Letter

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427 R&B 2HTU ICU 201 $0.00 $6,225.00

14050 R&B 4FE-CCU 210 $0.00 $6,225.00

14241 R&B 4FE-ICU 200 $0.00 $8,100.00

14308 R&B 4FE-ICU 200 $0.00 $6,225.00

22426 R&B 2HTU CCU 211 $0.00 $8,100.00

24059 R&B 4FE-CCU 211 $0.00 $8,100.00

32003 R&B 2FM-MS TELEMETRY 214 $0.00 $3,900.00

32425 R&B 2HTU INTERMEDIATE ICU 206 $0.00 $3,900.00

32466 R&B PEDS-INTERMEDIATE ICU 206 $0.00 $3,900.00

34009 R&B 4FM-INTERM/CCU 214 $0.00 $3,900.00

34058 R&B 4FE-CCU/INTERMIDIATE 214 $0.00 $3,900.00

34223 R&B 4FM-STEP DOWN UNIT/T 214 $0.00 $3,900.00

34249 R&B 4FE-INTERM/ICU 206 $0.00 $3,900.00

34306 R&B 4FE-INTERM/ICU 206 $0.00 $3,900.00

42218 R&B 2FE-MED/SURG PVT 121 $0.00 $2,900.00

42465 R&B 2FN-PEDS PVT 113 $0.00 $2,900.00

43000 R&B 3FM-MED/SURG PVT 121 $0.00 $2,900.00

43216 R&B 3FE-OBS/PVT 112 $0.00 $2,900.00

43471 R&B 3FE-LABOR/DELV PVT 112 $0.00 $2,900.00

44008 R&B 4FM-MED/SUR PVT 110 $0.00 $2,900.00

44057 R&B 4FE-CCU M/S PVT 210 $0.00 $2,900.00

44222 R&B 4FM-STEP DOWN UNIT 110 $0.00 $5,900.00

52001 R&B 2FM-MED/SUR SEMI-PVT 121 $0.00 $2,900.00

52217 R&B 2FE-MED/SUR SEM-PVT 121 $0.00 $2,900.00

52423 R&B 2HTU MED/SUR SEMI-PVT 121 $0.00 $2,900.00

52464 R&B 2FN-PEDS SEMI/PVT 123 $0.00 $2,900.00

53009 R&B 3FM-MED/SUR SEMI-PVT 121 $0.00 $2,900.00

53215 R&B 3FE-OB SEMI/PVT 122 $0.00 $2,900.00

53470 R&B 3FE LAB/DELIV OB S/PV 122 $0.00 $2,900.00

54007 R&B 4FM-MED/SUR SEM-PVT 121 $0.00 $2,900.00

54056 R&B 4FE-CCU M/S SEMI-PVT 121 $0.00 $2,900.00

54247 R&B 4FE-ICU M/S SEMI-PVT 121 $0.00 $2,900.00

54304 R&B 4FE-ICU M/S SEMI-PVT 121 $0.00 $2,900.00

62463 R&B 2FN-PEDS WARD 153 $0.00 $2,900.00

63404 R&B 2FM-NSY WARD 153 $0.00 $2,900.00

63420 R&B 3FM-SPCN WARD 153 $0.00 $2,900.00

73411 R&B 3FM-ICNN 174 $0.00 $7,600.00

83402 R&B 3FM-NURSERY / SPCN 173 $0.00 $3,900.00

83410 R&B 3FM-INTRM/CARE NEONT 173 $0.00 $3,900.00

83428 R&B 3FM-INTRM/CARE NEONT 173 $0.00 $3,900.00

83436 R&B 3FM-CONT/CARE NSY LII 172 $0.00 $2,900.00

93401 R&B 3FM-NEWBORN NSY 170 $0.00 $1,500.00

100016 VAGINAL DELIVERY NORMAL 722 $2,400.00 $0.00

100065 GEN ANESTHESIA 1/2HR 370 $328.30 $0.00

100099 SPINAL ANESTHESIA 370 $392.45 $0.00

100115 EPIDURAL ANESTHES 370 $392.45 $0.00

100123 NORMAL C-SECT DELIVERY 360 $6,255.90 $0.00

100255 RECOVERY RM 1/2HR 710 $344.00 $0.00

100263 EMERGENCY C-SECT DELIVERY 360 $5,000.00 $0.00



Page 5 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

100271 R&B 2HTU ICU

FETAL MONITORING P/DAY 920 59050 $982.95 $0.00

100289 KREISSELMAN-S/U 410 $1,007.75 $0.00

100297 D&C 360 59812 $3,417.00 $0.00

100305 PREGNANCY - LIMITED 402 76815 $794.50 $0.00

100313 VAGINAL DELIVERY HI-RISK 722 $3,712.00 $0.00

200022 OB EVALUATION AND MNGT 510 99215 $825.00 $0.00

200030 OXYTOXIN CH TEST 920 59020 $759.00 $0.00

200048 NON STRESS TEST 920 59025 $1,008.65 $0.00

200055 FETAL BIOPHYSICAL PROFILE 402 76818 $1,098.65 $0.00

200063 PLACENTA LOCALIZATION 402 76815 $794.50 $0.00

200071 PREGNANCY - LIMITED 402 76815 $794.50 $0.00

200105 CONTRACTION STRESS TEST 510 Z103099 $569.25 $0.00

200329 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00

200337 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

200345 HYDRATE IV INFUSON ADD-ON 260 90761 $231.00 $0.00

200352 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

200360 THER/PROPH/DIAG INJ SC/IM 940 90772 $247.50 $0.00

200378 TH/PR/DX INJ SC/IM EA ADD 940 9077276 $206.25 $0.00

200386 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

200394 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

200402 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

200410 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

250027 FETAL MONITORING P/HOUR 720 59050 $40.96 $0.00

300103 ICNN TRANSP/TEAM 1 HR 239 $210.90 $0.00

300129 ICNN TRANSP/TEAM RETURN 1 239 $210.90 $0.00

301002 LATE DISCHARGE ORDER ICNN 224 $0.00 $7,600.00

301028 LATE DISCHARGE ORDER SCN 224 $0.00 $3,900.00

500108 LATE DISCHARGE ORDER ICU 201 $0.00 $6,225.00

500801 CARDIOVERSION (ICU) 480 92960 $1,094.25 $0.00

600106 LATE DISCHARGE ORDER CCU 224 $0.00 $8,100.00

600809 CARDIOVERSION (CCU) 480 92960 $1,094.25 $0.00

700104 LATE DISCHARGE ORDER NSY 224 $0.00 $1,500.00

900308 OBSV CARE OBS 1 HR 762 99218 $116.50 $0.00

900407 OBSV CARE PEDS 1 HR 762 99218 $116.50 $0.00

900506 OBSV CARE 2E 1 HR 762 99218 $116.50 $0.00

900605 OBSV CARE 2M 1 HR 762 99218 $116.50 $0.00

900704 OBSV CARE 3M 1 HR 762 99218 $116.50 $0.00

900803 OBSV CARE 4M 1 HR 762 99218 $116.50 $0.00

1000017 CIRCUMCISION PROF FEE 510 $187.50 $0.00

1000033 PARENT CNFR 30 MIN/SOC WK 510 99361 $66.45 $0.00

1000041 HEARING SCREEN INITIAL IP 471 92585 $206.25 $0.00

1000058 NURSE SPECIALIST 30 MIN 510 99361 $176.50 $0.00

1000074 TELE CONSULT 30 MIN PHYS 510 99371 $159.40 $0.00

1000082 TELE CONSLT 15 MIN ALL/PR 510 99371 $159.40 $0.00

1000108 HISTORY & PHYSICAL PHYS 510 99242 $199.25 $0.00

1000116 CENTER CONFERENCE 30 MIN 510 99361 $100.55 $0.00

1000124 COMPREHENSIVE CHART RVW 510 99358 $148.00 $0.00

1000132 COORDINATOR FEE 510 99361 $199.25 $0.00

1000140 COORDINATOR ALLIED PROF 510 99361 $199.25 $0.00



Page 6 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

1000306 R&B 2HTU ICU

SYNAGIS TM 100MG 250 J3490 $4,018.45 $0.00

1000405 HEARING SCREEN FOLLW/U OP 471 92585 $206.25 $0.00

1000413 HEARING SCREEN OP 471 92585 $206.25 $0.00

1050020 BLOOD ADMINISTRATION 391 36430 $825.00 $0.00

1060086 PSY DIAG: TEST ADM 1HR/BN 510 96110 $159.50 $0.00

1060094 PSY DIAG: TEST ADM 2HR/BN 510 96110 $319.00 $0.00

1060102 PSY DIAG:TEST ADM 3HR/BYL 510 96111 $478.25 $0.00

1060110 PSY DIAG:TEST ADM 4 HR/BY 510 96111 $637.50 $0.00

1060128 PSY DIAG:TEST ADM 5HR/BYL 510 96111 $795.00 $0.00

1060136 PSY DIAG:TEST ADM 6HR/BYL 510 96111 $954.50 $0.00

1060144 PSY DIAG:TEST ADM 15MIN/B 510 96111 $89.50 $0.00

1060169 PSY DIAG:TEST SCRNG 1HR/B 510 96110 $159.50 $0.00

1060177 PSY DIAG:TEST SCRNG 2HR/B 510 96111 $319.00 $0.00

1060185 PSY DIAG:TEST SCRNG 15MIN 510 96111 $89.50 $0.00

1060201 PSY DIAG:WRITTEN RPT 1 HR 510 96110 $159.50 $0.00

1060219 PSY DIAG: WRITTEN RPT 2HR 510 96111 $319.00 $0.00

1060227 PSY DIAG:WRITTEN RPT 15 M 510 96111 $89.50 $0.00

1060326 DEVELOPMNTL TESTING LIMTD 918 96110 $318.80 $0.00

1060334 DEVELOPMENTAL TESTING 918 96111 $637.55 $0.00

1300045 OP NUTRITION INITIAL VIS 942 99245 $792.20 $0.00

1300086 SOCIAL WORKER 1/2 HOUR 942 99243 $412.70 $0.00

1300110 S/S NEW PT COMPR 60 MIN 942 99205 $540.75 $0.00

1300128 S/S EST PT COMPR 40 MIN 942 99215 $450.70 $0.00

1300136 S/S EST PT DETAIL 25 MIN 942 99214 $355.80 $0.00

1300144 S/S EST PT EXPN 15 MIN 942 99213 $288.75 $0.00

1300151 S/S EST PT FOCUS 10 MIN 942 99212 $275.00 $0.00

1300169 S/S EST PT MINIMAL 5 MIN 942 99211 $240.65 $0.00

1300177 S/S PRLNG SRV FACE/FAC 60 942 99354 $474.40 $0.00

1300185 S/S PRLNG F/FACE ADD 942 99355 $379.50 $0.00

1300193 S/S PREVENT/MED COUNS 15M 942 99401 $179.45 $0.00

1300201 S/S PREVN/MED COUNSL 30MI 942 99402 $355.80 $0.00

1300219 S/S PRVN/MED COUNSL 45 MI 942 99403 $450.70 $0.00

1300227 S/S PRVN/MED COUNSL 60MIN 942 99404 $540.75 $0.00

1300300 SSC CONSULT CPMPR 60 MIN 942 99244 $618.75 $0.00

1300326 SSC CONSULT COMPR 80 MIN 942 99245 $792.20 $0.00

1300342 SSC CONSULT DETAILED 45 M 942 99243 $412.70 $0.00

1300367 SSC CONSULT DETAILED 25 M 942 99242 $317.80 $0.00

1300383 SSC ORIENT HLTH/ED EA 15M 942 $103.15 $0.00

1300409 SSC PERINATAL ED EA 15MIN 942 $103.15 $0.00

1300425 SSC INITIAL NUTRITION 30M 942 $206.25 $0.00

1300441 SSC INITIAL NUTRIT EA 15M 942 $103.15 $0.00

1300466 SSC FOLLOW UP NUTR EA 15M 942 $103.15 $0.00

1300482 SSC POST PARTUM NUTR 15M 942 $103.15 $0.00

1400167 BREAST PUMP RENTAL PER MO 271 E0602 $107.25 $0.00

1400183 BREAST PUMP KIT 271 E0602 $107.25 $0.00

1600022 INITIAL TX.,COOLING MEASU 510 16000 $345.30 $0.00

1600030 DRSG &/OR DEBRIDEMENT - S 510 16020 $328.30 $0.00

1600048 DRSG &/OR DEBRIDEMENT - M 510 16025 $390.95 $0.00

1600055 DRSG &/OR DEBRIDEMENT - L 510 16030 $447.80 $0.00



Page 7 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

1600063 R&B 2HTU ICU

WHIRLPOOL 510 97022 $273.20 $0.00

1600071 RE-CHECK 510 99212 $168.90 $0.00

1900109 LATE DISCHARGE ORDER PEDS 224 $0.00 $2,900.00

2000065 SKULL LIMTED 320 70250 $462.00 $0.00

2000073 SKULL COMPLETE 320 70260 $1,007.90 $0.00

2000099 FACIAL BONES LIMITED 320 70140 $486.75 $0.00

2000107 FACIAL BONES COMPLETE 320 70150 $917.15 $0.00

2000123 NASAL BONES 320 70160 $486.75 $0.00

2000164 MANDIBLE LIMIT 320 70100 $519.75 $0.00

2000172 MANDIBLE COMP 320 70110 $906.15 $0.00

2000180 EYE FOR FB 320 70030 $749.40 $0.00

2000198 ORBITS 320 70200 $906.15 $0.00

2000206 OPTIC FORAMINA 320 70190 $511.50 $0.00

2000214 TEMPOROMANDIBULAR JOINTS 320 70330 $867.62 $0.00

2000222 SINUSES LIMIT 320 70210 $378.15 $0.00

2000230 SINUSE COMP. 320 70220 $680.65 $0.00

2000248 MAXILLA 320 70150 $954.25 $0.00

2000263 SOFT TISS NECK 320 70360 $416.65 $0.00

2000297 SPINE SINGLE VIEW 320 72020 $314.90 $0.00

2000305 CERVICAL SPINE LIMIT 320 72040 $507.40 $0.00

2000313 CERVICAL SPINE COMPLETE 320 72050 $804.40 $0.00

2000321 CERVICAL SPINE FLEX & E 320 72052 $1,094.50 $0.00

2000339 THORACIC SPINE 320 72070 $518.40 $0.00

2000347 THORACOLUMBAR SPINE 320 72080 $544.50 $0.00

2000354 SCOLIOSIS SERIES 320 72090 $605.00 $0.00

2000362 LUMBOSACRAL LIMITED 320 72100 $550.00 $0.00

2000370 LUMBOSACRAL COMPLETE 320 72110 $965.25 $0.00

2000388 LUMBOSACRAL BENDING VIEW 320 72120 $649.00 $0.00

2000396 PELVIS 1 VIEW 320 72170 $356.15 $0.00

2000404 PELVIS 3 VIEWS 320 72190 $507.40 $0.00

2000412 SACROILIAC JOINTS 320 72202 $617.40 $0.00

2000420 SACRUM 320 72220 $536.25 $0.00

2000438 COCCYX 320 72220 $536.25 $0.00

2000446 SACRUM & COCCYX 320 72220 $628.40 $0.00

2000453 STERUM 320 71120 $468.90 $0.00

2000461 STERNO/CLAVICULAR JOINTS 320 71130 $508.75 $0.00

2000487 RIBS BILATERAL 320 71110 $847.00 $0.00

2000537 ACROMIOCLAVICULAR JOINTS 320 73050 $490.90 $0.00

2000693 HIP BILATERAL COMPLETE 320 73520 $698.50 $0.00

2000701 HIPS & PELVIS INFANT 320 73540 $336.90 $0.00

2000842 CHEST PORT 1 VIEW 324 71010 $386.40 $0.00

2000859 CHEST PORT 2 VIEW 324 71020 $544.50 $0.00

2000867 ABD PORT 1 VIEW 320 74000 $438.65 $0.00

2000875 ABD PORT 2 VIEW 320 74010 $534.90 $0.00

2000883 CHILD FB 320 76010 $236.50 $0.00

2000891 CHEST 1 VIEW 324 71010 $291.50 $0.00

2000909 CHEST 2 VIEW 324 71020 $449.65 $0.00

2000917 CHEST 3 VIEW 324 71021 $464.75 $0.00

2000941 ABDOMEN 1 VIEW 320 74000 $343.75 $0.00



Page 8 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2000958 R&B 2HTU ICU

ABDOMEN 2 VIEW 320 74010 $440.00 $0.00

2000966 ABDOMEN 3 VIEW 320 74020 $464.75 $0.00

2001006 BONE AGE STUDY 320 76020 $478.50 $0.00

2001014 BONE SURVEY 320 76062 $1,348.90 $0.00

2001022 INFANT BONE SUR 320 76065 $1,288.40 $0.00

2001030 BONE LENGHT STUDY 320 76040 $1,199.00 $0.00

2001048 CHOLANG POST-OPERATIVE 320 74305 $1,237.50 $0.00

2001063 CHOLANGIOGRAPHY OPERATIVE 320 74300 $1,765.50 $0.00

2001071 PERCUTANEOUS CHOLANGIOGRP 320 74320 $4,222.65 $0.00

2001097 UROGRAM IVP 320 74410 $1,493.25 $0.00

2001105 INF IVP-TOMOS 320 74415 $1,710.50 $0.00

2001113 IVP W TOMO OR INF 320 74400 $1,398.40 $0.00

2001121 URO RETROGRADE 320 74420 $1,419.00 $0.00

2001147 CYSTOGRAM 320 74430 $1,139.90 $0.00

2001154 PERCUT TRANSHEP BIL DRNGE 320 75980 $7,277.90 $0.00

2001162 URETHRO CYST RETRO VOIDNG 320 74455 $1,523.50 $0.00

2001170 URETHRO CYST RETROGRADE 320 74450 $1,049.15 $0.00

2001188 TOMOGRAM INDEP 320 76100 $1,405.25 $0.00

2001196 TOMOGRAM W/ROUTINE 320 76100 $816.75 $0.00

2001204 PORTABLE SET UP 320 Q0092 $94.90 $0.00

2001220 NEPHRO GRAM IN OR 320 74000 $533.50 $0.00

2001238 URETERAL STENT PLACEMENT 320 74480 $1,436.25 $0.00

2001246 NEPHROSTOMY RIGHT 320 74475 $3,066.25 $0.00

2001279 ESOPHAGUS 320 74220 $961.15 $0.00

2001287 UPPER GI 320 74247 $1,278.75 $0.00

2001295 UPPER GI LIMIT 320 74246 $1,295.25 $0.00

2001303 UPPER GI/SMALL BOWEL 320 74249 $1,765.50 $0.00

2001311 SMALL BOWEL 320 74250 $1,318.65 $0.00

2001329 BARIUM ENEMA 320 74270 $1,156.40 $0.00

2001337 BARIUM ENEMA AIR CONTRAST 320 74280 $1,639.00 $0.00

2001378 FLUORO, UP TO 1 HOUR 320 76000 $982.95 $0.00

2001386 FLUOROSCOPY > 1 HR 320 76001 $1,318.65 $0.00

2001394 ENTEROCLYSIS 320 74251 $2,814.65 $0.00

2001410 BARIUM SWALLOW W/THERAPIS 320 74230 $1,100.00 $0.00

2001527 INSERT PICC AGE 5 /> 323 36569 $1,754.50 $0.00

2002228 FOOT LIMITED LEFT 320 73620 $336.90 $0.00

2002236 FOOT COMPLETE LEFT 320 73630 $423.50 $0.00

2002244 FEMUR LEFT 320 73550 $422.15 $0.00

2002251 ELBOW LEFT LIMITED 320 73070 $345.15 $0.00

2002269 CLAVICLE LEFT 320 73000 $456.50 $0.00

2002277 ANKLE COMPLETE LEFT 320 73610 $420.75 $0.00

2002285 ANKLE LIMITED LEFT 320 73600 $367.15 $0.00

2002293 FOREARM LEFT 320 73090 $367.15 $0.00

2002301 HAND LIMITED LEFT 320 73120 $367.15 $0.00

2002319 HAND COMPLETE LEFT 320 73130 $424.90 $0.00

2002327 HEEL LEFT 320 73650 $301.15 $0.00

2002335 HIP COMPLETE LEFT 320 73510 $547.25 $0.00

2002343 HIP OPERATIVE LEFT 320 73530 $1,687.15 $0.00

2002350 HIP LIMITED LEFT 320 73500 $361.65 $0.00



Page 9 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2002368 R&B 2HTU ICU

FINGERS LEFT 320 73140 $265.40 $0.00

2002376 HUMERUS LEFT 320 73060 $294.25 $0.00

2002384 KNEE & PATELLA LEFT 320 73564 $605.00 $0.00

2002392 KNEE COMPLETE RIGHT 320 73562 $372.65 $0.00

2002400 KNEE COMPLETE LEFT 320 73562 $372.65 $0.00

2002418 KNEE LIMITED LEFT 320 73560 $335.50 $0.00

2002426 NAVICULAR SERIES LEFT 320 73110 $422.15 $0.00

2002434 NEPHROSTOGRAM LEFT 320 74425 $1,419.00 $0.00

2002442 NEPHROSTOMY LEFT 320 74475 $3,066.25 $0.00

2002459 RIBS LEFT 320 71100 $569.25 $0.00

2002467 SCAPULA LEFT 320 73010 $508.75 $0.00

2002475 SHOULDER COMPLETE LEFT 320 73030 $471.65 $0.00

2002483 SHOULDER LIMITED LEFT 320 73020 $335.50 $0.00

2002491 TIBIA & FIBULA LEFT 320 73590 $379.50 $0.00

2002509 TOES LEFT 320 73660 $250.25 $0.00

2002517 WRIST COMPLETE LEFT 320 73110 $427.65 $0.00

2002525 WRIST LIMITED LEFT 320 73100 $363.00 $0.00

2002541 ELBOW RIGHT COMPLETE 320 73080 $427.65 $0.00

2002558 ELBOW LEFT COMPLETE 320 73080 $427.65 $0.00

2002566 URETERAL STENT PLACMNT/LT 320 74480 $1,435.50 $0.00

2002574 URETERAL STENT PLACMT/RT 320 74480 $1,435.50 $0.00

2002608 RIBS RIGHT 320 71100 $569.25 $0.00

2002616 SCAPULA RIGHT 320 73010 $508.75 $0.00

2002624 SHOULDER LIMITED RIGHT 320 73020 $335.50 $0.00

2002632 SHOULDER COMPLETE RIGHT 320 73030 $471.65 $0.00

2002640 HUMERUS RIGHT 320 73060 $294.25 $0.00

2002657 ELBOW RIGHT LIMITED 320 73070 $345.15 $0.00

2002665 FOREARM RIGHT 320 73090 $367.15 $0.00

2002673 WRIST LIMITED RIGHT 320 73100 $363.00 $0.00

2002681 WRIST COMPLETE RIGHT 320 73110 $427.65 $0.00

2002699 NAVICULAR SERIES RIGHT 320 73110 $422.15 $0.00

2002707 HAND COMPLETE RIGHT 320 73130 $424.90 $0.00

2002715 HAND LIMITED RIGHT 320 73120 $367.15 $0.00

2002723 FINGERS RIGHT 320 73140 $265.40 $0.00

2002731 HIP LIMITED RIGHT 320 73500 $361.65 $0.00

2002749 HIP COMPLETE RIGHT 320 73510 $547.25 $0.00

2002756 FEMUR RIGHT 320 73550 $422.15 $0.00

2002764 KNEE LIMITED RIGHT 320 73560 $335.50 $0.00

2002772 KNEE & PATELLA RIGHT 320 73564 $605.00 $0.00

2002780 TIBIA & FIBULA RIGHT 320 73590 $379.50 $0.00

2002798 ANKLE LIMITED RIGHT 320 73600 $367.15 $0.00

2002806 ANKLE COMPLETE RIGHT 320 73610 $420.75 $0.00

2002814 FOOT LIMITED RIGHT 320 73620 $336.90 $0.00

2002822 FOOT COMPLETE RIGHT 320 73630 $423.50 $0.00

2002830 HEEL RIGHT 320 73650 $301.15 $0.00

2002848 HIP OPERATIVE RIGHT 320 73530 $1,687.15 $0.00

2002855 NEPHROSTOGRAM RIGHT 320 74425 $1,419.00 $0.00

2002863 CLAVICLE RIGHT 320 73000 $456.50 $0.00

2002871 TOES RIGHT 320 73660 $250.25 $0.00



Page 10 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2002897 R&B 2HTU ICU TUBE CHANGE

