mnemonic descriptions td.price cpt‐4 hcpcs acu001000 …

MNEMONIC DESCRIPTIONS TD.PRICE CPT‐4 HCPCS

ACU001000 1 ACUTE PRIVATE ROOM $2,190.00

ATI001000 4 ACUTE TELE, ISOLATION $2,487.00

27200489 MEDIUM PHILLY COLLAR, 5‐1/4X13 $53.00

27200822 HEMOSTAT SURGICEL ABSORBABLE $4,547.00

27200875 CATHETER IV 14G X 1 1/4 JELCO $1,731.00

27200934 FULL FACE VENTED MASK, MEDIUM $118.00

27200935 FULL FACE VENTED MASK, LARGE $220.00

27201008 SUTURE 2‐0 VICRYL BR X‐1 $1,290.00

27201108 SUTURE 3‐0,VIOLET BRAIDED, FS‐ $37.00

27201109 SUTURE 4‐0 VICRYL PLUS, PC‐3, $79.00

27201110 SUTURE 5‐0 VICRYL PC‐3, 18 $70.00

27201207 SUTURE 5‐0 NYLON BLK,P‐3, 18 $60.00

27201740 SUTURE PDSII 5.0 PC‐3, CLEAR, $82.00

27201798 NEEDLE EZ‐IO 25MM, INTRAOSSEOU $590.00

27201826 SET EXT 18"" .2 MICRON FILTER $31.00

27201829 SUTURE, 5/0 PROLENE $101.00

27201830 SUTURE, 6/0 PROLENE $99.00

27201835 STERILE BOWL 32 OZ 7"" $15.00

27201837 STOOL MANAGEMENT SYSTEM, TUBE $787.00

27201838 RIB BELT, UNIVERSAL $59.00

27201839 CATHETER, DUETTE, 16FR $37.00

27201840 CAST TAPE 2"" BLUE $61.00

27201841 CAST TAPE 2"" RED $32.00

27201842 CAST TAPE 2"" PURPLE $32.00

27201855 INNER CANNULA, SIZE 8 DISP $10.00

27201864 CATHETER, SUCTION 12 FR $3.00

27201868 SOLUTION SET W/DV SPIKE 103"" $7.00

27201869 EXTEN SET, ULTRASITE, 1.2 MIC $27.00

27201871 HEMOSTAT, HALSTEAD MOSQUITO 5"" $18.00

27201872 FORCEP,HART ALLIG MICRO 3.25"" $100.00

27201873 FORCEP,ADSON 1:2 TEETH 4.75"" $15.00

27201874 FORCEP,SPLINTER,FINE,SER,SHARP $15.00

27201875 FORCEP,VIRTUS SPLINTER,FN,SER $60.00

27201876 FORCEP,JAN.BAYONET,SER,STRGHT $22.00

27201877 HOOK,SKIN,FINE,SHARP 4.75"" $35.00

27201878 TRAY, I&D $56.00

27201879 TRAY,LACERATION 9/2017 $66.00

27201880 TRAY,SUTURE REMOVAL $19.00

27201881 TRAY,CHEST TUBE INTERSTION $190.00

27201882 TRAY, NOSEBLEED $105.00

27201883 NEEDLE,HUBER 22G X 0.75"" $28.00

27201885 CATHETER, NEXIVA DIFFUSICS $30.00

27201886 CHLORAPREP APPLICATOR, 3ML $6.00

27201889 HEMOSTAT, HALSTEAD MOSQUITO 5"" $22.00

27201890 NAIL SPLITTER, ENGLISH ANV 5"" $83.00

27201891 SCISSOR, OPERATING STRT 4.5"" $21.00

27201892 FORCEP,HARTMAN ALLIGATOR 3.5"" $113.00

27201893 CATHETER,PUREWICK FEM EXTERNAL $69.00

27201894 INFUSER,PRESSURE,DISP 1000ML $60.00

27201895 CATHETER,SPEEDICATH,PEDI 6FR $11.00

27201896 TOTAL CONTACT CAST 3"" $644.00

27201897 SCISSORS,LITT.STITCH W/HOOK $19.00

27201898 FORCEPTS,TISSURE W/TEETH $19.00

27201899 FORCEPS, KELLY STRAIGHT $34.00

27201900 FORCEPS, KELLY CURVED $29.00

27201901 HOLDER, NEEDLE $30.00

27201902 CURETTE,BUCKEAR ANGLE #3 6.5"" $47.00

27201903 SCISSOR,IRIS SHARP CURVE 4.5"" $29.00

27201904 SCISSOR, IRIS SHARP STRT 4.5"" $17.00

27201905 FORCEP, IRIS FINE TIP 1/4"" CRV $23.00

27201906 EPISTAXIS,5.5 UNILAT W/O AW $210.00

27201907 EPISTAXIS,7.5 UNILAT W/O AW $217.00

27201940 DRESSING, QWICK 2X2 $32.00

27201941 DRESSING, QWICK 4.2 $32.00 A6196

27201943 SPLINT, ANKLE STIRRUP AIR $127.00

27201950 CATHETER KIT, TRIPLE LUMEN $473.00 A4301

27201951 PROSTHETIC SHRINKER,BELOW KNEE $192.00 L8440

27201955 PROTECTANT, NUTRASHIELD 2 OZ $14.00 A6250

27201959 WAFER, OSTOMY 2.76 $18.00 A4385

27201960 POUCH, OSTOMY 2.75 $5.00 A5054

27201962 WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387




27201969 CATH, SELF‐CATH 14FR COUDE 16"" $18.00 A4352

27210007 SOLUTION,SALINE IRRIGATION $22.00

27210008 SOLUTION, 1.45 SODIUM CHLOR $18.00

27210009 SOLUTION, 500ML SODIUM CHL $17.00

27210014 CATHETER, 16 FR FOLEY $62.00

27210023 HEPARIN SODIUM CHL 25,000 $62.00

27210062 WOUND‐VAC, RENTAL $333.00

27210063 WOUND DRESSING, WOUND‐VAC $252.00

27210064 WOUND CANISTER, WOUND‐VAC $194.00

27210065 EYE PATCH, PIRATE $12.00

27210082 STANDARDS, ETHENOL $605.00

27210083 STANDARDS, ELECTROLYTES $621.00

27210097 SUTURE, PLIABILIZED MONO, BLK, $38.00

27210098 SUTURE, PLIABILIZED MONO, BLK, $30.00

27210099 SUTURE, BLK MONO, 3‐0, 18 , FS $32.00

27210100 SUTURE,ETHILON, MONO, BLK, 4‐0 $36.00

27201911 TEGADERM, OVAL 4X4.75 $13.00 A6238

27201915 ADAPTIC, NON ADHESIVE 3X3 $4.00 A6222

27201921 XEROFORM, PETRO 5X9 $6.00 A6223

27201922 XEROFORM, PETRO 1X8 $5.00 A6222

27201924 TENDERWET, ROUND $107.00 A6242

27201925 TENDERWET, ACTIVE SQ $28.00 A6242

27201926 HYDRO TAC, NON ADHESIVE 4X4 $31.00 A6209

27201929 OPTIFOAM, SACRUM 6 X 5.5 $42.00 A6212

27201930 MEPITEL, CONTACT LAYER 2X3 $21.00 A6206

27201931 TEGEDERM, OVAL FOAM 7.5 X 9 $27.00 A6239

27201932 PURACOL+, AG 2X2 $39.00 A6021

27201933 PURACOL, COLLAGEN 2X2 $18.00 A6021

27201934 MAXORB, EXTRA 2X2 $9.00 A6196

27201935 OPTIFOAM, SILVER 4X4 $50.00 A6209

27201936 DUODERM, HYDROACTIVE 4X4 $16.00 A6234

27201937 ALGINATE, WOUND 4X4 $16.00 A6196

27201938 ROPE, SILVER ALGINATE $36.00 A6199

27201939 OPTIFOAM, 4X4 $29.00 A6212


2501000 COTININE, RANDOM UR $138.00 80323

2501002 CULTURE,STOOL,W/ISO,INCLUD ANA $149.00 87045

2501011 HEPATITIS B VIR GENOTYPING $1,105.00 87912

2501020 FREE TEST,CAL, BY LCMSMS $123.00 84402

2501026 TRICHINELLA AB, IgC (TRICAB) $248.00 86784

2501032 FL NON INF AB TITER, EACH $16.00 86256

2501035 CHLAMYDIA, IgM X3 $16.00 86632

2501060 PREGNANCY TEST, URINE $137.00 81025

2501092 LEAD, WHOLE BLOOD $238.00 83655

2501106 IGE, TOTAL $124.00 82785

2501252 HEP B CORE AB, TOTAL $129.00 86704

2501297 PROTEIN TOTAL URINE, RANDOM $77.00 84156

2501351 PROTEIN ELECTROPHORSIS, SERUM $129.00 84165

2501361 CORTISOL, TOTAL $229.00 82533

2501366 METHYLMALONIC ACID, SERUM $266.00 83921

2501402 DIFFERENTIAL, MANUAL $81.00 85007

2501406 SEDIMENTATION RATE, AUTO $65.00 85652

2501443 CULTURE THROAT, BETA STREP SCR $131.00 87081

2501446 CULTURE,STOOL,AEROBIC W/ISOL $94.00 87045

2501585 CREATININE, OTHER SOURCE URINE $71.00 82570

2502003 URIC ACID, FLUID (URICFL) $50.00 84560

2502007 BLOOD,OCCLT,QUAL FECES NO SCRN $69.00 82272

2502016 OPIATES, 1 OR MORE $66.00 80361

2502024 ZINC,URINE (URZN) $0.00

2502030 MUSCLE‐SPEC AUTOANTIBODY $1,153.00 83519

2502031 STRIATED MUSCLE AB, IgC $133.00 86255

2502037 HEAVY METAL 4,WHOLE BLOOD $0.00

2502043 SELENIUM, SERUM $130.00 84255

2502045 COTININE, SERUM (COTQ) $134.00 80307

2502049 COTININE, SERUM (COTQ) $134.00 80307

2502050 HEAVY METALS 4, WHOLE BLOOD $0.00

2502051 MERCURY, QUANTITATIVE $50.00 83825

2502054 STREP PNEUMO ABS, IgG (ASP23G) $792.00 86609

2502056 LACTOFERRIN, FECAL $149.00 83631

2502067 FREE K&L LIGHT CHAINS, QUANT $104.00 83883

2502068 CALCIUM, 24‐HR URINE $15.00 82340

2502070 PORPHYRINS, TOT $115.00 846311

2502071 CALCULI, URINARY $35.00 82360

2502072 CRYPTOCOCCUS ANTIBOD, QUANT $97.00 86641

2502075 COCCIDIODES AB, IgM $111.00 86635

2502076 COCCIDIOIDES, Ab, IgG $111.00 86635

2502078 CULTURE, CHLAMYDIA, ANY SOURCE $36.00 87110

2502079 CULTURE,TYP,IF METHOD, EACH $36.00 87140

2502097 HSV, AMPLIFIED PROBE TECHNIQUE $56.00 87529

2502103 REVERSE T3, SERUM $480.00 84482

2502108 THROMBIN TIME, PLASMA $124.00 85670

2502109 THROMB INHIBITION, TISSUE $124.00 85705

2502111 LUPUS ANTICOAG, COMP PANEL $0.00

2502120 pH, URINE $25.00 83986

2502121 POSTASSIUM, URINE 24‐HOUR $17.00 84133

2502122 CHLORIDE, URINE 24‐HOUR $15.00 82436

2502125 IMMUNOFIXATION, SERUM $53.00 86334

2502126 CULTURE, ANY SOURCE W/ISO $124.00 87116

2502127 SMEAR, FLUORESCENT &/OR STAIN $124.00 87206

2502129 IMMUNOFIXATION, URINE $103.00 86335

2502132 PROTEIN, BODY FLUID $15.00 84157

2502133 GLUCOSE, BODY FLUID $13.00 82945

2502134 FECAL FAT, QUAL $17.00 82705

2502137 CHROMIUM, PLASMA $140.00

2503040 HCG QUANTITATIVE, BETA $325.00 84702

2503041 PREGNANCY TEST, SERUM $152.00 84703

2503102 INSULIN, TOTAL $124.00 83525

2503117 REDUCING SUBSTANCES, STOOL $82.00 84376

2503144 CELIAC PANEL, EXTENDED $0.00

2503147 CORTISOL, RANDOM $223.00 82533

2503153 RHEUMATOID FACTOR IGM, IGG & I $102.00 83520

2503161 IMMUNOGLOBULINS, A, G & M $124.00 82784

2503167 CHLAMYDIA, ANTIBODY PANEL. IGG $0.00

2503179 LACTOFERRIN , FECAL BY ELISA $134.00 83630

2503188 CORTISOL FREE, URINE 24 HR LC $56.00 82530

2503217 HEP A VIRUS AB,IGM $158.00 86709

2503232 VIT D2 D3, 25‐HYDROXY BY LC‐MS $180.00 82306

2503302 MARFAN SYNDROME SEQUENCING $2,261.00 81408

3101592 30 DAY EVENT MONITOR‐TECH COMP $1,197.00 93270

4101713 MRI ORBIT‐FACE AND/OR NECK W/O $2,973.00 70540TC

4101714 MRI ORBIT FACE NECK W/CONT $4,864.00 70543TC

4101715 MRA HEAD W/O CONTRAST $3,297.00 70544TC

4101716 MRI BRAIN W/O CONTRAST $3,545.00 70551TC

4101717 MRI BRAIN W & W/O CONTRAST $5,213.00 70553TC

4101718 MRI CERVICAL SPINE W/O CONTRAS $3,341.00 72141TC

4101719 MRI THORACIC SPINE W/O CONTRAS $3,355.00 72146TC

4101720 MRI LUMBAR SPINE W/O CONTRAST $3,469.00 72148TC

4101721 MRI CERVICAL SPINE W & W/O CON $4,550.00 72156TC

4101722 MRI THORACIC SPINE W & W/O CON $4,618.00 72157TC

4101723 MRI LUMBAR SPINE W & W/O CONT $5,033.00 72158TC

4101724 MRI PELVIS W/O CONTRAST $3,647.00 72195TC

4101725 MRI PELVIS W/O CONT THEN W/CON $5,235.00 72197TC

4101726 MRI UPPER EXT NO JT W/O CONT L $3,455.00 73218LTTC

4101727 MRI UP EXT NO JT W&W/O CONT L $3,520.00 73220LTTC

4101728 MRI UPPER EXT JOINT W/O CONT L $3,259.00 73221LTTC

4101729 MRI UP EXT JOINT W&W/O CONT L $3,747.00 73223LTTC

4101730 MRI LOW EXT NO JOINT W/O CON L $3,376.00 73718LTTC

4101731 MRI LOW EXT NO JT W&W/O CONT L $4,692.00 73720LTTC

4101732 MRI LOWER EXT JOINT W/O CONT L $3,076.00 73721LTTC

4101733 MRI LOW EXT JT W&W/O CONT L $2,782.00 73723LTTC

4101734 MRI ABDOMEN W/O CONTRAST $2,745.00 74181TC

4101736 MRI UPPER EXT NO JT W/O CONT R $3,455.00 73218RTTC

4101737 MRI UP EXT NO JT W&W/O CONT R $3,520.00 73220RTTC

4101738 MRI UPPER EXT JOINT W/O CONT R $3,259.00 73221RTTC

4101739 MRI UP EXT JOINT W&W/0 CONT R $3,747.00 73223RTTC

4101740 MRI LOW EXT NO JOINT W/O CON R $3,376.00 73718RTTC

4101741 MRI LOW EXT NO JT W&W/O CONT R $4,692.00 73720RTTC

4101742 MRI LOWER EXT JOINT W/O CONT R $3,076.00 73721RTTC

4101743 MRI LOW EXT JT W&W/O CONT R $2,782.00 73723RTTC

4101744 MRA NECK WITH CONTRAST $2,758.00 70548TC

4101745 MRA NECK W & W/O CONTRAST $5,913.00 70549TC

4101746 MRI ABDOMEN W & WO CONTRAST $6,519.00 74183TC

4101748 MRI BRAIN W/CONT $3,797.00 70552TC

4101750 MRI ABDOMEN WITH CONTRAST $5,790.00 74182TC

4101803 MRA NECK W/O CONTRAST $2,700.00 70547TC

4101804 MRI CERVICAL SPINE W/CONTRAST $3,374.00 72142TC

4101805 MRI THORACIC SPINE W/CONTRAST $3,925.00 72147TC

4101806 MRI LUMBAR SPINE W/CONTRAST $3,253.00 72149TC

4101807 MRI PELVIS WITH CONTRAST $3,253.00 72196TC

4101808 MRI UP EXT NO JT W/CONT R $3,166.00 73219RTTC

4101809 MRI UP EXT NO JT W/CONT L $3,166.00 73219LTTC

4101810 MRI UP EXT JT W/CONT R $3,166.00 73222RTTC

4101811 MRI UP EXT JT W/CONT L $3,166.00 73222LTTC

4101812 MRI LOW EXT NO JT W/CONT R $3,950.00 73719RTTC

4101813 MRI LOW EXT NO JT W/CONT L $3,950.00 73719LTTC

4101814 MRI LOW EXT JT W/CONT R $3,201.00 73722RTTC

4101815 MRI LOW EXT JT W/CONT L $3,201.00 73722LTTC

4101816 MRA ABD WITH OR W/O CONTRAST $3,222.00 74185TC

4201001 CT OUT MIDDLE EAR W/O CONT L $2,435.00 70480LTTC

4201002 CT OUT MIDDLE INNER EAR W/CO L $2,923.00 70481LTTC

4201003 CT LOWER EXTREMITY W/O CONT R $1,299.00 73700RTTC

4201004 CT OUT MIDDLE EAR W&W/O CONT R $2,081.00 70482RTTC

4201730 CT LOWER EXTREM W&W/O CONT L $2,342.00 73702LTTC

4201731 CT UPPER EXTREM W&W/O CONT L $2,375.00 73202LTTC

4201732 CT LOWER EXTREMITY W/O CONT R $2,018.00 73700RTTC

4201733 CT UPPER EXTREMITY W/CONT R $2,008.00 73201RTTC

4201734 CT UPPER EXTREMITY W/O CONT R $1,911.00 73200RTTC

4201737 CT HEAD OR BRAIN W/O CONTRAST $1,700.00 70450TC

4201738 CT HEAD OR BRAIN WITH CONTRAST $2,007.00 70460TC

4201739 CT HEAD OR BRAIN W & W/O CONTR $2,923.00 70470TC

4201740 CT OUT MIDDLE EAR W/O CONT R $2,435.00 70480RTTC

4201741 CT OUT MIDDLE INNER EAR W/CO R $2,923.00 70481RTTC

4201742 CT OUT MIDDLE EAR W&W/O CONT L $2,081.00 70482LTTC

4201743 CT MAXILLOFACIAL W/O CONTRA $1,898.00 70486TC

4201744 CT MAXILLOFACIAL W/CONTRAST $2,002.00 70487TC

4201745 CT MAXILLOFACIAL W&W/O CONTRAS $2,393.00 70488TC

4201746 CT SOFT TISSUE NECK W/O CONTRA $2,167.00 70490TC

4201747 CT SOFT TISSUE NECK W/ CONTRAS $2,410.00 70491TC

4201748 CT SOFT TISSUE NECK W&W/O CONT $2,698.00 70492TC

4201749 CT CHEST W/O CONTRAST $2,124.00 71250TC

4201750 CT CHEST W/CONTRAST $2,724.00 71260TC

4201751 CT CHEST W & W/O CONTRAST $3,735.00 71270TC

4201752 CT CERVICAL SPINE W/O CONTRAST $2,331.00 72125TC

4201753 CT CERVICAL SPINE W/CONTRAST $2,502.00 72126TC

4201754 CT CERVICAL SPINE W&W/O CONTRA $3,103.00 72127TC

4201755 CT THORACIC SPINE W/O CONTRAST $2,254.00 72128TC

4201756 CT THORACIC SPINE W/CONTRAST $2,493.00 72129TC

4201757 CT THORACIC SPINE W&W/O CONTRA $2,654.00 72130TC

4201758 CT LUMBAR SPINE W/O CONTRAST $2,600.00 72131TC

4201759 CT LUMBAR SPINE W/ CONTRAST $3,197.00 72132TC

4201760 CT LUMBAR SPINE W&W/O CONTRAST $3,679.00 72133TC

4201761 CT PELVIS W/O CONTRAST $2,262.00 72192TC

4201762 CT PELVIS W/CONTRAST $2,738.00 72193TC

4201763 CT PELVIS W&W/O CONTRAST $3,471.00 72194TC

4201764 CT UPPER EXTREMITY W/O CONT L $1,911.00 73200LTTC

4201765 CT UPPER EXTREMITY W/CONT L $2,008.00 73201LTTC

4201766 CT UPPER EXTREM W&W/O CONT R $2,375.00 73202RTTC

4201767 CT LOWER EXTREMITY W/O CONT L $1,299.00 73700LTTC

4201768 CT LOWER XTREMITY W/CONTRAST L $2,018.00 73701LTTC

4201769 CT LOWER EXTREM W&W/O CONT R $2,342.00 73702RTTC

4201770 CT ABDOMEN W/O CONTRAST $1,925.00 74150TC

4201771 CT ABDOMEN W/CONTRAST $2,701.00 74160TC

4201772 CT ABDOMEN W/O&W/CONTRAST $3,736.00 74170TC

4201773 3D RENDERING $1,078.00 76376TC

4201775 CT UPPER EXTREMITY W/CONT R $1,911.00 73201RTTC

4201778 CT LOWER XTREMITY W/CONTRAST R $2,018.00 73701RTTC

4201780 CT ABDOMEN & PELVIS W/O CONT $4,733.00 74176TC

4201781 CT ABDOMEN & PELVIS W/CONT $5,148.00 74177TC

4201782 CT ABDOMEN & PELVIS W AND W/O $5,397.00 74178TC

4001000 XR HIP,UNI, W/PELVIS MIN 4V LT $516.00 73503LTTC

4001004 XR HIP,UNI, W/PELVIS MIN 4V RT $516.00 73503RTTC

4001635 XR SKULL, AP AND LAT $291.00 70250TC

4001640 XR MANDIBLE, 4 OR MORE $311.00 70110TC

4001642 XR MASTOID, COMPLETE $345.00 70130TC

4001646 XR RIBS, UNILATERAL LT $492.00 71101LTTC

4001649 XR RIBS, BILATERAL $636.00 71111TC

4001652 XR THORACIC SPINE, COMPLETE $703.00 72072TC

4001677 XR KNEE, 4 VIEWS LT $490.00 73564LTTC

4001678 XR KNEE, AP & LAT LT $516.00 73560LTTC

4001701 XR T‐SPINE, AP AND LAT $502.00 72070TC

4001702 XR TMJ, BILATERAL $331.00 70330TC

4001715 XR RIBS, UNILATERAL RT $492.00 71101RTTC

4001729 XR KNEE, 4 VIEWS RT $490.00 73564RTTC

4001730 XR KNEE, AP & LAT RT $516.00 73560RTTC

4001800 DXA BONE DENSITY, AXIAL $549.00 77080TC

4001801 DXA BONE DENSITY, PERIPHERAL $221.00 77081TC

4001802 DXA BONE DENSITY, VERT FX $191.00 77086TC

4001807 DXA, BODY COMPOSITION SCAN $298.00 76499TC

4001809 XR CHEST, 1 VIEW $305.00 71045TC

4001810 XR CHEST, 2 VIEWS $365.00 71046TC

4001811 XR CHEST, 3 VIEWS $452.00 71047TC

4001812 XR ABDOMEN, 1 VIEW $466.00 74018TC

4001813 XR ABDOMEN, 2 VIEWS $535.00 74019TC

4001814 XR ABDOMEN, 3 VIEWS $603.00 74021TC

4301000 US VENOUS DPLR LOW EXT BIL $1,168.00 93970TC

4301003 US CAROTID BILATERAL $1,283.00 93880TC

4301006 US ABDOMEN LIMIT (RUQ,HRN,PS) $646.00 76705TC

4301019 DUPLEX SCAN PELVIC ETC COMP $1,787.00 93975TC

4301020 DUPLEX SCAN AORTA COMPLETE $1,209.00 93978TC

4301022 2D ECHO TRANSTHORACIC COMPLETE $1,444.00 93306TC

4301025 2D ECHO PED CONGENITAL COMPLET $1,498.00 93303TC

4301027 2D ECHO STRESS $1,714.00 93351TC

3500250 NYSTATIN 100,000 UNITS/G CRM $0.00

3500251 NYSTATIN 100,000 UNITS/G PWD $0.00

3500252 NYSTATIN 500,000 UN/5ML SUSP $0.00

3501078 INFLUENZA VIRUS VACCINE, SEASO $0.00

3501632 SET,CONTINU‐FLO SOLUTION $0.00

3501633 BLANKET, HUGGER $0.00

3503857 NYSTATIN TOP CM 100,000 U/GM $0.00

3503458 MULTIPLE VITAMINS, ADULT, IV P $0.00 J3415

3503855 EPOGEN 10,000 UNITS $0.00 J0885

3504012 EPOETIN ALFA 20,000 UNITS/ML $0.00 J0885

3001645 ABI SEGMENTAL $1,449.00 93923

3001614 CPR $1,589.00 92950

3001650 CARDIOVASCULAR STRESS TEST (TR $1,049.00 93015

1202029 APP SKIN SUB 1ST 100 SQ CM $1,470.00

1202030 APP SKIN SUB EACH ADD 100 SQCM $1,176.00

1202035 FAC W/C DEB,OPEN 1ST 20SQCM< $340.00 97597

1202036 FAC W/C DEB,OPEN EA ADD 20SQCM $272.00 97598

1202037 FAC W/C DEB,SUBQ 1ST 20SQCM< $649.00 11042

1202038 FAC W/C DEB,MUS 1ST 20SQCM< $1,004.00 11043

1202039 FAC W/C DEB,BONE 1ST 20SQCM< $2,055.00 11044

1202040 FAC W/C DEB,SUBQ EA ADD 20SQCM $519.00 11045

1202041 FAC W/C DEB,MUS EA ADD 20SQCM $804.00 11046

1202042 FAC W/C DEB,BONE EA ADD 20SQCM $1,644.00 11047

1202051 FAC W/C I&D SINGLE, SIMPLE $340.00 10060

1202052 FAC W/C I&D COMPLICATED,MULTI $649.00 10061

1202076 FAC W/C I&D PILON CYST SIMPLE $1,195.00 10080

1202077 FAC W/C I&D PILON CYST COMPLC8 $1,195.00 10081

1202079 FAC W/C INC/REM FB SUBQ COMPLC $2,055.00 10121

1202080 FAC W/C I&D HEMATOMA, SEROMA $2,055.00 10140

1202082 FAC W/C I&D COMPLEX, PO INFECT $3,570.00 10180

1202083 FAC W/C EPI AG 1ST 100SQCM OR< $3,163.00 15110

1202084 FAC W/C EPI AG EA ADD 100SQCM $2,531.00 15111

1202085 FAC W/C EPI AG FACE ETAL 100< $3,163.00 15115

1202086 FAC W/C EPI AG FACE ETAL AD100 $2,531.00 15116

1202087 FAC W/C APP SKIN SUB 1ST 25SQ $1,551.00 15271

1202088 FAC W/C APP SKIN SUB EA ADD 25 $1,242.00 15272

1202089 FAC W/C APP SKIN SUB 1ST 100SQ $5,141.00 15273

1202090 FAC W/C APP SKIN SUB EA ADD100 $4,113.00 15274

1202092 FAC W/C SKIN SUB UP TO 100SQCM $3,461.00 15275

1204035 PF W/C DEB,OPEN 1ST 20SQCM< $67.00 97597

1204036 PF W/C DEB,OPEN EA ADD 20SQCM $32.00 97598

1204037 PF W/C DEB,SUBQ 1ST 20SQCM< $174.00 11042

1204038 PF W/C DEB,MUS 1ST 20SQCM< $436.00 11043

1204039 PF W/C DEB,BONE 1ST 20SQCM< $644.00 11044

1204040 PF W/C DEB,SUBQ EA ADD 20SQCM $74.00 11045

1204041 PF W/C DEB,MUS EA ADD 20SQCM $157.00 11046

1204042 PF W/C DEB,BONE EA ADD 20SQCM $278.00 11047

1204051 PF W/C I&D SINGLE, SIMPLE $276.00 10060

1204052 PF W/C I&D COMPLICATED, MULTI $504.00 10061

1204080 PF W/C I&D HEMATOMA, SEROMA $333.00 10140

1204082 PF W/C I&D COMPLEX, PO INFECT $497.00 10180

1204083 PF W/C WPI AG 1ST 100SQCM OR< $1,928.00 15110

1204085 PF W/C EPI AG FACE ETAL 100< $1,953.00 15115

5003002 IONTOPHORESIS, EACH 15 MIN $77.00 97033GP

6001835 IV THERAPY, CONCURRENT INF EA $179.00 96372

6001837 IV INFUSION, EA ADD'L DRUG $254.00 96367

6001843 ER FACILITY LEVEL 5 $3,057.00 99285

6001848 ER FACILITY LEVEL 4 $1,487.00 99284

6101854 F FB COMPLICATED SUB‐Q $1,645.00 10121

6101855 F I&D HEMATOMA SIMP $1,645.00 10140

6101868 F SHAVE SKIN LESION,TRUNK/ARM/ $293.00 11300

6101869 F SHAVE SKIN LES SCALP,NECK,GE $301.00 11305

6101872 F EXC SCLP/NECK/HAND/FT 1.5 OR $1,645.00 11420

6101881 F SIMP REP < 2.5CM SCALP,NECK, $267.00 12001

6101882 F SIMP REP 2.6/7.5CM SCALP,NEC $325.00 12002

6101883 F SIMP REP 7.6/12.5CM SCALP,NE $382.00 12004

6101884 F SIMP REP 12.6/20.0CM SCALP,N $488.00 12005

6101885 F SIMP REP 20.1/30.0CM SCALP,N $566.00 12006

6101886 F SIMP REP <2.5CM FACE,EAR,EYE $327.00 12011

6101887 F SIMP REP 2.6/5.0CM FACE,EARS $341.00 12013

6101888 F SIMP REP 5.1/7.5CM FACE, EAR $397.00 12014

6101889 F SIMP REP 7.6/12.5CM FACE,EAR $480.00 12015

6101890 F SIMP REP 12.6/20.0CM FACE,EA $607.00 12016

6101891 F SIMP REP 20.1/30.0CM FACE,EA $488.00 12017

6101892 F SIMP REP > 30.0 CM FACE, EAR $597.00 12018

6101898 F INTER REPAIR 12.6‐20.0 CM $1,141.00 12035

6101899 F INTER REPAIR 20.1‐30 CM $1,249.00 12036

6101900 F INTER REPAIR OVER 30 CM $4,163.00 12037

6101905 F INTER REPAIR 20.1‐30 CM $1,346.00 12046


6101910 F INTER REPAIR 7.6‐12.5 CM $1,109.00 12054

6101911 F INTER REPAIR 12.6‐20 CM $1,330.00 12055

6101912 F INTER REPAIR 20.0‐30 CM $1,640.00 12056


6101915 F COMPLEX REPAIR 206‐7.5 CM $1,128.00 13101

6101917 F COMPLEX REPAIR 2.6‐7.5 CM $1,164.00 13121





6101923 F SECONDARY CLOSURE $2,373.00 13160

6101934 F REMOVE FB MUSCLE/TENDON $1,645.00 20520

6101940 F NASAL FX SEPTUM $2,890.00 21337

6101946 F REMOVAL FB SUB‐Q $1,645.00 24200

6101947 F REDUCE CLSD ELB W/O ANES $1,029.00 24600

6101951 F DISTAL RADIAL FX W/MANIP $1,620.00 25605

6101961 F PATELLA DISLOC NO ANES $1,427.00 27550

6101962 F CLOSED TX PATELLAR DISLOCATE $1,025.00 27560

6101963 F CLOSED TX ANKLE DISLOCATION $1,043.00 27840

6101985 F CHEST TUBE INSERTION $2,262.00 32550

6101987 F SUBS CONTROL NASAL HEMO PST $1,011.00 30906

6101993 F PERICARDIOCENTESIS $1,138.00 33010

6101996 F N/G TUBE PLACEMENT $1,775.00 43246

6101998 F PROCTOSIGMOIDOSCOPY DX $1,110.00 45300

6101999 F ANAL ABSCESS INCISION $1,110.00 46050

6102000 F EXC THROMBOSED HEMORRHOID EX $1,459.00 46320

6102008 F VAGINAL DELIVERY $2,774.00 59409

6102011 F INTERCOSTAL BLOCK MULTIPLE $1,063.00 64421

6102039 F CLOSED TX ANKLE FX NO MANIP $1,242.00 27786

6102040 F CLOSED TX ARTIC FX W/MANIP $1,141.00 26742

6102043 F IMMUN ADMIN, 1 VACCINE $51.00 90471

6102048 F CLOSE TX SCAPULAR FX W/MANIP $1,113.00 23575

6102049 F CLS TX SHOULDER DIS MAN ANES $1,196.00 23655

6102051 F CLSED TX FEM SHAFT FX W/MAN $1,783.00 27502

6001868 SHAVE SKIN LESION,TRUNK/ARM/LG $280.00 11300

6001869 SHAVE SKIN LES SCALP,NECK, GEN $286.00 11305

6001881 SIMP REP < 2.5CM SCALP,NECK,EX $255.00 12001

6001882 SIMP REP 2.6/7.5CM SCALP,NECK $309.00 12002

6001883 SIMP REP 7.6/12.5CM SCALP,NECK $363.00 12004

6001884 SIMP REP 12.6/20.0CM SCALP,NCK $456.00 12005

6001885 SIMP REP 20.1/30.0CM SCALP,NEC $540.00 12006

6001886 SIMP REP <2.5CM FACE,EAR,EYELD $311.00 12011

6001887 SIMP REP 2.6/5.0CM FACE,EARS $325.00 12013

6001888 SIMP REP 5.1/7.5CM FACE, EARS $378.00 12014




6001892 SIMP REP > 30.0 CM FACE, EARS $569.00 12018

6001898 INTER REPAIR 12.6‐20.0 CM $1,086.00 12035

6001899 INTER REPAIR 20.1‐30 CM $1,190.00 12036

6001900 INTER REPAIR OVER 30 CM $1,347.00 12037

6001903 INTER REPAIR 7.6‐12.5 CM $1,023.00 12044

6001904 INTER REPAIR 12.6‐20.0 CM $1,146.00 12045

6001905 INTER REPAIR 20.1‐30 CM $1,346.00 12046


6001910 INTER REPAIR 7.6‐12.5CM $1,109.00 12054

6001911 INTER REPAIR 12.6‐20 CM $1,330.00 12055

6001912 INTER REPAIR 20.0‐30 CM $1,640.00 12056


6001915 COMPLEX REPAIR 2.6‐7.5 CM $1,128.00 13101

6001917 COMPLEX REPAIR 2.6 ‐ 7.5 CM $1,228.00 13121





6001923 SECONDARY CLOSURE $2,263.00 13160

6001940 NASAL FX SEPTUM $1,169.00 21337

6001947 REDUCTION CLSD ELB W/O ANSTHET $1,029.00 24600

6001951 FX‐DISTAL RAD W/MANIP $1,541.00 25605

6001961 PATELLA DISCOLATION NO ANESTH $1,427.00 27550

6001962 CLOSED TREAT PATELLAR DISLOCAT $1,025.00 27560

6001963 CLST TRMT OF ANKLE DISLOCATION $1,043.00 27840

6001985 CHEST TUBE INSERTION $2,262.00 32550

6001987 SUBSEQUENT NASAL HEM CONTROL $1,011.00 30906

6002008 VAGINAL DELIVERY $2,638.00 59409

6002034 CRIT CARE PROFEE 1ST 30‐74M $1,101.00 99291

6002039 CLOSED TX ANKLE FX NO MANIP $1,242.00 27786

6002040 CLOSED TX ART FX W/JT & MANIP $1,141.00 26742

6002043 CRUTCHES,FOREARM,PAIR $104.00 E0110

6002044 CRUTCHES,UNDERARM, ADJ, PAIR $97.00 E0114

