chippewa county-montevideo hospital · abdomen & aorta cta w $4,186.00 ... amoxic/clav susp...

CHIPPEWA COUNTY-MONTEVIDEO HOSPITAL

Description 1/1/19 Charge 2018 Avg Charge

1/2 NS WITH KCL 20 MEQ 1000ML 124.00

5 10 METHYLENETRAHYDROFOLATE M $366.00

6 MAM CONFIRMATION UR $197.00

AAA SCREENING STUDY $950.00

ABD PARACENTESIS $831.00

ABDOMEN & AORTA CTA W $4,186.00

ABDOMEN & PELVIS CTA W $4,186.00

ABDOMEN & PELVIS W $3,550.00

ABDOMEN & PELVIS W/WO $4,186.00

ABDOMEN & PELVIS WO $3,126.00

ABDOMEN CTA W $2,193.00

ABDOMEN ONE VIEW $295.00

ABDOMEN THREE OR MORE VIEWS $383.00

ABDOMEN TWO VIEWS $338.00

ABDOMEN W $1,790.00

ABDOMEN W/WO $2,108.00

ABDOMEN W/WO $3,140.00

ABDOMEN WO $1,578.00

ABDOMEN WO $2,410.00

ABDOMEN; LIMITED $850.00

ABDOMINAL PARACENTESIS W/IMAGE $1,452.00

ABDOMINAL; COMPLETE $986.00

ABORTION INDUCED BY 1> VAG SUPP W/WO C D $1,694.00

ACE 1 (ANGIOTENSIN I CONV ENZ) $145.00

ACETAMIN/CODEINE 300/30MG TAB 6.85

ACETAMIN/DIPHENHY 500/25MG TAB 6.85

ACETAMINOPHEN 1000MG/100ML INJ 336.25

ACETAMINOPHEN 160MG/5ML 5ML 16.99

ACETAMINOPHEN 500MG TAB 6.86

ACETAMINOPHEN SUPP 80MG 8.20



ACETAMINOPHEN TAB 325MG 6.90

ACETAZOLAMIDE INJ 500MG VIAL 136.36

ACETONE SERUM $40.00

ACETYLCYSTEINE SOLN 20% 30ML 55.94

ACID FAST SMEAR $81.00

ACNE SURGERY $440.00

ACTH (ADRENOCORTICOTROPIC HM) $171.00

ACUTE HEPATITIS PANEL $362.00

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2019.CCMH: Price Transp



ACYCLOVIR CAP 200MG 6.85

ACYCLOVIR INJ 500MG VIAL 51.00

ADACEL VACC (Tdap) 0.5ML 7 YR> 70.74

ADENOSINE 6MG 2ML INJ 46.05

ADJACENT TISSUE TRANSFER 30.1 $4,886.00

ADMIN INFLUENZA VIRUS VACCINE $37.00

ADMIN PATIENT FOCUSED RISK ASSESSMENT $163.00

ADMIN PNEUMOCOCCAL VACCINE $37.00

ADMINISTRATION HEP B VAC $37.00

ADMINISTRATION OF HEPATITIS B VACCINE $37.00

ADMINSTRATION OF INFLUENZA VIRUS VACCINE $37.00

ADMINSTRATION OF PNEUMOCOCCAL VACCINE $37.00

AEROBIKA $139.00

AG SCREEN PT SERUM PER UNT ARC $191.00

AIRWAY ORAL PLASTIC DISPOSABLE $16.00

ALARM BED/CHAIR $63.00

ALBUMIN 25% 100ML 539.90

ALBUMIN 5% SOLUTION 250ML 359.93

ALBUMIN SERUM PLASMA WHOLE BLD $57.00

ALBUTEROL INHLR 90MCG/ACT 8 GM 113.95

ALBUTEROL NEB 2.5MG/3ML 6.85

ALCOHOLS $200.00

ALDOLASE $145.00

ALDOSTERONE $475.00

ALENDRONATE 70MG TAB 6.85

ALFENTANIL INJ 0.5MG/ML 2ML 42.25

ALKALOIDS NOS $208.00

ALLERGEN IMMUNOTHERAPY;2+ INJECTIONS $94.00

ALLERGEN IMMUNOTHERAPY;SINGLE INJECTION $81.00

ALLERGEN SPECIFIC IGE EA $37.00

ALLERGEN SPECIFIC IgE EACH $62.00

ALLERGY INJECTION; TWO OR MORE $94.00

ALLOPURINOL TAB 100MG 6.85

ALLOPURINOL TAB 300 MG 6.90

ALPHA 1 ANTITRYPSIN PHENOTYPE $275.00

ALPHA 1 ANTITRYPSIN TOTAL $98.00

ALPHA FETOPROTEIN (AFP) SERUM $345.00

ALPHA FETOPROTEIN QUAD SCREEN $175.00

ALPHA-FETOPROTEIN, SERUM $344.00

ALPRAZOLAM TAB 0.25MG 6.85

ALTEPLASE 2MG INJ VIAL 728.08

ALUMINUM $83.00

ALVIMOPAN 12MG CAP (ENTEREG) 538.39

AMBU BAG $276.00

AMBULANCE ALS 1 EMERGENCY $2,380.00

AMBULANCE ALS 2 EMERGENCY $2,260.00

AMBULANCE BLS EMERGENCY $1,245.00

AMBULANCE BLS NONEMERGENCY $1,130.00

AMBULANCE INTRCPT 40% PMT DUE $0.01

AMBULATORY BP MONITORING 24 HR $176.00

AMINO ACIDS 4.25%/D25W 1000ML 124.00

AMINO ACIDS SINGLE QUANT DR G $109.00

AMINOPHYLLINE 25MG/ML 10ML INJ 93.10

AMIODARONE INJ 150MG/3ML VIAL 24.50

AMIODARONE TAB 200MG 6.85

AMITRIPTYLINE TAB 10MG 6.85

AMITRIPTYLINE TAB 25MG 6.85

AMLODIPINE TAB 5MG 6.84

AMMONIA $139.00

AMMONIA DR G $109.00

AMNISURE ROM $235.00

AMOXIC/CLAV SUSP 250MG/5 150ML 284.82

AMOXICILLIN 250MG/5ML 150ML BT 25.55

AMOXICILLIN CAP 500MG 6.85

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AMOXICILLIN/CLAV TAB 500MG 6.85

AMOXICILLIN/CLAV TAB 875 MG 10.30

AMPHETAMINES 1 OR 2 $205.00

AMPHETAMINES CONFIRMATION UR $80.00

AMPHETAMINES CONFIRMATION UR $154.00

AMPICILLIN INJ 500 MG VIAL 37.10

AMPICILLIN INJ 1GM VIAL 124.50

AMPICILLIN INJ 250MG VIAL 26.51

AMPICILLIN INJ 2GM VIAL 129.05

AMPICILLIN/SULB 1.5GM INJ VIAL 118.52

AMPICILLIN/SULB 3 GM INJ VIAL 145.78

AMPUTATION TOE $2,649.00

AMYLASE $102.00

ANALGESICS NON OPIOID 1 OR 2 $191.00

ANCA PANEL FOR VASCULITIS $169.00

ANDROSTENEDIONE $239.00

ANESTH FACILITY EA ADDL 15 MIN $176.00

ANESTHESIA FACILITY FEE $901.00

ANESTHESIA RENT; PER MONTH $147.00

ANESTHETIST (CRNA) EACH MINUTE $16.00

ANKLE; COMPLETE, MIN OF 3 VIEW $296.00

ANKLE; TWO VIEWS $274.00

ANNUAL DEPRESSION SCRN 15 MINUTES $70.00

ANNUAL WELLNESS VISIT INITIAL $476.00

ANNUAL WELLNESS VISIT; INITIAL $476.00

ANNUAL WELLNESS VISIT; SUBSEQU $294.00

ANNUAL WELLNESS VISIT; SUBSEQUENT VISIT $294.00

ANOSCOPY; DIAGNOSTIC $417.00

ANTEPARTUM CARE ONLY 7 OR MORE VISITS $2,900.00

ANTEPARTUM CARE ONLY;4-6 VISITS $1,986.00

ANTERIOR COLPORRHAPHY;REPAIR CYSTOCELE $2,988.00

ANTIBODY CANDIDA $150.00

ANTIBODY E HISTOLYTICA $137.00

ANTIBODY ELUTION RBC EACH $286.00

ANTIBODY FUNGUS OTHER $73.00

ANTIBODY FUNGUS OTHER $145.00

ANTIBODY ID PLATELETS $262.00

ANTIBODY ID RBC Ab EACH $349.00

ANTIBODY MUMPS $92.00

ANTIBODY MYCOPLASMA $139.00

ANTIBODY PARVOVIRUS IgG & IgM $138.00

ANTIBODY RUBELLA $92.00

ANTIBODY RUBEOLA $92.00

ANTIBODY SCREEN RBC EACH $103.00

ANTIBODY TREPONEMA PALLIDUM $103.00

ANTIBODY VARICELLA ZOSTER $92.00

ANTIBODY VARICELLA ZOSTER $230.00

ANTIBODY WEST NILE VIRUS $85.00

ANTIBODY WEST NILE VIRUS IgM $85.00

ANTICOAGULANT MANAGEMENT $44.00

ANTICOAGULANT MANAGEMENT $47.00

ANTIDEPRESSANTS TRICYCLIC 1OR2 $254.00

ANTIHUMAN GLOBULIN DIR COOMBS $58.00

ANTIMULLERIAN HORMONE $326.00

ANTINUCLEAR ANTIBODIES (ANA) $171.00

ANTISTREPTOLYSIN 0 TITER $150.00

ANTISTREPTOLYSIN O TITER $150.00

APPENDECTOMY, LAPAROSCOPY $1,316.00

APPLICATION FINGER SPLINT $185.00

APPLICATION LONG ARM SPLINT $391.00

APPLICATION OF UNNA BOOT $240.00

APPLICATION OF UNNA BOOT BILAT $358.00

APPLICATION SHORT ARM SPLINT $315.00

APPLICATION SHORT LEG SPLINT $327.00

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APPLICATION TOPICAL FLOURIDE VARNISH $0.01

APPLICATION TOPICAL FLUORIDE V $0.01

APPLICATION TOPICAL FLUORIDE VARNISH $62.00

APPLICATION,LONG ARM CAST,SHOULDER TO HA $429.00

APPLICATION,LONG ARM SPLINT;SHOULDER/HAN $391.00

APPLICATION,SHORT ARM CAST,ELBOW TO FING $404.00

APPLICATION,SHORT ARM SPLINT,FOREARM/HAN $315.00

APTT MIX $284.00

AQUATIC THERAPY/15MIN $122.00

ARCH SUPPORT FOOT REMOVABLE $3.00

ARIPIPRAZOLE 2MG TAB 22.40

ARIPIPRAZOLE 5MG TAB 14.43

ARSENIC $296.00

ARTERIAL PUNCTURE WDRAWL BLOOD $58.00

ARTERIAL PUNCTURE,WITHDRAW BLO $138.00

ARTERIAL PUNCTURE,WITHDRAW BLOOD FOR DX $138.00

ARTHROCENTESIS ASPIRAT/INJECT MAJOR JOIN $363.00

ARTHROCENTESIS ASPIRATION INTERMED. JOIN $295.00

ARTHROCENTESIS MAJOR JOINT BIL $527.00

ARTHROCENTESIS, MAJOR JOINT; BILATERAL $527.00

ARTHROCENTESIS; INTERMED JOINT $295.00

ARTHROCENTESIS; MAJOR JOINT $363.00

ARTHROTOMY;CARPOMETACARPAL JOINT $1,391.00

ASPERGILLUS AB $153.00

ASPIRATE PLEURA WITH IMAGING $2,439.00

ASPIRATE PLEURA WITHOUT IMAGIN $3,615.00

ASPIRIN CHEW TAB 81MG 6.85

ASPIRIN TAB 325MG 6.85

ASPIRIN TAB 81 MG 4 PACK 6.85

ASPIRIN TAB EC 81MG 6.85

ASPIRIN TAB EC 325MG 6.85

ASSESS & CARE PLAN COGNTV IMP $478.00

ASSESS & CARE PLAN COGNTV IMP $195.00

ASSESSMENT & CARE PLAN PT COGNITIVE IMP $478.00



ATENOLOL TAB 25 MG 6.85

ATENOLOL TAB 50 MG 6.99

ATORVASTATIN 40MG TAB 6.84

ATORVASTATIN TAB 10MG 6.85

ATRACURIUM INJ 100MG/10ML VIAL 10.04

ATROPINE ABBOJECT 1MG/10ML 79.82

ATROPINE INJ 0.4MG/ML VIAL 40.08

ATROPINE OPHTH SOL 1% 5ML BOT 179.65

ATTENDANCE AT DELIVERY AND STABILIZATION $426.00

ATTENTION FUNCTIONAL CURRENT $0.01

ATTENTION FUNCTIONAL DISCHARGE $0.01

ATTENTION FUNCTIONAL PROJECTED $0.01

AUDIOLOGY RENT; PER HOUR $21.00

AUTOTRANSFUSION SYSTEM $601.00

AVF HEMODIALYSIS ACCESS $489.00

AVULS NAIL PLATE, PARTIAL/COMPLETE/ >1 $194.00

AVULSION NAIL PLATE; EA ADD'L $194.00

AVULSION NAIL PLATE; SINGLE $438.00

AVULSION NAIL, PARTIAL OR COMPLETE, SING $438.00

AZACITIDINE 100MG VIAL 692.81

AZITHROMYCIN 100MG/5ML 15ML 78.45



AZITHROMYCIN 250MG 6 PACK 68.35

AZITHROMYCIN INJ 500MG VIAL 134.55

AZITHROMYCIN TAB 250 MG 16.41

AZTREONAM 2GM INJ VIAL 386.64

B CELLS TOTAL COUNT $251.00

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BACITRACIN 50MU VIAL 58.60

BACITRACIN OINT 15 GRAM TUBE 22.70

BACLOFEN TAB 10MG 6.85

BAG URINARY DRAINAGE 2000ML $14.00

BAG URINARY LEG DISPOSABLE $15.00

BALLOON HERNIA $649.00

BANDAGE SELF ADHERENT <5IN $41.00

BANDAGE SELF ADHERENT 2IN $14.00

BANDAGE SELF ADHERENT 6IN $14.00

BANDAGE SELF ADHERENT<5IN WIDE $41.00

BANDAGE SELF ADHERENT>5IN WIDE $14.00

BANDAGE ZINC PASTE IMPREGNATED $14.00

BANDAGE ZINC PASTE IMPREGNATED $15.00

BASIC METABOLIC PANEL $151.00

BASKET RETRIEVAL $139.00

BATH CLEANSING SYSTEM $10.00

BCG INJ VIAL 769.85

BCR/ABL1 MAJOR BREAKPOINT $390.00

BCR/ABL1 MINOR BREAKPOINT $390.00

BCR/ABL1 OTHER BREAKPOINT $390.00

BCRAB P210 MRNA $1,582.00

BECLOMETHASONE 80MCG/ACT INHAL 682.05

BEHAV QUAL ANLYS VOICE RESONAN $509.00

BELIMUMAB 120MG VIAL INJ 2,099.70

BELIMUMAB 400MG VIAL INJ 6,003.50

BELT TRANSFER $13.00

BENDAMUSTINE 25MG VIAL 2,786.55

BENZODIAZEPINES 1-12 $374.00

BENZODIAZEPINES CONFIRMATION U $171.00

BENZODIAZEPINES CONFIRMATION UR $171.00

BENZONATATE CAPS 100MG 6.74

BENZTROPINE TAB 2MG 6.85

BETA 2 GLYCOPROTEIN 1 ANTIBODY $89.00

BETADINE 5% OPHTH SOLN 30 ML 53.14

BETAMETHASONE S 6MG/ML 1ML INJ 71.04

BETAMETHASONE SOLUSPAN INJ 30MG/5ML VIAL $115.60

BEVACIZUMAB INJ 100MG VIAL 3,015.19

BICILLIN LA 1,200,000 UNIT SYR 684.40

BILE ACIDS TOTAL $231.00

BILIRUBIN DIRECT $62.00

BILIRUBIN TOTAL $62.00

BILIRUBIN TOTAL TRANSCUTANEOUS $37.00

BILIRUBIN, DIRECT $62.00

BIMATOPROST OPHTH 0.01% 2.5ML 571.80

BIOPSY LESION, MOUTH $1,345.00

BIOPSY LYMPH NODE(S) $1,929.00

BIOPSY LYMPH NODE(S) $2,368.00

BIOPSY OF LIVER, NEEDLE; DONE W/OTH PROC $522.00

BIOPSY OF PALATE,UVULA $704.00

BIOPSY OF PENIS $897.00

BIOPSY OF SKIN; EACH ADD'L $142.00

BIOPSY OF SKIN; SINGLE LESION $447.00

BIOPSY THYROID, NEEDLE $490.00

BIPAP MGMT FIRST DAY $684.00

BIPAP SUBSEQUENT DAY(S) $527.00

BIS SENSOR $88.00

BISACODYL SUPP 10MG 6.85

BISACODYL TAB 5MG 6.85

BISMUTH SUBSALICYLATE 262MG TB 6.85

BLADDER INSTILLATION CHEMO $482.00

BLADE BARREL BURR $167.00

BLADE COMMAND II $185.00

BLADE DERMATOME $129.00

BLADE LARYNGOSCOPE $191.00

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BLADE MYRINGOTOMY KNIFE $22.00

BLADE NON SHARPOINT DISPOSABLE $31.00

BLADE RECIPROCATING STRYKER $190.00

BLADE STRYKER SAGITTAL $227.00

BLADE STRYKER SHAVER $205.00

BLANKET FORCED AIR WARMING $16.00

BLASTOMYCES AB $156.00

BLOOD COLLECTION CAPILLARY $66.00

BLOOD COLLECTION FROM PICC $122.00

BLOOD COLLECTION PERIPH CATH $120.00

BLOOD COLLECTION PERIPH CATH $122.00

BLOOD COLLECTION VENIPUNCTURE $57.00

BLOOD COLLECTION VENOUS ACCESS $107.00

BLOOD COLLECTION VENOUS ACCESS $116.00

BLOOD OCCULT FECES BY CARD $48.00

BLOOD OSMOLALITY $117.00

BLOOD SMEAR MANUAL DIFF COUNT $103.00

BLOOD SMEAR WITHOUT DIFF COUNT $28.00

BLOOD TRANSFUSION $1,038.00

BLOOD TYPING ABO $95.00

BLOOD TYPING ANTIGEN TEST EA $153.00

BLOOD TYPING Rh(D) $63.00

BMI DOC ABOVE NORMAL FU PLANNED $0.01

BMI DOC OUTSIDE NORMAL PARA NO $0.01

BMI DOC OUTSIDE NORMAL PARA NO FU PLAN $0.01

BMI DOC OUTSIDE OF NORMAL FU PLAN NT ELI $0.01

BMI DOC WITHIN NORMAL PARA NO $0.01

BMI DOC WITHIN NORMAL PARA NO FU PLANNED $0.01

BONE AGE STUDIES $277.00

BONE MARROW; BIOPSY $748.00

BONE/JOINT IMAGING; WHOLE BODY $1,725.00

BORRELIA BURG (LYME DISEASE)AB $74.00

BORRETIA BURG (LYME DISEASE) $116.00

BORRETIA BURG (LYME DISEASE)AB $74.00

BORTEZOMIB INJ 3.5MG VIAL 5,610.50

BRA POST SURGICAL $218.00

BRACE DONJOY PLAYMAKER WRAP $183.00

BRACE KNEE HINGED $366.00

BRACE KNEE IMMOBILIZER $75.00

BRACE LAT AIR MESH STAB KNEE $50.00

BRACE TLSO CYBERTECH $341.00

BRAIN VENOGRAM W/WO $3,140.00

BRAIN W/WO $3,140.00

BRAIN WO $2,410.00

BREAST MARKER DEVICE $148.00

BREAST PUMP ELECTRIC ANY TYPE $362.00

BREAST PUMP SYSTEM $127.00

BREAST SHIELD $22.00

BREAST UNILATERAL COMPLETE $584.00

BREAST UNILATERAL LIMITED $584.00

BRIDION 200MG/2ML INJ 481.65

BRIEF EMOTIONAL/BEHAVIOR ASSESSMENT $163.00

BRIMONIDINE P OPHTH 0.15% 5ML 446.00

BRIMONIDINE/TIMOLOL OPHTH 5ML 511.90

BRONCHIAL ALLERGY TEST ADMINIS $121.00

BRONCHOSCOPY W/BRONCHIAL ALVE $1,451.00

BUDESONIDE INH 0.5MG/2ML NEB 52.21

BUDESONIDE/FORM 160/4.5MCG INH 501.14

BUDESONIDE/FORMO 80/4.5MCQ INH 489.55

BUFFERED LIDOCAINE KIT 5ML 25.60

BUMETANIDE TAB 1MG 7.10

BUPIVACAINE 0.25%/EPI 30ML INJ 31.55

BUPIVACAINE 0.5% INJ 10 ML 24.50

BUPIVACAINE 0.5%/EPI 50ML INJ 44.40

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BUPIVACAINE 0.75% DEX 2ML AMP 29.80

