At a glance
Charlotte hospital prices span $1 to $352,263 across 8716 shoppable procedures, drawn from 58 reporting hospitals across the metro area. Every price comes directly from federally mandated Machine-Readable Files under 45 CFR Part 180. ProcedureRadar last refreshed Charlotte data in Apr 2026, with monthly updates ongoing.
By Kevin Monangai, Founder, ProcedureRadar.
City pages are how we answer what does healthcare actually cost where I live. We aggregate every procedure we cover, across every hospital in that metro, into one place. About 140 shoppable procedures, all sourced from federally mandated transparency files, all refreshed monthly. If you live there, this is the page we built for you.
Every shoppable procedure in Charlotte, plotted by median price against how much prices vary across hospitals. Hover any point to see the procedure, median, and hospital spread. Click to view hospitals.
| Procedure | Category | Median Price | Low | High | Hospitals |
|---|---|---|---|---|---|
| Dressing Colactive Plus Nonsilver2x2 10160000 | other | $1 | $1 | $1 | 1 |
| Fesoterodine ER 4 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Olmesartan Medoxomil 20 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Oseltamivir Phos 30 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Picc Cath Statlock Secure Device 50ea/1ca | other | $1 | $1 | $1 | 1 |
| Preemie Little Sucker W/cover #n204c | other | $1 | $1 | $1 | 1 |
| Slings | other | $1 | $1 | $1 | 1 |
| Teds Thigh 2x-large Regular Novaplus #v8805r | other | $1 | $1 | $1 | 1 |
| Teds Thigh Large Long Novaplus #v9303l | other | $1 | $1 | $1 | 1 |
| Teds Thigh Large Short Novaplus #v8303s | other | $1 | $1 | $1 | 1 |
| Teds Thigh Medium Long Novaplus #v9302l | other | $1 | $1 | $1 | 1 |
| Teds Thigh Medium Regular Novaplus #v8802r | other | $1 | $1 | $1 | 1 |
| Teds Thigh Small Regular Novaplus #v8801r | other | $1 | $1 | $1 | 1 |
| Teds Thigh Small Short Novaplus #v8301s | other | $1 | $1 | $1 | 1 |
| Teds Thigh W/belt Xl Long Novaplus #v9304l | other | $1 | $1 | $1 | 1 |
| Teds Thigh W/belt Xl Regular Novaplus #v8804r | other | $1 | $1 | $1 | 1 |
| Zonisamide 100 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Zonisamide 100 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Blade Laryngoscope Disp Led Millr Sz00 1039.c | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl ER (xl) 150 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl Xl 150 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Carbamide Peroxide 6.5 % Ot Soln | other | $1 | $1 | $1 | 1 |
| Desogestrel-ethinyl Estradiol 0.15-30 Mg-mcg Po Tabs | other | $1 | $1 | $1 | 1 |
| Dexmethylphenidate Hcl 10 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Dressing Aquacel Foam 7x7 #420621 10ea/1bx | other | $1 | $1 | $1 | 1 |
| Ear Drops 6.5% | other | $1 | $1 | $1 | 1 |
| Fluconazole 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Glipizide ER 2.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Loperamide 2 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Loperamide Hcl 2 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Phenytoin 25 Mg Chewable Half Tablet | other | $1 | $1 | $1 | 1 |
| Phenytoin 50 Mg Tablet Chew | other | $1 | $1 | $1 | 1 |
| Sodium Chl 0.9% Irrigation 500ml Btl 18ea/1ca | other | $1 | $1 | $1 | 1 |
| Wound Filler, Gel/paste, Per Fluid Ounce, Not Otherwise Specified | other | $1 | $1 | $1 | 1 |
| Fleet Pedia-lax Enema | other | $1 | $1 | $1 | 1 |
| Isosorbide Dinitrate 5 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Isosorbide Dinitrate 5 Mg Tab | other | $1 | $1 | $1 | 1 |
| Methylphenidate ER 36 Mg Tab | other | $1 | $1 | $1 | 1 |
| Nicotine 14 Mg/24hr Patch | other | $1 | $1 | $1 | 1 |
| Nicotine 21 Mg/24hr Patch | other | $1 | $1 | $1 | 1 |
| Paroxetine ER 12.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Pencan Spinal Needle 24g X 4" with 20g Introducer Sterile 25ea/ct #333884 | other | $1 | $1 | $1 | 1 |
| Butalb-acetamin-caff 50-325 | other | $1 | $1 | $1 | 1 |
| Butalbital-apap-caffeine 50-325-40 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Cath Coude Tiemann 20fr Rusch 50ea/1bx | other | $1 | $1 | $1 | 1 |
| Celecoxib 200 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Celecoxib 200 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Cozaar 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Handle Laryngoscope Dispos Led Medium 2015.c | other | $1 | $1 | $1 | 1 |
| Handle Laryngoscope Dispos Led Pediatr 2016.c | other | $1 | $1 | $1 | 1 |
| Handle Laryngoscope Dispos Std Stubby 2017.c | other | $1 | $1 | $1 | 1 |
| Menest 0.3 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Milk of Magnesia - 30ml - Repackaging | other | $1 | $1 | $1 | 1 |
| Niacin ER (antihyperlipidemic) 500 Mg Po Tbcr | lab | $1 | $1 | $1 | 1 |
| Niacin ER 500 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Oxycodone-acetaminophen 10 | other | $1 | $1 | $1 | 1 |
| Paliperidone ER 3 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Pepto-bismol 525 Mg/30 Ml Susp | other | $1 | $1 | $1 | 1 |
| Piroxicam 10 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Prazosin 1 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Prochlorperazine Maleate, 5 Mg, Oral, Fda Approved Prescription Anti-emetic, ... | other | $1 | $1 | $1 | 2 |
| Chlorhexidine 0.12% 15 Ml Cup | other | $1 | $1 | $1 | 1 |
| Chlorhexidine 0.12% Soln - 15 Ml - Repackaging | other | $1 | $1 | $1 | 1 |
| Docusate Sod 100 Mg/10 Ml Cup | other | $1 | $1 | $1 | 1 |
| Dressing Hydrocolloid 6 X 6in | other | $1 | $1 | $1 | 1 |
| Finasteride 5 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Finasteride 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Nipple Shield 20mm Sma Contact 6ea/1cs | other | $1 | $1 | $1 | 1 |
| Strong Iodine Solution | other | $1 | $1 | $1 | 1 |
| Valproic Acid 250 Mg/5 Ml Cup | other | $1 | $1 | $1 | 1 |
| Valproic Acid Oral Soln 250 Mg/5 Ml - Repackaging | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphetamine 10 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphetamine 15 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Assessment By Trained Clinical Staff of Implant And/or Foreign Body for Mr Sa... | surgery | $1 | $1 | $1 | 1 |
| Banatrol Plus Powder Packet | other | $1 | $1 | $1 | 1 |
| Cannula Nasal Adult Oral 7ft O2 #4797-7-7 | other | $1 | $1 | $1 | 1 |
| Dressing Comfeel Plus 3" Butterfly #3350 | other | $1 | $1 | $1 | 1 |
| Dressing Foam Adhesive Heel Design #m90619 | other | $1 | $1 | $1 | 1 |
| Nyamyc 100,000 Unit/gm Powder | other | $1 | $1 | $1 | 1 |
| Sore Throat 1.4% Spray | other | $1 | $1 | $1 | 1 |
| Speculum Vaginal Small Disp Lighted C020100-1 Bx/18ea | other | $1 | $1 | $1 | 1 |
| Ted Hose Anti Emb Thigh Sm Short 3071lf- | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Lg Long Open Toe 3856lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Lg Reg Open Toe 3728lf- | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Lg Short Open Toe 3634lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Med Long Open Toe 3549lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Med Reg Close Toe 3416lf- | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Short Med Open Toe 3310lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Small Reg Open Toe 3130lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Xl Long Open Toe 3182lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Xl Reg Open Toe 3181lf | other | $1 | $1 | $1 | 1 |
| Ted Hose Comp Thigh Xxl Reg Open Toe 3184lf | other | $1 | $1 | $1 | 1 |
| Aspirin 300 Mg Suppository | other | $1 | $1 | $1 | 1 |
| Carbamazepine ER 100 Mg Cap | other | $1 | $1 | $1 | 1 |
| Cimetidine 800 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Emtricitabine-tenofovir Df 200-300 Mg Po Tabs #3 Dispense Pack | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Cuffed Oral 5.0 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Cuffed Oral 5.5 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Cuffed Oral 6.0 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Cuffed Oral 6.5 | other | $1 | $1 | $1 | 1 |
| Irrigation Kit Stoma Cone/tube Hollister #7721 1ea/1bx | other | $1 | $1 | $1 | 1 |
| Lansoprazole Dr 15 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Lansoprazole Dr 30 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Liquid E-z Paque 60% Susp | other | $1 | $1 | $1 | 1 |
| Paroxetine ER 25 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Paroxetine Hcl ER 25 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Tube Endo Trach Nasal Cuffed 4.5 | other | $1 | $1 | $1 | 1 |
| Tube Endo Trach Nasal Cuffed 5.0 | other | $1 | $1 | $1 | 1 |
| Tube Endo Trach Nasal Cuffed 5.5 | other | $1 | $1 | $1 | 1 |
| Tube Endo Trach Nasal/cuffed 4.0 | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dressing Silvasorb Circular #msc9310ep | other | $1 | $1 | $1 | 1 |
| Fenofibrate Micronized 200 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Mag-al Plus Xs Susp 30 Ml Cup | other | $1 | $1 | $1 | 1 |
| Mesalamine Dr 400 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Metoclopramide Hcl 10 Mg Po Tabs #2 Dispense Pack | other | $1 | $1 | $1 | 1 |
| Milk of Magnesia Suspension | other | $1 | $1 | $1 | 1 |
| Morphine Sulfate Ir 30 Mg Tab | other | $1 | $1 | $1 | 1 |
| Perfusion Adaptor 1/4" #10007 Dlp | surgery | $1 | $1 | $1 | 1 |
| Readi-cat 2 2% Suspension | other | $1 | $1 | $1 | 1 |
| Skin Trac Large 3"x40" #3874-13 24ea/1bx | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphet ER 15 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Dextroamp-amphet ER 15 Mg Cap | other | $1 | $1 | $1 | 1 |
| Dressing Aquagel Adv Hydrofiber 2x2" #422297 | other | $1 | $1 | $1 | 1 |
| Hydrocortisone 1% Ointment | other | $1 | $1 | $1 | 1 |
| Hydrocortisone-aloe 1% Cream | other | $1 | $1 | $1 | 1 |
| Mct Oil | other | $1 | $1 | $1 | 1 |
| Metoprolol Succ ER 50 Mg Tab | other | $1 | $1 | $1 | 1 |
| Metoprolol Succinate ER 50 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Nafcillin 25 Mg/ml Ns Syringe-peds - Compounded | other | $1 | $1 | $1 | 1 |
| Neomycin 500 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Ranolazine ER 500 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Rasagiline Mesylate 1 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Rasagiline Mesylate 1 Mg Tab | other | $1 | $1 | $1 | 1 |
| Flexinet Sz 3 Width 7/8"x25yds/bx #mto3a | other | $1 | $1 | $1 | 1 |
| Methylphenidate Hcl 20 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Mineral Oil 30 Ml Cup | other | $1 | $1 | $1 | 1 |
| Mineral Oil 30 Ml Ud - Repackaging | other | $1 | $1 | $1 | 1 |
| Oxycontin ER 10 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Hydrocodone-acetamn 7.5-325/15 | other | $1 | $1 | $1 | 1 |
| Methylphenidate ER 54 Mg Tab | other | $1 | $1 | $1 | 1 |
| Stopcock Plastic Three-way Ptws-2fll-mll-r #g00219 | other | $1 | $1 | $1 | 1 |
| Hydralazine 50 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Luki-disp Aspirating Tubes Argyle 20ml 6.25in #8886864604 48ea/1cs | other | $1 | $1 | $1 | 1 |
| Mesalamine Dr 1.2 Gm Tablet | other | $1 | $1 | $1 | 1 |
| Nisoldipine ER 17 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Nisoldipine ER 17 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Nystatin 100000 Unit/ml Mt Susp | other | $1 | $1 | $1 | 1 |
| Nystatin 500,000 Unit/5 Ml Cup | other | $1 | $1 | $1 | 1 |
| Phenobarbital 20 Mg/5 Ml Cup | other | $1 | $1 | $1 | 1 |
| Amphetamine-dextroamphet ER 10 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Captopril 25 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Lamotrigine ER 50 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Lamotrigine ER 50 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Ortho-glass Splint W2xl12in Fiberglass Double Sided Padded #og-2pc 10ea/bx | other | $1 | $1 | $1 | 1 |
| Primaquine 26.3 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Yasmin 28 Tablet | other | $1 | $1 | $1 | 1 |
| Cinacalcet Hcl 30 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dipyridamole 50 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dressing Aquacel Foam Sacral Sm 8"x7" #421579 | other | $1 | $1 | $1 | 1 |
| Dressing Steri-strip 1/4x1-1/2 (6/bx) #r1542 | other | $1 | $1 | $1 | 1 |
| Feeding Administration Set Kangaroo 1000ml for Pump Flush Baf Dehp-free Latex... | other | $1 | $1 | $1 | 1 |
| Fenofibrate 160 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Glucerna Shake | other | $1 | $1 | $1 | 1 |
| Injector N35-o #515052 1cs/200ea | other | $1 | $1 | $1 | 1 |
| Memantine Hcl ER 28 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Memantine Hcl ER 28 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Saf-gel 1ea #145730 | other | $1 | $1 | $1 | 1 |
| Sirolimus, Oral, 1 Mg | other | $1 | $1 | $1 | 1 |
| Feed Tube 12fr Kendall #8884-711501 10ea/1cs | other | $1 | $1 | $1 | 1 |
| Feeding Set Kangaroo Omni W/flush Bag 1000ml and Enplus Spike #bspff 30ea/case | other | $1 | $1 | $1 | 1 |
| Lactulose 10 Gm/15ml Po Soln | other | $1 | $1 | $1 | 1 |
| Lactulose 20 Gm/30 Ml Soln Cup | other | $1 | $1 | $1 | 1 |
| Nifedipine ER 90 Mg Po Tb24 | other | $1 | $1 | $1 | 1 |
| Nitrofurantoin Mcr 50 Mg Cap | other | $1 | $1 | $1 | 1 |
| Optilock Nonadhesive Super Absorbant Wound Dressing Msc64610ep 10ea/bx 5bx/ca... | other | $1 | $1 | $1 | 1 |
| Sodium Chloride 0.9 % in Aers | other | $1 | $1 | $1 | 1 |
| Triple Dye Swab | other | $1 | $1 | $1 | 1 |
| Zenpep Dr 5,000 Unit Capsule | other | $1 | $1 | $1 | 1 |
| Boot Cast Gelo Unna's 12ea/1cs | other | $1 | $1 | $1 | 1 |
| Cefpodoxime Proxetil 100 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Electrode Needle Tip #0013m 12/bx | other | $1 | $1 | $1 | 1 |
| Nebulizer Kit 1000ml #ck0010 | other | $1 | $1 | $1 | 1 |
| Airway Ovassapian #bd6075 5/cs | other | $1 | $1 | $1 | 1 |
| Benadryl Itch Stop 1%-0.1% Crm | other | $1 | $1 | $1 | 1 |
| Mirtazapine 7.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Neo-synephrine 0.5% Spray | other | $1 | $1 | $1 | 1 |
| Piroxicam 20 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Quinine Sulfate 324 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Blade Laryngoscope Dispo Robert Shaw 1 2011.c | other | $1 | $1 | $1 | 1 |
| Divalproex Sod ER 250 Mg Tab | other | $1 | $1 | $1 | 1 |
| Doxycycline Hyclate 100 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Endotrach Tube 6.5mm Nasal Rae #96365 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube 7.0mm Nasal Rae #96370 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 5.0mm Cuff #76251 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 5.5mm Cuff #76255 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 6.0mm Cuff #76260 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 6.5mm Cuff #76265 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 7.5mm Cuff #76275 | other | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae Cuffed 4.0mm 10/bx | other | $1 | $1 | $1 | 1 |
| Lubiprostone 8 Mcg Capsule | other | $1 | $1 | $1 | 1 |
| Nicotine 7 Mg/24hr Patch | other | $1 | $1 | $1 | 1 |
| Oxybutynin Cl ER 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Oxymorphone Hcl ER 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Sleeve Smoke Evac Suction 165mm 10/pk 0703-005 | other | $1 | $1 | $1 | 1 |
| 5fr Obturator | other | $1 | $1 | $1 | 1 |
| 6fr Obturator | other | $1 | $1 | $1 | 1 |
| 7fr Obturator | other | $1 | $1 | $1 | 1 |
| Arformoterol, Inhalation Solution, Fda Approved Final Product, Non-compounded... | other | $1 | $1 | $1 | 1 |
| Brace Wrist Right Small #79 | other | $1 | $1 | $1 | 1 |
| Clotrimazole-betamethasone Crm | other | $1 | $1 | $1 | 1 |
| Injection, Cytarabine, 100 Mg | other | $1 | $1 | $1 | 1 |
| Pradaxa 110 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Cevimeline Hcl 30 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Jackson Pratt Drain Flat 10mm | other | $1 | $1 | $1 | 1 |
| Light Compression Bandage, Elastic, Knitted/woven, Width Less Than Three Inch... | other | $1 | $1 | $1 | 1 |
| Ondansetron, Oral, 4 Mg | other | $1 | $1 | $1 | 1 |
| Osmolite 1 Cal Liquid | other | $1 | $1 | $1 | 1 |
| Ramelteon 8 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dressing Border 6x6 Mepilex #295400b | other | $1 | $1 | $1 | 1 |
| Enema | other | $1 | $1 | $1 | 1 |
| Focalin Xr 5 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Ketorolac 10 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Acetaminophen 650mg/20.3ml Cup | other | $1 | $1 | $1 | 1 |
| Arnuity Ellipta 100 Mcg Inh | other | $1 | $1 | $1 | 1 |
| Cast Splint 4"x 15" Comformable 10ea/1cs | other | $1 | $1 | $1 | 1 |
| Dutasteride 0.5 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Dutasteride 0.5 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Levalbuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded... | other | $1 | $1 | $1 | 1 |
| Nitro-bid 2% Ointment | other | $1 | $1 | $1 | 1 |
| Belt Gait W/ Buckle 72" #655702 | other | $1 | $1 | $1 | 1 |
| Fluvastatin Sodium 20 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Fluvastatin Sodium 40 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Focalin Xr 10 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Mesalamine ER 0.375 Gram Cap | other | $1 | $1 | $1 | 1 |
| Tobramycin 0.3% Eye Drop | other | $1 | $1 | $1 | 1 |
| Albuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded, A... | other | $1 | $1 | $1 | 2 |
| Boot Cast Extra Large 1ea | other | $1 | $1 | $1 | 1 |
| Boot Cast Small #2035-02 1ea | other | $1 | $1 | $1 | 1 |
| Boot Cast-large | other | $1 | $1 | $1 | 1 |
| Boot Cast-medium | other | $1 | $1 | $1 | 1 |
| Cannula Anterior Chamber 27 Ga | other | $1 | $1 | $1 | 1 |
| Darifenacin ER 7.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dextroamphetamine Sulfate ER 15 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| First Aid Antiseptic 10% Oint | other | $1 | $1 | $1 | 1 |
| Fluoxetine 20 Mg/ 5 Ml Oral Solution - Repackaging | other | $1 | $1 | $1 | 1 |
| Fluoxetine 20 Mg/5 Ml Soln Cup | other | $1 | $1 | $1 | 1 |
| Ortho-glass Splint W3xl12in Fiberglass Double Sided Padded #og-3pc 10ea/bx | other | $1 | $1 | $1 | 1 |
| Ziprasidone Hcl 20 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Ziprasidone Hcl 80 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Ziprasidone Hcl 80 Mg Po Caps | other | $1 | $1 | $1 | 1 |
| Amox-clav 200-28.5 Mg/5 Ml Sus | other | $1 | $1 | $1 | 1 |
| Atazanavir Sulfate 200 Mg Cap | other | $1 | $1 | $1 | 1 |
| Partitioned Scoop Dish #1388 | other | $1 | $1 | $1 | 1 |
| Anes Breathing Circuit Adult 3l #a4y520xxf | other | $1 | $1 | $1 | 1 |
| Cannula Nasal 50' #0150 | other | $1 | $1 | $1 | 1 |
| Ciprofloxacin 0.3% Eye Drop | other | $1 | $1 | $1 | 1 |
| Fluconazole 200 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Fluconazole 200 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Focalin Xr 15 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Focalin Xr 20 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Pilocarpine Hcl 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Polyethylene Glycol 3350 Powd | other | $1 | $1 | $1 | 1 |
| Splint Wrist Cockup Left Universal | other | $1 | $1 | $1 | 1 |
| Splint Wrist Cockup Right Universal | other | $1 | $1 | $1 | 1 |
| Valganciclovir 225 Mg Half Tablet | other | $1 | $1 | $1 | 1 |
| Valganciclovir 450 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Adaptor Meconium Aspiration #n0101 40ea/bx | other | $1 | $1 | $1 | 1 |
| Boudreauxs Butt Paste | other | $1 | $1 | $1 | 1 |
| Bromocriptine 2.5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Eye Itch Relief 0.025% Drops | other | $1 | $1 | $1 | 1 |
| Foam Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq. In. But Less T... | other | $1 | $1 | $1 | 1 |
| Hemorrhoidal Ointment | other | $1 | $1 | $1 | 1 |
| Juven Packet | other | $1 | $1 | $1 | 1 |
| Propranolol ER 80 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Propranolol Hcl ER 80 Mg Po Cp24 | other | $1 | $1 | $1 | 1 |
| Zidovudine 100 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Azithromycin 500 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Azithromycin 500 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Cannula Inner 6.0 Xltin Ext Length | other | $1 | $1 | $1 | 1 |
| Cannula Inner 7.0 Xltin Ext Length 12.3/100mm | other | $1 | $1 | $1 | 1 |
| Cannula Inner 8.0 Xltin Ext Length 13.3/105mm | other | $1 | $1 | $1 | 1 |
| Fenofibrate 48 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Fenofibrate 48 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Methylphenidate ER 18 Mg Tab | other | $1 | $1 | $1 | 1 |
| Namenda 5-10 Mg Titration Pk | other | $1 | $1 | $1 | 1 |
| Ritonavir 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Splint Wrist/forearm Left Large 1ea | other | $1 | $1 | $1 | 1 |
| Splint Wrist/forearm Left Medium 1ea | other | $1 | $1 | $1 | 1 |
| Splint Wrist/forearm Rt Medium 1ea | other | $1 | $1 | $1 | 1 |
| Acetylcysteine, Inhalation Solution, Fda-approved Final Product, Non-compound... | other | $1 | $1 | $1 | 1 |
| Brace Thumb Splint Universal #5026 | other | $1 | $1 | $1 | 1 |
| Catheter Coude 14fr #120614 Cs/12ea | cardiac | $1 | $1 | $1 | 1 |
| Aripiprazole 5 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Aripiprazole 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Tube Salem Sump Multi-functional Port Enfit Connection 18fr #7771810e | other | $1 | $1 | $1 | 1 |
| Vilazodone Hcl 10 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Vilazodone Hcl 20 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Vilazodone Hcl 20 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Vilazodone Hcl 40 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Vilazodone Hcl 40 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Eye Protector Regular/newborn 33-38cm | obstetric | $1 | $1 | $1 | 1 |
| Olanzapine Odt 5 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Propylthiouracil 50 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Timolol Maleate 0.25% Eye Drop | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 75 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Bupropion Hcl 75 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Eye Drops 0.05% | other | $1 | $1 | $1 | 1 |
| Injection, Von Willebrand Factor Complex (humate-p), Per Iu Vwf:rco | other | $1 | $1 | $1 | 1 |
| Quinidine Gluc ER 324 Mg Tab | other | $1 | $1 | $1 | 1 |
| Silver Nitrate Applicators - #10 - Repackaged | other | $1 | $1 | $1 | 1 |
| Synthroid 200 Mcg Tablet | other | $1 | $1 | $1 | 1 |
| Urinary Catheter Anchoring Device, Adhesive Skin Attachment, Each | cardiac | $1 | $1 | $1 | 1 |
| Urinary Catheter Anchoring Device, Leg Strap, Each | cardiac | $1 | $1 | $1 | 1 |
| Endotrach Tube Oral Rae 7.0mm Cuff #76270 | other | $1 | $1 | $1 | 1 |
| Feeding Set Kangaroo Omni W/flush Bag 1000ml #b10ff 30ea/case | other | $1 | $1 | $1 | 1 |
| Feeding Set Kangaroo Omni W/flush Bag 500ml #b5ff 30ea/case | other | $1 | $1 | $1 | 1 |
| Hydrocodone-chlorpheniramine ER Susp 5ml - Repackaged | other | $1 | $1 | $1 | 1 |
| Nateglinide 60 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Tube Port Gientri 12fr Salem Sump #7771210 | other | $1 | $1 | $1 | 1 |
| Tube Port Gientri 14fr Salem Sump #7771410 | other | $1 | $1 | $1 | 1 |
| Tube Port Gientri 16fr Salem Sump #7771610 | other | $1 | $1 | $1 | 1 |
| Voriconazole 100 Mg Half Tablet | other | $1 | $1 | $1 | 1 |
| Voriconazole 200 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Aliskiren 150 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Aspirin-dipyridam ER 25-200 Mg | other | $1 | $1 | $1 | 1 |
| Aspirin-dipyridamole ER 25-200 Mg Po Cp12 | other | $1 | $1 | $1 | 1 |
| Desitin 40% Paste | other | $1 | $1 | $1 | 1 |
| Ethacrynic Acid 25 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Adhesive, Liquid OR Equal, Any Type, Per Oz | other | $1 | $1 | $1 | 1 |
| Amox-clav 400-57 Mg/5 Ml Susp | other | $1 | $1 | $1 | 1 |
| Orajel 3x Toothache-gum Gel | other | $1 | $1 | $1 | 1 |
| Bacitracin 500 Unit/gm Ointmnt | other | $1 | $1 | $1 | 1 |
| Flexinet Sz 5 Width 1-1/4"x25yds/bx #mto5a | other | $1 | $1 | $1 | 1 |
| Toot Sweet Sub (glucose 25%) - 1 Ml - Repackaging | other | $1 | $1 | $1 | 1 |
| Trazodone 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Trazodone Hcl 100 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Dressing Xtrasorb Classic 6"x9" #89569 | other | $1 | $1 | $1 | 1 |
| Fluconazole 10 Mg/ml Susp | other | $1 | $1 | $1 | 1 |
| Lanthanum Carb 500 Mg Tab Chew | other | $1 | $1 | $1 | 1 |
| Lanthanum Carbonate 500 Mg Po Chew | other | $1 | $1 | $1 | 1 |
| Wound Cleanser 12 Oz Safe Clens #159712 6/cs | other | $1 | $1 | $1 | 1 |
| Clopidogrel 300 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dish Scoop Round 8 Inch 1ea | other | $1 | $1 | $1 | 1 |
| Dressing Foam Allevyn 7x7 Gntle Brdr 66800280 | other | $1 | $1 | $1 | 1 |
| Glucose 40 % Po Gel | other | $1 | $1 | $1 | 1 |
| Lidocaine Topical 2% 15 Ml Viscous Soln Ud - Repackaging | other | $1 | $1 | $1 | 1 |
| Lubiprostone 24 Mcg Capsule | other | $1 | $1 | $1 | 1 |
| Lubiprostone 24 Mcg Po Caps | other | $1 | $1 | $1 | 1 |
| Montelukast Sod 5 Mg Tab Chew | other | $1 | $1 | $1 | 1 |
| Montelukast Sodium 4 Mg Po Chew | other | $1 | $1 | $1 | 1 |
| Montelukast Sodium 5 Mg Po Chew | other | $1 | $1 | $1 | 1 |
| Splint Cool Blue Wrist Left #d5040 | other | $1 | $1 | $1 | 1 |
| Splint Wrist Univ Rt Cool Blue #d5040 | other | $1 | $1 | $1 | 1 |
| Tiagabine Hcl 4 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Allegra-d 24 Hour Tablet | other | $1 | $1 | $1 | 1 |
| Doxycycline Hyclate 100 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Doxycycline Hyclate 100 Mg Tab | other | $1 | $1 | $1 | 1 |
| Needle for Infusion Port Powerloc 20 Ga X 0.75in Injectable without Y Injecti... | surgery | $1 | $1 | $1 | 1 |
| Pvc Drain Surgical 10 Fr Round Mid Perforation 100 Cc Reservoir Standard Leng... | surgery | $1 | $1 | $1 | 1 |
| Valve Biopsy #maj-210 Endo/non-chrg | lab | $1 | $1 | $1 | 1 |
| Brimonidine 0.2% Eye Drop | other | $1 | $1 | $1 | 1 |
| Omega-3 Ethyl Esters 1 Gm Cap | other | $1 | $1 | $1 | 1 |
| Rivastigmine 9.5 Mg/24hr Patch | other | $1 | $1 | $1 | 1 |
| Tolterodine Tart ER 2 Mg Cap | other | $1 | $1 | $1 | 1 |
| Weighted Spork 1ea | other | $1 | $1 | $1 | 1 |
| Dressing Calcium Alginate 2x2 #31022 | other | $1 | $1 | $1 | 1 |
| Electrode Ultra Clean Accessory | other | $1 | $1 | $1 | 1 |
| Furosemide 10 Mg/ml Solution | other | $1 | $1 | $1 | 1 |
| Magnesium Citrate Solution | other | $1 | $1 | $1 | 1 |
| Olmesartan Medoxomil 40 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Skin Protectant Medline/remedy Specialized Extra Thick Zinc Oxide Paste 4oz #... | other | $1 | $1 | $1 | 1 |
| Tramadol Hcl ER 100 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Anesthesia for Other Repair of Upper Abdomen Hernia | surgery | $1 | $1 | $1 | 1 |
| Bactine Max 0.13% Solution | other | $1 | $1 | $1 | 1 |
| Nafcillin 1 Gm/ 50 Ml Ns Mini-bag Plus - Compounded | other | $1 | $1 | $1 | 1 |
| Nafcillin 2 Gm / 100 Ml Ns Mini-bag Plus - Compounded | other | $1 | $1 | $1 | 1 |
| Teds Thigh 3x-large Regular Ultra Care Open Toe Purple Latex Free #868-06 Cas... | other | $1 | $1 | $1 | 1 |
| Trazodone 50 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Trazodone Hcl 50 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Anesthesia for Procedure On Veins in Upper Leg | other | $1 | $1 | $1 | 1 |
| Colchicine 0.6 Mg Po Tabs | other | $1 | $1 | $1 | 1 |
| Colchicine 0.6 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Guaifenesin 200 Mg/10 Ml Cup | other | $1 | $1 | $1 | 1 |
| Wrist Splint 6" W/stays Left Lg #5015 | other | $1 | $1 | $1 | 1 |
| Wrist Splint 6" W/stays Left Md #5015 | other | $1 | $1 | $1 | 1 |
| Wrist Splint 6" W/stays Right Lg #5015 | other | $1 | $1 | $1 | 1 |
| Wrist Splint 6" W/stays Right Md #5015 | other | $1 | $1 | $1 | 1 |
| Bss Eye Solution | other | $1 | $1 | $1 | 1 |
| Injection, Topotecan, 0.1 Mg | other | $1 | $1 | $1 | 1 |
| Mask Lma Unique Silicone W/cuff Pilot Size 1 | other | $1 | $1 | $1 | 1 |
| Mask Lma Unique Silicone W/cuff Pilot Size 2 | other | $1 | $1 | $1 | 1 |
| Mask Lma Unique Silicone W/cuff Pilot Sz 1.5 | other | $1 | $1 | $1 | 1 |
| Mask Lma Unique Silicone W/cuff Pilot Sz 2.5 | other | $1 | $1 | $1 | 1 |
| Propafenone Hcl ER 425 Mg Cap | other | $1 | $1 | $1 | 1 |
| Propafenone Hcl ER 425 Mg Po Cp12 | other | $1 | $1 | $1 | 1 |
| Theophylline ER 300 Mg Po Tb12 | other | $1 | $1 | $1 | 1 |
| Theophylline ER 300 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Dextroamphetamine 10 Mg Tab | other | $1 | $1 | $1 | 1 |
| Injection, Fosphenytoin, 50 Mg Phenytoin Equivalent | other | $1 | $1 | $1 | 2 |
| Loperamide 2 Mg/15 Ml Oral Soln - Repackaging | other | $1 | $1 | $1 | 1 |
| Loperamide 2 Mg/15 Ml Soln Cup | other | $1 | $1 | $1 | 1 |
| Tube Salem Sump 14fr W/filter&valve | other | $1 | $1 | $1 | 1 |
| Tube Salem Sump 16fr W/filter&valve | other | $1 | $1 | $1 | 1 |
| Daytrana 10 Mg/9 Hr Patch | other | $1 | $1 | $1 | 1 |
| Daytrana 15 Mg/9 Hr Patch | other | $1 | $1 | $1 | 1 |
| Daytrana 20 Mg/9 Hour Patch | other | $1 | $1 | $1 | 1 |
| Daytrana 30 Mg/9 Hour Patch | other | $1 | $1 | $1 | 1 |
| Filter Disp W/connector Tube Obgyn Berkeley | other | $1 | $1 | $1 | 1 |
| Linezolid 600 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Menest 0.625 Mg Tablet | other | $1 | $1 | $1 | 1 |
| Bag Phlebotomy Set 25/bx #bk-64a | other | $1 | $1 | $1 | 1 |
| Electrode Disposable Pre-gel Monitoring 25/bg | other | $1 | $1 | $1 | 1 |
| Iontophoris Pad - Sp 6ea/1bx | other | $1 | $1 | $1 | 1 |
| Mesalamine ER 250 Mg Po Cpcr | other | $1 | $1 | $1 | 1 |
| Pentasa 250 Mg Capsule | other | $1 | $1 | $1 | 1 |
| Triamcinolone 0.1% Cream | other | $1 | $1 | $1 | 1 |
| Triamcinolone Acetonide 0.1 % Ex Crea | other | $1 | $1 | $1 | 1 |
| No Charge Item | other | $1 | $1 | $1 | 1 |
| Suture | other | $1 | $1 | $1 | 1 |
| Vitamin D12 1.25 Mg Powder Pac | other | $1 | $1 | $1 | 1 |
| Azathioprine, Oral, 50 Mg | other | $1 | $1 | $1 | 1 |
| Bacitracin Oint 0.9gm | other | $1 | $1 | $1 | 1 |
| Hyoscyamine Sulfate 120 Ml Dos | other | $1 | $1 | $1 | 1 |
| Injection, Ondansetron Hydrochloride, Per 1 Mg | other | $1 | $1 | $1 | 1 |
| Prednisone, Immediate Release OR Delayed Release, Oral, 1 Mg | other | $1 | $1 | $1 | 1 |
| Prescription Drug, Oral, Chemotherapeutic, Nos | other | $1 | $1 | $1 | 1 |
| Smoking Cessation Gum | other | $1 | $1 | $1 | 1 |
| Sodium Chloride 0.9% 3 Ml Neb | other | $1 | $1 | $1 | 1 |
| Noc Drugs, Inhalation Solution Administered Through DME | other | $1 | $1 | $1 | 1 |
| Flowcytometry/tc Add-on | other | $1 | $1 | $1 | 1 |
| Sevelamer 0.8 Gm Powder Packet | other | $2 | $1 | $2 | 2 |
| Injection, Dexamethasone Sodium Phosphate, 1 Mg | imaging | $2 | $1 | $3 | 2 |
| Methotrexate; Oral, 2.5 Mg | other | $2 | $1 | $3 | 2 |
| Methylprednisolone Oral, Per 4 Mg | other | $2 | $1 | $2 | 2 |
| Bandage Comprilan 6cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Desloratadine 5 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Diflunisal 500 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Dressing Biatain 5x5" Silicone Foam #33436 | other | $2 | $2 | $2 | 1 |
| Forcep Surgical Adson Dressing Serrated 4.75 | surgery | $2 | $2 | $2 | 1 |
| Glove Edema Compression Large Left 1ea | other | $2 | $2 | $2 | 1 |
| Glove Edema Compression Lrg Right 1ea | other | $2 | $2 | $2 | 1 |
| Glove Edema Compression Med Right 1ea | other | $2 | $2 | $2 | 1 |
| Glove Edema Compression Medium Left 1ea | other | $2 | $2 | $2 | 1 |
| Nitroglycerin 0.2 Mg / 5 Ml Syringe (for Radial Cocktail) - Compounded | other | $2 | $2 | $2 | 1 |
| Yaz 28 Tablet | other | $2 | $2 | $2 | 1 |
| Cuff Universal Lrg 3-1/2in #1489 | other | $2 | $2 | $2 | 1 |
| Dermoplast Pain Relieving Spry | other | $2 | $2 | $2 | 1 |
| Forcep Surgical Adson Tissue 1x2 4.75in | surgery | $2 | $2 | $2 | 1 |
| Medroxyprogesterone Acetate 10 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Midazolam Hcl 10 Mg/5 Ml Cup | other | $2 | $2 | $2 | 1 |
| Support Abducted Thumbspica Uni #79 | other | $2 | $2 | $2 | 1 |
| Support Abducted Thumbspica Uni Lt #79 | other | $2 | $2 | $2 | 1 |
| Acetaminophen 120 Mg Re Supp | other | $2 | $2 | $2 | 1 |
| Aripiprazole 2 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Clotrimazole 10 Mg Troche | other | $2 | $2 | $2 | 1 |
| Fleet Mineral Oil Enema | other | $2 | $2 | $2 | 1 |
| Rivastigmine 1.5 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Tropicamide 0.5% Eye Drops | other | $2 | $2 | $2 | 1 |
| Flexiseal Collect Bags W Fil 5ea/bx 6bx/cs #422291 | other | $2 | $2 | $2 | 1 |
| Irrigation Tur Set 21" #2c4006 12ea/1ca | other | $2 | $2 | $2 | 1 |
| Levetiracetam 500 Mg/5 Ml Cup | other | $2 | $2 | $2 | 1 |
| Injection, Fondaparinux Sodium, 0.5 Mg | other | $2 | $2 | $2 | 1 |
| Iontophoris Pad - 80 6ea/1bx | other | $2 | $2 | $2 | 1 |
| Raloxifene Hcl 60 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Factor Ix, Complex, Per I.u. | other | $2 | $2 | $2 | 1 |
| Montelukast Sod 10 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Nebivolol 10 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Nebivolol 2.5 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Nebivolol Hcl 10 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Spear Eye #10 Merocel 10ea/pk | other | $2 | $2 | $2 | 1 |
| Adaptic Finger Dressing Large 1-1/8" #mad023u Case=17bx=170each | other | $2 | $2 | $2 | 1 |
| Adaptic Finger Dressing Small 3/4" #mad003u Case=17bx=170each | other | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Removal of Prostate | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Bulging (aneurysm) Defect in Knee Artery | surgery | $2 | $2 | $2 | 1 |
| Cuff Universal Medium 3in #1487 | other | $2 | $2 | $2 | 1 |
| Temazepam 7.5 Mg Capsule | other | $2 | $2 | $2 | 1 |
| 1/2 Circle Rev Cut Richard Allen #209106 | other | $2 | $2 | $2 | 1 |
| Dress Aquacel Advantage Hydrofbr Rope #422300 | other | $2 | $2 | $2 | 1 |
| Glove Edema Compression Sm Left 1ea | other | $2 | $2 | $2 | 1 |
| Ligaclip-lg Titanium Orange #004200 120ea/bx | other | $2 | $2 | $2 | 1 |
| Thoracic Chest Tube 32fr 10ea/1cs | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedures On Nerves, Muscles, Tendons, and Tissue of Up... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Knee | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Saliva Gland | other | $2 | $2 | $2 | 1 |
| Demeclocycline Hcl 150 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Extension Set W/controller 60ea/1cs | other | $2 | $2 | $2 | 1 |
| Lavage Tray 34fr Argyle #88 | other | $2 | $2 | $2 | 1 |
| Amoxicillin 400 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Connector Straight 3/8 X 1/4" #050516000 | other | $2 | $2 | $2 | 1 |
| Efavirenz 600 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Hc Remote Cardiac Monitoring-additional Hrs | cardiac | $2 | $2 | $2 | 1 |
| Merit Medical K-50 Tube #08-01859 15/bx | other | $2 | $2 | $2 | 1 |
| Nausea Aromatic Pk Disp/quease Ease 30ea/1ca | other | $2 | $2 | $2 | 1 |
| Adaptic Toe Dressing 1-1/8" Size Lg #mad062u 10ea/bx | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, Fascia, and Bursae of S... | other | $2 | $2 | $2 | 1 |
| Cannula Vessel One Way Flow Bevd Tip #30000 | other | $2 | $2 | $2 | 1 |
| Intermittent Urinary Catheter; Straight Tip, with OR without Coating (teflon,... | cardiac | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 10 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 10 Mg Tab | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 20 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 40 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 40 Mg Tab | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 5 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Rosuvastatin Calcium 5 Mg Tab | other | $2 | $2 | $2 | 1 |
| Splint Wrist Lrg Right 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Med Left 1ea | other | $2 | $2 | $2 | 1 |
| Suction Cath-14fr-coude 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Varenicline 1 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Varenicline Tartrate 1 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Artery of Upper Leg | other | $2 | $2 | $2 | 1 |
| Ezetimibe-simvastatin 10-40 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Ezetimibe-simvastatin 10-80 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Oxycontin ER 15 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Penicillin Vk 250 Mg/5 Ml Soln | other | $2 | $2 | $2 | 1 |
| Arnuity Ellipta 200 Mcg Inh | other | $2 | $2 | $2 | 1 |
| Arthritis Hot 15%-10% Cream | other | $2 | $2 | $2 | 1 |
| Moxifloxacin Hcl 400 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Ortho-glass Splint W4xl15in Fiberglass Double Sided Padded Og-4pc 10ea/bx | other | $2 | $2 | $2 | 1 |
| Splint Clavicle-adult/large #3004 | other | $2 | $2 | $2 | 1 |
| Splint Clavicle-adult/x-lrg #3004 | other | $2 | $2 | $2 | 1 |
| Splint Clavicle-medium #3004 | other | $2 | $2 | $2 | 1 |
| Wilson Frame Headrest #1937dz 12/cs | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Front Abdomen | other | $2 | $2 | $2 | 1 |
| Carvedilol ER 10 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Carvedilol ER 20 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Carvedilol Phosphate ER 20 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Cast Splint 3" X 12" Comformable 10ea/1csquick Step Splint Scotchcast 3" X 12" | other | $2 | $2 | $2 | 1 |
| Imatinib Mesylate 100 Mg Tab | other | $2 | $2 | $2 | 1 |
| Injection, Aprepitant, 1 Mg | other | $2 | $2 | $2 | 1 |
| Nadolol 20 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Nadolol 20 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Repaglinide 1 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Repaglinide 1 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Venlafaxine Hcl ER 37.5 Mg Cap | other | $2 | $2 | $2 | 1 |
| Venlafaxine Hcl ER 37.5 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Alginate OR Other Fiber Gelling Dressing, Wound Filler, Sterile, Per 6 Inches | other | $2 | $2 | $2 | 1 |
| Anesthesia for Repair OR Removal of Vagina and Urinary Procedure | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Total Elbow Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Calmoseptine Ointment | other | $2 | $2 | $2 | 1 |
| Fluvastatin Sodium ER 80 Mg Po Tb24 | other | $2 | $2 | $2 | 1 |
| Single Use Distal Cover #maj-2315 20ea/bx | other | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion of Penile Prosthesis | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Abdomen Outside Abdominal Cavity | other | $2 | $2 | $2 | 1 |
| Lidocaine 5% Patch | other | $2 | $2 | $2 | 1 |
| Methylphenidate Hcl ER (cd) 10 Mg Po Cpcr | other | $2 | $2 | $2 | 1 |
| Methylphenidate Hcl ER (cd) 20 Mg Po Cpcr | other | $2 | $2 | $2 | 1 |
| Methylphenidate Hcl ER (cd) 30 Mg Po Cpcr | other | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Testicle Through Groin | surgery | $2 | $2 | $2 | 1 |
| Binder Abdominal 10" 27"-48" #ort21200 | other | $2 | $2 | $2 | 1 |
| Fluconazole 150 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Fluconazole 150 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Resuscitator Bag W/mask Child Manual Spur Ii Ambu 531613000 Case/6ea | other | $2 | $2 | $2 | 1 |
| Disposable Temperature Probe Sterile 400 Series Molex Esophageal OR Rectal Pr... | other | $2 | $2 | $2 | 1 |
| Estrogens Conjugated 0.625 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Nasal Aspirator without Syringe #mad300 | other | $2 | $2 | $2 | 1 |
| Premarin 0.3 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Premarin 0.625 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Anes Breathing Circuit Ped 2l W/mask B1557xx4 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Leg, Ankle, and Foot Bones | other | $2 | $2 | $2 | 1 |
| Dibucaine 1% Ointment | other | $2 | $2 | $2 | 1 |
| Jackson Rees Modification Circuit #3842-61z | other | $2 | $2 | $2 | 1 |
| Lanolin Cream | other | $2 | $2 | $2 | 1 |
| Nystatin 100,000 Unit/gm Oint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Skin of Arms, Legs, and Front Body | other | $2 | $2 | $2 | 1 |
| Fenofibrate 145 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Fenofibrate 145 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Brace Wrist/forearm Support Left #79 | other | $2 | $2 | $2 | 1 |
| Endotrach Tube 5mm Micro Oral/nasal #86387 | other | $2 | $2 | $2 | 1 |
| Endotrach Tube Oral/nasal Cuffed Murphy Eye 6mm 10ea/pk #86389 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Abdominal Wall Hernia | surgery | $2 | $2 | $2 | 1 |
| Scopolamine 1 Mg/3days Td Pt72 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Artery of Knee | other | $2 | $2 | $2 | 1 |
| Biofreeze W/ilex 4oz Tube 1ea | other | $2 | $2 | $2 | 1 |
| Clotrimazole 1 % Ex Crea | other | $2 | $2 | $2 | 1 |
| Dressing Port Chg Tegaderm #1665 | other | $2 | $2 | $2 | 1 |
| Dronabinol, 2.5 Mg, Oral, Fda Approved Prescription Anti-emetic, for Use As a... | other | $2 | $2 | $2 | 1 |
| Lacosamide 10 Mg/ml 20 Ml Ud Oral Soln - Repackaged | other | $2 | $2 | $2 | 1 |
| Pressure Damping Device #r.o.s.e. 25ea/1bx | other | $2 | $2 | $2 | 1 |
| Adderall Xr 20 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 25 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 30 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Adderall Xr 5 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Anesthesia for Open Amputation Below the Knee | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Elbow | other | $2 | $2 | $2 | 1 |
| Dextroamphetamine Sulfate ER 5 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Flexinet Sz 10 Width 3"x25yds/bx #mt1oa | other | $2 | $2 | $2 | 1 |
| Foam Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, without Adh... | other | $2 | $2 | $2 | 1 |
| Green Enternal Feeding Tube Declogger 20-22fr 39.5cm Item 913 | other | $2 | $2 | $2 | 1 |
| Putty Exercise Progressive Purple 1ea | other | $2 | $2 | $2 | 1 |
| Enulose 10 Gm/15 Ml Solution | other | $2 | $2 | $2 | 1 |
| Selenium Sulfide 2.5% Lotion | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Repair Upper Abdominal Incisional Hernia And/or W... | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Reconstruction of Breast | other | $2 | $2 | $2 | 1 |
| Catheter Purewick Female External Ltx #pwf030 | cardiac | $2 | $2 | $2 | 1 |
| Hydrodissector Cortical Clearing | other | $2 | $2 | $2 | 1 |
| Amoxicillin 200 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Neck Area | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 | $2 | 1 |
| Cocoa Butter Balm 1ea | other | $2 | $2 | $2 | 1 |
| Dressing Restore Wound Care 4x4 #519930 5/bx | other | $2 | $2 | $2 | 1 |
| Erythromycin 0.5% Eye Ointment | other | $2 | $2 | $2 | 1 |
| Mycophenolic Acid, Oral, 180 Mg | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Repair of Lower Abdomen Hernia | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of All OR Part of Breast | surgery | $2 | $2 | $2 | 1 |
| Bandage Comprilan 8cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Isosorbide Mononit ER 30 Mg Tb | other | $2 | $2 | $2 | 1 |
| Isosorbide Mononitrate ER 30 Mg Po Tb24 | other | $2 | $2 | $2 | 1 |
| Pantoprazole Dr 40 Mg Susp Pkt | other | $2 | $2 | $2 | 1 |
| Amoxicillin 125 Mg/5ml Po Susr | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Gallbladder, Pancreas, OR Liver Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Cefpodoxime 200 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Dilator Cook 5fr #g00972 | other | $2 | $2 | $2 | 1 |
| Dilator Cook 6fr X 20cm Long #g00937 | other | $2 | $2 | $2 | 1 |
| Drawtex Hydroconductive Dressing 18 Inch Strip 10/bx #00321 | other | $2 | $2 | $2 | 1 |
| Fentanyl 25 Mcg/hr Patch | other | $2 | $2 | $2 | 1 |
| Lactulose 10 Gm/15 Ml - 300 Ml (for Enemas) - Compounded | other | $2 | $2 | $2 | 1 |
| Splint, Prefabricated, Digit | other | $2 | $2 | $2 | 1 |
| Transparent Film, Sterile, 16 Sq. In. OR Less, Each Dressing | other | $2 | $2 | $2 | 1 |
| Vitamin D3 10 Mcg/ml Liquid | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Collar Bone and Shoulder Blade | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Upper Urinary Tubes OR Removal of Kidney for Tran... | surgery | $2 | $2 | $2 | 1 |
| Bandage Comprilan 10cm 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Dressing Aquacel Foam Sacral Lg 9.4"x8.4" | other | $2 | $2 | $2 | 1 |
| Dressing Drawtex Tracheostomy 4x4 #00310 | other | $2 | $2 | $2 | 1 |
| Forcep Surgical Fine 3.5in | surgery | $2 | $2 | $2 | 1 |
| Lidocaine Hcl 2% Jelly Uro-jet | other | $2 | $2 | $2 | 1 |
| Prevena V.a.c. Connector 10/pk Pre9090 | other | $2 | $2 | $2 | 1 |
| Short Ballard Adapter Tracheostomy 12 in Od14 Fr T-piece Swivel Clear #220135... | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Lrg R #317077 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Male Genitals | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Kneecap And/or Upper Part of Lower Leg Bones | other | $2 | $2 | $2 | 1 |
| Eliquis 5 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Specialty Absorptive Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Spine | other | $2 | $2 | $2 | 1 |
| Elevator Foam Arm 20x20.5 Lf Non Ster | other | $2 | $2 | $2 | 1 |
| Venlafaxine Hcl ER 75 Mg Cap | other | $2 | $2 | $2 | 1 |
| Venlafaxine Hcl ER 75 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Abdomen | other | $2 | $2 | $2 | 1 |
| Auryxia 210 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Brilinta 60 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Brilinta 90 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Injection, Promethazine Hcl, Up to 50 Mg | other | $2 | $2 | $2 | 2 |
| Ticagrelor 90 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Tranexamic Acid 1000 Mg / 100 Ml Ns - Compounded | other | $2 | $2 | $2 | 1 |
| Anes Breathing Circuit Ped 1l 20/cs B1554xx4 | other | $2 | $2 | $2 | 1 |
| Eplerenone 25 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Niacin ER (antihyperlipidemic) 1000 Mg Po Tbcr | lab | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Partial Removal of Rib | surgery | $2 | $2 | $2 | 1 |
| Binder Abdominal 12" 27"-48" #ort21300 | other | $2 | $2 | $2 | 1 |
| Carbamazepine ER 200 Mg Po Tb12 | other | $2 | $2 | $2 | 1 |
| Carbamazepine ER 200 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Composite Dressing, Sterile, Pad Size More Than 16 Sq. In. But Less Than OR E... | other | $2 | $2 | $2 | 1 |
| Ligaclip Medium St Titanium Blue 30pk/1bx | other | $2 | $2 | $2 | 1 |
| Metaxalone 800 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Metaxalone 800 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Knee Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Nerves, Muscles, Tendons, and Tissue of Low... | other | $2 | $2 | $2 | 1 |
| Sock and Stocking Aid W/notch #081007673 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Closed Sys Female Ll Connector #fc-1 120ea/bx | other | $2 | $2 | $2 | 1 |
| Filter Line Sampling Adult Pediatric 13ft Long Intubated Microstream Advance ... | other | $2 | $2 | $2 | 1 |
| Scar Tissue Massage Tool #a8113 | other | $2 | $2 | $2 | 1 |
| T-tube Drain 12fr | other | $2 | $2 | $2 | 1 |
| T-tube Drain 14fr | other | $2 | $2 | $2 | 1 |
| T-tube Drain 16fr | other | $2 | $2 | $2 | 1 |
| T-tube Drain 18fr | other | $2 | $2 | $2 | 1 |
| T-tube Drain 20fr | other | $2 | $2 | $2 | 1 |
| **discontinued** Endotrach Tube 2.0 Uncuffed 10ea/1bx | other | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Achilles Tendon | surgery | $2 | $2 | $2 | 1 |
| Endotrach Tube 3.0 Uncuffed 10ea/1bx | other | $2 | $2 | $2 | 1 |
| Endotrach Tube 3.5 Uncuffed 10ea/1bx | other | $2 | $2 | $2 | 1 |
| Endotrach Tube 4.0 Uncuffed 10ea/1bx | other | $2 | $2 | $2 | 1 |
| Endotrach Tube 4.5 Uncuffed | other | $2 | $2 | $2 | 1 |
| Promethazine Hcl 25 Mg Re Supp #2 Dispense Pack | other | $2 | $2 | $2 | 1 |
| Tube Endotracheal Rusch Slick-set 160mm Od 3.3mm Id 2.5mm Uncuffed Pre Stylet... | other | $2 | $2 | $2 | 1 |
| Ursodiol 300 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Lrg. L #317087 | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Med L #317085 | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Med R #317075 | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Small L #317083 | other | $2 | $2 | $2 | 1 |
| Wrist Brace Form Fit Small R #317073 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Tendon of Upper Arm Muscle | other | $2 | $2 | $2 | 1 |
| Anesthesia for Vaginal Removal of Uterus | surgery | $2 | $2 | $2 | 1 |
| Biotene Moisturizing Mouth Spr | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz 6 Spare #6sic Shiley | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz 8 Spare #8sic Shiley | other | $2 | $2 | $2 | 1 |
| Entry Needle 21g X 7cm | other | $2 | $2 | $2 | 1 |
| Needle Tuohy Epidural 20ga X 3.5" Lf 25ea/cs | other | $2 | $2 | $2 | 1 |
| Tape Cast W5inxl4yd White Fiberglass Polyurethane Delta-lite Plus 7345804 10e... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Lower Leg, Ankle, and Foot | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Female Genitals | other | $2 | $2 | $2 | 1 |
| Azithromycin 250 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Dressing Nugauze Iodoform 2 Inch | other | $2 | $2 | $2 | 1 |
| Injection, Aprepitant, (aponvie), 1 Mg | other | $2 | $2 | $2 | 1 |
| Metoclopramide 10 Mg/10 Ml Cup | other | $2 | $2 | $2 | 1 |
| Nadolol 40 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Nadolol 40 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Skintegrity Wound Cleanser 8oz Bottles with Trigger Sprayer #msc6008 6bt/case | other | $2 | $2 | $2 | 1 |
| Zithromax 250 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Breast Bone Tissue | surgery | $2 | $2 | $2 | 1 |
| Cath Coude Tiemann 12fr /rusch | other | $2 | $2 | $2 | 1 |
| Catheter Foley 22fr 5cc Silver Coat 12ea/1dz | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 24fr 5cc Silver 12ea/1dz | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley Peds 10fr 3cc Silvr 12ea/1cs | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley Peds 8fr 3cc Silver 12ea/1cs | cardiac | $2 | $2 | $2 | 1 |
| Flexinet Sz 6 Width 1-1/2"x25yds/bx #mto6a | other | $2 | $2 | $2 | 1 |
| Stylet Glidescope Pediatric Disp #0270 | other | $2 | $2 | $2 | 1 |
| Catheter Foley 18 Fr 5cc Silicone St | cardiac | $2 | $2 | $2 | 1 |
| Sheath Probe Cover W/gel Site Rite #9001c0197 10ea/sp | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Left #a125107 | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Left Med #a125106 | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Left Sm #a125105 | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Right Lrg #a125207 | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Right Med #a125206 | other | $2 | $2 | $2 | 1 |
| Splint Wrist W/thumb Right Sm #a125205 | other | $2 | $2 | $2 | 1 |
| Thoracic Chest Tube 28fr 10ea/1cs | other | $2 | $2 | $2 | 1 |
| Urethral Catheter Bardex 2-way Foley 16fr 5ml Balloon Silicone Sterile Latex ... | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Large Bowel Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Upper Leg | other | $2 | $2 | $2 | 1 |
| Brace Wrist Elastic Right Sm #79 | other | $2 | $2 | $2 | 1 |
| Convamax Superabsorber 8 X 16 Dropship Only 10ea/bx 5bx/cs. #422574 | other | $2 | $2 | $2 | 1 |
| Galantamine Hbr 4 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Teds Thigh Large Regular Novaplus #v8803r | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Abdomen | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Urinary System Through Urethra | other | $2 | $2 | $2 | 1 |
| Dressing Aquacel Ag Advantage 4 X 5in Hydrofiber #422299 | other | $2 | $2 | $2 | 1 |
| Injection, Cisplatin, Powder OR Solution, 10 Mg | other | $2 | $2 | $2 | 1 |
| Pin Ball Cover .035(.9mm) #wo35-db | other | $2 | $2 | $2 | 1 |
| Pin Ball Cover .062(1.1mm) #wo62-gn | other | $2 | $2 | $2 | 1 |
| Pin Ball Cover 5/64(2mm) #w564-bl | other | $2 | $2 | $2 | 1 |
| Risperidone 0.5 Mg Odt | other | $2 | $2 | $2 | 1 |
| Theo-24 ER 100 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Wilson Frame Pad #m60 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Relocation of Undescended Testicle Into Scrotum | other | $2 | $2 | $2 | 1 |
| Catheter Sheath Introducer 5fr#504605x 5ea/bx | cardiac | $2 | $2 | $2 | 1 |
| Catheter Sheath Introducer 6fr#504606x 5ea/bx | cardiac | $2 | $2 | $2 | 1 |
| Catheter Sheath Introducer 8fr #504608x | cardiac | $2 | $2 | $2 | 1 |
| Colchicine 0.3 Mg Half Tablet | other | $2 | $2 | $2 | 1 |
| Collagen Dressing, Sterile, Size 16 Sq. In. OR Less, Each | other | $2 | $2 | $2 | 1 |
| Cvvh Prisma 5l Effluent Bag #114423 50/cs | other | $2 | $2 | $2 | 1 |
| Esenta Sting Free Adhesive Remover Spray 50ml Can #423289 12cn/case | other | $2 | $2 | $2 | 1 |
| Needle Cook Entry 21 X 15 Echotip #g08700 | imaging | $2 | $2 | $2 | 1 |
| Resuscitator Bag W/mask Adult Manual 12ea/cs | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Skin, Muscles, OR Nerves of Head, Neck, and... | other | $2 | $2 | $2 | 1 |
| Entry Needle 21g X 15cm | other | $2 | $2 | $2 | 1 |
| Pant Clips -white 1ea | other | $2 | $2 | $2 | 1 |
| Tape-elastoplast-2 Inch 0294002 Latex 36ea/case | other | $2 | $2 | $2 | 1 |
| Amoxicillin 250 Mg/5 Ml Susp | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure OR Exam of Knee Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Capsaicin 0.025% Cream | other | $2 | $2 | $2 | 1 |
| Feed Tube 12fr 43" Entriflex | other | $2 | $2 | $2 | 1 |
| Tolterodine Tart ER 4 Mg Cap | other | $2 | $2 | $2 | 1 |
| Tolterodine Tartrate ER 4 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Nose and Sinuses | other | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Tissue From Around Lung | surgery | $2 | $2 | $2 | 1 |
| 20fr Y Ports #m00580641 10ea/bx | other | $2 | $2 | $2 | 1 |
| 24fr Y Ports #m00580651 10ea/bx | other | $2 | $2 | $2 | 1 |
| Anesthesia for Open OR Endoscopic Total Shoulder Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Hip Joint | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Lower Front Abdomen | other | $2 | $2 | $2 | 1 |
| Aquacel Adhesive Foam Dressing 4 X 10 #421153 140ea/case | other | $2 | $2 | $2 | 1 |
| Blade Beaver #bb365r Aesculap | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 10f/11cm M00115726b1 15-726b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 10f/25cm M00115735b1 15-735b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 11f/25cm M00115736b1 15-736b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 12f/11cm M00115728b1 15-728b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 12f/25cm M00115737b1 15-737b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 14f/11cm M00115740b1 15-740b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 14f/25cm M00115739b1 15-739b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 4f/11cm M00115720b1 15-720b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 5f/11cm M00115721b1 15-721b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 5f/25cm M00115730b1 15-730b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 6f/11cm M00115722b1 15-722b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 6f/25cm M00115731b1 15-731b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 7f/11cm M00115723b1 15-723b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 7f/25cm M00115732b1 15-732b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 8f/11cm M00115724b1 15-724b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 8f/25cm M00115733b1 15-733b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 9f/11cm M00115725b1 15-725b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer Guide Wire Not Included 9f/25cm M00115734b1 15-734b | other | $2 | $2 | $2 | 1 |
| Venlafaxine Hcl ER 150 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Access to Central Vein | other | $2 | $2 | $2 | 1 |
| Imipramine Hcl 25 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Tendon of Elbow to Shoulder | other | $2 | $2 | $2 | 1 |
| Catheter Foley 18fr30cc 2way Silver 12ea/dz | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 20fr 30cc 2way Silver Coat | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 24fr 30cc 2way Silver 12ea/dz | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 26fr 30cc 2way 12ea/1cs | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 28fr 30cc 2way Silver Coated | cardiac | $2 | $2 | $2 | 1 |
| Cavilon Adv Skin Protectant #5050 20ea/1cs | other | $2 | $2 | $2 | 1 |
| Electrode Needle Tip #0013 12/bx | other | $2 | $2 | $2 | 1 |
| Mask Lma Unique Evo W/cuff Pilot Size 3 | other | $2 | $2 | $2 | 1 |
| Mask Lma Unique Evo W/cuff Pilot Size 4 | other | $2 | $2 | $2 | 1 |
| Mask Lma Unique Evo W/cuff Pilot Size 5 | other | $2 | $2 | $2 | 1 |
| Nisoldipine ER 8.5 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Procto-med Hc 2.5% Cream | other | $2 | $2 | $2 | 1 |
| Valve-ambu Peep Disp #2k8082 10ea/cs | other | $2 | $2 | $2 | 1 |
| Amox-clav 250-62.5 Mg/5 Ml Sus | other | $2 | $2 | $2 | 1 |
| Catheter Bern 5fr/65cm/035 Angiograph #31 | imaging | $2 | $2 | $2 | 1 |
| Injection, Mesna, 200 Mg | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Ankle OR Foot Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Cath Coude Tiemann 22fr Rusch 50ea/1bx | other | $2 | $2 | $2 | 1 |
| Pin Ball Cover .045(.9mm) #wo45-yl | other | $2 | $2 | $2 | 1 |
| Pin Ball Cover 3/32(2.5mm) #w332-cr | other | $2 | $2 | $2 | 1 |
| Sucralfate 1 Gm/10 Ml Susp | other | $2 | $2 | $2 | 1 |
| Sucralfate 1 Gm/10 Ml Susp - 10 Ml - Repackaging | other | $2 | $2 | $2 | 1 |
| Addition to Ctlso OR Scoliosis Orthosis, Kyphosis Pad | other | $2 | $2 | $2 | 1 |
| Anesthesia for Heart Artery Bypass Grafting On Heart-lung Machine | cardiac | $2 | $2 | $2 | 1 |
| Duloxetine Hcl 20 Mg Po Cpep | other | $2 | $2 | $2 | 1 |
| Duloxetine Hcl Dr 20 Mg Cap | other | $2 | $2 | $2 | 1 |
| Gauze, Impregnated, Hydrogel, for Direct Wound Contact, Sterile, Pad Size 16 ... | other | $2 | $2 | $2 | 1 |
| Memantine Hcl ER 14 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Closed Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Eye for Corneal Transplant | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz 4 Fen #4dicfen | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz 6 Fen #6dicfen | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz 8 Fen #8dicfen 10ea/bx | other | $2 | $2 | $2 | 1 |
| Cannula Inner Sz10 Fen #10dicfen | other | $2 | $2 | $2 | 1 |
| Electrode Est Thymapad Disposable 96ea/1cs | other | $2 | $2 | $2 | 1 |
| Grounding Pad Split #cra-sgp 1cs/10ea | other | $2 | $2 | $2 | 1 |
| Hcs Adhesive 2.8x2.8 Medihoney #31722 50/cs | other | $2 | $2 | $2 | 1 |
| Mycophenolate Mofetil, Oral, 250 Mg | other | $2 | $1 | $2 | 2 |
| Oxymetazoline Hcl 0.05 % Na Soln | other | $2 | $2 | $2 | 1 |
| Refresh Tears 0.5% Eye Drop | other | $2 | $2 | $2 | 1 |
| Tranexamic Acid 650 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Tranexamic Acid 650 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Large Blood Vessel of Neck | other | $2 | $2 | $2 | 1 |
| Cath Purewick Female Ext Pwf030k 30ea/1cs | other | $2 | $2 | $2 | 1 |
| Metronidazole 500 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Metronidazole 500 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Tropicamide 1% Eye Drops | other | $2 | $2 | $2 | 1 |
| Bile Bag with Straps 0015850 12ea/case | other | $2 | $2 | $2 | 1 |
| Cast Tape 5"x4yd White Scotchcast #82005 | other | $2 | $2 | $2 | 1 |
| Precutaneous Entry Thinwall Needle 18g X 9cmsdn-18-9.0 G00273 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Left Suede/flannel <5.5" X-small 7"#79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Left Suede/flannel 5.5-6.5" Small 7"#79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Left Suede/flannel 6.5-7.5" Medium 7" #79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Left Suede/flannel 7.5-8.5" Large 7" #79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Left Suede/flannel 8.5+" X-large 7" #79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Right Suede/flannel 5.5-6.5" Small 7"#79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Right Suede/flannel 5.5" X-small 7"#79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Large 7"#79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Medium 7" #79 | other | $2 | $2 | $2 | 1 |
| Procare Wrist Adult Right Suede/flannel 8.5+" X-large 7" #79 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Shoulder Joint Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Esophagus, Stomach, OR Upper Small Bowel Us... | other | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Calf Muscle | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Repair of Elbow to Shoulder Tendon | surgery | $2 | $2 | $2 | 1 |
| Diphenhydramine 12.5mg/5ml Cup | other | $2 | $2 | $2 | 1 |
| Ferrous Sulf 15 Mg Iron/ml Drp | other | $2 | $2 | $2 | 1 |
| Phenytoin 100 Mg/4 Ml Susp Cup | other | $2 | $2 | $2 | 1 |
| Refresh P.m. Ointment | other | $2 | $2 | $2 | 1 |
| Speculum Vaginal Med Disp Lighted #c020110 | other | $2 | $2 | $2 | 1 |
| Cyclosporine 0.05% Eye Emuls | other | $2 | $2 | $2 | 1 |
| Dilator 10fr #jcd10.0-38 | other | $2 | $2 | $2 | 1 |
| Dilator 8fr 20cm | other | $2 | $2 | $2 | 1 |
| Electrode Dysphagia Ped .68"x.87" #05a170 | other | $2 | $2 | $2 | 1 |
| Azelastine 0.1% (137 Mcg) Spry | other | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr IM Merit #7511 | cardiac | $2 | $2 | $2 | 1 |
| Sleeve Advanced Fixation 5x100mm #cfs02 | other | $2 | $2 | $2 | 1 |
| Sleeve Z-thread 5x100mm #cts02 | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer with Guide Wire 10f/11cm .035 M00115716b1 15-716b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer with Guide Wire 11f/11cm .035 M00115717b1 15-717b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer with Guide Wire 4f/11cm .035 M00115710b1 15-710b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer with Guide Wire 5f/11cm .035 M00115711b1 15-711b | other | $2 | $2 | $2 | 1 |
| Super Sheath Introducer with Guide Wire 9f/11cm .035 M00115715b1 15-715b | other | $2 | $2 | $2 | 1 |
| Vashe Wound Solution 4 Oz Bottle #00312 24ea/case | other | $2 | $2 | $2 | 1 |
| Heel and Elbow Protectors | other | $2 | $2 | $2 | 1 |
| Lidocaine 2% Viscous 15 Ml Cup | other | $2 | $2 | $2 | 1 |
| Prothrombin Complex Concentrate (human), Kcentra, Per I.u. of Factor Ix Activity | other | $2 | $2 | $2 | 2 |
| Dotti 0.05 Mg Patch | other | $2 | $2 | $2 | 1 |
| Dotti 0.1 Mg Patch | other | $2 | $2 | $2 | 1 |
| Morphine Sulfate ER 20 Mg Cap | other | $2 | $2 | $2 | 1 |
| Oxycodone Hcl 5 Mg/5 Ml Cup | other | $2 | $2 | $2 | 1 |
| Quetiapine Fumarate 25 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Quetiapine Fumarate 25 Mg Tab | other | $2 | $2 | $2 | 1 |
| Suture Surgilon 6-0 Bk 18 Pc-10 #sbs566g | other | $2 | $2 | $2 | 1 |
| Catheter Foley 12fr 5ml Silicone Hydrogel Coating Lf 175812 12ea/case | cardiac | $2 | $2 | $2 | 1 |
| Isentress 100 Mg Powder Packet | other | $2 | $2 | $2 | 1 |
| Alaris Pump Module Admin Set 10942011 20ea/cs | other | $2 | $2 | $2 | 1 |
| Ammonium Lactate 12% Lotion | other | $2 | $2 | $2 | 1 |
| Benzoyl Peroxide 5 % Ex Gel | other | $2 | $2 | $2 | 1 |
| Clarithromycin 500 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Clarithromycin 500 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Feed Tube 12fr 43" Dobbhoff Kangaroo 10ea/cs | other | $2 | $2 | $2 | 1 |
| Feed Tube 8fr 43" Dobbhoff Kangaroo 10ea/1cs 8884710859e | other | $2 | $2 | $2 | 1 |
| Dextroamphetamine Sulfate ER 10 Mg Po Cp24 | other | $2 | $2 | $2 | 1 |
| Erythromycin 250 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Miconazole 2% Topical Cream | other | $2 | $2 | $2 | 1 |
| Minerin Creme | other | $2 | $2 | $2 | 1 |
| Sumatriptan 6 Mg/0.5 Ml Vial | other | $2 | $2 | $2 | 1 |
| Anesthesia for Extensive Procedure On Perineum | other | $2 | $2 | $2 | 1 |
| Grounding Pad Surgical Peds #425 | surgery | $2 | $2 | $2 | 1 |
| Colostomy OR Set #416928 5ea/1bx | other | $2 | $2 | $2 | 1 |
| Hcs Non-adhesive 2.4x2.4 Medihoney #31622 | other | $2 | $2 | $2 | 1 |
| Prasugrel 10 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Prasugrel Hcl 10 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Prasugrel Hcl 5 Mg Po Tabs | other | $2 | $2 | $2 | 1 |
| Restraints Wrist & Ankle #m20116 1pr/1ea | other | $2 | $2 | $2 | 1 |
| Trap Tissue Berkeley Safetouch 10/bx | other | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion OR Replace of Pacing Heart Defibrillator | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Mouth | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Control Urinary System Bleeding Including Use of ... | other | $2 | $2 | $2 | 1 |
| Dex 5%/0.45% Sodium Chl Inj Usp 1000m 14ea/cs | other | $2 | $2 | $2 | 1 |
| Gelfoam 12-7mm Sponge | other | $2 | $2 | $2 | 1 |
| Laryngoscope Handle Dispoled #77700 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Insertion of Permanent Heart Pacemaker | cardiac | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Chest with 1 Lung Inflated | other | $2 | $2 | $2 | 1 |
| Cane Standard Aluminum Adjustable 30"-38" 300lbs 6/cs #mds86415 | other | $2 | $2 | $2 | 1 |
| Catheter Coude 12fr | cardiac | $2 | $2 | $2 | 1 |
| Catheter Coude 16fr 12ea/1cs | cardiac | $2 | $2 | $2 | 1 |
| Catheter Coude 18fr 12ea/1dz | cardiac | $2 | $2 | $2 | 1 |
| Methylphenidate ER 27 Mg Tab | other | $2 | $2 | $2 | 1 |
| Morphine Sulf 10 Mg/5 Ml Soln | other | $2 | $2 | $2 | 1 |
| Phenytoin Susp - 100 Mg/4 Ml - Repackaging | other | $2 | $2 | $2 | 1 |
| Cath IV 14ga X 3.25 Angiocath Spec. Prodce | other | $2 | $2 | $2 | 1 |
| Centrum Adult Po Liqd | other | $2 | $2 | $2 | 1 |
| Convafoam Border Multisite 7.8x5x5 #423267 5ea/box | other | $2 | $2 | $2 | 1 |
| Feed Spike Set W/flush Bag #775100 1ea | other | $2 | $2 | $2 | 1 |
| Mvi W/iron Liquid - 15 Ml - Adult Oral Ud - Repackaged | other | $2 | $2 | $2 | 1 |
| Splint Wrist Lrg Left 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Med Right 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Sml Left 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Sml Right 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Xlg Left 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist Xlg Right 1ea | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure for Total Knee Joint Replacement | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Prostate Including Use of an Endoscope | surgery | $2 | $2 | $2 | 1 |
| Fecal Collector Sys Flexi Seal W/tail Closure | other | $2 | $2 | $2 | 1 |
| Nexium Dr 40 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Securement Device Picc/cvc 3m #1877 | other | $2 | $2 | $2 | 1 |
| Sodium Chloride 5% Eye Drop | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Lower Rear Abdomen | other | $2 | $2 | $2 | 1 |
| Locking Device W/biopsy Cup #m00545261 | lab | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 4f/11cm M00115960b1 15-960b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 4f/25cm M00115970b1 15-970b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/11cm M00115961b1 15-961b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/25cm M00115971b1 15-971b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/7cm M00115956b1 15-956b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 6f/11cm M00115962b1 15-962b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 6f/25cm M00115965b1 15-965b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 7f/11cm M00115963b1 15-963b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 7f/25cm M00115966b1 15-966b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 8f/11cm M00115964b1 15-964b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 8f/25cm M00115967b1 15-967b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/11cm M00115969b1 15-969b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/25cm M00115968b1 15-968b | other | $2 | $2 | $2 | 1 |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/7cm M00115955b1 15-955b | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure On Anus and Rectum | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Face Bones OR Skull | other | $2 | $2 | $2 | 1 |
| Methylphenidate Hcl ER (cd) 40 Mg Po Cpcr | other | $2 | $2 | $2 | 1 |
| Catheter Single Lumen Infusion 25/cs | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Heart Artery Bypass Grafting | cardiac | $2 | $2 | $2 | 1 |
| Duloxetine Hcl 30 Mg Po Cpep | other | $2 | $2 | $2 | 1 |
| Duloxetine Hcl Dr 30 Mg Cap | other | $2 | $2 | $2 | 1 |
| Anesthesia for Lens Surgery | surgery | $2 | $2 | $2 | 1 |
| Anesthesia for Removal of Urinary Bladder Tumors Including Use of an Endoscope | surgery | $2 | $2 | $2 | 1 |
| Dressing Prisma 4.34 SQ in #ma028 | other | $2 | $2 | $2 | 1 |
| Exsept Plus Skin and Wound Cleanser #15108 Angelini Pharma 24ea/case | other | $2 | $2 | $2 | 1 |
| Factor Viia (antihemophilic Factor, Recombinant), (novoseven Rt), 1 Microgram | other | $2 | $2 | $2 | 1 |
| Injection, Gadoteridol, (prohance Multipack), Per Ml | other | $2 | $2 | $2 | 1 |
| Loestrin 21 1-20 Tablet | other | $2 | $2 | $2 | 1 |
| Snare Medium Oval-flex 27mmx240cm #m00562673 | other | $2 | $2 | $2 | 1 |
| Abdominal Support 9in 1ea | other | $2 | $2 | $2 | 1 |
| Injection, Irinotecan, 20 Mg | other | $2 | $2 | $2 | 1 |
| Nasal Tampon 4.5cm #400400 20ea/1pk | other | $2 | $2 | $2 | 1 |
| Nortriptyline Hcl 25 Mg Cap | other | $2 | $2 | $2 | 1 |
| Nortriptyline Hcl 25 Mg Po Caps | other | $2 | $2 | $2 | 1 |
| Anesthesia for Amputation On Upper 2/3rd of Thigh Bone | other | $2 | $2 | $2 | 1 |
| Catheter Tray Add-a-foley Silver 10ea/1cs | cardiac | $2 | $2 | $2 | 1 |
| Dressing Tritec Silver 4x5 Precut 3000112331 | other | $2 | $2 | $2 | 1 |
| Thoracic Cath 32f Angled/argyle | other | $2 | $2 | $2 | 1 |
| Transducer Probe Cover X-large L/f #610 | other | $2 | $2 | $2 | 1 |
| Gentamicin 0.1% Cream | other | $2 | $2 | $2 | 1 |
| Resuscitator Bag W/mask Infant 12ea/1cs Ambu | other | $2 | $2 | $2 | 1 |
| Anesthesia for Fragmenting, Manipulation And/or Removal of Kidney Stone Inclu... | surgery | $2 | $2 | $2 | 1 |
| Blood Count, Hemoglobin | other | $2 | $2 | $2 | 2 |
| Cast Splint 3" X 35" Comformable 10ea/1cs | other | $2 | $2 | $2 | 1 |
| Lt200 Ligaclip Medium 36/bx | other | $2 | $2 | $2 | 1 |
| Red Blood Cell Concentration Measurement | other | $2 | $2 | $2 | 2 |
| Splint Wrist/forearm Left Small 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist/forearm Left Xlarge | other | $2 | $2 | $2 | 1 |
| Splint Wrist/forearm Rt Large 1ea | other | $2 | $2 | $2 | 1 |
| Splint Wrist/forearm Rt Small 1ea | other | $2 | $2 | $2 | 1 |
| Bra Compression White 34 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 36 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 38 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 40 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 42 #e5001 | other | $2 | $2 | $2 | 1 |
| Bra Compression White 44 #e5001 | other | $2 | $2 | $2 | 1 |
| Brace Ankle Air Gel 9in Small #79 | other | $2 | $2 | $2 | 1 |
| Femoral Canal Suction/irrigation Tip 12ea/pk #0210-004 | other | $2 | $2 | $2 | 1 |
| Mobility Glove Black Mesh Small #081173632 | other | $2 | $2 | $2 | 1 |
| Wheelchair Gloves Large #660802 | other | $2 | $2 | $2 | 1 |
| Wheelchair Gloves Medium #660801 | other | $2 | $2 | $2 | 1 |
| Wheelchair Gloves Xlarge #660803 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Arteries of Upper Arm and Elbow | other | $2 | $2 | $2 | 1 |
| Anesthesia for Procedure to Correct Abnormal Heart Rhythm | cardiac | $2 | $2 | $2 | 1 |
| Refresh Lacri-lube Ointment | other | $2 | $2 | $2 | 1 |
| 6 Fr Ultimate 4-t40 | other | $2 | $2 | $2 | 1 |
| Catheter Foley 14fr 5cc Lf Silver | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 18fr 5cc Latex Free Silver | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 20fr Lf 5cc #1758si20 | cardiac | $2 | $2 | $2 | 1 |
| Catheter Foley 24fr 5cc Ltx Free Silver | cardiac | $2 | $2 | $2 | 1 |
| Celexa 40 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Knife 2.75mm Angld Slit Dbl Bevel #ab-asl27db | other | $2 | $2 | $2 | 1 |
| Suction Cauterizer 12fr X 6" Handswitch | other | $2 | $2 | $2 | 1 |
| Brace Ankle Air Gel 8.5in Med #79 | other | $2 | $2 | $2 | 1 |
| Sam Splint Standard Roll Gray #61109 | other | $2 | $2 | $2 | 1 |
| 6 Fr Cas 1 | other | $2 | $2 | $2 | 1 |
| Cannula Arteriotomy 2.3 X 2mm #31102 20/pk | other | $2 | $2 | $2 | 1 |
| Cannula Arteriotomy 2.3 X 3mm #31103 20/pk | other | $2 | $2 | $2 | 1 |
| Cannula Arteriotomy 2.3 X 4mm #31104 | other | $2 | $2 | $2 | 1 |
| Cast Splint 4"x 30" Comformable 1ea | other | $2 | $2 | $2 | 1 |
| Corlanor 5 Mg Tablet | other | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr 3drc #533676 3/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Al1 #533-645 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Al2 #533646 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Al3 #533647 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Angled Pigtail #532652s | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Ar Mod #533648 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Ar1 Mod #533641 5ea/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Arii Mod #533643 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr IM #533660 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Jl3.5 #533618 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Jl4 #533 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Jl5 #533 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Jr3.5 #533619 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Jr4 Classic #533 | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Lcb #533672 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Mpb2 #533649 5/bx | cardiac | $2 | $2 | $2 | 1 |
| Diag Catheter 6fr Rbc #533 | cardiac | $2 | $2 | $2 | 1 |
| Tip Bone Cleaning #210 | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On Upper Spine | other | $2 | $2 | $2 | 1 |
| Cast Stockinette Delta-net Tubular Synthetic 1inx25yd Black #7272300 2rl/case | other | $2 | $2 | $2 | 1 |
| Fentanyl 12 Mcg/hr Patch | other | $2 | $2 | $2 | 1 |
| Jackson Pratt 15fr Round Drain Sil 1ea | other | $2 | $2 | $2 | 1 |
| Atomizer Mucosal Atomization Device | other | $2 | $2 | $2 | 1 |
| Clobetasol 0.05% Cream | other | $2 | $2 | $2 | 1 |
| Anesthesia for Exam of Uterus Using an Endoscope | other | $2 | $2 | $2 | 1 |
| Ankle Gel Splint #79 | other | $2 | $2 | $2 | 1 |
| Crutch Adult Tall 300lb 5'10"-6'6" 8pr/1cs | other | $2 | $2 | $2 | 1 |
| Crutch Medium Adult 300lb 5'2"-5'10" 8pr/cs | other | $2 | $2 | $2 | 1 |
| Crutch Youth 300lb 4'6"-5'2" 8pr/1cs | other | $2 | $2 | $2 | 1 |
| Lyrica 100 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Lyrica 75 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Pregabalin 150 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Pregabalin 150 Mg Po Caps | other | $2 | $2 | $2 | 1 |
| Pregabalin 25 Mg Capsule | other | $2 | $2 | $2 | 1 |
| Pregabalin 25 Mg Po Caps | other | $2 | $2 | $2 | 1 |
| Anesthesia for Other Procedure On External Middle and Inner Ear | other | $2 | $2 | $2 | 1 |
| Hurricaine One 20% U-d Spray | other | $2 | $2 | $2 | 1 |
| Injection, Zidovudine, 10 Mg | other | $2 | $2 | $2 | 1 |
| Injection, Prothrombin Complex Concentrate, Human-lans, Per I.u. of Factor Ix... | other | $2 | $2 | $2 | 1 |
| Injection, Metronidazole, 10 Mg | other | $2 | $2 | $2 | 1 |
| Buprenorphine, Oral, 1 Mg | other | $2 | $2 | $2 | 1 |
| Analysis of Urine, Except Immunoassays | other | $2 | $2 | $2 | 1 |
| Loperamide Hcl 1mg/7.5 Ml Ud | other | $2 | $2 | $2 | 1 |
| Ure-na 15 Gram Powder Packet | other | $3 | $1 | $4 | 2 |
| Diag Catheter 6fr Mpa1 #7513-b3 | cardiac | $3 | $3 | $3 | 1 |
| Diag Catheter 6fr Mpb1 #7513-e3 | cardiac | $3 | $3 | $3 | 1 |
| Light Compression Bandage, Elastic, Knitted/woven, Width Greater Than OR Equa... | other | $3 | $3 | $3 | 1 |
| Nerve Conduction Study of Arm OR Leg Movement And/or Feeling with Review and ... | other | $3 | $3 | $3 | 1 |
| Budesonide, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $3 | $3 | $3 | 1 |
| Cannula Nomoline Lh Adt Gas Sampling Adult Nasal Oral with Oxygen #3824 25ea/box | other | $3 | $3 | $3 | 1 |
| Professional Service for Preparation and Provision of 1 OR More Antigens | other | $3 | $3 | $3 | 1 |
| Automated White Blood Cell Count | other | $3 | $3 | $3 | 2 |
| Zzzquil 50 Mg/30 Ml Liquid | other | $3 | $3 | $3 | 1 |
| Abdominal Support 10in 1ea | other | $3 | $3 | $3 | 1 |
| Mesalamine 4 Gm/60 Ml Enema | other | $3 | $3 | $3 | 1 |
| Belt Gait W/buckle 48" 1ea | other | $3 | $3 | $3 | 1 |
| Injection, Fluorouracil, 500 Mg | other | $3 | $3 | $3 | 1 |
| Electrodes, (e.g., Apnea Monitor), Per Pair | other | $3 | $3 | $3 | 1 |
| Knife 300 Micron Precision 6ea/bx | other | $3 | $3 | $3 | 1 |
| Tetracycline Hcl 500 Mg Po Caps | other | $3 | $3 | $3 | 1 |
| Lidocaine-prilocaine 2.5-2.5 % Ex Crea | other | $3 | $3 | $3 | 1 |
| Lidocaine-prilocaine Cream | other | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure On Heart and Large Blood Vessels Using Heart-lung Ma... | cardiac | $3 | $3 | $3 | 1 |
| Blm Mouthwash - 10 Ml - Compounded | other | $3 | $3 | $3 | 1 |
| Dressing Foam Ultra Silver 4x5ster Mk30051018 | other | $3 | $3 | $3 | 1 |
| First-mouthwash Blm Mt Susp | other | $3 | $3 | $3 | 1 |
| Ketoconazole 2% Shampoo | other | $3 | $3 | $3 | 1 |
| Nucynta 50 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Xifaxan 200 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Hook Single Stay 5mm Sharp #3311-1g | other | $3 | $3 | $3 | 1 |
| Adaptive Mug Alimed #2970010571 Pk/20ea | other | $3 | $3 | $3 | 1 |
| Forceps Cold Biopsy Radial Jaw #m00513334 | lab | $3 | $3 | $3 | 1 |
| Ankle Brace-air/gel 10" Universal | other | $3 | $3 | $3 | 1 |
| Cervical, Flexible, Non-adjustable, Prefabricated, Off-the-shelf | other | $3 | $3 | $3 | 1 |
| Injection, Decitabine, 1 Mg | other | $3 | $3 | $3 | 1 |
| Dorzolamide Hcl 2% Eye Drops | other | $3 | $3 | $3 | 1 |
| Bandage Comprilan 12cm 20ea/1cs | other | $3 | $3 | $3 | 1 |
| Lidocaine 5% Ointment | other | $3 | $3 | $3 | 1 |
| Aspirin 1 Mg/1 Ml Po Suspension | other | $3 | $3 | $3 | 1 |
| Belt Gait W/buckle 60" 1ea | other | $3 | $3 | $3 | 1 |
| Cast Supplies, Long Arm Splint, Pediatric (0-10 Years), Fiberglass | other | $3 | $3 | $3 | 1 |
| Cast Supplies, Short Arm Splint, Pediatric (0-10 Years), Fiberglass | other | $3 | $3 | $3 | 1 |
| Pedialyte Advanced Care Soln | other | $3 | $3 | $3 | 1 |
| Pedialyte Solution | other | $3 | $3 | $3 | 1 |
| Pr Supplies&materials Above/beyond Prov By Phys/qhp | other | $3 | $3 | $3 | 1 |
| **discontinued** Filter Line H Set M1920a 25ea/1cs | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Procedure On Hip Joint | other | $3 | $3 | $3 | 1 |
| Catheter Filiform W/olive Tip 3fr | cardiac | $3 | $3 | $3 | 1 |
| Catheter Filiform W/olive Tip 5fr | cardiac | $3 | $3 | $3 | 1 |
| Catheter Filiform W/olive Tip 6fr | cardiac | $3 | $3 | $3 | 1 |
| Procare Wrist Adult Left Suede/flannel 5.5-6.5" Small 10"#79 | other | $3 | $3 | $3 | 1 |
| Procare Wrist Adult Left Suede/flannel 6.5-7.5" Medium 10" #79 | other | $3 | $3 | $3 | 1 |
| Procare Wrist Adult Right Suede/flannel 5.5-6.5" Small 10"#79 | other | $3 | $3 | $3 | 1 |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Medium 10" #79 | other | $3 | $3 | $3 | 1 |
| Procare Wrist Adult Right Suede/flannel 7.5-8.5" Large 10" #79 | other | $3 | $3 | $3 | 1 |
| Vent Tube Paparella Pair (100pr/pk) #1040019 | other | $3 | $3 | $3 | 1 |
| Finger Splint, Static | other | $3 | $3 | $3 | 1 |
| Wrap 2" Edema/pain Kinesio 6ea/1bx | other | $3 | $3 | $3 | 1 |
| Red Blood Cell Sedimentation Rate, to Detect Inflammation, Automated | other | $3 | $3 | $3 | 1 |
| Breast Comfort Gel Pads #17264 50ea/1cs | other | $3 | $3 | $3 | 1 |
| Catheter Tray Sure Step Add a Foley Silver | cardiac | $3 | $3 | $3 | 1 |
| Dilator Cook 4fr #g02366 | other | $3 | $3 | $3 | 1 |
| Feed Tube Extension Rt Angle Mickey 5ea/1ca | other | $3 | $3 | $3 | 1 |
| Feed Tube Extension Set Mickey Secure 5ea/1ca | other | $3 | $3 | $3 | 1 |
| Knee Immobilizer-16" Med | other | $3 | $3 | $3 | 1 |
| Nucynta ER 50 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Acuvail 0.45% Ophth Solution | other | $3 | $3 | $3 | 1 |
| Injection, Carboplatin, 50 Mg | other | $3 | $3 | $3 | 1 |
| Morphine Sulf 100 Mg/5 Ml Conc | other | $3 | $3 | $3 | 1 |
| Elmiron 100 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Graft Sizer Disp Sz 24mm-38mm #m002363200211 | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Procedure On Knee Joint | other | $3 | $3 | $3 | 1 |
| Fluticasone Prop 50 Mcg Spray | other | $3 | $3 | $3 | 1 |
| Fluticasone Propionate 50 Mcg/act Na Susp | other | $3 | $3 | $3 | 1 |
| Hemoclip Small Titan Cartridge 25ea/bx Yellow | other | $3 | $3 | $3 | 1 |
| Ligating Clip Small 24/pkg #1205 Horizon | other | $3 | $3 | $3 | 1 |
| Entresto 24 Mg-26 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Entresto 49 Mg-51 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Entresto 97 Mg-103 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Forcep Surgical Lucae Serrated Bayonet 5.5in | surgery | $3 | $3 | $3 | 1 |
| Trap Polyp Endo Suction #h334 #bx00711099 | other | $3 | $3 | $3 | 1 |
| Administration and Interpretation of Patient-focused Health Risk Assessment | other | $3 | $3 | $3 | 1 |
| Transducer Kit-disposable | other | $3 | $3 | $3 | 1 |
| Desvenlafaxine Succnt ER 25 Mg | other | $3 | $3 | $3 | 1 |
| Methylphenidate Hcl ER (cd) 50 Mg Po Cpcr | other | $3 | $3 | $3 | 1 |
| Methylphenidate Hcl ER (cd) 60 Mg Po Cpcr | other | $3 | $3 | $3 | 1 |
| Wrist/thumb Brace with Thumb Spica Left Cotton/foam Large/x-large #79 | other | $3 | $3 | $3 | 1 |
| Wrist/thumb Brace with Thumb Spica Right Cotton/foam Large/x-large #79 | other | $3 | $3 | $3 | 1 |
| Fluid Warming Set Std Flow 3m Ranger 24240 | other | $3 | $3 | $3 | 1 |
| Dressing Col-active Ag Plus 4x4 #10340000 | other | $3 | $3 | $3 | 1 |
| Procare Super Knee Splint Adult Foam 14-16" Small #79 | other | $3 | $3 | $3 | 1 |
| Procare Super Knee Splint Adult Foam 16-19" Medium 20" #79 | other | $3 | $3 | $3 | 1 |
| Procare Super Knee Splint Adult Foam 19-22" Large #79 | other | $3 | $3 | $3 | 1 |
| Anesthesia for Closed Exam of Chest Using an Endoscope with 1 Lung Inflated | other | $3 | $3 | $3 | 1 |
| Anesthesia for Extensive Surgery On Spine | surgery | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure to Assess Heart Electrical Activity | cardiac | $3 | $3 | $3 | 1 |
| Male External Catheter, with OR without Adhesive, Disposable, Each | cardiac | $3 | $3 | $3 | 1 |
| Eszopiclone 2 Mg Po Tabs | other | $3 | $3 | $3 | 1 |
| Forcep Surgical Tiss Del 4.75in Reuse 130 | surgery | $3 | $3 | $3 | 1 |
| Tetracaine 0.5% Steri-unit Sol | other | $3 | $3 | $3 | 1 |
| Anesthesia for Retinal Surgery | surgery | $3 | $3 | $3 | 1 |
| Guaifen-codeine 100-10 Mg/5 Ml | other | $3 | $3 | $3 | 1 |
| Marker Coronary Bypass Graft #40149 | cardiac | $3 | $3 | $3 | 1 |
| Wheels Walker Guardian #7722 for Walker 1pr | other | $3 | $3 | $3 | 1 |
| Anesthesia for Procedure On Eyelid | other | $3 | $3 | $3 | 1 |
| Mepilex Ag Antimicrobial Foam Dressings with Safetac Technology 4" X 5" | other | $3 | $3 | $3 | 1 |
| Wound Irrigation Cap System # Irig8 Centurion | other | $3 | $3 | $3 | 1 |
| 12 Ga Sertera Introducer5ea/bx #sertera Intro | other | $3 | $3 | $3 | 1 |
| Anesthesia for Other Procedure On Eye | other | $3 | $3 | $3 | 1 |
| Cannula Nasal Adult 4m Co2/o2 Nomoline Lh #4624 25ea/box | other | $3 | $3 | $3 | 1 |
| Catheterization for Collection of Specimen, Single Patient, All Places of Ser... | lab | $3 | $3 | $3 | 1 |
| Clobetasol 0.05% Ointment | other | $3 | $3 | $3 | 1 |
| Injection, Darbepoetin Alfa, 1 Microgram | other | $3 | $3 | $3 | 1 |
| Knife 2.4mm Angld Slit Dbl Bevel #ab-asl24db | other | $3 | $3 | $3 | 1 |
| Rd Sedline Eeg Sensor 25/box #4248 | other | $3 | $3 | $3 | 1 |
| Splint Wrist 8" #b | other | $3 | $3 | $3 | 1 |
| Introducer Bougie Coude Tip Adult 15fr X 70cm | other | $3 | $3 | $3 | 1 |
| Introducer Bougie Coude Tip Peds 10fr X 70cm | other | $3 | $3 | $3 | 1 |
| Univ Ankle Brace #79 | other | $3 | $3 | $3 | 1 |
| Lopinavir-ritonavr 200-50mg Tb | other | $3 | $3 | $3 | 1 |
| Tube Medihoney Gel 1.5 Oz #31815 | other | $3 | $3 | $3 | 1 |
| Blood Group Typing | other | $3 | $3 | $3 | 2 |
| Blood Typing for Rh (d) Antigen | other | $3 | $3 | $3 | 2 |
| Exofin Precision Pen Skin Adhesive #ep70412 12ea/bx | other | $3 | $3 | $3 | 1 |
| Lymphedema Tube Gauze Band Med Tg7 18ea/1cs | other | $3 | $3 | $3 | 1 |
| Support Ankle Stabilizing Large #79 | other | $3 | $3 | $3 | 1 |
| Support Ankle Stabilizing Medium #79 | other | $3 | $3 | $3 | 1 |
| Support Ankle Stabilizing Small #79 | other | $3 | $3 | $3 | 1 |
| Coban 2 #2094 1bx=1kit | other | $3 | $3 | $3 | 1 |
| Coban 2 Lite #2794 1bx=1kit | other | $3 | $3 | $3 | 1 |
| Doxycycline 25 Mg/5 Ml Susp | other | $3 | $3 | $3 | 1 |
| Collar Button Vent Tube 60 Ea/bx 70241060 | other | $3 | $3 | $3 | 1 |
| Nix 1% Creme Rinse Liquid | other | $3 | $3 | $3 | 1 |
| Wheels Walker Heavy Duty Extn Set #g07725 1st | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Large #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Medium #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Small #ab2900 | other | $3 | $3 | $3 | 1 |
| Brace Ankle As0 Xlarge #ab2900 | other | $3 | $3 | $3 | 1 |
| Red Blood Cell Count, Automated Test | other | $3 | $3 | $3 | 2 |
| Splint Hand Mason Allen Small 1ea | other | $3 | $3 | $3 | 1 |
| Nasal Tampon 8.0 Cm 20ea/1pk | other | $3 | $3 | $3 | 1 |
| Cast Splint 5" X 30" Comformable 10ea/1cs | other | $3 | $3 | $3 | 1 |
| Lymphedema Tube Gauze Band Lrg Tg9 12ea/1cs | other | $3 | $3 | $3 | 1 |
| Catheter Malecot 14fr #086014 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 16fr #086016 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 20fr #086020 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 30fr #086030 | cardiac | $3 | $3 | $3 | 1 |
| Anucort-hc 25 Mg Suppository | other | $3 | $3 | $3 | 1 |
| Hydrocortisone Acetate 25 Mg Re Supp | other | $3 | $3 | $3 | 1 |
| Trocar Natura Cannula 5mmx100mm #100-005 | other | $3 | $3 | $3 | 1 |
| Needle Jamshidi Infant Disp | other | $3 | $3 | $3 | 1 |
| Dilator 10fr 20cm G10207 | other | $3 | $3 | $3 | 1 |
| Dilator 6fr 20cm #g10284 | other | $3 | $3 | $3 | 1 |
| Diovan 320 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Ocular Device, Intraoperative, Detached Retina | other | $3 | $3 | $3 | 1 |
| Set Airway Adapter Adult/pediatric Nomoline-o Lh #4630 25ea/box | other | $3 | $3 | $3 | 1 |
| Ritalin La 10 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Ritalin La 20 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Trueplus Glucose 15 Gram Liq | other | $3 | $3 | $3 | 1 |
| Administration and Interpretation of Caregiver-focused Health Risk Assessment | other | $3 | $3 | $3 | 1 |