6002048 CLOSED TX SCAPULAR FX W/MANIP $1,018.00 23575

6002049 CLOSE TX SHOULDER DIS MAN ANES $1,095.00 23655

6002051 CLOSED TX FEMORAL SHAFT FX/MAN $1,647.00 27502

1501005 IV INFUSION, EA ADD'L HR $252.00 96366

1501006 IV INFUSION, THERAPY, 1 HOUR $598.00 96365

1501007 INFUSION, HYDRATION THERAPY $561.00 96360

1501008 INFUSION, HYDRATION EA HR $216.00 96361

1501010 IV THERAPY, ADDL SEG INF $254.00 96367

1501011 IV THERAPY, CONCURRENT INF $252.00 96368

1501012 THERAPEUTIC INJECTION, IM $179.00 96372

1501013 THERAPEUTIC INJECTION, IA $152.00 96373

1501017 BLOOD ADMINISTRATION ‐ 1 UNIT $1,541.00 36430

CFC11102 TANGENTIAL SKIN BIOPSY, SINGLE $250.00 11102

CFC11900 INJ INTRALESIONAL,UP TO 7 LES $96.00 11900

CFC12017 RPR FE/E/EN/L/M 20.1‐30.0 CM $1,169.00 12017

CFC12018 RPR F/E/E/N/L/M >30.0 CM $1,446.00 12018

CFC12036 INTMD RPR S/A/T/EXT 20.1‐30 $1,086.00 12036

CFC12037 INTMD RPR S/TR/EXT >30.0 CM $1,263.00 12037

CFC12046 INTMD RPR N‐HF/GENIT20.1‐30 $1,157.00 12046

CFC12047 INTMD RPR N‐HF/GENIT >30.0CM $1,318.00 12047

CFC12054 INTMD RPR FACE/MM 7.6‐12.5CM $1,117.00 12054

CFC12055 INTMD RPR FACE/MM 12.6‐20 CM $1,235.00 12055

CFC12056 INTMD RPR FACE/MM 20.1‐30.0 $1,650.00 12056

CFC12057 INTMD RPR FACE/MM >30.0 CM $1,874.00 12057

CFC14061 SKIN TISSUE REARRANGEMENT $2,075.00 14061

CFC17108 DESTRUCTION OF SKIN LESIONS $1,310.00 17108

CFC17272 DESTRUCTION OF SKIN LESION, De $383.00 17272

CFC24500 TREAT HUMERUS FRACTURE $1,002.00 24500

CFC25622 TREAT WRIST BONE FRACTURE $1,399.00 25622

CFC26600 TREAT METACARPAL FRACTURE $1,154.00 26600

CFC26605 TREAT METACARPAL FRACTURE $1,349.00 26605

CFC27750 TREATMENT OF TIBIA FRACTURE $1,375.00 27750

CFC27786 TREATMENT OF ANKLE FRACTURE $1,242.00 27786

CFC28190 REMOVE FOREIGN BODY,FOOT,SUBQ $807.00 28190

CFC28450 TREAT MIDFOOT FRACTURE EACH $1,154.00 28450

CFC36015 PLACE CATHETER IN ARTERY $1,836.00 36015

CFC46083 INC THROMB HEMORRHOID, EXT $549.00 46083

CFC53445 INSERT URO/VES NCK SPHINCTER $1,536.00 53445

CFC82272 BLOOD,OCCLT,QUAL FECES NO SCRN $69.00 82272

CFC90672S F INFLUENZA QUAD, LIVE, NASAL $0.00 90672SL

CFC90681S F ROTOVIRUS, 2 DOSE ORAL $126.00 90681

CFC96372 THERAPEUTIC INJECTION, IM $54.00 96372

CFC99201 OFFICE/OUTPATIENT VISIT, NEW $156.00 99201





CFC99211 OFFICE/OUTPATIENT VISIT, EST $90.00 99211





CFCA4467 BELT, STRAP, SLEEVE, GARMENT $49.00 A4467

CFCG0436 SMOKING CESSATION, 10 MINUTES $43.00 G0436

CFCL3900 WHFO DYN FLX HNG WRST DRVN CST $1,835.00 L3900

CFCL4387L G WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

CFCL4387M D WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

CFCL4387S M WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

CFCL4387X L WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

CFCL4387X S WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

CFCS9445 PT ED, NOC, NON‐PHYS PROV $90.00 S9445

CFCT1015 OFFICE VISIT, ALL INCLUSIVE $0.00

WFC11102 TANGENTIAL SKIN BIOPSY, SINGLE $250.00 11102

WFC11900 INJ, INTRALESIONAL UP TO 7 LES $96.00 11900

WFC12017 RPR FE/E/EN/L/M 20.1‐30.0 CM $1,169.00 12017

WFC12018 RPR F/E/E/N/L/M >30.0 CM $1,446.00 12018

WFC12036 INTMD RPR S/A/T/EXT 20.1‐30 $1,086.00 12036

WFC12037 INTMD RPR S/TR/EXT >30.0 CM $1,263.00 12037

WFC12046 INTMD RPR N‐HF/GENIT20.1‐30 $1,157.00 12046

WFC12047 INTMD RPR N‐HF/GENIT >30.0CM $1,318.00 12047

WFC12054 INTMD RPR FACE/MM 7.6‐12.5CM $1,117.00 12054

WFC12055 INTMD RPR FACE/MM 12.6‐20 CM $1,235.00 12055

WFC12056 INTMD RPR FACE/MM 20.1‐30.0 $1,650.00 12056

WFC12057 INTMD RPR FACE/MM >30.0 CM $1,874.00 12057

WFC14061 SKIN TISSUE REARRANGEMENT $2,075.00 14061

WFC17108 DESTRUCTION OF SKIN LESIONS $1,310.00 17108

WFC17272 DESTRUCTION OF SKIN LESION, De $383.00 17272

WFC24500 TREAT HUMERUS FRACTURE $1,002.00 24500

WFC25622 TREAT WRIST BONE FRACTURE $1,399.00 25622

WFC26600 TREAT METACARPAL FRACTURE $1,154.00 26600

WFC26605 TREAT METACARPAL FRACTURE $1,349.00 26605

WFC27750 TREATMENT OF TIBIA FRACTURE $1,375.00 27750

WFC27786 TREATMENT OF ANKLE FRACTURE $1,242.00 27786

WFC28190 REMOVE FOREIGN BODY,FOOT,SUBQ $807.00 28190

WFC28450 TREAT MIDFOOT FRACTURE EACH $1,154.00 28450

WFC36015 PLACE CATHETER IN ARTERY $1,836.00 36015

WFC4387XS WALK BOOT,NON‐PNEUM W/WO JOINT $134.00

WFC53445 INSERT URO/VES NCK SPHINCTER $1,536.00 53445

WFC82272 BLOOD,OCCLT,QUAL FECES NO SCRN $69.00 82272

WFC90672S F INFLUENZA QUAD, LIVE, NASAL $0.00 90672

WFC96372 THERAPEUTIC INJECTION, IM $54.00 96372

WFC99201 OFFICE/OUTPATIENT VISIT, NEW $156.00 99201





WFC99211 OFFICE/OUTPATIENT VISIT, EST $90.00 99211





WFCA4467 BELT, STRAP, SLEEVE, GARMENT $49.00 A4467

WFCG0436 SMOKING CESSATION, 10 MINUTES $43.00 G0436

WFCL3900 WHFO DYN FLX HNG WRST DRVN CST $1,835.00 L3900

WFCL4387L G WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

WFCL4387M D WALK BOOT,NON‐PNUM W/WO JOINT $134.00 L4387

WFCL4387S M WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

WFCL4387X L WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

WFCL4387X S WALK BOOT,NON‐PNEUM W/WO JOINT $134.00 L4387

WFCS9445 PT ED, NOC, NON‐PHYS PROV $90.00 S9445

WFCT1015 OFFICE VISIT, ALL INCLUSIVE $0.00

ACR0010002 ACUTE RESPITE ROOM $249.00

1001001 IP PROFEE LEVEL I (A/D SAME) $419.00 99234

1001002 IP PROFEE LEVEL II (A/D SAME) $601.00 99235

1001003 IP PROFEE LEVEL III (A/D SAME) $808.00 99236

1001004 IP PROFEE DSCHG UP TO 30 MIN $278.00 99238

1001005 IP PROFEE DSCHG 30+MIN $373.00 99239

1001009 INITIAL HOSP CARE PROFEE I $286.00 99221

1001010 INITIAL HOSP CARE PROFEE II $467.00 99222

1001011 INITIAL HOSP CARE PROFEE III $612.00 99223

1001012 SUB HOSP CARE PROFEE LEVEL I $178.00 99231

1001013 SUB HOSP CARE PROFEE LEVEL II $243.00 99232

1001014 SUB HOSP CARE PROFEE LEVEL III $352.00 99233

3101588 HOLTER PROFEE ONLY INPATIENT $194.00 93227

3101599 EKG PROFEE ONLY INPATIENT $187.00 93010

DNP0010005 NURSING HOME PRIVATE ROOM $263.00

DNS0010006 NURSING HOME SEMI‐PVT ROOM $234.00

ASB0010003 ACUTE SWING BED $452.00

ASB0010004 DGH HALL 1 SWB PRIVATE ROOM $263.00

ASB0010005 DGH HALL 1 SWB SEMI‐PVT ROOM $234.00

ASB0010006 ACUTE SWB TELEMETRY/ISOLATION $609.00

OBS0010007 OBSERVATION 1ST HOUR $432.00 G0378

OBS0010008 OBSERVATION 2‐24 HRS/HOUR $73.00 G0378

OBS0010009 OBSERVATION >24 HRS/HOUR $88.00 G0378

OBS0010010 OBS/TELE/ISO 1ST HOUR $467.00 G0378

OBS0010011 OBS/TELE/ISO 2‐24HRS./HOUR $81.00 G0378

OBS0010012 OBS/TELE/ISO >24 HRS./HOUR $97.00 G0378

OBS0010013 OBSERVATION DIRECT ADMISSION $368.00 G0379

1001006 OBS PROFEE LEVEL I (A/D SAME) $419.00 99234

1001007 OBS PROFEE LEVEL II(A/D SAME) $601.00 99235

1001008 OBS PROFEE LEVEL III(A/D SAME) $808.00 99236

1001100 OBS PROFEE DISCHARGE $725.00 99217

1001101 INITIAL OBS PROFEE LEVEL I $264.00 99218

1001102 INITIAL OBS PROFEE LEVEL II $450.00 99219

1001103 INITIAL OBS PROFEE LEVEL III $595.00 99220

1001104 SUBS OBS PROFEE LEVEL I $107.00 99224

1001105 SUBS OBS PROFEE LEVEL II $197.00 99225

1001106 SUBS OBS PROFEE LEVEL III $283.00 99226

27200208 OINTMENT A&D $11.00

27200240 50 ML .9% NORMAL SALINE $9.00

27200241 100ML 100% SALINE $9.00

27200242 250ML .9% NORMAL SALINE $12.00

27200243 500 ML .9% NORMAL SALINE $7.00

27200244 1000ML .9% NORMAL SALINE $10.00

27200245 1000 ML 0.45% NORMAL SALINE $9.00

27200246 1000 ML 5% DEXTROSE .9% SALINE $9.00

27200247 1000 ML D5 NS .45% $9.00

27200249 500ML D5 $8.00

27200250 1000 ML D5 $9.00

27200251 1000 ML LACTATED RINGERS $7.00

27200252 .9% SALINE IRRIGATION BOTTLE 2 $8.00

27200253 500 ML STERILE WATER $11.00

27200299 ENEMA OIL $14.00

27200300 ENEMA FLEET 4.5 OZ $10.00

27200301 PAD EGGCRATE 33 x 72 x 4 $155.00

27200302 STOCKING SMALL KNEE HIGH $35.00

27200303 STOCKING MEDIUM KNEE HIGH $21.00

27200304 STOCKING LARGE KNEE HIGH $21.00

27200305 STOCKING X‐LARGE KNEE HIGH $35.00

27200306 STOCKING X‐LARGE LONG KNEE HIG $32.00

27200307 STOCKING SMALL THIGH HIGH $46.00

27200308 STOCKING MEDIUM THIGH HIGH $64.00

27200309 STOCKING LARGE THIGH HIGH $32.00

27200310 STOCKING LARGE LONG THIGH HIGH $63.00

27200311 STOCKING XX‐LARGE THIGH HIGH $34.00

27200312 STOCKING XX‐L KNEE HIGH $20.00

27200346 SCOTCHCAST CASTING TAPE 3 WHI $28.00

27200374 AUTOGUARD 20G X 1.16 INSYTE P $13.00

27200375 AUTOGUARD 22G X 1 INSYTE BLUE $13.00

27200376 BIOPATCH $43.00

27200377 INJECTION SITE $10.00

27200394 ADAPTER LUER LOCK $6.00

27200395 SET PRIMARY EXTENSION $16.00

27200396 BLOOD TUBING Y‐TYPE BLOOD SOLU $35.00

27200397 IV CATHETER EXTENSION SET $20.00

27200398 PRIMARY TUBING‐NO FILTER $23.00

27200400 VENTED NITROGLYCERIN TUBING $35.00

27200401 SET CONTINU‐FLO SOLUTION 60ML $21.00

27200402 IV ADAPTER VIAL‐MATE $13.00

27200403 TRAY FOLEY CATHETER 15 FR $13.00

27200404 TRAY FOLEY CATHETER 16 FR $73.00

27200405 CATHETER 12FR FOLEY 2 WAY SILI $20.00

27200406 CATHETER 14FR FOLEY 2WAY SILIC $20.00

27200407 CATHETER 16FR FOLEY 5CC $24.00

27200408 CATHETER 18FR FOLEY 5CC $24.00

27200409 CATHETER MALE EXTERNAL STD $9.00

27200415 URINE DRAIN BAG $16.00

27200418 CATHETER STRAP ADULT $14.00

27200420 KIT FEMALE CATHETER $10.00

27200422 CATHETER 22FR FOLEY 3WAY 5CC $48.00

27200427 TRAY SUTURE REMOVAL $11.00

27200436 STAPLER SKIN DISPOSABLE $31.00

27200437 STAPLE REMOVER DISPOSABLE $17.00

27200438 TRAY IRRIGATION $13.00

27200441 TUBE SUCTION 12' CONNECTION $17.00

27200448 YANKAUER SUCTION $15.00

27200449 TRAY CATHETER 14 FR SUCTION $4.00

27200451 AEROCHAMBER DRUG DELIVERY $81.00

27200462 SUPPORT WRIST RIGHT SMALL $31.00

27200464 SUPPORT WRIST RIGHT MEDIUM $34.00

27200465 SUPPORT WRIST LEFT LARGE $34.00

27200466 SUPPORT WRIST RIGHT LARGE $31.00

27200467 SUPPORT ELBOW TENNIS $13.00

27200468 SLING ARM SMALL $12.00

27200469 SLING ARM MEDIUM $10.00

27200470 SLING ARM LARGE $10.00

27200471 SPLINT WRIST COCK‐UP SMALL $30.00

27200472 SPLINT WRIST COCK‐UP MEDIUM $28.00

27200473 SPLINT COLLES LEFT SMALL $27.00

27200474 SPLINT COLLES RIGHT SMALL $28.00

27200475 SPLINT COLLES LEFT MEDIUM $26.00

27200476 SPLINT COLLES RIGHT MEDIUM $30.00

27200477 SPLINT COLLES LEFT LARGE $30.00

27200478 SPLINT COLLES RIGHT LARGE $26.00

27200479 BRACE ANKLE STIRRUP UNIVERSAL $67.00

27200480 BRACE ANKLE SMALL SWEDE STRAP $144.00

27200481 BRACE ANKLE MEDIUM SWEDE STRAP $144.00

27200482 BRACE ANKLE LG SWEDE STRAP $144.00

27200483 BOOT CAST MEDIUM WEATHERPROOF $32.00

27200484 BOOT CAST SANDLE SMALL $50.00

27200485 BOOT CAST SANDAL MEDIUM $31.00

27200486 BOOT CAST SANDAL LARGE $32.00

27200487 UNIVERSAL 4 CERVICAL COLLAR $34.00

27200488 SMALL CERVICAL PHILLY 5‐1/4X10 $53.00

27200490 LARGE PHILLY COLLAR 5‐1/4X14‐1 $53.00

27200491 RIB BELT MALE SMALL $29.00

27200494 CLAVICLE X‐SMALL HEAVY PADDED $37.00

27200495 CLAVICLE XXSMALL SPLINT $37.00

27200496 CLAVICLE SMALL SPLINT $37.00

27200497 CLAVICLE MEDIUM SPLINT $37.00

27200498 CLAVICLE LARGE SPLINT $37.00

27200499 CLAVICLE X‐LARGE SPLINT $37.00

27200500 CLAVICLE UNIVERSAL SPLINT $50.00

27200501 KNEE SLEEVE OPEN PATELLA X‐LAR $29.00

27200502 KNEE SLEEVE OPEN PATELLA SMALL $32.00

27200503 KNEE SLEEVE OPEN PATELLA MEDIU $32.00

27200504 KNEE SLEEVE OPEN PATELLA LARGE $29.00

27200508 SPLINT KNEE 16 3 PANEL $78.00

27200509 SPLINT KNEE 24 3 PANEL $97.00

27200510 UNIVERSAL SHOULDER IMMOBILIZER $41.00

27200513 IMMOBILIZER SHOULDER MALE X‐LA $33.00

27200549 GLUCOSE TOLERANCE BEVERAGE 100 $23.00

27200613 AUTOGUARD 18G X 1.16 INSYTE G $11.00

27200616 SEAT RAISED TOILET WHITE PLAST $64.00

27200625 CATHETER 20FR 3WAY 5CC $48.00

27200635 ABDOMINAL BINDER LG/XL 9 46 $42.00

27200636 ABDOMINAL BINDER SM/MD 9 30 $33.00

27200637 BINDER ABDOMINAL 2XL 9 $44.00

27200638 BOOT CAST LARGE WEATHERPROOF $32.00

27200639 SPLINT COLLES RIGHT X‐SMALL PE $28.00

27200640 SPLINT COLLES LEFT X‐SMALL PED $28.00

27200643 NASAL SPLINT $12.00

27200658 THERMOMETER DIG/HYPOTHERMIA $40.00

27200686 GAUZE PACKING STRIP VASELINE 1 $18.00

27200717 SET BURETROL ADD‐ON IV 17 CLE $30.00

27200718 CATHETER 8FR FOLEY PEDIATRIC 3 $15.00

27200719 CATHETER 10FR FOLEY 3CC PEDIAT $15.00

27200720 CATHETER 16FR ROBINSON LTX $25.00

27200721 CATHETER 14FR ROBINSON LTX $8.00

27200724 CATHETER 18FR FOLEY COUDE 2WAY $79.00


27200726 CATHETER 16FR FOLEY COUDE 5CC $83.00

27200727 CATHETER 24FR FOLEY 3WAY 30CC $84.00

27200728 CATHETER 28FR FOLEY 2WAY 5CC L $24.00

27200729 SCALPEL #10 DISPOSABLE SAFETY $17.00


27200731 EAR SYRINGE BULB STERILE 2 OZ $5.00


27200733 BAG GAVAGE FEEDING $11.00

27200734 DRAIN CHEST SYSTEM $353.00

27200735 CATHETER 10FR SUCTION $3.00

27200736 TUBE 28FR GASTRIC LAVAGE $31.00

27200737 TUBE 32 FR GASTRIC LAVAGE $37.00

27200738 KIT GASTRIC LAVAGE $101.00

27200739 TUBE 34FR EDLICH GASTRIC LAV $34.00

27200740 BLADE DERMABLADE SHAVE BIOPSY $10.00

27200741 TUBE 16 FR STOMACH LEVIN $5.00

27200746 SET 14FR SUCTION COLLECTION 30 $11.00

27200747 SPLINT FINGER MEDIUM UNPADDED $2.00

27200748 SPLINT FINGER LARGE UNPADDED $2.00

27200749 ADULT CERVICAL COLLAR STIFFNEC $78.00

27200751 PRIMARY TUBING‐SET CONTINUE FL $31.00

27200752 SET SECONDARY MEDICATION 2C746 $7.00

27200762 STOCKINETTE 2 X 25YD TUBULAR $9.00

27200765 SOLUTION 1000 ML DEXT LACT RIN $3.00

27200787 LUBRICANT INSTRUMENT $117.00

27200795 BOOT CAST X‐SMALL WEATHERPROOF $33.00

27200796 BOOT CAST SMALL WEATHERPROOF $33.00

27200797 SPLINT WRIST COCK‐UP LARGE $30.00

27200799 STRAP LG ARM FULL PAD $15.00

27200801 BOOT CAST XL WEATHERPROOF $42.00

27200802 BOOT CAST SANDAL XL $33.00

27200803 TUBE 10 FRENCH SALEM SUMP $32.00

27200804 TUBE 14 FR SALEM SUMP 48 $10.00

27200805 TUBE 16 FR SALEM SUMP 48 $34.00


27200807 CLAMP CLOSURE TAIL POUCH $21.00

27200808 8FR SUCTION CATHETER $4.00

27200809 14FR SUCTION CATHETER $2.00

27200810 ENDOTRACHEAL TUBE HOLDER $24.00

27200811 PEDS ENDOTRACHEAL TUBE HOLDER $24.00

27200812 ELECTRODE MONITOR PEDIATRIC 4. $154.00

27200813 ENEMA SET $5.00

27200814 CUSHION INVALID RING $45.00

27200815 TUBE ENDOTRACHEAL 7.0 $11.00

27200816 AUTOGUARD 24G X 0.75 INSYTE Y $13.00

27200818 TRAY CATHETER NOZ STOP $250.00

27200819 TRACH ADULT QUICK $446.00

27200821 LENS MEDI FLOW $143.00

27200823 BATTERY OTOSCOPE # 72200 3.5V $133.00

27200825 ADHESIVE DERMABOND TOPICAL SKI $125.00

27200831 TRAY ADULT LUMBAR PUNCTURE $62.00

27200832 TRAY PED LUMBAR PUNCTURE $62.00

27200833 TRAY THORACENTESIS $222.00

27200839 AUTOGUARD 14G X 1.75 INSYTE O $11.00

27200840 AUTOGUARD 16G X 1.25' INSYTE $11.00

27200841 BASIN STERILE PREP $77.00

27200844 NEEDLE BONE MARROW ASPIRATION $422.00

27200845 NEEDLE HUBER 20X1 $46.00

27200857 METER 400ML URINE LATEX FREE $49.00

27200863 ELECTRODE NEEDLE 7/8 ANGLED 3 $186.00

27200864 PHENUMOTHORAX SET C‐TPT‐100 ER $680.00

27200865 PACKING NASAL STANDARD DRESSIN $59.00

27200866 AIRWAY NASAL 34FR 8MM $19.00

27200867 PACKING NASAL EPISTAXIS 10CM $56.00

27200868 BITE STICK $30.00

27200870 SUTURE 6‐0 DERMALON 18 PRE302 $12.00

27200871 PUNCH 6.0MM BIOPSY DISPOSABLE $18.00

27200872 BIOPSY PUNCH VARIETY PACK STER $17.00


27200882 NU‐TRAKE $769.00

27200889 SUTURE 5‐0 CLEAR 27 CE4 $138.00

27200890 SUTURE 6‐0 DERMALON PRE1 18 P $11.00

27200891 SUTURE 3‐0 CHROMIC GUT 27 $7.00

27200892 SUTURE 6‐0 MONOSOF $61.00

27200895 CATHETER 10FR THORACIC CHEST $58.00









27200907 TRACH PEDIATRIC EASY $446.00



27200919 IV START KIT $18.00

27200921 PATCH EYE SELF ADHESIVE JR $2.00

27200928 BLANKET BAIR HUGGER $32.00

27200929 BAIR HUGGER FLUID WARMING SET $52.00

27200930 EPISTAXIS BALLOON KIT $19.00

27200933 SET 5FR CENTRAL VENOUS CTH $333.00

27200938 SHIELD METAL EYE $8.00

27200992 SUTURE 3‐0 PROLENE FS‐1 18 $12.00

27200994 SUTURE 4‐0 PDSII FS‐2 CLEAR $8.00

27200995 SUTURE 3‐0 PROLENE PS‐2 18 $17.00

27200996 SUTURE 4‐0 CHROMIC GUT 27 $59.00

27200997 SUTURE 3‐0 ETHILON FS‐1 18 $9.00

27201000 SUTURE 4‐0 ETHILON FS‐2 $32.00

27201002 SUTURE 6‐0 ETHILON FS‐3 NEEDLE $32.00

27201003 SUTURE 6‐0 DERMALON CE‐3 8 $15.00

27201004 SUTURE 6‐0 MONOSOF PRE302 $24.00

27201005 SUTURE 4‐0 SILK RB‐1 18 $438.00

27201006 SUTURE 3‐0 PROLENE RB‐1 30 $39.00

27201007 SUTURE 4‐0 PROLENE RB‐1 30 $39.00

27201010 SUPPORT ELBOW MEDIUM W/STRAP $74.00

27201011 PEDIATRIC PHILLY COLLAR 6‐8 $49.00

27201012 SUPPORT ELBOW LARGE W/STRAP $68.00


27201015 SUPPORT WRIST LEFT X‐SMALL INF $61.00

27201038 ELECTRODE QUICK‐COMBO ADULT $300.00

27201039 ELECTRODE QUICK‐COMBO PEDIATRI $295.00

27201097 ANKLE SUPPORT RIGHT XS KALLASS $80.00

27201098 LT/RT XS KALLASSY ANKLE SUPPO $66.00

27201099 RIGHT SM/MD KALLASSY ANKLE SUP $79.00

27201100 LEFT SM/MD KALLASSY ANKLE SPLI $82.00

27201101 RIGHT LG/XL KALLASSY ANKLE SUP $79.00

27201102 LEFT LG/XL KALLASSY ANKLE SUPP $16.00

27201111 SM ANKLE SUPPORT NEOPRENE PULL $30.00

27201112 LG ANKLE SUPPORT NEOPRENE PULL $31.00


27201202 SPLINT WRIST 6 COCK‐UP LEFT S $56.00

27201203 SPLINT WRIST 6 COCK‐UP RIGHT $54.00

27201204 SPLINT WRIST 6 COCK‐UP LEFT M $56.00


27201206 SPLINT WRIST 6 COCK‐UP LEFT L $54.00


27201210 WRIST/FOREARM SPLINT WITH ABD $47.00






27201231 PUNCH 7.0MM BIOPSY DISP STER $14.00

27201271 SUTURE 6‐0 PS‐3 18 BLACK MONO $61.00

27201368 SUTURE 6‐0 SILK P‐3 18 BLACK $63.00

27201503 PEN CAUTERY DISPOSABLE $49.00

27201507 PEDS CERVICAL COLLAR SOFT $24.00

27201517 STYLET ENDOTRACHEAL TUBE 14FR $10.00

27201571 PEDIATRIC CERVICAL COLLAR SOFT $49.00

27201572 SMALL CERVICAL COLLAR SOFT $49.00

27201588 TUBING EXTENSION W/CONNECTOR $32.00

27201602 CATHETER 20FR FOLEY 2WAY SILI $8.00

27201603 CATHETER 22FR FOLEY 2WAY SILI $35.00

27201623 GLOVES SURGICAL SIZE 8 DERMA P $14.00

27201628 CREAM BARRIER DURABLE 3.25 OZ $38.00

27201643 CATH SECUREMENT $14.00

27201649 LARGE CERVICAL COLLAR SOFT $24.00

27201650 COLLAR CERIVCAL XL SOFT $24.00

27201663 TRAY PICC LINE DRESSING CHANGE $81.00

27201665 GEL SILVASORB 1.5 OZ $110.00

27201677 SUPPORT ELBOW SMALL W/STRAP CF $67.00

27201678 SCISSORS LITTAUER 4.25 SUTURE $21.00

27201681 SUPPORT ELBOW X‐LARGE W/STRAP $50.00

27201698 TRAY IRRIGATION BLOOD BODY FLU $34.00


27201704 BRACE ANKLE XLRG FIGURE 8 $68.00

27201713 SPLINT ANKLE PEDIATRIC UNIVERS $160.00

27201721 CATHETER IV PROTECT 20G X 1 1/ $13.00

27201722 CATHETER IV PROTECT 22G X 1 $12.00

27201734 CATHETER 18FR FOLEY SILVER 2WA $43.00

27201735 CATHETER EXTENSION Y TYPE $26.00

27201739 SUTURE 5.0 CHROMIC GUT RB‐1 NE $22.00

27201752 SUPPORT KNEE MUELLER ADJUSTABL $62.00

27201759 TUBING PCA SET MINI BORE W/UNT $31.00

27201774 CAP SHAMPOO WATERLESS $17.00

27201782 GEL MEDIHONEY ANTIBACTERIAL $118.00

27201783 16FR FOLEY SILVER 2WAY SILI $45.00

27201791 SUTURE 5.0 SILK BLACK RB‐1 30 $18.00

27201795 BRACE KNEE MED KUHL SHIELDS $285.00

27201796 BRACE KNEE LRG KUHL SHIELDS $285.00

27201797 BRACE KNEE XL KUHL SHIELDS $285.00

27201799 NEEDLE EZ‐IO 15MM PEDIATRIC $590.00

27201800 CATHETER 14FR FOLEY COUDE 5CC $83.00

27201801 45 MM EZ‐I0 $590.00

27201823 SUPPORT WRIST RIGHT XLARGE $31.00

27201824 SUPPORT WRIST LEFT XLARGE $31.00

27201825 SUTURE 4‐0 ETHILON PS‐2 VICRYL $71.00

27201827 KIT CVC 3 LUMEN 7FR X 20 CM $381.00

27201831 CATHETER 14 FR CLOSED TRACH $40.00

27201832 TRACH CARE KIT $9.00

27201833 HEATED RESPIRATORY CIRCUIT $129.00

27201834 HEEL PROTECTOR $95.00

27201836 STOOL COLLECTION BAG $26.00

27201843 XL COMPRESSION GARMENT $120.00

27201844 LG OMPRESSION GARMENT $100.00

27201845 MED COMPRESSION GARMENT $64.00

27201846 SM COMPRESSION GARMENT $84.00

27201847 XS‐SHORT COMPRESION GARMENT $84.00

27201848 14 FR DUETTE CATHETER $37.00

27201849 18 FR DUETE CATHETER $37.00

27201850 MEDI HONEY 1.5 OZ TUBE $83.00

27201851 MEDIHONEY 4X4 W/ADH BORDER $35.00

27201852 MEDIHONEY 6X6 W/ ADH BORDER $81.00

27201853 HONEYCOLLOID 3.5X3.5 W/ADH BOR $30.00

27201854 HONEYCOLLOID 6X6 W/ADH BORDER $76.00

27201856 KCI SENSARAC WHITE LG DRESSING $146.00

27201857 SALEM TUBE 18 FR $32.00 B4087

27201858 CA SELF FUN TIP 5 FR $8.00

27201859 INNER CANNULA SHILEY SZ 6 $19.00

27201867 TED HOSE XL THIGH HIGH PER PR $32.00

27201884 MICROKLENZ WOUND CLEANSER $25.00

27201887 CAVILON NO STING FILM BARRIER $7.00

27201888 TEGEDERM CHG 3.5 X 4.5 $42.00

27201942 SKINTEGRITY HYDROGEL 1 OZ BEL $7.00

27201944 PICO W/PUMP 6X8 STERILE $704.00

27201945 PICO W/PUMP 4X16 STERILE $704.00

27201946 STOCKING SMALL THIGH HIGH $31.00

27201947 COBAN 2 LAYER LITE $57.00 A6441

27201948 COBAN 2 LAYER COMPRESSION $57.00 A6452

27201949 PACKING STRIP 1/2X5 YD STERILE $12.00 A6407

27201953 EPIFIX MICRO 160 M $567.00 Q4131

27201954 EPIFIX MESH PER SQUARE CENT $567.00 Q4186

27201968 MEDIGRIP $34.00 A6457

27201970 INSERT TRAY W/BAG W/IND CATH $77.00 A4315

27202011 .2 MICRON EXTENSION SET $31.00

27210019 1000 ML DEXTROSE 5% 1/4 NS $36.00

27210020 1000 ML DEXTROSE 5% ALC $50.00

27210025 SODIUM CHLORIDE 0.45% $36.00

27210028 LACTATED RINGERS/D5 $33.00

27210030 DEXTROSE 5% WATER 500ML $35.00

27210031 500 ML D5W $53.00

27210039 500 ML 0.3% HYPERTONIC SALINE $24.00

27210040 BROSELOW ORANGE PACK $559.00

27210041 BROSELOW RED PACK $526.00

27210042 BROSELOW PURPLE PACK $559.00

27210043 BROSELOW YELLOW PACK $526.00

27210044 BROSELOW WHITE PACK $559.00

27210045 BROSELOW BLUE PACK $526.00

27210046 BROSELOW GREEN PACK $559.00

27210048 ENTERAL PUMP SET‐JOEY $14.00

27210049 ENTERAL (JOEY) PUMP $250.00

27210052 HOT COMPRESS $10.00

27210056 MASK LARYNGEAL SIZE 4 $31.00

27210057 MASK LARYNGEAL SIZE 5 $39.00

27210058 STOMACH TUBE 12FR 48 $8.00

27210059 STOMACH TUBE 18FR 48 $8.00

27210060 TUBE GASTRIC LAVAGE 28FR $58.00

27210066 KNEE BRACE PROCARE ADJUSTABLE $179.00




27210071 HOLTER PATIENT PREP KIT $48.00

27210074 LARYNGOSCOPE BLADE CHANNELED 1 $170.00

27210075 LARYNGOSCOPE BLADE STANDARD 13 $168.00

27210077 WIPES DIMENTHICONE $13.00

27210078 NEXCARE WATERPROOF BANDAGE $39.00

27210079 ENTERAL PUMP CONSUMABLE $15.00

27210081 UNNA BOOT‐WAITSBURG CLINIC $33.00

27210084 PHARM HOOD STERILE PRE SAT $652.00

27210085 PHARM HOOD MOP COVER $821.00

27210101 BROSELOW RED INTUBATION PACK $163.00

27210102 BROSELOW PURPLE INTUBATION PAC $163.00

27210103 BROSELOW YELLOW INTUBATION PAC $163.00

27210104 BROSELOW WHITE INTUBATION PACK $163.00

27210105 BROSELOW BLUE INTUBATION PACK $163.00

27210106 BROSELOW ORANGE INTUBATION PAC $163.00

27210107 BROSELOW GREEN INTUBATION PACK $163.00

27210108 BROSELOW RED INTRAOSSEOUS PACK $225.00

27210109 BROSELOW PURPLE INTRAOSSEOUS P $225.00

27210110 BROSELOW YELLOW INTRAOSSEOUS P $225.00

27210111 BROSELOW WHITE INTRAOSSEOUS PA $225.00

27210112 BROSELOW BLUE INTRAOSSEOUS PAC $225.00

27210113 BROSELOW ORANGE INTRAOSSEOUS P $225.00

27210114 BROSELOW GREEN INTRAOSSEOUS PA $225.00

27210115 BROSELOW RED OXYGEN DELIVERY P $82.00

27210116 BROSELOW PURPLE OXYGEN DELIVER $73.00

27210117 BROSELOW YELLOW OXYGEN DELIVER $73.00

27210118 BROSELOW WHITE OXYGEN DELIVERY $73.00

27210119 BROSELOW BLUE OXYGEN DELIVERY $73.00

27210120 BROSELOW ORANGE OXYGEN DELIVER $73.00

27210121 BROSELOW GREEN OXYGEN DELIVERY $73.00