BUPIVACAINE 0.75% MPF 2ML 24.50

BUPIVACAINE INJ 0.5% 50ML 28.45

BUPIVACAINE LIPOSOME 1.3% 20ML 1,379.70

BUPIVACAINE MPF 0.25% 10ML 24.50

BUPIVACAINE MPF INJ 0.5% 30ML 24.50

BUPIVICAINE MPF 0.25% 30ML 24.49

BUPREN & NORBU CONFIRMATION UR $297.00

BUPROPION XL TAB 150MG 7.30

BURN TREATMENT 1ST DEGREE $134.00

BURN TREATMENT MEDIUM $523.00

BURN TREATMENT MEDIUM $671.00

BURN TREATMENT SMALL $263.00

BURN TREATMENT SMALL $384.00

BURN TRTMNT 1ST DEGREE INITIAL $317.00

BUSPIRONE TAB 10MG 6.85

BX BREAST 1ST LESION US IMAGIN $2,889.00

BX BREAST ADD LESION US IMAG $2,374.00

BX CERVIX;SINGLE/MULTIPLE OR EXCISE LESI $567.00

BX MUSCLE, PERCUTANEOUS NEEDLE $1,079.00

BX SKIN, SUBCUT, MUCOUS MEMBRANE, ADD'L $142.00

BX SKIN, SUBCUT, MUCOUS MEMBRANE, SINGLE $447.00

BX THYROID, PERCUTANEOUS CORE NEEDLE $490.00

BX/EXCISE LYMPH NODES;DEEP AXILLARY NODE $1,929.00

BX/EXCISE LYMPH NODES;NEEDLE,SUPERFICIAL $581.00

C INHIBITORS ANTITHROMBIN III $242.00

C&M BODY POSITION FUNC CURRENT $0.01

C&M BODY POSITION FUNC DISCHG $0.01

C&M BODY POSITION FUNC PROJECT $0.01

CADMIUM $221.00

CALCANEUS, MINIMUM OF TWO VIEW $274.00

CALCIFEDIOL (25-OH VIT D-3) $250.00

CALCITONIN $244.00

CALCITONIN NASAL SPRAY 3.7 ML 144.80

CALCIUM ACETATE CAPS 667 MG 6.85

CALCIUM CARB TAB 500MG (TUMS) 6.85

CALCIUM CARB TAB 500MG W/VIT D 7.10

CALCIUM CARBONATE TAB 500MG 6.84

CALCIUM GLUCONATE INJ 10% 10ML 91.22

CALCIUM IONIZED $134.00

CALCIUM TOTAL $50.00

CALCIUM URINE QUANTITATIVE $109.00

CALCIUM URINE QUANTITATIVE DRG $109.00

CALMOSEPTINE OINT 2.5 OZ 35.00

CALPROTECTIN $682.00

CALR MUTATION ANALYSIS MPN $1,701.00

CANALITH REPOSITIONING PROC $110.00

CANCER ANTIGEN CA15-3 OR 27-29 $230.00

CANNABINOIDS NATURAL $92.00

CARBAMAZEPINE CHEW TAB 100MG 6.93

CARBAMAZEPINE TOTAL $165.00

CARBAMIDE PEROX 6.5% OTIC 15ML 37.60

CARBIDOPA-LEVODOPA TAB 25-100 6.85

CARBIDOPA-LEVODOPA TAB 25-250 6.85

CARBOPLATIN 10MG/ML 50MG CHARG 25.11

CARBOPROST 250 MG INJ VIAL 1,512.96

CARBOXYHEMOGLOBIN QUANTITATIVE $196.00

CARDIAC; 6 MINUTE WALK TEST $211.00

CARDIOLIPIN ANTIBODY EA Ig CIS $64.00

CARDIOLOGIST RENT EA ADD 30MIN $32.00

CARDIOLOGIST RENT; 0-4 HOURS $247.00

CARDIOPULMONARY RESUSCITATION $1,371.00

CARDIOVASCULAR STRESS TEST $697.00


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CARDIOVERSION $190.00

CARDIOVERSION $932.00

CARVEDILOL 25MG TAB 6.85

CARVEDILOL TAB 6.25MG 6.85

CASTING MATERIAL $57.00

CATARACT LENS $1,518.00

CATECHOLAMINES FRACTIONATED $259.00

CATHETER CLOSUREFAST 7FX100CM $2,329.00

CATHETER COUDE $67.00

CATHETER DRAINAGE SET $137.00

CATHETER DRAINAGE TRAY (SAFETCENTESIS) $238.00

CATHETER FEMALE KIT $15.00

CATHETER FOLEY $159.00

CATHETER FOLEY ALL SIZES $83.00

CATHETER INDWELLING(COUDE) $67.00

CATHETER INFUSION HICKMAN/PICC $702.00

CATHETER KUMAR CHOLANGIOGRAPHY $94.00

CATHETER MULTI LUMEN $328.00

CATHETER RED ROBINSON $29.00

CATHETER STRAIGHT $241.00

CATHETER THORACIC $25.00

CATHETER TRAY URETHRAL $10.00

CATHETER URINARY DRAIN 3.5FR $47.00

CAUTERY AND/OR ABLATION,MUCOSA OF INFERI $1,079.00

CBC AUTOMATED WITH DIFF $163.00

CBC AUTOMATED WITHOUT DIFF $103.00

CD 20 TOTAL COUNT $794.00

CEA (CARCINOEMBRYONIC ANTIGEN) $262.00

CEFAZOLIN 1GM IV IN D5W 50ML 150.00

CEFAZOLIN 2 GM/D5W 50ML 175.56

CEFAZOLIN INJ 1GM VIAL 24.89

CEFDINIR 250MG/5ML ORAL SUSP 152.65

CEFDINIR CAP 300 MG 12.75

CEFEPIME INJ 1GM VIAL 109.50

CEFOXITIN INJ 2GM VIAL 164.53

CEFTAZIDIME INJ 1 GM VIAL 128.93

CEFTRIAXONE INJ 500MG VIAL 33.41

CEFTRIAXONE INJ 1 GRAM VIAL $6.13

CEFTRIAXONE INJ 1GM VIAL 24.76

CEFTRIAXONE INJ 1GM VIAL +MBAG 117.02

CEFTRIAXONE INJ 2GM VIAL +MBAG 135.67

CEFTRIAXONE INJ 500MG VIAL $12.25

CELL COUNT BODY FLUIDS DIFF $81.00

CELL COUNT MISC BODY FLUIDS $130.00

CEMENT BONE $488.00

CEMENT MIXING BOWL $383.00

CEMENT MIXING BOWL DISPOSABLE $42.00

CEMENT PLUG $423.00

CEPASTAT LOZENGE 3 PACK 6.85

CEPHALEXIN CAP 500MG 6.85

CEPHALEXIN SUS 250MG/5ML 100ML 96.30

CERULOPLASMIN $141.00

CERVICAL TRACTION W/WATERBAG $16.00

CESAREAN DELIVERY $1,316.00

CESAREAN DELIVERY ONLY $3,998.00

CESAREAN DELIVERY ONLY;ASSISTANT SURGEON $1,011.00

CESAREAN DELIVERY/POSTPARTUM CARE $5,000.00

CETIRIZINE TAB 10MG 6.85

CFTR $546.00

CFTR GENE ANALYSIS, COMMON VARIANTS $546.00

CHEMICAL CAUTERIZ OF GRANULATION TISSUE $369.00

CHEMICAL CAUTERY GRAN TISSUE $178.00

CHEMICAL CAUTERY GRAN TISSUE $369.00

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CHEMO >8 HR; REQ PORT/IMP PUMP $781.00

