PRICE FILE

Effective January 1, 2019, in an effort to “improve the transparency of hospital charges”, the Center for Medicare and Medicaid Services (CMS) has mandated that all facilities participating in the Medicare and Medicaid programs “make public a list of their standard charges” via the internet [CMS-1694-F]. Santa Clara County Health and Hospital System (SCVHHS), at Saint Louise Regional Hospital, gladly supports this effort and is therefore providing this information to our patients by posting our price file for both facility and professional charges on this site. The Price File, also known as the Charge Description Master (CDM) consists of a list of charges related to all services including supplies, devices, vaccines, radiopharmaceuticals, and room accommodation charge codes for inpatients and outpatients of Saint Louise Regional Hospital.

1. The current price file for Saint Louise Regional Hospital. The Hospital Billing (HB) Price File (create link to excel file) contains all facility related charges.

This Price File constitutes the Charge Description Master (CDM) at SCVHHS. The Price File contains following elements:

• Charge Number – A unique identifier within the system for each chargeable item.

• Charge Description – A brief description of the service • CPT© (Current Procedural Terminology) or HCPCS (Healthcare Common

Procedure Coding System) code - This is a nationally recognized alphanumeric code utilized by the insurance industry and government payors to identify a particular service or item.

• Unit Charge – The gross dollar amount charged for each item to the account.

Variable prices may be present for services such as Reference Lab testing, implanted devices and items/services governed by other contracted rates. These prices may not be available for listing in the CDM since billed charges are based upon the charges invoiced by the contractor to Saint Louise Regional Hospital at the time the service is provided. Pharmaceutical prices listed are acquisition cost based. These costs may vary depending upon many factors such as date purchased and supplier. The patient may, therefore, see multiple prices for what appears to be the same medication. In practice, depending upon the dosage ordered by the provider, a patient may see multiple units of a single medication listed on a claim. The total of these units represents the total dosage provided to the patient. Due to these variances, we recommend that our patients contact the Saint Louise Regional Hospital Pharmacy department directly for the most accurate estimate based upon the providers medication orders.

CHARGE GENERATION

Individual departments within Saint Louise Regional Hospital may generate charges through an electronic charge or order communication system. Most charging information for a patient admission or encounter originates from the CDM. The charges, charge descriptions, and all codes attached to a line item in the CDM, flow through electronic systems to Patient Business Services (PBS), where corresponding claims are generated. The claims may be edited before submission to the appropriate payors based upon contractual terms. The total charges listed for a particular encounter or admission may not necessarily represent the total payment expected by Saint Louise Regional Hospital. The expected payment amount will vary based upon contractual arrangements between Saint Louise Regional Hospital and various payors, the insurance plan in which the patient is enrolled and other special programs for which the patient may apply and be found eligible for.

FINANCIAL ASSISTANCE

Should a patient require financial assistance or advice, they are encouraged to contact a Financial Counselor at (866) 967-4677 for direction.

VISIT AND PROCEDURE ESTIMATE

Should a patient wish to obtain an estimate of charges for a visit or procedure, they are encouraged to contact the Revenue Integrity Unit at (408) 885-6884 or via email at HHSCDM@hhs.sccgov.org for assistance.

CPT Codes © 2018 American Medical Association, use of this site denotes acceptance of below terms and conditions CPT codes, descriptions, and material only are copyright 2018 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained here in. CPT is a trademark of the American Medical Association.

Current Dental Terminology copyright © 2018 American Dental Association. All rights reserved.

Charge Number Charge Description CPT Code Unit Price

0001008 DHS ICU 19,995.00$ 0005009 HOLD BED 7,312.00$ 0011007 DHS TELEMETRY IN ICU 11,286.00$ 0012005 DHS TELEMETRY 11,286.00$ 0020016 DHS MED/SURG MED-JUSTIFD PRIV 8,114.00$ 0021006 DHS MED/SURG IN ICU 8,114.00$ 0022004 DHS MED/SURG PRIVATE 8,114.00$ 0032003 DHS MED/SURG SEMI-PRIV 7,312.00$ 0043000 DHS MATERNITY PRIVATE 7,493.00$ 0053009 DHS MATERNITY SEMI-PRIV 6,750.00$ 0063008 DHS NURSERY/LEVEL I 3,470.00$ 0073007 DHS BABY NON-NEWBORN 7,312.00$ 0083006 DHS GYN PRIVATE 8,114.00$ 0093005 DHS GYN SEMI-PRIVATE 7,312.00$ 0100248 MISCELLANEOUS MICRO -$ 0100255 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100271 EIA SHIGELLA-LIKE TOXIN AG QL/SQ 87427 53.00$ 0100289 IADNA CLOSTRIDIUM DIFF AMP PROBE TQ 87493 207.00$ 0100297 CULTURE BACT BLOOD AEROBIC W/ID ISO 87040 61.00$ 0100313 CULTURE STOOL AEROBIC SALM/SHIGELLA 87045 56.00$ 0100321 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100339 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100362 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100370 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100388 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100404 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100420 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100438 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100453 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100461 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100503 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100511 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100529 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0100537 CULTURE BACT ANAERB EXCEPT BLOOD 87075 57.00$ 0100545 IADNA NOS AMP PROBE EA ORGANISM 87798 156.00$ 0100578 IAAD ENZYME IMMUNO TQ HIV-1/HIV-2 G0432 78.00$ 0100628 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100636 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100644 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100669 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100677 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100685 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100693 CULTURE BACT QUANT COLO COUNT URINE 87086 47.00$ 0100719 CULTURE SCREEN SINGLE ORGANISM 87081 64.00$ 0100750 SUSCEPTIBLE MIC/AGAR EACH/PER PLATE 87186 50.00$ 0100776 SMEAR PRIMARY GRAM/GIEMSA STAIN 87205 25.00$

0100792 LEUKOCYTE ASSESS FECAL QU/SEMI QUAN 89055 19.00$ 0100834 SMEAR PRIMARY SPECIAL STAIN/PARASTE 87207 36.00$ 0100859 SMEAR WET MOUNT INFECTIOUS AGENT 87210 25.00$ 0100917 IAAD IMMUNO OPTICAL OBV STREP GRP A 87880 56.00$ 0100925 ANTINUCLEAR AB ANA TITER [AP 86039 10.35$ 0100941 IAAD IMMUNO OPTICAL OBV STREP GRP B 87802 53.00$ 0100958 IAAD INFLUENZA A/B ANTIGEN QL/SQ 87400 57.00$ 0100966 IAAD INFLUENZA A/B ANTIGEN QL/SQ 87400 57.00$ 0100990 RHEUMATOID FACTOR QUALITATIVE 86430 25.00$ 0101006 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0101014 NATRIURETIC PEPTIDE 83880 201.00$ 0101055 PARTICLE AGG SCREEN EA AB 86403 61.00$ 0101071 RHEUMATOID FACTOR QUALITATIVE 86430 25.00$ 0101139 BASIC METABOLIC PANEL CALCIUM TOTAL 80048 651.00$ 0101147 RHEUMATOID FACTOR QUANTITATIVE 86431 34.00$ 0101154 ELECTROLYTE PANEL 80051 39.00$ 0101162 COMPREHENSIVE METABOLIC PANEL 80053 1,096.00$ 0101170 HEPATIC FUNCTION PANEL 80076 46.00$ 0101196 LIPID PANEL 80061 48.00$ 0101220 RENAL FUNCTION PANEL 80069 735.00$ 0101246 ASSAY OF LIPASE 83690 41.00$ 0101279 DRUG ASSAY CARBAMAZEPINE TOTAL 80156 85.00$ 0101287 DRUG ASSAY DIGOXIN TOTAL 80162 78.00$ 0101295 DRUG ASSAY DIPROPYLACETIC ACD TOTAL 80164 80.00$ 0101303 DRUG ASSAY GENTAMICIN 80170 97.00$ 0101311 DRUG ASSAY LITHIUM 80178 39.00$ 0101329 DRUG ASSAY PHENOBARBITAL 80184 67.00$ 0101337 DRUG ASSAY PHENYTOIN TOTAL 80185 78.00$ 0101345 DRG SCRN ANALGESICS NON-OPIOID 1-2 80329 347.00$ 0101352 DRUG ASSAY THEOPHYLINE 80198 83.00$ 0101360 DRUG ASSAY TOBRAMYCIN 80200 96.00$ 0101378 DRUG ASSAY VANCOMYCIN 80202 80.00$ 0101394 COLLECT VENOUS BLOOD/VENIPUNCTURE 36415 13.00$ 0101444 NASAL SMEAR FOR EOSINOPHILS 89190 28.00$ 0101477 COLLECT CAPILLARY BLOOD 36416 12.00$ 0101485 URINALYSIS AUTO W/O SCOPE 81003 10.00$ 0101493 ASSAY OF LACTATE ACID 83605 63.00$ 0101501 URINE PREGNANCY TEST VISUAL 81025 14.00$ 0101519 DRG SCRN ANALGESICS NON-OPIOID 1-2 80329 347.00$ 0101527 KETONE BODIES SERUM QUANTITATIVE 82010 48.00$ 0101535 ALBUMIN SERUM PLASMA/WHLE BLOOD [AP 82040 4.02$ 0101543 DRUG SCREEN QUANTITATIVE ALCOHOLS 80320 347.00$ 0101568 ASSAY OF AMMONIA 82140 85.00$ 0101576 ASSAY OF AMYLASE 82150 38.00$ 0101592 ASSAY OF AMYLASE 82150 38.00$ 0101600 BILIRUBIN DIRECT 82248 29.00$ 0101618 BILIRUBIN TOTAL 82247 29.00$ 0101626 BLOOD OCCULT FECES QUAL CONSECUTVE 82270 20.00$

0101634 BLOOD OCCULT PEROX ACTV OTHR SOURCE 82271 20.00$ 0101642 C-REACTIVE PROTEIN 86140 30.00$ 0101659 ASSAY OF CALCIUM TOTAL 82310 30.00$ 0101675 ASSAY CARBON DIOXIDE BICARBONATE 82374 29.00$ 0101683 CARCINOEMBRYONIC ANTIGEN CEA 82378 111.00$ 0101691 ASSAY OF CHLORIDE BLOOD 82435 27.00$ 0101717 ASSAY CHOLESTEROL BLOOD/SERUM TOTAL 82465 26.00$ 0101733 CREATINE KINASE (CPK) TOTAL 82550 38.00$ 0101758 CREATINE KINASE (CPK) MB FRACTN 82553 68.00$ 0101766 CREATININE BLOOD 82565 30.00$ 0101774 CREATININE OTHER SOURCE 82570 30.00$ 0101782 CREATININE CLEARANCE 82575 57.00$ 0101790 CYANOCOBALAMIN (VITAMIN B-12) 82607 88.00$ 0101816 ASSAY OF FERRITIN 82728 80.00$ 0101824 ASSAY OF FOLIC ACID SERUM 82746 86.00$ 0101832 GLUCOSE BODY FLUID OTHER THAN BLOOD 82945 23.00$ 0101840 GLUCOSE QUANTITATIVE BLOOD NO STRIP 82947 23.00$ 0101857 GLUCOSE BODY FLUID OTHER THAN BLOOD 82945 23.00$ 0101881 GLUCOSE POST GLUCOSE DOSE INC/GLUC 82950 28.00$ 0101899 GLUCOSE TOLERANCE TEST X 3 SPMN 82951 76.00$ 0101915 ASSAY GLUTAMYLTRANSFERASE GAMMA 82977 42.00$ 0101964 ASSAY OF IRON 83540 38.00$ 0101972 IRON BINDING CAPACITY 83550 41.00$ 0102004 LACTATE (LD) (LDH) ENZYME 83615 36.00$ 0102012 LACTATE (LD) (LDH) ENZYME 83615 36.00$ 0102038 ASSAY LIPOPROTEIN (HDL CHOLESTEROL) 83718 48.00$ 0102046 ASSAY OF MAGNESIUM 83735 39.00$ 0102053 DRUG TEST PRESMP INST ASSIST EA DOS 80306 69.00$ 0102061 SEMEN ANALYSIS SPERM DETECTION 89321 54.00$ 0102087 ASSAY OF MYOGLOBIN 83874 57.00$ 0102111 ASSAY PHOSPHATASE ALKALINE 84075 30.00$ 0102137 ASSAY OF PHOSPHORUS INORGANIC 84100 28.00$ 0102152 POTASSIUM SERUM PLASMA/WHOLE BLOOD 84132 27.00$ 0102160 ASSAY OF POTASSIUM URINE 84133 25.00$ 0102194 ASSAY OF PSA TOTAL 84153 108.00$ 0102202 PROTEIN TOTAL SERUM PLASMA/WHL 84155 22.00$ 0102210 PROTEIN TOTAL REFRACTOMETRY OTHER 84157 22.00$ 0102228 PROTEIN TOTAL XCPT REFRACT URINE 84156 22.00$ 0102236 PROTEIN TOTAL XCPT REFRACT URINE 84156 22.00$ 0102244 PROTEIN TOTAL SERUM PLASMA/WHL 84155 22.00$ 0102269 SODIUM SERUM PLASMA OR WHOLE BLOOD 84295 28.00$ 0102277 ASSAY OF SODIUM URINE 84300 29.00$ 0102285 ASSAY OF THYROXINE TOTAL 84436 40.00$ 0102343 ASSAY THYROXINE FREE 84439 53.00$ 0102350 ASSAY OF THYROID STIM HORMONE 84443 100.00$ 0102368 TRANSFERASE ASPARTATE AMINO SGOT 84450 30.00$ 0102376 TRANSFEASE ALANINE AMINO ALT SGPT 84460 32.00$ 0102384 ASSAY OF TRIGLYCERIDES 84478 34.00$

0102418 ASSAY OF TRIIODOTHYRONINE T3 84480 83.00$ 0102426 ASSAY OF TROPONIN QUANTITATIVE 84484 59.00$ 0102434 ASSAY UREA NITROGEN QUANTITATIVE 84520 24.00$ 0102442 ASSAY OF URIC ACID BLOOD 84550 27.00$ 0102467 GONADOTROPIN CHORIONIC (HCG) QUALIT 84703 44.00$ 0102475 GONDADOTROPIN CHORIONIC QUAN 84702 88.00$ 0102491 HEMOGLOBIN GLYCOSYLATED (A1C) 83036 58.00$ 0102509 BLOOD COUNT CBC AUTO W/AUTO DIFF 85025 45.00$ 0102517 BLOOD COUNT CBC AUTO W/O DIFF 85027 38.00$ 0102525 BLOOD COUNT RETICULOCYTE MANUAL 85044 19.00$ 0102533 BLOOD COUNT LEUKOCYTE WBC AUTO 85048 11.00$ 0102566 CELL COUNT BODY FLUID NO BLD W/DIFF 89051 33.00$ 0102574 CELL COUNT BODY FLUID NO BLD W/DIFF 89051 33.00$ 0102582 CRYSTAL ID LIGHT MICROSCOPY NO URIN 89060 42.00$ 0102608 FIBRIN DEGRADE PROD QUAL/SEMIQ 85378 39.00$ 0102616 FIBRINOGEN ACTIVITY 85384 49.00$ 0102624 HEMAGLOBIN FETAL ROSETTE 85461 39.00$ 0102632 IMMUNOFLUO RESPIRATRY SYNCYTIAL [AP 87280 8.84$ 0102657 BLOOD COUNT PLATELET AUTOMATED 85049 27.00$ 0102665 PROTHROMBIN TIME 85610 23.00$ 0102681 RBC SED RATE NON-AUTOMATED 85651 21.00$ 0102707 THROMBOPLASTIN TIME PARTIAL 85730 36.00$ 0102749 COLD AGGLUTININ SCREEN 86156 39.00$ 0102756 HETEROPHILE ANTIBODIES SCREENING 86308 30.00$ 0103135 ASSAY OF GLYCATED PROTEIN [AP 82985 90.00$ 0103309 ASSAY TRIIODOTHYRONINE T3 FREE 84481 75.00$ 0103986 FETAL FIBRONECTIN CERVICOVAGINAL SQ 82731 380.00$ 0104067 ANTIBODY SCREEN RBC EACH SERUM TECH 86850 295.00$ 0104109 COOMBS TEST DIRECT EA ANTISERUM 86880 347.00$ 0104117 COOMBS TEST DIRECT EA ANTISERUM 86880 347.00$ 0104125 COOMBS TEST DIRECT EA ANTISERUM 86880 347.00$ 0104141 BLOOD TYPING SEROLOGIC ABO 86900 347.00$ 0104166 BLOOD TYPING SEROLOGIC RH (D) 86901 189.00$ 0104190 COMPATIBILITY TEST EA UN SPIN TEQ 86920 637.00$ 0104208 COMPATIBILITY TEST EA UN ANTIGLOB 86922 637.00$ 0104216 FRESH FROZEN PLASMA THAWING EA UN 86927 1,296.00$ 0104240 MISCELLANEOUS SENDOUT [AP -$ 0104281 IADNA HEPATITIS B VIRUS QUANT [AP 87517 38.33$ 0104307 CULTURE MYCOBACT W/ISO/PRESUM [AP 87116 9.12$ 0104315 SMEAR PRIMARY FLUORO/ACID STAIN [AP 87206 4.87$ 0104349 CULTURE BACTERIA OTHR SRC ISOL [AP 87070 9.52$ 0104356 OVA & PARASITES SMEARS CONC/ID [AP 87177 12.12$ 0104398 IAAD GIARDIA ANTIGEN QL/SQ [AP 87329 8.79$ 0104414 ANTIBODY CRYPTOCOCCUS [AP 86641 75.80$ 0104430 IADNA MULTI ORG AMP PROBE TQ [AP 87801 251.30$ 0104463 ASSAY SEX HORMONE BIND GLOBULIN [AP 84270 20.00$ 0104489 CARDIOLIPIN ANTIBDY EA IG CLASS [AP 86147 20.51$ 0104497 CARDIOLIPIN ANTIBDY EA IG CLASS [AP 86147 20.51$

0104513 VITA D 25 HYDRXY W/FRCT IF DONE [AP 82306 24.79$ 0104539 ANTIBODY MUMPS 86735 77.00$ 0104562 ACUTE HEPATITIS PANEL [AP 80074 41.79$ 0104588 HEPATITIS B CORE AB IGM AB [AP 86705 10.37$ 0104596 HEPATITIS A AB IGM ANTIBODY [AP 86709 9.91$ 0104695 DRUG ASSAY MYCOPHENOLATE [AP 80180 19.66$ 0104794 CORTISOL TOTAL [AP 82533 14.70$ 0104836 ASSAY OF ESTRADIOL [AP 82670 24.88$ 0104950 GONDADOTROPIN FSH [AP 83001 90.00$ 0104968 GONADOTROPIN LUTEINIZING HORMNE [AP 83002 90.00$ 0104992 DRUG ASSAY LEVETIRACETAM [AP 80177 14.43$ 0105098 ANTIBODY HERPES SIMPLEX TYPE 2 [AP 86696 17.27$ 0105171 ASSAY OF PROGESTERONE [AP 84144 18.74$ 0105189 ASSAY OF PROLACTIN [AP 84146 17.37$ 0105239 BLOOD OCCULT FECAL HGB 1-3 QUAL 82274 95.00$ 0105247 PROTEIN E-PHORESIS FRACT/QN SRM [AP 84165 7.45$ 0105312 THYROID HORMONE T3/T4 UPTKE/RAT [AP 84479 5.83$ 0105346 ANTIBODY WEST NILE VIRUS [AP 86789 15.66$ 0105353 ANTIBODY WEST NILE VIRUS IGM [AP 86788 18.34$ 0105361 ANTIBODY BARTONELLA [AP 86611 11.08$ 0105379 ANTIBODY BARTONELLA [AP 86611 11.08$ 0105429 RUSSELL VIPER VENOM DILUTED [AP 85613 8.52$ 0105437 PROTHROMBIN TIME [AP 85610 3.53$ 0105445 THROMBOPLASTIN TIME PARTIAL [AP 85730 5.43$ 0105452 HEMOGLOBIN FETAL KLEIHAUER-BETKE 85460 45.00$ 0105494 ANTINUCLEAR ANTIBODIES ANA [AP 86038 10.88$ 0105536 ANTIBODY BORDETELLA [AP 86615 14.36$ 0105544 ANTIBODY BORDETELLA [AP 86615 14.36$ 0105643 HEPATITIS B CORE AB TOTAL [AP 86704 10.83$ 0105650 HEPATITIS B SURFACE ANTIBODY [AP 86706 16.58$ 0105668 HEPATITIS BE ANTIBODY [AP 86707 4.68$ 0105684 HEPATITIS A ANTIBODY HAAB [AP 86708 11.26$ 0105700 ANTIBODY MYCOPLASMA [AP 86738 14.42$ 0105718 ANTIBODY MYCOPLASMA [AP 86738 14.42$ 0105742 ANTIBODY RUBEOLA [AP 86765 14.02$ 0105767 HEPATITIS C ANTIBODY [AP 86803 12.57$ 0105775 IADNA HEP C QUAN REVERSE TRANS [AP 87522 38.94$ 0105783 IAAD HEP B SURFCE AG QL/SQ [AP 87340 9.12$ 0105791 EIA HEP BE AG ANTIGEN QL/SQ [AP 87350 12.55$ 0106112 ANTIBODY GIARDIA LAMBLIA [AP 86674 63.00$ 0106120 CLOT INHIBIT PROT S FREE [AP 85306 16.68$ 0106203 ADRENOCORTICOTROPIC HRMN ACTH [AP 82024 42.05$ 0106211 ALBUMIN URINE MICROALBUMIN QUAN [AP 82043 5.11$ 0106229 ALDOLASE [AP 82085 8.73$ 0106237 ALDOSTERONE [AP 82088 44.37$ 0106245 ALPHA-1 ANTITRYPSIN TOTAL [AP 82103 14.63$ 0106294 ANGIOTENSIN I-CONV ENZYME (ACE) [AP 82164 15.90$ 0106302 ASSAY OF ARSENIC [AP 82175 20.66$

0106351 ASSAY OF CALCIUM IONIZED [AP 82330 12.24$ 0106393 ASSAY OF CERULOPLASMIN [AP 82390 11.70$ 0106401 DRUG ASSAY QUANTITATN DRUG NES [AP 80299 12.66$ 0106419 ASSAY OF COPPER [AP 82525 13.51$ 0106427 DEHYDROEPIANDROSTERONE (DHEA) [AP 82626 27.51$ 0106443 CORTISOL FREE [AP 82530 18.19$ 0106476 VITAMIN D 1 25 DIHYDROXY W/FRCT [AP 82652 33.59$ 0106484 ASSAY OF ERYTHROPOIETIN [AP 82668 20.46$ 0106500 ASSAY OF TESTOSTERONE FREE [AP 84402 22.68$ 0106518 ASSAY OF TESTOSTERONE TOTAL [AP 84403 23.16$ 0106534 ASSAY OF TESTOSTERONE FREE [AP 84402 22.68$ 0106575 ASSAY IGA/IGD/IGG/IGM EACH [AP 82784 6.08$ 0106583 GAMMAGLOBULIN IGE [AP 82785 14.88$ 0106609 ASSAY OF GASTRIN [AP 82941 19.20$ 0106633 ASSAY OF HAPTOGLOBIN QUANT [AP 83010 90.00$ 0106658 HYDROXYINDOLACETIC ACID 5-HIAA [AP 83497 14.04$ 0106674 IMMUNOASSAY QL/SQ MULTI STEP [AP 83516 8.60$ 0106682 ASSAY OF INSULIN TOTAL [AP 83525 10.29$ 0106690 IMMUNOASSAY QL/SQ MULTI STEP [AP 83516 8.60$ 0106716 ASSAY OF LEAD [AP 83655 10.75$ 0106732 IMMUNOASSAY QL/SQ MULTI STEP [AP 83516 8.60$ 0106740 IMMUNOASSAY QL/SQ MULTI STEP [AP 83516 8.60$ 0106765 ASSAY OF MERCURY QUANTITATIVE [AP 83825 14.12$ 0106864 ASSAY OF CALCIUM TOTAL [AP 82310 4.10$ 0106971 PYRIDOXAL PHOSPHATE VITAMIN B-6 [AP 84207 30.59$ 0106989 ASSAY OF RENIN [AP 84244 23.94$ 0107029 IAAD H PYLORI STOOL AG QL/SQ [AP 87338 13.06$ 0107037 ASSAY OF TESTOSTERONE TOTAL [AP 84403 23.16$ 0107078 ASSAY OF THYROGLOBULIN [AP 84432 14.33$ 0107086 TOCOPHEROL ALPHA (VITAMIN E) [AP 84446 12.00$ 0107094 ASSAY OF TRANSFERRIN [AP 84466 11.01$ 0107136 ASSAY OF VITAMIN A [AP 84590 10.52$ 0107144 ASSAY OF ZINC [AP 84630 10.21$ 0107151 ASSAY OF C-PEPTIDE [AP 84681 18.15$ 0107169 GONDADOTROPIN CHORIONIC QUAN [AP 84702 13.32$ 0107235 CLOT INHIBIT PROTEIN C ANTIGEN [AP 85302 13.08$ 0107243 CLOT INHIBIT PROTEIN C ACTIVITY [AP 85303 15.06$ 0107250 CLOT INHIBIT PROTEIN S TOTAL [AP 85305 12.63$ 0107292 ANTISTREPTOLYSIN O TITER [AP 86060 6.58$ 0107318 COMPLEMENT TOTAL HEMOLYTIC CH50 [AP 86162 22.12$ 0107342 FLUORESCENT ANTIBOTY SCREEN EA [AP 86255 10.87$ 0107383 IMMUNOELECTROPHORESIS SERUM [AP 86320 55.04$ 0107417 MICROSOMAL ANTIBODIES EA [AP 86376 13.16$ 0107441 ANTIBODY ASPERGILLUS [AP 86606 16.39$ 0107466 ANTIBODY BORRELIA BURGORFERI [AP 86618 18.54$ 0107490 ANTIBODY COCCIDIOIDES [AP 86635 10.64$ 0107524 ANTIBODY CHLAMYDIA [AP 86631 12.87$ 0107532 ANTIBODY CHLAMYDIA IGM [AP 86632 13.82$

0107540 ANTIBODY CHLAMYDIA [AP 86631 12.87$ 0107557 ANTIBODY CHLAMYDIA IGM [AP 86632 13.82$ 0107565 ANTIBODY CHLAMYDIA [AP 86631 12.87$ 0107573 ANTIBODY CHLAMYDIA IGM [AP 86632 13.82$ 0107672 AB HERPES SIMPLEX NON-SPEC [AP 86694 11.87$ 0107680 AB HERPES SIMPLEX NON-SPEC [AP 86694 11.87$ 0107714 ANTIBODY LEGIONELLA [AP 86713 16.66$ 0107730 ANTIBODY HERPES SIMPLEX TYPE 1 [AP 86695 11.86$ 0107748 ANTIBODY HERPES SIMPLEX TYPE 2 [AP 86696 17.27$ 0107789 ANTIBODY PARVOVIRUS [AP 86747 16.37$ 0107797 ANTIBODY PARVOVIRUS [AP 86747 16.37$ 0107805 ANTIBODY RUBELLA [AP 86762 12.93$ 0107839 ANTIBODY TOXOPLASMA [AP 86777 12.81$ 0107847 ANTIBODY TOXOPLASMA IGM [AP 86778 12.83$ 0107862 HLA TYPING A B OR C 1 ANTIGEN [AP 86812 28.10$ 0107888 DRUG ASSAY TACROLIMUS [AP 80197 12.46$ 0107904 PROTEIN TOTAL XCPT REFRACT URNE [AP 84156 3.30$ 0107920 ALBUMIN URINE MICROALBUMIN QUAN [AP 82043 5.11$ 0107938 IMMUNOFIX E-PHORSIS/URINE/CFS [AP 86335 31.95$ 0107946 NEPHELOMETRY EA ANALYTE NES [AP 83883 12.28$ 0107953 NEPHELOMETRY EA ANALYTE NES [AP 83883 12.28$ 0107979 AMINO ACIDS SINGLE QUAN EA SPMN [AP 82131 18.36$ 0107987 ASSAY RECEPTOR NON-ENDOCRINE [AP 84238 39.82$ 0108035 FLUORESCENT ANTIBOTY SCREEN EA [AP 86255 10.87$ 0108076 IMMUNOASSAY TUMOR QUAN CA 15-3 [AP 86300 18.92$ 0108092 COMPLEMENT FUNCT ACTIV EA COMP [AP 86161 13.06$ 0108126 DRUG ASSAY CYCLOSPORINE [AP 80158 16.21$ 0108217 ASSAY IGA/IGD/IGG/IGM EACH [AP 82784 6.08$ 0108225 ASSAY IGA/IGD/IGG/IGM EACH [AP 82784 6.08$ 0108522 DNA ANTIBODY NATIVE/DBL STRAND [AP 86225 12.39$ 0108563 EXTRACTABLE NUCLEAR ANTI EA AB [AP 86235 15.20$ 0108571 EXTRACTABLE NUCLEAR ANTI EA AB [AP 86235 15.20$ 0108589 EXTRACTABLE NUCLEAR ANTI EA AB [AP 86235 15.20$ 0108597 EXTRACTABLE NUCLEAR ANTI EA AB [AP 86235 15.20$ 0108613 EXTRACTABLE NUCLEAR ANTI EA AB [AP 86235 15.20$ 0108787 IMMUNOFIX ELECTROPHORESIS SERUM [AP 86334 20.03$ 0108894 ANTIBODY HELICOBACTER PYLORI [AP 86677 16.04$ 0108902 ANTIBODY HELICOBACTER PYLORI [AP 86677 16.04$ 0108944 AB EPSTEIN-BARR VIRUS VCA [AP 86665 15.82$ 0108951 AB EPSTEIN-BARR VIRUS VCA [AP 86665 15.82$ 0108977 ANTIBODY CYTOMEGALOVIRUS CMV [AP 86644 12.97$ 0108985 ANTIBODY CYTOMEGALOVIRUS IGM [AP 86645 15.07$ 0109041 CLOT ANTITHROMBIN III ACTIVITY [AP 85300 10.47$ 0109058 ASSAY OF PREALBUMIN [AP 84134 12.47$ 0109066 ANTITHROMBIN III ANTIGEN ASSAY [AP 85301 11.77$ 0109082 ASSAY OF BETA-2 MICROGLOBULIN [AP 82232 14.70$ 0109108 THYROGLOBULIN ANTIBODY [AP 86800 14.27$ 0109124 VIRUS ISOL TISSUE/CYTOPATHIC [AP 87252 21.87$