27210122 BROSELOW RED IV DELIVERY PACK $180.00

27210123 BROSELOW PURPLE IV DELIVERY PA $180.00

27210124 BROSELOW YELLOW IV DELIVERY PA $180.00

27210125 BROSELOW WHITE IV DELIVERY PAC $180.00

27210126 BROSELOW BLUE IV DELIVERY PACK $180.00

27210127 BROSELOW ORANGE IV DELIVERY PA $180.00

27210128 BROSELOW GREEN IV DELIVERY PAC $180.00

27210129 BROSELOW BABY BLUE RESUSC Z‐2 $120.00

27210130 BROSELOW PEDI BLUE RESUSC S‐2 $150.00

27210131 BROSELOW INFANT CUFF DISPOSABL $84.00

27210132 BROSELOW CHILD CUFF DISPOSABLE $84.00

27210133 BROSELOW BLOOD PRESSURE MANOME $167.00

27210135 NEBULIZER $112.00

27210138 OB KIT $82.00

27210144 ETCO2 INTUBATED MONITOR $124.00

27210145 ETCO2 NON INTUBATED WITH O2 & $131.00

27210146 WHISPER PAK $175.00

27210147 ETCO2 NON INTUBATED MONT. ONLY $24.00

27210148 CPAP/BIPAP MASK SMALL $399.00

27210149 CPAP/BIPAP MASK MED $399.00

27210150 CPAP/BIPAP MASK LARGE $399.00

27211000 CPM RENTAL $49.00

27211001 LUMBAR SACRAL ORTHOSIS $167.00 L0630

27220100 AIR FLUIDIZED BED DAILY RATE $421.00

27220101 BARIATRIC MATTRESS DAILY RATE $366.00

27220102 LOW AIR LOSS THERAPY BED RATE $232.00

HOSPRENT1 CONCENTRATOR RENT PER MONTH $158.00

HOSPRENT2 HIGH PRES PORT RENT PER MONTH $27.00

27201908 TEGEDERM TRANSPARENT 2X3 $3.00 A6257

27201909 TEGEDERM THIN SQUARE 4X4 $9.00 A6234

27201910 TEGEDERM THIN OVAL 4X4.75 $10.00 A6238

27201912 TEGEDERM TRANSPARENT 4X5 $4.00 A6231

27201913 MEDIPORE PAD 3.5 X 6 $10.00 A6219

27201914 MEDIPORE PAD 3.5 X 10 $12.00 A6219

27201916 EMULSION OIL 3 X 8 $3.00 A6223

27201917 STERI STRIP 1/8X3 $7.00 A4450

27201918 STERI STRIP 1/4X4 $10.00 A4450

27201919 STERI STRIP 1/4 X 1 1/2 $7.00 A4450

27201920 STERI STRIP 1/2 X 4 $11.00 A4450

27201923 TEGEDERM OVAL FOAM 5.5 X 6 $26.00 A6213

27201927 ALLEVYN 3X3 $12.00 A6212

27201928 ALLEVYN 5X5 $16.00 A6212

2501001 CULTURE STOOL $0.00

2501003 ANDRMS ANDROSTENEDIONE $156.00 82157

2501004 NMR LIPOPROFILE TEST $158.00 83704

2501005 HIV TYPE 2 (HIV2SB) $446.00 86702

2501012 COTININE (NIC) $24.00 80323

2501014 CARBOHYDRATE DEF TRANSFERRIN $98.00 82373

2501015 CDT EACH ADD'L AB STAIN $70.00 88350

2501017 SPECIAL STAIN (CRYSM) $0.00

2501018 NICOTINE & METABOLITES NICMUR $191.00 80323

2501019 MACROPROLACTIN (MAPRLA) $343.00 84146

2501021 NOROVIRUS GRP 1&2 BY PCR $428.00 87798

2501022 VIT B2 RIBOFLAVIN $604.00 84252

2501023 EPITH BASEMENT MEM ZONE AB $328.00 88346

2501027 RSV Ag. STAT (ANTIGEN BY IA) $110.00 87420

2501028 INF AGENT ANTIGEN DETECTION $36.00 87899

2501031 IMMUNOASSAY FOR ANALYTE X4 $16.00 83516

2501033 IMMUNOASSAY FOR ANALYTE X2 $16.00 83516

2501034 CHLAMYDIA X3 $16.00 86631

2501047 INFLUENZA A & B SWAB $166.00 87400

2501049 UA W/ MICRO CHARGE ONLY $96.00 81001

2501050 URINALYSIS DIP ONLY $52.00 81003

2501052 BB BLOOD TYPE ‐ RH CHARGE ONLY $77.00 86901

2501053 BB BLOOD TYPE ABO CHARGE ONLY $69.00 86900

2501054 BB COMPATIBILITY TESTING AHG $292.00 86922

2501059 HETEROPHILE AB SCREEN $94.00 86308

2501061 OCCULT BLOOD FECES‐SCREEN 3 CA $69.00 82270

2501063 RAPID STREP $93.00 87430

2501067 GTT 2 HOUR $198.00 82951

2501069 GTT 1 HOUR $163.00 82950

2501070 MISC LAB $0.00

2501071 H PYLORI $78.00 86318

2501078 CATECHOLAMINES 24 HR URINE $151.00 82384

2501079 SODIUM URINE RANDOM $86.00 84300

2501081 GTT 3 HOURS $267.00 82952

2501085 RUBELLA AB SCREEN IGG IMMUNE $117.00 86762

2501086 RUBEOLA AB IGG IMMUNE $182.00 86765

2501087 DRUG SCREEN URINE AUTOMATED $197.00 80307

2501089 OCCULT BLD GUIAC OTH SOURCES $72.00 82271

2501090 ANTI DNA DS $220.00 86225

2501095 LDL CHOLESTEROL DIRECT $92.00 83721

2501096 BNP $332.00 83880

2501097 SPECIMAN HANDLING $55.00 99001

2501099 DIGOXIN $172.00 80162

2501100 THEOPHYLLINE $289.00 80198

2501101 TETANUS ANITBODY $152.00 86774

2501102 TSH $155.00 84443

2501103 IRON TOTAL $87.00 83540

2501104 IRON BINDING CAPACITY (TIBC) $101.00 83550

2501107 IGG $124.00 82784

2501108 LITHIUM $111.00 80178

2501109 PHENYTOIN TOTAL $214.00 80185

2501110 T‐UP TAKE $123.00 84479

2501111 T4 $100.00 84436

2501113 CARBAMAZEPINE $189.00 80156

2501114 AMYLASE $126.00 82150

2501115 CYANOBALAMIN (VIT B) $179.00 82607

2501117 CPK $101.00 82550

2501118 AST $61.00 84450

2501119 LACTATE DEHYDROGENASE $77.00 83615

2501120 ALCOHOL ETHYL $175.00 80320

2501121 GLUCOSE BLOOD $72.00 82947

2501122 FOLATE $164.00 82746

2501123 COMP META PANEL (12) $179.00 80053

2501125 POTASSIUM $73.00 84132

2501126 SODIUM SERUM $45.00 84295

2501127 CHLORIDE BLOOD $118.00 82435

2501128 ASO TITER $129.00 86060

2501129 BUN $65.00 84520

2501130 CREATININE BLOOD $75.00 82565

2501131 CREATININE CLEARANCE 24 HR $146.00 82575

2501134 VENIPUNCTURE $50.00 36415

2501135 HOMOCYSTINE $267.00 83090

2501137 HEP B SURFACE AG $129.00 87340

2501138 ANAMP $132.00 86038

2501142 MAGNESIUM $111.00 83735

2501145 CBC $0.00 85025

2501146 LIPID PANEL $152.00 80061

2501147 PHENOBARBITAL $301.00 80184

2501151 MYOGLOBIN $183.00 83874

2501152 IGM $124.00 82784

2501153 LYME ANTIBODY IGG IGM $203.00 86618

2501155 DIPHTHERIA ANTIBODY $247.00 86648

2501157 C‐PEPTIDE $216.00 84681

2501158 SALICYLATE LEVEL $155.00 80329

2501159 TESTOSTERONE‐ TOTAL $215.00 84403

2501161 RSV SCREEN $84.00 87280

2501163 BILIRUBIN TOTAL $69.00 82247

2501164 BILIRUBIN DIRECT $72.00 82248

2501166 HSV NON SPECIFIC TYPE TEST $147.00 86694

2501170 TACROLIMUS $249.00 80197

2501177 URIC ACID BLOOD $66.00 84550

2501178 ACETAMINOPHEN LEVEL $172.00 80329

2501183 ESTRADIOL $193.00 82670

2501187 MICROALBUMIN URINE $97.00 82043

2501188 CRP HIGH SENSITIVITY $111.00 86141

2501190 MYCOPLASMA AB IGG $105.00 86738

2501192 HEPATITIS B DNA QNT PCR $525.00 87517

2501193 THYROID STIMULATING IMMUNOGLOB $177.00 84445

2501197 PERTUSSIS BORDETELLA PCR $283.00 87265

2501199 LUTEINIZING HORMONE $158.00 83002

2501203 SENSITIVITY (MIC) $158.00 87186

2501204 COPPER $200.00 82525

2501206 HIV 1 ULTRASENITIVE RNA(PSA) $467.00 87536

2501207 CD4/CD8 HELPER SUPPRESSOR $255.00 86360

2501208 HIV 1 2 $160.00 86703

2501209 EPSTEIN‐BARR EARLY ANT IG $166.00 86663

2501210 EPSTEIN‐BARR ANT NEU ANT IGG $239.00 86664

2501211 EPSTEIN‐BARR VIRAL CAPSID $134.00 86665

2501212 ALDOLASE $79.00 82085

2501215 CMV ANTIBODY IGG $46.00 86644

2501216 CMV ANITBODY IGM $46.00 86645

2501218 RENAL FUNCTION PANEL $176.00 80069

2501220 H PYLORI ANTIGEN $318.00 87338

2501223 VALPROIC ACID $210.00 80164

2501228 HCV RNA QUANTITATIVE BDNA $639.00 87522

2501229 APOLIPOPROTEIN B‐100 $109.00 82172

2501231 LACTIC ACID VENOUS $183.00 83605

2501234 SHBG $107.00 84270

2501236 PREALBUMIN $171.00 84134

2501238 CONCENTRATION FOR INF AGENT $73.00 87015

2501240 TROPONIN I $218.00 84484

2501241 VITAMIN A $83.00 84590

2501242 PROTEIN C ACTIVITY $233.00 85303

2501243 ANTITHROMBIN III ACIVITY $273.00 85300

2501244 CEA $159.00 82378

2501247 HBE AG $144.00 87350

2501248 HEP B SURFACE AB IMMUNE $112.00 86706

2501249 ACTH $213.00 82024

2501250 PROTEIN ELECTROPHORESIS URINE $142.00 84166

2501251 PROTEIN S TOTAL $146.00 85305

2501253 PROTEIN S FREE $296.00 85306

2501254 FERRITIN $132.00 82728

2501255 IGA $124.00 82784

2501259 IMMUNE COMPLEX ASSAY $136.00 86332

2501260 CELL COUNT BODY FLUID $132.00 89051

2501262 PRIMIDONE $170.00 80188

2501265 CULTURE FUNGAS REFLEXIVE $204.00 87102

2501266 HDL $134.00 83718

2501267 TOPIRAMATE $131.00 80201

2501269 CERULOPLASMIN $155.00 82390

2501273 ALPHA‐FETOPROTEIN TUMOR MARKER $156.00 82105

2501275 GIARDIA LAMBLIA ANTIGEN $212.00 87329

2501277 HEPATIC FUNCTION PANEL $118.00 80076

2501278 COLLAGEN CROSS LINKS $280.00 82523

2501280 TRANSFERRIN $101.00 84466

2501281 ALPHA‐1 ANTITRYPSIN $151.00 82103

2501284 PSA TOTAL/MONITOR $172.00 84153

2501299 ZINC $161.00 84630

2501306 PROGESTERONE $63.00 84144

2501307 DHEA SO4 $252.00 82627

2501308 T3 FREE $189.00 84481

2501309 FREE T4 $132.00 84439

2501310 ESTROGEN FRACTIONATED $208.00 82671

2501311 CCP AB $149.00 86200

2501312 C‐1 ESTERASE INHIBITOR TOTAL $177.00 86160

2501313 ELECTROLYTE PANEL $98.00 80051

2501314 ALKALINE PHOSPHATASE $67.00 84075

2501315 ALT $61.00 84460

2501316 PROTEIN TOTAL (SERUM) $117.00 84155

2501317 ALBUMIN $58.00 82040

2501319 GGT $71.00 82977

2501320 CHOLESTEROL $73.00 82465

2501321 TRIGLYCERIDES $62.00 84478

2501322 CALCIUM BLOOD $79.00 82310

2501323 PHOSPHORUS $77.00 84100

2501324 BASIC METABOLIC PANEL $139.00 80048

2501325 CA 19‐9 $250.00 86301

2501326 CA 15‐3 $243.00 86300

2501327 CA 125 $236.00 86304

2501333 HEPATITIS C ANTIBODY $166.00 86803

2501335 FSH $143.00 83001

2501336 PROLACTIN $160.00 84146

2501337 HLA B27 $175.00 86812

2501339 C4 $177.00 86160

2501340 C‐3 $177.00 86160

2501343 AMMONIA $192.00 82140

2501345 RENIN DIRECT $146.00 84244

2501346 OSMOLALITY BLOOD $89.00 83930

2501347 OSMOLALITY URINE $111.00 83935

2501349 CALC QUAL INF SPECT $93.00 82365

2501352 TESTOSTERONE‐FREE $259.00 84402

2501356 IMMUNOASSAY QUANT BY RIA EA $333.00 83520

2501359 CAROTENE $172.00 82380

2501360 CALCIUM‐IONIZED $192.00 82330

2501362 HEPATITIS PANEL ACUTE $506.00 80074

2501364 HEP A AB TOTAL $124.00 86708

2501367 MUMPS AB IGG $101.00 86735

2501368 D‐DIMER QUANT $212.00 85379

2501371 RA QUANT $102.00 86431

2501374 VIT D (25‐OH) $236.00 82306

2501378 VIT B6 $238.00 84207

2501379 VITAMIN B‐1 WHOLE BLOOD $227.00 84425

2501382 ZONISAMIDE $210.00 80203

2501385 VIT E $115.00 84446

2501386 LIPASE $133.00 83690

2501387 T3 TRIIODOTHYRONINE $153.00 84480

2501388 17‐HYDROXYPREGNENOLONE $293.00 84143

2501392 FLOURESCENT TREPONEMAL ABS $108.00 86780

2501395 PT‐INR $81.00 85610

2501396 PTT $109.00 85730

2501398 HCT $57.00 85014

2501399 HGB $55.00 85018

2501401 WBC $56.00 85048

2501403 HEMOGRAM $108.00 85027

2501404 CBC (AUTO DIFF) $122.00 85025

2501405 RETIC COUNT (AUTO) $73.00 85045

2501408 ERYTHROPOIETIN $182.00 82668

2501410 KETONE SERUM QUALITATIVE $76.00 82009

2501414 DIFF REV BY PATHOLOGIST $136.00 85060

2501415 ANGIOTENSIN l CONVERTING ENZYM $81.00 82164

2501421 THYROGLOBULIN AB $137.00 86800

2501424 ALDOSTERONE SERUM $181.00 82088

2501428 IGG SUBCLASSES EA $360.00 82787

2501429 VANCOMYCIN RANDOM $207.00 80202

2501432 ESTRONE $72.00 82679

2501444 CLOSTRIDIUM DIFF TOXIN $122.00 87230

2501448 CULTURE LOWER RESP $149.00 87070

2501449 CULTURE BLOOD $214.00 87040

2501450 STOOL CULTURE ADDL PATHOGENS $94.00 87046

2501452 CULTURE STOOL/YER/SHIGA $0.00

2501454 ORGANISM ID ‐ URINE $99.00 87088

2501462 CULTURE ANAEROBIC $151.00 87075

2501463 WET MOUNT SALINE KOH INDIAINK $67.00 87210

2501466 OVA & PARASITES $117.00 87177

2501471 CULTURE EYE $149.00 87070

2501472 CULTURE EAR $144.00 87070

2501473 BACTRIAL ID $112.00 87077

2501474 FECAL LEUKOCYTES $78.00 89055

2501475 SENSITIVITY (KIRBY BAUER) $104.00 87184

2501486 FAT FECAL QUALILTATIVE $133.00 89125

2501493 CRYPTOSPORIDIUM ANTIGEN $80.00 87328

2501500 CULTURE URINE $141.00 87086

2501506 CHLAM.TRACH/NEIS.GONO AMP $222.00 87591

2501509 FACTOR V LEIDEN $339.00 81241

2501510 MTHFR BY PCR $155.00 81291

2501516 CARDIOLIPIN AB IGG & IGM $164.00 86147

2501522 METHOTREXATE $204.00 80299

2501531 C‐1 ESTERASE INHIB/FUNCTIONAL $178.00 86161

2501535 PROTEIN C AG $247.00 85302

2501542 CHLAMYDIA AB PANEL IGG & IGM $168.00 86632

2501553 17‐ALPHA‐HYDROXYPROGESTERONE $122.00 83498

2501555 MANGANESE $178.00 83785

2501562 BACTERIA CULTURE (OTHER) $144.00 87070

2501565 VIRAL CULTURE REFLEXIVE $196.00 87252

2501579 TUBERCULOSIS TEST $198.00 86480

2501583 GLUCOSE BLOOD BY GM DEVICE $57.00 82962

2501584 ABG $318.00 82805

2501999 NON MEDICARE GEN HEALTH PANEL $454.00 80050

2502002 FENTANYL & METABOLITE (FENSTN) $252.00 80354

2502004 RBC MAGNESIUM (MGRBC) $186.00 83735

2502005 STOOL REDUCING SUBSTANCES $57.00 84376

2502006 STOOL MEAT FIBERS $351.00 89160

2502008 URINE EOSINOPILS (EOSUR) $73.00 89190

2502009 IMMUNODIFFUSION QUAL x7 $27.00 86331

2502010 ASPERGILLUS ANTIBODY x5 $12.00 86606

2502011 ALLERGEN SPEC IGE QUAL MULTI $39.00 86005

2502013 HYPERSENS PNEUMO EXT PANEL $0.00

2502014 HEROIN METABOLITE $66.00 80356

2502015 OXYCODONE $66.00 80365

2502017 PAIN MANAGEMENT OPIATES (PMOP) $0.00

2502018 AMPHETAMINES; 1 OR 2 $36.00 80324

2502019 METHYLENEDIOXYAMPHETAMINES $36.00 80359

2502020 EXTENDED AMPHETAMINE CONF $0.00

2502021 IMMUNODIFFUSION QUAL X4 $27.00 86331

2502022 ASPERGILLUS ANTIBODY X 2 $12.00 86606

2502023 HYPERSENS PNEUMO AB PANEL $0.00

2502025 MULTIPLE VENIPUNCTURE SAME DAY $0.00

2502026 SBX JAK2 MUTATION (JAK2M) $357.00 81270

2502027 LEGIONELL PNEUMO Ag UR $80.00 87449

2502028 VENOUS BLOOD GAS $142.00 82803

2502029 HUMAN T‐LYMPHOTROPIC VIRUS $117.00 86790

2502032 ACETYCHOLINE REC BINDING AB $205.00 83519

2502033 VITAMIN C (VITCL) $168.00 82180

2502034 CLOSTRIDIUM DIF BY PCR $168.00 87493

2502035 ARSENIC SCREENING $50.00 82175

2502036 CADMIUM SCREENING $50.00 82300

2502038 NONINVASIVE CARBOXYHEMOGLOBIN $27.00 88740

2502039 NONINVASIVE METHEMOGLOBIN $27.00 88741

2502040 FLUOR NON INF AGENT ANTIBODY $205.00 86255

2502041 IMMUNOASSAY INF AGENT QUANT $220.00 83519

2502042 MYASTHENIA GRAVIS PANEL 3 RFLX $0.00

2502044 NICOTINE & METABOLITES $185.00 80323

2502046 HCV GENOTYPE‐PCR/PROBE $583.00 87902

2502047 TRYPTASE (TRYPTA) $278.00 83520

2502048 ANA TITER (IFA) RFLX (IFANAR) $71.00 86039

2502052 PROCALCITONIN (PROCLC) $345.00 84145

2502053 REACTIVE RPR SCREEN $48.00 86593

2502055 ACETYLCHOLINE REC BIND ANTBDY $205.00 83519

2502057 NICKEL $113.00 83885

2502058 NICKEL PANEL $0.00

2502059 HEP B SURF AB QUANT (HBSAB) $79.00 86317

2502060 MRSA BY NAA $175.00 87641

2502061 HAPTOGLOBIN $24.00 83010

2502062 HEMOGLOBINOPATHY FRACTIONATION $41.00 85660

2502064 17 PANEL ALLERGEN PROFILE $14.00 86003

2502065 EPSTEIN‐BARR PANEL $0.00

2502066 NICKEL URINE PANEL $0.00

2502069 ANTI‐DNAse B STREP AB $41.00 86215

2502073 PHENYLALANINE PKU $61.00 84030

2502074 BLASTOMYCES DERMATITIDIS ABS $291.00 86612

2502077 ASPERGILLUS Ag $506.00 87305

2502080 CHLAMYDIA TRACHOMATIS CULTURE $0.00

2502081 BLOOD ALCOHOL INCLUDES VENIPCT $105.00

2502082 FLU A/B BY PCR $263.00 87502

2502083 HGB FRACT & QTY CHROMATOGRAPHY $11.00 83021

2502084 HIGH FRACTIONATION PROFILE $0.00

2502085 IMMUNODIFFUSION QUAL X1 $27.00 86331

2502086 ANTIBODY; ACTINOMYCES X2 $32.00 86602

2502087 ASPERGILLUS ANTIBODY X1 $12.00 86606

2502088 STREP PNEUMO FOR HYP PNEUM PNL $484.00 86609

2502089 ANTIBODY; FUNGUS NOT ELSE SPEC $32.00 86671

2502090 HYPERSENSITIVITY PNEUMO PANEL $0.00

2502091 OXCARBAZEPHINE $22.00 80183

2502092 AMY (VET CLINIC ONLY) $42.00

2502093 LIP (VET CLINIC ONLY) $45.00

2502094 PHOS (VET CLINIC ONLY) $26.00

2502095 TSH (VET CLINIC ONLY) $52.00

2502096 DIRECT COOMBS (DAT) $26.00 86880

2502098 IMMUNOASSAY FOR ANALYTE SINGLE $16.00 83516

2502099 CHROMOGRANIN A $318.00 86316

2502100 PT/INR (VET CLINIC ONLY) $45.00

2502101 FISH PROBE $220.00 88271

2502102 FISH MICRODELETION $494.00 88273

2502104 ANTI‐MULLERIAN HORMONE (AMH) $192.00 82397

2502105 VITAMIN K $428.00 84597

2502106 RESPIRATORY PROFILE PCR $851.00 87486

2502107 RUSSELL V VENOM TIME DILUTED $124.00 85613

2502110 THROMB INH SUB PLASMA FRAC EA $124.00 85732

2502112 EXTRACTABLE NUCLEAR ANTIBODY $23.00 86235

2502113 IMMUNOPHENOTYPING FLOW CYTO $266.00 88185

2502114 SOMATOMEDIN (IGF‐1) $333.00 84305

2502115 Lp‐PLA2 ACTIVITY $191.00 83698

2502116 HCV RNA NAA QUAL $438.00 87521

2502117 MEDICARE ONLY GEN HEALTH PANEL $0.00

2502118 REVERSE T3 $248.00 84482

2502119 THIOPURINE METABOLITES $315.00 80299

2502123 URINE CYTOLOGY $140.00 88112

2502124 THYROXINE BINDING GLOBULIN $104.00 84442

2502128 CULTURE & ISOLATION SMEAR $0.00

2502130 REVERSE T3 $248.00 84482

2502131 THIOPURINE METHYLTRANSFERASE $368.00 82657

2502135 FECAL CALCOPROTECTIN $252.00 83993

2502138 COCCIDIOMYCOSIS ANTIGEN $179.00 87449

2502139 CARBOXY‐THC CONFIRMATION $58.00 80349

2503000 HSV TYPE 2 $147.00 86696

2503013 GTT 1 HOUR WHEN PART OF CMP $89.00 82950

2503020 GLYCOSYLATED HGB $115.00 83036

2503023 OXYCODONE $116.00 80301

2503028 KEPPRA (LEVETIRACETAM) $210.00 80177

2503029 LAMOTRIGINE $210.00 80175

2503031 THYROID PEROXIDASE ANTIBODY $172.00 86376

2503036 MRSA SCREEN NO SENSI $131.00 87081

2503039 IGF BINDING PROTEIN‐1 $207.00 83519

2503043 RIBOSOMAL P AUTOANTIBODY (ANA $203.00 86235

2503044 JO‐1 AUTOANTIBODY $203.00 86235

2503045 SSB AUTOANTIBODY IGG $203.00 86235

2503046 SSA AUTOANTIBODY IGG $203.00 86235

2503047 CENTROMERE B AUTOANTIBODY $16.00 83516

2503048 SCL‐70 AUTOANTIBODY $203.00 86235

2503049 SMRNP AUTOANTIBODY $203.00 86235

2503050 RNP AUTOANTIBODY $203.00 86235

2503051 CHROMATIN AUTOANTIBODIES $203.00 86235

2503052 SMOOTH MUSCLE AB $199.00 86255

2503053 DS DNA $56.00 86225

2503058 HEP B SURFACE AB (CHRONIC HEP $166.00 86706

2503059 TISSUE TRANSGLUTAMINASE AB IGA $166.00 83516

2503066 TISSUE TRANSGLUTAMINASE AB IGG $166.00 83516

2503068 WELLNESS LIPID PANEL $0.00 80061

2503069 SM ANTOANTIBODY (ANA POS ONLY) $203.00 86235

2503070 RIBOSOMAL P AUTOANTIBODY (ANA $203.00 86235

2503081 ETHOSUXIMIDE $163.00 80168

2503084 CBC (VET CLINIC ONLY) $36.00

2503085 CMP (VET CLINIC ONLY) $53.00

2503087 RENAL FUNCTION PANEL (VET CLIN $44.00

2503094 23 PANEL ALLERGEN PROFILE $14.00 86003

2503101 PROTEIN TOTAL URINE 24HR $77.00 84156

2503106 T4 (VET CLINIC ONLY) $38.00

2503110 VARICELLA ZOSTER AB IGG $94.00 86787

2503113 DHEA $319.00 82626

2503118 PINWORM PREPARATION $32.00 87172

2503122 FIBRINOGEN $102.00 85384

2503123 LUPUS ANTICOAGULANT (REFLEXIVE $0.00

2503124 CULTURE WOUND REFLEXIVE $149.00 87070

2503125 HEP ABC $0.00

2503126 ANCA PANEL REFLEXIVE $0.00

2503130 HSV IGG & IGM ABS PANEL $0.00

2503137 SMEAR PRIMARY SOURCE W/INTERP $66.00 87205

2503142 METANEPHRINES PLASMA FRACTIONA $209.00 83835

2503150 CKMB $200.00 82553

2503151 D‐DIMER QUALITATIVE $162.00 85379

2503152 ADH $214.00 84588

2503164 CULTURE BODY FLUID (REFLEXIVE) $144.00 87070

2503176 CLOZAPINE $210.00 80159

2503187 SODIUM URINE 24HR $86.00 84300

2503194 HSV IGM $91.00 86695

2503196 BK VIRUS PCR QUAN BLOOD $646.00 87799

2503201 CULTURE GENITAL $149.00 87070

2503203 HEPATITIS PANEL CHRONIC $0.00

2503206 BB ANTIBODY SCREEN $124.00 86850

2503209 PTH INTACT NO CALCIUM $317.00 83970

2503216 PSA FREE $119.00 84154

2503219 HEP B CORE ANTIBODY IGM $109.00 86705

2503226 CORTISOL LC/MS/MS SALIVA $174.00 82530

2503238 MRSA NASAL SCREEN BY PCR $275.00 87641

2503247 CREATININE URINE RANDOM $71.00 82570

2503254 ANTI‐MITOCHONDRIAL ANTIBODY $205.00 86255

2503256 PROTEIN S ACTIVITY $290.00 85306

2503259 PROTHROMBIN 20210 MUTATION $402.00 81240

2503267 HANTAVIRUS ABS RFLX $397.00 86790

2503273 PSA MEDICARE SCREEN $171.00 G0103

2503274 H. PYLORI AB PANEL $193.00 86677

2503282 H PYLORI BREATH TEST $504.00 83013

2503283 URINALYSIS W/MICRO AND CULTURE $0.00 81003

2503291 CRP $52.00 86140

2503292 COENZYME Q10A TOTAL $66.00 83789

2503293 H PYLORI BREATH TEST‐PED $504.00 83013

2503297 ACETYCHOLINE RECEPT MOD ANTIBO $207.00 83519

2503301 HIV1 VIRAL LOAD/GENOTYPING $413.00 87536

2503303 PEMPHIGOID PANEL $385.00 88346

2600004 BB BLOOD UNIT CHARGE $563.00 P9016

2601587 BB BLOOD LEUKOPOOR IRRADIATED $488.00 P9038

3101590 EKG TECHNICAL COMPONENT OP DGH $187.00 93005

3101596 RHYTHM STRIP ‐ TECH ONLY $383.00 93041

3101587 HOLTER MONITOR ‐ TECH COMP $171.00 93225

4101800 CONTRAST PER MILLILITER (MRI) $14.00 A9579

4201805 LOCM 300‐399MG/ML IODINE/IML $146.00 A9579

4201802 CONTRAST 100 MILLILITER (CT) $182.00 Q9967

4001600 XR HIPS‐BIL 3‐4 VIEWS $512.00 73522TC

4001601 XR FEMUR 2 VIEWS RT $494.00 73552RTTC

4001602 XR FEMUR 2 VIEWS LT $494.00 73552LTTC

4001634 XR SKULL COMLPETE $406.00 70260TC

4001636 XR SINUSES $249.00 70210TC

4001637 XR FACIAL BONES COMPLETE $387.00 70150TC

4001638 XR NASAL BONES $423.00 70160TC

4001639 XR MANDIBLE 3 OR LESS $247.00 70100TC

4001641 XR TMJ'S UNILATERAL LT $212.00 70328LTTC

4001643 XR ORBIT 4 OR MORE VIEWS $386.00 70200TC

4001648 XR ABD SERIES 2VIEW + PA CHEST $348.00 74022TC

4001650 XR CERVICAL SPINE AP/LT $596.00 72040TC

4001651 XR CERVICAL SPINE COMP $517.00 72050TC

4001653 XR SINGLE SPINE FILM $571.00 72020TC

4001654 XR LUMBAR SPINE AP/LAT $382.00 72100TC

4001655 XR L SPINE W/OBLIQUE $549.00 72110TC

4001656 XR SI JOINTS 3 OR MORE VIEWS $811.00 72202TC

4001657 XR HIPS‐BIL 2 VIEWS $357.00 73521TC

4001658 XR PELVIS 1 VIEW $370.00 73501TC

4001660 XR HIP AP/LAT LT 4 VIEWS $478.00 73502LTTC

4001661 XR SACRUM/ COCCYX $470.00 72220TC

4001663 XR HIP 1 VIEW LT $277.00 73501LTTC

4001664 XR SHOULDER 1 VIEW LT $445.00 73020LTTC

4001665 XR SHOULDER 2 VIEW LT $460.00 73030LTTC

4001666 XR CLAVICLE LT $348.00 73000LTTC

4001667 XR AC JOINTS BILATERAL $221.00 73050TC

4001668 XR SCAPULA LT $348.00 73010LTTC

4001669 XR STERNUM $658.00 71120TC

4001670 XR HUMERUS LT $445.00 73060LTTC

4001671 XR ELBOW 3 OR MORE VIEWS LT $436.00 73080LTTC

4001672 XR FOREARM LT $397.00 73090LTTC

4001673 XR WRIST 3 OR MORE VIEWS LT $470.00 73110LTTC

4001674 XR HAND 3 OR MORE VIEWS LT $470.00 73130LTTC

4001675 XR FINGERS LT $315.00 73140LTTC

4001676 XR FEMUR LT 1 VIEW $494.00 73551LTTC

4001679 XR TIBIA/FIBULA LT $407.00 73590LTTC

4001680 XR ANKLE ‐3 VIEWS LT $470.00 73610LTTC

4001681 XR FOOT 3 OR MORE VIEWS LT $461.00 73630LTTC

4001682 XR CALCANEUS LT $328.00 73650LTTC

4001683 XR TOES MIN 2 VIEWS LT $328.00 73660LTTC

4001684 XR WRIST 2 VIEWS LT $380.00 73100LTTC

4001686 XR ELBOW 2 VIEWS LT $399.00 73070LTTC

4001687 XR KNEE‐3 VIEWS LT $479.00 73562LTTC

4001689 XR KNEE‐BILATERAL STANDING $365.00 73565TC

4001691 XR FOOT 2 VIEWS LT $354.00 73620LTTC

4001692 XR ANKLE‐2 VIEWS LT $346.00 73600LTTC

4001693 XR HAND 2 VIEWS LT $410.00 73120LTTC

4001694 XR SI JOINTS LESS THAN 3 VIEWS $258.00 72200TC

4001695 XR ORBIT 2 VIEWS (FOREIGN BODY $540.00 70030TC

4001696 XR INFANT UPPER EXTREM 2 V LT $196.00 73092LTTC

4001697 XR INFANT LOWER EXTREM 2 V RT $196.00 73592RTTC

4001699 XR THORACOLUMBAR 2 VIEWS $716.00 72080TC

4001704 XR SINUSES WATER VIEW $249.00 70210TC

4001705 XR FACIAL BONES LIMITED $293.00 70140TC

4001707 XR SOFT TISSUE NECK $331.00 70360TC

4001708 XR C‐SPINE SE W/FLEX/EX $995.00 72052TC

4001711 XR BONE AGE STUDIES $82.00 77072TC

4001713 XR TMJ'S UNILATERAL RT $212.00 70328RTTC

4001714 XR HIP AP/LAT RT $478.00 73502RTTC

4001716 XR HIP 1 VIEW RT $277.00 73501RTTC

4001717 XR SHOULDER 2 VIEW RT $460.00 73030RTTC

4001718 XR SHOULDER 1 VIEW RT $445.00 73020RTTC

4001719 XR CLAVICLE RT $348.00 73000RTTC

4001721 XR SCAPULA RT $348.00 73010RTTC

4001722 XR HUMERUS RT $445.00 73060RTTC

4001723 XR ELBOW 3 OR MORE VIEWS RT $436.00 73080RTTC

4001724 XR FOREARM RT $397.00 73090RTTC

4001725 XR WRIST 3 OR MORE VIEWS RT $470.00 73110RTTC

4001726 XR HAND 3 OR MORE VIEWS RT $470.00 73130RTTC

4001727 XR FINGERS RT $315.00 73140RTTC

4001728 XR FEMUR RT 1 VIEW $494.00 73551RTTC

4001731 XR TIBIA/FIBULA RT $407.00 73590RTTC

