Charge Master Description Price HCPCS Code4174153 0.9% SODIUM CHL BACTERIOSTATIC 30ML, 25 vials 9.00 4174695 8.4% SODIUM BICARB INJ 50MEQ, 10 syringes 45.00 4174738 ACETAMENOPHEN ADULT 500MG/15ML, bottle 33.00 4174504 ACETAMENOPHEN CHILD 160MG/5ML, 100 IUD 5ml cup 9.00 4174505 ACETAMINOPHEN TAB 325MG, 1000 eaches 3.00 4174503 ACETAMINOPHEN TAB 500MG, 1000 eaches 3.00 4174500 ACETAMINOPHEN SUPP 120MG, 12 eaches 6.00 4174499 ACETAMINOPHEN SUPP 325MG, 12 eaches 6.00 4174144 ACETYLCYSTEINE 20% 200mg/ml, 3 vials 94.00 4173410 ACTIVATED CHARCOAL 208mg/ml, one tube 81.00 4174618 ACYCLOVIR TAB 400MG, 100 eaches 3.00 4173416 ADACEL TETANUS/DITPHTH/PERTUSS, 10 vials 141.00 4173420 ADENOSINE INJ 6MG/2ML, 10 vials 15.00 J01534174533 ALBUTERIL SUL HFA 90MCG, 1HFA 181.00 4173433 ALBUTEROL SUL INH SOL 0.083, 30amps 3.00 4173445 ALOE VESTA PROTECTIVE OINT 3, 1 tube 27.00 4174564 ALPRAZOLAM TAB 0.25MG C4, 100 eaches 3.00 4174792 AMIDATE ETOMIDATE INJ 40MG/20ML, 10vials 33.00 J34904174221 AMIODARONE TAB 200MG, 100 eaches 5.00 4173457 AMIODARONE HYD INJ 150MG/3ML, 10vials 15.00 J34904174198 AMLODIPINE TAB 5MG, 100 eaches 3.00 4173512 AMOX/CLAVUL POT 125MG/5ML , 75ml bottle 835.00 4173514 AMOX/CLAVUL POT 875/125MG, 20 eaches 5.00 4173458 AMOXICILLIN CAP 250MG, 100 eaches 3.00 4173460 AMOXICILLIN ORAL SUSP 125MG/5ML, 80ml bottle 9.00 4174629 AMOXICILLIN ORAL SUSP 250MG/5ML, 100ml bottle 12.00 4174785 AMPICILLIN AND SULBACTAM INJ 3GM, 10 vials 68.00 4173689 ANTIVENIN CROTALIDAE POLY 1GM, 2 vials 3,800.00 4174506 APAP/CODEINE 120MG/12MG/5ML C3, bottle, dose 3.00 4174497 APAP/CODEINE 300MG/30MG C3, 100 eaches 3.00 4173495 ASPIRIN EC TAB 81MG, bottle, 100 eaches 3.00 4173493 ASPIRIN TAB 81MG CHEW, bottle, 36 eaches 3.00 4174445 ATENOLOL TAB 25MG, 100 eaches 3.00 4174046 ATORVASTATIN TAB 20MG, 100 eaches 5.00 4173508 ATROPINE SUL 1MG/10ML, 10 ea syringes 39.00 J04614174756 AZACTAM 1GM, 10 vials 131.00 4174784 AZITHROMYCIN INJ 500MG/VIAL, 10 vials 16.00 J04564174598 AZITHROMYCIN ORAL SUSP 100MG/5ML, 1 bottle 65.00 4174599 AZITHROMYCIN ORAL SUSP 200MG/5ML, 1 bottle 65.00 4174601 AZITHROMYCIN TAB 250MG, 1 pack 27.00 4174634 BACITRACIN ZINC OINT 30G, 1 tube 16.00 4174448 BENZONATATE CAP 100MG 5.00 4173617 BETAMETHASONE SOD PHOS/BETA ACE 5ml, vial 158.00 4173556 BICILLIN CR SY 1.2MMU -2ML, each syringe 364.00 J05584173557 BICILLIN LA SY 1.2MMU -2ML, each syringe 456.00 J05614174635 BICILLIN LA SY 600MU -1ML, each syringe 264.00 J0561

4173766 BISACODYL RECTAL SUPP 10MG-12/BX, each 3.00 4173767 BISACODYL TAB 5MG, 100 eaches 5.00 4173559 BLEPHAMIDE OINT 10% OPHTH, tube 400.00 4174319 BUDESONIDE INH 0.5MG/2ML, 30 each amps 17.00 4173570 BUMETANIDE 1MG/4ML, 10 vial 11.00 J34904173492 C VITAMIN TAB 250MG, 100 eaches 3.00 4174877 CALCIUM 600MG/VIT D 400IU, 100 eaches 3.00 4173585 CALCIUM CHL 100MG/ML, each syringe 39.00 4174898 CALCIUM GLUCONATE 1000 MG/10ML, vial 42.00 4173591 CAPTOPRIL TAB 25MG, 100 eaches 9.00 4173704 CARBAMIDE PEROXIDE 6.5% EAR DROP 11.00 4173670 CARVEDILOL TAB 6.25MG, 100 eaches 3.00 4173471 CEFAZOLIN INJ 1 GM, 25 vial 6.00 J06904174883 CEFEPIME INJ 2GM/VIAL, 10 vial 27.00 J06924173614 CEFPROZIL ORAL SUSP 125MG/5ML, bottle 119.00 4174363 CEFTRIAXONE INJ 1GM/VIAL, 25 vial 12.00 J06964174366 CEFTRIAXONE INJ 500MG/VIAL, 25 vial 9.00 J06964173612 CEFUROXIME TAB 250MG, 20 eaches 9.00 4173984 CEPHALEXIN CAP 250MG, 50 eaches 5.00 4173986 CEPHALEXIN ORAL SUSP 250MG/5ML, bottle 61.00 4174761 CIPROFLOXACIN INJ 400MG/200ML, 24 bag 15.00 J07444173640 CIPROFLOXACIN TAB 500MG, 100 eaches 3.00 4174641 CLARITHROMYCIN TAB 500MG, 30 eaches 21.00 4173650 CLINDAMYCIN INJ 900MG/6ML, 25 vials 18.00 4173609 CLONIDINE TAB 0.1MG, 100 eaches 5.00 4173692 CYANOCOBALAMIN 1000MCG/ML, 25 vials 21.00 4173833 CYCLOBENZAPRINE TAB 10MG, 100 eaches 3.00 4174884 CYKLOKAPRON TRANEXAMIC ACID INJ, vial 168.00 J10714173724 DEPO-ESTRADIOL 5MG/ML- 5ML, vial 305.00 4174885 DEPO-MEDROL 40MG/1ML, 25 vials 36.00 4173726 DEPO-MEDROL 80MG/1ML, 25 vials 72.00 J10404173727 DEPO-PROVERA 150MG/ML, vial 237.00 J10504173706 DEXAMETHASONE INJ 4MG/ML, 25 vial 6.00 J11004173708 DEXAMETHASONE TAB 4MG, 100 eaches 9.00 4173700 DEXTROSE 50% INJ 25G PER 50ML, each syringe 50.00 4174518 DIAZEPAM INJ 5MG/ML-10ml C4, 10 vials 154.00 J33604174519 DIAZEPAM TAB 5MG C4, 100 eaches 5.00 4174011 DIGOXIN INJ 500MCG/2ML AMP, 10 amps 31.00 4174012 DIGOXIN TAB 125MCG, 100 eaches 9.00 4173539 DIPHENHYDRAMINE CAP 25MG, 100 eaches 3.00 4173543 DIPHENHYDRAMINE SOL 12.5MG/5ML, 100 eaches 11.00 4173659 DOCUSATE SOD SOFGEL 100MG, 100 eaches 3.00 4173660 DOCUSATE SOD SYRUP 60MG/15ML, bottle -dose 3.00 4174775 DOPAMINE HCI 5% DEXTROSE 400MG, 12 bags 37.00 4174542 DOXYCYCLINE TAB 100MG, 30 eaches 11.00 4173832 ENEMA DISPOSABLE 4.5OZ, each 9.00 4174074 ENOXAPARIN SOD INJ 100MG/ML 25.00 J1650

4174075 ENOXAPARIN SOD INJ 30MG/0.3ML 17.00 J16504174076 ENOXAPARIN SOD INJ 40MG/0.4ML 30.00 J16504173797 EPINEPHRINE INJ 0.15MG AUTO INJECTOR 413.00 J01714173796 EPINEPHRINE INJ 0.3MG AUTO INJECTOR 573.00 J01714173423 EPINEPHRINE INJ 1:1000- 10ml , 10 syringe 24.00 J01704173422 EPINEPHRINE INJ 1MG/ML, 10 amps 45.00 J01704173927 ERYTHROMYCIN OPHTH OINT 0.5%, tube 36.00 4174037 ESCITALOPRAM TAB 10MG, 100 eaches 3.00 4173814 EYE WASH, bottle 22.00 4174410 FENTANYL CITRATE 100MCG/2ML C2, 10 amps 6.00 J30104174863 HD FLU VACCINE 2017-2018, 10 SYRINGES 165.00 4173841 FLU VACCINE 2017-2018 10 VAC IN VIAL, 10 DOSE 70.00 4174864 FLUCONAZOLE TAB 100MG, 9.00 4174368 FLUMAZENIL INJ 0.5MG/5ML, 10 VIALS 16.00 J34904173847 FOLIC ACID INJ 50MG/10ML, VIAL 104.00 J34904173848 FOLIC ACID TAB 1MG, 100 EACHES 6.00 4174016 FUROSEMIDE INJ 20MG/2ML, 25 each vial 9.00 J19404174018 FUROSEMIDE TAB 20MG, 100 eaches 5.00 4174172 GABAPENTIN CAP 100MG, 100 eaches 3.00 4174173 GABAPENTIN CAP 300MG, 100 eaches 3.00 4173869 GENTAMICIN 80MG/2ML, 25 vials 19.00 J15804173863 GENTAMICIN SUL OPHTH 0.3%, 1 each 143.00 4174148 GERILANTA ANTACID 5ml, bottle - dose 3.00 4173872 GLUCAGEN 1 MG/VIAL, vial 498.00 J16104174115 GLYBURIDE TAB 5MG, 100 eaches 5.00 4173884 GLYERCIN SUPPOSITORY 50 eaches 3.00 4174858 GUAIFENESIN ORAL SOL 200MG/10ML, 100 eaches 5.00 4174142 GUAIFENESIN TAB 600MG MUCINEX, 100 eaches 9.00 4173631 GUAIFENESIN/CODEINE 100/10MG-5ML C5, dose 5.00 4173891 HALOPERIDOL INJ 5MG/ML, 25 vials 31.00 J16304173892 HALOPERIDOL TAB 0.5MG, 100 eaches 5.00 4174122 HEALTHYLAX POLYETHYLENE GLYCL, 14 eaches 9.00 4174875 HEPARIN 25000 USP UN/500ML, 24 bags 26.00 4173903 HEPARIN 5000 USP UN/ML, 25 vials 11.00 J16444174760 HEPARIN LOCK FLUSH SYRINGE 500UN/5ML, 30 eaches 5.00 4174828 HYDRALAZINE HYD INJ 20MG/ML, 25 vials 13.00 J03604173895 HYDROCHLOROTHIAZIDE TAB 12.5MG, 100 eaches 9.00 4174786 HYDROCODONE/APAP 5MG/325MG C2, 100 eaches 5.00 4174048 HYDROCORTISONE CREAM USP 1% 28G, tube 31.00 4174771 HYDROMORPHONE HCI 1MG/ML C2, 10 amps 9.00 J11704173479 HYDROXYZINE ORAL SOL 10MG/5ML, dose 5.00 4173502 HYDROXYZINE TAB 25 MG, 100 eaches 5.00 4174887 HYOSCYAMINE 0.125MG, 100 eaches 5.00 4174135 IBUPROFEN TAB 200MG, 100 eaches 3.00 4174139 IBUPROFEN TAB 600MG, 100 eaches 3.00 4174136 IBUPROFEN CHILD 100MG/5ML, 30 eaches 9.00 4173940 INDOMETHACIN CAP 25MG, 50 eaches 5.00

4174146 INFUVITE MULTIVITAMIN ADULT, 5 eaches 44.00 4173510 IPRATROPIUM BRO 0.02%, 30 eaches 3.00 4173509 IPRATROPIUM BRO HFA 17MCG, 1 each 719.00 4173941 IRON DEXTRAN INFED 100MG/2ML, 10 vials 120.00 4174880 KETAMINE INJ 200MG/20ML C3, 10 vials 54.00 4174476 KETOROLAC TROMETHAMINE 30MG/ML, 25 vials 30.00 J17504174811 LABETALOL HYD INJ 100MG/20ML, each vial 18.00 4174004 LACTULOSE SOL 20G/30ML, 50 eaches 9.00 J18854173558 LANTUS INSULIN 100UN/ML, 200- 5un doses 5.00 4174567 LEVALBUTEROL INH SOL 1.25MG, 30 eaches 9.00 4174779 LEVOFLOXACIN INJ 750MG/30ML, each vial 190.00 4174896 LEVOFLOXACIN IV 500MG, 24 bags 13.00 J19564174897 LEVOFLOXACIN IV 750MG, 24 bags 32.00 J19564174027 LEVOFLOXACIN TAB 250MG, 100 eaches 3.00 4174028 LEVOFLOXACIN TAB 500MG, 100 eaches 5.00 4174778 LEVOFLOXACIN TAB 750MG, 100 eaches 6.00 4174802 LEVOPHED 4MG/4ML, 10 vials 82.00 4174420 LEVOTHYROXINE TAB 100MCG, 100 eaches 5.00 4174426 LEVOTHYROXINE TAB 25MCG, 100 eaches 5.00 4174568 LIDOCAINE 1% INJ 10MG/ML, 25 vials 9.00 J20014174569 LIDOCAINE 2% INJ 20MG/ML, 25 vials 9.00 J20014174575 LIDOCAINE 1% W/EPI INJ 50ML, 25 vials 10.00 4174576 LIDOCAINE 2% W/EPI INJ 20MG/ML, 25 vials 10.00 J20014174041 LIDOCAINE HCI INJ 2% 100MG/SYR 16.00 4174573 LIDOCAINE HYD JELLY USP 2% 5ML 15.00 4174572 LIDOCAINE VISC ORAL 2% 15ML, 40 eaches 9.00 4173792 LIDOCAINE/PRILOCAINE CREAM 2.5%/2.5%, each 53.00 4174587 LISINOPRIL TAB 10MG, 100 eaches 5.00 4173907 LISPRO INSULIN 100UUN/ML, 200-5un doses 5.00 4174050 LOMOTIL TAB 2.5MG/0.025MG C5, 100 eaches 16.00 4173933 LOPERAMIDE HCI IMODIUM 1MG/7.5ML, 16 doses 5.00 4173928 LOPERMIDE CAP 2MG, 100 eaches 9.00 4173646 LORATADINE TAB 10MG, 100 eaches 5.00 4173503 LORAZEPAM INJ 2MG/ML C4, 25 eaches 5.00 4173504 LORAZEPAM TAB 0.5MG C4, 100 eaches 3.00 4174878 LOSARTAN POT TAB 25MG, 100 eaches 5.00 4174082 LUTEIN SOFGEL 20MG , 60 eaches 3.00 4173643 MAG CITRATE ORAL SOL cherry 1.745G/1OZ, bottle 10.00 4174092 MAGNESIUM SUL INJ 1GM/2ML, 25 vials 9.00 J34754174683 MAGNESIUM SUL/5% DEXTROSE 1GM, 26.00 J34754174096 MANNITOL IV 20% 20G/100ML, 12 bags 77.00 J21504173475 MECLIZINE TAB 25MG, 100 eaches 5.00 4174643 MEROPENEM INJ 500MG/VIAL, 25 vials 66.00 J21854174107 METAMUCIL FIBER SUGAR FREE 30 DOSES 5.00 4173874 METFORMIN TAB 500MG, 100 eaches 5.00 4174357 METHOCARBAMOL TAB 750MG, 100 eaches 3.00 4174330 METOCLOPROMIDE 10MG/2ML, 25 vials 19.00

4174474 METOPROLOL SUCC TAB 25MG, 100 eaches 6.00 4174057 METOPROLOL TART TAB 25MG, 100 eaches 6.00 4173826 METRONIDAZOLE INJ 500MG/100ML, 24 bags 9.00 4173827 METRONIDAZOLE TAB 250MG, 100 eaches 5.00 4174538 MIDAZOLAM INJ 5MG/ML C4, 10 vials 9.00 J22504174120 MINERAL OIL 15ML, bottle 35.00 4174803 MORPHINE SUL 4MG/ML C2, 10 carpujet 11.00 J22704174450 MULTIVITAMIN 50 PLUS TAB, 50 eaches 5.00 4174630 MUPIROCIN OINT 2% 22G, 1 tube 28.00 4174161 NALOXONE HYD INJ 0.4MG/ML, 10 syringe 66.00 J23104174160 NAPROXEN TAB 500MG, 100 eaches 3.00 4174890 NASAL MOISTURE SPRAY DEEP SEA, 1 bottle 6.00 4174891 NEO SYNEPHRINE NASAL SPRAY, one bottle 25.00 4174169 NEOMYCIN/POLY B SUL/GRAMICIDIN OPHTH, 1 bottle 198.00 4173674 NEOMYCIN/POLY B SUL/HYDROCOR OTIC, 1 bottle 199.00 4174177 NEXIUM IV 40MG/VIAL, 10 vials 179.00 J34904174812 NICARDIPINE HYD INJ 25MG/10ML, 10 vials 72.00 4174184 NITRO BOD OINT 2%, 30 doses 5.00 4174689 NITRO LINGUAL SPRAY 400MCG/SPRAY, 1 bottle 321.00 4174728 NITROFURANTOIN CAP 50MG, 100 eaches 3.00 4174888 NITROGLY/D5W BT 50MG/250ML, 12 bag 51.00 4174188 NITROSTAT SUBLIGUAL TAB 0.4MG, 100 eaches 6.00 4174200 NOVOLIN N INSULIN, 200-5un doses 3.00 J18154173913 NOVOLIN R INSULIN, 200-5un doses 3.00 J18154174152 NS 0.9% FLUSH SYRINGE, 30 syringes 5.00 4174206 NYSTATIN CREAM 100000UN/GM 15GM, 1 tube 63.00 4174705 NYSTATIN ORAL SUSP 500000UN/5ML, 50 units 9.00 4174211 NYSTATIN/TRIAMCINOLONE ACE CREAM, 1 tube 133.00 4174292 OMEPRAZOLE DR CAP 20MG, 100 eaches 3.00 4174606 ONDANSETRON INJ 4MG/2ML, 25 vials 9.00 J24054174607 ONDANSETRON ODT 4 MG, 30 eaches 5.00 4174717 OSELTAMIVIR 10 CAP 30MG TAMIFLU, 10 eaches 63.00 4174718 OSELTAMIVIR 10 CAP 45MG TAMIFLU, 10 eaches 63.00 4174434 OSELTAMIVIR 10 CAP 75MG TAMIFLU, 10 eaches 63.00 4174245 OXYCODONE /APAP 5MG/325MG C2, 100 eaches 3.00 4174220 OXYCODONE TAB 5MG C2, 100 eaches 5.00 4174320 PHENAZOPYRIDINE TAB 100MG, 100 eaches 6.00 4174825 PHENYTOIN SOD ER CAP 100MG, 100 eaches 6.00 4173745 PHENYTOIN SOD INJ 100MG/2ML, 25 vials 5.00 J11654174612 PIPERACILLIN AND TAZOBACTAM 3.375GM, 10 vials 22.00 J25434174817 PNEUMOCOCCAL 13 PREVNAR, 10 syringe 522.00 4174267 PNEUMOVAX 23, 10 vials 264.00 4174895 POTASSIUM CHL 40MEQ/L, 14 bags 17.00 4174273 POTASSIUM CHL 40MEQ/20ML, 25 vials 24.00 4173997 POTASSIUM CHL ET TAB 10MEQ, 100 eaches 5.00 4174692 POTASSIUM EFFERVESCENT TAB 25MEQ, 30 eaches 3.00 4174280 PREDNISOLONE SOD 15MG/5ML, 33 doses 5.00 J7510

4174847 PREDNISONE TAB 20MG, 100 eaches 3.00 4174740 PREDNISONE TAB 5MG, 100 eaches 3.00 4174294 PRIMAXIN IV 500MG/VIAL, 25 vials 131.00 J75104173665 PROCHLORPERAZINE INJ 10MG/2ML, 10 vials 50.00 J75104174253 PROMETHAZINE 12.5MG SUPPOSITORY, 12 eaches 31.00 4174254 PROMETHAZINE 25MG SUPPOSITORY, 12 eaches 30.00 4174250 PROMETHAZINE INJ 25MG/ML, 25 amps 9.00 J25504174257 PROMETHAZINE TAB 25MG, 100 eaches 3.00 4174637 PROPARACAINE 0.5%, 1 bottle 105.00 4174732 PROPRANOLOL 1MG/ML, 10 vials 13.00 J18004174307 PROTAMINE SUL 250MG/25ML, 1 vial 110.00 4174369 RACEPINEPHRINE INH 2.25%, 30 amps 12.00 4174694 RANITIDINE INJ 150MG/6ML, 1 vial 126.00 J27804174580 RANITIDINE TAB 150MG, 100 eaches 3.00 4174708 RIVAROXABAN TAB 10MG XARELTO, 30 eaches 48.00 4174913 ROCURONIUM 10MG/ML-5ML , 10 VIALS 15.00 4174377 SENNA PLUS TAB 8.6MG/50MG, 100 eaches 5.00 4174648 SENSORCAINE BUPIVACINE 0.5%, 25 vials 12.00 4174384 SILVADENE CREAM 1% 20GM, tube 41.00 4174734 SILVASORB GEL 44.4ML/TUBE 80.00 4174385 SILVER NITRATE STICKS 100 eaches 27.00 4173982 SOD POLYSTYRENE SUL 15G, 30 doses 8.00 4174398 SODIUM CHL INH SOL 0.9%, 30 eaches 3.00 4174402 SOLU-MEDROL 125MG/VIAL, 25 vials 40.00 J29204174401 SOLU-MEDROL 1GM/VIAL 139.00 J29204174684 SOOTHE LUBRICANT EYE DROPS, 28 each 5.00 4174793 SUCCINYCHOLINE CHL 20MG/ML-10ml, 25 vials 81.00 4173594 SUCRALFATE TAB 1GRAM, 100 eaches 5.00 4174696 SULFACETAMIDE SOD OPHTH 10%, 1 bottle 157.00 4173533 SULFAMETHOXAZOLE /TRIM TAB 800/160MG, 100 eaches 3.00 4173931 SUMATRIPTAN INJ 6MG/0.5ML, 5 vials 38.00 J30304174464 TENECTEPLASE 50MG- TNKASE, 1 unit 7,028.00 J31014174697 TETANUS DIPTH TOX PED DT, 10 vials 177.00 4174272 TETRACAINE HCL DR 0.5%-15ML OPTH, 1 bottle 35.00 4174742 THERMOTABS 287/180/15, 100 eaches 3.00 4174468 TOBRAMYCIN DR 0.3% -5ML OPTH, 1 bottle 20.00 4174509 TRAMADOL TAB 50MG C4, 100 eaches 9.00 4173993 TRIAMCINOLONE ACE SUSP KENALOG-40 190.00 4174487 TRIPLE ANTIBIOTIC OINTMENT 3.00 4174702 TROPICAMIDE DR 1% -15ML OPTH, 1 bottle 28.00 4173477 TUBERSOL PPD, 10TESTS-VIAL 37.00 4174774 VANCOMYCIN HYD INJ 500MG/VIAL, 10 vial 41.00 4174866 VEDOLIZUMAB 300MG -ENTYVIO , 1 vial 7,036.00 4173578 VERAPAMIL HYD INJ 10MG/VIAL, 5 vials 123.00 4173582 VERAPAMIL TAB 80MG, 100 eaches 3.00 4174854 VITAMIN D SOFGEL 5000IU, 50 eaches 5.00 4173484 VITAMIN K INJ 10MG/ML, 25 amps 181.00 J3430

