Facility Charge Code Descrip3on CPT HCPC ChargeFVH 1000002 ROOM ICU $3,840.00FVH 1000032 ROOM NURSERY $730.00FVH 1000036 ROOM SWING BED SKILLED $830.00FVH 1000037 ROOM SWING BED INTERMED $330.00FVH 1000039 ROOM MEDICAL UNIT $2,030.00FVH 1100009 OBSERVATION EACH ADD HR $85.00FVH 2000043 PHLEBOTOMY - MANUAL 99195 $177.00FVH 2000066 DELIVERY CHARGE $758.00FVH 2000108 FETAL NON STRESS 59025 $391.00FVH 2000183 BLOOD ADMINISTRATION 36430 $970.00FVH 2000186 SUBQ/IM INJECTION 96372 $136.00FVH 2000187 CHEMOTHERAPY INF INITIAL 96413 $177.00FVH 2000188 LEVEL 1 OP VISIT 99211 $48.00FVH 2000204 IMPLANTED VAD FLUSH 96523 $165.00FVH 2000205 BLOOD DRAW IMPLANTED VAD 36591 $165.00FVH 2000208 DECLOT/THROMBO IMPL VAD 36593 $619.00FVH 2000211 CHEMOTHERAPY INF ADDL HR 96415 $177.00FVH 2000212 CHEMOTHERAPY IV PUSH 96409 $353.00FVH 2000215 IV INJECTION INITIAL 96374 $111.00FVH 2000223 IV INJECTION SUBSEQUENT 96375 $111.00FVH 2000224 CHEMOTHERAPY INJ SQ/IM NONHORM 96401 $127.00FVH 2000242 CIRCUMCISION >28 DAYS 54161 $190.00FVH 2000249 CIRCUMCISION NEONATE <=28 DAYS 54160 $190.00FVH 2000286 APPLICATION UNNA BOOT 29580 $240.00FVH 2000288 WOUND CARE LEVEL 1 99211 $50.00FVH 2000289 WOUND CARE LEVEL 2 99212 $138.00FVH 2000290 WOUND CARE LEVEL 3 99213 $265.00FVH 2000297 LABOR 0-4 HRS $1,251.00FVH 2000298 LABOR 5-8 HRS $1,743.00FVH 2000299 LABOR 9+ HRS $2,236.00FVH 2000314 CATH INSERT BLADDER SPEC P9612 $62.00FVH 2000316 BLADDER SCAN 51798 $209.00FVH 2000324 LEVEL 2 OP VISIT 99212 $134.00FVH 2000338 IV INJECTION EA ADD SAME DRUG 96376 $111.00FVH 2000341 LEVEL 3 OP VISIT 99213 $243.00FVH 2000342 LEVEL 4 OP VISIT 99214 $365.00FVH 2000343 LEVEL 5 OP VISIT 99215 $522.00FVH 2000345 CATH INSERT SMPL INDWELLING 51702 $62.00FVH 2000362 PORTA-CATH ACCESS FLUSH ONLY 99211 $62.00FVH 2000367 INF THERAPY MED INITIAL REC 96365 $160.00FVH 2000368 INF THERAPY MED ADDL HR REC 96366 $160.00FVH 2000410 NEWBORN HEARING SCREEN $15.00FVH 2000416 IV INJECTION INITIAL 760 96374 $111.00FVH 2000417 IV INJECTION SUBSEQUENT 760 96375 $111.00FVH 2000444 APPL MULTI LAYER VEN WND COMPR 29581 $367.00FVH 2000459 INF THERAPY HYD INITIAL O 96360 $136.00FVH 2000460 INF THERAPY HYD ADDL O 96361 $136.00FVH 2000461 INF THERAPY MED INITIAL O 96365 $160.00

1

FVH 2000467 INF THERAPY MED ADDL HR O 96366 $160.00FVH 2000488 LEVEL 4 WOUND CARE 99214 $406.00FVH 2000503 LEVEL 5 WOUND CARE 99215 $570.00FVH 2000509 ONC CLINIC LEVEL 1 99211 $50.00FVH 2000510 ONC CLINIC LEVEL 2 99212 $165.00FVH 2000511 ONC CLINIC LEVEL 3 99213 $279.00FVH 2000512 ONC CLINIC LEVEL 4 99214 $443.00FVH 2000513 ONC CLINIC LEVEL 5 99215 $632.00FVH 2000568 NEG PRESSURE WOUND DME <50 CM 97605 $315.00FVH 2000570 NEG PRESSURE WOUND DISP <50 CM 97607 $328.00FVH 2000571 NEG PRESSURE WOUND DISP >50 CM 97608 $355.00FVH 2001019 IMPLANTED VAD FLUSH MO 96523 $165.00FVH 2001050 BIOPSY & ASP DX BONE MARROW 38222 $450.00FVH 4000002 APPENDECTOMY $3,670.00FVH 4000003 BX BREAST PERCUTANEOUS $2,750.00FVH 4000004 BX OTHER $4,130.00FVH 4000005 RESC REPAIR REVIS $1,140.00FVH 4000007 CHOLECYSTECTOMY $4,130.00FVH 4000009 GI PROCEDURE $1,840.00FVH 4000010 RESECTION BOWEL COLON $4,130.00FVH 4000012 EXPLORATORY LAP $4,130.00FVH 4000015 COLOSTOMY $3,670.00FVH 4000018 REPAIR HERNIA $3,670.00FVH 4000024 EVACUATION HEMATOMA $2,750.00FVH 4000025 EXC PILONIDAL CYST $2,750.00FVH 4000031 RECTAL PROCEDURE $2,750.00FVH 4000033 MASTECTOMY SIMPLE $3,670.00FVH 4000038 ABDOMEN HYSTERECTOMY $4,570.00FVH 4000039 COLPOSCOPY CERVIX $2,300.00FVH 4000040 C-SECTION $4,130.00FVH 4000043 OOPHERECTOMY $4,130.00FVH 4000045 SALPINGECTOMY $4,570.00FVH 4000046 HYSTEROSCOPY $3,670.00FVH 4000052 OPEN REDUCTION $3,360.00FVH 4000053 AMPUTATION EXTREM $3,670.00FVH 4000054 AMPUTATION PHALANGIES $2,300.00FVH 4000060 EXCISION GANGLION $1,780.00FVH 4000061 FIXATION FEMORAL FX $2,500.00FVH 4000069 TENDON LIGAMENT NERVE REPAIR $2,650.00FVH 4000070 TOTAL HIP ARTHROPLASTY $5,590.00FVH 4000072 CARPAL TUNNEL TRIGGER FINGER $1,830.00FVH 4000073 TOTAL KNEE ARTHROPLASTY $5,490.00FVH 4000074 TOTAL SHOULDER ARTHROPLASTY $5,740.00FVH 4000075 REPAIR SHOULDER $1,780.00FVH 4000078 CIRCUMCISION $2,300.00FVH 4000080 CYSTOSCOPY/URETHROSCOPY $270.00FVH 4000081 HYDROCELECTOMY $2,750.00FVH 4000088 SUPRA PUBIC CYSTOTOMY $3,670.00FVH 4000099 SURGERY SINUS $3,200.00

2

FVH 4000101 LARYNGOSCOPY $1,130.00FVH 4000102 MYRINGOTOMY $740.00FVH 4000105 T & A $1,920.00FVH 4000109 TYMPAN W MASTOID $4,200.00FVH 4000118 REPAIR-REPLACE-REMOVE AV FISTU $2,750.00FVH 4000123 PLACEMENT PORTACATH $2,300.00FVH 4000173 I&D $1,780.00FVH 4000175 LACERATION WOUND CLOSURE $1,780.00FVH 4000176 EXCISION LUMP,CYST,ETC $1,780.00FVH 4000177 REMOVAL IMPLANTS/DEVICES $2,750.00FVH 4000235 UNLISTED PROCEDURE 1 $1,780.00FVH 4000236 UNLISTED PROCEDURE 2 $3,670.00FVH 4000237 UNLISTED PROCEDURE 3 $4,570.00FVH 4000238 UNLISTED PROCEDURE 4 $1,140.00FVH 4000240 UNLISTED PROCEDURE 6 $1,830.00FVH 4000269 LAPAROSCOPY $4,130.00FVH 4000270 ARTHROSCOPY $2,110.00FVH 4000396 SKIN GRAFT $1,780.00FVH 4000399 REDUCTION MAMMOPLASTY $4,330.00FVH 4000402 RHINOPLASTY $2,060.00FVH 4000403 SEPTOPLASTY $2,240.00FVH 4000534 ADDIT OR TIME $620.00FVH 4000600 INSERTION CHEST TUBE $2,300.00FVH 4000605 COLOSTOMY CLOSURE $3,670.00FVH 4000622 HYSTERECTOMY VAG LAP $5,490.00FVH 4000657 APPENDECTOMY LAPAROSCOPY $4,130.00FVH 4000661 REMOVAL LESION W/SCOPE $2,300.00FVH 4000682 COLONOSCOPY $1,840.00FVH 4000706 LAPAROSCOPIC CHOLECYSTECTOMY $5,490.00FVH 4000707 BLEPHAROPLASTY $2,750.00FVH 4000717 FRENULECTOMY $970.00FVH 4000723 RELEASE CONTRACTURE UPPER EXTR $1,830.00FVH 4000743 INFERIOR TURBINATE COBLATION $790.00FVH 4001086 RESECTION BOWEL COLON LAP $5,070.00FVH 4001123 KNEE REPAIR $1,780.00FVH 4001131 PANNICULECTOMY $2,160.00FVH 4001138 NECK CONTOURING $1,570.00FVH 5000008 EXCISION LUMP CYST $4,230.00FVH 5000016 LAP NISSEN FUNDOPLICATION $4,130.00FVH 5000017 ECTROPIAN REPAIR $1,400.00FVH 5000018 LACRIMAL DUCT PROBE $590.00FVH 5000021 D & C $2,300.00FVH 5000029 HEMORRHOIDECTOMY $2,750.00FVH 5000031 REMOVAL FB $1,780.00FVH 5000035 BUNIONECTOMY $2,300.00FVH 5000036 CARPAL/TARSAL TUNNEL RELEASE $1,830.00FVH 5000038 CLOSED REDUC W/WO PERC PINNING $1,830.00FVH 5000045 MINOR ORTHOPEDIC $1,760.00FVH 5000046 BX OTHER $3,200.00

3

FVH 5000049 DEBRIDEMENT CLOSURE WOUND $1,780.00FVH 5000050 SHOULDER REPAIR $3,980.00FVH 5000051 TENDON/NERVE/LIGAMENT REPAIR $3,200.00FVH 5000053 LAPAROSCOPIC HERNIA $4,570.00FVH 5000054 CATARACT EXTRACTION $5,620.00FVH 5000061 INJECTION LUMBAR $210.00FVH 5000086 UNLISTED PROCEDURE 1 $1,830.00FVH 5000088 UNLISTED PROCEDURE 3 $3,670.00FVH 5000089 UNLISTED PROCEDURE 4 $1,780.00FVH 5000090 UNLISTED PROCEDURE 5 $4,570.00FVH 5000091 UNLISTED PROCEDURE 6 $1,780.00FVH 5000092 UNLISTED PROCEDURE 7 $1,130.00FVH 5000122 OR BASIC ON CALL UNIT 1 HR $340.00FVH 5000648 ARTHROPLASTY INTERPOSITIONAL 25447 $1,800.00FVH 5000831 INCISION OF RECTAL ABSCESS 46040 $1,780.00FVH 5001711 REVISED COLOSTOMY: SIMPLE 44340 $2,379.00FVH 5001935 NASOPHARYNGOSCOPY $400.00FVH 5001936 LAP BOWEL HAND ASSIST $4,420.00FVH 5002062 BREAST RECONSTRUCTION $5,440.00FVH 5002063 ABDOMINAL LIPECTOMY $1,080.00FVH 5002135 RECONSTRUCT NAIL BED $1,800.00FVH 6000007 RECOVERY SIMPLE $390.00FVH 6000008 RECOVERY 0-2 HOURS $1,009.00FVH 6000009 RECOVERY 2-4 HOURS $1,203.00FVH 6000010 RECOVERY 4-6 HOURS $1,384.00FVH 6000011 RECOVERY 6-8 HOURS $1,567.00FVH 6000012 RECOVERY 8-10 HOURS $1,750.00FVH 6000013 RECOVERY 10-12 HOURS $1,931.00FVH 7000102 CPT 36620-CRNA SERV ARTER CATH 36620 $235.00FVH 7000109 INSERT PICC AGE 5YRS OR OLDER 36569 $410.00FVH 7000111 REPLACE TUNNELED PICC CATH 36584 $340.00FVH 7000169 INTUBATION 31500 $360.00FVH 7000170 IV START NOT IN SURGERY > 3 YR 36410 $45.00FVH 7000186 CPT 00103-CRNA SERVICE $18.00FVH 7000188 CPT 00120-CRNA SERVICE $18.00FVH 7000190 CPT 00126-CRNA SERVICE $18.00FVH 7000191 CPT 00140 CRNA SERVICE $18.00FVH 7000192 CPT 00142-CRNA SERVICE $18.00FVH 7000197 CPT 00160-CRNA SERVICE $18.00FVH 7000198 CPT 00162-CRNA SERVICE $18.00FVH 7000199 CPT 00164-CRNA SERVICE $18.00FVH 7000200 CPT 00170-CRNA SERVICE $18.00FVH 7000204 CPT 00190-CRNA SERVICE $18.00FVH 7000214 CPT 00300-CRNA SERVICE $18.00FVH 7000215 CPT 00320-CRNA SERVICE $18.00FVH 7000220 CPT 00400-CRNA SERVICE $18.00FVH 7000221 CPT 00402-CRNA SERVICE $18.00FVH 7000222 CPT 00404-CRNA SERVICE $18.00FVH 7000224 CPT 00410-CRNA SERVICE $18.00

4

FVH 7000225 CPT 00450-CRNA SERVICE $18.00FVH 7000234 CPT 00524-CRNA SERVICE $18.00FVH 7000238 CPT 00532-CRNA SERVICE $18.00FVH 7000263 CPT 00700-CRNA SERVICE $18.00FVH 7000266 CPT 00740-CRNA SERVICE $15.00FVH 7000267 CPT 00750-CRNA SERVICE $18.00FVH 7000268 CPT 00752-CRNA SERVICE $18.00FVH 7000272 CPT 00790-CRNA SERVICE $18.00FVH 7000277 CPT 00800-CRNA SERVICE $18.00FVH 7000278 CPT 00802-CRNA SERVICE $18.00FVH 7000279 CPT 00810-CRNA SERVICE $15.00FVH 7000281 CPT 00830-CRNA SERVICE $18.00FVH 7000282 CPT 00832-CRNA SERVICE $18.00FVH 7000286 CPT 00840-CRNA SERVICE $18.00FVH 7000288 CPT 00844-CRNA SERVICE $18.00FVH 7000289 CPT 00846-CRNA SERVICE $18.00FVH 7000291 CPT 00851-CRNA SERVICE $18.00FVH 7000292 CPT 00860-CRNA SERVICE $18.00FVH 7000294 CPT 00864-CRNA SERVICE $18.00FVH 7000303 CPT 00902-CRNA SERVICE $18.00FVH 7000307 CPT 00910-CRNA SERVICE $18.00FVH 7000312 CPT 00920-CRNA SERVICE $18.00FVH 7000313 CPT 00921-CRNA SERVICE $18.00FVH 7000323 CPT 00940-CRNA SERVICE $18.00FVH 7000325 CPT 00944-CRNA SERVICE $18.00FVH 7000326 CPT 00948-CRNA SERVICE $18.00FVH 7000328 CPT 00952-CRNA SERVICE $18.00FVH 7000329 CPT 01112-CRNA SERVICE $18.00FVH 7000339 CPT 01200-CRNA SERVICE $18.00FVH 7000340 CPT 01202-CRNA SERVICE $18.00FVH 7000341 CPT 01210-CRNA SERVICE $18.00FVH 7000343 CPT 01214-CRNA SERVICE $18.00FVH 7000346 CPT 01230-CRNA SERVICE $18.00FVH 7000349 CPT 01250-CRNA SERVICE $18.00FVH 7000354 CPT 01320-CRNA SERVICE $18.00FVH 7000356 CPT 01360-CRNA SERVICE $18.00FVH 7000357 CPT 01380-CRNA SERVICE $18.00FVH 7000358 CPT 01382-CRNA SERVICE $18.00FVH 7000360 CPT 01392-CRNA SERVICE $18.00FVH 7000361 CPT 01400-CRNA SERVICE $18.00FVH 7000362 CPT 01402-CRNA SERVICE $18.00FVH 7000370 CPT 01462-CRNA SERVICE $18.00FVH 7000372 CPT 01470-CRNA SERVICE $18.00FVH 7000375 CPT 01480-CRNA SERVICE $18.00FVH 7000384 CPT 01610-CRNA SERVICE $18.00FVH 7000385 CPT 01620-CRNA SERVICE $18.00FVH 7000387 CPT 01630-CRNA SERVICE $18.00FVH 7000391 CPT 01638-CRNA SERVICE $18.00FVH 7000399 CPT 01710-CRNA SERVICE $18.00

5

FVH 7000403 CPT 01730-CRNA SERVICE $18.00FVH 7000404 CPT 01732-CRNA SERVICE $18.00FVH 7000405 CPT 01740-CRNA SERVICE $18.00FVH 7000415 CPT 01810-CRNA SERVICE $18.00FVH 7000416 CPT 01820-CRNA SERVICE $18.00FVH 7000418 CPT 01830-CRNA SERVICE $18.00FVH 7000429 CPT 01922-CRNA SERVICE $18.00FVH 7000442 CPT 01961-CRNA SERVICE $18.00FVH 7000445 CPT 01965-CRNA SERVICE $18.00FVH 7000447 CPT 01967-CRNA SERVICE $18.00FVH 7000448 CPT 01968-CRNA SERVICE $18.00FVH 7000451 CPT 01991-CRNA SERVICE $450.00FVH 7000454 CPT 01996-CRNA SERVICE $330.00FVH 7000459 INJ EPIDURAL LUMBAR/SACRAL 62326 $375.00FVH 7000460 EPI STERIOD L/S INJEC 62322 $330.00FVH 7000461 INJ TENDON LIGAMENT 20550 $125.00FVH 7000462 ANESTH EPIDURAL BLOOD PATCH 62273 $330.00FVH 7000463 ANESTH CERVIAL PLEXUS INJ 64999 $330.00FVH 7000464 ANESTH BRACHIAL PLEXUS INJ 64415 $330.00FVH 7000466 ANESTH EXTREME AGE <1 OR > 70 99100 $55.00FVH 7000467 EMERGENT ANESTH 99140 $110.00FVH 7000468 SPINAL TAP 62270 $250.00FVH 7000474 INJ TRIGGER POINT 1 OR 2 20552 $125.00FVH 7000489 INJ GREATER OCCIPITAL NERVE 64405 $210.00FVH 7000490 INJ SACROILIAC JOINT 27096 $330.00FVH 7000491 INJ INTERM JT 20605 $125.00FVH 7000496 INJ LIGAMENT/TENDON 20551 $125.00FVH 7000497 INJ TRIGGER POINT 3 OR MORE 20553 $125.00FVH 7000498 ASPIR INJ MAJOR JT 20610 $130.00FVH 7000499 INJ LUMBAR SACRAL SINGLE LVL 64483 $375.00FVH 7000565 INJ ANES SCIATIC NERVE SINGLE 64445 $400.00FVH 7000570 INJ NERVE ROOT BLK LUMBAR EA 64484 $210.00FVH 7000571 INJ ANES SPHENOPALATINE GANGLI 64505 $330.00FVH 7000575 NEONATAL RESUSCITATION 99465 $450.00FVH 7000598 ANESTH COMPLIC BY HYPOTENSION 99135 $260.00FVH 7000686 INJ INTERCOSTAL NERVE 64420 $210.00FVH 7000694 INJ EPID CERV DX THER 62320 $375.00FVH 7000698 INJ NERVE ROOT BLK CERV THOR 64479 $460.00FVH 7000699 ASPIR INJ SM JT 20600 $125.00FVH 7000700 INSERT CVC NON-TUNNELED >5YR 36556 $313.00FVH 7000706 NERVE BLK STELLATE GANGLION 64510 $339.00FVH 7000707 INJECT FEMORAL NERVE 64447 $400.00FVH 7000709 INJ NERVE ROOT BLK CERV THOR E 64480 $250.00FVH 7000710 INJ INTERCOSTAL NERVE 64421 $330.00FVH 7000712 INJ FACET JNT CERV/THOR SNG LV 64490 $460.00FVH 7000713 INJ FACET JNT CERV/THOR 2ND LV 64491 $210.00FVH 7000714 INJ FACET JNT CERV/THOR 3RD LV 64492 $210.00FVH 7000715 INJ FACET JNT L/S SNG LEVEL 64493 $375.00FVH 7000716 INJ FACT JNT L/S 2ND LEVEL 64494 $165.00

6

FVH 7000717 INJ FACET JNT L/S 3RD LEVEL 64495 $165.00FVH 7000718 INJECT ANESTH AGENT OTH NERVE 64450 $350.00FVH 7000728 NERVE BLOCK AXILLARY NERVE 64417 $350.00FVH 7000731 VENIPUNCTURE MD NON ROUTINE 36406 $33.00FVH 7000737 INJ ILIONINGUINAL ILIOHYPOGAST 64425 $242.00FVH 7000738 INJECTION TMJ 21116 $275.00FVH 7000739 TRIGEMINAL NERVE INJECTION 64400 $385.00FVH 7000743 INJ ANES LUMBR\THRC PVRT SYM 64520 $330.00FVH 7000746 PAIN CLINIC EST PT LEVEL 3 99213 $90.00FVH 7000784 MUSCULOSKELETAL SYSTEM 20999 $135.00FVH 7000785 UNLISTED PROCEDURE,NERVOUS SYS 64999 $400.00FVH 7000797 INJECTION PLATELET PLASMA $250.00FVH 7000801 INJ TRANSVERSE ABD BIL 64488 $215.00FVH 7000802 INJ TRANSVERSE ABD SINGLE 64486 $125.00FVH 7000809 INJ SPINE CERV/THOR W IMG GDE 62321 $460.00FVH 7000810 INJ SPINE LUMBAR W IMG GUIDE 62323 $420.00FVH 7000812 INJ CATH L/S W IMG GUIDE 62327 $460.00FVH 7000813 MOD SED SAME PHYS/QHP 5/>YRS 99152 $50.00FVH 7000814 MOD SED SAME PHYS/QHP ADD 15 99153 $30.00FVH 7000816 INSRT PICC WO SQ PORT W IMG >5 36573 $405.00FVH 7001002 CPT 00731-CRNA SERVICE $15.00FVH 7001003 CPT 00732-CRNA SERVICE $15.00FVH 7001004 CPT 00811-CRNA SERVICE $15.00FVH 7001005 CPT 00812-CRNA SERVICE $15.00FVH 7001006 CPT 00813-CRNA SERVICE $15.00FVH 7001007 ASPIRATION/INJ GANGLION CYST 20612 $110.00FVH 7001010 MOD SED OTH PHYS/QHP >5 YRS 99156 $75.00FVH 7001011 ABLATION PERIPHERAL NERVE 64640 $400.00FVH 7001716 PARAVERTEBRAL BLOCK 64461 $320.00FVH 7001717 PARAVERTEBRAL BLOCK BI 6446150 $640.00FVH 7001718 PARAVERTEBRAL BLOCK ADDL INJ 64462 $175.00FVH 7001719 PARAVERTEBRAL BLOCK ADD INJ BI 6446250 $350.00FVH 9000036 PAIN CLINIC TREATMENT LEVEL 1 $150.00FVH 9000037 OUTPATIENT SURGERY $631.00FVH 9000069 COLONOSCOPY $1,543.00FVH 9000072 FLEXIBLE SIGMOIDOSCOPY $824.00FVH 9000139 CYSTOSCOPY 52000 $317.00FVH 9000155 TELEHEALTH FACILITY FEE Q3014 $32.00FVH 9000162 DEBRIDE WOUND SELECTIVE < 20 97597 $190.00FVH 9000199 COLONOSCOPY W/BIOPSY $1,750.00FVH 9000200 EGD W/BIOPSY $1,750.00FVH 9000201 EXTRACAPSULAR CAT EXT W LENS $1,604.00FVH 9000261 CHANGE GASTROSTOMY TUBE 43762 $73.00FVH 9000279 GASTROSCOPY $1,543.00FVH 9000305 OPTHAL PHOTO COAGULATION BILAT $3,207.00FVH 9000503 RHYTHM STRIP 93041 $254.00FVH 9000514 ESOPHAGEAL DILATION $425.00FVH 9000527 COLPOSCOPY $450.00FVH 9000528 COLPOSCOPY BX $863.00

7

FVH 9000529 ENDOMETRIAL ABLATION $1,033.00FVH 9000530 INJECTION PLATELET PLASMA $155.00FVH 9000534 EMERGENCY CALL-BACK $255.00FVH 9000612 ADIPOCELL PROCEDURE NON COV $1,000.00FVH 9000615 DESTROY HEMORRHOIDS 46946 $2,187.00FVH 9000617 ADIPOCELL PROC COLLECTION/BANK $2,110.00FVH 10000003 BLOOD PRODUCT THAWING 86927 $163.00FVH 10000008 CELL COUNT W/DIFF BODY FLD 89051 $141.00FVH 10000010 CRYSTALS SYNOVIAL FUID EXAM 89060 $141.00FVH 10000011 NASAL SMEAR FOR EOSINOPHILS 89190 $141.00FVH 10000012 SEMEN ANALYSIS AND/OR MOTILITY 89321 $141.00FVH 10000013 OCCULT BLD COLORECTAL SCR WAIV 82270 $55.00FVH 10000014 ACETONE/KETONES SERUM QUAL 82009 $55.00FVH 10000015 ACETONE/KETONES SERUM QUANT 80320 $73.00FVH 10000016 ALBUMIN SERUM 82040 $42.00FVH 10000017 ALBUMIN OTH SOURCE 82042 $55.00FVH 10000018 ALCOHOL/ETHANOL 80307 $105.00FVH 10000019 ALKALINE PHOSPHATASE 84075 $42.00FVH 10000020 AMMONIA 82140 $55.00FVH 10000022 AMYLASE SERUM 82150 $55.00FVH 10000023 AMYLASE URINE 82150 $55.00FVH 10000024 BILIRUBIN TOTAL 82247 $55.00FVH 10000025 BILIRUBIN DIRECT 82248 $55.00FVH 10000026 BLOOD GAS W/O OXIMETRY 82803 $55.00FVH 10000027 BLOOD GASES W/02 SATURATION 82805 $55.00FVH 10000028 B TYPE NATRIURETIC PEPTIDE 83880 $200.00FVH 10000029 UREA NITROGEN BLOOD 84520 $42.00FVH 10000030 CALCIUM TOTAL 82310 $42.00FVH 10000031 CALCIUM TOTAL FLUID 82310 $42.00FVH 10000032 CALCIUM 24 HOUR URINE 82340 $55.00FVH 10000033 CARBON MONOXIDE BLOOD 82375 $55.00FVH 10000034 CHLORIDE BLOOD 82435 $42.00FVH 10000035 CHLORIDE OTHER SOURCE 82438 $55.00FVH 10000036 CHLORIDE URINE 82436 $42.00FVH 10000037 CHOLESTEROL FLUID 84311 $7.00FVH 10000038 CHOLESTEROL BLOOD 82465 $42.00FVH 10000039 CPK TOTAL 82550 $55.00FVH 10000040 CREATININE BLOOD 82565 $55.00FVH 10000041 CREATININE URINE 82570 $55.00FVH 10000042 CREATININE OTH SOURCE 82570 $8.00FVH 10000043 CREATININE CLEARANCE 82575 $55.00FVH 10000046 DRUG SCREEN SINGLE DRUG CLASS 80307 $105.00FVH 10000047 ELECTROLYTE PANEL 80051 $55.00FVH 10000050 PROTEIN ELECTROPHORESIS 84165 $55.00FVH 10000051 PROTEIN ELECTROPHORESIS URINE 84166 $200.00FVH 10000052 ESTRADIOL 82670 $93.00FVH 10000053 GLUCOSE BLOOD 82947 $42.00FVH 10000054 GLUCOSE BODY FLUIDS 82945 $55.00FVH 10000055 GLUCOSE POST DOSE 82950 $42.00

8

FVH 10000056 GLUCOSE TOL 1ST 3 SPECIMENS 82951 $55.00FVH 10000057 GLUCOSE TOL ADDL SPEC #1 82952 $42.00FVH 10000058 GLUCOSE TOL ADDL SPEC #2 82952 $42.00FVH 10000059 GLUCOSE TOL ADDL SPEC #3 82952 $42.00FVH 10000063 GGT 82977 $42.00FVH 10000064 HDL CHOLESTEROL 83718 $55.00FVH 10000065 IMMUNOGLOBULIN EACH G/A/M/D 82784 $200.00FVH 10000068 IRON SERUM 83540 $55.00FVH 10000069 IRON BINDING CAPACITY 83550 $55.00FVH 10000070 LACTIC ACID 83605 $200.00FVH 10000071 LDH 83615 $42.00FVH 10000072 LDH BODY FLUIDS 83615 $42.00FVH 10000073 LIPASE 83690 $55.00FVH 10000074 LIPID PANEL 80061 $97.00FVH 10000075 LITHIUM 80178 $73.00FVH 10000076 MAGNESIUM 24 HR URINE 83735 $55.00FVH 10000077 MAGNESIUM 83735 $55.00FVH 10000079 METHEMOGLOBIN QUANT 83050 $200.00FVH 10000080 MICROALBUMIN QUANT 82043 $37.00FVH 10000082 OSMOLALITY BLOOD 83930 $55.00FVH 10000083 OSMOLALITY URINE 83935 $55.00FVH 10000084 PTH 83970 $93.00FVH 10000085 PHOSPHORUS SERUM 84100 $42.00FVH 10000086 PHOSPHORUS URINE 84105 $55.00FVH 10000087 POTASSIUM BLOOD 84132 $42.00FVH 10000088 POTASSIUM URINE 84133 $55.00FVH 10000089 POTASSIUM OTH SOURCE 84999 $55.00FVH 10000090 PROGESTERONE 84144 $72.00FVH 10000091 PROTEIN BODY FLUIDS 84157 $55.00FVH 10000092 PROTEIN BLOOD 84155 $42.00FVH 10000093 PROTEIN CSF 84157 $55.00FVH 10000094 PROTEIN URINE 84156 $55.00FVH 10000095 SALICYLATE 80307 $105.00FVH 10000096 AST SGOT 84450 $42.00FVH 10000097 ALT SGPT 84460 $42.00FVH 10000098 HEPATIC FUNCTION PANEL 80076 $97.00FVH 10000099 COMPREHENSIVE METABOLIC PANL 80053 $97.00FVH 10000100 BASIC METABOLIC PANEL 80048 $97.00FVH 10000101 SODIUM BLOOD 84295 $42.00FVH 10000103 SODIUM URINE 84300 $55.00FVH 10000104 TESTOSTERONE TOTAL 84403 $93.00FVH 10000105 TRIGLYCERIDE FLUID 84478 $9.00FVH 10000106 TRIGLYCERIDES 84478 $42.00FVH 10000107 RENAL FUNCTION PANEL 80069 $97.00FVH 10000108 ACUTE HEPATITIS PANEL 80074 $97.00FVH 10000109 HOMOCYSTEINE 83090 $93.00FVH 10000110 URIC ACID BLOOD 84550 $42.00FVH 10000111 HEMOGLOBIN A1C 83036 $55.00FVH 10000112 URINALYSIS AUTO W/MICRO 81001 $37.00

9

FVH 10000113 SPECIFIC GRAVITY URINE 81003 $31.00FVH 10000114 PH BODY FLUID EXCEPT BLOOD 83986 $55.00FVH 10000115 PROTEIN URINE AUTOMATED 81003 $31.00FVH 10000117 KETONE URINE AUTOMATED 81003 $31.00FVH 10000120 RED SUBSTANCE URINE 81002 $31.00FVH 10000121 URINALYSIS MICRO ONLY 81015 $37.00FVH 10000122 URINALYSIS AUTO W/O SCOPE 81003 $31.00FVH 10000123 OCCULT BLOOD PEROXIDASE WAIVED 82272 $42.00FVH 10000124 GLUCOSE URINE 82945 $55.00FVH 10000127 SPECIFIC GRAVITY OTH SOURCE 84315 $55.00FVH 10000128 CARBAMAZEPINE 80156 $73.00FVH 10000129 PHENOBARBITAL 80184 $73.00FVH 10000130 PHENYTOIN TOTAL 80185 $73.00FVH 10000131 ACETAMINOPHEN 80307 $105.00FVH 10000132 THEOPHYLLINE 80198 $73.00FVH 10000136 VALPROIC ACID 80164 $73.00FVH 10000137 ISOPROPANOL 80320 $73.00FVH 10000138 METHANOL 80320 $73.00FVH 10000139 METHOTREXATE 80299 $73.00FVH 10000140 PH BLOOD 82800 $55.00FVH 10000141 BICARBONATE 82374 $42.00FVH 10000143 HCG BETA QUAN SERUM 84702 $72.00FVH 10000144 HCG BETA QUAL URINE WAIVED 81025 $37.00FVH 10000145 URIC ACID OTH SOURCE 84560 $55.00FVH 10000148 UREA NITROGEN URINE 84540 $55.00FVH 10000150 CEA 82378 $55.00FVH 10000151 VANCOMYCIN 80202 $73.00FVH 10000153 T4 FREE 84439 $72.00FVH 10000154 CPK MB FRACTION 82553 $200.00FVH 10000155 PREALBUMIN 84134 $55.00FVH 10000156 PSA TOTAL 84153 $55.00FVH 10000157 ETHYLENE GLYCOL 82693 $91.00FVH 10000158 CYCLOSPORINE 80158 $73.00FVH 10000159 MYOGLOBIN 83874 $200.00FVH 10000160 TROPONIN, QUANT 84484 $200.00FVH 10000161 TACROLIMUS 80197 $73.00FVH 10000162 PSA SCREEN G0103 $55.00FVH 10000164 FSH 83001 $93.00FVH 10000165 LH 83002 $93.00FVH 10000166 PROLACTIN 84146 $93.00FVH 10000167 KAPPA LIGHT CHAIN 83883 $108.00FVH 10000168 LAMBDA LIGHT CHAIN 83883 $108.00FVH 10000169 HAPTOGLOBIN QUANT 83010 $200.00FVH 10000173 FETAL FIBRONECTIN 82731 $200.00FVH 10000174 CORTISOL TOTAL 82533 $93.00FVH 10000175 DIGOXIN 80162 $73.00FVH 10000176 FOLIC ACID BLOOD 82746 $55.00FVH 10000177 B12 82607 $72.00FVH 10000178 GENTAMICIN 80170 $73.00

10

FVH 10000180 T3 FREE 84481 $72.00FVH 10000181 TSH 84443 $72.00FVH 10000182 TOBRAMYCIN 80200 $73.00FVH 10000183 FERRITIN 82728 $55.00FVH 10000184 HCG BETA QUAL 84703 $55.00FVH 10000185 ANTIBODY SCREEN 86850 $76.00FVH 10000186 ANTIBODY ELUTION RBC EA 86860 $76.00FVH 10000188 RBC ANTIBODY IDENTIF PANEL 86870 $76.00FVH 10000189 COOMBS TEST DIRECT 86880 $76.00FVH 10000190 ANTIBODY TITER 86886 $76.00FVH 10000192 WARM AUTO ABSORPTION 86978 $163.00FVH 10000193 BLOOD TYPING ABO 86900 $163.00FVH 10000194 BLOOD TYPING RH D 86901 $163.00FVH 10000195 BLOOD TYPING RBC AG EA 86905 $163.00FVH 10000197 CROSSMATCH IMMED SPIN 86920 $163.00FVH 10000198 CROSSMATCH AHG 86922 $163.00FVH 10000199 HEP B SURFACE ANTIBODY 86706 $55.00FVH 10000202 HIV I 86701 $16.00FVH 10000203 HIV 2 86702 $16.00FVH 10000204 RUBELLA IGG 86762 $76.00FVH 10000205 RHEUMATOID FACTOR QUANT 86431 $76.00FVH 10000206 R P R 86592 $76.00FVH 10000207 C3 COMPLEMENT 86160 $76.00FVH 10000208 C4 COMPLEMENT 86160 $76.00FVH 10000209 C-REACTIVE PROTEIN HIGH SENS 86141 $55.00FVH 10000210 C-REACTIVE PROTEIN 86140 $76.00FVH 10000214 HEP B CORE ANTIBODY TOTAL 86704 $55.00FVH 10000215 HEP A ANTIBODY IGM 86709 $55.00FVH 10000216 CA 125 86304 $107.00FVH 10000217 INFECTIOUS MONO TEST 86308 $76.00FVH 10000218 IMMUNOFIX ELECTROPH SERUM 86334 $108.00FVH 10000219 HEP B CORE ANTIBODY IGM 86705 $55.00FVH 10000221 HEP C ANTIBODY 86803 $55.00FVH 10000224 ANTINUCLEAR ANTI ANA SCREEN 86038 $55.00FVH 10000226 ANTISTREPTOLYSIN O TITER 86060 $76.00FVH 10000227 DNA ABY DOUBLE STRAND 86225 $76.00FVH 10000230 CENTROMERE ABY 86235 $108.00FVH 10000231 HISTONE ANTIBODY 86235 $108.00FVH 10000232 JO-1 ENA ANTIBODY 86235 $108.00FVH 10000233 RNP ENA ANTIBODY 86235 $108.00FVH 10000234 SCL70 ENA ANTIBODY 86235 $108.00FVH 10000235 SMITH ENA ANTIBODY 86235 $108.00FVH 10000236 SSA ENA ANTIBODY 86235 $108.00FVH 10000237 SSB ENA ANTIBODY 86235 $108.00FVH 10000239 CMV ANTIBODY IGM 86645 $108.00FVH 10000240 CMV ANTIBODY IGG 86644 $108.00FVH 10000241 MYCOPLASMA ANTIBODY IGM 86738 $108.00FVH 10000243 CMV IGG AND IGM 86644 $108.00FVH 10000245 RHOGAM FETAL SCREEN 85461 $51.00

11

FVH 10000246 TRANFUSION REACTION WORKUP 86078 $90.00FVH 10000249 HEMATOCRIT 85014 $51.00FVH 10000250 PLATELET COUNT AUTOMATED 85049 $51.00FVH 10000251 HEMOGLOBIN 85018 $51.00FVH 10000252 HEPARIN XA 85520 $29.00FVH 10000255 CBC W/AUTO DIFF 85025 $51.00FVH 10000257 WBC AUTOMATED 85048 $51.00FVH 10000258 WBC AUTO DIFF 85004 $51.00FVH 10000259 WBC MANUAL DIFF 85007 $51.00FVH 10000261 EOSINOPHIL COUNT 85048 $7.00FVH 10000263 FACTOR V 85220 $392.00FVH 10000265 FACTOR VIII 85240 $85.00FVH 10000270 FIBRINOGEN 85384 $38.00FVH 10000272 BL SMEAR W/O DIFF WBC COUNT 85008 $51.00FVH 10000273 PLATELET FUNCTION EPI 85576 $85.00FVH 10000274 PLATELET FUNCTION ADP 85576 $85.00FVH 10000280 LUPUS ANTICOAGULANT 85705 $85.00FVH 10000282 APTT 85730 $38.00FVH 10000284 PROTHROMBIN TIME 85610 $38.00FVH 10000285 RETICULOCYTE COUNT AUTOMATED 85045 $51.00FVH 10000287 SEDIMENTATION RATE AUTOMATED 85652 $51.00FVH 10000288 THROMBIN TIME 85670 $38.00FVH 10000289 RBC SICKLE CELL TEST 85660 $51.00FVH 10000290 CBC W/O AUTO DIFF 85027 $51.00FVH 10000292 KLEIHAUER STAIN 85460 $96.00FVH 10000293 WBC FECAL 89055 $51.00FVH 10000294 REPTILASE 85635 $96.00FVH 10000297 D-DIMER QUANT 85379 $85.00FVH 10000308 CULTURE BLOOD 87040 $107.00FVH 10000309 CULTURE STOOL 87045 $41.00FVH 10000310 CULTURE STOOL ECOLI ADDL 87046 $41.00FVH 10000311 CULTURE STOOL CAMPY ADDL 8704659 $41.00FVH 10000312 CULTURE BACTERIA OTH 87070 $41.00FVH 10000313 CULTURE BACTERIA QUANT OTH 87071 $41.00FVH 10000314 CULTURE ANAEROBE EXEPT BLD 87075 $41.00FVH 10000315 BACTI ID ANAEROBIC 87076 $41.00FVH 10000316 BACTERIAL ID 87077 $41.00FVH 10000317 URINE CULT PRESUMP ID 87077 $41.00FVH 10000318 CULTURE SINGLE ORGANISM SCR 87081 $41.00FVH 10000319 CULTURE URINE W COL COUNT 87086 $41.00FVH 10000320 CULTURE FUNGUS OTH THAN BLD 87102 $41.00FVH 10000321 FUNGAL ID BIOCHEMICAL EA YEAST 87106 $41.00FVH 10000322 CULTURE SEROL TYPING AGN 1 87147 $41.00FVH 10000323 CULTURE SEROL TYPING AGN 2 87147 $41.00FVH 10000324 CULTURE SEROL TYPING AGN 3 87147 $41.00FVH 10000325 CULTURE SEROL TYPING AGN 4 87147 $41.00FVH 10000326 CULTURE SEROL TYPING AGN 5 87147 $41.00FVH 10000327 CULTURE SEROL TYPING AGN 6 87147 $17.00FVH 10000330 PARASITE MACROSCOPIC EXAM 87169 $41.00

