DESCRIPTION CURRENT FEEFACILITY CHG LEVEL 1 $252.00FACILITY CHG LEVEL 2 $606.00FACILITY CHG LEVEL 3 $1,261.00FACILITY CHG LEVEL 4 $2,400.00FACILITY CHG LEVEL 5 $3,150.00CRITICAL CARE 30-74 MIN $2,975.00CRITICAL CARE ADD 30 MIN $1,010.00HOSPITAL OBSERVATION SERVICES PER HOUR $1,576.00REMOVAL ACNE/COMEDONE $720.00INCISION/DRAINAGE ABSCESS $791.00INS/DRAIN ABSCESS COMPL $1,469.00I & D CYST SIMPLE $848.00I&D PILONIDAL CST COMP $1,414.00I & RMVL SUB-CUT SIMPLE $850.00I & RMVL FB, SUB-CUT,COMP $1,528.00I & D HEMATOMA/SEROMA $515.00PUNCTURE ASP OF ABSCESS $419.00DBRDMT X10SV ECZMT/INFCT $175.00DBRDMT, SKIN, PARTIAL THICK $156.00DEBRIDE SKIN, FULL $178.00DBRD SKN SUBQ TISSUE $197.00DEBRIDEMENT SUBQ TISS&MUS $933.00CORN/CALLUS RMVL $159.00RMVL SKIN TAGS $279.00SHAVING SKIN LESION 1 S/N $230.00EXC BGN LSN ARM/LEG LESS THAN 0.5 $389.00EXC BGN LSN TRUNK 0.6-1.0 $476.00EXC BGN LSN TRUNK 1.1-2.0 $533.00EXC BNGN LSN,TRUNK 2.1-3. $613.00EXC BGN LSN TRUNK 3.1-4.0 $697.00EXC BGN LSN ARM/LEG GREATER THAN 4.0 $1,002.00EXC BGN LES SCALP LESS THAN 0.5 CM $389.00EXC BGN LSN,SCALP 0.6-1.0 $505.00EXC BGN LSN,SCALP 1.1-2.0 $563.00EXC BGN LSN,SCALP 2.1-3.0 $659.00EXC BGN LSN,SCALP 3.1-4.0 $762.00

EXC BGN LSN,SCALP GREATER THAN 4.0 CM $1,097.00EXC BGN LSN, FACE LESS THAN 0.5 CM $427.00EXC BGN LSN,FACE 0.6-1.0 $545.00EXC BGN LSN,FACE 1.1-2.0 $611.00EXC BGN LSN,FACE 2.1-3.0 $733.00EXC BGN LSN,FACE 3.1-4.0 $928.00EXC BGN LSN,FACE GREATER THAN 4.0 CM $1,276.00EXC,MAL LSN,TRUNK .6-1.0 $740.00DEBRIDEMENT NAIL ANY METH $102.00AVULSION/1-NAIL PLATE $319.00REMOVAL OF ADDL NAIL PLAT $148.00EVAC SUBUNGUAL HEMATOMA $270.00EXC NAIL PART/COMP $1,436.00REPAIR NAIL BED $685.00WEDGE EXC SKIN/NAIL BED $431.00EXCISION OF PILONDIAL CYST, SIMPLE $624.00LACERATION REPAIR LESS THAN 2.5 CM $370.00REPAIR LAC SCALP 2.6-7.5 $488.00REPAIR LAC SCALP 7.6-12.5 $608.00REPAIR LAC,SCALP 12.6-20C $822.00REPAIR LAC SCALP 20.1-30. $998.00REPAIR LAC SCALP GREATER THAN 30.0CM $1,238.00REPAIR LAC FACE LESS THAN 2.5 CM $461.00REPAIR LAC FACE 2.6-5.0CM $516.00REPAIR LAC FACE 5.1-7.5CM $656.00REPAIR LAC FACE 7.6-12.5 $817.00REPAIR LAC,FACE 12.6-20CM $1,109.00REPAIR LAC FACE 20-30 CM $1,266.00REPAIR LAC FACE GREATER THAN 30.0 CM $1,433.00LYR CLSR S/A/T/E 2.5CM $1,254.00REPAIR-INT SCALP 2.6-7.5 $1,595.00INTERM RPR SCLP/TRNK/EXTR $1,696.00REPAIR INTERM S/A/T/E 12. $1,989.00LAYER CLSR NECK/HAND 2.6 $1,283.00REPAIR LAC HAND/FOOT 2.6- $1,638.00LYR CLSR N/H/F/ETRNL GENT $1,770.00LACERATION REPAIR, INTERMEDIATE, 12.6 CM TO 20.0 CM $2,222.00LAYER CLSR OF WND NCK/HND $1,408.00LYR CLSR WOUND 2.6-5.0FAC $1,668.00LYR CLSR F/E/E/N/L/M&/MUC $1,789.00REPAIR INTERMED F/E/E/N/L $2,501.00REPAIR COMPLEX TRUNK 1.1 $1,048.00RPR CMPLX TRUNK 2.6-7.5 $1,327.00RPR CPLX TRNK EA 5 CM/LESS THAN $361.00RPR CPLX S/A/L 1.1 CM-2.5 $1,941.00

RPR CMPX SCALP ARM2.6-7.5 $2,198.00CMPLX RPR ADD 5 CM OR LES $707.00RPR CMPLX FOREHEAD1.1-2.5 $1,205.00RPR CMPX FOREHEAD/CHECK/C $1,951.00REPAIR COMPEX F/C/C/M/N/A $572.00RPR CMPLX EYE NOSE LESS THAN 1.0 $1,200.00CMPX RPR EYE NOSE 1.1-2.5 $1,367.00RPR CPLX E/N/E/L 2.6-7.5 $1,888.00SUTURE RMVL W/ANESTHESIA $296.00SUTURE RMVL OTHER SURG. $313.00BURN, INITIAL TREATMENT $234.00BURN, DRESSING/DBRDMNT-SM $448.00BURN, DRESSING/DBRMNT-MED $498.00BURN, DRESSNG/DBRDMNT-LG $596.00ESCHAROTOMY EACH ADD INC $297.00DEST LESION 1ST NON-SURG $266.00DEST LESION 2-14 NON-SURG $27.00DESTRUCTION LSN 15 OR MOR $585.00DESTRCT WARTS UP TO 14 $361.00CHEMICAL CAUTERIZATION GR $247.00EXPLORATION WOUND-EXTREM $1,876.00RMVL FB MUSCLE,SIMPLE $641.00TRIGGER POINT INJECTION $195.00TRIGGER POINT INJ 1-2 MUS $178.00INJ SINGLE/MLT TRIG 3/GREATER THAN $204.00ARTHROCENTESIS, SML JOINT $183.00ARTHROCENTESIS, MED JOINT $198.00ARTHROCENTESIS, LG JOINT $258.00CLTX NSL B1 FX W/O MNPJ $229.00CLOSED TX NASAL FRACT W/O $875.00CLOSED TX NASAL FRAC W/ST $835.00CLSD TX FX ORBIT EXCEPT B $599.00CLDS TX TEMP DISLOCATION $299.00CLTX RIB FX UNCOMP EA $402.00CLTX CLAVICULAR FX WO MNP $697.00CLSD TX CLAVICULAR FRAC W $1,137.00CLSD TX SCAPULAR FX WO MA $742.00CLTX PROX HUMRL FX WO MAN $1,034.00CLTX PROX HUMRL FX W/MANI $2,676.00CLOSED TRX GREATER HUMERAL TUBEROSITY FRAC, WOUT MANIP $1,314.00SHOULDER DISLOCATION TRMT $2,358.00CLTX SHO DISLC W/MNPJ REQ $1,288.00I&D UPR ARM/ELB DP ABSC/H $1,163.00REMOVAL FOREIGN BODY ARM $448.00CLTX HUMRL SHFT FX W/O MN $1,131.00