4174807 VITAMIN K INJ 1MG/0.5ML, 25 amps 21.00 4173677 WARFARIN SOD TAB 1MG, 100 eaches 5.00 4173683 WARFARIN SOD TAB 5MG, 100 eaches 5.00 4174555 WATER BACTERIOSTATIC FOR INJ, 25 vials 9.00 4174556 WATER ST FOR INJ, 25 vials 9.00 4173454 ZOLPIDEM TART TAB 5MG C4, 100 eaches 3.00 4070090 CREATININE CLEARANCE 125.90 825754174853 MELATONIN MAX [5MG] (NF) 3.00 4070347 C DIFF 115.20 878034260075 INITIAL PUSH OR INFUSION 167.90 963744230017 LACERATION REPAIR 458.70 120514070061 IMMUNOFLUORESCENT 523.50 883464209786 MOBILITY CURRENT 80-100 0.01 G8978,CM,GP4140025 RIBS (BILAT.) CHEST 374.10 711114260079 LESION REMOVAL EACH ADDIT 47.40 170034260007 WOUND REPAIR,2.5 273.90 120014140084 CT-ABDOMEN W/CONTRAST 1,995.00 741604140155 CT-THORACIC SPINE W/CONTRAST 1,940.25 721294140048 SACRUM-COCCY X-2 262.30 722204209932 SUB CURRENT 1-20 0.01 G8993,CI,GP4230089 LONG LEG SPLINT 345.00 295054174909 POLYMYXIN B SUL/TRIMETHOPRIM 26.00 4174816 RT - FLUTICASONE PROPIONATE 50MCG 56.00 4173444 MICONAZOLE 2% OIN ** (N 313.00 4140146 CT-FACIAL BONES/SINUSES/MAXILLOFACIAL WO 1,533.75 704864070324 MYCOBACTERIA PROPOR (TB) 111.10 871904070223 FIBRINOGEN ACTIVITY 93.70 853844070291 MUMPS 134.40 867354070310 BLOOD CULTURE 169.40 870404070069 CARBON MONOXIDE 138.90 823753010006 I/P OBSERVATION COMPREHEN 306.60 992204140169 US ABDOMINAL LIMITED 334.50 767054070251 CA 27.29 228.10 863004140027 CT-THORAX W/WO CONTRAST 2,292.75 712704173435 SPIRONOLACTONE TAB [100 M 6.00 4260064 OUTPATIENT VISIT 118.60 992134230095 CAST BOOT 154.00 L43864140185 US DUPLEX SCAN ABD/PEL/SCROT/RPR LMTD 870.75 939764140056 ELBOW - 3 315.50 730804173527 VIT- B COMPLEX (NF) 3.00 4070420 FLOW CYTOMETRY 1ST MARKER 383.00 881844070087 CKMB 146.80 825534070189 FREE T3 125.00 844814070425 PATHOLOGIST REVIEW 146.80 850604230040 LONG ARM CAST 273.90 290654209805 MOBILITY D/C 60-80 0.01 G8980,CL,GP4174632 PREDNISOLONE LIQ [15 MG/5 6.00 J7510

4070244 ENDOMYSIAL AB 181.80 862554070470 NICOTINE AND COTININE, PLASMA 125.00 80323

433023 TC99M TETROFOSMIN 100.00 A95024070300 THYROGLOBULIN ANTIBODY 181.80 868004070269 CYCLOSPORINE 158.60 866444070202 BLEEDING TIME 55.80 850024070089 URINE CREA 74.25 825704070483 CATECHOLAMINES, FRACTIONATED PLASMA 253.09 823844070155 PARATHORMONE 484.60 839704070398 LDL CHOLESTEROL 52.40 837214174893 BUPROPION HYD TAB 75MG 6.00 4174881 DILTIAZEM TAB 120MG 5.00 4330003 CPR 793.40 929504174873 PAROXETINE TAB 50MG 3.00 4173571 BUMETANIDE TAB [1 MG] (N 15.00 4070465 HLA CLASS II TYPING 133.90 813824260078 LESION REMOVAL 153.50 170004209864 CARRY D/C 40-60 0.01 G8986,CK,GP4209803 MOBILITY D/C 20-40 0.01 G8980,CJ,GP4070305 ANTIHUMAN GLOBULIN TEST (DAT) 74.50 868804070218 PROTEIN C, ANTIGEN 199.30 853024070247 CA 19-9 228.10 863014070303 HLA TYPING A B OR C 241.70 868124140036 THORIACIC - 3 294.00 720724070259 RPR 61.00 865924174781 GLUCOSAMINE/CHONDROITIN [ 4.00 4140057 FOREARM - 2 235.30 730904174380 QUETIAPINE TAB [100 MG] 42.00 4209914 OTHER GOAL 40-60 0.01 G8991,CK,GP4070331 HERPES CULTURE 274.50 872524070214 FACTOR VIII VW FACTOR 263.20 852454070215 FACTOR VIII VW FACTOR (VON WILLEBRAND) 263.20 852464070374 GIARDIA ANTIGEN 102.20 873294070337 ENTAMOEBA HISTOLYTICA 97.10 873374070386 THYROID BINDING INHIBITOR 245.10 842354140072 LOWER LEG - 2 262.30 735904070317 URINE (PRESUMPTIVE ID) 88.10 870884230076 ER CRITICAL CARE DR 576.60 992894173402 ARIPIPRAZOLE TAB [10 MG] 51.00 4174666 NUR - VS/TEMPERATURE - 4070113 TOLERENCE TEST, 45.10 829523010004 I/P OBSERVATION DETAILED 184.60 992184230005 LACERATION REPAIR 344.50 120023010008 I/P COMPREHENSIVE ADMIT P 270.00 992224209952 SUB D/C 1-20 0.01 G8995,CI,GP4140130 FACE ORBITS >4 252.00 702004173597 DILTIAZEM CD ER CAP [240 MG] (NF) 6.00

4209911 OTHER GOAL 0 0.01 G8991,CH,GP4209793 MOBILITY GOAL 20-40 0.01 G8979,CJ,GP4070371 PARATHYROID HORMONE 263.20 839704070140 METANEPHRINES 344.50 838354140114 BLADDER ULTRASOUND 537.70 517984209890 SELF D/C NO 0.01 G8989,GP4070375 CEA 134.40 823784174241 FAMOTIDINE TAB [20 MG] ( 6.00 4070493 ANTIPARIETAL CELL ANTIBODY 110.24 862554070104 RBC FOLATE 192.00 827474209797 MBILITY GOAL 100 0.01 G8979,CN,GP

A0998 AMBULANCE RESPONSE & TREAT NO TRANSPORT 150.00 A09984070419 LIPOPROTEIN, HI RESOLUTIO 250.70 837014070256 INTRINSIC FACTOR ANTIBOD 194.30 863404174654 NUR - ACTIVITY/AMB IN HAL - 4230044 APPLICATION FORARM SPIN 157.50 291254173642 CALCIUM CIT/ VIT D TAB 3.00 4140131 THERAPEUTIC ENEMA 916.00 742834260038 ANT.HIP DISLOCATION 1,528.90 272504230026 INJECTION,MAJOR JOINT 233.20 206104070237 ANTI-PHOSPHATIDYLSERINE 204.50 86148

26720 FRACTURE TREATMENT PHALANGEAL 767.00 267204070130 IBC 89.47 835504260081 FOLEY BLADDER CATH 370.80 517024209796 MBILITY GOAL 80-100 0.01 G8979,CM,GP4174901 CALCIUM CITRATE +D3 TAB 3.00 4070035 SP GRAV 29.90 810054070496 HEALTH FAIR TESTOSTERONE 20.00 4209934 SUB CURRENT 40-60 0.01 G8993,CK,GP4330013 LOWER EXT. DOPPLER 448.50 939904070056 ANGIOTENSIN 1- 219.10 821644209824 BODY GOAL 40-60 0.01 G8982,CK,GP4174668 NUR - TED HOSE - 4070043 URINE, MICROALBUMIN 111.10 820434260028 INJECTION,MAJOR JOINT 233.20 206104174361 GUAIFEN/ DM LIQ [200MG/20 6.00 4070473 LORAZEPAM 82.80 803464070288 HEPATITIS A IGM ANTIBODY 115.20 867094260068 I&D ABSCESS ARM/ELBOW 911.00 239304070381 ENCEPHALITIS ANTIBODY 104.40 866524140044 PELVIS AP 249.40 721704070074 CL 41.70 824354070169 URINE PROTEIN 70.50 841564070093 CYSTINE- HOMOCYSTINE 123.10 826154230039 CL- TX METACARPAL FX 683.40 266054070357 BIOPSY 239.50 883044140005 FACIAL < 3 230.60 70140

4209907 OTHER CURRENT 100 0.01 G8990,CN,GP4070484 HISTAMINE, PLASMA 195.73 830884070491 LIVER KIDNEY MICROSOMAL (LKM-1) AB IGG 91.11 863764070376 DHEA 221.30 826264174904 VIT B-12 1000MCG 3.00 4140137 CT ABD W & W/O CONTRAST 2,576.25 741704174650 PRESERVISION EYE VIT MINE 7.00 4070118 HAPTOGLOBIN, QUANT 178.90 830104070485 DRUGS OF ABUSE SCREEN HAIR 50.00 803074070348 RAPID STREP 40.00 878804209800 MOBILITY D/C NO 0.01 G8980,GP4209884 SELF GOAL 40-60 0.01 G8988,CK,GP4140082 ABDOMEN - 2 CXR PA 436.80 740224070492 PARVOVIRUS B19 206.97 867474070100 ESTROGEN 238.30 826724230083 INTER REPAIR 613.40 120344070227 SICKLING OF RBC 72.20 856604140111 US TRANSVAGINAL PELVIC 604.50 768304260015 LAYERED CLOSURE,INTER 488.00 120324140063 HIP - 1 236.40 735014209953 SUB D/C 20-40 0.01 G8995,CJ,GP4173825 FISH OIL CAP [1000 MG] ( 3.00 4230061 REMOVE FOREIGN BODY 219.10 652054173688 ROSUVASTATIN TAB [10 MG] 9.00 4070302 HEPATITIS C CONFIRM TEST 155.20 868044174874 CALCITONIN 200UN/DOSE 82.00 4070139 MERCURY, QUANTITATIVE 207.20 838254209832 BODY D/C 1-20 0.01 G8983,CI,GP4140029 COMPLETE SPINE 471.70 720824140007 NASAL BONES COMPLETE 223.50 701604070276 HTLV I 132.70 866874230060 LUMBAR PUNCTURE 363.70 622704070002 BLOOD TRANSFUSION 437.70 364304140009 SINUS =3 342.60 702204173970 IVF - SOD CL PF 0.9% [100 75.00 J70304070156 PROSTATIC 129.30 840664070149 MIT AMPLIFICATION 240.60 838984174652 NUR - DRESSING CHANGE - 4140051 SHOULDER - 1 249.30 730204260048 SHORT LEG CAST 331.50 294054140075 FOOT - 2 208.20 736204209817 BODY CURRENT 100 0.01 G8981,CN,GP4174655 NUR - ACTIVITY/AMB WITH A - 4209954 SUB D/C 40-60 0.01 G8995,CK,GP4140181 US DUPLEX SCAN LOW EXT ARTERIES UNI/LMTD 823.50 939264174217 CALCIUM CARB/ VIT D TAB [ 4.00 4174298 EPOETIN ALFA INJ [20000 U 1,607.00 J0885

4230047 STRAPPING,HAND/FINGER 119.70 292804070344 GC PROBE 193.10 875904070095 DHEA SULFATE 274.50 826274209866 CARRY D/C 80-100 0.01 G8986,CM,GP4140080 ABDOMEN - 1 262.30 740184070079 CHROMATOGRAPHY 276.10 824864070023 DILANTIN 193.10 801854173798 VIT- D CAP [50,000 UNT] 5.00 4070368 SENSITIVITY 93.70 871864209946 SUB GOAL 80-100 0.01 G8994,CM,GP4070129 IRON 76.70 835404070136 LIPASE 64.00 836904209821 BODY GOAL 0 0.01 G8982,CH,GP4070137 HDL 72.20 837184070184 ALT 61.00 844604174850 TRAZODONE HCL [50MG] 3.00 4140153 CT-SPINE/CERVICAL W & WO CONTRAST 2,274.00 721274070252 IMMUNOASAY INFECTIOUS 136.70 863174260085 DRAIN THIGH OR KNEE LESION 2,870.00 273014173768 PT- HYDROCOLLOID BDG (NF 46.00 4230016 LACERATION REPAIR 657.40 120444140033 C-SPINE 4+FLE/EXT 409.10 720524209956 SUB D/C 80-100 0.01 G8995,CM,GP4174907 RESTASIS CYCLOSPORINE 0.05% 1,016.00 4209780 MOBILITY CURRENT NO 0.01 G8978,GP4070422 FLOW CYTOMETRY 9 -15 MARK 72.90 881884209867 CARRY D/C 100 0.01 G8986,CN,GP4070200 QUANT HCG 151.80 847024070208 CBC - NO DIFF 70.00 850274330017 EVENT MONITOR 239.25 932704070339 HBEAG 110.00 873504140019 CHEST - 2 342.60 710464070019 GENTAMICIN 309.00 801704260016 LAYERED CLOSURE 747.20 120354070414 BETA 2 GLYCOPROTEIN 236.10 861464174579 RANITIDINE/ NACL PREMIX [ 15.00 4070027 SALICYLATES 159.60 803294070110 GLUCOSE, BLOOD STRIP 37.70 829484070141 MYOGLOBIN 146.80 838744174301 EPOETIN ALFA INJ [40000 U 1,458.00 J08854174484 NEO/ BAC/ POLY OIN ** ( 3.00 4173548 BENZOIN COMP TINC BOTTLE 19.00 4140068 KNEE - 2 249.30 735604209840 CARRY CURRENT NO 0.01 G8984,GP4070067 CALCULUS QUALITATIVE 94.90 823554070401 BB RBC - PREFILTERED 535.60 P90164209913 OTHER GOAL 20-40 0.01 G8991,CJ,GP

4070059 TBILI 56.40 822474260052 CAST REMOVAL 145.60 297004209912 OTHER GOAL 1-20 0.01 G8991,CI,GP4174859 RISPERIDONE TAB 0.5MG 5.00 4070325 GRAM STAIN 64.40 872054070240 COMPLEMENT FUNCTIONAL 114.00 861614070446 DRUG SCREEN, QUALIT MULTI 212.20 803054070399 CLOSTRIDIUM DIFFICILE TOX 115.20 873244174794 PROBIOTIC TAB 5.00 4070287 HEP A AB 127.00 867084260009 SIMPLE REPAIR,7.5-12CM 398.10 120044260044 FOREARM SPLINT 157.50 291254174233 PAROXETINE TAB [20 MG] ( 3.00 4260051 STRAPPING,ANKLE 89.20 295404173862 GENTAMICIN 0.1% OIN ** 117.00 4070024 PRIMIDONE 138.90 801884070417 PLASMINOGEN ACTIVATOR 182.90 854154260066 IV INFUSION (1 HOUR) 232.10 963654070212 CLOTTING FACTOR II 141.20 852104209885 SELF GOAL 60-80 0.01 G8988,CL,GP4209850 CARRY GOAL NO 0.01 G8985,GP4070222 D-DIMER, QUANTITIVE 134.40 853794174201 INS - REG HUMAN INJ [100U 27.00 J18154070084 CORTISOL TOTAL 228.10 825334140078 TOE >= 2 189.90 736604173854 CEFTAZIDIME INJ [2GM] 67.00 J07134230031 NURSEMAID ELBOW / CHILD 373.30 246403010015 I/P ADMIT/DISCHG SAME DAY 443.30 992364140158 CT-LUMBAR SPINE W/CONTRAST 1,863.00 721323010007 I/P ADMIT DETAILED PHYSIC 202.70 992214230027 CL- RED TMJ DISLOCATION 390.80 214804174849 DIABETIC TUSSIN DM 5.00 4070165 PROLACTIN 175.00 841464260042 HAND/WRIST CAST 217.90 290854209847 CARRY CURRENT 100 0.01 G8984,CN,GP4070206 HGB 41.70 850184209870 SELF CURRENT NO 0.01 G8987,GP4209794 MOBILITY GOAL 40-60 0.01 G8979,CK,GP4174085 PREGABALIN CAP [100 MG] 33.00 4230052 STRAPPING,ANKLE 89.20 295404209792 MOBILITY GOAL 1-20 0.01 G8979,CI,GP4070455 NOROVIRUS STOOL 268.75 874494070296 TOXOPLASMA IGM 154.10 867784174745 DIGESTIVE ADVANTAGE (NF) 7.00 4070318 CULTURE FUNGI OTHER 85.20 871024070112 GTT 3 SPECIMENS 169.40 829514070238 COLD AGGLUTININ, TITER 96.00 86157

4140045 PELVIS COMPLETE MIN 3 315.50 721904230062 REMOVAL,FB,CORNEA 341.10 652224230072 E R VISIT-LEVEL 4 613.40 992844174772 SOLOSITE WOUND GEL 3OZ 73.00 4070025 PROCAINAMIDE W/ MET 249.00 801924174759 TRAZODONE HYD TAB (100MG) 3.00 4209782 MOBILITY CURRENT 1-20 0.01 G8978,CI,GP4070083 CORTISOL, FREE 214.50 825304070406 HELICOBACTER PYLORI STOOL 84.70 873384140043 CT- PELVIS W/O 1,571.25 721924070462 SODIUM, OTHER SOURCE 49.40 843024140024 RADEX RIBS UNI W/POSTEROANT CH <3 299.80 711014209804 MOBILITY D/C 40-60 0.01 G8980,CK,GP4070088 CREA 61.00 825654070147 SEPARATION BY GEL ELEC 108.90 838944070239 COMPLEMENT ANTIGEN 151.80 861604070022 PHENOBARB 155.20 801844070073 CERULOPLASMIN 145.60 823904070430 MASS SPECTROMETRY QUANT 175.10 837894174671 NUR - WEIGHT BEARING STAT - 4174701 MEPIVACAINE HCL 1% (SPEC 5.00 J06704070366 HAND & CONVEY 50.00 990014140099 US RETROPERITONEAL COMPLETE 706.50 767704173705 DEXAMETHASONE INJ [10 MG/ 23.00 J11003010001 ER CRITICAL CARE ADD'L 30 281.80 992904173476 HYDROCORTISONE ACET SUPP 57.00 4260008 LACER REPAIR,SIMPLE 344.50 120024070412 HEAVY METAL, QUANTITATIVE 203.30 830184070418 OSMOLALITY, URINE 134.40 839354070373 GLUCOSE, BODY FLUID 48.50 829454209882 SELF GOAL 1-20 0.01 G8988,CI,GP4209820 BODY GOAL NO 0.01 G8982,GP4174495 CALCIUM CARB TAB [500 MG] 4.00 4070204 SPUN HCT 28.70 850134260017 INTERMEDIATE CLOSURE 376.70 120414070356 CHROMOSOME FRAGILE X 1,130.20 882484070014 AMITRIPTYLIN 251.20 801524200015 THERAPUETIC EXERCISE 78.90 97110,GP4070415 TRIIODOTHYRONINE T3 REVER 335.70 844824070080 CITRATE 236.10 825074070429 SEROTONIN 484.60 842604070327 SMEAR FOR WBC 99.40 872074070459 HEMOSURE IFOB-MEDICARE 56.60 G03284230030 SHOULDER REDUCTION . 1,156.20 236554070295 TOXOPLASMA 140.10 867774070334 CMV 103.30 872704070245 FLUORESCENT TITER, 145.60 86256

4140026 STERNUM - 2 237.10 711204209923 OTEHR D/C 20-40 0.01 G8992,CJ,GP4270001 DIETICIAN CONSULT GROUP 62.80 990784070450 PROTHROMBIN 11 GENE MUTAT 223.50 812404174908 DUREZOL 0.05% EYE DROP 498.00 4173516 ANTIPYRINE/BENZOCAINE OTI 23.00 4260046 STRAPPING,SHOULDER 141.20 292404070393 MOLECULAR SEPARATION & ID 193.10 839094174855 ASPERCREAME [NF] 34.00 4070066 URINE CALCIUM 93.70 823404174865 NITROFURANTOIN MACRO 50MG 12.00

28510 FRACTURE TREATMENT PHALANX 666.00 285104330012 US DUPLEX SCAN VEINS COMP. BILATERAL 1,218.00 939704070380 ENCEPHALITIS ANTIBODY 104.40 866514070330 VIRUS ISOLATION 173.30 872504070349 URINE CYTOLOGY 228.10 881044330002 US DOPPLER EXTREMITY 364.00 939654070106 IGE LEVEL 181.20 827854260047 STRAPPING,HAND/FINGER 119.70 292804070190 TROPONIN 146.80 844844140062 FINGERS>=2 208.20 731404230079 THERAPUTIC INJECTIONS 62.60 907744070181 TSH 90.00 844434174900 PREDNISONE TAB 1MG 3.00 4070201 SERUM HCG (QUAL) 70.00 847034230013 LACERATION REPAIR 497.00 120324174322 VIT- B-6 TAB [50 MG] (NF 4.00 4070480 INHIBIN B 224.97 823974174022 LEVOFLOXACIN INJ [500MG] 66.00 J19564209802 MOBILITY D/C 1-20 0.01 G8980,CI,GP4140041 CT-SPINE/CERVICAL/ W/O 1,563.00 721254070281 HISTOPLASMA 137.80 866984070466 MTHFR 190.50 812914070143 MOLECULAR DIAGNOSTICS 82.90 838904070224 PT 64.40 856104070048 ALPHA-1- PHENOTYPE 206.10 821044173769 PT- HYDROCOLLOID BDG XTHN 26.00 4140050 SCAPULA>=2 208.20 730104070460 HEMOSURE IFOB-NONMEDICARE 56.60 822744174872 MIRTAZAPINE TAB 45MG 5.00 4174680 NUR - SEIZURE PRECAUTIONS - 4174356 METHOCARBAMOL TAB [500 MG 5.00 4174711 NEO/POLY/DEXAMTHASONE DRO 54.00 4230078 INTRAMUSCULAR INJECT 34.40 907724140162 CT-UPPER EXTREMITY W&WO CONTRAST 2,299.50 732024174673 NUR - CATHETER IRRIGATION - 4070279 HERPES IGG 169.40 86695

