Charge Code Description Fee 116057 Post-operative follow-up visit $0.00 114187 Application of long leg splint (thigh to ankle or toes) $129.94 114222 Strapping; ankle and or foot $75.44 114687 CT, thoracic spine; without contrast material $2,079.00 117177 Mefoxin / Cefoxitin Sodium, 1 g, IV/IM $50.00 117787 Ketamine 5 mg IV/IM $15.00 116145 Ear Curette $39.38 116734 EENT Tray (Ear, Eye, Nose, Throat) $204.75 117858 Lidocaine 4%, 50ml, topical solution $34.13 114644 Radiologic exam, spine; thoracic, 3 views $467.25 Infectious agent antigen detection by immunoassay with direct optical 115804 observation; Streptococcus, group A $141.75 118405 Ankle Brace / Air Gel Cast - size M $100.00 117253 Injection, Heparin sodium, per 1000 units $17.06 117939 Nitro-Bid, ointment 2%, 1gm $10.00 116749 Slings, arm $35.44 116911 Light compression bandage, elastic, knitted/woven, ace bandage, 4" $22.31 114720 CT, pelvis; without contrast material $1,568.44 114778 Radiologic exam, elbow; two views $240.19 114896 Radiologic examination hips, bilateral, with pelvis when performed, 2 views $400.43 116493 Mod sed same phys/qhp 5/>yrs $626.28 117690 Fentanyl, 25 mg, IV $10.00 115748 Infectious agent antigen detection; respiratory syncytial virus $141.75 117453 Acet/Tylenol #3 with Codeine, 300mg, Oral $7.88 114960 Radiologic exam, ankle; complete, minimum of three views $333.38 114197 Application of short leg splint (calf to foot) $129.94 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any 114224 method $783.96 114848 Radiologic exam, hand; two views $232.31 117658 Debrox, Earwax Removal Kit $15.00 Infectious agent antigen detection by enzyme immunoassay technique, 115738 Influenza B $115.50 117599 Cardene, PGBCK IV PREMIX SOD CHLORIDE 20 MG/200ML $165.00 116467 Vicryl 6.0 for sutures $52.50 117467 Acet/Tylenol, 120mg, Suppository $7.88 117715 Adult-Fleet Enema $10.00 117865 Lopressor/Metoprolol Tartrate 25 mg oral $11.81 115077 CT, abdomen and pelvis; without contrast material $2,729.43 WHO, wrist extension control cock-up, nonmolded, prefabricated, includes 118389 fitting and adjustment $35.00 114456 CT, maxillofacial area; without contrast material $1,568.44 118450 Splint supply, short arm, adult (11 years +), fiberglass (Orthoglass) $121.80 117442 Magnesium sulphate, per 500 mg, IM/IV $75.00 118111 Racemic EPI, 2.25%, inhalation $10.00 114419 CT, head or brain; without contrast material $2,310.00 116533 Facility - Emergency department visit, level 4 $3,500.00 117669 Erythromycin Eye Ointment $18.00 118530 Splint supplies / 4" Webril $7.88 Gauze, nonimpregnated, sterile, pad size 16 sq. in. or less, without adhesive 116879 border, each dressing $14.44 115301 Alcohol Level, Blood (ETOH) $36.00 115487 Phosphorus inorganic (phosphate); $34.96 117046 Adenosine for therapeutic use, 6 mg (vial), IV $490.35 115524 Troponin, quantitative $166.69 115310 Analgesics, non-opioid; 1 or 2 (Tylenol, Salicylate) Level $363.38 118138 Sodium Bicarbonate, 8.4%, 50 ml, 1meq/mL $20.00 117918 Mylanta/Maalox (oral) $7.88 117679 Eye Wash $10.00 116417 Tono Pen Tip $17.06 115089 CT, abdomen and pelvis; with contrast material(s) $2,425.58 116604 Sterile Water per 10 ml $5.00 CT, head or brain; without contrast material, followed by contrast material(s) 114434 and further sections $2,352.00 115517 Thyroid stimulating hormone (TSH) $140.44 Closed treatment of metacarpal fracture, single; without manipulation, each 114046 bone $129.94 118017 Phenergan/Promethazine Suppository 50 mg each $20.00 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding 113907 hands and feet); 7.6 cm to 12.5 cm $1,272.76 118127 Silver Nitrate $10.00 118006 Famotidine/Pepcid, 20 mg, oral $10.00 116076 Alligator Forceps $137.81 115644 Blood typing, serologic; Rh (D) $27.50 113831 Avulsion of nail plate, partial or complete, simple; single $404.88 117045 Injection, Acetylcysteine, 100 mg $5.24 117623 Cephalexin / Keflex 500MG PO $5.00 113977 Closed treatment of shoulder dislocation, with manipulation; without anesthesia $129.94 117237 Glucagon HCl/GlucaGen Diagnostic Kit, per 1 mg, SC/IM/IV $595.01 114426 CT, head or brain; with contrast material(s) $1,813.88 117010 Walker, folding (pickup), adjustable or fixed height $50.00 117327 Norflex/Orphenadrine citrate, up to 60 mg, IM/IV $75.00 115244 Electrolyte panel $233.63 116719 Surgical trays (Lac tray/ I&D tray/ Sut Removal) $168.00 118537 Gastrografin Oral Contrast $150.41 Closed treatment of fracture, phalanx or phalanges, other than great toe; 114117 without manipulation, each $129.94 115924 Intravenous infusion, hydration; initial, 31 minutes to 1 hour $427.88 118087 Pyridium/Phenazopyridine, 200MG PO $9.04 114023 Closed treatment of radial and ulnar shaft fractures; with manipulation $3,790.67 114980 Radiologic exam, foot; complete, minimum of three views $531.56 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or 113889 mucous membranes; 5.1 cm to 7.5 cm $545.92 115572 Gonadotropin, chorionic (hCG); qualitative $206.06 Critical care, evaluation and management of the critically ill or critically injured 116548 patient; first 30-74 minutes $5,300.00 117821 Lidocaine 1% with EPI, 20ml, IV $10.00 115415 Glutamyltransferase, gamma (GGT) $133.88 115626 C-reactive protein; $95.55 Contrast media / Omnipaque / Low osmolar contrast material, 300-399 mg/ml 118542 iodine concentration, per ml $15.60 118069 Proparacaine HCl / Alcaine Opth Drops $7.88 118194 Viscous Lidocaine, 10 ml, PO $17.06 114391 X-RAY EXAM OF EYE SOCKETS, MINIMUM OF 4 VIEWS $305.81 116877 Petroleum/ Vasoline gauze $7.88 115436 Hemoglobin; glycosylated (A1C) $72.00 118517 Splint supplies / 3" Webril $7.88 115374 Creatine kinase (CK), (CPK); total $242.81 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real 115101 time with image documentation $547.31 117122 Bicillin / Penicillin G Benzathine 1.2 ml , Injection (Per Dose/Vial) $144.38 117812 Labetalol HCI, 5mg/ml, IV $10.00 114755 Radiologic exam; scapula, complete $232.31 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal 114029 separation, with or without fracture of ulnar styloid; without manipulation $129.94 118213 Normal saline solution, sterile (500 ml = 1 unit), IV $35.00 Dressings and/or debridement of partial-thickness burns, initial or subsequent; 113954 small $129.94 118391 Ankle Brace / Air Gel Cast - size L $100.00 117538 Amidate / Etomidate 2mg, IV $10.00 118181 Norco / Vicodin / Hydrocodone 5/500mg (oral); 5 mg tablet $10.00 114629 Radiologic exam, spine, cervical; 4 or 5 views $485.63 116366 Secondary Tubing for IV $6.56 117587 Dicyclomine/ Bentyl 10mg (PO Med) $7.88 116615 Alcohol or peroxide, per pint $2.00 117776 Ketamine, 20 mg, for sedation, IV/IM $15.00 Xopenex / Levalbuterol, inhalation solution, FDA-approved final product, 118291 noncompounded, administered through DME, unit dose, 0.5 mg $50.00 114594 CT, thorax/chest; with contrast material $2,743.13 114926 Radiologic exam knee; complete, four or more views $389.81 114994 Radiologic exam; toe(s), minimum of two views $211.31 116910 Light compression bandage, elastic, ace bandage, 2" $22.31 118216 5% dextrose/NS (500 ml = 1 unit) $75.00 Culture, bacterial; any other source except urine, blood or stool, aerobic, with 115679 isolation and presumptive identification of isolates $118.13 115532 Urea nitrogen / BUN; quantitative $76.13 118570 Clindamycin/Cleocin phosphate, 300 mg, IV/IM $50.00 Shoulder orthotic (SO), figure of eight design abduction restrainer, canvas and 118377 webbing, prefabricated, includes fitting and adjustment $100.00 117603 Cardizem/Diltiazem 5mg per vial, IV $10.00 Tube thoracostomy, includes connection to drainage system (eg, water seal), 114233 when performed, open $1,713.32 114912 Radiologic exam, knee; three views $257.25 116109 Chromic sutures (Gut) $90.56 114291 Insertion of non-indwelling bladder catheter $254.63 118585 Magnesium Oxide 250 mg PO $6.25 116560 IV start kit $50.00 117285 Lasix/Furosemide, up to 20 mg, IV/IM $20.00 118441 Splint supply, long arm, adult (11 years +), fiberglass (Orthoglass) $148.05 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 115312 number of these constituents; automated, without microscopy $132.56 115935 Intravenous infusion, hydration; each additional hour $127.31 114717 Radiologic exam, pelvis; one or two views $228.38 115371 Calcium; total $38.04 116399 Urine strain cup $17.06 117561 Bactroban/ Mupirocin $20.00 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal 115887 contents and/or retroperitoneal organs; limited study $1,174.69 115272 Hepatic function panel; LFT $280.88 115707 Culture, bacterial; quantitative colony count, urine $59.90 116516 Screening test of visual acuity, quantitative, bilateral $55.28 115547 Uric acid; blood $33.52 118229 5% Dextrose/Water, 500 ml $10.00 116930 Tubular dressing / Tube gauze with or without elastic, any width, per linear yard $9.19 116545 Facility - Emergency department visit, level 5 $4,600.00 117968 Normal saline solution / Sodium Chloride, 100 ml $10.00 118414 Catheterization for collection of specimen, single patient, all places of service $10.00 118175 Valium/Diazepam, 5mg tablet (oral) $10.00 118477 Splint supply, long leg, pediatric (0-10 years), fiberglass (Orthoglass) $121.80 115916 Pulse oximetry for oxygen saturation; multiple determinations $152.25 117733 Fluor-I-Strip,