CDM Item Number Revenue Code Service ID Service Mod1 Service Mod2 Service Mod3 Service Mod4 Units Service Description Gross Charge Discounted Cash Price Minimum Negotiated Charge Maximum Negotiated Charge Payer Negotiated Charge: Administrative Concepts Inc Payer Negotiated Charge: Aetna health Plans " Payer Negotiated Charge: Aliera Healthcare, Inc " Payer Negotiated Charge: American Postal Works Health Plan Payer Negotiated Charge: Blue Cross and Blue Shield of Louisiana (Commercial) Payer Negotiated Charge: Blue Cross and Blue Shield of Louisiana (Federal) Payer Negotiated Charge: Cigna Payer Negotiated Charge: Employer's Coalition on Health Payer Negotiated Charge: Gilsbar Payer Negotiated Charge: Group and Pension Administrators Payer Negotiated Charge: Hawaii Mainland Administrators Payer Negotiated Charge: Health Cost Solutions Payer Negotiated Charge: Humana Payer Negotiated Charge: Insurance Management Services Payer Negotiated Charge: North American Administrators Payer Negotiated Charge: United Healthcare Payer Negotiated Charge: Vantage 442 99201 1 OFFICE VISIT/NEW PT LEVEL 1 99.00 49.50 39.14 87.38 42.82 41.99 42.82 42.20 45.06 45.06 39.14 42.82 40.47 42.82 42.20 42.20 87.38 42.20 42.20 42.20 61.17 443 99202 1 OFFICE VISIT/NEW PT LEVEL 2 149.00 74.50 64.23 146.32 71.70 72.08 71.70 68.48 75.62 75.62 67.16 71.70 70.36 71.70 68.48 68.48 146.32 68.48 68.48 64.23 102.42 444 99203 1 OFFICE VISIT/NEW PT LEVEL 3 225.00 112.50 93.60 208.16 102.00 105.04 102.00 99.81 108.01 108.01 97.55 102.00 102.29 102.00 99.81 99.81 208.16 99.81 99.81 93.60 145.71 445 99204 1 OFFICE VISIT/NEW PT LEVEL 4 344.00 172.00 143.73 320.92 157.25 161.29 157.25 154.46 165.07 165.07 150.03 157.25 158.86 157.25 154.46 154.46 320.92 154.46 154.46 143.73 224.64 446 99205 1 OFFICE VISIT/NEW PT LEVEL 5 443.00 221.50 186.98 406.40 199.14 202.97 199.14 192.95 208.05 208.05 186.98 199.14 201.00 199.14 192.95 192.95 406.40 192.95 192.95 201.53 284.48 447 99211 1 OFFICE VISIT EST PT/LEVEL 1 51.00 25.50 16.77 43.08 21.11 18.81 21.11 24.49 21.94 21.94 18.02 21.11 20.32 21.11 24.49 24.49 43.08 24.49 24.49 16.77 30.16 448 99212 1 OFFICE VISIT EST PT/LEVEL 2 90.00 45.00 37.03 86.76 42.51 41.55 42.51 39.90 44.29 44.29 39.14 42.51 40.84 42.51 39.90 39.90 86.76 39.90 39.90 37.03 60.73 449 99213 1 OFFICE VISIT EST PT / LEVEL 3 140.00 70.00 60.40 144.50 70.81 70.52 70.81 60.40 73.70 73.70 65.54 70.81 68.32 70.81 60.40 60.40 144.50 60.40 60.40 60.40 101.15 450 99214 1 OFFICE VISIT EST PT / LEVEL 4 214.00 107.00 92.81 210.22 103.01 104.15 103.01 94.87 108.20 108.20 97.17 103.01 103.06 103.01 94.87 94.87 210.22 94.87 94.87 92.81 147.15 451 99215 1 OFFICE VISIT EST PT / LEVEL 5 295.00 147.50 125.55 283.24 138.79 140.90 138.79 133.95 145.58 145.58 130.89 138.79 139.72 138.79 133.95 133.95 283.24 133.95 133.95 125.55 198.27 455 99384 1 Preventive Care New Pt. Age 12-17 237.00 118.50 89.50 267.32 130.99 137.31 130.99 101.62 129.92 129.92 123.31 130.99 89.50 130.99 101.62 101.62 267.32 101.62 101.62 101.62 187.12 456 99385 1 Preventive Care New Pt. Age 18-39 259.00 129.50 92.80 258.74 126.78 132.52 126.78 101.62 125.41 125.41 119.99 126.78 92.80 126.78 101.62 101.62 258.74 101.62 101.62 101.62 181.12 457 99386 1 Preventive Care New Pt. Age 40-64 288.00 144.00 111.41 300.56 147.27 154.63 147.27 119.88 146.18 146.18 139.52 147.27 111.41 147.27 119.88 119.88 300.56 119.88 119.88 119.88 210.39 459 99394 1 Preventive Care Est Pt. Age 12-17 191.00 95.50 76.60 227.72 111.58 117.13 111.58 82.44 110.96 110.96 104.87 111.58 76.60 111.58 82.44 82.44 227.72 82.44 82.44 82.44 159.40 460 99395 1 Preventive Care Est Pt. Age 18-39 221.00 110.50 78.86 233.24 114.29 119.67 114.29 83.38 113.35 113.35 107.17 114.29 78.86 114.29 83.38 83.38 233.24 83.38 83.38 83.38 163.27 461 99396 1 Preventive Care Est Pt. Age 40-64 245.00 122.50 78.86 249.04 122.03 127.77 122.03 92.22 120.95 120.95 114.58 122.03 78.86 122.03 92.22 92.22 249.04 92.22 92.22 92.22 174.33 462 99397 1 Preventive Care Est Pt. Age 65 and over 260.00 130.00 99.17 267.32 130.99 137.31 130.99 101.63 129.92 129.92 123.61 130.99 99.17 130.99 101.63 101.63 267.32 101.63 101.63 101.63 187.12 48479 99401 1 "P/M COUNSEL, INDIV 15 MIN" 95.00 47.50 26.36 76.60 37.53 36.41 37.53 35.72 38.58 38.58 33.22 37.53 26.36 37.53 35.72 35.72 76.60 35.72 35.72 35.72 53.62 48501 10030 1 I&D ABSCESS 648.69 324.35 177.33 " 1,143.24 " 817.42 976.37 817.42 651.15 566.16 566.16 177.33 817.42 " 1,030.81 " 817.42 651.15 651.15 " 1,143.24 " 651.15 651.15 651.15 914.59 48507 92551 1 AUDIOMETRY-SCREEN 42.00 21.00 8.09 21.20 10.92 15.28 10.92 8.27 14.92 14.92 12.38 10.92 8.09 10.92 8.27 8.27 21.20 8.27 8.27 8.27 14.84 48518 94010 1 SPIROMETRY 102.00 51.00 27.94 65.48 33.72 46.63 33.72 27.94 42.74 42.74 40.33 33.72 50.29 33.72 27.94 27.94 65.48 27.94 27.94 27.94 45.84 48520 94640 1 NEBULIZER TREATMENT - PRESSURIZED OR NONPRES 57.00 28.50 10.24 32.00 16.48 23.28 16.48 10.24 21.35 21.35 19.35 16.48 19.94 16.48 10.24 10.24 32.00 10.24 10.24 10.24 22.40 48526 81002 1 URINE-NO MICRO 10.00 5.00 1.64 6.96 4.14 4.18 4.14 2.14 3.65 3.65 1.64 4.14 4.49 4.14 2.14 2.14 6.96 2.14 2.14 2.09 5.57 48531 85018 QW 1 HEMOGLOBIN 17.00 8.50 1.49 4.74 2.82 3.88 2.82 1.99 2.76 2.76 1.49 2.82 4.07 2.82 1.99 1.99 4.74 1.99 1.99 1.99 3.79 48544 99218 1 INIT OBS-LOW COMPLEX 235.00 117.50 71.70 200.00 98.00 99.70 98.00 78.60 102.42 102.42 90.18 98.00 71.70 98.00 78.60 78.60 200.00 78.60 78.60 78.60 140.00 48545 99219 1 INIT OBS-MOD COMPLEX 300.00 150.00 118.79 270.56 132.57 135.22 132.57 130.73 139.21 139.21 123.85 132.57 118.79 132.57 130.73 130.73 270.56 130.73 130.73 120.50 189.39 48546 99220 1 INIT OBS-HI CPLX 438.00 219.00 164.62 369.30 180.96 184.74 180.96 183.68 190.02 190.02 169.94 180.96 166.57 180.96 183.68 183.68 369.30 183.68 183.68 164.62 258.51 48548 99221 1 INIT HOSP-LOW CPLX 251.00 125.50 79.55 204.62 100.26 101.77 100.26 79.55 104.42 104.42 93.49 100.26 102.85 100.26 79.55 79.55 204.62 79.55 79.55 79.55 143.23 48549 99222 1 INIT HOSP-MOD CPLX 308.00 154.00 121.99 275.54 135.01 136.89 135.01 131.33 140.47 140.47 126.65 135.01 140.40 135.01 131.33 131.33 275.54 131.33 131.33 121.99 192.88 48550 99223 1 INIT HOSP-HI CPLX 439.00 219.50 180.23 403.54 197.73 202.26 197.73 183.15 207.11 207.11 186.19 197.73 206.54 197.73 183.15 183.15 403.54 183.15 183.15 180.23 282.48 48567 99231 1 HOSP SUB DAY-LOW CPLX 104.00 52.00 36.39 78.68 38.55 39.40 38.55 37.37 40.43 40.43 36.39 38.55 42.46 38.55 37.37 37.37 78.68 37.37 37.37 39.72 55.08 48568 99239 1 HOSP SUB CARE-MOD CPLX 165.00 82.50 94.46 211.44 103.61 106.01 103.61 101.13 108.80 108.80 97.91 103.61 109.68 103.61 101.13 101.13 211.44 101.13 101.13 94.46 148.01 48569 99233 1 HOSP SUB CARE-HI CPLX 250.00 125.00 92.19 207.50 101.68 103.77 101.68 92.19 106.48 106.48 95.59 101.68 109.45 101.68 92.19 92.19 207.50 92.19 92.19 92.19 145.25 48570 99238 1 HOSP DISC <30MIN 175.00 87.50 63.79 144.30 70.71 71.59 70.71 68.38 74.24 74.24 66.24 70.71 82.34 70.71 68.38 68.38 144.30 68.38 68.38 63.79 101.01 48572 99234 1 ADM/DC DAME DAY-LOW CPLX 328.00 164.00 124.95 267.22 130.94 133.69 130.94 158.14 136.53 136.53 124.95 130.94 145.27 130.94 158.14 158.14 267.22 158.14 158.14 158.14 187.05 48573 99235 1 ADM/DC SAME DAY-MOD CPLX 416.00 208.00 157.05 337.14 165.20 168.57 165.20 208.47 173.31 173.31 157.05 165.20 190.81 165.20 208.47 208.47 337.14 208.47 208.47 208.47 236.00 48590 36600 1 ART PUNCTURE FOR DX* 99.00 49.50 26.53 58.16 41.58 43.82 41.58 26.53 48.59 48.59 34.89 41.58 47.92 41.58 26.53 26.53 58.16 26.53 26.53 26.53 46.53 48594 31500 1 INTUBATION 630.00 315.00 92.82 300.48 214.84 192.05 214.84 92.82 226.87 226.87 120.83 214.84 176.92 214.84 92.82 92.82 300.48 92.82 92.82 92.82 240.38 48599 36415 1 "VENIPUNCT, ROUTINE*" 20.00 10.00 - 14.00 3.57 4.35 3.57 1.26 3.00 3.00 2.69 3.57 5.25 3.57 1.26 1.26 14.00 1.26 1.26 1.26 - 48614 99349 1 HOME VISIT EST PT DETAILED 220.00 110.00 117.18 254.16 124.54 127.16 124.54 129.49 131.48 131.48 117.18 124.54 128.37 124.54 129.49 129.49 254.16 129.49 129.49 129.49 177.91 48615 99350 1 HOME VISIT EST PT COMPREHENSIVE 290.00 145.00 157.50 355.62 174.25 176.75 174.25 191.23 182.70 182.70 162.89 174.25 179.09 174.25 191.23 191.23 355.62 191.23 191.23 157.50 248.93 48621 99374 1 HOMEH MD SUPER <30MI 146.00 73.00 64.29 137.66 67.45 68.49 67.45 81.00 69.96 69.96 64.29 67.45 80.55 67.45 81.00 81.00 137.66 81.00 81.00 81.00 96.36 73729 142 1 "ANESTH, LENS SURGERY" 52.00 26.00 36.40 52.00 44.00 48.00 44.00 44.00 52.00 52.00 44.00 