| Catheter Guard Cont Shield 25ea/1cs | cardiac | $3 | $3 | $3 | 1 |
| Ortho-glass Splint W4xl30in Fiberglass Double Sided Padded #og-430pc 5ea/bx | other | $3 | $3 | $3 | 1 |
| Cath Rim 5ea/bx | other | $3 | $3 | $3 | 1 |
| Nasal Tampon 10.0 Cm 20ea/1pk #10115-c | other | $3 | $3 | $3 | 1 |
| Injection, Doxorubicin Hydrochloride, 10 Mg | other | $3 | $3 | $3 | 1 |
| Ritalin La 30 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Splint Knee Univ 18" Basic #79 | other | $3 | $3 | $3 | 1 |
| Vyvanse 10 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 20 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 30 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 40 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 50 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 60 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Vyvanse 70 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Cath Foley 26fr 30cc 3-way 12ea/1dz | other | $3 | $3 | $3 | 1 |
| Catheter Foley 16fr 30cc 3way Silver Coat | cardiac | $3 | $3 | $3 | 1 |
| Catheter Foley 18fr 30cc 3way Silver Coat | cardiac | $3 | $3 | $3 | 1 |
| Coagulator Foot Control Suction 10fr #130187 | other | $3 | $3 | $3 | 1 |
| Crutch Youth 300lb 4'6"-5'2" 8pr/case | other | $3 | $3 | $3 | 1 |
| Vimpat 50 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Angiocath 16ga 3-1/4 Bd #382258 | other | $3 | $3 | $3 | 1 |
| Chiba Biopsy Needle 20ga L20cm Aspiration #g00810 | lab | $3 | $3 | $3 | 1 |
| Chiba Biopsy Needle Dchn-20-15.0 #g00777 | lab | $3 | $3 | $3 | 1 |
| Collection Trap System Safetouch OB Gyn | other | $3 | $3 | $3 | 1 |
| Dressing Mepilex Border Sacrum 7.2x7.2 Foam | other | $3 | $3 | $3 | 1 |
| Dressing Wound Drawtex Wrap 4"x11.5 Ft #00352 | other | $3 | $3 | $3 | 1 |
| Guide Spring J-wire Curved 150cm | other | $3 | $3 | $3 | 1 |
| Perfusion Set Y-type 20/bx #per-1006s | surgery | $3 | $3 | $3 | 1 |
| Topical Skin Adhesive 2-octyl Lx6 6ea/1bx | other | $3 | $3 | $3 | 1 |
| Urinary Drainage Bag, Leg OR Abdomen, Vinyl, with OR without Tube, with Strap... | other | $3 | $3 | $3 | 1 |
| Dronedarone 200 Mg Half Tablet | other | $3 | $3 | $3 | 1 |
| Fentanyl 50 Mcg/hr Patch | other | $3 | $3 | $3 | 1 |
| Multaq 400 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Tracheal Suction Catheter, Any Type Other Than Closed System, Each | cardiac | $3 | $3 | $3 | 1 |
| Alginate OR Other Fiber Gelling Dressing, Wound Cover, Sterile, Pad Size 16 S... | other | $3 | $3 | $3 | 1 |
| Thoracic Chest Tube 24fr 10ea/1bx | other | $3 | $3 | $3 | 1 |
| Strattera 18 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Boots Sta-dri Knee-hi #kh | other | $3 | $3 | $3 | 1 |
| Forcep Surgical Dressing Serrated 4.5in | surgery | $3 | $3 | $3 | 1 |
| Mirabegron ER 50 Mg Po Tb24 | other | $3 | $3 | $3 | 1 |
| Mirabegron ER 50 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Bcg Live Intravesical Instillation, 1 Mg | other | $3 | $3 | $3 | 1 |
| Dilator Syracuse Medic Vaginal Small 7/8 22mm #sm-vd-s | other | $3 | $3 | $3 | 1 |
| Dilator Syracuse Medical Vaginal X-small Plus 1 1/16 18mm #sm-vd-xs Plus | other | $3 | $3 | $3 | 1 |
| Dilator Vaginal Syracuse Med X-small 1/2 13mm #sm-vd-xs | other | $3 | $3 | $3 | 1 |
| Ritalin La 40 Mg Capsule | other | $3 | $3 | $3 | 1 |
| Valacyclovir Hcl 500 Mg Po Tabs | other | $3 | $3 | $3 | 1 |
| Valacyclovir Hcl 500 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Sorbitol 70% Solution | other | $3 | $3 | $3 | 1 |
| Splint Hand Mason Allen Large 1ea | other | $3 | $3 | $3 | 1 |
| Ultrasound of Heart with Color-depicted Blood Flow, Rate and Valve Function | imaging | $3 | $3 | $3 | 1 |
| Blood Glucose (sugar) Test Performed By Hand-held Instrument | other | $3 | $3 | $3 | 1 |
| Specific Gravity (liquid Weight) Measurement | other | $3 | $3 | $3 | 2 |
| Catheter Malecot 22fr #086022 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 24fr #086024 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 26fr #086026 | cardiac | $3 | $3 | $3 | 1 |
| Catheter Malecot 28fr #086028 | cardiac | $3 | $3 | $3 | 1 |
| Stylet Gliderite Single Use Large 0270 | other | $3 | $3 | $3 | 1 |
| Injection, Hydromorphone, 0.1 Mg | other | $3 | $3 | $3 | 2 |
| Knee Immobilizer-22" Long | other | $3 | $3 | $3 | 1 |
| Splint Knee Univ 20" Basic #79 | other | $3 | $3 | $3 | 1 |
| Tc-99m From Non-highly Enriched Uranium Source, Full Cost Recovery Add-on, Pe... | other | $3 | $3 | $3 | 1 |
| Tube Vent Collar Button #70241014 | other | $3 | $3 | $3 | 1 |
| Bard Foley Drainage Syestem #a304400a | other | $3 | $3 | $3 | 1 |
| Test for Allergy Using Allergenic Extract | other | $3 | $3 | $3 | 1 |
| Estradiol 0.05 Mg Patch | other | $3 | $3 | $3 | 1 |
| Tube Salem Sump 10fr Ltx Fr W/reflux Filter | other | $3 | $3 | $3 | 1 |
| Cast Stockinette Delta-net Tubular Synthetic 2inx25yd Black #7272301 2rl/case | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Left-large | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Left-medium | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Left-small | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Left-xlarge | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Right Medium | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Right-large | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Right-xlarge | other | $3 | $3 | $3 | 1 |
| Roylan Wr Brace 6" Rt-small | other | $3 | $3 | $3 | 1 |
| Splint Knee Univ 22" Basic #79 | other | $3 | $3 | $3 | 1 |
| Anesthesia for Exam of Colon Using an Endoscope | other | $3 | $3 | $3 | 1 |
| Betamethasone Va 0.1% Cream | other | $3 | $3 | $3 | 1 |
| Prevacid Dr 30 Mg Solutab | other | $3 | $3 | $3 | 1 |
| Simple Syrup | other | $3 | $3 | $3 | 1 |
| Walker Basket 1ea | other | $3 | $3 | $3 | 1 |
| Collar Button Vent Tube 1.27mm Uncoated Silicon 6/pk #240014 | other | $3 | $3 | $3 | 1 |
| Bone Wax 2.5 Gram Non-absorbable #bw25g | other | $3 | $3 | $3 | 1 |
| Don-joy Knee Immoblizer 20" #79 | other | $3 | $3 | $3 | 1 |
| Microscopic Examination for White Blood Cells | other | $3 | $3 | $3 | 1 |
| Oxycontin ER 40 Mg Tablet | other | $3 | $3 | $3 | 1 |
| Dilator Syracuse Med Vaginal Sm Plus 1" 25mm #sm-vd-s Plus | other | $3 | $3 | $3 | 1 |
| Drain Btl W/o Drainln 1000m 12ea/1cs #sv1000s | other | $3 | $3 | $3 | 1 |
| Dressing Gel Silvasorb 1.5oz #msc9301ep | other | $3 | $3 | $3 | 1 |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, wit... | other | $3 | $3 | $3 | 1 |
| Snare Loop Hexagonal #m00562341 | other | $3 | $3 | $3 | 1 |
| Chiba 22g X 20cm Needle | other | $3 | $3 | $3 | 1 |
| Chiba Biopsy Needle Dchn-22-15.0 #g00012 | lab | $3 | $3 | $3 | 1 |
| Detector Co2 Easy Colorimetric Indicator Adult #562134 10ea/1cs | other | $3 | $3 | $3 | 1 |
| Electrode Dysphagia Therapy 1.0" #05a160 | other | $3 | $3 | $3 | 1 |
| Hospital Observation Service, Per Hour | other | $3 | $3 | $3 | 1 |
| Needle Insufflation Laproscopic | other | $3 | $3 | $3 | 1 |
| Sprotte 27g X 4'' (103mm) Needle with Introducer and Magnifying Hub Minimum O... | other | $3 | $3 | $3 | 1 |
| Sump Intracardiac 12fr #12013 20/bx | cardiac | $3 | $3 | $3 | 1 |
| Sleeve Scd Knee Lengthmed Comfrt#74022 5pr/cs | other | $3 | $3 | $3 | 1 |
| Tube Vent Armstrong 1.14mm Short #10 | other | $3 | $3 | $3 | 1 |
| Tube Inner Ear Myringotomy Ventilation Notched Flange with Tab 1.14 Mm Id Sil... | other | $3 | $3 | $3 | 1 |
| Injection, Morphine Sulfate, Up to 10 Mg | other | $3 | $3 | $3 | 1 |
| Glutose 15 Gel | other | $3 | $3 | $3 | 1 |
| Urinalysis | lab | $4 | $1 | $61 | 36 |
| Injection, Azithromycin, 500 Mg | other | $4 | $1 | $6 | 2 |
| Dextrose 10%-water IV Solution | other | $4 | $1 | $6 | 2 |
| Injection, Octreotide, Non-depot Form for Subcutaneous OR Intravenous Injecti... | other | $4 | $1 | $6 | 2 |
| Injection, Meropenem, 100 Mg | other | $4 | $2 | $5 | 2 |
| Cerebrospinal Fluid, OR Amniotic Fluid Albumin (protein) Level | other | $4 | $2 | $5 | 2 |
| Xarelto 10 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Hemoclip Medium Titan Cartridge #002204 24ea/pk/ 25pk/bx Blue | other | $4 | $4 | $4 | 1 |
| Strattera 60 Mg Capsule | other | $4 | $4 | $4 | 1 |
| Comfortform Left Wrist/thumb Adult Foam Laminate 5.5-6.5" Small 7.5" #79 | other | $4 | $4 | $4 | 1 |
| Comfortform Left Wrist/thumb Adult Foam Laminate 6.5-7.5" Medium 8" #79 | other | $4 | $4 | $4 | 1 |
| Comfortform Left Wrist/thumb Adult Foam Laminate 7.5-8.5" Large 8.5" #79 | other | $4 | $4 | $4 | 1 |
| Comfortform Right Wrist/thumb Adult Foam Laminate 5.5-6.5" Small 7.5"#79 | other | $4 | $4 | $4 | 1 |
| Comfortform Right Wrist/thumb Adult Foam Laminate 6.5-7.5" Medium 8"#79 | other | $4 | $4 | $4 | 1 |
| Comfortform Right Wrist/thumb Adult Foam Laminate 7.5-8.5" Large 8.5"#79 | other | $4 | $4 | $4 | 1 |
| Comfortform Right Wrist/thumb Adult Foam Laminate 8.5+" X-large 7.5"#79 | other | $4 | $4 | $4 | 1 |
| Diovan Hct 320-12.5 Mg Tab | other | $4 | $4 | $4 | 1 |
| Sodium Chloride Uromatic Irrigation .9% 3000ml Baxter Product Code #2b7127 4e... | other | $4 | $4 | $4 | 1 |
| 5 Fr Barbeau | other | $4 | $4 | $4 | 1 |
| 5 Fr IM | other | $4 | $4 | $4 | 1 |
| 5 Fr Jr 3.5 | other | $4 | $4 | $4 | 1 |
| Diag Catheter 5fr Jl4 #534520t | cardiac | $4 | $4 | $4 | 1 |
| Diag Catheter 5fr Jr4 #534521t | cardiac | $4 | $4 | $4 | 1 |
| Ortho-glass Splint W3xl35in Fiberglass Double Sided Padded #og-335pc 5ea/bx | other | $4 | $4 | $4 | 1 |
| Thoracic Chest Tube 36fr 10ea/1cs | other | $4 | $4 | $4 | 1 |
| Vashe Wound Therapy 250ml Bottle #00313 | other | $4 | $4 | $4 | 1 |
| Kittner Lap Dual Tip 20/bx Kt | other | $4 | $4 | $4 | 1 |
| Mask Procedural O2 Adult Elite 301-0318lt-msa | other | $4 | $4 | $4 | 1 |
| Knife 1mm Angled Dual Bevel 6/bx | other | $4 | $4 | $4 | 1 |
| Pantoprazole Sod Dr 40 Mg Tab | other | $4 | $4 | $4 | 1 |
| Pantoprazole Sodium 40 Mg Po Tbec | other | $4 | $4 | $4 | 1 |
| Stone Interceptor 12ea/1pk | other | $4 | $4 | $4 | 1 |
| Digi-flex Exercisor Green 5.0lbs | other | $4 | $4 | $4 | 1 |
| Digi-flex Exercisor Red 3.0lbs | other | $4 | $4 | $4 | 1 |
| Foot Brush 1ea | other | $4 | $4 | $4 | 1 |
| Body Fluid Ph Level | other | $4 | $4 | $4 | 1 |
| Cyclopentolate 1% Eye Drops | other | $4 | $4 | $4 | 1 |
| Donaldson Vent Tube 1.14 Mm I.d. Ultrasil Silicone 6 Ea/bx 70241015 | other | $4 | $4 | $4 | 1 |
| Escitalopram 10 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Escitalopram Oxalate 10 Mg Po Tabs | other | $4 | $4 | $4 | 1 |
| Cast Supplies, Short Arm Cast, Adult (11 Years +), Plaster | other | $4 | $4 | $4 | 1 |
| Atovaquone 750 Mg/5ml Susp Cup | other | $4 | $4 | $4 | 1 |
| Fluocinonide 0.05% Ointment | other | $4 | $4 | $4 | 1 |
| Forcep Surgical Tissue Teeth 1x2 4.5in | surgery | $4 | $4 | $4 | 1 |
| Dressing Acticoat Flex 7 4x5in Strl #66800405 | other | $4 | $4 | $4 | 1 |
| Irrigation Tur Y Set 80" #2c4041 12ea/1ca | other | $4 | $4 | $4 | 1 |
| Clobazam 5 Mg Half Tablet | other | $4 | $4 | $4 | 1 |
| Dilator Syracuse Med Vaginal Medium 1 1/8 29mm #sm-vd-m | other | $4 | $4 | $4 | 1 |
| Catheter Trocar 10fr 10ea/1bx | cardiac | $4 | $4 | $4 | 1 |
| Catheter Trocar 20fr 10ea/1cs | cardiac | $4 | $4 | $4 | 1 |
| Total Protein Level, Blood | other | $4 | $4 | $4 | 2 |
| Total Protein Level, Urine | other | $4 | $4 | $4 | 2 |
| Needle Cook 19x15 #g06275 | other | $4 | $4 | $4 | 1 |
| Clotrimazole 1 % Ex Soln | other | $4 | $4 | $4 | 1 |
| Bovie High Temp Fine Tip Cautery Surgical Disposable Aspen # Aa01 10ea/1bx | surgery | $4 | $4 | $4 | 1 |
| Purastat Catheter 20ea/bxwp-18/2200 | cardiac | $4 | $4 | $4 | 1 |
| Nystatin 100,000 Unit/gm Cream | other | $4 | $4 | $4 | 1 |
| Nystatin 100000 Unit/gm Ex Crea | other | $4 | $4 | $4 | 1 |
| Promote Liquid | other | $4 | $4 | $4 | 1 |
| Suction System Oral Swab Kit 20/cs #6464 | other | $4 | $4 | $4 | 1 |
| Oseltamivir Phos 75 Mg Capsule | other | $4 | $4 | $4 | 1 |
| Oseltamivir Phosphate 75 Mg Po Caps | other | $4 | $4 | $4 | 1 |
| Lap 5mm Sump Cannula Gleeson Flovac | other | $4 | $4 | $4 | 1 |
| Lexapro 20 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Opthalmic Burr 10ea/1bx | other | $4 | $4 | $4 | 1 |
| Cannula Ima 1mm Tip #31001 | other | $4 | $4 | $4 | 1 |
| Espocaná18 Ga. X 3+ In. Tuohy with Backeye Lumen Pencan Á27 Ga. X 5 In. Penci... | other | $4 | $4 | $4 | 1 |
| Myrbetriq ER 25 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Cannula Hydroexpression (corydon) 10/sp | other | $4 | $4 | $4 | 1 |
| Strattera 80 Mg Capsule | other | $4 | $4 | $4 | 1 |
| Microscopic Examination for White Blood Cells with Manual Cell Count | other | $4 | $4 | $4 | 2 |
| Sterilid Eyelid Cleanser Foam | other | $4 | $4 | $4 | 1 |
| Sump Cardiac 20fr #12112 20/bx | cardiac | $4 | $4 | $4 | 1 |
| Arch Support Medium #mdy10520 | other | $4 | $4 | $4 | 1 |
| Probe Myocardial Temp 15mm 20/bx | other | $4 | $4 | $4 | 1 |
| Blood Typing for Red Blood Cell Antigens | other | $4 | $4 | $4 | 2 |
| Catheter Foley Coude 18fr 5cc Silver 12ea/1cs | cardiac | $4 | $4 | $4 | 1 |
| Catheter Foley Coude 20fr 5cc Silver 12ea/1cs | cardiac | $4 | $4 | $4 | 1 |
| Restraint Vest Medium 3350m | other | $4 | $4 | $4 | 1 |
| Restraint Vest Small 3350s | other | $4 | $4 | $4 | 1 |
| Restraint Vest Xlarge 3350xl | other | $4 | $4 | $4 | 1 |
| Epidural Anes Kit-18ga Burron 10ea/1cs | other | $4 | $4 | $4 | 1 |
| Knee Immobilizer 24" X-long | other | $4 | $4 | $4 | 1 |
| Sleeve Foot Compression Regular #5897 10ea/cs | other | $4 | $4 | $4 | 1 |
| Dilator Vaginal Syracuse Medical Med Plus 1 1/4 32mm #sm-vd-m Plus | other | $4 | $4 | $4 | 1 |
| Tradjenta 5 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Abdominal Support 12in 1ea | other | $4 | $4 | $4 | 1 |
| Catheter Mediastinal 10/bx #14409 | cardiac | $4 | $4 | $4 | 1 |
| Ortho-glass Splint W5xl30in Fiberglass Double Sided Paddedog-5pc 5ea/bx | other | $4 | $4 | $4 | 1 |
| Injection, Belatacept, 1 Mg | other | $4 | $4 | $4 | 1 |
| Injection, Certolizumab Pegol, 1 Mg | other | $4 | $4 | $4 | 1 |
| Blood Glucose (sugar) Tolerance Test, Each Additional Beyond 3 Specimens | lab | $4 | $4 | $4 | 2 |
| Blood Glucose (sugar) Level | other | $4 | $4 | $4 | 2 |
| Glucose (sugar) Level On Body Fluid | other | $4 | $4 | $4 | 2 |
| Needle Weiss 18ga X 5" 10/bx | other | $4 | $4 | $4 | 1 |
| Sleeve Foot Compression Large #5898 10ea/1cs | other | $4 | $4 | $4 | 1 |
| Trap Digit Finger Large #9903 | other | $4 | $4 | $4 | 1 |
| 25-40cc Iabp Adaptor#0684-00-0510-01 5ea/pk | other | $4 | $4 | $4 | 1 |
| Probe Cover Civ-flex 5.5"x96"sterile 610 | other | $4 | $4 | $4 | 1 |
| Urea Nitrogen Level to Assess Kidney Function, Quantitative | other | $4 | $4 | $4 | 2 |
| Knife 2.75mm Angled Split | other | $4 | $4 | $4 | 1 |
| Jardiance 10 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Jardiance 25 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Mirror Flexible #6220 1ea | other | $4 | $4 | $4 | 1 |
| Trap Digit Finger Small .63 #9906 Bx/20ea | other | $4 | $4 | $4 | 1 |
| Dilator Vaginal Syracuse Medical Large 1 3/8 35mm #sm-vd-l | other | $4 | $4 | $4 | 1 |
| Application of Hot OR Cold Packs | other | $4 | $4 | $4 | 1 |
| Blanket-nsy Disp Therm Med #37.09.15 | other | $4 | $4 | $4 | 1 |
| Blanket-nsy Disp Therm Sm #37.09.14 | other | $4 | $4 | $4 | 1 |
| Cast Supplies, Gauntlet Cast (includes Lower Forearm and Hand), Pediatric (0-... | other | $4 | $4 | $4 | 1 |
| Cast Supplies, Long Arm Cast, Adult (11 Years +), Plaster | other | $4 | $4 | $4 | 1 |
| Diovan Hct 320-25 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Guidewire W/ Trocar Tip 0.45" #ar-8737 | other | $4 | $4 | $4 | 1 |
| Injection, Aztreonam, 500 Mg | other | $4 | $4 | $4 | 1 |
| Needle Jamshidi Adult Disp | other | $4 | $4 | $4 | 1 |
| Non-elastic Binder for Extremity | other | $4 | $4 | $4 | 1 |
| Nystatin-triamcinolone 100000-0.1 Unit/gm-% Ex Crea | other | $4 | $4 | $4 | 1 |
| Nystatin-triamcinolone Cream | other | $4 | $4 | $4 | 1 |
| Osmolite 1.5 Cal Liquid | other | $4 | $4 | $4 | 1 |
| Polyethylene Glycol 3350 17 Gm/scoop Po Powd | other | $4 | $4 | $4 | 1 |
| Red Blood Count, Automated Test | other | $4 | $4 | $4 | 2 |
| Smoke Elimination Device 15/cs | other | $4 | $4 | $4 | 1 |
| Smoking and Tobacco Use Intermediate Counseling, 3-10 Minutes | therapy | $4 | $4 | $4 | 1 |
| Total Protein Level, Body Fluid | other | $4 | $4 | $4 | 2 |
| Knee Immobilizer-12" X-small | other | $4 | $4 | $4 | 1 |
| Oxymorphone Hcl ER 20 Mg Tab | other | $4 | $4 | $4 | 1 |
| Prosthetic Sock, Single Ply, Fitting, Below Knee, Each | other | $4 | $4 | $4 | 1 |
| Trintellix 10 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Trintellix 5 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Vortioxetine Hbr 10 Mg Po Tabs | other | $4 | $4 | $4 | 1 |
| CPAP Nasal Mask Large #niv042l | other | $4 | $4 | $4 | 1 |
| Docusate Sodium 50 Mg/5 Ml Liq | other | $4 | $4 | $4 | 1 |
| Dressing Contact Layer W6xl8in Silver Urgotul #509342 10ea/bx | other | $4 | $4 | $4 | 1 |
| 4fr Simmons 1 | other | $4 | $4 | $4 | 1 |
| 4fr Sos 1 | other | $4 | $4 | $4 | 1 |
| 5fr Simmons 2 | other | $4 | $4 | $4 | 1 |
| 5fr Sos 2 | other | $4 | $4 | $4 | 1 |
| Binder Abdominal 12" 46-62" #13982000 | other | $4 | $4 | $4 | 1 |
| Antithrombin Iii (human), Per I.u. | other | $4 | $4 | $4 | 1 |
| Intubated Filter Lines Adult/pediatric Short Term Mfg# 989803204521 25ea/bx | other | $4 | $4 | $4 | 1 |
| Snare Cold Captivator 10mm Rnd M00561103 | other | $4 | $4 | $4 | 1 |
| Cannula Nasal Co2 Adult 10ea/1bx | other | $4 | $4 | $4 | 1 |
| Co2 Sampling O2 Delivery Cannula #989803206641 10ea/pk | obstetric | $4 | $4 | $4 | 1 |
| Dilating Mixture 0.5 Ml - Compounded | other | $4 | $4 | $4 | 1 |
| Male Purewick External Catheter #pwm030 30ea/case | cardiac | $4 | $4 | $4 | 1 |
| Tray Catheter 14fr Foley/bag #a300314a | cardiac | $4 | $4 | $4 | 1 |
| Tray Catheter 16fr Foley/bag #a300316a | cardiac | $4 | $4 | $4 | 1 |
| Tray Catheter 18fr Foley/bag #a300318a | cardiac | $4 | $4 | $4 | 1 |
| Y-adapter Ureteroscope Gateway #m0067301501 | other | $4 | $4 | $4 | 1 |
| Spiriva Handihaler 18 Mcg Cap | other | $4 | $4 | $4 | 1 |
| Paparella Vent Tube #240044 6ea/1bx | other | $4 | $4 | $4 | 1 |
| Tape Elastic 4" 6/bx #5177 | other | $4 | $4 | $4 | 1 |
| Prosthetic Sock, Single Ply, Fitting, Above Knee, Each | other | $4 | $4 | $4 | 1 |
| Seal 8mm Cannula Disp #400077 | other | $4 | $4 | $4 | 1 |
| Tobramycin, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $4 | $4 | $4 | 1 |
| Catheter Foley Council 16fr 5cc Ribbed Silver | cardiac | $4 | $4 | $4 | 1 |
| Catheter Foley Council 20fr 5cc Silver Coat | cardiac | $4 | $4 | $4 | 1 |
| Suction Cauterizer 10fr X 6" Handswitch | other | $4 | $4 | $4 | 1 |
| Cannula Shoulder 7cm #9718 | other | $4 | $4 | $4 | 1 |
| Injection, Ceftaroline Fosamil, 10 Mg | other | $4 | $4 | $4 | 1 |
| Sleeve Scd Knee Length Smcomfrt #74021 5pr/cs | other | $4 | $4 | $4 | 1 |
| Stool Analysis for Blood, By Peroxidase Activity | other | $4 | $4 | $4 | 2 |
| Detector Co2 Easy Colorimetric Indicator Pediatric Carbon Dioxide Detector #5... | other | $4 | $4 | $4 | 1 |
| Dilator Vaginal Syracuse Med Large Plus 39mm Sm-vd-l+ | other | $4 | $4 | $4 | 1 |
| Mitt Hand Peek-a-boo #2811 12pr/cs 1pr=1ea | other | $4 | $4 | $4 | 1 |
| Neomyc-bacit-polymix Eye Oint | other | $4 | $4 | $4 | 1 |
| Xodus Pillow Abduction Hip Large Disp #40410 4ea/case | other | $4 | $4 | $4 | 1 |
| Trocar 18g X 15cm | other | $4 | $4 | $4 | 1 |
| Composite Dressing, Sterile, Pad Size 16 Sq. In. OR Less, with Any Size Adhes... | other | $4 | $4 | $4 | 1 |
| Indwelling Catheter; Foley Type, Two-way Latex with Coating (teflon, Silicone... | cardiac | $4 | $4 | $4 | 1 |
| Jumpstart 2" X 5" Antimicrobial Wound Dressing Abs | other | $4 | $4 | $4 | 1 |
| Needle Disp. 2-part Trocar 18gax15cm #g14461 | other | $4 | $4 | $4 | 1 |
| Needle Disp. 2-part Trocar 18gax20cm #g14255 | other | $4 | $4 | $4 | 1 |
| Needle, Sterile, Any Size, Each | other | $4 | $4 | $4 | 1 |
| Pacemaker Lead End Kit #5867-3m | cardiac | $4 | $4 | $4 | 1 |
| Pressurizer Large 6ea/pk 0206-547 | other | $4 | $4 | $4 | 1 |
| Pressurizer Medium 6ea/pk #0206-546 | other | $4 | $4 | $4 | 1 |
| Pinworm Test | other | $4 | $4 | $4 | 2 |
| Special Gram OR Giemsa Stain for Microorganism | other | $4 | $4 | $4 | 2 |
| Syphilis Detection Test | other | $4 | $4 | $4 | 2 |
| Tissue Fungi OR Parasites | other | $4 | $4 | $4 | 1 |
| Coagulation Time Measurement, Activated | other | $4 | $4 | $4 | 1 |
| Dripline Ii Water Trap Adult 10ea/1bx | other | $4 | $4 | $4 | 1 |
| Tube Vent Armstrong 1.14mm - Sc | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 13.5-15.5" X-small #79 | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 15.5-18" Small #79 | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 18-20.5" Medium #79 | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 20.5-23" Large #79 | other | $4 | $4 | $4 | 1 |
| Breast Pump One-hand Manual #17161 | other | $4 | $4 | $4 | 1 |
| Cast Supplies, Short Arm Splint, Pediatric (0-10 Years), Plaster | other | $4 | $4 | $4 | 1 |
| Injection, Vinblastine Sulfate, 1 Mg | other | $4 | $4 | $4 | 1 |
| Red Blood Count, Manual Test | other | $4 | $4 | $4 | 1 |
| Lymphedema Tube Gauze Band X-lrg K1 10ea/1cs | other | $4 | $4 | $4 | 1 |
| Sleeve Scd Knee Length Lg Comfrt#74023 5pr/cs | other | $4 | $4 | $4 | 1 |
| Cholesterol Level | other | $4 | $4 | $4 | 2 |
| Injection, Pemetrexed, Not Otherwise Specified, 10 Mg | other | $4 | $4 | $4 | 1 |
| Electrode Vital Stim Adlt Julia Jones 12ea/pk | other | $4 | $4 | $4 | 1 |
| Injection, Degarelix, 1 Mg | other | $4 | $4 | $4 | 1 |
| Stool Analysis for Blood to Screen for Colon Tumors | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 23-25.5" X-large #79 | other | $4 | $4 | $4 | 1 |
| Crutch Steel Bariatric Adult 5'2"-5'10" 650lb #mds80335xw 1pr/case | other | $4 | $4 | $4 | 1 |
| Dressing Shield Zip Ds Ps1241 5ea/pk | other | $4 | $4 | $4 | 1 |
| Elastomer Vascular Loop #1041 (retract-o-tape | other | $4 | $4 | $4 | 1 |
| Caffeine Citrate 10 Mg/ml D5w Syringe - Peds - Compounded | other | $4 | $4 | $4 | 1 |
| Injection, Tocilizumab-aazg (tyenne), Biosimilar, 1 Mg | other | $4 | $4 | $4 | 1 |
| Linaclotide 145 Mcg Po Caps | other | $4 | $4 | $4 | 1 |
| Linzess 145 Mcg Capsule | other | $4 | $4 | $4 | 1 |
| Linzess 72 Mcg Capsule | other | $4 | $4 | $4 | 1 |
| Needle Biopsy Tru-cut Disp #2n2702x | lab | $4 | $4 | $4 | 1 |
| Levofloxacin 250 Mg Po Tabs | other | $4 | $4 | $4 | 1 |
| Levofloxacin 250 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Levofloxacin 500 Mg Po Tabs | other | $4 | $4 | $4 | 1 |
| Levofloxacin 500 Mg Tablet | other | $4 | $4 | $4 | 1 |
| Pad Spider Elbow Slv Xxxl Blk 11-0392-7 | other | $4 | $4 | $4 | 1 |
| Pad-sensa Trac W/tube/clamp/conn #m8275057/10 | other | $4 | $4 | $4 | 1 |
| Reddie Wraparound Knee Brace Adult Neoprene 25.5-28" 2x-large #79 | other | $4 | $4 | $4 | 1 |
| Thera Tears Sterilid Cleanser | other | $4 | $4 | $4 | 1 |
| Nasal Tampon W/tube 8.0 Cm #400410 20ea/1pk | other | $4 | $4 | $4 | 1 |
| Platelet Count, Automated Test | other | $4 | $4 | $4 | 2 |
| Tacrolimus, Immediate Release, Oral, 1 Mg | other | $4 | $2 | $5 | 2 |
| Patient Care Supplies | other | $4 | $4 | $4 | 1 |
| Test to Measure Oxygen Level in Blood Using Ear OR Finger Device | other | $4 | $4 | $4 | 1 |
| Urine Volume Measurement | other | $4 | $4 | $4 | 1 |
| Viscous Lidocaine 2% 15ml Udcu | other | $4 | $4 | $4 | 1 |
| 5% Dextrose and 0.45% Normal Saline, 1000 Ml | other | $4 | $4 | $4 | 1 |
| Dexamethasone, Oral, 0.25 Mg | imaging | $4 | $4 | $4 | 1 |
| Test to Measure Oxygen Level in Blood Using Ear OR Finger Device Multiple Times | other | $4 | $4 | $4 | 1 |
| Red Blood Cell Sedimentation Rate, to Detect Inflammation, Non-automated | other | $4 | $4 | $4 | 1 |
| 5fr Sos 80cm | other | $5 | $5 | $5 | 1 |
| Foam Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, with Any Si... | other | $5 | $5 | $5 | 1 |
| Needle Spinal Sterile 22gx20cm #dsn-22-20.0 | other | $5 | $5 | $5 | 1 |
| Flow Cytometry Technique for Dna OR Cell Analysis, Each Additional Marker | other | $5 | $5 | $5 | 1 |
| Guide Aiming 1.5mm Single Use Pdg-aim | other | $5 | $5 | $5 | 1 |
| Lasik Flap Roller | other | $5 | $5 | $5 | 1 |
| Male External Catheter with Integral Collection Chamber, Any Type, Each | cardiac | $5 | $5 | $5 | 1 |
| Paracervical-pudenal Block Tray Includes 20g X 6" Spinal Needle Trumpet Needl... | other | $5 | $5 | $5 | 1 |
| Punch Aortic 2.8mm #dp-28k | other | $5 | $5 | $5 | 1 |
| Tubing Set Ext Compress System 4ft #9595 20ea/case | other | $5 | $5 | $5 | 1 |
| Uric Acid Level, Blood | other | $5 | $5 | $5 | 2 |
| Lap Spatula Elec 5mm X 32mm 60-5272 | other | $5 | $5 | $5 | 1 |
| Avitene Ultrafoam Collagen Hemostatic Sponge 3/4 X 2-1/2 X 1/4 12 Ea/bx 1050020 | other | $5 | $5 | $5 | 1 |
| Freestyle Lite Meter | other | $5 | $5 | $5 | 1 |
| **discontinued** Catheter Imager Ii Cobra 5fr M0064003011 5/bx | cardiac | $5 | $5 | $5 | 1 |
| Drain Catheter 12fr Pezzer #064012 6ea/1bx | cardiac | $5 | $5 | $5 | 1 |
| Drain Catheter 14fr Pezzer #064014 6ea/1cs | cardiac | $5 | $5 | $5 | 1 |
| Jackson Pratt Drain 19fr #su130 | other | $5 | $5 | $5 | 1 |
| Immobilizer Knee 20" Black Elastic #bf7072 | other | $5 | $5 | $5 | 1 |
| Blood Chloride Level | other | $5 | $5 | $5 | 2 |
| Reddie Wraparound Knee Brace Adult Neoprene 28-31" 3x-large #79-82399 | other | $5 | $5 | $5 | 1 |
| Splint Nasal Septal Small | other | $5 | $5 | $5 | 1 |
| Dialator Cook 16fr #g03947 | other | $5 | $5 | $5 | 1 |
| Dilator 12fr #jcd12.0-38-20-coons | other | $5 | $5 | $5 | 1 |
| Dilator 14fr #jcd14.0-38-20-coons | other | $5 | $5 | $5 | 1 |
| Cautery Hot Biopsy Polyp #m00515033 | lab | $5 | $5 | $5 | 1 |
| Knee Immobilizer-19" Med" | other | $5 | $5 | $5 | 1 |
| Lap Electrode L Hook 5 X 32mm | other | $5 | $5 | $5 | 1 |
| M00561101 - Snare Vascular L240cm Loop W10mm Sheath Dia2.4mm Round Stiff Cold... | other | $5 | $5 | $5 | 1 |
| Arch Support Large #mdy10530 | other | $5 | $5 | $5 | 1 |
| Cannula Air Injection 27g | other | $5 | $5 | $5 | 1 |
| Catheter Trocar 32fr | cardiac | $5 | $5 | $5 | 1 |
| Catheter Kit Coude/foley Complete Care 16fr | cardiac | $5 | $5 | $5 | 1 |
| Cephalexin 125 Mg/5 Ml Susp | other | $5 | $5 | $5 | 1 |
| Body Fluid Cell Count | other | $5 | $5 | $5 | 2 |
| Endostitch 2-0 Polysorb #170053 | other | $5 | $5 | $5 | 1 |
| Needle Sonoplex Ii 20g X 6" (150mm) Echogenic Needle with Facet S Tip Nanolin... | imaging | $5 | $5 | $5 | 1 |
| Urine Potassium Level | other | $5 | $5 | $5 | 2 |
| Anesthesia for Incision of Ear Drum | other | $5 | $5 | $5 | 1 |
| Resuscitator Bag Infant W/peep Mask 6ea/1cs | other | $5 | $5 | $5 | 1 |
| Anesthesia for Exam of Ear Using an Endoscope | other | $5 | $5 | $5 | 1 |
| Blood Glucose (sugar) Level After Receiving Dose of Glucose | other | $5 | $5 | $5 | 2 |
| Desonide 0.05% Cream | other | $5 | $5 | $5 | 1 |
| Blood Potassium Level | other | $5 | $5 | $5 | 2 |
| Brace Elbow 11 Inch Adult #79 | other | $5 | $5 | $5 | 1 |
| Knife 4.1mm Angled Shortcut | other | $5 | $5 | $5 | 1 |
| Uterine Vac 5mm Flexible #505 Milex | other | $5 | $5 | $5 | 1 |
| Dakin's 0.25% Solution | other | $5 | $5 | $5 | 1 |
| Dakin's 0.5% Solution | other | $5 | $5 | $5 | 1 |
| Cast Supplies, Short Arm Cast, Pediatric (0-10 Years), Fiberglass | other | $5 | $5 | $5 | 1 |
| Cps Universal Ii Slitter Ds2a006 | other | $5 | $5 | $5 | 1 |
| Desonide 0.05% Ointment | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 6.0mm #86548 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 6.5mm #86549 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 7.0mm #86550 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 7.5mm #86551 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 8.0mm #86552 | other | $5 | $5 | $5 | 1 |
| Quick-use Disposable Bone Cement Curette 10 Ea/bx 00504905300#5049 | other | $5 | $5 | $5 | 1 |
| Blood Sodium Level | other | $5 | $5 | $5 | 2 |
| Catheter Trocar 12fr 10ea/1cs | cardiac | $5 | $5 | $5 | 1 |
| Pad Cold Therapy Univ Wrap On 11-0679-9 | other | $5 | $5 | $5 | 1 |
| Pad Cold Therapy Univ Wrap Xl 11-0681-9 | other | $5 | $5 | $5 | 1 |
| Bleeding Time | other | $5 | $5 | $5 | 2 |
| Cannula Air Injection 30g | other | $5 | $5 | $5 | 1 |
| Dressing Calcium Alginate 4x5 #31045 | other | $5 | $5 | $5 | 1 |
| Pin Steinman 5/32" Threaded 9" | other | $5 | $5 | $5 | 1 |
| Pin Steinman 5/64" Threaded 9" #262-07 | other | $5 | $5 | $5 | 1 |
| Pin Steinman 7/64 X 229mm Threaded #262-05 | other | $5 | $5 | $5 | 1 |
| Pin Steinman Threaded 1/8 X 229mm #262-06 | other | $5 | $5 | $5 | 1 |
| Pin Steinman Threaded 7/64" X 229mm | other | $5 | $5 | $5 | 1 |
| Steinman Pin Threaded 9/64 X 229mm #262-03 | other | $5 | $5 | $5 | 1 |
| Cast Stockinette Delta-net Tubular Synthetic 3inx25yd Non-sterile #7272302 2r... | other | $5 | $5 | $5 | 1 |
| Snare Rotatable 20mm #m00561831 | other | $5 | $5 | $5 | 1 |
| Sodium Level | other | $5 | $5 | $5 | 1 |
| Immobilizer Knee 18" W/elastc Straps #7071 | other | $5 | $5 | $5 | 1 |
| Carbon Dioxide (bicarbonate) Level | other | $5 | $5 | $5 | 2 |
| Uterine Vac 6mm Flexible #506 Milex 10ea/1bx | other | $5 | $5 | $5 | 1 |
| Nail Clipper W/file for One-handed Nail Care 1ea A85410 | other | $5 | $5 | $5 | 1 |
| Endostitch 0 Surgidac #173024 | other | $5 | $5 | $5 | 1 |
| Suspensory W/straps-large-adult Pfpfp02570lg | other | $5 | $5 | $5 | 1 |
| Suspensory W/straps-xlarge-adult Pfp2570xl | other | $5 | $5 | $5 | 1 |
| Moderate Sedation Services Provided By the Same Physician OR Other Qualified ... | other | $5 | $5 | $5 | 1 |
| Perfusion Set Multiple #14000 | surgery | $5 | $5 | $5 | 1 |
| Sleeve Scd Knee Length Xl Exprss #9790 5pr/cs | other | $5 | $5 | $5 | 1 |
| Albumin (protein) Level | other | $5 | $5 | $5 | 2 |
| Closed Injectate Delivery Sys (cardiac Output | cardiac | $5 | $5 | $5 | 1 |
| Dorzolamide-timolol Eye Drops | other | $5 | $5 | $5 | 1 |
| Ez-stabilizer 9066-vc-005 5ea/1bx | other | $5 | $5 | $5 | 1 |
| Akten 3.5% Gel Drops | other | $5 | $5 | $5 | 1 |
| Suspensory W/straps-medium-adult Pfp02570m | other | $5 | $5 | $5 | 1 |
| Vimpat 100 Mg Tablet | other | $5 | $5 | $5 | 1 |
| Forceps Radial Jaw 4 Jumbo 80/bx M00513374 | other | $5 | $5 | $5 | 1 |
| Chloride Level | other | $5 | $5 | $5 | 2 |
| Dressing Sorbson Wound Packing 12" | other | $5 | $5 | $5 | 1 |
| Diag Catheter 6fr Uf #451-504v5 | cardiac | $5 | $5 | $5 | 1 |
| Paparella-type Vent Tube 1.27 Mm I.d. Ultrasil Silicone 6 Ea/bx 70241046 | other | $5 | $5 | $5 | 1 |
| Bilirubin Level, Direct | other | $5 | $5 | $5 | 2 |
| Bilirubin Level, Total | other | $5 | $5 | $5 | 2 |
| Measurement of Bilirubin | other | $5 | $5 | $5 | 1 |
| Vashe Wound Vac Wash 8.5oz Antimicrobial Bottle Non-cytotoxic #00316 12ea/case | other | $5 | $5 | $5 | 1 |
| Cannula Seal 5mm-8mm #470361 Intuitive Surgic | other | $5 | $5 | $5 | 1 |
| Laryngoscope Blade - Gvl 3 Stat #0270 | other | $5 | $5 | $5 | 1 |
| Laryngoscope Blade - Gvl 4 Stat #0270 | other | $5 | $5 | $5 | 1 |
| Blood Glucose (sugar) Measurement Using Reagent Strip | other | $5 | $5 | $5 | 1 |
| Lap 5mm/44cm Sump Cannula Gleeson Flovac | other | $5 | $5 | $5 | 1 |
| Fentanyl 75 Mcg/hr Patch | other | $5 | $5 | $5 | 1 |
| Fentanyl 75 Mcg/hr Td Pt72 | other | $5 | $5 | $5 | 1 |
| Urine Sodium Level | other | $5 | $5 | $5 | 2 |
| Urovac Bladder Evacuator #m0067301251 | other | $5 | $5 | $5 | 1 |
| Uric Acid Level | other | $5 | $5 | $5 | 2 |
| Dermatac Drape 10 Pack Dtac10ldp | other | $5 | $5 | $5 | 1 |
| Monsel's Ferric Subsulfate Sol | other | $5 | $5 | $5 | 1 |
| Stool Fat OR Lipids Analysis, Qualitative | lab | $5 | $5 | $5 | 2 |
| Blood Creatinine Level | other | $5 | $5 | $5 | 2 |
| Channel Drain Round Silicone with Trocar 15fr 3/16" Full Fluted #dynjwe2189 1... | other | $5 | $5 | $5 | 1 |
| Valtrex 1 Gram Caplet | other | $5 | $5 | $5 | 1 |
| Xodus Pillow Abduction Hip Small W/straps Disp #40408b 6ea/case | other | $5 | $5 | $5 | 1 |
| Calcium Level, Total | other | $5 | $5 | $5 | 2 |
| Derma Hook | other | $5 | $5 | $5 | 1 |
| Quikclot 4x4 Topical Hemostatic #459 | other | $5 | $5 | $5 | 1 |
| Creatinine Level to Test for Kidney Function OR Muscle Injury | other | $5 | $5 | $5 | 2 |
| Liver Enzyme (sgot), Level | other | $5 | $5 | $5 | 2 |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation | other | $5 | $5 | $5 | 2 |
| Phosphatase (enzyme) Level, Alkaline | other | $5 | $5 | $5 | 2 |
| Screening Test for Mononucleosis | preventive | $5 | $5 | $5 | 2 |
| Micropuncture 5fr Access Set #g53574 | other | $5 | $5 | $5 | 1 |
| Catheter Phillips Follower 12fr Lf 10ea/bx | cardiac | $5 | $5 | $5 | 1 |
| Catheter Philllips Folllower 18fr Lf 10ea/bx | cardiac | $5 | $5 | $5 | 1 |
| Crutch Steel Bariatric Tall Adult 5'10"-6'6" 650lb 1pr/case #mds80334xw | other | $5 | $5 | $5 | 1 |
| Measurement of Antibody (ige) to Allergic Substance, Crude Allergen Extract, ... | other | $5 | $5 | $5 | 2 |
| Angiographic Catheter 5f (1.8mm) X 90cm Cobra 2 #10719711 5ea/bx | imaging | $5 | $5 | $5 | 1 |
| Profile Extra Small Oval Flexible Single Use Snare 10ea/bx M00562531 | other | $5 | $5 | $5 | 1 |
| Vincristine Sulfate, 1 Mg | other | $5 | $5 | $5 | 1 |
| Forceps Radial Jaw 4 Jumbo #m00513372 40/1bx | other | $5 | $5 | $5 | 1 |
| Knee Support Med Neoprene Hinged #302155blk | other | $5 | $5 | $5 | 1 |
| Cpm Pads Synthetic Patient Kit 1ea | other | $5 | $5 | $5 | 1 |
| Ambien 10 Mg Tablet | other | $5 | $5 | $5 | 1 |
| Diphenhydramine Hydrochloride, 50 Mg, Oral, Fda Approved Prescription Anti-em... | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Large Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Medium Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Small Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Xlarge Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Left Xsmall Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Large Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Medium Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Small Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Xlarge Ab2801 | other | $5 | $5 | $5 | 1 |
| Brace Foot Right Xsmall Ab2801 | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Left-large | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Left-medium | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Left-small | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Left-xlarge | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Right-large | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Right-medium | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Right-small | other | $5 | $5 | $5 | 1 |
| Comfort Cool Thumb Cmc Right-xlarge | other | $5 | $5 | $5 | 1 |
| Liver Enzyme (sgpt), Level | other | $5 | $5 | $5 | 2 |
| Endotrach Tube Reinforced 6.0mm 5/bx #5 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 6.5mm 5/bx #5 | other | $5 | $5 | $5 | 1 |
| Endotrach Tube Reinforced 7.0mm #5 | other | $5 | $5 | $5 | 1 |
| Lap Electrode Ball 3mm Ext | other | $5 | $5 | $5 | 1 |
| Lap Electrode Loop Medium 15x10mm | other | $5 | $5 | $5 | 1 |
| Lap Electrode Loop Small 12x8mm | other | $5 | $5 | $5 | 1 |
| Delflex with 1.5% Dextrose | other | $5 | $5 | $5 | 1 |
| Delflex with 2.5% Dextrose | other | $5 | $5 | $5 | 1 |
| Golytely Solution | other | $5 | $5 | $5 | 1 |
| Hc Ehc Rev | other | $5 | $5 | $5 | 1 |
| Indwelling Catheter, Foley Type, Two-way, All Silicone OR Polyurethane, Each | cardiac | $5 | $5 | $5 | 1 |
| Injection, Metronidazole, 500 Mg | other | $5 | $5 | $5 | 1 |
| Intuitive Da Vinci Xi Universal Seal 5mm-12mm10 Ea/bx 470500 | other | $5 | $5 | $5 | 1 |
| Non-coring Needle OR Stylet with OR without Catheter | cardiac | $5 | $5 | $5 | 1 |
| Orthopedic Shoe, Hightop with Supinator OR Pronator, Child | other | $5 | $5 | $5 | 1 |
| Pom Mask #1001-msa 30ea/pk | other | $5 | $5 | $5 | 1 |
| Spirometer, Non-electronic, Includes All Accessories | other | $5 | $5 | $5 | 1 |
| Splint | other | $5 | $5 | $5 | 1 |
| Tvi Tool #tvi-07 Medtronic 5/pk | other | $5 | $5 | $5 | 1 |
| Gradient Compression Garment, Not Otherwise Specified | other | $5 | $5 | $5 | 1 |
| Hydrocolloid Dressing, Wound Filler, Paste, Sterile, Per Ounce | other | $5 | $5 | $5 | 1 |
| Suction Control Valve/am Omi Cardiac | cardiac | $5 | $5 | $5 | 1 |
| Catheter Phillips Follower 22fr Lf 10ea/1bx | cardiac | $5 | $5 | $5 | 1 |
| Splint Bucks Traction-xlarge #8106 | other | $5 | $5 | $5 | 1 |
| Catheter Phillips Follower 10fr Lf 10ea/bx | cardiac | $5 | $5 | $5 | 1 |
| Catheter Tray Urine Meter E/ Foley 350ml | cardiac | $5 | $5 | $5 | 1 |
| Red Blood Cell Antibody Detection Test, Direct | other | $5 | $5 | $5 | 2 |
| Special Fluorescent And/or Acid Fast Stain for Microorganism | other | $5 | $5 | $5 | 2 |
| Walker Palm Relfoldguardian #g30756 4ea/1cs | other | $5 | $5 | $5 | 1 |
| Crutch Child Small 4'-4'6" 300 Lb 1pr | other | $5 | $5 | $5 | 1 |
| Glycerin Skin Protectant Liq | other | $5 | $5 | $5 | 1 |
| Lindane 1 % Ex Sham | other | $5 | $5 | $5 | 1 |
| Wire Breast Localization 10/bx #47720 | other | $5 | $5 | $5 | 1 |
| Wire Breast Localization 20gx5cm | other | $5 | $5 | $5 | 1 |
| Forceps Magill Child #792-9-3018 | other | $5 | $5 | $5 | 1 |
| Thermax Blood Warmer Disposable #955516 Ca/ 24ea | other | $5 | $5 | $5 | 1 |
| 4fr Sos Mini Omni 65cm - Must Be Ordered in Qty's of 5 Ea | other | $5 | $5 | $5 | 1 |
| Anesthesia for Procedure On Small and Large Bowel Using an Endoscope | other | $5 | $5 | $5 | 1 |
| Pillow Abduction Hip Small Disp #m60-076-s | other | $5 | $5 | $5 | 1 |
| Cryoglobulin (protein) Measurement | other | $5 | $4 | $6 | 2 |
| Ketone Bodies Analysis, Qualitative | other | $5 | $5 | $5 | 1 |
| Fern Test | other | $5 | $5 | $5 | 1 |
| Phosphate Level | other | $5 | $5 | $5 | 1 |
| Detection of Antimicrobial Drug | other | $5 | $5 | $5 | 1 |
| Urine Sulfate (acid) Level | other | $5 | $5 | $5 | 1 |
| Insertion of Needle Into Vein for Collection of Blood Sample | other | $5 | $5 | $5 | 1 |
| Technetium Tc-99m Pertechnetate, Diagnostic, Per Millicurie | other | $5 | $5 | $5 | 1 |
| Pantoprazole 40 Mg Inj | other | $5 | $5 | $5 | 1 |
| Cath Ua Collection | other | $5 | $5 | $5 | 1 |
| Oxygen Per Hour- Subsequent | other | $5 | $5 | $5 | 1 |
| Subseq Aerosol O2/hr | other | $5 | $5 | $5 | 1 |
| Thrombin Time, Fibrinogen Screening Test, Plasma | preventive | $5 | $5 | $5 | 1 |
| Red Blood Cell Antibody Level | other | $5 | $5 | $5 | 1 |
| Injection, Lidocaine Hcl with Epinephrine, 1 Mg | other | $5 | $5 | $5 | 1 |
| Injection, Droperidol, Up to 5 Mg | other | $5 | $5 | $5 | 1 |
| Blocking Needle | other | $5 | $5 | $5 | 1 |
| Subseq Oxy Hood Q Hr | other | $5 | $5 | $5 | 1 |
| Chlorhexidine Gluconate 4% Liq | other | $5 | $5 | $5 | 1 |
| Injection, Pantoprazole Sodium, 40 Mg | other | $6 | $2 | $10 | 2 |
| Catheter, Ureteral | cardiac | $6 | $4 | $7 | 2 |
| Phenylalanine, Pku (amino Acid) Level | other | $6 | $6 | $6 | 1 |
| Tube Vent Armstrong 1.14mm Reg #10 | other | $6 | $6 | $6 | 1 |
| Red Blood Cell Sickling Measurement | other | $6 | $6 | $6 | 2 |
| Juzo Compress Hose Belo Knee 20-30mmhg Ad Iii | other | $6 | $6 | $6 | 1 |
| Juzo Compress Hose Below Knee 20-30mmhg Ad I | other | $6 | $6 | $6 | 1 |
| Juzo Compress Hose Below Knee 20-30mmhg Ad Ii | other | $6 | $6 | $6 | 1 |
| Juzo Compress Hose Below Knee 20-30mmhg Ad IV | other | $6 | $6 | $6 | 1 |
| Juzo Compress Hose Below Knee 20-30mmhg Ad V | other | $6 | $6 | $6 | 1 |
| Dressing Ear Pediatric Glasscock #s | other | $6 | $6 | $6 | 1 |
| Oasis Wound Matrix, Per Square Centimeter | other | $6 | $6 | $6 | 1 |
| Electrode Eletrosurgical OR Electrocautery 5.12 Inch Length 20 Mm Diameter T ... | surgery | $6 | $6 | $6 | 1 |
| Urea Nitrogen Level to Assess Kidney Function, Urine | other | $6 | $6 | $6 | 2 |
| Lap Electrode Ball 5mm Ext | other | $6 | $6 | $6 | 1 |
| Lap Electrode Loop Lrge 20x10mm | other | $6 | $6 | $6 | 1 |
| Permethrin 5% Cream | other | $6 | $6 | $6 | 1 |
| Chiba 19g X 20cm Needle | other | $6 | $6 | $6 | 1 |
| Dressing Aquacel Ag Advantage 3.5x6" #422604 10ea/1bx | other | $6 | $6 | $6 | 1 |
| Tip Cover Accessory Version 12 | other | $6 | $6 | $6 | 1 |
| Spacer Sock-hole in Toe Med #6ss040hv | other | $6 | $6 | $6 | 1 |
| Bacitracin-polymyxin Eye Oint | other | $6 | $6 | $6 | 1 |
| Lap J-hook Elec 5mm X 32mm Plus #60-5274 | other | $6 | $6 | $6 | 1 |
| Abreva 10% Cream | other | $6 | $6 | $6 | 1 |
| Catheter Trocar 8fr Chest Tube 10ea/1cs | cardiac | $6 | $6 | $6 | 1 |
| Cephalexin 250 Mg/5 Ml Susp | other | $6 | $6 | $6 | 1 |
| Application of Hot Wax Bath | other | $6 | $6 | $6 | 2 |
| Knee Support Large Neoprene Hinged #302157blk | other | $6 | $6 | $6 | 1 |
| Rheumatoid Factor Level | other | $6 | $6 | $6 | 2 |
| Clozex Skin Closure 40mm X 50mm Cl1040l | other | $6 | $6 | $6 | 1 |
| Encore 26 Inflation Device M001151062 15 | other | $6 | $6 | $6 | 1 |
| Injection, Tocilizumab, 1 Mg | other | $6 | $6 | $6 | 1 |
| Red Blood Cell Antibody Detection Test, Indirect | other | $6 | $6 | $6 | 1 |
| Triglycerides Level | other | $6 | $6 | $6 | 2 |
| Urine Chloride Level | other | $6 | $6 | $6 | 2 |
| Dressing Mepilex 4x6 Post Op Ag 5/bx 498300 | other | $6 | $6 | $6 | 1 |
| Urine Microalbumin (protein) Level | other | $6 | $6 | $6 | 2 |
| Urine Phosphate Level | other | $6 | $6 | $6 | 2 |
| Suction Canister Omnijug W/cap #5036 | other | $6 | $6 | $6 | 1 |
| Pad Cold Therapy Shoulder Wrap11-1397-9 | other | $6 | $6 | $6 | 1 |
| Catheter Trocar 28fr 10ea/1cs | cardiac | $6 | $6 | $6 | 1 |
| Ultrasound Probe Cover Gel #610-833 12ea/1bx | imaging | $6 | $6 | $6 | 1 |
| Albuterol Hfa 90 Mcg Inhaler | other | $6 | $6 | $6 | 1 |
| Albuterol Sulfate Hfa 108 (90 Base) Mcg/act in Aers | other | $6 | $6 | $6 | 1 |
| Smear for Infectious Agents | other | $6 | $6 | $6 | 2 |
| All Potassium Hydroxide (koh) Preparations | other | $6 | $6 | $6 | 1 |
| Cast Supplies, Long Arm Cast, Adult (11 Years +), Fiberglass | other | $6 | $6 | $6 | 1 |
| Cast Supplies, Long Arm Splint, Adult (11 Years +), Plaster | other | $6 | $6 | $6 | 1 |
| Clozex Skin Closure 50mm X 50mm Cl1050l | other | $6 | $6 | $6 | 1 |
| Trocar 21g X 15cm | other | $6 | $6 | $6 | 1 |
| Tube Vent Sheehy #10-26145 Implant | surgery | $6 | $6 | $6 | 1 |
| Chemet 100 Mg Capsule | other | $6 | $6 | $6 | 1 |
| Vas-q Ligation Clip Adler #an2232 14ea/bx | other | $6 | $6 | $6 | 1 |
| Walker Folding - Guardianmust Order By Case/4each | other | $6 | $6 | $6 | 1 |
| Endo Close Trocar Site Closure Device 173022 12ea/case | other | $6 | $6 | $6 | 1 |
| Prosthetic Shrinker, Below Knee, Each | other | $6 | $6 | $6 | 1 |
| Sps 15 Gm/60 Ml Suspension | other | $6 | $6 | $6 | 1 |
| Clindamycin Ph 1% Solution | other | $6 | $6 | $6 | 1 |
| Prevena Plus 150ml Canister #pre4095us | other | $6 | $6 | $6 | 1 |
| Pledget Oval 4.5 X 6 Soft 10 Pk #vpg56se | other | $6 | $6 | $6 | 1 |
| Vacuum Birth Cup 60mm/tender Touch 10ea/1bx | other | $6 | $6 | $6 | 1 |
| Vacuum Birth Cup 65mm/tender Touch 10ea/1bx | other | $6 | $6 | $6 | 1 |
| Epidural Tray Perifix Tuohy 17ga X 3.5 Drape/syringe Latex Free Sterile #3320... | other | $6 | $6 | $6 | 1 |
| Forceps Magill Adult #792-9-3018 | other | $6 | $6 | $6 | 1 |
| Tube Vent Otologic 1.14mm Paprella Vt-0300-01 10ea/bx | other | $6 | $6 | $6 | 1 |
| Urine Calcium Level | other | $6 | $6 | $6 | 2 |
| Lactate Dehydrogenase (enzyme) Level | other | $6 | $6 | $6 | 2 |
| Spacer Sock-hole in Toe Wide #6ss045hv | other | $6 | $6 | $6 | 1 |
| Cromolyn Sodium 4 % Op Soln | other | $6 | $6 | $6 | 1 |
| Tube Vent Ultrasil #70241071 Implant | surgery | $6 | $6 | $6 | 1 |
| Lap Electrode L-hook #04-500mb | other | $6 | $6 | $6 | 1 |
| Co-set Cold Injection System 10ea/1cs | other | $6 | $6 | $6 | 1 |
| Famotidine 40 Mg/5 Ml Susp | other | $6 | $6 | $6 | 1 |
| Healon Pro 0.55ml 10340011 | other | $6 | $6 | $6 | 1 |
| Influenza Virus Vaccine, Split Virus, When Administered to Individuals 3 Year... | preventive | $6 | $6 | $6 | 1 |
| Kit Pacing Stylet 0.014in X 52cm Blue Knob Stainless Steel Ball Tip Straight ... | other | $6 | $6 | $6 | 1 |
| Kit Stylet L52cm Dia0.014in Stainless Steel Blue Knob Extended Taper Ball Tip... | other | $6 | $6 | $6 | 1 |
| Kit Stylet Lead Acc #6056m | other | $6 | $6 | $6 | 1 |
| Stylet Kit #6094 | other | $6 | $6 | $6 | 1 |
| Stylet Kit 0.014in X 58cm #6082 | other | $6 | $6 | $6 | 1 |
| Catheter Filiform with Spiral Tip 4f Sterile 10ea/bx #343104 | cardiac | $6 | $6 | $6 | 1 |
| Shield Corneal W/ Suction Cups Med #ssa-02 | other | $6 | $6 | $6 | 1 |
| Suction Wand Intracardiac Rigid #su | cardiac | $6 | $6 | $6 | 1 |
| Quikclot Hemostatic #467z 10/bx | other | $6 | $6 | $6 | 1 |
| Econazole Nitrate 1 % Ex Crea | other | $6 | $6 | $6 | 1 |
| Cannula Aortic Root 14ga Reg Tip #20014 | other | $6 | $6 | $6 | 1 |
| Knife Straight Cresent | other | $6 | $6 | $6 | 1 |
| Carrying Bag for Walker #6447 | other | $6 | $6 | $6 | 1 |
| Pin Fixation L65mm Speed for Journey Ii Bcs Knee System 3ea/bx #74013480 | other | $6 | $6 | $6 | 1 |
| Sling Sara Disposable #mfa3000 10/bx | other | $6 | $6 | $6 | 1 |
| Injection, Fomepizole, 15 Mg | other | $6 | $6 | $6 | 1 |
| Ertapenem (invanz) 1 Gm / 50 Ml Ns Mini-bag Plus - Compounded | other | $6 | $6 | $6 | 1 |
| Tray Laceration Disp 12ea/1cs | other | $6 | $6 | $6 | 1 |
| Amerigel Wound Dressing Gel | other | $6 | $6 | $6 | 1 |
| Screening Test for Compatible Blood Unit, Using Reagent Serum | preventive | $6 | $6 | $6 | 2 |
| Copilot #1003330 | other | $6 | $6 | $6 | 1 |
| CPAP Mask Full Face Medium Disp #niv040m | other | $6 | $6 | $6 | 1 |
| Crutches Underarm, Wood, Adjustable OR Fixed, Pair, with Pads, Tips and Handg... | other | $6 | $6 | $6 | 1 |
| Laryngoscope Blade - Gvl 1 Stat #0270 | other | $6 | $6 | $6 | 1 |
| Laryngoscope Blade - Gvl 2 Stat #0270 | other | $6 | $6 | $6 | 1 |
| Splint, Prefabricated, Wrist OR Ankle | other | $6 | $6 | $6 | 1 |
| Heart Left Vent Catheter 20fr | cardiac | $6 | $6 | $6 | 1 |
| Splint Nasal Airway Doyle Ii | other | $6 | $6 | $6 | 1 |
| Drive Walker Basket #563285 | other | $6 | $6 | $6 | 1 |
| Oseltamivir 6 Mg/ml Suspension | other | $6 | $6 | $6 | 1 |
| CPAP Mask Full Face Small Disp #niv040s | other | $6 | $6 | $6 | 1 |
| Complete Blood Cell Count (red Cells, White Blood Cell, Platelets), Automated... | other | $6 | $6 | $6 | 2 |
| Iron Level | other | $6 | $6 | $6 | 2 |
| Thyroid Hormone Evaluation | other | $6 | $6 | $6 | 2 |
| White Blood Cell Count | other | $6 | $6 | $6 | 1 |
| Amylase (enzyme) Level | other | $6 | $6 | $6 | 2 |
| Benzocaine 20 % Gel | other | $6 | $6 | $6 | 1 |
| Body Fluid Cell Count with Cell Identification | other | $6 | $6 | $6 | 1 |
| Nasal Smear for Eosinophils | other | $6 | $6 | $6 | 1 |
| Parenteral Nutrition Solution: Carbohydrates (dextrose), 50% OR Less (500 Ml ... | other | $6 | $6 | $6 | 1 |
| Ocycodone Hcl 5mg/5 Ml Soln | other | $6 | $6 | $6 | 1 |
| Special Stain for Inclusion Bodies OR Parasites | other | $6 | $6 | $6 | 1 |
| Injection, Prochlorperazine, Up to 10 Mg | other | $6 | $6 | $6 | 1 |
| G6pd (enzyme) Screening Test | preventive | $6 | $6 | $6 | 1 |
| Rheumatoid Factor Analysis | other | $6 | $6 | $6 | 1 |
| Hypertonic Saline Solution, 1 Ml | other | $6 | $6 | $6 | 1 |
| Lidocaine Jell Ur | other | $6 | $6 | $6 | 1 |
| Chlorpromazine Hydrochloride, 5 Mg, Oral, Fda Approved Prescription Anti-emet... | other | $6 | $6 | $6 | 1 |
| Therapy Procedure for Nutrition Management with Group, Each 30 Minutes | other | $6 | $6 | $6 | 1 |
| Measurement of Range of Motion in Arm, Leg OR Each Spine Section | other | $6 | $6 | $6 | 1 |
| Injection, Cefazolin Sodium, 500 Mg | other | $7 | $1 | $13 | 2 |
| Diclofenac Sodium 1% Gel | other | $7 | $3 | $11 | 2 |
| Diag Catheter 5fr Sim 1 #g08584 | cardiac | $7 | $7 | $7 | 1 |
| Injection, Onabotulinumtoxina, 1 Unit | other | $7 | $7 | $7 | 1 |
| Semen Analysis; Presence And/or Motility of Sperm Excluding Huhner | other | $7 | $7 | $7 | 1 |
| Creatine Kinase (cardiac Enzyme) Level, Total | cardiac | $7 | $7 | $7 | 2 |
| Trimming of Dystrophic Nails, Any Number | other | $7 | $7 | $7 | 1 |
| Promethazine-codeine 6.25-10 Mg/5ml Po Syrp | other | $7 | $7 | $7 | 1 |
| Promethazine-codeine Solution | other | $7 | $7 | $7 | 1 |
| Ligating Clip Lrg Vesolock #61114v | other | $7 | $7 | $7 | 1 |
| Knife V-lance Ophthalmic | other | $7 | $7 | $7 | 1 |
| Arch Support Xlarge #mdy10540 | other | $7 | $7 | $7 | 1 |
| Ketoconazole 2 % Ex Crea | other | $7 | $7 | $7 | 1 |
| Gelfoam Sponge Sz 100 8cmx12.5cm Sterile | other | $7 | $7 | $7 | 1 |
| Punch Aortic Rotating #rcb40 Sz 4.0 | other | $7 | $7 | $7 | 1 |
| Punch Aortic Rotating #rcb45 Sz 4.5 | other | $7 | $7 | $7 | 1 |
| Electrode Defib Pads Quik-combo Adult 1pk/1ea | other | $7 | $7 | $7 | 1 |
| Scalpel Micro Feather 0.4mm | other | $7 | $7 | $7 | 1 |
| Silver Sulfadiazine 1% Cream | other | $7 | $7 | $7 | 1 |
| Blood Osmolality (concentration) Measurement | other | $7 | $7 | $7 | 2 |
| Lithium Level | other | $7 | $7 | $7 | 2 |
| Screening Test for Pathogenic Organisms | preventive | $7 | $7 | $7 | 2 |
| Spinal/single Wall 20g X 15cm Needle | other | $7 | $7 | $7 | 1 |
| Spinal/single Wall 22g X 15cm Needle | other | $7 | $7 | $7 | 1 |
| Cannula Twist in 7x7mm Fully Threaded 5ea/1bx | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 5.75mmx7cm | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 6mm X 9cm | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 7mm X 7 Partial Thread | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 7mm X 7cm | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 8.25mm X 7cm | other | $7 | $7 | $7 | 1 |
| Cannula Twist-in 8.25mm X 9cm #ar | other | $7 | $7 | $7 | 1 |
| Capella Coaxial Micro-introducer Kit Nitinol with Gold/tungsten Tip 5f Sheath... | other | $7 | $7 | $7 | 1 |
| Cast Supplies, Long Arm Splint, Adult (11 Years +), Fiberglass | other | $7 | $7 | $7 | 1 |
| Cast Supplies, Short Leg Splint, Adult (11 Years +), Fiberglass | other | $7 | $7 | $7 | 1 |
| Finger Orthosis, Proximal Interphalangeal (pip)/distal Interphalangeal (dip),... | other | $7 | $7 | $7 | 1 |
| Infusion, Albumin (human), 25%, 20 Ml | surgery | $7 | $7 | $7 | 1 |
| Large Neurostimulator Fixation Belt #fp9000l | other | $7 | $7 | $7 | 1 |
| Ocucoat 1ml 6/bx #cc065s | other | $7 | $7 | $7 | 1 |
| Patient Programmer Case #casea10e | other | $7 | $7 | $7 | 1 |
| Physician Review, Interpretation, and Patient Management of Home Inr Testing ... | other | $7 | $7 | $7 | 1 |
| Preparation of Special Reports Beyond What Is Found in the Medical Record | other | $7 | $7 | $7 | 1 |
| Purastat Adapter 10ea/bx#001 | other | $7 | $7 | $7 | 1 |
| Rotation Tool Kit #6056 for Leads | other | $7 | $7 | $7 | 1 |
| Splint Supplies, Miscellaneous | other | $7 | $7 | $7 | 1 |
| Surgical Trays | surgery | $7 | $7 | $7 | 1 |
| Uroseal Adjustable Endoscopic Valve 5ea/bx #bx00913410 | other | $7 | $7 | $7 | 1 |
| Wrench Hex 7.6cm #sc-4276 Sc | other | $7 | $7 | $7 | 1 |
| Adapter Tuohy-borst #g18813 | other | $7 | $7 | $7 | 1 |
| Cath Soft Simplastic 20fr 3-way 30cc #570620 | other | $7 | $7 | $7 | 1 |
| Cath Soft Simplastic 24fr 3way 30cc #570624 | other | $7 | $7 | $7 | 1 |
| Sensica Uo Pt Ring ICU Sspk1025 25ea/1bx | other | $7 | $7 | $7 | 1 |
| Sensica Uo Pt Ring OR Sror1025 25ea/1bx | other | $7 | $7 | $7 | 1 |
| Vent Tube Venturi Reuter Bobbin #1070032 | other | $7 | $7 | $7 | 1 |
| Concentration of Specimen for Infectious Agents | lab | $7 | $6 | $7 | 2 |
| Terconazole 80 Mg Suppository | other | $7 | $7 | $7 | 1 |
| Aztreonam 1 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $7 | $7 | $7 | 1 |
| Magnesium Level | other | $7 | $7 | $7 | 2 |
| Pin High Strength #9744 5ea/1bx | other | $7 | $7 | $7 | 1 |
| Pin High Strength 3/32 X 9" 5ea/bx #9742 | other | $7 | $7 | $7 | 1 |
| Fischer Cone Biopsy Excisor Medium Extended | lab | $7 | $7 | $7 | 1 |
| Injection, Bortezomib, 0.1 Mg | other | $7 | $7 | $7 | 1 |
| Cdm9801 10-0 Nylon 2xm1-160 (corneal Transpl | other | $7 | $7 | $7 | 1 |
| Injection, Remdesivir, 1 Mg | other | $7 | $7 | $7 | 2 |
| Eye-stream Solution | other | $7 | $7 | $7 | 1 |
| Splint Nasal Reuter #15 | other | $7 | $7 | $7 | 1 |
| Hyaluronan OR Derivative, Durolane, for Intra-articular Injection, 1 Mg | other | $7 | $7 | $7 | 1 |
| Tubing Irrigation Set #031229-10 10/pk | other | $7 | $7 | $7 | 1 |
| Cannula Coronary Soft Tip Modified | cardiac | $7 | $7 | $7 | 1 |
| Lidocaine Hcl 4% Solution | other | $7 | $7 | $7 | 1 |
| M654g #6 Sternal Wire 4wires/pk 1pk=1ea | other | $7 | $7 | $7 | 1 |
| Urine Osmolality (concentration) Measurement | other | $7 | $7 | $7 | 2 |
| Haloperidol Lac 2 Mg/ml Conc | other | $7 | $7 | $7 | 1 |
| Test of Car Seat OR Bed (1 Year OR Younger), Each Additional 30 Minutes | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Left Small Plus | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Left-large Plus | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Left-medium Plus | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Right Large Plus | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Right Small Plus | other | $7 | $7 | $7 | 1 |
| Comfort Cool Thumb Cmc Right-medium Plus | other | $7 | $7 | $7 | 1 |
| Novolog 100 Unit/ml Flexpen | other | $7 | $7 | $7 | 1 |
| Thyroxine (thyroid Chemical), Total | other | $7 | $7 | $7 | 2 |
| CPAP Mask Full Face Large Disp #niv040l | other | $7 | $7 | $7 | 1 |
| Coagulation Function Analysis, Agglutination Slide, Semiquantitative | other | $7 | $7 | $7 | 1 |
| Lipase (fat Enzyme) Level | other | $7 | $7 | $7 | 2 |
| Neupro 2 Mg/24 Hr Patch | other | $7 | $7 | $7 | 1 |
| Adapter Connecting Ureteral Cath #uca5 | other | $7 | $7 | $7 | 1 |
| Guidewire .045" Trocar Thrded #ar-8737 | other | $7 | $7 | $7 | 1 |
| Insert Pad 61mm Surgical 15/bx | surgery | $7 | $7 | $7 | 1 |
| Insert Pad 86mm/surg Clamp Fog | other | $7 | $7 | $7 | 1 |
| Insert Pad Sz 5 10/bx #a0c04 | other | $7 | $7 | $7 | 1 |
| Insertion Tray with Drainage Bag with Indwelling Catheter, Foley Type, Two-wa... | cardiac | $7 | $7 | $7 | 1 |
| Insertion Tray without Drainage Bag with Indwelling Catheter, Foley Type, Two... | cardiac | $7 | $7 | $7 | 1 |
| Test for Allergy Using Allergenic Extract Injected Into Skin with Delayed Rea... | other | $7 | $7 | $7 | 1 |
| Fentanyl 100 Mcg/hr Patch | other | $7 | $7 | $7 | 1 |
| Pleur-evac Chest Drain System Single Collection Chamber 2500ml 16l/min Pleura... | other | $7 | $7 | $7 | 1 |
| Measurement of Antibody to Infectious Organism | other | $7 | $7 | $7 | 2 |
| Mini Enteral Extension Set Right Angle Connector with Y-port Adapter Amt Mini... | other | $7 | $7 | $7 | 1 |
| Electrode Loop 15 X 12mm Electrosurgical OR Electrocautery 5.12 Inch Length 1... | surgery | $7 | $7 | $7 | 1 |
| Moxifloxacin 0.5% Eye Drops | other | $7 | $7 | $7 | 1 |
| CPAP Mask - Lge #73-1019480ea | other | $7 | $7 | $7 | 1 |
| CPAP Mask - Med #73-1019479ea | other | $7 | $7 | $7 | 1 |
| CPAP Mask - Small #73-1019478ea | other | $7 | $7 | $7 | 1 |
| Hydrogel Dressing, Wound Filler, Gel, Per Fluid Ounce | other | $7 | $7 | $7 | 1 |
| Ultrasound of Heart Blood Flow, Valves and Chambers, Follow-up | imaging | $7 | $7 | $7 | 1 |
| Tube Ultrasil Modified T-tube #70241072 | other | $7 | $7 | $7 | 1 |
| Tube Vent Ultrasil Duravent #70241075 Implant | surgery | $7 | $7 | $7 | 1 |
| Ball Electrode 3mm Vaginal #e1563 | other | $7 | $7 | $7 | 1 |
| Electrode Loop 20x15mm Vag #e1562 | other | $7 | $7 | $7 | 1 |
| Sleeve Scd Thigh Med Comfort #74012- 5pr/1cs | other | $7 | $7 | $7 | 1 |
| Zinc Oxide 20 % Ex Oint | other | $7 | $7 | $7 | 1 |
| Tray Jamshidi Bone Marrow Latex Free 1ea | other | $7 | $7 | $7 | 1 |
| Dressing Mepilex 4x10 Post Op Ag 5/bx 498450 | other | $7 | $7 | $7 | 1 |
| Kirschner Wire .045 Threaded #47-0262 | other | $7 | $7 | $7 | 1 |
| Lead Cap 4033a | other | $7 | $7 | $7 | 1 |
| Valve Hemostasis #hva | other | $7 | $7 | $7 | 1 |
| Wet Mounts, Including Preparations of Vaginal, Cervical OR Skin Specimens | lab | $7 | $7 | $7 | 1 |
| Cannula Soft Tip 25g | other | $7 | $7 | $7 | 1 |
| Glutamyltransferase (liver Enzyme) Level | other | $7 | $7 | $7 | 2 |
| Fluocinonide 0.05% Cream | other | $7 | $7 | $7 | 1 |
| Diag Catheter 6fr Multipack #cp0255 5/bx | cardiac | $7 | $7 | $7 | 1 |
| Injection, Aripiprazole (abilify Maintena), 1 Mg | other | $7 | $7 | $7 | 1 |
| Interventional Kit K05-02131c | other | $7 | $7 | $7 | 1 |
| Measurement for Strep Antibody | other | $7 | $7 | $7 | 2 |
| Antimicrobial Study, Mycobacteria | other | $7 | $7 | $7 | 1 |
| Crystal Identification From Tissue OR Body Fluid | other | $7 | $7 | $7 | 2 |
| Medical Nutrition Therapy; Reassessment and Subsequent Intervention(s) Follow... | other | $7 | $7 | $7 | 1 |
| Endovive Gastrostomy Tube with Enfit 24fr Straight5 Ea / Bx M00509941 | other | $7 | $7 | $7 | 1 |
| G Tube 18fr Straight W/enfit M00509911 Bx/5ea | other | $7 | $7 | $7 | 1 |
| G Tube 20fr Straight W/enfit M00509921 Bx/5ea | other | $7 | $7 | $7 | 1 |
| Gastrostomy Tube Repl 16fr Straight M00582060 | other | $7 | $7 | $7 | 1 |
| Gastrostomy Tube Repl 20fr Std Balloon Straig | other | $7 | $7 | $7 | 1 |
| Gastrostomy Tube Repl 24fr Std Balloon Straig | other | $7 | $7 | $7 | 1 |
| Gastrostomy/jejunostomy Tube, Standard, Any Material, Any Type, Each | other | $7 | $7 | $7 | 1 |
| Proparacaine 0.5% Eye Drops | other | $7 | $7 | $7 | 1 |
| Antivenin (latrodectus) Vial | other | $7 | $7 | $7 | 1 |
| Ball Electrode 5mm Vaginal #e1564 | other | $7 | $7 | $7 | 1 |
| Vardenafil Hcl 20 Mg Po Tabs | other | $7 | $7 | $7 | 1 |
| Slitter Universal #6230uni Medtronic | other | $7 | $7 | $7 | 1 |
| Logicut Disp Lap Coag Mp Scissor #120 | other | $7 | $7 | $7 | 1 |
| Exam of Ear Using a Microscope | other | $7 | $7 | $7 | 1 |
| Office OR Other Outpatient Visit for the Evaluation and Management of Establi... | other | $7 | $7 | $7 | 1 |
| Outpatient Heart Rehabilitation, Qualified Health Care Professional Services | cardiac | $7 | $7 | $7 | 1 |
| Red Blood Cell Fragility Measurement, Unincubated | other | $7 | $7 | $7 | 1 |
| Tretinoin 0.025% Cream | other | $7 | $7 | $7 | 1 |
| Wire Pass Drill #1608-002 | other | $7 | $7 | $7 | 1 |
| Electrode Defib Pediatric Quick Combo 1ea | other | $7 | $7 | $7 | 1 |
| Evaluation of Antimicrobial Drug | other | $7 | $7 | $7 | 2 |
| Knee Pad-polar Wrap On Regular #04700 | other | $7 | $7 | $7 | 1 |
| Prednisolone Oral, Per 5 Mg | other | $7 | $1 | $12 | 2 |
| Injection, Heparin Sodium, (heparin Lock Flush), Per 10 Units | other | $7 | $1 | $13 | 2 |
| Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg | other | $7 | $1 | $13 | 2 |
| Injection, Bupivicaine, Not Otherwise Specified, 0.5 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Cefoxitin Sodium, 1 Gm | other | $7 | $7 | $7 | 1 |
| Injection, Ceftriaxone Sodium, Per 250 Mg | other | $7 | $7 | $7 | 1 |
| Injection, Heparin Sodium (pfizer), Not Therapeutically Equivalent to J1644, ... | other | $7 | $7 | $7 | 1 |
| Complete Blood Count (CBC) | lab | $8 | $5 | $239 | 15 |
| Hdl Cholesterol Level | other | $8 | $7 | $8 | 2 |
| Nuclear Medicine Study of Remaining Urine in Bladder | imaging | $8 | $8 | $8 | 1 |
| Gonadotropin (reproductive Hormone) Analysis | other | $8 | $8 | $8 | 2 |
| Pacemaker Cable Adapter #adap-2000 | cardiac | $8 | $8 | $8 | 1 |
| Anesthesia for Removal of Blood Clot From Upper Arm OR Elbow Artery | surgery | $8 | $8 | $8 | 1 |
| Walker Extra Duty Folding Guardian 1ea | other | $8 | $8 | $8 | 1 |
| Tunnelers-sheaths Disp On Q 11ga X 12" 5/bx | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Left-large | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Left-medium | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Left-small | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Left-xlarge | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Left-xsmall | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Rt-large | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Rt-medium | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Rt-small | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Rt-xlarge | other | $8 | $8 | $8 | 1 |
| Roylan Wr&th Spica Rt-xsmall | other | $8 | $8 | $8 | 1 |
| Lap Electrode L Hook 5 X 27mm | other | $8 | $8 | $8 | 1 |
| Lap Spatula Tip Solid Shaft #60-5159 | other | $8 | $8 | $8 | 1 |
| Dressing Aquacel Ag Advantage 3.5 X 10" #422605 10ea/bx | other | $8 | $8 | $8 | 1 |
| Fungal Culture (mold OR Yeast) of Skin, Hair, OR Nail | lab | $8 | $8 | $8 | 2 |
| Tube Trach 4.0 Ped Cuffless | other | $8 | $8 | $8 | 1 |
| Tube Trach Ped 5.0 Cuffless | other | $8 | $8 | $8 | 1 |
| Tube Trach Ped 5.5 Cuffless | other | $8 | $8 | $8 | 1 |
| Blood Typing Rh Phenotyping | other | $8 | $8 | $8 | 1 |
| Cefprozil 250 Mg/5ml Po Susr | other | $8 | $8 | $8 | 1 |
| Catheter Phillips Follower 8fr Lf 10ea/bx | cardiac | $8 | $8 | $8 | 1 |
| Closure Pilot Guide 15mm #pg-15s 5ea/bx | other | $8 | $8 | $8 | 1 |
| Cyclomydril Eye Drops | other | $8 | $8 | $8 | 1 |
| Cardioplegia Table Line #029463000 | other | $8 | $8 | $8 | 1 |
| Interpulse Handpiece W/coaxial Highflo | other | $8 | $8 | $8 | 1 |
| Short Cam Walker Lg #w0900blk | other | $8 | $8 | $8 | 1 |
| Short Cam Walker Med #w0700blk | other | $8 | $8 | $8 | 1 |
| Short Cam Walker Sm #w0500blk | other | $8 | $8 | $8 | 1 |
| Veltassa 16.8 Gm Powder Packet | other | $8 | $8 | $8 | 1 |
| Veltassa 8.4 Gm Powder Packet | other | $8 | $8 | $8 | 1 |
| Catheter Phillips Follower 20fr Lf 10ea/bx | cardiac | $8 | $8 | $8 | 1 |
| Lymphedema Foam 1/2" #cr-2-c 5ea/1cs | other | $8 | $8 | $8 | 1 |
| Injection, Elotuzumab, 1 Mg | other | $8 | $8 | $8 | 1 |
| Electrode Defib Preconnect Quik-combo 1st/1ea | other | $8 | $8 | $8 | 1 |
| Mini Access Kit Stiff #s-mak501n | other | $8 | $8 | $8 | 1 |
| Rybelsus 14 Mg Tablet | other | $8 | $8 | $8 | 1 |
| Rybelsus 3 Mg Tablet | other | $8 | $8 | $8 | 1 |
| Rybelsus 7 Mg Tablet | other | $8 | $8 | $8 | 1 |
| Semaglutide 14 Mg Po Tabs | other | $8 | $8 | $8 | 1 |
| Semaglutide 7 Mg Po Tabs | other | $8 | $8 | $8 | 1 |
| Levemir Flexpen 100 Unit/ml | other | $8 | $8 | $8 | 1 |
| Catheter H/s 5fr #ua61-5005 10/bx | cardiac | $8 | $8 | $8 | 1 |
| Hyaluronan OR Derivative, Synvisc OR Synvisc-one, for Intra-articular Injecti... | other | $8 | $8 | $8 | 1 |
| Tray Cath Surestep Urine Meter 14fr A319414am | other | $8 | $8 | $8 | 1 |
| Tray Cath Surestep Urine Meter 18fr A319418am | other | $8 | $8 | $8 | 1 |
| Vision Supply, Accessory And/or Service Component of Another Hcpcs Vision Code | other | $8 | $8 | $8 | 1 |
| Cable PSA Disp #6651 | other | $8 | $8 | $8 | 1 |
| Cane, Includes Canes of All Materials, Adjustable OR Fixed, with Tip | other | $8 | $8 | $8 | 1 |
| Cast Supplies, Gauntlet Cast (includes Lower Forearm and Hand), Adult (11 Yea... | other | $8 | $8 | $8 | 1 |
| Diag Catheter 6fr Jacky Radial 110cm #40 | cardiac | $8 | $8 | $8 | 1 |
| Diag Catheter 6fr Radial Tig 110cm #40 | cardiac | $8 | $8 | $8 | 1 |
| Diag Catheter 6fr Radial Tig 4.0 #40 | cardiac | $8 | $8 | $8 | 1 |
| Electrical Stimulation, (unattended), to One OR More Areas, for Chronic Stage... | other | $8 | $8 | $8 | 1 |
| Handling And/or Conveyance of Specimen for Transfer From Physician Office to ... | lab | $8 | $8 | $8 | 1 |
| Indwelling Catheter; Specialty Type, (e.g., Coude, Mushroom, Wing, Etc.), Each | cardiac | $8 | $8 | $8 | 1 |
| Iodine I-131 Sodium Iodide, Diagnostic, Per Microcurie | other | $8 | $8 | $8 | 1 |
| Plastazote Sandal, Each | other | $8 | $8 | $8 | 1 |
| Professional Service for Single Injection of Allergen | other | $8 | $8 | $8 | 1 |
| Screening for Visual Sharpness | preventive | $8 | $8 | $8 | 1 |
| Smoke Evac Pencil Push Button #0703-046 | other | $8 | $8 | $8 | 1 |
| Cannula Aortic Root W/flow Guard 10/bx | other | $8 | $8 | $8 | 1 |
| Gammaglobulin (immune System Protein) Measurement, Immunoglobulin Subclasses | other | $8 | $8 | $8 | 1 |
| Injection, Vinorelbine Tartrate, 10 Mg | other | $8 | $8 | $8 | 1 |
| Algicell 4 X 4 #88044 4ea/1cs | other | $8 | $8 | $8 | 1 |
| Measurement of Cold Agglutinin (protein) to Detect Infection OR Disease | other | $8 | $8 | $8 | 1 |
| Bacterial Colony Count, Urine | other | $8 | $8 | $8 | 1 |
| Urine Culture | lab | $8 | $8 | $8 | 2 |
| Catheter Phillips Follower 14fr Lf 10ea/bx | cardiac | $8 | $8 | $8 | 1 |
| Knife Orthopedic Hook Disp | other | $8 | $8 | $8 | 1 |
| Dressing Ear Adult Glasscock #s | other | $8 | $8 | $8 | 1 |
| Ketone Bodies Analysis, Quantitative | other | $8 | $8 | $8 | 2 |
| Short Can Walker Xl #w1100blk | other | $8 | $8 | $8 | 1 |
| Dressing Mepilex 4x12 Post Op Ag 5/bx 498600 | other | $8 | $8 | $8 | 1 |
| Transducer Trifucated Color Coded 10ea/1cs | other | $8 | $8 | $8 | 1 |
| Administration of Vaccine OR Toxoid Component with Counseling (18 Years OR Yo... | therapy | $8 | $8 | $8 | 1 |
| Administration of Vaccine, Each Additional Vaccine | preventive | $8 | $8 | $8 | 1 |
| Cannula 30ga 7mm | other | $8 | $8 | $8 | 1 |
| Cast Supplies, Long Arm Cast, Pediatric (0-10 Years), Plaster | other | $8 | $8 | $8 | 1 |
| Cast Supplies, Short Arm Splint, Adult (11 Years +), Plaster | other | $8 | $8 | $8 | 1 |
| Clozex Skin Closure 60mm X 50mm Cl1060l | other | $8 | $8 | $8 | 1 |
| Test for Ability to Detect and Repeat Spoken Words | other | $8 | $8 | $8 | 1 |
| Wound Debridement Handpiece Vericare 6ea/1pk | other | $8 | $8 | $8 | 1 |
| Wrench Kit #5873w | other | $8 | $8 | $8 | 1 |
| Electronic Assessment of Bladder Emptying | other | $8 | $8 | $8 | 1 |
| Pain Ease Mist Spray | other | $8 | $8 | $8 | 1 |
| Lead Pacing Temp Myocardial #6500 | other | $8 | $8 | $8 | 1 |
| Vent Tube Venturi Reuter Bobbin #1070031 | other | $8 | $8 | $8 | 1 |
| Fluocinonide 0.05% Solution | other | $8 | $8 | $8 | 1 |
| Tubes Micron Infant Titanium #145221 | other | $8 | $8 | $8 | 1 |
| Boot Prevalon Heel Protector I #7305 8/cs | other | $8 | $8 | $8 | 1 |
| Extended Exam Involving Color Vision Testing | other | $8 | $8 | $8 | 1 |
| Kwire Marked 0.9mm L70mm #agk09070m | other | $8 | $8 | $8 | 1 |
| Obturator Bladeless 8mm #470359 Intuitive Sur | other | $8 | $8 | $8 | 1 |
| Catheter Umbilical 3.5 Double Lumen 5ea/bx | cardiac | $8 | $8 | $8 | 1 |
| Catheter Umbilical 5.0 Double Lumen 5ea/bx | cardiac | $8 | $8 | $8 | 1 |
| Vac Pad Small Black 10ea/1ca | other | $8 | $8 | $8 | 1 |
| Irrigation Sys W/cleaning Tip & Suction Tb | other | $8 | $8 | $8 | 1 |
| Gastrostomy Tube Endovibe 20fr Rt Angle | other | $8 | $8 | $8 | 1 |
| Gastrostomy Tube Repl 24fr Rt Angle | other | $8 | $8 | $8 | 1 |
| Test to Assess Middle Ear Function | other | $8 | $8 | $8 | 1 |
| Triamcinolone 0.1% Ointment | other | $8 | $8 | $8 | 1 |
| Triamcinolone Acetonide 0.1 % Ex Oint | other | $8 | $8 | $8 | 1 |
| Tube Vent .76mm Tiny Tylan Titanium Lf | other | $8 | $8 | $8 | 1 |
| G6pd (enzyme) Level | other | $8 | $5 | $10 | 2 |
| Injection, Ciprofloxacin for Intravenous Infusion, 200 Mg | surgery | $8 | $3 | $13 | 2 |
| Injection, Diphenhydramine Hcl, Up to 50 Mg | other | $8 | $3 | $13 | 2 |
| Injection, Lorazepam, 2 Mg | other | $8 | $2 | $13 | 2 |
| Injection, Meperidine Hydrochloride, Per 100 Mg | other | $8 | $2 | $13 | 2 |
| Injection, Metoclopramide Hcl, Up to 10 Mg | other | $8 | $3 | $13 | 2 |
| Injection, Midazolam Hydrochloride, Per 1 Mg | other | $8 | $3 | $13 | 2 |
| Injection, Phenytoin Sodium, Per 50 Mg | other | $8 | $2 | $13 | 2 |
| Injection, Sterile Cefuroxime Sodium, Per 750 Mg | other | $8 | $3 | $13 | 2 |
| Albuterol, Up to 2.5 Mg and Ipratropium Bromide, Up to 0.5 Mg, Fda-approved F... | other | $8 | $1 | $15 | 2 |
| Analysis for Antibody to Brucella | other | $8 | $8 | $8 | 1 |
| Detection Test By Immunoassay Technique for Histoplasma Capsulatum | other | $8 | $8 | $8 | 1 |
| Phosphatase (enzyme) Measurement, Acid, Total | other | $8 | $8 | $8 | 1 |
| Cholinesterase (enzyme) Level, to Test for Exposure to Chemical OR Liver Disease | other | $8 | $8 | $8 | 1 |
| Thromboplastin Inhibition (circulating Anticoagulant) Measurement | other | $8 | $8 | $8 | 1 |
| Fetal Hemoglobin Analysis | other | $8 | $8 | $8 | 1 |
| Measurement of Cold Agglutinin (protein) to Screen for Infection OR Disease | other | $8 | $8 | $8 | 1 |
| Chemical Analysis Using Spectrophotometry | other | $8 | $8 | $8 | 1 |
| Methemoglobin (hemoglobin) Analysis, Quantitative | other | $8 | $8 | $8 | 1 |
| Tubersol 5t Unit/0.1 Ml Vial | other | $8 | $8 | $8 | 1 |
| Transfusion Medicine Procedures | surgery | $8 | $8 | $8 | 1 |
| Fungal Culture | lab | $8 | $8 | $8 | 1 |
| Urine Porphobilinogen (metabolism Substance) Level | other | $8 | $8 | $8 | 1 |
| Administration of Nasal OR Oral Vaccine, Each Additional Vaccine | preventive | $9 | $9 | $9 | 1 |
| Button Cannula 10mm Idx4 #ar-6592-10 | other | $9 | $9 | $9 | 1 |
| Button Cannula 10mm Idx5 #ar-6592-10 | other | $9 | $9 | $9 | 1 |
| Calcium Gluconate (antidote) 2.5 % Ex Gel | other | $9 | $9 | $9 | 1 |
| Cannula Passport Button 8 X 3cm 5ea/bx | other | $9 | $9 | $9 | 1 |
| Cannula Passport Button 8 X 4cm 5ea/bx | other | $9 | $9 | $9 | 1 |
| Cannula Passport Button 8x2cm Ar-6592-08 | other | $9 | $9 | $9 | 1 |
| Lacosamide 10 Mg/ml Solution | other | $9 | $9 | $9 | 1 |
| Nepro Carb Steady Liquid | other | $9 | $9 | $9 | 1 |
| Pin Drill Guide 2.4mm 6ea/bx Ar-1250l | other | $9 | $9 | $9 | 1 |
| Skin Test for Tuberculosis | other | $9 | $9 | $9 | 1 |
| Test for Screening Hearing | preventive | $9 | $9 | $9 | 1 |
| Sling Medium #mfa-1000m-m | other | $9 | $9 | $9 | 1 |
| Sling Xl #mf-a1000m-xl | other | $9 | $9 | $9 | 1 |
| Sling Xxlg #mf-a100m-xxlg | other | $9 | $9 | $9 | 1 |
| Pillow Abduction Hip Large Disp #m60-031-l | other | $9 | $9 | $9 | 1 |
| Injection, Epoetin Alfa, (for Non-esrd Use), 1000 Units | other | $9 | $9 | $9 | 2 |
| Hydroxyzine Hcl 10 Mg/5ml Po Syrp | other | $9 | $9 | $9 | 1 |
| Tray Cath Surstep Lf Urin Met 18fr #a319518am | other | $9 | $9 | $9 | 1 |
| Floseal Applicator Curved #ads201815 | other | $9 | $9 | $9 | 1 |
| Spiriva Respimat 2.5 Mcg Inh | other | $9 | $9 | $9 | 1 |
| Stirrup Air Orth Left | other | $9 | $9 | $9 | 1 |
| Stirrup Air Ortho. Right | other | $9 | $9 | $9 | 1 |
| Urine Pregnancy Test | other | $9 | $9 | $28 | 3 |
| Drainage Bag Aspira 1000ml#4992301 5ea/1bx | other | $9 | $9 | $9 | 1 |
| Sleeve 0.9mm Microsmooth -eye | other | $9 | $9 | $9 | 1 |
| Isentress 400 Mg Tablet | other | $9 | $9 | $9 | 1 |
| Wrap Breast Sterile Comp Silverstein #sw001 Minimum Order 24 Each. Order Incr... | other | $9 | $9 | $9 | 1 |
| Ortho Glass 2" X 15 #og-2l1 | other | $9 | $9 | $9 | 1 |
| Evaluation of Antimicrobial Drug (antibiotic, Antifungal, Antiviral), Microdi... | other | $9 | $9 | $9 | 2 |
| Wire Guide .025 X 40cm Fixed Core 10ea/1cs | other | $9 | $9 | $9 | 1 |
| Dressing Aquacel Ag Advantage 3.5 X 14" #422607 10ea/bx | other | $9 | $9 | $9 | 1 |
| Dressing Aquacel Ag Advantage 3.5 X 12" #420606 10ea/bx | other | $9 | $9 | $9 | 1 |
| Snapsecure 1-layer Foley Catheter Tray Temp Sensing 100% Silicone Urine Meter... | cardiac | $9 | $9 | $9 | 1 |
| Electrode Defib Radio-cmb#11996-000090 1st/1ea | other | $9 | $9 | $9 | 1 |
| Injection, Non-radioactive, Non-contrast, Visualization Adjunct (e.g., Methyl... | other | $9 | $9 | $9 | 2 |
| Tube Trach 3.5 Ped Cuffless Shiley | other | $9 | $9 | $9 | 1 |
| Iron Binding Capacity | other | $9 | $9 | $9 | 2 |
| 0.054 Wire Ws-1407st | other | $9 | $9 | $9 | 1 |
| Annual, Face-to-face Intensive Behavioral Therapy for Cardiovascular Disease,... | cardiac | $9 | $9 | $9 | 1 |
| Application of Electrical Stimulation | other | $9 | $9 | $9 | 1 |
| Cast Supplies, Long Arm Cast, Pediatric (0-10 Years), Fiberglass | other | $9 | $9 | $9 | 1 |
| Wrench Kit St Jude #442 | other | $9 | $9 | $9 | 1 |
| Catheter Trocar 16fr 10ea/1cs | cardiac | $9 | $9 | $9 | 1 |
| Cannula Distal Rib Clr W/obturator 5.5mmx75mm | other | $9 | $9 | $9 | 1 |
| Gentamicin 0.3% Eye Drop | other | $9 | $9 | $9 | 1 |
| Zidovudine 50 Mg/5 Ml Syrup | other | $9 | $9 | $9 | 1 |
| Smear for Parasites | other | $9 | $9 | $9 | 2 |
| Micropuncture Kit 5fr #g43871 | other | $9 | $9 | $9 | 1 |
| Terconazole 0.8% Cream | other | $9 | $9 | $9 | 1 |
| Trach Tube Sz8 Lpc Non-fen Dct W/cannula | other | $9 | $9 | $9 | 1 |
| Trach Tube Sz6 Lpc Non-fen Dct W/cannula | other | $9 | $9 | $9 | 1 |
| Tube Trach Cuffless Sz 6 W/cannula #6cfs | other | $9 | $9 | $9 | 1 |
| Tube Trach Cuffless Sz 8 W/cannula #8cfs | other | $9 | $9 | $9 | 1 |
| Diag Catheter 6fr Barbeau 100cm #srd5897 5/bx | cardiac | $9 | $9 | $9 | 1 |
| Thyroxine (thyroid Chemical), Free | other | $9 | $9 | $9 | 2 |
| Influenza Vaccine, Trivalent, 0.25 Ml Dosage | preventive | $9 | $9 | $9 | 1 |
| Skin Test for Candida | other | $9 | $9 | $9 | 1 |
| Tourniquet Emergency C-a-t 30 | emergency | $9 | $9 | $9 | 1 |
| Injection, Ceftolozane 50 Mg and Tazobactam 25 Mg | other | $9 | $9 | $9 | 1 |
| Forcep Biopsy Pediatric W/needle #m00513453 | lab | $9 | $9 | $9 | 1 |
| Butorphanol 10 Mg/ml Spray | other | $9 | $9 | $9 | 1 |
| Cannula Venous 24fr Malleable Single Stage | other | $9 | $9 | $9 | 1 |
| Cannula Venous 26fr Malleable Single Stage | other | $9 | $9 | $9 | 1 |
| Cannula Venous 28fr Malleable Single Stage | other | $9 | $9 | $9 | 1 |
| Cannula Venous 30fr Malleable Single Stage | other | $9 | $9 | $9 | 1 |
| Cannula Venous 32/40fr Two Stage #91263 | other | $9 | $9 | $9 | 1 |
| Catheter Venous Return 34fr Malleable | cardiac | $9 | $9 | $9 | 1 |
| Collagen Dressing, Sterile, Size More Than 16 Sq. In. But Less Than OR Equal ... | other | $9 | $9 | $9 | 1 |
| Clozex Skin Closure 80mm X 50mm Cl1080l | other | $9 | $9 | $9 | 1 |
| Needle Accucore Biopsy 10/bx #640914 | lab | $9 | $9 | $9 | 1 |
| Picc Introducer 4.5fr Micro Bard | other | $9 | $9 | $9 | 1 |
| Picc Introducer 5.0fr Micro Bard | other | $9 | $9 | $9 | 1 |
| Temno 18g X 6.0cm Biopsy Needle 5ea / Bx T186 | lab | $9 | $9 | $9 | 1 |
| Interdry 10"x36"sheet Moist-wick Fabric 10/bx | other | $9 | $9 | $9 | 1 |
| 6/7 Glidesheath Slender #50-1070 10ea/box | other | $9 | $9 | $9 | 1 |
| Defib /electrode Peds Pd-2300 Zoll 6ea/1cs | other | $9 | $9 | $9 | 1 |
| Gammaglobulin (immune System Protein) Measurement | other | $9 | $9 | $9 | 2 |
| Cannula Viscoelastic Asp Ang 10mm 19g | other | $9 | $9 | $9 | 1 |
| Cast Supplies, Short Arm Splint, Adult (11 Years +), Fiberglass | other | $9 | $9 | $9 | 1 |
| Lead Pacing Temp Atrial Unipolar #6492-xf53 | other | $9 | $9 | $9 | 1 |
| Lead Pacing Temp Pediatric #6491-xf53 | other | $9 | $9 | $9 | 1 |
| Professional Service for Multiple Injections of Allergen | other | $9 | $9 | $9 | 1 |
| Repair of Orthotic Device, Labor Component, Per 15 Minutes | surgery | $9 | $9 | $9 | 1 |
| Screening of Eye with Special Instrument Onsite Analysis | preventive | $9 | $9 | $9 | 1 |
| See Sharp Temp Control Laparoscope Cleaning and Defogging with Long Trocar #3... | surgery | $9 | $9 | $9 | 1 |
| Biopsy Inst Max-core Disposable Core #mc1820 | lab | $9 | $9 | $9 | 1 |
| Fetal Hemoglobin OR Red Blood Cells Measurement for Assessment of Fetal-mater... | other | $9 | $9 | $9 | 2 |
| Cefdinir 125 Mg/5 Ml Susp | other | $9 | $9 | $9 | 1 |
| Defib /electrode Stat-pads Adult Zoll 12ea/cs | other | $9 | $9 | $9 | 1 |
| Stool Culture | lab | $9 | $9 | $9 | 2 |
| Stool Culture, Additional Pathogens | lab | $9 | $9 | $9 | 2 |
| Creatinine Clearance Measurement to Test for Kidney Function | other | $9 | $9 | $9 | 2 |
| Bacterial Culture | lab | $9 | $8 | $53 | 3 |
| Catheter Venous Return 36fr Malleable | cardiac | $9 | $9 | $9 | 1 |
| Spinal Lumbar Puncture Adult 20gx3.5 #dynjts4301 10ea/case | other | $9 | $9 | $9 | 1 |
| Dressing Mepilex 4x14 Post Op Ag 5/bx 498650 | other | $9 | $9 | $9 | 1 |
| Clotting Factor X Assessment Test, Diluted | other | $9 | $8 | $10 | 2 |
| 5% Dextrose/normal Saline | other | $9 | $5 | $13 | 2 |
| Infusion, Normal Saline Solution, 250 Cc | surgery | $9 | $5 | $13 | 2 |
| Injection, Acetylcysteine, 100 Mg | other | $9 | $4 | $13 | 2 |
| Injection, Amiodarone Hydrochloride, 30 Mg | other | $9 | $4 | $13 | 2 |
| Injection, Digoxin, Up to 0.5 Mg | other | $9 | $5 | $13 | 2 |
| Injection, Furosemide, 1 Mg | other | $9 | $5 | $13 | 2 |
| Injection, Nalbuphine Hydrochloride, Per 10 Mg | other | $9 | $4 | $13 | 2 |
| Injection, Terbutaline Sulfate, Up to 1 Mg | other | $9 | $4 | $13 | 2 |
| Ringers Lactate Infusion, Up to 1000 Cc | surgery | $9 | $5 | $13 | 2 |
| White Blood Cell Alkaline Phosphatase (enzyme) Measurement with Cell Count | other | $9 | $9 | $9 | 1 |
| Non-covered Item OR Service | other | $9 | $9 | $9 | 1 |
| Injection, Epinephrine (international Medication Systems), Not Therapeuticall... | other | $9 | $9 | $9 | 1 |
| Analysis for Antibody to HIV -1 Virus | other | $9 | $9 | $9 | 1 |
| Benzocaine 20% 60 Ml Spray | other | $9 | $9 | $9 | 1 |
| Carotene Level | other | $9 | $9 | $9 | 1 |
| Platelet Storage Process Fee | other | $9 | $9 | $9 | 1 |
| Platelets, Pheresis, Irradiated, Each Unit | other | $9 | $9 | $9 | 1 |
| Platelets, Pheresis, Leukocytes Reduced, Irradiated, Each Unit | other | $9 | $9 | $9 | 1 |
| Liver Function Panel | lab | $10 | $7 | $209 | 15 |
| Hemoglobin A1C | lab | $10 | $7 | $900 | 23 |
| Use of a Drug to Induce Depression of Consciousness By Physician Performing a... | other | $10 | $9 | $11 | 2 |
| Caffeine Cit 60 Mg/3 Ml Oral | other | $10 | $10 | $10 | 1 |
| Max-core Disposable Core Biopsy Instrument 16g X 16cm #mc1616 5ea/case | lab | $10 | $10 | $10 | 1 |
| Spinal Tray-lumbar-infant 10ea/1cs | other | $10 | $10 | $10 | 1 |
| Catheter Tray Foley Criticore 16fr Surestep | cardiac | $10 | $10 | $10 | 1 |
| Interject Catheter #1836 25ga 7fr 240cm | cardiac | $10 | $10 | $10 | 1 |
| Promethazine Hydrochloride, 12.5 Mg, Oral, Fda Approved Prescription Anti-eme... | other | $10 | $10 | $10 | 1 |
| Tube Trach Cuffless Size 4cfn | other | $10 | $10 | $10 | 1 |
| Tube Trach Cuffless Size 6cfn 1ea | other | $10 | $10 | $10 | 1 |
| Tube Trach Cuffless Size 8cfn 1ea | other | $10 | $10 | $10 | 1 |
| Bra Compression Pink Post Surgery Large #042l | surgery | $10 | $10 | $10 | 1 |
| Bra Compression Pink Post Surgery Medium #042m | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression 2xl #0422xl | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression 3xl #0423xl | surgery | $10 | $10 | $10 | 1 |
| Bra Post Surgery Compression Xl #042xl | surgery | $10 | $10 | $10 | 1 |
| Cast Supplies, Short Arm Cast, Adult (11 Years +), Fiberglass | other | $10 | $10 | $10 | 1 |
| Cannula Venous 34/46fr #91246 Two-stage | other | $10 | $10 | $10 | 1 |
| Heart Muscle Strain Imaging | cardiac | $10 | $10 | $10 | 1 |
| Breather/speech/rehab 1ea | other | $10 | $10 | $10 | 1 |
| Aldolase (enzyme) Level | other | $10 | $10 | $10 | 2 |
| Fibrinogen (factor 1) Activity Measurement | other | $10 | $10 | $10 | 2 |
| Irrigator Lap Suction Davol 12/cs #5102710 | other | $10 | $10 | $10 | 1 |
| Thrombin-jmi 5,000 Units Vial | other | $10 | $10 | $10 | 1 |
| Reuter-bobbin Vent Tube 1.27 Mm Lumen I.d. 1 Mm Interflange Stainless Steel 6... | other | $10 | $10 | $10 | 1 |
| Rapid Rhino 5.5cm Rapid-pac Rr530 #rr 530 | other | $10 | $10 | $10 | 1 |
| Softkit Black Univ Xsmall 283900010 | other | $10 | $10 | $10 | 1 |
| Screening Test for Red Blood Cell Antibodies | preventive | $10 | $10 | $10 | 2 |
| Trach Tube Sz4 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 | $10 | 1 |
| Trach Tube Sz6 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 | $10 | 1 |
| Trach Tube Sz8 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 | $10 | 1 |
| Hc Dressing Aquacel Extra | other | $10 | $10 | $10 | 1 |
| Dressing Jumpstart Abs | other | $10 | $10 | $10 | 1 |
| Cyclogyl 2% Eye Drops | other | $10 | $10 | $10 | 1 |
| Phytonadione 5 Mg Po Tabs | other | $10 | $10 | $10 | 1 |
| Phytonadione 5 Mg Tablet | other | $10 | $10 | $10 | 1 |
| Aortical Surgical Flat 4.0 Punch #080-401 6ea/box | surgery | $10 | $10 | $10 | 1 |
| Cervical OR Vaginal Cancer Screening; Pelvic and Clinical Breast Examination | preventive | $10 | $10 | $10 | 1 |
| Semen Analysis Presence And/or Motility of Sperm | other | $10 | $10 | $10 | 1 |
| Suction Coag Tips #ps300 | other | $10 | $10 | $10 | 1 |
| Night Splint Lg #w | other | $10 | $10 | $10 | 1 |
| Betamethasone Dp 0.05% Lot | other | $10 | $10 | $10 | 1 |
| Softkit Black Univ Large/xlarge 283900013 | other | $10 | $10 | $10 | 1 |
| Softkit Black Univ Medium 283900012 | other | $10 | $10 | $10 | 1 |
| Softkit Black Univ Small 283900011 | other | $10 | $10 | $10 | 1 |
| Ascorbic Acid (vitamin C) Level, Blood | other | $10 | $10 | $10 | 2 |
| Perfusion Vavd W/specimen Trap 5/cs | surgery | $10 | $10 | $10 | 1 |
| Staple Reload Ta 90mm Disposable Ta9048l 6/cs | other | $10 | $10 | $10 | 1 |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq. In. Bu... | other | $10 | $10 | $10 | 1 |
| Shiley Tracheostomy Tube Uncuffed Id 6.5mm Od 9.4mm 62mm #4un65h | other | $10 | $10 | $10 | 1 |
| Shiley Tracheostomy Tube Uncuffed Id 8.5mm Od 12.2mm 5mm | other | $10 | $10 | $10 | 1 |
| Gatifloxacin 0.5 % Op Soln | other | $10 | $10 | $10 | 1 |
| Insertion of Probe in Esophagus for Heart Ultrasound | imaging | $10 | $10 | $10 | 1 |
| Carnitor 100 Mg/ml Oral Soln | other | $10 | $10 | $10 | 1 |
| Levocarnitine 1 Gm/10ml Po Soln | other | $10 | $10 | $10 | 1 |
| Catheter Kumar Disp Ltx-free #cc | cardiac | $10 | $10 | $10 | 1 |
| Clozex Skin Closure 100mm X 50mm Cl10100l | other | $10 | $10 | $10 | 1 |
| Endo Colon Spot Ex Tattoo #gis | other | $10 | $10 | $10 | 1 |
| Drop Foot Splint Standard Sm Lt #pls-ff-100l | other | $10 | $10 | $10 | 1 |
| Stiff Micropuncture Introducer #h787065971045 | other | $10 | $10 | $10 | 1 |
| Analysis for Antibody to Bartonella | other | $10 | $10 | $10 | 2 |
| Analysis for Antibody to Ehrlichia | other | $10 | $10 | $10 | 1 |
| Coagulation Function Measurement, D-dimer; Quantitative | other | $10 | $10 | $10 | 2 |
| Stylet Glidescope Adult Single Use #0270 | other | $10 | $10 | $10 | 1 |
| Wound Care Set, for Negative Pressure Wound Therapy Electrical Pump, Includes... | other | $10 | $10 | $10 | 1 |
| Fungal Culture, Yeast | lab | $10 | $10 | $10 | 1 |
| Detection Test By Immunoassay Technique for Hepatitis B Surface Antigen | other | $10 | $10 | $10 | 2 |
| Clindamycin (pedi) 75 Mg/5 Ml | other | $10 | $10 | $10 | 1 |
| Clindamycin Palmitate Hcl 75 Mg/5ml Po Solr | other | $10 | $10 | $10 | 1 |
| Expanula Port 8.25 X 7cm #ar | other | $10 | $10 | $10 | 1 |
| Knee Stabilizer Pad #o-tksp-a | other | $10 | $10 | $10 | 1 |
| Sleeve Scd Thigh Large Comfort #74013 3pr/1cs | other | $10 | $10 | $10 | 1 |
| Lotronex 0.5 Mg Tablet | other | $10 | $10 | $10 | 1 |
| Vac Pad Medium Black 10ea/1ca | other | $10 | $10 | $10 | 1 |
| Temno 20g X 6.0cm Biopsy Needle 5ea / Bx T206 | lab | $10 | $10 | $10 | 1 |
| Drop Foot Splint Standard Xlg Lt #pls-ff-400l | other | $10 | $10 | $10 | 1 |
| Drop Foot Splint Standard Xlg Rt #pls-ff-400r | other | $10 | $10 | $10 | 1 |
| Iodine I-131 Sodium Iodide Solution, Therapeutic, Per Millicurie | other | $10 | $10 | $10 | 1 |
| Transfer Board W/slots 1ea | other | $10 | $10 | $10 | 1 |
| Low Osmolar Contrast Material, 300-399 Mg/ml Iodine Concentration, Per Ml | other | $10 | $10 | $10 | 2 |
| Commode Bedside 300lb Fixedarm Alum #cpat0002 | other | $10 | $10 | $10 | 1 |
| Measurement of Hepatitis a Antibody | other | $10 | $8 | $11 | 2 |
| Analysis for Antibody to Coccidioides | other | $10 | $8 | $11 | 2 |
| 5% Dextrose in Lactated Ringers Infusion, Up to 1000 Cc | surgery | $10 | $6 | $13 | 2 |
| 5% Dextrose/water | other | $10 | $6 | $13 | 2 |
| Injection, Ampicillin Sodium, 500 Mg | other | $10 | $7 | $13 | 2 |
| Injection, Haloperidol, Up to 5 Mg | other | $10 | $6 | $13 | 2 |
| Injection, Levofloxacin, 250 Mg | other | $10 | $6 | $13 | 2 |
| Injection, Lidocaine Hydrochloride, 1 Mg | other | $10 | $7 | $13 | 2 |
| Injection, Vitamin B-12 Cyanocobalamin, Up to 1000 Mcg | other | $10 | $7 | $13 | 2 |
| Obs ICU Nonpaid Cc 44 | other | $10 | $10 | $10 | 1 |
| Obs OB Nonpaid Cc 44 | other | $10 | $10 | $10 | 1 |
| Sterile Water for Injection | other | $10 | $10 | $10 | 1 |
| Cholangiogram Catheter | cardiac | $10 | $10 | $10 | 1 |
| Phosphatase, Prostatic (prostate Enzyme) Level | other | $10 | $10 | $10 | 1 |
| Injection, Vancomycin Hcl (mylan), Not Therapeutically Equivalent to J3370, 5... | other | $10 | $10 | $10 | 1 |
| Injection, Cefepime Hydrochloride, 500 Mg | other | $10 | $10 | $10 | 1 |
| Screening Test for Compatible Blood Unit, Using Patient Serum | preventive | $10 | $10 | $10 | 1 |
| Preparation of Tissue for Examination By Removing Any Calcium Present | other | $11 | $9 | $13 | 2 |
| Ldl Cholesterol Level | other | $11 | $11 | $11 | 2 |
| Core Disposable Irrigation Cassette #5400-050 | other | $11 | $11 | $11 | 1 |
| Flunisolide 0.025% Spray | other | $11 | $11 | $11 | 1 |
| Injection, Paclitaxel Protein-bound Particles, 1 Mg | other | $11 | $11 | $11 | 1 |
| Hem-o-lok Med/lrg #544230 6ea/cartidg 14ct/bx | other | $11 | $11 | $11 | 1 |
| Ligating Clip Lrg Hemolok #544240 Teleflex | other | $11 | $11 | $11 | 1 |
| Surgineedle 120mm #172015 | other | $11 | $11 | $11 | 1 |
| Erythromycin 2 % Ex Soln | other | $11 | $11 | $11 | 1 |
| Sulfamethoxazole-tmp Susp | other | $11 | $11 | $11 | 1 |
| Needle Foramen 20ga 5.0 Parylene #041829 | other | $11 | $11 | $11 | 1 |
| Infusion, Albumin (human), 5%, 50 Ml | surgery | $11 | $11 | $11 | 2 |
| Cast Supplies, Short Leg Cast, Adult (11 Years +), Fiberglass | other | $11 | $11 | $11 | 1 |
| Cast Supplies, Short Leg Cast, Pediatric (0-10 Years), Fiberglass | other | $11 | $11 | $11 | 1 |
| Drain Ep Sil 3/16" Zimmer #2540-007 | other | $11 | $11 | $11 | 1 |
| Endocatch 10mm Gold Specimen Pouch #173050g | lab | $11 | $11 | $11 | 1 |
| Hc Boot Cast Gelo Unna's-wch | other | $11 | $11 | $11 | 1 |
| Inflation Device Encore 26 Vascular | other | $11 | $11 | $11 | 1 |
| Orthotic and Prosthetic Supply, Accessory, And/or Service Component of Anothe... | other | $11 | $11 | $11 | 1 |
| Stylet | other | $11 | $11 | $11 | 1 |
| Stylet #6082-52cm | other | $11 | $11 | $11 | 1 |
| Stylet 45cm Gray #6091-45cm | other | $11 | $11 | $11 | 1 |
| Stylet Cap & Ring Sc-4395 | other | $11 | $11 | $11 | 1 |
| Stylet Gray #6082-45cm | other | $11 | $11 | $11 | 1 |
| Stylet Kit with Stylet Cap M365sc4385700 #sc-4385 | other | $11 | $11 | $11 | 1 |
| Surgical Boot/shoe, Each | surgery | $11 | $11 | $11 | 1 |
| Granufoam Thin Dressing #m8275081/10.s 10ea/case | other | $11 | $11 | $11 | 1 |
| Drop Foot Splint Standard Med Lt #pls-ff-200l | other | $11 | $11 | $11 | 1 |
| Gelfoam Size 100 Sponge | other | $11 | $11 | $11 | 1 |
| For Diabetics Only, Multiple Density Insert, Direct Formed, Molded to Foot Af... | other | $11 | $11 | $11 | 1 |
| Phenylephrine 10% Eye Drop | other | $11 | $11 | $11 | 1 |
| Ceruloplasmin (protein) Level | other | $11 | $11 | $11 | 2 |
| Hepatitis B Surface Antibody Measurement | other | $11 | $11 | $11 | 2 |
| Protein Measurement, Serum | other | $11 | $11 | $11 | 2 |
| Knife Retrograde Dyonics Disp | other | $11 | $11 | $11 | 1 |
| 5fr Sos Omni (0) 80cm H787107120085 | other | $11 | $11 | $11 | 1 |
| 5fr Sos Omni (3) 80cm | other | $11 | $11 | $11 | 1 |
| Culture for Acid-fast Bacilli | lab | $11 | $11 | $11 | 2 |
| Reservoir Blood Collection Xres B #04259 6/cs | other | $11 | $11 | $11 | 1 |
| Catheter 5fr Filiform W/spiral Tip V. Mueller Gu2075-105 10ea/bx | cardiac | $11 | $11 | $11 | 1 |
