180
Charge Number Description CPT 230001 CGM SENSOR PLACEMENT 95250 400003 CR PHS II W/MON PER 93798 400004 CR PHS III 93798 400005 EXERCISE STRESS ECHO 93350 400006 TILT TABLE 93660 400007 TRANSESOPHAGEAL ECHO 93312 400008 BUBBLE STUDY 96365 400009 CARDIO-ABORTED PROC 93799 400010 CARDIOVERSION 92960 400011 EVENT MONITOR PLACE 93270 400012 EXTERNAL PACING 92953 400013 IV INFUSION PHARM/ST 96365 400014 NUTRITION CLASS S9452 400015 PHARMOCOL STRESS 93017 400016 RHYTHM STRIP EKG 93041 400017 STRESS TEST 93017 400019 NUCLEAR STRESS TEST WALKING 93017 400020 DOBUTAMINE NUC STRESS TEST 93017 400021 LEXISCAN NUC STRESS TEST 93017 400022 DOBUTAMINE STRESS ECHO 93350 400023 SUP IV START 96379 400026 EMG ONE LIMB NO NCS 95860 400027 EMG W/NCS COMPLETE/LIMB 95886 400028 EMG NCS 9-10 95911 400029 EMG NCS 11-12 95912 400030 EMG NCS 7-8 95910 400031 EMG NCS 1-2 95907 400032 EMG NCS 13 OR MORE 95913 400033 EMG NCS 5-6 95909 400034 BLINK 95933 400035 PULM REHAB COPD G0424 400036 PULM REHAB NON COPD 1ST 15 MINS G0237 400037 PULM REHAB NON COPD EACH ADDITIONAL G0238 400039 EMG NCS 3-4 95908 400040 TEE W BUBBLE STUDY 93312 400041 EMG W/NCS Limited 95885 400042 US ADMIN STRESS ECHO CONTRAST 93352 400043 PULM STRESS TEST 6 MIN 94618 400044 PULM REHAB II G0239 919185 ..TEST CULTURE CATH TIP 87070 919186 ..TEST CULTURE ANAEROBIC 87075 919187 ..TEST CULTURE STOOL 87045 919188 ..TEST CULTURE GENITAL 87070 919189 ..TEST CULTURE VIRUS 87252 919190 ..TEST OVA & PARASITE 87177 919191 ..TEST CULTURE YERSINIA 87046 919192 ..TEST CULTURE AFB 87116 919193 ..TEST CULTURE VIRUS VZ 87254 919194 ..TEST CULTURE VIRUS HERPES 87255 919195 ..TEST CULTURE FUNGUS 87101 919196 ..TEST CULTURE CHLAMYDIA 87110

Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

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Page 1: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

Charge Number Description CPT

230001 CGM SENSOR PLACEMENT 95250

400003 CR PHS II W/MON PER 93798

400004 CR PHS III 93798

400005 EXERCISE STRESS ECHO 93350

400006 TILT TABLE 93660

400007 TRANSESOPHAGEAL ECHO 93312

400008 BUBBLE STUDY 96365

400009 CARDIO-ABORTED PROC 93799

400010 CARDIOVERSION 92960

400011 EVENT MONITOR PLACE 93270

400012 EXTERNAL PACING 92953

400013 IV INFUSION PHARM/ST 96365

400014 NUTRITION CLASS S9452

400015 PHARMOCOL STRESS 93017

400016 RHYTHM STRIP EKG 93041

400017 STRESS TEST 93017

400019 NUCLEAR STRESS TEST WALKING 93017

400020 DOBUTAMINE NUC STRESS TEST 93017

400021 LEXISCAN NUC STRESS TEST 93017

400022 DOBUTAMINE STRESS ECHO 93350

400023 SUP IV START 96379

400026 EMG ONE LIMB NO NCS 95860

400027 EMG W/NCS COMPLETE/LIMB 95886

400028 EMG NCS 9-10 95911

400029 EMG NCS 11-12 95912

400030 EMG NCS 7-8 95910

400031 EMG NCS 1-2 95907

400032 EMG NCS 13 OR MORE 95913

400033 EMG NCS 5-6 95909

400034 BLINK 95933

400035 PULM REHAB COPD G0424

400036 PULM REHAB NON COPD 1ST 15 MINS G0237

400037 PULM REHAB NON COPD EACH ADDITIONAL G0238

400039 EMG NCS 3-4 95908

400040 TEE W BUBBLE STUDY 93312

400041 EMG W/NCS Limited 95885

400042 US ADMIN STRESS ECHO CONTRAST 93352

400043 PULM STRESS TEST 6 MIN 94618

400044 PULM REHAB II G0239

919185 ..TEST CULTURE CATH TIP 87070

919186 ..TEST CULTURE ANAEROBIC 87075

919187 ..TEST CULTURE STOOL 87045

919188 ..TEST CULTURE GENITAL 87070

919189 ..TEST CULTURE VIRUS 87252

919190 ..TEST OVA & PARASITE 87177

919191 ..TEST CULTURE YERSINIA 87046

919192 ..TEST CULTURE AFB 87116

919193 ..TEST CULTURE VIRUS VZ 87254

919194 ..TEST CULTURE VIRUS HERPES 87255

919195 ..TEST CULTURE FUNGUS 87101

919196 ..TEST CULTURE CHLAMYDIA 87110

Page 2: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

919197 ..TEST CULTURE GC SCREEN 87081

919198 ..TEST CULTURE PERTUSSIS 87070

919199 ..TEST CULTURE VIRUS MEASLE 87254

1100001 CHEST TUBE INSERTION 99070

1100002 WOUND CARE 99211

1100003 CRASH CART CODE 92950

1100004 EKG MED/SURG 93005

1100005 EPIMAX DRESSING 4X4

1100006 FLU VAC 3 YEARS& OLD 90471

1100007 FLU/H1N1 VACC ADMIN 90471

1100008 GI INTUBATION M/S 91105

1100009 IM PNEUMO VAC ADMIN 90471

1100010 IM/SQ MEDICATION INT 96372

1100011 INSERTION CENTRAL LI

1100012 INSERTION PICC LINE 36569

1100013 INTUBATION 31500

1100014 IRRIGATE VAD IMPLANT 96523

1100015 IV INF CONCURRENT 96368

1100016 IV INF HYDRA ADD HR 96361

1100017 IV INF HYDRA INTIAL 96360

1100018 IV INF SEQ UPTO 1 HR 96367

1100019 IV INF THERA INITAL 96365

1100020 IV INF THERAP EA ADD 96366

1100021 IV MED PUSH DIFF DRG 96375

1100022 IV MED PUSH INTIAL 96374

1100023 IV MED PUSH SAM DRG 96376

1100024 OBSERVATION 1ST HOUR

1100025 OBSERVATION ADDL HRS

1100026 TELEHEALTH CONSULT Q3014GT

1100027 THORACENTESIS

1100046 P1000 LV 2 SP/MAT

1100047 P2000 LV 1 SP/MAT

1100048 P2200 LV 3 SP/MAT

1100049 P2500 LV 4 SP/MAT

1100051 EXTENDED RECOV UP TO 1 HOUR 99356

1100052 EXTENDED RECOV EACH ADD 30 MIN 99357

1100057 INSERT OF TEM INDWELLING CATH SIMPLE 51702

1100058 INSERT OF TEM INDWELLING CATH COMPLE 51703

1100059 BLOOD PRESSURE 99211

1100060 MED MANAGEMENT 99211

1100061 APP OF MULTI LAY COMP SY LEG BELOW KNEE 29581

1100062 APP OF MULTI LAY COMP SY THIGH/LEG 29582

1100063 APP OF MULTI LAY COMP SY UP ARM/FOREARM 29583

1100064 APP OF MULTI LAY COMP SY UP ARM/FA/HA/FI 29584

1200001 CAPSULOTMY YAG RIGHT 66821RT

1200002 CAPSULOTOMY YAG LEFT 66821LT

1200003 CATARACT EXTRACT LFT 66984LT

1200004 CATARACT EXTRACT RGT 66984RT

1200005 CHEST TUBE INSERTION

1200006 CORNEAL TRANSPLANT 4

1200007 COVIDIEN MESH PCO201

1200008 CYSTOSCOPY LEVEL 4

Page 3: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1200010 DEV PMKR DUAL RT RES C1785

1200011 DEV PMKR SINGLE RTRE C1786

1200012 ESOPHAGOSCOPY LEVEL4

1200013 EXC FACIAL LESION L2

1200014 EXC OF NECK LESION

1200015 GLAUCOMA TB DEV TE

1200016 I&D ARM LEVEL 2

1200017 I&D OF FOOT LEVEL 2

1200018 ICD INTERR SINGLE W 93289

1200019 INSERTION ARTERIAL L

1200020 INSERTION CENTRAL LI

1200021 IRIDECTOMY LEVEL 6 66761LT

1200022 IRIDECTOMY LEVEL 6 66761LT

1200023 IRIDOTOMY YAG LEFT 66761LT

1200024 IRIDOTOMY YAG RIGHT 66761RT

1200025 MYRINGOTOMY LEVEL 4 69421

1200026 PACEMAKER BAT CHNGE4

1200027 PACEMAKER INSERTION4

1200028 PACEMKR REPLAC LEAD6

1200029 PICC LINE INSERTED 36569

1200030 POSTER CERV DIS/FU 6

1200031 PROCTOPLASTY 45505

1200032 PULSE GEN DUALNON-RE L8688

1200033 PULSE GEN SIN NON-RE L8686

1200034 PYLOROPLASTY LEVEL 4

1200035 REM INFUS PN PUMP 2

1200036 SI JOINT BLK LEVEL 2

1200037 SLING/SUB URETHRAL 4

1200038 STEREOTAC THALADOT 6

1200039 SURG 1/2 HOUR

1200040 SURG 1 HOUR

1200041 SURG 1 1/2 HOUR

1200042 SURG 2 HOUR

1200043 SURG 2 1/2 HOUR

1200044 SURG 3 HOUR

1200045 SWAN GANZ INSERTION 93503

1200046 THD PROCEDURE MULTIP 46946

1200047 THD SINGLE 46945

1200048 TUBE REMOVAL LEVEL 4 69424

1200049 TYMP MEM REPAIR LE 4 69610

1200050 TYMPANOSTOMY LEVEL 4 69436

1200051 VAGINAL BIOPSY LEV 4

1200052 RECOV LEV 1 PER MIN

1200053 SURG 3 I/2 HOUR

1200054 SURG 4 HOUR

1200055 SURG 4 1/2 HOUR

1200056 SURG 5 HOUR

1200057 INJ PARAVERT F JNT L/S LEV 1 (LUM FJN) 64493

1200058 INJ PARAVERT F JNT L/S LEV 2 (LUM FJN) 64494

1200059 INJ PARAVERT F JNT L/S LEV 3 (LUM FJN) 64495

1200060 INJ PARAVERT F JNT C/T LEV 1 (CER FJN) 64490

1200061 INJ PARAVERT F JNT C/T LEV 2 (CER FJN) 64491

Page 4: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1200062 INJ PARAVERT F JNT C/T LEV 3 (CER FJN) 64492

1200063 INJ SACROILIAC JOINT (SI INJECTIONS) 27096

1200064 GREATER OCCIPITAL NERVE (OCC NERVE BL) 64405

1200065 LUM SACRAL CAUDAL INTERLAMINAR ESI 62322

1200066 DRA/INJ JT/BURSA W/GUID (ANY JT,KN,SHOU 20611

1200067 DRA/INJ JT/BURSA W/O GUID(ANY JT,KN,SHOU 20610

1200068 INJ SINGLE/MTPI 1 OR 2 MUS 20552

1200069 THERAPEUTIC INJ TENDON TRIG P 3 OR > 20553

1200070 INJ PARAVERT F JNT L/S LEV 1 (LUM FJN) 6449350

1200071 INJ PARAVERT F JNT L/S LEV 2 (LUM FJN) 6449450

1200072 INJ PARAVERT F JNT L/S LEV 3 (LUM FJN) 6449550

1200073 INJ PARAVERT F JNT C/T LEV 1 (CER FJN) 6449050

1200074 INJ PARAVERT F JNT C/T LEV 2 (CER FJN) 6449150

1200075 INJ PARAVERT F JNT C/T LEV 3 (CER FJN) 6449250

1200076 INJ SACROILIAC JOINT (SI INJECTIONS) 2709650

1200077 GREATER OCCIPITAL NERVE (OCC NERVE BL) 6440550

1200078 LUM SACRAL CAUDAL INTERLAMINAR ESI 6232250

1200079 DRA/INJ JT/BURSA W/GUID (ANY JT,KN,SHOU 2061150

1200080 DRA/INJ JT/BURSA W/O GUID(ANY JT,KN,SHOU 2061050

1200081 INSERTION OF REVEAL LINQ DEVICE 33282

1200082 REMOVAL OF REVEAL LINQ DEVICE 33284

1200083 LUM SACRAL CAUDAL INTERLAMI ESI W/GUID 62323

1200084 LUM SACRAL CAUDAL INTERLAMI ESI W/GUID 6232350

1200085 LIMBAL RELAXING INCISION 65772

1200086 ARTHROCENTSIS SMALL JOINT W/O US GUIDANC 20600

1200087 ARTHROCENTSIS INTERM JOINT W/O US GUID 20605

1200088 EPIDURAL (CESI) W/GUIDANCE 62321

1200089 EPIDURAL (LESI) W/GUIDANCE 62323

1200090 INJECTION GREATER OCCIPITAL NERVE 64405

1200091 INJECTION PERIPHERAL NERVE OR BRANCH 64450

1200092 INJECTION TFESI CERVICAL AND THORASIC 64479

1200093 INJECTION TFESI CERVICAL ADD ON 64480

1200094 INJECTION TFESI LUMBAR/SI 64483

1200095 INJECTION TFESI LUMBAR ADD ON 64484

1200096 RFA CERVICAL 64633

1200097 RFA CERVICAL ADD LEVEL 64634

1200098 RFA LUMBAR 64635

1200099 RFA LUMBAR ADD LEVEL 64636

1200100 NEUROSTIM TRIAL 63650

1200101 NEUROSTIM PERMAMENT IMPLANT 63655

1200102 NEUROSTIM PERMAMENT IMPLANT 63685

1200103 INJECTION TFESI CERV AND THOR BIL 6447950

1200104 INJECTION TFESI CERV ADD ON BIL 6448050

1200105 INJECTION TFESI LUMBAR/SI BIL 6448350

1200106 INJECTION TFESI LUMBAR ADD ON BIL 6448450

1200107 TRANSVERSUS ABD PLANE BLOCK 64488

1200108 INJ SINGLE/MTPI 1 OR 2 MUS 2055250

1200109 THERAPEUTIC INJ TENDON TRIG P 3 OR > 2055350

1200110 INJECTION SCIATIC NERVE 6444550

1400001 ANES EACH ADD 15MIN 99145

1400002 ANESTHESIA TEE 30MIN 99144

1400003 ABD PERINEAL RESECT 00844QZ

Page 5: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1400005 AMPUTATION UPPER LEG 01232QZ

1400006 ANES ABDOMINAL WALL 00800

1400007 ANES ANORECTAL SUR 00902

1400008 ANES CT OR MRI 01922

1400009 ANES DEBRIDEMENT

1400010 ANES HERNIA UPPER AB 00752

1400011 ANES HERNIA VENTRAL 00832

1400012 ANES LOW INTESTINE 00810

1400013 ANES LOWER ABDOMEN 00840

1400014 ANES LOWER ARM W/O BONE 01810

1400015 ANES LUMBAR PUNCTURE 00635

1400016 ANES PACEMACKER INSE 00530

1400017 ANES UPPER ABDOMEN 00790

1400018 ANES UPPER GI VISUAL 00740

1400019 ANES VAG/URETHRAL 00942

1400020 ANES VASCULAR ACCESS 00532

1400021 ANEST /LOWER ABDOMEN 00830

1400022 ANES EAR SURGERY 00120

1400023 ANES HEAD/NECK/TRU 00300

1400024 ANES LENS SURGERY 00142

1400025 ANES NECK ORGAN 00320

1400026 ANES NECK VESSEL 00350

1400027 ANES NOSE/SINUS SU 00160

1400028 ANES SKIN EXT/PER/ 00400

1400029 ANES ANT CHEST 00400

1400030 ANES CARDIOVER 00410

1400031 ANES CORNEA TR 00144

1400032 ANES EAR NOS 00120

1400033 ANES ECT HEAD 00104

1400034 ANES EYE NOS 00140

1400035 ANES EYELID RE 00103

1400036 ANES FACE/SKUL 00190

1400037 ANES INTRAORAL 00170

1400038 ANES MD PER 15

1400039 ANES NECK NOS 00300

1400040 ANES NOSE/SINU 00160

1400041 ANES OPTI LENS 00142

1400042 ANES PHARYNX 00320

1400043 ANES SALIVARY 00100QZ

1400044 ANES VITREORET 00145

1400045 ANORECTAL PROCEDURE 00902QZ

1400046 ANT INTUG SYS CHEST 00400QZ

1400047 ARTERIES KNEE-POPLIT 01440QZ

1400048 ARTERIES UPPER LEGBY 01270QZ

1400049 CATH ENDO INTUB CRIO

1400050 CLOSED CHEST BRON 00520QZ

1400051 CLOSED PROC HIP JNT 01200QZ

1400052 CLOSED PROC LOW EXTR 01462QZ

1400053 CLOSED PROC SHOULDER 01620

1400054 COLPOTOMY COLOPECT 00942QZ

1400055 CT PERFUSION/WCONT/C 0042T

1400056 DELUXE A-LINE SUPPOR

Page 6: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1400057 DILATION&CURRETAGE 00940QZ

1400058 ELEC CONV OF ARRHTH 92960QZ

1400059 ESOPH THYR LARN TRAC 00320QZ

1400060 EXC TRUNK ARM LEG 00400QZ

1400061 EXT MIDDLE&INNER EAR 00120QZ

1400062 GALLBLADDER LAPSCOPE 00790QZ

1400063 HERNIA REPAIR LOWABD 00830QZ

1400064 I & D OF SKIN 00400QZ

1400065 INTEST ENDOSCOP PROC 00810QZ

1400066 INTRA LOWER ABDOMEN 00840QW

1400067 INTRAORAL PROC BIOP 00170QZ

1400068 INTRAPERIT LOW ABD 00844QZ

1400069 INTUBATION ENDO EMER 31500QZ

1400070 LAPSCOPE APPENDECT 44970QZ

1400071 LENS SURGERY 00142QZ

1400072 LOWER ANT ABD WALL 00800QZ

1400073 LUBAR & VENTRAL(INCIS) 00752QZ

1400074 MAJOR LOW ABD VESSEL 00880QZ

1400075 MALE EXT GENITALIA 00920QZ

1400076 MANAGE DAILY DRUG TH 01996

1400077 MOD SED EA ADD 15MIN 99150QZ

1400078 MODE SED 30 MINUTES 99149QZ

1400079 NECK PROCEDURES 00300QZ

1400080 NEEDLE CATH TRANSTRA

1400081 OPEN PROC HIP JOINT 01210QZ

1400082 ORCHIOPEXY UNI/BI 00930QZ

1400083 OXYGEN PER MINUTE

1400084 P ANES GENERAL/MIN

1400085 P ANES MAC/MIN

1400086 P ANES REGIONAL/MIN

1400087 PANNICULECTOMY 00802QZ

1400088 PERINEAL INTUG SYSTM 00902QZ

1400089 POST T U R BLEEDING 00916QZ

1400090 PROC EYE(TEAR ETC) 00140QZ

1400091 PROC HEAD INTUG SYST 00100QZ

1400092 PROC MAJOR ABD VESSL 00770QZ

1400093 PROC NOSE&ACCES SINU 00160QZ

1400094 RAD OR MOD BREAST 00404QZ

1400095 RAD/MOD BREAST W/NOD 00406QZ

1400096 RADICAL ORCHIOPEXYIN 00926QZ

1400097 RECON SURGERY BREAST 00402QZ

1400098 REGIONAL ANES LIMB 01710

1400099 SPECIAL SUPPLIES 99070

1400100 T U R (INC CYSTOS) 00910QZ

1400101 T U R BLADDER TUMOR 00912QZ

1400102 T U R P 00914QZ

1400103 UPPER ANTER ABD WALL 00700QZ

1400104 UPPER GI ENDOSCOPY 00740QZ

1400105 UPPER LEG VEIN PROC 01260QZ

1400106 VAGINAL HYSTERECTOMY 00944QZ

1400107 VAGINAL PROC/BIOPSY 00940QZ

1400108 VASECTOMY 00921QZ

Page 7: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1400109 VENTRAL & INS HERNIAS 00832QZ

1400110 VIRECTOMY 00145QZ

1400111 ANES 0-30 MINS

1400112 ANES 31-60 MINS

1400113 ANES 61-90 MINS

1400114 ANES 91-120 MINS

1400115 ANES EACH 30 MINS OVER 120

1400116 ANES NERVE/MUS/TEND/FASCIA/F/W/H 01810QZ

1500001 BRONCH BRUSH

1500002 BRONCH THROUGH TRACH 31615

1500003 BRONCH W/ ALVEOLAR L 31624

1500004 BRONCH W/ ASPIRATION 31645

1500005 BRONCH W/ BRUSHINGS 31623

1500006 BRONCH W/FB REMOVAL 31635

1500007 BRONCH W/NEEDLE BX 31629

1500008 BRONCH W/WO WASHING 31622

1500009 BRONCH WITH C-ARM 31622

1500010 BRONCHOSCOPY 31622

1500011 BRONCHOSCOPY W/BX 31625

1500012 CHG GASTROSTOMY TUBE 43760

1500013 COLON BRUSH/WASHING 45378

1500014 COLON STOM/CONTBLEED 44391

1500015 COLON STOMA BIOPSY 44389

1500016 COLON STOMA DIAGNOST 44388

1500017 COLON STOMA W/HOT BX 44392

1500018 COLON STOMAW/SNARE 44393

1500019 COLON W/ CONT BLEED 45382

1500020 COLON W/ POLYPEC HOT 45384

1500021 COLON W/PLY SNARE 45385

1500022 COLONOSCOPY 45378

1500023 COLONOSCOPY W/ BX 45380

1500024 COLONOSCOPY W/ C-ARM 45378

1500025 COLONOSCOPY W/FB REM 45379

1500026 COLONOSCOPY W/HOT BX 45384

1500027 EGD 43235

1500028 EGD W/ BAND LIG ESOP 43244

1500029 EGD W/ BLN DIL <30MM 43249

1500030 EGD W/ BX 43239

1500031 EGD W/ CONTROL BLEED 43255

1500032 EGD W/ DILATATION 43241

1500033 EGD W/ PEG TUBE 43246

1500034 EGD W/ REMOVAL FB 43247

1500035 EGD W/INJ SCLEROSIS 43243

1500036 EGD W/PLYPCTMY SNARE 43251

1500037 ENDO BIOPSY FORCEPS

1500038 GASTRIC LAVAGE 91105

1500039 GASTROSCOPY 43234

1500040 HEMROIDECTO COMPLEX 46260

1500041 HEMROIDECTO I/E SIMP 46255

1500042 INCOMPLETE COLONOSCO 4537852

1500043 RECTAL DILATION/EXAM 45910

1500044 SIGMOID FLEX W/BX 45331

Page 8: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1500045 SIGMOID FLEX W/PPECT 45333

1500046 SIGMOID FLEXIBLE 45330

1500047 SIGMOID W/CONT BLEED 45334

1500048 SIGMOID W/DECOMP VOV 45337

1500049 SIGMOID W/PLYP HOTBX 45333

1500050 SIGMOID W/PLYPEC HOT 45333

1500051 SIGMOID W/REMOVAL FB 45332

1500052 COLONOSCOPY W INJ SCLEROSIS 45381

1500053 SIGMOID RIGID 45300

2020001 CGM MIN 72 HR PLCMT, CALIB, TRN 95250

2020002 INTERP AND REPORT 95251

2020003 SELF-MGMT EDUC & TRAIN PER INDIVIDUAL 98960

2020004 SELF-MGMT EDUC & TRAIN GROUP 2-4 PT 98961

2020005 DIAB MGMT TRAINING PER INDIVIUAL G0108

2020006 DIAB MGMT TRAINING INDIV/GRP 2 OR MORE G0109

2020007 MED NUTR THERA INIT PER INDI PER 15 MIN 97802

2020008 MED NUTR THERA REAS PER INDI PER 15 MIN 97803

2020009 MED NUTR THERA GROUP PER 30 MIN 97804

2020010 MNT SUBS TX FOR CHANGE DX INDIV PER 15 G0270

2020011 GROUP MNT 2 OR MORE 30 MIN G0271

2020012 MED MANAGEMENT 1-15 MINS G0463

2020013 MED MANAGEMENT 16-30 MINS G0463

2020014 MED MANAGEMENT 31-45 MINS G0463

2020015 MED MANAGEMENT 46-64 MINS G0463

2100001 GRANULEX SPY 4 OZ SPRAY

2100002 LIDOCAINE 1GM/D5W 250ML DRIP

2100003 COENZYME Q-10 100MG CAP

2100004 MORPHINE 5MG/10 ML VIAL

2100005 PRECOSE 50MG TAB

2100006 AREDIA 90MG/10 ML VIAL(BILL 30MG) J2430

2100007 FIORICET TABLET

2100008 TYLENOL 120 MG SUPPOS

2100009 TYLENOL W CODEINE 5 ML LIQUID

2100010 TYLENOL 325 MG TABLET

2100011 APAP/COD 300/ 30MG TAB

2100012 TYLENOL 500 MG TABLET

2100013 TYLENOL 650 MG SUPPOS

2100014 DIAMOX 500 MG SEQUEL

2100015 ACETYLCYSTEINE 20% 4 ML NEB J7604

2100016 ACETYLCYSTEINE 20% 10 ML NEB J7604

2100017 ACTIDOSE/SORB 50 GM TBE LIQ

2100018 ACYCLOVIR 200 MG CAP

2100019 ZOVIRAX 5 % OINT

2100020 ADENOCARD 6 MG/ 2ML VIAL J0153

2100021 ProAir Inhaler

2100022 PERFOROMIST 20MCG/2ML NEB

2100023 ALBUTEROL INH 5 MG/ML SOL 20 ML

2100024 ALBUTEROL 2 MG TAB

2100025 COMBIVENT RESPIMAT INH 20MCG/100MCG

2100026 FOSAMAX 10 MG TAB

2100027 ALLOPURINOL 100 MG TAB

2100028 ALPRAZOLAM 0.25 MG

Page 9: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100029 ALPRAZOLAM 0.5 MG TAB

2100030 ACTIVASE 100 MG VL J2997

2100031 MAALOX SUS 30ML UD

2100032 AMANTADINE 100 MG CAP

2100033 PLAVIX 75 MG TABLET

2100034 AMINOPHYLL-DELETED--

2100035 PACERONE 200 MG TAB

2100036 AMIODARONE 50 MG/ML 3ML J0282

2100037 AMITRIPT 10 MG TAB

2100038 AMITRIPT 25 MG TAB

2100039 NORVASC 5 MG TAB

2100040 LOTREL 5/20 CAP

2100041 AMMONIA INH AMP

2100042 AMOXICILLIN 500MG TABLET

2100043 AMOX/CLAV POT 250/ 125MG TAB

2100044 AMOX/CLAV POT 875/ 125MG TAB

2100045 AMPICILLIN 1 GM VL J0290

2100046 AMPICILLIN 500 MG VL J0290

2100047 UNASYN 3 (2-1) GM SOLR VL J0295

2100049 ARTIFICIAL TEAR O/O 3.5 GM

2100050 PULMOCARE LIQUID 240 ML CAN

2100051 ASCORB ACID 500 MG TAB

2100052 ASPIRIN 300 MG SUP

2100053 ASPIRIN 325 MG TAB

2100054 ASPIRIN 325 MG EC TAB

2100055 ASPIRIN CHILD 81 MG CHW

2100056 ASPIRIN EC 81 MG TAB

2100057 ASPIRIN BUFFERED 325 MG TAB

2100058 ASMANEX TWST 220 MCG INH

2100059 ATENOLOL/CHLORTHALIDONE TAB 100MG-25MG

2100060 ATENOLOL 50 MG TAB

2100061 LIPITOR 10 MG TAB

2100062 LIPITOR 20 MG TAB

2100063 ATROPINE ANS 0.1 MG/ML SYG

2100064 AZATHIOPRINE 50 MG TAB J7500

2100065 ASTELIN READY SPRY PMP 30 ML

2100066 AZITHROMYCIN 250 MG TAB

2100067 AZITHROMYCIN 500 MG VL J0456

2100068 AZITHROMYCIN 200 MG/5ML SUS 15 ML

2100069 BACITR ZINC 500 UN/GM ONT

2100070 ATROPINE SULF 1 % DRP 5 ML

2100071 BACITRACIN ONT 30 GM

2100072 BACITRACIN POLYMYX O/O 3.5 GM

2100073 BACLOFEN 10 MG TAB

2100074 BYETTA 5MCG 250 MCG/ML CRT 1.2 ML

2100075 DONNATAL TAB

2100076 LOTENSIN 10 MG TAB

2100077 BELLADONNA/OP 16.2 /60MG SUP

2100078 HURRICAINE 20 % SPY 2 OZ

2100079 ANTIPYR/BENZ OTIC DRP 10 ML

2100080 BENZONATATE 100 MG CAP

2100081 BENZTROP MES 1 MG TAB

Page 10: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100082 BETAMETH DIP 0.05 % CRM 15 GM

2100083 LOTRISON 1/.05% CRM 15 GM

2100084 BISACODYL 10 MG SUP

2100085 BISACODYL 5 MG TAB

2100086 PEPTO BISMOL 262MG CHEW TAB

2100087 PEPTO BISMOL ORIG LIQ

2100088 PULMICORT 0.5 NEB

2100089 BUMEX 1 MG TABLET

2100090 BUMEX 0.25 MG/ML 10 ML VIAL

2100091 SENSORCAINE 0.5% 10 ML

2100092 SENSORCAINE/EPI 0.25% 10 ML

2100093 SENSORCAINE/EPI 0.5% (MARCAINE) 10ML

2100094 WELLBUTRIN SR 100 MG TABLET

2100095 WELLBUTRIN ER 150 MG TABLET

2100096 WELLBUTRIN 75 MG TABLET

2100097 BUSPAR 10 MG TABLET

2100098 FORTICAL NASL 200 IU SPY 3.7 ML

2100099 MIACALCIN 200 UN/ML VL 2 ML J0630

2100100 TUMS - 500 MG TABLET

2100101 CALCIUM CHLORIDE 100MG/ML 10ML SYRINGE

2100102 CALCIUM GLUC 10% 100MG/ML 10ML VL J0610

2100103 FIBERTAB 625 MG TAB

2100104 OSCAL W VITAMIN D 500MG

2100105 CAPOTEN 25 MG TAB

2100106 TEGRETOL 200 MG TABLET

2100107 DEBROX EARWAX REMOVAL DROPS 15 ML

2100108 CARBIDOPA/LEVOD 10/100MG

2100109 SINEMET CR 25/100 TABLET

2100110 CARISOPRODOL 350 MG TAB

2100111 COREG CR 10 MG CAP

2100112 COREG 25 MG TABLET

2100113 COREG 6.25 MG TABLET

2100114 KEFZOL 1GM IV PREMIX BAG J0690

2100115 KEFZOL 1GM VIAL(BILL 500MG) J0690

2100116 MAXIPIME 1 GM VL J0692

2100117 FORTAZ 1 GM VL

2100118 ROCEPHIN 1 GM J0696

2100119 ROCEPHIN 250 MG J0696

2100120 ROCEPHIN 500 MG J0696

2100121 CELEBREX 100 MG CAP

2100122 CEPHALEXIN 250 MG CAP

2100123 CEPHALEXIN 250 MG/5ML SUS 100 ML

2100124 CETIRIZINE 10 MG TAB

2100125 LIBRIUM 10 MG CAP

2100126 LIBRIUM 25 MG CAP

2100127 LIBRIUM 5 MG CAP

2100129 CHLOROTHIAZ 500 MG VL J1205

2100130 CHLOROTHIAZIDE 500 MG TAB

2100131 PREVALITE ORNG PWD

2100132 CIPROFLOXACIN 500 MG TAB

2100133 CIPRO HC OTIC SUS 10 ML

2100134 CELEXA 20 MG TAB UD

Page 11: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100135 BIAXIN 500 MG TAB

2100136 CLEOCIN 150 MG CAP

2100137 CLEOCIN 900 MG/6 ML VIAL J3490

2100138 CLEOCIN 300 MG VIAL SDV

2100139 CLEOCIN 600 MG VIAL

2100140 KLONOPIN 0.5 MG TAB

2100141 CLONIDINE 0.1MG TAB

2100142 CATAPRES 0.1 MG PAT

2100143 CLOTRIMAZOLE 1 % CRM 15G

2100144 COCAINE HCL 4 % SOL

2100145 COLCRYS 0.6 MG TAB

2100146 COLESTID 1 GM HCL TAB

2100147 SANTYL 250 U/GM ONT 30 GM

2100148 CYANOCO 1000 MCG/ML VL

2100149 FLEXERIL 10 MG TAB

2100150 DECADRON 4 MG TAB

2100151 DECADRON 4MG/1ML 1ML VIAL J8540

2100152 DECADRON 4MG/ML 5ML VIAL J8540

2100153 DEXTROSE 10 % SOL 1000ML

2100154 DEXTROSE/WATER 5% SOL 100ML

2100155 DEXTROSE 5 % SOL 1000ML

2100156 D5W EXCEL 250 ML SOL

2100157 D5 1/4 NS 1000 ML

2100158 DEX/NACL/KCL 5/.4 5/20ME SOL 1000ML

2100159 D5 NS 1000 ML

2100160 DEX 5% LACT RINGERS 1000 ML SOL

2100161 DEXTROSE 50% 50 ML SYRINGE

2100162 GASTROGRAFIN 37 % SOL

2100163 VALIUM 2 MG TAB

2100164 VALIUM 5MG TAB

2100165 VALIUM 10MG/2ML SYR J3360

2100166 TEGRETOL 100MG CHEW TAB

2100167 VOLTAREN 75 MG EC TAB

2100168 ARTHROTEC 50-200 MG-MCG TAB

2100169 BENTYL 10 MG AMP

2100170 LANOXIN .125 MG TAB

2100171 LANOXIN 0.25 MG TAB

2100172 CARDIZEM CD 120 MG CAP

2100173 CARDIZEM CD 180 MG CAP

2100174 CARDIZEM 30 MG TAB

2100175 CARDIZEM CD 300 MG CAP

2100176 CARDIZEM 50 MG/10M VL

2100177 IMITREX 25 MG TABLET

2100178 BENADRYL 25 MG CAP

2100179 BENADRYL 12.5 MG/5ML ELX UD

2100180 BENADRYL 50 MG VL J1200

2100181 LOMOTIL 2.5/ .025MG LIQ

2100182 LOMOTIL 2.5 MG TAB

2100183 AGGRENOX 25/200 CAPSULE-DELETE

2100184 DOBUTAMINE 250MG/ 250ML J1250

2100185 SURFAK 240 MG CAP

2100186 SENNA PLUS 8.6/50 MG TAB

Page 12: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100187 DOCUSATE SOD 100 MG CAP

2100188 DOMEBORO POWDER PKTS

2100189 Doxepin 10 MG Oral Liquid

2100190 DOXEPIN 10 MG CAP

2100191 DOXEPIN 25 MG CAP

2100192 DOXYCYCLINE 100 MG CAP

2100193 DOXYCYCLINE 100 MG VL

2100194 MARINOL 2.5 MG CAPSULE

2100195 LISINOPRIL 5 MG

2100196 LOVENOX 30 MG SYG J1650

2100197 LOVENOX 120 MG INJ J1650

2100198 LOVENOX 40 MG SYG J1650

2100199 LOVENOX 60 MG INJ J1650

2100200 ENGERIX-B (ADULT)20 MCG/ML PFS 90746

2100201 EPINEP LFS 1: 10000 SYG

2100202 EPINEPHRIN 1 MG/ML AMP/VL J0171

2100203 PROCRIT 2000 UN/ML VL(BILL 1000 UNITS) J0885

2100204 PROCRIT 4000 UN/ML VL(BILL 1000 U) J0885

2100205 PROCRIT 40 K UNITS/ML (BILL 1000U) J0885

2100206 INTEGRILIN 75 MG/100ML VIAL J1327

2100207 INTEGRILIN 20 MG/10M VL J1327

2100208 ERYTHROMYCIN 0.5 % O/O 3.5 GM

2100209 ERYTHROMYCIN 250 MG DR TAB

2100210 BREVIBLOC PRE MIX 2500MG BAG

2100211 CLIMARA TRN 0.1 MG/DAY PAT

2100212 ESTRACE 1 MG TAB

2100213 PREMARIN 0.625 MG TAB

2100214 PREMARIN IV 25 MG VL 5 ML J1410

2100215 PREMARIN VAG W/ APPL CRM 30 GM

2100216 LODINE 400 MG TAB

2100217 AMIDATE 2MG/ML 10ML

2100218 PEPCID 10MG/ML 2 ML VIAL J3490

2100219 TRICOR 145 MG TAB (F)

2100220 FENTANYL 100 MCG PATCH

2100221 FENTANYL 25 MCG PATCH

2100222 FENTANYL CITR 250MCG/5ML 5ML J3010

2100223 FENTANYL CIT 100MCG/2ML J3010

2100224 FERROUS SUL 325 MG TAB

2100225 FERROUS SUL 300 MG/ 6.8 ML LIQ

2100226 ALLEGRA 180 MG TAB

2100227 ALLEGRA 60 MG TAB

2100228 PROSCAR 5 MG TAB

2100229 DIFLUCAN 100 MG TABLET

2100230 DIFLUCAN 200 MG IV BAG J1450

2100231 FLUDROCORT AC 0.1 MG TAB

2100232 PROTAMINE SULFATE IV SOLUTION 10MG/1ML

2100233 FLUOROSTRIP (BIOSTRIP)

2100234 FLUOXETINE 20 MG TAB

2100235 HALDOL 1 MG TAB

2100236 MAGNEVIST 20 ML SYRINGE A9579

2100237 FLOVENT HFA 110 MCG INH 12 GM

2100238 FLOVENT HFA 220 MCG INH 12 GM

Page 13: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100239 FLONASE 50 MCG SPY 16 GM

2100240 FOLIC ACID 1 MG TAB

2100241 FOLIC ACID 5 MG/ML VL 10ML

2100242 FOLTX TABLETS

2100243 MONOPRIL 10 MG

2100245 FUROSEMIDE 20 MG TAB

2100246 FUROSEMIDE 40 MG TAB

2100247 FUROSEMIDE 10 MG/ML 4ML VL J1940

2100248 GABAPENTIN 300 MG CAP

2100249 GABAPENTIN 400 MG CAP

2100250 GARDASIL SDV

2100251 LOPID 600 MG TAB

2100252 GENTAMIC TOP 0.1 % ONT 15 GM

2100253 GENTAMIC 3MG/ML DRP 5 ML

2100254 GENTAMYCIN 80MG/2ML 2ML VIAL J1580

2100255 GLIMEPIRIDE 4 MG TAB

2100256 GLUCOTROL 5 MG TAB

2100257 GLUCOTROL XL 5 MG TAB

2100258 GLUCAGEN 1 MG VIAL J1610

2100259 GLYBURIDE 5 MG TAB

2100260 DONNATAL GRAPE ELX

2100261 ROBINUL 0.2 MG/ML 2ML VIAL

2100262 MUCINEX 600 MG TABLET

2100263 ROBITUSSIN 100MG/5ML UD LIQ

2100264 HALODOL 5 MG TAB

2100265 HALDOL 5MG/1ML IV J1630

2100266 MAXIDE 37.5/25MG TABLET

2100267 HEPARIN 5000 UNITS/1 ML INJ

2100268 HEPARIN FLUSH 100 UNITS/ML 1ML J1642

2100269 HEPARIN 25K/250 ML PREMIX DRIP

2100270 HEPAGAM B SDV 5 ML 90371

2100271 HETASTARCH/NS 6%/250 ML

2100272 ISOPTO HOMATR 5 % SOL

2100273 WYDASE(VITRASE) 200U/ML 2ML OPH J3470

2100274 APRESOLINE 10 MG TAB

2100275 APRESOLINE 20 MG VL J0360

2100276 APRESOLINE 25 MG TAB

2100277 HCTZ 25 MG TAB

2100278 HYCODAN 5MG/1.5MG 5ML SYR

2100279 HYDROCORT 1 % CRM 1 OZ

2100280 HYDROCORT 2.5 % CRM 20 GM

2100281 ANUCORT HC 25 MG SUP

2100282 SOLU CORTEF 100 MG VIAL J1720

2100283 GNP HYDRO PER 3 % LIQ

2100284 DILAUDID 2 MG TAB RN

2100285 DILAUDID 2 MG/ML AMP J1170

2100286 PLAQUENIL 200 MG TAB

2100287 ATARAX 50 MG/ML VL

2100288 MOTRIN (ADVIL) 200 MG TAB

2100289 MOTRIN 400 MG TAB

2100290 MOTRIN 600 MG TAB

2100291 LEVEMIR 100 UNITS/ML FLEXPEN 3ML

Page 14: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100292 TOFRANIL 25 MG TAB

