hospital_name last_updated_on version location_name hospital_address license_number|CA type_2_npi "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula." attester_name general_contract_provisions Roger Mills Memorial Hospital 12/1/2024 22.04.02 Roger Mills Memorial Hospital "501 South L.L. Males Avenue, Cheyenne, OK 73628" 2209 OK 1407950447 TRUE Cynthia Duncan description code|1 code|1|type code|2 code|2|type modifiers setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash standard_charge|UHC|PPO|negotiated_dollar standard_charge|UHC|PPO|negotiated_percentage standard_charge|UHC|PPO|negotiated_algorithm median_amount|UHC|PPO 10th_percentile|UHC|PPO 90th_percentile|Platform Health Insurance|PPO count|UHC|PPO standard_charge|Platform Health Insurance|PPO|methodology additional_payer_notes|Platform Health Insurance|PPO standard_charge|Region Health Insurance|HMO|negotiated_dollar standard_charge|Region Health Insurance|HMO|methodology Standard_charge|Blue Cross Blue Shield OK Standard_charge|BCBS|methodology Standard_charge|Healthchoice PPO| Standard_charge|Healthchoice| methodology Standard_charge|min Standard_charge|max RABIES IMM GLOB (Kedrab)10ML 90675 CPT 637 Revenue Code Both 2981 2235.75 2384.8 Fee Schedule 2384.8 Fee Schedule 1341.45 Fee Schedule 1788.6 Fee Schedule 1341.45 1788.6 UNNA BOOT 3' 29580 CPT 270 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 .COVID SWAB COLLECTION C9803 HCPCS 300 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 .RAPID SARS AG 87426 CPT 300 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 24 HOUR URINE ALDOSTERONE 82088 CPT 300 Revenue Code Both 257 192.75 205.6 Fee Schedule 205.6 Fee Schedule 115.65 Fee Schedule 154.2 Fee Schedule 115.65 154.2 24 HOUR URINE CALCIUM 82340 CPT 300 Revenue Code Both 151 113.25 120.8 Fee Schedule 120.8 Fee Schedule 67.95 Fee Schedule 90.6 Fee Schedule 67.95 90.6 24 HOUR URINE CC 82540 CPT 300 Revenue Code Both 159 119.25 127.2 Fee Schedule 127.2 Fee Schedule 71.55 Fee Schedule 95.4 Fee Schedule 71.55 95.4 24 HOUR URINE CORTISOL 82530 CPT 300 Revenue Code Both 266 199.5 212.8 Fee Schedule 212.8 Fee Schedule 119.7 Fee Schedule 159.6 Fee Schedule 119.7 159.6 24 HOUR URINE CREATININE 82570 CPT 300 Revenue Code Both 109 81.75 87.2 Fee Schedule 87.2 Fee Schedule 49.05 Fee Schedule 65.4 Fee Schedule 49.05 65.4 24 HOUR URINE PROTEIN 84156 CPT 300 Revenue Code Both 147 110.25 117.6 Fee Schedule 117.6 Fee Schedule 66.15 Fee Schedule 88.2 Fee Schedule 66.15 88.2 7.6 TO 12.5CM LAYER CLOSURE SCALP EXT 12034 CPT 981 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 ABDOMINAL PARACENTESIS (US GUIDANCE) 49083 CPT 270 Revenue Code Both 1092 819 873.6 Fee Schedule 873.6 Fee Schedule 491.4 Fee Schedule 655.2 Fee Schedule 491.4 655.2 ACA 86147 CPT 300 Revenue Code Both 81 60.75 64.8 Fee Schedule 64.8 Fee Schedule 36.45 Fee Schedule 48.6 Fee Schedule 36.45 48.6 ACE WRAP 6' A6449 HCPCS 636 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 ACETAMINOPHEN 80329 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 ACETAZOLAMIDE (DIAMOX) 500MG IVP J1120 HCPCS 636 Revenue Code Both 93 69.75 74.4 Fee Schedule 74.4 Fee Schedule 41.85 Fee Schedule 55.8 Fee Schedule 41.85 55.8 ACETYL FENTANYL QL 80354 CPT 300 Revenue Code Both 117 87.75 93.6 Fee Schedule 93.6 Fee Schedule 52.65 Fee Schedule 70.2 Fee Schedule 52.65 70.2 ACETYLCHOLINE RECEPTOR BINDING AB 83519 CPT 300 Revenue Code Both 266 199.5 212.8 Fee Schedule 212.8 Fee Schedule 119.7 Fee Schedule 159.6 Fee Schedule 119.7 159.6 ACETYLCHOLINE RECEPTOR BLOCKING AB 83519 CPT 300 Revenue Code Both 247 185.25 197.6 Fee Schedule 197.6 Fee Schedule 111.15 Fee Schedule 148.2 Fee Schedule 111.15 148.2 ACETYLCHOLINE RECEPTOR GANGLIONIC AB 83519 CPT 300 Revenue Code Both 965 723.75 772 Fee Schedule 772 Fee Schedule 434.25 Fee Schedule 579 Fee Schedule 434.25 579 ACETYLCHOLINE RECEPTOR MODULATING AB 83519 CPT 300 Revenue Code Both 301 225.75 240.8 Fee Schedule 240.8 Fee Schedule 135.45 Fee Schedule 180.6 Fee Schedule 135.45 180.6 ACETYLCYSTEINE (MUCOMYST) SOL 200MG J7608 HCPCS 637 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ACETYLCYSTEINE(ACETADOTE) 6GM/30ML INJ J0132 HCPCS 637 Revenue Code Both 93.25 69.9375 74.6 Fee Schedule 74.6 Fee Schedule 41.9625 Fee Schedule 55.95 Fee Schedule 41.9625 55.95 ACETYLSAL ACID(ASPIRIN) 81MG CHEW TAB J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 ACETYLSALICYLIC ACID (ASPIRIN) 325MG TAB J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 ACID PHOS 84066 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 ACID-FAST CULTURE 87015 CPT 300 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 ACID-FAST SMEAR 87206 CPT 300 Revenue Code Both 117 87.75 93.6 Fee Schedule 93.6 Fee Schedule 52.65 Fee Schedule 70.2 Fee Schedule 52.65 70.2 ACIDOPHILUS CAP J3490 HCPCS 637 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 ACOUSTIC REFLEX 92568 CPT 270 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 ACT HIB HIB PRP T 90648 CPT 270 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 ACT HIB HIB PRP T 90648 CPT 636 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 ACTH 82024 CPT 300 Revenue Code Both 277 207.75 221.6 Fee Schedule 221.6 Fee Schedule 124.65 Fee Schedule 166.2 Fee Schedule 124.65 166.2 ACTIVASE (ALTEPLASE) 50MG IV J2997 HCPCS 637 Revenue Code Both 5888 4416 4710.4 Fee Schedule 4710.4 Fee Schedule 2649.6 Fee Schedule 3532.8 Fee Schedule 2649.6 3532.8 ADDING WALKER TO PREVIOUSLY APPLIED CAST 29440 CPT 270 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 ADDT'L IV PUSH NEW DRUG 96375 CPT 450 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 ADENOSINE (ADENOCARD) 6MG/2ML INJ J0153 HCPCS 636 Revenue Code Both 54.75 41.0625 43.8 Fee Schedule 43.8 Fee Schedule 24.6375 Fee Schedule 32.85 Fee Schedule 24.6375 32.85 ADM VACCINE UNDER 19 COUNSEL EACH ADDITI 90461 CPT 771 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 ADMIN OF IM OR SUB Q INJECTION (ER) 96372 CPT 761 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 ADMIN OF IM OR SUB Q INJECTION (OP TR) 96372 CPT 762 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 ADMINISTER FLU VACCINE G0008 HCPCS 270 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 ADMINISTER VACCINE UNDER 19 WITH COUNSEL 90460 CPT 771 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 ADMINISTRATION FOR VFC 96372 CPT 771 Revenue Code Both 22 16.5 17.6 Fee Schedule 17.6 Fee Schedule 9.9 Fee Schedule 13.2 Fee Schedule 9.9 13.2 AFP TUMOR MARKER 82107 CPT 300 Revenue Code Both 338 253.5 270.4 Fee Schedule 270.4 Fee Schedule 152.1 Fee Schedule 202.8 Fee Schedule 152.1 202.8 ALBUMIN 82040 CPT 300 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 ALBUMIN 25% 100ml INJ P9046 HCPCS 637 Revenue Code Both 181 135.75 144.8 Fee Schedule 144.8 Fee Schedule 81.45 Fee Schedule 108.6 Fee Schedule 81.45 108.6 ALBUTEROL (PROVENTIL) 2.5MG/3ML NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ALBUTEROL (PROVENTIL) HFA MDI INH J7611 HCPCS 637 Revenue Code Both 210 157.5 168 Fee Schedule 168 Fee Schedule 94.5 Fee Schedule 126 Fee Schedule 94.5 126 ALBUTEROL INHALATION SOLUTION J7613 HCPCS 636 Revenue Code Both 5 3.75 4 Fee Schedule 4 Fee Schedule 2.25 Fee Schedule 3 Fee Schedule 2.25 3 ALBUTEROL/ATROVENT INHALATION SOLUTION J7620 HCPCS 636 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 ALBUTEROL/IPRATROPIUM(DUONEB)3ML NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ALCOHOL 80307 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 ALDOSTERONE 82088 CPT 300 Revenue Code Both 257 192.75 205.6 Fee Schedule 205.6 Fee Schedule 115.65 Fee Schedule 154.2 Fee Schedule 115.65 154.2 ALKALINE PHOSPHATASE 84075 CPT 300 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 ALOE VERA 1 BTL GEL J3490 HCPCS 637 Revenue Code Both 25 18.75 20 Fee Schedule 20 Fee Schedule 11.25 Fee Schedule 15 Fee Schedule 11.25 15 ALPHA-1-ANTITRYPSIN 82103 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 ALPHA-1-ANTITRYPSIN QN 82103 CPT 300 Revenue Code Both 146 109.5 116.8 Fee Schedule 116.8 Fee Schedule 65.7 Fee Schedule 87.6 Fee Schedule 65.7 87.6 ALTERNARIA ALTERNATA IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 ALTV 84460 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 AM CORTISOL 82533 CPT 300 Revenue Code Both 172 129 137.6 Fee Schedule 137.6 Fee Schedule 77.4 Fee Schedule 103.2 Fee Schedule 77.4 103.2 AMIKACIN PEAK 80150 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 AMIKACIN TROUGH 80150 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 AMIODARONE (CORDARONE) 150MG/3ML INJ J0282 HCPCS 637 Revenue Code Both 13.75 10.3125 11 Fee Schedule 11 Fee Schedule 6.1875 Fee Schedule 8.25 Fee Schedule 6.1875 8.25 AMMONIA 82140 CPT 300 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 AMOX/K CLAV(AUGMENTIN) 500MG TAB G9313 HCPCS 636 Revenue Code Both 33 24.75 26.4 Fee Schedule 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 AMOX/K CLAV(AUGMENTIN) 875MG TAB G9313 HCPCS 636 Revenue Code Both 54.25 40.6875 43.4 Fee Schedule 43.4 Fee Schedule 24.4125 Fee Schedule 32.55 Fee Schedule 24.4125 32.55 AMOXICILLIN (AMOXIL) 250/5ML SUSP G9315 HCPCS 636 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 AMOXICILLIN (AMOXIL) 875MG TAB G9315 HCPCS 637 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 AMOXICILLIN (AMOXIL)125MG/5ML 100ML SUSP G9315 HCPCS 637 Revenue Code Both 70 52.5 56 Fee Schedule 56 Fee Schedule 31.5 Fee Schedule 42 Fee Schedule 31.5 42 AMPICILLIN 250MG INJ J0290 HCPCS 637 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 AMPICILLIN (OMNIPEN) 500MG CAP J3490 HCPCS 636 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 AMPICILLIN 1GM Injectable J0290 HCPCS 636 Revenue Code Both 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 AMPICILLIN/SULBACTAM 1.5GM Injectable J0295 HCPCS 636 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 AMPUTATION FINGER OR THUMB 26951 CPT 981 Revenue Code Both 1166 874.5 932.8 Fee Schedule 932.8 Fee Schedule 524.7 Fee Schedule 699.6 Fee Schedule 524.7 699.6 AMYLASE 82150 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 ANA W/ REFLEX TO TITER + PATTERN 86038 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 ANAPLASMA PHAGOCYTOPHILUM AB IGG IGM 86666 CPT 300 Revenue Code Both 417 312.75 333.6 Fee Schedule 333.6 Fee Schedule 187.65 Fee Schedule 250.2 Fee Schedule 187.65 250.2 ANASTROZOLE (ARIMIDEX) 1MG TAB S0170 HCPCS 637 Revenue Code Both 64 48 51.2 Fee Schedule 51.2 Fee Schedule 28.8 Fee Schedule 38.4 Fee Schedule 28.8 38.4 ANCEF/CEFAZOLIN SOD 500 MG/1 GRM INJ J0690 HCPCS 636 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 ANGIOTENSIN I CONVERTING ENZYME 82164 CPT 300 Revenue Code Both 217 162.75 173.6 Fee Schedule 173.6 Fee Schedule 97.65 Fee Schedule 130.2 Fee Schedule 97.65 130.2 ANKLE WALKER LG (SHORT) L4386 HCPCS 270 Revenue Code Both 178 133.5 142.4 Fee Schedule 142.4 Fee Schedule 80.1 Fee Schedule 106.8 Fee Schedule 80.1 106.8 ANKLE WALKER MED (SHORT) L4386 HCPCS 270 Revenue Code Both 192 144 153.6 Fee Schedule 153.6 Fee Schedule 86.4 Fee Schedule 115.2 Fee Schedule 86.4 115.2 ANKLE WALKER SIDEKICK (LG) L4386 HCPCS 274 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 ANKLE WALKER SIDEKICK (MD) L4386 HCPCS 274 Revenue Code Both 191 143.25 152.8 Fee Schedule 152.8 Fee Schedule 85.95 Fee Schedule 114.6 Fee Schedule 85.95 114.6 ANKLE WALKER SIDEKICK (SM) L4386 HCPCS 274 Revenue Code Both 98 73.5 78.4 Fee Schedule 78.4 Fee Schedule 44.1 Fee Schedule 58.8 Fee Schedule 44.1 58.8 ANKLE WALKER SIDEKICK (XL) L4386 HCPCS 270 Revenue Code Both 98 73.5 78.4 Fee Schedule 78.4 Fee Schedule 44.1 Fee Schedule 58.8 Fee Schedule 44.1 58.8 ANKLE WALKER SM (SHORT) L4386 HCPCS 274 Revenue Code Both 98 73.5 78.4 Fee Schedule 78.4 Fee Schedule 44.1 Fee Schedule 58.8 Fee Schedule 44.1 58.8 ANKLE WALKER XL (SHORT) L4386 HCPCS 274 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 ANKLE WALKER XS (SHORT) L4386 HCPCS 274 Revenue Code Both 143 107.25 114.4 Fee Schedule 114.4 Fee Schedule 64.35 Fee Schedule 85.8 Fee Schedule 64.35 85.8 ANTI-NUCLEAR AB 86038 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 ANTI-PHOSPHOLIPID ANTIBODY 86148 CPT 300 Revenue Code Both 127 95.25 101.6 Fee Schedule 101.6 Fee Schedule 57.15 Fee Schedule 76.2 Fee Schedule 57.15 76.2 ANTI-STREPTOLYSIN O 86060 CPT 300 Revenue Code Both 165 123.75 132 Fee Schedule 132 Fee Schedule 74.25 Fee Schedule 99 Fee Schedule 74.25 99 Anusol-HC Rectal Suppository 25MG J3490 HCPCS 250 Revenue Code Both Each 98 73.5 78.4 Fee Schedule 78.4 Fee Schedule 44.1 Fee Schedule 58.8 Fee Schedule 44.1 58.8 APOLIPOPROTEIN B 82172 CPT 300 Revenue Code Both 33 24.75 26.4 Fee Schedule 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 "APOLIPOPROTEIN, EACH" 82172 CPT 300 Revenue Code Both 143 107.25 114.4 Fee Schedule 114.4 Fee Schedule 64.35 Fee Schedule 85.8 Fee Schedule 64.35 85.8 APP OF LONG ARM SPLINT 29105 CPT 450 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 APP OF SHORT LEG SPLINT 29515 CPT 450 Revenue Code Both 264 198 211.2 Fee Schedule 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 APPLICATION FINGER SPLINT 29130 CPT 450 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 APPLICATION FINGER SPLINT 29130 CPT 981 Revenue Code Both 46 34.5 36.8 Fee Schedule 36.8 Fee Schedule 20.7 Fee Schedule 27.6 Fee Schedule 20.7 27.6 APPLICATION OF SHORT ARM SPLINT 29125 CPT 270 Revenue Code Both 99 74.25 79.2 Fee Schedule 79.2 Fee Schedule 44.55 Fee Schedule 59.4 Fee Schedule 44.55 59.4 APPLICATION OF SHORT ARM SPLINT 29125 CPT 981 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 APPLICATION OF SHORT LEG CAST 29405 CPT 450 Revenue Code Both 400 300 320 Fee Schedule 320 Fee Schedule 180 Fee Schedule 240 Fee Schedule 180 240 APPLICATION SHORT ARM CAST 29075 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 APPLICATION SHORT ARM CAST 29075 CPT 981 Revenue Code Both 123 92.25 98.4 Fee Schedule 98.4 Fee Schedule 55.35 Fee Schedule 73.8 Fee Schedule 55.35 73.8 APPLICATION SHORT LEG CAST 29405 CPT 981 Revenue Code Both 104 78 83.2 Fee Schedule 83.2 Fee Schedule 46.8 Fee Schedule 62.4 Fee Schedule 46.8 62.4 APPLICATION SHORT LEG WALKING CAST 29425 CPT 960 Revenue Code Both 117 87.75 93.6 Fee Schedule 93.6 Fee Schedule 52.65 Fee Schedule 70.2 Fee Schedule 52.65 70.2 APPLY MULTI-LAY COMPRESS LWR LEG 29581 CPT 761 Revenue Code Both 435 326.25 348 Fee Schedule 348 Fee Schedule 195.75 Fee Schedule 261 Fee Schedule 195.75 261 APPLY SHORT ARM SPLINT 29125 CPT 450 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 APSIRATION AND OR INJECTION LARGE JT 20610 CPT 981 Revenue Code Both 83 62.25 66.4 Fee Schedule 66.4 Fee Schedule 37.35 Fee Schedule 49.8 Fee Schedule 37.35 49.8 APTT 85730 CPT 300 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 AQUA-MEPHYTON (VIT K) 10MG/ML INJ J3430 HCPCS 636 Revenue Code Both 99 74.25 79.2 Fee Schedule 79.2 Fee Schedule 44.55 Fee Schedule 59.4 Fee Schedule 44.55 59.4 ARFORMOTEROL (BROVANA) 15MCG SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ARTERIAL BLOOD GASES 82803 CPT 300 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 ARTERIAL PUNCTURE 36600 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 ASPERGILLUS FUMIGATUS IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 ASPIRATION AND OR INJ SMALL JOINT 20600 CPT 981 Revenue Code Both 71 53.25 56.8 Fee Schedule 56.8 Fee Schedule 31.95 Fee Schedule 42.6 Fee Schedule 31.95 42.6 ASPIRATION AND OR INJECTION MEDIUM JOINT 20605 CPT 981 Revenue Code Both 71 53.25 56.8 Fee Schedule 56.8 Fee Schedule 31.95 Fee Schedule 42.6 Fee Schedule 31.95 42.6 ASPIRATION AND/OR INJ OF MED JOINT 20605 CPT 450 Revenue Code Both 427 320.25 341.6 Fee Schedule 341.6 Fee Schedule 192.15 Fee Schedule 256.2 Fee Schedule 192.15 256.2 ASPIRATION AND/OR INJ OF SMALL JOINT 20600 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 ASPIRATION AND/OR INJECTION LARGE JOINT 20610 CPT 270 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 ASPIRATION LG JOINT 20610 CPT 450 Revenue Code Both 321 240.75 256.8 Fee Schedule 256.8 Fee Schedule 144.45 Fee Schedule 192.6 Fee Schedule 144.45 192.6 ASSAY OF SWEAT SODIUM 84302 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 ASSESSMENT OF ASPHASIA 96105 CPT 444 Revenue Code Both 249 186.75 199.2 Fee Schedule 199.2 Fee Schedule 112.05 Fee Schedule 149.4 Fee Schedule 112.05 149.4 AST 84450 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 ATIVAN 2MG J2060 HCPCS 636 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 ATROPHINE 0.01 MG J0461 HCPCS 636 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 ATROPINE (ATROPEN) 0.1 MG/ML INJ J0461 HCPCS 636 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 ATROVENT INHALATION SOLUTION J7644 HCPCS 636 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 AVONEX J1826 HCPCS 636 Revenue Code Both 443 332.25 354.4 Fee Schedule 354.4 Fee Schedule 199.35 Fee Schedule 265.8 Fee Schedule 199.35 265.8 AVULSION NAIL PLATE SINGLE 11730 CPT 981 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 AVULSION OF NAIL 11730 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 AZATHIOPRINE (IMURAN) 50 MG TAB J7500 HCPCS 637 Revenue Code Both 43 32.25 34.4 Fee Schedule 34.4 Fee Schedule 19.35 Fee Schedule 25.8 Fee Schedule 19.35 25.8 AZITHROMYCIN (ZITHROMAX) 100MG/5ML SUSP J0456 HCPCS 637 Revenue Code Both 161 120.75 128.8 Fee Schedule 128.8 Fee Schedule 72.45 Fee Schedule 96.6 Fee Schedule 72.45 96.6 AZITHROMYCIN (ZITHROMAX) 200MG/5ML SUSP Q0144 HCPCS 637 Revenue Code Both 157 117.75 125.6 Fee Schedule 125.6 Fee Schedule 70.65 Fee Schedule 94.2 Fee Schedule 70.65 94.2 AZITHROMYCIN (ZITHROMAX) 250MG TAB Q0144 HCPCS 637 Revenue Code Both 44 33 35.2 Fee Schedule 35.2 Fee Schedule 19.8 Fee Schedule 26.4 Fee Schedule 19.8 26.4 AZITHROMYCIN (ZITHROMAX) 500 MG TAB Q0144 HCPCS 637 Revenue Code Both 90 67.5 72 Fee Schedule 72 Fee Schedule 40.5 Fee Schedule 54 Fee Schedule 40.5 54 AZITHROMYCIN 500MG Injectable J0456 HCPCS 636 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 AZTREONAM 1GM Injectable S0073 HCPCS 637 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 B. PERTUSSIS/B. PARAPERTUSSIS 87798 CPT 300 Revenue Code Both 852 639 681.6 Fee Schedule 681.6 Fee Schedule 383.4 Fee Schedule 511.2 Fee Schedule 383.4 511.2 BABESIA MICROTI DNA REAL-TIME PCR 87798 CPT 300 Revenue Code Both 865 648.75 692 Fee Schedule 692 Fee Schedule 389.25 Fee Schedule 519 Fee Schedule 389.25 519 BAMLANIVIMA/ETESEVIMAB700-1400MG/20-40ML M0245 HCPCS 637 Revenue Code Both 477 357.75 381.6 Fee Schedule 381.6 Fee Schedule 214.65 Fee Schedule 286.2 Fee Schedule 214.65 286.2 BARRIER NO STING SKIN PRES 3345 A6250 HCPCS 272 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 BASIC METABOLIC PANEL 80048 CPT 300 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 BB ABO 86900 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 BB ANTIBODY SCREEN 86850 CPT 390 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 BB PLATELETS 1 UNIT P9019 HCPCS 300 Revenue Code Both 1114 835.5 891.2 Fee Schedule 891.2 Fee Schedule 501.3 Fee Schedule 668.4 Fee Schedule 501.3 668.4 BB RH 86901 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 BENADRYL 50 MG J1200 HCPCS 636 Revenue Code Both 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 BENTYL DICYCLOMINE UP TO 20MG J0500 HCPCS 636 Revenue Code Both 227 170.25 181.6 Fee Schedule 181.6 Fee Schedule 102.15 Fee Schedule 136.2 Fee Schedule 102.15 136.2 BERMUDA GRASS IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 BETA-2-MICROGLOBULIN 82232 CPT 300 Revenue Code Both 69 51.75 55.2 Fee Schedule 55.2 Fee Schedule 31.05 Fee Schedule 41.4 Fee Schedule 31.05 41.4 BETAMETHASONE (CELESTONE) 6MG INJ J0702 HCPCS 636 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 BETAMETHASONE-CELESTONE UP TO 3MG/ML J0702 HCPCS 636 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 BICILLIN CR 100 000 UNITS J0558 HCPCS 636 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 BICILLIN LA 1.2MU J0561 HCPCS 636 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 BILAT-APPLY MULTI-LAY COMPRES LWR 29581 CPT 761 Revenue Code Both 688 516 550.4 Fee Schedule 550.4 Fee Schedule 309.6 Fee Schedule 412.8 Fee Schedule 309.6 412.8 BIOPSY BONE SUPERFICIAL 20220 CPT 270 Revenue Code Both 827 620.25 661.6 Fee Schedule 661.6 Fee Schedule 372.15 Fee Schedule 496.2 Fee Schedule 372.15 496.2 BIOPSY BONE SUPERFICIAL 20220 CPT 981 Revenue Code Both 277 207.75 221.6 Fee Schedule 221.6 Fee Schedule 124.65 Fee Schedule 166.2 Fee Schedule 124.65 166.2 BIOPSY NAIL UNIT ANY METHOD 11755 CPT 981 Revenue Code Both 126 94.5 100.8 Fee Schedule 100.8 Fee Schedule 56.7 Fee Schedule 75.6 Fee Schedule 56.7 75.6 BIOPSY OF BREAST 10 DAY GLOBAL 19101 CPT 981 Revenue Code Both 340 255 272 Fee Schedule 272 Fee Schedule 153 Fee Schedule 204 Fee Schedule 153 204 BIOPSY SINGLE LESION SUB/Q 11100 CPT 981 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 BIOTENE ORAL BALANCE MM GEL J3490 HCPCS 250 Revenue Code Both Each 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 BIOTIN 1000MCG TAB J3490 HCPCS 637 Revenue Code Both 22 16.5 17.6 Fee Schedule 17.6 Fee Schedule 9.9 Fee Schedule 13.2 Fee Schedule 9.9 13.2 BK VIRUS 87798 CPT 300 Revenue Code Both 834 625.5 667.2 Fee Schedule 667.2 Fee Schedule 375.3 Fee Schedule 500.4 Fee Schedule 375.3 500.4 BK VIRUS QN PCR 87799 CPT 300 Revenue Code Both 938 703.5 750.4 Fee Schedule 750.4 Fee Schedule 422.1 Fee Schedule 562.8 Fee Schedule 422.1 562.8 BLOOD COLLECTION FROM CTRL/PICC LINE 36592 CPT 450 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 BLOOD COLLECTION FROM IMPLANTED PORT 36591 CPT 450 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 BLOOD GLUCOSE REAGENT STRIP 82962 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 BLOOD SPECIMEN COLLECT CTRL/PICC LINE 36592 CPT 760 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 BLOOD SPECIMENT COLLECT FROM PORT 36591 CPT 760 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 BLOOD TRANSFUSION < 2 HOURS 36430 CPT 391 Revenue Code Both 675 506.25 540 Fee Schedule 540 Fee Schedule 303.75 Fee Schedule 405 Fee Schedule 303.75 405 BLOOD TRANSFUSION >4 HOURS 36430 CPT 320 Revenue Code Both 1574 1180.5 1259.2 Fee Schedule 1259.2 Fee Schedule 708.3 Fee Schedule 944.4 Fee Schedule 708.3 944.4 BLOOD TRANSFUSION 2-4 HOURS 36430 CPT 391 Revenue Code Both 900 675 720 Fee Schedule 720 Fee Schedule 405 Fee Schedule 540 Fee Schedule 405 540 BLOOD UREA NITROGEN 84520 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 BNP 83880 CPT 300 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 BONE MINERAL DENSITY TEST 77081 CPT 300 Revenue Code Both 101 75.75 80.8 Fee Schedule 80.8 Fee Schedule 45.45 Fee Schedule 60.6 Fee Schedule 45.45 60.6 BORRELIA SPECIES DNA PCR W/REFLEX 87801 CPT 300 Revenue Code Both 623 467.25 498.4 Fee Schedule 498.4 Fee Schedule 280.35 Fee Schedule 373.8 Fee Schedule 280.35 373.8 BRETHINE 1 MG S/Q J3105 HCPCS 636 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 BRUCELLA AB IGG IGM 86622 CPT 300 Revenue Code Both 271 203.25 216.8 Fee Schedule 216.8 Fee Schedule 121.95 Fee Schedule 162.6 Fee Schedule 121.95 162.6 BUDESONIDE (PULMICORT) 0.5MG/2ML NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 BUDESONIDE (PULMICORT) 1MG/2ML NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 BUDESONIDE(PULMICORT) 0.25MG/2ML NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 BUPRENORPHINE (BELBUCA) 450MCG FILM J3490 HCPCS 636 Revenue Code Both 1100 825 880 Fee Schedule 880 Fee Schedule 495 Fee Schedule 660 Fee Schedule 495 660 BUPRENORPHINE (BELBUCA) 600MCG FILM J3490 HCPCS 637 Revenue Code Both 1195 896.25 956 Fee Schedule 956 Fee Schedule 537.75 Fee Schedule 717 Fee Schedule 537.75 717 BUPROPION SR (WELLBUTRIN) 150MG TAB S0106 HCPCS 637 Revenue Code Both 31 23.25 24.8 Fee Schedule 24.8 Fee Schedule 13.95 Fee Schedule 18.6 Fee Schedule 13.95 18.6 BUPROPION XL (WELLBUTRIN) 150MG TAB S0106 HCPCS 637 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 BURN DRESS/DEBRID - SMALL < 5% 16020 CPT 761 Revenue Code Both 300 225 240 Fee Schedule 240 Fee Schedule 135 Fee Schedule 180 Fee Schedule 135 180 BURN TREATMENT LARGE 16030 CPT 260 Revenue Code Both 759 569.25 607.2 Fee Schedule 607.2 Fee Schedule 341.55 Fee Schedule 455.4 Fee Schedule 341.55 455.4 BURN TREATMENT MEDIUM 16025 CPT 450 Revenue Code Both 759 569.25 607.2 Fee Schedule 607.2 Fee Schedule 341.55 Fee Schedule 455.4 Fee Schedule 341.55 455.4 BURN TREATMENT SMALL 16020 CPT 450 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 BURNDRESS/DEBRID-MED 5-10% 16025 CPT 761 Revenue Code Both 464 348 371.2 Fee Schedule 371.2 Fee Schedule 208.8 Fee Schedule 278.4 Fee Schedule 208.8 278.4 BUSPIRONE (BUSPAR) 30MG TAB J3490 HCPCS 637 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 BUTORPHANOL (STADOL) 1MG/ML INJ J0595 HCPCS 636 Revenue Code Both 14 10.5 11.2 Fee Schedule 11.2 Fee