Description

CPT

Charge

Program / Organization

FNA W/O IMAGE

10021

$417.00

AICS

DRAINAGE OF SKIN ABSCESS

10060

$310.00

AICS

DRAINAGE OF SKIN ABSCESS

10061

$300.00

AICS

DRAINAGE OF PILONIDAL CYST

10080

$440.00

AICS

REMOVE FOREIGN BODY

10120

$310.00

AICS

REMOVE FOREIGN BODY

10121

$640.00

AICS

DRAINAGE OF HEMATOMA/FLUID

10140

$261.00

AICS

PUNCTURE DRAINAGE OF LESION

10160

$239.00

AICS

DEBRIDE INFECTED SKIN

11000

$157.00

AICS

DEBRIDE SKIN/TISSUE

11042

$520.00

AICS

TRIM SKIN LESION

11055

$130.00

AICS

TRIM SKIN LESIONS, 2 TO 4

11056

$128.00

AICS

TRIM SKIN LESIONS, OVER 4

11057

$120.00

AICS

BIOPSY, SKIN LESION

11100

$266.00

AICS

BIOPSY, SKIN ADD-ON

11101

$126.00

AICS

REMOVAL OF SKIN TAGS

11200

$230.00

AICS

REMOVE SKIN TAGS ADD-ON

11201

$51.00

AICS

SHAVE SKIN LESION

11300

$184.00

AICS

SHAVE SKIN LESION

11301

$266.00

AICS

Shave Skin Les Trunk, Arm Leg 1.1cm To 2.0cm

11302

$351.00

AICS

SHAVE SKIN LESION

11303

$382.00

AICS

SHAVE SKIN LESION

11305

$196.00

AICS

SHAVE SKIN LESION

11306

$244.00

AICS

SHAVE SKIN LESION

11307

$372.00

AICS

SHAVE SKIN LESION

11310

$235.00

AICS

SHAVE SKIN LESION

11311

$278.00

AICS

SHAVE SKIN LESION

11312

$289.00

AICS

EXC TR-EXT B9+MARG 0.5 < CM

11400

$325.00

AICS

EXC TR-EXT B9+MARG 0.6-1 CM

11401

$407.00

AICS

EXC TR-EXT B9+MARG 1.1-2 CM

11402

$471.00

AICS

EXC TR-EXT B9+MARG 2.1-3 CM

11403

$609.00

AICS

EXC TR-EXT B9+MARG 3.1-4 CM

11404

$727.00

AICS

EXC TR-EXT B9+MARG > 4.0 CM

11406

$901.00

AICS

EXC H-F-NK-SP B9+MARG 0.5 <

11420

$342.00

AICS

EXC H-F-NK-SP B9+MARG 0.6-1

11421

$402.00

AICS

EXC H-F-NK-SP B9+MARG 1.1-2

11422

$527.00

AICS

EXC H-F-NK-SP B9+MARG 2.1-3

11423

$536.00

AICS

EXC H-F-NK-SP B9+MARG > 4 CM

11426

$790.00

AICS

EXC FACE-MM B9+MARG 0.5 < CM

11440

$383.00

AICS

EXC FACE-MM B9+MARG 0.6-1 CM

11441

$433.00

AICS

EXC FACE-MM B9+MARG 1.1-2 CM

11442

$472.00

AICS

EXC FACE-MM B9+MARG 2.1-3 CM

11443

$822.00

AICS

EXC TR-EXT MLG+MARG 0.5 < CM

11600

$477.00

AICS

EXC TR-EXT MLG+MARG 0.6-1 CM

11601

$567.00

AICS

Description

CPT

Charge

Program / Organization

EXC TR-EXT MLG+MARG 2.1-3 CM

11603

$561.00

AICS


EXC H-F-NK-SP MLG+MARG 0.5 <

11620

$500.00

AICS

EXC H-F-NK-SP MLG+MARG 0.6-1

11621

$577.00

AICS

EXC H-F-NK-SP MLG+MARG 1.1-2

11622

$625.00

AICS

EXC H-F-NK-SP MLG+MARG 2.1-3

11623

$762.00

AICS

EXC FACE-MM MALIG+MARG 0.5 <

11640

$469.00

AICS

EXC FACE-MM MALIG+MARG 0.6-1

11641

$598.00

AICS

EXC FACE-MM MALIG+MARG 1.1-2

11642

$687.00

AICS

EXC FACE-MM MALIG+MARG 2.1-3

11643

$880.00

AICS

EXC FACE-MM MALIG+MARG 3.1-4

11644

$1,012.00

AICS

TRIM NAIL(S)