0109231 INFECT NUC ACID GENOTYPE HEP C [AP 87902 236.13$ 0109413 IMMUNOFLUO HERPES SIMPLX TYPE 1 [AP 87274 10.10$ 0109421 IMMUNOFLUO HERPES SIMPLX TYPE 2 [AP 87273 15.36$ 0109470 IAAD IA ROTAVIRUS ANTIGEN QL/SQ [AP 87425 8.86$ 0110098 CALCULUS INFRARED SPECTROSCOPY [AP 82365 14.04$ 0110130 GALACTOS-1 TRANSFERASE SCREEN [AL 82776 18.25$ 0110148 ASSAY OF THYROID STIM HORMONE [AL 84443 18.25$ 0110155 HEMOGLOBIN FRACT/QUANT CHROM [AL 83021 18.25$ 0110163 COLLECT CAPILLARY BLOOD [AL 36416 6.00$ 0110189 ASSAY OF THIAMINE VITAMIN B-1 [AP 84425 23.11$ 0110205 LIPOPROTEIN BLD HR FRACT/QUANT [AP 83701 27.02$ 0110213 ASSAY OF TRIGLYCERIDES [AP 84478 5.02$ 0110239 ASSAY OF PROGESTERONE 17-D [AL 83498 18.25$ 0110247 MASS SPECTROMETRY QUAL/QUAN EA [AL 83789 19.75$ 0110254 ASSAY OF BIOTINIDASE EA SPMN [AL 82261 18.25$ 0110262 IMMUNOASSAY QL/SQ MULTI STEP [AL 83516 18.25$ 0110296 ALBUMIN OTHER SOURCE QUANT EA 82042 20.00$ 0110304 GLUCOSE BODY FLUID OTHER THAN BLOOD 82945 23.00$ 0110312 GLUCOSE BLOOD BY MONITORING DEV 82962 13.00$ 0110320 LACTATE (LD) (LDH) ENZYME 83615 36.00$ 0110338 LIPOPROTEIN MEAS LDL CHOLESTEROL 83721 57.00$ 0110346 PROTEIN TOTAL REFRACTOMETRY OTHER 84157 22.00$ 0110353 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0110361 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0110379 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0110387 CULTURE ANAEROBIC ID EA ISOLATE 87076 47.00$ 0110395 CULTURE ANAEROBIC ID EA ISOLATE 87076 47.00$ 0110403 CULTURE ANAEROBIC ID EA ISOLATE 87076 47.00$ 0110445 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0110452 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0110460 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0110478 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0110486 CULTURE AEROBIC IDENTIFY EA ISOLATE 87077 47.00$ 0110502 CULTURE BCT ISOL PRESUM ID EA URINE 87088 39.00$ 0110510 CULTURE BCT ISOL PRESUM ID EA URINE 87088 39.00$ 0110528 CULTURE URINE ID EA ISOLATE 87088 39.00$ 0110569 CULTURE TYPING IMMUNO NO FLUORO PER 87147 23.00$ 0110577 CULTURE TYPING IMMUNO NO FLUORO PER 87147 23.00$ 0110585 CULTURE TYPING IMMUNO NO FLUORO PER 87147 23.00$ 0110593 CULTURE TYPING IMMUNO NON FLUORO 87147 23.00$ 0110601 CULTURE TYPING IMMUNO NON FLUORO 87147 23.00$ 0110619 CULTURE TYPING IMMUNO NON FLUORO 87147 23.00$ 0110627 HOMOGENIZATION TISSUE FOR CULTURE 87176 26.00$ 0110635 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110643 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110650 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110668 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110676 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$

0110684 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110692 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110700 SUSCEPTIBILITY STUDY AGAR METH PER 87181 28.00$ 0110718 SUSCEPTIBLE ENZYME DETECT PER ENZ 87185 21.00$ 0110734 IAAD SHIGELLA-LIKE TOXIN AG QL/SQ 87427 53.00$ 0110759 URINALYSIS AUTO W/SCOPE 81001 19.00$ 0110767 BLOOD COUNT/SMEAR MICRO W/DIFF WBC 85007 21.00$ 0110783 CELL COUNT MISCELANEOUS BODY FLUIDS 89050 21.00$ 0110924 HEPARIN NEUTRALIZATION [AP 85525 7.76$ 0110965 REPTILASE TEST [AP 85635 10.71$ 0110981 THROMBIN TIME PLASMA [AP 85670 5.08$ 0111013 PTT SUBSTIT PLASMA FRACT EA [AP 85732 7.05$ 0111047 FLUORESCENT ANTIBODY TITER EA [AP 86256 10.44$ 0111054 FLUORESCENT ANTIBODY TITER EA [AP 86256 10.44$ 0111070 IMMUNOASSAY INF AGNT QUANT NOS [AP 86317 13.77$ 0111120 CULTURE CHLAMYDIA ANY SOURCE [AP 87110 12.67$ 0111138 CULTURE TYPING IMMUNO METHOD EA [AP 87140 6.07$ 0111161 ANTIBODY RUBEOLA 86765 76.00$ 0111195 IAAD HEP B SURF NEUT AG QL/SQ [AP 87341 11.25$ 0111237 GLUCOSE POST GLUCOSE DOSE INC/GLUC 82950 28.00$ 0111245 SUSCEPTIBILITY DISK PER PLATE <12 87184 41.00$ 0111252 SUSCEPTIBILITY DISK PER PLATE <12 87184 41.00$ 0111260 ALPHA-1-ANTITRYPSIN PHENOTYPE [AP 82104 15.74$ 0111294 ASSAY IGA/IGD/IGG/IGM EACH [AP 82784 6.08$ 0111302 ASSAY IGA/IGD/IGG/IGM EACH [AP 82784 6.08$ 0111310 HEMOGLOBIN FRACT/QUANT CHROM [AP 83021 15.40$ 0111328 PROTEIN TOTAL REFRACT ANY SRC [AP 84160 7.45$ 0111336 PROTEIN E-PHORESIS FRACT/QN SRM [AP 84165 7.45$ 0111344 ASSAY OF THYROGLOBULIN [AP 84432 14.33$ 0111351 ASSAY OF THYROGLOBULIN [AP 84432 14.33$ 0111377 SMEAR PRIMARY COMP SPECIAL STN [AP 87209 14.96$ 0111443 C-REACTIVE PROTEIN HIGH SENSITIVITY 86141 58.00$ 0111450 EVAL OF CERVICOVAG PAMG-1 PP12 84112 392.00$ 0111476 IADNA NOS AMP PROBE EA ORGANISM [AP 87798 34.18$ 0111484 COLLECT VENOUS BLOOD/VENIPUNCTURE 36415 13.00$ 0111492 HEPATITIS B CORE AB IGM AB 86705 69.00$ 0111500 HEPATITIS A AB HAAB IGM ANTIBODY 86709 66.00$ 0111518 HEPATITIS C ANTIBODY 86803 84.00$ 0111526 CULTURE TYPING IMMUNO NO FLUORO PER 87147 23.00$ 0111534 ASSAY OF PSA FREE 84154 82.00$ 0111567 TB TEST CELL IMM AG MEAS GAMMA 86480 365.00$ 0111575 HELICOBACTER PYLORI DRUG ADMIN 83014 46.00$ 0111583 H PYLORI (C-13) BREATH NO RADIO 83013 399.00$ 0111617 ANTIBODY HIV-1 & HIV-2 1 RESULT 86703 61.00$ 0111625 IAAD IA HIV-1 MULTI-STEP QL/SQ 87390 96.00$ 0111633 FLOW CYTO TC 1ST MARKER 2-8 [AP 88184 42.18$ 0111641 FLOW CYTO TC EA ADDL MARKER [AP 88185 10.00$ 0111658 ANTIBODY RUBELLA 86762 84.00$

0111666 ANTIBODY VARICELLA-ZOSTER 86787 76.00$ 0111674 SMEAR PRIMARY GRAM/GIEMSA STAIN 87205 25.00$ 0111682 PROTEIN EP OTHER FLUIDS CONTR [AP 84166 16.42$ 0111690 NEPHELOMETRY EA ANALYTE NES [AP 83883 12.28$ 0111708 ASSAY OF FOLIC ACID RBC [AP 82747 11.49$ 0111716 IADNA GI DETECT 6-11 TARGETS PROBE 87506 1,258.00$ 0111724 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111732 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111740 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111757 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111765 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111773 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111781 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111799 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111807 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111815 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111823 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111831 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111849 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111856 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111864 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111872 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111880 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111898 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111906 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111914 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111922 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111930 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111948 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111955 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111963 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111971 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111989 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0111997 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0112003 CULTURE DNA/RNA DIRECT PROBE PER/EA 87149 119.00$ 0112011 SUSCEPTIBLE MIC/AGAR EACH/PER PLATE 87186 50.00$ 0117374 CRYPTOCOCCUS NEOFORM AG QL/SQ 87327 54.00$ 0117382 IADNA NOS AMP PROBE EA ORGANISM 87798 156.00$ 0117390 CULTURE BACTERIA OTHER SOURCE ISOL 87070 50.00$ 0117408 IMMUNOASSAY TUMOR QUAN CA 15-3 86300 93.00$ 0117416 IMMUNOASSAY TUMOR QUAN CA 125 86304 122.00$ 0117424 ASSAY OF PSA FREE 84154 82.00$ 0117432 IMMUNOASSAY TUMOR QUAN CA 19-9 86301 93.00$ 0117440 ALPHA-FETOPROTEIN (AFP) SERUM 82105 99.00$ 0117457 ANTIBODY TREPONEMA PALLIDUM 86780 78.00$ 0117465 SYPHILIS TEST NON-TREP QUANT 86593 26.00$ 0117663 IADNA CYTOMEGALOVIRUS AMP PROB TQ 87496 156.00$ 0117671 IADNA PROBE CAN INCL REVERSE TRANS 87498 156.00$

0117689 IADNA HERPES SIMPLEX AMP PRB TQ 87529 156.00$ 0117697 IADNA HERPES VIRUS-6 AMP PROBE TQ 87532 156.00$ 0117705 IADNA STREP GRP B AMP PROBE 87653 207.00$ 0117713 IADNA NOS AMP PROBE EA ORGANISM 87798 156.00$ 0117721 IADNA STREP GRP A AMP PROBE 87651 156.00$ 0117739 CYTOPATH CONCENTRATE SMEAR W/INTRP 88108 189.00$ 0117747 CYTOPATH SMEAR OTHR 5+ SLIDES/STAIN 88162 295.00$ 0117754 CYTOP FNA DX EVAL EA ADD SAME SITE 88177 95.00$ 0117762 UNLISTED CYTOPATHOLOGY PROCEDURE 88199 300.00$ 0117770 LEVEL IV SURGICAL PATH/GROSS/MICRO 88305 295.00$ 0117788 SPECIAL STAIN GROUP 2 W/I & R MICRO 88313 295.00$ 0117796 MORPHOMETRC TUMOR/MAN EA SPM QL/SQ 88360 1,296.00$ 0117804 EXAM/SEL ARCHIVE TISS MOLECULAR ANA 88363 101.00$ 0117812 IN SITU HYBRID PER SPMN EA ADD STN 88364 350.00$ 0117820 IN SITU HYBRID PER SPMN 1ST STAIN 88365 851.00$ 0117838 HANDLE SPM FOR TFER FRM OFC TO LAB 99000 25.00$ 0117846 HANDLE SPM FOR TFER FRM PT TO LAB 99001 30.00$ 0117853 FLOW CYTOM TC 1ST MARKER 2-8 [NG 88184 86.00$ 0117861 FLOW CYTOMETRY TC EA ADDTL MARKER 88185 83.00$ 0117879 IMMUNOHISTO PER SPMN EA ADDL STAIN 88341 261.00$ 0117887 PATH CONSULT INTRAOP INITIAL SITE 88333 2,727.00$ 0117895 PATH CONSULT INTRAOP EA ADDL SITE 88334 106.00$ 0117903 ASSAY OF OSMOLALITY BLOOD 83930 39.00$ 0117911 ASSAY OF OSMOLALITY URINE 83935 40.00$ 0117929 TISSUE CULTURE BONE MARROW [NG 88237 350.00$ 0117937 CHROMOSOME ANALYSIS COUNT 5/1 88261 1,057.00$ 0117945 MORPHO ANLS IN SITU CMP PER/EA [NG 88374 300.00$ 0117952 MORPHO ANLS IN SITU CMP PER/EA [NG 88374 260.00$ 0117960 MORPHO ANLS IN SITU CMP PER/EA [NG 88374 290.00$ 0117978 ANAL TRANS BCR/ABL 1 MJR BP [NG 81206 220.00$ 0117986 EGFR GENE ANALYSIS COM VARIANTS [NG 81235 315.00$ 0117994 ANALYSIS GENE JAK2 V617F VAR [NG 81270 137.50$ 0118000 KRAS GENE ANALS VARI 12&13 EX 2 [NG 81275 256.00$ 0118018 TRG@ GENE REARRANGEMNT ANALYSIS [NG 81342 232.00$ 0118026 MOLECULAR PATH PROCEDURE LEVL 3 [NG 81402 365.00$ 0118034 MOLECULAR PATH PROCEDURE LEVL 4 [NG 81403 365.00$ 0118042 CYTOP URN 3-5 PROBES EA CMPTR [NG 88121 400.00$ 0118059 TISSUE CULTURE SKIN/BIOPSY [NG 88233 175.00$ 0118067 TISSUE CULTURE SOLID TUMOR [NG 88239 350.00$ 0118075 LEVEL IV SURG PATH/GROSS/MICRO [NG 88305 55.00$ 0118083 DECALCIFICATION PROCEDURE ADD [NG 88311 7.00$ 0118091 SPECIAL STN GRP 2 W/I & R MIC [NG 88313 44.00$ 0118109 IMMUNOHISTO PER SPMN EA ADD STN [NG 88341 42.00$ 0118117 IMMUNOHISTO PER SPMN 1ST ANTI [NG 88342 42.00$ 0118125 MORPHOMET TUMR/MAN EA SPM QL/SQ [NG 88360 140.00$ 0118133 MORPHOMETRC HYBRD QN/SQ 1ST SPM [NG 88367 130.00$ 0118141 MORPHO ANLY INSITU MAN MULTI [NG 88377 250.00$ 0118158 COMPLEMENT ANTIGEN EACH COMPONENT 86160 70.00$

0118166 FLOW CYTOM TC 1ST MARKER 2-8 [NG 88184 322.00$ 0118174 FLOW CYTOM TC 1ST MARKER 2-8 [NG 88184 247.00$ 0118182 FLOW CYTO TC EA ADDL MARKER [NG 88185 4.00$ 0118190 FLOW CYTO TC EA ADDL MARKER [NG 88185 11.00$ 0118208 ASSAY OF ESTRADIOL 82670 124.00$ 0118216 GONDADOTROPIN FSH 83001 109.00$ 0118224 GONADOTROPIN LUTEINIZING HORMONE 83002 109.00$ 0118232 ANTIBODY RUBELLA 86762 84.00$ 0118240 ASSAY OF PROGESTERONE 84144 93.00$ 0118257 ASSAY OF PROLACTIN 84146 114.00$ 0118265 ASSAY OF C-PEPTIDE 84681 122.00$ 0118273 NUCLEIC ACID CHLAMYDIA TRACH PROBE 87491 207.00$ 0118281 IADNA NEISSERIA GONORHH AMP PRB TQ 87591 207.00$ 0118299 ASSAY OF PARATHORMONE 83970 244.00$ 0118307 ALBUMIN URINE MICROALBUMIN QUAN 82043 34.00$ 0118315 ASSAY OF CALCIUM IONIZED 82330 81.00$ 0118323 ASSAY OF TRANSFERRIN 84466 76.00$ 0118331 SYPHLIS NON-TREPONEMAL AB QUAL 86592 19.00$ 0118342 INF NUC ACID RESP VIRUS 12-25 TARG 87633 2,058.00$ 0118359 IADNA CHLAMYDIA PNEUM AMP PRB TEQ 87486 156.00$ 0118367 IADNA MYCOPLASMA PNEUM AMP PROBE TQ 87581 156.00$ 0118372 INFECT AG CNS DNA AMP PROBE 12-25 87483 1,852.00$ 0118380 IAAD HEPATITIS B SURFACE AG QL/SQ 87340 61.00$ 0118398 IAAD HEPATITIS B SURF NEUT AG QL/SQ 87341 61.00$ 0118406 ACUTE HEPATITIS PANEL 80074 172.00$ 0118414 CORTISOL TOTAL 82533 97.00$ 0118425 HEPATITIS B SURFACE ANTIBODY 86706 64.00$ 0118430 DRUG TEST DEF 1-7 CLASSES QUAL/QUAN G0480 458.00$ 0118448 DRUG TEST DEF 8-14 CLASSES QL/QN G0481 626.00$ 0118455 DRUG TEST DEF 15-21 CLASSES QL/QN G0482 794.00$ 0118463 DRUG TEST DEF 15-21 CLASSES QL/QN G0483 988.00$ 0118471 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 17.18$ 0118489 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 12.66$ 0118497 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 20.45$ 0118505 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 21.51$ 0118513 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 15.84$ 0118521 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 19.97$ 0118539 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 16.75$ 0118547 DRUG TEST DEF 1-7 CLASSES QL/QN [AP G0480 18.05$ 0118554 HEPATITIS B SCREEN HIGH RISK INDIV G0499 126.00$ 0118562 ASSAY OF TESTOSTERONE TOTAL 84403 152.00$ 0118570 ASSAY OF HOMOCYSTINE 83090 75.00$ 0118588 IAAD H PYLORI STOOL AG QL/SQ 87338 84.00$ 0118596 ANALYSIS GENE BRAF V600 VARIANT [NG 81210 130.00$ 0118604 ANALYSIS GENE CALR COM VAR EX 9 [NG 81219 352.00$ 0118612 MOLECULAR PATH PROCEDURE LEVL 4 [NG 81403 365.00$ 0118620 ANALYSIS GENE JAK2 V617F VAR [NG 81270 137.50$ 0118638 MOLECULAR PATH PROCEDURE LEVL 3 [NG 81402 365.00$

0118646 ANALYSIS GENE BRAF V600 VARIANT [NG 81210 130.00$ 0118653 MOLECULAR PATH PROCEDURE LEVL 4 [NG 81403 365.00$ 0118661 KRAS GENE ANALS ADDL VARIANTS [NG 81276 263.00$ 0118679 KRAS GENE ANALS VARI 12&13 EX 2 [NG 81275 256.00$ 0118687 NRAS GENE ANALYSIS VAR EXON 2&3 [NG 81311 173.00$ 0118695 ANALYSIS GENE CALR COM VAR EX 9 [NG 81219 352.00$ 0118703 ANALYSIS METHYLATION MGMT [NG 81287 406.00$ 0118711 MLH1 GENE ALYS PROMO METHYLATIN [NG 81288 406.00$ 0118729 ANALYSIS MICROSATELLITE INSTAB [NG 81301 465.00$ 0118737 FLOW CYTOMETRY INTERP 16+ MRKR [NG 88189 75.00$ 0118745 CHROMOSOME ANALYSIS 20-25 CELL [NG 88264 175.00$ 0118752 CHROMOSOME ADDITINAL KARYOTYPE [NG 88280 45.00$ 0118760 CHROMOSOME ADDL CELL COUNT [NG 88285 33.00$ 0118778 CYTO/MOLECULAR CYTO INT & RPT [NG 88291 30.00$ 0118786 SPECIAL STAIN GRP 1 W/I & R MIC [NG 88312 50.00$ 0118794 IN SITU HYBRID PER SPMN EA ADD [NG 88364 110.00$ 0118802 IN SITU HYBRID PER SPMN 1ST STN [NG 88365 110.00$ 0118810 MOLECULAR PATH PROCEDURE LEVL 4 [NG 81403 365.00$ 0118828 TISSUE CULTURE BONE MARROW [NG 88237 90.00$ 0118836 TISSUE CULTURE BONE MARROW [NG 88237 175.00$ 0118844 IADNA RESP PROBE 3-5 TARGETS 87631 756.00$ 0118851 IADNA INFL 1ST 2 TYPES OR SUB TYPES 87502 383.00$ 0118869 IADNA RESP SYNCYTIAL VIRUS AMP PROB 87634 312.00$ 0118877 IADNA MYCOBACTERIA TUBRAMP PROBE 87556 173.00$ 0118885 IADNA S AUREUS METH RESIST AMP PRB 87641 156.00$ 0118893 NEWBORN METABOLIC SCREEN PANEL [DH S3620 141.25$ 0118901 EIA C DIFFICILE TOXIN(S) AG QL/SQ 87324 53.00$ 0118919 IAAD IA MULTI-STEP METHOD NOS QL/SQ 87449 53.00$ 0118927 PROCALCITONIN (PCT) 84145 159.00$ 0118935 ANALYSIS GENE CFTR COM VAR [AP 81220 180.00$ 0300046 XR EXAM AC JNTS BIL W-W/O WTS (FY) 73050 376.00$ 0300053 XR EXAM KNEE 1-2 VIEWS BILAT (FY) 73560 376.00$ 0300061 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 0300079 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 0300087 XR EXAM ABDOMEN 3+ VIEWS (FY) 74021 376.00$ 0300095 XR EXAM ABDOMEN 3+ VIEWS (FY) 74021 376.00$ 0300103 XR EXAM ABDOMEN 3+ VIEWS (FY) 74021 376.00$ 0300186 XR COLON ENEMA BARUM W/AIR DYE (FY) 74280 1,188.00$ 0300194 XR COLON W/DYE W OR W/O KUB (FY) 74270 623.00$ 0300202 XR COLON ENEMA THERAPEUTIC (FY) 74283 1,188.00$ 0300210 XR COLON W/DYE W OR W/O KUB (FY) 74270 623.00$ 0300236 XR EXAM BONE AGE STUDIES 77072 623.00$ 0300277 DXA BNE DENSITY STDY 1 + SITES (FY) 77080 623.00$ 0300293 XR EXAM OSSEOUS SURVEY INFANT 77076 623.00$ 0300301 XR EXAM OSSEOUS SURVEY COMPLETE 77075 623.00$ 0300319 FLUOROSCOPY EXAM UP TO 1 HOUR 76000 1,188.00$ 0300327 XR EXAM SPINE SINGLE VIEW 72020 376.00$ 0300335 XR EXAM SPINE SINGLE VIEW 72020 376.00$

0300350 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 0300368 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 0300376 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 0300384 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 0300400 XR EXAM SPINE CERVICAL 4-5 VIEWS 72050 623.00$ 0300426 XR EXAM SPINE CERVICAL 6+ VIEWS 72052 623.00$ 0300467 FLUOROSCOPY EXAM UP TO 1 HOUR 76000 1,188.00$ 0300491 XR EXAM CHEST 2 VIEWS 71046 376.00$ 0300509 XR EXAM CHEST SINGLE VIEW 71045 376.00$ 0300517 XR EXAM CHEST SINGLE VIEW 71045 376.00$ 0300533 XR EXAM CHEST 2 VIEWS 71046 376.00$ 0300574 XR CHOLANGIOGRAM INTRAOP (FY) 74300 187.00$ 0300582 XR CHOLECYSTOGRAPHY ORAL CONT (FY) 74290 1,188.00$ 0300608 FLUORO GUIDE FOR NEEDLE PLACEMENT 77002 288.00$ 0300616 XR CYSTOGRAPHY MINIMUM OF 3 VW (FY) 74430 1,188.00$ 0300632 INJ PROC CYSTO OR VOID URETHROCYSTO 51600 1,112.00$ 0300665 XR ENDO CATH BILIARY & PANC (FY) 74330 499.00$ 0300673 XR EXAM ESOPHAGUS (FY) 74220 623.00$ 0300681 XR SWALLOW FUNCT W/CINERAD/VID (FY) 74230 661.00$ 0300699 XR EXAM FACIAL BONES < 3 VIEWS 70140 376.00$ 0300715 XR EXAM FACIAL BONES MIN 3 VIEWS 70150 623.00$ 0300764 FLUOROSCOPY EXAM UP TO 1 HOUR 76000 1,188.00$ 0300806 XR EXAM EYE FOR FOREIGN BODY 70030 376.00$ 0300814 XR EXAM NOSE TO RECTUM 1 VIEW CHILD 76010 366.00$ 0300921 XR HYSTEROSALPINGOGRAPHY (FY) 74740 2,176.00$ 0300939 XR EXAM LOWER EXT INFANT 2VW (FY) 73592 376.00$ 0301036 XR EXAM BOTH KNEES STANDING AP (FY) 73565 376.00$ 0301044 XR EXAM SPINE SINGLE VIEW 72020 376.00$ 0301051 XR EXAM SPINE SINGLE VIEW 72020 376.00$ 0301069 XR EXAM SPINE LUMBOSAC 2-3 VW (FY) 72100 623.00$ 0301077 XR EXAM SPINE LUMBOSAC 2-3 VW (FY) 72100 623.00$ 0301085 XR EXAM SPINE LUMBO COMP 6+ VW 72114 623.00$ 0301093 XR EXAM SPINE LUMBOSAC 4+ VW (FY) 72110 623.00$ 0301101 XR EXAM SPINE LUMB BEND 2-3 (FY) 72120 376.00$ 0301127 FLUORO GUIDE FOR CV DEV PL/REP/REMV 77001 319.00$ 0301150 XR EXAM MANDIBLE < 4 VIEWS 70100 376.00$ 0301168 XR EXAM MANDIBLE < 4 VIEWS 70100 376.00$ 0301176 XR EXAM MANDIBLE MIN 4 VIEWS 70110 623.00$ 0301200 MYELOGRAPHY CERVICAL (FY) 72240 4,134.00$ 0301218 MYELOGRAPHY LUMBOSAC (FY) 72265 4,134.00$ 0301234 XR EXAM NASAL BONES MIN 3 VIEWS 70160 376.00$ 0301242 XR EXAM NECK SOFT TISSUE 70360 376.00$ 0301267 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 0301275 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 0301291 XR EXAM ORBITS COMP 4+ VIEWS 70200 661.00$ 0301333 XR EXAM PELVIS 1 OR 2 VW (FY) 72170 623.00$ 0301341 XR EXAM PELVIS 1 OR 2 VW (FY) 72170 623.00$ 0301358 XR EXAM PELVIS COMP MIN 3 VW (FY) 72190 623.00$

0301366 XR EXAM HIP W/PELV UNI 2-3V (FY) 73502 376.00$ 0301374 XR CYSTOGRAPHY MINIMUM OF 3 VW (FY) 74430 1,188.00$ 0301390 XR URETHROCYSTOGRAPHY RETRO (FY) 74450 1,188.00$ 0301408 XR EXAM RIBS 3 VIEWS BILATERAL 71110 623.00$ 0301416 XR EXAM RIBS/CHEST 4+ VWS BILAT 71111 623.00$ 0301440 XR EXAM SACROILIAC JNTS 3+ VW (FY) 72202 623.00$ 0301457 XR EXAM SACRUM & COCYX MN 2 VW (FY) 72220 376.00$ 0301473 XR EXAM BONE LENGTH STUDIES 77073 376.00$ 0301549 XR EXAM SINUSES PARANASAL <3 VW 70210 376.00$ 0301556 XR EXAM SINUSES PARANASAL 3+ VW 70220 376.00$ 0301564 XR EXAM SKULL LESS THAN 4 VIEWS 70250 623.00$ 0301572 XR EXAM SKULL LESS THAN 4 VIEWS 70250 623.00$ 0301580 XR EXAM SKULL COMPLETE 4+ VIEWS 70260 623.00$ 0301598 XR EXAM SM INTESTINE MULTI IMG (FY) 74250 623.00$ 0301614 XR EXAM STERNUM MIN 2 VIEWS 71120 376.00$ 0301648 XR EXAM SPINE THORACIC 2 VW (FY) 72070 623.00$ 0301655 XR EXAM SPINE THORACIC 2 VW (FY) 72070 623.00$ 0301663 XR EXAM SPINE THORACIC 3 VIEWS 72072 623.00$ 0301697 XR SPINE THORACOLMB JNCT 2+ VW (FY) 72080 376.00$ 0301721 XR EXAM TMJ OPEN/CLOSED BILAT 70330 376.00$ 0301754 XR GI UPR AIR CONT W/DYE W/KUB (FY) 74247 623.00$ 0301762 XR EXAM UGI W/AIR DYE W/SM INTN(FY) 74249 1,188.00$ 0301770 XR GI UPR W OR W/O DELAY W/KUB (FY) 74241 623.00$ 0301788 XR EXAM GI UPR W/SM INTESTINE (FY) 74245 1,188.00$ 0301804 XR EXAM GI UPR W/SM INTESTINE (FY) 74245 1,188.00$ 0301820 XR URETHROCYSTOGRAPHY VOID (FY) 74455 2,176.00$ 0301861 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 0301879 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 0301929 XR EXAM RIBS 2 VIEWS UNI LT 71100 376.00$ 0301937 XR EXAM RIBS 2 VIEWS UNI RT 71100 376.00$ 0301945 XR EXAM RIBS 2 VIEWS UNI LT 71100 376.00$ 0301952 XR EXAM RIBS 2 VIEWS UNI RT 71100 376.00$ 0301960 XR EXAM RIBS/CHEST 3+ VWE UNI LT 71101 623.00$ 0301978 XR EXAM RIBS/CHEST 3+ VWE UNI RT 71101 623.00$ 0301986 XR EXAM CLAVICLE COMP LT (FY) 73000 376.00$ 0301994 XR EXAM CLAVICLE COMP RT (FY) 73000 376.00$ 0302000 XR EXAM CLAVICLE COMP LT (FY) 73000 376.00$ 0302018 XR EXAM CLAVICLE COMP RT (FY) 73000 376.00$ 0302026 XR EXAM SCAPULA COMP LT (FY) 73010 376.00$ 0302034 XR EXAM SCAPULA COMP RT (FY) 73010 376.00$ 0302042 XR EXAM SHOULDER 1 VIEW LT (FY) 73020 376.00$ 0302059 XR EXAM SHOULDER 1 VIEW RT (FY) 73020 376.00$ 0302067 XR EXAM SHOULDER 1 VIEW LT (FY) 73020 376.00$ 0302075 XR EXAM SHOULDER 1 VIEW RT (FY) 73020 376.00$ 0302083 XR EXAM SHOULDER MIN 2 VW LT (FY) 73030 376.00$ 0302091 XR EXAM SHOULDER MIN 2 VW RT (FY) 73030 376.00$ 0302109 XR EXAM SHOULDER MIN 2 VW LT (FY) 73030 376.00$ 0302117 XR EXAM SHOULDER MIN 2 VW RT (FY) 73030 376.00$