Schedule 6.3 Fee Schedule 8.4 Fee Schedule 6.3 8.4 C & S THROAT 87070 CPT 300 Revenue Code Both 37 27.75 29.6 Fee Schedule 29.6 Fee Schedule 16.65 Fee Schedule 22.2 Fee Schedule 16.65 22.2 C & S WOUND/OTHER 87070 CPT 300 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 CA 125 86304 CPT 300 Revenue Code Both 120 90 96 Fee Schedule 96 Fee Schedule 54 Fee Schedule 72 Fee Schedule 54 72 CA 15-3 86300 CPT 300 Revenue Code Both 157 117.75 125.6 Fee Schedule 125.6 Fee Schedule 70.65 Fee Schedule 94.2 Fee Schedule 70.65 94.2 CA 19-9 86301 CPT 300 Revenue Code Both 130 97.5 104 Fee Schedule 104 Fee Schedule 58.5 Fee Schedule 78 Fee Schedule 58.5 78 CA 27.29 86300 CPT 300 Revenue Code Both 162 121.5 129.6 Fee Schedule 129.6 Fee Schedule 72.9 Fee Schedule 97.2 Fee Schedule 72.9 97.2 CALCITONIN 82308 CPT 300 Revenue Code Both 389 291.75 311.2 Fee Schedule 311.2 Fee Schedule 175.05 Fee Schedule 233.4 Fee Schedule 175.05 233.4 CALCITRIOL ORAL LIQ CAP 0.5MCG J0636 HCPCS 250 Revenue Code Both Each 35 26.25 28 Fee Schedule 28 Fee Schedule 15.75 Fee Schedule 21 Fee Schedule 15.75 21 CALCITROL (ROCALTROL) 0.25MCG CAP J3490 HCPCS 637 Revenue Code Both 37 27.75 29.6 Fee Schedule 29.6 Fee Schedule 16.65 Fee Schedule 22.2 Fee Schedule 16.65 22.2 CALCIUM 82310 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 CALCIUM 500/VIT D3 TAB J3490 HCPCS 637 Revenue Code Both 1 0.75 0.8 Fee Schedule 0.8 Fee Schedule 0.45 Fee Schedule 0.6 Fee Schedule 0.45 0.6 CALCIUM 500+D TAB J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 CALCIUM CL 10% 10ML INJ J0610 HCPCS 636 Revenue Code Both 49 36.75 39.2 Fee Schedule 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 CALCIUM GLUCONATE 1000MG/10ML INJ J0613 HCPCS 258 Revenue Code Both 51 38.25 40.8 Fee Schedule 40.8 Fee Schedule 22.95 Fee Schedule 30.6 Fee Schedule 22.95 30.6 CALCIUM GLUCONATE UP TO 10ML J0610 HCPCS 636 Revenue Code Both 22 16.5 17.6 Fee Schedule 17.6 Fee Schedule 9.9 Fee Schedule 13.2 Fee Schedule 9.9 13.2 CALPROTECTIN 83993 CPT 300 Revenue Code Both 297 222.75 237.6 Fee Schedule 237.6 Fee Schedule 133.65 Fee Schedule 178.2 Fee Schedule 133.65 178.2 CALRETICULIN MUTATION ANALYSIS 81219 CPT 300 Revenue Code Both 731 548.25 584.8 Fee Schedule 584.8 Fee Schedule 328.95 Fee Schedule 438.6 Fee Schedule 328.95 438.6 "CANALITH REPOSITIONING PROCEDURE,PER DAY" 95992 CPT 424 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 CARBAMAZEPINE 80156 CPT 300 Revenue Code Both 93 69.75 74.4 Fee Schedule 74.4 Fee Schedule 41.85 Fee Schedule 55.8 Fee Schedule 41.85 55.8 CARBON DIOXIDE 82374 CPT 300 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 CAREGIVER TRAINING 97550 CPT 440 Revenue Code Both 138 103.5 110.4 Fee Schedule 110.4 Fee Schedule 62.1 Fee Schedule 82.8 Fee Schedule 62.1 82.8 CAREGIVER TRAINING ADD 15 MIN 97551 CPT 440 Revenue Code Both 69 51.75 55.2 Fee Schedule 55.2 Fee Schedule 31.05 Fee Schedule 41.4 Fee Schedule 31.05 41.4 CARPOMETACARPAL FX DISLOC THUMB W\O MANI 26650 CPT 981 Revenue Code Both 992 744 793.6 Fee Schedule 793.6 Fee Schedule 446.4 Fee Schedule 595.2 Fee Schedule 446.4 595.2 CAST SHOE L3260 HCPCS 260 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 CAT DANDER IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 CATH 24FR 10CC C1758 HCPCS 270 Revenue Code Both 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 CATH STATLOCK STABILIZATION A4333 HCPCS 270 Revenue Code Both 44 33 35.2 Fee Schedule 35.2 Fee Schedule 19.8 Fee Schedule 26.4 Fee Schedule 19.8 26.4 CBC HEMOGRAM 85027 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 CBC MANUAL DIFF ONLY 85007 CPT 300 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 CBC W/AUTO DIFF 85025 CPT 300 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 CBD HEMP BALM 0.25 OZ J3490 HCPCS 250 Revenue Code Both Each 16 12 12.8 Fee Schedule 12.8 Fee Schedule 7.2 Fee Schedule 9.6 Fee Schedule 7.2 9.6 CBD HEMP BALM 2 OZ J3490 HCPCS 637 Revenue Code Both 164 123 131.2 Fee Schedule 131.2 Fee Schedule 73.8 Fee Schedule 98.4 Fee Schedule 73.8 98.4 CCP AB IGG 86200 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 CEA 82378 CPT 300 Revenue Code Both 206 154.5 164.8 Fee Schedule 164.8 Fee Schedule 92.7 Fee Schedule 123.6 Fee Schedule 92.7 123.6 CEFAZOLIN 1GM Injectable J0690 HCPCS 637 Revenue Code Both 17 12.75 13.6 Fee Schedule 13.6 Fee Schedule 7.65 Fee Schedule 10.2 Fee Schedule 7.65 10.2 CEFEPIME 1GM Injectable J0692 HCPCS 636 Revenue Code Both 31 23.25 24.8 Fee Schedule 24.8 Fee Schedule 13.95 Fee Schedule 18.6 Fee Schedule 13.95 18.6 CEFTRIAXONE (ROCEPHIN) 1GM INJ J0696 HCPCS 637 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 "CELL COUNT AND DIFF, ASCITES" 89051 CPT 300 Revenue Code Both 179 134.25 143.2 Fee Schedule 143.2 Fee Schedule 80.55 Fee Schedule 107.4 Fee Schedule 80.55 107.4 CENTRUM SILVER 1 TAB J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 CERUMEN REMOVAL INSTRUMENTATION 69210 CPT 450 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 CERUMEN REMOVAL IRRIGATION/LAVAGE 69209 CPT 450 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 CERVICAL COLLAR (ADULT) L0140 HCPCS 270 Revenue Code Both 59 44.25 47.2 Fee Schedule 47.2 Fee Schedule 26.55 Fee Schedule 35.4 Fee Schedule 26.55 35.4 CERVICAL COLLAR (PED&INF) L0140 HCPCS 270 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 CHANGE GASTROSTOMY TUBE 43760 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 CHEMO IV EACH ADDITIONAL HOUR 96415 CPT 270 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 CHLORHEXIDINE GLUC ORAL RINSE 473ML A4248 HCPCS 637 Revenue Code Both 65 48.75 52 Fee Schedule 52 Fee Schedule 29.25 Fee Schedule 39 Fee Schedule 29.25 39 CHLORIDE 82435 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 CHLORTHALIDONE (THALITONE) 50MGTAB J3490 HCPCS 637 Revenue Code Both 36 27 28.8 Fee Schedule 28.8 Fee Schedule 16.2 Fee Schedule 21.6 Fee Schedule 16.2 21.6 CHOLESTEROL 82465 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 CHROMIUM 82495 CPT 300 Revenue Code Both 273 204.75 218.4 Fee Schedule 218.4 Fee Schedule 122.85 Fee Schedule 163.8 Fee Schedule 122.85 163.8 CHROMOGRANIN A ECL 86316 CPT 300 Revenue Code Both 321 240.75 256.8 Fee Schedule 256.8 Fee Schedule 144.45 Fee Schedule 192.6 Fee Schedule 144.45 192.6 CIPROFLOXACIN (CIPRO) 400MG/200ML PREMIX J0744 HCPCS 636 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 CKMB 82553 CPT 300 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 CLADOSPORIUM HERBARUM IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 CLAVICLE STRAP (CHILD) L3650 HCPCS 270 Revenue Code Both 65 48.75 52 Fee Schedule 52 Fee Schedule 29.25 Fee Schedule 39 Fee Schedule 29.25 39 CLAVICLE STRAP (INF) L3650 HCPCS 270 Revenue Code Both 65 48.75 52 Fee Schedule 52 Fee Schedule 29.25 Fee Schedule 39 Fee Schedule 29.25 39 CLINDAMYCIN (CLEOCIN) 300MG CAP J3490 HCPCS 637 Revenue Code Both 30 22.5 24 Fee Schedule 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 CLINDAMYCIN (CLEOCIN) 300MG/2ML INJ J3490 HCPCS 637 Revenue Code Both 28 21 22.4 Fee Schedule 22.4 Fee Schedule 12.6 Fee Schedule 16.8 Fee Schedule 12.6 16.8 CLONIDINE (CATAPRES) 0.2MG TAB J0735 HCPCS 637 Revenue Code Both 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 CLOSED DISTLE PHALANGEAL FX NO MANIPUL 26750 CPT 981 Revenue Code Both 280 210 224 Fee Schedule 224 Fee Schedule 126 Fee Schedule 168 Fee Schedule 126 168 CLOSED DISTLE RADIUS FX NO MANIPULATION 25600 CPT 981 Revenue Code Both 390 292.5 312 Fee Schedule 312 Fee Schedule 175.5 Fee Schedule 234 Fee Schedule 175.5 234 CLOSED TMT FX CALCANEAL NO MANIP 28400 CPT 981 Revenue Code Both 461 345.75 368.8 Fee Schedule 368.8 Fee Schedule 207.45 Fee Schedule 276.6 Fee Schedule 207.45 276.6 CLOSED TREATMENT HUMERUS FX 24500 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 CLOSED TREATMENT OF PATELLAR DISLOCATION 27562 CPT 684 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 CLOSED TREATMENT OF PATELLAR DISLOCATION 27562 CPT 981 Revenue Code Both 499 374.25 399.2 Fee Schedule 399.2 Fee Schedule 224.55 Fee Schedule 299.4 Fee Schedule 224.55 299.4 CLOSED TRMT SHOULDER DISLOCATION W/O MAN 23650 CPT 981 Revenue Code Both 473 354.75 378.4 Fee Schedule 378.4 Fee Schedule 212.85 Fee Schedule 283.8 Fee Schedule 212.85 283.8 CLOSED TRT OF INTERPHALAN JOINT DISLOCAT 26770 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 CLOSED TX OF CLAVICULAR FX NO MANIPULATE 23500 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 CLOSURE OF SPLIT WOUND 12020 CPT 981 Revenue Code Both 275 206.25 220 Fee Schedule 220 Fee Schedule 123.75 Fee Schedule 165 Fee Schedule 123.75 165 CLSD TMT ANKLE DISLOCATION NO ANESTHESIA 27840 CPT 981 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 CLSD TREATMENT FX PROXIMAL ULNA 24670 CPT 981 Revenue Code Both 383 287.25 306.4 Fee Schedule 306.4 Fee Schedule 172.35 Fee Schedule 229.8 Fee Schedule 172.35 229.8 CLSD TREATMENT FX/DISLOC THUMB W/MANIP 26645 CPT 981 Revenue Code Both 659 494.25 527.2 Fee Schedule 527.2 Fee Schedule 296.55 Fee Schedule 395.4 Fee Schedule 296.55 395.4 CLSD TREATMENT PROX HUMERAL FX 23600 CPT 981 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 CLSD TREATMENT RADIAL HEAD OR NECK FX 24650 CPT 981 Revenue Code Both 347 260.25 277.6 Fee Schedule 277.6 Fee Schedule 156.15 Fee Schedule 208.2 Fee Schedule 156.15 208.2 CLSD TREATMENT ULNAR FX WITH MANIP 25535 CPT 981 Revenue Code Both 738 553.5 590.4 Fee Schedule 590.4 Fee Schedule 332.1 Fee Schedule 442.8 Fee Schedule 332.1 442.8 CLSD TREATMT DISTAL PHALANGEAL FX W/MAN 26755 CPT 981 Revenue Code Both 432 324 345.6 Fee Schedule 345.6 Fee Schedule 194.4 Fee Schedule 259.2 Fee Schedule 194.4 259.2 CLSD TREAT'T MEDIAL MALLEOLUS FX W/O MAN 27760 CPT 981 Revenue Code Both 465 348.75 372 Fee Schedule 372 Fee Schedule 209.25 Fee Schedule 279 Fee Schedule 209.25 279 CLSD TREAT'T UNLNAR&RADIAL SHAFT FX WO/M 25560 CPT 981 Revenue Code Both 361 270.75 288.8 Fee Schedule 288.8 Fee Schedule 162.45 Fee Schedule 216.6 Fee Schedule 162.45 216.6 CLSD TRMT INTERPHALANGEAL W/MANIPULATION 26770 CPT 981 Revenue Code Both 367 275.25 293.6 Fee Schedule 293.6 Fee Schedule 165.15 Fee Schedule 220.2 Fee Schedule 165.15 220.2 CLSD TRMT METACARPOPHALANGEAL DIS LOC 26700 CPT 981 Revenue Code Both 451 338.25 360.8 Fee Schedule 360.8 Fee Schedule 202.95 Fee Schedule 270.6 Fee Schedule 202.95 270.6 CLSD TRMT OF FX FINGER NO MAN 26750 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 CLSD TRTMT ANKLE FX W/O MANIPULATION 27816 CPT 981 Revenue Code Both 499 374.25 399.2 Fee Schedule 399.2 Fee Schedule 224.55 Fee Schedule 299.4 Fee Schedule 224.55 299.4 CLSD TRTMT DISLOC SHLDR W/MAN & ANESTHES 23655 CPT 981 Revenue Code Both 610 457.5 488 Fee Schedule 488 Fee Schedule 274.5 Fee Schedule 366 Fee Schedule 274.5 366 CLSD TRTMT DISLOCATED ELBOW 24600 CPT 981 Revenue Code Both 631 473.25 504.8 Fee Schedule 504.8 Fee Schedule 283.95 Fee Schedule 378.6 Fee Schedule 283.95 378.6 CLSD TRTMT DISLOCATION THUMB W/MANIP 26641 CPT 981 Revenue Code Both 524 393 419.2 Fee Schedule 419.2 Fee Schedule 235.8 Fee Schedule 314.4 Fee Schedule 235.8 314.4 CLSD TRTMT RADIAL HEAD SUBLIXATION 24640 CPT 460 Revenue Code Both 507 380.25 405.6 Fee Schedule 405.6 Fee Schedule 228.15 Fee Schedule 304.2 Fee Schedule 228.15 304.2 CLSD TRTMT RADIAL HEAD W/MANIPULATION 24640 CPT 981 Revenue Code Both 208 156 166.4 Fee Schedule 166.4 Fee Schedule 93.6 Fee Schedule 124.8 Fee Schedule 93.6 124.8 CLSD TRTMT TALUS FX NO MANIP 28430 CPT 981 Revenue Code Both 423 317.25 338.4 Fee Schedule 338.4 Fee Schedule 190.35 Fee Schedule 253.8 Fee Schedule 190.35 253.8 CLSD TX DISTAL RADIUS FX N/MANIP 25600 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 CMV AB IGG IGM 86644 CPT 300 Revenue Code Both 339 254.25 271.2 Fee Schedule 271.2 Fee Schedule 152.55 Fee Schedule 203.4 Fee Schedule 152.55 203.4 CMV DNA QN PCR 87497 CPT 300 Revenue Code Both 858 643.5 686.4 Fee Schedule 686.4 Fee Schedule 386.1 Fee Schedule 514.8 Fee Schedule 386.1 514.8 COBALT 83018 CPT 300 Revenue Code Both 246 184.5 196.8 Fee Schedule 196.8 Fee Schedule 110.7 Fee Schedule 147.6 Fee Schedule 110.7 147.6 COMMON RAGWEED IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 COMPAZINE INJ 10MG J0780 HCPCS 636 Revenue Code Both 30 22.5 24 Fee Schedule 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 COMPLEMENT COMPONENT C4 86160 CPT 300 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 COMPLEX DRAINAGE WOUND-10 DAY GLOBAL 10180 CPT 981 Revenue Code Both 246 184.5 196.8 Fee Schedule 196.8 Fee Schedule 110.7 Fee Schedule 147.6 Fee Schedule 110.7 147.6 COMPLEX REPAIR 1.1 TO 2.5 CM 13131 CPT 981 Revenue Code Both 407 305.25 325.6 Fee Schedule 325.6 Fee Schedule 183.15 Fee Schedule 244.2 Fee Schedule 183.15 244.2 COMPLEX REPAIR 2.6 TO 7.5 CM 13121 CPT 981 Revenue Code Both 457 342.75 365.6 Fee Schedule 365.6 Fee Schedule 205.65 Fee Schedule 274.2 Fee Schedule 205.65 274.2 COMPLEX REPAIR/ADD-ON FOR EACH 5CM WOUND 13122 CPT 981 Revenue Code Both 101 75.75 80.8 Fee Schedule 80.8 Fee Schedule 45.45 Fee Schedule 60.6 Fee Schedule 45.45 60.6 COMPREHENSIVE METABOLIC PANEL 80053 CPT 300 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 CONGNITIVE PERFORMANCE TEST 96125 CPT 440 Revenue Code Both 265 198.75 212 Fee Schedule 212 Fee Schedule 119.25 Fee Schedule 159 Fee Schedule 119.25 159 CONSCIOUS SEDATION EA ADD'L 15 MIN 99145 CPT 450 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 CONSCIOUS SEDATION FIRST 30 MINUTES 99144 CPT 450 Revenue Code Both 675 506.25 540 Fee Schedule 540 Fee Schedule 303.75 Fee Schedule 405 Fee Schedule 303.75 405 COPEPTIN 86255 CPT 300 Revenue Code Both 159 119.25 127.2 Fee Schedule 127.2 Fee Schedule 71.55 Fee Schedule 95.4 Fee Schedule 71.55 95.4 COPPER 82525 CPT 300 Revenue Code Both 42 31.5 33.6 Fee Schedule 33.6 Fee Schedule 18.9 Fee Schedule 25.2 Fee Schedule 18.9 25.2 Coreg CR Oral Capsule ER 40MG J3490 HCPCS 250 Revenue Code Both Each 60 45 48 Fee Schedule 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 CORTISOL TOTAL 82533 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 C-PEPTIDE 84681 CPT 300 Revenue Code Both 232 174 185.6 Fee Schedule 185.6 Fee Schedule 104.4 Fee Schedule 139.2 Fee Schedule 104.4 139.2 CPR 92950 CPT 300 Revenue Code Both 507 380.25 405.6 Fee Schedule 405.6 Fee Schedule 228.15 Fee Schedule 304.2 Fee Schedule 228.15 304.2 CPR 92950 CPT 760 Revenue Code Both 507 380.25 405.6 Fee Schedule 405.6 Fee Schedule 228.15 Fee Schedule 304.2 Fee Schedule 228.15 304.2 CREATINE CLEARANCE 82575 CPT 300 Revenue Code Both 193 144.75 154.4 Fee Schedule 154.4 Fee Schedule 86.85 Fee Schedule 115.8 Fee Schedule 86.85 115.8 CREATINE KINASE 82550 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 CREATININE W/EGFR 82565 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 CRITICAL CARE 30-74 MINUTES 99291 CPT 450 Revenue Code Both 2025 1518.75 1620 Fee Schedule 1620 Fee Schedule 911.25 Fee Schedule 1215 Fee Schedule 911.25 1215 CRITICAL CARE 30-74 MINUTES 99291 CPT 760 Revenue Code Both 2025 1518.75 1620 Fee Schedule 1620 Fee Schedule 911.25 Fee Schedule 1215 Fee Schedule 911.25 1215 CRITICAL CARE 30-74 MINUTES 99291 CPT 981 Revenue Code Both 504 378 403.2 Fee Schedule 403.2 Fee Schedule 226.8 Fee Schedule 302.4 Fee Schedule 226.8 302.4 CRITICAL CARE EA ADD'L 30 MINUTES 99292 CPT 450 Revenue Code Both 1653 1239.75 1322.4 Fee Schedule 1322.4 Fee Schedule 743.85 Fee Schedule 991.8 Fee Schedule 743.85 991.8 CRITICAL CARE EA ADD'L 30 MINUTES 99292 CPT 760 Revenue Code Both 1653 1239.75 1322.4 Fee Schedule 1322.4 Fee Schedule 743.85 Fee Schedule 991.8 Fee Schedule 743.85 991.8 CRITICAL CARE EACH ADDITIONAL 30 MINUTES 99292 CPT 960 Revenue Code Both 239 179.25 191.2 Fee Schedule 191.2 Fee Schedule 107.55 Fee Schedule 143.4 Fee Schedule 107.55 143.4 CROSSMATCH ANTIGLOBULIN 86922 CPT 300 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 CROSSMATCH IMMED SPIN 86920 CPT 300 Revenue Code Both 152 114 121.6 Fee Schedule 121.6 Fee Schedule 68.4 Fee Schedule 91.2 Fee Schedule 68.4 91.2 CROSSMATCH INCUBATION 86921 CPT 300 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 CROTALIDAE POLYVALENT (CROFAB) INJ J0840 HCPCS 636 Revenue Code Both 4271 3203.25 3416.8 Fee Schedule 3416.8 Fee Schedule 1921.95 Fee Schedule 2562.6 Fee Schedule 1921.95 2562.6 CRP 86141 CPT 300 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 CRYPTOSPORIDIUM AG EIA 87328 CPT 300 Revenue Code Both 149 111.75 119.2 Fee Schedule 119.2 Fee Schedule 67.05 Fee Schedule 89.4 Fee Schedule 67.05 89.4 CRYSTALS SYNOVIAL FLUID 89060 CPT 300 Revenue Code Both 229 171.75 183.2 Fee Schedule 183.2 Fee Schedule 103.05 Fee Schedule 137.4 Fee Schedule 103.05 137.4 CT ABDOMEN 74150 CPT 350 Revenue Code Both 1569 1176.75 1255.2 Fee Schedule 1255.2 Fee Schedule 706.05 Fee Schedule 941.4 Fee Schedule 706.05 941.4 CT ABDOMEN W/ IV CONTRAST 74160 CPT 350 Revenue Code Both 2025 1518.75 1620 Fee Schedule 1620 Fee Schedule 911.25 Fee Schedule 1215 Fee Schedule 911.25 1215 CT ABDOMEN W/WO CONTRAST 74170 CPT 350 Revenue Code Both 2278 1708.5 1822.4 Fee Schedule 1822.4 Fee Schedule 1025.1 Fee Schedule 1366.8 Fee Schedule 1025.1 1366.8 CT ABDOMEN/PELVIS 74176 CPT 350 Revenue Code Both 2396 1797 1916.8 Fee Schedule 1916.8 Fee Schedule 1078.2 Fee Schedule 1437.6 Fee Schedule 1078.2 1437.6 CT ABDOMEN/PELVIS W/ IV CONTRAST 74177 CPT 350 Revenue Code Both 3042 2281.5 2433.6 Fee Schedule 2433.6 Fee Schedule 1368.9 Fee Schedule 1825.2 Fee Schedule 1368.9 1825.2 CT ABDOMEN/PELVIS W/ ORAL AND IV CONTRAS 74177 CPT 350 Revenue Code Both 3042 2281.5 2433.6 Fee Schedule 2433.6 Fee Schedule 1368.9 Fee Schedule 1825.2 Fee Schedule 1368.9 1825.2 CT ABDOMEN/PELVIS W/ ORAL IV CONTRAST 74177 CPT 350 Revenue Code Both 3042 2281.5 2433.6 Fee Schedule 2433.6 Fee Schedule 1368.9 Fee Schedule 1825.2 Fee Schedule 1368.9 1825.2 CT ABDOMEN/PELVIS W/WO CONTRAST 74178 CPT 350 Revenue Code Both 3515 2636.25 2812 Fee Schedule 2812 Fee Schedule 1581.75 Fee Schedule 2109 Fee Schedule 1581.75 2109 CT ANKLE LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT ANKLE RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT ANKLE W/ IV CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT ANKLE W/ IV CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT ANKLE W/WO CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT ANKLE W/WO CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT CHEST 71250 CPT 350 Revenue Code Both 1726 1294.5 1380.8 Fee Schedule 1380.8 Fee Schedule 776.7 Fee Schedule 1035.6 Fee Schedule 776.7 1035.6 CT CHEST HIGH RESOLUTION 71250 CPT 350 Revenue Code Both 1726 1294.5 1380.8 Fee Schedule 1380.8 Fee Schedule 776.7 Fee Schedule 1035.6 Fee Schedule 776.7 1035.6 CT CHEST LOW DOSE 71271 CPT 350 Revenue Code Both 1461 1095.75 1168.8 Fee Schedule 1168.8 Fee Schedule 657.45 Fee Schedule 876.6 Fee Schedule 657.45 876.6 CT CHEST W/ & W/O CONTRAST 71270 CPT 350 Revenue Code Both 2148 1611 1718.4 Fee Schedule 1718.4 Fee Schedule 966.6 Fee Schedule 1288.8 Fee Schedule 966.6 1288.8 CT CHEST W/ CONTRAST 71260 CPT 350 Revenue Code Both 2137 1602.75 1709.6 Fee Schedule 1709.6 Fee Schedule 961.65 Fee Schedule 1282.2 Fee Schedule 961.65 1282.2 CT C-SPINE 72125 CPT 350 Revenue Code Both 2018 1513.5 1614.4 Fee Schedule 1614.4 Fee Schedule 908.1 Fee Schedule 1210.8 Fee Schedule 908.1 1210.8 CT C-SPINE W/ CONTRAST 72126 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT C-SPINE W/WO CONTRAST 70498 CPT 350 Revenue Code Both 1867 1400.25 1493.6 Fee Schedule 1493.6 Fee Schedule 840.15 Fee Schedule 1120.2 Fee Schedule 840.15 1120.2 CT ELBOW LEFT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT ELBOW RIGHT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT ELBOW W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT ELBOW W/ & W/O CONTRAST RIGHT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT ELBOW W/ IV CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT ELBOW W/ IV CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT FACIAL W/ CONTRAST 70487 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT FACIAL W/O CONTRAST 70486 CPT 350 Revenue Code Both 1613 1209.75 1290.4 Fee Schedule 1290.4 Fee Schedule 725.85 Fee Schedule 967.8 Fee Schedule 725.85 967.8 CT FACIAL W/WO CONTRAST 70488 CPT 350 Revenue Code Both 1226 919.5 980.8 Fee Schedule 980.8 Fee Schedule 551.7 Fee Schedule 735.6 Fee Schedule 551.7 735.6 CT FEMUR LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT FEMUR RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT FEMUR W/ & W/O CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT FEMUR W/ & W/O CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT FEMUR W/ CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FEMUR W/ CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FOOT LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT FOOT RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT FOOT W/ & W/O CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT FOOT W/ & W/O CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT FOOT W/ IV CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FOOT W/ IV CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FOREARM LEFT 73200 CPT 350 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 CT FOREARM RIGHT 73200 CPT 350 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 CT FOREARM W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FOREARM W/ & W/O CONTRAST RIGHT 73202 CPT 730 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT FOREARM W/ IV CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT FOREARM W/ IV CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT HAND LEFT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT HAND RIGHT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT HAND W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HAND W/ & W/O CONTRAST RIGHT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HAND W/ IV CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT HAND W/ IV CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT HEAD 70450 CPT 350 Revenue Code Both 1637 1227.75 1309.6 Fee Schedule 1309.6 Fee Schedule 736.65 Fee Schedule 982.2 Fee Schedule 736.65 982.2 CT HEAD W/ CONTRAST 70460 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT HEAD W/WO CONTRAST 70470 CPT 350 Revenue Code Both 2165 1623.75 1732 Fee Schedule 1732 Fee Schedule 974.25 Fee Schedule 1299 Fee Schedule 974.25 1299 CT HEART 75571 CPT 350 Revenue Code Both 641 480.75 512.8 Fee Schedule 512.8 Fee Schedule 288.45 Fee Schedule 384.6 Fee Schedule 288.45 384.6 CT HEART SPECIAL 75571 CPT 350 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 CT HIP LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT HIP RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT HIP W/ & W/O CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT HIP W/ & W/O CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT HIP W/ IV CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HIP W/ IV CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HUMERUS LEFT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT HUMERUS RIGHT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT HUMERUS W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HUMERUS W/ & W/O CONTRAST RIGHT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT HUMERUS W/ CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT HUMERUS W/ CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT KNEE LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT KNEE RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT KNEE W/ & W/O CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT KNEE W/ & W/O CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT KNEE W/ IV CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT KNEE W/ IV CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT L-SPINE 72131 CPT 350 Revenue Code Both 2098 1573.5 1678.4 Fee Schedule 1678.4 Fee Schedule 944.1 Fee Schedule 1258.8 Fee Schedule 944.1 1258.8 CT L-SPINE W/ & W/O CONTRAST 72133 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT L-SPINE W/ CONTRAST 72132 CPT 350 Revenue Code Both 2644 1983 2115.2 Fee Schedule 2115.2 Fee Schedule 1189.8 Fee Schedule 1586.4 Fee Schedule 1189.8 1586.4 CT PELVIS 72192 CPT 350 Revenue Code Both 1433 1074.75 1146.4 Fee Schedule 1146.4 Fee Schedule 644.85 Fee Schedule 859.8 Fee Schedule 644.85 859.8 CT PELVIS W/ & W/O CONTRAST 72194 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT PELVIS W/ CONTRAST 72193 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT SHOULDER LEFT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT SHOULDER RIGHT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT SHOULDER W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT SHOULDER W/ & W/O CONTRAST RIGHT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT SHOULDER W/ IV CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT SHOULDER