CLTX SPRCNDYLR/TRANSCNDYL $1,213.00CLTX HUMERAL EPICONYLAR $1,016.00CLTX HUMRL CNDLYR FX MEDI $1,068.00CLSD TX ELBOW DISLOCAT $1,191.00TX, CLOSED ELBOW DISLOC R $2,229.00RADIAL HEAD SUBLUX. CHILD $775.00CLTX RDL HEAD FX WO MANP $823.00CLSD TRX RADIAL HEAD OR NECK FRACTURE, W MANIPULATION $2,740.00CLTX ULNR FX PROX END WO $922.00ARTHRODESIS, ELBOW JNT LO $2,745.00I & D FOREARM/WRIST $1,717.00CLTX RDL SHFT FX WO MANP $846.00CLSD TX RAD SHAFT W/MANIP $1,635.00CLSD TX ULNAR SHFT FX NO $819.00CLTX RDL&UR SHFT FXS W/O $861.00CLOSED TX RADIAL&ULNAR SH $1,709.00CLSD TX DISTAL RAD FX WO $930.00CLSD TX DISTAL RAD FX $2,039.00CLSD TX NAVICULAR FX WO M $959.00CLTX CARPL B1 FX W/O MNPJ $976.00CLTX UR SYLOID FX $1,021.00I & D FINGER ABSCESS,SIMP $823.00I & D FINGER ABSCESS/FELO $1,243.00EXC XTNSR TDN W/IMPLTJ SY $2,369.00CLSD TX METACARPAL FX $907.00CLSD TX MEDICARPAL FX $1,022.00CLTX MTCRPL FX W/MNP W/XT $1,474.00REDUCTION FINGER DISLOCAT $1,075.00CLS TX MCP DISLOCATION $1,030.00CLSD TX PHALANGEAL SHFTFX $1,512.00CLTX PHLNGL FX PROX/MIDDL $2,488.00CLTX ARTICULAR FX INVG MT $1,200.00CLS TX FX FINGER/THUMB $1,515.00CLTX DSTL PHLNGL FX FNGR/ $2,241.00TREAT FINGER DISLOC FINGE $2,098.00CLTX IPHAL JT DISLC 1 W/M $1,230.00RED PROSTH HIP WOUT ANESTH $2,853.84I&D DP ABSC BURSA/HMTMA T $2,197.00CLTX SPRCNDYLR/TRNSCNDYLR $1,688.00CLTX FEM FX DSTAL END MED $1,733.00CLTX PATELLAR FX W/O MNPJ $1,028.00CLTX PATELLAR DISLC W/O A $1,217.00ARTH ANKL W/JT EXPL +BX+R $1,563.00RPR PRIM OPN/PRQ RPTD ACH $2,284.00CLSD TX TIBIAL SFT FX $1,109.00

CLTX TIBL SFT FX W/MANP $1,777.00CLTX MEDIAL MALLS FX W/O $1,068.00CLTX PROX FIVULA/SHFT FX $962.00CLSD TX DISTAL FIBULAR FX $1,014.00OPN TX DISTAL FIB FX LAT $2,404.00CLOSED TX BIMALLEOLAR ANK $1,062.00CLTX BIMAL ANKLE FX W/POT $1,556.00CLTX TRIMAL ANKL FX W/O M $1,008.00CLSD TX TRIMALLEOLAR FX W $1,603.00CLTX FX W8 BRG ARTCLR PRT $1,013.00CLOSED TX ANKLE DISLOCATI $1,200.00RMVL FB BODY FOOT SUBQ $800.00RMVL FB FOOT DEEP $1,525.00CLSD TX CLAVICLE FX WO MA $799.00CLTX TALUS FX W/O MNPJ $753.00TX TARSAL B1 FX XCP TALUS $693.00TX TARSAL B1 FX XCP TALUS $964.00CLTX METAR FX WO MNP $1,702.00CL TX METAR FX W/MNPJ $857.00CLTX FX GRT TOE W/O MNLJ $450.00CLSD TX FX GRT TOE W MANI $560.00CLSD TX FX PLALANX/PHALAN $389.00FX CARE PHALANX NOT GREAT $510.00CLOSED TX TALOTARSAL JOIN $430.00CLSD TX METATARSOPHLANGEA $493.00CLSD TX PIP JNT DISLOCATI $365.00BODY/UP EXTRM CAST HEAD $790.00APPL CST SHO HAND LNG ARM $308.00LONG ARM SPLINT $491.00SHORT ARM SPLINT $264.00APPLICATION FINGER SPLINT $80.00STRPG SHO $193.00LONG LEG SPLINT $251.00SHORT LEG SPLINT $413.00STRAPPING KNEE $172.00STRAPPING OF TOES $119.00DENIS-BROWNE SPLNT STRPG $182.00RMVL/BIVALV GAUNTLET BOOT $210.00REMOVAL/BIVALVING FULL AR $221.00REMOVAL/BIVALVING TURNBUC $287.00RMVL FOREIGN BODY NASAL $737.00NASAL PACKING $352.00CTRL NSL HEMRRG ANT CPLX $645.00CTRL NSL HEMRRG PST PST N $802.00INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE $508.00

LARYNGOSCOPY, INDRCT DX $279.00LARGSC +-TRACHEOSCOPY DX $1,338.00CATHETER ASPIRATION NASOT $186.00THORACENTESIS W/INS TUBE $688.00TUBE THORACOSTOMY INCLUDES CONNECTION TO DRAINAGE SYSTEM $1,462.00INTRODUCTION OF NEEDLE/IN $97.00VENIPUNCTURE, 3 YRS OR OLDER $71.00VENIPUNCTURE $48.00COLL CAPILLARY BLG SPEC $52.00INS NON TUN CTR CVC 5YR GREATER THAN $817.00INSJ PRPH CVS W/O SUBQ PO $907.00RPR TUN/NON-TUN CTR VAD C $548.00COLLECT BLOOD FROM IMPLAN $79.00COLLECT BLOOD FROM CATHET $86.00RPR LIP FULL THICKNESS $1,383.00RPR LIP FULL THKNS UP HAL $1,621.00RPR LIP FULL THKNS GREATER THAN 1.2 VE $1,909.00CLSR LAC VESTIBULE MOUTH $811.00LACERATION REPAIR, VESTIBULE OF MOUTH $937.00LACERATION REPAIR OF TONGUE $780.00DRNG ABSC DENTOALVEOLAR S $772.00REMOVAL OF SALIVARY GLAND STONE BY INCISION $937.00INCISION AND DRAINAGE ABSCESS PERITONSILLAR $1,248.00RMVL FB PHARYNX $576.00NASO/ORO-GASTRIC TUBE PL $151.00GASTRIC INTUBATION AND ASPIRATION THERAPUETIC NECESSATING PHYSICIANS SKILL $149.00CHANGE GASTROSTOMY TUBE $1,224.00REPLCMNT GASTRO TUBE, PERC INC REMO WOUT IMAG/ENDO, NO REVISION $1,119.20UNLIS PX STOMACH $572.00I&D SBMCSL ABSC RECTUM $837.00I&D ISCHIOR/PRIRC ABSC SP $1,673.00INC/DRAIN PERIANAL ABS SU $807.00INCISION THROM HEMORRHOID $575.00EXC MULTIPLE EXT PAPILLAE $859.00ENULEATION EXCC OF EXT HE $454.00INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS $344.00ANOSCOPY $272.00ANOSC RMVL FB $719.00RPR UMBILICAL HRNA LESS THAN 5 YRS $1,122.00RPR UMBILICAL HRNA 5 YR/GREATER THAN $1,492.00BLDR IRR SMPL LVG&/INSTLJ $272.00INSR NONDWELLING BLDR CAT $215.00INSERTION BLADDER CATH $275.00INSERT BLADDER CATH COMPL $502.00IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM $897.33