0302125 XR EXAM SHOULDER ARTHRO LT (FY) 73040 2,176.00$ 0302133 XR EXAM SHOULDER ARTHRO RT (FY) 73040 2,176.00$ 0302141 XR EXAM HUMERUS MIN 2 VW LT (FY) 73060 376.00$ 0302158 XR EXAM HUMERUS MIN 2 VW RT (FY) 73060 376.00$ 0302166 XR EXAM HUMERUS MIN 2 VW LT (FY) 73060 376.00$ 0302174 XR EXAM HUMERUS MIN 2 VW RT (FY) 73060 376.00$ 0302182 XR EXAM ELBOW 2 VW LT (FY) 73070 376.00$ 0302190 XR EXAM ELBOW 2 VW RT (FY) 73070 376.00$ 0302208 XR EXAM ELBOW 2 VW LT (FY) 73070 376.00$ 0302216 XR EXAM ELBOW 2 VW RT (FY) 73070 376.00$ 0302224 XR EXAM ELBOW COMP MIN 3 VW LT (FY) 73080 376.00$ 0302232 XR EXAM ELBOW COMP MIN 3 VW RT (FY) 73080 376.00$ 0302265 XR EXAM FOREARM 2 VW LT (FY) 73090 376.00$ 0302273 XR EXAM FOREARM 2 VW RT (FY) 73090 376.00$ 0302281 XR EXAM FOREARM 2 VW LT (FY) 73090 376.00$ 0302299 XR EXAM FOREARM 2 VW RT (FY) 73090 376.00$ 0302307 XR EXAM UPPER EXT INF 2+ VW LT (FY) 73092 623.00$ 0302315 XR EXAM UPPER EXT INF 2+ VW RT (FY) 73092 623.00$ 0302323 XR EXAM WRIST 2 VW LT (FY) 73100 376.00$ 0302349 XR EXAM WRIST 2 VW LT (FY) 73100 376.00$ 0302356 XR EXAM WRIST 2 VW RT (FY) 73100 376.00$ 0302364 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 0302372 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 0302380 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 0302398 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 0302463 XR EXAM HAND 2 VIEWS LT (FY) 73120 623.00$ 0302471 XR EXAM HAND 2 VIEWS RT (FY) 73120 623.00$ 0302489 XR EXAM HAND 2 VIEWS LT (FY) 73120 623.00$ 0302497 XR EXAM HAND 2 VIEWS RT (FY) 73120 623.00$ 0302505 XR EXAM HAND MINIMUM 3 VW LT (FY) 73130 376.00$ 0302513 XR EXAM HAND MINIMUM 3 VW RT (FY) 73130 376.00$ 0302711 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 0302729 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 0302737 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 0302745 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 0302752 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 0302760 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 0302778 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 0302786 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 0302794 XR EXAM HIP ARTHROGRAPHY LT (FY) 73525 2,176.00$ 0302802 XR EXAM HIP ARTHROGRAPHY RT (FY) 73525 2,176.00$ 0302810 XR FEMUR 2+ VIEWS LT (FY) 73552 376.00$ 0302828 XR FEMUR 2+ VIEWS RT (FY) 73552 376.00$ 0302836 XR FEMUR 2+ VIEWS LT (FY) 73552 376.00$ 0302844 XR FEMUR 2+ VIEWS RT (FY) 73552 376.00$ 0302851 XR EXAM KNEE 1-2 VIEWS LT (FY) 73560 376.00$ 0302869 XR EXAM KNEE 1-2 VIEWS RT (FY) 73560 376.00$ 0302877 XR EXAM KNEE 1-2 VIEWS LT (FY) 73560 376.00$

0302885 XR EXAM KNEE 1-2 VIEWS RT (FY) 73560 376.00$ 0302893 XR EXAM KNEE 1-2 VIEWS LT (FY) 73560 376.00$ 0302901 XR EXAM KNEE 1-2 VIEWS RT (FY) 73560 376.00$ 0302919 XR EXAM KNEE 3 VIEWS (FY) 73562 376.00$ 0302927 XR EXAM KNEE 3 VIEWS RT (FY) 73562 376.00$ 0302935 XR EXAM KNEE COMPLETE 4+ VW LT (FY) 73564 623.00$ 0302943 XR EXAM KNEE COMPLETE 4+ VW RT (FY) 73564 623.00$ 0302950 XR EXAM KNEE JOINT W/CONT LT (FY) 73580 2,176.00$ 0302968 XR EXAM KNEE JOINT W/CONT RT (FY) 73580 2,176.00$ 0302976 XR EXAM TIBIA/FIBULA 2 VW LT (FY) 73590 376.00$ 0302984 XR EXAM TIBIA/FIBULA 2 VW RT (FY) 73590 376.00$ 0302992 XR EXAM TIBIA/FIBULA 2 VW LT (FY) 73590 376.00$ 0303008 XR EXAM TIBIA/FIBULA 2 VW RT (FY) 73590 376.00$ 0303016 XR EXAM LOWER EXT INF 2VW LT (FY) 73592 376.00$ 0303024 XR EXAM LOWER EXT INF 2VW RT (FY) 73592 376.00$ 0303032 XR EXAM ANKLE 2 VIEWS LT (FY) 73600 376.00$ 0303040 XR EXAM ANKLE 2 VIEWS RT (FY) 73600 376.00$ 0303057 XR EXAM ANKLE 2 VIEWS LT (FY) 73600 376.00$ 0303065 XR EXAM ANKLE 2 VIEWS RT (FY) 73600 376.00$ 0303099 XR EXAM ANKLE COMP 3 VW LT (FY) 73610 376.00$ 0303107 XR EXAM ANKLE COMP 3 VW RT (FY) 73610 376.00$ 0303115 XR EXAM ANKLE COMP 3 VW LT (FY) 73610 376.00$ 0303123 XR EXAM ANKLE COMP 3 VW RT (FY) 73610 376.00$ 0303156 XR EXAM FOOT 2 VIEWS LT (FY) 73620 376.00$ 0303164 XR EXAM FOOT 2 VIEWS RT (FY) 73620 376.00$ 0303172 XR EXAM FOOT 2 VIEWS LT (FY) 73620 376.00$ 0303180 XR EXAM FOOT 2 VIEWS RT (FY) 73620 376.00$ 0303198 XR EXAM FOOT COMP MIN 3 VW LT (FY) 73630 376.00$ 0303206 XR EXAM FOOT COMP MIN 3 VW RT (FY) 73630 376.00$ 0303214 XR EXAM FOOT COMP MIN 3 VW LT (FY) 73630 376.00$ 0303222 XR EXAM FOOT COMP MIN 3 VW RT (FY) 73630 376.00$ 0303339 XR EXAM SHOULDER MIN 2 VW LT (FY) 73030 376.00$ 0303347 XR EXAM SHOULDER MIN 2 VW RT (FY) 73030 376.00$ 0303354 XR EXAM FNGR(S) MIN 2 VW LT (FY) 73140 376.00$ 0303362 XR EXAM FNGR(S) MIN 2 VW RT (FY) 73140 376.00$ 0303370 XR EXAM FNGR(S) MIN 2 VW LT (FY) 73140 376.00$ 0303388 XR EXAM FNGR(S) MIN 2 VW RT (FY) 73140 376.00$ 0303396 XR EXAM TOE(S) MIN 2 VIEWS LT (FY) 73660 376.00$ 0303404 XR EXAM TOE(S) MIN 2 VIEWS RT (FY) 73660 376.00$ 0303412 XR EXAM TOE(S) MIN 2 VIEWS LT (FY) 73660 376.00$ 0303420 XR EXM TOE(S) MIN 2 VW RT PORT (FY) 73660 376.00$ 0303438 XR EXAM HAND MINIMUM 3 VW LT (FY) 73130 376.00$ 0303446 XR EXAM HAND MINIMUM 3 VW RT (FY) 73130 376.00$ 0303560 VENOGRAPHY EXTREMITY UNI RT (FY) 75820 4,134.00$ 0303636 DUPLEX VENOUS EXT UNILAT/LMTD LT 93971 950.00$ 0303990 SPINAL PUNCTURE LUMBAR DIAGNOSTIC 62270 3,620.00$ 0304006 XR EXAM FACIAL BONES < 3 VIEWS 70140 376.00$ 0304048 XR EXAM HEEL MIN 2 VIEWS LT (FY) 73650 376.00$

0304055 XR EXAM HEEL MIN 2 VIEWS RT (FY) 73650 376.00$ 0304063 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 0304089 XR CHOLANGIOGRAM INTRAOP ADDL (FY) 74301 93.00$ 0304097 XR UROGR INFSN DRIP/BOLUS TECH (FY) 74420 2,807.00$ 0304113 XR EXAM HIP W/PELV UNI 2-3V (FY) 73502 376.00$ 0304121 XR EXAM HIP W/PELV UNI 2-3V (FY) 73502 376.00$ 0304139 XR EXAM KNEE COMPLETE 4+ VW LT (FY) 73564 623.00$ 0304147 XR EXAM KNEE COMPLETE 4+ VW RT (FY) 73564 623.00$ 0304287 SIMETHICONE 66.7MG/ML 30ML 19.00$ 0304295 OMNIPAQUE 180MG/ML 20ML Q9965 169.00$ 0304303 LIQ E-Z PAQUE 600MG/ML SUSP 355ML 116.00$ 0304311 E-Z PASTE ORAL CREAM 454GM 160.00$ 0304329 LIQ POLIBAR + 1.05G/ML SUSP 1900ML 135.00$ 0304337 OMNIPAQUE 300MG/ML 50ML INJ Q9967 173.00$ 0304345 XR ENDOSCOPIC CATH BILIARY DUCT(FY) 74328 499.00$ 0304352 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 0304360 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 0304378 XR EXAM HIP W/PELV UNI 4+V LT (FY) 73503 623.00$ 0304386 XR EXAM HIP W/PELV UNI 4+V RT (FY) 73503 623.00$ 0304394 XR EXM ENTIRE SPINE INC SKULL 2-3V 72082 623.00$ 0304402 XR EXAM ENTIRE SPINE INC SKULL 1V 72081 376.00$ 0304410 XR EXM ENTIRE SPINE INC SKULL 4-5V 72083 1,188.00$ 0304428 XR EXM ENTIRE SPINE INC SKULL 6+V 72084 1,188.00$ 0304436 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 0304444 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 0304451 XR EXAM HIPS/PELV BILAT 2V (FY) 73521 623.00$ 0304469 XR EXAM HIPS/PELV BILAT 3-4V (FY) 73522 623.00$ 0304477 XR EXAM HIPS/PELV BILAT 5+V (FY) 73523 1,188.00$ 0304485 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 0304493 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 0304501 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 0304519 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 0304527 XR EXAM HIP W/PELV UNI 4+V LT (FY) 73503 623.00$ 0304535 XR EXAM HIP W/PELV UNI 4+V RT (FY) 73503 623.00$ 0304543 XR EXAM HIPS/PELV BILAT 2V (FY) 73521 623.00$ 0304550 XR EXAM HIPS/PELV BILAT 3-4V (FY) 73522 623.00$ 0304568 XR EXAM HIPS/PELV BILAT 5+V (FY) 73523 1,188.00$ 0304576 INJ CHOLANGRPHY EXST ACC W/IMAG 47531 2,176.00$ 0304626 SCR MAM 2V EA W/CAD IF DONE UNI 77067 610.00$ 0304634 GASTROVIEW 120ML Q9963 47.00$ 0304642 CYSTOCONRAY 250ML Q9958 83.00$ 0304659 SODIUM BICARBONATE 50ML INJ J3490 59.00$ 0304667 CT HEART W/O DYE EVAL CORO CALCIUM 75571 79.00$ 0304675 US ELASTOGRAPHY 0346T -$ 0381095 XR EXAM TOE(S) MIN 2 VW BI (FY) 73660 376.00$ 0381145 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 0381160 BX BREAST 1ST LSN STRTCT DVC/IMG 19081 5,830.00$ 0381178 BX BREAST EA ADD LSN STRTCT 19082 317.00$

0381186 PERQ BREAST DEV 1ST LSN STRTCTC 19283 2,975.00$ 0381194 PERQ BRST DEV EA ADD LSN STRTCT 19284 185.00$ 0381202 XR EXAM SURGICAL SPECIMEN 76098 2,176.00$ 0381210 SCR MAM 2V EA W/CAD IF DONE BILAT 77067 610.00$ 0381228 DX MAMMO W/CAD IF DONE UNILAT RT 77065 465.00$ 0381236 DX MAMMO W/CAD IF DONE UNILAT LT 77065 465.00$ 0381244 DX MAMMO W/CAD IF DONE BILATERAL 77066 419.00$ 0381251 BX BREAST 1ST LSN STRTCT DVC/IMG 19081 5,830.00$ 0381269 BX BREAST EA ADD LSN STRTCT 19082 317.00$ 0381277 MAMMO GUIDE BREAST DEV 1ST LSN 19281 2,975.00$ 0381285 PERQ BREAST DEV 1ST LSN STRTCTC 19283 2,975.00$ 0381293 PERQ BRST DEV EA ADD LSN STRTCT 19284 185.00$ 0400051 ADAPTER LUER LOK MALE 1/8" 240.00$ 0400077 STATLOCK IV CATHETER6 2N9221K 26.00$ 0400085 STATLOCK FOLEY F0L0102 63.00$ 0400119 ADAPTER PLUG MALE LUER LOK 94.00$ 0400127 ADAPTER SPIKE VENTED 66.00$ 0400168 TUBING BLOOD WARMER(11-50) 152.00$ 0400242 AIRWAY NASO (11-50) 124.00$ 0400267 AIRWAY NASOPHARYNGEAL 124.00$ 0400317 AMNIHOOK 63.00$ 0400333 EXT PACING ELECTRODES (51-100) 474.90$ 0400374 LUMBAR ORTHOSIS SAGGITAL (11-50) L0626 152.00$ 0400424 CATHETER BARTHOLIN 116.00$ 0400440 BAG BILE 9 OZ 444.00$ 0400499 BAG ENEMA DISPOSABLE 16.00$ 0400523 BAG FEEDING GRAVITY 203.00$ 0400598 BAG RESUSCITATION INFANT 36.00$ 0400655 BAG URINE LEG STANDARD 49.00$ 0400788 SUPPLY DISP ROUTINE (0-100) -$ 0401018 BELT ABD TRANSDUCER 119.00$ 0401034 BINDER ABDOMINAL 3PAN 40-62 151.00$ 0401331 OTHALMIC BURR 190.00$ 0401406 BLANKET HYPOTHERMIA (11-50) 205.00$ 0401638 CANISTER:SUCTION VAC W/GEL 187.00$ 0401869 CST RL SYNTH SCOTCHCAST PLUS 152.00$ 0402255 CATHETER FOLEY 5 CC 217.00$ 0402305 CATHETER FOLEY 30 CC 54.00$ 0402479 CATHETER FOLEY 3 WAY 5CC 114.00$ 0402511 CATHETER FOLEY (11-50) C1758 132.00$ 0402560 CATHETER FOLEY PEDI 3 CC 152.00$ 0402628 CATHETER HEMODIALYSIS 16CM C1750 1,568.00$ 0402859 CATHETER IV PROTECT+18GAX1 1/4 93.00$ 0402867 CATHETER IV (11-50) 152.00$ 0402883 CATHETER IV PROTECT+ 22GA X 1 93.00$ 0402891 CATHETER IV PROTECT+24GA X 3/4 63.00$ 0403105 CATHETER QUINTON PERIT CRL 620 1,613.20$ 0403162 CATHETER ROBINSON STERILE 28.00$

0403220 CATHETER SILICONE FOLEY 79.00$ 0403246 CATHETER STREAM LINE 26GA 152.00$ 0403386 CATHETER SUPRAPUBC STAMY ST 14 856.60$ 0403477 CATHETER TROCAR CHEST 152.00$ 0403568 CATH URETHRAL COUDE TIP 148.00$ 0403600 CAUTERY ACCUTEMP 147.00$ 0403691 DRAIN CHEST UNIT PLUER VAC-165 162.00$ 0403931 CONTAINER EVACUATED 1000ML 91.00$ 0404855 DRESSING ADAPTIC 29.00$ 0404988 DRSG TEGASORB 5-1/2 X 6-3/4 312.00$ 0404996 DRESS SURGICAL ADHESIVE 4"X6" 91.00$ 0405050 DRESSING TEGADERM IV 7 X 8CM 66.00$ 0405084 DRESSING TRANSP TEGADERM 6"X8" 25.00$ 0405092 DRESSNG TRANSP TGADRM 4"X4.75" 91.00$ 0405191 DRESSING XEROFORM 66.00$ 0405225 CREAM:BARRIER 45.00$ 0405274 DRESSING:MAXORB EXTRA 39.00$ 0405290 DRESSING:ANTIMICROBAL W/POWDER 25.00$ 0405316 CREAM:SILVERSORB 121.00$ 0405340 DRESSING WOUND GEL 5.5CM 73.00$ 0405639 ELECTRODE SPIRAL 76.00$ 0405647 ENEMA FLEET ADULT 12.00$ 0405779 FILTER SET BLOOD TRANSFUSION 152.00$ 0406215 HEMOSTAT SURGICEL 2" X 3" 152.00$ 0406363 KNEE IMMOBILIZER L1830 152.00$ 0406413 SHOULDER ORTHOSIS ABDUCTION L3650 270.00$ 0406504 DISPOSABLE INNER CANNULA (11-50) 152.00$ 0406553 INTRAUTERINE PRESS MONITOR SET 1,494.00$ 0406611 IRRIG. 9% NACL 1500 CC BOTTLE 14.00$ 0406629 IRRIG. 9% NACL 3000 CC BAG 23.00$ 0406637 IRRIG. LACTATED RINGERS 3000ML 24.00$ 0406660 IRRIG WATER STERILE 1500ML 14.00$ 0406702 IRRIG WATER STERILE 3000ML 23.00$ 0406751 KERLIX ROLL 4 1/2" STERILE 66.00$ 0406819 KIT CATHETER NEONATAL SPECI 113.00$ 0406827 KIT CATHETER FEMALE 140.00$ 0406835 KIT CATH 3 LUMEN 7FR 2/ARROWGU C1751 1,717.00$ 0406843 KIT CENTRAL LINE (11-50) 152.00$ 0406892 KIT GASTRIC LAVAGE 474.00$ 0406926 KIT IV START STERILE 94.00$ 0407155 KIT:VAC DRESSING SMALL 187.00$ 0407163 KIT:VAC DRESSING MEDIUM 238.00$ 0407171 KIT:VAC DRESSING LARGE 238.00$ 0407205 KIT:VAC DRESSING 10 X 15CM 238.00$ 0407262 LENS MORGAN EYE IRRIGATION 63.00$ 0407288 LINER SUCT 1500ML W/SHUT OFF 152.00$ 0407346 LOOP IV 126.00$ 0407940 NEEDLE HUBER 19GA X 1" 90 117.00$

0407965 NEEDLE HUBER 22GA X 1" 117.00$ 0408039 NEEDLE SPINAL 18GA X 3.5" DISP 33.00$ 0408252 MITT, IV PROTECTOR 34.00$ 0408278 OXI SENSOR (11-50) 152.00$ 0408401 PACK DELIVERY STERILE 669.00$ 0408567 PACKING DOYLE NASAL 344.00$ 0408690 EXT PACING ELECTRODE (11-50) 152.00$ 0408708 PAD DEFIBRILLATOR (11-50) 152.00$ 0408781 CAST PADDING SOFT ROLL 31.00$ 0408864 PASTE STOMAHESIVE 21.00$ 0408997 DERMABOND (11-50) 210.00$ 0409029 PLUG CATHETER LARGE STERILE 57.00$ 0409052 POUCH DRAINABLE 2 1/2" 192.00$ 0409086 POUCH DRAINABLE 4" 57.00$ 0409094 POUCH SURFIT 2 1/4" 52.00$ 0409110 POUCH UROSTOMY 1" X 3/4" 37.00$ 0409185 PROTECTOR HEEL ELBOW 51.00$ 0409201 PUMP BREAST DBL ADAPTER 306.00$ 0409565 SET EXTENSION .22 MICRON INTER 91.00$ 0409607 SET IV 60" MICRO VOL.EXTENSION 91.00$ 0409649 SET IV EXTENSION 94.00$ 0409706 SET IV EXTENSION T CONNECTOR 94.00$ 0409748 SET IV NITROGLYCERIN 24.00$ 0409771 SET IV PRIMARY CONTINU-FLO 94.00$ 0409813 SET IV SECONDARY PIGGYBACK 94.00$ 0409904 SET BLOOD Y-TYPE W/PUMP VENTED 63.00$ 0409987 INTRO/SHEATH NON-LASER (11-50) C1894 152.00$ 0410027 SET THOROCENTESIS C1729 162.00$ 0410050 SET IN-LINE BURETTE 108.00$ 0410100 SET Y TYPE IRRIG LARGE BORE 270.00$ 0410142 SHEATH URO SMALL 5/8" 152.00$ 0410191 SHIELD FOX EYE ALUMINUM 63.00$ 0410217 SHIELD NIPPLE STERILE 39.00$ 0410431 SITZ BATH DISPOSABLE 54.00$ 0410530 SLING ARM (11-50) 152.00$ 0410712 SPECULUM VAGINAL MEDIUM DISP 22.00$ 0410787 SPLINT ORTHOGLASS PER FOOT 21.00$ 0410936 SPLINT FINGER ALUM 20.00$ 0411157 FOOT WAFFLE HEAL ELEVATOR 152.00$ 0411181 SPLINT THUMB 152.00$ 0411223 SPLINT THUMB RADIAL SPICA 152.00$ 0411504 REMOVER STAPLE DISP 15.00$ 0411843 BOOT SURGICAL (11-50) L3260 152.00$ 0411868 STOCKINETTE TUBULAR 4" STERILE 268.00$ 0411918 STOCKING TED KNEE A4500 127.00$ 0412064 STOPCOCK 3 WAY 63.00$ 0412114 STRAINER URINE CALCULI DISP 91.00$ 0412155 STRAP CLAVICLE 21.00$

0412171 SUPPORTER ATHLETIC (11-50) 152.00$ 0412197 STRAP MONTGOMERY 152.00$ 0412411 SPLINT WRIST/FOREARM (11-50) 178.00$ 0412635 STAPLER SKIN 35 C1713 272.00$ 0412924 SYRINGE EAR/ULCER 2 OZ. REUSE -$ 0413179 TRAY ANESTHESIA EPIDURAL 18GA 351.00$ 0413260 TRAY FOLEY INFECT CONTROL 16FR A4314 33.00$ 0413278 TRAY CENTER FOLEY NO/CATHETER 21.00$ 0413377 TRAY LUMBAR PUNCTURE ADULT 152.00$ 0413393 TRAY LUMBAR PUNCTURE PEDIATRIC 161.00$ 0413419 TRAY PERIOCARDIOCENTESES C1729 583.00$ 0413476 TRAY SPINAL 25GA X 3 1/2" 199.00$ 0413500 TRAY SUTURE REMOVAL 54.00$ 0413542 TRAY UMBILI CATH SILASTIC 3.5F 401.00$ 0413559 TRAY UMBILI CATH SILASTIC 5FR 401.00$ 0413625 TUBE TRACH INN CANN (11-50) A4623 152.00$ 0413633 TUBE CHEST 36FR 179.00$ 0414136 TUBE FEEDING CLEAR 10 X 42 66.00$ 0414169 TUBE FEEDING INFANT 5FR 66.00$ 0414177 TUBE FEEDING 3.5MM PREMIE 66.00$ 0414227 TUBE GASTROSTOMY/BAKER JEJUN 576.00$ 0414235 TUBE GAUZE (11-50) 475.00$ 0414367 TUBE SALEM SUMP 18FR 152.00$ 0414391 TUBE STOMACH 14FR 48" 66.00$ 0414417 CUFFED TRACH TUBE (51-100) 474.90$ 0414490 TRACH TUBE CUFFED (11-50) A7521 448.20$ 0414508 TUBE TRACH NONCUFF (11-50) A7520 352.40$ 0414524 TUBE TRACH SHILEY FEN CUFF #8 351.00$ 0414680 TUBING SUCTION 1/4" ID X 12' 111.00$ 0414789 TUBING PCA ADMINISTRATION 124.00$ 0414888 URINE METER ASPIRATING PORT 152.00$ 0414953 VALVE ANTI REFLEX NG 251.00$ 0414987 VALVE ENTERAL LOPEZ 76.00$ 0415026 WAFER DURAHESIVE 1 3/4" 25.00$ 0415034 WAFER DURAHESIVE 1-3/4 30.00$ 0415059 WAFER FLEXABLE 1 3/4" 52.00$ 0415067 WAFER FLEXIBEL 4" 52.00$ 0415570 STOCKING TED FULL 445.00$ 0415620 PROSHIELD PLUS SKIN PROTECT 270.00$ 0415679 CATH PACING WIRE BIPOLAR 5FR 3,146.00$ 0415794 COBAN BANDAGE 6" STERILE 132.00$ 0415844 STAPLER SKIN PRECISE DS-5 69.20$ 0415935 HUMIDIFIER 238.00$ 0415943 RESUSCITATION BAG 89.00$ 0415968 PEAK FLOW METER 272.00$ 0415976 DRESSING FOAM MEPILEX 40.00$ 0416172 BIOPSY NEEDLE 71.00$ 0416248 BOOT SURGICAL (51-100) L3260 474.90$

0416495 INTRA ABD PRESSURE MONITOR DEV 217.00$ 0416552 CATH UMBILICAL 5FR 474.90$ 0416644 CO2 DETECTORS 724.00$ 0416677 COLLAR CERVICAL FLEX L0120 16.00$ 0416818 DIAL-A-FLO EXTEN SET 166.00$ 0416834 DRAIN PENROSE 38.00$ 0416958 PACLITAXEL SET CLEAR LINK 33.00$ 0416990 ELECTRODE QUICK PACE EXT 1,676.00$ 0417196 SOLUTION GLYCINE IRRIG 1.5% 3000ML 28.00$ 0417311 KIT JUGULAR PUNCT PEDI 421.00$ 0417329 KIT JUGULAR PUNCTURE 516.00$ 0417337 KIT MONITOR W/TRANSDUCER 1,043.00$ 0417345 KIT MONITOR W/TRANSDUCER BI 555.00$ 0417378 LAVACUATOR 370.00$ 0418103 SUPPORT ART HAND WRIST 152.00$ 0418269 TUBE FEEDING 5FR X 36 93.00$ 0418277 NAVIGATOR UROLOGY SHEATH 663.00$ 0418301 LOW COST DISP SUPPLY (0-10) -$ 0418327 CONTINUFLOW W/3 Y'S LL 14.00$ 0418343 GRIP LOK EXTENSION SET 11.00$ 0418350 LOW COST DISP SUPPLY (0-10) -$ 0418368 Y-TYPE BLOOD SET WITH 1 Y 17.00$ 0418376 CONTINUFLOW W/2 Y'S LL 19.00$ 0418384 DRESSING SILVASORB SHEET 63.00$ 0418749 DRESSING OPTIFOAM 4" X 4" A6212 29.00$ 0418756 DRESING OPTIFOAM >16<=48 SQ"(11-50) A6213 263.00$ 0418764 PRECIP TRAY 1,571.00$ 0418905 BANDNET 5-12" 39.00$ 0418921 BANDNET 7 76.00$ 0418954 SPLINT ORTHO-GLASS 2"X15' (ft) 152.00$ 0418962 SPLINT ORTHO-GLASS 3"X15' (ft) 368.00$ 0418970 SPLINT ORTHO-GLASS 4"X15' (ft) 411.00$ 0418988 SPLINT ORTHO-GLASS 5"X15' (ft) 453.00$ 0419192 STOCKINETTE SYNTHETIC 4" RL 141.00$ 0419242 TRAY BONE MARROW ADULT 152.00$ 0419267 TRAY PARACENTESIS (51-100) 325.00$ 0419473 GAYMAR OVERLAY MATTRESS DISP 133.00$ 0419721 KIT THORACENTESIS C1729 341.00$ 0419747 ENDOTRACHEAL TUBE HOLDER 30.00$ 0419903 FLEXI SEAL 195.00$ 0419945 DRESSING, COLLAGEN <=16 SQ IN 39.00$ 0419952 STOCKING, ANTI EMBOLISM K-L 475.00$ 0420026 DRESSING RAPID RHINO (51-100) 474.90$ 0420034 DRESSING RAPID RHINO (11-50) 152.00$ 0420042 EPISTAT II CATH ONLY 263.00$ 0420067 DRESSING PASTE MEDIHONEY 1.5OZ 86.00$ 0420075 DRESSING MEDIHONEY CALC ALG 29.00$ 0420083 DRESSING UNNA BOOT 10 YD A6456 25.00$