11719

$64.00

AICS

DEBRIDE NAIL, 1-5

11720

$91.00

AICS

DEBRIDE NAIL, 6 OR MORE

11721

$140.00

AICS

REMOVAL OF NAIL PLATE

11730

$293.00

AICS

REMOVE NAIL PLATE, ADD-ON

11732

$121.00

AICS

DRAIN BLOOD FROM UNDER NAIL

11740

$140.00

AICS

REMOVAL OF NAIL BED

11750

$645.00

AICS

EXCISION OF NAIL FOLD, TOE

11765

$291.00

AICS

INSERT DRUG IMPLANT DEVICE

11981

$749.95

AICS

REMOVE DRUG IMPLANT DEVICE

11982

$870.98

AICS

REMOVE/INSERT DRUG IMPLANT

11983

$885.00

AICS

REPAIR SUPERFICIAL WOUND(S)

12001

$452.00

AICS

REPAIR SUPERFICIAL WOUND(S)

12002

$504.00

AICS

REPAIR SUPERFICIAL WOUND(S)

12004

$570.00

AICS

REPAIR SUPERFICIAL WOUND(S)

12011

$494.00

AICS

REPAIR SUPERFICIAL WOUND(S)

12013

$516.00

AICS

INTMD WND REPAIR S/TR/EXT

12031

$465.00

AICS

INTMD WND REPAIR S/TR/EXT

12032

$627.00

AICS

INTMD WND REPAIR S/TR/EXT

12034

$874.00

AICS

INTMD WND REPAIR N-HF/GENIT

12041

$688.00

AICS

INTMD WND REPAIR N-HG/GENIT

12042

$605.00

AICS

INTMD WND REPAIR FACE/MM

12052

$672.05

AICS

REPAIR OF WOUND OR LESION

13121

$1,259.00

AICS

REPAIR WOUND/LESION ADD-ON

13122

$393.00

AICS

REPAIR OF WOUND OR LESION

13132

$1,611.00

AICS

REPAIR WOUND/LESION ADD-ON

13133

$439.00

AICS

SKIN TISSUE REARRANGEMENT

14040

$1,540.00

AICS

INITIAL TREATMENT OF BURN(S)

