Charge Master List CPT/ Charge # Description Rev Code Charge Amt Status HCPCS 42000001 (TRANSCUTAN) NEUROSTIM 420 64550 $ 299.94 ACTIVE 0.45% NS 1000ML W/20MEQ (1/2 25000680 258 J7030 $ 30.00 ACTIVE NS-20MEQ POT CHL 1000ML) 0.9% SODIUM CHLORIDE 3ML 25000258 PREFILLED SALINE FLUSH 250 A4216 $ 14.00 ACTIVE SYRINGE 30100129 1 25-DIHYDROXYVITAMIN D 301 82652 $ 513.36 ACTIVE 27200001 10 FRENCH SHEATH 15-716B 272 C1894 $ 212.80 ACTIVE 10% LMD IN 5% DEXTROSE 25800005 500ML / DEXTRAN 40 IN 258 J7060 $ 280.00 ACTIVE DEXTROSE INJ 500ML 10% LMD IN 5%DEXTROSE 25800006 258 J7060 $ 322.00 ACTIVE 500ML/DE 30100216 17-KETOSTEROIDS TOTAL 301 83586 $ 170.64 ACTIVE 4.0MM ACROMIOBLASTER 27200199 272 A4649 $ 140.00 ACTIVE 7205668 4FR INT KIT MINI GW- 27200887 272 A4649 $ 112.00 ACTIVE POUCH/SHEATH 5.5MM PEDIPORT W/ LOCKING 27200845 272 C1751 $ 1,376.88 ACTIVE TROCAR 27200180 5FR POLLACK CATHETER 272 A4649 $ 32.46 ACTIVE 30100201 5-HYDROXYINDOLEACETIC ACID 301 83497 $ 171.96 ACTIVE 25901724 A&D ONINTMENT 2OZ 270 A6250 $ 64.00 ACTIVE 63600003 ABBOKINASE 5MU VIAL 636 J3365 $ 15,755.60 ACTIVE 32000001 ABD AORTAGRAM 320 75625 $ 6,708.00 ACTIVE ABD AORTAGRAM - NON 48100087 481 75625 $ 6,708.00 ACTIVE SELECTIVE ABD AORTAGRAM W/ BILATERAL 48100086 481 75630 $ 8,306.00 ACTIVE RUNOFF 32000002 ABD W/RUN OFFS 320 75630 $ 8,306.00 ACTIVE 27000561 ABDOMINAL BINDER UNIV 270 L0625 $ 500.00 ACTIVE 27000524 ABDOMINAL PAD 270 A4649 $ 3.10 ACTIVE ABDOMINAL PARACENTESIS 36000190 (DIAGNOSTIC OR THERAPEUTIC); 360 49083 $ 3,403.00 ACTIVE WITH IMAGING GUIDANCE ABDOMINAL PARACENTESIS 36000189 (DIAGNOSTIC OR THERAPEUTIC); 360 49082 $ 3,403.00 ACTIVE WITHOUT IMAGING GUIDANCE ABLATION OF ADDITIONAL 48100114 481 93655 $ 48,028.75 ACTIVE MECHANISM OF SVT OR VT 32000053 ABSCSS FIST SIN TRACT 320 76080 $ 2,656.50 ACTIVE 27000756 ACE WRAP 6" 270 A6449 $ 34.10 ACTIVE 25000011 ACETADOTE 20% INJECTION 250 J0132 $ 28.00 ACTIVE 25900029 ACETAMINOPH 160MG/5ML LIQ 259 J3490 $ 30.00 ACTIVE 25000029 ACETAMINOPHEN 1000MG IV 250 J0131 $ 59.00 ACTIVE 25900031 ACETAMINOPHEN 120MG SUPP. 250 J8498 45 ACTIVE 25900032 ACETAMINOPHEN 325MG SUPP. 250 J8498 45 ACTIVE 25900033 ACETAMINOPHEN 325MG TAB 250 A9150 $ 30.00 ACTIVE 25900030 ACETAMINOPHEN 500 MG TAB 250 J0131 $ 30.00 ACTIVE ACETAMINOPHEN 500MG TAB 25700002 250 A9150 $ 30.00 ACTIVE (MAPAP ES) 25900034 ACETAMINOPHEN 650MG SUPP 250 J8498 $ 45.00 ACTIVE Charge Master List CPT/ Charge # Description Rev Code Charge Amt Status HCPCS ACETAMINOPHEN SUSP. 25700001 250 A9150 $ 30.00 ACTIVE 160MG/5ML PRECISIONDOSE 25900036 ACETAMINOPHEN W/COD #4 250 J8499 $ 14.00 ACTIVE ACETAMINOPHEN/CODEINE 120- 25901937 250 J3490 $ 45.00 ACTIVE 12MG/5ML ORAL SOL 30100003 ACETONE BLOOD 301 82010 $ 108.96 ACTIVE 30100004 ACETONE SERUM QUALITATIVE 301 82009 $ 60.24 ACTIVE 30700001 ACETONE URINE NON AUTO 307 81002 $ 41.76 ACTIVE ACETYLCHOLINE RECEPTOR 30100005 301 84238 $ 341.32 ACTIVE ANTIBODY ACETYLCYSTEINE (MUCOMYST) 25901933 250 J7608 $ 112.00 ACTIVE 10% INH 100MG 30ML VIAL 25900041 ACETYLCYSTEINE 10PC 250 J7608 $ 202.00 ACTIVE 25900773 ACETYLCYSTEINE 20% 30ML 250 J7608 $ 184.50 ACTIVE 30100296 ACID PHOSPHATASE (TOTAL) 301 84060 $ 98.52 ACTIVE ACID-FAST BACILLUS SMEAR & 30600085 306 87206 $ 71.88 ACTIVE FUNGAL STAIN ACID-FAST BACILLUS SMEAR 30600001 306 87116 $ 144.00 ACTIVE AND CULTURE ACROMIOCLAVICULAR AC 32000054 320 73050 $ 818.52 ACTIVE JOINTS W/WO WEIGHTS - 2 VIEW ACTIDOSE WITH SORBITAL 50GM 25901306 250 J3490 $ 338.00 ACTIVE 240ML 30500002 ACTIVATED CLOTTING TIME 305 85347 $ 56.76 ACTIVE 30100007 ACUTE HEPATITIS PANEL 301 80074 $ 635.16 ACTIVE 27200883 ACUTRAK2 7.5 LONG DRILL 270 C1713 $ 9,315.00 ACTIVE 27000584 ADAPTER CATHETER 270 A4300 $ 52.00 ACTIVE 27000637 ADAPTER VALVE LL 270 A4649 $ 132.00 ACTIVE 32000003 ADD PERIPH S&I ADD FAMILY 320 75964 $ 4,945.92 ACTIVE 32000004 ADD VIS S&I 320 75968 $ 4,945.92 ACTIVE 48100112 ADDITIONAL A FIB ABLATIONS 481 93657 $ 41,671.40 ACTIVE 25400001 ADENOSINE 90MG/30ML VIAL 636 J0153 $ 710.10 ACTIVE 30200005 ADENOVIRUS ANTIBODY 302 86603 $ 171.60 ACTIVE ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY 36000366 360 14301 $ 45,499.50 ACTIVE AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM 42000004 ADL TRAIN EA 15 450 97535 $ 251.16 ACTIVE 77100001 ADMIN HEPATITIS B VACCNE 771 G0010 $ 144.90 ACTIVE 77100002 ADMIN INFLUENZA VACCINE 771 G0008 $ 411.96 ACTIVE ADMIN PNEUMOCOCCAL 77100003 771 G0009 $ 277.88 ACTIVE VACCNE ADRENOCORTICOTROPIC 30100006 301 82024 $ 363.86 ACTIVE HORMONE 25900058 ADVAIR DISKUS 250/50 250 J3535 $ 2,040.00 ACTIVE 25900059 ADVAIR DISKUS 500/50 250 J3535 $ 2,680.00 ACTIVE 25900061 ADVIL 200MG TABLET 250 A9150 $ 30.00 ACTIVE 25901316 ADVIL SUSP. 100MG/5ML 4 OZ 250 A9150 $ 30.00 ACTIVE 27000761 AERO CHAMBER 270 A4627 $ 13.50 ACTIVE 25900064 AFRIN 0.05 PC SPRY 15ML 250 J3490 $ 46.00 ACTIVE 30900019 