0420109 CATH RADIAL ART KIT 20 X 1 3/4 C1894 29.00$ 0420117 SLEEVE SCD (11-50) 152.00$ 0420125 CERVICAL COLLAR OCC/MAND (11-50) L0160 152.00$ 0420133 ORTHO ANKLE BRACE L4350 140.00$ 0420141 HYPOTHERMIA KOOL KIT 900 464.00$ 0420174 CT-H25 CELLUTOME HARVESTER 2.5X2.5 1,165.00$ 0420190 HC-APLIGRAF SHEET 44CM Q4101 5,287.00$ 0420208 HC-DERMAGRAFT 5X7.5CM (37.5) Q4106 150.00$ 0420216 LC-OASIS SINGLE LAYER 3X3.5CM(11) Q4102 577.00$ 0420224 LC-OASIS ULTRA TRILAYER 5X7CM (35) Q4124 1,021.00$ 0420240 CUFFED CRICO CATHETER SET C1769 669.00$ 0420257 FROVA INTUBATIN INTRO W/ADAPTERS 263.00$ 0420281 ADULT INTRODUCER BOUGIE 24.00$ 0420323 CRADLES NDL LOCALZTN WIRE PROTCTR 77.00$ 0420331 SURG TISS LOC/EXIC DEV (11-50) C1819 152.00$ 0420349 MICROMATRIX MATRISTEM 100MG Q4118 1,144.00$ 0420372 HC-EPIFIX 2X3CM (6) Q4131 763.00$ 0420414 TEMP PACING ELECTRODE CATH( 51-100) 475.00$ 0420430 HC-GRAFIX PRIME PL 5X5CM(25) Q4133 341.00$ 0420455 HC-GRAFIX CORE 2X3CM(6) Q4132 747.00$ 0420463 HC-GRAFIX PRIME 2X3CM(6) Q4133 747.00$ 0420471 HOVERMATT PATIENT TRANSFER DEV DISP 271.00$ 0420489 HC-GRAFIX PRIME 1.5X2CM(3) Q4133 1,255.00$ 0420497 HC-GRAFIX CORE 1.5X2CM(3) Q4132 284.00$ 0420505 HC-GRAFIX CORE 3X4CM(12) Q4132 418.00$ 0420513 HC-GRAFIX CORE PL 4X4CM(16) Q4132 7,150.00$ 0420521 HC-GRAFIX PRIME 3X4CM(12) Q4133 418.00$ 0420539 HC-GRAFIX PRIME PL 4X4CM(16) Q4133 1,255.00$ 0420547 HC-GRAFIX CORE 14MM (2) Q4132 1,477.00$ 0421008 NEEDLE SET INTRAOSSEOUS EZ-IO 300.00$ 0421016 QUICK PRESSURE MONITOR SET 173.00$ 0421024 HC-EPIFIX DISC 18MM (3) Q4131 1,768.00$ 0421032 HC-EPIFIX MESH 3.5X3.5CM (8) Q4131 284.00$ 0421040 HC-EPIFIX MESH 4X4.5CM (12) Q4131 284.00$ 0421057 HC-GRAFIX PRIME DISC 14MM (2) Q4133 790.00$ 0421065 HC-EPIFIX 2X4CM (8) Q4131 627.00$ 0500306 CYTOPATH FLUID NOGYN SMEAR W/INTERP 88104 189.00$ 0500330 CYTOP FNA EVAL DX 1ST EPISD EA SITE 88172 633.00$ 0500348 CYTOP FNA EVAL DX 1ST EPISD EA SITE 88172 633.00$ 0500355 CYTOPATH EVAL FNA INTERP & REPORT 88173 295.00$ 0500363 LEVEL I SURGICAL PATHG/ROSS EXAM 88300 189.00$ 0500371 LEVEL II SURGICAL PATH/GROSS/MICRO 88302 189.00$ 0500389 LEVEL III SURGICAL PATH/GROSS/MICRO 88304 295.00$ 0500397 LEVEL IV SURGICAL PATH/GROSS/MICRO 88305 295.00$ 0500405 LEVEL V SURGICAL PATH/GROSS/MICRO 88307 1,296.00$ 0500413 LEVEL VI SURGICAL PATH/GROSS/MICRO 88309 2,727.00$ 0500421 DECALCIFICATION PROCEDURE ADDITIONL 88311 35.00$ 0500447 SPECIAL STAIN GROUP 1 W/I & R MICRO 88312 295.00$

0500454 SPECIAL STAIN GROUP 2 W/I & R MICRO 88313 295.00$ 0500462 PATH CONS INTRAOP 1ST BLK FRZN 1 SP 88331 633.00$ 0500546 PATHOLOGY MISCELLANEOUS -$ 0500553 IMMUNOHISTO PER SPMN 1ST ANTIBODY 88342 1,296.00$ 0500561 IMMUNOHISTO PER SPMN EA MULTI ANTI 88344 1,612.00$ 0500579 IMMUNOHISTO PER SPMN EA ADDL STAIN 88341 261.00$ 0600239 CAL POOL THERAPY+THER EXER(30) MCLON 139.00$ 0600247 CAL TRMT 1+ AREA INIT (30) MCLON 349.00$ 0600254 CAL TRMT 1+AREA ADD'L (15) MCLON 173.00$ 0600403 APPL MODALITY 1+ AREA TRACT MECH 97012 82.00$ 0600411 APPL MODALITY 1+ AREA ELECT UNATTND 97014 173.00$ 0600429 APPL MODALITY 1+ AREA WHIRLPOOL 97022 45.00$ 0600452 APPL MOD 1+ AREA ELE STIM 15 MIN 97032 102.00$ 0600460 APPL MODALITY 1+ AREA US EA 15 MIN 97035 65.00$ 0600478 GATE TRAINING EACH 15 MINUTES 97116 149.00$ 0600494 THERAPEUTIC EXERCISE EA 15 MINUTES 97110 169.00$ 0600502 NEURO REEDUCATION EACH 15 MINUTES 97112 177.00$ 0600528 THERAPEUTIC ACTIVITIES EA 15 MIN 97530 185.00$ 0600536 SELF CARE MANAGE TRAIN EA 15 MIN 97535 186.00$ 0600585 AQUATIC THERAPY/EXERCISE EA 15 MIN 97113 233.00$ 0600601 MANUAL TECH 1+ REGIONS EA 15 MIN 97140 156.00$ 0600619 CAL PT EVAL INITIAL:30MIN MCLON 443.00$ 0600627 CAL PT EVAL EACH ADDL:15MIN MCLON 152.00$ 0600759 MOBILITY CURRENT STATUS, 0% G8978 0.01$ 0600767 MOBILITY CURRENT STATUS, 1%-19% G8978 0.01$ 0600775 MOBILITY CURRENT STATUS, 20%-39% G8978 0.01$ 0600783 MOBILITY CURRENT STATUS, 40%-59% G8978 0.01$ 0600791 MOBILITY CURRENT STATUS, 60%-79% G8978 0.01$ 0600809 MOBILITY CURRENT STATUS, 80%-99% G8978 0.01$ 0600817 MOBILITY CURRENT STATUS, 100% G8978 0.01$ 0600825 MOBILITY GOAL STATUS, 0% G8979 0.01$ 0600833 MOBILITY GOAL STATUS, 1%-19% G8979 0.01$ 0600841 MOBILITY GOAL STATUS, 20%-39% G8979 0.01$ 0600858 MOBILITY GOAL STATUS, 40%-59% G8979 0.01$ 0600866 MOBILITY GOAL STATUS, 60%-79% G8979 0.01$ 0600874 MOBILITY GOAL STATUS, 80%-99% G8979 0.01$ 0600882 MOBILITY GOAL STATUS, 100% G8979 0.01$ 0600890 MOBILITY D/C STATUS, 0% G8980 0.01$ 0600908 MOBILITY D/C STATUS, 1%-19% G8980 0.01$ 0600916 MOBILITY D/C STATUS, 20%-39% G8980 0.01$ 0600924 MOBILITY D/C STATUS, 40%-59% G8980 0.01$ 0600932 MOBILITY D/C STATUS, 60%-79% G8980 0.01$ 0600940 MOBILITY D/C STATUS, 80%-99% G8980 0.01$ 0600957 MOBILITY D/C STATUS, 100% G8980 0.01$ 0600965 BODY POS CURRENT STATUS, 0% G8981 0.01$ 0600973 BODY POS CURRENT STATUS, 1%-19% G8981 0.01$ 0600981 BODY POS CURRENT STATUS, 20%-39% G8981 0.01$ 0600999 BODY POS CURRENT STATUS, 40%-59% G8981 0.01$

0601005 BODY POS CURRENT STATUS, 60%-79% G8981 0.01$ 0601013 BODY POS CURRENT STATUS, 80%-99% G8981 0.01$ 0601021 BODY POS CURRENT STATUS, 100% G8981 0.01$ 0601039 BODY POS GOAL STATUS, 0% G8982 0.01$ 0601047 BODY POS GOAL STATUS, 1%-19% G8982 0.01$ 0601054 BODY POS GOAL STATUS, 20%-39% G8982 0.01$ 0601062 BODY POS GOAL STATUS, 40%-59% G8982 0.01$ 0601070 BODY POS GOAL STATUS, 60%-79% G8982 0.01$ 0601088 BODY POS GOAL STATUS, 80%-99% G8982 0.01$ 0601096 BODY POS GOAL STATUS, 100% G8982 0.01$ 0601104 BODY POS D/C STATUS, 0% G8983 0.01$ 0601112 BODY POS D/C STATUS, 1%-19% G8983 0.01$ 0601120 BODY POS D/C STATUS, 20%-39% G8983 0.01$ 0601138 BODY POS D/C STATUS, 40%-59% G8983 0.01$ 0601146 BODY POS D/C STATUS, 60%-79% G8983 0.01$ 0601153 BODY POS D/C STATUS, 80%-99% G8983 0.01$ 0601161 BODY POS D/C STATUS, 100% G8983 0.01$ 0601179 CARRY CURRENT STATUS, 0% G8984 0.01$ 0601187 CARRY CURRENT STATUS, 1%-19% G8984 0.01$ 0601195 CARRY CURRENT STATUS, 20%-39% G8984 0.01$ 0601203 CARRY CURRENT STATUS, 40%-59% G8984 0.01$ 0601211 CARRY CURRENT STATUS, 60%-79% G8984 0.01$ 0601229 CARRY CURRENT STATUS, 80%-99% G8984 0.01$ 0601237 CARRY CURRENT STATUS, 100% G8984 0.01$ 0601245 CARRY GOAL STATUS, 0% G8985 0.01$ 0601252 CARRY GOAL STATUS, 1%-19% G8985 0.01$ 0601260 CARRY GOAL STATUS, 20%-39% G8985 0.01$ 0601278 CARRY GOAL STATUS, 40%-59% G8985 0.01$ 0601286 CARRY GOAL STATUS, 60%-79% G8985 0.01$ 0601294 CARRY GOAL STATUS, 80%-99% G8985 0.01$ 0601302 CARRY GOAL STATUS, 100% G8985 0.01$ 0601310 CARRY D/C STATUS, 0% G8986 0.01$ 0601328 CARRY D/C STATUS, 1%-19% G8986 0.01$ 0601336 CARRY D/C STATUS, 20%-39% G8986 0.01$ 0601344 CARRY D/C STATUS, 40%-59% G8986 0.01$ 0601351 CARRY D/C STATUS, 60%-79% G8986 0.01$ 0601369 CARRY D/C STATUS, 80%-99% G8986 0.01$ 0601377 CARRY D/C STATUS, 100% G8986 0.01$ 0601385 SELF CARE CURRENT STATUS, 0% G8987 0.01$ 0601393 SELF CARE CURRENT STATUS, 1%-19% G8987 0.01$ 0601401 SELF CARE CURRENT STATUS, 20%-39% G8987 0.01$ 0601419 SELF CARE CURRENT STATUS, 40%-59% G8987 0.01$ 0601427 SELF CARE CURRENT STATUS, 60%-79% G8987 0.01$ 0601435 SELF CARE CURRENT STATUS, 80%-99% G8987 0.01$ 0601443 SELF CARE CURRENT STATUS, 100% G8987 0.01$ 0601450 SELF CARE GOAL STATUS, 0% G8988 0.01$ 0601468 SELF CARE GOAL STATUS, 1%-19% G8988 0.01$ 0601476 SELF CARE GOAL STATUS, 20%-39% G8988 0.01$

0601484 SELF CARE GOAL STATUS, 40%-59% G8988 0.01$ 0601492 SELF CARE GOAL STATUS, 60%-79% G8988 0.01$ 0601500 SELF CARE GOAL STATUS, 80%-99% G8988 0.01$ 0601518 SELF CARE GOAL STATUS, 100% G8988 0.01$ 0601526 SELF CARE D/C STATUS, 0% G8989 0.01$ 0601534 SELF CARE D/C STATUS, 1%-19% G8989 0.01$ 0601542 SELF CARE D/C STATUS, 20%-39% G8989 0.01$ 0601559 SELF CARE D/C STATUS, 40%-59% G8989 0.01$ 0601567 SELF CARE D/C STATUS, 60%-79% G8989 0.01$ 0601575 SELF CARE D/C STATUS, 80%-99% G8989 0.01$ 0601583 SELF CARE D/C STATUS, 100% G8989 0.01$ 0601591 OTHER PT/OT CURRENT STATUS, 0% G8990 0.01$ 0601609 OTHER PT/OT CURRENT STATUS, 1%-19% G8990 0.01$ 0601617 OTHER PT/OT CURRENT STATUS, 20%-39% G8990 0.01$ 0601625 OTHER PT/OT CURRENT STATUS, 40%-59% G8990 0.01$ 0601633 OTHER PT/OT CURRENT STATUS, 60%-79% G8990 0.01$ 0601641 OTHER PT/OT CURRENT STATUS, 80%-99% G8990 0.01$ 0601658 OTHER PT/OT CURRENT STATUS, 100% G8990 0.01$ 0601666 OTHER PT/OT GOAL STATUS , 0% G8991 0.01$ 0601674 OTHER PT/OT GOAL STATUS , 1%-19% G8991 0.01$ 0601682 OTHER PT/OT GOAL STATUS , 20%-39% G8991 0.01$ 0601690 OTHER PT/OT GOAL STATUS , 40%-59% G8991 0.01$ 0601708 OTHER PT/OT GOAL STATUS , 60%-79% G8991 0.01$ 0601716 OTHER PT/OT GOAL STATUS , 80%-99% G8991 0.01$ 0601724 OTHER PT/OT GOAL STATUS , 100% G8991 0.01$ 0601732 OTHER PT/OT D/C STATUS, 0% G8992 0.01$ 0601740 OTHER PT/OT D/C STATUS, 1%-19% G8992 0.01$ 0601757 OTHER PT/OT D/C STATUS, 20%-39% G8992 0.01$ 0601765 OTHER PT/OT D/C STATUS, 40%-59% G8992 0.01$ 0601773 OTHER PT/OT D/C STATUS, 60%-79% G8992 0.01$ 0601781 OTHER PT/OT D/C STATUS, 80%-99% G8992 0.01$ 0601799 OTHER PT/OT D/C STATUS, 100% G8992 0.01$ 0601807 SUB PT/OT CURRENT STATUS, 0% G8993 0.01$ 0601815 SUB PT/OT CURRENT STATUS, 1%-19% G8993 0.01$ 0601823 SUB PT/OT CURRENT STATUS, 20%-39% G8993 0.01$ 0601831 SUB PT/OT CURRENT STATUS, 40%-59% G8993 0.01$ 0601849 SUB PT/OT CURRENT STATUS, 60%-79% G8993 0.01$ 0601856 SUB PT/OT CURRENT STATUS, 80%-99% G8993 0.01$ 0601864 SUB PT/OT CURRENT STATUS, 100% G8993 0.01$ 0601872 SUB PT/OT GOAL STATUS, 0% G8994 0.01$ 0601880 SUB PT/OT GOAL STATUS, 1%-19% G8994 0.01$ 0601898 SUB PT/OT GOAL STATUS, 20%-39% G8994 0.01$ 0601906 SUB PT/OT GOAL STATUS, 40%-59% G8994 0.01$ 0601914 SUB PT/OT GOAL STATUS, 60%-79% G8994 0.01$ 0601922 SUB PT/OT GOAL STATUS, 80%-99% G8994 0.01$ 0601930 SUB PT/OT GOAL STATUS, 100% G8994 0.01$ 0601948 SUB PT/OT D/C STATUS, 0% G8995 0.01$ 0601955 SUB PT/OT D/C STATUS, 1%-19% G8995 0.01$

0601963 SUB PT/OT D/C STATUS, 20%-39% G8995 0.01$ 0601971 SUB PT/OT D/C STATUS, 40%-59% G8995 0.01$ 0601989 SUB PT/OT D/C STATUS, 60%-79% G8995 0.01$ 0601997 SUB PT/OT D/C STATUS, 80%-99% G8995 0.01$ 0602003 SUB PT/OT D/C STATUS, 100% G8995 0.01$ 0602011 PT EVAL LOW COMPLEXITY 20 MINUTES 97161 387.00$ 0602029 PT EVAL MOD COMPLEXITY 30 MINUTES 97162 387.00$ 0602037 PT EVAL HIGH COMPLEXITY 45 MINUTES 97163 387.00$ 0602045 PT RE-EVAL EST PLAN CARE 20 MINUTES 97164 219.00$ 0700005 BONE AND/OR JOINT IMG LIMITED AREA 78300 2,058.00$ 0700013 NM TC99M FILSLFRCOLL-SENT NODE A9541 1,731.00$ 0700039 BONE AND/OR JOINT IMG 3 PHASE STUDY 78315 2,058.00$ 0700047 BONE AND/OR JOINT IMG WHOLE BODY 78306 2,058.00$ 0700161 HEPATOBILIARY SYS IMG W/GALLBLADDER 78226 2,058.00$ 0700211 GASTRIC EMPTYING IMG STUDY 78264 2,058.00$ 0700229 ACUTE GASTROINTEST BLOOD LOSS IMG 78278 2,058.00$ 0700286 PULMONARY VENT & PERFUSION IMAG(FY) 78582 2,731.00$ 0700302 LYMPHATICS AND LYMPH NODES IMAGING 78195 2,058.00$ 0700419 PARATHYROID PLANAR W/SUB WHEN DONE 78070 2,058.00$ 0700427 UREA BREATH C-14 ISOTOPIC ACQUISTN 78267 44.00$ 0700450 NM RENAL FLOW/FUNCT SNGL NO RX 78707 2,731.00$ 0700468 KIDNEY IMG MORPH VASC F/F 1 W/RX 78708 2,731.00$ 0700518 NM AEROVENT NEB- LUNG VENT/PERF 132.00$ 0700526 NM TC99M PENTETATE AEROSOLIZED A9567 80.00$ 0700534 NM TC99M SLFRCOLL-GASTRIC EMPT A9541 174.00$ 0700567 THYROID UPTAKE SINGLE/MULTI MEASURE 78012 2,058.00$ 0700591 RADIOPHARM IMAGE LIMITED AREA 78805 6,860.00$ 0700799 NM TC99M MBROFENIN GALLBL SCAN A9537 91.00$ 0700807 NM GALLIUM GA67/MCI ISOTOPE A9556 102.00$ 0700823 NM TC99M MAA 5MCI STUDY DOSE A9540 41.00$ 0700864 NM TC99M MEDRNTE BONE SCAN A9503 30.00$ 0700872 ISOTOPE SESTAMIBI DX PER STUDY A9500 494.00$ 0700906 TECHNETIUM TC-99 DX MERTIATIDE/DOSE A9562 329.00$ 0700914 NM PYTEST ISOTOPE A4641 394.00$ 0700922 NM I123 SOD IOD CAP/100UCI ISO A9516 152.00$ 0700930 NM RBC LABELED KIT A9560 145.00$ 0700963 NM IN111 OXYQUINOLINE/0.5MCI A9547 4,258.00$ 0700989 NM SINCALIDE VL 5MCG DOSE J2805 199.00$ 0701052 HEPATOBILIARY SYS IMG W/PHARMACO 78227 2,058.00$ 0701128 BRAIN W/FLOW < 4 VIEWS STATIC 78601 2,058.00$ 0701136 NM TC99M EXAMETAZIME PER STUDY DOSE A9521 4,226.00$ 0701144 TC99 DIAGNOSTIC UP TO 0.5 MCI A9520 750.00$ 0800011 UNLISTED CHEMISTRY PROCEDURE [AP 84999 -$ 0800177 RHO (D) IMMUNE GLOB 300MCG INJ J2790 320.00$ 0800193 PLASMA FROZEN BETWEEN 8-24 HR EA UN P9059 113.00$ 0800219 CRYOPRECIPITATE EACH UNIT P9012 350.00$ 0800250 PLATELETS PHERESIS EACH UNIT P9034 630.50$ 0800268 RED CELLS L/R REDUCED EA UNIT [ARC P9016 315.00$

0800318 PLATELETS PHERESIS L/R EA UNIT P9035 836.00$ 0800334 PLATELETS PHER L/R IRRAD EA P9037 1,073.00$ 0800417 COOMBS TEST DIR EA ANTISERUM [AR 86880 18.00$ 0800490 AB ID RBC ANTIBODIES EA PANEL 86870 1,296.00$ 0800516 PLASMA FRZN >8-24< OF COL EA [ARC P9059 55.00$ 0900076 CARDIOVERSION ELECTIVE EXTERNAL 92960 2,891.00$ 0900084 CARDIOVERSION ELECTIVE EXTERNAL 92960 2,891.00$ 0900175 ICU OBSERVATION: HOURS G0378 305.00$ 0900183 TRACH TUBE CUFFED (51-100) A7521 421.00$ 0900191 LOW COST SUPPLY (0-10) -$ 1100007 MED NUTRITION INITL 1 PT EA 15 MIN 97802 164.00$ 1100015 MED NUTRITION SUBSEQ 1 PT EA 15 MIN 97803 139.00$ 1200039 INTUBATION GASTRIC TREATMENT 43753 1,364.00$ 1200047 ER LEVEL 0: N/C NRSG CARE-ER -$ 1200054 URINALYSIS AUTO W/O SCOPE 81003 10.00$ 1200062 URINE PREGNANCY TEST VISUAL 81025 14.00$ 1200104 REMOVE IMPACTED EAR WAX W/INST UNI 69210 347.00$ 1200112 CHANGE GASTROSTOMY TUBE NO IMG/GUDE 43760 1,236.00$ 1200211 SIMPLE PROCEDURE(S)-ER 499.00$ 1200229 INTERMEDIATE PROCEDURE(S)-ER 998.00$ 1200237 COMPLEX PROCEDURE(S)-ER 1,994.00$ 1200245 OBSTETRIC PROCEDURE(S)-ER 2,655.00$ 1200260 ER TRIAGE:SCREEN ONLY 50.00$ 1200278 ER LEVEL 1 MINOR SEVERITY 99281 383.00$ 1200286 ER LEVEL 2 LOW/MOD SEVERITY 99282 695.00$ 1200294 ER LEVEL 3 MODERATE SEVERITY 99283 1,256.00$ 1200302 ER LEVEL 4 HIGH SEVERITY 99284 2,074.00$ 1200310 ER LEVEL 5 HIGH SEVERITY/COMPLEX 99285 3,050.00$ 1200328 ER LEVEL 6 CRITICAL CARE 99291 4,122.00$ 1200336 IV INF THER/PROP/DX EA ADDL HR 96366 191.00$ 1200344 +ER LEVEL 1 MINOR SEVERITY 99281 383.00$ 1200351 +ER LEVEL 2 LOW/MOD SEVERITY 99282 695.00$ 1200369 +ER LEVEL 3 MODERATE SEVERITY 99283 1,256.00$ 1200377 +ER LEVEL 4 HIGH SEVERITY 99284 2,074.00$ 1200385 +ER LEVEL 5 HIGH SEVERITY/COMPLEX 99285 3,050.00$ 1200393 +ER LEVL 6 CRITICAL CARE 99291 4,122.00$ 1200682 IMMUNIZATION ADMIN 1 VACCINE 90471 5.00$ 1200690 INJECTION THER/PROPH/DX SQ/IM 96372 261.00$ 1200716 THER/PROPH/DX INJ IV PUSH 1/INIT 96374 572.00$ 1200724 IMMUNIZATION ADMIN EA ADD VACCINE 90472 5.00$ 1200773 CARDIOPULMONARY RESUSCITATION 92950 1,364.00$ 1200781 CARDIOVERSION ELECTIVE EXTERNAL 92960 2,891.00$ 1200799 THROMBOLYSIS CORONARY IV INFUSION 92977 1,236.00$ 1200807 INS ENDOTRACHAL EMERGENCY PROCEDURE 31500 800.00$ 1200815 RHYTHM ECG 1-3 LEADS/TRACE NO RPT 93041 189.00$ 1200823 AIRWAY INHALATION TREATMENT INITIAL 94640 925.00$ 1200831 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 1200856 BLOOD OCCULT PEROX ACTV OTHR SOURCE 82271 20.00$

1200864 COLLECT VENOUS BLOOD/VENIPUNCTURE 36415 13.00$ 1200872 IAAD IMMUNO OPTICAL OBV STREP GRP A 87880 56.00$ 1200898 URINALYSIS NONAUTO W/O SCOPE 81002 15.00$ 1200906 TEMPORARY TRANSCUTANEOUS PACING 92953 2,891.00$ 1200922 VITAL CAPACITY TOTAL 94150 802.00$ 1201003 BLOOD TRANSFUSION 1 HOUR 36430 2,161.00$ 1201029 INS TEMP INDWEL BLADDER CATH SIMPLE 51702 565.00$ 1201037 INS TEMP INDWELL BLADDER CATH COMP 51703 802.00$ 1201045 INS NON-INDWELLING BLADDER CATH 51701 565.00$ 1201052 THERAPY PROPH/DX INJ IV PUSH SAME 96376 254.00$ 1201086 BLOOD OCCULT FECES QUAL CONSECUTVE 82270 20.00$ 1201094 BLOOD OCCULT FECES 1-3 NOT COLO NEO 82272 20.00$ 1201102 IV INF THER HYDRATIN INIT 31-60 MIN 96360 572.00$ 1201110 IV INF THER HYDRATION EA ADDL HOUR 96361 191.00$ 1201128 IV INF THER PROP/DX INIT UP TO 1HR 96365 1,072.00$ 1201144 IV INF THER/PRO/DX ADDL SEQ NEW 1HR 96367 261.00$ 1201151 ER INFUSION:CONCURRENT 96368 78.00$ 1201201 THER/PROPH/DXINJ IV PUSH ADDL SEQ 96375 261.00$ 1201417 CRITICAL CARE E & M EA ADDL 30 MIN 99292 1,672.00$ 1201425 THROMBOLYSIS CORONARY IV INFUSION 92977 1,236.00$ 1201524 SLIT CATHETER SET (101-150) 447.00$ 1201532 LEVEL 1 INFUSION TUBING (51-100) 474.90$ 1201680 +CRITICAL CARE E & M EA ADDL 30 MIN 99292 1,672.00$ 1201698 SMOK/TOB CESS COUN INTMD >3-10 MIN 99406 168.00$ 1201706 SMOK/TOB CESS COUN INTSV >10 MIN 99407 168.00$ 1201714 SMOK/TOB CESS COUN INTMD >3-10 MIN 99406 168.00$ 1201722 SMOK/TOB CESS COUN INTSV >10 MIN 99407 168.00$ 1201730 REMOVAL FB EXT AUDIT CANAL NO ANEST 69200 565.00$ 1201748 REMOVE IMPACTD EAR WAX W/INST BILAT 69210 347.00$ 1201755 REMOVAL OF FOREIGN BODY FOOT 28190 5,830.00$ 1201763 BLADDER IRRIG SIMPLE LAVAGE/INSTILL 51700 1,278.00$ 1201789 THROMBOLYTIC VENOUS THERAPY INITIAL 37212 5,337.00$ 1201797 THROMBOLYSIS CEREBRAL IV INFUSION 37195 1,695.00$ 1201805 COLLECT CAPILLARY BLOOD 36416 12.00$ 1201813 BLOOD TRANSFUSION 2 HOURS 36430 2,161.00$ 1201821 BLOOD TRANSFUSION 3 HOURS 36430 2,161.00$ 1201839 BLOOD TRANSFUSION 4 HOURS 36430 2,161.00$ 1201847 BLOOD TRANSFUSION 5 HOURS 36430 2,161.00$ 1201854 ADMIN OF HEPATITIS B VACCINE G0010 5.00$ 1201862 ADMIN OF INFLUENZA VIRUS VACCINE G0008 5.00$ 1201870 ADMIN OF PNEUMOCOCCAL VACCINE G0009 5.00$ 1201888 US CHEST W/MEDIASTINUM REAL TIME 76604 570.00$ 1201896 US ABDOMINAL REAL TIME COMPLETE 76700 950.00$ 1201904 US ABDOMINAL REAL TIME LIMITED 76705 950.00$ 1201912 US RETROPERITONEAL REAL TIME COMP 76770 950.00$ 1201920 US PREGNANT UTERUS LIMITED FETUS(S) 76815 950.00$ 1201938 US PREGNANT UTERUS TRANSVAGINAL 76817 950.00$ 1201946 US EXAM TRANSVAGINAL NON OB 76830 950.00$