NEPHROSTOMY 320 75984 $948.75 $0.00

2002905 ASPIRATION OF MAJOR JOINT 320 20610 $948.75 $0.00

2002913 PERCUT TRANSHEP CATH INTR 323 47510 $1,684.40 $0.00

2003010 FLUORO FOR SPINAL 320 76005 $1,200.00 $0.00

2003168 PERC VERTEBROPLASTY FLUOR 320 76012 $1,200.00 $0.00

2080034 SHOULDER ARTHROGRAM 322 73040 $910.25 $0.00

2080067 SINUS FISTULA 323 76080 $946.00 $0.00

2080075 HYSTEROSALPINGOGRAPHY 320 74740 $958.40 $0.00

2080091 ERCP 320 74330 $1,145.40 $0.00

2080133 SURGICAL SPECIMEN MAMM 320 76098 $156.75 $0.00

2080141 HIP ARTHROGRAM 322 73525 $990.00 $0.00

2080158 MYELOGRAM CERVICAL 320 72240 $1,729.75 $0.00

2080166 MYELOGRAM THORACIC 320 72255 $2,349.90 $0.00

2080299 VENOGRAM EXTREMITY RT 320 75820 $4,079.65 $0.00

2080307 VENOGRAM EXTREMITY BILAT 320 75822 $4,130.50 $0.00

2080380 FLUORO GUIDED NDL PLCMNT 320 76003 $1,200.00 $0.00

2080448 MAMMO NEEDLE LOCAL UNILT 401 76096 $313.50 $0.00

2080455 MAMMO NEEDLE LOCAL AD/RT 401 7609676 $288.75 $0.00

2080471 INFERIOR VENA CAVA 323 75825 $6,441.90 $0.00

2080497 MYELOGRAM LUMBAR 320 72265 $1,370.90 $0.00

2080505 MYELOGRAM MULTI L 320 72270 $2,231.65 $0.00

2080562 ABSCESS DRAINAGE 320 75989 $2,329.25 $0.00

2080570 ANGIO EXISTING CATH 323 75898 $1,190.75 $0.00

2080588 CENTRAL VENOUS CATH PLACE 323 36558 $2,943.90 $0.00

2080687 ARTHRO SHOULDER RIGHT 322 73040 $910.25 $0.00

2080737 ARTHRO HIP LEFT 322 73525 $990.00 $0.00

2080786 MAMMO NEEDLE LOCAL LEFT 320 76096 $313.50 $0.00

2080802 VENOGRAM EXTREMITY LEFT 320 75820 $4,079.65 $0.00

2080885 AV SHUNT EXTREMITY LT 320 75790 $5,057.25 $0.00

2080893 AV SHUNT EXTREMITY RT 320 75790 $5,057.25 $0.00

2080901 THROMBOLYSIS PERIPHERAL R 320 75896 $7,610.65 $0.00

2080976 MAMMO NEEDLE LOCAL RIGHT 320 76096 $313.50 $0.00

2081248 REMOVE IMPL/VENOUS ACC/DV 323 36589 $2,043.25 $0.00

2081263 SPINAL PUNCTURE 361 62270 $788.55 $0.00

2081289 C VENOUS ACCESS DEVICE PL 323 36558 $2,943.90 $0.00

2081305 C VENOUS ACCESS DEV/REMOV 323 36590 $2,043.25 $0.00

2085009 RADIOLOGY SURG/COMPONENT 361 MULTI $948.75 $0.00

2200020 ABDOMEN COMPLETE 402 76700TC $1,295.25 $0.00

2200038 ABDOMEN LIMITED 402 76705TC $775.50 $0.00

2200046 LIVER SONOGRAM 402 76705TC $896.50 $0.00

2200053 GALL BLADDER SONOGRAM 402 76705TC $775.50 $0.00

2200061 KIDNEY SONOGRAM 402 76770TC $896.50 $0.00

2200095 AORTA SONOGRAM 402 76770TC $896.50 $0.00

2200111 CHEST 402 76604TC $896.50 $0.00

2200129 URINARY BLADDER 402 76856 $900.65 $0.00

2200137 PREGNANCY - LIMITED 402 76815 $793.40 $0.00

2200145 PREGNANCY - COMPLETE 402 76805TC $869.00 $0.00

2200178 PREGNANCY - MULTIPLE 402 76810 $1,166.00 $0.00

2200202 PELVIC 402 76856TC $875.90 $0.00



Page 11 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2200244 R&B 2HTU ICU

BREAST UNILATERAL 402 76645TC $331.40 $0.00

2200251 SCROTUM (TESTICLES) 402 76870TC $896.50 $0.00

2200269 THYROID/NECK MASS 402 76536 $896.50 $0.00

2200277 INTRALUMINAL PROSTATE 402 76872 $1,340.65 $0.00

2200285 NEONATAL HEAD 402 76506 $943.25 $0.00

2200319 BREAST COMP BILATERAL 402 76645TC $467.50 $0.00

2200327 ARTERIAL VASC-DUP BILAT 921 93925 $1,259.50 $0.00

2200335 INTRALUMINAL VAGINAL 402 76830TC $750.75 $0.00

2200343 EXTREMITY - NON VASCULAR 402 76880TC $896.50 $0.00

2200350 FETAL BIOPHYSICAL PROFILE 402 76818 $1,047.75 $0.00

2200384 GUIDANCE FOR THORACENTESI 402 76942TC $339.65 $0.00

2200392 GUIDANCE FOR PARACENTESIS 402 76942TC $339.65 $0.00

2200400 GUIDANCE FOR BIOPSY 402 76942 $339.65 $0.00

2200426 GUIDANCE FOR CYST/ASPIR 402 76942TC $339.65 $0.00

2200434 GUIDANCE FOR AMNIOCENTESI 402 76946TC $339.65 $0.00

2200475 GUIDANCE FOR ASPI 402 76942TC $339.65 $0.00

2200483 CAROTID IMAGING BILATERAL 921 93880 $1,200.40 $0.00

2200491 AORTA LLEO FEM 921 93925 $815.40 $0.00

2200517 PVL SEGMENTAL PRESSURES 921 93923 $1,709.15 $0.00

2200525 ANKLE-BRACHIAL INDEX (ABI 921 93922 $866.25 $0.00

2200533 PSEUDOANEURYSM COMPRESSIO 402 76936 $1,798.50 $0.00

2200541 PVL PENILE BRACHIAL INDIC 921 93980 $1,599.15 $0.00

2200558 SAPHENOUS VEIN MAPPING UN 921 93971 $892.40 $0.00

2200566 SAPHENOUS VEIN MAPPING BI 921 93970 $1,325.50 $0.00

2200574 PVL THORACIC OUTLET 921 93923 $1,709.15 $0.00

2200582 PVL RAYNAUDS SYNDROME 921 93923 $1,709.15 $0.00

2200590 PVL PPG PHOTOPLETHYSMOGR 921 93923 $1,709.15 $0.00

2200608 ARTERIAL VASC-DUPLEX UNIT 921 93926 $1,051.90 $0.00

2200624 PVL INTRAOPERATIVE DOPPLE 402 76986 $1,709.15 $0.00

2200640 VENOUS DUPLEX BILAT 921 93970 $1,325.50 $0.00

2200657 VENOUS DUPLEX UNILAT 921 93971 $892.40 $0.00

2200665 PORTABLE SET UP 921 Q0092 $94.90 $0.00

2200673 HEMODIALYSIS ACCESS 921 93990 $728.75 $0.00

2200681 SPINAL CANAL 402 76800 $948.75 $0.00

2200715 VEIN MAPPING UPPER EXT BI 921 93970 $1,325.50 $0.00

2200756 VEIN MAPPING UPPER EX UNI 921 93971 $892.40 $0.00

2200772 US GUIDE VASCULAR ACCESS 402 76937 $85.65 $0.00

2200848 NEONATAL HIP 402 76885 $948.75 $0.00

2200863 APPENDIX 402 76705 $775.50 $0.00

2200889 GUIDANCE FOR PICC LINE 402 76942 $282.95 $0.00

2200921 PERITONEOCENTESIS ABD 360 49080 $948.75 $0.00

2201002 ULTRASOUND SURG/COMPONENT 361 MULTI $948.75 $0.00

2300028 INCOMPLETE LIMITED EXAM 351 76380 $1,622.50 $0.00

2300051 HEAD W/O CONTRAST 351 70450 $2,717.00 $0.00

2300069 HEAD W/CONTRAST 351 70460 $2,970.00 $0.00

2300077 HEAD DBL STUDY 351 70470 $3,986.15 $0.00

2300085 ORBIT W/O CONTRAST 351 70480 $2,717.00 $0.00

2300176 EAR W/O CONTRAST 351 70480 $2,860.00 $0.00

2300200 FACIAL W/O CONTRAST 351 70486 $2,860.00 $0.00



Page 12 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2300218 R&B 2HTU ICU

FACIAL W/CONTRAST 351 70487 $3,126.75 $0.00

2300234 MAXILLA FACIAL W/O CONTRS 351 70486 $2,860.00 $0.00

2300242 MAXILLA FACIAL W/CONTRAST 351 70487 $3,126.75 $0.00

2300267 INTERNAL AUDITORY CANAL 351 70480 $2,860.00 $0.00

2300283 MAXILLA FACIAL LMT 351 76380 $745.25 $0.00

2300291 MASTOID 351 70480 $2,717.00 $0.00

2300309 TEMPORAL MANDIBULAR JTS 351 70486 $2,717.00 $0.00

2300317 NASOPHARYNX W/O CONTRAST 351 70486 $2,717.00 $0.00

2300325 NASOPHARYNX W/CONTRAST 351 70487 $2,970.00 $0.00

2300366 EXTREM UP W/O CONTRAST 352 73200 $2,316.90 $0.00

2300374 EXTREM UP W/CO 352 73201 $2,787.15 $0.00

2300390 EXTREM LOW W/O CONTRAST 352 73700 $2,316.90 $0.00

2300408 EXTREM LOW W/CONTRAST 352 73701 $2,648.25 $0.00

2300465 ABSCESS DRAINAGE 352 75989 $4,019.15 $0.00

2300473 GUIDANCE BIOPSY 352 76360 $3,814.25 $0.00

2300481 GUID CYST ASP 352 76360 $3,814.25 $0.00

2300549 CHEST W/O CONTRAST 352 71250 $2,970.00 $0.00

2300556 CHEST W/CONTRAST 352 71260 $3,302.75 $0.00

2300598 ABDOMEN W/O CONTRAST 352 74150 $2,970.00 $0.00

2300606 ABD W/CONTRAST 352 74160 $3,300.00 $0.00

2300622 PELVIS W/O CONTRAST 352 72192 $2,970.00 $0.00

2300630 PELVIS W/CONTRAST 352 72193 $3,300.00 $0.00

2300671 CHEST ANGIO R/O PE 352 71260 $3,302.75 $0.00

2300762 CERVICAL W/O CONTRAST 352 72125 $3,986.15 $0.00

2300770 CERVICAL W/CONTRAST 352 72126 $4,584.25 $0.00

2300788 THORACIC W/O CONTRAST 352 72128 $4,779.50 $0.00

2300796 THORACIC W/CONTRAST 352 72129 $5,658.15 $0.00

2300804 LUMBAR W/O CONTRAST 352 72131 $4,779.50 $0.00

2300812 LUMBAR W/CONTRAST 352 72132 $5,374.90 $0.00

2300820 NECK W/O CONTRAST 352 70490 $2,717.00 $0.00

2300838 NECK W/CONTRAST 352 70491 $2,970.00 $0.00

2300861 KIDNEY STONE STUDY 352 74150 $2,970.00 $0.00

2301026 GUIDANCE FOR TUBE PLACEMT 352 76360 $3,814.25 $0.00

2301034 PELVIS LIMITED 350 76380 $1,622.50 $0.00

2301042 ABDOMEN LIMITED 350 76380 $1,622.50 $0.00

2301059 CHEST LIMITED 350 76380 $1,622.50 $0.00

2301067 3D RENDER W/O POSTPROCESS 350 76376 $1,250.00 $0.00

2301075 3D RENDER WITH POSTPROCES 350 76377 $1,456.15 $0.00

2301125 CHEST TUBE PLACEMENT 352 76360 $3,814.25 $0.00

2301505 CT SURGICAL COMPONENT 361 MULTI $948.75 $0.00

2400026 THYROID UPTAKE & SCAN 341 78007 $875.25 $0.00

2400034 THY IMAGING ONLY 341 78010 $689.65 $0.00

2400059 THY CA NK/CST/OTH 341 78018 $2,266.40 $0.00

2400067 PARATHYROID IMAGING 341 78070 $1,756.20 $0.00

2400075 BONE MARROW MULTIPLE 341 78103 $2,423.90 $0.00

2400083 LIV/SPL VASC FLOW 341 78216 $1,655.25 $0.00

2400091 GALLBLADDER 341 78223 $2,539.30 $0.00

2400109 GASTRIC EMPTYING 341 78264 $2,641.65 $0.00

2400133 BONE IMAGING MUL. 341 78305 $2,020.15 $0.00



Page 13 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2400141 R&B 2HTU ICU BOD

BONE IM WHOLE 341 78306 $2,119.60 $0.00

2400158 BONE 3-PHASE 341 78315 $2,578.20 $0.00

2400166 BONE SPECT 341 78320 $1,337.40 $0.00

2400174 GATED W/EF, REF, VV 341 78472 $2,508.95 $0.00

2400182 PUL PERF IMA PART 341 78580 $1,668.25 $0.00

2400190 AEROSOL VENT. MUL. 341 78587 $1,283.50 $0.00

2400208 BRAIN SPECT 341 78607 $1,669.80 $0.00

2400216 RENOGRAM W/FLOW 341 78707 $2,461.45 $0.00

2400224 RENAL W/DRUG INTERVENTION 341 78708 $4,216.95 $0.00

2400232 TUMOR LOC ISO MUL 341 78801 $2,459.95 $0.00

2400240 TUMOR LOC ISO WHO 341 78802 $2,626.90 $0.00

2400257 STRESS MYOCAR/PERF W/WO R 341 78465 $3,795.00 $0.00

2400265 REST MYOCARDIAL PERF ONLY 341 78464 $1,988.15 $0.00

2400273 GATED WALL MOTION 341 78478 $383.35 $0.00

2400307 HYP THYR - INIT RX 342 79005 $347.50 $0.00

2400315 INDIUM WBC 341 78806 $4,000.05 $0.00

2400323 GI BLEED 341 78278 $2,410.95 $0.00

2400331 TESTICULAR 341 78761 $1,425.40 $0.00

2400356 GATED LVEF 341 78480 $409.85 $0.00

2400406 CISTERNOGRAM 341 78630 $3,715.31 $0.00

2400448 CYSTOGRAM 341 78740 $1,669.80 $0.00

2400455 TUMOR LOCALIZATION-SPECT 341 78803 $2,741.55 $0.00

2400463 THROMBOSIS IMAG/BILATERAL 341 78456 $1,062.60 $0.00

2400471 MECKELS 341 78290 $1,425.40 $0.00

2400620 PERFUSION/VENT LUNG SCAN 341 78588 $2,951.50 $0.00

2400661 I-131 RX / THYROID CANCER 342 79005 $1,100.00 $0.00

2490027 ISOT TC 99M MDP 343 A9503 $317.25 $0.00

2490076 ISOT TC 99M - 10MCI 343 A4641 $242.90 $0.00

2490175 ISOT TC 99M MYOVIEW 343 A9502 $910.80 $0.00

2490209 ISOT TL 201 1 MCI 343 A9505 $303.60 $0.00

2490225 ISOT TC 99M CERETEC 343 A9521 $2,072.05 $0.00

2490258 ISOT TC 99M CEA 343 A4641 $6,157.80 $0.00

2490266 ISOT TC 99M NEUTROSPECT 343 A4641 $3,410.40 $0.00

2490274 IN111 PENTETATE 0.5 MILLI 343 A9548 $1,789.38 $0.00

2490449 ISOT TC 99M ACUTECT 343 A9504 $2,277.00 $0.00

2490456 ISOT TC 99M NEOTECT 343 A9536 $2,428.80 $0.00

2490498 ISOT TC 99M CARDIOLITE 343 A9500 $910.80 $0.00

2490514 ISOT I-131 RX PER MCI 344 A9517 $79.20 $0.00

2490548 ISOT I 123 THYR PER 100UC 343 A9516 $206.80 $0.00

2490555 ISOT TC 99M DISOFENIN 343 A9510 $461.45 $0.00

2490563 ISOT I 131 MIBG 343 A9508 $4,400.00 $0.00

2490621 ISOT I-131 DX PER DOSE 343 A9528 $1,084.60 $0.00

2490670 ISOT I-131 RX PER 100 MCI 344 A9517 $3,000.00 $0.00

2490696 ISOT I-131 MIBG PER 500 U 343 A9508 $3,300.00 $0.00

2490720 ISOT TC99M SC PER DOSE 343 A9541 $365.00 $0.00

2490746 ISOT TC99M DTPA PER DOSE 343 A9539 $365.85 $0.00

2490761 ISOT TC99M CHOLTEC P-DOSE 343 A9537 $600.00 $0.00

2490787 ISOT IN-111 WBC PER DOSE 343 A9547 $1,800.00 $0.00

2490803 ISOT TC99M DMSA PER DOSE 343 A9551 $4,114.00 $0.00



Page 14 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

2490829 R&B 2HTU PER MCI

ISOT GA67 ICU 343 A9556 $105.60 $0.00

2490845 ISOT TC99M MAA PER DOSE 343 A9540 $1,200.00 $0.00

2490860 ISOT TC99M MAG3 PER DOSE 343 A9562 $3,900.00 $0.00

2490886 ISOT TC99M RBC PER DOSE 343 A9560 $1,800.00 $0.00

2490902 ISOT OCTREOTIDE PER MCI 343 A9565 $1,100.00 $0.00

2600104 LATE DISCH/ORDER MED/SUR 224 $0.00 $2,900.00

2600203 LATE DISCH/ORDER MED/SUR 224 $0.00 $2,900.00

2700102 LATE DISCHARGE ORDER OB 224 $0.00 $2,900.00

2800100 LATE DISCH/ORDER MED/SUR 224 $0.00 $2,900.00

2900108 LATE DISCH/ORDER MED/SUR 224 $0.00 $2,900.00

2900207 LATE DISCH/ORDER MED/SUR 224 $0.00 $3,900.00

3000031 OP DRAW FEE 300 36415 $39.90 $0.00

3000270 PHLEBOTOMY CHARGE 300 36415 $39.90 $0.00

3000288 SPECIMEN BANK 300 36415 $34.65 $0.00

3000346 C: NBN COLLECTION CARD 300 $1.00 $0.00

3000353 NBN SCREENING SERV 300 36416 $7.50 $0.00

3000387 SPECIMEN TNSFR; PT NOT MD 300 99001 $0.00 $0.00

3000395 SPECIMEN TNSFR; PT NOT MD 300 99001 $48.55 $0.00

3100013 BLEEDING TIME 305 85002 $156.90 $0.00

3100054 HEMATOCRIT 305 85014 $70.80 $0.00

3100070 CBC (MANUAL) 305 85027 $170.25 $0.00

3100088 CBC & AUTO WBC DIFF 305 85025 $120.15 $0.00

3100096 CBC ONLY 305 85027 $111.25 $0.00

3100104 RETICULOCYTE COUNT 305 85045 $128.45 $0.00

3100112 BONE MARROW PREP 310 85097 $76.75 $0.00

3100138 FDP 305 85362 $143.80 $0.00

3100146 FIBRINOGEN 305 85385 $185.65 $0.00

3100153 FETAL ROSETTE TEST 305 85461 $148.50 $0.00

3100195 PLATELET COUNT 305 85049 $83.20 $0.00

3100211 PROTHROMBIN TIME 305 85610 $123.30 $0.00

3100229 PT MIXTURE STUDY 305 85611 $151.95 $0.00

3100237 ESR WESTERGREN 305 85652 $123.30 $0.00

3100245 SICKLE CELL SCREEN 305 85660 $129.90 $0.00

3100260 PTT 305 85730 $152.20 $0.00

3100278 PTT MIXTURE STUDY 305 85732 $171.55 $0.00

3100294 ANTIBODY ABSORPTION 305 86978 $161.00 $0.00

3100302 ANTIBODY ELUTION 305 86860 $161.00 $0.00

3100310 ANTIBODY TITER RBC 305 86886 $252.80 $0.00

3100328 ANTIBODY ID STD RBC 305 86870 $377.20 $0.00

3100336 ANTIBODY ID SEL RBC 305 86870 $317.30 $0.00

3100344 COOMBS DIRECT POLY 305 86880 $141.15 $0.00

3100351 ANTIBODY SCREEN RBC 300 86850 $244.95 $0.00

3100369 CROSSMATCH IS/UNIT 305 86920 $174.00 $0.00

3100377 RH(D) ISG/DOSE 250 J2790 $189.25 $0.00

3100385 RH(D) ISG/MIC DOSE 636 J2788 $107.95 $0.00

3100393 TRANS RXN WORKUP 305 86880 $141.15 $0.00

3100401 SYRINGE ALIQUOT 305 86985 $115.90 $0.00

3100419 BLOOD TYPING ABO 300 86900 $138.70 $0.00

3100427 ANTIGEN RBC 305 86905 $135.20 $0.00



Page 15 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3100435 R&B 2HTU ICU

FFP THAW/UNIT 305 86927 $82.40 $0.00

3100443 CRYO THAW/UNIT 305 86927 $75.40 $0.00

3100450 NON-CROSSMATCH SETUP-TR 305 86999 $0.00 $0.00

3100468 DRAW CLOT & HOLD 305 36415 $74.40 $0.00

3100476 PREWARMED TECHNIQUE 305 86850 $197.50 $0.00

3100484 BLOOD TYPING RH 300 86901 $58.30 $0.00

3100492 POOLING COMPONENTS 305 86965 $43.40 $0.00

3100500 SPLITTING COMPONENT 305 86985 $173.50 $0.00

3100518 ANTIGEN RBC COOMBS 305 86905 $145.65 $0.00

3100526 CROSSMATCH CBS/UNIT 305 86922 $145.65 $0.00

3100534 CRYOFIBRINOGEN 300 82585 $85.25 $0.00

3100542 CRYOGLOBULIN 300 82595 $85.25 $0.00

3100567 KLEIHAUER TEST 300 85460 $226.95 $0.00

3100583 RUBELLA ANTIBODY IGG 300 86762 $123.30 $0.00

3100609 PLT AGG (IN VITRO) EA AGT 305 85576 $96.93 $0.00

3100617 PLT FUNCTION PLAVIX 305 85576 $96.93 $0.00

3100625 BLEEDING TIME 305 85002 $96.93 $0.00

3100633 PLT FUNCTION ASPRIN 305 85576 $96.93 $0.00

3100690 SMEAR, EOSINOPHILS 301 89190 $68.75 $0.00

3100708 ASO TITER 300 86060 $141.15 $0.00

3100716 RHEUMATOID FACTOR 300 86430 $141.15 $0.00

3100724 COLD AGGLUTININS 300 86157 $179.50 $0.00

3100732 HETEROPHILE ANTIBODY 300 86308 $123.30 $0.00

3100740 RPR 300 86592 $91.25 $0.00

3100757 HEMOGLOBIN 305 85018 $55.65 $0.00

3100765 PACKED CELL VOLUME 305 85013 $55.65 $0.00

3100773 WET MOUNT NON CX-VAG 305 87210 $96.05 $0.00

3100781 WET MOUNT SPERM ID 305 89321 $101.15 $0.00

3100799 CRYSTALS EXAM FLUID 305 89060 $123.30 $0.00

3100807 HEMATOCRIT FLUID 305 85013 $55.65 $0.00

3100815 CRYSTALS EXAM SYNOV 305 89060 $123.30 $0.00

3100823 CELL COUNT CSF 305 89051 $161.00 $0.00

3100831 CELL COUNT SYNOV 305 89051 $161.00 $0.00

3100849 CELL COUNT FLUID 305 89051 $161.00 $0.00

3100856 COOMBS DIRECT IGG 305 86880 $148.50 $0.00

3100864 COOMBS DIRECT CORD 305 86880 $148.50 $0.00

3100872 COOMBS DIRECT C3BD 305 86880 $148.50 $0.00

3100880 COOMBS INDIRECT 305 86885 $136.15 $0.00

3100898 SICKLE CELL SCREEN UNIT 305 85660 $129.90 $0.00

3100906 SMEAR WBC DIFF 305 85007 $59.00 $0.00

3100914 SMEAR SCAN ONLY 305 85008 $52.15 $0.00

3100922 SMEAR WBC DIFF BUFFY 305 85009 $65.90 $0.00

3100930 CBC AUTO & AUTO DIFF 305 85025 $120.15 $0.00

3100948 CBC AUTO & MAN DIFF 305 85027 $111.25 $0.00

3100955 OCMED RAPID HIV AB 305 86701 $78.15 $0.00

3101003 CR ABO TYPE 305 86900 $138.70 $0.00

3101011 CR ANTIBODY SCREEN 305 86850 $244.95 $0.00

3101029 CR ANTIBODY ID SEL 305 86870 $317.30 $0.00

3101037 CR ANTIBODY ID STD 305 86870 $377.20 $0.00



Page 16 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3101045 R&B 2HTU ICU TITER