DRAINAGE OF SCROTAL WALL ABSCESS $995.00INC/DRAIN VULVA/PERINEAL $382.00I & D BARTHOLIN ABSCESS $435.00REMOVAL IMPACTED VAG FB $561.00SPINAL PUNCTURE,LUMBAR $531.00INJ ANESTHETIC, TRIGEMINA $375.00INJ ANESTHETIC FACIAL NRV $382.00INJECTION, ANESTHETIC AGENT, GREATER OCCIPITAL NERVE $286.00INJ ANESTHETIC AGENT $381.00REMOVAL FB EYE-SUPERFCL $377.00REMOVAL FB EYE/CONJ EMBED $453.00RMVL FB EYE W/O SLIT LAMP $354.00RMVL FB EYE $251.00I&D ABSCESS EYELID $836.00EXPRESSION CONJUNCT FOLLI $218.00DRAINAGE EXT EAR ABSC $604.00DRAINAGE EXT AUDITORY CAN $765.00RMVL FOREIGN BODY EAR $405.00RMVL FB XTRNL AUD CANAL A $347.00REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL $272.00RMVL IMPACTED CERUMEN $205.00RADEX EYE DETCJ FB $99.00XRAY MANDIBLE LESS THAN 4 VIEWS $213.00XRAY MANDIBLE MIN 4 VIEWS $229.00XRAY MASTOIDS MIN 3 VIEWS $190.00XRAY FACIAL BONES LESS THAN 3 VIEW $166.00XRAY FACIAL BONES GREATER THAN 3 VIEW $248.00NASAL BONE X-RAY $210.00RAD EXAM ORBIT COMP. $248.00RADEX SINUSES PARANSL LESS THAN 3 $104.00RAD EXAM SINUS COMPLETE $136.00SKULL LESS THAN 4 VIEWS $208.00RAD EXAM SKULL COMPLETE $254.00RADEX TEETH COMP FL MOUTH $151.00RADEX TMPRMAND JT OPN&CLS $304.00RAD EXAM NECK,SOFT TISSUE $172.00COMPUTED TOMOGRAPHY HD/BR $839.00TOMOGRAPHY HEAD/BRAIN WIT $1,161.00COMPUTED TOMOGRAPHY HEAD/ $1,435.00CT ORBIT SELLA/POST FOSSA $1,293.00CT ORBIT SELLA/POST FOSSA $2,302.00CT ORBIT W&WO CONTRAST $2,586.00CT MAXLFCL AREA C-MATRL $1,293.00CT MAXLFCL AREA C+ MATRL $1,909.00CT MAXLFCL AREA C-/C+ $2,355.00

CT NECK WO CONTRAST $1,293.00CT SOFT TISS NCK C+MATRL $1,817.00CT SOFT TISS NCK C-/C+ $2,257.00CTA HEAD C-/C+ $2,313.00CT ANGIOGRAPHY NECK W/CON $2,985.00XRAY CHEST AP $119.00XRAY CHEST PA & LATERAL $163.00XRAY CHEST OBLIQUES-BOTH $160.00RADEX CH COMPL MIN 4 VIEW $160.00XRAY CHEST-LORDOTIC $122.00RAD EXAM, CHEST, 1 VIEW $147.00RAD EXAM, CHEST, TWO VIEWS $197.00BRONCHOGRAPHY BI RS&I $484.00RIBS UNILATERAL 2 VIEWS $181.00RIB UNILATERAL W CHEST $222.00RIBS BILATERAL 3 VIEWS $141.00RIBS BILATERAL W/CHEST $181.00CHEST 2 VIEWS $181.00STERNO CLAV JOINT 3 VIEW $131.00CT CHEST W/O CONTRAST $1,293.00CT THORAX W/CONTRAST $1,824.00CT THORAX WO CONTRAST $1,606.00CT ANGIOGRAPHY $2,858.00SPINE SINGLE VIEW $129.00SPINE, CERVICAL 2/3 VIEWS $300.00SPINE, CERVICAL MIN 4VIEW $405.00SPINE CERV. COMP FLEX/EXT $229.00SPINE THORACIC 2 VIEWS $187.00SPINE THORACIC 3 VIEWS $133.00RAD EXAN SPINE THROAC 4 V $152.00RADEX SPI THORACOLMBR 2 V $125.00SPINE LUMBO. MIN 4 VIEWS $202.00X-RAY, SPINE, LUMBOSACRAL, 4 VIEWS $278.00RAD EXAM SPINE LUMBO COMP $250.00SPINE LUMBAR AP & LAT W F $170.00COMPUTED TOMOGRAPHY CERVI $1,293.00CT CRV SPI C+MATRL $1,834.00CT CRV SPI C-/C+ $1,579.00CT THRC SPI C-MATRL $1,293.00CT THRC SPI C+ MATRL $1,834.00CT THRC SPI C-/C+ $2,315.00CT L SPINE WO CONTRST $1,293.00CT LMBR SPI C+ MATRL $1,828.00CT LMBR SPI C-/C+ $2,285.00RAD EXAM PELVIS 1/2 VEIW $163.00

RADEX PELVIS COMPL MIN 3 $141.00CTA PELVIS C-/C+ POST-PXE $2,985.00CT PELVIS WO CONTRAST $996.00TOMOGRAPHY PELVIS WCONTRS $1,824.00CT PELVIS W OR WO CONTRST $2,213.00SACROILIAC JOINTS 3+VIEWS $292.00XRAY COCCYX/SACRUM $243.00XRAY CLAVICLE 2 VIEWS $172.00SCAPULA COMPLETE $187.00RADEX SHO 1 VIEW $83.00SHOULDR COMPLETE 2 VIEWS $175.00XRAY AC JOINTS-BILAT $128.00XRAY HUMERUS MIN 2 VIEWS $169.00XRAY ELBOW 2 VIEWS $169.00XRAY ELBOW GREATER THAN 3 VIEWS-COMP $208.00XRAY FOREARM AP & LAT $163.00XRAY UPPER EXT,INFANT,2 V $99.00XRAY WRIST AP & LAT VIEW $103.00XRAY WRIST/COMP MIN 3 VIE $243.00XRAY HAND AP & LAT $160.00XRAY HAND MIN 3 VIEWS $202.00XRAY FINGER MIN 2 VIEWS $219.00CT UPPR EXTR WO CNTRS $1,293.00CT UXTR C+MATRL $1,248.00CT UXTR C-/C+ $1,593.00XRAY HIP UNILATERAL W PELVIS 2-3 VIEWS $353.00XRAY HIP MIN 2 VIEWS $330.00HIPS BILAT MIN 2 VIEW INC $139.00XRAY FEMUR AP & LAT VIEW $160.00FEMUR, 2 VIEWS MIN $310.00XRAY KNEE, SUNRISE VIEW $178.00XRAY KNEE MIN 3 VIEWS $229.00RAD EXAM KNEE 4 OR MORE $263.00XRAY TIBIA/FIBULA AP/LAT $157.00RAD EXAM L/E INFANT $101.00XRAY ANKLE 2 VIEWS $169.00XRAY ANKLE 3 VIEWS/COMPLE $208.00XRAY FOOT MIN 2 VIEWS $163.00XRAY FOOT MIN 3 VIEWS $193.00RAD EXAN HEEL MIN 2 VIEWS $169.00XRAY TOES, MIN 2 VIEWS $199.00CT LWR EXTR WO CONTRAST $1,293.00CT LWR EXT W CONT $1,834.00CT LXTR C-/C+ $1,597.00CT ANGIO, LOW EX W CONTRAST MAT, INC NONCON IM, IMAGE POSTPROC $3,551.02