2100293 INDIGO CARMINE 8% 5 ML

2100294 INDOCIN 25 MG CAPSULE

2100295 REMICADE 100 MG VL J1745

2100296 HUMULIN NPH 2 ML VIAL

2100297 NOVOLOG FLEX 3ML FLEXPEN (SS)

2100298 INTRALIPID 20% 250 ML BAG

2100299 IPRATROPIUM 0.02% 2.5 ML NEB

2100300 ATROVENT HFA 17 MCG INH 12.90 GM J7644

2100301 AVAPRO 150 MG TAB

2100302 INFED 50MG/ML 2ML VIAL J1750

2100303 VENOFER 20 MG/ML SDV J1756

2100304 FERREX 150 MG PLS CAP

2100305 ISORDIL 10 MG TAB (DINITRATE)

2100306 IMDUR 30 MG ER TABLET

2100307 IMDUR 60 MG ER TABLET

2100308 SOD CHLOR 0.9% W 20MEQ KCL 1000 ML 96360

2100309 SIMETHICONE 40MG /.6ML DRP 30 ML

2100310 D5 1/2NS W 40KCL 1000 ML IV

2100311 KETAMINE 50MG/ML 10 ML VIAL

2100312 ACULAR 0.5% OPTH SOL 5 ML

2100313 TORADOL 10 MG TAB

2100314 TORADOL 60MG/ 2 ML VIAL J1885

2100315 TORADOL 30 MG/1ML VIAL J1885

2100316 LABETALOL 5 MG/ML 4 ML INJECT

2100317 LABETALOL 5 MG/ML MDV 20 ML

2100318 LACTATED RINGERS 1000 ML SOL J7120

2100319 LACTINEX 1GM GRANULE PACKETS

2100320 LACTINEX CHEW TABS

2100321 LACTULOSE 10 GM/ 15 ML SOL UD

2100322 LAMICTAL 100 MG TAB

2100323 LAMICTAL 25 MG TAB

2100324 XALATAN .005 % SOL 2.5 ML

2100325 LANTUS 100 UNIT/ML 3ML PEN

2100326 XOPENEX HFA INH 15 GM

2100327 XOPENEX 1.25MG/3 ML NEB

2100328 BETAGAN 0.5% DRP 5 ML

2100329 SYNTHROID 50 MCG TAB

2100330 SYNTHROID 75 MCG TAB

2100331 SYNTHROID 88 MCG TAB

2100332 SYNTHROID 100 MCG TABLET

2100333 SYNTHROID 112 MCG TAB

2100334 SYNTHROID 125 MCG TAB

2100335 SYNTHROID 150 MCG TAB

2100336 LIDODERM 5% PATCH

2100337 LIDOCAINE 1% 20 ML VL

2100338 LIDOCAINE 2 % SYRINGE

2100339 LIDOCAINE 2% 20 ML VIAL

2100340 LIDO VIS 2 % TOP SOL 100 ML

2100341 LIDO VISC 2% 15 ML UD CUP

2100342 LIDO/PRILOC 2.5 % CRM 30 GM

2100343 PERMETHRIN 1 % LOT 60 ML

Page 15: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100344 ZYVOX IV 600 MG/300 SOL

2100345 INDAPAMIDE 2.5 MG TAB

2100346 LISINOPRIL 2.5 MG TAB

2100347 LITHIUM CARBONATE TABLET ER 450MG

2100348 LOPERAMIDE 2 MG CAP

2100349 LOPERAMIDE OR 1 MG/5ML SOL 4 OZ

2100350 LORATADINE 10 MG TAB

2100351 ATIVAN 0.5 MG TABLET

2100352 ATIVAN 1 MG TABLET

2100354 LORAZ/INTENSL 2 MG/ML LIQ

2100355 COZAAR 50 MG TAB

2100356 LOVASTATIN 20 MG TAB

2100357 CITRATE/MAG LEMON SOL

2100358 MILK/MAGN SUS

2100359 MAGNESIUM SULF 50% 1GM/2ML VIAL

2100360 MANNITOL 20% 500 ML BAG

2100361 M-M-R II SDV

2100362 ANTIVERT 25 MG TAB

2100363 PROVERA 2.5 MG TAB

2100364 DEPO PROVERA 150 MG/ML VL 1 ML J1050

2100365 MEGACE 40 MG TAB

2100366 MEGACE 40MG/ML SUS10 ML

2100367 DEMEROL 25 MG/ML C/J J2175

2100368 DEMEROL 50 MG/ML C/J J2175

2100369 LIALDA 1.2 GM

2100370 GLUCOPHAGE 500 MG TABLET

2100371 GLUCOPHAGE 500MG ER TABLET

2100372 METHADONE 10 MG TABLET

2100373 ROBAXIN 750 MG TABLET

2100374 METHOTREXATE 2.5 MG TABLET

2100375 ALDOMET 250MG/5 ML VIAL

2100376 METHYLENE BLUE 1% AMP

2100377 MEDROL 4MG DOSEPAK (GO TO STANDING ORDER

2100378 DEPO MEDROL 40 MG/ML VL

2100379 DEPO MEDROL 80 MG/ML VL

2100380 SOLU MEDROL 1 GM AOV 8 ML

2100381 SOLU MEDROL 125 MG VIAL J2930

2100382 SOLU MEDROL 40 MG VIAL J2920

2100383 REGLAN 10 MG TABLET

2100384 REGLAN 10MG/2ML VIAL

2100385 ZAROXOLYN 2.5 MG TABLET

2100386 TOPROL 100 MG SR TABLET

2100387 TOPROL XL 50 MG TAB

2100388 LOPRESSOR 1MG/ML 5 ML VIAL

2100389 LOPRESSOR 25 MG TABLET

2100390 FLAGYL 500 MG 100ML NS IV BAG J3490

2100391 MICONAZOL NIT 2 % CRM 1 OZ

2100392 VERSED 1 MG/ML 2 ML VIAL

2100393 VERSED 5 MG/1 ML VIAL (ER)

2100394 VERSED 1 MG/1ML 10 ML VIAL

2100395 MIDODRINE 5 MG TABLET

2100396 REMERON 30 MG TABLET

Page 16: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100397 NASONEX 50 MCG NA SPY 17 GM

2100398 SINGULAIR 10 MG TABLET

2100399 MORPHINE SULFATE IR 15 MG TABLET

2100400 MORPHINE 4 MG/ML VIAL

2100401 MORPHINE 2 MG/ML CARPUJECT 1ML

2100402 MORPHINE 0.5MG/L 30 ML PF AMP

2100403 MORPHINE 20MG/1 ML ORAL DOSE

2100404 MVI-12 (INFUVITE) VIAL

2100405 POLY-VI-SOL IRON DRP 50 ML

2100406 THERAVITE TABLET

2100407 OCUVITE (PRESERVATION) VITAMIN TAB

2100408 BACTROBAN 2% OINT 22 GM

2100409 NABUMETONE 500MG TABLET

2100410 CORGARD 20 MG TABLET

2100411 NAFCILLIN 2 GRAM VIAL

2100412 NUBAIN 10 MG/ML AMP

2100413 NUBAIN 20MG/ML AMP

2100414 NARCAN 0.4 MG/1ML 1 ML VIAL

2100415 NEOMYCIN SUL 500 MG TAB

2100416 COLY-MYCIN S OTIC SUS 5 ML

2100417 CORTISPORIN OTIC SUSP 10 ML

2100418 NEO/POLY/BAC OPTH/O 3.5 GM

2100419 NEOSTIGMINE 1:1000 VIAL 10 ML

2100420 NIACIN 100 MG TABLET

2100421 NIASPAN 1000 MG ER TABLET

2100422 NICOTINE 14 MG PATCH

2100423 DELETE 12/24/18 NICOTINE 21 MG S4990

2100424 NICOTINE 7 MG PATCH

2100425 NICOTINE 2 MG GUM

2100426 PROCARDIA 10 MG CAP

2100427 PROCARDIA XL 30 MG CAP

2100428 MACROBID 100 MG CAPSULE

2100429 NITROSTAT 0.4 MG 25/BT

2100430 NITROGLYCERIN 0.4 MG/HR PATCH

2100431 NITRO-BID 2 % ONT 30 GM

2100432 NITROGLYCERIN 0.2 MG/HR PATCH

2100433 LEVOPHED 1MG/4 ML VIAL

2100434 NYSTATIN USP 100M UN/GM CRM 15 GM

2100435 NYS/TRIAM/ACE ONT 15 GM

2100436 ZOFRAN 4MG/2ML 2ML VL J2405

2100437 SERAX 10MG CAP

2100438 DITROPAN 5 MG TAB

2100439 OXYCONTIN CR 10 MG TAB

2100440 OXYCONTIN CR 20 MG TAB

2100441 OXYCODONE HCL 5 MG TAB

2100442 PERCOCET 5/325 MG TAB

2100443 PITOCIN 10 UNITS/ML VIAL

2100444 AFRIN NASAL 0.05 % SPY 15 ML

2100445 FEIBA NF IV 1107 UNITS

2100446 PROTONIX 40 MG TAB. (F)

2100447 PROTONIX 40 MG VIAL

2100448 PAXIL 20MG TABLET

Page 17: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100449 GOLYTELY PREP KIT

2100450 PENICILLIN G 5 MILLION UNIT VIAL

2100451 BICILLIN LA 1200 MU J0561

2100452 PENICILLIN VK 250 MG/5ML SOL 100 ML

2100453 TRENTAL 400MG CR TAB

2100454 PHENOBARBITAL 32.4MG TABLET

2100455 PHENOBARBITAL 20MG/5ML LIQUID

2100456 AZO 95 MG TABLET

2100457 AK-DILATE 2.5% 5 ML OPH SOL

2100458 NEO-SYNEPH MILD SPY 15 ML

2100459 NEO-SYNEPHRINE 10MG/1ML AMPULE J2370

2100460 DILANTIN 100MG/2ML VIAL J1165

2100461 DILANTIN 250MG/5 ML VIAL J1165

2100462 DILANTIN 125/5ML SUSPENSION

2100463 NEOSTIGMINE 1 MG/ML VIAL

2100464 VITAMIN K 10 MG/0.5ML IV J3430

2100465 MEPHYTON 5 MG TAB

2100466 ISOPTO CARPINE 1% OPH DROP 15ML

2100467 ACTOS 30 MG TAB

2100468 ZOSYN 4.5 GM VIAL J2543

2100469 ZOSYN 2.25 GM VIAL J2543

2100470 ZOSYN 3.375 GM VIAL J2543

2100471 PEDIARIX PFS 0.5 ML VIAL

2100472 PREVNAR 13 (65 yrs+) 0.5 ML VIAL 90670

2100473 PNEUMOVAX 0.5 ML VIAL 90732

2100474 POTASSIUM CHLOR 20MEQ/15ML ORAL LIQ

2100475 K-DUR 20MEQ TABLET

2100476 POT CHL 20MEQ VIAL

2100477 BETADINE INST ANTI 10% SOL 4 OZ

2100478 MIRAPEX 0.125 MG TAB

2100479 PRAVASTATIN 40 MG TAB

2100480 PREDNISOLONE 15MG/ 5ML ORAL SOL

2100481 PREDNISONE 5 MG TAB J7510

2100482 PRIMIDONE 50 MG TAB

2100483 COMPAZINE 10 MG TAB

2100484 PHENERGAN 12.5MG SUPPOS

2100485 PHENERGAN 25 MG SUPPOS

2100486 PHENERGAN 25 MG TABLET

2100487 PHENERGAN 25MG/1ML VIAL J2550

2100488 PHENERGAN 12.5 MG/10 ML ORAL LIQUID

2100489 RYTHMOL 150 MG TAB

2100490 ALCAINE 0.5% OPTH SOL 15 ML

2100491 INDERAL 40 MG TABLET

2100492 DIPRIVAN 10 MG/ML 20 ML J2704

2100493 SUDAFED 30 MG TABLET

2100494 PYRAZINAMIDE 500 MG TAB

2100495 SEROQUEL 100 MG TABLET

2100496 SEROQUEL 25 MG TABLET

2100497 ACCUPRIL 20 MG TAB

2100498 EVISTA 60 MG TAB

2100499 RAMIPRIL 5 MG TAB

2100500 RIFAMPIN 300 MG CAP

Page 18: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100501 RIFAMPIN 600 MG VL

2100502 ACTONEL 5 MG TAB

2100503 RISPERADOL 1 MG TAB

2100504 ROPINIROLE HYDROCHLORIDE TAB 1MG

2100505 SEREVENT DISK INH

2100506 TRANSDERM SCO 1.5 MG PAT

2100507 ATRIPLA ORAL TABLET 600MG-200MG-300MG

2100508 SENNA LIQUID 8.8MG/5ML

2100509 ZOLOFT 50 MG TABLET

2100510 SILVADENE 1% 50 GM OINT

2100511 MYLICON (GAS-X) 80 MG CHEW TABS

2100512 MYLICON 40MG/0.6ML 15ML SUSP

2100513 ZOCOR 10 MG TABLET

2100514 ZOCOR 40 MG TABLET

2100515 KAYEXYLATE 15GM/60 ML SUSP

2100516 SOD BICARB 8.4% 50 MEQ/50 ML SYRINGE

2100517 SOD CHL 23.4% 4MEQ/ML 30 ML CONC VIAL

2100518 SOD CHL 0.9% 10 ML VIAL

2100519 SOD CHL 0.9% 1000 ML IV BAG

2100520 SOD CHL 0.45% 1000 ML IV BAG

2100521 SOD CHL IRRIG 0.9% 250 ML BOTTLE

2100522 SODIUM CHLORIDE 1 GM TAB

2100523 SOD CHL 0.9% 100 ML ADVANT BAG

2100524 SOD CHL 0.9% 100 ML IV BAG

2100525 SOD CHL IRRIG 0.9% 1000 ML BOTTLE

2100526 SOD CHLOR 0.9% W 40 MEQ KCL 1000 ML

2100527 SOD CHL 0.9% 250ML ADVANT BAG

2100528 SOD CHLO 0.9% 250 ML IV BAG

2100529 SOD CHL 0.9% 500 ML IV BAG

2100530 SOD CHL 0.9% 50 ML IV BAG

2100531 SOD CHL IRRIG 0.9% 500 ML BOTTLE

2100532 SOD CHL IRRIG 0.9% 3000 ML BAG

2100533 SOD PHOS 4MEQ/ML 3MMOLE/ML 15 ML VIAL

2100534 ALDACTONE 25 MG TABLET

2100535 ANECTINE (QUELICINE) 20 MG/ML 10 ML VIAL

2100536 CARAFATE 1GM TAB

2100537 CARAFATE 1GM/ 10ML SUSP

2100538 BLEPH 10 % O/S 5 ML

2100539 AZULFADINE 500 MG TAB

2100540 IMITREX 6MG/0.5 ML INJECT

2100541 TAMIFLU 75 MG CAP G9019

2100542 NOLVADEX 10 MG TAB

2100543 FLOMAX 0.4 MG CAP

2100544 RESTORIL 15 MG CAP

2100545 HYTRIN 1 MG CAPS

2100546 LAMISIL 250 MG TAB

2100547 TNKASE KIT 1

2100548 TETRACAINE 0.5% OPTH SOL 15 ML

2100549 THEODUR ER 200 MG TAB

2100550 THEODUR ER 300 MG TAB

2100551 THIAMINE B1 100MG TAB

2100552 THIAMINE 100MG/1ML 2ML VIAL

Page 19: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100553 MELLARIL 25 MG TAB

2100554 TIMOLOL O/S 0.25 % DRP 5 ML

2100555 TIMOLOL 0.5 % DRP 5 ML

2100556 ZANAFLEX 4 MG TAB

2100557 TOBRAMYCIN 80 MG/2ML J3260

2100558 TOBRADEX O/O 3.5 GM

2100559 TOBRADEX EYE DROP SUS 2.5 ML

2100560 DETROL 2 MG TAB

2100561 TOPAMAX 100 MG TAB

2100562 TOPAMAX 25 MG TABLET

2100563 DEMADEX 20 MG TAB

2100564 ULTRAM 50 MG TAB

2100565 TRAZADONE 50MG

2100566 TRIAMCINO ACE 0.1 % CRM 15 GM

2100567 KENALOG 40 MG/ML 1 ML J3301

2100568 NASACORT AQ 55 MCG SPY 16.5 GM

2100569 MAXZIDE 37.5-25 TAB

2100570 SULFAMETHOX/TRIMETH 800/160MG/20ML SUSP

2100571 TROPICAMIDE 1 % OPHT SOL 2 ML

2100572 APLISOL 5TU 10TEST VL 1 ML

2100573 URSO 300 MG CAP

2100574 DEPACON 500MG/5ML VIAL(VALPROIC)

2100575 DIOVAN 80 MG TAB

2100576 VANCOMYCIN 1 GM VL J3370

2100577 VANCOMYCIN 250 MG CAP

2100578 VASOPRESSIN 20UNITS/ML 1ML VIAL

2100579 VECURONIUM 20 MG VL

2100580 EFFEXOR 37.5 MG TAB

2100581 EFFEXOR SR 75 MG TAB

2100582 VERAPAMIL 180 MG ER TAB

2100583 VERAPAMIL 2.5 MG/ML 2 ML AMP

2100584 VERAPAMIL 80 MG TABLET

2100585 VESICARE 10 MG TAB

2100586 NEPHROCAP (RENAL) VITAMINS CAP

2100587 VITAMIN E 400 UNIT

2100588 COUMADIN 1 MG TAB

2100589 COUMADIN 2 MG TAB

2100590 COUMADIN 5 MG TAB

2100591 WATER STERILE 10 ML VIAL

2100592 STER WATER IRR SOL 1000ML

2100593 GEODON INJ SDV 20MG VL J3486

2100594 ZINC OXIDE ONT 1 OZ

2100595 ZINC SULFATE 220MG CAPS

2100596 TYLENOL 160MG/5ML SUS

2100597 LUMIGAN 0.03 % SOL 5 ML

2100598 CETIRIZINE 1 MG/ML (10 ML SYR)

2100599 ARANESP 300 MCG SDV 1 ML J0881

2100600 DIGOXIN 500MCG/2ML AMP J1160

2100601 COLACE 100 MG/10 ML LIQ UD

2100602 NEXTERONE IV SOLUTION 360MG/200ML-4.14% J0282

2100603 PEPCID 20 MG TAB (F)

2100604 ROBITUSSIN AC 100-10MG/5ML

Page 20: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100605 ROBITUSIN DM 200-20 MG/10ML UD

2100606 HAVRIX (ADULT) 1440 UN/ML SDV 90632

2100607 MOTRIN 100MG/5ML SUSP 5ML UD

2100608 XOPENEX 0.63MG/3ML NEB

2100609 DEPAKOTE 250MG TABLET

2100610 LYRICA 100 MG CAP

2100611 METAMUCIL PACKET

2100612 REGLAN 10MG/10ML ORAL SOLUTION

2100613 STARLIX 60 MG TABLET

2100614 NATRECOR 1.5 MG VL 5 ML

2100615 NYSTATIN ORAL 100M UN/ML SUS UD 5ML

2100616 SYSTANE LUB EYE DRP 15 ML

2100617 K-DUR 10 MEQ TABLET

2100618 EPINEPHRINE 2.25% RACEMIC 0.5 ML NEBS

2100619 DULERA 200/5 MCG INH

2100620 ADVAIR DISKUS INST 250/50 PWD

2100621 ADVAIR DISKUS INST 500/50 PWD

2100622 KINEVAC 5 MCG VIAL J2805

2100623 ADACEL 0.5 ML VL (10-64 yrs old) 90715

2100624 SURGICEL HEMO 1X2 PAD 10

2100625 DETROL LA 2 MG ER CAP

2100626 TYPHIM VI PFS 0.5 ML

2100627 CALMOSEPTINE OINT. 4 OZ

2100628 GEODON 60 MG CAP

2100629 AMBIEN 5 MG TAB

2100630 ALPHAGAN P 0.15 % DRP 5 ML

2100631 PULMICORT 0.25 NEB

2100632 ETHYL CHLORID MED SPRAY LIQ 3.5 OZ

2100633 EYE STREAM IRRG SOL 1 OZ

2100634 NOVOLIN 70/ 30U/ML VL 10 ML

2100635 DEL-HUMULIN R 3ML VIAL (SS)

2100636 MORPHINE 10MG/1 ML VIAL

2100637 THERAVITE LIQUID 5ML UD

2100638 VIVONEX TEN PACKET

2100639 NITRO-BID 2% 1GM UD OINTMENT

2100640 NITROGLYCERIN/D5W 50MG/ 250ML IV

2100641 LYRICA 25 MG CAP

2100642 PROMETHAZINE VC 6.25-5MG/5ML SYRUP

2100643 PCA TUBING EACH

2100644 NEURONTIN 100 MG CAP

2100645 CLINIMIX 5 /15% SOL

2100646 ACTHIB VL 0.5 ML

2100647 NUPERCAINAL 1 % ONT 30 GRAM

2100648 REMERON 15 MG TABLET

2100649 REMERON 30MG SOLTAB

2100650 ZYPREXA (ZYDIS) 5 MG TAB

2100651 MELATONIN 3 MG TAB

2100652 ZOSTAVAX vacc. (50 yrs +)

2100653 NORFLEX 30MG/ML AMP 2ML

2100654 LEXAPRO 10 MG TAB

2100655 MICARDIS 80 MG TABLET

2100656 PREDNISONE 20MG TAB

Page 21: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100657 CLARINEX REDI 5 MG TAB

2100658 PAXIL CR 12.5MG TAB

2100659 ZETIA 10 MG TAB

2100660 ARANESP 200 MCG PFS 0.4 ML J0881

2100661 SKELAXIN 800 MG CAPS

2100662 RENAGEL 800 MG TAB

2100663 CALCIUM ACE 667 MG CAP

2100664 PATANOL 0.1 % O/S 5 ML

2100665 MIRAPEX 0.5 MG TAB

2100666 CYMBALTA 30 MG DR CAP

2100667 DAPTACEL 0.5 ML VL 90715

2100668 DECAVAC SDV 0.5 ML 90714

2100669 ELIDEL 1 % CRM 30 GM

2100670 ENABLEX 7.5 MG TAB

2100671 TRILAFON 8 MG TABLET

2100672 L-LYSINE 500 MG TAB

2100673 LMX- 4% CREAM 5 GM

2100674 PREVACID 30MG SOLTAB

2100675 VARIVAX 0.5 ML VIAL

2100676 MENACTRA VIAL

2100677 PEDIALYTE 1000 ML SOL

2100678 VALTREX 500 MG TAB

2100679 FAMCICLOVIR 500 MG TAB

2100680 AMOX/CLAV 600/ 42.9MG SUS 75 ML

2100681 BENICAR 20 MG TAB

2100682 LIDO/EPI 2% 30 ML VIAL

2100683 ENGERIX-B (PED)10 MCG /0.5MG 90744

2100684 FOSAMAX 70 MG TAB

2100685 LESCOL XL 80 MG TAB

2100686 ABILIFY 5 MG TAB

2100687 ACTONEL 35 MG

2100688 GEODON 40 MG CAP

2100689 ZYVOX 600 MG TABLET

2100690 AMLACTIN LACT 12 % CRM 140 GM

2100691 CRESTOR 10 MG TAB UD

2100692 VANCOMYCIN 500 MG VIAL J3370

2100693 LEVAQUIN 250 MG/ 50 ML IV BAG J1956

2100694 LEVAQUIN 750 MG/150 ML IV BAG J1956

2100695 LEVAQUIN 500 MG TAB

2100696 LEVAQUIN 750 MG TABLET

2100697 NAMENDA 10 MG TABLET

2100698 IPOL VAC 0.5ML DOSE

2100699 LIBRAX 5/ 2.5MG CAP

2100701 ALCOHOL ISOP 70 % LIQ

2100702 AVODART 0.5 MG CAP

2100703 PLETAL 100 MG TAB

2100704 ATARAX 25 MG TAB

2100705 SPIRIVA

2100706 FLAGYL 500 MG TABLET

2100707 CODITUSS DM CHRY PUNCH SYR 5ML

2100708 CUBICIN DS 500 MG VL J0878

2100709 LEVAQUIN 500 MG/100 ML IV BAG J1956

Page 22: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100710 BOOSTRIX (TDAP) 10 yrs and older 90715

2100711 GLUCERNA 240 ML CAN

2100712 JEVITY 240 ML CAN

2100713 MASTISOL LIQ ADHESIVE UD

2100714 PROHANCE 279.3 MG/ML 20ML VIAL

2100715 EFFEXOR 75 MG TAB

2100716 AMITIZA 24 MCG GCP

2100717 JANUVIA 50 MG TAB

2100718 MOBIC 15 MG TAB

2100719 RESTASIS 0.05% 0.4 ML OPHTH

2100720 COREG CR 40 MG CAP

2100721 BISOPROLOL 5 MG TAB

2100722 SYMBICORT 160/4.5MCG INH 10.2 GM

2100723 CEPHALEXIN 500 MG CAP

2100724 SOD CHL 3% 500 ML BAG (CAUTION-CONCENTRA

2100725 VIGAMOX 0.5 % SOL 3 ML

2100726 MOTRIN 800 MG TAB

2100727 EXELON 4.6 MG PAT

2100728 CATHFLO ACTIV 2 MG VL 2 ML

2100729 CHLORASEPTIC CHERRY SPY 6 OZ

2100730 MAXALT 10 MG TAB (F)

2100731 AMITIZA 8 MCG GCP

2100732 SYMBICORT INS 80/ 4.5MCG INH 6.9 GM

2100733 AVELOX 400 MG TABS

2100734 MEROPENEM 1 GM VIAL

2100735 RECLAST5MG/100ML PREMIX J3489

2100736 SENSIPAR 30 MG TAB

2100737 NOVOLOG 10 ML VIAL

2100738 THROMBIN JMI 5MUN /DIL VL

2100739 DEPAKOTE ER 500MG 24HR TAB

2100740 HUMALOG 75/25 PEN

2100741 PLAVIX 300 MG TABLET

2100742 QVAR INHALER 80 MCG AER 7.3 GM

2100743 DUONEB 3 ML NEBS

2100744 AREDIA 30MG LYPH VIAL J2430

2100745 APRESOLINE 50 MG TAB

2100746 HYDROCORT 10 MG TAB

2100747 LIQUITEARS SOL 15 ML

2100748 ZOFRAN 4 MG ODT TABLET

2100749 LABETALOL 100 MG TAB

2100750 METHIMAZOLE 5 MG TABLET

2100751 PRED FORTE 1% OPTH SOL

2100752 NYSTOP 100M UN PWD 15 GM

2100753 PRISTIQ 50 MG TAB

2100754 DIPYRIDAMOLE 50 MG TAB

2100755 LACTAID 9000 UNIT TABS

2100756 BYSTOLIC 10 MG TAB

2100757 BRETHINE 1MG/ML VIAL J7681

2100758 FENTANYL 12 MCG PATCH

2100759 VITAMIN D 1000 IU TAB

2100760 RAZADYNE 8MG TAB

2100761 LEXISCAN 0.4 MG/5ML SYG J2785

Page 23: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100762 XIBROM .09 % O/S 2.5 ML

2100763 VITAMIN B-6(PYRIDOXINE) 50 MG TAB

2100764 RANEXA 500 MG ER TABLET

2100765 ATARAX 25 MG/ML VL J3410

2100766 ECONAZOLE NIT 1 % CRM 15 GM

2100767 TYGACIL 50 MG VIAL J3243

2100768 TOPROL 25MG SR TABLET

2100769 MEFOXIN 1GM VIAL J0694

2100770 TAMBOCOR 50 MG TAB

2100771 KAPIDEX 60 MG CAP

2100772 PERMETHRIN 5 % CRM 60 GM

2100773 VOLTAREN 1% GEL 100GM

2100774 CREON 12000 CAP

2100775 CREON 6,000 UNIT CAP

2100776 PROVIGEL 200 MG TABLET

2100777 PERCOCET 10/325 MG TAB

2100778 HYOSYNE 0.125 MG/5ML ELX

2100779 METANX TABLET

2100780 PLENDIL 10 MG ER TAB

2100781 ASPERCREME 10% 5 OZ

2100782 PROCTOSOL-HC 2.5 % CRM 1 OZ

2100783 UTI-STAT 30 fl.oz

2100784 K-Y LUBRICANT JELLY JEL 4 OZ

2100785 HYDROCOD/APAP 7.5/325MG TAB

2100786 HYDROCOD/APAP 10/325 MG TAB

2100787 TWINRIX 20 MCG (HEP A&B) 1ML VIAL

2100788 TRILAFON 2 MG TABLET

2100789 GLYCOPYRROLATE 1 MG TAB

2100790 TRAVATAN Z .004 % SOL 2.5 ML

2100791 CEFTIN 500 MG TAB

2100792 FLU VACCINE 0.5 ML 2018-2019 90682

2100793 ULORIC 40 MG TAB

2100794 LOPRESSOR 100 MG TABLET

2100795 MEDROL 4 MG TABLET

2100796 XENADERM ONT 60 GM

2100797 LAC HYDRIN 5 % LOT 8 OZ

2100798 VITAMIN D 50,000 UNITS TAB

2100799 GAMMAGARD 10% 20 GM J1569

2100801 GAMMAGARD 10% 10 GM J1569

2100802 HYDROCOD/APAP 5/325 MG TAB

2100803 ROBAXIN 500 MG TABLET

2100804 FLOXIN 0.3% OTIC SOL 5 ML

2100805 JANUVIA 100 MG TAB

2100806 METAMUCIL HEALTHY BONES CAPSULE

2100807 PROCRIT 20,000 UN/1ML MDV(BILL 1000UNIT) J0885

2100808 KRISTALOSE 10 GM PACKET

2100809 PHENERGAN/COD 6.25-5MG/5ML SYRUP

2100810 ACYCLOVIR 500 MG VIAL J0133

2100811 POTASS CHLOR 10 MEQ/100ML Premix

2100812 MESTINON 60 MG TAB

2100813 MUCINEX DM 600/30MG TABLET

2100814 VICTOZA PEN 18 MG/3ML

Page 24: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100815 VITAMIN B-12 1000 MCG TAB

2100816 EXELON 9.5 MG PAT

2100817 SODIUM BICARB 5 GR (325 MG) TAB

2100818 CALDOLOR 800 MG INJ J1741

2100819 PROLIA 60 MG PFS 1 ML

2100820 TUSSIONEX 10/8 MG/5ML SUS

2100821 LISINOPRIL 20 MG TAB

2100822 AMITRIPT 100 MG TAB

2100823 FLORASTOR 250 MG CAP

2100824 LOVENOX 100 MG SYG J1650

2100825 LEVOTHYROXINE 137 MCG TAB

2100826 MS CONTIN 30 MG ER TABLET

2100827 ZOMETA 4 MG VL 5 ML

2100828 CATAPRES 0.3 MG PAT

2100830 ESTRACE VAG .01 % CRM 42.5 GM

2100831 VERAPAMIL 120 MG ER TAB

2100832 VAPRISOL 20 MG BAG 100 ML

2100833 CLOBETASOL 0.05 % CRM 15 GM

2100834 PRADAXA 75 MG CAP

2100835 ATROPINE 1 MG VL

2100836 ALLOPURINOL 300 MG TAB

2100837 VIMPAT 50 MG TAB

2100838 NYSTATIN 100M UN/GM ONT 30 GM

2100839 LIPITOR 40 MG TAB

2100840 COREG 12.5 MG TABLET

2100841 SEROQUEL ER 300 MG TABLET

2100842 VALPROIC ACID 250MG/5ML ORAL LIQ

2100843 ARICEPT 23 MG TAB

2100846 BYETTA 10MCG 250 MCG/ML CRT 2.4 ML

2100847 DALIRESP 500 MCG TAB

2100848 AVELOX IV 400 MG FLX BAG

2100849 FOLIC ACID 400 MCG TAB

2100850 GLYSET 100 MG TABLET

2100851 BARACLUDE 0.5 MG TAB

2100852 ALBUMINAR ASD 25 % VL 100 ML P9041

2100853 BOOST ENERGY INST VAN LIQ

2100854 LIDOCAINE HCL 2% JEL 30 ML

2100855 NEUTRAPHOS 250MG CAPSULES

2100856 PINDOLOL 5 MG TABLET

2100857 TORADOL 15 MG/1ML VIAL J1885

2100858 CALCIUM 500 MG / VITAMIN D 200 IU TAB

2100859 BIAXIN 500 MG ER TAB

2100860 HYDROMORPH 40MG/20ML VL 20 ML

2100861 FLUNISOLIDE .025 MG SPY 25 ML

2100862 NEXTERONE IV SOLN 150MG/100ML-4.21% J0282

2100863 DONNTAL ELIXIR 5 ML

2100864 COREG 3.125 MG TABLET

2100865 PERCOCET 7.5/325 MG TAB

2100866 GLUCOSAMINE-CHONDROIT 1.5-1.103 Tab

2100867 DITROPAN 5 MG ER

2100868 COMTAN 200 MG TAB

2100869 XARELTO 10 MG TAB

Page 25: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100870 MIRAPEX 1 MG TABLET

2100871 NARCAN 0.4 MG/ 1ML 10 ML SYRINGE

2100872 CENTRUM LIQ 5 ML DOSE

2100873 SYNTHROID 100 MCG VIAL

2100874 MIRALAX 17 GM PACKET

2100875 LIDO/EPI 2% 30 ML VIAL

2100876 HALDOL 0.5 MG TAB

2100877 LIDOCAINE 1% -MPF 5 ML VL

2100878 VITAMIN D 400 IU TAB

2100879 HCTZ 12.5 MG CAPSULE

2100880 RISPERADOL 0.25 MG TAB

2100881 TYLENOL 325 MG/10.15 ML LIQUID

2100882 ENALAPRILAT 1.25 MG/ML VL

2100883 LACTULOSE 20 GM/30 ML SOL UD

2100884 CHLORPROM 25 MG TAB Q0161

2100885 ARANESP 100 MCG SDV J0881

2100886 KLOR-CON 20MEQ PACKET

2100887 NICOTINE 4 MG GUM

2100888 NICORETTE 2 MG LOZENGE

2100889 NICORETTE 4 MG LOZENGE

2100890 AMOXICILLIN 400MG/5ML SUSP

2100891 NIASPAN 500MG ER TABLET

2100892 NARCAN 1MG/ML 2 ML SYRINGE

2100893 XIFAXIN 550 MG TAB

2100894 ZYPREXA 20 MG TABLET

2100895 BETHANECHOL 25 MG TAB

2100896 NUVIGEL 250 MG TAB

2100897 CYTOTEC 100 MCG TABLET

2100898 BROMFENAC 0.09 % SOL 2.5 ML

2100899 HYDROCOD/APAP 7.5/325MG ELX

2100900 SAVELLA 25 MG TABLET

2100901 DOXEPIN 150 MG CAP

2100902 LOVAZA 1000 MG CAP

2100903 DIAMOX 125 MG TABLET

2100904 GUAIFENESIN 200MG/10 ML UD LIQ

2100905 OPTIRAY 350 SYRINGE 125 ML Q9967

2100906 OPTIRAY 320 SYR 100ML Q9967

2100907 OPTIRAY 240 SYRINGE 100 ML Q9966

2100908 INVANZ 1 GM VIAL J1335

2100909 ACCOLATE 20 MG TABLET

2100910 NAPROXEN 250 MG TABLET

2100911 RABIES VACCINE (IMOVAX)

2100912 SENSORCAINE 0.5% 30 ML

2100913 D5 1/2 NS 1000 ML

2100914 CIPROFLOXACIN .3% OPHTH DRP 2.5 ML

2100915 DICYCLOMINE 20 MG TAB

2100916 GENTAK 0.3 % O/O 3.5 GM

2100917 GLYCERIN ADULT SUPPOS

2100918 NABI-HB VL 5 ML J1571

2100919 SOD CHLOR 0.45% WITH 20MEQ KCL 1000 ML

2100920 MAGNESIUM OXIDE 400 MG TAB

2100921 LOPRESSOR 50 MG TABLET

Page 26: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100922 PHENOBARBITAL 65MG VIAL

2100924 SEVOFLURANE 250 ML BOTTLE

2100925 KEPPRA 500MG/5ML IV J1953

2100926 MERREM 500 MG VIAL

2100927 OPTIRAY 320 SYRINGE 50 ML Q9967

2100928 VERSED 5 MG/ 1ML VIAL

2100929 MIRALAX 14DAY PWD 238 GM

2100930 INDERAL 1 MG/ML VIAL

2100931 HAVRIX (PEDS) 720U /0.5ML SDV 90633

2100932 AMPICILLIN 1 GM VIAL J0290

2100933 ATIVAN 2MG/ML 10 ML VIAL (FOR DRIPS) J2060

2100934 AZITHROMYCIN 500 MG ADV J0456

2100935 BUMEX 0.25 MG/ML 4ML*DELET*

2100936 CLINIMIX E 5 /25% SOL

2100937 DEX/NACL/KCL 5/.9 /20MEQ SOL 1000ML

2100938 DEXTROSE 25% 10 ML INFANT SYRINGE

2100939 DIHYDROERGOT 1 MG/ML AMP J1110

2100940 DIPRIVAN 10 MG/ML SDV 100ML

2100941 LIDO/EPI 1% 20 ML VIAL

2100942 LIDOCAINE 2% 30 ML VL

2100943 LIDOCAINE 100MG/5ML ADULT BOLUS

2100944 PENICLLIN 20 MILLION UN VIAL

2100945 DEL-ROCEPHIN 1GM ADVANT IV J0696

2100946 SENSORCAINE/EPI 0.25% 30 ML

2100947 SOD BICARB 8.4% 10MEQ/10ML PEDIATRIC IV

2100948 SOD CHL BACT 0.9% 30 ML VIAL

2100949 ASTEPRO .15% 205 MCG SOL 30 ML

2100950 DEEP SEA NASAL SPY 44 ML

2100951 ALPHAGAN P 0.1 % O/S 5 ML

2100952 AZOPT 1 % SUS 10 ML

2100953 NEO/POLY/GRAM DRP 10 ML

2100954 CORTISPORIN OTIC SOLUTION 10 ML

2100955 DEBROX DROPS

2100956 Cough drops

2100957 ACETYLCYSTEINE 20% 30 ML

2100958 AMOX/CLAV POT 250/ 62.5MG SUS 75 ML

2100959 AZITHROMYCIN 600 MG TAB

2100960 BUSPAR 5 MG TABLET

2100961 CALCITRIOL 0.25 MCG CAP

2100962 CHLORASEPTIC CHERRY LOZENGES

2100963 FLUPHENAZ 10 MG TAB

2100964 INSTA GLUCOSE TRI- PACK GEL

2100965 ISONIAZID 300MG (INH) TABLET

2100966 DEPAKOTE DR 125MG TAB

2100967 NEXT CHOICE 0.75 MG TAB

2100968 PRANDIN 1 MG TAB

2100969 PRO-STAT LIQ (USE ENSURE PLUS)

2100970 EPIPEN 0.3 MG KIT

2100971 EPIPEN JR 0.15 MG KIT

2100972 FLUZONE PEDIATRIC SYRINGE 90689

2100973 BENADRYL 2 % CRM 1 OZ

2100974 HIBICLENS 4 % LIQ 118 ML

Page 27: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2100975 LIDOCAINE 2% JELLY 5 ML