50.00 44.00 44.00 44.00 36.40 44.00 44.00 52.00 50.00 73751 300 QZ 1 "ANESTH, HEAD/NECK/PTRUNK" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73752 320 1 "ANESTH, NECK ORGAN, 1" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73757 400 QZ 1 "ANESTH, SKIN, EXT/PER/ATRUNK" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73769 520 QZ 1 "ANESTH, CHEST PROCEDURE" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73771 524 QZ 1 "ANESTH, CHEST DRAINAGE" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73774 532 QZ 1 "ANESTH, VASCULAR ACCESS" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73814 800 QZ 1 "ANESTH, ABDOMINAL WALL SURG" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73817 820 QZ 1 "ANESTH, ABDOMINAL WALL SURG" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73839 902 QZ 1 "ANESTH, ANORECTAL SURGERY" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73905 1462 QZ 1 "ANESTH, LOWER LEG PROCEDURE" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 73919 1610 QZ 1 "ANESTH, SURGERY OF SHOULDER" 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 74006 11043 1 DEBRIDE TISSUE/MUSCLE 560.00 280.00 145.11 456.20 326.18 299.15 326.18 184.17 238.92 238.92 145.11 326.18 331.86 326.18 184.17 184.17 456.20 184.17 184.17 184.17 364.96 74007 11044 1 DEBRIDE TISSUE/MUSCLE/BONE 934.00 467.00 216.94 621.56 444.42 416.69 444.42 240.43 327.79 327.79 216.94 444.42 453.10 444.42 240.43 240.43 621.56 240.43 240.43 240.43 497.25 74009 11056 1 "TRIM SKIN LESIONS, 2 TO 4" 54.89 27.45 40.08 138.96 99.36 73.51 99.36 40.08 66.90 66.90 49.89 99.36 71.91 99.36 40.08 40.08 138.96 40.08 40.08 40.08 111.17 74011 11100 1 BIOPSY OF SKIN LESION 206.00 103.00 - 144.20 143.47 143.47 62.57 92.06 143.47 122.28 143.47 62.57 62.57 144.20 62.57 62.57 62.57 - 74014 11201 1 REMOVE SKIN TAGS ADD-ON 77.00 38.50 14.35 36.96 26.43 25.35 26.43 14.35 20.02 20.02 17.10 26.43 23.45 26.43 14.35 14.35 36.96 14.35 14.35 14.35 29.57 74023 11311 1 SHAVE SKIN LESION 0.6-1.0 CM 212.00 106.00 70.13 260.02 185.91 143.52 185.91 70.13 137.33 137.33 95.54 185.91 127.95 185.91 70.13 70.13 260.02 70.13 70.13 70.13 208.02 74037 11440 1 EXC FACE-MM B9 MARG 0.5 < CM 302.00 151.00 100.15 264.02 188.77 171.08 188.77 100.15 138.57 138.57 117.98 188.77 151.21 188.77 100.15 100.15 264.02 100.15 100.15 100.15 211.22 74057 11623 1 EXC H-F-NK-SP MLG MARG 2.1-3 665.00 332.50 185.37 578.24 413.44 390.39 413.44 185.37 308.86 308.86 268.02 413.44 350.73 413.44 185.37 185.37 578.24 185.37 185.37 185.37 462.59 74058 11624 1 EXC H-F-NK-SP MLG MARG 3.1-4 796.00 398.00 213.81 657.10 469.83 441.44 469.83 213.81 350.32 350.32 302.10 469.83 395.82 469.83 213.81 213.81 657.10 213.81 213.81 213.81 525.68 74062 11642 1 EXC FACE-MM MALIG MARG 1.1-2 627.00 313.50 186.43 519.42 371.39 350.74 371.39 186.43 278.12 278.12 242.47 371.39 320.96 371.39 186.43 186.43 519.42 186.43 186.43 186.43 415.54 74063 11643 1 EXC F/E/E/N/L MAL+MRG 2.1-3 784.00 392.00 216.42 616.56 440.84 416.27 440.84 216.42 329.09 329.09 286.92 440.84 379.84 440.84 216.42 216.42 616.56 216.42 216.42 216.42 493.25 74064 11644 1 EXC F/E/E/N/L MAL+MRG >4 CM 961.00 480.50 274.54 763.42 545.85 514.65 545.85 274.54 407.15 407.15 354.30 545.85 470.28 545.85 274.54 274.54 763.42 274.54 274.54 274.54 610.74 74065 11646 1 EXC F/E/E/N/L MAL+MRG >4 CM " 1,396.00 " 698.00 374.15 " 1,003.64 " 717.60 678.28 717.60 374.15 535.49 535.49 464.22 717.60 624.59 717.60 374.15 374.15 " 1,003.64 " 374.15 374.15 374.15 802.91 74096 11980 1 IMPLANT HORMONE PELLET(S) 317.00 158.50 81.97 183.78 131.40 121.90 131.40 81.97 97.33 97.33 94.28 131.40 132.14 131.40 81.97 81.97 183.78 81.97 81.97 81.97 147.02 74097 11981 1 INSERT DRUG IMPLANT DEVICE 428.00 214.00 99.70 203.70 145.65 182.72 145.65 99.70 146.73 146.73 152.42 145.65 167.94 145.65 99.70 99.70 203.70 99.70 99.70 99.70 162.96 74098 11982 1 REMOVE DRUG IMPLANT DEVICE 478.00 239.00 118.10 231.62 165.61 208.28 165.61 118.10 163.40 163.40 171.95 165.61 194.23 165.61 118.10 118.10 231.62 118.10 118.10 118.10 185.30 74099 11983 1 REMOVE/INSERT DRUG IMPLANT 691.00 345.50 177.12 303.15 206.16 295.32 206.16 177.12 242.14 242.14 248.20 206.16 303.15 206.16 177.12 177.12 288.34 177.12 177.12 177.12 230.67 74100 12002 1 RPR S/N/AX/GEN/TRK 2.5 CM/< 470.00 235.00 59.42 216.38 154.71 140.15 154.71 123.48 111.08 111.08 59.42 154.71 190.27 154.71 123.48 123.48 216.38 123.48 123.48 123.48 173.10 74103 12006 1 RPR S/N/A/GEN/TRK 20.1-30.0 CM 837.00 418.50 149.92 398.74 285.10 250.81 285.10 225.05 202.09 202.09 149.92 285.10 349.28 285.10 225.05 225.05 398.74 225.05 225.05 225.05 318.99 74105 12011 1 RPR F/E/E/N/L/M 2.5 CM/< 450.00 225.00 70.17 214.86 153.62 140.63 153.62 122.65 110.99 110.99 70.17 153.62 189.17 153.62 122.65 122.65 214.86 122.65 122.65 122.65 171.89 74114 12031 1 INTMD RPR S/A/T/EXT 2.5 CM/< 488.00 244.00 139.43 479.40 342.77 302.94 342.77 139.43 248.85 248.85 262.23 342.77 281.66 342.77 139.43 139.43 479.40 139.43 139.43 139.43 383.52 74115 12032 1 INTMD RPR S/A/T/EXT 2.6-7.5 606.00 303.00 194.46 574.30 410.62 387.46 410.62 194.46 308.51 308.51 339.48 410.62 360.38 410.62 194.46 194.46 574.30 194.46 194.46 194.46 459.44 74116 12034 1 INTMD RPR S/TR/EXT 7.6-12.5 718.00 359.00 192.69 623.24 445.62 401.75 445.62 192.69 325.64 325.64 345.90 445.62 359.18 445.62 192.69 192.69 623.24 192.69 192.69 192.69 498.59 74117 12035 1 INTMD RPR S/A/T/EXT 12.6-20 957.00 478.50 271.95 747.10 534.18 493.09 534.18 271.95 392.50 392.50 273.26 534.18 438.70 534.18 271.95 271.95 747.10 271.95 271.95 271.95 597.68 74121 12042 1 INTMD RPR N-HF/GENIT 2.6-7.5 621.00 310.50 186.23 574.56 410.81 372.40 410.81 186.23 301.90 301.90 323.81 410.81 344.20 410.81 186.23 186.23 574.56 186.23 186.23 186.23 459.65 74128 12053 1 INTMD RPR FACE/MM 5.1-7.5 CM 777.00 388.50 199.58 683.36 488.60 443.57 488.60 199.58 358.13 358.13 248.89 488.60 395.79 488.60 199.58 199.58 683.36 199.58 199.58 199.58 546.69 74133 13100 1 REPAIR OF WOUND OR LESION 638.00 319.00 224.33 652.34 466.42 429.47 466.42 224.33 374.85 374.85 351.33 466.42 378.38 466.42 224.33 224.33 652.34 224.33 224.33 224.33 521.87 74137 13121 1 REPAIR OF WOUND OR LESION 896.00 448.00 284.32 823.12 588.53 550.00 588.53 284.32 477.07 477.07 497.82 588.53 527.12 588.53 284.32 284.32 823.12 284.32 284.32 284.32 658.50 74138 13122 1 REPAIR WOUND/LESION ADD-ON 326.00 163.00 94.03 255.00 182.33 173.62 182.33 94.03 148.81 148.81 99.23 182.33 147.04 182.33 94.03 94.03 255.00 94.03 94.03 94.03 204.00 74143 13151 1 REPAIR OF WOUND OR LESION 915.00 457.50 288.78 821.26 587.20 546.62 587.20 288.78 474.65 474.65 457.05 587.20 494.28 587.20 288.78 288.78 821.26 288.78 288.78 288.78 657.01 74160 15100 1 SKIN SPLIT GRAFT " 2,580.00 " " 1,290.00 " 655.66 " 1,713.20 " " 1,224.94 " " 1,131.27 " " 1,224.94 " 694.42 898.03 898.03 655.66 " 1,224.94 " " 1,051.66 " " 1,224.94 " 694.42 694.42 " 1,713.20 " 694.42 694.42 694.42 " 1,370.56 " 74162 15120 1 SKIN SPLIT GRAFT " 2,845.00 " " 1,422.50 " 650.51 " 1,677.64 " " 1,199.51 " " 1,121.57 " " 1,199.51 " 659.48 887.14 887.14 650.51 " 1,199.51 " " 1,141.09 " " 1,199.51 " 659.48 659.48 " 1,677.64 " 659.48 659.48 659.48 " 1,342.11 " 74168 15240 1 SKIN FULL GRAFT " 2,436.00 " " 1,218.00 " 611.07 " 1,810.30 " " 1,294.36 " " 1,220.83 " " 1,294.36 " 611.07 " 1,050.77 " " 1,050.77 " 733.17 " 1,294.36 " " 1,108.19 " " 1,294.36 " 611.07 611.07 " 1,810.30 " 611.07 611.07 611.07 " 1,448.24 " 74170 15260 1 SKIN FULL GRAFT " 2,654.00 " " 1,327.00 " 634.03 " 1,943.60 " " 1,389.67 " " 1,324.63 " " 1,389.67 " 634.03 " 1,138.04 " " 1,138.04 " 912.84 " 1,389.67 " " 1,199.05 " " 1,389.67 " 634.03 634.03 " 1,943.60 " 634.03 634.03 634.03 " 1,554.88 " 74263 16030 1 DRESS/DEBRID P-THICK BURN L 530.00 265.00 136.65 379.64 271.44 242.53 271.44 136.65 196.00 196.00 203.62 271.44 215.48 271.44 136.65 136.65 379.64 136.65 136.65 136.65 303.71 74266 17000 1 DESTROY BENIGN/PREMLG LESION 149.00 74.50 47.92 124.32 88.89 85.75 88.89 47.92 66.27 66.27 71.94 88.89 93.06 88.89 47.92 47.92 124.32 47.92 47.92 47.92 99.46 74267 17003 1 DESTRUCT PREMALG LES 2-14 37.00 18.50 5.71 11.14 7.97 7.23 7.97 8.21 5.71 5.71 6.39 7.97 9.18 7.97 8.21 8.21 11.14 8.21 8.21 8.21 8.91 74268 17004 1 DESTROY PREMAL LESIONS 15/> 400.00 200.00 154.12 299.44 214.10 192.77 214.10 157.54 154.22 154.22 154.12 214.10 211.42 214.10 157.54 157.54 299.44 157.54 157.54 157.54 239.55 74272 17110 1 DESTRUCT B9 LESION 1-14 208.00 104.00 69.17 209.40 149.72 139.40 149.72 69.17 110.16 110.16 97.89 149.72 128.28 149.72 69.17 