| Nerve Locator/ Neuro Pulse 10/pk | other | $11 | $11 | $11 | 1 |
| Cannula Venous T Flex Ds #trf2937o2 10ea/1cs | other | $11 | $11 | $11 | 1 |
| Therapeutic Interventions That Focus On Cognitive Function (eg, Attention, Me... | other | $11 | $11 | $11 | 1 |
| Velys Array Drill Pin 100mm X 4mm 4515-70-004 Minimum Order 10 Each | other | $11 | $11 | $11 | 1 |
| **obsolete** Suture 0 Poly Prolene #833 | other | $11 | $11 | $11 | 1 |
| Injection, Risperidone (risperdal Consta), 0.5 Mg | other | $11 | $11 | $11 | 1 |
| Foley Cath 1.5cc 6fr #170003060 | other | $11 | $11 | $11 | 1 |
| Injection, Romiplostim, 1 Microgram | other | $11 | $11 | $11 | 1 |
| X-ray of Middle Spine, Minimum of 4 Views | imaging | $11 | $11 | $11 | 1 |
| Stiolto Respimat Inhaler | other | $11 | $11 | $11 | 1 |
| Aminocaproic Acid 500 Mg Tab | other | $11 | $11 | $11 | 1 |
| Cervical, Semi-rigid, Adjustable | other | $11 | $11 | $11 | 1 |
| Foley Urinary Catheter 18fr 5ml Silicone Council Tip #0196si18 12ea/cs | cardiac | $11 | $11 | $11 | 1 |
| Nucleotidase 5' (enzyme) Level | other | $11 | $11 | $11 | 2 |
| Dermatac Drape W/granufoam Dressing Small10pk | other | $11 | $11 | $11 | 1 |
| Imaging of Organ | other | $11 | $11 | $11 | 1 |
| Drop Foot Splint Standard Lg Lt #pls-ff-300l | other | $11 | $11 | $11 | 1 |
| Drop Foot Splint Standard Lg Rt #pls-ff-300r | other | $11 | $11 | $11 | 1 |
| Drop Foot Splint Standard Med Rt #pls-ff-200r | other | $11 | $11 | $11 | 1 |
| Drop Foot Splint Standard Sm Rt #pls-ff-100r | other | $11 | $11 | $11 | 1 |
| Trach Tube 6dct #6cn75h | other | $11 | $11 | $11 | 1 |
| Clobetasol 0.05% Solution | other | $11 | $11 | $11 | 1 |
| Trach Sz 8 Shiley Cuffed Trach Cann 8.5mm #8cn85h | other | $11 | $11 | $11 | 1 |
| Trach Tube 4dct #4cn65h | other | $11 | $11 | $11 | 1 |
| Drain Hemovac Replacement 5ea/1bx #00-2555-050 | surgery | $11 | $11 | $11 | 1 |
| Splint Denver Nasal Thermoplastic Sm #10-4021-05ks 5/bx | other | $11 | $11 | $11 | 1 |
| Pediatric Tracheostomy Tube Shiley Cuffless 4.0mm Id 6.0mm Od Medtronic 4.0pe... | other | $11 | $11 | $11 | 1 |
| Butrans 5 Mcg/hr Patch | other | $11 | $11 | $11 | 1 |
| Nasal 7.5 Epistaxis Ant/posterior 10ea/1bx | other | $11 | $11 | $11 | 1 |
| Immobilizer Shoulder Lg W/block Deroyal | other | $11 | $11 | $11 | 1 |
| Immobilizer Shoulder Med W/block Deroyal | other | $11 | $11 | $11 | 1 |
| Immobilizer Shoulder Small W/block Deroyal | other | $11 | $11 | $11 | 1 |
| Zinc Level | other | $11 | $11 | $11 | 2 |
| Tube Trach Cuff Size 8 Low Pressure | other | $11 | $11 | $11 | 1 |
| Tube Trach Cuff Sz-6 Low Pressure | other | $11 | $11 | $11 | 1 |
| Tube Trach Cuffless Sz 4 W/cannula #4cfs | other | $11 | $11 | $11 | 1 |
| Laser Trach Tube 3.0 #86400 Uncuffed | other | $11 | $11 | $11 | 1 |
| Laser Trach Tube 3.5 #86401 Uncuffed | other | $11 | $11 | $11 | 1 |
| Laser Trach Tube 4.0 #86402 Uncuffed | other | $11 | $11 | $11 | 1 |
| Insulin Measurement, Total | other | $11 | $11 | $11 | 2 |
| Detection Test By Immunoassay with Direct Visual Observation for Streptococcu... | other | $11 | $10 | $11 | 2 |
| Pin Guide 2.8 #ar | other | $11 | $11 | $11 | 1 |
| Provisc #8065-18 | other | $11 | $11 | $11 | 1 |
| Trach Sz 10 Shiley Cuffed Trach Cann 10.0mm 10cn10h | other | $11 | $11 | $11 | 1 |
| Injection, Ampicillin Sodium/sulbactam Sodium, Per 1.5 Gm | other | $11 | $8 | $13 | 2 |
| Injection, Butorphanol Tartrate, 1 Mg | other | $11 | $9 | $13 | 2 |
| Injection, Piperacillin Sodium/tazobactam Sodium, 1 Gram/0.125 Grams | other | $11 | $9 | $13 | 2 |
| Confirmation Test for Antibody to Borrelia Burgdorferi | other | $11 | $6 | $15 | 2 |
| Water for Injection Vial | other | $11 | $1 | $21 | 2 |
| Flector Patch | other | $11 | $11 | $11 | 1 |
| Antithrombin Iii Antigen (clotting Inhibitor) Level | other | $11 | $11 | $11 | 1 |
| Injection, Sumatriptan Succinate, 6 Mg | other | $11 | $11 | $11 | 1 |
| Blood Ph Level | other | $11 | $11 | $11 | 1 |
| Analysis for Antibody to Zika Virus | other | $11 | $11 | $11 | 1 |
| Analysis for Antibody to Hiv-1 and Hiv-2 Virus | other | $11 | $11 | $11 | 1 |
| Sacubitril/valsartan 97/103 Mg | other | $11 | $11 | $11 | 1 |
| Detection Test By Immunoassay Technique for Respiratory Syncytial Virus | other | $12 | $10 | $14 | 2 |
| Application of Blood Vessel Compression Device | other | $12 | $11 | $12 | 2 |
| Prosthetic Sock, Multiple Ply, Below Knee, Each | other | $12 | $12 | $12 | 1 |
| Ultrasound Mak Kit #k12t-05493a **must Order Increments of 10 Each** | imaging | $12 | $12 | $12 | 1 |
| Analysis of Substance Using Immunoassay Technique, Multiple Step Method | other | $12 | $12 | $12 | 2 |
| Detection of Pancreatic Elastase (enzyme) in Stool | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Hepatitis Be Surface Antigen | other | $12 | $12 | $12 | 2 |
| Screening Test for Presence of Antibody | preventive | $12 | $12 | $12 | 2 |
| Creatine Kinase (cardiac Enzyme) Level, Mb Fraction Only | cardiac | $12 | $12 | $12 | 2 |
| Cath Cholangiogram Orc-b | other | $12 | $12 | $12 | 1 |
| Hepatitis Be Antibody Measurement | other | $12 | $12 | $12 | 2 |
| Lactic Acid Level | other | $12 | $12 | $12 | 2 |
| Clindamycin Ph 1% Gel | other | $12 | $12 | $12 | 1 |
| Protein S (clotting Inhibitor) Level | other | $12 | $12 | $12 | 1 |
| Single Action Pumping Sys #m0067201001 | other | $12 | $12 | $12 | 1 |
| Vitamin a Level | other | $12 | $12 | $12 | 2 |
| Splint Nasal Intranasal 15-24050 5ea/1bx | other | $12 | $12 | $12 | 1 |
| Psychiatric Services Complicated By Communication Factor | therapy | $12 | $12 | $12 | 1 |
| Blood Viscosity Measurement | other | $12 | $12 | $12 | 2 |
| Pulmonary Biopsy Forcep Rj4 #m0515181 | lab | $12 | $12 | $12 | 1 |
| Injection, Lincomycin Hcl, Up to 300 Mg | other | $12 | $12 | $12 | 1 |
| Laser Flex Trach Tube 4.5mm #86397 Cuffed | other | $12 | $12 | $12 | 1 |
| Laser Flex Trach Tube 5.5 #86395 Cuffed | other | $12 | $12 | $12 | 1 |
| Laser Flex Tracheal Tube 6.0 Cuffed | other | $12 | $12 | $12 | 1 |
| Test to Determine Lung Volumes Using Sensors | other | $12 | $12 | $12 | 1 |
| Influenza Vaccine, Trivalent, Split Virus, Preservative-free, 0.5 Ml Dosage | preventive | $12 | $12 | $12 | 1 |
| Urethral Needle for Macroplastique | other | $12 | $12 | $12 | 1 |
| Vac Soft White Foam Sys Sm 10"x 7.5" M8275068 | other | $12 | $12 | $12 | 1 |
| Pleuravac - Infant #a-8020-08lf | other | $12 | $12 | $12 | 1 |
| Hepatitis B Core Antibody (igm) Measurement | other | $12 | $12 | $12 | 2 |
| Cannula Aortic Ez Glide 21fr X 35cm Ezs21ta | other | $12 | $12 | $12 | 1 |
| Betamethasone Dp 0.05% Oint | other | $12 | $12 | $12 | 1 |
| Cement Mix Bowl Quick Vac Vacuum | other | $12 | $12 | $12 | 1 |
| Antithrombin Iii Antigen (clotting Inhibitor) Activity | other | $12 | $12 | $12 | 2 |
| Immobilizer Shoulder Xlg W/block Deroyal | other | $12 | $12 | $12 | 1 |
| Topiramate Level | other | $12 | $11 | $12 | 2 |
| Cannula Endo 5fr Biliary ERCP 5-4-3 M00530880 | other | $12 | $12 | $12 | 1 |
| Cor-knot Quick Load Singles #030850 | other | $12 | $12 | $12 | 1 |
| Foot, Arch Support, Removable, Premolded, Metatarsal, Each | other | $12 | $12 | $12 | 1 |
| Introducer Peritoneal Taut #pi | other | $12 | $12 | $12 | 1 |
| Presto Inflation High Pressure Device with 30cc Barrel 5ea/ca Id4030 | other | $12 | $12 | $12 | 1 |
| Screening of Eye with Special Instrument with Remote Analysis | preventive | $12 | $12 | $12 | 1 |
| Splint, Prefabricated, Elbow | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Aspergillus | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Clostridium Difficile Toxins | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Giardia | other | $12 | $12 | $12 | 2 |
| Detection Test By Immunoassay Technique for Other Organism | other | $12 | $12 | $12 | 2 |
| Detection Test By Immunoassay Technique for Rotavirus | other | $12 | $12 | $12 | 2 |
| Tray Epidural #182221 Ballard | other | $12 | $12 | $12 | 1 |
| Measurement of Complement (immune System Proteins), Antigen | other | $12 | $12 | $12 | 2 |
| Protein C, (clotting Inhibitor) Activity | other | $12 | $12 | $12 | 1 |
| Pentam 300 Mg Vial | other | $12 | $12 | $12 | 1 |
| Brexpiprazole 2 Mg Po Tabs | other | $12 | $12 | $12 | 1 |
| Rexulti 1 Mg Tablet | other | $12 | $12 | $12 | 1 |
| Rexulti 2 Mg Tablet | other | $12 | $12 | $12 | 1 |
| Hepatitis B Core Antibody Measurement | other | $12 | $12 | $12 | 1 |
| Marker Scar Spee-d-line 3d Digital Breast | other | $12 | $12 | $12 | 1 |
| Screening Test for Antibody to Noninfectious Agent | preventive | $12 | $12 | $12 | 2 |
| Screening Test for Autoimmune Disorder | preventive | $12 | $12 | $12 | 2 |
| Shiley Pediatric Tracheostomy Tube Cuffless 3.0mm Id 4.8mm Od 39mm 3.0 Pef #3... | other | $12 | $12 | $12 | 1 |
| Shiley Pediatric Tracheostomy Tube Cuffless 4.5mm Id 6.7mm Od 42mm 4.5 Pef #4... | other | $12 | $12 | $12 | 1 |
| Lead Level | other | $12 | $12 | $12 | 2 |
| Infusion Set Rapid #d-60hl Smith Med.10ea/1cs | surgery | $12 | $12 | $12 | 1 |
| Catheter Duplocath Application 35cm #1506166 Be-10-01-106 for Billing Reference | cardiac | $12 | $12 | $12 | 1 |
| Shiley Tracheostomy Tube Twist Lock Ic Size 10.0 Adult #10fen | other | $12 | $12 | $12 | 1 |
| Tube Trach Cuff Size 6fen 1ea | other | $12 | $12 | $12 | 1 |
| Tube Trach Cuff Size 8fen 1ea | other | $12 | $12 | $12 | 1 |
| Administration of Hepatitis B Vaccine | preventive | $12 | $12 | $12 | 1 |
| Administration of Influenza Virus Vaccine | preventive | $12 | $12 | $12 | 1 |
| Administration of Pneumococcal Vaccine | preventive | $12 | $12 | $12 | 1 |
| Assessment of Emotional OR Behavioral Problems | other | $12 | $12 | $12 | 1 |
| Trocar 15mm X 100 6/bx #c0r37 | other | $12 | $12 | $12 | 1 |
| Cannula 15fr Coronary Ostial Perfusion | surgery | $12 | $12 | $12 | 1 |
| Cannula 17fr Coronary Ostial Perfusion | surgery | $12 | $12 | $12 | 1 |
| Cannula 20fr Coronary Ostial Perfusion | surgery | $12 | $12 | $12 | 1 |
| Lumbar Support Basic Xlrg #10155 | other | $12 | $12 | $12 | 1 |
| Sheath Storz/xomed 4mm/30" #1912010 Sc | other | $12 | $12 | $12 | 1 |
| Sheath Storz/xomed 4mm/45" #1912013 Sc | other | $12 | $12 | $12 | 1 |
| Carboxyhemoglobin (protein) Level | other | $12 | $12 | $12 | 2 |
| Injection, Inclisiran, 1 Mg | other | $12 | $12 | $12 | 1 |
| Test to Assess Middle Ear Muscle Reflex | other | $12 | $12 | $12 | 1 |
| Copper Level | other | $12 | $12 | $12 | 2 |
| Troponin (protein) Analysis, Quantitative | other | $12 | $12 | $12 | 2 |
| Analysis for Antibody to Virus | other | $12 | $11 | $13 | 2 |
| Analysis for Antibody to Blastomyces | other | $12 | $10 | $13 | 2 |
| Dextrose 5%-0.45% Nacl IV Soln | other | $12 | $10 | $13 | 2 |
| Injection, Ceftazidime, Per 500 Mg | other | $12 | $10 | $13 | 2 |
| Injection, Potassium Chloride, Per 2 Meq | other | $12 | $10 | $13 | 2 |
| Injection, Thiamine Hcl, 100 Mg | other | $12 | $10 | $13 | 2 |
| Analysis for Antibody to Histoplasma | other | $12 | $10 | $14 | 2 |
| Vitamin E Level | other | $12 | $9 | $14 | 2 |
| Injection, Labetalol Hydrochloride, 5 Mg | other | $12 | $4 | $20 | 2 |
| Sacubitril/valsartan 24/26mg | other | $12 | $12 | $12 | 1 |
| Analysis for Antibody to Chlamydia | other | $12 | $12 | $12 | 1 |
| Analysis for Antibody to Parvovirus | other | $12 | $12 | $12 | 1 |
| Measurement of Antibody to Noninfectious Agent | other | $12 | $12 | $12 | 1 |
| Detection Test By Immunoassay Technique for Shiga-like Toxin | other | $12 | $12 | $12 | 1 |
| Measurement of Complement Function | other | $12 | $12 | $12 | 1 |
| Semen Analysis for Sperm Presence | other | $12 | $12 | $12 | 1 |
| Electrical Stimulation (unattended), to One OR More Areas for Indication(s) O... | other | $12 | $12 | $12 | 1 |
| Islet Cell (pancreas) Antibody Measurement | other | $12 | $12 | $12 | 1 |
| Therapy Procedure Reassessment for Nutrition Management, Each 15 Minutes | other | $12 | $12 | $12 | 1 |
| Antibody Identification Test, Platelet Associated Immunoglobulin Assay | other | $12 | $12 | $12 | 1 |
| Hematocrit | other | $12 | $12 | $12 | 1 |
| Cholesterol Management | cardiac | $13 | $2 | $76 | 35 |
| Muri-lube Mineral Oil Vial | other | $13 | $5 | $21 | 2 |
| Pathology Examination of Tissue Using a Microscope | lab | $13 | $6 | $20 | 2 |
| Tacrolimus Level | other | $13 | $11 | $14 | 2 |
| Evaluation of Use of Breathing Device | other | $13 | $13 | $13 | 1 |
| Stylet S 53-j | other | $13 | $13 | $13 | 1 |
| Stylet S 53-jl | other | $13 | $13 | $13 | 1 |
| Stylet S 53-s | other | $13 | $13 | $13 | 1 |
| Stylet S53-k | other | $13 | $13 | $13 | 1 |
| Torque Wrench | other | $13 | $13 | $13 | 1 |
| Tobramycin-dexameth Ophth Susp | imaging | $13 | $13 | $13 | 1 |
| Tobramycin-dexamethasone 0.3-0.1 % Op Susp | imaging | $13 | $13 | $13 | 1 |
| Deluxe Paring Board 1ea | other | $13 | $13 | $13 | 1 |
| Neomyc-polym-gramicid Eye Drop | other | $13 | $13 | $13 | 1 |
| Cath Word Bartholin Gland 10fr 6ea/1bx | other | $13 | $13 | $13 | 1 |
| Haptoglobin (serum Protein) Level | other | $13 | $13 | $13 | 2 |
| Cannula Arterial 18fr Eopa Elongated One Piec | other | $13 | $13 | $13 | 1 |
| Cannula Arterial 20fr Eopa Elongated One Piec | other | $13 | $13 | $13 | 1 |
| Cannula Arterial 22fr Eopa Elongated One Piec | other | $13 | $13 | $13 | 1 |
| Boot Prevalon Iii W/wedge #7355 8ea/cs | other | $13 | $13 | $13 | 1 |
| Insulin for Administration Through DME (i.e., Insulin Pump) Per 50 Units | other | $13 | $13 | $13 | 1 |
| Prosthetic Sock, Multiple Ply, Above Knee, Each | other | $13 | $13 | $13 | 1 |
| Iodosorb Gel | other | $13 | $13 | $13 | 1 |
| Muscle Biopsy Clamp Rayport 12mm #su130 | lab | $13 | $13 | $13 | 1 |
| Tube Endobronchial 35fr Left #125035 | other | $13 | $13 | $13 | 1 |
| Tube Endobronchial 37fr Left #125037 | other | $13 | $13 | $13 | 1 |
| Tube Endobronchial 39fr Left #125039 | other | $13 | $13 | $13 | 1 |
| Tube Endobronchial 41fr Left #125041 | other | $13 | $13 | $13 | 1 |
| Surgiclip Lrg 13.0 #134048 | other | $13 | $13 | $13 | 1 |
| Surgiclip Sm 9.0 #133650 | other | $13 | $13 | $13 | 1 |
| Tube Trach Metal Jackson Sz 7 #pm1034317 | other | $13 | $13 | $13 | 1 |
| Transferrin (iron Binding Protein) Level | other | $13 | $13 | $13 | 2 |
| Haemophilus Influenzae Type B Vaccine, Prp-omp Conjugate | preventive | $13 | $13 | $13 | 1 |
| Ligaclip Medium 11.5 6/bx #134053 | other | $13 | $13 | $13 | 1 |
| Sensor Rectal Pressure #pg | other | $13 | $13 | $13 | 1 |
| Sensor Vaginal Emg #pg | other | $13 | $13 | $13 | 1 |
| Surgiclip Med 9.75 6 Ea/bx #134051 | other | $13 | $13 | $13 | 1 |
| Vac Pad Large Black 10ea/1ca | other | $13 | $13 | $13 | 1 |
| Irrigation Sys Bard Assist #160130 | other | $13 | $13 | $13 | 1 |
| Blood Glucose (sugar) Tolerance Test, 3 Specimens | lab | $13 | $13 | $13 | 2 |
| Chemical Analysis of Stone | other | $13 | $13 | $13 | 2 |
| Hemoglobin Analysis and Measurement, Electrophoresis | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Rubeola | other | $13 | $13 | $13 | 2 |
| Analysis for Antibody to Varicella-zoster Virus | other | $13 | $13 | $13 | 2 |
| Avitene Ultrafoam Collagen Sponge 100 SQ Cm 8cm X 12.5cm 3-1/18" X 5" 1050040 | other | $13 | $13 | $13 | 1 |
| Catheter Kit 5.0" Pain On Q Silversoaker 5/bx | cardiac | $13 | $13 | $13 | 1 |
| Hydroxyindolacetic Acid (product of Metabolism) Level | other | $13 | $13 | $13 | 2 |
| Infrared Analysis of Stone | other | $13 | $13 | $13 | 1 |
| Myoglobin (muscle Protein) Level | other | $13 | $13 | $13 | 2 |
| Tube Trach Metal Jackson Sz 5 #pm1034915 | other | $13 | $13 | $13 | 1 |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation, Hi... | other | $13 | $13 | $13 | 2 |
| Measurement of Antibody for Rheumatoid Arthritis Assessment | other | $13 | $13 | $13 | 2 |
| Clotting Factor Ii Prothrombin, Measurement | other | $13 | $13 | $13 | 1 |
| Rbn-114 Bone Marrow Biopsy Needle 11 Gauge X 4" Snarecoil Box/10each | lab | $13 | $13 | $13 | 1 |
| Rbn-116 Bone Marrow Biopsy Needle 11 Gauge X 6" Snarecoil Box/10each | lab | $13 | $13 | $13 | 1 |
| Ustekinumab, for Intravenous Injection, 1 Mg | other | $13 | $13 | $13 | 1 |
| Administration of First Vaccine OR Toxoid Component with Counseling | therapy | $13 | $13 | $13 | 1 |
| Administration of Nasal OR Oral Vaccine, 1 Vaccine | preventive | $13 | $13 | $13 | 1 |
| Administration of Vaccine | preventive | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Enterovirus | other | $13 | $13 | $13 | 1 |
| Hydro-surg Plus Laparoscopic Irrigator with Nezhat-dorsey Smokevac Trumpet Va... | surgery | $13 | $13 | $13 | 1 |
| Immobilizer Arm/shoulder Atlas#00052 Breg | other | $13 | $13 | $13 | 1 |
| Safety Amniocentesis 20gx3.5 29-am1sfa 10ea/case | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Mumps Virus | other | $13 | $13 | $13 | 2 |
| Buprenorphine 10 Mcg/hr Patch | other | $13 | $13 | $13 | 1 |
| Heparin Assay | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Early Antigen | other | $13 | $13 | $13 | 2 |
| Ultrasonic Guidance for Blood Vessel Access | other | $13 | $13 | $13 | 1 |
| Immobilizer Sling Shot Sz Large Breg | other | $13 | $13 | $13 | 1 |
| Immobilizer Sling Shot Sz Medium | other | $13 | $13 | $13 | 1 |
| Immobilizer Sling Shot Sz Small | other | $13 | $13 | $13 | 1 |
| Immobilizer Sling Shot Sz Xlarge Breg | other | $13 | $13 | $13 | 1 |
| Lap Probe Monopolar J Hook Tip | other | $13 | $13 | $13 | 1 |
| Viscera Retainer-medium Hs3204-1 Bx/10 | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Mycoplasma | other | $13 | $13 | $13 | 2 |
| Tube Ear Ventilation Richards T 1.14mm 240071 | other | $13 | $13 | $13 | 1 |
| Lamotrigine Level | other | $13 | $13 | $13 | 2 |
| Levetiracetam Level | other | $13 | $13 | $13 | 2 |
| Oxcarbazepine Level | other | $13 | $13 | $13 | 1 |
| Phenytoin Level, Total | other | $13 | $13 | $13 | 2 |
| Zonisamide Level | other | $13 | $13 | $13 | 1 |
| Nasal 4.5 Epistaxis Anterior 10ea/1bx | other | $13 | $13 | $13 | 1 |
| Nasal 5.5 Epistaxis Anterior 10ea/1bx | other | $13 | $13 | $13 | 1 |
| Cannula Endo 1.83mm X 210cm Tandem M00545820 | other | $13 | $13 | $13 | 1 |
| Nystatin-triamcinolone 100000-0.1 Unit/gm-% Ex Oint | other | $13 | $13 | $13 | 1 |
| Nystatin-triamcinolone Ointm | other | $13 | $13 | $13 | 1 |
| Digoxin Level, Total | other | $13 | $13 | $13 | 2 |
| Guardian Ii Hemostasis Valve #8211 | other | $13 | $13 | $13 | 1 |
| Polymyxin B-trimethoprim 10000-0.1 Unit/ml-% Op Soln | other | $13 | $13 | $13 | 1 |
| Adenovirus Type 4 Vaccine | preventive | $13 | $13 | $13 | 1 |
| Bacteriostatic Saline Vial | other | $13 | $13 | $13 | 1 |
| Bupivacaine-epinephrine (pf) 0.5% -1:200000 Ij Soln | other | $13 | $13 | $13 | 1 |
| Caffeine Cit 60 Mg/3 Ml Vial | other | $13 | $13 | $13 | 1 |
| Cefazolin 5 Mg/ml + Heparin 2500 Units/ml Antibiotic Catheter Mixture - Compo... | cardiac | $13 | $13 | $13 | 1 |
| Detection Test By Nucleic Acid for Strep (streptococcus, Group A), Amplified ... | other | $13 | $13 | $13 | 1 |
| Dextrose 2.5%-0.45% Nacl IV | other | $13 | $13 | $13 | 1 |
| Dextrose 5%-0.2% Nacl IV Soln | other | $13 | $13 | $13 | 1 |
| Diltiazem 25 Mg/5 Ml Vial | other | $13 | $13 | $13 | 1 |
| Encore 40 Inflation Device M001394472540 | other | $13 | $13 | $13 | 1 |
| Etomidate 2 Mg/ml IV Soln | other | $13 | $13 | $13 | 1 |
| Evoke Epidural Needle 6.5' #3014 | other | $13 | $13 | $13 | 1 |
| Haemophilus Influenzae Type B Vaccine, Prp-t Conjugate | preventive | $13 | $13 | $13 | 1 |
| Hc Dress Duoderm 5.5 X 5.5 Signal | other | $13 | $13 | $13 | 1 |
| Influenza Vaccine, Quadrivalent for Nasal Administration | preventive | $13 | $13 | $13 | 1 |
| Injection, Acetaminophen (fresenius Kabi), Not Therapeutically Equivalent to ... | other | $13 | $13 | $13 | 1 |
| Injection, Amikacin Sulfate, 100 Mg | other | $13 | $12 | $13 | 2 |
| Injection, Atropine Sulfate, 0.01 Mg | other | $13 | $12 | $13 | 2 |
| Injection, Bumetanide, 0.5 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Calcium Gluconate, Not Otherwise Specified, 10 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Dicyclomine Hcl, Up to 20 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Famotidine, 0.25 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Fluphenazine Decanoate, Up to 25 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Folic Acid, 0.1 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Granisetron Hydrochloride, 100 Mcg | other | $13 | $13 | $13 | 1 |
| Injection, Magnesium Sulfate, Per 500 Mg | other | $13 | $13 | $13 | 2 |
| Injection, Milrinone Lactate, 5 Mg | other | $13 | $13 | $13 | 1 |
| Injection, Paricalcitol, 1 Mcg | other | $13 | $13 | $13 | 1 |
| Injection, Phenylephrine Hydrochloride (biorphen), 20 Micrograms | other | $13 | $13 | $13 | 1 |
| Intraocular Vancomycin 10 Mg/ Ml- 3 Ml (for Dr. Ouano) - Compounded | other | $13 | $13 | $13 | 1 |
| Kcl 20 Meq/l-d5w-0.45% Nacl | other | $13 | $13 | $13 | 1 |
| Lactated Ringers Injection | other | $13 | $13 | $13 | 1 |
| Lidocaine / Bicarb 1 Ml Syringe - Compounded | other | $13 | $13 | $13 | 1 |
| Lidocaine / Sodium Bicarb 0.09 Meq/ Ml Vial - Compounded | other | $13 | $13 | $13 | 1 |
| Lidocaine 0.5%-epi 1:200,000 | other | $13 | $13 | $13 | 1 |
| Lidocaine-epinephrine 2 %-1:100000 Ij Soln | other | $13 | $13 | $13 | 1 |
| Metoprolol Tartrate 5 Mg/5ml IV Soln | other | $13 | $13 | $13 | 1 |
| Morphine 0.1 Mg/ml Peds Oral Solution - Compounded | other | $13 | $13 | $13 | 1 |
| Moxifloxacin Intracameral 600 Mcg / 0.4 Ml Syringe-surgery Center - Compounded | surgery | $13 | $13 | $13 | 1 |
| Neostigmine 10 Mg/10 Ml Vial | other | $13 | $13 | $13 | 1 |
| Norepinephrine Bitartrate 1 Mg/ml IV Soln | other | $13 | $13 | $13 | 1 |
| Removal of Sutures; By a Physician Other Than the Physician Who Originally Cl... | surgery | $13 | $13 | $13 | 1 |
| Rocuronium Bromide 50 Mg/5ml IV Soln | other | $13 | $13 | $13 | 1 |
| Slitter Catheter for Agilis Hispro Steerable Catheter#ds3a001 | cardiac | $13 | $13 | $13 | 1 |
| Sodium Acetate 40 Meq/20 Ml Vl | other | $13 | $13 | $13 | 1 |
| Sodium Chloride 0.45% Soln | other | $13 | $13 | $13 | 1 |
| Sterile Water for Irrigation | other | $13 | $13 | $13 | 1 |
| Test for Ability to Detect and Repeat Spoken Words with Speech Recognition | other | $13 | $13 | $13 | 1 |
| Tool Locking Helix for Tendril Sts Pacing Lead#a001helx | other | $13 | $13 | $13 | 1 |
| Tranexamic Acid 1000 Mg/10ml IV Soln | other | $13 | $13 | $13 | 1 |
| Ultrasharp Scleral Knife | other | $13 | $13 | $13 | 1 |
| Valproate Sod 500 Mg/5 Ml Vl | other | $13 | $13 | $13 | 1 |
| Vancomycin 2.5 Mg/ml + Heparin 2500 Units/ml Antibiotic Catheter Mixture - Co... | cardiac | $13 | $13 | $13 | 1 |
| Vancomycin Retention Enema 500 Mg/ns 100 Ml - Compounded | other | $13 | $13 | $13 | 1 |
| Verapamil 2.5 Mg/5 Ml Syringe (for Radial Cocktail) - Compounded | other | $13 | $13 | $13 | 1 |
| Xylocaine 1%-epi 1:100,000 | other | $13 | $13 | $13 | 1 |
| Xifaxan 550 Mg Tablet | other | $13 | $13 | $13 | 1 |
| Harvest of Vein Using an Endoscope | other | $13 | $13 | $13 | 1 |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size More Than 48 Sq. In., w... | other | $13 | $13 | $13 | 1 |
| Geo Matt Chair 6ea/1cs | other | $13 | $13 | $13 | 1 |
| Needle Angiody. Ministick Max 5f 10cm #h965457561 | other | $13 | $13 | $13 | 1 |
| Nephelometry, Test Method Using Light | other | $13 | $12 | $14 | 2 |
| Injection, Succinylcholine Chloride, Up to 20 Mg | other | $13 | $12 | $14 | 2 |
| Detection Test By Immunoassay Technique for Helicobacter Pylori (gi Tract Bac... | other | $13 | $11 | $14 | 2 |
| Analysis for Antibody to Cytomegalovirus | other | $13 | $12 | $14 | 2 |
| Analysis for Antibody to Aspergillus | other | $13 | $10 | $15 | 2 |
| Detection Test By Immunoassay with Direct Visual Observation for Other Organism | other | $13 | $10 | $16 | 2 |
| Injection, Lidocaine Hcl in 5% Dextrose, 1 Mg | other | $13 | $7 | $18 | 2 |
| Injection, Morphine Sulfate (fresenius Kabi), Not Therapeutically Equivalent ... | other | $13 | $2 | $24 | 2 |
| Testing for Presence of Drug, Read By Direct Observation | other | $13 | $13 | $13 | 1 |
| Detection Test By Immunoassay Technique for Escherichia Coli 0157 | other | $13 | $13 | $13 | 1 |
| Breathing Bag OR Tube | other | $13 | $13 | $13 | 1 |
| Organic Acids Analysis | other | $13 | $13 | $13 | 1 |
| Vldl Cholesterol Level | other | $13 | $13 | $13 | 1 |
| Lactate Dehydrogenase (enzyme) Measurement | other | $13 | $13 | $13 | 1 |
| Ketosteroids, 17 (hormone) Measurement, Total | other | $13 | $13 | $13 | 1 |
| Amino Acid Level, 6 OR More Amino Acids, Quantitative, Each Specimen | lab | $13 | $13 | $13 | 1 |
| Inhibin a (reproductive Organ Hormone) Measurement | other | $13 | $13 | $13 | 1 |
| Pap Test, Automated Thin Layer Preparation; Automated System and Manual Rescr... | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Herpes Simplex Virus, Type 1 | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody to Salmonella | other | $13 | $13 | $13 | 1 |
| Analysis for Antibody, Treponema Pallidum | other | $13 | $13 | $13 | 1 |
| Activated Charcoal 25gm Oral | other | $13 | $13 | $13 | 1 |
| Activated Charcoal; 25gm Water | other | $13 | $13 | $13 | 1 |
| Creatine Kinase (cardiac Enzyme) Level, Isoenzymes | cardiac | $13 | $13 | $13 | 1 |
| Injection, Clindamycin Phosphate, 300 Mg | other | $14 | $13 | $14 | 2 |
| Injection, Hydralazine Hcl, Up to 20 Mg | other | $14 | $13 | $14 | 2 |
| Analysis for Antibody to Hiv-2 Virus | other | $14 | $14 | $14 | 1 |
| Vac Soft White Foam Sys Lrg 10"x 15" M8275067 | other | $14 | $14 | $14 | 1 |
| Valproic Acid Level, Total | other | $14 | $14 | $14 | 2 |
| Vancomycin (antibiotic) Level | other | $14 | $14 | $14 | 2 |
| Fosfomycin 3 Gm Sachet | other | $14 | $14 | $14 | 1 |
| Caplyta 42 Mg Capsule | other | $14 | $14 | $14 | 1 |
| Injection, Methotrexate Sodium, 50 Mg | other | $14 | $14 | $14 | 1 |
| Ferritin (blood Protein) Level | other | $14 | $14 | $14 | 2 |
| Benzoyl Peroxide-erythromycin 5-3 % Ex Gel | other | $14 | $14 | $14 | 1 |
| Calcium Level, Ionized | other | $14 | $14 | $14 | 2 |
| Boot Prevalon Heel Protector Petite #7310 | other | $14 | $14 | $14 | 1 |
| Sheath Storz/xomed 4mm/0" #1912000 Sc | other | $14 | $14 | $14 | 1 |
| Surgiflo Endo Applicator 34cm #ms1995 | other | $14 | $14 | $14 | 1 |
| Tube Endobronchial 35fr Left #116100350 | other | $14 | $14 | $14 | 1 |
| Tube Endobronchial 37fr Left #5 | other | $14 | $14 | $14 | 1 |
| Tube Endobronchial 39fr Left #116100390 | other | $14 | $14 | $14 | 1 |
| Tube Endobronchial 41fr Left #5 | other | $14 | $14 | $14 | 1 |
| Sirolimus Level | other | $14 | $14 | $14 | 2 |
| Measurement of Dna Antibody, Native OR Double Stranded | other | $14 | $13 | $14 | 2 |
| Cialis 10 Mg Tablet | other | $14 | $14 | $14 | 1 |
| Cialis 20 Mg Tablet | other | $14 | $14 | $14 | 1 |
| Tube Gastrostomy Kangaroo 16fr #8884720163e 5ea/case | other | $14 | $14 | $14 | 1 |
| Healon5 Pro 0.60 Ml 10340015 Dr. Ouano | other | $14 | $14 | $14 | 1 |
| Test for Hearing Various Pitches Using Earphone | other | $14 | $14 | $14 | 1 |
| Irrigator Lap Suction W/pistol Grip/conmed | other | $14 | $14 | $14 | 1 |
| Physostigmine 1 Mg/ml Ampul | other | $14 | $14 | $14 | 1 |
| Visit Complexity Inherent to Evaluation and Management Associated with Medica... | other | $14 | $14 | $14 | 1 |
| Splint System Bsn Dynacast Fiberglass Padded Roll Form 4inx15ft #7449804 1ea/... | other | $14 | $14 | $14 | 1 |
| Dermatac Drape W/granufoam Dressing Med 10pk | other | $14 | $14 | $14 | 1 |
| Kyphon Cement Mixer Only #a07a | other | $14 | $14 | $14 | 1 |
| Immunologic Analysis Technique, Unspecified | other | $14 | $14 | $14 | 1 |
| Pushr Stent for 4/5fr Pancreatic Rx M00535010 | cardiac | $14 | $14 | $14 | 1 |
| Analysis Using Chemiluminescent Technique (light and Chemical )reaction | other | $14 | $14 | $14 | 2 |
| Coagulator Bipolar .5mm Tip Non-insul#20 | other | $14 | $14 | $14 | 1 |
| Theophylline Level | other | $14 | $14 | $14 | 2 |
| Addition to Lower Extremity Orthosis, Drop Lock Retainer, Each | other | $14 | $14 | $14 | 1 |
| Ephedrine Sulfate (pressors) 50 Mg/ml Soln Wrapper | other | $14 | $14 | $14 | 1 |
| Thyroid Hormone, T3 Measurement, Total | other | $14 | $14 | $14 | 2 |
| Ortho Glass 3" X 15 #og-3l22 Rolls/case | other | $14 | $14 | $14 | 1 |
| Sole Wedge, Outside Sole | other | $14 | $14 | $14 | 1 |
| Hepatitis C Antibody Measurement | other | $14 | $14 | $14 | 2 |
| Irrigation Tubeset for Bone Scalpel Mxb-t 5/b | other | $14 | $14 | $14 | 1 |
| Injection, Tafasitamab-cxix, 2 Mg | other | $14 | $14 | $14 | 1 |
| Neomycin-polymyxin-hc Ear Soln | other | $14 | $14 | $14 | 1 |
| Lipoprotein (a) Level | other | $14 | $14 | $14 | 1 |
| Vac Veraflo Veralink Cassette #ultlnk0500 | other | $14 | $14 | $14 | 1 |
| Bowl Cement Smart Mix #5401-76 | other | $14 | $14 | $14 | 1 |
| Hydrocortisone 2.5 % Ex Crea | other | $14 | $14 | $14 | 1 |
| Hydrocortisone 2.5% Cream | other | $14 | $14 | $14 | 1 |
| Nipple Prosthesis, Prefabricated, Reusable, Any Type, Each | other | $14 | $14 | $14 | 1 |
| Pin Fixation Pk #07.00656.002 | other | $14 | $14 | $14 | 1 |
| Special Casting Material | other | $14 | $14 | $14 | 1 |
| Trocar Cannula Alcon 25g #8065751448 | other | $14 | $14 | $14 | 1 |
| Analysis for Antibody to Herpes Simplex Virus | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Rubella | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Toxoplasma | other | $14 | $14 | $14 | 2 |
| Analysis for Antibody to Cryptococcus | other | $14 | $14 | $14 | 2 |
| Mask CPAP O2-resq Sys Sz Adult Med | other | $14 | $14 | $14 | 1 |
| Addition to Upper Extremity Orthosis, Sock, Fracture OR Equal, Each | other | $14 | $14 | $14 | 1 |
| Mammary Support Medium W/cups | other | $14 | $14 | $14 | 1 |
| Levalbuterol Tar Hfa 45mcg Inh | other | $14 | $14 | $14 | 1 |
| Cyanocobalamin (vitamin B-12) Level | other | $14 | $13 | $15 | 2 |
| Semen Evaluation Volume, Sperm Count, Motility and Analysis | other | $14 | $12 | $16 | 2 |
| Injection, Phenylephrine Hydrochloride, 20 Micrograms | other | $14 | $9 | $18 | 2 |
| Application of Ultrasound, Each 15 Minutes | imaging | $14 | $14 | $14 | 1 |
| Application of Mechanical Traction | other | $14 | $14 | $14 | 1 |
| Protein C Antigen (clotting Inhibitor) Measurement | other | $14 | $14 | $14 | 1 |
| Amino Acid Analysis, Multiple Amino Acids, Qualitative, Each Specimen | lab | $14 | $14 | $14 | 1 |
| Nacl 0.45 500 | other | $14 | $14 | $14 | 1 |
| Protein Measurement, Body Fluid | other | $14 | $14 | $14 | 1 |
| Injection, Heparin Sodium, Per 1000 Units | other | $14 | $14 | $14 | 1 |
| Special Stain for Parasites | other | $14 | $14 | $14 | 1 |
| Detection Test By Immunoassay Technique for Influenza Virus | other | $14 | $14 | $14 | 1 |
| Application of Electrical Stimulation with Therapist Present, Each 15 Minutes | other | $14 | $14 | $14 | 1 |
| Analysis for Antibody to West Nile Virus | other | $14 | $14 | $14 | 1 |
| Oxalate Level | other | $14 | $14 | $14 | 1 |
| Rbc Sed Rate Nonautomated | other | $14 | $14 | $14 | 1 |
| Venipuncture | lab | $15 | $1 | $22 | 6 |
| Microsomal Antibodies (autoantibody) Measurement | other | $15 | $15 | $15 | 2 |
| Geo Matt-foam Pressure Air 34x72x3.5 4ea/1cs | other | $15 | $15 | $15 | 1 |
| Ammonia Level | other | $15 | $15 | $15 | 2 |
| Carbamazepine Level, Total | other | $15 | $15 | $15 | 2 |
| Prealbumin (protein) Level | other | $15 | $15 | $15 | 2 |
| Angiotensin L - Converting Enzyme (ace) Level | other | $15 | $15 | $15 | 2 |
| Carbamazepine 100 Mg/5ml Po Susp | other | $15 | $15 | $15 | 1 |
| 4fr Pigtail | other | $15 | $15 | $15 | 1 |
| Blower Mister Kit Clearview #22150 | other | $15 | $15 | $15 | 1 |
| Crutches Underarm, Other Than Wood, Adjustable OR Fixed, Pair, with Pads, Tip... | other | $15 | $15 | $15 | 1 |
| Detection Test By Immunoassay with Direct Visual Observation for Influenza Virus | other | $15 | $14 | $15 | 2 |
| Inflation Device Sphere 20cc #g31027 | other | $15 | $15 | $15 | 1 |
| Plate Tack Acumed #pl-ptack | other | $15 | $15 | $15 | 1 |
| Test for Screening Hearing Using a Probe | preventive | $15 | $15 | $15 | 1 |
| Lidocaine Level | other | $15 | $15 | $15 | 2 |
| Folic Acid Level, Serum | other | $15 | $15 | $15 | 2 |
| Urine Porphyrins (metabolism Substance) Measurement | other | $15 | $15 | $15 | 2 |
| Hydrocortisone 2.5% Ointment | other | $15 | $15 | $15 | 1 |
| Tolvaptan 15 Mg Tablet | other | $15 | $15 | $15 | 1 |
| Phosphatase (enzyme) Measurement, Alkaline, Isoenzymes | other | $15 | $15 | $15 | 1 |
| Coag Bipolar Bayonet Non-insulated Tip1.5mm | other | $15 | $15 | $15 | 1 |
| Desmopressin 10 Mcg/0.1 Ml Spr | other | $15 | $15 | $15 | 1 |
| Tall Air Walker Lg #b | other | $15 | $15 | $15 | 1 |
| Tall Air Walker Med #b | other | $15 | $15 | $15 | 1 |
| Tall Air Walker Sm #b | other | $15 | $15 | $15 | 1 |
| Tall Air Walker Xs #b | other | $15 | $15 | $15 | 1 |
| Fitting/orientation/checking of Hearing Aid | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Left Knee Adult 15.5-18.5" Small #11-0261 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Left Knee Adult 18.5-21" Medium #11-0261 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Left Knee Adult 21-23.5" Large #11-0261 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Left Knee Adult 23.5-26.5" X-large #11-0261 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Right Knee Adult 18.5-21" Medium #11-0260 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Right Knee Adult 21-23.5" Large #11-0260 | other | $15 | $15 | $15 | 1 |
| Tru-pull Lite Right Knee Adult 23.5-26.5" X-large #11-0260 | other | $15 | $15 | $15 | 1 |
| Placement of Strapping to Ankle OR Foot | other | $15 | $15 | $15 | 1 |
| Test to Assess Balance During Warm OR Cool Irrigation in Both Ears | other | $15 | $15 | $15 | 1 |
| Drill Solid Side Cutting 2x40 Drll-ssc | other | $15 | $15 | $15 | 1 |
| Pressure Guard 12cm #82050 10ea/1bx | other | $15 | $15 | $15 | 1 |
| Grasper Babcock 533-005-925 8ea/1bx | other | $15 | $15 | $15 | 1 |
| Tube Endobronchial 35fr Right #126035 | other | $15 | $15 | $15 | 1 |
| Tube Endobronchial 37fr Right #126037 | other | $15 | $15 | $15 | 1 |
| Tube Endobroncial 39fr Right #126039 | other | $15 | $15 | $15 | 1 |
| Examination of Archival Tissue for Genetic Analysis | other | $15 | $15 | $15 | 1 |
| Detection of Infectious Agent Antibody, Quantitative | other | $15 | $15 | $15 | 1 |
| Temno Evolution Biopsy Needles Ctt1811 | lab | $15 | $15 | $15 | 1 |
| Temno Evolution Biopsy Needles Ctt1815 | lab | $15 | $15 | $15 | 1 |
| Temno Evolution Biopsy Needles Ctt1820 | lab | $15 | $15 | $15 | 1 |
| Gonadotropin, Chorionic (reproductive Hormone) Level | other | $15 | $15 | $15 | 2 |
| Lantus 100 Unit/ml Vial | other | $15 | $15 | $15 | 1 |
| Amikacin (antibiotic) Level | other | $15 | $15 | $15 | 2 |
| For Diabetics Only, Multiple Density Insert, Made By Direct Carving with Cam ... | other | $15 | $15 | $15 | 1 |
| Ethyl Chloride Spray | other | $15 | $15 | $15 | 1 |
| Drill Solid Side Cuttin 2.5x40 Drll-ssc | other | $15 | $15 | $15 | 1 |
| Inflation Device Stonemaster V #maj | other | $15 | $15 | $15 | 1 |
| Screening Papanicolaou Smear; Obtaining, Preparing and Conveyance of Cervical... | preventive | $15 | $15 | $15 | 1 |
| Stool Analysis for Blood, By Fecal Hemoglobin Determination By Immunoassay | other | $15 | $15 | $15 | 1 |
| Stylet Kit 58cm Ds06003/58 Ds06003 | other | $15 | $15 | $15 | 1 |
| Exam of Visual Field with Limited Testing | other | $15 | $15 | $15 | 1 |
| Lidocaine Hcl 2% Syringe | other | $15 | $15 | $15 | 1 |
| Pin Skull Disp | other | $15 | $15 | $15 | 1 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Nuclear An... | imaging | $15 | $15 | $15 | 2 |
| Injection, Pertuzumab, 1 Mg | other | $15 | $15 | $15 | 1 |
| Analysis for Antibody to Legionella | other | $15 | $15 | $15 | 2 |
| Gradient Compression Gauntlet, Each | other | $15 | $15 | $15 | 1 |
| Phenobarbital Level | other | $15 | $15 | $15 | 2 |
| Tray Umbilical Vessel Insertion #43201 | other | $15 | $15 | $15 | 1 |
| Protein S (clotting Inhibitor) Measurement | other | $15 | $15 | $15 | 2 |
| Diag Catheter 4fr Vert #srd6108 | cardiac | $15 | $15 | $15 | 1 |
| Radial Cocktail 10 Ml Kit (2-5 Ml Syringes)-compounded | other | $15 | $15 | $15 | 1 |
| Shoulder Suspension Kit 72200195 | other | $15 | $15 | $15 | 1 |
| Sodium Chloride 3% IV Soln | other | $15 | $15 | $15 | 1 |
| Marcaine 0.25%-epi 1:200,000 | other | $15 | $15 | $15 | 1 |
| Mycoplasma Culture | lab | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis Large Left 29rho-l-l | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis Large Right 29rho-l-r | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis Medium Right 29rho-m-r | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis Small Left 29rho-s-l | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis Small Right 29rho-s-r | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis X-large Left 29rho-xl-l | other | $15 | $15 | $15 | 1 |
| Resting Hand Orthosis X-large Right 29rho-xl-r | other | $15 | $15 | $15 | 1 |
| Resting Hand Othosis Medium Left 29rho-m-l | other | $15 | $15 | $15 | 1 |
| Brachytherapy Source, Non-stranded, Iodine-125, Per Source | other | $15 | $15 | $15 | 1 |
| Hc Epidural Anesthesia Time - Each Incremental 15 Minute | other | $15 | $15 | $15 | 1 |
| Hc Spinal Anes Ea Addl 15 Min | other | $15 | $15 | $15 | 1 |
| Stylet Kit 52cm Ds06001-52 Ds06001/52 | other | $15 | $15 | $15 | 1 |
| Tall Air Walker Xl #b | other | $15 | $15 | $15 | 1 |
| Pleur-evac Sahara Chest Drain #s-1100-08lf 6ea/case | other | $15 | $15 | $15 | 1 |
| Brachytherapy Needle | other | $15 | $15 | $15 | 1 |
| Confirmation Test for Hepatitis C Antibody | other | $15 | $15 | $15 | 1 |
| Thyroid Hormone, T3 Measurement, Reverse | other | $15 | $13 | $16 | 2 |
| Ige (immune System Protein) Level | other | $15 | $13 | $16 | 2 |
| Bile Acids Level, Total | other | $15 | $13 | $17 | 2 |
| Measurement of Substance Using Immunoassay Technique | other | $15 | $13 | $17 | 2 |
| Injection, Methylprednisolone Acetate, 1 Mg | other | $15 | $11 | $18 | 2 |
| Quinidine Level | other | $15 | $15 | $15 | 1 |
| Hemoglobin Analysis and Measurement, Chromatography | other | $15 | $15 | $15 | 1 |
| Ringers Injection-500cc | other | $15 | $15 | $15 | 1 |
| Injection, Neostigmine Methylsulfate, Up to 0.5 Mg | other | $15 | $15 | $15 | 1 |
| Application of Whirlpool Therapy | other | $15 | $15 | $15 | 1 |
| Pathology Examination of Tissue Using a Microscope, Limited Examination | lab | $15 | $15 | $15 | 1 |
| Inhalation Treatment for Acute Airway Obstruction, Each Additional Hour | other | $15 | $15 | $15 | 1 |
| Unclassified Drugs | other | $16 | $1 | $30 | 2 |
| Injection Fluconazole, 200 Mg | other | $16 | $13 | $19 | 2 |
| Injection, Dopamine Hcl, 40 Mg | other | $16 | $13 | $18 | 2 |
| Urine Vanillylmandelic Acid | other | $16 | $16 | $16 | 2 |
| Monoka Mini #s1-1500u | other | $16 | $16 | $16 | 1 |
| Vascular Sheath A/v Small Yellow | other | $16 | $16 | $16 | 1 |
| Needle/sheath Injector #nm-221c-0427 1ea/1bx | other | $16 | $16 | $16 | 1 |
| Picc Introducer 6.0fr Micro Bard | other | $16 | $16 | $16 | 1 |
| Detection Test By Immunofluorescent Technique for Legionella Pneumophila | other | $16 | $16 | $16 | 1 |
| Injection, Dalbavancin, 5 Mg | other | $16 | $16 | $16 | 1 |
| Ped Trach Tapershape Cuff 5.0mm Id 7.3mm Od 5.0pcf 1ea | other | $16 | $16 | $16 | 1 |
| Ped Trach Tapershape Cuff 5.5mm Id 7.9mm Od 5.5pcf 1ea | other | $16 | $16 | $16 | 1 |
| Shiley Pediatric Tracheostomy Tubes with Taperguard Cuff 3.5pcf | other | $16 | $16 | $16 | 1 |
| Shiley Pediatric Tracheostomy Tubes with Taperguard Cuff 4.0pcf | other | $16 | $16 | $16 | 1 |
| Tube Trach Pediatric 4.5 Cuff Medtronic #4.5pcf | other | $16 | $16 | $16 | 1 |
| Kcl 40 Meq/l-d5w-0.9% Nacl | other | $16 | $16 | $16 | 1 |
| Potassium Cl 20 Meq-0.45% Nacl | other | $16 | $16 | $16 | 1 |
| Cannula Tandem Xl Triple Lumen ERCP M00535700 | other | $16 | $16 | $16 | 1 |
| Cannula Eopa Arterial 22fr 77622 10ea/1pk | other | $16 | $16 | $16 | 1 |
| Loop Cutting 24fr #m0068802611 | other | $16 | $16 | $16 | 1 |
| Removal of Impacted Ear Wax By Washing | surgery | $16 | $16 | $16 | 1 |
| Repair Prosthetic Device, Labor Component, Per 15 Minutes | surgery | $16 | $16 | $16 | 1 |
| Gabapentin 250 Mg/5 Ml Soln | other | $16 | $16 | $16 | 1 |
| 10.0mm Shiley Flex Cuffless Reus Trach 10un10r | other | $16 | $16 | $16 | 1 |
| Orthopedic Footwear, Ladies Shoe, Depth Inlay, Each | other | $16 | $16 | $16 | 1 |
| Trach 4cfs 6.5mm Adt Flex Trach Cuffless 4un65r | other | $16 | $16 | $16 | 1 |
| Trach Tube 6cfs #6un75r | other | $16 | $16 | $16 | 1 |
| Trach Tube 8cfs #8un85r | other | $16 | $16 | $16 | 1 |
| Verapamil 10 Mg/4 Ml Vial | other | $16 | $16 | $16 | 1 |
| Thyroglobulin (thyroid Protein) Antibody Measurement | other | $16 | $16 | $16 | 2 |
| Viscoat #8065-18 | other | $16 | $16 | $16 | 1 |
| Shiley Xlt Extended -length Tracheostomy Tube Distal Extension Size 6 Uncuffe... | other | $16 | $16 | $16 | 1 |
| Trach Cuff Xlt 7.0mm #70xltcp | other | $16 | $16 | $16 | 1 |
| Tracheostomy Tube Shiley Uncuffed Id 8.0mm 105mm #80xltud | other | $16 | $16 | $16 | 1 |
| Tracheostomy Tube Shiley Uncuffed Size 6 Id 6mm 95mm 60xltup | other | $16 | $16 | $16 | 1 |
| Tube Trach Cuff 6.0mm Xlt Prox | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 6.0 Distal Ext Cuffed | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 7.0 Distal Ext Cuffed | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 7.0 Uncuffed Proximal #70xltup | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 8.0 Distal Ext Cuffed | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 8.0 Proximal Ext Cuffed | other | $16 | $16 | $16 | 1 |
| Tube Trach Xlt 8.0 Uncuff Proximal #80xltup | other | $16 | $16 | $16 | 1 |
| 20fr Standard Peg Kit Push Box of 2 #m00568211 | other | $16 | $16 | $16 | 1 |
| 24fr Standard Peg Kit Pull with Enfit M00509061 | other | $16 | $16 | $16 | 1 |
| Aveta Waste Management Accessory 3.0 #205-2036 6ea/ct | other | $16 | $16 | $16 | 1 |
| Breast Prosthesis, Mastectomy Bra, without Integrated Breast Prosthesis Form,... | other | $16 | $16 | $16 | 1 |
| Cast Supplies, Long Leg Cast, Pediatric (0-10 Years), Fiberglass | other | $16 | $16 | $16 | 1 |
| Gastrostomy 24fr Peg Kit/gastrodome #6824 | other | $16 | $16 | $16 | 1 |
| Influenza Vaccine, Trivalent, Derived From Cell Cultures, Antibiotic Free, 0.... | lab | $16 | $16 | $16 | 1 |
| Lap Gas Conditioning Device Vessel Guardian | other | $16 | $16 | $16 | 1 |
| Passport 12 X 3 #ar-6592-12 | other | $16 | $16 | $16 | 1 |
| Pessary, Reusable, Rubber, Any Type | other | $16 | $16 | $16 | 1 |
| Poliovirus Vaccine | preventive | $16 | $16 | $16 | 1 |
| Service Provided in an Office During Regularly Scheduled Office Hours, Evenin... | other | $16 | $16 | $16 | 1 |
| Thyroglobulin (thyroid Related Hormone) Level | other | $16 | $16 | $16 | 1 |
| Tobramycin (antibiotic) Level | other | $16 | $16 | $16 | 2 |
| Anesthesia for Electroshock Therapy | other | $16 | $16 | $16 | 1 |
| Vecuronium 10 Mg Vial | other | $16 | $16 | $16 | 1 |
| Vecuronium Bromide 10 Mg IV Solr | other | $16 | $16 | $16 | 1 |
| Beta-2 Microglobulin (protein) Level | other | $16 | $16 | $16 | 2 |
| Pelvic Exam | other | $16 | $16 | $16 | 1 |
| Catheter Endo 5.5fr Ercp-1-cramer #g21765 | cardiac | $16 | $16 | $16 | 1 |
| Metatarsal Bar Wedge, Rocker | other | $16 | $16 | $16 | 1 |
| Mercury Level | other | $16 | $16 | $16 | 2 |
| Tube Endobronchial 37fr Right #116200370 | other | $16 | $16 | $16 | 1 |
| Cortisol (hormone) Measurement, Total | other | $16 | $16 | $16 | 2 |
| Purstring 65 Instrument Medtronic #020242 Case/3ea | other | $16 | $16 | $16 | 1 |
| Gentamicin (antibiotic) Level | other | $16 | $16 | $16 | 2 |
| Splint Nasal Denver Aluminum Sm/md #10-1500-05ks | other | $16 | $16 | $16 | 1 |
| Temno Evolution Biopsy Needle Ctt2011 | lab | $16 | $16 | $16 | 1 |
| Temno Evolution Biopsy Needles Ctt2015 | lab | $16 | $16 | $16 | 1 |
| Aminolevulinic Acid (protein) Level | other | $16 | $16 | $16 | 1 |
| Catheter, Guiding | cardiac | $16 | $16 | $16 | 1 |
| Dermagraft, Per Square Centimeter | other | $16 | $16 | $16 | 1 |
| Hc Regional Anesthesia Time - Each Incremental 15 Minutes | other | $16 | $16 | $16 | 1 |
| Influenza Vaccine, Trivalent for Nasal Administration | preventive | $16 | $16 | $16 | 1 |
| Safeguard 24cm #82000 10ea/1bx | other | $16 | $16 | $16 | 1 |
| L.e.t. (lido-epineph-tetra) Ge | other | $16 | $16 | $16 | 1 |
| Haloperidol Level | other | $16 | $16 | $16 | 1 |
| Screening Examination of Specimen Cells, Screening and Interpretation | lab | $16 | $16 | $16 | 1 |
| Screening Examination of Specimen Cells, Extended Study | lab | $16 | $16 | $16 | 1 |
| Cement Mixer Optivac Triple Mi | other | $16 | $16 | $16 | 1 |
| Glucose Blood Test | lab | $16 | $16 | $16 | 1 |
| Prothrombin Time | lab | $16 | $16 | $16 | 1 |
| Assay of Urea Nitrogen | other | $16 | $16 | $16 | 1 |
| Rbc Sed Rate Automated | other | $16 | $16 | $16 | 1 |
| Injection, Methocarbamol, Up to 10 Ml | other | $17 | $13 | $20 | 2 |
| Primidone Level | other | $17 | $17 | $17 | 2 |
| Addition to Lower Extremity, Below Knee, Fork Strap | other | $17 | $17 | $17 | 1 |
| Human Growth Hormone Level | other | $17 | $17 | $17 | 1 |
| Cns Monitor Icp Drain Bag 1ea | other | $17 | $17 | $17 | 1 |
| Cortisol (hormone) Measurement, Free | other | $17 | $17 | $17 | 2 |
| Catheter Jet Ventilation Adult 30-02-013 | cardiac | $17 | $17 | $17 | 1 |
| Catheter Jet Ventilation Child 30-02-014 | cardiac | $17 | $17 | $17 | 1 |
| Catheter Jet Ventilation Infant 30-02-018 | cardiac | $17 | $17 | $17 | 1 |
| Detection Test By Immunoassay Technique for Streptococcus, Group a | other | $17 | $17 | $17 | 2 |
| Glycated Protein Level | other | $17 | $17 | $17 | 2 |
| Alpha-fetoprotein (afp) Level, Serum | other | $17 | $17 | $17 | 2 |
| Starchmark Ultracore Marker Ss 14g #stmk14gss | other | $17 | $17 | $17 | 1 |
| Ultra Clip Dual Trigger Marker #862017d | other | $17 | $17 | $17 | 1 |
| Ultra Clip Dual Trigger Marker Ribb #863017d | other | $17 | $17 | $17 | 1 |
| Ultraclip Dual Trigger Marker 108 Coil | other | $17 | $17 | $17 | 1 |
| Ultraclip Dual Trigger Marker 108 Venus | other | $17 | $17 | $17 | 1 |
| Ultraclip Dual Trigger Marker Titanium Heart | cardiac | $17 | $17 | $17 | 1 |
| Stool Fat OR Lipids Analysis, Quantitative | lab | $17 | $17 | $17 | 2 |
| Injection, Testosterone Cypionate, 1 Mg | other | $17 | $17 | $17 | 1 |
| Analysis for Antibody | other | $17 | $17 | $17 | 2 |
| Analysis for Antibody to Helicobacter Pylori | other | $17 | $17 | $17 | 2 |
| Carnitine Level | other | $17 | $17 | $17 | 2 |
| Aprepitant, Oral, 5 Mg | other | $17 | $17 | $17 | 1 |
| Evaluation of Cardiac Rhythm Monitor System | cardiac | $17 | $17 | $17 | 1 |
| Ultrasound of Heart Blood Flow, Valves and Chambers | imaging | $17 | $17 | $17 | 1 |
| Metanephrines Level | other | $17 | $17 | $17 | 2 |
| Thyroid Hormone, T3 Measurement, Free | other | $17 | $17 | $17 | 2 |
| Pump Cold Therapy Polar Care Cube | other | $17 | $17 | $17 | 1 |
| Smark Atec-2s-13 | other | $17 | $17 | $17 | 1 |
| Catheter Ph Internal 10cm Disp Dual Versaflex | cardiac | $17 | $17 | $17 | 1 |
| Education and Training for Patient Self-management, Each 30 Minutes | other | $17 | $17 | $17 | 1 |
| Piercing of Ear | other | $17 | $17 | $17 | 1 |
| Analysis for Antibody Borrelia Burgdorferi | other | $17 | $17 | $17 | 2 |
| Injection, Epoprostenol, 0.5 Mg | other | $17 | $17 | $17 | 1 |
| Restraint Vest Xxlrg #m227b-xl | other | $17 | $17 | $17 | 1 |
| Splint Ortho-glass 4"x15' 2rl/cs #og-4l2 | other | $17 | $17 | $17 | 1 |
| Vascular Sheath Blue #9009 | other | $17 | $17 | $17 | 1 |
| Testing for Presence of Drug, Read By Instrument Assisted Observation | other | $17 | $17 | $17 | 1 |
| Analysis for Antibody to Hepatitis D Virus | other | $17 | $17 | $17 | 1 |
| Miami Slim Lumbar 2xl #lmbsl | other | $17 | $17 | $17 | 1 |
| Injection, Pyridoxine Hcl, 100 Mg | other | $17 | $17 | $17 | 1 |
| Potassium Alum Powder | other | $17 | $17 | $17 | 1 |
| Crown Fistula Wound 00860013000301 | other | $17 | $17 | $17 | 1 |
| Myelin Basic Protein (nerve Protein) Level, Spinal Fluid | other | $17 | $17 | $17 | 1 |
| Balloon Armada 35 Wh 12x80x135cm #b2120 | other | $17 | $17 | $17 | 1 |
| Bellaire Comfort Lso Universal Fits Waist Circumference: 25-60inch (64-152cm)... | other | $17 | $17 | $17 | 1 |
| Wound Retractor/protector Medium | other | $17 | $17 | $17 | 1 |
| Wound Retractor/protector Small 5 Ea/bx #c8401 | other | $17 | $17 | $17 | 1 |
| Trimark Eviva 2s | other | $17 | $17 | $17 | 1 |
| Trimark Td 1309 | other | $17 | $17 | $17 | 1 |
| Electrode-bugbee Fulgurating 5frx58cm #be | other | $17 | $17 | $17 | 1 |
| Infusion Supplies for External Drug Infusion Pump, Per Cassette OR Bag | surgery | $17 | $17 | $17 | 1 |
| Surgicel 1/2 X 2 #1955s 12ea/cs | other | $17 | $17 | $17 | 1 |
| Valved Entry System 23ga 4mm #8065751585 | other | $17 | $17 | $17 | 1 |
| Miami Slim Lumbar 6xl #lmbsl | other | $17 | $17 | $17 | 1 |
| Tcc-ez Regular Boot Tcc21100 1 Each | other | $17 | $17 | $17 | 1 |
| Virus Isolation, Centrifuge Enhanced | other | $17 | $13 | $20 | 2 |
| Therapy Procedure for Nutrition Management, Each 15 Minutes | other | $17 | $14 | $20 | 2 |
| Guide Wire | other | $17 | $8 | $25 | 2 |
| Phospholipid Test | lab | $17 | $17 | $17 | 1 |
| Phosphatidylglycerol (amniotic Fluid Organic Acid) Level | other | $17 | $17 | $17 | 1 |
| Procainamide Level, with Metabolites | other | $17 | $17 | $17 | 1 |
| Analysis for Antibody (igm) to West Nile Virus | other | $17 | $17 | $17 | 1 |
| Catheter, Intradiscal | cardiac | $17 | $17 | $17 | 1 |
| D-5 Lr 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5- 1/2 500cc | other | $17 | $17 | $17 | 1 |
| D-5- 1/4 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5- Lr 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-1/2 Ns 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-1/4 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-s 100o Cc | other | $17 | $17 | $17 | 1 |
| D-5-s 500 Cc | other | $17 | $17 | $17 | 1 |
| D-5-w 1000 Cc | other | $17 | $17 | $17 | 1 |
| D-5-w 500 Cc | other | $17 | $17 | $17 | 1 |
| Lactated Ringers 500 Cc | other | $17 | $17 | $17 | 1 |
| Lactated Ringers-1000cc | other | $17 | $17 | $17 | 1 |
| Nacl 0.45 1000 Cc | other | $17 | $17 | $17 | 1 |
| Sodium Chlor(nacl)1000cc C\20m | other | $17 | $17 | $17 | 1 |
| Sodium Chloride 500 Cc | other | $17 | $17 | $17 | 1 |
| Aspiration of Cyst of Breast, Each Additional Cyst | other | $17 | $17 | $17 | 1 |
| Therapy Procedure in a Group Setting | other | $17 | $17 | $17 | 1 |
| Injection, Glycopyrrolate, 0.1 Mg | other | $17 | $17 | $17 | 1 |
| Sterile Water,irregation 250cc | other | $17 | $17 | $17 | 1 |
| Technetium Tc-99m Exametazime, Diagnostic, Per Study Dose, Up to 25 Millicuries | other | $17 | $17 | $17 | 1 |
| Assay of Protein Urine | other | $17 | $17 | $17 | 1 |
| Active Wound Care >20 Cm | other | $17 | $17 | $17 | 1 |
| Assay of Urine Sodium | other | $17 | $17 | $17 | 1 |
| Blood Draw (Venipuncture) | lab | $18 | $1 | $11,660 | 18 |
| Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 Mg | other | $18 | $4 | $32 | 2 |
| Injection, Esmolol Hydrochloride, 10 Mg | other | $18 | $15 | $21 | 2 |
| Dermatac Drape W/granufoam Dressing Lg 10pk | other | $18 | $18 | $18 | 1 |
| Amox-clav 600-42.9 Mg/5 Ml Sus | other | $18 | $18 | $18 | 1 |
| Amoxicillin-pot Clavulanate 600-42.9 Mg/5ml Po Susr | other | $18 | $18 | $18 | 1 |
| Protein Test for Diagnosis and Monitoring of Bladder Cancer | other | $18 | $18 | $18 | 1 |
| Rom Elbow Orthosis Right #w | other | $18 | $18 | $18 | 1 |
| Gastrin (gi Tract Hormone) Level | other | $18 | $18 | $18 | 2 |
| Folic Acid Level, Rbc | other | $18 | $18 | $18 | 2 |
| 10.0mm Shiley Flex Cuffed Reus Trach 10cn10r | other | $18 | $18 | $18 | 1 |
| 6.5mm Shiley Flex Cuffed Reus Trach 4cn65r | other | $18 | $18 | $18 | 1 |
| 8.5mm S Shiley Flex Cuffed Reus Trach 8cn85r | other | $18 | $18 | $18 | 1 |
| Trach Tube Shiley Cuffed 7mm Id 10.1mm Od 68mm Reusable 5cn70r 1ea | other | $18 | $18 | $18 | 1 |
| Fogarty Insert Safe Jaw 33mm Safehy33 | other | $18 | $18 | $18 | 1 |
| Packing Silverstein #14 | other | $18 | $18 | $18 | 1 |
| Tray Snarecoil Bone Marrow 11x4 W/rbn-114 Needle No Aspiration Needle Include... | other | $18 | $18 | $18 | 1 |
| Vascular Sheath Large Orange #9009 | other | $18 | $18 | $18 | 1 |
| Cement Mixer Smart Mix Mini #5401-39 | other | $18 | $18 | $18 | 1 |
| Check of Hearing Aid, 1 Ear | other | $18 | $18 | $18 | 1 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, Limited Study | other | $18 | $18 | $18 | 1 |
| Marker Biopsy Site Stainless Steel Stoplight Shape for Securmark MRI #smark-m... | imaging | $18 | $18 | $18 | 1 |
| Marker Breast Biopsy Clip 9 Gauge Stainless Steel Securmark Atec #smark-m-ss2... | lab | $18 | $18 | $18 | 1 |
| Marker Breast Biopsy Clip Stainless Steel Securmark Atec #smark-m-ss1 10ea/box | lab | $18 | $18 | $18 | 1 |
| Placement of Ear Probe for Computerized Measurement of Sound with Interpretat... | other | $18 | $18 | $18 | 1 |
| Cold Therapy Unit Donjoy Iceman Clear 11 | other | $18 | $18 | $18 | 1 |
| Injection, Secukinumab, Intravenous, 1 Mg | other | $18 | $18 | $18 | 1 |
| Kcl 10 Meq/l-d5w-0.45% Nacl | other | $18 | $18 | $18 | 1 |
| Kcl 20 Meq/l-d5w-0.9% Nacl | other | $18 | $18 | $18 | 1 |
| Kcl 40 Meq/l-d5w-0.45% Nacl | other | $18 | $18 | $18 | 1 |
| Clotting Factor Viii (ahg) Measurement | other | $18 | $18 | $18 | 1 |
| Measurement of Antibody for Assessment of Autoimmune Disorder, Any Method | other | $18 | $17 | $18 | 2 |
| Loop Cutting 24fr .012 #g46209 | other | $18 | $18 | $18 | 1 |
| Compass Lumbar Puncture #clph2o001-5 5ea/case | other | $18 | $18 | $18 | 1 |
| Aztreonam 2 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $18 | $18 | $18 | 1 |
| Cyclosporine Level | other | $18 | $18 | $18 | 2 |
| Mycophenolate (mycophenolic Acid) Level | other | $18 | $18 | $18 | 1 |
| Cefdinir 250 Mg/5 Ml Susp | other | $18 | $18 | $18 | 1 |
| Cefdinir 250 Mg/5ml Po Susr | other | $18 | $18 | $18 | 1 |
| Injection, Anifrolumab-fnia, 1 Mg | other | $18 | $18 | $18 | 1 |
| 14fr Entuit Gastrostomy Tube #g35615 | other | $18 | $18 | $18 | 1 |
| Entuit Gastrostomy Tube | other | $18 | $18 | $18 | 1 |
| Gastrostomy/jejunostomy Tube, Low-profile, Any Material, Any Type, Each | other | $18 | $18 | $18 | 1 |
| Physician OR Allowed Practitioner Re-certification for Medicare-covered Home ... | other | $18 | $18 | $18 | 1 |
| Rom Elbow Orthosis Left #w | other | $18 | $18 | $18 | 1 |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Viral Capsid | other | $18 | $18 | $18 | 2 |
| Cystotome Kelman Sharp 22g #e01412s | other | $18 | $18 | $18 | 1 |
| Auto Effluent Set #115370 Ca/ 8ea | other | $18 | $18 | $18 | 1 |
| Injection, Triamcinolone Acetonide, Preservative-free, Extended-release, Micr... | other | $18 | $18 | $18 | 1 |
| Vascular Sheath Sm Green | other | $18 | $18 | $18 | 1 |
| 7.5mm Shiley Flex Cuffed Reus Trach 6cn75r | other | $18 | $18 | $18 | 1 |
| Cefpodoxime Proxetil 100 Mg/5ml Po Susr | other | $18 | $18 | $18 | 1 |
| Pap Test, Evaluation of Fine Needle Aspirate, Immediate, Each Additional Eval... | other | $18 | $18 | $18 | 1 |
| Test for Abnormal Eye Movement without Stimulus | other | $18 | $18 | $18 | 1 |
| Antibody Identification Test, Platelet Antibodies | other | $18 | $18 | $18 | 2 |
| PSA (prostate Specific Antigen) Measurement, Free | other | $18 | $18 | $18 | 2 |
| PSA (prostate Specific Antigen) Measurement, Total | other | $18 | $18 | $18 | 2 |
| Measurement of Substance Using Immunoassay Technique, By Radioimmunoassay | other | $18 | $18 | $18 | 1 |
| For Diabetics Only, Multiple Density Insert, Custom Molded From Model of Pati... | other | $18 | $18 | $18 | 1 |
| Soft-flow Angled Tip Arterial Cannula with Suture Bulb 21fr X 14" ( 7.0mm ) 5761 | other | $18 | $18 | $18 | 1 |
| Pap Test, Manual Screening | preventive | $18 | $16 | $20 | 2 |
| Amino Acid Analysis, Quantitative, Each Specimen | lab | $18 | $13 | $23 | 2 |
| Abreva 2 Gm Tube | other | $18 | $18 | $18 | 1 |
| Glycine Sol.1.5%-3000cc | other | $18 | $18 | $18 | 1 |
| Plasmalyte-m | other | $18 | $18 | $18 | 1 |
| Sodium Chloride 1000 Cc | other | $18 | $18 | $18 | 1 |
| Hydroxycorticosteroids, 17 (adrenal Gland Hormone) Level | other | $18 | $18 | $18 | 1 |
| Homocysteine (amino Acid) Level | other | $18 | $18 | $18 | 1 |
| Platelet Function Test | other | $18 | $18 | $18 | 1 |
| Injection, Levetiracetam, 10 Mg | other | $18 | $18 | $18 | 1 |
| Ringers Injection-1000cc | other | $18 | $18 | $18 | 1 |
| Injection, Iron Dextran, 50 Mg | other | $18 | $18 | $18 | 1 |
| Application of Medication Using Electrical Current, Each 15 Minutes | other | $18 | $18 | $18 | 1 |
| Sterile Water,irrigation 3000c | other | $18 | $18 | $18 | 1 |
| Sodium Bicarbonate 8.4% IV | other | $18 | $18 | $18 | 1 |
| Urine Analysis for Thromboxane | other | $18 | $18 | $18 | 1 |
| ABO Blood Type | lab | $18 | $18 | $18 | 1 |
| Blood Typing Serologic Rh | other | $18 | $18 | $18 | 1 |
| Assay of Blood Chloride | other | $18 | $18 | $18 | 1 |
| Assay of Serum Potassium | other | $18 | $18 | $18 | 1 |
| Hc Sars-cov-2 Cdc | other | $18 | $18 | $18 | 1 |
| Pap Smear | preventive | $19 | $4 | $208 | 32 |
| X-ray of Jaw Joint On 1 Side of Mouth | imaging | $19 | $8 | $30 | 2 |
| Pathology Examination of Tissue Using a Microscope, Moderately Low Complexity | lab | $19 | $10 | $28 | 2 |
| Pap Test, Slides, Manual Screening | preventive | $19 | $18 | $19 | 2 |
| Gonadotropin, Luteinizing (reproductive Hormone) Level | other | $19 | $19 | $19 | 2 |
| Tray Paracentesis Quick Tap 15x3-1/4 4ea/1cs | other | $19 | $19 | $19 | 1 |
| Blood Smear Interpretation By Physician with Written Report | other | $19 | $19 | $19 | 1 |
| Tumark Pro X for Brevara Std Tumark-brev-s-x | other | $19 | $19 | $19 | 1 |
| Tumark Profess Q for Eviva Std Tumark-e13-s-q | other | $19 | $19 | $19 | 1 |
| Tumark Professional Q Shape 10cm 351220 Bx/10ea | other | $19 | $19 | $19 | 1 |
| Tumark Professional X Shape 10cm 351210 Bx/10ea | other | $19 | $19 | $19 | 1 |
| Tumark Vq for Brevera Standard 127.5mm 18g Tumark-brev-s-q-02 10/bx | other | $19 | $19 | $19 | 1 |
| Gonadotropin, Follicle Stimulating (reproductive Hormone) Level | other | $19 | $19 | $19 | 2 |
| Endoclip Ii Ml 10mm #176657 | other | $19 | $19 | $19 | 1 |
| Eric Arch Bar/6" Per Chrge | other | $19 | $19 | $19 | 1 |
| Exofin Fusion Skin Closure 22cm #ef70401 | surgery | $19 | $19 | $19 | 1 |
| Influenza Vaccine, Quadrivalent Derived From Cell Cultures, Preservative and ... | lab | $19 | $19 | $19 | 1 |
| Manta 14f Depth Locator 5 Ea/bx 114f | other | $19 | $19 | $19 | 1 |
| Shoulder Orthosis, Figure of Eight Design Abduction Restrainer, Prefabricated... | other | $19 | $19 | $19 | 1 |
| Stylet for Peritoneal Cath #sst | other | $19 | $19 | $19 | 1 |
| Wrist Hand Orthosis, Wrist Extension Control Cock-up, Non Molded, Prefabricat... | other | $19 | $19 | $19 | 1 |
| 4fr Pedal Access Set Micropuncture Transitionless #g02972 | other | $19 | $19 | $19 | 1 |
| 5fr Pedal Access Set Micropuncture Transitionless #g02988 | other | $19 | $19 | $19 | 1 |
| Measurement of Amiodarone | other | $19 | $19 | $19 | 1 |
| Quantitation of Therapeutic Drug | other | $19 | $19 | $19 | 2 |
| Bivona Uncuffed Tracheostomy Tube Flextend Size 8.0 Pediatric #60pfs55 | other | $19 | $19 | $19 | 1 |
| White Blood Cell Enzyme Activity Measurement | other | $19 | $19 | $19 | 1 |
| Tretinoin 0.025 % Ex Gel | other | $19 | $19 | $19 | 1 |
| Erythropoietin (protein) Level | other | $19 | $19 | $19 | 2 |
| Duovisc Viscoelastic System | other | $19 | $19 | $19 | 1 |
| Swan Ganz Catheter #131f7p 5/cs | cardiac | $19 | $19 | $19 | 1 |
| Hydromorphone 6 Mg/30 Ml-ns | other | $19 | $19 | $19 | 1 |
| Injection, Procainamide Hcl, Up to 1 Gm | other | $19 | $19 | $19 | 1 |
| Carcinoembryonic Antigen (cea) Protein Level | other | $19 | $19 | $19 | 2 |
| Arsenic Level | other | $19 | $19 | $19 | 2 |
| Sodium Chloride 120 Meq/30 Ml | other | $19 | $19 | $19 | 1 |
| Fluorometholone 0.1% Eye Drop | other | $19 | $19 | $19 | 1 |
| Needle Measurement of Electrical Activity in Arm, Leg, Trunk OR Head Muscles,... | other | $19 | $19 | $19 | 1 |
| Foot, Molded Shoe Plastazote (or Similar) Custom Fitted, Each | other | $19 | $19 | $19 | 1 |
| Orthopedic Footwear, Custom Shoe, Depth Inlay, Each | other | $19 | $19 | $19 | 1 |
| Orthopedic Footwear, Mens Shoe, Depth Inlay, Each | other | $19 | $19 | $19 | 1 |
| Vascular Occluder 30mm 1.50 5ea/bx | other | $19 | $19 | $19 | 1 |
| Vascular Occluders 1.25mm | other | $19 | $19 | $19 | 1 |
| X-ray of Entire Middle and Lower Spine, Minimum of 6 Views | imaging | $19 | $19 | $19 | 1 |
| Drill Flexible 25mm 71362925 S&n | other | $19 | $19 | $19 | 1 |
| Needle Measurement of Electrical Activity in Muscle with Injection of Chemica... | other | $19 | $19 | $19 | 1 |
| Osteopathic Manipulative Treatment, 1-2 Body Regions | other | $19 | $19 | $19 | 1 |
| Retrograde Cardioplegia Cannula Self Inflating Balloon 18mm and Sure Touch Ha... | other | $19 | $19 | $19 | 1 |
| Barron Vacuum Punch 9.0mm | other | $19 | $19 | $19 | 1 |
| Healon Gv Pro 0.85ml 10340014 | other | $19 | $19 | $19 | 1 |
| Test for Allergy Using Allergenic Extract Injected Into Skin | other | $19 | $19 | $19 | 1 |
| Elite Irrigation Sleeve 7cm #5407-010 | other | $19 | $19 | $19 | 1 |
| Analysis for Antibody to Rickettsia | other | $19 | $19 | $19 | 2 |
| Prolactin (milk Producing Hormone) Level | other | $19 | $19 | $19 | 2 |
| Obgyn Vacuum Palm Delivery Pump Mini Vac-6000m 5ea/1bx | obstetric | $19 | $19 | $19 | 1 |
| Obgyn Vacuum Palm Delivery Small Pump Vac-6000s 5ea/1bx | obstetric | $19 | $19 | $19 | 1 |
| Counseling for Genetic Testing Provided By a Genetic Counselor, Each 30 Minut... | therapy | $19 | $19 | $19 | 1 |
| Cell Examination of Specimen, Concentration Technique | lab | $19 | $16 | $21 | 2 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 15 | other | $19 | $16 | $21 | 2 |
| Collagen Cross Links Test | other | $19 | $19 | $19 | 1 |
| Evaluation for Wheelchair, Each 15 Minutes | other | $19 | $19 | $19 | 1 |
| Microbial Toxin OR Antitoxin Assay | other | $19 | $19 | $19 | 1 |
| Diagnostic Digital Breast Tomosynthesis, Unilateral OR Bilateral | other | $19 | $19 | $19 | 1 |
| Alcohol 5%&dextr.5%in Water 10 | other | $19 | $19 | $19 | 1 |
| D-10-w 500ml | other | $19 | $19 | $19 | 1 |
| D-5-0.2% Sodium Chloride(250cc | other | $19 | $19 | $19 | 1 |
| D-5-r 1000 Cc | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Cytomegalovirus (cmv), Amplified Probe Tec... | other | $19 | $19 | $19 | 1 |
| Detection Test By Nucleic Acid for Trichomonas Vaginalis (genital Parasite), ... | other | $19 | $19 | $19 | 1 |
| Dextrose 10%in Saline(d-10-s)1 | other | $19 | $19 | $19 | 1 |
| Dextrose 2.5% Strength Saline | other | $19 | $19 | $19 | 1 |
| Dextrose 5.5%in Salinec\20meq5 | other | $19 | $19 | $19 | 1 |
| Dextrose 5.5%in Salinec\meq 10 | other | $19 | $19 | $19 | 1 |
| Dextrose 5%inh2o(d5w)1000cc | other | $19 | $19 | $19 | 1 |
| Dextrose 5%inwatr(d5w)500cc | other | $19 | $19 | $19 | 1 |
| Dextrose 5%ring.inj.500cc | other | $19 | $19 | $19 | 1 |
| Sodium Bicarbonate Sol.5%500cc | other | $19 | $19 | $19 | 1 |
| Sodium Chloride 3% in Water | other | $19 | $19 | $19 | 1 |
| Sodium Lactate1/6molar 500cc | other | $19 | $19 | $19 | 1 |
| Sodium Lactate1/6molar1000cc | other | $19 | $19 | $19 | 1 |
| Sterile Water,irrigation 1000c | other | $19 | $19 | $19 | 1 |
| Analysis for Antibody to Herpes Simplex Virus, Type 2 | other | $19 | $19 | $19 | 1 |
| Therapy Procedure for a Range of Mental Processes, Initial 15 Minutes | other | $19 | $19 | $19 | 1 |
| Automated Reticulocyte Count | other | $19 | $19 | $19 | 1 |
| Flu Vaccination | preventive | $20 | $12 | $115 | 25 |
| Blood Culture | lab | $20 | $10 | $64 | 3 |
| Immunologic Analysis Technique On Serum | other | $20 | $18 | $22 | 2 |
| Tip Wet-field Bipolar Hemostatic Eraser 25g | other | $20 | $20 | $20 | 1 |
| Injection, Penicillin G Benzathine and Penicillin G Procaine, 100,000 Units | other | $20 | $20 | $20 | 1 |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System | cardiac | $20 | $20 | $20 | 1 |
| Speed Pins 3.2x110 #74013401 3ea/bx | other | $20 | $20 | $20 | 1 |
| Valve Speaking Passy-muir Trach #pmv | other | $20 | $20 | $20 | 1 |
| Stool Lactoferrin (immune System Protein) Level | other | $20 | $20 | $20 | 1 |
| Vascular Occluders 1.75mm | other | $20 | $20 | $20 | 1 |
| Vessel Occluder Coronary 12mm 2.50 | cardiac | $20 | $20 | $20 | 1 |
| Vessel Occluders 1.50mm | other | $20 | $20 | $20 | 1 |
| Vessel Occuluder 2.0mm #50200 | other | $20 | $20 | $20 | 1 |
| Blake Drain 19fr R/f #2230 Case/10ea | other | $20 | $20 | $20 | 1 |
| Bowl and Spatula Bone Cement Mixing Universal System Vacuum Rotor without Noz... | other | $20 | $20 | $20 | 1 |
| Shunt Javid Carotid 10frx27cm #007714 | other | $20 | $20 | $20 | 1 |
| Lap Sac Tissue Pouch 4" X 6" #g16495 | other | $20 | $20 | $20 | 1 |
| Lap Sac Tissue Pouch 8" X 10" #g16497 | other | $20 | $20 | $20 | 1 |
| Electrode Pacing Bipolar 4fr 5ea/1bx | other | $20 | $20 | $20 | 1 |
| Electrode Pacing Bipolar 5fr 5ea/1bx | other | $20 | $20 | $20 | 1 |
| Electrode Pacing Bipolar 6fr - 5ea/1bx | other | $20 | $20 | $20 | 1 |
| Test for Abnormal Eye Movement with Recording | other | $20 | $20 | $20 | 1 |
| Test of Car Seat OR Bed (1 Year OR Younger), 1 Hour | other | $20 | $20 | $20 | 1 |
| Injection, Nafcillin Sodium, 20 Mg | other | $20 | $20 | $20 | 1 |
| Outflare Wedge | other | $20 | $20 | $20 | 1 |
| Relpax 20 Mg Tablet | other | $20 | $20 | $20 | 1 |
| Relpax 40 Mg Tablet | other | $20 | $20 | $20 | 1 |
| Bone Hemostasis 2.5gm #bw012 Ostene | other | $20 | $20 | $20 | 1 |
| Evaluation of Implantable Heart and Blood Vessel Monitoring System | surgery | $20 | $20 | $20 | 1 |
| Ketamine 500 Mg/5 Ml Vial | other | $20 | $20 | $20 | 1 |
| Injection, Eptinezumab-jjmr, 1 Mg | other | $20 | $20 | $20 | 1 |
| Aerotech I Aerosol Unit Ca-1124 | other | $20 | $20 | $20 | 1 |
| Flow Cytometry Technique for Dna OR Cell Analysis, 16 OR More Markers | other | $20 | $20 | $20 | 1 |
| Influenza Vaccine, Trivalent, 0.5 Ml Dosage | preventive | $20 | $20 | $20 | 1 |
| Inserter Tip for Tibial Tray #00584305201 | other | $20 | $20 | $20 | 1 |
| Insertion Needle 6" #acck1015 | other | $20 | $20 | $20 | 1 |
| Interrogation Device Evaluation(s), (remote) Up to 30 Days; Implantable Cardi... | surgery | $20 | $20 | $20 | 1 |
| Needle Epimed 4" #epmd1040 | other | $20 | $20 | $20 | 1 |
| Omo Neurexa Plus Left Small 5065n=l-s | other | $20 | $20 | $20 | 1 |
| Omo Neurexa Plus Right Small 5065n=r-s | other | $20 | $20 | $20 | 1 |
| Omo Neurexa Plus Right Xlarge 5065n=r-xl | other | $20 | $20 | $20 | 1 |
| Optetrak (4) Holding Pins Mni Head Sharp Point Mini Length Diameter 3.2mm #20... | other | $20 | $20 | $20 | 1 |
| Optetrak (4) Short Head Pins 1.125in (28.575mm) Diameter 3.175mm Item # 201-78 | other | $20 | $20 | $20 | 1 |
| Optetrak Quick Release Pins with Collar 40mm #201-78 | other | $20 | $20 | $20 | 1 |
| Orthopedic Shoe, Oxford with Supinator OR Pronator, Infant | other | $20 | $20 | $20 | 1 |
| Pin Fixation 2.3in Threaded Collared #521-78 | other | $20 | $20 | $20 | 1 |
| Sensa Ii Ipg Template #acck7200 | other | $20 | $20 | $20 | 1 |
| Smoking and Tobacco Use Intensive Counseling, More Than 10 Minutes | therapy | $20 | $20 | $20 | 1 |
| Torque Wrench Kit #acck6006 | other | $20 | $20 | $20 | 1 |
| Hook Blunt 5mm #3316-8g 8ea/pk | other | $20 | $20 | $20 | 1 |
| Retractor Ring Plastic Single Use #3304-g | other | $20 | $20 | $20 | 1 |
| Injection, Cangrelor, 1 Mg | other | $20 | $20 | $20 | 1 |
| 3d Ultrasound Imaging of Heart for Evaluation of Heart Structure Performed Du... | imaging | $20 | $20 | $20 | 1 |
| Marker Breast MRI Compatible Senomark#smuc13c | imaging | $20 | $20 | $20 | 1 |
| Potassium Cl 40 Meq/1,000ml-ns | other | $20 | $20 | $20 | 1 |
| Brace Knee Post Op Warrior Kb9000 | other | $20 | $20 | $20 | 1 |
| Tube Inner Ear Myringotomy Ventilation Reuter Bobbin without Flange Holes 1 M... | other | $20 | $20 | $20 | 1 |
| Clozapine Level | other | $20 | $20 | $20 | 1 |
| Drill for Bi-cortical Post #ar-1365d | other | $20 | $20 | $20 | 1 |
| Influenza Vaccine, Trivalent, Split Virus, Preservative-free, 0.25 Ml Dosage | preventive | $20 | $20 | $20 | 1 |
| Post Op Knee Brace Regular #423100 | other | $20 | $20 | $20 | 1 |
| Vessel Occluder 1.75mm #50175 | other | $20 | $20 | $20 | 1 |
| Vitamin B-2 (riboflavin) Level | other | $20 | $20 | $20 | 1 |
| Orthopedic Shoe Addition, Sole, Full | other | $20 | $20 | $20 | 1 |
| Measurement of Complement (immune System Proteins), Total Hemolytic | other | $20 | $20 | $20 | 2 |
| Complete Ultrasound Study of Arm and Leg Arteries | imaging | $20 | $20 | $20 | 1 |
| Methacholine Chloride Administered As Inhalation Solution Through a Nebulizer... | other | $20 | $20 | $20 | 1 |
| Provocholine (methacholine) Dilutions (vials a -e) - Compounded | other | $20 | $20 | $20 | 1 |
| Globo Ped Mobil Gr Lg #36628000030000eu | other | $20 | $20 | $20 | 1 |
| Globo Ped Mobil Gr Shoe Med 36628000020000 | other | $20 | $20 | $20 | 1 |
| Midline Indicator Pdl | other | $20 | $20 | $20 | 1 |
| Injection, Infliximab-axxq, Biosimilar, (avsola), 10 Mg | other | $20 | $20 | $20 | 1 |
| Clotting Factor Viii Related Antigen Measurement | other | $20 | $20 | $20 | 1 |
| Cath Airway Exchange Cook 14fr Dbl #g57628 | other | $20 | $20 | $20 | 1 |
| Mupirocin Calcium 2 % Ex Crea | other | $20 | $20 | $20 | 1 |
| Transfer Set 6" Mini Cap 6ea/cs | other | $20 | $20 | $20 | 1 |
| Addition to Lower Extremity, Limited Ankle Motion, Each Joint | other | $20 | $20 | $20 | 1 |
| Beta 2 Glycoprotein 1 Antibody (autoantibody) Measurement | other | $20 | $19 | $21 | 2 |
| C-peptide (protein) Level | other | $20 | $18 | $21 | 2 |
| Screening 3d Breast Mammography | imaging | $20 | $19 | $21 | 2 |
| Estrogen Analysis, Total | other | $20 | $17 | $22 | 2 |
| Injection, Aminophyllin, Up to 250 Mg | other | $20 | $16 | $23 | 2 |
| Injection, Ziprasidone Mesylate, 10 Mg | other | $20 | $3 | $36 | 2 |
| Culture for Chlamydia | lab | $20 | $20 | $20 | 1 |
| Detection Test By Nucleic Acid for Enterovirus (intestinal Virus), Amplified ... | other | $20 | $20 | $20 | 1 |
| Therapy Procedure for Walking Training, Each 15 Minutes | other | $20 | $20 | $20 | 1 |
| Astelin | other | $20 | $20 | $20 | 1 |
| Infectious Agent Detection By Nucleic Acid (dna OR Rna); Human Papillomavirus... | other | $20 | $20 | $20 | 1 |
| Injection, Fentanyl Citrate, 0.1 Mg | other | $20 | $20 | $20 | 1 |
| Estriol (hormone) Level | other | $20 | $20 | $20 | 1 |
| Hydroxyprogesterone, 17-d (synthetic Hormone) Level | other | $20 | $20 | $20 | 1 |
| Virus Isolation | other | $20 | $20 | $20 | 1 |
| Detection Test By Nucleic Acid for Chlamydia, Direct Probe Technique | other | $20 | $20 | $20 | 1 |
| Assay Blood Carbon Dioxide | other | $20 | $20 | $20 | 1 |
| Introducer/sheath, Other Than Guiding, Other Than Intracardiac Electrophysiol... | cardiac | $21 | $6 | $35 | 2 |
| X-ray of Both Knees While Standing | imaging | $21 | $8 | $33 | 2 |
| Electronic Analysis of Spinal Canal Drug Infusion Pump | surgery | $21 | $21 | $21 | 1 |
| C-reamer 9mm #8772a 4/bx | other | $21 | $21 | $21 | 1 |
| Gelfoam Powder | other | $21 | $21 | $21 | 1 |
| Lap Sac Tissue Pouch 5" X 8" #g16496 | other | $21 | $21 | $21 | 1 |
| 45 Degree Kelman Mini-flare Tip | other | $21 | $21 | $21 | 1 |
| Marker Breast Stereotactic Senomark #smev9c | other | $21 | $21 | $21 | 1 |
| Removal of Tissue From Wound, Each Additional 20.0 SQ Cm | surgery | $21 | $21 | $21 | 2 |
| Tcc-ez Large Boot Tcc21114 1 Each | other | $21 | $21 | $21 | 1 |
| Omo Neurexa Plus Left Xlarge 5065n=l-xl | other | $21 | $21 | $21 | 1 |
| Analysis for Detection of Tumor Marker | other | $21 | $21 | $21 | 1 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 125 | other | $21 | $21 | $21 | 2 |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 19 | other | $21 | $21 | $21 | 2 |
| Lift, Elevation, Heel, Tapered to Metatarsals, Per Inch | other | $21 | $21 | $21 | 1 |
| Acclarent Balloon Inflation Device 5 Ea/bxdib30 | other | $21 | $21 | $21 | 1 |
| Inflation Device Acclarent Se #seid Order By Bx/5ea | other | $21 | $21 | $21 | 1 |
| Funnel Fistula 00860013000325 | other | $21 | $21 | $21 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Multiple Rib Nerves for Reg... | other | $21 | $21 | $21 | 1 |
| Progesterone (reproductive Hormone) Level | other | $21 | $21 | $21 | 2 |
| Xomed Nasal Postpac #15-26800 5/pk | other | $21 | $21 | $21 | 1 |
| Uterine Manipulator Dx Vcare | other | $21 | $21 | $21 | 1 |
| Test for Eardrum and Muscle Function | other | $21 | $21 | $21 | 1 |
| Removal of Skin and Tissue, Each Additional 20.0 SQ Cm OR Less | surgery | $21 | $21 | $21 | 1 |
| Flumazenil 0.5 Mg/5ml IV Soln | other | $21 | $21 | $21 | 1 |
| Brace Rcai Contour Fit Lso Med 451-cf-lso-m | other | $21 | $21 | $21 | 1 |
| Brace Rcai Control Fit Lso Large 451-cf-lso-l | other | $21 | $21 | $21 | 1 |
| Programming of Single, Dual OR Multiple Lead Implantable Defibrillator System... | surgery | $21 | $21 | $21 | 1 |
| Bio-medicus Venous Insertion Kit 5 Ea/pk 96551 | other | $21 | $21 | $21 | 1 |
| Addition to Lower Extremity, Below Knee, Waist Belt, Webbing | other | $21 | $21 | $21 | 1 |
| Interstim Therapy Antenna #3709 | other | $21 | $21 | $21 | 1 |
| Injection, Vancomycin Hcl, 500 Mg | other | $21 | $21 | $21 | 1 |
| Injection for Imaging of Right Heart Chambers with Review By Radiologist | cardiac | $21 | $21 | $21 | 1 |
| Tranexamic 1,000 Mg/100ml-nacl | other | $21 | $21 | $21 | 1 |
| Organic Acid Level | other | $21 | $20 | $21 | 2 |
| Ephedrine Sulfate (pressors) 5 Mg/ml IV Soln | other | $21 | $21 | $21 | 1 |
| Vitamin B-1 (thiamine) Level | other | $21 | $21 | $21 | 2 |
| Somatomedin (growth Factor) Level | other | $21 | $21 | $21 | 2 |
| Cath Cholangiogram #lap-13 6each/1box | other | $21 | $21 | $21 | 1 |
| Drill 3.0mm Step #ar-1250lt | other | $21 | $21 | $21 | 1 |
| Genetic Sequencing Localization, Initial Procedure | other | $21 | $21 | $21 | 1 |
| Group Psychotherapy | therapy | $21 | $21 | $21 | 1 |
| Pathology Examination of Specimen During Surgery, Each Additional Tissue Block | surgery | $21 | $21 | $21 | 1 |
| Injection, Vedolizumab, Intravenous, 1 Mg | other | $21 | $21 | $21 | 1 |
| Tissue Orientation Correct Clip #lcc6 | other | $21 | $21 | $21 | 1 |
| Insulin Antibody Measurement | other | $21 | $21 | $21 | 2 |
| Cyclogyl 0.5% Eye Drops | other | $21 | $21 | $21 | 1 |
| Shunt Coronary Coil 1.5mm X 18mm Cts Flo | cardiac | $21 | $21 | $21 | 1 |
| Shunt Coronary Coil 2.5mm X 18mm #ft | cardiac | $21 | $21 | $21 | 1 |
| Viagra 100 Mg Tablet | other | $21 | $21 | $21 | 1 |
| Viagra 50 Mg Tablet | other | $21 | $21 | $21 | 1 |
| Injection, Amphotericin B Liposome, 10 Mg | other | $21 | $21 | $21 | 1 |
| Influenza Vaccine, Quadrivalent, Preservative Free, 0.5 Ml Dosage | preventive | $21 | $21 | $21 | 1 |
| Analysis of Female Reproductive Genetic Marker | other | $21 | $21 | $21 | 1 |
| Abo & Rh Blood Type | other | $21 | $21 | $21 | 1 |
| Therapy Procedure Using Water Pool to Exercises, Each 15 Minutes | other | $21 | $21 | $21 | 1 |
| Assay of Creatinine | other | $21 | $21 | $21 | 1 |
| Small Parts Kit 23g Cannl&plugset #8065752149 | other | $22 | $22 | $22 | 1 |
| Tube Trach Hyperflex Sz 7 Cuffed #67fhxl70 | other | $22 | $22 | $22 | 1 |
| Wellbutrin Xl 300 Mg Tablet | other | $22 | $22 | $22 | 1 |
| Gabapentin Level | other | $22 | $22 | $22 | 2 |
| Sex Hormone Binding Globulin (protein) Level | other | $22 | $22 | $22 | 2 |
| Counseling Visit to Discuss Need for Lung Cancer Screening Using Low Dose CT ... | preventive | $22 | $22 | $22 | 1 |
| Cath 7fr Navilflex Rx Delivery Sys M00533560 | obstetric | $22 | $22 | $22 | 1 |
| Delivery System Rx 10fr Biliary M00533580 | obstetric | $22 | $22 | $22 | 1 |
| Delivery System Rx 7fr Biliary M00533560 | obstetric | $22 | $22 | $22 | 1 |
| Tcc-ez Extra Large Boot Tcc21124 1 Each | other | $22 | $22 | $22 | 1 |
| Ultrasound of One Arm Arteries OR Artery Grafts | imaging | $22 | $22 | $22 | 1 |
| Full Sole and Heel Wedge, Between Sole | other | $22 | $22 | $22 | 1 |
| Superficial And/or Low Voltage Radiation Treatment Delivery | obstetric | $22 | $22 | $22 | 1 |
| Nuclear Medicine Study of Liver and Spleen | imaging | $22 | $22 | $22 | 1 |
| Renin (kidney Enzyme) Level | other | $22 | $22 | $22 | 2 |
| Cath Fogarty Biliary 5fr 23cm 410235fp 5ea/case | other | $22 | $22 | $22 | 1 |
| Cath Fogarty Biliary 6fr 23cm 410236fp 5ea/case | other | $22 | $22 | $22 | 1 |
| External Breast Prosthesis Garment, with Mastectomy Form, Post Mastectomy | other | $22 | $22 | $22 | 1 |
| Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $22 | $22 | $22 | 1 |
| 4.2mm Trocar 210mm 03.010.070 | other | $22 | $22 | $22 | 1 |
| Strip Fistula Isolator 00860013000318 | other | $22 | $22 | $22 | 1 |
| Dehydroepiandrosterone (dhea-s) Hormone Level | other | $22 | $22 | $22 | 2 |
| Eleview Submucosal Injectable Composition 10ml Ampoule 5ea/bx #9000020 | other | $22 | $22 | $22 | 1 |
| Addition to Lower Extremity, Extended Steel Shank | other | $22 | $22 | $22 | 1 |
| Needle Transbronchial 19ga Aspiration W/syr | other | $22 | $22 | $22 | 1 |
| Needle Transbronchial 20ga Aspiration W/syr | other | $22 | $22 | $22 | 1 |
| Needle Transbronchial 21ga Aspiration W/syr | other | $22 | $22 | $22 | 1 |
| Ultrasound of One Side of Head and Neck Blood Flow | imaging | $22 | $22 | $22 | 1 |
| Pap Test | other | $22 | $22 | $22 | 1 |
| Endopath Electrosurgery Probe Plus Ii 5mm Hook 34cm Length Eps01 | surgery | $22 | $22 | $22 | 1 |
| Endopath Electrosurgery Probe Plus Ii 5mm Hook 29cm Length Eps05 | surgery | $22 | $22 | $22 | 1 |
| Review By Radiologist of Previous Placed Shunt Image | other | $22 | $22 | $22 | 1 |
| Detection Test By Immunoassay Technique for Hiv-1 Antigen and Hiv-1 and Hiv-2... | other | $22 | $19 | $24 | 2 |
| Surgical Supplies | surgery | $22 | $22 | $22 | 1 |
| Hemoglobin & Hematocrit | other | $22 | $22 | $22 | 1 |
| Fetal Lung Maturity Assessment, Lecithin Sphingomyelin (l/s) Ratio | other | $22 | $22 | $22 | 1 |
| Injection, Hydrocortisone Sodium Succinate, Up to 100 Mg | other | $22 | $22 | $22 | 1 |
| Assay of Protein Serum | other | $22 | $22 | $22 | 1 |
| Injection, Garamycin, Gentamicin, Up to 80 Mg | other | $23 | $13 | $33 | 2 |
| Programming of Single, Dual, OR Multiple Lead OR Leadless Pacemaker System Be... | cardiac | $23 | $14 | $31 | 2 |
| Review By Radiologist of Chest Aorta Image | other | $23 | $23 | $23 | 1 |
| Shunt Coronary Coil 2.0mm X 18mm Cts Flo | cardiac | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 7.5mm | other | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 8.0mm | other | $23 | $23 | $23 | 1 |
| Endoscopic Clip Applier 5mm M/l Port Universal Epix #ca500 3ea/box | other | $23 | $23 | $23 | 1 |
| Punch Barron Donor 7.75 K20 | other | $23 | $23 | $23 | 1 |
| Rd Rainbow Set 2 Adult Adhesive Sensor 4026 Box/10ea | other | $23 | $23 | $23 | 1 |
| Rd Rainbow Set 2 Neo Adhesive Sensor 4029 Box/10ea | other | $23 | $23 | $23 | 1 |
| Sensor Large Foresight Elite #fsesl Bx/20 | other | $23 | $23 | $23 | 1 |
| Service Provided On an Emergency Basis in the Office | emergency | $23 | $23 | $23 | 1 |
| Stylet Faller for Pd Cath #fs | other | $23 | $23 | $23 | 1 |
| Test for Detecting Genes Associated with Blood Cancer | other | $23 | $23 | $23 | 1 |
| Tube Fastrach Combo Sz 3 #135130 5ea/1case | other | $23 | $23 | $23 | 1 |
| Tube Fastrach Combo Sz 4 | other | $23 | $23 | $23 | 1 |
| Tube Fastrach Combo Sz 5 | other | $23 | $23 | $23 | 1 |
| Brush Biopsy Deflection 3.2frx115cm #g15045 | lab | $23 | $23 | $23 | 1 |
| Injection, Aminocaproic Acid, 1 Gram | other | $23 | $23 | $23 | 1 |
| Reaming Rod 3.0 W/offset Ball Tip 950mm Nonst | other | $23 | $23 | $23 | 1 |
| Reaming Rod 3.0mm X 950mm #351.76 | other | $23 | $23 | $23 | 1 |
| Centurion 45 Fms Cassette Only | other | $23 | $23 | $23 | 1 |
| Cook Chest Drain Valve #g36370 | other | $23 | $23 | $23 | 1 |
| Fogarty Insert Dbl Hydrajaw 33mm | other | $23 | $23 | $23 | 1 |
| Design and Construction of Simple Radiation Treatment Device | other | $23 | $23 | $23 | 1 |
| Closure Surgical Skin 16cm Zip16 Ps1160 10/pk | surgery | $23 | $23 | $23 | 1 |
| Clotting Factor Viii (vw Factor) Antigen | other | $23 | $23 | $23 | 1 |
| Gradient Compression Glove, Each | other | $23 | $23 | $23 | 1 |
| Grasping Forceps Rescue Combo #m00538351 | other | $23 | $23 | $23 | 1 |
| Retractor Ring Lone Star Disposable 3307g | other | $23 | $23 | $23 | 1 |
| Retrieval Net 30mm Rescue Net #dgn-538 | other | $23 | $23 | $23 | 1 |
| Sodium Bicarbonate 8.4 % IV Soln | other | $23 | $23 | $23 | 1 |
| Globo Ped Mobil Gr Small #36628000010000eu | other | $23 | $23 | $23 | 1 |
| Globo Ped Mobil Gr X-large #36628000040000 | other | $23 | $23 | $23 | 1 |
| Micro Nester .018 3mm X 14cm | other | $23 | $23 | $23 | 1 |
| Micro Nester .018 4mm X 14cm | other | $23 | $23 | $23 | 1 |
| Micro Nester .018 6mm X 14cn | other | $23 | $23 | $23 | 1 |
| Micro Nester .018 8mm X 7cm | other | $23 | $23 | $23 | 1 |
| Nester .035 16mm X 14cm | other | $23 | $23 | $23 | 1 |
| Nester .035 20mm X 14cm | other | $23 | $23 | $23 | 1 |
| Nester .035 3mm X 7cm | other | $23 | $23 | $23 | 1 |
| Nester .035 4mm X 14cm | other | $23 | $23 | $23 | 1 |
| Nester .035 6mm X 14cm | other | $23 | $23 | $23 | 1 |
| Addition to Lower Extremity, Varus/valgus Correction ('t') Strap, Padded/line... | other | $23 | $23 | $23 | 1 |
| Tcc-ez Transmet Boot Tcc21131 1 Each | other | $23 | $23 | $23 | 1 |
| Electrode Hf Needle 45deg 24-28fr #a22255c | other | $23 | $23 | $23 | 1 |
| Electrode Monopolar Roller Ball24-28f A22251c | other | $23 | $23 | $23 | 1 |
| Single Sensor W/lumen 7fr Catheter | cardiac | $23 | $23 | $23 | 1 |
| Cannula Grundy Retrograde 15fr #94115t | other | $23 | $23 | $23 | 1 |
| Cannula Perfusion Retrograde 15 Fr 32 Cm Length Stopcock Wirewound Body #9462... | surgery | $23 | $23 | $23 | 1 |
| Immunologic Analysis Technique On Body Fluid | other | $23 | $23 | $23 | 2 |
| Levemir 100 Unit/ml Vial | other | $23 | $23 | $23 | 1 |
| Brace Knee T-scope Post Op #08814 | other | $23 | $23 | $23 | 1 |
| Neomycin-polymyxin-hc Ear Susp | other | $23 | $23 | $23 | 1 |
| Uterine Manipulator Lrge Vcare | other | $23 | $23 | $23 | 1 |
| Uterine Manipulator Medium Vcare | other | $23 | $23 | $23 | 1 |
| Uterine Manipulator Small Vcare | other | $23 | $23 | $23 | 1 |
| Cement Mixer Sys Acm Stryker(used for Hip Rar | other | $23 | $23 | $23 | 1 |
| Comprehensive Hearing Test | other | $23 | $23 | $23 | 1 |
| Electrode Monopolar Loop A22205c | other | $23 | $23 | $23 | 1 |
| Alcohol And/or Substance (other Than Tobacco) Misuse Structured Assessment (e... | other | $23 | $23 | $23 | 1 |
| Alcohol And/or Substance Abuse Screening and Intervention, 15-30 Minutes | preventive | $23 | $23 | $23 | 1 |
| Barron Vacuum Punch 8.25mm | other | $23 | $23 | $23 | 1 |
| Catheter Dilation Soehendra Biliary G21571 | cardiac | $23 | $23 | $23 | 1 |
| Punch Cornea 8.5mm Barron Vacuum | other | $23 | $23 | $23 | 1 |
| Pigazzi Pad Pink Xl #40583 4ea/1cs | other | $23 | $23 | $23 | 1 |
| Testosterone (hormone) Level, Free | other | $23 | $21 | $25 | 2 |
| Training for Self-care OR Home Management, Each 15 Minutes | other | $23 | $23 | $23 | 1 |
| Lipoprotein Level, Quantitation of Lipoprotein Particle Number | other | $23 | $23 | $23 | 1 |
| Injection, Calcium Gluconate (wg Critical Care), Not Therapeutically Equivale... | other | $23 | $23 | $23 | 1 |
| Antibody Screen | lab | $23 | $23 | $23 | 1 |
| Prostate Cancer Screening | other | $24 | $8 | $255 | 35 |
| Hepatic Function Panel | lab | $24 | $4 | $49 | 6 |
| Complete Blood Count (CBC) | lab | $24 | $5 | $47 | 6 |
| Test to Examine How Well the Lungs Exchange Gases | other | $24 | $9 | $38 | 2 |
| Injection, Insulin, Per 5 Units | other | $24 | $13 | $35 | 2 |
| Therapy Procedure Using Massage, Each 15 Minutes | other | $24 | $20 | $28 | 2 |
| Snare System Lariat 30mm10mm6mm Port 2.5mm | other | $24 | $24 | $24 | 1 |
| Pessary, Reusable, Non Rubber, Any Type | other | $24 | $24 | $24 | 1 |
| Physician OR Allowed Practitioner Certification for Medicare-covered Home Hea... | other | $24 | $24 | $24 | 1 |
| Service Provided in the Office When the Office Is Normally Closed | other | $24 | $24 | $24 | 1 |
| Sulfacetamide 10% Eye Drops | other | $24 | $24 | $24 | 1 |
| Sulfacetamide Sodium 10 % Op Soln | other | $24 | $24 | $24 | 1 |
| Evaluation of Cardiac Rhythm Monitor System, Remote Up to 30 Days | cardiac | $24 | $24 | $24 | 1 |
| Evaluation of Implantable Heart and Blood Vessel Monitoring System, Remote Up... | surgery | $24 | $24 | $24 | 1 |
| Test for Abnormal Eye Movement Using 3 Positions with Recording | other | $24 | $24 | $24 | 1 |
| Tcc-ez Large Charcot Boot Tcc21116 1 Each | other | $24 | $24 | $24 | 1 |
| Endovive Soft Peg Pull 20f 2/bx M00509001 | other | $24 | $24 | $24 | 1 |
| Gastrostomy Safety Peg 24fr Kit Pull | other | $24 | $24 | $24 | 1 |
| Gastrostomy Safety Peg Set 20fr W/xylocaine | other | $24 | $24 | $24 | 1 |
| Olumiant 1 Mg Tablet | other | $24 | $24 | $24 | 1 |
| 3d Radiographic Procedure | imaging | $24 | $24 | $24 | 2 |
| Bra Cardiac Surgery Sz-40b-52dd 1ea | surgery | $24 | $24 | $24 | 1 |
| Cath Cholangiogram Aerostat Rigid Tip #c1002 | other | $24 | $24 | $24 | 1 |
| Prolonged Office OR Other Outpatient Evaluation and Management Service(s) Bey... | other | $24 | $24 | $24 | 1 |
| Retractor Alexis O Lg C-section 9-14cm #g6313 | obstetric | $24 | $24 | $24 | 1 |
| Wound Retractor/protector Large #c8403 | other | $24 | $24 | $24 | 1 |
| 9986-21-20 Flexible Osteotome Short 8 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-21 Flexible Osteotome Short 10 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-22 Flexible Osteotome Short 12 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-24 Flexible Osteotome Short Curved | other | $24 | $24 | $24 | 1 |
| 9986-21-26 Flexible Osteotome Long 10 Mm | other | $24 | $24 | $24 | 1 |
| 9986-21-27 Flexible Osteotome Long 8 Mm | other | $24 | $24 | $24 | 1 |
| Injection, Natalizumab, 1 Mg | other | $24 | $24 | $24 | 1 |
| Zomig 5 Mg Nasal Spray | other | $24 | $24 | $24 | 1 |
| Omo Neurexa Plus Left Medium 5065n=l-m | other | $24 | $24 | $24 | 1 |
| Chemical Analysis Using Chromatography Technique | other | $24 | $24 | $24 | 2 |
| Addition to Lower Extremity, Below Knee, Cuff Suspension | other | $24 | $24 | $24 | 1 |
| Preventive Medicine Counseling, Typically 15 Minutes | therapy | $24 | $24 | $24 | 1 |
| Humeral Splint Ext Length Medium 37-2162 | other | $24 | $24 | $24 | 1 |
| Humeral Splint Ext. Length Lg | other | $24 | $24 | $24 | 1 |
| Humeral Splint Ext. Length Xlg | other | $24 | $24 | $24 | 1 |
| Humeral Splint Mid Length Lg | other | $24 | $24 | $24 | 1 |