CHEMO ADMIN; IV PUSH, EA ADD'L $133.00

CHEMO ADMIN; IV PUSH, SINGLE $238.00

CHEMO ADMIN; SQ/IM, PER VISIT $141.00

CHEMO IV INFUS DIFF DRUG SEQ $263.00

CHEMO IV INFUS SAME EA ADDL HR $237.00

CHEMO, IV INFUSION; UP TO 1 HR $553.00

CHEMOTHERAPY ADMINISTRATION SUBQ OR IM $309.00

CHEST (INCLUDES MEDIASTINUM) $693.00

CHEST CTA W $2,193.00

CHEST SINGLE VIEW $273.00

CHEST THREE VIEWS $344.00

CHEST TWO VIEWS $353.00

CHEST W/WO $3,140.00

CHEST, TWO VIEW, FRONT/LAT $353.00

CHLAMYDIA TRACHOMATIS AMP PROB $265.00

CHLORASEPTIC THROAT SPR 20 ML 24.10

CHLORDIAZEPOXIDE CAP 25MG 6.85

CHLORIDE URINE (RANDOM) $50.00

CHLORIDE URINE (RANDOM) DR G $109.00

CHLOROTHIAZIDE 500MG VIAL INJ 272.55

CHOLANGIOGRAPHY; OPERATIVE $784.00

CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY $3,363.00

CHOLECYSTECTOMY, LAPAROSCOPY $1,316.00

CHOLESTEROL TOTAL $62.00

CHROMATOGRAPHY/MASS SPECT VITA $191.00

CHROMATOGRAPHY/MASS SPECT VITAMIN D $103.00

CHROMATOGRAPHY/MASS SPECT; QUANT,SINGLE $125.00

CHROMIUM SERUM $91.00

CHROMOSOME ANALYSIS 15-20 CELL $2,152.00

CHROMOSOME ANALYSIS 20-25 CELL $425.00

CHROMOSOME ANALYSIS CONGENITAL $1,390.00

CIMZIA 200 MG IM VIAL 4,828.18

CIPROFLOX/DEXAMETH OTIC 7.5ML 717.35

CIPROFLOXAC 200MG/100ML PREMIX 127.50

CIPROFLOXAC 400MG/200ML PREMIX 135.05

CIPROFLOXAC OPH SOL 0.3% 2.5ML 38.33

CIPROFLOXACIN TAB 500MG 6.84

CIRCUMCISION $863.00

CIRCUMCISION INFANT $304.00

CIRCUMCISION W/REGIONAL BLOCK $664.00

CISPLATIN 1MG/ML 10 MG INJEHRG 58.74

CISPLATIN 1MG/ML 10MG INJ/CHRG 57.19

CITALOPRAM TAB 20MG 6.85

CITRATE DR G $109.00

CITRATE SOD./ CITRIC ACID 30ML 22.12

CLAVICLE, COMPLETE $274.00

CLINDAMYCIN 300MG/50ML PREMIX 150.68



CLINDAMYCIN CAP 150 MG 2.54

CLINIMIX 5/15 1000ML IV SOLN 124.00

CLIP RESOLUTION $646.00

CLIPS FILSHIE $318.00

CLONAZEPAM TABLET 1MG 6.85

CLONIDINE TAB 0.1MG 7.08

CLOPIDOGREL TAB 75MG 6.85

CLOSED TX DISTAL PHALANGEAL FX $1,434.00

CLOSED TX DISTAL RADIAL FX $2,599.00

CLOSED TX HIP DISLOCATION $842.00

CLOSED TX HIP DISLOCATION $3,413.00

CLOSED TX INTERPHALANGEAL $1,263.00

CLOSED TX KNEE DISLOCATION $2,264.00

CLOSED TX METACARPAL FX $1,467.00

9 of 48




CLOSED TX PHALANGEAL SHAFT FX $1,495.00

CLOSED TX POST HIP ARTHROPLAST $2,579.00

CLOSED TX RADIAL HEAD SUBLUX $618.00

CLOSED TX SHOULDER DISLOCATION $1,370.00

CLOSED TX SHOULDER DISLOCATION $1,810.00

CLOSTRIDIUM DIFFICILE ANTIGEN $140.00

CLOSTRIDIUM DIFFICILE TOXIN GE $146.00

CLOTRIMAZOLE CREAM 1% 30 GRAM 18.11

CLOTRIMAZOLE TROCHES 10MG 11.35

CLOZAPINE (CLOZARIL) $165.00

CM&H FUNCTIONAL CURRENT $0.01

CM&H FUNCTIONAL DISCHARGE $0.01

CM&H FUNCTIONAL PROJECTED $0.01

CMACB CHROMO MICROARRAY BLOOD $4,967.00

CO2 DETECTOR END TIDAL $40.00

COCAINE $111.00

COCAINE TOPICAL SOL 4% 4ML BTL 579.95

COCCIDIOIDES AB CF/ID SERUM $65.00

COG SK DEVEL EA 15" MCR ONLY $169.00

COGNITIVE PERFORMANCE TESTING $515.00

COGNITIVE PERFORMNC TEST 60MIN $515.00

COGNITIVE SKILLS DEVEL UNTIMED $674.00

COLCHICINE TAB 0.6MG 51.93

COLD AGGLUTININ TITER $79.00

COLD THERAPY KODIAK $303.00

COLD/HEAT WRAP $133.00

COLECTOMY,PARTIAL W/ILEUM REM,ADDL 2HRS $5,000.00

COLECTOMY,PARTIAL;W/COLOPROCTOSTOMY $5,000.00

COLECTOMY,PARTIAL;W/REMOVAL TERMINAL ILE $5,000.00

COLLAGEN CROSSLINKS $586.00

COLLAGEN CROSSLINKS ANY METHOD $586.00

COLLAR CERVICAL $34.00

COLLAR PHILADELPHIA $74.00

COLON RESECTION $1,316.00

COLONOSCOPY $1,064.00

COLONOSCOPY WITH BIOPSY $330.00

COLONOSCOPY, FLEXIBLE; DIAGNOSTIC $1,727.00

COLONOSCOPY; BIOPSY $2,179.00

COLONOSCOPY; DIAGNOSTIC $1,829.00

COLONOSCOPY; REMOVAL TUMOR(S) $2,246.00

COLONOSCOPY; W/REMVL OF TUMOR/POLYP $2,246.00

COLONOSCOPY; WITH BIOPSY $331.00

COLONOSCOPY; WITH BIOPSY $2,057.00

COLORECTAL CA SCREENING FECAL $53.00

COLORECTAL CA SCREENING FECAL-OCCULT BLD $53.00

COLORECTAL CA SCREENING; COLONOSCOPY $1,829.00

COLORECTAL CANCER SCREENING $1,829.00

COLORECTAL CANCER SCRN RESULTS $0.01

COLORECTAL CANCER SCRN RESULTS DOC $0.01

COLPOPEXY;ABDOMINAL APPROACH $4,288.00

COLPOSCOPY OF VULVA $481.00

COLPOSCOPY OF VULVA W BX $632.00

COLPOSCOPY W/BX CERVIX & ENDOCERVICAL CU $685.00

COLPOSCOPY W/BX OF CERVIX $652.00

COLPOSCOPY W/ENDOCERVICAL CURETTAGE $603.00

COMFORT BAND CLEARCHEST $126.00

COMPATIBILITY TEST ANTIGLOBULI $301.00

COMPATIBILITY TEST IMMED SPIN $152.00

COMPLEMENT ANTIGEN EACH $88.00

COMPLEMENT TOTAL HEMOLYTIC $262.00

COMPLETE PFT WITH NEB TX $391.00

COMPLETED EPSDT SERVICE $70.00

COMPLEX REPAIR WOUND $1,945.00

COMPLEX SPECIAL STAIN $145.00

10 of 48




COMPREHENSIVE CONSULTATION W/R $675.00

COMPREHENSIVE METABOLIC PANEL $220.00

CONCENTRATION (ANY TYPE), FOR $171.00

CONCURRENT CHEMO INFUSION $263.00

CONSULT & REPORT ON REFRD SLIDES $553.00

CONSULTATION AND REPORT W/PREP $97.00

CONTROL NASAL HEMORRHAGE $474.00

CONTROL NASAL HEMORRHAGE $965.00

CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMP $473.00

COPPER $220.00

CORD ACTIVE DISPOSABLE $320.00

CORTISOL FREE $187.00

CORTISOL TOTAL $190.00

COSYNTROPIN INJ 0.25MG/ML VIAL 162.65

C-PEPTIDE $168.00

CPR WITH DEFIBRILLATION $118.00

C-REACTIVE PROTEIN (CRP) $103.00

CREAM SKIN REPAIR $15.00

CREATINE KINASE (CK) (CPK) TOT $103.00

CREATINE KINASE (CK) (CPK) TOTAL $103.00

CREATINE KINASE MB $153.00

CREATININE BLOOD $94.00

CREATININE OTHER SOURCE $94.00

CREATININE OTHER SOURCE DR G $109.00

CRITICAL CARE, EACH ADD 30MIN $800.00

CRITICAL CARE, EACH ADD 30MIN $400.00

CRITICAL CARE, EVAL & MANAGE/30-74 MIN $2,300.00

CRITICAL CARE, FIRST HOUR $2,300.00

CRITICAL CARE, FIRST HOUR $1,150.00

CRITICAL CARE;EACH ADDITIONAL 30 MINUTES $800.00

CRP HIGH SENSITIVITY $168.00

CRP HIGH SENSITIVITY $169.00

CRUTCHES $14.00

CRUTCHES UNDERARM, PAIR $14.00

CRYSTAL ID TISSUE OR BODY FLUI $92.00

CUDS AMPHETAMINES 5 OR MORE $18.00

CUDS ANALGESICS NON-OPIOID 6+ $18.00

CUDS ANTIDEPRESSANTS NOS $18.00

CUDS ANTIDEPRESSANTS SERO 6+ $18.00

CUDS ANTIDEPRESSANTS TRICYCLIC $18.00

CUDS ANTIEPILEPTICS NOS 7 > $18.00

CUDS ANTIPSYCHOTICS NOS 7 > $18.00

CUDS BENZODIAZEPINES 1-12 $18.00

CUDS BEPRENORPHINE $18.00

CUDS COCAINE $18.00

CUDS CREATININE OTHER SOURCE $18.00

CUDS DRUG SCREEN CLASS A LIST $18.00

CUDS DRUG SCREEN CLASS B LIST $18.00

CUDS DRUG TEST PRESUMPTIVE $18.00

CUDS DRUG(S) OR SUBSTANCE(S) $18.00

CUDS FENTANYL $18.00

CUDS GABAPENTIN NON-BLOOD $18.00

CUDS KATAMINE AND NORKETAMINE $18.00

CUDS METHADONE $18.00

CUDS METHYLENEDIOXYAMPHETAMINE $18.00

CUDS METHYLPHENIDATE $18.00

CUDS OPIATES 1 OR MORE $18.00

CUDS OPIOID/OPIATE ANALOGS 5> $18.00

CUDS OXYCODONE $18.00

CUDS PHENCYCLIDINE (PCP) $18.00

CUDS PREGABALIN $18.00

CUDS PROPOXYPHENE $18.00

CUDS SEDATIVE HYPNOTICS $18.00

CUDS SKELETAL MUSCLE RELAXANTS $18.00

11 of 48




CUDS STIMULANTS SYNTHETIC $18.00

CUDS TAPENTADOL $18.00

CUDS TRAMADOL $18.00

CULTURE BACTERIAL ANAEROBIC $141.00

CULTURE BACTERIAL ANAEROBIC AN $141.00

CULTURE BACTERIAL ANAEROBIC EA $62.00

CULTURE BACTERIAL ANAEROBIC ISOLATE EACH $62.00

CULTURE BACTERIAL BLOOD $181.00

CULTURE BACTERIAL ISOLATE ID $117.00

CULTURE BACTERIAL OTHER SOURCE $141.00

CULTURE BACTERIAL STOOL ADDL $66.00

CULTURE BACTERIAL STOOL PRELIM $131.00

CULTURE BACTERIAL URINE $152.00

CULTURE FUNGI DEFINITIVE ID EA $51.00

CULTURE FUNGI DEFINITIVE ID EA $134.00

CULTURE FUNGI ISOLATE OTH SRCE $349.00

CULTURE FUNGI ISOLATION $353.00

CULTURE FUNGI ISOLATION BLOOD $71.00

CULTURE MYCOBACTERIAL ID EA $281.00

CULTURE SCREENING ONLY $100.00

CULTURE TUBERCLE OR ANY AFB $153.00

CULTURE TYPING ID NUCLEIC ACID $176.00

CURRENT TOBACCO NON USER $0.01

CURRENT TOBACCO SMOKER $0.01

CYANOCOBALAMIN VIT B12 INJ 1000 MCG VIAL $35.50

CYCLIC CITRULLINATED PEPTIDE $206.00

CYCLOBENZAPRINE TAB 10MG 6.85

CYCLOPENTOLATE 1% OPH SOLN 2ML 36.75

CYCLOPHOSPHAMIDE 1000MG INJ VL 2,012.76

CYCLOPHOSPHAMIDE 500MG INJ VL 1,133.15

CYCLOSPORINE $222.00

CYSTO INCISE BLADDER/DRAIN URETER $2,130.00

CYSTORRHAPHY;SUTURE BLADDER WOUND/INJURY $3,973.00

CYSTOSTOMY;CYSTOTOMY W/DRAINAGE $1,286.00

CYTOGENETICS MOLECULAR I AND R $1,241.00

CYTOMEGALOVIRUS (CMU) AB IGM $163.00

CYTOMEGALOVIRUS (CMV) AB $167.00

CYTOMEGALOVIRUS (CMV) IgG AVIDITY $381.00

CYTOMEGALOVIRUS AMP PROBE $353.00

CYTOMEGALOVIRUS QUANTIFICATION $459.00

CYTOPATH CERVIC VAG AUTO MAN R $170.00

CYTOPATH CERVIC VAG AUTO MAN R $171.00

CYTOPATH CERVIC VAG THIN LAYER $171.00

CYTOPATH CONCENTRATION INTERP $371.00

CYTOPATH FLU WASH SMEAR INTERP $371.00

CYTOPATH FNA INTERP & REPORT $505.00

D5W/ 1/2 NS/ KCL 10mEq 1000ML 124.00

D5W/ 1/2 NS/ KCL 20mEq 1000ML 124.00

D5W/ 1/2 NS/ KCL 30mEq 1000ML 124.00

D5W/ 1/2 NS/ KCL 40mEq 1000ML 124.00

D5W/ NS/ KCL 20mEq 1000ML IV 124.00

DAPTOMYCIN 1MG INJ 3.57

DARBEPOETIN ALFA 100MCG/0.5ML 2,593.55

DARBEPOETN ALFA 60MCG/0.3ML IJ 1,430.12

DBL LOAD 4.75MM BIOCOMP SWVLK $1,693.00

D-DIMER QUANTITATIVE $172.00

DEBRIDE MASTOIDECTOMY CAVITY;SIMPLE $651.00

DEBRIDEMENT EA ADDL 20 SQ CM $332.00

DEBRIDEMENT NAILS, ANY METHOD, 1-5 $143.00

DEBRIDEMENT OF SKIN & SUB CU TISSUE ABD $515.00

DEBRIDEMENT OF SKIN TISSUE/MUSCLE $1,046.00

DEBRIDEMENT SUBQ TISSUE ADD-ON $182.00

DEBRIDEMENT, EACH ADDL 20 SQ CM $332.00

DEBRIDEMENT; SKIN $515.00

12 of 48




DEBRIDEMENT; SKIN $1,046.00

DECALCIFICATION PROCEDURE $41.00

DECLOTTING CENTRAL LINE $241.00

DEHYDRO SULFATE (DHEA-S) $208.00

DELIVERY FEE $1,765.00

DELIVERY OF PLACENTA $418.00

DELIVERY ROOM RESUSCITATION $191.00

DELIVERY/BIRTHING ROOM RESUSCITATION $595.00

DEMO/EVAL; PT USE OF EQUIP $138.00

DENOSUMAB 120MG/1.7ML INJ VIAL 7,551.94

DENOSUMAB 60MG/ML INJ SYRINGE 4,022.20

DESMOPRESSIN INJ 4MCG/ML 245.60

DESTRUCT BENIGN LESION 1-9 UNC $240.00

DESTRUCT BENIGN LESION<=14COMP $478.00

DESTRUCT BENIGN LESIONS 10-14 FOLLOWUP $176.00

DESTRUCT BENIGN LESIONS 10-14 UNCOMPLCTD $351.00

DESTRUCT BENIGN LESIONS 15 OR > UNCOMPLC $425.00

DESTRUCT BENIGN LESIONS 15 OR> FOLLOWUP $213.00

DESTRUCT BENIGN LESIONS 15+ COMPLEX $566.00

DESTRUCT BENIGN LESIONS 1-9 FOLLOWUP $120.00

DESTRUCT BENIGN LESIONS 1-9 UNCOMPLICATD $239.00

DESTRUCT BENIGN LESIONS COMPLEX FOLLOWUP $239.00

DESTRUCT BENIGN LESIONS UP TO 14 COMPLEX $478.00

DESTRUCT CUTAN VASC PROLIF LES $1,529.00

DESTRUCT CUTAN VASC PROLIF LESIONS < 10 $1,529.00

DESTRUCT PREMALIGN LESION 1ST $362.00

DESTRUCT PREMALIGN LESION 2-14 $53.00

DESTRUCT PREMALIGNANT LESIONS 15+ $770.00

DESTRUCT PREMALIGNANT LESIONS 1ST $362.00

DESTRUCT PREMALIGNANT LESIONS 2-14 $53.00

DESTRUCTION LESION $1,251.00

DESTRUCTION OF LESION EXTENSIVE $948.00

DEVELOPMENTAL TESTING; LIMITED $163.00

DEVELOPMENTAL TESTING;LIMITED $163.00

DEVICE V-LOC WOUND CLOSURE $100.00

DEXAMETHASONE 10MG/ML 1 ML INJ 24.86

DEXAMETHASONE 4MG/ML 5ML INJ 24.50

DEXAMETHASONE INJ 10MG/1ML 26.26

DEXAMETHASONE INJ 10MG/ML VIAL $20.55

DEXAMETHASONE INJ 4MG/ML 1ML 24.50

DEXAMETHASONE INJ 4MG/ML 5ML 24.50

DEXAMETHASONE TAB 4MG 12.15

DEXTROSE 5%/WATER EXCEL 500ML 98.00

DEXTROSE 50% 50 ML INJ VIAL 35.05

DEXTROSE 50% SYRINGE 50ML 79.20

DIABETIC SELF MGMT,INDIV 30MIN $190.00

DIABETIC SELF-MGMT: GROUP30MIN $150.00

DIAG MAMMO BIL 3D DIGITAL IMAG $53.00

DIAG MAMMO BIL DIGITAL IMAGE $427.00

DIAG MAMMO UNI 3D DIGITAL IMAG $53.00

DIAG MAMMO UNI DIGITAL IMAGE $362.00

DIAPER RASH OINT 120 GM 38.10

DIAZEPAM INJ 10MG/2ML 78.11

DIAZEPAM INJ 10MG/2ML SYRINGE $70.45

DIAZEPAM TAB 5MG 6.85

DICLOFENAC OPHTH SOL 0.1% 5ML 44.25

DIFFUSING CAPACITY $476.00

DIGOXIN $146.00

DIGOXIN INJ 0.5MG/2ML 59.27

DIGOXIN TAB 0.125MG 11.72

DIGOXIN TOTAL $146.00

DIHYDROERGOTAMINE 1MG/1 ML INJ 530.80

DIHYDROXYVITAMIN D S 1 25 $240.00

DILATION & CURETTAGE;DIAGNOSTIC/THERPEUT $1,174.00

13 of 48




DILTIAZEM 25MG/5ML INJ VIAL 31.85

DILTIAZEM CAP CD 120MG 6.85



DILTIAZEM INJ 5MG/ML 10ML 32.84

DILTIAZEM TAB 60MG 6.85

DINOPROSTONE 10 MG VAG INSERT 1,095.82

DIPHENHYDRAM 12.5MG/5ML 30ML 6.85

DIPHENHYDRAMIN 12.5MG/5ML DOSE 6.85

DIPHENHYDRAMINE 50MG/1 ML INJ 24.50

DIPHENHYDRAMINE CAP 25MG 6.85

DIPHENHYDRAMINE CAP 50MG 6.85

DIPHENHYDRAMINE INJ 50 MG VIAL $24.50

DIPHENNYDRAMINE 50MG/ML 1ML 24.50

DIPHENOXYLATE/ATROP TAB 6.85

DIPT/TET/PERTUS/HEPB/POLIO(Dta 0.01

DIPTHERIA TETANUS PERTUSSIS <7 0.01

DIPTHERIA,TETANUS,PERTUSSIS;<7 YRS;INTRA $0.01

DIPTHERIA,TETANUS,PERTUSSIS;<7 YRS;INTRA $24.85

DIPTHERIA;TETANUS;PERTUSSIS;HEPB;POLIOVI $79.35

DIPTHERIA;TETANUS;PERTUSSIS;HIB;POLIOVIR $0.01

DIPYRIDAMOLE/ASA CAP 200/25MG 55.45

DISCOVISC/DUOVISC/VISCOELASTIC $136.00

DIVALPROEX ENT COATED TB 250MG 6.85

DNA ANTIBODY NATIVE OR DBL $168.00

DOBUTAMINE INJ 250MG/20ML 56.40

DOCETAXEL 20MG/1ML INJ 249.28

DOCETAXEL 80MG/4ML INJ 495.04

DOCUSATE LIQ 50MG/5ML 30ML CHG 6.85

DOCUSATE SOD CAP 100MG 6.85

DOMICIL/R-HOME VISIT NEW PATIENT $542.00

DOMICILIARY, REST HOME, OR CUSTODIAL CAR $228.00

DOMICILIARY/REST HOME VISIT;HIGH COMPLEX $776.00

DOMICILIARY/REST HOME VISIT;LOW COMPLEXI $381.00

DOMICILIARY/REST HOME VISIT;MOD COMPLEXI $540.00

DOMICILIARY/REST HOME VISIT;PROBLEM FOCU $243.00

DONEPEZIL TAB 10MG 6.84

DONNATAL ELIXIR 30 ML 311.15

DOP VEL FETAL UMBILICAL ARTERY $383.00

DOPAMINE 800MG/D5W 250ML 189.45

DORZOLAMIDE 2% OPHTH SOLN 10ML 59.15

DORZOLAMIDE/TIMOLOL OPHTH 10ML 75.13

DOXAZOSIN 2 MG TABS 6.85

DOXORUBICIN INJ 2MG/ML 50MG 142.02

DOXORUBICIN LIPOSOME 50MG VIAL 7,046.05

DOXORUBICIN LIPOSOME IJ 20MG 3,072.86

DOXYCYCLINE INJ 100MG VIAL 247.89

DOXYCYCLINE TAB 100MG 11.75

DRAIN BLADDER W CATH INSERTION $979.00

DRAINAGE PALM BURSA;SINGLE $1,905.00

DRESSING ALGINATE <16 IN $40.00

DRESSING ALGINATE 16-48 IN $128.00

DRESSING AQUACEL AG SURGICAL $128.00

DRESSING AQUACEL FOAM 7X7 W/A $26.00

DRESSING AQUACEL FOAM NA 6X6 $26.00

DRESSING CODMAN SURGICAL PATTI $27.00

DRESSING EDEMA WEAR $26.00

DRESSING FOAM > 48 IN SQ $47.00

DRESSING FOAM > 48 SQ IN $47.00

DRESSING FOAM 16-48 IN $26.00

DRESSING HYDROCOLLOID <16 IN $26.00

DRESSING INTERDRY AG $16.00

DRESSING INTERDRY INDIVIDUAL $65.00

DRESSING THERA HONEY $13.00

14 of 48




DRESSING, FOAM 16-48 IN $24.00

DRESSING; AQUACEL AG SURGICAL $128.00

DRESSING; TEGADERM CHG $25.00

DRSG FOAM<16 IN $26.00

DRUG ASSAY; LAMOTRIGINE (LAMICTAL) $96.00

DRUG SCREEN $342.00

DRUG SCREEN SAL $191.00

DRUG TEST PRESUMPTIVE $331.00

DRUG TESTS DEFINITIVE 1-7 DRUG $127.00

DRUG TESTS DEFINITIVE 1-7 DRUG CLASSES $127.00

DRUG TESTS DEFINITIVE 22 OR > DRUG CLASS $559.00