69.17 209.40 69.17 69.17 69.17 167.52 74274 17250 1 "CHEMICAL CAUTERY, TISSUE" 184.00 92.00 53.24 160.34 114.64 99.84 114.64 53.24 81.27 81.27 68.73 114.64 87.73 114.64 53.24 53.24 160.34 53.24 53.24 53.24 128.27 74304 19020 1 INCISION OF BREAST LESION " 1,164.00 " 582.00 311.75 915.72 654.74 609.51 654.74 311.75 483.99 483.99 340.32 654.74 515.49 654.74 311.75 311.75 915.72 311.75 311.75 311.75 732.58 74307 19101 1 "BIOPSY OF BREAST, OPEN" " 1,036.00 " 518.00 244.11 658.54 470.86 445.32 470.86 244.11 349.29 349.29 249.36 470.86 387.12 470.86 244.11 244.11 658.54 244.11 244.11 244.11 526.83 74312 19120 1 REMOVAL OF BREAST LESION " 1,457.00 " 728.50 330.95 " 1,010.46 " 722.48 658.80 722.48 330.95 526.56 526.56 461.92 722.48 677.51 722.48 330.95 330.95 " 1,010.46 " 330.95 330.95 330.95 808.37 75126 38510 1 "BIOPSY/REMOVAL, LYMPH NODES" " 1,510.00 " 755.00 465.66 " 1,050.64 " 751.21 724.37 751.21 472.45 857.57 857.57 483.99 751.21 766.47 751.21 472.45 472.45 " 1,050.64 " 472.45 472.45 465.66 840.51 75141 43235 1 "UPPR GI ENDOSCOPY, DIAGNOSIS" 800.00 400.00 169.96 531.56 380.07 424.88 380.07 373.22 420.63 420.63 169.96 380.07 421.92 380.07 373.22 373.22 531.56 373.22 373.22 373.22 425.25 75680 65205 1 REMOVE FOREIGN BODY FROM EYE 178.00 89.00 50.95 85.61 51.54 85.61 51.54 50.95 66.32 66.32 52.60 51.54 76.94 51.54 50.95 50.95 72.08 50.95 50.95 50.95 57.66 76031 81003 QW 1 "URINALYSIS, AUTO, W/O SCOPE" 8.00 4.00 1.34 4.50 2.68 3.67 2.68 1.88 2.61 2.61 1.34 2.68 2.68 1.88 1.88 4.50 1.88 1.88 1.84 3.60 76284 87804 QW 1 INFLUENZA ASSAY W/OPTIC TEST A 25.00 12.50 7.46 33.10 19.69 19.60 19.69 14.00 17.38 17.38 7.46 19.69 20.62 19.69 14.00 14.00 33.10 14.00 14.00 9.80 26.48 76422 90473 1 IMMUNE ADMIN ORAL/NASAL 30.00 15.00 5.00 27.14 13.98 5.00 13.98 12.04 19.31 19.31 20.07 13.98 14.71 13.98 12.04 12.04 27.14 12.04 12.04 12.04 19.00 76423 90474 1 IMMUNE ADMIN ORAL/NASAL ADDL 20.00 10.00 5.00 24.42 12.58 5.00 12.58 8.53 14.92 14.92 10.73 12.58 9.87 12.58 8.53 8.53 24.42 8.53 8.53 8.53 17.09 76436 90691 1 "TYPHOID VACCINE, IM" 340.00 170.00 59.57 218.38 100.15 104.45 100.15 70.61 99.64 99.64 71.69 100.15 59.57 100.15 70.61 70.61 218.38 70.61 70.61 70.61 152.87 76665 93005 1 "ELECTROCARDIOGRAM, TRACING" 54.00 27.00 7.98 19.35 7.98 10.83 7.98 14.96 13.23 13.23 13.08 7.98 19.35 7.98 14.96 14.96 15.50 14.96 14.96 14.96 10.85 76666 93010 1 ELECTROCARDIOGRAM REPORT 51.00 25.50 7.58 16.98 8.74 11.79 8.74 7.95 14.42 14.42 11.54 8.74 16.04 8.74 7.95 7.95 16.98 7.95 7.95 7.58 11.89 76670 93018 1 CARDIOVASCULAR STRESS TEST REPORT 100.00 50.00 15.21 29.54 15.21 20.09 15.21 17.69 25.09 25.09 20.37 15.21 28.82 15.21 17.69 17.69 29.54 17.69 17.69 17.69 20.68 76771 93925 1 LOWER EXTREMITY STUDY 237.49 118.75 239.12 464.32 239.12 245.30 239.12 248.88 306.98 306.98 289.04 239.12 252.50 239.12 248.88 248.88 464.32 248.88 248.88 248.88 325.02 76798 94660 1 "POS AIRWAY PRESSURE, CPAP" 61.06 30.53 47.34 123.10 63.40 84.85 63.40 47.34 80.12 80.12 70.49 63.40 89.17 63.40 47.34 47.34 123.10 47.34 47.34 47.34 86.17 130079 21550 1 BIOPSY OF NECK/CHEST 634.00 317.00 194.22 501.82 358.80 376.51 358.80 225.37 388.35 388.35 194.22 358.80 355.93 358.80 225.37 225.37 501.82 225.37 225.37 225.37 401.46 130409 25112 1 REREMOVE WRIST TENDON LESION 381.28 190.64 412.77 771.68 551.75 570.11 551.75 412.77 596.46 596.46 469.61 551.75 554.88 551.75 412.77 412.77 771.68 412.77 412.77 412.77 617.34 130539 26010 1 DRAINAGE OF FINGER ABSCESS 735.00 367.50 280.71 568.08 406.18 369.91 406.18 280.71 397.37 397.37 309.38 406.18 342.36 406.18 280.71 280.71 568.08 280.71 280.71 280.71 454.46 130829 27301 1 DRAIN THIGH/KNEE LESION " 2,072.00 " " 1,036.00 " 610.42 " 1,329.22 " 950.39 979.74 950.39 689.56 " 1,026.95 " " 1,026.95 " 610.42 950.39 935.26 950.39 689.56 689.56 " 1,329.22 " 689.56 689.56 689.56 " 1,063.38 " 130838 27324 1 "BIOPSY, THIGH SOFT TISSUES" " 1,421.00 " 710.50 389.15 813.12 581.38 595.34 581.38 389.15 625.95 625.95 474.93 581.38 558.23 581.38 389.15 389.15 813.12 389.15 389.15 389.15 650.50 130968 27613 1 BIOPSY LOWER LEG SOFT TISSUE 548.00 274.00 218.47 485.02 346.79 361.59 346.79 218.47 375.49 375.49 306.70 346.79 347.09 346.79 218.47 218.47 485.02 218.47 218.47 218.47 388.02 131260 29105 1 APPLY LONG ARM SPLINT - SHOULDER TO HAND 269.00 134.50 86.88 157.06 112.30 127.07 112.30 86.88 122.42 122.42 104.85 112.30 120.19 112.30 86.88 86.88 157.06 86.88 86.88 86.88 125.65 131261 29125 1 APPLY FOREARM SPLINT - FOREARM TO HAND STATIC 202.00 101.00 65.39 122.26 87.42 91.88 87.42 65.39 95.05 95.05 76.65 87.42 92.23 87.42 65.39 65.39 122.26 65.39 65.39 65.39 97.81 131276 29405 1 APPLY SHORT LEG CAST 289.00 144.50 87.06 153.62 109.84 118.38 109.84 87.06 121.10 121.10 99.10 109.84 124.44 109.84 87.06 87.06 153.62 87.06 87.06 87.06 122.90 131283 29515 1 APPLICATION LOWER LEG SPLINT 227.00 113.50 66.28 136.88 97.87 103.62 97.87 66.28 106.76 106.76 85.32 97.87 99.21 97.87 66.28 66.28 136.88 66.28 66.28 66.28 109.50 131288 29580 1 APPLICATION OF UNNA BOOT 138.00 69.00 50.63 121.16 86.63 75.99 86.63 50.63 92.89 92.89 63.15 86.63 74.70 86.63 50.63 50.63 121.16 50.63 50.63 50.63 96.93 131550 40805 1 "REMOVAL, FOREIGN BODY, MOUTH" 313.63 156.82 363.43 569.76 407.38 511.54 407.38 363.43 467.28 467.28 375.84 407.38 434.96 407.38 363.43 363.43 569.76 363.43 363.43 363.43 455.81 131582 41112 1 EXCISION OF TONGUE LESION 325.67 162.84 353.96 640.52 457.97 474.86 457.97 362.57 503.67 503.67 353.96 457.97 443.57 457.97 362.57 362.57 640.52 362.57 362.57 362.57 512.42 131583 41113 1 EXCISION OF TONGUE LESION 942.00 471.00 386.46 698.56 499.47 521.24 499.47 401.66 550.59 550.59 386.46 499.47 488.24 499.47 401.66 401.66 698.56 401.66 401.66 401.66 558.85 131741 43239 1 "UPPER GI ENDOSCOPY, BIOPSY" 876.00 438.00 200.80 702.86 502.54 539.66 502.54 424.66 559.47 559.47 200.80 502.54 489.18 502.54 424.66 424.66 702.86 424.66 424.66 424.66 562.29 131747 43245 1 UPPR GI SCOPE DILATE STRICTR 990.00 495.00 219.94 " 1,103.22 " 788.80 828.77 788.80 234.37 830.96 830.96 219.94 788.80 285.60 788.80 234.37 234.37 " 1,103.22 " 234.37 234.37 234.37 882.58 131748 43246 1 PLACE GASTROSTOMY TUBE " 1,167.00 " 583.50 294.51 412.84 295.18 308.40 295.18 314.05 322.42 322.42 294.51 295.18 382.77 295.18 314.05 314.05 412.84 314.05 314.05 314.05 330.27 131751 43249 1 "ESOPH ENDOSCOPY, DILATION" 894.00 447.00 203.15 " 2,001.68 " " 1,431.20 " " 1,425.03 " " 1,431.20 " 213.87 " 1,509.08 " " 1,509.08 " 203.15 " 1,431.20 " 265.24 " 1,431.20 " 213.87 213.87 " 2,001.68 " 213.87 213.87 213.87 " 1,601.34 " 131822 43752 1 NASAL/OROGASTRIC W/STENT 214.00 107.00 47.42 84.36 60.32 60.41 60.32 54.55 64.48 64.48 47.42 60.32 63.89 60.32 54.55 54.55 84.36 54.55 54.55 54.55 67.49 132001 45378 1 DIAGNOSTIC COLONOSCOPY " 1,044.00 " 522.00 253.64 637.20 455.60 523.59 455.60 490.32 514.64 514.64 253.64 455.60 561.56 455.60 490.32 490.32 637.20 490.32 490.32 324.99 509.76 132003 45380 1 COLONOSCOPY AND BIOPSY " 1,266.00 " 633.00 303.64 811.76 580.41 642.48 580.41 579.35 654.51 654.51 303.64 580.41 674.07 580.41 579.35 579.35 811.76 579.35 579.35 579.35 649.41 132007 45384 1 LESION REMOVE COLONOSCOPY " 1,284.00 " 642.00 316.76 909.08 649.99 707.65 649.99 575.72 731.40 731.40 316.76 649.99 665.02 649.99 575.72 575.72 909.08 575.72 575.72 575.72 727.26 132008 45385 1 LESION REMOVAL COLONOSCOPY " 1,462.00 " 731.00 360.26 857.80 613.33 680.65 613.33 655.34 695.01 695.01 360.26 613.33 762.48 613.33 655.34 655.34 857.80 655.34 655.34 655.34 686.24 132029 46040 1 INCISION OF RECTAL ABSCESS " 1,328.00 " 664.00 462.77 " 1,075.40 " 768.91 756.10 768.91 541.37 821.42 821.42 462.77 768.91 672.49 768.91 541.37 541.37 " 1,075.40 " 541.37 541.37 541.37 860.32 132035 46083 1 INCISE EXTERNAL HEMORRHOID 496.00 248.00 196.69 370.18 264.68 243.64 264.68 197.23 272.97 272.97 196.69 264.68 234.07 264.68 197.23 197.23 370.18 197.23 197.23 197.23 296.14 132430 51701 1 INSERT BLADDER CATHETER 187.00 93.50 61.23 95.83 62.73 83.09 62.73 61.23 73.44 73.44 74.38 62.73 95.83 62.73 61.23 61.23 87.74 61.23 61.23 61.23 70.19 132585 54056 1 "CRYOSURGERY, PENIS LESION(S)" 335.00 167.50 83.83 267.66 191.38 203.36 191.38 83.83 224.57 224.57 184.56 191.38 197.35 191.38 83.83 83.83 267.66 83.83 83.83 83.83 214.13 132719 56405 1 I & D OF VULVA/PERINEUM 416.00 208.00 120.97 254.14 181.71 164.80 181.71 120.97 162.55 162.55 135.53 181.71 164.49 181.71 120.97 120.97 254.14 120.97 120.97 120.97 203.31 132720 56420 1 DRAINAGE OF GLAND ABSCESS 412.00 206.00 150.35 302.92 216.59 181.54 216.59 155.85 