W/ IV CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT SINUS 70486 CPT 350 Revenue Code Both 1613 1209.75 1290.4 Fee Schedule 1290.4 Fee Schedule 725.85 Fee Schedule 967.8 Fee Schedule 725.85 967.8 CT SINUS W/ & W/O CONTRAST 70488 CPT 350 Revenue Code Both 1226 919.5 980.8 Fee Schedule 980.8 Fee Schedule 551.7 Fee Schedule 735.6 Fee Schedule 551.7 735.6 CT SINUS W/ CONTRAST 70487 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT SOFT TISSUE NECK 70490 CPT 350 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 CT SOFT TISSUE NECK W/ & W/O CONTRAST 70492 CPT 350 Revenue Code Both 1417 1062.75 1133.6 Fee Schedule 1133.6 Fee Schedule 637.65 Fee Schedule 850.2 Fee Schedule 637.65 850.2 CT SOFT TISSUE NECK W/ CONTRAST 70491 CPT 350 Revenue Code Both 1968 1476 1574.4 Fee Schedule 1574.4 Fee Schedule 885.6 Fee Schedule 1180.8 Fee Schedule 885.6 1180.8 CT TEMPORAL BONE BILATERAL 70486 CPT 350 Revenue Code Both 1613 1209.75 1290.4 Fee Schedule 1290.4 Fee Schedule 725.85 Fee Schedule 967.8 Fee Schedule 725.85 967.8 CT TIB/FIB LEFT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT TIB/FIB RIGHT 73700 CPT 350 Revenue Code Both 1625 1218.75 1300 Fee Schedule 1300 Fee Schedule 731.25 Fee Schedule 975 Fee Schedule 731.25 975 CT TIB/FIB W/ & W/O CONTRAST LEFT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT TIB/FIB W/ & W/O CONTRAST RIGHT 73702 CPT 350 Revenue Code Both 1324 993 1059.2 Fee Schedule 1059.2 Fee Schedule 595.8 Fee Schedule 794.4 Fee Schedule 595.8 794.4 CT TIB/FIB WITH IV CONTRAST LEFT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT TIB/FIB WITH IV CONTRAST RIGHT 73701 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT T-SPINE 72128 CPT 350 Revenue Code Both 1545 1158.75 1236 Fee Schedule 1236 Fee Schedule 695.25 Fee Schedule 927 Fee Schedule 695.25 927 CT T-SPINE W/ & W/O CONTRAST 72130 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT T-SPINE W/ CONTRAST 72129 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT WRIST LEFT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT WRIST RIGHT 73200 CPT 350 Revenue Code Both 1676 1257 1340.8 Fee Schedule 1340.8 Fee Schedule 754.2 Fee Schedule 1005.6 Fee Schedule 754.2 1005.6 CT WRIST W/ & W/O CONTRAST LEFT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT WRIST W/ & W/O CONTRAST RIGHT 73202 CPT 350 Revenue Code Both 1231 923.25 984.8 Fee Schedule 984.8 Fee Schedule 553.95 Fee Schedule 738.6 Fee Schedule 553.95 738.6 CT WRIST WITH IV CONTRAST LEFT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CT WRIST WITH IV CONTRAST RIGHT 73201 CPT 350 Revenue Code Both 1072 804 857.6 Fee Schedule 857.6 Fee Schedule 482.4 Fee Schedule 643.2 Fee Schedule 482.4 643.2 CTA ABDOMEN 74175 CPT 350 Revenue Code Both 1928 1446 1542.4 Fee Schedule 1542.4 Fee Schedule 867.6 Fee Schedule 1156.8 Fee Schedule 867.6 1156.8 CTA CAROTIDS 70498 CPT 350 Revenue Code Both 1867 1400.25 1493.6 Fee Schedule 1493.6 Fee Schedule 840.15 Fee Schedule 1120.2 Fee Schedule 840.15 1120.2 CTA CHEST 71275 CPT 350 Revenue Code Both 1912 1434 1529.6 Fee Schedule 1529.6 Fee Schedule 860.4 Fee Schedule 1147.2 Fee Schedule 860.4 1147.2 CTA FEMORAL RUN-OFF 73706 CPT 350 Revenue Code Both 2265 1698.75 1812 Fee Schedule 1812 Fee Schedule 1019.25 Fee Schedule 1359 Fee Schedule 1019.25 1359 CTA HEAD 70496 CPT 350 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 CULTURE AEROBIC 87070 CPT 300 Revenue Code Both 191 143.25 152.8 Fee Schedule 152.8 Fee Schedule 85.95 Fee Schedule 114.6 Fee Schedule 85.95 114.6 CULTURE BLOOD 1 87040 CPT 300 Revenue Code Both 162 121.5 129.6 Fee Schedule 129.6 Fee Schedule 72.9 Fee Schedule 97.2 Fee Schedule 72.9 97.2 CULTURE BLOOD 2 87040 CPT 300 Revenue Code Both 162 121.5 129.6 Fee Schedule 129.6 Fee Schedule 72.9 Fee Schedule 97.2 Fee Schedule 72.9 97.2 CULTURE BODY 87075 CPT 300 Revenue Code Both 95 71.25 76 Fee Schedule 76 Fee Schedule 42.75 Fee Schedule 57 Fee Schedule 42.75 57 CULTURE ESCHERICHIA COLI 0157 87046 CPT 300 Revenue Code Both 194 145.5 155.2 Fee Schedule 155.2 Fee Schedule 87.3 Fee Schedule 116.4 Fee Schedule 87.3 116.4 CULTURE FUNGUS W/ KOH 87106 CPT 300 Revenue Code Both 213 159.75 170.4 Fee Schedule 170.4 Fee Schedule 95.85 Fee Schedule 127.8 Fee Schedule 95.85 127.8 CULTURE HSV 87255 CPT 300 Revenue Code Both 246 184.5 196.8 Fee Schedule 196.8 Fee Schedule 110.7 Fee Schedule 147.6 Fee Schedule 110.7 147.6 CULTURE MRSA 87641 CPT 300 Revenue Code Both 371 278.25 296.8 Fee Schedule 296.8 Fee Schedule 166.95 Fee Schedule 222.6 Fee Schedule 166.95 222.6 CULTURE RSV 87254 CPT 300 Revenue Code Both 198 148.5 158.4 Fee Schedule 158.4 Fee Schedule 89.1 Fee Schedule 118.8 Fee Schedule 89.1 118.8 CULTURE SPUTUM 87070 CPT 300 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 CULTURE STOOL 87045 CPT 300 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 CULTURE THROAT 87070 CPT 300 Revenue Code Both 191 143.25 152.8 Fee Schedule 152.8 Fee Schedule 85.95 Fee Schedule 114.6 Fee Schedule 85.95 114.6 CULTURE URINE 87086 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 CULTURE VIRAL 87252 CPT 300 Revenue Code Both 477 357.75 381.6 Fee Schedule 381.6 Fee Schedule 214.65 Fee Schedule 286.2 Fee Schedule 214.65 286.2 CYANOCOBALAMIN (VIT B-12) 1000MCG INJ J3420 HCPCS 250 Revenue Code Both Each 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 CYCLOSPORINE (GENGRAF) 50MG CAP J7515 HCPCS 637 Revenue Code Both 46 34.5 36.8 Fee Schedule 36.8 Fee Schedule 20.7 Fee Schedule 27.6 Fee Schedule 20.7 27.6 CYSTATIN C 82610 CPT 300 Revenue Code Both 284 213 227.2 Fee Schedule 227.2 Fee Schedule 127.8 Fee Schedule 170.4 Fee Schedule 127.8 170.4 CYSTOTOMY W/INSER URI CATHETER 51045 CPT 981 Revenue Code Both 850 637.5 680 Fee Schedule 680 Fee Schedule 382.5 Fee Schedule 510 Fee Schedule 382.5 510 D25 (DEXTROSE 25%) 2.5G/10ML IVP J7042 HCPCS 637 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 DAPTOMYCIN 500MG Injectable J0878 HCPCS 637 Revenue Code Both 300 225 240 Fee Schedule 240 Fee Schedule 135 Fee Schedule 180 Fee Schedule 135 180 D-DIMER QUANT 85378 CPT 300 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 DEBRIDEMENT OF SKIN INFECTED 11000 CPT 981 Revenue Code Both 60 45 48 Fee Schedule 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 DEBRIDEMENT SKIN/SUBCUTANEOUS TISSUE 11042 CPT 981 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 DEBRIDEMENT SUBCU TISS 20 SQ CM OR < 11042 CPT 450 Revenue Code Both 708 531 566.4 Fee Schedule 566.4 Fee Schedule 318.6 Fee Schedule 424.8 Fee Schedule 318.6 424.8 DECA DURABOLIN UP TO 50 MG J2320 HCPCS 636 Revenue Code Both 189 141.75 151.2 Fee Schedule 151.2 Fee Schedule 85.05 Fee Schedule 113.4 Fee Schedule 85.05 113.4 DECADRON 1MG J1100 HCPCS 636 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 DECLOT VAD OR CATH BY THROMBO AGENT 36593 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 DEFEROXAMINE MESYLATE(DESFERAL)500MG INJ J0895 HCPCS 637 Revenue Code Both 55 41.25 44 Fee Schedule 44 Fee Schedule 24.75 Fee Schedule 33 Fee Schedule 24.75 33 DELESTRGEN 10 MG J1380 HCPCS 250 Revenue Code Both Each 42 31.5 33.6 Fee Schedule 33.6 Fee Schedule 18.9 Fee Schedule 25.2 Fee Schedule 18.9 25.2 DELESTROGEN UP TO 10MG J1380 HCPCS 270 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 DEMEROL PER 100MG J2175 HCPCS 636 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 DEPO MEDROL 20MG J1020 HCPCS 636 Revenue Code Both 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 DEPO MEDROL 40MG J1030 HCPCS 636 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 DEPO MEDROL 80MG J1040 HCPCS 636 Revenue Code Both 61 45.75 48.8 Fee Schedule 48.8 Fee Schedule 27.45 Fee Schedule 36.6 Fee Schedule 27.45 36.6 DEPO PROVERA 1 MG J1050 HCPCS 636 Revenue Code Both 1 0.75 0.8 Fee Schedule 0.8 Fee Schedule 0.45 Fee Schedule 0.6 Fee Schedule 0.45 0.6 DEPOESTRADIAL CYPIONATE 5MG J1000 HCPCS 636 Revenue Code Both 82 61.5 65.6 Fee Schedule 65.6 Fee Schedule 36.9 Fee Schedule 49.2 Fee Schedule 36.9 49.2 DERMAL WOUND CLEANSER A6260 HCPCS 270 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 DERMATOPHAGOIDES FARINAE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 DERMATOPHAGOIDES PTERONYSSINUS 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 DESTRUCTION B9/PREMALIG LESION ADDITION 17003 CPT 761 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 DESTRUCTION B9/PREMALIG LESION FIRST 17000 CPT 761 Revenue Code Both 212 159 169.6 Fee Schedule 169.6 Fee Schedule 95.4 Fee Schedule 127.2 Fee Schedule 95.4 127.2 DESTRUCTION BENIGN LESION FACE 17000 CPT 981 Revenue Code Both 60 45 48 Fee Schedule 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 DESTRUCTION VAGINAL LESION ANY METHOD 57061 CPT 981 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 DESTURCTION WARTS ANY METHOD UP TO 15 17110 CPT 981 Revenue Code Both 64 48 51.2 Fee Schedule 51.2 Fee Schedule 28.8 Fee Schedule 38.4 Fee Schedule 28.8 38.4 DETEMIR (LEVEMIR) 10ML INS J1815 HCPCS 637 Revenue Code Both 769 576.75 615.2 Fee Schedule 615.2 Fee Schedule 346.05 Fee Schedule 461.4 Fee Schedule 346.05 461.4 DEX 5%/0.9% SOD CHLOR(D5 NACL) 1000ML IV J7042 HCPCS 330 Revenue Code Both 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 DEXA BONE DENSITY SCAN 77078 CPT 350 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 DEXAMETHASONE (DECADRON) 10MG SOL J1100 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 DEXAMETHASONE (DECADRON) 4MG INJ J1100 HCPCS 260 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 DEXAMETHASONE (DECADRON) 4MG TAB J8540 HCPCS 637 Revenue Code Both 38 28.5 30.4 Fee Schedule 30.4 Fee Schedule 17.1 Fee Schedule 22.8 Fee Schedule 17.1 22.8 DEXAMETHASONE (DECADRON) 6MG TAB J8540 HCPCS 637 Revenue Code Both 35 26.25 28 Fee Schedule 28 Fee Schedule 15.75 Fee Schedule 21 Fee Schedule 15.75 21 DEXTROSE 5% (D5W) 1000ML IV J7060 HCPCS 250 Revenue Code Both Each 14 10.5 11.2 Fee Schedule 11.2 Fee Schedule 6.3 Fee Schedule 8.4 Fee Schedule 6.3 8.4 DEXTROSE 5%/0.45%(D5 1/2 NACL)1000 ML IV J7042 HCPCS 250 Revenue Code Both Each 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 DHE-45 PER 1MG J1110 HCPCS 636 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 DHEA UNCONJUGATED 82626 CPT 300 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 DIAZEPAM (VALIUM) 10MG/2 ML INJ J3360 HCPCS 771 Revenue Code Both 62 46.5 49.6 Fee Schedule 49.6 Fee Schedule 27.9 Fee Schedule 37.2 Fee Schedule 27.9 37.2 DIAZEPAM INJ UP TO 5MG J3360 HCPCS 636 Revenue Code Both 61 45.75 48.8 Fee Schedule 48.8 Fee Schedule 27.45 Fee Schedule 36.6 Fee Schedule 27.45 36.6 DICYCLOMINE (BENTYL) 10MG/ML 2ML VIAL J0500 HCPCS 636 Revenue Code Both 39.5 29.625 31.6 Fee Schedule 31.6 Fee Schedule 17.775 Fee Schedule 23.7 Fee Schedule 17.775 23.7 DIGOXIN 80162 CPT 300 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 DIGOXIN IMMUNE FAB (DIGIFAB) 40MG INJ J1162 HCPCS 637 Revenue Code Both 6058.5 4543.875 4846.8 Fee Schedule 4846.8 Fee Schedule 2726.325 Fee Schedule 3635.1 Fee Schedule 2726.325 3635.1 DILANTIN 80185 CPT 300 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 DIMENHYDRINATE (DRAMAMINE) 50MG/ML INJ J1240 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 DIMERCAPROL (BAL IN OIL) 100MG INJ J0470 HCPCS 637 Revenue Code Both 313 234.75 250.4 Fee Schedule 250.4 Fee Schedule 140.85 Fee Schedule 187.8 Fee Schedule 140.85 187.8 DIPHENHYDRAMINE (BENADRYL) 50MG/ML INJ J1200 HCPCS 637 Revenue Code Both 22.25 16.6875 17.8 Fee Schedule 17.8 Fee Schedule 10.0125 Fee Schedule 13.35 Fee Schedule 10.0125 13.35 DIRECT ADMIT FOR HOSPITAL OBSERVATION G0379 HCPCS 760 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 DIRECT ANTIGLOBULIN TEST 86880 CPT 300 Revenue Code Both 42 31.5 33.6 Fee Schedule 33.6 Fee Schedule 18.9 Fee Schedule 25.2 Fee Schedule 18.9 25.2 Divalproex Sodium Tab ER 500MG J3490 HCPCS 250 Revenue Code Both Each 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 DNA (DS) AB 86225 CPT 300 Revenue Code Both 249 186.75 199.2 Fee Schedule 199.2 Fee Schedule 112.05 Fee Schedule 149.4 Fee Schedule 112.05 149.4 DNASE B AB 86215 CPT 300 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 DOG DANDER IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 DOPAMINE/D5W 800MG/250 ML PREMIX J1265 HCPCS 637 Revenue Code Both 83 62.25 66.4 Fee Schedule 66.4 Fee Schedule 37.35 Fee Schedule 49.8 Fee Schedule 37.35 49.8 DRAINAGE OF ABCESS WITH US GUIDANCE 20611 CPT 761 Revenue Code Both 607 455.25 485.6 Fee Schedule 485.6 Fee Schedule 273.15 Fee Schedule 364.2 Fee Schedule 273.15 364.2 DRAMAMINE UP TO 50MG J1240 HCPCS 636 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 DRESSING 4 X 4 MEPILEX A6212 HCPCS 272 Revenue Code Both 83 62.25 66.4 Fee Schedule 66.4 Fee Schedule 37.35 Fee Schedule 49.8 Fee Schedule 37.35 49.8 DRESSING AND DEBRIDEMENT BURN SMALL 16020 CPT 450 Revenue Code Both 135 101.25 108 Fee Schedule 108 Fee Schedule 60.75 Fee Schedule 81 Fee Schedule 60.75 81 DRESSING AND DEBRIDEMENT BURN SMALL 16020 CPT 981 Revenue Code Both 73 54.75 58.4 Fee Schedule 58.4 Fee Schedule 32.85 Fee Schedule 43.8 Fee Schedule 32.85 43.8 DRESSING AQUACEL AG 4 X 4 403708 A6196 HCPCS 272 Revenue Code Both 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 DRESSING AQUACEL AG RIBBON 403712 A6199 HCPCS 271 Revenue Code Both 66 49.5 52.8 Fee Schedule 52.8 Fee Schedule 29.7 Fee Schedule 39.6 Fee Schedule 29.7 39.6 DRESSING MEPILEX AG 8' X 20' A6211 HCPCS 271 Revenue Code Both 320 240 256 Fee Schedule 256 Fee Schedule 144 Fee Schedule 192 Fee Schedule 144 192 DRESSING MEPILEX LITE 4 X 4 A6209 HCPCS 272 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 DRESSING TELFA 3 X 4 STERILE A6402 HCPCS 271 Revenue Code Both 5 3.75 4 Fee Schedule 4 Fee Schedule 2.25 Fee Schedule 3 Fee Schedule 2.25 3 DRESSING VASELINE GAUZE 1/2 X 72 A6223 HCPCS 272 Revenue Code Both 4 3 3.2 Fee Schedule 3.2 Fee Schedule 1.8 Fee Schedule 2.4 Fee Schedule 1.8 2.4 DRESSINGS DEBRIDEMENT BURN NO ANES 16025 CPT 981 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 DRONABINOL (MARINOL) 2.5MG CAP Q0167 HCPCS 637 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 DRUG ABUSE PANEL 80307 CPT 300 Revenue Code Both 903 677.25 722.4 Fee Schedule 722.4 Fee Schedule 406.35 Fee Schedule 541.8 Fee Schedule 406.35 541.8 DRUG SCREEN IN HOUSE 80305 CPT 300 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 DTAP HIB IPV 90698 CPT 636 Revenue Code Both 227 170.25 181.6 Fee Schedule 181.6 Fee Schedule 102.15 Fee Schedule 136.2 Fee Schedule 102.15 136.2 DTAP IPV KINRIX 90696 CPT 636 Revenue Code Both 190 142.5 152 Fee Schedule 152 Fee Schedule 85.5 Fee Schedule 114 Fee Schedule 85.5 114 DTAP UNDER 7 YEARS 90700 CPT 636 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 EACH ADDITIONAL IMMUN ADM 90472 CPT 636 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 EAR - FOREIGN BODY REMOVAL 69200 CPT 450 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 EAR IMPACTED CERUMEN 69210 CPT 450 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 ECHO W/COLOR & DOPPLER 93306 93306 CPT 731 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 ED LEVEL 1 99281 CPT 450 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 ED LEVEL 2 99282 CPT 450 Revenue Code Both 269 201.75 215.2 Fee Schedule 215.2 Fee Schedule 121.05 Fee Schedule 161.4 Fee Schedule 121.05 161.4 ED LEVEL 3 99283 CPT 450 Revenue Code Both 461 345.75 368.8 Fee Schedule 368.8 Fee Schedule 207.45 Fee Schedule 276.6 Fee Schedule 207.45 276.6 ED LEVEL 4 99284 CPT 450 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 ED LEVEL 5 99285 CPT 450 Revenue Code Both 1041 780.75 832.8 Fee Schedule 832.8 Fee Schedule 468.45 Fee Schedule 624.6 Fee Schedule 468.45 624.6 EHRLICHIA CHAFF AB IGG IGM 86666 CPT 300 Revenue Code Both 400 300 320 Fee Schedule 320 Fee Schedule 180 Fee Schedule 240 Fee Schedule 180 240 EKG 93005 CPT 731 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 EKG SCREENING G0404 HCPCS 483 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 ELECTROLYTES 80051 CPT 300 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 ELM IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 EMERGENCY EXAM LEVEL 1 99281 CPT 981 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 EMERGENCY EXAM LEVEL 1 99281 CPT 981 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 EMERGENCY EXAM LEVEL 3 99283 CPT 981 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 EMERGENCY EXAM LEVEL 3 99283 CPT 981 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 EMERGENCY EXAM LEVEL 5 99285 CPT 981 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 EMERGENCY ROOM EXAM LEVEL 2 99282 CPT 981 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 EMERGENCY ROOM EXAM LEVEL 2 99282 CPT 981 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 EMERGENCY ROOM EXAM LEVEL 4 99284 CPT 981 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 EMERGENCY ROOM EXAM LEVEL 4 99284 CPT 981 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ENDOMYSIAL AB IGA W/REFLEX 86231 CPT 300 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 ENDOMYSIAL AB IGG W/REFLEX 86231 CPT 300 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 ENOXAPARIN (LOVENOX) 100MG/ML INJ J1650 HCPCS 636 Revenue Code Both 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 ENOXAPARIN (LOVENOX) 40MG/0.4ML INJ J1650 HCPCS 637 Revenue Code Both 20.75 15.5625 16.6 Fee Schedule 16.6 Fee Schedule 9.3375 Fee Schedule 12.45 Fee Schedule 9.3375 12.45 EOSINOPHILS 85004 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 EPINEPHRINE (ADRENALIN) 1MG/10ML SYR IVP J0169 HCPCS 637 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 EPINEPHRINE (ADRENALIN) 1MG/ML INJ J0171 HCPCS 637 Revenue Code Both 60 45 48 Fee Schedule 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 EPINEPHRINE (EPIPEN JR) 0.15MG INJ J0165 HCPCS 637 Revenue Code Both 305 228.75 244 Fee Schedule 244 Fee Schedule 137.25 Fee Schedule 183 Fee Schedule 137.25 183 EPINEPHRINE (EPIPEN) 0.3MG INJ J0165 HCPCS 637 Revenue Code Both 294 220.5 235.2 Fee Schedule 235.2 Fee Schedule 132.3 Fee Schedule 176.4 Fee Schedule 132.3 176.4 EPOETIN ALFA (EPOGEN) 4000U/ML INJ J0885 HCPCS 637 Revenue Code Both 179 134.25 143.2 Fee Schedule 143.2 Fee Schedule 80.55 Fee Schedule 107.4 Fee Schedule 80.55 107.4 EPSTEIN BARR VIRUS 86664 CPT 300 Revenue Code Both 151 113.25 120.8 Fee Schedule 120.8 Fee Schedule 67.95 Fee Schedule 90.6 Fee Schedule 67.95 90.6 ER ADD'L PUSH SAME DRUG NOT W/I 30 MIN 96376 CPT 450 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 ERYTHROPOIETIN 82668 CPT 300 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 ESCISION BENIGN LESION .5CM OR LESS 11400 CPT 981 Revenue Code Both 88 66 70.4 Fee Schedule 70.4 Fee Schedule 39.6 Fee Schedule 52.8 Fee Schedule 39.6 52.8 ESCISION MALIGNANT LESION .5 CM OR LESS 11640 CPT 981 Revenue Code Both 187 140.25 149.6 Fee Schedule 149.6 Fee Schedule 84.15 Fee Schedule 112.2 Fee Schedule 84.15 112.2 ESR 85651 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 ESTRADIOL 82670 CPT 300 Revenue Code Both 411 308.25 328.8 Fee Schedule 328.8 Fee Schedule 184.95 Fee Schedule 246.6 Fee Schedule 184.95 246.6 ESTRONE 82679 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 "ETHANOL, BLOOD" 80307 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 EVALUATION OF ORAL AND PHARYNGEAL SWALLO 92610 CPT 440 Revenue Code Both 223 167.25 178.4 Fee Schedule 178.4 Fee Schedule 100.35 Fee Schedule 133.8 Fee Schedule 100.35 133.8 EVALUATION OF SPEECH FLUENCY 92521 CPT 444 Revenue Code Both 345 258.75 276 Fee Schedule 276 Fee Schedule 155.25 Fee Schedule 207 Fee Schedule 155.25 207 EVALUATION OF SPEECH SOUND PRODUCTION 92522 CPT 444 Revenue Code Both 292 219 233.6 Fee Schedule 233.6 Fee Schedule 131.4 Fee Schedule 175.2 Fee Schedule 131.4 175.2 EX MALIGNANT LESION 1.1 TO 2.0 CM 11622 CPT 981 Revenue Code Both 263 197.25 210.4 Fee Schedule 210.4 Fee Schedule 118.35 Fee Schedule 157.8 Fee Schedule 118.35 157.8 EXC BREAST TISSUE (MASS) 19120 CPT 981 Revenue Code Both 596 447 476.8 Fee Schedule 476.8 Fee Schedule 268.2 Fee Schedule 357.6 Fee Schedule 268.2 357.6 EXC BREAST TISSUE MASS MALIG/BENIGN 19120 CPT 270 Revenue Code Both 1771 1328.25 1416.8 Fee Schedule 1416.8 Fee Schedule 796.95 Fee Schedule 1062.6 Fee Schedule 796.95 1062.6 EXC MALIG LES 2.1/3.0 FACE EAR ETC 11643 CPT 981 Revenue Code Both 390 292.5 312 Fee Schedule 312 Fee Schedule 175.5 Fee Schedule 234 Fee Schedule 175.5 234 EXC NAIL MATRIX FOR PERM REMOV 11750 CPT 981 Revenue Code Both 179 134.25 143.2 Fee Schedule 143.2 Fee Schedule 80.55 Fee Schedule 107.4 Fee Schedule 80.55 107.4 EXCISION B9 LESION TNK ARM LEG 0.5 LESS 11400 CPT 761 Revenue Code Both 300 225 240 Fee Schedule 240 Fee Schedule 135 Fee Schedule 180 Fee Schedule 135 180 EXCISION BENIGN LESION - 0.5 OR LESS 11400 CPT 761 Revenue Code Both 300 225 240 Fee Schedule 240 Fee Schedule 135 Fee Schedule 180 Fee Schedule 135 180 EXCISION BENIGN LESION .5 CM OR LESS 11440 CPT 981 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 EXCISION BENIGN LESION <0.5 CM 11420 CPT 981 Revenue Code Both 105 78.75 84 Fee Schedule 84 Fee Schedule 47.25 Fee Schedule 63 Fee Schedule 47.25 63 EXCISION BENIGN LESION >4.0 CM 11406 CPT 450 Revenue Code Both 647 485.25 517.6 Fee Schedule 517.6 Fee Schedule 291.15 Fee Schedule 388.2 Fee Schedule 291.15 388.2 EXCISION BENIGN LESION 0.5CM OR LESS 11420 CPT 761 Revenue Code Both 300 225 240 Fee Schedule 240 Fee Schedule 135 Fee Schedule 180 Fee Schedule 135 180 EXCISION BENIGN LESION 1.1 TO 2.0 CM 11442 CPT 981 Revenue Code Both 213 159.75 170.4 Fee Schedule 170.4 Fee Schedule 95.85 Fee Schedule 127.8 Fee Schedule 95.85 127.8 EXCISION BENIGN LESION 1.1 TO 2.0 CM 11422 CPT 981 Revenue Code Both 189 141.75 151.2 Fee Schedule 151.2 Fee Schedule 85.05 Fee Schedule 113.4 Fee Schedule 85.05 113.4 EXCISION BENIGN LESION 1.1 TO 2.0 CM 11402 CPT 981 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 EXCISION BENIGN LESION 1.2 TO 3.0 CM 11403 CPT 981 Revenue Code Both 206 154.5 164.8 Fee Schedule 164.8 Fee Schedule 92.7 Fee Schedule 123.6 Fee Schedule 92.7 123.6 EXCISION BENIGN LESION 2.1 TO C.0 CM 11423 CPT 981 Revenue Code Both 230 172.5 184 Fee Schedule 184 Fee Schedule 103.5 Fee Schedule 138 Fee Schedule 103.5 138 EXCISION BENIGN LESION 2.1-3.0 11423 CPT 761 Revenue Code Both 328 246 262.4 Fee Schedule 262.4 Fee Schedule 147.6 Fee Schedule 196.8 Fee Schedule 147.6 196.8 EXCISION BENIGN LESION 3.1 TO 4.0 CM 11424 CPT 981 Revenue Code Both 275 206.25 220 Fee Schedule 220 Fee Schedule 123.75 Fee Schedule 165 Fee Schedule 123.75 165 EXCISION BENIGN LESION OVER 4.0 CM 11406 CPT 981 Revenue Code Both 284 213 227.2 Fee Schedule 227.2 Fee Schedule 127.8 Fee Schedule 170.4 Fee Schedule 127.8 170.4 EXCISION LESION FACE .6 CM TO 1CM 11441 CPT 981 Revenue Code Both 159 119.25 127.2 Fee Schedule 127.2 Fee Schedule 71.55 Fee Schedule 95.4 Fee Schedule 71.55 95.4 EXCISION LESION FACE OVER 1CM 11642 CPT 981 Revenue Code Both 330 247.5 264 Fee Schedule 264 Fee Schedule 148.5 Fee Schedule 198 Fee Schedule 148.5 198 EXCISION MALIGNANT LESION 0.6-1.0CM 11601 CPT 450 Revenue Code Both 585 438.75 468 Fee Schedule 468 Fee Schedule 263.25 Fee Schedule 351 Fee Schedule 263.25 351 EXCISION MALIGNANT LESION 2.0 TO C.0 CM 11603 CPT 981 Revenue Code Both 258 193.5 206.4 Fee Schedule 206.4 Fee Schedule 116.1 Fee Schedule 154.8 Fee Schedule 116.1 154.8 EXCISION-BENIGN LESIONS 0.6 TO 1 CM 11401 CPT 761 Revenue Code Both 328 246 262.4 Fee Schedule 262.4 Fee Schedule 147.6 Fee Schedule 196.8 Fee Schedule 147.6 196.8 EXCIXION MALIGNANT LESION 1.1 TO 2.0 CM 11602 CPT 981 Revenue Code Both 233 174.75 186.4 Fee Schedule 186.4 Fee Schedule 104.85 Fee Schedule 139.8 Fee Schedule 104.85 139.8 EXCVISION BENIGN LESION .6 TO 1.0 CM 11421 CPT 981 Revenue Code Both 147 110.25 117.6 Fee Schedule 117.6 Fee Schedule 66.15 Fee Schedule 88.2 Fee Schedule 66.15 88.2 EYE REMOVE FB EXTERNAL 65205 CPT 450 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 FACTOR V MUTATION ANALYSIS 81241 CPT 300 Revenue Code Both 635 476.25 508 Fee Schedule 508 Fee Schedule 285.75 Fee Schedule 381 Fee Schedule 285.75 381 FECAL FAT 82705 CPT 300 Revenue Code Both 117 87.75 93.6 Fee Schedule 93.6 Fee Schedule 52.65 Fee Schedule 70.2 Fee Schedule 52.65 70.2 FECAL LEUKOCYTES 89055 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 FECAL PH 83986 CPT 300 Revenue Code Both 110 82.5 88 Fee Schedule 88 Fee Schedule 49.5 Fee Schedule 66 Fee Schedule 49.5 66 FENTANYL (SUBLIMAZE) 100MCG/2ML INJ J3010 HCPCS 636 Revenue Code Both 25 18.75 20 Fee Schedule 20 Fee Schedule 11.25 Fee Schedule 15 Fee Schedule 11.25 15 FERRITIN 82728 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 FERRLECIT IV SOLUTION 62.5MG/5ML J2916 HCPCS 250 Revenue Code Both Each 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 FERRLECIT SD 62.5MG/5ML J2916 HCPCS 250 Revenue Code Both Each 96.5 72.375 77.2 Fee Schedule 77.2 Fee Schedule 