| Humeral Splint Mid Length Med. | other | $24 | $24 | $24 | 1 |
| Humeral Splint Mid Length Small | other | $24 | $24 | $24 | 1 |
| Application of Nonmoveable Finger Splint | other | $24 | $24 | $24 | 1 |
| Programming of Cardiac Rhythm Monitor System | cardiac | $24 | $24 | $24 | 1 |
| Rally Vacuum Mixing Bowl7127 | other | $24 | $24 | $24 | 1 |
| Bard Single Lumen Picc 5fr #3195335 | other | $24 | $24 | $24 | 1 |
| Loop 3mm 12 Deg for Small Tur Set #wa47050c | other | $24 | $24 | $24 | 1 |
| 1.5mm Quick Release Drill Msdc15 Ms-dc15 | other | $24 | $24 | $24 | 1 |
| 16fr Entuit Gastrostomy Tube #g35616 | other | $24 | $24 | $24 | 1 |
| Dressing Nasal Foam Stammberger Sinus #rr650 | other | $24 | $24 | $24 | 1 |
| G Tube Entuit #g35618 | other | $24 | $24 | $24 | 1 |
| Cell Examination of Body Fluid, Smears | other | $24 | $21 | $26 | 2 |
| Injection, Nitroglycerin, 5 Mg | other | $24 | $20 | $28 | 2 |
| Organic Acids Level | other | $24 | $24 | $24 | 1 |
| Injection, Vancomycin Hydrochloride, 10 Mg | other | $24 | $24 | $24 | 1 |
| Icd-s/d/m In/cl-chec | other | $24 | $24 | $24 | 1 |
| Obs W/tel ICU Nonpaid Cc 44 | other | $24 | $24 | $24 | 1 |
| Obs W/tel OB Nonpaid Cc 44 | other | $24 | $24 | $24 | 1 |
| T Cell Count and Ratio | other | $24 | $24 | $24 | 1 |
| Telephonic Rhythm Strip Evaluation of Single, Dual, Multiple Lead OR Leadless... | other | $24 | $24 | $24 | 1 |
| Iodine I-131 Sodium Iodide Capsule(s), Therapeutic, Per Millicurie | other | $24 | $24 | $24 | 1 |
| Smear Gram Stain | other | $24 | $24 | $24 | 1 |
| Emergency Room Visit | emergency | $25 | $1 | $1,749 | 32 |
| Compass Compartment #cmps001 | other | $25 | $25 | $25 | 1 |
| Injection, Triamcinolone Acetonide, Preservative Free, 1 Mg | other | $25 | $25 | $25 | 1 |
| Nasal Packing Epostat 1ea | other | $25 | $25 | $25 | 1 |
| Nitroglycerin 400 Mcg Spray | other | $25 | $25 | $25 | 1 |
| Cath Nasal Posterior Epistaxis Rapid Rhino | other | $25 | $25 | $25 | 1 |
| Nasogastric/nasointestinal Feeding Tube Retention System 12fr White Corgrip S... | other | $25 | $25 | $25 | 1 |
| Nasogastric/nasointestinal Feeding Tube Retention System 14fr Yellow Corgrip ... | other | $25 | $25 | $25 | 1 |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 10fr Pink... | other | $25 | $25 | $25 | 1 |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 16fr Oran... | other | $25 | $25 | $25 | 1 |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 18fr Tan ... | other | $25 | $25 | $25 | 1 |
| Removal of Impacted Cerumen (one OR Both Ears) By Physician On Same Date of S... | surgery | $25 | $25 | $25 | 1 |
| Insertion of Lower Leg Neurostimulator Electrode | other | $25 | $25 | $25 | 1 |
| Simple Bladder Irrigation And/or Instillation | other | $25 | $25 | $25 | 1 |
| Omo Neurexa Plus Left Large 5065n=l-l | other | $25 | $25 | $25 | 1 |
| Omo Neurexa Plus Right Large 5065n=r-l | other | $25 | $25 | $25 | 1 |
| Omo Neurexa Plus Right Medium 5065n=r-m | other | $25 | $25 | $25 | 1 |
| Basket Retrieval 2.5x230cm Disp Roth 00711050 | other | $25 | $25 | $25 | 1 |
| Gradient Compression Arm Sleeve, Each | other | $25 | $25 | $25 | 1 |
| Roth Net Retrieval Basket #bx00711150 | other | $25 | $25 | $25 | 1 |
| Adapter/extension, Pacing Lead OR Neurostimulator Lead | other | $25 | $25 | $25 | 1 |
| X-ray of Bone At Base of Skull | imaging | $25 | $25 | $25 | 1 |
| Tcc-ez Extra Large Charcot Boot Tcc21126 1 Each | other | $25 | $25 | $25 | 1 |
| Hc Medihoney Alginate Dressing | other | $25 | $25 | $25 | 1 |
| Aplisol 5t Unit/0.1 Ml Vial | other | $25 | $25 | $25 | 1 |
| Duovisc Large #8065183150 | other | $25 | $25 | $25 | 1 |
| Comprehensive Hearing and Speech Recognition Test | other | $25 | $25 | $25 | 1 |
| Catecholamines (organic Nitrogen) Level | imaging | $25 | $25 | $25 | 2 |
| 5.5x85mm Rod Ti Alloy Curved Vitality #07.02015.014 | other | $25 | $25 | $25 | 1 |
| Cast Supplies | other | $25 | $25 | $25 | 1 |
| Dehydroepiandrosterone (dhea) Hormone Level | other | $25 | $25 | $25 | 1 |
| Home Sleep Test (hst) with Type IV Portable Monitor, Unattended; Minimum of 3... | other | $25 | $25 | $25 | 1 |
| Lineum 3.5mm X 80mm Ti Rod #14 | other | $25 | $25 | $25 | 1 |
| Other Allergy OR Clinical Immunology Service OR Procedure | other | $25 | $25 | $25 | 1 |
| Presbyopia Correcting Function of Intraocular Lens | other | $25 | $25 | $25 | 1 |
| Tornado .018 8mm X 4mm | other | $25 | $25 | $25 | 1 |
| Tornado .035 10mm X 5mm | other | $25 | $25 | $25 | 1 |
| Tornado Coil .035 10mm X 4mm | other | $25 | $25 | $25 | 1 |
| Vitality 5.5x300mm Rod Ti Alloy Straight #07.02013.001 | other | $25 | $25 | $25 | 1 |
| Foot Drop Splint, Recumbent Positioning Device, Prefabricated, Off-the-shelf | other | $25 | $25 | $25 | 1 |
| Orthopedic Footwear, Woman's Shoe, Oxford, Used As an Integral Part of a Brace | other | $25 | $25 | $25 | 1 |
| Hc Dress Aquacl Ag Xtr | other | $25 | $25 | $25 | 1 |
| Instrument Tracker 9733533xom ENT | other | $25 | $25 | $25 | 1 |
| Cell Examination of Specimen, Selective Cellular Enhancement Technique | lab | $25 | $25 | $25 | 1 |
| Cardiolipin Antibody (tissue Antibody) Measurement | other | $25 | $25 | $25 | 2 |
| Injection, Rho D Immune Globulin, Intravenous, Human, Solvent Detergent, 100 Iu | other | $25 | $25 | $25 | 1 |
| Vitamin B-6 Level | other | $25 | $22 | $28 | 2 |
| Programming of Single Lead Pacemaker System | cardiac | $25 | $19 | $30 | 2 |
| Injection, Enoxaparin Sodium, 10 Mg | other | $25 | $25 | $25 | 1 |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, Each Additional Growth | imaging | $25 | $25 | $25 | 1 |
| Ultrasound Measurement of Bladder Capacity After Voiding | imaging | $25 | $25 | $25 | 1 |
| Measure of Severe Acute Respiratory Syndrome Coronavirus 2 (covid-19) Antibody | other | $25 | $25 | $25 | 1 |
| Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up to 15 Millicuries | other | $25 | $25 | $25 | 1 |
| Aluminum Level | other | $25 | $25 | $25 | 1 |
| Injection, Phytonadione (vitamin K), Per 1 Mg | other | $26 | $3 | $49 | 2 |
| Injection, Penicillin G Potassium, Up to 600,000 Units | other | $26 | $6 | $46 | 2 |
| Oxcarbazepine 300 Mg/5 Ml Susp | other | $26 | $26 | $26 | 1 |
| Kit Mickey Gastrostomy Feeding Tube 14fr2.3cm | other | $26 | $26 | $26 | 1 |
| Kit Mickey Gastrostomy Feeding Tube 16fr2.3cm | other | $26 | $26 | $26 | 1 |
| Tube Inner Ear Myringotomy Ventilation Notched Flange with Tab 1.14 Mm Id Sof... | other | $26 | $26 | $26 | 1 |
| Pillow Intubating Positioner Including Disposable Head Cradle #10-910-00 3/bx | other | $26 | $26 | $26 | 1 |
| Tri-lumen Filtered Tube Set 6ea/cs | other | $26 | $26 | $26 | 1 |
| Foot, Arch Support, Removable, Premolded, Longitudinal/ Metatarsal, Each | other | $26 | $26 | $26 | 1 |
| Injection, Bevacizumab-bvzr, Biosimilar, (zirabev), 10 Mg | other | $26 | $26 | $26 | 1 |
| Immunologic Analysis for Autoimmune Disease, A, B, OR C, Single Antigen | other | $26 | $26 | $26 | 2 |
| Testosterone (hormone) Level, Total | other | $26 | $26 | $26 | 2 |
| Removal of Impacted Ear Wax | surgery | $26 | $26 | $26 | 1 |
| CT Scan of Heart with Evaluation of Blood Vessel Calcium | imaging | $26 | $26 | $26 | 1 |
| Check of Hearing Aid, Both Ears | other | $26 | $26 | $26 | 1 |
| Humeral Splint Mid Length 2xl #37-2185 | other | $26 | $26 | $26 | 1 |
| Adhesion Barrier | other | $26 | $26 | $26 | 1 |
| Blood Gases Measurement | other | $26 | $26 | $26 | 2 |
| Smart Ablate Irrigation Tubing #sat001 | other | $26 | $26 | $26 | 1 |
| Tissue Culture Inoculation for Virus Isolation | lab | $26 | $26 | $26 | 2 |
| Catheter, Occlusion | cardiac | $26 | $26 | $26 | 1 |
| Cement Mixer Smart Mix Tower #5401-98 | other | $26 | $26 | $26 | 1 |
| Injection, Gemcitabine Hydrochloride (accord), Not Therapeutically Equivalent... | other | $26 | $26 | $26 | 1 |
| Addition to Lower Extremity Orthosis, Knee Control, Full Kneecap | other | $26 | $26 | $26 | 1 |
| C-reamer 10mm Linvatec #8773a 4/bx | other | $26 | $26 | $26 | 1 |
| Anticoagulant Management for an Outpatient Taking Warfarin, Physician Review ... | other | $26 | $26 | $26 | 1 |
| Diabetes Outpatient Self-management Training Services, Individual, Per 30 Min... | other | $26 | $26 | $26 | 1 |
| Influenza Vaccine Split Virus, Preservative Free | preventive | $26 | $26 | $26 | 1 |
| Kyphon Bone Biopsy Device #3 #f05a | lab | $26 | $26 | $26 | 1 |
| Preparation of Report of Patient's Psychiatric Status | therapy | $26 | $26 | $26 | 1 |
| Sternal Zipfix with Needle Pk/20ea #08.501.001.20s | other | $26 | $26 | $26 | 1 |
| Transfer of an Orthosis From One Shoe to Another, Caliper Plate, Existing | other | $26 | $26 | $26 | 1 |
| Bone Marrow Asp Sys Dstl Hole 11g 710.150.97s | other | $26 | $26 | $26 | 1 |
| Injection, Haloperidol Decanoate, Per 50 Mg | other | $26 | $26 | $26 | 1 |
| Iodine I-123 Sodium Iodide, Diagnostic, Per Millicurie | other | $26 | $26 | $26 | 1 |
| Training for Community OR Work Reintegration, Each 15 Minutes | other | $26 | $26 | $26 | 1 |
| Follow-up Therapy Service to Facilitate Lung Function | other | $26 | $26 | $26 | 1 |
| X-ray of Finger, Minimum of 2 Views | imaging | $27 | $6 | $47 | 2 |
| Hearing Service, Miscellaneous | other | $27 | $27 | $27 | 1 |
| Indocin 50 Mg Suppository | other | $27 | $27 | $27 | 1 |
| Balloon Wedge Pressure Catheter 5fr 110cm | cardiac | $27 | $27 | $27 | 1 |
| Entrada Needle 11cm $sc-4220 | other | $27 | $27 | $27 | 1 |
| Entrada Needle 15cm #sc-4220 | other | $27 | $27 | $27 | 1 |
| Hand Finger Orthosis, without Joints, May Include Soft Interface, Straps, Pre... | other | $27 | $27 | $27 | 1 |
| Hepatitis a Vaccine Pediatric OR Adolescent Dosage | preventive | $27 | $27 | $27 | 1 |
| Irrigation Tubing #rob10031 | other | $27 | $27 | $27 | 1 |
| Pin Plug #6725 Medtronic | other | $27 | $27 | $27 | 1 |
| Repositioning Exercises of Head for Treatment of Dizziness, Each Day | other | $27 | $27 | $27 | 1 |
| Stent Introducer Set G22684 | cardiac | $27 | $27 | $27 | 1 |
| Test to Assess Hearing Sensitivity Using Visual Aids | other | $27 | $27 | $27 | 1 |
| Sheath Uropass 11/13 Fr X 38cm #61138bx | other | $27 | $27 | $27 | 1 |
| Addition to Lower Extremity Orthosis, Femoral Length Sock, Fracture OR Equal,... | other | $27 | $27 | $27 | 1 |
| Needle Ebus 22g #na-201sx-4022-a | other | $27 | $27 | $27 | 1 |
| Proinsulin (pancreatic Hormone) Level | other | $27 | $27 | $27 | 1 |
| Nasal Tube Bridal Pro System 12-14 Fr Dark Blue5ea/box #4 | other | $27 | $27 | $27 | 1 |
| Nasal Tube Bridle Pro System 16-18fr Yellow 5ea/box #4 | other | $27 | $27 | $27 | 1 |
| Nasal Tube Bridle Pro System 5-6 Fr Purple 5ea/box#4 | other | $27 | $27 | $27 | 1 |
| Nasal Tube Bridle Pro System 8-10 Fr Teal 5ea/box# 4 | other | $27 | $27 | $27 | 1 |
| Coil Embolization Nester 8mmx7cm #g52744 | other | $27 | $27 | $27 | 1 |
| Calcitonin (hormone) Level | other | $27 | $27 | $27 | 1 |
| Review By Radiologist of Image From Tube Placement Into Bile and Pancreatic D... | other | $27 | $27 | $27 | 1 |
| Alkaloids Levels | other | $27 | $27 | $27 | 1 |
| Cook Catheter Willis Oglesby Tube #g09892 | cardiac | $27 | $27 | $27 | 1 |
| Medical Management Interactions On the Patient's Behalf with Agencies, Employ... | other | $27 | $27 | $27 | 1 |
| Incision of Tissue Joining Lip and Gum | other | $27 | $27 | $27 | 1 |
| Common Carotid Intima-media Thickness (imt) Study for Evaluation of Atheroscl... | other | $27 | $27 | $27 | 1 |
| Calcium Chloride 10 % IV Soln | other | $27 | $27 | $27 | 1 |
| Albendazole 200 Mg Po Tabs | other | $27 | $27 | $27 | 1 |
| Collection of Blood Sample From Central Venous Tube | other | $27 | $27 | $27 | 1 |
| Guide Pin D1.5 Lg 300mm Gleno #230796000 | other | $27 | $27 | $27 | 1 |
| Guide Pin Metaglene 2.5 #2307-87 | other | $27 | $27 | $27 | 1 |
| Procalcitonin (hormone) Level | other | $27 | $27 | $27 | 1 |
| Pathology Examination of Specimen During Surgery | surgery | $27 | $27 | $27 | 1 |
| Technetium Tc 99m Pentetate Diagnostic 25 Mci | other | $27 | $27 | $27 | 1 |
| Belt, Strap, Sleeve, Garment, OR Covering, Any Type | other | $27 | $27 | $27 | 1 |
| Cath Cholangiogram/taut 4fr X 18in | other | $27 | $27 | $27 | 1 |
| Fulgurating Endo Electrode 2fr 105cm #be | other | $27 | $27 | $27 | 1 |
| Measurement of Immune Substance | other | $27 | $27 | $27 | 1 |
| Injection, Bleomycin Sulfate, 15 Units | other | $27 | $27 | $27 | 1 |
| 3.0mm Round Diamond 5820-012-030d | other | $27 | $27 | $27 | 1 |
| 4.0mm Round Diamond 5820-012-040d | other | $27 | $27 | $27 | 1 |
| Injection, Ketorolac Tromethamine, Per 15 Mg | other | $27 | $23 | $30 | 2 |
| Detection Test By Nucleic Acid for Chlamydia Trachomatis, Amplified Probe Tec... | other | $27 | $19 | $35 | 2 |
| Detection Test By Nucleic Acid for Neisseria Gonorrhoeae (gonorrhoeae Bacteri... | other | $27 | $19 | $35 | 2 |
| Therapy Procedure Using Manual Technique, Each 15 Minutes | other | $27 | $27 | $27 | 1 |
| Parenteral Nutrition Solution, Not Otherwise Specified, 10 Grams Lipids | lab | $27 | $27 | $27 | 1 |
| Initial Oxygen 30 Min | other | $27 | $27 | $27 | 1 |
| Hepatitis B Vaccine, Pediatric OR Adolescent Dosage | preventive | $27 | $27 | $27 | 1 |
| Injection, Medroxyprogesterone Acetate, 1 Mg | other | $27 | $27 | $27 | 1 |
| Automated Platelet Count | other | $27 | $27 | $27 | 1 |
| Blood,occult By Peroxidase Act | other | $27 | $27 | $27 | 1 |
| Assay of Blood/uric Acid | other | $27 | $27 | $27 | 1 |
| Lipid Panel | lab | $28 | $2 | $76 | 13 |
| Special Stained Specimen Slides to Examine Tissue Including Interpretation an... | lab | $28 | $7 | $49 | 2 |
| Cement Bone Mixing System #414702 1pk/10ea | other | $28 | $28 | $28 | 1 |
| Knee Brace Recover Neo Long Large #00364 | other | $28 | $28 | $28 | 1 |
| Knee Brace Recover Neo Long Medium #00363 | other | $28 | $28 | $28 | 1 |
| Knee Brace Recover Neo Long Small #00362 | other | $28 | $28 | $28 | 1 |
| Knee Brace Recover Neo Long Xlarge #00365 | other | $28 | $28 | $28 | 1 |
| Knee Brace Recover Neo Long Xxl #00366 | other | $28 | $28 | $28 | 1 |
| Endostitch Device 10mm #173016 | other | $28 | $28 | $28 | 1 |
| I&a Tip Straight | other | $28 | $28 | $28 | 1 |
| Diltiazem 100 Mg/100 Ml - Compounded | other | $28 | $28 | $28 | 1 |
| Potassium Acet 100 Meq/50 Ml | other | $28 | $28 | $28 | 1 |
| Diltiazem 100 Mg Add-van Vial | other | $28 | $28 | $28 | 1 |
| Therapeutic Procedures to Improve Respiratory Function, Other Than Described ... | other | $28 | $28 | $28 | 1 |
| Therapeutic Procedures to Increase Strength OR Endurance of Respiratory Muscl... | other | $28 | $28 | $28 | 1 |
| Removal of Blood Flow Assist Device in Aorta | surgery | $28 | $28 | $28 | 1 |
| Citrate Level | other | $28 | $28 | $28 | 2 |
| 2.2mm Match Head 5820-107 | other | $28 | $28 | $28 | 1 |
| Test to Measure Lung Airway Sensitivity | other | $28 | $28 | $28 | 1 |
| Injection, Rituximab-pvvr, Biosimilar, (ruxience), 10 Mg | other | $28 | $28 | $28 | 1 |
| Hydrocort-pramoxine 1%-1% Crm | other | $28 | $28 | $28 | 1 |
| Food Bolus 4cmx2.5mmx160cm Rothnet Bx00711155 | other | $28 | $28 | $28 | 1 |
| Placement of Ear Probe for Computerized Measurement of Repeated Sounds with I... | other | $28 | $28 | $28 | 1 |
| Residence Visit for Established Patient with Straightforward Medical Decision... | other | $28 | $28 | $28 | 1 |
| Measurement of Total Estradiol | other | $28 | $28 | $28 | 2 |
| Injection, Trastuzumab-qyyp, Biosimilar, (trazimera), 10 Mg | other | $28 | $28 | $28 | 1 |
| Coil Vascular Loop Shape Standard Stretch 8 Mm Dia 10 Cm Length Pushable 0.03... | other | $28 | $28 | $28 | 1 |
| Mreye .035 10mm X 10cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 10mm X 15cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 10mm X 8cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 15mm X 15cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 20mm X 15cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 4mm X 4cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 5mm X 3cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 5mm X 5cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 5mm X 8cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 6mm X 5cm | other | $28 | $28 | $28 | 1 |
| Mreye .035 8mm X 8cm | other | $28 | $28 | $28 | 1 |
| Lumbar Orthosis, Sagittal Control, with Rigid Posterior Panel(s), Posterior E... | lab | $28 | $28 | $28 | 1 |
| Probe Vascular 2.0-2.5mm 45cm 5/bx | other | $28 | $28 | $28 | 1 |
| Rasp #5100-037-114 Stryker (bone Shaver | other | $28 | $28 | $28 | 1 |
| Rasp Large Tear #5100-037 | other | $28 | $28 | $28 | 1 |
| Rasp Small Tear #5100-37 | other | $28 | $28 | $28 | 1 |
| Electronic Analysis and Reprogramming of Spinal Canal Drug Infusion Pump | surgery | $28 | $28 | $28 | 1 |
| Injection, Leucovorin Calcium, Per 50 Mg | other | $28 | $28 | $28 | 1 |
| Introducer/sheath, Guiding, Intracardiac Electrophysiological, Fixed-curve, O... | cardiac | $28 | $28 | $28 | 1 |
| Introducer/sheath, Guiding, Intracardiac Electrophysiological, Steerable, Oth... | cardiac | $28 | $28 | $28 | 1 |
| Cannula I&a Simcoe | other | $28 | $28 | $28 | 1 |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System, Remot... | cardiac | $28 | $28 | $28 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Drop Lock Knee Joint | other | $28 | $28 | $28 | 1 |
| Gastrointestinal Suture Anchor Kit #g04474 | other | $28 | $28 | $28 | 1 |
| Other Evaluation and Management Service | other | $28 | $28 | $28 | 1 |
| Reaming Rod 2.5mm X 850mm Ti Cannulated | other | $28 | $28 | $28 | 1 |
| Detection Test By Nucleic Acid for Clostridium Difficile, Amplified Probe Tec... | other | $28 | $19 | $37 | 2 |
| Injection, Midazolam in 0.9% Sodium Chloride, Intravenous, Not Therapeuticall... | other | $28 | $3 | $53 | 2 |
| Injection, Propofol, 10 Mg | other | $28 | $28 | $28 | 1 |
| Therapy Procedure Using Exercise to Develop Strength, Endurance, Range of Mot... | other | $28 | $28 | $28 | 1 |
| Lokelma 10 Gm Powder Packet | other | $28 | $28 | $28 | 1 |
| Impersol 1.5% 2000cc | other | $28 | $28 | $28 | 1 |
| Impersol 4.25% 2000 Cc | other | $28 | $28 | $28 | 1 |
| Decalcification of Tissue | other | $28 | $28 | $28 | 1 |
| Assay of Phosphorus | other | $28 | $28 | $28 | 1 |
| Mammogram | preventive | $29 | $4 | $1,356 | 32 |
| Allergy Testing Panel | diagnostic | $29 | $3 | $834 | 10 |
| X-ray of Toe, Minimum of 2 Views | imaging | $29 | $6 | $51 | 2 |
| X-ray of Shoulder, 1 View | imaging | $29 | $7 | $51 | 2 |
| X-ray of Spine, 1 View | imaging | $29 | $7 | $51 | 2 |
| Electronic Analysis Reprogramming and Refill of Spinal Canal Drug Infusion Pump | surgery | $29 | $29 | $29 | 1 |
| Detractor Guhl Ankle 6ea/bx | other | $29 | $29 | $29 | 1 |
| Psychiatric Evaluation of Hospital Records, Reports, Testing, OR Data for Dia... | therapy | $29 | $29 | $29 | 1 |
| Repair Arterial Blockage | surgery | $29 | $29 | $29 | 1 |
| Injection, Adrenalin, Epinephrine, 0.1 Mg | other | $29 | $29 | $29 | 1 |
| Tretinoin 0.05 % Ex Crea | other | $29 | $29 | $29 | 1 |
| Precedex 200 Mcg/50 Ml Bottle | other | $29 | $29 | $29 | 1 |
| Osteopathic Manipulative Treatment, 3-4 Body Regions | other | $29 | $29 | $29 | 1 |
| Injection of Anesthetic And/or Steroid Drug Into Foot Nerve | other | $29 | $29 | $29 | 1 |
| Probe Bio Vascular 1.0-1.5mm 5/bx | other | $29 | $29 | $29 | 1 |
| Cuffed Tracheostomy Tube Bivona Fome-cuf Disposable Ic Size 6.0 Adult 850160 | other | $29 | $29 | $29 | 1 |
| Cuffed Tracheostomy Tube Bivona Fome-cuf Disposable Ic Size 7.0 Adult 850170 | other | $29 | $29 | $29 | 1 |
| Tray Pneumothorax Infant 5ea/1cs | other | $29 | $29 | $29 | 1 |
| Centurion 30 Fms Cassette Only #8065000138 6ea/bx | other | $29 | $29 | $29 | 1 |
| Removal of Foreign Body From External Eye | surgery | $29 | $29 | $29 | 1 |
| Orthopedic Footwear, Man's Shoe, Oxford, Used As an Integral Part of a Brace | other | $29 | $29 | $29 | 1 |
| Nail Nippers 4" #881302 | other | $29 | $29 | $29 | 1 |
| Tretinoin 0.1 % Ex Crea | other | $29 | $29 | $29 | 1 |
| Cement Mixer 00-4501-090-00 00450109000 | other | $29 | $29 | $29 | 1 |
| Clip Avalon Filshie #avm-851j | other | $29 | $29 | $29 | 1 |
| Established Patient Office OR Other Outpatient Visit with Straightforward Med... | other | $29 | $29 | $29 | 1 |
| Group Preventive Medicine Counseling, Typically 1 Hour | therapy | $29 | $29 | $29 | 1 |
| Pathology Cytologic Examination of Specimen During Surgery, Each Additional Site | surgery | $29 | $29 | $29 | 1 |
| Resure Sealant Ocular #rs-1004-us-10 10/bx | other | $29 | $29 | $29 | 1 |
| 7fr Single Sensor W/lumen/coude Tip | other | $29 | $29 | $29 | 1 |
| Immunologic Analysis Technique On Body Fluid, Other Fluids with Concentration | other | $29 | $29 | $29 | 2 |
| Injection, Rituximab-abbs, Biosimilar, (truxima), 10 Mg | other | $29 | $29 | $29 | 1 |
| Hc Dress Aquacl Ag Hydrofiber | other | $29 | $29 | $29 | 1 |
| Lift, Elevation, Inside Shoe, Tapered, Up to One-half Inch | other | $29 | $29 | $29 | 1 |
| Application of Hinged Finger Splint | other | $29 | $29 | $29 | 1 |
| Closure Pilot Guides 5mm & 10/12mm Set | other | $29 | $29 | $29 | 1 |
| Sodium Phosphate P-32, Therapeutic, Per Millicurie | other | $29 | $29 | $29 | 1 |
| Assay of Serum Sodium | other | $29 | $29 | $29 | 1 |
| Vitamin D Test | lab | $30 | $25 | $465 | 15 |
| Test to Measure Largest Amount of Air Breathed in an Out | other | $30 | $3 | $56 | 2 |
| X-ray of Hand, 2 Views | imaging | $30 | $8 | $51 | 2 |
| X-ray of Joint Between Lower Spine and Hip Bone, 1-2 Views | imaging | $30 | $8 | $52 | 2 |
| 2.3mm Tapered Router5407-fa2 | other | $30 | $30 | $30 | 1 |
| 3.0mm Tapered Router5407-fa3 | other | $30 | $30 | $30 | 1 |
| Electrode Emg 18mm Needle 2 Channel 1m Cable Muscle Specific Prass Paired Ins... | other | $30 | $30 | $30 | 1 |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System OR Imp... | cardiac | $30 | $30 | $30 | 1 |
| Development of Cognitive Skills to Improve Attention, Memory, Problem Solving... | other | $30 | $30 | $30 | 1 |
| Test to Assess Balance During Warm and Cool Irrigation in Both Ears | other | $30 | $30 | $30 | 1 |
| Vitamin D-3 Level | other | $30 | $30 | $30 | 2 |
| Nester .035 4mm X 7cm #g47372 | other | $30 | $30 | $30 | 1 |
| Dexmedetomidine Hcl in Nacl 80 Mcg/20ml IV Soln | other | $30 | $30 | $30 | 1 |
| Zimmer Compact Vacuum Cement Mixing System #00-5049-035 | other | $30 | $30 | $30 | 1 |
| Side-by-side Bipolar Stimulating Probe 5ea/pk #8225401 | other | $30 | $30 | $30 | 1 |
| Injection, Lanreotide, (cipla), 1 Mg | other | $30 | $30 | $30 | 1 |
| Handle Sizer for Inhance Shoulder System #720530301 #7205-30 | other | $30 | $30 | $30 | 1 |
| Repair/modification of a Hearing Aid | surgery | $30 | $30 | $30 | 1 |
| Dificid 200 Mg Tablet | other | $30 | $30 | $30 | 1 |
| Injection, Fam-trastuzumab Deruxtecan-nxki, 1 Mg | other | $30 | $30 | $30 | 1 |
| Vac Veraflo Dress Sys-medium #ultvfl05md | other | $30 | $30 | $30 | 1 |
| Sterile Water, Saline And/or Dextrose, Diluent/flush, 10 Ml | other | $30 | $30 | $30 | 1 |
| Ankle Orthosis, Ankle Gauntlet OR Similar, with OR without Joints, Prefabrica... | other | $30 | $30 | $30 | 1 |
| X-ray of Bone Behind the Ear, 1-2 Views Per Side | imaging | $30 | $30 | $30 | 1 |
| Digoxin 0.05 Mg/ml Solution | other | $30 | $30 | $30 | 1 |
| Injection, Cilastatin Sodium; Imipenem, Per 250 Mg | other | $30 | $30 | $30 | 1 |
| Injection, Trastuzumab-anns, Biosimilar, (kanjinti), 10 Mg | other | $30 | $30 | $30 | 1 |
| Antibody Evaluation, Each Additional Single Antibody Stain Procedure | other | $30 | $30 | $30 | 1 |
| Cryoprecipitate, Each Unit | other | $30 | $12 | $151 | 3 |
| Injection, Pegfilgrastim-bmez (ziextenzo), Biosimilar, 0.5 Mg | other | $30 | $30 | $30 | 1 |
| Ultrasonic Guidance for Needle Placement | other | $30 | $30 | $30 | 1 |
| Injection, Infliximab-abda, Biosimilar, (renflexis), 10 Mg | other | $30 | $27 | $33 | 2 |
| Amplifed Dna OR Rna Probe Detection of Severe Acute Respiratory Syndrome Coro... | other | $30 | $25 | $35 | 2 |
| Detection Test By Nucleic Acid for Zika Virus, Amplified Probe Technique | other | $30 | $30 | $30 | 1 |
| Injection, Cefepime Hydrochloride (b Braun), Not Therapeutically Equivalent t... | other | $30 | $30 | $30 | 1 |
| Injection, Daptomycin, 1 Mg | other | $30 | $30 | $30 | 1 |
| Injection, Penicillin G Benzathine, 100,000 Units | other | $30 | $30 | $30 | 1 |
| Dxa Bone Density Measurement of Forearm, Finger, Hand, OR Foot | other | $30 | $30 | $30 | 1 |
| Injection, Methylergonovine Maleate, Up to 0.2 Mg | other | $30 | $30 | $30 | 1 |
| Assay of Serum Albumin | other | $30 | $30 | $30 | 1 |
| Bilirubin Direct | other | $30 | $30 | $30 | 1 |
| Bilirubin Total | other | $30 | $30 | $30 | 1 |
| Smear Fluorescent/acid Stai | other | $30 | $30 | $30 | 1 |
| Blood Test | lab | $31 | $2 | $547 | 28 |
| X-ray of Middle Spine, 3 Views | imaging | $31 | $10 | $52 | 2 |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine Including Spine Fracture A... | other | $31 | $14 | $47 | 2 |
| Fresh Frozen Plasma (single Donor), Frozen Within 8 Hours of Collection, Each... | other | $31 | $22 | $39 | 2 |
| Dihydroxyvitamin D, 1, 25 Level | other | $31 | $23 | $39 | 2 |
| Surgicel Original Hemostat 2in X 3in 1953s | other | $31 | $31 | $31 | 1 |
| Ear Mold/insert, Not Disposable, Any Type | other | $31 | $31 | $31 | 1 |
| Nanoneedle Diagnostic Sheath Kit 125 Mm #ar-3210 | other | $31 | $31 | $31 | 1 |
| Needle Osteo-site Bn Bx M2 #g36211 Dbbn-11-10.0-m2s | other | $31 | $31 | $31 | 1 |
| Needle Osteo-site Long #g36406 | other | $31 | $31 | $31 | 1 |
| Polyloop Ligating Device #hx-400u | other | $31 | $31 | $31 | 1 |
| Testosterone Pellet, 75 Mg | other | $31 | $31 | $31 | 1 |
| Endoclip 5mm #176630 | other | $31 | $31 | $31 | 1 |
| Reaming Rod 3.0mm X 950mm W/balltip Sterile | other | $31 | $31 | $31 | 1 |
| Reaming Rod 3.0mm X950mm W/offset Tip | other | $31 | $31 | $31 | 1 |
| Patient Tracker Noninvasive #9734887xom | other | $31 | $31 | $31 | 1 |
| Test to Assess Hearing Using Pictures | other | $31 | $31 | $31 | 1 |
| Wound Retractor/protector Xlrg #c8404 | other | $31 | $31 | $31 | 1 |
| Injection of Contrast Through Abdominal Cavity Tube for X-ray Study | imaging | $31 | $31 | $31 | 1 |
| Injection, Protamine Sulfate, Per 10 Mg | other | $31 | $31 | $31 | 1 |
| Tornade Embolization Coil 10 X 4 #g09217 | other | $31 | $31 | $31 | 1 |
| Addition to Lower Extremity Orthosis, Non-corrosive Finish, Per Bar | other | $31 | $31 | $31 | 1 |
| Serotonin (hormone) Level | other | $31 | $31 | $31 | 1 |
| 12.6mm X 10.4mm Boring Toolstryker #5130-123 | other | $31 | $31 | $31 | 1 |
| 9.5mm X 10.4mm Boring Tool 5130-123 | other | $31 | $31 | $31 | 1 |
| Injection, Infliximab, Excludes Biosimilar, 10 Mg | other | $31 | $31 | $31 | 2 |
| Injection, Mepolizumab, 1 Mg | other | $31 | $31 | $31 | 1 |
| Plasma-lyte a Ph 7.4 Soln. | other | $31 | $31 | $31 | 1 |
| Pin Steinmann 3.2mm 9" #110003484 | other | $31 | $31 | $31 | 1 |
| Sheath Navigator 11/13frx36cm #250-222 Bossci | other | $31 | $31 | $31 | 1 |
| Gastro Anchor Set Saf-t-pexy T-fastener | other | $31 | $31 | $31 | 1 |
| Exam of the Nose and Throat Using an Endoscope | other | $31 | $31 | $31 | 1 |
| Detection Test By Immunoassay Technique for Severe Acute Respiratory Syndrome... | other | $31 | $25 | $36 | 2 |
| Follow-up Training in the Use of Orthopedic Device OR Artificial Arm, Leg And... | other | $31 | $31 | $31 | 1 |
| Fracture Assessment of Spine Bones Using Dxa | other | $31 | $31 | $31 | 1 |
| Aspartate Aminotransferase | other | $31 | $31 | $31 | 1 |
| Assay Alkaline Phosphatase | other | $31 | $31 | $31 | 1 |
| Assay of Urine Creatinine | other | $31 | $31 | $31 | 1 |
| C-reactive Protein | other | $31 | $31 | $31 | 1 |
| Fibrinogen | other | $31 | $31 | $31 | 1 |
| Injection, Mannitol, 25% in 50 Ml | other | $32 | $13 | $50 | 2 |
| Commode Patient Bariatric (800lbs) Cpat0008d | other | $32 | $32 | $32 | 1 |
| Meniscal Knot Pusher/cutter #72201537 | other | $32 | $32 | $32 | 1 |
| Codman Disposable Catheter Passer #82 | cardiac | $32 | $32 | $32 | 1 |
| Avitene Microfibril Collagen Hemostat 1010020 | other | $32 | $32 | $32 | 1 |
| Resolution Clips 2.8mmx235cm 20ea/1bx | other | $32 | $32 | $32 | 1 |
| Occluder Colpo Pneumo Occluder | other | $32 | $32 | $32 | 1 |
| Dornase Alfa, Inhalation Solution, Fda-approved Final Product, Non-compounded... | other | $32 | $32 | $32 | 1 |
| Blood Gases Measurement, with O2 Saturation | other | $32 | $32 | $32 | 1 |
| Button Replacement 24fr X 2.4cm Low Profile | surgery | $32 | $32 | $32 | 1 |
| Gastrostomy Tube 24fr 3.4cm Kit Replacement | surgery | $32 | $32 | $32 | 1 |
| Hard-bone Drill 1.5 Mm Ar-9938 | other | $32 | $32 | $32 | 1 |
| Hard-bone Drill 1.7 Mm Ar-9938 | other | $32 | $32 | $32 | 1 |
| Inner Vision Fiber Optic Tip 56fr 1465 | other | $32 | $32 | $32 | 1 |
| Tip Detachable 40fr Transillumination #1465 | other | $32 | $32 | $32 | 1 |
| Fluticasone Furoate 27.5 Mcg/spray Na Susp | other | $32 | $32 | $32 | 1 |
| Pigazzi Pad #40595 3/cs | other | $32 | $32 | $32 | 1 |
| Neomy-polymyxin B 40 Mg/ml Amp | other | $32 | $32 | $32 | 1 |
| Basket Roth Net Pedia Foreign Body Bx00711057 | other | $32 | $32 | $32 | 1 |
| Subsequent Hospital Care with Straightforward OR Low Level of Medical Decisio... | other | $32 | $32 | $32 | 1 |
| Potassium Phosph 15 Mmol/5 Ml | other | $32 | $32 | $32 | 1 |
| Hetastarch 6%-0.9% Nacl Bag | other | $32 | $32 | $32 | 1 |
| Catheter Kit 7.5" Pain On Q Silversoaker 5/bx | cardiac | $32 | $32 | $32 | 1 |
| Follow-up Hospital Care of Newborn Per Day | obstetric | $32 | $32 | $32 | 1 |
| Influenza Vaccine, Inactivated | preventive | $32 | $32 | $32 | 1 |
| Lift, Elevation, Heel and Sole, Neoprene, Per Inch | other | $32 | $32 | $32 | 1 |
| Ofloxacin 0.3% Ear Drops | other | $32 | $32 | $32 | 1 |
| Catheter, Suprapubic/cystoscopic | cardiac | $32 | $26 | $37 | 2 |
| Therapy Procedure to Re-educate Brain-to-nerve-to-muscle Function, Each 15 Mi... | other | $32 | $32 | $32 | 1 |
| Ultrasonic Guidance for Removal of Amniotic Fluid | surgery | $32 | $32 | $32 | 1 |
| Test OR Measurement for Functional Capacity, Each 15 Minutes | other | $32 | $32 | $32 | 1 |
| Rbc Pretreatment with Enzymes | other | $32 | $32 | $32 | 1 |
| Alanine Amino | other | $32 | $32 | $32 | 1 |
| Rheumatoid Factor Quant | other | $32 | $32 | $32 | 1 |
| Cortisol, Serum | other | $32 | $32 | $32 | 1 |
| X-ray of Ankle, 2 Views | imaging | $33 | $8 | $58 | 2 |
| X-ray of Elbow, 2 Views | imaging | $33 | $8 | $57 | 2 |
| X-ray of Chest Bone, Minimum of 2 Views | imaging | $33 | $9 | $57 | 2 |
| Review By Radiologist of Bile And/or Pancreatic Duct Image During Surgery | surgery | $33 | $12 | $54 | 2 |
| Diphtheria, Tetanus, and Acellular Pertussis Vaccine | preventive | $33 | $21 | $45 | 2 |
| Pathology Examination of Tissue Using a Microscope, Intermediate Complexity | lab | $33 | $30 | $35 | 2 |
| Injection of Contrast for Imaging of Knee Joint | other | $33 | $33 | $33 | 1 |
| Steinmann Pin 9" Shoulder #405800 | other | $33 | $33 | $33 | 1 |
| Sensor Arterial Cdi #cdi510h | other | $33 | $33 | $33 | 1 |
| Evaluation of Lower Heart Chamber Assist Device | cardiac | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity Orthosis, Rocker Bottom for Total Contact Ankle F... | other | $33 | $33 | $33 | 1 |
| Dextrose 50%-water Abboject | other | $33 | $33 | $33 | 1 |
| Injection, Nivolumab, 1 Mg | other | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity, Split Flat Caliper Stirrups and Plate Attachment | other | $33 | $33 | $33 | 1 |
| 2.0mm Round Diamond 5820-012-020d | other | $33 | $33 | $33 | 1 |
| Electronic Analysis of Implanted Neurostimulator Generator with Simple Spinal... | surgery | $33 | $33 | $33 | 1 |
| Ligator Band 7 Speedband 4ea/1bx M00542253 | other | $33 | $33 | $33 | 1 |
| Addition to Lower Extremity, Dorsiflexion Assist (plantar Flexion Resist), Ea... | other | $33 | $33 | $33 | 1 |
| Ankle Control Orthosis, Stirrup Style, Rigid, Includes Any Type Interface (e.... | other | $33 | $33 | $33 | 1 |
| Caloric Vestibular Test | other | $33 | $33 | $33 | 1 |
| Catheter Venogram Balloon #6215 Mdt | cardiac | $33 | $33 | $33 | 1 |
| Corneal Vacuum Punch 8.00mm #17200d800 | other | $33 | $33 | $33 | 1 |
| Diphtheria, Tetanus, Acellular Pertussis, Hepatitis B, and Polio Vaccine | preventive | $33 | $33 | $33 | 1 |
| Extension Titanium for Pd Catheter #ta | cardiac | $33 | $33 | $33 | 1 |
| Hc Monitored Anesthesia Care Anesthesia Time - Each Incremental 15 Minutes | other | $33 | $33 | $33 | 1 |
| Hydrocortisone-acetic Ear Drop | other | $33 | $33 | $33 | 1 |
| Influenza Virus Vaccine, Quadrivalent (iiv4), Split Virus, Preservative Free,... | preventive | $33 | $33 | $33 | 1 |
| Preventive Medicine Counseling, Typically 30 Minutes | therapy | $33 | $33 | $33 | 1 |
| Punch Cornea Vacuum 7.75mm #17200d775 | other | $33 | $33 | $33 | 1 |
| Punch Corneal Vacuum 7.50mm #17200d750 | other | $33 | $33 | $33 | 1 |
| Loop 12 Degree for Long Tur Set #wa22037c | other | $33 | $33 | $33 | 1 |
| Neomycin-poly-hc Eye Drops | other | $33 | $33 | $33 | 1 |
| Screw Hex Female 2.5mm #42-5099-025 | other | $33 | $33 | $33 | 1 |
| Dacarbazine, 100 Mg | other | $33 | $33 | $33 | 1 |
| Prosthetic Shrinker, Above Knee, Each | other | $33 | $33 | $33 | 1 |
| Training in the Use of Artificial Arm And/or Leg, Each 15 Minutes | other | $33 | $31 | $34 | 2 |
| Detection Test By Nucleic Acid for Organism, Amplified Probe Technique | other | $33 | $30 | $35 | 2 |
| Injection, Oxytocin, Up to 10 Units | other | $33 | $29 | $36 | 2 |
| Injection, Gadolinium-based Magnetic Resonance Contrast Agent, Not Otherwise ... | other | $33 | $6 | $60 | 2 |
| Lipoprotein-associated Phospholipase A2 (enzyme) Level | other | $33 | $33 | $33 | 1 |
| Newborn Metabolic Screening Panel, Includes Test Kit, Postage and the Laborat... | lab | $33 | $33 | $33 | 1 |
| Injection, Diazepam, Up to 5 Mg | other | $33 | $33 | $33 | 1 |
| Assay of Triglycerides | other | $33 | $33 | $33 | 1 |
| Deb Bone Add-on | other | $33 | $33 | $33 | 1 |
| Coombs Test Direct | other | $33 | $33 | $33 | 1 |
| Special Stained Specimen Slides to Identify Organisms Including Interpretatio... | lab | $34 | $18 | $49 | 2 |
| Hepatitis a Vaccine Adult Dosage | preventive | $34 | $34 | $34 | 1 |
| Hepatitis B Vaccine, Adult Dosage | preventive | $34 | $34 | $34 | 1 |
| Test for Abnormal Eye Movement Using 3 Positions | other | $34 | $34 | $34 | 1 |
| Hc Coban 2 #2094 1bx=1kit | other | $34 | $34 | $34 | 1 |
| Hc Coban 2 Lite #2794 1bx=1kit | other | $34 | $34 | $34 | 1 |
| Needle Ebus 21g #na-201sx | other | $34 | $34 | $34 | 1 |
| Sizing Catheter Sf #g47308 5ea/1bx | cardiac | $34 | $34 | $34 | 1 |
| Super-dimension Premarked Biopsy Forceps #sdbf1000 5/ct | lab | $34 | $34 | $34 | 1 |
| Cannula Retrograde 14fr Research Med | other | $34 | $34 | $34 | 1 |
| Post Op Knee Brace Xlg #423101 | other | $34 | $34 | $34 | 1 |
| Electronic Analysis of Implanted Neurostimulator Generator with Complex Spina... | surgery | $34 | $34 | $34 | 1 |
| Ultrasound of Heart for Congenital Defect, Follow-up | imaging | $34 | $34 | $34 | 1 |
| Adh (antidiuretic Hormone) Level | other | $34 | $34 | $34 | 1 |
| Rotavirus Vaccine, Pentavalent | preventive | $34 | $34 | $34 | 1 |
| Addition to Knee Joint, Lift Loop for Drop Lock Ring | other | $34 | $34 | $34 | 1 |
| Evaluation of Implantable Defibrillator System | surgery | $34 | $34 | $34 | 1 |
| Vac Veraflo Cleanse Dress Sys Med #ultvcl05md | other | $34 | $34 | $34 | 1 |
| Biktarvy 50-200-25 Mg Tablet | other | $34 | $34 | $34 | 1 |
| Stone Extractor Perc Ncircle #g32862 | other | $34 | $34 | $34 | 1 |
| Pad Electrode Adult One Piece for Auto External Defibrillator Cpr-d-padz 8900... | other | $34 | $34 | $34 | 1 |
| Detection Test By Nucleic Acid for Organism, Quantification | other | $34 | $25 | $43 | 2 |
| Therapy Procedure Using Functional Activities | other | $34 | $34 | $34 | 1 |
| 3d/4d Prenatal Ultrasound | imaging | $34 | $34 | $34 | 1 |
| Injection, Caffeine Citrate, 5 Mg | other | $34 | $34 | $34 | 1 |
| Deb Subq Tissue Add-on | other | $34 | $34 | $34 | 1 |
| High Osmolar Contrast Material, 350-399 Mg/ml Iodine Concentration, Per Ml | other | $35 | $3 | $67 | 2 |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine | other | $35 | $9 | $61 | 2 |
| X-ray of Joint Between Breast and Collar Bones, Minimum of 2 Views | imaging | $35 | $10 | $59 | 2 |
| Irradiation of Blood Product, Each Unit | other | $35 | $34 | $36 | 2 |
| Injection, Trastuzumab-pkrb, Biosimilar, (herzuma), 10 Mg | other | $35 | $35 | $35 | 1 |
| Electrode Barrie Bar 3mm Storz #27050nx-s | other | $35 | $35 | $35 | 1 |
| Chest Tube Tray #cht2085 20ea/case6-8 Week Lead Time | other | $35 | $35 | $35 | 1 |
| Aveta Fluid Management Accessory #205-212 3/ctn | other | $35 | $35 | $35 | 1 |
| Endo Clip Applier 5mm #ae05ml 3 Ea/1bx | other | $35 | $35 | $35 | 1 |
| Fecal Collector Flexi Seal Sys #418000 1ea/bx | other | $35 | $35 | $35 | 1 |
| Knee Orthosis, Immobilizer, Canvas Longitudinal, Prefabricated, Off-the-shelf | other | $35 | $35 | $35 | 1 |
| Insertion of Probe in Esophagus for Recording Electrical Impulses to Upper an... | other | $35 | $35 | $35 | 1 |
| Alvimopan 12 Mg Capsule | other | $35 | $35 | $35 | 1 |
| Stopcock Universal #75u | other | $35 | $35 | $35 | 1 |
| Opticath High Flow Cath Lfr 8fr 110cm 6/cs | other | $35 | $35 | $35 | 1 |
| Evaluation of Single, Dual, OR Multiple Lead Implantable Defibrillator System | surgery | $35 | $35 | $35 | 1 |
| Pneumothorax Cath Tray Disp Arrow 5ea/1bx | other | $35 | $35 | $35 | 1 |
| Injection, Tobramycin Sulfate, Up to 80 Mg | other | $35 | $35 | $35 | 1 |
| Addition to Lower Extremity, Torsion Control, Ankle Joint and Half Solid Stirrup | other | $35 | $35 | $35 | 1 |
| Knot Pusher/suture Cutter and Slotted Cannula Set 72202674 | other | $35 | $35 | $35 | 1 |
| Closure Surgical Skin 24cm Zip24 Ps1240 5/pk | surgery | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Amplified Probe Technique | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Herpes Simplex Virus, Amplified Probe Tech... | other | $35 | $35 | $35 | 2 |
| Detection Test By Nucleic Acid for Human Papillomavirus (hpv), High-risk Types | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Mycoplasma Pneumoniae (bacteria), Amplifie... | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Staphylococcus Aureus, Methicillin Resista... | other | $35 | $35 | $35 | 1 |
| Identification of Organisms By Genetic Analysis, Amplified Probe Technique | other | $35 | $35 | $35 | 1 |
| Chemistry Procedures | other | $35 | $35 | $35 | 1 |
| Grasping Device-endo Raptor Disp #bx00711177 | other | $35 | $35 | $35 | 1 |
| Imaging Guidance for Localization of Radiation Treatment | other | $35 | $35 | $35 | 1 |
| Norepinephrine 4 Mg / 250 Ml Ns Bag - Compounded | other | $35 | $35 | $35 | 1 |
| Pressure Monitor Set/stryker Quick | other | $35 | $35 | $35 | 1 |
| Application of Lower and Upper Arm Splint | other | $35 | $35 | $35 | 1 |
| Declotting of Central Venous Tube | other | $35 | $35 | $35 | 1 |
| Vasoactive Intestinal Peptide (intestinal Hormone) Level | other | $35 | $35 | $35 | 1 |
| Measles, Mumps, and Rubella Vaccine | preventive | $35 | $35 | $35 | 1 |
| Test for Hearing Various Pitches Using Earphone and Device Placed Against the... | other | $35 | $35 | $35 | 1 |
| Hemostatic Sealant Floseal Matrix Recothrom 5ml 6/cs | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Quantification | other | $35 | $26 | $43 | 2 |
| Detection Test By Nucleic Acid for Multiple Organisms, Direct Probe(s) Technique | other | $35 | $35 | $35 | 1 |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Amplified Probe Technique | other | $35 | $35 | $35 | 1 |
| Initial Aerosol O2 - 30 Min | other | $35 | $35 | $35 | 1 |
| Injection, Acetaminophen, Not Otherwise Specified,10 Mg | other | $35 | $35 | $35 | 1 |
| Microalbumin, Urine | other | $35 | $35 | $35 | 1 |
| Antibody Id/eash Sel Reagent C | other | $35 | $35 | $35 | 1 |
| Gait Training Therapy | other | $35 | $35 | $35 | 1 |
| Physical Therapy Session | therapy | $35 | $35 | $35 | 1 |
| Self Care Mngment Training | other | $35 | $35 | $35 | 1 |
| Therapeutic Activities | therapy | $35 | $35 | $35 | 1 |
| Residence Visit for New Patient with Straightforward Medical Decision Making,... | other | $36 | $36 | $36 | 1 |
| Typhoid Vaccine for Injection Into Muscle | preventive | $36 | $36 | $36 | 1 |
| Programming of Dual Lead Pacemaker System | cardiac | $36 | $36 | $36 | 1 |
| Electrodes-4 Channel Paired Subdermal Ea=set | other | $36 | $36 | $36 | 1 |
| Oxytocin 20 Unit/1,000 Ml-ns | other | $36 | $36 | $36 | 1 |
| Obtaining Data Needed to Develop the Optimal Radiation Treatment, 1 Treatment... | other | $36 | $36 | $36 | 1 |
| Needle Measurement of Electrical Activity in Trunk OR Head Muscles | other | $36 | $36 | $36 | 1 |
| Removal of Foreign Body in Cornea | surgery | $36 | $36 | $36 | 1 |
| Bonopty Biopsy Set 16cm #10 | lab | $36 | $36 | $36 | 1 |
| Bonopty Penetration Set 9.5cms #10 | other | $36 | $36 | $36 | 1 |
| Drill Twist Trimed #drill-2.30l | other | $36 | $36 | $36 | 1 |
| Laser Fiber 200 Rnd Tip #dfs-200-rtsb | other | $36 | $36 | $36 | 1 |
| Laser Fiber 272mic #dfs-272sb | other | $36 | $36 | $36 | 1 |
| Shoulder Gps Threaded Pin Kit(1) Shoulder Gps Coracoid Pin Long(1) Shoulder G... | other | $36 | $36 | $36 | 1 |
| Injection Procedure for Imaging of Bladder During Voiding | other | $36 | $36 | $36 | 1 |
| Vac Veraflo Cleanse Choice Medium Ultvcc05md | other | $36 | $36 | $36 | 1 |
| Biopsy of Ear | lab | $36 | $36 | $36 | 1 |
| Conformity Evaluation | other | $36 | $36 | $36 | 1 |
| Exam for Hearing Aid, Both Ears | other | $36 | $36 | $36 | 1 |
| Loop 24fr Monopolar Angled 27050g-s Cysview | other | $36 | $36 | $36 | 1 |
| Technetium Tc 99m Pyrophosphate | other | $36 | $36 | $36 | 1 |
| Feeding Tube Mic Jejunal #0200-12lv | other | $36 | $36 | $36 | 1 |
| Application of Long Leg Splint From Thigh to Ankle OR Toe | other | $36 | $36 | $36 | 1 |
| Application of Nonmoveable Forearm to Hand Splint | other | $36 | $36 | $36 | 1 |
| Application of Short Leg Splint From Calf to Foot | other | $36 | $36 | $36 | 1 |
| Injection, Sacituzumab Govitecan-hziy, 2.5 Mg | other | $36 | $36 | $36 | 1 |
| Scraper Membrane Stiff 25g | other | $36 | $36 | $36 | 1 |
| Instillation of Anti-cancer Drug Into Bladder | other | $36 | $36 | $36 | 1 |
| Test to Measure Lung Function At High Altitude | other | $36 | $36 | $36 | 1 |
| Detection Test By Nucleic Acid for Cytomegalovirus, Quantification | other | $36 | $29 | $43 | 2 |
| Injection, Phenobarbital Sodium, Up to 120 Mg | other | $36 | $26 | $45 | 2 |
| Inhalational Anesth Ea 30min | other | $36 | $36 | $36 | 1 |
| Atropine Sulf Opth Sol | other | $36 | $36 | $36 | 1 |
| Partial Thromboplastin Time | lab | $36 | $36 | $36 | 1 |
| Lactate (ld) (ldh) Enzyme | other | $36 | $36 | $36 | 1 |
| X-ray of Heel, Minimum of 2 Views | imaging | $37 | $7 | $66 | 2 |
| X-ray of Upper Arm, Minimum of 2 Views | imaging | $37 | $8 | $65 | 2 |
| X-ray of Wrist, 2 Views | imaging | $37 | $8 | $66 | 2 |
| X-ray of Sacrum and Tailbone, Minimum of 2 Views | imaging | $37 | $8 | $65 | 2 |
| X-ray of Hip, Minimum of 4 Views | imaging | $37 | $13 | $61 | 2 |
| X-ray of Bone Behind the Ear, Minimum of 3 Views Per Side | imaging | $37 | $16 | $58 | 2 |
| Replace Leather Cuff Kafo-afo, Calf OR Distal Thigh | other | $37 | $37 | $37 | 1 |
| Skin Substitute Graft to Wound 100.0 SQ Cm OR More of Trunk, Arms, OR Legs, E... | other | $37 | $37 | $37 | 1 |
| Chemical Receptor Analysis | other | $37 | $37 | $37 | 1 |
| Ball 24fr Monopolar Coag 3mm 27050n-s Cysview | other | $37 | $37 | $37 | 1 |
| Cath Laparoscopic Chole Arrow | surgery | $37 | $37 | $37 | 1 |
| Injection, Rituximab 10 Mg and Hyaluronidase | other | $37 | $37 | $37 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Vagus Nerve | other | $37 | $37 | $37 | 1 |
| Injection, Enfortumab Vedotin-ejfv, 0.25 Mg | other | $37 | $37 | $37 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Other Nerve OR Branch | other | $37 | $37 | $37 | 1 |
| Feeding Tube Endovive Jejunal 12fr #m00566340 | other | $37 | $37 | $37 | 1 |
| Stone Extractor Tipless 4.5frx65cm #g17520 | other | $37 | $37 | $37 | 1 |
| Cement Mixer | other | $37 | $37 | $37 | 1 |
| Transfer of an Orthosis From One Shoe to Another, Solid Stirrup, New | other | $37 | $37 | $37 | 1 |
| Uterine Manipulator X-large Vcare | other | $37 | $37 | $37 | 1 |
| Nevirapine 50 Mg/5 Ml Susp | other | $37 | $37 | $37 | 1 |
| Diphtheria, Tetanus, Acellular Pertussis, Polio, and Haemophilus Influenzae T... | other | $37 | $37 | $37 | 1 |
| Kit Fecal Management Flexi-seal Protect Plus Enfit Connection Bag Nonsterile ... | other | $37 | $37 | $37 | 1 |
| Osteopathic Manipulative Treatment, 5-6 Body Regions | other | $37 | $37 | $37 | 1 |
| Drain Ethicon Blake Silicon Surg 15fr #2229 | other | $37 | $37 | $37 | 1 |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Belo... | other | $37 | $37 | $37 | 1 |
| Injection, Acyclovir, 5 Mg | other | $37 | $10 | $64 | 2 |
| Injection for X-ray of Hinged Joint of Upper and Lower Jaw Bones | imaging | $37 | $37 | $37 | 1 |
| 17 Ketogenicsteroids | other | $37 | $37 | $37 | 1 |
| Initial Oxy Hood 30 Min | other | $37 | $37 | $37 | 1 |
| Technetium Tc-99m Pyrophosphate, Diagnostic, Per Study Dose, Up to 25 Millicu... | other | $37 | $37 | $37 | 1 |
| Assay of Iron | other | $37 | $37 | $37 | 1 |
| PSA (Prostate-Specific Antigen) | lab | $38 | $18 | $912 | 16 |
| X-ray of Knee, 1-2 Views | imaging | $38 | $8 | $67 | 2 |
| X-ray of Soft Tissue of Neck | imaging | $38 | $8 | $67 | 2 |
| X-ray of Part of Lower Jaw, 1-4 Views | imaging | $38 | $9 | $67 | 2 |
| Application of Vein Wound Compression Bandages On Lower Leg, Ankle, and Foot | other | $38 | $23 | $52 | 2 |
| Needle Ez Io Ld 15ga 45mm #9079 | other | $38 | $38 | $38 | 1 |
| Needle-ez Io Ld 15g Io Set 25mm #9001 Vidacre | other | $38 | $38 | $38 | 1 |
| Needle-ez Io Pd 15g Io Set 15mm #9018 Vidacre | other | $38 | $38 | $38 | 1 |
| Removal of Foreign Body in Nose | surgery | $38 | $38 | $38 | 1 |
| Maxgrip Revolution Disp Forceps 23g #706.13 | other | $38 | $38 | $38 | 1 |
| T Cells Count, Total | other | $38 | $37 | $38 | 2 |
| Cath Single Lumen 6.6fr | other | $38 | $38 | $38 | 1 |
| Elbow Orthosis, Rigid, without Joints, Includes Soft Interface Material, Pref... | other | $38 | $38 | $38 | 1 |
| Design and Construction of Intermediate Radiation Treatment Device | other | $38 | $38 | $38 | 1 |
| Injection for Nonselective Imaging of Pulmonary Artery During Heart Catheteri... | cardiac | $38 | $38 | $38 | 1 |
| Aspiration And/or Injection of Fluid From Small Joint Using Ultrasound Guidance | imaging | $38 | $38 | $38 | 1 |
| Electronic Analysis Reprogramming and Refill of Spinal Canal Drug Infusion Pu... | surgery | $38 | $38 | $38 | 1 |
| Tube Inner Ear Myringotomy Ventilation Flange 4.8 Mm Length 1.32 Mm Id Silico... | other | $38 | $38 | $38 | 1 |
| 1203105 9.0 Uniblocker 1/ea | other | $38 | $38 | $38 | 1 |
| Irrigation of Implanted Venous Access Drug Delivery Device | surgery | $38 | $38 | $38 | 1 |
| Test to Assess Hearing Sensitivity Using Activity Related Feedback | other | $38 | $38 | $38 | 1 |
| Smog Enema - Compounded | other | $38 | $38 | $38 | 1 |
| Addition to Lower Extremity, Dorsiflexion and Plantar Flexion Assist/resist, ... | other | $38 | $38 | $38 | 1 |
| Diagnostic Exam of Anus Using an Endoscope | other | $38 | $38 | $38 | 1 |
| Addition to Lower Extremity, Torsion Control, Straight Knee Joint, Each Joint | other | $38 | $38 | $38 | 1 |
| Curved Knot Pusher/suture Cutter #72202675 | other | $38 | $38 | $38 | 1 |
| Needle Measurement of Electrical Activity in Muscles On Side of Body | other | $38 | $38 | $38 | 1 |
| Prolonged Outpatient Service, Each 15 Minutes of Total Time Beyond Required T... | other | $38 | $38 | $38 | 1 |
| Psychotherapy, 30 Minutes | therapy | $38 | $38 | $38 | 1 |
| Timolol 0.5% Gfs Gel-solution | other | $38 | $38 | $38 | 1 |
| Forcep Micro Holding 23g #dfh | other | $38 | $38 | $38 | 1 |
| Tube Blakemore Ng 20fr | other | $38 | $38 | $38 | 1 |
| Extractor Balloon 15-18mm Rx Pro #4702 | other | $38 | $38 | $38 | 1 |
| Extractor Pro Rx Below Injection 12-15 M00547040 | other | $38 | $38 | $38 | 1 |
| Extractor Pro Rx Below Injection 15-18 M00547050 | other | $38 | $38 | $38 | 1 |
| Extractor Pro Rx Below Injection 9-12 M00547030 | other | $38 | $38 | $38 | 1 |
| Extractor Retrieval Balloon 12.0-15mm Rx Pro | other | $38 | $38 | $38 | 1 |
| Extractor Retrieval Balloon 9-12mm Rx Pro | other | $38 | $38 | $38 | 1 |
| Blood Unit Compatibility Test, Incubation Technique | other | $38 | $38 | $38 | 1 |
| Technetium Tc-99m Sulfur Colloid, Diagnostic, Per Study Dose, Up to 20 Millic... | other | $38 | $38 | $38 | 1 |
| X-ray of Nose Bones, Minimum of 3 Views | imaging | $39 | $8 | $70 | 2 |
| X-ray of Shoulder Blade | imaging | $39 | $9 | $69 | 2 |
| X-ray of Infant Leg, Minimum of 2 Views | imaging | $39 | $25 | $52 | 2 |
| Collection of Blood Sample From Implanted Device | surgery | $39 | $28 | $49 | 2 |
| Electronic Analysis of Implanted Gastric Neurostimulator Generator During Sur... | surgery | $39 | $39 | $39 | 1 |
| Injection, Sulfamethoxazole 5 Mg and Trimethoprim 1 Mg | other | $39 | $39 | $39 | 1 |
| Measurement of Infliximab | other | $39 | $39 | $39 | 1 |
| Injection, Secretin, Synthetic, Human, 1 Microgram | other | $39 | $39 | $39 | 1 |
| Adrenocorticotropic Hormone (acth) Level | other | $39 | $39 | $39 | 2 |
| Blood Bank Physician Services for Cross Match And/or Evaluation and Written R... | other | $39 | $39 | $39 | 1 |
| Olopatadine Hcl 0.1 % Op Soln | other | $39 | $39 | $39 | 1 |
| Sodium Ferric Gluconate (ferrlecit) 125 Mg/ Ns 100 Mls - Compounded | other | $39 | $39 | $39 | 1 |
| Malyugin Ring 6.25mm Disp #mal-0001-d | other | $39 | $39 | $39 | 1 |
| Malyugin Ring 7.00mm Disp #mal-0002-d | other | $39 | $39 | $39 | 1 |
| D Stat Flowable #4000 | other | $39 | $39 | $39 | 1 |
| Gia Endo 30 2.5 Roticular Load #030451 | other | $39 | $39 | $39 | 1 |
| Gia Endo 30 3.5 Roticular Load #030452 | other | $39 | $39 | $39 | 1 |
| Gradient Compression Stocking, Below Knee, 30-40 Mmhg, Used As a Surgical Dre... | surgery | $39 | $39 | $39 | 1 |
| Mannitol 20% | other | $39 | $39 | $39 | 1 |
| Catheter Passer Disposable 38cm #8591 | cardiac | $39 | $39 | $39 | 1 |
| Catheter Passer Disposable 4.8mm X 3.3mm X 38cm #48407 | cardiac | $39 | $39 | $39 | 1 |
| Natriuretic Peptide (heart and Blood Vessel Protein) Level | cardiac | $39 | $39 | $39 | 2 |
| Programming of Single Lead Implantable Defibrillator System | surgery | $39 | $39 | $39 | 1 |
| Nail Nippers 6" #881862 | other | $39 | $39 | $39 | 1 |
| Tissue Culture for Tumor Disorders of Bone Marrow and Blood Cells | lab | $39 | $39 | $39 | 1 |
| Severe Acute Respiratory Syndrome Coronavirus 2 (covid-19) Vaccine, Recombina... | preventive | $39 | $39 | $39 | 1 |
| Injection for X-ray Imaging Procedure Into Vein of Arm OR Leg | imaging | $39 | $39 | $39 | 1 |
| Evaluation of Fine Needle Aspirate with Interpretation and Report | other | $39 | $28 | $50 | 2 |
| Therapy Procedure Using Sensory Experiences | other | $39 | $39 | $39 | 1 |
| Fresh Frozen Plasma Between 8-24 Hours of Collection, Each Unit | other | $39 | $39 | $39 | 1 |
| Xenon Xe-133 Gas, Diagnostic, Per 10 Millicuries | other | $39 | $39 | $39 | 1 |
| Assay of Thyroid | other | $39 | $39 | $39 | 1 |
| Ccp Antibodies | other | $39 | $39 | $39 | 1 |
| Assay of Amylase | other | $39 | $39 | $39 | 1 |
| Assay of Ck | other | $39 | $39 | $39 | 1 |
| X-ray of Middle and Lower Spine, 2 Views | imaging | $40 | $10 | $70 | 2 |
| X-ray of Jaw Joints On Both Sides of Mouth | imaging | $40 | $11 | $69 | 2 |
| Ultrasound Study of Arm and Leg Arteries | imaging | $40 | $11 | $69 | 2 |
| Budesonide 32 Mcg/act Na Susp | other | $40 | $40 | $40 | 1 |
| Removal of Foreign Body in Ear Canal | surgery | $40 | $40 | $40 | 1 |
| Puncture of Windpipe for Aspiration And/or Injection | other | $40 | $40 | $40 | 1 |
| Programming of Implantable Defibrillator System | surgery | $40 | $40 | $40 | 1 |
| Programming of Multiple Lead Pacemaker System | cardiac | $40 | $40 | $40 | 1 |
| New Patient Office OR Other Outpatient Visit with Straightforward Medical Dec... | other | $40 | $40 | $40 | 2 |
| Laser Fiber 365mic #dfs-365sb | other | $40 | $40 | $40 | 1 |
| Injection, Bezlotoxumab, 10 Mg | other | $40 | $40 | $40 | 1 |
| Diphtheria, Tetanus, Acellular Pertussis, and Polio Vaccine | preventive | $40 | $40 | $40 | 1 |
| Family Psychotherapy without Patient, 50 Minutes | therapy | $40 | $40 | $40 | 1 |
| Guide Sheath Kit Endo Sz 2mm 105cm #k | other | $40 | $40 | $40 | 1 |
| Needle Entrada #sc-4200 | other | $40 | $40 | $40 | 1 |
| Profile Drill 3.5mm Beveled Ft #ar-8741 | other | $40 | $40 | $40 | 1 |
| Profile Drill for Micro Compression Ft #ar-8737 | other | $40 | $40 | $40 | 1 |
| Aspiration And/or Injection of Cyst of Thyroid | other | $40 | $40 | $40 | 1 |
| Placement of Locating Device in Breast Using Imaging Guidance, Each Additiona... | other | $40 | $40 | $40 | 1 |
| Knee Orthosis, Elastic with Joints, Prefabricated, Off-the-shelf | other | $40 | $40 | $40 | 1 |
| Transfer of an Orthosis From One Shoe to Another, Caliper Plate, New | other | $40 | $40 | $40 | 1 |
| Diag Catheter 6fr Langston #5540 5/pk | cardiac | $40 | $40 | $40 | 1 |
| Alcohols Levels, 1 OR 2 | other | $40 | $40 | $40 | 1 |
| Barbiturates Levels | other | $40 | $40 | $40 | 1 |
| Cannabinoids Levels, Natural | other | $40 | $40 | $40 | 1 |
| Cocaine Level | other | $40 | $40 | $40 | 1 |
| Dextrose 70%-water IV Soln | other | $40 | $40 | $40 | 1 |
| Opiates Levels | other | $40 | $40 | $40 | 1 |
| Injection, Trastuzumab-dkst, Biosimilar, (ogivri), 10 Mg | other | $40 | $40 | $40 | 1 |
| Injection, Chloramphenicol Sodium Succinate, Up to 1 Gm | other | $40 | $40 | $40 | 1 |
| Addition to Knee Joint, Drop Lock, Each | other | $40 | $40 | $40 | 1 |
| Catheter Bernstein 4fr 140cm #h787107227085 | cardiac | $40 | $40 | $40 | 1 |
| Removal of Foreign Body in Cornea Using Slit Lamp | surgery | $40 | $40 | $40 | 1 |
| Evaluation of Hearing Ringing in Ear | other | $40 | $40 | $40 | 1 |
| Type & Screen | other | $40 | $40 | $40 | 1 |
| Assay of Magnesium | other | $40 | $40 | $40 | 1 |
| X-ray of Paranasal Sinus, 1-2 Views | imaging | $41 | $8 | $73 | 2 |
| X-ray From Nose to Rectum | imaging | $41 | $25 | $57 | 2 |
| X-ray of Infant Arm, Minimum of 2 Views | imaging | $41 | $30 | $52 | 2 |
| Training in the Use of Orthopedic Device for Arm, Leg And/or Trunk, Each 15 M... | other | $41 | $37 | $44 | 2 |
| Injection of Contrast for Imaging of Shoulder Joint | other | $41 | $41 | $41 | 1 |
| Dissecting Tool Disp #14mh30 Midas | other | $41 | $41 | $41 | 1 |
| Femoral Bone Cementing Prep Kit W/o Cement 00-5049-055-00 00504905500 | other | $41 | $41 | $41 | 1 |
| Ibandronate Sodium 150 Mg Po Tabs | other | $41 | $41 | $41 | 1 |
| Intralipid 20% IV Fat Emul | lab | $41 | $41 | $41 | 1 |
| Aldosterone Hormone Level | other | $41 | $41 | $41 | 2 |
| Injection, Voriconazole, 10 Mg | other | $41 | $41 | $41 | 1 |
| Coil Pusher 16 | other | $41 | $41 | $41 | 1 |
| Drill Cann Plyaxial Lck Screw 2mm Drll-pls | other | $41 | $41 | $41 | 1 |
| Knee Orthosis, Elastic with Condylar Pads and Joints, with OR without Patella... | other | $41 | $41 | $41 | 1 |
| Osteopathic Manipulative Treatment, 7-8 Body Regions | other | $41 | $41 | $41 | 1 |
| Parathormone (parathyroid Hormone) Level | other | $41 | $41 | $41 | 2 |
| Anesthesia for Procedure to Drain Brain and Spinal Cord Fluid | other | $41 | $41 | $41 | 1 |
| Complete Ultrasound Scan of Joint | imaging | $41 | $41 | $41 | 1 |
| Pack Robotic Rf | other | $41 | $41 | $41 | 1 |
| Sodium Citrate 4% Soln | other | $41 | $41 | $41 | 1 |
| Injection, Meropenem (b. Braun), Not Therapeutically Equivalent to J2185, 100 Mg | other | $41 | $29 | $52 | 2 |
| Placement of Locating Device in Breast Using X-ray with Needle Guidance, Each... | imaging | $41 | $41 | $41 | 1 |
| Silvasorb Gel | other | $41 | $41 | $41 | 1 |
| Assay of Total Thyroxine | other | $41 | $41 | $41 | 1 |
| Assay of Lipase | other | $41 | $41 | $41 | 1 |
| Comprehensive Metabolic Panel | lab | $42 | $2 | $499 | 15 |
| Molecular Pathology Procedure | lab | $42 | $7 | $77 | 2 |
| X-ray of Pelvis, 1-2 Views | imaging | $42 | $8 | $76 | 2 |
| X-ray of Infant Body Bones | imaging | $42 | $31 | $52 | 2 |
| Microscopic Genetic Analysis of Tumor, Manual | other | $42 | $42 | $42 | 1 |
| Addition to Lower Extremity, Straight Knee Joint, Heavy Duty, Each Joint | other | $42 | $42 | $42 | 1 |
| Sumatriptan 6 Mg/0.5ml Autoinj | other | $42 | $42 | $42 | 1 |
| Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $42 | $42 | $42 | 1 |
| Seprafilm #508602 6ea/pk & 5pk/bx | other | $42 | $42 | $42 | 1 |
| Probe Incrementing Nerve Stim W/std Prasstip #8225825x | other | $42 | $42 | $42 | 1 |
| Cyclosporine, Oral, 100 Mg | other | $42 | $42 | $42 | 1 |
| Grasping Device/endo Talon #00711175 | other | $42 | $42 | $42 | 1 |
| Prep Kit W/restrictors #5461-01 | other | $42 | $42 | $42 | 1 |
| Ultrasound of Heart | imaging | $42 | $42 | $42 | 1 |
| Injection, Luspatercept-aamt, 0.25 Mg | other | $42 | $42 | $42 | 1 |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Abov... | other | $42 | $42 | $42 | 1 |
| Oats 70 Degree Measure Probe #ar-4070-70s | other | $42 | $42 | $42 | 1 |
| Insertion of Implant in Urethra Within Prostate Gland Using an Endoscope, Eac... | surgery | $42 | $42 | $42 | 1 |
| Intubation Set Cook Retrograde | other | $42 | $42 | $42 | 1 |
| Simple Removal of Skin Debris and Drainage of Mastoid Cavity | surgery | $42 | $42 | $42 | 1 |
| Mometasone Furoate 50 Mcg/act Na Susp | other | $42 | $42 | $42 | 1 |
| Injection, Ado-trastuzumab Emtansine, 1 Mg | other | $42 | $42 | $42 | 1 |
| Antipsychotics Levels, 1 | other | $42 | $42 | $42 | 1 |
| Written Consultation Report On X-ray | imaging | $42 | $42 | $42 | 1 |
| Flulaval Trivalent 2024-25 Syr | other | $42 | $42 | $42 | 1 |
| Heel, New Rubber, Standard | other | $42 | $42 | $42 | 1 |
| Limited OR Follow-up CT Scan | imaging | $42 | $40 | $43 | 2 |
| Electrolyte Panel | lab | $42 | $42 | $42 | 1 |
| Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $43 | $36 | $50 | 2 |
| Diagnostic Exam of Rectum and Lower Large Bowel Using an Endoscope | other | $43 | $43 | $43 | 1 |
| 25 Left Quick Pass Lasso #ar-6068-25tl | other | $43 | $43 | $43 | 1 |
| 25 Right Quick Pass Lasso #ar-6068-25tr | other | $43 | $43 | $43 | 1 |
| 45 Left Quick Pass Lasso #ar-6068-45l | other | $43 | $43 | $43 | 1 |
| 45 Right Quick Pass Lasso #ar-6068-45r | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Left Quick Pass Lasso #ar-6068-90l | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Right Quick Pass Lasso #ar-6068-90r | other | $43 | $43 | $43 | 1 |
| 90 Degree Curve Straight Quick Pass Lasso #ar-6068 | other | $43 | $43 | $43 | 1 |
| Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-the-s... | other | $43 | $43 | $43 | 1 |
| Bonopty Biopsy Set 16.5cm #12 | lab | $43 | $43 | $43 | 1 |
| Bonopty Penetration Set 10cm #12 | other | $43 | $43 | $43 | 1 |
| Crescent Quick Pass Lasso #ar-6068c | other | $43 | $43 | $43 | 1 |
| Initial Preventive Physical Examination; Face-to-face Visit, Services Limited... | preventive | $43 | $43 | $43 | 1 |
| Pathology Examination of Specimen During Surgery, First Tissue Block | surgery | $43 | $43 | $43 | 1 |
| Detection Test By Nucleic Acid for Hepatitis B Virus, Quantification | other | $43 | $43 | $43 | 1 |
| Endopath Electrosurgery Probe Plus Ii Pistol Hand Control Eph02 | surgery | $43 | $43 | $43 | 1 |
| Inflator Kit Balloon ENT #18infkit | other | $43 | $43 | $43 | 1 |
| Review By Radiologist of Additional Artery Image | other | $43 | $43 | $43 | 1 |
| Application of Moveable OR Hinged Forearm to Hand Splint | other | $43 | $43 | $43 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Upper Neck and Back of Head... | other | $43 | $43 | $43 | 1 |
| Peripheral Arterial Disease Rehabilitation, Each Session | therapy | $43 | $43 | $43 | 1 |
| Rod Carbon Fiber 11.0mm X 200mm External | other | $43 | $43 | $43 | 1 |
| Extractor Foreign Body 5/cs #fb 5000 5ea/1cs | other | $43 | $43 | $43 | 1 |
| Tray Disp Exchange Transfusion 1ea #275.00 | surgery | $43 | $43 | $43 | 1 |
| Insertion of Tube Into Chest OR Arm Artery, Additional Second, Third Order an... | other | $43 | $43 | $43 | 1 |
| Treatment of Speech, Language, Voice, Communication, And/or Hearing Processin... | other | $43 | $43 | $43 | 1 |
| Microbe Susceptible Disk | other | $43 | $43 | $43 | 1 |
| Exam Synovial Fluid Crystals | other | $43 | $43 | $43 | 1 |
| Basic Metabolic Panel (BMP) | lab | $44 | $7 | $5,621 | 28 |
| X-ray of Elbow, Minimum of 3 Views | imaging | $44 | $8 | $79 | 2 |
| X-ray of Both Collar Bones Joints | imaging | $44 | $9 | $78 | 2 |
| X-ray for Estimating Bone Age | imaging | $44 | $38 | $49 | 2 |
| Progel Extended Applicator Spray Tip 16cm | other | $44 | $44 | $44 | 1 |
| Psychotherapy for Crisis, Each Additional 30 Minutes | therapy | $44 | $44 | $44 | 1 |
| Test to Measure Lung Function At High Altitude with Evaluation of Oxygen Need... | other | $44 | $44 | $44 | 1 |
| Pericardiocentesis Kit Latex Free 3ea/1bx#m00443151 | other | $44 | $44 | $44 | 1 |
| Reaming Rod/3.8mm Ball Tip 950mm Sterile #03.233.010s | other | $44 | $44 | $44 | 1 |
| Addition to Knee Lock with Integrated Release Mechanism (bail, Cable, OR Equa... | other | $44 | $44 | $44 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Face Nerve | other | $44 | $44 | $44 | 1 |
| Application of Finger Cast | other | $44 | $44 | $44 | 1 |
| Cervical, Collar, Semi-rigid Thermoplastic Foam, Two-piece, Prefabricated, Of... | other | $44 | $44 | $44 | 1 |
| Needle Transeptal Adult #tsnc-18-71.0 | other | $44 | $44 | $44 | 1 |
| Needle Transseptal Brk 18ga 71cm #407200 | other | $44 | $44 | $44 | 1 |
| Shoulder Orthosis, Acromio/clavicular (canvas and Webbing Type), Prefabricate... | other | $44 | $44 | $44 | 1 |
| Removal of Kidney Drainage Tube Using Fluoroscopic Guidance | surgery | $44 | $44 | $44 | 1 |
| Sheath Access 12/14fr X38cm #61238bx | other | $44 | $44 | $44 | 1 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, Complete Study | other | $44 | $44 | $44 | 1 |
| Injection, Abatacept, 10 Mg | other | $44 | $44 | $44 | 1 |
| Observation Care Discharge Day Management | other | $44 | $44 | $44 | 1 |
| Wand 3.0mm 45 Degree Turbo | other | $44 | $44 | $44 | 1 |
| Wand Arthro 2.5mm 60deg Dome #ac3525 | other | $44 | $44 | $44 | 1 |
| Wand Arthro 3.5mm 90deg Rt Angle #ac1340 | other | $44 | $44 | $44 | 1 |
| Wand Ortho Super Multivac 50 | other | $44 | $44 | $44 | 1 |
| Wand Saber 30 W/cable Arthrocare #ac4330 | other | $44 | $44 | $44 | 1 |
| Gradient Compression Wrap, Non-elastic, Below Knee, 30-50 Mmhg, Used As a Sur... | other | $44 | $44 | $44 | 1 |
| Testing of Autonomic (sympathetic) Nervous System Function, Heart Rate Respon... | cardiac | $44 | $44 | $44 | 1 |
| Injection, Hydroxyzine Hcl, Up to 25 Mg | other | $44 | $28 | $59 | 2 |
| Absorb.gelantin Sponge | other | $44 | $44 | $44 | 1 |
| Parenteral Nutrition Solution; Compounded Amino Acid and Carbohydrates with E... | other | $44 | $44 | $44 | 1 |
| Drug Test Prsmv Dir Opt Obs | other | $44 | $44 | $44 | 1 |
| Istat Chem 8-clia Waived | other | $44 | $44 | $44 | 1 |
| X-ray of Middle Spine, 2 Views | imaging | $45 | $9 | $80 | 2 |
| X-ray of Lower and Sacral Spine, 2-3 Views | imaging | $45 | $10 | $80 | 2 |
| X-ray of Ribs On Side of Body, Minimum of 3 Views | imaging | $45 | $12 | $78 | 2 |
| X-ray of Both Hips, Minimum of 5 Views | imaging | $45 | $14 | $75 | 2 |
| Kit Carotid Rf 2ea/1cs #dynj906961f | other | $45 | $45 | $45 | 1 |
| Hip Orthosis, Abduction Control of Hip Joints, Flexible, (pavlik Harness), Pr... | other | $45 | $45 | $45 | 1 |
| Epidisc Patch Kit #1417151 Xomed | other | $45 | $45 | $45 | 1 |
| Alpena Contour Lso Universal Fits Waist Circumference: 25-60inch (64-152cm) #... | other | $45 | $45 | $45 | 1 |
| Aspiration Tubing Kit #72-00114 | other | $45 | $45 | $45 | 1 |
| Review By Radiologist of 1 Arm OR Leg Vein of 1 Arm OR Leg Image | other | $45 | $45 | $45 | 1 |
| Application of On-body Injector for Under Skin Injection | other | $45 | $45 | $45 | 1 |
| Removal of Muscle And/or Tissue, Each Additional 20.0 SQ Cm OR Less | surgery | $45 | $45 | $45 | 1 |
| Wand Arthro 3.5x90deg Suc Foot #asc4250 | other | $45 | $45 | $45 | 1 |
| Wand Arthrocare 90deg W/suct & Finger Switch | other | $45 | $45 | $45 | 1 |
| Contact Layer, Sterile, More Than 48 Sq. In., Each Dressing | other | $45 | $45 | $45 | 1 |
| Gene Analysis (fms-related Tyrosine Kinase 3) Internal Tandem Duplication Var... | other | $45 | $45 | $45 | 1 |
| Residence Visit for Established Patient with Low Level of Medical Decision Ma... | other | $45 | $45 | $45 | 1 |
| Stone Extractor Basket 3.0frx120cm #390 | other | $45 | $45 | $45 | 1 |
| Tisseel Vhsd 2 Ml Kit | other | $45 | $45 | $45 | 1 |
| Insulin (novolin) R 100 Units / 100 Ml Ns - Compounded | other | $45 | $45 | $45 | 1 |
| Myxredlin 100 Unit/100 Ml Bag | other | $45 | $45 | $45 | 1 |
| Clinical Pathology Consultation; Limited, without Review of Patient's History... | lab | $45 | $45 | $45 | 1 |
| Injection of Ureter for Imaging | other | $45 | $45 | $45 | 1 |
| Unlisted Reference Lab | other | $45 | $45 | $45 | 1 |
| Application of Vein Wound Compression Bandages On Upper Arm, Forearm, Hand, a... | other | $45 | $45 | $45 | 1 |
| X-ray of Ankle, Minimum of 3 Views | imaging | $46 | $8 | $83 | 2 |
| X-ray of Hand, Minimum of 3 Views | imaging | $46 | $8 | $83 | 2 |
| X-ray of Wrist, Minimum of 3 Views | imaging | $46 | $8 | $83 | 2 |
| X-ray of Shoulder, Minimum of 2 Views | imaging | $46 | $9 | $83 | 2 |
| X-ray of Knee, 3 Views | imaging | $46 | $9 | $83 | 2 |
| Special Stained Specimen Slides to Examine Tissue, Initial Procedure | lab | $46 | $26 | $65 | 2 |
| Skin Substitute Graft to Wound 100.0 SQ Cm OR More of Face, Scalp, Eyelids, M... | other | $46 | $46 | $46 | 1 |
| Tissue Marker, Implantable, Any Type, Each | surgery | $46 | $46 | $46 | 1 |
| Ultrasonic Guidance During Surgery | surgery | $46 | $46 | $46 | 1 |
| Residence Visit for New Patient with Low Level of Medical Decision Making, Pe... | other | $46 | $46 | $46 | 1 |
| Tvt70100as - Tube Endotracheal L312mm Od10mm Id7mm Pvc Single Lumen Visualize... | other | $46 | $46 | $46 | 1 |
| Tvt75105as - Tube Endotracheal L323mm Od10.5mm Id7.5mm Pvc Single Lumen Visua... | other | $46 | $46 | $46 | 1 |
| Tvt80110as - Tube Endotracheal L323mm Od11mm Id8mm Pvc Single Lumen Visualize... | other | $46 | $46 | $46 | 1 |
| Dextrose 25%-water Syringe | other | $46 | $46 | $46 | 1 |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Un... | other | $46 | $46 | $46 | 1 |
| Imaging of Esophagus Done From the Inside of the Esophagus | other | $46 | $46 | $46 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Suprascapular Shoulder Nerve | other | $46 | $46 | $46 | 1 |
| Rod Carbon Fiber 11.0mm X 250mm External | other | $46 | $46 | $46 | 1 |
| Rod Carbon Fiber 11.0mm X 300mm External | other | $46 | $46 | $46 | 1 |
| Rod Carbon Fiber 11.0mm X 350mm External | other | $46 | $46 | $46 | 1 |
| Flovent Hfa 44 Mcg Inhaler | other | $46 | $46 | $46 | 1 |
| Hydromorphone Pca 1 Mg/ml *high Concentration* Cemc Batched Compounded | other | $46 | $46 | $46 | 1 |
| 3 Hour Gtt | other | $46 | $46 | $46 | 1 |
| Evaluation for Work Hardening OR Conditioning, Each Additional Hour | other | $46 | $46 | $46 | 1 |
| Compatibility Test Spin | other | $46 | $46 | $46 | 1 |
| Fungal Culture Hair,skin,nails | lab | $46 | $46 | $46 | 1 |
| X-ray of Paranasal Sinus, Minimum of 3 Views | imaging | $47 | $10 | $83 | 2 |
| X-ray of Upper Spine, 2-3 Views | imaging | $47 | $10 | $83 | 2 |
| Test to Determine Lung Volumes Using Gas Dilution OR Washout | other | $47 | $12 | $81 | 2 |
| Carbojet Co2 Tube Set #25-100 | other | $47 | $47 | $47 | 1 |
| Family Psychotherapy with Patient, 50 Minutes | therapy | $47 | $47 | $47 | 1 |
| Mini Bio-anchor Disp Kit | other | $47 | $47 | $47 | 1 |
| Pushlock Kit for 2.9mm Shrt Pshlck #ar-2923ds | other | $47 | $47 | $47 | 1 |
| Rotavirus Vaccine, Human, Attenuated | preventive | $47 | $47 | $47 | 1 |
| Sheath Access 12/14fr X24cm #61224bx | other | $47 | $47 | $47 | 1 |
| Sheath Access 12/14fr X54cm #61254bx | other | $47 | $47 | $47 | 1 |
| Dissecting Tool 3.0 Matchstick Long #10mh30l | other | $47 | $47 | $47 | 1 |
| Gallium Citrate Ga 67 | other | $47 | $47 | $47 | 1 |
| Wand Artho 3.0mm 50deg Suction #asc2530 | other | $47 | $47 | $47 | 1 |
| Doxycycline 100 Mg/100 Ml Ns Mini-bag Plus - Compounded | other | $47 | $47 | $47 | 1 |
| Doxy 100 Mg Vial | other | $47 | $47 | $47 | 1 |
| Injection, Immune Globulin, (octagam), Intravenous, Non-lyophilized (e.g., Li... | other | $47 | $47 | $47 | 1 |
| Injection of Local Anesthetic for Abdominal Wall Pain Control On Side Using I... | other | $47 | $47 | $47 | 1 |
| Simple Control of Nose Bleed | other | $47 | $47 | $47 | 1 |
| T Cell Count and Ratio, Including Ratio | other | $47 | $47 | $47 | 2 |
| Psychotherapy with Evaluation and Management Visit, 30 Minutes | therapy | $47 | $47 | $47 | 1 |
| Cath Reddick Cystic Duct 2401-52 *min Order 5 | other | $47 | $47 | $47 | 1 |
| Papaverine 60 Mg/2 Ml Vial | other | $47 | $47 | $47 | 1 |
| Barone Jejunostomy Set | other | $47 | $47 | $47 | 1 |
| Detection Test By Nucleic Acid for Multiple Types Influenza Virus | other | $47 | $47 | $47 | 1 |
| Injection, Vancomycin Hydrochloride (mylan) Not Therapeutically Equivalent to... | other | $47 | $47 | $47 | 1 |
| Ultrasound Scan of Fetal Brain Artery Blood Flow Rate | imaging | $47 | $47 | $47 | 1 |
| Limited Ultrasound Scan of Pelvis | imaging | $47 | $47 | $47 | 1 |
| Prosthesis, Penile, Non-inflatable | other | $47 | $47 | $47 | 1 |
| Rbc Pretreatment | other | $47 | $47 | $47 | 1 |
| Psychotherapy with Evaluation and Management Visit, 45 Minutes | therapy | $48 | $48 | $48 | 1 |
| Psychotherapy, 45 Minutes | therapy | $48 | $48 | $48 | 1 |
| Subsequent Hospital Inpatient OR Observation Care with Moderate Level of Medi... | other | $48 | $48 | $48 | 1 |
| Acute Hepatitis Panel | lab | $48 | $48 | $48 | 2 |
| Injection of Anesthetic Agent And/or Steroid Into Lower Abdomen and Groin Nerve | other | $48 | $48 | $48 | 1 |
| Velys Array Drill Pin 125mm X 4mm 4515-70-005 Minimum Order 10 Each | other | $48 | $48 | $48 | 1 |
| Velys Array Drill Pin 175mm X 4mm 4515-70-006 Minimum Order 10 Each | other | $48 | $48 | $48 | 1 |
| 2.5mm Mtch Hd 16cm Stryker #8470-107 | other | $48 | $48 | $48 | 1 |
| Dilator Healicoil Rg 4.75mm #72203951 | other | $48 | $48 | $48 | 1 |
| Dilator Healicoil Rg 5.5mm #72203952 | other | $48 | $48 | $48 | 1 |
| Rasp Small Riordan #5100-037 | other | $48 | $48 | $48 | 1 |
| Advance Care Planning, Each Additional 30 Minutes | other | $48 | $48 | $48 | 1 |
| Gene Analysis | other | $48 | $48 | $48 | 1 |
| Injection, Ibuprofen, 100 Mg | other | $48 | $48 | $48 | 1 |
| Flovent Hfa 110 Mcg Inhaler | other | $48 | $48 | $48 | 1 |
| Clinolipid 20% | lab | $48 | $48 | $48 | 1 |
| Kyphon Bone Biopsy Device #2 #f07a | lab | $48 | $48 | $48 | 1 |
| Meningococcal Vaccine, Serogroups A, C, W, Y, Diphtheria Toxoid Carrier Vaccine | preventive | $48 | $48 | $48 | 1 |
| Wound Retractor/protector Xxlrg #c8405 | other | $48 | $48 | $48 | 1 |
| Gentran 10%-5% Dextrose | other | $48 | $48 | $48 | 1 |
| Gentran 10%-saline 0.9% | other | $48 | $48 | $48 | 1 |
| Bld Typing Serologic Rh Phnt | other | $48 | $48 | $48 | 1 |
| Blood Typing Rbc Antigens | other | $48 | $48 | $48 | 1 |
| Ag Detect Nos Ia Mult | other | $48 | $48 | $48 | 1 |
| Clostridium Ag Ia | other | $48 | $48 | $48 | 1 |
| Fluoroscopic Guidance for Insertion OR Removal of Central Vein Access Device | surgery | $49 | $17 | $80 | 2 |
| Limited X-ray of Body Bones | imaging | $49 | $20 | $78 | 2 |
| Application of Walking Cast Covering Below Knee to Toe | other | $49 | $49 | $49 | 1 |
| Cxi .014 X 90cm | other | $49 | $49 | $49 | 1 |
| Margin Marker #mms6 | other | $49 | $49 | $49 | 1 |
| Injection, Carfilzomib, 1 Mg | other | $49 | $49 | $49 | 1 |
| Injection, Immune Globulin, (gamunex-c/gammaked), Non-lyophilized (e.g., Liqu... | other | $49 | $49 | $49 | 1 |
| Application of Elbow to Finger Cast | other | $49 | $49 | $49 | 1 |
| Genetic Sequencing Localization, Each Additional Procedure | other | $49 | $49 | $49 | 1 |
| Other Ultrasound Procedure | imaging | $49 | $49 | $49 | 1 |
| Programming of Heart Rhythm Stimulation After Drug Infusion | surgery | $49 | $49 | $49 | 1 |
| Overtube Guardus Endo 3/bx #bx00711147 | other | $49 | $49 | $49 | 1 |
| Physician Attendance At Delivery and Stabilization of Newborn | obstetric | $49 | $37 | $61 | 2 |
| Injection, Adenosine, 1 Mg | other | $49 | $6 | $91 | 2 |
| Thyroid Stimulating Immune Globulins (thyroid Related Protein) Level | other | $49 | $49 | $49 | 1 |
| Insertion of Tube and Introduction of Contrast for X-ray of Uterus and Fallop... | imaging | $49 | $49 | $49 | 1 |
| Iron Binding Test | other | $49 | $49 | $49 | 1 |
| Thyroid Test (TSH) | lab | $50 | $10 | $207 | 15 |
| X-ray for Bone Length Assessment | imaging | $50 | $13 | $87 | 2 |
| Low Dose CT Scan of Chest for Lung Cancer Screening | imaging | $50 | $48 | $51 | 2 |
| Grieshaber Revolution Dsp Ilm Forceps 25g | other | $50 | $50 | $50 | 1 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 1 Extremity | other | $50 | $50 | $50 | 1 |
| Review By Radiologist of Major Lower Body Vein Image | other | $50 | $50 | $50 | 1 |
| Review By Radiologist of Chest Aorta Serial Images | other | $50 | $50 | $50 | 1 |
| Scissors Ophthalmic 23ga Vertical Grieshaber | other | $50 | $50 | $50 | 1 |
| Vemp Testing of Upper and Lower Branches of Inner Ear Nerve with Interpretati... | other | $50 | $50 | $50 | 1 |
| Symbicort 80-4.5 Mcg Inhaler | other | $50 | $50 | $50 | 1 |
| Kit for 1.8mm Q-fix Implant #25 | surgery | $50 | $50 | $50 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Rib Nerve | other | $50 | $50 | $50 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Plastic Shoe Insert with Ankle... | other | $50 | $50 | $50 | 1 |
| Insertion of Probe to Widen Saliva Gland Duct | other | $50 | $50 | $50 | 1 |
| Injection, Chlorpromazine Hcl, Up to 50 Mg | other | $50 | $33 | $66 | 2 |
| Flow Cytometry Technique for Dna OR Cell Analysis | other | $50 | $50 | $50 | 1 |
| Drug Screen Quantalcohols | other | $50 | $50 | $50 | 1 |
| Urine Bacteria Culture | lab | $50 | $50 | $50 | 1 |
| Thyroid Panel (TSH) | lab | $51 | $17 | $101 | 6 |
| X-ray of Lower Jaw, Minimum of 4 Views | imaging | $51 | $11 | $91 | 2 |
| Addition to Lower Extremity, Long Tongue Stirrup | other | $51 | $51 | $51 | 1 |
| Dexmedetomidin 400mcg/100ml-ns | other | $51 | $51 | $51 | 1 |
| Injection, Immune Globulin (privigen), Intravenous, Non-lyophilized (e.g., Li... | other | $51 | $51 | $51 | 1 |
| Probe Laser Illuminated Directional 55.47.25p | other | $51 | $51 | $51 | 1 |
| Hospital Inpatient OR Observation Discharge Day Management, 30 Minutes OR Less | other | $51 | $51 | $51 | 1 |
| Diagnostic Exam of Lower Portion of Large Bowel Using a Flexible Endoscope | other | $51 | $51 | $51 | 1 |
| Rod Carbon Fiber 11.0mm X 400mm External | other | $51 | $51 | $51 | 1 |
| Vital-vue Urol/gen #8280-06 Extended Yank | other | $51 | $51 | $51 | 1 |
| Antidepressants Levels, 1 OR 2 | other | $51 | $51 | $51 | 1 |
| Osteopathic Manipulative Treatment, 9-10 Body Regions | other | $51 | $51 | $51 | 1 |
| Injection of Medication Into Nasal Air Passage | other | $51 | $51 | $51 | 1 |
| Injection, Ganciclovir Sodium, 500 Mg | other | $51 | $51 | $51 | 1 |
| Addition to Lower Extremity Prosthesis, Below Knee, Suspension/sealing Sleeve... | other | $51 | $51 | $51 | 1 |
| Review By Radiologist of Head OR Neck Vein System Image | other | $51 | $51 | $51 | 1 |
| Pretreatment of Red Blood Cells for Use in Red Blood Cells Antibody Analysis ... | other | $51 | $51 | $51 | 1 |
| Wrist Hand Finger Orthosis, without Joint(s), Prefabricated Item That Has Bee... | other | $51 | $51 | $51 | 1 |
| Falope-ring Band Disp 8ea/bx | other | $51 | $51 | $51 | 1 |
| Super Multivac 50 Wand-amblient | other | $51 | $51 | $51 | 1 |
| Wand 90 Degree Superturbovac Amb Fingerswitch | other | $51 | $51 | $51 | 1 |
| X-ray of Eye Canal | imaging | $51 | $51 | $51 | 1 |
| Anterior Chamber Intraocular Lens | other | $51 | $51 | $51 | 1 |
| Insertion of Temporary Bladder Tube | other | $51 | $51 | $51 | 1 |
| Complete X-ray of Body Bones | imaging | $52 | $25 | $78 | 2 |
| Blood Bank Physician Services for Investigation of Transfusion Reaction with ... | surgery | $52 | $39 | $65 | 2 |
| Blood Unit Compatibility Test, Antiglobulin Technique | other | $52 | $42 | $62 | 2 |
| Hepatitis a and Hepatitis B Vaccine | preventive | $52 | $52 | $52 | 1 |
| Subsequent Instillation of Agent Onto Lung Lining Using Chest Tube | other | $52 | $52 | $52 | 1 |
| Nerve Conduction, 1-2 Studies | other | $52 | $52 | $52 | 1 |
| Addition to Lower Extremity, Below Knee, Molded Distal Cushion | other | $52 | $52 | $52 | 1 |
| Sodium Bicarb 4.2% Abboject | other | $52 | $52 | $52 | 1 |
| Syringe Orise Twnpk23g Intej Needle M00519211 | other | $52 | $52 | $52 | 1 |
| Raltegravir Potassium 400 Mg Po Tabs #6 Dispense Pack | other | $52 | $52 | $52 | 1 |
| Review By Radiologist of Breast Artery of Breast Image | other | $52 | $52 | $52 | 1 |
| Sodium Phosphate 45 Mmol/15 Ml | other | $52 | $52 | $52 | 1 |
| Basket Nitinol 1.9 #390 | other | $52 | $52 | $52 | 1 |
| Application of Hand and Lower Forearm Cast | other | $52 | $52 | $52 | 1 |
| Chg Us, Breast(s), Real Time | other | $52 | $52 | $52 | 1 |
| Decompression Set 14fr #cdsg-14 | other | $52 | $52 | $52 | 1 |
| Needle Scorpion W/megaloader #ar-13999hdn 5ea/bx | other | $52 | $52 | $52 | 1 |
| Placement of Proximal OR Distal Extension Prosthesis for Endovascular Repair ... | surgery | $52 | $52 | $52 | 1 |
| Injection, Alprostadil, 1.25 Mcg | other | $52 | $52 | $52 | 1 |
| Arc Smart Argon Probe 2.3/220 G1140001 | other | $52 | $52 | $52 | 1 |
| X-ray of Voice Box OR Throat | imaging | $52 | $52 | $52 | 1 |
| Injection, Belinostat, 10 Mg | other | $52 | $52 | $52 | 1 |
| Preventive Medicine Counseling, Typically 45 Minutes | therapy | $52 | $52 | $52 | 1 |
| Retractor Dexterity 9-14cm #100301 | other | $52 | $52 | $52 | 1 |
| Injection, Margetuximab-cmkb, 5 Mg | other | $52 | $52 | $52 | 1 |
| X-ray Lower and Sacral Spine, 2-3 Views Bending Views | imaging | $52 | $52 | $52 | 1 |
| X-ray of Saliva Gland | imaging | $52 | $52 | $52 | 1 |
| Fungus Isolation Culture | lab | $52 | $52 | $52 | 1 |
| Test to Measure the Total Volume of Air That Can Be Exhaled After Inhaling | other | $53 | $18 | $87 | 2 |
| Established Patient Office OR Other Outpatient Visit with Low Level of Decisi... | other | $53 | $49 | $56 | 2 |
| Application of Short Leg Cast | other | $53 | $53 | $53 | 1 |
| Knee Orthosis, Elastic with Joints, Prefabricated Item That Has Been Trimmed,... | other | $53 | $53 | $53 | 1 |
| Ligasure Xtd Disp #ls3112 | other | $53 | $53 | $53 | 1 |
| Removal of Implanted Eardrum Tube Under Anesthesia | surgery | $53 | $53 | $53 | 1 |
| Dilator Urethral Set 14f to 26f #g14893 | other | $53 | $53 | $53 | 1 |
| Urethral S-curve Dilator Set 8fr-20fr #g32789 | other | $53 | $53 | $53 | 1 |
| Programming of Dual Lead Implantable Defibrillator System | surgery | $53 | $53 | $53 | 1 |
| Stent, Non-coronary, Temporary, without Delivery System | cardiac | $53 | $53 | $53 | 1 |
| X-ray of Joints, Multiple | imaging | $53 | $53 | $53 | 1 |
| Infusion, Albumin (human), 25%, 50 Ml | surgery | $53 | $53 | $53 | 2 |
| Cannulated Hex Driver 3.5 Ar-8967d | other | $53 | $53 | $53 | 1 |
| Carbonaid C02 Diffuser #carbonaid | other | $53 | $53 | $53 | 1 |
| Ear Impression, Each | other | $53 | $53 | $53 | 1 |
| Equinoxe Torque Defining Square Drive Screw Kit #300-20 | other | $53 | $53 | $53 | 1 |
| Hex Driver 2.0 70mm Ao Marked Cannulated #dvhx-2.0/070mc Ao | other | $53 | $53 | $53 | 1 |
| Laser Fiber 200micron Disp #clt1020fl | other | $53 | $53 | $53 | 1 |
| Shoulder Gps Reverse Shoulder Drill Kit (1) 2mm Drill (1) 3.2mm Drill #531-20 | other | $53 | $53 | $53 | 1 |
| Shoulder Orthosis, Vest Type Abduction Restrainer, Canvas Webbing Type OR Equ... | other | $53 | $53 | $53 | 1 |
| Spacer 36+6mm #ar-9555 | other | $53 | $53 | $53 | 1 |
| Sputum Specimen Collection | lab | $53 | $53 | $53 | 1 |
| Fentanyl 2 Mcg/ml, Bupivacaine 0.125% Epidural | other | $53 | $53 | $53 | 1 |
| Fentanyl 2 Mcg/ml, Bupivacaine 0.125% Epidural Pca - Compounded | other | $53 | $53 | $53 | 1 |
| Wand Arthro 3.0mm Capsure Low Temperature | other | $53 | $53 | $53 | 1 |
| Evaluation and Recording of Swallowing Using an Endoscope | other | $53 | $53 | $53 | 1 |
| Diffcult Airway-video-larygeo | other | $53 | $53 | $53 | 1 |
| Splitting of Blood OR Blood Products | other | $53 | $53 | $53 | 1 |
| Drug Test(s), Definitive, Utilizing (1) Drug Identification Methods Able to I... | other | $53 | $53 | $53 | 1 |
| X-ray of Skull, 1-3 Views | imaging | $54 | $8 | $100 | 2 |
| X-ray of Joint Between Lower Spine and Hip Bone, 3 OR More Views | imaging | $54 | $10 | $98 | 2 |
| X-ray of Face Bones, Minimum of 3 Views | imaging | $54 | $12 | $96 | 2 |
| Office OR Other Outpatient Consultation with Straightforward Medical Decision... | other | $54 | $54 | $54 | 1 |
| Translocation Analysis (bcr/abl1) Major Breakpoint | other | $54 | $54 | $54 | 1 |
| Biopsy of Lip | lab | $54 | $54 | $54 | 1 |
| Alcohol And/or Substance Abuse Screening and Intervention, More Than 30 Minutes | preventive | $54 | $54 | $54 | 1 |
| Exam for Hearing Aid, 1 Ear | other | $54 | $54 | $54 | 1 |
| Hyaluronan OR Derivative, Euflexxa, for Intra-articular Injection, Per Dose | other | $54 | $54 | $54 | 1 |
| Needle Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $54 | $54 | $54 | 1 |
| Injection, Belimumab, 10 Mg | other | $54 | $54 | $54 | 1 |
| Muscle Testing, Manual (separate Procedure) with Report; Total Evaluation of ... | other | $54 | $54 | $54 | 1 |
| Biopsy of Ear Canal | lab | $54 | $54 | $54 | 1 |
| Resolution 360 Clip 235cm X 2.8mm #m00521232 | other | $54 | $54 | $54 | 1 |
| Injection Procedure Through Bladder and Urethra for X-ray Imaging | imaging | $54 | $53 | $55 | 2 |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Ea... | imaging | $54 | $54 | $54 | 1 |
| Influenza Rapid Test | lab | $54 | $54 | $54 | 1 |
| Assay of Free Thyroxine | other | $54 | $54 | $54 | 1 |
| Measurement of Brain Wave Activity (eeg), Awake and Drowsy | other | $55 | $55 | $55 | 1 |
| Arista Surgical Hemostatic Powder 5 Gm Polysaccharide Hemospheres Absorbable ... | surgery | $55 | $55 | $55 | 1 |
| Electrode Pacing Bipolar 5fr-usci 5ea/1ca | other | $55 | $55 | $55 | 1 |
| Reamer Coring 10mm #ar-1224s W/collared Pin | other | $55 | $55 | $55 | 1 |
| Reamer Coring 11mm #ar-1226s | other | $55 | $55 | $55 | 1 |
| Reamer Coring 12mm Cannulated | other | $55 | $55 | $55 | 1 |
| Reamer Coring 8mm Cannulated W/collared Pin | other | $55 | $55 | $55 | 1 |
| Reamer Coring 9mm #ar-1223s W/collarded Pin | other | $55 | $55 | $55 | 1 |
| Application of Stress By Physician for Joint Imaging | other | $55 | $55 | $55 | 1 |
| Measurement of Brain Wave Activity (eeg), Awake and Asleep | other | $55 | $55 | $55 | 1 |
| Measurement of Brain Wave Activity (eeg), in Coma OR Asleep | other | $55 | $55 | $55 | 1 |
| Injection of Local Anesthetic for Abdominal Wall Pain Control On Both Sides U... | other | $55 | $55 | $55 | 1 |
| Injection of Medication Into Palm | other | $55 | $55 | $55 | 1 |
| Sodium Phosphate 15 Mmol/5 Ml | other | $55 | $55 | $55 | 1 |
| Paragon T2 Wand | other | $55 | $55 | $55 | 1 |
| Physician Supervision of Patient Home Health Agency Services Per Month, 15-29... | other | $55 | $55 | $55 | 1 |
| Injection of Contrast for Imaging of Hip Joint | other | $55 | $55 | $55 | 1 |
| Sodium Chloride 0.9% Irrig. | other | $55 | $55 | $55 | 1 |
| Prolonged Monitoring and Recording of Esophageal Function Through Nasal Tube ... | other | $55 | $55 | $55 | 1 |
| Treatment of Swallowing and Feeding Disorder | other | $55 | $55 | $55 | 1 |
| Assay of Calcium | other | $55 | $55 | $55 | 1 |
| Antibody; HIV 1&2 Single Assay | other | $55 | $55 | $55 | 1 |
| Injection, Daratumumab, 10 Mg and Hyaluronidase-fihj | other | $56 | $56 | $56 | 1 |
| Hip Knee Ankle Foot Orthosis, Torsion Control, Bilateral Rotation Straps, Pel... | other | $56 | $56 | $56 | 1 |
| Eviva Trocar 9g 10cm Length 12mm Aperture | other | $56 | $56 | $56 | 1 |
| Eviva_0913-20 9ga 13cm Length 20mm Aperture | other | $56 | $56 | $56 | 1 |
| Expect Slimline 25g Eus Needle #m00555521 Bx/5ea | other | $56 | $56 | $56 | 1 |
| Needle Eus 19ga Expect Slimline #m00555501 | other | $56 | $56 | $56 | 1 |
| Needle Eus 22ga Expect Slimline #m00555511 | other | $56 | $56 | $56 | 1 |
| Surgicel 4 X 8 #1952s 12ea/case | other | $56 | $56 | $56 | 1 |
| Pin Threaded Tip 1/8 X 2.5in #406669 | other | $56 | $56 | $56 | 1 |
| Annual Wellness Visit; Includes a Personalized Prevention Plan of Service (pp... | preventive | $56 | $56 | $56 | 1 |
| Gene Analysis (janus Kinase 2) Targeted Sequence Analysis | other | $56 | $56 | $56 | 1 |
| Inpatient OR Observation Consultation with Straightforward Medical Decision M... | other | $56 | $56 | $56 | 1 |
| Hydrocodone-chlorphen ER Susp | other | $56 | $56 | $56 | 1 |
| Acu-dispo-cautery2 Fine Tip-s #dcft2 | other | $56 | $56 | $56 | 1 |
| Carbojet Xf Handpiece Set with 40" Nozzle (10-unit Multi-pack) #27-100 | other | $56 | $56 | $56 | 1 |
| Supervision of Interfacility Transport Care of Critical Patient, Each Additio... | other | $56 | $56 | $56 | 1 |
| Telephone Evaluation and Management Service By a Physician OR Other Qualified... | other | $56 | $56 | $56 | 1 |
| Stone Extractor Tipless 2.2frx115cm Ncircle | other | $56 | $56 | $56 | 1 |
| Stone Extractor Tipless 3.0frx115cm Ncircle | other | $56 | $56 | $56 | 1 |
| Addition to Lower Extremity, Varus/valgus Correction, Plastic Modification, P... | other | $56 | $56 | $56 | 1 |
| Measurement of Brain Wave Activity (eeg), 41-60 Minutes | other | $56 | $56 | $56 | 1 |
| Injection, Ropivacaine Hydrochloride, 1 Mg | other | $56 | $22 | $89 | 2 |
| X-ray of Upper Spine, 4-5 Views | imaging | $57 | $13 | $100 | 2 |
| X-ray of Skull, Minimum of 4 Views | imaging | $57 | $13 | $100 | 2 |
| X-ray Lower and Sacral Spine, Minimum of 6 Views | imaging | $57 | $14 | $100 | 2 |
| X-ray of Upper Spine, 6 OR More Views | imaging | $57 | $14 | $100 | 2 |
| Imaging Guidance for Procedure, 60 Minutes OR Less | other | $57 | $15 | $98 | 2 |
| Removal of Tissue From Wound Gradually | surgery | $57 | $31 | $83 | 2 |
| Blood Unit Compatibility Test, Immediate Spin Technique | other | $57 | $51 | $62 | 2 |
| Septal Button Nasal 2 Part #1524110 | other | $57 | $57 | $57 | 1 |
| Gold Probe Injection 10fr #6016 | other | $57 | $57 | $57 | 1 |
| Gold Probe W/injector 7fr/210cm #6015 | other | $57 | $57 | $57 | 1 |