CR ANTIBODY 305 86886 $252.80 $0.00

3101052 CR ANTIGEN RBC CBS 305 86905 $145.65 $0.00

3101060 CR ANTIGEN RBC 305 86905 $135.20 $0.00

3101078 CR COOMBS DIRCT C3BD 305 86880 $148.50 $0.00

3101086 CR CROSSMAT CBS/UNIT 305 86922 $145.65 $0.00

3101094 CR COOMBS DIRCT IGG 305 86880 $148.50 $0.00

3101102 CR COOMBS DIRCT POLY 305 86880 $141.15 $0.00

3101110 CR DRAW CLOT & HOLD 305 36415 $74.40 $0.00

3101128 CR FETAL ROSE TEST 305 85461 $148.50 $0.00

3101136 CR KLEIHAUER TEST 305 85460 $226.95 $0.00

3101151 CR LEUKODEP FILTER 305 $137.75 $0.00

3101169 CR SICKLE CELL TEST 305 85660 $129.90 $0.00

3101177 CR RH TYPE 305 86901 $58.30 $0.00

3101185 D-DIMER - QUAN 305 85379 $212.00 $0.00

3101193 COAG TIME ACTIVATED 305 85347 $57.00 $0.00

3200011 CRYPTOCOCCUS ANTIGEN 306 86403 $105.90 $0.00

3200029 CONCENTRATION ANY 306 87015 $52.15 $0.00

3200045 CUL MISC 306 87070 $155.80 $0.00

3200060 CUL STOOL 306 87045 $242.70 $0.00

3200078 CUL THROAT 306 87070 $155.80 $0.00

3200086 CUL PEDS BLOOD 306 87040 $197.75 $0.00

3200094 CUL BLOOD 306 87040 $197.75 $0.00

3200110 CUL ANAEROBIC 306 87075 $226.55 $0.00

3200128 CUL ENVIRONMENTAL 306 87081 $47.00 $0.00

3200144 CUL URINE 306 87088 $187.80 $0.00

3200151 SMR WET MOUNT CX-VAG 306 87210 $96.05 $0.00

3200169 STREP SCREEN 306 87430 $177.95 $0.00

3200177 CUL FUNGUS 306 87102 $210.65 $0.00

3200185 CUL FUNGUS SKIN 306 87101 $221.65 $0.00

3200193 CUL FUNGUS BLOOD 306 87103 $221.65 $0.00

3200201 CUL AFB 306 87116 $210.65 $0.00

3200219 LISTERIA TYPE 306 87147 $104.25 $0.00

3200243 O&P SMR/CONC/ID 306 87177 $160.40 $0.00

3200250 ARTHROPOD-INSECT ID 306 87168 $55.75 $0.00

3200268 SENS KB EACH 306 87181 $38.50 $0.00

3200276 SENS KB PANEL 306 87184 $173.70 $0.00

3200284 SENS MIC PANEL 306 87186 $231.70 $0.00

3200300 SMR GRAM STAIN 306 87205 $73.30 $0.00

3200318 SMR AFB 306 87206 $96.05 $0.00

3200326 SMR MALARIAL 306 87207 $100.75 $0.00

3200334 SMR CRYPTOSPORIDIUM 306 87207 $160.40 $0.00

3200342 SMR PINWORM PREP 306 87172 $90.30 $0.00

3200359 SMR KOH 306 87220 $96.05 $0.00

3200367 CL DIFFICILE TOXIN 306 87324 $154.75 $0.00

3200375 ROTAVIRUS AG 306 87425 $202.55 $0.00

3200391 OCCULT BLOOD FECAL 306 82270 $59.00 $0.00

3200409 RSV ANTIGEN 306 87420 $148.50 $0.00

3200417 HAEMOPHILUS TYPE 306 87147 $104.25 $0.00

3200425 SMR GRAM STAIN 306 87205 $73.30 $0.00



Page 17 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3200433 R&B 2HTU ICU

SMR AFB 306 87206 $96.05 $0.00

3200441 SMR FUNGUS 306 87205 $72.25 $0.00

3200458 TISSUE GRINDING 306 87176 $52.15 $0.00

3200516 CL DIFFICILE TOXINS 306 87324 $154.75 $0.00

3200524 STREP LANCEFIELD A 306 87430 $47.45 $0.00

3200532 STREP LANCEFIELD B 306 86403 $47.45 $0.00

3200540 STREP LANCEFIELD C 306 86403 $47.45 $0.00

3200557 STREP LANCEFIELD F 306 86403 $47.45 $0.00

3200565 STREP LANCEFIELD G 306 86403 $47.45 $0.00

3200607 CUL ABCESS 306 87070 $155.80 $0.00

3200615 CUL NEEDLE ASPIRATE 306 87070 $155.80 $0.00

3200623 CUL BURN 306 87070 $155.80 $0.00

3200631 CUL CATHETER TIP 306 87070 $155.80 $0.00

3200649 CUL CSF 306 87070 $155.80 $0.00

3200656 CUL DECUBITUS 306 87070 $155.80 $0.00

3200664 CUL DRAINAGE 306 87070 $155.80 $0.00

3200672 CUL EAR - EYE 306 87070 $155.80 $0.00

3200680 CUL STERILE FLUID 306 87070 $155.80 $0.00

3200698 CUL GONORRHEAE 306 87081 $155.80 $0.00

3200706 CUL UROGENITAL 306 87070 $155.80 $0.00

3200714 CUL INCISION 306 87070 $155.80 $0.00

3200722 CUL IV SITE 306 87070 $155.80 $0.00

3200730 CUL MRSA 306 87070 $155.80 $0.00

3200748 CUL NEWBORN EYE 306 87070 $155.80 $0.00

3200755 CUL RESPIRATORY 306 87070 $155.80 $0.00

3200763 CUL TISSUE 306 87070 $155.80 $0.00

3200771 CUL TXN RXN-TR 306 87070 $0.00 $0.00

3200789 CUL VRE 306 87070 $155.80 $0.00

3200797 CUL WOUND 306 87070 $155.80 $0.00

3200805 SMR FUNGUS 306 87205 $72.25 $0.00

3200813 SMR ISOSPORA 306 87206 $101.15 $0.00

3200821 SMR WBC 306 87205 $72.25 $0.00

3200839 E COLI 0157 ANTIGEN 306 87335 $111.45 $0.00

3200847 NEISSERIA TYPE 306 87147 $104.25 $0.00

3200854 SALMON O D TYPE 306 87147 $104.25 $0.00

3200862 SALMON O A-I/VI TYPE 306 87147 $104.25 $0.00

3200870 SHIGELLA GR B TYPE 306 87147 $104.25 $0.00

3200888 SHIGELLA GR D TYPE 306 87147 $104.25 $0.00

3200896 CUL ID GNR 306 87077 $90.70 $0.00

3200904 CUL ID GNC 306 87077 $90.70 $0.00

3200912 CUL ID GPR 306 87077 $90.70 $0.00

3200920 CUL ID YEAST 306 87106 $90.70 $0.00

3200938 CUL ID STAPH 306 87077 $90.70 $0.00

3200946 CUL ID STREP 306 87077 $90.70 $0.00

3200953 CUL ID PSEUDOMONAS 306 87077 $90.70 $0.00

3200961 CUL ID HAEMOPHILUS 306 87077 $90.70 $0.00

3200979 CUL ID MORAXELLA 306 87077 $90.70 $0.00

3200987 CUL ID GARDNERELLA 306 87077 $90.70 $0.00

3200995 CUL ID ENTEROCOCCUS 306 87077 $90.70 $0.00



Page 18 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3201001 R&B ID E COLI

CUL 2HTU ICU 306 87077 $90.70 $0.00

3201019 CUL ID GROUP B STREP 306 87077 $90.70 $0.00

3201027 CUL ID S AUREUS 306 87077 $90.70 $0.00

3201035 CUL ID NON-S AUR (2) 306 87077 $90.70 $0.00

3201043 CUL ID SALMONELLA 306 87077 $90.70 $0.00

3201050 CUL ID SHIGELLA 306 87077 $90.70 $0.00

3201068 CUL ID YERSINIA 306 87077 $90.70 $0.00

3201076 CUL ID CAMPYLOBACTER 306 87077 $90.70 $0.00

3201084 CUL ID VIBRIO 306 87077 $90.70 $0.00

3201092 CUL ID E COLI 0157 306 87077 $90.70 $0.00

3201100 CUL ID GROUP A STREP 306 87077 $90.70 $0.00

3201118 ANA ID GNR 306 87076 $90.70 $0.00

3201126 ANA ID GPC 306 87076 $90.70 $0.00

3201134 ANA ID GNC 306 87076 $90.70 $0.00

3201142 ANA ID GPR 306 87076 $90.70 $0.00

3201159 ANA ID C DIFF 306 87076 $90.70 $0.00

3201167 BLD ID GNR 306 87077 $90.70 $0.00

3201175 BLD ID GNC 306 87077 $90.70 $0.00

3201183 BLD ID GPR 306 87077 $90.70 $0.00

3201191 BLD ID YEAST 306 87106 $90.70 $0.00

3201209 BLD ID STAPH 306 87077 $90.70 $0.00

3201217 BLD ID STREP 306 87077 $90.70 $0.00

3201225 BLD ID ENTEROCOCCUS 306 87077 $90.70 $0.00

3201233 BLD ID PSEUDOMONAS 306 87077 $90.70 $0.00

3201241 BLD ID HAEMOPHILUS 306 87077 $90.70 $0.00

3201258 BLD ID MORAXELLA 306 87077 $90.70 $0.00

3201266 BLD ID GARDNERELLA 306 87077 $90.70 $0.00

3201324 BLD ID GNR (2) 306 87077 $90.70 $0.00

3201332 BLD ID STAPH (2) 306 87077 $90.70 $0.00

3201340 BLD ID STREP (2) 306 87077 $90.70 $0.00

3201357 CUL ID ENTEROCOC (2) 306 87077 $90.70 $0.00

3201365 CUL ID GNC (2) 306 87077 $90.70 $0.00

3201373 CUL ID GNR (2) 306 87077 $90.70 $0.00

3201381 CUL ID GNR (3) 306 87077 $90.70 $0.00

3201399 CUL ID GNR (4) 306 87077 $90.70 $0.00

3201407 CUL ID GNR (5) 306 87077 $90.70 $0.00

3201415 CUL ID GPR (2) 306 87077 $90.70 $0.00

3201423 CUL ID HAEMOPHIL (2) 306 87077 $90.70 $0.00

3201431 CUL ID PSEUDOMON (2) 306 87077 $90.70 $0.00

3201449 CUL ID S AUREUS (2) 306 87077 $90.70 $0.00

3201456 CUL ID STAPH (2) 306 87077 $90.70 $0.00

3201464 CUL ID STAPH (3) 306 87077 $90.70 $0.00

3201472 CUL ID STREP (2) 306 87077 $90.70 $0.00

3201480 CUL ID STREP (3) 306 87077 $90.70 $0.00

3201498 CUL ID NON-S AUR (2) 306 87077 $90.70 $0.00

3201506 CUL ID BRP B STREP 306 87081 $90.70 $0.00

3300019 ELECTROLYTE PANEL 301 80051 $197.25 $0.00

3300027 METABOLIC BASE PANEL 301 80048 $241.05 $0.00

3300035 METABOLIC COMP PANEL 301 80053 $300.30 $0.00



Page 19 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3300043 R&B FUNC PANEL

HEP 2HTU ICU 301 80076 $230.15 $0.00

3300050 RENAL FUNC PANEL 301 80069 $263.05 $0.00

3300076 OSMOLALITY FLUID 301 83930 $138.15 $0.00

3300092 VANCOMYCIN TROUGH 301 80202 $231.95 $0.00

3300159 VOLUME URINE COLLECT 301 81050 $28.45 $0.00

3300167 LIPID PANEL 301 80061 $273.20 $0.00

3300183 UBG URINE QUAL 301 84578 $48.75 $0.00

3300191 CARBAMAZEPINE TOTAL 301 80156 $220.55 $0.00

3300209 VALPROIC ACID 301 80164 $220.55 $0.00

3300225 UA AUTO & MICRO 301 81001 $86.40 $0.00

3300233 UA REFLEX MICRO 301 81001 $86.40 $0.00

3300241 UA REAGENT STRIP AUTO 301 81003 $73.80 $0.00

3300258 UA MICROSCOPIC 301 81015 $12.50 $0.00

3300266 HCG URINE QUAL 301 81025 $141.90 $0.00

3300274 VOLUME TIMED URINE 301 81050 $28.45 $0.00

3300290 ACETAMINOPHEN 301 82003 $227.55 $0.00

3300308 KETONES SERUM 301 82009 $60.95 $0.00

3300316 KETONES URINE 301 81002 $60.95 $0.00

3300324 SALICYLATE 301 80196 $195.25 $0.00

3300332 ALBUMIN 301 82040 $90.50 $0.00

3300340 ETHANOL 301 82055 $249.00 $0.00

3300357 THEOPHYLLINE 301 80198 $222.75 $0.00

3300365 AMMONIA 301 82140 $183.30 $0.00

3300373 AMYLASE SERUM 301 82150 $184.80 $0.00

3300381 AMYLASE 24HR URINE 301 82150 $184.80 $0.00

3300399 PHENOBARBITAL 301 80184 $220.55 $0.00

3300407 CHLORIDE CSF 301 82438 $107.75 $0.00

3300431 CALCIUM TOTAL 301 82310 $140.25 $0.00

3300449 CALCIUM IONIZED 301 82330 $153.00 $0.00

3300456 CALCIUM 24HR URINE 301 82340 $140.25 $0.00

3300464 CO2 TOTAL 301 82374 $107.75 $0.00

3300472 CHLORIDE 301 82435 $113.45 $0.00

3300480 CHLORIDE 24HR URINE 301 82436 $107.75 $0.00

3300498 CHLORIDE FLUID 301 82438 $107.75 $0.00

3300506 CHOLESTEROL TOTAL 301 82465 $135.30 $0.00

3300514 CK TOTAL 301 82550 $167.75 $0.00

3300522 CK-MB FRACTION 301 82553 $201.30 $0.00

3300530 CREATININE 301 82565 $123.30 $0.00

3300548 CREATININE URINE 301 82570 $123.30 $0.00

3300555 CREATININE CLEAR 301 82575 $247.05 $0.00

3300563 DIGOXIN 301 80162 $263.30 $0.00

3300571 PHENYTOIN TOTAL 301 80185 $225.40 $0.00

3300605 UA DRUG SCREEN QUAL 301 80100 $252.20 $0.00

3300613 GENTAMICIN TROUGH 301 80170 $220.55 $0.00

3300621 PH 301 82800 $124.00 $0.00

3300639 ARTERIAL GASES 301 82805 $455.40 $0.00

3300647 REDUCING SUBS FECES 301 81002 $69.65 $0.00

3300654 GLUCOSE 301 82947 $147.65 $0.00

3300662 GTT 2-HR ADD 3 301 82952 $70.25 $0.00



Page 20 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3300670 R&B 2-HR ADD 6

GTT 2HTU ICU 301 82952 $70.25 $0.00

3300688 GTT 2-HR ADD 4 301 82952 $70.25 $0.00

3300696 GTT 2-HR 3-SPEC 301 82951 $313.65 $0.00

3300704 GTT 2-HR ADD 5 301 82952 $70.25 $0.00

3300712 GLUCOSE 1HR PPD 301 82950 $117.80 $0.00

3300720 GGT 301 82977 $153.00 $0.00

3300738 HCG SERUM QUAL 301 84703 $141.90 $0.00

3300753 FERRITIN 301 82728 $225.40 $0.00

3300761 BLOOD URINE 301 81001 $48.75 $0.00

3300779 HORMONE TSH 301 84443 $231.90 $0.00

3300787 IRON TOTAL 301 83540 $153.00 $0.00

3300795 TIBC 301 83550 $200.95 $0.00

3300803 LACTIC ACID 301 83605 $151.95 $0.00

3300811 LD TOTAL 301 83615 $127.55 $0.00

3300837 LD FLUID 301 83615 $153.00 $0.00

3300852 PHOSPHATIDLY GLY 301 84081 $283.70 $0.00

3300860 HDL CHOLESTEROL 301 83718 $186.95 $0.00

3300878 MAGNESIUM TOTAL 301 83735 $159.40 $0.00

3300886 MAGNESIUM IONIZED 301 83735 $159.40 $0.00

3300894 MYOGLOBIN 301 83874 $171.95 $0.00

3300902 OSMOLALITY 301 83930 $131.30 $0.00

3300910 OSMOLALITY URINE 301 83935 $131.30 $0.00

3300928 PH FLUID 301 83986 $46.25 $0.00

3300936 ALKALINE PHOSPHATASE 301 84075 $141.15 $0.00

3300944 PHOSPHORUS 301 84100 $136.15 $0.00

3300951 PHOSPHORUS 24HR URINE 301 84105 $129.20 $0.00

3300977 POTASSIUM 301 84132 $129.20 $0.00

3300985 POTASSIUM 24HR URINE 301 84133 $129.20 $0.00

3300993 PREALBUMIN 300 84134 $142.45 $0.00

3301009 PROTEIN TOTAL 301 84155 $105.90 $0.00

3301017 PROTEIN URINE QUAL 301 81002 $60.95 $0.00

3301025 PROTEIN TOTAL FLUID 301 84155 $105.90 $0.00

3301033 PROTEIN TOTAL CSF 301 84155 $111.45 $0.00

3301041 QUINIDINE 301 80194 $220.55 $0.00

3301058 SODIUM 301 84295 $129.20 $0.00

3301066 SODIUM 24HR URINE 301 84300 $129.20 $0.00

3301074 SP GR FLUID 301 84315 $46.25 $0.00

3301082 THYROXINE FREE 301 84439 $135.30 $0.00

3301090 TOBRAMYCIN TROUGH 301 80200 $220.55 $0.00

3301108 AST 301 84450 $141.15 $0.00

3301116 ALT 301 84460 $185.55 $0.00

3301124 TRIGLYCERIDES 301 84478 $141.15 $0.00

3301132 TROPONIN, QUAN 301 84484 $201.30 $0.00

3301140 UREA NITROGEN 301 84520 $123.30 $0.00

3301157 UREA NIT 24HR URINE 301 84540 $123.30 $0.00

3301165 UREA CLEARANCE 301 84545 $247.05 $0.00

3301173 URIC ACID 301 84550 $134.55 $0.00

3301181 URIC ACID 24HR FLUID 301 84560 $129.20 $0.00

3301207 CRP 301 86140 $123.30 $0.00



Page 21 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3301215 R&B 2HTU ICU

URIC ACID FLUID 301 84560 $136.15 $0.00

3301223 PSA TOTAL 301 84153 $223.00 $0.00

3301231 CEA 301 82378 $223.00 $0.00

3301249 VITAMIN B-12 301 82607 $199.25 $0.00

3301256 FOLIC ACID 301 82746 $199.25 $0.00

3301264 PROCAINAMIDE/NAPA 301 80192 $231.95 $0.00

3301272 HCG B-SUBUNIT QUANT 301 84702 $223.00 $0.00

3301405 BILIRUBIN TOTAL 301 82247 $89.65 $0.00

3301413 BILIRUBIN DIRECT 301 82248 $89.65 $0.00

3301421 GLUCOSE 2HR PPD 301 82950 $124.00 $0.00

3301439 AMYLASE 2HR URINE 301 82150 $161.00 $0.00

3301447 SODIUM URINE 301 84300 $136.15 $0.00

3301454 CHLORIDE URINE 301 82436 $113.45 $0.00

3301462 POTASSIUM URINE 301 84133 $136.15 $0.00

3301470 UREA NITROGEN URINE 301 84540 $129.90 $0.00

3301488 ALBUMIN FLUID 301 82042 $95.25 $0.00

3301496 AMYLASE FLUIS 301 82150 $161.00 $0.00

3301504 CALCIUM FLUID 301 82310 $147.65 $0.00

3301512 CHOLESTEROL FLUID 301 82465 $142.30 $0.00

3301520 CREATININ 24HR URINE 301 82570 $129.90 $0.00

3301538 CREATININE FLUID 301 82570 $129.90 $0.00

3301546 POTASSIUM FLUID 301 84132 $136.15 $0.00

3301553 SODIUM FLUID 301 84302 $136.15 $0.00

3301561 UREA NITROGEN FLUID 301 84520 $129.90 $0.00

3301579 VANCOMYCIN PEAK 301 80202 $231.95 $0.00

3301587 VANCOMYCIN RANDOM 301 80202 $231.95 $0.00

3301595 TOBRAMYCIN PEAK 301 80200 $231.95 $0.00

3301603 TOBRAMYCIN RANDOM 301 80200 $231.95 $0.00

3301611 GENTAMICIN RANDOM 301 80170 $231.95 $0.00

3301629 GENTAMICIN PEAK 301 80170 $231.95 $0.00

3301637 REDUCING SUBS URINE 301 81002 $55.75 $0.00

3301645 PROTEIN TOTAL URINE 301 84155 $111.45 $0.00

3301652 PROTEIN 24HR URINE 301 84155 $111.45 $0.00

3301660 GLUCOSE CSF 301 82945 $124.00 $0.00

3301678 GLUCOSE FLUID 301 82945 $124.00 $0.00

3301686 GLUCOSE URINE 301 82945 $124.00 $0.00

3301694 GLUCOSE 24HR URINE 301 82945 $124.00 $0.00

3301702 HORMONE TSH REFLEX 301 84443 $244.15 $0.00

3301710 OCMED CHEM PANEL 8 301 $13.20 $0.00

3301728 OCMED CHEM PANEL A 301 $61.90 $0.00

3301736 OCMED CHEM PANEL 16 301 $33.00 $0.00

3301744 OCMED EXEC PANEL B 301 $57.75 $0.00

3301751 OCMED EXEC PANEL C 301 $57.75 $0.00

3301769 SP GR URINE 301 81002 $48.75 $0.00

3301777 LIPASE 301 83690 $184.80 $0.00

3301876 MAGNESIUM 24HR URINE 301 83735 $129.20 $0.00

3301884 LD CSF 301 83615 $153.00 $0.00

3301892 MICROALBUMIN RANDOM 301 82043 $136.15 $0.00

3301900 LDL CHOLESTEROL 301 83721 $186.95 $0.00



Page 22 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3301918 R&B 2HTU ICU