4070158 PHOS 64.40 841004070231 ANTIBODY ID PLATELET 161.50 860234250005 AMBULANCE OXYGEN PER HR 12.00 A04224174625 CETIRIZINE TAB [10 MG] 3.00 4209846 CARRY CURRENT 80-100 0.01 G8984,CM,GP4070445 PINWORM IDENTIFICATION 43.30 871724070021 NORTRIPTYLINE 285.70 801824209892 SELF D/C 1-20 0.01 G8989,CI,GP4140189 CT ORBIT SELLA/ POST FOSSA/EAR W/CON 2,120.25 704814260036 CL TX FINGER DISLOCATION 654.00 267704230018 LACERATION REPAIR 581.70 120524230037 DISLOCATED FINGER 979.40 267754174669 NUR - IV FLUSH - 4140034 T-LUMBAR-SCOLIOIS 247.00 720694209784 MOBILITY CURRENT 40-60 0.01 G8978,CK,GP4174007 TERBINAFINE 1% CRM ** (N 45.00 4140172 US OB > 14 WEEKS 537.75 768054070125 IMMUNOASSAY, MULTIPLE 228.10 835164070004 ELECTOLYTES PROFILE 88.10 800514070385 CCP 134.40 862004070091 CRYOGLOBULIN 155.20 825954174653 NUR - ACTIVITY/BATHROOM P - 4070277 HTLV II 129.30 866884174617 ACYCLOVIR LIQ [200 MG/5ML 9.00 4330008 CAROTID DUPLEX, BIL 708.50 938804174905 DAPSONE TAB 100MG 16.00 4070359 SPECIAL STAINS 217.90 883124140073 ANKLE - 2 197.80 736004140123 CT ABD/PELVIS W CONTRAST 2,343.00 741774140035 THORACIC - 2 315.50 720704070207 CBC W/ AUTO DIFF 88.10 850254140165 CT-ABD/PELVIS W&WO CONTRAST 2,861.25 741784070063 CALCITONIN 265.40 823084070166 PSA 93.00 841534230029 SHOULDER REDUCTION 831.40 236504174547 VIT- D CAP [1000 UNT] (N 3.00 4173711 PREDNISONE TAB [10 MG] 3.00 4070225 RUSSELL VIPER VENOM 108.90 856134174860 LATANOPROST 0.005% 26.00 4070178 THYROGLOBULIN 168.30 844324140170 US AORTA SCREENING 557.25 767064174867 GLIMEPIRIDE 2MG (NF) 5.00 4070007 LIPID PROFILE 165.00 800614140046 CT-PELVIS-W/ CONTRAST 1,893.75 721934070249 CA 125 274.50 863044070482 RABIES TITER 107.00 863824070340 RESPIRATORY SYNCYTIAL 114.00 87420

4070402 ZINC 56.40 846304174667 OXYGEN 66.00 4260019 INTER CLOSURE,FACE 458.70 120514173639 CIPROFLOXACIN SDV 400MG ( 20.00 J07444230067 ER PROB FOC DR 98.30 992814174664 NUR - VS/BLOOD PRESSURE - 4209915 OTHER GOAL 60-80 0.01 G8991,CL,GP4174088 NITROFURANTOIN CAP [100 M 9.00 4230082 STRAPPING, KNEE 280.70 295304140124 US ADB SINGLE ORGAN 363.60 767054230012 LACERATION REPAIR 438.30 120314140014 CT-HEAD OR BRAIN W OUT 1,332.00 704504070031 VANCOMYCIN 135.00 802024070123 HYDROXYCORTIC 173.30 834914070342 HEPATITIS BV DNA 335.50 875164070304 ANTIBODY SCREEN RBC 88.10 868504174675 NUR - TELEMETRY - 4070108 GASTRIN 202.70 829414070159 PORPHOBILINOGEN, QUANT 98.30 841104070307 BLOOD TYPING ABO 104.00 869004070016 CYCLOSPORINE 372.10 801584070457 CALPROTECTIN, FECAL 248.20 839934070229 PTT 88.10 857304140069 KNEE - 3 315.50 735624070463 SPECTROPHOTOMETRY, STOOL 71.10 843114070328 WET PREP 45.10 872104230057 THORACENTESIS 641.00 320024209886 SELF GOAL 80-100 0.01 G8988,CM,GP4174870 FLEXBUMIN 25% IVSL 100ML 420.00 P90474140140 TRANSVAGINAL US, OBSTECTRIC 591.00 768174070092 VIT B 12 85.00 82607

25500 CLOSED RADIAL FX W/O MANIPULATION 1,213.50 2550099144 CONSCIOUS SEDATION 381.00 99144

4260069 DISLOCATED INTERPHALANGEA 601.00 286654209897 SELF D/C 100 0.01 G8989,CN,GP4140120 OB US >14 WEEKS 306.75 768054260053 CAST REMOVAL 186.30 297054140002 MANDIBLE < 4 315.50 701004174839 PRESERVISION AREDS 2 5.00 4070119 HEMOGLOBIN 117.40 830203010012 I/P SUBSEQUENT UNSTABLE P 217.90 992334260059 REMOVAL,FB EXT.CANAL 290.30 692004140141 US DUPLEX SCAN COMPLETE 1,286.25 939254230019 LACERATION REPAIR 707.20 120533010011 I/P SUBSEQUENT MILD CHNG 141.20 992324070132 KETOSTEROIDS 17-KS 141.20 835864070246 CA 15-3 274.50 86300

4070038 ACETAMINOPHEN 159.60 803294230058 NG TUBE PLACEMENT 319.60 437524174061 HYDROCOD/ ACET TAB [5-500 5.00 4070180 T4 FREE 90.00 844394330018 EXTRACRANIAL ART DOPPLER - 938754070160 PORPHYRINS, QUANT 193.10 841204140054 HUMERUS>=2 262.30 730604140167 US RETROPERITONEAL LIMITED 566.25 767754070497 SELENIUM 157.48 842554070103 FOLIC ACID 85.00 827464174662 NUR - PULSE OXIMETRY - 4230020 LACERATION REPAIR 1,395.10 131324070037 URINE HCG 64.90 810254140173 US OB LIMITED 505.50 768154140003 MASTOIDS COMPLETE 320.90 701304070285 HEP B S AB 123.10 867064174335 MIRTAZAPINE TAB [15 MG] 5.00 4140037 THORACOLUMBAR - 2 308.90 720804140088 SMALL INTESTINE MULTIPLE 318.30 742504070162 POTASSIUM, URINE 53.00 841334209930 SUB CURRENT NO 0.01 G8993,GP4070115 FSH 154.00 830014260073 HYDRATION INITIAL HR 235.90 963604230093 THORACENTESIS 642.00 325544209944 SUB GOAL 40-60 0.01 G8994,CK,GP4260011 SIMPLE REPAIR,FACE 388.60 120134173717 MEPERIDINE INJ [50 MG/ML] 54.00 J21754070435 CHROMOGRIN A 200.80 863164070388 CYTOMEGALOVIRUS IGM 123.10 866454140004 INTERIOR AUDIT MEATI 306.30 701344174796 BACITRACIN 500U/GM PCKT 7.00 4070036 MICRO UA 44.00 810034070451 POST VAS SPERM ANALYSIS 63.90 893214260001 OUTPATIENT VISIT 61.50 992114209865 CARRY D/C 60-80 0.01 G8986,CL,GP4070053 AMMONIA 184.60 821404070387 ASCA PROFILE 281.80 866714174647 CALCITONIN-SALMON NASAL S 402.00 4070439 ACETYLCHOLINE 222.70 835194070391 GLUCOSE-6-PHOSPHATE DEHYD 46.20 829604174836 MAGNESIUM TAB 250MG 3.00 4070370 GGT 47.40 829774260010 SIMPLE REPAIR,FACE 316.30 120114070289 INFLUENZA VIRUS 134.40 867104230009 LACERATION REPAIR 388.60 120134174644 VASOPRESSIN MDV 20U 17.00 4330019 SLEEP STUDY ATTENDED 2,939.40 95810

4140156 CT-THORACIC SPINE W & WO CONTRAST 2,315.25 721304070274 GIARDIA LAMBLIA 163.80 866744140093 IVP 630.30 744004140118 CT-HEAD W&W/O CONTRAST 3,006.00 704964230091 DRAINAGE OF ABS 498.50 418004260057 REMOVAL FB EXT. EY 219.10 652054140177 US EXTREMITY SOFT TISSUE 225.00 768824070311 STOOL CULTURE 275.00 870454070313 ANAER CULTER 93.70 870754260040 LONG ARM CAST 273.90 290654140136 CT ABD & PELVIS W/O 1,633.50 741764173537 MUPIROCIN OIN 2% ** (NF 36.00 4070012 DRUG SCREEN SINGLE 58.70 801014230021 LACERATION REPAIR 385.20 131334140126 OB US, DETAILED, ADDL 741.60 768124070316 CULTURE BACTERIAL URINE 85.20 870864174151 SIMETHICONE TAB [80 MG] 3.00 4174822 MAGNESIUM 250MG 3.00 4070268 COCCIDIOIDES 149.60 866354209822 BODY GOAL 1-20 0.01 G8982,CI,GP4174679 NUR - SKIN PRECAUTIONS - 4140180 US DUPLEX SCAN EXTRACRANIAL UNI/LIMTD 742.50 938824070135 LEAD 181.80 836554209861 CARRY D/C 0 0.01 G8986,CH,GP4174213 BETA CAR/ VIT A /C/E/MIN 3.00 4140116 CT-CHEST W/CONTRAST 1,928.25 712604209900 OTHER CURRENT NO 0.01 G8990,GP4070128 INSULIN TOTAL 146.80 835254070355 PAP 97.10 881414240004 OBSER / TELE 1-4 HR(RPH) 253.50 G03784209876 SELF CURRENT 80-100 0.01 G8987,CM,GP4070488 ALKALINE PHOSPHATASE ISOENZYMES 103.49 840804070117 GROWTH HORMONE -HGH 174.50 830034174703 CLOPIDOGREL BISULFATE [75 3.00 4070198 VITAMIN A SERUM 159.80 845904173894 HYDROCHLOROTHIAZIDE CAP [ 3.00 4140070 KNEE - 4 396.80 735644174788 SULFASALAZINE TAB (500MG) 5.00 4070292 MYCOPLASMA 134.90 867384209842 CARRY CURRENT 1-20 0.01 G8984,CI,GP4070050 AMINO ACIDS SINGLE 232.10 821314070432 HEALTH FAIR PANEL 36.00 4070044 ALCOHOL 123.10 80320

32551 TUBE THORACOSTOMY 1,320.75 325514070433 HEALTH FAIR MEN PANEL 56.00 4230007 LACERATION REPAIR 548.40 120054070486 RNP ANTIBODY 110.70 86235

4140163 CT-LOWER EXTREMITY W/CONTRAST 1,787.25 737014140157 CT-LUMBAR SPINE W/O CONTRAST 1,560.00 721314070124 HYDROXYINDOLACETIC 151.80 834974230049 SHORT LEG CAST 331.50 294054070407 HIV 1 & HIV 2, SGLE ESSAY 120.80 867034173633 VIT- B-12/ C/ FE/ IFC CAP 13.00 4140039 LUMBOSACRAL COMPLETE 376.80 721104070323 SUSCEPTIBILITY 85.20 871864173632 PHENOL SPR BTL ** (NF) 4.00 4070145 ENZYMATIC DIGESTION 88.10 838924070006 OBSTETRIC PANEL 239.50 800554174910 RITUXIMAB 10MGML-SDV 10ML 1,807.00 J93104174108 VIT- B-12/ B-6/ L-MFOLATE 17.00 4140154 CT-THORACIC SPINE W/O CONTRAST 1,560.00 721284230042 HAND/WRIST CAST 217.90 290854209940 SUB GOAL NO 0.01 G8994,GP4230064 REMOVE,FB EXT CANAL 290.30 692004209893 SELF D/C 20-40 0.01 G8989,CJ,GP4209851 CARRY GOAL 0 0.01 G8985,CH,GP4173879 GLIPIZIDE TAB [5 MG] (NF 5.00 4140147 CT-FACIAL BONES/SINUSES/MAXILLOFACIAL W 1,920.00 704874209790 MOBILITY GOAL NO 0.01 G8979,GP4174861 PSORIASIN COAL TAR 40.00 4174801 LEVONORGESTREL 20MCG/24HR 2,452.00 4070452 COLLECTION AND HANDLING 26.00 990004070072 CATECHOL TOTAL URINE 190.90 823824209856 CARRY GOAL 80-100 0.01 G8985,CM,GP4070230 PTT;SUBSTITUTIO (PTT-LA) 76.10 857324260012 REPAIR,SIMPLE 476.10 120144260072 HYDRATION EACH ADD HR 106.10 963614174862 COSYNTROPIN 0.25 111.00 J0835

A0429 AMBULANCE BLS REFUSAL 250.00 A04294174809 CARVEDILOL TAB 3.00 4209921 OTHER D/C 0 0.01 G8992,CH,GP4174848 HYDROCORTISONE SOD SUCC (100MG) 61.00 4174670 NUR - ACTIVITY/NON WEIGHT - 4070395 VIT B, WHOLE BLOOD 263.20 844254230074 E R VISIT-LEVEL 5 811.10 992854070319 CULTURE TUBERCLE 99.40 871164209955 SUB D/C 60-80 0.01 G8995,CL,GP4230063 INTOR OF NEEDLE IN 118.60 360004070154 OXALATE 163.80 839454174656 NUR - ACTIVITY/UP IN CHAI -

97164 PHYSICAL THERAPY RE-EVAL EST PLAN CARE 159.00 97164,GP4240001 OBSERVATION 1-4 HR (RPH) 184.60 G03784260031 NURSEMAID ELBOW CHILD 373.30 246404070068 CO2 49.60 82374

4140164 CT-LOWER EXTREMITY W&WO CONTRAST 2,256.75 737024070232 ANTINUCLEAR ANTIBODIES 163.80 860384070392 AMPLIFICATION, 1ST NUC AC 49.60 839004200019 MANUAL THERAPY 78.90 97140,GP3010017 I/P DISCHARGE >30MIN PHYS 221.30 992394174856 EYE OINT PM REFRESH 54.00 4070052 AMINO ACIDS 6 OR MORE 563.70 821394230043 SHOULDER/ARM SPLINT 217.90 291054070234 C REACTIVE SCREEN 70.00 861404230033 CL-TX ULNAR STYLOID FX 971.50 256503010018 SUBSEQUENT OBS 212.20 992244174776 MEROPENEM 1GM 57.00 J21854070176 TESTOSTERONE FREE 263.20 844024209937 SUB CURRENT 100 0.01 G8993,CN,GP4174408 IRR- STERILE WATER [1000 9.00 4070394 MUTATION ID, EACH SEGMENT 111.10 839144173694 VIT- B-12 TAB [100 MCG] 3.00 4174678 NUR - FALL PRECAUTIONS - 4174845 LEPTOSPERMUM HONEY 132.00 4140148 CT-FACIAL BONES/SINUSES/MAXOFACIAL W&W/O 2,127.00 704884173595 DILTIAZEM CD CAP [120 MG] 5.00 4209836 BODY D/C 80-100 0.01 G8983,CM,GP4230070 E R VISIT-LEVEL 3 379.60 992834209910 OTHER GOAL NO 0.01 G8991,GP4140102 CTA CHEST 2,934.75 712754209823 BODY GOAL 20-40 0.01 G8982,CJ,GP4070020 LITHIUM 115.20 80178

94761 PULSE OX MULT 46.00 9476151700 BLADDER IRRIGATION SIMPLE 362.25 51700

4070434 HEALTH FAIR PSA 20.00 4070397 HYDROXYPROGESTERONE 119.70 834983010009 I/P ADMIT COMPRHENSIVE PH 343.40 992234070094 DHEA 316.30 826264209881 SELF GOAL 0 0.01 G8988,CH,GP4260037 DISLOCATED FINGER 790.00 267754070436 IMMUNOFIXATION, URINE 275.50 863354140071 KNEE - AP STANDING 249.30 735654070120 HGB A1C 35.00 830364260054 CAUTERY,NASAL HEMOR 344.50 309014140190 CT LOW DOSE LUNG/CHEST 1,585.50 G02974260065 INTER REPAIR >2.5CM 520.10 120423010010 I/P SUBSEQUENT STABLE PHY 111.10 992314070379 PROTEIN BODY FLUID 44.00 841574209843 CARRY CURRENT 20-40 0.01 G8984,CJ,GP4174661 NUR - NEURO CHECKS - 4070243 EXTRACTABLE NUCLEAR 85.00 862354070258 RA FACTOR 111.80 86431

4200010 WHIRL POOL 48.80 97022,GP4174808 VANCOMYCIN HCL IVPB 5GM - 3010002 ER CRITICAL CARE ADD'L 30 253.50 992924070049 ALPHA- SERUM 237.20 821054230048 LONG LEG CAST 438.30 293454070458 SHIGA TOXIN, STOOL 114.30 874274209857 CARRY GOAL 100 0.01 G8985,CN,GP4174521 VALACYCLOVIR TAB [500 MG] 54.00 4070010 LIVER PROFILE 146.80 800764070111 POST GLUCOSE DOSE 52.40 829504174676 NUR - ACTIVITY/ELEVATE LE - 4173490 ARTIFICIAL TEARS DRP ** 9.00 4174436 METHIMAZOLE TAB [10 MG] 16.00 4070107 IMMUNOGLOBULIN 306.60 827874174818 LAMOTRIGINE TAB 100MG 5.00 4174757 TETRACYCLINE HYD (250MG) 3.00 4209853 CARRY GOAL 20-40 0.01 G8985,CJ,GP4070098 ERYTHROPOIETIN 217.90 826684209781 MOBILITY CURRENT 0 0.01 G8978,CH,GP4209860 CARRY D/C NO 0.01 G8986,GP4140064 HIP - 2-3 315.50 735024209906 OTHER CURRENT 80-100 0.01 G8990,CM,GP4070343 HEPATITIS C QUANTIFICATIO 789.00 875224209830 BODY D/C NO 0.01 G8983,GP4230035 CLOSED RED W/MAN 867.00 267254209827 BODY GOAL 100 0.01 G8982,CN,GP4209891 SELF D/C 0 0.01 G8989,CH,GP4174693 PROPAFENONE HCL [150MG] ( 3.00 4070188 T3 181.80 844804260014 INTERMEDIATE CLOSURE 356.30 120314070440 AMPLIF, SIGNAL, EA NUC AC 49.60 839084070054 ANDROSTENEDIONE 438.30 821574230034 CL-TX METACARPAL FX . 631.50 266004070369 KOH, SKIN, NAIL 48.50 872204070479 INHIBIN A 239.60 863364174744 CHOLESTYRAMIN LIGHT (4GM) 9.00 4174659 NUR - INTAKE AND OUTPUT - 4070464 LEVETIRACETAM 96.90 801774260074 INJECTION IM, SQ 58.70 963724209845 CARRY CURRENT 60-80 0.01 G8984,CL,GP4173675 NEO/ POLY/ HC DRP SUS [EA 21.00 4174327 VAC - HEPITITIS B [10MCG] 208.00 J3490

94640 NEBULIZER 40.00 946404070183 AST 61.00 844504070028 THEOPHYLLINE 193.10 801984140122 US SCROTUM 583.50 768704140176 US BLADDER/PELVIC LIMITED 491.25 76857

4070405 TUBERCULOSIS QUANTIFERON 481.20 864804209902 OTHER CURRENT 1-20 0.01 G8990,CI,GP4174906 LEFLUNOMIDE TAB (20MG) 14.00 4070058 BETA-2 MICROGLOBULIN 263.20 822324140001 EYE, FOREIGN BODY 271.40 700304140020 CHEST W/APICAL 280.60 710214070045 ALDOLASE 147.90 820854070250 MONO 64.40 863084230094 REMOVAL OF FOOT FOREIGN BODY 201.00 281904070469 GDH ANTIGEN 52.00 874494230090 FRACTURE W/ MANIPULATION 1,427.60 235254070114 GGT 64.40 829774209814 BODY CURRENT 40 -60 0.01 G8981,CK,GP4070213 FACTOR VIII AHG ONE 274.50 85240

951171 ALLERGY INJECTION MULTIPLE 14.00 951174070217 ANTITHROMBIN III, ANTIGEN 181.80 853014174657 NUR - HEMOCCULT STOOLS - 4070363 CELL CT. W/DIFF 84.00 890514240003 OBSERVATION 13-24 HR (RPH 12.90 G03784174882 NICOTINE POLACRILEX GUM 5.00 4140166 CTANGIOGRAM ABD & PELVIS W W/O CONTRAST 3,529.50 741744173865 VAC- HUMAN PAPILLOMAVIRUS 545.00 4209811 BODY CURRENT 0 0.01 G8981,CH,GP4209872 SELF CURRENT 1-20 0.01 G8987,CI,GP4070163 PREALBUMIN 169.40 841344209951 SUB D/C 0 0.01 G8995,CH,GP4140060 HAND 2 208.20 731204173771 VAC- H1N1 INFLUENZA VIRUS 3.00 4209927 OTHER D/C 100 0.01 G8992,CN,GP4140186 US DUPLEX SCAN AORTA IVC ILIAC COMPLETED 969.00 939784070216 CLOTTING INHIBITORS 204.50 853004209933 SUB CURRENT 20-40 0.01 G8993,CJ,GP4070367 THERAPUETIC PHLEB 105.10 991954070219 PROTEIN C ACTIVITY 228.10 85303

26750 FRACTURE TREATMENT PHALANGEAL CLOSED 786.00 267504070055 AMY 76.70 821504070267 CHLAMYDIA IGM 154.10 866324173772 FENTANYL PAT [25 MCG/HR] 14.00 4173686 CRANBERRY CAP [475 MG] ( 3.00 4330004 CARDIOVERSION 608.70 929604070034 UA DIP STICK 34.00 810024070029 TOBRAMYCIN 263.20 802004174768 LISINOPRIL 2.5MG (NF) 6.00 J34904070192 BUN 53.00 845204070297 FTA-ABS CONFIRM 120.80 867814140117 CT-CHEST W/O CONTRAST 1,585.50 712504070075 CHLORIDE URINE 65.50 82436

