America's ER Charge Master 20190408...105 27780 27780 CLTX PROX FIVULA/SHFT FX $ 1,037.78 106 27786 27786 CLSD TX DISTAL FIBULAR FX $ 1,077.58 107 27808 27808 CLOSED TX BIMALLEOLAR

c_id Charge# CPT Code Description Charge Amount1 10060 10060 INCISION/DRAINAGE ABSCESS 720.38$ 2 10061 10061 INS/DRAIN ABSCESS COMPL 787.04$ 3 10080 10080 I & D CYST SIMPLE 696.50$ 4 10081 10081 I&D PILONIDAL CST COMP 2,438.74$ 5 10120 10120 I & RMVL SUB-CUT SIMPLE 644.76$ 6 10121 10121 I & RMVL FB SUB-CUTCOMP 5,309.32$ 7 10160 10160 PUNCTURE ASP OF ABSCESS 849.73$ 8 11011 11011 DBRDMT W RMVL FM FX & DISLC SKN SUBQ T/M/F/ MUSC 2,867.59$ 9 11040 11040 DBRDMT SKIN PARTIAL THICK 260.00$

10 11042 11042 DBRD SKN SUBQ TISSUE 1,740.26$ 11 11200 11200 RMVL SKIN TAGS 384.07$ 12 11402 11402 EXC BGN LSN TRUNK 1.1-2.0 6,535.16$ 13 11404 11404 EXC BGN LSN TRUNK 3.1-4.0 5,159.08$ 14 11720 11720 DEBRIDEMENT NAIL ANY METH 232.83$ 15 11730 11730 AVULSION/1-NAIL PLATE 496.50$ 16 11740 11740 EVAC SUBUNGUAL HEMATOMA 387.06$ 17 11750 11750 EXC NAIL PART/COMP 1,440.76$ 18 11760 11760 REPAIR NAIL BED 1,205.94$ 19 11765 11765 WEDGE EXC SKIN/NAIL BED 442.78$ 20 11771 11771 EXCISION PILONIDAL CYST SINUS EXTENSIVE 11,036.50$ 21 12001 12001 LACERATION REPAIR 603.96$ 22 12002 12002 REPAIR LAC SCALP 2.6-7.5 611.92$ 23 12004 12004 REPAIR LAC SCALP 7.6-12.5 607.94$ 24 12005 12005 REPAIR LACSCALP 12.6-20C 1,037.78$ 25 12011 12011 REPAIR LAC FACE LESS THAN 2.5 CM 546.26$ 26 12013 12013 REPAIR LAC FACE 2.6-5.0CM 611.92$ 27 12014 12014 REPAIR LAC FACE 5.1-7.5CM 546.26$ 28 12015 12015 REPAIR LAC FACE 7.6-12.5 1,005.94$ 29 12020 12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE 1,358.18$ 30 12031 12031 LYR CLSR S/A/T/E 2.5CM 1,387.03$ 31 12032 12032 REPAIR-INT SCALP 2.6-7.5 2,212.88$ 32 12034 12034 INTERM RPR SCLP/TRNK/EXTR 1,605.93$ 33 12035 12035 REPAIR INTERM S/A/T/E 12. 1,800.95$ 34 12036 12036 REPAIR INTERM S/A/T/E 20.1-30.0 CM 2,462.62$ 35 12041 12041 LAYER CLSR NECK/HAND 2.6 1,032.81$ 36 12042 12042 REPAIR LAC HAND/FOOT 2.6- 1,300.46$ 37 12044 12044 LYR CLSR N/H/F/ETRNL GENT 1,672.60$ 38 12045 12045 REPAIR INTERMEDIATE N/H/F/XTRNAL GEN 12.6 -20 CM 1,295.49$ 39 12051 12051 LAYER CLSR OF WND NCK/HND 1,363.15$ 40 12052 12052 LYR CLSR WOUND 2.6-5.0FAC 546.26$ 41 12053 12053 LYR CLSR F/E/E/N/L/M&/MUC 1,343.25$ 42 12054 12054 REPAIR INTERMEDIATE F/E/E/N/L/M&MUC 7.6-12.5CM 960.18$ 43 13120 13120 RPR CPLX S/A/L 1.1 CM-2.5 1,943.24$ 44 13121 13121 RPR CMPX SCALP ARM2.6-7.5 1,864.63$ 45 13122 13122 CMPLX RPR ADD 5 CM OR LES 1,818.86$ 46 13131 13131 RPR CMPLX FOREHEAD1.1-2.5 1,737.27$ 47 13132 13132 RPR CMPX FOREHEAD/CHECK/C 2,415.86$ 48 13151 13151 CMPX RPR EYE NOSE 1.1-2.5 2,508.40$ 49 13152 13152 RPR CPLX E/N/E/L 2.6-7.5 2,502.42$ 50 13153 13153 REPAIR COMPLEX EYELID/NOSE/EAR/LIP EA 5 CM< 1,627.82$ 51 15850 15850 SUTURE RMVL W/ANESTHESIA 3,046.69$ 52 16000 16000 BURN INITIAL TREATMENT 541.28$ 53 16020 16020 BURN DRESSING/DBRDMNT-SM 616.90$ 54 20103 20103 EXPLORATION WOUND-EXTREM 3,104.40$ 55 20552 20552 TRIGGER POINT INJ 1-2 MUS 973.11$ 56 20600 20600 ARTHROCENTESIS SML JOINT 651.72$ 57 20610 20610 ARTHROCENTESIS LG JOINT 2,602.92$ 58 21310 21310 CLTX NSL B1 FX W/O MNPJ 646.75$ 59 21315 21315 CLOSED TX NASAL FRACT W/O 4,558.10$ 60 21480 21480 CLDS TX TEMP DISLOCATION 1,175.10$ 61 21800 21800 CLTX RIB FX UNCOMP EA 540.00$ 62 23500 23500 CLTX CLAVICULAR FX WO MNP 976.10$ 63 23570 23570 CLSD TX SCAPULAR FX WO MA 966.14$ 64 23600 23600 CLTX PROX HUMRL FX WO MAN 1,188.03$ 65 23605 23605 CLTX PROX HUMRL FX W/MANI 3,834.73$ 66 23650 23650 SHOULDER DISLOCATION TRMT 1,044.75$ 67 24500 24500 CLTX HUMRL SHFT FX W/O MN 1,360.16$ 68 24530 24530 CLTX SPRCNDYLR/TRANSCNDYL 1,268.62$ 69 24576 24576 CLTX HUMRL CNDLYR FX MEDI 1,022.86$ 70 24600 24600 CLSD TX ELBOW DISLOCAT 1,333.30$

America's ER Charge Master

71 24640 24640 RADIAL HEAD SUBLUX. CHILD 1,050.72$ 72 24650 24650 CLTX RDL HEAD FX WO MANP 966.14$ 73 24670 24670 CLTX ULNR FX PROX END WO 1,245.74$ 74 25500 25500 CLTX RDL SHFT FX WO MANP 1,145.24$ 75 25505 25505 CLSD TX RAD SHAFT W/MANIP 2,100.44$ 76 25530 25530 CLSD TX ULNAR SHFT FX NO 999.98$ 77 25560 25560 CLTX RDL&UR SHFT FXS W/O 1,088.53$ 78 25565 25565 CLOSED TX RADIAL&ULNAR SH 2,196.96$ 79 25600 25600 CLSD TX DISTAL RAD FX WO 1,047.74$ 80 25605 25605 CLSD TX DISTAL RAD FX 1,369.12$ 81 25622 25622 CLSD TX NAVICULAR FX WO M 1,335.29$ 82 25630 25630 CLTX CARPL B1 FX W/O MNPJ 1,161.16$ 83 25635 25635 CLTTX CARPL B1 FX W/MNPJ EA B1 1,612.90$ 84 25650 25650 CLTX UR SYLOID FX 1,022.86$ 85 26010 26010 I & D FINGER ABSCESSSIMP 897.49$ 86 26600 26600 CLSD TX METACARPAL FX 956.20$ 87 26605 26605 CLSD TX MEDICARPAL FX 991.02$ 88 26607 26607 CLTX MTCRPL FX W/MNP W/XT 4,169.05$ 89 26700 26700 CLS TX MCP DISLOCATION 1,079.58$ 90 26720 26720 CLSD TX PHALANGEAL SHFTFX 899.48$ 91 26725 26725 CLTX PHLNGL FX PROX/MIDDL 1,226.84$ 92 26750 26750 CLS TX FX FINGER/THUMB 885.55$ 93 26755 26755 CLTX DSTL PHLNGL FX FNGR/ 1,309.42$ 94 26770 26770 TREAT FINGER DISLOC FINGE 871.62$ 95 27220 27220 CLTX ACETABULUM HIP/SOCKT FX W/O MNP 1,234.80$ 96 27372 27372 REMOVAL FOREIGN BODY DEEP THIGH/KNEE 8,668.44$ 97 27508 27508 CLTX FEM FX DSTAL END MED 1,562.15$ 98 27520 27520 CLTX PATELLAR FX W/O MNPJ 1,150.22$ 99 27530 27530 CLTX TIBL FX PROX W/O MNPJ 1,116.39$

100 27550 27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA 1,469.62$ 101 27560 27560 CLTX PATELLAR DISLC W/O A 1,152.21$ 102 27752 27752 CLTX TIBL SFT FX W/MANP 5,144.15$ 103 27760 27760 CLTX MEDIAL MALLS FX W/O 960.18$

104 27762 27762CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION WITH OR WITHOU 5,218.00$

105 27780 27780 CLTX PROX FIVULA/SHFT FX 1,037.78$ 106 27786 27786 CLSD TX DISTAL FIBULAR FX 1,077.58$ 107 27808 27808 CLOSED TX BIMALLEOLAR ANK 1,185.04$ 108 27810 27810 CLTX BIMAL ANKLE FX W/POT 1,766.12$ 109 27818 27818 CLSD TX TRIMALLEOLAR FX W 1,932.29$ 110 27840 27840 CLOSED TX ANKLE DISLOCATI 1,445.74$ 111 28190 28190 RMVL FB BODY FOOT SUBQ 1,670.60$ 112 28192 28192 RMVL FB FOOT DEEP 7,071.46$ 113 28400 28400 CLSD TX CLAVICLE FX WO MA 1,197.98$ 114 28430 28430 CLTX TALUS FX W/O MNPJ 1,097.48$ 115 28450 28450 TX TARSAL B1 FX XCP TALUS 1,146.24$ 116 28470 28470 CLTX METAR FX WO MNP 975.10$ 117 28475 28475 CL TX METAR FX W/MNPJ 779.08$ 118 28490 28490 CLTX FX GRT TOE W/O MNLJ 826.84$ 119 28510 28510 CLSD TX FX PLALANX/PHALAN 815.90$ 120 28515 28515 FX CARE PHALANX NOT GREAT 838.78$ 121 28660 28660 CLSD TX PIP JNT DISLOCATI 936.30$ 122 29085 29085 CAST HAND/LOWER FOREARM GAUNTLET 612.92$ 123 29105 29105 LONG ARM SPLINT 576.10$ 124 29125 29125 SHORT ARM SPLINT 581.08$ 125 29126 29126 SHORT ARM SPLINT DYNAMIC 683.56$ 126 29130 29130 APPLICATION FINGER SPLINT 608.94$ 127 29240 29240 STRPG SHO 379.10$ 128 29280 29280 STRAPPING HAND/FINGER 411.93$ 129 29505 29505 LONG LEG SPLINT 647.74$ 130 29515 29515 SHORT LEG SPLINT 596.00$ 131 29540 29540 STRAPPING ANKLE/FOOT 380.09$ 132 29550 29550 STRAPPING TOES 533.32$ 133 29580 29580 STRAPPING UNNA BOOT 417.90$ 134 29700 29700 RMVL/BIVALV GAUNTLET BOOT 521.38$ 135 30300 30300 RMVL FOREIGN BODY NASAL 566.16$ 136 30901 30901 NASAL PACKING 593.02$ 137 30903 30903 CTRL NSL HEMRRG ANT CPLX 860.68$ 138 31500 31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE 576.10$ 139 31502 31502 TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT 668.64$ 140 31515 31515 LARYNGOSCOPY +- TRACHEOSCOPY ASPIRATION 4,715.30$ 141 32551 32551 TUBE THORACOSTOMY INCLUDES WATER SEAL 2,209.90$ 142 33415 33415 RESCJ/INC SUBVALVULAR TISSUE 1,246.00$ 143 36000 36000 INTRODUCTION OF NEEDLE/IN 110.44$ 144 36415 36415 VENIPUNCTURE 46.76$

145 36416 36416 COLL CAPILLARY BLG SPEC 58.70$ 146 36556 36556 INS NON TUN CTR CVC 5YR GREATER THAN 2,788.98$ 147 36558 36558 INSERT TUNNELED CV CATH - INSJ TUN CTR CVC W/O SUBQ POR 10,801.70$ 148 36591 36591 COLLECT BLOOD FROM IMPLAN 215.92$ 149 38300 38300 DRAINAGE LYMPH NODE ABSC/LYMPHADENITIS SMPL 7,240.62$ 150 40650 40650 RPR LIP FULL THICKNESS 3,229.77$ 151 41800 41800 DRNG ABSC DENTOALVEOLAR S 994.00$ 152 42700 42700 I&D ABSC PRITONSILLAR 1,019.88$ 153 43752 43752 NASO/ORO-GASTRIC TUBE PL 944.26$

