $ 20.54 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 scalp, neck, hands, feet, or genitals $ 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 scalp, neck, hands, feet, or genitals $ 1,235.00 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 (5.1 to 7.5 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes $ 308.00 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 face, ears, eyelids, nose, lips, and/or mucous membranes $ 308.00 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 RIVAROXABAN 15 MG TABLET [125739] $ 17.40 RIVAROXABAN 20 MG TABLET [125740] $ 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 SERTRALINE 25 MG TABLET [48021] $ 0.42 SERTRALINE 50 MG TABLET [49170] $ 3.48 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$ reporting 0.25 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 SUMATRIPTAN 25 MG TABLET [45070] $ 1.64 SUMATRIPTAN 50 MG TABLET [45483] $ 26.09 SUPER QUICK ANCHOR $ 1,596.50 SURG LEVEL 1 EA ADD 30 MIN $ 1,771.25 SURG LEVEL 2 EA ADD 30 MIN $ 2,334.25 SURG LEVEL 3 EA ADD 30 MIN $ 2,722.75 SURG LEVEL 4 EA ADD 30 MIN $ 3,043.75 SURG LEVEL 5 EA ADD 30 MIN $ 3,432.25 SURGERY LEVEL 1 1ST 30 MIN $ 2,400.25 SURGERY LEVEL 2 1ST 30 MIN $ 2,964.75 SURGERY LEVEL 3 1ST 30 MIN $ 3,351.25 SURGERY LEVEL 4 1ST 30 MIN $ 3,671.00 SURGERY LEVEL 5 1ST 30 MIN $ 4,061.00 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, 2,475.50 when performed, complete, without spectral or color doppler echocardiography Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode$ recording, 918.75 when performed, follow-up or limited study Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient;$ prorated 12.25 trip charge 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 TRAZODONE 150 MG TABLET [6341] $ 2.90 TRAZODONE 50 MG TABLET [5134] $ 0.45 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 VALSARTAN 40 MG TABLET [52185] $ 7.72 VALSARTAN 80 MG TABLET [45577] $ 4.82 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 VILAZODONE 20 MG TABLET [122288] $ 10.32 VILAZODONE 40 MG TABLET [122289] $ 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 10 MG TABLET [6542] $ 3.98 WARFARIN 2 MG TABLET [6535] $ 2.68 WARFARIN 2.5 MG TABLET [6536] $ 2.76 WARFARIN 3 MG TABLET [6537] $ 2.78 WARFARIN 4 MG TABLET [6538] $ 2.78 WARFARIN 5 MG TABLET [6539] $ 2.88 WARFARIN 6 MG TABLET [6540] $ 3.71 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 ZIPRASIDONE 40 MG CAPSULE [48497] $ 23.95 ZIPRASIDONE 60 MG CAPSULE [49045] $ 29.07 ZIPRASIDONE 80 MG CAPSULE [40466] $ 29.07 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