4070008 RENAL PANEL 158.10 800694174640 IRR - WATER STERILE [1000 9.00 4260050 SHORT LEG SPLINT 190.90 295154140030 SPINE 192.50 720204260030 SHOULDER REDUCTION 1,156.20 236554070284 HEP B IGM ANTIBODY 117.40 867054070423 SOMATOSTATIN 292.50 843054070164 PROGESTERONE 148.00 841444173593 SUCRALFATE SUS [1 GM/10ML 35.00 4209926 OTHER D/C 80-100 0.01 G8992,CM,GP4174610 ZOLEDRONIC ACID IV [4MG/5 2,710.00 J34884209795 MOBILTIY GOAL 60-80 0.01 G8979,CL,GP4070262 BORDETELLA 129.30 866154140151 CT-NECK SOFT TISSUE W&WO CONTRAST 2,127.75 704924173734 TOLTERODINE ER CAP[2 MG] 35.00 4209854 CARRY GOAL 40-60 0.01 G8985,CK,GP4070174 NA 45.10 842954260029 SHOULDER REDUCTION 831.40 236504070312 ROUTINE CULTURE 158.10 870704070040 ADRENOCORTICOTROPIC 199.30 820244200016 NEUROMUSCULAR RE-EDUCATION 78.90 97112,GP4173572 BUSPIRONE TAB [10 MG] (N 3.00 4070260 ASPIRGILLUS 144.50 866064140113 US SOFT TISSUE HEAD/NECK (THYROID) 587.25 765364174154 IRR - SODIUM CHLORIDE 0. 9.00 4260043 SHOULDER/ARM SPLINT 217.90 291054070060 DBILI 64.40 822484250002 AMBULANCE/MILE > 100 MI 21.00 A04254209785 MOBILITY CURRENT 60 -80 0.01 G8978,CL,GP4070261 BLASTOMYCES 125.90 866124260021 LAYERED CLOSURE,FACE 953.50 120534260035 CLOSED REDUCTION 867.00 267254140081 ABDOMEN - 2 302.40 740194140061 HAND 3 262.30 731304174639 IRR - WATER STERILE [250 9.00 4173971 IVF- SOD CL 0.9% [1000 ML 75.00 J70304174721 RT - FLUITICASONE MDI (11 751.00 4174086 PREGABALIN CAP [25 MG] ( 33.00 4070236 CARDIOLIPIN PHOSPHOLIPID 274.50 861474174903 OMEGA Q PLUS 3.00 4070170 PROTEIN ELCTROPHOR 134.40 841654174158 MEMANTINE TAB [10 MG] (N 35.00 4140145 CT-SELLA (PITUITARY W&W/O CONTRAST 2,910.00 704824070442 DIHYDROTESTOSTERONE 288.40 826514173974 IVF- SOD CL 0.9% [500 ML] 75.00 J70404260071 SEC CLOS/DEHISC OF WOUND 2,705.00 131604070157 ALK 47.40 84075

3010003 I/P OBSERVATION DISCHG PH 134.90 992174070197 ANTIDIURETIC HORMONE 375.50 845884070314 ORGANISIM ID 80.60 870774209917 OTHER GOAL 100 0.01 G8991,CN,GP4070179 T4 93.70 844364174672 NUR - ACTIVITY/OUT TO ACT - 4230036 CLOSED TX FINGER DISLOC 654.00 267704070182 THYROID STIMULATING IMM 322.40 844454070254 IMMUNOELECTROPHORESIS 190.90 841654140182 US DUPLEX SCAN UPPER EXT ARTERIES COMP. 1,191.00 939304173561 IBANDRONATE SODIUM INJ [3 686.00 J17404070362 CELL COUNT MISC BODY 70.00 890504070065 IONIZED CALCIUM 97.00 823304140038 L-S-2/3 315.50 721004209855 CARRY GOAL 0.01 G8985,CL,GP4260058 REMOVAL,FB,CORNEA 341.10 652224140022 CHEST SPECIALS 230.60 710354174167 NEO/ BAC/ POLY/ HC OIN [E 103.00 4070046 ALDOSTERONE 159.00 820884140008 SINUS < 3 243.10 702104250004 AMBULANCE/MILE < 100 MII 21.00 A04254230075 ER COMPREHENSIVE DR 440.50 992854070153 URINE OSMOLALITY 132.70 839354070444 SEX HORMONE (SHBG) 160.70 842704209905 OTHER CURRENT 60-80 0.01 G8990,CL,GP4230015 LACERATION REPAIR 376.70 120413010013 I/P ADMIT/DISCH SAME DAY 290.30 992344070293 RUBELLA SCREEN 146.80 867624174791 CAPSAICIN CREAM 0.02 60GM 27.00 4260063 OUTPATIENT VISIT 98.30 992124070142 BNP NATRURETIC PEPTIDE (PRO BNP) 259.80 838804070205 HCT 35.00 850144070077 CHOLINESTERASE, SERUM 120.80 824804070253 ANCA 122.00 863184174649 TRIAMTERENE/HCTZ 37 1/2/2 3.00 4250001 AMBULANCE BASIC 800.00 A04294070266 CHLAMYDIA IGG 140.10 866314140083 CT-ABDOMEN W/O CONTRAST 1,515.75 741504209812 BODY CURRENT 1-20 0.01 G8981,CI,GP4070196 VMA URINE 183.40 845854173922 TERAZOSIN CAP [5 MG] (NF 3.00 4070122 HVA 173.30 831504070494 HEALTH FAIR VITAMIN B12 20.00 4140097 ABD ULTRASOUND 702.75 767004209787 MOBILTIY CURRENT 100 0.01 G8978,CN,GP4174899 TRIAMTERENE/HCTZ 37.5/25MG 5.00 4174841 AMLODIPINE BESYLATE TAB (2.5MG) [NF] 3.00

4070242 DEOXYRIBONUCLEIC ACID 136.70 862254174381 QUETIAPINE TAB [25 MG] ( 26.00 4070033 UA 41.70 810004140149 CT-NECK SOFT TISSUE W/O CONTRAST 1,531.50 704904209862 CARRY D/C 1-20 0.01 G8986,CI,GP4070116 LH 154.00 830024140115 MOTION SWALLOW W/FLUOROSC 224.00 926114230051 SHORT LEG SPLINT 263.20 295154070350 CYTOPATHOLOGY CONCENT 233.20 881084070001 VENI PUNCTURE 30.90 364154230073 ER DETAILED DR 297.60 992844070322 SUSCEPTIBILITY STUDIES 65.50 871814173743 PHENYTOIN EX CAP [100 MG 5.00 4209841 CARRY CURRENT 0 0.01 G8984,CH,GP3010005 I/P OBSERVATION COMPREHEN 233.20 992194230028 CLAVICULAR FRACTURE 600.40 235004230010 LACERATION REPAIR 476.10 120144174737 ERTAPENEM SOD (1GR) [SPEC 373.00 4230008 LACERATION REPAIR 379.60 120114173729 TESTOSTERONE E CYP INJ 200MG 30.00 J10714209816 BODY CURRENT 80-100 0.01 G8981,CM,GP4174682 NUR - VS/RESPIRATIONS - 4140049 CLAVICLE>=2 235.30 730004140150 CT-NECK SOFT TISSUE W/ CONTRAST 1,759.50 704914174736 LINEZOLID (600MG/300ML) [ 293.00 J20204230071 ER EXPANDED DR 210.10 992834070286 HEPATITIS BE ANTIBODY 112.90 867074140016 CT SCAN - HEAD W/O 1,966.50 704704140018 CHEST - 1 235.30 710454173859 IMMUNE GLOBULIN INJ [10 G 3,804.00 4070148 NUCLEIC ACID PROBE 123.10 838964070081 COLLAGEN CROSS LINKS 236.10 825234209825 BODY GOAL 60-80 0.01 G8982,CL,GP4173673 NEO/ POLY/ HC DRP [EYE] 104.00 4173860 IMMUNE GLOBULIN INJ [5 GM 2,038.00 4173844 VIT- B-12/ B-6/ FA TAB [0 5.00 4174212 SOD CHLOR 0.65% SPR ** 6.00 4140065 HIP - BILATERAL - 5 336.00 735234070064 CA 70.00 823104174700 LIDOCAINE MPF 4% 23.00 J20014070101 FAT OR LIPIDS, FECES 115.20 827054209874 SELF CURRENT 40-60 0.01 G8987,CK,GP4209924 OTHER D/C 40-60 0.01 G8992,CK,GP4070096 DIHYDROXYVITAMIN D, 1,25 193.10 826524174141 GUAIFEN/ DM TAB [600-30 M 9.00 4140175 US FETAL UMBILICAL ARTERY 433.50 768204174665 NUR - VS/PULSE -

4070070 CHLAMYDIA PROBE 216.80 874914209950 SUB D/C NO 0.01 G8995,GP4209945 SUB GOAL 60-80 0.01 G8994,CL,GP4070057 MEPHOBARBITAL 102.20 822054174176 ESOMEPRAZOLE CAP [20 MG] 49.00 4070241 TOTAL HEMOLYTIC CH50 246.80 861624070175 URINE SODIUM 64.40 843004070013 DRUG CONFIRMATION 181.20 801024174237 PENICILLIN G POT INJ [5 M 59.00 J25404174746 LANSOPRAZOLE 15MG DELAY R 6.00 4070471 H PYLORI (BREATH) 218.48 830134070167 PSA FREE 204.50 84154

26070 EXPLORE/TREAT HAND JOINT 1,650.00 260704260020 INTER CLOSURE,FACE 581.70 120524209894 SELF D/C 40-60 0.01 G8989,CK,GP4260023 COMPLEX REPAIR 385.20 131334209916 OTHER GOAL 80-100 0.01 G8991,CM,GP4070290 LEGIONELLA 145.60 867134260018 LACERATION REPAIR 657.40 120444070272 EPSTEIN-BARR EB VIRUS, 193.10 866643010016 I/P DICHARGE 30MIN < PHYS 154.10 992384140187 US DUPLEX SCAN AORTA IVC ILIAC LMTD 639.75 939794070408 HIV-1, QUANITIFICATION 455.30 875364070400 STOOL CULTURE AD'L PATH 105.10 870464174686 OMEPRAZOLE CAP (40MG) (NF 3.00 4140011 SKULL COMPLETE 403.80 702604173695 VIT- B-12 TAB [500 MCG] 4.00 4140032 C SPINE>= 4 436.80 720524070099 ESTRADIOL 274.50 826704174433 OSELTAMIVIR CAP [75 MG] 41.89 3010014 I/P ADMIT/DISCHG SAME DAY 374.40 992354209883 SELF GOAL 20-40 0.01 G8988,CJ,GP4070172 QUININE 111.10 84228

80175 LAMOTRIGENE 111.40 8017543753 GASTRIC INTUBATION 141.75 43753

4070308 RH (D) 104.00 869014209896 SELF D/C 80-100 0.01 G8989,CM,GP4070005 CHEM PROFILE CMP 193.10 800534209826 BODY GOAL 80-100 0.01 G8982,CM,GP4070177 TESTOSTERONE 197.00 844034140085 ESOPHAGUS 334.70 742204174306 FINASTERIDE (5MG) [NF] 3.00 4140047 SACRO-ILIAC JOINT 222.20 722004174548 VIT- E CAP [1000 UNT] (N 4.00 4070431 LEUKOCYTE ASSESSMENT 102.80 890554260045 FINGER SPLINT APLICATION 101.00 291304070409 COXIELLA BURNETII (Q FEVE 167.20 86638

4070185 TRANSFERIN, IRON BINDING 181.80 844664230041 SHORT ARM CAST 227.50 290754070062 VITAMIN D 25-HYDROXY 193.10 823064270002 NUTRITION INITIAL P/15MIN 62.80 978024174719 GLUCOSE GEL 40% TUBE 31.00 4140152 CT-SPINE/CERVICAL W/ CONTRAST 1,872.75 721264174894 HEPARIN SUBQU 5000UN 11.00 4070335 HERPES SIMPLEX VIRUS 108.90 872744209871 SELF CURRENT 0 0.01 G8987,CH,GP4174819 ENBREL 50MG/ML 3,755.00 J14384070003 BASIC OR RENALYTES 134.40 800484173741 FLUCONAZOLE TAB [150 MG] 13.00 4209831 BODY D/C 0 0.01 G8983,CH,GP4140079 CT LOWER EXTREMITY W/O 1,479.75 737004070161 K 56.40 841324070416 ALLERGEN SPEC IGG 181.20 860014140074 ANKLE - 3 262.30 736104070410 ARSENIC 268.80 821754070121 HOMOCYSTIENE 193.10 830904174714 METOPROLOL SUCC ER [100MG 9.00 4070481 PROCALCITONIN 343.09 841454070449 FACTOR V LEIDEN 297.70 812414070271 EPSTEIN-BARR EB VIRUS, 181.80 866634070131 KETOGENIC STEROIDS, 155.20 835824174129 MORPHINE INJ [10 MG/ML] 9.00 J22704209783 MOBILITY CURRENT 20-40 0.01 G8978,CJ,GP4070326 SMEAR FLUORESCENT 88.10 872064174833 ENALAPRIL MAL TAB [5MG] 5.00 4209844 CARRY CURRENT 40-60 0.01 G8984,CK,GP4260022 COMPLEX WOUND REPAIR 1,395.10 131324209887 SELF GOAL 100 0.01 G8988,CN,GP4174271 POLYMYXIN/ TMP DRP [EYE] 60.00 4070453 GENERAL HEALTH PANEL 247.20 800504209922 OTHER D/C 1-20 0.01 G8992,CI,GP4070280 HERPES SIMPLEX TYPE 2 207.20 866964140031 C SPINE - 2 315.50 72040

29580 STRAPPING UNNA BOOT 136.50 295804070018 VALPORIC ACID 193.10 801644209815 BODY CURRENT 60-80 0.01 G8981,CL,GP4174762 NASAL GEL SODIUM CHLORIDE 21.00 4140143 HIP - 4< 325.00 735034140159 CT-PELVIS W&WO CONTRAST 2,245.50 721944260033 CLOSED TX OF ULNAR FX 971.50 256504070441 VOLTAGE GATED CA CHANNEL 287.80 835194240002 OBSERVATION 5-12 HR (RPH) 31.00 G03784209903 OTHER CURRENT 20-40 0.01 G8990,CJ,GP4173845 VIT- B-12/ B-6/ FA TAB ( 5.00

4174391 MONTELUKAST TAB [10 MG] 9.00 4070186 TRIG 49.60 84478

101200 INCISION REMOVAL FOREIGN BODY SUBQ SIMPL 351.00 101204173428 OXYMETAZOLINE 0.05% SPR 27.00 4070438 KAPPA/LAMDA LIGHT CHAINS 148.00 838834140010 SKULL < 4 342.60 702504140066 HIP - INFANT/CHILD - 2 241.70 735404209942 SUB GOAL 1-20 0.01 G8994,CI,GP4174723 NUR - ACTIVITY AS TOLERAT - 4070333 B. PERTUSSIS DNA PROBE 108.90 872654070273 EPSTEIN-BARR EB VIRUS, 216.80 866654140168 US CHEST 466.50 766044209935 SUB CURRENT 60-80 0.01 G8993,CL,GP4070282 HIV 158.10 867014173763 DOPAMINE SDV 40MG 200MG/5 37.00 J12654174681 NUR - SUICIDE PRECAUTIONS - 4070085 CPK 88.10 825504070372 CAPILLARY PUNCTURE 33.30 364164209863 CARRY D/C 20-40 0.01 G8986,CJ,GP4070365 SMEAR FOR WBC 45.10 891904070315 STREP SCREEN CULTURE 70.00 870814174453 VIT- B-1 THIAMINE TAB [100 MG] 3.00 4174523 VANCOMYCIN INJ [1 GM] 22.00 J33704209837 BODY D/C 100 0.01 G8983,CN,GP4070209 RETIC 56.40 850444070194 URIC ACID 61.00 845504070105 GAMMAGLOBULIN EACH 181.80 827844140076 FOOT - 3 436.90 736304140058 WRIST - 2 208.20 731004209852 CARRY GOAL 1-20 0.01 G8985,CI,GP4070195 URINE URIC ACID 52.40 845604140021 CHEST, PA LAT OBL 310.20 710474174868 TRADJENTA TAB 5MG (NF) 9.00 4140052 SHOULDER >=2 315.50 730304140013 NECK SOFT TISSUE 208.70 703604209936 SUB CURRENT 80-100 0.01 G8993,CM,GP4070127 IMMUNOASSAY NOS 193.10 835204200020 THERAPEUTIC ACTIVITIES 78.90 97530,GP4209931 SUB CURRENT 0 0.01 G8993,CH,GP4230092 REMOV FB IP JOINT 1,967.30 260804070152 OSMOLALITY, BLOOD 112.90 839304070144 ISOLATION OR EXTRACTION 88.10 838914174790 SERTRALINE (25MG) [NF] 9.00 4174344 TEMAZEPAM CAP [15 MG] (N 3.00 4070437 NEONATAL BILIRUBIN 56.40 822474070472 ESTRONE 214.16 826794070173 RENIN 296.40 84244

4070475 MYCOPLASMA PNEUMONIA, PCR 420.74 875814070187 T3 UPTAKE 93.70 844794209833 BODY D/C 20-40 0.01 G8983,CJ,GP4209810 BODY CURRENT NO 0.01 G8981,GP4260049 SHORT WALKING CAST 350.70 294254070233 ASO 82.90 860604070133 LACTATE (LACTIC ACID) 171.70 836054070109 GLU 88.10 829474070032 QUANTITATION OF DRUG 286.90 80299

88112 CYTOLOGY BODY FLUID 565.00 881124070168 TP 70.00 841554230050 SHORT LEG WALKING CAST 350.70 294254173911 INS- NPH HUMAN INJ [100 U 73.00 J18154174549 VIT- E CAP [400 UNT] (NF 3.00 4070283 HEP B CORE AB 127.00 867044070102 FERRITIN 50.00 827284140178 US GUIDANCE NEEDLE PLACEMENT 982.50 769424140184 US DUPLEX SCAN ABD/PEL/SCROT/RPR COMP. 1,414.50 939754330016 HOLTER MONITOR 252.75 932254070384 BB CROSSMATCH IMMED SPIN 98.90 869204070042 URIN ALB 115.20 820424070476 CHLAMYDIA PNUEMONIAE, PCR 246.60 874864209813 BODY CURRENT 20-40 0.01 G8981,CJ,GP4209791 MOBILITY GOAL 0 0.01 G8979,CH,GP4140125 OB US, DETAILED, SINGLE 828.10 768114240005 OBSER / TELE 5-12 HR(RPH) 43.40 G03784209901 OTHER CURRENT 0 0.01 G8990,CH,GP4174321 VIT- B-6 TAB [100 MG] (N 4.00 4140160 CT-UPPER EXTREMITY W/O CONTRAST 1,488.00 732004330001 US DUPLEX EXT VEINS UNILATERAL/LMTD 714.00 939714174658 NUR - WEIGHT - 4140101 CAROTID-BILAT DOPPLER 1,420.10 765364070294 RUBEOLA 134.40 86765

99316 NURSING FACILITY DISCHARGE 275.00 993164230056 INTUBATION,EMERGENCY 491.90 315004070377 CALCULAS ANALYSIS 111.10 823704070263 LYME DISEASE 215.70 866184140067 FEMUR - 2 262.30 735524070338 HEP BS AG 111.10 873404270003 NUTRITION REVISIT P/15MIN 57.70 978034174871 RIFAXIMIN TAB (550MG) (NF) 150.00 4070171 PYRUVATE 104.40 842104209904 OTHER CURRENT 40-60 0.01 G8990,CK,GP4070078 RBC 146.80 824824070495 HEALTH FAIR VITAMIN D 20.00 4173626 BENZOC/ TETRA/ BUTAM SPR 9.00 4070361 HEMOCCULT 56.40 82272

4230055 CAUTERY,NASAL HEMORR 344.50 309014174704 LAMOTRIGINE TAB [25MG] (N 3.00 4230045 APPLICATION FINGER SPINT 111.80 291304174582 METOLAZONE TAB [5 MG] (N 14.00 4173481 HYDRALAZINE TAB [25 MG] 3.00 4230069 ER EXPANDED DR 132.70 992824174724 NUR - READ PPD - 4209920 OTHER D/C NO 0.01 G8992,GP4260039 CL TX METATARPAL FX 683.40 284704230006 LACERATION REPAIR 398.10 120044070461 CHLORIDE, OTHER SOURCE 49.40 824384070383 ENCEPHALITIS ANTIBODY 104.40 866544174827 DEXAMETHASONE (4MG/ML) 19.00 4230077 ER CRITICAL CARE 3/M DR. 511.70 992914070257 MICROSOMAL ANTIBODY 163.80 863764070017 DIGOXIN 193.10 801624173793 VAC- HEPATITIS B INJ [20 208.00 4070396 PROSTATE SPECIFIC ANTIGEN 146.80 G01034070345 HPV 140.00 876244070220 PROTEIN S, TOTAL 202.70 853054070478 THYROTROPIN-BINDING INHIBITORY (TBII) 218.48 835194070071 CAROTENE 181.80 823804070210 WBC 36.60 850484070009 HEP ACUTE 520.80 800744070076 CHOL 56.40 824654330020 SLEEP STDY C-PAP ATTENDED 2,939.40 958114140012 TEMP-MANDIB. JOINT BIL 314.80 703304140161 CT-UPPER EXTREMITY W/CONTRAST 1,794.00 732014070226 ESR 61.00 856514209873 SELF CURRENT 20-40 0.01 G8987,CJ,GP4174087 CALCIUM ANTACID TAB [750M 3.00 4174804 BACLOFEN (10MG) [NF] 5.00 4174486 NEO/ BAC/ POLY OIN [EYE] 90.00 4230038 ANT.HIP DISLOCATION 1,528.90 272504140144 CT-PETROUS/TEMPORAL BONE W/O CONTRAST 2,329.50 704804174546 HYDROXYZINE INJ [50 MG/ML 28.00 J34104209801 MOBILITY D/C 0 0.01 G8980,CH,GP4209947 SUB GOAL 100 0.01 G8994,CN,GP4070026 QUINIDINE 211.30 801944070041 ALB 44.00 820404070490 5' NUCLEOTIDASE, SERUM 83.00 839154260067 IV INFUSION ADDL HOUR(S) 122.00 963664173780 VENLAFAXINE TAB [75 MG] 5.00 4209877 SELF CURRENT 100 0.01 G8987,CN,GP4070047 ALPHA-1- ANTITRYPSIN 193.10 821034070264 BRUCELLA 111.10 866224070474 EPSTIEN-BARR DNA QUAT, PCR 341.79 87799