154 43753 43753GASTRIC INTUBATION AND ASPIRATION THERAPUETIC NECESSATING PHYSICIANS SKILL 622.87$

155 46040 46040 I&D ISCHIOR/PRIRC ABSC SP 6,483.42$ 156 46083 46083 INCISION THROM HEMORRHOID 1,001.96$ 157 46320 46320 ENULEATION EXCC OF EXT HE 6,663.52$ 158 51700 51700 BLDR IRR SMPL LVG&/INSTLJ 797.00$ 159 51701 51701 INSR NONDWELLING BLDR CAT 680.58$ 160 51702 51702 INSERTION BLADDER CATH 545.26$ 161 51703 51703 INSERT BLADDER CATH COMPL 683.56$ 162 56405 56405 INC/DRAIN VULVA/PERINEAL 1,127.34$ 163 56420 56420 I & D BARTHOLIN ABSCESS 1,070.62$ 164 59025 59025 FTL NON-STRS TST 624.86$ 165 59409 59409 VAG DLVR ONLY 6,327.20$ 166 62270 62270 SPINAL PUNCTURELUMBAR 1,317.38$ 167 64402 64402 INJ ANESTHETIC FACIAL NRV 1,118.38$ 168 64450 64450 INJ ANESTHETIC AGENT 2,602.92$ 169 64640 64640 DSTRJ NULYT OTH PRPH NVR/BRANCH 2,582.02$ 170 65205 65205 REMOVAL FB EYE-SUPERFCL 554.22$ 171 65210 65210 REMOVAL FB EYE/CONJ EMBED 339.30$ 172 65220 65220 RMVL FB EYE W/O SLIT LAMP 678.59$ 173 65222 65222 RMVL FB EYE 639.78$ 174 67700 67700 I&D ABSCESS EYELID 1,057.68$ 175 69200 69200 RMVL FOREIGN BODY EAR 482.58$ 176 69205 69205 RMVL FB XTRNL AUD CANAL A 6,330.19$ 177 69209 69209 REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL 501.48$ 178 69210 69210 RMVL IMPACTED CERUMEN 222.88$ 179 70030 70030 RADEX EYE DETCJ FB 588.04$ 180 70100 70100 XRAY MANDIBLE LESS THAN 4 VIEWS 721.38$ 181 70110 70110 XRAY MANDIBLE MIN 4 VIEWS 968.14$ 182 70120 70120 RADEX MASTOIDS LESS THAN 3 VIEWS PR SIDE 395.02$ 183 70140 70140 XRAY FACIAL BONES LESS THAN 3 VIEW 675.60$ 184 70150 70150 XRAY FACIAL BONES GREATER THAN 3 VIEW 969.13$ 185 70160 70160 NASAL BONE X-RAY 883.56$ 186 70200 70200 RAD EXAM ORBIT COMP. 916.40$ 187 70220 70220 RAD EXAM SINUS COMPLETE 756.20$ 188 70250 70250 SKULL LESS THAN 4 VIEWS 692.52$ 189 70260 70260 RAD EXAM SKULL COMPLETE 973.11$ 190 70328 70328 RADEX TMPRMAND JT OPN&CLSD MOUTH UNI 446.00$ 191 70350 70350 CEPHALOGRAM ORTHODONTIC 326.00$ 192 70360 70360 RAD EXAM NECKSOFT TISSUE 542.28$ 193 70450 70450 COMPUTED TOMOGRAPHY HD/BR 3,780.00$ 194 70460 70460 TOMOGRAPHY HEAD/BRAIN WIT 4,418.80$ 195 70470 70470 COMPUTED TOMOGRAPHY HEAD/ 4,662.57$ 196 70480 70480 CT ORBIT SELLA/POST FOSSA 8,005.77$ 197 70481 70481 CT ORBIT SELLA/POST FOSSA 4,567.05$ 198 70486 70486 CT MAXLFCL AREA C-MATRL 3,365.09$ 199 70487 70487 CT MAXLFCL AREA C+ MATRL 3,820.80$ 200 70488 70488 CT MAXLFCL AREA C-/C+ 5,171.02$ 201 70490 70490 CT NECK WO CONTRAST 3,725.00$ 202 70491 70491 CT SOFT TISS NCK C+MATRL 4,202.88$ 203 70492 70492 CT SOFT TISS NCK C-/C+ 5,371.01$ 204 70496 70496 CTA HEAD C-/C+ 3,715.33$ 205 70544 70544 MRA HEAD C-MATRL 4,004.00$ 206 70547 70547 MRA NECK C-MATRL 3,523.00$ 207 70551 70551 MRI BRN BRN STEM C-MATRL 3,523.00$ 208 70553 70553 MRI BRN BRN STEM C-/C+ 4,153.00$ 209 71010 71010 XRAY CHEST AP 380.00$ 210 71020 71020 XRAY CHEST PA & LATERAL 590.00$ 211 71030 71030 RADEX CH COMPL MIN 4 VIEW 665.00$ 212 71045 71045 RADIOLOGIC EXAMINATION CHEST SINGLE VIEW 380.00$ 213 71046 71046 RADIOLOGIC EXAMINATION CHEST 2 VIEW 590.00$ 214 71047 71047 RADIOLOGIC EXAMINATION CHEST 3 VIEWS 627.00$ 215 71048 71048 RADIOLOGICAL EXAMANATION CHEST 4 VIEWS OR MORE 665.00$ 216 71060 71060 BRONCHOGRAPHY BI RS&I 683.00$ 217 71100 71100 RIBS UNILATERAL 2 VIEWS 1,126.34$ 218 71101 71101 RIB UNILATERAL W CHEST 951.22$

219 71110 71110 RIBS BILATERAL 3 VIEWS 951.22$ 220 71111 71111 RIBS BILATERAL W/CHEST 2,108.40$ 221 71120 71120 CHEST 2 VIEWS 692.52$ 222 71250 71250 CT CHEST W/O CONTRAST 4,929.23$ 223 71260 71260 CT THORAX W/CONTRAST 5,131.00$ 224 71270 71270 CT THORAX WO CONTRAST 4,414.82$ 225 71275 71275 CT ANGIOGRAPHY 5,743.00$ 226 71550 71550 MRI CH C-MATRL 3,522.00$ 227 72020 72020 SPINE SINGLE VIEW 374.12$ 228 72040 72040 SPINE CERVICAL 2/3 VIEWS 702.47$ 229 72050 72050 SPINE CERVICAL MIN 4VIEW 977.09$ 230 72052 72052 SPINE CERV. COMP FLEX/EXT 1,189.02$ 231 72069 72069 RADEX SPI THORACOLMBR STANDING SCOLIOSIS 475.00$ 232 72070 72070 SPINE THORACIC 2 VIEWS 756.20$ 233 72072 72072 SPINE THORACIC 3 VIEWS 941.27$ 234 72074 72074 RAD EXAN SPINE THROAC 4 V 802.96$ 235 72100 72100 SPINE LUMBO. MIN 4 VIEWS 798.98$ 236 72110 72110 LUMBAR X-RAY 4 VIEWS RADEX SPI LUMBOSAC MINIMUM 4 VIEWS 1,130.32$ 237 72114 72114 RAD EXAM SPINE LUMBO COMP 1,168.13$ 238 72120 72120 SPINE LUMBAR AP & LAT W F 948.24$ 239 72125 72125 COMPUTED TOMOGRAPHY CERVI 4,398.00$ 240 72126 72126 CT CRV SPI C+MATRL 2,192.98$ 241 72127 72127 CT CRV SPI C-/C+ 5,645.63$ 242 72128 72128 CT THRC SPI C-MATRL 4,272.00$ 243 72129 72129 CT THRC SPI C+ MATRL 8,164.97$ 244 72131 72131 CT L SPINE WO CONTRST 4,736.00$ 245 72132 72132 CT LMBR SPI C+ MATRL 3,399.92$ 246 72141 72141 MRI SPI CANAL&CNTS CRV C-MATRL 2,374.00$ 247 72146 72146 MRI SPI CANAL&CNTS THRC C-MATRL 3,523.00$ 248 72148 72148 MRI SPI CANAL&CNTS LMBR C-MATRL 3,523.00$ 249 72156 72156 MRI SPI CANAL&CNTS C-/C+ CRV 4,153.00$ 250 72157 72157 MRI SPI CANAL&CNTS C-/C+ 3,523.00$ 251 72158 72158 MRI SPI CANAL&CNTS C-/C+ LMBR 3,559.00$ 252 72170 72170 RAD EXAM PELVIS 1/2 VEIW 632.82$ 253 72190 72190 RADEX PELVIS COMPL MIN 3 719.38$ 254 72191 72191 CTA PELVIS C-/C+ POST-PXE 4,884.46$ 255 72192 72192 CT PELVIS WO CONTRAST 6,222.73$ 256 72193 72193 TOMOGRAPHY PELVIS WCONTRS 4,169.05$ 257 72194 72194 CT PELVIS W OR WO CONTRST 5,365.04$ 258 72195 72195 MRI PELVIS C-MATRL 4,125.27$ 259 72196 72196 MRI PELVIS C+ MATRL 6,988.88$ 260 72220 72220 XRAY COCCYX/SACRUM 814.90$ 261 73000 73000 XRAY CLAVICLE 2 VIEWS 853.71$ 262 73010 73010 SCAPULA COMPLETE 1,190.02$ 263 73020 73020 RADEX SHO 1 VIEW 793.02$ 264 73030 73030 SHOULDR COMPLETE 2 VIEWS 800.98$ 265 73050 73050 XRAY AC JOINTS-BILAT 731.32$ 266 73060 73060 XRAY HUMERUS MIN 2 VIEWS 918.38$ 267 73070 73070 XRAY ELBOW 2 VIEWS 858.68$ 268 73080 73080 XRAY ELBOW GREATER THAN 3 VIEWS-COMP 727.34$ 269 73090 73090 XRAY FOREARM AP & LAT 972.12$ 270 73100 73100 XRAY WRIST AP & LAT VIEW 1,077.58$ 271 73110 73110 XRAY WRIST/COMP MIN 3 VIE 929.33$ 272 73120 73120 XRAY HAND AP & LAT 636.80$ 273 73130 73130 XRAY HAND MIN 3 VIEWS 986.04$ 274 73140 73140 XRAY FINGER MIN 2 VIEWS 791.02$ 275 73200 73200 CT UPPR EXTR WO CNTRS 6,092.38$ 276 73220 73220 MRI UXTR OTH/THN JT C-/C+ 4,153.00$ 277 73221 73221 MRI ANY JT UXTR C-MATRL 3,523.00$ 278 73500 73500 RADIOLOGIC EXAM HIP UNILAT 1 VIEW 482.00$ 279 73502 73502 XRAY EXAM HIP UNI 2-3 VIEW 702.47$ 280 73510 73510 XRAY HIP MIN 2 VIEWS 605.00$ 281 73520 73520 HIPS BILAT MIN 2 VIEW INC 646.00$ 282 73550 73550 XRAY FEMUR AP & LAT VIEW 396.00$ 283 73552 73552 RT RADIOLOGIC EXAM FEMUR 2 VIEWS 1,116.39$ 284 73560 73560 XRAY KNEE SUNRISE VIEW 1,214.90$ 285 73562 73562 XRAY KNEE MIN 3 VIEWS 1,375.09$ 286 73564 73564 RAD EXAM KNEE 4 OR MORE 968.14$ 287 73590 73590 XRAY TIBIA/FIBULA AP/LAT 764.16$ 288 73600 73600 XRAY ANKLE 2 VIEWS 959.18$ 289 73610 73610 XRAY ANKLE 3 VIEWS/COMPLE 749.24$ 290 73620 73620 XRAY FOOT MIN 2 VIEWS 735.30$ 291 73630 73630 XRAY FOOT MIN 3 VIEWS 777.10$ 292 73650 73650 RAD EXAN HEEL MIN 2 VIEWS 615.90$ 293 73660 73660 XRAY TOES MIN 2 VIEWS 915.40$

294 73700 73700 CT LWR EXTR WO CONTRAST 4,033.73$ 295 73701 73701 CT LWR EXT W CONT 6,133.18$ 296 73702 73702 CT LXTR C-/C+ 5,301.36$ 297 73721 73721 MRI ANY JT LXTR C-MATRL 3,523.00$ 298 73722 73722 MRI ANY JT LXTR C+ MATRL 3,910.00$ 299 73723 73723 MRI ANY JT LXTR C-/C+ 6,416.00$ 300 73725 73725 MRA LXTR C+-MATRL 4,746.00$ 301 74000 74000 RAD EXAM ABD SINGL ANTER 965.00$ 302 74010 74010 RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS 541.00$ 303 74018 74018 RADIOLOGIC EXAMINATION ABDOMEN 1 VIEW 581.00$ 304 74019 74019 RADIOLOGIC EXAM ABDOMEN 2 VIEWS 595.00$ 305 74020 74020 RAD EXAM ABDOMEN COMPL 577.00$ 306 74021 74021 RADIOLOGIC EXAMINATION ABDOMEN 3 OR MORE VIEWS 677.00$ 307 74022 74022 RAD EXAM COMPLETE ABD 725.00$ 308 74150 74150 COMPUTED TOMOGRAPHY ABD 3,177.04$ 309 74160 74160 TOMOGRAPHY ABD W/CONTRAST 4,206.86$ 310 74170 74170 TOMOGRAPHY ABD W/OCONTRAS 4,666.55$ 311 74175 74175 CT ANGIO ABDOMEN W/CONTRA 3,531.26$ 312 74176 74176 COMP TOMOG AB/PEL W/O CON 2,381.00$ 313 74177 74177 COMP TOMO AB/PELV W/OCONT 3,238.00$ 314 74178 74178 CT ABD & PELVIS 1 PLUS SECTION/REGNS 7,900.30$ 315 74181 74181 MRI ABD C-MATRL 3,523.00$ 316 74183 74183 MRI ABD C-/C+ 4,153.00$ 317 74241 74241 RADEX GI TRC UPR +-DLYD FLMS W/KUB 1,832.79$ 318 74247 74247 RADEX GI UPR C+ +-GLUC +-DYLD FLMS W/KUB 1,889.50$ 319 75571 75571 CT HEART WITHOUT CONTRAST CALCIUM SCREEN 338.30$ 320 75574 75574 CT CORONARY 3,424.79$ 321 76376 76376 3D RNDR I&R CT MRI US/OTH 226.86$ 322 76536 76536 ULTRASOUND SOFT TISSUES OF HEAD AND NECK 1,428.82$ 323 76645 76645 US BREAST R-T W/IMAGE DOCUMENTATION 914.00$ 324 76700 76700 US ABDOMINAL R-T W/IMAGE 2,024.82$ 325 76705 76705 US ABDOMINAL 1,457.68$ 326 76770 76770 US RETROPERITONEAL R-T W/ 1,311.41$ 327 76775 76775 US RPR B-SCAN&/R-T IMG LMTD 977.09$ 328 76801 76801 ULTRASOUND 14 WK TABDL 1/1ST GESTATION 2,083.53$ 329 76805 76805 US PG UTER F&MAT AFTER 1S 1,141.26$ 330 76815 76815 ULTRASND PG UTER 1,646.72$ 331 76817 76817 UT PG UTER R-T IMG TRVG 1,633.79$ 332 76830 76830 TRANSVAGINAL ULTRASOUND 1,243.75$ 333 76856 76856 US PELVIC NONOB REAL-TIME 1,524.34$ 334 76857 76857 PEL NONOB B-SCAN&/R-T IMG LMTD/F-UP+C97 928.34$ 335 76870 76870 US SCROTUM&CNTS 1,295.49$ 336 76880 76880 US EXTREMITY 1,160.00$ 337 76882 76882 US XTR NON-VASC LMTD 1,418.87$ 338 77079 77079 CT BONE MINERAL DENSITY STUDY 1+SITS APPND R3060 756.00$ 339 77777 77777 SHORTNESS OF BREATH PANEL 16.00$ 340 78075 78075 ADRNL IMG CORTEX&/MEDULLA 5,310.32$ 341 78223 78223 HIDA SCAN-HEPATBL DUX SYS IMG GLBLDR 3,190.00$ 342 78306 78306 B1&/JT IMG WHBDY 5,084.45$ 343 78315 78315 B1&/JT IMG 3 PHASE STD 3,789.96$ 344 78320 78320 B1&/JT IMG TOMOG SPECT 3,905.38$ 345 78472 78472 CARD BPI GTD=BRM PLNR 1 STD REST/STRS 3,681.50$ 346 80047 80047 BASIC METABOLIC PANEL CALCIUM IONIZED 1,040.77$ 347 80048 80048 METABOLIC PANEL BASIC 490.54$ 348 80051 80051 ELECTROLYTE PANEL 369.14$ 349 80053 80053 METABOLIC COMPRE PANEL 688.54$ 350 80061 80061 LIPID PROFILE III 694.51$ 351 80074 80074 HEPATITIS PANEL 1,041.76$ 352 80076 80076 HEPATIC FUNCTION PANEL 976.10$ 353 80100 80100 DRUG ABUSE PANEL II 293.00$ 354 80104 80104 DRUG SCREEN 217.00$ 355 80178 80178 LITHIUM 364.17$ 356 80196 80196 SALICYLATE 143.00$ 357 80197 80197 TACROLIMUS 389.04$ 358 80202 80202 VANCOMYCIN PEAK 263.68$ 359 80304 80304 DRUG SCREEN 217.00$