43.425 Fee Schedule 57.9 Fee Schedule 43.425 57.9 FIBRINOGEN ACTIVITY 85384 CPT 300 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 FINASTERIDE (PROSCAR) 5MG TAB S0138 HCPCS 637 Revenue Code Both 38 28.5 30.4 Fee Schedule 30.4 Fee Schedule 17.1 Fee Schedule 22.8 Fee Schedule 17.1 22.8 FINGER PROTECTOR LG L3925 HCPCS 270 Revenue Code Both 18 13.5 14.4 Fee Schedule 14.4 Fee Schedule 8.1 Fee Schedule 10.8 Fee Schedule 8.1 10.8 FINGER PROTECTOR MED Q4049 HCPCS 270 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 FINGER PULSE OXIMETRY 94760 CPT 460 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 FINGER SPLINT APPLICATION 29130 CPT 270 Revenue Code Both 133 99.75 106.4 Fee Schedule 106.4 Fee Schedule 59.85 Fee Schedule 79.8 Fee Schedule 59.85 79.8 FINGER SPLINT APPLICATION 29130 CPT 270 Revenue Code Both 133 99.75 106.4 Fee Schedule 106.4 Fee Schedule 59.85 Fee Schedule 79.8 Fee Schedule 59.85 79.8 FIRST DEGREE BURN TREATMENT 16000 CPT 450 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 FLU SPLIT VIRUS VACCINE 6-35 MONTHS 90657 CPT 636 Revenue Code Both 49 36.75 39.2 Fee Schedule 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 FLUT PROP-SALMET (ADVAIR) 250/50 DISKUS J3490 HCPCS 637 Revenue Code Both 806 604.5 644.8 Fee Schedule 644.8 Fee Schedule 362.7 Fee Schedule 483.6 Fee Schedule 362.7 483.6 FOLATE 82746 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 FOLEY CATH INSERT NONDWELLING 51701 CPT 260 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 FOLEY CATH INSERTION SIMPLE 51702 CPT 450 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 FOLEY CATH INSERTION SIMPLE 51702 CPT 760 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 FOLEY CATHETER INSERTION COMPLICATED 51703 CPT 450 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 FOLEY CATHETER INSERTION COMPLICATED 51703 CPT 760 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 FOMEPIZOLE 1.5GM/1.5ML Injectable J1451 HCPCS 636 Revenue Code Both 839.25 629.4375 671.4 Fee Schedule 671.4 Fee Schedule 377.6625 Fee Schedule 503.55 Fee Schedule 377.6625 503.55 FOSPHENYTOIN (CEREBYX) 500MG/10ML INJ Q2009 HCPCS 636 Revenue Code Both 55 41.25 44 Fee Schedule 44 Fee Schedule 24.75 Fee Schedule 33 Fee Schedule 24.75 33 FRACTIONATED BILIRUBIN 82247 CPT 300 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 FRACTIONATED ESTROGEN 82671 CPT 300 Revenue Code Both 765 573.75 612 Fee Schedule 612 Fee Schedule 344.25 Fee Schedule 459 Fee Schedule 344.25 459 FREE T3 84481 CPT 300 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 FREE T4 84439 CPT 300 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 FRUCTOSAMINE 82985 CPT 300 Revenue Code Both 140 105 112 Fee Schedule 112 Fee Schedule 63 Fee Schedule 84 Fee Schedule 63 84 FSBS ACCUCHECK 82962 CPT 450 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 FSBS ACCUCHECK 82962 CPT 761 Revenue Code Both 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 FSH 83001 CPT 300 Revenue Code Both 33 24.75 26.4 Fee Schedule 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 FSH & LH 83001 CPT 300 Revenue Code Both 349 261.75 279.2 Fee Schedule 279.2 Fee Schedule 157.05 Fee Schedule 209.4 Fee Schedule 157.05 209.4 FUNGUS CULTURE 87101 CPT 300 Revenue Code Both 213 159.75 170.4 Fee Schedule 170.4 Fee Schedule 95.85 Fee Schedule 127.8 Fee Schedule 95.85 127.8 FUROSEMIDE (LASIX) 100MG/10ML INJ J1940 HCPCS 636 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 FUROSEMIDE (LASIX) 20MG/2 ML INJ J1941 HCPCS 637 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 GAMMA GLUTAMYL TRANSFERASE 82977 CPT 300 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 GARDASIL 90651 CPT 636 Revenue Code Both 379 284.25 303.2 Fee Schedule 303.2 Fee Schedule 170.55 Fee Schedule 227.4 Fee Schedule 170.55 227.4 GARDASIL 90649 CPT 250 Revenue Code Both Each 423 317.25 338.4 Fee Schedule 338.4 Fee Schedule 190.35 Fee Schedule 253.8 Fee Schedule 190.35 253.8 GASTRIN 82941 CPT 300 Revenue Code Both 55 41.25 44 Fee Schedule 44 Fee Schedule 24.75 Fee Schedule 33 Fee Schedule 24.75 33 GAUZE-KERLIX PER YARD STERILE A6446 HCPCS 636 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 GEL THERAHONEY 0.5OZ A6011 HCPCS 270 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 GENTAMICIN (GARAMYCIN) 40MG/ML INJ J1580 HCPCS 636 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 GENTAMICIN 80MG/2ML J1580 HCPCS 636 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 GENTAMICIN PEAK 80170 CPT 300 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 GENTAMICIN TROUGH 80170 CPT 300 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 GEST DIABETES MEL SCREEN 82950 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 GIARDIA 87329 CPT 300 Revenue Code Both 222 166.5 177.6 Fee Schedule 177.6 Fee Schedule 99.9 Fee Schedule 133.2 Fee Schedule 99.9 133.2 GIARDIA AG EIA 87329 CPT 300 Revenue Code Both 222 166.5 177.6 Fee Schedule 177.6 Fee Schedule 99.9 Fee Schedule 133.2 Fee Schedule 99.9 133.2 GLARGINE (LANTUS) 1U/0.01ML INS INJ J1815 HCPCS 740 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 GLUCAGON (GLUCAGEN) 1MG INJ J1610 HCPCS 637 Revenue Code Both 161 120.75 128.8 Fee Schedule 128.8 Fee Schedule 72.45 Fee Schedule 96.6 Fee Schedule 72.45 96.6 GLUCOSE 82947 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 GONADOTROPIN RELEASING HORMONE 83520 CPT 300 Revenue Code Both 422 316.5 337.6 Fee Schedule 337.6 Fee Schedule 189.9 Fee Schedule 253.2 Fee Schedule 189.9 253.2 GOSERELINE ACETATE 3.6 J9202 HCPCS 636 Revenue Code Both 689 516.75 551.2 Fee Schedule 551.2 Fee Schedule 310.05 Fee Schedule 413.4 Fee Schedule 310.05 413.4 GRAM STAIN 87205 CPT 300 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 GROUP CAREGIVER TRAINING 97552 CPT 270 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 GROUP STREP A AG W/REFLEX 87880 CPT 300 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 GTT FIRST 3 SPECIMENS 82951 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 GUAIAC TEST KIT 82272 CPT 450 Revenue Code Both 16 12 12.8 Fee Schedule 12.8 Fee Schedule 7.2 Fee Schedule 9.6 Fee Schedule 7.2 9.6 H. PYLORI AB 86677 CPT 300 Revenue Code Both 404 303 323.2 Fee Schedule 323.2 Fee Schedule 181.8 Fee Schedule 242.4 Fee Schedule 181.8 242.4 H. PYLORI AG EIA 87338 CPT 300 Revenue Code Both 355 266.25 284 Fee Schedule 284 Fee Schedule 159.75 Fee Schedule 213 Fee Schedule 159.75 213 "H. PYLORI, UREA BREATH TEST" 83013 CPT 300 Revenue Code Both 391 293.25 312.8 Fee Schedule 312.8 Fee Schedule 175.95 Fee Schedule 234.6 Fee Schedule 175.95 234.6 HALDOL 5MG J1630 HCPCS 636 Revenue Code Both 42 31.5 33.6 Fee Schedule 33.6 Fee Schedule 18.9 Fee Schedule 25.2 Fee Schedule 18.9 25.2 Haldol Decanoate IM Oil 100MG/1ML J1631 HCPCS 637 Revenue Code Both 212 159 169.6 Fee Schedule 169.6 Fee Schedule 95.4 Fee Schedule 127.2 Fee Schedule 95.4 127.2 HALOPERIDOL (HALDOL) 5MG/ML INJ J1630 HCPCS 636 Revenue Code Both 94 70.5 75.2 Fee Schedule 75.2 Fee Schedule 42.3 Fee Schedule 56.4 Fee Schedule 42.3 56.4 HAND HELD NEBUL EA TX INCLUDING MEDS 94640 CPT 270 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 HAPTOGLOBIN 83010 CPT 300 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 HCG 81025 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 HCG QUANT 84703 CPT 300 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 HCT 85014 CPT 300 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 HCV RNA QN 86803 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 HDL 83718 CPT 300 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 HEAVY METALS 83825 CPT 300 Revenue Code Both 697 522.75 557.6 Fee Schedule 557.6 Fee Schedule 313.65 Fee Schedule 418.2 Fee Schedule 313.65 418.2 HEMOCHROMATOSIS DNA MUTATION ANALYSIS 81256 CPT 300 Revenue Code Both 798 598.5 638.4 Fee Schedule 638.4 Fee Schedule 359.1 Fee Schedule 478.8 Fee Schedule 359.1 478.8 HEP A IGM ANTIBODY 86709 CPT 300 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 HEP B (ENGERIX) 20MCG/ML INJ 90746 CPT 636 Revenue Code Both 223.25 167.4375 178.6 Fee Schedule 178.6 Fee Schedule 100.4625 Fee Schedule 133.95 Fee Schedule 100.4625 133.95 HEP B CORE AB IGM 86705 CPT 300 Revenue Code Both 116 87 92.8 Fee Schedule 92.8 Fee Schedule 52.2 Fee Schedule 69.6 Fee Schedule 52.2 69.6 HEP B CORE IGM AB 86705 CPT 300 Revenue Code Both 76 57 60.8 Fee Schedule 60.8 Fee Schedule 34.2 Fee Schedule 45.6 Fee Schedule 34.2 45.6 HEP B VIRUS DNA W/ GENOTYPE REFLEX 87517 CPT 300 Revenue Code Both 688 516 550.4 Fee Schedule 550.4 Fee Schedule 309.6 Fee Schedule 412.8 Fee Schedule 309.6 412.8 "HEPARIN 5,000 UN/ML Solution" J1644 HCPCS 637 Revenue Code Both 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 HEPARIN LOCK FLUSH 500U/5ML INJ J1642 HCPCS 258 Revenue Code Both 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 HEPARIN SODIUM PER 1000 UNITS J1644 HCPCS 636 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 HEPATIC FUNCTION PANEL 80076 CPT 300 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 HEPATITIS A AB 86708 CPT 300 Revenue Code Both 193 144.75 154.4 Fee Schedule 154.4 Fee Schedule 86.85 Fee Schedule 115.8 Fee Schedule 86.85 115.8 HEPATITIS A PEDIATRIC/ADOLESCENT 90633 CPT 636 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 HEPATITIS A VACCINE ADULT DOSAGE 90632 CPT 636 Revenue Code Both 241 180.75 192.8 Fee Schedule 192.8 Fee Schedule 108.45 Fee Schedule 144.6 Fee Schedule 108.45 144.6 HEPATITIS B PEDIATRIC/ADOLESCENT 90744 CPT 636 Revenue Code Both 74 55.5 59.2 Fee Schedule 59.2 Fee Schedule 33.3 Fee Schedule 44.4 Fee Schedule 33.3 44.4 HEPATITIS B SURFACE AB 86706 CPT 300 Revenue Code Both 234 175.5 187.2 Fee Schedule 187.2 Fee Schedule 105.3 Fee Schedule 140.4 Fee Schedule 105.3 140.4 HEPATITIS B SURFACE AG 87340 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 HEPATITIS C VIRAL RNA QN 87902 CPT 300 Revenue Code Both 748 561 598.4 Fee Schedule 598.4 Fee Schedule 336.6 Fee Schedule 448.8 Fee Schedule 336.6 448.8 HEPATITIS C VIRUS AB W/REFLEX 86803 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 HEPATITIS C VIRUS RNA (VIRAL LOAD) 87522 CPT 300 Revenue Code Both 1058 793.5 846.4 Fee Schedule 846.4 Fee Schedule 476.1 Fee Schedule 634.8 Fee Schedule 476.1 634.8 HEPLOCK FLUSH J1642 HCPCS 270 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 HGB 85018 CPT 300 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 HGB A1C 83036 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 HICKORY/PECAN TREE IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 HIV-1 DNA QUAL PCR 87535 CPT 300 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 HLA-B27 AG 86812 CPT 300 Revenue Code Both 84 63 67.2 Fee Schedule 67.2 Fee Schedule 37.8 Fee Schedule 50.4 Fee Schedule 37.8 50.4 HLA-B27 DNA TYPING 81374 CPT 300 Revenue Code Both 228 171 182.4 Fee Schedule 182.4 Fee Schedule 102.6 Fee Schedule 136.8 Fee Schedule 102.6 136.8 HOLTER MONITOR 93225 CPT 730 Revenue Code Both 590 442.5 472 Fee Schedule 472 Fee Schedule 265.5 Fee Schedule 354 Fee Schedule 265.5 354 HOMOCYSTEINE 83090 CPT 300 Revenue Code Both 391 293.25 312.8 Fee Schedule 312.8 Fee Schedule 175.95 Fee Schedule 234.6 Fee Schedule 175.95 234.6 HOSPITAL ADMISSION LEVEL 1 99221 CPT 987 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 HOSPITAL ADMISSION LEVEL 1 - INACTIVE 99221 CPT 987 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 HOSPITAL ADMISSION LEVEL 2 99222 CPT 987 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 HOSPITAL ADMISSION LEVEL 2 - INACTIVE 99222 CPT 987 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 HOSPITAL ADMISSION LEVEL 3 99223 CPT 982 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 HOSPITAL ADMISSION LEVEL 3 - INACTIVE 99223 CPT 982 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 HOSPITAL DISCHARGE MANAGEMENT 99238 CPT 981 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 HOSPITAL DISCHARGE MANAGEMENT - INACTIVE 99238 CPT 981 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 HS-CRP 86141 CPT 300 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 "HSV TYPE 1/2 DNA, QL" 86696 CPT 300 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 HUMALOG (LISPRO) 1U/0.01ML INJ J1815 HCPCS 637 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 HUMALOG MIX 75/25 100 UNITS INJ J1815 HCPCS 636 Revenue Code Both 10 7.5 8 Fee Schedule 8 Fee Schedule 4.5 Fee Schedule 6 Fee Schedule 4.5 6 HUMULIN70/30MIX(NPH/REG)1U/0.01ML INJ J1815 HCPCS 636 Revenue Code Both 10 7.5 8 Fee Schedule 8 Fee Schedule 4.5 Fee Schedule 6 Fee Schedule 4.5 6 HYDRALAZINE (APRESOLINE) 20MG INJ J0360 HCPCS 637 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 HYDROCORTISONE (ANUCORT-HC) 25MG SUPP J3490 HCPCS 637 Revenue Code Both 98 73.5 78.4 Fee Schedule 78.4 Fee Schedule 44.1 Fee Schedule 58.8 Fee Schedule 44.1 58.8 HYDROCORTISONE (SOLU CORTEF) 250MG INJ J1720 HCPCS 637 Revenue Code Both 109 81.75 87.2 Fee Schedule 87.2 Fee Schedule 49.05 Fee Schedule 65.4 Fee Schedule 49.05 65.4 HYDROXYZINE (VISTARIL) 25MG/ML INJ J3410 HCPCS 250 Revenue Code Both Each 75.5 56.625 60.4 Fee Schedule 60.4 Fee Schedule 33.975 Fee Schedule 45.3 Fee Schedule 33.975 45.3 I & D ABSCESS PERITONSILLAR 42700 CPT 981 Revenue Code Both 239 179.25 191.2 Fee Schedule 191.2 Fee Schedule 107.55 Fee Schedule 143.4 Fee Schedule 107.55 143.4 I & D HEMATOMA OR FLUID COLLECTION 10140 CPT 981 Revenue Code Both 165 123.75 132 Fee Schedule 132 Fee Schedule 74.25 Fee Schedule 99 Fee Schedule 74.25 99 I & D OF VULVA/PERINEUM 56405 CPT 981 Revenue Code Both 186 139.5 148.8 Fee Schedule 148.8 Fee Schedule 83.7 Fee Schedule 111.6 Fee Schedule 83.7 111.6 I & D PILONIDAL CYST 10080 CPT 981 Revenue Code Both 130 97.5 104 Fee Schedule 104 Fee Schedule 58.5 Fee Schedule 78 Fee Schedule 58.5 78 I&D CARBUNCLE ABSCESS CYST SINGLE 10060 CPT 270 Revenue Code Both 154 115.5 123.2 Fee Schedule 123.2 Fee Schedule 69.3 Fee Schedule 92.4 Fee Schedule 69.3 92.4 I&D CARBUNCLE ABSCESS CYST SINGLE 10060 CPT 981 Revenue Code Both 123 92.25 98.4 Fee Schedule 98.4 Fee Schedule 55.35 Fee Schedule 73.8 Fee Schedule 55.35 73.8 I&D DENTOALVEOLAR STRUCTURES 41800 CPT 450 Revenue Code Both 416 312 332.8 Fee Schedule 332.8 Fee Schedule 187.2 Fee Schedule 249.6 Fee Schedule 187.2 249.6 I&D SKIN ABSCESS 10060 CPT 761 Revenue Code Both 719 539.25 575.2 Fee Schedule 575.2 Fee Schedule 323.55 Fee Schedule 431.4 Fee Schedule 323.55 431.4 I&D SKIN ABSCESS MORE THAN 1 10061 CPT 761 Revenue Code Both 577 432.75 461.6 Fee Schedule 461.6 Fee Schedule 259.65 Fee Schedule 346.2 Fee Schedule 259.65 346.2 IBUTILIDE FUMARATE (CORVERT)1MG/10ML J1742 HCPCS 637 Revenue Code Both 178.5 133.875 142.8 Fee Schedule 142.8 Fee Schedule 80.325 Fee Schedule 107.1 Fee Schedule 80.325 107.1 IGA ALLERGY 82784 CPT 300 Revenue Code Both 139 104.25 111.2 Fee Schedule 111.2 Fee Schedule 62.55 Fee Schedule 83.4 Fee Schedule 62.55 83.4 IGE ALLERGY 82785 CPT 300 Revenue Code Both 54 40.5 43.2 Fee Schedule 43.2 Fee Schedule 24.3 Fee Schedule 32.4 Fee Schedule 24.3 32.4 IGE ALLERGY 82785 CPT 300 Revenue Code Both 226 169.5 180.8 Fee Schedule 180.8 Fee Schedule 101.7 Fee Schedule 135.6 Fee Schedule 101.7 135.6 IGG ALLERGY 82784 CPT 300 Revenue Code Both 139 104.25 111.2 Fee Schedule 111.2 Fee Schedule 62.55 Fee Schedule 83.4 Fee Schedule 62.55 83.4 IGM ALLERGY 82784 CPT 300 Revenue Code Both 139 104.25 111.2 Fee Schedule 111.2 Fee Schedule 62.55 Fee Schedule 83.4 Fee Schedule 62.55 83.4 IM OR SUBQ INJECTION 96372 CPT 260 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 IM/SUBQ INJECTION 96372 CPT 761 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 IMITREX 6MG J3030 HCPCS 636 Revenue Code Both 95 71.25 76 Fee Schedule 76 Fee Schedule 42.75 Fee Schedule 57 Fee Schedule 42.75 57 IMMOBILIZER KNEE 12' L1830 HCPCS 270 Revenue Code Both 85 63.75 68 Fee Schedule 68 Fee Schedule 38.25 Fee Schedule 51 Fee Schedule 38.25 51 IMMOBILIZER KNEE 16' L1830 HCPCS 270 Revenue Code Both 97 72.75 77.6 Fee Schedule 77.6 Fee Schedule 43.65 Fee Schedule 58.2 Fee Schedule 43.65 58.2 IMMOBILIZER KNEE 20' L1830 HCPCS 274 Revenue Code Both 101 75.75 80.8 Fee Schedule 80.8 Fee Schedule 45.45 Fee Schedule 60.6 Fee Schedule 45.45 60.6 IMMOBILIZER KNEE 24' L1830 HCPCS 270 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 IMMOBILIZER KNEE 26' L1830 HCPCS 270 Revenue Code Both 82 61.5 65.6 Fee Schedule 65.6 Fee Schedule 36.9 Fee Schedule 49.2 Fee Schedule 36.9 49.2 IMMOBILIZER SHOULDER UNIV L3660 HCPCS 270 Revenue Code Both 74 55.5 59.2 Fee Schedule 59.2 Fee Schedule 33.3 Fee Schedule 44.4 Fee Schedule 33.3 44.4 IMMOBILIZER SHOULDER XXL L3670 HCPCS 274 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 IMMUNIZATION ADMIN EA ADD'L VACCINE 90472 CPT 450 Revenue Code Both 146 109.5 116.8 Fee Schedule 116.8 Fee Schedule 65.7 Fee Schedule 87.6 Fee Schedule 65.7 87.6 IMMUNIZATION ADMIN ONE VACCINE 90471 CPT 450 Revenue Code Both 73 54.75 58.4 Fee Schedule 58.4 Fee Schedule 32.85 Fee Schedule 43.8 Fee Schedule 32.85 43.8 IMMUNIZATION ADMINISTRATION 90471 CPT 771 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 "IMMUNOFIXATION, SERUM" 86334 CPT 300 Revenue Code Both 389 291.75 311.2 Fee Schedule 311.2 Fee Schedule 175.05 Fee Schedule 233.4 Fee Schedule 175.05 233.4 "IMMUNOFIXATION, URINE" 86335 CPT 300 Revenue Code Both 306 229.5 244.8 Fee Schedule 244.8 Fee Schedule 137.7 Fee Schedule 183.6 Fee Schedule 137.7 183.6 IMOVAX RABIES IM PWD FOR SUSP 2.5IU 90675 CPT 636 Revenue Code Both 615 461.25 492 Fee Schedule 492 Fee Schedule 276.75 Fee Schedule 369 Fee Schedule 276.75 369 INAPSIN INJ UP TO 5MG J1790 HCPCS 636 Revenue Code Both 22 16.5 17.6 Fee Schedule 17.6 Fee Schedule 9.9 Fee Schedule 13.2 Fee Schedule 9.9 13.2 INCENTIVE SPIROMETRY A9284 HCPCS 270 Revenue Code Both 42 31.5 33.6 Fee Schedule 33.6 Fee Schedule 18.9 Fee Schedule 25.2 Fee Schedule 18.9 25.2 INCISION & DRAIN OF FLUID 10140 CPT 260 Revenue Code Both 1799 1349.25 1439.2 Fee Schedule 1439.2 Fee Schedule 809.55 Fee Schedule 1079.4 Fee Schedule 809.55 1079.4 INCISION & REMOVAL OF FOREIGN BODY SUBQ 10120 CPT 450 Revenue Code Both 652 489 521.6 Fee Schedule 521.6 Fee Schedule 293.4 Fee Schedule 391.2 Fee Schedule 293.4 391.2 INCISION AND DRAINAGE OF ABCESS SIMPLE 10060 CPT 450 Revenue Code Both 427 320.25 341.6 Fee Schedule 341.6 Fee Schedule 192.15 Fee Schedule 256.2 Fee Schedule 192.15 256.2 INCISION AND REMOVAL RB SUBCUTANEOUS 10120 CPT 981 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 INCISION INTERPHALANGEAL JOINT EACH 26080 CPT 771 Revenue Code Both 2811 2108.25 2248.8 Fee Schedule 2248.8 Fee Schedule 1264.95 Fee Schedule 1686.6 Fee Schedule 1264.95 1686.6 INCISION THROMBOSED HEMORRHOID EXT 46083 CPT 981 Revenue Code Both 197 147.75 157.6 Fee Schedule 157.6 Fee Schedule 88.65 Fee Schedule 118.2 Fee Schedule 88.65 118.2 INFLUENA VACCINE (FLUZONE HD) 0.5ML 90662 CPT 637 Revenue Code Both 156 117 124.8 Fee Schedule 124.8 Fee Schedule 70.2 Fee Schedule 93.6 Fee Schedule 70.2 93.6 INFLUENZA MDV (FLUZONE) 0.5ML VAC 90658 CPT 637 Revenue Code Both 69 51.75 55.2 Fee Schedule 55.2 Fee Schedule 31.05 Fee Schedule 41.4 Fee Schedule 31.05 41.4 INFLUENZA VACCINE (FLUVIRIN) 0.5ML 90658 CPT 636 Revenue Code Both 69 51.75 55.2 Fee Schedule 55.2 Fee Schedule 31.05 Fee Schedule 41.4 Fee Schedule 31.05 41.4 INFLUENZA VIRUS VACCINE SPLIT AGE 3-UP 90658 CPT 636 Revenue Code Both 69 51.75 55.2 Fee Schedule 55.2 Fee Schedule 31.05 Fee Schedule 41.4 Fee Schedule 31.05 41.4 INIT TX 1ST DEGREE BURN 16000 CPT 761 Revenue Code Both 329 246.75 263.2 Fee Schedule 263.2 Fee Schedule 148.05 Fee Schedule 197.4 Fee Schedule 148.05 197.4 INITIAL TREATMENT BURN LOCAL 16000 CPT 981 Revenue Code Both 77 57.75 61.6 Fee Schedule 61.6 Fee Schedule 34.65 Fee Schedule 46.2 Fee Schedule 34.65 46.2 INJECT POSTASSIUM CHLORIDE PER 2MEQ/20MG J3480 HCPCS 636 Revenue Code Both 17 12.75 13.6 Fee Schedule 13.6 Fee Schedule 7.65 Fee Schedule 10.2 Fee Schedule 7.65 10.2 INJECTION TRIGGER PT LIGAMENT 1 OR 2 20552 CPT 450 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 INJECTION TRIGGER PT LIGAMENT GANGLION 20552 CPT 981 Revenue Code Both 77 57.75 61.6 Fee Schedule 61.6 Fee Schedule 34.65 Fee Schedule 46.2 Fee Schedule 34.65 46.2 INSERT FOLEY CATHETER 51702 CPT 981 Revenue Code Both 76 57 60.8 Fee Schedule 60.8 Fee Schedule 34.2 Fee Schedule 45.6 Fee Schedule 34.2 45.6 INSERTION OF NON-TUNNELED CENTRAL LINE 36556 CPT 260 Revenue Code Both 546 409.5 436.8 Fee Schedule 436.8 Fee Schedule 245.7 Fee Schedule 327.6 Fee Schedule 245.7 327.6 INSULIN 83525 CPT 300 Revenue Code Both 123 92.25 98.4 Fee Schedule 98.4 Fee Schedule 55.35 Fee Schedule 73.8 Fee Schedule 55.35 73.8 INSULIN 5 UNITS J1815 HCPCS 636 Revenue Code Both 10 7.5 8 Fee Schedule 8 Fee Schedule 4.5 Fee Schedule 6 Fee Schedule 4.5 6 INTERLEUKIN-2 RECEPTOR ALPHA CHAIN 84238 CPT 300 Revenue Code Both 306 229.5 244.8 Fee Schedule 244.8 Fee Schedule 137.7 Fee Schedule 183.6 Fee Schedule 137.7 183.6 INTERMED REPAIR 2.6-7.5CM 12042 CPT 450 Revenue Code Both 500 375 400 Fee Schedule 400 Fee Schedule 225 Fee Schedule 300 Fee Schedule 225 300 INTERMEDIATE REPAIR 2.6 TO 7.5 CM 12042 CPT 981 Revenue Code Both 284 213 227.2 Fee Schedule 227.2 Fee Schedule 127.8 Fee Schedule 170.4 Fee Schedule 127.8 170.4 INTERMEDIATE REPAIR 2.6 TO 7.5 CM 12032 CPT 981 Revenue Code Both 255 191.25 204 Fee Schedule 204 Fee Schedule 114.75 Fee Schedule 153 Fee Schedule 114.75 153 INTERMEDIATE REPAIR 20.1 TO 30.0CM 10DAY 12046 CPT 981 Revenue Code Both 467 350.25 373.6 Fee Schedule 373.6 Fee Schedule 210.15 Fee Schedule 280.2 Fee Schedule 210.15 280.2 INTERMEDIATE REPAIR 20.1 TO 30.0CM TRUNK 12036 CPT 981 Revenue Code Both 349 261.75 279.2 Fee Schedule 279.2 Fee Schedule 157.05 Fee Schedule 209.4 Fee Schedule 157.05 209.4 INTERMEDIATE REPAIR FACE 2.6 TO 5.0 CM 12052 CPT 981 Revenue Code Both 284 213 227.2 Fee Schedule 227.2 Fee Schedule 127.8 Fee Schedule 170.4 Fee Schedule 127.8 170.4 INTERMEDIATE REPAIR SCALP/EXTREM 2.5 12031 CPT 981 Revenue Code Both 213 159.75 170.4 Fee Schedule 170.4 Fee Schedule 95.85 Fee Schedule 127.8 Fee Schedule 95.85 127.8 INTRAOSSEOUS NEEDLE INSERTION 36680 CPT 450 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 INTRAVENOUS INFUS HYDRA INITIAL 1HR 96360 CPT 270 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 INTRAVENOUS PUSH INITIAL 96374 CPT 450 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 INTUBATION 31500 CPT 450 Revenue Code Both 900 675 720 Fee Schedule 720 Fee Schedule 405 Fee Schedule 540 Fee Schedule 405 540 INTUBATION 31500 CPT 760 Revenue Code Both 900 675 720 Fee Schedule 720 Fee Schedule 405 Fee Schedule 540 Fee Schedule 405 540 IODINE 82542 CPT 300 Revenue Code Both 194 145.5 155.2 Fee Schedule 155.2 Fee Schedule 87.3 Fee Schedule 116.4 Fee Schedule 87.3 116.4 IONIZED CALCIUM 82330 CPT 300 Revenue Code Both 183 137.25 146.4 Fee Schedule 146.4 Fee Schedule 82.35 Fee Schedule 109.8 Fee Schedule 82.35 109.8 IRON 83540 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 IRON DEXTRAN (INFED) 100MG/2ML J1750 HCPCS 637 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 IRON DEXTRON 50MG J1750 HCPCS 636 Revenue Code Both 88 66 70.4 Fee Schedule 70.4 Fee Schedule 39.6 Fee Schedule 52.8 Fee Schedule 39.6 52.8 IRON SUCROSE 100MG Solution J1756 HCPCS 637 Revenue Code Both 195 146.25 156 Fee Schedule 156 Fee Schedule 87.75 Fee Schedule 117 Fee Schedule 87.75 117 IV D5 & .45 SOD CHL 1000ML J7042 HCPCS 270 Revenue Code Both 14 10.5 11.2 Fee Schedule 11.2 Fee Schedule 6.3 Fee Schedule 8.4 Fee Schedule 6.3 8.4 IV DRUG CONCURRENT INFUSION 96368 CPT 761 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 IV DRUG INFUSION CONCURRENT 96368 CPT 450 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 IV DRUG INFUSION EACH ADD'L HOUR 96366 CPT 260 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 IV DRUG INFUSION INITIAL UP TO 1 HOUR 96365 CPT 260 Revenue Code Both 507 380.25 405.6 Fee Schedule 405.6 Fee Schedule 228.15 Fee Schedule 304.2 Fee Schedule 228.15 304.2 IV DRUG INFUSION INITIAL UP TO 1 HOUR 96365 CPT 270 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 IV DRUG INFUSION SEQUENTIAL UP TO 1 HR 96367 CPT 260 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 IV DRUG SEQUENTIAL INFUSTION UP TO 1 HR 96367 CPT 260 Revenue Code Both 146 109.5 116.8 Fee Schedule 116.8 Fee Schedule 65.7 Fee Schedule 87.6 Fee Schedule 65.7 87.6 IV FUSION HYDRATION EA ADD:L HR 96361 CPT 260 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 IV FUSION HYDRATION INITIAL 31 MIN-1 HR 96360 CPT 260 Revenue Code Both 315 236.25 252 Fee Schedule 252 Fee Schedule 141.75 Fee Schedule 189 Fee Schedule 141.75 189 IV HEPARIN HLF J1642 HCPCS 270 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 IV HYDRATION EACH ADDITIONAL HOUR 96361 CPT 270 Revenue Code Both 129 96.75 103.2 Fee Schedule 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 IV HYDRATION INITITAL 31 MIN TO 1HR 96360 CPT 260 Revenue Code