4070298 VARICELLA-ZOSTER 134.40 867874240006 OBSER / TELE 13-24 HR (RP 24.80 G03784209943 SUB GOAL 20-40 0.01 G8994,CJ,GP4070329 TOXIN OR ANTITOXIN ASSAY 210.10 872304270004 NUTRITION GROUP P/15MIN 40.20 978044070413 TACROLIMUS 315.20 801974140055 ELBOW - 2 235.30 730704070270 ENTEROVIRUS EG COXSACKIE, 133.80 866584230046 STRAPPING,SHOULDER 141.20 292404070332 VIRUS ISOLATION CENTRIF 111.10 872544070487 TRICHOMONAS VAGINALIS, THIN PREP 173.23 876614140183 US DUPLEX SCAN UPPER EXT ARTERIES LMTD 804.75 939314140171 US OB<14 WK ADD'L GEST 395.25 768024070477 METHYLMALONIC ACID 247.69 839214140040 L-S-4 530.10 721144140129 US EXAM, EXTREMITY 568.00 768814070228 THROMBIN TIME; PLASMA 64.40 856704070321 O & P 134.40 871774174698 SODIUM BICARBONATE 7.5% S 5.00 4070082 COPPER 181.80 825254070235 HIGH SENS CRP 134.40 861414140059 WRIST>=3 262.30 731104174902 CO Q 10 CAP 100MG 5.00 4200017 GAIT TRAINING 78.90 97116,GP4174857 FILGRASTIM-SNDZ 480MCG/0.8ML 702.00 J14424070278 HERPES SIMPLEX 168.30 866944140053 AC JOINTS, W-W/O WTS. 253.20 730504070443 CULTURE BACTERIA AEROBIC 93.70 870714070203 MANUAL DIFF 53.00 850074209835 BODY D/C 60-80 0.01 G8983,CL,GP4070389 ALLERGEN SPECIFIC IGE 57.90 860034070382 ENCEPHALITIS ANTIBODY 104.40 866534070404 WEST NILE VIRUS 193.10 867884070299 VIRUS NOS 129.30 867904174674 NUR - CATHETER CARE - 4174155 IRR - SODIUM CHLORIDE 0.9 75.00 4209925 OTHER D/C 60-80 0.01 G8992,CL,GP4070411 CADMIUM 280.20 823004230004 LACERATION REPAIR 286.90 120014174202 INS- ASPART INJ [100 UNT/ 124.00 J18154174691 CITALOPRAM TAB (10MG) (NF 3.00 4070221 FACTOR INHIBITOR TEST 136.70 853354140142 OBUS <14 WKS, SINGLE FETUS 696.75 768014209957 SUB D/C 100 0.01 G8995,CN,GP4070151 INTERPRET& REPORT 134.40 839124209941 SUB GOAL 0 0.01 G8994,CH,GP4140015 CT-HEAD OR BRAIN W 1,573.50 70460

4260002 OUTPATIENT VISIT 178.90 992144174663 NUR - INCENTIVE SPIROMETE - 4230086 EMERGENCY LEVEL 1 VISIT 98.30 992814070447 SMEAR FOR OVA & PARASITES 134.40 872094070086 CPK ISOENZYMES 149.60 825524209880 SELF GOAL NO 0.01 G8988,GP4209806 MOBILITY D/C 80-100 0.01 G8980,CM,GP4173897 VIT- B COM/ C/ FE,FA/MIN 6.00 4140006 FACIAL > 3 342.50 70150

25622 FRACTURE TREATMENT CARPAL SCAPHOID 1,300.50 256224140112 BREAST ULTRASOUND 376.20 766454260077 IV PUSH EA SAME DRUG 40.20 963764174846 VITAMIN D 50000UN 21.00 4174677 NUR - AIR MATTRESS - 4140174 US OB FOLLOWUP 498.00 768164174498 ACETAMINOPHEN ADULT SUP [ 32.00 4260041 SHORT ARM CAST 227.50 290754260076 IV PUSH EA DIFFERENT DRUG 203.90 963754209875 SELF CURRENT 60-80 0.01 G8987,CL,GP4070015 TEGRETOL 204.50 801564174852 PRADAXA [150MG] (NF) 32.00 4070456 PLASMODIUM (MALARIA) 283.20 867504070255 THY PEROPIDOSE AB 147.90 863764174813 NIACIN CAP (500MG) 3.00 4070428 PREGNENOLONE 233.80 841404230068 E R VISIT-LEVEL 2 245.10 992824070138 MG 93.70 837354070150 AMPLIFICATION 294.80 839014260034 CL TX METACARPAL FX 631.50 266004070364 CRYSTAL ID BY COMP 102.20 890604209834 BODY D/C 40-60 0.01 G8983,CK,GP4070199 C-PEPTIDE 214.50 846814209895 SELF D/C 60-80 0.01 G8989,CL,GP4174660 NUR - ACTIVITY/TURN-REPOS - 4209807 MOBILITY D/C 100 0.01 G8980,CN,GP4070211 PLT 47.40 850494070039 ACETONE QUANTITATIVE 61.50 820104070134 LDH 64.40 836154070468 ARTERIAL BLOOD GASES 200.00 828034140077 CALCANOUS - 2 197.80 736504140188 CTA NECK W/ CONTRAST 2,996.25 704984140103 CT LUMBAR W & W/O 2,294.25 721334174806 MELATONIN TAB 3MG 3.00 4070424 ASPERGILLUS 110.60 873054173850 VIT- B6, B12, FOLIC ACID 5.00 4070301 HEP C AB 145.60 868034070421 FLOW CYTOMETRY 2 - 8 MARK 72.90 88187

4174220 OXYCODONE TAB 5MG C2, 100 eaches 5.00 4174384 SILVADENE CREAM 1% 20GM, tube 41.00 4174812 NICARDIPINE HYD INJ 25MG/10ML, 10 vials 72.00 4174272 TETRACAINE HCL DR 0.5%-15ML OPTH, 1 bottle 35.00 4174618 ACYCLOVIR TAB 400MG, 100 eaches 3.00 4174076 ENOXAPARIN SOD INJ 40MG/0.4ML 30.00 J16504174445 ATENOLOL TAB 25MG, 100 eaches 3.00 4174717 OSELTAMIVIR 10 CAP 30MG TAMIFLU, 10 eaches 63.00 4173539 DIPHENHYDRAMINE CAP 25MG, 100 eaches 3.00 4174173 GABAPENTIN CAP 300MG, 100 eaches 3.00 4174756 AZACTAM 1GM, 10 vials 131.00 4174885 DEPO-MEDROL 40MG/1ML, 25 vials 36.00 4173457 AMIODARONE HYD INJ 150MG/3ML, 10vials 15.00 J34904173514 AMOX/CLAVUL POT 875/125MG, 20 eaches 5.00 4173872 GLUCAGEN 1 MG/VIAL, vial 498.00 J16104174792 AMIDATE ETOMIDATE INJ 40MG/20ML, 10vials 33.00 J34904174188 NITROSTAT SUBLIGUAL TAB 0.4MG, 100 eaches 6.00 4174891 NEO SYNEPHRINE NASAL SPRAY, one bottle 25.00 4173907 LISPRO INSULIN 100UUN/ML, 200-5un doses 5.00 4173420 ADENOSINE INJ 6MG/2ML, 10 vials 15.00 J01534173543 DIPHENHYDRAMINE SOL 12.5MG/5ML, 100 eaches 11.00 4173814 EYE WASH, bottle 22.00 4174847 PREDNISONE TAB 20MG, 100 eaches 3.00 4173993 TRIAMCINOLONE ACE SUSP KENALOG-40 190.00 4173445 ALOE VESTA PROTECTIVE OINT 3, 1 tube 27.00 4174697 TETANUS DIPTH TOX PED DT, 10 vials 177.00 4173891 HALOPERIDOL INJ 5MG/ML, 25 vials 31.00 J16304174505 ACETAMINOPHEN TAB 325MG, 1000 eaches 3.00 4174012 DIGOXIN TAB 125MCG, 100 eaches 9.00 4174142 GUAIFENESIN TAB 600MG MUCINEX, 100 eaches 9.00 4174828 HYDRALAZINE HYD INJ 20MG/ML, 25 vials 13.00 J03604174018 FUROSEMIDE TAB 20MG, 100 eaches 5.00 4174450 MULTIVITAMIN 50 PLUS TAB, 50 eaches 5.00 4173692 CYANOCOBALAMIN 1000MCG/ML, 25 vials 21.00 4174629 AMOXICILLIN ORAL SUSP 250MG/5ML, 100ml bottle 12.00 4174294 PRIMAXIN IV 500MG/VIAL, 25 vials 131.00 J75104174740 PREDNISONE TAB 5MG, 100 eaches 3.00 4174082 LUTEIN SOFGEL 20MG , 60 eaches 3.00 4173640 CIPROFLOXACIN TAB 500MG, 100 eaches 3.00 4174683 MAGNESIUM SUL/5% DEXTROSE 1GM, 26.00 J34754173585 CALCIUM CHL 100MG/ML, each syringe 39.00 4173767 BISACODYL TAB 5MG, 100 eaches 5.00 4174742 THERMOTABS 287/180/15, 100 eaches 3.00 4174448 BENZONATATE CAP 100MG 5.00 4174761 CIPROFLOXACIN INJ 400MG/200ML, 24 bag 15.00 J07444173927 ERYTHROMYCIN OPHTH OINT 0.5%, tube 36.00 4174476 KETOROLAC TROMETHAMINE 30MG/ML, 25 vials 30.00 J1750

4173502 HYDROXYZINE TAB 25 MG, 100 eaches 5.00 4174890 NASAL MOISTURE SPRAY DEEP SEA, 1 bottle 6.00 4174200 NOVOLIN N INSULIN, 200-5un doses 3.00 J18154174598 AZITHROMYCIN ORAL SUSP 100MG/5ML, 1 bottle 65.00 4174506 APAP/CODEINE 120MG/12MG/5ML C3, bottle, dose 3.00 4174718 OSELTAMIVIR 10 CAP 45MG TAMIFLU, 10 eaches 63.00 4174694 RANITIDINE INJ 150MG/6ML, 1 vial 126.00 J27804174115 GLYBURIDE TAB 5MG, 100 eaches 5.00 4174136 IBUPROFEN CHILD 100MG/5ML, 30 eaches 9.00 4174519 DIAZEPAM TAB 5MG C4, 100 eaches 5.00 4174580 RANITIDINE TAB 150MG, 100 eaches 3.00 4174464 TENECTEPLASE 50MG- TNKASE, 1 unit 7,028.00 J31014174057 METOPROLOL TART TAB 25MG, 100 eaches 6.00 4174120 MINERAL OIL 15ML, bottle 35.00 4174648 SENSORCAINE BUPIVACINE 0.5%, 25 vials 12.00 4174884 CYKLOKAPRON TRANEXAMIC ACID INJ, vial 168.00 J10714174643 MEROPENEM INJ 500MG/VIAL, 25 vials 66.00 J21854174775 DOPAMINE HCI 5% DEXTROSE 400MG, 12 bags 37.00 4173660 DOCUSATE SOD SYRUP 60MG/15ML, bottle -dose 3.00 4173792 LIDOCAINE/PRILOCAINE CREAM 2.5%/2.5%, each 53.00 4173492 C VITAMIN TAB 250MG, 100 eaches 3.00 4174363 CEFTRIAXONE INJ 1GM/VIAL, 25 vial 12.00 J06964174148 GERILANTA ANTACID 5ml, bottle - dose 3.00 4173617 BETAMETHASONE SOD PHOS/BETA ACE 5ml, vial 158.00 4173884 GLYERCIN SUPPOSITORY 50 eaches 3.00 4173677 WARFARIN SOD TAB 1MG, 100 eaches 5.00 4173874 METFORMIN TAB 500MG, 100 eaches 5.00 4174702 TROPICAMIDE DR 1% -15ML OPTH, 1 bottle 28.00 4174048 HYDROCORTISONE CREAM USP 1% 28G, tube 31.00 4174518 DIAZEPAM INJ 5MG/ML-10ml C4, 10 vials 154.00 J33604173700 DEXTROSE 50% INJ 25G PER 50ML, each syringe 50.00 4174410 FENTANYL CITRATE 100MCG/2ML C2, 10 amps 6.00 J30104174576 LIDOCAINE 2% W/EPI INJ 20MG/ML, 25 vials 10.00 J20014174606 ONDANSETRON INJ 4MG/2ML, 25 vials 9.00 J24054174542 DOXYCYCLINE TAB 100MG, 30 eaches 11.00 4174878 LOSARTAN POT TAB 25MG, 100 eaches 5.00 4173477 TUBERSOL PPD, 10TESTS-VIAL 37.00 4173766 BISACODYL RECTAL SUPP 10MG-12/BX, each 3.00 4174385 SILVER NITRATE STICKS 100 eaches 27.00 4174273 POTASSIUM CHL 40MEQ/20ML, 25 vials 24.00 4173724 DEPO-ESTRADIOL 5MG/ML- 5ML, vial 305.00 4174257 PROMETHAZINE TAB 25MG, 100 eaches 3.00 4174880 KETAMINE INJ 200MG/20ML C3, 10 vials 54.00 4173423 EPINEPHRINE INJ 1:1000- 10ml , 10 syringe 24.00 J01704173591 CAPTOPRIL TAB 25MG, 100 eaches 9.00 4173797 EPINEPHRINE INJ 0.15MG AUTO INJECTOR 413.00 J01714173533 SULFAMETHOXAZOLE /TRIM TAB 800/160MG, 100 eaches 3.00

4174122 HEALTHYLAX POLYETHYLENE GLYCL, 14 eaches 9.00 4173594 SUCRALFATE TAB 1GRAM, 100 eaches 5.00 4174771 HYDROMORPHONE HCI 1MG/ML C2, 10 amps 9.00 J11704173509 IPRATROPIUM BRO HFA 17MCG, 1 each 719.00 4174037 ESCITALOPRAM TAB 10MG, 100 eaches 3.00 4173940 INDOMETHACIN CAP 25MG, 50 eaches 5.00 4174587 LISINOPRIL TAB 10MG, 100 eaches 5.00 4174913 ROCURONIUM 10MG/ML-5ML , 10 VIALS 15.00 4173704 CARBAMIDE PEROXIDE 6.5% EAR DROP 11.00 4173495 ASPIRIN EC TAB 81MG, bottle, 100 eaches 3.00 4174487 TRIPLE ANTIBIOTIC OINTMENT 3.00 4174538 MIDAZOLAM INJ 5MG/ML C4, 10 vials 9.00 J22504173832 ENEMA DISPOSABLE 4.5OZ, each 9.00 4174599 AZITHROMYCIN ORAL SUSP 200MG/5ML, 1 bottle 65.00 4173650 CLINDAMYCIN INJ 900MG/6ML, 25 vials 18.00 4173609 CLONIDINE TAB 0.1MG, 100 eaches 5.00 4174139 IBUPROFEN TAB 600MG, 100 eaches 3.00 4173512 AMOX/CLAVUL POT 125MG/5ML , 75ml bottle 835.00 4173643 MAG CITRATE ORAL SOL cherry 1.745G/1OZ, bottle 10.00 4174184 NITRO BOD OINT 2%, 30 doses 5.00 4174802 LEVOPHED 4MG/4ML, 10 vials 82.00 4173796 EPINEPHRINE INJ 0.3MG AUTO INJECTOR 573.00 J01714173928 LOPERMIDE CAP 2MG, 100 eaches 9.00 4173895 HYDROCHLOROTHIAZIDE TAB 12.5MG, 100 eaches 9.00 4174135 IBUPROFEN TAB 200MG, 100 eaches 3.00 4174898 CALCIUM GLUCONATE 1000 MG/10ML, vial 42.00 4173986 CEPHALEXIN ORAL SUSP 250MG/5ML, bottle 61.00 4174555 WATER BACTERIOSTATIC FOR INJ, 25 vials 9.00 4173931 SUMATRIPTAN INJ 6MG/0.5ML, 5 vials 38.00 J30304174357 METHOCARBAMOL TAB 750MG, 100 eaches 3.00 4173578 VERAPAMIL HYD INJ 10MG/VIAL, 5 vials 123.00 4174533 ALBUTERIL SUL HFA 90MCG, 1HFA 181.00 4173982 SOD POLYSTYRENE SUL 15G, 30 doses 8.00 4173416 ADACEL TETANUS/DITPHTH/PERTUSS, 10 vials 141.00 4174004 LACTULOSE SOL 20G/30ML, 50 eaches 9.00 J18854174434 OSELTAMIVIR 10 CAP 75MG TAMIFLU, 10 eaches 63.00 4174016 FUROSEMIDE INJ 20MG/2ML, 25 each vial 9.00 J19404174607 ONDANSETRON ODT 4 MG, 30 eaches 5.00 4174074 ENOXAPARIN SOD INJ 100MG/ML 25.00 J16504174708 RIVAROXABAN TAB 10MG XARELTO, 30 eaches 48.00 4174426 LEVOTHYROXINE TAB 25MCG, 100 eaches 5.00 4174253 PROMETHAZINE 12.5MG SUPPOSITORY, 12 eaches 31.00 4173582 VERAPAMIL TAB 80MG, 100 eaches 3.00 4174320 PHENAZOPYRIDINE TAB 100MG, 100 eaches 6.00 4173471 CEFAZOLIN INJ 1 GM, 25 vial 6.00 J06904174500 ACETAMINOPHEN SUPP 120MG, 12 eaches 6.00 4174319 BUDESONIDE INH 0.5MG/2ML, 30 each amps 17.00

4174760 HEPARIN LOCK FLUSH SYRINGE 500UN/5ML, 30 eaches 5.00 4173665 PROCHLORPERAZINE INJ 10MG/2ML, 10 vials 50.00 J75104174738 ACETAMENOPHEN ADULT 500MG/15ML, bottle 33.00 4174637 PROPARACAINE 0.5%, 1 bottle 105.00 4173646 LORATADINE TAB 10MG, 100 eaches 5.00 4173826 METRONIDAZOLE INJ 500MG/100ML, 24 bags 9.00 4174877 CALCIUM 600MG/VIT D 400IU, 100 eaches 3.00 4173659 DOCUSATE SOD SOFGEL 100MG, 100 eaches 3.00 4174509 TRAMADOL TAB 50MG C4, 100 eaches 9.00 4174280 PREDNISOLONE SOD 15MG/5ML, 33 doses 5.00 J75104174503 ACETAMINOPHEN TAB 500MG, 1000 eaches 3.00 4174107 METAMUCIL FIBER SUGAR FREE 30 DOSES 5.00 4174634 BACITRACIN ZINC OINT 30G, 1 tube 16.00 4174177 NEXIUM IV 40MG/VIAL, 10 vials 179.00 J34904174211 NYSTATIN/TRIAMCINOLONE ACE CREAM, 1 tube 133.00 4174307 PROTAMINE SUL 250MG/25ML, 1 vial 110.00 4174160 NAPROXEN TAB 500MG, 100 eaches 3.00 4174144 ACETYLCYSTEINE 20% 200mg/ml, 3 vials 94.00 4174575 LIDOCAINE 1% W/EPI INJ 50ML, 25 vials 10.00 4173631 GUAIFENESIN/CODEINE 100/10MG-5ML C5, dose 5.00 4173913 NOVOLIN R INSULIN, 200-5un doses 3.00 J18154173556 BICILLIN CR SY 1.2MMU -2ML, each syringe 364.00 J05584174883 CEFEPIME INJ 2GM/VIAL, 10 vial 27.00 J06924173941 IRON DEXTRAN INFED 100MG/2ML, 10 vials 120.00 4174572 LIDOCAINE VISC ORAL 2% 15ML, 40 eaches 9.00 4174689 NITRO LINGUAL SPRAY 400MCG/SPRAY, 1 bottle 321.00 4173475 MECLIZINE TAB 25MG, 100 eaches 5.00 4174169 NEOMYCIN/POLY B SUL/GRAMICIDIN OPHTH, 1 bottle 198.00 4173997 POTASSIUM CHL ET TAB 10MEQ, 100 eaches 5.00 4174027 LEVOFLOXACIN TAB 250MG, 100 eaches 3.00 4174825 PHENYTOIN SOD ER CAP 100MG, 100 eaches 6.00 4173848 FOLIC ACID TAB 1MG, 100 EACHES 6.00 4174692 POTASSIUM EFFERVESCENT TAB 25MEQ, 30 eaches 3.00 4174198 AMLODIPINE TAB 5MG, 100 eaches 3.00 4174817 PNEUMOCOCCAL 13 PREVNAR, 10 syringe 522.00 4174793 SUCCINYCHOLINE CHL 20MG/ML-10ml, 25 vials 81.00 4174146 INFUVITE MULTIVITAMIN ADULT, 5 eaches 44.00 4174568 LIDOCAINE 1% INJ 10MG/ML, 25 vials 9.00 J20014174786 HYDROCODONE/APAP 5MG/325MG C2, 100 eaches 5.00 4174497 APAP/CODEINE 300MG/30MG C3, 100 eaches 3.00 4173484 VITAMIN K INJ 10MG/ML, 25 amps 181.00 J34304173433 ALBUTEROL SUL INH SOL 0.083, 30amps 3.00 4173422 EPINEPHRINE INJ 1MG/ML, 10 amps 45.00 J01704174292 OMEPRAZOLE DR CAP 20MG, 100 eaches 3.00 4174734 SILVASORB GEL 44.4ML/TUBE 80.00 4174377 SENNA PLUS TAB 8.6MG/50MG, 100 eaches 5.00 4173706 DEXAMETHASONE INJ 4MG/ML, 25 vial 6.00 J1100