190.36 190.36 150.35 216.59 187.26 216.59 155.85 155.85 302.92 155.85 155.85 155.85 242.34 132723 56501 1 "DESTROY, VULVA LESIONS, SIM" 377.00 188.50 143.35 317.84 227.26 195.57 227.26 143.35 202.64 202.64 160.79 227.26 195.31 227.26 143.35 143.35 317.84 143.35 143.35 143.35 254.27 132738 56740 1 REMOVE VAGINA GLAND LESION " 1,190.00 " 595.00 319.39 629.88 450.36 464.50 450.36 319.39 441.64 441.64 371.91 450.36 457.59 450.36 319.39 319.39 629.88 319.39 319.39 319.39 503.90 132792 57410 1 PELVIC EXAMINATION 397.00 198.50 133.63 217.36 155.41 166.33 155.41 161.60 155.79 155.79 133.63 155.41 165.05 155.41 161.60 161.60 217.36 161.60 161.60 161.60 173.89 133844 81025 QW 1 URINE PREGNANCY TEST 28.00 14.00 3.88 17.22 10.25 10.33 10.25 5.30 9.04 9.04 3.88 10.25 11.09 10.25 5.30 5.30 17.22 5.30 5.30 5.17 13.78 133897 82270 QW 1 "TEST FOR BLOOD, FECES" 13.00 6.50 2.09 8.76 5.21 5.32 5.21 2.72 4.60 4.60 2.09 5.21 5.21 2.72 2.72 8.76 2.72 2.72 2.72 7.01 134018 82947 QW 1 "ASSAY, GLUCOSE, BLOOD QUANT" 25.00 12.50 2.39 7.86 4.68 6.42 4.68 3.29 4.59 4.59 2.39 4.68 6.88 4.68 3.29 3.29 7.86 3.29 3.29 3.29 6.29 134025 82962 QW 1 GLUCOSE BLOOD TEST 10.00 5.00 1.49 6.56 3.90 3.83 3.90 1.96 3.44 3.44 1.49 3.90 3.90 1.96 1.96 6.56 1.96 1.96 1.96 5.25 134049 83036 QW 1 GLYCATED HEMOGLOBIN TEST 36.00 18.00 5.55 19.42 11.55 15.86 11.55 5.70 11.33 11.33 5.97 11.55 11.55 5.70 5.70 19.42 5.70 5.70 5.55 15.54 134089 83655 1 ASSAY OF LEAD 0.01 0.01 7.10 24.22 14.41 19.79 14.41 7.10 14.12 14.12 7.46 14.41 14.41 7.10 7.10 24.22 7.10 7.10 7.10 19.38 134329 85610 QW 1 PROTHROMBIN TIME 15.00 7.50 2.39 8.58 5.11 6.43 5.11 3.29 4.59 4.59 2.39 5.11 5.11 3.29 3.29 8.58 3.29 3.29 3.29 6.86 134334 85651 QW 1 "RBC SED RATE, NONAUTOMATED" 13.00 6.50 2.24 8.54 5.08 5.80 5.08 2.98 4.48 4.48 2.24 5.08 5.08 2.98 2.98 8.54 2.98 2.98 2.98 6.83 134384 86308 QW 1 HETEROPHILE ANTIBODIES (MONO) 48.00 24.00 3.28 10.36 6.16 8.46 6.16 4.34 6.04 6.04 3.28 6.16 6.16 4.34 4.34 10.36 4.34 4.34 4.34 8.29 134389 86318 QW 1 "IMMUNOASSAY,INFECTIOUS AGENT (H-PYLORI)" 54.00 27.00 8.06 36.18 21.53 21.16 21.53 10.85 18.99 18.99 8.06 21.53 21.53 10.85 10.85 36.18 10.85 10.85 10.58 28.94 134644 93000 1 "ELECTROCARDIOGRAM, COMPLETE" 81.00 40.50 14.54 35.39 16.73 22.62 16.73 16.11 27.64 27.64 24.62 16.73 35.39 16.73 16.11 16.11 32.48 16.11 16.11 14.54 22.74 134646 93016 1 CARDIOVASCULAR STRESS TEST SUPERVISION 101.00 50.50 22.89 44.44 22.89 30.88 22.89 27.00 37.74 37.74 30.16 22.89 43.51 22.89 27.00 27.00 44.44 27.00 27.00 27.00 31.11 134711 95115 1 "INJ ADMIN IMMUNOTHERAPY, 1 INJ" 25.00 12.50 7.25 16.76 8.63 11.27 8.63 11.93 8.84 8.84 8.61 8.63 12.87 8.63 11.93 11.93 16.76 11.93 11.93 7.25 11.73 134880 97602 1 WOUND(S) CARE NON-SELECTIVE 118.00 59.00 19.86 158.16 81.45 48.75 81.45 29.13 31.40 31.40 19.86 81.45 22.24 81.45 29.13 29.13 158.16 29.13 29.13 29.13 110.71 134896 99000 1 SPECIMEN HANDLING 25.00 12.50 2.18 10.86 5.59 7.56 5.59 2.18 3.00 3.00 6.36 5.59 7.68 5.59 2.18 2.18 10.86 2.18 2.18 2.18 7.60 134917 99173 1 VISUAL ACUITY SCREEN 39.00 19.50 2.27 5.34 2.75 4.16 2.75 2.27 2.67 2.67 2.72 2.75 3.73 2.75 2.27 2.27 5.34 2.27 2.27 2.27 3.74 135800 G0008 1 ADMN FLU VAC NO FEE SCHED SAME DAY 25.00 12.50 5.00 27.14 13.84 5.00 13.84 15.81 19.31 19.31 13.84 21.95 13.84 15.81 15.81 27.14 15.81 15.81 15.81 19.00 135801 G0009 1 ADMN PNEUMCOC VAC NO FEE SCHED DAY 25.00 12.50 5.00 27.14 13.84 5.00 13.84 15.81 19.31 19.31 13.84 21.95 13.84 15.81 15.81 27.14 15.81 15.81 15.81 19.00 135826 G0105 1 COLOREC CANCR SCR; COLNSCPY HI RISK " 1,306.00 " 653.00 252.47 636.30 324.51 252.47 324.51 490.32 514.64 514.64 324.51 340.34 324.51 490.32 490.32 636.30 490.32 490.32 490.32 445.41 135841 G0121 1 COLOREC CNCR SCR;COLNSCPY NO HI RSK " 1,044.00 " 522.00 252.77 638.10 325.43 252.77 325.43 490.32 514.64 514.64 325.43 340.34 325.43 490.32 490.32 638.10 490.32 490.32 490.32 446.67 136006 J0295 1 INJ AMPCLLN SODIM/SULBACTAM-1.5 G 15.00 7.50 1.75 7.16 2.63 2.60 2.63 1.75 2.27 2.27 2.58 2.63 3.62 2.63 1.75 1.75 7.16 1.75 1.75 1.75 5.01 136010 J0360 1 HYDRALAZINE (APRESOLINE) HCL UP 20 MG 15.00 7.50 2.75 7.54 2.75 3.79 2.75 3.13 4.15 4.15 3.12 2.75 5.48 2.75 3.13 3.13 7.54 3.13 3.13 3.13 5.28 136058 J0780 1 INJECTION PROCHLORPERAZINE UP TO 10MG 34.00 17.00 2.24 15.34 6.13 8.73 6.13 4.11 8.44 8.44 12.49 6.13 2.24 6.13 4.11 4.11 15.34 4.11 4.11 4.11 10.74 136069 J1030 1 DEPO MEDROL(METHYLPRDNISOLONE ACTA) 40 MG 15.00 7.50 2.75 12.10 5.81 6.35 5.81 2.75 6.66 6.66 5.57 5.81 4.72 5.81 2.75 2.75 12.10 2.75 2.75 2.75 8.47 136070 J1040 1 DEPO MEDROL (METHYLPRDNISOLONE ACT) 80 MG 30.00 15.00 5.26 23.26 11.15 12.01 11.15 5.26 12.79 12.79 10.61 11.15 9.01 11.15 5.26 5.26 23.26 5.26 5.26 5.26 16.28 136077 J1094 4 DEXAMETHASONE 4MG/ML (DECADRON ACTAT) 4.00 0.50 0.92 2.88 1.32 1.36 1.32 2.88 1.00 1.00 0.92 1.32 1.00 1.32 2.88 2.88 1.84 2.88 2.88 2.88 1.28 136133 J1642 1 HEPARIN SODIUM (HEPARIN LOCK FLUSH) 10 UNITS 1.50 0.75 0.01 0.33 0.01 0.33 0.01 0.16 0.02 0.02 0.18 0.01 0.13 0.01 0.16 0.16 0.04 0.16 0.16 0.16 0.03 136152 J1815 1 INSULIN (HUMULIN - N - ) PER 5 UNITS 15.00 7.50 0.35 1.78 0.79 0.91 0.79 0.62 0.97 0.97 0.81 0.79 0.35 0.79 0.62 0.62 1.78 0.62 0.62 0.62 1.25 136171 J2060 1 ATIVAN (LORAZEPAM) 2MG/1ML CIV (LOCK UP) 15.00 7.50 0.66 1.50 0.66 0.71 0.66 0.73 0.73 0.73 0.74 0.66 0.87 0.66 0.73 0.73 1.50 0.73 0.73 0.73 1.05 136173 J2175 1 MEPERIDINE (DEMEROL) HCL 50 MG / 1 ML 15.00 7.50 1.57 10.00 7.06 4.77 7.06 2.77 5.50 5.50 4.77 7.06 1.57 7.06 2.77 2.77 10.00 2.77 2.77 2.77 7.00 136198 J2510 1 PCN G PROCAINE AQUEOUS-600000 / 1ML 60.00 30.00 11.15 59.36 28.87 29.93 28.87 14.96 32.65 32.65 26.77 28.87 11.15 28.87 14.96 14.96 59.36 14.96 14.96 14.96 41.55 136230 J2930 1 SOLUMEDROL (METHYLPREDNISOLONE) TO 125 MG 16.00 8.00 2.42 12.78 6.40 6.38 6.40 2.42 6.73 6.73 5.57 6.40 3.83 6.40 2.42 2.42 12.78 2.42 2.42 2.42 8.95 136274 J3490 1 TESTOSTERONE PELLET 100 MG 130.00 65.00 - 78.00 0.55 0.55 78.00 - - 0.55 6.33 0.55 78.00 78.00 - 78.00 78.00 52.00 - 137730 S0189 1 TESTOSTERONE PELLET 75 MG 130.00 65.00 77.00 215.52 107.24 126.16 107.24 77.00 110.35 110.35 92.94 107.24 77.00 107.24 77.00 77.00 215.52 77.00 77.00 77.00 150.86 138763 90700 1 VACCINE DTAP (INFANRIX) 6 WKS+ 85.00 42.50 24.52 57.02 25.51 25.20 25.51 27.86 28.17 28.17 24.52 25.51 30.00 25.51 27.86 27.86 57.02 27.86 27.86 26.75 39.91 138772 90658 1 "Influenza (split), 3 yrs and above" 35.00 17.50 14.37 36.48 16.32 16.32 16.32 14.37 18.24 18.24 16.14 16.32 15.20 16.32 14.37 14.37 36.48 14.37 14.37 14.37 25.54 138779 90732 1 VACCINE PNEUMOCOCCAL (PNEUMOVAX 23) 160.00 80.00 43.25 239.84 107.30 114.21 107.30 81.95 125.63 125.63 97.12 107.30 43.25 107.30 81.95 81.95 239.84 81.95 81.95 81.95 167.89 140688 87880 QW 1 STREP A ASSAY W/OPTIC 52.00 26.00 7.46 33.06 19.67 19.60 19.67 10.06 17.36 17.36 7.46 19.67 20.62 19.67 10.06 10.06 33.06 10.06 10.06 9.80 26.45 140689 90471 1 VACCINE IMMUNIZATION ADMIN 25.00 12.50 7.00 27.14 13.98 7.00 13.98 21.54 19.31 19.31 21.86 13.98 21.99 13.98 21.54 21.54 27.14 21.54 21.54 21.02 19.00 140690 90472 1 "VACCINE IMMUNIZATION ADMIN, EACH ADD" 15.00 7.50 7.00 24.42 12.58 7.00 12.58 10.65 14.92 14.92 11.03 12.58 11.33 12.58 10.65 10.65 24.42 10.65 10.65 10.65 17.09 171819 G0179 1 MD recertification HHA PT 133.00 66.50 27.30 77.70 39.63 27.30 39.63 48.19 39.25 39.25 39.63 36.19 39.63 48.19 48.19 77.70 48.19 48.19 48.19 54.39 171820 G0180 1 MD certification HHA patient 146.00 73.00 35.86 102.36 52.20 35.86 52.20 63.15 51.24 51.24 52.20 48.25 52.20 63.15 63.15 102.36 63.15 63.15 46.12 71.65 171946 J0595 2 BUTORPHANOL TARTRATE (STADOL) 2 MG / 1ML 15.00 3.75 1.06 10.12 5.56 5.00 5.56 3.64 5.56 5.56 4.64 5.56 1.06 5.56 3.64 3.64 10.12 3.64 3.64 3.64 7.08 171953 J1335 1 Ertapenem injection 95.64 47.82 28.62 76.90 33.66 39.09 33.66 33.69 42.30 42.30 48.25 33.66 28.62 33.66 33.69 33.69 76.90 33.69 33.69 33.69 53.83 171966 J2001 1 Lidocaine injection 15.00 7.50 0.02 0.06 0.02 0.03 0.02 0.02 0.03 0.03 0.02 0.02 0.02 0.02 0.02 0.02 0.06 0.02 0.02 0.02 0.04 172003 J7621 1 (Levo)albuterol/Ipra-bromide 10.00 5.00 - 7.