| M00521231 - Clip Internal L235cm Channel 2.8mm with Ergonomic Handle Braided ... | other | $57 | $57 | $57 | 1 |
| Advance Care Planning, First 30 Minutes | other | $57 | $57 | $57 | 1 |
| Psychotherapy, 1 Hour | therapy | $57 | $57 | $57 | 1 |
| Reamer Cann Head 6.5mm #ar-1406.5 | other | $57 | $57 | $57 | 1 |
| Reamer Cann Head 6mm #ar | other | $57 | $57 | $57 | 1 |
| Reamer Cann Head 7.5mm #ar-1407.5 | other | $57 | $57 | $57 | 1 |
| Reamer Cann Head 7mm #ar | other | $57 | $57 | $57 | 1 |
| Reamer Cann Head 8mm #ar | other | $57 | $57 | $57 | 1 |
| Ultrasound Scan of Growth for Measuring Elasticity, Each Additional Growth | imaging | $57 | $57 | $57 | 1 |
| Symbicort 160-4.5 Mcg Inhaler | other | $57 | $57 | $57 | 1 |
| Meningococcal Vaccine, Serogroups A, C, Y, W | preventive | $57 | $57 | $57 | 1 |
| Evaluation of Swallowing Function | other | $57 | $57 | $57 | 1 |
| Rbc Pretreatment Serum | other | $57 | $57 | $57 | 1 |
| Compatibility Test Antiglob | other | $57 | $57 | $57 | 1 |
| Occupational Therapy | therapy | $58 | $20 | $829 | 38 |
| EKG (Electrocardiogram) | cardiac | $58 | $3 | $987 | 37 |
| X-ray of Ribs On Both Sides of Body, Minimum of 4 Views | imaging | $58 | $15 | $100 | 2 |
| X-ray Series of Abdomen with Single X-ray of Chest | imaging | $58 | $15 | $100 | 2 |
| Ultrasound of Heart, Follow-up | imaging | $58 | $24 | $91 | 2 |
| Programming of Multiple Lead Implantable Defibrillator System | surgery | $58 | $58 | $58 | 1 |
| Amplatz Grad Renal Dilation Set | other | $58 | $58 | $58 | 1 |
| Initial Instillation of Agent Onto Lung Lining Using Chest Tube | other | $58 | $58 | $58 | 1 |
| Blade Shave Biopsy Flex Dermablade 8ea/1cs | lab | $58 | $58 | $58 | 1 |
| Biopsy of Lining of Nose | lab | $58 | $58 | $58 | 1 |
| Needle Eus 22g Expect Slimline #m00555510 | other | $58 | $58 | $58 | 1 |
| Arc Smart Argon Probe 2.3/330 G1140002 | other | $58 | $58 | $58 | 1 |
| Design and Construction of Complex Radiation Treatment Device | other | $58 | $58 | $58 | 1 |
| Picc Cath 4fr Single Lumen Sapiens | other | $58 | $58 | $58 | 1 |
| Ultrasound Scan of Fetal Umbilical Artery Blood Flow Rate | imaging | $58 | $47 | $68 | 2 |
| Injection, Acetazolamide Sodium, Up to 500 Mg | other | $58 | $44 | $71 | 2 |
| Special Stained Specimen Slides to Examine Tissue, Each Additional Procedure | lab | $58 | $36 | $79 | 2 |
| X-ray of Collar Bone | imaging | $58 | $33 | $83 | 2 |
| X-ray of Hip, 1 View | imaging | $58 | $32 | $83 | 2 |
| Injection, Betamethasone Acetate 3 Mg and Betamethasone Sodium Phosphate 3 Mg | other | $58 | $11 | $105 | 2 |
| Ultrasound Scan of Pregnant Uterus (less Than 14 Weeks), Each Additional Fetus | imaging | $58 | $58 | $58 | 1 |
| A-scope 4 Rhinolaryngo Slim 510001000 5ea/1bx | other | $59 | $59 | $59 | 1 |
| Catheter Oximetry Nonheparin Swan-ganz782f75m | cardiac | $59 | $59 | $59 | 1 |
| Helmet, Protective, Hard, Prefabricated, Includes All Components and Accessories | other | $59 | $59 | $59 | 1 |
| Knot Pusher Suture Cutter #ar | other | $59 | $59 | $59 | 1 |
| Microspheres 700-900 S820gh 5ea/box | other | $59 | $59 | $59 | 1 |
| Robotic Suction Irrigator #410299 | other | $59 | $59 | $59 | 1 |
| Subsequent Observation Care, Per Day, for the Evaluation and Management of a ... | other | $59 | $59 | $59 | 1 |
| Ultrasound of Heart for Congenital Defect | imaging | $59 | $59 | $59 | 1 |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Knee Extens... | other | $59 | $59 | $59 | 1 |
| Carbojet Xf Handpiece Set with 40" Nozzle Individual Handpiece #27-100 | other | $59 | $59 | $59 | 1 |
| Evaluation of Hearing Function Related to Surgically Implanted Hearing Device... | surgery | $59 | $59 | $59 | 1 |
| Injection of Contrast for Imaging of Wrist | other | $59 | $59 | $59 | 1 |
| Injection Beneath Lining of Lower Large Bowel Using a Flexible Endoscope | other | $59 | $59 | $59 | 1 |
| Cannula Simcoe | other | $59 | $59 | $59 | 1 |
| Injection, Ocrelizumab, 1 Mg | other | $59 | $59 | $59 | 1 |
| Technetium Tc-99m Labeled Red Blood Cells, Diagnostic, Per Study Dose, Up to ... | other | $59 | $59 | $59 | 1 |
| Injection of Bladder and Ureter for Imaging | other | $59 | $59 | $59 | 1 |
| Atb45mm Standard Artic Cutter | other | $59 | $59 | $59 | 1 |
| 4 Hour Gtt | other | $59 | $59 | $59 | 1 |
| Cultr Bacteria Except Blood | other | $59 | $59 | $59 | 1 |
| Assay of Troponin Quant | other | $59 | $59 | $59 | 1 |
| Physical Therapy Evaluation | therapy | $60 | $22 | $262 | 14 |
| 2.5mm Prcsn Mtch Hd 13cm8450-107 | other | $60 | $60 | $60 | 1 |
| Tretinoin 0.01 % Ex Gel | other | $60 | $60 | $60 | 1 |
| Lap Grasper 5mm 6ea/bx #5dsg | other | $60 | $60 | $60 | 1 |
| Urethral Dilator Set 8fr-24fr #g14185 | other | $60 | $60 | $60 | 1 |
| 2.0 Mm Drive Shaft for Quickfix Screw System Ar-8930d | other | $60 | $60 | $60 | 1 |
| 3.0 Drive Shft for Quickfix Screw System Ar-8930d | other | $60 | $60 | $60 | 1 |
| Clip Resolution 360 Ultra17mm M00521402 20/bx | other | $60 | $60 | $60 | 1 |
| Erythromycin 200 Mg/5 Ml Susp | other | $60 | $60 | $60 | 1 |
| Pinning System #2544-00 | other | $60 | $60 | $60 | 1 |
| Ruby Coil Detachment Handle | other | $60 | $60 | $60 | 1 |
| Tube Nasal Moss Feed 18fr 44" Min Order of 2 | other | $60 | $60 | $60 | 1 |
| 2.0mm Carbide Round 5820-110-020c | other | $60 | $60 | $60 | 1 |
| 3.0mm Carbide Round5820-110-030c | other | $60 | $60 | $60 | 1 |
| 4.0mm Carbide Round 5820-110-040c | other | $60 | $60 | $60 | 1 |
| Varicella Vaccine | preventive | $60 | $60 | $60 | 1 |
| Injection, Pembrolizumab, 1 Mg | other | $60 | $60 | $60 | 1 |
| Application of Shoulder to Hand Cast | other | $60 | $60 | $60 | 1 |
| Gene Analysis (prothrombin, Coagulation Factor Ii) a Variant | other | $60 | $53 | $66 | 2 |
| Gene Analysis (coagulation Factor V) Leiden Variant | other | $60 | $46 | $73 | 2 |
| Gene Analysis (survival of Motor Neuron 1, Telomeric) for Dosage/deletion | other | $60 | $60 | $60 | 1 |
| Fluoroscopic Guidance for Needle Placement | other | $61 | $26 | $95 | 2 |
| Removal of Antibodies From Surface of Red Blood Cell | surgery | $61 | $58 | $64 | 2 |
| Addition to Lower Extremity Orthosis, High Strength, Lightweight Material, Al... | other | $61 | $61 | $61 | 1 |
| Static OR Dynamic Ankle Foot Orthosis, Including Soft Interface Material, Adj... | other | $61 | $61 | $61 | 1 |
| Alcohols Levels | other | $61 | $61 | $61 | 1 |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Bi... | other | $61 | $61 | $61 | 1 |
| Hepatitis B Vaccine (hepb), Cpg-adjuvanted, Adult Dosage, 2 Dose OR 4 Dose Sc... | preventive | $61 | $61 | $61 | 1 |
| Power Picc Solo Catheter 4f Sl 3cg #ck001030 3kits/1 Case | cardiac | $61 | $61 | $61 | 1 |
| Epinephrine Hcl (nasal) 0.1 % Na Soln | other | $61 | $61 | $61 | 1 |
| Gradient Compression Arm Sleeve, Custom, Medium Weight, Each | other | $61 | $61 | $61 | 1 |
| Tuberculosis Test, Gamma Interferon | other | $61 | $59 | $62 | 2 |
| Evaluation for Use of Voice Artificial Device to Supplement Oral Speech | other | $61 | $61 | $61 | 1 |
| X-ray of Abdomen, 1 View | imaging | $61 | $61 | $61 | 1 |
| Anesthesia Facility Charge | other | $61 | $61 | $61 | 1 |
| Single Contrast X-ray of Esophagus | imaging | $62 | $20 | $104 | 2 |
| Microscopic Genetic Analysis of Tumor, Using Computer-assisted Technology | other | $62 | $23 | $101 | 2 |
| Injection, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf, Per 10 Mg | other | $62 | $62 | $62 | 1 |
| Testing for Presence of Drug, By Chemistry Analyzers | other | $62 | $62 | $62 | 2 |
| Mic Tube Feeding Jejunal 18fr 30cm #0250-18 | other | $62 | $62 | $62 | 1 |
| Electrode Pacing Non-heparin 5frx110cm 5ea/ca | other | $62 | $62 | $62 | 1 |
| 2.0 Cann Driver Tip Ht | other | $62 | $62 | $62 | 1 |
| Human Papillomavirus Vaccine, Types 6, 11, 16, 18, Quadrivalent | preventive | $62 | $62 | $62 | 1 |
| Walking Boot, Non-pneumatic, with OR without Joints, with OR without Interfac... | other | $62 | $62 | $62 | 1 |
| Arndt Endobronchial Blocker Set 7fr G44114 | other | $62 | $62 | $62 | 1 |
| Hepatitis B Surface Ag Ia | other | $62 | $62 | $62 | 1 |
| Ultrasound Scan of Abdominal Aorta | imaging | $63 | $25 | $100 | 2 |
| Evaluation of Fine Needle Aspirate | other | $63 | $28 | $97 | 2 |
| Tobrex 0.3% Eye Ointment | other | $63 | $63 | $63 | 1 |
| Optisphere 700-1000 #osl271 5ea/1bx | other | $63 | $63 | $63 | 1 |
| Medtronic Percutaneous Extention Kit 3560022 | other | $63 | $63 | $63 | 1 |
| 3.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 4.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 5.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| 6.0 Precision Round 2flute5820-009 | other | $63 | $63 | $63 | 1 |
| Evaluation of Brain Response to Sound for Diagnosis of Nervous System Disorde... | other | $63 | $63 | $63 | 1 |
| Needle Biopsy of Thyroid Through Skin | lab | $63 | $63 | $63 | 1 |
| Desonide 0.05 % Ex Lotn | other | $63 | $63 | $63 | 1 |
| Home Visit for the Evaluation and Management of a New Patient, Which Requires... | other | $63 | $63 | $63 | 1 |
| Evaluation of Hearing Function Brain Responses, First Hour | other | $63 | $63 | $63 | 1 |
| Chg Stereotactic Guidance Breast Bx/ Needle Place | other | $63 | $63 | $63 | 1 |
| Hc General Anesthesia Time - Each Incremental 15 Minutes | other | $63 | $63 | $63 | 1 |
| Preventive Medicine Counseling, Typically 1 Hour | therapy | $63 | $63 | $63 | 1 |
| Pulmonary Needle Arcpoint 21g #ils-2100-pn 5/pk | other | $63 | $63 | $63 | 1 |
| Biopsy of Lower Large Bowel Using a Flexible Endoscope | lab | $63 | $63 | $63 | 1 |
| Pneumothorax Cath Set 10.2fr #c-tpt-200 1ea | other | $63 | $63 | $63 | 1 |
| X-ray of Thigh Bone, Minimum 2 Views | imaging | $63 | $42 | $83 | 2 |
| Tc99m Sulfur Colloid | other | $63 | $63 | $63 | 1 |
| Evaluation of Speech Sound Production | other | $63 | $63 | $63 | 1 |
| Assay Triiodothyronine | other | $63 | $63 | $63 | 1 |
| Limited Ultrasound Scan of Abdomen | imaging | $64 | $27 | $100 | 2 |
| Coblator Evac 70 Xtra W/cable | other | $64 | $64 | $64 | 1 |
| Hc Epidural Anesthesia Time - Initial Base Charge | other | $64 | $64 | $64 | 1 |
| Hc Spinal Anes 1st 30 | other | $64 | $64 | $64 | 1 |
| Diagnostic Exam of Surgically Created Pouch of Small Bowel Using an Endoscope | surgery | $64 | $64 | $64 | 1 |
| Evaluation of Brain Response to Sound for Determination of Hearing Status wit... | other | $64 | $64 | $64 | 1 |
| Fetal Fibronectin (protein) Analysis | other | $64 | $64 | $64 | 1 |
| Assay of Lactic Acid | other | $64 | $64 | $64 | 1 |
| Spirometry (Pulmonary Function) | diagnostic | $65 | $3 | $370 | 11 |
| Fiapc Probe W/ Filter 2200 a Od 2.3 Mm / 6.9 Fr; L 2.2 M / 7.2 Ft - #20132-21... | other | $65 | $65 | $65 | 1 |
| Biopsy of Small Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $65 | $65 | $65 | 1 |
| Fiapc Probe W/ Filter 2200 Cod 2.3 Mm / 6.9 Fr; L 2.2 M / 7.2 Ftno. #20132-21... | other | $65 | $65 | $65 | 1 |
| Embospheres 500-700 #s620gh 5ea/bx | other | $65 | $65 | $65 | 1 |
| Lacosamide 200 Mg/20 Ml Vial | other | $65 | $65 | $65 | 1 |
| Microspheres 300-500 #s420gh 5ea/box | other | $65 | $65 | $65 | 1 |
| Nerve Conduction, 3-4 Studies | other | $65 | $65 | $65 | 1 |
| Review By Radiologist of Both Arms and Legs Veins of Both Arms OR Legs Image | other | $65 | $65 | $65 | 1 |
| Forcep Long Kleppinger 45cm 5mm #910010pk | other | $65 | $65 | $65 | 1 |
| Hemostatic Sealant Floseal Matrix 10ml 6/ca | other | $65 | $65 | $65 | 1 |
| Instillation of Agent Onto Lung Surface Using Chest Tube | other | $65 | $65 | $65 | 1 |
| Biopsies of Rectum And/or Lower Large Bowel Using a Rigid Endoscope | other | $65 | $65 | $65 | 1 |
| Ergo Gps Drill 3.2mm #531-55 | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.0mm X 20mm L76mm Ao Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.0mm X 20mml82mm Dental Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.0mm X 20mml82mm Stryker Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 10mm L66mm Ao Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 10mm L72mm Dental Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 10mm L72mm Stryker Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 25mm L81mm Ao Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 25mm L87mm Dental Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.2mm X 25mm L87mm Stryker Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 10mm L66mm Ao Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 10mm L72mm Dental Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 10mm L72mm Stryker Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 25mm L81mm Ao Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 25mm L87mm Dental Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.6mm X 25mm L87mm Stryker Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.9mm X 35mm L91mm Ao Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.9mm X 35mm L97mm Dental Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 1.9mm X 35mm L97mm Stryker Fixation #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 2.1mm X 10mm L66mm Ao Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 2.1mm X 10mm L72 Stryker Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 2.1mm X 10mm L72mm Dental Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 2.35mm X 10mm L66mm Ao Lag #a | other | $65 | $65 | $65 | 1 |
| Twist Drill 2.35mm X 10mm L72mm Dental Lag #a | other | $65 | $65 | $65 | 1 |
| Gene Analysis (hemochromatosis) Common Variants | other | $65 | $65 | $65 | 1 |
| Study of Esophagus to Assess Movement | other | $65 | $65 | $65 | 1 |
| Balloon Oval Kidney Shape Str #omspdbs2 | other | $65 | $65 | $65 | 1 |
| Artery Puncture Collection of Blood Sample | other | $65 | $65 | $65 | 1 |
| Progesterone (reproductive Hormone) Receptor Analysis | other | $65 | $65 | $65 | 1 |
| Inhalation Treatment for Acute Airway Obstruction, First Hour | other | $65 | $65 | $65 | 1 |
| Injection, Lacosamide, 1 Mg | other | $65 | $65 | $65 | 1 |
| Analysis of Voice and Resonance Production | other | $65 | $65 | $65 | 1 |
| Assay of Vitamin B | other | $65 | $65 | $65 | 1 |
| Occupational Therapy Evaluation | therapy | $66 | $29 | $660 | 5 |
| Ultrasound Scan of Pelvic Region Through Rectum | imaging | $66 | $31 | $100 | 2 |
| Limited Ultrasound Scan of Joint OR Other Extremity Structure Except Blood Ve... | imaging | $66 | $31 | $100 | 2 |
| Complete Ultrasound Scan of Pelvis | imaging | $66 | $31 | $100 | 2 |
| Initial Therapy Service to Facilitate Lung Function | other | $66 | $50 | $81 | 2 |
| Injection, C-1 Esterase Inhibitor (human), Cinryze, 10 Units | other | $66 | $66 | $66 | 1 |
| Ultrasound of Heart During Rest, Exercise And/or Drug-induced Stress with Report | imaging | $66 | $66 | $66 | 1 |
| Ultrasound of Heart with Color-depicted Blood Flow, Rate, Direction and Valve... | imaging | $66 | $66 | $66 | 2 |
| Hc Regional Anesthesia Time - Initial Base Charge | other | $66 | $66 | $66 | 1 |
| Complex Control of Nose Bleed | other | $66 | $66 | $66 | 1 |
| Test for Exercise-induced Heart and Lung Stress | cardiac | $66 | $66 | $66 | 1 |
| Tralement Vial | other | $66 | $66 | $66 | 1 |
| Adapalene 0.3% Gel | other | $66 | $66 | $66 | 1 |
| Review By Radiologist of Image for Repair of Descending Aorta and Subclavian ... | surgery | $66 | $66 | $66 | 1 |
| Sensors Starling W/leadwires 25pk/1bx #cms25 | other | $66 | $66 | $66 | 1 |
| Injection, Irinotecan Liposome, 1 Mg | other | $66 | $66 | $66 | 1 |
| Injection, Erythromycin Lactobionate, Per 500 Mg | other | $66 | $66 | $66 | 1 |
| Reaming Rod Push Rod with Ball Handle 03.010.093 | other | $66 | $66 | $66 | 1 |
| Centurion Anterior Vitrectomy Probe | other | $66 | $66 | $66 | 1 |
| Initial Hospital Care with Straightforward OR Low Level of Medical Decision M... | other | $66 | $66 | $66 | 1 |
| Dilation of Saliva Gland Duct and Insertion of Tube | other | $66 | $66 | $66 | 1 |
| Injection, Benztropine Mesylate, Per 1 Mg | other | $66 | $60 | $71 | 2 |
| X-ray of Hip, 2-3 Views | imaging | $66 | $48 | $83 | 2 |
| Injection, Amiodarone Hydrochloride (nexterone), 30 Mg | other | $66 | $34 | $98 | 2 |
| Therapeutic Injection | preventive | $67 | $7 | $181 | 15 |
| Complete Ultrasound Scan Behind Abdominal Cavity | imaging | $67 | $33 | $100 | 2 |
| Administration of Hormonal Anti-neoplastic Chemotherapy Under Skin OR Into Mu... | other | $67 | $67 | $67 | 1 |
| Assistive Listening Device, Television Amplifier, Any Type | other | $67 | $67 | $67 | 1 |
| Aveta Coral Disposable Hysteroscope 4.6mm #214 | other | $67 | $67 | $67 | 1 |
| Aveta Pearl Disposable Hysteroscope 5.7mm #214 | other | $67 | $67 | $67 | 1 |
| Cables Ensite X Extension for Magnet #a-ens-magext-cbl | other | $67 | $67 | $67 | 1 |
| Custom Peg Board Kit #1 #pbk10001 | other | $67 | $67 | $67 | 1 |
| Ensnare 18-30mm #en2007030 Elgx | other | $67 | $67 | $67 | 1 |
| Exam of Neurobehavioral Status, First Hour | other | $67 | $67 | $67 | 1 |
| Hearing Aid OR Assistive Listening Device/supplies/accessories, Not Otherwise... | other | $67 | $67 | $67 | 1 |
| Pins 4x127 #rob10010 4ea/bx | other | $67 | $67 | $67 | 1 |
| Pins 4x152 #rob10011 2ea/bx | other | $67 | $67 | $67 | 1 |
| Screwdriver Bit Headless 3.0mm 212-40 | other | $67 | $67 | $67 | 1 |
| Bypass of Diseased OR Blocked Artery with Prosthetic and Vein | other | $67 | $67 | $67 | 1 |
| Ingrezza 40 Mg Capsule | other | $67 | $67 | $67 | 1 |
| Powerpicc Solo Provena Catheter 4f Dl 3cg #ck001031 3kt/cs | cardiac | $67 | $67 | $67 | 1 |
| Extracorp Shock Wv Tx Ms Nos | other | $67 | $67 | $67 | 1 |
| Catheter Angiographic Coronary OR Peripheral Guiding W/o Sideholes Right C315... | imaging | $67 | $67 | $67 | 1 |
| Diphtheria and Tetanus Vaccine | preventive | $67 | $67 | $67 | 1 |
| Biopsy of Anus Using an Endoscope | lab | $67 | $67 | $67 | 1 |
| Alvarado Traction Boot #00132021000 | other | $67 | $67 | $67 | 1 |
| Prevena Dressing 13cm #pre1155us 5/cs | other | $67 | $67 | $67 | 1 |
| Prevena Dressing 20cm #pre1055us 5/cs | other | $67 | $67 | $67 | 1 |
| Mycobacteria Culture | lab | $67 | $67 | $67 | 1 |
| Bone Density Scan | imaging | $68 | $9 | $230 | 35 |
| Ultrasound of Leg Arteries At Rest and After Exercise | imaging | $68 | $23 | $112 | 2 |
| Injection, Nicardipine, 0.1 Mg | other | $68 | $35 | $101 | 2 |
| Complete Ultrasound Scan of Abdomen | imaging | $68 | $36 | $100 | 2 |
| New Patient Office OR Other Outpatient Visit with Low Level of Medical Decisi... | other | $68 | $67 | $69 | 2 |
| Administration of Non-hormonal Anti-neoplastic Chemotherapy Under Skin OR Int... | other | $68 | $68 | $68 | 1 |
| Dressing Neg Press Veraflo Lg 5pk Ultvcc05lg | other | $68 | $68 | $68 | 1 |
| Drill Tip Set-acl Patella Tendon Reusable | other | $68 | $68 | $68 | 1 |
| Back Brace Aspen Summit 637 X-large 992380 | other | $68 | $68 | $68 | 1 |
| Ligator Six Bander #mbl-6-ov Implant | surgery | $68 | $68 | $68 | 1 |
| 8813e Suture Kit Dr Dumicz Oh Only 5kt/bx | other | $68 | $68 | $68 | 1 |
| Insertion of Tube Into Windpipe and Airways of Lung for Aspiration of Secreti... | other | $68 | $68 | $68 | 1 |
| Use of a Drug to Induce Depression of Consciousness By Physician Not Performi... | other | $68 | $68 | $68 | 1 |
| Antibody Evaluation, Initial Single Antibody Stain Procedure | other | $68 | $68 | $68 | 1 |
| Subsequent Hospital Inpatient OR Observation Care with High Level of Medical ... | other | $68 | $68 | $68 | 1 |
| Needle Biopsy of Growth of Abdominal Cavity | lab | $68 | $68 | $68 | 1 |
| Amnioexcel, Amnioexcel Plus OR Biodexcel, Per Square Centimeter | other | $68 | $68 | $68 | 1 |
| Free Assay | other | $68 | $68 | $68 | 1 |
| Antinuclear Antibodies | imaging | $68 | $68 | $68 | 1 |
| Pathology (Surgical Specimen) | lab | $69 | $3 | $949 | 20 |
| Hypertension Management | cardiac | $69 | $22 | $303 | 29 |
| Ultrasound of Leg Arteries OR Artery Grafts | imaging | $69 | $35 | $102 | 2 |
| Ultrasound of Arm Arteries OR Artery Grafts | imaging | $69 | $36 | $102 | 2 |
| CT Scan Head OR Brain without Contrast | imaging | $69 | $38 | $100 | 2 |
| CT Scan of Face without Contrast | imaging | $69 | $38 | $100 | 2 |
| Manipulation of Finger for Connective Tissue Release Following Enzyme Injection | other | $69 | $69 | $69 | 1 |
| Injection, Levocarnitine, Per 1 Gm | other | $69 | $69 | $69 | 1 |
| Gene Rearrangement Analysis Detection Abnormal Clonal Population | other | $69 | $69 | $69 | 1 |
| Candin Skin Test | other | $69 | $69 | $69 | 1 |
| Balloon Dilation of Lower Large Bowel Using a Flexible Endoscope | other | $69 | $69 | $69 | 1 |
| Basket Trapezoid 3cm #m00510890 | other | $69 | $69 | $69 | 1 |
| Basket Wireguided Retrieval 2.0 X .035 | other | $69 | $69 | $69 | 1 |
| Basket Wireguided Retrieval 2.5 X .035 | other | $69 | $69 | $69 | 1 |
| **discontinued 2/19/2021** Percut Kit 19fr X 18cm Femoral Arterial | other | $69 | $69 | $69 | 1 |
| Percut Kit 21fr X 18cm Femoral Arterial | other | $69 | $69 | $69 | 1 |
| 8815e Suture Dr Halligan CABG 1ea=1kt 5kt/1bx | other | $69 | $69 | $69 | 1 |
| Cvvh Prisma Dilution Set #106697 4ea/cs | other | $69 | $69 | $69 | 1 |
| Nuclear Medicine Study of Heart Muscle with Metabolic Evaluation | imaging | $69 | $69 | $69 | 1 |
| Administration of Additional New Drug OR Substance Into Vein Using Push Techn... | other | $69 | $69 | $69 | 1 |
| Administration of Additional New Drug OR Substance Into Vein, 1 Hour OR Less | other | $69 | $69 | $69 | 1 |
| Administration of Chemotherapy Into Vein, Each Additional Hour | other | $69 | $69 | $69 | 1 |
| Hti Regulator Kit H80215901011 15901 | other | $69 | $69 | $69 | 1 |
| Residence Visit for Established Patient with Moderate Level of Medical Decisi... | other | $69 | $69 | $69 | 1 |
| Tube Endobronchial 35 Vivasight-dl #dlvt35las | other | $69 | $69 | $69 | 1 |
| Tube Endobronchial 37 Vivasight-dl #dlvt37las | other | $69 | $69 | $69 | 1 |
| Tube Endobronchial 39 Vivasight-dl #dlvt39las | other | $69 | $69 | $69 | 1 |
| Tube Endobronchial 41 Vivasight-dl #dlvt41las | other | $69 | $69 | $69 | 1 |
| Closed Treatment of Dislocated Joint Between Toe and Foot | other | $69 | $69 | $69 | 1 |
| Santyl Ointment | other | $69 | $69 | $69 | 1 |
| Hemostat Surgicel Snow 2x4 Absrb Ster #2082 | other | $69 | $69 | $69 | 1 |
| Laser Probe 25g Vekt Illum Directl8065 | other | $69 | $69 | $69 | 1 |
| Cervicovaginal Secretion of Placenta Protein | other | $69 | $48 | $89 | 2 |
| Hormone Receptor Analysis | other | $69 | $69 | $69 | 1 |
| Injection of Contrast for Imaging of Lower Spinal Canal | other | $69 | $69 | $69 | 1 |
| Test to Assess the Loss of the Ability to Speak, Write, and Understand Language | other | $69 | $69 | $69 | 1 |
| Monurol 3 Gm Sacet | other | $69 | $69 | $69 | 1 |
| Clot Factor Viii Vw Ristoctn | other | $69 | $69 | $69 | 1 |
| Sars Antigen Fia | other | $69 | $69 | $69 | 1 |
| Creatine Mb Fraction | other | $69 | $69 | $69 | 1 |
| Percut Kit 15fr X 18cm Femoral Arterial | other | $70 | $70 | $70 | 1 |
| Removal of Appendix During Other Major Procedure | surgery | $70 | $70 | $70 | 1 |
| Ligator Band 7 Band Speed | other | $70 | $70 | $70 | 1 |
| Assessment for Hearing Aid | other | $70 | $70 | $70 | 1 |
| Established Patient Office OR Other Outpatient Visit with Moderate Level of D... | other | $70 | $70 | $70 | 1 |
| Retrieval Device, Insertable | other | $70 | $70 | $70 | 1 |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 9/27 Inner Diameter 10.... | other | $70 | $70 | $70 | 1 |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 9/36 Inner Diameter 13.... | other | $70 | $70 | $70 | 1 |
| Injection, Collagenase, Clostridium Histolyticum, 0.01 Mg | other | $70 | $70 | $70 | 1 |
| Pcp Drug Level | other | $70 | $70 | $70 | 1 |
| Laproscopic Alligator Grasper | other | $70 | $70 | $70 | 1 |
| Waveguide 12fr #1911273 | other | $70 | $70 | $70 | 1 |
| Albuterol Inhaler | other | $70 | $70 | $70 | 1 |
| Ultrasound Scan of Fetus | imaging | $70 | $70 | $70 | 1 |
| Ultrasound of Both Sides of Head and Neck Blood Flow | imaging | $71 | $36 | $106 | 2 |
| Injection of Anesthetic OR Steroid Into Joint Between Lower Spine and Hip Bon... | other | $71 | $71 | $71 | 1 |
| Rev - Ihs-moa Clinic Visit | other | $71 | $71 | $71 | 1 |
| Disposable Distal Attachment D-201 | other | $71 | $71 | $71 | 1 |
| Injection, Daratumumab, 10 Mg | other | $71 | $71 | $71 | 1 |
| Silicone Elastomer T-tube 10fr Su130 | other | $71 | $71 | $71 | 1 |
| Silicone Elastomer T-tube 12fr Su130 | other | $71 | $71 | $71 | 1 |
| Silicone Elastomer T-tube 14fr Su130 | other | $71 | $71 | $71 | 1 |
| Silicone Elastomer T-tube 16fr Su130 | other | $71 | $71 | $71 | 1 |
| Ultrasound Scan of Infant Hip | imaging | $71 | $71 | $71 | 1 |
| Stonetome 5.5fr 20mm #3511 | other | $71 | $71 | $71 | 1 |
| Bflex 2 Slim 3.8 Single-use Bronchoscope 0570-0448 Bx=pk/5ea | other | $71 | $71 | $71 | 1 |
| X-ray of Face Bones, 1-2 Views | imaging | $71 | $59 | $83 | 2 |
| Review By Radiologist of Urinary Bladder Image | other | $72 | $15 | $129 | 2 |
| Injection, Desmopressin Acetate, Per 1 Mcg | other | $72 | $62 | $81 | 2 |
| Non-canulated Non-sterile Torque Driver #00-8401-080 | other | $72 | $72 | $72 | 1 |
| Removal of Anal Polyps OR Growths Using an Endoscope with Electrical Cautery | surgery | $72 | $72 | $72 | 1 |
| Electrode Hf Loop 24fr .2 Wire #a22201d | other | $72 | $72 | $72 | 1 |
| Addition to Knee Joint, Disc OR Dial Lock for Adjustable Knee Flexion, Each J... | other | $72 | $72 | $72 | 1 |
| Review By Radiologist of Arm OR Leg Artery Image | other | $72 | $72 | $72 | 1 |
| Wand Arthro 2.3mm 35 Deg Short Bevel Sm Joint | other | $72 | $72 | $72 | 1 |
| Individual Physician Supervision of a Patient (patient Not Present) in Home, ... | other | $72 | $72 | $72 | 1 |
| Closed Treatment of 2 Broken Lower Leg Bones At Ankle | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken End of Finger OR Thumb | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Finger OR Hand At Base of Finger | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Hand Bone | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Outside Lower Leg Bone At Ankle | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Outside Lower Leg Bone At Ankle with Manipulation | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Toe | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Broken Toe with Manipulation | other | $72 | $72 | $72 | 1 |
| Closed Treatment of Inside Portion of Shin Bone At Ankle | other | $72 | $72 | $72 | 1 |
| Overtube Guardus Endo 50cm 3ea/bx #bx00711149 | other | $72 | $72 | $72 | 1 |
| X-ray of Chest, 1 View | imaging | $72 | $60 | $83 | 2 |
| Gross Exam Only By Pathologist | other | $72 | $72 | $72 | 1 |
| Physical Therapy | therapy | $73 | $7 | $701 | 38 |
| CT Scan of Leg without Contrast | imaging | $73 | $45 | $100 | 2 |
| CT Scan of Lower Spine without Contrast | imaging | $73 | $45 | $100 | 2 |
| CT Scan of Middle Spine without Contrast | imaging | $73 | $45 | $100 | 2 |
| CT Scan of Upper Spine without Contrast | imaging | $73 | $45 | $100 | 2 |
| Guidepin Resection 3mm X 100mm for Inhance Shoulder System #700030100 #7000-30 | other | $73 | $73 | $73 | 1 |
| Evaluation and Testing for Balance with Recording | other | $73 | $73 | $73 | 1 |
| Biopsy of Breast and Placement of Locating Device Using Mri, Each Additional ... | imaging | $73 | $73 | $73 | 1 |
| Technetium Tc 99m Labeled Red Blood Cell Diagnostic 30 Mci | other | $73 | $73 | $73 | 1 |
| Percut Kit 23fr X 18cm Femoral Venous | other | $73 | $73 | $73 | 1 |
| Acp Max Prp System W/acda Abs | other | $73 | $73 | $73 | 1 |
| Driver Surgical T8 Solid Ao for Colink Screw P04s0051 #p04 S0051 | surgery | $73 | $73 | $73 | 1 |
| Knot Pusher #kp1 Cardiac Surg Only | cardiac | $73 | $73 | $73 | 1 |
| Lag Screw Driver T8 Cannulated Sterile Single Use #p06 S0411 | other | $73 | $73 | $73 | 1 |
| Office OR Other Outpatient Consultation with Low Level of Medical Decision Ma... | other | $73 | $73 | $73 | 1 |
| Psychotherapy for Crisis, First Hour | therapy | $73 | $73 | $73 | 1 |
| Radioactive Drug Therapy Through a Tube Inserted in an Artery | other | $73 | $73 | $73 | 1 |
| Respiratory Syncytial Virus Vaccine, Pref, Recombinant, Subunit, Adjuvanted, ... | preventive | $73 | $73 | $73 | 1 |
| Tube Feed Gastrostomy 18fr Moss | other | $73 | $73 | $73 | 1 |
| Injection, Bevacizumab, 10 Mg | other | $73 | $73 | $73 | 1 |
| Clevercut Tome 7mm Tip 20mm Wire | other | $73 | $73 | $73 | 1 |
| Needle Biopsy of Liver Through Skin | lab | $73 | $73 | $73 | 1 |
| Gene Analysis (interferon, Lambda 3) for Rs12979860 Variant | other | $73 | $73 | $73 | 1 |
| Anesthesia for Tying OR Incision of Fallopian Tubes Using an Endoscope | other | $73 | $73 | $73 | 1 |
| Catheter, Balloon Dilatation, Non-vascular | cardiac | $73 | $65 | $80 | 2 |
| Levalbuterol, Inhalation Solution, Compounded Product, Administered Through D... | other | $73 | $73 | $73 | 1 |
| IV Hydration | therapy | $74 | $10 | $604 | 14 |
| DEXA Bone Density Scan | imaging | $74 | $22 | $249 | 14 |
| Urgent Care Visit | other | $74 | $2 | $304 | 24 |
| CT Scan of Chest without Contrast | imaging | $74 | $48 | $100 | 2 |
| CT Scan of Pelvis without Contrast | imaging | $74 | $48 | $100 | 2 |
| Complete Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $74 | $51 | $97 | 2 |
| Dilation of Esophagus with a Guide Wire | other | $74 | $74 | $74 | 1 |
| Initial Control of Nose Bleed and Insertion of Packing | other | $74 | $74 | $74 | 1 |
| Kyphon Bevel Osteo Introducer #t15k | other | $74 | $74 | $74 | 1 |
| Insertion of Needle OR Tube Into Artery of Arm OR Leg | other | $74 | $74 | $74 | 1 |
| Endowrist Suction Irrigator #480299 6ea/1bx | other | $74 | $74 | $74 | 1 |
| Injection, Ramucirumab, 5 Mg | other | $74 | $74 | $74 | 1 |
| Injection, Obinutuzumab, 10 Mg | other | $74 | $74 | $74 | 1 |
| Ibs 2in1 Drill 2.2 Diam / Lg22mm Ao Sterile Cannulated Lg65mm G01 00721 | other | $74 | $74 | $74 | 1 |
| Initial Evaluation and Management of Newborn Per Day | obstetric | $74 | $74 | $74 | 1 |
| Tool Delivery Large Cps Locator 3d#ds2c300 | obstetric | $74 | $74 | $74 | 1 |
| Tool Delivery Large Xlong Cps Locator 3d#ds2c300 | obstetric | $74 | $74 | $74 | 1 |
| Tool Delivery Medium Cps Locator 3d#ds2c200 | obstetric | $74 | $74 | $74 | 1 |
| Tool Delivery Medium Xlong Cps Locator 3d#ds2c200 | obstetric | $74 | $74 | $74 | 1 |
| Tool Delivery Small Cps Locator 3d#ds2c100 | obstetric | $74 | $74 | $74 | 1 |
| 5 Hour Gtt | other | $74 | $74 | $74 | 1 |
| Technetium Tc-99m Macroaggregated Albumin, Diagnostic, Per Study Dose, Up to ... | other | $74 | $74 | $74 | 1 |
| Red Blood Cells, Each Unit | other | $74 | $74 | $74 | 1 |
| IV Push Inj Each New Drug | other | $75 | $23 | $122 | 6 |
| 3d Radiographic Procedure with Computerized Image Postprocessing | imaging | $75 | $75 | $75 | 1 |
| Hc Dressing Aquacel Ag 3.5x6 | other | $75 | $75 | $75 | 1 |
| Benzodiazepines Levels, 1 | other | $75 | $75 | $75 | 1 |
| Established Patient Periodic Preventive Medicine Examination | preventive | $75 | $75 | $75 | 1 |
| Injection, Trastuzumab, Excludes Biosimilar, 10 Mg | other | $75 | $75 | $75 | 1 |
| Flovent Hfa 220 Mcg Inhaler | other | $75 | $75 | $75 | 1 |
| Injection, Rituximab, 10 Mg | other | $75 | $75 | $75 | 1 |
| Foot, Insert, Removable, Molded to Patient Model, Longitudinal Arch Support, ... | other | $75 | $75 | $75 | 1 |
| Blood (whole), for Transfusion, Per Unit | surgery | $75 | $75 | $75 | 1 |
| Red Blood Cells, Irradiated, Each Unit | other | $75 | $75 | $75 | 1 |
| Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit | other | $75 | $75 | $75 | 1 |
| Red Cells Process/store/handle | other | $75 | $75 | $75 | 1 |
| Ultrasound Study of Arm OR Leg Veins with Compression and Maneuvers | imaging | $76 | $31 | $121 | 2 |
| Catheter, Drainage | cardiac | $76 | $34 | $118 | 2 |
| 11mm Mcglamry Metatarsal Elevator Ar-8930m | other | $76 | $76 | $76 | 1 |
| Connecting Tube #maj | other | $76 | $76 | $76 | 1 |
| Removal of Blood Clot in Heart Artery | surgery | $76 | $76 | $76 | 1 |
| Removal of Drain (seton) From Anus | surgery | $76 | $76 | $76 | 1 |
| Hospital Inpatient OR Observation Discharge Day Management, More Than 30 Minutes | other | $76 | $76 | $76 | 1 |
| Splinting Tube 11mm X 13.2mm for Enteroscopy | other | $76 | $76 | $76 | 1 |
| Injection, Cetuximab, 10 Mg | other | $76 | $76 | $76 | 1 |
| X-ray of Chest, 2 Views | imaging | $76 | $69 | $83 | 2 |
| X-ray of Foot, 2 Views | imaging | $76 | $69 | $83 | 2 |
| Insertion of Tube Into Vena Cava | other | $76 | $62 | $90 | 2 |
| Drawing of Blood for a Medical Problem | other | $76 | $56 | $95 | 2 |
| Screening Mammography | imaging | $76 | $57 | $95 | 2 |
| X-ray of Chest, Minimum of 4 Views | imaging | $76 | $76 | $76 | 1 |
| X-ray of Forearm, 2 Views | imaging | $76 | $76 | $76 | 1 |
| CT Scan of Abdomen without Contrast | imaging | $77 | $53 | $100 | 2 |
| Pathology Examination of Tissue Using a Microscope, Moderately High Complexity | lab | $77 | $64 | $90 | 2 |
| Ultrasound Scan of Infant Hip During Movement | imaging | $77 | $71 | $83 | 2 |
| Needle Ultrafast Fix Straight | other | $77 | $77 | $77 | 1 |
| Pack Arthroscopic 1.2 Disposable Rap-pac B #72202797 | surgery | $77 | $77 | $77 | 1 |
| For Diabetics Only, Fitting (including Follow-up), Custom Preparation and Sup... | other | $77 | $77 | $77 | 1 |
| Gene Analysis (mpl Proto-oncogene, Thrombopoietin Receptor) Sequence Analysis... | other | $77 | $77 | $77 | 1 |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 8/27 Standard Inner Dia... | other | $77 | $77 | $77 | 1 |
| Bone Mill #bm210 Fine | other | $77 | $77 | $77 | 1 |
| All Lower Extremity Prosthesis, Solid Ankle Cushion Heel (sach) Foot, Replace... | other | $77 | $77 | $77 | 1 |
| Biopsy of Small Bowel Pouch Using an Endoscope | lab | $77 | $77 | $77 | 1 |
| Placement of Expandable Tube in Breast for Radiation Treatment Using Imaging ... | other | $77 | $77 | $77 | 1 |
| Nerve Conduction, 5-6 Studies | other | $77 | $77 | $77 | 1 |
| Evaluation of Speech Continuity, Smoothness, Rate, and Effort | other | $77 | $77 | $77 | 1 |
| Test to Assess the Ability to Complete Specific Functional Tasks Applicable t... | other | $77 | $77 | $77 | 1 |
| Assay of Ferritin | other | $77 | $77 | $77 | 1 |
| Culture Screen Only | lab | $77 | $77 | $77 | 1 |
| Rubeola Antibody | other | $77 | $77 | $77 | 1 |
| Injection of Radioactive Material for X-ray Identification of Lymph Node | imaging | $78 | $26 | $130 | 2 |
| S1294108d5 - Power Picc 4fr Dual 3ea/case | other | $78 | $78 | $78 | 1 |
| Powerpicc Solo Catheter 5f Tl Hf 3cg #ck001032 3kt/1cs | cardiac | $78 | $78 | $78 | 1 |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 8/36 Nonsterile Single-... | other | $78 | $78 | $78 | 1 |
| Gore Smoother 7.9mm Disp | other | $78 | $78 | $78 | 1 |
| Gore Smoother 9.5mm Disp | other | $78 | $78 | $78 | 1 |
| Biopsy of Mouth | lab | $78 | $78 | $78 | 1 |
| CT Scan of Heart Structure with Contrast | imaging | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary 10-11-12mm #m00558930 | other | $78 | $78 | $78 | 1 |
| Hyaluronan OR Derivative, Hyalgan, Supartz OR Visco-3, for Intra-articular In... | other | $78 | $78 | $78 | 1 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 2 Extremities | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary 6-7-8mmx5.5 #m00558860 | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary 8-9-10mm #m00558920 | other | $78 | $78 | $78 | 1 |
| Balloon Cre Rx Biliary12-13.5-15mm #m00558940 | other | $78 | $78 | $78 | 1 |
| Bio-tenodesis Disp Kit #ar-1530ds | other | $78 | $78 | $78 | 1 |
| Inpatient OR Observation Consultation with Low Level of Medical Decision Maki... | other | $78 | $78 | $78 | 1 |
| Limited Ultrasound Scan of 1 Breast | imaging | $78 | $72 | $83 | 2 |
| X-ray of Eye for Detection of Foreign Body | imaging | $78 | $78 | $78 | 1 |
| X-ray of Abdomen, 2 Views | imaging | $78 | $78 | $78 | 1 |
| CT Scan of Cranial Cavity without Contrast | imaging | $79 | $57 | $100 | 2 |
| CT Scan of Soft Tissue of Neck without Contrast | imaging | $79 | $57 | $100 | 2 |
| Insertion of Tube in Pulmonary Artery for Monitoring | other | $79 | $79 | $79 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Adjustable Motion Knee Joint, ... | other | $79 | $79 | $79 | 1 |
| Test to Assess Electrical Potentials Generated in the Inner Ear As a Result o... | other | $79 | $79 | $79 | 1 |
| Obtaining Data Needed to Develop the Optimal Radiation Treatment, 3 OR More T... | other | $79 | $79 | $79 | 1 |
| Cns Drainage System /latex Free #10-110 1ea | other | $79 | $79 | $79 | 1 |
| Evaluation of Sleep-disordered Breathing By Examination of Upper Airway Using... | other | $79 | $79 | $79 | 1 |
| Biopsy of Floor of Mouth | lab | $79 | $79 | $79 | 1 |
| X-ray of Chest, 3 Views | imaging | $79 | $75 | $83 | 2 |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Quantification | other | $79 | $72 | $85 | 2 |
| Test to Measure Expiratory Airflow and Volume | other | $79 | $79 | $79 | 1 |
| Physician Supervision of Patient Home Health Agency Services Per Month, 30 Mi... | other | $80 | $80 | $80 | 1 |
| Injection, Olanzapine, 0.5 Mg | other | $80 | $80 | $80 | 1 |
| Cables Ensite X Inquiry Quad #d-ens-inq-q-cbl | other | $80 | $80 | $80 | 1 |
| Cables Ensite X Supreme Quad #d-ens-sup-q-cbl | other | $80 | $80 | $80 | 1 |
| Ocular Implant | surgery | $80 | $80 | $80 | 1 |
| Work-related OR Medical Disability Examination By the Treating Physician | other | $80 | $80 | $80 | 1 |
| Removal of Polyp OR Growth of Rectum and Large Bowel Using an Endoscope with ... | surgery | $80 | $80 | $80 | 1 |
| Nim Trivantage Emg Endotracheal Tube 5.0 #8229705 | other | $80 | $80 | $80 | 1 |
| Tube Emg Trivantage 6mm #8229706 | other | $80 | $80 | $80 | 1 |
| Tube Emg Trivantage 7mm #8229707 | other | $80 | $80 | $80 | 1 |
| Tube Emg Trivantage 8mm #8229708 | other | $80 | $80 | $80 | 1 |
| Removal of Bone, Each Additional 20.0 SQ Cm OR Less | surgery | $80 | $80 | $80 | 1 |
| Balloon Seeker 6x17mm Em Sphn #1830617sph | other | $80 | $80 | $80 | 1 |
| Destination Slender Seath Guide 6fr 85cm Gs-r6st1c85w | other | $80 | $80 | $80 | 1 |
| Pedvaxhib Vaccine Vial | preventive | $80 | $80 | $80 | 1 |
| Assay of Digoxin | other | $80 | $80 | $80 | 1 |
| Electrode Hf Roller Lg 24-28fr 12/30deg | other | $81 | $81 | $81 | 1 |
| Rod Attacment for Lrg Multi-pin Clamp Externa | other | $81 | $81 | $81 | 1 |
| Reflex Ultra 45 Coblator Ii #eica4845 | other | $81 | $81 | $81 | 1 |
| Extended Physician Standby Service, Each 30 Minutes | other | $81 | $81 | $81 | 1 |
| Meningococcal Recombinant Protein and Outer Membrane Vesicle Vaccine, Serogro... | preventive | $81 | $81 | $81 | 1 |
| Microscopic Genetic Analysis of Tissue, Manual, Each Additional Multiplex Sta... | other | $81 | $81 | $81 | 1 |
| Fusion of Finger Joint, Each Additional Joint | surgery | $81 | $81 | $81 | 1 |
| Placement of External Device to Assist Circulation | other | $81 | $81 | $81 | 1 |
| Therapy Procedure Using a Positive Pressure Ventilator | other | $81 | $81 | $81 | 1 |
| Assay of Vancomycin | other | $81 | $81 | $81 | 1 |
| Review By Radiologist of Urinary Bladder and Urethra Images with Contrast | other | $82 | $15 | $149 | 2 |
| Injection, Cosyntropin, 0.25 Mg | other | $82 | $57 | $106 | 2 |
| X-ray of Thigh Bone, 1 View | imaging | $82 | $82 | $82 | 1 |
| Mtp Cup Reamer 22mm Gen #58890122 | other | $82 | $82 | $82 | 1 |
| Vital-vue/ob Gyn #8281-06 Slender Tip | other | $82 | $82 | $82 | 1 |
| Forceps Biopsy Piranha #m0065051600 | lab | $82 | $82 | $82 | 1 |
| Injection, Isatuximab-irfc, 10 Mg | other | $82 | $82 | $82 | 1 |
| Pneumococcal Vaccine, 13-valent | preventive | $82 | $82 | $82 | 1 |
| Wrist Hand Finger Orthosis, without Joint(s), Prefabricated, Off-the-shelf, A... | other | $82 | $82 | $82 | 1 |
| Evaluation of Brain Response to Sound for Determination of Hearing Threshold ... | other | $82 | $82 | $82 | 1 |
| Temno Biopsy Needle 20x20 Ctt2020 | lab | $82 | $82 | $82 | 1 |
| Imaging of Gallbladder with Contrast | other | $82 | $82 | $82 | 1 |
| Test to Measure Oxygen Level in Blood Using Ear OR Finger Device Continuously... | other | $82 | $82 | $82 | 1 |
| Lyme Disease Antibody | other | $82 | $82 | $82 | 1 |
| Shoulder X-Ray | imaging | $83 | $26 | $288 | 14 |
| Removal of Foreign Body in Ear Canal Under Anesthesia | surgery | $83 | $83 | $83 | 1 |
| Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 Mg | other | $83 | $83 | $83 | 1 |
| Breast Prosthesis, Mastectomy Form | other | $83 | $83 | $83 | 1 |
| Exam of Head, Neck, Including Ears, Nose and Throat Under General Anesthesia | other | $83 | $83 | $83 | 1 |
| Methohexital 10 Mg/ml Injection - Compounded | other | $83 | $83 | $83 | 1 |
| Photon Guide #104015 | other | $83 | $83 | $83 | 1 |
| Other MRI Scan | imaging | $83 | $83 | $83 | 2 |
| X-ray of Entire Middle and Lower Spine, 1 View | imaging | $83 | $83 | $83 | 1 |
| X-ray of Foot, Minimum of 3 Views | imaging | $83 | $83 | $83 | 2 |
| X-ray of Lower Jaws, Upper Jaws and Teeth | imaging | $83 | $83 | $83 | 1 |
| Low Osmolar Contrast Material, 200-299 Mg/ml Iodine Concentration, Per Ml | other | $83 | $66 | $99 | 2 |
| CT Scan for Measuring Calcium and Other Minerals in Bone | imaging | $83 | $83 | $83 | 1 |
| X-ray of Ribs On Side of Body, 2 Views | imaging | $83 | $83 | $83 | 1 |
| Assay of Folic Acid Serum | other | $83 | $83 | $83 | 1 |
| Foot X-Ray | imaging | $84 | $23 | $325 | 19 |
| Ankle X-Ray | imaging | $84 | $27 | $370 | 19 |
| Diabetes Management | other | $84 | $6 | $535 | 25 |
| Firstpass Mini Suture Passer - Left Curved 72290129 | other | $84 | $84 | $84 | 1 |
| Firstpass Mini Suture Passer - Right Curved 72290130 | other | $84 | $84 | $84 | 1 |
| Firstpass Mini Suture Passer - Straight 72290128 | other | $84 | $84 | $84 | 1 |
| C-reamer 11mm Linvatec #8774a 4/bx | other | $84 | $84 | $84 | 1 |
| Injection of Chemical for Paralysis of Nerve Muscles On Side of Face | other | $84 | $84 | $84 | 1 |
| Repositioning of Oral OR Nasal Feeding Tube in Small Bowel | other | $84 | $84 | $84 | 1 |
| Prismaflex St150 Set Us #107640us | other | $84 | $84 | $84 | 1 |
| Wand Turbinator Arthrocare #eica6895 | other | $84 | $84 | $84 | 1 |
| Ultrasound Scan of Pregnant Uterus (14 Weeks OR More), Each Additional Fetus | imaging | $84 | $84 | $84 | 1 |
| Flu Vaccine Administration | preventive | $84 | $84 | $84 | 1 |
| Nuclear Medicine Study of Thyroid Function | imaging | $85 | $8 | $161 | 2 |
| Imaging of Urinary Tract Following Injection of a Contrast Agent | other | $85 | $24 | $146 | 2 |
| Gene Analysis (calreticulin), Common Variants | other | $85 | $85 | $85 | 1 |
| Estradiol 0.01% Cream | other | $85 | $85 | $85 | 1 |
| Photonblade Rf Cautery #pb1 | other | $85 | $85 | $85 | 1 |
| Coblator Probe ENT Reflex #eica4835 | other | $85 | $85 | $85 | 1 |
| Drug Infusion OR Exercise for Heart Stimulation During Diagnostic Study | surgery | $85 | $85 | $85 | 1 |
| Brav0 Cf Capsule Delivery Dev 5-pk #fgs | obstetric | $85 | $85 | $85 | 1 |
| Initial Inpatient Hospital OR Birthing Center Same Date Care and Discharge of... | other | $85 | $85 | $85 | 1 |
| Injection, Durvalumab, 10 Mg | other | $85 | $85 | $85 | 1 |
| Interpretation and Report of Ultrasound of Heart | imaging | $85 | $85 | $85 | 1 |
| Measurement of Brain Wave Activity (eeg), 61-119 Minutes | other | $85 | $85 | $85 | 1 |
| Simple Drainage of Abscess of Finger | other | $85 | $85 | $85 | 1 |
| Complete Ultrasound Scan of 1 Breast | imaging | $85 | $69 | $100 | 2 |
| Vitamin B | other | $85 | $85 | $85 | 1 |
| COVID-19 Vaccination | preventive | $86 | $29 | $163 | 4 |
| Vitamin D Level | lab | $86 | $13 | $178 | 6 |
| Injection, Rho(d) Immune Globulin (human), (rhophylac), Intramuscular OR Intr... | other | $86 | $6 | $166 | 2 |
| Drill Staple Comp Charlotte #43112032 | other | $86 | $86 | $86 | 1 |
| Bflex 2 Ultraslim 2.8 Single-use Bronchoscope 0570-0447 Bx=pk/5ea | other | $86 | $86 | $86 | 1 |
| Foot, Insert, Removable, Molded to Patient Model, Longitudinal/ Metatarsal Su... | other | $86 | $86 | $86 | 1 |
| Needle Biopsy of Liver | lab | $86 | $86 | $86 | 1 |
| Application of Long Leg Cast From Thigh to Toe | other | $86 | $86 | $86 | 1 |
| Review By Radiologist of Both Arms OR Legs Arteries Image | other | $86 | $86 | $86 | 1 |
| 10.5mm Short Flipcutter #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Ii Short 8.5mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Ii Short 8mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Ii Short 9.5mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Ii Short 9mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Short 10mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Short 7.5mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flipcutter Short 7mm #ar-1204as | other | $86 | $86 | $86 | 1 |
| Flat Markers #pfsdv0016 18ea/bx | other | $86 | $86 | $86 | 1 |
| Injection, Linezolid, 200 Mg | other | $86 | $80 | $91 | 2 |
| Screening Evaluation of Brain Response to Sound with Automated Analysis | preventive | $86 | $78 | $94 | 2 |
| Contrast Injection for X-ray Imaging Through Existing Tube in Stomach, Small ... | imaging | $86 | $77 | $95 | 2 |
| 6 Hour Gtt | other | $86 | $86 | $86 | 1 |
| Hepatitis C Ab Test | other | $86 | $86 | $86 | 1 |
| Prevena Plus Dressing #pre4055us 5/cs | other | $87 | $87 | $87 | 1 |
| Caffeine-sod Benzoat 250 Mg/ml | other | $87 | $87 | $87 | 1 |
| Flow Cytometry Technique for Dna OR Cell Analysis, First Marker | other | $87 | $87 | $87 | 1 |
| Home Sleep Test (hst) with Type Iii Portable Monitor, Unattended; Minimum of ... | other | $87 | $87 | $87 | 1 |
| Aspiration And/or Injection of Fluid Large Joint Using Ultrasound Guidance | imaging | $87 | $87 | $87 | 1 |
| Micro Acutrak 2 Extended Long Drill Acumed #80 | other | $87 | $87 | $87 | 1 |
| Hand Orthosis, without Joints, May Include Soft Interface, Straps, Custom Fab... | other | $87 | $87 | $87 | 1 |
| Evaluation of Heart Function Using Tilt Table | cardiac | $87 | $87 | $87 | 1 |
| Review By Radiologist of Abdominal Aorta and Both Leg Arteries Image | other | $87 | $87 | $87 | 1 |
| Carcinoembryonic Antigen | other | $87 | $87 | $87 | 1 |
| Review By Radiologist of Urinary Bladder and Urethra Images with Contrast and... | other | $88 | $15 | $161 | 2 |
| Gene Analysis (myeloid Differentiation Primary Response 88) for P.leu265pro V... | other | $88 | $88 | $88 | 1 |
| Patch Vascular 1cm X 10cm Xenosure E1p10 | other | $88 | $88 | $88 | 1 |
| Captivator Emr Large Scope Single #m00561610 | other | $88 | $88 | $88 | 1 |
| Captivator Emr Standard Scope Single #m00561600 | other | $88 | $88 | $88 | 1 |
| Review By Radiologist of Abdominal Artery Image | other | $88 | $88 | $88 | 1 |
| Norepinephrine 16 Mg/250ml-d5w | other | $88 | $88 | $88 | 1 |
| Percut Kit 17fr X 18cm Femoral Arterial | other | $88 | $88 | $88 | 1 |
| Extended Patient Service without Direct Patient Contact, First Hour | other | $88 | $88 | $88 | 1 |
| Ensnare 7fr 45mm #en2007045 | other | $88 | $88 | $88 | 1 |
| Acyclovir 200 Mg/5 Ml Susp | other | $88 | $88 | $88 | 1 |
| Dressing Dermabond Prineo (2/bx) #clr222us | other | $88 | $88 | $88 | 1 |
| Shingles Vaccine for Injection Under Skin | preventive | $88 | $88 | $88 | 1 |
| Injection, Mepivacaine Hydrochloride, Per 10 Ml | other | $88 | $88 | $88 | 1 |
| Red Blood Cells, Leukocytes Reduced, Each Unit | other | $88 | $75 | $101 | 2 |
| Port, Indwelling | other | $88 | $70 | $106 | 2 |
| Assay of Prealbumin | other | $88 | $88 | $88 | 1 |
| Microscopic Genetic Analysis of Tissue, Computer-assisted Technology, Initial... | other | $89 | $81 | $97 | 2 |
| Identification of Red Blood Cell Antibodies | other | $89 | $87 | $90 | 2 |
| Review By Radiologist of Image for Replacement of Stomach OR Large Bowel Tube | surgery | $89 | $89 | $89 | 1 |
| Mitomycin 1.5 Ml (0.4 Mg/ Ml) - for Ophthalmic Use Only - Compounded | other | $89 | $89 | $89 | 1 |
| Ultrasound Guided Compression Repair of Blood Vessel | imaging | $89 | $89 | $89 | 1 |
| Mtp Cone Reamer 22mm Gen #58890222 | other | $89 | $89 | $89 | 1 |
| Arthrex Acl Fibertag Tightrope Abs Implant #ar-1588tnt | surgery | $89 | $89 | $89 | 1 |
| Psychiatric Diagnostic Evaluation | therapy | $89 | $89 | $89 | 1 |
| Forcep Biopsy Oval Cup 3.3frx15cm #g15054 | lab | $89 | $89 | $89 | 1 |
| Injection, Pegfilgrastim, Excludes Biosimilar, 0.5 Mg | other | $89 | $89 | $89 | 1 |
| Injection, Vasopressin, 1 Unit | other | $89 | $82 | $96 | 2 |
| Inhalation Treatment for Airway Obstruction OR Sputum Production | other | $89 | $89 | $89 | 1 |
| Insertion of Tube Into Airway for Aspiration of Secretions | other | $89 | $89 | $89 | 1 |
| X-ray of Pelvis, Minimum of 3 Views | imaging | $89 | $89 | $89 | 1 |
| Feces Culture Aerobic Bact | lab | $89 | $89 | $89 | 1 |
| Injection, Chlorothiazide Sodium, Per 500 Mg | other | $90 | $90 | $90 | 1 |
| Initial Hospital Inpatient OR Observation Care with Moderate Level of Medical... | other | $90 | $90 | $90 | 1 |
| Other Procedure On Skin, Mucous Membrane, and Tissue | other | $90 | $90 | $90 | 1 |
| Gene Analysis (v-kit Hardy-zuckerman 4 Feline Sarcoma Viral Oncogene Homolog)... | other | $90 | $90 | $90 | 1 |
| Residence Visit for Established Patient with High Level of Medical Decision M... | other | $90 | $90 | $90 | 1 |
| Injection of Anesthetic Agent, Trigeminal Nerve Bundle | other | $90 | $90 | $90 | 1 |
| Dissector Ultrasonic 13cm #scd13 Sonicision | other | $90 | $90 | $90 | 1 |
| Dissector Ultrasonic 26cm #scd26 Sonicision | other | $90 | $90 | $90 | 1 |
| Ultrasound Scan of Brain | imaging | $90 | $79 | $100 | 2 |
| Wand ENT Procise Max W/cable #eica8898 | other | $91 | $91 | $91 | 1 |
| 2.3mm X 30.0mm Tapered Routerstryker# 5130-071-223s1 | other | $91 | $91 | $91 | 1 |
| Application of Walking Cast Covering Thigh to Toe | other | $91 | $91 | $91 | 1 |
| Injection, Moxifloxacin, 100 Mg | other | $91 | $91 | $91 | 1 |
| Removal of Foreign Bodies in Lower Portion of Large Bowel Using a Flexible En... | surgery | $91 | $91 | $91 | 1 |
| Revision OR Removal of Sacral Integrated Nerve Stimulating System with Electr... | surgery | $91 | $91 | $91 | 1 |
| OB Cath System Bakri Balloon #g24237 | other | $91 | $91 | $91 | 1 |
| Catheter, Intraspinal | cardiac | $91 | $91 | $91 | 1 |
| Gene Analysis (janus Kinase 2) Variant | other | $92 | $92 | $92 | 1 |
| Initial New Patient Preventive Medicine Evaluation | preventive | $92 | $92 | $92 | 1 |
| Cervical, Collar, Semi-rigid, Thermoplastic Foam, Two Piece with Thoracic Ext... | other | $92 | $92 | $92 | 1 |
| Biopsy of Front 2/3 of Tongue | lab | $92 | $92 | $92 | 1 |
| Hemostat Surgicel Snow 4x4 Absrb Ster #2083 | other | $92 | $92 | $92 | 1 |
| Injection, Dobutamine Hydrochloride, Per 250 Mg | other | $92 | $92 | $92 | 1 |
| Injection, Naloxone Hydrochloride, Not Otherwise Specified, 0.01 Mg | other | $92 | $92 | $92 | 1 |
| Cardiac Stress Test | cardiac | $93 | $5 | $741 | 11 |
| Pathology Cytologic Examination of Specimen During Surgery, Initial Site | surgery | $93 | $43 | $143 | 2 |
| Insertion of Needle OR Tube Into Vein | other | $93 | $93 | $93 | 1 |
| Cables Ensite X Livewire Deca #d-ens-l/r-hod-cbl | other | $93 | $93 | $93 | 1 |
| Concave Cone Reamer 21mm P04 N0033 | other | $93 | $93 | $93 | 1 |
| Cone Reamer 23mm Non-sterile P04 N0034 | other | $93 | $93 | $93 | 1 |
| Convex Cup Reamer 21mm P04 N0023 | other | $93 | $93 | $93 | 1 |
| Cup Reamer 23mm Non-sterile P04 N0024 | other | $93 | $93 | $93 | 1 |
| Human Papillomavirus Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58, Nonavalent | preventive | $93 | $93 | $93 | 1 |
| Irrigation of Nasal Sinus | other | $93 | $93 | $93 | 1 |
| Diagnostic Exam of Anus and Rectum Under Anesthesia | other | $93 | $93 | $93 | 1 |
| Mic-key Gastric Jejunal Feeding Tube K 1 Ea/ca 0270-18-2.3 | other | $93 | $93 | $93 | 1 |
| Injection, Methylnaltrexone, 0.1 Mg | other | $94 | $26 | $162 | 2 |
| Ultrasound Scan of Spinal Canal | imaging | $94 | $93 | $95 | 2 |
| Drainage of Abscess of Roof of Mouth | other | $94 | $94 | $94 | 1 |
| Ipol Vial | other | $94 | $94 | $94 | 1 |
| Angiojet Power Pulse Kit #104834 | other | $94 | $94 | $94 | 1 |
| Initial Observation Care, Per Day, for the Evaluation and Management of a Pat... | other | $94 | $94 | $94 | 1 |
| Needle Biopsy Fine Endobronchial Ultrasound Acquire Pulmonary M00552350 | imaging | $94 | $94 | $94 | 1 |
| Forcep Bipolar Non Stick with Stop Insulated 0.5mm Tip 8 1/2in Buzz Hardy #nh05 | other | $94 | $94 | $94 | 1 |
| Incision and Drainage of Abscess of Female Genital Gland | other | $94 | $94 | $94 | 1 |
| Biocomposite Corkscrew Ft Suture Anchor 4.75 Mm X 14 Mm W/two 1.3 Mm Sutureta... | other | $94 | $94 | $94 | 1 |
| Kit-interstim Neurostimulator Extern #353101 | other | $94 | $94 | $94 | 1 |
| Upper Extremity Fracture Orthosis, Humeral, Prefabricated, Includes Fitting a... | other | $94 | $94 | $94 | 1 |
| Injection, Alteplase Recombinant, 1 Mg | other | $94 | $94 | $94 | 1 |
| Asthma Management | other | $95 | $3 | $1,346 | 32 |
| Replacement of Stomach-to-small Bowel Tube Using Fluoroscopic Guidance with C... | surgery | $95 | $95 | $95 | 1 |
| Biopsy of Back 1/3 of Tongue | lab | $95 | $95 | $95 | 1 |
| Endovascular Repair of Iliac Artery Aneurysm, Pseudoaneurysm, Arteriovenous M... | surgery | $95 | $95 | $95 | 1 |
| Brachytherapy Source, Non-stranded, Non-high Dose Rate Iridium-192, Per Source | other | $95 | $95 | $95 | 1 |
| Processing and Storage of Blood Unit OR Component, Predeposited | other | $95 | $95 | $95 | 1 |
| Nuclear Medicine Study of Lung Ventilation | imaging | $96 | $22 | $170 | 2 |
| Injection, Ertapenem Sodium, 500 Mg | other | $96 | $64 | $128 | 2 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 3 Extremities | other | $96 | $96 | $96 | 1 |
| External Counterpulsation, Per Treatment Session | other | $96 | $96 | $96 | 1 |
| Removal of Embedded Foreign Body in Eyelid | surgery | $96 | $96 | $96 | 1 |
| Biopsy of Roof of Mouth | lab | $96 | $96 | $96 | 1 |
| Nitirol Tipped Stone Extractor G36250 | other | $96 | $96 | $96 | 1 |
| Residence Visit for New Patient with Moderate Level of Medical Decision Makin... | other | $96 | $96 | $96 | 1 |
| Supervision of Interfacility Transport Care of Critical Patient, First 30 Min... | other | $96 | $96 | $96 | 1 |
| Injection, Oxaliplatin, 0.5 Mg | other | $96 | $96 | $96 | 1 |
| Alfuria 60 Mcg/0.5 Ml Flu Vacc | other | $96 | $96 | $96 | 1 |
| Chest X-Ray 1 View | imaging | $97 | $22 | $204 | 14 |
| Complete Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $97 | $36 | $157 | 2 |
| Incision of Tissue Connecting Tongue and Floor of Mouth | other | $97 | $97 | $97 | 1 |
| Sodium Floride F 18 Diagnostic 30 Mci | other | $97 | $97 | $97 | 1 |
| Gradient Compression Garment, Arm, Padded, for Nighttime Use, Each | other | $97 | $97 | $97 | 1 |
| Osteocool Bone Access Kit 10g | other | $97 | $97 | $97 | 1 |
| Control of Bleeding of Lower Large Bowel Using an Endoscope | other | $97 | $97 | $97 | 1 |
| Dissector Ultrasonic 39cm #scd396 Sonicision | other | $97 | $97 | $97 | 1 |
| Penumbra Max Canister | other | $97 | $97 | $97 | 1 |
| Drainage of Abscess, Cyst, OR Blood Accumulation of Side of Tongue From Insid... | other | $97 | $97 | $97 | 1 |
| Laser Fiber 150 Micron Tfl Single Use Tfl-fbx150s 5/box | other | $97 | $97 | $97 | 1 |
| Laser Fiber 200 Micron Tfl Single Use Tfl-fbx200s 5/box | other | $97 | $97 | $97 | 1 |
| Established Patient Synchronous Audio-only Visit with High Medical Decision M... | other | $97 | $97 | $97 | 1 |
| Laser Fiber 365 Micron Tfl Single Use Tfl-fbx365s 5/box | other | $97 | $97 | $97 | 1 |
| Arterial Cannula 19fr 96530 | other | $97 | $97 | $97 | 1 |
| Incision of Sperm Duct for X-ray Procedure | imaging | $97 | $97 | $97 | 1 |
| Injection of Blood OR Blood Clot Into Spinal Canal | other | $98 | $98 | $98 | 1 |
| Staple Boyd Fixation Medium Short #128724 | other | $98 | $98 | $98 | 1 |
| Clinimix 8%-10% Solution | other | $98 | $98 | $98 | 1 |
| Follow-up Intensive Care of Recovering Medium Birth Weight Infant Per Day | other | $98 | $98 | $98 | 1 |
| Fluoroscopic Guidance for Spine OR Back Muscle Injection | other | $98 | $98 | $98 | 2 |
| Ultrasound of Heart with Probe in Esophagus to Assess Heart Pump Function | imaging | $98 | $98 | $98 | 1 |
| Biopsy of Voice Box Using a Flexible Endoscope | lab | $98 | $98 | $98 | 1 |
| Regional Block | other | $98 | $98 | $98 | 1 |
| Hc 2019 Novel Coronavirus Naa | other | $98 | $41 | $154 | 2 |
| Exam to Assess Movement of Vocal Cord Flaps Using an Endoscope | other | $99 | $99 | $99 | 1 |
| Continuous Monitoring of Blood Sugar Level in Tissue Fluid Using Sensor Under... | other | $99 | $99 | $99 | 1 |
| Hc Monitored Anesthesia Care Anesthesia Time - Initial Base Charge | other | $99 | $99 | $99 | 1 |
| Insertion of Tube Into External Neck Artery for Diagnosis OR Treatment with R... | other | $99 | $99 | $99 | 1 |
| Ligasure 5mm #ls1500 | other | $99 | $99 | $99 | 1 |
| Injection of Chemical for Paralysis of Salivary Glands On Both Sides of Mouth | other | $99 | $99 | $99 | 1 |
| Basket Memory 2x4cm Eight Wire ERCP G21538 | other | $99 | $99 | $99 | 1 |
| X-ray of Knee, 4 OR More Views | imaging | $99 | $97 | $100 | 2 |
| Hand/Wrist X-Ray | imaging | $100 | $24 | $284 | 19 |
| Established Patient Office OR Other Outpatient Visit with High Level of Medic... | other | $100 | $100 | $100 | 1 |
| Release of Large Bowel From Spleen and Abdominal Wall with Partial Removal of... | surgery | $100 | $100 | $100 | 1 |
| Injection of Chemical for Paralysis of Facial and Neck Nerve Muscles On Both ... | other | $100 | $100 | $100 | 1 |
| Complex Measurement of Pressure of Urine Flow in Bladder with Voiding Pressur... | other | $100 | $100 | $100 | 1 |
| Injection of Radioactive Contrast Into a Vein for Non-imaging Gamma Probe | other | $100 | $100 | $100 | 1 |
| Injection, Avelumab, 10 Mg | other | $100 | $100 | $100 | 1 |
| Knife Bayonet Disc Non Pt Charge | other | $100 | $100 | $100 | 1 |
| Biopsy of Back of Throat | lab | $100 | $100 | $100 | 1 |
| Follow-up Ultrasound Scan of Pregnant Uterus | imaging | $100 | $100 | $100 | 2 |
| Ultrasound and Monitoring of Heart of Fetus | imaging | $100 | $100 | $100 | 2 |
| X-ray of Both Hips, 2 Views | imaging | $100 | $100 | $100 | 1 |
| X-ray of Both Hips, 3-4 Views | imaging | $100 | $100 | $100 | 1 |
| X-ray of Entire Middle and Lower Spine, 2-3 Views | imaging | $100 | $100 | $100 | 1 |
| X-ray of Eye Socket, Minimum of 4 Views | imaging | $100 | $100 | $100 | 2 |
| X-ray of Lower and Sacral Spine, Minimum of 4 Views | imaging | $100 | $100 | $100 | 2 |
| 3d Breast Mammography of Both Breasts | imaging | $100 | $100 | $100 | 1 |
| 2d Ultrasound Scan of Eye Tissue and Structures | imaging | $100 | $100 | $100 | 1 |
| CT Scan of Arm without Contrast | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound of Pregnant Uterus | imaging | $100 | $100 | $100 | 1 |
| Limited Ultrasound Scan Behind Abdominal Cavity | imaging | $100 | $100 | $100 | 1 |
| Ultrasound of One Leg Arteries OR Artery Grafts | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Scan of Head and Neck Soft Tissue | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Scan of Pregnant Uterus (14 Weeks OR More), Single OR First Fetus | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Scan of Pregnant Uterus (less Than 14 Weeks), Single OR First Fetus | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Scan of Scrotum | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Scan of Uterus, Ovaries, Tubes, Cervix and Pelvic Area Through Vagina | imaging | $100 | $100 | $100 | 1 |
| Ultrasound Study of One Arm OR Leg Veins with Compression and Maneuvers | imaging | $100 | $100 | $100 | 1 |
| Vaginal Ultrasound of Pregnant Uterus | imaging | $100 | $100 | $100 | 1 |
| X-ray of Body Plane | imaging | $100 | $100 | $100 | 1 |
| X-ray of Ribs On Both Sides of Body, 3 Views | imaging | $100 | $100 | $100 | 1 |
| Balloon Seeker 6x7mm Em Maxl #1830607max | other | $101 | $101 | $101 | 1 |
| Injection, Dihydroergotamine Mesylate, Per 1 Mg | other | $101 | $101 | $101 | 1 |
| 6' Dx Cable 10 Pin #c6tmrmst10sa | other | $101 | $101 | $101 | 1 |
| Administration of Prolonged Chemotherapy Into Vein | other | $101 | $101 | $101 | 1 |
| Removal of Tube Into Artery OR Vein with Review By Radiologist | surgery | $101 | $101 | $101 | 1 |
| Control of Bleeding of Lower Large Bowel Using a Flexible Endoscope | other | $101 | $101 | $101 | 1 |
| Other Procedure On Tongue OR Floor of Mouth | other | $101 | $101 | $101 | 1 |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 4 Extremities | other | $101 | $101 | $101 | 1 |
| Ligasure Small Jaw Open #lf1212a | other | $101 | $101 | $101 | 1 |
| Shoulder X-Ray | imaging | $102 | $83 | $200 | 6 |
| Blind Obt 22.5fr for A20914a #a20906a | other | $102 | $102 | $102 | 1 |
| Blind Obturator for A20931a 17fr #a20909a | other | $102 | $102 | $102 | 1 |
| Methohexital 100 Mg/10ml-water | other | $102 | $102 | $102 | 1 |
| Potassium Phosp 45 Mmol/15 Ml | other | $102 | $102 | $102 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material, Prefabricated, Includes Fitti... | other | $102 | $102 | $102 | 1 |
| Tisseel Vhsd Frozen Prima 10ml #1506080 | other | $102 | $102 | $102 | 1 |
| Radiation Treatment Management, 1-2 Treatment Sessions | other | $102 | $102 | $102 | 1 |
| Combivent Respimat 20-100 Mcg | other | $102 | $102 | $102 | 1 |
| Shingrix Vial Kit | other | $102 | $102 | $102 | 1 |
| Catheter, Electrophysiology, Diagnostic, Other Than 3d Mapping | cardiac | $102 | $102 | $102 | 1 |
| Immediate Post Surgical OR Early Fitting, Application of Non-weight Bearing R... | surgery | $102 | $102 | $102 | 1 |
| Aztreonam 1 G/3ml Ij | other | $102 | $102 | $102 | 1 |
| Aztreonam 1 Gm Vial | other | $102 | $102 | $102 | 1 |
| Follow-up Intensive Care of Recovering Low Birth Weight Infant Per Day | other | $102 | $102 | $102 | 1 |
| Alexis Extraction System #gtk17 | other | $102 | $102 | $102 | 1 |
| Bacillus Calmette-guerin Vaccine for Bladder Cancer | preventive | $102 | $102 | $102 | 1 |
| Exposure of Groin Artery for Delivery of Graft | obstetric | $102 | $102 | $102 | 1 |
| Ultrasound of Heart with Probe in Esophagus, with Report | imaging | $102 | $102 | $102 | 1 |
| Stress Test | cardiac | $103 | $5 | $3,839 | 36 |
| Nuclear Medicine Study of Bone And/or Joint Limited Area | imaging | $103 | $27 | $179 | 2 |
| Simple Drainage of Abscess OR Blood Accumulation of External Ear | other | $103 | $103 | $103 | 1 |
| Therapeutic Fracture of Nasal Passages | other | $103 | $103 | $103 | 1 |
| Fiber Laser 365um 6j 80hz 120w D/f/l for Lithotripsy Moses Ac | other | $103 | $103 | $103 | 1 |
| Special Radiation Treatment | other | $103 | $103 | $103 | 1 |
| Nerve Conduction, 7-8 Studies | other | $103 | $103 | $103 | 1 |
| Pneumococcal Conjugate Vaccine, 15 Valent (pcv15), for Intramuscular Use | preventive | $103 | $103 | $103 | 1 |
| Topaz Ifs Microdebrider Wand Ez #ach4041 | other | $103 | $103 | $103 | 1 |
| Forcep Bipolar Non Stick Insulated 1.2mm Tip 7 1/2in Buzz Cushing #n19c12 | other | $103 | $103 | $103 | 1 |
| Tumor Markers 1 Inteliq 6x2ml #12008289 | other | $103 | $103 | $103 | 1 |
| Tumor Markers 2 Inteliq 6x2ml #12008290 | other | $103 | $103 | $103 | 1 |
| Drainage of Deep Abscess OR Blood Accumulation of Leg OR Ankle | other | $103 | $103 | $103 | 1 |
| Injection, Aztreonam, 100 Mg | other | $103 | $36 | $169 | 2 |
| Removal of Polyps OR Growths of Lower Large Bowel Using a Flexible Endoscope ... | surgery | $104 | $104 | $104 | 1 |
| Loop Cysview Bipolar 24/26fr Longitudinal | other | $104 | $104 | $104 | 1 |
| Insertion of Drain (seton) Into Anus | other | $104 | $104 | $104 | 1 |
| Ambulatory Infusion Pump, Single OR Multiple Channels, Electric OR Battery Op... | surgery | $104 | $104 | $104 | 1 |
| Transitional Care Management Services for Problem of At Least Moderate Comple... | other | $104 | $104 | $104 | 1 |
| Laser Fiber 1000mic #dfs-1000sb | other | $104 | $104 | $104 | 1 |
| Incision, Aspiration, And/or Inflation of Eardrum | other | $104 | $104 | $104 | 1 |
| Management of Oxygen Chamber Therapy | other | $104 | $104 | $104 | 1 |
| Drainage of Abscess OR Blood Accumulation of Nose | other | $104 | $104 | $104 | 1 |
| Electrode Hf Band 30deg #wa22623s | other | $104 | $104 | $104 | 1 |
| Electrode Hf Loop Med 30deg #wa22606s | other | $104 | $104 | $104 | 1 |
| Emergency Surgery Fee | surgery | $104 | $104 | $104 | 1 |
| Lumbar Drainage Kit #10 | other | $105 | $105 | $105 | 1 |
| Clamp Lrg Open Adjustable External Mr Safe | other | $105 | $105 | $105 | 1 |
| Injection, Ceftazidime and Avibactam, 0.5 G/0.125 G | other | $105 | $105 | $105 | 1 |
| Removal of Dental Bone Growth | surgery | $105 | $105 | $105 | 1 |
| Needle Acquire Fnb 22 Ga #m00555540 1ea/1bx | other | $105 | $105 | $105 | 1 |
| Recording of Upper Heart Chamber Rhythm | cardiac | $105 | $105 | $105 | 1 |
| Drainage of Abscess OR Blood Accumulation of Nasal Cartilage | other | $105 | $105 | $105 | 1 |
| Abdominal Ultrasound | imaging | $106 | $20 | $2,131 | 36 |
| CT Scan of the Head | imaging | $106 | $22 | $3,570 | 15 |
| Injection, Glucagon Hydrochloride (fresenius Kabi), Not Therapeutically Equiv... | other | $106 | $106 | $106 | 1 |
| Graft Hemashield 15cm 18mm #m00202175118p0 | other | $106 | $106 | $106 | 1 |
| Graft Oh Hemashield 15cm 24mm #175124p | other | $106 | $106 | $106 | 1 |
| Norepinephrine 16 Mg / 250 Ml Ns Bag (quad Concentrate) - Compounded | other | $106 | $106 | $106 | 1 |
| Drainage of Fluid From Chest Cavity with Insertion of Indwelling Tube | other | $106 | $106 | $106 | 1 |
| Destruction of Peripheral Nerve OR Branch | other | $106 | $106 | $106 | 1 |
| Recording of Upper Heart Rhythm | cardiac | $106 | $106 | $106 | 1 |
| Insertion of Tube Into Right Heart OR Main Pulmonary Artery | cardiac | $106 | $106 | $106 | 1 |
| Simple Biopsy of Growth of Throat Behind Nose | lab | $106 | $106 | $106 | 1 |
| 3d Breast Mammography of 1 Breast | imaging | $106 | $106 | $106 | 1 |
| Cables Ensite X Inquiry Deca #d-ens-inq-od-cbl | other | $106 | $106 | $106 | 1 |
| Ensite X Duo Deca X Cable #d-ens-l/r-ddy-cbl | other | $106 | $106 | $106 | 1 |
| Psychotherapy with Evaluation and Management Visit, 1 Hour | therapy | $106 | $106 | $106 | 1 |
| Vitality Polyaxial 7.0x55mm #701m7055 | other | $106 | $106 | $106 | 1 |
| Review By Radiologist of Image for Drainage of Fluid | other | $107 | $107 | $107 | 1 |
| All Lower Extremity Prostheses, Foot, Single Axis Ankle/foot | other | $107 | $107 | $107 | 1 |
| CT Scan of Blood Vessels and Grafts of Heart with Contrast | imaging | $107 | $107 | $107 | 1 |
| Needle Del Sys 360 Curved 72202468 | other | $107 | $107 | $107 | 1 |
| Needle Del Sys 360 Reverse Curved #72202469 | other | $107 | $107 | $107 | 1 |
| Injection, Epinephrine (adrenalin), Not Therapeutically Equivalent to J0165, ... | other | $107 | $107 | $107 | 1 |
| IV Infusion, Ea Add Hr | surgery | $107 | $107 | $107 | 1 |
| Placement and Subsequent Removal of Device to Protect Brain From Embolism Thr... | surgery | $108 | $108 | $108 | 1 |
| Exposure of Arm Artery for Insertion of Prosthesis | other | $108 | $108 | $108 | 1 |
| Removal of Growth of Tissue of Mouth | surgery | $108 | $108 | $108 | 1 |
| Therapy Procedure Using a Special Bandage and Vacuum Pump, Surface Area 50.0 ... | other | $108 | $80 | $135 | 2 |
| Injection, Methylprednisolone Sodium Succinate, 5 Mg | other | $108 | $108 | $108 | 1 |
| IV Drug Infusion | therapy | $109 | $30 | $661 | 14 |
| CT Scan Head OR Brain with Contrast | imaging | $109 | $50 | $168 | 2 |
| CT Scan of Cranial Cavity with Contrast | imaging | $109 | $50 | $168 | 2 |
| CT Scan of Face with Contrast | imaging | $109 | $50 | $168 | 2 |
| New Patient Office OR Other Outpatient Visit with Moderate Level of Medical D... | other | $109 | $106 | $111 | 2 |
| Hydratome Rx44 450cm X .035" 20mm Cut Wire | other | $109 | $109 | $109 | 1 |
| Electrode Plasmabutton 12/30deg #wa22657s | other | $109 | $109 | $109 | 1 |
| Simple Removal of Embedded Foreign Body in Mouth | surgery | $109 | $109 | $109 | 1 |
| Exclusion of Appendage of Left Upper Chamber of Heart Performed During Other ... | cardiac | $109 | $109 | $109 | 1 |
| Cellutome Harvester 5cm X 5cm #ct-h50 | other | $109 | $109 | $109 | 1 |
| Closed Treatment of Broken Great Toe | other | $109 | $109 | $109 | 1 |
| Graft Oh Hemashield 15cm 22mm #m00202175122p0 | other | $109 | $109 | $109 | 1 |
| Foot, Insert, Removable, Molded to Patient Model, 'ucb' Type, Berkeley Shell,... | other | $109 | $109 | $109 | 1 |
| Adult Venous Cannula 25fr 96600 | other | $109 | $109 | $109 | 1 |
| Adult Venous Cannula 96600 | other | $109 | $109 | $109 | 1 |
| Percut Kit 21fr X 60cm Femoral Venous | other | $109 | $109 | $109 | 1 |
| Percut Kit 25fr X 60cm Femoral Venous | other | $109 | $109 | $109 | 1 |
| Insertion of Implant to Close Nasal Passage | surgery | $109 | $109 | $109 | 1 |
| X-Ray of the Knee | imaging | $110 | $26 | $365 | 15 |
| CT Scan of Pelvis with Contrast | imaging | $110 | $52 | $168 | 2 |
| CT Scan of Chest with Contrast | imaging | $110 | $52 | $168 | 2 |
| Office OR Other Outpatient Consultation with Moderate Level of Medical Decisi... | other | $110 | $110 | $110 | 1 |
| Destruction of Subsequent Incompetent Veins of Arm OR Leg Using Radiofrequenc... | other | $110 | $110 | $110 | 1 |
| Loop Cysview 24/26 Fr Bipolar Std27040gp130-s | other | $110 | $110 | $110 | 1 |
| Walking Boot, Pneumatic And/or Vacuum, with OR without Joints, with OR withou... | other | $110 | $110 | $110 | 1 |
| CT Scan of Middle Spine with Contrast | imaging | $111 | $54 | $168 | 2 |
| CT Scan of Pelvis Before and After Contrast | imaging | $111 | $54 | $168 | 2 |
| Adapalene 0.1 % Ex Gel | other | $111 | $111 | $111 | 1 |
| Single Contrast X-ray of Large Intestine | imaging | $111 | $53 | $168 | 2 |
| CT Scan of Chest Before and After Contrast | imaging | $112 | $56 | $168 | 2 |
| CT Scan of Cranial Cavity Before and After Contrast | imaging | $112 | $56 | $168 | 2 |
| Guide Precision Bipolar Clear 6ea/bx | other | $112 | $112 | $112 | 1 |
| Addition to Lower Extremity Fracture Orthosis, Hip Joint, Pelvic Band, Thigh ... | other | $112 | $112 | $112 | 1 |
| Removal of Single External Noncancer Growth of Anus | surgery | $112 | $112 | $112 | 1 |
| Removal of Growth of Tongue without Closure | surgery | $112 | $112 | $112 | 1 |
| Assistant W/stable Soft 3l #401-209s | other | $112 | $112 | $112 | 1 |
| Removal of Foreign Body in Voice Box Using a Flexible Endoscope | surgery | $112 | $112 | $112 | 1 |
| Surgical Pathology | lab | $112 | $48 | $116 | 3 |
| CT Scan of Abdomen with Contrast | imaging | $113 | $57 | $168 | 2 |
| CT Scan of Face Before and After Contrast | imaging | $113 | $57 | $168 | 2 |
| CT Scan of Head OR Brain Before and After Contrast | imaging | $113 | $57 | $168 | 2 |
| Closed Treatment of Broken Forearm (radius) Bone At the Wrist Area On the Thu... | other | $113 | $113 | $113 | 1 |
| Closed Treatment of Broken Midpart of Forearm Bone On Small Finger Side | other | $113 | $113 | $113 | 1 |
| Closed Treatment of Broken Midpart of Forearm Bone On Thumb Side | other | $113 | $113 | $113 | 1 |
| Closed Treatment of Broken OR Growth Plate Separate of Forearm Bone At Wrist ... | other | $113 | $113 | $113 | 1 |
| Intermediate Repair of Wound of Face, Ears, Eyelids, Nose, Lips, OR Mouth, 20... | surgery | $113 | $113 | $113 | 1 |
| Intermediate Repair of Wound of Face, Ears, Eyelids, Nose, Lips, OR Mouth, Mo... | surgery | $113 | $113 | $113 | 1 |
| Follow-up Intensive Care of Recovering Very Low Birth Weight Infant Per Day | other | $113 | $113 | $113 | 1 |
| Incision of Eardrum with Insertion of Eardrum Tube Under Local OR Topical Ane... | other | $113 | $113 | $113 | 1 |
| Graft Hemashield 15cm 28mm #175128p | other | $113 | $113 | $113 | 1 |
| Graft Hemashield 15cm 30mm #175130p | other | $113 | $113 | $113 | 1 |
| Graft Hemashield 15cm 32mm #175132p | other | $113 | $113 | $113 | 1 |
| Graft Hemashield 15cmx38mm #175138p | other | $113 | $113 | $113 | 1 |
| Removal of Polyp of Outer Ear | surgery | $113 | $113 | $113 | 1 |
| Simple Removal of Nasal Polyp | surgery | $113 | $113 | $113 | 1 |
| Pad Temp Arctic Sun Universal #317-00 | other | $113 | $113 | $113 | 1 |
| Tetracaine 1% (20 Mg/2 Ml) Vl | other | $113 | $113 | $113 | 1 |
| Cortisone Shot (Joint Injection) | surgery | $114 | $7 | $4,007 | 29 |
| Inpatient OR Observation Consultation with Moderate Level of Medical Decision... | other | $114 | $114 | $114 | 1 |
| Electrode Electrosurgical 24fr Angled Needle 12-30deg Hf Resection Plasma Nee... | surgery | $114 | $114 | $114 | 1 |
| Electrode Electrosurgical 24fr Standard Band 12-30deg Hf Resection Plasma Ban... | surgery | $114 | $114 | $114 | 1 |
| Esg Plasmaloop - Long Medium Wa22737s Bx/5ea | other | $114 | $114 | $114 | 1 |
| Generator Electrosurgical M Plasmaloop #wa22706s | surgery | $114 | $114 | $114 | 1 |
| Imaging of Digestive Tract Done From the Inside of the Digestive Tract | other | $114 | $114 | $114 | 1 |
| Loop TURP Plasmakinetic Superpuls #784415 | other | $114 | $114 | $114 | 1 |
| Imaging of Lymph Nodes During Surgery | surgery | $114 | $114 | $114 | 1 |
| X-ray of Surgical Specimen | imaging | $115 | $14 | $215 | 2 |
| CT Scan of Soft Tissue of Neck with Contrast | imaging | $115 | $62 | $168 | 2 |
| CT Scan of Abdomen Before and After Contrast | imaging | $115 | $62 | $168 | 2 |
| Hyaluronan OR Derivative, Orthovisc, for Intra-articular Injection, Per Dose | other | $115 | $115 | $115 | 1 |
| Proximal Reamer Headless 2.0mm Non-sterile #cd-fx | other | $115 | $115 | $115 | 1 |
| Proximal Reamer Headless 2.0mm Sterile #cd-fx-2520-s | other | $115 | $115 | $115 | 1 |
| Proximal Reamer Headless 3.0mm #cd-fx | other | $115 | $115 | $115 | 1 |
| Imaging for Evaluation of Swallowing Function | other | $115 | $65 | $165 | 2 |
| Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose | other | $115 | $115 | $115 | 1 |
| Ligasure Maryland Short Jaw #lf1923 | other | $116 | $116 | $116 | 1 |
| Upper Extremity Fracture Orthosis, Radius/ulnar, Prefabricated, Includes Fitt... | other | $116 | $116 | $116 | 1 |
| Atrovent 17 Mcg Hfa Inhaler | other | $116 | $116 | $116 | 1 |
| Removal of Growth of Roof of Mouth | surgery | $116 | $116 | $116 | 1 |
| Computer-assisted, Fluoroscopic Image-guided Musculoskeletal Surgical Navigat... | surgery | $116 | $116 | $116 | 1 |
| Computer-assisted Surgery for Muscle and Bone Procedure | surgery | $116 | $116 | $116 | 1 |
| **discontinued**laser Fiber 200 Ball Tip #m0068403961 | other | $116 | $116 | $116 | 1 |
| Test to Measure Expiratory Airflow and Volume Changes Before and After Medica... | other | $116 | $116 | $116 | 1 |
| Pneumococcal Vaccine, 23-valent | preventive | $116 | $116 | $116 | 1 |
| Tissue Culture to Identify White Blood Cell Disorders | lab | $116 | $116 | $116 | 1 |
| Blood Gases Any Combination | other | $116 | $116 | $116 | 1 |
| Review By Radiologist of Ultrasound of Digestive Tract Using an Endoscope | imaging | $117 | $38 | $195 | 2 |
| Review By Radiologist of Placement of Long Small Bowel Tube | other | $117 | $117 | $117 | 1 |
| Residence Visit for New Patient with High Level of Medical Decision Making, P... | other | $117 | $117 | $117 | 1 |
| Closed Treatment of Dislocated Joint Between Toe and Foot Under Anesthesia | other | $117 | $117 | $117 | 1 |
| Review By Radiologist of CT Guidance for Needle Placement | other | $117 | $117 | $117 | 2 |
| Dilation of Sphenoid Nasal Sinus Using an Endoscope | other | $117 | $117 | $117 | 1 |
| Refilling and Maintenance of Portable Pump | other | $117 | $117 | $117 | 1 |
| Pre Sympt Study<30 Days Hookup | other | $117 | $117 | $117 | 1 |
| Nuclear Medicine Study of Stomach to Assess Emptying | imaging | $118 | $35 | $201 | 2 |
| Pronto Lp #5010 | other | $118 | $118 | $118 | 1 |
| Insertion of Feeding Tube OR Tube Into Upper Small Bowel | other | $118 | $118 | $118 | 1 |
| Centered Nano Alto Partial #651 1/bx | other | $118 | $118 | $118 | 1 |
| Centered Nano Alton Total #611 1/bx | other | $118 | $118 | $118 | 1 |
| Bss Plus Eye Irrig Solution | other | $118 | $118 | $118 | 1 |
| Shockwave Destruction of Calcified Plaque in Coronary Artery Accessed Through... | cardiac | $118 | $118 | $118 | 1 |
| Apligraf | other | $118 | $118 | $118 | 1 |
| Tx/pro/dx Inj Same Drug Add On | other | $118 | $118 | $118 | 1 |
| Complex Removal of Skin Debris and Drainage of Mastoid Cavity | surgery | $119 | $119 | $119 | 1 |
| Snare Kit 18-30mm #382007030 | other | $119 | $119 | $119 | 1 |
| Arthroflex, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Dermacell, Dermacell Awm OR Dermacell Awm Porous, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Epifix, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Grafix Core and Grafixpl Core, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Grafix Prime, Grafixpl Prime, Stravix and Stravixpl, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Integra Bilayer Matrix Wound Dressing (bmwd), Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Primatrix, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Strattice Tm, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Theraskin, Per Square Centimeter | other | $119 | $119 | $119 | 1 |
| Flexiva Pulse Id Tractip M006l8406960 | other | $119 | $119 | $119 | 1 |
| Enema Using Air OR Contrast | other | $119 | $119 | $119 | 1 |
| Electrode Plasma Button Front Loading | other | $119 | $119 | $119 | 1 |
| Single Contrast X-ray of Small Intestine | imaging | $119 | $69 | $168 | 2 |
| Injection, Esmolol Hydrochloride (wg Critical Care), Not Therapeutically Equi... | other | $119 | $119 | $119 | 1 |
| CT Scan of Soft Tissue of Neck Before and After Contrast | imaging | $120 | $72 | $168 | 2 |
| Allograft Mis Dispenser Bl-1900-gun | other | $120 | $120 | $120 | 1 |
| Cables Ensite X Advisor/grid #d-ens-avse-6-cbl | other | $120 | $120 | $120 | 1 |
| Ligasure Maryland Jaw #lf1937 6/cs | other | $120 | $120 | $120 | 1 |
| Metatarsal Reamer 16 Mm #ar-8944mr | other | $120 | $120 | $120 | 1 |
| Metatarsal Reamer 18 Mm #ar-8944mr | other | $120 | $120 | $120 | 1 |
| Metatarsal Reamer 20 Mm #ar-8944mr | other | $120 | $120 | $120 | 1 |
| Metatarsal Reamer 22 Mm #ar-8944mr | other | $120 | $120 | $120 | 1 |
| Phalangeal Reamer 14 Mm #ar-8944pr | other | $120 | $120 | $120 | 1 |
| Phalangeal Reamer 16 Mm #ar-8944pr | other | $120 | $120 | $120 | 1 |
| Phalangeal Reamer 18 Mm #ar-8944pr | other | $120 | $120 | $120 | 1 |
| Phalangeal Reamer 20 Mm #ar-8944pr | other | $120 | $120 | $120 | 1 |
| Phalangeal Reamer 22 Mm #ar-8944pr | other | $120 | $120 | $120 | 1 |
| Breast Prosthesis, Silicone OR Equal, with Integral Adhesive | other | $120 | $120 | $120 | 1 |
| Breast Prosthesis, Silicone OR Equal, without Integral Adhesive | other | $120 | $120 | $120 | 1 |
| Aspiration of Bladder with Insertion of Bladder Tube to Skin | other | $120 | $120 | $120 | 1 |
| Complex Measurement of Pressure of Urine Flow in Bladder with Urethra Pressur... | other | $120 | $120 | $120 | 1 |
| Ultrasonic Guidance for Pericardiocentesis, Imaging Supervision and Interpret... | other | $120 | $120 | $120 | 1 |
| Cold Agglutinin Screen | other | $120 | $120 | $120 | 1 |
| IV Infusion, 1st Hr | surgery | $121 | $44 | $568 | 6 |
| Nuclear Medicine Study of Thyroid | imaging | $121 | $16 | $225 | 2 |
| Children's Tylenol 160 Mg/5 Ml | other | $121 | $121 | $121 | 1 |
| Balloon Dilation of Vein with Review By Radiologist, Each Additional Vein | other | $121 | $121 | $121 | 1 |
| Graft Hemashield 15cm 34mm #175134p M00202175134po | other | $121 | $121 | $121 | 1 |
| Complex Biopsy of Growth of Throat Behind Nose | lab | $121 | $121 | $121 | 1 |
| Review By Radiologist of Male Internal Genitals Image | other | $121 | $121 | $121 | 1 |
| Chemotherapy Administration | other | $122 | $2 | $888 | 28 |
| Tlso Flexible, Provides Trunk Support, Extends From Sacrococcygeal Junction t... | other | $122 | $122 | $122 | 1 |
| Destruction of Growth OR Soft Tissue of Roof of Mouth | other | $122 | $122 | $122 | 1 |
| Retinal Tamponade Device, Silicone Oil | other | $122 | $122 | $122 | 1 |
| Wrist Hand Finger Orthosis, Rigid without Joints, May Include Soft Interface ... | other | $122 | $122 | $122 | 1 |
| Removal of Growth of Voice Box Using an Endoscope | surgery | $122 | $122 | $122 | 1 |
| Simple Destruction of Growth of Anus | other | $122 | $122 | $122 | 1 |
| CT Scan of Blood Vessels of Head with Contrast | imaging | $123 | $78 | $168 | 2 |
| CT Scan of Blood Vessels of Neck with Contrast | imaging | $123 | $78 | $168 | 2 |
| Wilson Retractor System Tlc-5042-m | other | $123 | $123 | $123 | 1 |
| CT Scan of Blood Vessels of Pelvis with Contrast | imaging | $124 | $80 | $168 | 2 |
| CT Scan of Blood Vessels of Abdomen with Contrast | imaging | $124 | $80 | $168 | 2 |
| Aspiration of Subsequent Secretions of Lung Airway Using an Endoscope During ... | other | $124 | $124 | $124 | 1 |
| Liver Access/ Biopsy Needle Set | lab | $124 | $124 | $124 | 1 |
| Porous Purified Collagen Matrix Bone Void Filler (integra Mozaik Osteoconduct... | other | $124 | $124 | $124 | 1 |
| Drainage of Fluid From Chest Cavity with Insertion of Indwelling Tube Using I... | other | $124 | $124 | $124 | 1 |
| Tunneler #402 Vns Cyberonics | other | $124 | $124 | $124 | 1 |
| CT Scan of Blood Vessels of Chest with Contrast | imaging | $125 | $81 | $168 | 2 |
| All Lower Extremity Prostheses, Foot, Flexible Keel | other | $125 | $125 | $125 | 1 |
| Dressing Ab Thera Sensa Trac #m8275026/5 | other | $125 | $125 | $125 | 1 |
| Simple Chemical Destruction of Growth of Anus | other | $125 | $125 | $125 | 1 |
| Chromosome Analysis for Genetic Defects, Count 15-20 Cells | other | $125 | $125 | $125 | 1 |
| Dilation of Stomach And/or Small Bowel Using Long Gastrointestinal Tube | other | $126 | $16 | $236 | 2 |
| CT Scan of Blood Vessels of Lower Leg with Contrast | imaging | $126 | $84 | $168 | 2 |
| Loop TURP Plasmakinetic Supersect #784515 | other | $126 | $126 | $126 | 1 |
| Removal of Tissue Connecting Tongue and Floor of Mouth | surgery | $126 | $126 | $126 | 1 |
| Simple Removal of Growth of Anus | surgery | $126 | $126 | $126 | 1 |
| Dental Cleaning | other | $127 | $22 | $129 | 3 |
| Bypass of Upper OR Lower Leg Artery Reoperation More Than 1 Month After Origi... | other | $127 | $127 | $127 | 1 |
| Clamp Lrg Combination #390.005 External | other | $127 | $127 | $127 | 1 |
| Addition to Lower Extremity, Test Socket, Below Knee | other | $127 | $127 | $127 | 1 |
| Chest X-Ray | imaging | $128 | $10 | $26,107 | 27 |
| Nipride Rtu 50 Mg/100 Ml Vial | other | $128 | $128 | $128 | 1 |
| Destruction of Nasal Nerve By Heat Using an Endoscope | other | $128 | $128 | $128 | 1 |
| Dilation of Nasal Sinus Using an Endoscope | other | $128 | $128 | $128 | 1 |
| Diagnostic Exam of Voice Box Using an Endoscope with Operating Microscope OR ... | other | $128 | $128 | $128 | 1 |
| Nerve Conduction, 9-10 Studies | other | $128 | $128 | $128 | 1 |
| Knee X-Ray | imaging | $129 | $100 | $200 | 6 |
| X-Ray of the Chest | imaging | $129 | $84 | $204 | 6 |
| Revision of Peripheral Neurostimulator Electrodes | other | $129 | $129 | $129 | 1 |
| Addition to Lower Extremity, Socket Insert, Below Knee | other | $129 | $129 | $129 | 1 |
| Insertion of Tube Into Vein, First Order Branch | other | $129 | $129 | $129 | 1 |
| Lead, Neurostimulator Test Kit | other | $129 | $129 | $129 | 1 |
| Patch Pericardial W/encap 9x14cm #c0914 | other | $129 | $129 | $129 | 1 |
| Snare Kit 27-45mm #382007045 | other | $129 | $129 | $129 | 1 |
| Wrist Hand Finger Orthosis, Includes One OR More Nontorsion Joint(s), Turnbuc... | other | $129 | $129 | $129 | 1 |
| Initial Repair of Anal Tear with Dilation of Anal Muscle | surgery | $129 | $129 | $129 | 1 |
| Evaluation of Speech Sound Production with Evaluation of Language Comprehensi... | other | $129 | $129 | $129 | 1 |
| Cardene-nacl 40 Mg/200 Ml IV | other | $130 | $130 | $130 | 1 |
| Clinimix 4.25%-10% Solution | other | $130 | $130 | $130 | 1 |
| Clinimix 4.25%-5% Solution | other | $130 | $130 | $130 | 1 |
| Fiber Laser 200um 2j 80hz 60w D/f/l for Lithotripsy Moses Ac | other | $130 | $130 | $130 | 1 |
| Measurement of Brain Wave Activity (eeg) to Evaluate Brain Death | other | $130 | $130 | $130 | 1 |
| Transitional Care Management Services for Problem of High Complexity | other | $130 | $130 | $130 | 1 |
| Differin 0.1% Cream | other | $130 | $130 | $130 | 1 |
| Incision, Aspiration, and Inflation of Eardrum Under Anesthesia | other | $130 | $130 | $130 | 1 |
| Bone Dowel Revision Kit 10 Mm #abs-2850 | other | $130 | $130 | $130 | 1 |
| Mantis 235cm Closure Clip #m00521422 Bx/20 | other | $130 | $130 | $130 | 1 |
| Diagnostic Exam of Voice Box Using an Endoscope | other | $130 | $130 | $130 | 1 |
| Insertion of Stent Into Lower Large Bowel Using a Flexible Endoscope | cardiac | $130 | $130 | $130 | 1 |
| New Patient Office OR Other Outpatient Visit with a High Level of Medical Dec... | other | $131 | $126 | $135 | 2 |
| Repair of Lacerated Mouth, 2.5 Cm OR Less | surgery | $131 | $131 | $131 | 1 |
| Injection, Pegfilgrastim-apgf (nyvepria), Biosimilar, 0.5 Mg | other | $131 | $131 | $131 | 1 |
| Release of Nasal Scar Tissue | other | $131 | $131 | $131 | 1 |
| Removal of Lung Tissue Wedge for Diagnosis | surgery | $131 | $131 | $131 | 1 |
| Removal of Lung Tissue Wedge Through Chest, Each Additional Removal | surgery | $131 | $131 | $131 | 1 |
| Forcep Spybite Biopsy #moo546270 | lab | $131 | $131 | $131 | 1 |
| Spybite Max Biopsy Forceps #m00546470 | lab | $131 | $131 | $131 | 1 |
| Simple Drainage of Abscess of Saliva Gland | other | $131 | $131 | $131 | 1 |
| Test to Measure Rate of Airflow | other | $131 | $131 | $131 | 1 |
| Platelets, Pheresis, Leukocytes Reduced, Each Unit | other | $131 | $9 | $253 | 2 |
| Nuclear Medicine Study of Lymphatic System | imaging | $132 | $52 | $212 | 2 |
| Removal of Wedge of Tissue of Lung Using an Endoscope, Each Additional Removal | surgery | $132 | $132 | $132 | 1 |
| Addition to Lower Extremity, Lacer Molded to Patient Model, for Custom Fabric... | other | $132 | $132 | $132 | 1 |
| Blade Kahook Dual#kdb Glide | other | $132 | $132 | $132 | 1 |
| Lengthening of Esophagus Using an Endoscope | other | $132 | $132 | $132 | 1 |
| Destruction of Soft Tissue of Nasal Passages | other | $132 | $132 | $132 | 1 |
| Biopsy of Wedge of Lung Tissue Followed By Partial Removal of Lung | surgery | $132 | $132 | $132 | 1 |
| Ligasure Exact Dissector Lf2019 6ea/1cs | other | $132 | $132 | $132 | 1 |
| Hyperbaric Oxygen Under Pressure, Full Body Chamber, Per 30 Minute Interval | other | $132 | $132 | $132 | 1 |
| Ultrasound Exam of Esophagus Using a Flexible Endoscope | imaging | $132 | $132 | $132 | 1 |
| Addition to Lower Extremity, Below Knee, Total Contact | other | $132 | $132 | $132 | 1 |
| Double Contrast X-ray of Small Intestine | imaging | $132 | $95 | $168 | 2 |
| Emergent Insertion of Breathing Tube Into Windpipe Using an Endoscope | other | $132 | $132 | $132 | 1 |