RAD EXAM ABD SINGL ANTER $129.00RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS $527.00RADIOLOGICAL EXAM, ABDOMEN 1 VIEW $157.00RAD EXAM ABDOMEN 2 VIEWS $187.00RAD EXAM ABDOMEN COMPL $229.00RAD EXAM COMPLETE ABD $278.00COMPUTED TOMOGRAPHY ABD $974.00TOMOGRAPHY ABD W/CONTRAST $1,816.00TOMOGRAPHY ABD W/OCONTRAS $2,135.00CT ANGIO ABD PELVIS W CONTRAST MAT AND IMAGE POSTPROC $2,990.00CT ANGIO ABDOMEN W/CONTRA $2,985.00COMP TOMOG AB/PEL W/O CON $1,329.00COMP TOMO AB/PELV W/OCONT $2,400.00CT ABD & PELVIS 1 PLUS SECTION/REGNS $2,849.00PRITONEOGRAM RS&I $310.00UROGRPY NFS DRIP TQ&BOLUS $393.00CT CORONARY $2,625.00NOSE TO RECTUM FB CHILD $99.003D RNDR I&R CT MRI US/OTH $404.00ULTRASOUND, SOFT TISSUES OF HEAD AND NECK $776.00US EXAM, BREASTS $589.00US ABDOMINAL R-T W/IMAGE $832.00US ABDOMINAL $656.00US RETROPERITONEAL R-T W/ $794.00ULTRASOUND, RETROPERITONEAL, REAL TIME WITH IMAGE DOCUMENTATION $301.00ULTRASOUND, PREGNANT UTERUS, REAL TIME, FETAL AND MATERNAL EVALUATION $685.00ULTRASOUND, PREGNANT UTERUS, REAL TIME, FETAL AND MATERNAL EVALUTION 1ST TRI $615.00US PG UTER F&MAT AFTER 1S $800.00ULTRASND PG UTER $481.00ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL $636.00TRANSVAGINAL ULTRASOUND $758.00US PELVIC NONOB REAL-TIME $744.00ULTRASOUND OF PELVIS $287.00US SCROTUM&CNTS $346.00US EXTREMITY $450.00US XTR NON-VASC LMTD $619.00SHORTNESS OF BREATH PANEL $2,067.00PULMONARY FUNCTION STUDY $1,251.00CEREBSP FLU FLO IMG X INT $1,106.00METABOLIC PANEL BASIC $93.00GENERAL HEALTH PANEL $315.00ELECTROLYTE PANEL $34.00METABOLIC COMPRE PANEL $116.00LIPID PROFILE III $58.00HEPATITIS PANEL $237.00

HEPATIC FUNCTION PANEL $90.00DRUG ABUSE PANEL II $78.00DRUG SCREEN-EMERGENCY $72.00DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES $78.00CARBAMAZEPINE; TOTAL $160.00CYCLOSPORINE $60.00DESIPRAMINE LEVEL $76.00DIGOXIN $147.00DEPAKOTE LEVEL (VAL ACID) $149.00DOXEPIN (SINEQUAN LEVEL) $81.00IMIPRAMINE (TOFRONIL) $76.00LITHIUM $72.00NORTRIPTYLINE LEVEL $71.00PHENOBARBITAL $60.00DILANTIN $147.00QUINIDINE $60.00SALICYLATE $38.00THEOPHYLLINE $74.00VANCOMYCIN PEAK $149.00CLOMIPRAMINE $71.00DRUG SCREEN $78.00DRUG SCREEN $183.00DRUG SCREENING $181.00DRUG SCREEN $162.00DRUG SCREEN $183.00U/A DIPSTICK $14.00U/A DIP STICK $14.00URNLS DIP STICK/TABLET RG $14.00U/A W/O MICRO DIPSTICK $24.00U/A QUAL-SEMIQUAL $11.00PREG.TST URINE VISUAL $89.00VOLUME MEAS. COLLECTION $10.00ACETAMINOPHEN $106.00KETONES-SERUM $21.00ACETONE/OTH KETONE BODIES $81.00ALBUMIN; SERUM $22.00URINE MICROALBUMEN $33.00ALCOHOL-BLOOD $49.00ALCOHOL BREATH TEST $57.00ALDOLASE $52.00ALPHA-1-ANTITRYPSIN;TOTAL $71.00ALPHA FETA PROTEIN $60.00ALUMINUN $134.00AMINO ACIDS, URINE-QUAL $72.00AMINO ACIDS, SERUM-SINGLE $90.00

AMYLASE $71.00ANGIOTENSIN CONVERT (ACE) $78.00BETA-2 MICROGLOBULIN $86.00BILIRUBIN TOTAL $27.00BILIRUBIN DIR $55.00OCCULT BLOOD $18.00BLD OCLT PEROXIDASE ACTV $18.00BLD OCLT FECAL HGB DETER $84.00VITAMIN D-25OH $300.00CALCIUM $28.00CALCIUM IONIZED $71.00STONE ANALYSIS CHEM $67.00C02 CARBON DIOXIDE $27.00CEA $101.00CERULOPLASMIN $57.00CHEMILUMINESCENT ASSAY $155.00CHLORIDE $24.00CHOLESTEROL $23.00CHOLINESTERASE; SERUM $42.00RBC CHOLINESTERASE $42.00PORPHYRINS, PLASMA $199.00CORTISOL, SERUM $180.00CREATINE $24.00CREATINE CK-TOTAL $71.00CREATINE CKMB $67.00CREATININE $28.00CREATININE OTH SRC $28.00CREATININE CLEARANCE $50.00VITAMIN B-12 $60.00DHEA $134.00ESTRADOIL LEVEL $308.00STRGNS FXJATED $169.00ESTROGEN LEVEL TOTAL $114.00ESTRIOL $128.00ETHCHLORVYNOL $72.00FERRITIN $150.00FOLATES $60.00RBC FOLATS $91.00IGC IMMUNOGLOBULIN $49.00GASES BLD PH ONLY $149.00GASES BLD PH CALCULATED 0 $213.00BLOOD GASES WITH O2 SATURATION $313.00GASES BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY $166.00GLUC BDY FLU OTH/THN BLD $44.00GLUCOSE $44.00

GLUCOSE BLOOD REAGET STR $10.00GLUCOSE FINGER STICK $10.00GLUTAMYLTRANSFERASE-GTT $80.00FSH $205.00GONADOTROPIN-LH $204.00HEAVY METAL SCREENING $98.00HEMOGLOBIN A1C $41.00HOMOCYSTINE $90.00IMMUNOASSAY ANALYTE QUAL $61.00IRON-TOTAL $71.00IRON BINDING CAPACITY $96.00ASSAY OF LACTIC ACID $74.00LDH $66.00LACTOFERRIN FECAL QUAL $103.00LEAD BLOOD LEVEL $64.00LIPASE $38.00HDL CHOLESTEROL $33.00LIPOPROTEIN DIR MEAS VLDL $61.00LIPOPROTEIN DIR MEAS LDL $105.00MAGNESIUM $36.0024 HR URINE METANEPHRINES $31.00MUCIN SYNOVIAL FLUID $22.00MYOGLOBIN $143.00B-TYPE NATRIURETIC $373.00MOLECULAR DIAGNOSITIC $22.00SEPARATION BY GEL ELETRO $22.00PARATHORMONE(PARATHYRIOD) $216.00ASSAY PHENYLKETONES $65.00ALK PHOS/PROFILE OR PANEL $28.00PHOSPHORUS INORGANIC $52.00PORPHYRINS, URINE-QUAL $31.00POTASSIUM $60.00PROGESTERONE $231.00PROLACTIN $102.00PROSTATIC SPEC ANTIGE/PSA $203.00PSA SCREEN TOTAL $98.00PROTEIN,TOTAL,EXCEPT REFR $15.00PROTEIN TOTAL $55.00PROTEIN, TOTAL, EXCEPT REFRACTOMETRY $41.00PROTEIN EPHORESIS/URINE/CFS $109.00SODIUM; SERUM $67.00TSTOSTERONE FR $134.00TESTOSTERONE; TOTAL $285.00THIAMINE VIT B-1 $112.00THYRIXINE TOTAL $38.00