1201953 US EXAM PELVIC (NON-OB) LIMITED 76857 570.00$ 1201961 GLUCOSE BLOOD REAGENT STRIP 82948 20.00$ 1201979 ELECTROCARDIOGRAM 12/TRACE NO RPT 93005 347.00$ 1201987 CONTINUOUS TX W/MED FIRST HOUR 94644 604.00$ 1201995 CONT PRESSURE CPAP INIT & MGMT 94660 925.00$ 1202001 DEMO/EVAL PT USE OF INHALER 94664 925.00$ 1202019 US GUIDED VASCULAR ACCESS ADD ON 76937 122.00$ 1202027 PNEUMOTHORAX SET (51-100) 475.00$ 1202035 THORA-VENT (11-50) 152.00$ 1202043 MOD SED SAME PHYS/QHP <5 YEARS 99151 183.00$ 1202050 MOD SED SAME PHYS/QHP 1ST 15 MN >5Y 99152 183.00$ 1202068 MOD SED SAME PHYS/QHP EA ADD 15 MIN 99153 91.00$ 1202076 MOD SED OTH PHYS/QHP <5 YEARS 99155 183.00$ 1202084 MOD SED OTH PHYS/QHP 1ST 15 MIN >5Y 99156 183.00$ 1202092 MOD SED OTH PHYS/QHP EA ADD 15 MIN 99157 91.00$ 1202118 US PREGNANCY FOLLOWUP PER FETUS 76816 570.00$ 1202126 US PREGNANCY <14 WKS SING/1ST GEST 76801 950.00$ 1202134 DUPLEX VENOUS EXT UNI/LMTD UPR RT 93971 950.00$ 1202142 DUPLEX VENOUS EXT UNI/LMTD UPR LT 93971 950.00$ 1202159 DUPLEX VENOUS EXT UNI/LMTD LWR RT 93971 950.00$ 1202167 DUPLEX VENOUS EXT UNI/LMTD LWR LT 93971 950.00$ 1202175 COLLECT BLOOD FROM PICC NOS 36592 565.00$ 1202183 INJ TX/PROPH/DX INTRA-ARTERI 96373 572.00$ 1202191 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 1202209 BLOOD COUNT HEMAGLOBIN 85018 14.00$ 1202217 INTERG DVC EVAL F2F1/DUAL/MLT/ DFB 93289 208.00$ 1202225 SPMTRY W/VC EXP FLOW W/WO MX VOL 94010 802.00$ 1202233 STAPLE/SUTURE REMOVAL STATISTICAL -$ 1202241 ER TRIAGE (451) 93005 55.00$ 1202258 REPL GTUBE W/REMOVAL NO IMG/GDE/REV 43762 1,360.00$ 1202266 REPL GTUBE W/REMV W/O IMG/GDE W REV 43763 1,360.00$ 1300011 RECOVERY 1ST HOUR 1,051.00$ 1300029 RECOVERY ADDL HOUR 960.00$ 1300037 VAG DELIVERY RECOVERY 1ST 2 HR 2,142.00$ 1300045 VAG DELIVERY RECOVERY ADDL HR 960.00$ 1300052 CIRCUMCISION W/CLAMP/DEV W/BLOCK 54150 9,323.00$ 1300078 VAGINAL DELIVERY ONLY 59409 11,519.00$ 1300144 LABOR HOURLY CHARGE 218.00$ 1300151 OBSERVATION PER HOUR L&D G0378 305.00$ 1300169 AMNIOINFUSION 400.00$ 1300185 FETAL NON-STRESS TEST 59025 869.00$ 1300201 STERILE SPEC EXAM 263.00$ 1300250 EXT CEPHALIC VERSION W-W/O TOCLYSIS 59412 11,519.00$ 1300284 PHOTOTHERAPY PER HR(STAT) -$ 1300292 NEWBORN RESUSCITATION PER 15 MIN 99465 3,095.00$ 1300300 RETAINED PLACENTA 773.00$ 1300326 VACUME EXTRACTOR 475.00$ 1300359 IV INF THER HYDRATIN INIT 31-60 MIN 96360 572.00$

1300367 IV INF THER HYDRATION EA ADDL HOUR 96361 191.00$ 1300375 IV INF THER PROP/DX INIT UP TO 1HR 96365 1,072.00$ 1300383 IV INF THER/PROP/DX EA ADDL HR 96366 191.00$ 1300391 IV INF THER/PRO/DX ADDL SEQ NEW 1HR 96367 261.00$ 1300409 INJECTION THER/PROPH/DX SQ/IM 96372 261.00$ 1300417 THER/PROPH/DX INJ IV PUSH 1/INIT 96374 572.00$ 1300425 THER/PROPH/DXINJ IV PUSH ADDL SEQ 96375 261.00$ 1300433 THERAPY PROPH/DX INJ IV PUSH SAME 96376 254.00$ 1800002 SHUNT CAROTID BRENER (501-750) 2,780.00$ 1800135 ELECTRODE IMPLANTED TEMP PACING 220.00$ 1800184 CLOSURE DEVICE VASC (51-100) C1760 475.00$ 1800218 CLOSURE DEVICE VASC (101-150) C1760 667.00$ 1800721 MESH IMPLANT (3501-4500) C1781 10,666.00$ 1800747 MESH IMPLANT (51-100) C1781 475.00$ 1800754 MESH IMPLANT (151-200) C1781 857.00$ 1801422 SUPPLY SURGICAL DISP (11-50) 152.00$ 1801448 FORCEPS BIPOLAR (DISP)(501-750) 2,540.00$ 1801455 KIT REPAIR (51-100) 152.00$ 1801935 ORTHO PLATE (1001-1500) C1713 4,803.00$ 1802461 ALLOGRAFT (1501-2000) 5,869.00$ 1803642 K-WIRE (151-200) C1713 152.00$ 1803808 CANNULA SHOULDER 8.5 MM DEPUY 148.00$ 1803816 BIOPSY SUPPLIES DISP (101-150) 667.40$ 1803840 KIT WOUND VAC DRESS (251-500) 1,613.20$ 1803857 INTRODUCER ANESTHESIA 27.00$ 1803865 ELECTRODE SET MEDTRONIC NIMS 351.00$ 1803881 K-WIRE (11-50) C1713 263.00$ 1803899 DRIVER PEG DEPUY 2MM F.A.S.T. 114.00$ 1803907 CEMENT BONE SIMPLEX C1713 1,290.00$ 1803915 SUTURE KIT (51-100) 475.00$ 1803931 GUIDEWIRE ZIMMER 94.00$ 1803949 SHAVER ARTHROSCPY BLADE ANGLED 152.00$ 1803972 ORTHO NAIL (201-250) C1713 1,045.00$ 1803998 JOINT DEVICE (7001-8500) C1776 17,594.50$ 1804012 MESH IMPLANT (2501-3500) C1781 8,534.00$ 1804020 DERMACARRIER MESHER 105.00$ 1804038 DRILL BIT (251-500) 1,685.00$ 1804046 DRILL BIT (751-1000) 3,742.00$ 1804053 FORCEP BIOPSY (11-50) 152.00$ 1804061 MANIPULATOR (51-100) 475.00$ 1804087 INSTRUMENT SURGICAL DISP (151-200) 856.60$ 1804095 ORTHO NAIL (11-50) C1713 152.00$ 1804111 STENT COAT/CVD W/DEL SYS (2-2.5K) C1874 6,935.00$ 1804129 SYSTEM DISTAL BICEPS REPAIR C1713 3,635.00$ 1804194 SUTURE NYLON -$ 1804236 SUTURE NON-ABSORB SILK 49.00$ 1804277 IRRIGATOR TIP FEMORAL ZIMMER 35.00$ 1804327 BLADE EYE KNIFE SLIT MANI 30.00$

1804335 DRAPE SPIDER SHOULDER STAB KIT 161.00$ 1804392 GUIDE KNEE (1001-1500) 4,803.00$ 1804400 EXTERNAL NEURO STIMULATOR (251-500) 1,613.20$ 1804434 SWIVEL ELBOW -$ 1804459 DRILL BIT (101-150) 743.00$ 1804467 GRAFT BONE CHIPS MTF 15ML 705.00$ 1804558 ORTHO GUIDEWIRE (201-250) 1,045.00$ 1804574 ORTHO GUIDEWIRE (151-200) 857.00$ 1804699 ENDOSCOPIC DEVICE (101-150) 667.40$ 1804731 INSTRUMENT SURGICAL DISP (251-500) 1,613.20$ 1804749 INSTRUMENT SURGICAL DISP (501-750) 2,780.00$ 1804798 INSTRUMENT SURGICAL DISP (51-100) 474.90$ 1805084 TUBING TUR EXTENSION SET 23.00$ 1805126 TUBING BSS ADMIN SET EYE 78.00$ 1805134 TUBE T DRAIN BILE 53.00$ 1805142 TUBE SALEM SUMP NG 28.00$ 1805258 SYRINGE BULB EAR ULCER 35.00$ 1805266 SYRINGE BULB ASEPTO 35.00$ 1805274 SYRINGE 60ML REGULAT TIP CATH 23.00$ 1805282 SYRINGE 3ML SAFETY 22GA NEEDLE 23.00$ 1805290 SUTURE NON-ABSORB SILK 49.00$ 1805308 SUTURE NON-ABSORB PROLENE(11-50) 152.00$ 1805316 SUTURE NON-ABSORB NYLON 159.00$ 1805340 SUTURE ABSORB PDS 30.00$ 1805373 STYLET INTUBATING 14.00$ 1805399 STOPCOCK 3-WAY EXTENSION 16.00$ 1805407 STOCKING TED THIGH 28.00$ 1805415 STOCKINETTE BIAS 6" 25.00$ 1805423 STOCKINETTE BIAS CUT 6IN 46.00$ 1805522 SOLUTION ANTI FOG FRED 23.00$ 1805530 SOF-ROLL 25.00$ 1805555 SHOE POST OP 26.00$ 1805571 SET TWO LINE IRRIG Y- TUBING 21.00$ 1805589 TUBING IRRIGATION (11-50) 152.00$ 1805597 SET IV SECONDARY PIGGYBACK 94.00$ 1805605 SET IV PRIMARY CONTINU-FLO 94.00$ 1805613 SET IV EXTENSION TUBING 19.00$ 1805621 SET IV EXTENSION STATLOCK 19.00$ 1805639 SET IV EXTENSION MICROBORE 19.00$ 1805647 SET IV BURETTE IN LINE 14.00$ 1805654 RESERVOIR JACKSON PRATT BULB 25.00$ 1805670 PREP SKIN BETADINE GEL -$ 1805688 PREP CHOLOROPREP 53.00$ 1805696 MESH IMPLANT (501-750) C1781 2,780.00$ 1805704 MESH IMPLANT (251-500) C1781 1,613.00$ 1805720 MESH IMPLANT (101-150) C1781 677.00$ 1805738 HEMOSTAT ABSORBABLE (51-100) 474.90$ 1805746 KIT LTA (LARYNGO TRACH ANESTH) 25.00$

1805761 JOINT DEVICE (751-1000) C1776 3,742.00$ 1805779 JOINT DEVICE (5501-7000) C1776 15,462.90$ 1805787 JOINT DEVICE (501-750) C1776 2,780.00$ 1805795 JOINT DEVICE (4501-5500) C1776 12,797.90$ 1805803 KNEE JOINT DEVICE (3501-4500) C1776 10,665.90$ 1805811 JOINT DEVICE (251-500) C1776 1,613.20$ 1805829 JOINT DEVICE (2501-3500) C1776 8,534.00$ 1805837 JOINT DEVICE (2001-2500) C1776 6,935.00$ 1805845 JOINT DEVICE (151-200) C1776 856.60$ 1805852 JOINT DEVICE (1501-2000) C1776 5,869.00$ 1805860 JOINT DEVICE (101-150) C1776 667.40$ 1805878 JOINT DEVICE (1001-1500) C1776 4,803.00$ 1805886 IOL POSTERIOR CHAMBER (51-100) V2632 474.90$ 1805894 IOL POSTERIOR CHAMBER (101-150) V2632 667.40$ 1805910 SHOULDER ORTHOSIS ABD (11-50) L3650 152.00$ 1805928 GRAFT VASCULAR (501-750) C1768 2,780.00$ 1805951 EVACUATOR ELLIK BLADDER 41.00$ 1805969 ESMARK 12.00$ 1805985 DRAINAGE BAG URINE 2000ML 152.00$ 1805993 DRAIN JACKSON PRATT 177.00$ 1806025 CONNECTIVE TISSUE NON-HUMN(101-150) C1763 667.40$ 1806041 CIRCUIT ANESTHESIA ADULT 25.00$ 1806058 CAUTERY LOW TEMP OPHTHALMIC 39.00$ 1806066 CAUTERY CORD MONOPOLAR 25.00$ 1806074 CAUTERY CORD BIPOLAR 106.00$ 1806090 CATHETER RADIAL ARTERY 133.00$ 1806116 CATHETER FOLEY (11-50) C1758 132.00$ 1806165 BLANKET BAIR HUGGER 78.00$ 1806199 BLADE EYE KNIFE MICRO UNITOME 45.00$ 1806231 BERKLEY VACCURETTE CURVED 65.00$ 1806298 ORTHO SCREW (3501-4500) C1713 10,666.00$ 1806306 ORTHO SCREW (2501-3500) C1713 8,534.00$ 1806314 ORTHO SCREW (751-1000) C1713 3,742.00$ 1806322 ORTHO SCREW (501-750) C1713 2,780.00$ 1806330 ORTHO SCREW (251-500) C1713 1,613.00$ 1806348 ORTHO SCREW (201-250) C1713 1,045.00$ 1806355 ORTHO SCREW (2001-2500) C1713 6,935.00$ 1806363 ORTHO SCREW (151-200) C1713 857.00$ 1806371 ORTHO SCREW (101-150) C1713 667.00$ 1806389 ORTHO SCREW (1501-2000) C1713 5,869.00$ 1806397 ORTHO SCREW (1001-1500) C1713 4,803.00$ 1806405 ORTHO SCREW (51-100) C1713 475.00$ 1806413 ABDOMINAL BINDER (11-50) 125.00$ 1806421 SUCTION TRAP MUCUS -$ 1806439 SUCTION TIP FRAZIER 15.00$ 1806462 SPONGE PEANUT DISSECTOR 16.00$ 1806488 SPONGE COTTONOID SURG PATTIES 48.00$ 1806496 PAD BIO FLOTATION EGGCRATE 138.00$

1806512 LMA LARYNGEAL MASK AIRWAY 43.00$ 1806538 CAUTERY SUCTION FOOT CONTROL 37.00$ 1806561 PAD PROTECTOR ELBOW HEEL 160.00$ 1806587 BERKLEY SUCTION CANISTER 86.00$ 1806595 PILLOW ABDUCTION 152.00$ 1806603 IRRIGATOR SUCTION PULSAVAC 137.00$ 1806629 TUBING SUCTION LIPOSUCTION 146.00$ 1806637 SUCTION IRRIGATOR STRYKER 119.00$ 1806645 DEVICE LOCKING BILIARY SYSTEM 56.00$ 1806652 STOCKINETTE SYNTHETIC 56.00$ 1806678 CAUTERY HIGH TEMP LOOP 59.00$ 1806686 CATHETER URETERAL WHISTLE TIP 132.00$ 1806694 CATHETER COUDE 109.00$ 1806702 CATHETER URETERAL OPEN TIP 132.00$ 1806728 BRUSH CYTOLOGY (11-50) 132.00$ 1806736 BAG AMBU ADULT 70.00$ 1806777 TUBING INSUFFLATION (11-50) 152.00$ 1806785 KNEE IMMOBILIZER (11-50) L1830 152.00$ 1806793 SURE SET SINGLE BASIN 85.00$ 1806801 TUBE ET ORAL RAE CUFFED 88.00$ 1806819 TRAY SPINAL 199.00$ 1806835 BLADE MICRO OSC FINE 226.00$ 1806843 NEEDLE CYSTOTOME IRRIG EYE 48.00$ 1806850 TUBING STRAIGHT SHOT 99.00$ 1806868 SEQUENTIAL COMPRESSION DEVICE 271.00$ 1806876 CANNULA SHOULDER THREADED 104.00$ 1806892 TUBING SINUS EXTENSION 111.00$ 1806918 INFLATION DEVICE W/GAUGE(11-50) 152.00$ 1806934 SUTURE ABSORB CHROMIC 117.00$ 1806942 SPEARS WECK-CEL SURGICAL 25.00$ 1806967 NERVE STIMULATOR (51-100) 475.00$ 1806991 TUBE GASTROSTOMY MIC 557.00$ 1807007 TRAY BIOPSY (11-50) 152.00$ 1807023 TUBE TRACH (11-50) 152.00$ 1807056 SNARE (11-50) 152.00$ 1807064 STAYS FOR RETRACTOR (11-50) 114.00$ 1807072 DERMABOND (11-50) 210.00$ 1807080 SUTURE ABSORB MONCRYL 131.00$ 1807114 SHEATH ENDOSCRUB 137.00$ 1807122 KIT TRANSDUCER PRESSURE MONIT 152.00$ 1807130 SUTURE NON-ABSORB (11-50) 152.00$ 1807148 SUTURE NON-ABSORB FIBERWIRE 371.00$ 1807155 DRESSING PADDING UNDER CAST 142.00$ 1807163 SHAVER ARTHROSCOPY BUR 152.00$ 1807171 DRESSING WOUND VAC (11-50) 152.00$ 1807197 GRID BREAST BIOPSY ACCUGRID 146.00$ 1807239 NEEDLE SPINAL (11-50) 187.00$ 1807254 SUTURE NON-ABSORB HIFI 147.00$

1807262 SUTURE NON-ABSORB MERSILENE 147.00$ 1807270 TUBING BERKLEY W/SLIP HANDLE 148.00$ 1807288 CATHETER CHOLANGIOGRAM 122.00$ 1807296 SURGICEL 651.00$ 1807304 ELECTRODE ONE STEP EKG PACING 154.00$ 1807353 STAPLER SKIN 114.00$ 1807361 CANNULA ORTHO (51-100) 112.00$ 1807379 MANIPULATOR (11-50) 152.00$ 1807395 BLADE MYRINGOTOMY 98.00$ 1807403 SUTURE RETRIEVER HEWSON 575.00$ 1807411 TUBING ARTHROSCOPY 3M PUMP 170.00$ 1807429 PASSER SHUTTLE RELAY 152.00$ 1807437 GUIDEWIRE GLIDE WIRE ST C1769 152.00$ 1807445 PIN GUIDE THREADED TIP C1713 178.00$ 1807460 TROCAR BLADELESS XCEL 353.00$ 1807486 NEEDLE (101-150) 667.00$ 1807494 BLADE SAW (151-200) 857.00$ 1807502 DRILL BIT (51-100) 521.00$ 1807528 SHAVER BLADE ARTHROSCPY (51-100) 152.00$ 1807536 SHAVER ARTHROSCPY BLADE STER 152.00$ 1807551 CATHETER FOGARTY EMBOLECTOMY 671.00$ 1807569 APPLIER LIGACLIP 452.00$ 1807585 TROCAR LAPROSCOPIC 152.00$ 1807593 CATHETER CANNULA ERCP 201.00$ 1807601 SUTURE NON-ABSORB STEEL WIRE 98.00$ 1807619 TRAY CATHETER SUPRAPUBIC 275.00$ 1807635 SHEATH INTRODUCER LEAD 216.00$ 1807650 PERFORATOR ANSPACH 298.00$ 1807668 SPLINT ORTHOGLASS PER FOOT 21.00$ 1807676 BLADE MICRO SAG FINE 312.00$ 1807700 SCISSORS LAPAROSCOPIC ENDOSHR 272.00$ 1807742 TUBING EXTENSION ERBE 245.00$ 1807775 BUR (51-100) 475.00$ 1807783 CLAMP BABCOCK LAPAROSCOPIC 253.00$ 1807809 CIRCUIT ANESTHESIA PEDI 259.00$ 1807825 BALLOON SINUS DEVICE 276.00$ 1807833 BLADE MICRO SAG COARSE 312.00$ 1807841 BLADE SAW OSCILLATING 112.35$ 1807858 APPLIER CLIP LAPAROSCOPIC 451.74$ 1807866 PERFORATOR DISP 14MM 298.00$ 1807874 BRUSH FEMORAL CANAL 52.00$ 1807890 BALLOON LAP HERNIA (251-500) 1,613.20$ 1807932 STAPLER PPH 3,595.00$ 1807981 RETRACTOR (51-100) 475.00$ 1807999 APPLIER ENDOSCOPY RES CLIP 812.00$ 1808047 BASKET STONE RETRIEVAL 1,048.00$ 1808054 BIO-TENODESIS DISPOSABLE KIT 932.00$ 1808070 BLADE SAW RECIPROCATING 667.40$

1808088 BLADE SINUS INFERIOR TURBINATE 1,164.00$ 1808138 CARTRIDGE ALCON MONARCH 386.00$ 1808146 CASSETTE INFINITY ULTRASOUND 2,532.00$ 1808161 CATH BALLOON DIL NON VASC (101-150) C1726 913.00$ 1808211 CAUTERY EVEREST BIPOLAR 509.00$ 1808229 CAUTERY, KNIFE ELECTRODE(201-250) 1,045.00$ 1808245 CAUTERY LIGASURE HANDPIECE 953.00$ 1808252 CAUTERY NEEDLE TIP 474.90$ 1808278 CAUTERY SERFAS HOOK 923.00$ 1808286 CAUTERY URO CUTTING 474.90$ 1808310 DRAIN BLAKE 15FR ROUND 165.00$ 1808328 DRAIN CONSTAVAC 1,613.00$ 1808336 DRAIN HEMOVAC 536.00$ 1808369 ELECTRODE ROLLER BALL 370.00$ 1808385 INSTRUMENT SURGICAL DISP (201-250) 1,045.00$ 1808393 ENDOSCOPIC KITTNER 152.00$ 1808401 FORCEP BIOPSY ENDOSCOPY A 290.00$ 1808419 GOLDPROBE 857.00$ 1808450 ORTHO GUIDEWIRE (101-150) 667.00$ 1808468 GUIDE WIRE (101-150) C1769 667.40$ 1808476 GUIDEWIRE URO JAGWIRE 619.00$ 1808484 HARMONIC SCALPEL 1,109.00$ 1808492 HOOD FREEDOM 236.00$ 1808500 INTERCEED ADHESION BARRIER 628.50$ 1808518 IRRIGATOR PULSAVAC 1,353.00$ 1808526 DRAPE MICROSCOPE LEICA 92.00$ 1808534 ELECTROSURG PLATE (11-50) 152.00$ 1808591 SUTURE PASSER (201-250) 625.00$ 1808609 CATH PERF CENT/MID NO HEMO(201-250) C1751 762.00$ 1808617 CATH PERF CENT/MID NO HEMO(251-500) C1751 1,654.00$ 1808633 CATH PERF CENT/MID NO HEMO(101-150) C1751 652.00$ 1808641 PORT INDWELLING (IMP) (251-500) C1788 1,658.00$ 1808666 LEAD PMKR OTHER THAN TRNS (501-750) C1898 2,780.00$ 1808674 LEAD PMKR OTHER THAN TRANS (751-1K) C1898 3,742.00$ 1808682 IOL ANTERIOR CHMBR (51-100) V2630 474.90$ 1808716 BONE FILLER (101-150) C1713 630.00$ 1808732 ORTHO PLATE (2501-3500) C1713 8,534.00$ 1808740 ORTHO PLATE (1501-2000) C1713 5,869.00$ 1808757 PLATE SYNTHES 1/3 TUBULAR C1713 437.00$ 1808765 ORTHO PLATE (2001-2500) C1713 6,935.00$ 1809102 WIRE C C1713 29.00$ 1809110 ORTHO WASHER (11-50) C1713 152.00$ 1809128 K-WIRE (51-100) C1713 856.60$ 1809136 WIRE SYNTHES FIXATION C1713 342.00$ 1809151 WIRE ZIMMER FIXATION C1713 122.00$ 1809193 CATH PERF CENT/MID NO HEMO C1751 454.00$ 1809219 ABSORBATACK (251-500) 1,613.00$ 1809227 APPLIER PROTACK CLIP HERNIA 419.00$

1809235 TUBAL LIGATION CLIP (51-100) 475.00$ 1809276 CABLE READY GRIP COBALT C1713 1,070.00$ 1809284 BEADED CABLE/SLEEVE SET (251-500) 1,613.20$ 1809326 GRAFT AMBI0DRY 1,488.00$ 1809375 BONE PUTTY DBM (751-1000) 4,380.00$ 1809425 MESH IMPLANT (11-50) C1781 152.00$ 1809433 GRAFT TENDON BIOCLEANSE 6,352.50$ 1809557 PLUG BONE MEDIUM 11-13MM C1713 775.00$ 1809615 STENT NON-COR TEMP (101-150) C2625 667.00$ 1809623 STENT URETERAL 617.00$ 1809631 STENT NON-COR TEM W/O DEL (201-250) C2617 1,045.00$ 1809649 TISSEEL 10ML 649.00$ 1809656 TUBES T VENTILATION 68.00$ 1809722 ORTHO GUIDEWIRE (11-50) 152.00$ 1809755 TRAY EPIDURAL 72.00$ 1809789 STOCKINETTE 3IN 43.00$ 1809821 RETRACTOR LONESTAR 150.00$ 1809862 NEEDLE SPINAL 18GA 30.00$ 1809904 GUIDE PIN (201-250) 1,045.00$ 1810043 BAG BILE 36.00$ 1810076 STOCKINETTE BIAS 4" 25.00$ 1810084 STAPLER POWERED LDS 15W 1,155.80$ 1810118 NEEDLE SPINAL 25GA 3.5IN 20.00$ 1810126 VACURETTE BERKLEY 65.00$ 1810134 CAUTERY LOOP ELECTRODE 152.00$ 1810142 MESH IMPLANT (751-1000) C1781 3,742.00$ 1810241 DRAPE HIP (11-50) 152.00$ 1810514 SPECIMEN TRAP (11-50) 268.00$ 1810704 SUPPLY SURGICAL DISP (2501-3500) 8,534.00$ 1811066 SUPPORTER ATHLETIC MEDIUM 26.00$ 1811082 DISPOSABLE SUCTION MAT (51-100) 474.90$ 1811389 CATH KIT MICROSENSOR(751-1K) 3,742.00$ 1811397 KIT SURGICAL IMPLANT (2501-3500) 8,534.00$ 1811728 SUPPLY SURGICAL DISP (101-150) 667.00$ 1812205 PROTECTIVE EYE GOGGLES 25.00$ 1812221 ABLATOR PROBE (501-750) 2,780.00$ 1812346 INTRO/SHEATH NON-LASER (11-50) C1894 152.00$ 1812361 SUPPLY SURGICAL DISP (51-100) 475.00$ 1812502 BLADE ORTHO (501-750) 2,780.00$ 1812544 NEEDLE SPINAL 22GA X 3.5" WHIT 144.00$ 1812551 NEEDLE BIOPSY (51-100) 452.00$ 1812833 SUTURE ANCHOR (501-750) C1713 2,780.00$ 1813112 HEMOSTAT ABSORBABLE (151-200) 856.60$ 1813153 BLADE PLASMABLADE (251-500) 1,613.20$ 1813161 TAPE SUTURE (11-50) 152.00$ 1813187 IOL ASTIGMATISM (501-750) V2787 2,780.00$ 1813211 SHAVER INCISOR ELITE(51-100) 475.00$ 1813260 GUIDE WIRE (201-250) C1769 1,045.00$

1813278 REAMER STRYKER (201-250) 1,052.00$ 1813286 DRILL BIT (201-250) 1,095.00$ 1813328 ORTHO NAIL (2001-2500) C1713 6,935.00$ 1813344 KIT FILL ALLERGAN SALINE 168.00$ 1813377 BLADE HARMONIC CURVED 5M X32CM 1,109.00$ 1813385 ADAPTER HARMONIC HAND SWITCH 139.00$ 1813393 LEAD MEDTRONIC SNS 28CM C1778 7,600.00$ 1813401 GEN NEURO NON RECHARG (12-14K) C1767 30,919.90$ 1813419 KIT INTRODUCER MEDTRONIC LEAD 649.00$ 1813427 PROGRAMMER MEDTRONIC PATIENT 4,975.00$ 1813435 ANTENNA MEDTRONIC 224.00$ 1813450 ELECTRODE UROLOGY (51-100) 474.90$ 1813583 NEEDLE INSUFFLATION 220.00$ 1813690 ORTHO PLATE (251-500) C1713 1,613.00$ 1813724 GUIDE WIRE (251-500) C1769 1,613.20$ 1813732 GUIDE WIRE (151-200) C1769 856.60$ 1813757 PENCIL ESURG (11-50) 152.00$ 1813773 SMOKE EVACUATOR DEV (11-50) 152.00$ 1813799 GRAFT BONE PUTTY (251-500) C1713 1,613.20$ 1813815 BLADE SAW (51-100) 474.90$ 1813823 CATH PERF CENT/MID NO HEMO C1751 132.00$ 1813831 CATH PERF CENT/MID NO HEMO C1751 132.00$ 1813864 BONE FILLER (1501-2000) C1713 7,318.00$ 1814136 CATH BALLOON DIL NON VASC (201-250) C1726 951.00$ 1814201 INSTRUMENT SURGICAL DISP (101-150) 667.40$ 1814391 OR BASE RATE 1 INITIAL 30 MIN 1,878.00$ 1814409 OR BASE RATE 2 INITIAL 30 MIN 2,348.00$ 1814417 OR BASE RATE 3 INITIAL 30 MIN 7,375.00$ 1814425 OR BASE RATE 4 INITIAL 30 MIN 8,383.00$ 1814433 OR BASE RATE 5 INITIAL 30 MIN 10,056.00$ 1814458 OR BASE RATE 1 ADD'L 15 MIN 552.00$ 1814466 OR BASE RATE 2 ADD'L 15 MIN 844.00$ 1814474 OR BASE RATE 3 ADD'L 15 MIN 904.00$ 1814482 OR BASE RATE 4 ADD'L 15 MIN 999.00$ 1814490 OR BASE RATE 5 ADD'L 15 MIN 1,025.00$ 1814599 RECOV ROOM ADD'L 15M 235.00$ 1814615 RECOVERY ROOM 1ST HR 1,071.00$ 1814664 SUCTION IRRIGATOR (101-150) 475.00$ 1814672 CATH BALLOON DIL NON VASC (1.5-2K) C1726 5,869.00$ 1814698 CATHETER SINUS GUIDE 1,156.00$ 1814730 SYSTEM ILLUMINATION SINUS 1,947.00$ 1814847 OR PROCEDURE MINUTES -$ 1814862 RECOVERY PRODUCTIVITY/MINUTE -$ 1814995 TUBE TRACH PERCUTAN (251-500) 879.00$ 1815000 NON IMPLANT ANCHOR (51-100) 475.00$ 1815125 UTERINE ABLATION SYS (1001-1500) 4,803.00$ 1815158 POSITIONER DISP (51-100) 475.00$ 1815216 CATH BRANCHYTH (151-200) C1728 856.60$