16000

$170.00

AICS

DRESS/DEBRID P-THICK BURN, S

16020

$238.00

AICS

DRESS/DEBRID P-THICK BURN, M

16025

$313.00

AICS

DESTRUCT PREMALG LESION

17000

$192.00

AICS

DESTRUCT PREMALG LES, 2-14

17003

$21.00

AICS

DESTROY PREMLG LESIONS 15+

17004

$545.00

AICS

Description

CPT

Charge Program / Organization

DESTRUCT LESION, 15 OR MORE

17111

$238.00 AICS


DESTRUCTION OF SKIN LESIONS

17262

$497.00

AICS

DESTRUCTION OF SKIN LESIONS

17280

$399.00

AICS

DRAINAGE OF BREAST LESION

19000

$345.00

AICS

THER INJECTION, CARP TUNNEL

20526

$185.00

AICS

INJ TENDON SHEATH/LIGAMENT

20550

$170.00

AICS

INJ TENDON ORIGIN/INSERTION

20551

$178.00

AICS

INJ TRIGGER POINT, 1/2 MUSCL

20552

$158.00

AICS

INJECT TRIGGER POINTS, =/> 3

20553

$203.00

AICS

DRAIN/INJECT, JOINT/BURSA

20600

$160.00

AICS

DRAIN/INJECT, JOINT/BURSA

20605

$153.00

AICS

DRAIN/INJECT, JOINT/BURSA

20610

$233.00

AICS

ASPIRATE/INJ GANGLION CYST

20612

$177.00

AICS

REMOVAL OF SUPPORT IMPLANT

20670

$929.00

AICS

TREATMENT OF RIB FRACTURE

21800

$335.00

AICS

TREAT CLAVICLE FRACTURE

23500

$620.00

AICS

TREAT SHOULDER DISLOCATION

23650

$687.00

AICS

TREAT ELBOW DISLOCATION

24600

$1,158.00

AICS

TREAT RADIUS FRACTURE

24650

$896.00

AICS

TREAT ULNAR FRACTURE

24670

$660.00

AICS

TREAT FRACTURE OF RADIUS

25500

$973.00

AICS

TREAT FRACTURE OF ULNA

25530

$940.00

AICS

TREAT FRACTURE RADIUS & ULNA

25560

$948.00

AICS

TREAT FRACTURE RADIUS & ULNA

25565

$1,916.00

AICS

TREAT FRACTURE RADIUS/ULNA

25600

$965.00

AICS

TREAT FRACTURE RADIUS/ULNA

25605

$1,197.00

AICS

TREAT WRIST BONE FRACTURE

25630

$930.00

AICS

DRAINAGE OF FINGER ABSCESS

26010

$352.00

AICS

REPAIR HAND TENDON

26410

$1,715.00

AICS

TREAT METACARPAL FRACTURE

26600

$718.00

AICS

TREAT METACARPAL FRACTURE

26605

$884.00

AICS

TREAT FINGER FRACTURE, EACH

26720

$527.00

AICS

TREAT FINGER FRACTURE, EACH

26750

$404.00

AICS

TREAT FINGER FRACTURE, EACH

26755

$844.00

AICS

TREATMENT OF TIBIA FRACTURE

27750

$1,329.00

AICS

TREATMENT OF ANKLE FRACTURE

27786

$934.00

AICS

REMOVAL OF TOE LESIONS

28092

$642.00

AICS

REMOVAL OF FOOT FOREIGN BODY

28190

$371.00

AICS

TREAT MIDFOOT FRACTURE, EACH

28450

$800.00

AICS

TREAT METATARSAL FRACTURE

28470

$703.00

AICS

TREATMENT OF TOE FRACTURE

28510

$336.00

AICS

APPLICATION OF LONG ARM CAST

29065

$277.00

AICS

APPLICATION OF FOREARM CAST

29075

$257.00

AICS

Description

CPT

Charge

Program / Organization

APPLY LONG ARM SPLINT

29105

$204.00

AICS


APPLY FOREARM SPLINT

29125

$202.00

AICS

APPLICATION OF LONG LEG CAST

29345

$347.00

AICS

APPLY SHORT LEG CAST

29405

$260.00

AICS

APPLY SHORT LEG CAST

29425

$244.00

AICS

APPLICATION LOWER LEG SPLINT

29515

$138.00

AICS

APPLICATION OF PASTE BOOT

29580

$155.00

AICS

REMOVAL/REVISION OF CAST

29700

$180.00

AICS

INTRANASAL BIOPSY

30100

$293.00

AICS

REMOVE NASAL FOREIGN BODY

30300

$725.90

AICS

CONTROL OF NOSEBLEED

30901

$312.00

AICS

340B Medication

340B

$10.00

AICS

ROUTINE VENIPUNCTURE

36415

$24.00

AICS

CAPILLARY BLOOD DRAW

36416

$28.82

AICS

INSERT NON-TUNNEL CV CATH

36556

$645.00

AICS

REMOVAL TUNNELED CV CATH

36589

$450.00

AICS

BIOPSY/REMOVAL, LYMPH NODES

38500

$950.00

AICS

NEEDLE BIOPSY, LYMPH NODES

38505

$1,083.00

AICS

EXCISION OF MOUTH LESION

40810

$503.00

AICS

DRAINAGE OF TONSIL ABSCESS

42700

$338.00

AICS

UPPR GI ENDOSCOPY, DIAGNOSIS

43235

$771.00

AICS

UPPER GI ENDOSCOPY, BIOPSY

43239

$896.00

AICS

OPERATIVE UPPER GI ENDOSCOPY

43247

$592.00

AICS

CHANGE GASTROSTOMY TUBE

43760

$1,101.00

AICS

DIAGNOSTIC COLONOSCOPY

45378

$1,017.00

AICS

COLONOSCOPY W/FB REMOVAL

45379

$1,288.00

AICS

COLONOSCOPY AND BIOPSY

45380

$1,400.00

AICS

COLONOSCOPY, SUBMUCOUS INJ

45381

$1,197.00

AICS

COLONOSCOPY/CONTROL BLEEDING

45382

$1,611.00

AICS

LESION REMOVE COLONOSCOPY

45384

$1,202.00

AICS

LESION REMOVAL COLONOSCOPY

45385

$1,381.00

AICS

INCISE EXTERNAL HEMORRHOID

46083

$495.00

AICS

DIAGNOSTIC ANOSCOPY

46600

$133.00

AICS

PUNCTURE, PERITONEAL CAVITY

49080

$495.00

AICS

ABD PARACENTESIS W/O IMG GUIDANCE

49082

$424.80

AICS

IRRIGATION OF BLADDER

51700

$122.48

AICS

INSERT BLADDER CATHETER

51701

$172.00

AICS

INSERT TEMP BLADDER CATH

51702

$174.00

AICS

CHANGE OF BLADDER TUBE

51705

$349.00

AICS

DESTRUCTION, PENIS LESION(S)

54050

$267.00

AICS

BIOPSY OF PENIS

54100

$354.00

AICS

CIRCUMCISION W/REGIONL BLOCK

54150

$456.00

AICS

REMOVAL OF SPERM DUCT(S)