12

FVH 10000331 PIN WORM MACROSCOPIC EXAM 87172 $41.00FVH 10000332 OVA AND PARASITES DIR SMEAR 87177 $8.00FVH 10000333 OVA AND PARASITES SMEARS 87177 $41.00FVH 10000335 SENS AGAR DIFFUSION 87181 $41.00FVH 10000337 SENS AGAR DIFFUSION CLINDAMYC 87181 $7.00FVH 10000338 MICROBE SUSCEPTIBLE DISK 87184 $41.00FVH 10000339 SUSCEPTIBLE ENZYME MICROBE 87185 $41.00FVH 10000340 MINIMUM INHIBITORY CONC 87186 $41.00FVH 10000341 SMEAR GRAM STAIN 87205 $41.00FVH 10000346 RSV 87807 $41.00FVH 10000347 ROTAVIRUS 87425 $76.00FVH 10000349 STREP PNEUM URINE AGN 87449 $76.00FVH 10000350 SMEAR INCLUSION BODIES 87207 $41.00FVH 10000351 LEGIONELLA ANTIGEN URINE 87449 $76.00FVH 10000353 WET MOUNT FOR INFECTIOUS AGENT 87210 $41.00FVH 10000354 KOH SKIN HAIR NAILS 87220 $41.00FVH 10000356 CLOSTRIDIUM DIFFICILE TOXIN 87324 $76.00FVH 10000357 CRYPTOSPORIDIUM AGN 87328 $76.00FVH 10000358 GIARDIA ANTIGEN 87329 $76.00FVH 10000359 CHLAMYDIA DNA AMP PROBE 87491 $76.00FVH 10000361 N GONORRHOEAE DNA AMP PROBE 87591 $107.00FVH 10000364 SMEAR PRIMARY SOURCE CELL TYPE 87205 $41.00FVH 10000365 HEP B SURFACE AGN 87340 $76.00FVH 10000367 T4 TOTAL 84436 $72.00FVH 10000373 TRICHROME STAIN FOR OP 87209 $55.00FVH 10000377 CRYOPRECIPITATE P9012 $100.00FVH 10000378 PLATELET PHERESIS LEUK RED IRR P9037 $1,100.00FVH 10000379 PLATELET PHERESIS LEUKO REDUC P9035 $1,100.00FVH 10000380 PLATELET PHERESIS P9034 $1,100.00FVH 10000382 PLASMA FRESH FROZEN P9017 $100.00FVH 10000386 PACKED RBCS PROCESS/STORAGE P9021 $400.00FVH 10000387 PLATELET CONCENTRATE P9019 $100.00FVH 10000389 POOLING BLOOD PLATELETS 86965 $163.00FVH 10000393 BX BONE MARROW NEEDLE/TROCAR 38221 $1,313.00FVH 10000394 RH IMMUNE GLOBULIN DOSE 90384 J2790 $237.00FVH 10000395 PHLEBOTOMY THERAPEUTIC 99195 $469.00FVH 10000397 IMMUNOFIX ELECTROPH FLUID 86335 $108.00FVH 10000413 MYELOPEROXIDASE 83516 $200.00FVH 10000414 PROTEASE 3 83516 $76.00FVH 10000415 HSV DNA AMP PROBE 87529 $107.00FVH 10000416 OCCULT BLOOD DIAGNOSTIC 82272 $5.00FVH 10000418 CONCENTRATION FOR INFECT AGENT 87015 $41.00FVH 10000421 BREATH ALCOHOL TESTING $40.00FVH 10000431 URINE COLLECTION ONLY $30.00FVH 10000435 ARTERIAL PUNCTURE 36600 $31.00FVH 10000437 HEALTH SCREEN PANEL $22.00FVH 10000439 HEALTH SCREEN - BUSINESS $257.00FVH 10000445 DRUG SCREEN URINE RAPID 80305 $64.00FVH 10000452 RED BLOOD CELLS LEKOREDUCED P9016 $400.00

13

FVH 10000453 CULTURE FUNGAL HAIR SKIN NAIL 87101 $41.00FVH 10000458 PLATE INTEPRET ONLY (ID CLIENT 87999 $41.00FVH 10000459 OB PANEL 80055 $97.00FVH 10000462 SEDIMENTATION RATE NON AUTO 85651 $51.00FVH 10000474 RSV BY EIA WAIVED $41.00FVH 10000475 CROSSMATCH 37 DEGREE 86921 $163.00FVH 10000476 GENERAL HEALTH PANEL 80050 $97.00FVH 10000478 MICROALBUMIN SEMI QUANT 82044 $37.00FVH 10000479 CLO TEST WAIVED $41.00FVH 10000480 CAPILLARY STICK 36416 $17.00FVH 10000481 RBC 85041 $51.00FVH 10000483 H PYLORI AB 86318 $108.00FVH 10000487 ALCOHOLSAL 80305 $73.00FVH 10000490 HIV 1,2 SINGLE ASSAY 86703 $76.00FVH 10000502 STREP GROUP A RAPID WAIVED $41.00FVH 10000503 POC BLOOD OCCULT GASTRIC WAIVE $42.00FVH 10000515 REGIONAL BUSINESS UDS $50.00FVH 10000516 HEALTHSCREEN GLUCOSE $55.00FVH 10000517 HEALTHSCREEN LIPID PANEL $98.00FVH 10000518 CMV QUANT BY PCR 87497 $107.00FVH 10000520 STREP GROUP A RAPID NON WAIVED 87880 $41.00FVH 10000521 PSA FREE 84154 $55.00FVH 10000522 HOMOGENIZATION TISSUE 87176 $41.00FVH 10000525 FUNGAL ID EA ORGANISM, MOLD 87107 $107.00FVH 10000527 PERIPH BLOOD SMEAR INTRP/PROC 85060 $25.00FVH 10000529 RBC PACKED LEUKO-REDUC,IRRAD P9040 $400.00FVH 10000530 BLOOD TYPING RBC AG UNIT 86902 $163.00FVH 10000548 EBV BY PCR QUANT 87799 $107.00FVH 10000549 STREPTOZYME TITER 86406 $76.00FVH 10000552 PARAGONIMIASIS ANTIBODY 86682 $76.00FVH 10000561 CANDIDA SPECIES DNA PROBE 87480 $76.00FVH 10000562 GARDNERELLA VAGINALIS DNA PRB 87510 $107.00FVH 10000563 TRICHOMONAS VAGINALIS DNA PRB 87660 $107.00FVH 10000566 PAMG 1 CERV/VAGINAL SECRETION 84112 $200.00FVH 10000567 PROCESSING FEE 99001 $20.00FVH 10000571 URINE DIP STICK 81002 $31.00FVH 10000576 INFLUENZA A or B 87804 $41.00FVH 10001063 RBC PACKED LEUKO-REDUC IRR CMV P9058 $400.00FVH 10001117 CORTISOL TOTAL SALIVARY 82533 $93.00FVH 10001119 IFOB WAIVED $42.00FVH 10001122 VIRUS AG POLYVALENT 87300 $76.00FVH 10001123 ADENOVIRUS ISOLATION 87254 $107.00FVH 10001124 RSV ISOLATION 87254 $107.00FVH 10001125 INFLUENZA A ISOLATION 87254 $107.00FVH 10001126 INFLUENZA B ISOLATION 87254 $107.00FVH 10001127 PARAINFLU 1 ISOLATION 87254 $107.00FVH 10001128 PARAINFLU 2 ISOLATION 87254 $107.00FVH 10001129 PARAINFLU 3 ISOLATION 87254 $107.00FVH 10001130 ADENOVIRUS DFA 87260 $76.00

14

FVH 10001131 RSV DFA 87280 $76.00FVH 10001132 INFLUENZA A DFA 87276 $76.00FVH 10001133 INFLUENZA B DFA 87275 $76.00FVH 10001134 PARAINFLUENZA 1 DFA 87279 $76.00FVH 10001135 PARAINFLUENZA 2 DFA 8727959 $76.00FVH 10001136 PARAINFLUENZA 3 DFA 8727959 $76.00FVH 10001137 CMV ISOLATION SHELL VIAL 87254 $107.00FVH 10001138 HSV ISOLATION SHELL VIAL 87254 $107.00FVH 10001146 VITAMIN D 25 OH 82306 $200.00FVH 10001177 FLOW CYTOMETRY FIRST MARKER 88184 $150.00FVH 10001178 CMV IGM 86645 $108.00FVH 10001179 LYME DISEASE ANTIBODY 86618 $108.00FVH 10001180 EPSTEIN BARR CAPSID IGG 86665 $108.00FVH 10001181 EPSTEIN BARR CAPSID IGM 86665 $108.00FVH 10001182 EPSTEIN BARR NUCLEAR ANTIGEN 86664 $108.00FVH 10001183 EPSTEIN BARR EARLY ANTIGEN 86663 $108.00FVH 10001184 VARICELLA ZOSTER IGG 86787 $76.00FVH 10001185 HUMAN GROWTH HORMONE 83003 $93.00FVH 10001278 FLOW CYTOMETRY EA ADDIT MARKER 88185 $50.00FVH 10001279 SHIGA TOXIN BROTH ENRICHMENT 87015 $41.00FVH 10001280 SHIGA TOXIN 1 87899 $41.00FVH 10001281 SHIGA TOXIN 2 8789959 $41.00FVH 10001291 AFP TM 82105 $200.00FVH 10001293 CITRULLINE ANTIBODY 86200 $76.00FVH 10001296 HEP B SURFACE AGN CONFIRM 87341 $76.00FVH 10001298 INFLUENZA A PCR 87798 $107.00FVH 10001299 MALARIA ANTIGEN 87449 $76.00FVH 10001300 C PEPTIDE 84681 $200.00FVH 10001301 CA 19-9 86301 $107.00FVH 10001302 CERULAPLASMIN 82390 $200.00FVH 10001303 DHEAS 82627 $93.00FVH 10001304 IMMUNOGLOBULIN E 82785 $200.00FVH 10001305 INSULIN 83525 $72.00FVH 10001306 LDL CHOLESTEROL DIRECT 83721 $55.00FVH 10001307 SIROLIMUS 80195 $73.00FVH 10001308 PLATELETS LEUKOCYTE REDUCED P9031 $100.00FVH 10001312 LEAD BLOOD 83655 $64.00FVH 10001317 HIV 1 & 2 SCREEN 87389 $76.00FVH 10001319 FRUCTOSAMINE 82985 $200.00FVH 10001320 BETA 2 MICROGLOBULIN 82232 $93.00FVH 10001324 COOMBS IGG 86880 $7.00FVH 10001332 CLOSTRIDIUM DIFFICILE ANTIGEN 87449 $76.00FVH 10001334 AFB CULTURE 87116 $107.00FVH 10001335 AFB SMEAR 87206 $41.00FVH 10001338 INFLUENZA B ANTIGEN QW $41.00FVH 10001339 INFLUENZA A ANTIGEN QW $41.00FVH 10001340 B CELLS TOTAL SS5 86355 $108.00FVH 10001342 CD4 AND CD8 ABS CNT SS4 86360 $99.00FVH 10001343 NK CELLS TOTAL SS5 86357 $108.00

15

FVH 10001344 T CELLS TOTAL 86359 $108.00FVH 10001345 T CELL TOTAL SS4 86359 $99.00FVH 10001346 T CELLS TOTAL SS5 86359 $108.00FVH 10001347 CD4 AND CD8 ABS CNT SS5 86360 $108.00FVH 10001348 C DIFF BY PCR 87493 $76.00FVH 10001349 IFOB SCREEN WAIVED $42.00FVH 10001355 TB SKIN TEST 86580 $76.00FVH 10001358 HIV1AG/HIV12AB SNG RSLT 87389 $76.00FVH 10001360 HCG TUMOR MARKER 84702 $72.00FVH 10001361 LACTOSE TOLERANCE 82951 $55.00FVH 10001362 BODEANS DRUG TEST NO MRO 80305 $25.00FVH 10001363 WELLS DRUG TEST MRO 80305 $45.00FVH 10001364 WELLS DRUG TEST NO MRO 80305 $25.00FVH 10001365 BODEANS DRUG TEST MRO 80305 $45.00FVH 10001366 REGIONAL BUSINESS DOT UDS $50.00FVH 10001369 KOH OTHER SOURCE 87210 $41.00FVH 10001371 GLIADIN 83516 $76.00FVH 10001372 THYROID PEROXIDASE ABY 86376 $93.00FVH 10001374 TISSUE TRANSGLUTAMINASE 83516 $76.00FVH 10001403 CA 27-29 86300 $66.00FVH 10001437 HEP C RNA PCR QUANT 87522 $107.00FVH 10001439 CULTURE MRSA SCREEN 87081 $41.00FVH 10001440 CULTURE GC SCREEN 87081 $41.00FVH 10001441 CULTURE GROUP B SCREEN 87081 $41.00FVH 10001442 CULTURE GROUP A SCREEN 87081 $41.00FVH 10001443 CULTURE VRE SCREEN 87081 $41.00FVH 10001444 CULTURE CRE SCREEN 87081 $41.00FVH 10001451 CA 15-3 86300 $107.00FVH 10001452 TBING QUANTIFERON 86481 $150.00FVH 10001454 LEVETIRACETAM 80177 $73.00FVH 10001461 GLOM BASE MEMBRANE ABY 83516 $76.00FVH 10001464 FACTOR V LEIDEN MUT 81241 $108.00FVH 10001465 PROTHROMBIN MUT 81240 $108.00FVH 10001466 HEP B NA QUAN 87517 $107.00FVH 10001467 HIV 1 NA QUAN 87536 $206.00FVH 10001468 KETONE WHOLE BLOOD 82010 $31.00FVH 10001469 BK VIRUS QUANT PCR 87799 $107.00FVH 10001476 HEPATITIS C SCREEN 86803 $23.00FVH 10001480 MTHFR (FOLIC ACID CONVERSION) 81291 $108.00FVH 10001487 DRUG SCREEN MULTICHANNEL ASSAY 80307 $125.00FVH 10001489 RESPIRATORY VIRUS PCR MULTIPLX 87633 $624.00FVH 10001490 MYCO PNEUMO AMP PROBE 87581 $52.00FVH 10001491 CHYLMD PNEUM AMP PROBE 87486 $52.00FVH 10001492 BORD PERTUSIS AMP PROBE 87798 $52.00FVH 10001493 PROCALCITONIN 84145 $307.00FVH 10001500 EBV BY PCR QUAL 87798 $66.00FVH 10001503 BACTERIAL ID MOLDI-TOF 87077 $41.00FVH 10001504 BACTERIAL ID ANAEROB MOLDI-TOF 87076 $13.00FVH 10001505 FUNGLA ID YEAST MOLDI-TOF 87106 $26.00

16

FVH 10001512 OB PANEL WITH HIV 80081 $173.00FVH 10001514 ALCOHOL/ETHANOL AUTO ANALYZER 80307 $105.00FVH 10001515 DRUG SCREEN URINE DIRECT OBV 80305 $64.00FVH 10001533 PHARMACOGENOMIC GENO 81479 $176.00FVH 10001535 H PYLORI AG STOOL 87338 87338 $84.00FVH 10001542 EVEROLIMUS 80169 80169 $141.00FVH 10001543 DRUG SCREEN DIRECT OBV WAIVED $20.00FVH 10001544 TREPONEMA PALLIDUM EIA 86780 $20.00FVH 10001558 ANTINUCLEAR ANTIBODY IFA 86039 $20.00FVH 10001565 ALPHA 1 ANTITRYPSIN 82103 $25.00FVH 10001566 BORD PARAPERT AMP PROBE 87798 $53.00FVH 10001574 CULTURE ID BY NA AMPPROBE EACH 87150 $60.00FVH 10001576 RESPIR PATH 21 TARGETS BIOFIRE $758.22FVH 10900384 PLATELET CONC IRR POOL $607.00FVH 11000003 POTASSIUM BLOOD POCT 84132 $42.00FVH 11000005 GLUCOSE BLOOD POCT 82947 $43.00FVH 11000006 CALCIUM TOTAL IONIZED POCT 82330 $42.00FVH 11000007 BLOOD GAS PH PO2 & PCO2 POCT 82803 $55.00FVH 11000008 CHLORIDE BLOOD POCT WAIVED $42.00FVH 11000009 SODIUM BLOOD POCT 84295 $42.00FVH 11000012 VENIPUNCTURE 36415 $17.00FVH 11000013 CREATININE POCT WAIVED $55.00FVH 11000019 LACTIC ACID POCT 83605 $200.00FVH 11000021 GLUCOSE BLOOD POCT WAIVED $42.00FVH 12000010 CYTOPATH FLUIDS 88104 $141.00FVH 12000017 IMMUNOHISTO STAIN CHEMISTRY 88342 $141.00FVH 12000019 DECALCIFY TISSUE 88311 $141.00FVH 12000020 PATH CONSULT INTRAOP, 1 BLOC 88331 $141.00FVH 12000021 PATH CONSULT INTRAOP, ADD'L 88332 $141.00FVH 12000024 CYTOPATH CON TECH BODY FLUID 88112 $141.00FVH 12000028 SURG PATH GROSS EXAM ONLY 88300 $141.00FVH 12000029 SURG PATH L2 88302 $141.00FVH 12000030 SURG PATH L3 88304 $141.00FVH 12000031 SURG PATH L4 88305 $141.00FVH 12000032 SURG PATH L5 88307 $401.00FVH 12000033 SURG PATH L6 88309 $401.00FVH 12000035 SPECIAL STAINS 88312 $141.00FVH 12000117 IMMUNOHISTO STAIN PIN COCKTAIL 88344 $141.00FVH 12000152 EGFR MUTATION TUMOR ANALYSIS 8123590 $1,600.00FVH 12000156 BONE MARROW SUPPLIES/MATERIALS $100.00FVH 12000175 SPECIAL STAINS GROUP 2 88313 $141.00FVH 12000179 BONE MARROW MORPHOLOGY 85097 $141.00FVH 12000184 FNA REPORT INTERPRETATION 88173 $141.00FVH 12000215 ALK REARRANGEMENT FISH 8837790 $141.00FVH 12000217 EGFR MICRODISSECTION 8838190 $141.00FVH 12000218 CYTOPATH CON TECH FLUID 88108 $141.00FVH 12000220 RECEPTOR ASSAY 88361 $141.00FVH 12000228 PROSTATE SAT BIOPSY $366.00FVH 12000243 IMMUNOHISTO STAIN CHEM ADDNL $64.00

17

FVH 12000246 IMMUNOHISTO STAIN ADD PER SPC 88341 $141.00FVH 13000002 SPERM ANTIBODIES 8932590 89325 $141.00FVH 13000006 GANGLIOSIDE ABY 8351690 83516 $62.00FVH 13000008 17OH PROGESTERONE 8349890 83498 $93.00FVH 13000009 ALPHA 1 ANTITRYPSIN TOTAL 8210390 82103 $200.00FVH 13000010 ALPHA 1 ANTITRYPSIN PHENO 8210490 82104 $200.00FVH 13000012 ACTH ADRENOCORTICOTROPIC HOR 8202490 82024 $93.00FVH 13000013 VASOPRESSIN ADH 8458890 84588 $93.00FVH 13000014 ANDROSTENEDIONE 8215790 82157 $93.00FVH 13000016 AMINOLEVULINIC ACID 8213590 82135 $200.00FVH 13000017 ALDOSTERONE 8208890 82088 $93.00FVH 13000018 AMIODARONE 8029990 80299 $73.00FVH 13000019 AMYLASE FRACTION 8215090 82150 $55.00FVH 13000020 ARSENIC 8217590 82175 $64.00FVH 13000021 CALCITONIN 8230890 82308 $93.00FVH 13000022 CAROTENE 8238090 82380 $55.00FVH 13000023 CATECHOLAMINES FRACT 8238490 82384 $93.00FVH 13000025 CADMIUM 8230090 82300 $64.00FVH 13000027 CLONAZEPAM $73.00FVH 13000028 CHROMIUM 8249590 82495 $64.00FVH 13000029 COPPER SERUM 8252590 $64.00FVH 13000031 DIHYDROTESTOSTERONE 8264290 $200.00FVH 13000033 ESTRADIOL 8267090 82670 $46.00FVH 13000034 FATS/LIPIDS FECES QUANT 8271090 82710 $200.00FVH 13000035 GASTRIN 8294190 82941 $93.00FVH 13000036 HUMAN GROWTH HORMONE 8300390 83003 $40.00FVH 13000039 HOMOVANILLIC ACID HVA 8315090 83150 $93.00FVH 13000040 IMMUNOGLOBULIN E IGE 8278590 82785 $34.00FVH 13000041 INSULIN 8352590 83525 $72.00FVH 13000042 LEAD BLOOD 8365590 83655 $34.00FVH 13000044 MYELIN BASIC PROTEIN 8387390 $200.00FVH 13000045 MERCURY BLOOD 8382590 83825 $64.00FVH 13000046 METANEPHRINES 8383590 $93.00FVH 13000048 RENIN 8424490 84244 $93.00FVH 13000049 TBG 8444290 84442 $72.00FVH 13000050 TSI 8444590 84445 $93.00FVH 13000051 ALDOSTERONE URINE 8208890 82088 $93.00FVH 13000052 ARSENIC URINE 8217590 82175 $64.00FVH 13000053 COPPER URINE 8252590 82525 $64.00FVH 13000054 CORTISOL FREE URINE 8253090 82530 $55.00FVH 13000055 CYSTINE QUANT 8213190 82131 $200.00FVH 13000056 LEAD URINE 8365590 83655 $64.00FVH 13000057 MERCURY URINE 8382590 83825 $64.00FVH 13000058 PORPHYRIN FRACT URINE 8412090 84120 $200.00FVH 13000059 ZINC URINE 8463090 84630 $64.00FVH 13000060 VITAMIN A 8459090 84590 $200.00FVH 13000061 VMA 8458590 84585 $93.00FVH 13000062 ZINC 8463090 84630 $64.00FVH 13000064 ERYTHROPOIETIN 8266890 82668 $200.00

18

FVH 13000066 VITAMIN E 8444690 84446 $200.00FVH 13000067 VITAMIN B1 8442590 84425 $200.00FVH 13000068 FATTY ACIDS VLC 8272690 82726 $200.00FVH 13000069 VITAMIN B6 8420790 84207 $200.00FVH 13000070 ALUMINUM 8210890 82108 $64.00FVH 13000071 TRAZADONE 8029990 80299 $73.00FVH 13000074 VASOACTIVE INTEST PEPTIDE VIP 8458690 $93.00FVH 13000077 IGG 1, 2, 3 OR 4, EACH 8278790 82787 $108.00FVH 13000079 REVERSE T3 8448290 $72.00FVH 13000080 SELENIUM 8425590 84255 $200.00FVH 13000081 ALKALINE PHOS ISOENZYMES 8408090 84080 $200.00FVH 13000082 ORGANIC ACID QUAL EA 8391990 $200.00FVH 13000083 FLECAINIDE 8029990 80299 $73.00FVH 13000084 ACETYLCHOLINE RECEPT ABY 8351990 83519 $76.00FVH 13000085 QUANT ASSAY 10,11 EPOXIDE 8029990 80299 $73.00FVH 13000086 HALOPERIDOL 8017390 80173 $73.00FVH 13000088 ACYLCARNITINE PANEL 8201790 82017 $200.00FVH 13000089 OXALATE 8394590 83945 $200.00FVH 13000090 FRUCTOSAMINE 8298590 82985 $29.00FVH 13000091 CYANIDE 8260090 82600 $64.00FVH 13000093 CLOMIPRAMINE / METABOLITE $73.00FVH 13000094 PROTOPORPHYRINS RBC QUANT 8254290 $99.00FVH 13000095 IMMUNOGLOBULIN M IGM 8278490 82784 $200.00FVH 13000097 SEROTONIN 8426090 84260 $93.00FVH 13000098 INSULIN FREE 8352790 83527 $93.00FVH 13000099 SOMATOMEDIN 8430590 84305 $93.00FVH 13000100 QUANT ASSAY ISONIAZID 8029990 80299 $73.00FVH 13000101 ACETYLCHOLINE BLOCK ABY 8351690 83516 $76.00FVH 13000102 ACETYLCHOLINE MOD ABY 8351690 83516 $76.00FVH 13000103 CARBAMAZEPINE FREE 8015790 80157 $73.00FVH 13000104 LACTIC ACID 8360590 $200.00FVH 13000105 NUCLEOTIDASE 5 8391590 83915 $200.00FVH 13000106 PROINSULIN 8420690 84206 $93.00FVH 13000107 CITRIC ACID URINE 8250790 82507 $200.00FVH 13000114 PYRUVATE 8421090 84210 $200.00FVH 13000115 CARNITINE TOTAL AND FREE 8237990 82379 $200.00FVH 13000116 17 KETOSTEROIDS TOTAL 8358690 83586 $72.00FVH 13000117 GLUCAGON 8294390 82943 $93.00FVH 13000121 VITAMIN K 8459790 84597 $104.00FVH 13000122 MUCOPOLYSACCHARIDES 8386490 83864 $200.00FVH 13000123 BETA HYDROXYBUTERATE 8201090 82010 $55.00FVH 13000125 THC QUANT $73.00FVH 13000126 FELBATOL $73.00FVH 13000127 PHOSPHATASE PROSTATIC 8406690 84066 $200.00FVH 13000129 THYROGLOBULIN 8443290 84432 $93.00FVH 13000130 HISTAMINE 8308890 $200.00FVH 13000136 NEURONTIN/GABAPENTIN 8017190 80171 $73.00FVH 13000138 LAMOTRIGINE 8017590 80175 $73.00FVH 13000139 DRUG SCREEN PLASMA 8030790 $64.00

19

FVH 13000140 HEAVY METAL SCREEN 8301890 83018 $64.00FVH 13000142 THIOPURINE METHYLTRANSFERASE 8378990 $200.00FVH 13000143 METANEPHRINES 8383590 83835 $93.00FVH 13000145 LIPOPRO BLD ELECTROPHORETIC 8370090 83700 $200.00FVH 13000146 OLIGOCLONAL BANDS 8391690 83916 $200.00FVH 13000147 DISOPYRAMIDE 8029990 80299 $73.00FVH 13000148 TRANSFERRIN 8446690 84466 $55.00FVH 13000149 RBC FOLIC ACID 8274790 82747 $51.00FVH 13000150 GM1 ANTIBODY 8351690 83516 $62.00FVH 13000154 METHYLMALONIC ACID 8392190 83921 $200.00FVH 13000155 HEMOSIDERIN QUAL 8307090 83070 $200.00FVH 13000156 CLOZAPINE 8015990 80159 $73.00FVH 13000157 HCG TUMOR MARKER 8470290 84702 $72.00FVH 13000162 ALDOLASE 8208590 82085 $55.00FVH 13000163 ANGIOTENSIN CONV ENZYME 8216490 82164 $200.00FVH 13000168 BENZODIAZEPINE CONFIRMATION $73.00FVH 13000171 GALACTOSE SCREEN 8277690 82776 $200.00FVH 13000176 ESTROGEN FRACTIONATED 8267190 82671 $93.00FVH 13000177 PSA TOTAL 8415390 84153 $55.00FVH 13000180 HYDROXYINDOLACETIC ACID 5HIAA 8349790 83497 $72.00FVH 13000181 TESTOSTERONE FREE 8440290 84402 $93.00FVH 13000182 AFP SERUM 8210590 82105 $200.00FVH 13000183 HCG QUANT 8470290 84702 $72.00FVH 13000184 ESTRIOL 8267790 82677 $93.00FVH 13000185 COCAINE QUANT 8035390 $73.00FVH 13000186 AMPHETAMINES OR METHAMPHETA $73.00FVH 13000188 IMMUNOGLOB G SER MS PROFILE 8278490 82784 $200.00FVH 13000192 MANGANESE 8378590 83785 $64.00FVH 13000193 CAFFEINE QUANT 8015590 80155 $73.00FVH 13000195 PORPHOBILINOGEN URINE QUANT 8411090 84110 $200.00FVH 13000196 TOPIRAMATE 8020190 80201 $73.00FVH 13000198 VALPROIC ACID FREE 8016590 $73.00FVH 13000199 IGF BINDING PROTEIN 3 8239790 82397 $55.00FVH 13000200 TRYPTASE 8352090 $76.00FVH 13000201 DHEA 8262690 82626 $200.00FVH 13000202 TSH NEONATAL 8444390 84443 $72.00FVH 13000203 VITAMIN D 1,25 DIHYDROXY 8265290 82652 $200.00FVH 13000205 PHENYTOIN TOTAL 8018590 80185 $73.00FVH 13000206 PHENYTOIN FREE 8018690 80186 $73.00FVH 13000215 AMINO ACIDS SINGLE QUANT 8213190 82131 $200.00FVH 13000217 VITAMIN C 8218090 82180 $55.00FVH 13000218 SEX HORMONE BINDING GLOBULIN 8427090 84270 $200.00FVH 13000221 NICOTINE COTININE 8032390 $73.00FVH 13000228 T3 TOTAL 8448090 84480 $72.00FVH 13000229 LIPOPROTEIN A 8369590 83695 $200.00FVH 13000230 AMINO ACID/ACYLCARNITINE SCR 8378990 83789 $200.00FVH 13000231 AMIKACIN 8015090 80150 $73.00FVH 13000232 BILE ACIDS TOTAL 8223990 82239 $200.00FVH 13000233 FATS/LIPIDS FECES QUAL 8270590 82705 $55.00

20

FVH 13000237 APOLIPOPROTEIN A-1 8217290 82172 $200.00FVH 13000241 PROTEASE 3 8351690 83516 $76.00FVH 13000244 HEMOGLOBIN ELECTROPHORESIS 8302090 83020 $200.00FVH 13000245 PORPHYRIN TOTAL SERUM 8431190 84311 $55.00FVH 13000247 APOLIPOPROTEIN B-100 8217290 82172 $200.00FVH 13000257 AMINO ACID QUANT 6 OR MORE 8213990 82139 $200.00FVH 13000258 ZONISAMIDE 8020390 $73.00FVH 13000261 17 HYDROXYPREGNENOLONE 8414390 84143 $93.00FVH 13000262 SIROLIMUS/RAPAMYCIN 8019590 80195 $149.00FVH 13000263 ETHOSUXIMIDE 8016890 80168 $73.00FVH 13000264 LEVETIRACETAM 8017790 80177 $73.00FVH 13000266 CPK ISOENZYMES 8255290 82552 $55.00FVH 13000267 HEMOGLOBIN PLASMA 8305190 83051 $200.00FVH 13000270 GLUCOSE G6PD QUANT 8295590 82955 $200.00FVH 13000272 PAROXETINE 8029990 80299 $73.00FVH 13000278 OXCARBAZEPINE 8018390 80183 $73.00FVH 13000280 SARC CEREVISIAVE IGA (IBD) 8352090 83520 $76.00FVH 13000281 ESTRONE 8267990 82679 $93.00FVH 13000283 TISSUE TRANSGLUTAMASE 8351690 83516 $76.00FVH 13000285 IBUPROFEN 8032990 $73.00FVH 13000288 QUINIDINE 8019490 80194 $73.00FVH 13000289 ITRACONAZOLE 8029990 80299 $73.00FVH 13000290 MYCOPHENOLIC ACID 8018090 80180 $73.00FVH 13000291 MITOCHONDRIAL ANTIBODY 8351690 83516 $76.00FVH 13000295 BILE ACID FRACTIONATED 8378990 83789 $200.00FVH 13000298 ALKALINE PHOS BONE SPECIFIC 8408090 84080 $200.00FVH 13000301 CARBOHYDRATE DEFICIENT TRNSFE 8237390 82373 $240.00FVH 13000320 LDH ISOENZYMES 8362590 83625 $200.00FVH 13000321 LDH ARUP 8361590 83615 $42.00FVH 13000322 CALCIUM CHAN BINDING ABY 8351990 83519 $76.00FVH 13000323 PARANEOPLASTIC WESTERN BLOT 8418290 84182 $108.00FVH 13000330 PREGNENOLONE 8414090 84140 $93.00FVH 13000334 ZINC PROTOPORPHYRIN RBC 8420290 84202 $200.00FVH 13000342 CYSTATIN-C 8261090 $200.00FVH 13000345 RED SUBSTANCE FECAL SUG QUAL 8437690 84376 $55.00FVH 13000347 PERINUC PATTERN (IBD) 8834690 $141.00FVH 13000348 CHOLINESTERASE 8248090 82480 $200.00FVH 13000349 LIGHT CHAINS 8388390 83883 $81.00FVH 13000350 MYOGLOBIN URINE 8387490 83874 $200.00FVH 13000351 PRIMIDONE 8018890 80188 $73.00FVH 13000352 DOXEPIN 8033590 $73.00FVH 13000357 OPIATES $73.00FVH 13000358 FENTANYL G0480 $123.00FVH 13000364 INHIBIN B 8352090 $149.00FVH 13000366 T4 FREE BY DIALYSIS 8443990 84439 $72.00FVH 13000367 IGF BINDING PROTEIN 1 8351990 83519 $76.00FVH 13000370 NORTRIPTYLINE $73.00FVH 13000371 DESIPRAMINE 8033590 $73.00FVH 13000372 IMIPRAMINE 8033590 $73.00

21

FVH 13000384 HEMOGLOBIN CHROM A2 S C &OR F 8302190 $96.00FVH 13000404 CITRULLINE ANTIBODY 8620090 86200 $76.00FVH 13000414 TESTOSTERONE FRE FEMALE/CHILD 8440290 84402 $93.00FVH 13000417 VALPROIC ACID 8016490 80164 $73.00FVH 13000418 IMMUNOGLOBULIN A IGA 8278490 82784 $200.00FVH 13000420 HOMOCYSTINE 8309090 83090 $93.00FVH 13000421 BIONTINIDASE DEFICIENCY SCREEN 8226190 82261 $200.00FVH 13000422 CONGENITAL ADR HYPERPLASIA 8349890 83498 $93.00FVH 13000423 CYSTIC FIBROSIS SCREEN 8351690 83516 $76.00FVH 13000424 MUSK ANTIBODY 8351990 83519 $76.00FVH 13000426 ALPHA 1 ANTITRYPSIN FECES 8210390 82103 $200.00FVH 13000432 TESTOSTERONE FREE EQUIL DIAL 8440290 84402 $93.00FVH 13000433 TESTOSTERONE TOTAL EQUIL DIAL 8440390 84403 $93.00FVH 13000434 TESTOSTERONE FR BIOAV EQL DIAL 8441090 $93.00FVH 13000436 ACHR ABY RECEPTOR (MAYO) 35199059 8351959 $76.00FVH 13000437 STRIATIONAL ANTIBODY MAYO 8352090 83520 $76.00FVH 13000438 PTH RELATED PEPTIDE MAYO 8239790 82397 $55.00FVH 13000451 TESTOSTERONE TOTAL ARUP 8440390 84403 $116.00FVH 13000461 PLASMINOGEN ACT INHIB AGN 8352090 83520 $76.00FVH 13000462 THYROTROPIN RECEPT ABY 8352090 83520 $76.00FVH 13000463 CARBAMAZEPINE TOTAL ARUP 8015690 80156 $73.00FVH 13000473 MULLERIAN INHIB HORMONE 8352090 83520 $76.00FVH 13000484 THYROGLOBULIN USC ENDOCRINE 8443290 84432 $91.00FVH 13000485 NIACIN VIT B3 8459190 84591 $73.00FVH 13000489 TRANSFERRIN RECEPTOR 8423890 84238 $52.00FVH 13000492 CROSS LINKED N-TELEOP URINE 8252390 82523 $108.00FVH 13000495 METHADONE 8035890 $73.00FVH 13000496 FLUOXETINE/PROZAC 8033290 $73.00FVH 13000498 ALKALINE PHOS SENT OUT 8407590 84075 $42.00FVH 13000501 CRYOGLOBULIN 8259590 82595 $55.00FVH 13000504 ADENOVIRUS ANTIBODY 8660390 86603 $108.00FVH 13000505 C1 ESTERASE INHIBITOR 8616090 86160 $76.00FVH 13000506 CA 15-3 8630090 86300 $107.00FVH 13000507 CARDIOLIPIN ANTIBODY 8614790 86147 $108.00FVH 13000510 FRANCISELLA TULARENSIS 8666890 86668 $108.00FVH 13000511 TREPONEMA PALLIDUM FTA ABS 8678090 $108.00FVH 13000512 GLOM BASE MEMBRANE 8351690 83516 $76.00FVH 13000514 HLA B27 8681290 86812 $163.00FVH 13000516 INFLUENZA B ANTIBODY 8671090 86710 $76.00FVH 13000518 Q FEVER ANTIBODY 8663890 86638 $108.00FVH 13000519 RICKETTSIA ANTIBODY 8675790 86757 $108.00FVH 13000521 MUMPS ANTIBODY 8673590 86735 $76.00FVH 13000522 C1Q BINDING 8633290 86332 $108.00FVH 13000526 BRUCELLA ANTIBODY 8662290 86622 $108.00FVH 13000527 RICKETTSIA ANTIBODY 8675790 86757 $108.00FVH 13000529 COXSACKIE A ABY 8665890 86658 $108.00FVH 13000530 COXSACKIE B ABY 8665890 86658 $108.00FVH 13000531 C1 ESTERASE INHIBIT FUNCTIONAL 8616190 86161 $76.00FVH 13000532 ALLERGEN SPEC IGE 8600390 86003 $76.00

22

FVH 13000535 ECHOVIRUS ANTIBODY 8665890 86658 $108.00FVH 13000537 ISLET CELL ANTIBODY 8634190 86341 $108.00FVH 13000539 PARVOVIRUS ANTIBODY 8674790 86747 $108.00FVH 13000540 STRIATIONAL ANTIBODY 8625590 86255 $108.00FVH 13000542 TOXOCARA CANIS ANTIBODY 8668290 86682 $76.00FVH 13000544 INSULIN ANTIBODIES 8633790 86337 $93.00FVH 13000546 HAEMOPHILUS INFLU B ABY 8631790 86317 $92.00FVH 13000548 HCV BY RIBA 8680490 86804 $200.00FVH 13000549 ANTI NEURONAL NUC ABY 8625590 $108.00FVH 13000550 LYME DISEASE ANTI WESTERN BLOT 8661790 86617 $108.00FVH 13000557 CHROMOGRANIN A 8631690 86316 $200.00FVH 13000558 ANTIPHOSPHATIDYLSERINE ABY 8614890 86148 $119.00FVH 13000559 ASPERGILLUS ABY 8660690 86606 $55.00FVH 13000560 EHRLICHIA ANTIBODY 8666690 86666 $46.00FVH 13000562 VDRL SERUM 8659290 86592 $76.00FVH 13000563 INTRINSIC FACTOR BLOCK ABY 8634090 86340 $93.00FVH 13000565 RETICULIN ANTIBODY 8625590 86255 $108.00FVH 13000566 COCCIDIOIDES ANTIBODY 8663590 86635 $38.00FVH 13000567 HISTOPLASMA ANTIBODY 8669890 86698 $108.00FVH 13000569 RUBEOLA ANTIBODY 8676590 86765 $76.00FVH 13000570 ENDOMYSIAL ABY 8625690 $72.00FVH 13000571 WESTERN EQUINE ENCEPH ABY 8665490 86654 $108.00FVH 13000572 ST LOUIS ENCEPH ANTIBODY 8665390 86653 $108.00FVH 13000573 CALIFORNIA ENCEPH ABY 8665190 86651 $108.00FVH 13000574 GLIADIN ANTIBODY 8351690 83516 $76.00FVH 13000575 TETANUS/DIPTH ANTIBODY 8631790 86317 $108.00FVH 13000577 YERSINIA ANTIBODY 8679390 86793 $108.00FVH 13000580 HELMINTH ANTIBODY NOS 8668290 86682 $81.00FVH 13000582 COMPLEMENT TOTAL 8616290 86162 $76.00FVH 13000586 RABIES ANTIBODY TITER 8679090 $76.00FVH 13000587 CA 27-29 8630090 86300 $107.00FVH 13000588 TOXOPLASMA IGG 8677790 $108.00FVH 13000589 TOXOPLASMA IGM 8677890 86778 $108.00FVH 13000590 THYROID PEROXIDASE ABY 8637690 86376 $93.00FVH 13000593 VARICELLA ZOSTER IGM 8678790 86787 $76.00FVH 13000594 VARICELLA ZOSTER IGG 8678790 86787 $76.00FVH 13000596 DEOXYRIBONUCLEASE ANTIBODY 8621590 86215 $76.00FVH 13000597 HERPES SIMPLEX I IGG 8669590 86695 $34.00FVH 13000598 HERPES SIMPLEX II IGG 8669690 86696 $32.00FVH 13000599 GIARDIA ANTIBODY 8667490 86674 $106.00FVH 13000603 EPSTEIN BARR CAPSID IGG 8666590 86665 $21.00FVH 13000604 EPSTEIN BARR CAPSID IGM 8666590 86665 $21.00FVH 13000605 EPSTEIN BARR EARLY ANTIGEN 8666390 86663 $108.00FVH 13000608 EASTERN EQUINE ENCEPH ABY 8665290 86652 $108.00FVH 13000609 CHLAMYDIA IGG 8663190 86631 $41.00FVH 13000610 CHLAMYDIA IGM 8663290 86632 $41.00FVH 13000611 CRYPTOCOCCUS LTX AGGLUTINATION 8640390 86403 $76.00FVH 13000612 FUNGAL SEROL BLASTOMYCES 8661290 86612 $108.00FVH 13000613 FUNGAL SEROL COCCIDIODES 8663590 86635 $108.00

23

FVH 13000614 FUNGAL SEROL HISTOPLASMA 8669890 86698 $108.00FVH 13000615 FARMER LUNG ALLERGEN 8600390 86003 $76.00FVH 13000616 FARMER LUNG IMMUNODIFF 8633190 86331 $108.00FVH 13000617 HEP BE ANTIBODY 8670790 86707 $55.00FVH 13000618 ANCA 8625590 86255 $78.00FVH 13000619 THYROGLOBULIN ANTIBODY 8680090 86800 $93.00FVH 13000621 BARTONELLA (IFA) 8661190 86611 $108.00FVH 13000626 DNA ABY DOUBLE STRAND 8622590 86225 $37.00FVH 13000627 SSA ENA ANTIBODY 8623590 86235 $26.00FVH 13000628 SSB ENA ANTIBODY 8623590 86235 $26.00FVH 13000629 RNP ENA ANTIBODY 8623590 86235 $26.00FVH 13000631 SMITH ENA ANTIBODY 8623590 86235 $108.00FVH 13000633 CD4 AND CD8 8636090 86360 $86.00FVH 13000634 ISLET CELL ANTIBODY ICA 512 8634190 86341 $332.00FVH 13000635 RUBELLA IGG 8676290 $108.00FVH 13000636 GLUTMIC ACID DECARBOX ABY 8634190 $76.00FVH 13000637 COLD AGGLUTININ TITER 8615790 86157 $76.00FVH 13000638 SYPHILIS IGG 8659390 86593 $71.00FVH 13000640 HERPES NON TYPE SPECIFIC 8669490 86694 $108.00FVH 13000642 MICROSOME LIVER/KIDNEY ABY 8637690 86376 $93.00FVH 13000643 HEP A ANTIBODY TOTAL 8670890 86708 $55.00FVH 13000647 HERPES SIMPLEX I/II, IgM 8669490 86694 $108.00FVH 13000650 PNEUMOCOCCAL ANTIBODY 8631790 86317 $108.00FVH 13000652 LEGIONELLA IGM 8671390 86713 $35.00FVH 13000655 INHIBIN A 8633690 86336 $73.00FVH 13000656 VDRL 8659290 86592 $76.00FVH 13000657 RUBELLA IGM 8676290 86762 $76.00FVH 13000658 PARIETAL CELL ANTIBODY 8351690 $76.00FVH 13000659 SMOOTH MUSCLE ANTIBODY 8351690 83516 $76.00FVH 13000660 CRYPTOCOCCUS ANTIBODY 8664190 86641 $108.00FVH 13000661 BETA-2-GLYCOPROTEIN IGG OR IGM 8614690 86146 $81.00FVH 13000663 SACCHAROMYCES ANTIBODY 8667190 86671 $76.00FVH 13000666 AMPHIPHYSIN 8625590 $108.00FVH 13000667 CRMP 5 IGG 8625590 $108.00FVH 13000668 BETA 2 GLYCOPROTEIN IGA 8614690 86146 $57.00FVH 13000669 ALLERGEN IGG 8600190 86001 $70.00FVH 13000670 LEGIONELLA IGG 8671390 86713 $108.00FVH 13000673 MULTIALLERGEN SCREEN 8600590 86005 $76.00FVH 13000681 HEP B CORE ANTIBODY, TOTAL 8670490 86704 $55.00FVH 13000686 ANCA TITER 8625690 86256 $132.00FVH 13000687 BACTERIAL AGN PART AGGLUT 8640390 86403 $76.00FVH 13000689 PURKINJE CELL ANTIBODY 8625590 $108.00FVH 13000691 NEUTRALIZATION TEST VIRAL 8638290 86382 $108.00FVH 13000695 IMMUNOFIX ELECTROPH SERUM 8633490 86334 $85.00FVH 13000697 GLOM BASE MEMBRANE ABY 8625590 86255 $108.00FVH 13000698 MYCOPLASMA ANTIBODY IGG 8673890 86738 $108.00FVH 13000699 ANTIBODY TITER (ARUP) 8625690 86256 $108.00FVH 13000700 H PYLORI AB 8667790 86677 $108.00FVH 13000701 ANTINUCLEAR ANTI TITER 8603990 86039 $55.00