1815265 BLADE/DRIVER (251-500) 1,613.20$ 1815281 OMNIOPAQUE 300 50ML 749.00$ 1815299 OMNIOPAQUE 350 50ML 404.00$ 1815307 PAD IMP KNEE POSITIONER 117.00$ 1815323 SUPPLY SURGICAL DISP (151-200) 857.00$ 1815331 SUCTION DEVICE (11-50) 205.00$ 1815349 IRRIGATOR TIP FEMORAL 408.00$ 1815364 KIT SURGICAL DISP (101-150) 667.40$ 1815372 PILOT GUIDE (101-150) 667.00$ 1815380 CLOSURE DEVICE (11-50) 239.00$ 1815406 BLADE COLD URETHEROTOME URO 667.40$ 1815422 LIGASURE ENDOSCOPIC HANDPIECE 953.00$ 1815448 LIGATOR ENDO ESOPHAGEAL 667.00$ 1815455 LMA FAST TRACK 1,347.00$ 1815471 MAMMOSITE 8,470.00$ 1815489 MARKER SPOT ENDOSCOPY 272.00$ 1815497 MIXER CEMENT (101-150) 667.00$ 1815505 BIOPSY SUPPLIES DISP (251-500) 1,613.20$ 1815539 NEEDLE SCLEROTHERAPY 770.00$ 1815547 NEEDLE SCORPION (101-150) 667.00$ 1815612 POUCH ENDOPOUCH LAP RETRIEVER 472.00$ 1815620 PROBE PRASS ENT 682.00$ 1815646 SENSOR BIS MONITOR LEAD 1,424.00$ 1815653 SHEARS (251-500) 1,613.00$ 1815695 SHEATH URETERAL ACCESS 633.00$ 1815703 SHOULDER FOAM 349.00$ 1815729 GUIDE WIRE (251-500) C1769 1,613.20$ 1815737 SPHINCTERTOME NEEDLE KNIFE 667.00$ 1815745 SPLINT NASAL THERMASPLINT 70.00$ 1815752 STAPLER CURVED CUTTER CONTOUR 755.00$ 1815778 STAPLER ENDO GIA 786.00$ 1815786 STAPLER GIA TL C75 756.00$ 1815794 STAPLER LINEAR RELOADABLE 575.00$ 1815810 PROBE DISP (151-200) 667.00$ 1815836 TRAY CENTRAL LINE 666.00$ 1815844 TRAY PARACENTESIS (51-100) 325.00$ 1815851 TRAY PONSKY PEG TUBE 773.00$ 1815869 TROCAR LABROSCOPIC HERNIA 2,181.00$ 1815877 TUBING ARTHROSCOPY 10K 374.00$ 1815885 TUBING BERKLEY LARGE DIAMETER 563.00$ 1815919 TUBE EMG ENDOTRACHEAL 989.00$ 1815927 FORCEP BIOPSY URETEROSCOPIC 929.00$ 1815950 SLING ARM ECONOMY 38.00$ 1816008 BLADE SAW OSCILLATING 5071-304 474.90$ 1816016 DRAPE C-ARM MINI 328.00$ 1816024 PREP PREVAIL 25.00$ 1816065 SIZER: ORTHO IMPLANT (51-100) 475.00$ 1816180 GRAFT TENDON (2-2.5K) 6,935.00$

1816198 TUBING BLOOD WARMER(11-50) 152.00$ 1816214 PACEMAKER NON-SINGLE DUAL (7-8.5K) C2621 21,533.00$ 1816230 EXTERNAL FIXATION DEV (251-500) 1,613.20$ 1816271 PASSER SUPER SHUTTLE RELAY 281.00$ 1816289 CATHETER GUIDING (251-500) C1887 1,568.00$ 1816305 POSITIONER (11-50) 52.00$ 1816362 STAPLER DEVICE (11-50) 152.00$ 1816370 STAPLER DEVICE (51-100) 475.00$ 1816388 STAPLER DEVICE (101-150) 667.00$ 1816396 STAPLER DEVICE (151-200) 856.00$ 1816404 STAPLER DEVICE (201-250) 1,045.70$ 1816412 STAPLER DEVICE (251-500) 1,431.00$ 1816438 ORTHO SCREW (11-50) C1713 152.00$ 1816461 SUTURE (11-50) 152.00$ 1816479 PMKR DUAL CHAMBER RR (3501-4500) C1785 10,666.00$ 1816495 AICD DUAL CHAMBER (16001-18000) C1721 38,382.00$ 1816503 HIP JOINT DEVICE (5501-7000) C1776 15,462.90$ 1816511 LIGASURE ENDOSCOPIC HANDPIECE 953.00$ 1816537 ALLOGRAFT (2501-3500) 8,534.00$ 1816545 GEN NEURO RCHG BAT&CHG SYS (20-22K) C1820 46,909.90$ 1816586 KIT CHARGING SYSTEM (2001-2500) 6,935.00$ 1816594 LEAD PMKR OTHER THAN TRNS (251-500) C1898 1,613.20$ 1816628 BUR (151-200) 857.00$ 1816636 WANG TRANS BRONCH NEEDLE 152.00$ 1816669 OBTURATOR SET (51-100) 475.00$ 1816677 SEAL SET 667.00$ 1816792 CRANIAL ACCESS KIT (251-500) 1,613.20$ 1816834 ADHESIVE SKIN CLOSURE (51-100) 475.00$ 1816859 CORD ENDOSCOPIC (11-50) 152.00$ 1817022 TRANSDUCER (11-50) 475.00$ 1817121 CAUTERY, KNIFE ELECTRODE (51-100) 474.90$ 1817139 SUPPLY SURGICAL DISP (251-500) 1,613.00$ 1817568 CATH BALLOON DIL NON VASC (151-200) C1726 856.60$ 1817667 ORTHO GUIDEWIRE (251-500) 1,613.00$ 1817840 ORTHOSIS ANKLE/FOOT (11-50) L4396 282.00$ 1818053 DRAIN BLAKE (51-100) 474.90$ 1818236 SUTURE ABSORB (11-50) 152.00$ 1818285 CANNULA KNEE CLEAR THREAD 111.00$ 1818293 CANNULA (11-50) 132.00$ 1818319 BONE GRAFT VITOSS (2501-3500) C1713 8,139.00$ 1818392 VACURETTE STRAIGHT 32.00$ 1818400 VACURETTE CURVED 61.00$ 1818418 STAPLER PURSESTRING 272.00$ 1818434 TUBE CHEST STRAIGHT 29.00$ 1818442 DRAIN CHEST TUBE WATER SEAL SYS A7041 436.00$ 1818459 MESH IMPLANT (201-250) C1781 1,045.00$ 1818467 SPECULUM GYNOVA 26.00$ 1818517 INSTRUMENT SURGICAL DISP (751-1K) 3,139.00$

1818764 CATHETER MALECOT 70.00$ 1818772 CAUTERY EXTENDED TEFLON TIP 21.00$ 1818814 CATHETER GUIDING (51-100) C1887 195.00$ 1818822 STIMULATION CABLE (11-50) 152.00$ 1818855 BLADE BEAVER (11-50) 152.00$ 1818871 TROCAR LAPAROSCOPY DYNAMICS 12.00$ 1818897 DRILL BIT BIOMET QUICK RELEASE 148.00$ 1818913 ORTHO WASHER (51-100) C1713 475.00$ 1818939 TIP INSERTER (51-100) 475.00$ 1819028 TROCAR LAPROSCOPIC 152.00$ 1819036 WAND, ABLATION NOVASURE 4,803.00$ 1819077 SET IV NITROGLYCERIN 24.00$ 1819127 EVENT RECORDER CARDIAC (3.5-4.5K) C1764 10,665.90$ 1819143 GUIDEWIRE URO SENSOR 21.00$ 1819150 TUBING ASPIRATION BERKELEY 33.00$ 1819176 APPLIER ENDO CLIP 942.69$ 1819184 TROCAR 11MM VERSASTEP 589.00$ 1819200 PMKR DUAL CHAMBER RR (4501-5500) C1785 12,798.00$ 1819226 TROCAR VERSASTEP 589.00$ 1819259 STAPLER RELOAD ENDO 785.00$ 1819309 HANDLE ENDO GIA UNIVERSAL 819.00$ 1819317 GRASPER ENDO (51-100) 474.90$ 1819333 NEEDLE INSUFFLATION 220.00$ 1819358 MORCELLATOR (501-750) C1782 2,780.00$ 1819366 DEVICE CAPSULE DELIVERY ADV 478.00$ 1819432 GRAFT TISSUE HUMAN (1.5-2K) 5,869.00$ 1819457 GRAFT TISSUE HUMAN (1-1.5K) 4,803.00$ 1819465 GRAFT TISSUE HUMAN (151-200) 856.60$ 1819499 GRAFT TISSUE HUMAN (251-500) 1,613.20$ 1819507 GRAFT TISSUE HUMAN (501-750) 2,780.00$ 1819515 GRAFT TISSUE HUMAN (751-1K) 3,742.00$ 1819523 GRAFT TISSUE HUMAN (2.5-3.5K) 8,534.00$ 1819531 GRAFT TISSUE HUMAN (3.5-4.5K) 10,665.90$ 1819549 MESH IMPLANT (1001-1500) C1781 4,803.00$ 1819572 PT PROGRAM NEUROSTIMULATOR (1-1.5K) C1787 4,803.00$ 1819580 GEN NEURO NON-RECHARG (14-16K) C1767 34,117.90$ 1819614 PORT SILS 5MM 1,405.00$ 1819622 KNIFE/CURETTE WHITNEY CEMENT 86.00$ 1819630 SNARE COOK DUCKBILL 122.00$ 1819648 GUHL ANKLE DISTRACTOR 127.00$ 1819705 GRASPER ENDO (201-250) 1,045.00$ 1819747 SUTURE NON-ABSORB PROLENE 147.00$ 1819796 SUTURE NON-ABSORB PROLENE 147.00$ 1819804 BLADE PRECISION CARTG 1,051.00$ 1819838 DEVICE TARGETING HANDLE 1,008.00$ 1819853 ORTHO GUIDEWIRE (51-100) 475.00$ 1819887 HYDRODEBRIDER 840.00$ 1819895 ENDOBUTTON (251-500) C1713 1,613.20$

1819937 INSERTER (151-200) 856.60$ 1819986 TUBE TRACH (51-100) 475.00$ 1820018 REAMER (501-750) 1,550.00$ 1820042 DRILL BIT 318.00$ 1820109 SUTURE ANCHOR (251-500) C1713 1,477.00$ 1820141 PIN STEINMAN (11-50) C1713 354.00$ 1820182 CATHETER INTRASPINAL C1755 474.90$ 1820190 STAPLER RELOAD CONTOUR 561.00$ 1820208 SPIDER BAR 374.00$ 1820240 NEEDLE SHORT BEVEL 68.00$ 1820257 NEEDLE TOUHY 31.00$ 1820265 CATHETER EPIDURAL 83.00$ 1820273 LINE MINIBORE EXTENSION 16.00$ 1820299 TRAY SPINAL 152.00$ 1820323 GRAFT BONE PUTTY (1501-2000) C1713 5,869.00$ 1820331 BONE PUTTY DBM (1-1.5K) 4,803.00$ 1820380 DERMATOME PADGETT BLADE 121.00$ 1820406 PLASMA COAG SUPPL (201-250) 1,045.00$ 1820414 DRILL BIT (151-200) 867.00$ 1820422 GUIDEWIRE URO LUBRIGUIDE 103.00$ 1820430 LENS IOL C1780 (101-150) C1780 667.40$ 1820471 FLEXOR DUAL LUMAN (151-200) 631.00$ 1820570 AXXCESS CATH 46.00$ 1820620 BALLOON GYN UTERINE THERAPY 1,114.00$ 1820646 CAUTERY GYN LOOP RESECT ELECT 943.00$ 1820679 GRAFT BONE INFUSE (2501-3500) 8,534.00$ 1820695 GUIDEWIRE URO SENSOR 150.00$ 1820760 HOOD ORTHO T5 PEEL AWAY FACE 126.00$ 1820778 SET QUICK PRESSURE MONITOR 150.00$ 1820786 RETRACTOR (11-50) 152.00$ 1820844 SUTURE REGULAR 91.00$ 1820943 MESH IMPLANT (12001-14000) C1781 28,788.00$ 1821008 KIT SURGICAL DISP (501-750) 2,780.00$ 1821099 AICD DUAL CHAMBER (20001-22000) C1721 46,910.00$ 1821107 AICD DUAL CHAMBER (22001-24000) C1721 51,174.00$ 1821180 TISSEEL 2ML 649.00$ 1821206 TISSEEL 4ML 649.00$ 1821230 LEAD AICD ENDO SNGLE COIL(2.5-3.5K) C1777 8,534.00$ 1821248 LEAD AICD ENDO SNGLE COIL(3.5-4.5K) C1777 10,665.90$ 1821388 PMKR SINGLE RATE-RESP (4501-5500) C1786 12,798.00$ 1821396 PMKR SINGLE RATE-RESP (5501-7000) C1786 15,463.00$ 1821404 PMKR SINGLE RATE-RESP (3501-4500) C1786 12,475.00$ 1821438 SHEATH/INTRO FIX PEEL-AWAY (11-50) C1892 328.00$ 1821446 LEAD CARD-DEFIB DUAL COIL(3.5-4.5K) C1895 10,665.90$ 1821529 EVENT RECORDER CARDIAC (4.5-5.5K) C1764 12,797.90$ 1821651 GEN NEURO RCHG BAT&CHG SYS (14-16K) C1820 34,117.90$ 1821677 ADAPT/EXT PACE/NEURO LEAD (1501-2K) C1883 7,718.00$ 1821685 PT PROGRAM NEUROSTIMULATOR (751-1K) C1787 3,742.00$

1821735 CATH FOGARTY EMBOLECT 5.5 FR 671.00$ 1821743 INSTRUMENT SURGICAL DISP (11-50) 152.00$ 1821750 BALOON HALO SIZING 34MM 1,232.00$ 1821768 CAP HALO SMALL 94.00$ 1821776 CATH ABLATION (1501-2000) C1886 5,869.00$ 1821834 LEAD AICD ENDO SNGLE COIL(4.5-5.5K) C1777 12,797.90$ 1821842 CLIP RANEY 126.00$ 1821859 KIT, CRANIOPLASTIC C1713 4,875.00$ 1821867 BUR (101-150) 667.00$ 1821875 KIT DURASEAL (501-750) 2,780.00$ 1821909 MAMMOSITE RADIATION TX SYS C1728 7,350.00$ 1821925 CLIP LIGATION (11-50) 152.00$ 1821958 GELPORT 2,266.00$ 1821966 LAP SAC 163.00$ 1821974 STAPLER ENDO GIA 45 ATS45 856.00$ 1821982 CANNULA O2/CO2 (11-50) 112.00$ 1821990 CATHETER HALO 90 ABLATION 3,360.00$ 1822006 SUTURE, TELEFLEX CO-BRAID BL 5 110.00$ 1822121 CATHETER HEMODIALYSIS 2 LUMEN C1750 723.00$ 1822139 GUIDE WIRE (51-100) C1769 474.90$ 1822188 ORTHO SCREW (4501-5500) C1713 12,798.00$ 1822196 KIT DRILL & PIN ZIMMER 164.00$ 1822246 GUIDE PIN PT SPEC (1001-1500) 4,803.00$ 1822279 GUIDE WIRE (11-50) C1769 152.00$ 1822287 TEMP FIXATION (101-150) 667.00$ 1822295 GUIDE PIN BIOMET OXFORD 1,613.20$ 1822303 GRAFT BONE HUMAN(1001-1500) 4,803.00$ 1822394 INTRODUCER RUSCH SUPRAPUBIC CA 65.00$ 1822485 GSTMY BUTTON BARD 24FR X 3.4CM 540.00$ 1822535 ADAPT/EXT PACE/NEURO LEAD (751-1K) C1883 3,742.00$ 1822576 CATH HEMO/PERI SHORT-TERM C1752 198.00$ 1822600 AICD NON SINGLE OR DUAL (22-24K) C1882 51,174.00$ 1822618 KIT, BONE PREP 132.00$ 1822626 RETREIVER POLYP 252.00$ 1822634 RETREIVER FOREIGN BODY STD 51.00$ 1822642 NEEDLE CARR-LOCKE INJECTION 287.00$ 1822691 CAUTERY LOOP LINA GOLD MED 980.00$ 1822717 STAPLER ENDO LOAD GIA (251-500 1,329.00$ 1822766 REAMER, LO PRO ARTHREX 667.00$ 1822774 TROCAR VERSAPORT (11-50) 152.00$ 1822782 TROCAR BLADELESS FIX (11-50) 152.00$ 1822808 TROCAR BLADELESS LP (11-50) 152.00$ 1822824 TROCAR BLTPRT (11-50) 152.00$ 1822832 PLUG, BONE FOR CANAL C1713 561.00$ 1822840 SHEARS (51-100) 475.00$ 1822857 NEEDLE, SURGI 60.00$ 1822865 DEVICE SPEC RTRVL ENDO CATCH 191.00$ 1822881 SUTURE ABSORBABLE (11-50) 152.00$

1822899 CAUTERY, LOOP (51-100) 474.90$ 1822907 CAUTERY, ROLLER BALL (51-100) 474.90$ 1822915 CAUTERY, VAPORTRODE GROOVED GY 367.00$ 1822923 CAUTERY, KNIFE ELECTRODE GYRUS 276.00$ 1822931 CAUTERY, CABLE GYRUS UROLOGY 65.00$ 1822972 NEEDLE, INTERSTIM MEDTRONIC 152.00$ 1823004 ORTHO PLATE (751-1000) C1713 3,742.00$ 1823012 SLEEVE, SHOULDER TRACTION ROTA 520.00$ 1823061 GRAFT BONE INFUSE (4501-5.5K) 12,797.90$ 1823079 CLIP GAMMA3 CLOSED TUBE 532.00$ 1823087 CTH BALN TISS DIS NO VASC (251-500) C1727 1,568.00$ 1823129 CATH VENTRICULAR (251-500) 1,613.20$ 1823178 VALVE SYSTEM HYDROCEPHALIC (1-1.5K) 6,580.00$ 1823186 ORTHO PLATE (501-750) C1713 2,780.00$ 1823202 DRESSING NASAL NASOPORE 125.00$ 1823236 TUBING INSUFFLATION (51-100) 475.00$ 1823244 DRAIN CONSTAVAC ORTHO 190.00$ 1823251 DRAIN PVC ROUND W TROCAR 165.00$ 1823269 BLADE SAW (11-50) 152.00$ 1823293 BUR (11-50) 239.00$ 1823319 TWIST-LOCK CABLE (51-100) 152.00$ 1823483 BALLOON SPIN SINUPLASTY SYS 6,484.00$ 1823491 KNEE JOINT DEVICE (1501-2000) C1776 5,869.00$ 1823517 KIT REVISION NEURO STIM(251-500) C1778 1,613.20$ 1823525 COUNTERSINK (151-200) 856.60$ 1823533 STAPLER DEVICE (751-1000) 2,331.00$ 1823541 BLADE PLASMABLADE (201-250) 1,045.00$ 1823558 AICD NON SINGLE OR DUAL (20-22K) C1882 46,910.00$ 1823574 BONE FILLER (251-500) C1713 2,086.00$ 1823582 TOOL TUNNELING (251-500) 899.00$ 1823590 BREAST IMPLANT (201-250) C1789 723.00$ 1823632 GRAFT BONE FILLER (751-1000) C1713 3,742.00$ 1823640 IOL POSTERIOR CHAMBER (751-1000) V2632 3,742.00$ 1823657 NEEDLE SCORPION MULTIFIRE 838.00$ 1823665 EXTERNAL FIXATION DEV (751-1000) 3,742.00$ 1823723 PLASMA COAG SUPPL (11-50) 152.00$ 1823731 PLASMA COAG SUPPL (251-500) 1,613.00$ 1823756 CATH ABLATION (2001-2500) C1886 6,935.00$ 1823764 AICD SINGLE CHAMBER (14001-16000) C1722 37,118.00$ 1823822 EXTERNAL FIXATION DEV (101-150) 667.40$ 1823830 DRILL BIT (501-750) 2,184.00$ 1823848 ENDO CLIP 234.00$ 1823863 HC-GRAFTJACKET 4X8 Q4107 9,438.00$ 1823871 TUBING INSUFLOW 273.00$ 1823897 CATH BALLOON DIL NON VASC (751-1K) C1726 3,742.00$ 1823913 SNARE POLY LOOP DEVICE 253.00$ 1823921 BONE FILLER (2501-3500) C1713 8,139.00$ 1823939 CATH ABLATE NON-CARD ENDO (1-1.5K) C1888 4,803.00$

1823947 SNARE 25 GA ISNARE NDL HEX ESCP STR 433.00$ 1823954 HC-INTGRA MESH BILYR MTRX 4X5CM(20) C9363 13,110.00$ 1823962 KIT: D-HELP ENDO LENS PROTECTOR 135.00$ 1823970 IMP LEAD NEUROSTIM (1001-1500) C1778 4,803.00$ 1823988 IMPL INJEX NEUROSTIM ANCHOR BUMPY C1713 688.00$ 1823996 NEEDLE STIMUPLEX 22G X 4IN 125.00$ 1824002 ENVELOPE PACEMAKER ANTI-BACTERIAL 2,488.00$ 1824036 ANOSPEC DISPOSABLE DEVICE 20.00$ 1824044 BREAST IMPLANT (501-750) C1789 2,866.00$ 1824051 PERMACOL IMP 10X15CM (150) C9364 9,648.00$ 1824077 MESH IMPLANT (4501-5500) C1781 12,798.00$ 1825082 CTH BALN TISS DIS NO VASC (1.5-2K) C1727 5,869.00$ 1825090 PLASMA-LYTE A 1000ML BAG 294.00$ 1825108 TOE JOINT DEVICE (1501-2000) C1776 5,869.00$ 1825116 AMNIOTIC MEMBRANE (1001-1500) V2790 5,336.00$ 1825132 KNEE JOINT DEVICE (2001-2500) C1776 6,935.00$ 1825140 CATH BALLOON DIL NON VASC (251-500) C1726 1,568.00$ 1825157 CATH BALLOON DIL NON VASC (11-50) C1726 132.00$ 1825165 HIP JOINT DEVICE (3501-4500) C1776 10,665.90$ 1825173 HIP JOINT DEVICE (2001-2500) C1776 6,935.00$ 1825181 HIP JOINT DEVICE (2501-3500) C1776 8,534.00$ 1825199 HIP JOINT DEVICE (1001-1500) C1776 4,803.00$ 1825207 HIP JOINT DEVICE (1501-2000) C1776 5,869.00$ 1825215 REP DEV URIN W/SLING GRFT (1-1.5K) C1771 3,999.00$ 1825231 HC-EPIFIX 2X4CM (8) Q4131 4,018.00$ 1825256 KNEE JOINT DEVICE (751-1000) C1776 3,742.00$ 1825264 ORTHO NAIL (1501-2000) C1713 5,869.00$ 1825272 KNEE JOINT DEVICE (2501-3500) C1776 8,534.00$ 1825280 KNEE JOINT DEVICE (1001-1500) C1776 4,803.00$ 1825298 HIP JOINT DEVICE (501-750) C1776 2,780.00$ 1825306 HIP JOINT DEVICE (751-1000) C1776 3,742.00$ 1825330 GASTRO/JEJUNO TUBE (201-250) B4087 1,049.00$ 1825348 CATHETER DRAINAGE (101-150) C1729 667.40$ 1825355 CATH EP DX/AB NO 3D/COOL TIP(2-2.5) C1733 6,935.00$ 1825363 CATH TRANS ANGIO NO-LASER (251-500) C1725 1,802.67$ 1825371 HIP JOINT DEVICE (51-100) C1776 474.90$ 1825389 HC-ALLODERM THK RTU 132CMX2 (264) Q4116 15,568.00$ 1825397 STENT NON-COR TEMP W/DEL (501-750) C2625 2,780.00$ 1825405 OR CARDIAC RATE INITIAL 30 MIN 3,432.00$ 1825413 OR CARDIAC RATE ADDL 15 MIN 343.00$ 1825421 CATH TRANS ANGIO NO-LASER (51-100) C1725 251.00$ 1825439 PACEMAKER SINGLE NON RATE(3.5-4.5K) C2620 10,666.00$ 1825447 HIP JOINT DEVICE (251-500) C1776 1,613.20$ 1825454 PACEMAKER DUAL NON RATE (14-16K) C2619 34,118.00$ 1825462 AMNIOTIC MEMBRANE (751-1000) V2790 4,059.00$ 2000008 XR EXAM NECK SOFT TISSUE 70360 376.00$ 2000016 XR EXAM CHEST SINGLE VIEW 71045 376.00$ 2000024 XR EXAM CHEST 2 VIEWS 71046 376.00$

2000057 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 2000065 XR EXAM SPINE CERVICAL 6+ VIEWS 72052 623.00$ 2000073 XR EXAM SPINE THORACIC 2 VW (FY) 72070 623.00$ 2000107 XR EXAM SPINE LUMBOSAC 2-3 VW (FY) 72100 623.00$ 2000115 XR EXAM SPINE LUMBOSAC 4+ VW (FY) 72110 623.00$ 2000123 XR EXAM PELVIS 1 OR 2 VW (FY) 72170 623.00$ 2000131 XR EXAM SACRUM & COCYX MN 2 VW (FY) 72220 376.00$ 2000222 XR EXAM HAND MINIMUM 3 VIEWS (FY) 73130 376.00$ 2000297 XR EXAM KNEE 3 VIEWS (FY) 73562 376.00$ 2000313 XR EXAM BOTH KNEES STANDING AP (FY) 73565 376.00$ 2000396 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 2000404 XR EXAM ABDOMEN 3+ VIEWS (FY) 74021 376.00$ 2000446 XR EXAM SKULL COMPLETE 4+ VIEWS 70260 623.00$ 2000453 XR EXAM NASAL BONES MIN 3 VIEWS 70160 376.00$ 2000479 XR EXAM SKULL LESS THAN 4 VIEWS 70250 623.00$ 2000487 XR EXAM RIBS 2 VIEWS UNI LT 71100 376.00$ 2000495 XR EXAM RIBS 2 VIEWS UNI RT 71100 376.00$ 2000503 XR EXAM RIBS/CHEST 3+ VWE UNI LT 71101 623.00$ 2000511 XR EXAM RIBS/CHEST 3+ VWE UNI RT 71101 623.00$ 2000529 XR EXAM CLAVICLE COMP LT (FY) 73000 376.00$ 2000537 XR EXAM CLAVICLE COMP RT (FY) 73000 376.00$ 2000545 XR EXAM SHOULDER MIN 2 VW LT (FY) 73030 376.00$ 2000552 XR EXAM SHOULDER MIN 2 VW RT (FY) 73030 376.00$ 2000560 XR EXAM HUMERUS MIN 2 VW LT (FY) 73060 376.00$ 2000578 XR EXAM HUMERUS MIN 2 VW RT (FY) 73060 376.00$ 2000586 XR EXAM ELBOW 2 VW LT (FY) 73070 376.00$ 2000594 XR EXAM ELBOW 2 VW RT (FY) 73070 376.00$ 2000602 XR EXAM ELBOW COMP MIN 3 VW LT (FY) 73080 376.00$ 2000610 XR EXAM ELBOW COMP MIN 3 VW RT (FY) 73080 376.00$ 2000628 XR EXAM FOREARM 2 VW LT (FY) 73090 376.00$ 2000636 XR EXAM FOREARM 2 VW RT (FY) 73090 376.00$ 2000644 XR EXAM WRIST 2 VW LT (FY) 73100 376.00$ 2000651 XR EXAM WRIST 2 VW RT (FY) 73100 376.00$ 2000669 XR EXAM WRIST 2 VW LT (FY) 73100 376.00$ 2000685 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 2000693 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 2000701 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 2000719 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 2000727 XR EXAM HAND 2 VIEWS LT (FY) 73120 623.00$ 2000735 XR EXAM HAND 2 VIEWS RT (FY) 73120 623.00$ 2000743 XR EXAM FNGR(S) MIN 2 VW LT (FY) 73140 376.00$ 2000750 XR EXAM FNGR(S) MIN 2 VW RT (FY) 73140 376.00$ 2000768 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 2000776 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 2000784 XR FEMUR 2+ VIEWS LT (FY) 73552 376.00$ 2000792 XR FEMUR 2+ VIEWS RT (FY) 73552 376.00$ 2000800 XR EXAM KNEE 1-2 VIEWS LT (FY) 73560 376.00$ 2000818 XR EXAM KNEE 1-2 VIEWS RT (FY) 73560 376.00$