DRUG TESTS DEFINITIVE 8-14 DRU $253.00

DRUGS TEST(S) DEFINITIVE 22 > $559.00

DTAP IVP $0.01

DTAP IVP $51.00

DTAP IVP $52.45

DULOXETINE 20MG CAP 6.85

DULOXETINE 30MG CAP 13.05

DUPLEX SCAN AR INFLW/VEN OTFLW $365.00

DX BONE MARROW BX AND ASPIRATI $728.00

DXA, BONE DENSITY STUDY $625.00

ECHO 2D COMPLETE (NO CONTRAST) $2,365.00

ECHO 2D COMPLETE W/WO CONTRAST $2,506.00

ECHO 2D LIMITED (NO CONTRAST) $932.00

ECHO 2D LIMITED W/WO CONTRAST $1,073.00

ECHO COLOR FLOW $741.00

ECHO DOPPLER LIMITED STUDY $517.00

EDROPHONIUM INJ 10MG/1 ML DOSE 46.90

EGD W/TUMOR/POLYP REMOVAL BY SNARE $2,155.00

EGD WITH BALLOON DILATION $4,634.00

EGD WITH BIOPSY $206.00

EGFR T790M GENE COM VARIANTS $1,381.00

EHRLICHIA $93.00

EHRLICHIA $237.00

EIA HIV1/HIV2 SCREEN $147.00

EKG INTERPRETATE/REPORT ONLY $48.00

EKG; INTERPRETATE/REPORT ONLY $48.00

ELBOW; COMPLETE, MIN OF 3 VIEW $349.00

ELBOW; TWO VIEWS $274.00

ELECTRIC STIM (ATTENDED)/15MIN $92.00

ELECTROCARDIOGRAM EKG $220.00

ELECTROCARDIOGRAM;INTERPRETATION & REPOR $48.00

ELECTROCARDIOGRAM;ROUTINE ECG,12 LEADS $267.00

ELECTRODE $8.00

ELECTRODE CUTTING LOOP $191.00

ELECTRODE DEFIB $114.00

ELECTRODE VAPOR S90 4.OMM $807.00

ELECTROLYTE PANEL $119.00

EMER DEPT VISIT, LEVEL 1 $400.00






EMER DEPT VISIT, LEVEL 4 $1,200.00


EMER DEPT VISIT, LEVEL 5 $1,500.00


ENALAPRIL TAB 10MG 6.85

ENDO CLIP $613.00

ENDO CLOSE DEVICE $97.00

ENDO CUT SCISSORS $105.00

ENDO SCISSORS $405.00

ENDO STITCH $1,072.00

15 of 48




ENDOMETRIAL ABLATION, THERMAL $4,466.00

ENDOMETRIAL BIOPSY $487.00

ENDOMETRIAL BIOPSY; W/COLPOSCOPY $217.00

ENDOMETRIAL OBLATION, THERMAL $4,466.00

ENDOVEN ABLA TH RF 1ST V BIL $5,000.00

ENDOVENOUS ABLATION THERAPY RF $5,000.00

ENDOVENOUS ABLATION THERAPY,RF, 1ST VEIN $5,000.00

ENDOVENOUS ABLATION THR RF 1ST VEIN BIL $5,000.00

ENDOVENOUS RF VEIN ADD-ON $1,289.00

ENOXAPARIN 120MG/0.8 ML INJ 90.35

ENOXAPARIN 150MG/ML INJ 103.20

ENOXAPARIN SOD INJ 30MG/0.3ML 31.89




ENOXAPARIN SOD INJ 100MG/1ML 74.12

ENTEROLYSIS $4,875.00

ENTEROVIRUS AMPLIFIED PROBE $1,214.00

EPHEDRINE INJ 50MG/ML 1 ML 186.89

EPINEPHRINE 0.3MG SYRINGE 587.25

EPINEPHRINE 1MG/10ML SYRINGE 49.65

EPINEPHRINE INJ 1MG/ 1ML 136.45

EPSTEIN BARR VIRUS (VCA) $296.00

EPSTEIN BARR VIRUS AB $233.00

ERIBULIN 1MG/2ML INJ VIAL 3,838.33

ERTAPENEM INJ 1GM 632.69

ERYTHROMYCIN BASE TAB 250 MG 36.86

ERYTHROMYCIN OPHTH OINT 1 GRAM 35.97

ERYTHROPOIETIN (EPO) $206.00

ESCITALOPRAM TAB 10MG 6.85

ESOMEPRAZOLE DR CAP 20MG 33.55

ESOPHAGEAL DILATION $1,064.00

EST PATIENT PREVENTIVE 12-17 Y $240.00

EST PATIENT PREVENTIVE 1-4 YR $210.00



EST PT OV/OP VISIT MINIMAL $16.00

ESTAB PT PREVENTIVE VISIT, 12-17 YEARS $240.00















ESTAB PT PREVENTIVE VISIT, 65 + YEARS $290.00



ESTAB PT PREVENTIVE VISIT, INFANT $194.00



ESTABLISHED PATIENT $39.00






16 of 48







ESTABLISHED PATIENT 10 MINUTES $136.00





ESTABLISHED PATIENT COMP P.M. $87.00



ESTABLISHED PATIENT; 10MIN $75.00




ESTABLISHED PATIENT; COMP P.M. $372.00

ESTABLISHED PATIENT; COMP P.M. $408.00

ESTABLISHED PT HIGH LEV 40 MIN $120.00

ESTABLISHED PT LOW LEV 10 MIN $39.00

ESTABLISHED PT MOD LEV 15 MIN $58.00

ESTABLISHED PT MOD LEV 25 MIN $87.00

ESTABLISHED PT OV/HIGH COMPLEX/40 MINUTE $315.00

ESTABLISHED PT OV/LOW COMPLEX/15 MINUTE $155.00

ESTABLISHED PT OV/MOD COMPLEX/25 MINUTE $225.00

ESTABLISHED PT OV/OUTPT PROB FOCUSED EXA $75.00

ESTABLISHED PT OV/OUTPT PROB FOCUSED EXA $30.00

ESTABLISHED PT OV/OUTPT VISIT, HIGH COMP $224.00

ESTABLISHED PT OV/OUTPT VISIT, HIGH COMP $91.00

ESTABLISHED PT OV/OUTPT VISIT, LOW COMPL $110.00

ESTABLISHED PT OV/OUTPT VISIT, LOW COMPL $45.00

ESTABLISHED PT OV/OUTPT VISIT, MINIMAL $39.00



ESTABLISHED PT OV/OUTPT VISIT, MOD COMPL $160.00

ESTABLISHED PT OV/OUTPT VISIT, MOD COMPL $65.00

ESTABLISHED PT OV/PROB FOCUS/10 MINUTE $105.00

ESTRADIOL $290.00

ESTRIOL $278.00

ETOMIDATE INJ 2MG/ML 10ML 47.51

ETOPOSIDE 20MG/ML 10MG DOSE/CH 22.92

EVACUATION OF SUBUNGUAL HEMATO $218.00

EVAL SPEECH SOUND PROD W LANG $509.00

EVAL SPEECH SOUND PRODUCTION $509.00

EVAL SWALLOWING FUNCTION $509.00

EVALUATION OF SPEECH FLUENCY $509.00

EVENT LOOP HOOKUP MAX 30 DAY $581.00

EVENT LOOP REPORT $2,637.00

EVEROLIMUS $710.00

EXC ABD TUM 5 CM OR LESS $5,000.00

EXC TUMOR NECK/THORAX SUBFAS 5CM OR > $3,277.00

EXC TUMOR THIGH/KNEE DEP 5CM O $3,309.00

EXCISE ABD TUMOR > 10 CM $5,000.00

EXCISE BENIGN LESION INCL MARGIN > 4.0 $1,415.00

EXCISE BENIGN LESION INCL MARGIN >4.0 CM $1,500.00

EXCISE BENIGN LESION INCL MARGIN 0.6/1.0 $721.00






EXCISE BENIGN LESION INCL MARGIN 3.1/4.0 $1,288.00

EXCISE LESION TENDON SHEATH/JOINT CAPSUL $2,640.00

EXCISE MALIG LESION INCL MARGIN 1.1/2.0 $1,098.00


17 of 48











EXCISE NAIL & NAIL MATRIX, PART/COMPLETE $963.00

EXCISE OTHER BENIGN LESION $743.00

EXCISE OTHER BENIGN LESION 2.1/3.0 CM $1,019.00

EXCISE PILONIDAL CYST OR SINUS, COMPLICA $3,157.00

EXCISE PILONIDAL CYST OR SINUS, EXTENSIV $2,595.00

EXCISE SWEAT GLAND LESION $1,609.00

EXCISE TUMOR, SOFT TISSUE NECK OR THORAX $2,000.00

EXCISION CYST; BREAST $2,164.00

EXCISION FOREARM LESION SC 3CM> $1,918.00

EXCISION LESION SKIN $1,537.00

EXCISION LOCAL LESION EPIDIDYM $2,488.00

EXCISION MOLE OR LESION $1,316.00

EXCISION NAIL & NAIL MATRIX $963.00

EXCISION OF LIP $2,232.00

EXCISION OF SYNOVIAL CYST;POPLITEAL SPAC $2,169.00

EXCISION PILONIDAL CYST; EXTEN $2,595.00

EXCISION RECTAL TUMOR TRANSANA $2,641.00

EXCISION RECTAL TUMOR TRANSANAL APPROACH $2,641.00

EXCISION TUMOR AXILLA $3,277.00

EXCISION TUMOR; SHOULDER AREA $1,891.00

EXCISION WEDGE SKIN NAIL FOLD $759.00

EXCISION, BENIGN LESION $721.00






EXCISION, MALIGNANT LESION $1,098.00





EXCISION,TUMOR, BACK, SUBQ; 3 CM OR > $2,121.00

EXTRACRANIAL ARTERIES; BILAT $1,369.00

EXTRACTABLE NUCLEAR AG OR AB $155.00

EXTREMITY LOWER CTA W $2,193.00

EXTREMITY LOWER JOINT W/WO $3,140.00

EXTREMITY LOWER JOINT WO $2,410.00

EXTREMITY LOWER W $1,790.00

EXTREMITY LOWER W/WO $3,140.00

EXTREMITY LOWER WO $1,578.00

EXTREMITY LOWER WO $2,410.00

EXTREMITY NON VASCULAR LIMITED $367.00

EXTREMITY UPPER JOINT W/WO $3,140.00

EXTREMITY UPPER JOINT WO $2,410.00

EXTREMITY UPPER W/WO $3,140.00

EXTREMITY UPPER WO $1,578.00

EXTREMITY UPPER WO $2,410.00

EXTREMITY VEINS; BILATERAL $1,294.00

EXTREMITY VEINS; UNILATERAL $1,124.00

EYE WASH IRRIGATING SOLN 118ML 26.60

EZETIMIBE TAB 10 MG 68.31

EZ-IO INTRAOSSEOUS NEEDLE SET $303.00

F.B. LOCAL; HEAD/NECK SOFT TIS $367.00

FACTOR V LEIDEN $238.00

FACTOR V LEIDEN MUTATION BLOOD $220.00

FACTOR VIII AHC 1-STAGE $435.00

18 of 48




FACTOR VIII VONWILLERBRAND $523.00

FALLS RISK ASSESS DOC NOT A FA $0.01

FALLS RISK ASSESS DOC NOT A FALLS RISK $0.01

FAMOTIDINE 20MG/50ML PREMIX 149.88

FAMOTIDINE TAB 20MG 6.87

FASIECTOMY,PART PALMAR RELEASE DIGIT $1,249.00

FASIECTOMY;PART PALMER;RELEASE SINGLE DI $3,708.00

FAT EMULSION 20% 500 ML PREMIX 98.00

FAT EMULSON 20% 250ML 98.00

FAT OR LIPIDS FECES QUALITATIV $62.00

FECAL OCCULT BLOOD iFOB $48.00

FEMUR TWO VIEWS $296.00

FENTANYL 50MCG/ML 2ML 24.50

FENTANYL 50MCG/ML 5ML 28.68

FENTANYL 50MCG/ML PCA 30ML 255.29

FENTANYL 50MCQ/ML 2 ML VIAL NA 58.40

FENTANYL CONFIRMATION UR $292.00

FENTANYL PATCH 25MCG/HR 2.70

FENTANYL PATCH 50MCG/HR 29.20

FENTANYL ROPIVACAINE EPIDURAL 385.40

FERAMOXYTOL 510MG/17ML INJ VIA 2,871.55

FERRIC CARBOXYMALTSE 750MG INJ 3,270.79

FERRITIN $151.00

FERROUS GLUCONATE 324MG TAB 6.85

FERROUS SULFATE TAB 324MG 6.84

FETAL CONGEN ABNORM,ASSAY 4 ANALYTES $174.00

FETAL FIBRONECTIN $995.00

FETAL MONITORING NON-STRESS $468.00

FETAL MONITORING; NON STRESS $220.00

FETAL NON-STRESS TEST $221.00

FETAL PROFILE; W/O NON-STRESS $695.00

FEXOFENADINE TAB 60MG 6.85

FFP THAWING EA UNIT $63.00

FIBRINOGEN ACTIVITY $153.00

FILGRASTIM 300MCG INJ 1,004.08

FINASTERIDE 5MG TAB 6.85

FINE NEEDLE ASPIRATION $634.00

FINE NEEDLE ASPIRATION; W/ IMAGING GUIDE $634.00

FINGERS, MINIMUM OF TWO VIEWS $274.00

FISH OIL 1000MG CAP 6.85

FIT. & INSERT. PESSARY INTRAVAGINAL DEVI $341.00

FIX G/COLON TUBE W/DEVICE $3,155.00

FLORASTOR 250MG CAPS 6.89

FLOW CYTOMETRY CELL SURFACE $427.00

FLOW CYTOMETRY EA ADD MARKER $209.00

FLOW CYTOMETRY INTERP 16> $534.00

FLOW CYTOMETRY INTERP 2-8 $220.00

FLOW CYTOMETRY INTERP 9-15 MRK $450.00

FLOW CYTOMETRY, INTERP; 16> MARKERS $534.00

FLOW CYTOMETRY,CELL SURFACE, CYTOPLASMIC $427.00

FLUCONAZOLE 400MG/200ML INJ 184.45

FLUCONAZOLE TAB 100 MG 12.73

FLUDROCORTISONE TAB 0.1MG 6.85

FLUMAZENIL INJ. 0.5MG/5ML 76.04

FLUORESCENT ANTIBODY $190.00

FLUORESCENT NONINFECT AB SCRN $888.00

FLUORESCENT NONINFECTIOUS AB $190.00

FLUORO EVAL SWALLOWING FUNCT $509.00

FLUORO GUIDE CV ACCESS DEVICE $240.00

FLUOROGUIDE FOR VEIN DEVICE $79.00

FLUOROGUIDE FOR VEIN DEVICE $124.00

FLUOROSCOPY, SEPARATE PROCEDUR $192.00

FLUOROURACIL 2500MG/50ML INJ 151.38

FLUOROURACIL INJ 5000MG/100ML 288.87

19 of 48




FLUOROURACIL INJ 500MG/10ML 50.38

FLUOXETINE CAP 20MG 6.94

FLUOXETINE TAB 10MG 6.85

FLUTICASONE 0.05% NASAL SPR 6G 40.00

FLUTICASONE HFA 110MCQ INHALER 740.78

FLUTICASONE HFA 220MCQ INHALER 1,135.40

FLUTICASONE/SALMET 100/50 DISK 450.89



FMH ROSETTE $103.00

FOLIC ACID INJ 5MG/ML 1MG DOSE 24.50

FOLIC ACID SERUM $208.00

FOLIC ACID TAB 1MG 6.84

FOOT; COMPLETE, MIN OF 3 VIEWS $296.00

FOOT; TWO VIEWS $274.00

FORCEPS BIOPSY $274.00

FOREARM, TWO VIEWS $274.00

FORESKIN MANIP LYSIS PREPUTIAL $304.00

FORMOTEROL 20MCG/2ML NEB 49.15

FOSAPREPITANT 150MG/10ML INJ 1,375.77

FOSPHENYTOIN PE 500MG/10ML INJ 174.65

FRACTURE/DISLOCATION CARE $555.00

FRED ANTI-FOG SOLUTIONS $13.00

FRESH FROZEN PLASMA EACH UNIT $221.00

FULVESTRANT INJ 250MG/5ML 3,316.80

FUROSEMIDE INJ 20MG/2ML 24.49



FUROSEMIDE TAB 20MG 6.85

FUROSEMIDE TAB 40MG 6.85

GABAPENTIN CAP 100MG 6.85

GABAPENTIN CAP 300MG 6.85

GADAVIST 10ML INJ 241.50

GADAVIST 7.5ML INJ 208.75

GADOBENATE 529MG/ML 20ML INJ 304.71

GAIT TRAINING/15MIN $110.00

GAMMAGLOBULIN IgA IgD IgG IgM $348.00

GAMMAGLOBULIN IgE $70.00

GASES BLOOD ANY COMBINATION $208.00

GASES BLOOD WITH O2 SATURATION $372.00

GASTRIC EMPTYING STUDY $1,685.00

GASTRIC INTUBATION AND ASPIRAT $97.00

GASTROGRAFIN ORAL SLUTION 30ML 8.45

GASTRORRHAPHY $5,000.00

GASTROSCOPY $1,064.00

GASTROSTOMY TUBE, LOW PROFILE $472.00

GEMCITABINE 1 GRAM INJ 212.89

GEMCITABINE 2000MG INJ VIAL 383.83

GEMCITABINE INJ 200MG 120.31

GEMFIBROZIL TAB 600MG 6.85

GEMSTAR, PUMP SET $34.00

GENERAL HEALTH PANEL $255.00

GENTAMICIN $171.00

GENTAMICIN INJ 10MG/ML 2ML PED 45.35

GENTAMICIN INJ 40MG/ML 2ML 24.50

GENTAMICIN INJ 80MG/2ML (20ML) 28.56

GENTAMICIN OPH SOLN 0.3% 5ML 38.10

GEO MATT BODY ALIGNER $73.00

GI PANEL 12-25 TARGETS $1,048.00

GLIMEPIRIDE TAB 2MG 6.99

GLIPIZIDE TAB 5MG 7.10

GLIPIZIDE TAB XL 5MG 6.85

GLUCAGON 1MG EMERGENCY KIT 537.10

GLUCOSAMINE/CHONDROI 500/400MG 6.85

20 of 48




GLUCOSE 6-PHOSPH DEHYDROGENASE $228.00

GLUCOSE BLOOD REAGENT STRIP $83.00

GLUCOSE BODY FLUID NOT BLOOD $61.00

GLUCOSE MONITORING; MIN 72 HRS $344.00

GLUCOSE POST DOSE $130.00

GLUCOSE QUANTITATIVE BLOOD $94.00

GLUCOSE TOLERANCE TEST $191.00

GLUTAMYLTRANSFERASE GAMMA(GTT) $63.00

GLUTOSE GEL 15 GRAM 65.00

GLYBURIDE TAB 5MG 6.85

GLYCERIN SUPPOSITORY 7.38

GLYCOPYRROLATE 0.2MG/ML VIAL 60.65

GONADOTROPIN CHORIONIC QUAL $131.00

GONADOTROPIN CHORIONIC QUANT $190.00

GONADOTROPIN FSH $81.00

GONADOTROPIN LH $86.00

GONADOTROPIN, CHORIONIC (hCG);QUALITATIV $131.00

GRANISETRON INJ 1MG/ML VIAL 41.05

GROUND MILEAGE PER LOADED MILE $3.50

GROUND MILEAGE PER LOADED MILE $40.00

GROWTH HORMONE HUMAN (HGH) $170.00

GUAIFENESIN 100MG/5ML 120ML 21.10

GUAIFENESIN AC SYRUP 120ML 43.75

GUAIFENESIN AC SYRUP 5ML UD 6.84

GUAIFENESIN DM SYRUP 120ML 22.95

GUAIFENESIN ER 600 MG TAB 8.32

GUAIFENESIN SYRUP 100MG/5ML 6.85

GUIDANCE, NEEDLE PLACEMENT $920.00

GUIDANCE; NEEDLE PLACEMENT $182.00

HAEMOPHILUS INFLUENZA AB $514.00

HALOPERIDOL INJ 5MG/1ML VIAL 26.28

HALOPERIDOL TAB 2MG 6.90

HAND; MINIMUM OF THREE VIEWS $274.00

HAND; TWO VIEWS $274.00

HAPTOGLOBIN QUANTITATIVE $151.00

HEAD CTA W $2,193.00

HEAD OR BRAIN W $1,790.00

HEAD OR BRAIN W/WO $2,108.00

HEAD OR BRAIN WO $1,578.00

HEAD WO $2,410.00

HEAVY METAL SCREEN QUANT EACH $708.00

HEEL CUP TULI $13.00

HEEL CUSHION/SPUR CUSHION $60.00

HEEL OR ELBOW PROTECTOR,EACH $183.00

HEEL OR ELBOW PROTECTOR,EACH $38.00

HELICOBACTER PYLORI AB $172.00

HELICOBACTER PYLORI BREATH TST $445.00

HELICOBACTER PYLORI BREATH TST $447.00

HELICOBACTER PYLORI DRUG ADMIN $57.00

HELICOBACTER PYLORI STOOL $361.00

HEMATOCRIT (HCT) $84.00

HEMOGLOBIN (HGB) $83.00

HEMOGLOBIN 0XYGEN AFFINITY $532.00

HEMOGLOBIN GLYCOSYLATED (A1C) $112.00

HEMOPHILUS INFLUENZA B VACCINE $0.01

HEMOPHILUS INFLUENZA B VACCINE 0.01

HEMOPHILUS INFLUENZA B VACCINE; 4 DOSE $11.30

HEMOPHILUS INFLUENZA B VACCINE;3 DOSE $0.01

HEMORRHOIDECTOMY $1,316.00



HEMORRHOIDECTOMY, EXTERNAL, COMPLETE $2,130.00

HEMORRHOIDECTOMY, INT AND EXT, COMPLEX $2,148.00

HEMORRHOIDOPEXY $1,735.00

21 of 48




HEMORRHOIDOPEXY BY STAPLING $1,735.00

HEP B VAC PED 10MCQ/0.5ML VIAL 52.17

HEPARIN 1,000 UN/ML 10 ML INJ 26.70

HEPARIN 25,000 UNITS/250ML BAG 159.25

HEPARIN ASSAY $178.00

HEPARIN IJ 5,000 UNITS/ML VIAL 24.50

HEPARIN LOCK 500 UNITS/5ML SYR 24.50

HEPATIC FUNCTION PANEL $138.00

HEPATITIS A ANTIBODY TOTAL $155.00

HEPATITIS A IgM ANTIBODY $296.00

HEPATITIS A VACCINATION ADOLES 0.01

HEPATITIS A VACCINE 1440 ELU 71.70

HEPATITIS A VACCINE 720 ELU 33.60

HEPATITIS A;ADULT DOSE;INTRAMUSCULAR $71.60

HEPATITIS A;PEDIATRIC/ADOLESCENT;INTRAMU $0.01

HEPATITIS A;PEDIATRIC/ADOLESCENT;INTRAMU $33.95

HEPATITIS ACUTE PANEL $362.00

HEPATITIS B CORE AB TOTAL $275.00

HEPATITIS B CORE IGM AB $259.00

HEPATITIS B SURFACE AB (HBSAB) $119.00

HEPATITIS B SURFACE ANTIGEN $116.00

HEPATITIS B VAC ADLT 10MCG/1ML 65.80

HEPATITIS B VACCINE 5MCG/0.5ML 50.20

HEPATITIS B VACCINE PEDIATRIC 0.01

HEPATITIS B VACCINE;ADULT DOSE;INTRAMUSC $45.85

HEPATITIS B VACCINE;PED/ADOLESCENT;3 DOS $0.01

HEPATITIS B VACCINE;PED/ADOLESCENT;3 DOS $16.20

HEPATITIS B VIRUS QUANTIFICAT $494.00

HEPATITIS Be ANTIBODY (HBeAb) $232.00

HEPATITIS Be ANTIGEN $232.00

HEPATITIS C ANTIBODY $130.00

HEPATITIS C QUANTIFICATION $587.00

HEPATITIS C SCREENING $130.00

HEPATOBILIARY SYSTEM (HIDA) $1,818.00