AG DETECT NOS IA MULT 306 87449 $ 44.40 ACTIVE 30600064 AGENT NOS ASSAY W/OPTIC 306 87899 $ 192.84 ACTIVE 27000015 AIRWAY NASAL 28FR (11267) 270 A7034 $ 100.00 ACTIVE 27000016 AIRWAY NASAL 30FR (11268) 270 A7034 $ 92.00 ACTIVE Charge Master List CPT/ Charge # Description Rev Code Charge Amt Status HCPCS 27000017 AIRWAY NASAL 32FR (11269) 270 A7034 $ 100.00 ACTIVE 27200813 AIRWAYS NASAL (ALL) 272 A7034 $ 336.00 ACTIVE 27200812 AIRWAYS ORAL (ALL) 272 A7044 $ 204.00 ACTIVE 30100022 ALANINE AMINOTRANSFERASE 301 84460 $ 70.68 ACTIVE 30100011 ALBUMIN (SERUM) 301 82040 $ 66.00 ACTIVE 30100010 ALBUMIN (URINE) 301 82042 $ 93.36 ACTIVE ALBUTEROL (MCR) INHALER 25900071 250 J7609 $ 446.00 ACTIVE UNIT DOSE 1MG ALBUTEROL (VENTOLIN) INHALR 25901201 250 J7613 $ 592.50 ACTIVE 90MCG/ACT INH ALBUTEROL INH 0.5% 2.5MG 25000032 250 J7613 $ 32.50 ACTIVE 0.5ML VIAL ALBUTEROL SULFATE 0.083% 25900072 250 J7613 $ 30.00 ACTIVE 3ML-NEBULIZER ALBUTEROL UP TO 2.5MG & 25901774 IPRATROPIUM BROMIDE UP TO 259 J7620 $ 24.00 ACTIVE 0.5MG ALBUTEROL/IPRABROMIDE 0.5- 25901319 250 J7620 $ 82.50 ACTIVE 3MG/3ML 30100632 ALCOHOL (ETHANOL) 301 80320 $ 112.80 ACTIVE ALCOHOL ISOPROPYL 70% 4OZ 27000754 250 A4244 $ 5.25 ACTIVE BTL ALCOHOL, ISOPROPYL 70% 16OZ 27000755 250 A4244 $ 5.25 ACTIVE (473ML) BTL 30000013 ALDOLASE 301 82085 $ 129.48 ACTIVE 30100015 ALDOSTERONE 301 82088 $ 392.84 ACTIVE 30100017 ALKALINE PHOSPHATASE 301 84075 $ 69.00 ACTIVE ALKALINE PHOSPHATASE 30100016 301 84080 $ 197.16 ACTIVE ISOENZYMES ALL POTASSIUM HYDROXIDE 30600002 306 Q0112 $ 69.78 ACTIVE (KOH) PREPARATIONS ALLERGEN SPECIFIC IGE 30200174 QUANTITATIVE/SEMIQUANTITATI 302 86003 $ 69.60 ACTIVE VE 30100574 ALLERGY SKIN TEST 301 95028 $ 222.74 ACTIVE 25900083 ALLOPURINOL 100MG TAB 250 J8499 $ 16.00 ACTIVE 30100019 ALPHA-1-ANTITRYPSIN (TOTAL) 301 82103 $ 179.16 ACTIVE ALPHA-FETOPROTEIN AMNIOTIC 30000041 301 82106 $ 223.68 ACTIVE FLUID ALPHA-FETOPROTEIN TUMOR 30100009 301 82105 $ 223.68 ACTIVE MARKER ALPRAZOLAM (XANAX) 0.5MG 25901234 250 J8499 $ 30.00 ACTIVE TAB 25900086 ALPRAZOLAM .25MG TAB 250 J8499 $ 24.00 ACTIVE 25900087 ALPRAZOLAM 0.5MG TAB 250 J8499 $ 44.00 ACTIVE 25901854 ALPRAZOLAM 1MG TAB 250 J8499 $ 45.00 ACTIVE 30100021 ALPRAZOLMAM-XANAX 301 80299 $ 223.68 ACTIVE ALTEPLASE (CATHFLO 63600025 636 J2997 $ 813.80 ACTIVE ACTIVASE) 2MG VIAL 25900094 AMBIEN 10 MG TAB 250 J8499 $ 57.00 ACTIVE 25900095 AMBIEN 5MG TAB 250 J8499 $ 57.00 