THYROXINE-FREE $47.00TSH $86.00AST $56.00ALT-TRANSFERASE;ALANINE $30.00TRANSFERRIN $64.00TRIGLYCERIDES $31.00THYROID HORMONE $71.00T3 TOTAL $74.00T3 FREE $187.00TROPONIN I $108.00BUN $22.00URIC ACID $24.00C-PEPTIDE $109.00HCG QUANTATIVE $79.00PREGNANCY TEST BLOOD $41.00UNLIS CHEMISTRY $144.00WBC COUNT DIFF-MANUAL $11.00WBC W/DIFF $42.00HEMATOCRIT $10.00HEMOGLOBIN $26.00CBC $86.00CBC W/O DIFF $35.00BLD# MNL C-CNT RBC/PLTLT EA $188.00RETICULOCYTE COUNT $21.00BLD # RETICULOCYTE AUTO $45.00BLOOD COUNT PLATELET AUT $19.00CLOTTING FACTOR VIII $60.00CLOTTING FACTOR IX $60.00ANTITHROMBIN III $63.00COAGJ TM OTH METHS $12.00FIBRIN DEGRADATION PROD $39.00D-DIMER $103.00FIBRIN DGRADJ PRODUXS D-D $39.00FIBRINOGEN ACTIVITY $45.00PROTHROMBIN TIME $44.00SEDIMENTATION RATE NONAUT $19.00SED RATE ERYTHROCYTE NON $14.00THROMBOPLASTIN TIME PART $66.00AGGLUTININ FEBRILE-BRUCEL $19.00IGE $27.00ANTINUCLEAR AB $46.00ANTINUCLEAR AB TITER $58.00ASO TITER $39.00C REACTIVE PROTEIN $28.00C-REACTIVE PROTEIN HI SEN $68.00

CARDIOLIPIN AB $112.00COLD AGGLUTININ SCREEN $36.00COLD AGGLUTININ TITER $44.00GROWTH HORMONE AB $83.00MONO,HETEROPHILE ANTIBODI $56.00HETEROPHILE $35.00CA 125 $109.00IMMUNOASSAY INFECTION AGENT $119.00IMMUNOELECTROPHORESIS WITH CONCENTRATION $57.00ANTITHYROID PEROXIDASE AB $160.00MONO SPOT $112.00RHEUMATOID FACTOR $62.00RHEUMATOID FACTOR QUANTIT $21.00SKN TST COCCIDIOIDOMYCOSI $23.00SKN TST HISTOPLASMOSIS $23.00TB INTRADERMAL $63.00RPR $15.00EHRLICHIA AB $68.00BARTONELLA ANTIBODY $27.00LYME DISEASE-EARLY IGG $170.00LYME DISEASE IGC AB $188.00ANTB CHLAMYDIA $134.00ANTB COCCIDIOIDES $27.00CMV $76.00ANITBODY, ENTEROVIRUS $92.00EPSTEIN-BARR VIRUS EA $68.00EPSTEIN-BARR VIRUS EBNA $168.00GIARDIA LAMBLIA $162.00HELICOBACTOR CULTURE $76.00HERPES SIMPLEX, SERUM $76.00ANTB HERPES SMPLX TYP 1 $146.00ANTB HERPES SMPLX TYP 2 $213.00HIV SERUM $98.00ANTB HIV-1&HIV-2 1 ASSAY $53.00HEPATITIS B CORE-AB $134.00HEPATITIS B CORE IGM $131.00HEPATITIS B SURFACE-AB $57.00HEPATITIS A-AB $137.00HEPATITIS A AB-IGM $124.00INFLUENZA VIRUS ANITBODY $71.00LEGIONELLA PNEUMONPILA AB $76.00MUMPS ANTIBODY $94.00PARVOVIRUS $79.00ANTB RSV $68.00ROTAVIRUS $69.00

RUBELLA $76.00ANTB RUBEOLA $68.00TOXOPLASMA ANTIBODY $76.00TOXOPLASMA IGM ANTIBODY $141.00VARICELLA $90.00WEST NILE, IGM $90.00ANTIBODY, WEST NILE VIRUS $51.00THYROGLOBULIN ANTIBODY $175.00HEPATITIS C-AB $157.00HEP C ANTB CONFIRMATORY T $81.00HLA B27 $120.00BLOOD TYPING $34.00RH FACTOR-BLOOD $34.00BLD TYPING RH PHEXYPING COMPL $88.00BLOOD CULTURE $114.00CULTURE FECES $104.00CUL BACT STL AERC ADDL PA $104.00CULTURE BODY FLUID $21.00CUL BACT QUAN ANAERC ISOL $21.00CULTURE ANAEROBIC $50.00CUL BACT ANAERC ADDL METH $89.00CUL BACT AERC ADDL METHS $50.00CULTURE, BACTERIAL-SCREEN $21.00URINE CULTURE $89.00CULTURE BCT ISOL&PRSMPTV $89.00CULTURE FUNGUS OTHER $23.00CULTURE FUNGUS BLOOD $47.00CHLAMYDIA CULTURE $103.00CUL TUBERCLE/OTH ACID-FAS $63.00CULTURE AFB W/CONCENTRATI $250.00OVA & PARASITES SMEAR $120.00SUSCEPTIBILTY STUDY MICRO $95.00SMEAR GRAM STAIN $48.00CRYPTOSPORIDIUM $23.00SMR PRIM SRC SPEC STAIN $46.00SMR PRIM SRC CPLX SPEC ST $198.00WET SMEAR $23.00TISS KOH SLIDE SAMPS SKN/ $48.00C-DIFFICLE TOXIN $218.00CULTURE HERPES $150.00VIRUS ID NON-IMMUNOLOGIC $373.00IA ADI BORDETELLA PRTUSSI $133.00IAADI HERPES SMPLX VIRUS $133.00IAADI INF B VIRUS $63.00IAADI INF VIRUS $63.00