HEPATOBILIARY WO CCK $1,818.00

HERNIA REPAIR, LAPAROSCOPY $1,316.00

HERNIA REPAIR; LAP VENTRAL $3,273.00

HEROIN METABOLITE $133.00

HERPES SIMPLEX NS TYPE TEST $103.00

HERPES SIMPLEX NS TYPE TEST $253.00

HERPES SIMPLEX TYPE 1 $101.00




HERPES SIMPLEX VIRUS AMP PROBE $272.00

HETEROPHILE AB SCREENING $81.00

HFE GENE ANALYSIS $815.00

HGB FQ CHROMATOGRAPHY $496.00

HGB FQ ELECTROPHORESIS $254.00

HH ADMIN INFLUENZA VIRUS VACCN $37.00

HIP UNI W/WO PELVIS 1 VIEW $274.00

HIP UNI W/WO PELVIS 2-3 VIEWS $320.00

HIPS BIL W/WO PELVIS 2 VIEWS $589.00

HIPS BIL W/WO PELVIS 3-4 VIEWS $636.00

HIPS BIL W/WO PELVIS MIN 5 VIE $589.00

HIPS BIL W/WO PELVIS MIN 5 VIEWS $589.00

HISTOPLASMA AB $323.00

HISTOPLASMA AB, SCREEN $104.00

HISTOPLASMA CAPSULATUM $523.00

HIV 1 & HIV 2 SINGLE RESULT $146.00

HIV 1 AB $345.00

HIV 1 REVERSE TRANS & QUANT $279.00

HIV 2 AB $200.00

HIV SCREENING ANTIGEN/ANTIBODIES $237.00

22 of 48




HIV1 AG HIV1 & HIV2 ANTIBODIES $237.00

HIV-1 ANTIGEN WITH HIV-1 & HIV-2 AB $101.00

HLA CLASS II TYPING ONE LOCUS $266.00

HLA CLASS II TYPING ONE LOCUS EACH $266.00

HOLTER MONITOR HOOKUP $454.00

HOLTER MONITOR REP0RT $761.00

HOME VISIT, PROBLEM FOCUSED $226.00

HOME VISIT; MODERATE COMPLEXITY $514.00

HOMOCYSTEINE $214.00

HOSP DISCHARGE DAY MANAGE. 30 MIN./LESS $200.00

HOSP DISCHARGE DAY MANAGEMENT, > 30 MIN. $300.00

H-PROGEST CAPRO INJ 250MG CHRG 3,028.96

HUMAN PAP VIRUS VACC 9 VALENT 143.57

HUMAN PAPILLOMA VIRUS VACCINE 9 VALENT $0.01

HUMAN PAPILLOMA VIRUS VACCINE 9-VALENT $215.05

HUMAN PAPILLOMAVIRUS $166.00



HUMERUS, MINIMUM OF TWO VIEWS $274.00

HYALURONIDASE 200U/ML 1ML VIAL 504.55

HYDRALAZINE 10MG TAB 6.85

HYDRALAZINE 20MG/ML 1ML VIAL 58.85

HYDRALAZINE TAB 25 MG 6.85

HYDROCDNE/ACETA 5/325MG 6 PAC 20.90

HYDROCHLOROTHIAZIDE TAB 25MG 6.85

HYDROCODONE/ACETA 5/325 MG TAB 6.87

HYDROCORTISONE 100MG/2ML VIAL 118.04

HYDROCORTISONE CREAM 1% 30 GM 102.85

HYDROCORTISONE CREAM 2.5% 30GM 164.73

HYDROMORPHONE .4MG/ML 30ML PCA 201.45

HYDROMORPHONE 0.5MG/0.5ML SYRI 48.87

HYDROMORPHONE INJ 1 MG/ML SYR 29.52

HYDROMORPHONE INJ 2MG SYRINGE $24.00

HYDROMORPHONE INJ 2MG/ML SYR 32.25

HYDROMORPHONE TAB 2MG 6.85

HYDRO-SURG LAP IRRIGATOR $379.00

HYDROXYINDOLACETIC ACID 5-HIAA $553.00

HYDROXYPROGESTERONE 17-d $170.00

HYDROXYZINE INJ 25MG/ML VIAL 152.37

HYDROXYZINE TAB 25MG 6.85

HYPERINFLATION THERAPY DEVICE $66.00

I & D; PERIRECTAL ABSCESS $2,451.00

I&D PERIANAL ABSCESS $950.00

IA-2 AB SERUM $122.00

IBANDRONATE INJ 3MG/3ML SYRING 2,072.45

IBUPROFEN SUSP 100MG/5ML UD 13.47

IBUPROFEN TAB 200MG 6.85



IgG SUBCLASSES $30.00

IgG TOTAL $52.00

IGH GENE REARRANGE AMP METH $673.00

IGK REARRANGEABN CLONAL POP $518.00

IMIPENEM-CILASTA INJ 500MG SDV 272.75

IMMUNE GLOB 30GM/300ML PREMIX 8,960.79

IMMUNIZATION ADMIN EACH ADD'L $23.00

IMMUNIZATION ADMIN EACH ADD'L $37.00

IMMUNIZATION ADMIN; EA ADD'L, ORAL/NASAL $23.00

IMMUNIZATION ADMIN; EA ADD'L, SINGLE/COM $23.00

IMMUNIZATION ADMINIS.;EA ADD'L;ORAL/NASA $37.00

IMMUNIZATION ADMINIS.;EA ADD'L;SINGLE/CO $37.00

IMMUNIZATION ADMINISTRATION $23.00

IMMUNIZATION ADMINISTRATION $37.00

IMMUNIZATION ADMINISTRATION;ORAL/NASAL $37.00

23 of 48




IMMUNIZATION ADMINISTRATION;SINGLE/COMBO $23.00

IMMUNIZATION ADMINISTRATION;SINGLE/COMBO $37.00

IMMUNO ASSAY ANALYTE OTHER $168.00

IMMUNO PER SPECIMEN EACH ADDL $188.00

IMMUNOASSAY ANTIGEN CA 125 $206.00

IMMUNOASSAY ANTIGEN CA 15-3 $230.00

IMMUNOASSAY ANTIGEN CA 19-9 $188.00

IMMUNOASSAY ANTIGEN OTHER EA $148.00

IMMUNOASSAY INFECTIOUS AB QUAN $271.00

IMMUNOASSAY QUANT BY RIA $100.00

IMMUNOASSAY QUANT BY RIA $203.00

IMMUNOASSAY QUANT NOS $283.00

IMMUNOFIXATION ELP OTHER $88.00

IMMUNOFIXATION ELP SERUM $163.00

IMMUNOFIXATION ONLY SERUM $393.00

IMMUNOHISTOCHEMISTRY EA ADDL AB STAIN $188.00

IMMUNOHISTOCHEMISTRY EA ANTIB $373.00

IMMUNOHISTOCHEMISTRY EA MULTIP $197.00

IMMUNOHISTOCHEMISTRY EA MULTIPLEX STAIN $196.00

IMPLANT MESH FOR INCISIONAL/VENT. HERNIA $1,199.00

IMPLANTATION MESH $1,199.00

INCISE & DRAIN DEEP ABSCESS;THIGH/KNEE $3,068.00

INCISION AND DRAINAGE ABSCESS $506.00

INCISION AND DRAINAGE ABSCESS $928.00

INCISION AND DRAINAGE HEMATOMA $744.00

INCISION AND DRAINAGE OF ABSCE $506.00

INCISION AND DRAINAGE OF ABSCESS $506.00

INCISION AND DRAINAGE OF ABSCESS, COMPL $928.00

INCISION AND DRAINAGE OF HEMATOMA, SEROM $744.00

INCISION AND DRAINAGE OF PILONIDAL CYST $828.00

INCISION AND DRAINAGE, PERIANAL ABSCESS $950.00

INCISION AND REMOVAL F.B. $654.00

INCISION AND REMOVAL FOREIGN BODY COMPLI $1,258.00

INCISION AND REMOVAL FOREIGN BODY SUBQ $654.00

INCISION/DRAINAGE BARTHOLN'S GLAND ABSCE $541.00

INDOMETHACIN 25MG CAP 6.85

INFECTIOUS AGENT AMP PROBE EA $95.00

INFECTIOUS AGENT AMP PROBE EA $454.00

INFECTIOUS AGENT ANTIGEN $93.00

INFECTIOUS AGENT ANTIGEN $114.00

INFECTIOUS AGENT NUCLEIC ACID $834.00

INFLIXIMAB INJ 100MG VIAL 4,038.36

INFLUENZA IMMUNIZATION ADMIN O $0.01

INFLUENZA IMMUNIZATION ADMIN OR PREV ORD $0.01

INFLUENZA IMMUNIZATION ORDERED OR ADMIN $0.01

INFLUENZA VACC HIGH DOSE 0.5ML 46.84

INFLUENZA VACCINE ADULT 0.5ML 20.50

INFLUENZA VACCINE HIGH DOSE 0.5ML $50.55

INFLUENZA VACCINE PED 0.5ML 4.79

INFLUENZA VACCINE QUADRIVALENT $17.95

INFLUENZA VACCINE QUADRIVALENT 3 YRS & > $0.01

INFLUENZA VACCINE QUADRIVALENT 3 YRS & > $17.95

INFLUENZA VACCINE QUADRIVALENT6-35 MO IM $0.01

INFLUENZA VACCINE QUADRIVALENT6-35 MO IM $17.95

INFLUENZA VIRUS VACCINE TRIVAL 21.00

INHALATION TREATMENT $100.00

INHALATION TREATMENT $200.00

INHALATION TREATMENT - ER $200.00

INHIBIN A $114.00

INITIAL HOSP CARE, NORMAL NEWBORN $393.00

INITIAL HOSPITAL CARE, LOW COMPLEXITY $300.00

INITIAL HOSPITAL CARE, MODERATE COMPLEXI $400.00

INITIAL HSP CARE HIGH (ER ADM) $600.00

INITIAL HSP CARE LOW (ER ADM) $300.00

24 of 48




INITIAL HSP CARE MOD (ER ADM) $400.00

INITIAL NURSING FACILITY CARE $375.00

INITIAL NURSING FACILITY CARE;HIGH COMPL $672.00

INITIAL NURSING FACILITY CARE;LOW COMPLE $375.00

INITIAL NURSING FACILITY CARE;MOD COMPLE $530.00

INITIAL OBS CARE HGH $737.00

INITIAL OBS CARE HGH (ER ADM) $737.00

INITIAL OBS CARE LOW $396.00

INITIAL OBS CARE LOW (ER ADM) $396.00

INITIAL OBS CARE MOD $538.00

INITIAL OBS CARE MOD (ER ADM) $538.00

INITIAL OBSERVATION CARE, HIGH COMPLEXIT $737.00

INITIAL OBSERVATION CARE, LOW COMPLEXITY $396.00

INITIAL OBSERVATION CARE, MODERATE COMPL $538.00

INITIAL PREVENTIVE PHYS EXAM $476.00

INITIAL PREVENTIVE PHYS EXAM, NEW BENEF $476.00

INJ ANES AGENT; PERIPHERAL NER $480.00

INJ W/FLUOR EVAL CV DEVICE $479.00

INJECT SCLEROSING SOLUTION;MULTIPLE VEIN $810.00

INJECT SINGLE TENDON SHEATH/LIGAMENT, AP $262.00

INJECT SINGLR ORMULTIPLE TRIGGER POINTS $249.00

INJECTION IV PUSH EA ADD DIFF $82.00

INJECTION IV PUSH EA ADD SAME $100.00

INJECTION OCCIPITAL NERVE $530.00

INJECTION PROC ID SENTNL NODE $182.00

INJECTION PROCEDURE; ID OF SENTINEL NODE $362.00

INJECTION SQ OR IM $82.00

INJECTION, DEXAMETHASONE, 1 MG $24.50

INJECTION, INTRALESIONAL, MORE THAN 7 $314.00

INJECTION, INTRALESIONAL, UP TO & INCL 7 $249.00

INJECTION, SINCALIDE, 5MCG $607.00

INJECTION; EACH ADD'L NEW DRUG $100.00

INJECTION; ID SENTINEL NODE $362.00

INJECTION; IV PUSH EA ADD'L $82.00

INJECTION; IV PUSH SINGLE $82.00

INJECTION; IV PUSH SINGLE $100.00

INJECTION; IV PUSH, SINGLE $82.00

INJECTION; ONE OR TWO MUSCLES $249.00

INJECTION; SINGLE $262.00

INJECTION; SQ OR IM $82.00

INJECTION; SQ OR IM $100.00

INJECTION; TRIGEMINAL NERVE $562.00

INJECTION;ANESTHETIC AGENT;OCCIPITAL NER $530.00

INPATIENT CONSULTATION;EXPANDED PROB. HI $298.00

INPATIENT CONSULTATION;HIGH COMPLEXITY $785.00

INPATIENT CONSULTATION;LOW COMPLEXITY $452.00

INPATIENT CONSULTATION;MODERTE COMPLEXIT $651.00

INPATIENT HOSPITAL CARE, HIGH COMPLEXITY $600.00

INSERT CATH PLEURA WITH IMAGE $2,224.00

INSERT INTRAUTERINE CONTRACEPTIVE DEVICE $314.00

INSERT PESSARY/OTHER DEVICE $341.00

INSERT TEMPORARY INDWELLING BLADDER CATH $343.00

INSERT TUNNELED CV CATH;5YRS/> $5,000.00

INSERTION CENTRAL VENOUS CATH $1,071.00

INSERTION CENTRAL VENOUS CATHETER $1,071.00

INSERTION DRUG DELIVERY IMPLANT $620.00

INSERTION OF PICC LINE - NSG $837.00

INSERTION PICC LINE - ONCOLOGY $837.00

INSERTION TEMPORARY CATHETER $343.00

INSERTION VENOUS ACCESS DEVICE $5,000.00

INSOLES SPENCO $11.00

INSOLES VASYLI $45.00

INSULIN ANTIBODIES $322.00

INSULIN TOTAL $103.00

25 of 48




INTERPULSE HANDPIECE $231.00

INTRINSIC FACTOR ANTIBODIES $168.00

INTRODUCER ENDOTRACEAL $51.00

INTUBATION ENDOTRACHEAL EMER $661.00

INTUBATION, EMERGENCY PROC $661.00

INTUBATION,ENDOTRACHEAL,EMERGENCY PROCED $661.00

IODINE I-123 SODIUM IODIDE/100 $436.00

IONTOPHORESIS/15MIN $127.00

IPRATROPIUM NEB 0.5MG/2.5ML 6.85

IPRATROPIUM/ALBUTEROL IN SPRAY 1,023.55

IPRATROPIUM/ALBUTEROL NEB 3ML 6.85

IRINOTECAN INJ 100MG/5ML VIAL 162.71

IRINOTECAN INJ 40MG/2ML VIAL 180.90

IRON $126.00

IRON BINDING CAPACITY $85.00

IRON SUCROSE INJ 100MG/5ML SDV 242.31

IRRADIATION BLOOD PRODUCT EA $112.00

IRRIG IMPLANT VENOUS ACCESS DE $133.00

IRRIGATION SOLUTIONS; 1000CC < $58.00

IRRIGATION SOLUTIONS; 3000CC $69.00

IRRIGATION VENOUS ACCESS DEVCE $133.00

ISLET CELL ANTIBODY $92.00

ISOSORBIDE MONONITRATE 30MG TA 6.84

ISOSORBIDE MONONITRATE 60MG TA 6.96

ISOSULFAN BLUE 1% 5ML INJ 1,840.11

IV CONSCIOUS SEDATION $1,268.00

IV HYDRATION 1ST HOUR $263.00

IV HYDRATION EACH ADDL HOUR $237.00

IV INFUSION ADDL SEQUENTIAL $263.00

IV INFUSION CONCURRENT $263.00

IV INFUSION EACH ADDL HOUR $237.00

IV INFUSION FIRST HOUR $263.00

IV INFUSION, ADD'L SEQUENTIAL $263.00

IV INFUSION, CONCURRENT $263.00

IV INFUSION, EACH ADD'L HOUR $237.00

IV INFUSION, HYDRATION, 1 HR $263.00

IV INFUSION, HYDRATION, ADD HR $237.00

IV INFUSION, UP TO 1 HOUR $263.00

IV SOLUTIONS 1000CC $131.00

IV SOLUTIONS 500CC OR LESS $104.00

JAK 2 V617F MUTATION $1,170.00

JAK2 EXON 12 SEQUENCE $961.00

JOINT SURVEY 1 VIEW, 2+JOINTS $279.00

JOINT SURVEY, SNGLE VIEW,2 OR MORE JOINT $279.00

KETAMINE INJ 500MG/10ML VIAL 43.11

KETONE BODY(S) QUANTITATIVE $38.00

KETORALAC INJ 30MG/ML VIAL $24.50

KETOROLAC 0.5% OPHTH SOL 3ML 57.35

KETOROLAC INJ 30MG/ML VIAL 24.58

KETOROLAC TAB 10MG 10.74

KIDNEY IMAGING; (ANGIOTENSIN) $1,837.00

KIDNEY STONE ANALYSIS $116.00

KIT CENTRAL LINE DRESSING $44.00

KIT PAD $76.00

KIT PEG FEEDING TUBE $522.00

KIT SMOKE EVACUATION $67.00

KIT SUTURE REMOVAL $26.00

KIT URETHRAL CATHETERIZATION $11.00

KNEE BRACE RIGID SUPPORT $205.00

KNEE ORTHOTIC ELASTIC $54.00

KNEE; BOTH KNEES, STANDING $240.00

KNEE; COMPLETE, 4 OR MORE VIEW $349.00

KNEE; ONE OR TWO VIEWS $296.00

KNEE; THREE VIEWS $320.00

26 of 48




LABETALOL INJ 100MG/20ML VIAL 50.64

LABETALOL TAB 200 MG 6.93

LABOR ROOM 1ST HOUR $678.00

LABOR ROOM EA ADDL HR UP TO 5 $276.00

LACERATION CARE; LEVEL I $279.00

LACERATION CARE; LEVEL II $420.00

LACERATION CARE; LEVEL III $693.00

LACRI-LUBE OPHTH OINT 3.5GM 60.55

LACTATE (LACTIC ACID) $186.00

LACTATE DEHYDROGENASE (LD/LDH) $63.00

LACTATE RINGERS; UP TO 1,000CC $131.00

LACTOBACILLUS CHW TAB 6.85

LACTOFERRIN FECAL QUALITATIVE $112.00

LAMOTRIGINE $71.00

LAMOTRIGINE 100MG TABLET 6.85

LANOLIN ANHYDROUS OINT 60GM 17.07

LAP CHOLE WITH CHOLANGIOGRAPHY $3,363.00

LAP REPAIR PARAESOPHAGE HERNIA $5,000.00

LAP REPAIR VENT UMB HERNIA INC $4,098.00

LAP REPAIR, VENT,UMB,SPIEG, HERNIA $3,273.00

LAPAROSCOPIC CHOLECYSTECTOMY $3,169.00

LAPAROSCOPY CHOLECYSTECTOMY $3,169.00

LAPAROSCOPY REPAIR PARAESOPHAGEAL HERNIA $5,000.00

LAPAROSCOPY, SURGICAL, APPENDECTOMY $2,699.00

LAPAROSCOPY,SURGICAL,ENTEROLYSIS $4,098.00

LAPAROSCOPY; OCCLUSION OVIDUCT $1,663.00

LAPAROSCOPY; REPAIR ING HERNIA $1,893.00

LAPAROSCOPY; REPAIR INITIAL ING HERNIA $1,893.00

LAPAROSCOPY; WITH ASPIRATION $1,667.00

LAPAROSCOPY;OCCLUSION OF OVIDUCTS BY DEV $1,663.00

LAPAROSCOPY;REPAIR VENT,UMB HERNIA,INCAR $4,098.00

LAPAROSCOPY;REPR INCARC INCISIONL HERNIA $4,535.00

LARYNGOSCOPY DIAGNOSTIC $551.00

LARYNGOSCOPY,FLEXIBLE FIBEROPTIC;DIAGNOS $551.00

LATANOPROST OPTH 0.005% 2.5ML 46.83

LAYER CLOSURE WOUND $1,093.00







LAYER CLOSURE WOUND 12.6-20.0 CM $2,003.00

LAYER CLOSURE WOUND INTERMED. 2.6-7.5 CM $1,390.00

LAYER CLOSURE WOUND, INTERM. 2.6-5.0 CM $1,357.00

LAYER CLOSURE WOUND, INTERM. 2.6-7.5 CM $1,315.00

LDL CHOLESTEROL DIRECT $103.00

LEAD $149.00

LEG HOLDER ACUFEX $84.00

LENS MORGAN $75.00

LET SOLUTION 43.70

LEUCOVORIN CALCIUM 100MG VIAL 122.52

LEUCOVORIN CALCIUM 350MG VIAL 131.38

LEUKOCYTE COUNT AUTOMATED $41.00

LEVALBUTEROL NEB 0.63MG/3ML 18.70

LEVALBUTEROL NEB 1.25MG/3ML 18.45

LEVEMIR INSULIN 3ML FLEXPEN 197.78

LEVETIRACETAM (KEPPRA) $103.00

LEVETIRACETAM 500MG TABLET 6.85

LEVETIRACETAM 500MG/5ML INJ 30.39

LEVOBUNOLOL 0.5% OP SOL 10ML 43.70

LEVOFLOXACIN 500MG TAB 2 PACK 6.85

LEVOFLOXACIN 750MG/150ML IV PM 132.83

LEVOFLOXACIN INJ 500MG/100ML 210.90

27 of 48




LEVOFLOXACIN TAB 500 MG 6.84

LEVOTHYROXINE INJ 100MCG VIAL 514.08

LEVOTHYROXINE TAB 25MCG 6.85






LEXISCAN 0.4MG/5ML INJ 973.32

LIDO 2.5%/PRILOCAINE 2.5% 5GM 38.50

LIDOCAINE 1% 10ML VIAL 31.95

LIDOCAINE 1% SYR 50MG/5ML 57.99

LIDOCAINE 1% W/EPI 20ML VIAL 24.50

LIDOCAINE 1% W/EPI 30ML VIAL 37.34

LIDOCAINE 2% MPF INJ 2ML VIAL 24.50

LIDOCAINE 2% MPF INJ 5ML 24.49

LIDOCAINE EPNEPHR 2%MPF 20ML 46.33

LIDOCAINE INJ 0.5% PF 50ML VIA 33.96

LIDOCAINE INJ 1% 2ML 23.76

LIDOCAINE INJ 1% 20ML VIAL 24.50



LIDOCAINE JELLY 2% 5ML 29.10

LIDOCAINE JELLY UROJET 2% 10ML 45.76

LIDOCAINE MPF 1% INJ 5 ML VIAL 24.50

LIDOCAINE PATCH 5% 32.51

LIDOCAINE TOPICAL SOLN 4% 50ML 91.26

LIDOCAINE VISCOUS SOL 2% 20ML $12.00

LIFT ELEVATION INSIDE SHOE $7.00

LIGATION OR BX TEMPORAL ARTERY $1,412.00

LIGATION/BX TEMPORAL ARTERY BI $2,120.00

LIGATION/BX TEMPORAL ARTERY BILATERAL $2,120.00

LIGATION/TRANSECT TUBE,W/C-SECT; ASSIST $92.00

LIGATION/TRANSECTION FALLOPIAN TUBES $355.00

LIGATION/TRANSECTION FALLOPIAN TUBES $1,500.00

LIMB HOLDER $20.00

LINEZOLID INJ 600MG/300ML PM 280.08

LIPASE $141.00

LIPID PANEL $176.00

LIQUIBAND $121.00

LIQUIBAND SKIN ADHESIVE $120.00

LISINOPRIL TAB 5MG 6.84



LITHIUM $96.00

LITHIUM CARBONATE 150 MG CAP 6.85

LIVER IMAGING (SPECT) $2,308.00

LOPERAMIDE CAP 2MG 8.13

LORATADINE TAB 10MG 6.85

LORATADINE TAB 5MG/PSEUDO120MG 8.95

LORAZEPAM INJ 2MG/1ML VIAL 24.50

LORAZEPAM TAB 0.5MG 6.85