4174046 ATORVASTATIN TAB 20MG, 100 eaches 5.00 4174041 LIDOCAINE HCI INJ 2% 100MG/SYR 16.00 4174402 SOLU-MEDROL 125MG/VIAL, 25 vials 40.00 J29204174330 METOCLOPROMIDE 10MG/2ML, 25 vials 19.00 4174564 ALPRAZOLAM TAB 0.25MG C4, 100 eaches 3.00 4174368 FLUMAZENIL INJ 0.5MG/5ML, 10 VIALS 16.00 J34904173863 GENTAMICIN SUL OPHTH 0.3%, 1 each 143.00 4174398 SODIUM CHL INH SOL 0.9%, 30 eaches 3.00 4173683 WARFARIN SOD TAB 5MG, 100 eaches 5.00 4174254 PROMETHAZINE 25MG SUPPOSITORY, 12 eaches 30.00 4174778 LEVOFLOXACIN TAB 750MG, 100 eaches 6.00 4174695 8.4% SODIUM BICARB INJ 50MEQ, 10 syringes 45.00 4174888 NITROGLY/D5W BT 50MG/250ML, 12 bag 51.00 4174556 WATER ST FOR INJ, 25 vials 9.00 4173674 NEOMYCIN/POLY B SUL/HYDROCOR OTIC, 1 bottle 199.00 4174153 0.9% SODIUM CHL BACTERIOSTATIC 30ML, 25 vials 9.00 4174075 ENOXAPARIN SOD INJ 30MG/0.3ML 17.00 J16504174028 LEVOFLOXACIN TAB 500MG, 100 eaches 5.00 4174250 PROMETHAZINE INJ 25MG/ML, 25 amps 9.00 J25504174011 DIGOXIN INJ 500MCG/2ML AMP, 10 amps 31.00 4173827 METRONIDAZOLE TAB 250MG, 100 eaches 5.00 4174811 LABETALOL HYD INJ 100MG/20ML, each vial 18.00 4173479 HYDROXYZINE ORAL SOL 10MG/5ML, dose 5.00 4173493 ASPIRIN TAB 81MG CHEW, bottle, 36 eaches 3.00 4173570 BUMETANIDE 1MG/4ML, 10 vial 11.00 J34904174474 METOPROLOL SUCC TAB 25MG, 100 eaches 6.00 4174172 GABAPENTIN CAP 100MG, 100 eaches 3.00 4174206 NYSTATIN CREAM 100000UN/GM 15GM, 1 tube 63.00 4173708 DEXAMETHASONE TAB 4MG, 100 eaches 9.00 4173745 PHENYTOIN SOD INJ 100MG/2ML, 25 vials 5.00 J11654173510 IPRATROPIUM BRO 0.02%, 30 eaches 3.00 4174887 HYOSCYAMINE 0.125MG, 100 eaches 5.00 4174875 HEPARIN 25000 USP UN/500ML, 24 bags 26.00 4174684 SOOTHE LUBRICANT EYE DROPS, 28 each 5.00 4173557 BICILLIN LA SY 1.2MMU -2ML, each syringe 456.00 J05614174499 ACETAMINOPHEN SUPP 325MG, 12 eaches 6.00 4174401 SOLU-MEDROL 1GM/VIAL 139.00 J29204173504 LORAZEPAM TAB 0.5MG C4, 100 eaches 3.00 4173558 LANTUS INSULIN 100UN/ML, 200- 5un doses 5.00 4174858 GUAIFENESIN ORAL SOL 200MG/10ML, 100 eaches 5.00 4173614 CEFPROZIL ORAL SUSP 125MG/5ML, bottle 119.00 4174732 PROPRANOLOL 1MG/ML, 10 vials 13.00 J18004174369 RACEPINEPHRINE INH 2.25%, 30 amps 12.00 4174096 MANNITOL IV 20% 20G/100ML, 12 bags 77.00 J21504174221 AMIODARONE TAB 200MG, 100 eaches 5.00 4173454 ZOLPIDEM TART TAB 5MG C4, 100 eaches 3.00 4174779 LEVOFLOXACIN INJ 750MG/30ML, each vial 190.00

4174504 ACETAMENOPHEN CHILD 160MG/5ML, 100 IUD 5ml cup 9.00 4174705 NYSTATIN ORAL SUSP 500000UN/5ML, 50 units 9.00 4174854 VITAMIN D SOFGEL 5000IU, 50 eaches 5.00 4173727 DEPO-PROVERA 150MG/ML, vial 237.00 J10504173892 HALOPERIDOL TAB 0.5MG, 100 eaches 5.00 4174092 MAGNESIUM SUL INJ 1GM/2ML, 25 vials 9.00 J34754173689 ANTIVENIN CROTALIDAE POLY 1GM, 2 vials 3,800.00 4174420 LEVOTHYROXINE TAB 100MCG, 100 eaches 5.00 4173410 ACTIVATED CHARCOAL 208mg/ml, one tube 81.00 4174573 LIDOCAINE HYD JELLY USP 2% 5ML 15.00 4174807 VITAMIN K INJ 1MG/0.5ML, 25 amps 21.00 4174895 POTASSIUM CHL 40MEQ/L, 14 bags 17.00 4174267 PNEUMOVAX 23, 10 vials 264.00 4173869 GENTAMICIN 80MG/2ML, 25 vials 19.00 J15804173670 CARVEDILOL TAB 6.25MG, 100 eaches 3.00 4173833 CYCLOBENZAPRINE TAB 10MG, 100 eaches 3.00 4173508 ATROPINE SUL 1MG/10ML, 10 ea syringes 39.00 J04614174245 OXYCODONE /APAP 5MG/325MG C2, 100 eaches 3.00 4173503 LORAZEPAM INJ 2MG/ML C4, 25 eaches 5.00 4174630 MUPIROCIN OINT 2% 22G, 1 tube 28.00 4174366 CEFTRIAXONE INJ 500MG/VIAL, 25 vial 9.00 J06964173847 FOLIC ACID INJ 50MG/10ML, VIAL 104.00 J34904173460 AMOXICILLIN ORAL SUSP 125MG/5ML, 80ml bottle 9.00 4174696 SULFACETAMIDE SOD OPHTH 10%, 1 bottle 157.00 4173903 HEPARIN 5000 USP UN/ML, 25 vials 11.00 J16444174152 NS 0.9% FLUSH SYRINGE, 30 syringes 5.00 4174569 LIDOCAINE 2% INJ 20MG/ML, 25 vials 9.00 J20014174774 VANCOMYCIN HYD INJ 500MG/VIAL, 10 vial 41.00 4173494 ASPIRIN EC TAB 325MG, bottle, 100 eaches 3.00 4174161 NALOXONE HYD INJ 0.4MG/ML 66.00 J23104174914 guaiFENesin 200 MG/10 ML SOLN 200 mg, 10 mL 5.00 4174889 BENEFIBER, 2 scoops 5.00 4174840 FAMOTIDINE TAB 10MG PEPCID, 30 eaches 3.00 4173818 FEROSOL TAB 325MG IRON, 100 eaches 3.00 4174093 MAGNESIUM TAB 400MG, 100 eaches 6.00 4174055 METOPROLOL TART INJ 5MG/5ML, 12 eaches 13.00 4174119 MILK OF MAGNESIA 400mg/5ml, 70 doses 3.00 4174699 SENNA LAX TAB 8.6MG, 100 eaches 5.00 4174432 FLECAINIDE ACETATE 50 MG TAB 50 mg, 100 eaches 6.00 4174777 LIDOCAINE 5% PATCH 5 ea, 30 eaches 39.00 4173760 DONNATAL ELIXIR 16.2 mg, 120 mL 70.00 4174917 ETHYL CHLORIDE SPRAY 1 mL, 103.5 mL - 4174916 PHENOL EZ SWABS 89 unit, 30 eaches - 3070001 ROOM RATE/ WITH OUT TELEM 1,800.00 3070002 ROOM RATE/ WITH TELEMETRY 2,160.00 3360001 SWING BED,HOSPITAL 1,591.30 3360002 SWING BED,HOSPITAL W/TELE 1,960.10

4173528 ACIDOPHILUS W/ CITRUS PECTIN, 100 eaches 3.00 4174918 colchicine 0.6 MG CAPSULE 0.6 mg, 100 eaches 29.00 4179738 DUTASTERIDE 0.5 MG CAPSULE 0.5 mg, 30 eaches 6.00 4174277 pravastatin SODIUM 20 MG TAB 20 mg, 100 eaches 6.00 4174452 THIAMINE INJ 200MG/2ML, 25 eaches 31.00 J34114174070 CLOTRIM 1% VAGINAL CREAM 45 g, 45 g 15.00 4174182 NICOTINE 14 MG/24HR PATCH 14 mg, 14 eaches 15.00 4174896 LEVOFLOXACIN IV 500MG, 24 bags 100.00 J19564174915 DOCU LIQUID 100 MG/10 ML 100 mg, 10 mL 5.00 4174879 MAGNESIUM TAB 250MG, 100 eaches 3.00 4173967 IVF- SOD CL 0.45% [1000 M 75.00 J34904.17E+22 SODIUM CHLORIDE 0.9% SOLUTION 1000 mL, 1000 mL 75.00 4173949 IVF- DEX 5%/ 0.45% SOD CL 75.00 J70424173959 IVF- DEXTROSE 5% [1000 ML 75.00 J70704173963 IVF- DEXTROSE 5% [500 ML] 75.00 J70604173956 IVF- DEX 5%/ 0.9% SOD CL 75.00 J70704173966 IVF- LACTATED RINGERS [10 75.00 J71204330015 EKG TRACING ONLY 65.80 930054174619 ALLOPURINOL 100 MG TABLET 100 mg, 100 eaches 5.00 4174798 DUTASTERIDE (0.5MG) [NF] 6.00 4174532 IRON SUCROSE INJ [100 MG/ 149.00 J1756

97161 PHYSICAL THERAPY EVAL LOW 234.00 97161,GP97162 PHYSICAL THERAPY EVAL MODERATE 336.00 97162,GP97163 PHYSICAL THERAPY EVAL HIGH 486.00 97163,GP

4070501 BRCA 1&2 2,659.68 811624174208 NYSTATIN PWD [100,000 UNT 30.00 4174921 NEXTERONE 150 MG/100 ML BAG 150 mg, 100 mL 156.00 4174922 POTASSIUM CL 20 MEQ/50 ML SOL 20 mEq, 50 mL 15.00 4173612 CEFUROXIME TAB 250MG, 20 eaches 15.00 4174866 VEDOLIZUMAB 300MG -ENTYVIO , 1 vial 7,558.00

11111111111 ZERO DOLLAR CHARGE - 4173436 SPIRONOLACTONE TAB [25 MG 3.00

27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA 694.50 2756093922 ABI LIMITED BILATERAL NONINVASIVE 786.00 9392293923 ABI COMPLETE BILATERAL NONINVASIVE 1,288.00 93923

4174567 LEVALBUTEROL INH SOL 1.25MG, 30 eaches 17.00 4070502 ARSENIC, BLOOD 182.23 821754070503 HERPES SIMPLEX 1 ANTIBODIES 158.67 866954070504 HERPES SIMPLEX 2 ANITBODIES 221.34 866964070505 HERPES SIMPLEX VIRUS, 1 & 2 QL PCR 388.08 875294330005 ECHO CARDIOGRAM COMPLETE 708.50 933064174919 Activase 100 MG VIAL 100 mg, 1 each 10,551.00 4173984 CEPHALEXIN CAP 250MG, 100 eaches 5.00 4174923 FluZONE HIGH-DOSE 2018-19 SYR 0.5 mL, 0.5 mL 185.00 4174924 FluZONE QUAD 2018-2019 VIAL 0.5 mg pe, 5 mL 68.00 4173841 FLU VACCINE 2017-2018 10 VAC IN VIAL, 10 DOSE 70.00 4174863 HD FLU VACCINE 2017-2018, 10 SYRINGES 165.00

4209958 MOBILITY GOAL 60-80 0.01 G8979,CL,GP4079999 LAB/RAD NO CHARGE - 4209999 PHYSICAL THERAPY NO CHARGE - 4174844 DILTIAZEM ER HCL CAP 120MG 5.00 4140191 MRI BRAIN W & W/O CONTRAST 2,688.00 70553

99304 NURSING CARE FACILITY INITIAL CARE 223.00 9930499315 NURSING FACILITY DISCHARGE <30 134.00 99315

4070011 DRUG SCREEN 190.90 803054174925 RITUXAN 10 MG/ML VIAL 500 mg, 50 mL 5,700.00 4140098 US PELVIC COMPLETE 599.25 768564140192 US OB <14 WEEKS 690.67 768014174926 MEGESTROL ACET 40 MG/ML SUSP 40 mg, 240 mL 3.00 4173458 AMOXICILLIN CAP 250MG, 100 eaches 3.00 4174927 NITROFURANTOIN MONO-MCR 100 MG 100 mg, 100 eaches 15.00 4174612 PIPERACILLIN AND TAZOBACTAM 3.375GM, 10 vials 23.00 J25434174928 FLUCONAZOLE 150 MG TABLET 150 mg, 12 eaches 13.00 4174864 FLUCONAZOLE TAB 100MG, 9.00 4174728 NITROFURANTOIN CAP 50MG, 100 eaches 3.00 4174929 NEXPLANON 68 MG IMPLANT 68 mg, 1 each 1,780.00 4174930 MIRENA SYSTEM 52 mg, 1 each 1,818.00 4173542 DIPHENHYDRAMINE INJ 50MG/ML, 25 vials 11.00 J12004174803 MORPHINE SUL 2MG/ML C2, 10 carpujet 13.00 J22704174931 OXYTOCIN 10 UNITS/ML VIAL 10 unit, 1 mL 6.00 4174886 VECURONIUM BRO 10MG/ML 44.00 4173726 DEPO-MEDROL 80MG/1ML, 25 vials 72.00 J10404173709 VAC- TETANUS DIPH TOX ADU 130.00 907144174892 PROPOFOL 10MG/ML-50ML 30.00 4174920 FIRVANQ 25 MG/ML SOLUTION 25 mg, 300 mL 9.00 4173972 IVF- SOD CL 0.9% [250 ML] 75.00 J70504174932 Engerix-B 20 MCG/ML SYRN 20 mcg, 1 mL 194.00 4173599 DILTIAZEM INJ [25 MG/5 ML 17.00 4070506 EVEROLIMUS 188.98 801694070097 QUAL FLU A & B 621.00 875024070336 RSV 621.00 876344140193 CTA ABDOMEN W CONTRAST 2,883.00 741754174936 simvastatin 20 MG TABLET 20 mcg, 100 eaches 9.00 4174605 simvastatin 40 MG TABLET 40 mcg, 30 eaches 3.00 4174933 AMPICILLIN 2 GM VIAL 2 g, 1 each 15.00 4174935 FLORAJEN3 CAPSULE 1 ea, 30 eaches 83.00 4174934 ANORO ELLIPTA 62.5-25 MCG INH 62.5 mcg, 60 eaches 796.00 J76994174835 POTASSIUM CHL ER TAB (20MEQ) 6.00 4174912 JANUVIA TAB 50MG 65.00 4174911 PRADAXA 150MG 12.00 4174937 EZETIMIBE-SIMVASTATIN 10-20 MG 1 unit, 30 eaches 19.00 4174938 metOLazone 2.5 MG TABLET 2.5 mg, 100 eaches 11.00

99305,FAC NH-SW NEW ADMISSION 60.40 9930599305 NH-SW NEW ADMISSION 302.00 99305

99305,PRO NH-SW NEW ADMISSION 241.60 99305993077,PRO NH-SW SUBSEQUENT 100.00 99307

993077 NH-SW SUBSEQUENT 125.00 99307993077,FAC NH-SW SUBSEQUENT 25.00 99307

99308 NH-SW SUBSEQUENT EXPANDED 189.00 9930899308,PRO NH-SW SUBSEQUENT EXPANDED 151.20 9930899308,FAC NH-SW SUBSEQUENT EXPANDED 37.80 99308

99309 NH-SW NEW PROBLEM 252.00 9930999309,PRO NH-SW NEW PROBLEM 201.60 9930999309,FAC NH-SW NEW PROBLEM 50.40 9930999304,PRO NURSING CARE FACILITY INITIAL CARE 178.40 9930499304,FAC NURSING CARE FACILITY INITIAL CARE 44.60 99304

99306 NURSING CARE FACILITY INITIAL CARE 365.00 9930699306,PRO NURSING CARE FACILITY INITIAL 292.00 9930699306,FAC NURSING CARE FACILITY INITIAL 73.00 99306

99310 NH-SW SUBSEQUENT DETAILED 323.00 9931099310,PRO NH-SW SUBSEQUENT DETAILED 258.40 9931099310,FAC NH-SW SUBSEQUENT DETAILED 64.60 9931099315,PRO NURSING CARE FACILITY DISCHARGE <30 107.20 9931599315,FAC NURSING CARE FACILITY DISCHARGE <30 26.80 9931599316,PRO NURSING CARE FACILITY DISCHARGE >30 220.00 9931699316,FAC NURSING CARE FACILITY DISCHARGE >30 55.00 99316

4174940 DONEPEZIL HCL 10 MG TABLET 10 mg, 100 eaches 3.00 4174941 PENTACEL VIAL KIT 1 unit, 1 each 177.00 4174942 ROTATEQ VACCINE 1 unit, 2 mL 260.00 4174943 M-M-R II VACCINE WITH DILUENT 1 unit, 10 eaches 228.00 4174944 GARDASIL 9 SYRINGE 1 unit, 0.5 mL 396.00 4174945 Menactra VIAL 1 unit, 0.5 mL 190.00 4174946 Engerix-B PEDI 10 MCG/0.5 SYRN 1 unit, 0.5 mL 77.00 4174947 ACTHIB VACCINE WITH DILUENT 1 unit, 1 each 27.00 4174948 HAVRIX 720 UNIT/0.5 ML SYRINGE 1 unit, 0.5 mL 153.00 4174949 Varivax VACCINE WITH DILUENT 1 unit, 1 each 423.00 4174950 PROQUAD VIAL 1 unit, 1 each 699.00 4174951 ELIQUIS 2.5 MG TABLET 2.5 mg, 60 eaches 35.00 4173834 TAMSULOSIN CAP [0.4 MG] 6.00 4174939 rOPINIRole HCL 0.25 MG TABLET 0.25 mcg, 100 eaches 5.00 4174601 AZITHROMYCIN TAB 250MG, 1 pack 9.00 4230000 EMERGENCY DEPARTMENT NO CHARGE - 4174952 penicillin VK 500 MG TABLET 500 mg, 100 eaches 9.00 4174831 DENOSUMAB 60MG/ML PROLIA 2,129.00 J08974174869 RIVAROXABAN TAB 15MG 48.00 4174953 VERAPAMIL ER 120 MG TABLET 120 mg, 100 eaches 3.00 4174954 midodrine HCL 10 MG TABLET 10 mg, 100 eaches 9.00 4173933 LOPERAMIDE HCI IMODIUM 1MG/7.5ML, 16 doses 6.00 4174955 midodrine HCL 5 MG TABLET 5 mg, 100 eaches 6.00 4260086 CLOSED TX OF DISTAL RADIAL FX W/O MANIPULATION 747.00 256004174956 LORazepam 1 MG TABLET 1 mg, 100 eaches 6.00

4260032 DISTAL RADIAL FX 747.00 256004230032 DISTAL RADIAL FX 747.00 256004140023 RADEX RIBS UNILATERAL 2 VIEWS 315.50 711004260000 TREATMENT ROOM NO CHARGE - 3360000 SWING BED NO CHARGE - 4070498 RESPIRATORY VIRAL PANEL 890.00 876334174957 RECLAST 5 MG/100 ML SOLUTION 5 mcg, 100 mL 1,950.00 4174876 CEFTRIAXONE/DEXTROSE 2GM/50ML 82.00 J06964174641 CLARITHROMYCIN TAB 500MG, 30 eaches 21.00 4174785 AMPICILLIN AND SULBACTAM INJ 3GM, 10 vials 68.00 4174050 LOMOTIL TAB 2.5MG/0.025MG C5, 100 eaches 16.00 4173559 BLEPHAMIDE OINT 10% OPHTH, tube 400.00 4174784 AZITHROMYCIN INJ 500MG/VIAL, 10 vials 16.00 J04564174635 BICILLIN LA SY 600MU -1ML, each syringe 264.00 J05614174468 TOBRAMYCIN DR 0.3% -5ML OPTH, 1 bottle 20.00

CPT DescriptioAmbulance Base Rate Type Fee10060 I & D ABCESS SINGLE 228.00

10060,FAC I & D ABCESS SINGLE 46.00 10060,PRO I & D ABCESS SINGLE 182.00

10061 I & D ABCESS MULTIPLE 288.00 10061,FAC I & D ABCESS MULTIPLE 58.00 10061,PRO I & D ABCESS MULTIPLE 230.00

10080 I & D PILONIDAL CYST 204.00 10080,FAC I & D PILONIDAL CYST 41.00 10080,PRO I & D PILONIDAL CYST 163.00

11100 BIOPSY SKIN 1 LESION 139.00 11100,FAC BIOPSY SKIN 1 LESION 28.00 11100,PRO BIOPSY SKIN 1 LESION 111.00

11200 SKIN TAG REMOVAL ANY AREA UP TO 15 122.00 11200,FAC SKIN TAG REMOVAL ANY AREA UP TO 15 24.00 11200,PRO SKIN TAG REMOVAL ANY AREA UP TO 15 98.00

11201 SKIN TAG REMOVAL EADS ADDITIONAL 15+ 64.00 11201,FAC SKIN TAG REMOVAL EADS ADDITIONAL 15+ 13.00 11201,PRO SKIN TAG REMOVAL EADS ADDITIONAL 15+ 51.00

11400 EXCISION BENIGN LESION 146.00 11400,FAC EXCISION BENIGN LESION 29.00 11400,PRO EXCISION BENIGN LESION 117.00

11719 TRIMMING NONDYSTROPHIC NAIL ANY 45.00 11719,FAC TRIMMING NONDYSTROPHIC NAIL ANY 9.00 11719,PRO TRIMMING NONDYSTROPHIC NAIL ANY 36.00

11720 DEBRIDEMENT NAIL 1-5 70.00 11720,FAC DEBRIDEMENT NAIL 1-5 14.00 11720,PRO DEBRIDEMENT NAIL 1-5 56.00

11721 DEBRIDEMENT NAIL 6 OR MORE 101.00 11721,FAC DEBRIDEMENT NAIL 6 OR MORE 20.00 11721,PRO DEBRIDEMENT NAIL 6 OR MORE 81.00

11730 AVULSION OF NAIL SINGLE 140.00 11730,FAC AVULSION OF NAIL SINGLE 28.00 11730,PRO AVULSION OF NAIL SINGLE 112.00

11732 AVULSION OF NAIL EACH ADDITIONAL 87.00 11732,FAC AVULSION OF NAIL EACH ADDITIONAL 17.00 11732,PRO AVULSION OF NAIL EACH ADDITIONAL 70.00

11740 EVACUATION SUBUNGUAL HEMATOMA 84.00 11740,FAC EVACUATION SUBUNGUAL HEMATOMA 18.00 11740,PRO EVACUATION SUBUNGUAL HEMATOMA 66.00

11750 EXCISION NAIL PERMANENT 463.00 11750,FAC EXCISION NAIL PERMANENT 93.00 11750,PRO EXCISION NAIL PERMANENT 370.00

11765 WEDGE EXCISION OF SKIN OF NAIL 308.00 11765,FAC WEDGE EXCISION OF SKIN OF NAIL 62.00 11765,PRO WEDGE EXCISION OF SKIN OF NAIL 246.00

11900 INJ INTRALESION 7 LESIONS 122.00 11900,FAC INJ INTRALESION 7 LESIONS 24.00 11900,PRO INJ INTRALESION 7 LESIONS 98.00

11981 INSERTION, NON-BIODEGRADABLE IMPLANT 691.00 11981,FAC INSERTION, NON-BIODEGRADABLE IMPLANT 138.00 11981,PRO INSERTION, NON-BIODEGRADABLE IMPLANT 553.00

11982 REMOVAL NON-BIODEGRADABLE DRUG IMPLANT 718.00 11982,FAC REMOVAL NON-BIODEGRADABLE DRUG IMPLANT 144.00 11982,PRO REMOVAL NON-BIODEGRADABLE DRUG IMPLANT 574.00

12001 SIMPLE REPAIR SCALP/NECK/TRUNK/EXT <2.5 CM 184.00 12001,FAC SIMPLE REPAIR SCALP/NECK/TRUNK/EXT <2.5 CM 37.00 12001,PRO SIMPLE REPAIR SCALP/NECK/TRUNK/EXT <2.5 CM 147.00

12002 SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 2.6-7.5 CM 213.00 12002,FAC SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 2.6-7.5 CM 43.00 12002,PRO SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 2.6-7.5 CM 170.00