55250

$1,272.00

AICS

Description

CPT

Charge

Program / Organization

EXAM/BIOPSY OF VAG W/SCOPE

57421

$410.00

AICS


EXAM OF CERVIX W/SCOPE

57452

$314.00

AICS

BX/CURETT OF CERVIX W/SCOPE

57454

$409.00

AICS

BIOPSY OF CERVIX W/SCOPE

57455

$428.00

AICS

ENDOCERV CURETTAGE W/SCOPE

57456

$391.00

AICS

BIOPSY OF UTERUS LINING

58100

$327.00

AICS

INSERT INTRAUTERINE DEVICE

58300

$206.00

AICS

REMOVE INTRAUTERINE DEVICE

58301

$286.00

AICS

ARTIFICIAL INSEMINATION

58321

$217.00

AICS

ARTIFICIAL INSEMINATION

58322

$252.00

AICS

FETAL MONITOR/INTERPRET ONLY

59051

$100.00

AICS

ANTEPARTUM CARE ONLY

59425

$1,000.00

AICS

ANTEPARTUM CARE ONLY

59426

$1,787.00

AICS

CARE AFTER DELIVERY

59430

$213.00

AICS

N BLOCK INJ, PLANTAR DIGIT

64455

$457.48

AICS

REMOVE FOREIGN BODY FROM EYE

65205

$147.00

AICS

REMOVE FOREIGN BODY FROM EYE

65210

$265.00

AICS

REMOVE FOREIGN BODY FROM EYE

65220

$188.00

AICS

REMOVE FOREIGN BODY FROM EYE

65222

$228.00

AICS

REVISE EYELASHES

67820

$334.80

AICS

CLEAR OUTER EAR CANAL

69200

$408.00

AICS

REMOVE IMPACTED EAR WAX

69210

$152.00

AICS

Drug Screen Multiple Drug Classes

80104

$15.00

AICS

DRUG TEST PRSMV DIR OPT OBS

80305

$112.84

AICS

URINALYSIS NONAUTO W/O SCOPE

81002

$25.00

AICS

URINE PREGNANCY TEST

81025

$25.00

AICS

URINALYSIS TEST PROCEDURE

81099

$53.00

AICS

OCCULT BLOOD, FECES

82270

$25.00

AICS

OCCULT BLD FECES, 1-3 TESTS

82272

$25.00

AICS

ASSAY TEST FOR BLOOD, FECAL

82274

$8.00

AICS

GLUCOSE BLOOD TEST

82962

$25.00

AICS

GLYCOSYLATED HEMOGLOBIN TEST

83036

$109.88

AICS

HEMOGLOBIN

85018

$20.00

AICS

AUTOMATED LEUKOCYTE COUNT

85048

$25.00

AICS

PROTHROMBIN TIME

85610

$81.26

AICS

TB INTRADERMAL TEST

86580

$25.00

AICS

HIV-1/HIV-2, SINGLE ASSAY

86703

$114.48

AICS

SMEAR, WET MOUNT, SALINE/INK

87210

$27.00

AICS

INFLUENZA ASSAY W/OPTIC

87804

$45.00

AICS

STREP A ASSAY W/OPTIC

87880

$30.00

AICS

Immun Admin <19, First Comp

90460

$27.44

AICS

H1N1 Administration

90470

$25.16

AICS

IMMUNIZATION ADMIN

90471

$27.44

AICS

Description

CPT

Charge

Program / Organization

IMMUNE ADMIN ORAL/NASAL

90473

$27.44

AICS


IMMUNE ADMIN ORAL/NASAL ADDL

90474

$27.44

AICS

HEP A VACCINE, ADULT IM

90632

$95.00

AICS

HEP A VACC, PED/ADOL, 2 DOSE

90633

$25.00

AICS

HEP A/HEP B VACC, ADULT IM

90636

$84.76

AICS

HPV VACCINE 4 VALENT, IM

90649

$193.00

AICS

HPV9 Vaccine IM

90651

$221.00

AICS

FLU VACCINE NO PRESERV 6-35M

90655

$28.00

AICS

FLU VACCINE NO PRESERV 3 & >

90656

$28.00

AICS

FLU VACCINE,6-35 MOS, IM