LORAZEPAM TAB 1MG 6.85

LOSARTAN 50 MG TAB 7.21

LOWER EXTREMITY ARTERIES; BIL $1,294.00

LOWER EXTREMITY ARTERIES; UNI $1,080.00

LOWER EXTREMITY INFANT 2 VIEWS $296.00

LUNG CANCER SCREENING WO $1,578.00

LUTEINIZING RELEASE HORMONE $761.00

LUTEINIZNG HORMONE REL HORMONE $761.00

LYME DISEASE DETECTION $278.00

LYRICA 75MG CAPS 56.73

MAALOX SUSP 200/225MG 30ML 11.07

MACROSCOPIC EXAM PARASITE $33.00

28 of 48




MAGNESIUM CITRATE LIQUID 300ML 17.19

MAGNESIUM OXIDE TAB 400MG 6.85

MAGNESIUM SERUM $120.00

MAGNESIUM SUL INJ 1GM/2ML VIAL 22.08

MAGNESIUM SUL/D5W 1G/100ML 149.73

MAGNESIUM SUL/D5W 4G/100ML 128.61

MAGNESIUM SULF 5GM/10ML VIAL 24.50

MAGNESIUM SULFTE 20G/500ML 138.75

MAGNESIUM URINE DR G $109.00

MALYUGIN RING (PUPIL DILATOR) $183.00

MANIPULATION CHEST WALL; INI $119.00

MANIPULATION CHEST WALL; SUB $100.00

MANNITOL 20% INJ 500ML 98.00

MANNITOL INJ 12.5GMS/50ML VIAL 65.10

MANUAL THERAPY TECHNIQUE/15min $122.00

MASK LARYNGEAL AIRWAY $42.00

MASK VENTILATION $59.00

MASS SPECTROMETRY TANDEM MASS $1,507.00

MASTECTOMY, MOD. RAD., INCL AXIL. LYMPH $5,000.00

MASTECTOMY, PARTIAL $2,881.00

MASTECTOMY, SIMPLE, COMPLETE $4,515.00

MATTRESS DISP LATERAL TRANSFER $219.00

MAXILLOFACIAL W $1,790.00

MAXILLOFACIAL W/WO $2,108.00

MAXILLOFACIAL WO $1,578.00

MAXIMUM BREATHING CAPACITY $130.00

MEASLES MUMPS RUBELLA VACCINE 100.98

MEASLES, MUMPS, RUBELLA VIRUS VACCINE $73.15

MEASLES,MUMPS,RUBELLA VIRUS VACCINE $0.01

MEASLES,MUMPS,RUBELLA,VARICELLA VACCINE $0.01

MEASLES,MUMPS,RUBELLA,VARICELLA VACCINE $221.35

MECHANICAL CHEST WALL OSCILL $119.00

MECLIZINE TAB 25MG 6.85

MED TEAM CONF FAM NOT PRESENT $328.00

MED TEAM CONFERNC FACE TO FACE $328.00

MED TH MGMT INITIAL 15" NEW PT $48.00

MEDIHONEY GEL 1.5 OZ OINT 92.55

MEDROXYPROGEST INJ 150MG VIAL 306.40

MEDROXYPROGESTERONE ACETA INJ 150MG VIAL $211.95

MELATONIN 3MG TAB 6.85

MEMANTINE 5MG TAB 6.85

MEMORY FUNCTIONAL CURRENT $0.01

MEMORY FUNCTIONAL DISCHARGE $0.01

MEMORY FUNCTIONAL PROJECTED $0.01

MENINGITIS ENCEPHALI CSF PANEL $1,308.00

MENINGOCOCCAL CON VACCINE IM 0.01

MENINGOCOCCAL CONJUGATE VACCINE $0.01

MENINGOCOCCAL CONJUGATE VACCINE;INTRAMUS $113.65

MENINGOCOCCAL POLYSACHARIDE VACCINE $244.00

MEPERIDINE INJ 25MG/ML CPJ 60.45

MEPIVACAINE 1% 50ML INJ 62.05

MEPIVACAINE HCL 2% 20ML VIAL 73.80

MEPIVACAINE INJ 1% 30ML VIAL 58.40

MERCURY QUANTITATIVE $319.00

MEROPENEM INJ 1 GM VIAL 167.84

MESH IMPLANTABLE $265.00

MESH IMPLANTABLE $755.00

MESH IMPLANTABLE $1,392.00

METANEPHRINES (PLASMA/URINE) $232.00

METFORMIN TAB 500MG 6.85

METFORMIN TAB 850MG 6.85

METFORMIN XR TAB 500MG 6.85

METHACHOLINE 100 MG INH PWDR 317.46

METHACHOLINE CHALLENGE $477.00

29 of 48




METHADONE 10 MG TAB 7.99

METHADONE CONFIRMATION UR $139.00

METHOCARBAMOL 500MG TAB 6.85

METHOHEXITAL SOD INJ 50MG CHRG 60.55

METHOTREXATE INJ 50MG/2ML VIAL 57.68

METHYLENEDIOXYAMPHETAMINES $205.00

METHYLERGONOVINE INJ 0.2MG/ML 115.33

METHYLERGONOVINE TAB 0.2MG 171.93

METHYLMALONIC ACID $151.00

METHYLPREDNISOLON IJ 125MG/2ML 78.02

METHYLPREDNISOLON IJ 500MG VIA 136.48

METHYLPREDNISOLON SUSP 40MG/ML 77.98

METHYLPREDNISOLON SUSP 80MG/ML 118.75

METHYLPREDNISOLONE 1000MG VIAL 205.45

METHYLPREDNISOLONE 4MG TAB 10.45

METHYLPREDNISOLONE ACETATE INJ 40 MG VIA $70.90

METHYLPREDNISOLONE ACETATE INJ 80MG VIAL $122.80

METHYLPREDNISOLONE INJ 125 MG VIAL $78.70

METOCLOPRAMIDE INJ 10MG/2ML VI 24.50

METOCLOPRAMIDE TAB 10MG 6.84

METOLAZONE TAB 2.5MG 12.80

METOPROLOL INJ 5MG/5ML VIAL 24.50

METOPROLOL TAB 25MG 6.85

METOPROLOL TAB 50MG 6.85

METOPROLOL TAB XL 50MG 11.39

METRONIDAZOLE 500MG/100ML PRMX 116.03

METRONIDAZOLE TAB 500MG 7.50

MICONAZOLE POWDER 2% 90GM 45.75

MICROSOM0L ANTIBODIES EACH $231.00

MIDAZOLAM 1MG/ML 2ML VIAL 24.50

MIDAZOLAM 5MG/ML 1 ML VIAL NAS 24.50

MIDAZOLAM SYRUP 2MG/ML 5ML DOS 45.95

MILEAGE OCCUPATIONAL THERAPY $0.58

MILEAGE SPEECH THERAPY $0.58

MILEAGE; OPERATING ROOM $1.00

MILK OF MAGNESIA SUSP 30 ML 18.09

MINERAL OIL (STERILE) 2ML VIAL 105.15

MINERAL OIL LUBR LAXATIVE 30ML 6.85

MIRENA IUD $1,447.00

MIRTAZAPINE ODT 15 MG 8.07

MISC DME SUPPLY; BREAST SHIELD $22.00

MISC DME SUPPLY; TENNIS ARMBAND $41.00

MISC PROCEDURE $140.00

MISOPROSTOL TAB 100MCG 9.11

MISOPROSTOL, 200 MCG 71.00

MITOMYCIN 40 MG VIAL 3,140.00

MMRV VACCINE 104.51

MNT, RE-ASSESS, INDIV 15MIN $99.00

MNT-INITIAL ASSESS-INDIV 15min $99.00

MOBILITY W&M FUNCTION CURRENT $0.01

MOBILITY W&M FUNCTION DISCHG $0.01

MOBILITY W&M FUNCTION PROJECTD $0.01

MOBILIZATION SPLENIC FLEXURE $543.00

MOD SED SAME PHY 5YRS> INI 15 MIN $222.00

MOD SED SAMEPHY 5YRS> ADDL 15 MIN $48.00

MOD SED SAMEPHY 5YRS>ADD 15MIN $48.00

MOD SED SAMEPHYS 5YR>INI 15MIN $222.00

MOLECULAR CYTOGENETICS DNA PRO $279.00

MOLECULAR CYTOGENETICS INTERPH $266.00

MOLECULAR PATH PROC LEVEL 4 $27.00

MOMETASONE 50MCG NASAL SPR 6GM 328.75

MONOPTY BIOPSY $1,064.00

MONOPTY BIOPSY NEEDLE $164.00

MONTELUKAST TAB 10MG 15.22

30 of 48




MORPHINE 10MG 10ML PF VIAL 126.97

MORPHINE INJ 2MG/ML 26.70

MORPHINE INJ 4MG/ML 41.62

MORPHINE ORAL SO 10MG/0.5ML UD 17.36

MORPHINE PCA 150 MG/30ML INJ 86.95

MORPHINE PCA 30MG/30ML INJ 77.05

MORPHINE TAB CR 15MG 6.85

MORPHINE TAB CR 30MG 10.96

MORPHOMETRIC ANALYSIS MANUAL $504.00

MORPHOMETRIC ANALYSIS PER SPEC $256.00

MORPHOMETRIC ANALYSIS PER SPEC $1,041.00

MORPHOMETRIC ANALYSIS TUMOR IM $308.00

MOTOR SPEECH FUNCTION CURRENT $0.01

MOTOR SPEECH FUNCTION DISCHG $0.01

MOTOR SPEECH FUNCTION PROJECTD $0.01

MOXIFLOXACIN OPH SOLN 0.5% 3ML 501.55

MULTIPLE VITAMIN INJ 10ML 93.15

MULTIVITAMIN EYE FORMULA TAB 6.85

MULTIVITAMIN TAB 6.96

MULTIVITAMIN WITH MINERALS TAB 6.84

MUPIROCIN OINTMENT 2% 15 GRAM 54.32

MYOCARDIAL PERFUSION; MULTIPLE $4,117.00

MYOCARDIAL PERFUSION; SINGLE $3,950.00

MYOGLOBIN $206.00

MYRINGOTOMY;ASPIRATION &/OR EUSTACHIAN T $901.00

N20 $35.00

NACL LOCK FLUSH 2.5ML 24.51

NACL LOCK FLUSH 10ML 24.28

NALBUPHINE INJ 10MG/ML 38.23

NALOXONE INJ 0.4MG/ML 1ML 89.75

NAPROXEN TAB 500MG 6.85

NASAL BONES; COMPLETE $296.00

NASAL ENDOSCOPY DIAGNOSTIC $911.00

NASAL PACKING $107.00

NASAL SMEAR FOR ESOSINOPHILS $41.00

NATRIURETIC PEPTIDE (BNP) $262.00

NECK CTA W $2,193.00

NECK SOFT TISSUE W $1,790.00

NECK SOFT TISSUE W/WO $2,108.00

NECK SOFT TISSUE WO $1,578.00

NECK W/WO $3,140.00

NECK WO $2,410.00

NECK, SOFT TISSUE $274.00

NEEDLE BIOPSY; LYMPH NODE $581.00

NEEDLE FREE INJ DEVICE (RHINO $57.00

NEEDLE JAMSHIDE $130.00

NEEDLE MULTIFIRE SCORPION $690.00

NEEDLE STEP ACCESS $130.00

NEEDLE STIMUPLEX A $48.00

NEGATIVE PRESSURE DSG > 50 CM $173.00

NEISSERA GONORRHOEAE AMP PROBE $159.00

NEO/POLY/HC OTIC SUSP 10ML 294.50

NEOMYCIN TAB 500MG 11.25

NEOMYCIN/POLYB/DEXA OPHTH SOLN 94.30

NEOSTIGMINE 1MG/1ML 10 ML INJ 455.70

NEPHETOMETRY FREE LIGHT CHAINS $238.00

NEPHROCAPS CAPSULE 6.85

NEUROMUSCLAR RE-EDUCATN/15MIN $110.00

NEUROMUSCULAR RE-ED/15MIN $110.00

NEUROPLASTY MEDIAN NERVE AT CARPAL TUNNE $1,943.00

NEUROPLASTY; CARPAL TUNNEL $1,316.00

NEUROPLASTY; CARPAL TUNNEL $1,943.00

NEUTRALIZATION TEST VIRAL $221.00

NEW PATIENT $94.00

31 of 48




NEW PATIENT $182.00

NEW PATIENT $290.00

NEW PATIENT $53.00

NEW PATIENT $84.00

NEW PATIENT $137.00

NEW PATIENT $179.00

NEW PATIENT HIGH LEVEL 60 MIN $181.00

NEW PATIENT INITIAL COMP P.M. $110.00

NEW PATIENT OV/OUTPT VISIT PROBLEM FOCUS $67.00

NEW PATIENT OV/OUTPT VISIT PROBLEM FOCUS $27.00

NEW PATIENT PREVENTIVE 18-39Y $270.00

NEW PATIENT PREVENTIVE VISIT, 12-17 YEAR $270.00



NEW PATIENT PREVENTIVE VISIT, 1-4 YEARS $222.00












NEW PATIENT PREVENTIVE VISIT, 65 + YEARS $359.00



NEW PATIENT PREVENTIVE VISIT, INFANT $209.00



NEW PATIENT; 20MIN $129.00




NEW PT OV/OUTPT VISIT, DETAILED LOW COMP $206.00

NEW PT OV/OUTPT VISIT, DETAILED LOW COMP $84.00

NEW PT OV/OUTPT VISIT, EXPANDED PROB FOC $129.00

NEW PT OV/OUTPT VISIT, EXPANDED PROB FOC $53.00

NEW PT OV/OUTPT VISIT, HIGH COMPLEXITY $437.00

NEW PT OV/OUTPT VISIT, HIGH COMPLEXITY $179.00

NEW PT OV/OUTPT VISIT, MODERATE COMPLEXI $337.00

NEW PT OV/OUTPT VISIT, MODERATE COMPLEXI $137.00

NEW PT OV/OUTPT VISIT/EXP PROB/20 MINUTE $182.00

NEW PT OV/OUTPT VISIT/HIGH COM/60 MINUTE $616.00

NEW PT OV/OUTPT VISIT/LOW COM/30 MINUTE $290.00

NEW PT OV/OUTPT VISIT/MOD COM/45 MINUTE $474.00

NEW PT OV/OUTPT VISIT/PROB FOC 10 MINUTE $94.00

NEWBORN HEARING SCREENING $155.00

NEXPLANON (CONTRACEPTIVE) IMPLANT SYS $1,225.00

NEXT GEN SEQ HEMA NEOPLASMS $6,350.00

NICARDIPINE 25MG/10ML VIAL 126.00

NICOTINE PATCH 7 MG 21.01

NICOTINE PATCH 14MG 12.46

NICOTINE PATCH 21MG 19.93

NIFEDIPINE CAP 10 MG 7.05

NITROFURANTION CAP 100MG 29.25

NITROGLYCERIN 50MG/250ML PREMX 211.86

NITROGLYCERIN OINT 2% 1G FPACS 23.80

NITROGLYCERIN SL TAB 0.4MG 7.00

NON-FORMULARY MED_ 11.91

NOREPINEPHRINE INJ 1MG/ML 4ML 73.00

NORMAL SALINE FLUSH $31.00

32 of 48




NORMAL SALINE SOLUTION 250 CC $55.00

NORMAL SALINE SOLUTION, 1000CC $131.00

NORTRIPTYLINE CAP 25MG 6.85

NOVOLOG 10ML VIAL 262.70

NOVOLOG INSULIN FLEXPEN 134.44

NOVOLOG MIX 70/30 FLEXPEN 135.27

NPH INSULIN PEN 3ML 111.37

NRSG FACILITY DISCH DAY MANAGE; > 30 MIN $420.00

NRSG FACILITY DISCH DAY MANAGE;30 OR < $294.00

NS/ KCL 20mEq 1000ML PREMIX 124.00

NYSTATIN CRE 100,000 U/GM 15GM 49.95

NYSTATIN SUSP 100,000 U/ML 5ML 11.25

NYSTATIN TOP POWDER 30GRAM 53.98

NYSTATIN/TRIAMC OINT 15GM TUBE 155.55

O.T.CONTRACT/15MIN $16.25

OB, <14 WEEKS $788.00

OB, <14 WEEKS, EACH ADDITIONAL $610.00

OB, >14 WEEKS $788.00

OB, FOLLOW-UP $607.00

OB, LIMITED $607.00

OB, TRANSVAGINAL $711.00

OBS ROOM EA ADDL HR UP TO 10 $90.00

OBS ROOM TELE EA ADDL HR TO 10 $110.00

OBS ROOM TELEMETRY 1ST HOUR $1,300.00

OBS/IP HOSP CARE HGH $600.00

OBS/IP HOSP CARE LOW $400.00

OBS/IP HOSP CARE LOW (ER ADM) $400.00

OBS/IP HOSP CARE MOD $500.00

OBS/IP HOSP CARE MOD (ER ADM) $500.00

OBSERVATION CARE DISCHARGE $298.00

OBSERVATION ROOM 1ST HOUR $1,070.00

OBSERVATION/INPATIENT HOSP CARE, MOD COM $500.00

OBSERVATION/INPT HOSP CARE, HIGH COMPLEX $600.00

OBSTETRIC CARE/ANTEPARTUM CARE/VAG DELIV $7,900.00

OBSTETRIC PANEL $341.00

OCCUPATIONAL THERAPY EVAL HIGH $260.00

OCCUPATIONAL THERAPY EVAL LOW $200.00

OCCUPATIONAL THERAPY EVAL MOD $230.00

OCCUPATIONAL THERAPY RE-EVAL $110.00

OCTREOTIDE 100MCG/ML INJ 92.92

OCTREOTIDE 500MCG/ML VIAL 38.15

OFFICE CONSULT; 40MIN $260.00

OFFICE CONSULT; 60MIN $417.00

OFFICE CONSULT; EXP PROB FOCUS/30 MINUTE $262.00

OFFICE CONSULT; LOW COMPLEX/40 MINUTES $366.00

OFFICE CONSULT; MOD COMPLEX/60 MINUTES $588.00

OFFICE CONSULT; PROB FOCUSED/15 MINUTE $125.00

OFFICE CONSULTATION; LOW COMPLEXITY $260.00

OFFICE CONSULTATION;LOW COMPLEXITY $106.00

OFFICE CONSULTATION;MODERATE COMPLEXITY $417.00

OFFICE CONSULTATION;MODERATE COMPLEXITY $172.00

OLANZAPINE ODT TAB 5MG 9.44

OLOPATADINE OPHTH SOL 0.1% 5ML 138.20

ON BODY INJECTOR NEULASTA $104.00

ONDANSETRON 4MG DOSE 20ML MDV 24.50

ONDANSETRON INJ 4MG/2ML 24.50

ONDANSETRON ODT 4MG 6.85

OPDIVO 100MG/10ML VIAL 9,187.57

OPDIVO 40MG/4ML VIAL 3,707.35

OPIATES 1 OR MORE $206.00

OPIATES CONFIRMATION UR $77.00




33 of 48




ORAJEL 9 GRAM GEL 43.78

ORBIT FACE NECK W/WO $3,140.00

ORBIT SELLA W $1,790.00

ORBIT SELLA W/WO $2,108.00

ORBIT SELLA WO $1,578.00

ORBITS; COMPLETE $349.00

ORGANIC ACID SINGLE QUANT $117.00

ORTHO PROCEDURE $1,316.00

ORTHOPEDIC SURG BOOT/SHOE EA $67.00

ORTHOTIC ANKLE FOOT MULTILIGAMENTUS $40.00

ORTHOTIC HAND SPLINT TP UNIVER $218.00

ORTHOTIC HINGED KNEE SUPPORT $193.00

ORTHOTIC KNEE CANVAS LONGITUDINAL $89.00

ORTHOTIC KNEE ELASTIC CONDYLAR PADS $58.00

ORTHOTIC LUMBAR SUPPORT $35.00

ORTHOTIC MGMT/TRAINING/15MIN $92.00

ORTHOTIC SACROILIAC PELVIC SACRAL SUP $40.00

ORTHOTIC SHOULDER CLAVICLE STR $14.00

ORTHOTIC SHOULDER CLAVICLE STRAP $16.00

ORTHOTIC SHOULDER IMMOBILIZER $29.00

ORTHOTIC SUP WALKNG BOOT PREFB $66.00

ORTHOTIC SUPPORT ANKLE CONTROL $40.00

ORTHOTIC SUPPORT ANKLE FOOT $161.00

ORTHOTIC SUPPORT WALKING BOOT PNEUMATIC $277.00

ORTHOTIC SUPPORT WALKING BOOT PREFAB $66.00

ORTHOTIC SURG BOOT/SHOE EA $60.00

ORTHOTIC WRIST HAND EXTENSION $36.00

ORTHOTIC WRIST HAND EXTENSION $41.00

ORTHOTIC WRIST HAND FINGER PRE $30.00

ORTHOTIC WRIST HAND FINGER PREFAB $34.00

OSELTAMIVIR 6MG/ML 60ML 381.84

OSELTAMIVIR CAP 75MG 66.72

OSSEOUS SURVEY, INFANT $418.00

OSSEOUS SURVEY; COMPLETE SKLTN $3,125.00

OSTOMY POUCH DRAINABLE $9.00

OSTOMY POUCH DRAINABLE 2 PIECE $6.00

OSTOMY SKIN BARRIER POWDER $9.00

OSTOMY SKIN BARRIER W FLANGE $16.00

OTHER PRIMARY FUNCTION CURRENT $0.01

OTHER PRIMARY FUNCTION DISCHG $0.01

OTHER PRIMARY FUNCTION PROJECT $0.01

OTHER SL PATH FUNCTION CURRENT $0.01

OTHER SL PATH FUNCTION DISCHG $0.01

OTHER SL PATH FUNCTION PROJECT $0.01

OTHER SUBSE FUNCTION CURRENT $0.01

OTHER SUBSE FUNCTION DISCHARGE $0.01

OTHER SUBSE FUNCTION PROJECTED $0.01

OTHR RESP PROC INDIV EA 15 MIN $112.00

OUTRCH RENT CLINIC+1NRS/15MIN $20.00

OUTREACH CONSULT; 40MIN $106.00

OUTREACH CONSULT; 60MIN $171.00

OUTREACH RENT > THAN 4 HRS $212.00

OUTREACH RENT 0-4 HRS MINIMUM $106.00

OUTREACH RENT OR(NO NRS)/15MIN $17.00

OUTREACH RENT PER 15" ORTHO $6.25

OXALATE $250.00

OXALATE DR G $109.00

OXALIPLATIN INJ 50 MG 230.14

OXCARBAZEPINE METABOLITE $93.00

OXYBUTYNIN TAB 5MG 6.85

OXYBUTYNIN TAB XL 5MG 9.98

OXYCODONE $109.00

OXYCODONE 5MG TAB 6.85

OXYCODONE 5MG/5ML ORAL SOLUTIO 47.65

34 of 48




OXYCODONE CR TAB 10MG 27.95

OXYCODONE CR TAB 20MG 45.25

OXYCODONE/APAP TAB 5MG/325MG 6.92

OXYGEN BLENDED PER HR $34.00

OXYGEN PER HOUR $16.00

OXYGEN PROBE FOR USE WITH OXIMETER DEVIC $44.00

OXYGEN SENSOR $40.00

OXYMETAZOLINE .05% NAS SPR 15M 12.22

OXYTOCIN 30 UNITS/D5LR 500ML 164.76

OXYTOCIN INJ. 10U/ML 24.50

P.T.CONTRACT/15MIN $16.25

PACLITAXEL 100MG INJ (ABRAXANE 4,348.65

PACLITAXEL 1MG DOSE 50ML MDV 1.19

PAD KODIAK COLD THERAPY $118.00

PAIN PUMP ORTHO $846.00

PALONOSETRON INJ 0.25MG/5ML 585.35

PANCREATIC ELASTASE STOOL $267.00

PANTOPRAZOLE 40MG ORAL SUS PKT 76.95

PANTOPRAZOLE INJ 40MG 136.23

PANTOPRAZOLE TAB 20MG 6.85

PANTOPRAZOLE TAB 40MG 6.85

PAPILLECTOMY OR EXC OF SINGLE TAG, ANUS $963.00

PAR, LOCAL ONLY $369.00

PAR, PHASE 1, 1ST HOUR $638.00

PAR, PHASE I, EACH ADD 30MIN $165.00

PAR, PHASE II, 1ST HOUR $515.00

PAR, PHASE II, EACH ADD 30MIN $136.00

PAR,PHASE II, EACH ADD'L 30MIN $136.00

PARAFFIN BATH $66.00