IAADI RSV $133.00INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE $182.00INFECTIOUS AGENT DETECTIO $63.00GIARDIA $133.00IAAD EIA HPYLORI $63.00HEPATITIS B SURFACE AG $55.00INFLUENZA A&B $63.00RESPIRATORY SYNCYIAL VIRU $63.00ROTAVIRUS AG EIA $68.00INF AGT IMMUNO STREP A $133.00IAAD EIA NOS EA ORGANISM $50.00INF AGENT DET NUCLEIC ACID, CANDIDA, DIR PROBE $262.00IADNA CHLABYDIA TRACHOMAT $106.00IADNA CHLAMYDIA TRACHOMAT $387.00INF AGENT DET NUCLEIC ACID, GASTRO PATH, INC MULTI REV TRANS, AMP PROBE 6-11 $268.00LADNA DNA MA PROBE TQ 12-25 GI PANEL $2,634.00INF AGENT DET NUCLEIC ACID, DNA RNA, GARDERELLA VAGINALIS, DIR PROBE $58.00HEPATITIS C PCR $224.00INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA) $387.00HERPES SIMPLEX VIRUS QUAN $313.00IADNA NEISSERIA GONORRHOE $221.00IADNA NEISSERIA GONORRHOE $387.00HPB LAB $184.00INF AGENT DET BY NUCLEIC ACID, TRICHOMONAS VAGINALIS $202.00INF AGENT DET NUC ACID, DNA RNA, TRICH VAG AMP PROBE $243.00O&P SMEAR W/AMPLIFIC $387.00INFECTIOUS AGENT DETECTION BY NUCLEIC ACID $185.00INF AGNENT DET $443.00INFLUENZA IMMUNOASSAY OPT $133.00INF AGT DET IMNAS OPT RSV $133.00IAADIADOO TRICH VAGINALIS $63.00CHALAMYDIA TRACHOMATIS DE $63.00NEISSERIA GONORRHOEAE DET $133.00RAPID STREP-BETA STREP $133.00INFECTIOUS AGEN DETECTION BY NUCLEIC ACID, DIRECT PROBE TECHNIQUE $185.00CYTOPATOLOGY CERVICAL/VAG $56.00CYTP SLIDES C/V MNL SCR&R $56.00PATH LEVEL 1 $84.00PATH LEVEL III $218.00PATH SURG LEVEL IV $366.00STAIN TRICHOME $258.00FLUID CELL COUNT $52.00CELL COUNT MISC BODY FLUI $60.00WBC ASSMT FECAL QUAL/SEMI $48.00CRYSTAL INDENTIFICATION $27.00

IMMUNE ADMIN H1N1 IM/NASA $81.00IMMUN ADM 1 VAC $205.00IMADM PRQ ID SUBQ/IM NJXS $102.00INFLUENZA VIRUS VACC SPLI $114.00INFLUENZA VIRUS VACC SPLI $36.00INFLUENZA VACCINE $36.00TETANUS DTAP 1CC $149.00TETANUS TOXID $69.00TETANUS DIPHTHERIA TOXOID $86.00TDAP 7YRS OR OLDER FOR INTRAMUSCULAR USE $168.11TETANUS & DIPTHERIA $86.00PNEUMONIA VAC ADULT $94.00IV NFS HYDRATION 1ST HR $282.00IV INFUS HYDRA EACH ADD H $91.00IV NFS THER PROPH/DX 1ST $345.00IV INF EACH ADD HR $115.00INTRV. INF UP TO 1 HR $282.00INTRAV. INF CONCURRENT $110.00IV PUSH 1ST $308.00IV PUSH EACH SQUL $64.00ADMIN INJECTION INTRAVEN $32.00INTRAMUSCULAR INJ $45.00GASTRIC INTUBATION/ASPER $287.00OPH MEDICAL XM&EVAL INTRM $255.00VIS FLD XM UNI/BI I&R LMT $182.00AUDIO SCREENING $39.00PURE TONE AUDIOMTRY AIR O $79.00CPR $1,533.00EKG W/INTREP AND REPORT $86.00EKG $66.00RTN ECG 12 LEADS INTRP/RP $41.00RHYTHM ECG 1-3 LDS W/I&R $58.00RHYTHEM ECG 1-3 LDS $21.00RHYTHM ECG 1-3 LDS I&R ON $31.00DUP-SCAN XTRC ART COMPL B $666.00N-INVAS PHYSIOLOGIC STD $419.00DUP SCAN LOW EXTREMETY ART/ART BYP GRAFTS, UNI/LIM STUDY $1,156.00QUANT VENOUS FLOW ST $426.00DUP-SCAN XTR VEINS COMPL $683.00DPLX SCN EXTRM VEINS $750.00DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD, PELVIC, SCROTAL $572.00DUPLEX SCAN OF ARTERIAL INFLW/VENOUS OUTFLOW OF ABDML, PLVC, SCRTL CONTENTS $376.00SPIROMETRY W/RECORD $118.00BRNCDILAT RSPSE SPMTRY PR $449.00VC TOT SPX $83.00

PULMANARY FUNCTION SCREEN $137.00RESPIR FLO VOL LOOP $310.00NEBULIZER TREATMENT $60.00CONTINUOUS INHALATION TREATMENT, FIRST HOUR $206.00CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTR $102.00DEMO&/EVAL OF PT UTILIZ $52.00PULM COMPLIANCE STD $254.00EAR OR PULSE OXIMETRY $27.00N-INVAS EAR/PLS OXIMTRY F $43.00ALLERGY INJ SRVC; SINGLE $36.00ALLERGY INJ SRVC; 2 OR MO $44.00IV INFUS INIT 31 MIN 1 HR $307.00IV INFUS HYDR EA ADD'T HR $122.00IV INFUSION THERAPY/PROPH $561.00IV INFUS THER PROPH/DX EA $151.00IV NFS THER PROPH/DX ADDL $137.00IV NFS TX PROPHYLAXIS/DX $144.00SUB INFUS EA ADD HR $55.00THERAPEUTIC PROPHYLACTIC/ $205.00THER PROPH/DX NJX IV PUSH $458.00THER PROPH/DX NJX EA SEQL $181.00SUB INFU EA ADD IV PUSH $71.00THER PX 1+ AREAS EA 15 MI $84.00RMVL DEVITAL TISS SLCTV D $223.00RMVL DEVITAL TISS SLCTV $275.00INITIAL DIETICIAN ASSESS $106.00OSTEOPATHIC MAN TX 1-2 BD $103.00SPECIMEN HANDLING $30.00COC COLLECITON ONLY $30.00BLUE CROSS RQRD LVL3 $47.00SCV PRV OV REG SCHED EVN $30.00SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY $184.00BLUE CROSS RQRD LVL5 $86.00SUPPLIES AND MATERIALS $215.00MEDICAL RECORDS $44.00MOD SEDATION <5YRS 30 $644.00MOD SEDATION SERV UNDER 5 $644.00M-SEDAJ BY SM PHY 15 MIN $357.00MOD SEDATION PHY LESS THAN 5 YRS $644.00MOD SEDATION $138.00M-SEDAJ PHY OTH/THIN HC P $52.00MOD SEDATION $389.00SCREENING TEST OF VISION $18.00NEW PATIENT VISIT LEVEL 1 $171.00NEW PT LEVEL 2 $245.00