12004 SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 7.6-12.5 CM 308.00 12004,FAC SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 7.6-12.5 CM 62.00 12004,PRO SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 7.6-12.5 CM 246.00

12005 SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 12.6-20 CM 392.00 12005,FAC SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 12.6-20 CM 78.00 12005,PRO SIMPLE REPAIR SCALP/NECK/TRUNK/EXT 12.6-20 CM 314.00

12011 SIMPLE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 219.00 12011,FAC SIMPLE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 44.00 12011,PRO SIMPLE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 175.00

12013 SIMPLE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 269.00 12013,FAC SIMPLE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 54.00 12013,PRO SIMPLE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 215.00

12014 SIMPLE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 336.00 12014,FAC SIMPLE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 67.00 12014,PRO SIMPLE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 269.00

12015 SIMPLE REPAIR FACE/EARS/EYES/NOSE 7.6-12.5 CM 448.00 12015,FAC SIMPLE REPAIR FACE/EARS/EYES/NOSE 7.6-12.5 CM 90.00 12015,PRO SIMPLE REPAIR FACE/EARS/EYES/NOSE 7.6-12.5 CM 358.00

12031 INTERMEDIATE REPAIR SCALP/TRUNK/EXT <2.5 CM 236.00 12031,FAC INTERMEDIATE REPAIR SCALP/TRUNK/EXT <2.5 CM 47.00 12031,PRO INTERMEDIATE REPAIR SCALP/TRUNK/EXT <2.5 CM 189.00

12032 INTERMEDIATE REPAIR SCALP/TRUNK/EXT 2.6-7.5 CM 348.00 12032,FAC INTERMEDIATE REPAIR SCALP/TRUNK/EXT 2.6-7.5 CM 70.00 12032,PRO INTERMEDIATE REPAIR SCALP/TRUNK/EXT 2.6-7.5 CM 278.00

12034 INTERMEDIATE REPAIR SCALP/TRUNK/EXT 7.6-12.5CM 426.00 12034,FAC INTERMEDIATE REPAIR SCALP/TRUNK/EXT 7.6-12.5CM 85.00 12034,PRO INTERMEDIATE REPAIR SCALP/TRUNK/EXT 7.6-12.5CM 341.00

12035 INTERMEDIATE REPAIR SCALP/TRUNK/EXT 12.6-20 CM 426.00 12035,FAC INTERMEDIATE REPAIR SCALP/TRUNK/EXT 12.6-20 CM 85.00 12035,PRO INTERMEDIATE REPAIR SCALP/TRUNK/EXT 12.6-20 CM 341.00

12041 INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN <2.5 CM 258.00 12041,FAC INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN <2.5 CM 52.00 12041,PRO INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN <2.5 CM 206.00

12042 INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 2.6-7.5 CM 381.00 12042,FAC INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 2.6-7.5 CM 76.00 12042,PRO INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 2.6-7.5 CM 305.00

12044 INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 7.6-12.5 CM 482.00 12044,FAC INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 7.6-12.5 CM 96.00 12044,PRO INTERMEDIATE REPAIR NECK/HAND/FEET/EXT GEN 7.6-12.5 CM 386.00

12051 INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 312.00 12051,FAC INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 62.00 12051,PRO INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE <2.5 CM 250.00

12052 INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 420.00 12052,FAC INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 84.00 12052,PRO INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 2.6-5 CM 336.00

12053 INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 552.00 12053,FAC INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 100.00 12053,PRO INTERMEDIATE REPAIR FACE/EARS/EYES/NOSE 5.1-7.5 CM 442.00

13120 COMPLEX REPAIR SCALP/ARMS/LEGS 1.1-2.5 CM 546.00 13120,FAC COMPLEX REPAIR SCALP/ARMS/LEGS 1.1-2.5 CM 109.00 13120,PRO COMPLEX REPAIR SCALP/ARMS/LEGS 2.6-7.5 CM 974.00

13121 COMPLEX REPAIR SCALP/ARMS/LEGS 2.6-7.5 CM 1,217.00 13131 COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 1.1-2.5 CM 686.00

13131,FAC COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 1.1-2.5 CM 137.00 13131,PRO COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 1.1-2.5 CM 549.00

13132 COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 2.6-7.5 CM 1,395.00 13132,FAC COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 2.6-7.5 CM 279.00 13132,PRO COMPLEX REPAIR FACE/NECK/AXILLAE/GEN/HANDS/FEET 2.6-7.5 CM 1,116.00

17000 DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 1 104.00 17000,FAC DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 1 21.00 17000,PRO DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 1 83.00

17003 DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 2-14 43.00 17003,FAC DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 2-14 9.00 17003,PRO DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 2-14 34.00

17004 DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 15 + 482.00 17004,FAC DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 15 + 96.00 17004,PRO DESTRUCTION BENIGN LESION CRYO/SKIN TAGS 15 + 386.00

17110 DESTRUCT LESIONS/WARTS 0-14 108.00 17110,FAC DESTRUCT LESIONS/WARTS 0-14 22.00 17110,PRO DESTRUCT LESIONS/WARTS 0-14 86.00

17111 DESTRUCT LESIONS/WARTS 15 OR MORE 135.00 17111,FAC DESTRUCT LESIONS/WARTS 15 OR MORE 27.00 17111,PRO DESTRUCT LESIONS/WARTS 15 OR MORE 108.00

17260 DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS <0.5 CM 208.00 17260,FAC DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS <0.5 CM 42.00 17260,PRO DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS <0.5 CM 166.00

17261 DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS 0.6-1.0 CM 247.00 17261,FAC DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS 0.6-1.0 CM 49.00 17261,PRO DESTRUCTION MALIGNAT LESION CRYO TRUNK/ARMS/LEGS 0.6-1.0 CM 198.00

17270 DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN <0.5 CM 442.00 17270,FAC DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN <0.5 CM 88.00 17270,PRO DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN <0.5 CM 354.00

17271 DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN 0.6-1.0 CM 518.00 17271,FAC DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN 0.6-1.0 CM 104.00 17271,PRO DESTRUCTION MALIGNAT LESION CRYO SCALP/NECK/HANDS/FEET/GEN 0.6-1.0 CM 414.00

17280 DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS <0.5 CM 314.00 17280,FAC DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS <0.5 CM 63.00 17280,PRO DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS <0.5 CM 251.00

17281 DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS 0.6-1.0 CM 593.00 17281,FAC DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS 0.6-1.0 CM 119.00 17281,PRO DESTRUCTION MALIGNAT LESION CRYO FACE/EYES/EARS/LIPS 0.6-1.0 CM 474.00

17286 DESTRUCTION MALIGNAT LESION 896.00 20520 REMOVAL FB SIMPLE 454.00 20552 TRIGGER PT SING/MULT 1-2 MUSCLES 85.00

20552,FAC TRIGGER PT SING/MULT 1-2 MUSCLES 17.00 20552,PRO TRIGGER PT SING/MULT 1-2 MUSCLES 68.00

20553 TRIGGER PT SING/MULT TRIGGER 3> MUSCLES 356.00 20553,FAC TRIGGER PT SING/MULT TRIGGER 3> MUSCLES 71.00 20553,PRO TRIGGER PT SING/MULT TRIGGER 3> MUSCLES 285.00

20600 INJECTION/ASPIRATION SMALL JOINT 153.00 20600,FAC INJECTION/ASPIRATION SMALL JOINT 31.00 20600,PRO INJECTION/ASPIRATION SMALL JOINT 122.00

20605 INJECTION/ASPIRATION MEDIUM JOINT 115.00 20605,FAC INJECTION/ASPIRATION MEDIUM JOINT 23.00 20605,PRO INJECTION/ASPIRATION MEDIUM JOINT 92.00

20610 INJECTION/ASPIRATION LARGE JOINT 227.00 20610,FAC INJECTION/ASPIRATION LARGE JOINT 45.00 20610,PRO INJECTION/ASPIRATION LARGE JOINT 182.00

21310 CLOSED FX TREATMENT NOSE W/O MANIPULATION 269.00 21310,FAC CLOSED FX TREATMENT NOSE W/O MANIPULATION 54.00 21310,PRO CLOSED FX TREATMENT NOSE W/O MANIPULATION 215.00

21315 CLOSED FX TREATMENT NOSE W/O STABALIZATION 415.00 21315,FAC CLOSED FX TREATMENT NOSE W/O STABALIZATION 83.00

21315,PRO CLOSED FX TREATMENT NOSE W/O STABALIZATION 332.00 21320 CLOSED FX TREATMENT NOSE W/ STABALIZATION 840.00

21320,FAC CLOSED FX TREATMENT NOSE W/ STABALIZATION 168.00 21320,PRO CLOSED FX TREATMENT NOSE W/ STABALIZATION 672.00

21800 FRACTURE TREATMENT RIB 213.00 22305 FRACTURE TREATMENT VERTEBRAE 560.00 22310 FRACTURE TREATMENT VERTEBRAE 840.00 23500 CLOSED FX TREATMENT CLAVICULAR W/O MANIUPLATION 426.00

23500,FAC CLOSED FX TREATMENT CLAVICULAR W/O MANIUPLATION 85.00 23500,PRO CLOSED FX TREATMENT CLAVICULAR W/O MANIUPLATION 341.00

23505 CLOSED FX TREATMENT CLAVICULAR W/ MANIPULATION 672.00 23505,FAC CLOSED FX TREATMENT CLAVICULAR W/ MANIPULATION 134.00 23505,PRO CLOSED FX TREATMENT CLAVICULAR W/ MANIPULATION 538.00

23540 CLOSED TREATMENT AC JOINT W/O MANIPULATION 392.00 23540,FAC CLOSED TREATMENT AC JOINT W/O MANIPULATION 78.00 23540,PRO CLOSED TREATMENT AC JOINT W/O MANIPULATION 314.00

23545 CLOSED TREATMENT AC JOINT W MANIPULATION 583.00 23545,FAC CLOSED TREATMENT AC JOINT W MANIPULATION 117.00 23545,PRO CLOSED TREATMENT AC JOINT W MANIPULATION 466.00

23570 CLOSED FX TREATMENT SCAPULAR W/O MANIPULATION 462.00 23570,FAC CLOSED FX TREATMENT SCAPULAR W/O MANIPULATION 92.00 23570,PRO CLOSED FX TREATMENT SCAPULAR W/O MANIPULATION 370.00

23650 CLOSED TREATMENT DISLOCATION SHOULDER W/ MANIPULATION 560.00 23650,FAC CLOSED TREATMENT DISLOCATION SHOULDER W/ MANIPULATION 112.00 23650,PRO CLOSED TREATMENT DISLOCATION SHOULDER W/ MANIPULATION 448.00

23655 DISLOCATION TREATMENT SHOULDER 784.00 24065 BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 533.00

24065,FAC BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 107.00 24065,PRO BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL 426.00

24066 BIOPSY SOFT TISSUE DEEP 560.00 24200 FB REMOVAL ARM/ELBOW SUBCUTANEOUS 645.00

24200,FAC FB REMOVAL ARM/ELBOW SUBCUTANEOUS 129.00 24200,PRO FB REMOVAL ARM/ELBOW SUBCUTANEOUS 516.00

24500 CLOSED FX TREATMENT HUMERAL W/O MANIPULATION 560.00 24500,FAC CLOSED FX TREATMENT HUMERAL W/O MANIPULATION 112.00 24500,PRO CLOSED FX TREATMENT HUMERAL W/O MANIPULATION 448.00

24505 CLOSED FX TREATMENT HUMERAL W/ MANIPULATION 952.00 24505,FAC CLOSED FX TREATMENT HUMERAL W/ MANIPULATION 190.00 24505,PRO CLOSED FX TREATMENT HUMERAL W/ MANIPULATION 762.00

24600 CLOSED DISLOCATION TREATMENT ELBOW W/O ANESTHESIA 476.00 24600,FAC CLOSED DISLOCATION TREATMENT ELBOW W/O ANESTHESIA 95.00 24600,PRO CLOSED DISLOCATION TREATMENT ELBOW W/O ANESTHESIA 381.00

24605 DISLOCATION TREATMENT ELBOW 672.00 24640 CLOSED FX TREATMENT RADIAL CHILD W/ MANIPULATION 258.00

24640,FAC CLOSED FX TREATMENT RADIAL CHILD W/ MANIPULATION 52.00 24640,PRO CLOSED FX TREATMENT RADIAL CHILD W/ MANIPULATION 206.00

24650 CLOSED FX TREATMENT RADIAL W/O MANIPULATION 504.00 24650,FAC CLOSED FX TREATMENT RADIAL W/O MANIPULATION 101.00 24650,PRO CLOSED FX TREATMENT RADIAL W/O MANIPULATION 403.00

24655 CLOSED FX TREATMENT RADIAL W/ MANIPULATION 756.00 24655,FAC CLOSED FX TREATMENT RADIAL W/ MANIPULATION 151.00 24655,PRO CLOSED FX TREATMENT RADIAL W/ MANIPULATION 605.00

24670 CLOSED FX TREATMENT ULNAR W/O MANIPULATION 437.00 24670,FAC CLOSED FX TREATMENT ULNAR W/O MANIPULATION 87.00 24670,PRO CLOSED FX TREATMENT ULNAR W/O MANIPULATION 350.00

24675 CLOSED FX TREATMENT ULNAR W/ MANIPULATION 773.00 24675,FAC CLOSED FX TREATMENT ULNAR W/ MANIPULATION 155.00 24675,PRO CLOSED FX TREATMENT ULNAR W/ MANIPULATION 618.00

25248 EXP REMOVAL DEEP FB ARM/WRIST 530.00 25248,FAC EXP REMOVAL DEEP FB ARM/WRIST 106.00 25248,PRO EXP REMOVAL DEEP FB ARM/WRIST 424.00

25500 CLOSED RADIAL FX W/O MANIPULATION 1,214.00 25500,FAC CLOSED RADIAL FX W/O MANIPULATION 243.00 25500,PRO CLOSED RADIAL FX W/O MANIPULATION 971.00

25560 CLOSED FX TREATMENT RADIAL-ULNAR W/O MANIPULATION 616.00 25560,FAC CLOSED FX TREATMENT RADIAL-ULNAR W/O MANIPULATION 123.00 25560,PRO CLOSED FX TREATMENT RADIAL-ULNAR W/O MANIPULATION 493.00

25600 CLOSED FX TREATMENT DIST RADIAL W/O MANIPULATION 616.00 25600,FAC CLOSED FX TREATMENT DIST RADIAL W/O MANIPULATION 123.00 25600,PRO CLOSED FX TREATMENT DIST RADIAL W/O MANIPULATION 493.00

25605 CLOSED FX TREATMENT DIST RADIAL W/ MANIPULATION 952.00 25605,FAC CLOSED FX TREATMENT DIST RADIAL W/ MANIPULATION 190.00 25605,PRO CLOSED FX TREATMENT DIST RADIAL W/ MANIPULATION 762.00

25611 FRACTURE TREATMENT DIST RADIAL 1,456.00 25650 CLOSED FX ULNA STYLOID PROCESS 865.00

25650,FAC CLOSED FX ULNA STYLOID PROCESS 173.00 25650,PRO CLOSED FX ULNA STYLOID PROCESS 692.00

26080 REMOVAL FB IP JOINT 1,910.00 26080,FAC REMOVAL FB IP JOINT 382.00 26080,PRO REMOVAL FB IP JOINT 1,528.00

26600 CLOSED FX TREATMENT METACARPAL SINGLE W/O MANIPULATION 392.00 26600,FAC CLOSED FX TREATMENT METACARPAL SINGLE W/O MANIPULATION 78.00 26600,PRO CLOSED FX TREATMENT METACARPAL SINGLE W/O MANIPULATION 314.00

26605 CLOSED FX TREATMENT METACARPAL W/ MANIPULATION 583.00 26605,FAC CLOSED FX TREATMENT METACARPAL W/ MANIPULATION 117.00 26605,PRO CLOSED FX TREATMENT METACARPAL W/ MANIPULATION 466.00

26645 CLOSED FX/DISLOCATION OF CARPOMET THUMB W MANIPULATION 1,682.00 26645,FAC CLOSED FX/DISLOCATION OF CARPOMET THUMB W MANIPULATION 336.00 26645,PRO CLOSED FX/DISLOCATION OF CARPOMET THUMB W MANIPULATION 1,346.00

26720 CLOSED FX TREATMENT PHALANGEAL W/O MANIPULATION 767.00 26720,FAC CLOSED FX TREATMENT PHALANGEAL W/O MANIPULATION 153.00 26720,PRO CLOSED FX TREATMENT PHALANGEAL W/O MANIPULATION 614.00

26725 CLOSED FX TREATMENT PHALANGEAL W/ MANIPULATION 493.00 26725,FAC CLOSED FX TREATMENT PHALANGEAL W/ MANIPULATION 99.00 26725,PRO CLOSED FX TREATMENT PHALANGEAL W/ MANIPULATION 394.00

26735 OPEN TX PHALANGEAL SHAFT FX PROX/MI EA 2,815.50 26740 CLOSED FX TREATMENT MCP OR IP JOINT W/O MANIPULATION 487.00

26740,FAC CLOSED FX TREATMENT MCP OR IP JOINT W/O MANIPULATION 97.00 26740,PRO CLOSED FX TREATMENT MCP OR IP JOINT W/O MANIPULATION 390.00

26750 CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/O MANIPULATION 786.00 26750,FAC CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/O MANIPULATION 157.00 26750,PRO CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/O MANIPULATION 629.00

26755 CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/ MANIPULATION 381.00 26755,FAC CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/ MANIPULATION 76.00 26755,PRO CLOSED FX TREATMENT PHALANGEAL FINGER/THUMB W/ MANIPULATION 305.00

26765 FRACTURE TREATMENT PHALANGEAL 756.00 26770 CLOSED DISLOCATION IP SINGLE W/ MANIPULATION 325.00

26770,FAC CLOSED DISLOCATION IP SINGLE W/ MANIPULATION 65.00 26770,PRO CLOSED DISLOCATION IP SINGLE W/ MANIPULATION 260.00

26775 FRACTURE TREATMENT PHALANGEAL 493.00 27200 CLOSED FX TREATMENT COCCYGEAL 392.00

27200,FAC CLOSED FX TREATMENT COCCYGEAL 78.00 27200,PRO CLOSED FX TREATMENT COCCYGEAL 314.00

27520 CLOSED FX TREATMENT PATELLAR W/O MANIPULATION 420.00 27520,FAC CLOSED FX TREATMENT PATELLAR W/O MANIPULATION 84.00 27520,PRO CLOSED FX TREATMENT PATELLAR W/O MANIPULATION 336.00

27613 BIOPSY SOFT TISSUE SUPERFICIAL LEG/ANKLE 357.00 27613,FAC BIOPSY SOFT TISSUE SUPERFICIAL LEG/ANKLE 71.00 27613,PRO BIOPSY SOFT TISSUE SUPERFICIAL LEG/ANKLE 286.00

27750 CLOSED FX TREATMENT TIBIAL W/O MANIPULATION 501.00 27750,FAC CLOSED FX TREATMENT TIBIAL W/O MANIPULATION 100.00 27750,PRO CLOSED FX TREATMENT TIBIAL W/O MANIPULATION 401.00

27752 CLOSED FX TREATMENT TIBIAL W/ MANIPULATION 1,232.00 27752,FAC CLOSED FX TREATMENT TIBIAL W/ MANIPULATION 246.00 27752,PRO CLOSED FX TREATMENT TIBIAL W/ MANIPULATION 986.00

27760 CLOSED FX TREATMENT MED MALLEOLUS W/O MANIPULATION 920.00 27760,FAC CLOSED FX TREATMENT MED MALLEOLUS W/O MANIPULATION 184.00 27760,PRO CLOSED FX TREATMENT MED MALLEOLUS W/O MANIPULATION 736.00

27780 CLOSED FX PROXIMAL FIBULA W/O MANIPULATION 1,275.75 27786 CLOSED FX TREATMENT FIBULAR W/O MANIPULATION 583.00

27786,FAC CLOSED FX TREATMENT FIBULAR W/O MANIPULATION 117.00 27786,PRO CLOSED FX TREATMENT FIBULAR W/O MANIPULATION 466.00

27788 CLOSED FX TREATMENT FIBULAR W/ MANIPULATION 818.00 27788,FAC CLOSED FX TREATMENT FIBULAR W/ MANIPULATION 164.00 27788,PRO CLOSED FX TREATMENT FIBULAR W/ MANIPULATION 654.00

27808 CLOSED FX TREATMENT ANKLE W/O MANIPULATION 717.00 27808,FAC CLOSED FX TREATMENT ANKLE W/O MANIPULATION 143.00 27808,PRO CLOSED FX TREATMENT ANKLE W/O MANIPULATION 574.00

27810 CLOSED FX TREATMENT ANKLE W/ MANIPULATION 1,232.00 27810,FAC CLOSED FX TREATMENT ANKLE W/ MANIPULATION 246.00 27810,PRO CLOSED FX TREATMENT ANKLE W/ MANIPULATION 986.00

27824 FRACTURE TREATMENT TIBIA 740.00 28190 REMOVAL FB FOOT SUBCUTANEOUS 201.00

28190,FAC REMOVAL FB FOOT SUBCUTANEOUS 40.00 28190,PRO REMOVAL FB FOOT SUBCUTANEOUS 161.00

28400 CLOSED FX TREATMENT CALCANEAL W/O MANIPULATION 594.00 28400,FAC CLOSED FX TREATMENT CALCANEAL W/O MANIPULATION 119.00 28400,PRO CLOSED FX TREATMENT CALCANEAL W/O MANIPULATION 475.00

28470 CLOSED FX TREATMENT METATARSAL W/O MANIPULATION EACH 426.00 28470,FAC CLOSED FX TREATMENT METATARSAL W/O MANIPULATION EACH 83.00 28470,PRO CLOSED FX TREATMENT METATARSAL W/O MANIPULATION EACH 343.00

28475 CLOSED FX TREATMENT METATARSAL W/ MANIPULATION EACH 583.00 28475,FAC CLOSED FX TREATMENT METATARSAL W/ MANIPULATION EACH 117.00 28475,PRO CLOSED FX TREATMENT METATARSAL W/ MANIPULATION EACH 466.00

28490 CLOSED FX TREATMENT GREAT TOE W/O MANIPULATION 202.00 28490,FAC CLOSED FX TREATMENT GREAT TOE W/O MANIPULATION 40.00 28490,PRO CLOSED FX TREATMENT GREAT TOE W/O MANIPULATION 162.00

28495 CLOSED FX TREATMENT GREAT TOE W/ MANIPULATION 314.00 28495,FAC CLOSED FX TREATMENT GREAT TOE W/ MANIPULATION 63.00 28495,PRO CLOSED FX TREATMENT GREAT TOE W/ MANIPULATION 251.00

28496 FRACTURE TREATMENT GREAT TOE 538.00 28510 CLOSED FX TREATMENT OTHER THAN GREAT TOE W/O MANIPULATION 666.00

28510,FAC CLOSED FX TREATMENT OTHER THAN GREAT TOE W/O MANIPULATION 133.00 28510,PRO CLOSED FX TREATMENT OTHER THAN GREAT TOE W/O MANIPULATION 533.00