24

FVH 13000702 B CELL TOTAL 8635590 86355 $68.00FVH 13000703 NK CELL TOTAL 8635790 86357 $73.00FVH 13000704 T CELLS TOTAL 8635990 86359 $132.00FVH 13000705 ALLERGEN SPEC EACH (IBT) 8600390 86003 $76.00FVH 13000707 THYROGLOBULIN ANTIBODY USC 8680090 86800 $63.00FVH 13000708 NEUROMYELITIS OPTIC ABY 8625590 86255 $108.00FVH 13000709 DENGUE FEVER ABY 8679090 86790 $75.00FVH 13000710 PROTEIN C ANTIGEN 8530290 85302 $85.00FVH 13000711 PROTEIN S FUNCTIONAL 8530690 85306 $85.00FVH 13000712 RISTOCETIN COFACTOR 8524590 85245 $85.00FVH 13000713 VON WILLEB MULTIMER 8524790 85247 $85.00FVH 13000714 FACTOR VIII 8524090 85240 $85.00FVH 13000715 FACTOR VIII REL AGN 8524690 85246 $85.00FVH 13000716 PROTEIN C RESISTANCE 8530790 85307 $200.00FVH 13000717 PROTEIN C ACTIVITY 8530390 85303 $85.00FVH 13000718 PROTEIN S TOTAL 8530590 85305 $85.00FVH 13000719 ANTI THROMBIN III ANTIGEN 8530190 85301 $85.00FVH 13000721 PROTEIN S FREE 8530690 85306 $85.00FVH 13000722 VISCOSITY 8581090 85810 $96.00FVH 13000725 MURAMIDASE LYSOZYME 8554990 85549 $200.00FVH 13000731 ANTITHROMBIN ACTIVITY 8530090 85300 $85.00FVH 13000732 OSMOTIC FRAGILITY RBC 8555790 85557 $96.00FVH 13000733 RBC SICKLE CELL TEST 8566090 85660 $40.00FVH 13000737 CULTURE CHLAMYDIA 8711090 87110 $41.00FVH 13000738 CULTURE FUNGUS BLOOD 8710390 87103 $107.00FVH 13000741 MYCOPLASMA UREAPLCULTURE 8710990 87109 $107.00FVH 13000743 CULTURE VIRAL 8725290 87252 $107.00FVH 13000744 CRYPTOCOCCUS NEOF BLOOD AGN 8732790 87327 $76.00FVH 13000747 MINIMUM BACTERICIDAL CONC 8718690 87186 $169.00FVH 13000748 HEP C RNA PCR QUAL 8752190 87521 $107.00FVH 13000749 HSV DNA AMP PROBE 8752990 87529 $107.00FVH 13000750 LYME DIS DNA AMP PROBE 8747690 87476 $107.00FVH 13000753 MYCOBACTERIA SMEAR AFB 8720690 87206 $11.00FVH 13000758 HERPES TYPING MONOCLONAL ABY 8725390 87253 $13.00FVH 13000762 BORDETELLA PERTUSSIS DFA 8726590 87265 $76.00FVH 13000763 ADENOVIRUS DFA 8726090 87260 $9.00FVH 13000764 INFLUENZA A DFA 8727690 87276 $9.00FVH 13000765 INFLUENZA B DFA 8727590 87275 $9.00FVH 13000766 PARAINFLUENZA 1 DFA 8727990 87279 $9.00FVH 13000767 PARAINFLUENZA 2 DFA 8727990 87279 $9.00FVH 13000768 PARAINFLUENZA 3 DFA 8727990 87279 $9.00FVH 13000770 RSV DFA 8728090 87280 $11.00FVH 13000771 CMV DNA AMP PROBE 8749690 87496 $200.00FVH 13000773 HEP BE ANTIGEN 8735090 87350 $76.00FVH 13000775 VARICELLA ZOSTER PCR 8779890 87798 $107.00FVH 13000776 TOXOPLASMA PCR 8779890 87798 $192.00FVH 13000777 H PYLORI AG STOOL 8733890 87338 $76.00FVH 13000778 ENTEROVIRUS BY PCR 8749890 $230.00FVH 13000779 PARVOVIRUS PCR 8779890 87798 $161.00

25

FVH 13000782 HISTOPLASMA ANTIGEN 8738590 87385 $76.00FVH 13000783 BORDETELLA PERTUSSIS PCR 87801 8780190 $163.00FVH 13000786 HEP C RNA PCR QUANT 8752290 87522 $107.00FVH 13000790 HEP B DNA QUANT 8751790 87517 $107.00FVH 13000791 CHLAMYDIA TRACHOMATIS AG, IF 8727090 87270 $76.00FVH 13000793 HEP C DNA GENOTYPE 8790290 87902 $107.00FVH 13000795 HHV 6 BY PCR 8753390 87533 $107.00FVH 13000796 WEST NILE VIRUS PCR 8779890 87798 $299.00FVH 13000797 BK VIRUS QUANT PCR 8779990 87799 $107.00FVH 13000798 MYCOPLASMA PNEUM PCR 8758190 87581 $253.00FVH 13000803 INFECTIOUS AGENT ANTIGEN 8744990 87449 $138.00FVH 13000804 SPECIAL STAIN INCL BODIES/PARA 8720790 87207 $41.00FVH 13000805 ASPERGILLUS GALACT AGN 8730590 87305 $41.00FVH 13000806 BARTONELLA DNA AMP PROBE 8747190 87471 $320.00FVH 13000807 ADENOVIRUS PCR 8779890 87798 $107.00FVH 13000809 DET AG DNA JC BY PCR 8779890 87798 $107.00FVH 13000817 NOROVIRUS PCR 1 OR 2 EACH 8779890 87798 $107.00FVH 13000819 MYCOBACTERIA TB AMP PROBE 8755690 87556 $532.00FVH 13000827 CHROM TISS CULTURE BONE MAR 8823790 88237 $401.00FVH 13000836 CHROMOSOMAL ISH(10-30) 8827390 88273 $108.00FVH 13000837 FISH DNA PROBE 8827190 88271 $108.00FVH 13000838 INTERPHASE ISH 100-300 CELLS 8827590 88275 $297.00FVH 13000839 CYTOGENETIC INTERPR 8829190 88291 $75.00FVH 13000845 CHROMOSOME ANALYSIS 20-25 CELL 8826490 88264 $108.00FVH 13000850 IMMUNOPHENOTYPE FIRST MARKER 8818490 88184 $141.00FVH 13000851 IMMUNOPHENOTYPE ADDITIONAL 8818590 $401.00FVH 13000866 CYTOGENETIC STUDY 8829990 88299 $401.00FVH 13000869 NEUTROPHILIC OXID BURST 8635290 $108.00FVH 13000895 IODINE 8301890 $200.00FVH 13000899 WEST NILE VIRUS IGG-ARUP 8678990 $108.00FVH 13000910 BORRELIA BURGDORFERI 8661890 $108.00FVH 13000911 WEST NILE VIRUS IGM ARUP 8678890 $108.00FVH 13000913 VIRUS ISOLATION TISS CUL ADDL 8725390 $107.00FVH 13000914 GC/HPLC MASS SPEC QUANT 8254290 $200.00FVH 13000919 IMMUNOASSAY NOS 8352090 83520 $76.00FVH 13000924 LACTOFERRIN FECAL QUALITATIVE 8363090 83630 $200.00FVH 13000927 HHSV8 8679090 $76.00FVH 13000931 REFERRED TEST MRL 0-75 $61.00FVH 13000932 REFERRED TEST MRL 76-150 $118.00FVH 13000933 REFERRED TEST MRL 151-300 $220.00FVH 13000934 REFERRED TEST MRL 301-500 $407.00FVH 13000935 REFERRED TEST MRL 501-700 $765.00FVH 13000938 PORPHYRIN FECAL 8412690 $200.00FVH 13000939 MHATP-SYPH CONFIR 8678090 $108.00FVH 13000940 ENA AB 8623590 $108.00FVH 13000951 PANCREATIC ELASTASE 8352090 $76.00FVH 13000952 SARC CEREVISIAE IGG (IBD) 8352090 $76.00FVH 13000953 OMPC IGA (IBD) 8352090 $76.00FVH 13000954 CBIR1 ELISA (IBD) 8352090 $76.00

26

FVH 13000955 NEUTROPHIC AUTOLAB (IBD) 8352090 $76.00FVH 13000956 DNASE AB (IBD) 8835090 $141.00FVH 13000958 HEMOGLOBIN URINE 8306990 $37.00FVH 13000959 DRVVT CONFIRM REF 8561390 $85.00FVH 13000960 DRVVT MIX REF 8561390 $85.00FVH 13000961 DRVVT REF 8561390 $85.00FVH 13000962 HEXAGONAL PHOSPHOLIPID NEU REF 8559890 $85.00FVH 13000963 PLATELET NEUTRALIZATION 8559790 $85.00FVH 13000964 PROTRHOMBIN TIME REF 8561090 $38.00FVH 13000966 PTT MIX REF 8573290 $38.00FVH 13000967 PARTIAL THROMBOPLASTIN TME REF 8573090 $38.00FVH 13000973 CRYOFIBRINOGEN ARUP 8258590 $200.00FVH 13000979 CONCENTRATION FOR INFECT AGENT 8701590 $41.00FVH 13000980 EPSTEIN BARR CAPSID IGA 8666590 $108.00FVH 13000982 LEUKOCYTE HISTAMINE RELEASE 8634390 $108.00FVH 13000984 EBV BY PCR 8779990 $107.00FVH 13000985 TESTOSTERONE BY LC/MS 8440390 $72.00FVH 13000988 CPK TOTAL ARUP 8255090 $55.00FVH 13000990 CMV IGG 8664490 $108.00FVH 13000991 CMV IGM 8664590 $108.00FVH 13000992 THYROID UPTAKE/BINDING RATIO 8447990 $72.00FVH 13000995 CHROMOSOME ANALYSIS 15-20 CELL 8826290 $401.00FVH 13000996 TISSUE CULTURE NON NEOPLASTIC 8823090 $401.00FVH 13001008 FLOW CYT INTERP 9-15 MARK HEMA 8818890 $141.00FVH 13001175 OPIATE URINE CONF/QNT $73.00FVH 13001176 HISTAMINE,SERUM 8308890 $200.00FVH 13001179 REFERRED TEST MRL 1301-1500 $1,534.00FVH 13001205 IONIZED CALCIUM 8233090 82330 $42.00FVH 13001212 ANA BY IFA TITER MAYO 8603990 $55.00FVH 13001213 ANA BY IFA 8603890 $55.00FVH 13001216 CULTURE TYPING 1 8714090 $38.00FVH 13001217 CULTURE TYPING 2 8714090 $38.00FVH 13001223 LEUKOCYTE ALK PHOS W CT 8554090 $51.00FVH 13001225 CALPROTECTIN 8399390 $200.00FVH 13001230 HEMOGLOBIN SCREEN NEWBORN 8302090 $200.00FVH 13001233 VITAMIN B2 (RIBOFLAVIN) 8425290 84252 $200.00FVH 13001242 STONE RISK URINE AMMONIA 8214090 82140 $55.00FVH 13001243 STONE RISK URINE CALCIUM 8234090 82340 $55.00FVH 13001244 STONE RISK URINE CITRATE 8250790 82507 $200.00FVH 13001245 STONE RISK URINE CREAT 8257090 82570 $55.00FVH 13001246 STONE RISK URINE MAGNESIUM 8373590 83735 $55.00FVH 13001247 STONE RISK URINE OXALATE 8394590 83945 $200.00FVH 13001248 STONE RISK URINE PH 8398690 83986 $55.00FVH 13001249 STONE RISK URINE PHOSPHORUS 8410590 84105 $55.00FVH 13001250 STONE RISK URINE POTASSIUM 8413390 84133 $55.00FVH 13001251 STONE RISK URINE SODIUM 8430090 84300 $55.00FVH 13001252 STONE RISK URINE SULFATE 8439290 84392 $37.00FVH 13001253 STONE RISK URINE TOT VOLUME 8105090 81050 $37.00FVH 13001254 STONE RISK URINE URIC ACID 8456090 84560 $55.00

27

FVH 13001259 FLUPHENAZINE 8034290 $73.00FVH 13001262 DEOXYCORTISOL 8263490 $93.00FVH 13001264 TBINT QUANTIFERON 8648190 $108.00FVH 13001272 PREGABALIN $73.00FVH 13001273 ZIPRASIDONE $178.00FVH 13001275 CMV PCR QUANT ARUP 8749790 $107.00FVH 13001278 IMMUNOGLOBULIN D 8278490 $200.00FVH 13001293 PHENOBARBITAL 8018490 $73.00FVH 13001308 LIDOCAINE 8017690 $73.00FVH 13001309 PROCAINAMIDE 8019290 $73.00FVH 13001310 CONSULT REFERRED 8832390 $141.00FVH 13001318 ASERGILLUS FUMIGATUS AB 8660690 $108.00FVH 13001325 FDP 8536290 $38.00FVH 13001326 FACTOR 2 ACTIVITY 8521090 $38.00FVH 13001327 FACTOR 5 ACTIVITY 8522090 $85.00FVH 13001328 FACTOR 7 ACTIVITY 8523090 $85.00FVH 13001329 FACTOR 9 ACTIVITY 8525090 $85.00FVH 13001330 FACTOR 10 ACTIVITY 8526090 $85.00FVH 13001331 FACTOR 11 ACTIVITY 8527090 $85.00FVH 13001332 FACTOR 12 ACTIVITY 8528090 $85.00FVH 13001341 HEXOSAMINIDASE 8308090 $200.00FVH 13001344 FATTY ACIDS ESSENTIAL C12-C22 8254290 $455.00FVH 13001347 MAG AB IGM 8351690 $66.00FVH 13001350 SODIUM FECAL 8430290 $42.00FVH 13001351 POTASSIUM FECAL 8499990 $55.00FVH 13001356 BORDETELLA PERTUSSIS PCR 87798 8779890 $107.00FVH 13001357 LYME DISEASE ANTIBODY 8661890 $108.00FVH 13001359 SOMATOSTATIN 8430790 $93.00FVH 13001361 STONE ANALYSIS XRAY DIFF 8237090 $200.00FVH 13001362 DESMOGLEIN 3 8351690 $76.00FVH 13001363 DESMOGLEIN 1 8351690 $76.00FVH 13001370 CANDIDA IGA ANTIBODY 8662890 $41.00FVH 13001371 CANDIDA IGG ANTIBODY 8662890 $41.00FVH 13001372 CANDIDA IGM ANTIBODY 8662890 $41.00FVH 13001377 LACOSAMIDE 8018790 $73.00FVH 13001380 RISPERIDONE 8034290 $73.00FVH 13001381 CULTURE TYPING BY IF 8714090 $107.00FVH 13001388 HYPOGLYCEMIC SCREEN 8030790 $73.00FVH 13001394 ARSENIC FRACTIONATED 8217590 $64.00FVH 13001395 EHRLICHIA ANTIBODY ANAPLASMA 8666690 86666 $126.00FVH 13001397 HUMAN METAPNEUMAVIRUS 8729990 $9.00FVH 13001403 LIPOPROTEIN BY NMR 8370490 $200.00FVH 13001405 25 HYDVIT D2 AND D3 8230690 $200.00FVH 13001415 CIRCULATING TUMOR CELL COUNT 8615290 $108.00FVH 13001439 HTLV I/II ANTIBODY 8679090 $30.00FVH 13001443 CHRONIC URTICARIA INDEX 8635290 $108.00FVH 13001455 LIPOPROTEIN BLD HR FRACTION 8370190 $62.00FVH 13001459 TRIGLYCERIDES 8447890 $9.00FVH 13001460 POTASSIUM OTHER SOURCE 8499990 $55.00

28

FVH 13001469 21 HYDROXYLASE 8351990 $76.00FVH 13001470 INTERLEUKIN 6 8352090 $143.00FVH 13001471 INFLIXIMAB/HACA 8023090 $76.00FVH 13001472 TUMOR NECROSIS FACTOR ALPHA 8352090 $76.00FVH 13001482 FUNGAL ID EA MOLD REF 8710790 $52.00FVH 13001484 FLAS2 (IBD) 8352090 $76.00FVH 13001485 FLAX (IBD) 8352090 $76.00FVH 13001486 VEGF (IBD) 8352090 $76.00FVH 13001487 ICAM (IBD) 8239790 $55.00FVH 13001488 VCAM (IBD) 8239790 $55.00FVH 13001489 SAA (IBD) 8239790 $55.00FVH 13001490 CRP (IBD) 8614090 $76.00FVH 13001509 HEMOCHROMAT MUT 8125690 $108.00FVH 13001510 MTHFR MUT 8129190 $108.00FVH 13001511 PROTHROMBIN MUT 8124090 $108.00FVH 13001512 FACTOR V LEIDEN MUT 8124190 $108.00FVH 13001525 ACGH WHOLE GENOME 8122990 $1,310.00FVH 13001527 QUANT ASSAY THERAPEUTIC DRUG 8029990 80299 $73.00FVH 13001534 CULT TYP DNA/RNA SEQUENCING 8715390 $107.00FVH 13001543 BCR/ABL1 MAJOR MUT 8120690 $358.50FVH 13001544 JAK2 MUT 8127090 $300.00FVH 13001545 CUTANEOUS IMMFLUOR AB IGG 8834690 $108.00FVH 13001547 STONE RISK URINE CHLORIDE 8243690 82436 $42.00FVH 13001561 TITIN ANTIBODY 8351690 83516 $76.00FVH 13001562 FARMER LUNG ASPERGILLUS AB 8660690 86606 $108.00FVH 13001563 ANTIBODY IMMUNOASSAY 8351690 83516 $76.00FVH 13001565 MONONUCL CELL ANTIGEN,QNT 8635690 $74.00FVH 13001568 THIOPURINE METHYLTRANSFER RBC 8265790 82657 $200.00FVH 13001569 AMPHETAMINE URINE CONF/QNT $73.00FVH 13001570 BARBITURATE URINE CONF/QNT $73.00FVH 13001571 BENZODIAZEPINE URINE CONF/QNT $73.00FVH 13001572 CANNABINOIDS URINE CONF/QNT $120.00FVH 13001573 COCAINE URINE CONF/QNT $73.00FVH 13001574 METHADONE URINE CONF/QNT $73.00FVH 13001575 TRICYCLIC URINE CONF/QNT $73.00FVH 13001576 PHENCYCLIDINE URINE CONF/QNT $64.00FVH 13001577 PROPOXYPHENE URINE CONF/QNT $73.00FVH 13001578 IBT ALLERGENS IGE QUANTITATIVE 8600390 86003 $76.00FVH 13001579 IBT CELLULAR FUNCTION ASSAY 8635290 86352 $108.00FVH 13001588 TPMT MUT 8133590 $108.00FVH 13001589 IBD SGI MUT 8147990 $108.00FVH 13001592 BCR/ABL1 MINOR MUT 8120790 $358.50FVH 13001593 JAK2 EXON 12 MUT 8140390 $401.00FVH 13001604 BETA D GLUCAN 8744990 $231.00FVH 13001641 AFB CULTURE ID BY NA PROBE 8714990 $111.00FVH 13001646 HLA B*57:01 8138190 $108.00FVH 13001652 AFP TOTAL AND L3% 8210790 $215.00FVH 13001660 MATERNAL SER SCRN 4 ANAL 8151190 81511 $494.00FVH 13001668 ANA ELISA 8603890 $20.00

29

FVH 13001682 TREPONEMA PALLIDUM TP-PA 8678090 $32.00FVH 13001683 RAJI CELL IMMUNE COMPLEX 8633290 $108.00FVH 13001696 SCID MUT 8147990 $108.00FVH 13001718 JCV ANTIBODIES 8671190 86711 $1,554.00FVH 13001721 MYCOBACTERIUM PCR 8755190 $804.00FVH 13001730 LIPID PANEL 8006190 $44.00FVH 13001731 APOLIPOPROTEIN B MAYO 8217290 $55.00FVH 13001740 AMITRIPTYLINE/NORTRIPTYLINE $55.00FVH 13001741 IMIPRAMINE/DESIPRAMINE $90.00FVH 13001742 DRUG SCREEN MULTICHAN MECONIUM 8030790 $22.00FVH 13001743 DRUG SCREEN ALCOHOL 8032090 $73.00FVH 13001744 DRUG SCREEN MULTICHAN URINE 8030790 $125.00FVH 13001752 Hep C VIRUS SEQUENCING 8790290 $386.00FVH 13001848 CULTURE HERPES VIRUS 8725290 $40.00FVH 13001867 BUPRENORPHINE QUANT 80348 $31.00FVH 13001868 COLBALT SERUM 8301890 $41.00FVH 13001873 BABESIA ABS IGG/M BY IFA 8675390 $37.00FVH 13001875 CD57/CD3 NK CELL ANT,QNT 8635690 $130.00FVH 13001880 DRUG SCREEN UMBILICAL CORD 8030790 $21.00FVH 13001881 CUTANEOUS IMMFLOUR AB IGG ADD 8835090 $108.00FVH 13001882 THIOPURINE METABOLITES 8029990 $110.00FVH 13001884 Q FEVER IGM PH 1 OR 2 TITER 8663890 $107.00FVH 13001885 Q FEVER IGG PH 1 OR 2 TITER 8663890 $64.00FVH 13001903 GI PATH PANEL 12-25 8750790 $627.00FVH 13001925 CEA 8237890 $55.00FVH 13001950 FLUORESCENT ANTIBODY 8625590 86255 $80.00FVH 13001951 NMO AQP4 IGG TITER 8625690 86256 $96.00FVH 13001999 BUPRENORPHINE URINE CONF/QNT $125.00FVH 13002000 DRUG SCREEN MULTICHAN PLASMA 8030790 $154.00FVH 13002005 CORTISOL TOT SALIVARY 8253390 $74.00FVH 13002008 GENETIC MISC TEST GROUP 3 $297.00FVH 13002010 GENETIC MISC TEST GROUP 5 $874.00FVH 13002011 GENETIC MISC TEST GROUP 6 $1,975.00FVH 13002012 ALCOHOL QUANT URINE $70.00FVH 13002040 BLASTOMYCES AG QNT 8744990 $190.00FVH 13002041 ALLERGEN SPEC IGE PURE 8600890 $60.00FVH 13002045 THC UMBILICAL CORD $97.00FVH 13002047 RABIES AB SCREEN 8638290 $111.00FVH 13002051 DRUG TEST DEF 1-7 CLASSES G0480 $126.00FVH 13002053 ACE CSF 8216490 82164 $55.00FVH 13002055 MUMPS IGG ABY 8673590 86735 $76.00FVH 13002056 RUBEOLA IGG ABY 8676590 86765 $76.00FVH 13002057 WNV IGG CSF 8678990 $108.00FVH 13002058 WNV IGM CSF 8678890 $108.00FVH 13002070 MECA/MECC GENE DETECTION REF 8764190 87641 $179.00FVH 13900442 MACROPROLACTIN $144.00FVH 17000390 TRIAMCINOLONE INJ 40MG/1ML VL J3301 $41.52FVH 17000810 CEFTRIAXONE SOD 250 MG VIAL J0696 $20.00FVH 17001531 PNEUMOCOCCAL VACCINE-23 5 DOSE 90732 $95.00

30

FVH 17001550 MEASLES,MUMPS,RUBELLA VACCINE 90707 $75.00FVH 17001560 VARICELLA VIRUS VACC, VARIVAX 90716 $125.00FVH 17002070 HYLAN G-F 20 16MG/2ML SYR J7325 $735.00FVH 17002101 METHYLPRED SOD SUC 40MG/1ML IV J2920 $6.00FVH 17002120 METHYLPRED SOD SUC 125MG/2ML J2930 $12.00FVH 17002301 HYDROCORTISONE INJ 100 MG/2 ML J1720 $4.00FVH 17002430 METHYLPRED ACE 80MG/ML 1ML IM J1040 $15.00FVH 17004760 MEPERIDINE INJ 50 MG/ML SYR J2175 $8.00FVH 17006681 VARICELLA VIRUS VACC, ZOSTAVAX 90736 $195.00FVH 17007650 KETOROLAC INJ 30 MG/ML VIAL J1885 $5.00FVH 17010610 TESTOSTERONE CYPIONATE 200MG/M J1071 $20.00FVH 17014480 BUPIVACAINE HCL 0.25% INJ 10 M $18.06FVH 17018590 HEPATITIS B VACC 20MCG/ML VL 90746 $91.00FVH 17019180 CYANOCOBALAMIN INJ 1000MCG/1ML J3420 $2.00FVH 17021080 DIPHENHYDRAMINE INJ 50 MG/ML J1200 $6.00FVH 17021160 PROMETHAZINE INJ 25 MG/ML VIAL J2550 $5.00FVH 17023640 LORAZEPAM INJ 2 MG/ML VIAL J2060 $5.00FVH 17024510 DIPHTH/TET/A.PERT (ADULT) VIAL 90715 $58.00FVH 17025210 TETANUS/DIP TOX ADS PF 0.5 SYR 90714 $41.00FVH 17025230 MENINGOCOCCAL VAX (MENACTRA) 90734 $122.00FVH 17026420 POLIOVIRUS VACCINE INACTIVATED 90713 $45.00FVH 17026620 PNEUMOCOCCAL VACCINE (CLINIC) 90732 $95.00FVH 17026660 PNEUMOCOCCAL VACCINE PNU-IMUNE 90732 $95.00FVH 17026665 ADMIN VACCINE PNEUMO $10.00FVH 17029990 HEPATITIS A VACCINE1440 ELUNIT 90632 $74.00FVH 17033730 ENOXAPARIN 40 MG/0.4 ML SYR J1650 (Null)FVH 17037230 HALOPERIDOL LACTATE 5 MG/ML J1630 $17.76FVH 17037540 IBANDRONATE SOD. 3 MG/3 ML KIT J1740 $214.00FVH 17038075 ADMIN VACCINE INFLUENZA $51.00FVH 17038820 MEASLES/RUBELLA VACCINE VIAL 90707 $75.00FVH 17038850 MEDROXYPROGEST 150MG J1050 $79.00FVH 17043740 INFLUENZA VAX .5ML PF,V3 * 90656 90656 $25.00FVH 17045010 QUINAPRIL 40 MG TAB A9270GY (Null)FVH 17049930 EPOETIN ALFA 10000U/ML RC635 Q4081 (Null)FVH 17049960 EPOETIN ALFA 4000 U/ML RC635 Q4081 (Null)FVH 17049970 EPOETIN ALFA 2000 U/ML RC634 Q4081 (Null)FVH 17049980 EPOETIN ALFA 3000 U/ML RC634 Q4081 (Null)FVH 17049990 EPOETIN ALFA 4000 U/ML RC634 Q4081 (Null)FVH 17052550 ROTAVIRUS VACCINE, LIVE PV 2ML 90681 $105.00FVH 17052690 SITAGLIPTIN/METFOR 50/1000 TAB A9270GY (Null)FVH 17052940 THYROID 90 MG TAB A9270GY (Null)FVH 17052950 ACITRETIN 10 MG CAP A9270GY (Null)FVH 17052960 ACITRETIN 25 MG CAP A9270GY (Null)FVH 17052980 MIN OIL/PETROLA/GLYCERI PF 7GM A9270GY (Null)FVH 17052990 MENTHOL 5% TOPICAL PATCH A9270GY (Null)FVH 17054670 METHYLPRED ACE 40MG/ML 10ML IM J1030 $9.00FVH 17054810 ROTAVIRUS VACC, LIVE (ROTARIX) 90681 $105.00FVH 17060550 INFLUENZA HIDOSE VAX 0.5 SYR * 90662 $58.00FVH 17062710 INFLUENZA VX .5 AD FLULAVAL x 90688 $38.00

31

FVH 17062760 INFLUENZA VX .5 ADLT FLUZONE x Q2038 $15.00FVH 17063911 ELTA LITE CREAM 3 OZ (Null)FVH 17075230 INFLUENZA VAX .5ML FLUARIX V4x 90686 $15.00FVH 17075320 INFLUENZA VAX .5ML FLUARIX x 90656 $15.00FVH 17079050 PNEUMOCOCCAL 13-VAL CONJ VAC x 90670 $270.00FVH 17085430 INFLUENZA VX .5 AD FLULA V4S x 90686 $25.00FVH 17085630 HYDROXYPROGEST. CAPR 250MG/1ML J1726 $36.00FVH 17099994 MISC MEDS 253 TAKE HOME A9270GY (Null)FVH 17099995 MISC MEDS 250 REQUISITION (Null)FVH 17099996 MISC MEDS 636 (Null)FVH 17099997 MISC MEDS 250 (Null)FVH 17099998 MISC MEDS 637 NON-COV A9270GY (Null)FVH 17938090 INFLUENZA VAX 0.25ML PED V3 X (Null)FVH 19000275 SHINGRIX VACCINE 90750 $250.00FVH 19001000 TD TOXOID PRESERVE FREE 90714 $41.00FVH 19001005 DEXAMETHASONE 1 MG J1100 $2.00FVH 19001010 KENALOG 10 MG J3301 $7.00FVH 19001012 BONIVA 1 MG INJ J1740 $214.00FVH 19001056 HEPATITIS A VACCINE ADULT 90632 $74.00FVH 19001059 PNEUMOCOCCAL VACC CONJ 13 VAL 90670 $275.00FVH 19001065 PNEUMOVAX VACCINE 90732 $95.00FVH 19001066 MENINGOCOCCAL VACCINE 90734 $122.00FVH 19001067 HEPATITIS B VACCINE ADULT 90746 $91.00FVH 19001068 CEFTRIAXONE ROCEPHIN 250 MG J0696 $20.00FVH 19001069 DEPR MEDROL 80MG J1040 $15.00FVH 19001071 DEMEROL 100 MG J2175 $8.00FVH 19001072 PROMETHAZINE HCL 50MG J2550 $5.00FVH 19001073 VITAMIN B12 1000MCG J3420 $2.00FVH 19001078 TDAP VACCINE > 7 90715 $58.00FVH 19001079 KETOROLAC INJ 15 MG J1885 $5.00FVH 19001081 DEPO MEDROL 40 MG J1030 $9.00FVH 19001082 BENADRYL PER 50 MG J1200 $6.00FVH 19001086 FLU VACCINE NO PRESERV 3 & > 90656 $25.00FVH 19001094 DENOSUMAB PER 1 MG J0897 $17.00FVH 19001095 LORAZEPAM 2 MG J2060 $5.00FVH 19001097 SOLUMEDROL 125 MG J2930 $12.00FVH 19001099 HYDROXYZINE HCL 25 MG J3410 $6.00FVH 19001118 VARICELLA VIRUS VACC, ZOSTAVAX 90736 $195.00FVH 19001130 METHYLPRED SOD SUC 40MG/1ML IV J2920 $6.00FVH 19001138 TESTOSTERONE CYPIONATE 1 MG J1071 $20.00FVH 19001147 HYDROCORTISONE INJ TO 100 MG J1720 $4.00FVH 19002070 HYLAN G-F 20 INJ 1 MG (SYNVISC J7325 $735.00FVH 19002076 NALTREXONE DEPOT FORM 1 MG J2315 $3.56FVH 19038850 MEDROXYPROGESTERONE 1 MG INJ J1050 $0.80FVH 21000006 PLACEMT BREAST LOC EA 19282 $515.00FVH 21000007 PLACEMT BREAST LOC 19281 $390.00FVH 21000013 INJ MAMMARY DUCTOGRAM 19030 $469.00FVH 21000014 DUCTOGRAM MULT DUCTS S&I RT $701.00FVH 21000015 DUCTOGRAM MULT DUCTS S&I LT $701.00

32

FVH 21000016 DUCTOGRAM SNGL DUCT S&I RT $479.00FVH 21000017 DUCTOGRAM SNGL DUCT S&I LT $479.00FVH 21000018 MAMMO BREAST SPECIMEN 76098 $90.00FVH 21000023 MAMMO DX DIGIT BILAT 77066 $323.00FVH 21000029 MAMMO DX DIGIT UNILAT RT $256.00FVH 21000030 MAMMO DX DIGIT UNILAT LT $256.00FVH 21000046 MAMMO SCRN DIGIT BILAT 77067 $279.00FVH 21000050 MAMMO SCRN DIGIT UNILAT RT $268.00FVH 21000051 MAMMO SCRN DIGIT UNILAT LT $268.00FVH 21000058 MAMMO SCREEN 3D 77063 $25.00FVH 21000059 MAMMO DIAG UNILATERAL 3D G0279 $25.00FVH 21000060 MAMMO DIAG BILATERAL 3D G0279 $25.00FVH 21000109 MAMMO DX DIGIT BILAT W CAD 77066 $380.00FVH 21000110 MAMMO DX DIGIT IMPL BIL W CAD 77066 $380.00FVH 21000111 MAMMO DX DGT IMPL UNI RT CAD $313.00FVH 21000112 MAMMO DX DGT IMPL UNI LT CAD $313.00FVH 21000115 MAMMO DX DIGIT UNILAT RT CAD $313.00FVH 21000116 MAMMO DX DIGIT UNILAT LT CAD $313.00FVH 21000117 MAMMO SCRN DIGIT BILAT W CAD 77067 $336.00FVH 21000118 MAMMO SCRN DGT IMPL BILAT CAD 77067 $335.00FVH 21000119 MAMMO SCRN DGT IMPL UNI R CAD $324.00FVH 21000120 MAMMO SCRN DGT IMPL UNI L CAD $324.00FVH 21000121 MAMMO SCRN DIGIT UNI RT CAD $324.00FVH 21000122 MAMMO SCRN DIGIT UNI LT CAD $324.00FVH 25000002 CHEST COMPLETE MIN 4 VIEW 71048 $194.00FVH 25000003 ABDOMEN SINGLE AP VIEW 74018 $111.00FVH 25000005 ABDOMEN COMPL DECUB/ERECT 74019 $145.00FVH 25000006 ABDOMEN COMPL SERIES 3 WAY 74022 $168.00FVH 25000007 ACROMIO CLAVICULAR JOINTS 73050 $157.00FVH 25000011 ANKLE 2 VIEW RT $111.00FVH 25000012 ANKLE 2 VIEW LT $111.00FVH 25000013 ANKLE COMPL MIN 3 VIEW RT $124.00FVH 25000014 ANKLE COMPL MIN 3 VIEW LT $124.00FVH 25000015 ARTHROGRAM ELBOW S&I RT $283.00FVH 25000016 ARTHROGRAM ELBOW S&I LT $283.00FVH 25000017 ARTHROGRAM KNEE S&I RT $569.00FVH 25000018 ARTHROGRAM KNEE S&I LT $569.00FVH 25000019 ARTHROGRAM SHOULDER S&I RT $469.00FVH 25000020 ARTHROGRAM SHOULDER S&I LT $469.00FVH 25000023 ARTHROGRAM HIP 27093 $413.00FVH 25000024 ARTHROGRAM HIP S&I RT $402.00FVH 25000025 ARTHROGRAM HIP S&I LT $402.00FVH 25000026 ARTHROGRAM ANKLE RT $402.00FVH 25000027 ARTHROGRAM ANKLE LT $402.00FVH 25000029 BONE AGE STUDIES 77072 $79.00FVH 25000030 BONE LENGTH STUDY LONG 77073 $75.00FVH 25000032 BONE SURVEY COMPL 77075 $357.00FVH 25000034 CALCANEUS MIN 2 VIEW RT $111.00FVH 25000035 CALCANEUS MIN 2 VIEW LT $111.00

33

FVH 25000039 CHEST LATERAL 71045 $124.00FVH 25000041 CHOLANGIOGRAM INTRAOPERATIVE 74300 $111.00FVH 25000042 CLAVICLE COMPL RT $111.00FVH 25000043 CLAVICLE COMPL LT $111.00FVH 25000045 COLON AIR CONTR W/HIGH DENS BA 74280 $624.00FVH 25000046 COLON BARIUM ENEMA W/WO KUB 74270 $469.00FVH 25000048 BONE SURVEY INFANT 77076 $222.00FVH 25000049 CYSTOGRAM MIN 3 VIEW 74430 $279.00FVH 25000052 ELBOW 2 VIEW RT $111.00FVH 25000053 ELBOW 2 VIEW LT $111.00FVH 25000054 ELBOW COMPL MIN 3 VIEW RT $134.00FVH 25000055 ELBOW COMPL MIN 3 VIEW LT $134.00FVH 25000056 EYE FB DETECTION 70030 $101.00FVH 25000059 ESOPHAGRAM W/CONTR 74220 $302.00FVH 25000061 FACIAL BONES COMPL MIN 3 VIEW 70150 $178.00FVH 25000064 FINGER MIN 2 VIEW RT $111.00FVH 25000065 FINGER MIN 2 VIEW LT $111.00FVH 25000066 *FLUOR >1 HR NON-RADIOLOGIST 76001 $212.00FVH 25000072 FOOT 2 VIEW RT $111.00FVH 25000073 FOOT 2 VIEW LT $111.00FVH 25000074 FOOT COMPL MIN 3 VIEW RT $124.00FVH 25000075 FOOT COMPL MIN 3 VIEW LT $124.00FVH 25000076 FOREARM 2 VIEW RT $111.00FVH 25000077 FOREARM 2 VIEW LT $111.00FVH 25000080 GI TRACT UPPER W/O KUB 74240 $357.00FVH 25000081 GI TRACT UPPER W/SM BOWEL 74240 $603.00FVH 25000082 GI TRACT AIR CONTRAST W/O KUB 74246 $413.00FVH 25000084 HAND 2 VIEW RT $111.00FVH 25000085 HAND 2 VIEW LT $111.00FVH 25000086 HAND MIN 3 VIEW RT $124.00FVH 25000087 HAND MIN 3 VIEW LT $124.00FVH 25000088 HIP BILAT MIN 2 VIEW 73521 $157.00FVH 25000091 HIP UNILAT 1 VIEW RT $101.00FVH 25000092 HIP UNILAT 1 VIEW LT $101.00FVH 25000093 HIP UNILAT 2 VIEW RT $134.00FVH 25000094 HIP UNILAT 2 VIEW LT $134.00FVH 25000095 HUMERUS MIN 2 VIEW RT $124.00FVH 25000096 HUMERUS MIN 2 VIEW LT $124.00FVH 25000097 HYSTEROSALPINGOGRAM S&I 74740 $312.00FVH 25000099 METABOLIC SURVEY 77077 $222.00FVH 25000100 KNEE 1 OR 2 VIEW RT $124.00FVH 25000101 KNEE 1 OR 2 VIEW LT $124.00FVH 25000102 KNEE 3 VIEW RT $134.00FVH 25000103 KNEE 3 VIEW LT $134.00FVH 25000104 KNEE COMPL 4 OR MORE VIEW RT $157.00FVH 25000105 KNEE COMPL 4 OR MORE VIEW LT $157.00FVH 25000106 KNEE STANDING AP BILAT 73565 $111.00FVH 25000110 MANDIBLE COMPL MIN 4 VIEW 70110 $167.00FVH 25000111 MANDIBLE PARTIAL <4 VIEW 70100 $124.00

34

FVH 25000113 MASTOIDS COMPL MIN 3 VIEW 70130 $191.00FVH 25000114 MYELOGRAM CERVICAL S&I 72240 $925.00FVH 25000115 MYELOGRAM LUMBAR S&I 72265 $814.00FVH 25000116 MYELOGRAM SPINAL CANAL COMPL S 72270 $1,226.00FVH 25000117 MYELOGRAM THORACIC S&I 72255 $847.00FVH 25000118 NASAL BONES COMPL MIN 3 VIEW 70160 $124.00FVH 25000120 ORBITS COMPL MIN 4 VIEW 70200 $178.00FVH 25000122 FLUOR GUIDE SPINE PROC 77003 $256.00FVH 25000124 PELVIS 1 OR 2 VIEW 72170 $111.00FVH 25000125 PELVIS & HIP 2 VIEW FROGLEG 73521 $145.00FVH 25000126 PELVIS COMPL PUBIC RA MIN 3 VI 72190 $157.00FVH 25000128 RIB BILAT W/PA CHEST MIN 4 VIE 71111 $212.00FVH 25000129 RIB UNILATERAL 2 VIEW LT $134.00FVH 25000130 RIB UNILATERAL 2 VIEW RT $134.00FVH 25000131 RIB UNILAT W/PA CHEST RT $157.00FVH 25000132 RIB UNILAT W/PA CHEST LT $157.00FVH 25000133 SACROILIAC JT < 3 VIEW 72200 $124.00FVH 25000134 SACROILIAC JT 3 OR MORE VIEW 72202 $145.00FVH 25000136 SACRUM/COCCYX MIN 2 VIEW 72220 $124.00FVH 25000139 SCAPULA COMPL RT $124.00FVH 25000141 SHOULDER 1 VIEW RT $101.00FVH 25000142 SHOULDER 1 VIEW LT $101.00FVH 25000143 SHOULDER COMPL MIN 2 VIEW RT $124.00FVH 25000144 SHOULDER COMPL MIN 2 VIEW LT $124.00FVH 25000146 SINUSES COMPL MIN 3 VIEW 70220 $168.00FVH 25000147 SKULL <4 VIEW 70250 $145.00FVH 25000148 SKULL COMPL MIN 4 VIEW 70260 $191.00FVH 25000150 SMALL BOWEL W/MULT SERIAL FILM 74250 $346.00FVH 25000151 SPINE CERVICAL 2-3 VIEW 72040 $145.00FVH 25000152 SPINE CERV COMPL W/OBLIQ FLEX 72052 $256.00FVH 25000153 SPINE CERVICAL MIN 4-5 VIEW 72050 $212.00FVH 25000155 SPINE DORSAL THOR 3 VIEW 72072 $168.00FVH 25000157 SPINE LUMBAR 2 - 3 VIEW 72100 $157.00FVH 25000158 SPINE SINGLE VIEW 72020 $101.00FVH 25000159 SPINE LUMBAR MIN 4 VIEW 72110 $212.00FVH 25000160 SPINE NECK SOFT TISSUE 70360 $101.00FVH 25000161 SPINE SCOLIOSIS 2-3 VIEW 72082 $168.00FVH 25000162 SPINE THORACIC 2 VIEW 72070 $145.00FVH 25000163 SPINE SCOLIOSIS 1 VIEW 72081 $168.00FVH 25000164 STERNO CLAV JT MIN 3 VIEW 71130 $157.00FVH 25000165 STERNUM MIN 2 VIEW 71120 $145.00FVH 25000167 SWALLOW STUDY W/MODIFIED VIDEO 74230 $312.00FVH 25000168 TIBIA/FIBULA 2 VIEW LOW LEG RT $111.00FVH 25000169 TIBIA/FIBULA 2 VIEW LOW LEG LT $111.00FVH 25000170 TM JOINT OPEN CLOSED BILAT 70330 $191.00FVH 25000171 TOE MIN 2 VIEW RT $101.00FVH 25000172 TOE MIN 2 VIEW LT $101.00FVH 25000173 URETHROCYSTOGRAPHY RETRO 74450 $386.00FVH 25000174 VOIDING CYSTOGRAM 74455 $380.00