360 80305 80305DRUGTESTSPRESUMPTIVEANYNUMBEROFDRUGCLASSESANYNUMBEROFDEVICESORPROCEDURES 384.07$

361 80306 80306 UNDER PRESUMPTIVE DRUG CLASS SCREENING PROCEDURES 459.69$ 362 80307 80307 PRESUMPTIVE DRUG CLASS SCREENING 1,096.49$ 363 80320 80320 DRUG SCREEN 381.08$ 364 80329 80329 DRUG SCREEN 487.55$ 365 81000 81000 U/A DIPSTICK 21.89$ 366 81001 81001 U/A DIP STICK 108.00$ 367 81002 81002 URNLS DIP STICK/TABLET RG 163.00$

368 81003 81003 U/A W/O MICRO DIPSTICK 138.30$ 369 81025 81025 PREG.TST URINE VISUAL 266.66$ 370 82003 82003 ACETAMINOPHEN 290.00$ 371 82009 82009 KETONES-SERUM 135.32$ 372 82010 82010 ACETONE/OTH KETONE BODIES 162.18$ 373 82040 82040 ALBUMIN; SERUM 126.36$ 374 82055 82055 ALCOHOL-BLOOD 257.00$ 375 82075 82075 ALCOHOL BREATH TEST 117.00$ 376 82140 82140 AMMONIA 260.69$ 377 82150 82150 AMYLASE 318.40$ 378 82247 82247 BILIRUBIN TOTAL 151.24$ 379 82248 82248 BILIRUBIN DIR 211.94$ 380 82253 82253 MB FRACTION 196.00$ 381 82270 82270 OCCULT BLOOD 114.42$ 382 82272 82272 BLD OCLT PEROXIDASE ACTV 60.70$ 383 82306 82306 VITAMIN D-25OH 435.81$ 384 82310 82310 CALCIUM 131.34$ 385 82376 82376 ASSAY CARBOXYHBQUAL 350.24$ 386 82379 82379 CARNITINE LEVEL 251.00$ 387 82540 82540 CREATINE 158.20$ 388 82541 82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE 154.00$ 389 82550 82550 CREATINE CK-TOTAL 205.96$ 390 82553 82553 CREATINE CKMB 337.30$ 391 82565 82565 CREATININE 167.16$ 392 82607 82607 VITAMIN B-12 535.31$ 393 82728 82728 FERRITIN 200.99$ 394 82800 82800 GASES BLD PH ONLY 126.36$ 395 82803 82803 GASES BLD PH CALCULATED 0 495.51$ 396 82805 82805 BLOOD GASES W O2 SATURATION 633.82$

397 82810 82810GASES BLOOD O2 SATURATION ONLY BY DIRECT MEASUREMENT EXCEPT PULSE OXIMETRY 388.05$

398 82945 82945 GLUC BDY FLU OTH/THN BLD 201.98$ 399 82947 82947 GLUCOSE 280.59$ 400 82948 82948 GLUCOSE BLOOD REAGET STR 19.90$ 401 82962 82962 GLUCOSE FINGER STICK 36.82$ 402 82977 82977 GLUTAMYLTRANSFERASE-GTT 255.72$ 403 83036 83036 HEMOGLOBIN A1C 246.76$ 404 83069 83069 ASSAY OF URINE HEMOGLOBIN 77.61$ 405 83380 83380 NATRIURETIC PEPTIDE 408.00$ 406 83520 83520 IMMUNOASSAY ANALYTE QUANTITIATIVE NOS 398.00$ 407 83540 83540 IRON-TOTAL 95.52$ 408 83550 83550 IRON BINDING CAPACITY 129.35$ 409 83605 83605 ASSAY OF LACTIC ACID 300.49$ 410 83615 83615 LDH 154.22$ 411 83690 83690 LIPASE 383.08$ 412 83735 83735 MAGNESIUM 189.05$ 413 83874 83874 MYOGLOBIN 135.32$ 414 83880 83880 B-TYPE NATRIURETIC 721.38$ 415 83970 83970 PARATHORMONE(PARATHYRIOD) 608.94$ 416 84035 84035 ASSAY PHENYLKETONES 178.10$ 417 84075 84075 ALK PHOS/PROFILE OR PANEL 131.34$ 418 84100 84100 PHOSPHORUS INORGANIC 200.00$ 419 84155 84155 PROTEINTOTALEXCEPT REFR 21.89$ 420 84156 84156 PROTEIN TOTAL 182.08$ 421 84165 84165 PROTEIN ELECTROPHORESIS 183.08$ 422 84166 84166 PROTEIN EPHORESIS/URINE/CSF 230.84$ 423 84402 84402 TSTOSTERONE FR 331.34$ 424 84403 84403 TESTOSTERONE; TOTAL 1,787.02$ 425 84436 84436 THYRIXINE TOTAL 226.86$ 426 84439 84439 THYROXINE-FREE 223.88$ 427 84443 84443 TSH 299.50$ 428 84450 84450 AST 190.04$ 429 84460 84460 ALT-TRANSFERASE;ALANINE 150.24$ 430 84479 84479 THYROID HORMONE 222.88$ 431 84480 84480 T3 TOTAL 345.26$ 432 84481 84481 T3 FREE 429.84$ 433 84484 84484 TROPONIN I 318.40$ 434 84512 84512 TROPONIN QUAL 390.04$ 435 84520 84520 BUN 100.50$ 436 84550 84550 URIC ACID 206.96$ 437 84560 84560 URIC ACID OTH SRC 180.10$ 438 84702 84702 HCG QUANTATIVE 440.78$ 439 84703 84703 PREGNANCY TEST BLOOD 395.02$ 440 85014 85014 HEMATOCRIT 181.09$ 441 85018 85018 HEMOGLOBIN 174.12$

442 85025 85025 CBC 217.90$ 443 85027 85027 CBC W/O DIFF 188.00$ 444 85032 85032 BLD# MNL C-CNT RBC/PLTLT EA 193.00$ 445 85044 85044 RETICULOCYTE COUNT 54.00$ 446 85347 85347 COAGJ TM ACTIVATED 328.35$ 447 85378 85378 FIBRIN DEGRADATION PROD 314.42$ 448 85379 85379 D-DIMER 277.60$ 449 85384 85384 FIBRINOGEN ACTIVITY 454.72$ 450 85385 85385 FIBRINOGEN ANTIGEN 329.34$ 451 85540 85540 WBC ALKALINE PHOSPHATASE 357.20$ 452 85597 85597 PHOSPHOLIPID NEUTRALIZATION PLATELET 426.86$ 453 85610 85610 PROTHROMBIN TIME 349.24$ 454 85651 85651 SEDIMENTATION RATE NONAUT 125.37$ 455 85652 85652 SED RATE ERYTHROCYTE NON 287.56$ 456 85730 85730 THROMBOPLASTIN TIME PART 410.94$ 457 86005 86005 IGE 147.26$ 458 86038 86038 ANTINUCLEAR AB 228.85$ 459 86140 86140 C REACTIVE PROTEIN 170.14$ 460 86141 86141 C-REACTIVE PROTEIN HI SEN 104.48$ 461 86200 86200 CYCLIC CITRULLINATED PEPTIDE CCP ANTIBODY 246.76$ 462 86256 86256 SMOOTH MUSCLE AB TITER 103.48$ 463 86308 86308 MONOHETEROPHILE ANTIBODI 275.62$ 464 86318 86318 IMMUNOASSAY INFECTIOUS AGENT 381.08$ 465 86320 86320 IMMUNOELECTROPHORESIS 789.04$ 466 86403 86403 MONO SPOT 171.14$ 467 86430 86430 RHEUMATOID FACTOR 249.74$ 468 86431 86431 RHEUMATOID FACTOR QUANTIT 117.41$ 469 86631 86631 ANTB CHLAMYDIA 161.19$ 470 86663 86663 EPSTEIN-BARR VIRUS EA 350.00$ 471 86677 86677 HELICOBACTOR CULTURE 337.30$ 472 86689 86689 ANTB HTLV/HIV ANTB CONFIRMATION TST 523.37$ 473 86701 86701 HIV SERUM 307.46$ 474 86702 86702 ANTB HIV-2 367.16$ 475 86705 86705 HEPATITIS B CORE IGM 299.50$ 476 86709 86709 HEPATITIS A AB-IGM 256.71$ 477 86750 86750 MALARIA ANTIBODY 315.42$ 478 86756 86756 ANTB RSV 339.30$ 479 86768 86768 ANTIBODY SALMONELLA 190.04$ 480 86771 86771 ANTIBODY SHIGELLA 358.20$ 481 86803 86803 HEPATITIS C-AB 206.96$ 482 86850 86850 ANTB SCR RBC EA SERUM TQ 258.70$ 483 86900 86900 BLOOD TYPING 187.06$ 484 86901 86901 RH FACTOR-BLOOD 129.35$ 485 86906 86906 BLD TYPING RH PHEXYPING COMPL 432.82$ 486 87040 87040 BLOOD CULTURE 411.93$ 487 87045 87045 CULTURE FECES 335.32$ 488 87046 87046 CUL BACT STL AERC ADDL PA 168.16$ 489 87070 87070 CULTURE BODY FLUID 462.68$ 490 87075 87075 CULTURE ANAEROBIC 215.92$ 491 87077 87077 CUL BACT AERC ADDL METHS 226.86$ 492 87081 87081 CULTURE BACTERIAL-SCREEN 230.84$ 493 87086 87086 URINE CULTURE 318.40$ 494 87088 87088 CULTURE BCT ISOL&PRSMPTV 270.64$ 495 87106 87106 CUL FNGI DEFINITIVE ID EA ORGANISM YEAST 115.42$ 496 87110 87110 CHLAMYDIA CULTURE 495.51$ 497 87116 87116 CUL TUBERCLE/OTH ACID-FAS 623.86$ 498 87177 87177 OVA & PARASITES SMEAR 407.95$ 499 87205 87205 SMEAR GRAM STAIN 340.29$ 500 87207 87207 SMR PRIM SRC SPEC STAIN 252.73$ 501 87210 87210 WET SMEAR 174.12$ 502 87230 87230 C-DIFFICLE TOXIN 539.29$ 503 87252 87252 CULTURE HERPES 816.90$ 504 87275 87275 IAADI INF B VIRUS 172.14$ 505 87324 87324 INFECTIOUS AGENT DETECTIO 189.05$ 506 87339 87339 IAAD EIA HPYLORI 399.99$ 507 87340 87340 HEPATITIS B SURFACE AG 152.24$ 508 87400 87400 INFLUENZA A&B 221.00$ 509 87425 87425 ROTAVIRUS AG EIA 346.26$ 510 87430 87430 INF AGT IMMUNO STREP A 351.24$

511 87480 87480INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES DIRECT 343.00$

512 87490 87490 IADNA CHLABYDIA TRACHOMAT 365.16$ 513 87491 87491 IADNA CHLAMYDIA TRACHOMAT 272.63$ 514 87493 87493 INF AGENT DET NUC ACID CLOSTRIDIUM AMP PROBE 326.36$ 515 87510 87510 INFECTIOUS AGENT BY NUCLEIC ADID 291.54$

516 87590 87590 IADNA NEISSERIA GONORRHOE 379.10$ 517 87591 87591 IADNA NEISSERIA GONORRHOE 252.73$ 518 87798 87798 O&P SMEAR W/AMPLIFIC 120.40$ 519 87804 87804 INFLUENZA IMMUNOASSAY OPT 255.72$

520 87806 87806INFECT AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION;HI 715.40$

521 87807 87807 INF AGT DET IMNAS OPT RSV 339.30$ 522 87847 87847 NO DESCRIPTION 520.00$ 523 87850 87850 NEISSERIA GONORRHOEAE DET 362.18$ 524 87880 87880 RAPID STREP-BETA STREP 183.08$ 525 88233 88233 TISSUE CULTURE SKIN/BIOPSY 1,801.94$ 526 88305 88305 PATH SURG LEVEL IV 1.00$ 527 89050 89050 FLUID CELL COUNT 68.00$ 528 89055 89055 WBC ASSMT FECAL QUAL/SEMI 47.00$ 529 89060 89060 CRYSTAL INDENTIFICATION 1.00$ 530 89220 89220 SPTM OBTG SPEC AERSL INDUCED SPX 124.00$ 531 90471 90471 IMMUN ADM 1 VAC 158.20$ 532 90656 90656 INFLUENZA VIRUS VACC SPLI 53.73$ 533 90660 90660 INFLUENZA VIRUS INTRANASA 196.02$ 534 90703 90703 TETANUS TOXID 193.00$ 535 90714 90714 TETANUS DIPHTHERIA TOXOID 245.76$ 536 90715 90715 TDAP VACCINE 406.96$ 537 90718 90718 TETANUS & DIPTHERIA 193.00$ 538 90746 90746 HEPATITIS B VACCINE/ADULT 342.28$ 539 90765 90765 IV NFS THER PROPH/DX 1ST 266.00$ 540 90997 90997 HEMOPERFUSION 520.00$ 541 91105 91105 GASTRIC INTUBATION/ASPER 757.00$ 542 92002 92002 OPH MEDICAL XM&EVAL INTRM 1.00$ 543 92081 92081 VIS FLD XM UNI/BI I&R LMT 1.00$ 544 92552 92552 PURE TONE AUDIOMTRY AIR O 1.00$ 545 92950 92950 CARDIOPULMONARY RESUSCITATION 1,146.24$ 546 92960 92960 CARDIOVERSION ELECTIVE ARRHYT XTRNL 2,496.46$ 547 93000 93000 EKG W/INTREP AND REPORT 239.80$ 548 93005 93005 EKG 764.16$ 549 93010 93010 RTN ECG 12 LEADS INTRP/RP 38.80$ 550 93040 93040 RHYTHM ECG 1-3 LDS W/I&R 205.96$ 551 93041 93041 RHYTHEM ECG 1-3 LDS 247.76$ 552 93224 93224 WEARABLE ECG 24 HR W/VIS SUPIMPOS SCAN PHYS R&I 188.00$ 553 93306 93306 ECHO TEST 8,565.96$ 554 93313 93313 TEE R-T IMG 2D W/PROBE PLMT ONLY 3,336.00$ 555 93351 93351 ECHO TTHRC R-T 2D-+M-MODE REST&STRS CONT ECG 1,982.00$ 556 93875 93875 N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD 1,068.00$ 557 93880 93880 DUP-SCAN XTRC ART COMPL B 2,695.46$ 558 93882 93882 DUP-SCAN XTRC ART UNI/LMTD STD 1,457.68$