2100976 RID PLAS BTL LIQ 2 OZ

2100977 SILVER NITRATE STICKS 10/PACKAGE

2100978 THERA GESIC CRM 3 OZ

2100979 TRIPLE ANTIB FOIL ONT UD

2101005 RECLAST/NS IVPB : 5MG/100ML J3489

2101007 ZOSYN/NS IVPB : 3.375GM/100ML

2101042 TYLENOL/CODEINE #3 TAB: 300MG/30MG

2101043 ACETADOTE 200MG/1ML: 30 ML J0132

2101044 ALBUMIIN 25% 25GM/100ML

2101045 ALBUTEROL 2MG/5ML SYRUP

2101046 TEKTURNA 150MG CAP

2101047 ALKA-SELTZER TABLET

2101048 AMILORIDE 5 MG TAB

2101049 AMLODIPINE/BENAZEPRIL 5MG/10MG CAP

2101050 AMOXICILLIN/CLAVUNLENATE 500 MG TAB

2101052 AMYL NITRATE/SOD NITR/SOD THIOSULFATE

2101053 GI-COCKATIL BELLAD/LIDOC/MAALOX: 50 ML

2101054 BUMETANIDE 0.25MG/ML 4 ML VL

2101056 CALCIUM 100MG/ML: 100 ML VIAL

2101058 CALCIUM GLUCONATE GEL

2101061 POTASSIUM/DEX/NACL 30/5/0.45 1000ML

2101063 ONDANSETRON ODT 8 MG Q0162

2101064 LIDOCAINE 1% 10 ML VL

2101065 XYLOCAINE MPF 2% 10 ML VL

2101066 DTAP (DIPTH,TET,PERT) 0.5ML (6wks-6yrs)

2101067 LIDOCAINE 1% 30 ML VL

2101068 XYLOCAINE MPF 2% 2 ML VL

2101069 PANCRELIPASE 5000 UNIT CAP

2101070 LIDO/EPI 1% 10 ML VIAL

2101071 HEPARIN FLUSH 100 UNITS/ML 5ML SYRINGE

2101072 FUROSEMIDE 10 MG/ML 2ML J1940

2101073 RIVASTIGMINE 3 MG CAP

2101074 SENSORCAINE/EPI 0.5% (MARCAINE) 30ML

2101075 SULFAMETHOZOLE & TRIMETHOPRIM DS TAB

2101076 MIDAZOLAM 1 MG/ML 5ML VIAL

2101077 DABIGATRAN 150 MG CAP

2101078 MIDAZOLAM 1MG/ML 2 ML VIAL

2101079 DOXAZOSIN 2 MG TAB

2101080 ROBITUSSIN 100MG/5ML 118ML LIQ

2101081 SOTALOL 80 MG TAB

2101082 METOPROLOL 1MG/ML 5 ML SYR

2101084 ESTROGEN CONJUGATED 1.25 MG TAB

2101085 ISONIAZID 100 MG TAB

2101086 CHLORTHALIDONE 25 MG TAB

2101087 EPSOM SALT 16OZ

2101088 TRIAMCINOLONE 0.1% DENTAL PASTE

2101089 ROSUVASTATIN 20 MG

2101090 TRIPLE ANTIBIOTIC 14GM

2101091 PRASUGREL 10 MG TAB

2101092 LEVETIRACETAM 250 MG TAB

2101093 PROPRANOLOL 10 MG

Page 28: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2101096 SODIUM CHLORIDE INJ SOLN 0.9% 3ML

2101097 SODIUM CHLORIDE FLUSH 0.9% 10 ML

2101100 SUDAFED 12 HR 120 MG CAPLET

2101101 PENICILLIN G PROC 600,000/ML 2ML SYR

2101102 Delete- was procrit J0885

2101103 PROCRIT 10,000 UNITS/1ML J0885

2101105 SURGI-SEAL ADHESIVE 0.7ML TUBE

2101106 GLYBURIDE 1.25 MG TAB

2101108 SODIUM CHLORIDE 0.9% 5ML VIAL

2101109 METOPROLOL TARTRATE INJ 5MG/5ML

2101110 FENOFIBRATE 48 MG (F)

2101111 WHITE PETROLATUM TOPICAL OINTMENT

2101112 WHITE PETROLATUM TOPICAL OINTMENT

2101113 GLYCERIN PEDIATRIC SUPPOS 1.2 GM

2101114 LORATADINE ORAL SYRUP 5MG/5ML

2101115 ENALAPRILAT 2.5 MG/ 2 ML INJ

2101116 EPHEDRINE 50MG/ML 1 ML AMP

2101117 LIDOCAINE 4% 5ml amp

2101118 LIDOCAINE 50G/5ML PEDIATRIC BOLUS

2101119 EPINEPHRINE 1:1000 1MG/ML 30 ML VIAL

2101120 AQUAPHOR HEALING OINTMENT

2101121 ADENOCARD 6 MG/ 2 ML SYRINGE J0153

2101122 MURI LUBE 10 ML VIAL

2101123 HEPARIN 10,000 UNITS/1 ML VIAL

2101124 XYLOCAINE MPF 2% 20ML VIAL

2101126 CALCIUM GLUC 10% 46.5 MEQ/100 ML VIAL

2101127 THEOPHYLLINE ORAL 80MG/15ML

2101128 TERRELL INH LIQ 250ML BTL

2101129 CYANOCOBALAMIN 1000 MCG/1 ML INJ

2101130 VISION BLUE 0.06% OPTH SOL

2101131 NF-VIACTIV 500 MG CHEW TABS

2101132 VITAMIN E 1000 UNIT CAP

2101133 LIQUID BANDAGE SPRAY 1OZ

2101134 PHENYTOIN 100 MG CAP

2101135 TRAMADOL / APAP 37.5/325MG TAB

2101136 PHYTONADION 10 MG/1 ML AMP J3430

2101137 SODIUM BICARBONATE 8.4% 50ML VIAL

2101139 PHISOHEX 148 ML CLEANSER

2101140 ATACAND 32MG TABLET

2101141 PROPYLTHIOURACIL 50 MG TAB

2101142 ZONISAMIDE 100MG CAPSULE

2101143 PHENOBARBITAL 16.2 MG (1/4TH GR) TAB

2101145 GI COCKTAIL

2101147 NIACIN 250 MG TABLET

2101148 NF-ANDROGEL GEL 1.62%

2101150 PREMPRO 0.625/2.5 MG TABLET

2101151 SELSUN BLUE SHAMPOO 4OZ

2101152 DERMOPLAST 78 GM SPRAY

2101153 POT PHOS 22MEQ 15 MMOLE/5 ML

2101155 SODIUM CHLOR 0.9% 10 ML

2101156 POTASSIUM CHLORIDE 2MEQ/ML 10 ML VIAL

2101158 HUMULIN R 3ML VIAL

Page 29: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2101159 NOVOLOG 10ML VIAL (INSULIN Aspart)

2101160 NOVOLIN 70/30 (ER) 1 DOSE

2101161 DEL-NOVOLIN NPH (ER) 1 DOSE

2101162 DEMECLOCYCLINE HCL TAB 300MG

2101163 DEFINITY KIT 2 ML J3490

2101164 FUROSEMIDE 100 MG/10ML 10ML VL

2101165 FENTANYL 75 MCG/HR PATCH

2101179 DAKINS 1/8TH SOLUTION 1000 ML

2101180 DAKINS 1/2 ST SOL 1000 ML

2101182 FOSPHENYTOIN 100 MG/2ML VIAL

2101186 VENOFER 100MG IV PUSH OVER 3-5MIN J1756

2101191 NF-COMBIGAN OPHTH SOLN 0.2%-0.5%

2101193 NF-COMBIGAN 5 ML OPTH SOL

2101194 COLESEVELAN 625 MG TAB

2101196 GLUCOSE ORAL GEL J1610

2101198 COMBIVIR 150/300 TABLET

2101199 VIRACEPT 625 MG CAP

2101208 FENTANYL 50 MCG/HR PATCH

2101209 DURAGESIC 50MCG PATCH

2101222 TRAMADOL ER 200 MG TAB

2101225 REGLAN 10MG/10ML ORAL SOLUTION

2101226 NF-ABILIFY ORAL TABLET 2MG

2101227 NF-CAPSAICIN CREAM 0.025%

2101233 NF-LEVETIRACETAM ORAL TAB ER 500MG

2101235 JAPANESE ENCEPHALITIS 1 DOSE

2101236 MEASLES,MUMPS,RUBELLA VACCINE

2101237 YELLOW FEVER VACCINE 0.5ML

2101241 CAPSAICIN CREAM

2101242 ARIPIPRAZOLE 2 MG TAB

2101244 GLUCOSAMINE ORAL CAPSULE 500MG

2101254 BUPIVICAINE 0.5% 50ML VIAL

2101255 LIDOCAINE 1% 50 ML VIAL

2101256 OMNIPAQUE 240MG/ML 50 ML Q9966

2101257 BUPIVACAINE/EPI 0.5% 50 ML

2101258 NF-ABREVA TOPICAL CREAM 10%

2101259 D5W 500 ML SOL

2101260 SINEMET 25/100 TABLET

2101261 MEPERIDINE 50 MG TAB

2101263 NF-DULERA INH AER PWD 5MCG-200MCG/ACT

2101271 COSYNTROPIN 0.25 MG/2ML VIAL

2101272 TETANUS/DIPHTHERIA TOXOID (AGE 7 &UP) 90714

2101277 NF-SAPHRIS SUBLINGUAL TABLET 5MG

2101279 NF-IPRATROPIUM BROM NASAL SPRAY 0.03%

2101280 DEXAMETHASONE 100MG/10ML

2101281 BETAMETHASONE 7MG/ML 10 ML VIAL

2101285 BRILINTA 90MG TAB

2101287 MAGIC MOUTH WASH

2101288 TPN CENTRAL

2101290 NF-REQUIP TAB 4MG

2101295 AZILECT 1MG TABLET

2101296 LOVAZA 1000 MG CAP

2101297 ARIXTRA 2.5MG/0.5ML SYG J1652

Page 30: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2101299 ARIXTRA 7.5MG/0.6ML SYG J1652

2101300 ARIXTRA 10MG/0.8ML SYG J1652

2101303 LEVETIRACETAM XR 500MG TAB

2101304 MARY'S MAGIC CREAM

2101305 METHYLPREDNISOLONE 100MG/ML 10 ML

2101307 STALEVO 150 TAB 37.5MG-200MG-150MG

2101310 CHLORDIAZEPOXIDE 5 MG CAP

2101316 NS IRRIG 0.9% 1000 ML FOR ENEMA

2101320 CHANTIX 1MG TABLET

2101327 DELETE THIS-WAS DOBUTAMINE J1250

2101328 NF-NUEDEXTA CAP 20MG-10MG

2101334 NALTREXONE HCL TAB 50MG

2101335 NF-TENEX ORAL TABLET 1MG

2101349 NF-VERAMYST NASAL SPRAY 27.5MCG/1 ACT

2101351 NF-PREMARIN ORAL TABLET 0.45MG

2101352 NEUPRO TD PATCH ER 2MG/24HR

2101358 DURAMORPH 5MG/10ML AMP

2101375 NAMENDA 14MG XR TABLET

2101376 ACYCLOVIR 500 MG VIAL J0133

2101380 NF-CLINDAGEL 1% TOPICAL APPLICATION GEL/

2101381 NF-DORZOLAMIDE HYDROCHLORIDE 2% OPHTHALM

2101384 DAKINS SOL 1/4 STR WITH LIDO. 1000 ML

2101394 ENSURE CLEAR

2101398 ZONISAMIDE 25MG CAP

2101400 D5 1/2 NS/SOD BICARB 50/1000 ML

2101403 NF-METROGEL CREAM 0.75%

2101408 MYCOPHENOLATE TAB 500MG

2101409 PROGRAF CAP 1MG

2101415 LORATADINE 5MG/5ML SYRUP

2101417 NF-LIALDA TAB DR 1.2GM

2101422 SOD CHL 0.9% 100 ML Minibag Plus

2101423 SOD CHL 0.9% 100 ML ADVANT BAG

2101424 GLIMEPIRIDE 1 MG TAB

2101427 POT PHOS 66MEQ 45 MMOLE/15 ML

2101429 NF-FEMARA TAB 2.5MG

2101430 MUCINEX DM 1200/60MG TABLET

2101435 NF-FLORA-Q CAPSULE

2101439 FLU VACCINE 0.5 ML(NAS ONLY) 90688

2101446 BROVANA INH SOLN 15MCG/2ML

2101457 LUNESTRA 1 MG TAB

2101469 Dobutamine 250MG/250ML J1250

2101478 BYDUREON SUBQ INJ ER 2MG

2101487 NF-KETOTIFEN FUMARATE 0.025% OPHTHALMIC

2101491 D5/45/20 NS/SOD BICARB 50/1000 ML

2101497 DEXTROSE 10%/SOD BICARB 8.4% 50/1000 ML

2101498 D5W/D50 1000/50 ML

2101503 ACETYLCYSTEINE 20% 30 ML IV

2101516 RAPAFLO 4 MG CAP

2101549 TUDORZA PRESSAIR INHALER

2101552 NF-NEXIUM 40 MG

2101561 MAGNEVIST 15ML VIAL

2101567 NF-PERFOROMIST 20MCG/2ML INHALATION SOLU

Page 31: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2101568 NF-FORADIL AEROLIZER CAPSULE 0.012MG

2101572 LOVENOX 80 MG SYG J1650

2101573 INVOKANA 100MG TABLET

2101574 ENSURE PLUS PROTEIN

2101577 NF-POLYTRIM OPHTH SOLN 10,000U/1ML-1MG/1

2101584 LISINOPRIL 10 MG TAB

2101587 1/2 NS/SOD BICARB 1000/50 ML

2101602 MIOCHOL-E INTRAOCULAR SOL.

2101612 FUROSEMIDE 40MG/4ML ORAL LIQ

2101617 MINERAL OIL

2101619 ZYPREXA 10MG VL

2101623 NF-ANDROGEL 1% 2.5GM TOPICAL

2101629 NF-LINZESS CAP 290MCG

2101633 ONGLYZA 5MG TABLET

2101646 SUPRPEP ORAL BOWEL PREP KIT

2101647 ARNICA GEL

2101648 FARXIGA 5MG TABLET

2101649 RABIES IMMUNE GLOBULIN 2ML VIAL

2101660 CYTOMEL 25MCG TAB.

2101664 BENAZEPRIL 20 MG TAB

2101665 XOLAIR 150MG SC INJ

2101669 CLINDAMYCIN/D5 900MG/50ML PREMIXED J3490

2101681 NF-DULERA INH AER PWD 5MCG-100MCG/ACT

2101691 BACITR/NEOM/POLY OINTMENT 14GM

2101692 BICILLIN LA 600,000 UNITS SYR J0561

2101694 MAGNESIUM SULF 50% 5GM/10ML VIAL

2101696 NF-FLUOCINOLONE ACETONIDE CRM 0.05%

2101702 NF-XARELTO TAB 15MG

2101705 CELEXA 40 MG TAB UD

2101707 ADDERALL ER 5MG ORAL CAPSULE

2101708 NEUPOGEN 300MCG/1ML VL

2101709 ZEMPLAR 1MCG CAPSULE

2101718 CARDIZEM 125 MG/25ML VL (ER)

2101725 BUMEX 0.5 MG TABLET

2101727 FOLIC ACID/NS IVPB: 1MG/100ML

2101728 THIAMINE/NS IVPB: 100MG/100ML

2101731 ROCURONIUM 10MG/ML 5ML VL

2101740 MAGNESIUM SULF 1GM/100ML PREMIX

2101745 LACTATED RINGERS 500 ML SOL J7120

2101749 NF-MAXITROL OPHTH SUSPENSION

2101756 BREO 100/25 MCG INHALER

2101765 NOVOLOG 70/ 30 U/ML VL 10 ML

2101773 AMINOPHYLLINE 500 MG 20ML VL

2101774 MEXILETINE HCL 200MG CAP

2101775 NF-MEXILETINE HCL CAP 200MG

2101780 DEPAKOTE D.R.500MG 12HR TAB

2101786 ROTAVIRUS VACC. 2ML UD

2101788 REQUIP 1 MG TABLET

2101794 ELIQUIS 5MG TAB

2101813 ACYCLOVIR 800 MG CAP

2101814 PRAZOSIN 1 MG TABLET

2101824 CLINDAMYCIN/D5 : 600MG/50ML PREMIX J3490

Page 32: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2101832 LINZESS 145MCG ORAL CAPSULE

2101837 NF-FLECTOR TOPICAL PATCH ER 1.3%

2101864 FOSPHENYTOIN 500MG/10ML VIAL

2101868 VANCOMYCIN 250MG/5ML ORAL SOL

2101871 VITAMIN D3 1000IU ORAL TABLET

2101884 ALFUZOSIN ER 10MG TAB-DELETE

2101892 ANORO ELLIPTA INH PWD 62.5MCG-25MCG/1

2101895 ALBUTEROL 0.083% 2.5MG/3ML

2101897 NF-METHYLPHENIDATE HCL CAP ER 10MG

2101915 DEX/NA/KCL/CA GLUC 5/.4 5/20/10 1000ML

2101916 XARELTO 15 MG TAB

2101917 CLOTRIMAZOLE 10 MG TROCHE

2101919 MANNITOL 25% 50 ml vial

2101920 ZOCOR 20 MG TABLET

2101921 SOD BICARB /D5W IV: 100MEQ/1000ML

2101923 NF-Linzess Oral Capsule 145MCG

2101927 ROSUVASTATIN 40 MG TAB

2101931 LIPITOR 80 MG TAB

2101939 NF-CYPROHEPTADINE HCL ORAL TABLET 4MG

2101947 BENAZEPRIL 10MG

2101948 NICARDIPINE 25MG/10ML VL

2101951 IMITREX 100 MG TABLET

2101955 STRIBILD (HIV-KIT)

2101988 NF-AVAPRO ORAL TABLET 150MG

2102021 HYALGAN 20MG/2ML SYR J7321

2102036 GARDASIL 9 (9-26yrs)

2102063 NF-Citalopram Oral Tablet 10MG

2102099 NF-Peridex Liquid 0.12%

2102109 BIOTENE MOUTH SPRAY

2102110 DOPAMINE PREMIX 400MG/250ML BAG J1265

2102114 NF-Sinemet 25-250 Oral Tablet 25MG-250MG

2102143 FLUOROSTRIP/BENOXINATE 0.25% OPTH SOL.

2102144 FLUOROSTRIP/BENOXINATE 0.25% OPTH SOL.

2102153 MIDODRINE 2.5 MG TABLET

2102156 NF-VITAL 1.5 CAL ORAL LIQUID 1 LITER

2102170 BACTRIM DS 800/160MG 10ML VL

2102231 ORBACTIV 1200MG (IVPB CHOOSE W/D5) J2407

2102233 NF-VANCOCIN CAP 125MG

2102234 TRIAMCINOLONE/MOXIFLOXACIN 15MG/MG 1 ML

2102262 VIMPAT 200 MG TAB

2102288 ZOSYN 3.375 GM FROZ. BAG J2543

2102289 ZOSYN 4.5 GM/100ML FROZ. BAG J2543

2102296 OCTREOTIDE 100MCG/ML 1 ML VIAL S0028

2102297 NF-Onfi Oral Tablet 10MG

2102324 NF-OxyCONTIN Tablet Extended Release 15M

2102327 OTO-END 10 OTIC DRP 10 ML

2102333 FARXIGA 10MG TABLET

2102334 ARICEPT 5 MG TAB

2102335 LISINOPRIL 5 MG TAB

2102339 NF-Trihexyphenidyl HCl Tablet 2MG

2102340 VARIZIG 125 UNITS/VIAL J9999

2102342 EVACUATED CONTAINER

Page 33: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2102360 TRADJENTA 5MG TABLET

2102377 HYOSCYAMINE 0.125MG ODT Q0162

2102393 MOVANTIK 12.5 MG TABLET

2102405 RELISTOR 12MG/0.6ML SYR

2102414 Eszopiclone 2mg

2102536 ENSURE

2102548 NF-Mexiletine HCl Capsule 200MG

2102571 TORADOL 60MG/2 ML SYR J1885

2102581 LIDO/EPI 1% 10 ML VIAL

2102582 LETS KIT

2102602 PROTONIX 2MG/ML SUSPENSION

2102609 CARDIZEM 50 MG/ 10ML VL (ER)

2102615 PHISODERM CLEANSER

2102635 OXYCODONE HCL 30 MG TAB

2102642 NF-Diclofenac Sodium DR Tablet 50MG

2102662 SilvaSorb Gel

2102668 RABIES IMMUNE GLOBULIN 10ML VIAL

2102690 INVOKANA TABLET 300MG

2102699 VIAGRA 25MG TABLET

2102700 TETRACAINE 1% OPTH 10MG/ML (2ML)

2102704 FEIBA 549 UNITS

2102746 MOVANTIK 25 MG TABLET

2102762 LORAZEPAM 2MG/1ML J2060

2102785 ENTRESTO 24MG/26MG

2102800 FLUMAZENIL DELETED

2102810 DALVANCE 500MG (IVPB CHOOSE W/D5) J0875

2102820 NF-Ipratropium Brom Nasal Spray 0.03%

2102830 TRESIBA 100 UNIT/ML 3ML PEN

2102834 NF-Atrovent Spray 0.03%

2102857 A & D OINTMENT

2102859 HEPARIN FLUSH 100 UNITS/ML 3ML Syringe J1642

2102877 NF-Morphine Sulfate Oral Capsule ER 50MG

2102895 NAMENDA 21MG XR CAPSULE

2102898 BENZ-O-STHETIC DENTAL TOPICAL

2102899 DAKINS (1/4) 0.125% SOLUTION

2102900 DAKINS (1/2) 0.25% SOLUTION

2102901 STERILE EYE IRR. (SURGERY DEPT)

2102907 SEROQUEL ER 400 MG TABLET

2102916 Senna Tablet 8.6MG

2102957 Ropinirole 0.25 mg

2102995 DILTIAZEM 50MG/100ML NS

2103032 GUANFACINE HCL ORAL TAB ER 1MG

2103056 NF-Amphetamine Salt Combination Tab 1.87

2103183 DEXTROSE 50% 50 ML VIAL

2103280 ARIPiprazole Oral Tablet 2MG

2103364 ARICEPT 10 MG TAB

2103428 NF-GUANFACINE HCL ORAL TAB ER 1MG

2103430 LIDO/EPI 2% 20 ML VIAL

2103466 NF-guanFACINE HCl Tablet 1MG

2103558 DOPAMINE PREMIX 400MG/500ML BAG J1265

2103560 CEFDINIR SUSPENSION 250MG/5ML

2103572 TENORMIN TABLET 25MG

Page 34: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2103596 ADDERALL 15 MG ORAL TAB

2103713 ALPRAZOLAM XR 2 mg

2103726 VIMPAT 50MG/5ML

2103827 CARDIZEM 25MG/5ML BOLUS

2103852 MS CONTIN 15 MG ER TABLET

2103872 VENELEX OINT 60GM

2103873 kETOCONAZOLE 2$ SHAMPOO

2103901 CREON 3000 UNITS

2103933 METHYLPHENIDATE 10 MG ORAL TAB

2103948 BREO 200/25 MCG INHALER

2103956 HYOSCYAMINE ODT 0.125MG

2103957 MORPHINE 8MG/1ML INJ

2103958 VITAMIN K IV/PO J3430

2103962 LINZESS 72MCG ORAL CAPSULE

2103963 JARDIANCE 25MG ORAL TABLET

2103964 VIIBRYD 10 MG ORAL TABLET

2103965 VIIBRYD 20 MG ORAL TABLET

2103979 RAPAFLO 4 MG

2103980 SAW PALMETTO 160MG

2103984 FLUMAZENIL 0.5mg/5ml

2103991 SHINGRIX VACC (ZOSTER) 90750

2104000 AMPICILLIN/NS IVPB : 2GM/100ML

2104003 VISINE EYE DROPS

2104006 SOD CHLOR 7% NEBS (FOR SPUTUM) J7699

2104009 SAVAYSA 60 MG

2104010 VERAPAMIL 120 MG

2104020 HUMULIN R u-500 PEN

2104021 INJECTAFER 750 MG

2104032 INJECTAFER/NS IVPB : 750MG/250ML

2104033 INJECTAFER 50MG/ML SDV

2104048 PROMOD PROTEIN SUPP

2104063 BROMOCRIPTINE 2.5MG

2104064 AMANTADINE 50MG/5ML

2104074 WATER STERILE 100 ML VIAL

2104075 METFORMIN 850MG TAB

2104087 ACETAMINOPHEN 1000MG IV

2104096 RIVASTIGMINE 1.5 MG

2104119 BRILINTA 90 MG

2104143 TRIMETHOPRIM 100MG

2104149 HYDROXYUREA 500MG CAP

2104166 VERSED 10MG/5ML ORAL SYRUP

2104167 METHIMAZOLE 10 MG

2104189 Imiquimod 5% cream

2104215 NF-Psoriasis Topical Shampoo 3%

2104222 Actos 15MG

2104225 Multaq Oral Tablet 400MG

2104235 TRELEGY ELLIPT

2104239 NF-Singulair Chewable Tablet 4MG

2104240 NF-Cetirizine HCl Oral Syrup 1MG/1ML

2104242 INCRUSE ELLIPTA

2104261 CEFEPIME 2 GM VL J0692

2104273 DEL- ILEVERO OPH 0.3% SOL

Page 35: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2104293 ENALAPRIL 5 MG

2104294 ENALAPRIL 20 MG

2104310 DANTROLENE 250 MG J0696

2104313 ILEVRO OPTH SUSP

2104328 BUPIVACAINE 0.25% 10ML

2104350 LEFLUNOMIDE 20 MG

2104365 PREDNISONE/GATIFLOXIN/BROMFENC

2104368 METHENAMINE 1GM TAB

2104378 METHENAMINE 1GM

2104391 NF-Pristiq Extended-Release Tablet 100MG

2104401 NF-PRISTIQ TAB ER 50MG

2104442 NICOTINE 21MG PATCH

2104458 PROPRANOLOL 60MG LA

2104459 PROPRANOLOL 80MG ER

2104468 PERIACTIN 4MG

2700001 ACTIGRAPHY 95803

2700002 BASELINE REDUCED 9581052

2700003 MUL SLP LATENCY TEST 95805

2700004 SLEEP STUDY BASELINE 95810

2700005 SLEEP STUDY TITRATIO 95811

2700006 TITRATION REDUCED 9581152

2700007 NO SHOW SLEEP STUDY

2700008 OVNIGHT EEG W/VIDEO 95951

2700009 AMBULATORY HOME STUDY TEST 95806

2700010 AMBULATORY SLEEP TESTING 95806

2800003 EVAL/ASSESSMENT 90791

2800004 IND THERAPY 20-30MIN 90832

2800005 IND THERAPY 45-50MIN 90834

2800006 IND THERAPY 75-80MIN 90837

2800007 FAM THERAPY W/O PT 90846

2800008 FAM THERAPY W/PT 90847

2800009 GROUP THERAPY 1 HR 90853

2800010 PSYCHOTHERAPY FOR CRISIS 1ST 60MIN 90839

2800011 HOSPITAL OP CLINIC VISIT PHY FOLLOW UP G0463

3100014 OSS URINALYSIS 81003

3100015 OSS S/U AMINO ACIDS 82131

3100016 OSS S/U AMMONIA 82140

3100017 OSS S/U CALCIUM 82340

3100018 OSS S/U CHLORIDE URIN 82436

3100019 OSS S/U CITRATE 82507

3100020 OSS S/U CREATININE 82570

3100021 OSS S/U MAGNESIUM 83735

3100022 OSS S/U OSMOTIC URIN 83935

3100023 OSS S/U OXALATE 83945

3100024 OSS S/U PHOSPHO URIN 84105

3100025 OSS S/U POTASSI URIN 84133

3100026 OSS S/U SODIUM URINE 84300

3100027 OSS S/U URIC ACID 84560

3100028 BB ANTIBODY ID PREWARM 86870

3100029 BB ANTIBODY SC AHG 86850

3100030 BB ANTIBODY SCREEN IMME 86850

3100031 BB ANTIBODY SCREEN INCU 86850

Page 36: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100033 BB BLOOD TYPING ABO 86900

3100034 BB BLOOD TYPING RH(D) 86901

3100035 BB CROSSMATCH AHG 86922

3100036 BB CROSSMATCH IMMEDIATE 86920

3100037 BB CROSSMATCH INC TUBE 86921

3100038 BB DIRECT ANTIGLOBULIN 86880

3100039 ELUTION 86860

3100040 FASTING BLOOD GLUCOSE 82947

3100041 REF NATP - PLATELET 86022

3100042 REF PLATELET ABY STU 86022

3100043 REF PLATELET CROSSMA 86022

3100044 REF DIFFERENTIAL/AUTO ADS OF SERUM 86978

3100045 REF ANTIBODY ID/EA PANEL & MEDIA 86870

3100046 REF ANTIBODY SCREEN 86850

3100047 REF ANTIGEN SCREEN EACH 86905

3100048 REF RBC ANTIGEN 86905

3100049 REF DAT EA 86880

3100050 REF DILUTION 86976

3100051 REF ELUTION 86860

3100052 REF HEMOGLOBIN S / P 85660

3100053 REF HEMOLYSIS/AGGLUTININS AUTO EA 86940

3100054 REF HEMOLYSIS/AGGLUTININS INCUBATED 86941

3100055 REF INCUBATION SERUM & DRUGS 86975

3100056 REF INDIRECT TITER 86886

3100057 REF INCUBATION WITH INHIBITORS 86977

3100058 REF PRETREAT W/ CHEMICALS/DRUGS 86970

3100059 REF PRETREAT W/ ENZYMES 86971

3100060 REF RETICULOCYTE SEP 86972

3100061 REF RH PHENOTYPE COMPLETE 86906

3100063 BB ANTIBODY SCREEN 86850

3100064 REF COLD AGGLUTININ 86156

3100065 STREP B AG 87802

3100066 BACTERIAL ANTIGEN CSF 87899

3100067 ACCT BMP 80048

3100070 IRRADIATION FEE EA 86945

3100081 REF NATP PLT ABS 86022

3100083 ACC DBIL 82248

3100085 17 OH PROGEST SERUM 83498

3100086 5 HIAA 83497

3100087 5 NUCLEOTIDASE 83915

3100088 ACETAMINOPHEN LEVEL 80299

3100089 MMA SERUM 83921

3100090 ACTH 82024

3100091 HEPATITIS PANEL 80074

3100092 MMA URINE 83921

3100093 ALBUMIN SERUM 82040

3100094 PHOSPHOLIPIDS SERUM 84311

3100095 RAPAMUNE 80195

3100096 TTG IGG 83516

3100097 ALCOHOL VOLATILES 80320

3100098 ALCOHOL/ETOH 80320

3100099 ALDOLASE 82085

Page 37: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100100 ALDOSTERONE URINE 82088

3100101 TTG IGA 83516

3100102 ALKALINE PHOSPHATASE 84075

3100103 ALPHA FETOPROTIEN 82105

3100104 ALDOSTERONE SERUM 82088

3100105 AMITRIPTYLINE/ELAVIL 80335

3100106 AMMONIA 82140

3100107 AMP PT NUC ACD MULT 83901

3100108 AMYLASE 82150

3100109 FREE KAPPA LAMBDA CHAINS, SERUM 83883

3100110 FREE KAPPA LAMBDA CHAINS URINE 83883

3100111 ANGIOTENSIN I CONV E 82164

3100113 PTH RELATED PEPTIDE 82397

3100114 ANTIDIURETIC HORMONE, PLASMA 84588

3100115 ARSENIC, WHOLE BLOOD 82175

3100116 CA 27.29 86300

3100117 BARBITURATES CONFIRMATION, WB 80345

3100118 BASIC METABOLIC PANEL 80048

3100120 BILIRUBIN DIRECT 82248

3100122 BILIRUBIN TOTAL 82247

3100124 IMMUNOGLOBULINS 82784

3100125 PROTEIN ELEC URINE 84166

3100126 METANEPHRINES PLASMA 83835

3100127 BUN 84520

3100128 FASTING C PEPTIDE 84681

3100129 CRP HS 86141

3100130 CA 125 86304

3100132 CADMIUM, WHOLE BLOOD 82300

3100133 LEVETIRACETAM 80177

3100134 CALCITONIN 82308

3100135 CALCIUM IONIZED 82330

3100136 CALCIUM TOTAL 82310

3100137 CALCIUM 24 HR URINE 82340

3100138 LAMOTRIGRINE 80175

3100139 FACTOR V (LEIDEN) 81241

3100140 CARBAMAZEPINE/TEGRET 80156

3100141 CARBON MONOXIDE/CARB 82375

3100142 MTHFR 81291

3100143 CATECHOL T&F PLASMA 82384

3100144 CATECHOL T&F RAND UR 82384

3100145 CATECHOL T&F 24 H UR 82384

3100146 FLOW CYTO 1ST MARKER 88184

3100147 CEA 82378

3100149 CHLORIDE BLOOD 82435

3100150 CHLORIDE CSF 82438

3100151 CHLORIDE URINE 82436

3100152 LUPUS ANTICOAGULANT 85732

3100153 FACTOR II, DNA ANALYSIS 81240

3100154 CHOLESTEROL TOTAL 82465

3100157 CITRATE, 24 HR URINE 82507

3100158 CK MB 82553

3100159 CK/CPK TOTAL 82550

Page 38: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100160 CYSTIC FRIBROSIS SCR 81220

3100161 CO2/CARBON DIOXIDE 82374

3100162 COMP METABOLIC PANEL 80053

3100163 COPPER, WHOLE BLOOD 82525

3100164 CORTISOL URINARY FREE 82530

3100165 CORTISOL TOTAL 82533

3100166 CREAT CLEARANCE 82575

3100167 CREATINE 82540

3100168 CREATININE BLOOD 82565

3100169 CREATININE 24 HR 82570

3100170 DHEA 82626

3100171 DHEA SULFATE 82627

3100172 DIGOXIN/LANOXIN 80162

3100173 DIHYDROTESTOSTERONE 80327

3100174 DOXEPIN/SINEQUAN 80335

3100178 ELECTROLYTE PANEL 80051

3100179 ERYTHROPOIETIN 82668

3100180 ESTRADIOL 82670

3100181 ESTRIOL 82677

3100182 ESTROGENS TOTAL 82672

3100183 ETHYLENE GLYCOL 82693

3100184 FAT FECES QUAL 82705

3100185 FECAL FAT QUANTITATIVE 82710

3100186 FERRITIN 82728

3100187 FOLIC ACID SERUM 82746

3100188 FOLIC ACID RBC 82747

3100189 FSH 83001

3100190 G6PD 82955

3100193 GENTAMYCIN TROUGH 80170

3100194 GGT 82977

3100195 GLUC TOL 3 SPEC 82951

3100196 GLUC TOL ADDL SPEC 82952

3100197 GLUCOSE BLD QUANT 82947

3100198 GLUCOSE FLD 82945

3100199 GLUCOSE-CSF 82945

3100201 GLUCOSE POST DOSE 82950

3100202 GROWTH HORMONE 83003

3100203 HCG SERUM QUAL 84703

3100204 HCG SERUM QUANT 84702

3100205 HDL CHOLESTEROL 83718

3100206 HEAVY METAL PROFILE I, URINE 82175

3100207 HEP A AB, TOTAL 86708

3100208 HEP A AB IGM 86709

3100209 HEP B CORE AB 86704

3100210 HEP B CORE AB IGM 86705

3100211 HEP B E AG 87350

3100212 HEP B SURF AG 87340

3100213 HEP B SURFACE AB 86706

3100214 HEP BE AB 86707

3100215 HEP C AB 86803

3100216 HEP C QUALITATIVE 87521

3100217 HEPATIC FUNCTION PAN 80076

Page 39: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100218 HGB EVAL 83021

3100219 HGB/A1C/GLYCOSYLATED 83036

3100220 HOMOCYSTEINE PLASMA 83090

3100221 IMIPRAMINE/TOFRANIL 80335

3100222 INSULIN FREE AND TOTAL 83527

3100223 INSULIN TOTAL 83525

3100224 IRON 83540

3100226 ISOENZYME CPK 82552

3100227 LACTIC ACID 83605

3100228 LDH 83615

3100229 LEAD PEDIATRIC VENOUS 83655

3100230 LH 83002

3100231 LIPASE 83690

3100232 LIPID PANEL 80061

3100233 LITHIUM 80178

3100234 MAGNESIUM 83735

3100235 MERCURY 83825

3100236 METANEPHRINES 24 HR URINE 83835

3100237 METHADONE/DOLOPHINE 80358

3100238 MICROALBUMIN QUANT RANDOM 82043

3100245 BENZODIAZEPINES SERUM 80347

3100247 OPIATES SERUM 80356

3100248 PTH INTACT 83970

3100249 MYOGLOBIN 83874

3100250 NICOTINE, URINE 80323

3100251 NORTRIPTYLINE/AVENTY 80335

3100252 H PYLORI BREATH 83013

3100253 OSMOLALITY URINE 83935

3100254 OSMOLALITY SERUM 83930

3100255 OXALATE, 24 HR URINE 83945

3100257 PH BODY FLUID 83986

3100258 PHENOBARBITAL 80184

3100259 PHENYTOIN/DILANTIN 80185

3100260 PHOSPHORUS BLOOD 84100

3100261 PHOSPHORUS 24 HR URINE 84105

3100262 PKU 84030

3100263 PORPHOBILINOGEN 24 HR UR 84110

3100265 PORPHYRINS QUANT 24 HR URINE 84120

3100266 POTASSIUM BLOOD 84132

3100267 POTASSIUM URINE 84133

3100268 PRIMIDONE/MYSOLINE 80188

3100269 PROCAINAMIDE & NAPA 80192

3100270 PROGESTERONE 84144

3100271 PROINSULIN 84206

3100272 PROLACTIN 84146

3100273 TOTAL PROTEIN BLD 84155

3100274 PSA TOTAL 84153

3100275 RENAL FUNCTION PANEL 80069

3100276 RENIN 84244

3100277 REVERSE T3 84482

3100278 SALICYLATE LEVEL 80299

3100279 SEROTONIN 84260

Page 40: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100280 SEX HORMONE BINDING 84270

3100281 SGOT/AST 84450

3100282 SGPT/ALT 84460

3100283 SODIUM BLOOD 84295

3100284 SODIUM URINE 84300

3100285 SOMATOMEDIN C 84305

3100286 VENIPUNCTURE 36415

3100287 STONE(CALCULI) 82360

3100288 T3 FREE 84481

3100289 T3 TOTAL 84480

3100290 T3 UPTAKE 84479

3100291 T4 FREE 84439

3100292 T4 TOTAL 84436

3100293 TACROLIMUS/PROGRAF 80197

3100294 TBG/THYROXIN BIND GLOBULIN 84442

3100295 TESTOSTERONE FREE & TOTAL 84402

3100296 TESTOSTERONE TOTAL 84403

3100297 THEOPHYLLINE/AMINOPH 80198

3100298 TRILEPTAL 80183

3100299 THYROGLOBULIN AB 86800

3100300 TOBRAMYCIN TROUGH 80200

3100301 TOPAMAX 80201

3100302 PEST/INSECT PANEL 82489

3100303 TRIGLYCERIDES 84478

3100304 TROPONIN I 84484

3100305 SMITH AB 86235

3100306 RNP AB 86235

3100307 TSH 84443

3100308 TSI/THYROID STIM IMMUNOGLOBIN 84445

3100309 SJORGRENS SSA/SSB ABS 86235

3100310 UREA NITROGEN UR RANDOM 84540

3100311 URIC ACID BLOOD 84550

3100312 DRUG CLASS EA URINE 80305

3100313 URIC ACID 24 HR URINE 84560

3100314 OXYCODONE SERUM 80365

3100315 VALPROIC ACID/DEPAKE 80164

3100316 VANCOMYCIN LEVEL 80202

3100317 PCP GCMS UR 83992

3100318 MDMA CONF UR 80359

3100319 VISCOSITY 85810

3100320 VIT A 84590

3100321 VIT B 6/PYRIDOXINE 84207

3100322 VIT B1 THIAMINE 84425

3100323 VIT D 1/25 DIHYDROXY 82652

3100324 VIT D3/25 HYDROXY 82306

3100325 VIT E/TOCOPHEROL 84446

3100326 VITAMIN B 12 82607

3100327 VITAMIN C/ASCORBIC A 82180

3100328 VMA URINE 84585

3100329 ZINC WHOLE BLOOD 84630

3100330 SJOGRENS SSB AB 86235

3100331 SCL 70 SCLERODERMA 86235

Page 41: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100332 MITOCHONDRIAL AB 83516

3100333 PSA FREE AND TOTAL 84154

3100334 ACETONE SERUM QUAL 82009

3100337 DRUG SCR COC 80301

3100339 ALCOHOL UR COC 82055

3100340 ALCOHOL BLD COC 82055

3100341 RBC ONLY 85041

3100342 ZPP 84202

3100343 OXYCOD/GCMS CONF 80307

3100347 LDL CHOLESTEROL DIRE 83721

3100348 HEP C VIRAL LOAD 87522

3100349 IRON BINDING CAPACIT 83550

3100350 TRAMADOL/ULTRAM 80373

3100351 DRUG SCR SERUM 80307

3100352 ACETONE SERUM QUANT 82010

3100353 URINE ACETONE 82009

3100354 PROTEIN C ACTIVITY 85303

3100356 VITAMIN K 84597

3100357 AMPHET UR GCMS 80324

3100358 COCAINE UR GCMS 80353

3100360 THC UR GCMS 80349

3100361 METHADONE UR GCMS 80358

3100362 BCR-ABL1 KINASE MUTATION 81170

3100363 THYROGLOBULIN REFLEX TO AB 86800

3100364 BENZODIAZEPINE UR GC 80346

3100365 MDPV 80307

3100366 MEPHEDRONE 80307

3100368 OPIATES UR GCMS 80361

3100369 LACOSAMIDE/VIMPAT 80339

3100370 SUBOXONE 80307

3100373 PROPOXYPHENE UR GCMS 80301

3100374 TRICYC ANTIDEP SERUM 80337

3100375 PCP BLOOD GCMS 80301

3100376 THC BLOOD 80349

3100377 BARBITUATE UR GCMS 80345

3100379 C-TELOPEPTIDE 82523

3100380 NMR LIPOPROFILE 83704

3100381 URINALYSIS MICROSCOP 81015

3100382 URINALYSIS AUTO W/O 81003

3100383 C REACTIVE PROTEIN 86140

3100384 BNP 83880

3100385 HERPES 1&2 PCR 87529

3100386 HPV AMP 87624

3100387 17-HYDROXYPREGNEOLON 84143

3100388 CHROMIUM URINE 82495

3100389 PSA SCREEN OVER AGE G0103

3100390 FRAGILE X 81243

3100392 DAVITA ION CALCIUM 82330

3100393 DAVITA CHLORIDE 82435

3100396 SODIUM OTHER 84302

3100398 GASTRIC OCCULT BLOOD 82271

3100399 COLL CAP BLOOD HEEL 36416

Page 42: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100400 AMPHETAMINE/METHAMPH 80301