35

FVH 25000176 IVP 74400 $424.00FVH 25000178 PARACENTESIS ABD W/O IMAGING 49082 $413.00FVH 25000179 WRIST 2 VIEW RT $111.00FVH 25000180 WRIST 2 VIEW LT $111.00FVH 25000181 WRIST COMPL MIN 3 VIEW RT $134.00FVH 25000182 WRIST COMPL MIN 3 VIEW LT $134.00FVH 25000184 CHEST 1 VIEW FRONTAL PA ONLY 71045 $101.00FVH 25000187 CHEST 2 VIEW PA/LAT 71046 $134.00FVH 25000188 CHEST 2 VIEW LORDOTIC 71046 $157.00FVH 25000195 ARTHROGRAM ANKLE RT $400.00FVH 25000196 ARTHROGRAM ANKLE LT $400.00FVH 25000197 ARTHROGRAM ELBOW RT $618.00FVH 25000198 ARTHROGRAM ELBOW LT $618.00FVH 25000199 ARTHROGRAM KNEE RT $302.00FVH 25000200 ARTHROGRAM KNEE LT $302.00FVH 25000201 ARTHROGRAM SHOULDER RT $302.00FVH 25000202 ARTHROGRAM SHOULDER LT $302.00FVH 25000203 ARTHROGRAM WRIST RT $319.00FVH 25000204 ARTHROGRAM WRIST LT $319.00FVH 25000206 PLACEMT NASO OROGAST TUBE FLU 43752 $163.00FVH 25000212 INJ MYELOGRAPHY/CT SPINAL 62284 $513.00FVH 25000253 LE 2 VIEW INFANT RT $111.00FVH 25000254 LE 2 VIEW INFANT LT $111.00FVH 25000255 UE 2 VIEW INFANT RT $111.00FVH 25000256 UE 2 VIEW INFANT LT $111.00FVH 25000257 FLUORO GUIDE BIOPSY OR INJ 77002 $279.00FVH 25000263 CHEST W OBLIQUES 71048 $168.00FVH 25000274 TM JOINT OPEN CLOSED RT $111.00FVH 25000275 TM JOINT OPEN CLOSED LT $111.00FVH 25000289 SPINE THOROCOLUMBAR 2 VIEW 72080 $145.00FVH 25000292 RIB BILATERAL 3 VIEW 71110 $168.00FVH 25000304 CONTRAST NON-ION 100-199 MG/ML Q9965 $2.00FVH 25000306 DEXA HIP PELVIS SPINE 77080 $220.00FVH 25000307 CONTRAST IONIC UP TO 149 MG/ML Q9958 $2.00FVH 25000310 CONTRAST NON ION 200-299 MG/ML Q9966 $2.00FVH 25000311 CONTRAST NON ION 300-399 MG/ML Q9967 $0.20FVH 25000315 SCAPULA COMPL LT $124.00FVH 25000323 HAND 2 VIEW BILAT SINGLE IMAGE 73120 $75.00FVH 25000345 ADIPOCELL PROCEDURE NON COV $900.00FVH 25000346 NERVE BLOCK BRACHIAL PLEXUS 64415 $464.00FVH 25000347 MYELOGRAM CERV INC S/I SAME MD 62302 $513.00FVH 25000348 MYELOGRAM THOR INC S/I SAME MD 62303 $513.00FVH 25000349 MYELOGRAM L/S INC S/I SAME MD 62304 $513.00FVH 25000350 MYELOGRAM >2 INC S/I SAME MD 62305 $513.00FVH 25000359 ARTHROGRAM WRIST BILAT 2524650 $479.00FVH 25000364 ASP INJ SM JOINT 20600 $155.00FVH 25000365 FEMUR 1 VIEW RT $124.00FVH 25000366 FEMUR 1 VIEW LT $124.00FVH 25000367 FEMUR 2 VIEW RT $124.00

36

FVH 25000368 FEMUR 2 VIEW LT $124.00FVH 25000369 HIP UNILAT W PELVIS 1 VIEW RT $101.00FVH 25000370 HIP UNILAT W PELVIS 1 VIEW LT $101.00FVH 25000371 HIP UNILAT W PELVIS 2-3 RT $134.00FVH 25000372 HIP UNILAT W PELVIS 2-3 LT $134.00FVH 25000373 HIP UNILAT W PELVIS 4 VIEW RT $134.00FVH 25000374 HIP UNILAT W PELVIS 4 VIEW LT $134.00FVH 25000375 HIP BILAT W PELVIS 2 VIEW 73521 $157.00FVH 25000377 HIP BILAT W PELVIS 3-4 73522 $157.00FVH 25000396 LUMBAR PUNCTURE DX W FLURO/CT 62328 $380.00FVH 25000398 UGI FOLLOW THROUGH STUDY 74248 $175.00FVH 25000502 LUMBAR PUNCTURE PROC DIAG 62270 $380.00FVH 25000707 INJECTION PLATELET PLASMA $155.00FVH 25000716 ST BX SHOULDER; SUPERFICIAL 23065 $773.00FVH 25000717 ABDOMEN FLAT/DECUB/ERECT 74021 $100.00FVH 25000720 ASP FN NDL BX W/FLUOR GDN 1ST 10007 $546.00FVH 25000721 ASP FN NDL BX W/FLUO GDN EA AD 10008 $356.00FVH 27000004 MRA ABDOMEN W/WO CONTR 74185 C8902 $2,663.00FVH 27000007 MRA CHEST W/WO CONTR 71555 C8911 $2,685.00FVH 27000008 MRA LE W/CONTRAST RT C8912RT $2,674.00FVH 27000009 MRA LE W/CONTRAST LT C8912LT $2,674.00FVH 27000010 MRA LE W/O CONTRAST RT C8913RT $2,630.00FVH 27000011 MRA LE W/O CONTRAST LT C8913LT $2,630.00FVH 27000012 MRA LE W/WO CONTRAST RT C8914RT $6,227.00FVH 27000013 MRA LE W/WO CONTRAST LT C8914LT $6,227.00FVH 27000014 MRA UE W/CONTRAST RT $2,507.00FVH 27000015 MRA UE W/CONTRAST LT $2,507.00FVH 27000020 MRA PELVIS W/CONTR 72198 C8918 $2,663.00FVH 27000023 MRI ABDOMEN W/CONTR 74182 $3,142.00FVH 27000024 MRI ABDOMEN W/O CONTR 74181 $2,517.00FVH 27000025 MRI ABDOMEN W/WO CONTR 74183 $5,147.00FVH 27000037 MRI CHEST W/CONTR 71551 $3,175.00FVH 27000038 MRI CHEST W/O CONTR 71550 $2,719.00FVH 27000039 MRI CHEST W/WO CONTR 71552 $5,292.00FVH 27000040 MRI LE ANY JT W/CONTRAST RT $2,997.00FVH 27000041 MRI LE ANY JT W/CONTRAST LT $2,997.00FVH 27000042 MRI LE ANY JT W/O CONTRAST RT $2,585.00FVH 27000043 MRI LE ANY JT W/O CONTRAST LT $2,585.00FVH 27000044 MRI LE ANY JT W/WO CONTRAST RT $5,058.00FVH 27000045 MRI LE ANY JT W/WO CONTRAST LT $5,058.00FVH 27000046 MRI LE EXC JT W/CONTRAST RT $3,030.00FVH 27000047 MRI LE EXC JT W/CONTRAST LT $3,030.00FVH 27000048 MRI LE EXC JT W/O CONTRAST RT $2,608.00FVH 27000049 MRI LE EXC JT W/O CONTRAST LT $2,608.00FVH 27000050 MRI LE EXC JT W/WO CONTRAST RT $5,136.00FVH 27000051 MRI LE EXC JT W/WO CONTRAST LT $5,136.00FVH 27000052 MRI UE ANY JT W/CONTRAST RT $2,987.00FVH 27000053 MRI UE ANY JT W/CONTRAST LT $2,986.00FVH 27000054 MRI UE ANY JT W/O CONTRAST RT $2,574.00

37

FVH 27000055 MRI UE ANY JT W/O CONTRAST LT $2,574.00FVH 27000056 MRI UE ANY JT W/WO CONTRAST RT $5,069.00FVH 27000057 MRI UE ANY JT W/WO CONTRAST LT $5,069.00FVH 27000058 MRI UE EXC JT W/CONTRAST RT $3,042.00FVH 27000059 MRI UE EXC JT W/CONTRAST LT $3,042.00FVH 27000060 MRI UE EXC JT W/O CONTRAST RT $2,630.00FVH 27000061 MRI UE EXC JT W/O CONTRAST LT $2,630.00FVH 27000062 MRI UE EXC JT W/WO CONTRAST RT $5,136.00FVH 27000063 MRI UE EXC JT W/WO CONTRAST LT $5,136.00FVH 27000064 MRI FACE/NECK/ORBITS W/CONTR 70542 $3,030.00FVH 27000065 MRI FACE/NECK/ORBITS W/O CONT 70540 $2,608.00FVH 27000066 MRI PELVIS W/CONTR 72196 $3,042.00FVH 27000067 MRI PELVIS W/O CONTR 72195 $2,618.00FVH 27000068 MRI PELVIS W/WO CONTR 72197 $5,136.00FVH 27000070 MRI TMJ 70336 $2,530.00FVH 27000071 MRA HEAD W/WO CONTR 70546 $4,969.00FVH 27000072 MRA NECK W/WO CONTR 70549 $4,957.00FVH 27000076 MRI BRAIN STEM W/CONTR 70552 $3,075.00FVH 27000077 MRI BRAIN STEM W/O CONTR 70551 $2,641.00FVH 27000078 MRI BRAIN STEM W/WO CONTR 70553 $5,157.00FVH 27000079 MRI FACE/NECK/ORBITS W/WO CONT 70543 $5,124.00FVH 27000089 MRI SPINE CERVICAL W/CONTR 72142 $3,075.00FVH 27000090 MRI SPINE CERVICAL W/O CONTR 72141 $2,540.00FVH 27000091 MRI SPINE CERVICAL W/WO CONTR 72156 $5,136.00FVH 27000092 MRI SPINE DORS/THOR W/CONTR 72147 $2,963.00FVH 27000093 MRI SPINE DORS/THOR W/O 72146 $2,752.00FVH 27000094 MRI SPINE DORS THOR W/WO CONTR 72157 $5,046.00FVH 27000095 MRI SPINE LUMBAR W/CONTR 72149 $3,075.00FVH 27000096 MRI SPINE LUMBAR W/O CONTR 72148 $2,752.00FVH 27000097 GADOLINIUM PER ML A9579 $4.80FVH 27000098 MRI SPINE LUMBAR W/WO CONTR 72158 $5,136.00FVH 27000099 MRA HEAD W/CONTR 70545 $2,719.00FVH 27000105 MRA HEAD W/O CONTR 70544 $2,719.00FVH 27000106 MRA NECK W/CONTR 70548 $2,763.00FVH 27000107 MRA NECK W/O CONTR 70547 $2,719.00FVH 27000136 GADAVIST PER .1 ML A9585 $4.80FVH 29000002 BONE LENGTH STUDY SCANOGRAM 77073 $191.00FVH 29000003 CT 3D RENDER W/O POSTPROCESS 76376 $636.00FVH 29000005 CT LIMITED 76380 $825.00FVH 29000006 PERITONEAL ABSCESS DRAIN PERC 49406 $1,545.00FVH 29000014 BX PANCREAS PERCUTANEOUS 48102 $1,505.00FVH 29000019 CTA ABD AORTA W/ RUNOFF 75635 $1,391.00FVH 29000020 CT ABDOMEN W/CONTR 74160 $1,605.00FVH 29000021 CT ABDOMEN W/O CONTR 74150 $1,259.00FVH 29000023 CT ABDOMEN W/WO CONTR 74170 $2,061.00FVH 29000026 CT CERVICAL SPINE W/O CONTR 72125 $1,326.00FVH 29000027 CT LE W/O CONTRAST RT $1,160.00FVH 29000028 CT LE W/O CONTRAST LT $1,160.00FVH 29000029 CT UE W/O CONTRAST RT $1,160.00

38

FVH 29000030 CT UE W/O CONTRAST LT $1,160.00FVH 29000031 CT GUIDE NEEDLE PLACEMT 77012 $402.00FVH 29000032 CT GUIDE STEREOTACTIC LOCALIZ 77011 $285.00FVH 29000035 CT LUMBAR SPINE W/CONTR 72132 $1,605.00FVH 29000036 CT LUMBAR SPINE W/O CONTR 72131 $1,326.00FVH 29000037 CT MAX/SINUSES W/O CONTR 70486 $1,137.00FVH 29000038 CT NECK SOFT TISSUE W/O CONTR 70490 $1,126.00FVH 29000039 CT PELVIS W/CONTR 72193 $1,538.00FVH 29000040 CT PELVIS W/O CONTR 72192 $1,304.00FVH 29000042 CT PELVIS W/WO CONTR 72194 $1,950.00FVH 29000043 CT ANGIO HEAD W/WO CONTR 70496 $1,288.00FVH 29000044 CT ANGIO NECK W/WO CONTR 70498 $1,316.00FVH 29000045 CT BRAIN W/CONTR 70460 $1,281.00FVH 29000046 CT BRAIN W/O CONTR 70450 $1,048.00FVH 29000047 CT BRAIN W/WO CONTR 70470 $1,593.00FVH 29000048 CT FACIAL BONES W/CONTR 70487 $1,393.00FVH 29000049 CT FACIAL BONES W/O CONTR 70486 $1,137.00FVH 29000050 CT FACIAL BONES W/WO CONTR 70488 $1,727.00FVH 29000051 CT NECK SOFT TISSUE W/CONTR 70491 $1,360.00FVH 29000052 CT NECK SOFT TISSUE W/WO CONT 70492 $1,705.00FVH 29000053 CT ORBITS W/CONTR 70481 $1,461.00FVH 29000054 CT ORBITS W/O CONTR 70480 $1,226.00FVH 29000055 CT ORBITS W/WO CONTR 70482 $1,772.00FVH 29000056 CT ANGIO ABDOMEN W/WO CONTR 74175 $1,795.00FVH 29000057 CT ANGIO CHEST W/WO CONTR 71275 $2,150.00FVH 29000060 CT ANGIO UE W/WO CONTRAST RT $1,500.00FVH 29000061 CT ANGIO UE W/WO CONTRAST LT $1,500.00FVH 29000063 CT CERVICAL SPINE W/CONTR 72126 $1,605.00FVH 29000064 CT CERVICAL SPINE W/WO CONTR 72127 $950.00FVH 29000065 CT LE W/CONTRAST RT $1,404.00FVH 29000066 CT LE W/CONTRAST LT $1,404.00FVH 29000067 CT LE W/WO CONTRAST RT $1,805.00FVH 29000068 CT LE W/WO CONTRAST LT $1,805.00FVH 29000069 CT UE W/CONTRAST RT $1,404.00FVH 29000070 CT UE W/CONTRAST LT $1,404.00FVH 29000071 CT UE W/WO CONTRAST RT $1,794.00FVH 29000072 CT UE W/WO CONTRAST LT $1,794.00FVH 29000073 CT LUMBAR SPINE W/WO CONTR 72133 $1,677.00FVH 29000074 CT THORACIC SPINE W/CONTR 72129 $1,605.00FVH 29000075 CT THORACIC SPINE W/O CONTR 72128 $1,326.00FVH 29000077 CT THORAX W/CONTR CHEST 71260 $1,605.00FVH 29000078 CT THORAX W/O CONTR CHEST 71250 $1,326.00FVH 29000079 CT THORAX W/WO CONTR CHEST 71270 $2,017.00FVH 29000080 BX BONE TROC/NDLE DEEP 20225 $691.00FVH 29000081 BX BONE TROC/NDLE SUPERF 20220 $330.00FVH 29000083 *ASPIR FINE NEEDLE W/IMG TISSU 10022 $390.00FVH 29000086 BX LIVER NEEDLE PERC 47000 $580.00FVH 29000087 BX LUNG/MEDIAST NDLE PERC 32405 $590.00FVH 29000092 BX CT GUIDED ABD/RENAL/NEEDLE 50200 $891.00

39

FVH 29000098 CT CHEST SCREENING $72.00FVH 29000104 CONTRAST NON ION 300-399 MG/ML Q9967 $0.20FVH 29000106 CT GUIDED PERC DRAIN ABSCESS 75989 $636.00FVH 29000119 CT ABD AND PELVIS WO CONTRAST 74176 $1,713.00FVH 29000120 CT ABD AND PELVIS W CONTRA 74177 $2,088.00FVH 29000121 CT ABD AND PELVIS W/WO CONTRA 74178 $2,726.00FVH 29000124 CT MUSCLE BIOPSY PERCUTANEOUS 20206 $368.00FVH 29000125 CTA ABD PELVIS W CONTRAST 74174 $2,326.00FVH 29000137 ASP INJ MAJOR JOINT 20610 $109.00FVH 29000138 INJ SACROILIAC JNT 27096 $361.00FVH 29000147 INJ FACET JNT L/S SNG LEVEL 64493 $361.00FVH 29000177 INJ TRIGGER POINT 1 OR 2 20552 $165.00FVH 29000180 BX BONE MARROW 38221 $1,100.00FVH 29000196 ASP FN NDL BX W/CT GDN 1ST LES 10009 $665.00FVH 29000197 ASP FN NDL BX W/CT GDN EA ADDL 10010 $485.00FVH 30000101 SIALOGRAM S&I 70390 $424.00FVH 30000102 SINUS TRACT OR TUBE INJ S&I 76080 $150.00FVH 30000165 US GUIDE VASC ACCESS/SPEC PROC 76937 $101.00FVH 30000166 BX ABD RETROPERITO PERC FLU 49180 $524.00FVH 30000177 ASPIR INJ MAJOR JT 20610 $289.00FVH 30000178 ASPIR INJ INTERM JT 20605 $245.00FVH 30000266 LUMBAR ASP PERC DISK ANY METH 62267 $650.00FVH 30000284 INJ NERVE ROOT BLK LUMBAR 64483 $647.00FVH 30000290 INSERT PICC W/O SQ PORT >5YR 36569 $446.00FVH 30000325 DRAIN RENAL/PERIRENAL ABSC PER 49405 $1,545.00FVH 30000327 INJ SACROILIAC JOINT 27096 $379.00FVH 30000330 SINUS TRACT FISTULA INJ DX 20501 $575.00FVH 30000682 CHANGE GJ TUBE PERC INCL S/I 49452 $657.00FVH 30000737 INJ LIGAMENT/TENDON 20550 $235.00FVH 30000776 INJ TRIGGER POINT 1 OR 2 20552 $201.00FVH 30000796 INJ FACET JNT L/S SINGLE LEVEL 64493 $216.00FVH 30000911 INJ ANES SPHENOPALATINE GANGLI 6450550 $340.00FVH 30000977 INSRT PICC WO SQ PORT W IMG >5 36573 $446.00FVH 31000003 PARACENTESIS ABD W/O IMAGING 49082 $361.00FVH 31000015 PUNCTURE ASPIR BREAST CYST US 19000 $175.00FVH 31000016 *ASPIR FINE NEEDLE W/IMG TISSU 10022 $379.00FVH 31000023 BX PROSTATE NEEDLE PUNCH US 55700 $780.00FVH 31000029 US ABDOMEN COMPL 76700 $479.00FVH 31000030 US ABDOMEN LIMITED 76705 $357.00FVH 31000031 US ABD LIMITED TRAUMA 4 QUAD 76705 $361.00FVH 31000034 US AORTA LIMITED 76775 $357.00FVH 31000038 US CHEST 76604 $312.00FVH 31000039 US EXTREMITY NON VASC RT 76882 $402.00FVH 31000044 US GUIDE NEEDLE PLACEMENT 76942 $803.00FVH 31000045 US HEAD NEONATAL 76506 $380.00FVH 31000046 US HEAD NECK SOFT TISSUE 76536 $380.00FVH 31000050 US INTRAOPERATIVE 76998 $101.00FVH 31000051 US KIDNEY TRANSPL W/WO DOPPL 76776 $502.00FVH 31000052 US LIVER LIMITED 76705 $357.00

40

FVH 31000053 US OB <14 WK ADDIT GESTATION 76802 $222.00FVH 31000054 US OB <14 WK SNGL GESTATION 76801 $479.00FVH 31000055 US OB >14 WK ADDIT GESTATION 76810 $279.00FVH 31000056 US OB >14 WK SNGL GESTATION 76805 $502.00FVH 31000057 US OB BIOPHYS PROF W/O N-STRES 76819 $357.00FVH 31000058 US OB DETAIL ADDIT GESTATION 76812 $413.00FVH 31000059 US OB DETAIL SNGL GESTATION 76811 $769.00FVH 31000060 US OB LIMITED 76815 $334.00FVH 31000061 US OB FOLLOW-UP 76816 $312.00FVH 31000062 US OB TRANSVAGINAL 76817 $357.00FVH 31000064 US PELVIC LIMITED/FOLLOW-UP 76857 $413.00FVH 31000065 US PELVIS COMPL 76856 $402.00FVH 31000066 US TRANSRECTAL 76872 $513.00FVH 31000067 US PROSTATE VOL STUDY BRACHY T 76873 $650.00FVH 31000070 US SCROTUM 76870 $792.00FVH 31000072 US SPINAL CANAL AND CONTENTS 76800 $309.00FVH 31000073 US SPLEEN LIMITED 76705 $361.00FVH 31000074 US TRANSVAGINAL NON OB 76830 $402.00FVH 31000075 US URINE CAPACITY MEASURE 76857 $220.00FVH 31000077 PLACEMT BREAST LOC 19285 $1,406.00FVH 31000082 DUPLEX ABDOMEN LIMITED US 93976 $903.00FVH 31000084 US RETROPERITONEAL COMPLETE 76770 $479.00FVH 31000096 ASPIR ABSCESS/HEMATOMA/CYST 10160 $412.00FVH 31000104 TISSUE MARKER IMPLANTABLE US A4648 $258.00FVH 31000107 US GALLBLADDER 76705 $357.00FVH 31000118 US EXTREMITY NON VASC LT 76882 $402.00FVH 31000122 US HIP INFANT DYNAMIC BIL 76885 $424.00FVH 31000126 US HIP INFANT STATIC 76886 $357.00FVH 31000130 BX LIVER NEEDLE US GUIDED 47000 $515.00FVH 31000135 US OB NUCHAL TRANSLU SNGL GEST 76813 $402.00FVH 31000136 US OB NUCHAL TRANSL ADDIT GEST 76814 $201.00FVH 31000188 BX LYMPH NODE SUPERFICIAL 38505 $530.00FVH 31000193 PARACENTESIS ABD W/IMAGING 49083 $413.00FVH 31000202 THORACENTESIS W/IMG GUIDE 32555 $457.00FVH 31000206 BX ABD RETROPERITO PERC FLU 49180 $371.00FVH 31000210 BX CYST ASPIRATION 50390 $400.00FVH 31000213 US AXILLA RT $402.00FVH 31000214 US AXILLA LT $402.00FVH 31000218 US BREAST COMPLETE RT $279.00FVH 31000219 US BREAST COMPLETE LT $279.00FVH 31000220 US BREAST LIMITED RT $279.00FVH 31000221 US BREAST LIMITED LT $279.00FVH 31000222 US BREAST LIMITED BILAT 7664250 $464.00FVH 31000223 US BREAST COMPLETE BILAT 7664150 $515.00FVH 31000225 ASPIR INJ INTERM JT W/US 20606 $618.00FVH 31000226 ASPIR INJ MAJOR JT W/US 20611 $386.00FVH 31000558 BX OF SALIVARY GLAND NEEDLE 42400 $180.00FVH 31000700 US AXILLA RT ABC 76882 $402.00FVH 31000701 US AXILLA LT ABC 76882 $402.00

41

FVH 31000710 REMOVE FB MUSCLE/TEN SIMPLE 20520 $390.00FVH 31000713 BX BREAST 1ST LESION US IMAG 19083 $2,001.00FVH 31000714 BX BREAST ADD LESION US IMAG 19084 $1,613.00FVH 31000715 PLACEMT BREAST LOC EA 19286 $1,178.00FVH 31000716 BX BREAST PERC W/DEV US 1LES 19083 $2,001.00FVH 31000717 BX BREAST PERC W/DEV US EA LES 19084 $2,001.00FVH 31000718 US MUSCLE BIOPSY PERCUTANEOUS 20206 $247.00FVH 31000725 ASP FN NDL BX W/US GDN 1ST LES 10005 $425.00FVH 31000726 ASP FN NDL BX W/US GDN EA ADDL 10006 $290.00FVH 33000018 LIVER IMAGING SPECT 78803 $1,271.00FVH 33000062 RADIOPHAR I 123 (200) A9516 $435.00FVH 33000075 RADIOPHAR XE 133 GAS A9558 $271.00FVH 33000076 RADIOPHAR TC99M LABELED RBCS A9560 $235.00FVH 33000077 RADIOPHAR TC99M OXIDRONATE(HDP A9561 $268.00FVH 33000078 RADIOPHAR TC99M SESTAMIBI DOSE A9500 $268.00FVH 33000080 RADIOPHAR TC99M MEBROFENIN A9537 $513.00FVH 33000081 RADIOPHAR TC99M MYOVIEW A9502 $1,155.00FVH 33000083 RADIOPHAR TC99M ALBUMIN (MAA) A9540 $245.00FVH 33000084 RADIOPHAR TC99M PENTETATE-DTPA A9539 $268.00FVH 33000085 RADIOPHAR TC99M SULFUR COLLOID A9541 $268.00FVH 33000086 RADIOPHAR TC99M MERTIATIDE A9562 $802.00FVH 33000097 RADIOPHAR I 123 (300) A9516 $541.00FVH 33000102 PARATHYROID NUCLEAR IMAGING 78070 $881.00FVH 33000106 LYMPHOSCINTOGRAM 78195 $1,281.00FVH 33000107 LIVER SPLEEN IMAGING 78215 $748.00FVH 33000108 HEPATOBILIARY SCAN W/O EF 78226 $1,048.00FVH 33000110 GASTRIC EMPTYING 78264 $1,069.00FVH 33000111 GI BLEED 78278 $1,259.00FVH 33000112 MECKELS SCAN 78290 $948.00FVH 33000115 BONE SCAN WHOLE BODY 78306 $1,025.00FVH 33000127 BONE SCAN 3 PHASE 78315 $1,237.00FVH 33000128 BONE SCAN SPECT 78803 $1,271.00FVH 33000131 CARDIAC GATED REST SNGL 78472 $1,248.00FVH 33000135 LUNG PERFUSION IMAGING 78580 $836.00FVH 33000136 LUNG PERFUSION & VENTILATION 78582 $1,290.00FVH 33000137 LUNG SCAN QUANT PERF AND VENT 78598 $981.00FVH 33000141 RENAL IMAGING W/FLOW 78701 $881.00FVH 33000142 RENAL IMAGIING FLOW&FUNCTION 78707 $1,025.00FVH 33000143 RENAL IMAGING FUNC PHARM INTER 78708 $925.00FVH 33000190 PET BRAIN IMAGING INITIAL $3,632.00FVH 33000191 PET CT SKULL TO MID THIGH INIT $6,840.00FVH 33000192 PET CT WHOLE BODY INITIAL $3,605.00FVH 33000193 RADIOPHAR FDG A9552 $390.00FVH 33000205 LUNG PERFUSION & VENT AEROSOL 78582 $981.00FVH 33000211 PET SCAN IMAGING CARDIAC INIT $1,461.00FVH 33000228 INJ PROC LYMPHANGIOGRAPHY 38792 $178.00FVH 33000232 PET CT WHOLE BODY SUBSEQUENT $2,987.00FVH 33000237 MYOCARD PERF SPECT REST OR STR 78451 $1,463.00FVH 33000238 MYOCARD PERF SPECT REST+STRESS 78452 $2,639.00

42

FVH 33000245 RADIOPHAR TC99M PENTETATE-AERO A9567 $390.00FVH 33000247 HIDA W/EF W/ PHARM 78227 $1,048.00FVH 33000250 THYROID UPTAKE SINGLE OR MULT 78012 $282.00FVH 33000251 THYROID UPTAKE W SIMULATION 78014 $725.00FVH 33000261 PET CT WHOLE BODY SUBSEQ KX $2,987.00FVH 33000285 HIDA W/EF FATTY CHALLENGE 78226 $1,048.00FVH 34000099 KINEVEC 5UG IV J2805 $498.00FVH 34000100 LASIX 20MG IV $50.00FVH 40000018 PULSE OXIMETRY MULTIPLE 94761 $66.00FVH 40000027 VENT ADULT FIRST DAY 94002 $2,711.00FVH 40000028 VENT ADULT SUBSEQUENT DAY 94003 $1,625.00FVH 40000035 CHEST PHYSIO & PD INITIAL 94667 $175.00FVH 40000036 CHEST PHYSIO & PD SUBSEQUENT 94668 $141.00FVH 40000037 CPAP/BIPAP FIRST DAY 94660 $1,625.00FVH 40000061 FLUTTER VALVE/ACAPELLA TREAT 94664 $515.00FVH 40000065 PENTAMIDINE AEROSOL ADMIN 94642 $397.00FVH 40000091 IPPB/AERO TREATMENT INITIAL 94640 $175.00FVH 40000118 PULMONARY REHAB INDIV 15 MIN 97530 $152.00FVH 40000121 PULMONARY REHAB ASSESSMENT 99211 $246.00FVH 40000123 PFT SCREEN SPIROMETRY 94010 $187.00FVH 40000124 PFT PRE&POST SCREEN SPIROME 94060 $526.00FVH 40000140 TCM MAPPING BILATERAL 93922 $636.00FVH 40000145 IPPB /AERO TREATMENT SUBSEQ 9464076 $64.00FVH 40000147 BREATHING EXERCISES $175.00FVH 40000165 NEBULIZER UPDRAFT-INITIAL 94640 $351.00FVH 40000193 PULM REHAB COPD 60 MIN G0424 $280.00FVH 40000210 CAR SEAT TESTING 60 MINS 94780 $64.00FVH 40000211 CAR SEAT TESTING EA ADD 30 MIN 94781 $23.00FVH 40000215 NEB/MDI DEMO DAILY 94664 $515.00FVH 41000005 EKG W/RHYTHM 93005 $265.00FVH 41000015 DUPLEX VENOUS COMPLETE BILAT 93970 $1,204.00FVH 41000016 DUPLEX VENOUS LTD SNGL EXT RT $802.00FVH 41000019 DUPLEX ABDOMEN COMPL STUDY 93975 $1,626.00FVH 41000023 EXERCISE REACTIVE HYPEREMIA 93924 $1,579.00FVH 41000027 ARTERIAL LOWER EXTREMITY 93923 $795.00FVH 41000031 DUPLEX CAROTID SCAN COMPL 93880 $1,248.00FVH 41000035 DUPLEX ARTERIAL LE LIMITED RT $530.00FVH 41000037 ECHO M-MODE+2D W/O COLOR/SPEC 93307 $500.00FVH 41000041 ECHO LIMITED OR FOLLOW UP 93308 $515.00FVH 41000043 ECHO STRESS 93350 $750.00FVH 41000055 HOLTER MONITOR HOOKUP 48 HR 93225 $297.00FVH 41000059 HOLTER MON ANALY 24HR W/REPORT 93226 $519.00FVH 41000064 CARD EVENT RECORDER HOOK UP 93270 $678.00FVH 41000066 STRESS TEST TREADMILL 93017 $615.00FVH 41000071 DUPLEX VENOUS LTD SNGL EXT LT $802.00FVH 41000072 DUPLEX ARTERIAL LE LIMITED LT $530.00FVH 41000077 CARDIAC REHAB PHASE II 93798 $250.00FVH 41000081 US AAA SCREEN 76706 $155.00FVH 41000095 EVENT MONITOR RECORDING 93271 $445.00

43

FVH 41000099 TTE 2D + M MODE W/CONTRAST C8923 $600.00FVH 41000101 TTE COMPL W DOPPLER SPEC+COLOR 93306 $800.00FVH 41000102 TTE STRESS COMPLETE 93351 $750.00FVH 41000103 TTE DOPPLER SPEC+COL W/CONTR C8929 $900.00FVH 41000104 TTE STRESS COMPLETE W/ CONTR C8930 $850.00FVH 41000106 HOLTER MONTR ANALY 48 HR W/REP 93226 $519.00FVH 41000508 CARDIAC REHAB W/O ECG MONITOR 93797 $250.00FVH 41000526 CARDIAC REHAB ASSESSMENT 99211 $250.00FVH 42000313 FLUORO UP TO 1 HR 76000 $368.00FVH 44000002 POLYSOMNOGRAM 95810 $2,500.00FVH 44000003 POLYSOMNOGRAM W/CPAP 95811 $2,850.00FVH 44000007 MULTIPLE SLEEP LATENCY TEST 95805 $3,159.00FVH 44000009 PNEUMOGRAM 6 CHANNEL 95806 $1,500.00FVH 46000004 ULTRASOUND OT 15 MIN $27.00FVH 46000005 IONTOPHORESIS OT 15 MIN $53.00FVH 46000006 ELECTRICAL STIMULAT OT 15 MIN $38.00FVH 46000009 ORTHOTIC MGMT &TRN OT 1ST ENC $97.00FVH 46000010 THERAPEUTIC EXER OT $66.00FVH 46000020 ELECTRICAL STIMULATION $38.00FVH 46000025 FUNCTIONAL TESTING OT 15 MIN 97750GO $68.00FVH 46000028 IONTOPHORESIS PT 15 MIN $53.00FVH 46000034 WHIRLPOOL PT $40.00FVH 46000036 ORTHOTIC MGMT & TRAIN 1ST ENC $97.00FVH 46000038 THERAPEUTIC EXER PT $66.00FVH 46000040 TRACTION CERVICAL/PELVIC $34.00FVH 46000041 THERAPY MANUAL PT EACH 15 MIN $63.00FVH 46000042 ULTRASOUND PT $29.00FVH 46000043 WHIRLPOOL OT $40.00FVH 46000052 GAIT TRAINING $57.00FVH 46000057 THERAPY MANUAL OT EACH 15 MIN $63.00FVH 46000059 PARAFFIN PT $16.00FVH 46000060 PARAFFIN OT $16.00FVH 46000070 THERAPEUTIC ACTIVITY PT $69.00FVH 46000071 THERAPEUTIC ACTIVITY OT $69.00FVH 46000173 SPEECH THERAPY TRMT $155.00FVH 46000175 SWALLOW EVAL NON RADIOL $238.00FVH 46000176 DYSPHAGIA TRMT $191.00FVH 46000183 FUNCTIONAL TESTING PT 15 MIN $68.00FVH 46000195 ELECTRICAL STIM UNATTENDED $29.00FVH 46000196 ELECTRICAL STIM UNATTENDED $29.00FVH 46000197 ORTHOTIC/PROSTHETIC USE EST PT $92.00FVH 46000199 ELECTRODE PLACEMENT TENS $24.00FVH 46000200 ORTHOTIC/PROSTHETIC USE EST OT $92.00FVH 46000213 ROM TEST OR MEASURE,HAND $13.00FVH 46000216 COGNITIVE SKILLS DEVELOPMENT $58.00FVH 46000221 NEUROMUSCULAR RE-EDUC PT $68.00FVH 46000224 DEVELOP TESTING LIM PED $12.00FVH 46000240 COGNITIVE PERFORMANCE TEST ST $204.00FVH 46000274 MEDICAL TEAM CONFERENCE 99366 $95.00

44

FVH 46000282 MUSCLE TESTING TOTAL EXC HANDS $51.00FVH 46000292 CANALITH REPOSITIONING PROC $76.00FVH 46000328 APPLICATION SHORT ARM CAST OT $85.00FVH 46000329 APPLICATION FINGER SPLINT OT $63.00FVH 46000340 APHASIA EVALUATION 96105GN $204.00FVH 46000341 MEDICAL TEAM CONF PROVIDERS $95.00FVH 46000342 APPLICATION SHORT ARM CAST PT $85.00FVH 46000343 APPLICATION SHORT ARM SPLINT $109.00FVH 46000344 APPLICATION FINGER SPLINT PT $70.00FVH 46000345 APPLICATION FINGER SPLINT PT $63.00FVH 46000371 PULM REHAB COPD 60 MIN G0424 $138.00FVH 46000517 PT EVAL LOW COMPLEXITY $179.00FVH 46000518 PT EVAL MOD COMPLEXITY $179.00FVH 46000519 PT EVAL HIGH COMPLEXITY $179.00FVH 46000520 PT REEVALUATION $85.00FVH 46000521 OT EVAL LOW COMPLEXITY $179.00FVH 46000522 OT EVAL MOD COMPLEXITY $179.00FVH 46000523 OT EVAL HIGH COMPLEXITY $179.00FVH 46000524 OT REEVALUATION $98.00FVH 46000525 ORTHC/PROSTC MGMT SBSQ ENC $97.00FVH 46000527 DRY NEEDLING $5.00FVH 46000537 DRY NEEDLING 3 OR MUSCLES $5.00FVH 47000002 W/C SEATING FIT & TRAIN Q15 PT $64.00FVH 47000104 ORTHC/PROSTC MGMT SBSQ ENC $97.00FVH 48000010 HOME ASSESS OT $69.00FVH 48000020 NEUROMUSCULAR RE-EDUC OT $68.00FVH 48000030 W/C SEATING FIT & TRAIN Q15 OT $64.00FVH 48000075 PULM REHAB COPD 60 MIN G0424 $138.00FVH 49000005 AUDIO AIR CONDUCTION 92552 $12.50FVH 49000026 SPEECH THERAPY TRMT GROUP $47.00FVH 49000028 SWALLOW EVAL VIDEO $262.00FVH 49000084 PROG/MOD OF SPEECH GEN DEVICE $227.00FVH 49000085 COGNITIVE SKILLS DEVELOPMENT $61.00FVH 49000086 EVAL SPEECH GEN AAC DEVICE $334.00FVH 49000100 INFANT HEARING SCREENING 92558 $15.00FVH 49000128 EVAL ST FLUENCY $167.00FVH 49000129 EVAL ST SPEECH PRODUCTION $144.00FVH 49000130 SPEECH SOUND LANG COMPREHEN $286.00FVH 49000131 BEHAVRAL QUALIT ANALYS VOICE 92524GN $144.00FVH 55000002 INF THERAPY HYD INITIAL ER 96360 $136.00FVH 55000003 INF THERAPY HYD ADDL ER 96361 $136.00FVH 55000004 INF THERAPY MED SEQUENTIAL ER 96367 $136.00FVH 55000006 INF THERAPY MED CONCURRENT ER 96368 $136.00FVH 55000007 IV INJECTION SUBSEQUENT ER 96375 $111.00FVH 55000009 CRITICAL CARE ADDL 30(AFTER 74 99292 $595.00FVH 55000010 LEVEL I LOW SEVERITY 99281 $111.00FVH 55000011 LEVEL II LOW MOD SEVERITY 99282 $211.00FVH 55000012 LEVEL III MOD SEVERITY 99283 $435.00FVH 55000013 LEVEL IV MOD HIGH SEVERITY 99284 $850.00

45

FVH 55000014 LEVEL V HIGH SEVERITY 99285 $1,674.00FVH 55000015 CRITICAL CARE 99291 $1,772.00FVH 55000016 REPAIR LACERATION SIMPLE $62.00FVH 55000017 REPAIR LACERATION COMPLEX $160.00FVH 55000018 IRRIGATION WITHOUT SUTURE $160.00FVH 55000019 DISLOCATION REDUCTION TMT $160.00FVH 55000020 FRACTURE REDUCTION TREATMENT $160.00FVH 55000021 APPLICATION SPLINT OR CAST $160.00FVH 55000022 INF THERAPY MED INITIAL ER 96365 $160.00FVH 55000023 SUBQ/IM INJECTION ER 96372 $136.00FVH 55000024 IV INJECTION INITIAL ER 96374 $111.00FVH 55000025 PROCEDURE EYE $160.00FVH 55000026 PROCEDURE EAR $160.00FVH 55000027 TREATMENT OF NOSEBLEED $160.00FVH 55000028 I&D ABSCESS HEMATOMA $160.00FVH 55000029 REPAIR NAIL BED $62.00FVH 55000030 INSERTION CHEST TUBE $334.00FVH 55000031 EXTERNAL PACER 92953 $334.00FVH 55000032 PERITONEAL LAVAGE $334.00FVH 55000033 INTUBATION 31500 $334.00FVH 55000034 CPR 92950 $792.00FVH 55000035 PROCEDURE ED $160.00FVH 55000036 PROCEDURE UPPER AIRWAY $160.00FVH 55000040 CVS LINE PLACEMENT OR REMOVAL $160.00FVH 55000041 INF THERAPY MED ADDL HR ER 96366 $160.00FVH 55000042 LUMBAR PUNCTURE 62270 $334.00FVH 55000043 VENIPUNCTURE ED 36415 $21.00FVH 55000045 CATH INSERT STRAIGHT NON-INDWE 51701 $62.00FVH 55000046 PROCEDURE ED MINOR $62.00FVH 55000092 BLOOD ALCOHOL $79.00FVH 55000098 ER LEVEL 1 WITH PROC 9928125 $111.00FVH 55000099 ER LEVEL 2 WITH PROC 9928225 $211.00FVH 55000100 ER LEVEL 3 WITH PROC 9928325 $435.00FVH 55000103 FETAL NON STRESS 59025 $391.00FVH 55000107 INSERTION NEEDLE INTRAOSSEOUS 36680 $160.00FVH 55000111 CATH INSERT BLADDER SPEC P9612 $62.00FVH 55000112 CATH INSERT SMPL INDWELLING 51702 $62.00FVH 55000113 IRRIGATION BLADDER 51700 $334.00FVH 55000296 BLOOD ADMINISTRATION ER 36430 $942.00FVH 55000299 BLOOD DRAW IMPLANTED VAD ER 36591 $160.00FVH 55000317 BLADDER SCAN 51798 $211.00FVH 55000348 US GUIDE NEEDLE PLACEMENT 76942 $160.00FVH 55000349 IMMUNIZ ADMINISTRATION 90471 $62.00FVH 55000350 ADMIN VACCINE EA ADDIT 90472 $62.00FVH 55000351 GASTRIC LAVAGE GAVAGE 43753 $334.00FVH 55000356 IMPLANTED VAD FLUSH ED 96523 $160.00FVH 55000357 ER NURSE ONLY PROCEDURE 99211 $100.00FVH 55000364 JOINT INJECTION PROCEDURE $160.00FVH 55000365 SKIN PROCEDURE $62.00