559 93925 93925DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILA 3,320.00$

560 93926 93926 DOPPLER-DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STD 1,333.30$ 561 93931 93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STD 1,108.43$ 562 93965 93965 QUANT VENOUS FLOW ST 1,528.32$ 563 93970 93970 DUP-SCAN XTR VEINS COMPL 3,190.96$ 564 93971 93971 DPLX SCN EXTRM VEINS 1,674.58$

565 93975 93975DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABD PELVIC SCROTAL 2,114.38$

566 94621 94621 PULM STRS TSTG CPLX 2,464.62$ 567 94640 94640 NEBULIZER TREATMENT 281.58$ 568 94644 94644 INHALATION TREATMENT - CONTINUOUS 1ST HR 661.68$ 569 94664 94664 DEMO&/EVAL OF PT UTILIZ 1.00$ 570 94760 94760 EAR OR PULSE OXIMETRY 175.12$ 571 94761 94761 N-INVAS EAR/PLS OXIMTRY F 135.32$ 572 96360 96360 IV INFUS INIT 31 MIN 1 HR 588.04$ 573 96361 96361 IV INFUS HYDR EA ADD'T HR 296.00$ 574 96365 96365 IV INFUSION THERAPY/PROPH 619.88$ 575 96366 96366 IV INFUS THER PROPH/DX EA 146.26$ 576 96367 96367 IV NFS THER PROPH/DX ADDL 458.70$ 577 96368 96368 IV NFS TX PROPHYLAXIS/DX 427.85$ 578 96372 96372 THERAPEUTIC PROPHYLACTIC/ 223.88$ 579 96373 96373 INJECTION INTRA-ARTERIAL 483.57$ 580 96374 96374 THER PROPH/DX NJX IV PUSH 550.24$ 581 96375 96375 THER PROPH/DX NJX EA SEQL 417.90$ 582 96376 96376 SUB INFU EA ADD IV PUSH 215.92$ 583 96379 96379 INJECTION- UNLISTED THERAPEUTIC PROPH/DX/IVA NJX/NFS 271.00$ 584 99000 99000 SPECIMEN HANDLING 57.71$ 585 99001 99001 COC COLLECITON ONLY 63.68$ 586 99050 99050 BLUE CROSS RQRD LVL3 123.38$ 587 99053 99053 SERVICES PROVIDED BETWEEN 10P AND 8A AT A 24 HOUR FACILITY 108.46$

588 99080 99080 MEDICAL RECORDS 23.88$ 589 99143 99143 MOD SEDATION &#60;5YRS 30 557.00$ 590 99144 99144 MOD SEDATION SERV UNDER 5 552.00$ 591 99145 99145 M-SEDAJ BY SM PHY 15 MIN 215.00$ 592 99149 99149 MOD SEDATION 461.00$ 593 99151 99151 MODERATE SED SERVICES PROVIDED BY SAME PHY 571.13$ 594 99152 99152 SEDATION 372.13$ 595 99153 99153 MODERATE (CONSCIOUS) SEDATION 128.00$ 596 99173 99173 SCREENING TEST OF VISION 372.00$ 597 99217 99217 OBS CARE DSCHRG D MGMT 454.00$ 598 99220 99220 INITIAL OBS CARE 1,030.00$ 599 99236 99236 OBS HOSP SAME DATE 1,462.00$ 600 99281 99281 FACILITY CHG LEVEL 1 394.02$ 601 99282 99282 FACILITY CHG LEVEL 2 725.36$ 602 99283 99283 FACILITY CHG LEVEL 3 1,256.68$ 603 99284 99284 FACILITY CHG LEVEL 4 2,836.74$ 604 99285 99285 FACILITY CHG LEVEL 5 3,301.41$ 605 99291 99291 CRITICAL CARE 30-74 MIN 4,814.80$ 606 99292 99292 CRITICAL CARE ADD 30 MIN 701.48$ 607 99406 99406 SMOKING CESSATION 3-10 79.60$ 608 99407 99407 SMOKING CESSATION 10 MIN 132.34$ 609 A0394 A0394 ALS IV DRUG THERAPY SUPPLIES 1.00$ 610 A0396 A0396 ALS ESPOHAGEAL INTUB SUPPLIES 37.00$ 611 A4208 A4208 3 CC STERILE SYRINGE & NEEDLE 41.00$ 612 A4209 A4209 5+ CC STERILE SYRINGE & NEEDLE 44.00$ 613 A4213 A4213 20+ CC SYRINGE ONLY 8.00$ 614 A4215 A4215 NEEDLE STERILE ANY SIZE EACH 16.00$ 615 A4216 A4216 Flush 10ml 5.00$ 616 A4217 A4217 Sterile Water (Saline) Up to 500 ml 34.00$ 617 A4218 A4218 STERILE SALINE OR WATER 34.00$ 618 A4222 A4222 EXT UNFU PMP PER CASS/BAG 223.00$ 619 A4224 A4224 Peroxide 6.00$ 620 A4244 A4244 ALCOHOL OR PEROXIDE PER PINT 12.00$ 621 A4246 A4246 Betadine 31.00$ 622 A4247 A4247 Betadine Swabs 31.00$ 623 A4252 A4252 GLUCOSE TEST STRIP-BLOOD KETONE TEST OR STRIP 7.00$ 624 A4311 A4311 CATHETER W/O BAG 2 WAY LATEX 44.00$ 625 A4314 A4314 INSRT TRAY W/DRAINAGE BAG 16.00$ 626 A4316 A4316 CATH W DRAINAGE 3 WAY 89.00$ 627 A4320 A4320 IRR TRAY W/BULB/PISTON SY 12.00$ 628 A4322 A4322 Bulb Syringe 20.00$ 629 A4327 A4327 URIN CUP FEMALE COLLECT DEV CUP 5.00$ 630 A4332 A4332 LUBE STERILE PACKET 8.00$ 631 A4335 A4335 INCONTINENCE SUPPLY MISC 5.00$ 632 A4338 A4338 INDWELLING CATHETER FOLEY TYPE TWO-WAY LATEX WITH COATING 67.00$ 633 A4344 A4344 INDWELLING CATH FOLEY TYP 16.00$ 634 A4351 A4351 INTERMIT URIN CATH STRAIG 30.00$ 635 A4353 A4353 INTERMIT URINARY CATHETER 30.00$ 636 A4358 A4358 URINARY DRAINAGE BAG 19.00$ 637 A4364 A4364 DERMABOND- ADHESIVE LIQUID OR EQUAL PER OZ 42.00$ 638 A4450 A4450 TAPE NO WATERPROOF 13.00$ 639 A4452 A4452 TAPE WATERPROOF 18 SQ IN 13.00$ 640 A4550 A4550 LACERATION- SURGICAL KIT 520.00$ 641 A4554 A4554 DISPOSABLE UNDERPADS 37.00$ 642 A4565 A4565 SLING 186.00$ 643 A4566 A4566 Arm Sling + Swath 49.20$ 644 A4570 A4570 SPECIAL CASTING MATERIAL 160.00$ 645 A4590 A4590 3 ORTHO GLASS 4 SPECIAL CASTING MATERIAL 107.00$ 646 A4595 A4595 TENS SUPPL 2 LEAD PER MONTH R3060 59.00$ 647 A4606 A4606 OXYGEN PROBE USED W OXIMETER 161.00$ 648 A4614 A4614 HAND HELD PEFR METER 48.00$ 649 A4615 A4615 CANNULA NASAL 7.00$ 650 A4616 A4616 TUBING (OXYGEN) PER FOOT 1.00$ 651 A4617 A4617 MOUTHPIECE FOR RESPIRATORY OXYGEN EQUIPMENT 71.00$ 652 A4620 A4620 VARIABLE CONCENTRATION MASK 72.00$ 653 A4649 A4649 SURGICAL SUPPLY MISC 29.00$ 654 A4653 A4653 PD CATHERTER ANCHOR BELT R3060 17.00$ 655 A4657 A4657 SYRINGE W OR WO NEEDLE 8.00$ 656 A4670 A4670 AUTOMATIC BP MONITOR #11 46.00$ 657 A4673 A4673 SALINE BLADE #11 17.00$ 658 A4927 A4927 GLOVES NON STERILE 1.00$ 659 A4930 A4930 GLOVES STERILE PER PAIR 5.00$ 660 A5120 A5120 SWAB OR WIPE SKIN BARRIER 7.00$ 661 A5200 A5200 PERCUTANEOUS CATHETER ANCHOR R3060 149.00$ 662 A6021 A6021 COLLAGEN DRESSING STERIL 22.00$

663 A6205 A6205 COMPOSITE DRSG LESS THAN 48 SQ IN 28.00$ 664 A6210 A6210 FOAM DRSG LESS THAN 16=48 SQ IN W/ BORDER 124.00$ 665 A6211 A6211 FOAM DRG LESS THAN 16 LESS THAN 48 SQ IN WO BORDER 38.00$ 666 A6213 A6213 FOAM DRG 16-48 SQ IN W/BRDR 14.00$ 667 A6216 A6216 4x4 Gauze Tray 17.00$ 668 A6217 A6217 4x4 Gauze Large Pack 17.00$ 669 A6218 A6218 GAUZE NON STERILE 17.00$ 670 A6219 A6219 GAUZE- STERILE 17.00$ 671 A6222 A6222 GAUZE IMPREGNATED WITH ME 10.00$ 672 A6231 A6231 GAUZE 16 LESS THAN SQ IN EACH 89.00$ 673 A6250 A6250 SKIN SEAL PROTECT MOISTURIZER OINTMENT 43.00$ 674 A6260 A6260 WOUND CLEANSER 127.00$ 675 A6261 A6261 WOUND FILLER 127.00$ 676 A6402 A6402 Tube Gauze 7.00$ 677 A6407 A6407 PACK STRIPS NON-IMPREGNTD 36.00$ 678 A6410 A6410 STERILE EYE PAD OR STRIP 7.00$ 679 A6412 A6412 Eye Patch 37.00$ 680 A6413 A6413 ADHESIVE BANDAGE FIRST AI 7.00$ 681 A6441 A6441 PADDING BANDAGE NON-ELASTIC NON WOVEN 14.00$ 682 A6446 A6446 CONFORMING BANDAGE NON-EL 14.00$ 683 A6448 A6448 LT COMP BANDAGE LESS THAN 3IN 14.00$ 684 A6449 A6449 LIGHT COMP BANDAGE 14.00$ 685 A6450 A6450 LT COMPRS BANDAGE ELAST 22.00$ 686 A6453 A6453 BANDAGE SELF ADHER BAND W LESS THAN 3 2.00$ 687 A6454 A6454 SELF ADHER BANDAGE 17.00$ 688 A6455 A6455 SELF ADHER BANDAGE 17.00$ 689 A6457 A6457 TUBULAR DRESSING 52.00$ 690 A7002 A7002 SUCTION TUBING USED W PUMP 120.00$ 691 A7003 A7003 ADMN SET SM VOL NONFILTER 72.00$ 692 A7011 A7011 NONDISPOS CORRUGATED TUBING 16.00$ 693 A7015 A7015 Nebulizer Kit W/ Mouthpiece 72.00$ 694 A7016 A7016 DOME/MOUTHPEICE NEB 149.00$ 695 A7017 A7017 NEBULIZER MASK NOT USED W/ OXYGEN 72.00$ 696 A7040 A7040 ONE WAY CHEST DRAIN VALVE 89.00$ 697 A7520 A7520 TRACH LARYN TUBE NON CUFFED 48.00$ 698 A9150 A9150 NON PRESCRIPTION DRUG 29.00$ 699 A9273 A9273 HOT/COLD H2OBOT/CAP/COL/WRAP 34.00$ 700 A9284 A9284 NON-ELECTRONIC SPIROMETER 323.00$ 701 A9579 A9579 GAD-BASE MR CONTRAST NOS1ML 20.00$ 702 B4082 B4082 NASOGASTRIC TUBING WITHOUT STYLET 78.00$ 703 CASH CASH XRAY DISC 22.00$ 704 E0114 E0114 CRUTCHES UNDERARM 74.00$ 705 E0116 E0116 CRTCH UNDARM NOT WOOD ADJ 74.00$ 706 E0220 E0220 HOT WATER BOTTLE 44.00$ 707 E0230 E0230 ICE CAP OR COLLAR 16.00$ 708 E0275 E0275 BED PAN STANDARD 14.00$ 709 E0325 E0325 Plastic Urinal 2.52$ 710 E0352 E0352 DISPOSABLE PACK W/BOWEL SYST (VAG SPECULUM) 224.00$ 711 E04114 E04114 E04114 52.00$ 712 E0445 E0445 OXIMETER NON-INVASIVE 734.00$ 713 E0570 E0570 NEBULIZER WITH COMPRESSION 859.00$ 714 E0580 E0580 NEBULIZER FOR USE W/ REGULAT 372.00$ 715 G0009 G0009 ADM PNEUMOCOCCAL VACCINE 115.00$ 716 G0168 G0168 WND CLS TISSUE ADHESIVE 193.00$ 717 G0378 G0378 HOSPITAL OBSERVATION SERVICES PER HOUR 1,600.00$ 718 G0434 G0434 DRUG ABUSE PANEL II 293.00$ 719 J0150 J0150 ADENOSINE INJ 6MG VIAL 82.00$ 720 J0153 J0153 ADENOSINE INJ 1MG 8.00$ 721 J0170 J0170 EPINEPHRINE 3 1/2 NDL 10M 10.00$ 722 J0171 J0171 ADRENALIN EPINEPHRINE INJECT 29.00$ 723 J0282 J0282 INJ AMIODARONE HYDROCHLOR 17.00$ 724 J0290 J0290 AMPICILLIN 500 MG INJ 28.00$ 725 J0295 J0295 INJ AMPCLLN SODIUM/SULBA 24.00$ 726 J0330 J0330 SUCCINYLCHOLINE CHLO 20MG 218.00$ 727 J0360 J0360 HYDRALAZINE HCL INJ UP TO 20MG 218.00$ 728 J0390 J0390 CHLOROQUINE INJ 34.00$ 729 J0456 J0456 INJ AZITHROMYCIN 500MG 103.00$ 730 J0461 J0461 INJ ATROPINE SULFATE 0.01 1.00$ 731 J0500 J0500 DICYCLOMINE HCL 20MG 28.00$ 732 J0550 J0550 BICILLIN - PENICILLIN G BENZATHINE INJ 82.00$ 733 J0559 J0559 BICILLIN - PENICILLIN G BENZATHINE INJ 2500 UNITS 82.00$ 734 J0560 J0560 BICILLIN 600000 64.00$ 735 J0561 J0561 INJECTION PENICILLIN G BENZATHINE 100000 UNITS 71.00$ 736 J0570 J0570 BICILLIN 1200000 139.00$ 737 J0595 J0595 STADOL 17.00$