3100401 COCAINE OR METABOLIT 80353

3100402 TOTAL PROTEIN 24 HR 84156

3100403 TOTAL PROTEIN RANDOM 84156

3100404 T PROTEIN URINE RAND 84156

3100405 IFOB DIAGNOSTIC 82274QW

3100407 ANTITHROMBIN III ACTIVITY 85300

3100408 CBC/PLT/AUTO DIFF 85025

3100409 CBC/PLT/NO DIFF 85027

3100410 CELL CT CSF-NO DIFF 89050

3100411 CELL CT CSF W/DIFF 89051

3100412 D DIMER QUANT 85379

3100413 EOSINOPHIL COUNT 85048

3100414 EOSINOPHIL SMEAR 89190

3100415 FACTOR II ASSAY 85210

3100416 FACTOR IX ACTIVITY 85250

3100417 FACTOR IX INHIBITOR 85335

3100418 FACTOR V ACTIVITY 85220

3100419 FACTOR VII ASSAY 85230

3100420 FACTOR VIII ACTIVITY 85240

3100421 FACTOR VIII INHIBITO 85240

3100422 FACTOR VIII ANTIGEN 83520

3100423 FACTOR X ACTIVITY 85260

3100424 FACTOR XI ACTIVITY 85270

3100425 FACTOR XII ACTIVITY 85280

3100426 FACTOR XIII ACTIVITY 85290

3100427 FDP/FSP 85362

3100428 FIBRINOGEN ACTIVITY 85384

3100429 HCG URINE QUAL 81025

3100430 HEMATOCRIT 85014

3100431 HEMOGLOBIN 85018

3100432 GAD ANTIBODY 86341

3100433 LEUKOCYTE ALKALINE PHOSPHATASE 85540

3100434 MYOGLOBIN URINE 83874

3100435 PLATELET COUNT AUTO 85049

3100436 PROTHROMBIN TIME 85610

3100437 PTT ACTIVATED 85730

3100438 REDUCING SUBSTANCE STOOL 84376

3100439 RETIC COUNT 85045

3100440 DILUTE RUSSELL VIPER VENOM TIME 85613

3100441 SED RATE MANUAL 85651

3100442 SEMEN ANALYSIS MOTIL 89321

3100443 SPEC GRAV-FLD 81005

3100444 STOOL LEUKOCYTE 89055

3100445 THROMBIN TIME 85670

3100446 UA AUTO W/MICRO 81001

3100447 VON WILLEBRAND FACTOR ANTIGEN 85246

3100448 WBC W/O DIFF 85048

3100449 PH FECES 83986

3100450 PLATELET COUNT-MANUA 85032

3100451 MANUAL DIFF 85007

3100455 CRYSTAL EXAM-BODY FL 89060

Page 43: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100459 PROTEIN S ACTIVITY 85306

3100461 CBC W/MANUAL DIFF/CHARGE 85007

3100463 CBC W DIFF 85025

3100465 PAP SMEAR 88175

3100466 AFB ID 87149

3100467 AFB SMEAR 87206

3100468 ORG ID ANAEROBE EA 87076

3100469 B PERTUSSIS PCR 87798

3100470 BETA LACTAMASE 87185

3100471 C DIFFICILE TOXIN A AND B EIA 87324

3100472 CHLAMYD PNEUM PCR 87486

3100473 CHLAMYD TRACH AMP PR 87491

3100474 CRYPTOSPORIDIUM 87328

3100475 CULTURE AFB 87116

3100476 CULTURE ANAEROBIC 87075

3100477 CULTURE BLOOD 87040

3100478 CULTURE BODY FLUID 87070

3100480 CULTURE CATH TIP 87070

3100481 CULTURE CSF 87070

3100482 CULTURE FUNGUS 87101

3100483 CULTURE GC SCREEN 87081

3100484 CULTURE GENITAL 87070

3100486 CULTURE MYCOPL/UREPL 87109

3100487 CULTURE PERTUSSIS 87070

3100488 CULTURE SPUTUM 87070

3100489 CULTURE STOOL 87045

3100490 CULTURE THROAT 87070

3100491 CULTURE URINE COLONY 87086

3100492 CULTURE VIRUS CMV 87254

3100493 CULTURE VIRUS HERPES 87255

3100494 CULTURE VIRUS MEASLE 87254

3100495 CULTURE VIRUS MUMPS 87254

3100496 CULTURE VIRUS 87252

3100497 CULTURE VIRUS RESP P 87254

3100498 CULTURE VIRUS VZ 87254

3100499 CULTURE WOUND 87070

3100500 TUBERCU PCR NON RESP 87556

3100501 GC AMP PROBE 87591

3100502 GRAM STAIN 87205

3100503 HIV VIRAL LOAD 87536

3100504 H PYLORI AG-STOOL 87338

3100505 INDIA INK PREP 87210

3100506 KOH PREP-VAGINAL 87210

3100507 LEGIONELLA AG 87449

3100508 MACRO EXAM- ARTHROPO 87168

3100509 CULTURE YERSINIA 87046

3100511 MRSA SCREEN 87081

3100512 ORG ID-AEROBIC EACH 87077

3100513 OVA & PARASITE 87177

3100514 PINWORM PREP 87172

3100515 SENSITIVITY AFB 87188

3100516 SENSITIVITY MIC 87186

Page 44: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100517 FUNGAL STAIN 87206

3100518 STOOL ADD PATHOGEN/P 87046

3100519 STREP GROUP B AG CSF 87802

3100521 STREP SCREEN 87880

3100522 VRE SCREEN 87081

3100523 WET PREP 87210

3100524 YEAST-DEFINITIVE ID 87106

3100525 PNEUMOCYSTIS CARNINI SMEAR 87281

3100526 GIARDIA AG EIA 87329

3100527 LYME PCR 87476

3100528 VAGINITIS PANEL 87798

3100529 HSV SWAB 87529

3100530 T/B LYMPHOCYTE DIFF PROFILE 86355

3100531 WEST NILE VIRUS AB 86788

3100532 WEST NILE VIRUS PCR 87798

3100533 URINE EOSINOPHIL 87205

3100535 Q FERON TB 86480

3100536 PATH SPECIAL STAIN GROUP 2, OTHER 88313

3100537 KOH PREP - SKIN, HAIR, NAILS 87220

3100538 ACETYCHOLINE RECEPTOR ABS 83519

3100539 ALBUMIN CSF 82042

3100540 ALLERGEN MULTI INHALANT 86003

3100541 FOOD ALLERGEN PROFILE 86003

3100543 ALPHA 1 ANTITRYPSIN TOTAL 82103

3100544 ROCKY MT SPOTTED FEVER IGG 86757

3100545 RSV AG 87807

3100546 ANTI HISTONE ABS 86235

3100547 ANA SCREEN 86038

3100548 ANA TITER 86039

3100549 URTICARIA INDEX 86343

3100550 GLIADIN AB IGA/IGG PROFILE 83516

3100551 SMOOTH MUSCLE AB 83516

3100552 H PYLORI IGG 86677

3100553 IMFX URINE 86335

3100554 IMMUNOGLOB A 82784

3100555 IMMUNOGLOB G 82784

3100556 IMMUNOGLOB M 82784

3100557 ASO TITER 86060

3100558 B PERTUSSIS ABS 86615

3100559 BARTONELLA AB 86611

3100560 BLASTOMYCES AB EA 86612

3100561 ANTICARDIOLIPIN IGA 86147

3100562 CD4 86361

3100563 CD4/CD8 RATIO 86360

3100564 CERULOPLASMIN 82390

3100565 CHLAMYDIA AB IGG 86631

3100566 CHLAMYDIA AB IGM 86632

3100567 CMV AB IGG 86644

3100568 CMV AB IGM 86645

3100569 E COLI SHIGA TOXINS 87427

3100570 COLD AGGLUTININ TITE 86157

3100571 COMPLEMENT C3 86160

Page 45: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100572 CCP 86200

3100573 COMPLEMENT, TOTAL CH50 86162

3100574 COMPLEMENT C4 86160

3100575 FLU A ANTIGEN 87804

3100576 CRYOGLOBULIN 82595

3100577 DIPTHERIA AB EA 86317

3100578 DNA DOUBLE STRAND AB 86225

3100580 DNASE B ANTIBODY 86215

3100581 EBV EARLY AG AB 86663

3100582 EBV NUCLEAR AB/EBNA 86664

3100583 EBV VCA EA 86665

3100585 COXSACKIE A VIRUS AB 86658

3100586 ENTEROVIRUS AB 86658

3100587 FLO CYT EA AD MARKER 88185

3100591 H PYLORI ABS 86677

3100592 HIV 86701

3100593 HAPTOGLOBIN QUANT 83010

3100594 HSV 1/2 IGM 86694

3100595 HSV AB TYPE 1 IGG 86695

3100596 HSV AB TYPE 2 IGG 86696

3100599 STREP PNEUMONIAE ANTIGEN 87899

3100600 IMMUNOFIXATION SERUM 86334

3100601 IMMUNOGLOB G SUBCLASS 82787

3100602 INTRINSIC FACTOR 86340

3100603 LYME DIS IGG IGM 86618

3100604 LYME DISEASE WEST BL 86617

3100605 THYROIDPEROXIDASE AB 86376

3100606 MONO TEST 86308

3100607 BK VIRUS, BLOOD 87799

3100608 MUMPS AB IGM 86735

3100609 MYCOPLASMA PNEUMONIAE AB 86738

3100610 ANCA SCRN 83520

3100611 PARVOVIRUS AB 86747

3100612 PNEUMOCOCCAL AB 86609

3100613 PREALBUMIN 84134

3100614 RHEUMATOID FACT TITER 86431

3100615 ROTAVIRUS AG 87425

3100616 RPR QUAL 86592

3100617 RPR QUANT 86593

3100618 RUBELLA AB IGG 86762

3100619 RUBEOLA IGG 86765

3100620 TETANUS AB IGG 86317

3100621 TOXOPLASMA AB IGG 86777

3100622 TOXOPLASMA AB IGM 86778

3100623 TRANSFERRIN 84466

3100624 VARICELLA ZOSTER IGG 86787

3100625 MMR IMMUNE PAN 86735

3100627 IGE, TOTAL 82785

3100628 CRYPTOCOCCUS AB 86641

3100629 RA QUAL 86430

3100630 ALLERGEN IGE 86003

3100631 CLOPIDOGREL 81225

Page 46: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100632 FLU B ANTIGEN 87804

3100634 PROTEIN ELECT SERUM 84165

3100635 ISLET CELL AB 86341

3100636 PHOSPHOLIPID ABS 86148

3100640 PATH IMMUNOHISTOCHEMISTRY I 88342

3100641 PATH GROSS ONLY 88300

3100642 PATH LVL II 88302

3100643 PATH LVL III 88304

3100644 PATH LVL IV 88305

3100645 PATH LVL V 88307

3100646 PATH LVL VI 88309

3100647 RITALIN URINE 80360

3100648 CYTO FLUIDS/WASH/BRU 88104

3100649 CYTO SELECT CELL ENH 88112

3100650 PROCALCITONIN 88112

3100652 CBC/PLT/AUTO/CHG 85025

3100653 CBC/PLT/NO DIFF/CHG 85027

3100654 TP CSF 84157

3100655 HIV AB CONFIRMATION 86702

3100656 MICROALBUMIN QUANT 24 HR 82043

3100657 CREATININE UR RANDOM 82570

3100658 CLOTEST 87077

3100659 VANCOMYCIN TROUGH 80202

3100660 VANCOMYCIN PEAK 80202

3100671 ALLERGEN PANEL 86003

3100672 IMMUNOGLOB A SUBCLASSES 1-2 83883

3100673 IMMUNOGLOB A SUBCLASS 2 83883

3100674 ESTRONE 82679

3100675 ANTIPARIETAL CELL AB 83516

3100677 SICKLE CELL TEST 85660

3100678 GASTRIN SERUM 82941

3100679 REF ANTIBODY ID REAGENT CELL 86885

3100680 NOROVIRUS PCR 87798

3100681 HISTOPLASMA ANTIBODIES 86698

3100682 BETA CAROTENE 82380

3100683 RSV ANTIBODIES 86756

3100684 ANTIMYOCARDIAL ANTIBODIES 86256

3100685 IODINE 83789

3100686 HISTOPLASMA AG BLOOD 87385

3100687 N. GONORRHOEAE AB 86609

3100688 AMIKACIN TROUGH 80150

3100689 THIOPURINE METABOLITES 80375

3100690 RESPIRATORY VIRUS PANEL PCR 87633

3100691 HIV GENOTYPE 87903

3100692 NEUROPATHY PANEL 83516

3100693 CULTURE AEROBIC - INHOUSE 87070

3100694 PATH SPECIAL STAIN GROUP 1, MICRO 88312

3100695 B PERTUSSIS IGM 86615

3100696 BB RHOGAM 90384

3100697 LEGIONELLA AB 86713

3100698 PREGNENOLONE 84140

3100699 AMIKACIN PEAK 80150

Page 47: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100700 AMYLASE BODY FLUID 82150

3100701 CULTURE AEROBIC - LABCORP 87070

3100702 CELL CT SYNOVIAL FLD 89051

3100703 CHROMIUM PLASMA 82495

3100704 CORTISOL AM 82533

3100705 GENTAMYCIN PEAK 80170

3100706 HEAVY METAL WHOLE BLOOD 82175

3100707 H PYLORI IGA 86677

3100708 H PYLORI IGM 86677

3100709 HISTOPLASMA AG URINE 87385

3100710 LDH BODY FLUID 83615

3100711 LEAD ADULT 83655

3100712 LIPASE BODY FLUID 83690

3100713 TP BODY FLUID 84157

3100714 RUBELLA AB IGM 86762

3100715 CORTISOL SALIVARY X2 82533

3100716 TRIGLYCERIDES BODY FLUID 84478

3100717 TOBRAMYCIN PEAK 80200

3100718 UREA NITROGEN URINE 24 HOUR 84540

3100719 VARICELLA ZOSTER IGM 86787

3100720 17 OH PROGEST/CREAT RATIO UR 83498

3100725 TRICHOMONAS VAGINALIS AMP 87661

3100726 ROCKY MT SPOTTED FEVER IGM 86757

3100727 LYME DISEASE IGM 86618

3100728 EBV VCA IGG 86665

3100729 EBV VCA IGM 86665

3100730 ENDOMYSIAL AB 86255

3100731 FRUCTOSAMINE 82985

3100732 HEP C GENOTYPE 87902

3100734 IA-2 AUTOANTIBODIES 86341

3100735 CRYPTOCOCCUS AG CSF 87899

3100736 CA 15-3 86300

3100738 RUBEOLA IGM 86765

3100740 CANDIDA ALBICANS ABS 86628

3100741 NEUROMYELITIS OPTICA IGG 83520

3100742 VAP 83701

3100743 PHENYTOIN FREE & TOTAL 80185

3100744 PHENOBARBITAL FREE 80184

3100745 RABIES ABS 86382

3100746 Q FEVER IGG 86638

3100747 CHOLINESTERASE RBC 82480

3100748 JAK 2 MUTATION 81270

3100749 HLA B-27 ANTIGEN 81374

3100750 PCB 82441

3100751 BETA 2 GLYCOPROTEIN ANTIBODIES 86146

3100752 PATH IMMUNOHISTOCHEMISTRY II 88341

3100754 EBV PCR QUANT 87799

3100755 CMV PCR QUANT 87497

3100756 CYCLOSPORINE 80158

3100757 LISTERIA AB 86609

3100758 IMMUNOGLOBULIN D 82784

3100759 EGG YOLK IGE 86003

Page 48: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100760 EGG WHITE IGE 86003

3100761 ENTEROVIRUS PCR 87498

3100762 TRYPTASE 83520

3100763 N-METHYL HISTAMINE 82542

3100764 HEPARIN INDUCED PLATELET AB 86022

3100766 LYSOZYME 85549

3100767 PSILOCIN 80323

3100768 ANDROSTENEDIONE 82157

3100769 11 DEOXYCORTISOL 82634

3100770 CULTURE CHLAMYDIA 87110

3100771 VIT B 2/RIBOFLAVIN 84252

3100772 VIT B 3/NIACIN 84591

3100773 ANTI-MULLERIAN HORMONE 82397

3100774 NICOTINE, BLOOD 80323

3100775 RISPERIDONE/RISPERDAL 80342

3100776 LEFLUNOMIDE 80375

3100777 IMMUKNOW 86352

3100778 BK VIRUS, URINE 87799

3100779 N-TELOPEPTIDE CROSS-LINKS, URINE 82523

3100780 ADENOVIRUS STOOL AG 87301

3100781 CELL CT BODY FLUID 89051

3100782 IBUPROFEN, SERUM/PLASMA 80329

3100783 HEREDITARY HEMOCHROMATOSIS DNA 81256

3100784 CYSTATIN C 82610

3100785 HEP C FIBROSURE 82172

3100786 AMIODARONE LEVEL 80299

3100787 ORGANIC ACID, URINE 83919

3100788 ANTIEXTRACTABLE NUCLEAR ANTIGENS

3100789 MORPHINE 80361

3100790 ANTITHROMBIN III ANTIGEN 85301

3100791 PROTEIN C ANTIGEN 85302

3100792 PROTEIN S ANTIGEN 85305

3100793 ACTIVATED PROTEIN C RESISTANCE 85307

3100794 HTLV 1,2 AB 86790

3100795 RETINOL-BINDING PROTEIN 83883

3100796 TOXOCARA ABS 86682

3100797 TRICHINELLA SPIRALIS AB 86784

3100798 STRONGYLOIDES IGG 86682

3100799 RETICULOCYTE HEMOGLOBIN 85046

3100800 ISOHEMAGGLUTININ TITER 86940

3100801 CALPROTECTIN, FECAL 83993

3100802 HEMOGLOBIN PHYS PRACTICE 85018

3100803 MICROSPORIDIA 87207

3100804 GLUTATHIONE 82978

3100805 COENZYME Q10, TOTAL 82542

3100806 EVEROLIMUS 80169

3100807 ORG ID-FUNGAL 87107

3100808 HIV 1/2 ANTIGEN/ANTIBODY 87389

3100810 LEPTIN 83520

3100811 ADIPONECTIN 83520

3100812 ALLERGEN 29 INHALANTS 86003

3100813 ALLERGEN 56 FOODS 86003

Page 49: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100814 THYROTROPIN RECEPTOR ANTIBODY 83520

3100815 HUNTINGTON DISEASE MUTATION 81401

3100816 ASPERGILLUS FLAVUS PRECIPITATING ABS 86606

3100817 ALKALINE PHOSPHATASE ISOENZYMES 84080

3100818 APOLIPOPROTEIN PANEL 82172

3100819 OMEGA FATTY ACIDS 82725

3100820 PEANUT ALLERGEN 86003

3100821 PEANUT COMPONENT ALLERGEN PANEL 86003

3100823 HEPARIN ANTI-Xa 85520

3100824 HEMOGLOBIN, FREE, PLASMA 83051

3100825 HPV RECTAL SOURCE 87624

3100826 PAP W/ REFLEX TO HPV HR 88175

3100827 CHROMOSOME ANALYSIS 88230

3100828 CHROMOSOME ANALYSIS - ADDITIONAL 88262

3100829 NT-PRO BNP 83880

3100830 COMPREHENSIVE HEALTH PANEL 80050

3100831 CLOZAPINE 80159

3100832 FTA-ABS 86780

3100833 CRYPTOCOCCUS AG SERUM 87899

3100834 FUNGAL ANTIBODIES 86606

3100835 PATHOLOGY DECALCIFICATION 88311

3100836 TESTOSTERONE FREE & TOTAL WOMEN/CHILD 84402

3100837 CORTISOL SALIVARY 82533

3100838 HEP C GENOSURE NS3/4A 87900

3100839 HALDOL 80173

3100840 SEROQUEL 80342

3100841 MACROPROLACTIN 84146

3100842 B2-MICROGLOBULIN, URINE 82232

3100843 ESTRADIOL, FREE AND TOTAL 82670

3100844 ALPHA 1 ANTITRYPSIN PHENOTYPE 82103

3100845 HUMAN EPIDIDYMIS PROTEIN 4 86305

3100846 POTASSIUM, FECES 84999

3100847 TESTOSTERONE, WOMEN/CHILDREN 84403

3100848 COPPER, URINE 82525

3100849 PARANEOPLASTIC ANTIBODIES 86256

3100850 CA 19-9 86301

3100851 ZIKA VIRUS COMP PROFILE 87662

3100852 LEAD PEDIATRIC CAPILLARY 83655

3100853 INSULIN ANTIBODIES 86337

3100854 IFOB CANCER SCREENING G0328

3100855 ZIKA VIRUS IGM 86794

3100856 PLASMINOGEN ACTIVATOR INHIBITOR 1 85415

3100857 PAI-1 4G/5G POLYMORPHISM 81400

3100858 CHROMOGRANIN A 86316

3100859 MYOSITIS PANEL II 86235

3100860 PLATELET ANTIBODY PROFILE 86022

3100861 HEP C QUAL WITH REFLEX TO QUANT 87521

3100862 HEPATITIS A,B PROFILE I 86705

3100863 C1 ESTERASE INHIBITOR 86160

3100864 C1 ESTERASE INH, FUNCTIONAL 86161

3100865 COMPLEMENT C1q, QUANTITATIVE 86160

3100866 BABESIA MICROTI ANTIBODIES 86753

Page 50: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3100867 EHRLICHIOSIS ANTIBODIES 86666

3100868 VALPROIC ACID FREE 80165

3100869 METHADONE PEAK/TROUGH 80358

3100870 INTERLEUKIN-2, PLASMA 83520

3100871 CARNITINE, TOTAL AND FREE 82379

3100872 VIT B5 84591

3100873 MANGANESE, WHOLE BLOOD 83785

3100874 MOLYBDENUM 83018

3100875 COMPLETE TESTOSTERONE EVALUATION 84402

3100876 HEP B QUANTATIVE PCR 87517

3100877 ALPHA-THALASSEMIA, DNA ANALYSIS 81257

3100878 ALPHA GAL IGE 86603

3100879 MYCOPLASMA PNEUMONIAE PCR 87581

3100880 BROMIDE 82542

3100881 HPV HIGH RISK 16/18 87624

3100882 H PYLORI BREATH - PEDIATRIC 83013

3100883 SELENIUM, WHOLE BLOOD 84255

3100884 ASPERGILLUS GALACTOMANNAN ANTIGEN 87305

3100885 B-D-GLUCAN (1,3) 87449

3100886 ALPHA-1 ANTITRYPSIN, FECAL 82103

3100887 INFLIXIMAB/ANTI-INFLIXIMAB AB 80299

3100888 EPI proCOLON 81327

3100889 SOLUBLE TRANSFERRIN RECEPTOR 84238

3100890 HIV-1 QUALITATIVE RNA 87535

3100891 LIPOPROTEIN(a) 83695

3100892 GASTROINTESTINAL PROFILE, STOOL 87507

3100893 EHRLICHIOSIS PROFILE 86666

3100894 14.3.3 eta, RHEUMATOID ARTHRITIS 83520

3100895 BETA HCG (TUMOR SERIAL MONITOR) 84702

3100896 NICKEL, WHOLE BLOOD 83885

3100897 THYROGLOBULIN, COMPREHENSIVE 86800

3100898 VITAMIN B7/BIOTIN 84591

3200001 BB AUTOLOGOUS DONATION 86890

3200002 BB CELL WASHING PER UNI

3200003 BB CRYO REDUCED FFP P9059

3200004 BB CRYOPRECIPITATE EA U P9012

3200005 BB FFP JUMBO UNIT P9017

3200006 BB FRESH FROZEN PLASMA P9017

3200007 BB FROZEN & DEGLYCED RB P9057

3200008 BB GRANULOCYTES P9050

3200009 BB LEUKO REDUCED PLATEL P9031

3200010 BB LEUKO REDUCED PLT WB P9031

3200011 BB LEUKO REDUCED RED CE P9016

3200012 BB PACKED CELLS UNFILTE P9021

3200013 BB PARTIAL COMPONENT PL P9034

3200014 BB PLATELET PHERESIS, LEUKO REDUCED P9035

3200015 BB RED CELLS WASHED P9022

3200016 BB REDUC VOL LR PLT WBD P9035

3200017 BB REDUCED VOL PLATELET P9034

3200018 BB REF HLA A B OR C MA P9052

3200019 BB WHOLE BLOOD P9010

3200020 BB WHOLE BLOOD DERIVED P9010

Page 51: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3200050 VENIPUNCTURE PHYS PRACTICE 36415

3200051 HCG URINE QUAL PHYS PRACTICE 81025

3200052 URINALYSIS AUTO W/O PHYSICIAN PRACTICES 81003

3200053 URINALYSIS NON-AUTOMATED W/O PHY PRAC 81002

3200054 MICROALBUMIN SEMI-QUANT PHY PRAC 82044

3200055 OCCULT BLOOD SCREENING PHY PRAC 82270

3200056 OCCULT BLOOD OTHER PHY PRAC 82272

3200057 GLUCOSE POCT PHYSICIAN PRACTICE 82948

3200058 PROTHROMBIN TIME PHYSICIAN PRACTICE 85610

3200059 STREP SCREEN PHYSICIAN PRACTICE 87880

3200060 FLU A & B PHYSICIAN PRACTICE 87804

3300001 RETIREMENT PHY/FIT FOR DUTY

3300002 ADD IMMUN ADMIN 90472

3300003 ADECCO RAPID DRUG 80100

3300004 AFTER HOURS TESTING

3300005 ASP/INJ INTER JOINT 20605

3300006 ASP/INJ MAJOR JOINT 20610

3300007 ASP/INJ SMALL JOINT 20600

3300008 AUDIOGRAM BASELINE 92553

3300009 AUDIOGRAM OUTPT 92553

3300010 BELTERRA DRUG SCREEN 80101

3300011 BLOOD SUGAR CHECK 82962

3300012 BREATH ALCOHOL CONF

3300013 BREATH SAL/ALCOHOL S 82075

3300014 BURSA DRAINAGE IJ 20605

3300015 BURSA DRAINAGE MJ 20610

3300016 BURSA DRAINAGE SJ 20600

3300017 CALC GLUC EYE IRRIGA 92499

3300018 CALCIUM GLUCONATE IN 96372

3300019 CCBOE BUS DRIVER PE

3300020 CCBOE OTHER STAFF

3300022 CONSULT ER CHRG OCC 99253

3300023 CUSTOM EXAM 99243

3300024 DOW ANNUAL PHE

3300025 DOW PRE-PLACE PHY 97750

3300026 EKG CHRG OCCMED 93005

3300027 EST PATIENT DETAILED 99214

3300028 EST PT COMPREHENSIVE 99215

3300029 EST PT EXPANDED 99213

3300030 EST PT FOCUSED 99212

3300031 EYE RUST RING REMOVE 92499

3300032 FB REM EYE CORNEAL 20520

3300033 FB REM-EYE SIMCONJCT 20520

3300034 FB REMOVAL LID/LASH 67938

3300035 FB REMOVAL SKIN COMP 10121

3300036 FB REMOVAL SKIN SIMP 10120

3300037 FINGER STICK 36416

3300038 FIT TEST

3300039 HAIR SCREEN COLLECT

3300040 HAIR/COLL/MRO/SEN/DR 80104

3300041 HAZMAT

3300042 INCISION & DRAINAGE 10060

Page 52: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3300043 INDUSTRIAL VISIT/HR 99411

3300044 MENOMUNE VACCINATION 90733

3300046 NAIL REMOVAL 11750

3300047 NDI BAT CONFIRMATION

3300048 NDI BREATH ALCOHOL

3300049 NDI DOT PHYSICIAL

3300050 NDI NON DOT PHYSICAL

3300051 NDI U/A SPECI NONDOT 80100

3300052 NDI U/A SPECIMEN DOT 80100

3300053 NO SHOW/NO CALL CHRG 82055

3300054 NP COMPREHENSIVE 99204

3300055 NP COMPREHENSIVE INT 99205

3300056 NP DETAILED 99203

3300057 NP FOCUSED 99201

3300058 OBSERVED URINE DRUG 99199

3300059 OXIMETRY CHECK 94760

3300060 PFT 94010

3300061 PHE LAB

3300062 PNUEMONIA VACC 90669

3300063 PRE WORK ASSESSMENT

3300064 RAPID DRUG SCREEN - 80305

3300065 REP COMP LEG/ARM WOU 13120

3300066 REPAIR INTER UPP BOD 12031

3300067 REPAIR OF NAIL BED 11760

3300068 RESP EXAM USER W/PFT 94010

3300069 RESP FIT TESTING

3300070 RETURN TO WORK T 1 99241

3300071 RETURN TO WORK T 3 99242

3300072 RETURN TO WORK T2 99241

3300073 REVIEW OF RESPIRATOR

3300074 SUTURE 2.5 TO 7.5CM 12002

3300075 SUTURE REMOVAL 99199

3300076 SUTURE TO 2.5CM 12001

3300077 TB SKIN TEST 86580

3300078 TITMUS VISION TEST 99173

3300079 U/A DIP STICK 81000

3300080 UDS COLLECTION ONLY 80100

3300081 UDS/MRO SEND OFF 80100

3300082 URINE SPECIMEN COLL 99000

3300083 VACCINATION MMR 90700

3300084 VACCINE ADMINISTRATI 90471

3300085 CPR INSTRUCTION

3300086 NAS AUDIOGRAM BASELINE 92553

3300088 NAS BREATH ALCOHOL CONF

3300089 NAS BREATH SAL/ALCOHOL S 82075

3300090 NAS CUSTOM EXAM 99243

3300091 NAS RESP EXAM USER W/PFT 94010

3300092 NAS RETURN TO WORK T 3 99242

3300093 NAS RETURN TO WORK T2 99241

3300095 DOW REVIEW OF CHARTS

3300096 BIOMETRIC SCREENING

3300097 STEEL TECH HAIR SCREEN COLLECT

Page 53: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3300099 PMC AUDIOGRAM BASELINE 92553

3300100 PMC BREATH ALCOHOL CONF

3300101 PMC BREATH SAL/ALCOHOL S 82075

3300102 PMC CUSTOM EXAM 99243

3300103 PMC FIT TEST

3300104 PMC RAPID DRUG SCREEN - 80104

3300105 PMC RESP EXAM USER W/PFT 94010

3300106 PMC RETURN TO WORK T 3 99242

3300107 PMC RETURN TO WORK T2 99241

3300109 PMC TITMUS VISION TEST 99173

3300110 PMC UDS/MRO SEND OFF 80100

3300111 PMC PFT 94010

3300112 PMC EKG 93005

3300113 DOW EAR EXAM

3300114 EAR IRRIGATION

3300115 NAS HEPATITIS A VAC 90632

3800001 OBS TELEMETRY 1ST HR

3800002 OBS TELEMETRY ADD HR

4000043 PULM STRESS TEST 6 MIN 94618

4100001 DRESS ALLDRESS 6X6 ALA265349Z

4100002 BLOOD COLLECT PORT 36591

4100003 BLOOD COLLECT VAD 36592

4100004 BLOOD COLLECT VPX 36415

4100005 BLOOD TRANSFUSION 36430

4100006 CATH 10FR PED BRD0165PL10

4100007 CATHETER RED 10F RUBBER KC8410

4100008 CATH 12FR 5CC 0165L12

4100009 CATH 12FR 5CC 0165812

4100010 CATH 12FR 5CC 265712

4100011 CA UROL 12FR COUDE 010112

4100012 CATH 14FR 5CC 0165L14

4100013 CATH 16FR 5CC BRD0119L16

4100014 CATH 16FR 5CC 265716

4100015 CATHETER COUDE 16F DYND11592

4100016 CATH FOLEY 18FR 2WAY 5CC 17060

4100017 CATH 18FR 30CC 0118L18

4100018 CATH 18FR COUDE TIP DYND11593

4100019 CATH 20FR 36C RB 0166L20

4100020 CATH 20FR 3-WAY 5CC 0119L20

4100021 CATH 24F 5CC 3WAY 0119L24

4100022 CATH 24FR 5CC BAL 265724

4100023 CATH 26FR 30C RB 0166L26

4100024 CATH FOLEY 28FR 30CC 0166V28S

4100025 CATH 28FR 5CC BAL 265728

4100026 CA FOL8FR16 4371000808

4100027 CA FOL8FR PED 06200165PL08

4100028 CATH ALL PURPOSE 12F 94120

4100029 CATH ALL PURP 14F DYND13514

4100030 CATH FOLEY 16FR 30CC 0166V16S

4100031 CATH FOLEY 18FR 5CC BRD0165L18

4100032 FOLEY CATH 20F RIB 0102L20

4100033 SECURESTRAP FIXATION DEVICE ETHSTRAP25

Page 54: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100034 CATH 20FR BALOON BRD165L20

4100035 CATH 22F 5CC RB BRD0165L22

4100036 CATH 22FR 3-WAY 5CC 0119L22

4100037 FOLEY CATH 24FR 0166L24

4100038 CATH RED RUBBER 16 SWD660168H

4100039 CATH SUCT DELEE 257469

4100040 CATH SUCT 14F-16F DC12815

4100041 CATH SUCTION 10FR DYND41900

4100042 CATH URETH 16FR DC94160

4100043 TROCAR 12X100 STRT BLADELESS FOGCTF73

4100044 PICC KIT XCELA 5FR H965750031

4100045 TRAP MUCUS DELEE 10FR DYND4411

4100046 COBAN STERILE LF 4 DYNJ089004

4100047 CLEARVUE ISP PORT 1606062

4100048 GREEN THYROID RETRACTOR 8.5 23-3512

4100050 POUCH SURFIT 2 1/4 401508

4100051 POUCH SURFIT 2 3/4 BLUE401509

4100052 POUCH SURFIT 1 3/4 SQU401502

4100053 PROBE HYPER/HYPO DISP DP400CE

4100054 PASTE STOMADHESIVE 183910

4100055 OSTOMY POWDER 1OZ 0255-10A

4100056 STRYKER SOFTCARE OVERLAY

4100057 CATH SUCT 10FR DYND40700

4100058 VAC ATS CANISTER

4100059 VAC ATS THERAPY UNIT

4100060 VAC GRANUFOAM SM

4100061 WAFER SURFIT 1 1/2 ORANGE 125

4100062 WAFER SURFIT FLEX 1.5X 2.25

4100063 WAFER SURFIT 2 1/4 125265

4100064 WAFER SURFIT 2 3/4 BLUE 125266

4100065 WOUND VAC

4100067 SUTURE 1637G CHRO 4-0 PS-2

4100068 SUTURE 1638H CHRO 3-0 PS-2

4100069 SUTURE 1662G ETHI 4-0 PS-4

4100070 SUTURE 1667G ETHI 4-0 PS-2

4100071 SUTURE 1691H ETHI 3-0 PSL

4100072 SUTURE 1915G PLN GUT 5-0 PC-1

4100073 SUTURE 1971-61 SURGILON 0 GS-2

4100074 EYE KNIFE SLIT 2.4 BVS378224

4100075 SUTURE 687G CHRO 5-0 P-3

4100076 SUTURE 8557H PROL 4-0 RB-1

4100077 SUTURE 8682H PROL 4-0 PS-2

4100078 SUTURE 8687 PROL 3-0 PS-2

4100079 SUTURE 8824G PROL 1 TP-1

4100080 SURESITE 123 W/PAD 3.5X10 MSC2610Z

4100081 VIRECTOMY SET ALCON 8065750157

4100082 APPLIED BALLOON TROCAR 12F C07

4100083 SURESITE 123+PAD 4X4.8 MSC2605Z

4100084 ASEPTO SYRINGE DYND20125

4100085 APPLIED A-TRAC C4120 5MM GRASP

4100086 AUTOSUTURE ABSTACK30

4100087 AUTOSUTURE ABSTACK15

Page 55: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100088 AUTOSUTURE OMSTTSS

4100089 AUTOSUTURE TACKER 5MM OMSTTSD3

4100091 APPLIED FOGCD001 RETRIEVAL BAG

4100092 MESH 112640 FLAT SHEET 1X4

4100093 PACK BASIC DYNJP1025

4100094 BASKET STONE 11MM 041415

4100095 BASKET STONE FLAT 045215

4100096 PORT POWERPORT 6FR 1606062

4100100 BOVIE PAD 9165

4100101 BOVIE PENCIL CAUTERY ESPB3002

4100102 BOVIE TEFLON TIP ES0013M

4100103 SUTURE C013D 3-0 SILK C/R

4100104 SUTURE C513D 3-0 NURO SH C/R

4100105 APPLIED CTS02 TROCAR 5X100

4100106 APPLIED C0Q11 TROCAR 5X150

4100107 CATARACT PATIENT CARE KIT 2

4100108 CATH RED RUBBER 16FR

4100109 EYE CELLUGEL 8065183810

4100110 DRAIN HEMOVAC BLAKE 19FR 07219

4100111 CHOLANGIOGRAPHY SET STRANGE G0

4100112 SUTURE 803H CHRO 1 CT

4100113 SUTURE ETHL114G 0 CHR REEL

4100114 SUTURE S111H CHRO 4-0 TIES

4100115 APPLIED A0C03 BOWEL CLAMP 60MM

4100116 CLIP APPLIER ETHMCM20

4100117 CLIP APPLIER 5MM ETHEL5ML

4100118 CLIP APPLIER ETHMCL20

4100119 MESH BARD COLLAMEND 1175102

4100120 COLORADO DISSECTION NEEDLE N10

4100121 COMMON BILE DUCT EXPLORE SET

4100122 MESH COMPOSIX OVAL 6.3 10209

4100123 ETHI CR40B CONTOUR RELOAD BLU

4100124 ETHI CR40G CONTOUR RELOAD GRN

4100125 ETHI STAPLER BLUE ETHCS40B

4100126 ETHI CS40G CONTOUR STAPLER GRN

4100127 COOK PERCUT SUPRA CATH 10FR 08

4100128 CATH COUDE 12F 16IN ME812

4100129 MESH COVIDIEN USUTEM1208GR

4100130 MESH COVIDIEN USUTEM1409GL

4100131 SUTURE CHROMIC GUT ETHG123H

4100132 DART FIRE SCREW 2.5X12MM D2N25

4100133 DART FIRE SCREW 4.0X26MM D1N40

4100134 PICC KIT 5FR DUAL CT RATED MR17035206

4100135 ETHI ECR60G ECHELON RELOAD GRN

4100136 ELECTRODE LAP HOOK ESLAP14

4100137 KITTNER LAPAROSCOPIC APOKT9101

4100138 ENDOLOOP 0PDS ETHEZ10G

4100139 ENTERAL FEEDING TUBE ADAPTER MED

4100140 ENDOLOOP COATED VICRYL ETHEJ10

4100141 ETHI EC60 ECHELON 60 ENDO STAP

4100142 FEEDING TUBE ENDOVIVE 20F M00582080

4100143 FEEDING TUBE ENDOVIVE 22F M00582860

Page 56: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100144 ESMARK BANDAGE 4 X12' DYNJ0591

4100145 TROCAR XCEL 12MMX15MM B12XT

4100146 TROCAR SHARP 12MM ETHICON B12LT

4100147 IV TUBING EXTENSION SET (OR) BMG354220

4100148 PACK EXTREMITY II DYNJS3009

4100150 CATH 18FR 5CC RIB 336-18

4100151 FRED ANTIFOG NONFB100

4100152 CHROMIC GUT G253 USUG253

4100153 GATOR GRASPER STRYKER 0255-000

4100154 APPLIED GEL PORT FOGC8XX2

4100155 GIGLI SAW WIRE 12 NL850

4100156 EYE GRIESHABER 611.75

4100157 PORT GROSHONG 7FR B0603870

4100158 PORT GROSHONG 9.6FR BAR0607555

4100159 HARMONIC ETHICON ETHHAR23

4100160 CATH ALL PURP 18F DYND13518

4100161 HARMONIC ETHHAR36

4100162 EYE HEALON .85 10290953

4100163 HOLLISTER LOOP BRIDGE HL7767

4100164 TUBING INSUFFLATION DYNJ05933

4100165 INSUFLOW HEAT TUBING 6198

4100166 SUTURE J548G 8-0 VICR TG140-8

4100167 SUTURE J682G VICR 4-0 PS-1

4100168 DRAIN JP RESERVIOR SU130-1305

4100169 EYE KNIFE 15 DEGREE B-D378235

4100170 EYE KNIFE 2.85 SLIT B-D378228Z

4100171 EYE KNIFE 3.5 SHORTCUT 99356

4100172 EYE KNIFE CRESENT B-D378234

4100173 MESH 115810 MOD KUGEL MD CIRCL

4100174 MESH 10203 KUGEL SM CIRCLE

4100175 K WIRES .9 1600-35NS

4100176 K WIRES 1.4 DSDS1014

4100177 DRAPE LAPAROTOMY W/POUCH DYNJP3103

4100178 PACK LAP CHOLE DYNJS3046

4100179 PACK LAPAROTOMY IV DYNJP3030

4100180 LENS IO MTA4U170

4100181 LENS MA60AC

4100182 LENS SA60AT

4100183 LENS-SN60WF

4100184 SUTURE VICRYL ANTIBACTERIAL ETHVCP700D

4100185 SUTURE VICRYL PLUS ETHVCP701D

4100186 ETHI TLC10 LINCUT 100MM BLU

4100187 ETHI TLC75 LINCUT 75MM BLU

4100188 ETHI TCT75 LINCUT 75MM GRN

4100189 ETHI TCT10 LINCUT 100MM GRN

4100190 ETHI TL60 LINEAR STAPLER 60MM

4100191 LOOP RECORDER DM2100

4100192 MAXORB ROPE DRESSING 12 MSC70

4100193 CQUR MESH 12.5X12.5 31544

4100194 MESH 112670 FLAT SHEET 2X12

4100195 CQUR MESH 4.3X4.3 31200

4100196 MESH COMP 0134610 6X10 L/P

Page 57: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100197 MESH COMP 4.5 CRCL 0134450 LP