FETAL FIBRONECTIN 301 82731 $379.50 $0.00

3301926 CRP HIGH SENSITIVITY 301 86141 $151.25 $0.00

3301934 SALICYLATE 301 80196 $195.25 $0.00

3301942 TRANSFERRIN 301 84466 $200.95 $0.00

3301959 HEMOGLOBIN GLYCO 301 83036 $195.25 $0.00

3301967 NATRIURETIC PEPTIDE 301 83880 $282.70 $0.00

3301975 CHLAMYDIA URINE 300 87491 $22.45 $0.00

3302007 CR UA REAGENT AUTO 301 81003 $73.80 $0.00

3410016 A: PROTEIN S TOTAL 300 85306 $22.00 $0.00

3410057 A: ACE 300 82164 $12.00 $0.00

3410065 A: AFP 300 82105 $10.25 $0.00

3410073 A: ALA URINE 300 82135 $34.40 $0.00

3410081 A: ALDOLASE BLOOD 300 82085 $8.50 $0.00

3410099 A: ALDOSTERONE BLOOD 300 82088 $15.00 $0.00

3410107 A: ALDOSTERONE URINE 300 82088 $16.95 $0.00

3410115 A: ALK PHOS, ISOENZ 300 84080 $18.00 $0.00

3410123 A: AMEBIASIS AB 300 86753 $16.15 $0.00

3410149 A: AMPHETAMINE GCMS 300 80102 $22.50 $0.00

3410156 A: ANTI-THROMBIN III 300 85301 $15.00 $0.00

3410164 A: ANTIBODY DNA DS 300 86225 $11.50 $0.00

3410172 A: ANTIBODY MITCHND 300 86256 $11.45 $0.00

3410180 A: ANTIBODY NEUTRO 300 86255 $50.70 $0.00

3410198 A: ANTIBODY NUCLEAR 300 86038 $8.00 $0.00

3410206 A: ANTIBODY SM MUSC 300 86255 $11.00 $0.00

3410214 A: ASPERGILLIS AB 300 86606 $13.50 $0.00

3410222 A: ANTITRIPSIN 300 82103 $12.25 $0.00

3410305 A: BARBITURATES GC/MS 300 82542 $60.20 $0.00

3410313 A: BENZODIAZEPN GC/MS 300 80102 $64.45 $0.00

3410404 A: CANCER AG 125 300 86304 $9.65 $0.00

3410412 A: CANCER AG 27.29 300 86300 $14.60 $0.00

3410420 A: CANNABIS GC/MS 300 80102 $45.10 $0.00

3410438 A: CARDIOLIPIN AB 300 86147 $17.50 $0.00

3410446 A: CATECHOL PLS FRAC 300 82384 $19.20 $0.00

3410453 A: CATECHOL URN FRAC 300 82384 $19.30 $0.00

3410461 A: CEA 300 82378 $17.25 $0.00

3410479 A: CERULOPLASMIN 300 82390 $16.45 $0.00

3410487 A: CHLAMYDIA AG 300 87490 $10.79 $0.00

3410495 A: CHROMOSOME BLOOD 310 PANEL $305.00 $0.00

3410503 A: CMV AB-IGG 300 86644 $10.50 $0.00

3410511 A: COCAINE GC/MS 300 80102 $64.45 $0.00

3410537 A: COCCI AB-COMP FIX 300 86171 $26.50 $0.00

3410545 A: COCCI AB-ID 300 86331 $9.50 $0.00

3410552 A: COMPLEMENT CH50 300 86162 $15.50 $0.00

3410560 A: COMPLEMENT C3C 300 86160 $10.00 $0.00

3410578 A: COMPLEMENT C4 300 86160 $10.00 $0.00

3410586 A: COPPER BLOOD 300 82525 $14.55 $0.00

3410594 A: CORTISOL TOTAL 300 82533 $13.00 $0.00

3410602 A: CRYOGLOBULIN 300 82595 $14.00 $0.00

3410610 A: CULTURE CHLAMYDIA 300 87110 $21.20 $0.00



Page 23 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3410628 R&B 2HTU ICU

A: CULTURE CMV 300 87252 $43.60 $0.00

3410636 A: CULTURE VIRUS 300 87252 $36.60 $0.00

3410800 A: DHEA-S HORMONE 300 82627 $16.00 $0.00

3410818 A: DRUG SCREEN MECO 300 80101 $51.25 $0.00

3410826 A: EBV AB 300 86665 $27.75 $0.00

3410859 A: ESTRADIOL (E2) 300 82670 $17.25 $0.00

3410909 A: FACTOR IX 300 85250 $66.25 $0.00

3410917 A: FACTOR V 300 85220 $26.50 $0.00

3410925 A: FACTOR VIII 300 85240 $26.70 $0.00

3410933 A: FACTOR VIII AG 300 85246 $33.50 $0.00

3410958 A: FEBRILE AGGLUTININ 300 86000 $36.50 $0.00

3410966 A: FOLIC ACID RBC 300 82747 $10.00 $0.00

3410974 A: FOLIC ACID 300 82746 $14.52 $0.00

3411006 A: G-6-PD QUANT 300 82955 $29.75 $0.00

3411014 A: GASTRIN 300 82941 $16.25 $0.00

3411022 A: HAPTOGLOBIN 300 83010 $13.00 $0.00

3411105 A: HEMOGLOBIN EP 300 83020 $15.00 $0.00

3411113 A: HEMOGLOBIN GLYCO 300 83036 $9.09 $0.00

3411121 A: HEP A AB-IGM 300 86709 $5.56 $0.00

3411147 A: HEP B CORE AB 300 86704 $9.75 $0.00

3411154 A: HEP B E AG 300 87350 $11.75 $0.00

3411162 A: HEP B SURF AB 300 86706 $8.20 $0.00

3411170 A: HEP ABC PANEL 300 80074 $24.69 $0.00

3411188 A: HEP B SURF AG 300 87340 $4.00 $0.00

3411196 A: HEP C RIBA 300 86804 $69.50 $0.00

3411204 A: AB IMMUNOASSAY 300 86701 $15.50 $0.00

3411220 A: HORMONE ACTH 300 82024 $20.25 $0.00

3411238 A: HORMONE FSH 300 83001 $7.00 $0.00

3411246 A: HORMONE GROWTH 300 83003 $10.25 $0.00

3411253 A: HORMONE LH 300 83002 $10.00 $0.00

3411261 A: HORMONE PROLACTIN 300 84146 $10.00 $0.00

3411279 A: HSV CULTURE 300 87252 $25.00 $0.00

3411287 A: HSV I&II ABS-IGG 300 86695 $34.15 $0.00

3411295 A: HVY MTL QT BLOOD 300 82175 $37.50 $0.00

3411303 A: HVY MTL SCRN URN 300 83015 $29.90 $0.00

3411402 A: IG G/A/M QT 300 82784 $27.00 $0.00

3411410 A: IGA 300 82784 $10.80 $0.00

3411428 A: IGE 300 82784 $14.00 $0.00

3411436 A: IGM 300 82784 $10.80 $0.00

3411444 A: IMMUNOFIX EP SERUM 300 86334 $40.65 $0.00

3411451 A: INSULIN 300 83525 $10.50 $0.00

3411477 A: LIDOCAINE 300 80176 $31.16 $0.00

3411527 A: LEAD, BLOOD 300 83655 $15.85 $0.00

3411535 A: LEGIONELLA AB 300 86713 $11.45 $0.00

3411543 A: LIPASE 300 83690 $4.48 $0.00

3411550 A: LUPUS INHIBITOR 300 85613 $33.75 $0.00

3411568 A: LIME DISEASE AB 300 86618 $38.00 $0.00

3411600 A: METANEPHRINES 300 83835 $29.80 $0.00

3411618 A: MYCOPLASMA AB 300 86738 $12.45 $0.00



Page 24 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3411634 R&B 2HTU ICU URINE

A: MYOGLOBIN 300 83874 $15.00 $0.00

3411709 A: OLIGOCLONAL BANDS 300 83916 $32.50 $0.00

3411717 A: OPIATE GC/MS 300 80102 $64.45 $0.00

3411766 A: PCP GC/MS 300 80102 $60.20 $0.00

3411774 A: PHOS ACID (PAP) 300 84066 $10.25 $0.00

3411808 A: PP, RBC 300 84202 $15.65 $0.00

3411824 A: PROGESTERONE 300 84144 $10.00 $0.00

3411832 A: PROTEIN C ASSAY 300 85303 $19.75 $0.00

3411840 A: PROTEIN EP CSF 300 84166 $14.50 $0.00

3411857 A: PROTEIN EP FLUID 300 84166 $39.12 $0.00

3411865 A: PROTEIN EP SERUM 300 84165 $15.67 $0.00

3411873 A: PROTEIN EP URINE 300 84166 $15.67 $0.00

3411881 A: PSA TOTAL 300 84153 $10.40 $0.00

3411899 A: PTH C-TERMINAL 300 83970 $46.35 $0.00

3411907 A: Q FEVER AB 300 86638 $23.00 $0.00

3411964 A: RUBELLA IGM 300 86762 $9.45 $0.00

3411972 A: RUBEOLA IGG 300 86765 $8.00 $0.00

3412004 A: STONE ANALYSIS 300 82365 $13.00 $0.00

3412020 A: T CELL CD4 COUNT 300 88182 $26.90 $0.00

3412038 A: T CELL H/S PROFILE 300 85025 $88.28 $0.00

3412046 A: TESTOSTERONE 300 84403 $13.75 $0.00

3412053 A: TORCH IGG AB PANEL 300 80090 $28.99 $0.00

3412061 A: TORCH IGM AB PANEL 300 80090 $49.63 $0.00

3412079 A: TOXOPLASMA IGM 300 86778 $17.50 $0.00

3412087 A: TRANSFERRIN 300 84466 $20.81 $0.00

3412095 A: T3 TOTAL 300 84480 $8.00 $0.00

3412152 A: VDRL CSF 300 86593 $8.50 $0.00

3412160 A: VITAMIN B-12 300 82607 $14.37 $0.00

3412178 A: VMA URINE 300 84585 $15.75 $0.00

3412186 A: VZV IGG 300 86787 $8.50 $0.00

3412251 A: WESTERN BLOT 300 86689 $42.75 $0.00

3412301 A: ZINC 300 84630 $38.00 $0.00

3412350 A: 17-KETOSTEROIDS 300 83586 $10.00 $0.00

3412368 A: 17-OHCS 300 83491 $45.10 $0.00

3412376 A: 5-HIAA URINE 300 83497 $15.60 $0.00

3412392 A: O&P SMR/CONC/ID 300 87177 $15.50 $0.00

3412400 A: ASO TITER 300 86060 $6.50 $0.00

3412418 A: RHEUMATOID FACTOR 300 86431 $5.50 $0.00

3412426 A: COLD AGGILLUTININGS 300 86157 $16.00 $0.00

3412434 A: CHLAMYDIA URINE 300 87491 $17.95 $0.00

3412442 A: OC URINE 300 87591 $17.95 $0.00

3412509 B: CYCLOSPORINE 300 80158 $30.00 $0.00

3412525 A: IGG 300 82784 $10.80 $0.00

3412541 B: LIDOCAINE 300 80176 $23.00 $0.00

3412566 B: LITHIUM 300 80178 $12.00 $0.00

3412582 B: PRIMIDONE 300 80188 $33.00 $0.00

3412608 B: NAPA/PROCAINAMIDE 300 80192 $33.00 $0.00

3412624 B: PSEUDO CHE 300 82480 $15.00 $0.00

3412681 C: NBN SCREEN-PHYLALAINE 300 84030 $15.40 $0.00



Page 25 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3412707 R&B 2HTU ICU

F: CUL AFB BLOOD 300 87116 $21.97 $0.00

3412715 F: SENS AFB PANEL (6) 300 87190 $119.28 $0.00

3412723 F: MHA-TP 300 86781 $8.22 $0.00

3412731 F: RPR QUAL 300 86592 $5.34 $0.00

3412749 F: RPR QUANT 300 86593 $5.82 $0.00

3412756 F: TP-PA 300 86781 $13.19 $0.00

3412764 GLUCOSE MON DEVICE 300 82962 $9.12 $0.00

3412772 GLUCOSE REAGENT STRIP 300 82948 $9.12 $0.00

3412806 MISC BATTERY 300 $0.00 $0.00

3412814 A: PTH INTACT 300 83970 $22.40 $0.00

3412830 A: H PYLORI ABS-IGG 300 86677 $20.25 $0.00

3412848 A: MICROALBUMIN 300 82043 $8.87 $0.00

3412855 F: SENS AFB EACH 301 87190 $18.24 $0.00

3412863 A: FERRITIN 300 82728 $15.14 $0.00

3412871 A: PRIMIDONE 300 80188 $35.95 $0.00

3412889 B: TOBRAMYCIN PEAK 300 80200 $25.00 $0.00

3412897 B: TOBRAMYCIN RANDOM 300 80200 $25.00 $0.00

3412905 B: TOBRAMYCIN TROUGH 300 80200 $25.00 $0.00

3412913 B: QUINIDINE 300 80194 $23.00 $0.00

3412921 A: ANTIBODY NUCLEAR TITER 300 86039 $21.63 $0.00

3412939 B: CARBAMAZEPINE 300 80156 $23.00 $0.00

3412947 A: HEP C RNA QUANT 300 87522 $173.00 $0.00

3412954 A: HEP C RNA QUAL 300 87521 $99.00 $0.00

3412962 A: HEP C AB REFLEX 300 86803 $8.87 $0.00

3412970 A: HEP C RIBA 300 86804 $75.25 $0.00

3413002 C: NBN SCREENING-TYROSINE 300 84510 $15.40 $0.00

3413010 C: NBN SCREENING-HGB QT 300 83021 $15.40 $0.00

3413028 C: NBN SCREEN-TRANSFERASE 300 82776 $15.40 $0.00

3413044 C: NBN SCREEN-THYROID STM 300 84443 $15.40 $0.00

3413069 C: NBN SCREEN-HEMO/CHROM 300 83021 $15.40 $0.00

3413093 C: NBN SCREENING-17 OPH 300 83498 $15.40 $0.00

3500022 FFP PP/3 CMV PF-DBB 390 P9017 $45.00 $0.00

3500071 WB PROC FEE-DBB 390 P9010 $210.00 $0.00

3500089 PRBC PROC FEE-DBB 390 P9021 $190.00 $0.00

3500113 CRYO PROC FEE-DBB 390 P9012 $69.00 $0.00

3500121 WB CMV PROC FEE-DBB 390 P9010 $170.00 $0.00

3500170 PLT ESIS PF-DBB 390 P9021 $595.00 $0.00

3500204 FFP PROC FEE-DBB 390 P9017 $69.00 $0.00

3500220 PLT PROC FEE-DBB 390 P9019 $65.00 $0.00

3500238 PRBC LP PROC FEE-DBB 390 P9016 $199.00 $0.00

3500287 PRBC LV PROC FEE-DBB 390 P9021 $125.00 $0.00

3500303 FFP PP CMV PF-DBB 390 P9017 $135.00 $0.00

3500345 DESIGNATION FEE-DBB 390 $50.00 $0.00

3500352 FFP SPECIAL-DBB 390 $0.00 $0.00

3500360 AUTO PF (FC L/M)-DBB 390 P9021 $300.00 $0.00

3500386 BLOOD UNIT-OTHER 390 $0.00 $0.00

3500436 E: HLA MATCH/UNIT-DBB 300 86813 $185.00 $0.00

3500451 FFP CYROPOOR PF-DBB 390 P9044 $56.00 $0.00

3500477 PLT ESIS LP PF-DBB 390 P9035 $595.00 $0.00



Page 26 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3500485 R&B 2HTU ICU FEE-DBB

STERILE DOCK 270 99070 $30.00 $0.00

3500493 E: SATELLITES PP 4 270 99070 $60.00 $0.00

3500501 E: SATELLITES PP 8 270 99070 $80.00 $0.00

3510021 E: CMV UNIT TESTING 300 86644 $30.00 $0.00

3510039 E: IRRADIATION/UNIT 300 86945 $60.00 $0.00

3510047 E: SCREENED UNIT/AG 300 86903 $40.00 $0.00

3510054 E: ANTIBODY ID PANEL 300 86870 $150.00 $0.00

3510062 E: ANTIBODY ID AUTO 300 86978 $130.00 $0.00

3510070 E: OUT-AREA SURCHARGE 399 $0.00 $0.00

3510088 E: CROSS AHG/UNIT 300 86922 $85.00 $0.00

3510096 E: UNIT COST DIFF 380 $0.00 $0.00

3510104 E: ADD PROC, REFER 399 $0.00 $0.00

3510120 E: PREWARM TECHNIQUE 300 86850 $75.00 $0.00

3510138 E: SPECI TNSFR; PT NOT MD 300 99001 $0.00 $0.00

3510146 E: ANTIBODY ID ALLO 300 86978 $180.00 $0.00

3510153 E: ANTIBODY ID EXTRA 300 86870 $50.00 $0.00

3510161 E: ABD TESTING 300 86900 $25.00 $0.00

3510179 E: TX RXN EVALUATION 399 $300.00 $0.00

3510187 E: ANTIBODY TITER 300 86886 $90.00 $0.00

3510195 E: ANTIBODY ELUTION 300 86860 $125.00 $0.00

3510203 E: EXT PHENOTYPE/AG 300 86903 $40.00 $0.00

3510211 E: HTLA NEUTRALIZE 300 86977 $100.00 $0.00

3510229 E: WNV RNA 390 WNV $8.00 $0.00

3510518 E:CR ABO TESTING 300 86900 $25.00 $0.00

3510526 E:CR ANTIBODY ELUT 300 86800 $125.00 $0.00

3510534 E:CR ANTIBODY TITER 300 86886 $90.00 $0.00

3510542 E:CR ANTIBODY ID AL 300 86978 $180.00 $0.00

3510559 E:CR ANTIBODY ID PN 300 86870 $150.00 $0.00

3510567 E:CR SCREEN UNIT/AG 300 86903 $40.00 $0.00

3510575 E:CR ANTIBODY ID AU 300 86978 $130.00 $0.00

3510583 E:CR CMV UNIT TESTING 300 86644 $30.00 $0.00

3510591 E:CR CROSS AHG/UNIT 300 86922 $85.00 $0.00

3510609 E:CR EXT PHENOTYPE/AG 300 86903 $40.00 $0.00

3510617 E:CR ANTIBODY ID EX 300 86870 $50.00 $0.00

3510625 E:CR HLA MATCH/UNIT 300 86813 $185.00 $0.00

3510633 E:CR HTLA NEUTRAL 300 86977 $100.00 $0.00

3510641 E:CR IRRADIATE/UNIT 300 86945 $60.00 $0.00

3510666 E:CR PWRM TECHNIQUE 300 86850 $75.00 $0.00

3510674 E:CR SATELLITES PP4 270 99070 $60.00 $0.00

3510682 E:CR SATELLITES PP8 270 99070 $80.00 $0.00

3510690 E:CR STER DOCK FEE 270 99070 $30.00 $0.00

3510708 E:CR TX RXN EVAL 399 $300.00 $0.00

3510716 E:CR WNV 399 87798 $8.00 $0.00

3600012 HEM: PERIPH BLD SMR 310 85060 $75.45 $0.00

3600020 MARROW: ASP INT 310 85097 $94.30 $0.00

3600038 MARROW: ASP ST+INT 310 85097 $187.20 $0.00

3600079 MARROW: IRON ST 310 85536 $112.70 $0.00

3600087 NECROPSY: W/O CNS 310 88020 $1,217.80 $0.00

3600095 NECROPSY: W/BRAIN 310 88025 $1,360.30 $0.00



Page 27 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3600103 R&B 2HTU ICU

NECROPSY: W/BRN & SC 310 88027 $1,574.45 $0.00

3600111 NECROPSY: INF W/BRN 310 88028 $899.40 $0.00

3600129 NECROPSY: NBN W/BRN 310 88029 $449.70 $0.00

3600137 NECROPSY: LIMITED 310 88036 $449.70 $0.00

3600145 NECROPSY: SINGLE ORG 310 88037 $337.05 $0.00

3600152 CYTO FL: NON-GYN INT 310 88104 $187.20 $0.00

3600160 CYTO FL: FIL+INT 310 88106 $187.20 $0.00

3600178 CYTO FL: SM+FIL+INT 310 88107 $225.30 $0.00

3600186 CYTO: SEX CHROM ID 310 88130 $187.20 $0.00

3600194 CYTO GYN: TECH SCRN 310 88150 $75.45 $0.00

3600202 CYTO GYN: PHYS INT 310 88141 $75.45 $0.00

3600210 CYTO GYN: SM W/MI 310 88155 $75.45 $0.00

3600228 CYTO OTH: SCR+INT 310 88160 $75.45 $0.00

3600236 CYTO OTH: PREP+INT 310 88161 $187.20 $0.00

3600244 CYTO OTH: EXTENDED 310 88162 $39.15 $0.00

3600277 FNA: IMMED. EVAL. 310 88172 $173.20 $0.00

3600285 FNA: INT. + REPORT 310 88173 $82.95 $0.00

3600392 CONS: REF.SLIDES 310 88321 $131.75 $0.00

3600400 CONS: W/SL. PREP. 310 88323 $187.20 $0.00

3600418 CONS: COMPREH. REV. 310 88325 $212.50 $0.00

3600426 CONS: DURING SURG 310 88329 $94.30 $0.00

3600459 OUT CONS: REF SLIDES 310 88321 $0.00 $0.00

3600467 OUT CONS: REF BLOCKS 310 88323 $0.00 $0.00

3600475 OUT CONS: COMPRE REV 310 88325 $0.00 $0.00

3600632 UNLISTED SURG PATH 310 88399 $0.00 $0.00

3600640 SPECIMEN TNSFR; PT NOT MD 310 99001 $72.05 $0.00

3600657 REFER LAB,ADD PROC 310 $0.00 $0.00

3600665 CYTOPATH TOUCH PREP 310 88161 $75.45 $0.00

3600707 SPECIMEN TNSFR; PT NOT MD 310 99001 $0.00 $0.00

3650009 K:LEVEL I:GRS 310 88300 $69.35 $0.00

3650025 K:LEVEL II: GRS+MIC 310 88302 $162.30 $0.00

3650041 K:LEVEL III: GRS+MIC 310 88304 $172.15 $0.00

3650066 K:LEVEL IV: GRS+MIC 310 88305 $214.50 $0.00

3650082 K: MARROW: BX INT 310 88305 $93.50 $0.00

3650108 K: MARROW: BX ST+INT 310 88305 $149.75 $0.00

3650124 K:LEVEL V: GRS+MIC 310 88307 $275.65 $0.00

3650140 K:LEVEL VI: GRS+MIC 310 88309 $370.35 $0.00

3650165 K:DECALCIFICATION 310 88311 $29.75 $0.00

3650181 K:ACID FAST/AFB 310 88312 $74.85 $0.00

3650207 K:GIEMSA/H PYLORI 310 88312 $74.85 $0.00

3650223 K:GMS/FUNGUS 310 88312 $74.85 $0.00

3650249 K:GMS/PCP 310 88312 $74.85 $0.00

3650264 K:GRAM/MICROORGANISMS 310 88312 $74.85 $0.00

3650280 K:PAS/FUNGUS 310 88312 $74.85 $0.00

3650306 K:SPEC STAINS: GRP 1 310 88312 $90.15 $0.00

3650322 K:ALB-MPS 310 88313 $79.10 $0.00

3650348 K:ALB-PAS/MPS 310 88313 $79.10 $0.00

3650363 K:CONGO RED/AMYLOID 310 88313 $79.10 $0.00

3650389 K:G&S/RETICULUM 310 88313 $79.10 $0.00



Page 28 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

3650405 R&B 2HTU ICU

K:MUCICARMINE/MUCIN`````` 310 88313 $79.10 $0.00

3650421 K:PAS/GLYCOGEN 310 88313 $79.10 $0.00

3650447 K:PRUSSIAN BLUE/IRON 310 88313 $79.10 $0.00

3650462 K:SPEC STAINS: GRP 2 310 88313 $90.15 $0.00

3650488 K:TRICHROME/COLLAGEN 310 88313 $79.10 $0.00

3650504 K:VERHOEFF/ELASTIN 310 88313 $79.10 $0.00

3650520 K:CONS: FS FIRST SPEC 310 88331 $142.25 $0.00

3650546 K:CONS: FS ADD SPECS 310 88332 $0.00 $0.00

3800018 ECG 12LD NEWBORN 730 93000 $330.00 $0.00

3800026 ECG 12LD ADULT 730 93000 $313.50 $0.00

3800034 ECG 12LD PEDIATRIC 730 93000 $330.00 $0.00

3800042 ECG RHYTHM TRACE 730 93041 $149.75 $0.00

3800059 ECG 12LD WITH MAGNET 730 93000 $342.65 $0.00

3800091 ROUTINE VENIPUNCTURE 300 36415 $39.90 $0.00

3900016 CARDIAC STRESS TEST/MD SP 482 93017 $1,602.15 $0.00

3900040 CARDIAC STRESS TEST W/NM 482 93017 $1,602.15 $0.00

4000501 EEG HV/PHOTIC STIM 740 95819 $690.70 $0.00

4000543 EEG CEREBRAL DEATH EVAL 740 95824 $506.65 $0.00

4000568 EEG ASLEEP ONLY 740 95822 $651.45 $0.00

4000584 EEG EXTENDED 1HR 740 95813 $995.70 $0.00

4000626 EEG AWAKE/DROWSY HV/PHOTC 740 95816 $690.70 $0.00

4100087 URINE HCG 300 81025 $76.45 $0.00

4100244 TRIAGE (TRACKING ONLY) 450 $0.00 $0.00

4100251 MINOR BURN CARE 450 MULTI $224.60 $0.00

4100905 ER VISIT - LEVEL 1 450 99281 $450.45 $0.00

4100921 ER VISIT - LEVEL 2 450 99282 $579.15 $0.00

4100947 ER VISIT - LEVEL 3 450 99283 $910.91 $0.00

4100962 ER VISIT - LEVEL 4 450 99284 $1,295.95 $0.00

4100988 ER VISIT - LEVEL 5 450 99285 $1,587.30 $0.00

4101101 TD TOXOIDS 450 90718 $94.65 $0.00

4101119 IMMUNIZATION ADM 1 VACCI 450 90471 $103.76 $0.00

4101143 BLOOD ADMINISTRATION 391 36430 $1,532.45 $0.00

4101168 INTRAOSSEUS PLACEMENT 450 36680 $436.30 $0.00

4101184 PEDIATRIC CATHERIZATION 450 51702 $687.75 $0.00

4101200 CUTDOWN 450 36625 $458.50 $0.00

4101226 CENTRAL LINE/DIALYSIS CAT 450 MULTI $1,419.45 $0.00

4101309 THORACENTESIS 450 32000 $956.80 $0.00

4101325 TRACHEOSTOMY INSERTION 450 31603 $3,272.40 $0.00

4101341 CRICOTHYROTOMY 450 31605 $3,272.40 $0.00

4101408 THROMBOLYTIC THERAPY 450 92977 $436.30 $0.00

4101424 PACEMAKER EXTERNAL PROC 450 92953 $1,185.40 $0.00

4101440 CARDIOVERSION 450 92960 $1,185.40 $0.00

4101465 CPR 450 92950 $1,185.40 $0.00

4101523 EWALD INSERTION/LAVAGE 450 91105 $362.75 $0.00

4101622 FEMCATH INSERTION 450 51701 $244.55 $0.00

4101648 FOLEY INSERTION 450 51702 $229.30 $0.00

4101705 EAR IRRIGATION 450 69210 $273.40 $0.00

4101820 EPISTAXSIS SIMPLE 450 30901 $580.90 $0.00



Page 29 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4101846 R&B 2HTU ICU