738 J0610 J0610 Calcium Gluconate Injectable SDV 100mg/mL 10mL PF 10ml/Vl 109.60$ 739 J0641 J0641 LEVOLEUCOVORIN INJECTION 2.00$ 740 J0690 J0690 KEFZOL 1 GR VIAL 28.00$ 741 J0692 J0692 INJ CEFEPIME HCI 500MG 59.00$ 742 J0696 J0696 ROCEPHIN 250 MG 66.00$ 743 J0708 J0708 J0708 28.00$ 744 J0735 J0735 CLONIDINE 1MG 10.00$ 745 J0744 J0744 CIPRO 200MG 68.00$ 746 J0760 J0760 COLCHICINE INJECTION 29.00$ 747 J0780 J0780 COMPAZINE 10 MG 16.00$ 748 J1020 J1020 INJ METHYLPREDNISOLONE AC 2.00$ 749 J1030 J1030 DEPO MEDROL 40 MG/ML 7.00$ 750 J1040 J1040 METHYLPREDNISOLONE 80MG 13.00$ 751 J1094 J1094 DECADRON DEXAMETHASONE ACETATE 1MG 28.00$ 752 J1100 J1100 DECADRON 1 MG 28.00$ 753 J1165 J1165 DILANTIN 100 MG VIAL 52.00$ 754 J1170 J1170 DILAUDID 4 MG 52.00$ 755 J1200 J1200 BENADRYL 50MG 28.00$ 756 J1240 J1240 ANTIVERT - DIMENHYDRINATE INJECTION 50MG 42.00$ 757 J1265 J1265 INJ DOPAMINE HCL 40 MG 26.00$ 758 J1335 J1335 ERTAPENEM INJECTION 26.00$ 759 J1580 J1580 GARAMYCINGENTAMICIN 80MG 64.00$ 760 J1610 J1610 GLUCOGAN 1 MG VIAL 86.00$ 761 J1630 J1630 HALOPERIDOL 5MG 27.00$ 762 J1631 J1631 HALOPERIDOL DECANOATE INJ PER 50MG 68.00$ 763 J1642 J1642 HEPARIN SODIUM PER 10 UNI 17.00$ 764 J1644 J1644 INJ HEPARIN SOD PER 1000 6.00$ 765 J1650 J1650 ENOXAPARIN SODIUM 10MG 48.00$ 766 J1670 J1670 TETANUS INJECTION 52.00$ 767 J1815 J1815 INJ INSULIN PER 5 UNITS 38.00$ 768 J1817 J1817 INSULIN FOR INSULIN PUMP USE 28.00$ 769 J1830 J1830 INJECTION INTERFERON BETA 1B 0.25MG 250.00$ 770 J1885 J1885 TORADOL INJ 15 MG 28.00$ 771 J1890 J1890 INJECTION CEPHALOTHIN SODIUM 70.00$ 772 J1930 J1930 INJECTION LANREOTIDE 1MG 50.00$ 773 J1940 J1940 LASIX 40 MG IV VIAL 28.00$ 774 J1950 J1950 LEUPROLIDE ACETATE /3.75 MG 50.00$ 775 J1956 J1956 LEVOFLOXACIN 250 MG 152.00$ 776 J1980 J1980 INJ HYOSCYAMINE SULFATE 59.00$ 777 J2001 J2001 LIDOCAINE HCI 10MG 38.00$ 778 J2060 J2060 Injection, lorazepam, 2 mg 127.00$ 779 J2150 J2150 MANNITOL INJECTION 34.00$ 780 J2175 J2175 DEMEROL 50 MG SYRINGE 35.00$ 781 J2185 J2185 INJECTIONMEROPENEM100MG 34.00$ 782 J2250 J2250 MIDAZOLAM HCI PER 1 MG 14.00$ 783 J2270 J2270 INJ MORPHINE SULFATE 10 M 28.00$ 784 J2300 J2300 NUBAIN 10MG AMP 64.00$ 785 J2310 J2310 INJ NALOXONE HCL 1MG 37.00$ 786 J2360 J2360 ORPHENADRINE CITRATE 60MG 156.00$ 787 J2370 J2370 NEO-SYNEPHRINE UP TO 1 ML 103.00$ 788 J2405 J2405 ONDANSETRON HCI PER MG 28.00$ 789 J2543 J2543 ZOSYN - PIPERACILLIN/TAZOBACTAM 74.00$ 790 J2550 J2550 PHENERGAN 50 MG 28.00$ 791 J2650 J2650 PRELONE - INJECTION PREDNISOLONE ACTATE UP TO 1 ML 7.00$ 792 J2675 J2675 INJ PROGESTERONE PER 50 MG 26.00$ 793 J2690 J2690 PRONESTYL 10 ML 28.00$ 794 J2704 J2704 INJECTION PROPOFOL 10MG 100.00$ 795 J2730 J2730 PRALIDOXINE CHLORIDE 28.00$ 796 J2760 J2760 PHENTOLAINE MESYLATE INJ 52.00$ 797 J2765 J2765 METOCLOPRAMIDE HCL 10MG 52.55$ 798 J2780 J2780 INJ RANITIDINE 25 MG 48.00$ 799 J2790 J2790 RHOGAM INJECTION 253.00$ 800 J2791 J2791 RHOPHYLAC INJECTION 75.00$ 801 J2920 J2920 SOLU-MEDROL 40MG 13.00$ 802 J2930 J2930 SOLU-MEDROL 125 MG 95.68$ 803 J2997 J2997 INJECTION ALTEPLASE RECOMBIANANT 60.00$ 804 J3010 J3010 INJ FENTANYL CITRATE .1MG 1.00$ 805 J3030 J3030 IMITREX 6MG VIAL 8.00$ 806 J3105 J3105 INJECTION TREBUTALINE SULFATE UP TO 1 MG 44.00$ 807 J3130 J3130 TESTOSTERONE ENANTHATE INJ 30.00$ 808 J3260 J3260 TOBRAMYCIN SULFATE INJECTION 46.00$ 809 J3301 J3301 KENOLOG 10 MG 45.00$ 810 J3360 J3360 VALIUM INJ 5 MG 52.00$ 811 J3370 J3370 VANCOMYCIN HCI INJ 500MG 290.00$ 812 J3410 J3410 VISTERIL INJ 50 MG 28.00$

813 J3411 J3411 INJ THIAMINE 100 MG 14.00$ 814 J3430 J3430 INJECTION (PHYTONADIONE) VITAMIN K PER 1 MG 16.00$ 815 J3475 J3475 Magnesium Sulfate 50% IV Inj Sol SDV 2mL PF Sterile 14.56$ 816 J3480 J3480 POTASSIUM CHLORIDE 2 MG 64.00$ 817 J3486 J3486 GEODON - ZIPRASIDONE MESYLATE 10MG 44.00$ 818 J3490 J3490 UNCLASSIFIED DRUGS 46.00$ 819 J7030 J7030 INFUS NORM SALINE 1000CC 67.00$ 820 J7040 J7040 INFUS NORM SALINE 500ML 34.00$ 821 J7042 J7042 5% DEXTROSE 34.00$ 822 J7050 J7050 INFS NORM SALINE 250CC 34.00$ 823 J7060 J7060 INFUSION D5W 250ML 35.00$ 824 J7070 J7070 INFUSION D5W 1000ML 35.00$ 825 J7120 J7120 RINGERS LACTATE INFUS 115.00$ 826 J7130 J7130 HYPERTONIC SALINE SOLUTION 96.00$ 827 J7506 J7506 PREDNISONE ORAL 5 MG 10.00$ 828 J7510 J7510 PREDNISOLONE ORAL 5 MG 10.00$ 829 J7512 J7512 PREDNISONE 1MG 11.00$ 830 J7607 J7607 LEVALBUTEROL COMP CON 17.00$ 831 J7610 J7610 ALBUTEROL THRU DME 1MG 17.00$ 832 J7611 J7611 ALBUTEROL 1MG CONC INHALA 17.00$ 833 J7612 J7612 LEVALBUTEROL CONCENTRATE 18.50$ 834 J7613 J7613 ALBUT INHAL NON-CP 1MG 17.00$ 835 J7614 J7614 ALBUTEROL ALL FOMULATIONS 24.00$ 836 J7615 J7615 LEVALBTERAL INHALATION SO 24.00$ 837 J7620 J7620 ALBUTEROL 2.5 MG ATROVENT 17.00$ 838 J7622 J7622 BECLOMETHASONE COMP UNIT 42.00$ 839 J7638 J7638 DEXAMETHASONE INHALATION SOLUTION COMPOUNDED PRODUCT 9.38$ 840 J7644 J7644 IPRATROPIUM BROMIDE INHAL 38.00$ 841 J7699 J7699 NOC DRUGS INHAL SOL ADMIN 10.00$ 842 J8498 J8498 ENEMA SUPPOSITORY ANTIEMETIC RECTAL 38.00$ 843 J8499 J8499 NONCHEMOTHERAPEUTIC ORAL 22.00$ 844 J8540 J8540 DEXAMETHASONE ORAL .25MG 24.00$ 845 J9027 J9027 CLOFARALINE INJECTION 179.00$ 846 L0120 L0120 CERVICAL FLEX NONADJ COLL 408.00$ 847 L0172 L0172 Clavicle Splint 52.00$ 848 L1630 L1630 ABDUCT CONTROL HIP SEMI FLEX 52.00$ 849 L1830 L1830 Knee Immobilizer 20 Inches 30.00$ 850 L1906 L1906 ANKLE SUPPORT 168.00$ 851 L3260 L3260 SURGICAL BOOT/SHOE 110.00$ 852 L3650 L3650 SO FIGURE EIGHT ABDUCTION 318.00$ 853 L3660 L3660 SO FIG 8 ABDUCTION RESTRA 210.00$ 854 L3670 L3670 SO ACROMIO/CLAVICULAR 79.00$ 855 L3908 L3908 WRIST EXTN CONTROL COCKUP 110.00$ 856 L3999 L3999 UPPER LIMB ORTHOSIS NOS 223.00$ 857 L4350 L4350 AIR SPLINT 576.00$ 858 L4360 L4360 WALK BOOT PNEUMATIC 149.00$ 859 L4361 L4361 WALKING BOOTPNEUMATIC AND OR VACUUM 215.00$ 860 L4380 L4380 PNEUMATIC KNEE SPLINT 160.00$ 861 L4386 L4386 WALKING BOOT NON PNEUMATIC 215.00$ 862 P7001 P7001 CULTURE BACTERIAL URINE 114.00$ 863 P9612 P9612 CATHETERIZE FOR URINE 224.00$ 864 Q0144 Q0144 AZITH DIHY ORAL CAP/POWD 204.00$ 865 Q0169 Q0169 PROMETHAZINE HCI 12.5 HCI 28.00$ 866 Q0179 Q0179 ONDANESTRONG HCL 8MG ORL 6.00$ 867 Q4006 Q4006 LONG ARM CAST ADULT 118.00$ 868 Q4007 Q4007 CAST SUPPLIES LONG ARM CA 20.00$ 869 Q4008 Q4008 CAST SUPPLIES LONG ARM 50.00$ 870 Q4009 Q4009 CAST SUPPLIES SHORT ARM 178.00$ 871 Q4010 Q4010 SHORT ARM CAST ADULT 71.00$ 872 Q4012 Q4012 CAST SUPPLIES SHORT ARM 110.00$ 873 Q4020 Q4020 LNG ARM SPLNT 0-10 YRS 49.00$ 874 Q4022 Q4022 SHRT ARM SPLNT 11 YRS + 1,024.00$ 875 Q4034 Q4034 CAST SUP LNG LEG CYLINDER FB 223.00$ 876 Q4037 Q4037 CAST SUPPLIES SHORT LEG 186.00$ 877 Q4038 Q4038 CAST SUP SHRT LEG FIBERGLASS 30.00$ 878 Q4039 Q4039 CAST SUPPLIES SHORT LEG C 186.00$ 879 Q4042 Q4042 LNG ARM SPLNT 11 YRS + 149.00$ 880 Q4046 Q4046 SHRT LG SPLNT 11 YRS + 316.00$ 881 Q4049 Q4049 FINGER SPLNT STATIC 262.00$ 882 Q4051 Q4051 SPLINT SUPPLIES MISC 160.00$ 883 Q9954 Q9954 ORAL MR CONTRAST 100ML 528.00$ 884 Q9961 Q9961 HIGH OSMOLAR CONTRAST MATERIAL 250-299MG/ML PER ML 2.20$ 885 Q9963 Q9963 HI OSM CONTRST MATL 350-3 29.00$ 886 Q9965 Q9965 LOW OSMOLAR CON MAT PER M 31.00$ 887 Q9966 Q9966 LOCM 200-299MG ML IODINE 1ML 28.00$