2000883 XR EXAM KNEE COMPLETE 4+ VW LT (FY) 73564 623.00$ 2000891 XR EXAM KNEE COMPLETE 4+ VW RT (FY) 73564 623.00$ 2000925 XR EXAM TIBIA/FIBULA 2 VW LT (FY) 73590 376.00$ 2000933 XR EXAM TIBIA/FIBULA 2 VW RT (FY) 73590 376.00$ 2000941 XR EXAM ANKLE 2 VIEWS LT (FY) 73600 376.00$ 2000958 XR EXAM ANKLE 2 VIEWS RT (FY) 73600 376.00$ 2000966 XR EXAM ANKLE COMP 3 VW LT (FY) 73610 376.00$ 2000974 XR EXAM ANKLE COMP 3 VW RT (FY) 73610 376.00$ 2000982 XR EXAM FOOT 2 VIEWS LT (FY) 73620 376.00$ 2000990 XR EXAM FOOT 2 VIEWS RT (FY) 73620 376.00$ 2001006 XR EXAM FOOT COMP MIN 3 VW LT (FY) 73630 376.00$ 2001014 XR EXAM FOOT COMP MIN 3 VW RT (FY) 73630 376.00$ 2001022 XR EXAM HEEL MIN 2 VIEWS LT (FY) 73650 376.00$ 2001030 XR EXAM HEEL MIN 2 VIEWS RT (FY) 73650 376.00$ 2001048 XR EXAM TOE(S) MIN 2 VIEWS LT (FY) 73660 376.00$ 2001055 XR EXAM TOE(S) MIN 2 VIEWS RT (FY) 73660 376.00$ 2001063 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 2001071 XR EXAM HIP W/PELV UNI 2-3V LT (FY) 73502 376.00$ 2001105 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 2001113 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 2001121 XR EXAM HIPS/PELV BILAT 2V (FY) 73521 623.00$ 2001139 XR EXAM HIPS/PELV BILAT 3-4V (FY) 73522 623.00$ 2400000 HEMODIALYSIS WITH PHYS EVAL 90935 3,442.00$ 2400018 UNSCHEDULED DIALYSIS TX ESRD G0257 3,596.00$ 2400034 DIALYSIS PERITONEAL O/P 1 EVAL 90945 2,046.00$ 2800043 RESP FUNCTION 1 PT PER 15 MIN G0238 347.00$ 2800068 RESP STRENGTH/ENDURANCE 1 PT 15 MIN G0237 189.00$ 2800183 RESP FUNCTION GROUP PER 15 MN G0239 189.00$ 2800241 PULMONARY REHAB W/EXER PER HR G0424 329.00$ 2900041 ELECTROCARDIOGRAM 12/TRACE NO RPT 93005 347.00$ 2900066 ECHO TEE COMPLETE W/INT & REPORT 93312 4,324.00$ 2900108 EVAL CARDIO W/TILT TABLE (STAT) 93660 2,676.00$ 2900116 CARDIOVASC STRESS TEST TRACE ONLY 93017 1,364.00$ 2900173 EEG AWAKE/ASLEEP W/RECORDING 95819 1,364.00$ 2900199 EEG CEREBRAL DEATH EVALUATION ONLY 95824 2,454.00$ 2900215 2D ECHO WITH CONTRAST C8929 4,152.00$ 2900231 AEROCHAMBER 155.37$ 2900249 BLOOD GASES ANY COMBINATION 82803 113.00$ 2900256 RESP THER TIME PER 15 MIN (STAT) -$ 2900264 GASSES BLOOD PH ONLY 82800 48.00$ 2900272 CARDIOPULMONARY RESUSCITATION 92950 1,364.00$ 2900355 AIRWAY INHALATION TREATMENT INITIAL 94640 925.00$ 2900397 VENTILATION MGMT INITIAL DAY 94002 2,829.00$ 2900405 CONTINUOUS TX W/MED FIRST HOUR 94644 604.00$ 2900520 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 2900538 IN-LINE SUCTION CATHETER 104.00$ 2900561 CARBON MONOXIDE (DLCO) CAPACITY 94729 209.00$ 2900579 PULMONARY STRESS TESTING 94618 565.00$

2900587 METANEB CIRCUIT SYS (51-100) 272.00$ 2900637 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 2900645 I.S. SET UP EXERCISE 360.00$ 2900678 CONT PRESSURE CPAP INIT & MGMT INIT 94660 925.00$ 2900686 CONT PRESSURE CPAP INIT & MGMT SUB 94660 925.00$ 2900694 PULSE OXIMETRY OVERNIGHT CONTINUE 94762 802.00$ 2900728 DEMO/EVAL PT USE OF INHALER 94664 925.00$ 2900736 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 2900744 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 2900769 PULSE OXIMETRY SATURATION 1 LEVEL 94760 79.00$ 2900777 PULSE OXIMETRY SATURATION 1+ LEVELS 94761 110.00$ 2900819 VITAL CAPACITY TOTAL 94150 802.00$ 2900835 SPMTRY W/VC EXP FLOW W/WO MX VOL 94010 802.00$ 2900843 MANIPULATE CHEST WALL DEMO/EVAL 94667 565.00$ 2900850 SPIROMETRY/PFT PRE & POST BRONCH 94060 1,364.00$ 2900876 AIRWAY INHALATION TREATMENT INITIAL 94640 925.00$ 2900900 CATHETER ASPIRATION NASOTRACHEAL 31720 1,126.32$ 2900926 PLETHYSMOGRAPHY LUNG VOL AIR RESIST 94726 1,364.00$ 2900942 ECHO 2D W/SPEC/COLOR FL M-MODE COMP 93306 2,580.00$ 2900983 MANIPULATE CHEST WALL DEMO/EVAL 94667 565.00$ 2900991 MANIPULATE CHEST WALL SUBSEQUENT 94668 347.00$ 2901007 INTUBATION SUPPLIES 795.00$ 2901023 ARTERIAL PUNCTURE WITHDRAW BLOOD 36600 565.00$ 2901031 HAND HELD NEB CIRC CHANGE 84.00$ 2901049 CONTINUOUS AEROSOL SETUP 546.00$ 2901056 VENTILATOR CIRCUIT CHANGE 216.00$ 2901080 PASSY MUIR VALVE-RESPIRATORY 177.00$ 2901098 BIPAP CIRCUIT CHANGE 382.00$ 2901106 BLOOD GAS O2 SAT ONLY NO PULSE OX 82810 51.00$ 2901114 BIPAP MASK (11-50) 152.00$ 2901122 CONTIN NEB ADDL HR 94645 50.00$ 2901148 VENTILATION MGMT SUBSEQUENT DAY 94003 2,829.00$ 2901205 ASSAY OF LACTATE ACID 83605 63.00$ 2901296 CONT PRESSURE CPAP INIT & MGMT INIT 94660 925.00$ 2901304 CONT PRESSURE CPAP INIT & MGMT SUB 94660 925.00$ 2901361 ANCHOR FAST (11-50) 263.00$ 2901379 SUPPLY SURGICAL DISPOSABLE (11-50) 152.00$ 2901403 BIPAP MASK TOTAL FACE 474.90$ 2901411 BRONCHOSCOPY (ASSIST) PER 15 MIN -$ 2901429 MAX BREATH CAPACITY/MAX VOL VENT 94200 565.00$ 2901445 INS ENDOTRACHAL EMERGENCY PROCEDURE 31500 800.00$ 2901486 SMOK/TOB CESS COUN INTSV >10 MIN 99407 168.00$ 2901494 TRACHEAL SUCTIONING (IN-LINE) -$ 2901502 CPR BY RT PER 15 MIN (STAT) -$ 2901510 RESP THER EDUCATION PER 15 MIN (STA -$ 2901528 INCENTIVE SPIROMETRY BY RT (STAT) -$ 2901536 RT INTERNAL TRANSPORT PER 15 MIN (S -$ 2901544 VENT MGMT: WEANING (STAT) -$

2901551 VENT MGMT: SETTING ADJ (STAT) -$ 2901569 VENT MGMT: CIRCUIT CHANGE (STAT) -$ 2901577 ET TUBE RETAPE/REPOSITION (STAT) -$ 2901635 OR TRANSESOPHAGEAL ECHO ASSIST(STAT -$ 2901650 CONT PRESSURE CPAP INIT & MGMT INIT 94660 925.00$ 2901668 CONT PRESSURE CPAP INIT & MGMT SUB 94660 925.00$ 3600111 EVAL SWALLOW CINE/VID/FLUORO (90) 92611 446.00$ 3600129 EVAL SWALLOW CINE/VID/FLUORO (90) 92611 446.00$ 3600137 EVAL SWALLOW/ORAL FUNCT (30) 92610 442.00$ 3600145 EVAL SWALLOW/ORAL FUNCT (45) 92610 442.00$ 3600152 EVAL SWALLOW/ORAL FUNCT (60) 92610 442.00$ 3600160 EVAL SWALLOW/ORAL FUNCT (75) 92610 442.00$ 3600178 EVAL SWALLOW/ORAL FUNCT (90) 92610 442.00$ 3600244 SPEECH THERAPY (30) 92507 405.00$ 3600251 SPEECH THERAPY (45) 92507 405.00$ 3600269 SPEECH THERAPY (60) 92507 405.00$ 3600277 SPEECH THERAPY (75) 92507 405.00$ 3600285 SPEECH THERAPY (90) 92507 405.00$ 3600293 TREAT SWALLOW/ORAL FUNCT LIM (15) 92526 445.00$ 3600301 TREAT SWALLOW/ORAL FUNCT LIM (30) 92526 445.00$ 3600319 TREAT SWALLOW/ORAL FUNCT LIM (45) 92526 445.00$ 3600327 TREAT SWALLOW/ORAL FUNCT LIM (60) 92526 445.00$ 3600335 TREAT SWALLOW/ORAL FUNCT LIM (75) 92526 445.00$ 3600343 TREAT SWALLOW/ORAL FUNCT LIM (90) 92526 445.00$ 3602059 TREAT SWALLOW/ORAL FUNCT LIM (120) 92526 445.00$ 3602067 SPEECH THERAPY (105) 92507 405.00$ 3602075 EVAL SWALLOW/ORAL FUNCT (120) 92610 442.00$ 3602109 MC-LANGUAGE EVAL -30 MIN X4300 550.00$ 3602125 MC-LANGUAGE EVAL -60 MIN X4300 550.00$ 3602133 EVALUATION OF SPEECH FLUENCY (15) 92521 571.00$ 3602141 EVALUATION OF SPEECH FLUENCY (30) 92521 571.00$ 3602166 EVALUATION OF SPEECH FLUENCY (60) 92521 571.00$ 3602174 EVALUATE SPEECH PRODUCTION (15) 92522 475.00$ 3602182 EVALUATE SPEECH PRODUCTION (30) 92522 475.00$ 3602190 EVALUATE SPEECH PRODUCTION (45) 92522 475.00$ 3602208 EVALUATE SPEECH PRODUCTION (60) 92522 475.00$ 3602216 EVAL SPEECH SOUND LANG COMPR (30) 92523 1,003.00$ 3602224 EVAL SPEECH SOUND LANG COMPR (45) 92523 1,003.00$ 3602232 EVAL BEHAV\ QUAL ANALYS VOICE (45) 92524 458.00$ 3602240 EVAL SPEECH SOUND LANG COMPR (15) 92523 1,003.00$ 3602257 EVAL SPEECH SOUND LANG COMPR (60) 92523 1,003.00$ 3602265 EVAL BEHAV\ QUAL ANALYS VOICE (15) 92524 458.00$ 3602273 EVAL BEHAV\ QUAL ANALYS VOICE (30) 92524 458.00$ 3602281 EVAL BEHAV\ QUAL ANALYS VOICE (60) 92524 458.00$ 3602356 MC-LANGUAGE EVAL -90 MIN X4300 550.00$ 3602372 MC-SPEECH EVAL -30 MIN X4301 475.00$ 3602380 MC-SPEECH EVAL -45 MIN X4301 475.00$ 3602398 MC-SPEECH EVAL -60 MIN X4301 475.00$

3602406 MC-SPEECH EVAL -75 MIN X4301 475.00$ 3602414 MC-SPEECH EVAL -90 MIN X4301 475.00$ 3602422 MC-INDV SPCH/LANG THERAPY EA 30 MIN X4304 405.00$ 3602455 MC-GRP SPCH/LANG THERAPY-15 MIN X4302 123.00$ 3602463 MC-GRP SPCH/LANG THERAPY-30 MIN X4302 123.00$ 3602471 MC-GRP SPCH/LANG THERAPY-45 MIN X4302 123.00$ 3602489 MC-GRP SPCH/LANG THERAPY-60 MIN X4302 123.00$ 3602497 MC-SPEECH THRPY ADDL TO EVAL-1 HR X4303 722.00$ 4000048 THERAPY PROPH/DX INJ IV PUSH SAME 96376 254.00$ 4000063 THORACENTESIS NDL/CTH PLEURA NO IMG 32554 2,988.00$ 4000071 INSERT PICC W/O SQ PORT/PUMP 5+ YRS 36569 5,337.00$ 4000089 REPLACE PICC W/O PORT/PUMP 36584 5,337.00$ 4000279 INJECTION THER/PROPH/DX SQ/IM 96372 261.00$ 4000287 THER/PROPH/DX INJ IV PUSH 1/INIT 96374 572.00$ 4000303 IRRIGATE IMP VENOUS ACCESS DEVICE 96523 347.00$ 4000592 CHEMO IV INF SINGLE/1ST DRUG <1HR 96413 1,735.00$ 4000600 CHEMO IV INFUSION ADDL HR 96415 261.00$ 4000618 REMOVE CV CATH TUNNEL W/O PORT/PUMP 36589 2,988.00$ 4000626 BLOOD TRANSFUSION 1 HOUR 36430 2,161.00$ 4000634 BLOOD TRANSFUSION 2 HOURS 36430 2,161.00$ 4000642 BLOOD TRANSFUSION 3 HOURS 36430 2,161.00$ 4000659 BLOOD TRANSFUSION 4 HOURS 36430 2,161.00$ 4000667 BLOOD TRANSFUSION 5 HOURS 36430 2,161.00$ 4000675 BLOOD TRANSFUSION 6 HOURS 36430 2,161.00$ 4000683 BLOOD TRANSFUSION 7 HOURS 36430 2,161.00$ 4000691 BLOOD TRANSFUSION 8 HOURS 36430 2,161.00$ 4000717 BLOOD TRANSFUSION 10 HOURS 36430 2,161.00$ 4000733 BLOOD TRANSFUSION 12 HOURS 36430 2,161.00$ 4000824 PHLEBOTOMY THERAPEUTIC 99195 565.00$ 4000857 DEBR NON-SELECTIVE W/O ANES SESSION 97602 729.00$ 4000865 NPWT USING DME RENTAL <=50 SQ CM 97605 729.00$ 4000873 NPWT USING DME RENTAL >50 SQ CM 97606 729.00$ 4000972 IV INF THER HYDRATIN INIT 31-60 MIN 96360 572.00$ 4000980 IV INF THER HYDRATION EA ADDL HOUR 96361 191.00$ 4000998 IV INF THER PROP/DX INIT UP TO 1HR 96365 1,072.00$ 4001004 IV INF THER/PROP/DX EA ADDL HR 96366 191.00$ 4001012 IV INF THER/PRO/DX ADDL SEQ NEW 1HR 96367 261.00$ 4001053 PROLONGED IV INF REQ PUMP:8HRS C8957 1,695.00$ 4001079 THER/PROPH/DXINJ IV PUSH ADDL SEQ 96375 261.00$ 4001087 CHEMO ADMN SUBQ/IM NO HORM ANTI NEO 96401 572.00$ 4001178 MED/SUR OBS DIRECT ADMIT G0379 305.00$ 4001186 MED/SUR OBSERVATION: HOURS G0378 305.00$ 4001251 DRAINAGE OF SCROTAL WALL ABSCESS 55100 5,830.00$ 4001269 CARDIOPULMONARY RESUSCITATION 92950 1,364.00$ 4001277 IMMUNIZATION ADMIN 1 VACCINE 90471 5.00$ 4001293 INTMD RPR FACE/MM 5.1-7.5 CM 12053 1,397.00$ 4001335 UNLISTED ABD/PERITONEUM/OMENTUM 49999 4,477.00$ 4001343 NPWT W/DISP VAC >=50 SQ CM 97608 1,397.00$

4001350 I & D ABSCESS SIMPLE OR SINGLE 10060 729.00$ 4300000 US ABDOMINAL REAL TIME COMPLETE 76700 950.00$ 4300018 US ABDOMINAL REAL TIME COMPLETE 76700 950.00$ 4300026 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 4300059 US ABDOMINAL REAL TIME COMPLETE 76700 950.00$ 4300067 US ABDOMINAL REAL TIME LIMITED 76705 950.00$ 4300091 FLUORO ABSCESS DRAIN/SPECIMN COLL 75989 506.00$ 4300117 US ABDOMINAL REAL TIME LIMITED 76705 950.00$ 4300125 US EXAM PELVIC (NON OB) COMPLETE 76856 950.00$ 4300133 US BREAST UNILAT REAL TIME COMP BI 76641 1,140.00$ 4300158 US CHEST W/MEDIASTINUM REAL TIME 76604 570.00$ 4300174 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 4300182 US EXAM TRANSVAGINAL NON OB 76830 950.00$ 4300190 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 4300208 THORACENTESIS NDL/CTH PLEURA W/IMG 32555 2,988.00$ 4300224 US RETROPERITONEAL REAL TIME LIM 76775 950.00$ 4300232 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 4300281 US ECHOENCEPHALOGRAPHY 76506 570.00$ 4300307 US INFANT HIPS REAL TIME DYNAMIC 76885 570.00$ 4300331 US FETAL BIOPHYSICAL PROFLE W/O NST 76819 950.00$ 4300356 US ABD PARACENTESIS GUIDANCE 49083 2,988.00$ 4300364 US EXAM PELVIC (NON OB) COMPLETE 76856 950.00$ 4300372 US EXAM PELVIC (NON-OB) LIMITED 76857 570.00$ 4300406 US SCROTUM AND CONTENTS 76870 950.00$ 4300422 US GUIDED NEEDLE PLACE BIOPSY 76942 290.00$ 4300430 US EXAM HEAD/NECK REAL TIME 76536 950.00$ 4300448 US PREGNANCY <14 WKS SING/1ST GEST 76801 950.00$ 4300455 US PREGNANCY <14 WKS EA ADD GEST 76802 261.00$ 4300471 US PREGNANT UTERUS LIMITED FETUS(S) 76815 950.00$ 4300497 US PREGNANT UTERUS TRANSVAGINAL 76817 950.00$ 4300505 US PREGNANCY DETAILED SING/1ST GEST 76811 950.00$ 4300513 US PREGNANCY DETAILED EA ADD GEST 76812 516.00$ 4300521 US BREAST UNILAT REAL TIME COMP LT 76641 570.00$ 4300539 US BREAST UNILAT REAL TIME COMP RT 76641 570.00$ 4300588 US GUIDED NEEDLE PLACE BIOPSY LT 76942 290.00$ 4300596 US GUIDED NEEDLE PLACE BIOPSY RT 76942 290.00$ 4300604 US RETROPERITONEAL REAL TIME COMP 76770 950.00$ 4300612 US EXTREMITY NONVASCULAR COMP LT 76881 950.00$ 4300620 US EXT NON VASC LIM ANATMY SPEC LT 76882 570.00$ 4300638 US EXTREMITY NONVASCULAR COMP RT 76881 950.00$ 4300646 US EXT NON VASC LIM ANATMY SPEC RT 76882 570.00$ 4300679 DUPLEX SCAN EXTRACRANIAL COMP BI 93880 950.00$ 4300687 DUP-SCAN XTR VEINS COMP BILAT STUDY 93970 950.00$ 4300695 DUP-SCAN XTR VEINS COMP BILAT STUDY 93970 950.00$ 4300703 DUPLEX VENOUS EXT UNILAT/LMTD LT 93971 950.00$ 4300711 DUPLEX VENOUS EXT UNILAT/LMTD RT 93971 950.00$ 4300745 DUPLEX VENOUS EXT UNILAT/LMTD LT 93971 950.00$ 4300752 DUPLEX VENOUS EXT UNILAT/LMTD RT 93971 950.00$

4300778 US SPINAL CANAL AND CONTENTS 76800 570.00$ 4330734 BX BREAST 1ST LSN DVC ULTRASOUND 19083 5,830.00$ 4330742 BX BREAST EA ADD LSN DVC US 19084 299.00$ 4330759 US PERC BREAST DEV 1ST LSN 19285 2,975.00$ 4600219 CAL TRMT INITIAL (30) MCLON 349.00$ 4600227 CAL TRMT ADD'L (15) MCLON 173.00$ 4600276 THERAPEUTIC EXERCISE EA 15 MINUTES 97110 169.00$ 4600284 MANUAL TECH 1+ REGIONS EA 15 MIN 97140 156.00$ 4600292 APPL MODALITY 1+ AREA US EA 15 MIN 97035 65.00$ 4600300 APPL MODALITY 1+ AREA ELECT UNATTND 97014 173.00$ 4600318 THERAPEUTIC ACTIVITIES EA 15 MIN 97530 185.00$ 4600359 SELF CARE MANAGE TRAIN EA 15 MIN 97535 186.00$ 4600441 CAL OT EVAL INITIAL:30MIN MCLON 443.00$ 4600458 CAL OT EVAL EACH ADDL:15MIN MCLON 191.00$ 4601720 OT EVAL LOW COMPLEXITY 30 MINUTES 97165 443.00$ 4601738 OT EVAL MOD COMPLEXITY 45 MINUTES 97166 443.00$ 4601746 OT EVAL HIGH COMPLEXITY 60 MINUTES 97167 443.00$ 4601753 OT RE-EVAL EST PLAN CARE 30 MINUTES 97168 282.00$ 5400007 SIMP RPR S/N/AX/GEN/TRNK 2.6-7.5CM 12002 729.00$ 5400023 APPLY MULTI LAYER COMP LOWER LEG 29581 737.00$ 5400031 REMOVAL/BIVALVING ARM/LEG CAST 29705 1,286.00$ 5400080 SIMPLE REPAIR S/N/AX/GEN/TRUNK 2.5 12001 729.00$ 5400106 EXC TR-EXT B9+MARG 1.1-2 CM 11402 2,975.00$ 5400114 DEBRIDE SUBQ TISSUE EA ADD 20 SQ CM 11045 63.00$ 5400130 TRIM NAIL(S) ANY NUMBER 11719 347.00$ 5400148 CHEMICAL CAUTERY OF GRANUL TISSUE 17250 729.00$ 5400155 UPR/LWR EXT ART STDY 1-2 LVL BILAT 93922 565.00$ 5400163 DOPPLER ARTERIAL EXTREMITY COMPLETE 93923 802.00$ 5400171 OFFICE OR OP NEW VISIT APRX 60 MIN G0463 609.00$ 5400189 I & D ABSCESS COMPLICATED/MULTIPLE 10061 1,412.00$ 5400197 PUNCTURE ASP OF ABSC HEMA/BULA/CYST 10160 1,412.00$ 5400213 DEBRIDEMENT SUB TISSUE 1ST 20 SQ CM 11042 1,397.00$ 5400221 DEBRIDE MUSC/FASCIA 1ST 20 SQ CM 11043 2,653.00$ 5400239 DEBRIDE BONE 1ST 20 SQ CM OR LESS 11044 5,830.00$ 5400247 DEBRIDEMENT NAIL(S) ANY METHOD 1-5 11720 332.00$ 5400254 DEBRIDEMENT NAIL(S) ANY METHOD 6+ 11721 347.00$ 5400262 REMOVAL OF NAIL PLATE SINGLE SIMPLE 11730 729.00$ 5400304 APPLY RIGID TOTAL CONTACT LEG CAST 29445 1,378.00$ 5400312 STRAPPING UNNA BOOT RT 29580 737.00$ 5400320 GLUCOSE BLOOD BY MONITORING DEV 82962 13.00$ 5400353 DEBRIDEMENT OPEN WOUND 20 SQCM/< 97597 1,397.00$ 5400361 DEBRIDE OPEN WOUND EA ADDL 20 SQCM 97598 231.00$ 5400379 DEBR NON-SELECTIVE W/O ANES SESSION 97602 729.00$ 5400387 NPWT USING DME RENTAL <=50 SQ CM 97605 729.00$ 5400395 NPWT USING DME RENTAL >50 SQ CM 97606 729.00$ 5400411 OFFICE OR OP EST VISIT APRX 5 MIN G0463 208.00$ 5400429 OFFICE OR OP EST VISIT APRX 10 MIN G0463 259.00$ 5400437 OFFICE OR OP EST VISIT APRX 15 MIN G0463 324.00$

5400445 OFFICE OR OP EST VISIT APRX 25 MIN G0463 406.00$ 5400452 OFFICE OR OP EST VISIT APRX 40 MIN G0463 507.00$ 5400494 PARING/CUT BENIGN LESION SINGLE LSN 11055 729.00$ 5400502 PARING/CUT BENIGN LESION 2 TO 4 LSN 11056 729.00$ 5400510 BIOPSY SKIN LESION SINGLE 11100 -$ 5400585 OFFICE OR OP NEW VISIT APRX 20 MIN G0463 312.00$ 5400593 OFFICE OR OP NEW VISIT APRX 30 MIN G0463 390.00$ 5400601 OFFICE OR OP NEW VISIT APRX 45 MIN G0463 487.00$ 5400619 REMOVAL OF NAIL BED PERMANENT 11750 1,412.00$ 5400627 I & D POSTOPERATIVE WOUND COMPLEX 10180 8,753.00$ 5400635 STRAPPING UNNA BOOT (BILATERAL) 29580 737.00$ 5400668 WOUND PREP F/N/HF/G 1ST 100 SQCM/1% 15004 2,653.00$ 5400684 APPLY MULTI LAYER COMP LOWER LEG BI 29581 1,474.00$ 5400718 EXC TR-EXT MAL+MARG 3.1-4 CM 11604 5,830.00$ 5400726 INTMD RPR S/A/T/EXT 2.6-7.5 CM 12032 1,397.00$ 5400775 UPR/LWR EXT ART STDY 1-2 LVL BILAT 93922 565.00$ 5400783 DOPPLER ARTERIAL EXTREMITY COMPLETE 93923 802.00$ 5400809 BIOPSY SKIN LESION EA ADDITIONAL 11101 -$ 5400825 I & D ABSCESS SIMPLE OR SINGLE 10060 729.00$ 5400833 I & D HEMATOMA SEROMA/FLUID COLLECT 10140 5,830.00$ 5400882 DEBRIDE MUSC/FASCIA EA ADD 20 SQ CM 11046 135.00$ 5400890 DEBRIDE BONE EA ADD 20 SQ CM 11047 235.00$ 5400916 STRAPPING UNNA BOOT LT 29580 737.00$ 5400932 +OFFICE OR OP NEW VISIT APRX 20 MIN G0463 312.00$ 5400940 +OFFICE OR OP NEW VISIT APRX 30 MIN G0463 390.00$ 5400957 +OFFICE OR OP NEW VISIT APRX 45 MIN G0463 487.00$ 5400965 +OFFICE OR OP NEW VISIT APRX 60 MIN G0463 609.00$ 5400999 +OFFICE OR OP EST VISIT APRX 15 MIN G0463 324.00$ 5401005 +OFFICE OR OP EST VISIT APRX 25 MIN G0463 406.00$ 5401013 +OFFICE OR OP EST VISIT APRX 40 MIN G0463 507.00$ 5401047 WND PRP TRK/ARM/LEG 1ST 100 SQCM/1% 15002 9,106.00$ 5401179 DRESS/DEBRID PART THICK BURNS SMALL 16020 729.00$ 5401187 DRESS/DEBRID PART THICK BURNS MED 16025 1,397.00$ 5401203 I & REMOVE FOREIGN BODY COMP 10121 8,753.00$ 5401278 HC APP SKSUB TRK ARM LG 1ST 25SQ CM 15271 9,106.00$ 5401286 HC APP SKSUB TRK ARM LG ADD 25SQ CM 15272 77.72$ 5401294 HC APP SKSUB TRK ARM LG 1ST 100SQCM 15273 13,228.00$ 5401302 HC APP SKSUB TRK ARM LG ADD 100SQCM 15274 205.00$ 5401310 HC APP SKSUB FC HND FT 1ST 25 SQ CM 15275 8,733.00$ 5401328 HC APP SKSUB FC HND FT ADD 25SQ CM 15276 87.00$ 5401336 HC APP SKSUB FC HND FT 1ST 100SQ CM 15277 8,909.00$ 5401344 HC APP SKSUB FC HND FT ADD 100SQ CM 15278 195.00$ 5401583 LC APP SKSUB TRK ARM LG 1ST 25SQ CM C5271 2,839.00$ 5401609 LC APP SKSUB TRK ARM LG 1ST 100SQCM C5273 9,105.00$ 5401625 LC APP SKSUB FC HND FT 1ST 25 SQ CM C5275 2,827.00$ 5401633 LC APP SKSUB FC HND FT ADD 25SQ CM C5276 85.00$ 5401708 TENOTOMY OPN TEND FLEX FOOT 1 OR > 28230 7,720.00$ 5401716 BX BONE OPEN SUPERFICIAL 20240 13,981.00$