28515 CLOSED FX TREATMENT OTHER THAN GREAT TOE W/ MANIPULATION 280.00 28515,FAC CLOSED FX TREATMENT OTHER THAN GREAT TOE W/ MANIPULATION 56.00 28515,PRO CLOSED FX TREATMENT OTHER THAN GREAT TOE W/ MANIPULATION 224.00

28525 FRACTURE TREATMENT PHALANX 721.00 29125 SPLINT SHORT ARM 101.00

29125,FAC SPLINT SHORT ARM 20.00 29125,PRO SPLINT SHORT ARM 81.00

29130 SPLINT FINGER 73.00 29130,FAC SPLINT FINGER 15.00 29130,PRO SPLINT FINGER 58.00

29260 STRAPPING ELBOW OR WRIST 172.00 29260,FAC STRAPPING ELBOW OR WRIST 34.00 29260,PRO STRAPPING ELBOW OR WRIST 138.00

29280 STRAPPING HAND/FINGER 116.00 29280,FAC STRAPPING HAND/FINGER 23.00 29280,PRO STRAPPING HAND/FINGER 93.00

29505 SPLINT LONG LEG 216.00 29505,FAC SPLINT LONG LEG 43.00 29505,PRO SPLINT LONG LEG 173.00

29515 SPLINT SHORT LEG 131.00 29515,FAC SPLINT SHORT LEG 26.00 29515,PRO SPLINT SHORT LEG 105.00

30300 REMOVAL FB INTRANASAL 126.00 30300,FAC REMOVAL FB INTRANASAL 25.00 30300,PRO REMOVAL FB INTRANASAL 101.00

30901 CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD 139.32 30901,FAC CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD 27.86 30901,PRO CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD 111.46

46916 DESTRUCTION LESION CRYOSURGEY 236.00 54056 DESTUCTION CRYOSURGEY PENIS 165.00 58300 INSERTION OF IUD 196.00

58300,FAC INSERTION OF IUD 39.00 58300,PRO INSERTION OF IUD 157.00

58301 REMOVAL OF IUD 130.00 58301,FAC REMOVAL OF IUD 26.00 58301,PRO REMOVAL OF IUD 104.00

65205 REMOVAL FB SUPERFICIAL CONJUNCTIVAL 206.00 65205,FAC REMOVAL FB SUPERFICIAL CONJUNCTIVAL 41.00 65205,PRO REMOVAL FB SUPERFICIAL CONJUNCTIVAL 165.00

65210 REMOVAL FB CONJUNCTIVAL EMBEDDED 224.00 65210,FAC REMOVAL FB CONJUNCTIVAL EMBEDDED 45.00 65210,PRO REMOVAL FB CONJUNCTIVAL EMBEDDED 179.00

65220 REMOVAL FB CORNEAL W/O LAMP 128.00 65220,FAC REMOVAL FB CORNEAL W/O LAMP 26.00 65220,PRO REMOVAL FB CORNEAL W/O LAMP 102.00

65222 REMOVAL FB CORNEAL W/ LAMP 158.00 65222,FAC REMOVAL FB CORNEAL W/ LAMP 32.00 65222,PRO REMOVAL FB CORNEAL W/ LAMP 126.00

67800 EXCISION OF CHALAZION SINGLE 508.00 67800,FAC EXCISION OF CHALAZION SINGLE 102.00 67800,PRO EXCISION OF CHALAZION SINGLE 406.00

69000 DRAINAGE EXT EAR SIMPLE 147.00 69000,FAC DRAINAGE EXT EAR SIMPLE 29.00 69000,PRO DRAINAGE EXT EAR SIMPLE 118.00

69100 BIOPSY EXT EAR 324.00 69100,FAC BIOPSY EXT EAR 65.00 69100,PRO BIOPSY EXT EAR 259.00

69200 REMOVAL FB EXT AUDI CANAL 179.00 69200,FAC REMOVAL FB EXT AUDI CANAL 36.00 69200,PRO REMOVAL FB EXT AUDI CANAL 143.00

69209 REMOVAL IMPACTED CERUMEN USING IRRIGATION UNILATERAL 77.00 69209,FAC REMOVAL IMPACTED CERUMEN USING IRRIGATION UNILATERAL 15.00 69209,PRO REMOVAL IMPACTED CERUMEN USING IRRIGATION UNILATERAL 62.00

69210 REMOVAL IMPACTED CERUMEN PROVIDER UNILATERAL 147.00 69210,FAC REMOVAL IMPACTED CERUMEN PROVIDER UNILATERAL 29.00 69210,PRO REMOVAL IMPACTED CERUMEN PROVIDER UNILATERAL 118.00

81002 UA DIP 33.00 81002,FAC UA DIP 7.00

81002,PRO UA DIP 26.00 81015 UA MICROSCOPIC ONLY 28.00 81025 URINE PREGNACY TEST 63.00

81025,FAC URINE PREGNACY TEST 13.00 81025,PRO URINE PREGNACY TEST 50.00

82948 ACCUCHEK 36.00 82948,FAC ACCUCHEK 7.00 82948,PRO ACCUCHEK 29.00

84703 SERUM HCG 91.00 86308 MONO TEST 62.00 86318 H PYLORI REAGENT STRIP RAPID 56.00 86403 RAPID H-PYLORI TEST 29.00 86580 TUBERCULOSIS, INDERMAL 30.00 87804 INFLUENZA A&B 119.00 87880 RAPID STREP TEST 85.00

87880,FAC RAPID STREP TEST 17.00 87880,PRO RAPID STREP TEST 68.00

90471 IMM ADMINISTRATION 31.00 90471,FAC IMM ADMINISTRATION 6.00 90471,PRO IMM ADMINISTRATION 25.00

90657 INFLUENZA 6-35 MO 28.00 90657,FAC INFLUENZA 6-35 MO 6.00 90657,PRO INFLUENZA 6-35 MO 22.00

90658 INFLUENZA IMMUNIZATION 71.00 90658,FAC INFLUENZA IMMUNIZATION 14.00 90658,PRO INFLUENZA IMMUNIZATION 57.00

90662 FLUZONE HIGH DOSE 2018-2019 185.00 90662,FAC FLUZONE HIGH DOSE 2018-2019 37.00 90662,PRO FLUZONE HIGH DOSE 2018-2019 148.00

90669 PNEUMOVAX UNDER 5 YEARS OF AGE 41.00 90669,FAC PNEUMOVAX UNDER 5 YEARS OF AGE 14.00 90669,PRO PNEUMOVAX UNDER 5 YEARS OF AGE 57.00

90686 FLUZONE QUAD 2018-2019 68.00 90686,FAC FLUZONE QUAD 2018-2019 13.60 90686,PRO FLUZONE QUAD 2018-2019 54.40

90715 TETANUS DIPTHERIA PERTUSSIS 222.00 90715,FAC TETANUS DIPTHERIA PERTUSSIS 44.00 90715,PRO TETANUS DIPTHERIA PERTUSSIS 178.00

90732 PNEUMOVAX ADULT 33.00 90732,FAC PNEUMOVAX ADULT 7.00 90732,PRO PNEUMOVAX ADULT 26.00

90740 HEP B VACCINE 987.00 90740,FAC HEP B VACCINE 197.00 90740,PRO HEP B VACCINE 790.00

90744 HEP B VACCINE PEDIATRIC/ADOLESCENT 6.00 90744,FAC HEP B VACCINE PEDIATRIC/ADOLESCENT 1.00 90744,PRO HEP B VACCINE PEDIATRIC/ADOLESCENT 5.00

91299 UNLSTD GI PROC 406.00 93005 EKG TRACING ONLY 66.00

93005,FAC EKG TRACING ONLY 13.00 93005,PRO EKG TRACING ONLY 53.00

94010 SPIROMETRY 133.00 94010,FAC SPIROMETRY 27.00 94010,PRO SPIROMETRY 106.00

94664 NEBULIZER TREATMENT 76.00 94664,FAC NEBULIZER TREATMENT 15.00 94664,PRO NEBULIZER TREATMENT 61.00

94760 PULSE OXIMETRY NON INVASIVE, SINGLE 32.00

94760,FAC PULSE OXIMETRY NON INVASIVE, SINGLE 6.00 94760,PRO PULSE OXIMETRY NON INVASIVE, SINGLE 26.00

95115 ALLERGY INJECTION SINGLE 40.00 95115,FAC ALLERGY INJECTION SINGLE 8.00 95115,PRO ALLERGY INJECTION SINGLE 32.00

95117 ALLERGY INJECTION MULTIPLE 45.00 95117,FAC ALLERGY INJECTION MULTIPLE 4.00 95117,PRO ALLERGY INJECTION MULTIPLE 36.00

96127 PHQ 9 SCREENING 30.00 96160 PT FOCUSED HEALTH RISK ASSMT 2.00

96160,FAC PT FOCUSED HEALTH RISK ASSMT 1.00 96160,PRO PT FOCUSED HEALTH RISK ASSMT 1.00

96161 CAREGIVER HEALTH RISK ASSMT 2.00 96161,FAC CAREGIVER HEALTH RISK ASSMT 1.00 96161,PRO CAREGIVER HEALTH RISK ASSMT 1.00

96372 ADMINISTRATION IM 31.00 96372,FAC ADMINISTRATION IM 6.00 96372,PRO ADMINISTRATION IM 25.00

97602 WOUND CARE EXTRIMITY 87.00 97602,FAC WOUND CARE EXTRIMITY 17.00 97602,PRO WOUND CARE EXTRIMITY 70.00

99188 FLUORIDE VARNISH APPLICATION 46.00 99188,FAC FLUORIDE VARNISH APPLICATION 9.00 99188,PRO FLUORIDE VARNISH APPLICATION 37.00

99201 NP OFFICE VISIT LEVEL 1 98.00 99201,FAC NP OFFICE VISIT LEVEL 1 22.00 99201,PRO NP OFFICE VISIT LEVEL 1 81.00

99202 NP OFFICE VISIT LEVEL 2 119.00 99202,FAC NP OFFICE VISIT LEVEL 2 27.00 99202,PRO NP OFFICE VISIT LEVEL 2 97.00

99203 NP OFFICE VISIT LEVEL 3 155.00 99203,FAC NP OFFICE VISIT LEVEL 3 35.00 99203,PRO NP OFFICE VISIT LEVEL 3 125.00

99204 NP OFFICE VISIT LEVEL 4 211.00 99204,FAC NP OFFICE VISIT LEVEL 4 46.00 99204,PRO NP OFFICE VISIT LEVEL 4 170.00

99205 NP OFFICE VISIT LEVEL 5 254.00 99205,FAC NP OFFICE VISIT LEVEL 5 54.00 99205,PRO NP OFFICE VISIT LEVEL 5 205.00

99211 OFFICE VISIT LEVEL 1 65.00 99211,FAC OFFICE VISIT LEVEL 1 17.00 99211,PRO OFFICE VISIT LEVEL 1 83.00

99212 OFFICE VISIT LEVEL 2 82.00 99212,FAC OFFICE VISIT LEVEL 2 20.00 99212,PRO OFFICE VISIT LEVEL 2 67.00

99213 OFFICE VISIT LEVEL 3 101.00 99213,FAC OFFICE VISIT LEVEL 3 24.00 99213,PRO OFFICE VISIT LEVEL 3 82.00

99214 OFFICE VISIT LEVEL 4 139.00 99214,FAC OFFICE VISIT LEVEL 4 32.00 99214,PRO OFFICE VISIT LEVEL 4 112.00

99215 OFFICE VISIT LEVEL 5 190.00 99215,FAC OFFICE VISIT LEVEL 5 42.00 99215,PRO OFFICE VISIT LEVEL 5 153.00

99307 NH - SW - SUBSEQUENT PROBLEM FOCUS 125.00 99307,FAC NH - SW - SUBSEQUENT PROBLEM FOCUS 25.00 99307,PRO NH - SW - SUBSEQUENT PROBLEM FOCUS 100.00

99308 NH - SW EXPANDED FOCUSED 185.00

99308,FAC NH - SW EXPANDED FOCUSED 37.00 99308,PRO NH - SW EXPANDED FOCUSED 148.00

99310 NH - SW SUBSEQUENT DETAILED 323.00 99310,FAC NH - SW SUBSEQUENT DETAILED 65.00 99310,PRO NH - SW SUBSEQUENT DETAILED 258.00

99315 NH - SW DISCHARGE 30 MIN OR LESS 134.00 99315,FAC NH - SW DISCHARGE 30 MIN OR LESS 27.00 99315,PRO NH - SW DISCHARGE 30 MIN OR LESS 107.00

99318 NH-SW ANNUAL EXAM 253.00 99318,FAC NH-SW ANNUAL EXAM 51.00 99318,PRO NH-SW ANNUAL EXAM 202.00

99381 NP WELL EXAM UNDER 1 95.00 99381,FAC NP WELL EXAM UNDER 1 23.00 99381,PRO NP WELL EXAM UNDER 1 77.00

99382 NP WELL EXAM 1-4 95.00 99382,FAC NP WELL EXAM 1-4 23.00 99382,PRO NP WELL EXAM 1-4 77.00

99383 NP WELL EXAM 5-11 118.00 99383,FAC NP WELL EXAM 5-11 28.00 99383,PRO NP WELL EXAM 5-11 95.00

99384 NP WELL EXAM 12-17 118.00 99384,FAC NP WELL EXAM 12-17 28.00 99384,PRO NP WELL EXAM 12-17 95.00

99385 NP WELL EXAM 18-39 160.00 99385,FAC NP WELL EXAM 18-39 36.00 99385,PRO NP WELL EXAM 18-39 129.00

99386 NP WELL EXAM 40-64 160.00 99386,FAC NP WELL EXAM 40-64 36.00 99386,PRO NP WELL EXAM 40-64 129.00

99387 NP WELL EXAM 65+ 160.00 99387,FAC NP WELL EXAM 65+ 36.00 99387,PRO NP WELL EXAM 65+ 129.00

99391 WELL EXAM UNDER 1 80.00 99391,FAC WELL EXAM UNDER 1 20.00 99391,PRO WELL EXAM UNDER 1 65.00

99392 WELL EXAM 1-4 80.00 99392,FAC WELL EXAM 1-4 20.00 99392,PRO WELL EXAM 1-4 65.00

99393 WELL EXAM 5-11 98.00 99393,FAC WELL EXAM 5-11 24.00 99393,PRO WELL EXAM 5-11 79.00

99394 WELL EXAM 12-17 98.00 99394,FAC WELL EXAM 12-17 24.00 99394,PRO WELL EXAM 12-17 79.00

99395 WELL EXAM 18-39 229.00 99395,FAC WELL EXAM 18-39 50.00 99395,PRO WELL EXAM 18-39 184.00

99396 WELL EXAM 40-64 229.00 99396,FAC WELL EXAM 40-64 50.00 99396,PRO WELL EXAM 40-64 184.00

99397 WELL EXAM 65 + 229.00 99397,FAC WELL EXAM 65 + 50.00 99397,PRO WELL EXAM 65 + 184.00

99490 CHRONIC CARE MANAGEMENT NON FACE-TO-FACE FOR MULTIPLE CHRONIC CONDITIONS 50.00 99490,FAC CHRONIC CARE MANAGEMENT NON FACE-TO-FACE FOR MULTIPLE CHRONIC CONDITIONS 10.00 99490,PRO CHRONIC CARE MANAGEMENT NON FACE-TO-FACE FOR MULTIPLE CHRONIC CONDITIONS 40.00

99999 SCHOOL PHYSICALS 20.00 99999,FAC SCHOOL PHYSICALS 4.00

99999,PRO SCHOOL PHYSICALS 16.00 A4565 SLING 23.00 A4565,FAC SLING 5.00 A4565,PRO SLING 18.00 A4570 SPLINT COCKUP WRIST 30.00 A4570,FAC SPLINT COCKUP WRIST 6.00 A4570,PRO SPLINT COCKUP WRIST 24.00 D0145 ORAL HEALTH 0-2 YRS 46.00 D0145,FAC ORAL HEALTH 0-2 YRS 9.00 D0145,PRO ORAL HEALTH 0-2 YRS 37.00 D0190 ORAL HEALTH 3+ YRS 46.00 D0190,PRO ORAL HEALTH 3+ YRS 37.00 D1090,FAC ORAL HEALTH 3+ YRS 9.00 D1206 FLUORIDE VARNISH APPLICATION 46.00 D1206,FAC FLUORIDE VARNISH APPLICATION 9.00 D1206,PRO FLUORIDE VARNISH APPLICATION 37.00 G0351 MEDICARE ADMINISTRATION 31.00 G0351,FAC MEDICARE ADMINISTRATION 6.00 G0351,PRO MEDICARE ADMINISTRATION 25.00 G0402 WELCOME TO MEDICARE PHYSICAL 155.00 G0402,FAC WELCOME TO MEDICARE PHYSICAL 31.00 G0402,PRO WELCOME TO MEDICARE PHYSICAL 124.00 G0438 ANNUAL WELL VISIT INITIAL MEDICARE 122.00 G0438,FAC ANNUAL WELL VISIT INITIAL MEDICARE 24.00 G0438,PRO ANNUAL WELL VISIT INITIAL MEDICARE 98.00 G0439 ANNUAL WELL VISIT SUBSEQUENT MEDICARE 134.00 G0439,FAC ANNUAL WELL VISIT SUBSEQUENT MEDICARE 27.00 G0439,PRO ANNUAL WELL VISIT SUBSEQUENT MEDICARE 107.00 J0561 PENICILLIN G BENZATHINE INJ 100,000 UNITS 456.00 J0561,FAC PENICILLIN G BENZATHINE INJ 100,000 UNITS 91.00 J0561,PRO PENICILLIN G BENZATHINE INJ 100,000 UNITS 365.00 J0696 CEFTRIAZONE INJ 250 MG 9.00 J0696,FAC CEFTRIAZONE INJ 250 MG 2.00 J0696,PRO CEFTRIAZONE INJ 250 MG 7.00 J1000 DEPO-ESTRADIOL CYP INJ 5MG 305.00 J1000,FAC DEPO-ESTRADIOL CYP INJ 5MG 61.00 J1000,PRO DEPO-ESTRADIOL CYP INJ 5MG 244.00 J1040 METHYLPREDNISOLONE INJ 80 MG 72.00 J1040,FAC METHYLPREDNISOLONE INJ 80 MG 14.00 J1040,PRO METHYLPREDNISOLONE INJ 80 MG 58.00 J1050 MEDROXYPROGESTERONE INJ 1 MG 237.00 J1050,FAC MEDROXYPROGESTERONE INJ 1 MG 47.00 J1050,PRO MEDROXYPROGESTERONE INJ 1 MG 190.00 J1080 TESTOSTERONE INJ 200 MG 81.00 J1080,FAC TESTOSTERONE INJ 200 MG 16.00 J1080,PRO TESTOSTERONE INJ 200 MG 65.00 J1100 DEXAMETHASONE INJ 1 MG 23.00 J1100,FAC DEXAMETHASONE INJ 1 MG 5.00 J1100,PRO DEXAMETHASONE INJ 1 MG 18.00 J1200 DIPHENHYDRAMINE INJ 50 MG 6.00 J1200,FAC DIPHENHYDRAMINE INJ 50 MG 1.00 J1200,PRO DIPHENHYDRAMINE INJ 50 MG 5.00 J1885 KETOROLAC INJ 15 MG 30.00 J1885,FAC KETOROLAC INJ 15 MG 6.00 J1885,PRO KETOROLAC INJ 15 MG 24.00 J2175 MEPERIDINE INJ 100 MG 54.00 J2175,FAC MEPERIDINE INJ 100 MG 11.00 J2175,PRO MEPERIDINE INJ 100 MG 43.00

J2250,FAC PROMETHAZINE HCL INJ 50 MG 2.00 J2405 ONDANSETRON INJ 1 MG 9.00 J2405,FAC ONDANSETRON INJ 1 MG 2.00 J2405,PRO ONDANSETRON INJ 1 MG 7.00 J2550 PROMETHAZINE HCL INJ 50 MG 9.00 J2550,PRO PROMETHAZINE HCL INJ 50 MG 7.00 J3030 SUMATRIPTAN INJ 6MG 38.00 J3030,FAC SUMATRIPTAN INJ 6MG 8.00 J3030,PRO SUMATRIPTAN INJ 6MG 30.00 J3301 TRIAMCINOLONE INJ 10 MG 190.00 J3301,FAC TRIAMCINOLONE INJ 10 MG 38.00 J3301,PRO TRIAMCINOLONE INJ 10 MG 152.00 J3360 DIAZEPAM INJ 5 MG 154.00 J3360,FAC DIAZEPAM INJ 5 MG 31.00 J3360,PRO DIAZEPAM INJ 5 MG 123.00 J3420 VITAMIN B12 INJ 1000 MCG 21.00 J3420,FAC VITAMIN B12 INJ 1000 MCG 4.00 J3420,PRO VITAMIN B12 INJ 1000 MCG 17.00 J7307 NEXPLANON 68 MG IMPLANT 68 MG, 1 EACH 1,780.00 J7611 RT- ALBUTEROL NEB .083% 3.00 J7611,FAC RT- ALBUTEROL NEB .083% 1.00 J7611,PRO RT- ALBUTEROL NEB .083% 2.00 J7644 RT-IPRATROPIUM NEB 0.02% 3.00 J7644,FAC RT-IPRATROPIUM NEB 0.02% 1.00 J7644,PRO RT-IPRATROPIUM NEB 0.02% 2.00 L1830 KNEE IMMOBILIZER 170.00 L1830,FAC KNEE IMMOBILIZER 34.00 L1830,PRO KNEE IMMOBILIZER 136.00 L1906 AIR CAST 202.00 L1906,FAC AIR CAST 40.00 L1906,PRO AIR CAST 162.00 L3807 IMMOB WRIST/THUMB 103.00 L3807,FAC IMMOB WRIST/THUMB 21.00 L3807,PRO IMMOB WRIST/THUMB 82.00 L3908 WRIST IMMOBILIZER 44.00 L3908,FAC WRIST IMMOBILIZER 9.00 L3908,PRO WRIST IMMOBILIZER 35.00 L3961 SHOULDER IMMOBILIZER 72.00 L3961,FAC SHOULDER IMMOBILIZER 14.00 L3961,PRO SHOULDER IMMOBILIZER 58.00 L3970 IMMOB UNIV SLING 27.00 L3970,FAC IMMOB UNIV SLING 5.00 L3970,PRO IMMOB UNIV SLING 22.00 L4350 ANKLE BRACE 134.00 L4350,FAC ANKLE BRACE 27.00 L4350,PRO ANKLE BRACE 107.00 L4386 CAST BOOT 195.00 L4386,FAC CAST BOOT 39.00 L4386,PRO CAST BOOT 156.00 L4387 WALKING BOOT 195.00 L4387,FAC WALKING BOOT 39.00 L4387,PRO WALKING BOOT 156.00