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 7.00 6.00 6.00 4.00 - 172507 36556 1 INSERT NON-TUNNEL CV CATH 770.00 385.00 143.33 406.98 290.99 326.15 290.99 264.92 331.42 331.42 143.33 290.99 365.23 290.99 264.92 264.92 406.98 264.92 264.92 264.92 325.58 172509 36558 1 INSERT TUNNELED CV CATH " 1,772.00 " 886.00 327.50 " 1,526.32 " " 1,091.32 " " 1,067.12 " " 1,091.32 " 835.65 " 1,186.35 " " 1,186.35 " 327.50 " 1,091.32 " " 1,241.73 " " 1,091.32 " 835.65 835.65 " 1,526.32 " 835.65 835.65 835.65 " 1,221.06 " 172511 36561 1 INSERT TUNNELED CV CATH " 2,727.00 " " 1,363.50 " 414.54 " 2,017.74 " " 1,442.68 " " 1,596.98 " " 1,442.68 " " 1,141.46 " " 1,670.87 " " 1,670.87 " 414.54 " 1,442.68 " " 1,733.66 " " 1,442.68 " " 1,141.46 " " 1,141.46 " " 2,017.74 " " 1,141.46 " " 1,141.46 " " 1,141.46 " " 1,614.19 " 172518 36571 1 INSERT TUNNELED CV CATH " 2,678.00 " " 1,339.00 " 374.30 " 2,421.30 " " 1,731.23 " " 1,760.62 " " 1,731.23 " " 1,232.54 " " 1,944.51 " " 1,944.51 " 374.30 " 1,731.23 " " 1,839.09 " " 1,731.23 " " 1,232.54 " " 1,232.54 " " 2,421.30 " " 1,232.54 " " 1,232.54 " " 1,232.54 " " 1,937.04 " 172529 36590 1 REMOVAL TUNNELED CV CATH " 1,022.00 " 511.00 230.80 447.70 320.11 417.17 320.11 230.80 365.06 365.06 238.45 320.11 432.71 320.11 230.80 230.80 447.70 230.80 230.80 230.80 358.16 172610 90734 1 VACCINE MENINGOCOCCAL CONJ SEROG C Y&W 135 TITR 135 (MENACTRA) 270.00 135.00 101.91 292.42 130.82 124.63 130.82 135.37 139.29 139.29 126.48 130.82 101.91 130.82 135.37 135.37 292.42 135.37 135.37 126.53 204.69 186646 97597 1 REMVL DEVITAL TIS 20CM/< 145.00 72.50 40.73 182.18 93.82 97.47 93.82 42.06 66.29 66.29 40.73 93.82 59.27 93.82 42.06 42.06 182.18 42.06 42.06 42.06 127.53 186647 97598 1 ACTIVE WOUND CARE > 20 CM 125.00 62.50 13.60 89.10 45.89 32.20 45.89 53.48 21.07 21.07 13.60 45.89 73.57 45.89 53.48 53.48 89.10 53.48 53.48 53.48 62.37 187208 J2794 1 INJ RISPERIDONE LONG ACTING 0.5 MG 400.00 200.00 5.47 20.10 9.95 10.15 9.95 5.94 11.04 11.04 8.17 9.95 5.47 9.95 5.94 5.94 20.10 5.94 5.94 5.94 14.07 188178 99391 1 Preventive Care Est. Pt. Age less than 1 Year 166.00 83.00 62.66 194.48 95.30 99.81 95.30 67.33 94.69 94.69 89.51 95.30 62.66 95.30 67.33 67.33 194.48 67.33 67.33 67.33 136.14 188179 99392 1 Preventive Care Est. Pt. Age 1-4 169.00 84.50 70.63 207.04 101.45 106.82 101.45 75.55 101.27 101.27 95.98 101.45 70.63 101.45 75.55 75.55 207.04 75.55 75.55 75.55 144.93 188180 99393 1 Preventive Care Est. Pt. Age 5-11 177.00 88.50 69.94 206.40 101.14 106.49 101.14 74.61 100.96 100.96 95.68 101.14 69.94 101.14 74.61 74.61 206.40 74.61 74.61 74.61 144.48 188181 99381 1 Preventive Care New Pt. Age less than 1 Year 209.00 104.50 86.14 214.66 105.18 110.82 105.18 88.40 105.04 105.04 100.45 105.18 86.14 105.18 88.40 88.40 214.66 88.40 88.40 88.40 150.26 188182 99382 1 Preventive Care New Pt. Age 1-4 218.00 109.00 80.49 225.32 110.41 115.92 110.41 95.28 110.24 110.24 105.10 110.41 80.49 110.41 95.28 95.28 225.32 95.28 95.28 95.28 157.72 188183 99383 1 Preventive Care New Pt. Age 5-11 226.00 113.00 71.67 235.34 115.32 121.13 115.32 93.40 114.71 114.71 109.05 115.32 71.67 115.32 93.40 93.40 235.34 93.40 93.40 93.40 164.74 196771 99304 1 "NURSING FACILITY CARE, INIT LOW SEVERITY" 175.00 87.50 76.61 179.08 87.75 90.72 87.75 76.61 91.90 91.90 85.04 87.75 89.02 87.75 76.61 76.61 179.08 76.61 76.61 76.61 125.36 196772 99305 1 NURSING FACILITY CARE INIT MOD SEVERITY 250.00 125.00 101.79 255.60 125.24 129.05 125.24 101.79 132.55 132.55 120.28 125.24 124.57 125.24 101.79 101.79 255.60 101.79 101.79 101.79 178.92 196773 99306 1 NURSING FACILITY CARE INIT HI SEVERITY 350.00 175.00 125.68 330.68 162.03 164.80 162.03 125.68 169.79 169.79 152.96 162.03 160.17 162.03 125.68 125.68 330.68 125.68 125.68 125.68 231.48 196777 99310 1 NURSING FACILITY SUBSQ CARE 257.00 128.50 115.74 264.50 129.61 133.97 129.61 115.74 137.48 137.48 122.34 129.61 131.74 129.61 115.74 115.74 264.50 115.74 115.74 115.74 185.15 197166 G0372 1 MD SERVICE REQUIRED FOR PMD 20.00 10.00 6.12 18.33 9.31 6.12 9.31 18.33 8.80 8.80 9.31 10.57 9.31 18.33 18.33 18.26 18.33 18.33 18.33 12.78 205532 32551 1 INSERTION OF CHEST TUBE 766.00 383.00 137.14 330.16 236.06 298.51 236.06 137.14 252.36 252.36 217.70 236.06 286.08 236.06 137.14 137.14 330.16 137.14 137.14 137.14 264.13 205617 99406 1 BEHAV CHNG SMOKING 3-10 MIN 38.00 19.00 10.49 29.92 14.66 14.60 14.66 10.49 15.07 15.07 12.90 14.66 14.33 14.66 10.49 10.49 29.92 10.49 10.49 10.49 20.94 205655 3044F 1 HG A1C LEVEL LT 7.0% 0.01 0.01 0.01 0.01 0.01 0.01 266960 96360 1 "HYDRATION IV INFUSION, INIT" 200.00 100.00 32.41 73.02 32.41 73.02 32.41 53.45 42.85 42.85 52.25 32.41 65.65 32.41 53.45 53.45 62.94 53.45 53.45 53.45 44.06 266968 96372 1 "THER/PROPH/DIAG INJ, SC/IM" 25.00 12.50 13.98 32.69 13.98 32.69 13.98 15.81 19.31 19.31 22.52 13.98 24.86 13.98 15.81 15.81 27.14 15.81 15.81 15.81 19.00 267003 93306 1 "TTE W/DOPPLER, COMPLETE" 268.00 134.00 199.19 445.61 199.19 294.37 199.19 214.11 329.09 329.09 272.76 199.19 445.61 199.19 214.11 214.11 386.78 214.11 214.11 305.40 270.75 267039 96361 1 "HYDRATE IV INFUSION, ADD-ON" 75.00 37.50 12.96 25.16 12.96 19.79 12.96 17.18 15.41 15.41 14.18 12.96 19.47 12.96 17.18 17.18 25.16 17.18 17.18 17.18 17.61 275534 11045 1 DEB SUBQ TISSUE ADD-ON 124.00 62.00 27.65 82.30 58.84 53.54 58.84 27.65 43.10 43.10 36.67 58.84 42.59 58.84 27.65 27.65 82.30 27.65 27.65 27.65 65.84 275535 11046 1 DEB MUSC/FASCIA ADD-ON 197.00 98.50 48.21 148.62 106.26 98.00 106.26 48.21 77.41 77.41 65.15 106.26 74.36 106.26 48.21 48.21 148.62 48.21 48.21 48.21 118.90 275536 11047 1 DEB BONE ADD-ON 392.00 196.00 79.58 249.14 178.14 166.83 178.14 79.58 131.44 131.44 89.88 178.14 122.38 178.14 79.58 79.58 249.14 79.58 79.58 79.58 199.31 275563 21933 1 EXC BACK TUM DEEP 5+ CM " 2,422.00 " " 1,211.00 " 802.75 " 1,520.88 " " 1,087.43 " " 1,124.65 " " 1,087.43 " 802.75 " 1,168.53 " " 1,168.53 " 911.87 " 1,087.43 " " 1,147.93 " " 1,087.43 " 802.75 802.75 " 1,520.88 " 802.75 802.75 802.75 " 1,216.70 " 275772 78452 1 HT MUSCLE IMAGE SPECT MULT 446.59 223.30 313.51 870.00 539.40 578.95 539.40 606.89 597.63 597.63 313.51 539.40 539.40 606.89 606.89 870.00 606.89 606.89 606.89 609.00 275856 99224 1 SUBSEQUENT OBSERVATION CARE 96.00 48.00 31.97 79.32 38.87 39.72 38.87 36.22 40.76 40.76 36.94 38.87 31.97 38.87 36.22 36.22 79.32 36.22 36.22 36.22 55.52 275857 99225 1 SUBSEQUENT OBSERVATION CARE 162.00 81.00 56.64 144.64 70.87 72.47 70.87 63.83 74.82 74.82 67.00 70.87 56.64 70.87 63.83 63.83 144.64 63.83 63.83 63.83 101.25 275858 99226 1 SUBSEQUENT OBSERVATION CARE 250.00 125.00 84.75 208.14 101.99 104.61 101.99 95.60 107.03 107.03 96.23 101.99 84.75 101.99 95.60 95.60 208.14 95.60 95.60 95.60 145.70 275969 G0438 1 MEDICARE ANNUAL WELLNESS 1ST VISIT 175.00 87.50 115.23 328.64 167.61 115.23 167.61 153.87 123.96 123.96 167.61 155.54 167.61 153.87 153.87 328.64 153.87 153.87 153.87 230.05 275970 G0439 1 MEDICARE ANNUAL WELLNESS SUBSEQUENT 145.00 72.50 77.74 221.72 113.08 77.74 113.08 101.94 111.95 111.95 113.08 103.63 113.08 101.94 101.94 221.72 101.94 101.94 99.95 155.20 278890 90647 1 VACCINE HIB (PRP-OMP) 3 DOSE (PEDVAX HIB) 94.40 47.20 26.23 59.52 26.63 26.63 26.63 27.32 29.76 29.76 28.28 26.63 26.84 26.63 27.32 27.32 59.52 27.32 27.32 26.23 41.66 278891 90648 1 VACCINE HIB (PRP-T) 4 DOSE SCHEDULE IM 91.00 45.50 10.94 31.30 11.25 10.94 11.25 31.30 12.23 12.23 11.49 11.25 26.25 11.25 31.30 31.30 25.14 31.30 31.30 31.30 17.60 278897 90662 1 VACCINE FLU HIGH DOSE 65 YRS+ 94.00 47.00 33.50 112.02 54.56 56.01 54.56 33.50 56.01 56.01 42.11 54.56 33.59 54.56 33.50 33.50 112.02 33.50 33.50 33.50 78.41 279274 32554 1 ASPIRATE PLEURA W/O IMAGING 578.00 289.00 302.19 856.21 302.19 323.74 302.19 483.01 312.59 312.59 675.18 302.19 856.21 302.19 483.01 483.01 422.64 483.01 483.01 483.01 338.11 279275 32555 1 ASPIRATE PLEURA W/ IMAGING 273.66 136.83 143.34 988.30 419.30 464.90 419.30 557.53 439.30 439.30 143.34 419.30 988.30 419.30 557.53 557.53 586.44 557.53 557.53 557.53 469.15 279393 49082 1 ABD PARACENTESIS 500.00 250.00 182.75 384.94 275.23 261.35 275.23 231.07 291.56 291.56 182.75 275.23 245.16 275.23 231.07 231.07 384.94 231.07 231.07 231.07 307.95 279725 G0442 1 ANNUAL ALCOHOL MISUSE SCREEN 15 MIN 30.00 15.00 11.93 34.20 17.44 11.93 17.44 16.46 17.15 17.15 17.44 15.93 17.44 16.46 16.46 34.20 16.46 16.46 16.46 23.94 361586 45388 1 COLONOSCOPY W/ABLATION " 1,780.00 " 890.00 604.87 " 5,318.46 " " 3,802.70 " " 4,320.34 " " 3,802.70 " " 1,068.00 " " 4,346.93 " " 4,346.93 " 604.87 " 3,802.70 " " 4,916.24 " " 3,802.70 " " 1,068.00 " " 1,068.00 " " 5,318.46 " " 1,068.00 " " 1,068.00 " " 2,681.59 " " 4,254.77 " 361847 99497 1 ADVNCD CARE PLAN 30 MIN 150.00 75.00 75.09 168.44 82.54 79.26 82.54 90.00 82.54 100.12 82.54 90.00 90.00 168.44 90.00 90.00 75.09 117.91 362261 J1071 200 TESTOSTERONE CYPIONATE 200MG/1ML 40.00 0.10 4.00 24.00 6.00 6.00 6.00 24.00 4.00 4.00 4.00 6.00 8.00 6.00 24.00 24.00 12.00 24.00 