Both 287 215.25 229.6 Fee Schedule 229.6 Fee Schedule 129.15 Fee Schedule 172.2 Fee Schedule 129.15 172.2 IV PUSH EACH ADD'L DIFFERENT DRUG 96375 CPT 260 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 IV PUSH EACH ADD'L SAME DRUG 96376 CPT 260 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 IV PUSH INITIAL INJECTION 96374 CPT 260 Revenue Code Both 186 139.5 148.8 Fee Schedule 148.8 Fee Schedule 83.7 Fee Schedule 111.6 Fee Schedule 83.7 111.6 IV THERAPY OVER 1HR PER HR THERAPEUTIC 96366 CPT 260 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 JAK2 EXON 12 MUTATION 81279 CPT 300 Revenue Code Both 689 516.75 551.2 Fee Schedule 551.2 Fee Schedule 310.05 Fee Schedule 413.4 Fee Schedule 310.05 413.4 JO-1 AB 86235 CPT 300 Revenue Code Both 127 95.25 101.6 Fee Schedule 101.6 Fee Schedule 57.15 Fee Schedule 76.2 Fee Schedule 57.15 76.2 JOHNSON GRASS IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 KANGAROO PUMP B9002 HCPCS 260 Revenue Code Both 212 159 169.6 Fee Schedule 169.6 Fee Schedule 95.4 Fee Schedule 127.2 Fee Schedule 95.4 127.2 KANGAROO PUMP SET 1000ML B4035 HCPCS 270 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 KAPPA/LAMBDA LIGHT CHAINS FREE 83883 CPT 300 Revenue Code Both 294 220.5 235.2 Fee Schedule 235.2 Fee Schedule 132.3 Fee Schedule 176.4 Fee Schedule 132.3 176.4 KENALOG 10MG J3301 HCPCS 636 Revenue Code Both 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 KETOROLAC (TORADOL) 15MG/ML INJ J1885 HCPCS 250 Revenue Code Both Each 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 KETOROLAC (TORADOL) 30MG/ML INJ J1885 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 KETOROLAC TRO (TORADOL) 60MG/2ML IM J1885 HCPCS 250 Revenue Code Both Each 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 KOH WET PREP 87220 CPT 300 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 LACOSAMIDE 80235 CPT 300 Revenue Code Both 226 169.5 180.8 Fee Schedule 180.8 Fee Schedule 101.7 Fee Schedule 135.6 Fee Schedule 101.7 135.6 LACTATE 83605 CPT 300 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 LACTATED RINGER'S (LR) 1000ML IV J7120 HCPCS 250 Revenue Code Both Each 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 LACTIC ACID 83605 CPT 300 Revenue Code Both 189 141.75 151.2 Fee Schedule 151.2 Fee Schedule 85.05 Fee Schedule 113.4 Fee Schedule 85.05 113.4 LAMOTRIGINE 80175 CPT 300 Revenue Code Both 183 137.25 146.4 Fee Schedule 146.4 Fee Schedule 82.35 Fee Schedule 109.8 Fee Schedule 82.35 109.8 LANOXIN (DIGOXIN) 250MCG/ML INJ J1160 HCPCS 636 Revenue Code Both 144 108 115.2 Fee Schedule 115.2 Fee Schedule 64.8 Fee Schedule 86.4 Fee Schedule 64.8 86.4 LASIX UP TO 20MG J1940 HCPCS 636 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 LAXATIVE SCREEN 84100 CPT 300 Revenue Code Both 476 357 380.8 Fee Schedule 380.8 Fee Schedule 214.2 Fee Schedule 285.6 Fee Schedule 214.2 285.6 LAYER CLOSURE OF WOUND 12.6 TO 20.0 CM 12035 CPT 981 Revenue Code Both 349 261.75 279.2 Fee Schedule 279.2 Fee Schedule 157.05 Fee Schedule 209.4 Fee Schedule 157.05 209.4 LAYER CLOSURE OF WOUNDS 2.5CM OR LESS 12051 CPT 981 Revenue Code Both 367 275.25 293.6 Fee Schedule 293.6 Fee Schedule 165.15 Fee Schedule 220.2 Fee Schedule 165.15 220.2 LAYER CLOSURE WOUND 2.5 CM OR LESS 12041 CPT 981 Revenue Code Both 218 163.5 174.4 Fee Schedule 174.4 Fee Schedule 98.1 Fee Schedule 130.8 Fee Schedule 98.1 130.8 LAYER CLSR 7.6 -12.5 CM NECK HAND FT 12044 CPT 981 Revenue Code Both 325 243.75 260 Fee Schedule 260 Fee Schedule 146.25 Fee Schedule 195 Fee Schedule 146.25 195 LDH 83615 CPT 300 Revenue Code Both 110 82.5 88 Fee Schedule 88 Fee Schedule 49.5 Fee Schedule 66 Fee Schedule 49.5 66 LEAD 83655 CPT 300 Revenue Code Both 245 183.75 196 Fee Schedule 196 Fee Schedule 110.25 Fee Schedule 147 Fee Schedule 110.25 147 "LEGIONELLA ANTIGEN EIA, URINE" 87449 CPT 300 Revenue Code Both 357 267.75 285.6 Fee Schedule 285.6 Fee Schedule 160.65 Fee Schedule 214.2 Fee Schedule 160.65 214.2 LEUKO REDUCED RED BLOOD CELLS PER UNIT P9016 HCPCS 300 Revenue Code Both 579 434.25 463.2 Fee Schedule 463.2 Fee Schedule 260.55 Fee Schedule 347.4 Fee Schedule 260.55 347.4 LEVALBUTEROL (XOPENEX) 0.63MG NEB SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 LEVALBUTEROL (XOPENEX) HFA 45MC 15GM J7615 HCPCS 637 Revenue Code Both 223 167.25 178.4 Fee Schedule 178.4 Fee Schedule 100.35 Fee Schedule 133.8 Fee Schedule 100.35 133.8 LEVETIRACETAM 80177 CPT 300 Revenue Code Both 240 180 192 Fee Schedule 192 Fee Schedule 108 Fee Schedule 144 Fee Schedule 108 144 LEVETIRACETAM 80177 CPT 300 Revenue Code Both 240 180 192 Fee Schedule 192 Fee Schedule 108 Fee Schedule 144 Fee Schedule 108 144 LevETIRAcetam Oral Tablet 750MG J3490 HCPCS 250 Revenue Code Both Each 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 LEVOFLOXACIN/D5W 500MG/100ML PREMIX J1956 HCPCS 636 Revenue Code Both 54 40.5 43.2 Fee Schedule 43.2 Fee Schedule 24.3 Fee Schedule 32.4 Fee Schedule 24.3 32.4 LH 83002 CPT 300 Revenue Code Both 39 29.25 31.2 Fee Schedule 31.2 Fee Schedule 17.55 Fee Schedule 23.4 Fee Schedule 17.55 23.4 LICE SHAMPOO (NIX) 4OZ A9180 HCPCS 637 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 LIDOCAINE (XYLOCAINE) 2% 20MG/ML INJ J2002 HCPCS 250 Revenue Code Both Each 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 LIDOCAINE HCL/D5W 2GM/250ML PREMIX J2001 HCPCS 637 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 LINCOMYCIN (LINCOCIN) 300MG/2ML INJ J2010 HCPCS 637 Revenue Code Both 110 82.5 88 Fee Schedule 88 Fee Schedule 49.5 Fee Schedule 66 Fee Schedule 49.5 66 LIPASE 83690 CPT 300 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 LIPIDS 80061 CPT 300 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 LIPOPROTEIN A 83695 CPT 300 Revenue Code Both 67 50.25 53.6 Fee Schedule 53.6 Fee Schedule 30.15 Fee Schedule 40.2 Fee Schedule 30.15 40.2 LITHIUM 80178 CPT 300 Revenue Code Both 152 114 121.6 Fee Schedule 121.6 Fee Schedule 68.4 Fee Schedule 91.2 Fee Schedule 68.4 91.2 LIVER FIBROSIS FIBROTEST/ACTITEST PANEL 81596 CPT 300 Revenue Code Both 613 459.75 490.4 Fee Schedule 490.4 Fee Schedule 275.85 Fee Schedule 367.8 Fee Schedule 275.85 367.8 LORAZEPAM (ATIVAN) 1MG TAB J3490 HCPCS 637 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 LORAZEPAM (ATIVAN) 2MG/1ML INJ J2060 HCPCS 637 Revenue Code Both 7.5 5.625 6 Fee Schedule 6 Fee Schedule 3.375 Fee Schedule 4.5 Fee Schedule 3.375 4.5 LOVENOX 10 MG J1650 HCPCS 636 Revenue Code Both 6 4.5 4.8 Fee Schedule 4.8 Fee Schedule 2.7 Fee Schedule 3.6 Fee Schedule 2.7 3.6 LYME DISEASE ANTIBODIES IGG 86618 CPT 300 Revenue Code Both 312 234 249.6 Fee Schedule 249.6 Fee Schedule 140.4 Fee Schedule 187.2 Fee Schedule 140.4 187.2 "LYME DISEASE ANTIBODIES, IGM" 86618 CPT 300 Revenue Code Both 312 234 249.6 Fee Schedule 249.6 Fee Schedule 140.4 Fee Schedule 187.2 Fee Schedule 140.4 187.2 MAGNESIUM 83735 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 MAGNESIUM SULF 5GM/10ML INJ J3475 HCPCS 636 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 MAGNESIUM SULFATE 50% 1GM/2ML INJ J3475 HCPCS 260 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 MAGNESIUM SULFATE 50% 1GM/2ML Solution J3475 HCPCS 637 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 MANNITOL (OSMITROL) 25% 50 ML INJ J2150 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 MAPLE IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 MEADOW FESCUE IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 "MEASLES VIRUS, QUAL, PCR, NASOPHARYNGEAL" 87798 CPT 300 Revenue Code Both 706 529.5 564.8 Fee Schedule 564.8 Fee Schedule 317.7 Fee Schedule 423.6 Fee Schedule 317.7 423.6 MECLIZINE (ANTIVERT) 25MG TAB J3490 HCPCS 637 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 MEDICARE ANNUAL WELLNESS SUBSEQUENT G0439 HCPCS 636 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 MEGARED (BRAIN POWER) 500MG CAP J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 MEGESTROL (MEGACE) 40MG/ML SUSP 240ML S0179 HCPCS 637 Revenue Code Both 597 447.75 477.6 Fee Schedule 477.6 Fee Schedule 268.65 Fee Schedule 358.2 Fee Schedule 268.65 358.2 MENINGOCOCCAL POLYSACCHARIDE VACCINE 90733 CPT 636 Revenue Code Both 315 236.25 252 Fee Schedule 252 Fee Schedule 141.75 Fee Schedule 189 Fee Schedule 141.75 189 MEPERIDINE (DEMEROL) 100MG/ML INJ J2175 HCPCS 637 Revenue Code Both 38 28.5 30.4 Fee Schedule 30.4 Fee Schedule 17.1 Fee Schedule 22.8 Fee Schedule 17.1 22.8 MEPERIDINE (DEMEROL) 25MG/ML INJ J2175 HCPCS 637 Revenue Code Both 25 18.75 20 Fee Schedule 20 Fee Schedule 11.25 Fee Schedule 15 Fee Schedule 11.25 15 MEPERIDINE (DEMEROL) 50MG/ML INJ J2175 HCPCS 636 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 MEPILEX A6213 HCPCS 270 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 MEPILEX AG 10 X 10 CM (4 X 4) 287100 A6209 HCPCS 271 Revenue Code Both 43 32.25 34.4 Fee Schedule 34.4 Fee Schedule 19.35 Fee Schedule 25.8 Fee Schedule 19.35 25.8 MERCURY 83825 CPT 300 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 MEROPENEM 1G Injectable J2185 HCPCS 637 Revenue Code Both 26.25 19.6875 21 Fee Schedule 21 Fee Schedule 11.8125 Fee Schedule 15.75 Fee Schedule 11.8125 15.75 MESALAMINE (ASACOL HD) 800MG CAP J3490 HCPCS 637 Revenue Code Both 61 45.75 48.8 Fee Schedule 48.8 Fee Schedule 27.45 Fee Schedule 36.6 Fee Schedule 27.45 36.6 METHOTREXATE (TREXALL) 2.5 MG TAB J8610 HCPCS 637 Revenue Code Both 36 27 28.8 Fee Schedule 28.8 Fee Schedule 16.2 Fee Schedule 21.6 Fee Schedule 16.2 21.6 METHYLMALONIC ACID 83921 CPT 300 Revenue Code Both 365 273.75 292 Fee Schedule 292 Fee Schedule 164.25 Fee Schedule 219 Fee Schedule 164.25 219 METHYLPHENIDATE 80307 CPT 300 Revenue Code Both 179 134.25 143.2 Fee Schedule 143.2 Fee Schedule 80.55 Fee Schedule 107.4 Fee Schedule 80.55 107.4 METHYLPHENIDATE (RITALIN) 5MG TAB 80360 CPT 637 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 METHYLPRED (DEPO MEDROL) 80MG/ML INJ J1010 HCPCS 250 Revenue Code Both Each 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 METHYLPRED (SOLU MEDROL) INJ 125MG J2919 HCPCS 250 Revenue Code Both Each 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 METHYLPREDNISOLONE (MEDROL) PAK 4MG J7509 HCPCS 637 Revenue Code Both 160 120 128 Fee Schedule 128 Fee Schedule 72 Fee Schedule 96 Fee Schedule 72 96 METRONIDAZOLE/NS (FLAGYL) 500MG PREMIX J1836 HCPCS 636 Revenue Code Both 16 12 12.8 Fee Schedule 12.8 Fee Schedule 7.2 Fee Schedule 9.6 Fee Schedule 7.2 9.6 MI-2 AUTOANTIBODY 86235 CPT 300 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 MICAFUNGIN (MYCAMINE) 100MG Injectable J2248 HCPCS 637 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 MICROALBUMIN 82043 CPT 300 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 MIDAZOLAM (VERSED) 2MG/2ML inj J2250 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 MINOXIDIL (LONITEN) 10MG TAB S0139 HCPCS 637 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 MITOCHONDRIA W/ REFLEX 86255 CPT 300 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 MMR 90707 CPT 636 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 MOLECULAR PATHOLGY PROCEDURE LEVEL 2 11441 CPT 761 Revenue Code Both 409 306.75 327.2 Fee Schedule 327.2 Fee Schedule 184.05 Fee Schedule 245.4 Fee Schedule 184.05 245.4 MONO SPOT 86403 CPT 300 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 MONO SPOT 86308 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 MORPHINE SULF 10MG/ML INJ J2270 HCPCS 636 Revenue Code Both 31 23.25 24.8 Fee Schedule 24.8 Fee Schedule 13.95 Fee Schedule 18.6 Fee Schedule 13.95 18.6 MORPHINE SULF 2MG/ML INJ J2270 HCPCS 636 Revenue Code Both 38 28.5 30.4 Fee Schedule 30.4 Fee Schedule 17.1 Fee Schedule 22.8 Fee Schedule 17.1 22.8 MORPHINE SULF 4MG/ML INJ J2270 HCPCS 637 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 MORPHINE SULF 5MG/ML INJ J2270 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 MORPHINE SULFATE UP TO 10MG J2270 HCPCS 636 Revenue Code Both 30 22.5 24 Fee Schedule 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 MOUNTAIN CEDAR IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 MPL MUTATION ANALYSIS 81339 CPT 300 Revenue Code Both 519 389.25 415.2 Fee Schedule 415.2 Fee Schedule 233.55 Fee Schedule 311.4 Fee Schedule 233.55 311.4 MULTIVITAMIN ADULT 50+ TAB A9153 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 MUPIROCIN (BACTROBAN) 2% OINT J3490 HCPCS 637 Revenue Code Both 30.5 22.875 24.4 Fee Schedule 24.4 Fee Schedule 13.725 Fee Schedule 18.3 Fee Schedule 13.725 18.3 MYCOPHENOLATE (CELLCEPT) 500MG TAB J7517 HCPCS 637 Revenue Code Both 48 36 38.4 Fee Schedule 38.4 Fee Schedule 21.6 Fee Schedule 28.8 Fee Schedule 21.6 28.8 "MYOGLOBIN, SERUM" 83874 CPT 300 Revenue Code Both 299 224.25 239.2 Fee Schedule 239.2 Fee Schedule 134.55 Fee Schedule 179.4 Fee Schedule 134.55 179.4 "MYOGLOBIN, URINE" 83874 CPT 300 Revenue Code Both 299 224.25 239.2 Fee Schedule 239.2 Fee Schedule 134.55 Fee Schedule 179.4 Fee Schedule 134.55 179.4 NAIL CARE 0 - 5 NAILS LIMITED 11720 CPT 761 Revenue Code Both 164 123 131.2 Fee Schedule 131.2 Fee Schedule 73.8 Fee Schedule 98.4 Fee Schedule 73.8 98.4 NAIL CARE 6 - 10 NAILS LIMITED 11721 CPT 761 Revenue Code Both 191 143.25 152.8 Fee Schedule 152.8 Fee Schedule 85.95 Fee Schedule 114.6 Fee Schedule 85.95 114.6 NAIL EXCISION 11750 CPT 450 Revenue Code Both 844 633 675.2 Fee Schedule 675.2 Fee Schedule 379.8 Fee Schedule 506.4 Fee Schedule 379.8 506.4 NALBUPHINE (NUBAIN) 10MG/ML INJ J2300 HCPCS 637 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 NALOXONE (NARCAN) 0.4MG/ML INJ J2312 HCPCS 636 Revenue Code Both 27 20.25 21.6 Fee Schedule 21.6 Fee Schedule 12.15 Fee Schedule 16.2 Fee Schedule 12.15 16.2 NALOXONE (NARCAN) 2MG/2ML INJ J2312 HCPCS 636 Revenue Code Both 84.5 63.375 67.6 Fee Schedule 67.6 Fee Schedule 38.025 Fee Schedule 50.7 Fee Schedule 38.025 50.7 NALTREXONE (REVIA) 50MG TAB J2315 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 NASAL PACKING 30901 CPT 450 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 NEG PRESSURE WOUND TX > 50 CM 97606 CPT 300 Revenue Code Both 412 309 329.6 Fee Schedule 329.6 Fee Schedule 185.4 Fee Schedule 247.2 Fee Schedule 185.4 247.2 NEISSERIA GONORRHOEAE 87591 CPT 300 Revenue Code Both 352 264 281.6 Fee Schedule 281.6 Fee Schedule 158.4 Fee Schedule 211.2 Fee Schedule 158.4 211.2 NEOSTIGMINE .5MG IM J2710 HCPCS 636 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 NICOTINE AND METABOLITES 80323 CPT 300 Revenue Code Both 157 117.75 125.6 Fee Schedule 125.6 Fee Schedule 70.65 Fee Schedule 94.2 Fee Schedule 70.65 94.2 NOC DRUG ADMINISTERED/DME J7799 HCPCS 636 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 NORFLEX UP TO 60MG J2360 HCPCS 636 Revenue Code Both 25 18.75 20 Fee Schedule 20 Fee Schedule 11.25 Fee Schedule 15 Fee Schedule 11.25 15 NORTRIPTYLINE (PAMELOR) 10MG CAP G6037 HCPCS 637 Revenue Code Both 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 NORTRIPTYLINE (PAMELOR) 25MG CAP G6037 HCPCS 637 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 NPH HUMAN (HUMULIN N) 1U/0.01ML INS INJ J1815 HCPCS 250 Revenue Code Both Each 10 7.5 8 Fee Schedule 8 Fee Schedule 4.5 Fee Schedule 6 Fee Schedule 4.5 6 NS 0.9 (SALINE) 5ML INH SOL 94640 CPT 410 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 NT-PROBNP 83880 CPT 300 Revenue Code Both 304 228 243.2 Fee Schedule 243.2 Fee Schedule 136.8 Fee Schedule 182.4 Fee Schedule 136.8 182.4 NUBAIN 10 MG J2300 HCPCS 636 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 NURSING FACILITY DISCHARGE 30MIN/LESS 99315 CPT 960 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 O & P CONCENTRATE AND SMEAR 87177 CPT 300 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 OAK IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 OBS/IP CARE ONE DAY STAY - INACTIVE 99236 CPT 987 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 OBS/IP CARE ONE DAY STAY - INACTIVE 99235 CPT 982 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 OBS/IP CARE ONE DAY STAY LEVEL 1 99234 CPT 987 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 OBS/IP CARE ONE DAY STAY LEVEL 2 99235 CPT 987 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 OBS/IP CARE ONE DAY STAY LEVEL 3 99236 CPT 987 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 OBS/IP ONE DAY STAY - INACTIVE 99234 CPT 982 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 OBSERVATION DISCHARGE DAY 99217 CPT 982 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 OBSERVATION DISCHARGE DAY 99217 CPT 982 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 OBSERVATION LEVEL 1 99218 CPT 982 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 OBSERVATION LEVEL 1 99218 CPT 982 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 OBSERVATION LEVEL 2 99219 CPT 982 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 OBSERVATION LEVEL 2 99219 CPT 982 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 OBSERVATION LEVEL 3 99220 CPT 987 Revenue Code Both 196 147 156.8 Fee Schedule 156.8 Fee Schedule 88.2 Fee Schedule 117.6 Fee Schedule 88.2 117.6 OBSERVATION LEVEL 3 99220 CPT 987 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 OBSERVATION PER HOUR G0378 HCPCS 270 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 OBSERVATION PER HOUR G0378 HCPCS 761 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 OBSERVATION SUBSEQUENT DAY LEVEL 1 99224 CPT 982 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 OBSERVATION SUBSEQUENT DAY LEVEL 1 99224 CPT 982 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 OBSERVATION SUBSEQUENT DAY LEVEL 2 99225 CPT 982 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 OBSERVATION SUBSEQUENT DAY LEVEL 2 99225 CPT 982 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 OBSERVATION SUBSEQUENT DAY LEVEL 3 99226 CPT 987 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 OBSERVATION SUBSEQUENT DAY LEVEL 3 99226 CPT 987 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 OBSERVATION TELEMETRY ROOM PER HOUR G0378 HCPCS 762 Revenue Code Both 109 81.75 87.2 Fee Schedule 87.2 Fee Schedule 49.05 Fee Schedule 65.4 Fee Schedule 49.05 65.4 OCCULT BLOOD 82272 CPT 300 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 OCCULT BLOOD 82272 CPT 300 Revenue Code Both 49 36.75 39.2 Fee Schedule 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 OCCULT BLOOD X 3 82270 CPT 300 Revenue Code Both 51 38.25 40.8 Fee Schedule 40.8 Fee Schedule 22.95 Fee Schedule 30.6 Fee Schedule 22.95 30.6 OCTREOTIDE ACETATE(SANDOSTATIN)50MCG INJ J2353 HCPCS 636 Revenue Code Both 16 12 12.8 Fee Schedule 12.8 Fee Schedule 7.2 Fee Schedule 9.6 Fee Schedule 7.2 9.6 OLANZIPINE (ZYPREXA) 10MG/VL INJ J2358 HCPCS 637 Revenue Code Both 65 48.75 52 Fee Schedule 52 Fee Schedule 29.25 Fee Schedule 39 Fee Schedule 29.25 39 OLMESARTAN (BENICAR) 20MG TAB J3490 HCPCS 637 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 ONDANSETRON (ZOFRAN) 4MG ODT TAB Q0162 HCPCS 637 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 ONDANSETRON (ZOFRAN) 4MG/2ML INJ J2405 HCPCS 637 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 ORGANISM ID 87077 CPT 300 Revenue Code Both 43 32.25 34.4 Fee Schedule 34.4 Fee Schedule 19.35 Fee Schedule 25.8 Fee Schedule 19.35 25.8 ORPHENADRINE (NORFLEX) 60MG/2ML INJ J2360 HCPCS 636 Revenue Code Both 62.5 46.875 50 Fee Schedule 50 Fee Schedule 28.125 Fee Schedule 37.5 Fee Schedule 28.125 37.5 "OSMOLALITY, SERUM" 83930 CPT 300 Revenue Code Both 190 142.5 152 Fee Schedule 152 Fee Schedule 85.5 Fee Schedule 114 Fee Schedule 85.5 114 "OSMOLALITY, URINE" 83935 CPT 300 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 OSTOMY STOMAHESIVE PASTE 7930 A4405 HCPCS 271 Revenue Code Both 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 OT ACTIVITIES OF DAILY LIVING TRAINING 97535 CPT 440 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 OUTPATIENT TREATMENT 99212 CPT 762 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 OXACARBAZEPINE METABOLITE 80183 CPT 300 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 OXACILLIN INJ PWD 1GM/NS100ML J2700 HCPCS 250 Revenue Code Both Each 60 45 48 Fee Schedule 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 OXCARBAZEPINE 80339 CPT 300 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 OYSTER SHELL CALCIUM 500MG TAB J3490 HCPCS 637 Revenue Code Both 21 15.75 16.8 Fee Schedule 16.8 Fee Schedule 9.45 Fee Schedule 12.6 Fee Schedule 9.45 12.6 "PACKED RED BLOOD CELLS, PER UNIT" P9021 HCPCS 390 Revenue Code Both 400 300 320 Fee Schedule 320 Fee Schedule 180 Fee Schedule 240 Fee Schedule 180 240 PANCREATIC ELASTASE 82653 CPT 300 Revenue Code Both 475 356.25 380 Fee Schedule 380 Fee Schedule 213.75 Fee Schedule 285 Fee Schedule 213.75 285 PANCREATIC ELASTASE -1 82656 CPT 300 Revenue Code Both 422 316.5 337.6 Fee Schedule 337.6 Fee Schedule 189.9 Fee Schedule 253.2 Fee Schedule 189.9 253.2 PANTOPRAZOLE (PROTONIX) 40MG/ML INJ J2470 HCPCS 636 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 PARACENTESIS (ABDOMINAL) W/O IMAGING 49082 CPT 761 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 PATHOLOGIST REVIEW 85060 CPT 300 Revenue Code Both 144 108 115.2 Fee Schedule 115.2 Fee Schedule 64.8 Fee Schedule 86.4 Fee Schedule 64.8 86.4 PCN BENZ (BICILLIN LA) 1.2MU/2ML INJ J0561 HCPCS 637 Revenue Code Both 402 301.5 321.6 Fee Schedule 321.6 Fee Schedule 180.9 Fee Schedule 241.2 Fee Schedule 180.9 241.2 PEDIAREX DTAP HEP B IPV 90723 CPT 636 Revenue Code Both 182 136.5 145.6 Fee Schedule 145.6 Fee Schedule 81.9 Fee Schedule 109.2 Fee Schedule 81.9 109.2 PENICILLIUM NOTATUM IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 PHARYNX REMOVAL OF FOREIGN BODY 42809 CPT 450 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 PHENERGAN UP TO 50MG J2550 HCPCS 636 Revenue Code Both 9 6.75 7.2 Fee Schedule 7.2 Fee Schedule 4.05 Fee Schedule 5.4 Fee Schedule 4.05 5.4 PHENOBARBITAL 80184 CPT 300 Revenue Code Both 137 102.75 109.6 Fee Schedule 109.6 Fee Schedule 61.65 Fee Schedule 82.2 Fee Schedule 61.65 82.2 PHENOBARBITAL 65MG/ML INJ J2560 HCPCS 637 Revenue Code Both 67 50.25 53.6 Fee Schedule 53.6 Fee Schedule 30.15 Fee Schedule 40.2 Fee Schedule 30.15 40.2 PHENYLEPHRINE(NEOSYNEPRINE)1%10MG/ML INJ J2372 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 PHENYTOIN (DILANTIN) 50MG/ML 2ML VIAL J1165 HCPCS 637 Revenue Code Both 9.5 7.125 7.6 Fee Schedule 7.6 Fee Schedule 4.275 Fee Schedule 5.7 Fee Schedule 4.275 5.7 PHOSPHORUS 84100 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 PHYSOSTIGMINE (ANTILIRIUM) 2MG/2ML INJ J3490 HCPCS 636 Revenue Code Both 105 78.75 84 Fee Schedule 84 Fee Schedule 47.25 Fee Schedule 63 Fee Schedule 47.25 63 PIOGLITAZONE (ACTOS) 15MG TAB J3490 HCPCS 637 Revenue Code Both 49 36.75 39.2 Fee Schedule 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 PIPER/TAZ (ZOSYN) 2.25G J2543 HCPCS 258 Revenue Code Both 18 13.5 14.4 Fee Schedule 14.4 Fee Schedule 8.1 Fee Schedule 10.8 Fee Schedule 8.1 10.8 PIPERACILLIN & TAZOBACTAM 3.375 GM INJ J2543 HCPCS 250 Revenue Code Both Each 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 PLASMA P9017 HCPCS 390 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 PLATELETS 85049 CPT 300 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 PM CORTISOL 82533 CPT 300 Revenue Code Both 172 129 137.6 Fee Schedule 137.6 Fee Schedule 77.4 Fee Schedule 103.2 Fee Schedule 77.4 103.2 PNEUMONIA 23 VACCINE ADULT DOSE 90732 CPT 636 Revenue Code Both 217 162.75 173.6 Fee Schedule 173.6 Fee Schedule 97.65 Fee Schedule 130.2 Fee Schedule 97.65 130.2 PNEUMONIA VACCINE UNDER AGE 5 90670 CPT 636 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 POLIOVIRUS IP0L 90713 CPT 636 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 POTASSIUM 84132 CPT 300 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 POTASSIUM CHL (KCL) 20MEQ/10ML INJ J3480 HCPCS 636 Revenue Code Both 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 POUCH FECAL 1 PC ACTIVE LIFE 22771 A4424 HCPCS 270 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 POWDER ARGLASE 5 GRAM A6262 HCPCS 271 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 PRALIDOXIME (PROTOPAM CHL) 1GM INJ J2730 HCPCS 636 Revenue Code Both 195 146.25 156 Fee Schedule 156 Fee Schedule 87.75 Fee Schedule 117 Fee Schedule 87.75 117 PREALBUMIN 84134 CPT 300 Revenue Code Both 161 120.75 128.8 Fee Schedule 128.8 Fee Schedule 72.45 Fee Schedule 96.6 Fee Schedule 72.45 96.6 PREALBUMIN 84134 CPT 300 Revenue Code Both 166 124.5 132.8 Fee Schedule 132.8 Fee Schedule 74.7 Fee Schedule 99.6 Fee Schedule 74.7 99.6 PREDNISOLONE (PRELONE) 15MG/5ML LIQ J7510 HCPCS 637 Revenue Code Both 6 4.5 4.8 Fee Schedule 4.8 Fee Schedule 2.7 Fee Schedule 3.6 Fee Schedule 2.7 3.6 PREDNISONE (DELTASONE) 1MG TAB J7512 HCPCS 636 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 PREGNANCY TEST URINE 81025 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 PRESUMPTIVE ID 87088 CPT 300 Revenue Code Both 43 32.25 34.4 Fee Schedule 34.4 Fee