5401724 EXCISION TUMOR FACE/SCLP SUBQ <2CM 21011 8,086.00$ 5403878 EPIDM AUTOGFT TRK/A/L 1ST 100 SQ CM 15110 9,106.00$ 5403894 EXC MAL LSN TRUNK/ARM/LEG 2.1-3.0CM 11603 5,830.00$ 5403910 NPWT W/DISP VAC <=50 SQ CM 97607 1,397.00$ 5403928 NPWT W/DISP VAC >=50 SQ CM 97608 1,397.00$ 5403993 REMOVAL BREAST LSN 1 OR MORE 19120 13,540.00$ 5404017 APPLICATION SHORT LEG SPLINT 29515 737.00$ 5404033 TANGENTIAL BX SKIN SINGLE LESION 11102 1,037.00$ 5404041 PUNCH BX OF SKIN SINGLE LESION 11104 1,037.00$ 5404058 INCISIONAL BX SKIN SINGLE LESION 11106 1,846.32$ 5404066 TANGENTIAL BX SKIN EA ADD LSN 11103 107.00$ 5404074 PUNCH BX SKIN EA ADD LESION 11105 126.00$ 5404082 INCISIONAL BX SKIN EA ADD LESION 11107 151.00$ 5404090 CLOSURE WOUND COMPLEX SECONDARY 13160 13,228.00$ 5450028 HYPERBARIC OXYGEN CHAMBR PER 30 MIN G0277 2,808.00$ 5450036 HYPERBARIC OXYGEN CHAMBR PER 30 MIN G0277 784.00$ 5450044 HBO INITIAL 15M FOR MEDI-CAL MCONL 278.00$ 5450051 HBO INIT EA ADD'L 15M FOR MCAL MCONL 278.00$ 5500004 OFFICE OR OP NEW VISIT APRX 10 MIN 99201 250.00$ 5500012 OFFICE OR OP NEW VISIT APRX 20 MIN 99202 312.00$ 5500020 OFFICE OR OP NEW VISIT APRX 30 MIN 99203 390.00$ 5500053 OFFICE OR OP EST VISIT APRX 5 MIN 99211 208.00$ 5500061 OFFICE OR OP EST VISIT APRX 10 MIN 99212 259.00$ 5500079 OFFICE OR OP EST VISIT APRX 15 MIN 99213 324.00$ 5500087 OFFICE OR OP EST VISIT APRX 25 MIN 99214 406.00$ 5500103 IMMUNIZATION ADMIN 1 VACCINE 90471 5.00$ 5500111 AIRWAY INHALATION TREATMENT INITIAL 94640 925.00$ 5500194 REMOVE IMPACTED EAR WAX W/INST UNI 69210 347.00$ 5500202 MCAL PRO FEE LEVEL 1 NEW 223.00$ 5500228 MCAL PRO FEE LEVEL 2 NEW 420.00$ 5500244 MCAL PRO FEE LEVEL 3 NEW 630.00$ 5500301 MCAL PRO FEE LEVEL 1 EST 77.00$ 5500327 MCAL PRO FEE LEVEL 2 EST 211.00$ 5500343 MCAL PRO FEE LEVEL 3 EST 423.00$ 5500368 MCAL PRO FEE LEVEL 4 EST 655.00$ 5500426 XR EXAM ELBOW COMP MIN 3 VIEWS (FY) 73080 376.00$ 5500434 XR EXAM FOREARM 2 VIEWS (FY) 73090 376.00$ 5500459 XR EXAM HAND MINIMUM 3 VW RT (FY) 73130 376.00$ 5500491 XR EXAM ANKLE COMP MIN 3 VW (FY) 73610 376.00$ 5500509 XR EXAM FOOT COMP MIN 3 VIEWS (FY) 73630 376.00$ 5500517 XR EXAM ABDOMEN 1 VIEW (FY) 74018 376.00$ 5500566 URINE PREGNANCY TEST VISUAL 81025 14.00$ 5500608 IMMUNIZATION ADMIN EA ADD VACCINE 90472 5.00$ 5500616 INJECTION THER/PROPH/DX SQ/IM 96372 261.00$ 5500707 ELECTROCARDIOGRAM 12/TRACE NO RPT 93005 347.00$ 5500715 UCR PROCEDURE COMPLEX 578.00$ 5500806 XR EXAM SPINE CERVICAL 2-3 VIEWS 72040 623.00$ 5500814 XR EXAM SPINE THORACIC 2 VW (FY) 72070 623.00$

5500822 XR EXAM SPINE LUMBOSAC 2-3 VW (FY) 72100 623.00$ 5500830 XR EXAM CHEST 2 VIEWS 71046 376.00$ 5500848 XR EXAM SKULL LESS THAN 4 VIEWS 70250 623.00$ 5500863 IAAD INFLUENZA A/B ANTIGEN QL/SQ 87400 57.00$ 5500871 URINALYSIS NONAUTO W/O SCOPE 81002 15.00$ 5500905 IAAD IMMUNO OPTICAL OBV STREP GRP A 87880 56.00$ 5500921 AIRWAY INHALATION TX SUBSEQUENT 94640 925.00$ 5500954 XR EXAM ABDOMEN 3+ VIEWS (FY) 74021 376.00$ 5500962 XR EXAM ANKLE 2 VIEWS RT (FY) 73600 376.00$ 5500970 XR EXAM SPINE CERVICAL 6+ VIEWS 72052 623.00$ 5500988 XR EXAM HEEL MIN 2 VIEWS (FY) 73650 376.00$ 5501028 XR EXAM FINGER(S) MIN 2 VW (FY) 73140 376.00$ 5501036 XR EXAM FOOT 2 VIEWS (FY) 73620 376.00$ 5501044 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 5501077 XR EXAM KNEE COMPLETE 4+ VIEWS (FY) 73564 623.00$ 5501085 XR EXAM KNEE 3 VIEWS (FY) 73562 376.00$ 5501093 XR EXAM SPINE LUMBOSAC 4+ VW (FY) 72110 623.00$ 5501101 XR EXAM NECK SOFT TISSUE 70360 376.00$ 5501119 XR EXAM PELVIS 1 OR 2 VW (FY) 72170 623.00$ 5501143 XR EXAM SACRUM & COCYX MN 2 VW (FY) 72220 376.00$ 5501192 XR EXAM WRIST 2 VIEWS (FY) 73100 376.00$ 5501200 XR EXAM CHEST SINGLE VIEW 71045 376.00$ 5501218 XR EXAM NASAL BONES MIN 3 VIEWS 70160 376.00$ 5501242 TDAP 7+YR VACCINE INJ (C) 90715 84.00$ 5502653 UCR PROCEDURE SIMPLE 117.00$ 5502661 UCR PROCEDURE INTERMED 198.00$ 5502679 UCR LEVEL 0-LEFT BEFORE SEEN -$ 5502695 XR EXAM RIBS 2 VIEWS UNI LT 71100 376.00$ 5502703 XR EXAM RIBS 2 VIEWS UNI RT 71100 376.00$ 5502711 XR EXAM RIBS/CHEST 3+ VWE UNI LT 71101 623.00$ 5502729 XR EXAM RIBS/CHEST 3+ VWE UNI RT 71101 623.00$ 5502737 XR EXAM CLAVICLE COMP LT (FY) 73000 376.00$ 5502745 XR EXAM CLAVICLE COMP RT (FY) 73000 376.00$ 5502752 XR EXAM SHOULDER MIN 2 VW LT (FY) 73030 376.00$ 5502760 XR EXAM SHOULDER MIN 2 VW RT (FY) 73030 376.00$ 5502778 XR EXAM HUMERUS MIN 2 VW LT (FY) 73060 376.00$ 5502786 XR EXAM HUMERUS MIN 2 VW RT (FY) 73060 376.00$ 5502794 XR EXAM ELBOW 2 VW LT (FY) 73070 376.00$ 5502802 XR EXAM ELBOW 2 VW RT (FY) 73070 376.00$ 5502810 XR EXAM ELBOW COMP MIN 3 VW LT (FY) 73080 376.00$ 5502828 XR EXAM ELBOW COMP MIN 3 VW RT (FY) 73080 376.00$ 5502836 XR EXAM FOREARM 2 VW LT (FY) 73090 376.00$ 5502844 XR EXAM FOREARM 2 VW RT (FY) 73090 376.00$ 5502851 XR EXAM WRIST 2 VW LT (FY) 73100 376.00$ 5502869 XR EXAM WRIST 2 VW RT (FY) 73100 376.00$ 5502877 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 5502885 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 5502893 XR EXAM HAND 2 VIEWS LT (FY) 73120 623.00$

5502901 XR EXAM HAND 2 VIEWS RT (FY) 73120 623.00$ 5502919 XR EXAM FNGR(S) MIN 2 VW LT (FY) 73140 376.00$ 5502927 XR EXAM FNGR(S) MIN 2 VW RT (FY) 73140 376.00$ 5502943 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 5502950 XR FEMUR 2+ VIEWS LT (FY) 73552 376.00$ 5502968 XR FEMUR 2+ VIEWS RT (FY) 73552 376.00$ 5502992 XR EXAM KNEE COMPLETE 4+ VW LT (FY) 73564 623.00$ 5503008 XR EXAM KNEE COMPLETE 4+ VW RT (FY) 73564 623.00$ 5503016 XR EXAM TIBIA/FIBULA 2 VW LT (FY) 73590 376.00$ 5503024 XR EXAM TIBIA/FIBULA 2 VW RT (FY) 73590 376.00$ 5503032 XR EXAM ANKLE 2 VIEWS LT (FY) 73600 376.00$ 5503057 XR EXAM ANKLE COMP 3 VW LT (FY) 73610 376.00$ 5503065 XR EXAM ANKLE COMP 3 VW RT (FY) 73610 376.00$ 5503073 XR EXAM FOOT 2 VIEWS LT (FY) 73620 376.00$ 5503081 XR EXAM FOOT 2 VIEWS RT (FY) 73620 376.00$ 5503099 XR EXAM FOOT COMP MIN 3 VW LT (FY) 73630 376.00$ 5503107 XR EXAM FOOT COMP MIN 3 VW RT (FY) 73630 376.00$ 5503115 XR EXAM HEEL MIN 2 VIEWS LT (FY) 73650 376.00$ 5503123 XR EXAM HEEL MIN 2 VIEWS RT (FY) 73650 376.00$ 5503131 XR EXAM TOE(S) MIN 2 VIEWS LT (FY) 73660 376.00$ 5503149 XR EXAM TOE(S) MIN 2 VIEWS RT (FY) 73660 376.00$ 5503156 XR EXAM WRIST COMP 3+ VW LT (FY) 73110 376.00$ 5503164 XR EXAM WRIST COMP 3+ VW RT (FY) 73110 376.00$ 5503172 XR EXAM KNEE 3 VIEWS LT (FY) 73562 376.00$ 5503180 XR EXAM KNEE 3 VIEWS RT (FY) 73562 376.00$ 5503271 UC APAP 325MG/10.15ML LIQ 3.00$ 5503289 DEXAMETHASONE 4MG/1ML INJ J1100 3.00$ 5503305 UC APAP 120MG SUPPOSITORY 3.00$ 5503313 UC APAP 325MG TABLET 1.00$ 5503321 UC APAP 500MG TABLET 1.00$ 5503347 UC ASPIRIN 81MG CHEWABLE TAB 1.00$ 5503354 UC ASPIRIN 325MG TABLET 1.00$ 5503370 UC OXYMETAZOLIN 0.05% NASSPRY15ML 6.00$ 5503396 METHYLCELLULOSE 150MG TOP PWD 16.00$ 5503404 INS NON-INDWELLING BLADDER CATH 51701 565.00$ 5503420 UC GLYCERIN PEDIATRIC SUPPOSITORY -$ 5503438 +OFFICE OR OP NEW VISIT APRX 10 MIN 99201 250.00$ 5503446 +OFFICE OR OP NEW VISIT APRX 20 MIN 99202 312.00$ 5503453 +OFFICE OR OP NEW VISIT APRX 30 MIN 99203 390.00$ 5503487 +OFFICE OR OP EST VISIT APRX 5 MIN 99211 208.00$ 5503495 +OFFICE OR OP EST VISIT APRX 10 MIN 99212 259.00$ 5503503 +OFFICE OR OP EST VISIT APRX 15 MIN 99213 324.00$ 5503511 +OFFICE OR OP EST VISIT APRX 25 MIN 99214 406.00$ 5503529 +OFFICE OR OP EST VISIT APRX 40 MIN 99215 507.00$ 5503537 DEXAMETHASONE 10MG/ML ORAL J8540 8.00$ 5503545 DEXAMETHASONE 4MG/ML ORAL J8540 3.00$ 5503552 IAAD IMMUNO OPTICAL OBV RESP SYNCYT 87807 53.00$ 5503560 PHENAZOPYRIDINE 200MG TABLET 6.00$

5503578 APAP 650MG/20.3ML SOLN 4.00$ 5503586 XR EXAM HIP W/PELV UNI 2-3V RT (FY) 73502 376.00$ 5503628 XR EXAM HIP W/PELV UNI 1V LT (FY) 73501 376.00$ 5503636 XR EXAM HIP W/PELV UNI 1V RT (FY) 73501 376.00$ 5503644 XR EXAM HIPS/PELV BILAT 2V (FY) 73521 623.00$ 5503677 XR EXAM HAND MINIMUM 3 VW LT (FY) 73130 376.00$ 5503685 REMOVE IMPACTD EAR WAX W/INST BILAT 69210 347.00$ 5550009 SCR MAM 2V EA W/CAD IF DONE BILAT 77067 610.00$ 5550017 DX MAMMO W/CAD IF DONE UNILAT RT 77065 465.00$ 5550025 DX MAMMO W/CAD IF DONE UNILAT LT 77065 465.00$ 5550033 DX MAMMO W/CAD IF DONE BILATERAL 77066 419.00$ 5550041 SCR MAM 2V EA W/CAD IF DONE UNI 77067 610.00$ 5700000 CT ABDOMEN WITH CONTRAST 74160 1,466.00$ 5700018 CT ABDOMEN & PELVIS W/O CONTRAST 74176 1,188.00$ 5700026 CT ABDOMEN & PELVIS WITH CONTRAST 74177 2,153.00$ 5700034 CT ABD & PELV W/O & W/DYE 1+ REGNS 74178 2,153.00$ 5700042 CT ABDOMEN W/O & W/CONTRAST 74170 1,466.00$ 5700059 CT ABDOMEN W/O CONTRAST 74150 696.00$ 5700083 FLUORO ABSCESS DRAIN/SPECIMN COLL 75989 506.00$ 5700091 CT CERVICAL SPINE W/O CONTRAST 72125 696.00$ 5700109 CT CERVICAL SPINE WITH CONTRAST 72126 2,153.00$ 5700158 CTA CHEST (NON CORO) W/CONTRAST 71275 1,466.00$ 5700182 CT MAXILLOFACIAL NO CONTRAST 70486 696.00$ 5700190 CTA ABDOMEN W & W/O CONTRAST 74175 1,466.00$ 5700208 CTA HEAD W/DYE & NO DYE IF PERF 70496 1,466.00$ 5700216 CTA LOWER EXT W & W/O CONT LT 73706 1,466.00$ 5700224 CTA LOWER EXT W & W/O CONT RT 73706 1,466.00$ 5700232 CT HEAD/BRAIN WITH CONTRAST 70460 1,466.00$ 5700240 CTA NECK W/DYE & W/O IF PERFORMED 70498 1,466.00$ 5700257 CT ANGIO PELVIS W & W/O CONTRAST 72191 1,466.00$ 5700265 CTA UPR EXT W & W/O DYE IF DONE LT 73206 1,466.00$ 5700273 CTA UPR EXT W & W/O DYE IF DONE RT 73206 1,466.00$ 5700281 CT HEAD/BRAIN W/O & W/CONTRAST 70470 1,466.00$ 5700299 CT HEAD OR BRAIN WITHOUT CONTRAST 70450 696.00$ 5700331 CT ORBIT/SELLA/FOSSA/EAR NO DYE 70480 696.00$ 5700349 CT LUMBAR SPINE WITHOUT CONTRAST 72131 696.00$ 5700356 CT LUMBAR SPINE WITH CONTRAST 72132 2,153.00$ 5700372 CT GUIDANCE FOR NEEDLE PLACEMENT 77012 565.00$ 5700380 BX LUNG/MEDIASTINUM PERC NEEDLE 32405 5,830.00$ 5700398 CT GUIDANCE FOR NEEDLE PLACEMENT 77012 565.00$ 5700430 CT SOFT TISSUE NECK WITH CONTRAST 70491 1,466.00$ 5700448 CT SOFT TISSUE NECK W/O & W/CONT 70492 1,466.00$ 5700455 CT SOFT TISSUE NECK W/O CONTRAST 70490 696.00$ 5700463 CT ORBIT/SELLA/FOSSA/EAR W/DYE 70481 1,466.00$ 5700471 CT ORBIT/SELLA/FOSSA/EAR W/O&W/DYE 70482 1,466.00$ 5700489 CT ORBIT/SELLA/FOSSA/EAR NO DYE 70480 1,466.00$ 5700513 CT PELVIS WITH CONTRAST 72193 1,466.00$ 5700539 CT PELVIS WITHOUT CONTRAST 72192 696.00$

5700554 CT GUIDANCE FOR NEEDLE PLACEMENT 77012 565.00$ 5700596 CT UPPER EXTREMITY NO CONTRAST 73200 696.00$ 5700646 CT THORACIC SPINE W/O CONTRAST 72128 696.00$ 5700653 CT THORACIC SPINE WITH CONTRAST 72129 1,466.00$ 5700687 CT THORAX WITH CONTRAST 71260 1,466.00$ 5700695 CT THORAX WITHOUT CONTRAST 71250 696.00$ 5700745 MEDRAD STELLANT CT SYRINGE KIT 39.00$ 5700778 CT UPPER EXTREMITY NO CONTRAST LT 73200 696.00$ 5700786 CT UPPER EXTREMITY NO CONTRAST RT 73200 696.00$ 5700810 CT LOWER EXT W/O CONTRAST LT 73700 696.00$ 5700828 CT LOWER EXT W/O CONTRAST RT 73700 696.00$ 5700836 CT LIMITED/LOCALIZED FOLLOW UP STDY 76380 376.00$ 5700844 CT LIMITED/LOCALIZED FOLLOW UP STDY 76380 376.00$ 5700851 CT THORAX W/O & WITH CONTRAST 71270 2,153.00$ 5700869 CT HEAD OR BRAIN WITHOUT CONTRAST 70450 696.00$ 5700901 CT MAXILLOFACIAL WITH CONTRAST 70487 1,466.00$ 5700927 CT THORAX WITHOUT CONTRAST 71250 696.00$ 5700950 CT LUMBAR SPINE W/O & WITH CONTRAST 72133 1,466.00$ 5700968 CT LOWER EXT W/CONTRAST LT 73701 1,466.00$ 5700976 CT LOWER EXT W/CONTRAST RT 73701 1,466.00$ 5700984 CT LOWER EXT W/O & W/CONTRAST LT 73702 1,466.00$ 5701008 GASTROVIEW SOLUTION 30ML Q9963 81.00$ 5701016 CT LOWER EXT W/O CONTRAST RT 73700 696.00$ 5701024 CT LOWER EXT W/O CONTRAST LT 73700 696.00$ 5701040 CTA ABD & PELV W/DYE & W/O DYE 74174 2,153.00$ 5701057 CT UPPER EXTREMITY W/CONTRAST LT 73201 2,153.00$ 5701065 CT UPPER EXTREMITY W/CONTRAST RT 73201 2,153.00$ 5701081 OPTIRAY 350MG/100ML BOTTLE Q9967 356.00$ 5701099 READI-CAT2 BERRY 2% SUSP 450ML 19.00$ 5701289 CT CERVICAL SPINE W/CONTRAST (CT) 72126 2,153.00$ 6000137 ANESTHESIA PER MINUTE 24.00$ 6400006 BAKRI TAMPONADE 1,114.00$ 6400014 ASSAY PH BODY FLUID NOS 83986 22.00$ 6400030 CO2 DETECTOR 48.00$ 6400048 TRANSWARMER MATTRESS (101-150) 667.00$ 6400055 SUPPLEMENTAL FEEDING DEVICE 41.00$ 6400063 AUDITORY EVOKED POTENTIAL COMP 92585 1,364.00$ 6400071 AUDITORY EVOKED POTENTIAL COMP 92585 1,364.00$ 6400089 AUDITORY EVOKED POTENTIAL COMP 92585 1,364.00$ 6400105 OB/GYN OBSERVATION PER HR G0378 305.00$ 6400139 INJ EPIDURAL OF BLOOD/CLOT PATCH 62273 3,620.00$ 6400147 INJECTION THER/PROPH/DX SQ/IM 96372 261.00$ 8300006 MRI ABDOMEN W/O & WITH CONTRAST 74183 2,812.00$ 8300071 MRA PELVIS W OR W/O CONTRAST 72198 2,268.00$ 8300097 MRI BRAIN/STEM WITH CONTRAST 70552 2,812.00$ 8300105 MRI BRAIN/STEM W/O & WITH CONTRAST 70553 2,812.00$ 8300113 MRI BRAIN/STEM WITHOUT CONTRAST 70551 1,693.00$ 8300154 MRI SPINE WITHOUT & WITH CONTRAST 72156 2,812.00$

8300162 MRI SPINE CERVICAL W/O CONTRAST 72141 1,693.00$ 8300188 MRI CHEST W/O AND WITH CONTRAST 71552 2,812.00$ 8300212 MRI SPINE LUMBAR WITH CONTRAST 72149 2,812.00$ 8300220 MRI SPINE LUMBAR W/O & W/CONTRAST 72158 2,812.00$ 8300238 MRI SPINE LUMBAR WITHOUT CONTRAST 72148 1,693.00$ 8300311 MRI BRAIN/STEM W/O & WITH CONTRAST 70553 2,812.00$ 8300329 MRI BRAIN/STEM WITHOUT CONTRAST 70551 1,693.00$ 8300360 MRI ORBIT/FACE/NCK WO & W/CONT 70543 2,812.00$ 8300378 MRI PELVIS W/O & W/CONTRAST 72197 2,812.00$ 8300386 MRI PELVIS WITHOUT CONTRAST 72195 1,693.00$ 8300402 MRI BRAIN/STEM W/O & WITH CONTRAST 70553 2,812.00$ 8300451 MRI SPINE THORACIC WITH CONTRAST 72147 2,812.00$ 8300469 MRI SPINE THORACIC W/O & W/CONTRAST 72157 2,812.00$ 8300477 MRI SPINE THORACIC NO CONTRAST 72146 1,693.00$ 8300485 MRI TEMPOROMANDIBULAR JOINT(S) 70336 1,693.00$ 8300832 MRA UPR EXT WITH OR W/O CONTRAST LT 73225 2,269.00$ 8300857 MRI ORBIT/FACE/NECK NO CONTRAST 70540 1,693.00$ 8300873 MRI CHEST WITHOUT CONTRAST 71550 1,693.00$ 8300899 MRI ABDOMEN WITHOUT CONTRAST 74181 1,693.00$ 8300907 MRA HEAD WITHOUT CONTRAST 70544 1,693.00$ 8300915 MRA HEAD W/CONTRAST 70545 1,693.00$ 8300931 MRA NECK WITHOUT CONTRAST 70547 1,693.00$ 8300949 MRA NECK WITH CONTRAST 70548 2,812.00$ 8300956 MRA NECK W/O & WITH CONTRAST 70549 2,812.00$ 8300964 MRI UPPER EXT NON JOINT W/O DYE LT 73218 1,693.00$ 8300972 MRI UPPER EXT NON JOINT W/O DYE RT 73218 1,693.00$ 8301004 MRI UPPER EXT NO JNT W/O & W/DYE LT 73220 2,812.00$ 8301012 MRI UPPER EXT NO JNT W/O & W/DYE RT 73220 2,812.00$ 8301020 MRI UPPER EXT ANY JNT W/O CONT LT 73221 1,693.00$ 8301038 MRI UPPER EXT ANY JNT W/O CONT RT 73221 1,693.00$ 8301046 MRI UPPER EXT ANY JNT W/CONT LT 73222 2,812.00$ 8301053 MRI UPPER EXT ANY JNT W/CONT RT 73222 2,812.00$ 8301061 MRI UPR EXT ANY JNT W/O & W/DYE LT 73223 2,812.00$ 8301079 MRI UPR EXT ANY JNT W/O & W/DYE RT 73223 2,812.00$ 8301087 MRI LOWER EXT NON JNT W/O CONT LT 73718 1,693.00$ 8301095 MRI LOWER EXT NON JNT W/O CONT LT 73718 1,693.00$ 8301103 MRI LOWER EXT NON JNT WITH CONT LT 73719 2,812.00$ 8301129 MRI LWR EXT NON JNT W/O & W/CONT LT 73720 2,812.00$ 8301137 MRI LWR EXT NON JNT W/O & W/CONT RT 73720 2,812.00$ 8301145 MRI LOWER EXT ANY JNT W/O CONT LT 73721 1,693.00$ 8301152 MRI LOWER EXT ANY JNT W/O CONT RT 73721 1,693.00$ 8301160 MRI ANY JNT LOWER EXT W/CONTRAST LT 73722 2,812.00$ 8301186 MRI LWR EXT JNT W/O & W/CONT LT 73723 2,812.00$ 8301194 MRI LWR EXT JNT W/O & W/CONT RT 73723 2,812.00$ 8301236 MRI ABDOMEN W/O & WITH CONTRAST 74183 2,812.00$ 8301244 MRI ABDOMEN WITHOUT CONTRAST 74181 1,693.00$ 8301251 MRA ABDOMEN W OR W/O CONTRAST 74185 2,268.00$ 8301525 GADOTERATE MEGLUMINE 10ML INJ A9575 181.00$

8301533 GADOTERATE MEGLUMINE 15ML INJ A9575 260.00$ 8301541 GADOTERATE MEGLUMINE 20ML INJ A9575 338.00$ 8301558 GADOBUTROL 1MMOL/ML 7.5ML VIAL A9585 170.00$ 8301566 GADOBUTROL 1MMOL/ML 10ML VIAL A9585 181.00$ 9301144 HC-PURAPLY AG (54) PER CM Q4172 364.00$ 9301169 HC-PURAPLY AG (25) PER CM Q4172 364.00$ 9301185 HC-PURAPLY AG (8) PER CM Q4172 364.00$ 9301201 HC-PURAPLY AG (4) PER CM Q4172 481.00$ 9301227 HC-PURAPLY AG (128) PER CM Q4172 343.00$ 9301409 HC-EPIFIX 2X2CM (4) Q4131 1,102.00$ 9301441 HC-EPIFIX 2X4CM (8) Q4131 627.00$ 9301474 HC-EPIFIX MESH 3.5X3.5CM (8) Q4131 391.00$ 9301482 HC-EPIFIX MESH 4X4.5CM (12) Q4131 284.00$ 9301490 HC-GRAFIX CORE 1.5X2CM (3) Q4132 284.00$ 9301508 HC-GRAFIX CORE 2X3CM (6) Q4132 747.00$ 9301516 HC-GRAFIX CORE 3X4CM (12) Q4132 418.00$ 9301524 HC-GRAFIX PRIME 3X4CM (12) Q4133 418.00$ 9301532 HC-GRAFIX PRIME 1.5X2CM (3) Q4133 1,255.00$ 9301540 HC-GRAFIX PRIME 2X3CM (6) Q4133 747.00$ 9301557 HC-GRAFIX PRIME DISC 14MM (2) Q4133 790.00$ 9301581 HC-EPIFIX MESH 4X4.5CM (11) Q4131 284.00$ 9301599 HC-APLIGRAF SHEET 44CM Q4101 5,287.00$ 9301615 HC-DERMAGRAFT 5X7.5CM (37.5) Q4106 150.00$ 9301706 HC-EPIFIX 2X3CM (6) Q4131 763.00$ 9301730 HC-GRAFIX PRIME DISC 16MM (2) Q4133 1,477.00$ 9301797 HC-GRAFIX CORE DISC 14MM (2) Q4132 -$ 9301805 HC-GRAFIX CORE DISC 16MM (2) Q4132 1,477.00$ 9301813 HC-EPIFIX DISC 14MM (2) Q4131 524.00$ 9301821 HC-EPIFIX MESH 2X3CM (6) Q4131 763.00$ 9301987 HC-AFFINITY 1.5 X 1.5 (2) Q4159 866.00$ 9301995 HC-AFFINITY 2.5 X 2.5 (6) Q4159 1,741.00$ 9302001 HC-NUSHIELD 1.6 DISC (2) Q4160 691.00$ 9302019 HC-NUSHIELD 2X3 (6) Q4160 464.00$ 9302027 HC-NUSHIELD 2X4 (8) Q4160 416.00$ 9302035 HC-NUSHIELD 3X4 (12) Q4160 408.00$ 9302043 HC-NUSHIELD 4X4 (16) Q4160 407.00$ 9302050 HC-NUSHIELD 4X6 (24) Q4160 379.00$ 9302068 HC-NUSHIELD 6X6 (36) Q4160 345.00$ 9302118 HC-ALLOPATCH PLIABLE 1.5X1.5 (3) Q4128 284.00$ 9302126 HC-ALLOPATCH PLIABLE 2 X 2 (4) Q4128 378.00$ 9302134 HC-ALLOPATCH PLIABLE 4 X 4 (16) Q4128 273.00$ 9302142 HC-ALLOPATCH PLIABLE 4 X 8 (32) Q4128 144.00$ 9302159 HC-AMNIOBAND MEMBRANE DISK 10MM Q4151 473.00$ 9302167 HC-AMNIOBAND MEMBRANE DISK 14MM Q4151 948.00$ 9302175 HC-AMNIOBAND MEMBRANE DISK 16MM Q4151 1,622.00$ 9302183 HC-AMNIOBAND MEMBRANE DISK 18MM Q4151 1,893.00$ 9302191 HC-AMNIOBAND MEMBRANE 2 X 2 (4) Q4151 266.00$ 9302209 HC-AMNIOBAND MEMBRANE 2 X 3 (6) Q4151 266.00$

9302217 HC-AMNIOBAND MEMBRANE 2 X 4 (8) Q4151 277.00$ 9302225 HC-AMNIOBAND MEMBRANE 3 X 4 (12) Q4151 7,200.00$ 9302233 HC-AMNIOBAND VIABLE DISK 14MM Q4151 948.00$ 9302241 HC-AMNIOBAND VIABLE DISK 18MM Q4151 1,893.00$ 9302258 HC-AMNIOBAND VIABLE 2 X 2 (4) Q4151 728.00$ 9302266 HC-AMNIOBAND VIABLE 2 X 4 (4) Q4151 406.00$ 9302274 HC-AMNIOBAND VIABLE 3 X 4 (12) Q4151 305.00$ 9302282 HC-EPICORD 2X3CM (6) Q4131 816.00$ 9302290 HC-PURAPLY AM 16MM (2) PER CM Q4172 691.00$ 9302316 HC-GRAFIXPL PRIME DISC 16MM (2) Q4133 1,477.00$ 9302324 HC-GRAFIXPL PRIME 1.5X2CM (3) Q4133 1,255.00$ 9302332 HC-GRAFIXPL PRIME 2X3CM (6) Q4133 747.00$ 9302340 HC-GRAFIXPL PRIME 3X3CM (9) Q4133 -$ 9302357 HC-GRAFIXPL PRIME 3X4CM(12) Q4133 418.00$