4001732 XR ANKLE ‐3 VIEWS RT $470.00 73610RTTC

4001733 XR FOOT 3 OR MORE VIEWS RT $461.00 73630RTTC

4001734 XR CALCANEUS RT $328.00 73650RTTC

4001735 XR TOES 2 VIEW MIN RT $328.00 73660RTTC

4001736 XR WRIST 2 VIEWS RT $380.00 73100RTTC

4001737 XR ELBOW 2 VIEWS RT $399.00 73070RTTC

4001738 XR KNEE‐3 VIEWS RT $479.00 73562RTTC

4001739 XR FOOT 2 VIEWS RT $354.00 73620RTTC

4001740 XR ANKLE‐2 VIEWS RT $346.00 73600RTTC

4001741 XR HAND 2 VIEWS RT $410.00 73120RTTC

4001742 XR INFANT UPPER EXTREM 2 V RT $196.00 73092RTTC

4001743 XR INFANT LOWER EXTREM 2 V LT $196.00 73592LTTC

4001744 XR L‐SPINE COMPLETE PLUS FEX/E $467.00 72114TC

4001745 XR LOWER SPINE BENDING VIEWS $497.00 72120TC

4001815 SHUNTOGRAM TO CHECK SHUNT $617.00 75809

4001816 XR 1V CHEST AND 3V CHEST $647.00 74022

4301001 US VENOUS DPLR LOW EXT RT $873.00 93971RTTC

4301002 US VENOUS DPLR LOW EXT LT $873.00 93971LTTC

4301004 US AORTA $669.00 76706TC

4301005 US ABDOMEN COMPLETE $780.00 76700TC

4301007 US EXTREMITY NON VASCULAR $352.00 76882TC

4301008 US KIDNEYS AND BLADDER $730.00 76770TC

4301009 US TESTICULAR $495.00 76870TC

4301010 US SOFT TISSUE HEAD/NECK $801.00 76536TC

4301011 US PELVIC TRANSVAGINAL $796.00 76830TC

4301012 US PELVIC TRANSABDOMINAL $726.00 76856TC

4301013 US PELVIC LIMIT FOR BLADDER $422.00 76857TC

4301014 US OB <14 WEEKS $788.00 76811TC

4301015 US OB FETAL SURVEY $957.00 76811TC

4301016 US OB FOLLOW UP $742.00 76816TC

4301017 US BIOPHYSICAL PROFILE W/O NST $791.00 76818TC

4301018 US BIOPHYSICAL PROFILE W/NST $583.00 76819TC

4301021 DUPLEX SCAN AORTA LIMITED $835.00 93979TC

4301029 US CHEST $643.00 76604TC

4301030 US ELBOW $517.00 76882TC

4301031 US GROIN $517.00 76882TC

4301032 US AXILLA RIGHT $517.00 76882RTTC

4301033 US AXILLA LEFT $517.00 76882LTTC

4301034 US THYROID $720.00 76536TC

4301035 US PREGNANT UTERUS $426.00 76815TC

4301036 US VENOUS DPLR UP EXT RT $873.00 93971RTTC

4301037 US VENOUS DPLR UP EXT LT $873.00 93971LTTC

4301023 2D ECHO MOD PULSED WAVE/SPECT $493.00 93320TC

4301024 2D ECHO MODIFIER COLOR FLOW $415.00 93325TC

4301026 2D ECHO PED CONG ANOM LIMITED $983.00 93304TC

4301028 2D ECHO TRANSTHORACIC LIMITED $858.00 93308TC

3500001 NOSE BLEED QR 0.8OZ PWDR $0.00 93005

3500005 ACETAMINOPHEN 650MG SUPP $0.00

3500007 ACETAMINOPHEN 325MG TAB $0.00



3500013 CHARCOAL 50GM/240ML SUSP $0.00

3500016 ALBUTEROL HFA 90MCG INH $0.00

3500025 AMOXICILLIN 250MG/5ML SUSP $0.00

3500026 AMOX/CLAV 500‐125MG TAB $0.00

3500027 AMOX/CLAV 875‐125MG TAB $0.00

3500031 ANTIVENIN (CROFAB) 1GM VL $0.00

3500033 ASCORBIC ACID 500MG TAB $0.00

3500035 ASPIRIN 300MG SUPP $0.00

3500036 ASPIRIN EC 325MG TAB $0.00

3500037 ASPIRIN 81MG CHEW TAB $0.00

3500039 ASPIRIN 81MG EC TAB $0.00

3500044 AZITHROMYCIN 250MG TABLET $0.00

3500048 BACLOFEN 10MG TAB $0.00

3500050 BISACODYL 10MG SUPP $0.00

3500052 BISACODYL 5MG TAB $0.00

3500054 CALCIUM/VIT D 500‐200MG TAB $0.00

3500061 CALCIUM CHLORIDE 100MG/ML SYRG $0.00

3500062 CARBAM PER (DEBROX) 0.065% OTI $0.00

3500063 CARBIDOPA/LEVO 25‐100MG TAB $0.00

3500064 CARVEDILOL 25MG TAB $0.00

3500070 CEPHALEXIN 250MG/5ML SUSP $0.00

3500071 CEPHALEXIN 250MG CAP $0.00

3500075 COLCHICINE 0.6MG TAB $0.00

3500079 DEXTROSE (INSTA‐GLUCOSE) 15GM $0.00

3500081 DEXTROSE 50% 50ML SYRINGE $0.00

3500092 DOCUSATE SODIUM 100MG $0.00

3500094 DOCUSATE SODIUM 250MG CAP $0.00

3500098 DOXAZOSIN MESYLATE 2MG TABLET $0.00

3500099 DOXYCYCLINE 100MG CAP $0.00

3500104 ENALAPRILAT DIHYDRATE 1.25MG/M $0.00

3500112 ERYTHROMYCIN OPTH OINT 3.5GM $0.00

3500114 ETHYL CHLORIDE 100% SPRAY 3.5O $0.00

3500121 FERROUS SULFATE 325MG TAB $0.00

3500125 FLUCONAZOLE 100MG TAB $0.00

3500126 FLUTICASONE HFA 110MCG INH $0.00

3500127 FOLIC ACID 1MG TAB $0.00

3500131 GENTAMICIN 0.1% OINTMENT $0.00

3500132 GLIPIZIDE 5MG TAB $0.00

3500135 GUAIFEN/CODEINE 100‐10MG UDC $0.00

3500136 GUAIFENESIN‐DM 4 OZ BOTTLE $0.00

3500138 GUAIFENESIN 100MG/5ML UDC $0.00

3500141 HALOPERIDOL 1MG TAB $0.00

3500149 HUM PAP VAC (GARDASIL)20‐40/0. $0.00

3500152 HYDROCORTISONE 1% CREAM $0.00

3500154 HYDROGEN PEROXIDE 3% SOLUTION $0.00

3500155 HYDROMORPHONE 2MG TAB $0.00

3500163 IBUPROFEN 200MG TAB $0.00

3500171 ISOPROPYL ALCOHOL (ALCOHOL) 70 $0.00

3500175 LABETALOL 5MG/ML 20ML VIAL $0.00

3500183 LIDOCAINE 1% 10MG/ML 20ML $0.00

3500184 LIDOCAINE 2% 20ML VIAL $0.00

3500188 LISINOPRIL 20MG TAB $0.00

3500189 LOPERAMIDE 2MG CAP $0.00

3500190 LORATADINE 10MG TAB $0.00

3500191 LORAZEPAM 2MG/ML ORAL SOL $0.00

3500193 LOSARTAN POT 50MG TAB $0.00

3500194 MAG HYD (MILK OF MAG)400MG/5ML $0.00

3500198 MAG/AL/SIM (MAALOX PLUS) 200‐2 $0.00

3500199 MAGNESIUM CITRATE SOL $0.00

3500200 MAGNESIUM OXIDE 400MG TAB $0.00

3500202 MECLIZINE 12.5MG TAB $0.00

3500208 METFORMIN 500MG TAB $0.00

3500209 METHOCARBAMOL 500MG TAB $0.00

3500211 METHYLERGONAVINE 0.2 TAB $0.00

3500216 METOPROLOL 5MG/5ML VIAL $0.00

3500218 MICONAZOLE 100MG VAG CREAM $0.00

3500222 MIN OIL/PETROL(LACRI‐LUBE) OPH $0.00

3500224 MORPHINE 20MG/ML ORAL CONC $0.00

3500226 MORPHINE SULF (MS) 15MG TAB $0.00

3500227 MORPHINE ER 15MG TAB $0.00

3500231 MULTIVITAMINS WITH MINERALS TA $0.00

3500239 NAPROXEN 250MG TAB $0.00

3500241 NICOTINE PATCH 21MG/24HR $0.00

3500242 NITROGLY/D5W 50MG/250ML INFUS $0.00

3500243 NITROGLYCERIN 0.4MG SL TAB $0.00

3500244 NITROGLYCERIN 0.1MG/HR PATCH $0.00

3500245 NITROGLYCERIN 2% OINT $0.00

3500246 NITROGLYCERIN 2.5MG CAP $0.00

3500253 OMEPRAZOLE 20MG CAP $0.00

3500255 ONDANSETRON 4MG ODT $0.00 Q0162

3500258 OXYCODONE 5MG TAB $0.00

3500259 OXYMETAZOLINE 0.05% NASAL SPRY $0.00

3500263 PHENYTOIN ER 100MG CAP $0.00

3500265 PHOSPHORUS 250MG TAB $0.00

3500268 POLYETHYLENE GLYCOL 17GM $0.00

3500269 POLYVINYL ALC (ART. TEARS) 1.4 $0.00

3500271 POTASSIUM CHL (KLOR‐CON) 10MEQ $0.00


3500274 PREDNISOLONE(PEDIAPRED)15MG/5M $0.00

3500275 PREDNISONE (DELTASONE) 10MG TA $0.00

3500279 PROCHLORPERAZ (COMPAZINE) 25MG $0.00

3500280 PROMETHAZINE (PHENERGAN) 12.5M $0.00

3500283 PROPAFENONE (RYTHMOL) 150MG TA $0.00

3500284 PROPOX/ACE(DARVOCET‐N)100‐650M $0.00

3500285 PSEUDOEPHEDRINE (SUDAFED) 30MG $0.00

3500286 PSYLLIUM SEED PWDR $0.00

3500287 PSYLLIUM SEED (VEGETAB) PWDR $0.00

3500288 PSYLLIUM SEED/DEXTR (KONSYL‐D) $0.00

3500289 RACEPINEPHRINE (S‐2) 2.25% NEB $0.00

3500290 SENNOSIDES (SENNA LAX) 8.6MG T $0.00

3500291 SENNOSIDES/DOCUSATE 8.6MG‐50MG $0.00

3500292 SERTRALINE (ZOLOFT) 100MG TAB1 $0.00

3500293 SOD BOR/BOR AC/H2O/NS (EYE WAS $0.00

3500294 SOD POLYSTY(KAYEXELATE)15G/60M $0.00

3500295 SODIUM BICARB 50 mEq SYRINGE $0.00

3500297 SODIUM CHLOR (DEEP SEA) 0.65% $0.00

3500298 SODIUM CL FOR INH 0.90% 3ML VL $0.00

3500299 SODIUM/POT/SOD CHL (EYE WASH) $0.00

3500301 SULFAMET/TRIM (BACTRIM)800‐160 $0.00

3500303 TETRACYCLINE (SUMYCIN) 250MG C $0.00

3500306 TRAMADOL (ULTRAM) 50MG TAB2 $0.00

3500307 TRAZODONE (DESYREL) 50MG TAB $0.00

3500310 TRIAMCINOLONE ACET 0.10% CRM $0.00

3500311 TRIAMCINOLONE ACET 0.10% OINT $0.00

3500312 UBIDECARENONE (COQ10) 100MG CA $0.00

3500315 VITAMIN B COMPLEX CAP $0.00

3500316 VITAMIN E 400UNIT CAP $0.00

3500317 WARFARIN (COUMADIN) 2MG TAB $0.00


3500319 WATER FOR INJECTION VIAL $0.00

3500320 ACETAMIN/CODEINE 300/30MG TAB $0.00

3500324 ACETAMINOPHEN 500MG TAB $0.00

3500326 ALLOPURINOL 100MG TAB $0.00

3500327 ALPRAZOLAM 0.5MG TAB $0.00

3500330 AMIODARONE HCL 200 MG TAB $0.00

3500331 AMITRIPTYLINE 25MG TAB $0.00

3500332 AMLODIPINE 5MG TAB $0.00

3500333 AMMONIA 15% (W/V) INH AMP $0.00

3500335 AMOXICILLIN 500MG CAP $0.00

3500340 ATENOLOL 25MG TAB $0.00

3500345 BENZONATATE 100MG CAP $0.00

3500346 BUPIVACAINE 0.5% 10ML VIAL $0.00

3500349 CARBIDOPA/LEVODOPA 25‐100MG TA $0.00

3500350 CARVEDILOL 6.25MG TAB $0.00

3500353 CEPHALEXIN 500MG CAP $0.00

3500354 CIPROFLOXACIN (CIPRO) 0.30% DR $0.00

3500355 CIPROFLOXACIN 500MG TAB $0.00

3500356 CITALOPRAM 20MG TAB $0.00

3500358 CLINDAMYCIN 150MG CAP $0.00

3500359 CLONAZEPAM 0.5 MG TAB $0.00

3500360 CLONIDINE 0.1MG TAB $0.00

3500361 CLOPIDOGREL 75MG TAB $0.00

3500362 CRANBERRY EXTRACT 300MG TAB $0.00

3500363 CYCLOBENZAPRINE 10MG TAB $0.00

3500367 DEXTRAN/HYPRO (RENEW TEARS) OP $0.00

3500368 DIAZEPAM 10MG TAB $0.00

3500369 DICYCLOMINE 10MG CAP $0.00

3500370 DIGOXIN 125MCG TAB $0.00

3500372 DILTIAZEM HCL 5MG/ML VIAL $0.00

3500373 DIPHENHYDRAMINE 25MG CAP $0.00

3500379 EPINEPH (EPIPEN) 0.15MG/0.3ML $0.00

3500380 EPINEPH (EPIPEN) 0.3MG INJ $0.00

3500382 FAMOTIDINE 20MG/2ML VIAL $0.00

3500383 FENTANYL 25MCG/HR PATCH $0.00



3500386 FENTANYL (DURAGESIC)100MCG/HR $0.00

3500387 FLUMAZENIL 0.5MG/ 5 ML VIAL $0.00

3500388 FOLIC ACID (FOLATE) 1MG TAB2 $0.00

3500389 FUROSEMIDE (LASIX) 20MG TAB $0.00

3500390 FUROSEMIDE (LASIX) 40MG TAB $0.00

3500391 GABAPENTIN (NEURONTIN) 100MG C $0.00

3500392 GABAPENTIN (NEURONTIN) 300MG C $0.00

3500393 GENTAMICIN (GENTAK) 0.30% OPT $0.00

3500394 GENTAMICIN (GENTAK) 0.30% OPT $0.00

3500396 GLYBURIDE (DIABETA) 5MG TAB $0.00

3500397 HEPATITS A VACCINE 1440 EL.U $0.00

3500400 HEPARIN SODIUM 10000UNIT/ML VL $0.00

3500401 HYDROCHLOROTHIAZIDE (HCTZ) 25M $0.00

3500402 HYDROCOD/ACET (LORTAB) 5‐500MG $0.00

3500403 HYDROCOD/ACET (NORCO) 10‐325MG $0.00

3500404 HYDROCORT (PROCTOZONE HC) 0.02 $0.00

3500405 HYDROCORTISONE (HYTONE) 0.50% $0.00

3500406 HYDROGEN PEROXIDE 3% BOTTLE $0.00

3500407 HYOSCYAMINE SULF (LEVSIN) 0.12 $0.00

3500408 IBUPROFEN (MOTRIN) 600MG TAB $0.00

3500411 ISOSORBIDE MON ER (IMDUR) 60M $0.00

3500413 LACTULOSE (CEPHULAC) 10G/15ML $0.00

3500414 LANOLIN/MIN OIL/PET (AKWA) OPT $0.00

3500417 LEVOFLOXACIN (LEVAQUIN) 500MG $0.00

3500418 LEVONORGESTREL (PLAN B) 1.5 MG $0.00

3500419 LEVOTHYROXINE 100MCG TAB $0.00

3500423 LIDOCAINE HCL 2% JELLY $0.00

3500424 LISINOPRIL (PRINIVIL) 10MG TAB $0.00

3500425 LORAZEPAM (ATIVAN) 1MG TAB $0.00

3500427 MAG/AL/SIM(GERILANTA)200‐200‐2 $0.00

3500428 MAGNESIUM OXIDE 400MG TAB $0.00

3500430 MENTHOL 4.5‐5.8MG COUGH/THROAT $0.00

3500431 METFORMIN (GLUCOPHAGE) 500MG T $0.00

3500433 METOCLOPRAMIDE (REGLAN) 10MG T $0.00

3500434 METOLAZONE (ZAROXOLYN) 2.5MG T $0.00

3500436 METOPROLOL IR (LOPRESSOR) 50MG $0.00

3500437 METRONIDAZOLE (FLAGYL) 500MG T $0.00

3500438 METRONIDAZOLE (FLAGYL) 500MG T $0.00

3500442 NEO/POLY/DEX (CORTISPORIN)0.1% $0.00

3500443 NEO/POLY/DEX (CORTISPORIN)0.1% $0.00

3500444 NEO/POLY/GRAM (NEOSPORIN)OPT D $0.00

3500445 NEO/POLY/HC (CORTISPORIN) 1% O $0.00

3500446 NITROFURANTOIN (MACROBID) 100M $0.00

3500447 NYSTATIN (NYSTOP) 100000G CRM $0.00

3500448 OMEPRAZOLE (PRILOSEC) 20MG CAP $0.00

3500449 OMEPRAZOLE (PRILOSEC) 20MG CAP $0.00

3500451 PENICILLIN V POT (PEN VK) 500M $0.00

3500452 PHEN/HY/AT/SC(DONNATAL)16MG/5M $0.00

3500453 PHENAZOPYRIDINE (PYRIDIUM) 100 $0.00

3500455 PHENYTOIN (DILANTIN) 100MG/4ML $0.00

3500459 PILOCARPINE HCL 0.01% OPT DRPS $0.00

3500460 PIOGLITAZONE (ACTOS) 15MG TAB $0.00


3500465 PROMETHAZINE (PHENERGAN) 25MG $0.00

3500466 PROPARACAINE HCL 0.50% DRPS $0.00

3500467 PROPOX/ACE(DARVOCET‐N)100‐650M $0.00

3500468 PROPRANOLOL (INDERAL) 20MG TAB $0.00

3500470 RANITIDINE (ZANTAC) 150MG TAB $0.00

3500473 SERTRALINE (ZOLOFT) 100MG TAB $0.00

3500474 SILVER NITRATE APPL 75‐25% STI $0.00

3500475 SILVER SULFADIAZINE 1% 25GM $0.00

3500476 SILVER SULFADIAZINE 1% 50GM $0.00

3500477 SIMETHICONE 80MG CHEW TAB $0.00

3500478 SIMVASTATIN (ZOCOR) 20MG TAB $0.00

3500479 SIMVASTATIN (ZOCOR) 20MG TAB2 $0.00

3500481 SOD THIOSULF/SOD NIT/AMYL NIT $0.00

3500482 SPIRONOLACTONE (ALDACTONE) 25M $0.00

3500483 SPIRONOLACTONE (ALDACTONE) 25M $0.00

3500484 SUCRALFATE (CARAFATE) 1G TAB $0.00

3500485 SULFACETAMIDE SOD 10% DRPS $0.00

3500486 SULFAME/TRIM(BACTRIM)200‐40/5M $0.00

3500487 SUMATRIP SUC (IMITREX) 50MG TA $0.00

3500488 TEMAZEPAM (RESTORIL) 15MG CAP $0.00

3500491 TET/DIP/PERT(ADACEL)2‐2.5‐5/.5 $0.00

3500492 TET/DIPHT/PF (DECAVAC) 0.5ML S $0.00

3500493 TET/DIPT/PF (DECAVAC) 0.5ML VL $0.00

3500494 THIAMINE (VITAMIN B‐1) 100MG T $0.00

3500496 TOBRAMY/DEX (TOBREX) 0.3‐0.1% $0.00

3500497 TRAMADOL (ULTRAM) 50MG TAB $0.00

3500498 TUBERCULIN (APLISOL) 5TU/0.1ML $0.00

3500502 VERAPAMIL ER 120MG TAB $0.00

3500503 ZOLPIDEM TART (AMBIEN) 5MG TAB $0.00


3500505 HYDROCORT ACETATE (ANUCORT‐HC) $0.00

3500506 CHOLECALCIFEROL 1000 UNITS TAB $0.00

3500507 DILTIAZEM 60MG TAB $0.00

3500509 GUAIFENESIN 400MG TAB $0.00

3500510 CAPTOPRIL 25MG TAB $0.00

3500511 ZINC GLUCONATE 50MG TAB $0.00

3500512 MORPHINE SULF (MS) ER 15MG TAB $0.00

3500514 GABAPENTIN 300MG CAP $0.00

3500528 VITAMIN E 100UNIT CAP $0.00

3500530 VITAMIN B‐12 100MCG TAB $0.00

3500536 GLIPIZIDE ER (GLUCOTROL) 5MG T $0.00

3500539 FLUCONAZOLE (DIFLUCAN) 200MG $0.00

3500542 MECLIZINE HCL (ANTIVERT) 25MG $0.00


3500545 FLEET GLYCERIN SUPPOS RECTA $0.00


3500550 FLUOXETINE (PROZAC) 20MG CAP $0.00

3500552 PREDNISOLONE ACETATE 1%(OMNIPR $0.00

3500553 FLUOROMETHOLONE 0.1% 5ML OPH S $0.00

3500682 METOPROLOL ORAL TABLET 50MG $0.00

3500731 INSULIN GLARGINE 100U/ML $0.00

3500824 FLUTICASONE/SALMET 250/50 INH $0.00

3500939 CLOTRIMAZOLE 10MG LOZENGE $0.00

3500940 SULFASALAZINE (AZULFIDINE) 500 $0.00

3500941 DONEPEZIL 5MG TAB $0.00

3500942 BUSPIRONE 5MG TAB $0.00

3500944 IMIPRAMINE HCL (TOFRANIL) 10MG $0.00

3500952 SOOTH XP OPTHALMIC SOLUTION 15 $0.00

3500960 CALCIUM CARBONATE 500MG CHEW $0.00

3500974 OXYCODONE (ROXICODONE) 15MG TA $0.00

3500976 OXYCODONE/ACETAMIN (PERCOCET) $0.00

3500997 TRIVITA NERVE FORMULA $0.00

3501023 LISINOPRIL ORAL TABLET 5MG $0.00

3501045 METOPROLOL ORAL TABLET 50MG $0.00

3501051 TAMSULOSIN 0.4 MG CAP $0.00

3501085 ALCOHOL BEVERAGE $0.00

3501125 FLEET ENEMA $0.00

3501161 ALPRAZOLAM 0.25 MG TAB $0.00

3501165 MEGESTROL SUSPENSION 40MG/ML $0.00

3501168 HYDRALAZINE HCL 25MG TAB $0.00

3501202 SALINE LOCK FLUSH $0.00

3501220 DIAZEPAM 5MG TAB $0.00

3501221 CHOLECALCIFEROL 5000 UNIT TAB $0.00

3501239 ACYCLOVIR 400MG TAB $0.00

3501247 TUBERCULIN (APLISOL) **READ SK $0.00

3501268 PANTOPRAZOLE 40 MG INJ $0.00


3501369 NEUROPATHIC CREAM $0.00

3501435 BUPROPION HCL SR 150MG (12HR) $0.00

3501451 HYDROXYCHLOROQUINE 200MG TAB $0.00

3501629 DISP CAUTERY PEN $0.00

3501689 VENLAFAXINE XR 150MG CAP $0.00

3501699 TRIAMCINOLONE 0.5% CREAM $0.00

3501745 WARFARIN 2.5 MG TAB $0.00

3501749 Vitamin B12 1000 mcg $0.00

3501833 HYDROCODONE/APAP 10‐325MG TAB $0.00

3501844 FAMOTIDINE 20 MG TABLET $0.00

3501877 LIDOCAINE VISCOUS 2% SOL $0.00

3501912 TAMIFLU CAP 75MG $0.00

3501919 PULMICORT (BUDESONIDE) 0.5MG/2 $0.00

3501920 OSELTAMIVIR (TAMIFLU) 75 MG CA $0.00

3501952 THERMOTABS ORAL TAB 287MG‐180M $0.00

3501974 CLOTRIMAZOLE/BETAMETH DIPRO 15 $0.00


3502168 NEOMYCIN SULFATE TAB 500MG $0.00

3502227 LORAZEPAM 0.5MG TAB $0.00

3502336 MYLANTA/LIDOCAINE/DONNATOL 30: $0.00

3502379 CLOTRIMAZOLE 1% TOP CREAM 15GM $0.00

3502444 CHLORDIAZEPOXIDE 25MG CAP $0.00

3502475 TYGACIL 50 MG VIAL $0.00

3502564 SERTRALINE 50MG ORAL TABLET $0.00

3502566 QUETIAPINE FUMARATE 300MG TAB $0.00

3502585 RIFAMPIN (RIFADIN) CAP 300MG $0.00

3502606 SANTYL OINTMENT 250 U 30 GM $0.00

3502694 EYE WASH SOLUTION 120 ML $0.00

3502729 ALENDRONATE 70 MG TAB $0.00

3502813 ETOMIDATE 2MG/ML 10ML VIAL $0.00

3502828 BENZTROPINE 1 MG TAB $0.00

3502832 PREDNISONE SOLUTION 5MG/5ML $0.00

3502918 MIRTAZAPINE 45MG TAB $0.00

3502923 THEOPHYLLINE 100MG ER TAB (12H $0.00

3502955 IPRATROPIUM BROMIDE INH/NEB SO $0.00

3502958 PNEUMOCOCCAL 13‐VALENT VACC $0.00

3502982 HYDROCOD/ACET (NORCO) 5‐325MG $0.00

3503045 POTASSIUM CHLOR 10MEQ ORAL TAB $0.00

3503055 NORMAL SALINE FLUSH INJECTION $0.00

3503079 VENLAFAXINE XR 75MG CAP $0.00


3503094 ROPINIROLE HCL 1MG TAB $0.00

3503152 SODIUM CHLORIDE 0.9% 100ML $0.00


3503193 TIZANIDINE 4MG ORAL TABLET $0.00

3503212 SUMATRIP SUC (IMITREX) 25MG TA $0.00

3503307 NITROPRUSSIDE 50MG/2ML INJ $0.00

3503311 SODIUM CHLORIDE 0.9% 10 ML SD $0.00

3503319 IVPB TRACKING $0.00

3503322 DIVALPROEX DR 250MG TABLET $0.00

3503323 VITAMIN A&D OINTMENT $0.00

3503324 TROPICAMIDE 1% OPTH SOLUTION $0.00

3503325 MUPIROCIN 2% OINTMENT $0.00

3503332 TOPIRAMATE 100MG TAB $0.00

3503355 CLOTRIMAZOLE 1% VAG CR TUBE/AP $0.00

3503358 HYDROMORPHONE (DILAUDID) 1MG/M $0.00


3503383 DILTIAZEM 125MG/25ML VIAL $0.00

3503399 SODIUM CHLORIDE 3% 500 ML $0.00

3503430 AZITHROMYCIN ORAL SUSP 100MG/5 $0.00

3503445 TRIAMCINOLONE ACET 40MG/ML VIA $0.00

3503456 ROCURONIUM BROMIDE 50MG/5ML $0.00




3503493 OXYCODONE HCL 10MG ORAL TAB $0.00

3503500 MEGESTROL ACETATE 40MG/1ML ORA $0.00


3503781 ANTIVENIN POLYVALENT 1 VIAL V $0.00

3503791 NAFCILLIN 2GM IVPB $0.00

3503792 NON‐FORMULARY (SPECIAL) 1 MISC $0.00

3503795 NS FLUSH 10ML $0.00

3503797 PATIENT OWN MEDICATION 1 DOSE $0.00

3503798 METHYLPREDNISOLONE 1000MG VIAL $0.00

3503799 FINGER STICK BLOOD SUGAR 1 STR $0.00

3503800 TPN PER PHARM PRTCOL 1BAG DOSE $0.00

3503809 ROBIDML $0.00

3503810 GI COCKTAIL 1 DOSE $0.00

3503811 ACETAMINOPHEN 160MG/5ML ELIXIR $0.00

3503812 LIDOCAINE JELLY 2% $0.00

3503813 ATORVASTATIN 20MG TABLET

3503814 LIDOCAINE 2% 100MG/5ML SYR $0.00

3503815 LIDOCAINE UROJET $0.00

3503816 LEVONORTESTREL 1.5MG $0.00

3503817 OLANZAPINE 10MG INJ $0.00

3503819 LEVETIRACETAM 500 MG TABLET $0.00

3503820 PHENAZOPYRIDINE 95MG $0.00

3503821 BUDESONIDE 0.5 MG/2ML $0.00

3503822 PNEUMOCOCCAL (PNEUMOVAX 23) $0.00

3503824 LIDOCAINE 1% WITH EPI $0.00 J2001

3503825 LIDOCAINE 2% WITH EPI 20ML VI $0.00 J2001

3503826 NEO/POLYB/HYDRO SOL $0.00

3503827 MICONAZOLE 2% 30 GRAM TUBE $0.00

3503828 DONNATAL ELIXIR $0.00

3503830 TIOTROPIUM 18MCG INH CAP $0.00

3503831 DIPT/TTN/ACET.PERT VACC $0.00

3503833 QUETIAPINE 25MG TABLET $0.00

3503834 IBUPROFEN 100MG/5ML SUSPENSION $0.00

3503835 PROMETH/CODEINE 6.25MG SYR $0.00

3503836 DIPHENHYDRAMINE 12.5MG/5ML SOL $0.00

3503838 PREDNISONE 5MG/ML ORAL SUSP $0.00

3503839 ZIPRASIDONE 20MG $0.00

3503841 DEEP SEA NASAL SPRAY $0.00

3503843 MINERAL OIL/PETROLATUM $0.00

3503844 TRIAMCINOLONE 0.1% $0.00

3503845 CYANOCOBALAMIN 1000MCG/ML $0.00

3503847 ALBUMIN 25% 100ML BOTTLE $0.00

3503850 PHOSPHA 250 NEUTRAL $0.00

3503851 LACTULOSE 20GM/30ML $0.00

3503852 DILTIAZEM CD 120MG CAP $0.00

3503853 DILTIAZEM CD 180MG CAP $0.00

3503854 PROPRANOLOL 10MG $0.00

3503856 RIFAXIMIN 550MG TAB $0.00

3503858 METOPROLOL TARTRATE 25MG $0.00


3503863 METHYLPREDNISOLONE 4MG DOSEPAK $0.00

3503865 PREGABALIN 75MG CAP $0.00

3503866 ARIPIPRAZOLE 10MG TAB $0.00

3503867 LIDOCAINE 5% (LIDODERM) PATCH $0.00

3503869 CELECOXIB 100MG CAP $0.00

3503870 SOLIFENACIN (VESICARE) 5MG TAB $0.00

3503871 GUAFENESIN (MUCINEX) 600MG SRT $0.00

3503874 CLONIDINE 0.2MG/24HR PATCH $0.00

3503875 CLONIDINE 0.3MG/24HR PATCH $0.00

3503876 CARBAMAZEPINE (TEGRETOL) 100MG $0.00

3503877 BUMETANIDE 1MG TAB $0.00

3503881 PANTOPRAZOLE 40MG TAB $0.00

3503882 MESALAMINE HD 800MG CAP $0.00

3503886 BACITRACIN/POLYMIX OINTMENT $0.00

3503887 LIDOCAINE 4% SOLN 50ML BOT $0.00

3503889 ZINC OXIDE OINT 30GM TUBE $0.00

3503890 NOREPINEPHRINE 4MG/4ML INJ $0.00

3503891 VITAMIN A & D OINTMENT 5GM PK $0.00

3503892 SILVER SULFADIZINE 1% 400GM JA $0.00

3503894 KETAMINE 50MG/ML 10ML VIAL $0.00

3503896 CHOLESTYRAMINE 4GM PKT $0.00

3503899 VERAPAMIL 2.5MG/ML 4ML VIAL $0.00

3503902 METFORMIN 750MG XR TAB $0.00

3503903 MINOCYCLINE 100MG CAP $0.00

3503904 MELOXICAM 7.5MG TAB $0.00

3503905 NITROGLYCERIN 6.5MG SR CAP $0.00

3503906 SCOPOLAMINE TD 1.5MG/3DAY PATC $0.00

3503907 NORTRIPTYLINE 10MG CAP $0.00

3503909 PAROXETINE 40MG TAB $0.00

3503913 POTASSIUM CHL (K‐DUR)20MEQ TAB $0.00

3503916 MEDROXYPROGESTERONE 10MG TAB $0.00

3503917 SITAGLIPTAN PHOS 50MG TAB $0.00

3503918 HYDROCORTISONE 2.5% OINT TUBE $0.00

3503919 PROCHLORPERAZINE 5MG TAB $0.00

3503920 CEFDINIR 300MG CAP $0.00

3503921 URSODIOL 250MG TAB $0.00

3503922 LIDOCAINE 2% MPF 5ML SD VIAL $0.00

3503925 ACETAMINOPHEN 1000MG IV SOL $0.00

3503930 Selenium Sulfide 2.5% Top Susp $0.00

3503931 Simvastatin 40mg tablet $0.00

3503932 TRANEXAMIC ACID 1000MG/10ML VL $0.00

3503933 OXYCODONE SR (OXYCONTIN) 20MG $0.00

3503934 SERTRALINE 50MG TABLET $0.00

3503935 VANCOMYCIN 250MG CAP $0.00

3503937 LINEZOLID 600MG TAB $0.00

3503939 MORPHINE 15MG IMMED REL TAB $0.00


3503941 OLANZAPINE 5 MG TAB $0.00

3503942 OXYCODONE SR 10MG TAB $0.00

3503944 NITRGLYCERIN 0.2MG TD PATCH $0.00

3503945 NITROPRUSSIDE 50MG/2ML INJ $0.00

3503946 METHADONE 10MG TAB $0.00

3503948 RIFAMPIN 600MG INJ VIAL $0.00

3503949 HYDROMORPHONE‐HP 10MG/ML INJ V $0.00

3503950 AMOXIXLL/CLAV 400MG/5ML SUSPEN $0.00

3503951 APIXABAN 2.5MG TAB $0.00

3503952 Beclomethasone (QVAR) 80mcg In $0.00

3503953 RISPERIDONE 0.5MG TAB $0.00

3503954 VANCOMYCIN 125MG CAPSULE $0.00

3503955 TETRACAINE 0.5% OS $0.00

3503956 LISINOPRIL 2.5MG TABLET $0.00

3503957 CIPRODEX OTIC SUSPENSION $0.00

3503958 OXYCODONE 5MG/5ML LIQ $0.00

3503959 MIDODRINE 10MG TABLET $0.00

3503960 KETAMINE 10MG/ML VIAL $0.00

3503961 MORPHINE SULF 30MG SR TAB $0.00

3503962 COLLAGENASE OINTMENT $0.00

3503963 ENTECAVIR 0.5MG TAB $0.00

3503964 CARISOPRODOL 350MG TAB $0.00

3503966 LIDOCAINE 1% 10ML VIAL $0.00

3503968 DAKINS HALF STRENGTH SOL $0.00

3503969 DRONABINOL 2.5MG CAP $0.00

3503970 OMEPRAZOLE 10MG SUSP PACKET $0.00

3503971 BETAMETHASONE AUG 0.05% CR $0.00

3503972 COAL TAR 2% OINT $0.00

3503973 BETAMETHASONE AUG .05% OINT $0.00

3503974 PANCREALIPASE $0.00

3503976 ARIPIPRAZOLE 15 MG TAB $0.00

3503977 GABAPENTIN 400MG CAP $0.00

3503978 ALBUTEROL 5MG/ML SOLUTION $0.00

3503979 RIVASTIGMINE 4.6MG PATCH $0.00

3503980 PROPRANOLOL 60MG TAB $0.00

3503981 ESTRADIOL TD 0.1MG PATCH $0.00

3503982 NITROGLYCERIN 0.4MG OINT $0.00

3503984 VALACYCLOVIR 1000MG TAB $0.00

3503985 PROMETHAZINE W/CODEINE 5ML $0.00

3503988 RHOGAM $0.00

3503989 HYDRALAZINE 20MG/ML VIAL $0.00

3503990 SITAGLIPTIN 100MG TAB $0.00

3503991 HYDROMORPHONE 0.5MG/0.5ML SYR $0.00

3503992 DEXMETHYLPHENIDATE 2.5 MG TAB $0.00

3503993 LIDOCAINE/EPI/TETRACAINE GEL $0.00

3503996 FERROUS SULFATE LIQUID $0.00

3503997 FERROUS SO4 300MG/5ML LIQ $0.00

3503998 LEVOTHYROXINE 75MCG TABLET $0.00

3503999 LEVOTHYROXINE 125MCG TABLET $0.00

3504000 ATORVASTATIN 40MG TABLET $0.00

3504001 HEPARIN 500U/5ML VIAL $0.00

3504006 NADOLOL 20MG TAB $0.00


3504008 ROPINIROLE 0.25MG TAB $0.00

3504009 PREDNISONE 5MG TAB $0.00

3504010 NICARDIPINE 25MG/10ML INJ $0.00

3504014 SIMVASTATIN 5MG TAB $0.00

3504015 ARGININE 4.5 GM POWDER PACKET $0.00

3504016 PROMOD PROTEIN SUPPLEMENT 30ML $0.00

3504017 NEO/POLY/DEX OPTH SUSP 5ML $0.00

3504018 NEO/POLY/DEX 5ML OPTH PREPACK $0.00

3504019 SODIUM BICAR 50MEQ 50ML VIAL $0.00

3504022 LEVOFLOXACIN 250MG TAB $0.00

3504023 TPN IV BAG $0.00

3504024 ENEMA MINERAL OIL $0.00

3504025 DANTROLENE 20MG VIAL $0.00

3504026 BIMATOPROST 0.01% OPTH SOL $0.00

3504027 SOD CHLORIDE 3% INH SOL $0.00

3504028 PAROXETINE 10MG TAB $0.00

3504029 CLONAZEPAM 1MG TAB $0.00

3504030 PANTOPRAZOLE 40MG FOR SUSP $0.00

3504031 GABAPENTIN 250MG/5ML SOL 470ML $0.00