Schedule 19.35 Fee Schedule 25.8 Fee Schedule 19.35 25.8 PROBIOTIC CAPSULE (COLON HEALTH) 1 CAP J3490 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 PROCHLORPERAZINE (COMPAZINE) 10MG/2M INJ J0780 HCPCS 771 Revenue Code Both 14 10.5 11.2 Fee Schedule 11.2 Fee Schedule 6.3 Fee Schedule 8.4 Fee Schedule 6.3 8.4 PROCHLORPERAZINE (COMPAZINE) 25MG SUPP J8498 HCPCS 637 Revenue Code Both 44 33 35.2 Fee Schedule 35.2 Fee Schedule 19.8 Fee Schedule 26.4 Fee Schedule 19.8 26.4 PROCHLORPERAZINE (COMPAZINE) 5MG TAB J3490 HCPCS 637 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 PROGESTERONE 84144 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 PROLACTIN 84146 CPT 300 Revenue Code Both 305 228.75 244 Fee Schedule 244 Fee Schedule 137.25 Fee Schedule 183 Fee Schedule 137.25 183 PROMETHAZINE (PHENERGAN) 12.5MG SUPP J8498 HCPCS 636 Revenue Code Both 114 85.5 91.2 Fee Schedule 91.2 Fee Schedule 51.3 Fee Schedule 68.4 Fee Schedule 51.3 68.4 PROMETHAZINE (PHENERGAN) 25MG SUPP J8498 HCPCS 637 Revenue Code Both 114 85.5 91.2 Fee Schedule 91.2 Fee Schedule 51.3 Fee Schedule 68.4 Fee Schedule 51.3 68.4 PROMETHAZINE (PHENERGAN) 25MG TAB Q0169 HCPCS 637 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 PROMETHAZINE (PHENERGAN) 25MG/ML INJ J2550 HCPCS 637 Revenue Code Both 19.5 14.625 15.6 Fee Schedule 15.6 Fee Schedule 8.775 Fee Schedule 11.7 Fee Schedule 8.775 11.7 PROMETHAZINE (PHENERGAN) 50MG TAB Q0169 HCPCS 637 Revenue Code Both 14 10.5 11.2 Fee Schedule 11.2 Fee Schedule 6.3 Fee Schedule 8.4 Fee Schedule 6.3 8.4 PROMETHAZINE (PHENERGAN) 50MG/ML INJ J2550 HCPCS 637 Revenue Code Both 22 16.5 17.6 Fee Schedule 17.6 Fee Schedule 9.9 Fee Schedule 13.2 Fee Schedule 9.9 13.2 PRO-STAT SF CITRUS SPLASH 1OZ. B4155 HCPCS 637 Revenue Code Both 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 PRO-STAT SF GRAPE 1OZ. B4155 HCPCS 637 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 PROTAMINE 250MG/25ML INJ J2720 HCPCS 637 Revenue Code Both 9.5 7.125 7.6 Fee Schedule 7.6 Fee Schedule 4.275 Fee Schedule 5.7 Fee Schedule 4.275 5.7 PROTEIN ELECTROPHORESIS W/KAPPA 84165 CPT 300 Revenue Code Both 214 160.5 171.2 Fee Schedule 171.2 Fee Schedule 96.3 Fee Schedule 128.4 Fee Schedule 96.3 128.4 "PROTEIN ELECTROPHORESIS, URINE" 84166 CPT 300 Revenue Code Both 176 132 140.8 Fee Schedule 140.8 Fee Schedule 79.2 Fee Schedule 105.6 Fee Schedule 79.2 105.6 PROTIME W/INR 85610 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 PSA G0103 HCPCS 300 Revenue Code Both 152 114 121.6 Fee Schedule 121.6 Fee Schedule 68.4 Fee Schedule 91.2 Fee Schedule 68.4 91.2 PSA 84153 CPT 300 Revenue Code Both 154 115.5 123.2 Fee Schedule 123.2 Fee Schedule 69.3 Fee Schedule 92.4 Fee Schedule 69.3 92.4 PT CARDIAC REHABILITATION 93797 CPT 420 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 PT CONTRAST BATHS 15 MIN 97034 CPT 420 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 PT DEBRIDEMENT < OR = 20 CM 97597 CPT 420 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 PT E-STIMULATION 97014 CPT 420 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 PT EVALUATION HIGH LEVEL COMPLEXITY 97163 CPT 420 Revenue Code Both 269 201.75 215.2 Fee Schedule 215.2 Fee Schedule 121.05 Fee Schedule 161.4 Fee Schedule 121.05 161.4 PT EVALUATION LOW COMPLEXITY 97161 CPT 424 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 PT EVALUATION MODERATE COMPLEXITY 97162 CPT 424 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 PT GAIT TRAINING 15 MIN 97116 CPT 420 Revenue Code Both 84 63 67.2 Fee Schedule 67.2 Fee Schedule 37.8 Fee Schedule 50.4 Fee Schedule 37.8 50.4 PT HEP 97535 CPT 420 Revenue Code Both 102 76.5 81.6 Fee Schedule 81.6 Fee Schedule 45.9 Fee Schedule 61.2 Fee Schedule 45.9 61.2 PT HOT PACKS 97010 CPT 420 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 PT IONTOPHORESIS 15 MIN 97033 CPT 420 Revenue Code Both 93 69.75 74.4 Fee Schedule 74.4 Fee Schedule 41.85 Fee Schedule 55.8 Fee Schedule 41.85 55.8 PT MANUAL THERAPY TECHNIQUES 15 MIN 97140 CPT 420 Revenue Code Both 89 66.75 71.2 Fee Schedule 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 PT MASSAGE THERAPY 15 MIN 97124 CPT 420 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 420 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 PT PARAFFIN BATH 97018 CPT 420 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 PT PHYSICAL PERFORMANCE TEST/MEASUREMENT 97750 CPT 420 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 PT RE-EVALUATION 97164 CPT 420 Revenue Code Both 186 139.5 148.8 Fee Schedule 148.8 Fee Schedule 83.7 Fee Schedule 111.6 Fee Schedule 83.7 111.6 PT REMOVAL OF DEVITALIZED TISSUE 97602 CPT 420 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 PT THERAPEUTIC ACTIVITIES 15 MIN 97530 CPT 424 Revenue Code Both 96 72 76.8 Fee Schedule 76.8 Fee Schedule 43.2 Fee Schedule 57.6 Fee Schedule 43.2 57.6 PT THERAPEUTIC EXERCISE 15 MIN 97110 CPT 420 Revenue Code Both 93 69.75 74.4 Fee Schedule 74.4 Fee Schedule 41.85 Fee Schedule 55.8 Fee Schedule 41.85 55.8 PT ULTRASOUND 15 MIN 97035 CPT 420 Revenue Code Both 73 54.75 58.4 Fee Schedule 58.4 Fee Schedule 32.85 Fee Schedule 43.8 Fee Schedule 32.85 43.8 PT WHEELCHAIR TRAINING 15 MIN 97542 CPT 420 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 PT WOUND CARE > 20 CM 97598 CPT 420 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 "PTH, INTACT W/O CALCIUM" 83970 CPT 300 Revenue Code Both 194 145.5 155.2 Fee Schedule 155.2 Fee Schedule 87.3 Fee Schedule 116.4 Fee Schedule 87.3 116.4 PTT 85730 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 PULMONARY FUNCTION 94060 CPT 460 Revenue Code Both 439 329.25 351.2 Fee Schedule 351.2 Fee Schedule 197.55 Fee Schedule 263.4 Fee Schedule 197.55 263.4 PULMONARY FUNCTION STUDY 94060 CPT 410 Revenue Code Both 111 83.25 88.8 Fee Schedule 88.8 Fee Schedule 49.95 Fee Schedule 66.6 Fee Schedule 49.95 66.6 PULSE OX BY ORDER OF THE PHYSCIAN 94760 CPT 450 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 PULSE OXIMETRY 94760 CPT 990 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 PULSE OXIMETRY ER 94760 CPT 460 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 PUNCH BIOPSY OF SKIN 11104 CPT 761 Revenue Code Both 383 287.25 306.4 Fee Schedule 306.4 Fee Schedule 172.35 Fee Schedule 229.8 Fee Schedule 172.35 229.8 PUNCTURE ASPIRATION BREAST CYST 19000 CPT 981 Revenue Code Both 77 57.75 61.6 Fee Schedule 61.6 Fee Schedule 34.65 Fee Schedule 46.2 Fee Schedule 34.65 46.2 PUNCTURE ASPIRATION CYST/ABSCESS./HEMA 10160 CPT 981 Revenue Code Both 111 83.25 88.8 Fee Schedule 88.8 Fee Schedule 49.95 Fee Schedule 66.6 Fee Schedule 49.95 66.6 PUNCTURE ASPIRATION OF ABCESS 10160 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 PYRIDOXINE (VIT B6) 100MG/ML INJ J3415 HCPCS 636 Revenue Code Both 67 50.25 53.6 Fee Schedule 53.6 Fee Schedule 30.15 Fee Schedule 40.2 Fee Schedule 30.15 40.2 QCT BONE DENSITY 77078 CPT 350 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 QUANTAFLO MULTIPLE LEVELS 93923 CPT 460 Revenue Code Both 427 320.25 341.6 Fee Schedule 341.6 Fee Schedule 192.15 Fee Schedule 256.2 Fee Schedule 192.15 256.2 QUANTIFERON TB GOLD 86480 CPT 300 Revenue Code Both 451 338.25 360.8 Fee Schedule 360.8 Fee Schedule 202.95 Fee Schedule 270.6 Fee Schedule 202.95 270.6 QUEST AD-DETECT BETA-AMYLOID 42/40 RATIO 0346U CPT 300 Revenue Code Both 1193 894.75 954.4 Fee Schedule 954.4 Fee Schedule 536.85 Fee Schedule 715.8 Fee Schedule 536.85 715.8 QUEST ASSURED VITAMIN D 82306 CPT 300 Revenue Code Both 358 268.5 286.4 Fee Schedule 286.4 Fee Schedule 161.1 Fee Schedule 214.8 Fee Schedule 161.1 214.8 RABEPRAZOLE (ACIPHEX) 20MG TAB J3490 HCPCS 636 Revenue Code Both 66 49.5 52.8 Fee Schedule 52.8 Fee Schedule 29.7 Fee Schedule 39.6 Fee Schedule 29.7 39.6 RABIES IMM GLOB (HYPERAB)300U/ML 5ML INJ 90375 CPT 637 Revenue Code Both 4453 3339.75 3562.4 Fee Schedule 3562.4 Fee Schedule 2003.85 Fee Schedule 2671.8 Fee Schedule 2003.85 2671.8 RABIES VACCINE (RABAVERT) INJ 90675 CPT 637 Revenue Code Both 623 467.25 498.4 Fee Schedule 498.4 Fee Schedule 280.35 Fee Schedule 373.8 Fee Schedule 280.35 373.8 RABIES VACCINE IM 90675 CPT 636 Revenue Code Both 498 373.5 398.4 Fee Schedule 398.4 Fee Schedule 224.1 Fee Schedule 298.8 Fee Schedule 224.1 298.8 RACEPINEPHRINE (S2) 2.25% INH SOL 94640 CPT 637 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 RANITIDINE (ZANTAC) 50MG TAB J2780 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 RANITIDINE (ZANTAC) 50MG/2ML INJ J2780 HCPCS 637 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 RBC FOLATE 82747 CPT 300 Revenue Code Both 120 90 96 Fee Schedule 96 Fee Schedule 54 Fee Schedule 72 Fee Schedule 54 72 REDUCING SUBSTANCES 84376 CPT 300 Revenue Code Both 178 133.5 142.4 Fee Schedule 142.4 Fee Schedule 80.1 Fee Schedule 106.8 Fee Schedule 80.1 106.8 REFLEX CHARGE ANA TITER AND PATTERN 86039 CPT 300 Revenue Code Both 99 74.25 79.2 Fee Schedule 79.2 Fee Schedule 44.55 Fee Schedule 59.4 Fee Schedule 44.55 59.4 REGLAN 10MG J2765 HCPCS 636 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 REM FOREIGN BODY MUSCLE TENDON 20520 CPT 981 Revenue Code Both 363 272.25 290.4 Fee Schedule 290.4 Fee Schedule 163.35 Fee Schedule 217.8 Fee Schedule 163.35 217.8 REMDESIVIR (VEKLURY) 100MG INJ J0248 HCPCS 637 Revenue Code Both 1113 834.75 890.4 Fee Schedule 890.4 Fee Schedule 500.85 Fee Schedule 667.8 Fee Schedule 500.85 667.8 REMOVAL FB AUDITORY CANAL 69200 CPT 982 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 REMOVAL FB CORNEA 65220 CPT 450 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 REMOVAL FOREIGN BODY FOOT DEEP 28192 CPT 981 Revenue Code Both 679 509.25 543.2 Fee Schedule 543.2 Fee Schedule 305.55 Fee Schedule 407.4 Fee Schedule 305.55 407.4 REMOVAL FOREIGN BODY INTRANASAL 30300 CPT 450 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 REMOVAL IMPACTED CERUMEN 69210 CPT 320 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 REMOVAL IMPACTED CERUMEN 69210 CPT 982 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 REMOVAL OF FOREIGHN BODY FOOT DEEP 28192 CPT 450 Revenue Code Both 679 509.25 543.2 Fee Schedule 543.2 Fee Schedule 305.55 Fee Schedule 407.4 Fee Schedule 305.55 407.4 REMOVAL OF FOREIGN BODY FOOT: SUBCUTANE 28190 CPT 450 Revenue Code Both 553 414.75 442.4 Fee Schedule 442.4 Fee Schedule 248.85 Fee Schedule 331.8 Fee Schedule 248.85 331.8 REMOVAL OF IUD 58301 CPT 270 Revenue Code Both 108 81 86.4 Fee Schedule 86.4 Fee Schedule 48.6 Fee Schedule 64.8 Fee Schedule 48.6 64.8 REMOVAL SKIN TAGS UP TO 15 LESIONS 11200 CPT 981 Revenue Code Both 88 66 70.4 Fee Schedule 70.4 Fee Schedule 39.6 Fee Schedule 52.8 Fee Schedule 39.6 52.8 REMOVE F B DEEP THIGH\KNEE REGION 27372 CPT 981 Revenue Code Both 765 573.75 612 Fee Schedule 612 Fee Schedule 344.25 Fee Schedule 459 Fee Schedule 344.25 459 REMOVE NASAL FOREIGN BODY 30300 CPT 981 Revenue Code Both 95 71.25 76 Fee Schedule 76 Fee Schedule 42.75 Fee Schedule 57 Fee Schedule 42.75 57 REPAIR INT HANDS FEET NECK >2.5CM 12041 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 REPAIR INTERMED 12.6 - 20.0CM 12035 CPT 450 Revenue Code Both 579 434.25 463.2 Fee Schedule 463.2 Fee Schedule 260.55 Fee Schedule 347.4 Fee Schedule 260.55 347.4 REPAIR INTERMED 2.5CM OR LESS 12031 CPT 450 Revenue Code Both 434 325.5 347.2 Fee Schedule 347.2 Fee Schedule 195.3 Fee Schedule 260.4 Fee Schedule 195.3 260.4 REPAIR INTERMED 2.6-7.5 CM' 12032 CPT 450 Revenue Code Both 500 375 400 Fee Schedule 400 Fee Schedule 225 Fee Schedule 300 Fee Schedule 225 300 REPAIR INTERMED 7.6-12.5 CM 12034 CPT 450 Revenue Code Both 434 325.5 347.2 Fee Schedule 347.2 Fee Schedule 195.3 Fee Schedule 260.4 Fee Schedule 195.3 260.4 REPAIR OF WOUND OR LESION- COMPLEX 13101 CPT 981 Revenue Code Both 418 313.5 334.4 Fee Schedule 334.4 Fee Schedule 188.1 Fee Schedule 250.8 Fee Schedule 188.1 250.8 REPAIR WOUND 7.6 TO 12.5 CM 12004 CPT 981 Revenue Code Both 223 167.25 178.4 Fee Schedule 178.4 Fee Schedule 100.35 Fee Schedule 133.8 Fee Schedule 100.35 133.8 REPAIR-INT LAYER CLOSURE FACE EAR ETC 12051 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 REPAIR-SIMPLE 20.1 TO 30.0CM 12006 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 RESPIRATORY VIRAL PANEL 87633 CPT 300 Revenue Code Both 1484 1113 1187.2 Fee Schedule 1187.2 Fee Schedule 667.8 Fee Schedule 890.4 Fee Schedule 667.8 890.4 RETICULOCYTE COUNT 85044 CPT 300 Revenue Code Both 45 33.75 36 Fee Schedule 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 REVERSE T3 84482 CPT 300 Revenue Code Both 518 388.5 414.4 Fee Schedule 414.4 Fee Schedule 233.1 Fee Schedule 310.8 Fee Schedule 233.1 310.8 RHEUMATOID FACTOR 86430 CPT 300 Revenue Code Both 78 58.5 62.4 Fee Schedule 62.4 Fee Schedule 35.1 Fee Schedule 46.8 Fee Schedule 35.1 46.8 RIB BELT UNIV (FEMALE) 29200 CPT 274 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 RIB BELT UNIV (MALE) 29200 CPT 270 Revenue Code Both 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 RIBOSOMAL P AB 83516 CPT 300 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 "RMSF ANTIBODIES, IGG" 86757 CPT 300 Revenue Code Both 264 198 211.2 Fee Schedule 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 "RMSF ANTIBODIES, IGM" 86757 CPT 300 Revenue Code Both 264 198 211.2 Fee Schedule 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 ROCEPHIN 250MG J0696 HCPCS 636 Revenue Code Both 3 2.25 2.4 Fee Schedule 2.4 Fee Schedule 1.35 Fee Schedule 1.8 Fee Schedule 1.35 1.8 ROTAVIRUS 90680 CPT 636 Revenue Code Both 215 161.25 172 Fee Schedule 172 Fee Schedule 96.75 Fee Schedule 129 Fee Schedule 96.75 129 ROTAVIRUS AG 90680 CPT 300 Revenue Code Both 215 161.25 172 Fee Schedule 172 Fee Schedule 96.75 Fee Schedule 129 Fee Schedule 96.75 129 ROTAVIRUS ANTIGEN DETECTION 90680 CPT 636 Revenue Code Both 215 161.25 172 Fee Schedule 172 Fee Schedule 96.75 Fee Schedule 129 Fee Schedule 96.75 129 ROUTINE VENIPUNCTURE 36415 CPT 761 Revenue Code Both 41 30.75 32.8 Fee Schedule 32.8 Fee Schedule 18.45 Fee Schedule 24.6 Fee Schedule 18.45 24.6 RPR W/REFLEX 86592 CPT 300 Revenue Code Both 73 54.75 58.4 Fee Schedule 58.4 Fee Schedule 32.85 Fee Schedule 43.8 Fee Schedule 32.85 43.8 RSV 90378 CPT 771 Revenue Code Both 767 575.25 613.6 Fee Schedule 613.6 Fee Schedule 345.15 Fee Schedule 460.2 Fee Schedule 345.15 460.2 RSV 87807 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 RSV (RAPID) MAL 87420 CPT 300 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 RT ANTI-REFLUX VALVE B4082 HCPCS 270 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 RT CPAP SYSTEM LG ADULT 94660 CPT 270 Revenue Code Both 236 177 188.8 Fee Schedule 188.8 Fee Schedule 106.2 Fee Schedule 141.6 Fee Schedule 106.2 141.6 RT CPAP SYSTEM LG ADULT 94660 CPT 270 Revenue Code Both 251 188.25 200.8 Fee Schedule 200.8 Fee Schedule 112.95 Fee Schedule 150.6 Fee Schedule 112.95 150.6 RT CPAP SYSTEM MED/SM E0470 HCPCS 270 Revenue Code Both 84 63 67.2 Fee Schedule 67.2 Fee Schedule 37.8 Fee Schedule 50.4 Fee Schedule 37.8 50.4 RT CPAP SYSTEM MED/SMALL ADULT E0470 HCPCS 270 Revenue Code Both 236 177 188.8 Fee Schedule 188.8 Fee Schedule 106.2 Fee Schedule 141.6 Fee Schedule 106.2 141.6 RT NASAL CANNULA 25' A4615 HCPCS 270 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 RT NASAL CANNULA 25' A4615 HCPCS 270 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 RT O2 INCENTIVE SPIROMETER A9284 HCPCS 270 Revenue Code Both 56 42 44.8 Fee Schedule 44.8 Fee Schedule 25.2 Fee Schedule 33.6 Fee Schedule 25.2 33.6 RT PULSE OX E0445 HCPCS 270 Revenue Code Both 64 48 51.2 Fee Schedule 51.2 Fee Schedule 28.8 Fee Schedule 38.4 Fee Schedule 28.8 38.4 RT PULSE OX E0445 HCPCS 410 Revenue Code Both 64 48 51.2 Fee Schedule 51.2 Fee Schedule 28.8 Fee Schedule 38.4 Fee Schedule 28.8 38.4 RT SALEM SUMP TUBING 10 FR B4082 HCPCS 270 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 RT SALEM SUMP TUBING 16 FR B4082 HCPCS 270 Revenue Code Both 82 61.5 65.6 Fee Schedule 65.6 Fee Schedule 36.9 Fee Schedule 49.2 Fee Schedule 36.9 49.2 RT SALEM SUMP TUBING 18FR B4082 HCPCS 270 Revenue Code Both 33 24.75 26.4 Fee Schedule 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 SALEM SUMP ANTIREF VALVE B4082 HCPCS 270 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 SALEM SUMP TUBING 10 FR B4082 HCPCS 270 Revenue Code Both 86 64.5 68.8 Fee Schedule 68.8 Fee Schedule 38.7 Fee Schedule 51.6 Fee Schedule 38.7 51.6 SALEM SUMP TUBING 16FR B4082 HCPCS 270 Revenue Code Both 87 65.25 69.6 Fee Schedule 69.6 Fee Schedule 39.15 Fee Schedule 52.2 Fee Schedule 39.15 52.2 SALEM SUMP TUBING 18FR B4082 HCPCS 270 Revenue Code Both 35 26.25 28 Fee Schedule 28 Fee Schedule 15.75 Fee Schedule 21 Fee Schedule 15.75 21 SALICYLATE 80329 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 SARS COV 2 SEROLOGY (COVID 19) 86769 CPT 300 Revenue Code Both 207 155.25 165.6 Fee Schedule 165.6 Fee Schedule 93.15 Fee Schedule 124.2 Fee Schedule 93.15 124.2 "SARS COV-2 AB IGG SPIKE, SEMI-QN" 86769 CPT 300 Revenue Code Both 138 103.5 110.4 Fee Schedule 110.4 Fee Schedule 62.1 Fee Schedule 82.8 Fee Schedule 62.1 82.8 "SARS COV-2 RNA, QL" 87635 CPT 300 Revenue Code Both 212 159 169.6 Fee Schedule 169.6 Fee Schedule 95.4 Fee Schedule 127.2 Fee Schedule 95.4 127.2 SCREENING/RECTAL EXAM G0102 HCPCS 637 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 SERUM BENZODIAZEPINES 80346 CPT 300 Revenue Code Both 261 195.75 208.8 Fee Schedule 208.8 Fee Schedule 117.45 Fee Schedule 156.6 Fee Schedule 117.45 156.6 SERUM DRUG ABUSE PANEL W/CONFIRMATION 80307 CPT 300 Revenue Code Both 1009 756.75 807.2 Fee Schedule 807.2 Fee Schedule 454.05 Fee Schedule 605.4 Fee Schedule 454.05 605.4 SERUM OSMOLALITY 83930 CPT 300 Revenue Code Both 190 142.5 152 Fee Schedule 152 Fee Schedule 85.5 Fee Schedule 114 Fee Schedule 85.5 114 SEX HORMONE BINDING GLOBULIN 84270 CPT 300 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 SHAVE BIOPSY SKIN SCLP NECK HAND 2.5CM 11305 CPT 981 Revenue Code Both 66 49.5 52.8 Fee Schedule 52.8 Fee Schedule 29.7 Fee Schedule 39.6 Fee Schedule 29.7 39.6 SHAVE LESION FACE 0.6 CM TO 1.0 CM 11311 CPT 981 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 SHAVE SKIN LESION FACE .5 CM OR LESS 11310 CPT 981 Revenue Code Both 71 53.25 56.8 Fee Schedule 56.8 Fee Schedule 31.95 Fee Schedule 42.6 Fee Schedule 31.95 42.6 SHAVE SKIN LESION NECK HANDS OVER 2CM 11308 CPT 981 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 SHAVING EPIDERMAL LESION <.5CM 11300 CPT 981 Revenue Code Both 49 36.75 39.2 Fee Schedule 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 SHAVING OF EPIDERMAL OR DERMAL LESION 11300 CPT 761 Revenue Code Both 164 123 131.2 Fee Schedule 131.2 Fee Schedule 73.8 Fee Schedule 98.4 Fee Schedule 73.8 98.4 SHORT LEG SPLINT 29515 CPT 270 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 SHOULDER CLOSED TX DISLOCATION WO MAN 23650 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 SILDENAFIL (VIAGRA) 20MG TAB S0090 HCPCS 637 Revenue Code Both 92 69 73.6 Fee Schedule 73.6 Fee Schedule 41.4 Fee Schedule 55.2 Fee Schedule 41.4 55.2 SIMPLE REPAIR 12.6CM TO 20.0CM 12005 CPT 450 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 SIMPLE REPAIR 2.5 CM OR LESS 12001 CPT 981 Revenue Code Both 147 110.25 117.6 Fee Schedule 117.6 Fee Schedule 66.15 Fee Schedule 88.2 Fee Schedule 66.15 88.2 SIMPLE REPAIR 2.6 TO 7.5 CM 12002 CPT 981 Revenue Code Both 191 143.25 152.8 Fee Schedule 152.8 Fee Schedule 85.95 Fee Schedule 114.6 Fee Schedule 85.95 114.6 SIMPLE REPAIR 2.6CM TO 7.5CM 12002 CPT 450 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 SIMPLE REPAIR 20.1 TO 30.0 CM 10 DAY GLO 12006 CPT 981 Revenue Code Both 355 266.25 284 Fee Schedule 284 Fee Schedule 159.75 Fee Schedule 213 Fee Schedule 159.75 213 SIMPLE REPAIR 5.1-7.5CM 12014 CPT 450 Revenue Code Both 230 172.5 184 Fee Schedule 184 Fee Schedule 103.5 Fee Schedule 138 Fee Schedule 103.5 138 SIMPLE REPAIR 7.6CM TO 12.5CM 12004 CPT 450 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 SIMPLE REPAIR FACE 12015 CPT 450 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 SIMPLE REPAIR FACE 2.5 CM OR LESS 12011 CPT 981 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 SIMPLE REPAIR FACE 2.5 TO 5.0 CM 12013 CPT 960 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 SIMPLE REPAIR FACE 2.5CM OR LESS 12011 CPT 450 Revenue Code Both 332 249 265.6 Fee Schedule 265.6 Fee Schedule 149.4 Fee Schedule 199.2 Fee Schedule 149.4 199.2 SIMPLE REPAIR FACE 2.6-5.0CM 12013 CPT 450 Revenue Code Both 422 316.5 337.6 Fee Schedule 337.6 Fee Schedule 189.9 Fee Schedule 253.2 Fee Schedule 189.9 253.2 SIMPLE REPAIR SCALP NECK 7.6CM TO 12.5 12015 CPT 981 Revenue Code Both 240 180 192 Fee Schedule 192 Fee Schedule 108 Fee Schedule 144 Fee Schedule 108 144 SIMPLE REPAIR SCALP NECK 7.6CM TO 12.5 12015 CPT 981 Revenue Code Both 301 225.75 240.8 Fee Schedule 240.8 Fee Schedule 135.45 Fee Schedule 180.6 Fee Schedule 135.45 180.6 SIMPLE RPR SCLP//NECK/AX/GNTL/TRNK 2.5 L 12001 CPT 450 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 SJOGREN'S SS-A AND SS-B AB 86235 CPT 300 Revenue Code Both 277 207.75 221.6 Fee Schedule 221.6 Fee Schedule 124.65 Fee Schedule 166.2 Fee Schedule 124.65 166.2 SKIN TAG REMOVAL ADDITIONAL 10 11201 CPT 270 Revenue Code Both 106 79.5 84.8 Fee Schedule 84.8 Fee Schedule 47.7 Fee Schedule 63.6 Fee Schedule 47.7 63.6 SKIN TAG REMOVAL FIRST 15 11200 CPT 761 Revenue Code Both 212 159 169.6 Fee Schedule 169.6 Fee Schedule 95.4 Fee Schedule 127.2 Fee Schedule 95.4 127.2 SKIN TEST-CANADIDA 86485 CPT 300 Revenue Code Both 95 71.25 76 Fee Schedule 76 Fee Schedule 42.75 Fee Schedule 57 Fee Schedule 42.75 57 SLING ARM DLX XL A4565 HCPCS 270 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 SM/RNP AB 86235 CPT 300 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 SMEAR SPECIAL STAIN 87207 CPT 300 Revenue Code Both 75 56.25 60 Fee Schedule 60 Fee Schedule 33.75 Fee Schedule 45 Fee Schedule 33.75 45 SNF EVALUATION COMPLEX 99306 CPT 960 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 SNF EVALUATION LOW 99304 CPT 960 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 SNF SUBSEQENT VISIT LEVEL 1 99307 CPT 960 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 SODIUM 84295 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 SODIUM CHLORIDE 0.9% (NACL) 1000ML IV J7030 HCPCS 250 Revenue Code Both Each 15 11.25 12 Fee Schedule 12 Fee Schedule 6.75 Fee Schedule 9 Fee Schedule 6.75 9 SODIUM CHLORIDE 0.9% (NACL) 100ML IV J7050 HCPCS 250 Revenue Code Both Each 13 9.75 10.4 Fee Schedule 10.4 Fee Schedule 5.85 Fee Schedule 7.8 Fee Schedule 5.85 7.8 SODIUM CHLORIDE 0.9% (NACL) 250ML IV J7050 HCPCS 250 Revenue Code Both Each 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 SOLUMEDROL INJ UP TO 125 MG J2930 HCPCS 637 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 SPEECH THERAPY FEES 92612 CPT 444 Revenue Code Both 530 397.5 424 Fee Schedule 424 Fee Schedule 238.5 Fee Schedule 318 Fee Schedule 238.5 318 SPLIT GRAFT 100 SQ CM OR LESS 15120 CPT 981 Revenue Code Both 1240 930 992 Fee Schedule 992 Fee Schedule 558 Fee Schedule 744 Fee Schedule 558 744 SPLT GRFT 100 CM OR LESS 15100 CPT 981 Revenue Code Both 1042 781.5 833.6 Fee Schedule 833.6 Fee Schedule 468.9 Fee Schedule 625.2 Fee Schedule 468.9 625.2 STERILE 4 X 4 A6402 HCPCS 270 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 STONE ANALYSIS W/IMAGE 82365 CPT 300 Revenue Code Both 227 170.25 181.6 Fee Schedule 181.6 Fee Schedule 102.15 Fee Schedule 136.2 Fee Schedule 102.15 136.2 STRAIGHT CATH FOR RESIDUAL URINE 51701 CPT 760 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 STRAIGHT CATH URINE SPECIMEN COLLECTION P9612 HCPCS 760 Revenue Code Both 34 25.5 27.2 Fee Schedule 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 STRAIGHT CATH URINE SPECIMENT COLLECT P9612 HCPCS 760 Revenue Code Both 11 8.25 8.8 Fee Schedule 8.8 Fee Schedule 4.95 Fee Schedule 6.6 Fee Schedule 4.95 6.6 STRAPPING ANKLE AND/OR FOOT 29540 CPT 450 Revenue Code Both 230 172.5 184 Fee Schedule 184 Fee Schedule 103.5 Fee Schedule 138 Fee Schedule 103.5 138 STRAPPING OF ELBOW OR WRIST 29260 CPT 450 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 STRAPPING OF KNEE 29530 CPT 450 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 STRAPPING OF SHOULDER 29240 CPT 450 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 STRAPPING THORAX 29200 CPT 450 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 STREP A 87880 CPT 300 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 SUBSEQUENT IH CARE LEVEL 1 99231 CPT 987 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 SUBSEQUENT IH CARE LEVEL 1 - INACTIVE 99231 CPT 987 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 SUBSEQUENT IH CARE LEVEL 2 99232 CPT 987 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 SUBSEQUENT IH CARE LEVEL 2 - INACTIVE 99232 CPT 987 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 SUBSEQUENT IH CARE