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All Services Other

CPT J3490

Unclassified drugs

$22.50 Standard Charge

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CPT J1170

Injection, hydromorphone, up to 4 mg

$45.31 Standard Charge

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CPT J1200

Injection, diphenhydramine hcl, up to 50 mg

$24.31 Standard Charge

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CPT A0429

Ambulance service, basic life support, emergency transport (bls-emergency)

$598.00 Standard Charge

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CPT J0456

Injection, azithromycin, 500 mg

$27.10 Standard Charge

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CPT J3475

Injection, magnesium sulfate, per 500 mg

$24.21 Standard Charge

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CPT C1713

Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)

$12.00 Standard Charge

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CPT J3010

Injection, fentanyl citrate, 0.1 mg

$42.42 Standard Charge

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CPT J7040

Infusion, normal saline solution, sterile (500 ml = 1 unit)

$66.70 Standard Charge

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CPT J2704

Injection, propofol, 10 mg

$28.17 Standard Charge

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CPT J2270

Injection, morphine sulfate, up to 10 mg

$45.41 Standard Charge

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CPT J1100

Injection, dexamethasone sodium phosphate, 1 mg

$23.16 Standard Charge

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CPT J0897

Injection, denosumab, 1 mg

$3,451.70 Standard Charge

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CPT V2632

Posterior chamber intraocular lens

$124.00 Standard Charge

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CPT J7050

Infusion, normal saline solution, 250 cc

$65.26 Standard Charge

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CPT J1885

Injection, ketorolac tromethamine, per 15 mg

$22.83 Standard Charge

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CPT J1815

Injection, insulin, per 5 units

$32.80 Standard Charge

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CPT J2250

Injection, midazolam hydrochloride, per 1 mg

$41.09 Standard Charge

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CPT J3480

Injection, potassium chloride, per 2 meq

$23.55 Standard Charge

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CPT J0131

Injection, acetaminophen, 10 mg

$34.78 Standard Charge

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CPT J7060

5% dextrose/water (500 ml = 1 unit)

$66.28 Standard Charge

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CPT S0013

Esketamine, nasal spray, 1 mg

$2,938.16 Standard Charge

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CPT J0690

Injection, cefazolin sodium, 500 mg

$23.31 Standard Charge

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CPT J2405

Injection, ondansetron hydrochloride, per 1 mg

$20.96 Standard Charge

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CPT J1940

Injection, furosemide, up to 20 mg

$23.68 Standard Charge

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CPT J1650

Injection, enoxaparin sodium, 10 mg

$26.50 Standard Charge

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CPT G0463

Hospital outpatient clinic visit for assessment and management of a patient

$200.00 Standard Charge

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CPT A0425

Ground mileage, per statute mile

$2.00 Standard Charge

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CPT J7120

Ringers lactate infusion, up to 1000 cc

$66.80 Standard Charge

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CPT J1745

Injection, infliximab, excludes biosimilar, 10 mg

$973.38 Standard Charge

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CPT J7030

Infusion, normal saline solution , 1000 cc

$66.80 Standard Charge

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CPT J3301

Injection, triamcinolone acetonide, not otherwise specified, 10 mg

$32.51 Standard Charge

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CPT Q9967

Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml

$172.76 Standard Charge

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CPT J2001

Injection, lidocaine hcl for intravenous infusion, 10 mg

$23.11 Standard Charge

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CPT J1756

Injection, iron sucrose, 1 mg

$140.90 Standard Charge

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CPT J2060

Injection, lorazepam, 2 mg

$44.20 Standard Charge

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CPT A0426

Ambulance service, advanced life support, non-emergency transport, level 1 (als 1)

$464.00 Standard Charge

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CPT J2357

Injection, omalizumab, 5 mg

$1,484.96 Standard Charge

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CPT J1642

Injection, heparin sodium, (heparin lock flush), per 10 units

$21.27 Standard Charge

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CPT J0696

Injection, ceftriaxone sodium, per 250 mg

$23.86 Standard Charge

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CPT J2795

Injection, ropivacaine hydrochloride, 1 mg

$38.39 Standard Charge

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CPT G0379

Direct admission of patient for hospital observation care

$460.00 Standard Charge

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CPT G0378

Hospital observation service, per hour

$62.00 Standard Charge

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CPT A0427

Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency)

$889.00 Standard Charge

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CPT A9270

Non-covered item or service

$1.03 Standard Charge

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CPT G0480

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed

$139.00 Standard Charge

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