| Initial Hospital Inpatient OR Observation Care with High Level of Medical Dec... | other | $133 | $133 | $133 | 1 |
| Removal of Blood Clot and Portion of Neck Artery Following Previous Surgery | surgery | $133 | $133 | $133 | 1 |
| 12x11x14mm 7 Degree Vista-s Dev #06-401 | other | $133 | $133 | $133 | 1 |
| 5x11x14mm Vista-s Dev #06-401 | other | $133 | $133 | $133 | 1 |
| Administration of Chemotherapy Into Vein Using Push Technique | other | $133 | $133 | $133 | 1 |
| Harvest and Injections of Platelet Rich Plasma Using Imaging Guidance | other | $133 | $133 | $133 | 1 |
| Lead, Pacemaker, Other Than Transvenous Vdd Single Pass | cardiac | $133 | $133 | $133 | 1 |
| Primary Removal and Dissolving of Blood Clot From Artery OR Artery Graft Usin... | surgery | $133 | $133 | $133 | 1 |
| Hith Kit #inshith | other | $133 | $133 | $133 | 1 |
| Fetal Test | other | $133 | $119 | $146 | 2 |
| X-ray of Inside of Ear Canal | imaging | $134 | $134 | $134 | 1 |
| Repositioning of Blood Flow Assist Device in Lower Heart Chamber Using Imagin... | cardiac | $134 | $134 | $134 | 1 |
| Lumbar Spine X-Ray | imaging | $135 | $46 | $700 | 15 |
| Exam of Bile Duct During Surgery Using an Endoscope | surgery | $135 | $135 | $135 | 1 |
| Delivery of Complex Radiation Treatment | obstetric | $135 | $135 | $135 | 1 |
| Detection Test By Nucleic Acid for Digestive Tract Pathogen, Multiple Types O... | other | $135 | $135 | $135 | 1 |
| Bear Claw Otsc Sys Set 11/6t 165cm #100.10 | other | $135 | $135 | $135 | 1 |
| Bear Claw Otsc Sys Set 12/6t 220cm #100.31 | other | $135 | $135 | $135 | 1 |
| Otsc 11/6a Bear Claw System Set #100.09 | other | $135 | $135 | $135 | 1 |
| Dissector Spacemaker Pro 10mm-12mm #smsbtovlx | cardiac | $136 | $136 | $136 | 1 |
| Insertion of Temporary Pacemaker Lead in Upper and Lower Heart Chambers | cardiac | $136 | $136 | $136 | 1 |
| Office OR Other Outpatient Consultation with High Level of Medical Decision M... | other | $136 | $136 | $136 | 1 |
| Prog Eval Inper Leadls Pm | other | $136 | $136 | $136 | 1 |
| Destruction of Polyp OR Growth of Lower Large Bowel Using a Flexible Endoscope | other | $136 | $136 | $136 | 1 |
| Bone Marrow, Smear Interpretation | other | $137 | $38 | $236 | 2 |
| CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast | imaging | $137 | $106 | $168 | 2 |
| Incision of Eardrum with Placement of Eardrum Tube Under General Anesthesia | other | $137 | $137 | $137 | 1 |
| Spy Bite Basket Retrieval Working L286cm Channel 1.2mm Cable Dia 1mm for Dire... | other | $137 | $137 | $137 | 1 |
| Computer-assisted Procedure Outside Membrane Covering Brain | other | $137 | $137 | $137 | 1 |
| Sonicone OR Sharpvac Mxc-c2-vac 5ea/1bx | other | $137 | $137 | $137 | 1 |
| Sonicvac Kit Mxc-x2-vac 5ea/bx | other | $137 | $137 | $137 | 1 |
| Simple Control of Bleeding of Throat | other | $137 | $137 | $137 | 1 |
| Microsatellite Instability Analysis | other | $138 | $138 | $138 | 1 |
| Graft Hemashield 30cm X 6mm #175206p | other | $138 | $138 | $138 | 1 |
| Graft Hemashield 30cm X 8mm #175208p | other | $138 | $138 | $138 | 1 |
| Complicated Drainage of External Ear Abscess OR Blood Accumulation | other | $138 | $138 | $138 | 1 |
| Repair of Collapsed Nostril Using Implant in Side of Nose | surgery | $138 | $138 | $138 | 1 |
| Repair of Nerve Using Nerve Graft, Each Additional Strand | surgery | $138 | $138 | $138 | 1 |
| Stapler Hemorrhoid Ph #ppho3 3/bx | other | $138 | $138 | $138 | 1 |
| Diagnostic Exam of Voice Box Using a Flexible Endoscope | other | $138 | $138 | $138 | 1 |
| Inpatient OR Observation Consultation with High Level of Medical Decision Mak... | other | $138 | $138 | $138 | 1 |
| Hernia Tacker #abstack30 | other | $138 | $138 | $138 | 1 |
| Strapping, Unna Boot | other | $139 | $123 | $155 | 2 |
| Nerve Conduction, 11-12 Studies | other | $139 | $139 | $139 | 1 |
| Shaving of Part of Shoulder Bone and Repair of Ligament Using an Endoscope | surgery | $139 | $139 | $139 | 1 |
| Electrode Electrosurgical Resection with Hf Cable Plasma Oval Button | surgery | $139 | $139 | $139 | 1 |
| Tlso, Triplanar Control, Hyperextension, Rigid Anterior and Lateral Frame Ext... | other | $139 | $139 | $139 | 1 |
| Drug Delivery Using a Drug-coated Balloon for Male Treatment of Urethral Stri... | obstetric | $139 | $139 | $139 | 1 |
| Review By Radiologist of Ankle Joint Image | other | $139 | $139 | $139 | 1 |
| Review By Radiologist of Hinged Joint of Upper and Lower Jaw Bones Image | other | $139 | $139 | $139 | 1 |
| Arexvy Vial Kit | other | $139 | $139 | $139 | 1 |
| Nuclear Medicine Study of Kidney, Blood, Flow, and Function with Drug Adminis... | imaging | $140 | $53 | $226 | 2 |
| Fiber Laser 550um 6j 80hz 120w D/f/l for Lithotripsy Moses Ac | other | $140 | $140 | $140 | 1 |
| 3.0 Knotless Suture Tak Anchor #ar-8934bck | other | $140 | $140 | $140 | 1 |
| Arthrex Acl Fibertag Tightrope Implant #ar-1588rtt | surgery | $140 | $140 | $140 | 1 |
| Nano Swivelock Suture Anchor #ar-8998t | other | $140 | $140 | $140 | 1 |
| Nanoneedle Scope 125 Mm #ar-3210 | other | $140 | $140 | $140 | 1 |
| Removal of Indwelling Tube in Lining of Lung | surgery | $140 | $140 | $140 | 1 |
| Control of Bleeding in Esophagus Using a Flexible Endoscope | other | $140 | $140 | $140 | 1 |
| Removal OR Destruction of Growth of Throat | surgery | $140 | $140 | $140 | 1 |
| Manipulation of Knee Joint Under Anesthesia | other | $140 | $140 | $140 | 1 |
| Clamp Large Multi-pin 4position External | other | $140 | $140 | $140 | 1 |
| Mantis Closure Clip Box 10 #m00521421 | other | $140 | $140 | $140 | 1 |
| Injection, Micafungin Sodium, 1 Mg | other | $141 | $96 | $186 | 2 |
| Incision of Sphincter of Anus | other | $141 | $141 | $141 | 1 |
| Dilation of Canal Between Middle Ear and Throat (eustachian Tube) On One Side... | other | $141 | $141 | $141 | 1 |
| Versajet Ii Plus Handset 45deg/14mm #66800044 | other | $141 | $141 | $141 | 1 |
| Versajet Ii Plus Handset 45deg/8mm #66800045 | other | $141 | $141 | $141 | 1 |
| Autoinjector Endologix #tv-a101-n | other | $141 | $141 | $141 | 1 |
| Radioactive Drug Therapy of Radiolabeled Monoclonal Antibody Through a Vein | other | $141 | $141 | $141 | 1 |
| Hip/Pelvis X-Ray | imaging | $142 | $78 | $621 | 15 |
| Nuclear Medicine Study of Thyroid and Thyroid Function | imaging | $142 | $22 | $262 | 2 |
| Exam with Injections of Chemical for Destruction of Bladder Using an Endoscope | other | $142 | $142 | $142 | 1 |
| Removal of Growth of Roof of Mouth with Simple Closure | surgery | $142 | $142 | $142 | 1 |
| Ventriculostomy Kit - Ghajar Guide | other | $143 | $143 | $143 | 1 |
| Removal of Soft Tissue of Roof of Mouth | surgery | $143 | $143 | $143 | 1 |
| Balloon Dilation of Artery with Review By Radiologist, Each Additional Artery | other | $143 | $143 | $143 | 1 |
| Pathology Examination of Tissue Using a Microscope, High Complexity | lab | $143 | $143 | $143 | 1 |
| Clamp Large Multi-pin External Fix 6 Position | other | $144 | $144 | $144 | 1 |
| Evaluation for Work Hardening OR Conditioning, Initial 2 Hours | other | $144 | $144 | $144 | 1 |
| Lumbar Spine X-Ray | imaging | $145 | $81 | $376 | 6 |
| Destruction of Growth OR Scar of Mouth | other | $145 | $145 | $145 | 1 |
| Dilation of Frontal Nasal Sinus Using an Endoscope | other | $145 | $145 | $145 | 1 |
| Biopsy of Prostate Gland | lab | $145 | $145 | $145 | 1 |
| Insertion of Tube Into Vein, Second Order Branch | other | $145 | $145 | $145 | 1 |
| Epifix OR Epicord | other | $145 | $145 | $145 | 1 |
| Mesh Fixation Device 5mm W/25 Absorb Straps | other | $145 | $145 | $145 | 1 |
| Laser Fiber 150 Micron Tfl Ball Tip Single Use Tfl-fbx150bs 5/box | other | $145 | $145 | $145 | 1 |
| Laser Fiber 200 Micron Tfl Ball Tip Single Use Tfl-fbx200bs 5/box | other | $145 | $145 | $145 | 1 |
| Removal of Nasal Air Passage Under Lining Tissue | surgery | $145 | $145 | $145 | 1 |
| Fetal Congenital Abnormalities, Biochemical Assays of Four Analytes (afp, Ue3... | other | $145 | $145 | $145 | 1 |
| Removal of Tissue From Wound, 20.0 SQ Cm OR Less | surgery | $145 | $145 | $145 | 1 |
| Addition to Lower Extremity, Below Knee, Acrylic Socket | other | $146 | $146 | $146 | 1 |
| Needle Acquire Fnb 19 Ga #m00555580 1ea/1bx | other | $146 | $146 | $146 | 1 |
| Endoclip Cartridge M/l-#1112 Microline Clip Titanium K2 Single Use 19/clip 10/bx | other | $146 | $146 | $146 | 1 |
| Injection, Icatibant, 1 Mg | other | $146 | $146 | $146 | 1 |
| Obturator 24 Fr #a22081a | other | $146 | $146 | $146 | 1 |
| Drg Tunneling Tool #mn15000 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Ag 61cm # 900300 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Ag 71cm# 900301 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Fc 65cm# 900304 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Sl 63cm# 900302 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Sl 81cm# 900309 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Vz 71cm# 900303 | other | $146 | $146 | $146 | 1 |
| Flexcath Cross Wt 75cm# 900308 | other | $146 | $146 | $146 | 1 |
| Jeti Non-sterile Cannister Set Wv1500a | other | $146 | $146 | $146 | 1 |
| Reference Patch Carto 3 (6pack) #crefp6 | other | $146 | $146 | $146 | 1 |
| Cisatracurium 200 Mg/20 Ml Vl | other | $146 | $146 | $146 | 1 |
| Blood Pressure Monitoring | other | $147 | $18 | $214 | 23 |
| Review By Radiologist of Salivary Structure Image | other | $147 | $147 | $147 | 1 |
| Repair of Prosthetic Device, Repair OR Replace Minor Parts | surgery | $147 | $147 | $147 | 1 |
| Harvest of Artery From Arm for Heart Bypass Graft Using an Endoscope | cardiac | $147 | $147 | $147 | 1 |
| Insertion of Temporary Pacemaker Electrode for Diagnostic Upper Heart Pacing | cardiac | $147 | $147 | $147 | 1 |
| Nuclear Medicine Study of Limited Area for Thyroid Cancer | imaging | $148 | $148 | $148 | 1 |
| Insertion of Temporary Pacemaker Electrode for Diagnostic Lower Heart Pacing | cardiac | $148 | $148 | $148 | 1 |
| Atrial Depressor W/quick Connect Clearview Mv | other | $148 | $148 | $148 | 1 |
| Hip Knee Ankle Foot Orthosis, Torsion Control, Bilateral Torsion Cables, Hip ... | other | $148 | $148 | $148 | 1 |
| Acutrak 2 Drill Acumed #at2-m1813 | other | $148 | $148 | $148 | 1 |
| Destruction of Internal Hemorrhoids Using Heat | other | $148 | $148 | $148 | 1 |
| Prevena Plus System Kit #pre4001us | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Cd39-l Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Cd39-r Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Ef311l Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Ef311r Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Gh712l Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Sensor Persona Cr Zimmer Bio Gh712r Zbh-psncr | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 1-2 Lt #snn-jrnybcs12-l | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 1-2 Rt #snn-jrnybcs12-r | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 3-4 Lt #snn-jrnybcs34-l | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 3-4 Rt #snn-jrnybcs34-r | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 5-6 Lt #snn-jrnybcs56-l | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 5-6 Rt #snn-jrnybcs56-r | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 7-8 Lt #snn-jrnybcs78-l | other | $149 | $149 | $149 | 1 |
| Verasense Journey Bcs 7-8 Rt #snn-jrnybcs78-r | other | $149 | $149 | $149 | 1 |
| Verasense Legion Ps 1-2 #snn-lgnps12 | other | $149 | $149 | $149 | 1 |
| Verasense Legion Ps 3-4 #snn-lgnps34 | other | $149 | $149 | $149 | 1 |
| Verasense Legion Ps 5-6 #snn-lgnps56 | other | $149 | $149 | $149 | 1 |
| Verasense Legion Ps 7-8 #snn-lgnps78 | other | $149 | $149 | $149 | 1 |
| Graft Accessory Component Kit #hero 1003 | other | $149 | $149 | $149 | 1 |
| Progreat 2.8fr Microcatheter Mc*pe28151yv 1ea/1box | cardiac | $149 | $149 | $149 | 1 |
| Scrotal Retraction System Skw Deep #72403867 | other | $149 | $149 | $149 | 1 |
| Balloon Dilation Treatment of Stricture of Ureter Using Imaging Guidance with... | other | $149 | $149 | $149 | 1 |
| Amputation of Toe At Toe Joint | other | $149 | $149 | $149 | 1 |
| Technetium Tc-99m Mertiatide, Diagnostic, Per Study Dose, Up to 15 Millicuries | other | $149 | $149 | $149 | 1 |
| Laser Fiber 550 Micron Tfl Single Use Tfl-fbx550s 5/box | other | $150 | $150 | $150 | 1 |
| Bipolar Sealer 2.3 Neuro Aquamantys | other | $150 | $150 | $150 | 1 |
| Surgical Supply; Miscellaneous | surgery | $150 | $150 | $150 | 1 |
| Retractor-reddick Saye Screw #e2504 | other | $150 | $150 | $150 | 1 |
| Phytonadione Inj 1 Mg/0.5 Ml C | other | $150 | $150 | $150 | 1 |
| Emergency Room Visit (Level 3) | emergency | $151 | $1 | $495 | 5 |
| Radioactive Drug Therapy By Mouth | other | $151 | $79 | $223 | 2 |
| Chord-x Pre-measured Loops for Mitral Chordal Replacement 2-0 U.s.p 16mm Cxl-... | surgery | $151 | $151 | $151 | 1 |
| Mantis Clip L235cm 2.8mm Minimum Working Channel #m00521420 | other | $151 | $151 | $151 | 1 |
| Therapy Procedure Using a Special Bandage and Vacuum Pump, Surface Area More ... | other | $151 | $140 | $162 | 2 |
| Elbow Orthosis (eo), with Adjustable Position Locking Joint(s), Prefabricated... | other | $152 | $152 | $152 | 1 |
| Dispensing Fee, Monaural Hearing Aid, Any Type | other | $152 | $152 | $152 | 1 |
| Laser Fiber Sidefire 600 #ftir600 | other | $152 | $152 | $152 | 1 |
| Harmonic Ace Curved Shears Xi #480275 6ea/1bx | other | $152 | $152 | $152 | 1 |
| Contrast Injection for Imaging to Evaluate Central Venous Access Device | other | $152 | $100 | $204 | 2 |
| Mental Health Evaluation | therapy | $153 | $29 | $367 | 18 |
| CT Scan of Abdomen and Pelvis without Contrast | imaging | $153 | $77 | $228 | 2 |
| Clamp 4.0 Adj for Distal Radius Fixatr Extern | other | $153 | $153 | $153 | 1 |
| Gps User Kit for Gps Station V2 Ref# A10012 | other | $153 | $153 | $153 | 1 |
| Biopsy of Voice Box Using an Endoscope | lab | $154 | $154 | $154 | 1 |
| Intraocular Vancomycin 10 Mg/ Ml- **10ml** (for Dr. Ouano) - Compounded | other | $154 | $154 | $154 | 1 |
| Removal of Blood Flow Assist Device in Left Lower Heart Chamber Through the Skin | surgery | $154 | $154 | $154 | 1 |
| 8mm Blunt Xi #470008 | other | $154 | $154 | $154 | 1 |
| Injection, Panitumumab, 10 Mg | other | $154 | $154 | $154 | 1 |
| Closed Treatment of Broken Finger OR Thumb At Midportion OR Part Near Hand | other | $154 | $154 | $154 | 1 |
| Amputation of Toe At Joint Between Forefoot and Toes | other | $154 | $154 | $154 | 1 |
| X-ray of Lower Leg, 2 Views | imaging | $154 | $77 | $230 | 2 |
| Magnetic Resonance Angiography without Contrast, Chest | imaging | $154 | $154 | $154 | 1 |
| 2019-ncovid Any Technq-non-cdc | other | $154 | $154 | $154 | 1 |
| Partial Release of Large Bowel and Partial Removal of Large Bowel Using an En... | surgery | $155 | $155 | $155 | 1 |
| Single Contrast X-ray of Upper Digestive Tract | imaging | $155 | $141 | $168 | 2 |
| Addition to Lower Extremity, Suction Suspension, Above Knee OR Knee Disarticu... | other | $156 | $156 | $156 | 1 |
| Ligasure Impact #lf4418 | other | $156 | $156 | $156 | 1 |
| Removal of Multiple External Noncancer Growths of Anus | surgery | $156 | $156 | $156 | 1 |
| Cannula 8mm #420002 | other | $156 | $156 | $156 | 1 |
| Clinimix 5%-15% Solution | other | $156 | $156 | $156 | 1 |
| Diagnostic Exam of Large Bowel Using a Flexible Endoscope | other | $157 | $157 | $157 | 1 |
| Fluzone High-dose Triv 2024 | other | $157 | $157 | $157 | 1 |
| Suture of Internal Abdominal Lining Using an Endoscope | other | $157 | $157 | $157 | 1 |
| Harvest of Arm Artery Segment for Heart Byplass Procedure | cardiac | $157 | $157 | $157 | 1 |
| Gradient Compression Garment, Glove, Padded, for Nighttime Use, Custom, Each | other | $158 | $158 | $158 | 1 |
| Dilation of Sphincter of Anus Under Anesthesia | other | $158 | $158 | $158 | 1 |
| Astigmatism Correcting Function of Intraocular Lens | other | $158 | $158 | $158 | 1 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 1 Graft | cardiac | $158 | $158 | $158 | 1 |
| Vessel Sealer (6/bx) #410322 | other | $158 | $158 | $158 | 1 |
| Vessel Sealer # 480322 Intuitive Surgical | surgery | $158 | $158 | $158 | 1 |
| Obturator Deflecting Tip 24 Fr #a22085 | other | $159 | $159 | $159 | 1 |
| Proximal Reamer Cannulated 3.0mm #cd-fx | other | $159 | $159 | $159 | 1 |
| Removal of Growth of Mouth with Simple Repair | surgery | $159 | $159 | $159 | 1 |
| Repair of Lacerated Roof of Mouth, 2.0 Cm OR Less | surgery | $159 | $159 | $159 | 1 |
| Hydrate IV Infusion Add-on | surgery | $160 | $58 | $201 | 6 |
| Aveta Smol Disposable Resecting Device 2.9mm #210-100 3/ctn | other | $160 | $160 | $160 | 1 |
| Dispensing Fee, Binaural | other | $160 | $160 | $160 | 1 |
| Laser Fiber Sidefire 550 | other | $160 | $160 | $160 | 1 |
| Auto-id Quad Cable; Vizigo Cable #cy1212ct | other | $161 | $161 | $161 | 1 |
| Carto 3 Ablation Cable Irrigated #cr3434ct | other | $161 | $161 | $161 | 1 |
| Carto 3 Dx Cable Vizigo #cb3412ct | other | $161 | $161 | $161 | 1 |
| Decanav Cable #cb3434ct | other | $161 | $161 | $161 | 1 |
| Nerve Conduction, 13 OR More Studies | other | $161 | $161 | $161 | 1 |
| Pentaray and Lasso Cable #d134401 | other | $161 | $161 | $161 | 1 |
| Ligasure Retractable L-hook 37cm Lf5637 6/cs | other | $161 | $161 | $161 | 1 |
| Nuclear Medicine Study of Non-cardiac Blood Flow | imaging | $161 | $161 | $161 | 1 |
| Evaluation of Single OR Dual Chamber Pacing Cardioverter-defibrillator At Tim... | other | $162 | $162 | $162 | 1 |
| Dressing Kit Open Abdomen Abthera Advance | other | $162 | $162 | $162 | 1 |
| Removal of Foreign Bodies From Small Bowel Using an Endoscope | surgery | $162 | $162 | $162 | 1 |
| Conversion of Stomach Tube to Tube in Middle Small Bowel Using an Endoscope | other | $162 | $162 | $162 | 1 |
| Viscoat Syringe | other | $162 | $162 | $162 | 1 |
| Extensive Destruction of Growth of Anus | other | $162 | $162 | $162 | 1 |
| Fdp,fibrinogen Degradation Pro | other | $162 | $162 | $162 | 1 |
| Irrig Drug Delivery Device | obstetric | $162 | $162 | $162 | 1 |
| Meas Post-voiding Residl Urine | other | $162 | $162 | $162 | 1 |
| Injection, Siltuximab, 10 Mg | other | $163 | $163 | $163 | 1 |
| Removal of Foreign Body in Voice Box Using an Endoscope | surgery | $164 | $164 | $164 | 1 |
| Obturator Optical 24 Fr #a22071a | other | $164 | $164 | $164 | 1 |
| Anchor/screw for Opposing Bone-to-bone OR Soft Tissue-to-bone | other | $164 | $90 | $238 | 2 |
| Injection, Benralizumab, 1 Mg | other | $165 | $165 | $165 | 1 |
| Insertion of Tube in Left Heart Chamber Through Heart Septum | cardiac | $165 | $165 | $165 | 1 |
| Repair Device, Urinary, Incontinence, without Sling Graft | surgery | $165 | $165 | $165 | 1 |
| Incision of Achilles Tendon Using Local Anesthetic | other | $165 | $165 | $165 | 1 |
| Insertion of Vein Patch At Lowest Portion of Bypass Graft | other | $166 | $166 | $166 | 1 |
| Insertion of Tube Into Chest Aorta for Diagnosis OR Treatment with Review By ... | other | $166 | $166 | $166 | 1 |
| Addition, Endoskeletal System, Below Knee, Alignable System | other | $166 | $166 | $166 | 1 |
| Double Contrast X-ray of Upper Digestive Tract | imaging | $166 | $164 | $168 | 2 |
| Radiation Treatment Management, 5 Treatment Sessions | other | $167 | $167 | $167 | 1 |
| Addition to Lower Extremity, Test Socket, Above Knee | other | $167 | $167 | $167 | 1 |
| Cervical, Multiple Post Collar, Occipital/mandibular Supports, Adjustable Cer... | other | $167 | $167 | $167 | 1 |
| Injection of Implant Material Beneath Lining of Bladder And/or Urethra Using ... | surgery | $167 | $167 | $167 | 1 |
| CT Head | imaging | $168 | $50 | $17,398 | 36 |
| Cannula 8 Mm Size Reusable for Da Vinci X/xi Endoscopic System #470002 | other | $168 | $168 | $168 | 1 |
| Review By Radiologist of Image for Repair of Descending Aorta with Insertion ... | surgery | $168 | $168 | $168 | 1 |
| CT Scan of Arm Before and After Contrast | imaging | $168 | $168 | $168 | 2 |
| CT Scan of Leg Before and After Contrast | imaging | $168 | $168 | $168 | 2 |
| CT Scan of Leg with Contrast Material | imaging | $168 | $168 | $168 | 2 |
| CT Scan of Lower Spine Before and After Contrast | imaging | $168 | $168 | $168 | 2 |
| CT Scan of Middle Spine Before and After Contrast | imaging | $168 | $168 | $168 | 2 |
| CT Scan of Upper Spine Before and After Contrast | imaging | $168 | $168 | $168 | 2 |
| Double Contrast X-ray of Large Intestine | imaging | $168 | $168 | $168 | 2 |
| Imaging of Urinary Tract with Injection of Contrast Into a Vein | other | $168 | $168 | $168 | 2 |
| Insertion of Device to Block Groin Artery | other | $168 | $168 | $168 | 1 |
| CT Scan of Blood Vessels of Arm with Contrast | imaging | $168 | $168 | $168 | 1 |
| Imaging of Urinary Tract Using Infusion Technique | surgery | $168 | $168 | $168 | 1 |
| Imaging of Urinary Tract Using Infusion Technique with Kidney Section Filming | surgery | $168 | $168 | $168 | 1 |
| Tobradex Eye Ointment | other | $169 | $67 | $270 | 2 |
| Azactam 2 Gm Vial | other | $169 | $169 | $169 | 1 |
| Gene Analysis (t Cell Antigen Receptor Beta) Amplification Methodology | other | $169 | $169 | $169 | 1 |
| Biopsy of Large Bowel Using a Flexible Endoscope | lab | $169 | $169 | $169 | 1 |
| Injection Beneath Lining of Large Bowel Using a Flexible Endoscope | other | $169 | $169 | $169 | 1 |
| Removal of Dental Bone Growth with Simple Repair | surgery | $169 | $169 | $169 | 1 |
| Special Stains Group 1 | other | $169 | $169 | $169 | 1 |
| Biopsy of Voice Box Using an Endoscope with Operating Microscope OR Telescope | lab | $170 | $170 | $170 | 1 |
| Cup Removal System 52mm #00705305220 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 48mm #00705304820 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 50mm #00705305020 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 54mm #00705305420 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 56mm #00705305620 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 58mm #00705305820 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Full 60mm #00705306020 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Truncatd 50mm #00705305010 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Truncatd 52mm #00705305210 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Truncatd 54mm #00705305410 | surgery | $170 | $170 | $170 | 1 |
| Cup Removal System Truncatd 58mm #00705305810 | surgery | $170 | $170 | $170 | 1 |
| Exposure of Thigh Artery for Insertion of Prosthesis | other | $171 | $171 | $171 | 1 |
| Implantation of Biologic Implant to Soft Tissue | surgery | $172 | $172 | $172 | 1 |
| Repair of Wound By Transferring Skin, Each Additional 30.0 SQ Cm | surgery | $172 | $172 | $172 | 1 |
| Injection, Tenecteplase, 1 Mg | other | $172 | $172 | $172 | 2 |
| Injection, Ibutilide Fumarate, 1 Mg | other | $172 | $172 | $172 | 1 |
| Removal of Small Bowel Polyps OR Growths Using an Endoscope with Mechanical S... | surgery | $172 | $172 | $172 | 1 |
| Removal of Foreign Body in Voice Box Using an Endoscope with Operating Micros... | surgery | $172 | $172 | $172 | 1 |
| Nicardipin 40mg/200ml-0.9%nacl | other | $173 | $173 | $173 | 1 |
| Destruction of Surface Soft Tissue of Nasal Passages | other | $173 | $173 | $173 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material with Ankle Joint, Prefabricate... | other | $173 | $173 | $173 | 1 |
| Catheter Angiographic Coronary OR Peripheral Delivery 45 Degree Angled Tip 15... | imaging | $173 | $173 | $173 | 1 |
| Respiratory Syncytial Virus Antibody, 0.5 Ml Dosage for Injection Into Muscle | other | $173 | $173 | $173 | 1 |
| Respiratory Syncytial Virus Antibody, 1.0 Ml Dosage for Injection Into Muscle | other | $173 | $173 | $173 | 1 |
| Cyberwand Probe Set #cw-rbpbx | other | $173 | $173 | $173 | 1 |
| Injection, Methylprednisolone Sodium Succinate, Up to 125 Mg | other | $173 | $173 | $173 | 1 |
| Vessel Xi Sealer Extnd #480422 Intuitive Surg | other | $175 | $175 | $175 | 1 |
| Forcep Flexo Grasping #fg53s-x | other | $175 | $175 | $175 | 1 |
| Complicated Removal of Embedded Foreign Body in Mouth | surgery | $175 | $175 | $175 | 1 |
| Unclassified Biologics | other | $175 | $175 | $175 | 1 |
| Nanoscope Handpiece #ar-3210 | other | $175 | $175 | $175 | 1 |
| Psychotherapy Session (45 min) | therapy | $176 | $22 | $367 | 7 |
| Insertion of Implant in Urethra Within Prostate Gland Using an Endoscope, 1 I... | surgery | $176 | $176 | $176 | 1 |
| Electronic Analysis of Pacemaker to Correct Rapid Heart Rate | cardiac | $176 | $176 | $176 | 1 |
| Visual Obturator 22.5 Fr #a20924a | other | $176 | $176 | $176 | 1 |
| Leuprolide Acetate (for Depot Suspension), 7.5 Mg | other | $176 | $176 | $176 | 1 |
| Laser Fiber 940 Micron Tfl Single Use Tfl-fbx940s 5/box | other | $177 | $177 | $177 | 1 |
| Dilation of Narrowing of Rectum Under Anesthesia | other | $177 | $177 | $177 | 1 |
| Incision of Artery for Creation of Channel for Ecmo External Blood Circulatio... | other | $177 | $177 | $177 | 1 |
| Removal of Tissue At Dental Edge and Cheek | surgery | $177 | $177 | $177 | 1 |
| Treatment of Broken Spine Bone with Stabilizing Device, Each Additional Segment | other | $177 | $177 | $177 | 1 |
| Hospital Inpatient OR Observation Care with Admission and Discharge On the Sa... | other | $177 | $177 | $177 | 1 |
| Pt Re-eval Est Plan Care | other | $177 | $177 | $177 | 1 |
| Obstetric Ultrasound | imaging | $178 | $65 | $720 | 21 |
| CT Chest | imaging | $178 | $99 | $3,650 | 31 |
| Wrist Hand Orthosis, without Joints, May Include Soft Interface, Straps, Cust... | other | $178 | $178 | $178 | 1 |
| Tx/proph/dg Addl Seq IV Inf | other | $178 | $178 | $178 | 1 |
| Ultrasound of the Abdomen | imaging | $179 | $22 | $550 | 14 |
| Injection, Ipilimumab, 1 Mg | other | $179 | $179 | $179 | 1 |
| Balloon Dilation of Large Bowel Using a Flexible Endoscope | other | $179 | $179 | $179 | 1 |
| Complicated Drainage of Abscess, Cyst, OR Blood Accumulation of Mouth | other | $179 | $179 | $179 | 1 |
| Removal of Foreign Body in Nose Under Anesthesia | surgery | $179 | $179 | $179 | 1 |
| Analysis Test By Nucleic Acid for Hepatitis C Virus | other | $179 | $179 | $179 | 1 |
| Control of Bleeding of Esophagus | other | $179 | $179 | $179 | 1 |
| Addition to Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, E... | other | $179 | $179 | $179 | 1 |
| 000-030 Min - Anesthesia | other | $179 | $179 | $179 | 1 |
| Add'l 30 Min Anesthesia | other | $179 | $179 | $179 | 1 |
| Injection, Zoledronic Acid, 1 Mg | other | $179 | $179 | $179 | 1 |
| Convalescent Plasma | other | $179 | $179 | $179 | 1 |
| Insertion of Expandable Tube in Breast for Radiation Treatment Using Imaging ... | other | $180 | $180 | $180 | 1 |
| Removal of Embedded Foreign Body in Soft Tissue of Tooth Bearing Bone | surgery | $180 | $180 | $180 | 1 |
| Red Blood Cells, Washed, Each Unit | other | $180 | $180 | $180 | 1 |
| Nuclear Medicine Study, 1 Area | imaging | $181 | $29 | $332 | 2 |
| Reviving Newborn At Delivery | obstetric | $181 | $120 | $242 | 2 |
| Trimark Td 13mr Breast Biopsy Site Marker MRI | imaging | $181 | $181 | $181 | 1 |
| Injection, Baclofen, 10 Mg | other | $181 | $181 | $181 | 1 |
| Removal of Lymph Nodes of Chest Cavity and Breast Bone | surgery | $181 | $181 | $181 | 1 |
| Removal of Lymph Nodes of Chest Cavity Using an Endoscope | surgery | $181 | $181 | $181 | 1 |
| X-ray Exam Hip Uni 1 View | imaging | $182 | $100 | $200 | 6 |
| Biomed Fiber Optic Probe Assembly Pteye | other | $182 | $182 | $182 | 1 |
| Cannula Long 8mm #470004 | other | $182 | $182 | $182 | 1 |
| Injection, Glucagon Hydrochloride, Per 1 Mg | other | $182 | $182 | $182 | 1 |
| All Lower Extremity Prostheses, Energy Storing Foot | other | $184 | $184 | $184 | 1 |
| Td Vacc No Presv 7 Yrs+ IM | other | $184 | $184 | $184 | 1 |
| Special Stains Group 2 | other | $184 | $184 | $184 | 1 |
| Pr Rom Rad Therapy Bone Mets, Pc | other | $185 | $185 | $185 | 1 |
| Fetal Pillow #fp-010 6ea/bx | other | $185 | $185 | $185 | 1 |
| Stabilizer Enclose #en240 | other | $185 | $185 | $185 | 1 |
| Injection Into Vocal Cords Using an Endoscope | other | $186 | $186 | $186 | 1 |
| Ultrasound of Heart with Probe in Esophagus During Surgery On Heart OR Great ... | imaging | $186 | $186 | $186 | 1 |
| Intracept Access Instruments Additional Level #rlv 0075 | other | $186 | $186 | $186 | 1 |
| Placement of Occlusive Device Into Either a Venous OR Arterial Access Site, P... | other | $186 | $186 | $186 | 1 |
| Tb Test Cell Immun Measure | other | $186 | $186 | $186 | 1 |
| Review By Radiologist of Uterine Tube and Ovary Image | other | $187 | $161 | $213 | 2 |
| Removal of Sample of Amniotic Fluid Surrounding Fetus for Diagnosis | surgery | $187 | $187 | $187 | 1 |
| Removal of Abdominal Cavity Tube | surgery | $188 | $188 | $188 | 1 |
| Suture of Recent Wound of Eyelid | other | $188 | $188 | $188 | 1 |
| Harmonic Lap Dissector 9cm #har9f 6ea/bx | other | $189 | $189 | $189 | 1 |
| Room & Board - Private (one Bed) - Pediatric | other | $189 | $189 | $189 | 1 |
| Review By Radiologist of Abscess OR Sinus Cavity Study | other | $189 | $161 | $217 | 2 |
| Removal of Growth of Floor of Mouth | surgery | $190 | $190 | $190 | 1 |
| Gelport Laparoscopic Colectomy 120mm | surgery | $190 | $190 | $190 | 1 |
| Medical Testimony | other | $190 | $190 | $190 | 1 |
| Insertion of Tube Into Artery OR Vein for Drug Infusion for Blood Clot with R... | surgery | $191 | $191 | $191 | 1 |
| Biopsy of Saliva Gland | lab | $191 | $191 | $191 | 1 |
| Vaccine Administration | preventive | $191 | $191 | $191 | 1 |
| Implantation of Nerve End Into Bone OR Muscle | surgery | $192 | $192 | $192 | 1 |
| Removal of Polyps OR Growths of Large Bowel Using a Flexible Endoscope with E... | surgery | $193 | $193 | $193 | 1 |
| CT Scan of Lower Spine with Contrast | imaging | $194 | $54 | $333 | 2 |
| CT Scan of Upper Spine with Contrast | imaging | $194 | $54 | $333 | 2 |
| Needle Biopsy of Prostate Gland Using Image Guidance | lab | $194 | $194 | $194 | 1 |
| Foot X-Ray | imaging | $194 | $194 | $194 | 1 |
| Forearm X-Ray | imaging | $194 | $194 | $194 | 1 |
| Humerus X-Ray | imaging | $194 | $194 | $194 | 1 |
| Wrist X-Ray | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Ankle | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Clavicle Left | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Femur 1 | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Femur 2/> | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Finger | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Lower Leg | imaging | $194 | $194 | $194 | 1 |
| X-ray Exam of Toe | imaging | $194 | $194 | $194 | 1 |
| X-Ray of the Hand | imaging | $194 | $194 | $194 | 1 |
| Pelvic Ultrasound | imaging | $195 | $67 | $839 | 20 |
| Removal of Plaque From Heart Artery At Time of Coronary Artery Bypass | surgery | $195 | $195 | $195 | 1 |
| Room & Board - Private (one Bed) - General Classification | other | $195 | $195 | $195 | 1 |
| Removal of Growth of Throat And/or Stripping of Vocal Cords Using an Endoscope | surgery | $195 | $195 | $195 | 1 |
| Dilation of Canal Between Middle Ear and Throat (eustachian Tube) On Both Sid... | other | $195 | $195 | $195 | 1 |
| Material for Vocal Cord Medialization, Synthetic | other | $196 | $196 | $196 | 1 |
| Ankle Orthosis, Supramalleolar with Straps, with OR without Interface/pads, C... | other | $196 | $196 | $196 | 1 |
| Mesh | other | $196 | $107 | $284 | 2 |
| Twin Grasper Otsc 220cm #200.45 | other | $197 | $197 | $197 | 1 |
| Daily Management of Ecmo External Vein to Artery Blood Circulation in Heart a... | cardiac | $198 | $198 | $198 | 1 |
| Fluciclovine F-18, Diagnostic, 1 Millicurie | other | $198 | $198 | $198 | 1 |
| Needle Biopsy of Saliva Gland | lab | $198 | $198 | $198 | 1 |
| Induction of Abnormal Heart Rhythm By Electrical Pacing | cardiac | $199 | $199 | $199 | 1 |
| Removal OR Revision of a Peripheral, Sacral, OR Gastric Neurostimulator Pulse... | surgery | $199 | $199 | $199 | 1 |
| Removal of Growth of Front 2/3 of Tongue with Switches | surgery | $199 | $199 | $199 | 1 |
| Injection of Dilated Vein of Stomach And/or Esophagus Using a Flexible Endoscope | other | $199 | $199 | $199 | 1 |
| Bactisure Wound Lavage #00888700200(qtys of 6 | other | $200 | $200 | $200 | 1 |
| Coil Vascular 2mm X 1cm Ruby #rby4c0201 | other | $200 | $200 | $200 | 1 |
| Coil Vascular 2mm X 2cm Ruby #rby4c0202 | other | $200 | $200 | $200 | 1 |
| Coil Vascular 2mm X 4cm Ruby #rby4c0204 | other | $200 | $200 | $200 | 1 |
| Coil Vascular 3mm X 5cm Ruby #rby4c0305 | other | $200 | $200 | $200 | 1 |
| Cooled Radiofrequency Kit #crk-17-75 | other | $200 | $200 | $200 | 1 |
| Cooled Rf Probe Kit #crk-17-50 | other | $200 | $200 | $200 | 1 |
| Gelpoint Mini Advanced Access Platform | other | $200 | $200 | $200 | 1 |
| Hemostatic Agent, Gastrointestinal, Topical | other | $200 | $200 | $200 | 1 |
| Pars Suture Implant Ar-8860ds | surgery | $200 | $200 | $200 | 1 |
| Ruby Complex Soft 3 Mm X 15 Cm | other | $200 | $200 | $200 | 1 |
| Ruby Complex Soft 4 Mm X 6 Cm | other | $200 | $200 | $200 | 1 |
| Ruby Complex Standard 3mm X 5cm | other | $200 | $200 | $200 | 1 |
| Vas-q-clip Applier 10mm - 45cm #an1462-l | other | $200 | $200 | $200 | 1 |
| All Endoskeletal Lower Extremity Prosthesis, Axial Rotation Unit, with OR wit... | other | $200 | $200 | $200 | 1 |
| Hip X-Ray | imaging | $200 | $200 | $200 | 1 |
| X-ray Exam of Elbow | imaging | $200 | $200 | $200 | 1 |
| X-ray Exam of Shoulder | imaging | $200 | $200 | $200 | 1 |
| Removal of Impacted Stool OR Foreign Body in Rectum Under Anesthesia | surgery | $201 | $201 | $201 | 1 |
| Injection Into Vocal Cords Using an Endoscope with Operating Microscope OR Te... | other | $201 | $201 | $201 | 1 |
| Primary Removal of Adenoids | surgery | $201 | $201 | $201 | 1 |
| Internal Shock to Heart to Regulate Heart Beat | cardiac | $201 | $201 | $201 | 1 |
| Partial Removal and Reconnection of Small Bowel, Each Additional Removal and ... | surgery | $201 | $201 | $201 | 1 |
| Addition to Lower Extremity, Above Knee OR Knee Disarticulation, Acrylic Socket | other | $202 | $202 | $202 | 1 |
| Insertion of Tube Into Middle Small Bowel Using an Endoscope | other | $202 | $202 | $202 | 1 |
| Reamer 40/44 Depuy Low Profile #2230-00 | other | $202 | $202 | $202 | 1 |
| Reamer 48/52/56 Depuy #2230-00-031 Low Profil | other | $202 | $202 | $202 | 1 |
| Reamer Shoulder 40mm Depuy #223600008 | other | $202 | $202 | $202 | 1 |
| Reamer Shoulder 48mm #223000010 Depuy | other | $202 | $202 | $202 | 1 |
| Ankle Foot Orthosis, Double Upright Free Plantar Dorsiflexion, Solid Stirrup,... | other | $203 | $203 | $203 | 1 |
| Aspiration And/or Injection of Fluid From Medium Joint Using Ultrasound Guidance | imaging | $203 | $203 | $203 | 1 |
| Cor-knot Mini Device Kit W/ Loads #031350 | other | $203 | $203 | $203 | 1 |
| Secondary Removal and Dissolving of Blood Clot From Artery OR Artery Graft Us... | surgery | $204 | $204 | $204 | 1 |
| Injection, Octreotide, Depot Form for Intramuscular Injection, 1 Mg | other | $204 | $204 | $204 | 1 |
| Destruction of Growth OR Polyp of Large Bowel Using an Endoscope Inserted Thr... | other | $204 | $204 | $204 | 1 |
| Refilling and Maintenance of Implantable Pump OR Reservoir for Drug Delivery | surgery | $204 | $204 | $204 | 1 |
| Carboprost 250 Mcg/ml Vial | other | $204 | $204 | $204 | 1 |
| Repair of Lung Airway and Removal of Segment of Lung | surgery | $205 | $205 | $205 | 1 |
| Dilation of Sphenoid and Frontal Nasal Sinus Using an Endoscope | other | $205 | $205 | $205 | 1 |
| Aortic Balloon Pump Cath 7.5fr 34cc 0684-00-0479-01u | other | $205 | $205 | $205 | 1 |
| Nursery - Newborn - Level I | obstetric | $206 | $206 | $206 | 1 |
| X-ray Exam Abdomen 1 View | imaging | $206 | $206 | $206 | 1 |
| X-ray Exam Neck Spine 2-3 Vw | imaging | $206 | $206 | $206 | 1 |
| Nuclear Medicine Study of Parathyroid | imaging | $207 | $35 | $378 | 2 |
| CT Scan of Abdomen and Pelvis with Contrast | imaging | $207 | $81 | $333 | 2 |
| Detection Test By Nucleic Acid for Multiple Types of Respiratory Virus, Multi... | other | $207 | $207 | $207 | 1 |
| Fibrin Sealant Patch Large Tachosil #1144922 | other | $207 | $207 | $207 | 1 |
| Balloon Seeker 70dg Frt 6x17 #1830617frt0 | other | $207 | $207 | $207 | 1 |
| Injection, Lurbinectedin, 0.1 Mg | other | $207 | $207 | $207 | 1 |
| Positioner Heart Urchin Evo #hp3500 | cardiac | $207 | $207 | $207 | 1 |
| Moderate Sedation | other | $208 | $5 | $10,074 | 23 |
| Nuclear Medicine Study of Liver and Bile Duct System | imaging | $208 | $33 | $382 | 2 |
| Nuclear Medicine Study of Lung Circulation | imaging | $208 | $33 | $382 | 2 |
| Fine Needle Aspiration Biopsy Using Fluoroscopic Guidance, First Growth | lab | $208 | $208 | $208 | 1 |
| Intravenous Infusion OR Subcutaneous Injection, Casirivimab and Imdevimab Inc... | surgery | $208 | $208 | $208 | 1 |
| Intravenous Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post... | surgery | $208 | $208 | $208 | 1 |
| Decompression of Twisted OR Abnormally Dilated Large Bowel Using a Flexible E... | other | $209 | $209 | $209 | 1 |
| Review By Radiologist of Upper Urinary Tract Image | other | $209 | $133 | $285 | 2 |
| Nuclear Medicine Study of Bone And/or Joint Whole Body | imaging | $210 | $38 | $382 | 2 |
| Insertion of Blood Flow Assist Device in Aorta Through Skin | other | $210 | $210 | $210 | 1 |
| Reamer / + 5.5mm 03.045.029 | other | $210 | $210 | $210 | 1 |
| Lap Harmonic Shear Curved 36cm 6/bx #har36 | other | $210 | $210 | $210 | 1 |
| Removal of Growth of Lung Airways Using an Endoscope | surgery | $210 | $210 | $210 | 1 |
| Room & Board - Private (one Bed) - Rehabilitation | therapy | $210 | $210 | $210 | 1 |
| Room & Board - Semi-private (two Beds) - General Classification | other | $210 | $210 | $210 | 1 |
| Secondary Removal of Adenoids | surgery | $210 | $210 | $210 | 1 |
| Destruction of First Division of Face Nerve Branch | other | $210 | $210 | $210 | 1 |
| Pr Rom Rad Therapy Brain Mets, Pc | other | $211 | $211 | $211 | 1 |
| Kyphon Osteo Introducer Size 2 #t34a | other | $211 | $211 | $211 | 1 |
| Kyphon Osteo Introducer Size 3 #t15j | other | $211 | $211 | $211 | 1 |
| Tying of Single Internal Hemorrhoid Group | other | $211 | $211 | $211 | 1 |
| Insertion of Tube Into First Order Main and Accessory Arteries of Kidney for ... | other | $211 | $211 | $211 | 1 |
| Prosthesis, Breast | other | $211 | $211 | $211 | 1 |
| Rts Instruments Size 1-2 M03 S0002 | other | $211 | $211 | $211 | 1 |
| Immunihistology-additional Sli | other | $211 | $211 | $211 | 1 |
| CT Scan of Abdomen and Pelvis Before and After Contrast | imaging | $212 | $90 | $333 | 2 |
| Removal of Growth of Tongue And/or Stripping of Vocal Cord Using an Endoscope... | surgery | $212 | $212 | $212 | 1 |
| Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm OR Dissection, Ra... | surgery | $212 | $212 | $212 | 1 |
| Olm Intracranial Pressure Monitor Kit 1ea | other | $212 | $212 | $212 | 1 |
| Nuclear Medicine Study of Testicle and Blood Flow | imaging | $212 | $212 | $212 | 1 |
| Nuclear Medicine Study of Heart Pumping Function By Labeling Red Blood Cells ... | imaging | $213 | $44 | $382 | 2 |
| Aveta Flex Disposable Resecting Device 2.9mm #210-080 3/ctn | other | $213 | $213 | $213 | 1 |
| Fixate Suture Device Band Pk=2ea Fb-201-01 Sc | other | $213 | $213 | $213 | 1 |
| Orthoalign Plus Unit #403001 | other | $213 | $213 | $213 | 1 |
| Removal of Polyps OR Growths of Large Bowel Using an Endoscope with Mechanica... | surgery | $213 | $213 | $213 | 1 |
| Echo Limit | imaging | $213 | $213 | $213 | 1 |
| Nuclear Medicine Study of Bone Taken At Different Times | imaging | $214 | $45 | $382 | 2 |
| Tying of Multiple Internal Hemorrhoid Groups | other | $214 | $214 | $214 | 1 |
| Removal of Connective Tissue of Palm and Release of Finger, Each Additional D... | surgery | $214 | $214 | $214 | 1 |
| Echelon Contour Curved Cutter Stapler Blue 2.0 Gcs40g Bx/3ea | other | $215 | $215 | $215 | 1 |
| Amniotic Membrane for Surgical Reconstruction, Per Procedure | surgery | $215 | $215 | $215 | 1 |
| Waterjet Destruction of Prostrate Accessed Through the Urethra | other | $215 | $215 | $215 | 1 |
| CT Scan of Blood Vessels of Abdomen and Pelvis with Contrast | imaging | $216 | $98 | $333 | 2 |
| MRI Scan of Pelvis Before and After Contrast | imaging | $216 | $98 | $333 | 2 |
| Destruction of Growth OR Narrowing of Lung Airway Using an Endoscope | other | $216 | $216 | $216 | 1 |
| Repair of Lacerated Roof of Mouth, More Than 2.0 Cm | surgery | $216 | $216 | $216 | 1 |
| Ultrasound Exam of Large Bowel Using a Flexible Endoscope | imaging | $216 | $216 | $216 | 1 |
| Control of Bleeding of Upper Large Bowel Using a Flexible Endoscope | other | $217 | $217 | $217 | 1 |
| Repair of Tissue Connecting Tongue to Floor of Mouth | surgery | $217 | $217 | $217 | 1 |
| Work-related OR Medical Disability Examination By Other Than the Treating Phy... | other | $217 | $217 | $217 | 1 |
| Preparation of Skin Graft Site of Face, Scalp, Eyelids, Mouth, Neck, Ears, Ar... | other | $217 | $217 | $217 | 1 |
| Delivery of Placenta | obstetric | $218 | $218 | $218 | 1 |
| Review By Radiologist of Elbow Image | other | $218 | $218 | $218 | 1 |
| Nuclear Medicine Study of Lung Ventilation and Circulation and Blood Flow to ... | imaging | $218 | $218 | $218 | 1 |
| Removal of Tonsils | surgery | $219 | $219 | $219 | 1 |
| Injection to Cause Blood Clot in Diseased OR Pseudoaneurysm of Arm OR Leg | other | $219 | $219 | $219 | 1 |
| Ultrasound Guided Needle Aspiration OR Biopsy of Esophagus, Stomach, And/or U... | imaging | $220 | $220 | $220 | 1 |
| Rom Rad Therapy Lymphoma, Pc | other | $220 | $220 | $220 | 1 |
| Hc an Epidural Block Charge | other | $220 | $220 | $220 | 1 |
| Dmsa Injection Kit | other | $222 | $222 | $222 | 1 |
| Addition, Endoskeletal System, Below Knee, Flexible Protective Outer Surface ... | other | $223 | $223 | $223 | 1 |
| Removal of Growth in Soft Tissue of Ear Canal | surgery | $223 | $223 | $223 | 1 |
| Biopsy of Lung Lining Using an Endoscope | lab | $223 | $223 | $223 | 1 |
| Hla B27 | other | $223 | $223 | $223 | 1 |
| Closed Treatment of Broken Middle OR Upper End of Outside Lower Leg Bone | other | $224 | $224 | $224 | 1 |
| Radioactive Drug Therapy Through a Vein | other | $224 | $224 | $224 | 1 |
| Additions to Lower Extremity, Total Contact, Above Knee OR Knee Disarticulati... | other | $224 | $224 | $224 | 1 |
| Inceptiv Programming Handset and Communicator #th91scsr | other | $224 | $224 | $224 | 1 |
| Spinal Pt Programmer #97740 Restoresensor | other | $224 | $224 | $224 | 1 |
| Fresh Frozen Plasma | other | $224 | $224 | $224 | 1 |
| Nuclear Medicine Study, SPECT Imaging, 1 Area OR Single Acquisition, Single D... | imaging | $225 | $48 | $402 | 2 |
| Injection of Agent to Destroy Nerve to Internal Sphincter of Anus | other | $225 | $225 | $225 | 1 |
| Complicated Removal of Saliva Gland Stone From Inside Mouth | surgery | $226 | $226 | $226 | 1 |
| Nuclear Medicine Studies of Kidney, Blood Flow, and Function | imaging | $226 | $226 | $226 | 1 |
| Removal of Infected Artificial Material OR Mesh From Abdomen | surgery | $227 | $227 | $227 | 1 |
| Platelets, Pheresis, Each Unit | other | $227 | $227 | $227 | 1 |
| Exposure of Major Groin Artery with Creation of Conduit | other | $228 | $228 | $228 | 1 |
| Biopsy OR Removal of Lymph Nodes | surgery | $228 | $228 | $228 | 1 |
| MRI Scan of Arm Joint without Contrast | imaging | $228 | $228 | $228 | 1 |
| MRI Scan of 1 Breast without Contrast | imaging | $229 | $229 | $229 | 1 |
| MRI Scan of Abdomen without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Arm without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Blood Vessels of Head without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Blood Vessels of Neck without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Both Breasts without Contrast | imaging | $229 | $229 | $229 | 1 |
| MRI Scan of Brain without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Chest without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Jaw Joint | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Leg Joint without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Leg without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Lower Spinal Canal without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Middle Spinal Canal without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Pelvis without Contrast | imaging | $229 | $228 | $229 | 2 |
| MRI Scan of Upper Spinal Canal without Contrast | imaging | $229 | $228 | $229 | 2 |
| Review By Radiologist of Breast Duct Image, 1 Duct | other | $229 | $229 | $229 | 1 |
| Ultrasound Scan of Pregnant Uterus with Detailed Fetal Anatomic Examination, ... | imaging | $229 | $229 | $229 | 1 |
| Ultrasound Scan of Uterus and Uterine Cavity | imaging | $229 | $229 | $229 | 1 |
| Gradient Compression Garment, Arm, Padded, for Nighttime Use, Custom, Each | other | $229 | $229 | $229 | 1 |
| Magnetic Resonance Angiography with Contrast, Chest | imaging | $229 | $229 | $229 | 1 |
| Addition, Endoskeletal System, Below Knee, Ultra-light Material | other | $230 | $230 | $230 | 1 |
| Ankle Foot Orthosis, Plastic OR Other Material, Custom Fabricated | other | $230 | $230 | $230 | 1 |
| Injection, Azacitidine, 1 Mg | other | $230 | $230 | $230 | 1 |
| Destruction of First Incompetent Vein of Arm OR Leg Using Radiofrequency and ... | other | $230 | $230 | $230 | 1 |
| Insertion of Tube for 3d Mapping of Electrical Impulses to Heart Muscle | cardiac | $231 | $231 | $231 | 1 |
| Injection, Brentuximab Vedotin, 1 Mg | other | $231 | $231 | $231 | 1 |
| Programming of Pacing Cardioverter-defibrillator | other | $231 | $231 | $231 | 1 |
| Drainage of Abscess, Cyst, OR Blood Accumulation Under Jaw Bone From Inside M... | other | $231 | $231 | $231 | 1 |
| Removal of Growth of Back 1/3 of Tongue with Suturing | surgery | $231 | $231 | $231 | 1 |
| Nuclear Medicine Study of Brain and Blood Flow | imaging | $232 | $232 | $232 | 1 |
| Room & Board - Private | other | $233 | $233 | $233 | 1 |
| Review By Radiologist of Wrist Joint Image | other | $233 | $233 | $233 | 1 |
| Insertion of Tube Into Extracranial Artery for Diagnosis OR Treatment with Re... | other | $234 | $234 | $234 | 1 |
| Addition to Lower Extremity, Pre-tibial Shell, Molded to Patient Model | other | $235 | $235 | $235 | 1 |
| Removal of Growth Under Skin of Face OR Scalp, Less Than 2.0 Cm | surgery | $235 | $235 | $235 | 1 |
| Administration of Chemotherapy Into Vein, 1 Hour OR Less | other | $235 | $235 | $235 | 1 |
| X-ray Ac Joints Bi W/wo Weight | imaging | $235 | $235 | $235 | 1 |
| Repair of Eardrum | surgery | $236 | $236 | $236 | 1 |
| Heart Rhythm Recording for More Than 7 Days Up to 15 Days By Continuous Rhyth... | cardiac | $237 | $237 | $237 | 1 |
| Diagnostic Exam of Small Bowel (including Lower Small Intestine) Using an End... | other | $238 | $238 | $238 | 1 |
| Coring Reamer Cannulated 6 Mm #ar-8900cr | other | $238 | $238 | $238 | 1 |
| Coring Reamer Cannulated 8 Mm #ar-8901cr | other | $238 | $238 | $238 | 1 |
| Endoblade Plantar Fascia Release Ar-8856ds | other | $238 | $238 | $238 | 1 |
| Weight Management Program | preventive | $238 | $37 | $238 | 6 |
| Fibrin Degradation Quant | other | $238 | $238 | $238 | 1 |
| Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom Fabricated | other | $239 | $239 | $239 | 1 |
| Leadless C Pm Ins/rpl Ventr | other | $239 | $239 | $239 | 1 |
| Removal of Tube for Ecmo External Blood Circulation in Heart and Lungs Using ... | surgery | $240 | $240 | $240 | 1 |
| Wand Laryngeal Procise Mlw #eica7071 | other | $241 | $241 | $241 | 1 |
| Wand Procise Lw Arthrocare #eica7070 | other | $241 | $241 | $241 | 1 |
| Insertion of Stent in Large Bowel Using a Flexible Endoscope | cardiac | $242 | $242 | $242 | 1 |
| Partial Foot, Shoe Insert with Longitudinal Arch, Toe Filler | other | $243 | $243 | $243 | 1 |
| Gradient Compression Garment, Lower Leg and Foot, Padded, for Nighttime Use, ... | other | $243 | $243 | $243 | 1 |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Alignable S... | other | $243 | $243 | $243 | 1 |
| Removal of Congenital Skin and Tissue Cyst of Neck | surgery | $243 | $243 | $243 | 1 |
| Injection, Dostarlimab-gxly, 10 Mg | other | $244 | $244 | $244 | 1 |
| Periprosthetic Wire Guide 03.233.000 | other | $244 | $244 | $244 | 1 |
| Delayed Insertion of Prosthesis for Repair of Abdominal OR Groin Artery with ... | surgery | $245 | $245 | $245 | 1 |
| Microcatheter Canaloplasty Itrack 250a | cardiac | $245 | $245 | $245 | 1 |
| Review By Radiologist of Abdominal Cavity Lining Image | other | $246 | $246 | $246 | 1 |
| Custom Shaped Protective Cover, Below Knee | other | $246 | $246 | $246 | 1 |
| Protopam Chloride 1 Gm Vial | other | $246 | $246 | $246 | 1 |
| Exam of Kidney Using an Endoscope Inserted Through Surgically Created Opening... | surgery | $247 | $247 | $247 | 1 |
| Nuclear Medicine Study of Lung Ventilation and Circulation | imaging | $248 | $47 | $449 | 2 |
| Assay of Parathormone | other | $248 | $248 | $248 | 1 |
| Nuclear Medicine Study of Liver and Bile Duct System with Use of Drugs | imaging | $249 | $40 | $458 | 2 |
| Biopsy of Small Bowel Using an Endoscope | lab | $249 | $249 | $249 | 1 |
| ICU Nursing Increment | other | $249 | $249 | $249 | 1 |
| Newborn Care | obstetric | $250 | $35 | $371 | 8 |
| Retrieval of Foreign Body in Blood Vessel with Review By Radiologist | other | $250 | $250 | $250 | 1 |
| Closed Treatment of Broken Wrist Bone Near Base of Thumb | other | $250 | $250 | $250 | 1 |
| Exposure of Underarm OR Upper Chest Artery for Delivery of Prosthesis | obstetric | $250 | $250 | $250 | 1 |
| Vena Cava Filter | other | $250 | $250 | $250 | 1 |
| Removal of Growth of Mouth with Complicated Repair | surgery | $250 | $250 | $250 | 1 |
| Removal of Growth of Dental Bone Growth with Complex Repair | surgery | $250 | $250 | $250 | 1 |
| Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, P... | other | $250 | $250 | $250 | 1 |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth | imaging | $251 | $251 | $251 | 1 |
| Injection Procedure for Imaging of Kidney and Ureter Through Already Existing... | other | $252 | $252 | $252 | 1 |
| Ruby Complex Soft 4 Mm X 15 Cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Soft 6 Mm X 20 Cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 3mm X 12cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 3mm X 20cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 4mm X 10cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 4mm X 15cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 4mm X 20cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 5mm X 12cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 6mm X 20cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 7mm X 25cm | other | $253 | $253 | $253 | 1 |
| Ruby Complex Standard 8mm X 25cm | other | $253 | $253 | $253 | 1 |
| Insertion OR Replacement of Peripheral, Sacral, OR Gastric Neurostimulator Ge... | surgery | $253 | $253 | $253 | 1 |
| Hospital Observation | other | $254 | $3 | $890 | 18 |
| Fine Needle Aspiration And/or Biopsy of Large Bowel with Ultrasound Guidance ... | imaging | $254 | $254 | $254 | 1 |
| Placement of Tubes in Breast for Radiation Treatment Using Imaging Guidance D... | other | $254 | $254 | $254 | 1 |
| Bupivacaine, Collagen-matrix Implant, 1 Mg | surgery | $255 | $255 | $255 | 1 |
| Blood Gases W/o2 Saturation | other | $255 | $255 | $255 | 1 |
| Ahmed Valve | other | $255 | $255 | $255 | 1 |
| Pr Sigmoidoscopy,ablate Lesn | other | $256 | $256 | $256 | 1 |
| Incision of Windpipe for Insertion of Breathing Tube | other | $257 | $257 | $257 | 1 |
| Test for Detecting Nucleic Acid of Organism Causing Infection of Central Nerv... | other | $257 | $257 | $257 | 1 |
| Removal of Biliary Drainage Tube Using Imaging Guidance with Review By Radiol... | surgery | $257 | $257 | $257 | 1 |
| Complex Removal of Tissue and Muscle Growth of Mouth | surgery | $257 | $257 | $257 | 1 |
| Removal of Tonsils and Adenoid Glands | surgery | $258 | $258 | $258 | 1 |
| Insertion of Sacral Nerve Neurostimulator Electrode Array | other | $258 | $258 | $258 | 1 |
| Stent, Non-coronary, Temporary, with Delivery System | cardiac | $259 | $259 | $259 | 1 |
| Incision of Bladder with Drainage | other | $259 | $259 | $259 | 1 |
| Addition, Endoskeletal Knee-shin System, Single Axis, Friction Swing and Stan... | other | $259 | $259 | $259 | 1 |
| Implant System Achillies Midsubstance Speedbridge Ar-8929bc-cp | surgery | $259 | $259 | $259 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Chest | imaging | $259 | $259 | $259 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Sp... | imaging | $259 | $259 | $259 | 1 |
| Vein Harvest Dumicz Endovascular #vsp550ex | other | $261 | $261 | $261 | 1 |
| Nuclear Medicine Study of Lung Ventilation and Blood Flow to Lung | imaging | $261 | $261 | $261 | 1 |
| Initiation of Ecmo External Vein to Vein Blood Circulation in Heart and Lungs... | cardiac | $262 | $262 | $262 | 1 |
| Emergent Incision of Windpipe Through Neck for Insertion of Breathing Tube | other | $262 | $262 | $262 | 1 |
| Closed Treatment of Broken Kneecap | other | $263 | $263 | $263 | 1 |
| Hc General Anesthesia Time - Initial Base Charge | other | $263 | $263 | $263 | 1 |
| Pr Rom Rad Therapy Breast, Pc | other | $263 | $263 | $263 | 1 |
| Aveta Wave+ Disposable Resecting Device 3.9mm #210-2005 3/ctn | other | $263 | $263 | $263 | 1 |
| Ruby Complex Standard 5mm X 20cm | other | $263 | $263 | $263 | 1 |
| Ruby Complex Standard 6mm X 12cm | other | $263 | $263 | $263 | 1 |
| Addition to Lower Extremity, Below Knee / Above Knee Suspension Locking Mecha... | other | $264 | $264 | $264 | 1 |
| Insertion of Tube Into Ureter Using an Endoscope Inserted Through Surgically ... | surgery | $264 | $264 | $264 | 1 |
| Scleral Tutoplast Processed | other | $264 | $264 | $264 | 1 |
| Drainage of Fluid From Abdominal Cavity Using Imaging Guidance | other | $264 | $264 | $264 | 1 |
| Blood Platelet Aggregation | other | $264 | $264 | $264 | 1 |
| Brevital Sodium 500 Mg Vial | other | $265 | $265 | $265 | 1 |
| Spiration Deployment Catheter and Loader Hudhus-c26n | cardiac | $266 | $266 | $266 | 1 |
| Watchman Fxd Access System Double Curve Tu8002 | other | $266 | $266 | $266 | 1 |
| Watchman Trueseal Access System Anterior Curve Tu7004 | other | $266 | $266 | $266 | 1 |
| Removal of Foreign Body OR Stone in Kidney OR Ureter Using an Endoscope Inser... | surgery | $266 | $266 | $266 | 1 |
| Nuclear Medicine Study of Liver, Spleen, and Blood Flow | imaging | $266 | $266 | $266 | 1 |
| Biopsy of Anal And/or Rectal Wall Through Anus | lab | $268 | $268 | $268 | 1 |
| Repair of Abdominal OR Groin Artery with Prosthesis with Review By Radiologist | surgery | $268 | $268 | $268 | 1 |
| Diagnostic Exam of Lungs, Heart Sac, Chest Cavity, OR Lung Lining Using an En... | cardiac | $268 | $268 | $268 | 1 |
| Application of Walking Cast Covering Foot, Ankle, and Lower Leg | other | $268 | $268 | $268 | 1 |
| Injection, Epinephrine, Not Otherwise Specified, 0.1 Mg | other | $268 | $268 | $268 | 1 |
| Graft Applic<100cm,add-on 25cm | other | $268 | $268 | $268 | 1 |
| Biopsy of Fluid Collection of Lung Using an Endoscope | lab | $269 | $269 | $269 | 1 |
| Incision of Tendon Covering of Finger | other | $269 | $269 | $269 | 1 |
| Joint Device | other | $269 | $244 | $293 | 2 |
| Insertion of Tube Into Chest Artery for Diagnosis OR Treatment with Review By... | other | $271 | $271 | $271 | 1 |
| Control of Bleeding of Large Bowel Using an Endoscope Inserted Through Surgic... | other | $271 | $271 | $271 | 1 |
| Removal of Growths OR Polyps of Large Bowel By Electrical Cautery Using an En... | surgery | $271 | $271 | $271 | 1 |
| Injectable Bulking Agent, Collagen Implant, Urinary Tract, 2.5 Ml Syringe, In... | surgery | $271 | $271 | $271 | 1 |
| Gene Analysis (tumor Protein 53) Targeted Sequence Analysis | other | $272 | $272 | $272 | 1 |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated From Ex... | other | $272 | $272 | $272 | 1 |
| Removal of Voice Box Cartilage Using an Endoscope with Operating Microscope O... | surgery | $273 | $273 | $273 | 1 |
| Graft, Vascular | other | $273 | $273 | $273 | 1 |
| Bronchospam Complete | other | $273 | $273 | $273 | 1 |
| All Lower Extremity Prostheses, Multi-axial Rotation Unit | other | $274 | $274 | $274 | 1 |
| Annual Wellness Visit (Established) | preventive | $275 | $28 | $374 | 8 |
| Injection of Anesthetic Agent And/or Steroid Into Arm Nerve Bundle | other | $275 | $275 | $275 | 1 |
| Injection of Anesthetic Agent And/or Steroid Into Upper Arm and Shoulder Nerve | other | $275 | $275 | $275 | 1 |
| Review By Radiologist of Knee Joint Image | other | $276 | $276 | $276 | 1 |
| Closed Treatment of Dislocated Finger Joint with Manipulation Under Anesthesia | other | $276 | $276 | $276 | 1 |
| Small Joint Injection | surgery | $277 | $62 | $10,074 | 18 |
| Trigger Point Injection | therapy | $277 | $8 | $10,074 | 18 |
| Follow-up Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 | $277 | 1 |
| Initial Hospital Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 | $277 | 1 |
| Insertion of Tube Into Vein for Drug Infusion for Blood Clot with Review By R... | surgery | $278 | $278 | $278 | 1 |
| Pr Renal Angio, Cardiac Cath | cardiac | $278 | $278 | $278 | 1 |
| Removal of Nasal Air Passage | surgery | $278 | $278 | $278 | 1 |
| Removal of Growth Under Skin of Leg OR Ankle, Less Than 3.0 Cm | surgery | $279 | $279 | $279 | 1 |
| Ensite X Surface Electrodes #ensite-sek-5-01 5ea/bx | other | $279 | $279 | $279 | 1 |
| Nuclear Medicine Study of Intestine | imaging | $279 | $175 | $383 | 2 |
| Ankle Foot Orthosis, Spiral, (institute of Rehabilitative Medicine Type), Pla... | other | $280 | $280 | $280 | 1 |
| Injection of Anesthetic Agent Into Abdominal Sympathetic Nerve Bundle | other | $280 | $280 | $280 | 1 |
| Rabies Immune Globulin for Injection | other | $280 | $280 | $280 | 1 |
| Placement of Locating Device in Breast Using X-ray with Needle Guidance, Firs... | imaging | $280 | $280 | $280 | 1 |
| Nuclear Medicine Study of Kidney, Blood Flow, and Function | imaging | $281 | $42 | $519 | 2 |
| Removal and Replacement of Single Lead Permanent Pacemaker | surgery | $281 | $281 | $281 | 1 |
| Closed Treatment of Broken Shin Bone | other | $281 | $281 | $281 | 1 |
| Injectable Bulking Agent, Synthetic Implant, Urinary Tract, 1 Ml Syringe, Inc... | surgery | $282 | $282 | $282 | 1 |
| Custom Seal Kit Endologix #tv-cs14-g | other | $282 | $282 | $282 | 1 |
| Evaluation of Single OR Dual Chamber Pacing Cardioverter-defibrillator and Ge... | other | $282 | $282 | $282 | 1 |
| Emergent Incision of Windpipe for Insertion of Breathing Tube | other | $283 | $283 | $283 | 1 |
| Partial Removal of External Ear with Simple Repair | surgery | $283 | $283 | $283 | 1 |
| Gastrografin 66-10 Sol 120 Ml | other | $283 | $283 | $283 | 1 |
| Closure of Permanent Windpipe Opening OR Abnormal Drainage Tract | other | $284 | $284 | $284 | 1 |
| Addition to Lower Extremity, Below Knee Suction Socket | other | $284 | $284 | $284 | 1 |
| Harvest of Upper Leg to Thigh Vein Segment | other | $285 | $285 | $285 | 1 |
| Injection, Imipenem 4 Mg, Cilastatin 4 Mg and Relebactam 2 Mg | other | $285 | $285 | $285 | 1 |
| Incision and Drainage of Abscess Within Wall of Rectum Under Anesthesia | other | $285 | $285 | $285 | 1 |
| Rom Rad Therapy Lung, Pc | other | $285 | $285 | $285 | 1 |
| Glucagon Kit - Compounded | other | $286 | $286 | $286 | 1 |
| Removal of Vena Cava Filter with Review By Radiologist | surgery | $287 | $287 | $287 | 1 |
| Initial Intensive Care of Newborn Per Day | obstetric | $287 | $287 | $287 | 1 |
| Hem-o-lok Medium/large 5mm Endo Applier # 544965 | other | $287 | $287 | $287 | 1 |
| Initiation of Ecmo External Vein to Artery Blood Circulation in Heart and Lun... | cardiac | $288 | $288 | $288 | 1 |
| Progel Pleural Air Leak Sealant 4ml 4ea/capgps002 | other | $288 | $288 | $288 | 1 |
| Pegasys 180 Mcg/ml Vial | other | $289 | $289 | $289 | 1 |
| Insertion of Tube Into First Order Main and Accessory Arteries of Both Kidney... | other | $289 | $289 | $289 | 1 |
| Removal of Growth of Tendon Finger OR Hand | surgery | $289 | $289 | $289 | 1 |
| Release of Tissue of Palm | other | $289 | $289 | $289 | 1 |
| Destruction And/or Removal of Growth of Kidney Using an Endoscope Inserted Th... | surgery | $290 | $290 | $290 | 1 |
| Removal of Vocal Cord Growths and Reconstruction with Local Tissue Flap Using... | surgery | $290 | $290 | $290 | 1 |
| Nursery - General Classification | other | $290 | $290 | $290 | 1 |
| Review By Radiologist of Shoulder Joint Image | other | $291 | $291 | $291 | 1 |
| Implantable Breast Prosthesis, Silicone OR Equal | surgery | $291 | $291 | $291 | 1 |
| Insertion of Tube Into Second OR Third Order Branches of Arteries of Kidney f... | other | $292 | $292 | $292 | 1 |
| Resecting Device Symphion #fg | other | $292 | $292 | $292 | 1 |
| Insertion of Blood Flow Assist Device in Aorta Through Upper Leg Artery | other | $293 | $293 | $293 | 1 |
| Afo, Rigid Anterior Tibial Section, Total Carbon Fiber OR Equal Material, Pre... | other | $293 | $293 | $293 | 1 |
| Repair of Abdomen Using Abdominal Lining Graft | surgery | $294 | $294 | $294 | 1 |
| Removal and Replacement of Dual Lead Permanent Pacemaker | surgery | $294 | $294 | $294 | 1 |
| Diagnostic Exam of Abdomen Using an Endoscope | other | $294 | $294 | $294 | 1 |
| Review By Radiologist of Image for Insertion of Material to Block Blood Flow | other | $295 | $295 | $295 | 1 |
| Simple Repair of Salivary Duct | surgery | $296 | $296 | $296 | 1 |
| Application of Paste Boot | other | $296 | $296 | $296 | 1 |
| Knee Orthosis, Adjustable Knee Joints (unicentric OR Polycentric), Positional... | other | $297 | $297 | $297 | 1 |
| Alexis Ces W/gel Point Mini #gtm14 | other | $297 | $297 | $297 | 1 |
| Destino Catheter (steerable Sheath 55cm 7mm Curve) #dst0655507d2 | cardiac | $297 | $297 | $297 | 1 |
| Insertion of Pacemaker Pulse Generator with Existing Multiple Leads | cardiac | $297 | $297 | $297 | 1 |
| Removal of Growth Under Skin of Face OR Scalp, 2.0 Cm OR More | surgery | $297 | $297 | $297 | 1 |
| Knee Orthosis (ko), Single Upright, Thigh and Calf, with Adjustable Flexion a... | other | $297 | $297 | $297 | 1 |
| Sodium Nitrite 300 Mg/10 Ml Vl | other | $298 | $298 | $298 | 1 |
| Sodium Thiosulfat 12.5 G/50 Ml | other | $298 | $298 | $298 | 1 |
| Removal of Multiple External Hemorrhoids | surgery | $298 | $298 | $298 | 1 |
| Accessory Kit Ams 700 #72401850 | other | $299 | $299 | $299 | 1 |
| Knee Orthosis, Single Upright, Thigh and Calf, with Adjustable Flexion and Ex... | other | $299 | $299 | $299 | 1 |
| Removal of Wedge of Lip Tissue with Closure | surgery | $300 | $300 | $300 | 1 |
| Signature One Alliance Glenoid Shoulder Guide and Bone Model Left 20-8090-008 | other | $300 | $300 | $300 | 1 |
| Removal (1.5 Centimeters OR Greater) Tissue Growth Beneath the Skin of Foot O... | surgery | $300 | $300 | $300 | 1 |
| Removal of Chronic Tear of Anus | surgery | $300 | $300 | $300 | 1 |
| Bridion 200 Mg/2 Ml Vial | other | $301 | $301 | $301 | 1 |
| Removal (less Than 1.5 Centimeters) Tissue Beneath the Skin Growth of Hand OR... | surgery | $301 | $301 | $301 | 1 |
| Nuclear Medicine Study of Bone Marrow Limited Area | imaging | $301 | $301 | $301 | 1 |
| Review By Radiologist of Hip Joint Image | other | $301 | $301 | $301 | 1 |
| Ultraflex Intra-aortic Ballon 7.5fr 40cc Iab-06840-u | other | $303 | $303 | $303 | 1 |
| Nuclear Medicine Study to Assess Blood Loss | imaging | $303 | $268 | $337 | 2 |
| Endobronchial Us Add-on | other | $304 | $304 | $304 | 1 |
| Prostin Vr Pedi 500 Mcg/ml Amp | other | $305 | $305 | $305 | 1 |
| Apply Multlay Comprs Lwr Leg | other | $305 | $305 | $305 | 1 |
| Shunt Carotid Pruitt W/t-port(outlying)*min 3 | other | $306 | $306 | $306 | 1 |
| Removal of Salivary Cyst Under Tongue | surgery | $306 | $306 | $306 | 1 |
| Speed Compression Implant Kit #se | surgery | $306 | $306 | $306 | 1 |
| Biopsy of Abdomen Using an Endoscope | lab | $307 | $307 | $307 | 1 |
| Removal and Replacement of Single Lead Defibrillator | surgery | $307 | $307 | $307 | 1 |
| Repair Umbilical Hernia, Younger Than Age 5 Years; Reducible | surgery | $307 | $307 | $307 | 1 |
| Removal and Replacement of Multiple Lead Permanent Pacemaker | surgery | $307 | $307 | $307 | 1 |
| Tactiflex Radiofrequency Cable #tsq-rf-tfse-cbl | other | $307 | $307 | $307 | 1 |
| Incision of Nasal Sinus Through Nose | other | $308 | $308 | $308 | 1 |
| Removal of Growth of Soft Tissue of Abdominal Wall, Less Than 3.0 Cm | surgery | $308 | $308 | $308 | 1 |
| V-shaped Removal of Lip Tissue | surgery | $308 | $308 | $308 | 1 |
| Nursery - Newborn - Level Ii | obstetric | $309 | $309 | $309 | 1 |
| Dilation of Esophagus | other | $309 | $309 | $309 | 1 |
| Incision of Lower Finger Joint for Exploration, Fluid Drainage, OR Removal of... | surgery | $309 | $309 | $309 | 1 |
| Injection, Regadenoson, 0.1 Mg | other | $309 | $20 | $598 | 2 |
| Insertion of Defibrillator with Existing Dual Leads | other | $310 | $310 | $310 | 1 |
| Knee Orthosis (ko), Double Upright, Thigh and Calf, with Adjustable Flexion a... | other | $310 | $310 | $310 | 1 |
| Removal of Saliva Gland Under Tongue | surgery | $311 | $311 | $311 | 1 |
| Allopatch Human Dermis 5x5 Cm | other | $311 | $311 | $311 | 1 |
| Assay of Natriuretic Peptide | other | $312 | $312 | $312 | 1 |
| Revision of Permanent Windpipe Opening Scar | other | $313 | $313 | $313 | 1 |
| Cardioplegia Del Nido Formula | other | $313 | $313 | $313 | 1 |
| Repair Device, Urinary, Incontinence, with Sling Graft | surgery | $313 | $313 | $313 | 1 |
| Replacement of Stomach OR Large Bowel Tube Using Fluoroscopic Guidance with C... | surgery | $313 | $313 | $313 | 1 |
| Rabies Vaccine for Injection Into Muscle | preventive | $314 | $314 | $314 | 1 |
| Exposure of Underarm OR Upper Chest Artery with Creation of Conduit | other | $314 | $314 | $314 | 1 |
| Carotid Ultrasound | imaging | $315 | $99 | $1,484 | 15 |
| Removal of Border of Lip | surgery | $315 | $315 | $315 | 1 |
| Bone And/or Joint Imaging; Tomographic | other | $315 | $315 | $315 | 1 |
| Drainage of Abscess of Throat From Inside Mouth | other | $316 | $316 | $316 | 1 |
| Injection, Amphotericin B, 50 Mg | other | $316 | $316 | $316 | 1 |
| Patient Programmer, Neurostimulator | other | $317 | $317 | $317 | 1 |
| Rom Rad Therapy Pancreas, Pc | other | $317 | $317 | $317 | 1 |
| Stapling of Internal Hemorrhoid | other | $317 | $317 | $317 | 1 |
| Hemabate 250 Mcg IM | other | $317 | $317 | $317 | 1 |
| Insertion of Tube Into Artery for Drug Infusion for Blood Clot with Review By... | surgery | $318 | $318 | $318 | 1 |
| Removal and Replacement of Dual Lead Defibrillator | surgery | $319 | $319 | $319 | 1 |
| Room & Board - Private (one Bed) - Psychiatric | therapy | $319 | $319 | $319 | 1 |
| Right Angled Slimline Cryoprobe #pcs | other | $319 | $319 | $319 | 1 |
| Mitomycin Pyelocalyceal Instillation, 1 Mg | other | $319 | $319 | $319 | 1 |
| Pr Rom Rad Therapy Colorectal, Pc | other | $320 | $320 | $320 | 1 |
| Control of Bleeding of Small Bowel Using an Endoscope | other | $320 | $320 | $320 | 1 |
| Platelets, Pheresis, Pathogen-reduced, Each Unit | other | $320 | $320 | $320 | 1 |
| X-ray Exam Entire Spi 2/3 Vw | imaging | $320 | $320 | $320 | 1 |
| Puraply Am 1 SQ Cm | other | $323 | $323 | $323 | 1 |
| Primary Repair of Tendon On Front of Leg | surgery | $324 | $324 | $324 | 1 |
| Duraseal Exact 5ml Spine Sealant Sys #206520 | other | $325 | $325 | $325 | 1 |
| Mediastinoscopy Incl Biopsy | lab | $325 | $325 | $325 | 1 |
| Repair Epigastric Hernia | surgery | $325 | $325 | $325 | 1 |
| Control of Bleeding of Throat Requiring Hospitalization | other | $326 | $326 | $326 | 1 |
| Pr Rom Rad Therapy Cns, Pc | other | $327 | $327 | $327 | 1 |
| Removal of Growth of Leg And/or Ankle Tendon Lining OR Capsule | surgery | $327 | $327 | $327 | 1 |
| Follow-up Inpatient Hospital Critical Care of Newborn Per Day | obstetric | $327 | $327 | $327 | 1 |
| Removal of Growth Under Skin of Pelvis and Hip, Less Than 3.0 Cm | surgery | $328 | $328 | $328 | 1 |
| Biopsy of Growth of Lung Using an Endoscope | lab | $328 | $328 | $328 | 1 |
| Catheter Frontrunner Xp Ctd #fbp39140 | cardiac | $328 | $328 | $328 | 1 |
| Monitoring and Recording of Esophageal Function Through a Capsule Attached to... | other | $328 | $328 | $328 | 1 |
| Injection, Hyaluronidase, Recombinant, 1 Usp Unit | other | $328 | $328 | $328 | 1 |
| Injection, Dactinomycin, 0.5 Mg | other | $328 | $328 | $328 | 1 |
| Removal of Single External and Internal Hemorrhoid Group | surgery | $329 | $329 | $329 | 1 |
| Tlso, Flexible, Provides Trunk Support, Thoracic Region, Rigid Posterior Pane... | other | $330 | $330 | $330 | 1 |
| Extensive Removal of Nasal Polyp | surgery | $330 | $330 | $330 | 1 |
| Removal of Foreign Body OR Stone in Kidney Using an Endoscope Inserted Throug... | surgery | $330 | $330 | $330 | 1 |
| ERCP (Gallstone Removal) | other | $331 | $22 | $3,569 | 33 |
| Insertion of Defibrillator with Existing Multiple Leads | other | $331 | $331 | $331 | 1 |
| Removal and Replacement of Multiple Lead Defibrillator | surgery | $331 | $331 | $331 | 1 |
| Other Procedure On Voice Box | other | $332 | $332 | $332 | 1 |
| Radiopharmaceutical Localization of Inflammatory Process; Whole Body | other | $332 | $332 | $332 | 1 |
| MRI Spine | imaging | $333 | $227 | $4,964 | 31 |
| Jada System 2.0 Vacuum Induced Hemorrhage Control System Blue Seal Valve Gree... | other | $333 | $333 | $333 | 1 |
| Packing Coil 45cm Rbypodj45 | other | $333 | $333 | $333 | 1 |
| Pod J-soft Packing Coil 60cm Rbypodj60 | other | $333 | $333 | $333 | 1 |
| Ruby Coil Standard 10 Mm X 35 Cm Rby2c1035 | other | $333 | $333 | $333 | 1 |
| Ruby Coil Standard 12 Mm X 60 Cm Rby2c1260 | other | $333 | $333 | $333 | 1 |
| Ruby Complex Soft 16 Mm X 50 Cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Soft 20 Mm X 60 Cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Soft 6 Mm X 30 Cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Soft 8 Mm X 35 Cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Soft 8 Mm X 60 Cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 14mm X 60cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 16mm X 60cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 18mm X 57cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 20mm X 60cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 24mm X 57cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 28mm X 60cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 32mm X 60cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 4mm X 35cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 5mm X 30cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 6mm X 30cm | other | $333 | $333 | $333 | 1 |
| Ruby Complex Standard 8mm X 40cm | other | $333 | $333 | $333 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Ab... | imaging | $333 | $333 | $333 | 1 |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Pe... | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Head Before and After Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Head with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI Scan of Blood Vessels of Neck with Contrast | imaging | $333 | $333 | $333 | 1 |
| MRI of the Shoulder | imaging | $334 | $7 | $4,594 | 30 |
| Repositioning of Defibrillator Electrode | other | $334 | $334 | $334 | 1 |
| CT Scan of Arm with Contrast | imaging | $334 | $332 | $335 | 2 |
| MRI Scan of Abdomen Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Abdomen with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Arm Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Arm Joint Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Arm with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Blood Vessels of Neck Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Brain Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Brain with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Chest Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Leg Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Leg Joint Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Leg with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Lower Spinal Canal Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Lower Spinal Canal with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Middle Spinal Canal Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Middle Spinal Canal with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Pelvis with Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Upper Spinal Canal Before and After Contrast | imaging | $334 | $333 | $335 | 2 |
| MRI Scan of Upper Spinal Canal with Contrast | imaging | $334 | $333 | $335 | 2 |
| Thyroid Ultrasound | imaging | $334 | $334 | $334 | 1 |
| Dress/debrid P-thick Burn S | other | $334 | $334 | $334 | 1 |
| Neg Press Wound Tx <=50 Cm | other | $334 | $334 | $334 | 1 |
| CT Abdomen and Pelvis | imaging | $335 | $185 | $6,606 | 23 |
| Matristem Micromatrix, 1 Mg | other | $335 | $335 | $335 | 1 |
| Second Stage Repair of Abnormal Anal Drainage Tract | surgery | $336 | $336 | $336 | 1 |
| Tying, Incision, and Stripping of Short Leg Vein | other | $337 | $337 | $337 | 1 |
| Graft Hemashield 28x10x50 | other | $337 | $337 | $337 | 1 |
| Graft Hemashield 30x10x50 | other | $337 | $337 | $337 | 1 |
| Nuclear Medicine Study to Assess Urine Flow | imaging | $337 | $337 | $337 | 1 |
| Implantable Surgical Supplies | surgery | $339 | $339 | $339 | 1 |
| Insertion of Abdominal Cavity Tube Using an Endoscope | other | $340 | $340 | $340 | 1 |
| Destruction of Tongue Tissue, Per Session | other | $340 | $340 | $340 | 1 |
| Accessory Kit Ams 800 #720066 | other | $340 | $340 | $340 | 1 |
| Rom Rad Therapy Gi, Pc | other | $341 | $341 | $341 | 1 |
| Spacemaker Pro Trocar Endoscoic Blunt Tip W/oval Dissection Balloon #smbttovlx | cardiac | $342 | $342 | $342 | 1 |
| Insert Temp Bladder Cath | other | $342 | $342 | $342 | 1 |
| Ruby Complex Soft 10 Mm X 35 Cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Soft 12 Mm X 40 Cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Standard 12mm X 40cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Standard 14mm X 40cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Standard 4mm X 30cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Standard 7mm X 40cm | other | $343 | $343 | $343 | 1 |
| Ruby Complex Standard 9mm X 30cm | other | $343 | $343 | $343 | 1 |
| Removal of Single External and Internal Hemorrhoid Group and Chronic Tear in ... | surgery | $344 | $344 | $344 | 1 |
| Osteogenesis Stimulator, Electrical, Surgically Implanted | surgery | $344 | $344 | $344 | 1 |
| Shunt Carotid Flexcel Inlying #2020 | other | $344 | $344 | $344 | 1 |
| Nuclear Medicine Study, Whole Body | imaging | $344 | $344 | $344 | 1 |
| Intermediate Joint Injection | surgery | $345 | $10 | $10,074 | 19 |
| Active Wound Care/20 Cm OR < | other | $345 | $345 | $345 | 1 |
| Chem Caut of Granltj Tissue | other | $345 | $345 | $345 | 1 |
| Hospital Follow-up Care | other | $346 | $23 | $346 | 7 |
| MRI of the Lower Back (Lumbar) | imaging | $346 | $22 | $3,490 | 11 |
| CT Abdomen and Pelvis without Contrast | imaging | $346 | $22 | $5,912 | 11 |
| Shunt Carotid Pruitt F3 T-port 8f #e2013 | other | $346 | $346 | $346 | 1 |
| Shunt Carotid Pruitt Inahara 2012-11 Min. 3 | other | $346 | $346 | $346 | 1 |
| Skin Substitute, Not Otherwise Specified | other | $346 | $346 | $346 | 1 |
| Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Custom... | other | $346 | $346 | $346 | 1 |
| Repair of Abnormal Anal Drainage Tract | surgery | $346 | $346 | $346 | 1 |
| Skin Tag Removal | other | $347 | $15 | $10,074 | 17 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 2 Grafts | cardiac | $347 | $347 | $347 | 1 |
| Nuclear Medicine Study of Liver | imaging | $347 | $347 | $347 | 1 |
| MRI of the Knee | imaging | $349 | $22 | $4,326 | 30 |
| Removal of Growth of Muscle of Face OR Scalp, Less Than 2.0 Cm | surgery | $349 | $349 | $349 | 1 |
| Removal of Growth Under Skin of Leg OR Ankle, 3.0 Cm OR More | surgery | $350 | $350 | $350 | 1 |
| Graft Hemashield 32x10x50 | other | $350 | $350 | $350 | 1 |
| Rom Rad Therapy Uterus, Pc | other | $350 | $350 | $350 | 1 |
| Exam of Windpipe and Lung Airways Through Permanent Windpipe Opening Using an... | other | $350 | $350 | $350 | 1 |
| Removal of Saliva Gland Under Floor of Mouth | surgery | $350 | $350 | $350 | 1 |
| Removal of Growth Under Skin of Upper Arm OR Elbow, 3.0 Cm OR More | surgery | $351 | $351 | $351 | 1 |
| Exam of Chest with Biopsy of Lymph Node Using an Endoscope | lab | $351 | $351 | $351 | 1 |
| Monitoring and Recording of Esophageal Function Through Nasal Tube | other | $351 | $351 | $351 | 1 |
| Incision of Connective Tissue of Front OR Side of Lower Leg to Relieve Pressure | other | $352 | $352 | $352 | 1 |
| Repair of Wound of Eyelid Margin | surgery | $352 | $352 | $352 | 1 |
| Twist Drill U44-645 | other | $352 | $352 | $352 | 1 |
| Removal OR Destruction of Growth of Nose Through Nose | surgery | $352 | $352 | $352 | 1 |
| Removal of Growth of Finger OR Toe Nerve, Same Digit | surgery | $353 | $353 | $353 | 1 |
| Ankle Foot Orthosis, Plastic with Ankle Joint, Custom Fabricated | other | $353 | $353 | $353 | 1 |
| Insertion of Catheters for Recording and Pacing of Right Heart Chambers Rhythm | cardiac | $353 | $353 | $353 | 1 |
| Hospital Discharge | other | $354 | $81 | $354 | 7 |
| Removal OR Scraping of Skin On Nose | surgery | $354 | $354 | $354 | 1 |
| Tying of Sphenopalatine Artery Using an Endoscope | other | $354 | $354 | $354 | 1 |
| Vh-4000 - System Vein Harvest Connical Dissector Tip with Insulated Jaw Short... | other | $354 | $354 | $354 | 1 |
| Biopsy OR Removal of Deep Lymph Nodes of Neck | surgery | $355 | $355 | $355 | 1 |
| Removal of Growth Under Skin of Thigh OR Knee, Less Than 3.0 Cm | surgery | $355 | $355 | $355 | 1 |
| Pr Rom Rad Therapy Bladder, Pc | other | $356 | $356 | $356 | 1 |
| Nursery - Newborn - Level Iii | obstetric | $356 | $356 | $356 | 1 |
| Exam of Nose and Sinus with Removal of Nasal Sinus Using an Endoscope | surgery | $356 | $356 | $356 | 1 |
| MRI of the Brain | imaging | $357 | $22 | $4,610 | 31 |
| Nuclear Medicine Study of Whole Body for Thyroid Cancer | imaging | $357 | $192 | $521 | 2 |
| Removal of Growth of Muscle of Foot OR Toe, 1.5 Cm OR More | surgery | $358 | $358 | $358 | 1 |
| Study of Stomach to Assess Movement | other | $358 | $358 | $358 | 1 |
| Insertion of Tube Through the Skin for Ecmo External Blood Circulation in Hea... | other | $359 | $359 | $359 | 1 |
| Biopsy OR Removal of Deep Lymph Nodes of Underarm | surgery | $359 | $359 | $359 | 1 |
| Fuzeright Peg and Hole Reaming Kit Sterile #ht-60-8000-s | other | $359 | $359 | $359 | 1 |
| Addition, Endoskeletal System, Above Knee, Ultra-light Material | other | $360 | $360 | $360 | 1 |
| Cath Intra-aortic Balloon 30cc #iab-05830-lws | other | $360 | $360 | $360 | 1 |
| Cath Intra-aortic Balloon 40cc #iab-05840-lws | other | $360 | $360 | $360 | 1 |
| Menquadfi Vial | other | $361 | $361 | $361 | 1 |
| Revision of Abdominal Cavity Tube Using an Endoscope | other | $361 | $361 | $361 | 1 |
| Removal of Growth of Soft Tissue Under Skin of Neck OR Front of Chest, 3.0 Cm... | surgery | $361 | $361 | $361 | 1 |
| Exploration of Neck Artery | other | $361 | $361 | $361 | 1 |
| Fusion of Big Toe Between Toe Joints | surgery | $362 | $362 | $362 | 1 |
| Removal of Growth Under Skin of Shoulder Area, 3.0 Cm OR More | surgery | $362 | $362 | $362 | 1 |
| Release And/or Relocation of Wrist Nerve | other | $363 | $363 | $363 | 1 |
| Incision of Finger Joint for Exploration, Fluid Drainage, OR Removal of Forei... | surgery | $363 | $363 | $363 | 1 |
| Stabilizer Tissue Octopus 4.3 #ts2000 | other | $364 | $364 | $364 | 1 |
| Complicated Drainage of Abscess of Saliva Gland | other | $364 | $364 | $364 | 1 |
| Hbo Therapy Per 30 Min Session | other | $364 | $364 | $364 | 1 |
| Removal of Plaque with Balloon Dilation of Coronary Artery OR Branch, Each Ad... | surgery | $365 | $365 | $365 | 1 |
| Us Exam Abdo Back Wall Lim | other | $365 | $365 | $365 | 1 |
| Us Extremity Non Vascular Lt | other | $365 | $365 | $365 | 1 |
| Breast Ultrasound Complete | imaging | $365 | $365 | $365 | 1 |
| CT Lower Extremity | imaging | $365 | $365 | $365 | 1 |
| Hip Bilateral 2 V | other | $365 | $365 | $365 | 1 |
| Lower Extremity Study | other | $365 | $365 | $365 | 1 |
| Thoracic Spine X-Ray | imaging | $365 | $365 | $365 | 1 |
| Ultrasound Breast Limited | imaging | $365 | $365 | $365 | 1 |
| Us Compl Joint R-t W/img | other | $365 | $365 | $365 | 1 |
| Us Exam Scrotum | other | $365 | $365 | $365 | 1 |
| X-ray Exam of Jaw 4/> Views | imaging | $365 | $365 | $365 | 1 |
| Rotalink Plus Burr 1.25mm #23631 | other | $366 | $366 | $366 | 1 |
| Low Osmolar Contrast Material, 100-199 Mg/ml Iodine Concentration, Per Ml | other | $366 | $366 | $366 | 1 |
| Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis, Rigid, Prefabricated... | other | $366 | $366 | $366 | 1 |
| Removal of Growth of Soft Tissue of Abdominal Wall, 3.0 Cm OR More | surgery | $366 | $366 | $366 | 1 |
| Removal OR Destruction of Growth of Tongue Lymph Node | surgery | $366 | $366 | $366 | 1 |
| Banding of Hemorrhoids Using a Flexible Endoscope | other | $367 | $367 | $367 | 1 |
| Destruction of Polyp OR Growth of Large Bowel Using a Flexible Endoscope | other | $367 | $367 | $367 | 1 |
| Insertion of Left Lower Heart Electrode for Pacemaker OR Defibrillator | cardiac | $367 | $367 | $367 | 1 |
| Removal (1.5 Centimeters OR Greater) Tissue Beneath the Skin Growth of Hand O... | surgery | $368 | $368 | $368 | 1 |
| CT Chest without Contrast | imaging | $368 | $368 | $368 | 1 |
| Injection, Rasburicase, 0.5 Mg | other | $370 | $370 | $370 | 1 |
| Repair of Abnormal Anal Drainage Tract with Implanted Plug | surgery | $372 | $372 | $372 | 1 |
| Test for Detecting Genes Associated with Fetal Disease, Aneuploidy Genomic Se... | other | $372 | $372 | $372 | 1 |
| Pelvic Ultrasound Complete | imaging | $372 | $372 | $372 | 1 |
| X-ray Exam Abdomen 3+ Views | imaging | $372 | $372 | $372 | 1 |
| Simple Revision of Permanent Opening of Windpipe for Breathing | other | $373 | $373 | $373 | 1 |
| Removal of Blood Clot and Portion of Tibial OR Peroneal Artery, Each Addition... | surgery | $373 | $373 | $373 | 1 |
| Inceptiv Recharger #rs7230 | other | $373 | $373 | $373 | 1 |
| Recharger 97755 Intellis Rtm #97755 | other | $373 | $373 | $373 | 1 |
| Skin Biopsy | other | $374 | $19 | $10,074 | 21 |
| Removal of Growth Under Skin of Forearm OR Wrist, 3.0 Cm OR More | surgery | $374 | $374 | $374 | 1 |
| Diagnostic Exam of Knee Using an Endoscope | other | $374 | $374 | $374 | 1 |
| Er-o.v.-established Level 3 | other | $374 | $374 | $374 | 1 |
| Pad Temp Arctic Sun Large Kit #317-09 | other | $375 | $375 | $375 | 1 |
| Pad Temp Arctic Sun Sml Kit #3170502 2ea/1cs | other | $375 | $375 | $375 | 1 |
| Amputation of Toe and Midfoot Bone | other | $375 | $375 | $375 | 1 |
| Removal of Plaque, Insertion of Stent and Balloon Dilation of Coronary Artery... | surgery | $375 | $375 | $375 | 1 |
| Extremity Study | other | $376 | $376 | $376 | 1 |
| Retroperitoneal Ultrasound | imaging | $376 | $376 | $376 | 1 |
| X-ray Exam Abdomen 2 Views | imaging | $376 | $376 | $376 | 1 |
| CT Upper Ext Left W/o Contrast | other | $376 | $376 | $376 | 1 |
| X-ray Exam of Pelvis | imaging | $376 | $376 | $376 | 1 |
| Removal of Tissue From Sphenoid Sinus Using an Endoscope | surgery | $377 | $377 | $377 | 1 |
| Replacement of Small Bowel Tube Using Fluoroscopic Guidance with Contrast | surgery | $378 | $378 | $378 | 1 |
| Incision and Drainage of Abscess Above Pelvic Floor OR Behind Rectum | other | $378 | $378 | $378 | 1 |
| Injection, Paclitaxel, 1 Mg | other | $378 | $378 | $378 | 1 |
| Nuclear Medicine Study of Bone And/or Joint Multiple Areas | imaging | $379 | $379 | $379 | 1 |
| Injection of Substance Into Lower Spine Canal Using Imaging Guidance | other | $380 | $380 | $380 | 1 |
| Octaray Mapping Cable #d-1344 | other | $381 | $381 | $381 | 1 |
| CT Orbit/ear/fossa W/o Dye | other | $381 | $381 | $381 | 1 |
| Nuclear Medicine Study of Kidney and Blood Flow | imaging | $382 | $382 | $382 | 1 |
| Nuclear Medicine Study, Multiple Areas | imaging | $383 | $383 | $383 | 1 |
| Removal OR Partial Removal of Lower End of Forearm Bone On Small Finger Side ... | surgery | $385 | $385 | $385 | 1 |
| Primary Repair of Tendon OR Muscle of Palm Side of Forearm OR Wrist | surgery | $385 | $385 | $385 | 1 |
| Destruction of Second and Third Division of Face Nerve Branch | other | $385 | $385 | $385 | 1 |
| Inner 24 Fr for 26 Fr Outer #a22040a | other | $386 | $386 | $386 | 1 |
| Skin Lesion Destruction | other | $387 | $2 | $10,074 | 17 |
| Placement of Stabilizing Device for Broken End of Finger OR Thumb | other | $387 | $387 | $387 | 1 |
| Removal of Cerebrospinal Fluid with Lower Back Spinal Tap for Diagnostic Test | surgery | $387 | $387 | $387 | 1 |
| Partial Removal of Wrist Bone Near Thumb | surgery | $388 | $388 | $388 | 1 |
| Complicated Plastic Repair of Salivary Duct | surgery | $388 | $388 | $388 | 1 |
| Rom Rad Therapy Cervical, Pc | other | $388 | $388 | $388 | 1 |
| Vision Exam | other | $389 | $91 | $419 | 8 |
| Incision of Tendon of Forearm And/or Wrist, Open Procedure | other | $389 | $389 | $389 | 1 |
| Removal of Growth Under Skin of Back OR Lower Sides, 3.0 Cm OR More | surgery | $389 | $389 | $389 | 1 |
| Large Clip Applier #470230 | other | $391 | $391 | $391 | 1 |
| Injection, Mycophenolate Mofetil, 10 Mg | other | $392 | $392 | $392 | 1 |
| Injection, Estrogen Conjugated, Per 25 Mg | other | $392 | $392 | $392 | 1 |
| Addition, Endoskeletal Knee-shin System, Polycentric, Mechanical Stance Phase... | other | $392 | $392 | $392 | 1 |
| Incision of Connective Tissue of Back of Lower Leg to Relieve Pressure | other | $392 | $392 | $392 | 1 |
| Injection, Iron Sucrose, 1 Mg | other | $393 | $393 | $393 | 1 |
| CT Abdomen without Contrast | imaging | $393 | $393 | $393 | 1 |
| Tying, Incision, and Stripping of Long Leg Vein | other | $394 | $394 | $394 | 1 |
| Repair of Groin Hernia Using an Endoscope | surgery | $394 | $394 | $394 | 1 |
| Elastomeric Pump Reservoir 8 Ml/hr | other | $395 | $395 | $395 | 1 |
| Tissueblue 0.025% Syringe | other | $396 | $396 | $396 | 1 |
| Release And/or Relocation of Hand Nerve | other | $396 | $396 | $396 | 1 |
| Rom Rad Therapy Anal, Pc | other | $396 | $396 | $396 | 1 |
| Rom Rad Ther Head/neck, Pc | other | $397 | $397 | $397 | 1 |