90657

$28.00

AICS

FLUVIRIN, 4 YRS & >, IM

90658

$28.00

AICS

FLU VACCINE, NASAL

90660

$0.01

AICS

FLU VACC PRSV FREE INC ANTIG

90662

$42.78

AICS

Pneumococcal Vacc 13 Valent

90670

$195.70

AICS

RABIES VACCINE, IM

90675

$424.00

AICS

Influenza Quadrivalent Pres Free 3 Yrs Up

90686

$28.00

AICS

DTAP-IPV VACC 4-6 YR IM

90696

$25.00

AICS

DTAP VACCINE, < 7 YRS, IM

90700

$25.00

AICS

MMR VACCINE, SC

90707

$70.00

AICS

POLIOVIRUS, IPV, SC/IM

90713

$25.00

AICS

TD VACCINE NO PRSRV >/= 7 IM

90714

$32.00

AICS

TDAP VACCINE >7 IM

90715

$46.00

AICS

CHICKEN POX VACCINE, SC

90716

$177.00

AICS

TD VACCINE > 7, IM

90718

$32.00

AICS

DTAP-HEP B-IPV VACCINE, IM

90723

$25.00

AICS

PNEUMOCOCCAL VACCINE

90732

$106.00

AICS

MENINGOCOCCAL VACCINE, IM

90734

$147.00

AICS

ZOSTER VACC, SC

90736

$315.00

AICS

HEPB VACC PED/ADOL 3 DOSE IM

90744

$25.00

AICS

HEP B VACCINE, ADULT, IM

90746

$17.00

AICS

HZV VACC RECOMBINANT IM NJX

90750

$302.40

AICS

Psytx Interactive Complexity

90785

$12.00

AICS

Psych Diagnostic Evaluation

90791

$404.00

AICS

Psych diagnostic evaluation

90791

$404.00

AICS

Psych diagnostic evaluation

90791

$404.00

AICS

Psych Diag Eval W/ Med Srvcs

90792

$372.00

AICS

Psych diag eval w/med srvcs

90792

$372.00

AICS

Psych diag eval w/med srvcs

90792

$372.00

AICS

Psytx Pt/Family 30 Min

90832

$147.00

AICS

Psytx pt&/family 30 minutes

90832

$147.00

AICS

Psytx pt&/family 30 minutes

90832

$147.00

AICS

Psytx Pt/Fam W EM 30 Min

90833

$98.00

AICS

Psytx Pt/Fam 45 Min

90834

$190.00

AICS

Description

CPT

Charge

Program / Organization

Psytx pt&/family 45 minutes

90834

$190.00

AICS


Psytx Pt/Fam W EM 45 Min

90836

$180.00

AICS

Psytx Pt/Fam 60 Min

90837

$278.00

AICS

Psytx pt&/family 60 minutes

90837

$278.00

AICS

Psytx pt&/family 60 minutes

90837

$278.00

AICS

Psytx Pt/Fam W EM 60 Min

90838

$256.00

AICS

Psytx Crisis Initial 60 Min

90839

$285.00

AICS

Psytx crisi initial 60 min

90839

$285.00

AICS

Psytx crisi initial 60 min

90839

$285.00

AICS

Psyth Crisis Ea Addl 30 Min

90840

$130.00

AICS

PSYCHOANALYSIS

90845

$150.00

AICS

Psychoanalysis

90845

$150.00

AICS

Psychoanalysis

90845

$150.00

AICS

FAMILY PSYTX W/O PATIENT

90846

$157.00

AICS

FAMILY PSYTX W/PATIENT

90847

$208.00

AICS

MULTIPLE FAMILY GROUP PSYTX

90849

$80.00

AICS

GROUP PSYCHOTHERAPY

90853

$53.00

AICS

INTAC GROUP PSYTX

90857

$58.00

AICS

Pharmacologic Mgmt W Psytx

90863

$35.00

AICS

PURE TONE HEARING TEST, AIR

92551

$31.00

AICS

PURE TONE AUDIOMETRY, AIR