PARAGARD INTRAUTERINE COPPER CONTRACEPTV $903.00

PARANEOPLAST AUTOAB EVAL CSF $2,431.00

PARATHORMONE $240.00

PARATHYROID IMAGING $1,248.00

PARING BENIGN HYPER LESION $207.00

PARING OR CUTTING OF BENIGN LE $207.00

PARING OR CUTTING OF BENIGN LESION $207.00

PARING OR CUTTING OF BENIGN LESION 2-4 $253.00

PAROXETINE CR TAB 12.5 MG 36.19

PAROXETINE TAB 20MG 6.85

PARTIAL EXCISION, TARSAL/METATARSAL BONE $2,734.00

PARTICLE AGGLUTINAT SER EA AB $472.00

PATHOLGOY CONSULT; REF SLIDES $435.00

PATIENT CIRCUIT HIGH FLOW $249.00

PATIENT SUPPLY NON STERILE 46.91

PATIENT SUPPLY PT 28.25

PATIENT SUPPLY STERILE 86.27

PEAK EXPIRATORY FLOW RATE METER HANDHELD $63.00

PEAK FLOW $83.00

PEAK FLOW METER $63.00

PELVIC (NONOB); COMPLETE $781.00

PELVIC (NONOB); LIMITED OR FU $610.00

PELVIS W $1,790.00

PELVIS W/WO $3,140.00

PELVIS WO $1,578.00

PELVIS WO $2,410.00

PELVIS; COMPLETE, MIN 3 VIEWS $296.00

PELVIS; ONE OR TWO VIEWS $296.00

PENICILLIN G BENZ 600,000U INJ 442.30

PENICILLIN G BENZA LA 1.2 MILLION UNITS $684.40

PENICILLIN G BENZATHINE LA 600,000 UNITS $460.20

PENICILLIN G POT INJ 5MU VIAL 128.73

PERIPHERAL BLOOD SMEAR $28.00

PERQ DEV BREAST 1ST US IMAGE $2,216.00

PERQ DEVICE BREAST 1ST IMAGE $1,044.00

35 of 48




PESSARY-NON RUBBER LATEX FREE $141.00

pH BODY FLUID NOS $141.00

PHASE II CARDIAC REHAB $266.00

PHASE III CARDIAC REHAB $12.00

PHENAZOPYRIDINE TAB 100MG 20.85

PHENOBARBITA INJ 130MG/ML VIAL 368.10

PHENOBARBITAL $165.00

PHENOBARBITAL INJ 65MG/1ML 449.95

PHENYLALANINE (PKU) $302.00

PHENYLEPHRINE 0.5% NAS SPR 15M 28.00

PHENYLEPHRINE INJ 10MG/ML 1ML 50.60

PHENYTOIN ER CAP 30MG 11.30

PHENYTOIN ER CAP 100MG 6.85

PHENYTOIN FREE $206.00

PHENYTOIN INJ 250MG/5ML 24.50

PHENYTOIN TAB 50MG 6.85

PHENYTOIN TOTAL $172.00

PHLEBOTOMY THERAPEUTIC $169.00

PHOS NAK 1.5G POWDER PACKETS 5.41

PHOSPHATASE ALKALINE $61.00

PHOSPHOLIPASE A2 RECEPTOR IFA $537.00

PHOSPHOLIPASE A2 RECEPTR ELISA $537.00

PHOSPHORUS INORGANIC BLOOD $48.00

PHOSPHORUS INORGANIC URINE DRG $109.00

PHYSICAL THERAPY EVAL HGH COMP $260.00

PHYSICAL THERAPY EVAL LOW COMP $200.00

PHYSICAL THERAPY EVAL MOD COMP $230.00

PHYSICAL THERAPY RE-EVALUATION $110.00

PHYSICIAN CERTIFICATION FOR HOME HLTH $264.00

PHYSICIAN INTERPRET & REPORT $178.00

PHYSICIAN RE-CERTIFICATION FOR HOME HLTH $226.00

PIPERCILLIN/TAZOBAC 2.25GM INJ 130.50

PIPERCILLIN/TAZOBACTA 3.375GM 143.63

PIPERCILLIN/TAZOBACTA 4.5GM 166.98

PLATELET COUNT AUTOMATED $41.00

PLATELET NEUTRALIZATION $305.00

PLATELETS IRRADIATED EA UNIT $2,070.00

PLATELETS IRRADIATED PHER LEU $2,070.00

PLATELETS IRRADIATED PHERESIS $2,070.00

PLATELETS PHERESIS EACH UNIT $1,958.00

PML/RAR ALPHA $1,901.00

PNEUMOCOCCAL 23-VALENT $79.20

PNEUMOCOCCAL 23-VALENT $79.30

PNEUMOCOCCAL VAC 0.5ML INJ 105.12

PNEUMOCOCCAL VACCINE ADMIN OR $0.01

PNEUMOCOCCAL VACCINE ADMIN OR PREV REC $0.01

PNEUMOCOCCAL VACCINE, 13-VALEN $0.01

PNEUMOCOCCAL VACCINE, 13-VALEN $195.00

PNEUMOCOCCAL VACCINE, 13-VALENT $0.01

PNEUMOCOCCAL VACCINE, 13-VALENT $194.80

PNEUMONIA AB PANEL EACH TEST $10.00

PNEUMOTHORAX SET $255.00

POLIOVIRUS VACCINE;INACTIVATED;SUBCU/INT $0.01

POLIOVIRUS VACCINE;INACTIVATED;SUBCU/INT $24.25

POLYETHYLENE GLYCOL 17GM PKT 8.07

POLYETHYLENE GLYCOL3350 238GMS 44.02

POLYMIXIN B TRIMETHOP OPH SOLN 39.04

POLYMYXIN B INJ 500,000U 113.15

PORPHYRINS FECES QUANT $165.00

PORT INDWELLING (IMPLANTABLE) $1,477.00

POSTERIOR COLPORRHAPHY;REPAIR RECTOCELE $3,062.00

POSTPARTUM CARE ONLY $500.00

POTASSIUM BICARB EFF. 25MEQ 6.85

POTASSIUM CHL INJ 10mEq 186.85

36 of 48




POTASSIUM CHL INJ 20mEq VIAL 26.20

POTASSIUM CHL INJ 40mEq VIAL 45.15

POTASSIUM CHLORIDE 10mEq/100ML 136.41

POTASSIUM CHLORIDE TAB 10 mEq 7.08

POTASSIUM CHLORIDE TAB 20 mEq 6.88

POTASSIUM ORAL SOL. 20MEQ/15ML 52.64

POTASSIUM PHOS INJ 45mM/15ML 118.87

POTASSIUM SERUM $81.00

POTASSIUM URINE $109.00

POTASSIUM URINE DR G $109.00

POUCH ENDOCATCH SPECIMAN $327.00

PRAMIPEXOLE 0.25 MG TAB 6.85

PREALBUMIN $259.00

PREDNISOLONE LIQ 15MG/5ML 30ML 24.65

PREDNISONE TAB 1MG 6.85




PREGABALIN 100MG CAPSULE 55.76

PREGABALIN 50MG CAPSULE 58.05

PREVALON TURN & POSTITION SYS $451.00

PREVNAR 13 VACCINE 0.5ML 169.11

PRIMIDONE $206.00

PROBE THERMAL TEMP DISP $23.00

PROCALCITONIN (PCT) $456.00

PROCHLORPERAZINE INJ 10MG/2ML 97.23

PROCHLORPERAZINE TAB 5MG 6.85

PROFERRIN ES 10.5MG TAB 7.95

PROGESTERONE $120.00

PROLACTIN $86.00

PROLONGED PHY SVC; 1ST HOUR $398.00

PROLONGED SERVICE, INPT; 1ST HOUR $369.00

PROLONGED SERVICE, OUTPATIENT;1ST HOUR $398.00

PROLONGED SERVICE, OUTPT; EA ADD'L 30 MI $392.00

PROMETHAZINE INJ 25 MG AMP $24.50

PROMETHAZINE INJ 25MG/ML VIAL 24.50

PROMETHAZINE TAB 25 MG 6.85

PROPOFOL INJ 10MG/ML 20ML VIAL 28.32

PROPOFOL INJ 10MG/ML 50ML VIAL 60.99

PROPRANOLOL TAB 20MG 6.93

PROSTATE CANCER SCREENING PSA $303.00

PROSTATE CANCER SCREENING; PSA $303.00

PROSTATE HEALTH INDEX SERUM $49.00

PROSTHETIC IMPLANT NOS(iSTENT) $3,906.00

PROTEIN C ACTIVITY $230.00

PROTEIN C ANTIGEN $274.00

PROTEIN ELECTROPHORETIC OTHER $145.00

PROTEIN ELECTROPHORETIC SERUM $163.00

PROTEIN S FREE $280.00

PROTEIN TOTAL OTHER SOURCE $71.00

PROTEIN TOTAL SERUM $63.00

PROTEIN TOTAL URINE $102.00

PROTHROMBIN G20210A MUTATION $301.00

PROTHROMBIN TIME $95.00

PSA FREE $140.00

PSA FREE $206.00

PSA TOTAL $303.00

PSYLLIUM SF POWDER 3.4GM 6.83

PTH RELATED PEPTIDE $768.00

PTT; SUBSTITUTION, PLASMA FRACTIONS EACH $284.00

PULLEY OVERHEAD $22.00

PULMONARY REHAB/EXERCISE 60MIN $161.00

PULMONARY STRESS TESTING $371.00

PULSE OXIMETRY; MULTIPLE $176.00

37 of 48




PULSE OXIMETRY; OVERNIGHT $345.00

PULSE OXIMETRY; SINGLE $78.00

PUNCTURE ASPIRATION OF ABSCESS,HEMATOMA $582.00

PUNCTURE ASPIRATION OF CYST OF BREAST $488.00

PURE TONE; AIR ONLY; SCREEN HEARING TEST $0.01

PURE TONE;AIR ONLY;SCREENING HEARING TES $50.00

PUTTY THERA OR ALL IN ONE PROG $10.00

PYRIDOSTIGMINE INJ 10MG/2ML 212.83

PYRIDOXAL PHOSPHATE (VIT B-6) $189.00

QUANT GOLD TB TEST $430.00

QUANT GOLD TB TEST $432.00

QUANTITATION OF DRUG UNLISTED $185.00

QUEASE EASE $13.00

QUETIAPINE TAB 100 MG 6.85

QUETIAPINE TAB 25MG 6.85

R&B ACUTE $1,870.00

R&B ACUTE W/TELEMETRY $2,340.00

R&B NURSERY $1,100.00

R&B RESPITE $500.00

R&B SKILLED $650.00

RABIES IMMUNE GLOB 300IU/2ML 2,017.82

RABIES IMMUNE GLOBULIN;INTRAMUSCULAR USE $2,646.55

RABIES VACCINE 2.5 IU/ML SYRIN 342.40

RABIES VACCINE;INTRAMUSCULAR USE $319.00

RACEPINEPHRINE NEB 2.25% 0.5ML 17.78

RAD. EXAM;BOTH KNEES;STANDING;ANTEROPOST $239.00

RADIOLOGIC EXAM; CHEST TWO VIEWS $353.00

RADIOLOGIC EXAM; MANDIBLE, COMPLETE $397.00

RADIOLOGIC EXAM;ANKLE;COMPLETE;3 VIEWS $296.00

RADIOLOGIC EXAM;CALCANEUS;2 VIEWS $274.00

RADIOLOGIC EXAM;CHEST;2VIEW;FRONT & LATE $308.00

RADIOLOGIC EXAM;CLAVICLE;COMPLETE $274.00

RADIOLOGIC EXAM;ELBOW;2 VIEWS $274.00

RADIOLOGIC EXAM;ELBOW;COMPLETE;3 VIEWS $349.00

RADIOLOGIC EXAM;FACIAL BONES;COMPLETE;3 $383.00

RADIOLOGIC EXAM;FINGERS;2 VIEWS $274.00

RADIOLOGIC EXAM;FOOT;COMPLETE;3 VIEWS $296.00

RADIOLOGIC EXAM;FOREARM;2 VIEWS $274.00

RADIOLOGIC EXAM;HAND;3 VIEWS $274.00

RADIOLOGIC EXAM;HUMERUS;2 VIEWS $274.00

RADIOLOGIC EXAM;KNEE;1-2 VIEWS $296.00

RADIOLOGIC EXAM;KNEE;3 VIEWS $320.00

RADIOLOGIC EXAM;KNEE;4 OR MORE VIEWS $349.00

RADIOLOGIC EXAM;NECK;SOFT TISSUE $274.00

RADIOLOGIC EXAM;ORBITS;COMPLETE;4 VIEWS $349.00

RADIOLOGIC EXAM;PELVIS;1-2 VIEWS $296.00

RADIOLOGIC EXAM;PELVIS;COMPLETE;3 VIEWS $296.00

RADIOLOGIC EXAM;RIBS;INCL POSTEROANTERIO $349.00

RADIOLOGIC EXAM;RIBS;INCL POSTEROANTERIO $412.00

RADIOLOGIC EXAM;SACRUM & COCCYX;2 VIEWS $296.00

RADIOLOGIC EXAM;SCAPULA;COMPLETE $296.00

RADIOLOGIC EXAM;SHOULDER;COMPLETE;2 VIEW $296.00

RADIOLOGIC EXAM;SINUSES,PARANASAL,<3 VIE $320.00

RADIOLOGIC EXAM;SINUSES;PARANASAL;COMPLE $369.00

RADIOLOGIC EXAM;SKULL;< 4 VIEWS $369.00

RADIOLOGIC EXAM;SPINE;CERVICAL; 4 VIEWS $369.00

RADIOLOGIC EXAM;SPINE;CERVICAL;2-3 VIEWS $320.00

RADIOLOGIC EXAM;SPINE;LUMBOSACRAL;2-3 VI $383.00

RADIOLOGIC EXAM;SPINE;LUMBOSACRAL;4 VIEW $454.00

RADIOLOGIC EXAM;SPINE;THORACIC;2 VIEWS $274.00

RADIOLOGIC EXAM;STERNUM; 2 VIEWS $296.00

RADIOLOGIC EXAM;TIBIA & FIBULA;2 VIEWS $320.00

RADIOLOGIC EXAM;TM JOINT;BILATERAL $369.00

RADIOLOGIC EXAM;TOES;2 VIEWS $274.00

38 of 48




RADIOLOGIC EXAM;WRIST;2 VIEWS $274.00

RADIOLOGIC EXAM;WRIST;COMPLETE;3 VIEWS $274.00

RALTEGRAVIR 400MG TAB 103.60

RANITIDINE INJ 50MG/2ML VIAL 129.80

RANITIDINE SYRUP 15MG/ML 30ML 6.85

RBC AG OT THN ABO OR D EA ARC $109.00

REACHER LONG HANDLE $15.00

RECONSTRUCTION ORIG $773.00

RED BLOOD CELLS EACH UNIT $840.00

RED BLOOD CELLS IRRADIATED EA $951.00

RED BLOOD CELLS IRRADIATED LEU $951.00

REFRESH PLUS OPHTH 0.5% 0.4ML 6.85

REMOVAL DEVITALIZED TISSUE $351.00

REMOVAL F.B. FOOT; SUBCU $1,194.00

REMOVAL FB EXTERNAL EYE $400.00

REMOVAL IMPACTED CERUMEN $239.00

REMOVAL OF FECAL IMPACTION OR $1,519.00

REMOVAL OF IUD $435.00

REMOVAL OF SKIN TAGS $379.00

REMOVAL SKIN TAGS, EACH ADD'L 10 $84.00

REMOVAL SKIN TAGS, MULTIPLE UP TO 15 $379.00

REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSU $657.00

REMOVE DEVITALIZED TISSUE;WOUND 20CM/< $351.00

REMOVE DRUG IMPLANT DEVICE $690.00

REMOVE FOREIGN BODY MUSCLE COM $2,222.00

REMOVE FOREIGN BODY MUSCLE; SIMPLE $928.00

REMOVE FOREIGN BODY;CORNEAL,NO SLIT LAMP $400.00

REMOVE FOREIGN BODY;EXTERNAL AUDITORY CA $568.00

REMOVE IMPACTED CERUMEN BILATE $93.00

REMOVE IMPACTED CERUMEN BILATERAL $356.00

REMOVE IMPACTED CERUMEN IRRIG $62.00

REMOVE IMPACTED CERUMEN IRRIG BILATERAL $93.00

REMOVE IMPACTED CERUMEN IRRIG UNILATERAL $62.00

REMOVE IMPACTED CERUMEN UNILAT $62.00

REMOVE IMPACTED CERUMEN UNILATERAL $239.00

REMOVE INTRAUTERINE CONTRACEPTIVE DEVICE $435.00

REMOVE TUNNELED CV CATHETER $1,354.00

REMOVE/INSERT DRUG IMPLANT $961.00

REMOVL OF INTRAPERITONEAL CATH $1,704.00

RENAL FUNCTION PANEL $138.00

RENIN $188.00

REP INIT INCISIONAL/VENTRAL HERNIA;INCAR $4,159.00

REP INIT INCISIONAL/VENTRAL HERNIA;REDUC $3,300.00

REPAIR FEMORAL HERNIA $3,300.00

REPAIR INGUINAL HERNIA $2,341.00

REPAIR INIT INGUINAL HERNIA BI $3,511.00

REPAIR INITIAL INGUINAL HERNIA, >5 YRS $2,341.00

REPAIR RECURR INGUINAL HERNIA $2,832.00

REPAIR UMBILICAL HERNIA $1,965.00

REPAIR UMBILICAL HERNIA $2,321.00

REPAIR UMBILICAL HERNIA >5 YRS; REDUCIBL $1,965.00

REPAIR UMBILICAL HERNIA >5 YRS;INCARCER $2,321.00

REPAIR,COMPLEX,SCALP,ARMS, 1.1-2.5 CM $1,592.00

REPR RECUR INCISION/VENTRAL HERNIA;INCAR $4,204.00

REPTILASE TIME $155.00

RESPIRATORY PANEL 12-25 TARGET $1,200.00

RESPIRATORY PANEL 12-25 TARGETS $1,200.00

RESPIRGARD II $37.00

RETICULOCYTE COUNT AUTOMATED $62.00

RETRACTOR OB $138.00

RETROPERITONEAL; COMPLETE $950.00

RHEUMATOID FACTOR QUANTITATIVE $150.00

RHO D IMMUNE GLOBULIN, 300 MCG $294.00

RHO D IMMUNE GLOBULIN, 300 MGS $294.00

39 of 48




RHYTHM EKG $94.00

RIBOFLAVIN (VITAMIN B-2) $159.00

RIBS, BIL; INC PA CHEST, MIN 4 $412.00

RIBS, UNI; INC PA CHEST, MIN 3 $349.00

RIBS, UNILATERAL; TWO VIEWS $309.00

RISPERIDONE TAB 1MG 6.85

RITUXIMAB INJ 100MG/10ML VIAL 3,281.82

RIVAROXABAN 10MG TAB (XARELTO) 69.78

ROCURONIUM 10MG/ML 10 ML INJ 48.88

ROFLUMILAST 500MCG TAB 62.39

ROPINIROLE 0.5MG TABLET 6.85

ROPIVACAINE 0.5% 30ML INJ 63.67

ROTAVIRUS VACCINE;3 DOSE;LIVE;ORAL USE $0.01

ROTAVIRUS VACCINE;3 DOSE;LIVE;ORAL USE $82.75

ROUTINE OBSTETRIC CARE/CESAREAN DELIVERY $7,900.00

RUSSELL VIPER VENOM TIME DILUT $294.00

RUSSELL VIPER VENOM TIME DILUTED $294.00

S.T.CONTRACT/15MIN $16.25

SACCHAROMYCES AB; IgA & IgG-IBS PANEL $257.00

SACRUM AND COCCYX, MIN 2 VIEWS $296.00

SALINE NASAL SPRAY 0.65% 45 ML 19.10

SCALPEL HARMONIC ACE $1,962.00

SCAPULA, COMPLETE $296.00

SCHEDULED OUTPATIENT LOW LEVEL $82.00

SCOPOLAMINE PATCH 1.5MG 105.04

SCREEN MAMMO BIL 3D DIGITAL IM $53.00

SCREEN MAMMO BIL DIGITAL IMAGE $327.00

SCREENING CYTOPATH THIN PREP $170.00

SCREENING CYTOPATH THIN PREP $171.00

SCREENING TEST PURE TONE AIR $50.00

SCREENING TEST VISUAL ACUITY $57.00

SCREENING TEST VISUAL ACUITY; QUANTI BIL $0.01

SCREENING TEST;VISUAL ACUITY;QUANTIT;BIL $57.00

SCRN DEPRESSION DOC AS NEG NO $0.01

SCRN DEPRESSION DOC AS NEG NO FU PLANNED $0.01

SCRN DEPRESSION DOC POS FU PLAN DOC $0.01

SCRN FUTURE FALL RISK DOC 2 OR $0.03

SCRN FUTURE FALL RISK DOC 2 OR MORE FALL $0.01

SCRN FUTURE FALL RISK DOC NO F $0.01

SCRN MAMMOGRAPHY RESULTS DOC & REVIEWED $0.01

SCROTUM AND CONTENTS $771.00

SEDIMENTATION RATE (ESR) $105.00

SELF CARE ADL'S/15MIN $122.00

SELF CARE FUNCTIONAL CURRENT $0.01

SELF CARE FUNCTIONAL DISCHARGE $0.01

SELF CARE FUNCTIONAL PROJECTED $0.01

SELF-CARE ADL'S/15MIN $122.00

SEMEN ANALYSIS $408.00

SEMEN ANALYSIS POST VAS $117.00

SENNA TABS 8.6 MG 6.85

SENNA-S TABLET 6.88

SENSORY SKILLS/15MIN $122.00

SERTRALINE TAB 50MG 6.86

SHAVE EPIDERM OR DERM LESION 1.1/2.0 CM $617.00

SHAVE EPIDERM OR DERM LESION, FACE, EARS $490.00

SHAVE EPIDERM, DERMAL, SINGLE, SCALP, NE $427.00

SHAVE EPIDERM. OR DERMAL LESION 0.6/1.0 $514.00

SHAVE EPIDERMAL OR DERMAL LESI $419.00

SHAVE EPIDERMAL OR DERMAL LESION, 0.5 CM $419.00

SHOEHORN $25.00

SHOULDER; COMPLETE, MIN 2 VIEW $296.00

SHOULDER; ONE VIEW $136.00

SICKLING OF RBC/HEMOGLOBIN S $150.00

SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC $721.00

40 of 48




SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY $1,105.00

SIGMOIDOSCOPY; BIOPSY $1,105.00

SIGMOIDOSCOPY; DIAGNOSTIC $721.00

SILVER NITRATE APPLIC. 6.85

SILVER SULFADIAZCRM 1% 400GM 159.80

SILVER SULFADIAZIN CRM 1% 25GM 48.55

SIMETHICONE CHEWABLE TAB 80MG 6.85

SIMPLE REPAIR SUPERFICIAL WOUN $416.00




SIMPLE REPAIR SUPERFICIAL WOUND 2.5 OR < $416.00

SIMPLE REPAIR SUPERFICIAL WOUND 2.5 OR < $506.00

SIMPLE REPAIR SUPERFICIAL WOUND 2.6-7.5 $501.00

SIMPLE REPAIR WOUND $416.00





SIMVASTATIN TAB 20MG 6.85

SINUSES, LESS THAN 3 VIEWS $320.00

SKIN SEALANT $14.00

SKIN TEST TUBERCULOSIS $69.00

SKULL; LESS THAN FOUR VIEWS $369.00

SL COMP FUNCTION CURRENT $0.01

SL COMP FUNCTION DISCHARGE $0.01

SL COMP FUNCTION PROJECTED $0.01

SL EXPRESSION FUNCTION CURRENT $0.01

SL EXPRESSION FUNCTION DISCHG $0.01

SL EXPRESSION FUNCTION PROJECT $0.01

SLEEP STAGING; POLYSOMNO/CPAP $4,700.00

SLEEP STAGING; POLYSOMNOGRAPHY $4,000.00

SLING $14.00

SLING $16.00

SMALL INTESTINE, MULT SERIAL $416.00

SMEAR SPECIAL STAIN $257.00