LEVEL 3 99233 CPT 987 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 SUBSEQUENT IH CARE LEVEL 3 - INACTIVE 99233 CPT 982 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 SUMATRIPTAN (IMITREX) 6MG/0.5ML INJ J3030 HCPCS 637 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 SUSCEPTIBILITY 87186 CPT 300 Revenue Code Both 52 39 41.6 Fee Schedule 41.6 Fee Schedule 23.4 Fee Schedule 31.2 Fee Schedule 23.4 31.2 SUTURE 0 PDS PLUS ANTIBACTERIAL TP-1 41510 CPT 270 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 SUTURE FACE EAR EYELID LIP 5-7.5 CM 12014 CPT 981 Revenue Code Both 240 180 192 Fee Schedule 192 Fee Schedule 108 Fee Schedule 144 Fee Schedule 108 144 SYNVISC 1MG J7325 HCPCS 250 Revenue Code Both Each 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 SYNVISC 1MG J7325 HCPCS 636 Revenue Code Both 43 32.25 34.4 Fee Schedule 34.4 Fee Schedule 19.35 Fee Schedule 25.8 Fee Schedule 19.35 25.8 SYNVISC 1MG INJ J7325 HCPCS 637 Revenue Code Both 57.25 42.9375 45.8 Fee Schedule 45.8 Fee Schedule 25.7625 Fee Schedule 34.35 Fee Schedule 25.7625 34.35 T B INTRADERMAL 86580 CPT 636 Revenue Code Both 38 28.5 30.4 Fee Schedule 30.4 Fee Schedule 17.1 Fee Schedule 22.8 Fee Schedule 17.1 22.8 T3 UPTAKE 84479 CPT 300 Revenue Code Both 68 51 54.4 Fee Schedule 54.4 Fee Schedule 30.6 Fee Schedule 40.8 Fee Schedule 30.6 40.8 TACROLIMUS 80197 CPT 300 Revenue Code Both 378 283.5 302.4 Fee Schedule 302.4 Fee Schedule 170.1 Fee Schedule 226.8 Fee Schedule 170.1 226.8 TACROLIMUS (PROTOPIC) 1MG CAP J7507 HCPCS 637 Revenue Code Both 32 24 25.6 Fee Schedule 25.6 Fee Schedule 14.4 Fee Schedule 19.2 Fee Schedule 14.4 19.2 Tamoxifen Citrate Tab 20MG J3490 HCPCS 250 Revenue Code Both Each 19 14.25 15.2 Fee Schedule 15.2 Fee Schedule 8.55 Fee Schedule 11.4 Fee Schedule 8.55 11.4 TB INTRADERMAL 86580 CPT 940 Revenue Code Both 25 18.75 20 Fee Schedule 20 Fee Schedule 11.25 Fee Schedule 15 Fee Schedule 11.25 15 TD ADULT 86580 CPT 636 Revenue Code Both 90 67.5 72 Fee Schedule 72 Fee Schedule 40.5 Fee Schedule 54 Fee Schedule 40.5 54 TDAP ADACEL OVER 7 YEARS 90715 CPT 636 Revenue Code Both 142 106.5 113.6 Fee Schedule 113.6 Fee Schedule 63.9 Fee Schedule 85.2 Fee Schedule 63.9 85.2 TELEHEALTH VISIT G2025 HCPCS 636 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 TENECTEPLASE (TNKASE) 50MG INJ J3101 HCPCS 250 Revenue Code Both Each 10745 8058.75 8596 Fee Schedule 8596 Fee Schedule 4835.25 Fee Schedule 6447 Fee Schedule 4835.25 6447 TESTOSTERONE CYPIONATE 1MG J1071 HCPCS 636 Revenue Code Both 1 0.75 0.8 Fee Schedule 0.8 Fee Schedule 0.45 Fee Schedule 0.6 Fee Schedule 0.45 0.6 "TESTOSTERONE, FREE" 84402 CPT 300 Revenue Code Both 514 385.5 411.2 Fee Schedule 411.2 Fee Schedule 231.3 Fee Schedule 308.4 Fee Schedule 231.3 308.4 "TESTOSTERONE, FREE & TOTAL" 84402 CPT 300 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 "TESTOSTERONE, TOTAL, FEMALE" 84403 CPT 300 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 "TESTOSTERONE, TOTAL, MALE" 84403 CPT 300 Revenue Code Both 175 131.25 140 Fee Schedule 140 Fee Schedule 78.75 Fee Schedule 105 Fee Schedule 78.75 105 TETANUS IMMUNE GLOB (HYPERTET) 250UNITS J1670 HCPCS 637 Revenue Code Both 848 636 678.4 Fee Schedule 678.4 Fee Schedule 381.6 Fee Schedule 508.8 Fee Schedule 381.6 508.8 "TETANUS, DIPTH, PERTUSSIS(ADACEL)INJ VAC" 90715 CPT 636 Revenue Code Both 153 114.75 122.4 Fee Schedule 122.4 Fee Schedule 68.85 Fee Schedule 91.8 Fee Schedule 68.85 91.8 "TETANUS, DIPTHERIA (TENIVAC) INJ VAC" 90714 CPT 637 Revenue Code Both 101 75.75 80.8 Fee Schedule 80.8 Fee Schedule 45.45 Fee Schedule 60.6 Fee Schedule 45.45 60.6 THEOPHYLLINE 80198 CPT 300 Revenue Code Both 123 92.25 98.4 Fee Schedule 98.4 Fee Schedule 55.35 Fee Schedule 73.8 Fee Schedule 55.35 73.8 THER COG FUNCTION (EACH ADD 15) 97130 CPT 440 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 THERAPEUTIC INTERVENTIONS COG 97129 CPT 440 Revenue Code Both 58 43.5 46.4 Fee Schedule 46.4 Fee Schedule 26.1 Fee Schedule 34.8 Fee Schedule 26.1 34.8 THERAPEUTIC PHLEBOTOMY 99195 CPT 300 Revenue Code Both 152 114 121.6 Fee Schedule 121.6 Fee Schedule 68.4 Fee Schedule 91.2 Fee Schedule 68.4 91.2 THIAMINE (VIT-B-1) 100MG/ML INJ J3411 HCPCS 637 Revenue Code Both 30 22.5 24 Fee Schedule 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 THORACENTESIS (PLEURAL CAVITY) 32554 CPT 981 Revenue Code Both 1031 773.25 824.8 Fee Schedule 824.8 Fee Schedule 463.95 Fee Schedule 618.6 Fee Schedule 463.95 618.6 THORACENTESIS CHEST NEEDLE OR CATH 32554 CPT 450 Revenue Code Both 1096 822 876.8 Fee Schedule 876.8 Fee Schedule 493.2 Fee Schedule 657.6 Fee Schedule 493.2 657.6 THUMB BRACE ADJ STRIPS L3923 HCPCS 270 Revenue Code Both 70 52.5 56 Fee Schedule 56 Fee Schedule 31.5 Fee Schedule 42 Fee Schedule 31.5 42 THYROGLOBULIN AB 86800 CPT 300 Revenue Code Both 48 36 38.4 Fee Schedule 38.4 Fee Schedule 21.6 Fee Schedule 28.8 Fee Schedule 21.6 28.8 THYROID PEROXIDASE AB 86376 CPT 300 Revenue Code Both 222 166.5 177.6 Fee Schedule 177.6 Fee Schedule 99.9 Fee Schedule 133.2 Fee Schedule 99.9 133.2 THYROID STIMULATING IMMUNOGLOBULIN 84445 CPT 300 Revenue Code Both 624 468 499.2 Fee Schedule 499.2 Fee Schedule 280.8 Fee Schedule 374.4 Fee Schedule 280.8 374.4 TICAGRELOR (BRILINTA) 90MG TAB J3490 HCPCS 637 Revenue Code Both 46 34.5 36.8 Fee Schedule 36.8 Fee Schedule 20.7 Fee Schedule 27.6 Fee Schedule 20.7 27.6 TIGAN 200MG SHOT J3250 HCPCS 636 Revenue Code Both 30 22.5 24 Fee Schedule 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 TIMOTHY GRASS IGE 86003 CPT 300 Revenue Code Both 103 77.25 82.4 Fee Schedule 82.4 Fee Schedule 46.35 Fee Schedule 61.8 Fee Schedule 46.35 61.8 TISSUE TRANSGLUTAMINASE AB IGA 83516 CPT 300 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 "TISSUE TRANSGLUTAMINASE, IGA" 83516 CPT 300 Revenue Code Both 304 228 243.2 Fee Schedule 243.2 Fee Schedule 136.8 Fee Schedule 182.4 Fee Schedule 136.8 182.4 TORADOL 15MG J1885 HCPCS 636 Revenue Code Both 8 6 6.4 Fee Schedule 6.4 Fee Schedule 3.6 Fee Schedule 4.8 Fee Schedule 3.6 4.8 TOTAL BILIRUBIN 82247 CPT 300 Revenue Code Both 112 84 89.6 Fee Schedule 89.6 Fee Schedule 50.4 Fee Schedule 67.2 Fee Schedule 50.4 67.2 TOTAL CORTISOL 82533 CPT 300 Revenue Code Both 172 129 137.6 Fee Schedule 137.6 Fee Schedule 77.4 Fee Schedule 103.2 Fee Schedule 77.4 103.2 TOTAL ESTROGEN 82672 CPT 300 Revenue Code Both 355 266.25 284 Fee Schedule 284 Fee Schedule 159.75 Fee Schedule 213 Fee Schedule 159.75 213 TOTAL PROTEIN 84155 CPT 300 Revenue Code Both 40 30 32 Fee Schedule 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 "TOTAL PROTEIN, ASCITES" 84157 CPT 300 Revenue Code Both 113 84.75 90.4 Fee Schedule 90.4 Fee Schedule 50.85 Fee Schedule 67.8 Fee Schedule 50.85 67.8 TOTAL T3 84480 CPT 300 Revenue Code Both 53 39.75 42.4 Fee Schedule 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 TOTAL T4 84436 CPT 300 Revenue Code Both 110 82.5 88 Fee Schedule 88 Fee Schedule 49.5 Fee Schedule 66 Fee Schedule 49.5 66 TPMT ACTIVITY 82657 CPT 300 Revenue Code Both 756 567 604.8 Fee Schedule 604.8 Fee Schedule 340.2 Fee Schedule 453.6 Fee Schedule 340.2 453.6 "TRAMADOL, URINE" 80373 CPT 300 Revenue Code Both 244 183 195.2 Fee Schedule 195.2 Fee Schedule 109.8 Fee Schedule 146.4 Fee Schedule 109.8 146.4 TRANEXAMIC ACID IV SOLN 100MG/1ML 10ML J3490 HCPCS 637 Revenue Code Both 17 12.75 13.6 Fee Schedule 13.6 Fee Schedule 7.65 Fee Schedule 10.2 Fee Schedule 7.65 10.2 TRANSFERRIN 84466 CPT 300 Revenue Code Both 214 160.5 171.2 Fee Schedule 171.2 Fee Schedule 96.3 Fee Schedule 128.4 Fee Schedule 96.3 128.4 TRANSFUSION OF BLOOD 36430 CPT 981 Revenue Code Both 66 49.5 52.8 Fee Schedule 52.8 Fee Schedule 29.7 Fee Schedule 39.6 Fee Schedule 29.7 39.6 TRAUMA TEAM ACTIVATION G0390 HCPCS 771 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 TRAVEL ALLOWANCE PER MILE P9603 HCPCS 300 Revenue Code Both 6 4.5 4.8 Fee Schedule 4.8 Fee Schedule 2.7 Fee Schedule 3.6 Fee Schedule 2.7 3.6 TRAVEL ALLOWANCE PER TRIP P9604 HCPCS 300 Revenue Code Both 29 21.75 23.2 Fee Schedule 23.2 Fee Schedule 13.05 Fee Schedule 17.4 Fee Schedule 13.05 17.4 TREAT FX RADIUS & ULNAR SHAFT W/MANIP 25565 CPT 981 Revenue Code Both 790 592.5 632 Fee Schedule 632 Fee Schedule 355.5 Fee Schedule 474 Fee Schedule 355.5 474 TREAT FX ULNAR SHAFT 25530 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TREATMENT BIMALLEOLAR ANKLE FX CLSD 27808 CPT 981 Revenue Code Both 496 372 396.8 Fee Schedule 396.8 Fee Schedule 223.2 Fee Schedule 297.6 Fee Schedule 223.2 297.6 TREATMENT BURN LARGE-MORE THAN ONE 16030 CPT 981 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 TREATMENT CLDS FX DISTLE TIBIA 27824 CPT 981 Revenue Code Both 499 374.25 399.2 Fee Schedule 399.2 Fee Schedule 224.55 Fee Schedule 299.4 Fee Schedule 224.55 299.4 TREATMENT CLOSED CARPAL SCAPHOID FX 25622 CPT 981 Revenue Code Both 386 289.5 308.8 Fee Schedule 308.8 Fee Schedule 173.7 Fee Schedule 231.6 Fee Schedule 173.7 231.6 TREATMENT CLSD COLLES FX WITH MAINPULAT 25605 CPT 981 Revenue Code Both 815 611.25 652 Fee Schedule 652 Fee Schedule 366.75 Fee Schedule 489 Fee Schedule 366.75 489 TREATMENT CLSD FX DISTLE FIBULA 27786 CPT 981 Revenue Code Both 447 335.25 357.6 Fee Schedule 357.6 Fee Schedule 201.15 Fee Schedule 268.2 Fee Schedule 201.15 268.2 TREATMENT CLSD FX GREAT TOE NO MANIP 28490 CPT 981 Revenue Code Both 220 165 176 Fee Schedule 176 Fee Schedule 99 Fee Schedule 132 Fee Schedule 99 132 TREATMENT CLSD FX METATARSAL 28470 CPT 981 Revenue Code Both 363 272.25 290.4 Fee Schedule 290.4 Fee Schedule 163.35 Fee Schedule 217.8 Fee Schedule 163.35 217.8 TREATMENT CLSD FX PHALANX 26720 CPT 981 Revenue Code Both 230 172.5 184 Fee Schedule 184 Fee Schedule 103.5 Fee Schedule 138 Fee Schedule 103.5 138 TREATMENT CLSD FX TIBIA 27530 CPT 981 Revenue Code Both 552 414 441.6 Fee Schedule 441.6 Fee Schedule 248.4 Fee Schedule 331.2 Fee Schedule 248.4 331.2 TREATMENT CLSD METACARPAL FX SINGLE 26600 CPT 260 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TREATMENT CLSD METACRAPL FX SINGLE 26600 CPT 981 Revenue Code Both 323 242.25 258.4 Fee Schedule 258.4 Fee Schedule 145.35 Fee Schedule 193.8 Fee Schedule 145.35 193.8 TREATMENT CLSD PATELLAR DISLOCATION 27560 CPT 981 Revenue Code Both 529 396.75 423.2 Fee Schedule 423.2 Fee Schedule 238.05 Fee Schedule 317.4 Fee Schedule 238.05 317.4 TREATMENT CLSD PATELLAR FX 27520 CPT 981 Revenue Code Both 451 338.25 360.8 Fee Schedule 360.8 Fee Schedule 202.95 Fee Schedule 270.6 Fee Schedule 202.95 270.6 TREATMENT FX CLAVICLE NO MANIPULATION 23500 CPT 981 Revenue Code Both 333 249.75 266.4 Fee Schedule 266.4 Fee Schedule 149.85 Fee Schedule 199.8 Fee Schedule 149.85 199.8 TREATMENT FX ULNAR SHAFT NO MANIPULATE 25530 CPT 981 Revenue Code Both 334 250.5 267.2 Fee Schedule 267.2 Fee Schedule 150.3 Fee Schedule 200.4 Fee Schedule 150.3 200.4 TREATMENT FX ULNAR STYLOID 25650 CPT 981 Revenue Code Both 426 319.5 340.8 Fee Schedule 340.8 Fee Schedule 191.7 Fee Schedule 255.6 Fee Schedule 191.7 255.6 TREATMENT FX VETEBRAL BODY 22310 CPT 981 Revenue Code Both 418 313.5 334.4 Fee Schedule 334.4 Fee Schedule 188.1 Fee Schedule 250.8 Fee Schedule 188.1 250.8 "TREATMENT OF SPEECH, LANGUAGE, VOICE" 92507 CPT 444 Revenue Code Both 201 150.75 160.8 Fee Schedule 160.8 Fee Schedule 90.45 Fee Schedule 120.6 Fee Schedule 90.45 120.6 TREATMENT ROOM E&M 99211 CPT 761 Revenue Code Both 1 0.75 0.8 Fee Schedule 0.8 Fee Schedule 0.45 Fee Schedule 0.6 Fee Schedule 0.45 0.6 TREATMENT SHOULDERBLADE FX 23570 CPT 981 Revenue Code Both 399 299.25 319.2 Fee Schedule 319.2 Fee Schedule 179.55 Fee Schedule 239.4 Fee Schedule 179.55 239.4 TREAT'T TARSAL BONE W/O MANIPULATION 28450 CPT 981 Revenue Code Both 399 299.25 319.2 Fee Schedule 319.2 Fee Schedule 179.55 Fee Schedule 239.4 Fee Schedule 179.55 239.4 TRIAMCINOLONE (KENALOG) 40MG INJ J3301 HCPCS 636 Revenue Code Both 32.25 24.1875 25.8 Fee Schedule 25.8 Fee Schedule 14.5125 Fee Schedule 19.35 Fee Schedule 14.5125 19.35 TRIGGER POINT INJ 3 OR MORE MUSCLES 20553 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 TRIGLYCERIDES 84478 CPT 300 Revenue Code Both 63 47.25 50.4 Fee Schedule 50.4 Fee Schedule 28.35 Fee Schedule 37.8 Fee Schedule 28.35 37.8 TRIMMING NONSYSTROPHIC NAILS 11719 CPT 761 Revenue Code Both 162 121.5 129.6 Fee Schedule 129.6 Fee Schedule 72.9 Fee Schedule 97.2 Fee Schedule 72.9 97.2 TRMT BIMALLEOAR ANKLE FX CLOSED 27808 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TRMT CLOSED FX DISTAL FIBULA 27786 CPT 450 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 TROPONIN-I 84484 CPT 300 Revenue Code Both 152 114 121.6 Fee Schedule 121.6 Fee Schedule 68.4 Fee Schedule 91.2 Fee Schedule 68.4 91.2 TRTMT FX HUM NO MANIP 24500 CPT 981 Revenue Code Both 559 419.25 447.2 Fee Schedule 447.2 Fee Schedule 251.55 Fee Schedule 335.4 Fee Schedule 251.55 335.4 TRTMT FX RADIAL NO MANIP 25500 CPT 981 Revenue Code Both 365 273.75 292 Fee Schedule 292 Fee Schedule 164.25 Fee Schedule 219 Fee Schedule 164.25 219 TRYPANOSOMA CRUZI AB 86753 CPT 300 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 TRYPTASE 83520 CPT 300 Revenue Code Both 181 135.75 144.8 Fee Schedule 144.8 Fee Schedule 81.45 Fee Schedule 108.6 Fee Schedule 81.45 108.6 TSH 84443 CPT 300 Revenue Code Both 136 102 108.8 Fee Schedule 108.8 Fee Schedule 61.2 Fee Schedule 81.6 Fee Schedule 61.2 81.6 TUBERSOL (TUBERCULIN) PPD 5U/0.1ML INJ 86580 CPT 636 Revenue Code Both 51 38.25 40.8 Fee Schedule 40.8 Fee Schedule 22.95 Fee Schedule 30.6 Fee Schedule 22.95 30.6 TUBIN IV EXT 32 IN TWINSITE A4223 HCPCS 760 Revenue Code Both 12 9 9.6 Fee Schedule 9.6 Fee Schedule 5.4 Fee Schedule 7.2 Fee Schedule 5.4 7.2 TX CLOSED CARPAL SCAPHOID FX 25622 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TX CLOSED FX METATARSAL 28470 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TX OF SWALLOWING DYSFUNCTION AND/OR ORA 92526 CPT 444 Revenue Code Both 223 167.25 178.4 Fee Schedule 178.4 Fee Schedule 100.35 Fee Schedule 133.8 Fee Schedule 100.35 133.8 TX RADIAL HEAD FX CLOSED 24650 CPT 450 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 TYPHOID VACCINE 90691 CPT 636 Revenue Code Both 84 63 67.2 Fee Schedule 67.2 Fee Schedule 37.8 Fee Schedule 50.4 Fee Schedule 37.8 50.4 UA W/O MICRO 81002 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 UREA BREATH TEST 83013 CPT 300 Revenue Code Both 251 188.25 200.8 Fee Schedule 200.8 Fee Schedule 112.95 Fee Schedule 150.6 Fee Schedule 112.95 150.6 URIC ACID 84550 CPT 300 Revenue Code Both 41 30.75 32.8 Fee Schedule 32.8 Fee Schedule 18.45 Fee Schedule 24.6 Fee Schedule 18.45 24.6 URIC ACID 84550 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 URINE CREATININE 82570 CPT 300 Revenue Code Both 109 81.75 87.2 Fee Schedule 87.2 Fee Schedule 49.05 Fee Schedule 65.4 Fee Schedule 49.05 65.4 URINE DIP 81003 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 URINE DRUG SCREEN 80305 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 URINE MICROSCOPIC 81001 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 "URINE POTASSIUM, RANDOM" 84133 CPT 300 Revenue Code Both 151 113.25 120.8 Fee Schedule 120.8 Fee Schedule 67.95 Fee Schedule 90.6 Fee Schedule 67.95 90.6 "URINE PROTEIN, RANDOM" 84156 CPT 300 Revenue Code Both 147 110.25 117.6 Fee Schedule 117.6 Fee Schedule 66.15 Fee Schedule 88.2 Fee Schedule 66.15 88.2 "URINE SODIUM, RANDOM" 84300 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 US ABDOMEN COMPLETE 76700 CPT 402 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 US ABDOMEN DOPPLER 93975 CPT 921 Revenue Code Both 1686 1264.5 1348.8 Fee Schedule 1348.8 Fee Schedule 758.7 Fee Schedule 1011.6 Fee Schedule 758.7 1011.6 US ABDOMEN LIMITED 76705 CPT 402 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US AORTA 76706 CPT 402 Revenue Code Both 619 464.25 495.2 Fee Schedule 495.2 Fee Schedule 278.55 Fee Schedule 371.4 Fee Schedule 278.55 371.4 US CAROTID BILATERAL 93880 CPT 921 Revenue Code Both 1237 927.75 989.6 Fee Schedule 989.6 Fee Schedule 556.65 Fee Schedule 742.2 Fee Schedule 556.65 742.2 US CHEST 76604 CPT 402 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US LOWER EXTREMITY ARTERIAL BILATERAL 93923 CPT 921 Revenue Code Both 844 633 675.2 Fee Schedule 675.2 Fee Schedule 379.8 Fee Schedule 506.4 Fee Schedule 379.8 506.4 US LOWER EXTREMITY ARTERIAL LEFT 93922 CPT 921 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US LOWER EXTREMITY ARTERIAL RIGHT 93922 CPT 921 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US LOWER EXTREMITY VENOUS BILATERAL 93970 CPT 921 Revenue Code Both 1237 927.75 989.6 Fee Schedule 989.6 Fee Schedule 556.65 Fee Schedule 742.2 Fee Schedule 556.65 742.2 US LOWER EXTREMITY VENOUS LEFT 93971 CPT 921 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 US LOWER EXTREMITY VENOUS RIGHT 93971 CPT 350 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 US PELVIS COMPLETE 76856 CPT 402 Revenue Code Both 731 548.25 584.8 Fee Schedule 584.8 Fee Schedule 328.95 Fee Schedule 438.6 Fee Schedule 328.95 438.6 US RENAL BILATERAL 76770 CPT 402 Revenue Code Both 731 548.25 584.8 Fee Schedule 584.8 Fee Schedule 328.95 Fee Schedule 438.6 Fee Schedule 328.95 438.6 US RENAL DOPPLER 93976 CPT 402 Revenue Code Both 1012 759 809.6 Fee Schedule 809.6 Fee Schedule 455.4 Fee Schedule 607.2 Fee Schedule 455.4 607.2 US SCROTUM BILATERAL 76870 CPT 402 Revenue Code Both 449 336.75 359.2 Fee Schedule 359.2 Fee Schedule 202.05 Fee Schedule 269.4 Fee Schedule 202.05 269.4 US SOFT TISSUE (ARMS AND LEGS ONLY) 76881 CPT 921 Revenue Code Both 675 506.25 540 Fee Schedule 540 Fee Schedule 303.75 Fee Schedule 405 Fee Schedule 303.75 405 US SOFT TISSUES OF HEAD AND NECK 76536 CPT 402 Revenue Code Both 731 548.25 584.8 Fee Schedule 584.8 Fee Schedule 328.95 Fee Schedule 438.6 Fee Schedule 328.95 438.6 US TRANSVAGINAL 76830 CPT 402 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 US UPPER EXTREMITY ARTERIAL BILATERAL 93923 CPT 921 Revenue Code Both 844 633 675.2 Fee Schedule 675.2 Fee Schedule 379.8 Fee Schedule 506.4 Fee Schedule 379.8 506.4 US UPPER EXTREMITY ARTERIAL LEFT 93922 CPT 921 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US UPPER EXTREMITY ARTERIAL RIGHT 93922 CPT 921 Revenue Code Both 562 421.5 449.6 Fee Schedule 449.6 Fee Schedule 252.9 Fee Schedule 337.2 Fee Schedule 252.9 337.2 US UPPER EXTREMITY VENOUS BILATERAL 93970 CPT 921 Revenue Code Both 1237 927.75 989.6 Fee Schedule 989.6 Fee Schedule 556.65 Fee Schedule 742.2 Fee Schedule 556.65 742.2 US UPPER EXTREMITY VENOUS LEFT 93971 CPT 921 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 US UPPER EXTREMITY VENOUS RIGHT 93971 CPT 921 Revenue Code Both 788 591 630.4 Fee Schedule 630.4 Fee Schedule 354.6 Fee Schedule 472.8 Fee Schedule 354.6 472.8 VALPROIC ACID 80164 CPT 300 Revenue Code Both 48 36 38.4 Fee Schedule 38.4 Fee Schedule 21.6 Fee Schedule 28.8 Fee Schedule 21.6 28.8 VALPROIC ACID 80164 CPT 300 Revenue Code Both 86 64.5 68.8 Fee Schedule 68.8 Fee Schedule 38.7 Fee Schedule 51.6 Fee Schedule 38.7 51.6 VANCOMYCIN 1GM Injectable J3373 HCPCS 250 Revenue Code Both Each 18 13.5 14.4 Fee Schedule 14.4 Fee Schedule 8.1 Fee Schedule 10.8 Fee Schedule 8.1 10.8 VANCOMYCIN PEAK 80202 CPT 300 Revenue Code Both 386 289.5 308.8 Fee Schedule 308.8 Fee Schedule 173.7 Fee Schedule 231.6 Fee Schedule 173.7 231.6 VANCOMYCIN TROUGH 80202 CPT 300 Revenue Code Both 386 289.5 308.8 Fee Schedule 308.8 Fee Schedule 173.7 Fee Schedule 231.6 Fee Schedule 173.7 231.6 VANCOMYCIN/NS IVPB : 1GM/250ML J3373 HCPCS 258 Revenue Code Both 18 13.5 14.4 Fee Schedule 14.4 Fee Schedule 8.1 Fee Schedule 10.8 Fee Schedule 8.1 10.8 VARICELLA (CHICKEN POX) VIRUS VACCINE 90716 CPT 636 Revenue Code Both 304 228 243.2 Fee Schedule 243.2 Fee Schedule 136.8 Fee Schedule 182.4 Fee Schedule 136.8 182.4 VENIPUNCTURE 36415 CPT 300 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 VENOUS BLOOD GASES 82803 CPT 300 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 VERSED PER 1MG J2250 HCPCS 636 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 VFC BOOSTRIX INTRAMUSCULAR SUSPENSION 90715 CPT 636 Revenue Code Both 150 112.5 120 Fee Schedule 120 Fee Schedule 67.5 Fee Schedule 90 Fee Schedule 67.5 90 VFC MMR VACCINE 90707 CPT 250 Revenue Code Both Each 183.5 137.625 146.8 Fee Schedule 146.8 Fee Schedule 82.575 Fee Schedule 110.1 Fee Schedule 82.575 110.1 VFC PEDVAXHIB INJ 90648 CPT 637 Revenue Code Both 118 88.5 94.4 Fee Schedule 94.4 Fee Schedule 53.1 Fee Schedule 70.8 Fee Schedule 53.1 70.8 VFC TDAP 90700 CPT 637 Revenue Code Both 150 112.5 120 Fee Schedule 120 Fee Schedule 67.5 Fee Schedule 90 Fee Schedule 67.5 90 VISTERIL UP TO 25MG J3410 HCPCS 636 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 VIT A 84590 CPT 300 Revenue Code Both 260 195 208 Fee Schedule 208 Fee Schedule 117 Fee Schedule 156 Fee Schedule 117 156 VIT B1 THIAMINE 84425 CPT 300 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 VIT B2 RIBOFLAVIN 84252 CPT 300 Revenue Code Both 343 257.25 274.4 Fee Schedule 274.4 Fee Schedule 154.35 Fee Schedule 205.8 Fee Schedule 154.35 205.8 VITAMIN A 84590 CPT 300 Revenue Code Both 260 195 208 Fee Schedule 208 Fee Schedule 117 Fee Schedule 156 Fee Schedule 117 156 VITAMIN B1 84425 CPT 300 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 VITAMIN B12 82607 CPT 300 Revenue Code Both 107 80.25 85.6 Fee Schedule 85.6 Fee Schedule 48.15 Fee Schedule 64.2 Fee Schedule 48.15 64.2 VITAMIN B-12 2500MCG SUBL TAB 82607 CPT 637 Revenue Code Both 33 24.75 26.4 Fee Schedule 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 VITAMIN B-12 COMPLEX 1 TAB J3490 HCPCS 637 Revenue Code Both 35 26.25 28 Fee Schedule 28 Fee Schedule 15.75 Fee Schedule 21 Fee Schedule 15.75 21 VITAMIN B-12 INJECTION J3420 HCPCS 636 Revenue Code Both 24 18 19.2 Fee Schedule 19.2 Fee Schedule 10.8 Fee Schedule 14.4 Fee Schedule 10.8 14.4 VITAMIN B3 84591 CPT 300 Revenue Code Both 412 309 329.6 Fee Schedule 329.6 Fee Schedule 185.4 Fee Schedule 247.2 Fee Schedule 185.4 247.2 VITAMIN B6 84207 CPT 300 Revenue Code Both 428 321 342.4 Fee Schedule 342.4 Fee Schedule 192.6 Fee Schedule 256.8 Fee Schedule 192.6 256.8 "VITAMIN D, 25-HYDROXY" 82306 CPT 300 Revenue Code Both 76 57 60.8 Fee Schedule 60.8 Fee Schedule 34.2 Fee Schedule 45.6 Fee Schedule 34.2 45.6 VITAMIN E 84446 CPT 300 Revenue Code Both 114 85.5 91.2 Fee Schedule 91.2 Fee Schedule 51.3 Fee Schedule 68.4 Fee Schedule 51.3 68.4 VITAMIN K 84597 CPT 300 Revenue Code Both 567 425.25 453.6 Fee Schedule 453.6 Fee Schedule 255.15 Fee Schedule 340.2 Fee Schedule 255.15 340.2 VITAMIN K 1 MG J3430 HCPCS 636 Revenue Code Both 6 4.5 4.8 Fee Schedule 4.8 Fee Schedule 2.7 Fee Schedule 3.6 Fee Schedule 2.7 3.6 VIVONEX RTF TUBE FEEDING FORMULA B4153 HCPCS 637 Revenue Code Both 114 85.5 91.2 Fee Schedule 91.2 Fee Schedule 51.3 Fee Schedule 68.4 Fee Schedule 51.3 68.4 VORICONAZOLE IV PWD FOR SOLN 200MG J3465 HCPCS 250 Revenue Code Both Each 52.75 39.5625 42.2 Fee Schedule 42.2 Fee Schedule 23.7375 Fee Schedule 31.65 Fee Schedule 23.7375 31.65 WARFARIN (COUMADIN) 1MG TAB G9928 HCPCS 637 Revenue Code Both 17 12.75 13.6 Fee Schedule 13.6 Fee Schedule 7.65 Fee Schedule 10.2 Fee Schedule 7.65 10.2 WARFARIN (COUMADIN) 2.5MG TAB G9928 HCPCS 637 Revenue Code Both 36 27 28.8 Fee Schedule 28.8 Fee Schedule 16.2 Fee Schedule 21.6 Fee Schedule 16.2 21.6 WARFARIN (COUMADIN) 2MG TAB G9928 HCPCS 637 Revenue Code Both 36 27 28.8 Fee Schedule 28.8 Fee Schedule 16.2 Fee Schedule 21.6 Fee Schedule 16.2 21.6 WARFARIN (COUMADIN) 4MG TAB G8967 HCPCS 636 Revenue Code Both 17 12.75 13.6 Fee Schedule 13.6 Fee Schedule 7.65 Fee Schedule 10.2 Fee Schedule 7.65 10.2 WARFARIN (COUMADIN) 5MG TAB G8967 HCPCS 636 Revenue Code Both 36 27 28.8 Fee Schedule 28.8 Fee Schedule 16.2 Fee Schedule 21.6 Fee Schedule 16.2 21.6 WATER STERILE 10ML INJ A4216 HCPCS 637 Revenue Code Both 7 5.25 5.6 Fee Schedule 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 WEST NILE VIRUS ANTIBODIES IGG 86789 CPT 300 Revenue Code Both 275 206.25 220 Fee Schedule 220 Fee Schedule 123.75 Fee Schedule 165 Fee Schedule 123.75 165 WEST NILE VIRUS ANTIBODIES IGM 86788 CPT 300 Revenue Code Both 275 206.25 220 Fee Schedule 220 Fee Schedule 123.75 Fee Schedule 165 Fee Schedule 123.75 165 WHITE BLOOD COUNT (WBC) 85048 CPT 300 Revenue Code Both 57 42.75 45.6 Fee Schedule 45.6 Fee Schedule 25.65 Fee Schedule 34.2 Fee Schedule 25.65 34.2 WITH EVAL OF LANG COMP AND EXPRESS 92523 CPT 440 Revenue Code Both 594 445.5 475.2 Fee Schedule 475.2 Fee Schedule 267.3 Fee Schedule 356.4 Fee Schedule 267.3 356.4 WORK RELATED OR MEDICAL DISABILITY EVAL 99455 CPT 270 Revenue Code Both 141 105.75 112.8 Fee Schedule 112.8 Fee Schedule 63.45 Fee Schedule 84.6 Fee Schedule 63.45 84.6 WOUND CARE (ED) G0463 HCPCS 761 Revenue Code Both 261 195.75 208.8 Fee Schedule 208.8 Fee Schedule 117.45 Fee Schedule 156.6 Fee Schedule 117.45 156.6 WOUND CARE NON-SELECTIVE 97602 CPT 761 Revenue Code Both 295 221.25 236 Fee Schedule 236 