46

FVH 55000367 BIOPSY PROCEDURE $334.00FVH 55000368 IV INJECTION EA ADD SAME DRUG 96376 $111.00FVH 55000369 BLOOD DRAW CENT OR PERIPH CATH 36592 $160.00FVH 55000371 CATH INSERT COMP INDWELLING 51703 $62.00FVH 55000375 CARDIOVERSION 92960 $334.00FVH 55000377 CHANGE GASTROSTOMY TUBE 43762 $334.00FVH 55000378 ANOSCOPY W/FB REMOVAL $334.00FVH 55000379 ARTERIAL LINE PLACEMENT $160.00FVH 55000385 FB REMOVAL INTRANASAL $62.00FVH 55000389 I&D PILONIDAL CYST, SIMPLE $160.00FVH 55000390 INCISION EXTERNAL HEMMORHOID $160.00FVH 55000392 PROCEDURE- ED COMPLEX $160.00FVH 55000393 PERICARDIOCENTESIS $334.00FVH 55000396 THORACENTESIS $334.00FVH 55000401 REPAIR LACERATION INTERMEDIATE $334.00FVH 55000402 PROCEDURE ED MAJOR $334.00FVH 55000403 BURN CARE PROCEDURE SIMPLE $160.00FVH 55000404 BURN CARE PROCEDURE COMPLEX $334.00FVH 55000405 PARACENTESIS ER $334.00FVH 55000406 TRACHEOSTOMY ER $334.00FVH 55000408 REMOVE CERUMEN $62.00FVH 55000412 REMOVE FB EYE $62.00FVH 55000414 INCISION/REMOVAL FB SIMPLE $160.00FVH 55000421 REMOVE FB EAR 69200 $62.00FVH 55000422 DEBRIDEMENT WOUND $190.00FVH 55000429 EVACUATION SUBUNGUAL HEMATOMA $160.00FVH 55000442 MEDICATION PICK UP 99211 $62.00FVH 55000444 VAGINAL DELIVERY $758.00FVH 55000445 FX CARE W/ANESTH $160.00FVH 55000446 DISLOCATION TX W/ANESTH $334.00FVH 55000477 TRANSCUTANEOUS CARBOXYHB 88740 $19.00FVH 56000008 CRITICAL CARE 1ST HOUR 99291 $514.00FVH 56000009 CRITICAL CARE-ADD 99292 $258.00FVH 56000013 EKG INTERPRETATION 93010 $19.00FVH 56000015 PHYS SERVICES LEVEL 1 99281 $49.00FVH 56000016 PHYS SERVICES LEVEL 2 99282 $95.00FVH 56000017 PHYS SERVICES LEVEL 3 99283 $142.00FVH 56000018 PHYS SERVICES LEVEL 4 99284 $271.00FVH 56000019 PHYS SERVICES LEVEL 5 99285 $397.00FVH 56000027 I&D HEMATOMA SEROMA 10140 $274.00FVH 56000028 ASPIR ABSCESS/HEMATOMA/CYST 10160 $222.00FVH 56000029 I&D ABSCESS FINGER SIMPLE 26010 $319.00FVH 56000033 I&D ABSCESS HEMATOMA EAR 69000 $281.00FVH 56000038 CARDIOVERSION ERP 92960 $282.00FVH 56000039 INJ TRIGGER POINT MUSC 20552 $88.00FVH 56000041 INJ ANES AGENT TRIGEMINAL 64400 $150.00FVH 56000043 I&D ABSCESS & CYST SIMPLE 10060 $224.00FVH 56000045 I&REMOVE FB,SIMPLE 10120 $240.00FVH 56000046 AVULSION NAIL PARTIAL/COMPLETE 11730 $119.00

47

FVH 56000047 EVACUATION SUBUNGUAL HEMATOMA 11740 $76.00FVH 56000048 I&D PERIANAL ABS SUPERFICIAL 46050 $227.00FVH 56000049 I&D ABSCESS COMPL MULT 10061 $415.00FVH 56000051 DRAINAGE OF GUM LESION 41800 $353.00FVH 56000052 I&D PILONIDAL CYST SIMPLE 10080 $238.00FVH 56000054 LUMBAR PUNCTURE DX 62270 $180.00FVH 56000055 PARACENTESIS ABD W/O IMAGING 49082 $169.00FVH 56000057 VENIPUNCTURE CUT DOWN < 1 YR 36420 $122.00FVH 56000058 VENIPUNCTURE CUT DOWN > 1 YR 36425 $92.00FVH 56000061 PERICARDIOCENTESIS 33010 $268.00FVH 56000063 THORACENTESIS W/O IMG GUIDE 32554 $210.00FVH 56000065 INTUBATION 31500 $255.00FVH 56000066 TRACHEOSTOMY 31603 $512.00FVH 56000069 REMOVAL FB PHARYNX 42809 $314.00FVH 56000072 INCISION THROMBOSED HEMORRHOID 46083 $247.00FVH 56000073 ANOSCOPY 46600 $95.00FVH 56000077 PLACEMENT CHEST TUBE 32551 $399.00FVH 56000078 LARYNGOSCOPY 31505 $116.00FVH 56000079 CRICOTHYROID MEMBRANE 31605 $420.00FVH 56000080 EXCISION OF NAIL PART/COMPLETE 11750 $405.00FVH 56000081 EXCISION WEDGE NAIL FOLD SKIN 11765 $220.00FVH 56000082 REPAIR NAILBED 11760 $309.00FVH 56000086 REMOVAL SKIN TAGS ERP 11200 $169.00FVH 56000087 TRMT SUPF WOUND DEHIS;SIMPLE 12020 $450.00FVH 56000088 INJ ANES AGENT OTHER NERVE 64450 $250.00FVH 56000089 I&D BARTHOLIN'S GLAND ABSCES 56420 $213.00FVH 56000090 I&D PERINEAL ABSCESS 56405 $252.00FVH 56000092 REMOVAL FB CONJUNCTIVAL 65205 $104.00FVH 56000093 REMOVAL FB CORNEAL EMB 65220 $99.00FVH 56000094 REMOVAL FB SUBCONJUNCTIVAL EMB 65210 $126.00FVH 56000095 REMOVE FB INTRANASAL 30300 $300.00FVH 56000097 POST NASAL HEMORRHAGE 30905 $232.00FVH 56000098 FRACTURE NASAL CLOSED 21310 $63.00FVH 56000100 REMOVAL FB EYELID EMB 67938 $274.00FVH 56000101 REMOVE FB EAR 69200 $136.00FVH 56000102 REMOVAL FB CORNEAL W/SLIT LAMP 65222 $125.00FVH 56000103 REMOVE CERUMEN INSTRUMENTATION 69210 $76.00FVH 56000105 ANTERIOR NASAL HEMORRHAGE 30901 $130.00FVH 56000106 ANT NOSE BLEED/PACKING 30903 $184.00FVH 56000111 BURN TREATMENT INIT 1ST DEG 16000 $107.00FVH 56000112 BURN TREATMENT 1ST/2ND DEG SM 16020 $125.00FVH 56000118 FRACTURE CLAVICLE W/O MANIP 2350054 $512.00FVH 56000119 FRACTURE HUMERUS W/O MANIP 2360054 $708.00FVH 56000120 DISLOCATION TMJ 21480 $74.00FVH 56000121 DISLOCATION SHOULDER 2365054 $666.00FVH 56000123 DISLOCATION ELBOW 2460054 $772.00FVH 56000124 DISLOCATION MCP 2670054 $701.00FVH 56000125 DISLOCATION IP JOINT 2677054 $591.00FVH 56000126 FRACTURE PHALANX W/MANIP 2672554 $450.00

48

FVH 56000127 DISLOCATION SHOULDER W/ANES 23655 $915.00FVH 56000128 FRACTURE METACARPAL W/O MANIP 2660054 $638.00FVH 56000132 FRACTURE DISTAL PHAL W/MANIP 2675554 $629.00FVH 56000133 ASPIR INJ SM JT 20600 $81.00FVH 56000134 ASPIR INJ INTERM JT 20605 $122.00FVH 56000135 ASPIR INJ MAJOR JT 20610 $105.00FVH 56000136 APPLICATION PLSTR SPLINT L ARM 29105 $138.00FVH 56000137 APPLICATION PLSTR SPLINT S ARM 29125 $92.00FVH 56000138 APPLICATION PLSTR SPLINT L LEG 29505 $116.00FVH 56000139 APPLICATION PLSTR SPLINT S LEG 29515 $116.00FVH 56000140 REMOVAL CAST 29700 $77.00FVH 56000141 DISLOCATION PATELLA 2756054 $776.00FVH 56000142 DISLOCATION THUMB 2664154 $750.00FVH 56000143 DISLOCATION ANKLE 2784054 $862.00FVH 56000144 DISLOCATION TOE W/REDUCTION 28660 $275.00FVH 56000145 FRACTURE TOE W/ MANIPULATION 2851554 $334.00FVH 56000147 FRACTURE DISTAL RADIUS W/O MAN 2560054 $715.00FVH 56000151 FRACTURE MED MALLEOUS W/O MAN 2776054 $704.00FVH 56000153 FRACTURE LAT MALLEOUS W/O MAN 2778654 $662.00FVH 56000156 FRACTURE GREAT TOE W/O MANIP 2849054 $294.00FVH 56000158 DISLOCATION KNEE W/ANES 2755254 $1,050.00FVH 56000160 FRACTURE RADIUS ULNA W/MANIP 25605 2560554 $1,181.00FVH 56000161 FRACTURE ANKLE W/MANIPULATION 2781054 $450.00FVH 56000162 DISLOCATION SUBLUX RADIAL HEAD 24640 $220.00FVH 56000164 APPLICATION FINGER SPLINT 29130 $66.00FVH 56000165 APPLICATION UNNA BOOT 29580 $83.00FVH 56000168 REPAIR LACERATION SIMPLE < 2.5 12001 $103.00FVH 56000169 REPAIR LACERATION SIMPLE > 2.5 12002 $136.00FVH 56000170 REPAIR LACERATION SIMPLE > 7.5 12004 $170.00FVH 56000171 REPAIR LACERATION > 12.5 12005 $229.00FVH 56000172 REPAIR LACERATION SIMPLE > 20 12006 $286.00FVH 56000177 REPAIR LACERATION SIMPLE < 2.5 12011 $129.00FVH 56000178 REPAIR LACERATION SIMPLE > 2.5 12013 $143.00FVH 56000179 REPAIR LACERATION SIMPLE >5 12014 $182.00FVH 56000180 REPAIR LACERATION > 7.5 12015 $227.00FVH 56000181 REPAIR LACERATION > 12.5 12016 $306.00FVH 56000182 REPAIR LACERATION > 20 12017 $351.00FVH 56000187 REPAIR LACERATION < 2.5 12031 $355.00FVH 56000188 REPAIR LACERATION > 2.5 12032 $452.00FVH 56000189 REPAIR LACERATION > 7.5 12034 $476.00FVH 56000190 REPAIR LACERATION > 12.5 12035 $556.00FVH 56000191 REPAIR LACERATION > 20 12036 $641.00FVH 56000194 REPAIR LACERATION INTERM < 2.5 12041 $362.00FVH 56000195 REPAIR LACERATION > 2.5 12042 $463.00FVH 56000196 REPAIR LACERATION > 7.5 12044 $494.00FVH 56000197 REPAIR LACERATION > 12.5 12045 $625.00FVH 56000198 REPAIR LACERATION > 20 12046 $776.00FVH 56000201 REPAIR LACERATION < 2.5 12051 $397.00FVH 56000202 REPAIR LACERATION > 2.5 12052 $471.00

49

FVH 56000203 REPAIR LACERATION > 5.0 12053 $501.00FVH 56000204 REPAIR LACERATION > 7.5 12054 $527.00FVH 56000205 REPAIR LACERATION > 12.5 12055 $692.00FVH 56000206 REPAIR LACERATION > 20 12056 $873.00FVH 56000214 REPAIR LACERATION > 2.5 13121 $617.00FVH 56000215 EXPLORE PENETRATING WND EXTREM 20103 $796.00FVH 56000246 CATH INSERT SMPL INDWELLING 51702 $69.00FVH 56000280 FRACTURE RAD/ULNAR W/O MANIP 2556054 $579.00FVH 56000281 FRACTURE RAD/ULNAR W/MANIP 2556554 $1,100.00FVH 56000294 DISLOCATION HIP POST 27265 $926.00FVH 56000296 DISLOCATION KNEE W/O ANES 2755054 $500.00FVH 56000299 FRACTURE LAT MALLEOLUS W/MANIP 2778854 $887.00FVH 56000309 FRACTURE TOE W/O MANIPULATION 2851054 $282.00FVH 56000320 WINDOWING CAST 29730 $104.00FVH 56000321 LARYNGOSCOPY INDIR W/FB REMOVE 31511 $301.00FVH 56000329 I&D ABSCESS/CYST/VEST OF MOUTH 40800 $312.00FVH 56000332 REPAIR LAC TONG ANT 2/3 2.5OR< 41250 $367.00FVH 56000335 PROCTO,DIAGNOSTIC 45300 $126.00FVH 56000340 CATH INSERT COMPL INDWELLING 51703 $186.00FVH 56000389 APPLICATION SHORT ARM CAST 29075 $143.00FVH 56000391 DEBRIDE SKIN SUBCUTANEOUS 11042 $143.00FVH 56000392 REPAIR COMPLEX SCALP ARMS LEGS 13122 $196.00FVH 56000393 CHANGE GASTROSTOMY TUBE 43762 $111.00FVH 56000394 FX HUMERAL PROX W/MANIP W/WO T 23605 $973.00FVH 56000395 FX HUMERAL SHFT W/MANIP W/WO T 24505 $450.00FVH 56000397 UNLISTED PROC SKIN/MEMB/TISSUE 17999 $150.00FVH 56000398 REP MOUTH LACERATION <2.5 CM 40830 $400.00FVH 56000404 APPLICATION GAUNTLET CAST 29085 $155.00FVH 56000422 REPAIR BLOOD VESSEL HAND 35207 $1,727.00FVH 56000423 APPLICATION SHORT ARM SPLINT 29126 $113.00FVH 56000424 APPLICATION SHORT LEG CAST 29405 $139.00FVH 56000425 DISLOCATION PATELLA W/ ANESTH 27562 $1,101.00FVH 56000426 REPAIR BLOOD VESSEL UPPER EX 35206 $1,810.00FVH 56000431 APPLY FINGER CAST 29086 $180.00FVH 56000434 APPLICATION LONG LEG CAST 29345 $289.00FVH 56000484 OBSERVATION ADMIT SIMPLE 99218 $175.00FVH 56000485 OBSERVATION INITIAL MODERATE 99219 $238.00FVH 56000486 OBSERVATION ADMIT COMPLEX 99220 $326.00FVH 56000488 DISLOCATION ELBOW W/ ANESTHES 2460554 $800.00FVH 56000489 DRAINAGE SCROTAL WALL ABSCESS 55100 $460.00FVH 56000597 REMOVE DRUG DELIVERY IMPLANT 11982 $215.00FVH 56000604 REM CERUMEN IRRIG/LAVAGE 69209 $76.00FVH 56000605 *INC SOFT TISS ABSC DP/COMP 20005 $650.00FVH 56000612 ASPIR FINE NEEDLE W/O IMAG GUI 10021 $260.00FVH 56000613 I&D DPABSA/HMTMA TH/KN 27301 $1,160.00FVH 56000624 REM FB SHOULDER; SQ 23330 $362.00FVH 56000637 BIOPSY TEMPORAL ARTERY 37609 $485.00FVH 62000002 HOME CARE VISIT RN G0299 $145.00FVH 62000003 HOME CARE VISIT AIDE G0156 $38.00

50

FVH 62000004 HOME HEALTH PT G0151 $110.00FVH 62000005 HOME HEALTH OT G0152 $110.00FVH 62000006 HOME HEALTH ST G0153 $110.00FVH 85000019 CUT & DRAIN ABSCESS 10060 $93.00FVH 85000020 CUT & DRAIN ABSCESS 10061 $164.00FVH 85000021 REMOVE FB SIMPLE 10120 $116.00FVH 85000024 ASPIR ABSCESS/HEMATOMA/CYST 10160 $104.00FVH 85000025 REMOVE DAMAGED SKIN 11000 $44.00FVH 85000029 REMOVAL SKIN TAGS 11200 $70.00FVH 85000030 REMOVE SKIN TAGS EA ADD 11201 $31.00FVH 85000031 SHAVE LESION <.5 CM 11300 $58.00FVH 85000032 SHAVE LESION >.5CM 11301 $77.00FVH 85000033 SHAVE LESION <.5 CM 11305 $58.00FVH 85000034 SHAVE LESION <.5 CM 11310 $71.00FVH 85000035 EXCISION BENIGN LESION <.5CM 11400 $98.00FVH 85000036 EXCISION BENIGN LESION >.5CM 11401 $118.00FVH 85000037 EXCISION BENIGN LESION <2CM 11402 $132.00FVH 85000038 EXCISION BENIGN LESION <.5CM 11420 $98.00FVH 85000039 EXCISION BENIGN LESION >.5CM 11421 $126.00FVH 85000040 EXCISION BENIGN LESION <2CM 11422 $140.00FVH 85000041 EXCISION BENIGN LESION >2CM 11423 $162.00FVH 85000042 EXCISION BENIGN LESION >3CM 11424 $198.00FVH 85000043 EXCISION BENIGN LESION <.5CM 11440 $108.00FVH 85000044 EXCISION BENIGN LESION >.5CM 11441 $134.00FVH 85000045 EXCISION BENIGN LESION <2CM 11442 $150.00FVH 85000046 EXCISION BENIGN LESION >2CM 11443 $197.00FVH 85000048 EXCISION MALIGNANT LESION<.5 11600 $154.00FVH 85000049 EXCISION MALIGNANT LESION>.5 11601 $182.00FVH 85000051 EXCISION MALIGNANT LESION < 2 11622 $204.00FVH 85000052 EXCISION MALIGNANT LESION<.5 11640 $160.00FVH 85000053 EXCISION MALIGNANT LESION>.5 11641 $190.00FVH 85000054 EXCISION MALIGNANT LESION <2 11642 $216.00FVH 85000055 EXCISION MALIGNANT LESION>2 11643 $257.00FVH 85000056 TRIM NAILS 11719 $16.00FVH 85000057 AVULSION NAIL PLATE SIMP SINGL 11730 $80.00FVH 85000060 INJ LESION 11900 $35.00FVH 85000061 REPAIR LACERATION SIMPLE < 2.5 12001 $105.00FVH 85000062 REPAIR LACERATION SIMPLE >2.5 12002 $112.00FVH 85000063 REPAIR LACERATION SIMPLE > 7.5 12004 $81.00FVH 85000064 REPAIR LACERATION SIMPLE>12.5 12005 $109.00FVH 85000065 REPAIR LACERATION SIMPLE < 2.5 12011 $112.00FVH 85000066 REPAIR LACERATION SIMPLE > 2.5 12013 $123.00FVH 85000070 REPAIR LACERATION INTERM < 2.5 12031 $200.00FVH 85000074 REPAIR LACERATION INTERM < 2.5 12041 $192.00FVH 85000079 REPAIR LACERATION INTERM >2.5 12052 $226.00FVH 85000080 REPAIR LACERATION INTERM>5 12053 $240.00FVH 85000094 DESTROY BENIGN PREMAL LESION 17000 $60.00FVH 85000095 DESTROY BENIGN LESION 2-14 17003 $16.00FVH 85000096 DESTROY BENIGN LESION >15 17004 $139.00

51

FVH 85000097 DESTROY BENIGN LESION UP TO 14 17110 $87.00FVH 85000098 INJ LIGAMENT/TENDON 20550 $63.00FVH 85000099 INJ TRIGGER POINT 1 OR 2 20552 $42.00FVH 85000100 ASPIR INJ SM JT 20600 $61.00FVH 85000101 ASPIR INJ INTERM JT 20605 $61.00FVH 85000102 ASPIR INJ MAJOR JT 20610 $64.00FVH 85000103 ASPIR INJ GANGLION CYST 20612 $46.00FVH 85000107 DISLOCATION FINGER W/O ANES 26770 $246.00FVH 85000111 FX MEDIAL MALLEOLUS 27760 $293.00FVH 85000112 FX DISTAL FIBULA 27786 $275.00FVH 85000113 APPLICATION SHORT ARM CAST 29075 $60.00FVH 85000114 APPLICATION LONG ARM SPLINT 29105 $67.00FVH 85000115 APPLICATION SHORT ARM SPLINT 29125 $50.00FVH 85000116 APPLICATION FINGER SPLINT 29130 $32.00FVH 85000117 APPLICATION LONG LEG CAST 29345 $96.00FVH 85000120 ANOSCOPY 46600 $45.00FVH 85000123 COLPOSCOPY 57454 $126.00FVH 85000125 REMOVAL ENDOCERVICAL POLYPS 57500 $100.00FVH 85000126 CRYOCAUTERY INTIAL OR REPEAT 57511 $115.00FVH 85000127 BX UTERUS LINING 58100 $90.00FVH 85000129 REMOVE CERUMEN INSTRUMENTATION 69210 $42.00FVH 85000133 SUBQ/IM INJECTION 96372 $56.00FVH 85000134 HEARING SCREENING 92567 $19.00FVH 85000135 INJECTION ALLERGY 95115 $21.00FVH 85000136 INJECTION ALLERGY 2 OR MORE 95117 $29.00FVH 85000138 LEVEL 1 NEW PT 99201 $26.00FVH 85000139 LEVEL 2 NEW PT 99202 $45.00FVH 85000140 LEVEL 3 NEW PT 99203 $66.00FVH 85000141 LEVEL 4 NEW PT 99204 $101.00FVH 85000142 LEVEL 5 NEW PT 99205 $123.00FVH 85000143 LEVEL 1 EST PT 99211 $13.00FVH 85000144 LEVEL 2 EST PT 99212 $27.00FVH 85000145 LEVEL 3 EST PT 99213 $44.00FVH 85000146 LEVEL 4 EST PT 99214 $66.00FVH 85000147 LEVEL 5 EST PT 99215 $88.00FVH 85000148 LEVEL 2 CONSULT 99242 $59.00FVH 85000149 LEVEL 3 CONSULT 99243 $80.00FVH 85000152 WELCOME TO MEDICARE INIT EXAM G0402 $83.00FVH 85000153 EKG WELCOME TO MDICARE TRACING $28.00FVH 85000154 LEVEL 1 CONSULT 99241 $24.00FVH 85000155 ASPIR FINE NEEDLE W/O IMAG GUI 10021 $77.00FVH 85000156 ACNE SURGERY 10040 $81.00FVH 85000157 I&D PILONIDAL CYST SIMPLE 10080 $114.00FVH 85000158 I&D POSTOP WOUND INFECTION 10180 $196.00FVH 85000159 DEBRIDE SKIN SUBCUTANEOUS 11042 $69.00FVH 85000160 PARING LESION (SINGLE) BENIGN 11055 $37.00FVH 85000163 SHAVE LESION 2 CM 11302 $92.00FVH 85000164 SHAVE LESION > 2CM 11303 $109.00FVH 85000165 SHAVE LESION > .5 CM 11306 $80.00

52

FVH 85000166 SHAVE LESION 2 CM 11307 $93.00FVH 85000167 SHAVE LESION >.5CM 11311 $88.00FVH 85000168 SHAVE LESION 2 CM 11312 $103.00FVH 85000170 EXCISION BENIGN LESION >2CM 11403 $153.00FVH 85000171 EXCISION BENIGN LESION > 4 CM 11406 $250.00FVH 85000172 EXCISION BENIGN LESION > 4 CM 11426 $300.00FVH 85000173 EXCISION MALIGNANT LESION <2 11602 $197.00FVH 85000174 EXCISION MALIGNANT LESION>3 11604 $251.00FVH 85000175 EXCISION MALIGNANT LESION >4 11606 $360.00FVH 85000176 EXCISION MALIGNANT LESION>.5 11621 $182.00FVH 85000177 EXCISION MALIGNANT LESION>2 11623 $240.00FVH 85000178 EXCISION MALIGNANT LESION >3 11624 $264.00FVH 85000179 EXCISION MALIGNANT LESION >3 11644 $322.00FVH 85000181 REPAIR LACERATION INTERM >30 12037 $355.00FVH 85000184 BURN TREATMENT SMALL 16020 $66.00FVH 85000189 ASPIR BREAST CYST 19000 $47.00FVH 85000192 FX CLAVICLE 23500 $213.00FVH 85000193 FX SCAPULA 23570 $229.00FVH 85000195 DISLOCATION SHOULDER W/O ANEST 23650 $277.00FVH 85000197 FX HUMERAL SHAFT 24500 $311.00FVH 85000200 DISLOCATION NURSEMAID ELBOW 24640 $92.00FVH 85000201 FX RADIAL HEAD OR NECK 24650 $230.00FVH 85000202 FX ULNA PROXIAMAL 24670 $251.00FVH 85000203 FX RADIAL SHAFT 25500 $240.00FVH 85000205 FX ULNA SHAFT 25530 $227.00FVH 85000207 FX DISTAL RADIUS 25600 $262.00FVH 85000208 FX NAVICULAR 25622 $266.00FVH 85000209 FX CARPAL 25630 $268.00FVH 85000211 FX METACARPAL 26600 $237.00FVH 85000212 FX METACARPAL W/REDUCTION 26605 $280.00FVH 85000215 FX FINGER 26720 $177.00FVH 85000224 FX PATELLA 27520 $283.00FVH 85000227 FX FIBULA PROXIMAL OR SHAFT 27780 $248.00FVH 85000228 FX BIMALLEOLAR 27808 $289.00FVH 85000231 REMOVE FB FOOT 28190 $154.00FVH 85000234 FX METATARSAL 28470 $199.00FVH 85000240 APPLICATION LONG ARM CAST 29065 $65.00FVH 85000242 APPLICATION SHORT LEG CAST 29405 $58.00FVH 85000244 APPLICATION LONG LEG SPLINT 29505 $48.00FVH 85000245 APPLICATION UNNA BOOT 29580 $40.00FVH 85000253 HEMORRHOIDECTOMY LIGATURE 46221 $218.00FVH 85000254 EXCISE EXT HEMORRHOID TAGS 46230 $191.00FVH 85000258 IMMUNIZATION ADMIN 90471 $51.00FVH 85000259 IMMUNIZATION ADMIN EA ADDIT 90472 $25.00FVH 85000266 PROLONGED MD SERVICE 30-74 99354 $76.00FVH 85000287 EXCISION BENIGN LESION >3 CM 11404 $173.00FVH 85000294 EXCISION MALIGNANT LESION >2 11603 $225.00FVH 85000295 IMMUNIZ ADMIN INFLUENZA 90471 $51.00FVH 85000296 IMMUNIZ ADMIN PNEUMO 90471 $51.00

53

FVH 85000306 CHANGE GASTROSTOMY TUBE 43762 $53.00FVH 85000309 INJ LIGAMENT/TENDON 20551 $41.00FVH 85000318 REMOVAL TUNNELED CVC W/O PORT 36589 $155.00FVH 85000320 IV INJECTION INITIAL 96374 $114.00FVH 85000326 PELVIC/BREAST G0101 $24.00FVH 85000337 EKG TRACING ONLY 93005 $28.00FVH 85000338 SPIROMETRY 94010 $53.00FVH 85000339 INSERTION PESSARY 57160 $62.00FVH 85000345 DESTRUCT LESION PENIS 54050 $105.00FVH 85000350 I&D ABSCESS FINGER SIMPLE 26010 $153.00FVH 85000357 INJECT GREATER OCCIPITAL NERVE 64405 $61.00FVH 85000367 OSTEOPATHIC MANIP TREAT 3-4 98926 $37.00FVH 85000438 OSTEOPATHIC MANIP TREAT 1-2 98925 $18.00FVH 85000439 INJECT CARPAL TUNNEL 20526 $54.00FVH 85000442 *ASPIR FINE NEEDLE W IMG TISSU 10022 $72.00FVH 85000458 SHAVE LESION > 2CM 11308 $102.00FVH 85000477 IMMUNIZ ADMIN HEPATITIS G0010 $51.00FVH 85000478 DEBRIDEMENT, SKIN SUBCUTANEOUS 11044 $222.00FVH 85000501 BX BREAST NEEDLE 19100 $74.00FVH 85000502 REMOVE FB MUSCLE/TEN SIMPLE 20520 $162.00FVH 85000503 I&D ABSCESS ANAL 46050 $109.00FVH 85000510 DEBRIDE WOUND SELECT < 20 97597 $42.00FVH 85000516 DEBRIDEMENT NAILS 1-5 11720 $26.00FVH 85000597 CATH INSERT BLADDER SPEC P9612 $51.00FVH 85000602 ANTERIOR NASAL CONTROL SIMPLE 30901 $76.00FVH 85000605 INCISION THROMBOSED HEMORRHOID 46083 $150.00FVH 85000606 CATH INSERT SMPL INDWELLING 51702 $216.00FVH 85000608 I&D PERINEAL ABSCESS 56405 $121.00FVH 85000617 ABSCESS/HEMOTOMA EAR 69000 $135.00FVH 85000618 REMOVE FB W/O ANST EXT EAR 69200 $100.00FVH 85000619 EVACUATION SUBUNGUAL HEMATOMA 11740 $36.00FVH 85000620 REPAIR NAILBED 11760 $148.00FVH 85000621 EXCISION INGROWN TOENAIL 11765 $132.00FVH 85000623 MEASURE OXYGEN LEVEL 94760 $48.00FVH 85000624 REMOVE IMPLANT SUPERFICIAL 20670 $142.00FVH 85000629 DEBRIDE SKIN MUSCLE SUBCUTANEO 11043 $172.00FVH 85000630 PAPILLECTOMY/EXC ANUS TAG 46220 $132.00FVH 85000652 INSTRUCTION RESP TREATMENT 94664 $39.00FVH 85000688 EXCISION LESION VULVULAR 56605 $67.00FVH 85000699 INSERT DRUG DELIVERY IMPLANT 11981 $88.00FVH 85000720 BX VAGINAL MUCOSA SIMP SEP PRO 57100 $44.00FVH 85000730 FEMALE 6 58301 $78.00FVH 85000733 EXCISION MALIGNANT LESION >4 11626 $328.00FVH 85000821 REPAIR LACERATION COMP ADD <5 13122 $94.00FVH 85000822 REPAIR LACERATION COMP ADD <5 13133 $145.00FVH 85000835 DESTROY BENIGN LESIONS <10CM 17106 $270.00FVH 85000986 EXCITION BREAST CYST 19120 $448.00FVH 85000991 EXC BACK LESION SUBCUT > 3CM 21931 $513.00FVH 85001002 INJ ANES AGNT OR STR PLANTAR 64455 $34.00

54

FVH 85001003 SLING MISC A4565 $16.00FVH 85001010 IMMOBILIZER KNEE L1830 $117.00FVH 85001015 BOOT/SHOE SURGICAL L3260 $35.00FVH 85001019 BRACE WRIST/HAND/FINGER NO JNT L3807 $273.00FVH 85001020 SPLINT WRIST COCK-UP NON-MOLD L3908 $85.00FVH 85001024 BOOT WALKING NON-PNEUM PRE CST L4386 $360.00FVH 85001037 NEBULIZER TREATMENT 94640 $45.00FVH 85001043 INCISION AND DRAINAGE UPPER AR 23931 $154.00FVH 85001047 FX SUPRA TRANS GONDYLAR 24530 $328.00FVH 85001052 STRAPPING ELBOW OR WRIST 29260 $41.00FVH 85001057 IMMUNE ADMIN ORAL/NASAL 1 VAC 90473 $51.00FVH 85001058 EXC FOREARM LES SC < 3 CM 25075 $348.00FVH 85001059 DEB SUBQ TISS ADD ON <20 SQ CM 11045 $30.00FVH 85001062 EXC TUMOR UPPER ARM/ELBOW 24071 $448.00FVH 85001073 PESSARY A4562 $51.00FVH 85001077 DESCTRUCT LESION OR SCAR MOUTH 40820 $219.00FVH 85001090 ECG RECORDING 93225 $83.00FVH 85001091 ECG ANALYSIS 93226 $127.00FVH 85001093 CERVICAL COLLAR $34.00FVH 85001094 DRESSING GAUZE $6.00FVH 85001095 BRACE GEL CAST $126.00FVH 85001096 SPLINT CARPAL TUNNEL WRIST $273.00FVH 85001097 SPLINT FINGER $24.00FVH 85001098 SPLINT THUMB SPICA $254.00FVH 85001099 SPLINT TENNIS ELBOW $88.00FVH 85001100 DRESSING TEGADERM $18.00FVH 85001102 APPLY CYLINDER CAST 29365 $84.00FVH 85001119 AIRCAST ANKLE BRACE L4350 $126.00FVH 85001164 DEBRIDEMENT OPEN FX DISLOCATIO 11010 $266.00FVH 85001176 PESSARY RUBBER A4561 $51.00FVH 85001201 CREATININE OTHER SOURCE 82570 $55.00FVH 85001313 BIOPSY MUSCLE DEEP 20205 $166.00FVH 85001314 SPLINT THUMB FORMFIT PREFABRIC L3931 $254.00FVH 85001317 TRANS CARE MGMT 14 DAY DISCH 99495 $150.00FVH 85001318 TRANS CARE MGMT 7 DAY DISCH 99496 $150.00FVH 85001332 EXC ARM/ELBOW LES SC <3CM 24075 $314.00FVH 85001334 TREATMENT OF HUMEROUS FX 24576 $345.00FVH 85001340 FRACTURE TIBIA PROX W/O MANIP 27530 $269.00FVH 85001342 BIOPSY OR EXC OF LYMPH NODE 38500 $279.00FVH 85001356 BX OR EXCISION OF LYMPH NODE 38505 $82.00FVH 85001357 CLSD TX GR TUBEROSITY FX 23620 $246.00FVH 85001677 EXCISION OF VAGINAL CYST/TUMOR 57135 $192.00FVH 85001684 REM CERUMEN IRRIG/LAVAGE 69209 $42.00FVH 85001707 EXC LEG/ANKLE TUMOR < 3 CM 27618 $291.00FVH 85001708 CLTX POST ANKLE FX 27767 $272.00FVH 85001709 ASP & INJ TX OF BONE CYST 20615 $156.00FVH 85001711 ADVNCD CARE PLANNING 1ST 30MIN 99497 $52.00FVH 85001712 ADVNCD CARE PLAN ADDL 30MIN 99498 $34.00FVH 85001719 SCREENING FOR DEPRESSON ADULT G0444 $6.00

55

FVH 85002039 BRIEF EMOTIONAL/BEHAV ASSMT 96127 $6.00FVH 85002203 TANGNTL BX SKIN SINGLE LES 11102 $74.00FVH 85002205 TANGNTL BX SKIN EA SEP/ADDL 11103 $40.00FVH 85002207 PUNCH BX SKIN SINGLE LESION 11104 $92.00FVH 85002209 PUNCH BX SKIN EA SEP/ADDL 11105 $46.00FVH 85002211 INCISIONAL BX SKIN SINGLE LES 11106 $112.00FVH 85002213 INCISIONAL BX SKIN SEP/ADDL 11107 $54.00FVH 85002234 OBSERVATION CARE DISCHARGE 99217 $70.00FVH 85002246 INJ TRANSVERSE ABD SINGLE 64486 $66.00FVH 85002259 DESTROY HEMORRHOIDS 46930 $170.00FVH 85005412 EXCISION BENIGN LESION>4CM 11446 $368.00FVH 85005429 EXC TUMOR THIGH >3CM 27337 $458.00FVH 85005434 CL TX METATARSAL FX W MANIP 28475 $222.00FVH 85005451 EXC LES TDN SHTH/CPSL LEG&/ANK 27630 $451.00FVH 85005775 SMOKING CESSATION 3-10 MIN 99406 $6.00FVH 85005839 I&D PILONDIAL CYST 10081 $190.00FVH 85005840 I&D HEMATOMA SEROMA 10140 $132.00FVH 85005841 REPAIR LACERATION SIMPLE >5 12014 $88.00FVH 85005842 REPAIR LACERATION SMPLE >7.5 12015 $109.00FVH 85005843 REPAIR LACERATION INTERM >2.5 12032 $217.00FVH 85005844 REPAIR LACERATION INTERM >7.5 12034 $228.00FVH 85005845 REPAIR LACERATION INTERM >2.5 12042 $222.00FVH 85005846 REPAIR LACERATION INTERM >7.5 12044 $237.00FVH 85005847 REPAIR LACERATION INTERM < 2.5 12051 $190.00FVH 85005848 CHEM CAUTERY GRANULATION TISSU 17250 $42.00FVH 85005849 MUSCLE BIOPSY 20200 $102.00FVH 85005850 EXC SHOULDER TUM DEEP < 5 CM 23076 $516.00FVH 85005851 EXC HAND LES SC <1.5CM 26115 $364.00FVH 85005852 INJ PROC LYMPHANGIOGRAPHY 38792 $44.00FVH 85005853 ANOSCOPY W/ DILATION 46604 $74.00FVH 85005854 DESTRUCTION OF LESION ANUS 46922 $150.00FVH 85005855 HEMORROID LIGATION INTERNAL 46945 $253.00FVH 85005856 REPLACE G/C TUBE PERC 49450 $75.00FVH 85005857 LEVEL 4 CONSULT 99244 $116.00FVH 85005858 LEVEL 5 CONSULT 99245 $145.00FVH 85005859 DEBRIDE W/ REMOVAL FB 11012 $400.00FVH 85005860 APPLICATION OF UNIPLANE UNILAT 20690 $560.00FVH 85005861 I&D ABSCESS FINGER COMP 26011 $176.00FVH 85005935 COG/FUNC ASSESS OUTPT 99483 $115.00FVH 85005963 ALCOHOL SCREENING G0442 $6.00FVH 86000166 INFECTIOUS AGENT ANTIGEN DETEC 87449 $76.00FVH 87000002 LEVEL 1 NEW PATIENT 99201 $65.00FVH 87000003 LEVEL 2 NEW PATIENT 99202 $123.00FVH 87000004 LEVEL 3 NEW PATIENT 99203 $186.00FVH 87000005 LEVEL 4 NEW PATIENT 99204 $315.00FVH 87000006 LEVEL 5 NEW PATIENT 99205 $309.00FVH 87000007 LEVEL 1 EST PATIENT 99211 $17.00FVH 87000008 LEVEL 2 EST PATIENT 99212 $62.00FVH 87000009 LEVEL 3 EST PATIENT 99213 $126.00

56

FVH 87000010 LEVEL 4 EST PATIENT 99214 $193.00FVH 87000011 LEVEL 5 EST PATIENT 99215 $272.00FVH 87000012 ASPIR FINE NEEDLE W/O IMAG GUI 10021 $193.00FVH 87000014 I&D ABSCESS & CYST SIMPLE 10060 $269.00FVH 87000015 I&D ABSCESS COMPLICATED 10061 $498.00FVH 87000016 I&D PILONIDAL CYST SIMPLE 10080 $286.00FVH 87000017 I&D PILONDIAL CYST 10081 $475.00FVH 87000018 REMOVE FB SIMPLE 10120 $288.00FVH 87000019 I&D HEMATOMA SEROMA 10140 $329.00FVH 87000020 ASPIR ABSCESS/HEMATOMA/CYST 10160 $266.00FVH 87000021 I&D POSTOP WOUND INFECTION 10180 $490.00FVH 87000022 DEBRIDE SKIN SUBCUTANEOUS 11042 $172.00FVH 87000023 DEBRIDE SKIN MUSCLE SUBCUTANEO 11043 $431.00FVH 87000024 DEB SUBQ TISSUE ADD ON 11045 $74.00FVH 87000027 REMOVAL SKIN TAGS 11200 $203.00FVH 87000028 REMOVE SKIN TAGS EA ADD 11201 $46.00FVH 87000029 SHAVE LESION <.5 CM 11300 $97.00FVH 87000030 SHAVE LESION >.5CM 11301 $148.00FVH 87000031 SHAVE LESION <.5 CM 11305 $109.00FVH 87000032 SHAVE LESION <.5 CM 11310 $130.00FVH 87000033 SHAVE LESION >.5CM 11311 $182.00FVH 87000034 EXCISION BENIGN LESION <.5CM 11400 $221.00FVH 87000035 EXCISION BENIGN LESION >.5CM 11401 $288.00FVH 87000036 EXCISION BENIGN LESION <2CM 11402 $315.00FVH 87000037 EXCISION BENIGN LESION> 2CM 11403 $406.00FVH 87000038 EXCISION BENIGN LESION> 2CM 11404 $446.00FVH 87000039 EXCISION BENIGN LESION > 4 CM 11406 $672.00FVH 87000040 EXCISION BENIGN LESION <.5CM 11420 $228.00FVH 87000041 EXCISION BENIGN LESION >.5CM 11421 $307.00FVH 87000042 EXCISION BENIGN LESION <2CM 11422 $376.00FVH 87000043 EXCISION BENIGN LESION >2CM 11423 $436.00FVH 87000044 EXCISION BENIGN LESION> 2CM 11424 $495.00FVH 87000045 EXCISION BENIGN LESION > 4 CM 11426 $751.00FVH 87000046 EXCISION BENIGN LESION <.5CM 11440 $288.00FVH 87000047 EXCISION BENIGN LESION >.5CM 11441 $365.00FVH 87000048 EXCISION BENIGN LESION <2CM 11442 $403.00FVH 87000049 EXCISION BENIGN LESION >2CM 11443 $493.00FVH 87000050 EXCISION MALIGNANT LESION<.5 11600 $331.00FVH 87000051 EXCISION MALIGNANT LESION>.5 11601 $412.00FVH 87000052 EXCISION MALIGNANT LESION <2 11602 $453.00FVH 87000053 EXCISION MALIGNANT LESION>2 11603 $539.00FVH 87000054 EXCISION MALIGNANT LESION>3 11604 $593.00FVH 87000055 EXCISION MALIGNANT LESION >4 11606 $877.00FVH 87000056 EXCISION MALIGNANT LESION>.5 11621 $418.00FVH 87000057 EXCISION MALIGNANT LESION <2 11622 $475.00FVH 87000058 EXCISION MALIGNANT LESION>2 11623 $587.00FVH 87000059 EXCISION MALIGNANT LESION >3 11624 $662.00FVH 87000060 EXC MAL LESION >4CM 11626 $809.00FVH 87000061 EXCISION MALIGNANT LESION<.5 11640 $347.00