888 Q9967 Q9967 LOW OSMOLAR CNTRS MAT 8.00$ 889 S0020 S0020 INJ BUPIVICAINE 30ML 59.00$ 890 S0028 S0028 INJECT FAMOTIDINE 20 MG 89.00$ 891 S0030 S0030 METRONIDAZOLE 500 MG INJ 239.00$ 892 S0077 S0077 INJECTION CLINDAMYCIN PHOSPHATE 300MG 41.00$ 893 S0119 S0119 ZOFRAN 4MG ORAL 10.00$ 894 S0164 S0164 PROTONIX PANTROPRAZOLE 40MG 246.00$ 895 S0622 S0622 PHYS EXAM FOR COLLEGE 110.00$ 896 S0630 S0630 RMV SUTURES; PHYS NOT PHY 82.00$ 897 S3000 S3000 BILAT DIL RETINAL EXAM 14.00$ 898 S5000 S5000 PRESCRIPTION DRUG GENERIC 1.00$ 899 S5001 S5001 PRESCRIPTION DRUG BAND NM 10.00$ 900 S5010 S5010 STERILE SALINE 5% DEXTROSE AND 0.45% SALINE 295.00$ 901 S5011 S5011 5% DEXTROSE 1000 ML 1.00$ 902 S5550 S5550 INSULIN RAPID 5 U 34.00$ 903 S8037 S8037 MRCP MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY 1,632.00$ 904 S8100 S8100 SPACER WITHOUT MASK R3060 66.00$ 905 S8101 S8101 MASK NEBULIZER MASK SPACER WITH MASK R3060 74.00$ 906 S8450 S8450 SPLINT 107.00$ 907 4000454618 Ace 2 Inches 2.46$ 908 4000454619 Ace 3 Inches 3.60$ 909 4000454620 Ace 4 Inches 3.78$ 910 4000454621 Ace 5 Inches 6.84$ 911 4000946429 Tube Gause Size 1 33.78$ 912 4000946439 Tube Gauze Size 2 36.96$ 913 4000946435 DRESSING, TUBLR ELAS NET SZ4 (10BX/CS) 30.90$ 914 4000946431 DRESSING, TUBLR ELAS NET SZ5 (10BX/CS) 56.10$ 915 4000081473 Hibiclens Cleanser 23.76$ 916 4000368486 Orthoglass 2 inches 479.58$ 917 4000282603 Orthoglass 3 Inches 662.22$ 918 4000463508 OB Kit 36.54$ 919 4000282600 Orthoglass 4 Inches 533.82$ 920 4000282601 Orthoglass 5 Inches 655.86$ 921 4000485072 Bite Block Large 6.48$ 922 4000485067 Bite Block Small 3.96$ 923 4000485070 AIRWAY, BERMAN 80MM LF (1/PK 24PK/BX) 5.76$ 924 4000741741 AIRWAY, NASAPHARYN DISP BLU 20FR-36FR (9/PK) 19.98$ 925 4000494228 Blade Mac Size 2 Disposable 31.80$ 926 4000494229 Blade Mac Size 3 Disposable 31.80$ 927 4000494230 Blade Mac Size 4 Disposable 31.80$ 928 4000583725 Bougie 15 FR 35.58$ 929 4000371940 ELECTRODE, QUICK COMBO ADLT 125.52$ 930 4000472417 ELECTRODE, QUICK COMBO PED (1PR/PK) 3010107-001 152.76$ 931 4000840128 Bougie 10 FR 61.44$ 932 4000669645 LOCK, BREAK AWAY YLW (100/PK) 1.20$ 933 4000698558 LMA Size 4.0 47.16$ 934 4000698559 LMA Size 3.0 47.16$ 935 4000232283 Stylet 14 FR 21.36$ 936 4000232282 Stylet 6 FR 17.46$ 937 4000349769 ETT 2.5 Uncuff 30.30$ 938 4000349770 ETT 3.0 Uncuff 36.24$ 939 4000241111 ETT 4.5 12.18$ 940 4000241112 ETT 5.0 11.88$ 941 4000232299 ETT 4.0 12.18$ 942 4000241113 ETT 5.5 11.70$ 943 4000278368 ETT 6.0 11.94$ 944 4000278369 ETT 6.5 11.94$ 945 4000232268 ETT 7.0 11.94$ 946 4000232269 ETT 7.5 12.18$ 947 4000232270 ETT 8.0 11.76$ 948 4000232304 ETT 3.5 Uncuff 8.28$ 949 4000232305 TUBE, TRACH UNCUFF 4.0MM (10/BX) MALMED 8.28$ 950 4000232307 TUBE, TRACH UNCUFF 5.0MM (10/BX) MALMED 8.28$ 951 4000860742 Dermabond 88.74$ 952 4000447753 BAG, PAT DRWSTRNG 20X20X4 WHT (250/CS) 0.78$ 953 4000730973 Adult Diaper 2.04$ 954 4000005785 CLOSURE, STRI-STP 1/2 Inches X4 Inches (6/PK,50PK/BX) 8.52$ 955 4000005784 Steri-Strip 1/4 Inch 8.52$ 956 4000989772 CUP, DRINK SIPPY SPILL PROOF PLAS ASTD COLOR 10OZ (16/CS) 30.00$ 957 4000314311 Baby Diaper 1.66$ 958 4000475614 DIAPER, BABYDRY THIN UNISX SZ3 16-28LB (28/PK 4PK/CS) 26.94$ 959 4000475615 DIAPER, BABYDRY THIN UNISX SZ5 27+LB (22/PK 4PK/CS) 26.76$ 960 4000287951 FINGER SPLINT, BASEBALL PADDED LG 5 Inches (12/PK) 8.46$ 961 4000381624 FINGER SPLINT, BASEBALL PADDED MED 4.5 Inches (12/PK) 8.46$ 962 4000287949 FINGER SPLINT, BASEBALL PADDED SM 4 Inches (12/PK) 8.52$

963 4000508142 Finger Trap 774.36$ 964 4000770442 NURSER, CLASSIC W/O BPA TINTED BT 4OZ (3/PK 12PK/CS) 20.40$ 965 4000625083 OCCLUDER, EYE 27.24$ 966 4000983810 Maxi Pad 0.96$ 967 4000734224 Cast Padding 2 inch 3.12$ 968 4000734225 Cast Padding 3 inch 3.78$ 969 4000734226 Cast Padding 4 inch 5.40$ 970 4000540920 Scalpel #11 3.12$ 971 4000540921 Scalpel #15 3.12$ 972 4000457629 STOCKINETTE, TUBE CTN ORTHO 2 Inches X25YD(12RL/CS) 39.24$ 973 4000457631 STOCKINETTE, TUBE CTN ORTHO 4 Inches X25YD(10RL/CS) 66.72$ 974 4000457632 STOCKINETTE, TUBE CTN ORTHO 6 Inches X25YD(6RL/CS) 104.04$ 975 4000907000 SUTURE, NYLON BLK 3-0 DS24/FS1 18 Inches (12/BX) 12.72$ 976 4000906993 SUTURE, NYLON BLK 4-0 DSM18/PS2 18 Inches (12/BX) 24.96$ 977 4000906987 SUTURE, PGA 4-0 DSM13/P3 18 Inches (12/BX) 30.60$ 978 4000906986 SUTURE, PGA 5-0 DSM13/P3 (12/BX) 30.42$ 979 4000906988 SUTURE, PGA BLU 4-0 PC31/PS2 18 Inches (12/BX) 30.60$ 980 4000906985 SUTURE, PGA BR 6-0 45CM DSM13/P3 (12/BX) 33.00$ 981 4000907010 SUTURE, POLYPR BLU 4-0 DSM13/P3 18 Inches (12/BX) 33.60$ 982 4000907009 SUTURE, POLYPR BLU 5-0 DSM13/P3 18 Inches (12/BX) 33.60$ 983 4000907008 SUTURE, POLYPR BLU 6-0 DSM13/P3 18 Inches (12/BX) 33.66$ 984 4000504021 SUTURE, POLYSORB UD 3-0 18 Inches P14 (12/BX) 57.60$ 985 4000962199 Suture Prolene 3.0 FS2 86.10$ 986 4000220213 Suture Silk 0 CT1 17.52$ 987 4000354615 SUTURE, SOFSILK BLK 3-0 18 Inches (12/BX) 21.18$ 988 4000386904 WIPE, BABY NICE&CLEAN SCNTD (40/BX) 9.42$ 989 4000123771 Suture Ethilon 3.0 PS1 71.88$ 990 4000132872 Suture Ethilon 4.0 PS2 67.26$ 991 4000002686 Suture Ethilon 5.0 PS2 56.94$ 992 4000099422 Suture Vicryl 4.0 PS2 80.10$ 993 4000099420 Suture Vicryl 4.0 PS3 75.24$ 994 4000003266 Suture Prolene 4.0 FS2 57.00$ 995 4000003278 Suture Prolene 5.0 P3 13.12$ 996 4000127633 Suture Prolene 6.0 P3 17.17$ 997 4000661789 SKIN MARKER 0.68$ 998 4000382261 Morgan Lens Eye Irrigation 28.81$ 999 4000192676 BRUSH, INSTRUMENT S/S (3/PK) 13.56$

1000 4000850332 ECG PAPER Z-FOLD 8.5X11 INCH RED GRID 27.23$ 1001 4000639015 EKG Tabs Foam 0.18$ 1002 4000536376 EKG Tabs 4.44$ 1003 4000233155 BAG, BIOHAZ HD 24X32 1.2MIL (250/CS) MGM03 0.13$ 1004 4000533886 Infant Ambu 8.73$ 1005 4000533885 Pedi Ambu 9.29$ 1006 4000544775 Adult Ambu 9.56$ 1007 4000327718 U/S Probe Cover 0.84$ 1008 4000476705 Crutches 5.2 - 5.10 100.08$ 1009 4000475660 Crutches 4.0 - 4.6 14.16$ 1010 4000472044 Crutches 3.7 - 4.0 13.44$ 1011 4000475663 Crutches 5.10 - 6.5 68.82$ 1012 4000475661 Crutches 4.6 - 5.2 100.08$ 1013 4000404084 Mouthpiece w/ Strap 0.41$ 1014 4000809780 TOWELETTE, MOIST OB IND WRAP 5 Inches X7 Inches (100/BX 10BX/CS) 0.02$ 1015 4000809891 Wipes 1.70$ 1016 4000612655 WIPES,SCRN CLEAN 40/BX,WE 40 TWIN-PACKS PER BOX 21.16$ 1017 4000629871 Blade Mac Size 1 Disposable 5.30$ 1018 4000344588 Suction Canister 2.98$ 1019 4000368092 End TIdal C02 Tubing 2.20$ 1020 4000543704 Nasal Cannula Pedi 1.17$ 1021 4000543696 Nasal Cannula Adult 0.32$ 1022 4000333417 Pedi CO2 Detector 10.26$ 1023 4000371583 Adult CO2 Detector 10.46$ 1024 4000634850 ENDOTRACHEAL TUBE INTRODUCER 10FR X 70CM 6.57$ 1025 4000541420 LARYNGOSCOPE HANDLE GREENLINE 68.33$ 1026 4000461711 Incentive Spirometer 4.17$ 1027 4000543520 Nebulizer Mask Kit 0.49$ 1028 4000543538 Adult Non Re-Breather 0.85$ 1029 4000543539 Pedi Non Re-breather 1.29$ 1030 4000543793 Adult Continuous Nebulizer Mask 1.39$ 1031 4000543795 Adult Nebulizer Mask 1.01$ 1032 4000130514 NIPPLE & NUT, OXY OUTLETS DISP (50/CS) 0.65$ 1033 4000787573 Pedi O2 Sensor 14.45$ 1034 4000244708 SUCTION CANISTER HOLDER 4.54$ 1035 4000892565 SUCTION CATH KIT 8FR 50/CS PSSRDC 0.82$ 1036 4000419600 SUCTION, FRAZIER INSTRUMENT 10FR 4.47$ 1037 4000649120 Yankauer 0.71$

1038 4000348520 SYRINGE, EAR BULB STR 2OZ (50/CS) 0.82$ 1039 4000194545 NG Tube 14 FR 2.73$ 1040 4000194687 NG Tube 16 FR 2.79$ 1041 4000067210 TUBE, STOMACH LEVIN N/S 14FR 48 Inches (50/CS) 1.04$ 1042 4000045947 TUBE, STOMACH LEVIN N/S 16FR 48 Inches (50/CS) 1.08$ 1043 4000649127 Suction Tubing 0.93$ 1044 4000649125 TUBING, CONN STR 3/16 Inches X1.5 Feet (50/CS) 0.57$ 1045 4000649048 Vent Tubing 8.71$ 1046 4000717900 ABDOMINAL BINDER, VELC CLSR 12 Inches LF WHT 60 Inches -75 Inches 24.48$ 1047 4000890881 Pedi Bandage 4.04$ 1048 4000239054 BANDAGE, ADHSV BUTTERFLY MD (100/BX) 197500 3.82$ 1049 4000466873 BANDAGE, ADHSV FABR KNCKL 1.5X3 (100/BX 24BX/CS) 0.04$ 1050 4000514534 Large Band-Aid 4.12$ 1051 4000466872 Small Band-aid 0.02$ 1052 4000557627 BANDAGE, BLUE/PINK CAMMO 3/4 Inches X3 Inches (100/BX 12BX/CS) 3.39$ 1053 4000373775 BANDAGE, CNFRM STRCH 3 Inches STR LF (12RL/BX) 0.36$ 1054 4000645796 BANDAGE, CNFRM STRCH 4 Inches STR (12RL/BX 8BX/CS) 0.29$ 1055 4000464157 Coban 1 Inch 0.15$ 1056 4000710816 Kerlix 2 1/4 Inches 0.70$ 1057 4000010173 Kerlix 4 1/2 inches 1.46$ 1058 4000488925 DRESSING, ISLAND BORDER-GZE STR LF 4X10 Inches (25/BX 4BX/CS) 1.68$ 1059 4000373777 Telfa Dressing 3x4 0.06$ 1060 4000121652 Tegaderm Large 1.13$ 1061 4000222004 Tegaderm Small 0.30$ 1062 4000485416 Ice Bag 1.22$ 1063 4000131596 Incision and Drainage Tray 3.88$ 1064 4000153784 INSTANT HEAT BAG, QUICK HEAT 6X9 (24/CS) 1.12$ 1065 4000163946 IRRIGATION TRAY, PISTON SYR STR (20/CS) 1.10$ 1066 4000148893 Irrigation tray w/ 60CC Syringe 1.71$ 1067 4000199467 Lac Tray 6.38$ 1068 4000470440 Packing Strip, Iodfrm 2.53$ 1069 4000296449 Staple Removal Tray 1.07$ 1070 4000455907 Irrigation Splash Guard 1.34$ 1071 4000373772 2x2 Gauze Tray 0.76$ 1072 4000762703 SPONGE, GZE 4 Inches X4 Inches 12PLY STR 2 Feet S (25PK/BX) 0.09$ 1073 4000440028 SPONGE, GZE 4 Inches X4 Inches 8PLY N/S (200/BG) 2.65$ 1074 4000481055 4x4 Gauze single pack 0.78$ 1075 4000498029 STAPLER, SKIN 35REG FXD HEAD (6BX 4BX/CS) 10.15$ 1076 4000166492 Stapler 6.74$ 1077 4000471085 Suture Removal Tray 1.80$ 1078 4000869660 SYRINGE, IRR PISTON STR LF 60CC (50/CS) 0.62$ 1079 4000455534 Silk tape 1 inch 0.83$ 1080 4000005775 TAPE, ADHSV DURAPORE 1 Inches X10YDS (12/BX) 0.83$ 1081 4000005776 TAPE, ADHSV DURAPORE 2 Inches X10YDS (6/BX) 1.68$ 1082 4000005777 TAPE, ADHSV DURAPORE 3 Inches X10YDS (4/BX) 2.50$ 1083 4000005959 TAPE, ADHSV FOAM 1 Inches X5 1/2YDS (12/BX) 1.88$ 1084 4000005947 Foam Tape 3 Inch 1.88$ 1085 4000005960 Foam Tape 4 Inches 7.52$ 1086 4000005767 Paper Tape 1 inch 0.54$ 1087 4000684273 Paper Tape 3 Inch 1.64$ 1088 4000455537 Tape 1 Inch 0.71$ 1089 4000324081 TAPE, MEDIPORE SFT CLTH 2X10YDS (12RL/CS) 4.49$ 1090 4000684060 TAPE, MEDIPORE SFT CLTH 3 Inches X10YDS (12/CS) 9.61$ 1091 4000364637 WIPE, SKIN PREP NO-STING (50/BX 20BX/CS) 20.68$ 1092 4000864638 XEROFAOM PETROLEUM DRESSING 1 X 8 INCH 0.43$ 1093 4000337454 BANDAGE, ADHSV ASTD NEON 3/4 Inches X3 Inches (100/BX) 4.03$ 1094 4000416158 Disposable Nose Clip 0.99$ 1095 4000911820 Adult Ear Curette 33.38$ 1096 4000911821 Pedi Ear Curette 28.38$ 1097 4000487037 EAR SPECULUM (ADULT) KLEENSPEC BLACK 1.13$ 1098 4000487036 EAR SPECULUM (PEDIACTRIC) KLEENSPEC BLACK 1.10$ 1099 4000865298 Katz Extractor 84.16$ 1100 4000487477 FORCEP, ALLIGATOR OG SERR 3.5 Inches 26.13$ 1101 4000487478 FORCEP, ALLIGATOR OG SERR 5 1/2 Inches 30.45$ 1102 4000510931 Rhino Rocket Medium 15.24$ 1103 4000505749 Packing, Plain 4.74$ 1104 4000467977 Oval Eye Pad 0.10$ 1105 4000476698 Alum Eye Shield 0.92$ 1106 4000689979 TAPE, MEASURE PAPER INF 24 Inches LF (1000/BX) 0.03$ 1107 4000481650 TAPE, MEASURE RETR LINEN 72 Inches LF (6/BX) 2.03$ 1108 4000482774 AIR WALKER BOOT MEDIUM (LOW RISE) 35.76$ 1109 4000482773 AIR WALKER BOOT SMALL (LOW RISE) 36.08$ 1110 4000482780 Walking Boot Large 44.06$ 1111 4000482779 Walking Boot Medium 44.06$ 1112 4000482778 Walking Boot Small 44.06$