92552

$87.00

AICS

TYMPANOMETRY

92567

$39.00

AICS

ELECTROCARDIOGRAM, COMPLETE

93000

$60.00

AICS

ELECTROCARDIOGRAM, TRACING

93005

$28.50

AICS

ELECTROCARDIOGRAM REPORT

93010

$24.50

AICS

PT/CAREGIVER TRAINJ HOME INR

93792

$153.08

AICS

ANTICOAG MGMT PT WARFARIN

93793

$40.02

AICS

EXTREMITY STUDY

93922

$305.00

AICS

BREATHING CAPACITY TEST

94010

$274.00

AICS

EVALUATION OF WHEEZING

94060

$457.00

AICS

VITAL CAPACITY TEST

94150

$169.00

AICS

AIRWAY INHALATION TREATMENT

94640

$62.00

AICS

MEASURE BLOOD OXYGEN LEVEL

94760

$8.00

AICS

MEASURE BLOOD OXYGEN LEVEL

94761

$15.00

AICS

IMMUNOTHERAPY, ONE INJECTION

95115

$45.90

AICS

IMMUNOTHERAPY INJECTIONS

95117

$68.84

AICS

ANALYZE NEUROSTIM, NO PROG

95970

$172.00

AICS

ANALYZE NEUROSTIM, SIMPLE

95971

$152.00

AICS

PSYCHO TESTING BY PSYCH/PHYS

96101

$712.01

AICS

DEVELOPMENTAL TEST, LIM

96110

$31.15

AICS

DEVELOPMENTAL TEST, EXTEND

96111

$445.37

AICS

ASSESS HLTH/BEHAVE, INIT

96150

$91.28

AICS

ASSESS HLTH/BEHAVE, SUBSEQ

96151

$45.64

AICS

Description

CPT

Charge

Program / Organization

INTERVENE HLTH/BEHAVE, GROUP

96153

$65.20

AICS


INTERV HLTH/BEHAV, FAM W/PT

96154

$65.20

AICS

INTERV HLTH/BEHAV FAM NO PT

96155

$65.20

AICS

HYDRATION IV INFUSION, INIT

96360

$75.00

AICS

HYDRATE IV INFUSION, ADD-ON

96361

$60.00

AICS

THER/PROPH/DIAG IV INF, INIT

96365

$373.00

AICS

THER/PROPH/DIAG IV INF ADDON

96366

$172.00

AICS

THER/PROPH/DIAG INJ, SC/IM

96372

$61.00

AICS

ACTIVE WOUND CARE/20 CM OR <

97597

$236.00

AICS

ACTIVE WOUND CARE > 20 CM

97598

$70.00

AICS

WOUND(S) CARE NON-SELECTIVE

97602

$104.00

AICS

OSTEOPATHIC MANIPULATION

98925

$83.00

AICS

OSTEOPATHIC MANIPULATION

98926

$113.00

AICS

OSTEOPATHIC MANIPULATION

98927

$148.00

AICS

HC PRO PHONE CALL 21-30 MIN

98968

$171.00

AICS

SPECIMEN HANDLING

99000

$13.00

AICS

MEDICAL SERVICES AFTER HRS

99050

$60.04

AICS

SPECIAL SUPPLIES

99070

$15.00

AICS

SPECIAL REPORTS OR FORMS

99080

$30.00

AICS

OFFICE/OUTPATIENT VISIT, NEW

99201

$121.00

AICS

OFFICE/OUTPATIENT VISIT, NEW

99202

$184.00

AICS

OFFICE/OUTPATIENT VISIT, NEW

99203

$253.00

AICS

OFFICE/OUTPATIENT VISIT, NEW

99204

$367.00

AICS

OFFICE/OUTPATIENT VISIT, NEW

99205

$429.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99211

$54.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99212

$98.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99213

$139.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99214

$250.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99214