4100198 MESH 0134680 COMPOSIX L/P 6X8

4100199 MESH 0134790 COMPOSIX L/P 7X9

4100200 MESH 0134113 COMPOSX L/P 10X13

4100201 MESH 134114 COMPOSIX L/P 10X14

4100202 MESH 0134460 COMPOSIX L/P 4X6

4100203 MESH 0134810 COMPOSIX L/P 8X10

4100204 MESH 112660 FLAT SHEET 10X14

4100205 MESH 112650 FLAT SHEET 2X4

4100206 MESH 112680 FLAT SHEET 3X6

4100207 MESH 112720 FLAT SHEET 6X6

4100208 MESH KUGEL 3 CIRCLE DVL0115808

4100209 MESH 10202 KUGEL LG OVAL

4100210 MESH 10201 KUGEL SM OVAL

4100211 MESH XLG OVAL 10X13 0010207

4100212 MESH OVAL EPTFE 8X10 0010206

4100213 MESH 10205 KUGEL MD OVAL

4100214 MESH 112700 PRESHAPE 1.8X4

4100215 MESH EXTRA LARGE OVAL DC001020

4100216 MESH 115812 MOD KUGEL LG CIRCL

4100217 PORT GROSHONG 8FR 602850

4100218 MYRINGOTOMY KNIFE

4100219 NASOPORE 4CM STANDARD 5400-10-

4100220 NASOPORE 8CM STANDARD 5400-10-

4100222 OPTIFOAM DRESSING 4X4 MSC2044E

4100223 OPTILOCK DRESSING 4X4 MSC6444E

4100224 OSTOMY CLAMP HOLLISTER 8770

4100225 PACER BATTERY 1876602 5620 C1785

4100226 EYE PACK AS5713

4100227 PACKING STRIP IODOFORM 1X5 NON256015

4100228 PARIETEX COMPOSITE PCO1510OS

4100229 PARIETEX COMPOSITE PCO12

4100230 MESH 10301 VENTRALEX SM CIRCLE

4100231 MESH 10302 VENTRALEX MD CIRCLE

4100232 KIT PULL PEG 20FR BOSTON M0056

4100233 DRAIN PENROSE 1/4 DYND50427

4100234 SUTURE 1824H PLN GUT 4-0 SC-1

4100235 POST OP SHOE M SM ORT30300MS

4100236 PURACOL PLUS 2X2 MSC8622EPZ

4100237 AUTOSUTURE 020242 PURSTRING 65

4100238 PREP TRAY PVP-1 DYND70360

4100239 RANFAC CATHETER XL RFCXL11

4100240 INTROD PERCUT PIN15

4100241 REDDICK SCOUP TIP/INTRO KIT

4100242 ETHI TRT10 LINCUT RELOAD 100GR

4100243 ETHI TCR10 LINCUT RELOAD 100BL

4100244 ETHI TCR 75 LINCUT RELOAD 75 B

4100245 ETHI TRT75 LINCUT RELOAD 75GRN

4100246 SUTURE ETHILON 4/0 ETH626H

4100248 ETHI TR60 LINEAR STAPLER RELOA

4100249 SUTURE MERSILENE GREEN 5/0 ETH740G

4100250 MALONEY DILATOR 56F BOUGIE PWK507956

Page 58: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100251 SALUTE18CM 30 IMPLAN

4100252 SALUTE38CM 30 IMPLAN

4100253 SALUTE38CM 60 IMPLAN

4100254 ETHICON ENDOPATH LAPAROSCOPIC SCISSORS

4100255 APPLIED CB040 LAP SCISSORS

4100256 APPLIED C3101 SEAL SCOPE WARM

4100257 SUTURE O VICRYL ETHJ701D

4100258 CYSTO BLADDER IRR 07062C4040

4100259 SILVASORB DRESSING MSC9340EPZ

4100260 PACK SINGLE BASIN DYNJ06400

4100261 SUTURE VICRYL 0 ETHJ727D

4100262 DRAPE SPLIT DYNJP2498

4100263 ETHI ECS25 EEA STAPLER 25MM

4100264 ETHI ECS25 EEA STAPLER 29MM

4100265 ETHI ECS33 EEA STAPLER 33MM

4100266 SKIN STAPLER ETHPXW35

4100267 STAPLER SINGLE USE 092001

4100268 OSTOMY SYSTEM CENTERPT 4 3706

4100269 INSUFFLATION TUBING STRYKER SKE620030407

4100270 CANNISTER SUCTION 2000 BXT6565

4100271 SUTURE VICRYL ETHVCP662H

4100273 SURGIFOAM ETH1972

4100274 STRYKER SURGILAV 207-553ST

4100275 CATH STRAIGHT TROC 28F 88-5705

4100276 CATH TROCAR 36 FR 88-570564

4100277 SUTURE 2-0 VICR X-1 ETHJ459H

4100278 SUTURE ETHY227H 2-0 MONO MH

4100279 SUTURE PROLENE ETH8424H

4100280 SUTURE CHROMIC 802H

4100281 SUTURE 1673H ETHI 3-0 FSLX

4100282 SUTURE Y334H 0 MONO CT-2

4100283 SUTURE 2-0 MONO SH ETHY317H

4100284 SUTURE ETHY318H 0 MONO SH

4100285 SUTURE Y333H 2-0 MONO CT-2

4100286 SUTURE MONOCRYL ETHY352H

4100287 SUTURE Y415H MONO 4-0 SH

4100288 SUTURE NURO 0 CT-1 ETH5424H

4100289 SUTURE PROLENE 8623H

4100290 SUTURE 8832H PROL 3-0 SH

4100291 SUTURE 8833H PROL 2-0 SH

4100292 SUTURE 8684H PROL 3-0 FS-1

4100293 SUTURE A305H 2-0 SILK TIES

4100294 SUTURE A306H 0 SILK TIES

4100295 SUTURE K832H SILK 3-0 SH

4100296 SUTURE K833H SILK 2-0 SH

4100297 SUTURE K834H SILK 0 SH

4100298 SUTURE SILK 0 MH ETHK844H

4100299 SUTURE SILK 2-0 TIES ETHSA65H

4100300 SUTURE J259H 2-0 VICR CT-1

4100301 SUTURE J269H VICR 2-0 CT-2

4100302 SUTURE J310 4-0 VICR SH-1

4100303 SUTURE J316H VICR 3-0 SH

Page 59: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100304 PACKING STRIP IODOFORM 2X5 NON256025H

4100305 SUTURE 0 VICR CT-1 ETHJ340H

4100306 SUTURE J341H VICR 1 CT-1

4100307 SUTURE J603H VICR 0 UR-6

4100308 SUTURE J615H VICR 2-0 TIES

4100309 SUTURE J616H VICR 0 TIES

4100310 SUTURE Y909G MONO 2-0 TIES

4100311 SUTURE MONO 0PDS ETHZ340H

4100312 ENDOSUTURE SW120 ETHSW120

4100313 ENDOSUTURE SW122 ETHSW122

4100314 T TUBE 16 FR BRD0099830

4100315 TAUT CHOLANGIOCATH 20018-010

4100316 STOCKING TED HIGH SM-LG LF

4100317 DRESSING AMD ISLAND 4X5 KDL766

4100318 THD SLIDE ONE KIT 800070

4100319 SUTURE VICRYL 0 ETHJ280H

4100320 CATH TROCAR 32F 388-561076

4100321 APPLIED TROCAR SHARP 5X100 FOGCTB03

4100322 TROCAR 5MM XCEL ETHICON B5XT

4100323 ETHI H12LP TROCAR HUSAN 12MM

4100324 APPLIED FOGC0R47 TROCAR 12X100

4100325 CATH TROCAR 10FR 88-561019

4100326 CATH TROCAR 12 FR 88-561027

4100327 CATH TROCAR 24 FR 88-561050

4100328 CATH TROCAR 8FR 88-560805

4100329 CATH TROCAR 20 FR 88-561043

4100330 APPLIED CTF03 TROCAR 5 OBTR

4100331 APPLIED C0Q05 TROCAR5X150 OBTR

4100332 NEEDLE BIOPSY 14G TRU-CUT 2N27

4100333 AIRWAY TUB DISP. KLTD204

4100334 SUCTION IRRIGATOR STRYKEFLOW SKE02500705

4100335 SUCTION TUBING STERILE DYND50252

4100336 SUTURE U10T UMBILICAL TAPE

4100338 MESH 10303 VENTRALEX LG

4100339 VERESS NEEDLE ETHUV120

4100340 HOTLINE WARMING SET LVLL70H

4100341 DRAIN JP FLAT KIT BXTSU1301360

4100342 SUTURE Y427H MONO 3-0 PS-2

4100343 SUTURE Y496G 4-0 MONO PS-2

4100344 SUTURE Y907G MONO 4-0 TIES

4100345 SUTURE Y910G MONO 0 TIES

4100346 SUTURE J493 5-0 VICR P-3

4100347 SUTURE Z463G 5-0 PDS P-3

4100348 SUTURE J496 4-0 VICR PS-2

4100349 SUTURE ETHILON 10-0 CS160-6 90

4100350 SUTURE 706G SILK 6-0 CV-1

4100351 SUTURE PERMAHAND FS2 5-0 682G

4100352 SUTURE 683G 4-0 SILK FS2

4100353 AIRWAY KING SZ 3 KNGKLTD203

4100354 COOK CATH NEEDLE TRANSTRACHEAL

4100355 ANST EPIDURAL TRAY BMG332221

4100356 SUTURE LIGAPAK VICRYL ETHJ286G

Page 60: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100357 ANST KING BREATH CIRCUIT

4100358 ETHICON ENDOPATH LINEAR CUTTER ETHATB35

4100359 ANST AIRWAY LARANG TUBE DISP KLTD20

4100360 LMA FASTRACH SIZE 3 135230

4100361 ANST LMA FASTRACH SIZE 4 135240

4100362 LMA FASTRACH SIZE 5 HUD135250

4100363 ANST LMA UNIQUE PLUS SZ 3 LMA128030

4100364 LMA UNIQUE PLUS SZ 4

4100365 ANST LMA UNIQUE PLUS SIZE 5 LMA128050

4100366 SPINAL TRAY 27G P27LK

4100367 HOTLINE WARMING SET PTX0L370H

4100368 ENDO MBL-6 6-SHOOTER

4100369 ENDO BALLOON ESOPH CRE 5837

4100370 ENDO CONMED HOT BIOPSY CND0008

4100371 KIT PULL PEG PONSKY 20F 000330

4100372 STAPLER ECHELON FLEX ETHEC45A

4100373 ENDO SCLEROTHERAPY NEEDLE 25G

4100374 KING AIRWAY SZ 2 KNGKLTD202

4100375 ENDO PUSH PEG KIT 24F M0056675

4100376 ENDO SNARE CONMED CND00460

4100377 SPECIMEN TRAP DYND44180

4100378 5060-05 INTEGRATED INFLATION

4100379 BINDER ABD 12 4-PANEL SM/MD

4100380 BINDER ABD 12 4 PANEL LARGE

4100381 BINDER ABD 12 4 PANEL MD/LG

4100382 BINDER ABD 12 4-PANEL XLG

4100383 BINDER ABD 12 4-PANEL XXLG

4100384 SUTURE 684H SILK 3-0 FS-1

4100385 ACE WRAP 2 MDS077002Z

4100386 ACE WRAP 3 MDS077003Z

4100387 ACE WRAP 4 MDS077004Z

4100388 ACE WRAP 6 MDS077006Z

4100389 CANNISTER SUCTION 800CC 424410

4100390 ECHELON FLEX POWERED STAPLER 35MM

4100391 STAPLER RELOAD BLUE 45MM ETH6R45B

4100392 ETHICON ENDOPATH LINEAR CUTTER ETHATS45

4100393 EYE SIDEPORT KNIFE ALCON

4100394 ZIMMER DISPOSABLE TOURNIQUET 24 NO SLEE

4100395 ZIMMER DISPOSABLE TOURNIQUET 34

4100396 TUBE SHILEY SZ 6 6DIC

4100397 NASAL CANNULA HCS4514

4100398 ZIMMER DISPOSABLE TOURNIQUET 18

4100399 SUTURE J427 3-0 VICR

4100400 CANNULA INTERTRACH DISP 8DIC

4100402 CA FOL14FR 5CC KC1614

4100403 CATHETER COUDE 14FR KDL8403

4100404 CATH COUDE 16F 5CC KC1516C

4100405 CATH COUDE 18F 5CC KDL1618C

4100406 DRAPE MAGNETIC SURGICAL

4100407 SUTURE 1916G PLN GUT 6-0 PC-1

4100408 CATH 8FR FEMALE DYND10805

4100409 STERILE SLEEVE

Page 61: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100410 MEDEX 6IN POUR SPOUT WITH SPIKE

4100412 CATH FOL 18F 3W RSH173830180

4100413 CA FOL18FR 5CC 556817060518

4100414 FOLEY CATH 22F 06200166L22

4100415 CATH ALL PURP 10F 06200094100

4100416 CATH FOL SIL 16F5CC 0620033616

4100417 CENTRAL LINE MULT LUM 7F ARWCDC457031A

4100418 SUTURE VICRYL 3.0 ETHJ416H

4100419 CATH STRT THOR 32FR 88-570556

4100420 LENS-AU00T0

4100421 SUTURE ETHIBOND ETHCX21D

4100422 SUCTION CATH 14FR DYND40982

4100423 SUTURE VICRYL 3-0 FS-2 ETHJ423H

4100424 CATH TIEMAN 18F BRD0102L18

4100425 CATH TROCAR 16F 88-561035

4100426 SUTURE VICRYL PS-2 ETHJ426H

4100427 CA URETHRAL 18F DC9418

4100428 CAUTERY PEN LOW TEMP ESCT000

4100429 COBAN STERILE 1 MDS089001

4100430 COBAN DRESSING 2 MDS086002

4100431 COBAN DRESSING 3 MDS086003

4100432 COBAN WRAP 4X5 MDS086004

4100433 CVC KIT 7F TRPL LUMEN M3720HKI

4100434 PEDI CAP CO2 NPBPEDICAP

4100436 DRESS COMFEEL EXUDERM 4X4 MSC5200

4100437 DRESS PK STR/IDO 1 NON256015

4100438 PACKING IODOFORM 1/2 NON256125

4100439 PACKING IODOFORM 1/4 NON256145

4100441 DRESS POLYMEM 4X4 FER5044

4100442 DRESSING TELFA 3X4 NONADH NON25710Z

4100443 DRESSING VARI 1/2X3 43815030

4100444 DRESSING CALCIUM ALGINATE

4100445 DRESSING FIBRACOL PLUS ROPE MSC861X8EPZ

4100446 ELECTRODE PHILIPS DEFIB ADLT/PED DEFM371

4100447 CAUTERY PEN HIGH TEMP

4100448 TRAY IRRIGATION DYND20302

4100449 ARTERIAL BLOOD SAMPLE KIT PTX4699P1

4100450 SUTURE ETHIBOND 0 M06 NEEDLE ETHCX45D

4100451 CATH NEO SPECIMEN DYND10820

4100452 CENT VENOUS CATH PED ARWAK2240

4100453 ARTFLEX 10CM X 3M

4100454 ETHICON ECHELON RELOAD BLUE 45MM ETHECR

4100455 PERCUT SHEATH INTRO 8.5 09804

4100456 LACERATION TRAY DYNJ03014

4100457 ARTFLEX 15CM X 3M

4100458 COMPRILAN 4CM X 5M

4100459 KIT LUMBAR PUNC 18G DYNJTS4301

4100460 KIT LUMBAR PUNCTURE 4302C

4100461 COMPRILAN 6CM X 5M

4100462 KIT PARACENTESIS 88-568006

4100463 COMPRILAN 8CM X 5M

4100464 COMPRILAN 10CM X 5M

Page 62: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100465 KIT THORACENT KDL5016H

4100466 COMPRILAN 12CM X 5M

4100467 TRICOFIX E6

4100468 TRICOFIX F7

4100469 TRACH TRAY CLN DYND40582

4100470 TRICOFIX G9

4100471 LENS DELIVERY SET

4100472 LENS IOL THERAPY

4100473 NASAL MASK LARGE WIDE 312104

4100474 MEDIUM NASAL MASK 312105

4100475 NASAL MASK SMALL RESPIRONICS

4100476 HYDROCERIN CREAM

4100477 METER PEAK FLOW 1SZ HCSPF100

4100478 PACKING NASAL MEROCEL 440402

4100479 NEBULIZER ADULT HUD1883

4100480 NEEDLE HUBER 20 INFSET 0102010

4100481 NEEDLE HUBER 20GX1 BMG585114

4100482 NEEDLE HUBER 22 INFSET 0102210

4100483 MASK SIMPLE OXYGEN 0707001201

4100484 KIT OB PACK 29740CE

4100485 KOMPREX BINDE

4100486 EZ-IO STABILIZER DRESSING

4100487 PACKING STRIP AMD 1/4 KDL7831A

4100488 PACKING STRIP IODO AMD KDL7832

4100489 LENS SN:4289951608

4100490 LENS SN:8707081610

4100491 PACKING STRIP PLAIN 1/2 KDL7632

4100492 PAD DEFIB LITTMAN MMM2345NZ

4100494 PAD TEMPERATURE THER

4100495 PED AMBU BAG

4100496 SUTURE MONOCRYL 4/0 ETHY494G

4100497 PLEUR-EVAC PLUS A-9250 LF (DEKA9250LF)

4100498 POUCH COLOSTOMY 126600

4100499 IOL TECNIS ZCB00 20.5

4100500 POUCH SURFIT DRAIN 10 1 1/2

4100501 POUCH SURFIT DRAIN 10 1 3/4

4100502 LINEAR CUTTER RELOAD 55MM ETHSR55

4100503 STAPLER RELOAD BLUE 60MM ETHXR60BX

4100504 SYMPHONY LENS SN:ZXR00U0200

4100505 LINEAR CUTTER 55MM ETHNTLC55

4100506 PORT POWERPORT MRI 8FR BAR1808001

4100507 SUTURE VICRYL 2-0 SH NEEDLE J417H

4100508 SUTURE VICRYL 2-0 CR SH NEEDLE J775D

4100509 AMBU BAG ADULT CPRM1116

4100510 SCD LARGE KNEE MDS601LD

4100511 SCD MEDIUM KNEE MDS601MD

4100512 SCD KNEE HOSE XL MDS601BD

4100513 ETHICON TORQUE WRENCH ETHTLB01

4100514 SCD SM KNEE MDS601PD

4100515 IV TUBING SECONDARY BHL2C7462

4100516 OXISENSOR D 25 4130000D25

4100517 OXISENSOR I-20 NPBI20

Page 63: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100518 OXISENSOR D-20 NPBD20

4100519 OXISENSOR N-25 NPBN25

4100520 ETHICON TROCAR BLADED 5MMX100 ETHD5LT

4100521 INTERLIN EXT W/CTRL 07062C6890

4100522 SHOE POST OP F MD ORT30300WM

4100523 ETHICON TROCAR BLADED 11MMX100 ETHD11LT

4100524 ETHICON TROCAR BLADED 12MMX100 ETHD12LT

4100525 SHOE POST OP M/M D2007-03

4100526 ENDOPATH XCEL TROCAR SLEEVE ETHCB5LT

4100527 ENDOPATH XCEL TROCAR SLEEVE ETHCB11LT

4100528 SLEEVE LG 5329 KNEE MDS601LD

4100529 SLEEVE LG 5489 KNEE

4100531 SPONGE EXCILON 4X4 AMD KDL7088

4100532 SUTURE SILK 2-0 ETHC012D

4100534 STAPLER PRECISE MMMDS15

4100535 STOCKING KNEE LG RG MDS160664

4100536 ADULT CO2 CANNULA 009822 SAMPLING SET

4100537 STOCKING KNEE MD RG MDS160644

4100538 STOCKING KNEE SM RG MDS160624

4100540 STOCKING KNE XL LNG MDS160688

4100541 STOCKING TED KNEE XLG REG 7604

4100545 SCROTAL SUPPORT LRG

4100547 STRIP PKG PLAIN 1/4 NON255145

4100548 STYLET ENDO 10F MLK85864

4100549 STYLET ALUMINUM 14F MLK85865

4100550 STYLET ENDO PED 06F 4130085863

4100551 CATH 12FR SUC 3583031279

4100552 CATHETER SUCT 18F KC37724

4100553 DRESSING KERLIX AMD KC6662

4100556 STOCKING TED THIGH MED-REG LF

4100557 STOCKING TED THIGH MED-LONG LF

4100558 SCROTAL SUPPORT XXL

4100559 STOCKING TED THIGH SM-REG LF

4100560 TEMPERATURE THER PAD TP12E

4100562 SYRINGE TOOMEY DYND70642

4100563 KIT TRACH CARE 12 220135

4100564 TRACH SHILEY 413004DFEN

4100565 SINGLE TRANSDUCER PX272

4100566 ANST TRIPLE TRANSDUCER KIT PX3X3272

4100568 FOLEY CATH TRAY 16F DYND160416

4100569 FOLEY CATH TRAY 18F DYND160418

4100570 TRAY DRESS CHANGE DYND75230

4100571 TRAY CATH ADD FOLEY DYND11820

4100577 TUBE SHILEY UNCUFF MLK6CFS

4100578 KANGAROO FEEDING BAG SWD773656

4100579 FEED TUBE 18FR 0612000256

4100580 TUBE FEEDING DOBBHOFF 12FR

4100582 TUBE SALEMSUMP10F SWD264911

4100583 SALEM SUMP 14F SWD264945

4100584 SALEM SUMP 16F SWD264960

4100585 SALEM SUMP 18F SWD264986

4100587 TUBE SHILEY 10LGT

Page 64: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100588 TRACH SHILEY MLK6DCT

4100589 TUBE SHILEY 6LPC

4100590 TUBE SHILEY 8DCFS

4100591 TRACH SHILEY MLK8PERC

4100592 TUBE SHILEY 8LGT

4100593 TUBE SHILEY MLK8LPC

4100595 TUBE TRACH 6 UNCUFF MLK86229

4100596 UNNA BOOT 3X10 STRETCH ELASTIC

4100597 UNNA BOOT 4X10 NONUNNA4

4100598 UNNA BOOT 3X10 NONUNNA13

4100599 UNNA BOOT 4X10 STRETCH ELASTIC

4100600 FORCEP POLYGRAB TRIPOD OLYMPUS FG-600U

4100601 WEBRIL UNDERCAST PADDING KDL2502

4100602 REACHER/GRABBER

4100603 SOCK AIDE

4100604 WEBRIL UNDERCAST PADDING 2IN DYNJ066002H

4100606 WAFER SUR FIT NATURA 1 1/2

4100607 WAFER SUR FIT NATURA 1 3/4

4100608 MASK ADULT AEROSOL HCS4630

4100609 ST BIPAP CIRCUIT 003769

4100610 MASK BIPAP FULL FACE LG RT040L

4100611 MASK BIPAP FULL FACE RT040-M

4100612 MASK BIPAP FULL FACE RT040-S

4100615 FLUTTER DEVICE IS-370-02

4100616 HUMIDIFIER 350ML HCS00350

4100617 KIT HUMID 500ML/CLEAN ADAPTER

4100618 HUMIDIFIER PREFILLED 371-0352

4100620 CANNULA NASAL 25FT HCS4515B

4100621 NEBULIZER CAP 1000ML 01770

4100623 MASK NONREBREATH AD HUD1935

4100624 OPTICHAMBER HCSA100

4100625 OXYMIZER PENDENT CANNULA IVOP224

4100627 POCKET SPACER 620-110

4100628 SHILEY XL 8.0 MLK80XLTIN

4100629 TUBE TRACH 7XL CUFF PROX MLK70

4100630 TUBE TRACH 8XL CUFF PROX MLK80

4100631 TRACH INNER CANULA 6XL MLK60XL

4100632 TRACH KIT 6XL MLK60XLTUP

4100633 VENTILATOR CIRCUIT ADT 01627

4100634 VENTILATION CIRCUIT GMCL599190

4100635 PACK DOUBLE BASIN DYNJS0132

4100636 ORTHO GLASS 1 SCSOG1L2

4100637 SPLINT ORTHOGLASS 2 SCSOG2L2

4100638 SPLINT ORTHOGLASS 3 SCSOG3L2

4100639 SPLINT ORTHOGLASS 4 SCSOG4L2

4100640 SPLINT ORTHO GLASS 6 SCSOG6L2

4100641 CIRCUIT PASSIVE ADULT 1073228

4100642 ENDO BRONCH BRUSH

4100644 FLEXIBLE TRACH ADAPTER 1073904

4100645 ENDO CONMED BIOPSY CND000389

4100648 LENS IOL THERAPY MQMT2000

4100649 STERI-STRIP 1/2 MMMR1547Z

Page 65: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100650 STERI-STRIP 1/4 MMMR1546Z

4100651 STERI-STRIP 1/8X3 MR1540

4100653 CRICOTHROTOMY CATH 600SPOPS

4100654 DELUXE A-LINE SUPPORT RC95985

4100655 SUTURE VICRYL 4-0 ETHJ507G

4100656 REMOVER STAPLE DYNJ04058

4100658 CENTRAL LINE DRESS TRAY DYND75221

4100659 DRESS PETROLATUM WHITE 1X8 CUR251180Z

4100660 CANNULA NASAL INFANT FPYBC274520

4100661 CANNULA NASAL PED 002602

4100662 OXISENSOR PEDIATRIC MASIMO0600

4100663 OXISENSOR ADULT MASIMO 0600-00

4100664 CATH SUCT RR 14F DYND40992

4100665 EASY CAP CO2 NPBEASYCAP6

4100666 DRESSING ADAPTIC 3X8 J-J2015Z

4100667 DRESSING NONADHERING 3X3 KDL6112Z

4100668 BLADE SCALPEL 10 B-D372610Z

4100669 BLADE SCALPEL 11 B-D372611Z

4100670 BLADE SCALPEL 15 B-D372615Z

4100671 SUTURE CHROMIC GUT ETH1635G

4100672 SUTURE ETH 4-0 FS-2 ETH662G

4100673 SUTURE ETHILON 3-0 BLK

4100674 SUTURE ETHILON 2-0 BLK ETH664G

4100675 SUTURE ETHILON 6-0 BLK ETH697G

4100676 SUTURE ETHLON 3-0 ETH1663G

4100677 SUTURE ETHLON4-0 18 699G P-3

4100678 SUTURE ETHLON 5-0 18 1865G

4100679 SUTURE ETHLON5-0 18 ETH698G

4100680 SUTURE ETH5-0 18CLR 690G

4100681 SUTURE ETHILON 6-0 P3 ETH1698G

4100682 SUTURE ETH6-0 18CLR 689G

4100683 SUTURE PLN 5.0 ETHH820G

4100684 SUTURE PROLENE 3-0 8926H

4100685 SUTURE PROLENE 6-0 P-3 8695

4100686 SUTURE PROLEN4-0 18 8682G

4100687 SUTURE PROLEN4-0 18 ETH8699G

4100688 SUTURE VICRYL 5-0 ETHJ506G

4100689 SUTURE VICRYL4-0 18 ETHJ507G

4100690 SUTURE 4-0 GUT CHROMIC G1798

4100691 DRESS VAS GAU 3X9 CUR251390Z

4100692 MASK NONREBREAT PED SAL-1130

4100693 TRACH SHILEY MLK4CFS

4100695 SUTURE ETHILON 7-0 BK ETH1696G

4100696 SUTURE VICRYL 6-0 ETHJ510G

4100697 SUTURE J219 VICR 3-0 SH-1

4100698 EPI-MAX DRESSING DUS0404BX

4100699 RAPID RHINO NASAL PACK 7.5 RR7

4100700 RAPID RHINO NASAL PACK 5.5 RR5

4100701 EPISTAXIS BALLOON CATH 890911

4100704 BAG DRAINAGE CATHETER 2000ML

4100705 OXYMIZER CONSERVING SUBCDO224

4100706 COVIDIEN MESH PCO2015OS

Page 66: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4100708 SUTURE ETHILON P3 4-0 ETH691G

4100709 PLAIN GUT SUTURE P3 ETH1644G

4100711 WARMGEL TRANSWRM INFANT 20421

4100712 CATH FOLEY 20FR 2W 5CC 0165L20

4100713 ETHI ECR60B ECHELON RELOAD BLU

4100714 SUTURE 8623H PROL 2-0 KS

4100715 CAFOL 16FR 5CC 06200196L16

4100716 CA FOL16FRCOUD 5CC BRD0102L16

4100717 CATHETER FOLEY 3WAY 18FR 06200119L18

4100718 CATH 16FR 5CC RSH17060516

4100719 LENS MN60AC

4100721 TRAY THROA/PARA BXTTPT1000H

4100722 TAMPON NASAL MEROCEL 3458

4100723 NEEDLE HUBER 20G BMG585112

4100724 NEEDLE HUBER 20X1.5 BMG573116H

4100725 NEEDLE HUBER 22G BMG583114

4100726 ELECTRODE DEFIB PED DEFM3717A

4100728 POSTOP SHOE MALE SM VINYL/VEL

4100729 POSTOP SHOE MALE LG VINYL/VEL

4100730 STOCKING THIGH M RG 3583003416

4100731 PARTIAL REBREATHER

4100733 PEAK FLOW

4100734 OXYGEN TUBING

4100735 BIPAP CIRCUIT

4100736 AEROSOL TUBING

4100737 IS DEVICE (FLOW METER)

4100738 SUCTION KIT

4100739 VENTI MASK

4100740 NONREBREATHER 001201

4100741 25 FT CANNULA

4100742 SUTURE CHROMIC GUT 3-0 ETHG122H

4100743 CONMED MEDIUM OVAL SNARE CND000462

4100744 LARIAT SNARE 00711119

4100774 SUTURE VICRYL 3-0 ETHJ774D

4100806 APPLIED ENDO CLIPPER FOGCA090

4100807 APPLIED TROCAR 5X100 FOGCFF03

4100808 SALEM SUMP 8FR SWD268086

4100809 LENS-SA60WF

4100821 EXTREMITY PACK DYNJS0821

4100823 SUTURE VICRYL 4-0 ETHJ823G

4100824 SUTURE MONOCRYL 4/0 ETHY823G

4100825 20G EPIDURAL TRAY 20205

4100826 22G NERVE BLOCK TRAY 30509

4100864 SUTURE VICRYL UNDYED ETHJ864D

4100873 SUTURE PLAIN GUT 3/0 ETH873H

4100889 SUTURE PROLENE 5-0 30 ETH8890H

4100970 SUTURE PROLENE 4-0 30 ETH9706H

4100990 SUTURE PDS II MONO ETHZ990G

4100991 SUTURE PDS 0 ETHZ991G

4101002 APPLIED CHOLANGIOGRAM CATH FOGC1002

4101630 SUTURE PLAIN GUT 3-0 PS-2 ETH1630H

4101640 SUTURE PLAIN GUT 3-0 PS-1 ETH1640H

Page 67: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

4102100 SUTURE 0 SILK CT-1 ETHC021D

4102870 SUTURE VICRYL 0 REEL ETHJ287G

4103200 LIGACLIP ROTATING 10MM ETHER320

4103500 ETHICON LINEAR RELOAD ETHTR35B

4103501 STAPLER SKIN ETHPMW35

4105220 ENDOPATH BABCOCK 5MM ETH5BB

4105221 DISSECTOR ENDOSCOPIC MARILYN 5MM

4105442 AMBU BAG NEO/INF AMB544216069

4107400 SUTURE VICRYL ETHJ740D

4107777 DELIVERY SET 8065977773

6100001 CHEST SPECIAL VIEWS 71035

6100002 FINGERS MIN 2 VWS RT 73140RT

6100003 FLUORO UP TO 1 HOUR 76000

6100004 LOW EXT INFANT 2V RT 73592RT

6100005 THORACIC COMP MIN 4 VIEWS 72074

6100006 AAS FLT/UP/DECUB W/PA CXR 74022

6100007 ABDOMEN AP ONLY 74018

6100008 AC JNTS BIL W & W WT 73050

6100009 ANKLE AP & LAT LT 73600LT

6100010 ANKLE AP & LAT RT 73600RT

6100011 ANKLE MIN 3 VWS LT 73610LT

6100012 ANKLE MIN 3 VWS RT 73610RT

6100013 BONE AGE STUDY 77072

6100014 BONE LENGTH STUDY 77073

6100015 BONE SURVEY COMPLETE 77075

6100016 BONE SURVEY INFANT 77076

6100017 OSSEOUS SURVEY LIMITED 77074

6100018 C ARM > 1 HR 76001

6100019 C ARM BLCK/SPNL GUID 77003

6100020 C ARM FLURORO UP TO 76000

6100021 C ARM PACEMAKER EXTE 71090

6100022 C ARM PACEMAKER INTE 71090

6100023 SPINE CERVICAL 1 VIEW 72020

6100024 SPINE CERVICAL COMP FLX/EXT 72052

6100025 SPINE CERVICAL MIN 4 VIEWS 72050

6100026 CALCANEUS MIN 2 V L 73650LT

6100027 CALCANEUS MIN 2 V R 73650RT

6100028 CHEST 1 VIEW 71045

6100029 CHEST 2 VW W APICAL 71046

6100030 CHEST 2 VW W OBLIQUE 71048

6100031 CHEST MIN 4 VWS 71048

6100032 CHEST PA AND LAT 71046

6100033 CHOLANGIO/PANCREAT OPERATIVE 74300

6100034 CLAVICLE COMPLETE LT 73000LT

6100035 CLAVICLE COMPLETE RT 73000RT

6100036 EEG AWAKE AND ASLEEP 95819

6100037 EEG AWAKE AND DROWSY 95816

6100038 EEG GREATER 1 HOUR 95813

6100039 EEG MONITOR 41-60MIN 95812

6100040 ELBOW AP & LAT LT 73070LT

6100041 ELBOW AP & LAT RT 73070RT

6100042 ELBOW COMP 3 VWS LT 73080LT

Page 68: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6100043 ELBOW COMP 3 VWS RT 73080RT

6100044 EVAL ORALPHA SWALLOW 92610GN

6100045 EYE FOREIGN BODY DET 70030

6100046 F/B XRAY CHILD 1VIEW 76010

6100047 FACIAL BONES MIN 3 V 70150

6100048 FACIAL BONES UNDR 3 70140

6100049 FEMUR AP & LAT LT 73552LT

6100050 FEMUR AP & LAT RT 73552RT

6100051 FINGERS MIN 2 VWS LT 73140LT

6100052 FLEX F-OPT ENDO EVAL 9261259

6100053 FLUORO MORE THAN 1 H 76001

6100054 FLUORO LOC NEEDLE/CATH SPINE 77003

6100055 FOOT AP & LAT LT 73620LT

6100056 FOOT AP & LAT RT 73620RT

6100057 FOOT COMP 3 VWS LT 73630LT

6100058 FOOT COMP 3 VWS RT 73630RT

6100059 FOREARM AP & LAT LT 73090LT

6100060 FOREARM AP & LAT RT 73090RT

6100061 HAND 2 VWS LT 73120LT

6100062 HAND 2 VWS RT 73120RT

6100063 HAND MIN 3 VWS LT 73130LT

6100064 HAND MIN 3 VWS RT 73130RT

6100065 HIP UNILAT W/PELVIS 1 VIEW LT 73501LT

6100066 HIP UNILAT W/PELVIS 1 VIEW RT 73501RT

6100067 HIP LT UNILAT W/PELVIS 2-3 VIEWS 73502LT

6100068 HIP RT UNILAT W/PELVIS 2-3 VIEWS 73502RT

6100069 HUMERUS MIN 2 VWS LT 73060LT

6100070 HUMERUS MIN 2 VWS RT 73060RT

6100071 UROGRAM (IVP) W/ OR W/O TOMO 74400

6100072 KNEE 2 VWS LT 73560LT

6100073 KNEE 2 VWS RT 73560RT

6100074 KNEE 3 VWS LT 73562LT

6100075 KNEE 3 VWS RT 73562RT

6100076 KNEE LT 4 OR MORE VWS 73564LT

6100077 KNEE RT 4 OR MORE VWS 73564RT

6100078 SPINE LUMBAR 3 VIEWS 72100

6100079 SPINE LUMBAR 2 VIEWS 72100

6100080 SPINE LUMBAR BEND ONLY 2 OR 3 VIEWS 72120

6100081 SPINE LUMBAR W/BENDING MIN 6 VIEWS 72114

6100082 LOW EXT INFANT 2V LT 73592LT

6100083 MANDIBLE MIN 4 VWS 70110

6100084 MANDIBLE PARTIAL <4 70100

6100085 MASTOIDS COMP MIN 3 70130

6100086 NASAL BONES MIN 3 VW 70160

6100087 NO SHOW FEE RAD 76499

6100088 ORBITS COMP MIN 4 VW 70200

6100089 PACEMAKER INSERT FLU 71090

6100090 PEL/HIP IN/CHILD 2V 73502

6100091 PELVIS AP ONLY 72170

6100092 PELVIS TWO VIEWS 72170

6100093 PYELOGRAM INFUSN DRI 74410

6100094 RIBS UNI LT 3V W/CXR 71101LT

Page 69: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6100095 RIBS UNI RT W/PA CXR 71101RT

6100096 RIBS UNILAT LT 2 VWS 71100LT

6100097 RIBS UNILAT RT 2 VWS 71100RT

6100098 SACRUM & COCCYX MIN 72220

6100099 SCAPULA COMPLETE LT 73010LT

6100100 SCAPULA COMPLETE RT 73010RT

6100101 SCOLIOSIS 2 OR 3 VIEWS 72082

6100102 SHOULDER COMP 2V LT 73030LT

6100103 SHOULDER COMP 2V RT 73030RT

6100104 SI JOINTS 3 VIEWS 72202

6100105 SINUS PARANASAL <3V 70210

6100106 SINUS PARANASAL MIN3 70220

6100107 SKULL AP LAT 4 VIEWS 70250

6100108 SKULL COMP MIN 4 VWS 70260

6100109 SOFT TISSUE NECK 70360

6100110 SPINE LUMBAR 4 VIEWS 72110

6100111 STERNAL CLAV JT 3V 71130

6100112 STERNUM MIN 2 VWS 71120

6100113 SPINE THORACIC 2 VIEW 72070

6100114 SPINE THORACIC 3 VWS 72072

6100115 TIB/FIB AP/LAT LT 73590LT

6100116 TIB/FIB AP/LAT RT 73590RT

6100117 TMJ OPEN & CLOSED BI 70330

6100118 TOES MIN 2 VWS LT 73660LT

6100119 TOES MIN 2 VWS RT 73660RT

6100120 UPR EXT INFANT 2V LT 73092LT

6100121 UPR EXT INFANT 2V RT 73092RT

6100122 VOIDING URETHROCYSTG 74455

6100123 WRIST AP & LAT LT 73100LT

6100124 WRIST AP & LAT RT 73100RT

6100125 WRIST COMP MIN 3 V L 73110LT

6100126 WRIST COMP MIN 3 V R 73110RT

6100127 X-RAY PICC LINE 36569

6100129 SPINE CERVICAL 2 VIEWS 72040

6100130 ABD FLAT AND UPRIGHT 74019

6100131 HIPS BILAT W/PELVIS 2 VIEWS 73521

6100132 INJECTION SHOULDER ARTHROGRAPHY 36569

6100154 BARIUM SWALLOW ESOPHAGUS 74220

6100155 DOW CORNING CHEST PA AND LAT 71020

6100156 FLUORO LOC NEEDLE 77002

6100157 CHOLANGIOGRAM T TUBE NON OR 47531

6100158 RIBS BILATERAL 3 VWS 71110

6100159 RIBS BILATERAL 4 VWS 71111

6100160 BIL AP KNEES STANDING 73565

6100161 SCOLIOSIS 4 OR 5 VIEWS 72083

6200001 TTE W/DOPPLER COMPLETE 93306

6200002 US ABD COMPLETE 76700

6200003 US ABDOMEN LIMITED 76705

6200004 NPS BILAT EXTREMITY ART LIMITED 93922

6200005 DUP AORTA,IVC,ILC,VSC,BYG COMP 93978

6200006 US BREAST BIL 76641

6200007 ULTRASOUND BREASTCOMPLETE/LT 76641LT

Page 70: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6200008 ULTRASOUND BREAST COMPLETE/RT 76641RT