3504032 KCL 20MEQ/15ML SOL 473ML BOT $0.00

3504034 BETHANECOL 10MG TAB $0.00

3504035 DOCUSATE 100MG/10ML UDC $0.00

3504036 CHLORHEXIDINE 0.12% ORAL RINSE $0.00

3504037 DILTIAZEM 10MG/2ML SYRINGE $0.00

3504042 LOSARTAN 25MG TAB $0.00

3504045 DELAFLOXACIN 450MG TAB $0.00

3504046 MISOPROSTOL 200MCG TAB $0.00

3504047 LAC HYDRIN 12% LOTION $0.00

3504048 ZINC SULFATE 220MG CAP $0.00

3504049 DILTIAZEM 50MG/10ML VIAL $0.00

3504050 SODIUM CHLORIDE 150MG BAG $0.00

3504052 METHOCARBAMOL 750MG TAB $0.00

3504053 BUPRENORPHINE 8MG SL TABLET $0.00

3504055 ACETAZOLAMIDE 250MG TAB $0.00

3504056 TIMOLOL 0.5% OPTH SOL $0.00

3504058 BRIMONIDINE 0.15% OPTH SOL $0.00

3504059 BRIMONIDINE 0.1% OPTH SOL $0.00

3504060 NICOTINE 4MG GUM $0.00

3504061 SOTALOL 120MG TABLET $0.00

3504062 MEMANTINE 5MG TAB $0.00

3504063 CALCITRIOL 0.25MG CAP $0.00

3504064 ISOSORBIDE MONO SR 30MG TAB $0.00

3504067 THEOPHYLLINE SR 300MG TAB $0.00

3504070 IMPACT PEPTIDE 250ML TUBE FEED $0.00

3504071 METHADONE ORAL CONC 10MG/ML $0.00

3504072 METHYLPHENIDATE CD 30MG CAP $0.00

3504073 NALDEMEDINE 0.2MG TAB $0.00

3504074 TESTOSTERONE 4MG PATCH $0.00

3504075 COMBIGAN OPTH SOL 5ML $0.00

3504076 I‐VIT (OCUVITE) TAB $0.00

3504077 AMOXICILLIN 250MG/5ML BOT 80ML $0.00

3504079 ALBUMIN 25% 50ML BOTTLE $0.00

3504081 LUBIPROSTONE (AMITIZA) 24MG CA $0.00

3504084 BIOTENE DRY MOUTH SPRAY $0.00

3504085 JUVEN SUPPLEMENT PACKET $0.00

3504086 APIXABAN 5MG TAB $0.00

3504089 HYDROXYZINE HCL 50MG TAB $0.00

3504090 ARTIFICIAL TEARS OPTH OINTMENT $0.00

3504091 CHLORASEPTIC THROAT SPRAY $0.00

3504092 VECURONIUM 10MG VIAL $0.00

3504093 DIPHENHYDRAMINE 25MG/10ML UDC $0.00

3504094 TRIAMCINOLONE 0.1% CREAM 30GM $0.00

3504096 GABAPENTIN 600MG TABLET $0.00

3504098 BUSPIRONE 10MG TABLET $0.00

3504099 AMILORIDE 5MG TABLET $0.00

3504116 PROMOD PROTEIN SUPP LIQUID $0.00

3505000 OSELTAMIVIR 6MG/ML 60ML SUSP $0.00

3505003 INTRALIPID 20% 250ML $0.00


3505006 DICLOFENAC 1% GEL $0.00

3505007 ESCITALOPRAM 10MG TABLET $0.00

3505008 NOVASURCE RENAL 8OZ TUBE FEED $0.00

3505009 LINACLOTIDE 145MG CAP $0.00

3505010 BIOTENE MOUTHWASH $0.00

3505011 PEPTAMEN PREBIO FORMULA $0.00

3505012 FLUDROCORTISONE 0.1MG TAB $0.00

3505015 DEPAKOTE 125MG SPRINKLE CAP

3505016 MORPHINE 10MG/10ML VIAL $0.00

3505018 ATROPINE 1% OPTHALMIC SOL $0.00

3505019 ALPRAZOLAM 1MG TABLET $0.00

3505020 BACLOFEN 20MG TABLET $0.00

3505021 LEVODOPA/CARB CR 50/200MG TAB $0.00

3505022 LEVODOPA/CARB CR 25/100MG TAB $0.00

3505023 PROPARACAINE/FLUORESCEIN OPTH $0.00

3505024 DIABETISOURCE AC 250ML LIQ $0.00

3505028 BUPRENORPHINE 2MG SL TAB $0.00

3505029 ETHACRYNIC ACID 25MG TAB $0.00

3505030 FEBUXOSTAT 40MG TAB $0.00

3505031 LEFLUNOMIDE 20MG TAB $0.00

3505032 SULFASALAZINE 500MG TAB $0.00

3505033 METHYLNALTREXONE 12MG SYRINGE $0.00

3505034 NICOTINE LOZENGE 2MG $0.00

3505035 SOD CITRATE/CITRIC ACID SOL $0.00

3505039 BACITRACIN/POLYMYXIN OPTH OINT $0.00

3508999 PHARM NON‐PATIENT SALE $0.00

3509000 MISC PHARMACY ITEM $0.00

3509001 PATIENTS OWN MED $0.00

3590749 SULFAMETH/TRIMETH 100ML SUS $0.00

3590750 BUPROPION XL150MG TAB $0.00

3590753 CETIRIZINE HCL 10MG TAB $0.00

3590754 CLONIDINE 0.1MG/24HR TD PATCH $0.00

3590756 LACTOBACILLUS ACIDOPHILUS CAP $0.00

3590763 DULOXETINE 30MG CAP $0.00

3590765 ESTRADIOL 0.5MG TAB $0.00

3590767 FINASTERIDE 5MG TAB $0.00

3590768 FLUTICASONE 50MG NASAL SPRY $0.00

3590769 GLIMEPIRIDE 2MG TAB $0.00

3590770 GLUCO/CHONDR 500MG CAP $0.00

3590771 GLUCO/CHOND 500MG/400MG TAB $0.00

3590773 LACOSAMIDE 100MG TAB $0.00

3590775 LAMOTRIGINE 100MG TAB $0.00

3590776 LATANOPROST 0.005% OPTH SOL $0.00


3590779 OMEGA‐3/DHA/EPA/FISH OIL 1 CAP $0.00

3590780 MELATONIN 3MG TAB $0.00

3590781 METFORMIN 850MG TAB $0.00

3590782 METOPROLOL XL 50MG TAB $0.00

3590783 MIRTAZAPINE 15MG TAB $0.00

3590784 MONTELUKAST 10 MG TAB $0.00

3590785 MUPIROCIN 2% CREAM 15GM TUB $0.00

3590786 NIACIN 500MG SR 24HR TAB $0.00

3590787 OXYBUTYNIN 5MG TAB $0.00

3590788 PIOGLITAZONE 15MG TAB $0.00

3590790 PRAMIPEXOLE 0.25MG TAB $0.00


3590792 QUETIAPINE 100MG TAB $0.00

3590793 RIVAROXABAN 10MG TAB $0.00

3590794 RIVAROXABAN 15MG TAB $0.00


3590796 VALACYCLOVIR 500MG CAP $0.00

3590797 VENLAFAXINE XR 37.5MG CAP $0.00

3590798 ZIPRASIDONE 20MG CAP $0.00

BIMA.01OS BIMATOPROST 0.01% OPTH SOL $0.00

CB001 MAILING LABELS $27.99

CB002 PROCESSING FEE $5.00

CB003 MISC CHARGES $0.00

METOP25 METOPROLOL TARTRATE 25MG TAB $0.00

3500045 AZITHROMYCIN 250MG 6TAB PRE.PK $0.00

3500074 CIPRO 500MG 6 TAB PRE.PK $0.00

3500343 AZITHROMYCIN 100MG/5ML SUSP PP $0.00

3503793 HYDROCODONE/APAP 5/325MG #6 PP $0.00

3503803 AMOXICILLIN 250/5ML SUS PRE.PK $0.00

3503804 AMOXICILLIN 500MG 6 CAP PRE.PK $0.00

3503805 SULFA/TMP DS #6 PRE.PK $0.00

3503806 CEPHALEXIN 250MG 8 CAP/PRE.PK $0.00

3503807 CEPHALEXIN 500MG 8CAP/PRE.PK $0.00

3503808 IBUPROFEN 600MG 6 TAB PRE.PACK $0.00

3503864 ACETAMINOPNEN ELIXIR 118ML/PP $0.00

3503929 PROMETHAZINE W/CODEINE LIQ PP $0.00

3503967 CLINDAMYCIN 150MG 8CAP/PRE.PK $0.00

3504003 PENICILLIN VK 500MG #6 PREPACK $0.00

3504004 PREDNISOLONE 15MG/5ML 60ML PP $0.00

3504038 ALBUTEROL INHALER PRE.PACK $0.00

3504039 ONDANSETRON 4MG #6 PRE.PK $0.00

3504040 TRAMADOL 50MG TAB #8 PRE.PK $0.00

3504043 NITROGLYCERIN 0.4MG PRE.PK $0.00

3504051 NEOMYCIN/POLY/HC OTIC PREPACK $0.00

3504054 ERYTHROMYCIN OPTH OINT PP $0.00

3504078 PHENAZOPYRIDINE 100MG PP #8 TA $0.00

3504087 ALBUTEROL NEB SOLN PREPACK $0.00

3504088 DUONEB NEBULIZER PREPACK $0.00

3504095 AMOXICILLIN 250MG/5ML 80ML PP $0.00

3505017 GENTAMICIN OPTH SOL PRE.PACK $0.00

2000240 SODIUM CHLORIDE 0.9% 50ML BAG $0.00




2000244 SODIUM CHLORIDE 0.9% 1000ML BG $0.00

2000245 SODIUM CHLORIDE 0.45% 1000ML B $0.00

2000246 D5NS 1000 ML BAG $0.00

2000247 D5‐1\2NS 1000 ML BAG $0.00

2000248 D5W 100 ML BAG $0.00

2000249 D5W 500 ML BAG $0.00

2000251 LACTATED RINGERS SOLU 1000ML B $0.00

3502842 DEXTROSE 5% WATER 500ML $0.00

3502865 D5W 1/2 NS $0.00

3503783 D5W 1000 ML BAG $0.00

3503784 D5W 250 ML BAG $0.00

3503837 3% HYPERTONIC SALINE IV $0.00

3504002 D5 1/2NS W/KCL 20MEQ 1000ML $0.00

3505004 DEXTROSE 10% 1000ML BAG $0.00

3500002 ABATACEPT/MALTOS 250MG VIAL $0.00 J0129

3500011 ACETYLCYST (ACETADOTE) 100MG/M $0.00 J0132

3500012 ACETYLCYST (MUCOMYST) 200MG/ML $0.00 J7608

3500018 ALBUTEROL 2.5MG/3ML NEB $0.00 J7613

3500019 ALBUTEROL SULF 2.5MG/3ML NEB2 $0.00 J7613

3500020 ALBUTEROL SULF 2.5MG/3ML NEB3 $0.00 J7613

3500022 AMIODARONE (CARDARONE) 50MG/ML $0.00 J0282

3500029 AMPICIL/SUBACT (UNASYN) 1.5GM $0.00 J0295

3500030 AMPICIL/SUBACT (UNASYN) 3GM VL $0.00 J0295

3500042 ATROPINE SUL (ISOPTO)0.1MG/ML $0.00 J0461

3500043 ATROPINE SULFATE (ISOPTO) 1MG/ $0.00 J0461

3500049 BETAMETHASONE ACET/BET 6MG/ML $0.00 J0702

3500065 CEFAZOLIN SODIUM (ANCEF) 1GM V $0.00 J0690

3500067 CEFTAZIDIME PENT (TAZICEF) 1GM $0.00 J0713

3500068 CEFTRIAXONE 1GM VL INTRAMUSCUL $0.00 J0696

3500069 CEFTRIAXONE 2GM VL INTRAMUSCUL $0.00 J0696

3500073 CIPROFLOXACIN (CIPRO) 400MG/40 $0.00 J0744

3500076 CYANOCOBALAMIN (B‐12) 1000MCG $0.00 J3420

3500077 DEFEROXAMINE (DESFERAL) 500MG $0.00 J0895

3500078 DEXAMETHASONE (DECADRON) 4MG T $0.00 J1100

3500083 DIAZEPAM (VALIUM) 5MG/ML SYRG $0.00 J3360

3500084 DIGOXIN (DIGITEK) 250MCG/ML AM $0.00 J1160

3500086 DIHYDROERGOTAMINE (DHE) 1MG/ML $0.00 J1110

3500089 DIPHENHYDRAMINE 50MG/ML SDV $0.00 J1200

3500090 DOBUTAMINE 250MG/20ML VIAL $0.00 J1250

3500097 DOPAMINE HCL 400MG/10ML VL $0.00 J1265

3500102 DROPERIDOL (INAPSINE) 2.5MG/ML $0.00 J1790

3500105 ENOXAPARIN (LOVENOX) 100MG/ML $0.00 J1650

3500106 ENOXAPARIN (LOVENOX)30MG/0.3ML $0.00 J1650



3500109 EPINEPH (ADRENALIN) 0.1MG/ML S $0.00 J0171

3500110 EPINEPH (ADRENALIN) 0.1MG/ML S $0.00 J0171

3500111 EPINEPHRINE (ADRENALIN) 1MG/ML $0.00 J0171

3500119 FENTANYL CITRATE 100MCG/2ML VI $0.00 J3010

3500124 FLUCONAZOLE 200MG/100ML IV SOL $0.00 J1450

3500128 FUROSEMIDE 20MG/2ML VIAL $0.00 J1940

3500129 FUROSEMIDE 40MG/4ML VIAL $0.00 J1940

3500133 GLUCAGON 1MG EMERG KIT $0.00 J1610

3500134 GLUCAGON 1MG INJ KIT $0.00 J1610

3500142 HALOPERIDOL LACT 5MG/ML INJ VI $0.00 J1630

3500143 HEPARIN/D5W 25000U/500ML IV $0.00 J1644

3500146 HEPARIN SODIUM 10UNIT/ML FLUSH $0.00 J1642

3500147 HEPARIN SODIUM 5000UNIT/1ML VI $0.00 J1644

3500148 HUM INSUL/RG INS(HUMULIN)70‐30 $0.00 J1815

3500156 HYDROMORPHONE (DILAUDID) 2MG/M $0.00 J1170

3500157 HYDROMORPHONE (DILAUDID) 2MG/M $0.00 J1170

3500158 HYDROXYZINE (VISTARIL) 25MG CA $0.00 Q0177

3500160 IBANDRONAT SOD (BONIVA) 3MG/3M $0.00 J1740

3500164 IMIPEN/CILASTAT (PRIMAXIN) 500 $0.00 J0743

3500165 INSULIN LISPRO (HUMALOG) INJ P $0.00 J1815

3500167 INSULIN LISPRO (HUMALOG) 100UN $0.00 J1815

3500168 INSULIN REG (HUMULIN R) 100ML $0.00 J1815

3500169 IPATROPIUM 0.02% 2.5ML NEB $0.00 J7644

3500170 IRON/DEXTRAN (DEXFERRUM) 50MG/ $0.00 J1750

3500172 KETOROLAC (TORADOL) 15MG/ML VL $0.00 J1885

3500173 KETOROLAC (TORADOL) 30MG/ML VL $0.00 J1885

3500174 KETOROLAC (TORADOL) 60MG/2ML V $0.00 J1885

3500177 LEVOFLOXACIN (LEVAQUIN) 25MG/M $0.00 J1956

3500178 LEVOFLOXACIN (LEVAQUIN) 25MG/M $0.00 J1956

3500186 LIDOCAINE/D5W 4MG/ML 250ML IV $0.00 J2001

3500192 LORAZEPAM 2MG/ML INJ VL $0.00 J2060

3500201 MANNITOL 0.25% 12.5G/50ML VL $0.00 J2150

3500203 MEPERIDINE 25MG/ML INJ $0.00 J2175

3500206 MEPERIDINE (DEMEROL) 50MG/ML S $0.00 J2175

3500207 MEPERIDINE (DEMEROL) 75MG/ML S $0.00 J2175

3500210 METHYLERG (METHERGINE) 0.2MG/M $0.00 J2210

3500212 METHYLPRED(SOLU‐MEDROL) 40MG/M $0.00 J2920

3500213 METHYLPRED(SOLU‐MEDROL)125MG/2 $0.00 J2930

3500214 METHYLPREDNISOLONE (MEDROL) 4M $0.00 J7509

3500215 METOCLOPRAMIDE 5MG/ML INJ $0.00 J2765

3500217 METRONIDAZOLE 500MG/100ML IVPB $0.00 S0030

3500228 MORPHINE SULF 2MG/ML INJ $0.00 J2270


3500237 NALOXONE 0.4MG/ML 1ML SYRINGE $0.00 J2310

3500249 NPH INSULIN (HUMULIN N) 100ML $0.00 J1815

3500254 ONDANSETRON (ZOFRAN) 2MG/ML VL $0.00 J2405

3500256 ORPHENADRINE 30MG/ML INJ $0.00 J2360

3500262 PHENYTOIN 50MG/ML VIAL $0.00 J1165

3500270 POTASS CH/NS (KCL/NS)20MEQ/L I $0.00 J3480

3500273 POTASSIUM CHL (KLOR‐CON) 2MEQ/ $0.00 J3480

3500276 PREDNISONE (DELTASONE) 1MG TAB $0.00 J7512

3500277 PREDNISONE 20MG TAB $0.00 J7512

3500278 PROCAINAMIDE 1GM/10ML INJ $0.00 J2690

3500281 PROMETHAZINE 25MG/ML INJ $0.00 J2550

3500282 PROMETHAZINE (PHENERGAN) 50MG/ $0.00 J2550

3500300 SUCCINYL CHL (ANECTINE) 20MG/M $0.00 J0330

3500302 SUMATRIPTAN SUC 6MG/0.5 INJ $0.00 J3030

3500308 TRIAMCINOLONE ACET 40MG/ML VIA $0.00 J3301

3500309 TRIAMCIN ACET (KENELOG) 40MG/M $0.00 J3301

3500328 ALTEPLASE (CATHFLO) 2MG/ML INJ $0.00 J2997

3500329 AMIODARONE 360MG/200ML IV PREM $0.00 J0282

3500336 AMPICILLIN SOD (OMNIPEN) 2000M $0.00 J0295

3500342 AZITHROMYCIN 500MG VIAL $0.00 J0456

3500347 BUTORPHANOL TART (STADOL) 2MG/ $0.00 J0595

3500348 CALCIUM GLUCONATE 100MG/ML VL $0.00 J0610

3500351 CEFTAZIDIME PENT (FORTAZ) 1GM $0.00 J0713

3500352 CEFTAZIDIME PENT (FORTAZ) 1GM $0.00 J0713

3500357 CLINDAMYCIN (CLEOCIN) 150MG/ML $0.00 S0077

3500366 DEXAMETHASONE (DECADRON) 4MG/M $0.00 J1100

3500378 DOXYCYCLINE 100MG VIAL $0.00 J3490

3500395 GENTAMICIN 40MG/ML INJ VL $0.00 J1580

3500398 HEP B VAC (ENGERIX B) 20MG/ML $0.00 90746

3500399 HEP B VAC (ENGERIX B)10MCG/0.5 $0.00 90744

3500412 KETOROLAC 60MG/2ML VIAL 2 ML $0.00 J1885

3500416 LEVOFLOXACIN (LEVAQUIN) 25MG/M $0.00 94640

3500426 LORAZEPAM (ATIVAN) 2MG/ML VIAL $0.00 J2060

3500429 MAGNESIUM SULF 1GM/2ML INJ $0.00 J3475

3500439 MIDAZOLAM 2MG/2ML VIAL $0.00 J2250

3500454 PHENTOLAMINE MESYL 5MG/2ML INJ $0.00 J2760

3500462 PRALIDOXIME CHL (PROTOPAM) 1G $0.00 J2730

3500464 PROCHLORPERAZINE 5MG/ML 2ML $0.00 J0780

3500469 PROTAMINE SULFATE 10MG/ML INJ $0.00 J2720

3500472 RITUXIMAB 10MG/ML 50ML $0.00 J9312

3500489 TENECTEPLASE (TNKASE) 50MG KIT $0.00 J3101

3500490 TET IMMUNE GLOB (HYPERTET)250U $0.00 J1670

3500495 THIAMINE (VIT B‐1) 100MG/ML IN $0.00 J3411

3500499 VANCOMYCIN 1GM VIAL $0.00 J3370

3500500 VANCOMYCIN (VANCOCIN) 1GM VL $0.00 J3370

3500501 VANCOMYCIN (VANCOCIN) 500MG VI $0.00 J3370

3500508 VANCOMYCIN (VANCOCIN) 250MG VL $0.00 J3370

3500558 ADENOSINE 6MG/2ML VIAL $0.00 J0153

3500560 AMIODARONE 150MG/3ML INJ VIAL $0.00 J0282

3500569 FLUPHENAZINE DECANOATE 25MG/ML $0.00 J2680

3500578 NALOXONE 0.4MG/ML 1ML VIAL $0.00 J2310

3500584 METHYLPRED(SOLU‐MEDROL) 500MG $0.00 J2930

3500587 HYDROCORT SOD SUCC 100MG VIAL $0.00 J1720

3500590 METHYLPRED SOD SUCC 1000MG MDV $0.00 J2930

3500592 PHYTONADIONE 10MG/ML AMPULE $0.00 J3430

3500598 PIPERACILLIN/TAZOBACT 3.375GM $0.00 J2543

3501906 LEVAQUIN/D5W 500MG/100ML IV SO $0.00 J1956

3502125 ALBUTEROL‐IPATROPIUM 3ML NEB $0.00 J7620

3502504 IRON SUCROSE 100MG/5ML INJ $0.00 J1756

3502536 ALTEPLASE (ACTIVASE) 100MG VL $0.00 J2997

3502558 CEFTRIAXONE 500MG VAIL INJ $0.00 J0696

3502784 AMPICILLIN 1GM PWD VIAL INJ $0.00 J0290

3503054 CEFTRIAXONE 1GM VIAL $0.00 J0696


3503455 IMIPEN/CILAST 500MG/500MG/100M $0.00 J0743

3503459 FOLIC ACID 50MG/10ML IV VIAL $0.00 J3490

3503464 POTASSIUM CL/NS 10MEQ/100ML IV $0.00 J3480

3503490 ERTAPENEM 1000MG/50ML NS IVPB $0.00 J1335

3503491 ERTAPENEM (INVANZ) 1000MG VL $0.00 J1335

3503588 INSULIN REG (HUMULIN R) 100 UN $0.00 J1815

3503782 D5NS+KCL 20 MEQ/L 1000ML BAG $0.00 J3480

3503785 DAPTOMYCIN 500MG VIAL $0.00 J0878

3503787 LEVETIRACETAM 500 MG/5ML INJ $0.00 J1953

3503788 LEVOFLOXACIN 250 MG/50 ML IVPB $0.00 J1956

3503790 LEVOFLOXACIN 750 MG/150 ML IV $0.00 J1956

3503794 NS 0.9%+KCL 20MEQ/L 1000ML BAG $0.00 J3480

3503796 PHENYTOIN 250 MG/5 ML VIAL $0.00 J1165

3503801 PIPERACILLIN\TAZOBACTAM 2.25GM $0.00 J2543

3503802 PIPERACILLIN\TAZOBACTAM 4.5GM $0.00 J2543

3503818 ALTEPLASE 100MG INJECTION J2997

3503823 MEPERIDINE 50MG/ML INJ $0.00 J2175

3503829 ORENCIA 250MG IV $0.00 J0129

3503832 DIAZEPAM 10MG/2ML INJ $0.00 J3360

3503840 CEFEPIME HCL 1000MG INJ $0.00 J0692

3503842 DEFEROXAMINE 500MG VIAL $0.00 J0895

3503848 LINZEOLID 600MG/300ML IV $0.00 J2020

3503849 REMICADE $0.00 J1745

3503860 INFLUENZA VACCINE QV 2018‐2019 $0.00 90674

3503861 INFLUENZA VACCINE HIGH DOSE $0.00 90662

3503879 AZATHIOPRINE (IMURAN) 50MG TAB $0.00 J7500

3503884 PROPOFOL 10MG/ML IV 20ML VIAL $0.00 J2704

3503893 HYDROCORTISONE SOD SUCC 250MG $0.00 J1720

3503900 AMIODARONE 450MG/9ML INJ VIAL $0.00 J0282

3503901 CLINDAMYCIN 900MG/50ML IV PREM $0.00 S0077

3503908 CEFTRIAXONE 2GM/50ML PREMIX IV $0.00 J0696

3503910 ENOXAPARIN 100MG/ML 3ML MDVIAL $0.00 J1650

3503912 VANCOMYCIN (VANCOCIN) 750MG VL $0.00 J3370

3503914 CLINDAMYCIN 600MG/50ML IV PREM $0.00 S0077

3503915 LEVALBUTEROL 1.25MG/0.5ML INH $0.00 J7612

3503923 CIPROFLOXACIN IV 200MG/100ML $0.00 JO744

3503924 MEROPENEM 1GM IV PWD VL $0.00 J2185

3503926 MEROPENENM 1GM/50ML IV PREMIX $0.00 J2185

3503927 MEROPENEM 500MG/50ML IV PREMIX $0.00 J2185

3503936 FLUCON/NS (DIFLUCAN)400MG/200M $0.00 J1450

3503938 COSYNTROPIN 0.25MG INJ $0.00 J0834

3503943 NAFCILLIN 2GM VIAL $0.00 S0032

3503947 ACETYLCYSTEINE 20% 30ML PO/INH $0.00 J7608

3503965 CEFTRIAXONE 250MG VIAL $0.00 J0696

3503975 TIGECYCLINE 50MG INJ $0.00 J3243

3503994 CEFEPIME 1GM $0.00 J0692

3503995 CEFEPIME 2GM VIAL $0.00 J0692

3504005 MICAFUNGIN 100MG VIAL $0.00 J2248

3504013 MICAFUNGIN 100MG VIAL $0.00 J2248

3504020 AMIODARONE 360MG/200ML PREMIX $0.00 J0282

3504021 POT CHLOR 10MEQ INJECTION $0.00 J3480

3504033 IMMUNE GLOBULIN 20GM/200ML BOT $0.00 J1569

3504041 CEFTAZIDIME 2GM VIAL $0.00 J0713

3504044 MEROPENEM 500MG VIAL $0.00 J2185

3504057 MAGNESIUM SULF 1GM/100ML BAG $0.00 J3475

3504065 CLINDAMYCIN 900MG/6ML VIAL $0.00 S0077

3504066 MIDAZOLAM 10MG/2ML VIAL $0.00 J2250

3504068 FERRIC CARBOXY 750MG VIAL $0.00 J1439

3504069 ZOLEDRONIC ACID 5MG/100ML INJ $0.00 J3488

3504080 PENICILLIN G POT 5 MU VIAL $0.00 J2540

3504082 DARBEPOETIN 25MCG VIAL $0.00 J0881

3504083 DARBEPOETIN 10MCG SYRINGE $0.00 J0881

3504097 ZOLEDRONIC ACID 4MG $0.00 J3489

3505001 ZOLEDRONIC ACID 4MG/100ML BAG $0.00 J3489

3505002 D5.5NS+KCL 20MEQ/L 1000ML BAG $0.00 J3480

3505013 ARANESP 60 MCG INJECTION $0.00 J0881

3505014 ARANESP 40 MCG INJ $0.00 J0881

3505026 AZTREONAM 2GM VIAL $0.00 S0073

3505027 MANNITOL 20% IV PREMIX $0.00 J2150

3505036 VANCOMYCIN 1 GM PREMIX BAG $0.00 J3370

3505037 VANCOMYCIN 1.5GM PREMIX BAG $0.00 J3370

3509002 CIPROFLOXACIN/D5W 400MG/200ML $0.00 J0744

3509020 CEFTRIAXONE 1GM/50ML PREMIX IV $0.00 J0696

3586580 TB TEST $0.00

3590460 PEDIATRIC IMMUNIZATION ADMINIS $0.00 86580

3590461 PED IMM ADMIN‐EA ADDTL SHOT $0.00 90460

3590471 ADULT IMMUNIZATION ADMINISTRAT $0.00 90461

3590472 ADULT IMM ADMIN‐EA ADDTL SHOT $0.00 90471

3590633 HEP A VACCINE PEDIATRIC 720EL. $0.00 90472

3590649 HUMAN PAPILLOMAVIRUS VACC 20‐4 $0.00 90633

3590655 INFLUENZA PP 6‐35 MONTHS $0.00 90649

3590658 INFLUENZA MDV W/ PRESERVATIVES $0.00 90655

3590672 INFLUENZA LIVE‐INTRANASAL $0.00 90658

3590681 ROTAVIRUS VACCINE $0.00 90672

3590707 MEASLES/MUMPS/RUBELLA 12500/0. $0.00 90681

3590710 MEASLES/MUMPS/RUBELLA/VARICELL $0.00 90707

3590713 POLIOMYELITIS VACCINE 40‐8‐32 $0.00 90710

3590715 TETANUS/DIPHTHERIA/PERTUSSIS V $0.00 90713

3590716 VARICELLA VACCINE 1350UNITS/0. $0.00 90715

3590723 DTa‐HepB‐IPV 10‐25‐25 $0.00 90716

3590732 PNEUMOCOCCAL POLYSACCHARIDE VA $0.00 90723

3590734 MENINGOCOCCAL VACCINE 5‐2.5/0. $0.00 90732

3590736 ZOSTAVAX 19400/0.65ML $0.00 90734

3590744 HEP B VACC PEDIATRIC 10MCG/0.5 $0.00 90736

3590748 HAEMOPHILUS INFLUENZAE TYPE B $0.00 90744

3590777 LEVALBUTEROL 0.63MG/3ML NEB $0.00 J7614

3001613 OXYGEN THERAPY PER DAY $403.00

3001675 OXYGEN THERAPY PER HOUR $20.00

3001500 RESPIRATOR FIT TEST $56.00

3001597 CPAP PER DAY $132.00 94660

3001615 INTUBATION $853.00 31500

3001626 SMOKING CESSATION 3‐10 MIN. $43.00 99406

3001627 SMOKING CESSATION OVER 10 MIN $101.00 99407

3001628 ARTERIAL PUNCTURE FEE $261.00 36600

3001630 VENT/ BIPAP INITIAL IP ONLY $789.00 94002

3001631 VENT/ BIPAP DAILY $176.00 94003

3001644 ABI STANDARD $365.00 93922

3001646 ABI EXERCISE $672.00 93924

3001647 ABI EXERCISE DISCONTINUE TEST $504.00 9392453

3001648 ED & TRNG SELF MGMT EA 30 MIN $252.00 98960

3001649 ED & TRNG SELF MGMT 2‐4 PAT $210.00 98961

3001651 ED & TRNG SELF MGMT 5‐8 PAT $189.00 98962

3001598 SPUTUM COLLECTION $88.00 89220

3001599 IPPB INITIAL THERAPY $206.00 94640

3001603 MVV $122.00 94200

3001604 CATHETER ASPIRATION NASAL $428.00 31720

3001606 PULSE OX W/EXERCISE $197.00 94761

3001607 CONT AERO 1ST HOUR $357.00 94644

3001608 CONT AEROSOL EACH ADD HR $357.00 94645

3001610 NEBULIZER THERAPY‐INITIAL $206.00 94640

3001611 CPT SUBSEQUENT $132.00 94668

3001612 CPR INITIAL $419.00 94667

3001616 NEBULIZER THERAPY SUBSEQUENT $206.00 9464076

3001617 SPIROMETRY $264.00 94010

3001620 MDI THERAPY $206.00 94640

3001621 PT ED/DEMO/EVAL $554.00 94664

3001625 CONTINUOUS OXIMETRY NOC $405.00 94762

3001633 SPIROMETRY PRE/POST BRON/EXER $545.00 94060

3001634 DLCO $428.00 94729

3001636 PLETHYSMOGRAPHY $339.00 94726

3001637 PLETHYSMOGRAPHY DISCONTINUE TE $141.00 9472653

3001639 WALK TEST‐ 6 MINUTE $483.00 94618

3001676 CAR SEAT TESTING‐INITIAL $545.00 94780

3001677 CAR SEAT TESTING‐SUBSEQUENT $264.00 94781

3001678 EXERCISE TEST FOR BRONCHO $458.00 94617

1202000 FAC W/C OP VIS NEW LEVEL I $94.00 99201

1202001 FAC W/C OP VIS NEW LEVEL II $132.00 99202

1202002 FAC W/C OP VIS NEW LEVEL III $186.00 99203

1202003 FAC W/C OP VIS NEW LEVEL IV $259.00 99204

1202004 FAC W/C OP VIS NEW LEVEL V $327.00 99205

1202005 FAC W/C OP VIS EST LEVEL I $36.00 99211

1202006 FAC W/C OP VIS EST LEVEL II $83.00 99212

1202007 FAC W/C OP VIS EST LEVEL III $108.00 99213

1202008 FAC W/C OP VIS EST LEVEL IV $162.00 99214

1202009 FAC W/C OP VIS EST LEVEL V $235.00 99215

1202010 SKIN SUB APLIGRAF PER 1 SQ CM $66.00 Q4101

1202011 SKIN SUB OASIS WOUND MAT 1SQCM $24.00 Q4102

1202012 SKIN SUB OASIS BURN MTX 1SQCM $23.00 Q4103

1202013 SKIN SUB INTEGRA BILAY 1SQCM $82.00 Q4104

1202014 SKIN SUB INTEGRA DERM REG 1SCM $64.00 Q4105

1202015 SKIN SUB DERMAGRAFT PER 1SQCM $71.00 Q4106

1202016 SKIN SUB GRAFT JACKET PER 1SCM $186.00 Q4107

1202017 SKIN SUB INTEGRA MTRX PER 1SCM $86.00 Q4108

1202018 SKIN SUB PRIMATRIX PER 1 SQ CM $107.00 Q4110

1202019 SKIN SUB ALLODERM PER 1 SQ CM $68.00 Q4116

1202020 SKIN SUB MATRISTEM NON‐MCR $7.00 Q4118

1202021 SKIN SUB THERASKIN PER 1SQCM $90.00 Q4121

1202022 SKIN SUB OASIS ULTRA 3LAY 1SCM $29.00 Q4124

1202023 SKIN SUB EPIFIX PER 3X3 SQ CM $356.00 Q4131

1202024 SKIN SUB GRAFIX PRIME 1 SQ CM $273.00 Q4133

1202025 SKIN SUB CYTAL PER 1 SQ CM $11.00 Q4166

1202026 SKIN SUB PURAPLY PER 1 SQ CM $251.00 Q4172

1202027 APP SKIN SUB 1ST 25 SQ CM $887.00

1202028 APP SKIN SUB EA ADD 25 SQ CM $710.00

1202031 APP SKIN SUB FACE ETAL 1ST 25 $887.00

1202032 APP SKIN SUB FACE EACH ADD 25 $710.00

1202033 APP SKIN SUB FACE 1ST 100 SQCM $887.00

1202034 APP SKIN SUB FACE EACH ADD 100 $710.00

1202043 FAC W/C NONSELECT DEB PER SESS $340.00 97602

1202044 FAC W/C NPWT <OR= 50SQCM $340.00 97605

1202045 FAC W/C NPWT >50SQCM $649.00 97606

1202046 FAC W/C NPWT DISP <50SQCM $649.00 97607

1202047 FAC W/C NPWT DISP >50SQCM $649.00 97608

1202048 FAC W/C DRESSING SMALL $340.00 16020

1202049 FAC W/C DRESSING MEDIUM $340.00 16025

1202050 FAC W/C DRESSING LARGE $649.00 16030

1202053 FAC W/C PARING CORN/CALLUS X1 $340.00 11055

1202054 FAC W/C PARING CORN/CALLUS 2‐4 $340.00 11056

1202055 FAC W/C PARING CORN/CALLUS >4 $340.00 11057

1202056 FAC W/C BIOPSY X1 LESION $649.00 11100

1202057 FAC W/C BIOPSY EA ADD LESION $519.00 11101

1202058 FAC W/C APP RIGID LEG CAST $490.00 29445

1202059 FAC W/C APP UNNA BOOT $278.00 29580

1202060 FAC W/C TCOM LIM BIL 1‐2 LEVEL $333.00 93922

1202061 FAC W/C TCOM LIM BIL UNILATERL $267.00 9392252

1202062 FAC W/C TCOM COMP BIL 3 OR MOR $424.00 93923

1202063 FAC W/C THERA INJ SUBQ OR IM $119.00 96372

1202064 FAC W/C GLUCOSE BY GM DEVICE $57.00 82962

1202065 FAC W/C REM IMP CERUMEN LAVAGE $122.00 69209

1202066 FAC W/C REM IMP CERUMEN INSTRU $122.00 69210

1202067 FAC W/C APP BILAT UNNA BOOT $500.00 2958050

1202068 FAC W/C APP VWCS BELOW KNEE $278.00 29581

1202069 FAC W/C APP BIL VWCS BELOWKNEE $500.00 2958150

1202070 FAC W/C TRIM NONDYS NAILS ANY# $122.00 11719

1202071 FAC W/C DEB NAILS 1‐5 NAILS $122.00 11720

1202072 FAC W/C DEB NAILS 6 0R MORE $122.00 11721

1202073 FAC W/C AVULSION NAIL PLATE X1 $340.00 11730

1202074 FAC W/C EXCISION NAIL $272.00 11750

1202075 FAC W/C CHEMICAL CAUT GRN TIS $649.00 17250

1202078 FAC W/C INC/REM FB SUBQ SIMPLE $649.00 10120

1202081 FAC W/C PUNC ASPIRATE ABSCESS $650.00 10160

1204000 PF W/C OP VIS NEW LEVEL I $62.00 99201

1204001 PF W/C OP VIS NEW LEVEL II $88.00 99202

1204002 PF W/C OP VIS NEW LEVEL III $124.00 99203

1204003 PF W/C OP VIS NEW LEVEL IV $173.00 99204

1204004 PF W/C OP VIS NEW LEVEL V $218.00 99205

1204005 PF W/C OP VIS EST LEVEL I $36.00 99211