ACTIVE 27000587 AMBU BAG 270 S8999 $ 400.00 ACTIVE 30100023 AMIKACIN 301 80150 $ 201.00 ACTIVE AMINO ACIDS MX QUALITATE 30100024 301 82128 $ 184.92 ACTIVE EACH SPECIMEN AMINOLEVULINIC ACID DELTA 30100025 301 82135 $ 219.36 ACTIVE (ALA) Charge Master List CPT/ Charge # Description Rev Code Charge Amt Status HCPCS AMIODARONE 150MG (50MG/3ML) 25000875 636 J0282 $ 70.00 ACTIVE 3ML SDVIAL 63600149 AMIODARONE 360MG/200ML IV 636 J0282 $ 93.36 ACTIVE 63600150 AMIODARONE 450MG/9ML VIAL 636 J0282 $ 9.66 ACTIVE 63600151 AMIODARONE 900MG/18ML 636 J0282 $ 34.00 ACTIVE AMIODARONE CORDARONE 25900306 250 J8499 $ 54.00 ACTIVE 200MG TABLET AMITRIPTYLINE (ELAVIL) 10MG 25901419 250 J8499 $ 18.40 ACTIVE TABS AMITRIPTYLINE (ELAVIL) 25MG 25901420 250 J8499 $ 30.00 ACTIVE TABS AMLODIPINE (NORVASC) 5 MG 25900843 250 J8499 $ 52.00 ACTIVE TAB 25900105 AMLODIPINE 10MG TAB 250 J8499 $ 68.00 ACTIVE 30100028 AMMONIA 301 82140 $ 194.28 ACTIVE 25900107 AMMONIA INHALANT 250 J7699 $ 32.00 ACTIVE 27000696 AMNIOFIX PARTICULATE 40MG 250 C1762 $ 2,902.00 ACTIVE AMOXICILLIN (AMOXIL) 25901323 259 J8499 $ 96.60 ACTIVE 125MG/5ML OS AMOXICILLIN + CLAVULANATE 25900145 POTASSIUM (AUGMENTIN) 875 259 J8499 $ 94.50 ACTIVE MG TAB AMOXICILLIN +CLAVULANATE 25901946 250 J3490 $ 24.00 ACTIVE 400MG 5ML OS 25901322 AMOXICILLIN 250 MG. CAP. 250 J8499 $ 24.00 ACTIVE 25901855 AMOXICILLIN 250MG/5ML 150ML 250 J8499 $ 24.00 ACTIVE 25901856 AMOXICILLIN 400MG/5ML 50ML 250 J8499 $ 24.00 ACTIVE 25901857 AMOXICILLIN 400MG/5ML 80ML 250 J8499 $ 24.00 ACTIVE 25100039 AMOXICILLIN 500MG CAP 259 J8499 $ 24.00 ACTIVE AMOXICILLIN+CLAV POTAS 25900143 250 J8499 $ 76.50 ACTIVE (AUGMENTIN) 500/125MG TAB 25901324 AMOXIL 250MG/5ML 100ML 250 J8499 $ 228.00 ACTIVE 30100029 AMPHETAMINE 301 82145 $ 183.54 ACTIVE 63600185 AMPICILLIN 250MG VIAL 636 J0290 $ 33.68 ACTIVE 63600190 AMPICILLIN/SULBACTAM 1.5GM 636 J0290 $ 33.68 ACTIVE 63600191 AMPICILLIN/SULBACTAM 3GM 636 J0290 $ 33.68 ACTIVE AMPLICATION OF PATIENT 30100031 301 83900 $ 379.96 ACTIVE NUCLEIC ACID AMPUTATION FINGER/THUMB ANY JOINT/PHALAN SINGLE 36000238 360 26951 $ 33,190.50 ACTIVE INCLUDING NEURECTOMIES W/DIRECT CLOSURE AMPUTATION, TOE; 36000298 360 28825 $ 18,346.50 ACTIVE INTERPHALANGEAL JOINT 30100032 AMYLASE 301 82150 $ 86.40 ACTIVE 30100071 ANABOLIC STEROIDS; 1 OR 2 301 80327 $ 40.20 ACTIVE 30100059 ANALGESICS NON-OPIOID 1-2 301 80329 $ 221.28 ACTIVE 30100114 ANALGESICS, NON-OPIOID; 3-5