Charge Code Description Fee 116561 18 G IV Cath needle, sterile $5.00 116577 20 G IV Cath needle, sterile $5.00 116588 22 G IV Cath needle, sterile $5.00 118216 5% dextrose/NS (500 ml = 1 unit) $75.00 118237 5% Dextrose/Water, 250 ml $10.00 118229 5% Dextrose/Water, 500 ml $10.00 117453 Acet/Tylenol #3 with Codeine, 300mg, Oral $7.88 117515 Acet/Tylenol drops, 80mg $7.88 117525 Acet/Tylenol w/ Codeine, 12.5mg, Elixer $7.88 117467 Acet/Tylenol, 120mg, Suppository $7.88 117493 Acet/Tylenol, 325 mg, PO $7.88 117523 Acetaminophen/Tylenol Elixir, 160mg $7.88 117483 Acetaminophen/Tylenol, 160 mg, chewable tablet $7.88 117498 Acetaminophen/Tylenol, 500 mg tablet $7.88 117514 Acetaminophen/Tylenol, 60mg suppository $7.88 117528 Activated Charcoal, 25mg with Sorbital, Suspension $25.00 116826 Adaptic / Gel sheet / Kling for dermal or epidermal application, each $23.63 117046 Adenosine for therapeutic use, 6 mg (vial), IV $490.35 116958 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable $35.00 117061 Adrenalin, Epinephrine, 0.1 mg, IV/IM/SC $42.00 117715 Adult-Fleet Enema $10.00 116967 Aerosol mask, used with DME nebulizer $15.00 117535 Afrin Nasal Spray (Oxymetazoline) $7.88 115336 Albumin; serum, plasma or whole blood $71.00 118279 Albuterol, inhalation solution, unit dose (per vial) $20.00 118293 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, $40.00 115301 Alcohol Level, Blood (ETOH) $36.00 116615 Alcohol or peroxide, per pint $2.00 116076 Alligator Forceps $137.81 117538 Amidate / Etomidate 2mg, IV $10.00 117077 Amiodarone HCl, 30 mg, IV $168.00 117086 Ampicillin Sodium, 500 mg, IV/IM $101.06 115342 Amylase $136.50 115310 Analgesics, non-opioid; 1 or 2 (Tylenol, Salicylate) Level $363.38 117154 Ancef/Cefazolin Sodium, up to 500 mg, IV/IM $50.00 118391 Ankle Brace / Air Gel Cast - size L $100.00 118405 Ankle Brace / Air Gel Cast - size M $100.00 118599 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease $327.31 [COVID-19]) 114173 Application of finger splint; static (foam) $129.94 114152 Application of long arm splint (shoulder to hand) $129.94 114187 Application of long leg splint (thigh to ankle or toes) $129.94 114163 Application of short arm splint (forearm to hand); static $129.94 114197 Application of short leg splint (calf to foot) $129.94 116086 Arm board, for IV stabilization $27.56 117554 Aspirin Tablet, 81mg PO $7.88 117544 Aspirin, 325mg, PO $7.88 117292 Ativan/Lorazepam, 2 mg/mL, IV/IM $98.44 118307 Atrovent/Ipratropium bromide, inhalation solution, unit dose form, per mg $25.00 113831 Avulsion of nail plate, partial or complete, simple; single $404.88 117561 Bactroban/ Mupirocin $20.00 115237 Basic metabolic panel $252.00 115226 Basic metabolic panel; CHEM8; (Calcium, ionized) Must include 82330, 82374, 82435, 82565, 82947, $279.71 84132, 84295 & 84520 117579 Benadryl / Diphenhydramine Elixir $7.88 117232 Benadryl/Diphenhydramine HCl, up to 50 mg, IV/IM $20.00 117573 Benadryl/Diphenhydramine, 25 mg, PO $7.88 117115 Bentyl, up to 20 mg, IM $145.69 116619 Betadine, 4 ounce bottle $5.00 117122 Bicillin / Penicillin G Benzathine 1.2 ml , Injection (Per Dose/Vial) $144.38 115343 Bilirubin; direct $139.01 116787 Blades, surgical supplies $13.13 115579 Blood count; complete (CBC) $127.31 115642 Blood typing, serologic; ABO $27.50 115644 Blood typing, serologic; Rh (D) $27.50 115351 Blood, occult, by peroxidase activity (eg, guaiac), qualitative $36.75 115367 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, single specimen $36.75 117124 Calcium gluconate, per 10 ml, Injection, IV $20.00 115371 Calcium; total $38.04 116782 Cannula, nasal $44.63 117599 Cardene, PGBCK IV PREMIX SOD CHLORIDE 20 MG/200ML $165.00 116102 Cardiac Monitoring/Telemetry $351.75 115841 Cardioversion, elective, electrical conversion of arrhythmia; external $758.63 117618 Cardizem / Diltiazem 25mg/5ml vial, IV $15.00 117603 Cardizem/Diltiazem 5mg per vial, IV $10.00 117641 Catapres/Clonidine, 0.1mg PO $6.00 118414 Catheterization for collection of specimen, single patient, all places of service $10.00 116105 Cautery, Micro-temp Fine Tip / Bovie $51.19 117623 Cephalexin / Keflex 500MG PO $5.00 118428 Cerebyx/Fosphenytoin, 50 mg, Injection, IM/IV $20.00 118342 Cervical, collar, semi-rigid thermoplastic foam, 2 piece $20.00 118337 Cervical, flexible, nonadjustable (foam collar) $50.00 118339 Cervical, flexible, thermoplastic collar $20.00 116622 Chlorhexidine Antiseptic $6.00 116109 Chromic sutures (Gut) $90.56 117632 Cipro Ophthalmic Drops $25.00 117635 