1204006 PF W/C OP VIS EST LEVEL II $56.00 99212

1204007 PF W/C OP VIS EST LEVEL III $72.00 99213

1204008 PF W/C OP VIS EST LEVEL IV $109.00 99214

1204009 PF W/C OP VIS EST LEVEL V $157.00 99215

1204044 PF W/C NPWT <OR= 50SQCM $71.00 97605

1204045 PF W/C NPWT >50SQCM $77.00 97606

1204048 PF W/C DRESSING SMALL $153.00 16020

1204049 PF W/C DRESSING MEDIUM $313.00 16025

1204050 PF W/C DRESSING LARGE $374.00 16030

1204053 PF W/C PARING CORN/CALLUS X1 $47.00 11055

1204054 PF W/C PARING CORN/CALLUS 2‐4 $65.00 11056

1204055 PF W/C PARING CORN/CALLUS >4 $84.00 11057

1204056 PF W/C BIOPSY X1 LESION $138.00 11100

1204057 PF W/C BIOPSY EA ADD LESION $71.00 11101

1204058 PF W/C APP RIGID LEG CAST $293.00 29445

1204059 PF W/C APP UNNA BOOT $100.00 29580

1204060 PF W/C TCOM LIM BIL 1‐2 LEVEL $36.00 93922

1204061 PF W/C TCOM LIM BIL UNILATERAL $36.00 9392252

1204062 PF W/C TCOM COMP BIL 3 OR MORE $63.00 93923

1204066 PF W/C REM IMP CERUMEN INSTRUM $93.00 69210

1204067 PF W/C APP BILAT UNNA BOOT $180.00 2958050

1204068 PF W/C APP VWCS BELOW KNEE $37.00 29581

1204069 PF W/C APP BIL VWCS BELOW KNEE $67.00 2958150

1204070 PF W/C TRIM NONDYS NAILS ANY # $23.00 11719

1204071 PF W/C DEB NAILS 1‐5 NAILS $42.00 11720

1204072 PF W/C DEB NAILS 6 OR MORE $71.00 11721

1204073 PF W/C AVULSION NAIL PLATE X1 $157.00 11730

1204074 PF W/C EXCISION NAIL $51.00 11750

1204075 PF W/C CHEMICAL CAUT GRN TIS $322.00 17250

1204076 PF W/C I&D PILON CYST SIMPLE $289.00 10080

1204077 PF W/C I&D PILON CYST COMPLC8 $475.00 10081

1204078 PF W/C INC/REM FB SUBQ SIMPLE $292.00 10120

1204079 PF W/C INC/REM FB SUBQ COMPLC8 $519.00 10121

1204081 PF W/C PUNC ASPIRATE ABSCESS $270.00 10160

1204084 PF W/C WPI AG EA ADD 100SQCM $286.00 15111

1204086 PF W/C EPI AG FACE ETAL ADD100 $415.00 15116

1204087 PF W/C APP SKIN SUB 1ST 25SQCM $238.00 15271

1204088 PF W/C APP SKIN SUB EA ADD 25 $49.00 15272

1204089 PF W/C APP SKIN SUB 1ST 100SQ $566.00 15273

1204090 PF W/C APP SKIN SUB EA ADD 100 $129.00 15274

1204091 PF W/C TOB CESS COUNS 3‐10 MIN $43.00 99406

1204092 PF W/C TOB CESS COUNS 10+MIN $82.00 99407

1204093 PF W/C UNLIST NON‐INV VAS DX $57.00 93998

1204094 PF W/C SKIN SUB UP TO 100SQCM $452.00 15275

1201000 FAC HBOT OP VIS NEW LEVEL I $94.00 99201

1201001 FAC HBOT OP VIS NEW LEVEL II $132.00 99202

1201002 FAC HBOT OP VIS NEW LEVEL III $186.00 99203

1201003 FAC HBOT OP VIS NEW LEVEL IV $259.00 99204

1201004 FAC HBOT OP VIS NEW LEVEL V $327.00 99205

1201005 FAC HBOT OP VIS EST LEVEL I $54.00 99211

1201006 FAC HBOT OP VIS EST LEVEL II $83.00 99212

1201007 FAC HBOT OP VIS EST LEVEL III $108.00 99213

1201008 FAC HBOT OP VIS EST LEVEL IV $162.00 99214

1201009 FAC HBOT OP VIS EST LEVEL V $235.00 99215

1203000 PF HBOT OP VIS NEW LEVEL I $62.00 99201

1203001 PF HBOT OP VIS NEW LEVEL II $88.00 99202

1203002 PF HBOT OP VIS NEW LEVEL III $124.00 99203

1203003 PF HBOT OP VIS NEW LEVEL IV $173.00 99204

1203004 PF HBOT OP VIS NEW LEVEL V $218.00 99205

1203005 PF HBOT OP VIS EST LEVEL I $36.00 99211

1203006 PF HBOT OP VIS EST LEVEL II $56.00 99212

1203007 PF HBOT OP VIS EST LEVEL III $72.00 99213

1203008 PF HBOT OP VIS EST LEVEL IV $109.00 99214

1203009 PF HBOT OP VIS EST LEVEL V $157.00 99215

1203010 PROV ATTEND/SUPERVISION HBOT $325.00 99183

5001004 PT AQUATIC THER PER 15 MIN $87.00 97113GP

5001005 PT GROUP THERAPY PER 15 MIN $52.00 97150GP

5001778 P97012 TRACTION‐MECHANICAL $122.00 97012GP

5001781 P97116 GAIT TRAINING‐EA 15 MIN $125.00 97116GP

5001783 P97112 NEUROMUSCULAR RED‐ EA 1 $164.00 97112GP

5001786 P97035 ULTRASOUND‐EA 15 MIN $108.00 97035GP

5001798 P97140 SOFT TISSUE & JOINT MOB $145.00 97140GP

5001817 P97530 THERAPEUTIC ACTIVITY 15 $159.00 97530GP

5001821 CERVICAL PILLOW $59.00

5001832 P97110 THERAPEUTIC EXERCISE 15 $144.00 97110GP

5001938 ELECT STIMULATION UNASSISTED $97.00 97014 G0283GP

5003001 E‐STIM CONSTANT ATTENDANCE 15M $56.00 97032GP

5003003 PARAFFIN BATH $39.00 97018GP

5003004 DIATHERMY $32.00 97024GP

5003005 APPLICATION OF INFRARED $27.00 97026GP

5003006 ORTHOTIC/PROS MGMT EACH 15 MIN $142.00 97763GP

5003007 ORTHOTIC MGMT & TRAINING $165.00 97760GP

5003008 THER INTERVENTION COG FUNCTION $130.00 97127GP

5003009 ED & TRNG PATIENT SELF MGMT $150.00 98960GP

5001000 PT EVAL: LOW COMPLEXITY $258.00 97161GP

5001001 PT EVAL: MODERATE COMPLEXITY $314.00 97162GP

5001002 PT EVAL: HIGH COMPLEXITY $361.00 97163GP

5001003 PT RE‐EVAL $140.00 97164GP

5001792 P97001‐ PT EVALUATION INITIAL $361.00 97001GP

5001829 PT HOME EVALUATION $322.00 99349GP

5001831 PT WHEELCHAIR EVALUATION $124.00 97542GP

5101000 ACUP NEW PT OFFICE VISIT LEV 1 $151.00 99201 G0463

5101001 ACUP NEW PT OFFICE VISIT LEV 2 $212.00 99202 G0463

5101002 ACUP EST PT OFFICE VISIT LEV 2 $135.00 99212 G0463

5101003 ACUP TX W/O STIM 15 MIN $123.00 97810

5101004 ACUP TX W/O STIM EA ADD 15 MIN $93.00 97811

5101005 ACUP TX W/STIM 15 MIN $132.00 97813

5101006 ACUP TX W/STIM EA ADD 15 MIN $104.00 97814

5101007 ACUP MASSAGE THERAPY $32.00 97124

5101008 ACUP EST PT OFFICE VISIT LEV I $90.00 99211

5101009 ACUPUNC SATURDAY GROUP CLINIC $10.00

5101010 SPECIAL PROMO ACUPUNCTURE $0.00

5501000 MASSAGE THERAPY $24.00 97124

5501001 SPECIAL PROMOTIONAL MASSAGE $0.00

5501002 MASSAGE CHAIR SATURDAY CLINIC $10.00

6001829 INFUSION HYDRATION INITIAL HR $265.00 96360

6001831 IV PUSH ‐ EACH ADDL SAME DRUG $249.00 96376

6001832 IV PUSH ‐ EACH ADD NEW DRUG $259.00 96375

6001833 IV PUSH ‐ SINGLE OR INTITAL $391.00 96374

6001834 THER INJ INTRA‐ARTERIAL $265.00 96373

6001836 IV THERAPY CONCURRENT INFUSION $252.00 96368

6001838 IV INFUSION EACH ADD HOUR $89.00 96366

6001839 IV INFUSION INITIAL UP TO 1 HR $89.00 96365

6001840 INFUSION HYDRATION EACH ADD HR $89.00 96361

6002038 THER INJ SUB‐Q OR IM $129.00 96372

6001841 CRIT CARE FACILITY 1ST 30‐74M $868.00 99291

6001842 CRIT CARE FACILITY EACH ADD 30 $389.00 99292

6001844 ER FACILITY LEVEL 2 $509.00 99282



6101800 F CLOSED TX GREAT TOE FX NO MP $280.00 28490

6101849 F I & D SIMPLE $256.00 10060

6101850 F I & D COMPLICATED $488.00 10061

6101851 F I & D PIL CYST SIMPLE $897.00 10080

6101852 F I&D PIL CYST COMPLICATED $897.00 10081

6101853 F FB SIMPLE SUB‐Q $488.00 10120

6101856 F PUNCTURE ASPIRATION $488.00 10160

6101859 F DEBRIDE SKIN TO 10% $754.00 11000

6101860 F DEBRIDE EA ADDITIONAL 10% $565.00 11055

6101861 F SHAVE REMOVAL SINGLE CORN/CL $159.00 11055

6101862 F PARING/CORN CALLUSES 2‐4 $195.00 11056

6101863 F PARING CORN/CALUSSES >4 $218.00 11057

6101864 F BIOPSY SKIN LESION $488.00 11100

6101865 F BIOPSY SKIN EA ADDITIONAL $366.00 11101

6101866 F SKIN TAGS UP TO 15 $264.00 11200

6101867 F SKIN TAGS EA ADDL 10 $192.00 11201

6101870 F SHAVE LESION FACE $342.00 11310

6101871 F EXC TRNK/ARMS/LEGS 0.5 OR LE $897.00 11400

6101873 F DEBRIDEMENT NAILS 1‐5 $115.00 11720

6101874 F DEBRIDEMENT NAILS 6 OR MORE $176.00 11721

6101875 F REMOVAL OF NAIL PLATE $300.00 11730

6101877 F REMOVAL ADDITIONAL NAIL PLAT $192.00 11732

6101878 F EVAC SUBUNG HEMATOMA $167.00 11740

6101879 F REMOVAL OF NAIL BED $741.00 11750

6101880 F WEDGE EXCISION NAIL FOLD TOE $509.00 11765

6101893 F CLOSURE WOUND DEHISC $860.00 12020

6101894 F CLOSURE WITH PACKING $532.00 12021

6101895 F INTER REPAIR LESS THAN 2.5 C $792.00 12031

6101896 F INTER REPAIR 2.6‐7.5 CM $909.00 12032

6101897 F INTER REPAIR 7.6‐12.5 CM $929.00 12034

6101901 F INTER REPAIR LESS THAN 2.5 C $709.00 12041

6101902 F INTER REPAIR 2.6‐7.5 CM $863.00 12042

6101903 F INTER REPAIR 7.6‐12.5 CM $754.00 12044

6101904 F INTER REPAIR 12.6‐20.0 CM $754.00 12045

6101907 F INTER REPAIR LESS THAN 2.5CM $735.00 12051

6101908 F INTER REPAIR 2.6‐5.0 CM $836.00 12052

6101909 F INTER REPAIR 5.1‐7.5 CM $982.00 12053

6101914 F COMPLEX REPAIR 1.1‐2.5 CM $953.00 13100

6101916 F COMPLEX REPAIR 1.1‐2.5 CM $996.00 13120

6101925 F BURN INITIAL TX 1ST DEGREE $256.00 16000

6101926 F BURN TREATMENT SMALL $256.00 16020

6101927 F BURN TREATMENT MEDIUM $418.00 16025

6101928 F BURN TREATMENT LARGE $588.00 16030

6101929 F DESTRUCTION LESION QTY 1 $220.00 17000

6101930 F DESTRUCTION LESION QTY 2‐14 $67.00 17003

6101931 F DESTRUCTION LESIONS UP TO 14 $320.00 17110

6101933 F CHEMICAL CAUTERIZATION $256.00 17250

6101935 F TRIGGER INJECTION $385.00 20550

6101936 F SMALL JOINT INJECTION $385.00 20600

6101937 F INTERMEDIATE JOINT INJECTION $385.00 20605

6101938 F MAJOR JOINT INJECTION $385.00 20610

6101939 F NASAL FX W/O MANIPULATION $386.00 21310

6101941 F TMJ DISLOCATION $333.00 21480

6101942 F CLOSED TX STERNUM FRACTURE $554.00 21820

6101943 F FB REMOVE SUB‐Q SHOULDER $897.00 23330

6101944 F FX CLAVICAL W/O MANIPULATION $621.00 23500

6101945 F SHOULDER DISLOCATION $890.00 23650

6101948 F ELBOW DISLOCATION $385.00 24640

6101949 F FX RADIAL/ULNAR W/O MANIP $791.00 25560

6101950 F FX DISTAL RADIAL $935.00 25600

6101952 F CLOSED FX NAVICULAR W/O MANI $866.00 25622

6101953 F DRAIN DIGIT ABSCESS SIMPLE $762.00 26010

6101954 F METACARPAL FX W/O REDUCTION $837.00 26600

6101955 F METACARPAL FX W/MANIPULATION $918.00 26605

6101956 F CLOSED TX METACARP DISLOCATE $912.00 26700

6101957 F CLOSED FX PHALANGEAL SHAFT $565.00 26720

6101958 F CLOSED PHAL SHAFT W/MANIP $954.00 26725

6101959 F CLOSED PHAL SHAFT W/O MANIP $524.00 26750

6101960 F CLOSED TX INTERPHAL JT DIS $780.00 26770

6101964 F REMOVAL FB FOOT $897.00 28190

6101965 F METATARSAL FX W/O MANIP $633.00 28470

6101966 F CLOSED TX METATARSAL W/ANES $464.00 28630

6101967 F DISLOCATION TOE $335.00 28660

6101968 F LONG ARM CAST $369.00 29065

6101969 F SHORT ARM CAST $368.00 29075

6101970 F GAUNTLET CAST $275.00 29085

6101971 F LONG ARM SPLINT $252.00 29105

6101972 F SHORT ARM SPLINT $187.00 29125

6101973 F FINGER SPLINT APPLICATION $143.00 29130

6101974 F MCCONNELL STRAPPING $212.00 29240

6101975 F LONG LEG CAST $499.00 29345

6101976 F SHORT LEG CAST $368.00 29405

6101977 F SHORT WALKING LEG CAST $368.00 29425

6101978 F LONG LEG SPLINT $322.00 29505

6101979 F SHORT LEG SPLINT $209.00 29515

6101980 F REMOVE CAST FULL ARM OR LEG $368.00 29705

6101981 F CAST WINDOW $246.00 29730

6101982 F REMOVE FB FROM NOSE $543.00 30300

6101983 F NASAL CAUTERY SIMPLE $272.00 30901

6101984 F NASAL CAUTERY COMPLEX $681.00 30903

6101986 F CONTROL NASAL HEMO POSTERIOR $839.00 30905

6101988 F ENDOTRACH INTUBATION $309.00 31500

6101989 F LARYNGOSCOPY INDIRECT DX $244.00 31505

6101990 F LARYNGOSCOPY FB REMOVAL $609.00 31511

6101991 F THORACENTESIS $747.00 32554

6101994 F VENIPUNCTURE CUT DOWN <1 YR $176.00 36420

6101995 F VENIPUNCTURE CUT DOWN 1+ YRS $131.00 36425

6101997 F NASAL GASTRIC INSERT $439.00 43752

6102001 F ANOSCOPY DIAGNOSTIC $257.00 46600

6102002 F PERITONEAL LAVAGE $353.00 49084

6102003 F CATHETERIZATION URINE $167.00 51701

6102004 F CATHETERIZATION COMPLICATED $371.00 51703

6102005 F DESTRUCTION LESIONS PENIS $488.00 54050

6102006 F DESTRUCT LESIONS PENIS CRYO $408.00 54056

6102007 F IUD REMOVAL $459.00 58301

6102009 F LUMBAR PUNCTURE DIAGNOSTIC $844.00 62270

6102010 F INTERCOSTAL BLOCK SINGLE $353.00 64420

6102012 F REMOVAL FB EXERNAL EYE $221.00 65205

6102013 F REMOVAL FB EYE CORN NO SLIT $439.00 65220

6102014 F REMOV FB CORNEAL W/SLIT LAMP $269.00 65222

6102015 F REMOVAL FB EXTERNAL EAR $264.00 69200

6102016 F REMOVE IMPACTED CERUMEN $157.00 69210

6102017 F SKIN TEST TUBERCULOSIS ID $63.00 86580

6102018 F DTAP IMMUNIZATION $144.00 90700

6102019 F THERAPEUTIC INJECT SUB‐Q/IM $81.00 96372

6102020 F GASTRIC LAVAGE $964.00 43753

6102021 F CPR EACH 15 MINUTES $239.00 92950

6102023 F DEBRIDE WOUND $239.00 97597

6102024 F OMT 1‐2 BODY REGIONS $125.00 98925

6102025 F SPECIAL REPORTS $67.00 99080

6102026 F IPECAC ADMIN AND OBSERVATION $51.00 99175

6102041 F REMOVE IMPACT CERUMEN IRRIG $71.00 69209

6102042 F ANKLE AND/OR FOOT STRAPPING $81.00 29540

6102044 F IMMUN ADMIN EACH ADD VACCINE $29.00 90472

6102045 F INSERTION TEMP INDWELL CATH $227.00 51702

6102046 F LWOBS NO CHARGE VISIT $0.00

6102047 SUTURE REMOVAL ONLY ‐ NCV $0.00

6102050 F NERVE BLOCK PERIPHERAL $133.00 64450

6102052 F TRIGGER POINT INJECTION $220.00 20552

6001800 CLOSED TX GREAT TOE FX NO MANP $267.00 28490

6001849 I & D SIMPLE $360.00 10060

6001850 I & D COMPLICATED $587.00 10061

6001851 I & D PIL CYST SIMPLE $516.00 10080

6001852 I&D PIL CYST COMPLICATED $767.00 10081

6001853 FB SIMPLE SUB‐Q $437.00 10120

6001854 FB COMPLICATED SUB‐Q $781.00 10121

6001855 I&D HEMATOMA SIMP $467.00 10140

6001856 PUNCTURE ASPIRATION $373.00 10160

6001857 PHY INT REPORT ROA $67.00

6001858 ACTIVITY PRESCRIPTION FORM $110.00

6001859 DEBRIDE SKIN TO 10% $220.00 11000

6001860 DEBRIDE EA ADDITIONAL 10% $177.00 11001

6001861 SHAVE REMOVAL SINGLE CORN/CAL $152.00 11055

6001862 PARING/CORN CALLUSES 2‐4 $185.00 11056

6001863 PARING/CORN CALLUSES >4 $208.00 11057

6001864 BIOPSY SKIN LESION $297.00 11100

6001865 BIOPSY SKIN EA ADDITIONAL $174.00 11101

6001866 SKIN TAGS UP TO 15 $251.00 11200

6001867 SKIN TAGS EA ADDL 10 $113.00 11201

6001870 SHAVE LESION FACE $326.00 11310

6001871 EXC TRNK/ARMS/LEGS 0.5 OR LESS $355.00 11400

6001872 EXC SCLP/NECK/HAND/FT 0.5 OR < $369.00 11420

6001873 DEBRIDEMENT NAILS 1‐5 $110.00 11720

6001874 DEBRIDEMANT NAILS 6 OR MORE $167.00 11721

6001875 REMOVAL OF NAIL PLATE $285.00 11730

6001877 REMOVAL ADDITONAL NAIL PLATE $144.00 11732

6001878 EVAC SUBUNG HEMATOMA $159.00 11740

6001879 REMOVAL OF NAIL BED $705.00 11750

6001880 WEDGE EXCISION NAIL FOLD TOE $485.00 11765

6001893 CLOSURE WOUND DEHISC $819.00 12020

6001894 CLOSURE WITH PACKING $507.00 12021

6001895 INTER REPAIR LESS THAN 2.5 CM $754.00 12031

6001896 INTER REPAIR 2.6‐7.5 CM $866.00 12032

6001897 INTER REPAIR 7.6‐12.5 CM $885.00 12034


6001902 INTER REPAIR 2.6‐7.5 CM $822.00 12042


6001908 INTER REPAIR 2.6‐5.0 CM $836.00 12052

6001909 INTER REPAIR 5.1‐7.5 CM $982.00 12053

6001914 COMPLEX REPAIR 1.1‐2.5 CM $953.00 13100

6001916 COMPLEX REPAIR 1.1‐ 2.5 CM $996.00 13120

6001925 BURN INT TREATMENT 1ST DEGREE $209.00 16000

6001926 BURN TREATMENT SMALL $235.00 16020

6001927 BURN TREATMENT MEDIUM $418.00 16025

6001928 BURN TREATMENT LARGE $588.00 16030

6001929 DESTRUCTION LESION 1 $220.00 17000

6001930 DESTRUCTION LESION 2‐14 $67.00 17003

6001931 DEST SKIN LESION UP TO 14 $320.00 17110

6001933 CHEMICAL CAUTERIZATION $228.00 17250

6001934 REMOVAL FB MUSCLE/TENDON $583.00 20520

6001935 TRIGGER INJECTION $213.00 20550

6001936 SMALL JOINT INJECTION $207.00 20600

6001937 INTERMEDIATE JOINT INJECTION $217.00 20605

6001938 MAJOR JOINT INJECTION $246.00 20610

6001939 NASAL FX W/O MANIPULATION $386.00 21310

6001941 TMJ DISLOCATION $288.00 21480

6001942 CLOSED TX STERNUM FRACTURE $554.00 21820

6001943 FB REMOVAL SUBCUTAN SHOULDER $742.00 23330

6001944 FX CLAVICAL W/O MANIPULATION $621.00 23500

6001945 SHOULDER DISLOCATION $890.00 23650

6001946 REMOVAL FB SUBCUT $594.00 24200

6001948 ELBOW/DISLOCATION $385.00 24640

6001949 FRACTURE RADIAL/UNLAR W/O MAN $791.00 25560

6001950 FX‐DISTAL RAD $935.00 25600

6001952 CLOSED FX NAVICULAR W\O MANIP $866.00 25622

6001953 DRAIN DIGIT ABCESS SIMPLE $762.00 26010

6001954 METACARPAL FX W\O REDUCTION $837.00 26600

6001955 FRACTURE CLD TRE/WITH MANIPUL $918.00 26605

6001956 METACARPAL FX W REDUCTION $912.00 26700

6001957 CLOSED SHAFT FX PHALANGEAL SHA $565.00 26720

6001958 CLOSED PHAL SHAFT FX W MANIP $954.00 26725

6001959 PHALANX‐CLOSED W/O MAN $524.00 26750

6001960 CLOSED TREAT INTERPHALANGEL JO $780.00 26770

6001964 FB REMOVAL FOOT $755.00 28190

6001965 METATARSAL FX W/O MANIP $633.00 28470

6001966 CLOSED TREATMENT METARS W/A AN $464.00 28630

6001967 DISLOCATION TOE $335.00 28660

6001968 LONG ARM CAST $369.00 29065

6001969 SHORT ARM CAST $285.00 29075

6001970 GAUNTLET CAST $275.00 29085

6001971 LONG ARM SPLINT $252.00 29105

6001972 SHORT ARM SPLINT $187.00 29125

6001973 SPLINT‐FINGER APPLICATION $143.00 29130

6001974 MCCONNELL STRAPPING $212.00 29240

6001975 LONG LEG CAST $499.00 29345

6001976 SHORT LEG CAST $236.00 29405

6001977 SHORT LEG WALKING CAST $227.00 29425

6001978 LONG LEG SPLINT $322.00 29505

6001979 SHORT LEG SPLINT $207.00 29515

6001980 REMOVAL CAST FULL ARM OR LEG $191.00 29705

6001981 CAST WINDOW $246.00 29730

6001982 FB REMOVAL NOSE $543.00 30300

6001983 NASAL CAUTRY SIMPLE $272.00 30901

6001984 NASAL CAUTRY COMPLEX $681.00 30903

6001986 CON NASAL HEM POST PACK/CAUT $839.00 30905

6001988 ENDOTRAC INTUBATION $309.00 31500

6001989 LARYNGOSCOPY‐DX $242.00 31505

6001990 LARYNGOSCOPY FB REMOVAL $609.00 31511

6001991 THORACENTESIS $747.00 32554

6001993 PERICARDIOCENTESIS $332.00 33010

6001994 CUT DOWN LESS THAN 1 YEAR $176.00 36420

6001995 CUT DOWN 1 + YEARS $131.00 36425

6001996 N/G TUBE PLACEMENT $590.00 43246

6001997 NASAL GASTRIC INSERT $118.00 43752

6001998 PROCTOSIGMOIDOSCOPY‐DIAGNOSTIC $393.00 45300

6001999 ABCESS‐ANAL INCISION $581.00 46050

6002000 I AND D THROMB HEMROID $525.00 46320

6002001 ANOSCOPY‐DX $257.00 46600

6002002 PERITONEAL LAVAGE $353.00 49084

6002003 CATHETERIZATION URINE $158.00 51701

6002004 CATHERTERIZATION COMPLICATED $371.00 51703

6002005 DESTRUCTION PENIS LESIONS $378.00 54050

6002006 DESTRUCTION CRYO PENIS $408.00 54056

6002007 IUD REMOVAL $302.00 58301

6002009 LMBAR PUNCUTRE DX $506.00 62270

6002010 INTERCOSTAL BLK SINGLE $353.00 64420

6002011 INTERCOSTAL BLK MULTI $476.00 64421

6002012 REMOVAL FB EXTERNAL EYE $221.00 65205

6002013 REMOVAL FB EYE CORNEAL NO SLIT $273.00 65220

6002014 FB REMOVAL CORNEAL W/SLIT LMP $269.00 65222

6002015 FB REMOVAL EAR EXTERNAL $264.00 69200

6002016 REMOVAL EAR WAX $157.00 69210

6002017 TB PPD MANTOUX TEST $63.00 86580

6002018 DTAP IMMUNIZATION $144.00 90700

6002019 VACCINE ADMIN $81.00 96372

6002020 GASTRIC LAVAGE $72.00 43753

6002021 CPR EA 15 MIN $964.00 92950

6002023 DEBRIDE WOUND $239.00 97597

6002024 OMT TREATMENT 1‐2 REGIONS $125.00 98925

6002025 INSURANCE REPORTS $67.00 99080

6002026 IPECAC ADMIN AND OBS $51.00 99175

6002029 ER PROFEE LEVEL 1 $261.00 99281

6002030 ER PROFEE LEVEL 2 $376.00 99282

6002031 ER PROFEE LEVEL 3 $570.00 99283

6002032 ER PROFEE LEVEL 4 $914.00 99284

6002033 ER PROFEE LEVEL 5 $957.00 99285

6002035 CRIT CARE PROFEE EACH ADD 30M $485.00 99292

6002041 REMOVAL IMPACTED CERUMEN $71.00 69209

6002042 ANKLE AND/OR FOOT STRAPPING $81.00 29540

6002045 IMMUNIZATION ADMIN 1 VACCINE $54.00 90471

6002046 IMMUNIZATION ADMIN EACH ADD VX $29.00 90472

6002047 LWOBS NO CHARGE VISIT $0.00

6002050 NERVE BLOCK PERIPHERAL $133.00 64450

6002052 TRIGGER POINT INJECTION $172.00 20552

1501014 IV PUSH ‐ INITIAL $391.00 96374

1501015 IV PUSH ‐ EACH ADDL NEW DRUG $249.00 96375

1501016 IV PUSH ‐ EACH ADDL SAME DRUG $205.00 96376

1501025 IRRIG IMP VAD FOR DRUG DELIVRY $98.00 96523

1501020 DRESSING CHANGE ‐ SIMPLE $21.00 A4663

1501021 DRESSING CHANGE ‐ MODERATE $25.00 A4663

1501022 DRESSING CHANGE ‐ COMPLEX $30.00 A4663

1501001 OP SPEC NURSING MINIMAL $159.00 99211

1501002 OP SPEC INSERT INDWELL CATH $217.00 51702

CFC94620 6 MINUTE WALK TEST BY PROV $470.00 94620

CFC10021 FINE NEEDLE ASP W/O IMAGING $258.00 10021

CFC10040 ACNE SURGERY $208.00 10040

CFC10060 DRAINAGE OF SKIN ABSCESS $331.00 10060

CFC10061 DRAINAGE OF SKIN ABSCESS $425.00 10061

CFC10080 DRAINAGE OF PILONIDAL CYST $375.00 10080

CFC10081 DRAINAGE OF PILONIDAL CYST $556.00 10081

CFC10120 REMOVE FOREIGN BODY $382.00 10120

CFC10121 REMOVE FOREIGN BODY $806.00 10121

CFC10140 DRAINAGE OF HEMATOMA/FLUID $339.00 10140

CFC10160 PUNCTURE DRAINAGE OF LESION $270.00 10160

CFC1028M JOB OFFER OR ANALYSIS $43.00

CFC1038M REVIEW OF JOB DESCRIPTION $57.00

CFC1040M PHYSICIAN INITIAL REPORT $44.00

CFC1063M IME REPORT $44.00

CFC1073M ACTIVITY PRESCRIPTION FORM $56.00

CFC1076M SUBACUTE OPIOID REQUEST FORM $35.00

CFC1078M CHRONIC OPIOID REQUEST FORM $35.00

CFC11042 DEBRIDEMENT SUBCUTAN TISSUE $202.00 11042

CFC11055 TRIM SKIN LESION $114.00 11055

CFC11056 TRIM SKIN LESIONS 2 TO 4 $123.00 11056

CFC11057 TRIM SKIN LESIONS OVER 4 $138.00 11057

CFC11100 BIOPSY SKIN LESION $250.00 11100

CFC11101 BIOPSY SKIN ADD‐ON $67.00 11101

CFC11103 TANGENTIAL SKIN BIOPSY EA ADD $107.00 11103

CFC11104 PUNCH BIOPSY SINGLE LESION $250.00 11104

CFC11105 PUNCH BIOPSY EACH ADDITIONAL $107.00 11105

CFC11106 INCISIONAL WEDGE BIOPSY SINGLE $250.00 11106

CFC11107 INCISIONAL WEDGE BIOPSY EA ADD $107.00 11107

CFC11200 REMOVAL OF SKIN TAGS <W/15 $254.00 11200

CFC11201 REMOVE SKIN TAGS ADD‐ON $114.00 11201

CFC11300 SHAVE SKIN LESION 0.5 CM/< $224.00 11300

CFC11301 SHAVE SKIN LESION 0.6‐1.0 CM $254.00 11301


CFC11303 SHAVE SKIN LESION >2.0 CM $332.00 11303









CFC11400 EXC TR‐EXT B9+MARG 0.5 CM< $375.00 11400

CFC11401 EXC TR‐EXT B9+MARG 0.6‐1 CM $446.00 11401


CFC11403 EXC TR‐EXT B9+MARG 2.1‐3CM/< $571.00 11403


CFC11406 EXC TR‐EXT B9+MARG >4.0 CM $775.00 11406

CFC11420 EXC H‐F‐NK‐SP B9+MARG 0.5/< $309.00 11420

CFC11421 EXC H‐F‐NK‐SP B9+MARG 0.6‐1 $393.00 11421




CFC11426 EXC H‐F‐NK‐SP B9+MARG >4 CM $775.00 11426

CFC11440 EXC FACE‐MM B9+MARG 0.5 CM/< $369.00 11440

CFC11441 EXC FACE‐MM B9+MARG 0.6‐1 CM $446.00 11441

CFC11442 EXC FACE‐MM B9+MARG 1.1‐2 CM $482.00 11442

CFC11600 EXC TR‐EXT MAL+MARG 0.5 CM/< $553.00 11600

CFC11601 EXC TR‐EXT MAL+MARG 0.6‐1 CM $650.00 11601




CFC11606 EXC TR‐EXT MAL+MARG >4 CM $916.00 11606

CFC11640 EXCISION MALIGNANT LESION F/E/ $414.00 11640

CFC11719 TRIM NAIL(S) ANY NUMBER $31.00 11719

CFC11720 DEBRIDE NAIL 1‐5 $80.00 11720

CFC11721 DEBRIDE NAIL 6 OR MORE $166.00 11721

CFC11730 REMOVAL OF NAIL PLATE $297.00 11730

CFC11732 REMOVE NAIL PLATE ADD‐ON $81.00 11732

CFC11740 DRAIN BLOOD FROM UNDER NAIL $104.00 11740

CFC11750 REMOVAL OF NAIL BED $814.00 11750

CFC11765 EXCISION OF NAIL FOLD TOE $352.00 11765

CFC1191M STANDARD IMPAIRMENT RATING EXA $682.00 1191M

CFC1192M COMPLEX IMPAIRMENT RATING EXAM $853.00 1192M

CFC11980 IMPLANT HORMONE PELLET(S) $228.00 11980

CFC12001 RPR S/N/AX/GEN/TRNK 2.5CM/< $393.00 12001

CFC12002 RPR S/N/AX/GEN/TRNK2.6‐7.5CM $439.00 12002

CFC12004 RPR S/N/AX/GEN/TRK7.6‐12.5CM $493.00 12004

CFC12005 RPR S/N/A/GEN/TRK12.6‐20.0CM $634.00 12005

CFC12006 RPR S/N/A/GEN/TRK20.1‐30.0CM $788.00 12006

CFC12011 RPR F/E/E/N/L/M 2.5 CM/< $464.00 12011

CFC12013 RPR F/E/E/N/L/M 2.6‐5.0 CM $586.00 12013

CFC12014 RPR F/E/E/N/L/M 5.1‐7.5 CM $627.00 12014

CFC12015 RPR F/E/E/N/L/M 7.6‐12.5 CM $704.00 12015

CFC12016 RPR FE/E/EN/L/M 12.6‐20.0 CM $882.00 12016

CFC12020 CLOSURE OF SPLIT WOUND $588.00 12020

CFC12021 CLOSURE OF SPLIT WOUND $487.00 12021

CFC12031 INTMD RPR S/A/T/EXT 2.5 CM/< $559.00 12031

CFC12032 INTMD RPR S/A/T/EXT 2.6‐7.5 $639.00 12032

CFC12034 INTMD RPR S/TR/EXT 7.6‐12.5 $710.00 12034

CFC12035 INTMD RPR S/A/T/EXT 12.6‐20 $879.00 12035

CFC12041 INTMD RPR N‐HF/GENIT 2.5CM/< $520.00 12041

CFC12042 INTMD RPR N‐HF/GENIT2.6‐7.5 $669.00 12042