$209.00

AICS

OFFICE/OUTPATIENT VISIT, EST

99215

$329.00

AICS

SUBSEQUENT HOSPITAL CARE

99231

$210.00

AICS

SUBSEQUENT HOSPITAL CARE

99232

$300.00

AICS

HOSPITAL DISCHARGE DAY

99238

$331.00

AICS

OFFICE CONSULTATION

99241

$132.00

AICS

OFFICE CONSULTATION

99242

$230.00

AICS

OFFICE CONSULTATION

99243

$284.00

AICS

OFFICE CONSULTATION

99244

$323.00

AICS

HOME VISIT, NEW PATIENT

99341

$253.00

AICS

HOME VISIT, NEW PATIENT

99342

$277.00

AICS

HOME VISIT, NEW PATIENT

99343

$400.00

AICS

HOME VISIT, EST PATIENT

99347

$169.00

AICS

HOME VISIT, EST PATIENT

99348

$234.00

AICS

HOME VISIT, EST PATIENT

99349

$338.00

AICS

Description

CPT

Charge

Program / Organization

PROLONGED SERVICE, OFFICE

99354

$262.00

AICS


PROLONGED SERVICE, OFFICE

99355

$259.00

AICS

PROLONGED SERV, W/O CONTACT

99358

$514.00

AICS

PROLONGED SERV, W/O CONTACT

99359

$257.00

AICS

INIT PM E/M, NEW PAT, INF

99381

$275.00

AICS

INIT PM E/M, NEW PAT 1-4 YRS

99382

$222.00

AICS

PREV VISIT, NEW, AGE 5-11

99383

$230.00

AICS

PREV VISIT, NEW, AGE 12-17

99384

$238.00

AICS

PREV VISIT, NEW, AGE 18-39

99385

$252.00

AICS

PREV VISIT, NEW, AGE 40-64

99386

$274.00

AICS

INIT PM E/M, NEW PAT 65+ YRS

99387

$277.00

AICS

PER PM REEVAL, EST PAT, INF

99391

$169.00

AICS

PREV VISIT, EST, AGE 1-4

99392

$205.00

AICS

PREV VISIT, EST, AGE 5-11

99393

$211.00

AICS

PREV VISIT, EST, AGE 12-17

99394

$223.00

AICS

PREV VISIT, EST, AGE 18-39

99395

$235.00

AICS

PREV VISIT, EST, AGE 40-64

99396

$242.00

AICS

PER PM REEVAL EST PAT 65+ YR

99397

$272.00

AICS

BEHAV CHNG SMOKING 3-10 MIN

99406

$51.00

AICS

AUDIT/DAST, 15-30 MIN

99408

$172.46

AICS

PHONE E/M BY PHYS 5-10 MIN

99441

$35.00

AICS

PHONE E/M BY PHYS 11-20 MIN

99442

$72.00

AICS

PHONE E/M BY PHYS 21-30 MIN

99443

$106.00

AICS

BASIC LIFE DISABILITY EXAM

99450

$55.86

AICS

WORK RELATED DISABILITY EXAM

99455

$150.00

AICS

TRANS CARE MGMT 14 DAY DISCH

99495

$406.02

AICS

TRANS CARE MGMT 7 DAY DISCH

99496

$588.58

AICS

Medicaid Phys Services

9999

$196.52

AICS

Hand-held PEFR meter

A4614

$15.00

AICS

Surgical supplies

A4649

$85.00

AICS

Contact layer > 48 sq in

A6208

$22.00

AICS

Gauze > 48 in no w/sal w/o b

A6224

$22.00

AICS

Hydrogel dsg>16<=48 sq in

A6232

$5.00

AICS

Hydrocolld drg <=16 w/o bdr

A6234

$9.21

AICS

Hydrocolld drg >16<=48 w/o b

A6235

$17.63

AICS

Hydrogel drg >16<=48 w/o bdr

A6243

$6.70

AICS

Impreg gauze no h20/sal/yard

A6266

$4.89

AICS

Packing strips, non-impreg

A6407

$4.59

AICS

Zinc paste band w >=3<5"/yd"