57

FVH 87000062 EXCISION MALIGNANT LESION>.5 11641 $433.00FVH 87000063 EXCISION MALIGNANT LESION <2 11642 $509.00FVH 87000064 EXCISION MALIGNANT LESION>2 11643 $638.00FVH 87000065 EVACUATION SUBUNGUAL HEMATOMA 11740 $91.00FVH 87000066 REPAIR NAILBED 11760 $370.00FVH 87000067 INJ LESION 11900 $87.00FVH 87000068 INSET DRUG DELIVERY IMPLANT 11981 $221.00FVH 87000069 REPAIR LACERATION SIMPLE < 2.5 12001 $123.00FVH 87000070 REPAIR LACERATION SIMPLE >2.5 12002 $163.00FVH 87000071 REPAIR LACERATION SIMPLE > 7.5 12004 $203.00FVH 87000072 REPAIR LACERATION SIMPLE >12.5 12005 $274.00FVH 87000073 REPAIR LACERATION SIMPLE < 2.5 12011 $154.00FVH 87000074 REPAIR LACERATION SIMPLE > 2.5 12013 $172.00FVH 87000075 REPAIR LACERATION SIMPLE >5 12014 $219.00FVH 87000076 REPAIR LACERATION SMPLE >7.5 12015 $273.00FVH 87000077 REPAIR LACERATION INTERM < 2.5 12031 $425.00FVH 87000078 REPAIR LACERATION INTERM >2.5 12032 $542.00FVH 87000079 REPAIR LACERATION INTERM >7.5 12034 $571.00FVH 87000080 REPAIR LACERATION INTERM>30 12037 $888.00FVH 87000081 REPAIR LACERATION INTERM < 2.5 12041 $434.00FVH 87000082 REPAIR LACERATION INTERM >2.5 12042 $556.00FVH 87000083 REPAIR LACERATION INTERM >7.5 12044 $593.00FVH 87000084 REPAIR LACERATION INTERM < 2.5 12051 $476.00FVH 87000085 REPAIR LACERATION INTERM > 2.5 12052 $565.00FVH 87000086 REPAIR LACERATION INTERM >5 12053 $601.00FVH 87000087 REPAIR LAC COMPLEX EA ADD 5 CM 13122 $235.00FVH 87000088 REPAIR OF WOUND/LESION ADD ON 13133 $362.00FVH 87000089 BURN TREATMENT SMALL 16020 $150.00FVH 87000090 DESTROY BENIGN LESION UP TO 14 17110 $195.00FVH 87000091 CHEM CAUTERY GRANULATION TISSU 17250 $104.00FVH 87000092 ASPIR BREAST CYST 19000 $119.00FVH 87000093 BX BREAST NEEDLE 19100 $187.00FVH 87000094 EXCISION BREAST CYST 19120 $1,122.00FVH 87000095 MUSCLE BIOPSY 20200 $257.00FVH 87000096 BIOPSY MUSCLE DEEP 20205 $417.00FVH 87000097 REMOVE FB MUSCLE/TEN SIMPLE 20520 $404.00FVH 87000098 INJ TRIGGER POINT 1 OR 2 20552 $106.00FVH 87000099 ASPIR INJ INTERM JT 20605 $146.00FVH 87000100 ASPIRATION/INJ GANGLION CYST 20612 $115.00FVH 87000101 EXC BACK LESION SUBCUT >3CM 21931 $1,283.00FVH 87000102 EXC SHOULDER TUM DEEP < 5 CM 23076 $1,291.00FVH 87000103 EXC TUMOR UPPER ARM/ELBOW 24071 $1,122.00FVH 87000104 EXC FOREARM LES SC <3CM 25075 $871.00FVH 87000105 I&D FINGER ABSCESS SIMPLE 26010 $383.00FVH 87000106 EXC HAND LES SC <1.5CM 26115 $910.00FVH 87000107 EXC TUMOR THIGH >3CM 27337 $1,146.00FVH 87000108 REMOVE FB FOOT 28190 $385.00FVH 87000109 APPLICATION LONG ARM SPLINT 29105 $167.00FVH 87000110 APPLICATION FINGER SPLINT 29130 $79.00

58

FVH 87000111 APPLICATION UNNA BOOT 29580 $99.00FVH 87000112 REMOVAL TUNNELED CVC W/O PORT 36589 $389.00FVH 87000113 BX OR EXCISION OF LYMPH NODE 38505 $206.00FVH 87000114 INJ PROC LYMPHANGIOGRAPHY 38792 $112.00FVH 87000115 CHANGE GASTROSTOMY TUBE 43762 $134.00FVH 87000116 I&D PERIANAL ABSCESS 46050 $273.00FVH 87000117 INCISION THROMBOSED HEMORRHOID 46083 $296.00FVH 87000118 PAPILLECTOMY/EXC ANUS TAG 46220 $329.00FVH 87000119 EXCISE EXT HEMORRHOID TAGS 46230 $478.00FVH 87000120 ANOSCOPY 46600 $114.00FVH 87000121 ANOSCOPY W/ DILATION 46604 $185.00FVH 87000122 DESTRUCTION OF LESION ANUS 46922 $375.00FVH 87000123 HEMORROID LIGATION INTERNAL 46945 $633.00FVH 87000124 REPLACE G/C TUBE PERC 49450 $188.00FVH 87000125 CATH INSERT SMPL INDWELLING 51702 $490.00FVH 87000126 I&D VULVA 56405 $303.00FVH 87000127 BX OF VULVA OR PERINEUM 56605 $168.00FVH 87000128 BX VAGINA 57100 $183.00FVH 87000129 EXCISION OF VAGINAL CYST/TUMOR 57135 $479.00FVH 87000130 REMOVAL ENDOCERVICAL POLYPS 57500 $211.00FVH 87000131 BX UTERUS LINING 58100 $244.00FVH 87000132 FEMALE 6 58301 $189.00FVH 87000133 ABSCESS/HEMOTOMA EAR 69000 $337.00FVH 87000134 LEVEL 1 CONSULT 99241 $62.00FVH 87000135 LEVEL 2 CONSULT 99242 $131.00FVH 87000136 LEVEL 3 CONSULT 99243 $183.00FVH 87000137 LEVEL 4 CONSULT 99244 $291.00FVH 87000138 LEVEL 5 CONSULT 99245 $363.00FVH 87000139 DEBRIDEMENT OPEN FX DISLOCATN 11010 $789.00FVH 87000140 DEBRIDE W/ REMOVAL FB 11012 $999.00FVH 87000141 DEBRIDEMENT SKIN SUBCUT 11044 $555.00FVH 87000142 INJECT CARPAL TUNNEL 20526 $161.00FVH 87000143 INJ TENDON SHEATH LIGAMENT 20550 $111.00FVH 87000144 INJ SINGLE TENDON 20551 $121.00FVH 87000145 ASPIR INJ SM JOINT 20600 $101.00FVH 87000146 ASPIR INJ MAJOR JT 20610 $129.00FVH 87000147 APPLICATION OF UNIPLANE UNILAT 20690 $1,650.00FVH 87000148 FX CLAVICLE 23500 $533.00FVH 87000149 FX SCAPULA 23570 $572.00FVH 87000150 TUBEROSITY HUMERAL FRACTURE 23620 $614.00FVH 87000151 DISLOCATION SHOULDER W/O ANEST 23650 $803.00FVH 87000152 EXC ARM/ELBOW LES SC <3CM 24075 $786.00FVH 87000153 FX HUMERAL SHAFT 24500 $778.00FVH 87000154 FX SUPRA TANS GONDYLAR 24530 $820.00FVH 87000155 FX RADIAL HEAD OR NECK 24650 $575.00FVH 87000156 FX ULNA PROXIMAL 24670 $728.00FVH 87000157 FX ULNA SHAFT 25530 $567.00FVH 87000158 FX DISTAL RADIUS 25600 $744.00FVH 87000159 FX NAVICULAR 25622 $664.00

59

FVH 87000160 FX CARPAL 25630 $669.00FVH 87000161 I&D ABSCESS FINGER COMP 26011 $440.00FVH 87000162 FX METACARPAL 26600 $769.00FVH 87000163 FX METACARPAL CLOSED TX 26605 $700.00FVH 87000164 FX FINGER 26720 $443.00FVH 87000165 FX DISTAL PHALANX 26750 $443.00FVH 87000166 DISLOCATION FINGER W/O ANESTH 26770 $615.00FVH 87000167 FX PATELLA 27520 $707.00FVH 87000168 FRACTURE TIBIA PROX W/O MANIP 27530 $672.00FVH 87000169 EXC LEG/ANKLE TUMOR < 3 CM 27618 $727.00FVH 87000170 FX MEDIAL MALLEOLUS 27760 $732.00FVH 87000171 FX DISTAL FIBULA 27786 $688.00FVH 87000172 FX BIMALLEOLAR 27808 $722.00FVH 87000173 FX METATARSAL 28470 $498.00FVH 87000174 APPL LONG ARM CAST SHOU>HAND 29065 $163.00FVH 87000175 APPLICATION SHORT ARM CAST 29075 $174.00FVH 87000176 APPLICATION SHORT ARM CAST OT 29125 $111.00FVH 87000177 APPLICATION LONG LEG CAST 29345 $241.00FVH 87000178 APPLICATION CYLINDER CAST 29365 $209.00FVH 87000179 APPLICATION PLSTR SPLINT LEG 29505 $120.00FVH 87000180 INJ ANES AGNT OR STR PLANTAR 64455 $85.00FVH 87000181 APPLICATION SHORT LEG CAST 29405 $168.00FVH 87000182 SUBQ/IM INJECTION 96372 $61.00FVH 87000183 DISLOCATION NURSEMAID ELBOW 24640 $229.00FVH 87000184 REMOVE IMPLANT SUPERFICIAL 20670 $355.00FVH 87000185 CLTX POST ANKLE FX 27767 $680.00FVH 87000186 ASP & INJ TX OF BONE CYST 20615 $390.00FVH 87000187 FRACTURE METATARSAL W/MANIP 28475 $555.00FVH 87000188 INCISION AND DRAINAGE UPPER AR 23931 $385.00FVH 87000189 EXC LES TDN SHTH/CPSL LEG&/ANK 27630 $1,035.00FVH 87000190 EXCISION BENIGN LESION>4CM 11446 $920.00FVH 87000191 INJ GREATER OCCIPITAL NERVE 64405 $175.00FVH 87000193 FX RADIAL SHAFT 25500 $600.00FVH 87000194 OBSERVATION CARE DISCHARGE 99217 $175.00FVH 87000195 TANGNTL BX SKIN SINGLE LES 11102 $114.00FVH 87000196 TREATMENT OF HUMEROUS FX 24576 $860.00FVH 87000197 INJ TRANSVERSE ABD SINGLE 64486 $165.00FVH 87000198 BIOPSY OR EXC OF LYMPH NODE 38500 $694.00FVH 87000199 HEMORRHOIDECTOMY LIGATURE 46221 $545.00FVH 87000200 DESTROY HEMORRHOIDS 46930 $425.00FVH 87000201 DEBRIDE WOUND SELECTIVE < 20 97597 $108.00FVH 88000008 UCC LEVEL 3 99213 $100.00FVH 90000002 I&D ABSCESS & CYST SIMPLE 10060 $168.00FVH 90000003 I&D ABSCESS COMPLICATED 10061 $245.00FVH 90000006 EXCISION BENIGN LESION <2CM 11442 $257.00FVH 90000007 REPAIR LACERATION SIMPLE < 2.5 12001 $184.00FVH 90000008 REPAIR LACERATION SIMPLE >2.5 12002 $196.00FVH 90000012 REPAIR LACERATION SIMPLE < 2.5 12011 $195.00FVH 90000013 REPAIR LACERATION SIMPLE > 2.5 12013 $215.00

60

FVH 90000017 REPAIR LACERATION INTERM < 2.5 12031 $342.00FVH 90000021 REPAIR LACERATION INTERM < 2.5 12041 $289.00FVH 90000028 ANTERIOR NASAL CONTROL SIMPLE 30901 $227.00FVH 90000031 REMOVE CERUMEN INSTRUMENTATION 69210 $74.00FVH 90000056 LEVEL 1 NEW PT 99201 $48.00FVH 90000057 LEVEL 2 NEW PT 99202 $79.00FVH 90000058 LEVEL 3 NEW PT 99203 $116.00FVH 90000059 LEVEL 4 NEW PT 99204 $177.00FVH 90000060 LEVEL 5 NEW PT 99205 $205.00FVH 90000061 LEVEL 1 EST PT 99211 $24.00FVH 90000062 LEVEL 2 EST PT 99212 $47.00FVH 90000063 LEVEL 3 EST PT 99213 $78.00FVH 90000064 LEVEL 4 EST PT 99214 $114.00FVH 90000065 LEVEL 5 EST PT 99215 $154.00FVH 90000067 LEVEL 2 CONSULT 99242 $103.00FVH 90000068 LEVEL 3 CONSULT 99243 $119.00FVH 90000072 PERIODIC PREVENTIVE MED 18-39 99395 $183.00FVH 90000073 PERIODIC PREVENTIVE MED 40-64 99396 $194.00FVH 90000074 PERIODIC PREVENTIVE MED 65 99397 $209.00FVH 90000083 REMOVE ENDOCERVICAL POLYPS 57500 $195.00FVH 90000085 CAUTERIZE CERVIX 57511 $228.00FVH 90000086 BIOPSY UTERUS 58100 $156.00FVH 90000097 INSERTION PESSARY 57160 $94.00FVH 90000103 DESTRUCT LESION PENIS 54050 $190.00FVH 90000108 SHAVE LESION > 2 CM 11308 $235.00FVH 90000120 ANNUAL WELLNESS VISIT INITIAL G0438 $175.00FVH 90000121 ANNUAL WELLNESS VISIT SUBSEQUE G0439 $120.00FVH 90000417 ACNE SURGERY 10040 $158.00FVH 90000419 REMOVE FB SIMPLE 10120 $219.00FVH 90000422 ASPIR ABSCESS/HEMATOMA/CYST 10160 $183.00FVH 90000424 DEBRIDEMENT INFECTED SKIN 11000 $65.00FVH 90000425 PARING LESION (SINGLE) BENIGN 11055 $87.00FVH 90000430 REMOVAL SKIN TAGS 11200 $124.00FVH 90000431 SHAVE LESION <.5 CM 11300 $157.00FVH 90000432 SHAVE LESION >.5CM 11301 $187.00FVH 90000433 SHAVE LESION 2 CM 11302 $217.00FVH 90000434 SHAVE LESION > 2CM 11303 $231.00FVH 90000435 SHAVE LESION <.5 CM 11305 $167.00FVH 90000436 SHAVE LESION > .5 CM 11306 $188.00FVH 90000437 SHAVE LESION 2 CM 11307 $224.00FVH 90000438 SHAVE LESION <.5 CM 11310 $180.00FVH 90000439 SHAVE LESION >.5CM 11311 $211.00FVH 90000440 SHAVE LESION 2 CM 11312 $248.00FVH 90000442 EXCISION BENIGN LESION <.5CM 11400 $170.00FVH 90000443 EXCISION BENIGN LESION >.5CM 11401 $208.00FVH 90000444 EXCISION BENIGN LESCION <2CM 11402 $230.00FVH 90000445 EXCISION BENIGN LESION >2CM 11403 $265.00FVH 90000446 EXCISION BENIGN LESION> 2CM 11404 $301.00FVH 90000447 EXCISION BENIGN LESION > 4 CM 11406 $376.00

61

FVH 90000448 EXCISION BENIGN LESION <.5CM 11420 $170.00FVH 90000449 EXCISION BENIGN LESION >.5CM 11421 $219.00FVH 90000450 EXCISION BENIGN LESION <2CM 11422 $245.00FVH 90000451 EXCISION BENIGN LESION >2CM 11423 $274.00FVH 90000454 EXCISION BENIGN LESION <.5CM 11440 $189.00FVH 90000455 EXCISION BENIGN LESION >.5CM 11441 $231.00FVH 90000458 EXCISION MALIGNANT LESION<.5 11600 $264.00FVH 90000459 EXCISION MALIGNANT LESION>.5 11601 $319.00FVH 90000460 EXCISION MALIGNANT LESION <2 11602 $345.00FVH 90000461 EXCISION MALIGNANT LESION >2 11603 $393.00FVH 90000462 EXCISION MALIGNANT LESION>3 11604 $425.00FVH 90000463 EXCISION M ALIGNANT LESION >4 11606 $630.00FVH 90000465 EXCISION MALIGNANT LESION>.5 11621 $313.00FVH 90000466 EXCISION MALIGNANT LESION <2 11622 $357.00FVH 90000467 EXCISION MALIGNANT LESION>2 11623 $406.00FVH 90000469 EXCISION MALIGNANT LESION<.5 11640 $274.00FVH 90000470 EXCISION MALIGNANT LESION>.5 11641 $322.00FVH 90000471 EXCISION MALIGNANT LESION <2 11642 $378.00FVH 90000472 EXCISION MALIGNANT LESION>2 11643 $385.00FVH 90000473 EXCISION MALIGNANT LESION >3 11644 $525.00FVH 90000474 TRIM NAILS 11719 $25.00FVH 90000475 AVULSION NAIL PLATE SIMP SINGL 11730 $159.00FVH 90000479 EXCISION INGROWN TOENAIL 11765 $241.00FVH 90000489 BURN TREATMENT SMALL 16020 $98.00FVH 90000492 DESTROY BENIGN PREMAL LESION 17000 $106.00FVH 90000493 DESTROY BENIGN LESION 2-14 17003 $29.00FVH 90000494 DESTROY BENIGN LESION >16 17004 $208.00FVH 90000495 DESTROY BENIGN LESION UP TO 14 17110 $153.00FVH 90000500 ASPIR INJ SM JT 20600 $106.00FVH 90000501 ASPIR INJ INTERM JT 20605 $106.00FVH 90000502 ASPIR INJ MAJOR JT 20610 $113.00FVH 90000516 FX RADIAL SHAFT 25500 $360.00FVH 90000520 FX DISTAL RADIUS 25600 $468.00FVH 90000524 FX METACARPAL 26600 $356.00FVH 90000545 FX FIBULA PROXIMAL OR SHAFT 27780 $372.00FVH 90000563 APPLICATION SHORT ARM SPLINT 29125 $76.00FVH 90000579 HEARING SCREENING 92567 $28.00FVH 90000581 PROLONGED MD SERVICE 30-74 99354 $134.00FVH 90000582 PROLONGED MD SERVICE 75-105 99355 $182.00FVH 90000583 PREVENTIVE MED < 1YR NEW 99381 $170.00FVH 90000584 PREVENTIVE MED 1-4 YRS NEW 99382 $179.00FVH 90000585 PREVENTIVE MED 5-11 YRS NEW 99383 $185.00FVH 90000586 PREVENTIVE MED 12-17 YRS NEW 99384 $209.00FVH 90000587 PREVENTIVE MED 18-39 YRS NEW 99385 $202.00FVH 90000588 PREVENTIVE MED 40-64 YRS NEW 99386 $234.00FVH 90000589 PREVENTIVE MED 65 & OLDER NEW 99387 $254.00FVH 90000593 WELCOME TO MEDICARE EXAM G0402 $125.00FVH 90000594 SMOKING CESSATION 10 MIN 99406 $9.00FVH 90000596 SCREENING PAP Q0091 $65.00

62

FVH 90000597 STRESS TEST SUPERVISION 93016 $67.00FVH 90000598 STRESS TEST INTERP AND REPORT 93018 $76.00FVH 90000599 EKG WELCOME TO MEDICARE G0405 $41.00FVH 90000601 REMOVE SKIN TAG EA ADD 11201 $55.00FVH 90000606 DEBRIDEMENT NAILS 1-5 11720 $46.00FVH 90000615 INJ LIGAMENT/TENDON 20550 $111.00FVH 90000664 INCISION THROMBOSED HEMORRHOID 46083 $256.00FVH 90000684 BIOPSY VAGINA 57100 $161.00FVH 90000685 COLPOSCOPY 57454 $221.00FVH 90000697 EKG INTERPRETATION 93010 $41.00FVH 90000703 ECG INTERPRETATION 93227 $75.00FVH 90000726 PELVIC OR BREAST EXAM G0101 $37.00FVH 90000770 EXC LES TDN SHTH/CPSL LEG&/ANK 27630 $787.00FVH 90000796 DEBRIDE WOUND SELECTIVE < 20 97597 $64.00FVH 90000798 REMOVE FB EAR 69200 $175.00FVH 90001196 STRAPPING ELBOW /WRIST 29260 $62.00FVH 90001219 PFT SCREEN SPIROMETRY 94010 $20.00FVH 90001220 OSTEOPATHIC MANIP TREAT 1-2 98925 $37.00FVH 90001221 CARDIAC EVENT MONITOR INTERP 93272 $81.00FVH 90001222 CARDIAC STRESS TEST STIX 93015 $130.00FVH 90001223 BASIC LIFE EXAM 99450 $245.00FVH 90001224 DESTRUCT LESION OR SCAR MOUTH 40820 $328.00FVH 90001239 DESTROY BENIGN LESIONS <10CM 17106 $406.00FVH 90001240 EXC MAL LESION >4CM 11626 $492.00FVH 90001320 TRANS CARE MGMT 14 DAY DISCH 99495 $225.00FVH 90001321 TRANS CARE MGMT 7 DAY DISCH 99496 $225.00FVH 90001365 EXC BACK TUMOR DEEP < 5CM 21932 $1,800.00FVH 90001426 LTC SUBS LEVEL 3 VISIT 99309 $215.00FVH 90001561 REM CERUMEN IRRIG/LAVAGE 69209 $13.00FVH 90001572 ADVANCED CARE PLAN 1ST 30MIN 99497 $78.00FVH 90001573 ADVANCED CARE PLAN ADDL 30MIN 99498 $51.00FVH 90001580 SCREENING FOR DEPRESSON ADULT G0444 $9.00FVH 90001687 EXC HIP/PELVIS LES SC < 3 CM 27047 $1,296.00FVH 90001692 COG/FUNC ASSESS OUTPT 99483 $304.00FVH 90001911 BRIEF EMOTIONAL/BEHAV ASSMT 96127 $9.00FVH 90001917 ALCOHOL SCREENING PF G0442 $9.00FVH 90002044 TANGNTL BX SKIN SINGLE LES 11102 $110.00FVH 90002045 TANGNTL BX SKIN EA SEP/ADDL 11103 $74.00FVH 90002046 PUNCH BX SKIN SINGLE LESION 11104 $174.00FVH 90002047 PUNCH BX SKIN EA SEP/ADDL 11105 $84.00FVH 90002048 INCISIONAL BX SKIN SINGLE LES 11106 $210.00FVH 90002049 INCISIONAL BX SKIN SEP/ADDL 11107 $100.00FVH 90002055 LEVEL 4 HOME VISIT 99350 $285.00FVH 90002056 HOME VISIT NEW PATIENT 99345 $375.00FVH 91000002 ASPIR FINE NEEDLE W/O IMAG GUI 10021 $116.00FVH 91000004 I&D ABSCESS & CYST SIMPLE 10060 $176.00FVH 91000005 I&D ABSCESS COMPLICATED 10061 $334.00FVH 91000006 I&D PILONIDAL CYST SIMPLE 10080 $172.00FVH 91000007 REMOVE FB SIMPLE 10120 $172.00

63

FVH 91000008 REMOVE FB COMPLICATED 10121 $516.00FVH 91000009 I&D HEMATOMA SEROMA 10140 $197.00FVH 91000010 ASPIR ABSCESS/HEMATOMA/CYST 10160 $162.00FVH 91000011 I&D POSTOP WOUND INFECTION 10180 $294.00FVH 91000014 DEBRIDE SKIN SUBCUTANEOUS 11042 $103.00FVH 91000020 REMOVAL SKIN TAGS 11200 $133.00FVH 91000021 REMOVE SKIN TAGS EA ADD 11201 $15.00FVH 91000022 SHAVE LESION <.5 CM 11300 $39.00FVH 91000023 SHAVE LESION >.5CM 11301 $71.00FVH 91000026 SHAVE LESION <.5 CM 11305 $51.00FVH 91000029 SHAVE LESION <.5 CM 11310 $59.00FVH 91000030 SHAVE LESION >.5CM 11311 $94.00FVH 91000033 EXCISION BENIGN LESION <.5CM 11400 $123.00FVH 91000034 EXCISION BENIGN LESION >.5CM 11401 $170.00FVH 91000035 EXCISION BENIGN LESION <2CM 11402 $183.00FVH 91000036 EXCISION BENIGN LESION> 2CM 11403 $253.00FVH 91000037 EXCISION BENIGN LESION> 2CM 11404 $273.00FVH 91000038 EXCISION BENIGN LESION > 4 CM 11406 $422.00FVH 91000039 EXCISION BENIGN LESION <.5CM 11420 $130.00FVH 91000040 EXCISION BENIGN LESION >.5CM 11421 $181.00FVH 91000041 EXCISION BENIGN LESION <2CM 11422 $236.00FVH 91000042 EXCISION BENIGN LESION >2CM 11423 $274.00FVH 91000043 EXCISION BENIGN LESION> 2CM 11424 $297.00FVH 91000044 EXCISION BENIGN LESION > 4 CM 11426 $451.00FVH 91000045 EXCISION BENIGN LESION <.5CM 11440 $180.00FVH 91000046 EXCISION BENIGN LESION >.5CM 11441 $231.00FVH 91000047 EXCISION BENIGN LESION <2CM 11442 $253.00FVH 91000048 EXCISION BENIGN LESION >2CM 11443 $296.00FVH 91000049 EXCISION MALIGNANT LESION<.5 11600 $177.00FVH 91000050 EXCISION MALIGNANT LESION>.5 11601 $230.00FVH 91000051 EXCISION MALIGNANT LESION <2 11602 $256.00FVH 91000052 EXCISION MALIGNANT LESION>2 11603 $314.00FVH 91000053 EXCISION MALIGNANT LESION>3 11604 $342.00FVH 91000054 EXCISION MALIGNANT LESION >4 11606 $517.00FVH 91000056 EXCISION MALIGNANT LESION>.5 11621 $236.00FVH 91000057 EXCISION MALIGNANT LESION <2 11622 $271.00FVH 91000058 EXCISION MALIGNANT LESION>2 11623 $347.00FVH 91000059 EXCISION MALIGNANT LESION >3 11624 $398.00FVH 91000060 EXCISION MALIGNANT LESION<.5 11640 $187.00FVH 91000061 EXCISION MALIGNANT LESION>.5 11641 $243.00FVH 91000062 EXCISION MALIGNANT LESION <2 11642 $293.00FVH 91000063 EXCISION MALIGNANT LESION>2 11643 $381.00FVH 91000064 EXCISION MALIGNANT LESION >3 11644 $787.00FVH 91000066 EVACUATION SUBUNGUAL HEMATOMA 11740 $55.00FVH 91000068 REPAIR NAILBED 11760 $222.00FVH 91000070 REMOVE CYST 11770 $505.00FVH 91000071 INJ LESION 11900 $52.00FVH 91000072 REPAIR LACERATION SIMPLE < 2.5 12001 $18.00FVH 91000073 REPAIR LACERATION SIMPLE >2.5 12002 $51.00

64

FVH 91000074 REPAIR LACERATION SIMPLE > 7.5 12004 $122.00FVH 91000075 REPAIR LACERATION SIMPLE >12.5 12005 $165.00FVH 91000077 REPAIR LACERATION SIMPLE < 2.5 12011 $66.00FVH 91000078 REPAIR LACERATION SIMPLE > 2.5 12013 $49.00FVH 91000079 REPAIR LACERATION SIMPLE >5 12014 $131.00FVH 91000080 REPAIR LACERATION SMPLE >7.5 12015 $164.00FVH 91000081 REPAIR LACERATION INTERM < 2.5 12031 $236.00FVH 91000082 REPAIR LACERATION INTERM >2.5 12032 $325.00FVH 91000083 REPAIR LACERATION INTERM >7.5 12034 $343.00FVH 91000084 REPAIR LACERATION INTERM>30 12037 $533.00FVH 91000085 REPAIR LACERATION INTERM < 2.5 12041 $242.00FVH 91000086 REPAIR LACERATION INTERM >2.5 12042 $334.00FVH 91000087 REPAIR LACERATION INTERM >7.5 12044 $356.00FVH 91000089 REPAIR LACERATION INTERM < 2.5 12051 $286.00FVH 91000090 REPAIR LACERATION INTERM > 2.5 12052 $339.00FVH 91000091 REPAIR LACERATION INTERM >5 12053 $361.00FVH 91000092 REPAIR LACERATION COMPLEX >2.5 13101 $705.00FVH 91000093 REPAIR LACERATION COMPLEX <2.5 13120 $655.00FVH 91000094 REPAIR LACERATION COMPLEX >2.5 13121 $741.00FVH 91000096 REPAIR LACERATION COMPLEX >2.5 13132 $872.00FVH 91000098 BURN TREATMENT SMALL 16020 $84.00FVH 91000104 DESTROY BENIGN LESION UP TO 14 17110 $108.00FVH 91000107 ASPIR BREAST CYST 19000 $72.00FVH 91000108 BX BREAST NEEDLE 19100 $113.00FVH 91000109 BX BREAST OPEN 19101 $602.00FVH 91000110 EXCISION BREAST CYST 19120 $674.00FVH 91000111 REMOVE FB MUSCLE/TEN SIMPLE 20520 $242.00FVH 91000114 INJ TRIGGER POINT 1 OR 2 20552 $64.00FVH 91000117 ASPIR INJ INTERM JT 20605 $85.00FVH 91000169 REMOVE FB FOOT 28190 $231.00FVH 91000181 APPLICATION LONG ARM SPLINT 29105 $100.00FVH 91000183 APPLICATION FINGER SPLINT 29130 $47.00FVH 91000189 APPLICATION UNNA BOOT 29580 $59.00FVH 91000199 THORACENTESIS W/O IMG GUIDE 32554 $253.00FVH 91000205 EGD DIAGNOSTIC 43235 $390.00FVH 91000206 EGD W/BIOPSY 43239 $450.00FVH 91000207 EGD W/REMOVAL OF FB 43247 $558.00FVH 91000208 EGD W/POLYP HOT BIOPSY 43250 $526.00FVH 91000209 EGD W/POLYP SNARE 43251 $607.00FVH 91000210 COLECTOMY PARTIAL 44140 $3,646.00FVH 91000211 COLOPROCTOSTOMY 44145 $4,522.00FVH 91000213 CLOSURE ENTEROSTOMY W/RESEC 44625 $2,792.00FVH 91000214 APPENDECTOMY 44950 $1,743.00FVH 91000215 APPENDECTOMY LAPAROSCOPY 44970 $1,636.00FVH 91000216 BX ANORECTAL WALL 45100 $833.00FVH 91000217 PROCTOSIGMOIDOSCOPY 45300 $152.00FVH 91000218 PROCTOSIGMOIDOSCOPY W DILATE 45305 $221.00FVH 91000219 SIGMOIDOSCOPY DIAGNOSTIC 45330 $179.00FVH 91000220 SIGMOIDOSCOPY W/BIOPSY 45331 $213.00

65

FVH 91000222 COLONOSCOPY DIAGNOSTIC 45378 $600.00FVH 91000223 COLONOSCOPY W/BIOPSY 45380 $685.00FVH 91000224 COLONOSCOPY W/POLYP 45384 $730.00FVH 91000225 COLONOSCOPY W/POLYP SNARE 45385 $830.00FVH 91000226 INCISION THROMBOSED HEMORRHOID 46083 $146.00FVH 91000227 HEMORRHOIDECTOMY LIGATURE 46221 $327.00FVH 91000228 EXCISE EXT HEMORRHOID TAGS 46230 $287.00FVH 91000229 HEMORRHOIDECTOMY EXTERNAL 46250 $867.00FVH 91000230 ANOSCOPY 46600 $69.00FVH 91000231 CATH INSERT SMPL INDWELLING 51702 $294.00FVH 91000236 CIRCUMCISION SURGICAL >28 DAYS 54161 $541.00FVH 91000238 BX VAGINA 57100 $139.00FVH 91000240 PELVIC EXAM UNDER ANESTH 57410 $298.00FVH 91000241 REMOVAL ENDOCERVICAL POLYPS 57500 $111.00FVH 91000244 BX UTERUS LINING 58100 $154.00FVH 91000245 D & C NON OB 58120 $607.00FVH 91000246 LAPAROSCOPY LYSIS ADHESIONS 58660 $1,865.00FVH 91000247 CURRETTAGE POSTPARTUM 59160 $469.00FVH 91000249 EPISIOTOMY 59300 $403.00FVH 91000253 ABSCESS/HEMOTOMA EAR 69000 $202.00FVH 91000259 OBSERVATION CARE DISCHARGE 99217 $105.00FVH 91000260 OBSERVATION INITIAL SIMPLE 99218 $183.00FVH 91000261 OBSERVATION INITIAL MODERATE 99219 $333.00FVH 91000262 OBSERVATION INITIAL COMPLEX 99220 $457.00FVH 91000264 ADMIT/DISCH SAME DAY MODERATE 99235 $310.00FVH 91000268 COLONOSCOPY SCREEN HIGH RISK $600.00FVH 91000271 COLONOSCOPY SCREEN $600.00FVH 91000288 MOBILIZATION SPLENIC FLEXURE 44139 $328.00FVH 91000289 LEVEL 1 EST PT 99211 $4.00FVH 91000290 LEVEL 2 EST PT 99212 $35.00FVH 91000291 LEVEL 3 EST PT 99213 $77.00FVH 91000292 LEVEL 4 EST PT 99214 $127.00FVH 91000293 LEVEL 5 EST PT 99215 $184.00FVH 91000294 INSERT CVC NON-TUNNELLED >5 YR 36556 $338.00FVH 91000295 INSERT PICC LINE >5 YR 36569 $256.00FVH 91000299 COLONOSCOPY W/POLYP 45388 $936.00FVH 91000302 FEMALE 8 58605 $917.00FVH 91000319 CHEM CAUTERY GRANULATION TISSU 17250 $62.00FVH 91000320 EXC TUMOR THIGH/KNEE AREA SUB 27327 $859.00FVH 91000322 INSERT CVC TUNNEL W/PORT>5 YR 36561 $986.00FVH 91000324 REMOVAL TUNNELED CVC W/O PORT 36589 $234.00FVH 91000325 REMOVAL TUNNELED CVAD 36590 $570.00FVH 91000326 REMOVE SPLEEN 38100 $3,125.00FVH 91000327 UPPER GI ENDOSCOPY PLACE TUBE 43246 $675.00FVH 91000328 CHANGE GASTROSTOMY TUBE 43762 $81.00FVH 91000329 COLONOSCOPY THERAPEUTIC 45337 $398.00FVH 91000331 HEMORROID LIGATION INTERNAL 46945 $380.00FVH 91000332 HEMORRHOIDS LIGATION >1 46946 $628.00FVH 91000333 LAPAROSCOPIC CHOLECYSTECTOMY 47562 $1,788.00

66

FVH 91000334 LAP CHOLECY W/CHOLANGIOGRAPHY 47563 $1,941.00FVH 91000335 HERNIA REPAIR 6 MOS THRU 4 YRS 49500 $1,017.00FVH 91000336 HERNIA REPAIR 5 YRS AND OLDER 49505 $1,418.00FVH 91000337 HERNIA REPAIR ING INCARCERATED 49507 $1,593.00FVH 91000338 HERNIA REPAIR RECURRENT 49520 $1,717.00FVH 91000339 HERNIA REPAIR FEMORAL INCAR/ST 49553 $1,715.00FVH 91000340 HERNIA REPAIR RECURRENT INS/VE 49565 $2,085.00FVH 91000341 HERNIA REPAIR W/MESH 49568 $721.00FVH 91000342 HERNIA REPAIR EPIGASTRIC INCAR 49572 $1,405.00FVH 91000343 HERNIA REPAIR UNBILICAL 5 YRS> 49585 $1,213.00FVH 91000344 HERNIA REPAIR UMBIL INCAR OR S 49587 $1,297.00FVH 91000345 SUTURE GRANULOMA 49999 $800.00FVH 91000347 FEMALE 11 58671 $1,017.00FVH 91000349 LEVEL I NEW PT 99201 $39.00FVH 91000350 LEVEL 2 NEW PT 99202 $78.00FVH 91000351 LEVEL 3 NEW PT 99203 $120.00FVH 91000352 LEVEL 4 NEW PT 99204 $214.00FVH 91000353 LEVEL 1 SUBSQ HOSP FOCUSED 99231 $96.00FVH 91000354 LEVEL 2 SUBSQ HOSP EXPANDED 99232 $178.00FVH 91000355 LEVEL 3 SUBSQ HOSP HIGH COMPL 99233 $256.00FVH 91000356 LEVEL 1 CONSULT 99241 $38.00FVH 91000357 LEVEL 2 CONSULT 99242 $72.00FVH 91000358 LEVEL 3 CONSULT 99243 $103.00FVH 91000359 LEVEL 4 CONSULT 99244 $175.00FVH 91000360 LEVEL 5 CONSULT 99245 $218.00FVH 91000367 LEVEL 1 INP CONSULT FOCUSED 99251 $93.00FVH 91000368 LEVEL 2 INP CONSULT EXPANDED 99252 $143.00FVH 91000369 LEVEL 3 INP CONSULT LOW COMPL 99253 $217.00FVH 91000370 LEVEL 4 INP CONSULT LOW COMPL 99254 $315.00FVH 91000371 LEVEL 5 INP CONSULT HIGH COMPL 99255 $383.00FVH 91000372 LEVEL V HIGH SEVERITY 99285 $422.00FVH 91000373 EXPLORATION OF WOUND EXTRM 20103 $955.00FVH 91000374 HERNIA REPAIR INGUNIAL SLIDING 49525 $1,558.00FVH 91000377 BX OR EXC LYMPH NODE 38525 $1,190.00FVH 91000378 MASTECTOMY PARTIAL 19301 $1,766.00FVH 91000379 APPENDECTOMY/RUPTURED APPENDIX 44960 $2,369.00FVH 91000380 UNLISTED LAPAROSCOPY 49659 $975.00FVH 91000382 LAP PROCEDURE ABD UNLISTED 49329 $650.00FVH 91000383 LAP PROCEDURE LIVER UNLISTED 47379 $3,401.00FVH 91000384 I&D PERIANAL ABSCESS 46050 $164.00FVH 91000385 ENTERECTOMY RESECTION SM INT 44120 $3,319.00FVH 91000386 CHOLECYSTECTOMY 47600 $2,900.00FVH 91000387 REPAIR INI INCIS OR VER HERNIA 49560 $2,002.00FVH 91000388 MASTECTOMY,SIMPLE & COMPLETE 19303 $2,734.00FVH 91000389 THYROIDECTOMY TOTAL COMPLETE 60240 $2,526.00FVH 91000391 FREE ADHESIONS 44005 $2,970.00FVH 91000394 EXC HYDROCELE, UNILATERAL 55040 $931.00FVH 91000396 INCISION RECTAL ABSCESS 46040 $1,141.00FVH 91000398 INGUINAL HERNIA INI LAPAROSCOP 49650 $1,168.00

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FVH 91000399 PARACENTESIS ABD W/O IMAGING 49082 $202.00FVH 91000400 HEMORRHOIDECTOMY INT & EXT SIM 46255 $973.00FVH 91000403 INSERTION CHEST TUBE 32551 $479.00FVH 91000404 INSERT CVC PERIPH W/PORT >5YR 36571 $892.00FVH 91000405 CHOLECYSTECTOMY W/CHOLANGIOGRA 47605 $3,051.00FVH 91000406 FEMALE 35 58670 $1,017.00FVH 91000410 REMOVAL OF COLON 44160 $3,380.00FVH 91000411 APPENDECTOMY NOT MAJOR PROCED 44955 $227.00FVH 91000413 HEMORRHOIDOPEXY PROLAP/STAPLIN 46947 $1,053.00FVH 91000414 REPAIR OF STOMACH LESION 43840 $3,684.00FVH 91000415 RPR VENTRAL HERNIA INIT BLOCK 49561 $2,522.00FVH 91000416 DEBRIDE SKIN MUSCLE SUBCUTANEO 11043 $259.00FVH 91000417 OOPHROECTOMY 58940 $1,439.00FVH 91000418 ESOPH ENDOSCOPY DILATION 43249 $484.00FVH 91000422 LAP W/ REMVL OF LESIONS -OVARY 58662 $1,959.00FVH 91000423 LAPAROSCOPY W/ ASP OF CAVITY 49322 $1,015.00FVH 91000424 PHYS SERVICES LEVEL 1 99281 $39.00FVH 91000425 MAST SUBQ 19304 $1,567.00FVH 91000426 I&D DPABSA/HMTMA TH/KN 27301 $1,371.00FVH 91000430 BIOPSY OR EXC OF LYMPH NODE 38500 $415.00FVH 91000431 FEMALE 7 58600 $1,015.00FVH 91000433 PAPILLECTOMY/EXC ANUS TAG 46220 $197.00FVH 91000434 INP ADMIT LOW COMPLEX 99221 $246.00FVH 91000435 EXC PILONIDAL CYST/SINUS EXTEN 11771 $1,181.00FVH 91000436 SPLIT GRAFT, 100 SQ CM OR LESS 15100 $1,972.00FVH 91000437 WND PREP TRK/ARM/LEG 15002 $627.00FVH 91000438 REPLACE TUNNELED CVD W/PORT 36582 $851.00FVH 91000440 COLONOSCOPY THROUGH STOMA 44388 $464.00FVH 91000441 LAPAROSCOPY SURG ENTEROLYSIS 44180 $2,498.00FVH 91000442 DEBRIDE ABD WALL 11005 $2,113.00FVH 91000443 EXC BRST LSN AFT PREOP XRAY 19125 $1,246.00FVH 91000445 EXC OF UMBILICUS 49250 $1,594.00FVH 91000446 MASTECTOMY/GYNECOMASTIA 19300 $1,121.00FVH 91000448 DILATE ESOPHAGUS 43450 $249.00FVH 91000449 INSERT TUNNELED CV CATH 36565 $968.00FVH 91000450 SUTURE LARGE INTESTINE 44604 $2,870.00FVH 91000451 CLOSURE OF ENTEROSTOMY LG/SM 44620 $2,372.00FVH 91000452 ENTEROENTEROSTOMY ANATOMOSIS 44130 $3,690.00FVH 91000454 EXCISION TUMOR NECK OR THORAX 21555 $846.00FVH 91000455 COLONOSCOPY THROUGH STOMA W/BX 44389 $516.00FVH 91000458 SALPINGECTOMY 58700 $2,151.00FVH 91000464 RPR REC ING HRN-ANY AGE-INC/S 49521 $1,944.00FVH 91000465 REREPAIR VENTRL HERNIA BLOCK 49566 $2,548.00FVH 91000467 BX OF VULVA OR PERINEUM 56605 $101.00FVH 91000469 DRAIN PERCU PERITONEAL ABSCESS 49406 $465.00FVH 91000471 CESAREAN DELIVERY ONLY 59514 $3,300.00FVH 91000473 UNLISTED PROC VASCULAR SURG 37799 $350.00FVH 91000474 LAPAROSCOPY BIOPSY 49321 $946.00FVH 91000478 REP EPIGASTRIC HERNIA REDUCIB 49570 $1,139.00