EPISTAXSIS COMPLEX 450 30903 $807.05 $0.00

4101903 SPLINT SHORT ARM PROC 450 29125 $457.30 $0.00

4101929 SPLINT LONG ARM PROC 450 29105 $457.30 $0.00

4101945 SPLINT SHORT LEG PROC 450 29515 $286.55 $0.00

4101960 SPLINT LONG LEG PROC 450 29505 $286.55 $0.00

4102109 LUMBAR PUNCTURE ADULT 450 62270 $788.55 $0.00

4102125 LUMBAR PUNCTURE PED 450 62270 $788.55 $0.00

4102240 GT REPLACEMENT 450 43760 $620.30 $0.00

4102349 FB REMOVAL EAR 450 69200 $441.55 $0.00

4102364 ET INSERT/MAINT 450 31500 $1,185.40 $0.00

4102380 CHEST TUBE INSERTION 450 32020 $956.80 $0.00

4102448 NG IRRIGATION 450 91105 $366.80 $0.00

4102463 FOLEY IRRIGATION 450 51700 $817.95 $0.00

4102489 ACCUCHECK (INITIAL) 300 82962 $61.15 $0.00

4102505 ACCUCHECK (ALL SUBSEQ) 300 8296291 $61.15 $0.00

4102521 D&C 450 59812 $3,417.00 $0.00

4102547 VISUAL ACUITY 450 99173 $152.80 $0.00

4102562 CRITICAL CARE 450 99291 $3,850.00 $0.00

4102588 CRITICAL CARE EA ADD 30MN 450 99292 $929.50 $0.00

4102604 FB REMOVAL NOSE 450 30300 $441.55 $0.00

4102687 FINGER SPLINT PROCEDURE 450 29130 $457.30 $0.00

4102703 SUTURE/STAPLING PROCEDURE 450 MULTI $638.70 $0.00

4102711 DERMABOND PROCEDURE 450 MULTI $638.70 $0.00

4102760 I&D 450 10060 $525.70 $0.00

4102786 I&D WITH PACKING 450 10061 $628.30 $0.00

4102802 KNEE IMMOBILIZER PROC 450 29530 $286.55 $0.00

4102828 SHOULDER IMMOBILIZER PROC 450 29240 $457.30 $0.00

4102844 CLAVICLE SPLINT PROCEDURE 450 29240 $457.30 $0.00

4102869 CAST REMOVAL 450 29705 $286.55 $0.00

4102885 EXTREMITY REDUCT LOCAL 450 MULTI $570.45 $0.00

4102901 EXTREMITY REDUC CONSC/SED 450 MULTI $2,896.55 $0.00

4102927 ED DELIVERY/STABILIZATION 450 59409 $2,943.90 $0.00

4102943 NEWBORN RESUSCITATION 450 99440 $1,185.40 $0.00

4103008 ANKLE BRACE PROCEDURE 450 29540 $286.55 $0.00

4103024 FB REMOVAL EXTREMITY 450 MULTI $441.55 $0.00

4103040 REMOVAL OF NAIL BED 450 MULTI $152.80 $0.00

4103065 FB REMOVAL EYE 450 MULTI $352.20 $0.00

4103081 EXTREMITY REDUCT SIMPLE 450 MULTI $191.25 $0.00

4103206 PACEMAKER PERCUT PROC 450 33210 $3,215.80 $0.00

4103222 DEBRIDEMENT PROC WOUND 450 97597 $152.80 $0.00

4103248 DEBRIDEMENT PROC BURN 450 MULTI $152.80 $0.00

4103263 MISCELLANEOUS ER PROCED 450 MULTI $178.75 $0.00

4103271 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00

4103289 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

4103297 HYDRATE IV INFUSON ADD-ON 260 90761 $231.00 $0.00

4103305 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

4103313 THER/PROPH/DIAG INJ SC/IM 940 90772 $247.50 $0.00

4103321 TH/PR/DX INJ SC/IM EA ADD 940 9077276 $206.25 $0.00

4103339 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00



Page 30 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4103347 R&B 2HTUIV PUSH EA ADD

TH/PR/DX ICU 940 9077476 $206.25 $0.00

4103354 THER/PROPH/DIAG INJ SC/IM 450 90772 $247.50 $0.00

4103362 PT LEFT W/OUT BEING SEEN 450 $0.00 $0.00

4103370 TH/PR/DX INJ SC/IM EA ADD 450 9077276 $206.25 $0.00

4103388 MOD CS BY SAME PHYS 323 36556 $2,180.88 $0.00

4600953 INS TNLD CVAD W PORT RT 323 36561RT $8,684.00 $0.00

4600961 INS TNLD CVAD W PORT LT 323 36561LT $8,684.00 $0.00

4600979 INTUBATION ENDOTRACH EMER 323 31500 $651.32 $0.00

4600987 DECORTICATION PLM PARTIAL 323 32225 $4,445.50 $0.00

4600995 INS/REPO LDS SC W INS PG 481 33249 $10,000.00 $0.00

4601001 CORONARY PTCBA LAD 480 92982LD $14,861.00 $0.00

4601019 CORONARY PTCBA RCA 480 92982RC $14,861.00 $0.00

4601027 CORONARY STENT LAD 480 92980LD $15,435.75 $0.00

4601035 CORONARY STENT CIRC 480 92980LC $15,435.75 $0.00

4601043 CORON STENT ADD VES CIRC 480 92981LC $8,346.25 $0.00

4601050 CORON STENT ADD VES LAD 480 92981LD $8,346.25 $0.00

4601068 PTCA SINGLE VESSEL CIRC 480 92995LC $16,575.65 $0.00

4601076 PTCA SINGLE VESSEL LAD 480 92995LD $16,575.65 $0.00

4601084 PTA BRACHCEPHLC ARTERIES 323 35475 $5,599.30 $0.00

4601092 THRMBCTY ART/VEN GRFT-W R 323 35876 $4,837.04 $0.00

4601100 SEL CATH PL ART ADD THR/B 323 36218 $1,754.50 $0.00

4601118 REVISE AV FISTULA - GRAFT 323 36832 $4,837.04 $0.00

4601126 OPEN REV AVF W THROMBECT 323 36833 $4,837.04 $0.00

4601134 PERC NON CRNRY STENT INIT 323 37205 $8,788.20 $0.00



Page 32 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4601142 R&B 2HTU ICU STENT EA AD

PERC NON CNRY 323 37206 $8,788.20 $0.00

4601159 INS/REPO LDS DC W INS PG 481 33249 $10,000.00 $0.00

4601167 CABG VEIN ONLY-3 COR VEIN 481 33512 $10,174.25 $0.00

4601175 CABG VEN/ART GRFTS-2 VEN 481 33518 $1,340.20 $0.00

4601183 CABG/VLV >1 MTH AFT INIT 481 33530 $1,611.80 $0.00

4601191 CABG ART'L GRFT(S) 1 ART 481 33533 $9,571.30 $0.00

4601209 UNLISTED CARDIAC SURGERY 481 33999 $1,064.45 $0.00

4601217 BYPS GRFT W VEIN FEM-POP 323 35556 $6,521.00 $0.00

4601225 TRANSFUS BLOOD-BLOOD COMP 391 36430 $550.00 $0.00

4601233 ARTERIAL PUNCT BLOOD - DX 323 36600 $181.70 $0.00

4601241 CREATE AVF N-AUTOGEN GRFT 323 36830 $3,547.35 $0.00

4601258 CHNG IV CATH AT THROMB TX 323 37209 $601.60 $0.00

4601266 IVC FILTER PLACEMENT 323 37620 $3,268.85 $0.00

4601274 INJ ART CONDUIT PATENCY 481 93539 $109.35 $0.00

4601282 PTCBA EA ADD VESSEL CIRC 480 92984LC $8,346.25 $0.00

4601290 PTCBA EA ADD VESSEL LAD 480 92984LD $8,346.25 $0.00

4601308 PTCBA EA ADD VESSEL RCA 480 92984RC $8,346.25 $0.00

4601316 ART OCCLUSIVE DVICE PLCMT 480 G0269 $312.50 $0.00

4601324 BLOOD GASES-O2 SAT ONLY 301 82810 $55.65 $0.00

4601332 HEMOGLOBIN 305 85018 $55.65 $0.00

4601340 INS/REPL TEMP PACER SC 481 33210 $9,750.00 $0.00

4601357 INS/REPL TEMP PACER DC 481 33211 $9,750.00 $0.00

4601365 INS/REPL PERM PACER AV 481 33208 $15,000.00 $0.00

4601373 REPOSTION PACING-DEFIB LD 481 33215 $9,500.00 $0.00

4601381 PERC DRN-INJ RENAL PELVIS 323 50392 $4,922.92 $0.00

4602017 EXTMTY ART UNI ANG RT INI 323 75710RT $7,272.40 $0.00

4602025 EXTMTY ART UNI ANG LT INI 323 75710LT $7,272.40 $0.00

4602033 EXTY ART UNI ANG RT EA AD 323 7571076 $7,272.40 $0.00

4602041 EXTY ART UNI ANG LT EA AD 323 7571076 $7,272.40 $0.00

4602058 TRANSCATHETER BIOPSY RT 320 75970 $4,303.75 $0.00

4602066 TRANSCATHETER BIOPSY LT 320 75970 $4,303.75 $0.00

4602074 TRANSCATH EMBOLIZ TX RT 320 75894 $9,350.00 $0.00

4602082 TRANSCATH EMBOLIZ TX LT 320 75894 $9,350.00 $0.00

4602090 PULM UNIL SEL ANG RT INIT 323 75741RT $6,413.00 $0.00

4602108 PULM UNIL SEL ANG LT INIT 323 75741LT $6,413.00 $0.00

4602132 UNIL SEL RENAL VENOGRM RT 320 75831 $4,552.65 $0.00

4602140 UNIL SEL RENAL VENOGRM LT 320 75831 $4,552.65 $0.00

4602157 TRANSCATH INFUSION TX RT 320 75896 $8,080.90 $0.00

4602165 TRANSCATH INFUSION TX LT 320 75896 $8,080.90 $0.00

4602199 TC NONCARD STNT EA VES RT 320 75960 $14,861.00 $0.00

4602207 TC NONCARD STNT EA VES LT 320 75960 $14,861.00 $0.00

4602231 INS URETERL CATH/STENT RT 320 74480RT $3,514.50 $0.00

4602249 INS URETERL CATH/STENT LT 320 74480LT $3,514.50 $0.00

4602256 NEPHROSTOMY TUBE INS RT 320 74475RT $3,346.75 $0.00

4602264 NEPHROSTOMY TUBE INS LT 320 74475LT $3,346.75 $0.00

4602272 A-V SHUNT ANGIOGRAM RT 323 75790 $5,420.25 $0.00

4602280 A-V SHUNT ANGIOGRAM LT 323 75790 $5,420.25 $0.00

4602298 TL ATHCTOMY PERIPH ART RT 320 75992RT $16,575.65 $0.00

4602306 TL ATHCTOMY PERIPH ART LT 320 75992LT $16,575.65 $0.00



Page 33 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4602314 R&B 2HTU ICU CV CATH RT

INSERT TUNLD 323 36558RT $2,943.90 $0.00

4602322 INSERT TUNLD CV CATH LT 323 36558LT $2,943.90 $0.00

4602355 TL ATH EA ADD PERI ART RT 320 75993RT $4,977.50 $0.00

4602363 TL ATH EA ADD PERI ART LT 320 75993LT $4,977.50 $0.00

4602371 TC NONCARD STNT RT EA ADD 320 7596076 $4,977.50 $0.00

4602389 TC NONCARD STNT LT EA ADD 320 7596076 $4,977.50 $0.00

4602397 REMOVE TNLD CV CATH 323 36589 $2,043.25 $0.00

4602405 TLBA PERIPHRAL ARTERY RT 320 75962RT $14,481.50 $0.00

4602413 TLBA PERIPH ART RT EA ADD 320 75964RT $4,977.50 $0.00

4602421 TLBA PERIPHRAL ARTERY LT 320 75962LT $14,481.50 $0.00

4602439 TLBA PERIPH ART LT EA ADD 320 75964LT $4,977.50 $0.00

4602447 VENOUS TLBA RIGHT INIT 320 75978 $14,481.50 $0.00

4602454 VENOUS TLBA RIGHT EA ADD 320 7597876 $4,977.50 $0.00

4602462 VENOUS TLBA LEFT INIT 320 75978 $14,481.50 $0.00

4602470 VENOUS TLBA LEFT EA ADD 320 7597876 $4,977.50 $0.00

4602488 EXISTNG CATH ANGIO-FOL-UP 320 75898 $1,190.75 $0.00

4602496 KIDNEY ANGIOGRAM - UNIL 323 75722 $5,410.00 $0.00

4602504 PTA VENOUS 323 35476 $4,000.00 $0.00

4602520 INTRO NEEDLE OR CATH VEIN 323 36000 $987.25 $0.00

4602538 PTH BILIRY DRAIN-CONT MON 320 75980 $8,080.90 $0.00

4602546 INTR CTH SUP/INF VENA CAV 481 36010 $1,754.50 $0.00

4602553 KIDNEY ANGIOGRAM - BILAT 323 75724 $6,413.00 $0.00

4602561 SEL CATH PLACE VENOUS SYS 323 36011 $1,754.50 $0.00

4602587 CREATE AV DIALYSIS SHUNT 323 36145 $1,754.50 $0.00

4602603 INS TUNLD CV CATH AGE 5/> 323 36558 $2,943.90 $0.00

4602629 INSERT PICC AGE 5 /> 323 36569 $1,754.50 $0.00

4602660 PTA TIBIOPERONEAL TRUNK 323 35470 $4,000.00 $0.00

4602686 PTA RENAL/VISCERAL ARTER 323 35471 $4,000.00 $0.00

4602702 PTA AORTIC 481 35472 $4,000.00 $0.00

4602728 PTA ILIAC 323 35473 $4,000.00 $0.00

4602744 PTA FEMORAL POPLITEAL 323 35474 $4,000.00 $0.00

4602769 INT CTH RT HRT/MN PLM ART 481 36013 $1,754.50 $0.00

4602785 SEL CATH PLACE LT/RT PULM 323 36014 $1,754.50 $0.00

4602801 INT NDL/CTH CARTD/VTB ART 323 36100 $1,754.50 $0.00

4602827 INT NDL/CTH RTRG BRAC ART 323 36120 $1,754.50 $0.00

4602843 INT NDL/CTH EXTREMITY ART 323 36140 $1,754.50 $0.00

4602868 INTRO CATHETER AORTA 323 36200 $1,754.50 $0.00

4602884 SEL CATH PL ART 1 THOR/BR 323 36215 $1,754.50 $0.00

4602900 SEL CATH PL ART 2 THOR/BR 323 36216 $1,754.50 $0.00

4602926 SEL CATH PL ART 3 THOR/BR 323 36217 $1,754.50 $0.00

4602942 SEL CATH PL ART 1 AB/LO-X 323 36245 $1,754.50 $0.00

4602967 SEL CATH PL ART 2 AB/LO-X 323 36246 $1,754.50 $0.00

4602983 SEL CATH PL ART 3 AB/LO-X 323 36247 $1,754.50 $0.00

4603015 NEPH/PYLOSTOMY TUBE CHNGE 323 50398 $3,346.75 $0.00

4603080 RECOVERY RM LV-M/S FLOOR 710 $893.75 $0.00

4603122 UNIL CERV CAROTID ANGIO 323 75676 $3,379.75 $0.00

4603197 THOR AORTOGRM W SRIAL ADD 323 7560576 $7,767.40 $0.00

4603213 ABDOMINAL AORTGRAM EA ADD 323 7562576 $7,536.40 $0.00

4603239 ABDOMEN SELECTIVE 2 RUNS 323 7572676 $11,061.90 $0.00



Page 34 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4603502 R&B 2HTU ICU CARD CATH

ILIAC ANGIO W 320 G0278 $1,190.75 $0.00

4603510 POSTOP PERC BD STONE REM 320 74327 $1,896.15 $0.00

4603528 REM BILI STONE VIA T-TUBE 323 47630 $3,775.00 $0.00

4603536 SQ REM SC/DC ICD GENERATR 481 33241 $9,500.00 $0.00

4604039 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

4604070 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

4604112 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

4604138 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

4604146 RENAL ANGIO W CARD CATH 320 G0275 $1,190.75 $0.00

4604153 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

4604161 CHG PERC TUBE OR DR CATH 320 75984 $3,346.75 $0.00

4604179 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

4604187 INTRAVASCULAR CATH EXCHG 320 75900 $3,346.75 $0.00

4604195 REPLACE TUNNELED CV CATH 323 36581 $8,875.00 $0.00

4604203 FLUORO GUIDED CENTRAL VAD 320 75998 $2,043.25 $0.00

4604211 INTERNAL MAMMARY ANGIO 323 75756 $2,304.76 $0.00

4604229 INS SWAN GANZ BEDSIDE 481 93503 $3,985.60 $0.00

4604237 ART CATH FOR ANGIO WO LHC 481 93508 $9,376.15 $0.00

4604302 PERC AVF THROMBECT GRAFT 323 36870 $5,337.50 $0.00

4606042 AAI PACER INSERTION 481 33206 $15,000.00 $0.00

4606067 VVI PACER INSERTION 481 33207 $15,000.00 $0.00

4606166 LV PACING LEAD ADD-ON 481 33225 $12,500.00 $0.00

4606174 REPOSITION L VENTRIC LEAD 481 33226 $9,875.00 $0.00

4606182 INS/RPL PG ONLY SGL CHAM 481 33212 $15,000.00 $0.00

4606208 INS/RPL PG ONLY DUAL CHAM 481 33213 $15,000.00 $0.00

4606224 REMOVE PPM PLS GEN 481 33233 $9,500.00 $0.00

4606240 EVAL INT IMP/REP LEADS 480 93640 $3,125.00 $0.00

4606257 EVAL INT IMP/RP LDS & GEN 480 93641 $3,125.00 $0.00

4606273 INSRT SC ICD GENERATOR 481 33240 $10,000.00 $0.00

4606281 INSRT DC ICD GENERATOR 481 33240 $10,000.00 $0.00

4606307 PACER SINGLE LEAD REMOVAL 481 33234 $9,750.00 $0.00

4606315 PACER DUAL LEAD REMOVAL 481 33235 $10,000.00 $0.00

4606323 REPLACE NON-TUNLD CV CATH 323 36580 $8,875.00 $0.00

4700043 OXIMETER CHECK 460 94760 $88.15 $0.00

4700076 PERCUSSION, SUBSEQUENT 410 94668 $214.75 $0.00

4700100 SUCTION NT 410 31720 $181.70 $0.00

4700118 EXTUBATE 410 94799 $225.75 $0.00

4700126 PULSE OXIMETRY W/EXERCISE 460 94761 $267.15 $0.00

4700134 INTUBATION 410 31500 $335.95 $0.00

4700142 OXIMETER-PER H. 460 94762 $112.90 $0.00

4700183 CARDIOVERSION 480 92960 $435.05 $0.00

4700191 TRANSPORT CRITICAL PT 419 94799 $658.00 $0.00

4700241 IPPB INITIAL 412 94640 $435.05 $0.00

4700266 CONT PULSE OX S/U 410 94762 $597.45 $0.00

4700290 PERCUSSION, INITIAL 410 94667 $435.05 $0.00

4700332 RESUSCITATION 410 92950 $1,591.45 $0.00

4700407 ICN EXTERNAL TRANSPORT 419 $6,685.00 $0.00

4700415 BRONCHOSCOPY-ASSIT/THER 410 31622 $1,591.45 $0.00

4700431 NEWBORN RESUSCITATION 410 99440 $1,591.45 $0.00



Page 35 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4700449 R&B 2HTU ICU