1113 4000413490 Arm Sling Large 2.06$ 1114 4000380600 Arm Sling Medium 2.06$ 1115 4000416800 Arm Sling Small 2.05$ 1116 4000380615 Arm Sling Extra-Large 2.05$ 1117 4000380613 Arm Sling Pedi 2.05$ 1118 4000410224 CERVICAL COLLAR PHILADELPHIA (LARGE) 15.61$ 1119 4000410223 C-Collar Adult 15.67$ 1120 4000410222 C-Collar Pedi 15.72$ 1121 4000374576 COLLAR, CERVICAL EXTRICATION ADJ (30/CS) 7.88$ 1122 4000425616 COLLAR, EXTRICATION LT GRN 3 Inches PED (50/CS) 6.82$ 1123 4000580557 Shoulder Immobilizer 5.76$ 1124 4000370146 KNEE BRACE, NEOP HINGED WRPRND MED 31.04$ 1125 4000370084 Knee Immobilizer 12 Inches 14.39$ 1126 4000370115 Knee Immobilizer 16 inches 14.90$ 1127 4000410162 Post-op Shoe Female Large 12.88$ 1128 4000410161 Post-op Shoe Female Medium 6.44$ 1129 4000410160 Post-op Shoe Female Small 6.44$ 1130 4000410159 Post-op Shoe Male Large 6.44$ 1131 4000410158 Post-op Shoe Male Medium 6.44$ 1132 4000410157 Post-op Shoe Male Small 6.44$ 1133 4000381408 Post-op Shoe Male Extra-Large 6.44$ 1134 4000412020 THUMB SPLINT, SPICA ABDUCTED LT UNIV 7.74$ 1135 4000251621 THUMB SPLINT, SPICA ABDUCTED RT UNIV 7.74$ 1136 4000346149 Alum Wrist Splint Lt Large 8.00$ 1137 4000346148 Alum Wrist Splint Lt Medium 8.00$ 1138 4000346147 Alum Wrist Splint Lt Small 8.00$ 1139 4000346150 Alum Wrist Split Lt Extra-Large 8.10$ 1140 4000346157 Alum Wrist Split Lt Pedi 8.00$ 1141 4000346145 Alum Wrist Splint Rt Large 8.00$ 1142 4000346144 Alum Wrist Splint Rt Medium 8.00$ 1143 4000370093 Alum Wrist Splint Rt Small 8.01$ 1144 4000346146 Alum Wrist Splint Rt Extra-Large 8.10$ 1145 4000346525 Alum Wrist Splint Rt Pedi 8.00$ 1146 4000721111 BAG, BROWN PAPER GROCERY #4 (500/PK) 0.02$ 1147 4000738078 Emisis Bag 15.62$ 1148 4000225259 Wash Basin 3.60$ 1149 4000456600 BRACKET, ALCARE DSPN W/CLIP (24/CS) (FOAM DISP) 2.39$ 1150 4000497383 CUP, DENTURE TEAL W/OPAQ LID 8OZ LF (25/SL 10SL/CS) 0.20$ 1151 4000449464 FRAMES, SAFETY SFVW ASTD COL (10/PK 10PK/CS) KIMCLK 0.67$ 1152 4000714956 GLASSES,SAFETY,CLR 1.64$ 1153 4000975531 GLOVE, AQUASOFT PF NITRILE LG (300/BX 10BX/CS) 15.60$ 1154 4000975530 GLOVE, AQUASOFT PF NITRILE MED (300/BX 10BX/CS) 15.60$ 1155 4000975529 GLOVE, AQUASOFT PF NITRILE SM (300/BX 10BX/CS) 15.60$ 1156 4000975532 GLOVE, AQUASOFT PF NITRILE XLG (250/BX 10BX/CS) 15.60$ 1157 4000721892 Sterile Glove 6 1.68$ 1158 4000721894 Sterile Glove 7 1.68$ 1159 4000721895 Sterile Glove 7.5 1.69$ 1160 4000721896 Sterile Glove 8 1.68$ 1161 4000552406 Isolation Gown Yellow 8.05$ 1162 4000342891 Procedure Gown Blue 2.73$ 1163 4000689981 Face Mask W/ Earloop 3.58$ 1164 4000304648 N95 Mask Small 20.21$ 1165 4000420651 MASK, N95 MED (20/BX) 0.92$ 1166 4000450502 MASK, PARTICULATE RESP T-FOLD N95 (20/BX) 0.79$ 1167 4000877023 NO-RINSE SHAMPOO AND BODY WASH 8 OZ. 1.17$ 1168 4000474851 Disposable Razor 0.36$ 1169 4000202819 Restraints 2.30$ 1170 4000334874 SLIPPER SOCKS ADULT 1.26$ 1171 4000334875 SLIPPER SOCKS ADULT XL 1.24$ 1172 4000504733 SLIPPER SOCKS ADULT XXL 1.22$ 1173 4000334873 Socks 1.31$ 1174 4000484875 E-Z Scrub 5.45$ 1175 4000485517 STRAW, PLASTIC FLEX WRAP LF (500/BX 20BX/CS) 3.75$ 1176 4000736869 TISSUE, FACIAL ANGEL SOFT 7.6 X 8.5 R3060 1.32$ 1177 4000477563 Chux 0.10$ 1178 4000928732 WIPE, SANICLOTH SUPER GERMICIDE LG (160/CN 12CN/CS 5.02$ 1179 4000482924 Small Pedi Armboard 0.87$ 1180 4000052013 Large Pedi Armboard 0.80$ 1181 4000652281 Central Line Kit 109.19$ 1182 4000231564 20G IV Cath 118.25$ 1183 4000231560 18G IV Cath 110.79$ 1184 4000231558 22G IV Cath 110.79$ 1185 4000231559 24G IV Cath 110.79$ 1186 4000161339 Trochar 24 FR 6.11$ 1187 4000031713 Pleuravac 22.42$

1188 4000471087 Nosebleed Tray 4.86$ 1189 4000478112 J-loop 2.64$ 1190 4000412491 EXTENSION SET18 INCH 1 PORT 2.7ML PRIMING VOLUME 4.84$ 1191 4000486949 IV HUB 0.97$ 1192 4000298004 IV Buretrol 6.98$ 1193 4000471088 IV Start Kit 1.87$ 1194 4000498851 LP Tray Adult 9.97$ 1195 4000498850 LP Tray Pedi 8.86$ 1196 4000443843 Blunt Needle 11.41$ 1197 4000037825 Filter Needle 0.22$ 1198 4000651680 27G Needle 0.21$ 1199 4000770834 Power Port Needle 6.39$ 1200 4000775374 Port-a-cath Needle 5.66$ 1201 4000721358 21G Needle 0.16$ 1202 4000721361 23G Needle 0.16$ 1203 4000721364 25G x 1.5 inches Needle 0.20$ 1204 4000204920 NEEDLE, SPINAL DISP 23GX3 1/2 Inches (25/BX) 1.97$ 1205 4000171492 Stopcock 0.71$ 1206 4000234732 1 ML Syringe 0.46$ 1207 4000626062 10ml Syringe 0.09$ 1208 4000863714 SYRINGE, LL 20CC 0.25$ 1209 4000863715 3 CC Syringe 0.05$ 1210 4000863717 5 CC Syringe 0.07$ 1211 4000869662 SYRINGE, LL 60CC 0.33$ 1212 4000629838 Insulin Syringe 0.09$ 1213 4000863702 25G x 5/8 inches Needle 0.07$ 1214 4000035664 TOURNIQUET, LTX FREE (25/BX OR 500/CS) 0.34$ 1215 4000319070 Chest Tube Insert Tray 77.91$ 1216 4000226131 Butterfly with Vacutainer 1.16$ 1217 4000630153 IV non pump tubing 2.46$ 1218 4000457971 Secondary IV Tubing 1.65$ 1219 4000832556 IV Dial-A-Flow 3.06$ 1220 4000191089 ALCOHOL PREP PAD 1.47$ 1221 4000439864 Chloraprep 1.12$ 1222 4000526681 Cloraprep 0.87$ 1223 4000508713 APPLICATOR, COTTONTIP STR 6 Inches (2/PK 100PK/BX 10BX/CS) 3.34$ 1224 4000584264 BAG, SPCMN BIOHAZ 3WALL W/ZIP RED 6 Inches X9 Inches (1000/CS) 0.04$ 1225 4000883863 Pedi Urine Bag 0.90$ 1226 4000911680 Leg Bag 1.88$ 1227 4000450030 Fracture Pan 0.89$ 1228 4000225266 Bedpan 6.54$ 1229 4000508714 BLADE, TONGUE SR STR 6 Inches (100/BX 10BX/CS) 2.84$ 1230 4000528370 Stat Lock Foley 4.62$ 1231 4000143554 Foley Cath 16 FR 10.95$ 1232 4000204313 Female Cath Kit 5.10$ 1233 4000204312 Infant Cath Kit 4.24$ 1234 4000701378 Female Straight Cath Kit 2.80$ 1235 4000046086 Coude Cath 14 FR 19.04$ 1236 4000046085 Coude Cath 16 FR 19.04$ 1237 4000533913 Coude Cath 20 FR 15.10$ 1238 4000170551 Urine Cup 0.13$ 1239 4000953916 COVER, PROBE ORAL SURETEMP DISP (250/BX 30BX/CS) 9.58$ 1240 4000805517 Disposable BP Cuff Infant 2.16$ 1241 4000653660 CUFF, BP FLEXIPORT SOFT DISP ADLT (20/CS) 2.10$ 1242 4000653656 Disposable BP Cuff Pedi 2.10$ 1243 4000653506 CUFF, BP FLEXIPORT SOFT DISP LG ADLT (20/CS) 2.61$ 1244 4000702185 Disposable BP Cuff Adult 2.94$ 1245 4000702186 Disposable BP Cuff Small Adult 2.20$ 1246 4000487566 FORCEP, FOERSTER OG STRT SERR 9 1/2 Inches 18.25$ 1247 4000231066 Irrigation Catheter 17.78$ 1248 4000788485 Lubricating Jelly, 3GM 0.06$ 1249 4000188675 PAD, ADHSV TAPE REMOVER (100/BX) 4.29$ 1250 4000103596 PAD, NAIL POLISH REMOVER (100/BX) 2.99$ 1251 4000584270 Vaginal Specula 1.87$ 1252 4000584269 SPECULA, VAGINAL SMALL KLEENSPEC PREM 590 1.87$ 1253 4000482530 Urine Strainer 1.03$ 1254 4000051723 OB Swabs 3.97$ 1255 4000739976 Vacutainer 0.85$ 1256 4000370602 SWABSTICK, POVIDONE/IODINE (50/BX 10BX/CS) 0.19$ 1257 1000001476 MultiStix Urine Dip Test Strips 2.40$ 1258 1000001477 UDS Test Kits 56.40$ 1259 1000001479 Mono Test Kit 16.08$ 1260 1000001482 RSV 67.56$ 1261 1000001483 Fecal Occult Bood Test Kit 28.20$ 1262 1000001484 Alcohol Test Kit 39.54$