CFC12044 INTMD RPR N‐HF/GENIT7.6‐12.5 $759.00 12044

CFC12045 INTMD RPR N‐HF/GENIT12.6‐20 $933.00 12045

CFC12051 INTMD RPR FACE/MM 2.5 CM/< $630.00 12051

CFC12052 INTMD RPR FACE/MM 2.6‐5.0 CM $721.00 12052

CFC12053 INTMD RPR FACE/MM 5.1‐7.5 CM $857.00 12053

CFC15852 DRESSING CHANGE NOT FOR BURN $95.00 15852

CFC16000 INITIAL TREATMENT OF BURN(S) $194.00 16000

CFC16020 DRESS/DEBRID P‐THICK BURN S $192.00 16020

CFC16025 DRESS/DEBRID P‐THICK BURN M $451.00 16025

CFC16030 DRESS/DEBRID P‐THICK BURN L $626.00 16030

CFC17000 DESTRUCT PREMALG LESION $238.00 17000

CFC17003 DESTRUCT PREMALG LES 2‐14 $62.00 17003

CFC17004 DESTROY PREMAL LESIONS 15/> $732.00 17004

CFC17106 DESTRUCTION OF SKIN LESIONS $702.00 17106


CFC17110 DESTRUCT B9 LESION 1‐14 $233.00 17110

CFC17111 DESTRUCT LESION 15 OR MORE $275.00 17111


CFC17340 CRYOTHERAPY OF SKIN $81.00 17340

CFC17380 HAIR REMOVAL BY ELECTROLYSIS $608.00 17380

CFC20520 REMOVAL OF FOREIGN BODY $785.00 20520

CFC20526 THER INJECTION CARP TUNNEL $158.00 20526

CFC20550 INJ TENDON SHEATH/LIGAMENT $122.00 20550

CFC20551 INJ TENDON ORIGIN/INSERTION $125.00 20551

CFC20552 INJ TRIGGER POINT 1/2 MUSCL $172.00 20552

CFC20553 INJECT TRIGGER POINTS 3/> $133.00 20553

CFC20600 DRAIN/INJECT JOINT/BURSA $250.00 20600



CFC20612 ASPIRATE/INJ GANGLION CYST $126.00 20612

CFC24640 TREAT ELBOW DISLOCATION $254.00 24640

CFC25500 TREAT FRACTURE OF RADIUS $836.00 25500

CFC25560 TREAT FRACTURE RADIUS & ULNA $835.00 25560

CFC25600 TREAT FRACTURE RADIUS/ULNA $856.00 25600

CFC25650 TREAT WRIST BONE FRACTURE $980.00 25650

CFC26080 EXPLORE/TREAT FINGER JOINT $796.00 26080

CFC26720 TREAT FINGER FRACTURE EACH $781.00 26720



CFC28470 TREAT METATARSAL FRACTURE $695.00 28470

CFC29065 APPLICATION OF LONG ARM CAST $342.00 29065

CFC29075 APPLICATION OF FOREARM CAST $390.00 29075

CFC29086 APPLY FINGER CAST $164.00 29086

CFC29105 APPLY LONG ARM SPLINT $184.00 29105

CFC29125 APPLY FOREARM SPLINT $259.00 29125

CFC29130 APPLICATION OF FINGER SPLINT $132.00 29130

CFC29280 STRAPPING OF HAND OR FINGER $79.00 29280

CFC29345 APPLICATION OF LONG LEG CAST $461.00 29345

CFC29405 APPLY SHORT LEG CAST $342.00 29405

CFC29425 APPLY SHORT LEG CAST $164.00 29425

CFC29515 APPLICATION LOWER LEG SPLINT $251.00 29515

CFC29540 STRAPPING OF ANKLE AND/OR FT $55.00 29540

CFC29580 APPLICATION OF PASTE BOOT $128.00 29580

CFC30300 REMOVE NASAL FOREIGN BODY $491.00 30300

CFC30801 ABLTJ SOFT TIS INFERIOR TURBIN $486.00 30801

CFC30901 CONTROL OF NOSEBLEED $396.00 30901

CFC30903 CONTROL OF NOSEBLEED COMPLEX $518.00 30903

CFC36415 ROUTINE VENIPUNCTURE $32.00 36415

CFC36416 CAPILLARY BLOOD DRAW $21.00 36416

CFC36592 COLLECT BLOOD FROM PICC $57.00 36592

CFC46320 REMOVAL OF HEMORRHOID CLOT $382.00 46320

CFC46600 DIAGNOSTIC ANOSCOPY $245.00 46600

CFC51701 INSERT BLADDER CATHETER $114.00 51701

CFC51702 INSERT TEMP BLADDER CATH $147.00 51702

CFC51705 CHANGE OF CYSTOSTOMY; SIMPLE $282.00 51705

CFC54150 CIRCUMCISION W/REGIONL BLOCK $549.00 54150

CFC57160 INSERT PESSARY/OTHER DEVICE $158.00 57160

CFC58301 REMOVE INTRAUTERINE DEVICE $174.00 58301

CFC64450 N BLOCK OTHER PERIPHERAL $168.00 64450

CFC64455 N BLOCK INJ PLANTAR DIGIT $99.00 64455

CFC65205 REM FOREIGN BODY EXT EYE $204.00 65205

CFC65220 REM FOREIGN BOD CORNEA NO SLIT $344.00 65220

CFC69200 CLEAR OUTER EAR CANAL $260.00 69200

CFC69209 REMOVE IMPACT CERUMEN W/IRRIG $25.00 69209

CFC69210 REMOVE IMPACT CERUMEN W/INSTMT $182.00 69210

CFC81002 URINALYSIS NONAUTO W/O SCOPE $32.00 81002

CFC81002CL URINALYSIS FOR CDL EXAMS ONLY $0.00 81002

CFC81025 URINE PREGNANCY TEST $29.00 81025

CFC82270 OCCULT BLOOD FECES $12.00 82270

CFC82962 GLUCOSE BLOOD TEST $48.00 82962

CFC85610 PROTHROMBIN TIME $28.00 85610QW

CFC86580 TB INTRADERMAL TEST ADULT $55.00 86580

CFC87210 SMEAR WET MOUNT SALINE/INK $28.00 87210QW

CFC87880 STREP A ASSAY W/OPTIC $29.00 87880QW

CFC90378 SYNAGIS INJ PATIENT SUPPLIED $0.00

CFC90460 IM ADMIN 1ST/ONLY COMPONENT $54.00 90460

CFC90461 IM ADMIN EACH ADDL COMPONENT $29.00 90461

CFC90471 IMMUNIZATION ADMIN $54.00 90471

CFC90471TD IMMUN ADMIN TDAP ONLY FOR RHC $54.00 90471

CFC90472 IMMUNIZATION ADMIN EACH ADD $29.00 90472

CFC90473 IMMUNE ADMIN ORAL/NASAL $29.00 90473

CFC90474 IMMUNE ADMIN ORAL/NASAL ADDL $29.00 90474

CFC90632 HEP A VACCINE ADULT IM $213.00 90632

CFC90633SF HEP A VAC PED/ADOL 2 DOSE $30.00 90633

CFC90647SF HIB 3 DOSE $20.00 90647

CFC90648SF HIB VACCINE PRP‐T IM 4 DOSE $16.00 90648

CFC90651SF HPV (9) VACCINE $204.00 90651

CFC90653 FLUAD 65+ FLU VACCINE $27.00 90653

CFC90655SF INFLUENZA PRES FREE 6‐35 MOS $0.00 90655SL

CFC90656 FLU VACCINE NO PRESERV 3 & > $56.00 90656

CFC90661 FLU VACC CELL CULT PRSV FREE $57.00 90661

CFC90662SF FLUZONE 0.5ML SINGLE DOSE $28.00 90662

CFC90670 PCV 13 ADULT $265.00 90670

CFC90670SF PNEUMOCOCCAL VACC 13 VAL $183.00 90670

CFC90674 FLU VACC FLUCELVAX QUADRIV $57.00 90674

CFC90685SF FLUZONE $28.00 90685

CFC90686SF FLUARIX SINGLE 3+ $20.00 90686

CFC90688SF FLULAVAL MULTI 3+ $20.00 90688

CFC90696SF DTAP‐IPV VACC 4‐6 YR IM $56.00 90696

CFC90698SF PENTACEL DTAP‐IPV‐HIB $92.00 90698

CFC90700SF DTAP UNDER 7 Y/O $28.00 90700

CFC90707SF MMR VACCINE SC $33.00 90707

CFC90710SF MMRV VACCINE SC $183.00 90710

CFC90713SF POLIOVIRUS IPV SC/IM $21.00 90713

CFC90714 TD VACC NO PRES ADULT $140.00 90714

CFC90714SF SF‐TD NO PRES PED $30.00 90741

CFC90715 TDAP VACC ADULT $140.00 90715

CFC90715SF SF‐TDAP VACC PED $51.00 90715

CFC90716SF SF‐VARICELLA VACC $123.00 90716

CFC90723SF SF‐DTAP‐HEPB‐IPV VACCINE $84.00 90723

CFC90732 PNEUMOCOCCAL VACCINE $75.00 90732

CFC90734SF SF‐MENINGOCOCCAL VACCINE $137.00 90734

CFC90736 $0 ‐ ZOSTER VACC SC $0.00 90736

CFC90744SF SF‐HEPB VAC PED/ADOL 3 DOS $19.00 90744

CFC90746 HEP B VACC ADULT 3 DOSE IM $209.00 90746

CFC90887 CONSULTATION WITH FAMILY $111.00 90887

CFC92551 HEARING SCREENING $21.00 92551

CFC92567 TYMPANOMETRY $96.00 92567

CFC92950 CPR $416.00 92950

CFC93010 ELECTROCARDIOGRAM PROF COMP $183.00 93010

CFC93042 RHYTHM STRIP ‐ PROF COMP $183.00 93042

CFC93227 HOLTER REPORT & INTERP ONLY $55.00 93227

CFC93272 30 DAY EVENT MONITOR‐PROF COMP $183.00 93272

CFC94010 BREATHING CAPACITY TEST $80.00 94010

CFC94060 EVALUATION OF WHEEZING $130.00 94060

CFC94200 LUNG FUNCTION TEST (MBC/MVV) $93.00 94200

CFC94618 WALK TEST ‐ 6 MIN $483.00 94618

CFC94640 AIRWAY INHALATION TREATMENT $122.00 94640

CFC94664 EVALUATE PT USE OF INHALER $110.00 94664

CFC95115 IMMUNOTHERAPY ONE INJECTION $33.00 95115

CFC95117 IMMUNOTHERAPY INJECTIONS $37.00 95117

CFC97005 ATHLETIC TRAIN EVAL $75.00 97005

CFC97010 HOT OR COLD PACKS THERAPY $28.00 97010

CFC97597 DEBRIDEMENT OPEN WOUND 20 SQ C $160.00 97597

CFC97602 WOUND(S) CARE NON‐SELECTIVE $62.00 97602

CFC97607 Negative Pressure Wound Therap $250.00 97607

CFC97750 PHYSICAL PERFORMANCE TEST $104.00 97750

CFC98966 TELEPHONE CALL 5‐10 MIN $0.00 98966



CFC99024 POST OP FOLLOW UP VISIT $0.00 99024

CFC99070 SUPPLIES AND MATERIALS $0.00 99070

CFC99075 MEDICAL TESTIMONY $361.00 99075

CFC99080 SPECIAL REPORTS OR FORMS $62.00 99080

CFC99173 VISUAL ACUITY SCREENING $0.00 99173

CFC99195 THERAPEUTIC PHLEBOTOMY $213.00 99195

CFC99199 DID NOT KEEP APPOINTMENT $0.00 99199

CFC99241 OFFICE CONSULTATION $209.00 99241





CFC99251 INPATIENT CONSULT LEVEL I $249.00 99251

CFC99252 INPATIENT CONSULT LEVEL II $318.00 99252

CFC99253 INPATIENT CONSULT LEVEL III $386.00 99253

CFC99254 INPATIENT CONSULT LEVEL IV $542.00 99254

CFC99255 INPATIENT CONSULT LEVEL V $742.00 99255

CFC99339 BRH CARE PLAN PT NOT PRES 29M $133.00 99339

CFC99340 BRH CARE PLAN PT NOT PRES 30M+ $185.00 99340

CFC99341 HOME VISIT NEW PATIENT LEV I $174.00 99341

CFC99342 HOME VISIT NEW PATIENT LEV II $134.00 99342

CFC99343 HOME VISIT NEW PATIENT LEV III $298.00 99343

CFC99344 HOME VISIT NEW PATIENT LEV IV $369.00 99344

CFC99347 HOME VISIT EST PATIENT LEV I $204.00 99347

CFC99348 HOME VISIT EST PATIENT LEV II $189.00 99348

CFC99349 HOME VISIT EST PATIENT LEV III $260.00 99349

CFC99354 PROLONG SVC W/DIRECT PT CONTCT $428.00 99354

CFC99366 TEAM CONF W/PAT $88.00 99366

CFC99367 TEAM CONF W/O PAT BY PHYS $186.00 99367

CFC99368 TEAM CONF W/O PAT $191.00 99368

CFC99374 CARE PLAN OVERSIGHT UP TO 29M $191.00 99374

CFC99375 CARE PLAN OVERSIGHT 30 MIN + $227.00 99375

CFC99377 SUPERVISION HOSPICE PT 15‐29MN $151.00 99377

CFC99378 SUPERVISION HOSPICE PT 30+MIN $179.00 99378

CFC99379 BRH SUPERVISE PT NOT PRES 29M $191.00 99379

CFC99380 NURSING FAC CARE 30+MIN $227.00 99380

CFC99381 INITIAL WELLNESS UP TO 1 YR $293.00 99381

CFC99382 INITIAL WELLNESS 1‐4 YR $318.00 99382





CFC99387 INITIAL WELLNESS 65+ YR $439.00 99387

CFC99391 PERIODIC WELLNESS EST TO 1 YR $238.00 99391

CFC99392 PERIODIC WELLNESS EST 1‐4 YR $263.00 99392





CFC99397 PERIODIC WELLNESS EST 65+YR $371.00 99397

CFC99406 TOBACCO USE CESS COUNS 3‐10MIN $43.00 99406

CFC99429 SPORTS PHYSICAL $100.00 99429

CFC99429CD CDL PHYSICAL $128.00 99429

CFC99441 TELEPHONE E/M BY PROV 5‐10MIN $50.00 99441

CFC99442 TELEPHONE E/M BY PROV 11‐20MIN $113.00 99442

CFC99443 TELEPHONE DISCUSS 21‐30 MIN $162.00 99443

CFC99444 ONLINE E/M BY PHYS/QHP $56.00 99444

CFC99450 BASIC LIFE DISABILITY EXAM $342.00 99450

CFC99455 DOT PHYSICAL $128.00 99455

CFC99456 DISABILITY EXAMINATION $342.00 99456

CFC99490 CHRONIC CARE MGMT SERVICES $129.00 99490

CFC99495 TRANSITIONAL CARE MGMT‐MOD COM $269.00 99495

CFC99496 TRANS CARE MGMT HIGH COMPLEX $401.00 99496

CFC99497 ADVNCD CARE PLAN 30 MIN $91.00 99497

CFCA4332 LUBRICANT INDIVIDUAL STERL $0.00 A4332

CFCA4340 $0 ‐ INDWELL CATHETER; SPECIAL $20.00 A4340

CFCA4565 SLINGS $25.00 A4565

CFCA4570 SPLINTS $71.00 A4570

CFCA5112 URINARY DRAIN BAG LEG/ABD LATE $17.00 A5112

CFCA6210 FOAM DRESS >16 <=48SQ W/O ADHE $6.00 A6210

CFCA6212 FOAM DRESS 16 SQ/< W/ADHES BOR $14.00 A6212

CFCA6213 FOAM DRESS >16 <= 48 SQ W/ADHE $17.00 A6213

CFCA6222 GAUZ IMPREG NOT H2O/HYDRGEL 16 $7.00 A6222

CFCA6231 GAUZ IMPREG HYDRGEL DIR WND 16 $11.00 A6231

CFCA6257 TRNSPRT FILM STERL 16 SQ/< EA $5.00 A6257

CFCA6448 LT COMPRS BANDGE ELAST WDTH < $15.00 A6448

CFCA6449 LT COMPRS BANDGE WDTH >/= 3 & $15.00 A6449

CFCA6450 LT COMPRS BANDGE WDTH >/= 5 IN $15.00 A6450

CFCA6456 PASTE BOOT SUPPLIES $39.00 A6456

CFCB4082 NASOGASTRIC TUBE SALEM S 16FR $13.00 B4082

CFCE0110 CRTCHES FORARM VARIOUS MATL PA $104.00 E0110

CFCE0114 CRTCHES UNDARM OTH THAN WOOD P $97.00 E0114

CFCE0116 CRTCH UNDARM OTH THAN WOOD ADJ $38.00 E0116

CFCE1800 DYN ADJUSTABLE ELB EXT/FLX DEV $244.00 E1800

CFCG0008 ADMINISTRATION INFLUENZA VIRUS $29.00 G0008

CFCG0009 ADMINISTRATION PNEUMOCOCCAL VA $29.00 G0009

CFCG0010 ADMINISTRATION HEPATITIS B VAC $29.00 G0010

CFCG0101 CERV/VAG CANCR SCR;PELV&CLN BR $79.00 G0101

CFCG0108 DIAB OP SELF‐MGMT TRN SRVC IND $134.00 G0108

CFCG0127 TRIM DYSTROPHIC NAILS ANY NUMB $49.00 G0127

CFCG0250 PHYS REV INTEPR HOME INR MON; $34.00 G0250

CFCG0293 NONCOVR SURG SEDAT ANES‐MCR QU $134.00 G0293

CFCG0372 PHYS EST & DOC NEED PWR MOBIL $57.00 G0372

CFCG0402 WELCOME TO MEDICARE EXAM ‐ 1ST $371.00 G0402

CFCG0404 ECG RTN ECG W/12 LEADS TRACING $44.00 G0404

CFCG0405 ECG RTN ECG W/12 LEADS I&R ONL $183.00 G0405

CFCG0438 ANNUAL WELLNES VST; PERSNL PPS $361.00 G0438

CFCG0439 ANNUAL WELLNESS VST; PPS SUBSQ $361.00 G0439

CFCG0444 ANNUAL DEPRESSION SCREENING $54.00 G0444

CFCG0511 CHRONIC CARE MGMT OR BHI $121.00 G0511

CFCG0512 PSYCH COLL CARE MODEL 60 MIN + $121.00 G0512

CFCJ0120 INJ TETRACYCLINE UP TO 250MG $5.00 J0120

CFCJ0171 INJ ADRENALIN EPI 0.1MG $36.00 J0171

CFCJ0210 INJ METHYLDOPATE HCL TO 250MG $100.00 J0210

CFCJ0400 INJ ARIPIPRAZOLE IM 0.25 MG $12.00 J0400

CFCJ0696 INJ CEFTRIAXONE SOD PER 250MG $42.00 J0696

CFCJ0698 INJ CEFOTAXIME SOD PER 750MG $9.00 J0698

CFCJ1000 INJ DEPO‐ESTRADIOL UP TO 5MG $0.00 J1000

CFCJ1050 INJ MEDROXYPROGESTERNE ACE 1MG $0.00 J1050

CFCJ1071 INJ TESTOSTERONE CYP 1MG $12.00 J1071

CFCJ1100 INJ DEXMETHOSONE SODIUM 1MG $79.00 J1100

CFCJ1110 INJ DIHYDROERGOTAMINE MES 1MG $111.00 J1110

CFCJ1170 INJ HYDROMORPHONE UP TO 4MG $7.00 J1170

CFCJ1200 INJ DIPHENHYDRAMINE UP TO 50MG $47.00 J1200

CFCJ1380 INJ ESTRADIOL VALERATE TO 10MG $33.00 J1380

CFCJ1630 INJ HALOPERIDOL UP TO 5 MG $17.00 J1630

CFCJ1631 INJ HALOPERIDOL DEC PER 50MG $33.00 J1631

CFCJ1650 INJ ENOXAPARIN SODIUM 10MG $71.00 J1650

CFCJ1670 INJ TETNS IMMUN GLOB TO 250MG $490.00 J1670

CFCJ1710 INJ HYDROCORTISONE 50MG $0.00 J1710

CFCJ1815 INJ INSULIN PER 5 UNITS $108.00 J1815

CFCJ1885 INJ KETOROLAC TROM 15MG $69.00 J1885

CFCJ2001 INJ LIDOCAINE HCL 10 MG $34.00 J2001

CFCJ2060 INJ LORAZAPAM 2MG $27.00 J2060

CFCJ2175 INJ MEPERIDINE HCL PER 100MG $34.00 J2175

CFCJ2405 INJ ONDANSETRON HYDRO 1MG $117.00 J2405

CFCJ2426 $0 ‐ INJ PALIPERIDONE PALM EXT $0.00 J2426

CFCJ2550 INJ PROMETHAZINE HCL TO 10MG $32.00 J2550

CFCJ2765 INJ METOCLOPRAMIDE HCL TO 10MG $46.00 J2765

CFCJ2794 $0 ‐ INJ RISPERIDONE LONG ACTI $0.00 J2794

CFCJ2920 INJ SOLU‐MEDROL UP TO 40MG $34.00 J2920

CFCJ2930 INJ METHYLPREDNISOLONE TO 125M $17.00 J2930

CFCJ3030 INJ SUMATRIPTAN SUC 60MG $140.00 J3030

CFCJ3121 INJ TESTO ENANTHATE 1MG $25.00 J3121

CFCJ3301 INJ TRIAMCIOLNE ACE 10MG $37.00 J3301

CFCJ3410 INJ HYDROXYZINE HCL TO 25MG $79.00 J3410

CFCJ3411 INJ THIAMINE HCL 100MG $29.00 J3411

CFCJ3420 INJ VIT B‐12 CYNO TO 1MG $29.00 J3420

CFCJ3490 UNCLASSIFIED DRUGS $0.00 J3490

CFCJ7620 ALBUTEROL TO 2.5 MG IPT TO 0.5 $1.00 J7620

CFCJ7644 IPRATROPIUM BROM INHAL NON‐CP $8.00 J7644

CFCL0120 CERVICAL FLEXIBLE NONADJUSTABL $47.00 L0120

CFCL0172 CERV COLLR SEMI‐RIGD FOAM 2 PI $178.00 L0172

CFCL0220 THORACIC RIB BELT CUSTOM FABRI $171.00 L0220

CFCL1810 KO ELAST W/JNT PREFAB INCL FIT $147.00 L1810

CFCL1820 KO ELAST W/CONDYLR PADS&JNT PR $186.00 L1820

CFCL1830 KO IMMOBLIZR CANVAS LNGTUDNL P $281.00 L1830

CFCL1832 KO ADJ UNICNT/POLYCNT RIGD PRE $784.00 L1832

CFCL1833 KNEE ORTHOSIS ADJUST KNEE JT $784.00 L1833

CFCL1902 AFO ANK GAUNTLT PREFAB W/FIT & $203.00 L1902

CFCL1904 AFO MOLDED ANK GAUNTLET CUSTOM $606.00 L1904

CFCL1906 AFO MXILIGUS ANKLE SUPP PRFAB $156.00 L1906

CFCL3260 SURGICAL BOOT/SHOE EACH $32.00 L3260

CFCL3265 CAST SANDAL EACH $35.00 L3265

CFCL3650 SHOULDER IMMOBILIZER $80.00 L3650

CFCL3670 SO ACROMIO/CLAVICULR PRFAB FIT $160.00 L3670

CFCL3702 EO W/O JOINTS CUSTOM FABRICATE $354.00 L3702

CFCL3762 ELB ORTHOT RIGD W/O JNT W/INTE $133.00 L3762

CFCL3763 EWHO RIGID W/O JOINTS CUSTOM F $905.00 L3763

CFCL3808 WHF ORTHOTIC RIGID NO JNT; CUS $441.00 L3808

CFCL3809 WHFO W/O JOINTS PRE OTS $307.00 L3809

CFCL3908 WHO EXT CNTRL COCK‐UP NONMOLD $101.00 L3908

CFCL3913 HFO W/O JOINTS CUSTOM FABRICAT $332.00 L3913

CFCL3923 HFO W/O JOINTS STRAPS PRFAB $121.00 L3923

CFCL3924 Hfo without joints pre ots $121.00 L3924

CFCL3927 FO PIP/DIP W/O JOINT/SPRING PR $111.00 L3927

CFCL4350 ANKLE CNTRL ORTHOSIS STIRRUP P $128.00 L4350

CFCL4360 WALK BOOT PNEUMATC PREFAB W/FI $476.00 L4360

CFCL4361 PNEUMA/VAC WALK BOOT PRE OTS $517.00 L4361

CFCL4387 Non‐pneum walk boot pre ots $423.00 L4387

CFCL5685 KUHL SHEILDS KNEE SLEEVE $181.00 L5685

CFCNCV NC VISIT $0.00

CFCQ0091 SCR PAP SMER; OBTAIN PREP&CONV $94.00 Q0091

CFCQ0111 WET MOUNTS W/PREP VAG CERV/SKN $11.00 Q0111

CFCQ0162 ONDANSETRON 1 MG ORAL $11.00 Q0162

CFCQ4001 CAST BDY CAST ADLT W/WO HEAD P $113.00 Q4001

CFCQ4010 CAST SPL SHRT ARM CAST ADLT FI $71.00 Q4010

CFCQ4051 SPLINT SUPPLIES MISCELLANEOUS $71.00 Q4051

CFCS8451 SPLINT $0.00 S8451

CFCS9982 MEDICAL RECORDS COPYING FEE‐PA $2.00 S9982

CFC99306 INITIAL SWB PROFEE LEVEL III $346.00 99306

CFC99307 SUB SWB PROFEE LEVEL I $258.00 99307

CFC99308 SUB SWB PROFEE LEVEL II $330.00 99308

CFC99309 SUB SWB PROFEE LEVEL III $374.00 99309

CFC99310 SUB SWB PROFEE LEVEL IV $410.00 99310

CFC99315 SWB DISCHARGE PROFEE LEVEL I $218.00 99315

CFC99316 SWB DISCHARGE PROFEE LEVEL II $272.00 99316

CFC99318 ANNUAL NURSING FAC ASSESSMENT $494.00 99318

CFC99304NS NF INITIAL PROFEE LEVEL I $224.00 99304

CFC99305NS NF INITIAL PROFEE LEVEL II $224.00 99305

CFC99306NS NF INITIAL PROFEE LEVEL III $346.00 99306

CFC99307NS NF SUB PROFEE LEVEL I $258.00 99307

CFC99308NS NF SUB PROFEE LEVEL II $330.00 99308

CFC99309NS NF SUB PROFEE LEVEL III $374.00 99309

CFC99310NS NF SUB PROFEE LEVEL IV $410.00 99310

CFC99315NS NF DISCHARGE PROFEE LEV I $218.00 99315

CFC99316NS NF DISCHARGE PROFEE LEV II $272.00 99316

CFC99379NS NF SUPERVISION PT NOT PRES 29M $191.00 99379

CFC99380NS NF SUPERVISION PT NOT PRES 30+ $227.00 99380

CFC90785 INTERACTIVE COMPLEXITY (ADD) $42.00 90785

CFC90791 PSYCH DIAGNOSTIC EVAL $220.00 90791

CFC90792 PSYCH DIAG EVAL W/MED SRVCS $246.00 90792

CFC90832 PSYTX PT/FAM 30 MIN $108.00 90832

CFC90833 PSYCHOTHERAPY 30 MIN W/E&M $111.00 90833





CFC90839 PSYTX CRISIS INITIAL 60 MIN $417.00 90839

CFC90840 PSYCHOTHERAPY CRISIS ADD ON $42.00 90840

CFC90845 PSYCHOANALYSIS $153.00 90845

CFC90846 FAMILY PTHERAPY 50 MIN NO PAT $173.00 90846

CFC90847 FAMILY PTHERAPY 50 MIN W/PAT $179.00 90847

CFC90863 PHARMACOLOGIC MGMT $179.00 90863

CFC0556F PLAN OF CARE ACHIEVE LIPID DOC $1.00 0513F

CFC1036F CURRENT TOBACCO NON‐USER $1.00 1036F

CFC1100F PT SCRN FALL RISK 2 OR MORE YR $1.00 1100F

CFC1101F PT SCRN FALL RISK NONE OR 1 $1.00 1101F

CFC1111F D/C MEDS REC W/CURRENT MED LST $1.00 1111F

CFC1157F ADVANCE CARE PLAN PRESENT $1.00 1157F

CFC1158F ADV CARE PLAN DISCUSSION $1.00 1158F

CFC1159F MED LIST DOCUMENTED IN MED REC $1.00 1159F

CFC1160F REVIEW OF ALL MEDS BY PROV $1.00 1160F

CFC2022F DILATED RET EYE EXAM DOC & REV $1.00 2022F

CFC2024F 7 STEREOSCOPIC PHOTOS BY OPHTH $1.00 2024F

CFC2026F EYE IMAGING FROM 7 PHOTOS DOC $1.00 2026F

CFC2028F FOOT EXAM PERFORMED $1.00 2028F

CFC3008F BODY MASS INDEX DOCUMENTED $1.00 3008F

CFC3014F BREAST CA SCN RESULTS REV/DOC $1.00 3014F

CFC3017F COLONOSCOPY RESULTS DOC/REV $1.00 3017F

CFC3044F A1C <7 $1.00 3044F

CFC3045F A1C BETWEEN 7 AND 9 RECORDED $1.00 3045F

CFC3046F A1C >9 RECORDED $1.00 3046F

CFC3048F MOST RECENT LDL‐C <100MG/DL $1.00 3048F

CFC3049F MOST RECENT LDL‐C 100‐129 MG $1.00 3049F

CFC3050F MOST RECENT LDL‐C >/= 130 MG $1.00 3050F

CFC3072F LOW RISK FOR RETINOPATHY $1.00 3072F

CFC3288F FALL RISK ASSESSMENT DOCUMENT $1.00 3288F

CFC3725F DEPRESSION SCREENING $1.00 3725F

CFC4004F TOBACCO SCREEN AND COUNSELING $1.00 4004F

CFC4013F STATIN THERAPY PRES OR CURRENT $1.00 4013F

CFC4037F FLU VACCINE GIVEN $1.00 4037F

CFC4040F PNEUMO VACC ADMIN/PREV RECVD $1.00 4040F

CFC4274F FLU VAX PREVIOUS LAST 12 MOS $1.00 4274F

CFCG0104 COLORECTAL CA SCREEN FLEX SIG $1.00 G0104

CFCG0105 COLORECTAL CA SCREEN HIGH RISK $1.00 G0105

CFCG0121 COLORECTAL CA SCREEN LOW RISK $1.00 G0121

CFCG0202 SCREEN BILAT MAMMO INCLUDE CAD $1.00 G0202

CFCG0204 DIAGNOSTIC BILAT MAMMO + CAD $1.00 G0204

CFCG0206 DIAGNOSTIC UNILAT MAMMO + CAD $1.00 G0206

CFCG0464 COLORECTAL CA SCREEN STOOL DNA $1.00 G0464

CFCG8417 CALCULATED BMI > NORMAL + PLAN $1.00 G8417

CFCG8418 CALCULATED BMI < NORMAL + PLAN $1.00 G8418

CFCG8420 DOCUMENTED NORMAL BMI=NO PLAN $1.00 G8420

CFCG8431 POSITIVE DEPRESSION SCREENING $1.00 G8431

CFCG8482 INFLUENZA IMMUN ADMIN OR PREV $1.00 G8482

CFCG8510 NEGATIVE DEPRESSION SCREENING $1.00 G8510

CFCG8752 MOST RECENT SYSTOLIC BP <140 $1.00 G8752

CFCG8754 MOST RECENT DIASTOLIC BP <90 $1.00 G8754

CFCG9393 PHQ‐9 >9 REMISSION 12 MOS <5 $1.00 G9393

CFCG9509 DEPRESSION REMISSION 12 MOS <5 $1.00 G9509

CFCM1069 SCREEN FOR FALL RISK $1.00 M1069

WFC10021 FINE NEEDLE ASP W/O IMAGING $258.00 10021

WFC10040 ACNE SURGERY $208.00 10040

WFC10060 DRAINAGE OF SKIN ABSCESS $331.00 10060

WFC10061 DRAINAGE OF SKIN ABSCESS $425.00 10061

WFC10080 DRAINAGE OF PILONIDAL CYST $375.00 10080

WFC10081 DRAINAGE OF PILONIDAL CYST $556.00 10081

WFC10120 REMOVE FOREIGN BODY $382.00 10120

WFC10121 REMOVE FOREIGN BODY $806.00 10121

WFC10140 DRAINAGE OF HEMATOMA/FLUID $339.00 10140

WFC10160 PUNCTURE DRAINAGE OF LESION $270.00 10160

WFC1028M JOB OFFER OR ANALYSIS $43.00

WFC1038M REVIEW OF JOB DESCRIPTION $57.00

WFC1040M PHYSICIAN INITIAL REPORT $44.00

WFC1063M IME REPORT $44.00

WFC1073M ACTIVITY PRESCRIPTION FORM $57.00

WFC1076M SUBACUTE OPIOID REQUEST FORM $35.00

WFC1078M CHRONIC OPIOID REQUEST FORM $35.00

WFC11042 DEBRIDEMENT SUBCUTAN TISSUE $202.00 11042

WFC11055 TRIM SKIN LESION $114.00 11055

WFC11056 TRIM SKIN LESIONS 2 TO 4 $123.00 11056

WFC11057 TRIM SKIN LESIONS OVER 4 $138.00 11057

WFC11100 BIOPSY SKIN LESION $250.00 11100

WFC11101 BIOPSY SKIN ADD‐ON $67.00 11101

WFC11103 TANGENTIAL SKIN BIOPSY EA ADD $107.00 11103

WFC11104 PUNCH BIOPSY SINGLE LESION $250.00 11104

WFC11105 PUNCH BIOPSY EACH ADDITIONAL $107.00 11105

WFC11106 INCISIONAL WEDGE BIOPSY SINGLE $250.00 11106

WFC11107 INCSIONAL WEDGE BIOPSY EA ADD $107.00 11107

WFC11200 REMOVAL OF SKIN TAGS <W/15 $254.00 11200

WFC11201 REMOVE SKIN TAGS ADD‐ON $114.00 11201

WFC11300 SHAVE SKIN LESION 0.5 CM/< $224.00 11300

WFC11301 SHAVE SKIN LESION 0.6‐1.0 CM $254.00 11301


WFC11303 SHAVE SKIN LESION >2.0 CM $332.00 11303









WFC11400 EXC TR‐EXT B9+MARG 0.5 CM< $375.00 11400

WFC11401 EXC TR‐EXT B9+MARG 0.6‐1 CM $446.00 11401


WFC11403 EXC TR‐EXT B9+MARG 2.1‐3CM/< $571.00 11403


WFC11406 EXC TR‐EXT B9+MARG >4.0 CM $775.00 11406

WFC11420 EXC H‐F‐NK‐SP B9+MARG 0.5/< $309.00 11420

WFC11421 EXC H‐F‐NK‐SP B9+MARG 0.6‐1 $393.00 11421




WFC11426 EXC H‐F‐NK‐SP B9+MARG >4 CM $775.00 11426

WFC11440 EXC FACE‐MM B9+MARG 0.5 CM/< $369.00 11440

WFC11441 EXC FACE‐MM B9+MARG 0.6‐1 CM $446.00 11441

WFC11442 EXC FACE‐MM B9+MARG 1.1‐2 CM $482.00 11442

WFC11600 EXC TR‐EXT MAL+MARG 0.5 CM/< $553.00 11600

WFC11601 EXC TR‐EXT MAL+MARG 0.6‐1 CM $650.00 11601




WFC11606 EXC TR‐EXT MAL+MARG >4 CM $916.00 11606

WFC11640 EXCISION MALIGNANT LESION F/E/ $414.00 11640

WFC11719 TRIM NAIL(S) ANY NUMBER $31.00 11719

WFC11720 DEBRIDE NAIL 1‐5 $80.00 11720

WFC11721 DEBRIDE NAIL 6 OR MORE $166.00 11721

WFC11730 REMOVAL OF NAIL PLATE $297.00 11730

WFC11732 REMOVE NAIL PLATE ADD‐ON $81.00 11732

WFC11740 DRAIN BLOOD FROM UNDER NAIL $104.00 11740

WFC11750 REMOVAL OF NAIL BED $814.00 11750

WFC11765 EXCISION OF NAIL FOLD TOE $352.00 11765

WFC1191M STANDARD IMPAIRMENT RATING EXA $682.00 1191M

WFC1192M COMPLEX IMPAIRMENT RATING EXAM $853.00 1192M

WFC11980 IMPLANT HORMONE PELLET(S) $228.00 11980

WFC12001 RPR S/N/AX/GEN/TRNK 2.5CM/< $393.00 12001

WFC12002 RPR S/N/AX/GEN/TRNK2.6‐7.5CM $439.00 12002

WFC12004 RPR S/N/AX/GEN/TRK7.6‐12.5CM $493.00 12004

WFC12005 RPR S/N/A/GEN/TRK12.6‐20.0CM $634.00 12005

WFC12006 RPR S/N/A/GEN/TRK20.1‐30.0CM $788.00 12006

WFC12011 RPR F/E/E/N/L/M 2.5 CM/< $464.00 12011

WFC12013 RPR F/E/E/N/L/M 2.6‐5.0 CM $586.00 12013

WFC12014 RPR F/E/E/N/L/M 5.1‐7.5 CM $627.00 12014

WFC12015 RPR F/E/E/N/L/M 7.6‐12.5 CM $704.00 12015

WFC12016 RPR FE/E/EN/L/M 12.6‐20.0 CM $882.00 12016

WFC12020 CLOSURE OF SPLIT WOUND $588.00 12020

WFC12021 CLOSURE OF SPLIT WOUND $487.00 12021