DELIVERY STAND BY 410 99436 $446.05 $0.00

4700456 BEDSIDE SPIROMETRY 460 94010 $214.75 $0.00

4700480 ABG, CALCULATED SAT. 301 82803 $520.40 $0.00

4700498 ABG, MEASURED SATURTN INI 301 82805 $751.65 $0.00

4700506 ABG, PH ONLY 301 82800 $267.15 $0.00

4700522 CARBOXYHEMOGLOBIN INITIAL 301 82375 $275.40 $0.00

4700555 PPV NWBRN (NOT RESUSC)INT 410 94640 $264.40 $0.00

4700571 OXIMETER EXERC MULT READN 410 94761 $112.90 $0.00

4700589 FORCED VITAL CAPACITY/FVC 410 94150 $123.90 $0.00

4700605 CPAP/BIPAP DAILY 410 94660 $568.20 $0.00

4700639 VENTILATOR MGMT INITL/DAY 410 94656 $4,573.45 $0.00

4700647 VENTILATOR MGMT SUBSQ/DAY 410 94657 $3,221.65 $0.00

4700662 ARTERIAL PUNCTURE 300 36600 $181.70 $0.00

4700670 OP EVAL FOR PULSE OXIMTRY 410 99211 $89.40 $0.00

4700696 PPV NWBORN (NOT RESUSC)SB 410 9464076 $177.40 $0.00

4700902 INHALATION TX LEV 1 INIT 412 94640 $554.80 $0.00

4700928 INHALATION TX LV 2 INITL 412 94640 $623.55 $0.00

4700944 INHALATION TX LV 3 INITL 412 94640 $692.30 $0.00

4700969 INHALATION TX LV 4 INITL 412 94640 $761.05 $0.00

4700985 INHALATION TX LV 1 SUBSQ 412 9464076 $554.80 $0.00

4701009 INHALATION TX LV 2 SUBS 412 9464076 $623.55 $0.00

4701025 INHALATION TX LV 3 SUBSQ 412 9464076 $692.30 $0.00

4701041 INHALATION TX LV 4 SUBSQ 412 9464076 $761.05 $0.00

4701066 ABG CALC SAT EA ADD'L 301 8280391 $520.40 $0.00

4701082 ABG MEAS SAT EA ADD'L 301 8280591 $751.65 $0.00

4701108 CARBOXYHEMOGLOBIN EA ADD' 301 8237591 $189.75 $0.00

4701124 CODE BLUE SERVICES INPAT 230 $5,156.25 $0.00

4701207 CODE BLUE OP/CRITICAL CAR 480 99291 $4,812.50 $0.00

4701223 CODE BLUE OP/CPR 940 92950 $343.75 $0.00

4701322 CODE BLUE OP/MISC PROCED 361 MULTI $206.25 $0.00

4701348 CODE BLUE OP/SERVICE 410 $206.25 $0.00

4701363 ARTERIAL PUNCTURE EA ADDL 300 3660059 $181.70 $0.00

4701389 CO, EXPIRED GAS BY IR 460 94770 $109.90 $0.00

4701405 CO, EXPIRED GAS BY IR 460 9477076 $109.90 $0.00

4708004 RCP TIME 15 MIN 410 $0.00 $0.00

4708103 INIT PT ASSESS/TR 410 $0.00 $0.00

4708129 SUB PT ASSESS/TR 410 $0.00 $0.00

4708145 TRACH TUBE CHANGE/TR 410 $0.00 $0.00

4708160 TRACH TUBE CARE/TR 410 $0.00 $0.00

4708186 ETT RETAPE POSITIONING/TR 410 $0.00 $0.00

4708202 MONITOR CUFF PRESSURE/TR 410 $0.00 $0.00

4708228 PLCMT OF NASAL AIRWAY/TR 410 $0.00 $0.00

4708244 PLCMTREMOV SPEECH VALV/TR 410 $0.00 $0.00

4708269 ET SUCTIONING/TR 410 $0.00 $0.00

4708285 PLACE CHANGE INLINE SX/TR 410 $0.00 $0.00

4708301 IN/LINE ET SUCTIONING/TR 410 $0.00 $0.00

4708327 INCENTIVE SPIROMETRY/TR 410 $0.00 $0.00

4708343 CONT AERO EQUIP CHANGE/TR 410 $0.00 $0.00

4708368 OXYGEN SETUP/TR 410 $0.00 $0.00



Page 36 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

4708384 R&B 2HTU ICU

OXYGEN ASSESSMENT/TR 410 $0.00 $0.00

4708400 OXYGEN EQUIP CHANGE/TR 410 $0.00 $0.00

4708426 PTSYS ASSESNIV NON EMR/TR 410 $0.00 $0.00

4708442 SETTING ADJ NIV NON EMRTR 410 $0.00 $0.00

4708467 PTSYS ASSESS NIV EMER/TR 410 $0.00 $0.00

4708483 SETTING ADJ NIV EMER/TR 410 $0.00 $0.00

4708509 NIV EQUIP CHANGE/TR 410 $0.00 $0.00

4708525 PTVENT ASSESSMENT/TR 410 $0.00 $0.00

4708541 VENT SETTING ADJUST/TR 410 $0.00 $0.00

4708566 CENT EQUIP CHANGE/TR 410 $0.00 $0.00

4708582 VENT CIRCUIT CHANGE/TR 410 $0.00 $0.00

4800124 FLOW VOLUME LOOP 460 94375 $317.30 $0.00

4800207 MULTPL 02 SAT'S 460 94761 $403.75 $0.00

4800231 ABG, SATUR ONLY 301 82810 $184.05 $0.00

4800249 ABG, CALC. SAT. 301 82803 $358.65 $0.00

4800256 ABG, MEAS. SAT. 301 82805 $518.05 $0.00

4800603 CARBOXYHEMOGLOBIN INITIAL 301 82375 $275.40 $0.00

4800611 CARBOXYHEMOGLOBIN EA ADDL 301 8237591 $189.75 $0.00

4800629 PULM STRESS TEST SIMPLE 460 94620 $2,126.20 $0.00

4800652 MAX VOLUNTARY VENT/ONLY 460 94200 $307.40 $0.00

4801080 SPIROMETRY 460 94010 $598.90 $0.00

4801106 SPIROMETRY/BR0NCH W/O INT 460 94060 $875.30 $0.00

4801122 FRC 460 94240 $261.00 $0.00

4801148 S B DLCO 460 94720 $288.45 $0.00

4801163 PULM STRESS TEST COMPLEX 460 94621 $2,817.20 $0.00

4801205 BEDSIDE SPIROMETRY 460 94010 $215.20 $0.00

4801247 ARTERIAL PUNCTURE 300 36600 $181.70 $0.00

4801502 INHALATION TX LV 1 INITL 410 94640 $554.80 $0.00

4801528 INHALATION TX LV 1 SUBSQ 410 9464076 $554.80 $0.00

4801544 INHALATION TX LV 2 INITL 410 94640 $623.55 $0.00

4801569 INHALATION TX LV 2 SUBSQ 410 9464076 $554.80 $0.00

4801585 ABG CALC SAT EA ADD'L 300 8280391 $520.40 $0.00

4801601 ABG MEAS SAT EA ADD'L 300 8280591 $751.65 $0.00

4801809 ARTERIAL PUNCTURE EA ADDL 300 3660091 $181.70 $0.00

4808002 RCP TIME 15 MIN 410 $0.00 $0.00

4900072 TEE PROBE PLACEMENT ONLY 483 93313 $379.50 $0.00

4900080 TEE 2ND ACQUISITION 483 93313 $2,231.90 $0.00

4900205 STRESS ECHO EKG W/MD SUPV 483 93017 $1,273.25 $0.00

4900304 STRESS/EXERCISE ECHOCARD 483 93350 $2,020.80 $0.00

4900320 ECHOCARDIO M/MODE/2D 483 93307 $996.20 $0.00

4900346 DOPPLER ECHO; COMPLETE 483 93320 $284.65 $0.00

4900361 TRANSESOPHAGEAL ECHO 483 93312 $2,231.90 $0.00

4900387 COLOR MAPPING 483 93325 $284.65 $0.00

4900403 FOLLOW UP ECHOCARDIOGRAPH 483 93308 $498.15 $0.00

4900429 TTE CONG ABN; COMPLETE 483 93303 $1,031.25 $0.00

4900445 TTE CONG ABN LIMITED/F-UP 483 93304 $562.50 $0.00

4900460 DOPPLER ECHO LMITED/ F-UP 483 93321 $281.25 $0.00

5000138 ADAPTER IV BOTTLES SCREW 272 $11.50 $0.00

5000161 TUBING BLOOD Y SET (9155) 272 $29.35 $0.00



Page 37 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5000427 R&B 2HTU ICU

SUTURE SURGITIC CHROMIC 272 $45.00 $0.00

5000526 ELECTRODE LEEP BALL 5.5CM 272 $71.00 $0.00

5000773 DRAIN CHEST SYS MULTI PUR 272 $124.25 $0.00

5000997 TRAY AMNIOCENTESIS 272 $40.50 $0.00

5001003 TRAY GENERAL BASIC BX 272 $30.25 $0.00

5001276 VACUUM TND TCH ULTRA CUP 272 $74.25 $0.00

5001532 CRUTCHES ADULT MED ADJ 271 E0114 $32.50 $0.00

5001540 CRUTCHES ADULT TALL ADJ 271 E0114 $32.50 $0.00

5001557 CRUTCHES YOUTH ADJ 271 E0114 $43.25 $0.00

5002563 KIT MATERNITY 271 $96.95 $0.00

5002589 PATCH HERNIA SM OVAL 8X12 278 $2,211.50 $0.00

5002597 IMPLANT PATCH/HERN OV 11X 278 $2,622.50 $0.00

5002605 KIT BREAST PUMP HYGIENIKI 271 $103.00 $0.00

5003058 CANES WOOD 271 E0100 $16.50 $0.00

5003660 TRANDUCER KIT DOUBLE 272 $60.00 $0.00

5003835 TUBE FEEDING WEIGHTED 12F 272 $65.75 $0.00

5003843 TUBE FEEDING WEIGHTED 8FR 272 $60.50 $0.00

5004643 DRAPE SURG W/TWL 17 5/8X1 272 $19.70 $0.00

5004932 CATH THORACIC ANGLED 28FR 272 $54.75 $0.00

5004940 CATH THORACIC ANGLED 32FR 272 $54.75 $0.00

5004957 CATH THORACIC ANGLED 36FR 272 $54.75 $0.00

5004981 CATH THORACIC STRAIGHT 20 272 $49.25 $0.00

5005004 CATH THORACIC STRAIGHT 28 272 $49.25 $0.00

5005012 CATH THORACIC STRAIGHT 32 272 $49.25 $0.00

5005020 CATH THORACIC STRAIGHT 36 272 $49.25 $0.00

5005038 CATH THORACIC STRAIGHT 40 272 $45.50 $0.00

5005327 ELECTRODE LEEP 1.5X0.5 272 $116.95 $0.00

5005467 ELECTRODE RADIUS 2.0X1.0 272 $71.00 $0.00

5005673 NEEDLE 15GX3/8-1 7/8"STER 272 $46.75 $0.00

5005699 NEEDLE BONE MARROW/ASPIR 272 $56.25 $0.00

5005707 NEEDLE TRU CUT BI 14GX4 1 272 $44.25 $0.00

5005715 NEEDLE TRU CUT BI 14GX6" 272 $51.25 $0.00

5005731 TRAY ADULT LUMBAR PUNCTUR 272 $50.50 $0.00

5005749 TRAY CONT EPIDURAL 18G TO 272 $75.25 $0.00

5005756 TRAY DISP MYELOGRAM 272 $46.50 $0.00

5005764 TRAY JAMSHIDI BONE MARROW 272 $83.25 $0.00

5005772 TRAY JAMSHIDI BONE MARROW 272 $66.00 $0.00

5005798 TRAY PED LUMBAR PUNCTURE 272 $50.50 $0.00

5005806 TRAY THORACENTESIS CATH 272 $76.00 $0.00

5005814 TRAY THORACENTESIS W/ASP 272 $71.25 $0.00

5006317 PAD HYPER/HYPOTHERMIA 271 $52.00 $0.00

5007257 ADAPTER PORTEX SWIVEL FIB 272 $8.75 $0.00

5007356 LINER SPENCO BOOT 271 $140.75 $0.00

5007364 BOOT SPENCO 271 $205.75 $0.00

5007711 MASK LARGYNGEAL LMA AIRWA 272 $34.25 $0.00

5007992 DILATOR FILIFORM TIP 4FR 272 $107.00 $0.00

5008024 CATH BILIARY DRAINAGE 10F 272 $273.00 $0.00

5008602 LIGACLIP APPLIER 20/20 ME 278 $1,223.50 $0.00

5008800 SPONGE SURG 2X4 ABS HEMOS 272 $153.75 $0.00



Page 38 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5008818 R&B 2HTU ICU 4X8 ABS HEMOS

SPONGE SURG 272 $153.50 $0.00

5008826 SPONGE SURG 2X3 ABS HEMOS 272 $84.00 $0.00

5008842 TRAY URINE METER W/FOLEY 272 $99.00 $0.00

5009147 TUBE BRONCH SZ 35 LEFT 272 $266.50 $0.00

5009154 TUBE BRONCH SZ 37 LEFT 272 $266.50 $0.00

5009162 TUBE BRONCH SZ 39 LEFT 272 $266.50 $0.00

5009188 TUBE BRONCH SZ 35 RIGHT 272 $291.00 $0.00

5009220 TRAY OPEN HEART SUPPLY PA 272 $2,697.50 $0.00

5009287 DRAPE IOBAN C-ARM ANTIMIC 272 $70.25 $0.00

5009444 LIGACLIP MULTIPLE CLIP MS 278 $1,226.50 $0.00

5009469 STAPLER PREM TA MF 30 V-3 278 $807.25 $0.00

5009477 LOADING UNIT PREM TA MF 3 278 $355.25 $0.00

5009485 STAPLER PREM TA MF 30 3.5 278 $702.25 $0.00

5009493 LOADING UNIT PREM TA MF 3 278 $323.00 $0.00

5009501 STAPLER PREM TA MF 30 4.8 278 $702.25 $0.00

5009519 LOADING UNIT PREM TA MF 3 278 $323.00 $0.00

5009527 STAPLER PREM TA MF 60 3.5 278 $726.50 $0.00

5009535 LOADING UNIT PREM TA 60 3 278 $363.25 $0.00

5009543 STAPLER PREM MF TA 60-4.8 278 $815.75 $0.00

5009550 LOADING UNIT 60-4.8 MF 278 $408.00 $0.00

5009568 STAPLER PREM TA MF 90 3.5 278 $861.00 $0.00

5009584 STAPLER PREM TA MF 90 4.8 278 $751.50 $0.00

5009618 STAPLER TA ROTICULATOR 30 278 $1,753.25 $0.00

5009626 STAPLER TA ROTICULATOR 55 278 $1,762.00 $0.00

5009634 STAPLER TA ROTICULATOR 55 278 $1,758.50 $0.00

5009642 STAPLER PREMIUM CEEA 25 D 278 $2,288.00 $0.00

5009675 PURSESTRING 65 INSTR DISP 278 $679.75 $0.00

5009683 STAPLER MF GIA 60 3.8 BLU 278 $769.25 $0.00

5009691 LOADING UNIT MF GIA 60 3. 278 $415.75 $0.00

5009709 STAPLER MF GIA 80 3.8 278 $1,164.25 $0.00

5009717 LOADING UNIT MF GIA 80 3. 278 $607.00 $0.00

5009725 STAPLER PREM SURGI W/TIA 278 $525.50 $0.00

5009733 STAPLER PREM SURGI W/TIA 278 $525.50 $0.00

5009741 STAPLER PREM SURGI W/TIA 278 $446.00 $0.00

5009758 TROCAR VERSAPORT RADIO 5M 272 $157.25 $0.00

5009774 TROCAR VERSAPORT RADIO 5- 272 $187.00 $0.00

5009782 TROCAR VERSAPORT RADIO 5- 272 $187.00 $0.00

5009790 SURGIPORT LONG 10MM SS SL 272 $205.75 $0.00

5009816 TROCAR VERSAPORT BLUNT 5- 272 $224.50 $0.00

5009865 TROCAR THORACOPORT 5.5MM 272 $58.50 $0.00

5009873 TROCAR THORACOPORT 10.5MM 272 $72.75 $0.00

5009881 THORACOPORT 11.5MM TROCAR 272 $58.50 $0.00

5009907 SURGINEEDLE 120MM 272 $57.25 $0.00

5009915 SURGINEEDLE 150MM 272 $57.25 $0.00

5009923 INSTRUMENT DISP CLOSE AUT 272 $89.75 $0.00

5009931 CLAMP ENDO LUNG 12MM 272 $286.50 $0.00

5009949 INSTRUMT DISP CLIP APP ML 272 $350.75 $0.00

5009964 SHEATH INTRODUCER VENOUS 272 C1766 $61.00 $0.00

5009998 SHEARS LAB DISP 5MM 272 $236.75 $0.00



Page 39 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5010004 R&B 2HTU ICU

INSTRUMENT DISP GRASP II 272 $297.00 $0.00

5010012 INSTR DISP DISSECT 5MM 272 $244.75 $0.00

5010020 INSTRUMENT DISP CLINCH II 272 $286.50 $0.00

5010038 INSTRUMENT DISP BABCOCK 272 $281.75 $0.00

5010046 INSTR DISP ENDOPADDLE 12M 272 $510.75 $0.00

5010053 DEVICE LASE DEL ENDST 5MM 272 $248.25 $0.00

5010079 SHEARS 5MM SHORT 272 $255.00 $0.00

5010095 STAPLER POWERED LDS 15W D 278 $1,364.75 $0.00

5010111 STAPLER CONCORD SKIN 50W 272 $55.25 $0.00

5010137 SUCTION SURGIWAND II 5MM 272 $133.75 $0.00

5014766 GUIDEWIRE CHOICE PT 272 C1769 $346.00 $0.00

5014881 BALLOON UT SDS 9X4X75 272 C1725 $701.75 $0.00

5014931 BALLOON UT SDS 5X2X75 272 C1725 $701.75 $0.00

5014949 BALLOON UT SDS 5X4X75 272 C1725 $701.75 $0.00

5015078 SLEEVE SCD THIGH LENGTH M 271 $176.75 $0.00

5015094 BLADE MANDIBULAR OS 272 $429.75 $0.00

5015128 CATH JAVID CAROTID 272 C1751 $365.25 $0.00

5015243 TUBE VENT MODIFD T-TUBE 272 $78.00 $0.00

5015250 CATH BALLOON DILATATION 272 C1725 $1,126.50 $0.00

5015268 VENT SUMP LV W/SENTINEL E 272 $73.25 $0.00

5015276 TRAY PERCUTANEOUS AK09807 272 $154.25 $0.00

5015375 KIT ARTERIAL LINE 20G 6" 272 $65.25 $0.00

5015383 KIT ARTERIAL LINE 18G 6" 272 $65.25 $0.00

5015391 KIT ARTERIAL LINE 20G 3" 272 $62.75 $0.00

5015409 KIT ARTERIAL LINE 18G 3" 272 $62.75 $0.00

5015565 TRAY TRACHEOTOMY C.S. 272 $738.75 $0.00

5015573 TRAY SUTURE C.S. 272 $192.25 $0.00

5015599 TOTE CV LINE INSERTION 272 $293.25 $0.00

5015664 TRAY PERC.SHEATH INTRO.AK 272 C1766 $137.50 $0.00

5015797 CATH IV ANGIO #3828125 272 C1751 $34.50 $0.00

5015938 SET LOCAL C.S. 272 $173.00 $0.00

5015961 BASIN COMPRESS PROCESSED 271 $40.50 $0.00

5016043 STRIP STERI 1/4 X 4" SKIN 272 $13.45 $0.00

5016472 KNIFE MYRINGOTOMY 272 $40.75 $0.00

5016571 SPLINT WRIST LEFT XSM 274 L3914 $86.50 $0.00

5016589 SPLINT WRIST LEFT SMALL 274 L3914 $79.75 $0.00

5016613 EXTRACTOR 3 LUMEN 272 $461.50 $0.00

5016670 SENSOR DIGITAL D25R ADULT 272 $23.25 $0.00

5016712 BLADE HALL OSCILLATOR 272 $73.25 $0.00

5016746 CATH 6FR JL4.0 272 C1887 $39.50 $0.00

5016787 CATH 6FR CARDMULTI STRA 272 C1887 $113.25 $0.00

5016803 CATH PIGTAIL 4FR 65CM 272 $62.75 $0.00

5016811 CATH VERTEBRAL 4FR 272 $62.75 $0.00

5016829 CATH VERTEBRAL 5FR 272 $68.25 $0.00

5016969 TUBE TRACH SIZE 6 272 $143.50 $0.00

5016985 TUBE TRACH SINGLE CANNUAL 272 $110.50 $0.00

5017009 PADS ADULT STAT 272 $78.50 $0.00

5017017 LENS MEDI FLOW 276 $140.75 $0.00

5017207 KIT GASTRIC LAVAGE 272 $71.25 $0.00



Page 40 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5017223 R&B 2HTU ICU

GUIDEWIRE STRAIGHT 145CM 272 C1769 $23.00 $0.00

5017249 SENSOR DIGITAL I20R INFNT 272 $25.50 $0.00

5017280 MESH TRELEX NATURAL POLY 278 $620.75 $0.00

5017314 RESERVOIR CARDIOTOMY 272 $137.50 $0.00

5017405 DRAIN BLAKE ROUND 19F 272 $61.50 $0.00

5017413 DRAIN BLAKE ROUND 10F 272 $61.50 $0.00

5017447 SYRINGE HEALON .4% 250 $124.50 $0.00

5017462 SYRINGE VISCOAT 272 $238.50 $0.00

5017470 CATH THROMBECTOMY AVD 4F 272 $216.75 $0.00

5017678 RESERVOIR 400C JACKSON PR 272 $55.25 $0.00

5017686 KNIFE ACL GRAFT 12MM 272 $235.25 $0.00

5017710 EVACUATOR 400CC 3/16" PVC 272 $36.25 $0.00

5017728 BLADE SURG OSCILLATOR DIS 272 $73.25 $0.00

5017744 BANDAGE SPANDAFLEX SIZE 7 271 $41.25 $0.00

5017769 BANDNET SIZE 5.5 271 $88.75 $0.00

5017785 BANDAGE SPANDAFLEX SZ 10 271 $62.25 $0.00

5017793 BANDAGE SPANDAFLEX SZ 8 271 $49.00 $0.00

5017819 TUBE SUCTION 6FR 272 $54.00 $0.00

5017827 ADAPTER STOPCOCK ANTEGRDE 272 $144.50 $0.00

5017835 PERFUSION SET MULTIPLE 272 $65.00 $0.00

5017868 CATH GUIDE JL4 272 C1887 $226.75 $0.00

5017900 SPLINT KNEE 24" 271 L1830 $53.50 $0.00

5017918 SPLINT KNEE 19" 271 L1830 $46.50 $0.00

5017959 SHOE WOMEN POST OP SZ MED 271 $15.25 $0.00

5017967 SHOE WOMEN POST OP SZ LAR 271 $15.25 $0.00

5018049 TUBING STERILE 3/8X3/32X7 272 $48.50 $0.00

5018056 BRAT PAK 250CC 272 $256.75 $0.00

5018064 ASSEMBLY BRAT PERFUSION 272 $65.75 $0.00

5018072 KIT LAP CHOLE 272 $977.50 $0.00

5018080 KIT LAP CHOLE A 272 $1,780.25 $0.00

5018106 TRAY CARDIAC CATH 272 C1887 $381.25 $0.00

5018114 TRAY DIALYSIS DLC600TEC 272 $280.75 $0.00

5018122 BAG RESUSCITAT RSRV/ADULT 271 $34.25 $0.00

5018189 ORTHOSIS ANKLE SML 274 L1902 $202.00 $0.00

5018197 ORTHOSIS ANKLE LG 274 L1902 $202.00 $0.00

5018205 SHUNT CAROTD ENDRT EXT3X4 278 $1,804.00 $0.00

5018213 SHUNT CARTD ENDA EX 3.5X5 278 $1,804.00 $0.00

5018247 KIT WOUND DEBRIDEMENT W/F 272 $104.00 $0.00

5018320 PULLEY OVER DOOR ECONOMY 271 $42.25 $0.00

5018528 TUBE BRONCH 41 LEFT 272 $266.50 $0.00

5018585 POUCH ENDO CATCH 10MM 272 $350.00 $0.00

5018593 STAPLER PREM SURGI W/TIA 278 $446.00 $0.00

5018692 INSERT FOGARTY 33MM 272 $81.50 $0.00

5018700 CATH FOGARTY EMBOLECTMY 3 272 $119.25 $0.00

5018841 CANNULA FEMORAL VENOUS 21 272 $448.25 $0.00

5018858 CANNULA RETROGRADE RCSP 272 $282.50 $0.00

5018874 PAD INSULATION CARDIAC SH 272 $90.75 $0.00

5018965 SYRINGE HEALON .85% 272 $184.50 $0.00

5019153 TRAY ANGIOGRAPHY 272 $209.50 $0.00



Page 41 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5019187 R&B 2HTU ICU

FELT TEFLN PATCH 1X6"STRL 278 $290.50 $0.00

5019195 GRAFT SAUVAGE VASCULAR 1" 278 $528.00 $0.00

5019203 STENT URETERAL POLAR 7X26 278 C2617 $1,425.50 $0.00

5019252 SENSOR DIGITAL N25R NEONT 272 $24.25 $0.00

5019310 BLADE ARTHRO ABR NBLASTER 272 $233.25 $0.00

5019336 CANNULA ARTHROSCOPY 4.5 272 $58.25 $0.00

5019435 INTRODUCER VASCULAR 9F 272 C1766 $163.50 $0.00

5019443 KIT TURBOSONIC PHACO 30 272 $351.50 $0.00

5019468 CATH BALLOON DILATATION 272 C1725 $1,126.50 $0.00

5019492 RETRACTOR STONE FLAT WIRE 272 $757.25 $0.00

5019757 SUTURE SURGIT POLISORB 21 272 $68.00 $0.00

5020078 TRAY MULTILUMEN AK25703 272 $257.00 $0.00

5020151 LIGATOR 7 BAND SPEEDBAND 272 $1,098.75 $0.00

5020193 EVACUATOR 100CC BULB 272 $19.00 $0.00

5020201 DERMACARRIER 1.5 TO 1 272 $68.00 $0.00

5020573 SLEEVES SCD STERILE THIGH 272 $148.75 $0.00

5020631 SPLINT ANKLE SIZE MED 272 $64.25 $0.00

5020649 BELT RIB MENS UNV. 271 $17.50 $0.00

5020656 BELT RIB WOMEN UNV 271 $17.50 $0.00

5020672 SHOE POST OP MENS SZ MEDI 271 $15.25 $0.00

5020706 WRIST UNN-BRACE NEOPRENE 274 L3909 $86.00 $0.00

5020714 BRACE THUMB BLACK NEOPREM 274 L3909 $94.50 $0.00

5020870 SUTURE LASSO 90 272 $442.25 $0.00

5020961 KIT BLOWER/MISTER 272 $192.25 $0.00

5020987 DILATOR FILIFORM TIP 5FR 272 $267.75 $0.00

5020995 SET INTRODUCER CK FLO 272 C1766 $165.25 $0.00

5021001 ELECTRODE VAPOR 90 DEGR/H 272 $688.25 $0.00

5021423 VALVE HEMO MERIT 272 $43.50 $0.00

5021472 GUIDEWIRE RDRUNR 018 272 C1769 $469.00 $0.00

5021480 GUIDEWIRE J 80CM 272 C1769 $43.75 $0.00

5021498 SET VASCULAR DILATOR 272 $169.25 $0.00

5021506 GUIDEWIRE ROADRUNNER 272 C1769 $102.75 $0.00

5021514 CATH 6FR CARDMULTI ANG 272 C1887 $113.25 $0.00

5021571 TIP IM FOUR ORIFICES 272 $50.00 $0.00

5021647 GUIDEWIRE SUP STIF ST 272 C1769 $104.75 $0.00

5021746 SUTURE BRIDGE RETENTION 272 $50.00 $0.00

5022058 PATELLA NEOTRACKER MED 271 $109.50 $0.00

5022140 DRAPE SLUSH & WARMING 272 $147.50 $0.00

5022256 BAG INFUSION 500CC 272 $49.00 $0.00

5022306 SHEARS LCS 5MM KNIFE DOWN 272 $1,260.50 $0.00

5022314 BLADE ARTHRO FULL RADIUS 272 $228.75 $0.00

5022322 BLADE ARTHRO INCISOR 4.5M 272 $228.75 $0.00

5022330 BLADE ARTHRO FULL RADIUS 272 $228.75 $0.00

5022694 GLOVE RADIATION RESISTANT 271 $161.50 $0.00

5022975 TROCAR OPTICAL VISIPORT 5 272 $213.75 $0.00

5023007 SPLINT WRIST LEFT MD 274 L3914 $124.75 $0.00

5023015 TRAY MULTI LUMEN M2720HK 272 $140.00 $0.00

5023098 SLEEVE SCD THIGH MED V 271 $55.25 $0.00

5023130 CATH THROMBECTOMY 4F 40CM 272 $216.75 $0.00



Page 42 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5023155 R&B 2HTU ICU 5MM