NEW PT LEVEL 3 $353.00NEW PT LEVEL 4 $548.00NEW PT LEVEL 5 $690.00EST OFFICE VISIT LEVEL 1 $171.00EST OFFICE VISIT LEVEL 2 $171.00EST OFFICE VISIT LEVEL 3 $239.00EST OFFICE VISIT LEVEL 4 $355.00EST OFFICE VISIT LEVEL 5 $480.00OBS CARE DSCHRG D MGMT $247.00OV CONSULT 15 MIN $175.00CONSULT NEW/EST PT-EXPAND $333.00CONSULT NEW/EST PT-DETAIL $452.00OV CONSLTJ 60 MIN $669.00OV CONSLTJ 80 MIN $819.00PROLNG PHYS SVC OV O/P DI $339.00PROLNG PHYS SVC OV O/P DI $339.00PREV. MED NEW UNDER 1 YR $327.00PREV MED NEW 1-4 YRS $358.00PREV. MED NEW 5-11 YRS $357.00PREV. MED NEW 12-17 $388.00PREV. MED NEW 18-39 $388.00PREV. MED NEW 40-60 YRS $453.00PREV. MED NEW 65 YRS & UP $499.00PREV MED EST UNDER 1 YR $275.00PREV MED EXT AGE 1-4 $308.00PREV. MED EST AGE 5-11 $307.00PREV. MED EST AGE 12-17 $339.00PREV. MED EST AGE 18-39 $340.00PREV. MED EST AGE 40-64 $370.00PREV. MED EST AGE 65 & UP $418.00SMOKING CESSATION 3-10 $49.00SMOKING CESSATION 10 MIN $93.00ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES, ESOPHAGEAL INTUBATION $21.001 CC STERILE NEEDLE AND SYRINGE $27.00SYRINGE WITH NEEDLE, STERILE 5CC OR GREATER, EACH $11.0020G HUBERNEEDLE $15.00SYRINGE, STERILE, 20 CC OR GREATER, EACH $15.00NEEDLE, STERILE, ANY SIZE $32.001 CC SYRINGE INSULIN W/NEEDLE WITH LIDOCAINE FOR NUMBING $6.00STERILE SALINE WATER PER 500 ML $11.00CHLORHEXIDINE CONTAINING ANTISEPTIC, 1 ML $27.00INSRT TRAY W/DRAINAGE BAG $36.00CATH W DRAINAGE 3 WAY $71.00IRR TRAY W/BULB/PISTON SY $9.00IRRIGATION SYRINGE, BULB $6.00

INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING $57.00INDWELLING CATH FOLEY TYP $67.00INTERMIT URIN CATH STRAIG $4.00URINARY CATHETER $27.30INTERMIT URINARY CATHETER $22.00URINARY DRAINAGE BAG $14.00DERMABOND- ADHESIVE, LIQUID OR EQUAL PER OZ $39.00OST POUCH DRNABLE W/EXT B $2.00TAPE, NON-WATERPROOF, PER 18 SQ INCH $10.00SURGICAL TRAY $71.00SLING $27.00SPLINT $71.00SPECIAL CASTING MATERIAL $104.00CANNULA NASAL $2.00OXYGEN TUBING PER FOOT $10.00MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT $11.00VARIABLE CONCENT MASK $4.90SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR METERED DOSE INHALER $38.00SURGICAL SUPPLY MISC $22.00GLOVES NON STERILE $1.00GLOVES STERILE PER PAIR $7.00COMPOSITE DRESSING, STERILE, 16 SQUARE INCHES OR LESS $12.00COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ INCHES $10.00GAUZE NONIMPREG 16 SQ IN $4.00GAUZE, NON STERILE $16.00STERILE GAUZE LESS THAN OR = 16 INCH WITH SQUARE BORDER $12.00GAUZE IMPREGNATED WITH ME $3.00GAUZE IMPREG NOT H20 SALI $7.00SKIN SEAL PROTECT MOISTURIZER OINTMENT $30.00WOUND CLEANSER $32.00GAUZE $6.00GAUZE NON-IMPREG STERL 16 $3.00PACK STRIPS NON-IMPREGNTD $3.00ADHESIVE BANDAGE FIRST AI $7.00LT COMP BANDAGE LESS THAN 3IN $9.00LIGHT COMP BANDAGE $9.00LT COMPRS BANDAGE ELAST $26.00SELF-ADHER BAND W LESS THAN 3 YD $6.00SELF ADHER BANDAGE $14.00TUBULAR DRESSING $7.00CANNISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH $15.00TUBING, USED WITH SUCTION PUMP, EACH $15.00ADMN SET SM VOL NONFILTER $7.00DOME/MOUTHPEICE NEB $138.00ONE WAY CHEST DRAIN VALVE $21.00

WATER SEAL DRAINAGE CONTAINER AND TUBING FOR USE WITH IMPLANTED CHEST TUBE $15.00NON PERSCRIPTION DRUG $22.00HOT/COLD H2OBOT/CAP/COL/WRAP $41.00URINE STRAINER $12.00NASOGASTRIC TUBING WITH STYLET $27.00NASOGASTRIC TUBING $27.00CATHETER, BALLOON DILATION, NONVASCULAR $52.00CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE $52.00PALLIATIVE TX OF DENTAL $207.00CRUTCHES UNDERARM $101.00CRTCH UNDARM NOT WOOD ADJ $44.00SPRIOMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES $23.00NEBULIZER W/COMPRESSOR HE $30.00DYN KNEE EXT/FLEX DEVC W/ $90.00FEE FOR SERVICE BALANCE OF 1063 $1,216.00FEE FOR SERVICE BALANCE OF 1688 $1,931.00INFLUENZA INJECTION $44.00ADM PNEUMOCOCCAL VACCINE $90.00ADMIN HEPATITIS B INJ $35.00CERV/VAGINAL CANCER SCR $98.00PROS CANCER SCREENING; DI $23.00COLOREC CANCR SCR; COLONS $148.00COLOREC CANCR SCR; ALT $125.00GLAUC SCR HI RISK BY OPT $127.00COLOREC CANCR SCR $316.00COLOREC CANCR SCR; COLNSC $519.00SCR CYTOPATH CERV/VAG THI $64.00SEXA BN DNSITY STDY 1/GREATER THAN SI $28.00SCR CYTOPATH SMERS CERV/V $171.00WND CLS TISSUE ADHESIVE $204.00PHYS CERT MCR-COVR HOM HL $147.00SCR MAMMO PRODUCING DIR D $327.00DX MAMMO PRODUCING DIR DI $370.00DX MAMMO PRODUCING DIR DI $297.00INITIAL PHYS E&M DIABETIC $171.00REMV IMP CERUMEN PHYS SAM $116.00RENAL ANGIOGRAPHY NONSELE $35.00PERQ ISLET CELL TPLNT INC $914.00BN MARROW ASPIR PRFRM W/B $24.00VESSEL MAPPING OF VESSELS $33.00LEVEL 1 HOSP EMERG DEPT V $71.00LEVEL 2 HOSP EMERGENCY DE $144.00LEVEL 3 HOSP EMERGENCY VI $250.00LEVEL 4 HOSP EMERG DEPT V $321.00LEVEL 5 HOSP EMERG DEPT V $464.00

US B-SCAN &/OR REAL TIME $283.00DRUG ABUSE PANEL II $78.00INFLUENZA A H1N1 IMM ADM $64.00INJ ACETAMINOPHEN, 10MG $2.00ADENOSINE INJ 6MG VIAL $179.00EPINEPHRINE 3 1/2 NDL 10M $114.00INJECTION, ADRENALINE, EPINEPHRINE, 0.1 MG $27.00INJ AMIODARONE HYDROCHLOR $86.00AMPICILLING SODIUM IM OR IV, 500MG $42.00INJ AMPCLLN SODIUM/SULBA $12.00SUCCINYLCHOLINE CHLO 20MG $30.00HYDRALAZINE HCL INJ UP TO 20MG $207.00INJ AZITHROMYCIN 500MG $98.00ATROPINE 1.2MG PED SYRUP $20.00INJ ATROPINE SULFATE 0.01 $20.00DICYCLOMINE HCL 20MG $20.00BICILLIN 600,000 $107.00INJECTION PENICILLIN G BENZATHINE 100,000 UNITS $19.00BICILLIN 1,200,000 $171.00INJ CALCIUM GLUCONATE PER $107.00KEFZOL 1 GR VIAL $57.00ROCEPHIN 250 MG $55.00CLAFORAN 1 GR VIAL $44.00INJ BETAMETHASONE ACETATE $18.00CLONIDINE 1MG $130.00CIPRO 200MG $64.00COMPAZINE 10 MG $7.00INJ METHYLPREDNISOLONE AC $22.00DEPO MEDROL 40 MG/ML $44.00METHYLPREDNISOLONE 80MG $38.00INJ TESTOSTERONE TO 100MG $30.00DECADRON DEXAMETHASONE ACETATE 1MG $28.00DECADRON 4 MG VIAL $10.00DILAUDID 4 MG $127.00BENADRYL 50MG $30.00INJ DOPAMINE HCL 40 MG $44.00GARAMYCIN,GENTAMICIN 80MG $22.00HALOPERIDOL 5MG $60.00INJ HALOPERIDOL DECANOATE PER 50MG $72.66HEPARIN SODIUM PER 10 UNI $10.00INJ HEPARIN SOD PER 1000 $36.00ENOXAPARIN SODIUM 10MG $44.00TETANUS INJECTION $64.00SOLU-CORTEF, A-HYDROCORT $7.00INJ INSULIN PER 5 UNITS $36.00