24.00 4.00 8.00 366784 80305 QW 1 DRUG TEST PRSMV DIR OPT OBS 40.00 20.00 6.27 25.20 14.99 17.95 14.99 24.00 13.23 13.23 6.27 14.99 14.99 24.00 24.00 25.20 24.00 24.00 6.28 20.16 366797 90750 1 VACCINE (SHINGRIX) HZV RECOMBINANT IM NJX 292.00 146.00 144.20 310.40 154.44 147.08 154.44 175.20 164.39 164.39 154.44 154.44 175.20 175.20 310.40 175.20 175.20 144.20 217.28 368552 99316 1 SNF DISCHARGE 30 MIN OR MORE 196.00 98.00 84.10 208.00 101.92 104.85 101.92 94.68 107.59 107.59 95.26 101.92 84.10 101.92 94.68 94.68 208.00 94.68 94.68 94.68 145.60 368555 99343 1 HOME VISIT NEW PT MODERATE 216.00 108.00 122.61 255.92 125.40 129.69 125.40 145.76 133.53 133.53 122.61 125.40 140.32 125.40 145.76 145.76 255.92 145.76 145.76 145.76 179.14 368562 99495 1 TRANS CARE MGMT 14 DAY DISCH 342.00 171.00 152.08 354.04 173.48 158.31 173.48 209.32 162.47 162.47 152.08 173.48 182.42 173.48 209.32 209.32 354.04 209.32 209.32 209.32 247.83 368594 1 1 DOT PHYSICAL 125.00 62.50 - - 368598 G0101 1 CA SCREEN/ PELVIC/BREAST EXAM 276.00 138.00 25.68 77.78 39.67 25.68 39.67 32.13 37.56 37.56 39.67 32.39 39.67 32.13 32.13 77.78 32.13 32.13 32.13 54.45 374576 J1200 1 BENADRYL (DIPHENHYDRAMINE) 50MG/1ML 15.00 7.50 0.68 1.68 0.69 0.91 0.69 0.68 0.92 0.92 0.72 0.69 0.86 0.69 0.68 0.68 1.68 0.68 0.68 0.68 1.18 374577 J0558 12 BICILLIN C-R (PENICILLIN C-R) 1.2 MU/ 2ML 240.00 10.00 42.48 259.44 133.56 131.64 133.56 48.84 142.68 142.68 102.48 133.56 42.48 133.56 48.84 48.84 259.44 48.84 48.84 48.84 181.56 374578 J0561 6 "BICILLIN L-A (PENICILLIN L-A) 600,000 UN / 1 ML" 180.00 15.00 26.88 165.96 85.92 83.40 85.92 30.72 91.20 91.20 64.50 85.92 26.88 85.92 30.72 30.72 165.96 30.72 30.72 30.72 116.16 374579 J0690 1 CEFAZOLIN SODIUM (ANCEF) 500MG 15.00 7.50 0.67 1.64 0.74 0.83 0.74 0.80 0.85 0.85 0.83 0.74 0.67 0.74 0.80 0.80 1.64 0.80 0.80 0.80 1.15 374581 J0696 1 CEFTRIAXONE (ROCEPHIN) 250MG 15.00 7.50 0.51 1.06 0.51 0.60 0.51 0.73 0.58 0.58 0.67 0.51 0.80 0.51 0.73 0.73 1.06 0.73 0.73 0.54 0.74 374582 J0702 1 CELESTONE (BETAMETHSN) 6MG/1ML MDV 7.50 3.75 5.80 14.64 7.06 7.14 7.06 5.80 7.66 7.66 6.06 7.06 6.69 7.06 5.80 5.80 14.64 5.80 5.80 5.80 10.25 374583 S0077 1 CLINDAMYCIN (CLEOCIN) 300 MG 15.00 7.50 0.78 6.00 1.43 1.68 1.43 1.63 0.87 0.87 0.78 1.43 6.00 1.43 1.63 1.63 5.08 1.63 1.63 1.40 3.56 374584 J1380 1 ESTRADIOL VALERATE (DELESTROGEN) 10MG/0.5ML 231.00 115.50 7.38 17.46 7.62 8.51 7.62 8.45 9.60 9.60 7.38 7.62 10.88 7.62 8.45 8.45 17.46 8.45 8.45 8.45 12.22 374587 J1050 150 DEPO-PROVERA 150 MG(MEDROXYPROGESTERONE) 150.00 0.50 39.00 168.00 81.00 85.50 81.00 76.50 93.00 93.00 67.50 81.00 39.00 81.00 76.50 76.50 168.00 76.50 76.50 76.50 117.00 374590 J1240 1 DRAMAMINE 50 MG/ 1ML (DIMENHYDRINATE) 15.00 7.50 3.96 13.04 6.76 7.00 6.76 4.86 7.17 7.17 7.09 6.76 3.96 6.76 4.86 4.86 13.04 4.86 4.86 4.86 9.13 374592 J1580 1 GENTAMYCIN 80MG/2ML (GARAMYCIN) 15.00 7.50 0.95 4.10 1.85 1.99 1.85 1.34 2.10 2.10 1.54 1.85 0.95 1.85 1.34 1.34 4.10 1.34 1.34 1.34 2.87 374593 J1631 1 HALOPERIDOL DECANOATE 50 MG 45.00 22.50 2.81 30.90 14.91 16.44 14.91 19.96 17.00 17.00 17.87 14.91 2.81 14.91 19.96 19.96 30.90 19.96 19.96 19.96 21.63 374595 J3030 1 IMITREX 6MG/0.5ML (SUMATRIPTAN SUCCNATE) 100.00 50.00 49.98 92.95 49.98 66.19 49.98 58.57 62.88 62.88 51.89 49.98 92.95 49.98 58.57 58.57 85.76 58.57 58.57 58.57 60.03 374600 J3301 1 KENOLOG (TRIAMCINOLON) 10MG/1ML 10.00 5.00 1.41 3.00 1.41 1.58 1.41 1.82 1.65 1.65 1.78 1.41 1.73 1.41 1.82 1.82 3.00 1.82 1.82 1.57 2.10 374601 J1940 1 LASIX 10 MG/ 1ML (FUROSEMIDE) 15.00 7.50 0.23 2.42 0.58 0.60 0.58 2.42 0.69 0.69 1.06 0.58 0.23 0.58 2.42 2.42 1.26 2.42 2.42 2.42 0.88 374602 J2360 1 ORPHENADRINE CITRATE (NORFLEX) 60MG / 1ML 25.00 12.50 5.22 15.42 6.20 7.42 6.20 6.06 7.08 7.08 5.22 6.20 8.64 6.20 6.06 6.06 15.42 6.06 6.06 6.06 10.79 374603 J2300 2 NUBAINE (NALBUPHINE HCL) 20MG / 1ML 10.00 2.50 2.24 10.40 4.52 6.36 4.52 3.28 5.72 5.72 5.04 4.52 2.24 4.52 3.28 3.28 10.40 3.28 3.28 3.28 7.28 374604 J2550 1 PHENERGAN (PROMETHANZINE) 25MG 13.00 6.50 1.62 3.94 2.12 2.08 2.12 1.62 2.17 2.17 2.19 2.12 1.80 2.12 1.62 1.62 3.94 1.62 1.62 1.62 2.76 374605 J7325 16 HYALURONAN DERIV (SYNVISC) 16MG/2ML PFS 400.00 12.50 170.72 352.00 170.72 178.24 170.72 205.76 193.60 193.60 200.64 170.72 206.56 170.72 205.76 205.76 352.00 205.76 205.76 205.76 246.40 374606 J1885 2 TORADOL (KETOROLAC) 30MG/1ML 15.00 3.75 0.60 2.20 1.12 1.04 1.12 0.78 1.10 1.10 1.38 1.12 0.60 1.12 0.78 0.78 2.20 0.78 0.78 0.78 1.54 374608 J3420 1 VIT B-12 CYNOCOBLMN TO 1000 MCG/1ML 15.00 7.50 1.64 4.52 1.64 2.23 1.64 2.10 2.08 2.08 3.35 1.64 2.31 1.64 2.10 2.10 4.52 2.10 2.10 1.89 3.16 374610 J2405 4 ZOFRAN (ONDANSETRON HCL) 4MG/2ML 4.00 0.50 0.36 1.72 0.36 0.36 0.36 0.40 0.40 0.40 1.72 0.36 0.92 0.36 0.40 0.40 0.72 0.40 0.40 0.40 0.52 374611 90716 1 VACCINE VARICELLA IMMUN (CHICKEN POX) 1+ YRS 250.00 125.00 98.00 309.16 138.31 138.31 138.31 115.58 147.26 147.26 128.98 138.31 98.00 138.31 115.58 115.58 309.16 115.58 115.58 115.58 216.41 374612 90723 1 VACCINE DTAP-HEP B-IPV IM (PEDIARIX) 6WKS+ 270.00 135.00 75.00 209.62 83.94 80.10 83.94 84.12 89.52 89.52 81.46 83.94 75.00 83.94 84.12 84.12 209.62 84.12 84.12 79.15 146.73 374613 90698 1 VACCINE DTAP-HIB-IP IM (PENTACEL) 6WKS - 5YRS 175.00 87.50 57.00 248.20 101.19 97.43 101.19 95.76 108.89 108.89 100.80 101.19 57.00 101.19 95.76 95.76 248.20 95.76 95.76 95.76 173.74 374614 90696 1 VACCINE DTAP-IPV (KINRIX) 4-6 YRS 180.00 90.00 52.46 143.10 54.18 53.70 54.18 57.00 58.87 58.87 55.27 54.18 89.50 54.18 57.00 57.00 143.10 57.00 57.00 52.46 100.17 374616 90685 1 VACCINE FLUZONE QUAD NO PRESERV (PED) 6-35MTHS PFS 35.00 17.50 18.20 40.68 18.20 20.34 18.20 24.45 20.34 20.34 25.95 18.20 26.71 18.20 24.45 24.45 40.68 24.45 24.45 24.45 28.48 374617 90633 1 VACCINE HEP A PED/ADOL 2 DOSE (HAVRIX PED) 180.00 90.00 33.10 75.62 33.83 33.42 33.83 35.36 37.35 37.35 33.76 33.83 39.00 33.83 35.36 35.36 75.62 35.36 35.36 33.10 52.93 374618 90632 1 VACCINE HEP A ADULT IM 19YRS+ (HAVRIX) 240.00 120.00 53.41 119.84 58.34 59.91 58.34 75.28 64.80 64.80 71.37 58.34 53.41 58.34 75.28 75.28 119.84 75.28 75.28 75.28 83.89 374622 90651 1 VACCINE HPV (GARDASIL-9) 9-26YRS 440.00 220.00 190.00 519.40 232.36 232.36 232.36 264.00 247.37 247.37 216.87 232.36 190.00 232.36 264.00 264.00 519.40 264.00 264.00 227.93 363.58 374623 90713 1 VACCINE IPOL POLIOVIRUS (IPV) 120.00 60.00 30.39 79.90 35.74 34.07 35.74 32.78 38.08 38.08 34.79 35.74 30.39 35.74 32.78 32.78 79.90 32.78 32.78 32.78 55.93 374625 90707 1 "VACCINE MMRII - MEASLES, MUMPS, RUBELLA (MMR) 1YRS+" 240.00 120.00 59.00 178.52 79.87 79.87 79.87 66.92 85.12 85.12 75.07 79.87 59.00 79.87 66.92 66.92 178.52 66.92 66.92 66.92 124.96 374626 90710 1 VACCINE MMRV (PROQUAD) 1YRS+ 450.00 225.00 158.00 533.70 228.92 228.92 228.92 188.57 243.81 243.81 214.05 228.92 158.00 228.92 188.57 188.57 533.70 188.57 188.57 188.57 373.59 374627 90670 1 VACCINE PNEUMOCOCCAL (PREVAR 13) 320.00 160.00 162.07 460.28 205.28 214.62 205.28 162.07 236.86 236.86 189.40 205.28 166.88 205.28 162.07 162.07 460.28 162.07 162.07 162.07 322.20 374628 90681 1 VACCINE ROTAVIRUS MONOVALENT 2 DOSE (ROTARIX) 260.00 130.00 110.00 283.70 126.92 123.24 126.92 127.73 137.74 137.74 122.92 126.92 110.00 126.92 127.73 127.73 283.70 127.73 127.73 127.73 198.59 374629 90714 1 VACCINE TETANUS DIPHTERIA ABSORBED (TENIVAC) 125.00 62.50 22.77 48.42 27.57 25.11 27.57 25.08 26.63 26.63 26.80 27.57 22.77 27.57 25.08 25.08 48.42 25.08 25.08 25.08 33.89 374677 99402 1 "P/M COUNSEL, INDIV 30 MIN AR MCAID" 171.00 85.50 57.52 128.36 62.90 62.90 62.90 60.52 64.41 64.41 57.52 62.90 72.15 62.90 60.52 60.52 128.36 60.52 60.52 60.52 89.85 379092 86580 1 TB SKIN TEST 25.00 12.50 3.41 16.76 9.97 8.52 9.97 5.92 8.17 8.17 3.41 9.97 7.61 9.97 5.92 5.92 16.76 5.92 5.92 4.26 13.41 379275 90715 1 VACCINE TDAP (ADACEL) >7 IM PRESERVATIVE FREE 165.00 82.50 31.87 66.20 31.87 33.64 31.87 47.02 36.15 36.15 43.24 31.87 36.62 31.87 47.02 47.02 66.20 47.02 47.02 43.35 46.34 379555 S0171 1 BUMETANIDE (BUMEX) 1MG/4ML 7.50 3.75 0.86 1.90 0.86 1.01 0.86 1.00 0.96 0.96 0.86 0.86 0.86 1.00 1.00 1.90 1.00 1.00 1.00 1.33 380401 99307 1 NURSING FACILITY SUBSQ CARE 86.00 43.00 39.29 86.66 42.46 44.10 42.46 39.62 44.60 44.60 40.31 42.46 43.92 42.46 39.62 39.62 86.66 39.62 39.62 39.29 60.66 380402 99308 1 NURSING FACILITY SUBSQ CARE 133.00 66.50 60.78 136.00 66.64 68.21 66.64 65.50 69.67 69.67 62.45 66.64 67.07 66.64 65.50 65.50 136.00 65.50 65.50 60.78 95.20 380403 99309 1 NURSING FACILITY SUBSQ CARE 187.00 93.50 