PUNCH AORTIC 272 $115.25 $0.00

5023163 PACING WIRE TEMP. 272 $99.25 $0.00

5023171 CABLE SURGCAL DISP. 272 $80.75 $0.00

5023197 CANNULA ARTHROSCOPY 7.0 272 $58.25 $0.00

5023205 CATH ATRIAL VEIN 18FR 272 C1751 $96.00 $0.00

5023387 CATH DRAINAGE 8FR 272 $280.75 $0.00

5023395 CATH PIGTAIL 8FR 272 $296.00 $0.00

5023403 CATH DRAINAGE 10FR 272 $280.75 $0.00

5023544 CATH 5FR HEADHUNT MALLIN 272 C1887 $62.75 $0.00

5023551 CATH 5FR 90CM PIG MALLIN 272 C1887 $68.25 $0.00

5023577 SHEATH 8FR FLEX 272 C1766 $178.50 $0.00

5023700 GUIDEWIRE FLOPPY 300CM 272 C1769 $307.50 $0.00

5023742 SPLINT WRIST & THUMB RIGH 272 $115.25 $0.00

5024476 TRAY TWO LUMEN AK12122H 272 $289.25 $0.00

5024542 NEEDLE POTTS COURNA.CATH 272 $49.00 $0.00

5024609 TUBE TRACH SINGLE CANNULA 272 $113.25 $0.00

5024757 CATH SWAN GANZ 831HF7.5 272 C1887 $176.75 $0.00

5024872 CIRCUIT PEDI SS SURGERY 272 $5.25 $0.00

5024898 KIT PEG SAFETY 20FR PUSH 272 $499.75 $0.00

5024930 SLEEVES SCD KNEE LENGTH 271 $114.75 $0.00

5025135 CATH BALLOON LIGHTWAVE 30 272 C1725 $2,795.50 $0.00

5025150 CANNULA CORONARY OSTIA P 272 $115.25 $0.00

5025176 HOOD STERI SHIELD SYSTEM 272 $79.00 $0.00

5025333 TRAY LACERATION SUTURE 272 $17.25 $0.00

5025358 TRAY LACERATION 272 $22.00 $0.00

5025416 PILLOW ABDUCTION MED 271 $69.00 $0.00

5025622 CATH CHOLANGIOGRAPHY 4F 272 C1887 $108.25 $0.00

5025648 CATH FOGARTY EMBOLECTM 4F 272 C1757 $119.25 $0.00

5025655 CATH FOGARTY EMBOLECTM 5F 272 $119.25 $0.00

5025754 PACK INTRA-COMPART SYSTEM 272 $221.75 $0.00

5025796 SHEATH SUPER 6FR 272 C1766 $43.25 $0.00

5025804 SHEATH SUPER 7FR 272 C1766 $43.25 $0.00

5025820 SHEATH SUPER 8FR 272 C1766 $43.25 $0.00

5025945 VALVE 3 272 $61.00 $0.00

5025952 VALVE 4 272 $65.00 $0.00

5025960 DEVICE INFLATION 272 $357.50 $0.00

5025978 DEVICE INFLATION BASIX 272 $140.25 $0.00

5025986 VALVE HEMO DBL 272 $73.00 $0.00

5026000 TRAY EPIDURAL SINGLE SHOT 272 $59.25 $0.00

5026026 SUCTION SURGIWAND II SPT 272 $126.00 $0.00

5026158 TUBE GASTROE MIS SIL/28FR 272 $149.00 $0.00

5026638 SHEET DURALASTIC STRL 030 272 $86.50 $0.00

5026646 SHEET DURALASTIC STRL 020 272 $99.50 $0.00

5026794 CANNULA INTER DISPOSABLE 272 $31.75 $0.00

5026828 PUNCH AORTIC 4MM 272 $115.25 $0.00

5026836 TRAY DIALYSIS DLC800TEC 272 $280.75 $0.00

5027008 INSERTS FOGARTY 61MM 272 $83.50 $0.00

5027024 WRAP KNEE ARTHROSCOPY 272 $127.00 $0.00

5027032 WRAP SHOULDER ARTHROSCOPY 272 $207.50 $0.00



Page 43 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5027065 R&B 2HTU ICU UNIVERSAL B

BOOT TRACTION 271 $53.75 $0.00

5027081 CATH CENTRAL VENOUS MULTI 272 C1751 $257.00 $0.00

5027099 FABRIC CARDIOVASCULAR 1"X 278 $215.50 $0.00

5027131 VALVE TALKING PASSY MUIR 272 $223.00 $0.00

5027180 BLADE SURG SAW DISP NEXGE 272 $252.25 $0.00

5027255 CATH BROVIAC 6.6F SURECUF 272 C1751 $476.75 $0.00

5027297 INTRODUCER VASCULAR 10F 272 C1766 $234.50 $0.00

5027313 CATH BALL MAVERICK 1.5 20 272 C1725 $897.75 $0.00

5027321 CATH BALL MAVERICK 2.0 20 272 C1725 $897.75 $0.00

5027339 CATH BALL MAVERICK 2.5 20 272 C1725 $897.75 $0.00

5027347 CATH BALL MAVERICK 3.0 20 272 C1725 $897.75 $0.00

5027354 CATH BALL MAVERICK 3.5 20 272 C1725 $897.75 $0.00

5027362 CATH BALL MAVERICK 4.0 20 272 C1725 $897.75 $0.00

5027628 SPLINT TENNIS ELBOW SZ ME 274 L3700 $94.50 $0.00

5027636 SPLINT TENNIS ELBOW SZ LA 274 L3700 $94.50 $0.00

5027719 SPLINT WRIST LEFT LG 274 L3914 $124.75 $0.00

5027727 SPLINT WRIST XLG RIGHT 274 L3914 $124.75 $0.00

5027735 SPLINT WRIST MED RIGHT 274 L3914 $86.00 $0.00

5027743 SPLINT WRIST LRG RIGHT 274 L3914 $124.75 $0.00

5027768 ORTHOSIS ANKLE XLG 274 L1902 $202.00 $0.00

5027776 ORTHOSIS ANKLE MD 274 L1902 $202.00 $0.00

5027818 CATH CONE TIP 8FR 272 $44.50 $0.00

5028063 CATH EMBOLECTOMY 2FR. 272 $526.75 $0.00

5028154 TUBE GASTROSTOMY 22FR 272 $56.00 $0.00

5028600 PROBE LACRIMAL SIL 11.7CM 272 $180.75 $0.00

5028618 GUIDEWIRE GLIDE ANGLED 272 C1769 $131.75 $0.00

5028626 LINE PRESSURE 48" 272 $9.00 $0.00

5028642 GUIDEWIRE BALANCE 272 C1769 $307.50 $0.00

5028659 GUIDEWIRE STEX 272 C1769 $60.00 $0.00

5028667 GUIDEWIRE BENS 272 C1769 $60.00 $0.00

5028691 CATH 7FR AL1 272 C1887 $47.75 $0.00

5028717 CATH 6FR RCB 272 C1887 $39.50 $0.00

5028725 CATH ANGLED PIG MALL 272 C1887 $39.50 $0.00

5028741 TUBE TRACH SINGLE CANNULA 272 $113.25 $0.00

5028758 TUBE TRACH SINGLE CANNULA 272 $113.25 $0.00

5028766 TUBE TRACH SINGLE CANN SZ 272 $113.25 $0.00

5028782 TUBE TRACH LOW PRESSURE S 272 $143.50 $0.00

5028865 CATH THERMOD PACEPORT 7.5 272 C1751 $230.75 $0.00

5028923 CATH TROCAR 20FR 272 $73.75 $0.00

5028964 TRAY PERMCATH DUAL LUMEN 272 C1751 $673.75 $0.00

5029020 DRAIN SUMP TRIPLE ABRAMSO 272 $83.50 $0.00

5029194 ELECTRODE RADIUS 2.0 X 0. 272 $71.00 $0.00

5029210 TOURNIQUET STERILE 8" 271 $60.25 $0.00

5029269 BOWL ULTRAMIX 272 $225.00 $0.00

5029350 KIT NOSE STOP 272 $136.00 $0.00

5029376 TRAY DIFFICULT CATH 272 C1751 $669.75 $0.00

5029384 DRAIN SUCTION TRU CLOSE 272 $73.00 $0.00

5029442 VALVE VENTRICLE VENT 272 $52.25 $0.00

5029517 TRAY MULTI LUMEM AK22123 272 $494.40 $0.00



Page 44 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5029533 RETAINER ICU

R&B 2HTU FISH VISCERA 272 $114.25 $0.00

5029905 TUBE GASTROSTOMY 16FR. 272 $56.00 $0.00

5029913 TUBE GASTROSTOMY 18FR. 272 $56.00 $0.00

5029921 TUBE GASTROSTOMY 20FR. 272 $56.00 $0.00

5029939 TUBE TRACH FENESTRATED SZ 272 $160.50 $0.00

5029947 SHOE POST OP MENS SZ LARG 271 $15.25 $0.00

5029954 SHOE POST OP MENS SZ. SMA 271 $15.25 $0.00

5030010 TUBE TRACH FENES CUFFED 272 $155.50 $0.00

5030085 STRIPPER VIEN 272 $79.50 $0.00

5030358 SUTURE ANCHOR CRKSCRW 5MM 278 $1,980.00 $0.00

5030366 DRAPE MICRO W/TUBE 272 $30.75 $0.00

5030382 CEMENT BONE SIMPLEX 278 $708.50 $0.00

5030408 SPLINT ANKLE SZ SMALL 271 $64.25 $0.00

5030473 SHOE WOMEN POST OP SZ SMA 271 $15.25 $0.00

5030689 SHEATH SUPER 4FR 272 C1766 $69.00 $0.00

5030705 CATH PIG 4FR 90CM 272 $62.75 $0.00

5030713 CATH HOOK 0.8 4FR 272 $62.75 $0.00

5030952 TOURNIQUET STERILE 12" 272 $70.00 $0.00

5030960 TOURNIQUET STERILE 18" 272 $77.75 $0.00

5030978 TOURNIQUET STERILE 24" 272 $86.75 $0.00

5030986 TOURNIQUET STERILE 30" 272 $92.50 $0.00

5030994 TOURNIQUET STERILE 34" 271 $100.00 $0.00

5031000 TOURNIQUET STERILE 42" 272 $103.25 $0.00

5031166 BLADE MICRO OSC SAW DISP 272 $28.25 $0.00

5031174 BLADE SURGERY SAW DISP 26 272 $72.50 $0.00

5031182 BLADE SURGERY SAW DISP 17 272 $72.50 $0.00

5031190 BLADE SURG SAW DISP BRAZO 272 $151.25 $0.00

5031240 ELECTRODE PACING INTRA 10 272 $428.75 $0.00

5031273 ELECTRODE KNIFE COLLNS 272 $346.00 $0.00

5031299 ELECTRODE ROLLER LOOP 28F 272 $287.25 $0.00

5031307 LOOP CUTTING 24FR 272 $239.25 $0.00

5031513 BURR DIAMOND OSTEON 162 272 $320.00 $0.00

5031687 BRACE ANKLE (SCOTT) LG. 274 L1902 $99.50 $0.00

5031695 BRACE ANKLE (SCOTT) X-LG 274 L1902 $68.25 $0.00

5031745 TUBE TRACH FENES CUFFED S 272 $155.50 $0.00

5031752 TUBE TRACH FENES CUFFED S 272 $155.50 $0.00

5031794 CATH GUIDE WISE FL4 272 C1887 $246.75 $0.00

5031802 CATH GUIDE WISE FL4SH 272 C1887 $246.75 $0.00

5032073 LOOP CUTTING 22F 272 $173.00 $0.00

5032206 STENT URETERAL POLAR 7X28 278 C2617 $1,425.50 $0.00

5032313 MESH DEXON 7"X9" 278 $775.00 $0.00

5032453 SLING ROLYAN H/ARM II LM 272 $155.75 $0.00

5032511 STENT SINGLE J DIVERSION 278 C2625 $2,112.00 $0.00

5032628 BANDAGE SPANDAFLEX SZ 11 271 $67.00 $0.00

5032776 TRAY CATH UMBIL VESSEL 3. 272 C1751 $222.75 $0.00

5032784 TRAY CATH UMBIL VESSEL 5. 272 C1751 $361.50 $0.00

5032818 CATH 6FR JL5.0 272 C1887 $39.50 $0.00

5032826 CATH 6FR AR1 272 C1887 $39.50 $0.00

5032834 CATH 6FR LCB 272 C1887 $39.50 $0.00



Page 45 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5032842 CATH 6FR ICU

R&B 2HTUIMA 272 C1887 $39.50 $0.00

5032859 CATH SIMMONS 2 5FR 272 C1887 $62.75 $0.00

5032867 GUIDEWIRE SUPER STIF J 272 C1769 $157.75 $0.00

5033048 MINI VIBRATORS 271 $45.25 $0.00

5033097 KNEE NEO WRAP JUMBO 274 L1825 $290.00 $0.00

5033303 CATH COBRA 1 5FR 272 C1725 $62.75 $0.00

5033345 SHEATH SUPER 5FR 272 C1766 $69.00 $0.00

5033360 LITHOTRIPER DISP 31MM 272 $1,414.75 $0.00

5033535 PACK CATARACT 272 $533.75 $0.00

5033600 CURRETTE SPATULA RING 272 $119.25 $0.00

5033782 CARTRIDGE LIGACLIP SMALL 278 $82.50 $0.00

5033980 CATH MP A2 6FR 272 C1887 $39.50 $0.00

5034012 GUIDEWIRE FLOPPY EXSU .01 272 C1769 $307.50 $0.00

5034087 TRAY CENTRAL VENOUS AK267 272 $175.25 $0.00

5034269 LEAD WIRES EKG SET/5 UNST 271 $79.75 $0.00

5034343 PROBE IRIGATING OCUTOME 272 $635.75 $0.00

5034467 TRAY HEMODIALYSIS DUEL LU 272 $406.75 $0.00

5034491 BAG INFUSION 1000 CC 272 $49.00 $0.00

5034517 SENSOR MYOCARDIAL TEMP 272 $62.75 $0.00

5034541 HEMOSTAT FIBRILLAR 1"X2" 272 $178.25 $0.00

5034673 SLEEVE SCD KNEE LNGTH V 271 $51.00 $0.00

5034681 CATH URINARY ICN NSY 3.5F 272 $90.00 $0.00

5034699 CATH URINARY ICN NSY 6.5F 272 $47.25 $0.00

5035126 NEEDLE FLEXITIP (000199) 272 $152.25 $0.00

5035134 NEEDLE FLEXITIP (000138) 272 $123.00 $0.00

5035191 SUTURE PDS 2-0 STP10 27" 272 $101.50 $0.00

5035324 SLIPPER COMPRESSION REGUL 271 $253.25 $0.00

5035332 SENSOR OXIMETER NEO/TODD 271 $55.50 $0.00

5035365 SLIPPER COMPRESSION LARGE 272 $126.50 $0.00

5035381 CATH THERM S TIP 604244 272 C1751 $179.50 $0.00

5035407 CATH MONITOR WEDGE 6 FR 272 C1751 $144.00 $0.00

5035431 CATH BALL MAVERICK 3.5 9 272 C1725 $897.75 $0.00

5035498 BRACE KNEE PATELLA SZ XLA 274 L1800 $263.50 $0.00

5035688 NEEDLE BIOP HAWKINS 3 20G 272 $84.50 $0.00

5035738 HEMOCONCENTRATOR UNKLE PH 272 $269.25 $0.00

5035852 BALLOON 3 LUMEN RETRIEVAL 272 C1725 $461.50 $0.00

5035944 SPLINT COCKUP HAND LARGE 271 $20.50 $0.00

5035951 SPLINT COCKUP HAND SM/MED 271 $13.50 $0.00

5035969 SPLINT COCKUP HAND YOUTH/ 271 $13.50 $0.00

5036116 GUIDEWIRE BABY J 272 C1769 $40.75 $0.00

5036132 CATH COBRA 1 4FR 272 C1725 $62.75 $0.00

5036140 CATH HOOK 0.8 5FR 272 C1725 $62.75 $0.00

5036157 CATH HOOK 1.0 4FR 272 C1725 $62.75 $0.00

5036405 NEEDLE ELECTRODE EMG CHAN 272 $92.75 $0.00

5036413 NEEDLE ELECTRODE EMG CHAN 272 $92.75 $0.00

5036553 KNIFE ACL GRAFT 10MM 272 $235.25 $0.00

5036637 STAPLER PREMIUM PLUS CEEA 278 $2,288.00 $0.00

5036652 CATH PIG 5FR 65CM 272 C1766 $62.75 $0.00

5036660 SHEATH 6FR FLEX 272 $91.25 $0.00



Page 46 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5037064 CATH 6FR ICU

R&B 2HTUPROGRESSIVE RT 272 C1887 $52.50 $0.00

5037114 ORTHOSIS WRIST LEFT SMALL 274 L3914 $124.75 $0.00

5037122 SPLINT WRIST SML RIGHT 271 $36.50 $0.00

5037130 BRACE KNEE PATELLA SZ XXL 274 L1800 $263.50 $0.00

5037155 BANDAGE UNNA BOOT 271 $20.25 $0.00

5037346 SPONGE STICK KITTNER ENDO 272 $65.25 $0.00

5037353 INJECTOR HUMI 272 $107.00 $0.00

5037411 SPLINT NASAL OVERSZ REUTE 272 $87.00 $0.00

5037437 CANNULA STRGHT VENOUS 34F 272 $94.00 $0.00

5037445 TRACTION KIT SHOULDER UPP 271 $128.75 $0.00

5037460 PACK SINUS KENNEDY SLIM 272 $57.75 $0.00

5037544 SAC PLEATMAN FOR LAP 272 $101.50 $0.00

5037577 SUCTION DEVICE PUDDLEVAC 270 $77.00 $0.00

5037627 MANIPULATOR KRONNER 272 $106.00 $0.00

5037742 CATH CHOLE OPERATIVE 4.5F 272 C1887 $117.25 $0.00

5037759 CATH INTR PERITL 9F PI93 272 C1751 $84.50 $0.00

5037999 CATH 6FR FR 4.0 272 C1887 $39.50 $0.00

5038542 BRUSH CYTOLOGY 1604 272 $142.85 $0.00

5038583 RETRIEVER SUTURE ACUFEX 278 $221.75 $0.00

5038856 ADAPTER UROLOK 272 $65.25 $0.00

5038872 DRAPE TUR PERINEAL 272 $53.75 $0.00

5038914 LOOP RESECT CUTTING 24F 272 $239.25 $0.00

5039383 NEEDLE BIOP HAWKINS 20GX1 272 $84.50 $0.00

5039821 CATH WHISTLE TIP 4FR 272 $44.50 $0.00

5039847 CATH WHISTLE TIP 5FR 272 $44.50 $0.00

5039862 CATH WHISTLE TIP 6FR 272 $36.25 $0.00

5039870 CATH CONE TIP 10FR 272 $36.25 $0.00

5039888 CATH OPEN TIP URET 5FR 272 $36.25 $0.00

5039920 RETRIEVER STONE GEMINI 4W 272 $794.00 $0.00

5039946 RETRIEVER SEGURA BASKET 4 272 $654.00 $0.00

5039995 CATH BALL MAVERICK 2.5 9 272 C1725 $897.75 $0.00

5040340 STENT URETERAL POLAR 6X22 278 C2617 $1,425.50 $0.00

5040357 STENT URETERAL POLAR 6X24 278 C2617 $1,425.50 $0.00

5040381 STENT URETERAL POLAR 7X24 278 C2617 $1,425.50 $0.00

5040399 GUIDEWIRE PTPE COATED 035 272 C1769 $53.75 $0.00

5040415 GLIDEWIRE ANGLE 150CMX.03 272 $157.75 $0.00

5040514 FORCEP GRASPING TRICEP 3P 272 $764.50 $0.00

5040530 PROBE LITHOTRIPTOR 1.9F 272 $769.50 $0.00

5040548 PROBE LITHOTRIPTOR 3F 272 $720.25 $0.00

5040555 PROBE LITHOTRIPTOR 5FR 272 $510.75 $0.00

5040563 PROBE LITHOTRIPTOR 9F 272 $672.75 $0.00

5040571 FELT TEFLON 6X6" MESH 278 $994.50 $0.00

5040589 FABRIC SAUVAGE VASCU 4X4" 278 $818.50 $0.00

5040779 BREAST PUMP KIT HOLLISTER 272 $105.25 $0.00

5040811 CANNULA VENOUS MC2 272 $112.00 $0.00

5040878 SPLINT BRIDGEMASTER NASAL 272 $100.00 $0.00

5040985 PACK ORTHOARTS MAJOR 272 $141.50 $0.00

5041454 BRUSH CYTOLOGY #1601 272 $52.50 $0.00

5041520 CATH MULTIPURP 272 $110.50 $0.00



Page 47 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5041652 R&B 2HTU ICU

KIT D&C SUCTION SETUP 272 $88.50 $0.00

5041900 TUBE ENDO DUAL UNIVENT 6. 272 $538.25 $0.00

5041918 TUBE ENDO DUAL UNIVENT 7. 272 $538.25 $0.00

5041926 TUBE ENDO DUAL UNIVENT 7. 272 $538.25 $0.00

5041934 TUBE ENDO DUAL UNIVENT 8. 272 $538.25 $0.00

5041975 CATH LEONARD 10F SURECUFF 272 C1751 $596.00 $0.00

5041983 CATH PORTA 8.FR SINGL/LUM 272 C1751 $879.00 $0.00

5042007 CATH HICKMAN ROUND 12.0F 272 C1751 $392.25 $0.00

5042049 INSERT SURG CLAMP 86MM 272 $58.00 $0.00

5042064 CANNULA SAPHENOUS VEIN 272 $12.75 $0.00

5042429 CATH IRRIGATING FOGARTY 4 272 $95.25 $0.00

5042452 CATH ADHERANT CLOT 5/8 272 $720.25 $0.00

5042460 CATH ADHERANT CLOT 6/10 272 $720.25 $0.00

5042536 SUCTION VITALVUE SYSTEM 7 272 $336.50 $0.00

5042544 SUCTION VITALVUE SYSTEM 7 272 $356.50 $0.00

5042551 SHEET BILATERAL LIMB 272 $64.50 $0.00

5042635 CANNULA ARTERIAL 20F 272 $63.25 $0.00

5042775 TUBE GASTROS MIC SILICON 272 $153.50 $0.00

5042841 LOCATOR NERVE VERI STIM 272 $140.50 $0.00

5042973 TUBE LASER CUFFED 5.5 272 $230.75 $0.00

5042999 TUBE REINFORCED CUFF 6.0 272 $31.75 $0.00

5043005 TUBE REINFORCED CUFF 8.0 272 $31.75 $0.00

5043013 MASK LARGYNGEAL LMA AIRWA 272 $26.86 $0.00

5043062 PUNCH VASCULAR GOOSEN 4.8 272 $128.25 $0.00

5043112 PROBE DILATOR PARSONNETT 272 $259.50 $0.00

5043120 PROBE DILATOR PARSONNETT 272 $259.50 $0.00

5043179 GLOVE CUT RESISTANT SZ ME 272 $188.50 $0.00

5043187 GLOVE CUT RESISTANT SZ LG 272 $188.50 $0.00

5043195 GLOVE CUT RESISTANT SZ XL 272 $188.50 $0.00

5043211 GUIDEWIRE STRGHT TIP 272 C1769 $157.75 $0.00

5043245 KIT ORTHOSORB ABSORB PIN 278 $5,940.00 $0.00

5043310 CANNULA ARTHROSCOPY 5.5 272 $58.25 $0.00

5043419 BLADE ARTHRO RAZOR CUT 4. 272 $226.50 $0.00

5043427 CATH FOGARTY BIL PROBE 5F 272 C1725 $119.25 $0.00

5043484 MESH SURGIPRO 3X5" 278 $313.32 $0.00

5043492 MESH MARLEX PERFIC PLUG 278 $1,949.25 $0.00

5043534 PROSTHESIS MALLEABLE 3.25 274 $2,773.75 $0.00

5043617 SUTURE ANCHOR GII MINI 278 $2,525.50 $0.00

5043625 KIT FINGER TRAP SM 272 $100.00 $0.00

5043633 KIT FINGER TRAP MED 272 $100.00 $0.00

5043641 KIT FINGER TRAP LG 272 $100.00 $0.00

5043740 CATH DRAIN SUPRAPUBIC ROB 272 $269.25 $0.00

5043948 INTRODUCER MINIPORT 2MM 272 $158.50 $0.00

5044227 PACK C-SECTION CUSTOM 271 $344.00 $0.00

5044383 CANNULA AORTIC ROOT 272 $54.25 $0.00

5044482 BRACE NEOPRENE ELBOW UNIV 274 L3700 $86.50 $0.00

5045273 GUIDEWIRE PLAT PLUS ST 272 C1769 $346.00 $0.00

5045588 CATH ATLANTIS 6FR US 272 $2,056.00 $0.00

5045604 TUBE BRONCH SZ 37 RIGHT 272 $291.00 $0.00



Page 48 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5045638 R&B 2HTU ICU