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FVH 91000479 ILEOSTOMY/JEJUNOSTOMY 44310 $2,853.00FVH 91000480 LAPARO CHOLECYSTECOMY\EXPLO 47564 $3,024.00FVH 91000481 LARPO PARTIAL COLECTOMY 44204 $4,203.00FVH 91000482 LAP MOBILE SPLENIC FL 44213 $514.00FVH 91000483 PHYS SERVICES LEVEL 4 99284 $217.00FVH 91000485 REPAIR OF UTERUS 59350 $784.00FVH 91000487 INSERT TUNNELED CV CATH 36563 $1,046.00FVH 91000488 BX LIVER 47001 $279.00FVH 91000491 HYSTEROSCOPY W ENDO ABLATION 58563 $952.00FVH 91000493 HOSP DISCHARGE < 30 MIN 99238 $179.00FVH 91000494 AMPUTATE FINGER 26951 $1,776.00FVH 91000502 HERNIA REPAIR SPIGELIAN 49590 $1,558.00FVH 91000503 EXCISION BENIGN LESION > 3 CM 11444 $625.00FVH 91000505 FEMALE 9 58611 $215.00FVH 91000507 DESTROY HEMORRHOIDS 46930 $255.00FVH 91000509 HYSTEROSCOPY W/WO D & C 58558 $741.00FVH 91000511 REPLACE G/C TUBE PERC 49450 $113.00FVH 91000512 DESTRUCTION OF LESION ANUS 46922 $225.00FVH 91000513 INP ADMIT HIGH COMPLEX 99223 $497.00FVH 91000516 HEMORRHOIDECTOMY COMPLEX 46260 $1,309.00FVH 91000517 LTC INITIAL CARE MOD COMPLEX 99305 $243.00FVH 91000518 LTC LEVEL 1 VISIT 99307 $82.00FVH 91000519 TRMT SUPF WOUND DEHIS SIMPLE 12020 $522.00FVH 91000520 UNLIST PROC FEMALE GENITAL SYS 58999 $500.00FVH 91000521 INP ADMIT MOD COMPLEX 99222 $334.00FVH 91000524 LAP REPR HERNIA W/MESH INSERT 49652 $1,944.00FVH 91000525 CESAREAN DELIVERY 59515 $3,421.00FVH 91000526 REPAIR LACERATION INTERM >7.5 12054 $633.00FVH 91000531 DEBRIDE WOUND SELECTIVE < 20 97597 $66.00FVH 91000532 DEBRIDE WOUND SELECT EA ADD 20 97598 $31.00FVH 91000533 OBSERVATION SUBSEQUENT SIMPLE 99224 $98.00FVH 91000534 OBSERVATION SUBSEQUENT MODERAT 99225 $180.00FVH 91000535 OBSERVATION SUBSEQUENT COMPLEX 99226 $192.00FVH 91000537 MUSCLE BIOPSY 20200 $155.00FVH 91000545 BIOPSY TEMPORAL ARTERY 37609 $581.00FVH 91000546 LAPAROSCOPY W/REM ADNEXAL STRC 58661 $1,787.00FVH 91000547 TX ECTOPIC PREGNANCY 59120 $2,156.00FVH 91000554 FEMALE 12 59820 $972.00FVH 91000557 COLONOSCOPY CONTROL BLEEDING 45382 $919.00FVH 91000558 EXPLORE SMALL INTESTINE 44020 $2,645.00FVH 91000559 REMOVAL OF OVARY 58720 $2,009.00FVH 91000562 MASTECTOMY, MOD RAD W AXILLARY 19307 $3,242.00FVH 91000566 REPAIR BOWEL BLADDER W/RESECT 44661 $4,229.00FVH 91000567 I&D VULVA 56405 $182.00FVH 91000569 REDUCTION OF RECTAL PROLAPSE 45900 $562.00FVH 91000570 EXCISION DRAINAGE EPIDYMIS 54700 $589.00FVH 91000573 EXPLORE WOUND 20102 $692.00FVH 91000575 I&D PILONDIAL CYST 10081 $285.00FVH 91000578 EXCISION PILONIDIAL CYST 11772 $1,578.00

69

FVH 91000579 OPERATIVE UPPER GI ENDO 43255 $760.00FVH 91000581 LAP REPAIR INC HERNIA 49655 $2,896.00FVH 91000585 REMOVAL ANAL FISTULA 46270 $1,080.00FVH 91000586 TOTAL HYSTERECTOMY 58150 $2,776.00FVH 91000588 REMOVAL OMENTUM 49255 $2,160.00FVH 91000592 SUTURE SMALL INTESTINE 44602 $3,930.00FVH 91000594 REPAIR COMPLEX TRUNK 13100 $586.00FVH 91000595 REM LESION BACK FLANK 21930 $1,002.00FVH 91000596 TREAMENT OF MISCARRIAGE 59812 $803.00FVH 91000607 REPAIR LACERATION INTERM>12.5 12045 $750.00FVH 91000631 COLOSTOMY REVISION: SIMPLE 44340 $1,752.00FVH 91000638 TANGNTL BX SKIN SINGLE LES 11102 $40.00FVH 91001161 EXC LESION SPERMATIC CORD 55520 $1,238.00FVH 91001163 INJ PROC LYMPHANGIOGRAPHY 38792 $68.00FVH 91001166 LEVEL 5 NEW PT 99205 $186.00FVH 91001171 LAPAROSCOPY 49320 $895.00FVH 91001172 REPAIR LAC TONG ANT 2/3 2.5OR< 41250 $441.00FVH 91001173 PHYS SERVICES LEVEL 2 99282 $101.00FVH 91001174 PHYS SERVICES LEVEL 3 99283 $151.00FVH 91001176 LAP INC HERNIA W MESH 49654 $2,368.00FVH 91001179 DEB SUBQ TISSUE ADD ON 11045 $44.00FVH 91001180 EXC OF HYDROCELE BILATERAL 55041 $1,402.00FVH 91001187 REMOVAL WALL LESION 22900 $1,534.00FVH 91001192 GASTRIC TUBE PLACEMENT 43752 $114.00FVH 91001193 SMALL BOWEL ENDO 44376 $841.00FVH 91001195 SIGMOID W/TUMOR REMOVAL 45338 $394.00FVH 91001196 SURG DX EXAM ANORECTAL 45990 $294.00FVH 91001197 PLACEMENT OF SETON 46020 $653.00FVH 91001198 DESTRUCT LESION ANUS EXT 46924 $520.00FVH 91001202 DRAIN GLAND ABSCESS 56440 $508.00FVH 91001205 PARTIAL HYSTERECTOMY 58180 $2,663.00FVH 91001206 LAP VAG HYSTERECTOMY 58552 $2,728.00FVH 91001212 DILATION ANAL SPHINCTER 45905 $468.00FVH 91001213 REMOVAL PROSTHETIC MESH 11008 $742.00FVH 91001215 EXC MAL LESION >4CM 11626 $481.00FVH 91001216 INSET DRUG DELIVERY IMPLANT 11981 $133.00FVH 91001217 WOUND CLOSURE LAYER 12.6-20CM 12035 $667.00FVH 91001218 SEC CLOSURE OF SURG WND/DEHISC 13160 $2,220.00FVH 91001219 WOUND PREP ADDL 100CM 15003 $124.00FVH 91001220 SPLIT THICK AUTOGRFT ADDTL 100 15101 $303.00FVH 91001221 UNLISTED PROC SKIN/MEMB TISSUE 17999 $250.00FVH 91001222 EXCISION CHEST TUMOR 21601 $3,311.00FVH 91001223 MASTECTOMY PARTIAL W/AXIL LYMP 19302 $2,433.00FVH 91001224 REMOVAL OF MAMMERY IMPLANT 19330 $1,747.00FVH 91001225 ASPIRATION/INJ GANGLION CYST 20612 $69.00FVH 91001226 EXC BACK LESION SUBCUT >3CM 21931 $770.00FVH 91001227 EXC ABD WALL <3CM 22902 $897.00FVH 91001228 EXC TUM ABD WALL >3CM 22903 $1,191.00FVH 91001229 BX SOFT TISSUE SHOULDER 23073 $1,885.00

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FVH 91001230 EXC FOREARM LES SC <3CM 25075 $523.00FVH 91001231 EXC HAND LES SC <1.5CM 26115 $546.00FVH 91001232 EXC TUMOR THIGH >3CM 27337 $688.00FVH 91001233 REPAIR OF LEG TENDON EACH 27658 $1,047.00FVH 91001234 DECLOT THROMBO IMPL VAD 36593 $84.00FVH 91001235 GASTROSCOPE INJECTION 43236 $489.00FVH 91001236 EGD W/DILITATION GASTRIC OUTLE 43245 $523.00FVH 91001237 GATROSTOMY OPEN 43830 $1,907.00FVH 91001238 ENTERECTOMY ADDITIONAL 44121 $654.00FVH 91001239 COLECTOMY 44143 $4,531.00FVH 91001240 COLECTOMY WITH RESECTION 44144 $4,821.00FVH 91001241 CLOSURE ENTEROSTOMY RESECTION 44626 $4,363.00FVH 91001242 UNLISTED PROC SMALL INTESTINE 44799 $800.00FVH 91001243 EXCISION MECKELS DIVERTICULUM 44800 $2,085.00FVH 91001244 COLONOSCOPY W/ SUBMUCOSAL INJ 45381 $685.00FVH 91001245 SPHINCTEROTOMY ANAL 46080 $438.00FVH 91001246 FISTULECTOMY SUBMUSCULAR 46275 $1,149.00FVH 91001247 CHEMODENERVATION ANAL SPHINCT 46505 $670.00FVH 91001248 REPAIR ANAL FIST W/ GLUE 46706 $470.00FVH 91001249 DRAIN LIEVER ABSCESS/CYST PERC 49405 $510.00FVH 91001250 BX LIVER WEDGE 47100 $2,304.00FVH 91001251 LAPAROSCOPY PROC BILIARY TRAC 47579 $2,081.00FVH 91001252 LAPAROTOMY 49000 $2,096.00FVH 91001253 EXPLORATION RETROPERITONEAL 49010 $2,547.00FVH 91001254 PERITONEAL ABSCESS DRAINAGE 49020 $4,322.00FVH 91001255 LAPAR W/INSERT INTRAPERIT CATH 49324 $1,073.00FVH 91001256 LAP VENT/ABD HERN PROC COMP 49653 $2,424.00FVH 91001257 LAP RPR RECUR INC HERNIA W/MES 49656 $2,392.00FVH 91001258 DRAIN HYDROCELE 55000 $234.00FVH 91001259 MALE 1 55250 $625.00FVH 91001260 INCISION/DRAIN BARTHOLIN GLAND 56420 $255.00FVH 91001261 MYOMECTOMY 58146 $3,209.00FVH 91001262 FEMALE 6 58301 $111.00FVH 91001263 THERMAL ENDOMETRIAL ABLATION 58353 $610.00FVH 91001264 HYSTERECTOMY LAP V 58550 $2,454.00FVH 91001265 FALLOPIAN TUBE OCCLUSION 58615 $679.00FVH 91001266 TRANSPOSITION OVARIES 58925 $2,053.00FVH 91001267 LAP TX ECTOPIC PREGW/ SALP/OOP 59151 $2,029.00FVH 91001268 TX OF INCOMP MISCARRIAGE SECON 59821 $973.00FVH 91001269 PARATHYROIDECTOMY OR EXPL 60500 $2,644.00FVH 91001270 BLEPHAROTOMY DRAIN ABSCESS EYE 67700 $329.00FVH 91001274 REPAIR LACERATION > 1 13151 $797.00FVH 91001275 BIOPSY OVARY 58900 $1,165.00FVH 91001276 EXC NECK LESION SUBCUT - 3 CM 21552 $1,220.00FVH 91001277 EXCISION RECTAL TUMOR 45172 $2,247.00FVH 91001278 EXC TUM NECK/ANT THORAX > 5 CM 21554 $1,996.00FVH 91001279 LAPROSCOPIC ETOPIC PREG 59150 $2,088.00FVH 91001282 REPAIR PARAESOPHAGEAL HERNIA 43332 $3,155.00FVH 91001283 LTC INITIAL CARE HIGH COMPLEX 99306 $308.00

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FVH 91001286 I&D DEEP ABSC SFT TISSUE NK/TH 21501 $893.00FVH 91001292 UCC LEVEL 1 EST PT 99211 $21.00FVH 91001293 UCC LEVEL 2 EST PT 99212 $57.00FVH 91001294 UCC LEVEL 3 EST PT 99213 $117.00FVH 91001295 UCC LEVEL 4 EST PT 99214 $181.00FVH 91001296 UCC LEVEL 5 EST PT 99215 $254.00FVH 91001297 EXC MALG LES FACE OVER 4.0 11646 $1,089.00FVH 91001300 BX LYMPH NODE DEEP 38510 $1,157.00FVH 91001312 REPAIR LAC COMPLEX EA ADD 5 CM 13122 $141.00FVH 91001313 REPAIR OF WOUND/LESION ADD ON 13133 $217.00FVH 91001324 EXC SHOULDER LES SC < 3 CM 23075 $896.00FVH 91001332 EXC GANGLION WRIST PRIMARY 25111 $877.00FVH 91001333 REM WRIST TENDON LESION, RECUR 25112 $1,058.00FVH 91001340 EXC LES TENDON SHEATH FINGER 26160 $915.00FVH 91001361 EXCISION OF VAGINAL CYST/TUMOR 57135 $287.00FVH 91001362 I&D FINGER ABSCESS SIMPLE 26010 $230.00FVH 91001363 EXCISION OF SPERMATOCELE 54840 $883.00FVH 91001364 MASTOTOMY W/EXPLOR DRAIN ABSC 19020 $838.00FVH 91001369 EXC HYDROCELE-SPERMATIC CORD 55500 $1,090.00FVH 91001372 LAPAROSCOPY OF UTERUS 58578 $350.00FVH 91001375 REDUCTION OF TORSION OF TESTIS 54600 $1,244.00FVH 91001376 COLONOSCOPY FLEX W REM FB 45379 $757.00FVH 91001378 EXC BACK TUM DEEP 5CM/> 21933 $2,007.00FVH 91001379 CERVICECTOMY AMPUTATION 57530 $959.00FVH 91001384 LAPAROSCOPY SUPRACERVICAL HYST 58542 $2,268.00FVH 91001386 LTC INITIAL CARE LOW COMPLEX 99304 $171.00FVH 91001388 HYSTERSCOPY DX 58555 $528.00FVH 91001389 DILATE RECTAL STRUCTURE ANES 45910 $542.00FVH 91001390 EXC TUM SHOULDER 23071 $1,145.00FVH 91001395 UNLISTED PROCEDURE ANUS 46999 $350.00FVH 91001403 CHOLECYSTECTOMY W/ EXPL DUCT 47610 $3,359.00FVH 91001404 LAP BAND ADJUSTMENT 47999 $350.00FVH 91001405 INC/ DRAINAGE W/ FISTULOTOMY 46060 $1,318.00FVH 91001406 ADJACENT TISSUE 10 SQ CM LESS 14000 $1,395.00FVH 91001409 BIOPSY MUSCLE DEEP 20205 $251.00FVH 91001410 HYSTEROSCOPY W/REM IMPACT BODY 58562 $806.00FVH 91001412 PROCTECTOMY RSCT RCTUM TRNSABD 45111 $2,982.00FVH 91001418 EXC NECK TUM DEEP<5CM 21556 $1,486.00FVH 91001425 EXC LES TDN SHTH/CPSL LEG/A 27630 $584.00FVH 91001436 UNLSTD PROC MATERNITY CARE/DEL 59899 $350.00FVH 91001442 COLONOSCOPY STOMA REM HBF/BPC 44392 $614.00FVH 91001443 REPAIR BLADDER COMPL 51865 $2,580.00FVH 91001444 BILIARY ENDOSCOPY INTRAOP 47550 $446.00FVH 91001445 INCISION OF LINGUAL FRENUM 41010 $313.00FVH 91001448 LAPAROSCOPE PROC INTESTINE 44238 $350.00FVH 91001452 UNLISTED PROCEDURE ABDOMEN 22999 $350.00FVH 91001453 EXCISION BENIGN LESION>4CM 11446 $552.00FVH 91001458 HYSTEROSCOPY W LYSIS INTRA ADH 58559 $953.00FVH 91001461 ANOSCOPY W/ DILATION 46604 $111.00

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FVH 91001463 NIPPLE EXPL W/WO EXC DUCT 19110 $937.00FVH 91001477 BX LIVER, NEEDLE PERCUTANEOUS 47000 $289.00FVH 91001491 EXC TUMOR UPPER ARM/ELBOW 24071 $674.00FVH 91001494 BIOPSY OF SOFT TISSUE PEL/HIP 27040 $564.00FVH 91001505 FLEX SIG W/SUBMUCOSA INJ 45335 $261.00FVH 91001519 BX SOFT TISS HIP/PELVIS AREA 27045 $2,096.00FVH 91001536 ESOPHAGOSCOPY CONTROL BLEED 43227 $500.00FVH 91001762 EGD BALLOON DIL ESOPH30 MM/> 43233 $668.00FVH 91001787 DRAIN APPENDIX ABSCESS OPEN 44900 $2,108.00FVH 91001837 LAPARO-VAG HYST CMPLX >250GM 58553 $3,200.00FVH 91001838 LAPAR VAG HYST W/T/O CMPL >250 58554 $3,750.00FVH 91001842 LAP HYSTERECT W/REM TUBE/OVARY 58571 $2,971.00FVH 91001864 LAPAROSCOPY REC INGUINAL HERNI 49651 $1,538.00FVH 91001867 EXC SHOULDER TUM DEEP < 5 CM 23076 $775.00FVH 91001879 BX OR EXCISION OF LYMPH NODE 38505 $124.00FVH 91001922 COLONOSCOPY W/BAND LIGATION 45398 $682.00FVH 91001957 UNLISTED PROC COLON 45399 $350.00FVH 91001973 LAP REMOVAL RESTRICT DEVICE 43772 $2,663.00FVH 91001991 LAPAROSCOPIC CHOLE W/REM ILEUM 44205 $3,780.00FVH 91002023 EXC ABDL TUM DEEP 5 CM/> 22901 $1,864.00FVH 91002024 INJ TRANSVERSE ABD SINGLE 64486 $99.00FVH 91002040 EXC ABD TUM 5 CM OR LESS 49203 $3,305.00FVH 91002065 DELIVERY OF PLACENTA 59414 $256.00FVH 91002077 INTRA OP SENTNEL LYMPH NODE 38900 $388.00FVH 91002116 REPAIR OF UTERINE CERVIX 57720 $850.00FVH 91002128 CYSTOTOMY EXC BLADDER TUMOR 51530 $2,285.00FVH 91002132 EXC LEG/ANKLE TUM DEP 5 CM/> 27634 $1,670.00FVH 91002195 INSRT PICC WO SQ PORT W IMG >5 36573 $256.00FVH 91002213 SURG TX OF ANAL FISTUAL 46280 $1,342.00FVH 92000003 DENTAL PARTIAL < FULL MOUTH 70100 $22.00FVH 92000006 FACIAL BONES COMPL MIN 3 VIEW 70150 $33.00FVH 92000007 NASAL BONES COMPL MIN 3 VIEW 70160 $21.00FVH 92000009 SINUSES COMPL MIN 3 VIEW 70220 $31.00FVH 92000010 SKULL <4 VIEW 70250 $31.00FVH 92000011 TM JOINT OPEN CLOSED 70328 $22.00FVH 92000012 SPINE NECK SOFT TISSUE 70360 $21.00FVH 92000014 CHEST 1 VIEW 71045 $22.00FVH 92000015 CHEST 2 VIEW PA/LAT 71046 $27.00FVH 92000016 CHEST LATERAL 71045 $22.00FVH 92000017 RIB UNILATERAL 2 VIEW 71100 $28.00FVH 92000018 STERNUM MIN 2 VIEW 71120 $25.00FVH 92000020 SPINE SINGLE VIEW 72020 $19.00FVH 92000021 SPINE CERVICAL 2-3 VIEWS 72040 $28.00FVH 92000022 SPINE CERVICAL MIN 4-5 VIEW 72050 $39.00FVH 92000023 SPINE CERV COMPL W/OBLIQ FLEX 72052 $45.00FVH 92000024 SPINE SCOLIOSIS 1 VIEW 72081 $33.00FVH 92000025 SPINE THORACIC 2 VIEW 72070 $28.00FVH 92000026 SPINE DORSAL THOR 3 VIEW 72072 $27.00FVH 92000027 SPINE LUMBAR 2-3 VIEW 72100 $28.00

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FVH 92000028 SPINE LUMBAR MIN 4 VIEW 72110 $39.00FVH 92000030 PELVIS 1 OR 2 VIEW 72170 $21.00FVH 92000031 PELVIS COMPL PUBIC RA MIN 3 VI 72190 $27.00FVH 92000032 SACROILIAC JT < 3 VIEW 72200 $21.00FVH 92000033 SACRUM/COCCYX MIN 2 VIEW 72220 $21.00FVH 92000034 MYELOGRAM THORACIC S&I 72255 $114.00FVH 92000035 MYELOGRAM LUMBAR S&I 72265 $100.00FVH 92000036 CLAVICLE COMPLETE 73000 $21.00FVH 92000037 SCAPULA COMPL 73010 $22.00FVH 92000038 SHOULDER 1 VIEW 73020 $20.00FVH 92000039 SHOULDER 2 VIEW 73030 $23.00FVH 92000040 ARTHROGRAM SHOULDER S&I 73040 $67.00FVH 92000041 ACROMIO CLAVICULAR JOINTS 73050 $26.00FVH 92000042 HUMERUS MIN 2 VIEW 73060 $21.00FVH 92000043 ELBOW 2 VIEW 73070 $20.00FVH 92000044 FOREARM 2 VIEW 73090 $21.00FVH 92000045 WRIST 2 VIEW 73100 $21.00FVH 92000046 WRIST COMPLETE MIN 3 VIEW 73110 $21.00FVH 92000047 HAND 2 VIEW 73120 $21.00FVH 92000048 HAND MIN 3 VIEW 73130 $21.00FVH 92000049 FINGER MIN 2 VIEW 73140 $17.00FVH 92000050 HIP UNILAT 1 VIEW 73501 $23.00FVH 92000051 HIP UNILAT 2 VIEW 73502 $28.00FVH 92000052 HIP BILATERAL MIN 2 VIEW 73521 $28.00FVH 92000053 PELVIS & HIP 2 VIEW FROGLEG 73521 $26.00FVH 92000055 KNEE 1 OR 2 VIEW 73560 $21.00FVH 92000056 KNEE 3 VIEW 73564 $28.00FVH 92000057 TIBIA/FIBULA 2 VIEW LOWER LEG 73590 $20.00FVH 92000058 LE 2 VIEW INFANT 73592 $20.00FVH 92000059 ANKLE 2 VIEW 73600 $21.00FVH 92000060 ANKLE COMPL MIN 3 VIEW 73610 $21.00FVH 92000061 FOOT 2 VIEW 73620 $19.00FVH 92000062 FOOT COMPL MIN 3 VIEW 73630 $21.00FVH 92000063 CALCANEUS MIN 2 VIEW 73650 $20.00FVH 92000064 TOE MIN 2 VIEW 73660 $16.00FVH 92000065 ABDOMEN SINGLE AP VIEW 74018 $22.00FVH 92000067 ABDOMEN COMPL DECUB/ERECT 74019 $28.00FVH 92000068 MANDIBLE COMPL 4 VIEWS INTERP 70110 $31.00FVH 92000069 SKULL COMPL INTERP 70260 $43.00FVH 92000070 RIBS 3 VIEW INCLUDING PA INTER 71101 $33.00FVH 92000071 RIBS 4 VIEW INCLUDING PA INTER 71111 $40.00FVH 92000073 ELBOW COMPL INTERP 73080 $21.00FVH 92000074 KNEE 3 VIEW INTERP 73562 $23.00FVH 92000075 KNEE COMPL INTERP 73565 $21.00FVH 92000076 ABDOMEN COMPL INTERP 74022 $39.00FVH 92000077 ESOPHAGUS INTERP 74220 $82.00FVH 92000078 GI TRACTAIR CONTRAST INTERP 74246 $84.00FVH 92000079 COLON BARIUM INTERP 74270 $84.00FVH 92000080 COLON AIR CONTRAST INTERP 74280 $121.00

74

FVH 92000082 CHOLANGIOGRAPHY I NTRAOP INTER 74300 $44.00FVH 92000084 UROGRAPHY INTERP 74400 $60.00FVH 92000086 MASTOIDS COMPL MIN 3 VIEW 70130 $42.00FVH 92000087 TM JOINT OPEN CLOSED BILAT 70330 $30.00FVH 92000088 ORBITS COMPL MIN 4 VIEW 70200 $35.00FVH 92000089 RIB BILATERAL 3 VIEW 71110 $36.00FVH 92000090 FLUORO PHY SUPERV,INTER & RPT 7700326 $74.00FVH 92000091 CT BONE DENSITY AXIAL 77080 $41.00FVH 92000093 CHEST 2 VIEW LORDOTIC 71046 $27.00FVH 92000094 STERNOCLAVICULAR 3 VIEW 71130 $27.00FVH 92000100 US HEAD NEONATAL 7650626 $77.00FVH 92000101 US HEAD NECK SOFT TISSUE 7653626 $69.00FVH 92000103 US ABDOMEN COMPLETE 7670026 $99.00FVH 92000104 US ABDOMEN LIMITED 7670526 $71.00FVH 92000105 US RETROPERITONEAL COMPLETE 7677026 $90.00FVH 92000106 US RETROPERITONEAL LTD 7677526 $71.00FVH 92000107 US TRANSPLANT KIDNEY W/WO DOPP 7677626 $93.00FVH 92000108 US OB < 14 WEEKS SGL GESTATION 7680126 $122.00FVH 92000109 US OB <14 WK ADDIT GESTATION 7680226 $102.00FVH 92000110 US OB > 14 WKS SNGL GESTATION 7680526 $122.00FVH 92000111 OB US > 14 WK ADDIT GESTATION 7681026 $122.00FVH 92000112 US OB DETAILED SNGL GESTATION 7681126 $235.00FVH 92000113 OB US DETAIL ADDIT GESTATION 7681226 $222.00FVH 92000114 US OB NUCHAL TRANS SNGL GEST 7681326 $147.00FVH 92000115 US OB NUCHAL TRANS ADDIT GEST 7681426 $124.00FVH 92000116 US OB LIMITED 7681526 $80.00FVH 92000117 US OB FOLLOW-UP 7681626 $105.00FVH 92000118 US OB TRANSVAGINAL 7681726 $92.00FVH 92000119 US OB BIOPHYSICAL WO STRESS 7681926 $95.00FVH 92000120 US TRANSVAGINAL NON OB 7683026 $85.00FVH 92000122 US PELVIS NON OB 7685626 $84.00FVH 92000123 US PELVIC LIMITED OR F/U 7685726 $61.00FVH 92000124 US SCROTUM 7687026 $78.00FVH 92000125 US TRANSRECTAL/PROSTATE 7687226 $83.00FVH 92000127 US GUIDE NEEDLE PLACEMENT 7694226 $79.00FVH 92000129 US CAROTID DOPPLER 9388026 $97.00FVH 92000131 VENOUS DUPLEX BILATERAL 9397026 $83.00FVH 92000132 VENOUS DUPLEX LIMITED 9397126 $54.00FVH 92000133 US ABDOME DOPPLER COLOR FLOW 93975 $139.00FVH 92000135 DUPLEX ABDOMEN LIMITED 9397626 $97.00FVH 92000141 INJ MAMMARY DUCTOGRAM 19030 $189.00FVH 92000149 DUCTOGRAM S&I SINGLE DUCTS 77053 $44.00FVH 92000150 DUCTOGRAM MULT DUCTS S&I 77054 $56.00FVH 92000158 SPINE SCOLIOSIS 2-3 VIEW 72082 $39.00FVH 92000159 URETHROCYSTOGRAPHY 74450 $40.00FVH 92000160 MRI TMJ 70336 $180.00FVH 92000161 MRI FACE/NECK/ORBITS 70540 $165.00FVH 92000162 MRI CHEST 71550 $178.00FVH 92000163 MRI C-SPINE W/ CONTRAST 72142 $219.00

75

FVH 92000164 MRI PELVIS 72196 $212.00FVH 92000166 MRI ANGIO NECK 70547 $147.00FVH 92000167 MRA UE W/WO CONTRAST RT $207.00FVH 92000168 BONE AGE 77072 $23.00FVH 92000169 MRI LE W/ CONTRAST LT $198.00FVH 92000170 MRI LE W/ CONTRAST RT $198.00FVH 92000171 MRI LE EXC JT W/CONTRAST LT $198.00FVH 92000172 MRA UE W/WO CONTRAST LT $207.00FVH 92000176 MRI ABDOMEN W/ CONTRAST 74182 $212.00FVH 92000178 CT LE W/ CONTRAST LT $142.00FVH 92000179 CT LE W/ CONTRAST RT $142.00FVH 92000180 CT MAXILLOFACIAL CONT 70487 $138.00FVH 92000181 CT SELLA/POST/FOSS/EAR 70481 $169.00FVH 92000182 CT C-SPINE W/ CONTRAST 72126 $149.00FVH 92000183 CT T-SPINE W/ CONTRAST 72129 $149.00FVH 92000184 CT LE W/ WO CONTRAST 73702 $149.00FVH 92000189 CT GUIDE STEROETACTIC LOC 77011 $153.00FVH 92000193 ARTHROGRAM WRIST BILAT 2524650 $183.00FVH 92000200 FEMUR 1 VIEW RT $21.00FVH 92000201 FEMUR 1 VIEW LT $21.00FVH 92000202 FEMUR 2 VIEW RT $22.00FVH 92000203 FEMUR 2 VIEW LT $22.00FVH 92000204 HIP UNILAT W PELVIS 1 VIEW RT $23.00FVH 92000205 HIP UNILAT W PELVIS 1 VIEW LT $23.00FVH 92000206 HIP UNILAT W PELVIS 2-3 RT $28.00FVH 92000207 HIP UNILAT W PELVIS 2-3 LT $28.00FVH 92000208 HIP UNILAT W PELVIS 4 VIEW RT $34.00FVH 92000209 HIP UNILAT W PELVIS 4 VIEW LT $34.00FVH 92000210 HIP BILAT W PELVIS 2 VIEW 73521 $28.00FVH 92000212 HIP BILAT W PELVIS 3-4 73522 $37.00FVH 92000354 CT ABD AND PELVIS NO CONTRA 74176 $213.00FVH 92000355 CT ABD AND PELVIS W/CONTRA 74177 $223.00FVH 92000356 CT ABD AND PELVIS W/WO CONTRA 74178 $245.00FVH 92000357 MAMMO SCREENING DIGITAL UNILAT 7706752 $93.00FVH 92000358 ASPIR INJ SM JT W/US 20604 $113.00FVH 92000359 ASPIR INJ INTERM JT W/US 20606 $128.00FVH 92000360 ASPIR INJ MAJOR JT W/US 20611 $146.00FVH 92000361 US BREAST COMPLETE RT $89.00FVH 92000362 US BREAST COMPLETE LT $89.00FVH 92000363 US BREAST LIMITED RT $83.00FVH 92000364 US BREAST LIMITED LT $83.00FVH 92000373 MYELOGRAM CERV INC S/I SAME MD 62302 $297.00FVH 92000374 MYELOGRAM THOR INC S/I SAME MD 62303 $297.00FVH 92000375 MYELOGRAM L/S INC S/I SAME MD 62304 $292.00FVH 92000376 MYELOGRAM >2 INC S/I SAME MD 62305 $305.00FVH 92000381 BX BREAST 1ST LESION US IMAG 19083 $385.00FVH 92000382 BX BREAST ADD LESION US IMAG 19084 $192.00FVH 92000385 PLACEMT BREAST LOC DEVICE 19281 $247.00FVH 92000386 PLACEMT BREAST LOC DEVICE EA A 19282 $124.00

76

FVH 92000389 PLACEMT BREAST LOC DEVICE 19285 $211.00FVH 92000390 PLACEMT BREAST LOC DEVICE EA A 19286 $105.00FVH 92000393 US BREAST LIMITED BILAT 7664250 $83.00FVH 92000394 US BREAST COMPLETE BILAT 7664150 $89.00FVH 92000504 BIOPSY NEEDLE BONE MARROW PC 38221 $170.00FVH 92000538 CONSULT REFERRED SLIDES 88321 $141.00FVH 92000562 B-EX CNSLT DRG SRG W/O FR SEC 88329 $141.00FVH 92000569 EYE FB DETECTION 70030 $21.00FVH 92000570 SWALLOW STUDY W/MODIFIED VIDEO 74230 $65.00FVH 92000571 GI TRACT UPPER W/O KUB 74240 $85.00FVH 92000573 SMALL BOWEL W/MULT SERIAL FILM 74250 $57.00FVH 92000574 CYSTOGRAM MIN 3 VIEW 74430 $39.00FVH 92000575 FLUOR GUIDE PERC ASPIR & DRAIN 75989 $141.00FVH 92000576 FLUOR UP TO 1 HR 76000 $37.00FVH 92000577 *FLUOR >1 HR RADIOLOGIST 76001 $86.00FVH 92000579 BONE LENGTH STUDY LONG 77073 $38.00FVH 92000581 BONE SURVEY COMPL 77075 $66.00FVH 92000583 RIB UNILATERAL 2 VIEW LT $28.00FVH 92000584 RIB UNILATERAL 2 VIEW RT $28.00FVH 92000585 RIB UNILAT W/PA CHEST LT $33.00FVH 92000587 CLAVICLE COMPL LT $21.00FVH 92000588 CLAVICLE COMPL RT $21.00FVH 92000589 SCAPULA COMPL LT $22.00FVH 92000590 SCAPULA COMPL RT $22.00FVH 92000592 SHOULDER COMPL MIN 2 VIEW LT $23.00FVH 92000593 SHOULDER COMPL 5 VIEW LT $23.00FVH 92000598 HUMERUS MIN 2 VIEW LT $21.00FVH 92000599 HUMERUS MIN 2 VIEW RT $21.00FVH 92000600 ELBOW 2 VIEW LT $20.00FVH 92000601 ELBOW 2 VIEW RT $20.00FVH 92000602 ELBOW COMPL MIN 3 VIEW LT $21.00FVH 92000603 ELBOW COMPL MIN 3 VIEW RT $21.00FVH 92000604 FOREARM 2 VIEW LT $21.00FVH 92000605 FOREARM 2 VIEW RT $21.00FVH 92000606 WRIST 2 VIEW LT $21.00FVH 92000607 WRIST 2 VIEW RT $21.00FVH 92000608 WRIST COMPL MIN 3 VIEW LT $21.00FVH 92000609 WRIST COMPL MIN 3 VIEW RT $21.00FVH 92000611 HAND 2 VIEW LT $21.00FVH 92000612 HAND 2 VIEW RT $21.00FVH 92000613 HAND MIN 3 VIEW LT $21.00FVH 92000614 HAND MIN 3 VIEW RT $21.00FVH 92000625 HIP UNILAT 1 VIEW LT $23.00FVH 92000626 HIP UNILAT 1 VIEW RT $23.00FVH 92000627 HIP UNILAT 2 VIEW LT $28.00FVH 92000628 HIP UNILAT 2 VIEW RT $28.00FVH 92000629 ARTHROGRAM HIP S&I RT $70.00FVH 92000632 KNEE 1 OR 2 VIEW LT $21.00FVH 92000633 KNEE 1 OR 2 VIEW RT $21.00

77

FVH 92000634 KNEE 3 VIEW LT $23.00FVH 92000635 KNEE 3 VIEW RT $23.00FVH 92000636 KNEE COMPL 4 OR MORE VIEW LT $28.00FVH 92000637 KNEE COMPL 4 OR MORE VIEW RT $28.00FVH 92000638 ARTHROGRAM KNEE S&I RT $69.00FVH 92000639 TIBIA/FIBULA 2 VIEW LOW LEG LT $20.00FVH 92000640 TIBIA/FIBULA 2 VIEW LOW LEG RT $20.00FVH 92000643 ANKLE COMPL MIN 3 VIEW LT $21.00FVH 92000644 ANKLE COMPL MIN 3 VIEW RT $21.00FVH 92000645 FOOT 2 VIEW LT $19.00FVH 92000646 FOOT 2 VIEW RT $19.00FVH 92000647 FOOT COMPL MIN 3 VIEW LT $21.00FVH 92000648 FOOT COMPL MIN 3 VIEW RT $21.00FVH 92000649 CALCANEUS MIN 2 VIEW LT $20.00FVH 92000650 CALCANEUS MIN 2 VIEW RT $20.00FVH 92000654 HEPATOBILIARY IMAGING 78226 $89.00FVH 92000655 GASTRIC EMPTYING 78264 $95.00FVH 92000656 BONE SCAN WHOLE BODY 78306 $104.00FVH 92000657 BONE SCAN 3 PHASE 78315 $122.00FVH 92000661 CT NECK SOFT TISSUE W/O CONTR 70490 $156.00FVH 92000662 CT CERVICAL SPINE W/O CONTR 72125 $131.00FVH 92000663 CT LUMBAR SPINE W/O CONTR 72131 $123.00FVH 92000665 CT PELVIS RENAL SPIRAL W/O CON 72192 $133.00FVH 92000666 CT PELVIS W/CONTR 72193 $142.00FVH 92000667 CT PELVIS W/WO CONTR 72194 $149.00FVH 92000668 CT ABDOMEN W/O CONTR 74150 $146.00FVH 92000670 CT ABDOMEN W/CONTR 74160 $156.00FVH 92000671 CT ABDOMEN W/WO CONTR 74170 $171.00FVH 92000672 CTA ABD AORTA W/ RUNOFF 75635 $289.00FVH 92000673 CT LIMITED 76380 $118.00FVH 92000674 CT UE W/O CONTRAST LT $123.00FVH 92000675 CT UE W/O CONTRAST RT $123.00FVH 92000676 CT LE W/O CONTRAST LT $123.00FVH 92000677 CT LE W/O CONTRAST RT $123.00FVH 92000678 CT BRAIN W/O CONTR 70450 $104.00FVH 92000679 CT BRAIN W/WO CONTR 70470 $156.00FVH 92000680 CT ORBITS W/O CONTR 70480 $156.00FVH 92000681 CT FACIAL BONES W/O CONTR 70486 $105.00FVH 92000682 CT NECK SOFT TISSUE W/CONTR 70491 $169.00FVH 92000683 CT NECK SOFT TISSUE W/WO CONT 70492 $198.00FVH 92000684 CT THORAX W/O CONTR CHEST 71250 $142.00FVH 92000685 CT THORAX W/CONTR CHEST 71260 $152.00FVH 92000686 CT THORAX W/WO CONTR CHEST 71270 $169.00FVH 92000687 CT ANGIO CHEST W/WO CONTR 71275 $223.00FVH 92000688 CT CERVICAL SPINE W/WO CONTR 72127 $155.00FVH 92000689 CT THORACIC SPINE W/O CONTR 72128 $123.00FVH 92000690 CT ANGIO ABDOMEN W/WO CONTR 74175 $221.00FVH 92000691 CT UE W/CONTRAST RT $142.00FVH 92000693 PARACENTESIS ABD W/O IMAGING 49082 $177.00

78

FVH 92000698 US EXTREMITY NON VASC LT $60.00FVH 92000699 US EXTREMITY NON VASC RT $60.00FVH 92000700 PET CT SKULL/THIGH INIT NOPR $291.00FVH 92000703 ECHO LIMITED OR FOLLOW UP 9330826 $63.00FVH 92000707 DRAIN PERCU PERITONEAL ABSCESS 49406 $486.00FVH 92000708 MRI PELVIS W/O CONTR 72195 $179.00FVH 92000709 MRI PELVIS W/WO CONTR 72197 $269.00FVH 92000710 MRA ABDOMEN W/CONTR 74185 $218.00FVH 92000711 MRI UE EXC JT W/O CONTRAST LT $166.00FVH 92000712 MRI UE EXC JT W/O CONTRAST RT $166.00FVH 92000713 MRI UE EXC JT W/WO CONTRAST LT $262.00FVH 92000714 MRI UE EXC JT W/WO CONTRAST RT $262.00FVH 92000715 MRI UE ANY JT W/O CONTRAST LT $166.00FVH 92000716 MRI UE ANY JT W/O CONTRAST RT $166.00FVH 92000717 MRI UE ANY JT W/WO CONTRAST LT $263.00FVH 92000718 MRI UE ANY JT W/WO CONTRAST RT $263.00FVH 92000719 MRI LE EXC JT W/O CONTRAST LT $165.00FVH 92000720 MRI LE EXC JT W/O CONTRAST RT $165.00FVH 92000721 MRI LE EXC JT W/WO CONTRAST LT $262.00FVH 92000722 MRI LE EXC JT W/WO CONTRAST RT $262.00FVH 92000723 MRI LE ANY JT W/O CONTRAST LT $166.00FVH 92000724 MRI LE ANY JT W/O CONTRAST RT $166.00FVH 92000725 MRI LE ANY JT W/WO CONTRAST LT $262.00FVH 92000726 MRI LE ANY JT W/WO CONTRAST RT $262.00FVH 92000727 MRA NECK W/WO CONTR 70549 $220.00FVH 92000728 MRI BRAIN STEM W/O CONTR 70551 $181.00FVH 92000730 MRI BRAIN STEM W/WO CONTR 70553 $279.00FVH 92000731 MRI SPINE CERVICAL W/O CONTR 72141 $182.00FVH 92000732 MRI SPINE DORS/THOR W/O 72146 $182.00FVH 92000733 MRI SPINE LUMBAR W/O CONTR 72148 $182.00FVH 92000734 MRI SPINE CERVICAL W/WO CONTR 72156 $279.00FVH 92000735 MRI SPINE DORS THOR W/WO CONTR 72157 $279.00FVH 92000736 MRI SPINE LUMBAR W/WO CONTR 72158 $279.00FVH 92000737 MRA HEAD W/O CONTR 70544 $147.00FVH 92000738 MRA NECK W/CONTR 70548 $184.00FVH 92000743 DUPLEX ARTERIAL LE LIMITED LT $58.00FVH 92000746 MRI UE ANY JT W/CONTRAST LT $199.00FVH 92000747 DUPLEX ARTERIAL LE LIMITED RT $58.00FVH 92000748 CT LUMBAR SPINE W/CONTR 72132 $149.00FVH 92000749 MRI FACE/NECK/ORBITS W/WO CONT 70543 $261.00FVH 92000751 CT GUIDE NEEDLE PLACEMT 77012 $180.00FVH 92000752 INJ MYELOGRAPHY CT SPINAL 62284 $211.00FVH 92000753 FLUORO GUIDE BIOPSY OR INJ 77002 $68.00FVH 92000754 ASPIR INJ MAJOR JT 20610 $109.00FVH 92000755 INJ LUMBAR SACRAL SINGLE LVL 64483 $270.00FVH 92000756 INJ SHOULDER 23350 $125.00FVH 92000757 *ASPIR FINE NEEDLE W/IMG TISSU 10022 $158.00FVH 92000759 ASPIR ABSCESS/HEMATOMA/CYST 10160 $226.00FVH 92000761 MRA LE W/WO CONTRAST RT $219.00