6200009 DUPLEX EXTRACRN ART COMP BILAT 93880

6200011 ECHO DOPPLER COMPLETE 93320

6200012 DUP AR IFL/VN OFL AB/PL/SC,COM 93975

6200013 US DUP FEMORAL BIL 93926

6200014 US DUP FEMORAL LT 93926LT

6200015 US DUP HEMODIAL ACC 93990

6200016 DUPLEX LW EXTRM ART/BYG COM BI 93925

6200017 DUPLEX LW EXTRM ART/BYG COM UN LT 93926LT

6200018 DUPLEX LW EXTRM ART/BYG COM UN RT 93926RT

6200019 DUPLEX LV EXTREM VEINS UNIL/RT 93971RT

6200023 DUPLEX UP EXTRM ART/BY COM BI 93930

6200024 DUPLEX UP EXTRM ART/BYG COM UN LT 93931LT

6200025 DUPLEX UP EXTRM ART/BYG COM UN RT 93931RT

6200026 DUPLEX EXTREM VEINS COMP UV BIL 93970

6200027 DUPLEX UV EXTREM VEINS UNIL/LT 93971LT

6200028 DUPLEX UV EXTREM VEINS UNIL/RT 93971RT

6200029 DUPLEX EXTREM VEINS COMP LV BIL 93970

6200030 DUPLEX LV EXTREM VEINS UNIL/LT 93971LT

6200031 ECHO DOPPLER COLOR FLOW MAP 93325

6200032 US COMPLETE LT XTR NON-VASC 76881LT

6200033 US COMPLETE RT XTR NON-VASC 76881RT

6200034 US FEMORAL DUPLEX RT 93926RT

6200035 US GUIDE NEEDLE PLCE 76942

6200036 US LIMITED ECHO 93308

6200037 US PELVIC NON OB COM 76856

6200038 US PELVIC NON OB LTD 76857

6200039 NPS BILAT EXTEMITY ART COMPLETE 93923

6200040 US RETROPERITON COMP 76770

6200041 US RETROPERITON LTD 76775

6200042 US SCROTUM/TESTICULA 76870

6200043 US SOFT TISSUE HEAD/NECK 76536

6200044 US TRANSVAGINAL 76830

6200045 US VEIN MAP LE BL 93970

6200046 US VEIN MAP LE LT 93971LT

6200047 US VEIN MAP LE RT 93971RT

6200048 US VEIN MAP UE BL 93970

6200049 US VEIN MAP UE LT 93971LT

6200050 US VEIN MAP UE RT 93971RT

6200051 US AORTA SCREEN 76706

6200052 US CHEST (INC MEDIA) 76604

6200053 US CONTRAST ECHO COMPLETE C8929

6200054 US NO SHOW FEE 76999

6200055 US TRANSABDOMINAL OB 76801

6200056 US TRANSVAGINAL OB 76817

6200057 US VA FEE

6200058 US OB 1ST TRIMESTER (<14 WEEKS) 1ST FETU 76801

6200059 US OB 2ND/3RD TRIMESTER 1ST FETUS 76805

6200060 US RENAL ARTERY DUPLEX 93975

6200061 US ABI WITH TOE PRESSURE 93922

6200062 US OB TRIMESTER 1 LIMITED 76815

6200063 CONTRAST STRESS ECHO 93352

Page 71: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6200072 US LIM LT XTR NON-VASC 76882LT

6200073 US LIM RT XTR NON-VASC 76882RT

6200074 ULTRASOUND BREAST LIMITED/RT 76642RT

6200076 ULTRASOUND BREAST LIMITED/LT 76642RT

6200077 US OB 1ST TRIMESTER (<14 WEEKS) 2nd FETU 76802

6300001 CT ABD W & W/O CONT 74170

6300002 CT ABD W CONT 74160

6300003 CT ABD W/O CONT 74150

6300004 CT CERV SPINE W CONT 72126

6300005 CT CERV SPINE W&W/O 72127

6300006 CT CERV SPINE W/O CONT 72125

6300007 CT CHEST W CONTR 71260

6300008 CT CHEST W&W/O CONT 71270

6300009 CT CHEST W/O CONTR 71250

6300010 CT COMP RECONSTRUCTI 76497

6300011 CT FACIAL BONES W CO 70487

6300012 CT FACIAL BONES W&W/ 70488

6300013 CT FACIAL BONES W/O 70486

6300014 CT HEAD W & W/O CONT 70470

6300015 CT HEAD W/O CONTRAST 70450

6300016 CT HEAD WITH CONTRAS 70460

6300017 CT IAC TB W & W/O CONTR 70482

6300018 CT IAC TB W CONTR 70481

6300019 CT IAC TB W/O CONTR 70480

6300020 CT L SPINE W CONT 72132

6300021 CT L SPINE W&W/O CON 72133

6300022 CT L SPINE W/O CO 72131

6300023 CT LOW EXT W/O C LT 73700LT

6300024 CT LOW EXT W/O C RT 73700RT

6300025 CT LOWER EXT W & W/O RT 73702RT

6300026 CT LOWER EXT W & W/O LT 73702LT

6300027 CT LOWER EXT W CONTR RT 73701RT

6300028 CT LOWER EXT W CONTR LT 73701LT

6300029 CT MASTOIDS W CONTRA 70481

6300030 CT MASTOIDS W&W/O CO 70482

6300031 CT MASTOIDS W/O CONT 70480

6300032 CT ORB/SEL/PST FOSS/IAC W/CON 70481

6300033 CT ORB/PST FOS/EAR W/W/O CONT 70482

6300034 CT ORB/PST FOSS/EAR W/O CON 70480

6300035 CT PELVIS W CONTR 72193

6300036 CT PELVIS W&W/O CONT 72194

6300037 CT PELVIS W/O CONTRA 72192

6300038 CT SINUSES W CONTR 70487

6300039 CT SINUSES W&W/O CON 70488

6300040 CT SINUSES W/O CONTR 70486

6300041 CT SOFT TISSUE NECK W & W/O CONT 70492

6300042 CT SOFT TISSUE NECK W CONTR 70491

6300043 CT SOFT TISSUE NECK W/O CONTR 70490

6300044 CT T SPINE W & W/O C 72130

6300045 CT T SPINE W/CONTR 72129

6300046 CT T SPINE W/O CONTR 72128

6300047 CT UP EXT W&WO CO LT 73202LT

Page 72: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6300048 CT UP EXT W&WO CO RT 73202RT

6300049 CT UP EXT W/CON LT 73201LT

6300050 CT UP EXT W/CON RT 73201RT

6300051 CT UP EXT W/O CON LT 73200LT

6300052 CT UP EXT W/O CON RT 73200RT

6300053 CTA CHEST INC IMG PP 71275

6300054 CTA HEAD W/CONTRAST 70496

6300055 CTA LOW EXT W/PP LT 73706LT

6300056 CTA LOW EXT W/PP RT 73706RT

6300057 CTA NECK W/CONTRAST 70498

6300058 CTA UP EXT W/PP LT 73206LT

6300059 CTA UP EXT W/PP RT 73206RT

6300060 CT ABD & PELV 1+ SECTION/RENS 74178

6300061 CT ABD & PEL W/OUT 74176

6300062 CT ABD & PEL WITH 74177

6300063 CT NO SHOW FEE 76497

6300064 CT VA FEE

6300065 CTA ABD/PELVIS WITH 74174

6300066 CT GUIDED NEEDLE BIOPSY 77012

6300067 CTA AORTA ILIOFEMORAL RUNOFF 75635

6300068 LD CT LUNG SCAN G0297

6400001 MRI UP EXT NON JT W/W/O CON RT 73220RT

6400002 MRI UP EXT NON JT W/ CON LT 73219LT

6400003 MRI UP EXT NON JT W/O CON RT 73218RT

6400004 MRI UP EXT NON JT W/ CON RT 73219RT

6400005 MRI UP EXT NON JT W/O CON LT 73218LT

6400006 MRI UP EXT NON JT W/ W/O CON LT 73220LT

6400007 MRI LOW EXT JT W/O CON LT 73721LT

6400008 MRI UP EXT JT W/W/O CON LT 73223LT

6400009 MRI UP EXT W/W/O CON RT 73223RT

6400010 MRI UP EXT JT W/O CON LT 73221LT

6400011 MRI UP EXT JT W/ CON LT 73222LT

6400012 MRI UP EXT JT W/O CON RT 73221RT

6400013 MRI LOW EXT NON JT W/ CON LT 73719LT

6400014 MRI UP EXT JT W/ CON RT 73222RT

6400015 MRA ABDOMEN W/O OR W 74185

6400016 MRA CHEST W OR W/O C 71555

6400017 MRA HEAD W CONTRAST 70545

6400018 MRA HEAD W&W/O CONTR 70546

6400019 MRA HEAD W/O CONTRAS 70544

6400020 MRA LOW EXT W OR W/O LT 73725LT

6400021 MRA LOW EXT W OR W/O RT 73725RT

6400022 MRA NECK W&W/O CONTR 70549

6400023 MRA NECK W/ CONTRAST 70548

6400024 MRA NECK W/O CONTRAS 70547

6400025 MRA PELVIS W OR W/O 72198

6400026 MRA UP EXT W OR W/O LT 73225LT

6400027 MRA UP EXT W OR W/O RT 73225RT

6400028 MRA UP EXT W/O CONT LT 73225LT

6400029 MRA UP EXT W/O CONT RT 73225RT

6400030 MRI ABDOMEN W & W/O 74183

6400031 MRI ABDOMEN W CONTRA 74182

Page 73: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6400032 MRI ABDOMEN W/O CONT 74181

6400033 MRI BRAIN W CONTRAST 70552

6400034 MRI BRAIN W&W/O CONT 70553

6400035 MRI BRAIN W/O CONTRA 70551

6400036 MRI C SPINE W & W/O 72156

6400037 MRI C SPINE W CON 72142

6400038 MRI C SPINE W/O CONT 72141

6400039 MRI CHEST W CONTRAST 71551

6400040 MRI CHEST W&W/O CONT 71552

6400041 MRI CHEST W/O CONTRA 71550

6400042 MRI LOW EXT JT W/O CON RT 73721RT

6400043 MRI LOW EXT JT W/ CON LT 73722LT

6400044 MRI LOW EXT JT W/ CON RT 73722RT

6400045 MRI L SPINE W & W/O 72158

6400046 MRI L SPINE W/O CONT 72148

6400047 MRI LOW EXTNON W/W/O CON LT 73720LT

6400048 MRI LOW EXT NON JT W/W/O CON RT 73720RT

6400049 MRI LOW EXT NON JT W/ CON RT 73719RT

6400050 MRI LOWER EXT NON JT W/O CON LT 73718LT

6400051 MRI LOWER EXT NON JT W/O CON RT 73718RT

6400052 MRI LUMBAR SPINE W C 72149

6400053 MRI ORB/FCE/NCK W/WO 70543

6400054 MRI ORB/FCE/NECK W C 70542

6400055 MRI ORB/FCE/NECK W/O 70540

6400056 MRI PELVIS W CONTRAS 72196

6400057 MRI PELVIS W/O CONTR 72195

6400058 MRI T SPINE W & W/O 72157

6400059 MRI TMJ JOINT(S) 70336

6400060 MRI T-SPINE W/O CONT 72146

6400061 MRI TSPINE WITH CONT 72147

6400062 MRI PELVIS W&W/O CON 72197

6400063 MRI VA FEE

6400064 NO SHOW FEE MRI 76498

6400065 MRI LOW EXT JT W/W/O CON LT 73723LT

6400066 MRI LOW EXT JT W/W/O CON RT 73723RT

6500001 NM 3 PHASE BONE SCAN 78315

6500002 NM INTESTINE IMAGING (MECKELS) 78290

6500003 NM ABORTED PROC 78999

6500004 NM ADRENAL IMG CORTEX/MEDULA 78075

6500005 HEPATOBILIARY SYSTEM IMAGING 78226

6500006 NM BONESCAN MLT AREA 78305

6500007 NM C-99M CERETE WBC NM 78300

6500009 NM GALLIUM PER MCI NM 78999

6500010 NM GASTRIC EMPTYING 78264

6500011 NM GE REFLUX 78262

6500012 NM GI BLEEDING SCAN 78278

6500013 NM I-123 100 UCI NM A9509

6500014 NM I-123 200 UCI NM 78999

6500015 NM IN-111 WBC'S NM 78999

6500016 NM KIDNEY IMAG MORPHOLOGY 78700

6500017 NM LIVER IMG SPECT W/VASC FLW 78206

6500018 NM LIVER/SPLN W/FLOW 78216

Page 74: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6500019 NM LTD BONE SCAN 78300

6500020 NM PULM VENT AND PERF IMAGING 78582

6500021 NM LVR/SPLEEN STATIC 78215

6500022 MUGA SINGLE STUDY 78494

6500023 HT MUSCLE IMAGE SPECT MULT 78452

6500024 NM MYOVIEW UNIT DOSE NM A9502

6500025 NM PARATHYROID PLANAR IMAGE 78070

6500026 NM KIDNEY FLOW/FUNCTION MULT W/W/O DRUG 78709

6500027 NM RENOGRAM WO PHARM 78707

6500028 NM SPECT BONE SCAN 78320

6500029 NM LIVER IMAGING SPECT 78205

6500030 NM TC-99 CHOLETEC NM A9510

6500031 NM TC-99 DTPA 78579

6500032 NM TC-99M MAA NM 78580

6500033 NM TC-99M MAG-3 NM 78709

6500034 NM TC-99M MDP NM A9503

6500035 NM TC-99M SULFR COLL NM 78264

6500036 NM TC-99M UNIT DOSE NM 78399

6500037 NM TI-201 78454

6500038 NM TOTAL BODY BONE 78306

6500039 NM TUMOR LOC MULT AR 78801

6500040 NM TUMOR LOC WB 1DAY 78802

6500041 NM TUMOR LOC WB 2+DA 78804

6500042 NM TUMOR LOCAL LTD A 78800

6500043 NM WBC SCAN LIMITED 78805

6500044 NM WBC SCAN LTD F/U 78805

6500045 NM WBC SCAN WB F/U 78806

6500046 NM WBC SCN WHOLEBODY 78806

6500047 NM GASTRIC STDY NO SHOW

6500048 NM HEPATOBIL SCAN W/PHA 78223

6500049 NM HIDA SCAN NO SHOW

6500050 NM MUGA TC-04 NM A9512

6500051 NM MYOCARDIAL EJECTI 78453

6500052 NM NO CHARGE BONE 78999

6500053 NM NO SHOW HIDA SCAN 78999

6500054 NM PYP KIT NUM A9900

6500055 NM STRESSTEST NOSHOW 78999

6500056 NM TC-99M BULK

6500057 NM ULTRATEC KIT A9900

6500058 NM VENTA SCAN SUPPLY 79999

6500059 HEPATOBILIARY SYS IMAGING W/KINEVAC 78227

6600001 MAMMO COMP AIDED DET 77052

6600002 MAMMO DIG SCREEN BILAT 77067

6600003 DXA 1 OR MORE SITES AXIAL SKEL 77080

6600004 MAMMO DIG SCREEN LT G0202LT

6600005 MAMMO DIG SCREEN RT G0202RT

6600006 MAMMO DIG DIAGNOSTIC BILAT 77066

6600007 MAMMO DIG DIAGNOSTIC LT 77065LT

6600008 MAMMO DIG DIAGNOSTIC RT 77065RT

6600009 SCREENING DIG BR TOMOSYNTHESIS BIL 77063

6600010 DIG BR TOMOSYNTHESIS RT 77061RT

6600011 DIG BR TOMOSYNTHESIS LT 77061LT

Page 75: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6600012 DIG BR TOMOSYNTHESIS BIL 77062

6600013 MAMMO DIG SCREEN UNILATERAL 7706752

7100001 OXYGEN PER HOUR

7100004 HOLTER MON 24/48 93225

7100005 ABG 82805

7100006 ABG W/ CO-OX 82805

7100007 AEROSOL INITIAL 94640

7100008 AEROSOL SUBSEQ 9464076

7100011 ARTERIAL PUNCTURE COLLECTION 36600

7100012 SPIROMETRY BASIC 94010

7100013 CO OXIMETRY ONLY 82810

7100014 CONT MINI NEB 94640

7100015 CONT NEB 1ST HR 94644

7100016 CONT NEB SUBQ HOUR 94645

7100017 CONTINUOUS AEROSOL 94640

7100018 CONTINUOUS PULSE OX 94762

7100019 CORD PH ARTERIAL 82800

7100020 CPAP/BIPAP INITIAL 94660

7100021 CPAP/BIPAP SUBSEQ 94660

7100022 CPR 92950

7100023 CPR IP 92950

7100024 CPT INITIAL 94667

7100025 CPT SUBSEQ 94668

7100026 ECG 12 LEAD, TRACING ONLY 93005

7100027 PULSE OXIMETRY, MULT DETERM 94761

7100028 FLUTTER THERAPY 94664

7100029 FLUTTER THERAPY SUB 94664

7100032 MDI INITIAL 94664

7100033 MDI INSTRUCT 94664

7100034 MDI SUBSEQ 9464076

7100035 MINI NEB 9464076

7100036 MINI NEB SUBSEQ 9464076

7100037 NASOTRACHEAL SUCTION 31720

7100038 OXIMETRY OVERNIGHT A 94762

7100039 PULSE OXIMETRY, SINGLE DETERM 94760

7100040 OXYGEN PER HOUR

7100041 OXYMIZER O-224

7100042 SPIROMETRY PRE/POST 94060

7100043 PRE/POST FLOW VOL LO 94060

7100044 SPUTUM INDUCTION 94640

7100045 VENT MGMT INPAT, INIT DAY 94002

7100046 VENT MGMT INPAT, SUBC DAY 94003

7100047 WEANING PARAMETERS 94799

7100050 EKG PHY PRACTICE 93005

7100051 PFT PRE AND POST PHY PRACTICE 94060

7100052 SCAN/PRODUCE HOLTER REPORT 93226

8100003 PT ADL TRAINING 15 MIN 97535GP

8100004 PT BURN DEBRID DRESS LG 16030GP

8100005 PT BURN DEBRID DRESS ME 16025GP

8100006 PT BURN DEBRID DRESS SM 16020GP

8100007 PT CONTRAST BATH 15 MIN 97034GP

8100008 PT DEBRIDEMENT SKIN FUL 11041GP

Page 76: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

8100009 PT DEBRIDEMENT SKIN PAR 11040GP

8100010 PT DEBRIDEMENT SKIN SUB 11042GP

8100011 PT E STIM ATTENDED 15 M 97032GP

8100012 PT E STIM UNATTEND 97014GP

8100013 PT LOW COMPLEXITY 97161GP

8100014 PT EVAL COMPREHENSIV 97163GP

8100015 PT FUNC THERA ACT PT 15 97530GP

8100016 PT GAIT TRAINING 15 MI 97116GP

8100017 PT IONTOPHORESIS 15 MIN 97033GP

8100018 PT JOB ASSESSMENT 15 MI 97537GP

8100019 PT JOB SIMULATION 15 MI 97537GP

8100020 PT LOW INTENSITY LASER 97039

8100021 PT MANUAL THERAPY 15 MI 97140GP

8100022 PT MASSAGE 15 MIN 97124GP

8100023 PT NEUROMUS RE-ED 15MIN 97112GP

8100024 PT ORTHO MGMT/TRAIN 15 97760GP

8100025 PT PARAFFIN BATH 97018GP

8100026 PT PAT/FAMLY TRAIN PT 1 97530GP

8100027 PT PROCEDURE ASSIST 97799GP

8100028 PT PROSTHETIC TRAIN 15 97761GP

8100029 PT RE-EVALUATION 97164GP

8100030 PT SPLINT/ORTH CHECK PT 97762GP

8100031 PT STRAPPING ANKLE/FOOT 29540GP

8100032 PT STRAPPING ELB/WRIST 29260GP

8100033 PT TENS APPLIC 15 MIN 97032GP

8100034 PT THERAPEUTIC PROC GRP 97150GP

8100035 PT THERAPUTTY

8100036 PT THERP EXECISE 15 MIN 97110GP

8100037 PT TRACTION MECHANICAL 97012GP

8100038 PT ULTRASOUND 15 MIN 97035GP

8100039 PT VASOPNEUMATIC PUMP 97016GP

8100040 PT WH CHAIR MGMT 15 MIN 97542GP

8100041 PT WHIRLPOOL 97022GP

8100042 PT WORK HARD/COND INIT 97545GP

8100043 PT WORK HARDENING ADD H 97546GP

8100044 PT WOUND MGMT <=20 97597GP

8100045 PT WOUND MGMT >20 97598GP

8100151 CANALITH REPOSITIONING 95992

8100152 PT EQUIPMENT USE

8100153 PT MODERATE COMPLEXITY 97162GP

8100154 OT LOW COMPLEXITY 97165GO

8100155 OT MODERATE COMPLEXITY 97166GO

8100156 OT HIGH COMPLEXITY 97167GO

8100157 OT RE-EVALUATION 97168GO

8100158 OT PARAFFIN BATH 97018GO

8100159 OT WHIRLPOOL 97022GO

8100160 OT E STIM ATTENDED 15 M 97032GO

8100161 OT CONTRAST BATH 15 MIN 97034GO

8100162 OT ULTRASOUND 15 MIN 97035GO

8100163 OT THERP EXECISE 15 MIN 97110GO

8100164 OT NEUROMUS RE-ED 15MIN 97112GO

8100165 OT MASSAGE 15 MIN 97124GO

Page 77: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

8100166 OT MANUAL THERAPY 15 MI 97140GO

8100167 OT FUNC THERA ACT PT 15 97530GO

8100168 OT COGNITIVE SKILLS DEV PT 15 97532GO

8100169 OT SENSORY INTEGRATIVE TECH PT 15 97533GO

8100170 OT SELF CARE/HOME MANG TRA15 MIN 97535GO

8100171 OT WH CHAIR MGMT 15 MIN 97542GO

8100172 OT WORK HARD/COND INIT 97545GO

8100173 OT WORK HARDENING ADD H 97546GO

8100174 OT ORTHO MGMT/TRAIN 15 97760GO

8100175 OT PROSTHETIC TRAIN 15 97761GO

8100176 OT C/O ORTH/PROSTH USE 15 MIN 97762GO

9100001 14FR RR SUCTION CATH

9100002 ADAPTIC DRESS 3X8

9100003 AEROSOL BEDSIDE SET

9100005 BIOCLUSIVE 8X10

9100006 BIOCLUSIVE DRESS 2X3

9100007 BIOCLUSIVE DRESS 5X7

9100008 BLADE SCALPEL 10

9100009 BLADE SCALPEL 11

9100010 BLADE SCALPEL 15

9100011 BLOOD PRODUCTS ADMIN 36430

9100012 CAPILLARY PUNCTURE 36416

9100013 C-LINE DRESSING TRAY

9100014 COLD PACK INSTANT

9100015 DRAIN CHEST ADULT

9100016 DRESS NONADHER 3X3

9100017 DRESS VASELINE 3X9

9100018 INIT NB EM PER DAY, HOSP 99460

9100019 EAR BULB SYRINGE

9100020 EASY CAP CO2

9100021 EKG 12 LEAD 93005

9100022 EKG 12 LEAD REPEAT 93005

9100023 EPISTAXIS CATHETER

9100024 ER VISIT, LEVEL 1 99281

9100025 ER VISIT, LEVEL 2 99282

9100026 ER VISIT, LEVEL 3 99283

9100027 ER VISIT, LEVEL 4 99284

9100028 ER VISIT, LEVEL 5 99285

9100029 CRITICAL CARE, 1ST 30-74 MIN 99291

9100030 ER OXYGEN ADMIN/HOUR

9100031 EXC BL, TRK/ARM/LG; 0.5 OR < 11400

9100032 EXC BL, SCLP/HND/FT/GEN; 0.5 OR > 11420

9100033 I & D ABSCESS/SMPLE 10060

9100034 I&D ABSCESS/COMPLEX 10061

9100035 I&D COMPLEX POSTOP WOUND 10180

9100036 IM/SQ MEDICATION INJ 96372

9100037 IMMUN ADMIN; 1 VACCINE 90471

9100038 IMMUN ADMIN; EACH ADDITIONL VACCINE 90472

9100040 INFANT NASAL CANNULA

9100041 INTUBATION 31500

9100042 IV INF CONCURRENT 96368

9100043 IV INF HYD ADD HOUR 96361

Page 78: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9100044 IV HYDRATION, INIT, 31 MIN TO 1 HR 96360

9100045 IV INF SEQ UP TO 1HR 96367

9100046 IV INFUSION, ADDL HR 96366

9100047 IV INFUSION, INIT, UP TO 1 HR 96365

9100048 IV PUSH, SEQUENT, NEW DRUG 96375

9100049 IV PUSH INITNAL 96374

9100050 IV PUSH, SEQUENT, SAME DRG 96376

9100051 MASK PEDI NONREBREAT

9100052 ER VISIT, LEVEL 1 99281

9100053 MORGAN LENS THERAPY

9100054 TX GASTRO INTUB W/ASP 43753

9100055 ORTHOGLASS 1

9100056 ORTHOGLASS 2 PER IN

9100057 ORTHOGLASS 4 PER IN

9100058 ORTHOGLASS 5 PER IN

9100059 ORTHOGLASS 6 PER IN

9100060 OXISENSOR ADT DATASC

9100061 OXISENSOR PED DATASC

9100062 PED AMBU BAG 65060

9100063 PEDIATRIC NASAL CANN

9100064 RAPID RHINO 5.5

9100065 RAPID RHINO 7.5

9100066 REMOVAL SKIN TAG: UP TO 15 11200

9100067 CPR 92950

9100068 STERI STRIP 1/2

9100069 STERI-STRIP 1/4

9100070 STERI-STRIP 1/8

9100071 SUTURE 1644G

9100072 SUTURE 691G

9100073 SUTURE ETH 2-0 664G

9100074 SUTURE ETH 3-0 1663G

9100075 SUTURE ETH 3-0 663G

9100076 SUTURE ETH 4-0 662G

9100077 SUTURE ETH 4-0 699G

9100078 SUTURE ETH 5-0 1865G

9100079 SUTURE ETH 5-0 690G

9100080 SUTURE ETH 5-0 698G

9100081 SUTURE ETH 6-0 1698G

9100082 SUTURE ETH 6-0 689G

9100083 SUTURE ETH 6-0 697G

9100084 SUTURE ETHI 7-0 BLK

9100085 SUTURE GUT 1635G

9100086 SUTURE GUT 4-0 1798

9100087 SUTURE PLN 5-0 H820G

9100088 SUTURE PROL 4-0 8682

9100089 SUTURE PROL 4-0 8699

9100090 SUTURE PROLE 6-0 869

9100091 SUTURE PROLENE 3 892

9100092 SUTURE VICRYL 4 507G

9100093 SUTURE VICRYL 5 506G

9100094 SUTURE VICRYL 7-0

9100095 SUTURE VICRYL J219

Page 79: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9100096 TELFA DRESS 2X3 1961

9100097 TRANSWARMER INFANT

9100098 TUBE SHILEY 4CFS

9100099 VASELINE GAUZE 1X8

9100100 VENOUS DRAW 36415

9100101 THROMBOLYSIS, CORON IV PUSH 92977

9100102 THROMBOLYSIS, CEREB IV PUSH 37195

9100103 DRAINAGE OF FINGER ABSCESS SIMPLE 26010

9100104 DRAINAGE OF FINGER ABSCESS COMPL 26011

9100105 DRAINAGE OF ABSCESS PALATE/UVULA 42000

9100106 I & D ABSCESS SCROTAL WALL ABSCESS 55100

9100107 DRAINAGE EXTER EAR ABSC OR HEMAT SIM 69000

9100108 INCIS OF THROMBOSED HEMMOR EXTERNAL 46083

9100109 I & D ABSCESS PERITONSILLAR 42700

9100110 I & D PERIANAL ABSCESS/SUPERFICIAL 46050

9100111 I & D OF ISCHIORECTAL/PERIRECTAL ABSCESS 46040

9100112 I & D OF VULVA/PERINEAL ABSCSSS 56405

9100113 I & D OF BARTHONLINS GLAND ABSCESS 56420

9100114 BIEPHAROTOMY DRAINAGE OF ABS EYELID 67700

9100115 INIT TX 1ST DEGREE BURN W/LOCAL ANEST 16000

9100116 MED (WHOLE FACE/EXT) 5-10% BODY SUR 16025

9100117 DRES/DEBRID PARTIAL INTI/SUB < 5% TOTAL 16020

9100118 LARGE (MORE THAN 1 EXT) >10 % TOTAL BODY 16030

9100119 ARTH/ASP/INJ SM JT FINGERS/TOES 20600

9100120 ARTH/ASP/INJ INTER JT TEM/ACR/WRI/ELB/AN 20605

9100121 ARTH/ASP/INJ SHOU/HIP/KNEE 20610

9100122 TREAT OF CLOSED ELB DISLO/ W/O ANSTE 24600

9100123 FX/DISLO W/ANES CARP FX/DIS O/T THU W/MA 26675

9100124 CLOSED TX KNEE DISL REQU ANES 27552

9100125 CLOSED TX CMC FX/DIS THUMB W/MANI 26645

9100126 APPL OF LONG LEG SPLINT THIGH/ANKLE/TOE 29505

9100127 APPL OF SHORT LEG SPLINT CALF TO FOOT 29515

9100128 TREAT OF CLOSED ELBOW DIS/W MANIPU 24655

9100129 FX/DIS W/MANI GRT/TOE/PHALANX/PHALANGES 28495

9100130 FX/DISLOCA SHOULDER REQU ANESTH 23655

9100131 FX/DISLO W/MANIPU EACH BONE 26605

9100132 HIP DISL/ABDU/SPLI OR TRAC W/MAN RE/ANES 27257

9100133 THROMBOLYSIS, CORON IV INFUSION 92977

9100134 THROMBOLYSIS, CEREB IV INFUSION 37195

9100135 REMOVAL OF SKIN TAG (EH ADD 10) 11201

9100136 AVULSION NAIL SINGLE 11730

9100137 AVULSION NAIL EACH ADD 11732

9100138 EXC SCA/HAND/FING/GEN/NECK BENIGN .5CM 11420

9100139 EXC EAR/EYE/FACE/LIPS/NOSE BENIGN .5CM 11440

9100140 REM FB FROM EXTER AUD CANEL W/O ANES 69200

9100141 REM IMPACTED CER USING IRR/LAVA UNIL 69209

9100142 REMOVE FB SIMPLE SUB Q 10120

9100143 REMOVE INGROWN TOENAIL 11730

9100144 REMOVAL OF FOREIGN BODY INTRANASAL 30300

9100145 REM FB EX/EYE/CONJU SUPERFICAL 65205

9100146 REM OF EMBEDDED FB EYELID 67938

9100147 REM OF FB EXT EYE CONJUCT EMBEDDED 65210

Page 80: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9100148 REM OF FB FROM PHARYNX 42809

9100149 INSER OF TEMP INDW BLADDER CATH SIMPLE 51702

9100150 INSER OF TEMP INDW BLADDER CATH COM 51703

9100151 VAGINAL DELIVERY ONLY 59409

9100152 BLADDER IRR SIM/LAVAGE/INSTILLATION 51700

9100153 CHAN GTUBE PERC/W/O IMAGI OR GUIDANCE 43760

9100154 DELIVERY OF PLACENTA 59414

9100155 CONT OROPH HEMO PRI/SEC/SIMPLE 42960

9100156 CONT NASAL HEMO ANT/SIMPLE ANY METHOD 30901

9100157 INTUBATION/ET EMER PROCEDURE 31500

9100158 PLACEMENT OF IO 36680

9100159 COLL OF BLOOD SPEC FR COMP IMPLAN VAD 36591

9100160 INSER OF NON-TUN CIC VEN CATH < 5 YRS 36555

9100161 DECLO THROMB AG OF IMPLA VAS AD OR CATH 36593

9100162 PLEU DRA PERCU W/INSE OF IND CATH W/O G 32554

9100163 SPINAL PUNCTURE LUMBAR DIAGNOSTIC 62270

9100164 CONT NASAL HEMO ANT COMPLEX AN METH 30903

9100165 TRACHEOSTOMY EM PROD TRANSTRACHEAL 30963

9100166 CATHETER ASPIRATION NASOTRACHEAL

9100167 COLL OF BL SPEC U EST CEN/PER/CATH VEN 36592

9100168 INSER OG NON-TUN VIV VEN CATH 5YR OR > 36556

9100169 COLL OF BLD SPEC FRO COM IMPLAN VAD 36591

9100170 THOROCEN NE/CATH ASP OF PLEU SPA W/GU 32554

9100171 SIM RE OF SUP 2.5CM OR < SCA/NECK/ARM 12001

9100172 SIM RE OF SUP 2.6-7.5CM SCA/NECK/ARM 12002

9100173 SIM RE OF SUP 7.6-12.5CM SCA/NECK/ARM 12004

9100174 SIM RE OF SUP 12.6-20.0CM SCA/NECK/ARM 12005

9100175 SIM RE OF SUP 20.1-30.0CM SCA/NECK/ARM 12006

9100176 SIM RE OF SUP OVER 30CM SCA/NECK/ARM 12007

9100177 SIM RE SUP WD F/E/E/N/L/MM 2.5 OR LESS 12011

9100178 SIM RE SUP WD F/E/E/N/L/MM 2.6-5.0CM 12013

9100179 SIM RE SUP WD F/E/E/N/L/MM 5.1-7.5CM 12014

9100180 SIM RE SUP WD F/E/E/N/L/MM 7.6-12.5CM 12015

9100181 SIM RE SUP WD F/E/E/N/L/MM 12.6-20CM 12016

9100182 RE INTER WD S/A/T/EXT(EX H/F) 2.5 OR < 12031

9100183 RE INTER WD S/A/T/EXT(EX H/F) 2.6-7.5CM 12032

9100184 RE INTER WD S/A/T/EXT(EX H/F) 7.6-12.5CM 12034

9100185 RE INTER WD S/A/T/EXT(EX H/F) 12.6-20.CM 12035

9100186 RE INTER WD S/A/T/EXT(EX H/F) 20.1-30CM 12036

9100187 RE INTER WD S/A/T/EXT(EX H/F) OVER 30CM 12037

9100188 RE INTER WD F/E/E/N/L/MM 2.5 CM OR < 12051

9100189 RE INTER WD F/E/E/N/L/MM 2.6-5.0CM 12052

9100190 RE INTER WD F/E/E/N/L/MM 5.1-7.5CM 12053

9100191 RE INTER WD F/E/E/N/L/MM 7.5-12.5CM 12054

9100192 RE INTER WD F/E/E/N/L/MM 12.6-20.0CM 12055

9100193 SIM RE SUP WD F/E/E/N/L/MM 20.1-30.0CM 12017

9100194 SIM RE SUP WD F/E/E/N/L/MM OVER 30CM 12018

9100195 REPAIR COMPLEX TRUNK 1.1-2.5CM 13100

9100196 REPAIR COMPLEX TRUNK 2.6-7.5CM 13101

9100197 RE COMPLE F/C/C/M/N/A/G/H/F 1.1-2.5CM 13131

9100198 RE COMPLE F/C/C/M/N/A/G/H/F 2.6-7.5CM 13132

9100199 RE INTERM N/H/F/AND/OR EXT GEN 2.5 OR < 12041

Page 81: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9101100 RE INTERM N/H/F/AND/OR EXT GEN 2.6-7.5CM 12042

9101101 RE INTER N/H/F/AND/OR EXT GEN 7.6-12.5CM 12044

9101102 RE INTER N/H/F/AND/OR EXT GEN 12.6-20CM 12045

9101103 RE INTER N/H/F/AND/OR EXT GEN 20.1-30CM 12046

9101104 RE INTER N/H/F/AND/OR EXT GEN OVER 30CM 12047

9101105 RE INTER WD F/E/E/N/L/MM 20.1-30.0CM 12056

9101106 RE INTER WD F/E/E/N/L/MM OVER 30.0CM 12057

9101107 REPAIR COMPLEX SCALP/ARM 1.1-2.5CM 13120

9101108 REPAIR COMPLEX SCALP/ARM 2.6-7.5CM 13121

9101109 CLOSE OF LAC/VESTIBULE MOUTH 2.5 OR < 40830

9101110 CLOSE OF LAC/VESTIBULE MOUTH 2.5 OR COM 40831

9101111 REPAIR LACERATION OF TONGUE 41252

9101112 REPAIR LAC POST 1/3 OF TONGUE 41251

9101113 RE LAC 2.5 OR< FL OF M ANT 2/3 OF TON CL 41250

9101114 SUT WD EYE/IN/LM/T/P/CDC/PT 67930

9101115 SUT WD EYE/IN/LM/T/P/CDC/PT 67935

9101116 RE COMPLEX E/N/E/L 1.1-2.5CM 13151

9101117 RE COMPLEX E/N/E/L 2.6-7.5CM 13152

9101118 LONG ARM SPLINT 29515

9101119 SHORT ARM SPLINT FOREARM TO HAND 29125

9101120 SHORT ARM SPLINT FARM/HAND MOVABLE 29126

9101121 FINGER SPLINT 29130

9300001 EMERGENCY DEPT LEVEL 1 99281

9300002 EMERGENCY DEPT LEVEL 2 99282

9300003 EMERGENCY DEPT LEVEL 3 99283

9300004 EMERGENCY DEPT LEVEL 4 99284

9300005 CLTX MTCRPL FX W/MANIPULATION 26605

9300006 CLTX MTCRPL FX W/O MANIPULATION 26600

9300007 OBSERV/INP HOSP LOW 99234

9300008 OBSERV/INP HOSP HIGH 99236

9300009 OBSERV/INP HOSP MED 99235

9300010 ACNE SURG 10040

9300011 ANRCT XM SUGR R 45990

9300012 APPENDEC 44950

9300013 ASPIR & NJX GANG 20612

9300014 ASPIR BLDR NDL 51100

9300015 ASPIR BLDR W/IN 51102

9300016 AVLSN NAIL PLAT 11732

9300017 BLOOD OCLT PEROXID 82272

9300018 BURN CARE INITIAL 16000

9300019 BX BRST OPN INC 19101

9300020 BX BRST PRQ NDL 19100

9300021 BX SKIN SUBQ/MUC 11100

9300022 BX/EXC LYMPH NO 38500

9300024 CARROLL COUNTY

9300025 CHEM CAUT GRANL 17250

9300026 CHOLECSTC 47600

9300027 CHOLECSTC CHOLA 47605

9300028 CHOLECSTC EXPL 47610

9300029 CLTX DSTL PHLNG 26750

9300030 CLTX PHLNGL FX 26720

9300031 CNTRST NJX RAD 36598

Page 82: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300032 COLCT PRTL W/AN 44140

9300033 COLCT PRTL W/AN 44140

9300034 COLCT PRTL W/RM 44160

9300035 COLON CA SCREEN G0105

9300036 COLSC FLX PROX 45384

9300037 COLSC FLX PROX 45385

9300038 COLSC FLX PROX 45382

9300039 DBRDMT NAIL ANY 11720

9300040 DBRDMT NAIL ANY 11721

9300041 DBRDMT SKIN SUBQ 11004

9300042 DBRDMT SKN SUQ 11403

9300043 DBRDMT X10SV EC 11000

9300044 DBRMT SKIN PARTIAL 11010

9300045 DBRMT SKIN SUBQ 11005

9300046 DBRMT W/RMVL F 11010

9300047 DESTRUCTION LES 17000

9300048 DESTRUCTION LES 17003

9300049 DRG ABSC CST HM 40801

9300050 DSTRJ B9 SK TGS 17111

9300051 DSTRJ LES ANUS 46922

9300052 DSTRJ MAL LES F 17280

9300053 DSTRJ MAL LES F 17281

9300054 DSTRJ MAL LES T 17260

9300055 DSTRJ MAL LES T 17261

9300056 DSTRJ MAL LES T 17262

9300057 DSTRJ MAL LES T 17263

9300058 DSTRJ MAL LES T 17271

9300059 DSTRJ MAL LES T 17272

9300060 ENCL/EXE EXTRNL 46230

9300061 ENTERLOSS FRING 44005

9300062 ENTEROLSS FRING 44005

9300063 ENTERORRHAPHY M 44603

9300064 ENTRC RESCJ SM 44120

9300065 ENTRC RESCJ SM 44120

9300066 ENTRC RESCJ SM 44121

9300067 EVAC SUBUNGUAL 11740

9300068 EXC ABDL WALL T 22900

9300069 EXC B9 LES MARGN 11400

9300070 EXC B9 LES MARGN 11401

9300071 EXC B9 LES MARGN 11402

9300072 EXC B9 LES MARGN 11403

9300073 EXC B9 LES MARGN 11404

9300074 EXC B9 LES MARGN 11406

9300075 EXC B9 LES MARGN 11420

9300076 EXC B9 LES MARGN 11421

9300077 EXC B9 LES MARGN 11422

9300078 EXC B9 LES MARGN 11423

9300079 EXC B9 LES MARGN 11424

9300080 EXC B9 LES MARGN 11426

9300081 EXC B9 LES MARGN 11440

9300082 EXC B9 LES MARGN 11441

9300083 EXC B9 LES MARGN 11442

Page 83: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300084 EXC B9 LES MARGN 11443