TORADOL INJ 15 MG $36.00LASIX 40 MG IV VIAL $30.00INJECTION, LEVETIRACETAM, 10MG $40.00LEVOFLOXACIN 250 MG $107.00INJ HYOSCYAMINE SULFATE $71.00LIDOCAINE HCI 10MG $30.00ATIVAN 2ML SYRUP $30.00DEMEROL 50 MG SYRINGE $107.00MEPERIDINE/PROMETHA UP50M $4.00INJ MEROPENEM 100 MG $109.17MIDAZOLAM HCI PER 1 MG $14.00INJ MORPHINE SULFATE 10 M $107.00NUBAIN 10MG AMP $57.23INJ NALOXONE HCL 1MG $18.00ORPHENADRINE CITRATE 60MG $30.00ONDANSETRON HCI, PER MG $42.00PIPERACILLIN SODIUM (ZOSYN) 1 GRAM $18.00PENTAMIDINE ISETHIONATE INHALATION SOLUTION 300MG $47.00PHENERGAN 50 MG $57.00PRONESTYL 10 ML $3.00INJ PROPOFOL 10MG $25.00METOCLOPRAMIDE HCL 10MG $36.00INJ RANITIDINE 25 MG $30.00SOLU-MEDROL 40MG $6.00SOLU-MEDROL 125 MG $71.00INJ FENTANYL CITRATE .1MG $114.00IMITREX 6MG VIAL $201.00INJECTION, TREBUTALINE SULFATE, UP TO 1 MG $42.00TRIMETHOBENZAMIDE 200MG $13.00KENOLOG 10 MG $4.00VALIUM INJ 5 MG $36.00VANCOMYCIN HCI INJ 500MG $35.00VISTERIL INJ 50 MG $1.00INJ THIAMINE 100 MG $71.00MAGNESIUM SULFATE 2CC AMP $30.00POTASSIUM CHLORIDE 2 MG $3.00UNCLASSIFIED DRUGS $36.00INFUS NORM SALINE 1000CC $50.00INFUS NORM SALINE 500ML $34.005% DEXTROSE $57.00INFS NORM SALINE 250CC $33.00INFUSION D5W 250ML $57.00RINGER'S LACTATE INFUS $30.00PREDNISONE ORAL 5 MG $3.00PREDNISOLONE ORAL 5 MG $4.00

PREDNISONE 5 MG $3.00ALBUTEROL I SOL 1 MG ALBU $36.00ABUTERAL INHALATION 1MG $18.00ALBUTEROL, THRU DME 1MG $36.00ALBUTEROL 1MG CONC INHALA $14.00LEVALBUTEROL CONCENTRATE $14.00ALBUT INHAL NON-CP 1MG $36.00ALBUTEROL ALL FOMULATIONS $36.00ALBUTEROL UP TO 5 MG $36.00ALBUTEROL 2.5 MG ATROVENT $6.00DEXMETHASONE, COMPOUNDED, UNIT DOSE 1 MG $9.00IPRATROPIUM BROMIDE INHAL $14.00NOC DRUGS INHAL SOL ADMIN $32.00NONCHEMOTHERAPEUTIC ORAL $7.00DEXAMETHASONE, ORAL .25MG $6.00CERVICAL FLEX NONADJ COLL $30.00KNEE IMMOBOLIZER $114.00SURGICAL BOOT/SHOE $36.00SO FIGURE EIGHT ABDUCTION $30.00COLLES SPLINT $52.00WRIST EXTN CONTROL COCKUP $36.00HFO W/O JOINTS CUSTOM FAB $30.00UP EXTREM FX ORTHOTIC HUM $593.00UPPER LIMB ORTHOSIS NOS $30.00WALK BOOT PNEUMATIC $269.00WALKING BOOT NON PNEUMATIC $148.00CARDIOKYMOGRAPHY $53.00SCREEN PAP SMEAR; OBTAIN $101.00WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENS $62.00AZITH DIHY ORAL CAP/POWD $153.00DIPHENHYDRAMINE HYDROCLOR $6.00ONDANESTRONG HCL 8MG ORL $30.00CAST SUPPLIES LONG ARM CA $144.00LONG ARM CAST ADULT $144.00CAST SUPPLIES LONG ARM CA $144.00CAST SUPPLIES LONG ARM $144.00CAST SUPPLIES SHORT ARM $144.00SHORT ARM CAST ADULT $144.00CAST SUPPLIES SHORT ARM $144.00CAST SUPPLIES SHORT ARM $144.00CAST SUPPLIES GAUNTLET C $71.00CAST SUPPLIES GAUNTLET CA $71.00CAST SUPPLIES LONG ARM SP $144.00LNG ARM SPLNT 11 YRS + $144.00CAST SUPPLIES LONG ARM SP $144.00

LNG ARM SPLNT 0-10 YRS $144.00SHRT ARM SPLNT 11 YRS + $96.00SHRT ARM SPLNT 0-10 YRS $50.00CAST SUPPLIES LONG LEG C $144.00CAST SUPPLIES LONG LEG CA $144.00CAST SUPPLIES, LONG LEG PEDIATRIC (0-10 YEARS) FIBERGLASS $208.00CAST SUPPLIES SHORT LEG $144.00SHORT LEG FIBERGLASS CAST $104.00CAST SUPPLIES SHORT LEG C $144.00CAST SUPPLIES SHORT LEG $112.00SHRT LG SPLNT 11 YRS + $93.00CAST SUPPLIES PED (0-10) $144.00FINGER SPLNT STATIC $36.00LW OSMOLAR CNTRT 300-349 $144.00ORAL MR CONTRAST, 100ML $498.00HI OSM CONTRST MATL 350-3 $6.00LOW OSMOLAR CON MAT PER M $6.00LOW OSMOLAR CNTRS MAT $6.00INJ, BUPIVICAINE, 30ML $30.00INJECT FAMOTIDINE 20 MG $86.00METRONIDAZOLE 500 MG INJ $71.00INJ SULFAMETHOXAZOLE&TRIM $30.00CLANDAMYCIN PHOSPHATE 300 $71.00ZOFRAN, 4MG, ORAL $41.00PROTONIX PANTROPRAZOLE 40MG $238.00ONDANESTRON HCA, ORAL 4MG $41.00RMV SUTURES; PHYS NOT PHY $144.00ADJ GASTRIC BAND DIAM SUB $572.00PRESCRIPTION DRUG GENERIC $3.00PRESCRIPTION BRAND NAME $5.005% DEXTROSE 1000 ML $4.00OXYGEN CONTENTS, GASEOUS, 1 UNIT EQUALS 1 CUBIC FOOT $32.00SPLINT $34.00SPLINT, WRIST OR ANKLE $64.00SERVICES PROV IN URGENT C $357.00SPORTS PHYSICAL $44.00VISN SPL ACSS&/SRVC CMPNT $36.00