79

FVH 92000762 MRA LE W/WO CONTRAST LT $219.00FVH 92000765 BX LIVER NEEDLE PERC 47000 $218.00FVH 92000768 INJ TRIGGER POINT 1 OR 2 20552 $92.00FVH 92000770 MRI ABDOMEN W/WO CONTR 74183 $269.00FVH 92000773 INJ SACROILIAC JOINT 27096 $202.00FVH 92000774 ARTHROGRAM HIP 27093 $169.00FVH 92000776 US CHEST 76604 $66.00FVH 92000777 BIOPSY ABDOMEN 49180 $209.00FVH 92000778 ARTHROGRAM HIP S&I 73525 $70.00FVH 92000780 GI TRACT UPPER W/SM BOWEL 74240 $111.00FVH 92000785 ARTHROGRAM ELBOW 24220 $165.00FVH 92000786 ARTHROGRAM ELBOW S&I 73085 $70.00FVH 92000787 BX OR EXCISION OF LYMPH NODE 38505 $170.00FVH 92000788 ARTHROGRAM WRIST 25246 $183.00FVH 92000789 CT ORBITS W/WO CONTR 70482 $177.00FVH 92000790 MRI ABDOMEN W/O CONTR 74181 $179.00FVH 92000792 CT BRAIN W/CONTR 70460 $139.00FVH 92000793 MRI COMPL CORD THOR W/CONTR 72147 $218.00FVH 92000797 VOIDING CYSTOGRAM 74455 $40.00FVH 92000798 BX LUNG MEDIAST NDLE PERC 32405 $221.00FVH 92000801 INSERT PICC >5 YR 36569 $231.00FVH 92000802 CT ANGIO NECK W/WO CONTR 70498 $214.00FVH 92000811 MRI LE ANY JT W/CONTRAST 73722 $199.00FVH 92000813 MAMMO BREAST SPECIMEN 76098 $20.00FVH 92000815 THORACENTESIS W/O IMG GUIDE 32554 $218.00FVH 92000816 ASPIR INJ SM JT 20600 $86.00FVH 92000819 LUMBAR PUNCTURE 62270 $186.00FVH 92000822 CT UE W/CONTRAST LT $142.00FVH 92000824 ASPIR BREAST CYST 19000 $105.00FVH 92000826 CT UE W/WO CONTRAST 73202 $149.00FVH 92000829 INJ FACET JNT L/S SNG LEVEL 64493 $218.00FVH 92000832 CT FACIAL BONES W/WO CONTRAST 70488 $156.00FVH 92000833 US GUIDE VASC ACCESS SONOSITE 76937 $35.00FVH 92000834 MAMMO SCREENING DIGITAL BILAT 77067 $93.00FVH 92000835 MAMMO DIAGNOSTIC DIGITAL BILAT 77066 $123.00FVH 92000836 MAMMO DIAGNOSTIC DIGITAL UNILA 7706526 $99.00FVH 92000837 PLACEMMT NG TUBE B 43752 $99.00FVH 92000838 INJ PROC LYMPHANGIOGRAPHY 38792 $80.00FVH 92000839 NEEDLE BIOPSY MUSCLE 20206 $142.00FVH 92000841 ASPIR INJ RENAL CYST PERC 50390 $236.00FVH 92000846 MRI BRAIN PITUITARY W/CONTR 70552 $218.00FVH 92000850 CT ANGIO HEAD W/WO CONTR 70496 $214.00FVH 92000851 MRI SPINE LUMBAR W/CONTR 72149 $219.00FVH 92000861 BX BONE TROC/NDLE DEEP 20225 $259.00FVH 92000862 DRAIN RENAL/PERIRENAL ABSC PER 49405 $486.00FVH 92000864 BX BONE TROC/NDLE SUPERF 20220 $174.00FVH 92000874 SINUS TRACT FISTULA INJ DX 20501 $92.00FVH 92000875 SINUS TRACT OR TUBE INJ S&I 76080 $64.00FVH 92000878 SPINE THOROCOLUMBAR 2 VIEW 72080 $28.00

80

FVH 92000880 US AAA SCREEN 76706 $67.00FVH 92000884 CHEST COMPLETE MIN 4 VIEW 71048 $40.00FVH 92000885 ARTHROGRAM KNEE RT $98.00FVH 92000886 ARTHROGRAM KNEE LT $98.00FVH 92000887 ARTHROGRAM KNEE S&I LT $69.00FVH 92000888 MRI 3D RECON W/O WORKSTATION 76376 $24.00FVH 92000890 US HIP DYNAMIC BIL 76885 $91.00FVH 92000891 US INTRAOPERATIVE 76998 $148.00FVH 92000895 PARATHYROID NUCLEAR IMAGING 78070 $96.00FVH 92000896 LYMPHOSCINTOGRAM 78195 $143.00FVH 92000897 GI BLEED 78278 $120.00FVH 92000898 MYOCARD PERF SPECT REST+STRESS 78452 $194.00FVH 92000899 CARDIAC GATED REST SNGL 78472 $118.00FVH 92000900 LUNG PERFUSION IMAGING 78580 $89.00FVH 92000902 RENAL IMAGING FLOW& FUNCTION 78707 $114.00FVH 92000904 MRI UE ANY JT W/ CONTRAST RT $199.00FVH 92000905 CHANGE GJ TUBE PERC INCL S/I 49452 $341.00FVH 92000906 BONS SCAN SPECT 78803 $124.00FVH 92000907 MRI FACE/NECK/ORBITS W/CONT 70542 $198.00FVH 92000908 MRI UE EXC JT W/CONTRAST RT $198.00FVH 92000909 ABD PARACENTESIS W/IMAGING 49083 $263.00FVH 92000910 SACROILIAC JT 3 OR MORE VIEWS 72202 $23.00FVH 92000912 LUNG SCAN QUANT PERF AND VENT 78598 $101.00FVH 92000913 HEPATOBILIARY SCAN W/ CCK 78227 $109.00FVH 92000918 HYSTEROSALPINGOGRAM S&I 74740 $46.00FVH 92000919 PERITONEAL ABSCESS DRAINAGE 49020 $3,733.00FVH 92000920 MRA CHEST W/CONTR 71555 $219.00FVH 92000921 MRA PELVIS W/CONTR 72198 $217.00FVH 92000922 MYELOGRAM CERVICAL S&I 72240 $111.00FVH 92000923 MYELOGRAM SPINAL CANAL COMPL S 72270 $165.00FVH 92000924 UE 2 VIEW INFANT 73092 $20.00FVH 92000925 HYSTEROSALPINGOGRAM S&I 74740 $46.00FVH 92000926 US HIP INFANT STATIC 76886 $76.00FVH 92000927 BONE SURVEY INFANT 77076 $86.00FVH 92000928 METABOLIC SURVEY 77077 $39.00FVH 92000929 LIVER IMAGING SPECT 78803 $82.00FVH 92000930 LIVER SPLEEN IMAGING 78215 $59.00FVH 92000931 MECKELS SCAN 78290 $82.00FVH 92000932 MYOCARD PERF SPECT REST OR STR 78451 $165.00FVH 92000933 PET SCAN IMAGING CARDIAC INIT 78459 $174.00FVH 92000934 CARDIAC GATEDSTRESS 78473 $175.00FVH 92000935 PET BRAIN IMAGING SUBSEQUENT $176.00FVH 92000936 RENAL IMAGING FUNC PHARM INTER 78708 $145.00FVH 92000937 PET CT WHOLE BODY INITIAL $295.00FVH 92000938 INJ TENDON SHEATH LIGAMENT 20550 $95.00FVH 92000939 INJ INTERM JT 20605 $90.00FVH 92000940 BX PANCREAS PERCUTANEOUS 48102 $589.00FVH 92000941 RENAL BX 50200 $313.00FVH 92000942 MRA HEAD W/CONTR 70545 $147.00

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FVH 92000943 MRA HEAD W/WO CONTR 70546 $181.00FVH 92000944 CHEST W OBLIQUES 71048 $40.00FVH 92000945 MRI CHEST W/CONTR 71551 $211.00FVH 92000946 MRI CHEST W/WO CONTR 71552 $276.00FVH 92000947 RENAL IMAGING W/FLOW 78701 $59.00FVH 92000949 US SPINAL CANAL AND CONTENTS 76800 $140.00FVH 92000953 REMOVE FB MUSCLE/TEN SIMPLE 20520 $348.00FVH 92000961 CT LUMBAR SPINE W/WO CONTR 72133 $155.00FVH 92000962 THORACENTESIS W/IMG GUIDE 32555 $274.00FVH 92000965 THYROID UPTAKE W/SIMULATION 78014 $60.00FVH 92000966 CTA ABD PELVIS W CONTRAST 74174 $266.00FVH 92000968 THYROID UPTAKE SINGLE OR MULT 78012 $23.00FVH 92000969 LUNG PERFUSION & VENTILATION 78582 $129.00FVH 92000976 CT CHEST SCREENING 71250 $142.00FVH 92000986 NERVE BLOCK BRACHIAL PLEXUS 64415 $160.00FVH 92000987 CT ANGIO UE W/WO CONTRAST 73206 $219.00FVH 92000988 INJECTION PLATELET PLASMA $250.00FVH 92000991 INJ ANES SPHENOPALATINE GANGLI 6450550 $220.00FVH 92000994 ST BX SHOULDER; SUPERFICIAL 23065 $397.00FVH 92000995 ARTHROGRAM ANKLE LT $127.00FVH 92000996 ARTHROGRAM ANKLE RT $127.00FVH 92000997 ABDOMEN FLAT/DECUB/ERECT 74021 $35.00FVH 92001018 MAMMO DX DIGIT UNILAT LT $99.00FVH 92001019 MAMMO DX DIGIT UNILAT RT $99.00FVH 92001043 BIOPSY & ASP DX BONE MARROW 38222 $191.00FVH 92001044 LUMBAR ASP PERC DISK ANY METH 62267 $385.00FVH 92001051 ASP FN NDL BX W/US GDN 1ST LES 10005 $177.00FVH 92001052 ASP FN NDL BX W/US GDN EA ADDL 10006 $121.00FVH 92001053 ASP FN NDL BX W/FLUOR GDN 1ST 10007 $228.00FVH 92001054 ASP FN NDL BX W/FLUO GDN EA AD 10008 $148.00FVH 92001055 ASP FN NDL BX W/CT GDN 1ST LES 10009 $277.00FVH 92001056 ASP FN NDL BX W/CT GDN EA ADDL 10010 $202.00FVH 92001058 INSRT PICC WO SQ PORT W IMG >5 36573 $207.00FVH 92001059 MAMMO DIAG UNILATERAL 3D G0279 $130.00FVH 92001060 MAMMO DIAG BILATERAL 3D G0279 $130.00FVH 92001061 MAMMO SCREEN 3D 77063 $73.00FVH 92001062 BIOPSY SALIVARY GLAND NEEDLE 42400 $135.00FVH 93000171 ADIPOCELL PROCEDURE NON COV $1,790.00FVH 93000200 ADIPOCELL PROC COLLECTION/BANK $1,106.00FVH 94000100 FINE NEEDLE ASPIRATION 10021 $101.00FVH 94000101 INCISION/DRAINAGE OF ABSCESS 10060 $140.00FVH 94000102 INC/REM OF FOREIGN BODY SIMPLE 10120 $149.00FVH 94000103 I&D OF HEMATOMA 10140 $219.00FVH 94000104 PUNCT ASP ABSCESS/HEMA/CYST 10160 $139.00FVH 94000105 I&D COMPLEX 10180 $254.00FVH 94000106 DEBRIDEMENT OPEN FX DISLOCATN 11010 $523.00FVH 94000107 DEBRIDE W/ REMOVAL FB 11012 $599.00FVH 94000108 DERIDEMENT SKIN/SUBCUT TISSUE 11042 $89.00FVH 94000109 DEBRIDE SKIN SUBCUT TISS/MUSCL 11043 $224.00

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FVH 94000110 DEBRIDEMENT SKIN SUBCUT 11044 $333.00FVH 94000111 EXC BENIGN LESION .6 TO 1CM 11401 $149.00FVH 94000112 EXC BENIGN LIESION 3.1 TO 4CM 11404 $232.00FVH 94000113 EXC BENIGN LESION <.5 CM 11420 $118.00FVH 94000114 REMOVAL SKIN LESION 11421 $160.00FVH 94000115 REPAIR NAIL BED 11760 $193.00FVH 94000116 REPAIR WOUND SIMPLE <2.5 12001 $64.00FVH 94000117 SURG PREP SITE EXC WOUND SCAR 15002 $544.00FVH 94000118 SPLIT GRAFT <100SQ CM 15100 $1,709.00FVH 94000119 EXC BONE BX DEEP 20245 $1,484.00FVH 94000120 INJECT CARPAL TUNNEL 20526 $107.00FVH 94000121 INJ TENDON SHEATH LIGAMENT 20550 $71.00FVH 94000122 INJ SINGLE TENDON 20551 $80.00FVH 94000123 INJ TRIGGER POINT 1 OR 2 20552 $55.00FVH 94000124 ASPIR INJ SM JOINT 20600 $67.00FVH 94000125 INJ INTERM JT 20605 $76.00FVH 94000126 ASPIR INJ MAJOR JT 20610 $85.00FVH 94000127 ASPIRATION/INJ GANGLION CYST 20612 $60.00FVH 94000128 REMOVAL OF IMPLANT DEEP 20680 $1,180.00FVH 94000129 APPLICATION OF UNIPLANE UNILAT 20690 $1,090.00FVH 94000130 ACROMIOPLASTY OR ACROMIONECTMY 23130 $1,442.00FVH 94000131 REPAIR OF ROTATOR CUFF ACUTE 23410 $1,945.00FVH 94000132 REP RUPT MCLOTDIOUS CUFF ROT 23412 $2,019.00FVH 94000133 CORACOAROMIAL LIGAMENT RELEASE 23415 $1,647.00FVH 94000134 REPAIR OF COMPLETE SHOULDER 23420 $2,687.00FVH 94000135 TENDONESIS LG TENDON OF BICEP 23430 $1,775.00FVH 94000136 CAPSULORRHAPHY 23450 $2,238.00FVH 94000137 ARTHROPLASTY TOTAL SHOULDER 23472 $4,043.00FVH 94000138 FX CLAVICLE 23500 $320.00FVH 94000139 TREAT CLAVICLE FX 23515 $1,709.00FVH 94000140 FX SCAPULA 23570 $343.00FVH 94000141 FX PROXIMAL HUMERUS 23600 $737.00FVH 94000142 OPEN TX OF PROXIMAL HUMERAL FX 23615 $2,097.00FVH 94000143 TUBEROSITY HUMERAL FRACTURE 23620 $368.00FVH 94000144 DISLOCATION SHOULDER W/O ANEST 23650 $526.00FVH 94000145 CLSD TX SHOULD DISLOC W/ MANIP 23655 $952.00FVH 94000146 MANIP W/ ANESTH SHOULDER 23700 $464.00FVH 94000147 EXC ARM/ELBOW LES SC <3CM 24075 $472.00FVH 94000148 EXCISION OLECRANON BURSA 24105 $973.00FVH 94000149 PARTIAL EXCISION BONE HUMERUS 24140 $1,660.00FVH 94000150 REPAIR OF BICEPS TENDON 24340 $1,456.00FVH 94000151 TENOTOMY ELBOW 24357 $1,045.00FVH 94000152 DEBR SOFT TIS OPEN W/ TEND REP 24359 $1,561.00FVH 94000153 FX HUMERAL SHAFT 24500 $467.00FVH 94000154 FX SUPRA TANS GONDYLAR 24530 $492.00FVH 94000155 OPEN TX HUMERUS FX 24545 $2,198.00FVH 94000156 FX RADIAL HEAD OR NECK 24650 $345.00FVH 94000157 FX ULNA PROXIMAL 24670 $477.00FVH 94000158 EXC FOREARM LES SC <3CM 25075 $452.00

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FVH 94000159 RXC GANGLION WRIST PRIMARY 25111 $890.00FVH 94000160 REM WRIST TENDON LESION RECUR 25112 $917.00FVH 94000161 TENDON TRANSPLANT FOREARM 25310 $1,464.00FVH 94000162 REP NONUNION SCAPHOID BONE 25440 $2,140.00FVH 94000163 FX ULNA SHAFT 25530 $340.00FVH 94000164 FX RADIUS AND ULNA W/ MANIP 25565 $1,292.00FVH 94000165 FX DISTAL RADIUS 25600 $446.00FVH 94000166 TREAT DISTAL RADIAL FX CLOSED 25605 $1,413.00FVH 94000167 FX DISTAL RADIAL 25606 $1,836.00FVH 94000168 FX DISTAL RADIAL W/ INT FIX 25607 $2,038.00FVH 94000169 FX SEPARATION DISTAL 25608 $1,949.00FVH 94000170 OPEN TX DISTAL FX W/3+ FRAG 25609 $2,909.00FVH 94000171 FX NAVICULAR 25622 $398.00FVH 94000172 OPEN TX CARPAL SCAPHOID FX 25628 $2,000.00FVH 94000173 FX CARPAL 25630 $401.00FVH 94000174 CARPAL BONE FX 25645 $1,344.00FVH 94000175 DSITAL ULNAR FX 25650 $718.00FVH 94000176 CL TX LUNATE DISLC W/MANIP 25690 $1,139.00FVH 94000177 I&D ABSCESS FINGER COMP 26011 $264.00FVH 94000178 DRAEIN TEND SHEATH DIG/PAL EA 26020 $1,031.00FVH 94000179 TENDON SHEATH INC TRIGGER FNGR 26055 $862.00FVH 94000180 ARTHROMTOMY METACARPOPHAL JOIN 26075 $778.00FVH 94000181 EXCISION TUMOR HAND > 1.5CM 26111 $989.00FVH 94000182 EXC HAND LES SC <1.5CM 26115 $789.00FVH 94000183 FASCIECTOMY PALM 26121 $1,411.00FVH 94000184 EXC LES TENDON SHEATH FINGER 26160 $929.00FVH 94000185 REP TENDON EXT W/O GRAFT 26418 $1,370.00FVH 94000186 PRIM REPAIR OF COLLATERAL LIG 26540 $1,549.00FVH 94000187 REP NONUNION METACARPAL/PHAL 26546 $2,341.00FVH 94000188 FX METACARPAL 26600 $503.00FVH 94000189 FX METACARPAL CLOSED TX 26605 $420.00FVH 94000190 PERCUTANEOUS SKELETL META FX 26608 $1,131.00FVH 94000191 OPEN TX OF METACARPAL FX EACH 26615 $1,600.00FVH 94000192 FX FINGER 26720 $266.00FVH 94000193 UNSTABLE PHALANGEAL FX 26727 $1,112.00FVH 94000194 OPEN TX PHALANGEAL SHAFT 26735 $1,414.00FVH 94000195 FRACTURE ARTIC MCP/PIP W/MANIP 26742 $792.00FVH 94000196 OPEN TX ARTICULAR FX 26746 $1,752.00FVH 94000197 FX DISTAL PHALANX 26750 $266.00FVH 94000198 PAHALANGEAL FX 26756 $994.00FVH 94000199 OPEN TX OF DISTAL FX EACH 26765 $1,391.00FVH 94000200 DISLOCATION FINGER W/O ANESTH 26770 $369.00FVH 94000201 INCISION BONE CORTEX 26992 $2,272.00FVH 94000202 ARTHROTOMY HIP 27030 $2,137.00FVH 94000203 ACETABULOPLASTY RESECT FEM HD 27122 $2,599.00FVH 94000204 TOTAL HIP ANTHROPLASTY 27130 $3,766.00FVH 94000205 CONVERSION HIP SURG TOTAL HIP 27132 $3,964.00FVH 94000206 REVISION HIP ACETABULAR ONLY 27137 $3,484.00FVH 94000208 TREATMENT FX FEMORAL 27235 $2,148.00

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FVH 94000209 OP TX FEMORAL FRACTURE 27236 $2,831.00FVH 94000210 FX INT/PER/SUB FEMORAL W/PL-SC 27244 $2,910.00FVH 94000211 FX INT/PER/SUB FEMORAL W/INT 27245 $2,911.00FVH 94000213 UNLISTED PROCEDURE PELVIS/HIP 27299 $800.00FVH 94000214 ARTHROSCOPY KNEE 27332 $1,517.00FVH 94000215 ARTHROTOMY MEDIAL & LATERAL 27333 $1,385.00FVH 94000216 EXCISION LESION MENISCUS 27347 $1,254.00FVH 94000217 REPAIR OF THIGH MUSCLE 27385 $1,592.00FVH 94000218 RECONSTRCT DISLOCATING PATELLA 27422 $1,760.00FVH 94000219 ARTHROPLASTY KNEE TOTAL 27447 $3,762.00FVH 94000220 REMOVAL KNEE PROSTHESIS 27488 $2,844.00FVH 94000221 FX FEMORAL SHAFT 27500 $1,133.00FVH 94000222 OPTX FEM SHFT W INS IMED IMPL 27506 $3,165.00FVH 94000223 OPTX FEM SHAFT FX W PLATES SCR 27507 $2,299.00FVH 94000224 FEMORAL FRACTURE OPEN 27511 $2,355.00FVH 94000225 FX PATELLA 27520 $424.00FVH 94000226 FRACTURE TIBIA PROX W/O MANIP 27524 $2,084.00FVH 94000227 FRACTURE TIBIA PROX W/O MANIP 27530 $403.00FVH 94000228 EXC LEG/ANKLE TUMOR < 3 CM 27618 $436.00FVH 94000229 REPAIR OF LEG TENDON EA 27658 $907.00FVH 94000230 CL TX TIB FX W MANIP 27752 $1,179.00FVH 94000231 FX MEDIAL MALLEOLUS 27760 $439.00FVH 94000232 FX DISTAL FIBULA 27786 $413.00FVH 94000233 DISTAL FIBULAR FRACTURE 27792 $1,686.00FVH 94000234 FX BIMALLEOLAR 27808 $433.00FVH 94000235 FRACTURE ANKLE W/MANIPULATION 27810 $1,021.00FVH 94000236 OPEN TREAT BIMALLEOLAR ANKL FX 27814 $2,138.00FVH 94000237 FX TRIMALLEOLAR ANKLE W MANIP 27818 $1,040.00FVH 94000238 OPEN TX TRIMALLEOLAR ANKLE FX 27822 $2,383.00FVH 94000239 OPEN TX OF FX DISTAL TIBIA 27827 $2,574.00FVH 94000240 REPAIR TENDON FLEXOR FOOT 28208 $748.00FVH 94000241 OPEN TREATMENT OF TARSAL BONE 28465 $1,460.00FVH 94000242 FX METATARSAL 28470 $299.00FVH 94000243 OPEN TRMNT OF METATARSAL FX 28485 $1,272.00FVH 94000244 PERCUTANEOUS SKELATAL FIXATION 28496 $576.00FVH 94000245 OPEN FRACTURE TOE 28505 $1,195.00FVH 94000246 APPL LONG ARM CAST SHOU>HAND 29065 $98.00FVH 94000247 APPLICATION SHORT ARM CAST 29075 $114.00FVH 94000248 APPLICATION SHORT ARM CAST OT 29125 $73.00FVH 94000249 APPLICATION FINGER SPLINT 29130 $41.00FVH 94000250 APPLICATION LONG LEG CAST 29345 $145.00FVH 94000251 APPLICATION CYLINDER CAST 29365 $125.00FVH 94000252 APPLICATION PLSTR SPLINT LEG 29505 $72.00FVH 94000253 ARTHROSCOPY SHOULDER SLAP 29807 $2,450.00FVH 94000254 ARTHROS SHOULDER DISTAL CLAV 29824 $1,863.00FVH 94000255 ARTHROSCOPY SHOULDER 29826 $488.00FVH 94000256 ARTHROSCOPY ROT CUGG RPR 29827 $2,948.00FVH 94000257 ELBOW ARTHROSCOPY 29834 $1,166.00FVH 94000258 KNEE ARTHROSCOPY DRAINAGE 29871 $1,221.00

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FVH 94000259 ARTHROSC KNEE W LAT RELEASE 29873 $1,457.00FVH 94000260 ARTHRO KNEE REM SE/FB 29874 $1,489.00FVH 94000261 ARTHRO KNEE SYNOVECTOMY LIMIT 29875 $1,375.00FVH 94000262 ARTHROSCOPY KNEE CHONDROPLASTY 29877 $1,480.00FVH 94000263 ARTHROSCOPY KNEE ARTHROPLASTY 29879 $1,575.00FVH 94000264 ARTHRO KNEE W/ MENIS MED & LAT 29880 $1,562.00FVH 94000265 ARTHRO KNEE W/ MENIS MED OR LA 29881 $1,504.00FVH 94000266 ARTHRO KNEE W MEN REP MED/LAT 29882 $1,661.00FVH 94000267 ARTHRO KNEE W MEN REP MED&LAT 29883 $1,992.00FVH 94000268 KNEE ARTHROSCOPY W/ADHESIONS 29884 $1,475.00FVH 94000269 ARTRHO AIDED ANTERIOR LIG REPR 29888 $2,732.00FVH 94000270 ARTHROSCOPY PROCEDURE UNLISTED 29999 $2,016.00FVH 94000271 INJ ANES AGNT OR STR PLANTAR 64455 $51.00FVH 94000272 NEUROPLASTY ULNAR NERVE 64718 $1,642.00FVH 94000273 CARPAL TUNNEL REL MEDIAN NERVE 64721 $1,183.00FVH 94000274 ADMINISTRATIVE REPORT 99080 $200.00FVH 94000275 LEVEL 2 NEW PT 99202 $78.00FVH 94000276 LEVEL 3 NEW PT 99203 $116.00FVH 94000277 LEVEL 4 NEW PT 99204 $197.00FVH 94000278 EST PATIENT VISIT LEVEL 1 99211 $14.00FVH 94000279 EST PATIENT VISIT LEVEL 2 99212 $40.00FVH 94000280 EST PATIENT VISIT LEVEL 3 99213 $79.00FVH 94000281 EST PATIENT VISIT LEVEL 4 99214 $122.00FVH 94000282 INP ADMIT LOW COMPLEX 99221 $241.00FVH 94000283 INP ADMIT MOD COMPLEX 99222 $328.00FVH 94000284 INP ADMIT HIGH COMPLEX 99223 $484.00FVH 94000285 LEVEL 3 CONSULT 99243 $238.00FVH 94000286 LEVEL 4 CONSULT 99244 $379.00FVH 94000287 LEVEL 2 INP CONSULT EXP 99252 $186.00FVH 94000288 LEVEL 3 INPT CONSULT LOW COMPL 99253 $283.00FVH 94000289 LEVEL 4 INPT CONSULT MOD COMPL 99254 $409.00FVH 94000290 EXC SOFT TISS TUM THIGH > 3CM 27337 $993.00FVH 94000291 OPEN FX RAD HEAD/NECK FX W/WO 24665 $1,813.00FVH 94000292 EXCISION MALIGNANT LESION>3 11604 $308.00FVH 94000293 ARTHROTOMY, KNEE 27310 $1,730.00FVH 94000294 EXC TUM SHOULDER 23071 $992.00FVH 94000295 APPLICATION SHORT LEG CAST 29405 $110.00FVH 94000296 CLTX PROX HUMRL FX W/MANJP SKE 23605 $1,012.00FVH 94000297 DISLOCATION MCP W/IV ANES 26705 $902.00FVH 94000298 REPAIR FLEXOR TENDON 25260 $1,494.00FVH 94000299 REPAIR LACERATION SIMPLE >2.5 12002 $85.00FVH 94000300 SUBQ/IM INJECTION 96372 $37.00FVH 94000301 REPAIR ELBOW DEBRIDEMENT OPEN 24358 $1,241.00FVH 94000302 EXC BACK LESION SUBCUT >3CM 21931 $1,112.00FVH 94000303 RECONSTRUCT SHOULDER 23470 $3,328.00FVH 94000304 I&D DPABSA/HMTMA TH/KN 27301 $1,188.00FVH 94000305 FX FEMORAL DISTAL 27508 $1,176.00FVH 94000306 ARTHRO KNE W MENIS MD LT G0289 G0289 $205.00FVH 94000307 FX CARE PROX TIBIA W TRACTION 27532 $1,367.00

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FVH 94000308 REP RUPTURED ACHILLES TENDON 27650 $1,593.00FVH 94000309 DISLOCATION HIP POST 27265 $963.00FVH 94000310 ARTHROSCOPY SHOULDER LIMITED 29822 $1,585.00FVH 94000311 CL TX RADIAL SHAFT FX W MANIP 25505 $1,096.00FVH 94000312 OPEN TX OF LUNATE DISLOCATION 25695 $1,494.00FVH 94000313 DISLOCATION NURSEMAID ELBOW 24640 $137.00FVH 94000314 EXPLORATION OF WOUND EXTRM 20103 $828.00FVH 94000315 REPAIR TENDON/MUSCLE;ARM/ELBOW 24341 $1,775.00FVH 94000316 VASC GRAFT INTO CARPAL BONE 25430 $1,699.00FVH 94000317 FX DISTAL TIBIA W OR W/O ANES 27824 $726.00FVH 94000318 FX TRIMALLEOLAR 27816 $685.00FVH 94000319 RPR W/BONE GRAFT, NONUN/MALUN 23485 $2,264.00FVH 94000320 LTC INITIAL CARE LOW COMPLEX 99304 $222.00FVH 94000321 OPEN TX OF DISTAL FIB FX 27792 $1,557.00FVH 94000322 EXCISION PREPATELLAR BURSA 27340 $1,029.00FVH 94000323 REMOVE IMPLANT SUPERFICIAL 20670 $213.00FVH 94000324 SEC CLOSURE OF SURG WND/DEHISC 13160 $1,924.00FVH 94000325 REPAIR EXTENSOR TENDON, HAND 26410 $1,334.00FVH 94000326 TESTIMONY MEDICAL PHYSICIAN 99075 $400.00FVH 94000327 AMPUTATION FINGER/THUMB W FLAP 26952 $1,771.00FVH 94000328 OPEN TX OF DISTL JOINT DISRUPT 27829 $1,932.00FVH 94000329 OPTX MEDIAL MALLEOUS FX 27766 $1,450.00FVH 94000330 AMPUTATE FINGER 26951 $1,539.00FVH 94000331 CLTX POST ANKLE FX 27767 $408.00FVH 94000332 ASP & INJ TX OF BONE CYST 20615 $234.00FVH 94000333 OPEN TX HUMERAL SHAFT FX 24515 $2,074.00FVH 94000334 FX RADIUS AND ULNA SHAFT 25560 $602.00FVH 94000335 REP NU CARPAL BONE EACH 25431 $1,861.00FVH 94000336 INCISE BONE CORTEX SHOULDER 23035 $1,610.00FVH 94000337 ARTHROTOMY FOR INFECTION 26080 $926.00FVH 94000338 MANIPULATION OF KNEE W/ ANES 27570 $358.00FVH 94000339 SYNOVIAL BX IP JOINT 26110 $763.00FVH 94000340 ADJACENT TISSUE TRANSFER <10CM 14020 $1,370.00FVH 94000385 ARTHROTOMY AC W/BIOPSY 23101 $1,086.00FVH 94000440 DISLOCATION ANKLE 27842 $1,180.00FVH 94000441 OBSERVATION ADMIT SIMPLE 99218 $237.00FVH 94000442 OBSERVATION INITIAL MODERATE 99219 $323.00FVH 94000443 OBSERVATION INITIAL COMPLEX 99220 $443.00FVH 94000444 OBSERVATION SUBSEQUENT SIMPLE 99224 $95.00FVH 94000445 OBSERVATION SUBSEQUENT MODERAT 99225 $173.00FVH 94000446 OBSERVATION SUBSEQUENT COMPLEX 99226 $250.00FVH 94000447 ARTHRS SHO SURG CAPULORRHAPHY 29806 $2,940.00FVH 94000450 DISLOCATION HIP POST ARTHOPLAS 27266 $1,376.00FVH 94000451 LAT RETINACULAR RLS OPN 27425 $1,062.00FVH 94000452 RPR 1 TRN LIGM &/CAPSL KNE COL 27405 $1,604.00FVH 94000457 FX TIBIA SHAFT 27750 $760.00FVH 94000469 ARTHRS KNE DRLG OSTEO DISS LES 29886 $1,768.00FVH 94000476 EXCISION OF INTERDIGITAL EA 28080 $896.00FVH 94000485 EXCISION BENIGN LESION <2CM 11402 $122.00

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FVH 94000488 EXCISION BENIGN LESION <2CM 11422 $196.00FVH 94000516 REPAIR OF RUPTURE TENDON 24342 $1,885.00FVH 94000520 FX TROCHANTERIC 27238 $1,095.00FVH 94000521 ANTHROSCOPY SHOULDER SURGICAL 29823 $1,490.00FVH 94000522 RPR DISL PERONEAL TENDON FIB 27676 $1,480.00FVH 94000526 CLTX SCAPULAR FX W/MNPJ 23575 $890.00FVH 94000527 OPEN TX FX DISTAL TIBIA/FIBULA 27828 $3,071.00FVH 94000530 I&D LEG/ANKLE HEMATOMA 27603 $935.00FVH 94000531 OPEN TX RADIUS & ULNA FX 25575 $2,495.00FVH 94000533 ARTHROSCOPY BICEPS TENDESIS 29828 $2,538.00FVH 94000534 CL TX SHLDR DISLOC FX GT W MAN 23665 $942.00FVH 94000535 REPAIR FOREARM TENDON 25275 $1,200.00FVH 94000536 OPEN TREATMENT ULNAR FX 24685 $1,571.00FVH 94000538 ARTHRO KNEE-SYNO-MAJ-2 MORE 29876 $1,583.00FVH 94000541 BIOPSY OF WRIST JOINT 25100 $820.00FVH 94000547 LTC LEVEL 1 VISIT 99307 $106.00FVH 94000548 EXCISION TUMOR FOOT/TOE 28043 $650.00FVH 94000549 LEVEL 1 SUBSQ HOSP FOCUSED 99231 $100.00FVH 94000550 FRACTURE METATARSAL W/MANIP 28475 $333.00FVH 94000551 LEVEL 2 SUBSQ HOSP FOCUSED 99232 $180.00FVH 94000552 LEVEL 3 SUBSQ HOSP FOCUSED 99233 $260.00FVH 94000553 TENDON SHEATH INCISION 25000 $800.00FVH 94000554 INCISION AND DRAINAGE UPPER AR 23931 $231.00FVH 94000555 REV TOT KNEE ARTHR FEM TIB 27487 $4,271.00FVH 94000726 TRMT SUPF WOUND DEHIS SIMPLE 12020 $530.00FVH 94000838 DIVIDE PLANTAR FASCIA & MSCL 28250 $994.00FVH 94000839 FX TIBIAL SHFT INT IMPL W/WO S 27759 $2,412.00FVH 94000840 OP TX SCLAV DISL ACUTE/CHR 23530 $1,372.00FVH 94000841 ARTHRS AID TIB FX PROX UNICOND 29855 $1,897.00FVH 94000843 REMOVAL TOE LESIONS 28108 $716.00FVH 94000845 PART EXC BONE/TALLUS/CALCANEOU 28120 $1,228.00FVH 94000894 LTC SUBS LEVEL 4 VISIT 99310 $334.00FVH 94000895 EXC LES TDN SHTH/CPSL LEG/A 27630 $442.00FVH 94000896 FX CARE OPEN INTRACONDYLAR 27540 $1,972.00FVH 94000897 FX CARE FIBULA 27784 $1,740.00FVH 94000898 EXC RAD WRIST BRSA/TEND SHTH 25115 $1,840.00FVH 94000899 NEUROPLASTY MAJOR PERI NERVE 64708 $1,206.00FVH 94000900 FRACTURE ULNAR SHAFT W/MANIP 25535 $1,247.00FVH 94000901 PARTIAL EXCISION OF BONE 28122 $1,251.00FVH 94000902 INJ GREATER OCCIPITAL NERVE 64405 $114.00FVH 94000903 QUADRICEPSPLASTY 27430 $2,050.00FVH 94000904 FX PERC FIX SC/TC HUMERUS 24538 $2,058.00FVH 94000905 REM FB UP ARM OR ELBOW 24200 $390.00FVH 94000906 PEPAIR GRAFT RADIUS ULNA 25405 $2,529.00FVH 94000907 KNEE ARTHROT W /JOINT EXPL BX 27331 $1,150.00FVH 94000908 REM IMPLANT FINGER OR HAND 26320 $841.00FVH 94000909 ADJACENT TISSUE TRANS <10 CM 14040 $1,798.00FVH 94000910 RECONSTR DILOCATING PATELLA 27420 $2,084.00FVH 94000911 TREAT FRACTURE OF ULNA 25545 $1,746.00

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FVH 94000912 ARTHROTOMY ELBOW 24000 $1,300.00FVH 94000913 REPAIR EXTENSOR TENDON 25270 $1,375.00FVH 94000914 ELBOW ARTHROSCOPY 29837 $1,460.00FVH 94000915 ARTHROSCOPY SHLDR; W REM FB/LB 29819 $1,620.00FVH 94000916 ST BX SHOULDER DEEP 23066 $990.00FVH 94000917 OPEN TX TIB FX PROXIM BICOND 27536 $3,300.00FVH 94000918 HIP REVISION 27134 $5,319.00FVH 94000919 CLTX POST ANKLE FX W/MNPJ 27768 $1,220.00FVH 94000923 ARTHRO KNEE DIAGNOSTIC 29870 $1,135.00FVH 94000924 PERCUTANEOUS SKEL;METATARSL FX 28476 $980.00FVH 94000925 ADVANCE POSTERIO TIBIAL TENDON 28238 $1,410.00FVH 94000934 REPAIR TARSOMETATARSAL JNT DIS 28615 $2,300.00FVH 94000935 REMOVAL OF RADIUS HEAD IMPLANT 24164 $2,050.00FVH 94000936 TREATMENT OF HUMEROUS FX 24576 $515.00FVH 95000002 THERAPY INDIVIDUAL 45 MIN 90834 $350.00FVH 95000003 THERAPY INDIVIDUAL 30 MIN 90832 $325.00FVH 95000004 THERAPY INDIVIDUAL 60 MIN 90837 $375.00FVH 95000006 THERAPY FAMILY WITH PATIENT 90847 $375.00FVH 95000008 THERAPY FAMILY WITHOUT PATIENT 90846 $375.00FVH 95000016 THERAPY GROUP OUTPATIENT 90853 $295.00FVH 95000165 TELEHEALTH FACILITY FEE Q3014 $50.00FVH 95000166 HOSPITAL OUTPT CLINIC VISIT $50.00FVH 98000032 MNT INDIV INITIAL EA 15MIN 97802 $29.00FVH 98000033 MNT INDIV SUBSEQUENT EA 15 97803 $25.00FVH 98000035 DIABETES MGMT MNT GROUP EA 30 G0109 $38.00FVH 98000036 DIABETES MGMT MNT INDIV EA 30 G0108 $58.00FVH 98000056 GLUC MONITOR CONT 72 + HRS 95250 $230.00FVH 98000066 DIAB ED MNT F/UP T19 INDIV 60M $58.00FVH 98000067 DIAB ED MNT F/U GROUP T19 60M $38.00FVH 98000111 DIET CONSULT 99211 $45.00FVH 98000115 PRE DIABETES CLASS $10.00FVH 99000060 EDUCATION INSTRUCTION 98960 $15.00FVH 980000021 RUBEOLA ANTIBODY IGG 86765 $76.00FVH 982000002 DRUG TEST-URINE (LAB) 80100 $64.00FVH 982000007 VARICELLA ZOSTER IGG 86787 $76.00FVH 995000010 CLINIC ALLEN $175.00FVH 995000010 CLINIC CNOS $175.00FVH 995000010 CLINIC CVA $175.00FVH 995000010 CLINIC KENNY $150.00FVH 995000010 CLINIC MARTIN $175.00FVH 995000010 CLINIC ONCOLOGY $120.00FVH 995000010 CLINIC PULMONARY ASSOCIATES $175.00FVH 995000010 CLINIC RENAL ASSOCIATES $150.00FVH 995000010 CLINIC SELTZER $150.00FVH 995000010 CLINIC UROLOGY $200.00FVH 995000011 CLINIC ELSON $175.00FVH 995000011 CLINIC MERCY CARDIOLOGY $175.00FVH 995000011 CLINIC VANDEN BOSCH $175.00FVH 995000011 CLINIC VASCULAR $175.00

89

FVH 995000011 CLINIC WAGNER $175.00FVH 995000011 GEN SURGERY OUTREACH CLINIC $180.00FVH 995000020 ET CONTRACT SERVICES $45.00FVH 995000020 MILEAGE CHARGE $2.00FVH 995000030 AUDIO CLINIC $10.00FVH 995000030 HEARING TEST INDUST $14.00FVH 995000030 VISION SCREEN $20.00FVH 995000040 MASK FITTING $78.00FVH 995000050 HEALTH RISK APPRAISAL $5.00FVH 995000050 MEDICAL DIRECTOR FEE PER MONTH $200.00FVH 995000050 MEDICAL VISIT JAIL PER HOUR $100.00FVH 995000060 TRI-STATE SPECIALISTS $175.00FVH 995000090 ACCOMPANY TO MEDICAL APPT $60.00FVH 995000090 ADDITIONAL PERSON $1,380.00FVH 995000090 APARTMENT DEPOSIT (1) $1,100.00FVH 995000090 APARTMENT DEPOSIT (2) $1,600.00FVH 995000090 BREAKFAST GUEST $4.50FVH 995000090 GUEST MEAL (DINNER) $8.50FVH 995000090 GUEST MEAL (SUPPER) $6.50FVH 995000090 GUEST SUITE $50.00FVH 995000090 HEALTH CARE MANAGEMENT 1 $90.00FVH 995000090 HEALTH CARE MANAGEMENT 2 $490.00FVH 995000091 HEALTH CARE MANAGEMENT 3 $600.00FVH 995000091 HEALTH CARE MANAGEMENT 4 $700.00FVH 995000091 HOUSEKEEPING SERVICES(15MIN) $10.00FVH 995000091 IM INJECTION $6.00FVH 995000091 INTER-FACILITY MOVE $280.00FVH 995000091 LVL I/II EYE DROP ADM 1-2 $50.00FVH 995000091 LVL I/II EYE DROP ADM 3-4 $70.00FVH 995000091 MEDICATION MANAGEMENT LEVEL 1 $45.00FVH 995000092 MEDICATION MANAGEMENT LEVEL 2 $195.00FVH 995000092 MEDICATION MANAGEMENT LEVEL 3 $300.00FVH 995000092 PENDANT REPLACEMENT $80.00FVH 995000092 PERSONAL LAUNDRY (PER LOAD) $9.50FVH 995000092 PHARMACY ORDER PICK -UP $20.00FVH 995000092 RESERVATION AGREEMENT $500.00FVH 995000092 RN PROF SERVICES 1/4HR $22.50FVH 995000092 ROOM DELIVERED MEAL $3.50FVH 995000092 SHORT TERM CARE $180.00FVH 995000093 CLINIC NORTH CENTRAL HEART $180.00FVH 995000093 TB IMMUNIZATION $10.00FVH 995000093 SINGLE BASE $3,170.00FVH 995000093 STUDIO BASE $3,070.00FVH 995000093 TAXI SERVICE $1.00FVH 995000093 URGENT/ UNSCHEDULED TRANSPORT $50.00FVH 995000093 WHIRLPOOL BATH $10.00FVH 995000150 JOB SCREEN $50.00FVH 995000160 DIALYSIS ADMIN EXPENSE $750.00FVH 995000170 JOB FUNCTION TESTING $150.00

90