80.13 179.02 87.72 89.92 87.72 92.39 92.72 92.72 82.25 87.72 89.09 87.72 92.39 92.39 179.02 92.39 92.39 80.13 125.31 381603 90460 1 VACCINE IMADM ANY ROUTE 1ST VAC/TOX 25.00 12.50 13.98 27.14 13.98 15.00 13.98 21.79 19.31 19.31 22.16 13.98 25.24 13.98 21.79 21.79 27.14 21.79 21.79 21.02 19.00 381604 90461 1 VACCINE INADM ANY ROUTE ADDL VAC/TOX 10.00 5.00 2.50 24.42 12.58 6.00 12.58 11.05 2.50 2.50 11.63 12.58 12.77 12.58 11.05 11.05 24.42 11.05 11.05 10.66 17.09 381653 A6449 1 BANDAGE ACE 4 INCH 6.00 3.00 1.14 4.08 2.12 1.46 2.12 1.14 1.31 1.31 2.12 1.84 2.12 1.14 1.14 4.08 1.14 1.14 1.14 2.86 381654 A6450 1 BANDAGE ACE 6 INCH 8.00 4.00 1.16 4.80 2.12 4.50 2.12 4.80 1.31 1.31 2.12 1.95 2.12 4.80 4.80 4.08 4.80 4.80 1.16 2.86 383057 G0444 1 ANNUAL DEPRESSION SCREENING 15 MIN 30.00 15.00 11.93 34.20 17.44 11.93 17.44 16.46 17.15 17.15 17.44 15.93 17.44 16.46 16.46 34.20 16.46 16.46 16.46 23.94 385020 G0511 1 CCM CODE 67.03 33.52 40.22 127.02 64.78 41.17 64.78 64.78 64.78 40.22 40.22 127.02 40.22 40.22 52.66 88.91 385598 731 QZ 1 ANES UPR GI NDSC PX NOS 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 385600 811 QZ 1 ANES LWR INTST NDSC NOS 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 385601 812 QZ 1 ANES LWR INTST SCR COLSC 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 385602 813 QZ 1 ANES UPR LWR GI NDSC PX 52.00 26.00 31.20 52.00 44.00 48.00 44.00 31.20 52.00 52.00 44.00 50.00 44.00 31.20 31.20 36.40 31.20 31.20 52.00 50.00 386582 99315 1 SNF DISCHARGE UNDER 30 149.00 74.50 66.19 144.94 71.02 72.23 71.02 71.82 74.57 74.57 66.19 71.02 71.02 71.82 71.82 144.94 71.82 71.82 71.82 101.46 386755 99499 1 PRE EMPLOYMENT PHYSICAL 125.00 62.50 - - - - 387639 99217 1 Hosp. Observation Care Discharge Sevices 190.00 95.00 64.18 143.68 70.40 72.02 70.40 82.38 74.24 74.24 66.49 70.40 75.82 70.40 82.38 82.38 143.68 82.38 82.38 64.18 100.58 389470 87804 QW 59 1 INFLUENZA ASSAY W/OPTIC TEST B 25.00 12.50 7.46 33.10 19.69 19.60 19.69 14.00 17.38 17.38 7.46 19.69 20.62 19.69 14.00 14.00 33.10 14.00 14.00 9.80 26.48 389650 90686 1 VACCINE FLU VAC QUAD PRES. FREE 6 MONTHS+ 35.00 17.50 17.03 38.06 17.03 19.03 17.03 18.93 19.03 19.03 18.84 17.03 22.32 17.03 18.93 18.93 38.06 18.93 18.93 17.50 26.64 390566 99232 1 HOSP SUB DAY MODERATE - COMPLX 173.00 86.50 64.01 144.00 70.56 71.83 70.56 64.81 74.49 74.49 66.65 70.56 76.37 70.56 64.81 64.81 144.00 64.81 64.81 64.01 100.80 391865 90739 1 VACCINE HEP B (Heplisav) ADULT 2 DOSE 192.00 96.00 99.30 262.20 117.30 131.10 117.30 99.30 131.10 131.10 117.30 117.30 99.30 99.30 262.20 99.30 99.30 99.30 183.54 392136 11102 1 TANGNTL BX SKIN SINGLE LES 134.00 67.00 80.40 188.10 134.49 125.83 134.49 80.40 98.80 98.80 134.49 134.49 80.40 80.40 188.10 80.40 80.40 83.36 150.48 392137 11103 1 TANGNTL BX SKIN EA SEP/ADDL 73.00 36.50 43.80 100.48 71.84 68.01 71.84 43.80 53.40 53.40 71.84 71.84 43.80 43.80 100.48 43.80 43.80 45.05 80.38 392138 11104 1 PUNCH BX SKIN SINGLE LESION 170.00 85.00 102.00 236.18 168.87 158.14 168.87 102.00 124.17 124.17 168.87 168.87 102.00 102.00 236.18 102.00 102.00 104.76 188.94 392140 11106 1 INCAL BX SKN SINGLE LES 198.00 99.00 118.80 285.34 204.02 191.52 204.02 118.80 150.38 150.38 204.02 204.02 118.80 118.80 285.34 118.80 118.80 126.87 228.27 392156 43762 1 RPLC GTUBE NO REVJ TRC 297.00 148.50 178.20 419.02 299.60 298.70 299.60 178.20 319.30 319.30 299.60 299.60 178.20 178.20 419.02 178.20 178.20 184.21 335.22 393168 0296T 1 HOLTER MONITOR 48HRS TO 21 DAYS 56.00 28.00 18.27 72.55 24.65 72.55 24.65 36.50 39.87 39.87 24.65 24.65 36.50 36.50 36.90 36.50 36.50 18.27 25.83 393169 0298T 1 HOLTER MONITOR READING 48 HRS TO 21 DAYS 77.00 38.50 27.12 93.82 27.12 93.82 27.12 31.40 44.74 44.74 27.12 27.12 31.40 31.40 51.04 31.40 31.40 31.40 35.73 394334 87807 QW 1 RSV SWAB WITH DIRECT OBSERVATION 68.00 34.00 7.04 26.20 15.59 19.60 15.59 7.04 13.99 13.99 7.46 15.59 15.59 7.04 7.04 26.20 7.04 7.04 7.04 20.96 400132 20610 1 "DRAIN/INJECT, JOINT/BURSA" 233.00 116.50 52.98 122.44 87.54 88.30 87.54 72.65 91.81 91.81 84.75 87.54 110.43 87.54 72.65 72.65 122.44 72.65 72.65 52.98 97.95 400150 20552 1 INJ TRIGGER POINT 1/2 MUSCLE 192.00 96.00 48.00 109.08 77.99 79.99 77.99 55.90 83.17 83.17 65.73 77.99 76.59 77.99 55.90 55.90 109.08 55.90 55.90 48.00 87.26 400310 11730 1 REMOVAL OF NAIL PLATE 170.00 85.00 70.09 210.82 150.74 113.14 150.74 70.09 110.19 110.19 86.65 150.74 120.54 150.74 70.09 70.09 210.82 70.09 70.09 70.09 168.66 400311 11732 1 "REMOVAL OF NAIL PLATE, ADD ON" 104.00 52.00 32.39 64.40 46.05 41.04 46.05 33.01 33.51 33.51 32.39 46.05 56.49 46.05 33.01 33.01 64.40 33.01 33.01 33.01 51.52 400397 30300 1 REMOVE NASAL FOREIGN BODY 526.00 263.00 167.93 355.64 254.28 297.43 254.28 167.93 269.95 269.95 243.10 254.28 302.46 254.28 167.93 167.93 355.64 167.93 167.93 167.93 284.51 400399 12001 1 LACERATION >2CM 404.00 202.00 83.27 178.22 125.18 114.32 125.18 116.05 90.66 90.66 83.27 125.18 178.22 125.18 116.05 116.05 175.08 116.05 116.05 116.05 140.06 400400 16020 1 DRESS/DEBRID P-THICK BURN S 204.00 102.00 65.27 158.26 113.16 104.30 113.16 65.27 82.87 82.87 90.12 113.16 97.92 113.16 65.27 65.27 158.26 65.27 65.27 65.27 126.61 400401 69200 1 FOREIGN BODY/EAR 293.00 146.50 78.42 156.26 111.73 136.49 111.73 92.54 78.42 78.42 131.58 111.73 138.67 111.73 92.54 92.54 156.26 92.54 92.54 84.72 125.01 400402 69210 1 REMOVE IMPACTED EAR WAX REQ INSTRUMENT 125.00 62.50 37.75 94.04 67.24 69.20 67.24 37.75 46.11 46.11 54.41 67.24 65.87 67.24 37.75 37.75 94.04 37.75 37.75 37.75 75.23 400403 10120 1 REMOVE FOREIGN BODY 302.00 151.00 105.68 287.62 205.65 193.17 205.65 105.68 153.32 153.32 156.08 205.65 160.83 205.65 105.68 105.68 287.62 105.68 105.68 105.68 230.10 400405 10140 1 DRAINAGE OF HEMATOMA/FLUID 320.00 160.00 106.16 327.44 234.12 209.78 234.12 106.16 170.83 170.83 178.86 234.12 186.35 234.12 106.16 106.16 327.44 106.16 106.16 106.16 261.95 400406 10160 1 PUNCTURE DRAINAGE OF LESION 289.00 144.50 88.88 250.34 178.99 167.49 178.99 88.88 132.55 132.55 143.60 178.99 151.15 178.99 88.88 88.88 250.34 88.88 88.88 88.88 200.27 400407 11000 1 DEBRIDE INFECTED SKIN 121.00 60.50 38.02 109.00 77.94 70.07 77.94 38.02 56.38 56.38 47.88 77.94 65.87 77.94 38.02 38.02 109.00 38.02 38.02 38.02 87.20 400408 11010 1 "DEBRIDE SKIN, FX" 996.00 498.00 256.33 916.36 655.20 634.37 655.20 354.69 495.07 495.07 256.33 655.20 564.44 655.20 354.69 354.69 916.36 354.69 354.69 354.69 733.09 400409 11042 1 DEBRIDE SKIN/TISSUE 268.00 134.00 67.66 238.56 170.57 148.84 170.57 67.66 123.03 123.03 96.59 170.57 91.52 170.57 67.66 67.66 238.56 67.66 67.66 67.66 190.85 400410 11055 1 DEBRIDE SKIN/TISSUE 85.00 42.50 31.45 116.80 83.51 59.67 83.51 31.45 55.63 55.63 44.34 83.51 58.33 83.51 31.45 31.45 116.80 31.45 31.45 31.45 93.44 400412 11200 1 REMOVAL OF SKIN TAGS 186.00 93.00 55.58 169.48 121.18 112.93 121.18 55.58 89.78 89.78 76.89 121.18 97.37 121.18 55.58 55.58 169.48 55.58 55.58 55.58 135.58 400413 11300 1 SHAVE TRUNK <0.5 CM 160.00 80.00 45.73 187.04 133.73 121.98 133.73 45.73 97.40 97.40 61.75 133.73 79.95 133.73 45.73 45.73 187.04 45.73 45.73 45.73 149.63 400414 11301 1 SHAVE TRUNK 0.6-1 CM 185.00 92.50 60.09 229.18 163.86 151.67 163.86 60.09 120.52 120.52 83.16 163.86 110.61 163.86 60.09 60.09 229.18 60.09 60.09 60.09 183.34 400415 11302 1 SHAVE TRUNK 1.1-2 CM 230.00 115.00 72.18 265.28 189.68 178.68 189.68 72.18 141.18 141.18 99.35 189.68 132.54 189.68 72.18 72.18 265.28 72.18 72.18 72.18 212.22 400416 11303 1 SHAVE TRUNK >2 CM 295.00 147.50 86.94 292.68 209.27 198.24 209.27 86.94 156.30 156.30 117.21 209.27 155.82 209.27 86.94 86.94 292.68 86.94 86.94 86.94 234.14 400418 11306 1 "SHAVE S,N,H 0.6-1 CM" 203.00 101.50 65.23 232.88 166.51 154.42 166.51 65.23 122.36 122.36 85.48 166.51 115.65 166.51 65.23 65.23 232.88 65.23 65.23 65.23 186.30 400419 11307 1 "SHAVE S,N,H 1.1-2 CM" 232.00 116.00 75.40 272.94 195.15 182.93 195.15 75.40 145.56 145.56 100.30 195.15 136.34 195.15 75.40 75.40 272.94 75.40 75.40 75.40 218.35 400420 11308 1 SHAVE SKIN LESION > 2.0 CM 264.00 132.00 90.61 293.24 209.67 192.77 209.67 90.61 155.15 155.15 111.65 209.67 154.64 209.67 90.61 90.61 293.24 90.61 90.61 90.61 234.59 400421 11310 1 SHAVE SKIN LESIONS 0.5 CM/< 195.00 97.50 56.39 218.16 155.98 143.26 155.98 56.39 114.22 114.22 75.98 155.98 100.20 155.98 56.39 56.39 218.16 56.39 56.39 56.39 174.53 400425 11400 1 EXC TR-EXT B9 MARG 0.5 < CM 268.00 134.00 86.80 237.34 169.70 156.97 169.70 86.80 125.05 125.05 107.60 169.70 136.00 169.70 86.80 86.80 237.34 