| Removal of Extra Breast Tissue in Male | surgery | $397 | $397 | $397 | 1 |
| CT Contrast Low Osmolar 200-299ml | imaging | $397 | $397 | $397 | 1 |
| Biopsy of Tissue of Chest Using an Endoscope | lab | $398 | $398 | $398 | 1 |
| Repair of Fibrous Tissue of Arch of Foot Using an Endoscope | surgery | $398 | $398 | $398 | 1 |
| Repair of Abnormal Drainage Tract Between Nasal Sinuses | surgery | $398 | $398 | $398 | 1 |
| Repair of Abnormal Drainage Tract in Anal Sphincter | surgery | $399 | $399 | $399 | 1 |
| Clip Flex 35mm Atriclip #ach235 | other | $399 | $399 | $399 | 1 |
| Clip Flex 40mm Atriclip #ach240 | other | $399 | $399 | $399 | 1 |
| Clip Flex 45mm Atriclip #ach245 | other | $399 | $399 | $399 | 1 |
| Endoscope, Single-use | other | $399 | $399 | $399 | 1 |
| Laa Exclusion Sys Flex 50mm Clip #a000919 | other | $399 | $399 | $399 | 1 |
| Stent, Non-coated/non-covered, with Delivery System | cardiac | $399 | $399 | $399 | 1 |
| Complete Exam of Nose and Sinuses Using an Endoscope | other | $399 | $399 | $399 | 1 |
| Graft Jacket | other | $399 | $399 | $399 | 1 |
| Complex Application of Radiation Source | other | $400 | $400 | $400 | 1 |
| Gradient Compression Garment, Full Leg and Foot, Padded, for Nighttime Use, C... | other | $401 | $401 | $401 | 1 |
| Review By Radiologist of MRI Guidance for Needle Placement | imaging | $401 | $401 | $401 | 1 |
| Bexsero Prefilled Syringe | other | $401 | $401 | $401 | 1 |
| Removal of Growth Under Skin of Pelvis and Hip, 3.0 Cm OR More | surgery | $401 | $401 | $401 | 1 |
| Programmer Kit Interstim Smart #th90q01 | other | $402 | $402 | $402 | 1 |
| Insertion of Tube for Ecmo External Blood Circulation in Heart and Lungs Usin... | cardiac | $402 | $402 | $402 | 1 |
| Repair Umbilical Hernia, Age 5 Years OR Older; Incarcerated OR Strangulated | surgery | $404 | $404 | $404 | 1 |
| Removal of Cyst OR Growth of Wrist Bone | surgery | $404 | $404 | $404 | 1 |
| Drainage of Skin Abscess | other | $404 | $404 | $404 | 1 |
| Removal of Fluid-filled Sac (bursa) OR Calcium Deposit of Pelvis | surgery | $405 | $405 | $405 | 1 |
| Biopsy OR Removal of Lymph Nodes of Neck with Removal of Fat Pad | surgery | $406 | $406 | $406 | 1 |
| Aspiration of Fluid From Cyst of Spinal Cord OR Fluid-filled Cavity | other | $406 | $406 | $406 | 1 |
| Closure of Permanent Windpipe Opening OR Abnormal Drainage Tract with Plastic... | other | $407 | $407 | $407 | 1 |
| Management of Complete Single Session Course of Stereotactic Radiation Treatm... | other | $407 | $407 | $407 | 1 |
| Removal of Infected Neck Graft | surgery | $407 | $407 | $407 | 1 |
| Repair Epigastric Hernia (eg, Preperitoneal Fat); Incarcerated OR Strangulated | surgery | $409 | $409 | $409 | 1 |
| Knee Orthosis, without Knee Joint, Rigid, Custom Fabricated | other | $410 | $410 | $410 | 1 |
| Lumbar-sacral Orthosis, Sagittal-coronal Control, Rigid Shell(s)/panel(s), Po... | lab | $411 | $411 | $411 | 1 |
| Removal of Growth of Muscle of Leg OR Ankle, Less Than 5.0 Cm | surgery | $411 | $411 | $411 | 1 |
| Incision of Bladder with Removal of Bladder Stone | surgery | $412 | $412 | $412 | 1 |
| Diagnostic Exam of Wrist Using an Endoscope | other | $412 | $412 | $412 | 1 |
| Incision of Connective Tissue of Front And/or Side and Back of Lower Leg to R... | other | $413 | $413 | $413 | 1 |
| Repair of Brow Paralysis | surgery | $413 | $413 | $413 | 1 |
| Closed Treatment of Back Portion of Shin Bone At Ankle with Manipulation | other | $413 | $413 | $413 | 1 |
| Implantation of Cochlear Stimulating System Into Skull with Attachment Throug... | surgery | $413 | $413 | $413 | 1 |
| Release of Ligaments of Knee Joint | other | $414 | $414 | $414 | 1 |
| Aspiration And/or Injection of Cyst of Kidney | other | $416 | $382 | $449 | 2 |
| Complicated Control of Bleeding of Throat | other | $417 | $417 | $417 | 1 |
| Lengthening OR Shortening of Tendon of Leg OR Ankle | other | $419 | $419 | $419 | 1 |
| Diagnostic Exam of Shoulder Using an Endoscope | other | $420 | $420 | $420 | 1 |
| Partial Removal of Breast | surgery | $423 | $423 | $423 | 1 |
| Revision of Prosthetic Vaginal Graft | other | $423 | $423 | $423 | 1 |
| Correction of Rigid Deformity of First Joint of Big Toe Using Implant | surgery | $424 | $424 | $424 | 1 |
| Aspiration of Fluid From Chest Cavity Using Imaging Guidance | other | $424 | $424 | $424 | 1 |
| Path Consult Intraop Frozen Se | other | $425 | $425 | $425 | 1 |
| Microporous Collagen Implantable Tube (neuragen Nerve Guide), Per Centimeter ... | surgery | $426 | $426 | $426 | 1 |
| Repair of Defect OR Tear of Eardrum | surgery | $426 | $426 | $426 | 1 |
| Placement of Stabilizing Device for Broken Finger OR Thumb At Midportion OR P... | other | $428 | $428 | $428 | 1 |
| Repair Spigelian Hernia | surgery | $428 | $428 | $428 | 1 |
| Delivery of Single Session of Intraoperative Radiation Treatment with X-ray | imaging | $428 | $428 | $428 | 1 |
| Hip Orthosis, Abduction Control of Hip Joint, Postoperative Hip Abduction Typ... | other | $429 | $429 | $429 | 1 |
| Incision of Bladder with Insertion of Tube OR Stent in Ureter | cardiac | $431 | $431 | $431 | 1 |
| Rom Rad Therapy Prostate, Pc | other | $432 | $432 | $432 | 1 |
| Removal of Navel and Surrounding Tissue | surgery | $432 | $432 | $432 | 1 |
| Injection, Phentolamine Mesylate, Up to 5 Mg | other | $432 | $432 | $432 | 1 |
| Nervous System Surgery | surgery | $432 | $432 | $432 | 1 |
| Removal of Lining of Large Bowel Using an Endoscope Inserted Through Surgical... | surgery | $434 | $434 | $434 | 1 |
| Treatment of Broken Finger Bone with Stabilizing Device Accessed Through Skin | other | $435 | $435 | $435 | 1 |
| Needle Biopsy of Lining of Lung | lab | $435 | $382 | $487 | 2 |
| Removal of Multiple Hemorrhoid Groups and Chronic Tear in Anus | surgery | $437 | $437 | $437 | 1 |
| Removal of Plaque with Balloon Dilation of Single Coronary Artery OR Branch | surgery | $437 | $437 | $437 | 1 |
| Mometasone Furoate Sinus Implant, 370 Micrograms | surgery | $438 | $438 | $438 | 1 |
| Removal of Wrist Bone | surgery | $438 | $438 | $438 | 1 |
| Closed Treatment of Broken Hand Bone with Manipulation and Placement of Exter... | other | $439 | $439 | $439 | 1 |
| Release of Arm OR Leg Nerve | other | $439 | $439 | $439 | 1 |
| Custom Shaped Protective Cover, Above Knee | other | $439 | $439 | $439 | 1 |
| Aspiration of Initial Secretion of Lung Airway Using an Endoscope | other | $440 | $408 | $472 | 2 |
| Primary Repair of Tendon OR Muscle of Top Side of Forearm OR Wrist | surgery | $441 | $441 | $441 | 1 |
| Partial Removal of Wrist Joint Lining Using an Endoscope | surgery | $441 | $441 | $441 | 1 |
| Stent, Non-coated/non-covered, without Delivery System | cardiac | $442 | $442 | $442 | 1 |
| Release And/or Relocation of Cranial Nerve | other | $442 | $442 | $442 | 1 |
| Removal of Deep Lymph Nodes of Neck | surgery | $442 | $442 | $442 | 1 |
| Coronary Artery Bypass OR Valve Procedure Reoperation More Than 1 Month After... | cardiac | $444 | $444 | $444 | 1 |
| Partial Removal of Knee Joint Lining Using an Endoscope | surgery | $444 | $444 | $444 | 1 |
| Graft Hemashield 30x10x8x8x10mm #175930p | other | $444 | $444 | $444 | 1 |
| Secondary Closure OR Revision of Scar At Previous Thigh Amputation | other | $445 | $445 | $445 | 1 |
| Gene Analysis (cystic Fibrosis Transmembrane Conductance Regular) Common Vari... | other | $446 | $446 | $446 | 1 |
| Repair Umbilical Hernia, Age 5 Years OR Older; Reducible | surgery | $449 | $449 | $449 | 1 |
| Removal of Multiple Hemorrhoid Groups | surgery | $449 | $449 | $449 | 1 |
| Pod 12mm X 60cm Coil Rbypod12 | other | $450 | $450 | $450 | 1 |
| Biopsy and Removal of Lymph Nodes of Abdominal Cavity Using an Endoscope | surgery | $450 | $450 | $450 | 1 |
| Exploration, Drainage, Biopsy, OR Removal of Foreign Body in Chest Cavity Thr... | surgery | $450 | $450 | $450 | 1 |
| Removal of Joint Lining and Repair of Tendon On the Topside of Finger | surgery | $451 | $451 | $451 | 1 |
| Removal of Growth of Muscle of Face OR Scalp, 2.0 Cm OR More | surgery | $451 | $451 | $451 | 1 |
| Removal of Congenital Cyst OR Abnormal Drainage Tract of Neck And/or Throat | surgery | $452 | $452 | $452 | 1 |
| Treatment of Broken Midportion of Foot | other | $452 | $452 | $452 | 1 |
| Repair of Abnormal Drainage Tract Around Anal Sphincter | surgery | $453 | $453 | $453 | 1 |
| Removal of Defect in Wall of Esophagus Using a Rigid Endoscope | surgery | $454 | $454 | $454 | 1 |
| Anti-xa | other | $454 | $454 | $454 | 1 |
| Bydureon Bcise 2 Mg Autoinject | other | $456 | $456 | $456 | 1 |
| Cranial Access W/subdural Port Medtronic | other | $457 | $457 | $457 | 1 |
| Repair of Tendon, Finger, And/or Palm of Hand | surgery | $457 | $457 | $457 | 1 |
| Intensive Care Unit - Intermediate ICU | other | $458 | $458 | $458 | 1 |
| Removal OR Repair of Wrist Cartilage Using an Endoscope | surgery | $458 | $458 | $458 | 1 |
| Placement of Stabilizing Device for Dislocated Hand Bone At Wrist Joint with ... | other | $458 | $458 | $458 | 1 |
| Procedure Kit Illumisite 180 #ils-1800-kt | other | $459 | $459 | $459 | 1 |
| Release of Finger Nerve | other | $459 | $459 | $459 | 1 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 3 Grafts | cardiac | $459 | $459 | $459 | 1 |
| Repair of Hand Muscle | surgery | $461 | $461 | $461 | 1 |
| Biopsy of Esophagus Using a Flexible Endoscope Through Mouth | lab | $461 | $461 | $461 | 1 |
| Injection Into Esophagus Using a Flexible Endoscope | other | $461 | $461 | $461 | 1 |
| Drainage of Tendon of Finger And/or Palm | other | $462 | $462 | $462 | 1 |
| Creation of Opening of Windpipe and Insertion of Speech Prosthesis | other | $463 | $463 | $463 | 1 |
| Destruction of Heart Conduction Tissue to Create Heart Block | cardiac | $463 | $463 | $463 | 1 |
| Diagnostic Exam of Esophagus Using a Flexible Endoscope Through Mouth | other | $463 | $463 | $463 | 1 |
| Removal of Growth of Muscle of Hand OR Finger, Less Than 1.5 Cm | surgery | $463 | $463 | $463 | 1 |
| Balloon Dilation of Esophagus Using a Flexible Endoscope, Less Than 3.0 Cm | other | $464 | $464 | $464 | 1 |
| Dilation of Esophagus with Insertion of Guide Wire Using a Flexible Endoscope | other | $464 | $464 | $464 | 1 |
| Needle Biopsy OR Removal of Surface Lymph Nodes | surgery | $464 | $464 | $464 | 1 |
| Removal of Foreign Bodies in Esophagus Using a Flexible Endoscope | surgery | $464 | $464 | $464 | 1 |
| Pretreatment of Rbc By Density | other | $465 | $465 | $465 | 1 |
| Removal of Scar Tissue to Release Tendon of Forearm OR Wrist | surgery | $466 | $466 | $466 | 1 |
| Incision of Ear Canal with Release of Scar Tissue | other | $468 | $468 | $468 | 1 |
| Incision of Elbow Tendon with Removal of Tissue | surgery | $468 | $468 | $468 | 1 |
| Removal of Infected Skin, Tissue OR Muscle of Genitals | surgery | $470 | $470 | $470 | 1 |
| Partial Removal of Shoulder Joint Lining Using an Endoscope | surgery | $471 | $471 | $471 | 1 |
| Repair of Groin Hernia | surgery | $471 | $471 | $471 | 1 |
| Therapy Using Electrical Currents | other | $471 | $471 | $471 | 1 |
| Albumin (human) 5% Glass Bottl | other | $472 | $472 | $472 | 1 |
| Biopsy of Lung Airway Using an Endoscope | lab | $473 | $473 | $473 | 1 |
| Diagnostic Exam of Lung Airway Using an Endoscope | other | $473 | $473 | $473 | 1 |
| Exam of Lung Airways Using an Endoscope | other | $473 | $473 | $473 | 1 |
| Irrigation and Suction of Lung Airways to Obtain Cells Using an Endoscope | other | $473 | $473 | $473 | 1 |
| Needle Biopsy of Windpipe Cartilage, Airway, And/or Lung Using an Endoscope | lab | $473 | $473 | $473 | 1 |
| Removal of Foreign Body in Lung Airways Using an Endoscope | surgery | $473 | $473 | $473 | 1 |
| Removal of Loose OR Foreign Body in Knee Joint Using an Endoscope | surgery | $474 | $474 | $474 | 1 |
| Removal of Tendon of Forearm And/or Wrist | surgery | $475 | $475 | $475 | 1 |
| Removal of Growth of Muscle of Forearm OR Wrist, 3.0 Cm OR More | surgery | $475 | $475 | $475 | 1 |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated Socket ... | other | $475 | $475 | $475 | 1 |
| Laceration Repair | emergency | $476 | $11 | $10,074 | 20 |
| Annual Wellness Visit (New) | preventive | $476 | $39 | $476 | 7 |
| Placement of Locating Device in Breast Using Imaging Guidance, First Growth | other | $476 | $456 | $496 | 2 |
| Diagnostic Exam of Jaw Joint Using an Endoscope | other | $476 | $476 | $476 | 1 |
| Vivigen Mis Delivery System Bl-1900 | obstetric | $476 | $476 | $476 | 1 |
| Amniomatrix OR Biodmatrix, Injectable, 1 Cc | other | $479 | $479 | $479 | 1 |
| Hip Extraction System S9-hip S9hip | other | $479 | $479 | $479 | 1 |
| Universal Knee Implant Extraction System #s9kne #s9knee | surgery | $479 | $479 | $479 | 1 |
| Removal of Growth of Muscle of Hand OR Finger, 1.5 Cm OR More | surgery | $480 | $480 | $480 | 1 |
| Removal of Infected Graft of Arm OR Leg | surgery | $481 | $481 | $481 | 1 |
| Diagnostic Exam of Small Bowel Using an Endoscope Inserted Through Surgically... | surgery | $481 | $481 | $481 | 1 |
| Replacement of Peripherally Inserted Central Venous Tube (picc) with Review B... | surgery | $481 | $481 | $481 | 1 |
| Removal of Knee Cartilage Using an Endoscope | surgery | $483 | $483 | $483 | 1 |
| Limited Removal of Abnormal Shoulder Joint Tissue Using Endoscope | surgery | $483 | $483 | $483 | 1 |
| Repair of Abnormal Anal Drainage Tract with Rectal Tissue Flap | surgery | $484 | $484 | $484 | 1 |
| Incision OR Removal of Spinal Nerve | surgery | $485 | $485 | $485 | 1 |
| Needle Biopsy of Pancreas | lab | $487 | $487 | $487 | 1 |
| Release of Ligaments At Outer Side of Knee Joint Using an Endoscope | other | $487 | $487 | $487 | 1 |
| Graft Hemashield 32x12x10x10x10mm #175732p | other | $488 | $488 | $488 | 1 |
| Lumbar-sacral Orthosis, Sagittal-coronal Control, with Rigid Anterior and Pos... | other | $491 | $491 | $491 | 1 |
| Exploration (not Followed By Surgical Repair), with OR without Lysis of Arter... | surgery | $491 | $491 | $491 | 1 |
| Nuclear Medicine Study of Parathyroid with SPECT and CT Scan | imaging | $492 | $492 | $492 | 1 |
| Clip Flexv Dvice W/vclp 50mm Atriclip Achv50 | other | $492 | $492 | $492 | 1 |
| Dissector Articlating Instrument #mid1 | other | $492 | $492 | $492 | 1 |
| Tlso, Triplanar Control, Modular Segmented Spinal System, Four Rigid Plastic ... | other | $493 | $493 | $493 | 1 |
| Complications of Treatment without Cc/mcc | other | $493 | $493 | $493 | 1 |
| Incision of Hand OR Finger Bone | other | $493 | $493 | $493 | 1 |
| Cable Torch Grip 5 X 115mm 71340004 | other | $493 | $493 | $493 | 1 |
| Injection, Etanercept, 25 Mg | other | $494 | $494 | $494 | 1 |
| Shock Wave Crushing of Kidney Stones | other | $495 | $495 | $495 | 1 |
| Biopsy OR Removal of Lymph Nodes of Breast | surgery | $496 | $496 | $496 | 1 |
| Lengthening OR Shortening of Tendon of Forearm And/or Wrist | other | $499 | $499 | $499 | 1 |
| Removal of Both Knee Cartilages Using an Endoscope | surgery | $499 | $499 | $499 | 1 |
| Removal of Growth of Rectum Through Anus | surgery | $499 | $499 | $499 | 1 |
| Removal of Blood Clot of Artery OR Vein Graft | surgery | $500 | $500 | $500 | 1 |
| Intracept Access Instruments #rlv 0045 | other | $500 | $500 | $500 | 1 |
| Repair of Femoral Groin Hernia | surgery | $500 | $500 | $500 | 1 |
| Removal of Diseased Part of Forearm Bone On Small Finger Side | surgery | $501 | $501 | $501 | 1 |
| Insertion of Indwelling Tube for Drainage of Lung Fluid | other | $502 | $173 | $831 | 2 |
| Ocular Implant, Aqueous Drainage Assist Device | surgery | $502 | $502 | $502 | 1 |
| Knee Ankle Foot Orthosis, Double Upright, Free Ankle, Solid Stirrup, Thigh an... | other | $503 | $503 | $503 | 1 |
| Spinal Cs Charging Sys Restoresensor #97754 | other | $504 | $504 | $504 | 1 |
| Removal of Blood Clot in Artery of Upper Arm | surgery | $504 | $504 | $504 | 1 |
| Removal of Blood Clot in Artery of Lower Arm | surgery | $505 | $505 | $505 | 1 |
| 23x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 | $505 | 1 |
| 41x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 | $505 | 1 |
| Connective Tissue, Human | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 4x100mm #lx1813041004f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 4x40mm #lx181304404f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 4x60mm #lx181304604f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 4x80mm #lx181304804f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 5x100mm #lx1813051005f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 5x40mm #lx181305405f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 5x60mm #lx181305605f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 5x80mm #lx181305805f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 6x100mm #lx1813061005f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 6x40mm #lx181306405f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 6x60mm #lx181306605f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 7x100mm #lx1813071005f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 7x40mm #lx181307405f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 7x60mm #lx181307605f | other | $505 | $505 | $505 | 1 |
| Lutonix .018" Dcb 130cm 7x80mm #lx181307805f | other | $505 | $505 | $505 | 1 |
| Removal of Growth of Soft Tissue of Pelvis and Hip, Less Than 5.0 Cm | surgery | $505 | $505 | $505 | 1 |
| Vbr-s Dev 26mm X 11mm X 14mm #06-115 | other | $505 | $505 | $505 | 1 |
| Vbr-s Dev 29mm X 11mm X 14mm #06-115 | other | $505 | $505 | $505 | 1 |
| Removal of Cyst OR Growth of Wrist Bone with Self Bone Graft | surgery | $506 | $506 | $506 | 1 |
| CT Guidance for Tissue Removal | surgery | $508 | $508 | $508 | 1 |
| Secondary Closure OR Revision of Scar of Lower Leg Bone Amputation | other | $510 | $510 | $510 | 1 |
| Tying of Ethmoidal Artery Ethmoidal for Control of Nose Bleed | other | $510 | $510 | $510 | 1 |
| Repair of Recurrent Groin Hernia Using an Endoscope | surgery | $510 | $510 | $510 | 1 |
| External Shock to Heart to Regulate Heart Beat | cardiac | $510 | $510 | $510 | 1 |
| Toenail Removal | surgery | $511 | $63 | $10,074 | 20 |
| Dialysis | other | $513 | $2 | $114,715 | 37 |
| Removal of Cyst OR Growth of Lower Leg Bone | surgery | $513 | $513 | $513 | 1 |
| Treatment of Broken Finger At Midportion OR Part Near Hand | other | $513 | $513 | $513 | 1 |
| Treatment of Broken Midhand Bone | other | $513 | $513 | $513 | 1 |
| Balloon Dilation of Pulmonary Artery, Single Vessel | other | $514 | $514 | $514 | 1 |
| Repair of Sliding Groin Hernia | surgery | $514 | $514 | $514 | 1 |
| Punch Bx Skin Single Lesion | other | $515 | $515 | $515 | 1 |
| Removal of Loose OR Foreign Body in Shoulder Joint Using an Endoscope | surgery | $516 | $516 | $516 | 1 |
| Removal of Plaque, Insertion of Stent and Balloon Dilation of Single Coronary... | surgery | $516 | $516 | $516 | 1 |
| Removal of Plaque, Insertion of Stent And/or Balloon Dilation of Coronary Ves... | surgery | $516 | $516 | $516 | 1 |
| Immediate Post Surgical OR Early Fitting, Application of Initial Rigid Dressi... | surgery | $517 | $517 | $517 | 1 |
| Removal of Shoulder Scar Tissue Using an Endoscope | surgery | $518 | $518 | $518 | 1 |
| Labor Room/delivery - General Classification | obstetric | $519 | $519 | $519 | 1 |
| Removal of Foreskin | surgery | $519 | $519 | $519 | 1 |
| Nuclear Medicine Study of Cerebrospinal Fluid Flow After Injection of Contras... | imaging | $521 | $521 | $521 | 1 |
| Nuclear Medicine Study, Whole Body Requiring Multiple Imaging Days | imaging | $521 | $521 | $521 | 1 |
| Technetium Tc-99m Tilmanocept, Diagnostic, Up to 0.5 Millicuries | other | $521 | $521 | $521 | 1 |
| Repair of Bulging of Rectum Into Vagina | surgery | $522 | $522 | $522 | 1 |
| Removal of Extensive Shoulder Joint Tissue Using an Endoscope | surgery | $523 | $523 | $523 | 1 |
| Creation of Surgical Opening From Stomach to Skin Using an Endoscope | surgery | $525 | $525 | $525 | 1 |
| Insertion of Small Bowel Tube Using Fluoroscopic Guidance with Contrast | other | $526 | $526 | $526 | 1 |
| Removal of Growth of Saliva Gland OR Saliva Gland, Lateral Lobe | surgery | $526 | $526 | $526 | 1 |
| Carotid Duplex Ultrasound | imaging | $527 | $227 | $740 | 6 |
| Removal of Connective Tissue of Palm | surgery | $527 | $527 | $527 | 1 |
| Repair of Trapped Groin Hernia | surgery | $527 | $527 | $527 | 1 |
| Drainage of Abscess of Throat From Outside Mouth | other | $528 | $528 | $528 | 1 |
| Removal of Growth of Muscle of Abdomen, 5.0 Cm OR More | surgery | $528 | $528 | $528 | 1 |
| Tlso, Triplanar Control, One Piece Rigid Plastic Shell with Interface Liner, ... | other | $529 | $529 | $529 | 1 |
| Addition to Lower Extremity, Endoskeletal System, Above Knee - Knee Disarticu... | other | $529 | $529 | $529 | 1 |
| Partial Destruction and Reconstruction of Right Upper Heart Chamber | cardiac | $529 | $529 | $529 | 1 |
| IUD Insertion | other | $536 | $22 | $4,962 | 35 |
| Removal of Large Bowel Tissue Using a Flexible Endoscope | surgery | $536 | $536 | $536 | 1 |
| Removal of Appendix Using an Endoscope | surgery | $537 | $537 | $537 | 1 |
| Ankle Foot Orthosis, Walking Boot Type, Varus/valgus Correction, Rocker Botto... | other | $538 | $538 | $538 | 1 |
| Release And/or Relocation of Elbow Nerve | other | $538 | $538 | $538 | 1 |
| Ultrasound Evaluation of Heart Blood Vessel During Diagnosis OR Treatment, Ea... | imaging | $539 | $539 | $539 | 1 |
| Critical Care | emergency | $541 | $2 | $3,727 | 21 |
| Repair of Recurrent Femoral Groin Hernia | surgery | $541 | $541 | $541 | 1 |
| Removal of Multiple Wrist Bones | surgery | $542 | $542 | $542 | 1 |
| Treatment of Dislocated Wrist Bones | other | $542 | $542 | $542 | 1 |
| Airway Inhalation Treatment | other | $542 | $542 | $542 | 1 |
| Pos Airway Pressure CPAP | other | $542 | $542 | $542 | 1 |
| Knee Orthosis, Double Upright, Thigh and Calf, with Adjustable Flexion and Ex... | other | $543 | $543 | $543 | 1 |
| Treatment of Broken Thumb At Wrist | other | $543 | $543 | $543 | 1 |
| Nuclear Medicine Study of Heart Muscle At Rest and with Stress and SPECT | imaging | $545 | $61 | $1,028 | 2 |
| Insertion of Stomach Tube Using Fluoroscopic Guidance with Contrast | other | $548 | $526 | $570 | 2 |
| Removal of Scar Tissue From Knee Using an Endoscope | surgery | $549 | $549 | $549 | 1 |
| Removal OR Shaving of Knee Joint Cartilage Using an Endoscope | surgery | $549 | $549 | $549 | 1 |
| Epifix 1 SQ Cm | other | $549 | $549 | $549 | 1 |
| Repair Recurrent Incisional OR Ventral Hernia; Reducible | surgery | $550 | $550 | $550 | 1 |
| Addition to Lower Extremity, Above Knee, Flexible Inner Socket, External Frame | other | $551 | $551 | $551 | 1 |
| Addition to Lower Extremity, Below Knee, Flexible Inner Socket, External Frame | other | $551 | $551 | $551 | 1 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 4 Grafts | cardiac | $551 | $551 | $551 | 1 |
| IOL Akreos Lens B&l | other | $551 | $551 | $551 | 1 |
| Delivery of Fixation Device to Graft with Review By Radiologist | obstetric | $552 | $552 | $552 | 1 |
| Repair of Joint Between Hand and Finger Bones with Prosthesis | surgery | $552 | $552 | $552 | 1 |
| Repair of Congenital Defect of Bladder | surgery | $552 | $552 | $552 | 1 |
| Removal of Growth of Muscle of Back OR Lower Sides, Less Than 5.0 Cm | surgery | $553 | $553 | $553 | 1 |
| Complicated Treatment of Dislocated Midhand Bone At Wrist | other | $554 | $554 | $554 | 1 |
| Partial Removal of Lymph Nodes of Underarm | surgery | $555 | $555 | $555 | 1 |
| Interfyl, 1 Mg | other | $556 | $556 | $556 | 1 |
| Removal of Growth Under Nasal Bone OR Cartilage | surgery | $557 | $557 | $557 | 1 |
| Fusion of Finger Joint, Initial Joint | surgery | $557 | $557 | $557 | 1 |
| Insertion of Sacral Nerve Neurostimulator Electrode | other | $558 | $558 | $558 | 1 |
| Lymph OR Ln Nm Scan | other | $558 | $558 | $558 | 1 |
| Neg Press Wnd Tx <=50 SQ Cm | other | $558 | $558 | $558 | 1 |
| Reshaping of Nasal Cartilage | other | $559 | $559 | $559 | 1 |
| Repair Initial Incisional OR Ventral Hernia; Reducible | surgery | $559 | $559 | $559 | 1 |
| Repair of Trapped Femoral Groin Hernia | surgery | $559 | $559 | $559 | 1 |
| Diagnostic Exam of Small Bowel (excluding Lower Small Intestine) Using an End... | other | $559 | $559 | $559 | 1 |
| Biopsy of Small Bowel (except Ileum) Using an Endoscope | lab | $561 | $561 | $561 | 1 |
| CT Pelvis W/o Dye | other | $562 | $562 | $562 | 1 |
| CT Soft Tissue Neck W/o Dye | other | $562 | $562 | $562 | 1 |
| CT Scan of the Chest | imaging | $563 | $22 | $1,316 | 12 |
| Removal of Appendix | surgery | $563 | $563 | $563 | 1 |
| Drainage of Lymph Fluid to Abdominal Cavity Using an Endoscope | other | $563 | $563 | $563 | 1 |
| CT Sinus without Contrast | imaging | $563 | $563 | $563 | 1 |
| Repair of Groin Hernia That Is Not Trapped | surgery | $564 | $564 | $564 | 1 |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Fi... | imaging | $564 | $564 | $564 | 1 |
| Removal of Plaque, Insertion of Stent And/or Balloon Dilation, Each Additiona... | surgery | $566 | $566 | $566 | 1 |
| Removal of Lymph Nodes of Both Sides of Pelvis Using an Endoscope | surgery | $566 | $566 | $566 | 1 |
| Connective Tissue, Non-human | other | $569 | $569 | $569 | 1 |
| Treatment of Broken Outer Lower Leg Bone At Ankle | other | $570 | $570 | $570 | 1 |
| Intensive Care Unit - General Classification | other | $571 | $388 | $754 | 2 |
| 8x21x32mm 7 Degree Tm-400 Dev #06-131 | other | $572 | $572 | $572 | 1 |
| Removal of Foreskin Using Clamp OR Device | surgery | $572 | $572 | $572 | 1 |
| Repair of Openings of Nasal Cartilage | surgery | $573 | $573 | $573 | 1 |
| Velys Puresight Array Set Knee 4515-70-011 Minimum Order 5 Each | other | $573 | $573 | $573 | 1 |
| Hydration IV Infusion Init | surgery | $573 | $573 | $573 | 1 |
| Amputation of Foot Across Instep | other | $574 | $574 | $574 | 1 |
| Complex Removal of Soft Tissue of Roof of Mouth | surgery | $575 | $575 | $575 | 1 |
| Injection, Tetanus Immune Globulin, Human, Up to 250 Units | other | $575 | $557 | $593 | 2 |
| Removal of Joint Lining From Multiple Knee Joint Compartments Using an Endoscope | surgery | $576 | $576 | $576 | 1 |
| Repair of Left Upper Heart Chamber with Implant with Review By Radiologist | surgery | $576 | $576 | $576 | 1 |
| Biopsy of Large Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $578 | $578 | $578 | 1 |
| Repair of Tendon OR Muscle On Top Side of Forearm OR Wrist with Graft | surgery | $578 | $578 | $578 | 1 |
| Incision and Repair of Elbow Tendon with Removal of Tissue OR Bone | surgery | $578 | $578 | $578 | 1 |
| Echocardiogram | imaging | $579 | $7 | $11,016 | 38 |
| CT Cervical Spine without Contrast | imaging | $579 | $579 | $579 | 1 |
| Other Procedure On Appendix Using an Endoscope | other | $580 | $580 | $580 | 1 |
| Tying of Dilated Veins of Stomach And/or Esophagus Using a Flexible Endoscope | other | $580 | $580 | $580 | 1 |
| Creation of Opening From Small Bowel to Skin with Insertion of a Tube for Dec... | other | $580 | $580 | $580 | 1 |
| CT Lumbar Spine without Contrast | imaging | $580 | $580 | $580 | 1 |
| Lumbar Puncture (Spinal Tap) | other | $581 | $18 | $2,476 | 23 |
| Pneumococcal Conjugate Vaccine, 20 Valent (pcv20), for Intramuscular Use | preventive | $583 | $583 | $583 | 1 |
| Removal of Infected Skin, Tissue OR Muscle of Genitals, Perineum, OR Abdomen | surgery | $583 | $583 | $583 | 1 |
| Repair of Knee Joint with Drilling and OR Scraping of Joint Using an Endoscope | surgery | $583 | $583 | $583 | 1 |
| Multiple Incisions of Connective Tissue of Thigh And/or Knee to Relieve Pressure | other | $584 | $584 | $584 | 1 |
| Amputation of Thigh Through Thigh Bone Leaving Wound | other | $585 | $585 | $585 | 1 |
| Closure Device, Vascular | other | $585 | $585 | $585 | 1 |
| Lutonix .018" Dcb 130cm 5x150mm #lx1813051505f | other | $585 | $585 | $585 | 1 |
| Lutonix .018" Dcb 130cm 6x150mm #lx1813061505f | other | $585 | $585 | $585 | 1 |
| Lutonix .018" Dcb 130cm 7x150mm #lx1813071505f | other | $585 | $585 | $585 | 1 |
| Microporous Collagen Implantable Slit Tube (neurawrap Nerve Protector), Per C... | surgery | $585 | $585 | $585 | 1 |
| Repair of Forearm And/or Wrist Tendon Covering with Graft | surgery | $585 | $585 | $585 | 1 |
| Removal of Gallbladder Using an Endoscope | surgery | $586 | $586 | $586 | 1 |
| Injection of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible En... | other | $588 | $588 | $588 | 1 |
| Repair of Ruptured Achilles Tendon | surgery | $588 | $588 | $588 | 1 |
| Repair of Penis | surgery | $589 | $589 | $589 | 1 |
| Dilation of Stomach Outlet Using a Flexible Endoscope | other | $590 | $590 | $590 | 1 |
| Exploration of Stomach OR Removal of Foreign Body in Stomach | surgery | $593 | $593 | $593 | 1 |
| Treatment of Broken Midpart of Forearm Bone On Thumb Side | other | $594 | $594 | $594 | 1 |
| Placement of Stabilizing Device for Broken Forearm Bone On Thumb Side At Wrist | other | $595 | $595 | $595 | 1 |
| Release of Hand Muscle | other | $595 | $595 | $595 | 1 |
| Primary Repair of Torn Ligament OR Joint Capsule At Outside Part of Knee | surgery | $597 | $597 | $597 | 1 |
| Repair of Abdominal Muscle Hernia | surgery | $597 | $597 | $597 | 1 |
| Simple Surgical Treatment of Kidney Stone with Imaging Guidance | surgery | $598 | $598 | $598 | 1 |
| Partial Removal of Collar Bone At Shoulder Using an Endoscope | surgery | $598 | $598 | $598 | 1 |
| Incision of Mastoid Bone | other | $600 | $600 | $600 | 1 |
| Removal of Leg At Knee Joint | surgery | $600 | $600 | $600 | 1 |
| Repair of Inside OR Outside Knee Joint Cartilage Using an Endoscope | surgery | $602 | $602 | $602 | 1 |
| Suture of Hand OR Foot Digital Nerve, First Digital Nerve | other | $604 | $604 | $604 | 1 |
| Mole Removal | other | $605 | $22 | $10,074 | 22 |
| Adhesion of Linings of Lung Using an Endoscope | other | $605 | $605 | $605 | 1 |
| Removal of Growth of Muscle of Neck OR Front of Chest, 5.0 Cm OR More | surgery | $606 | $606 | $606 | 1 |
| Revision of Permanent Opening of Windpipe for Breathing with Flap Rotation | other | $606 | $606 | $606 | 1 |
| Removal of Growth of Muscle of Upper Arm OR Elbow, 5.0 Cm OR More | surgery | $609 | $609 | $609 | 1 |
| Apply Rigid Leg Cast | other | $609 | $609 | $609 | 1 |
| Needle Biopsy of Kidney | lab | $610 | $610 | $610 | 1 |
| Other Procedure On Stomach Using an Endoscope | other | $612 | $612 | $612 | 1 |
| Strontium Sr-89 Chloride, Therapeutic, Per Millicurie | other | $612 | $612 | $612 | 1 |
| Anchoring of Flexing Tendon of Fingers to Wrist Bone | other | $614 | $614 | $614 | 1 |
| Removal of Growth of Muscle of Shoulder, 5.0 Cm OR More | surgery | $614 | $614 | $614 | 1 |
| Forcep - Prograsp | other | $614 | $614 | $614 | 1 |
| Forceps Tenaculum for Davinci Xi/x 8mm Instrument #470207 | other | $614 | $614 | $614 | 1 |
| Re-amputation of Thigh Through Thigh Bone | other | $615 | $615 | $615 | 1 |
| Technetium Tc 99m Exametazime Diagnostic 25 Mci | other | $615 | $615 | $615 | 1 |
| Drainage of Deep Abscess OR Blood Accumulation of Pelvis OR Hip Near Joint | other | $617 | $617 | $617 | 1 |
| Treatment of Ligament Tear At Ankle Joint | other | $618 | $618 | $618 | 1 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 5 Grafts | cardiac | $618 | $618 | $618 | 1 |
| Removal of Lining Covering Abdominal Organs | surgery | $619 | $619 | $619 | 1 |
| Amputation of Finger OR Thumb with Direct Closure | other | $620 | $620 | $620 | 1 |
| Exploration of Neck for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $620 | $620 | $620 | 1 |
| Reconstruction of Ligaments Outside Knee Joint | other | $621 | $621 | $621 | 1 |
| Cranial Neurostim Complex | other | $622 | $622 | $622 | 1 |
| Removal of Blood Flow Assist Device in Aorta with Repair of Upper Leg Artery | surgery | $625 | $625 | $625 | 1 |
| Drainage of Fluid Collection By Tube Through Skin Using Imaging Guidance | other | $626 | $626 | $626 | 1 |
| Radiation Therapy | other | $627 | $22 | $33,804 | 34 |
| Closure of Surgically Created Opening From Stomach to Skin | surgery | $627 | $627 | $627 | 1 |
| Relocation of Tendon of Forearm And/or Wrist | other | $627 | $627 | $627 | 1 |
| Partial Removal of Pelvic and Aortic Lymph Nodes | surgery | $627 | $627 | $627 | 1 |
| Treatment of Broken Wrist Bone Located Near Base of Thumb | other | $628 | $628 | $628 | 1 |
| Insertion of Stomach Feeding Tube | other | $628 | $628 | $628 | 1 |
| Removal of Growth of Muscle of Back OR Lower Sides, 5.0 Cm OR More | surgery | $628 | $628 | $628 | 1 |
| Ther/proph/diag Inj IV Push | other | $628 | $628 | $628 | 1 |
| Goserelin Acetate Implant, Per 3.6 Mg | surgery | $629 | $629 | $629 | 1 |
| Abscess Drainage (I&D) | emergency | $630 | $32 | $2,823 | 20 |
| Insertion of Tube in Peripheral Blood Vessel for Heart-lung Machine Support | cardiac | $630 | $630 | $630 | 1 |
| Victoza 3-pak 18 Mg/3 Ml Pen | other | $630 | $630 | $630 | 1 |
| Removal of Growth of Peripheral Nerve | surgery | $631 | $631 | $631 | 1 |
| Severing of Muscle At Stomach Outlet to Upper Small Bowel | other | $631 | $631 | $631 | 1 |
| Repair of Nasal Passage Through Nose | surgery | $634 | $634 | $634 | 1 |
| Removal of Heart Artery Blood Clot By Dissolving Using Imaging Guidance | surgery | $634 | $634 | $634 | 1 |
| Removal of Gallbladder with X-ray Study of Bile Ducts Using an Endoscope | imaging | $635 | $635 | $635 | 1 |
| Repair of Trapped OR Strangulated Groin Hernia | surgery | $636 | $636 | $636 | 1 |
| Destruction of Growth of Rectum | other | $636 | $636 | $636 | 1 |
| Repair of Ligament of Finger OR Hand and Finger Joint | surgery | $636 | $636 | $636 | 1 |
| Repair of Abnormal Artery-vein Connection in Arm OR Leg | surgery | $637 | $637 | $637 | 1 |
| Aspiration of Bone Marrow Sample for Diagnosis | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 25mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 29mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 31mm #tarp | other | $637 | $637 | $637 | 1 |
| Annuloplasty Ring 33mm #tarp | other | $637 | $637 | $637 | 1 |
| Misc Implant | surgery | $637 | $637 | $637 | 1 |
| Secondary Repair of Ruptured Achilles Tendon | surgery | $638 | $638 | $638 | 1 |
| Lead, Cardioverter-defibrillator, Endocardial Dual Coil | other | $638 | $638 | $638 | 1 |
| Lead, Left Ventricular Coronary Venous System | cardiac | $638 | $638 | $638 | 1 |
| Repair Recurrent Incisional OR Ventral Hernia; Incarcerated OR Strangulated | surgery | $639 | $639 | $639 | 1 |
| Review By Radiologist of Image for Biopsy of Blood Vessel with Tube | lab | $640 | $640 | $640 | 1 |
| Removal of Growth Plate of Both Lower Leg Bones | surgery | $643 | $643 | $643 | 1 |
| Removal of Infected Skin, Tissue OR Muscle of Abdomen | surgery | $644 | $644 | $644 | 1 |
| Preparatory, Below Knee 'ptb' Type Socket, Non-alignable System, No Cover, Sa... | other | $644 | $644 | $644 | 1 |
| Treatment of Broken Finger OR Hand At Base of Finger | other | $646 | $646 | $646 | 1 |
| Removal of Growth of Muscle of Pelvis and Hip, 5.0 Cm OR More | surgery | $646 | $646 | $646 | 1 |
| Removal of Polyps OR Growths of Esophagus, Stomach, And/or Upper Small Bowel ... | surgery | $648 | $648 | $648 | 1 |
| Repair of Ligament of Hand to Finger Joint with Local Tissue | surgery | $652 | $652 | $652 | 1 |
| Anjeso (meloxicam) Inj 30 Mg | other | $652 | $652 | $652 | 1 |
| Removal of Foreign Body in Abdominal Cavity | surgery | $653 | $653 | $653 | 1 |
| Repair of Dislocating Kneecap with Realignment | surgery | $654 | $654 | $654 | 1 |
| Nuclear Medicine Studies of Heart Muscle At Rest and with Stress and SPECT | imaging | $655 | $72 | $1,237 | 2 |
| Partial Removal of Finger Bone | surgery | $655 | $655 | $655 | 1 |
| Repair of Nerve with Graft | surgery | $656 | $656 | $656 | 1 |
| Reconstruction of Dislocating Kneecap with Removal | surgery | $658 | $658 | $658 | 1 |
| Repair of Dislocating Kneecap | surgery | $659 | $659 | $659 | 1 |
| Rbc Leukocytes Reduced | other | $659 | $659 | $659 | 1 |
| Treatment of Broken Kneecap with Placement of Stabilizing Device And/or Remov... | other | $660 | $660 | $660 | 1 |
| Nuclear Medicine Study Limited Area with CT Scan | imaging | $661 | $661 | $661 | 1 |
| Transfer of Deep Tendon of Foot with Muscle Rerouting | other | $661 | $661 | $661 | 1 |
| Repair of Non-healed Wrist Bone, Scaphoid OR Navicular At the Base of the Thumb | surgery | $661 | $661 | $661 | 1 |
| Shortening of One of the Forearm Bones | other | $661 | $661 | $661 | 1 |
| Fusion of Joint Between Finger and Hand | surgery | $662 | $662 | $662 | 1 |
| Laparoscopy, Surgical, Repair, Ventral, Umbilical, Spigelian OR Epigastric He... | surgery | $664 | $664 | $664 | 1 |
| Repair of Knee Joint with Bone Graft and Internal Stabilizing Device Using an... | surgery | $664 | $664 | $664 | 1 |
| Laparoscopy, Surgical, Repair, Incisional Hernia (includes Mesh Insertion, Wh... | surgery | $665 | $665 | $665 | 1 |
| Laparoscopy, Surgical, Repair, Recurrent Incisional Hernia (includes Mesh Ins... | surgery | $665 | $665 | $665 | 1 |
| Probe 10cm Malleable A000683 | other | $665 | $665 | $665 | 1 |
| Removal of Growth of Muscle of Thigh OR Knee, 5.0 Cm OR More | surgery | $666 | $666 | $666 | 1 |
| Repair of Knee Joint with Bone Graft Using an Endoscope | surgery | $666 | $666 | $666 | 1 |
| Injection, Etoposide, 10 Mg | other | $667 | $667 | $667 | 1 |
| Repair Initial Incisional OR Ventral Hernia; Incarcerated OR Strangulated | surgery | $668 | $668 | $668 | 1 |
| Addition to Lower Limb Prosthesis, Vertical Shock Reducing Pylon Feature | other | $668 | $668 | $668 | 1 |
| Treatment of Both Broken Lower Leg Bones At Ankle | other | $670 | $670 | $670 | 1 |
| Amputation of Thigh Through Thigh Bone | other | $670 | $670 | $670 | 1 |
| MRI Scan of Chest with Contrast | imaging | $670 | $588 | $752 | 2 |
| Flotufolastat F 18, Diagnostic, 1 Millicurie | other | $671 | $671 | $671 | 1 |
| Biopsy of Lung Lining | lab | $671 | $671 | $671 | 1 |
| Removal of Lymph Nodes From Chin to Thyroid Cartilage | surgery | $672 | $672 | $672 | 1 |
| Repair of Joint Capsule of Hand and Palm, 1 Finger | surgery | $672 | $672 | $672 | 1 |
| Exchange of Abdominal Cavity Drainage Tube Using Imaging Guidance | other | $672 | $672 | $672 | 1 |
| Removal of Defect in Wall of Esophagus Through Neck | surgery | $672 | $672 | $672 | 1 |
| Removal and Replacement of Stent in Kidney and Ureter Using Fluoroscopic Guid... | surgery | $672 | $672 | $672 | 1 |
| Repair of Blood Vessel of Arm | surgery | $675 | $675 | $675 | 1 |
| Deb Subq Tissue 20 SQ Cm/< | other | $675 | $675 | $675 | 1 |
| Instillation, Bupivacaine and Meloxicam, 1 Mg/0.03 Mg | other | $677 | $677 | $677 | 1 |
| Insertion of Tube Into Small Bowel | other | $677 | $677 | $677 | 1 |
| Exploration of Abdominal Cavity | other | $678 | $678 | $678 | 1 |
| Creation of Permanent Opening of Windpipe for Breathing | other | $678 | $678 | $678 | 1 |
| Catheter, Transluminal Angioplasty, Drug-coated, Non-laser | cardiac | $678 | $678 | $678 | 1 |
| Vascular Graft Material, Synthetic, Implant | surgery | $681 | $681 | $681 | 1 |
| Core Needle Biopsy of Lung OR Center Cavity of Chest (mediastinum), Accessed ... | lab | $682 | $682 | $682 | 1 |
| MRI Scan of Arm Joint with Contrast | imaging | $683 | $613 | $752 | 2 |
| Biopsy of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible Endos... | lab | $684 | $684 | $684 | 1 |
| Control of Bleeding of Esophagus, Stomach, And/or Upper Small Bowel Using a F... | other | $684 | $684 | $684 | 1 |
| Insertion of Guide Wire with Dilation of Esophagus Using a Flexible Endoscope | other | $684 | $684 | $684 | 1 |
| Insertion of Stomach Tube Using a Flexible Endoscope | other | $684 | $684 | $684 | 1 |
| Insertion of Hypoglossal Nerve Neurostimulator Electrode and Generator and Br... | other | $685 | $685 | $685 | 1 |
| Hosp Obs Direct Referral | other | $685 | $685 | $685 | 1 |
| Intracept Access Instrument Rlv 0055 | other | $686 | $686 | $686 | 1 |
| Removal of Blood Clot and Portion of Upper Thigh Artery | surgery | $686 | $686 | $686 | 1 |
| Tumor Immunohistochem/comput | other | $687 | $687 | $687 | 1 |
| Repair of Congenital Bowel Defect | surgery | $688 | $688 | $688 | 1 |
| Removal of Bony Growths of Ear Canal | surgery | $688 | $688 | $688 | 1 |
| Express Tray 15/2 First Fracture with Kyphx | other | $689 | $689 | $689 | 1 |
| Insertion of Electrode to Outer Layer of Heart | cardiac | $689 | $689 | $689 | 1 |
| Plastic OR Reconstructive Repair of Throat | surgery | $690 | $690 | $690 | 1 |
| Repair Non-healed Fracture of Forearm Bone | surgery | $691 | $691 | $691 | 1 |
| Clamp Long Jaw A000362 | other | $692 | $692 | $692 | 1 |
| Clamp Short Jaw A000432 | other | $692 | $692 | $692 | 1 |
| Endovascular Repair of Iliac Artery (eg, Aneurysm, Pseudoaneurysm, Arterioven... | surgery | $692 | $692 | $692 | 1 |
| Balloon Dilation of Groin Artery, Each Additional Vessel | other | $692 | $692 | $692 | 1 |
| Amputation of Finger OR Thumb | other | $693 | $693 | $693 | 1 |
| Release of Major Arm OR Leg Nerve | other | $695 | $695 | $695 | 1 |
| Deep Biopsy of Bone Using Needle OR Trocar | lab | $696 | $674 | $718 | 2 |
| Fusion of Part of Wrist Joint with Patient-derived Bone Graft | surgery | $698 | $698 | $698 | 1 |
| Replacement of Joint Between Wrist and Fingers Using Tissue | surgery | $698 | $698 | $698 | 1 |
| Repair of Torn Ligament And/or Joint Capsule At Front of Knee | surgery | $700 | $700 | $700 | 1 |
| Repair of Blood Vessel of Leg | surgery | $702 | $702 | $702 | 1 |
| Removal of Growth of Rectum Through Anus with Removal of a Portion of Muscle | surgery | $703 | $703 | $703 | 1 |
| Insertion of Tube Through the Chest for Ecmo External Blood Circulation in He... | other | $704 | $704 | $704 | 1 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 6 OR More Grafts | cardiac | $704 | $704 | $704 | 1 |
| Catheter, Intravascular Ultrasound | imaging | $705 | $705 | $705 | 1 |
| Suture of Hand Median Motor Nerve | other | $706 | $706 | $706 | 1 |
| Revision OR Replacement of Hypoglossal Nerve Neurostimulator Electrode and Br... | surgery | $707 | $707 | $707 | 1 |
| MRI Scan of Leg Joint with Contrast | imaging | $707 | $661 | $752 | 2 |
| Immunohisto Antb 1st Stain | other | $708 | $708 | $708 | 1 |
| Exploration, Drainage, Biopsy, OR Removal of Foreign Body in Chest Cavity | surgery | $709 | $709 | $709 | 1 |
| Flowcytometry/ Tc 1 Marker | other | $709 | $709 | $709 | 1 |
| Rbc Antibody Identification | other | $709 | $709 | $709 | 1 |
| Biopsy of Fluid Collection of Lung | lab | $710 | $710 | $710 | 1 |
| Diagnostic Exam of Large Bowel Using an Endoscope Inserted Through Surgically... | surgery | $711 | $711 | $711 | 1 |
| Removal of Growths OR Polyps of Large Bowel By Mechanical Snare Using an Endo... | surgery | $711 | $711 | $711 | 1 |
| Incision OR Partial Removal of Middle Portion of Thigh Bone | surgery | $713 | $713 | $713 | 1 |
| Treatment of Broken Shin Bone At Knee | other | $713 | $713 | $713 | 1 |
| Repair of Upper End of Shin Bone At Knee Joint | surgery | $715 | $715 | $715 | 1 |
| Biopsy of Growth of Lung | lab | $716 | $716 | $716 | 1 |
| Insertion of Electrode to Outer Layer of Heart Using an Endoscope | cardiac | $716 | $716 | $716 | 1 |
| Repair of Joint Between Finger and Palm | surgery | $717 | $717 | $717 | 1 |
| Delivery of Simple High Precision Radiation Treatment | obstetric | $720 | $720 | $720 | 1 |
| Creation of Open Flap Tract for Drainage of Infected Material From Lining Aro... | other | $720 | $720 | $720 | 1 |
| Incision of Corner of Eye At Eyelid | other | $720 | $720 | $720 | 1 |
| Exploration of Arm OR Leg for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $721 | $721 | $721 | 1 |
| Incision and Exploration of Chest Cavity | other | $723 | $723 | $723 | 1 |
| Treatment of 2 Broken Lower Forearm Bone Pieces On Thumb Side Inside Wrist Jo... | other | $723 | $723 | $723 | 1 |
| Repair of Wound By Transferring Skin, 30.1-60.0 SQ Cm | surgery | $724 | $724 | $724 | 1 |
| Suture Repair of Ureter | surgery | $725 | $725 | $725 | 1 |
| Repair of Wrist Joint | surgery | $727 | $727 | $727 | 1 |
| Removal of Lymph Nodes of Groin | surgery | $729 | $729 | $729 | 1 |
| Catheter Spyscope Ds #m00546600 | cardiac | $730 | $730 | $730 | 1 |
| Spyscope Ds Ii Access & Delivery Catheter M00546610 | cardiac | $730 | $730 | $730 | 1 |
| Repair of Blood Vessel of Arm with Graft | surgery | $731 | $731 | $731 | 1 |
| Clip Pro 35mm Atriclip #a000824 | other | $732 | $732 | $732 | 1 |
| Clip Pro 40mm Atriclip #a000825 | other | $732 | $732 | $732 | 1 |
| Clip Pro 50mm Atriclip #a000827 | other | $732 | $732 | $732 | 1 |
| Hearing Aid, Digital, Monaural, Bte | other | $732 | $732 | $732 | 1 |
| Scp Foot & Ankle Kit #514.315 | other | $732 | $732 | $732 | 1 |
| Drainage of Fluid Collection of Abdominal Cavity By Tube Using Imaging Guidance | other | $732 | $732 | $732 | 1 |
| X-ray of Lower Spinal Canal with Review By Radiologist | imaging | $732 | $732 | $732 | 1 |
| Removal of Connective Tissue of Palm and Release of Finger, First Digit | surgery | $733 | $733 | $733 | 1 |
| Partial Removal of Liver Tissue | surgery | $734 | $734 | $734 | 1 |
| X-ray of Middle Spinal Canal with Review By Radiologist | imaging | $734 | $734 | $734 | 1 |
| X-ray of Upper Spinal Canal with Review By Radiologist | imaging | $734 | $734 | $734 | 1 |
| Repair of Ruptured Bowel Into Bladder | surgery | $735 | $735 | $735 | 1 |
| Ultrasound Guided Needle Aspiration OR Biopsy of Esophagus Using a Flexible E... | imaging | $735 | $735 | $735 | 1 |
| Knee Ankle Foot Orthosis, Fracture Orthosis, Femoral Fracture Cast Orthosis, ... | other | $738 | $738 | $738 | 1 |
| Exclusion of Appendage of Left Upper Chamber of Heart Using an Endoscope | cardiac | $740 | $740 | $740 | 1 |
| Upper Extremity Study | other | $740 | $740 | $740 | 1 |
| Lutonix .018" Dcb 130cm 4x220mm # Lx1813042204f | other | $745 | $745 | $745 | 1 |
| Lutonix .018" Dcb 130cm 5x220mm #lx1813052205f | other | $745 | $745 | $745 | 1 |
| Lutonix .018" Dcb 130cm 6x220mm #lx1813062205f | other | $745 | $745 | $745 | 1 |
| Lutonix .018" Dcb 130cm 7x220mm #lx1813072205f | other | $745 | $745 | $745 | 1 |
| Fusion of Wrist Joint with Graft From Hip OR Other Bone | surgery | $745 | $745 | $745 | 1 |
| Reshaping of Tip of Nose | other | $747 | $747 | $747 | 1 |
| Injection, Dmso, Dimethyl Sulfoxide, 50%, 50 Ml | other | $749 | $749 | $749 | 1 |
| Simple Complete Removal of Breast | surgery | $751 | $751 | $751 | 1 |
| X-ray of Multiple Regions of Spinal Canal with Review By Radiologist | imaging | $752 | $752 | $752 | 1 |
| Byfavo 20 Mg Vial | other | $752 | $752 | $752 | 1 |
| Remimazolam Besylate 20 Mg IV Solr | other | $752 | $752 | $752 | 1 |
| Closure of Surgically Created Large OR Small Bowel Opening | surgery | $752 | $752 | $752 | 1 |
| Repair of Eardrum and Ear Canal with Opening to Ear Bones | surgery | $754 | $754 | $754 | 1 |
| Prosthetic Implant, Not Otherwise Specified | surgery | $754 | $754 | $754 | 1 |
| Forcep - Fenestrated Bipolar | other | $754 | $754 | $754 | 1 |
| Forcep Maryland Bipolar | other | $754 | $754 | $754 | 1 |
| Forceps Cadiere #471049 | other | $754 | $754 | $754 | 1 |
| Forceps Prograsp #471093 | other | $754 | $754 | $754 | 1 |
| Initial Inpatient Hospital Critical Care of Newborn Per Day | obstetric | $757 | $757 | $757 | 1 |
| Conversion of Kidney Tube to Nephroureteral Tube Using Imaging Guidance and S... | other | $757 | $757 | $757 | 1 |
| Kyphon 10/2 #kex102eb | other | $758 | $758 | $758 | 1 |
| Kyphon Kit 15/2 #kex152eb | other | $758 | $758 | $758 | 1 |
| Stent, Coated/covered, with Delivery System | cardiac | $758 | $758 | $758 | 1 |
| Kyphon 15/3 Expender Ii Tray #kpx153pb | other | $758 | $758 | $758 | 1 |
| Genomic Sequence Analysis Panel of Dna OR Combined Dna and Rna of 5-50 Genes ... | lab | $760 | $760 | $760 | 1 |
| Fusion of Thumb At Wrist with Bone Graft | surgery | $763 | $763 | $763 | 1 |
| Repair of Muscle of Stomach Outlet Into Upper Small Bowel | surgery | $763 | $763 | $763 | 1 |
| Extensive Destruction and Reconstruction of Right Upper Heart Chamber On Hear... | cardiac | $764 | $764 | $764 | 1 |
| Amputation of Both Lower Leg Bones | other | $765 | $765 | $765 | 1 |
| Ca15l2 15cm Reinforced Percutaneous Antenna X1 | other | $767 | $767 | $767 | 1 |
| Ca20l2 Reinforced Percutaneous Antenna Emprint X1 | other | $767 | $767 | $767 | 1 |
| Repair of Nerve Using Nerve Graft, First Strand | surgery | $768 | $768 | $768 | 1 |
| Replacement of Joint Between Wrist and Fingers Using Tendon OR Stitches | surgery | $769 | $769 | $769 | 1 |
| Control of Bleeding of First OR Second Part of Small Bowel Using an Endoscope | other | $769 | $769 | $769 | 1 |
| Biopsy and Aspiration of Bone Marrow Sample for Diagnosis | lab | $772 | $772 | $772 | 1 |
| Removal of Cyst Below Breast Bone | surgery | $773 | $773 | $773 | 1 |
| Removal of Blood Clot in Neck to Chest Artery | surgery | $774 | $774 | $774 | 1 |
| Treatment of 3 Broken Lower Leg Bones At Ankle | other | $774 | $774 | $774 | 1 |
| Repair of Tendons of Outer Forearm At Wrist Joint | surgery | $777 | $777 | $777 | 1 |
| Initial Removal of Wedge of Lung Tissue Using an Endoscope | surgery | $780 | $780 | $780 | 1 |
| Revision of Leg Artery Bypass with Vein Patch | other | $780 | $780 | $780 | 1 |
| Removal of Lymph Nodes of Underarm | surgery | $781 | $781 | $781 | 1 |
| Repair of Blood Vessel of Leg with Graft | surgery | $781 | $781 | $781 | 1 |
| Destruction of Cyst of Kidney Using an Endoscope | other | $782 | $782 | $782 | 1 |
| Small Clip Applier Xi #470401 Intuitive Surgical | surgery | $782 | $782 | $782 | 1 |
| Repair of Blood Vessel of Neck | surgery | $787 | $787 | $787 | 1 |
| Destruction of Polyp OR Growth of Small Bowel Using an Endoscope | other | $787 | $787 | $787 | 1 |
| Incision of Chest Cavity for Complications After Surgery | surgery | $789 | $789 | $789 | 1 |
| Release of Tendon Connecting Biceps Muscle and Shoulder Using an Endoscope | other | $791 | $791 | $791 | 1 |
| Preparatory, Below Knee 'ptb' Type Socket, Non-alignable System, Pylon, No Co... | other | $792 | $792 | $792 | 1 |
| Catheter, Intracardiac Echocardiography | imaging | $792 | $792 | $792 | 1 |
| Cardiac Catheterization | cardiac | $793 | $7 | $49,200 | 37 |
| Removal of Middle Ear (mastoid) Bone | surgery | $794 | $794 | $794 | 1 |
| Removal of Blood Clot and Revision of Artery OR Vein Graft | surgery | $795 | $795 | $795 | 1 |
| Drain/inj Joint/bursa W/us | other | $795 | $795 | $795 | 1 |
| Sleep Study (Polysomnography) | diagnostic | $796 | $8 | $2,274 | 33 |
| Release of Small Bowel Scar Tissue Using an Endoscope | other | $796 | $796 | $796 | 1 |
| Knee Ankle Foot Orthosis, Full Plastic, Double Upright, with OR without Free ... | other | $799 | $799 | $799 | 1 |
| Removal of Cyst OR Growth of Chest Cavity Using an Endoscope | surgery | $800 | $800 | $800 | 1 |
| Removal of Blood Clot in Artery of Lower Leg | surgery | $800 | $800 | $800 | 1 |
| Exploration of Ureter | other | $800 | $800 | $800 | 1 |
| Exploration Behind Abdominal Cavity | other | $803 | $803 | $803 | 1 |
| Replacement of Kidney Drainage Tube Using Imaging Guidance with Review By Rad... | surgery | $805 | $805 | $805 | 1 |
| Partial Removal of Breast and Underarm Lymph Nodes | surgery | $805 | $805 | $805 | 1 |
| Treatment of 3 OR More Broken Lower Forearm Bone Pieces On Thumb Side Inside ... | other | $807 | $807 | $807 | 1 |
| Balloon Dilation of Artery of Leg, Each Additional Vessel | other | $807 | $807 | $807 | 1 |
| Repair of Aneurysm OR Forearm Artery with Graft | surgery | $809 | $809 | $809 | 1 |
| Partial Removal of Roof of Mouth | surgery | $809 | $809 | $809 | 1 |
| Graft Applic <100cm, 1st 25 Cm | other | $810 | $810 | $810 | 1 |
| Graft Applic <100cm, 1st 25cm | other | $810 | $810 | $810 | 1 |
| Hearing Aid, Digital, Binaural, Bte | other | $811 | $811 | $811 | 1 |
| Tlso, Triplanar Control, Two Piece Rigid Plastic Shell with Interface Liner, ... | other | $812 | $812 | $812 | 1 |
| Review By Radiologist of Major Upper Body Vein Image | other | $817 | $817 | $817 | 1 |
| Repair of Twisted OR Herniated Small Bowel | surgery | $818 | $818 | $818 | 1 |
| Treatment of Broken Side of Lower End of Thigh Bone | other | $819 | $819 | $819 | 1 |
| Removal and Replacement of Stent in Ureter with Review By Radiologist | surgery | $819 | $819 | $819 | 1 |
| Removal of Blood Clot and Portion of Deep Upper Thigh Artery | surgery | $821 | $821 | $821 | 1 |
| Insertion of Stent and Blood Clot Protection Device in Neck Artery with Revie... | cardiac | $823 | $823 | $823 | 1 |
| Repair of Chronic Injury to Muscle Separating Chest and Abdominal Cavities | surgery | $824 | $824 | $824 | 1 |
| Simple Partial Removal of Bladder | surgery | $826 | $826 | $826 | 1 |
| Creation of Flap Graft to Nose, Forehead, Temple, OR Scalp | other | $829 | $829 | $829 | 1 |
| Relocation of Nerve and Muscle to Restore Voice Box Function | other | $829 | $829 | $829 | 1 |
| Addition, Endoskeletal, Knee-shin System, Stance Flexion Feature, Adjustable | other | $831 | $831 | $831 | 1 |
| Initial Removal of Wedge of Lung Tissue | surgery | $832 | $832 | $832 | 1 |
| Repair of Blood Vessel of Neck with Graft | surgery | $832 | $832 | $832 | 1 |
| Repair of Anterior Cruciate Ligament of Knee Using an Endoscope | surgery | $834 | $834 | $834 | 1 |
| Transfer of Nerve to Injured Nerve, Stage 1 of 2 | other | $835 | $835 | $835 | 1 |
| Incision OR Partial Removal of Upper Portion of Lower Leg Bone to Repair Defo... | surgery | $835 | $835 | $835 | 1 |
| Ca30l2 Reinforced Percutaneous Antenna Emprint X1 | other | $837 | $837 | $837 | 1 |
| Cath Ensite Cath Array #ec1000-204 5/bx | other | $838 | $838 | $838 | 1 |
| Prostate Biopsy | other | $841 | $22 | $10,074 | 22 |
| Repair of Throat At Esophagus | surgery | $841 | $841 | $841 | 1 |
| Ropivacaine/ Ketorolac 400 Ml On-q Pump (greenlaw) - Compounded | other | $842 | $842 | $842 | 1 |
| Implantation of Self Cartilage Cells Into Knee Bone | surgery | $844 | $844 | $844 | 1 |
| Extensive Removal of Growth of Face OR Scalp, 2.0 Cm OR More | surgery | $847 | $847 | $847 | 1 |
| Repair of Aneurysm OR Arm Artery with Graft | surgery | $847 | $847 | $847 | 1 |
| Paracentesis | diagnostic | $849 | $40 | $2,213 | 22 |
| Removal of Growth of Ear Canal | surgery | $849 | $849 | $849 | 1 |
| Insertion of Brain Neurostimulator Pulse Device with Connection to 2 OR More ... | other | $851 | $851 | $851 | 1 |
| Removal of Air Sac of Lung Using an Endoscope | surgery | $851 | $851 | $851 | 1 |
| Lead, Neurostimulator | other | $851 | $851 | $851 | 1 |
| Repair of Blood Vessel of Arm with Vein Graft | surgery | $854 | $854 | $854 | 1 |
| Removal of Stomach Ulcer OR Growth | surgery | $854 | $854 | $854 | 1 |
| Reopening of Recent Abdominal Incision | other | $854 | $854 | $854 | 1 |
| Insertion of Stents with Balloon Dilation of Coronary Artery OR Branch, Each ... | cardiac | $855 | $855 | $855 | 1 |
| Biopsy OR Removal of Foreign Body in Large Bowel | surgery | $855 | $855 | $855 | 1 |
| Insertion of Stent in Arteries of Leg | cardiac | $856 | $856 | $856 | 1 |
| Suture and Relocation of Arm OR Leg Peripheral Nerve | other | $857 | $857 | $857 | 1 |
| Extensive Removal of Tonsils, Tissue, Muscle, and Bone | surgery | $859 | $859 | $859 | 1 |
| Recording of Right Lower Heart Chamber Rhythm | cardiac | $859 | $859 | $859 | 1 |
| CT Lower Ext Left W/wo Contras | other | $859 | $859 | $859 | 1 |
| CT Upper Ext Left W/contrast | other | $859 | $859 | $859 | 1 |
| CT Upper Ext Left W/wo Contras | other | $859 | $859 | $859 | 1 |
| Platelet Pheres Leuko-storage& | other | $859 | $859 | $859 | 1 |
| Removal of Blood Clot in Artery of Groin and Leg | surgery | $860 | $860 | $860 | 1 |
| Njx Interlaminar Lmbr/sac | other | $862 | $22 | $2,550 | 10 |
| Removal of Gallbladder | surgery | $862 | $862 | $862 | 1 |
| Repair of Blood Vessel of Leg with Vein Graft | surgery | $863 | $863 | $863 | 1 |
| Relocation of Defibrillator Skin Pocket | other | $865 | $865 | $865 | 1 |
| Relocation of Pacemaker Skin Pocket | cardiac | $865 | $865 | $865 | 1 |
| Removal of Blood Clot and Portion of Artery of Upper Thigh | surgery | $865 | $865 | $865 | 1 |
| Removal of Gallbladder with Exploration of Common Bile Duct Using an Endoscope | surgery | $865 | $865 | $865 | 1 |
| Repair of Shoulder Rotator Cuff Using an Endoscope | surgery | $866 | $866 | $866 | 1 |
| N Block, Other Peripheral | other | $866 | $866 | $866 | 1 |
| Relocation And/or Reimplantation of Neck Artery to Chest Artery | surgery | $867 | $867 | $867 | 1 |
| Revision of Leg Artery Bypass with Placement of Relocated Vein | other | $867 | $867 | $867 | 1 |
| Reconstruction of Wrist Joint | other | $870 | $870 | $870 | 1 |
| Repair of Shoulder Joint Capsule Using an Endoscope | surgery | $870 | $870 | $870 | 1 |
| Repair of Nasal Passage | surgery | $870 | $870 | $870 | 1 |
| Removal of Growth of Saliva Gland with Release of Facial Nerve | surgery | $871 | $871 | $871 | 1 |
| Removal of Growth of Windpipe Cartilage | surgery | $872 | $872 | $872 | 1 |
| Insertion of Stent in Ureter | cardiac | $872 | $872 | $872 | 1 |
| Reconstruction of Opening From Small Bowel to Skin | other | $874 | $874 | $874 | 1 |
| Complex Repair of Eardrum and Ear Canal with Removal of Mastoid Bone | surgery | $876 | $876 | $876 | 1 |
| Valvulotome 1.8 Expandable #1009 | other | $878 | $878 | $878 | 1 |
| Catheter, Transluminal Atherectomy, Rotational | cardiac | $879 | $879 | $879 | 1 |
| Balloon Dilation of Coronary Artery OR Branch, Each Additional Artery OR Branch | cardiac | $880 | $880 | $880 | 1 |
| Repair Non-healed Fracture of Forearm Bone with Patient-derived Bone Graft | surgery | $881 | $881 | $881 | 1 |
| Release of Intestinal Scar Tissue | other | $884 | $884 | $884 | 1 |
| Bypass of Diseased OR Blocked Chest to Opposite Chest Artery with Other Than ... | other | $884 | $884 | $884 | 1 |
| CT Lower Ext Left W/contrast | other | $884 | $884 | $884 | 1 |
| Indium-111 Pentetate | other | $885 | $885 | $885 | 1 |
| Catheter, Extravascular Tissue Ablation, Any Modality | cardiac | $885 | $885 | $885 | 1 |
| Removal of Ureter and Partial Removal of Bladder | surgery | $885 | $885 | $885 | 1 |
| Skin Graft Except for Skin Ulcer OR Cellulitis without Cc/mcc | other | $886 | $886 | $886 | 1 |
| Repair of Eardrum, Ear Canal, and Bones with Insertion of Prosthesis | surgery | $889 | $889 | $889 | 1 |
| Review By Radiologist of Liver Vein Image with Assessment of Blood Flow | other | $891 | $891 | $891 | 1 |
| Repair of Shoulder Socket Using an Endoscope | surgery | $891 | $891 | $891 | 1 |
| Repair of Descending Aorta, Initial Extension | surgery | $894 | $894 | $894 | 1 |
| Postpartum Care | obstetric | $898 | $22 | $10,074 | 12 |
| Removal of Growth of Esophagus Through Chest OR Abdomen | surgery | $900 | $900 | $900 | 1 |
| Removal of Growth OR Cyst of From Heart Sac | surgery | $900 | $900 | $900 | 1 |
| Complicated Reconstruction of Opening From Large Bowel to Skin | other | $901 | $901 | $901 | 1 |
| Deb Musc/fascia 20 SQ Cm/< | other | $902 | $251 | $12,544 | 7 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Thigh Artery with Other Than... | other | $902 | $902 | $902 | 1 |
| Csi Burr 1.5 Classic | other | $903 | $903 | $903 | 1 |
| Csi Burr 2.0 Classic | other | $903 | $903 | $903 | 1 |
| Stealth 1.5 Classic Crown #dbp-150classic145 | other | $903 | $903 | $903 | 1 |
| Stealth 2.0 #dbp-200classic145 | other | $903 | $903 | $903 | 1 |
| Stealth Th 1.5 Solid Crown #dbp-150solid145 | other | $903 | $903 | $903 | 1 |
| Suture of Tear OR Hole in Large Bowel | other | $903 | $903 | $903 | 1 |
| Creation of Opening From Small Bowel to Skin | other | $903 | $903 | $903 | 1 |
| Argatroban Non-esrd 1mg | other | $906 | $906 | $906 | 1 |
| Removal of Extra Finger | surgery | $908 | $908 | $908 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Oth... | other | $911 | $911 | $911 | 1 |
| Intravitreal Injection | surgery | $912 | $912 | $912 | 1 |
| Creation of Opening From Large Bowel to Skin with Multiple Bowel Biopsies | other | $913 | $913 | $913 | 1 |
| Repair of Eardrum, Ear Canal, and Bones | surgery | $914 | $914 | $914 | 1 |
| Central Line Insertion | other | $916 | $6 | $2,725 | 24 |
| Repair of Knee Cartilage and Bone with Patient-derived Healthy Cartilage Tran... | surgery | $916 | $916 | $916 | 1 |
| Catheter, Transluminal Intravascular Lithotripsy, Coronary | cardiac | $918 | $918 | $918 | 1 |
| Implantable/insertable Device, Not Otherwise Classified | surgery | $918 | $918 | $918 | 1 |
| Injection, Crotalidae Immune F(ab')2 (equine), 120 Mg | other | $918 | $918 | $918 | 1 |
| Bypass of Diseased OR Blocked Arm to Chest Artery with Other Than Vein | other | $919 | $919 | $919 | 1 |
| Forceps Maryland Bipolar #471172 | other | $919 | $919 | $919 | 1 |
| Repair of Aneurysm OR Upper Thigh Artery with Graft | surgery | $919 | $919 | $919 | 1 |
| Exclusion of Appendage of Left Upper Chamber of Heart | cardiac | $919 | $919 | $919 | 1 |
| Respiratory Syncytial Virus Antibody for Injection Into Tissue OR Muscle | other | $920 | $920 | $920 | 1 |
| Removal of Less Than Half of Tongue | surgery | $921 | $921 | $921 | 1 |
| Bypass of Diseased OR Blocked Upper Arm to Opposite Arm Artery with Vein | other | $928 | $928 | $928 | 1 |
| Probe, Image-guided, Robotic, Waterjet Ablation | other | $928 | $928 | $928 | 1 |
| Dupixent 200 Mg/1.14 Ml Syring | other | $933 | $933 | $933 | 1 |
| Dupixent 300 Mg/2 Ml Syringe | other | $933 | $933 | $933 | 1 |
| Technetium Tc-99m Exametazime Labeled Autologous White Blood Cells, Diagnosti... | other | $934 | $934 | $934 | 1 |
| Repair of Aneurysm OR Neck OR Upper Chest Artery with Graft | surgery | $934 | $934 | $934 | 1 |
| Pacemaker, Single Chamber, Rate-responsive | cardiac | $936 | $936 | $936 | 1 |
| Replacement of Tunneled Central Venous Tube | surgery | $936 | $936 | $936 | 1 |
| Repositioning of Left Lower Heart Electrode | cardiac | $936 | $936 | $936 | 1 |
| Removal of Foreign Body in Lining of Chest Cavity Using an Endoscope | surgery | $937 | $937 | $937 | 1 |
| Delivery of Complex High Precision Radiation Treatment | obstetric | $937 | $937 | $937 | 1 |
| Strengthening of Muscle Between Esophagus and Stomach By Wrapping Part of Sto... | other | $939 | $939 | $939 | 1 |
| Removal of Blood Clot and Portion of Superficial Femoral Artery | surgery | $939 | $939 | $939 | 1 |
| Creation of Opening From Large Bowel to Skin | other | $942 | $942 | $942 | 1 |
| Repair of Side of Voice Box By Moving Vocal Cord to Middle | surgery | $943 | $943 | $943 | 1 |
| Repair of Aorta OR Great Vessels with Sutures | surgery | $945 | $945 | $945 | 1 |
| Repair of Prolapsed Rectum Through Anus | surgery | $946 | $946 | $946 | 1 |
| Removal of Gallbladder with X-ray Study of Bile Ducts | imaging | $947 | $947 | $947 | 1 |
| Balloon Viabahn Bx 7mmx59mm 7fr Bxa075902a | other | $948 | $948 | $948 | 1 |
| Removal of Blood Clot and Portion of Chest, Neck, OR Brain Artery | surgery | $951 | $951 | $951 | 1 |
| Connection of Ureter to Bladder | other | $953 | $953 | $953 | 1 |
| Bypass of Diseased OR Blocked Knee to Lower Leg Arteries with Other Than Vein | other | $954 | $954 | $954 | 1 |
| Complex Surgical Treatment of Kidney Stone with Imaging Guidance | surgery | $955 | $955 | $955 | 1 |
| Infasurf 35 Mg/ml Vial | other | $957 | $957 | $957 | 1 |
| Removal of Gallbladder with Exploration of Common Bile Duct | surgery | $960 | $960 | $960 | 1 |
| Creation of Opening From Small Bowel to Skin Using an Endoscope | other | $961 | $961 | $961 | 1 |
| CT Lumbar Spine W/dye | other | $962 | $962 | $962 | 1 |
| CT Abdomen with Contrast | imaging | $963 | $963 | $963 | 1 |
| CT Pelvis W/dye | other | $963 | $963 | $963 | 1 |
| Partial Removal of Chest Cavity Lining and Lung Lining Using an Endoscope | surgery | $966 | $966 | $966 | 1 |
| Stabilization of Thigh Bone with Device | other | $969 | $969 | $969 | 1 |
| Partial Replacement of Thigh Bone At Hip Joint with Prosthesis | surgery | $969 | $969 | $969 | 1 |
| Removal of Kidney Stone | surgery | $971 | $971 | $971 | 1 |
| Division of Extra Arch of Aorta | other | $971 | $971 | $971 | 1 |
| Removal of Growth of Saliva Gland OR Saliva Gland with Release of Facial Nerve | surgery | $972 | $972 | $972 | 1 |
| Reconstruction Ligaments Inside Knee Joint | other | $973 | $973 | $973 | 1 |
| Limb Ext Iliac Cuff Left #is20-25/c55 Sa | other | $974 | $974 | $974 | 1 |
| Limb Extension Cuff #is20-25/c65 Sa | other | $974 | $974 | $974 | 1 |
| Limb Extensions Cuff #i16-16/c55f Sa | other | $974 | $974 | $974 | 1 |
| Limb Extensions Cuff #i20-13/c88f Sa | other | $974 | $974 | $974 | 1 |
| Limb Extensions Cuff #i20-20/c55f Sa | other | $974 | $974 | $974 | 1 |
| Reconstruction of Ear Canal | other | $976 | $976 | $976 | 1 |
| Repair of Groin Artery with Graft for Other Than Rupture with Review By Radio... | surgery | $976 | $976 | $976 | 1 |
| Suture of Perforated Ulcer, Wound, OR Injury of Stomach OR Upper Small Bowel | other | $976 | $976 | $976 | 1 |
| CT Spine | imaging | $977 | $101 | $4,945 | 20 |
| Revision of Opening From Large Bowel to Skin with Repair of Hernia | surgery | $978 | $978 | $978 | 1 |
| Gore Excluder Endorosthesis Iliac Branch Comp #hgb161007a | other | $980 | $980 | $980 | 1 |
| Replacement of Knee Joint On Side of Knee | surgery | $980 | $980 | $980 | 1 |
| Repair of Rectal Prolapse Using an Endoscope | surgery | $984 | $984 | $984 | 1 |
| Bypass of Diseased OR Blocked Under Arm to Arm Artery with Vein | other | $987 | $987 | $987 | 1 |
| Bypass of Diseased OR Blocked Neck to Chest Artery with Other Than Vein | other | $988 | $988 | $988 | 1 |
| Bypass of Diseased OR Blocked Groin to Upper Leg Artery with Other Than Vein | other | $989 | $989 | $989 | 1 |
| CT Neck with Contrast | imaging | $992 | $992 | $992 | 1 |
| MRI of the Abdomen | imaging | $995 | $232 | $13,143 | 21 |
| Injection of Bile Duct for X-ray Through Already Existing Skin Access Using I... | imaging | $995 | $995 | $995 | 1 |
| Removal of Growth Below Breast Bone | surgery | $995 | $995 | $995 | 1 |
| Mechanical Heart Valve Aortic Size 27mm 27agn | cardiac | $998 | $998 | $998 | 1 |
| Suture of Bleeding Stomach Ulcer | other | $998 | $998 | $998 | 1 |
| Gore Excluder Aaa Endoprosthesis 12fr Pll161207 | other | $998 | $998 | $998 | 1 |
| Gore Excluder Aaa Endoprosthesis 16mm X 14.5mm Pll161407 | other | $998 | $998 | $998 | 1 |
| Bronchoscopy | diagnostic | $1,000 | $79 | $3,260 | 18 |
| Removal of Extra Skin and Tissue of Abdomen | surgery | $1,000 | $1,000 | $1,000 | 1 |
| Repair of Paraesophageal Hernia Through Abdomen | surgery | $1,001 | $1,001 | $1,001 | 1 |
| Repair of Ruptured Aneurysm of Arm Artery with Graft | surgery | $1,001 | $1,001 | $1,001 | 1 |
| Dilation of Windpipe Cartilage OR Treatment of Broken Windpipe Cartilage Usin... | other | $1,003 | $1,003 | $1,003 | 1 |
| Replacement of Aortic Valve Through the Skin and Femoral Artery | surgery | $1,004 | $1,004 | $1,004 | 1 |
| Cystoscopy | diagnostic | $1,005 | $22 | $9,199 | 23 |
| Revision of Groin Artery Bypass with Patch Graft | other | $1,005 | $1,005 | $1,005 | 1 |
| Extensive Removal of Growth of Forearm OR Wrist, 3.0 Cm OR More | surgery | $1,010 | $1,010 | $1,010 | 1 |
| Hearing Aid, Digital, Binaural, Ite | other | $1,011 | $1,011 | $1,011 | 1 |
| Reshaping of Bone, Cartilage, And/or Tip of Nose | other | $1,011 | $1,011 | $1,011 | 1 |
| Removal of Blood Clot and Portion of Tibial OR Peroneal Artery, Initial Artery | surgery | $1,021 | $1,021 | $1,021 | 1 |
| Partial Removal of Small Bowel with Creation of Opening to Skin | surgery | $1,022 | $1,022 | $1,022 | 1 |
| Suture of Tear of Hole in Small Bowel | other | $1,023 | $1,023 | $1,023 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Vein | other | $1,024 | $1,024 | $1,024 | 1 |
| Partial Removal of Small Bowel with Reconnection | surgery | $1,024 | $1,024 | $1,024 | 1 |
| Epidural Steroid Injection | other | $1,025 | $256 | $10,074 | 18 |
| Removal of Kidney and Partial Removal of Ureter Using an Endoscope | surgery | $1,026 | $1,026 | $1,026 | 1 |
| Repair of Eardrum and Ear Canal with Removal of Middle Ear Bone | surgery | $1,026 | $1,026 | $1,026 | 1 |
| Isoproterenol 1 Mg/5 Ml Vial | other | $1,028 | $1,028 | $1,028 | 1 |
| Removal OR Destruction of Growth(s) in the Abdomen, 5.0 Cm OR Less | surgery | $1,028 | $1,028 | $1,028 | 1 |
| Removal of Total Knee Joint Prosthesis | surgery | $1,029 | $1,029 | $1,029 | 1 |
| Revision to Reshape Nasal Bones After Previous Repair | surgery | $1,030 | $1,030 | $1,030 | 1 |
| Gore Excluder Aortic Extender Endoprosthesis 28.5mm X 3.3cm #pla280300 | other | $1,031 | $1,031 | $1,031 | 1 |
| Repositioning of Ureter with Creation of Bladder OR Muscle Flap | other | $1,032 | $1,032 | $1,032 | 1 |
| Removal of Blood Clot and Portion of Popliteal Artery | surgery | $1,033 | $1,033 | $1,033 | 1 |
| Removal of Bone Cavity Behind Eye for Decompression | surgery | $1,035 | $1,035 | $1,035 | 1 |
| Repair of Aorta with Graft for Other Than Rupture with Review By Radiologist | surgery | $1,036 | $1,036 | $1,036 | 1 |
| Removal of Uterus, Tubes, And/or Ovaries Through Abdomen Using an Endoscope, ... | surgery | $1,037 | $1,037 | $1,037 | 1 |
| Catheter, Electrophysiology, Diagnostic/ablation, Other Than 3d OR Vector Map... | cardiac | $1,037 | $1,037 | $1,037 | 1 |
| Lead, Cardioverter-defibrillator, Endocardial Single Coil | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 19mm #esp100-19-00 Epic Supra | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 21mm #e100-21a-00 Epic | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 21mm #esp100-21-00 Epic Supra | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 23mm #e100-23a-00 Epic | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 23mm #esp100-23-00 Epic Supra | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 25mm #e100-25a-00 Epic | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 25mm #esp100-25-00 Epic Supra | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 27mm #e100-27a-00 Epic | other | $1,037 | $1,037 | $1,037 | 1 |
| Valve Aortic 27mm #esp100-27-00 Epic Supra | other | $1,037 | $1,037 | $1,037 | 1 |
| Bypass of Diseased OR Blocked Upper Arm to Arm Artery with Vein | other | $1,038 | $1,038 | $1,038 | 1 |
| Tissue Exam By Pathologist | other | $1,039 | $1,039 | $1,039 | 1 |
| CT Angiography Chest | imaging | $1,040 | $167 | $1,316 | 6 |
| Inj Paravert F Jnt L/s 2 Lev | other | $1,041 | $1,041 | $1,041 | 1 |
| Inj Paravert F Jnt L/s 3 Lev | other | $1,041 | $1,041 | $1,041 | 1 |
| Repair of Aneurysm OR Lower Leg Artery with Graft | surgery | $1,042 | $1,042 | $1,042 | 1 |
| Exploration of Abdomen for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $1,044 | $1,044 | $1,044 | 1 |
| Revision of Groin Artery Bypass with Vein Patch Graft | other | $1,045 | $1,045 | $1,045 | 1 |
| Repositioning of Pacemaker OR Defibrillator Electrode | cardiac | $1,046 | $1,046 | $1,046 | 1 |
| Removal of Breast and Underarm Lymph Nodes | surgery | $1,046 | $1,046 | $1,046 | 1 |
| Thoracentesis | other | $1,047 | $39 | $2,948 | 20 |
| Release of Scar Tissue At Ureter | other | $1,048 | $1,048 | $1,048 | 1 |
| Injection of Bile Duct for X-ray Through New Skin Access Using Imaging Guidan... | imaging | $1,049 | $1,049 | $1,049 | 1 |
| Placement of External Drainage Tube of Biliary Duct Using Imaging Guidance wi... | other | $1,049 | $1,049 | $1,049 | 1 |
| Placement of Internal-external Drainage Tube of Biliary Duct Using Imaging Gu... | other | $1,049 | $1,049 | $1,049 | 1 |
| Replacement of Liver Duct Drainage Tube Using Imaging Guidance with Review By... | surgery | $1,049 | $1,049 | $1,049 | 1 |
| Repair of Kidney Using an Endoscope | surgery | $1,051 | $1,051 | $1,051 | 1 |
| Incision and Exploration of Heart | cardiac | $1,052 | $1,052 | $1,052 | 1 |
| Other Circulatory System Diagnoses without Cc/mcc | other | $1,054 | $509 | $1,598 | 2 |
| Creation of Window Into Nasal Sinus | other | $1,054 | $1,054 | $1,054 | 1 |
| Removal of Stone OR Debris From Bile OR Pancreatic Duct Using a Flexible Endo... | surgery | $1,054 | $1,054 | $1,054 | 1 |
| Dissector Curved Bipolar #471344 | other | $1,056 | $1,056 | $1,056 | 1 |
| Injection, Calcitonin Salmon, Up to 400 Units | other | $1,060 | $202 | $1,917 | 2 |
| Drainage of Abscess OR Cyst of Liver | other | $1,061 | $1,061 | $1,061 | 1 |
| Inj Paravert F Jnt C/t 2 Lev | other | $1,061 | $1,061 | $1,061 | 1 |
| **obsolete** Valve Mitral 25mm Bicor #b100-25m | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 25mm #e100-25m-00 Epic | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 27mm #b100-27m Bicor | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 27mm #e100-27m-00 Epic | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 29mm #b100-29m Bicor | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 29mm #e100-29m-00 Epic | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 31mm #e100-31m-00 Epic | other | $1,064 | $1,064 | $1,064 | 1 |
| Valve Mitral 33mm #e100-33m-00 Epic | other | $1,064 | $1,064 | $1,064 | 1 |
| Creation of Large Bowel Opening Using an Endoscope | other | $1,064 | $1,064 | $1,064 | 1 |
| Repair of Aorta OR Great Vessels with Sutures Using a Shunt Bypass | surgery | $1,065 | $1,065 | $1,065 | 1 |
| CT Abdomen with and without Contrast | imaging | $1,067 | $1,067 | $1,067 | 1 |
| Removal of Malignant Growth of Stomach | surgery | $1,068 | $1,068 | $1,068 | 1 |
| Removal of Thymus Gland Using an Endoscope | surgery | $1,069 | $1,069 | $1,069 | 1 |
| Removal of Lymph Nodes of Neck | surgery | $1,070 | $1,070 | $1,070 | 1 |
| Removal of Blood Clot and Portion of Tibioperoneal Trunk Artery | surgery | $1,071 | $1,071 | $1,071 | 1 |
| Injection, Crotalidae Polyvalent Immune Fab (ovine), Up to 1 Gram | other | $1,072 | $1,072 | $1,072 | 1 |
| Complicated Partial Removal of Bladder | surgery | $1,074 | $1,074 | $1,074 | 1 |
| Repositioning of Ureter Using an Endoscope | other | $1,078 | $1,078 | $1,078 | 1 |
| Repair of Nonhealed Broken Thigh Bone with Self Bone Graft | surgery | $1,081 | $1,081 | $1,081 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Other Than Vein | other | $1,083 | $1,083 | $1,083 | 1 |
| Repair of Paraesophageal Hernia Through Chest | surgery | $1,083 | $1,083 | $1,083 | 1 |
| Partial Removal of Large Bowel with Connection | surgery | $1,083 | $1,083 | $1,083 | 1 |
| Removal of Blood Clot and Portion of Artery of Groin | surgery | $1,085 | $1,085 | $1,085 | 1 |
| Replacement of Knee Joint, Both Sides of Knee | surgery | $1,085 | $1,085 | $1,085 | 1 |
| Removal of Kidney, Lymph Nodes, And/or Blood Clot From Major Vein with Partia... | surgery | $1,086 | $1,086 | $1,086 | 1 |
| Replacement of Thigh Bone and Hip Joint with Prosthesis | surgery | $1,087 | $1,087 | $1,087 | 1 |
| Repair of Paraesophageal Hernia with Mesh Implant Through Abdomen | surgery | $1,091 | $1,091 | $1,091 | 1 |
| Replacement of Aortic Valve By Through Femoral Artery | surgery | $1,093 | $1,093 | $1,093 | 1 |
| Removal of Lower Part of Stomach with Reattachment of Remaining Stomach to Fi... | surgery | $1,094 | $1,094 | $1,094 | 1 |
| Addition to Lower Extremity, Ischial Containment/narrow M-l Socket | other | $1,094 | $1,094 | $1,094 | 1 |
| CT Angiography Neck | imaging | $1,099 | $1,099 | $1,099 | 1 |
| CT Angio Abdom W/o & W/dye | other | $1,099 | $1,099 | $1,099 | 1 |
| CT Angiography Head | imaging | $1,099 | $1,099 | $1,099 | 1 |
| Repair of Knee Cartilage and Bone with Donor Cartilage Graft Using an Endoscope | surgery | $1,102 | $1,102 | $1,102 | 1 |
| Removal of Growth of Saliva Gland OR Saliva Gland, and Surrounding Lymph Node... | surgery | $1,103 | $1,103 | $1,103 | 1 |
| Removal of Gallbladder and Creation of Bile Duct Drainage to Bowel | surgery | $1,104 | $1,104 | $1,104 | 1 |
| Removal of Kidney and Ureter with Partial Removal of Bladder Through Same Inc... | surgery | $1,104 | $1,104 | $1,104 | 1 |
| Probe/needle, Cryoablation | other | $1,105 | $1,105 | $1,105 | 1 |
| Endograft Iliac Limb 14x12x160 | other | $1,107 | $1,107 | $1,107 | 1 |
| Repair of Ruptured Aneurysm of Upper Thigh Artery with Graft | surgery | $1,108 | $1,108 | $1,108 | 1 |
| Removal of Defibrillator | surgery | $1,109 | $1,109 | $1,109 | 1 |
| Removal of Single Electrode From Right Heart | surgery | $1,109 | $1,109 | $1,109 | 1 |
| Digital Nerve Block | other | $1,110 | $1,110 | $1,110 | 1 |
| Repair of Muscle At Lower Esophagus and Stomach Using an Endoscope | surgery | $1,113 | $1,113 | $1,113 | 1 |
| Bypass of Diseased OR Blocked Lower Leg to Lower Leg Artery with Vein | other | $1,113 | $1,113 | $1,113 | 1 |
| Colonoscopy with Polypectomy | other | $1,123 | $310 | $3,147 | 19 |
| Repair of Aneurysm OR Upper Chest OR Neck Artery with Graft | surgery | $1,126 | $1,126 | $1,126 | 1 |
| Removal of Kidney and Lymph Nodes Using an Endoscope | surgery | $1,130 | $1,130 | $1,130 | 1 |
| Partial Removal of Kidney | surgery | $1,133 | $1,133 | $1,133 | 1 |
| Repair of Prolapsed Rectum Through Abdomen and Anus | surgery | $1,134 | $1,134 | $1,134 | 1 |
| Biopsy of Gallbladder, Pancreatic, Liver, and Bile Ducts Using a Flexible End... | lab | $1,134 | $1,134 | $1,134 | 1 |
| Removal of Kidney and Ureter Using an Endoscope | surgery | $1,135 | $1,135 | $1,135 | 1 |
| Replacement of Aortic Valve Through Axillary Artery | surgery | $1,136 | $1,136 | $1,136 | 1 |
| Review By Radiologist of Abdominal Aorta Image | other | $1,137 | $1,137 | $1,137 | 1 |
| Extensive Removal of Growth of Neck OR Front of Chest, 5.0 Cm OR More | surgery | $1,143 | $1,143 | $1,143 | 1 |
| Other Antepartum Diagnoses without O.r. Procedures without Cc/mcc | other | $1,146 | $693 | $1,598 | 2 |
| Bypass of Diseased OR Blocked Arm to Both Lower Thigh Arteries with Other Tha... | other | $1,147 | $1,147 | $1,147 | 1 |
| Biopsy of Lobe of Lung Using an Endoscope, 1 Lobe | lab | $1,147 | $1,147 | $1,147 | 1 |
| Partial Removal of Small and Large Bowel with Attachment of Small and Large B... | surgery | $1,147 | $1,147 | $1,147 | 1 |
| Insertion of Tube Into Gallbladder Using Imaging Guidance with Review By Radi... | other | $1,153 | $1,153 | $1,153 | 1 |
| Removal of Blood Clot and Portion of Artery of Abdominal Organ | surgery | $1,154 | $1,154 | $1,154 | 1 |
| Destr L/s Facet Jnt Addtl | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Foramen Epidural Add-on | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Foramen Epidural L/s | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Paravert F Jnt C/t 1 Lev | other | $1,160 | $1,160 | $1,160 | 1 |
| Inj Paravert F Jnt L/s 1 Lev | other | $1,160 | $1,160 | $1,160 | 1 |
| N Block Stellate Ganglion | other | $1,160 | $1,160 | $1,160 | 1 |
| Destr Paravertebrl N Add-on | other | $1,160 | $1,160 | $1,160 | 1 |
| Repair of Lung Airway with Graft | surgery | $1,164 | $1,164 | $1,164 | 1 |
| Incision of Pancreatic Outlet Using a Flexible Endoscope | other | $1,166 | $1,166 | $1,166 | 1 |
| Partial Removal of Stomach with Attachment of Stomach to Small Bowel | surgery | $1,167 | $1,167 | $1,167 | 1 |
| Repair of Aneurysm OR Groin Artery with Graft | surgery | $1,168 | $1,168 | $1,168 | 1 |
| Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm OR Dissection; Us... | surgery | $1,171 | $1,171 | $1,171 | 1 |
| Bypass of Diseased OR Blocked Upper to Lower Leg Artery with Vein | other | $1,171 | $1,171 | $1,171 | 1 |
| Hospital Admission | other | $1,172 | $83 | $10,074 | 11 |
| Removal of Blood Clot in Artery of Abdominal Organs | surgery | $1,172 | $1,172 | $1,172 | 1 |
| Veklury 100 Mg Vial | other | $1,172 | $1,172 | $1,172 | 1 |
| Removal of Defibrillator Electrodes Through Vein | surgery | $1,172 | $1,172 | $1,172 | 1 |
| Removal of Dual Electrodes From Right Heart | surgery | $1,172 | $1,172 | $1,172 | 1 |
| Endograft Iliac Limb 14x10x100 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x10x160 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x12x100 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x12x120 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x12x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x14x100 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x14x120 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x14x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x14x160 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x14x80 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x16x100 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x16x120 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x16x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x16x160 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x18x120 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x18x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x22x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x22x160 | other | $1,173 | $1,173 | $1,173 | 1 |
| Endograft Iliac Limb 14x28x140 | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 10-10-45 #tv-ex101045-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 12-12-45 #tv-ex121245-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 14-14-45 #tv-ex141445-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 16-16-45 #tv-ex161645-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 18-18-45 #tv-ex181845-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Ext System Ovation Ix Pma 28-28-45 #tv-ex282845-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-10-120 #tv-il1410120-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-10-80 #tv-il141080-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-12-80 #tv-il141280-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-16-80 #tv-il141680-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-18-100 #tv-il1418100-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-18-160 #tv-il1418160-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-18-80 #tv-il141880-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-22-100 #tv-il1422100-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-22-120 #tv-il1422120-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-22-80 #tv-il142280-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-28-100 #tv-il1428100-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-28-120 #tv-il1428120-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Iliac Limb System Ovation Ix Pma 14-28-80 #tv-il142880-j | other | $1,173 | $1,173 | $1,173 | 1 |
| Ovation Ix Iliac Stent Graft Tv-il1428160-j | cardiac | $1,173 | $1,173 | $1,173 | 1 |
| Placement of Tube of Kidney Using Imaging Guidance with Review By Radiologist | other | $1,174 | $1,174 | $1,174 | 1 |
| Insertion of Stent in Groin Artery, Additional Vessel | cardiac | $1,174 | $1,174 | $1,174 | 1 |
| Repositioning of Ureter and Insertion of Stent Using an Endoscope | cardiac | $1,175 | $1,175 | $1,175 | 1 |
| Implantation of Donor Cartilage Cells Into Knee Joint | surgery | $1,177 | $1,177 | $1,177 | 1 |
| Injection, Cyclophosphamide (dr. Reddy's), 5 Mg | other | $1,177 | $1,177 | $1,177 | 1 |
| Removal of Segment of Lung Tissue Using an Endoscope | surgery | $1,177 | $1,177 | $1,177 | 1 |
| Repair of Ruptured Aneurysm of Lower Leg Artery with Graft | surgery | $1,179 | $1,179 | $1,179 | 1 |
| Extreme Immaturity OR Respiratory Distress Syndrome, Neonate | other | $1,179 | $1,179 | $1,179 | 1 |
| Cardiac Congenital and Valvular Disorders without Mcc | cardiac | $1,184 | $770 | $1,598 | 2 |
| Colonoscopy (Diagnostic) | diagnostic | $1,186 | $22 | $2,550 | 9 |
| Drainage OR Removal of Bile Duct Stone with Redirection of Bile Flow and Inci... | surgery | $1,190 | $1,190 | $1,190 | 1 |
| Bypass of Diseased OR Blocked Neck to Opposite Neck Artery with Vein | other | $1,191 | $1,191 | $1,191 | 1 |
| Revision of Component of Total Knee Joint Prosthesis | other | $1,193 | $1,193 | $1,193 | 1 |
| Removal of Lymph Nodes, Muscle, and Tissue of Neck | surgery | $1,194 | $1,194 | $1,194 | 1 |
| Repair of Descending Aorta and Subclavian Artery with Insertion of Graft and ... | surgery | $1,195 | $1,195 | $1,195 | 1 |
| Partial Removal and Reconnection of Small Bowel Using an Endoscope | surgery | $1,199 | $1,199 | $1,199 | 1 |
| Closure of Abnormal Drainage Tract From Small Bowel to Urinary Bladder with R... | other | $1,200 | $1,200 | $1,200 | 1 |
| Angiojet Solent Dista Set #111303 | other | $1,202 | $1,202 | $1,202 | 1 |
| Suture of Injured Bile Duct | other | $1,203 | $1,203 | $1,203 | 1 |
| Partial Destruction and Reconstruction of Upper Heart Chamber | cardiac | $1,203 | $1,203 | $1,203 | 1 |
| Limited Reconstruction of Upper Heart Chamber and Alteration of Electrical Pa... | cardiac | $1,203 | $1,203 | $1,203 | 1 |
| Bypass of Diseased OR Blocked Thigh to Knee Artery with Vein Graft | other | $1,208 | $1,208 | $1,208 | 1 |
| Extensive Removal of Growth of Pelvis and Hip, Less Than 5.0 Cm | surgery | $1,209 | $1,209 | $1,209 | 1 |
| Transfer of Chest Artery to Neck Artery and Repair of Descending Aorta | surgery | $1,210 | $1,210 | $1,210 | 1 |
| Repair of Eardrum, Ear Canal, and Bones with Placement of Implant and Opening... | surgery | $1,211 | $1,211 | $1,211 | 1 |
| Ultrasound Evaluation of Heart Blood Vessel During Diagnosis OR Treatment, In... | imaging | $1,216 | $1,216 | $1,216 | 1 |
| Repair of Tear of Lung And/or Control of Traumatic Bleeding Through Chest | surgery | $1,217 | $1,217 | $1,217 | 1 |
| Extensive Removal of Growth of Back OR Lower Side, 5.0 Cm OR More | surgery | $1,218 | $1,218 | $1,218 | 1 |
| Insertion of Abdominal Tube Using Imaging Guidance with Review By Radiologist | other | $1,223 | $1,223 | $1,223 | 1 |
| Addition to Lower Limb Prosthesis, Multiaxial Ankle with Swing Phase Active D... | other | $1,229 | $1,229 | $1,229 | 1 |
| Revision of Hip Socket Part of Hip Prosthesis | other | $1,233 | $1,233 | $1,233 | 1 |
| Repair of Rectal Prolapse with Partial Removal of Lower Large Bowel Using an ... | surgery | $1,233 | $1,233 | $1,233 | 1 |
| Blood Transfusion Service | surgery | $1,233 | $1,233 | $1,233 | 1 |
| Repair of Aorta OR Great Vessels with Sutures On Heart-lung Machine | surgery | $1,234 | $1,234 | $1,234 | 1 |
| Closure of Abnormal Drainage Tract Within Small Bowel OR Small to Large Bowel | other | $1,235 | $1,235 | $1,235 | 1 |
| Event Recorder, Cardiac | cardiac | $1,236 | $1,236 | $1,236 | 1 |
| Reshaping of Bony Cartilage Dividing Nasal Passages | other | $1,237 | $1,237 | $1,237 | 1 |
| Processing, Preserving and Transporting Corneal Tissue | other | $1,237 | $1,237 | $1,237 | 1 |
| Partial Removal of Large Bowel Using an Endoscope | surgery | $1,248 | $1,248 | $1,248 | 1 |
| Catheter, Transluminal Angioplasty, Non-laser | cardiac | $1,250 | $1,250 | $1,250 | 1 |
| Ethacrynate Sodium 50 Mg Vial | other | $1,252 | $1,252 | $1,252 | 1 |
| Destruction of Stone of Bile OR Pancreatic Duct Using a Flexible Endoscope | other | $1,253 | $1,253 | $1,253 | 1 |