SMEAR STAIN PRIMARY SOURCE $75.00

SMEAR, STAIN & INTERPRETATION $81.00

SMX/TMP SUSP 200MG/40MG 30ML 62.85

SMZ-TMP INJ 10ML VIAL 107.35

SNARE ROTATABLE $111.00

SOCK AID $29.00

SOD BICARB INJ 4.2% 5ML VIAL 74.85

SOD BICARB INJ 8.4% 50ML VIAL 64.95

SOD BICARB INJ 8.4% SYR 50MEQ 76.91

SOD CHLORIDE 0.9% 50ML EXCEL 98.00

SOD HYPOCHLO 0.125% 473ML SOLN 60.96

SODIUM CHLOR 4MEQ/ML 30ML VIAL 56.74

SODIUM CHLORIDE 10% 15ML NEB 8.55

SODIUM CHLORIDE 3% 500ML 98.00

SODIUM HYPOCHLORITE 0.5% 473ML 58.40

SODIUM PHOSPHAT INJ 15mMol/5ml 106.00

SODIUM POLYSTYRENE 15G/60ML 47.75

SODIUM SERUM $103.00

SODIUM URINE $109.00

SODIUM URINE $117.00

SODIUM URINE DR G $109.00

SOFT TISSUES OF HEAD AND NECK $729.00

SOMATOMEDIN $110.00

SOTALOL TAB 80MG 6.85

SPACER FOR USE WITH INHALER $33.00

SPECIAL COAGULATION INTERPRETA $161.00

SPECIAL STAINS GROUP I $303.00

SPECIAL STAINS GROUP II $254.00

41 of 48




SPECIFIC GRAVITY EXCEPT URINE $23.00

SPECIMEN HANDLING OFF TO LAB $71.00

SPECIMEN HANDLING OFF TO LAB $103.00

SPECIMEN HANDLING PT TO LAB $82.00

SPECTROPHOTOMETRY ANALYTE NOS $833.00

SPECULUM LIGHTED $11.00

SPINAL PUNCTURE LUMBAR $732.00

SPINAL PUNCTURE,LUMBAR,DIAGNOSTIC $732.00

SPINE CERVICAL W/WO $3,140.00

SPINE CERVICAL WO $1,578.00

SPINE CERVICAL WO $2,410.00

SPINE LUMBAR W/WO $3,140.00

SPINE LUMBAR WO $1,578.00

SPINE LUMBAR WO $2,410.00

SPINE LUMBOSACRAL COMP W B&F $545.00

SPINE THORACIC W/WO $3,140.00

SPINE THORACIC WO $1,578.00

SPINE THORACIC WO $2,410.00

SPINE THORACOLUMBAR STANDING $239.00

SPINE, CERVICAL; 2 OR 3 VIEWS $320.00

SPINE, CERVICAL; COMPLETE $369.00

SPINE, CERVICAL; MIN 4 VIEWS $369.00

SPINE, LUMBOSACRAL; 2 OR 3 VIE $384.00

SPINE, LUMBOSACRAL; MIN 4 VIEW $455.00

SPINE, SINGLE VIEW $239.00

SPINE; THORACIC, THREE VIEWS $384.00

SPINE; THORACIC, TWO VIEWS $274.00

SPIROMETRY (Global) $253.00

SPIRONOLACTONE TAB 25MG 6.85

SPLINT FINGER $17.00

SPLINT FINGER $20.00

SPLINT LEG/ARM/FOOT $32.00

SPLINT NASAL SEPTAL $116.00

SPLINT SOCK STRASSBURG $37.00

SPLINTING $146.00

SPLIT-THICKNESS AUTOGRAFT $4,074.00

SPLIT-THICKNESS AUTOGRAFT, 1ST 100 SQ CM $4,074.00

SQ IM HORMONAL ANTI NEOPLASTIC $153.00

SQ/IM; NON-HORM ANTINEOPLASTIC $161.00

ST CONTRACT REDWOOD HOSP 15MIN $18.75

STAB PHLEBECTOMY;VARICOSE VEIN $3,063.00

STAB PHLEBECTOMY;VARICOSE VEINS,1 EXTREM $3,063.00

STACLOT LA P $823.00

STAFF TIME CARDIAC REHAB 30MIN $30.00

STAFF TIME; OR PER HOUR $139.00

STAPLER CURVED CUTTER $1,434.00

STAPLER EEA $1,219.00

STAPLER ENDO $1,140.00

STAPLER ENDO GIA UNI 12 MM $382.00

STAPLER ENDO RELOAD $416.00

STAPLER MULTIFIRE $464.00

STAPLER PRECISE DS $33.00

STAPLER PROXIMATE PPH $1,746.00

STAPLER PURSE STRINGER $272.00

STAPLER SKIN $48.00

STAPLER SKIN INSORB $151.00

STAPLER TA $666.00

STAPLER TACKER $1,128.00

STAPLER TK 5 DEVICE $1,023.00

STAPLER TK 5 QUICK LOAD $140.00

STAPLER VERSATACK $348.00

STERILE WATER FOR INJ 1000ML 124.00

STERILE WATER/SALINE 500 ML $31.00

STERNUM, MINIMUM OF TWO VIEWS $296.00

42 of 48




STOCKING SURG BELOW KNEE $32.00

STOCKING SURG BELOW KNEE $37.00

STOCKING SURGICAL ABOVE KNEE E $32.00

STOCKING SURGICAL ABOVE KNEE EA $37.00

STREP PNEUMO ANTIGEN URINE $215.00

STREPTOCOCCUS GROUP A $107.00

STRESS ECG INTER/REPORT ONLY $95.00

STRESS ECG SUPERVISION ONLY $146.00

STRESS ECHO 2D WITH CONTRAST $1,907.00

SUBCULTURE ANAEROBIC $62.00

SUBSEQ HOSP CARE, NORMAL NEWBORN $176.00

SUBSEQUENT HOSPITAL CARE, HIGH COMPLEXIT $300.00

SUBSEQUENT HOSPITAL CARE, LOW COMPLEXITY $110.00

SUBSEQUENT HOSPITAL CARE, MODERATE COMPL $200.00

SUBSEQUENT NRSG FACILITY CARE;HIGH COMPL $537.00

SUBSEQUENT NRSG FACILITY CARE;LOW COMPLE $262.00

SUBSEQUENT NRSG FACILITY CARE;MOD COMPLE $365.00

SUBSEQUENT NRSG FACILITY CARE;PROB FOCUS $181.00

SUBSEQUENT OBS CARE (ER ADM) $110.00



SUBSEQUENT OBSERVATION CARE $200.00

SUBSEQUENT OBSERVATION CARE PER DAY $110.00

SUCCINYLCHOLINE 20MG/ML 10ML 139.93

SUCRALFATE SUSP UD 1GM/10ML 64.45

SUCTION TIP HI-D $15.00

SULFAMETH/TMP DS TAB 800/160MG 6.85

SULFATE URINE DR G $109.00

SUMATRIPTAN INJ 6 MG VIAL $74.70

SUMATRIPTAN INJ 6MG VIAL 74.73

SUMATRIPTAN TAB 25MG 15.32

SUPRANE $48.00

SURGERY MAJOR, 1ST 30 MINUTES $1,316.00

SURGERY MAJOR, EA AD'L 15 MIN $638.00

SURGERY MINOR, 1ST 30 MINUTES $1,064.00

SURGERY MINOR, EA AD'L 15 MIN $515.00

SURGICAL PATHOLOGY LEVEL I $98.00

SURGICAL PATHOLOGY LEVEL I $99.00

SURGICAL PATHOLOGY LEVEL II $200.00

SURGICAL PATHOLOGY LEVEL III $244.00

SURGICAL PATHOLOGY LEVEL III $245.00

SURGICAL PATHOLOGY LEVEL IV $279.00

SURGICAL PATHOLOGY LEVEL V $341.00

SURGICAL PATHOLOGY LEVEL VI $412.00

SURGICAL PREPARATION $1,588.00

SURGICAL PREPARATION $1,822.00

SURGICAL SPECIMEN $129.00

SURGICEL HEMOSTAT $150.00

SUSCEPTIBILITY MACRODILUTION $258.00

SUSCEPTIBILITY MICRODILUTION 1 $260.00

SUSCEPTIBILITY STUDIES ENZYME $231.00

SUSCEPTIBILITY STUDIES; ENZYME DETECTION $231.00

SUSCEPTIBLITY STUDIES ANTIBIOT $65.00

SUSCEPTIBLITY STUDIES;ANTIMICROBIAL AGEN $65.00

SUTURE $69.00

SUTURE ANCHOR BIO CORKSCREW FT $1,319.00

SUTURE MULTI PACKS $38.00

SUTURE ORTHOPEDIC $57.00

SUTURE REELS $183.00

SUTURE SINGLE PACKS $16.00

SUTURE TIES $14.00

SWALLOWING FUNCTION, VIDEORAD $453.00

SWALLOWING FUNCTIONAL CURRENT $0.01

SWALLOWING FUNCTIONAL DISCHG $0.01

43 of 48




SWALLOWING FUNCTIONAL PROJECTD $0.01

SYPHILIS TEST QUALITATIVE $75.00

SYRINGE INFLATION $76.00

SYRINGE RAULERSON 5 CC $25.00

T&A; AGE 12 OR OVER $1,488.00

TACROLIMUS $201.00

TAMSULOSIN 0.4 MG CAPS 6.85

TAPE WATERPROOF $12.00

TCB GENE ANALYSIS $817.00

TCG GENE ANALYSIS $817.00

TEAM CONF FAMILY NOT PRESENT $328.00

TEAM CONFERENCE FACE TO FACE $328.00

TEARS, ARTIFICIAL OP 15 ML 137.28

TECHNETIUM Tc-99M MEBROFENIN $400.00

TECHNETIUM Tc-99M MEDRONATE $840.00

TECHNETIUM Tc-99m MERTIATIDE $1,132.00

TECHNETIUM Tc-99M SESTAMIBI $800.00

TECHNETIUM Tc-99M SULFUR COLL $531.00

TELEHEALTH ORIG SITE FACILITY $94.00

TENDON SHEATH INCISION $2,575.00

TENIVAC VACCINE 0.5ML 65.25

TERAZOSIN CAP 1MG 6.85

TERAZOSIN CAP 5MG 6.85

TERBUTALINE INJ 1MG/1ML VIAL 24.50

TESTOSTERONE BIOAVAILABLE DIR $119.00

TESTOSTERONE CYP INJ 200MG VIA 68.44

TESTOSTERONE FREE $195.00

TESTOSTERONE FREE $283.00

TESTOSTERONE INJ 200 MG VIAL $87.90

TESTOSTERONE PER 1 MG (MCR) $0.44

TESTOSTERONE TOTAL $195.00

TESTOSTERONE TOTAL $206.00

TETANUS & DIPTHERIA TOXOIDS;7 YRS OR > $31.25

TETANUS DIPHTHERIA TOX; ADULT 53.92

TETANUS DIPTHERIA PERTUSSIS;7> 43.10

TETANUS,DIPTHERIA,PERTUSSIS;7 YRS & > $0.01

TETANUS,DIPTHERIA,PERTUSSIS;7 YRS & > $38.05

TETRACAINE INJ 1% 2ML VIAL 87.65

TETRACAINE OP DROPS 0.5% 4 ML 46.40

THALLIUM TI-201 THAL PER mCi $405.00

THER PROC STRG ENDUR 15 MIN $112.00

THER PROC STRG ENDUR GRP $80.00

THERA CANE MASSAGER $43.00

THERAPEUTIC ACTIVITIES/15min $122.00

THERAPEUTIC EXERCISE/15MIN $110.00

THERPAPEUTIC,PROPHYLACTIC,DIAG INJECTION $82.00

THIAMINE (VIT B-1) $211.00

THORACENTESIS MARKING $99.00

THORAX W $1,790.00

THORAX WO $1,578.00

THROMBIN TIME (PLASMA) $254.00

THROMBOLYTIC THERAPY STROKE $263.00

THROMBOPLASTIN TIME PARTIAL $143.00

THYROGLOBULIN $271.00

THYROGLOBULIN ANTIBODY $159.00

THYROID HORMONE UPTAKE T3/T4 $86.00

THYROID IMGE UPTKE & SCAN COMP $1,477.00

THYROID STIMULATING HORMONE $206.00

THYROID STIMULATING IMMU GLOB $603.00

THYROTROPIN ALFA 0.9 MG INJ 3,437.65

THYROXINE FREE $205.00

THYROXINE TOTAL $94.00

TIBIA AND FIBULA, TWO VIEWS $320.00

TICAGRELOR 60MG TABLET 42.61

44 of 48




TIMOLOL OPHTH SOLN 0.5% 5ML 35.37

TIOTROPIUM INHAL 18MCG 5 CAPS 160.45

TIP FEMORAL $62.00

TIPS I&A $41.00

TISSUE CULTURE ND BONE MARROW $425.00

TISSUE CULTURE SKIN OR OTHER $417.00

TISSUE EXAM BY KOH $63.00

TISSUE PROCESSING $63.00

TISSUE TRANSFER $3,176.00

TISSUE TRANSGLUTAMINASE (tTG) IgA/IgG $206.00

TIZANIDINE 4MG TAB 6.85

TOBRAMYC/DEXAMET OP OINT 3.5GM 706.55

TOBRAMYCIN $133.00

TOBRAMYCIN INJ 80MG/2ML VIAL 29.51

TOBRAMYCIN/DEXAM OP SUSP 2.5ML 146.70

TOCILIZUMAB INJ 400MG/20ML VIL 7,282.47

TOCOPHEROL ALPHA (VIT E) $166.00

TOE(S), MINIMUM OF TWO VIEWS $274.00

TOLTERODINE LA CAP 2MG 42.95

TONSILLECTOMY, AGE 12 OR OVER $1,163.00

TONSILLECTOMY; > AGE 12 OR OVR $1,163.00

TOPIRAMATE $296.00

TOPIRAMATE 100MG TAB 6.85

TOPOTECAN INJ 4MG VIAL 310.17

TORSEMIDE 20MG TAB 6.85

TOTAL ABD. HYSTERECT. W/OR W/OUT REMOVAL $4,504.00

TOTAL THYROID LOBECTOMY;UNILATERAL $3,327.00

TRACE ELEMENTS, MULTIPLE 4ML 87.90

TRACTION, MECHANICAL $92.00

TRAMADOL CONFIRMATION UR $139.00

TRAMADOL TAB 50MG 6.85

TRANEXAMIC ACID 1000MG/10ML IJ 79.59

TRANSFERASE ALANINE ALT/SGPT $100.00

TRANSFERASE ASPARTATE AST/SGOT $61.00

TRANSFERRIN $191.00

TRANSVAGINAL $781.00

TRAUMA TEAM ACTIVATION $2,436.00

TRAVOPROST OP SOL 0.004% 2.5ML 558.41

TRAY CATHETER DRAINAGE $238.00

TRAY FOLEY 2-WAY W DRAINAGE BG $37.00

TRAY FOLEY CATHETER W DRAINBAG $34.00

TRAY SPINAL LUMBAR PUNCTURE $67.00

TRAZODONE TAB 50MG 6.94

TREATMENT OF SPEECH; INDIVID $328.00

TREATMENT OF SWALLOWING DYSF $328.00

TRIAMCINOLO NAS IN 55MCG 16.5G 81.00

TRIAMCINOLON ACET 40MG/ML VIAL 86.59

TRIAMCINOLONE CREAM 0.1% 15GM 27.29

TRIAMCINOLONE INJ 40MG VIAL $86.65

TRIAMCINOLONE/MOXIFL 0.6ML INJ 163.05

TRIAMTERENE 75MG/HCTZ 50MG 8.55

TRIGLYCERIDES $66.00

TRIIODOTHYRONINE FREE T3 $105.00

TRIIODOTHYRONINE TOTAL T3 $190.00

TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER $102.00

TRIMMING OF NONDYSTROPHIC NAILS, ANY NUM $99.00

TROCAR ADAPT $327.00

TROCAR BALLOON $1,173.00

TROCAR BLADELESS $506.00

TROCAR BLADELESS OPTICAL VERSA $56.00

TROCAR BLUNT PORT $327.00

TROCAR STEP $379.00

TROCAR VERSA STEP PLUS $327.00

TROCAR VERSA STEP SLEEVE $156.00

45 of 48




TROPONIN QUANTITATIVE $224.00

TRTMT MISSED AB;COMP. SURG.;1ST TRIMESTE $1,606.00

TRTMT MISSED AB;COMP. SURG.;2ND TRIMESTE $1,656.00

TRUVADA 200/300MG TAB 168.70

TUBE KING LTS-D $156.00

TUBE POSITUBE $22.00

TUBE SET FOR ARTHROSCOPY $161.00

TUBE THORACOSTOMY $797.00

TUBE THORACOSTOMY/WATER SEAL $797.00

TUBE VENTILATION EAR $44.00

TUBERCULIN PPD 0.1ML SKIN TEST 73.22

TUCKS PADS 40/PKG 30.77

TX CLOSED ELBOW DISLOCATION $2,125.00

TX HIP DISLOCATION WITH MANIPU $1,497.00

TYMPANOMETRY $86.00

TYMPANOSTOMY, BILATERAL; GEN A $1,129.00

TYMPANOSTOMY, GEN ANESTHESIA; BILATERAL $1,128.00

TYPHOID VACCINE;INTRAMUSCULAR USE $103.50

UDS-RMH $60.00

ULTANE $48.00

ULTRASOUND GUIDANCE $278.00

ULTRASOUND GUIDANCE, NEEDLE PLACEMENT $190.00

ULTRASOUND/15MIN $92.00

UNLISTED LAPAROSCOPY ABDOMEN,PERITONEUM $2,265.00

UPPER EXTREMITY ARTERIES; BIL $1,294.00

UPPER EXTREMITY ARTERIES; UNI $1,080.00

UPPER GASTROINTESTINAL ENDOSCOPY $1,389.00

UPPER GASTROINTESTINAL ENDOSCOPY W/BX $1,715.00

UPPER GI ENDOSCOPY W/REMOVAL FOREIGN BOD $1,797.00

UPPER GI ENDOSCOPY W/TUMOR REMOVAL $1,968.00

UPPER GI ENDOSCOPY; BIOPSY $1,715.00

UPPER GI ENDOSCOPY; DIAGNOSTIC $1,389.00

UPPER GI ENDOSCOPY; PEG TUBE $1,112.00

UREA NITROGEN (BUN) QUANTITATI $94.00

URGENT CARE LEVEL 1 ESTABLISHD $41.00


URGENT CARE LEVEL 1 NEW $41.00











URIC ACID BLOOD $65.00

URIC ACID OTHER SOURCE DR G $109.00

URINALYSIS AUTOMATED W MICRO $83.00

URINALYSIS AUTOMATED WO MICRO $48.00

URINALYSIS DIPSTICK DR G $109.00

URINARY DRAINAGE BAG, LEG OR ABDOMEN $15.00

URINE MICROALBUMIN $153.00

URINE OSMOLALITY $109.00

URINE OSMOLALITY $117.00

URINE OSMOLALITY DR G $109.00

URINE, TRAMADOL AND METABOLIES $140.00

UROTHELIAL CANCER FISH $1,461.00

US GUIDE VASCULAR ACCESS $64.00

US VASCULCAR ACCESS $99.00

US/POST VOIDING RESID URINE $96.00

US/POST-VOIDING RESID. URINE/BLADDER CAP $96.00

VAG DELIVERY ONLY; W OR W/OUT EPISIOTOMY $3,595.00

46 of 48




VAGINAL DEL. AFTER PRIOR CESAREAN ONLY $3,818.00

VAGINAL DELIVERY INCLUDING POSTPARTUM CA $4,569.00

VALPROIC ACID FREE $191.00

VALPROIC ACID TOTAL $191.00

VALSARTAN TAB 80MG 12.63

VANCOMYCIN $172.00

VANCOMYCIN INJ 1GM VIAL 57.00

VANCOMYCIN INJ 1GM VIAL MBAG 151.72

VANILLYLMANDELIC ACID URINE $214.00

VARICELLA VIRUS VACCINE;LIVE;SUBCUTANEOU $0.01

VARICELLA VIRUS VACCINE;LIVE;SUBCUTANEOU $125.90

VARICELLA ZOSTER IMMUNE GLOBULIN $5,227.88

VARIVAX INJ VACCINE 159.90

VASECTOMY $1,655.00

VASECTOMY;UNILATERAL OR BILATERAL $1,655.00

VECURONIUM INJ 10MG VIAL 73.45

VENLAFAXINE CAP XR 37.5MG 6.85

VENLAFAXINE TAB 37.5MG 6.90

VENT BIPAP ASSIST 1ST DAY $592.00

VENT BIPAP ASSIST SUBSEQNT DAY $621.00

VENTILATOR BREATHING CIRCUIT $420.00

VERAPAMIL TAB SR 120MG 6.85

VINCRISTINE INJ 1MG/ML VIAL 56.03

VISCOELASTIC 64.00

VITAMIN A $167.00

VITAMIN B-1 INJ 200MG/2ML VIAL 89.45

VITAMIN B-1 TAB 100MG 6.84

VITAMIN B12 (CYANOBALAMIN) $214.00

VITAMIN B12 IJ 1000MCG/ML VIAL 36.33

VITAMIN B-12 TAB 500 MCG 6.94

VITAMIN B-6 PROFILE FOR EXPLOD $232.00

VITAMIN B-6 TAB 50MG 6.85

VITAMIN C TAB 500 MG 6.85

VITAMIN D 1000 UNIT TAB 6.85

VITAMIN D 25-HYDROXY $250.00

VITAMIN D 400 IO TABS 6.85

VITAMIN D 50,000 UNITS CAP 6.85

VITAMIN D; 25 HYDROXY $221.00

VITAMIN E CAP 400 I.U. 6.85

VITAMIN K INJ 1MG/0.5ML AMP 142.13

VITAMIN K INJ 10MG/ML AMP 267.76

VITAMIN K TAB 5MG*PHYTONADIONE 197.09

VITAMINS, PRENATAL W/F.A. TAB 6.85

VIVITROL EXT RELEASE 380MG INJ 4,478.45

VOICE FUNCTIONAL CURRENT $0.01

VOICE FUNCTIONAL DISCHARGE $0.01

VOICE FUNCTIONAL PROJECTED $0.01

VOLDYNE EXERCISER $38.00

VOLDYNE EXERCISER (INCENTIVE SPIROMETER) $38.00

VON WILLEBRAND FACTOR ACTIVITY $524.00

WARFARIN TAB 1MG 6.85


WARFARIN TAB 2.5MG 6.85


WET MOUNT INTERPRETATION $65.00

WET PREP FOR HELMINTHS $49.00

WHEELCHAIR MGMT/15MIN $122.00

WIRE CRE FIXED 18-19 20MM $481.00

WORK RELATED OR MEDICAL DISABILITY EXAM $295.00

WOUND CARE PER SESSION $173.00

WRIST; COMPLETE, MIN OF 3 VIEW $274.00

WRIST; TWO VIEWS $274.00

ZARONTINE (ETHOSUXIMIDE) $145.00

ZINC GLUCONATE 50 MG CAP 6.85

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ZINC OXIDE OINTMENT 28GM 28.58

ZINC SERUM $64.00

ZOLEDRONIC ACID INJ 4MG VIAL 197.41

ZOLEDRONIC ACID INJ 5MG VIAL 717.68

ZOLPIDEM TAB 5MG 6.85

ZONIOSAMIDE $183.00

ZOSTAVAX INJ VACCINE 197.05

ZOSTER VACCINE 50MCG/0.5ML INJ 150.20

ZOSTER VACCINE RECOMBINANT $150.00

ZOSTER VACCINE;LIVE;SUBCUTANEOUS INJ $150.00

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chippewa county-montevideo hospital · abdomen & aorta cta w $4,186.00 ... amoxic/clav susp...

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