Fee Schedule 132.75 Fee Schedule 177 Fee Schedule 132.75 177 WOUND CARE NURSE VISIT G0463 HCPCS 272 Revenue Code Both 261 195.75 208.8 Fee Schedule 208.8 Fee Schedule 117.45 Fee Schedule 156.6 Fee Schedule 117.45 156.6 WOUND CARE NURSE VISIT G0463 HCPCS 761 Revenue Code Both 261 195.75 208.8 Fee Schedule 208.8 Fee Schedule 117.45 Fee Schedule 156.6 Fee Schedule 117.45 156.6 WOUND VAC CANISTER 500ML A9272 HCPCS 270 Revenue Code Both 114 85.5 91.2 Fee Schedule 91.2 Fee Schedule 51.3 Fee Schedule 68.4 Fee Schedule 51.3 68.4 WOUND VAC GRANUFOAM MED A9272 HCPCS 270 Revenue Code Both 125 93.75 100 Fee Schedule 100 Fee Schedule 56.25 Fee Schedule 75 Fee Schedule 56.25 75 WRIST & FA UNIV R SPLINT L3908 HCPCS 270 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 WRIST & FOREARM (UNIV) L SPLINT L3908 HCPCS 274 Revenue Code Both 50 37.5 40 Fee Schedule 40 Fee Schedule 22.5 Fee Schedule 30 Fee Schedule 22.5 30 WYCILLIN-PENICILLIN G PROCAIN UP TO 600 J2510 HCPCS 636 Revenue Code Both 20 15 16 Fee Schedule 16 Fee Schedule 9 Fee Schedule 12 Fee Schedule 9 12 XOPENEX INHALATION SOLUTION J7612 HCPCS 636 Revenue Code Both 23 17.25 18.4 Fee Schedule 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 XR A.C. JOINTS 2 VIEW W/&W/OUT WEIGHTS 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR ABDOMEN 1 VIEW (KUB) 74018 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR ABDOMEN 1 VIEW (UPRIGHT) 74018 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR ABDOMEN 2 VIEW (UPRIGHT & SUPINE) 74019 CPT 320 Revenue Code Both 371 278.25 296.8 Fee Schedule 296.8 Fee Schedule 166.95 Fee Schedule 222.6 Fee Schedule 166.95 222.6 XR ABDOMEN SERIES 74021 CPT 320 Revenue Code Both 394 295.5 315.2 Fee Schedule 315.2 Fee Schedule 177.3 Fee Schedule 236.4 Fee Schedule 177.3 236.4 XR ANKLE AP/LAT VIEW LEFT 73600 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR ANKLE AP/LAT VIEW RIGHT 73600 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR ANKLE AP/LAT/OBLIQUE VIEW LEFT 73610 CPT 320 Revenue Code Both 287 215.25 229.6 Fee Schedule 229.6 Fee Schedule 129.15 Fee Schedule 172.2 Fee Schedule 129.15 172.2 XR ANKLE AP/LAT/OBLIQUE VIEW RIGHT 73610 CPT 320 Revenue Code Both 287 215.25 229.6 Fee Schedule 229.6 Fee Schedule 129.15 Fee Schedule 172.2 Fee Schedule 129.15 172.2 XR ANKLE LAT VIEW LEFT 73600 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR ANKLE LAT VIEW RIGHT 73600 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR CALCANEUS AP/LAT VIEW LEFT 73650 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR CALCANEUS AP/LAT VIEW RIGHT 73650 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR CHEST 1 VIEW (APICAL LORDOTIC) 71045 CPT 320 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 XR CHEST 1 VIEW (DECUBITUS) 71045 CPT 320 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 XR CHEST 1 VIEW AP (UPRIGHT) 71045 CPT 320 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 XR CHEST 1 VIEW PA (UPRIGHT) 71045 CPT 320 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 XR CHEST 2 VIEW PA/LATERAL VIEW 71046 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR CHEST SUPINE AP VIEW 71045 CPT 320 Revenue Code Both 248 186 198.4 Fee Schedule 198.4 Fee Schedule 111.6 Fee Schedule 148.8 Fee Schedule 111.6 148.8 XR CLAVICLE 2 VIEW (AP/45 DEGREES) LEFT 73000 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR CLAVICLE 2 VIEW (AP/45 DEGREES) RIGHT 73000 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR C-SPINE 2 VIEW AP/LATERAL/ODONTOID 72040 CPT 320 Revenue Code Both 332 249 265.6 Fee Schedule 265.6 Fee Schedule 149.4 Fee Schedule 199.2 Fee Schedule 149.4 199.2 XR C-SPINE 5 VIEW AP/LAT/OBL/ODONTOID 72050 CPT 320 Revenue Code Both 540 405 432 Fee Schedule 432 Fee Schedule 243 Fee Schedule 324 Fee Schedule 243 324 XR C-SPINE CROSS TABLE LATERAL VIEW 72020 CPT 320 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 XR C-SPINE FLEXION EXTENSION VIEW 72040 CPT 320 Revenue Code Both 332 249 265.6 Fee Schedule 265.6 Fee Schedule 149.4 Fee Schedule 199.2 Fee Schedule 149.4 199.2 XR ELBOW AP/LAT VIEW LEFT 73070 CPT 320 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 XR ELBOW AP/LAT VIEW RIGHT 73070 CPT 320 Revenue Code Both 235 176.25 188 Fee Schedule 188 Fee Schedule 105.75 Fee Schedule 141 Fee Schedule 105.75 141 XR ELBOW AP/LAT/OBLIQUE VIEW LEFT 73080 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR ELBOW AP/LAT/OBLIQUE VIEW RIGHT 73080 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR FACIAL BONES COMPLETE 70150 CPT 320 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 XR FEMUR AP VIEW LEFT 73551 CPT 320 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 XR FEMUR AP VIEW RIGHT 73551 CPT 320 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 XR FEMUR AP/LAT VIEW LEFT 73552 CPT 320 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 XR FEMUR AP/LAT VIEW RIGHT 73552 CPT 320 Revenue Code Both 202 151.5 161.6 Fee Schedule 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 XR FINGER 2 VIEW AP/LATERAL LEFT 73140 CPT 320 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 XR FINGER 2 VIEW AP/LATERAL RIGHT 73140 CPT 320 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 XR FINGER 3 VIEW LEFT 73140 CPT 320 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 XR FINGER 3 VIEW RIGHT 73140 CPT 320 Revenue Code Both 253 189.75 202.4 Fee Schedule 202.4 Fee Schedule 113.85 Fee Schedule 151.8 Fee Schedule 113.85 151.8 XR FOOT AP/LAT VIEW LEFT 73620 CPT 320 Revenue Code Both 264 198 211.2 Fee Schedule 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR FOOT AP/LAT VIEW RIGHT 73620 CPT 320 Revenue Code Both 264 198 211.2 Fee Schedule 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR FOOT AP/LAT/OBLIQUE VIEW LEFT 73630 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR FOOT AP/LAT/OBLIQUE VIEW RIGHT 73630 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR FOREARM AP/LAT VIEW LEFT 73090 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR FOREARM AP/LAT VIEW RIGHT 73090 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR HAND AP/LAT VIEW LEFT 73120 CPT 320 Revenue Code Both 219 164.25 175.2 Fee Schedule 175.2 Fee Schedule 98.55 Fee Schedule 131.4 Fee Schedule 98.55 131.4 XR HAND AP/LAT VIEW RIGHT 73120 CPT 320 Revenue Code Both 219 164.25 175.2 Fee Schedule 175.2 Fee Schedule 98.55 Fee Schedule 131.4 Fee Schedule 98.55 131.4 XR HAND AP/LAT/OBLIQUE VIEW LEFT 73130 CPT 320 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 XR HAND AP/LAT/OBLIQUE VIEW RIGHT 73130 CPT 320 Revenue Code Both 282 211.5 225.6 Fee Schedule 225.6 Fee Schedule 126.9 Fee Schedule 169.2 Fee Schedule 126.9 169.2 XR HIP 1 VIEW W/PELVIS IF DONE LEFT 73501 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP 1 VIEW W/PELVIS IF DONE RIGHT 73501 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP 2 VIEW UNI W/PELVIS IF DONE RIGHT 73502 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP 2 VIEW W/PELVIS IF DONE LEFT 73502 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP AP VIEW LEFT 73501 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP AP VIEW RIGHT 73501 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP AP/LATERAL VIEW LEFT 73502 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP AP/LATERAL VIEW RIGHT 73502 CPT 320 Revenue Code Both 209 156.75 167.2 Fee Schedule 167.2 Fee Schedule 94.05 Fee Schedule 125.4 Fee Schedule 94.05 125.4 XR HIP BIL 3-4 VIEW 73522 CPT 320 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 XR HIP BIL 5VIEW ONLY IF PELVIS INCLUDED 73523 CPT 320 Revenue Code Both 647 485.25 517.6 Fee Schedule 517.6 Fee Schedule 291.15 Fee Schedule 388.2 Fee Schedule 291.15 388.2 XR HUMERUS AP/LATERAL VIEW LEFT 73060 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR HUMERUS AP/LATERAL VIEW RIGHT 73060 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR KNEE 3 VIEW AP/LATERAL/SUNRISE LEFT 73562 CPT 320 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 XR KNEE 3 VIEW AP/LATERAL/SUNRISE RIGHT 73562 CPT 320 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 XR KNEE AP/LATERAL VIEW LEFT 73560 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR KNEE AP/LATERAL VIEW RIGHT 73560 CPT 320 Revenue Code Both 276 207 220.8 Fee Schedule 220.8 Fee Schedule 124.2 Fee Schedule 165.6 Fee Schedule 124.2 165.6 XR L-SPINE 1 VIEW CROSS TABLE LATERAL 72020 CPT 320 Revenue Code Both 337 252.75 269.6 Fee Schedule 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 XR L-SPINE 2 VIEW FLEXION/EXTENSION 72100 CPT 320 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 XR L-SPINE 3 VIEW AP/LATERAL 72100 CPT 320 Revenue Code Both 326 244.5 260.8 Fee Schedule 260.8 Fee Schedule 146.7 Fee Schedule 195.6 Fee Schedule 146.7 195.6 XR L-SPINE 5 VIEW AP/LATERAL/OBLIQUES 72110 CPT 320 Revenue Code Both 647 485.25 517.6 Fee Schedule 517.6 Fee Schedule 291.15 Fee Schedule 388.2 Fee Schedule 291.15 388.2 XR MANDIBLE AP/LAT VIEW LEFT 70100 CPT 320 Revenue Code Both 170 127.5 136 Fee Schedule 136 Fee Schedule 76.5 Fee Schedule 102 Fee Schedule 76.5 102 XR MANDIBLE AP/LAT VIEW RIGHT 70110 CPT 320 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 XR MANDIBLE PA/TOWNE/OBLIQUES BILATERAL 70110 CPT 320 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 XR NASAL BONES 3 VIEW WATERS/LATERALS 70160 CPT 320 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 XR NASAL BONES COMPLETE 70160 CPT 320 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 XR ORBITS 4 VIEWS BILATERAL 70200 CPT 320 Revenue Code Both 182 136.5 145.6 Fee Schedule 145.6 Fee Schedule 81.9 Fee Schedule 109.2 Fee Schedule 81.9 109.2 XR ORBITS ROUTINE LEFT 70200 CPT 320 Revenue Code Both 182 136.5 145.6 Fee Schedule 145.6 Fee Schedule 81.9 Fee Schedule 109.2 Fee Schedule 81.9 109.2 XR ORBITS ROUTINE RIGHT 70110 CPT 320 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 XR PELVIS AP VIEW ROUTINE 72170 CPT 320 Revenue Code Both 602 451.5 481.6 Fee Schedule 481.6 Fee Schedule 270.9 Fee Schedule 361.2 Fee Schedule 270.9 361.2 XR PELVIS AP/INLET/OUTLET VIEW 72170 CPT 320 Revenue Code Both 242 181.5 193.6 Fee Schedule 193.6 Fee Schedule 108.9 Fee Schedule 145.2 Fee Schedule 108.9 145.2 XR PELVIS JUDET VIEW 72170 CPT 320 Revenue Code Both 602 451.5 481.6 Fee Schedule 481.6 Fee Schedule 270.9 Fee Schedule 361.2 Fee Schedule 270.9 361.2 XR RIB SERIES (INCLUDES PA CHEST) LEFT 71110 CPT 320 Revenue Code Both 371 278.25 296.8 Fee Schedule 296.8 Fee Schedule 166.95 Fee Schedule 222.6 Fee Schedule 166.95 222.6 XR RIB SERIES (INCLUDES PA CHEST) RIGHT 71110 CPT 320 Revenue Code Both 371 278.25 296.8 Fee Schedule 296.8 Fee Schedule 166.95 Fee Schedule 222.6 Fee Schedule 166.95 222.6 XR RIBS 2 VIEWS AP/OBLIQUE LEFT 71100 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR RIBS 2 VIEWS AP/OBLIQUE RIGHT 71100 CPT 320 Revenue Code Both 298 223.5 238.4 Fee Schedule 238.4 Fee Schedule 134.1 Fee Schedule 178.8 Fee Schedule 134.1 178.8 XR S.I. JOINTS 2 VIEW AP/OBLIQUES 72190 CPT 320 Revenue Code Both 148 111 118.4 Fee Schedule 118.4 Fee Schedule 66.6 Fee Schedule 88.8 Fee Schedule 66.6 88.8 XR SACRUM/COCCYX 2 VIEW AP/LATERAL 72202 CPT 320 Revenue Code Both 259 194.25 207.2 Fee Schedule 207.2 Fee Schedule 116.55 Fee Schedule 155.4 Fee Schedule 116.55 155.4 XR SCAPULA 2 VIEW AP/LATERAL LEFT 73010 CPT 320 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 XR SCAPULA 2 VIEW AP/LATERAL RIGHT 73010 CPT 320 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 XR SCOLIOSIS 2 VIEW AP/LATERAL 72082 CPT 320 Revenue Code Both 342 256.5 273.6 Fee Schedule 273.6 Fee Schedule 153.9 Fee Schedule 205.2 Fee Schedule 153.9 205.2 XR SCOLIOSIS SERIES EVAL 4OR 5 VIEW 72083 CPT 320 Revenue Code Both 647 485.25 517.6 Fee Schedule 517.6 Fee Schedule 291.15 Fee Schedule 388.2 Fee Schedule 291.15 388.2 XR SCOLIOSIS SPINE EVAL 6OR7 VIEW 72084 CPT 320 Revenue Code Both 647 485.25 517.6 Fee Schedule 517.6 Fee Schedule 291.15 Fee Schedule 388.2 Fee Schedule 291.15 388.2 XR SHOULDER 3 VIEW INT/EXT/Y-VIEW LEFT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SHOULDER 3 VIEW INT/EXT/Y-VIEW RIGHT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SHOULDER AP VIEW LEFT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SHOULDER AP VIEW RIGHT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SHOULDER AP/LAT VIEW LEFT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SHOULDER AP/LAT VIEW RIGHT 73030 CPT 320 Revenue Code Both 303 227.25 242.4 Fee Schedule 242.4 Fee Schedule 136.35 Fee Schedule 181.8 Fee Schedule 136.35 181.8 XR SINUS 2 VIEW WATER/LATERAL 70220 CPT 320 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 XR SINUS 3 VIEWS 70220 CPT 320 Revenue Code Both 174 130.5 139.2 Fee Schedule 139.2 Fee Schedule 78.3 Fee Schedule 104.4 Fee Schedule 78.3 104.4 XR SKULL 4 VIEWS 70260 CPT 320 Revenue Code Both 217 162.75 173.6 Fee Schedule 173.6 Fee Schedule 97.65 Fee Schedule 130.2 Fee Schedule 97.65 130.2 XR SKULL TRAUMA 2 VIEW PA/LT LATERAL 70250 CPT 320 Revenue Code Both 148 111 118.4 Fee Schedule 118.4 Fee Schedule 66.6 Fee Schedule 88.8 Fee Schedule 66.6 88.8 XR SOFT TISSUE NECK 2 VIEW AP/LATERAL 70360 CPT 320 Revenue Code Both 180 135 144 Fee Schedule 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 XR STERNUM 2 VIEWS RAO/LATERAL 71120 CPT 320 Revenue Code Both 139 104.25 111.2 Fee Schedule 111.2 Fee Schedule 62.55 Fee Schedule 83.4 Fee Schedule 62.55 83.4 XR TIBIA/FIBULA 1 VIEW LEFT 73590 CPT 320 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 XR TIBIA/FIBULA 1 VIEW RIGHT 73590 CPT 921 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 XR TIBIA/FIBULA 2 VIEW AP/LATERAL LEFT 73590 CPT 320 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 XR TIBIA/FIBULA 2 VIEW AP/LATERAL RIGHT 73590 CPT 320 Revenue Code Both 293 219.75 234.4 Fee Schedule 234.4 Fee Schedule 131.85 Fee Schedule 175.8 Fee Schedule 131.85 175.8 XR TMJ BILATERAL 3 VIEW 70330 CPT 320 Revenue Code Both 217 162.75 173.6 Fee Schedule 173.6 Fee Schedule 97.65 Fee Schedule 130.2 Fee Schedule 97.65 130.2 XR TOE 1 VIEW LEFT 73660 CPT 320 Revenue Code Both 225 168.75 180 Fee Schedule 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 XR TOE 1 VIEW RIGHT 73660 CPT 320 Revenue Code Both 225 168.75 180 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 XR TOES 3 VIEW AP/LATERAL/OBLIQUE LEFT 73660 CPT 320 Revenue Code Both 225 168.75 180 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 XR TOES 3 VIEW AP/LATERAL/OBLIQUE RIGHT 73660 CPT 320 Revenue Code Both 225 168.75 180 180 Fee Schedule 101.25 Fee Schedule 135 Fee Schedule 101.25 135 XR T-SPINE 1 VIEW CROSS TABLE LATERAL 72020 CPT 320 Revenue Code Both 337 252.75 269.6 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 XR T-SPINE 2 VIEW FLEXION EXTENSION 72070 CPT 320 Revenue Code Both 383 287.25 306.4 306.4 Fee Schedule 172.35 Fee Schedule 229.8 Fee Schedule 172.35 229.8 XR T-SPINE 3 VIEWS AP/LATERAL/SWIMMERS 72070 CPT 320 Revenue Code Both 383 287.25 306.4 306.4 Fee Schedule 172.35 Fee Schedule 229.8 Fee Schedule 172.35 229.8 XR WRIST 1 VIEW SCAPHOID LEFT 73100 CPT 320 Revenue Code Both 264 198 211.2 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR WRIST 1 VIEW SCAPHOID RIGHT 73100 CPT 320 Revenue Code Both 264 198 211.2 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR WRIST 2 VIEW AP/LATERAL LEFT 73100 CPT 320 Revenue Code Both 264 198 211.2 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR WRIST 2 VIEW AP/LATERAL RIGHT 73100 CPT 320 Revenue Code Both 264 198 211.2 211.2 Fee Schedule 118.8 Fee Schedule 158.4 Fee Schedule 118.8 158.4 XR WRIST 3 VIEW AP/LATERAL/OBLIQUE LEFT 73110 CPT 320 Revenue Code Both 269 201.75 215.2 215.2 Fee Schedule 121.05 Fee Schedule 161.4 Fee Schedule 121.05 161.4 XR WRIST 3 VIEW AP/LATERAL/OBLIQUE RIGHT 73110 CPT 320 Revenue Code Both 269 201.75 215.2 215.2 Fee Schedule 121.05 Fee Schedule 161.4 Fee Schedule 121.05 161.4 XYLO/EPI(LIDO/EPI)1%1:100000/ML INJ J2001 HCPCS 637 Revenue Code Both 30 22.5 24 24 Fee Schedule 13.5 Fee Schedule 18 Fee Schedule 13.5 18 ZANAMIVIR (RELENZA) INH POWD DISK 5MG G9034 HCPCS 637 Revenue Code Both 165 123.75 132 132 Fee Schedule 74.25 Fee Schedule 99 Fee Schedule 74.25 99 ZIKA VIRUS 86794 CPT 300 Revenue Code Both 601 450.75 480.8 480.8 Fee Schedule 270.45 Fee Schedule 360.6 Fee Schedule 270.45 360.6 ZINC 84630 CPT 300 Revenue Code Both 316 237 252.8 252.8 Fee Schedule 142.2 Fee Schedule 189.6 Fee Schedule 142.2 189.6 ZIO 93246 CPT 731 Revenue Code Both 53 39.75 42.4 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 ZIO PLACEMENT 93246 CPT 420 Revenue Code Both 53 39.75 42.4 42.4 Fee Schedule 23.85 Fee Schedule 31.8 Fee Schedule 23.85 31.8 ZOFRAN 1MG J2405 HCPCS 636 Revenue Code Both 7 5.25 5.6 5.6 Fee Schedule 3.15 Fee Schedule 4.2 Fee Schedule 3.15 4.2 ZOFRAN 1MG ODT Q0162 HCPCS 636 Revenue Code Both 110 82.5 88 88 Fee Schedule 49.5 Fee Schedule 66 Fee Schedule 49.5 66 ZOLEDRONIC ACID 4MG/5ML Injectable J3489 HCPCS 637 Revenue Code Both 34 25.5 27.2 27.2 Fee Schedule 15.3 Fee Schedule 20.4 Fee Schedule 15.3 20.4 ZZ.. HYPERSENSITIVITY PNEUMONITIS SCREEN 86331 CPT 300 Revenue Code Both 424 318 339.2 339.2 Fee Schedule 190.8 Fee Schedule 254.4 Fee Schedule 190.8 254.4 ZZ... ALLERG SPECIFIC IGE CRUDE EXTR 86003 CPT 300 Revenue Code Both 28 21 22.4 22.4 Fee Schedule 12.6 Fee Schedule 16.8 Fee Schedule 12.6 16.8 ZZ... ASSAY OTHER FLUID CHLORIDES 82438 CPT 300 Revenue Code Both 89 66.75 71.2 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 ZZ... BETA-1 GLOBULIN 84155 CPT 300 Revenue Code Both 40 30 32 32 Fee Schedule 18 Fee Schedule 24 Fee Schedule 18 24 ZZ... BETA-2 GLYCOPROTEIN ANTIBODY 86146 CPT 300 Revenue Code Both 127 95.25 101.6 101.6 Fee Schedule 57.15 Fee Schedule 76.2 Fee Schedule 57.15 76.2 ZZ... C DIFFICILE TOX A 87324 CPT 300 Revenue Code Both 180 135 144 144 Fee Schedule 81 Fee Schedule 108 Fee Schedule 81 108 ZZ... C DIFFICILE TOX B 87230 CPT 300 Revenue Code Both 129 96.75 103.2 103.2 Fee Schedule 58.05 Fee Schedule 77.4 Fee Schedule 58.05 77.4 ZZ... C3 86160 CPT 300 Revenue Code Both 60 45 48 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 ZZ... C3 C4 C5 86160 CPT 300 Revenue Code Both 169 126.75 135.2 135.2 Fee Schedule 76.05 Fee Schedule 101.4 Fee Schedule 76.05 101.4 ZZ... C4 86160 CPT 300 Revenue Code Both 60 45 48 48 Fee Schedule 27 Fee Schedule 36 Fee Schedule 27 36 ZZ... CARDIOLIPIN ANTIBODY EA IG 86147 CPT 300 Revenue Code Both 127 95.25 101.6 101.6 Fee Schedule 57.15 Fee Schedule 76.2 Fee Schedule 57.15 76.2 ZZ... CATECHOL F T PL 82384 CPT 300 Revenue Code Both 202 151.5 161.6 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 ZZ... CATECHOLAMINES FRAC 82384 CPT 300 Revenue Code Both 202 151.5 161.6 161.6 Fee Schedule 90.9 Fee Schedule 121.2 Fee Schedule 90.9 121.2 ZZ... CH50 86162 CPT 300 Revenue Code Both 123 92.25 98.4 98.4 Fee Schedule 55.35 Fee Schedule 73.8 Fee Schedule 55.35 73.8 ZZ... CHLAMYDIA TRACHOMATIS 87491 CPT 300 Revenue Code Both 352 264 281.6 281.6 Fee Schedule 158.4 Fee Schedule 211.2 Fee Schedule 158.4 211.2 ZZ... CONCENTRATION FOR INFECT AGENT 87015 CPT 300 Revenue Code Both 75 56.25 60 60 Fee Schedule 33.75 Fee Schedule 45 Fee Schedule 33.75 45 ZZ... CYCLOSPORINE A TROUGH 80158 CPT 300 Revenue Code Both 154 115.5 123.2 123.2 Fee Schedule 69.3 Fee Schedule 92.4 Fee Schedule 69.3 92.4 ZZ... DRUG SCREENING OXYCODONE 80365 CPT 300 Revenue Code Both 75 56.25 60 60 Fee Schedule 33.75 Fee Schedule 45 Fee Schedule 33.75 45 ZZ... FECAL NA 84302 CPT 300 Revenue Code Both 204 153 163.2 163.2 Fee Schedule 91.8 Fee Schedule 122.4 Fee Schedule 91.8 122.4 ZZ... FINGERSTICK 36416 CPT 300 Revenue Code Both 23 17.25 18.4 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 ZZ... FTA ABSORPTION TEST 86780 CPT 300 Revenue Code Both 119 89.25 95.2 95.2 Fee Schedule 53.55 Fee Schedule 71.4 Fee Schedule 53.55 71.4 ZZ... GLUCAGON 82943 CPT 300 Revenue Code Both 314 235.5 251.2 251.2 Fee Schedule 141.3 Fee Schedule 188.4 Fee Schedule 141.3 188.4 ZZ... HEPARIN LOW MOLECULAR WEIGHT XA 85520 CPT 300 Revenue Code Both 301 225.75 240.8 240.8 Fee Schedule 135.45 Fee Schedule 180.6 Fee Schedule 135.45 180.6 ZZ... HEROIN METABOLITE 80356 CPT 300 Revenue Code Both 75 56.25 60 60 Fee Schedule 33.75 Fee Schedule 45 Fee Schedule 33.75 45 ZZ... HERPES VIRUS 7 AB 86790 CPT 300 Revenue Code Both 66 49.5 52.8 52.8 Fee Schedule 29.7 Fee Schedule 39.6 Fee Schedule 29.7 39.6 ZZ... HOMOCYSTEINE 83090 CPT 300 Revenue Code Both 391 293.25 312.8 312.8 Fee Schedule 175.95 Fee Schedule 234.6 Fee Schedule 175.95 234.6 ZZ... HYDROMORPHONE 80361 CPT 300 Revenue Code Both 190 142.5 152 152 Fee Schedule 85.5 Fee Schedule 114 Fee Schedule 85.5 114 "ZZ... IG LIGHT CHAINS FREE, EACH" 83521 CPT 300 Revenue Code Both 254 190.5 203.2 203.2 Fee Schedule 114.3 Fee Schedule 152.4 Fee Schedule 114.3 152.4 ZZ... IMMUNOASSAY QUANT NOS NONAB 83520 CPT 300 Revenue Code Both 33 24.75 26.4 26.4 Fee Schedule 14.85 Fee Schedule 19.8 Fee Schedule 14.85 19.8 ZZ... INSULIN GROWTH FACTOR 84305 CPT 300 Revenue Code Both 337 252.75 269.6 269.6 Fee Schedule 151.65 Fee Schedule 202.2 Fee Schedule 151.65 202.2 ZZ... IRON 83540 CPT 300 Revenue Code Both 49 36.75 39.2 39.2 Fee Schedule 22.05 Fee Schedule 29.4 Fee Schedule 22.05 29.4 ZZ... IRON BINDING CAPACITY 83550 CPT 300 Revenue Code Both 73 54.75 58.4 58.4 Fee Schedule 32.85 Fee Schedule 43.8 Fee Schedule 32.85 43.8 ZZ... LIPOPROTEIN 83695 CPT 300 Revenue Code Both 108 81 86.4 86.4 Fee Schedule 48.6 Fee Schedule 64.8 Fee Schedule 48.6 64.8 ZZ... LIPOPROTEIN ASSOCIATED PHOSPHO 83698 CPT 300 Revenue Code Both 313 234.75 250.4 250.4 Fee Schedule 140.85 Fee Schedule 187.8 Fee Schedule 140.85 187.8 ZZ... LIPOPROTEIN BLOOD QUANTITATIVE 83704 CPT 300 Revenue Code Both 263 197.25 210.4 210.4 Fee Schedule 118.35 Fee Schedule 157.8 Fee Schedule 118.35 157.8 ZZ...24 HOUR URINE SODIUM 84300 CPT 300 Revenue Code Both 23 17.25 18.4 18.4 Fee Schedule 10.35 Fee Schedule 13.8 Fee Schedule 10.35 13.8 ZZ...HEPATITIS C VIRAL RNA GENOTYPE 87902 CPT 300 Revenue Code Both 424 318 339.2 339.2 Fee Schedule 190.8 Fee Schedule 254.4 Fee Schedule 190.8 254.4 ZZ...LUPUS ACTIVITY PANEL 2 86625 CPT 300 Revenue Code Both 531 398.25 424.8 424.8 Fee Schedule 238.95 Fee Schedule 318.6 Fee Schedule 238.95 318.6 ZZ...MEASLES AB IGG 86765 CPT 300 Revenue Code Both 232 174 185.6 185.6 Fee Schedule 104.4 Fee Schedule 139.2 Fee Schedule 104.4 139.2 ZZ...MEASLES AB IGM 86765 CPT 300 Revenue Code Both 232 174 185.6 185.6 Fee Schedule 104.4 Fee Schedule 139.2 Fee Schedule 104.4 139.2 "ZZ...MORPHINE, SERUM" 80361 CPT 300 Revenue Code Both 251 188.25 200.8 200.8 Fee Schedule 112.95 Fee Schedule 150.6 Fee Schedule 112.95 150.6 ZZ...MUMPS AB IGG 86735 CPT 300 Revenue Code Both 182 136.5 145.6 145.6 Fee Schedule 81.9 Fee Schedule 109.2 Fee Schedule 81.9 109.2 ZZ...MUMPS AB IGM 86735 CPT 300 Revenue Code Both 165 123.75 132 132 Fee Schedule 74.25 Fee Schedule 99 Fee Schedule 74.25 99 "ZZ...OXYCODONE, SERUM" 80365 CPT 300 Revenue Code Both 188 141 150.4 150.4 Fee Schedule 84.6 Fee Schedule 112.8 Fee Schedule 84.6 112.8 "ZZ...PRESCRIBED DRUGS, MEDMATCH" 80307 CPT 300 Revenue Code Both 479 359.25 383.2 383.2 Fee Schedule 215.55 Fee Schedule 287.4 Fee Schedule 215.55 287.4 "ZZ...PTH, INTACT" 82310 CPT 300 Revenue Code Both 250 187.5 200 200 Fee Schedule 112.5 Fee Schedule 150 Fee Schedule 112.5 150 ZZ...RUBELLA AB IGG 86762 CPT 300 Revenue Code Both 72 54 57.6 57.6 Fee Schedule 32.4 Fee Schedule 43.2 Fee Schedule 32.4 43.2 ZZ...RUBELLA AB IGM 86762 CPT 300 Revenue Code Both 72 54 57.6 57.6 Fee Schedule 32.4 Fee Schedule 43.2 Fee Schedule 32.4 43.2 ZZ...SLE DISEASE ACTIVITY 86235 CPT 300 Revenue Code Both 411 308.25 328.8 328.8 Fee Schedule 184.95 Fee Schedule 246.6 Fee Schedule 184.95 246.6 ZZ...SPECTROPHOTOMETRY 84311 CPT 300 Revenue Code Both 89 66.75 71.2 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 ZZ...STOOL- PH 83986 CPT 300 Revenue Code Both 162 121.5 129.6 129.6 Fee Schedule 72.9 Fee Schedule 97.2 Fee Schedule 72.9 97.2 ZZZ...INFLUENZA A B 87804 CPT 300 Revenue Code Both 89 66.75 71.2 71.2 Fee Schedule 40.05 Fee Schedule 53.4 Fee Schedule 40.05 53.4 ZZZ...OPIATES 1 OR MORE 80361 CPT 300 Revenue Code Both 75 56.25 60 60 Fee Schedule 33.75 Fee Schedule 45 Fee Schedule 33.75 45 ZZZ...RETICULOCYTES ABSOLUTE 85044 CPT 300 Revenue Code Both 45 33.75 36 36 Fee Schedule 20.25 Fee Schedule 27 Fee Schedule 20.25 27 "ZZZ...RHEUMATOID FACTOR, QUANT (MAL)" 86431 CPT 300 Revenue Code Both 37 27.75 29.6 29.6 Fee Schedule 16.65 Fee Schedule 22.2 Fee Schedule 16.65 22.2 ZZZ...VZV AB IGG 86787 CPT 300 Revenue Code Both 434 325.5 347.2 347.2 Fee Schedule 195.3 Fee Schedule 260.4 Fee Schedule 195.3 260.4 ZZZ...VZV AB IGM 86787 CPT 300 Revenue Code Both 434 325.5 347.2 347.2 Fee Schedule 195.3 Fee Schedule 260.4 Fee Schedule 195.3 260.4 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee Schedule 0 Fee 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