1263 1000001485 Ethanol Controls 186.48$ 1264 1000001486 Green Top Tubes 75.90$ 1265 1000001487 Purple Top tubes 54.78$ 1266 1000001488 Blue Top tubes 68.82$ 1267 1000001489 Lancets Blue 1.32$ 1268 1000001490 Lancets 0.13$ 1269 1000001491 Glucometer Control Level 1 43.92$ 1270 1000001492 Glucometer Control Level 2 41.34$ 1271 1000001493 Glucometer Test Strips 123.18$ 1272 1000001494 Glucomter Test Strips 2.16$ 1273 1000001495 Alere Triage Total 5 Control 2 107.52$ 1274 1000001496 Alere Triage Total 5 Control 1 17.93$ 1275 1000001497 Urine Drug Controls 184.74$ 1276 1000001498 Piccolo Controls 180.42$ 1277 1000001499 Piccolo Liver Panel 77.76$ 1278 1000001500 Sysmex Controls 142.86$ 1279 1000001501 HCG controls 137.58$ 1280 1000001502 Urine Dip Controls 407.52$ 1281 1000001503 Piccolo CMP Cartridges 61.38$ 1282 1000001504 Triage BNP 190.38$ 1283 1000001505 Triage Cardiac 193.02$ 1284 1000001506 Triage D-Dimer 134.94$ 1285 1000001507 Istat CG4 Cartidges 56.40$ 1286 1000001508 Cell Pack 244.26$ 1287 1000001509 Reagent 275.64$ 1288 1000001510 Pipettes for Piccolo 81.06$ 1289 4000848909 Sweet Ease 6.72$ 1290 4000226132 23g Butterfly 1.16$ 1291 500002072 Urine Hat 2.89$ 1292 700010037 Tiger top collection tube 4.25$ 1293 1000007566 Sponge Forceps 91.25$ 1294 90003269271 Fluroescein Strips 12.42$ 1295 4000380614 Bacitracin 47.55$ 1296 4000380612 Augmentin 875mg 10.65$ 1297 4000380611 Acetaminophen 180mg 13.00$ 1298 4000380610 Acetaminophen-Hydrocodone Tablet 5/325mg 73.50$ 1299 4000380609 Prednisone tablet 20mg 6.85$ 1300 4000380608 Flexeril 10mg tablet 6.40$ 1301 4000380607 Azithromycin 500mg tablet 11.70$ 1302 4000380606 Ibuprofen 600mg tablet 5.50$ 1303 4000380605 Acetaminophen w/codeine elixir 15ml 31.00$ 1304 4000454622 Small Aluminum Foam Finger Splint 7.00$ 1305 4000454623 J3490 Labetalol Inj 10mg 20.88$ 1306 4000454624 Aspirin Tablet 325mg 1.15$ 1307 4000454625 Nitroglycerin 0.4mg tablet 3.60$ 1308 4000454626 Nitroglycerin Paste Topical 107.60$ 1309 50004001 Tramadol 50mg PO 89.42$ 1310 82005 Amoxicillin 500mg tablet 2.20$ 1311 82006 Tetracaine 69.10$ 1312 82007 Acetaminophen 650mg tablet 14.40$ 1313 82008 Ibuprofen 100mg tablet 1.35$ 1314 82011 Famotidine 20mg tablet 15.35$ 1315 82012 Acetaminophen 1000mg tablet 1.20$ 1316 4000454627 Benadryl 7.2mg tablet 12.10$ 1317 4000454628 Atarx (Hydroxyzine) 12.5mg tablet 20.00$ 1318 82013 Benadryl PO 50mg 2.55$ 1319 82014 Meclizine 25mg tablet 27.65$ 1320 82015 GI Cocktail (Calcium Carbonate Antacid) PO 50ml 18.49$ 1321 82016 Lidocaine and Prilocaine topical cream 213.85$ 1322 82017 Silvadene topical cream 20.00$ 1323 C9113 C9113 Injection, pantoprazole sodium, per vial 28.00$ 1324 82018 Amoxicillin Susp PO 25mg 17.00$ 1325 82019 Ibuprofen PEDS PO 10mg 42.70$ 1326 82020 Cipro 500mg PO 37.65$ 1327 82021 Potassium Chloride PO 20mg 38.00$ 1328 82022 Clindamycin 300mg 7.50$ 1329 82023 Doxycycline 100mg PO 7.25$ 1330 82024 Levaquin 750mg tablet 56.00$ 1331 82025 Phenazopyridine 200mg 2.00$ 1332 82026 Sulfamethoxazole/ Trimethoprim 800/160mg 2.05$ 1333 82028 Tylenol PED 650mg 32.80$ 1334 82029 J3490 D-50 Saline 100ml Bag 34.00$ 1335 82030 Amoxicillin 250mg 3.80$ 1336 82031 Cephalexin 500mg 48.75$ 1337 82032 Lomotil (Diphenoxylate-Atropine) PO tablet 176.05$

1338 76604 76604 Ultrasound, chest (includes mediastinum), real time with image documentation 433.95$ 1339 82033 J3490 Ketamine 7.5mg 3.00$

1340 76642 76642Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited 430.10$

1341 82034 Lidocaine Viscous PO 5ml 50.00$ 1342 82035 Bactroban (Mupirocin calcium) Topical 61.55$ 1343 82036 Benzonatate 200mg 5.00$ 1344 82037 Carafate (Sucralfate) 1gm 69.90$ 1345 82038 Flagyl 500mg PO 8.00$ 1346 82039 Orthopedic Shoe 144.95$

1347 51798 51798Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging 151.45$

1348 82041 J3490 Etomidate IVP 10mg 76.64$ 1349 82042 Metoprolol PO 25mg 2.75$ 1350 82043 Nitrous Oxide Inhaled Drip 50% 19.00$ 1351 S8451 S8451 Splint, prefabricated, wrist or ankle 74.95$ 1352 82044 Pepcid (Famotidine) PO 40mg 29.65$ 1353 82045 Acetaminophen PEDS PO 15mg 20.55$ 1354 82046 Magnesium Citrate PO Solution Elixir 300ml 10.70$

1355 41250 41250Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue 768.25$

1356 29260 29260 Strapping; elbow or wrist 98.15$ 1357 82047 Phenergan PO 12.5mg 23.30$ 1358 82048 Zantac (Ranitidine) PO 150mg 3.50$ 1359 82049 Cerumenex (Triethanolamine) Ear Drops 38.75$ 1360 73501 73501 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view 145.00$ 1361 54220 54220 Irrigation of corpora cavernosa for priapism 674.70$ 1362 55100 55100 Drainage of scrotal wall abscess 831.80$ 1363 82050 Amoxicillin Clavulanate PO 7ml 4.20$ 1364 82051 Loperamide 2mg PO 2.30$

1365 70482 70482Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections 1,448.75$

1366 25535 25535 Closed treatment of ulnar shaft fracture; with manipulation 2,211.10$

1367 76811 76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation 897.95$

1368 86617 86617 Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot) 968.00$

1369 86757 86757 Antibody; Rickettsia 1,628.00$

1370 26705 26705Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia 1,859.15$

1371 Levsin Levsin (Hyoscyamine Sulfate) PO Tablet 0.125 mg 14.00$ 1825 73201 73201 Computed tomography, upper extremity; with contrast material(s) 1,074.60$

1826 76810 76810Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester 458.25$

1827 64400 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 355.75$ 1828 Tamiflu Tamiflu PO Capsule 75mg 34.00$ 1829 79-90183 Post-Op Shoe Pedi 36.66$ 1830 79-90185 Shoe Post-Op Nylon/Foam Blue Rocker Sole Men 9-11 Size Medium Ea 36.66$ 1831 H9387110 Syringe Oral ExactaMed Polypropylene 10cc Transparent 2.64$ 1832 V933-140 Cutter Ring Vantage 6-1/2" Chrome EA 231.42$ 1833 8839181 Ear Irrigation Tubing 13.31$ 1834 100-1290 Speculum Nasal Vienna Henry Schein Medium Stainless Steel Ea 137.04$ 1835 Marcaine J3490 Marcaine Injection 0.5% 59.00$ 1836 ClonidineTab Clonidine PO Tablet 0.2mg 2.50$

1837 76802 76802Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester 320.10$

1838 29530 29530 Strapping; knee 95.00$ 1839 Diazepam Diazepam PO 5mg 23.15$

1840 17110 17110

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 343.20$

1841 82052 Metoprolol 1.25mg 32.35$ 1842 Q0162 Q0162 Ondansetron 1 mg, oral, 6.00$ 1843 ShortLegFiberglass Short Leg Fiberglass Splint 211.95$ 1844 FentanylIntranasal Fentanyl Intranasal 25mcg 70.00$ 1845 5000PCAK Port-a-catch Access Kit 8.00$ 1846 4000PEDJLOP Pedi IV J-Loop 2.64$ 1847 4000HEEL Heel Warmer 8.40$ 1848 4000IVPMPTUB IV Pump Tubing 4.70$ 1849 4000TAPE3IN Tape 3 Inch 2.10$ 1850 4000SKTP3IN Silk Tape 3 Inch 2.49$ 1851 4000COBAN2 Coban 2 Inches 0.30$ 1852 4000COBAN3 Coban 3 Inches 0.45$

1853 4000COBAN4 Coban 4 Inches1854 4000TELFA2X3 Telfa Dressing Small 2x3 0.06$ 1855 4000ADAPTIC Adaptic 3x3 8.40$ 1856 4000ABDPADSM Abdominal Pad Small 4.40$ 1857 4000ABDPADLG Abdominal Pad Large 8x3 9.20$ 1858 4000XEROFORM Xeroform Dressing up to 4x4 2.10$ 1859 4000ADAPTIC2X3 Adaptic 2x3 6.40$ 1860 Hydrocodone Hydrocodone PO 5/325mg 20.55$ 1861 4000MALLINKROT Contrast Syringe, Mallinkrot 11.50$ 1862 4000CTEXT CT Extension Coiled 23.40$ 1863 4000GELPAK U/S Gel Packet 7.30$ 1864 4000O2SENS Adult O2 Sensor 19.20$ 1865 4000DISBPLG Disposable BP Cuff Adult Lg 4.80$ 1866 4000STRGLV65 Sterile Glove 6.5 1.68$ 1867 4000MASKSHIELD Mask W/ Faceshield 11.50$ 1868 4000N95MED N95 Mask Medium 20.21$ 1869 4000N95LG N95 Mask Large 20.21$ 1870 4000SURGGOWN Sterile Surgical Gown 18.40$ 1871 4000MASTISOL 272 Mastisol 13.40$ 1872 4000STERI12 Steri-Strip 1/2 Inch 16.20$ 1873 4000ETH40P3 Suture Ethilon 4.0 P3 56.94$ 1874 4000ETH50P3 Suture Ethilon 5.0 P3 56.94$ 1875 4000ETH60P3 Suture Ethilon 6.0 P3 56.94$ 1876 4000NYL20C15 Suture Nylon 2.0 C-15 89.20$ 1877 4000CHR20CT1 Suture Chromic Gut 2.0 CT1 89.61$ 1878 4000CHR30CTA Suture Chromic Gut 3.0 CT1 59.47$ 1879 4000CHR40P3 Suture Chromic Gut 4.0 P3 31.20$ 1880 4000CHR40FS2 Suture Chromic Gut 4.0 FS2 43.21$ 1881 4000VIC30PS1 Suture Vicryl 3.0 PS1 112.30$ 1882 4000VIC40P3 Suture Vicryl 4.0 P3 74.80$ 1883 4000VIC60P3 Suture Vicryl 6.0 P3 65.20$ 1884 4000VIC50PS2 Suture Vicryl 5.0 PS2 78.20$ 1885 4000GUTSUT Suture, Plain Gut 5.0 PC1 50.19$ 1886 4000ETH60PS3 Suture Ethilon 6.0 PS3 62.12$ 1887 4000VIC50PS3 Suture Vicryl 5.0 PS3 64.20$ 1888 4000WXRM Ear Wax Removal Solution 32.10$ 1889 4000RHINSM Rhino Rocket Small 11.30$ 1890 4000RHINMD Rhino Rocket Large 18.20$ 1891 4000SPO2ADLT Adult SP02 Monitor Disposable 14.20$ 1892 4000SP02PEDI Pedi SP02 Monitor Disposable 14.20$ 1893 4000NEBPED Pedi Nebulizer Mask 1.40$ 1894 4000NASTRM Nasal Trumpet 2.40$ 1895 4000STY10FR Stylet 10 FR 17.25$ 1896 4000ETTSC ETT Securement Device 4.80$ 1897 4000CPAP Adult CPAP Mask 74.00$ 1898 4000GLDSCP1 Glidescope Size 1 18.20$ 1899 4000GLDSCP2 Glidescope Size 2 19.20$ 1900 4000GLDSCP3 Glidescope Size 3 21.29$ 1901 4000GLDSCP4 Glidescope Size 4 22.40$ 1902 4000ICEBAG Reuseable Ice Bag 1.22$ 1903 4000ALUMFSMED Medium Aluminum Foam Finger Splint 7.00$ 1904 4000ALUMFSLG Large Aluminum Foam Finger Splint 7.00$ 1905 4000ALUMFSXLG Extra-Large Aluminum Foam Finger Splint 7.00$ 1906 4000ANKGEL85 Ankle Gel Support 8.5 19.20$ 1907 4000ANKGEL90 Ankle Gel Support 9.0 22.30$ 1908 4000ANKGEL10 Ankle Gel Support 10 23.80$ 1909 4000WDCTH Wards Cath 1.90$ 1910 4000EMBSN Emisis Basin 3.60$ 1911 4000NGTB10 NG Tube 10 FR 2.70$ 1912 4000NGTB18 NG Tube 18 FR 2.70$ 1913 4000NGTUBVLAR NG Tube Valve Anti-Reflux 4.90$ 1914 4000NGTUBHLD NG Tube Adhesive Holder 4.15$ 1915 4000CATHADD Add-a-Cath 4.20$ 1916 LongLegFiberglass Long Leg Fiberglass Splint 87.90$ 1918 FentanylIntraNas Fentanyl Intranasal 25mcg 70.00$ 1919 4000IVKIT205 IV Kit 20 G -$ 1920 4000IVKITPEDI24G IV Kit Pedi 24G -$ 1921 4000IVKIT22G IV Kit 22G1922 4000IVKIT18G IV Kit 18G1923 4000EYEXKIT Eye Exam Kit -$ 1924 4000EYEIRIGKIT Eye Irrigation Kit1925 4000EARIRIGKIT Ear Irrigation Kit1926 4000BLDDWKIT Blood Draw Kit1927 4000VAGEXKIT Vaginal Exam Kit1928 4000NGTBKIT NG Tube Kit

1929 4000ALCOLLESLTSM Alum Colles Splint Lt Small 11.00$ 1930 4000ALCOLLESLTMD Alum Colles Splint Lt. Med 11.00$ 1931 4000ALCOLLESLTLG Alum Colles Splint Lt Large 11.00$ 1932 4000ALCOLLESRTSM Alum Colles Splint Rt Small 11.00$ 1933 4000ALCOLLESRTMD Alum Colles Splint Rt Medium 11.00$ 1934 4000ALCOLLESRTLG Alum Colles Splint Rt Large 11.00$

1935 82274 82274Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations 88.35$

1936 Afrin Afrin (Oxymetazolin) Nasal Spray 13.35$ 1937 AmoxicillinSuspen Amoxicillin Suspension 400mg/5ml 19.95$ 1938 28193 28193 Removal of foreign body, foot; complicated 1,851.25$ 1939 ClindamycinPO Clindamycin PO 150mg 7.05$ 1940 Erythromycin Erythromycin Eye Ointment 20.00$ 1941 Levofloxacin500mg Levofloxacin 500mg 7.45$ 1942 77046 77046 Magnetic resonance imaging, breast, without contrast material; unilateral 1,200.45$ 1943 77047 77047 Magnetic resonance imaging, breast, without contrast material; bilateral 1,234.00$ 1944 77048 77048 Magnetic resonance imaging, breast, without and with contrast material(s), 1,904.50$

1945 77049 77049Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection(bilateral) 1,947.05$

1946 A9270 A9270 Noncovered Item or Service 1.00$ 1947 20612 20610 Aspiration and/or injection of ganglion cyst(s) any location 1,237.40$