A6456

$4.36

AICS

Admin influenza virus vac

G0008

$27.44

AICS

Admin pneumococcal vaccine

G0009

$27.44

AICS

CA screen;pelvic/breast exam

G0101

$88.00

AICS

Ca screen; pelvic/breast exam

G0101

$88.00

AICS

Description

CPT

Charge

Program / Organization

Colorectal scrn; hi risk ind

G0105

$950.00

AICS


Colon ca scrn not hi rsk ind

G0121

$950.00

AICS

Trim nail(s)

G0127

$57.00

AICS

Initial foot exam pt lops

G0245

$64.00

AICS

Fecal blood scrn immunoassay

G0328

$30.00

AICS

Initial preventive exam

G0344

$250.00

AICS

Initial preventive exam

G0402

$225.00

AICS

Annual Wellness Visit, Initial

G0438

$247.00

AICS

Annual Wellness Visit, Subsequent

G0439

$247.00

AICS

Brief alcohol misuse counsel

G0443

$81.75

AICS

FQHC visit, new patient

G0466

$302.14

AICS

FQHC visit, established patient

G0467

$219.88

AICS

FQHC visit, IPPE or AWV

G0468

$281.79

AICS

FQHC visit, mental health, new patient

G0469

$295.42

AICS

FQHC visit, mental health, established patient

G0470

$295.42

AICS

Adrenalin epinephrin inject

J0170

$42.00

AICS

Inj mepivacaine HCL/10 ml

J0670

$15.00

AICS

Ceftriaxone sodium injection

J0696

$17.00

AICS

Betamethasone acet&sod phosp

J0702

$35.00

AICS

Ceftizoxime sodium / 500 MG

J0715

$15.00

AICS

Methylprednisolone 20 MG inj

J1020

$17.00

AICS

Methylprednisolone 40 MG inj

J1030

$25.00

AICS

Methylprednisolone 80 MG inj

J1040

$15.00

AICS

Medroxyprogesterone Inj Per 1 Mg

J1050

$0.34

AICS

Dexamethasone sodium phos

J1100

$4.00

AICS

Diphenhydramine hcl injectio

J1200

$17.00

AICS

Haloperidol decanoate inj

J1631

$15.00

AICS

Ketorolac tromethamine inj

J1885

$17.00

AICS

Lorazepam injection

J2060

$15.00

AICS

Meperidine hydrochl /100 MG

J2175

$17.00

AICS

Ondansetron hcl injection

J2405

$2.85

AICS

Promethazine hcl injection

J2550

$17.00

AICS

Methylprednisolone injection

J2920

$17.00

AICS

Methylprednisolone injection

J2930

$17.00

AICS

Sumatriptan succinate / 6 MG

J3030

$94.23

AICS

Triamcinolone acet inj NOS

J3301

$17.00

AICS

Vitamin b12 injection

J3420

$17.00

AICS

Drugs unclassified injection

J3490

$17.00

AICS

Ringers lactate infusion

J7120

$10.00

AICS

Levonorgestrel IUD Contraception

J7298

$455.00

AICS

Intraut copper contraceptive

J7300

$416.00

AICS

Skyla, 13.5 mg

J7301

$455.00

AICS

Etonogestrel implant system

J7307

$1,575.54

AICS

Description

CPT

Charge

Program / Organization

Synvisc Or Synvisc-One

J7325

$217.00

AICS


Albuterol non-comp con

J7611

$1.00

AICS

Albuterol non-comp unit

J7613

$1.00

AICS

Budesonide non-comp unit

J7626

$1.00

AICS

Ipratropium bromide non-comp

J7644

$1.00

AICS

Leuprolide acetate suspnsion

J9217

$163.00

AICS

Cerv flexible non-adjustable

L0120

$11.30

AICS

LO flexibl L1-below L5 pre

L0625

$13.90

AICS

Ko immobilizer canvas longit

L1830

$21.00

AICS

Plastazote sandal each

L3265

$8.11

AICS

Shlder fig 8 abduct restrain

L3650

$21.00

AICS

WHFO, rigid w/o joints

L3808

$42.70

AICS

Wrist cock-up non-molded

L3908

$22.50

AICS

Upper limb orthosis NOS

L3999

$7.00

AICS

Ankle control orthosi prefab

L4350

$32.25

AICS

Telehealth facility fee

Q3014

$35.00

AICS

Finger splint, static

Q4049

$2.50

AICS

Removal of sutures

S0630

$80.00

AICS

Sport Physical

SPORT

$30.00

AICS