| Endurant Ii Contralateral Limb 16mm X 16mm X 124mm #etlw1616c124e | other | $1,258 | $1,258 | $1,258 | 1 |
| Bypass of Diseased OR Blocked Aorta to Upper Leg Artery with Other Than Vein | other | $1,260 | $1,260 | $1,260 | 1 |
| Below Knee, Molded Socket, Shin, Sach Foot, Endoskeletal System | other | $1,261 | $1,261 | $1,261 | 1 |
| Catheter, Electrophysiology, Diagnostic/ablation, 3d OR Vector Mapping | cardiac | $1,262 | $1,262 | $1,262 | 1 |
| Kidney and Urinary Tract Neoplasms without Cc/mcc | other | $1,265 | $1,265 | $1,265 | 1 |
| Pacemaker, Dual Chamber, Rate-responsive | cardiac | $1,266 | $1,266 | $1,266 | 1 |
| Partial Removal of Kidney Using an Endoscope | surgery | $1,266 | $1,266 | $1,266 | 1 |
| Repair of Aorta OR Great Vessels with Graft | surgery | $1,269 | $1,269 | $1,269 | 1 |
| Extensive Repair of Eardrum and Ear Canal with Removal of Middle Ear Bone | surgery | $1,273 | $1,273 | $1,273 | 1 |
| Partial Removal of Large Bowel with Creation of Opening From Large Bowel to Skin | surgery | $1,274 | $1,274 | $1,274 | 1 |
| Normal Newborn | other | $1,275 | $1,080 | $1,469 | 2 |
| Repair of Blood Vessel of Chest with Vein Graft On Heart-lung Machine | surgery | $1,275 | $1,275 | $1,275 | 1 |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Other Than Rupture... | surgery | $1,276 | $1,276 | $1,276 | 1 |
| Injection, Tbo-filgrastim, 1 Microgram | other | $1,278 | $875 | $1,680 | 2 |
| Revision of Thigh Bone Prosthesis | other | $1,279 | $1,279 | $1,279 | 1 |
| Correction of Abnormal Rotation of Small Bowel | other | $1,279 | $1,279 | $1,279 | 1 |
| Removal of Blood Clot and Portion of Abdominal Aorta and Groin Artery | surgery | $1,283 | $1,283 | $1,283 | 1 |
| Partial Removal of Large Bowel with Creation of Opening From Large Bowel to S... | surgery | $1,285 | $1,285 | $1,285 | 1 |
| Closure of Surgically Created Large OR Small Bowel Opening with Bowel Removal... | surgery | $1,286 | $1,286 | $1,286 | 1 |
| Removal of Defect in Wall of Esophagus Through Chest | surgery | $1,289 | $1,289 | $1,289 | 1 |
| Addition, Endoskeletal System, High Activity Knee Control Frame | other | $1,293 | $1,293 | $1,293 | 1 |
| Repair of Eardrum, Ear Canal, and Bones with Removal of Mastoid Bone, with In... | surgery | $1,293 | $1,293 | $1,293 | 1 |
| Addition, Endoskeletal Knee-shin System, Single Axis, Fluid Swing and Stance ... | other | $1,295 | $1,295 | $1,295 | 1 |
| Diagnostic Exam of Gallbladder and Pancreatic, Liver, and Bile Ducts Using an... | other | $1,296 | $1,296 | $1,296 | 1 |
| Removal of Lobe of Lung | surgery | $1,303 | $1,303 | $1,303 | 1 |
| Removal of Lung Segment to Reduce Lung Volume Through Chest | surgery | $1,307 | $1,307 | $1,307 | 1 |
| Closure of Opening From Large OR Small Bowel to Skin Using an Endoscope | other | $1,309 | $1,309 | $1,309 | 1 |
| Circumcision | surgery | $1,314 | $31 | $2,550 | 17 |
| Replacement, Socket, Below Knee, Molded to Patient Model | surgery | $1,314 | $1,314 | $1,314 | 1 |
| Repair of Hernia of Muscle At Esophagus and Stomach Using an Endoscope | surgery | $1,321 | $1,321 | $1,321 | 1 |
| Epic Plus Aortic Valve 29mm E200-29a | other | $1,323 | $1,323 | $1,323 | 1 |
| Epic Supra Plus Aortic Valve 19mm Esp200 | other | $1,323 | $1,323 | $1,323 | 1 |
| Epic Supra Plus Aortic Valve 21mm Esp200 | other | $1,323 | $1,323 | $1,323 | 1 |
| Epic Supra Plus Aortic Valve 23mm Esp200 | other | $1,323 | $1,323 | $1,323 | 1 |
| Epic Supra Plus Aortic Valve 25mm Esp200 | other | $1,323 | $1,323 | $1,323 | 1 |
| Epic Supra Plus Aortic Valve 27mm Esp200 | other | $1,323 | $1,323 | $1,323 | 1 |
| Other Procedure On Stomach | other | $1,330 | $1,330 | $1,330 | 1 |
| Removal of Air Sac of Lung Through Chest | surgery | $1,332 | $1,332 | $1,332 | 1 |
| Extensive Removal of Growth of Thigh OR Knee, 5.0 Cm OR More | surgery | $1,336 | $1,336 | $1,336 | 1 |
| Endograft Vela Infrarenal #a25-25/c75v | other | $1,337 | $1,337 | $1,337 | 1 |
| Endograft Vela Infrarenal #a28-28/c95v | other | $1,337 | $1,337 | $1,337 | 1 |
| Endograft Vela Infrarenal #a34-34/c100v | other | $1,337 | $1,337 | $1,337 | 1 |
| Endograft Vela Infrarenal #a34-34/c80v | other | $1,337 | $1,337 | $1,337 | 1 |
| Vela Suprarenal Endograft 25mm X 25mm / 75mm X 20mm #a25-25/c75-o20v | other | $1,337 | $1,337 | $1,337 | 1 |
| Addition, Endoskeletal Knee-shin System, Polycentric, Hydraulic Swing Phase C... | other | $1,342 | $1,342 | $1,342 | 1 |
| Custom Breast Prosthesis, Post Mastectomy, Molded to Patient Model | other | $1,346 | $1,346 | $1,346 | 1 |
| Extensive Repair and Reconstruction of Eardrum and Ear Canal with Removal of ... | surgery | $1,349 | $1,349 | $1,349 | 1 |
| Partial Removal of Pancreas | surgery | $1,353 | $1,353 | $1,353 | 1 |
| 25mj-501 Valve Mitral Size 25 Mm Rotatable Standard Cuff Mechanical | other | $1,357 | $1,357 | $1,357 | 1 |
| Valve Aortic Mechanical 21mm #21aj | other | $1,357 | $1,357 | $1,357 | 1 |
| Valve Mitral 27mm St Jude Cuffed #27mj | other | $1,357 | $1,357 | $1,357 | 1 |
| Valve Mitral 29mm St Jude Cuffed #29mj | other | $1,357 | $1,357 | $1,357 | 1 |
| Valve Mitral 31mm St Jude Cuffed #31mj | other | $1,357 | $1,357 | $1,357 | 1 |
| Valve Mitral 33mm St Jude Cuffed #33mj | other | $1,357 | $1,357 | $1,357 | 1 |
| Biopsy of Breast and Placement of Locating Device Using Mri, First Growth | imaging | $1,357 | $1,357 | $1,357 | 1 |
| Partial Removal of Large Bowel and Reattachment to Rectum | surgery | $1,357 | $1,357 | $1,357 | 1 |
| Repair of Aneurysm Above Heart Valve to Lung On Heart-lung Machine | surgery | $1,361 | $1,361 | $1,361 | 1 |
| Removal of Blood Clot and Portion of Chest OR Neck Artery | surgery | $1,361 | $1,361 | $1,361 | 1 |
| Partial Removal of Large Bowel with Creation of Opening to Skin | surgery | $1,371 | $1,371 | $1,371 | 1 |
| Nuclear Medicine Study From Skull Base to Mid-thigh with CT Scan | imaging | $1,371 | $1,371 | $1,371 | 1 |
| Nuclear Medicine Study Whole Body with CT Scan | imaging | $1,371 | $1,371 | $1,371 | 1 |
| All Lower Extremity Prostheses, Flex-walk System OR Equal | other | $1,373 | $1,373 | $1,373 | 1 |
| Review By Radiologist of Imaging Guidance for Removal of Blood Sample | surgery | $1,376 | $1,376 | $1,376 | 1 |
| Bypass of Diseased OR Blocked Arm to Lower Thigh OR Leg Artery with Other Tha... | other | $1,376 | $1,376 | $1,376 | 1 |
| Repair of Ruptured Aneurysm of Groin Artery with Graft | surgery | $1,377 | $1,377 | $1,377 | 1 |
| Valve Aortic 19mm Mech #19agn | other | $1,383 | $1,383 | $1,383 | 1 |
| Valve Aortic 21mm Mech #21agn | other | $1,383 | $1,383 | $1,383 | 1 |
| Valve Aortic 23mm Mech #23agn | other | $1,383 | $1,383 | $1,383 | 1 |
| Valve Aortic 25mm Mech #25agn | other | $1,383 | $1,383 | $1,383 | 1 |
| Removal of Lung | surgery | $1,384 | $1,384 | $1,384 | 1 |
| Removal of Rectum for Congenital Defect Through Abdomen and Region Between Th... | surgery | $1,388 | $1,388 | $1,388 | 1 |
| Review By Radiologist of Arteries of Both Lungs Image | other | $1,391 | $1,391 | $1,391 | 1 |
| Bypass of Diseased OR Blocked Major Upper to Lower Leg Artery with Vein | other | $1,393 | $1,393 | $1,393 | 1 |
| Removal of 2 Lobes of Lung Using an Endoscope | surgery | $1,394 | $1,394 | $1,394 | 1 |
| Removal of 2 Lobes of Lung | surgery | $1,397 | $1,397 | $1,397 | 1 |
| Bypass of Diseased OR Blocked Aorta to Groin Artery with Other Than Vein | other | $1,398 | $1,398 | $1,398 | 1 |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Vein Graft | other | $1,398 | $1,398 | $1,398 | 1 |
| Insertion OR Replacement of Ear Bone Hearing Device | surgery | $1,403 | $1,403 | $1,403 | 1 |
| Placement of Stent of Ureter and Separate Tube in Kidney Through New Skin Acc... | cardiac | $1,409 | $1,409 | $1,409 | 1 |
| Epic Mitral Plus Mitral Valve 29mm E200-29m | other | $1,410 | $1,410 | $1,410 | 1 |
| Epic Mitral Plus Mitral Valve 31mm E200-31m | other | $1,410 | $1,410 | $1,410 | 1 |
| Epic Mitral Plus Mitral Valve 33mm E200-33m | other | $1,410 | $1,410 | $1,410 | 1 |
| Partial Removal of Large Bowel with Creation of 2 Openings From Small OR Larg... | surgery | $1,414 | $1,414 | $1,414 | 1 |
| Repair of Knee Cartilage with Donor Cartilage Graft Using an Endoscope | surgery | $1,415 | $1,415 | $1,415 | 1 |
| Removal of Infected Chest Graft | surgery | $1,415 | $1,415 | $1,415 | 1 |
| Gore Excluder Aaa Endoprosthesis 12fr Plc121000 | other | $1,419 | $1,419 | $1,419 | 1 |
| Gore Excluder Aaa Endoprosthesis Plc141000 | other | $1,419 | $1,419 | $1,419 | 1 |
| Gore Excluder Aaa Endoprosthesis Plc141200 | other | $1,419 | $1,419 | $1,419 | 1 |
| Gore Excluder Aaa Endoprosthesis 16mm X 1105cm Plc161200 | other | $1,420 | $1,420 | $1,420 | 1 |
| Repair of Congenital Defect Between Upper Heart Chambers On Heart-lung Machine | surgery | $1,424 | $1,424 | $1,424 | 1 |
| Bypass of Diseased OR Blocked Artery Aorta to Upper Leg and Opposite Upper Le... | other | $1,431 | $1,431 | $1,431 | 1 |
| Atricure Isolator Synergy Encompass Long #olh | other | $1,436 | $1,436 | $1,436 | 1 |
| Extensive Destruction and Reconstruction of Upper Heart Chamber | cardiac | $1,443 | $1,443 | $1,443 | 1 |
| Addition to Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Manageme... | other | $1,446 | $1,446 | $1,446 | 1 |
| Revision of Total Shoulder Repair, Total Shoulder | surgery | $1,455 | $1,455 | $1,455 | 1 |
| Removal of Chest Cavity Lining and Lung Lining Using an Endoscope | surgery | $1,458 | $1,458 | $1,458 | 1 |
| Repair of Aneurysm OR Abdominal Aorta with Graft | surgery | $1,460 | $1,460 | $1,460 | 1 |
| CT Scan of the Abdomen and Pelvis | imaging | $1,461 | $230 | $5,912 | 6 |
| Atriclip Pro-v Device 35mm #prov35 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Pro-v Device 45mm #prov45 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Pro-v Device 50mm #prov50 | other | $1,463 | $1,463 | $1,463 | 1 |
| Atriclip Prov-5 Device 40mm #prov40 | other | $1,463 | $1,463 | $1,463 | 1 |
| Bypass of Diseased OR Blocked Aorta to Groin to Opposite Groin Artery with Ot... | other | $1,467 | $1,467 | $1,467 | 1 |
| Repair of Aorta At Heart | surgery | $1,467 | $1,467 | $1,467 | 1 |
| Revision of Thigh and Lower Leg Bone Components of Total Knee Joint Prosthesis | other | $1,473 | $1,473 | $1,473 | 1 |
| Placement of Stent of Ureter Through Existing Skin Access Using Imaging Guida... | cardiac | $1,482 | $1,482 | $1,482 | 1 |
| Repair of Hernia of Muscle At Esophagus and Stomach with Implantation of Mesh... | surgery | $1,485 | $1,485 | $1,485 | 1 |
| Byetta 5 Mcg Dose Pen Inj | other | $1,487 | $1,487 | $1,487 | 1 |
| Byetta 10 Mcg Dose Pen Inj | other | $1,487 | $1,487 | $1,487 | 1 |
| Injection, Ferumoxytol, for Treatment of Iron Deficiency Anemia, 1 Mg | other | $1,489 | $770 | $2,208 | 2 |
| Gore Excluder Aaa Endoproshesis Contralateral Leg 16mm X 20mm X 13.5cm 12fr P... | other | $1,490 | $1,490 | $1,490 | 1 |
| Gore Excluder Aaa Endoprosthesis Plc201200 | other | $1,490 | $1,490 | $1,490 | 1 |
| Gore Excluder Aaa Endoprosthesis Plc271400 | other | $1,490 | $1,490 | $1,490 | 1 |
| Gore Excluder Aortic Extender Endoprosthesis 23mm X 10cm #plc231000 | other | $1,490 | $1,490 | $1,490 | 1 |
| Gore Excluder Endoprosthesis Aaa #plc181200 | other | $1,490 | $1,490 | $1,490 | 1 |
| Gore Excluder Endoprosthesis Aaa #plc271200 | other | $1,490 | $1,490 | $1,490 | 1 |
| Acute Myocardial Infarction, Expired without Cc/mcc | other | $1,497 | $1,497 | $1,497 | 1 |
| Removal of Defibrillator Electrode | surgery | $1,502 | $1,502 | $1,502 | 1 |
| Indium in 111 Labeled Autologous White Blood Cells | other | $1,508 | $1,508 | $1,508 | 1 |
| Repair of Ruptured Aorta with Graft with Review By Radiologist | surgery | $1,509 | $1,509 | $1,509 | 1 |
| Repair of 2 Electrodes for Permanent Pacemaker OR Defibrillator | surgery | $1,510 | $1,510 | $1,510 | 1 |
| Removal OR Destruction of Growth(s) in the Abdomen, 10.1 to 20.0 Cm | surgery | $1,517 | $1,517 | $1,517 | 1 |
| Removal and Dissolving of Blood Clot From Vein Using Fluoroscopic Guidance, R... | surgery | $1,527 | $1,527 | $1,527 | 1 |
| Partial Removal of Large Bowel and Reattachment to Rectum Using an Endoscope | surgery | $1,528 | $1,528 | $1,528 | 1 |
| Repair of Groin Artery with Graft for Rupture with Review By Radiologist | surgery | $1,529 | $1,529 | $1,529 | 1 |
| Removal of Large Bowel with Attachment of Small Bowel to Rectum OR Creation o... | surgery | $1,530 | $1,530 | $1,530 | 1 |
| Revision to Reshape Nasal Bones and Tip of Nose After Previous Repair | surgery | $1,539 | $1,539 | $1,539 | 1 |
| Viral Meningitis without Cc/mcc | other | $1,541 | $1,541 | $1,541 | 1 |
| Bypass of Diseased OR Blocked Artery Aorta to Abdominal OR Kidney Artery with... | other | $1,553 | $1,553 | $1,553 | 1 |
| Alcohol, Drug Abuse OR Dependence, Left Ama | other | $1,554 | $1,427 | $1,681 | 2 |
| CT Abdomen and Pelvis with and without Contrast | imaging | $1,564 | $1,564 | $1,564 | 1 |
| Catheter, Transluminal Atherectomy, Directional | cardiac | $1,567 | $1,567 | $1,567 | 1 |
| Removal of Rectum with Creation of Opening From Large Bowel to Skin Through A... | surgery | $1,573 | $1,573 | $1,573 | 1 |
| Replacement, Socket, Above Knee/knee Disarticulation, Including Attachment Pl... | surgery | $1,578 | $1,578 | $1,578 | 1 |
| Neonates, Died OR Transferred to Another Acute Care Facility | other | $1,582 | $1,566 | $1,598 | 2 |
| Revision of Thigh Bone and Hip Joint Prosthesis | other | $1,586 | $1,586 | $1,586 | 1 |
| PET Scan | imaging | $1,596 | $16 | $13,340 | 16 |
| Acute Leukemia with Cc | other | $1,598 | $1,598 | $1,598 | 1 |
| Endocrine Disorders without Cc/mcc | other | $1,598 | $1,598 | $1,598 | 1 |
| Malignancy, Male Reproductive System with Cc | other | $1,598 | $1,598 | $1,598 | 1 |
| Injection, Leuprolide Acetate (for Depot Suspension), Per 3.75 Mg | other | $1,599 | $1,599 | $1,599 | 1 |
| Colonoscopy | preventive | $1,605 | $1 | $32,295 | 30 |
| Image-guided Robotic Linear Accelerator-based Stereotactic Radiosurgery, Deli... | surgery | $1,606 | $1,606 | $1,606 | 1 |
| Addition, Endoskeletal Knee/shin System, 4-bar Linkage OR Multiaxial, Pneumat... | other | $1,609 | $1,609 | $1,609 | 1 |
| Injection, Zolbetuximab-clzb, 1 Mg | other | $1,609 | $1,609 | $1,609 | 1 |
| Vyloy 100 Mg Vial | other | $1,609 | $1,609 | $1,609 | 1 |
| CT Angio Abd&pelv W/o&w/dye | other | $1,610 | $1,610 | $1,610 | 1 |
| Extensive Reconstruction of Upper Heart Chamber and Alteration of Electrical ... | cardiac | $1,618 | $1,618 | $1,618 | 1 |
| Postpartum and Post Abortion Diagnoses without O.r. Procedures | obstetric | $1,627 | $1,598 | $1,655 | 2 |
| Coronary Artery Bypass Using Artery Graft, 1 Graft | cardiac | $1,634 | $1,634 | $1,634 | 1 |
| Endurant Ii Contralateral Limb 16mm X 13mm X 146mm Etlw1613c146e | other | $1,634 | $1,634 | $1,634 | 1 |
| Neonate with Other Significant Problems | other | $1,637 | $1,283 | $1,990 | 2 |
| Laryngoscopy | other | $1,643 | $22 | $5,405 | 27 |
| Repair of Aorta OR Great Vessels with Graft On Heart-lung Machine | surgery | $1,647 | $1,647 | $1,647 | 1 |
| Removal of Lower Portion of Stomach with Reattachment of Upper Portion of Rem... | surgery | $1,649 | $1,649 | $1,649 | 1 |
| Removal of Rectum with Creation of Opening From Large Bowel to Skin Using an ... | surgery | $1,652 | $1,652 | $1,652 | 1 |
| Injection, Thyrotropin Alpha, 0.9 Mg, Provided in 1.1 Mg Vial | other | $1,657 | $1,657 | $1,657 | 1 |
| Placement of Stent of Ureter Through New Skin Access Using Imaging Guidance w... | cardiac | $1,661 | $1,661 | $1,661 | 1 |
| Vasectomy | surgery | $1,663 | $10 | $2,894 | 28 |
| Indium In-111 Pentetreotide IV Diagnostic | other | $1,665 | $1,665 | $1,665 | 1 |
| Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and... | other | $1,670 | $1,598 | $1,742 | 2 |
| Insertion of Vena Cava Filter with Review By Radiologist | other | $1,681 | $1,681 | $1,681 | 1 |
| Coronary Artery Bypass Using Vein Graft, 1 Graft | cardiac | $1,687 | $1,687 | $1,687 | 1 |
| Balloon Dilation of Groin Artery, Initial Vessel | other | $1,687 | $1,687 | $1,687 | 1 |
| Ultrasound Evaluation of Heart Blood Vessel OR Graft with Review By Radiologi... | imaging | $1,688 | $1,688 | $1,688 | 1 |
| Partial Removal of Large Bowel and Reattachment to Rectum and Creation of Ope... | surgery | $1,690 | $1,690 | $1,690 | 1 |
| All Lower Extremity Prostheses, Flex Foot System | other | $1,700 | $1,700 | $1,700 | 1 |
| Depressive Neuroses | other | $1,700 | $1,700 | $1,700 | 1 |
| Extensive Destruction and Reconstruction of Upper Heart Chamber On Heart-lung... | cardiac | $1,701 | $1,701 | $1,701 | 1 |
| Review By Radiologist of Pelvis Artery Image | other | $1,703 | $1,703 | $1,703 | 1 |
| Lithotripsy-s/w | other | $1,704 | $1,704 | $1,704 | 1 |
| Ultrasound Evaluation of Heart Blood Vessel with Review By Radiologist | imaging | $1,711 | $1,711 | $1,711 | 1 |
| Papaverine 30 Mg in 100 Ml 0.9% Sodium Chloride - Irrigation - Compounded | other | $1,714 | $1,714 | $1,714 | 1 |
| Anesthesia for Procedure On Esophagus | other | $1,722 | $1,722 | $1,722 | 1 |
| Intraop Cyto Path Consult 1 | other | $1,726 | $1,726 | $1,726 | 1 |
| Ryanodex 250 Mg Vial | other | $1,729 | $1,729 | $1,729 | 1 |
| Exploration of Chest for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $1,739 | $1,739 | $1,739 | 1 |
| Astigmatism-correct Function | other | $1,746 | $1,746 | $1,746 | 1 |
| LASIK Eye Surgery | other | $1,750 | $5 | $2,894 | 8 |
| Removal of Thickened Heart Muscle At Left Lower Heart Chamber | surgery | $1,768 | $1,768 | $1,768 | 1 |
| Incision OR Removal of Tissue Below Aortic Valve | surgery | $1,770 | $1,770 | $1,770 | 1 |
| Repair of Blood Vessel of Chest | surgery | $1,775 | $1,775 | $1,775 | 1 |
| Removal of Growth of Lung and Reconstruction of Chest Wall | surgery | $1,782 | $1,782 | $1,782 | 1 |
| Balloon Dilation of Artery of Leg | other | $1,786 | $1,786 | $1,786 | 1 |
| Soft Tissue Procedures without Cc/mcc | other | $1,800 | $1,800 | $1,800 | 1 |
| Injection, Filgrastim-sndz, Biosimilar, (zarxio), 1 Microgram | other | $1,808 | $1,808 | $1,808 | 1 |
| Partial Removal of Large Bowel and Reattachment to Rectum and Creation of Lar... | surgery | $1,811 | $1,811 | $1,811 | 1 |
| Partial Removal of Tongue and Surrounding Lymph Nodes On Side of Neck | surgery | $1,811 | $1,811 | $1,811 | 1 |
| Removal of Growth of Heart On Heart-lung Machine | surgery | $1,814 | $1,814 | $1,814 | 1 |
| Insertion of Tube in Upper And/or Lower Heart Chambers to Record and Identify... | cardiac | $1,820 | $1,820 | $1,820 | 1 |
| Deb Bone 20 SQ Cm/< | other | $1,825 | $1,825 | $1,825 | 1 |
| Above Knee, Molded Socket, Open End, Sach Foot, Endoskeletal System, Single A... | other | $1,828 | $1,828 | $1,828 | 1 |
| Placement of Tube of Kidney and Urinary Tube Through New Skin Access Using Im... | other | $1,830 | $1,830 | $1,830 | 1 |
| Carpal Tunnel Release | surgery | $1,832 | $106 | $10,074 | 22 |
| Otitis Media and Uri without Mcc | other | $1,835 | $1,598 | $2,071 | 2 |
| Repair of Electrode for Permanent Pacemaker OR Defibrillator | surgery | $1,837 | $1,837 | $1,837 | 1 |
| Inject Epidural Patch | other | $1,843 | $1,843 | $1,843 | 1 |
| Graft Conduit 21mm Aortic Valved 21cavgj | other | $1,849 | $1,849 | $1,849 | 1 |
| Graft Conduit 23mm Aortic Valved 23cavgj | other | $1,849 | $1,849 | $1,849 | 1 |
| Graft Conduit 27mm Aortic Valved 27cavgj | other | $1,849 | $1,849 | $1,849 | 1 |
| Graft Conduit 29mm Aortic Valved 29cavgj | other | $1,849 | $1,849 | $1,849 | 1 |
| Graft Conduit 31mm Aortic Valved 31cavgj | other | $1,849 | $1,849 | $1,849 | 1 |
| Coronary Artery Bypass Using Vein Graft, 2 Grafts | cardiac | $1,854 | $1,854 | $1,854 | 1 |
| Pacemaker, Other Than Single OR Dual Chamber | cardiac | $1,861 | $1,861 | $1,861 | 1 |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Rupture with Revie... | surgery | $1,872 | $1,872 | $1,872 | 1 |
| Other Antepartum Diagnoses without O.r. Procedures with Cc | other | $1,878 | $1,598 | $2,158 | 2 |
| Insertion of Catheters for Recording, Pacing, and Induction of Abnormal Heart... | cardiac | $1,887 | $1,887 | $1,887 | 1 |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Rupture On Both Si... | surgery | $1,903 | $1,903 | $1,903 | 1 |
| Septal Defect Implant System, Intracardiac | surgery | $1,904 | $1,904 | $1,904 | 1 |
| Coronary Artery Bypass Using Artery Graft, 2 Grafts | cardiac | $1,916 | $1,916 | $1,916 | 1 |
| Glucagon Emergency Kit 1 Mg | emergency | $1,943 | $1,943 | $1,943 | 1 |
| Destr Paravertebrl Nerve | other | $1,944 | $1,944 | $1,944 | 1 |
| Destr L/s Facet Jnt | other | $1,947 | $1,947 | $1,947 | 1 |
| Repair of Aortic Arch with Graft On Heart-lung Machine | surgery | $1,957 | $1,957 | $1,957 | 1 |
| Replacement of Aortic Valve On Heart-lung Machine | surgery | $1,976 | $1,976 | $1,976 | 1 |
| Hernia Repair (Inguinal) | surgery | $1,984 | $22 | $4,950 | 8 |
| Pericardial Tissue Heart Valve All Sizes #3300tfx | cardiac | $1,995 | $1,995 | $1,995 | 1 |
| Insertion of Stent in Groin Artery, Initial Vessel | cardiac | $2,000 | $2,000 | $2,000 | 1 |
| Prosthesis, Urinary Sphincter | other | $2,000 | $2,000 | $2,000 | 1 |
| Implant Pat-active Ht Record | surgery | $2,060 | $2,060 | $2,060 | 1 |
| Repair of Mitral Valve with Artificial Valve On Heart-lung Machine | surgery | $2,074 | $2,074 | $2,074 | 1 |
| Removal of Remaining Lung After Previous Partial Removal of Lung | surgery | $2,079 | $2,079 | $2,079 | 1 |
| Coronary Artery Bypass Using Vein Graft, 3 Grafts | cardiac | $2,100 | $2,100 | $2,100 | 1 |
| Balloon Dilation of Artery with Review By Radiologist, Initial Artery | other | $2,101 | $2,101 | $2,101 | 1 |
| Repair of Wound to Heart | surgery | $2,108 | $2,108 | $2,108 | 1 |
| Repositioning of Tricuspid Valve | other | $2,109 | $2,109 | $2,109 | 1 |
| Repair of Tricuspid Valve with Ring Insertion | surgery | $2,115 | $2,115 | $2,115 | 1 |
| Radical Reconstruction of Mitral Valve On Heart-lung Machine | cardiac | $2,116 | $2,116 | $2,116 | 1 |
| Coronary Artery Bypass Using Artery Graft, 3 Grafts | cardiac | $2,125 | $2,125 | $2,125 | 1 |
| Coronary Artery Bypass Using Vein Graft, 4 Grafts | cardiac | $2,143 | $2,143 | $2,143 | 1 |
| Removal of Heart Sac On Heart-lung Machine | surgery | $2,148 | $2,148 | $2,148 | 1 |
| Endoscopy | preventive | $2,165 | $454 | $10,330 | 24 |
| Balloon Dilation of Artery of Leg, Initial Vessel | other | $2,179 | $2,179 | $2,179 | 1 |
| Inspira Resilian Aortic Valve 19mm #11500a19 | other | $2,181 | $2,181 | $2,181 | 1 |
| Inspira Resilian Aortic Valve 21mmá #11500a21 | other | $2,181 | $2,181 | $2,181 | 1 |
| Inspira Resilian Aortic Valve 23mmá #11500a23 | other | $2,181 | $2,181 | $2,181 | 1 |
| Inspira Resilian Aortic Valve 25mmá #11500a25 | other | $2,181 | $2,181 | $2,181 | 1 |
| Inspira Resilian Aortic Valve 27mmá #11500a27 | other | $2,181 | $2,181 | $2,181 | 1 |
| Inspira Resilian Aortic Valve 29mmá #11500a29 | other | $2,181 | $2,181 | $2,181 | 1 |
| Image-guided Robotic Linear Accelerator-based Stereotactic Radiosurgery, Comp... | surgery | $2,185 | $2,185 | $2,185 | 1 |
| Bronchitis and Asthma without Cc/mcc | other | $2,226 | $1,292 | $3,160 | 2 |
| Zynrelef Implant (bupivacaine | surgery | $2,228 | $2,228 | $2,228 | 1 |
| Anesthesia for Closed Drainage of Lung Fluid | other | $2,245 | $2,245 | $2,245 | 1 |
| ACL Reconstruction | surgery | $2,250 | $8 | $46,499 | 23 |
| Coronary Artery Bypass Using Vein Graft, 5 Grafts | cardiac | $2,282 | $2,282 | $2,282 | 1 |
| Removal of Blood Clot in Pulmonary Artery On Heart-lung Machine | surgery | $2,284 | $2,284 | $2,284 | 1 |
| Coronary Artery Bypass Using Artery Graft, 4 Grafts | cardiac | $2,287 | $2,287 | $2,287 | 1 |
| Iodine I-123 Iobenguane, Diagnostic, Per Study Dose, Up to 15 Millicuries | other | $2,318 | $2,318 | $2,318 | 1 |
| Abortion without D&c | other | $2,318 | $1,598 | $3,038 | 2 |
| Insertion of Catheters for Recording and Pacing of Left Lower Heart Chamber R... | cardiac | $2,319 | $2,319 | $2,319 | 1 |
| Non-needle Measurement and Recording of Electrical Activity of Muscles At Bla... | other | $2,330 | $2,330 | $2,330 | 1 |
| Removal of Large Bowel, Rectum, Bladder and Ureter | surgery | $2,342 | $2,342 | $2,342 | 1 |
| Wound Debridement | surgery | $2,354 | $70 | $66,385 | 21 |
| Coronary Artery Bypass Using Vein Graft, 6 OR More Grafts | cardiac | $2,364 | $2,364 | $2,364 | 1 |
| Repair of Mitral Valve On Heart-lung Machine | surgery | $2,370 | $2,370 | $2,370 | 1 |
| Insertion of Stent in Artery of Leg, Each Additional Vessel | cardiac | $2,374 | $2,374 | $2,374 | 1 |
| Replacement of Tricuspid Valve On Heart-lung Machine | surgery | $2,384 | $2,384 | $2,384 | 1 |
| Njx Aa&/strd Brach Plexus | other | $2,394 | $2,394 | $2,394 | 1 |
| Treatment of Broken Lower Spine Bone with Placement of Stabilizing Device | other | $2,410 | $2,410 | $2,410 | 1 |
| Treatment of Broken Middle Spine Bone with Placement of Stabilizing Device Us... | other | $2,410 | $2,410 | $2,410 | 1 |
| Prematurity without Major Problems | other | $2,438 | $1,751 | $3,125 | 2 |
| Replacement of Mitral Valve On Heart-lung Machine | surgery | $2,438 | $2,438 | $2,438 | 1 |
| Partial Removal of Lower Esophagus | surgery | $2,441 | $2,441 | $2,441 | 1 |
| N Block Inj Fem Cont Inf | other | $2,455 | $2,455 | $2,455 | 1 |
| Interspinous Process Distraction Device | other | $2,461 | $2,461 | $2,461 | 1 |
| Hysteroscopy | other | $2,481 | $22 | $4,950 | 24 |
| Balloon Dilation of Vein with Review By Radiologist, Initial Vein | other | $2,481 | $2,481 | $2,481 | 1 |
| Other Factors Influencing Health Status | other | $2,484 | $1,838 | $3,129 | 2 |
| Dilation of Bile Ducts with Stent Insertion Using an Endoscope | cardiac | $2,494 | $2,494 | $2,494 | 1 |
| Insertion of Temporary Pacemaker Lead in Single Heart Chamber | cardiac | $2,498 | $2,498 | $2,498 | 1 |
| Cataract Surgery | surgery | $2,507 | $671 | $10,074 | 18 |
| Insertion of Pacemaker Pulse Generator with Existing Single Lead | cardiac | $2,541 | $2,541 | $2,541 | 1 |
| Insertion of 1 Electrode for Permanent Pacemaker OR Defibrillator | cardiac | $2,545 | $2,545 | $2,545 | 1 |
| Stent Endograft Endurant Iis Bifurcated 28mm X 14mm X 103mm #esbf2814c103e | cardiac | $2,547 | $2,547 | $2,547 | 1 |
| Dental and Oral Diseases without Cc/mcc | other | $2,548 | $1,431 | $3,665 | 2 |
| Tubal Ligation | surgery | $2,550 | $241 | $10,074 | 8 |
| Tonsillectomy | surgery | $2,550 | $22 | $9,094 | 15 |
| Hernia Repair | surgery | $2,550 | $13 | $9,094 | 22 |
| Prenatal Care | obstetric | $2,550 | $22 | $10,074 | 12 |
| Upper GI Endoscopy (EGD) | diagnostic | $2,550 | $22 | $3,743 | 9 |
| Catheter, Thrombectomy/embolectomy | cardiac | $2,567 | $2,567 | $2,567 | 1 |
| Ascending Aorta Graft, with Cardiopulmonary Bypass, Includes Valve Suspension... | other | $2,568 | $2,568 | $2,568 | 1 |
| Removal of Plaque in Artery of Leg, Each Additional Vessel | surgery | $2,576 | $2,576 | $2,576 | 1 |
| Cardiac Ablation | other | $2,597 | $17 | $50,861 | 21 |
| Renal Failure without CC/MCC | other | $2,605 | $1,598 | $3,612 | 2 |
| Removal of Permanent Pacemaker Pulse Generator | surgery | $2,623 | $2,623 | $2,623 | 1 |
| Iris Prosthesis | other | $2,633 | $2,633 | $2,633 | 1 |
| Major Chest Trauma without Cc/mcc | emergency | $2,648 | $1,598 | $3,698 | 2 |
| Repair of Tricuspid Valve | surgery | $2,665 | $2,665 | $2,665 | 1 |
| Repair of Lower Heart Chamber Following Heart Attack | surgery | $2,669 | $2,669 | $2,669 | 1 |
| Breast Biopsy | other | $2,686 | $18 | $139,721 | 35 |
| Other Male Reproductive System O.r. Procedures Except Malignancy with Cc/mcc | other | $2,700 | $2,700 | $2,700 | 1 |
| Other Kidney and Urinary Tract Diagnoses without Cc/mcc | other | $2,749 | $2,301 | $3,196 | 2 |
| Drainage of Hematoma/fluid | other | $2,751 | $2,751 | $2,751 | 1 |
| Insertion of Stent in Artery of Leg, Initial Vessel | cardiac | $2,752 | $2,752 | $2,752 | 1 |
| Repair of Ascending Aorta with Graft On Heart-lung Machine with Aortic Root R... | surgery | $2,757 | $2,757 | $2,757 | 1 |
| Injection, Glofitamab-gxbm, 2.5 Mg | other | $2,768 | $2,768 | $2,768 | 1 |
| Insert Picc Cath - OR | other | $2,836 | $2,836 | $2,836 | 1 |
| Dexametha Opth Insert 0.1 Mg | imaging | $2,867 | $2,867 | $2,867 | 1 |
| Allergic Reactions without Mcc | other | $2,868 | $2,868 | $2,868 | 1 |
| Other Respiratory System Diagnoses without Mcc | other | $2,870 | $2,870 | $2,870 | 1 |
| Other Kidney and Urinary Tract Procedures without Cc/mcc | other | $2,890 | $2,890 | $2,890 | 1 |
| Replacement of Aortic Valve with Aorta Enlargement | surgery | $2,897 | $2,897 | $2,897 | 1 |
| Vaginal Delivery with OR Procedure except Sterilization/D&C | obstetric | $2,911 | $2,457 | $3,364 | 2 |
| Major Skin Disorders with Mcc | other | $2,912 | $2,912 | $2,912 | 1 |
| Other Disorders of Nervous System without Cc/mcc | other | $2,915 | $1,598 | $4,232 | 2 |
| Acute Myocardial Infarction, Expired with Cc | other | $2,933 | $2,933 | $2,933 | 1 |
| Insertion of 2 Electrodes for Permanent Pacemaker OR Defibrillator | cardiac | $2,936 | $2,936 | $2,936 | 1 |
| Peripheral Vascular Disorders without Cc/mcc | other | $2,962 | $2,728 | $3,196 | 2 |
| Shoulder Surgery | surgery | $2,967 | $92 | $46,499 | 21 |
| Rotator Cuff Repair | surgery | $2,967 | $92 | $6,805 | 5 |
| Other Digestive System Diagnoses without Cc/mcc | other | $2,982 | $1,598 | $4,366 | 2 |
| Other Skin, Subcutaneous Tissue and Breast Procedures without Cc/mcc | other | $3,005 | $2,409 | $3,600 | 2 |
| Full Term Neonate with Major Problems | other | $3,024 | $1,580 | $4,467 | 2 |
| Knee Arthroscopy | other | $3,044 | $161 | $12,476 | 21 |
| Urinary Stones without Mcc | other | $3,050 | $1,598 | $4,501 | 2 |
| Epi-sense Guided 6130 Device #cdp-4330 | other | $3,059 | $3,059 | $3,059 | 1 |
| C-Section (Cesarean Delivery) | obstetric | $3,068 | $17 | $36,823 | 39 |
| Testes Procedures without Cc/mcc | other | $3,072 | $3,072 | $3,072 | 1 |
| Graft Bifurcated Stent #ba28-100/i16 | cardiac | $3,080 | $3,080 | $3,080 | 1 |
| Respiratory Neoplasms without Cc/mcc | other | $3,083 | $3,083 | $3,083 | 1 |
| Bunionectomy | other | $3,091 | $393 | $4,950 | 15 |
| Hosp Obs Hrs 8 & Above | other | $3,091 | $3,091 | $3,091 | 1 |
| Septoplasty | surgery | $3,156 | $382 | $9,094 | 10 |
| Destruction of Growth of Kidney By Freezing | other | $3,195 | $3,195 | $3,195 | 1 |
| Benign Prostatic Hypertrophy without Mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Diabetes without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Inflammatory Bowel Disease without Cc/mcc | other | $3,196 | $3,196 | $3,196 | 1 |
| Prematurity with Major Problems | other | $3,237 | $2,662 | $3,812 | 2 |
| Cath, Bal Dil, Non-vascular | other | $3,247 | $3,247 | $3,247 | 1 |
| Alloderm 1518320 | other | $3,248 | $3,248 | $3,248 | 1 |
| Other Multiple Significant Trauma with Cc | emergency | $3,252 | $1,710 | $4,794 | 2 |
| Heart Failure and Shock without CC/MCC | cardiac | $3,272 | $1,598 | $4,945 | 2 |
| Endograft Aortic Body 23mm Tv-ab2380-j | other | $3,273 | $3,273 | $3,273 | 1 |
| Endograft Aortic Body 26mm Tv-ab2680-n | other | $3,273 | $3,273 | $3,273 | 1 |
| Endograft Aortic Body 29mm Tv-ab2980-n | other | $3,273 | $3,273 | $3,273 | 1 |
| Endograft Aortic Body 34mm Tv-ab3480-n | other | $3,273 | $3,273 | $3,273 | 1 |
| Kidney Stone Removal | other | $3,285 | $22 | $97,500 | 37 |
| IOL Crystalens OR Trulign | other | $3,312 | $3,312 | $3,312 | 1 |
| Insertion of Pacemaker Pulse Generator with Existing Dual Leads | cardiac | $3,333 | $3,333 | $3,333 | 1 |
| All Lower Extremity Prosthesis, Shank Foot System with Vertical Loading Pylon | other | $3,336 | $3,336 | $3,336 | 1 |
| Cardioverter-defibrillator, Dual Chamber | other | $3,378 | $3,378 | $3,378 | 1 |
| Other Cerebrovascular Disorders without Cc/mcc | other | $3,384 | $3,196 | $3,572 | 2 |
| Vaginal Delivery | obstetric | $3,414 | $22 | $11,589 | 37 |
| Traumatic Injury without Mcc | emergency | $3,418 | $1,831 | $5,004 | 2 |
| Neuragen | other | $3,423 | $3,423 | $3,423 | 1 |
| Disorders of Pancreas Except Malignancy without Cc/mcc | other | $3,425 | $3,196 | $3,653 | 2 |
| Removal and Dissolving of Blood Clot From Vein Using Fluoroscopic Guidance, I... | surgery | $3,437 | $3,437 | $3,437 | 1 |
| Headaches without Mcc | other | $3,456 | $1,598 | $5,314 | 2 |
| Injection, Pegloticase, 1 Mg | other | $3,457 | $3,457 | $3,457 | 1 |
| Infections, Female Reproductive System without Cc/mcc | other | $3,461 | $3,461 | $3,461 | 1 |
| Gore Excluder Aaa Endoprosthesis 26mm X 14.5mm Rlt261414 | other | $3,461 | $3,461 | $3,461 | 1 |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures without Cc/mcc | other | $3,482 | $3,482 | $3,482 | 1 |
| Cardioverter-defibrillator, Single Chamber | other | $3,486 | $3,486 | $3,486 | 1 |
| Propel Mometasone Furoate Sinu | other | $3,497 | $3,497 | $3,497 | 1 |
| Ankle Surgery | other | $3,499 | $254 | $7,051 | 12 |
| Repair of Wound to Heart On Heart-lung Machine | surgery | $3,500 | $3,500 | $3,500 | 1 |
| Insertion of Left Lower Heart Electrode and Attachment to Pacemaker OR Defibr... | cardiac | $3,500 | $3,500 | $3,500 | 1 |
| Insertion of Pacemaker and Lower Heart Chamber Electrode | cardiac | $3,500 | $3,500 | $3,500 | 1 |
| Cardiac Arrhythmia and Conduction Disorders without Cc/mcc | cardiac | $3,506 | $3,196 | $3,816 | 2 |
| Gore Excluder Endoporsthesis Iliac Branch Comp #ceb231010a | other | $3,511 | $3,511 | $3,511 | 1 |
| Gore Excluder Iliac Branch Endoprosthesis Iliac Branch Component 14.35mm X 10... | other | $3,511 | $3,511 | $3,511 | 1 |
| Bronchitis and Asthma with Cc/mcc | other | $3,512 | $3,196 | $3,828 | 2 |
| Insertion of 2 Chamber Pacemaker System | cardiac | $3,518 | $3,518 | $3,518 | 1 |
| Aftercare without Cc/mcc | other | $3,522 | $3,522 | $3,522 | 1 |
| Viral Illness without Mcc | other | $3,542 | $3,099 | $3,985 | 2 |
| Other Ear, Nose, Mouth and Throat O.r. Procedures with Mcc | other | $3,558 | $3,558 | $3,558 | 1 |
| Insertion of Catheters for Recording and Pacing of Left Upper Heart Chamber R... | cardiac | $3,572 | $3,572 | $3,572 | 1 |
| Gore Excluder Ipsilateral Leg Endoprosthesis 28.5mm X 14.5mm X 12cm #rlt281412 | other | $3,575 | $3,575 | $3,575 | 1 |
| Knee Procedures without Principal Diagnosis of Infection with Cc/mcc | other | $3,600 | $3,600 | $3,600 | 1 |
| Other Antepartum Diagnoses with O.r. Procedures with Cc | other | $3,600 | $3,600 | $3,600 | 1 |
| Other Digestive System O.r. Procedures without Cc/mcc | other | $3,600 | $3,600 | $3,600 | 1 |
| Wound Debridements for Injuries without Cc/mcc | other | $3,619 | $3,619 | $3,619 | 1 |
| Dental and Oral Diseases with Cc | other | $3,672 | $2,550 | $4,794 | 2 |
| Other O.r. Procedures of the Blood and Blood Forming Organs without Cc/mcc | other | $3,676 | $3,676 | $3,676 | 1 |
| Injection, Digoxin Immune Fab (ovine), Per Vial | other | $3,698 | $3,698 | $3,698 | 1 |
| Insertion of Pacemaker and Upper and Lower Heart Chamber Electrode | cardiac | $3,714 | $3,714 | $3,714 | 1 |
| Hepatobiliary Diagnostic Procedures with Cc | other | $3,721 | $3,721 | $3,721 | 1 |
| Abortion with D&c, Aspiration Curettage OR Hysterotomy | other | $3,739 | $3,600 | $3,878 | 2 |
| Hernia Procedures Except Inguinal and Femoral without Cc/mcc | other | $3,753 | $1,800 | $5,706 | 2 |
| Thyroidectomy | surgery | $3,773 | $888 | $10,074 | 17 |
| Lumpectomy (Breast) | surgery | $3,805 | $83 | $4,950 | 15 |
| Major Gastrointestinal Disorders and Peritoneal Infections without Cc/mcc | other | $3,811 | $3,811 | $3,811 | 1 |
| Bifurcated Stent #bea28-90/i16 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Bifurcated Stent #bea28-90/i20 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Bifurcated Stent Bea22-60/i16 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea25-100/i16 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea25-100/i20 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea25-90/i16 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea28-100/i16 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea28-70/i16 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea28-80/i16 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Afx2 #bea28-80/i20 | other | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Stent #ba25-100/i20 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Graft Bifurcated Stent #bea25-90/i20 | cardiac | $3,818 | $3,818 | $3,818 | 1 |
| Fever and Inflammatory Conditions | other | $3,818 | $1,598 | $6,037 | 2 |
| Other Musculoskeletal System and Connective Tissue Diagnoses without Cc/mcc | other | $3,819 | $3,196 | $4,442 | 2 |
| Spinal Fusion (Lumbar) | surgery | $3,822 | $1,700 | $32,341 | 6 |
| Balloon Dilation Repair of Aortic Valve | surgery | $3,881 | $3,881 | $3,881 | 1 |
| Gastrointestinal Obstruction without Cc/mcc | other | $3,891 | $3,538 | $4,244 | 2 |
| Reticuloendothelial and Immunity Disorders with Cc | other | $3,909 | $3,196 | $4,622 | 2 |
| Allergic Reactions with Mcc | other | $3,963 | $1,598 | $6,327 | 2 |
| Traumatic Stupor and Coma >1 Hour with Cc | emergency | $3,978 | $3,196 | $4,760 | 2 |
| Gore Excluder Conformable Aaa Endoprosthesis 18fr Cxt321414 | other | $3,996 | $3,996 | $3,996 | 1 |
| Gore Excluder Conformable Aaa Endoprosthesis Cxt281412 | other | $3,996 | $3,996 | $3,996 | 1 |
| Principal Diagnosis Invalid As Discharge Diagnosis | other | $3,996 | $3,996 | $3,996 | 1 |
| COPD Management | other | $4,000 | $5 | $19,047 | 40 |
| Destruction of Growths and Adjacent Soft Tissue | other | $4,003 | $4,003 | $4,003 | 1 |
| Pneumothorax with Cc | other | $4,019 | $3,196 | $4,841 | 2 |
| Uncomplicated Peptic Ulcer with Mcc | other | $4,038 | $2,485 | $5,591 | 2 |
| Alcohol/Drug Abuse or Dependence without Rehabilitation without MCC | therapy | $4,059 | $2,521 | $5,597 | 2 |
| Other O.r. Procedures for Injuries without Cc/mcc | other | $4,063 | $4,063 | $4,063 | 1 |
| Respiratory Infections and Inflammations without Cc/mcc | other | $4,097 | $1,598 | $6,596 | 2 |
| Gastrointestinal Hemorrhage without Cc/mcc | other | $4,105 | $3,196 | $5,014 | 2 |
| Infections, Female Reproductive System with Mcc | other | $4,126 | $4,126 | $4,126 | 1 |
| Gore Excluder Endoprosthesis Aaa Conformable Endo #cxt261412 | other | $4,128 | $4,128 | $4,128 | 1 |
| Respiratory Neoplasms with Cc | other | $4,143 | $1,598 | $6,687 | 2 |
| Insertion of Catheters for Recording and Pacing of Right Heart Chambers Rhyth... | cardiac | $4,163 | $4,163 | $4,163 | 1 |
| Local Excision and Removal of Internal Fixation Devices Except Hip and Femur ... | surgery | $4,184 | $4,184 | $4,184 | 1 |
| Occlusion of Growths OR Obstructed Vessels with Review By Radiologist | other | $4,190 | $4,190 | $4,190 | 1 |
| Occlusion of Vein with Review By Radiologist | other | $4,190 | $4,190 | $4,190 | 1 |
| Anal and Stomal Procedures with Cc | other | $4,206 | $3,600 | $4,811 | 2 |
| Insertion of Pacemaker and Upper Heart Chamber Electrode | cardiac | $4,255 | $4,255 | $4,255 | 1 |
| Postpartum and Post Abortion Diagnoses with O.r. Procedures | obstetric | $4,279 | $3,157 | $5,400 | 2 |
| Cirrhosis and Alcoholic Hepatitis without Cc/mcc | other | $4,288 | $4,288 | $4,288 | 1 |
| Endocrine Disorders with Cc | other | $4,308 | $2,452 | $6,164 | 2 |
| Cardioverter-defibrillator, Other Than Single OR Dual Chamber | other | $4,319 | $4,319 | $4,319 | 1 |
| Chest Pain | other | $4,321 | $4,321 | $4,321 | 1 |
| Simple Pneumonia without CC/MCC | other | $4,344 | $3,196 | $5,491 | 2 |
| Acute Major Eye Infections with Cc/mcc | other | $4,350 | $4,350 | $4,350 | 1 |
| Major Skin Disorders without Mcc | other | $4,383 | $4,244 | $4,522 | 2 |
| Fractures of Hip and Pelvis with Mcc | other | $4,399 | $3,196 | $5,602 | 2 |
| Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes wit... | other | $4,422 | $3,518 | $5,326 | 2 |
| Minor Bladder Procedures with Mcc | other | $4,443 | $1,800 | $7,085 | 2 |
| Pulmonary Embolism without MCC | other | $4,455 | $4,115 | $4,794 | 2 |
| Prosthesis, Penile, Inflatable | other | $4,461 | $4,461 | $4,461 | 1 |
| Pneumothorax without Cc/mcc | other | $4,463 | $4,463 | $4,463 | 1 |
| Atherosclerosis without Mcc | other | $4,466 | $3,196 | $5,736 | 2 |
| Skin Grafts for Injuries with Cc/mcc | other | $4,467 | $4,467 | $4,467 | 1 |
| Non-malignant Breast Disorders without Cc/mcc | other | $4,471 | $4,471 | $4,471 | 1 |
| Cellulitis without Mcc | other | $4,502 | $4,448 | $4,556 | 2 |
| Watchman Flex Device 20mm Wu5020 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flex Device 24mm Wu5024 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flex Device 27mm Wu5027 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flex Device 31mm Wu5031 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 20mm Wu6020 M635wu60200 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 24mm Wu6024 M635wu60240 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 27mm Wu6027 M635wu60270 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 31mm Wu6031 M635wu60310 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 35mm Wu6035 M635wu60350 | other | $4,522 | $4,522 | $4,522 | 1 |
| Watchman Flx Pro Laa Closure 40mm Wu6040 M635wu60400 | other | $4,522 | $4,522 | $4,522 | 1 |
| Peripheral Vascular Disorders with Cc | other | $4,523 | $4,251 | $4,794 | 2 |
| Kidney and Urinary Tract Infections without MCC | other | $4,533 | $4,317 | $4,748 | 2 |
| Tendonitis, Myositis and Bursitis without Mcc | other | $4,569 | $4,439 | $4,698 | 2 |
| Mouth Procedures without Cc/mcc | other | $4,610 | $4,610 | $4,610 | 1 |
| Insertion of Stent in Vein with Review By Radiologist, Initial Vein | cardiac | $4,611 | $4,611 | $4,611 | 1 |
| Other Antepartum Diagnoses without O.r. Procedures with Mcc | other | $4,616 | $4,438 | $4,794 | 2 |
| Kidney and Urinary Tract Signs and Symptoms without Mcc | other | $4,619 | $4,496 | $4,741 | 2 |
| Other Ear, Nose, Mouth and Throat Diagnoses with Cc | other | $4,670 | $4,670 | $4,670 | 1 |
| Nervous System Neoplasms with Mcc | other | $4,683 | $1,598 | $7,768 | 2 |
| Cardiac Arrhythmia and Conduction Disorders with Cc | cardiac | $4,685 | $4,576 | $4,794 | 2 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis without Cc/mcc | other | $4,696 | $1,800 | $7,591 | 2 |
| Esophagitis and GI Disorders with MCC | other | $4,710 | $4,632 | $4,788 | 2 |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Cc | other | $4,715 | $3,196 | $6,234 | 2 |
| Hysterectomy (Laparoscopic) | surgery | $4,729 | $22 | $57,631 | 30 |
| IOL Staar Visian Clearlens Exc | other | $4,755 | $4,755 | $4,755 | 1 |
| Peripheral Vascular Disorders with Mcc | other | $4,763 | $3,196 | $6,329 | 2 |
| Fractures of Femur without Mcc | other | $4,765 | $4,765 | $4,765 | 1 |
| Endometrial Ablation | other | $4,781 | $22 | $19,770 | 19 |
| Amplatzer Amulet Laao 16mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 18mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 20mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 22mm 9-acp2-007 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 25mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 28mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 31mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Amplatzer Amulet Laao 34mm 9-acp2-010 | other | $4,788 | $4,788 | $4,788 | 1 |
| Watchman Device 27mm | other | $4,788 | $4,788 | $4,788 | 1 |
| Watchman Device 30mm | other | $4,788 | $4,788 | $4,788 | 1 |
| Watchman Device 33mm | other | $4,788 | $4,788 | $4,788 | 1 |
| Watchman Flex Device 35mm Wu5035 | other | $4,788 | $4,788 | $4,788 | 1 |
| HIV with Major Related Condition with Cc | other | $4,794 | $4,794 | $4,794 | 1 |
| Cranial and Peripheral Nerve Disorders without Mcc | other | $4,804 | $4,794 | $4,813 | 2 |
| Other Injury, Poisoning and Toxic Effect Diagnoses without Mcc | other | $4,808 | $3,196 | $6,420 | 2 |
| Hypertension without Mcc | other | $4,815 | $4,167 | $5,463 | 2 |
| Diabetes with Cc | other | $4,816 | $4,234 | $5,397 | 2 |
| Valiant Thoracic Stent Graft W/ Captivia Delivery System 38mm X 34mm X 150mm ... | cardiac | $4,821 | $4,821 | $4,821 | 1 |
| Uncomplicated Peptic Ulcer without Mcc | other | $4,894 | $4,894 | $4,894 | 1 |
| Psychoses | therapy | $4,906 | $2,788 | $7,023 | 2 |
| Poisoning and Toxic Effects of Drugs without MCC | emergency | $4,916 | $4,916 | $4,916 | 1 |
| Respiratory Infections and Inflammations with Cc | other | $4,923 | $4,794 | $5,052 | 2 |
| Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy w... | other | $4,924 | $3,456 | $6,392 | 2 |
| Simple Pneumonia with CC | other | $4,929 | $4,608 | $5,250 | 2 |
| Skin Ulcers with Cc | other | $4,945 | $2,867 | $7,023 | 2 |
| Hip Arthroscopy | other | $4,950 | $783 | $10,074 | 10 |
| Otitis Media and Uri with Mcc | other | $4,960 | $3,118 | $6,801 | 2 |
| Myeloproliferative Disorders OR Poorly Differentiated Neoplasms with Other Pr... | other | $4,962 | $4,962 | $4,962 | 1 |
| Complicated Peptic Ulcer without Cc/mcc | other | $4,967 | $4,967 | $4,967 | 1 |
| Minor Bladder Procedures without Cc/mcc | other | $4,970 | $4,970 | $4,970 | 1 |
| Menstrual and Other Female Reproductive System Disorders without Cc/mcc | other | $4,976 | $4,976 | $4,976 | 1 |
| Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with Mcc | other | $4,989 | $3,196 | $6,781 | 2 |
| Major Esophageal Disorders with Cc | other | $4,995 | $4,794 | $5,196 | 2 |
| Hypertensive Encephalopathy with Cc | other | $5,000 | $4,794 | $5,205 | 2 |
| Skin Graft for Skin Ulcer OR Cellulitis without Cc/mcc | other | $5,021 | $5,021 | $5,021 | 1 |
| Inflammatory Bowel Disease with Cc | other | $5,025 | $4,794 | $5,256 | 2 |
| Syncope and Collapse | other | $5,026 | $4,794 | $5,258 | 2 |
| Peripheral, Cranial Nerve and Other Nervous System Procedures without Cc/mcc | other | $5,032 | $5,032 | $5,032 | 1 |
| Acute and Subacute Endocarditis with Cc | other | $5,035 | $5,035 | $5,035 | 1 |
| COPD without CC/MCC | other | $5,047 | $4,627 | $5,466 | 2 |
| Generator, Neurostimulator (implantable), with Rechargeable Battery and Charg... | surgery | $5,054 | $5,054 | $5,054 | 1 |
| Multiple Sclerosis and Cerebellar Ataxia with Cc | other | $5,057 | $3,721 | $6,392 | 2 |
| Nervous System Neoplasms without Mcc | other | $5,061 | $4,669 | $5,452 | 2 |
| Osteomyelitis with Cc | other | $5,061 | $5,061 | $5,061 | 1 |
| Valiant Thoracic Stent Graft with the Captivia Delivery System Vamf3838c200tu | cardiac | $5,082 | $5,082 | $5,082 | 1 |
| Transient Ischemia | other | $5,088 | $3,196 | $6,979 | 2 |
| Malignancy, Female Reproductive System with Cc | other | $5,107 | $3,196 | $7,017 | 2 |
| Extracranial Procedures with Cc | other | $5,111 | $5,111 | $5,111 | 1 |
| Skin Debridement without Cc/mcc | other | $5,144 | $3,687 | $6,601 | 2 |
| Renal Failure with CC | other | $5,144 | $4,716 | $5,571 | 2 |
| Integra Silicone Pip Implant | surgery | $5,150 | $5,150 | $5,150 | 1 |
| Inborn and Other Disorders of Metabolism | other | $5,161 | $1,598 | $8,723 | 2 |
| Graft Thoracic 10cmx21mmx21mm Tgm212110 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 10cmx28mmx28mm Tgm282810 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 10cmx31mmx26mm Tgmr312610 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 10cmx31mmx31mm Tgmr313110 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 15cmx31mmx31mm Tgmr313115 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 15cmx34mmx34mm Tgm343415 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 15cmx37mmx37mm Tgmr373715 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 15cmx40mmx40mm Tgmr404015 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 15cmx45mmx45mm Tgm454515 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 20cmx31mmx31mm Tgmr313120 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 20cmx37mmx37mm Tgmr373720 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 20cmx40mmx40mm Tgmr404020 | other | $5,163 | $5,163 | $5,163 | 1 |
| Graft Thoracic 20cmx45mmx45mm Tgm454520 | other | $5,163 | $5,163 | $5,163 | 1 |
| Gastric Sleeve (Weight Loss Surgery) | other | $5,165 | $1,046 | $10,330 | 12 |
| Connective Tissue Disorders with Cc | other | $5,176 | $1,598 | $8,754 | 2 |
| Pleural Effusion with Cc | surgery | $5,182 | $5,182 | $5,182 | 1 |
| Other Ear, Nose, Mouth and Throat O.r. Procedures without Cc/mcc | other | $5,204 | $5,204 | $5,204 | 1 |
| Appendectomy (Laparoscopic) | surgery | $5,212 | $3 | $40,890 | 28 |
| Destruction Neurolytic Agt Gen | other | $5,222 | $5,222 | $5,222 | 1 |
| Seizures without MCC | other | $5,226 | $4,556 | $5,896 | 2 |
| Red Blood Cell Disorders without Mcc | other | $5,230 | $4,425 | $6,034 | 2 |
| COPD with CC | other | $5,266 | $4,742 | $5,789 | 2 |
| Trauma to the Skin, Subcutaneous Tissue and Breast without Mcc | emergency | $5,284 | $4,911 | $5,656 | 2 |
| Aftercare, Musculoskeletal System and Connective Tissue without Cc/mcc | other | $5,342 | $4,124 | $6,559 | 2 |
| Other Antepartum Diagnoses with O.r. Procedures with Mcc | other | $5,358 | $1,800 | $8,916 | 2 |
| Signs and Symptoms of Musculoskeletal System and Connective Tissue without Mcc | other | $5,360 | $5,360 | $5,360 | 1 |
| Heart Failure and Shock with CC | cardiac | $5,374 | $4,794 | $5,953 | 2 |
| Intracranial Hemorrhage or Cerebral Infarction with CC | other | $5,387 | $4,794 | $5,979 | 2 |
| Gastrointestinal Obstruction with Cc | other | $5,394 | $4,794 | $5,994 | 2 |
| Breast Biopsy, Local Excision and Other Breast Procedures with Cc/mcc | surgery | $5,400 | $5,400 | $5,400 | 1 |
| Peripheral, Cranial Nerve and Other Nervous System Procedures with Cc OR Peri... | other | $5,400 | $5,400 | $5,400 | 1 |
| Urethral Procedures with Cc/mcc | other | $5,400 | $5,400 | $5,400 | 1 |
| Implant Neuroelectrodes | surgery | $5,400 | $5,400 | $5,400 | 1 |
| Generator, Neurostimulator (implantable), Non-rechargeable | surgery | $5,453 | $5,453 | $5,453 | 1 |
| Minor Skin Disorders without Mcc | other | $5,460 | $4,794 | $6,126 | 2 |
| Neurological Eye Disorders | other | $5,470 | $5,470 | $5,470 | 1 |
| Other Disorders of Nervous System with Cc | other | $5,470 | $4,794 | $6,145 | 2 |
| Prostatectomy with Cc | other | $5,489 | $5,489 | $5,489 | 1 |
| Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh ... | other | $5,495 | $4,794 | $6,195 | 2 |
| Other Multiple Significant Trauma without Cc/mcc | emergency | $5,507 | $5,507 | $5,507 | 1 |
| Inflammation of the Male Reproductive System without Mcc | other | $5,516 | $4,647 | $6,384 | 2 |
| Concussion with Cc | other | $5,532 | $5,532 | $5,532 | 1 |
| Hypertension with Mcc | other | $5,546 | $4,699 | $6,392 | 2 |
| Gallbladder Removal (Laparoscopic) | surgery | $5,558 | $22 | $57,587 | 39 |
| D&c, Conization, Laparoscopy and Tubal Interruption with Cc/mcc | surgery | $5,569 | $5,400 | $5,737 | 2 |
| Major Chest Trauma with Cc | emergency | $5,592 | $5,592 | $5,592 | 1 |
| Inflammation of the Male Reproductive System with Mcc | other | $5,611 | $1,598 | $9,623 | 2 |
| Prostatectomy without Cc/mcc | other | $5,630 | $5,630 | $5,630 | 1 |
| Hand Procedures for Injuries | other | $5,644 | $4,088 | $7,200 | 2 |
| Mastectomy for Malignancy without Cc/mcc | other | $5,644 | $5,644 | $5,644 | 1 |
| Reticuloendothelial and Immunity Disorders with Mcc | other | $5,653 | $1,598 | $9,708 | 2 |
| Fractures of Hip and Pelvis without Mcc | other | $5,663 | $4,933 | $6,392 | 2 |
| Lymphoma and Non-acute Leukemia with Cc | other | $5,673 | $3,196 | $8,150 | 2 |
| Implantable Wireless Pulmonary Artery Pressure Sensor with Delivery Catheter,... | surgery | $5,692 | $5,692 | $5,692 | 1 |
| Urethral Stricture | other | $5,709 | $5,709 | $5,709 | 1 |
| Prostatectomy | other | $5,732 | $70 | $33,079 | 31 |
| Angina Pectoris | other | $5,758 | $5,758 | $5,758 | 1 |
| Septic Arthritis with Cc | other | $5,770 | $4,517 | $7,023 | 2 |
| Medical Back Problems without Mcc | other | $5,775 | $5,353 | $6,197 | 2 |
| Hypertensive Encephalopathy without Cc/mcc | other | $5,780 | $5,780 | $5,780 | 1 |
| Other Disorders of Nervous System with Mcc | other | $5,792 | $4,556 | $7,028 | 2 |
| Extracranial Vascular Procedures with MCC | other | $5,795 | $5,795 | $5,795 | 1 |
| Digestive Malignancy with Cc | other | $5,796 | $3,196 | $8,395 | 2 |
| Other Endocrine, Nutritional and Metabolic O.r. Procedures without Cc/mcc | lab | $5,816 | $5,816 | $5,816 | 1 |
| Laminectomy (Back Decompression) | other | $5,826 | $314 | $10,074 | 16 |
| Removal of Plaque in Artery of Leg, Initial Vessel | surgery | $5,836 | $5,836 | $5,836 | 1 |
| Signs and Symptoms with Mcc | other | $5,844 | $5,844 | $5,844 | 1 |
| Multiple Sclerosis and Cerebellar Ataxia with Mcc | other | $5,849 | $5,849 | $5,849 | 1 |
| Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh without Cc/mcc | other | $5,877 | $5,877 | $5,877 | 1 |
| Appendix Procedures without Cc/mcc | other | $5,901 | $1,800 | $10,001 | 2 |
| Complicated Peptic Ulcer with Cc | other | $5,933 | $3,196 | $8,670 | 2 |
| Seizures with Mcc | other | $5,952 | $4,794 | $7,110 | 2 |
| Urinary Stones with Mcc | other | $5,962 | $4,794 | $7,130 | 2 |
| Other Cerebrovascular Disorders with Cc | other | $5,972 | $4,556 | $7,388 | 2 |
| Disorders of the Biliary Tract without Cc/mcc | other | $6,011 | $4,794 | $7,228 | 2 |
| Hip and Femur Procedures except Major Joint without CC/MCC | surgery | $6,024 | $3,600 | $8,448 | 2 |
| Acute Myocardial Infarction Discharged Alive without CC/MCC | cardiac | $6,040 | $5,762 | $6,317 | 2 |
| Postoperative and Post-traumatic Infections with Mcc | emergency | $6,043 | $4,794 | $7,292 | 2 |
| Disorders of Pancreas Except Malignancy with Cc | other | $6,065 | $5,801 | $6,329 | 2 |
| Minor Small and Large Bowel Procedures without Cc/mcc | other | $6,082 | $1,800 | $10,363 | 2 |
| Complications of Treatment with Mcc | other | $6,093 | $1,598 | $10,587 | 2 |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy without Cc/mcc | other | $6,094 | $6,094 | $6,094 | 1 |
| Digestive Malignancy with Mcc | other | $6,097 | $4,794 | $7,399 | 2 |
| Foot Procedures with Cc | other | $6,110 | $5,019 | $7,200 | 2 |
| Kidney and Urinary Tract Neoplasms with Cc | other | $6,129 | $5,865 | $6,392 | 2 |
| Endocrine Disorders with Mcc | other | $6,129 | $5,865 | $6,392 | 2 |
| Nutritional and Metabolic Disorders without MCC | other | $6,180 | $5,968 | $6,392 | 2 |
| COPD with MCC | other | $6,239 | $6,085 | $6,392 | 2 |
| Other Kidney and Urinary Tract Diagnoses with Cc | other | $6,243 | $6,077 | $6,408 | 2 |
| GI Hemorrhage with CC | other | $6,269 | $6,146 | $6,392 | 2 |
| Skin Graft for Skin Ulcer OR Cellulitis with Cc | other | $6,274 | $6,274 | $6,274 | 1 |
| Septicemia or Severe Sepsis without Ventilator 96+ Hours without MCC | other | $6,277 | $6,113 | $6,440 | 2 |
| Inguinal and Femoral Hernia Procedures with Cc | other | $6,279 | $3,600 | $8,958 | 2 |
| Removal of Plaque in Arteries of Leg | surgery | $6,293 | $6,293 | $6,293 | 1 |
| Penis Procedures with Cc/mcc | other | $6,303 | $3,600 | $9,005 | 2 |
| Amputation for Musculoskeletal System and Connective Tissue Disorders without... | other | $6,323 | $6,323 | $6,323 | 1 |
| Pulmonary Edema and Respiratory Failure | other | $6,378 | $5,732 | $7,023 | 2 |
| Disorders of the Biliary Tract with Cc | other | $6,379 | $3,196 | $9,561 | 2 |
| Interstitial Lung Disease with Mcc | other | $6,392 | $6,392 | $6,392 | 1 |
| Major Chest Trauma with Mcc | emergency | $6,392 | $6,392 | $6,392 | 1 |
| Non-extensive Burns | other | $6,392 | $6,392 | $6,392 | 1 |
| Nontraumatic Stupor and Coma with Mcc | emergency | $6,392 | $6,392 | $6,392 | 1 |
| Complications of Treatment with Cc | other | $6,412 | $5,800 | $7,023 | 2 |
| Epistaxis without Mcc | other | $6,412 | $6,412 | $6,412 | 1 |
| Acute Myocardial Infarction Discharged Alive with CC | cardiac | $6,412 | $4,794 | $8,030 | 2 |
| Minor Skin Disorders with Mcc | other | $6,415 | $6,415 | $6,415 | 1 |
| Bone Diseases and Arthropathies with Mcc | other | $6,462 | $1,598 | $11,325 | 2 |
| Major Head and Neck Procedures with Cc | other | $6,465 | $6,465 | $6,465 | 1 |
| Heart Failure and Shock with MCC | cardiac | $6,469 | $5,915 | $7,023 | 2 |
| Simple Pneumonia with MCC | other | $6,497 | $5,970 | $7,023 | 2 |
| Malignant Breast Disorders with Cc | other | $6,535 | $6,535 | $6,535 | 1 |
| Major Gastrointestinal Disorders and Peritoneal Infections with Cc | other | $6,560 | $6,358 | $6,762 | 2 |
| Dysequilibrium | other | $6,566 | $6,566 | $6,566 | 1 |
| Kidney and Ureter Procedures for Non-neoplasm without Cc/mcc | other | $6,577 | $5,400 | $7,754 | 2 |
| Connective Tissue Disorders with Mcc | other | $6,601 | $6,179 | $7,023 | 2 |
| Acute Adjustment Reaction and Psychosocial Dysfunction | other | $6,618 | $5,043 | $8,193 | 2 |
| Multiple Sclerosis and Cerebellar Ataxia without Cc/mcc | other | $6,618 | $6,618 | $6,618 | 1 |
| Red Blood Cell Disorders with Mcc | other | $6,627 | $6,231 | $7,023 | 2 |
| Cardiac Arrhythmia and Conduction Disorders with Mcc | cardiac | $6,631 | $6,392 | $6,869 | 2 |
| Other Musculoskeletal System and Connective Tissue Diagnoses with Cc | other | $6,646 | $6,268 | $7,023 | 2 |
| Impella Cp #4000021 | other | $6,650 | $6,650 | $6,650 | 1 |
| Other Respiratory System O.r. Procedures without Cc/mcc | other | $6,664 | $6,664 | $6,664 | 1 |
| Other Myeloproliferative Disorders OR Poorly Differentiated Neoplastic Diagno... | other | $6,672 | $4,794 | $8,549 | 2 |
| Pulmonary Embolism with MCC | other | $6,674 | $4,794 | $8,553 | 2 |
| Other Circulatory System Diagnoses with Cc | other | $6,678 | $6,333 | $7,023 | 2 |
| Cellulitis with Mcc | other | $6,696 | $6,368 | $7,023 | 2 |
| Intracranial Hemorrhage or Cerebral Infarction | other | $6,732 | $6,392 | $7,072 | 2 |
| Cardiac Pacemaker Revision Except Device Replacement with Cc | surgery | $6,747 | $6,747 | $6,747 | 1 |
| Samarium Sm 153 Lexidronam 1850 Mbq/ml IV Soln | other | $6,767 | $6,767 | $6,767 | 1 |
| Bone Diseases and Arthropathies without Mcc | other | $6,792 | $6,331 | $7,252 | 2 |
| Tendonitis, Myositis and Bursitis with Mcc | other | $6,825 | $6,626 | $7,023 | 2 |
| Other Infectious and Parasitic Diseases Diagnoses with Mcc | other | $6,825 | $6,627 | $7,023 | 2 |
| Aftercare, Musculoskeletal System and Connective Tissue with Cc | other | $6,860 | $6,392 | $7,327 | 2 |
| Signs and Symptoms without Mcc | other | $6,867 | $6,867 | $6,867 | 1 |
| Kidney and Urinary Tract Infections with MCC | other | $6,886 | $6,748 | $7,023 | 2 |
| Craniotomy and Endovascular Intracranial Procedures without Cc/mcc | other | $6,891 | $6,891 | $6,891 | 1 |
| Generator, Neurostimulator (implantable), High Frequency, with Rechargeable B... | surgery | $6,916 | $6,916 | $6,916 | 1 |
| Aftercare, Musculoskeletal System and Connective Tissue with Mcc | other | $6,931 | $6,839 | $7,023 | 2 |
| Postoperative and Post-traumatic Infections without Mcc | emergency | $6,996 | $5,274 | $8,718 | 2 |
| HIV with Major Related Condition with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Hypertensive Encephalopathy with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Other Disorders of the Eye with Mcc OR Thrombolytic Agent | other | $7,023 | $7,023 | $7,023 | 1 |
| Precerebral Occlusion without Infarction with Mcc | other | $7,023 | $7,023 | $7,023 | 1 |
| Renal Failure with MCC | other | $7,039 | $7,023 | $7,055 | 2 |
| Aftercare with Cc/mcc | other | $7,058 | $7,058 | $7,058 | 1 |
| Infectious and Parasitic Diseases with O.r. Procedures with Cc | other | $7,081 | $5,629 | $8,532 | 2 |
| Organic Disturbances and Intellectual Disability | other | $7,095 | $7,023 | $7,167 | 2 |
| Other Digestive System Diagnoses with Cc | other | $7,099 | $6,022 | $8,175 | 2 |
| Removal of Plaque and Insertion of Stents in Arteries of Leg | surgery | $7,103 | $7,103 | $7,103 | 1 |
| Medical Back Problems with Mcc | other | $7,107 | $7,107 | $7,107 | 1 |
| Degenerative Nervous System Disorders without Mcc | other | $7,108 | $4,794 | $9,421 | 2 |
| Angioplasty with Stent (PCI) | other | $7,129 | $22 | $160,325 | 37 |
| Cirrhosis and Alcoholic Hepatitis with Cc | other | $7,144 | $7,023 | $7,265 | 2 |
| Traumatic Injury with Mcc | emergency | $7,149 | $3,196 | $11,101 | 2 |
| Skin Debridement with Mcc | other | $7,151 | $4,566 | $9,736 | 2 |
| Acute Myocardial Infarction Discharged Alive with MCC | cardiac | $7,160 | $4,794 | $9,526 | 2 |
| Other Injury, Poisoning and Toxic Effect Diagnoses with Mcc | other | $7,180 | $7,180 | $7,180 | 1 |
| Thyroid, Parathyroid and Thyroglossal Procedures without Cc/mcc | other | $7,180 | $7,180 | $7,180 | 1 |
| Degenerative Nervous System Disorders with Mcc | other | $7,196 | $6,392 | $8,000 | 2 |
| Prostatectomy with Mcc | other | $7,200 | $7,200 | $7,200 | 1 |
| Rectal Resection with Cc | other | $7,200 | $7,200 | $7,200 | 1 |
| Other Antepartum Diagnoses with O.r. Procedures without Cc/mcc | other | $7,207 | $7,207 | $7,207 | 1 |
| Lymphoma and Non-acute Leukemia with Mcc | other | $7,217 | $4,794 | $9,639 | 2 |
| Upper Limb and Toe Amputation for Circulatory System Disorders with Cc | other | $7,253 | $5,400 | $9,106 | 2 |
| Other Musculoskeletal System and Connective Tissue Diagnoses with Mcc | other | $7,257 | $6,392 | $8,121 | 2 |
| Appendix Procedures with Cc | other | $7,279 | $3,600 | $10,958 | 2 |
| Coagulation Disorders | other | $7,389 | $7,023 | $7,755 | 2 |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures with Cc/mcc | other | $7,391 | $5,782 | $9,000 | 2 |
| Biliary Tract Procedures Except Only Cholecystectomy with OR without C.d.e. w... | other | $7,393 | $7,200 | $7,586 | 2 |
| Gastrointestinal Obstruction with Mcc | other | $7,398 | $4,794 | $10,001 | 2 |
| Other Kidney and Urinary Tract Diagnoses with Mcc | other | $7,445 | $7,023 | $7,867 | 2 |
| Transurethral Procedures with Cc | other | $7,490 | $7,490 | $7,490 | 1 |
| Benign Prostatic Hypertrophy with Mcc | other | $7,509 | $4,794 | $10,223 | 2 |
| Major Gastrointestinal Disorders and Peritoneal Infections with Mcc | other | $7,565 | $6,392 | $8,737 | 2 |
| Cranial and Peripheral Nerve Disorders with Mcc | other | $7,586 | $6,392 | $8,779 | 2 |
| Spinal Disorders and Injuries with Cc/mcc | other | $7,601 | $7,601 | $7,601 | 1 |
| Alcohol, Drug Abuse OR Dependence without Rehabilitation Therapy with Mcc | therapy | $7,626 | $6,724 | $8,528 | 2 |
| Hernia Repair (Umbilical) | surgery | $7,658 | $358 | $19,770 | 7 |
| Rectal Resection without Cc/mcc | other | $7,681 | $3,600 | $11,762 | 2 |
| Concussion with Mcc | other | $7,751 | $7,751 | $7,751 | 1 |
| Laparoscopic Cholecystectomy without CC/MCC | surgery | $7,766 | $3,600 | $11,932 | 2 |
| Other Digestive System Diagnoses with Mcc | other | $7,787 | $6,392 | $9,182 | 2 |
| Insertion of Defibrillator with Existing Single Lead | other | $7,792 | $7,792 | $7,792 | 1 |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur without Cc/mcc | other | $7,792 | $7,200 | $8,384 | 2 |
| Poisoning and Toxic Effects of Drugs with MCC | emergency | $7,800 | $4,556 | $11,044 | 2 |
| HIV with Major Related Condition without Cc/mcc | other | $7,815 | $7,815 | $7,815 | 1 |
| Dental and Oral Diseases with Mcc | other | $7,853 | $7,853 | $7,853 | 1 |
| Intracranial Hemorrhage OR Cerebral Infarction with Mcc | other | $7,853 | $6,392 | $9,313 | 2 |
| Postoperative OR Post-traumatic Infections with O.r. Procedures with Cc | emergency | $7,863 | $5,990 | $9,736 | 2 |
| Peritoneal Adhesiolysis without Cc/mcc | other | $7,872 | $7,872 | $7,872 | 1 |
| Skin Ulcers with Mcc | other | $7,879 | $7,023 | $8,735 | 2 |
| Respiratory Infections with MCC | other | $7,894 | $7,023 | $8,765 | 2 |
| Postoperative OR Post-traumatic Infections with O.r. Procedures without Cc/mcc | emergency | $7,900 | $7,900 | $7,900 | 1 |
| Diabetes with Mcc | other | $7,920 | $6,392 | $9,448 | 2 |
| Other Skin, Subcutaneous Tissue and Breast Procedures with Cc | other | $7,934 | $7,200 | $8,668 | 2 |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Mcc | other | $8,030 | $6,392 | $9,668 | 2 |
| Inguinal and Femoral Hernia Procedures without Cc/mcc | other | $8,072 | $8,072 | $8,072 | 1 |
| Malignancy, Female Reproductive System with Mcc | other | $8,103 | $8,103 | $8,103 | 1 |
| Ungroupable | other | $8,110 | $8,110 | $8,110 | 1 |
| Major Head and Neck Procedures without Cc/mcc | other | $8,167 | $8,167 | $8,167 | 1 |
| Cirrhosis and Alcoholic Hepatitis with Mcc | other | $8,168 | $7,023 | $9,313 | 2 |
| Vagina, Cervix and Vulva Procedures with Cc/mcc | other | $8,184 | $8,184 | $8,184 | 1 |
| Shoulder, Elbow OR Forearm Procedures, Except Major Joint Procedures without ... | other | $8,317 | $5,400 | $11,234 | 2 |
| Other Respiratory System Diagnoses with Mcc | other | $8,331 | $7,023 | $9,639 | 2 |
| Malignancy of Hepatobiliary System OR Pancreas with Cc | other | $8,345 | $6,808 | $9,882 | 2 |
| Cardiac Congenital and Valvular Disorders with Mcc | cardiac | $8,383 | $4,794 | $11,972 | 2 |
| Biopsies of Musculoskeletal System and Connective Tissue without Cc/mcc | other | $8,406 | $8,406 | $8,406 | 1 |
| Kidney and Urinary Tract Neoplasms with Mcc | other | $8,459 | $8,459 | $8,459 | 1 |
| Removal Tunneled Cv Cath | surgery | $8,480 | $8,480 | $8,480 | 1 |
| Traumatic Stupor and Coma <1 Hour with Mcc | emergency | $8,545 | $7,023 | $10,066 | 2 |
| Major Thumb OR Joint Procedures | other | $8,590 | $8,590 | $8,590 | 1 |
| Respiratory Neoplasms with Mcc | other | $8,612 | $6,392 | $10,832 | 2 |
| Transcath Heart Valve 20mm Sapien 3 Ref# S3ucm220a | cardiac | $8,645 | $8,645 | $8,645 | 1 |
| Transcath Heart Valve 23mm Sapien 3 S3ucm223a | cardiac | $8,645 | $8,645 | $8,645 | 1 |
| Transcath Heart Valve 26mm Sapien 3 S3ucm226a | cardiac | $8,645 | $8,645 | $8,645 | 1 |
| Transcath Heart Valve 29mm Sapien 3 9600cm29a | cardiac | $8,645 | $8,645 | $8,645 | 1 |
| Inflammatory Bowel Disease with Mcc | other | $8,647 | $7,023 | $10,270 | 2 |
| Hepatobiliary Diagnostic Procedures without Cc/mcc | other | $8,656 | $8,656 | $8,656 | 1 |
| Other Infectious and Parasitic Diseases Diagnoses with Cc | other | $8,727 | $8,727 | $8,727 | 1 |
| Soft Tissue Procedures with Cc | other | $8,768 | $7,799 | $9,736 | 2 |
| Pneumothorax with Mcc | other | $8,816 | $4,794 | $12,838 | 2 |
| Septicemia or Severe Sepsis without Ventilator 96+ Hours with MCC | other | $8,835 | $7,023 | $10,646 | 2 |
| Disorders of Pancreas Except Malignancy with Mcc | other | $8,875 | $7,023 | $10,726 | 2 |
| Stomach, Esophageal and Duodenal Procedures without Cc/mcc | other | $8,926 | $6,501 | $11,351 | 2 |
| Other Cerebrovascular Disorders with Mcc | other | $8,994 | $7,023 | $10,964 | 2 |
| Trauma to the Skin, Subcutaneous Tissue and Breast with Mcc | emergency | $8,996 | $8,996 | $8,996 | 1 |
| Transcath Heart Valve 20mm Sapien 3 Resilia S3urcm20a | cardiac | $9,044 | $9,044 | $9,044 | 1 |
| Transcath Heart Valve 23mm Sapien 3 Resilia S3urcm23a | cardiac | $9,044 | $9,044 | $9,044 | 1 |
| Transcath Heart Valve 26mm Sapien 3 Resilia S3urcm26a | cardiac | $9,044 | $9,044 | $9,044 | 1 |
| Transcath Heart Valve 29mm Sapien 3 Resilia S3urcm29a | cardiac | $9,044 | $9,044 | $9,044 | 1 |
| Viral Illness with Mcc | other | $9,059 | $9,059 | $9,059 | 1 |
| Repair of Congenital Abnormality in Wall Between Upper Heart Chambers with Im... | surgery | $9,064 | $9,064 | $9,064 | 1 |
| Uterine and Adnexa Procedures for Non-malignancy with Cc/mcc | other | $9,071 | $9,071 | $9,071 | 1 |
| Acute Myocardial Infarction, Expired with Mcc | other | $9,106 | $1,598 | $16,614 | 2 |
| Complicated Peptic Ulcer with Mcc | other | $9,173 | $9,173 | $9,173 | 1 |
| Soft Tissue Procedures with Mcc | other | $9,215 | $8,693 | $9,736 | 2 |
| Transurethral Prostatectomy without Cc/mcc | other | $9,238 | $9,238 | $9,238 | 1 |
| Spinal Procedures without Cc/mcc | other | $9,256 | $9,256 | $9,256 | 1 |
| Minor Small and Large Bowel Procedures with Cc | other | $9,262 | $8,031 | $10,492 | 2 |
| Other Respiratory System O.r. Procedures with Cc | other | $9,275 | $9,275 | $9,275 | 1 |
| Osteomyelitis with Mcc | other | $9,298 | $7,023 | $11,573 | 2 |
| Knee Procedures without Principal Diagnosis of Infection without Cc/mcc | other | $9,304 | $9,304 | $9,304 | 1 |
| Major Small and Large Bowel Procedures without CC/MCC | surgery | $9,341 | $7,200 | $11,482 | 2 |
| Other Male Reproductive System O.r. Procedures Except Malignancy without Cc/mcc | other | $9,398 | $9,398 | $9,398 | 1 |
| Skin Debridement with Cc | other | $9,498 | $9,260 | $9,736 | 2 |
| Adrenal and Pituitary Procedures with CC/MCC | surgery | $9,544 | $9,544 | $9,544 | 1 |
| Other Hepatobiliary OR Pancreas O.r. Procedures with Cc | other | $9,565 | $9,565 | $9,565 | 1 |
| Cardiac Pacemaker Revision Except Device Replacement without Cc/mcc | surgery | $9,619 | $9,619 | $9,619 | 1 |
| Kidney and Ureter Procedures for Non-neoplasm with Cc | other | $9,635 | $7,722 | $11,547 | 2 |
| Kidney and Ureter Procedures for Neoplasm without Cc/mcc | other | $9,696 | $9,696 | $9,696 | 1 |
| Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma | emergency | $9,736 | $9,736 | $9,736 | 1 |
| Other Endocrine, Nutritional and Metabolic O.r. Procedures with Mcc | lab | $9,736 | $9,736 | $9,736 | 1 |
| Wound Debridements for Injuries with Cc | other | $9,736 | $9,736 | $9,736 | 1 |
| Major Hip and Knee Joint Replacement without MCC | surgery | $9,780 | $7,200 | $12,360 | 2 |
| Minor Small and Large Bowel Procedures with Mcc | other | $9,808 | $9,808 | $9,808 | 1 |
| Myeloproliferative Disorders OR Poorly Differentiated Neoplasms with Major O.... | other | $9,821 | $9,821 | $9,821 | 1 |
| Minor Bladder Procedures with Cc | other | $9,837 | $9,837 | $9,837 | 1 |
| Peritoneal Adhesiolysis with Mcc | other | $9,839 | $7,200 | $12,477 | 2 |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $9,849 | $7,200 | $12,497 | 2 |
| GI Hemorrhage with MCC | other | $9,906 | $7,023 | $12,788 | 2 |
| Other Kidney and Urinary Tract Procedures with Cc | other | $9,952 | $9,736 | $10,168 | 2 |
| Cervical Spinal Fusion with CC | surgery | $9,977 | $9,977 | $9,977 | 1 |
| Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders w... | lab | $10,099 | $9,736 | $10,462 | 2 |
| Integra 10x25cm | other | $10,127 | $10,127 | $10,127 | 1 |
| Transurethral Procedures with Mcc | other | $10,155 | $9,736 | $10,574 | 2 |
| Transurethral Prostatectomy with Cc/mcc | other | $10,167 | $7,200 | $13,134 | 2 |
| Respiratory System Diagnosis with Ventilator Support <=96 Hours | other | $10,181 | $4,794 | $15,568 | 2 |
| Thyroid, Parathyroid and Thyroglossal Procedures with Cc | other | $10,198 | $10,198 | $10,198 | 1 |
| Hernia Procedures Except Inguinal and Femoral with Cc | other | $10,302 | $9,736 | $10,868 | 2 |
| Pleural Effusion with Mcc | surgery | $10,320 | $7,023 | $13,616 | 2 |
| Major Shoulder OR Elbow Joint Procedures with Cc/mcc | other | $10,321 | $10,321 | $10,321 | 1 |
| Other Female Reproductive System O.r. Procedures without Cc/mcc | other | $10,337 | $10,337 | $10,337 | 1 |
| Malignancy of Hepatobiliary System OR Pancreas with Mcc | other | $10,359 | $7,023 | $13,694 | 2 |
| Hip and Femur Procedures except Major Joint with CC | surgery | $10,415 | $9,736 | $11,094 | 2 |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy with Cc | other | $10,465 | $10,465 | $10,465 | 1 |
| Lymphoma and Leukemia with Major O.r. Procedures without Cc/mcc | other | $10,519 | $10,519 | $10,519 | 1 |
| Laparoscopic Cholecystectomy without Common Duct with CC | surgery | $10,534 | $7,200 | $13,868 | 2 |
| Major Esophageal Disorders with Mcc | other | $10,560 | $10,560 | $10,560 | 1 |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $10,560 | $9,736 | $11,384 | 2 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Cc | other | $10,572 | $7,200 | $13,944 | 2 |
| CABG (Heart Bypass Surgery) | other | $10,639 | $69 | $27,399 | 19 |
| Local Excision and Removal of Internal Fixation Devices of Hip and Femur with... | surgery | $10,662 | $7,200 | $14,124 | 2 |
| Kidney and Ureter Procedures for Neoplasm with Cc | other | $10,702 | $10,702 | $10,702 | 1 |
| Non-bacterial Infection of Nervous System Except Viral Meningitis without Cc/mcc | other | $10,717 | $10,717 | $10,717 | 1 |
| Wound Debridement and Skin Graft Except Hand for Musculoskeletal and Connecti... | other | $10,783 | $9,736 | $11,830 | 2 |
| Major Male Pelvic Procedures without Cc/mcc | other | $10,830 | $10,830 | $10,830 | 1 |
| Insertion of Implantable Defibrillator System | surgery | $10,859 | $10,859 | $10,859 | 1 |
| Other Circulatory System Diagnoses with Mcc | other | $11,025 | $6,392 | $15,658 | 2 |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur with Cc | other | $11,048 | $11,048 | $11,048 | 1 |
| Lymphoma and Non-acute Leukemia with Other Procedures with Cc | other | $11,079 | $11,079 | $11,079 | 1 |
| Other Digestive System O.r. Procedures with Cc | other | $11,233 | $9,000 | $13,465 | 2 |
| Splenic Procedures without Cc/mcc | other | $11,279 | $11,279 | $11,279 | 1 |
| Chemotherapy without Acute Leukemia As Secondary Diagnosis with Cc | other | $11,422 | $11,422 | $11,422 | 1 |
| Other Endocrine, Nutritional and Metabolic O.r. Procedures with Cc | lab | $11,463 | $9,736 | $13,189 | 2 |
| Pacemaker Insertion | cardiac | $11,540 | $22 | $55,429 | 33 |
| Kcentra 1,000 Unit Injection V | other | $11,591 | $11,591 | $11,591 | 1 |
| Extracranial Procedures with Mcc | other | $11,661 | $11,661 | $11,661 | 1 |
| Cholecystectomy with C.d.e. with Mcc | other | $11,674 | $11,674 | $11,674 | 1 |
| Other Circulatory System O.r. Procedures | other | $11,700 | $9,736 | $13,664 | 2 |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures with Cc | other | $11,778 | $5,400 | $18,155 | 2 |
| Lymphoma and Non-acute Leukemia with Other Procedures without Cc/mcc | other | $11,789 | $11,789 | $11,789 | 1 |
| Cholecystectomy Except By Laparoscope without C.d.e. without Cc/mcc | surgery | $11,910 | $11,910 | $11,910 | 1 |
| Knee Procedures with Principal Diagnosis of Infection without Cc/mcc | other | $12,036 | $12,036 | $12,036 | 1 |
| Anchor Tissue to Bone | other | $12,062 | $12,062 | $12,062 | 1 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe without... | other | $12,095 | $12,095 | $12,095 | 1 |
| Peritoneal Adhesiolysis with Cc | other | $12,118 | $9,736 | $14,500 | 2 |
| Hip and Femur Procedures except Major Joint with MCC | surgery | $12,134 | $9,736 | $14,531 | 2 |
| Adrenal and Pituitary Procedures without Cc/mcc | other | $12,225 | $12,225 | $12,225 | 1 |
| Total Hip Replacement | surgery | $12,257 | $17 | $75,212 | 39 |
| Ischemic Stroke, Precerebral Occlusion OR Transient Ischemia with Thrombolyti... | other | $12,264 | $12,264 | $12,264 | 1 |
| Skin Graft Except for Skin Ulcer OR Cellulitis with Mcc | other | $12,286 | $12,286 | $12,286 | 1 |
| Testes Procedures with Cc/mcc | other | $12,288 | $9,736 | $14,839 | 2 |
| Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Di... | lab | $12,336 | $9,000 | $15,672 | 2 |
| Other Vascular Procedures without Cc/mcc | other | $12,341 | $12,341 | $12,341 | 1 |
| Knee Procedures with Principal Diagnosis of Infection with Mcc | other | $12,388 | $9,736 | $15,040 | 2 |
| Total Knee Replacement | surgery | $12,476 | $70 | $77,311 | 39 |
| Other Hepatobiliary OR Pancreas O.r. Procedures with Mcc | other | $12,501 | $12,501 | $12,501 | 1 |
| Upper Limb and Toe Amputation for Circulatory System Disorders with Mcc | other | $12,550 | $9,736 | $15,363 | 2 |
| Kidney and Ureter Procedures for Non-neoplasm with Mcc | other | $12,551 | $9,736 | $15,365 | 2 |
| Insertion OR Replacement of Defibrillator with Electrode | surgery | $12,587 | $12,587 | $12,587 | 1 |
| Major Bladder Procedures without Cc/mcc | other | $12,635 | $12,635 | $12,635 | 1 |
| Biopsies of Musculoskeletal System and Connective Tissue with Cc | other | $12,740 | $9,736 | $15,744 | 2 |
| Other Vascular Procedures with Cc | other | $12,888 | $12,888 | $12,888 | 1 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $12,889 | $9,736 | $16,042 | 2 |
| Other Skin, Subcutaneous Tissue and Breast Procedures with Mcc | other | $13,034 | $9,736 | $16,331 | 2 |
| Percutaneous Cardiovascular Procedures without Intraluminal Device without Mcc | cardiac | $13,056 | $13,056 | $13,056 | 1 |
| Zevalin Y-90 Vial | other | $13,113 | $13,113 | $13,113 | 1 |
| Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy with Cc | other | $13,117 | $13,117 | $13,117 | 1 |
| Cardiac Pacemaker Revision Except Device Replacement with Mcc | surgery | $13,161 | $13,161 | $13,161 | 1 |
| Cervical Spinal Fusion without CC/MCC | surgery | $13,184 | $9,736 | $16,632 | 2 |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Mcc | other | $13,264 | $9,736 | $16,792 | 2 |
| Major Joint OR Limb Reattachment Procedures of Upper Extremities | other | $13,298 | $13,298 | $13,298 | 1 |
| Disorders of the Biliary Tract with Mcc | other | $13,345 | $13,345 | $13,345 | 1 |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures without Cc... | other | $13,425 | $13,425 | $13,425 | 1 |
| Major Small and Large Bowel Procedures with CC | surgery | $13,490 | $9,000 | $17,979 | 2 |
| Other Digestive System O.r. Procedures with Mcc | other | $13,569 | $3,600 | $23,538 | 2 |
| Other O.r. Procedures for Injuries with Cc | other | $13,584 | $9,736 | $17,431 | 2 |
| Cardiac Arrest, Unexplained with Mcc | cardiac | $13,645 | $13,645 | $13,645 | 1 |
| Other O.r. Procedures for Injuries with Mcc | other | $13,695 | $13,695 | $13,695 | 1 |
| Fractures of Femur with Mcc | other | $13,696 | $13,696 | $13,696 | 1 |
| Major Chest Procedures without Cc/mcc | other | $13,733 | $13,733 | $13,733 | 1 |
| Permanent Cardiac Pacemaker Implant without Cc/mcc | surgery | $13,758 | $13,758 | $13,758 | 1 |
| Bilateral or Multiple Major Joint Procedures of Lower Extremity | surgery | $13,799 | $13,799 | $13,799 | 1 |
| Bacterial and Tuberculous Infections of Nervous System without Cc/mcc | other | $13,917 | $7,023 | $20,811 | 2 |
| Stomach, Esophageal and Duodenal Procedures with Mcc | other | $14,013 | $9,000 | $19,025 | 2 |
| Appendix Procedures with Mcc | other | $14,062 | $7,200 | $20,923 | 2 |
| Kidney and Ureter Procedures for Neoplasm with Mcc | other | $14,207 | $14,207 | $14,207 | 1 |
| Dermacell, Awm, Porous SQ Cm | other | $14,345 | $14,345 | $14,345 | 1 |
| Spinal Fusion | surgery | $14,401 | $70 | $352,263 | 33 |
| ERCP Duct Stent Placement | cardiac | $14,520 | $14,520 | $14,520 | 1 |
| Anal and Stomal Procedures with Mcc | other | $14,725 | $14,725 | $14,725 | 1 |
| Infectious and Parasitic Diseases with O.r. Procedures with Mcc | other | $14,804 | $5,629 | $23,978 | 2 |
| Postoperative OR Post-traumatic Infections with O.r. Procedures with Mcc | emergency | $15,059 | $9,000 | $21,117 | 2 |
| Cardiac Pacemaker Device Replacement with Mcc | surgery | $15,157 | $15,157 | $15,157 | 1 |
| Shoulder, Elbow OR Forearm Procedures, Except Major Joint Procedures with Cc | other | $15,319 | $15,319 | $15,319 | 1 |
| Corneal Tissue Processing | other | $15,355 | $15,355 | $15,355 | 1 |
| Percutaneous Cardiovascular Procedures with Intraluminal Device without Mcc | cardiac | $15,402 | $15,402 | $15,402 | 1 |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures with Mcc | other | $15,420 | $15,420 | $15,420 | 1 |
| Wound Debridements for Injuries with Mcc | other | $15,588 | $15,588 | $15,588 | 1 |
| Sipuleucel-t, Minimum of 50 Million Autologous Cd54+ Cells Activated with Pap... | other | $15,783 | $15,783 | $15,783 | 1 |
| Malignancy, Male Reproductive System with Mcc | other | $15,810 | $15,810 | $15,810 | 1 |
| Stomach, Esophageal and Duodenal Procedures with Cc | other | $15,836 | $15,836 | $15,836 | 1 |
| Other Kidney and Urinary Tract Procedures with Mcc | other | $16,215 | $9,736 | $22,694 | 2 |
| Permanent Cardiac Pacemaker Implant with Mcc | surgery | $16,245 | $16,245 | $16,245 | 1 |
| Peripheral, Cranial Nerve and Other Nervous System Procedures with Mcc | other | $16,409 | $16,409 | $16,409 | 1 |
| Major Chest Procedures with Cc | other | $16,501 | $16,501 | $16,501 | 1 |
| Spinal Fusion except Cervical without MCC | surgery | $16,653 | $16,653 | $16,653 | 1 |
| Ear, Nose, Mouth and Throat Malignancy with Mcc | other | $16,889 | $16,889 | $16,889 | 1 |
| Carotid Artery Stent Procedures without Cc/mcc | cardiac | $16,973 | $16,973 | $16,973 | 1 |
| Exactech Total Shoulder | other | $17,020 | $17,020 | $17,020 | 1 |
| Amputation for Musculoskeletal System and Connective Tissue Disorders with Cc | other | $17,022 | $17,022 | $17,022 | 1 |
| Other Respiratory System O.r. Procedures with Mcc | other | $17,474 | $17,474 | $17,474 | 1 |
| Cardiac Pacemaker Device Replacement without Mcc | surgery | $17,571 | $17,571 | $17,571 | 1 |
| Cholecystectomy with C.d.e. with Cc | other | $17,667 | $17,667 | $17,667 | 1 |
| O.r. Procedures with Diagnoses of Other Contact with Health Services without ... | other | $17,715 | $17,715 | $17,715 | 1 |
| Splenic Procedures with Mcc | other | $17,740 | $9,736 | $25,744 | 2 |
| Major Hip and Knee Joint Replacement with MCC | surgery | $17,803 | $17,803 | $17,803 | 1 |
| Drugs Unclassified Injection | other | $18,095 | $18,095 | $18,095 | 1 |
| Knee Procedures with Principal Diagnosis of Infection with Cc | other | $18,269 | $18,269 | $18,269 | 1 |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $18,337 | $9,736 | $26,937 | 2 |
| O.r. Procedures with Principal Diagnosis of Mental Illness | other | $18,475 | $18,475 | $18,475 | 1 |
| Hepatobiliary Diagnostic Procedures with Mcc | other | $18,524 | $18,524 | $18,524 | 1 |
| Permanent Cardiac Pacemaker Implant with Cc | surgery | $18,616 | $18,616 | $18,616 | 1 |
| Percutaneous Cardiovascular Procedures without Intraluminal Device with Mcc | cardiac | $19,067 | $19,067 | $19,067 | 1 |
| Major Bladder Procedures with Cc | other | $19,092 | $19,092 | $19,092 | 1 |
| Septicemia OR Severe Sepsis with Mv >96 Hours | other | $19,611 | $7,023 | $32,199 | 2 |
| Major Small and Large Bowel Procedures with MCC | surgery | $19,876 | $7,200 | $32,552 | 2 |
| Bacterial and Tuberculous Infections of Nervous System with Cc | other | $20,182 | $20,182 | $20,182 | 1 |
| O.r. Procedures with Diagnoses of Other Contact with Health Services with Cc | other | $20,416 | $20,416 | $20,416 | 1 |
| Hernia Procedures Except Inguinal and Femoral with Mcc | other | $20,526 | $20,526 | $20,526 | 1 |
| Back and Neck Procedures except Spinal Fusion without CC/MCC | surgery | $20,644 | $20,644 | $20,644 | 1 |
| Carotid Artery Stent Procedures with Cc | cardiac | $20,884 | $20,884 | $20,884 | 1 |
| Lymphoma and Non-acute Leukemia with Other Procedures with Mcc | other | $21,092 | $21,092 | $21,092 | 1 |
| Heart Valve Replacement | other | $21,279 | $22 | $170,998 | 27 |
| Coronary Bypass without Cardiac Catheter without MCC | cardiac | $22,290 | $22,290 | $22,290 | 1 |
| Other Major Cardiovascular Procedures without Cc/mcc | cardiac | $22,304 | $22,304 | $22,304 | 1 |
| Non-bacterial Infection of Nervous System Except Viral Meningitis with Mcc | other | $22,716 | $22,716 | $22,716 | 1 |
| Acute and Subacute Endocarditis with Mcc | other | $23,642 | $23,642 | $23,642 | 1 |
| Percutaneous Cardiovascular Procedures with Intraluminal Device with Mcc OR 4... | cardiac | $23,728 | $23,728 | $23,728 | 1 |
| Other Vascular Procedures with Mcc | other | $23,909 | $23,909 | $23,909 | 1 |
| Foot Procedures with Mcc | other | $24,384 | $24,384 | $24,384 | 1 |
| Thyroid, Parathyroid and Thyroglossal Procedures with Mcc | other | $25,835 | $25,835 | $25,835 | 1 |
| Lifecell Strattice Tissue 16x2 | other | $26,226 | $26,226 | $26,226 | 1 |
| Other Cardiothoracic Procedures without Mcc | other | $27,097 | $27,097 | $27,097 | 1 |
| Coronary Intravascular Lithotripsy with Intraluminal Device without Mcc | cardiac | $27,528 | $27,528 | $27,528 | 1 |
| Percutaneous and Other Intracardiac Procedures without Mcc | cardiac | $28,757 | $28,757 | $28,757 | 1 |
| Respiratory System Diagnosis with Ventilator 96+ Hours | other | $28,878 | $28,878 | $28,878 | 1 |
| Aortic and Heart Assist Procedures Except Pulsation Balloon without Mcc | cardiac | $29,028 | $29,028 | $29,028 | 1 |
| Other Major Cardiovascular Procedures with Cc | cardiac | $31,069 | $31,069 | $31,069 | 1 |
| Cholecystectomy Except By Laparoscope without C.d.e. with Mcc | surgery | $31,124 | $31,124 | $31,124 | 1 |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy with Mcc | other | $31,190 | $31,190 | $31,190 | 1 |
| Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structur... | imaging | $31,507 | $31,507 | $31,507 | 1 |
| Other Endovascular Cardiac Valve Procedures with Mcc | cardiac | $32,419 | $32,419 | $32,419 | 1 |
| Cardiac Valve and Other Major Cardiothoracic without Cardiac Catheter | cardiac | $32,509 | $32,509 | $32,509 | 1 |
| Aortic and Heart Assist Procedures Except Pulsation Balloon with Mcc | cardiac | $33,878 | $33,878 | $33,878 | 1 |
| Percutaneous and Other Intracardiac Procedures with Mcc | cardiac | $36,042 | $36,042 | $36,042 | 1 |
| Spinal Procedures with Mcc | other | $36,510 | $36,510 | $36,510 | 1 |
| Major Chest Procedures with Mcc | other | $36,629 | $36,629 | $36,629 | 1 |
| Other Major Cardiovascular Procedures with Mcc | cardiac | $36,680 | $36,680 | $36,680 | 1 |
| Coronary Intravascular Lithotripsy with Intraluminal Device with Mcc | cardiac | $37,806 | $37,806 | $37,806 | 1 |
| Aicd Generator Procedures | other | $39,859 | $39,859 | $39,859 | 1 |
| Cardiac Defibrillator Implant without Mcc | surgery | $40,349 | $40,349 | $40,349 | 1 |
| Endovascular Cardiac Valve Replacement and Supplement Procedures without Mcc | surgery | $41,592 | $41,592 | $41,592 | 1 |
| Major Bladder Procedures with Mcc | other | $43,656 | $43,656 | $43,656 | 1 |
| Coronary Bypass with PTCA without Mcc | cardiac | $44,214 | $44,214 | $44,214 | 1 |
| Coronary Bypass with PTCA with MCC | cardiac | $44,413 | $44,413 | $44,413 | 1 |
| Cardiac Defibrillator Implant with Mcc OR Carotid Sinus Neurostimulator | surgery | $45,752 | $45,752 | $45,752 | 1 |
| Coronary Bypass with Cardiac Catheter with MCC | cardiac | $49,716 | $49,716 | $49,716 | 1 |
| Cardiac Valve and Other Major Cardiothoracic with Cardiac Catheter | cardiac | $50,721 | $50,721 | $50,721 | 1 |
| Endovascular Cardiac Valve Replacement and Supplement Procedures with Mcc | surgery | $53,540 | $53,540 | $53,540 | 1 |
| Other Heart Assist System Implant | surgery | $64,199 | $64,199 | $64,199 | 1 |
| Tracheostomy with Mv >96 Hours OR Principal Diagnosis Except Face, Mouth and ... | other | $91,022 | $91,022 | $91,022 | 1 |
| Ecmo OR Tracheostomy with Mv >96 Hours OR Principal Diagnosis Except Face, Mo... | other | $122,514 | $122,514 | $122,514 | 1 |
Every shoppable procedure with real Charlotte pricing data across 58 hospitals. Sort by median price, variability, or number of reporting hospitals.
Ranked by their median price position across all reporting procedures, relative to the Charlotte metro median. Lower index scores mean consistently cheaper.
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Pricing data sourced from federally mandated hospital Machine-Readable Files.
Disclosure required by 45 CFR Part 180.
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