9300085 EXC B9 LES MARGN 11444

9300086 EXC B9 LES MARGN 11446

9300087 EXC BACK TUM DE 21933

9300088 EXC CYST/ABERRA 19120

9300089 EXC MAL LES W/M 11622

9300090 EXC MAL LES W/M 11623

9300091 EXC MAL LES W/M 11624

9300092 EXC MAL LES W/M 11626

9300093 EXC MAL LES W/M 27200

9300094 EXC MAL LES W/M 11641

9300095 EXC MAL LES W/M 11642

9300096 EXC MAL LES W/M 11642

9300097 EXC MAL LES W/M 11643

9300098 EXC MAL LES W/M 11644

9300099 EXC MAL LES W/M 11646

9300100 EXC NAIL MATRIX 11750

9300101 EXC NECK LES SC 21552

9300102 EXC PILONIDAL C 11770

9300103 EXC PILONIDAL C 11772

9300104 EXC PILONIDAL CYST 11771

9300105 EXC SKIN & SUBQ HI 11450

9300106 EXC SKIN & SUBQ HI 11462

9300107 EXC SOFT TISSUE T 23076

9300108 EXC TUM SOFT TI 21555

9300109 EXC TUM SOFT TI 21930

9300110 EXC TUM SOFT TI 24075

9300111 EXC TUM SOFT TI 25075

9300112 EXC XTRNL HEMOR 46230

9300113 EXCISION TUMOR 21931

9300114 EXCISION TUMOR 21931

9300115 EXE MAL LES W/M 11600

9300116 EXE MAL LES W/M 11601

9300117 EXE MAL LES W/M 11602

9300118 EXE MAL LES W/M 11603

9300119 EXE MAL LES W/M 11604

9300120 EXE MAL LES W/M 11620

9300121 EXE MAL LES W/M 11606

9300122 EXE MAL LES W/M 11621

9300123 EXPL LAPT EXPL 47564

9300124 EXPL LAPT EXPL 49000

9300125 EXPL LAPT EXPL 49000

9300126 FINE NDL ASPIR 10021

9300127 FLUOR EXAM 76000

9300128 FOLLOW UP INPATIENT

9300129 FOREIGN BODY SKIN 10121

9300130 FOREIGN BODY SKIN 10120

9300131 HOSPITAL DISCHA 99239

9300132 HOSPITAL DISCHARGE 99238

9300133 HRHC CPLX/X10SV 46260

9300134 HRHC CPLX/X10SV 46260

9300135 HRHC SMPL 46255

Page 84: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300136 I & D PELVIS/HIP 26990

9300137 I & D PILONIDAAL CYS 10080

9300138 I & D UPR ARM/ELB 23930

9300139 I & D UPR ARM/ELB 23931

9300140 I & D VULVA/PRNL 56405

9300141 I&D ABSC COMP/M 10061

9300142 I&D ABSCESS 10060

9300143 I&D CPLX PO WND 10180

9300144 I&D DP ABSC BUR 27301

9300145 I&D HEMATOMA SKIN 10140

9300146 I&D ISCHIORCT 46040

9300147 I&D OF BARTHOLI 56420

9300148 I&D PELVIS/HIP 26990

9300149 I&D PERIANAL ABS 46050

9300150 I&D PILONIDAL CYST 10081

9300151 I&D SBMCSL ABSC 45005

9300152 IMPLTJ MESH/OTH 49568

9300153 IMPLTJ MESH/OTH 49568

9300154 INC THROMBOSED 46083

9300155 INGUINOFEM LMPH 38760

9300156 INITIAL HOSPITAL 99221

9300157 INITIAL HOSPITAL 99222

9300158 INITIAL HOSPITAL 99223

9300159 INITIAL INPATIENT 99251

9300160 INITIAL INPATIENT 99253

9300161 INITIAL INPATIENT 99254

9300162 INITIAL INPATIENT 99252

9300163 INITIAL INPATIENT 99255

9300164 INITIAL OBSERVATION 99218

9300165 INITIAL OBSERVATION 99218

9300166 INITIAL OBSERVATION 99219

9300167 INITIAL OBSERVATION 99220

9300168 INSJ NON-NDWELL 51701

9300169 LAP HERNIA REPAIR 49653

9300170 LAP SURG CHOLE 47562

9300171 LAPAROSCOPE SURGERY 49654

9300172 LAPAROSCOPY SUR 49652

9300173 LAPS ABD PRTM&O 49320

9300174 LAPS ABD PRTM&O 49320

9300175 LAPS CLST/SKN L 44188

9300176 LAPS ENTEROLSS 44180

9300177 LAPS ENTRC RESC 44202

9300178 LAPS FULG OVIDU 58670

9300179 LAPS FULG/EXC O 58662

9300180 LAPS FULG/EXE O 58662

9300181 LAPS LSS ADS SP 58660

9300182 LAPS RMVL ADNEX 58661

9300183 LAPS RMVL ADNEX 58661

9300184 LAPS SURG APPEN 44970

9300185 LAPS SURG APPEN 44970

9300186 LAPS SURG CHOLE 47564

9300187 LAPS SURG CHOLE 47563

Page 85: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300188 LAPS SURGE CHOLE 47564

9300189 LESION BIOPSY E 11101

9300190 MARSUPALIZATION 56440

9300191 MAST GYNECOMAST 19300

9300192 MAST MODF RAD W 19307

9300193 MAST PRTL 19301

9300194 MEASUREMENT OF 94760

9300196 NAIL REMOVAL PA 11730

9300197 NEGATIVE PRESSURE 97605

9300199 OBSERVATION CARE 99217

9300200 OFFICE CONSULTAION 99242

9300201 OFFICE CONSULTATION 99243

9300202 OFFICE CONSULTATION 99244

9300203 OFFICE CONSULTATION 99245

9300204 OFFICE CONSULTATION 99239

9300205 OFFICE CONSULTATION 99241

9300206 OFFICE EMERGENCY 99058

9300207 OFFICE OUTPATIENT 99202

9300208 OFFICE OUTPATIENT 99203

9300209 OFFICE OUTPATIENT 99204

9300210 OFFICE OUTPATIENT 99212

9300211 OFFICE OUTPATIENT 99213

9300212 OFFICE OUTPATIENT 99214

9300213 OFFICE/OUTPAITENT 99211

9300214 OFFICE/OUTPATIENT 99201

9300215 OFFICE/OUTPATIENT 99205

9300216 OFFICE/OUTPATIENT 99215

9300217 OMNTC EPIPLOECT 49255

9300218 OMNTC EPIPLOECT 49255

9300220 PARING/CUTTING 11056

9300221 PARING/CUTTING 11055

9300222 PARING/CUTTING 11057

9300224 PHELBOTOMY 99195

9300225 PHYSICIAN PHONE 99367

9300226 PNXR ASPIR ABSC 10160

9300227 PNXR ASPIR CST 19000

9300228 PNXR ASPIR CST 19001

9300229 PREVENTIVE COUN 99401

9300230 PREVENTIVE COUN 99402

9300231 PREVENTIVE COUN 99403

9300232 PROLONGED SERVICE 99354

9300233 PROLONGED SERVICE 99355

9300234 PROLONGED SERVICE 99356

9300235 PROLONGED SERVICE 99357

9300236 PROLONGED SERVICE 99358

9300237 PROLONGED SERVICE 99359

9300238 REMOVAL OF DAMA 11402

9300239 REMOVAL SKIN TAG MLT 11200

9300240 REMOVAL SKIN TAG MLT 11201

9300241 REMOVE DEVITALI 97597

9300242 REMVL FB UPR ARM 24200

9300243 REPAIR FIRST AB 49560

Page 86: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300244 REPAIR FIRST AB 49560

9300245 REPLACEMENT GAS 49452

9300247 RMVL EMBEDDED F 40804

9300248 RMVL FB FROM PH 42809

9300249 RMVL FECAL IMPACT 45915

9300250 RMVL PROSTC MAT 11008

9300251 RPR 1ST FEM HR 49550

9300252 RPR 1ST INCAL/V 49561

9300253 RPR 1ST INCAL/V 49561

9300254 RPR 1ST INGU H 49491

9300255 RPR 1ST INGU H 49505

9300256 RPR 1ST INGU H 49507

9300257 RPR 1ST INGUN H 49505

9300258 RPR CTR VAD W/S 36576

9300259 RPR EPIGASTRIC HRN 49570

9300260 RPR EPIGSTR HRN 49570

9300261 RPR RECRT INCAL 49565

9300262 RPR RECRT INCAL 49566

9300263 RPR RECRT INGUN 49520

9300264 RPR RECRT INGUN 49520

9300265 RPR RECRT INGUN 49521

9300266 RPR UMBILICAL 49585

9300267 RPR UMBILICAL H 49585

9300268 RPR UMBILICAL H 49587

9300269 RPSG GSTR FEEDI 43761

9300270 SALPINGECTOMY C 58700

9300271 SALPINGO-OOPHOR 58720

9300272 SCOPE OF COLON 45378

9300273 SCOPE OF COLON 45380

9300274 SCOPE OF SIGMOI 45330

9300275 SCOPE OF SIGMOI 45331

9300276 SHVG SKIN LES 1 11307

9300277 SHVG SKIN LES 1 11310

9300278 SHVG SKIN LES 1 11311

9300279 SHVG SKIN LESION 1 11300

9300280 SHVG SKIN LESION 1 11301

9300281 SHVG SKN LES 1 11302

9300282 SHVG SKN LES 1 11303

9300283 SHVG SKN LES 1 11305

9300284 SHVG SKN LES 1 11306

9300285 SHVG SKN LES 1 11308

9300286 SHVG SKN LES 1 11312

9300287 SHVG SKN LES 1 11313

9300288 SPECIAL REPORTS 99080

9300290 STOMACH-INTESTINE 43247

9300291 SUBSEQUENT HOSP 99231

9300292 SUBSEQUENT HOSP 99232

9300293 SUBSEQUENT HOSP 99233

9300294 SUBSEQUENT HOSP 99232

9300295 SUBSEQUENT OBS 99224

9300296 SUBSEQUENT OBS 99226

9300297 SUBSEQUENT OBSE 99225

Page 87: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9300298 SURGICAL CHANGE 43760