Clindamycin/Cleocin phosphate, 150 mg, IV/IM $6.00 118570 Clindamycin/Cleocin phosphate, 300 mg, IV/IM $50.00 114086 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation $129.94 114035 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or $2,222.29 without fracture of ulnar styloid; with manipulation 114029 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or $129.94 without fracture of ulnar styloid; without manipulation 114115 Closed treatment of fracture great toe, phalanx or phalanges; with manipulation $129.94 114128 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each $129.94 114117 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, $129.94 each 114076 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia $129.94 114048 Closed treatment of metacarpal fracture, single; with manipulation, each bone $129.94 114046 Closed treatment of metacarpal fracture, single; without manipulation, each bone $129.94 114059 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without $852.72 anesthesia 114104 Closed treatment of metatarsal fracture; without manipulation, each $129.94 114142 Closed treatment of metatarsophalangeal joint dislocation; without anesthesia $902.13 114068 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with $129.94 manipulation, with or without skin or skeletal traction, each 114023 Closed treatment of radial and ulnar shaft fractures; with manipulation $3,790.67 114005 Closed treatment of radial head or neck fracture; without manipulation $129.94 114000 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation $129.94 114018 Closed treatment of radial shaft fracture; with manipulation $129.94 113977 Closed treatment of shoulder dislocation, with manipulation; without anesthesia $129.94 113967 Closed treatment of temporomandibular dislocation; initial or subsequent $1,375.15 116123 Coban/ Co-Flex Bandage $11.81 114265 Collection of capillary blood specimen (eg, finger, heel, ear stick) $17.06 114252 Collection of venous blood by venipuncture $42.00 117204 Compazine/Prochlorperazine, up to 10 mg, injection, IM/IV $81.38 115256 Comprehensive metabolic panel; CHEM13 $363.56 114863 Computed tomography, upper extremity; with contrast material(s) $2,539.94 116899 Conforming bandage, nonelastic, knitted/woven, nonsterile, width 3" to 4.9", per yd. $9.19 116894 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard $4.51 118542 Contrast media / Omnipaque / Low osmolar contrast material, 300-399 mg/ml iodine concentration, $15.60 per ml 114224 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method $783.96 118597 COVID-19 $427.31 115626 C-reactive protein; $95.55 115387 Creatine kinase (CK), (CPK); MB fraction only (CKMB) $173.25 115374 Creatine kinase (CK), (CPK); total $242.81 115396 Creatinine; blood $132.56 116548 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 $5,300.00 minutes 116999 Crutches, underarm, pair, with pads, tips and handgrips $103.69 114482 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST #N/A 114498 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST #N/A 114599 CT angiography, chest, without and with contrast $2,401.88 116129 CT Injector Kit $87.94 114452 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL $2,352.00 115089 CT, abdomen and pelvis; with contrast material(s) $2,425.58 115077 CT, abdomen and pelvis; without contrast material $2,729.43 115100 CT, abdomen and pelvis; without contrast material in one or both body regions, followed by $3,065.90 contrast material(s) and further sections in one or both body regions 115063 CT, abdomen; with contrast material(s) $2,079.00 114671 CT, cervical spine; without contrast material $2,079.00 114426 CT, head or brain; with contrast material(s) $1,813.88 114419 CT, head or brain; without contrast material $2,310.00 114434 CT, head or brain; without contrast material, followed by contrast material(s) and further sections $2,352.00 115019 CT, lower extremity; with contrast material(s) $1,601.25 115005 CT, lower extremity; without contrast material $1,392.56 114702 CT, lumbar spine; without contrast material $2,079.00 114460 CT, maxillofacial area; with contrast material(s) $2,361.19 114456 CT, maxillofacial area; without contrast material $1,568.44 114443 CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material $2,079.00 114724 CT, pelvis; with contrast material(s) $1,813.88 114720 CT, pelvis; without contrast material $1,568.44 114471 CT, soft tissue neck; with contrast material(s) $2,079.00 114462 CT, soft tissue neck;