86.80 86.80 86.80 189.87 400426 11401 1 EXC TR-EXT B9 MARG 0.6-1 CM 303.00 151.50 101.75 291.22 208.22 190.41 208.22 101.75 153.50 153.50 131.03 208.22 168.75 208.22 101.75 101.75 291.22 101.75 101.75 101.75 232.98 400427 11402 1 EXC TR-EXT B9 MARG 1.1-2 CM 352.00 176.00 116.46 324.24 231.83 212.10 231.83 116.46 170.97 170.97 145.89 231.83 188.69 231.83 116.46 116.46 324.24 116.46 116.46 116.46 259.39 400428 11403 1 EXC TR-EXT B9 MARG 2.1-3 CM 441.00 220.50 131.53 377.66 270.03 247.77 270.03 131.53 199.14 199.14 168.53 270.03 218.30 270.03 131.53 131.53 377.66 131.53 131.53 131.53 302.13 400429 11404 1 EXC TR-EXT B9 MARG 3.1-4 CM 552.00 276.00 150.39 430.12 307.54 282.05 307.54 150.39 226.21 226.21 191.61 307.54 248.98 307.54 150.39 150.39 430.12 150.39 150.39 150.39 344.10 400430 11406 1 EXC TR-EXT B9 MARG > 4.0 CM 738.00 369.00 186.55 623.48 445.79 411.72 445.79 186.55 329.18 329.18 220.05 445.79 354.35 445.79 186.55 186.55 623.48 186.55 186.55 186.55 498.78 400431 11420 1 EXC H-F-NK-SP B9 MARG 0.5 < 250.00 125.00 85.21 240.36 171.86 155.81 171.86 85.21 125.37 125.37 107.55 171.86 138.69 171.86 85.21 85.21 240.36 85.21 85.21 85.21 192.29 400432 11421 1 EXC H-F-NK-SP B9 MARG 0.6-1 327.00 163.50 109.01 305.74 218.60 201.03 218.60 109.01 160.88 160.88 139.04 218.60 181.00 218.60 109.01 109.01 305.74 109.01 109.01 109.01 244.59 400433 11422 1 EXC H-F-NK-SP B9 MARG 1.1-2 388.00 194.00 122.14 345.08 246.73 225.67 246.73 122.14 181.68 181.68 154.93 246.73 202.58 246.73 122.14 122.14 345.08 122.14 122.14 122.14 276.06 400434 11424 1 EXC H-F-NK-SP B9+ MARG 3.1-4 610.00 305.00 166.19 457.36 327.01 303.83 327.01 166.19 242.28 242.28 206.70 327.01 273.86 327.01 166.19 166.19 457.36 166.19 166.19 166.19 365.89 400435 11426 1 EXC H-F-NK-SP B9 MARG > 4 CM 843.00 421.50 234.39 665.06 475.52 439.88 475.52 234.39 351.43 351.43 247.66 475.52 396.65 475.52 234.39 234.39 665.06 234.39 234.39 234.39 532.05 400436 11423 1 EXC H-F-NK-SP B9+MARG 2.1-3 473.00 236.50 144.97 394.16 281.82 261.56 281.82 144.97 208.23 208.23 179.29 281.82 236.71 281.82 144.97 144.97 394.16 144.97 144.97 144.97 315.33 400444 11719 1 TRIM NAIL(S) ANY NUMBER 45.00 22.50 13.28 27.14 19.41 15.82 19.41 13.28 14.74 14.74 19.67 19.41 25.43 19.41 13.28 13.28 27.14 13.28 13.28 13.28 21.71 400445 11720 1 "DEBRIDE NAIL, 1-5" 60.00 30.00 21.27 62.60 44.76 36.51 44.76 21.27 33.47 33.47 28.09 44.76 37.89 44.76 21.27 21.27 62.60 21.27 21.27 21.27 50.08 400446 11721 1 "DEBRIDE NAIL, 6 OR MORE" 82.00 41.00 32.08 87.92 62.86 51.57 62.86 32.08 46.52 46.52 39.48 62.86 54.93 62.86 32.08 32.08 87.92 32.08 32.08 32.08 70.34 400448 11750 1 REMOVAL OF NAIL BED 473.00 236.50 128.83 299.38 214.06 204.05 214.06 128.83 157.69 157.69 246.64 214.06 259.75 214.06 128.83 128.83 299.38 128.83 128.83 128.83 239.50 400450 11770 1 REMOVAL OF PILONIDAL LESION 773.00 386.50 194.55 604.28 432.06 361.56 432.06 194.55 292.62 292.62 206.87 432.06 311.34 432.06 194.55 194.55 604.28 194.55 194.55 194.55 483.42 400451 11771 1 REMOVAL OF PILONIDAL LESION " 1,329.00 " 664.50 369.26 " 1,186.88 " 848.62 753.59 848.62 369.26 611.42 611.42 486.35 848.62 642.96 848.62 369.26 369.26 " 1,186.88 " 369.26 369.26 369.26 949.50 400456 11900 1 INJECTION INTO SKIN LESIONS 120.00 60.00 35.75 104.86 74.97 71.23 74.97 35.75 55.26 55.26 49.80 74.97 67.15 74.97 35.75 35.75 104.86 35.75 35.75 35.75 83.89 400458 10021 1 FNA W/O IMAGE 368.00 184.00 100.32 190.16 135.96 159.18 135.96 105.90 100.32 100.32 163.20 135.96 169.80 135.96 105.90 105.90 190.16 105.90 105.90 105.90 152.13 400459 10040 1 ACNE SURGERY 202.00 101.00 67.72 207.70 148.51 132.70 148.51 67.72 110.18 110.18 91.93 148.51 122.42 148.51 67.72 67.72 207.70 67.72 67.72 67.72 166.16 400460 10060 1 DRAINAGE OF SKIN ABSCESS 226.00 113.00 75.83 232.42 166.18 151.00 166.18 75.83 121.01 121.01 127.51 166.18 132.57 166.18 75.83 75.83 232.42 75.83 75.83 75.83 185.94 400461 10061 1 DRAINAGE OF SKIN ABSCESS 396.00 198.00 137.05 408.80 292.29 268.81 292.29 137.05 213.06 213.06 224.27 292.29 230.06 292.29 137.05 137.05 408.80 137.05 137.05 137.05 327.04 400462 10080 1 DRAINAGE OF PILONIDAL CYST 401.00 200.50 130.92 395.82 283.01 227.23 283.01 130.92 184.51 184.51 193.16 283.01 193.17 283.01 130.92 130.92 395.82 130.92 130.92 130.92 316.66 400468 11442 1 EXC FACE-MM B9 MARG 1.1-2 CM 488.00 244.00 133.38 366.44 262.00 242.06 262.00 133.38 193.49 193.49 167.16 262.00 218.30 262.00 133.38 133.38 366.44 133.38 133.38 133.38 293.15 400469 11443 1 EXC FACE-MM B9 MARG 2.1-3 CM 562.00 281.00 163.98 438.30 313.38 290.87 313.38 163.98 232.06 232.06 199.82 313.38 263.77 313.38 163.98 163.98 438.30 163.98 163.98 163.98 350.64 400470 11444 1 EXC FACE-MM B9 MARG 3.1-4 CM 669.00 334.50 209.50 553.56 395.80 367.55 395.80 209.50 292.50 292.50 251.25 395.80 334.44 395.80 209.50 209.50 553.56 209.50 209.50 209.50 442.85 400471 11446 1 EXC FACE-MM B9 MARG > 4 CM 890.00 445.00 272.27 767.06 548.45 513.68 548.45 272.27 408.05 408.05 347.01 548.45 458.10 548.45 272.27 272.27 767.06 272.27 272.27 272.27 613.65 400473 11600 1 EXC TR-EXT MAL+MARG 0.5 CM/< 408.00 204.00 121.15 375.84 268.73 245.67 268.73 121.15 197.28 197.28 167.89 268.73 210.82 268.73 121.15 121.15 375.84 121.15 121.15 121.15 300.67 400475 11602 1 EXC TR-EXT MLG MARG 1.1-2 CM 491.00 245.50 147.17 471.96 337.45 318.60 337.45 147.17 253.08 253.08 220.48 337.45 286.53 337.45 147.17 147.17 471.96 147.17 147.17 147.17 377.57 400476 11603 1 EXC TR-EXT MLG MARG 2.1-3 CM 610.00 305.00 163.35 540.84 386.70 366.44 386.70 163.35 290.75 290.75 251.34 386.70 327.27 386.70 163.35 163.35 540.84 163.35 163.35 163.35 432.67 400477 11604 1 EXC TR-EXT MLG MARG 3.1-4 CM 735.00 367.50 180.06 605.32 432.80 408.17 432.80 180.06 322.91 322.91 279.25 432.80 362.12 432.80 180.06 180.06 605.32 180.06 180.06 180.06 484.26 400478 11606 1 EXC TR-EXT MLG MARG > 4 CM " 1,082.00 " 541.00 237.57 877.90 627.70 590.19 627.70 237.57 467.82 467.82 398.46 627.70 514.10 627.70 237.57 237.57 877.90 237.57 237.57 237.57 702.32 400503 20550 1 INJ TENDON SHEATH/LIGAMENT 184.00 92.00 61.03 107.96 77.19 85.64 77.19 61.03 81.13 81.13 70.13 77.19 85.90 77.19 61.03 61.03 107.96 61.03 61.03 61.03 86.37 400504 20551 1 INJECT TENDON ORIGIN/INSERT 168.00 84.00 59.42 110.50 79.01 87.38 79.01 59.42 81.93 81.93 71.71 79.01 84.81 79.01 59.42 59.42 110.50 59.42 59.42 59.42 88.40 400505 20553 1 INJECT TRIGGER POINTS 3> 248.00 124.00 62.80 124.46 88.99 92.14 88.99 62.80 95.81 95.81 75.33 88.99 85.32 88.99 62.80 62.80 124.46 62.80 62.80 62.80 99.57 400506 20600 1 DRAIN/INJ JOINT/ BURSA W/O US 155.00 77.50 54.69 99.56 71.19 69.51 71.19 54.69 73.94 73.94 66.13 71.19 80.38 71.19 54.69 54.69 99.56 54.69 54.69 54.69 79.65 400508 20605 1 DRAIN/INJ JOINT/BURSA W/O US 182.00 91.00 59.65 102.90 73.57 73.14 73.57 59.65 77.04 77.04 69.74 73.57 85.90 73.57 59.65 59.65 102.90 59.65 59.65 59.65 82.32 400510 20611 1 DRAIN/INJ JOINT/BURSA W/US 334.00 167.00 79.96 200.40 130.96 133.27 130.96 200.40 138.88 138.88 108.71 130.96 152.10 130.96 200.40 200.40 183.16 200.40 200.40 79.96 146.53 400511 20612 1 ASPIRATE/INJ GANGLION CYST 183.00 91.50 59.52 120.20 85.94 87.72 85.94 59.52 90.72 90.72 71.83 85.94 86.07 85.94 59.52 59.52 120.20 59.52 59.52 59.52 96.16 400516 69209 1 REMOVE IMPACTED EAR WAX UNI 38.00 19.00 10.40 25.64 18.33 16.74 18.33 22.80 12.90 12.90 12.31 18.33 16.17 18.33 22.80 22.80 25.64 22.80 22.80 10.40 20.51 401942 OCC10 1 OCC CDL 125.00 62.50 - - 403528 G0071 1 Phone Communication Medicare 75.00 37.50 9.21 26.58 24.66 9.21 24.66 24.66 24.66 26.58 11.76 18.61 403537 99441 1 Phone E/M 5-10 minutes 75.00 37.50 11.40 86.76 42.51 13.65 42.51 14.63 14.01 14.01 12.94 42.51 11.40 42.51 14.63 14.63 86.76 14.63 14.63 12.16 60.73 403538 99442 1 Phone E/M 11-20 minutes 90.00 45.00 17.40 144.50 70.81 26.77 70.81 26.51 27.47 27.47 24.94 70.81 17.40 70.81 26.51 26.51 144.50 26.51 26.51 23.85 101.15 403539 99443 1 Phone E/M 21-30 minutes 140.00 70.00 25.50 210.22 103.01 39.13 103.01 39.34 40.49 40.49 36.94 103.01 25.50 103.01 39.34 39.34 210.22 39.34 39.34 34.87 147.15 403968 G2025 1 TELEHEALTH 100.00 50.00 90.30 90.30 90.30 90.30 90.30 90.30 403969 G2025 95 1 TELEHEALTH MEDICARE 100.00 50.00 90.30 90.30 90.30 90.30 90.30 90.30 405318 G0402 1 IPPE WELCOME TO MEDICARE 175.00 87.50 83.76 321.02 163.72 112.12 163.72 83.76 161.51 161.51 163.72 87.33 163.72 83.76 83.76 321.02 83.76 83.76 83.76 224.71 405436 90682 1 FLUBLOK 94.00 47.00 50.11 112.02 50.11 56.01 50.11 56.40 56.01 56.01 50.11 50.11 56.40 56.40 112.02 56.40 56.40 56.01 78.41