9300299 SURGICAL CHARGE 43760

9300300 SVC PRV BTW 10 99053

9300301 TABACCO COUN 99406

9300302 TABACCO COUN 99407

9300303 TAH RMVL TUBE 58150

9300304 THD PROCEDURE MULTIP 46946

9300305 TRIMMING NONDYS 11719

9300306 UMBILECTOMY OMP 49250

9300307 UNLIST LAPS PX H 49659

9300308 UNLISTED EVALUATION 99499

9300309 UPPER GI NDSC BAL 43249

9300310 UPPER GI NDSC DIL 43245

9300311 UPPER GI NDSC DIR 43246

9300312 UPPER GI NDSC RMV 43251

9300313 UPPER STOMACH-I 43235

9300314 UPPER STOMACH-I 43239

9300315 UPPER STOMACH-I 43235

9300316 UPPER STOMACH-I 43239

9300317 UPR GI NDSC BAL 43249

9300318 UPR GI NDSC DIR 43246

9300320 WART FLAT 1-14 17110

9300321 WEDGE EXC SKIN N 11765

9300322 WEDGE RESCJ/BIS 58920

9300323 PANNICULECTOMY 15830

9700008 NUTRITION THRPY F/W 97803

9700009 NUTRITION THRPY INT 97802

9700015 WEIGHT LOSS PROGRAM

12000108 INJECTION SCIATIC NERVE 64445

12500057 LIMBAL RELAXING INCISION 65772

41000002 MALYUGIN RING 7.0 MAL-0002

41000003 MALYUGIN RING 6.5 MAL-0001

41000004 CAPSULAR TENSION RING 10MM

41000005 CAPSULAR TENSION RING 11MM

41000006 CAPSULAR TENSION RING 12MM

41000007 MACKOOL CATARACT SUPPORT SYSTEM II

41000025 BONE WAX STERILE DYNJBW25

41000585 SUTURE ETHILON 2/0 ETH585H

41000807 APPLIED TROCAR BLADED 11X100 FOGCTB33

41000810 BLADE LARYNGOSCOPE MAC 2

41000991 SUTURE PDS LOOP 0 ETHPDPB991G

41001015 SURGIMESH T1015-8

41001210 SUTURE CHROMIC GUT 4/0 ETHG121H

41001301 JP DRAIN KIT WITH TROCAR/BULB SU130-1010

41001302 JP DRAIN SU130-1325

41002236 LOR SYRINGE 5CC PTX4903

41002237 TUOHY NEEDLE 18X3.5

41002238 TUOHY NEEDLE 18X5

41002239 QUINCKE SPINAL NEEDLE 22GX5

41002240 QUINCKE SPINAL NEEDLE 22GX3.5

41002241 RFA NEEDLE 20GX15CM CC15120-P

41002242 GROUNDING PAD DGP-PMC

Page 88: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

41002243 RFA NEEDLE 5CM CC5422-P

41002608 CHLORAPREP 26ML MDF260800

41002812 MEPILEX BORDER 3X3 SCP295200

41002813 MEPILEX BORDER 4X4 ALA295300

41002814 MEPILEX BORDER SACRUM 7 ALA282055Z

41002870 MEPILEX BORDER 6X6 SCP295400Z

41002901 PLEATMAN SAC 004942-901

41004030 I-GEL SUPRAGLOTTIC AIRWAY SZ 4 ISU820403

41004486 NEBULIZER PEDIATRIC KIT HCS4486

41004620 FILTERLINE MICROSTREAM ADT/PED SWDXS0462

41005030 I-GEL SUPRAGLOTTIC AIRWAY SZ 5 ISU820503

41006815 CHLORAPREP ORANGE TINT 26ML MDF260815

41008654 ET TUBE CUFFED 9.0 MLK86454

41009100 LAPAROSCOPY PACK DYNJP9100A

41009818 OPTICELL AG+ FIBER W/SILVER MSC9818EPZ

41009819 DRESSING CALCIUM ALGINATE SCP255100

41009820 DRESSING COLLAGEN J-JMA028

41009821 DRESSING HYDROFERA BLUE HTPHBRT2525

41009822 THREEFLEX COMPRESSION SYSTEM MSC4300

80000080 ET TUBE CUFF 7.5 MLK86451

80000120 BOVIE TEFLON SPATULA TIP ES0012BL

80000202 MEDTRONIC WRENCH KIT 5873W

80000650 POWER INJECTOR SYRINGE MRI SQK65VS

80000663 SKIN PREP TRAY CHG DYND70663

80001040 MINOR SETUP II PLUS DYNJS0104

80001065 BUTTERFLY DRESSING W/FOAM MSC1

80001301 TUBING OXYGEN HCS4507

80001551 BOVIE EXTENSION TIP ESE15516IX

80001621 ENDO-BOOT TIP PROTECTOR SM 00711621

80001622 ENDO-BOOT TIP PROTECTOR LG 00711622

80003035 BREAST BIOPSY/MINOR DYNJS3035

80003152 SCISSOR TIP ENDO 13.5MM 3152

80003382 BABCOCK GRASPER FORCEP 10MM 3382

80004230 UNCUFFED ET TUBE 3.5 PTXH4023P

80004315 UNCUFF ENDO TR TUBE 4.5 86226

80004316 TUBE ENDO TRACH C 6.5 MLK86449

80005008 RHINO ROCKET NASAL PACK MEDIUM SGY11S050

80005018 POOLE TIP SUCTION DYND50180

80006518 VISCOAT .75 8065183975

80007011 RECTAL TUBE 18FR DYND70110

80007102 RECTAL TUBE 24FR KDL155731

80007850 MEDTRONIC IPG ADDR01 ADAPTA DR IS-1 US

80008008 RHINO ROCKET NASAL PACK LG SGY11S08008

80009336 ALLDRESS 4X4 ALA265329Z

80009351 DRESSING SURESITE OPSITE 6X8 MSC2206Z

80009523 BOVIE SPATULA 90-9523

80009604 OPTIFOAM AG+ ADHESIVE MSC9604EPZ

80031437 INCENTIVE SPIROMETER DHD224000

80035539 TUBE ET CUFF3.0 PED 4130086043

80035764 ET TUBE CUFF 7.0 MLK86450

80036239 ET TUBE CUFF 8.0 MLK86452

80037023 TUBE ET UNCUFF 6.5

Page 89: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

80060019 HEEL PROTECTOR FOOT PILLOW NON0097

80065056 MASK VENTURI HCS120E

80065193 POWERLOC NEEDLE 19GX.75 BAR0651934

80068002 BLOOD SETS BHL2C8750

80069031 BERMAN AIRWAY 8MM DYND60415

80069032 BERMAN AIRWAY 9MM DYND60420

80069033 BERMAN AIRWAY 10CM DYND60425

80069034 BERMAN AIRWAY 7MM DYND60412

80069035 BERMAN AIRWAY 6MM DYND60410

80069038 NASAL AIRWAY RSH125200280

80070001 YANKAUR TUBING DYND50138

80070002 SMOKE EVACUATOR TUBING MEN6084

80070026 TRACH TUBE CUFF 4.5 4130086445

80070027 TRACH TUBE CUFF 5.5 4130086228

80070028 TRACH UNCUFF 4.0 4130086225

80070029 TRACH UNCUFF 5.0 4130086227

80070030 TRACH UNCUFF 5.5 MLK86228

80070031 TRACH UNCUFF 2.5 KDL510405

80070032 ET TUBE 8.5 CUFFED MLK86453

80070033 TRACH UNCUFF 5.5 DYND48055

88000010 DERMATOME BLADE 0088000010

90000017 OPTIFOAM HEEL WOUND DRESSING MSC1200EPZ

90000028 OPSITE POSTOP DRESSING 3.5 UTD66000709Z

90000029 OPSITE DRESSING 4.75 UTD66000710Z

90000036 DIRECT CONNECT ELECTRODE CND31121731

90000064 K-PAD TEMP THERAPY

90000103 MINOR SETUP SURG TRAY DYNJS0103

90000108 DUOVISC - OR (EYES)

90000183 SUTURE A183H 4-0 SILK TIES

90000184 SUTURE A184H 3-0 SILK TIES

90000188 SUTURE A185H 2-0 SILK TIES

90000277 ELECTRODE DEFIB ADULT PN22770R

90000435 CLIPPER BLADE DYND70850

90000617 ENDO CLEANING BRUSH CND000617

90000706 SHOE POST OP F/L ORT30300WL

90000804 BIOPSY NEEDLE T-LOK DBMNJ0804TL

90000806 BIOPSY NEEDLE T-LOK DBMNJ0806TL

90001039 SAW BLADE SAGITTAL ZS-039

90001100 REVEAL LINQ SYSTEM LINQSYS C1764

90001132 EYE HYDRODISSECTOR B-D585037

90001203 PLEURAGUIDE CHEST TUBE KIT IUM17100

90001465 BOVIE TIP NEEDLE COATED VALLEY LAB E1465

90001819 ALARM BED PAD 96 CORD 107517

90001879 ALARM CHAIR PAD 96 CORD 107477

90001951 SURGICEL ETH1951Z

90002312 SKIN AFFIX ADHESIVE

90002543 STOCKINETTE IMP 16X48 NON22550

90003301 DRESSING XEROFORM 1X8 SWD431302Z

90004251 EYE IRRIGATING CYSTITOME 8065-4251

90004660 END TIDAL CO2 PHYSIOCONTROL 11996-000080

90005020 ANST BREATH CIRCUIT ADLT DYNJAA0011

90005445 ANST MASK SMALL 005455

Page 90: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

90005455 ANST MASK MED PTX005445

90005465 ANST MASK LARGE PTX005465

90005836 ENDO BALLOON ESOPH CRE 5836

90005838 ENDO BALLOON ESOPH CRE 5838

90006952 PREP DURAPREP MMM8630

90009276 PACK PERI/GYN 29171

90009326 IOBAN MMM6640EZH

90009396 ENDO SPONGE K-C69396

90011301 BASIN MAJOR LAP DYNJS0301

90022540 STOCKINETTE IMP 14X48 NON22540

90023374 EXTENSION INTERLINK SET BAX2N3374

90031605 DRESS PETROLATUM XEROFORM 5X9 SWD433605Z

90032771 FORCEP BIOP 240 1598

90052348 MASTISOL SURG ADHEV FRN052348Z

90062090 DRAIN PENROSE 1/2 DYND50428

90062211 FEEDING TUBE ENDOVIVE 24F M00566491

90073910 BLADE SZ 10 SAFETY B-D373910Z

90073911 BLADE SIZE 11 SAFETY 373911

90073915 BLADE SIZE 15 SAFETY B-D373915

90079028 BITE BLOCK ST-94

90093592 NEEDLE COUNTER NC60FSBR

90095614 SPLINT ORTHOGLASS 5 SCSOG5L2

90099820 T TUBE 14 FR BRD0099820

2101094 SOOTHE & COOL MOISTURE BARRIER OINTME

2102230 ORBACTIV/D5 IVPB : 1200MG/1000ML J2407

4100440 ENDO SPOT MARKER GIS-44

90000009 INTRAOSSEOUS NEEDLE 45MM LG 9079-VC-005

90000014 INTRAOSSEOUS NEEDLE 25MM 9001-VC-005

90000015 INTRAOSSEOUS NEEDLE 15MM 9018-VC-005

Page 91: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

Charge

231.00$

233.00$

32.00$

2,128.00$

2,734.00$

1,933.00$

414.00$

465.00$

1,163.00$

268.00$

652.00$

469.00$

263.00$

1,215.00$

258.00$

1,833.00$

1,833.00$

1,833.00$

1,833.00$

2,128.00$

235.00$

156.00$

427.00$

504.00$

357.00$

183.00$

583.00$

270.00$

165.00$

245.00$

156.00$

156.00$

226.00$

2,348.00$

114.00$

321.00$

331.00$

100.00$

698.00$

91.00$

733.00$

176.00$

17.00$

21.00$

14.00$

321.00$

42.00$

82.00$

638.00$

1,185.00$

1,161.00$

Page 92: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

116.00$

80.00$

85.00$

254.00$

279.00$

348.00$

127.00$

42.00$

85.00$

40.00$

115.00$

36.00$

61.00$

895.00$

48.00$

20.00$

38.00$

48.00$

265.00$

262.00$

67.00$

78.00$

91.00$

91.00$

91.00$

91.00$

91.00$

91.00$

4,405.00$

4,405.00$

4,405.00$

4,405.00$

543.00$

73.00$

3,907.00$

73.00$

8.00$

8.00$

73.00$

42.00$

42.00$

854.00$

42.00$

42.00$

2,059.00$

775.00$

636.00$

115.00$

115.00$

2,193.00$

2,193.00$

73.00$

Page 93: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

73.00$

73.00$

115.00$

962.00$

115.00$

3,704.00$

9,287.00$

9,287.00$

73.00$

42.00$

42.00$

73.00$

115.00$

1,812.00$

2,714.00$

3,616.00$

4,536.00$

5,455.00$

6,375.00$

2,652.00$

13,476.00$

1,856.00$

67.00$

73.00$

73.00$

73.00$

16.00$

7,293.00$

8,195.00$

9,097.00$

9,999.00$

2,117.00$

529.00$

529.00$

2,117.00$

529.00$

529.00$

771.00$

1,087.00$

1,738.00$

795.00$

771.00$

771.00$

771.00$

2,117.00$

529.00$

529.00$

2,117.00$

529.00$

529.00$

771.00$

1,087.00$

Page 94: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,738.00$

795.00$

771.00$

1,738.00$

1,738.00$

3,622.00$

3,622.00$

1,217.00$

771.00$

771.00$

1,712.00$

1,712.00$

771.00$

1,712.00$

2,117.00$

529.00$

2,117.00$

529.00$

5,073.00$

1,268.00$

5,073.00$

1,268.00$

19,075.00$

57,862.00$

87,859.00$

2,117.00$

529.00$

2,117.00$

529.00$

225.00$

771.00$

771.00$

1,712.00$

87.00$

102.00$

143.00$

130.00$

403.00$

386.00$

138.00$

102.00$

605.00$

721.00$

133.00$

605.00$

369.00$

109.00$

403.00$

605.00$

133.00$

345.00$

269.00$

Page 95: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

403.00$

688.00$

605.00$

133.00$

605.00$

345.00$

403.00$

403.00$

102.00$

102.00$

102.00$

150.00$

102.00$

143.00$

102.00$

102.00$

143.00$

133.00$

143.00$

150.00$

102.00$

102.00$

143.00$

145.00$

145.00$

102.00$

130.00$

130.00$

708.00$

102.00$

130.00$

143.00$

145.00$

145.00$

929.00$

31.00$

145.00$

130.00$

102.00$

102.00$

150.00$

145.00$

102.00$

102.00$

143.00$

143.00$

143.00$

150.00$

102.00$

102.00$

102.00$

102.00$

Page 96: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

102.00$

130.00$

102.00$

125.00$

102.00$

102.00$

143.00$

205.00$

128.00$

130.00$

1.00$

21.00$

17.00$

21.00$

130.00$

102.00$

130.00$

143.00$

143.00$

130.00$

150.00$

102.00$

102.00$

150.00$

130.00$

125.00$

825.00$

143.00$

102.00$

145.00$

102.00$

143.00$

130.00$

130.00$

145.00$

130.00$

145.00$

145.00$

488.00$

731.00$

806.00$

999.00$

119.00$

13.00$

72.00$

1,489.00$

1,875.00$

1,491.00$

1,677.00$

1,972.00$

1,972.00$

1,491.00$

Page 97: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,294.00$

1,491.00$

1,875.00$

442.00$

2,366.00$

2,316.00$

1,972.00$

1,923.00$

1,972.00$

2,564.00$

1,380.00$

2,705.00$

2,688.00$

2,627.00$

2,738.00$

2,627.00$

3,208.00$

2,815.00$

2,516.00$

1,923.00$

3,930.00$

2,614.00$

3,422.00$

2,546.00$

3,425.00$

3,098.00$

3,349.00$

2,578.00$

202.00$

1,040.00$

1,380.00$

1,368.00$

1,672.00$

275.00$

790.00$

1,032.00$

1,429.00$

645.00$

662.00$

979.00$

1,435.00$

3,057.00$

1,358.00$

3,557.00$

178.00$

1,684.00$

2,615.00$

2,615.00$

5,230.00$

5,412.00$

2,708.00$

436.00$

Page 98: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9,711.00$

404.00$

404.00$

507.00$

190.00$

318.00$

444.00$

318.00$

342.00$

342.00$

318.00$

161.00$

385.00$

165.00$

249.00$

202.00$

163.00$

510.00$

137.00$

1,634.00$

3,193.00$

1,894.00$

293.00$

857.00$

770.00$

266.00$

1,894.00$

1,456.00$

516.00$

2,118.00$

409.00$

1,036.00$

178.00$

406.00$

39.00$

331.00$

2,795.00$

832.00$

741.00$

754.00$

52.00$

754.00$

477.00$

947.00$

464.00$

2,819.00$

203.00$

491.00$

480.00$

24.00$

15.00$

1,341.00$

Page 99: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

373.00$

398.00$

106.00$

344.00$

348.00$

115.00$

115.00$

75.00$

82.00$

197.00$

216.00$

580.00$

410.00$

814.00$

703.00$

138.00$

106.00$

174.00$

144.00$

138.00$

106.00$

119.00$

116.00$

75.00$

75.00$

124.00$

218.00$

61.00$

14.00$

656.00$

98.00$

853.00$

557.00$

155.00$

347.00$

292.00$

240.00$

137.00$

282.00$

211.00$

1,013.00$

142.00$

115.00$

349.00$

349.00$

152.00$

140.00$

185.00$

128.00$

112.00$

118.00$

231.00$

Page 100: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

115.00$

197.00$

210.00$

151.00$

152.00$

120.00$

148.00$

180.00$

117.00$

115.00$

115.00$

154.00$

89.00$

31.00$

162.00$

162.00$

162.00$

139.00$

125.00$

383.00$

399.00$

182.00$

267.00$

383.00$

180.00$

6.00$

349.00$

349.00$

349.00$

349.00$

180.00$

151.00$

383.00$

142.00$

137.00$

162.00$

162.00$

197.00$

115.00$

231.00$

152.00$

152.00$

152.00$

155.00$

125.00$

399.00$

182.00$

210.00$

148.00$

115.00$

2.00$

3.00$

Page 101: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

28.00$

20.00$

1.00$

11.00$

8.00$

8.00$

16.00$

594.00$

26.00$

12.00$

8.00$

283.00$

1.00$

2.00$

1,041.00$

3.00$

47.00$

181.00$

181.00$

37.00$

376.00$

434.00$

575.00$

971.00$

1,369.00$

3,842.00$

42.00$

241.00$

241.00$

53.00$

113.00$

84.00$

84.00$

42.00$

42.00$

8.00$

1,165.00$

84.00$

84.00$

253.00$

295.00$

125.00$

349.00$

42.00$

84.00$

42.00$

16.00$

116.00$

33.00$

265.00$

1.00$

2.00$

Page 102: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3.00$

3.00$

5.00$

74.00$

84.00$

92.00$

3.00$

117.00$

122.00$

162.00$

1,036.00$

3.00$

3.00$

2.00$

23.00$

11.00$

8.00$

16.00$

8.00$

8.00$

16.00$

18.00$

16.00$

16.00$

16.00$

16.00$

16.00$

18.00$

21.00$

107.00$

9.00$

20.00$

21.00$

21.00$

28.00$

17.00$

18.00$

18.00$

8.00$

1.00$

98.00$

169.00$

1.00$

23.00$

101.00$

101.00$

140.00$

206.00$

61.00$

141.00$

108.00$

145.00$

Page 103: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

105.00$

206.00$

145.00$

61.00$

66.00$

66.00$

427.00$

583.00$

558.00$

674.00$

27.00$

28.00$

34.00$

53.00$

116.00$

116.00$

53.00$

74.00$

45.00$

53.00$

53.00$

116.00$

53.00$

116.00$

419.00$

419.00$

61.00$

210.00$

133.00$

61.00$

61.00$

149.00$

27.00$

81.00$

120.00$

96.00$

169.00$

169.00$

290.00$

496.00$

68.00$

79.00$

464.00$

102.00$

66.00$

232.00$

87.00$

110.00$

340.00$

134.00$

99.00$

437.00$

Page 104: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

116.00$

98.00$

84.00$

127.00$

126.00$

92.00$

10.00$

437.00$

28.00$

98.00$

53.00$

65.00$

92.00$

116.00$

146.00$

169.00$

53.00$

65.00$

77.00$

92.00$

116.00$

65.00$

92.00$

116.00$

146.00$

169.00$

169.00$

65.00$

92.00$

105.00$

116.00$

146.00$

146.00$

169.00$

185.00$

205.00$

92.00$

116.00$

65.00$

92.00$

116.00$

146.00$

169.00$

181.00$

169.00$

181.00$

90.00$

113.00$

116.00$

146.00$

142.00$

164.00$

Page 105: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

116.00$

146.00$

169.00$

92.00$

116.00$

74.00$

45.00$

29.00$

17.00$

1,712.00$

1,217.00$

159.00$

7.00$

6.00$

9.00$

68.00$

162.00$

6.00$

5.00$

180.00$

5.00$

18.00$

11.00$

22.00$

25.00$

5.00$

5.00$

5.00$

5.00$

7.00$

175.00$

31.00$

103.00$

26.00$

52.00$

77.00$

18.00$

11.00$

5.00$

10.00$

6.00$

6.00$

6.00$

14.00$

5.00$

36.00$

10.00$

26.00$

26.00$

47.00$

8.00$

14.00$

Page 106: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

276.00$

18.00$

9.00$

10.00$

10.00$

47.00$

7.00$

30.00$

13.00$

5.00$

5.00$

24.00$

6.00$

5.00$

99.00$

16.00$

16.00$

29.00$

6.00$

125.00$

156.00$

160.00$

180.00$

5.00$

5.00$

10.00$

10.00$

10.00$

6.00$

6.00$

6.00$

5.00$

5.00$

10.00$

70.00$

10.00$

47.00$

51.00$

15.00$

47.00$

6.00$

5.00$

7.00$

13.00$

5.00$

10.00$

10.00$

17.00$

2,820.00$

10.00$

18.00$

5.00$

Page 107: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

43.00$

100.00$

225.00$

14.00$

5.00$

5.00$

5.00$

5.00$

86.00$

12.00$

26.00$

23.00$

52.00$

6.00$

180.00$

15.00$

36.00$

65.00$

36.00$

73.00$

32.00$

73.00$

260.00$

267.00$

216.00$

5.00$

6.00$

10.00$

7.00$

21.00$

6.00$

10.00$

5.00$

6.00$

5.00$

6.00$

6.00$

6.00$

10.00$

12.00$

10.00$

11.00$

5.00$

156.00$

7.00$

6.00$

23.00$

14.00$

5.00$

20.00$

10.00$

12.00$

Page 108: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

364.00$

15.00$

16.00$

10.00$

416.00$

48.00$

1,000.00$

7.00$

10.00$

40.00$

5.00$

10.00$

10.00$

5.00$

33.00$

26.00$

11.00$

26.00$

38.00$

40.00$

40.00$

5.00$

40.00$

40.00$

40.00$

40.00$

40.00$

38.00$

40.00$

40.00$

26.00$

40.00$

10.00$

5.00$

61.00$

6.00$

12.00$

62.00$

5.00$

99.90$

37.00$

5.00$

17.00$

5.00$

5.00$

73.00$

7,276.00$

35.00$

5.00$

7.00$

5.00$

36.00$

Page 109: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

5.00$

52.00$

52.00$

5.00$

10.00$

338.00$

192.00$

12.00$

10.00$

10.00$

5.00$

5.00$

5.00$

21.00$

37.00$

260.00$

5.00$

7.00$

68.00$

12.00$

7.00$

78.00$

12.00$

66.00$

60.00$

21.00$

68.00$

52.00$

21.00$

5.00$

29.00$

5.00$

22.00$

5.00$

5.00$

5.00$

5.00$

5.00$

6.00$

10.00$

74.00$

7.00$

5.00$

6.00$

404.00$

5.00$

3,432.00$

78.00$

6.00$

156.00$

5.00$

6.00$

Page 110: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6.00$

185.00$

6.00$

26.00$

5.00$

12.00$

6.00$

6.00$

9.00$

2,572.00$

7.00$

30.00$

6.00$

10.00$

575.30$

229.00$

314.00$

293.00$

84.00$

213.00$

21.00$

207.00$

15.00$

37.00$

10.00$

172.00$

23.00$

98.00$

49.00$

104.00$

30.00$

10.00$

5.00$

16.00$

7.00$

26.00$

18.00$

7.00$

8.00$

5.00$

212.00$

145.00$

18.00$

12.00$

16.00$

48.00$

5.00$

484.00$

99.00$

16.00$

17.00$

5.00$

Page 111: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

20.00$

10.00$

17.00$

2,912.00$

12.00$

15.00$

6.00$

255.00$

17.00$

24.00$

107.00$

93.00$

228.00$

17.00$

6.00$

5.00$

52.00$

25.00$

187.00$

233.00$

5.00$

21.00$

31.00$

85.00$

11.00$

31.00$

156.00$

16.00$

17.00$

15.00$

104.00$

41.00$

50.00$

28.77$

19.00$

21.00$

68.00$

172.00$

70.00$

26.00$

18.00$

70.00$

27.00$

7.00$

14.00$

5.00$

5.00$

172.00$

6.00$

8.00$

572.00$

104.00$

Page 112: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

116.00$

8.00$

6.00$

10.00$

310.00$

10.00$

17.08$

31.00$

5.00$

17.00$

16.00$

6.00$

454.00$

5.00$

31.00$

325.00$

5.00$

36.00$

302.00$

14.00$

114.00$

17.06$

268.00$

67.00$

172.00$

3,750.00$

52.00$

30.00$

257.00$

6.00$

119.00$

91.00$

221.00$

6.00$

94.00$

5.00$

6.00$

8.00$

16.00$

6.00$

6.00$

78.00$

21.00$

8.00$

6.00$

5.00$

8.00$

14.00$

62.00$

5.00$

8.00$

749.00$

Page 113: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

258.00$

5.00$

14.00$

11.00$

42.00$

256.00$

6.00$

33.00$

5.00$

51.00$

132.00$

107.00$

6.00$

6.00$

62.00$

15.00$

5.00$

6.00$

8.00$

15.00$

47.00$

6.00$

11.00$

5.00$

6.00$

591.00$

6.00$

6.00$

208.00$

61.00$

27.00$

22.00$

5.00$

6.00$

156.00$

40.00$

6.00$

4,283.00$

2,141.00$

5.00$

5.00$

78.00$

31.00$

5.00$

2,080.00$

7.00$

6.00$

43.00$

21.00$

6.00$

6.00$

468.00$

Page 114: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9.00$

36.00$

5.00$

46.00$

1,718.00$

10.00$

5.00$

5.00$

7.00$

190.00$

5.00$

6.00$

3,536.00$

126.00$

312.00$

6.00$

1,846.00$

75.00$

14.00$

11.00$

5.00$

17.00$

50.00$

6.00$

8.00$

52.00$

7.00$

32.00$

725.00$

22.00$

153.00$

5.00$

6.00$

96.00$

307.00$

6.00$

5.00$

5.00$

6.00$

10.00$

5.00$

11.00$

78.00$

182.00$

149.00$

5.00$

7.00$

15.00$

5.00$

6.00$

14.00$

35.44$

Page 115: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

19.00$

216.00$

5.00$

234.00$

6.00$

26.00$

5.00$

50.00$

5.00$

5.00$

10.00$

6.00$

10.00$

6.00$

25.00$

2,007.00$

6.00$

1.00$

6.00$

6.00$

35.00$

11.00$

60.00$

73.00$

68.00$

5.00$

51.00$

6.00$

223.00$

11.00$

9.00$

6.00$

5.00$

6.00$

6.00$

364.00$

342.00$

371.00$

227.00$

6.00$

5.00$

730.00$

50.00$

40.00$

52.00$

5.00$

62.00$

5.00$

2,256.00$

40.00$

5.00$

5.00$

Page 116: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

22.00$

312.00$

152.00$

147.00$

286.00$

26.00$

31.00$

28.00$

125.00$

57.00$

24.00$

99.00$

10.00$

223.00$

40.00$

40.00$

263.00$

208.00$

11.00$

50.00$

11.00$

75.00$

43.00$

31.00$

36.00$

8.00$

214.00$

6.00$

158.00$

232.00$

130.00$

156.00$

6.00$

5.00$

90.00$

121.00$

12.00$

5.00$

6.00$

5.00$

5.00$

22.00$

5.00$

5.00$

58.00$

11.00$

6.00$

388.00$

388.00$

27.00$

11.00$

7.00$

Page 117: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

11.00$

24.00$

14.00$

11.00$

5.00$

1,400.00$

112.00$

5.00$

2,567.00$

184.00$

5.00$

12.00$

5.00$

6.00$

12.00$

10.00$

645.00$

10.00$

10.00$

18.00$

26.00$

9.00$

21.00$

50.00$

50.00$

90.00$

50.00$

50.00$

6.00$

50.00$

9.00$

11.00$

12.00$

11.00$

5.00$

33.00$

16.00$

10.00$

5.00$

5.00$

5.00$

17.00$

9.00$

5.00$

5.00$

6.00$

88.00$

20.00$

8.88$

26.00$

8.00$

5.00$

Page 118: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

5.00$

20.00$

5.00$

75.00$

2,080.00$

1,040.00$

45.00$

5.00$

5.00$

17.00$

7.00$

5.00$

5.00$

5.00$

2.50$

23.00$

21.00$

26.00$

29.00$

31.00$

20.00$

157.00$

28.00$

26.00$

48.00$

18.00$

5.00$

75.00$

19.00$

182.00$

3.00$

5.00$

14.00$

5.00$

5.00$

36.00$

16.00$

58.00$

14.00$

5.00$

7.00$

5.00$

26.00$

5.00$

16.00$

15.00$

15.00$

20.00$

16.00$

5.00$

11.00$

20.00$

Page 119: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

20.00$

7.00$

10.00$

22.00$

572.00$

10.00$

156.00$

7.00$

7.00$

21.00$

156.00$

260.00$

292.00$

12.00$

10.00$

31.00$

22.00$

156.00$

44.00$

16.00$

6.00$

33.00$

16.00$

13.50$

503.00$

135.00$

208.00$

12.00$

68.00$

5.00$

50.00$

50.00$

156.00$

22.00$

26.00$

40.00$

5.00$

26.00$

265.00$

286.00$

54.00$

21.00$

88.00$

26.00$

100.00$

16.00$

3.00$

156.00$

10.00$

16.00$

5.00$

182.00$

Page 120: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

234.00$

260.00$

20.00$

26.00$

125.00$

24.00$

5.00$

40.00$

10.00$

25.00$

36.00$

5.00$

5.00$

208.00$

10.00$

26.00$

20.00$

18.00$

43.00$

702.00$

129.00$

16.00$

5.00$

5.00$

66.00$

182.00$

37.00$

16.00$

5.00$

20.00$

40.00$

40.00$

5.00$

31.00$

21.00$

6.00$

3.00$

25.00$

18.00$

29.00$

25.00$

331.00$

25.00$

66.00$

66.00$

66.00$

468.00$

18.25$

172.00$

20.00$

390.00$

450.00$

Page 121: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

400.00$

160.00$

28.50$

5.00$

35.00$

5.00$

66.00$

85.00$

5.00$

20.00$

115.00$

25.00$

25.00$

24.76$

145.00$

15.00$

20.00$

1,100.00$

5.00$

5.00$

1,500.00$

25.00$

265.00$

5.00$

225.00$

15.00$

25.00$

40.00$

8.00$

21.53$

825.00$

15.00$

200.00$

5.00$

75.00$

36.00$

68.00$

18.50$

31.00$

45.00$

322.32$

104.00$

32.00$

5.00$

10.00$

6.00$

159.00$

10.00$

17.00$

5.00$

5.00$

25.00$

Page 122: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

20.00$

25.00$

100.00$

168.00$

5.00$

5.00$

197.00$

6.00$

5.00$

40.00$

37.00$

5.00$

25.00$

10.00$

66.00$

20.00$

25.00$

6.00$

5.00$

5.00$

45.00$

6.00$

240.00$

10.00$

245.00$

412.00$

5.00$

25.00$

15.00$

130.00$

4.00$

5.00$

45.00$

8.00$

10.00$

45.00$

8,553.00$

52.00$

66.00$

25.00$

73.00$

73.00$

11.00$

30.00$

15.00$

23.00$

25.00$

5.00$

5.00$

5.00$

3,000.00$

30.00$

Page 123: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

25.00$

5.00$

24.50$

295.00$

5.00$

5.00$

10.00$

16.00$

10.00$

89.00$

26.00$

41.00$

8.00$

5.00$

10.00$

40.00$

5,300.00$

28.50$

95.00$

120.00$

1,340.00$

33.00$

24.00$

26.70$

35.00$

1,967.00$

45.00$

197.00$

45.00$

15.00$

5.00$

12.00$

22.00$

5.00$

15.00$

15.00$

5.00$

20.00$

2.00$

5.00$

100.00$

5.00$

5.00$

26.00$

10.00$

5.00$

5.00$

50.00$

5.00$

130.00$

75.00$

5.00$

Page 124: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

21.53$

5.00$

39.00$

41.00$

6.00$

85.00$

27.00$

6.00$

10.00$

322.32$

5.00$

10.00$

15.00$

20.00$

41.00$

24.00$

24.00$

17.00$

5.00$

75.00$

450.00$

35.00$

10.00$

6.00$

24.88$

8.50$

750.00$

1,600.00$

1,620.56$

1,580.56$

30.00$

10.00$

7.50$

10.00$

5.00$

117.50$

12.00$

22.50$

5.00$

8.50$

21.06$

5.00$

55.00$

25.00$

5.00$

20.00$

486.00$

10.00$

30.00$

135.00$

98.00$

500.00$

Page 125: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

5.00$

5.00$

5,000.00$

500.00$

64.00$

7.50$

114.00$

5.00$

7.00$

5.00$

5.00$

8.00$

10.00$

10.00$

6.00$

1,603.39$

2,490.35$

2,490.35$

4,980.69$

5,154.44$

2,579.36$

415.06$

9,248.17$

385.03$

385.03$

482.63$

181.25$

302.45$

422.57$

302.45$

326.04$

326.04$

302.45$

153.37$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

51.00$

148.00$

120.00$

26.00$

26.00$

Page 126: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

81.00$

77.00$

246.00$

84.00$

68.00$

108.00$

134.00$

72.00$

226.00$

32.00$

226.00$

330.00$

231.00$

163.00$

110.00$

194.00$

78.00$

44.00$

332.00$

94.00$

214.00$

190.00$

616.00$

191.00$

106.00$

127.00$

36.00$

168.00$

411.00$

173.00$

241.00$

51.00$

51.00$

13.72$

132.00$

205.00$

11.00$

358.00$

106.00$

123.00$

205.00$

344.00$

550.00$

376.00$

335.00$

52.00$

69.00$

401.00$

463.00$

241.00$

184.00$

141.00$

Page 127: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

214.00$

211.00$

101.00$

188.00$

214.00$

99.00$

188.00$

84.00$

182.00$

154.00$

381.00$

131.00$

443.00$

584.00$

147.00$

104.00$

154.00$

175.00$

58.00$

71.00$

207.00$

142.00$

609.00$

81.00$

138.00$

184.00$

190.00$

103.00$

286.00$

555.00$

96.00$

104.00$

120.00$

305.00$

359.00$

242.00$

116.00$

285.00$

214.00$

214.00$

214.00$

226.00$

262.00$

29.00$

71.00$

71.00$

546.00$

366.00$

77.00$

335.00$

163.00$

82.00$

Page 128: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

421.00$

48.00$

214.00$

197.00$

262.00$

242.00$

160.00$

376.00$

58.00$

67.00$

295.00$

357.00$

160.00$

265.00$

148.00$

128.00$

216.00$

386.00$

357.00$

106.00$

197.00$

90.00$

192.00$

171.00$

160.00$

141.00$

106.00$

163.00$

262.00$

103.00$

156.00$

67.00$

72.00$

72.00$

72.00$

122.00$

242.00$

144.00$

274.00$

122.00$

584.00$

178.00$

122.00$

197.00$

128.00$

148.00$

160.00$

182.00$

92.00$

202.00$

347.00$

77.00$

Page 129: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

173.00$

122.00$

194.00$

332.00$

197.00$

142.00$

156.00$

270.00$

106.00$

83.00$

154.00$

149.00$

138.00$

190.00$

156.00$

122.00$

138.00$

99.00$

138.00$

140.00$

492.00$

425.00$

317.00$

183.00$

197.00$

130.00$

475.00$

110.00$

110.00$

438.00$

101.00$

242.00$

192.00$

94.00$

94.00$

204.00$

98.00$

216.00$

83.00$

83.00$

191.00$

188.00$

231.00$

503.00$

291.00$

88.00$

190.00$

168.00$

174.00$

116.00$

226.00$

602.00$

Page 130: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

125.00$

101.00$

101.00$

83.00$

101.00$

509.00$

23.00$

158.00$

241.00$

161.00$

110.00$

154.00$

118.00$

494.00$

292.00$

582.00$

279.00$

176.00$

98.00$

449.00$

106.00$

154.00$

841.00$

94.00$

194.00$

29.00$

29.00$

186.00$

396.00$

104.00$

61.00$

71.00$

541.00$

101.00$

120.00$

190.00$

203.00$

120.00$

154.00$

85.00$

154.00$

360.00$

270.00$

291.00$

291.00$

149.00$

160.00$

75.00$

130.00$

182.00$

52.00$

68.00$

Page 131: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

83.00$

226.00$

69.00$

60.00$

57.00$

63.00$

29.00$

68.00$

154.00$

90.00$

420.00$

121.00$

108.00$

579.00$

122.00$

122.00$

434.00$

383.00$

154.00$

120.00$

154.00$

120.00$

1,275.00$

83.00$

120.00$

281.00$

281.00$

122.00$

662.00$

191.00$

120.00$

128.00$

457.00$

492.00$

120.00$

452.00$

161.00$

31.00$

41.00$

184.00$

320.00$

914.00$

369.00$

479.00$

182.00$

292.00$

1,780.00$

20.42$

6.87$

101.00$

55.00$

11.00$

Page 132: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

469.00$

457.00$

138.00$

138.00$

138.00$

55.00$

220.00$

159.00$

99.00$

81.00$

140.00$

197.00$

83.00$

44.00$

230.00$

400.00$

406.00$

230.00$

331.00$

599.00$

425.00$

387.00$

387.00$

308.00$

421.00$

201.00$

132.00$

140.00$

127.00$

28.00$

38.00$

320.00$

94.00$

191.00$

81.00$

99.00$

122.00$

423.00$

63.00$

200.00$

83.00$

118.00$

32.00$

68.00$

121.00$

83.00$

641.00$

67.00$

101.00$

98.00$

55.00$

132.00$

Page 133: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

609.00$

55.00$

159.00$

115.00$

243.00$

81.00$

103.00$

859.00$

41.00$

141.00$

823.00$

204.00$

267.00$

201.00$

118.00$

248.00$

173.00$

130.00$

173.00$

132.00$

118.00$

173.00$

171.00$

132.00$

173.00$

183.00$

173.00$

211.00$

483.00$

173.00$

579.00$

116.00$

372.00$

460.00$

133.00$

173.00$

1,170.00$

275.00$

81.00$

609.00$

197.00$

99.00$

98.00$

177.00$

17.00$

68.00$

132.00$

114.00$

106.00$

85.00$

323.00$

168.00$

Page 134: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

46.00$

17.00$

114.00$

138.00$

335.00$

98.00$

92.00$

438.00$

122.00$

597.00$

504.00$

219.00$

636.00$

396.00$

728.00$

31.00$

712.00$

176.00$

98.00$

748.00$

92.00$

593.00$

226.00$

148.00$

92.00$

190.00$

419.00$

164.00$

710.00$

340.00$

305.00$

101.00$

122.00$

211.00$

83.00$

83.00$

83.00$

118.00$

312.00$

88.00$

90.00$

97.00$

446.00$

344.00$

97.00$

106.00$

106.00$

94.00$

94.00$

52.00$

121.00$

83.00$

Page 135: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

463.00$

360.00$

77.00$

108.00$

214.00$

340.00$

106.00$

177.00$

156.00$

92.00$

85.00$

833.00$

21.00$

92.00$

168.00$

173.00$

149.00$

88.00$

101.00$

101.00$

133.00$

253.00$

130.00$

184.00$

125.00$

140.00$

77.00$

99.00$

947.00$

154.00$

97.00$

525.00$

173.00$

28.00$

244.00$

38.00$

163.00$

130.00$

186.00$

125.00$

103.00$

364.00$

186.00$

149.00$

176.00$

121.00$

38.00$

203.00$

92.00$

106.00$

38.00$

898.00$

Page 136: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

108.00$

142.00$

163.00$

832.00$

159.00$

78.00$

129.00$

181.00$

297.00$

382.00$

716.00$

343.00$

197.00$

134.00$

814.00$

159.00$

99.00$

138.00$

317.00$

140.00$

67.00$

114.00$

203.00$

203.00$

1,634.00$

260.00$

130.00$

200.00$

54.00$

26.00$

174.00$

31.00$

793.00$

62.00$

51.00$

304.00$

53.00$

191.00$

334.00$

256.00$

54.00$

936.00$

1,529.00$

5,644.00$

2,730.00$

173.00$

176.00$

156.00$

366.32$

63.00$

212.00$

54.00$

Page 137: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

182.00$

118.00$

81.00$

182.00$

242.00$

262.00$

584.00$

122.00$

122.00$

334.00$

83.00$

154.00$

138.00$

138.00$

125.00$

242.00$

94.00$

106.00$

81.00$

121.00$

358.00$

125.00$

92.00$

62.00$

85.00$

85.00$

83.00$

537.00$

764.00$

210.00$

83.00$

104.00$

103.00$

465.00$

1,350.00$

135.00$

330.00$

337.00$

171.00$

60.00$

160.00$

600.00$

99.00$

220.00$

587.00$

154.00$

734.00$

406.00$

55.00$

429.00$

31.00$

20.00$

Page 138: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

20.00$

477.00$

129.00$

855.00$

210.00$

53.00$

255.00$

124.00$

135.00$

171.00$

81.00$

930.00$

306.00$

240.00$

270.00$

552.00$

803.00$

792.00$

162.00$

108.00$

81.00$

228.00$

327.00$

405.00$

495.00$

60.00$

305.00$

58.00$

333.00$

48.00$

150.00$

123.00$

145.00$

81.00$

214.00$

261.00$

330.00$

270.00$

213.00$

99.00$

600.00$

26.00$

225.00$

225.00$

86.00$

548.00$

90.00$

590.00$

180.00$

636.00$

522.00$

1,008.00$

Page 139: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

138.00$

735.00$

217.00$

30.00$

63.00$

532.00$

38.00$

525.00$

420.00$

41.00$

375.00$

115.00$

300.00$

430.00$

409.00$

559.00$

55.00$

28.00$

83.00$

110.00$

14.00$

582.00$

140.00$

2,058.00$

66.00$

340.00$

267.00$

375.00$

225.00$

148.00$

683.00$

101.00$

279.00$

99.00$

1,785.00$

100.00$

1,950.00$

154.00$

55.00$

55.00$

225.00$

525.00$

1,050.00$

330.00$

1,755.00$

606.00$

347.00$

42.00$

41.40$

106.00$

20.00$

336.00$

Page 140: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

810.00$

356.00$

700.00$

365.00$

72.00$

621.00$

116.00$

201.00$

1,708.00$

495.00$

1,350.00$

187.00$

750.00$

330.00$

369.00$

475.00$

132.00$

621.00$

722.00$

568.00$

1,200.00$

825.00$

170.00$

190.00$

35.00$

1,950.00$

320.00$

360.00$

274.00$

222.00$

507.00$

621.00$

157.15$

236.78$

192.19$

155.02$

485.24$

130.60$

1,556.60$

3,041.00$

1,804.00$

279.25$

816.52$

733.70$

253.77$

1,804.00$

1,386.71$

491.61$

2,017.42$

389.68$

986.41$

169.89$

Page 141: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

15.00$

41.00$

31.00$

27.00$

27.00$

16.00$

27.00$

17.00$

31.00$

30.00$

26.00$

302.00$

5.00$

21.00$

136.00$

190.00$

282.00$

132.00$

31.00$

119.00$

38.00$

33.00$

49.00$

49.00$

190.00$

282.00$

132.00$

217.00$

295.00$

72.00$

60.00$

447.00$

81.00$

68.00$

269.00$

129.00$

272.00$

326.00$

217.00$

164.00$

179.00$

171.00$

131.00$

109.00$

413.00$

160.00$

10.00$

22.00$

49.00$

150.00$

108.00$

299.00$

Page 142: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

109.00$

146.00$

138.00$

33.00$

33.00$

76.00$

76.00$

16.00$

16.00$

30.00$

326.00$

381.00$

272.00$

217.00$

14.00$

49.00$

70.00$

49.00$

141.00$

206.00$

47.00$

490.00$

381.00$

337.00$

107.00$

109.00$

71.00$

131.00$

98.00$

27.00$

361.00$

72.00$

336.00$

12.00$

19.00$

22.00$

22.00$

46.00$

22.00$

118.00$

28.00$

28.00$

20.00$

25.00$

25.00$

40.00$

80.00$

50.00$

50.00$

55.00$

20.00$

25.00$

Page 143: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

20.00$

25.00$

25.00$

40.00$

22.00$

47.00$

80.00$

50.00$

50.00$

19.00$

46.00$

25.00$

25.00$

15.00$

60.00$

110.00$

386.39$

36.95$

315.00$

4.27$

100.41$

100.41$

11.75$

573.62$

24.57$

4.27$

17.09$

20.30$

17.09$

13.89$

17.09$

27.77$

17.09$

30.98$

18.16$

64.09$

28.84$

19.23$

28.84$

55.55$

17.09$

19.23$

19.23$

17.09$

6.41$

25.64$

3.20$

2.14$

13.89$

16.02$

64.09$

1,794.58$

Page 144: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

16.02$

16.02$

28.84$

17.09$

2.14$

9.61$

5.34$

2.14$

3.20$

289.48$

538.37$

5.34$

11.75$

1,394.00$

67.30$

4.27$

4.27$

2.14$

19.23$

25.64$

12.82$

94.00$

4.27$

366.39$

118.57$

341.82$

3.20$

3.20$

1.07$

1.07$

447.58$

13.89$

54.48$

10.68$

10.68$

35.25$

14.95$

30.98$

134.59$

19.23$

14.95$

13.89$

12.82$

10.68$

6.41$

467.87$

289.48$

3.20$

2.14$

490.30$

1,983.65$

1,288.25$

Page 145: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

990.22$

2,354.31$

447.58$

264.91$

28.84$

617.42$

904.77$

1,329.91$

7.48$

17.09$

11.75$

24.57$

34.18$

123.91$

43.80$

12.82$

10.68$

91.87$

77.98$

1,568.12$

8.55$

10.68$

8.55$

75.84$

186.94$

468.94$

184.80$

3,364.83$

290.55$

2,788.00$

6,098.35$

842.81$

842.81$

1,559.57$

572.56$

136.73$

6.41$

1,106.66$

1,139.77$

9.61$

961.38$

913.31$

390.96$

847.08$

118.57$

74.77$

134.59$

27.77$

127.12$

840.67$

89.73$

89.73$

Page 146: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

25.64$

233.94$

327.94$

12.82$

100.41$

25.64$

5.34$

21.36$

785.13$

555.46$

14.95$

452.92$

2,210.11$

2,932.21$

1,505.09$

7.48$

1,505.09$

288.41$

16.02$

22.43$

306.57$

40.59$

10.68$

13.89$

36.32$

53.41$

39.52$

60.89$

1,529.66$

2,142.81$

86.52$

86.52$

34.18$

204.03$

38.46$

2,662.18$

792.18$

706.18$

718.18$

49.18$

44.86$

727.44$

476.42$

526.62$

1,130.16$

314.05$

12,818.40$

19.23$

1,121.61$

414.46$

1,115.20$

4,453.33$

Page 147: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2,614.95$

3,677.81$

4,875.26$

7,688.90$

8,091.62$

1,557.44$

6,081.26$

788.33$

390.96$

402.71$

285.21$

1,529.66$

4,893.42$

2,611.75$

7,470.99$

5,976.58$

3,857.27$

387.76$

7,716.68$

1,788.17$

2,024.24$

37.39$

439.03$

730.65$

10.68$

6.41$

3.20$

16,330.64$

1,085.00$

9.61$

2,093.67$

1,647.16$

1,286.00$

2,107.56$

331.14$

6.41$

9.61$

30.98$

22.43$

586.44$

14.95$

131.39$

90.80$

421.94$

528.76$

383.48$

369.60$

262.78$

5.34$

226.46$

35.25$

1,442.07$

Page 148: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2,084.06$

1,878.96$

3,554.97$

217.53$

551.19$

19.23$

42.73$

17.09$

37.39$

9.61$

32.05$

14.95$

894.08$

894.08$

894.08$

27.77$

1,301.07$

19.23$

298.03$

6.41$

6.41$

22.43$

370.67$

19.23$

19.23$

6.41$

6.41$

6.41$

8.55$

5.34$

6.41$

6.41$

6.41$

6.41$

6.41$

6.41$

6.41$

7.48$

7.48$

7.48$

5.34$

7.48$

3.20$

4.27$

4.27$

4.27$

4.27$

6.41$

5.34$

5.34$

5.34$

5.34$

Page 149: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

9.61$

14.95$

5.34$

6.41$

5.34$

5.34$

14.95$

7.48$

88.66$

88.66$

40.59$

255.30$

33.11$

3.20$

1,676.01$

5.34$

48.07$

247.82$

259.57$

321.53$

289.48$

48.07$

48.07$

48.07$

48.07$

48.07$

247.82$

169.84$

27.77$

90.80$

208.30$

5.34$

4.27$

2,107.56$

61.96$

43.80$

30.98$

13.89$

13.89$

19.23$

14.95$

10.68$

13.89$

10.68$

47.00$

16.02$

5.34$

5.34$

35.25$

213.64$

143.14$

6.41$

Page 150: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

163.43$

836.40$

85.46$

282.00$

282.00$

282.00$

385.62$

38.46$

385.62$

76.91$

43.80$

833.20$

606.74$

145.28$

750.94$

997.70$

88.66$

41.66$

837.47$

53.41$

5.34$

506.33$

33.11$

52.34$

39.52$

36.32$

68.36$

5.34$

2.14$

3.20$

3.20$

3.20$

12.82$

1,156.86$

442.23$

799.01$

41.66$

82.25$

124.98$

9.61$

2.14$

97.21$

11.75$

10.68$

7.48$

7.48$

28.84$

36.32$

19.23$

14.95$

6.41$

11.75$

Page 151: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

6.41$

25.64$

19.23$

13.89$

2.14$

22.43$

270.25$

5.34$

19.23$

718.18$

32.05$

5.34$

6.41$

50.21$

48.07$

10.68$

3.20$

20.30$

3.20$

4.27$

6.41$

7.48$

150.62$

29.91$

13.89$

9.61$

7.48$

7.48$

14.95$

1.07$

11.75$

40.59$

28.84$

107.89$

23.50$

4.27$

4.27$

37.39$

12.82$

164.50$

10.68$

434.76$

139.93$

18.16$

13.89$

13.89$

69.43$

25.64$

18.16$

1,071.40$

23.50$

27.77$

Page 152: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

134.59$

34.18$

53.41$

64.09$

4.27$

70.50$

88.66$

76.91$

51.27$

67.30$

238.21$

20.30$

27.77$

43.80$

2.14$

45.93$

10.00$

29.91$

2.14$

38.46$

43.80$

57.68$

2.14$

2.14$

454.18$

902.18$

5.34$

7.48$

14.95$

41.66$

13.89$

207.23$

14.95$

442.18$

4.27$

4.27$

205.09$

151.68$

2,685.00$

135.66$

3,617.99$

15.00$

95.00$

38.46$

76.91$

198.69$

77.98$

110.02$

76.91$

4.27$

39.52$

40.59$

Page 153: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

30.98$

40.59$

150.62$

19.23$

22.43$

193.34$

193.18$

34.18$

87.59$

111.09$

117.50$

153.82$

1.07$

24.57$

16.02$

13.89$

42.00$

12.82$

13.89$

13.89$

12.82$

18.16$

7.48$

7.48$

7.48$

7.48$

2.14$

3.20$

2.14$

19.23$

33.11$

21.36$

17.09$

14.95$

2.14$

20.30$

120.71$

279.87$

658.01$

53.41$

54.48$

9.61$

23.50$

124.98$

8.55$

32.05$

33.11$

4.27$

5.34$

5.34$

5.34$

151.68$

Page 154: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

117.50$

168.78$

117.50$

126.05$

152.75$

155.96$

229.66$

15.00$

18.16$

15.00$

18.16$

3,642.56$

5.34$

33.00$

21.00$

6.00$

10.68$

1.07$

2.14$

20.30$

76.91$

77.98$

76.91$

99.34$

6.41$

20.30$

12.82$

4.27$

12.82$

4.27$

17.09$

79.05$

40.59$

17.09$

204.03$

204.03$

17.09$

222.19$

22.43$

42.73$

44.86$

1.07$

2.14$

3.20$

3.20$

4.27$

107.89$

3.20$

24.57$

59.82$

97.21$

3.20$

Page 155: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3.20$

2.14$

669.76$

28.84$

10.68$

2.14$

14.95$

2.14$

25.00$

3.20$

54.48$

48.07$

6.00$

29.91$

2.14$

1.07$

5.34$

7.48$

7.48$

19.23$

5.34$

7.48$

5.34$

10.68$

10.68$

10.68$

12.82$

10.68$

10.68$

10.68$

10.68$

9.61$

25.64$

13.89$

12.82$

12.82$

10.68$

10.68$

98.27$

3.20$

9.61$

128.18$

10.68$

10.68$

5.34$

17.09$

112.16$

107.89$

27.77$

19.23$

98.27$

2,909.78$

Page 156: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

10.68$

18.16$

99.34$

17.09$

442.23$

5.34$

40.59$

64.09$

28.84$

10.68$

467.18$

86.52$

43.80$

52.34$

10.00$

32.05$

151.68$

24.57$

24.57$

25.64$

53.41$

53.41$

6.41$

53.41$

53.41$

53.41$

5.34$

35.25$

2.14$

53.41$

9.61$

53.41$

57.68$

30.98$

441.17$

66.23$

17.09$

457.18$

104.68$

12.82$

14.95$

34.00$

29.00$

32.05$

9.61$

16.02$

42.73$

17.09$

17.09$

192.28$

18.16$

18.16$

Page 157: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

25.64$

5.34$

294.82$

353.57$

23.18$

242.48$

213.64$

115.37$

32.05$

588.58$

645.28$

311.92$

507.01$

513.44$

502.72$

562.75$

307.64$

388.03$

304.42$

304.42$

382.67$

382.67$

399.82$

645.28$

1,487.80$

399.82$

1,470.65$

629.21$

1,402.05$

965.78$

965.78$

965.78$

237.96$

532.73$

556.32$

295.84$

295.84$

295.84$

359.09$

433.05$

645.28$

351.58$

1,313.08$

358.01$

358.01$

2,083.77$

1,272.35$

2,083.77$

1,208.03$

270.12$

270.12$

382.67$

Page 158: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

382.67$

706.38$

345.15$

150.07$

486.64$

345.15$

351.58$

351.58$

311.92$

706.38$

665.65$

1,922.99$

382.67$

382.67$

495.22$

495.22$

303.35$

303.35$

293.70$

293.70$

382.67$

382.67$

235.82$

235.82$

351.58$

351.58$

301.20$

301.20$

876.81$

360.16$

360.16$

395.53$

395.53$

483.43$

483.43$

513.44$

435.19$

513.44$

513.44$

513.44$

382.67$

344.08$

486.64$

351.58$

50.38$

527.37$

1,659.30$

311.92$

311.92$

295.84$

926.12$

439.48$

Page 159: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

439.48$

400.89$

400.89$

345.15$

350.51$

350.51$

455.56$

382.67$

382.67$

382.67$

386.96$

405.18$

486.64$

495.22$

359.09$

635.64$

486.64$

375.17$

502.72$

502.72$

303.35$

303.35$

446.98$

280.84$

280.84$

482.36$

482.36$

948.63$

334.43$

334.43$

385.88$

385.88$

942.20$

435.19$

330.15$

702.09$

501.65$

450.20$

394.46$

1,922.99$

1,261.63$

509.15$

562.75$

395.53$

513.44$

2,115.47$

878.06$

807.47$

620.31$

683.41$

696.24$

484.48$

Page 160: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

484.48$

1,691.95$

665.23$

1,089.82$

863.09$

728.33$

664.16$

1,043.83$

863.09$

863.09$

863.09$

992.50$

863.09$

863.09$

1,368.96$

863.09$

863.09$

1,368.96$

863.09$

675.92$

696.24$

696.24$

728.33$

1,398.91$

483.41$

696.24$

598.92$

1,368.96$

1,052.39$

771.11$

728.33$

623.52$

722.98$

1,368.96$

450.26$

450.26$

727.26$

450.26$

450.26$

683.41$

960.41$

2,558.24$

50.27$

1,056.67$

863.09$

59.89$

1,056.67$

1,091.96$

1,368.96$

727.26$

935.81$

99.46$

Page 161: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

696.24$

696.24$

484.48$

484.48$

565.00$

2,788.00$

1,855.00$

2,045.00$

2,295.00$

1,960.00$

1,698.00$

2,295.00$

2,737.00$

1,803.00$

874.00$

2,442.00$

3,136.00$

1,750.00$

2,737.00$

1,931.00$

1,787.00$

3,046.00$

2,153.00$

1,855.00$

2,321.00$

2,307.00$

2,307.00$

1,592.00$

1,592.00$

1,693.00$

1,693.00$

1,612.00$

1,612.00$

2,153.00$

1,821.00$

1,855.00$

2,153.00$

2,261.00$

1,855.00$

2,193.00$

2,663.00$

1,611.00$

1,623.00$

3,136.00$

1,808.00$

2,737.00$

2,073.00$

1,698.00$

1,721.00$

1,503.00$

1,698.00$

1,503.00$

Page 162: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,503.00$

2,153.00$

2,153.00$

1,479.00$

1,479.00$

2,215.00$

3,307.00$

2,870.00$

2,870.00$

2,871.00$

2,871.00$

2,871.00$

3,229.00$

2,392.00$

3,110.00$

47.00$

111.00$

4,687.00$

4,687.00$

4,687.00$

900.00$

3,398.00$

3,191.00$

2,162.00$

3,191.00$

2,162.00$

3,398.00$

2,512.00$

3,398.00$

3,398.00$

3,193.00$

3,191.00$

3,042.00$

3,191.00$

3,191.00$

3,398.00$

3,398.00$

3,191.00$

2,528.00$

1,879.00$

3,398.00$

3,398.00$

3,398.00$

3,191.00$

2,010.00$

3,398.00$

3,398.00$

3,398.00$

3,398.00$

3,398.00$

3,794.00$

2,642.00$

Page 163: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

3,011.00$

2,756.00$

3,337.00$

3,326.00$

3,794.00$

2,610.00$

2,592.00$

2,896.00$

3,398.00$

2,896.00$

2,512.00$

2,460.00$

2,460.00$

3,794.00$

2,511.00$

3,398.00$

3,398.00$

3,191.00$

2,896.00$

2,896.00$

3,191.00$

3,398.00$

2,756.00$

2,511.00$

3,046.00$

2,511.00$

3,794.00$

2,896.00$

3,324.00$

3,162.00$

3,398.00$

124.00$

47.00$

3,398.00$

3,398.00$

1,761.63$

1,263.66$

594.35$

1,105.17$

1,976.88$

2,011.15$

4,490.28$

117.80$

2,398.82$

844.94$

1,647.04$

234.53$

314.84$

4,753.73$

1,121.23$

861.00$

1,205.83$

Page 164: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,834.45$

3,464.36$

1,959.75$

2,329.21$

4,396.04$

471.20$

1,105.17$

2,327.07$

2,635.48$

819.24$

861.00$

197.05$

149.93$

289.14$

950.96$

82.46$

140.29$

56.76$

38.55$

1,959.75$

1,367.54$

1,367.54$

1,471.42$

686.45$

1,841.95$

1,754.13$

1,754.13$

1,841.95$

58.90$

1,976.88$

40.69$

131.72$

816.03$

18.21$

43.91$

209.90$

198.12$

1.07$

426.22$

188.48$

2,298.15$

78.29$

263.00$

935.22$

72.93$

72.93$

289.00$

240.00$

240.00$

412.56$

377.00$

377.00$

Page 165: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

454.00$

131.50$

13.94$

1,277.30$

355.10$

379.48$

90.10$

68.90$

100.70$

327.54$

331.78$

109.18$

109.18$

71.02$

78.44$

187.62$

205.64$

552.26$

390.08$

774.86$

669.92$

131.44$

100.70$

165.90$

136.74$

131.44$

100.70$

113.42$

90.10$

110.24$

71.02$

71.02$

117.66$

207.76$

58.30$

13.78$

103.88$

624.34$

391.14$

93.28$

811.96$

735.64$

144.16$

26.50$

73.14$

530.00$

147.67$

330.66$

278.23$

229.00$

130.55$

268.60$

Page 166: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

201.18$

965.23$

134.83$

109.15$

332.80$

332.80$

144.46$

133.76$

176.57$

121.99$

107.01$

112.36$

220.44$

109.15$

187.27$

200.11$

143.39$

144.46$

114.50$

141.25$

171.22$

111.29$

109.15$

109.15$

146.60$

84.54$

29.96$

154.09$

154.09$

154.09$

132.69$

118.78$

364.90$

379.89$

173.36$

254.68$

364.90$

171.22$

5.35$

332.80$

332.80$

332.80$

332.80$

171.22$

143.39$

364.90$

134.83$

130.55$

154.09$

154.09$

187.27$

109.15$

Page 167: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

220.44$

144.46$

144.46$

144.46$

147.67$

118.78$

379.89$

173.36$

200.11$

141.25$

109.15$

2.14$

3.22$

26.80$

19.30$

1.07$

10.72$

7.50$

7.50$

15.01$

566.02$

24.66$

11.79$

7.50$

269.07$

1.07$

2.14$

991.60$

3.22$

45.02$

172.59$

172.59$

35.38$

358.05$

413.79$

547.79$

925.14$

1,303.55$

3,658.74$

39.66$

229.41$

229.41$

50.38$

107.20$

80.40$

80.40$

39.66$

39.66$

7.50$

1,109.52$

80.40$

80.40$

Page 168: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

241.20$

280.86$

118.99$

332.32$

39.66$

80.40$

39.66$

15.01$

110.42$

31.09$

251.92$

1.07$

2.14$

3.22$

3.22$

4.29$

70.75$

80.40$

87.90$

3.22$

111.49$

115.78$

154.37$

986.24$

3.22$

3.22$

2.14$

21.44$

10.72$

7.50$

15.01$

7.50$

7.50$

15.01$

17.15$

15.01$

15.01$

15.01$

15.01$

15.01$

17.15$

20.37$

101.84$

8.58$

19.30$

20.37$

20.37$

26.80$

16.08$

17.15$

17.15$

7.50$

Page 169: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1.07$

93.26$

160.80$

1.07$

21.44$

96.48$

96.48$

132.93$

196.18$

57.89$

134.00$

102.91$

138.29$

99.70$

196.18$

138.29$

57.89$

63.25$

63.25$

406.29$

555.30$

531.71$

642.13$

25.73$

26.80$

32.16$

50.38$

110.42$

110.42$

50.38$

70.75$

42.88$

50.38$

50.38$

110.42$

50.38$

110.42$

398.78$

398.78$

57.89$

200.46$

126.50$

57.89$

57.89$

141.50$

25.73$

77.18$

114.70$

91.12$

160.80$

160.80$

276.58$

Page 170: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

472.75$

64.32$

75.04$

441.66$

97.55$

63.25$

220.83$

82.54$

105.06$

323.74$

127.57$

94.34$

415.94$

110.42$

93.26$

80.40$

121.14$

120.06$

87.90$

9.65$

415.94$

26.80$

93.26$

50.38$

62.18$

87.90$

110.42$

139.36$

160.80$

50.38$

62.18$

72.90$

87.90$

110.42$

62.18$

87.90$

110.42$

139.36$

160.80$

160.80$

62.18$

87.90$

99.70$

110.42$

139.36$

139.36$

160.80$

175.81$

195.10$

87.90$

110.42$

62.18$

Page 171: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

87.90$

110.42$

139.36$

160.80$

172.59$

160.80$

172.59$

85.76$

107.20$

110.42$

139.36$

135.07$

156.51$

110.42$

139.36$

160.80$

87.90$

110.42$

70.75$

42.88$

27.87$

16.08$

35.00$

66.00$

107.00$

196.00$

477.00$

392.00$

296.00$

404.00$

342.00$

143.00$

200.00$

131.00$

92.00$

152.00$

473.00$

67.00$

26.00$

105.00$

489.00$

278.00$

137.00$

485.00$

4,480.00$

109.00$

1,575.00$

1,260.00$

2,300.00$

266.00$

284.00$

136.00$

Page 172: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

2,263.00$

2,076.00$

1,470.00$

674.00$

794.00$

906.00$

650.00$

44.00$

67.00$

788.00$

452.00$

79.00$

68.00$

1,050.00$

704.00$

105.00$

12.00$

432.00$

171.00$

351.00$

185.00$

239.00$

140.00$

187.00$

231.00$

255.00$

217.00$

250.00$

243.00$

1,829.00$

1,678.00$

327.00$

2,023.00$

1,856.00$

248.00$

62.00$

525.00$

174.00$

208.00$

231.00$

269.00$

306.00$

425.00$

174.00$

224.00$

249.00$

294.00$

337.00$

488.00$

196.00$

242.00$

271.00$

Page 173: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

331.00$

419.00$

114.00$

1,300.00$

688.00$

347.00$

414.00$

474.00$

593.00$

272.00$

332.00$

384.00$

384.00$

460.00$

575.00$

770.00$

305.00$

800.00$

263.00$

950.00$

1,350.00$

394.00$

5.00$

1,050.00$

641.00$

7.00$

420.00$

606.00$

650.00$

10.00$

900.00$

264.00$

306.00$

330.00$

381.00$

423.00$

264.00$

596.00$

308.00$

1,635.00$

11,296.00$

1,188.00$

232.00$

22.00$

40.00$

399.00$

211.00$

166.00$

338.00$

872.00$

800.00$

696.00$

Page 174: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

980.00$

259.00$

567.00$

459.00$

179.00$

280.00$

159.00$

345.00$

981.00$

221.00$

525.00$

222.00$

1,068.00$

245.00$

402.00$

380.00$

477.00$

438.00$

246.00$

1,310.00$

221.00$

287.00$

391.00$

133.00$

266.00$

359.00$

182.00$

396.00$

162.00$

162.00$

233.00$

308.00$

131.00$

1,500.00$

1,218.00$

1,550.00$

1,775.00$

458.00$

420.00$

442.00$

1,425.00$

2,150.00$

368.00$

1,300.00$

1,417.00$

680.00$

973.00$

893.00$

10.00$

899.00$

1,264.00$

1,160.00$

Page 175: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,500.00$

48.00$

299.00$

588.00$

2,100.00$

1,200.00$

4.00$

144.00$

62.00$

183.00$

166.00$

228.00$

310.00$

384.00$

166.00$

122.00$

47.00$

120.00$

170.00$

254.00$

76.00$

116.00$

168.00$

47.00$

74.00$

316.00$

224.00$

1,305.00$

1,197.00$

84.00$

67.00$

104.00$

25.00$

32.00$

184.00$

173.00$

44.00$

65.00$

114.00$

164.00$

160.00$

159.00$

147.00$

148.00$

114.00$

56.00$

126.00$

117.00$

28.00$

114.00$

317.00$

1,237.00$

Page 176: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

1,135.00$

1,155.00$

291.00$

340.00$

471.00$

399.00$

872.00$

1,853.00$

170.00$

140.00$

780.00$

1,200.00$

850.00$

343.00$

900.00$

981.00$

945.00$

1,155.00$

859.00$

788.00$

1,400.00$

715.00$

656.00$

950.00$

315.00$

764.00$

587.00$

337.00$

801.00$

220.00$

287.00$

160.00$

119.00$

148.00$

150.00$

127.00$

153.00$

183.00$

100.00$

137.00$

187.00$

171.00$

221.00$

20.00$

316.00$

116.00$

165.00$

213.00$

125.00$

100.00$

190.00$

130.00$

Page 177: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

390.00$

1,100.00$

1.00$

22.00$

41.00$

1,620.00$

1,750.00$

28.00$

878.00$

630.00$

158.00$

273.00$

297.00$

750.00$

420.00$

512.00$

545.00$

470.00$

500.00$

298.00$

818.00$

144.00$

169.00$

1,156.00$

3,264.00$

88.00$

140.00$

103.00$

1,630.14$

1,159.18$

400.58$

400.58$

227.53$

227.53$

227.53$

432.62$

10.68$

10.68$

110.02$

19.00$

23.50$

1,361.96$

9.61$

94.00$

19.23$

23.00$

23.00$

28.00$

13.00$

5.00$

54.00$

30.00$

Page 178: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

54.00$

22.43$

7.48$

9.61$

21.36$

17.09$

180.53$

49.14$

5.34$

47.00$

49.14$

19.23$

5.34$

20.30$

39.52$

18.00$

28.00$

13.00$

27.00$

5.34$

10.68$

153.82$

58.75$

17.09$

111.09$

16.02$

1.07$

9.61$

20.30$

20.30$

141.00$

14.95$

202.96$

7.48$

5.34$

5.34$

41.66$

5.34$

213.23$

5.34$

13.89$

15,061.62$

40.59$

3.20$

7.48$

425.14$

32.05$

33.11$

5.34$

5.34$

5.34$

3.20$

Page 179: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

65.16$

7.48$

50.21$

21.36$

1.07$

1.07$

1.07$

1.07$

1.07$

37.39$

6.41$

86.52$

5.34$

4.27$

4.27$

4.27$

4.27$

4.27$

5.34$

4.27$

151.18$

28.84$

3.20$

4.27$

64.09$

21.36$

107.89$

283.07$

5.34$

5.34$

5.34$

60.89$

9.61$

10.68$

23.50$

111.09$

111.09$

34.18$

16,968.36$

16.02$

435.83$

18.16$

54.48$

48.07$

332.21$

41.66$

21.00$

2.14$

18.16$

55.55$

10.68$

5.34$

Page 180: Charge Number Description CPT 230001 CGM SENSOR … · 1200090 injection greater occipital nerve 64405 1200091 injection peripheral nerve or branch 64450 1200092 injection tfesi cervical

5.34$

5.34$

606.74$

606.74$

13.89$

39.52$

14.95$

11.75$

165.57$

16.02$

6.41$

2.14$

86.52$

8.55$

12.82$

283.07$

5.34$

3.20$

5.34$

6.41$

2.14$

3.20$

40.59$

5.00$

8,553.00$

95.07$

383.48$

359.98$

359.98$