WFC12031 INTMD RPR S/A/T/EXT 2.5 CM/< $559.00 12031

WFC12032 INTMD RPR S/A/T/EXT 2.6‐7.5 $639.00 12032

WFC12034 INTMD RPR S/TR/EXT 7.6‐12.5 $710.00 12034

WFC12035 INTMD RPR S/A/T/EXT 12.6‐20 $879.00 12035

WFC12041 INTMD RPR N‐HF/GENIT 2.5CM/< $520.00 12041

WFC12042 INTMD RPR N‐HF/GENIT2.6‐7.5 $669.00 12042

WFC12044 INTMD RPR N‐HF/GENIT7.6‐12.5 $759.00 12044

WFC12045 INTMD RPR N‐HF/GENIT12.6‐20 $933.00 12045

WFC12051 INTMD RPR FACE/MM 2.5 CM/< $630.00 12051

WFC12052 INTMD RPR FACE/MM 2.6‐5.0 CM $721.00 12052

WFC12053 INTMD RPR FACE/MM 5.1‐7.5 CM $857.00 12053

WFC15852 DRESSING CHANGE NOT FOR BURN $95.00 15852

WFC16000 INITIAL TREATMENT OF BURN(S) $194.00 16000

WFC16020 DRESS/DEBRID P‐THICK BURN S $192.00 16020

WFC16025 DRESS/DEBRID P‐THICK BURN M $451.00 16025

WFC16030 DRESS/DEBRID P‐THICK BURN L $626.00 16030

WFC17000 DESTRUCT PREMALG LESION $238.00 17000

WFC17003 DESTRUCT PREMALG LES 2‐14 $62.00 17003

WFC17004 DESTROY PREMAL LESIONS 15/> $732.00 17004

WFC17106 DESTRUCTION OF SKIN LESIONS $702.00 17106


WFC17110 DESTRUCT B9 LESION 1‐14 $233.00 17110

WFC17111 DESTRUCT LESION 15 OR MORE $275.00 17111


WFC17340 CRYOTHERAPY OF SKIN $81.00 17340

WFC17380 HAIR REMOVAL BY ELECTROLYSIS $608.00 17380

WFC20520 REMOVAL OF FOREIGN BODY $785.00 20520

WFC20526 THER INJECTION CARP TUNNEL $158.00 20526

WFC20550 INJ TENDON SHEATH/LIGAMENT $122.00 20550

WFC20551 INJ TENDON ORIGIN/INSERTION $125.00 20551

WFC20552 INJ TRIGGER POINT 1/2 MUSCL $172.00 20552

WFC20553 INJECT TRIGGER POINTS 3/> $133.00 20553

WFC20600 DRAIN/INJECT JOINT/BURSA $250.00 20600



WFC20612 ASPIRATE/INJ GANGLION CYST $126.00 20612

WFC24640 TREAT ELBOW DISLOCATION $254.00 24640

WFC25500 TREAT FRACTURE OF RADIUS $836.00 25500

WFC25560 TREAT FRACTURE RADIUS & ULNA $835.00 25560

WFC25600 TREAT FRACTURE RADIUS/ULNA $856.00 25600

WFC25650 TREAT WRIST BONE FRACTURE $980.00 25650

WFC26080 EXPLORE/TREAT FINGER JOINT $796.00 26080

WFC26720 TREAT FINGER FRACTURE EACH $781.00 26720



WFC28470 TREAT METATARSAL FRACTURE $695.00 28470

WFC29065 APPLICATION OF LONG ARM CAST $342.00 29065

WFC29075 APPLICATION OF FOREARM CAST $390.00 29075

WFC29086 APPLY FINGER CAST $164.00 29086

WFC29105 APPLY LONG ARM SPLINT $184.00 29105

WFC29125 APPLY FOREARM SPLINT $259.00 29125

WFC29130 APPLICATION OF FINGER SPLINT $132.00 29130

WFC29280 STRAPPING OF HAND OR FINGER $79.00 29280

WFC29345 APPLICATION OF LONG LEG CAST $461.00 29345

WFC29405 APPLY SHORT LEG CAST $342.00 29405

WFC29425 APPLY SHORT LEG CAST $164.00 29425

WFC29515 APPLICATION LOWER LEG SPLINT $251.00 29515

WFC29540 STRAPPING OF ANKLE AND/OR FT $55.00 29540

WFC29580 APPLICATION OF PASTE BOOT $128.00 29580

WFC30300 REMOVE NASAL FOREIGN BODY $491.00 30300

WFC30801 ABLTJ SOFT TIS INFERIOR TURBIN $486.00 30801

WFC30901 CONTROL OF NOSEBLEED $396.00 30901

WFC30903 CONTROL OF NOSEBLEED $518.00 30903

WFC36415 ROUTINE VENIPUNCTURE $32.00 36415

WFC36416 CAPILLARY BLOOD DRAW $21.00 36416

WFC36592 COLLECT BLOOD FROM PICC $57.00 36592

WFC46083 I&D THROMBOISED HEMORRHOID $549.00 46083

WFC46320 REMOVAL OF HEMORRHOID CLOT $382.00 46320

WFC46600 DIAGNOSTIC ANOSCOPY $245.00 46600

WFC51701 INSERT BLADDER CATHETER $114.00 51701

WFC51702 INSERT TEMP BLADDER CATH $147.00 51702

WFC51705 CHANGE OF CYSTOSTOMY; SIMPLE $282.00 51705

WFC54150 CIRCUMCISION W/REGIONL BLOCK $249.00 54150

WFC57160 INSERT PESSARY/OTHER DEVICE $158.00 57160

WFC58301 REMOVE INTRAUTERINE DEVICE $174.00 58301

WFC64450 N BLOCK OTHER PERIPHERAL $168.00 64450

WFC64455 N BLOCK INJ PLANTAR DIGIT $99.00 64455

WFC65205 REMOVE FOREIGN BODY FROM EYE $204.00 65205

WFC65220 REMOVE FOREIGN BODY FROM EYE $344.00 65220

WFC69200 CLEAR OUTER EAR CANAL $260.00 69200

WFC69209 REMOVE IMPACT CERUMEN W/IRRIG $25.00 69209

WFC69210 REMOVE IMPACT CERUMEN W/INSTMT $182.00 69210

WFC81002 URINALYSIS NONAUTO W/O SCOPE $32.00 81002

WFC81002CL URINALYSIS FOR CDL EXAMS ONLY $0.00 81002

WFC81025 URINE PREGNANCY TEST $29.00 81025

WFC82270 OCCULT BLOOD FECES $33.00 82270

WFC82962 GLUCOSE BLOOD TEST $48.00 82962

WFC85610 PROTHROMBIN TIME $28.00 85610QW

WFC86580 TB INTRADERMAL TEST ADULT $55.00 86580

WFC87210 SMEAR WET MOUNT SALINE/INK $27.00 87210

WFC87400 INFLUENZA B $29.00 87400

WFC87804 Infectious agent antigen detec $34.00 87804

WFC87880 STREP A ASSAY W/OPTIC $29.00 87880QW

WFC90460 IM ADMIN 1ST/ONLY COMPONENT $54.00 90460

WFC90461 IM ADMIN EACH ADDL COMPONENT $29.00 90461

WFC90471 IMMUNIZATION ADMIN $54.00 90471

WFC90471TD IMMUN ADMIN TDAP ONLY FOR RHC $54.00 90471

WFC90472 IMMUNIZATION ADMIN EACH ADD $29.00 90472

WFC90473 IMMUNE ADMIN ORAL/NASAL $29.00 90473

WFC90474 IMMUNE ADMIN ORAL/NASAL ADDL $29.00 90474

WFC90632 HEP A VACCINE ADULT IM $213.00 90632

WFC90633SF SF‐HEPA VAC PED/ADOL 2 DOS $30.00 90633

WFC90647 HIB 3 DOSE $20.00 90647

WFC90647SF HIB 3 DOSE $19.00 90647

WFC90648SF HIB VACCINE PRP‐T IM $16.00 90648

WFC90651SF HPV (9) VACCINE $204.00 90651

WFC90653 FLUAD 65+ FLU VACCINE $27.00 90653

WFC90655SF INFLUENZA PRES FREE 6‐35 MOS $0.00 90655

WFC90656 FLU VACCINE NO PRESERV 3 & > $56.00 90656

WFC90658SF FLU VACCINE 3 YRS & > IM $57.00 90658

WFC90661 FLU VACC CELL CULT PRSV FREE $57.00 90661

WFC90662SF FLUZONE 0.5ML SINGLE DOSE $28.00 90662

WFC90670 PCV 13 ADULT $265.00 90670

WFC90670SF PNEUMOCOCCAL VACCC 13 VAL $183.00 90670

WFC90674 FLU VACC FLUCELVAX QUADRIV $57.00 90674

WFC90681SF ROTOVIRUS 2 DOSE ORAL $126.00 90681

WFC90685SF FLUZONE $28.00 90685

WFC90686SF FLUARIX SINGLE 3+ $20.00 90686

WFC90688SF FLULAVAL MULTI 3+ $20.00 90688

WFC90696 DTAP‐IPV VACC 4‐6 YR IM $56.00 90696

WFC90696SF DTAP‐IPV VACC 4‐6 YR IM $56.00 90696

WFC90698SF PENTACEL DTAP‐IPV‐HIB $92.00 90698

WFC90700SF DTAP UNDER 7 Y/O $28.00 90700

WFC90707SF MMR VACCINE SC $33.00 90707

WFC90710 MMRV VACCINE SC $183.00 90710

WFC90710SF MMRV VACCINE SC $183.00 90710

WFC90713SF POLIOVIRUS IPV SC/IM $21.00 90713

WFC90714 TD VACC NO PRES ADULT $140.00 90714

WFC90714SF TD NO PRESERVATIVE PEDIATRIC $30.00 90714

WFC90715 TDAP VACC ADULT $140.00 90715

WFC90715SF TDAP VACCINE PEDIATRIC $51.00 90715

WFC90716SF VARICELLA VACCINE $123.00 90716

WFC90723SF DTAP ‐ HEPB ‐ IPV VACCINE $84.00 90723

WFC90732 PNEUMOCOCCAL VACCINE $75.00 90732

WFC90734SF MENINGOCOCCAL VACCINE $137.00 90734

WFC90736 ZOSTER (SHINGLES) SUB‐Q (ELK) $0.00 90736

WFC90744SF HEP B VACC PED/ADOL 3 DOSE $19.00 90744

WFC90746 HEP B VACC ADULT 3 DOSE IM $209.00 90746

WFC90887 CONSULTATION WITH FAMILY $111.00 90887

WFC92551 HEARING SCREEN $21.00 92551

WFC92567 TYMPANOMETRY $96.00 92567

WFC92950 CPR $416.00 92950

WFC93005 ELECTROCARDIOGRAM TRACING $44.00 93005

WFC93010 ELECTROCARDIOGRAM INTERP & REP $183.00 93010

WFC93042 RHYTHM STRIP ‐ PROF COMP $183.00 93042

WFC93227 HOLTER REPORT & INTERP ONLY $55.00 93227

WFC94200 LUNG FUNCTION TEST (MBC/MVV) $93.00 94200

WFC94618 WALK TEST ‐ 6 MIN $483.00 94618

WFC94640 AIRWAY INHALATION TREATMENT $122.00 94640

WFC94664 EVALUATE PT USE OF INHALER $110.00 94664

WFC95115 IMMUNOTHERAPY ONE INJECTION $33.00 95115

WFC95117 IMMUNOTHERAPY INJECTIONS $37.00 95117

WFC97005 ATHLETIC TRAIN EVAL $75.00 97005

WFC97010 HOT OR COLD PACKS THERAPY $28.00 97010

WFC97597 DEBRIDEMENT OPEN WOUND 20 SQ C $160.00 97597

WFC97602 WOUND(S) CARE NON‐SELECTIVE $62.00 97602

WFC97607 Negative Pressure Wound Therap $250.00 97607

WFC97750 PHYSICAL PERFORMANCE TEST $104.00 97750

WFC98966 TELEPHONE CALL 5‐10 MIN $0.00 98966



WFC99000 SPECIMEN HANDLING $49.00 99000

WFC99024 POST OP FOLLOW UP VISIT $0.00 99024

WFC99070 SUPPLIES AND MATERIALS $0.00 99070

WFC99075 MEDICAL TESTIMONY $361.00 99075

WFC99080 SPECIAL REPORTS OR FORMS $62.00 99080

WFC99173 VISUAL ACUITY SCREENING $0.00 99173

WFC99195 THERAPEUTIC PHLEBOTOMY $213.00 99195

WFC99199 $0 ‐ DID NOT KEEP APPOINTMENT $0.00 99199

WFC99217 OBSERVATION CARE DISCHARGE $273.00 99217

WFC99222 INITIAL HOSP CARE LEVEL II $448.00 99222

WFC99241 OFFICE CONSULTATION $209.00 99241





WFC99251 INPATIENT CONSULT LEVEL I $249.00 99251

WFC99252 INPATIENT CONSULT LEVEL II $318.00 99252

WFC99253 INPATIENT CONSULT LEVEL III $386.00 99253

WFC99254 INPATIENT CONSULT LEVEL IV $542.00 99254

WFC99255 INPATIENT CONSULT LEVEL V $742.00 99255

WFC99339 BRH CARE PLAN PT NOT PRES 29M $133.00 99339

WFC99340 BRH CARE PLAN PT NOT PRES 30M+ $185.00 99340

WFC99341 HOME VISIT NEW PATIENT LEV I $174.00 99341

WFC99342 HOME VISIT NEW PATIENT LEV II $134.00 99342

WFC99343 HOME VISIT NEW PATIENT LEV III $298.00 99343

WFC99344 HOME VISIT NEW PATIENT LEV IV $369.00 99344

WFC99347 HOME VISIT EST PATIENT LEV I $204.00 99347

WFC99348 HOME VISIT EST PATIENT LEV II $189.00 99348

WFC99349 HOME VISIT EST PATIENT LEV III $260.00 99349

WFC99354 PROLONG SVC W/DIRECT PT CONTCT $297.00 99354

WFC99366 TEAM CONF W/PAT $88.00 99366

WFC99367 TEAM CONF W/O PAT BY PHYS $186.00 99367

WFC99368 TEAM CONF W/O PAT $191.00 99368

WFC99374 CARE PLAN OVERSIGHT UP TO 29M $191.00 99374

WFC99375 CARE PLAN OVERSIGHT 30 MIN + $227.00 99375

WFC99377 SUPERVISION HOSPICE PT 15‐29MN $151.00 99377

WFC99378 SUPERVISION HOSPICE PT 30+MIN $179.00 99378

WFC99379 BRH SUPERVISE PT NOT PRES 30M+ $191.00 99379

WFC99380 NURSING FAC CARE 30+MIN $227.00 99380

WFC99381 INITIAL WELLNESS UP TO 1 YR $293.00 99381

WFC99382 INITIAL WELLNESS 1‐4 YR $318.00 99382

WFC99383 PREV VISIT NEW AGE 5‐11 $271.00 99383




WFC99387 INITIAL WELLNESS 65+ YR $439.00 99387

WFC99391 PERIODIC WELLNESS UP TO 1 YR $238.00 99391

WFC99392 PERIODIC WELLNESS EST 1‐4 YR $263.00 99392





WFC99397 PERIODIC WELLNESS EST 65+ $371.00 99397

WFC99406 TOBACCO USE CESS COUNS 3‐10MIN $43.00 99406

WFC99429 SPORTS PHYSICAL $100.00 99429

WFC99429CD CDL PHYSICAL $128.00 99429

WFC99441 TELEPHONE E/M BY PROV 5‐10MIN $50.00 99441

WFC99442 TELEPHONE E/M BY PROV 11‐20MIN $113.00 99442

WFC99443 TELEPHONE DISCUSS 21‐30 MIN $162.00 99443

WFC99444 ONLINE E/M BY PHYS/QHP $56.00 99444

WFC99450 BASIC LIFE DISABILITY EXAM $342.00 99450

WFC99455 DOT PHYSICAL $128.00 99455

WFC99456 DISABILITY EXAMINATION $342.00 99456

WFC99490 CHRONIC CARE MGMT SERVICES $129.00 99490

WFC99495 TRANSITIONAL CARE MGMT MOD COM $269.00 99495

WFC99496 TRANS CARE MGMT HIGH COMPLEX $401.00 99496

WFC99497 ADVNCD CARE PLAN 30 MIN $91.00 99497

WFCA4332 $0 ‐LUBRICNT INDIVIDUAL STERL $0.00 A4332

WFCA4340 $0 ‐ INDWELL CATHETER; SPECIAL $20.00 A4340

WFCA4565 SLINGS $25.00 A4565

WFCA4570 SPLINTS $71.00 A4570

WFCA5112 URINARY DRAIN BAG LEG/ABD LATE $17.00 A5112

WFCA6210 FOAM DRESS >16 <=48SQ W/O ADHE $6.00 A6210

WFCA6212 FOAM DRESS 16 SQ/< W/ADHES BOR $14.00 A6212

WFCA6213 FOAM DRESS >16 <= 48 SQ W/ADHE $17.00 A6213

WFCA6222 GAUZ IMPREG NOT H2O/HYDRGEL 16 $7.00 A6222

WFCA6231 GAUZ IMPREG HYDRGEL DIR WND 16 $11.00 A6231

WFCA6257 TRNSPRT FILM STERL 16 SQ/< EA $5.00 A6257

WFCA6448 LT COMPRS BANDGE ELAST WDTH < $15.00 A6448

WFCA6449 LT COMPRS BANDGE WDTH >/= 3 & $15.00 A6449

WFCA6450 LT COMPRS BANDGE WDTH >/= 5 IN $15.00 A6450

WFCA6456 PASTE BOOT SUPPLIES $39.00 A6456

WFCE0110 CRTCHES FORARM VARIOUS MATL PA $104.00 E0110

WFCE0114 CRTCHES UNDARM OTH THAN WOOD P $97.00 E0114

WFCE0116 CRTCH UNDARM OTH THAN WOOD ADJ $38.00 E0116

WFCE1800 DYN ADJUSTABLE ELB EXT/FLX DEV $244.00 E1800

WFCG0008 ADMINISTRATION INFLUENZA VIRUS $29.00 G0008

WFCG0009 ADMINISTRATION PNEUMOCOCCAL VA $29.00 G0009

WFCG0010 ADMINISTRATION HEPATITIS B VAC $29.00 G0010

WFCG0101 CERV/VAG CANCR SCR;PELV&CLN BR $79.00 G0101

WFCG0108 DIAB OP SELF‐MGMT TRN SRVC IND $134.00 G0108

WFCG0127 TRIM DYSTROPHIC NAILS ANY NUMB $49.00 G0127

WFCG0250 PHYS REV INTEPR HOME INR MON; $34.00 G0250

WFCG0293 NONCOVR SURG SEDAT ANES‐MCR QU $134.00 G0293

WFCG0372 PHYS EST & DOC NEED PWR MOBIL $57.00 G0372

WFCG0402 WELCOME TO MEDICARE EXAM ‐ 1ST $371.00 G0402

WFCG0404 ECG RTN ECG W/12 LEADS TRACING $44.00 G0404

WFCG0405 ECG RTN ECG W/12 LEADS I&R ONL $183.00 G0405

WFCG0438 ANNUAL WELLNES VST; PERSNL PPS $361.00 G0438

WFCG0439 ANNUAL WELLNESS VST; PPS SUBSQ $361.00 G0439

WFCG0444 ANNUAL DEPRESSION SCREENING $54.00 G0444

WFCG0511 CHRONIC CARE MGMT OR BHI $121.00 G0511

WFCG0512 PSYCH COLL CARE MODEL 60 MIN + $121.00 G0512

WFCJ0120 INJ TETRACYCLINE UP TO 250MG $5.00 J0120

WFCJ0171 INJ ADRENALIN EPI 0.1MG $36.00 J0171

WFCJ0210 INJ METHYLDOPATE HCL TO 250MG $100.00 J0210

WFCJ0400 INJ ARIPIPRAZOLE IM 0.25 MG $12.00 J0400

WFCJ0696 INJ CEFTRIAXONE SOD PER 250MG $42.00 J0696

WFCJ0698 INJ CEFOTAXIME SOD PER 750MG $9.00 J0698

WFCJ1000 INJ DEPO‐ESTRADIOL UP TO 5MG $0.00 J1000

WFCJ1050 INJ MEDROXYPROGESTERNE ACE 1MG $0.00 J1050

WFCJ1071 INJ TESTOSTERONE CYP 1MG $12.00 J1071

WFCJ1100 INJ DEXMETHOSONE SODIUM 1MG $79.00 J1100

WFCJ1110 INJ DIHYDROERGOTAMINE MES 1MG $111.00 J1110

WFCJ1170 INJ HYDROMORPHONE UP TO 4MG $7.00 J1170

WFCJ1200 INJ DIPHENHYDRAMINE UP TO 50MG $47.00 J1200

WFCJ1380 INJ ESTRADIOL VALERATE TO 10MG $33.00 J1380

WFCJ1630 INJ HALOPERIDOL UP TO 5MG $17.00 J1630

WFCJ1631 INJ HALOPERIDOL DEC PER 50 MG $33.00 J1631

WFCJ1650 INJ ENOXAPARIN SODIUM 10MG $71.00 J1650

WFCJ1670 INJ TETNS IMMUN GLOB TO 250MG $490.00 J1670

WFCJ1710 INJ HYDROCORTISONE 50MG $0.00 J1710

WFCJ1815 INJ INSULIN PER 5 UNITS $108.00 J1815

WFCJ1885 INJ KETOROLAC TROM 15 MG $69.00 J1885

WFCJ2001 INJ LIDOCAINE HCL 10MG $34.00 J2001

WFCJ2060 INJ LORAZAPAM 2MG $27.00 J2060

WFCJ2175 INJ MEPERIDINE HCL PER 100MG $34.00 J2175

WFCJ2405 INJ ONDANSETRON HYDRO 1MG $117.00 J2405

WFCJ2426 INJ PALIPERIDONE PALM EXT $0.00 J2426

WFCJ2550 INJ PROMETHAZINE HCL TO 50MG $32.00 J2550

WFCJ2765 INJ METOCLOPRAMIDE HCL TO 10MG $46.00 J2765

WFCJ2794 INJ RISPERIDONE LONG ACTING $0.00 J2794

WFCJ2920 INJ SOLU‐MEDROL UP TO 40MG $34.00 J2920

WFCJ2930 INJ METHYLPREDNISOLONE TO 125M $17.00 J2930

WFCJ3030 INJ SUMATRIPTAIN SUC 6MG $140.00 J3030

WFCJ3121 INJ TESTO ENANTHATE 1MG $25.00 J3121

WFCJ3301 INJ TRIAMCINOLONE ACE 10MG $37.00 J3301

WFCJ3410 INJ HYDROXYZINE HCL TO 25MG $79.00 J3410

WFCJ3411 INJ THIAMINE HCL 100MG $29.00 J3411

WFCJ3420 INJ VIT B‐12 CYNO TO 1MG $29.00 J3420

WFCJ3490 UNCLASSIFIED DRUGS $0.00 J3490

WFCJ7620 ALBUTEROL TO 2.5 MG IPT TO 0.5 $1.00 J7620

WFCJ7644 IPRATROPIUM BROM INHAL NON‐CP $8.00 J7644

WFCL0120 CERVICAL FLEXIBLE NONADJUSTABL $47.00 L0120

WFCL0172 CERV COLLR SEMI‐RIGD FOAM 2 PI $178.00 L0172

WFCL0220 THORACIC RIB BELT CUSTOM FABRI $171.00 L0220

WFCL1810 KO ELAST W/JNT PREFAB INCL FIT $147.00 L1810

WFCL1820 KO ELAST W/CONDYLR PADS&JNT PR $186.00 L1820

WFCL1830 KO IMMOBLIZR CANVAS LNGTUDNL P $281.00 L1830

WFCL1832 KO ADJ UNICNT/POLYCNT RIGD PRE $784.00 L1832

WFCL1833 Ko adj jnt pos r sup pre ots $784.00 L1833

WFCL1902 AFO ANK GAUNTLT PREFAB W/FIT & $203.00 L1902

WFCL1904 AFO MOLDED ANK GAUNTLET CUSTOM $606.00 L1904

WFCL1906 AFO MXILIGUS ANKLE SUPP PRFAB $156.00 L1906

WFCL3260 SURGICAL BOOT/SHOE EACH $32.00 L3260

WFCL3265 CAST SANDAL EACH $35.00 L3265

WFCL3650 SHOULDER IMMOBILIZER $80.00 L3650

WFCL3670 SO ACROMIO/CLAVICULR PRFAB FIT $160.00 L3670

WFCL3702 EO W/O JOINTS CUSTOM FABRICATE $354.00 L3702

WFCL3762 ELB ORTHOT RIGD W/O JNT W/INTE $133.00 L3762

WFCL3763 EWHO RIGID W/O JOINTS CUSTOM F $905.00 L3763

WFCL3808 WHF ORTHOTIC RIGID NO JNT; CUS $441.00 L3808

WFCL3809 WHFO W/O JOINTS PRE OTS $307.00 L3809

WFCL3908 WHO EXT CNTRL COCK‐UP NONMOLD $101.00 L3908

WFCL3913 HFO W/O JOINTS CUSTOM FABRICAT $332.00 L3913

WFCL3923 HFO W/O JOINTS STRAPS PRFAB $121.00 L3923

WFCL3924 Hfo without joints pre ots $121.00 L3924

WFCL3927 FO PIP/DIP W/O JOINT/SPRING PR $111.00 L3927

WFCL4350 ANKLE CNTRL ORTHOSIS STIRRUP P $128.00 L4350

WFCL4360 WALK BOOT PNEUMATC PREFAB W/FI $476.00 L4360

WFCL4361 PNEUMA/VAC WALK BOOT PRE OTS $517.00 L4361

WFCL4387 Non‐pneum walk boot pre ots $423.00 L4387

WFCL5685 KUHL SHEILDS KNEE SLEEVE $181.00 L5685

WFCNCV NC VISIT $0.00

WFCQ0091 SCR PAP SMER; OBTAIN PREP&CONV $94.00 Q0091

WFCQ0111 WET MOUNTS W/PREP VAG CERV/SKN $11.00 Q0111

WFCQ0162 ONDANSETRON 1 MG ORAL $15.00 Q0162

WFCQ4001 CAST BDY CAST ADLT W/WO HEAD P $113.00 Q4001

WFCQ4010 CAST SPL SHRT ARM CAST ADLT FI $71.00 Q4010

WFCQ4051 SPLINT SUPPLIES MISCELLANEOUS $71.00 Q4051

WFCS8451 SPLINT $0.00 S8451

WFCS9982 MEDICAL RECORDS COPYING FEE‐PA $2.00 S9982

WFC99304 INITIAL SWB PROFEE LEVEL I $224.00 99304

WFC99305 INITIAL SWB PROFEE LEVEL II $286.00 99305

WFC99306 INITIAL SWB PROFEE LEVEL III $346.00 99306

WFC99307 SUB SWB PROFEE LEVEL I $258.00 99307

WFC99308 SUB SWB PROFEE LEVEL II $330.00 99308

WFC99309 SUB SWB PROFEE LEVEL III $374.00 99309

WFC99310 SUB SWB PROFEE LEVEL IV $410.00 99310

WFC99315 SWB DISCHARGE PROFEE LEVEL I $218.00 99315

WFC99316 SWB DISCHARGE PROFEE LEVEL II $272.00 99316

WFC99318 ANNUAL NURSING FAC ASSESSMENT $494.00 99318

WFC99304NS NF INITIAL PROFEE LEVEL I $224.00 99304

WFC99305NS NF INITIAL PROFEE LEVEL II $286.00 99305

WFC99306NS NF INTIAL PROFEE LEV III $346.00 99306

WFC99307NS NF SUB PROFEE LEVEL I $258.00 99307

WFC99308NS NF SUB PROFEE LEVEL II $330.00 99308

WFC99309NS NF SUB PROFEE LEVEL III $374.00 99309

WFC99310NS NF SUB PROFEE LEVEL IV $410.00 99310

WFC99315NS NF DISCHARGE PROFEE LEV I $218.00 99315

WFC99316NS NF DISCHARGE PROFEE LEV II $272.00 99316

WFC99377NS NS SUPERVISION HOSPICE 15‐29MN $151.00 99377

WFC99379NS NF SUPERVISION PT NOT PRES 29M $191.00 99379

WFC99380NS NF SUPERVISION PT NOT PRES 30+ $227.00 99380

WFC90791 PSYCH DIAG EVAL $220.00 90791

WFC90792 PSYCH DIAG EVAL W/MED SRVCS $246.00 90792

WFC90832 PSYTX PT/FAM 30 MIN $108.00 90832



WFC90839 PSYTX CRISIT INITIAL 60 MIN $417.00 90839

WFC90845 PSYCHOANALYSIS $153.00 90845

WFC90846 FAMILY PTHERAPY 50 MIN NO PAT $173.00 90846

WFC90847 FAMILY PTHERAPY 50 MIN W/PAT $179.00 90847

WFC90863 PHARMACOLOGIC MGMT $179.00 90863

WFC0513F ELEVATED BP POC DOCUMENTED $1.00 0513F

WFC0556F PLAN OF CARE ACHIEVE LIPID DOC $1.00 0556F

WFC1036F CURRENT TOBACCO NON‐USER $1.00 1036F

WFC1100F PT SCRN FALL RISK 2 OR MORE YR $1.00 1100F

WFC1101F PT SCRN FALL RISK NONE OR 1 $1.00 1101F

WFC1111F D/C MEDS REC W/CURRENT MED LST $1.00 1111F

WFC1157F ADVANCE CARE PLAN PRESENT $1.00 1157F

WFC1158F ADV CARE PLAN DISCUSSION $1.00 1158F

WFC1159F MED LIST DOCUMENTED IN MED REC $1.00 1159F

WFC1160F REVIEW OF ALL MEDS BY PROV $1.00 1160F

WFC2022F DILATED RET EYE EXAM DOC & REV $1.00 2022F

WFC2024F 7 STEREOSCOPIC PHOTOS BY OPHTH $1.00 2024F

WFC2026F EYE IMAGING FROM 7 PHOTOS DOC $1.00 2026F

WFC2028F FOOT EXAM PERFORMED $1.00 2028F

WFC3008F BODY MASS INDEX DOCUMENTED $1.00 3008F

WFC3014F BREAST CA SCN RESULTS REV/DOC $1.00 3014F

WFC3017F COLONOSCOPY RESULTS DOC/REV $1.00 3017F

WFC3044F A1C <7% $1.00 3044F

WFC3045F A1C BETWEEN 7 AND 9 RECORDED $1.00 3045F

WFC3046F A1C >9 RECORDED $1.00 3046F

WFC3048F MOST RECENT LDL‐C <100MG/DL $1.00 3048F

WFC3049F MOST RECENT LDL‐C 100‐129 MG $1.00 3049F

WFC3050F MOST RECENT LDL‐C >/= 130 MG $1.00 3050F

WFC3072F LOW RISK FOR RETINOPATHY $1.00 3072F

WFC3288F FALL RISK ASSESSMENT DOCUMENT $1.00 3288F

WFC3725F DEPRESSION SCREENING $1.00 3725F

WFC4004F TOBACCO SCREEN AND COUNSELING $1.00 4004F

WFC4013F STATIN THERAPY PRES OR CURRENT $1.00 4013F

WFC4037F FLU VACCINE GIVEN $1.00 4037F

WFC4040F PNEUMO VACC ADMIN/PREV RECVD $1.00 4040F

WFC4274F FLU VAX PREVIOUS LAST 12 MOS $1.00 4274F

WFCG0104 COLORECTAL CA SCREEN FLEX SIG $1.00 G0104

WFCG0105 COLORECTAL CA SCREEN HIGH RISK $1.00 G0105

WFCG0121 COLORECTAL CA SCREEN LOW RISK $1.00 G0121

WFCG0202 SCREEN BILAT MAMMO INCLUDE CAD $1.00 G0202

WFCG0204 DIAGNOSTIC BILAT MAMMO + CAD $1.00 G0204

WFCG0206 DIAGNOSTIC UNILAT MAMMO + CAD $1.00 G0206

WFCG0464 COLORECTAL CA SCREEN STOOL DNA $1.00 G0464

WFCG8417 CALCULATED BMI > NORMAL + PLAN $1.00 G8417

WFCG8418 CALCULATED BMI < NORMAL + PLAN $1.00 G8418

WFCG8420 DOCUMENTED NORMAL BMI=NO PLAN $1.00 G8420

WFCG8431 POSITIVE DEPRESSION SCREENING $1.00 G8431

WFCG8482 INFLUENZA IMMUN ADMIN OR PREV $1.00 G8482

WFCG8510 NEGATIVE DEPRESSION SCREENING $1.00 G8510

WFCG8752 MOST RECENT SYSTOLIC BP <140 $1.00 G8752

WFCG8754 MOST RECENT DIASTOLIC BP <90 $1.00 G8754

WFCG9393 PHQ‐9 >9 REMISSION 12 MOS <5 $1.00 G9393

WFCG9509 DEPRESSION REMISSION 12 MOS <5 $1.00 G9509

WFCM1069 SCREEN FOR FALL RISK $1.00 M1069

5201004 OT AQUATIC THER PER 15 MIN $98.00 97113GO

5201005 OT GROUP THERAPY PER 15 MIN $63.00 97150GO

5201821 OT NEUROMSCLAR RED EA 15 MIN $164.00 97112GO

5201823 OT THERAPEUTIC EXERCISES $144.00 97110GO

5201824 OT ADL TRAINING $134.00 97535GO

5201829 OT MANUAL THERAPY $145.00 97140GO

5201830 OT ULTRA SOUND‐EA 15 MIN $108.00 97035GO

5201839 OT THERAPEUTIC ACTIVITY $159.00 97530GO

5202018 OT ERGONOMIC EVALUATION $406.00 97537GO

5202019 E‐STIM CONSTANT ATTENDANCE 15M $53.00 97032GO

5202020 ED & TRNG PATIENT SELF MGMT $150.00 98960GO

5202021 APP MULTI‐LAYR COMP BELOW KNEE $250.00 29581

5203065 ELECT STIMULATION UNASSISTED $97.00 G0283GO

5203066 PARAFFIN BATH $39.00 97018GO

5203067 ORTHOTIC MGMT & TRAINING $165.00 97760GO

5203068 THER INTERVENTION COG FUNCTION $130.00 97127GO

5203069 OT APPLICATION OF INFRARED $27.00 97026GO

5201000 OT EVAL: LOW COMPLEXITY $286.00 97165GO

5201001 OT EVAL: MODERATE COMPLEXITY $343.00 97166GO

5201002 OT EVAL: HIGH COMPLEXITY $406.00 97167GO

5201003 OT RE‐EVAL $172.00 97168GO

5201852 OT HOME EVALUATION $322.00 99349GO

5201853 OT WHEELCHAIR EVALUATION $322.00 97542GO

5201854 STANDARD COG PERFORM TESTING $368.00 96125GO

5401837 ST DGH‐SPEECH THER TREATMENT $332.00 92507GN

5401838 ST DGH‐SPEECH ACT EACH 15 MIN $159.00 97530GN

5401842 ST DGH‐TREATMENT OF SWAL/ORAL $348.00 92526GN

5401844 ST DGH‐SPE DEVELOPMENT CONGNIT $140.00 97532GN G0515

5401855 ST DGH‐BEHAVIORAL & QUALITATIV $429.00 92524GN

5401858 ST DEVELOPMENTAL TEST W/REPORT $418.00 96111GN

5401860 THER SVCS USE SPEECH DEVICE $292.00 92609GN

5301002 MOTION FLUOR EVAL SWALLOW FUNC $293.00 92611GN

5301003 FLEX ENDOSCOPIC EVAL SWALLOW $532.00 92612GN

5301004 FLEX ENDO EVAL INTERP/REPORT $108.00 92613GN

5301005 FLEX ENDO EVAL LARYNG SENSORY $409.00 92614GN

5301006 FLEX ENDO EVAL LARYN INT/REPRT $95.00 92615GN

5301007 FLEX ENDO EVAL SWALL/LARYNG $584.00 92616GN

5301008 FLEX ENDO SWAL/LRN INT/REPORT $118.00 92617GN

5301012 ABORT MOTION FLUOR EVAL SWALL $220.00 9261153GN

5301013 ABORT FLEX ENDO EVA SWALLOW $398.00 9261253GN

5301017 ABORT FLEX ENDO EVAL SWAL/LARN $447.00 9261653GN

5301018 ABORT FLEX ENDO EVAL LARN SENS $307.00 9261453GN

5401841 ST DGH‐EVAL OF SPEECH FLUENCY $426.00 92521GN

5401843 ST DGH‐SPEECH EVAL ORAL/PHARYN $438.00 92610GN

5401845 ST DGH‐LANG COMP EVAL $429.00 92523GN

5401846 ST DGH‐SPEECH SOUND PROD EVAL $429.00 92522GN

5401856 ASSESSMENT OF APHASIA $341.00 96105GN

5401857 STANDARD COG PERFORM TESTING $368.00 96125GN

5401859 EVAL FOR RX SPEECH DEVICE 1 HR $350.00 92607GN

9003230 NUTRITIONAL ASSESSMENT $93.00 97802

9003234 NUTRITIONAL ASSESSMENT FOLLOW $56.00 97803

mnemonic descriptions td.price cpt‐4 hcpcs acu001000 …

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