SUTURE MERSILENE 3/16X12" 272 $242.25 $0.00

5045687 MASK LARYNG/LMA AIRWY SZ5 272 $32.50 $0.00

5045760 FILTER LEUKODEP. (DEL TO 272 $64.50 $0.00

5046040 LIGACLIP MCS SMALL 20/20 278 $1,221.00 $0.00

5046255 TRAY DIALYSIS MCDLTSLI5 S 272 $423.00 $0.00

5046263 TRAY DIALYSIS MCDLTSL20 S 272 $423.00 $0.00

5046388 CATH URETH/FOLLWR 14 FR 272 $197.75 $0.00

5046396 CATH URETH/FOLLWR 8 FR 272 $197.75 $0.00

5046693 CANNULA FLEXARCH STRGHT 2 272 $66.75 $0.00

5046776 SUTURE TI-CRON 2-0 CV316 272 $469.90 $0.00

5046859 BRACE KNEE PATELLA SZ LAR 274 L1800 $263.50 $0.00

5046867 BRACE KNEE PATELLA SZ MED 274 L1800 $263.50 $0.00

5046974 SPLINT WRIST LEFT XLRG 274 L3914 $79.75 $0.00

5046982 SPLINT WRIST AND THUMB LG 271 $88.00 $0.00

5047055 DRAPE IOBAN SZ 90CMX85CM 272 $42.00 $0.00

5047378 CATH 6FR JL3.5 272 C1887 $39.50 $0.00

5047394 CATH BALL MAVERICK 4.0 9 272 C1725 $897.75 $0.00

5047436 CATH BALL MAVERICK 3.0 12 272 C1725 $897.75 $0.00

5047907 BLADE ARTHRO STONE CUT 4. 272 $233.25 $0.00

5047915 BLADE ARTHRO STONE CUT 5. 272 $233.25 $0.00

5048210 GUIDEWIRE IRONMAN 272 C1769 $384.50 $0.00

5048228 CATH BALL MAVERICK 2.0 12 272 C1725 $897.75 $0.00

5048244 KIT CARPAL LIG.TUNNEL REL 272 $639.25 $0.00

5048269 CATH URETH/FOLLWR 10 FR 272 $197.75 $0.00

5048830 CUTTER 3.5MM AGGRESSIVE I 272 $343.00 $0.00

5048848 CUTTER 4.0MM AGGRESSIVE I 272 $366.75 $0.00

5048855 CASSETTE DISP HUMMER2 271 $127.00 $0.00

5048863 DRAIN BLAKE 15F R HUBLESS 272 $65.50 $0.00

5048871 BRACE ANKLE (SCOTT) MED 274 L1902 $73.50 $0.00

5048897 CATH 5FR FL4 272 C1887 $39.50 $0.00

5048905 CATH 5FR FR4 272 C1887 $39.50 $0.00

5048913 CATH 5FR PIGTAIL 272 C1887 $39.50 $0.00

5049036 BALLOON UT SDS 4X4X75 272 C1725 $701.75 $0.00

5049044 CATH PIGTAIL 6FR 272 $39.50 $0.00

5049119 BLADE INCISOR ORBIT 4.5MM 272 $302.25 $0.00

5049135 BLADE INCISOR 5.5MM 272 $228.75 $0.00

5049143 BLADE SYNOVATOR 5.5MM 272 $228.75 $0.00

5049150 BLADE INCISOR PLUS 4.5MM 272 $226.50 $0.00

5049192 BLADE STONE CUTTER 4.0MM 272 $233.25 $0.00

5049226 SET PUMP TUBE 272 $218.00 $0.00

5049937 CATH BALL MAVERICK 3.0 9 272 C1725 $897.75 $0.00

5049994 PACK ANTERIOR CERVICAL 272 $344.75 $0.00

5050414 SET INSUFFLATION (AIR) 272 $96.00 $0.00

5050422 PAC VISUAL IMPLATATION Y- 272 $676.75 $0.00

5050612 CATH 6FR JR 5.0 272 C1887 $39.50 $0.00

5050620 CATH 6FR AL1 272 C1887 $39.50 $0.00

5051453 CATH PORTA XPORT 6.FR 1LU 272 $1,311.25 $0.00

5051487 CLOSURE SYST PERCLOS/PR6F 272 $868.00 $0.00

5052170 CATH GUIDE JR4.5 ST 272 C1887 $227.00 $0.00



Page 49 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5052774 R&B 2HTU ICU

PROBE V/PACING 272 C1751 $442.25 $0.00

5052980 BLADE SYNOVATOR ORBIT 4.5 272 $302.25 $0.00

5053582 DRAIN BLAKE ROUND 15FR 272 $58.75 $0.00

5054036 CATH 6FR JL 6.0 272 C1887 $39.50 $0.00

5054192 CATH SWAN NECK LEFT 272 C1751 $690.25 $0.00

5054788 HEMOSTAT NU-KNIT 6X9" 272 $395.75 $0.00

5054796 TUBE GASTROSTOMY 24FR 272 $56.00 $0.00

5054929 CATH TURBOTRACKER 272 $1,514.50 $0.00

5054937 COIL INTRAVASCULAR DIAMON 278 $716.00 $0.00

5054945 COIL INTRAVASCULAR DIAMON 278 $695.25 $0.00

5055041 CANNULA ARTERIAL FEM W/LL 272 $426.75 $0.00

5055355 BALLOON UT SDS 8X4X135 272 C1725 $701.75 $0.00

5055363 CATH 5FR FR 3.5 272 C1887 $39.50 $0.00

5055397 CATH 5FR FL 3.5 272 C1887 $39.50 $0.00

5055405 CATH 5FR FL 5 272 C1887 $39.50 $0.00

5055439 CATH 5FR AL1 272 C1887 $40.00 $0.00

5055447 CATH 5FR IM 272 C1887 $39.50 $0.00

5055561 INSTR DISP ENDOCLIP 5MM 278 $1,338.00 $0.00

5055835 PROBE HEMOSTASIS BIPOLAR 272 $960.25 $0.00

5055975 GUIDEWIRE GLIDE J 272 C1769 $114.00 $0.00

5055983 BALLOON UT SDS 8X2X75 272 C1725 $1,001.00 $0.00

5055991 CATH BALL MAVERICK 2.5 12 272 C1725 $897.75 $0.00

5056213 SET INTRODUCER POSI STICK 272 $292.25 $0.00

5056221 DRAPE MICRO FOR ZEISS MD 272 $87.25 $0.00

5056247 LOOP RESECTOSCOPE CUTTING 272 $340.50 $0.00

5056312 SHEATH SUPER 8FR 25CM 272 C1766 $146.00 $0.00

5056338 GUIDEWIRE LLT 272 C1769 $51.00 $0.00

5056684 SUTURE STEEL #5 B-P 18" 272 $2,991.00 $0.00

5056734 CATH BALL MAVERICK 2.0 15 272 C1725 $897.75 $0.00

5056759 GUIDEWIRE BENTSON EX 272 C1769 $66.50 $0.00

5056932 NEEDLE BIOPSY 18GA 15CM 272 $169.25 $0.00

5057005 BLADE MINI ARTHRO FULL #3 272 $228.75 $0.00

5057013 BLADE MINI ARTHRO FULL #3 272 $226.50 $0.00

5057260 SET INTRODUCER STENT 10 278 $843.75 $0.00

5057302 PAD DEFIB ELECTRO STRL ST 272 $147.00 $0.00

5057328 QUICKANCHOR GII EASY ANCH 278 $841.25 $0.00

5057427 BLADE MANDIBULAR OS 11.5 272 $562.00 $0.00

5057435 BLADE RECIPROCATING 27.0 272 $280.00 $0.00

5058128 CATH GLIDE 5FR ANGLED 272 $213.00 $0.00

5058136 CATH SIMMONS 1 4FR 272 C1887 $80.75 $0.00

5058144 CATH HOOK 1.0 5FR 272 C1725 $62.75 $0.00

5058409 CARTRIDGE PRISM II 272 $398.50 $0.00

5059068 SET CATH H/S 5FR 272 C1751 $94.75 $0.00

5059779 CATH 6FR AL2 272 C1887 $40.00 $0.00

5059829 TRAY PICC 5FR DOUBLE LUMN 272 $385.75 $0.00

5059985 REAMER CANN COR W/COLLPIN 272 $757.25 $0.00

5059993 REAMER CANN COR W/COLLPIN 272 $757.25 $0.00

5060009 KIT TRTREX TRANSTIBIAL AC 272 $557.50 $0.00

5060017 SCREW CANN/INTERF 7X20MM 278 $1,012.00 $0.00



Page 50 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5060025 R&B 2HTU ICUINTERF 7X25MM

SCREW CANN 278 $1,012.00 $0.00

5060033 SCREW CANN INTERF 8X20MM 278 $1,012.00 $0.00

5060041 SCREW CANN INTERF 8X25MM 278 $1,012.00 $0.00

5060066 SCREW CANN INTERF 9X25MM 278 $1,012.00 $0.00

5060173 SET MINI LIFE SET DIALYSI 272 $165.50 $0.00

5060561 SUTURE ANCHOR CORKSCREW 5 278 $1,584.00 $0.00

5060579 PUSHER KNOT 6TH FINGER 272 $307.50 $0.00

5060595 CANNULA TWIST IN CLEAR 8. 272 $96.00 $0.00

5060603 SUTURE LASSO 272 $442.25 $0.00

5060967 OXYMIZER PEDANT 272 $50.50 $0.00

5061155 BAG HYPRNFLTN 1/2L NOMASK 272 $42.50 $0.00

5061361 SURGICLIP II PREMIUM MED 278 $578.41 $0.00

5061817 MASK BI PAP SM 272 $58.25 $0.00

5061825 MASK BIPAP NASAL MED/LGW/ 272 $58.25 $0.00

5062179 SET COLON DECOMPRESSION 272 $346.00 $0.00

5062328 TRAY ARTHROGRAM DBL SNGL 272 $139.75 $0.00

5062427 BLADE SAW 1" 272 $530.50 $0.00

5062526 INSTRUMENT ENDO GIA II 1 278 $880.00 $0.00

5062534 LOAD UNIT ENDO GIA II 45- 278 $777.25 $0.00

5062542 LOAD UNIT ENDO GIA II 30- 278 $777.25 $0.00

5062559 LOAD UNIT ENDO GIA II 30- 278 $777.25 $0.00

5062567 LOAD UNIT ENDO GIA II 45- 278 $777.25 $0.00

5063003 PROBE HOOKED KNIFE CURVED 272 $456.50 $0.00

5063359 MASK LARGYNGEAL LMA SZ 3 272 $52.25 $0.00

5063367 MASK LARGYNGEAL LMA SZ 4 272 $52.25 $0.00

5063490 ULTRATOME DLWG 30MM STD T 272 $688.25 $0.00

5063730 KIT POST OPEN HEART 272 $77.00 $0.00

5063763 CATH IV ANGIO 16GAX1 1/4" 272 C1751 $10.40 $0.00

5064092 STENT VISION 3.0 12 278 C1876 $10,956.00 $0.00

5064233 GUIDEWIRE BMW 175CM 272 C1769 $307.50 $0.00

5064241 GUIDEWIRE BMW 300CM 272 C1769 $307.50 $0.00

5064464 LOAD UNIT ENDO GIA II 30- 278 $1,359.50 $0.00

5064472 LOAD UNIT ENDO GIA II 60- 278 $2,030.75 $0.00

5064480 LOAD UNIT ENDO GIA II 60- 278 $1,223.75 $0.00

5064613 FORCEP LG CAP W/NEEDLE 272 $240.25 $0.00

5064621 FORCEP LG CAP W/O NEEDLE 272 $265.25 $0.00

5064639 FORCEP LG CAP W/NEEDLE 24 272 $240.25 $0.00

5064787 BLADE SHARP HOOK 10CM 272 $403.75 $0.00

5064811 CATH 5FR PIG ANG 272 C1887 $39.50 $0.00

5064910 BALL GREEN PHYSIO GYMNIC 271 $32.25 $0.00

5064936 SUTURE ETHIBOND 2-0 STP-1 272 $107.00 $0.00

5065297 GLIDEWIRE STRAIGHT .020 272 $460.50 $0.00

5065685 SHEATH SUPER 7FR MT 272 C1766 $67.50 $0.00

5065933 SHEATH SUPER 6FR MT 272 C1766 $65.75 $0.00

5066113 BINDERS ABDOMINAL LARGE 271 $124.50 $0.00

5066758 CANNULA SOFT TIP CORONARY 272 $86.75 $0.00

5066782 BALLOON UT SDS 4X4X120 272 C1725 $1,056.25 $0.00

5066790 GUIDEWIRE SUPER STIF J 26 272 C1769 $164.75 $0.00

5067087 SYSTEM INFLATION 272 $150.00 $0.00



Page 51 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5067236 R&B 2HTU ICU

PACK ARTHROSCOPY KNEE 272 $343.50 $0.00

5067244 PACK ACL 272 $846.50 $0.00

5067251 PACK SHOULDER ARTHROSCOPY 272 $303.50 $0.00

5067269 PACK LAPAROSCOPY 272 $628.75 $0.00

5067392 KIT TOTAL HIP REPLACEMENT 272 $280.50 $0.00

5067715 CATH 6FR JR3.5 272 C1887 $39.50 $0.00

5067806 BRACE COMFRT/ELBOW SUPP L 271 $54.25 $0.00

5067996 GUIDEWIRE JAG 272 C1769 $557.50 $0.00

5068283 CATH DRAINAGE 14FR 272 $284.50 $0.00

5068572 BLADE CUTTLER AGGRESSIVE 272 $366.75 $0.00

5068606 BAG DRAINAGE 271 $50.50 $0.00

5068770 MESHERCARRIER SKIN GRAFT 272 $89.50 $0.00

5069240 PROBE GOLD INJECTION 10FR 272 $1,219.00 $0.00

5069265 IMMOBILIZER SHOULDER LG 271 $19.75 $0.00

5069323 NEEDLE BIOPSY ASAP 15GA 1 272 $169.25 $0.00

5069331 DRESSING ADHESIVE INTERCE 272 $736.75 $0.00

5069406 BALLOON DIALATOR 8-10MM 272 $860.50 $0.00

5069471 PROBE GOLD INJECTION 7FR 272 $1,219.00 $0.00

5069489 PROBE GOLD DIRECT 10FR 272 $634.50 $0.00

5069919 CATH GUIDE WISE Q4 272 C1887 $246.75 $0.00

5070248 CATH ESPH BLN 272 $860.50 $0.00

5070255 BALLOON DIALATOR 12-15CM 272 $868.00 $0.00

5070495 PACK TOTAL KNEE 272 $584.50 $0.00

5070503 PACK TOTAL HIP 272 $760.50 $0.00

5070545 BRUSH CYTOLOGY RX 272 $419.00 $0.00

5070842 CATH COBRA 2 4FR 272 $80.75 $0.00

5071113 FABRIC CARDIOVASC ULTRA T 278 $950.00 $0.00

5071295 STAPLER PROTACK 5MM W/FAS 278 $3,520.00 $0.00

5071303 BALLOON DIALATOR 18-20MM 272 $868.00 $0.00

5071311 BALLOON DIALATOR 15-18MM 272 $886.50 $0.00

5071519 ELECTRODE SIDE EFFECT 3.5 271 $711.25 $0.00

5072079 BINDER ABDOMINAL XXXLG 271 $134.50 $0.00

5072087 BINDER ABDOMINAL XLG 271 $134.50 $0.00

5072269 CATH BILIARY DRAINAGE 272 $273.00 $0.00

5072293 CATH NEPHRO 272 $280.75 $0.00

5072327 CATH 6FR AR2 272 C1887 $39.50 $0.00

5072715 STENT BILLIARY 10F 7CM 278 C2617 $176.50 $0.00

5072897 MESH SURGIPRO MONOFIL 1X4 278 C1781 $721.50 $0.00

5072905 MESH SURGIPRO MONOFIL 3X5 278 $994.50 $0.00

5072921 MESH SURGIPRO MONOFIL 14X 278 $1,042.25 $0.00

5073184 PILLOW ABD ULTRSLING II L 271 $207.50 $0.00

5073226 SNARE OVAL STANDARD CAPTI 272 $61.50 $0.00

5073234 SNARE OVAL MICRO CAPTIFLE 272 $61.50 $0.00

5073242 SNARE OVAL MINI CAPTIFLEX 272 $61.50 $0.00

5073937 INTRODUCER PERCUTANEOUS 1 272 $173.00 $0.00

5073978 IMPLANR HERNIA SM CIRCLE 278 $2,591.50 $0.00

5074026 PILLOW POSTURE NECK ROYLA 271 $63.00 $0.00

5074398 SHEET DURALASTIC STRL 010 272 $99.50 $0.00

5074711 FEEDER HABERMAN 272 $48.50 $0.00



Page 52 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5074992 R&B 2HTU UT SDS 7X4X75

BALLOON ICU 272 C1725 $701.75 $0.00

5075031 SHUNT INTRACORONARY 1.5MM 272 $288.25 $0.00

5075049 SHUNT CTS FLO COIL 2.0 272 $288.25 $0.00

5075056 SHUNT INTRACORONARY 2.25 272 $288.25 $0.00

5075064 SHUNT INTRACORONARY 2.5 272 $288.25 $0.00

5075072 SHUNT INTRACORONARY 3.0 272 $288.25 $0.00

5075155 MASK LARGYNGEAL LMA AIRWA 271 $29.50 $0.00

5075296 BALLOON UT SDS 6X4X75 272 C1725 $701.75 $0.00

5075395 SHUNT INTRACORONARY 1.75 272 $288.25 $0.00

5075767 CATH BALLOON PTCA 272 $1,792.75 $0.00

5075932 GRIP POWER HAND 271 $65.50 $0.00

5076054 DEVICE CLOSURE 6FR ANGIOS 272 $912.25 $0.00

5076419 LOAD UNIT ENDO GIA II 4.5 278 $777.25 $0.00

5076427 STAPLER PREMIUM CEEA 28 D 278 $2,288.00 $0.00

5076476 SUCTION SURGIWAND II 5MM 272 $126.00 $0.00

5076583 CATH GUIDE RWY 6FR JL4 272 C1887 $246.75 $0.00

5076591 CATH GUIDE RWY 6FR JL3.5 272 C1887 $246.75 $0.00

5076609 CATH GUIDE RWY 6FR AL1 272 C1887 $246.75 $0.00

5076617 CATH GUIDE RUNWAY 6F AL2 272 C1887 $246.75 $0.00

5076633 CATH GUIDE RWY 6FR JR4 272 C1887 $246.75 $0.00

5076641 CATH 6FR KIMNY 272 C1887 $39.50 $0.00

5076674 CATH GUIDE RUNWAY 6FR MP 272 C1887 $246.75 $0.00

5076914 STENT BILIARY RX 10CM 7FR 278 C2625 $1,012.00 $0.00

5076922 STENT BILIARY RX 12CM 7FR 278 C2625 $1,012.00 $0.00

5076948 STENT BILIARY RX 7CM 10FR 278 C2625 $1,012.00 $0.00

5076963 STENT BILIARY RX 5CM 10FR 278 C2625 $1,012.00 $0.00

5077136 BLADE MINI RECIPROCATING 272 $280.00 $0.00

5077144 PROBE BILATOR PARSONNETT 272 $259.50 $0.00

5077276 TRAY PERICARDIOCENTESIS 272 $531.75 $0.00

5077284 VALVE 1 272 $55.75 $0.00

5077318 TUBE TRACH CUFFLESS SZ 10 272 $140.75 $0.00

5077474 KNIFE MINI CARPAL TUNNEL 272 $399.75 $0.00

5077573 SUTURE RETRIEVER SMALL 272 $180.75 $0.00

5077581 SUTURE RETRIEVER MEDIUM 272 $180.75 $0.00

5077599 SUTURE RETRIEVER LARGE 272 $180.75 $0.00

5077615 BALLOON UT SDS 6X2X75 272 C1725 $701.75 $0.00

5077656 SPONGE TONSIL X-RAY STRG. 272 $9.25 $0.00

5077847 SUTURE ETHIBOND 2-0 V-5 3 272 $670.00 $0.00

5078217 BAG BLOOD WARMING STD FLW 272 $38.25 $0.00

5078308 KIT FEMORAL PREP 272 $437.75 $0.00

5078340 BALLOON UT SDS 8X4X75 272 C1725 $701.75 $0.00

5078357 CATH BALL MAVERICK 1.5 9 272 C1725 $897.75 $0.00

5078639 CATH BALL MAVERICK 3.5 12 272 C1725 $897.75 $0.00

5078647 CATH 5FR SIM 1 272 C1887 $62.75 $0.00

5078720 SET INTRODUCER MICRO PUN. 272 C1751 $117.50 $0.00

5078738 SET INTRODUCER MICRO PUN 272 $189.00 $0.00

5078837 SUTURE NUROLON 4-0 TF 8-1 272 $102.75 $0.00

5078928 CUP MUSHROOM EXTRACTOR 272 $75.00 $0.00

5079041 MESH GRAFT DUAL 20X30 278 $14,880.75 $0.00



Page 53 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5079074 R&B 2HTU ICU X 15 DUAL

MESH GRAFT 10 278 $4,056.75 $0.00

5079207 INTRODUCER VASCULAR 7FR 272 $163.50 $0.00

5079231 BRACE WRIST D RING LG 271 $55.50 $0.00

5079397 DRAPE BI-LVL SURG TBL LRG 272 $120.00 $0.00

5079462 SHEATH NEEDLE TLA 272 $98.00 $0.00

5080270 SPRING FINGER EXT. ASST. 271 $54.75 $0.00

5080692 BLADE RD IRRIGATED BUR 272 $366.75 $0.00

5080742 CLIP LIGATING & MARKING S 278 $31.00 $0.00

5080759 CLIP LIGATING & MARKING M 278 $34.50 $0.00

5080767 CLIP LIGATING & MARKING L 278 $67.75 $0.00

5081047 BALLOON AVENGER 2.75 15 272 $2,591.00 $0.00

5081252 BALLOON UT SDS 10X4X75 272 C1725 $701.75 $0.00

5081609 STENT LIBERTE 4.0 32 278 C1876 $8,360.00 $0.00

5081617 STENT LIBERTE 3.0 16 278 C1876 $8,360.00 $0.00

5081658 STENT LIBERTE 4.0 24 278 C1876 $8,360.00 $0.00

5081674 STENT EXPRESS 2 3.0 24 278 C1876 $8,360.00 $0.00

5081690 STENT LIBERTE 4.0 16 278 C1876 $8,360.00 $0.00

5081708 STENT EXPRESS 2 3.5 16 278 C1876 $8,360.00 $0.00

5082011 SYSTEM NEPHRAOSTOMU CATH 272 $635.25 $0.00

5082029 SYSTEM BILIARY CATHETER 272 $635.25 $0.00

5082110 ADHESIVE SKIN INDERMAL 272 $80.00 $0.00

5082128 SUTURE TI-CRON 5-0 CV-11 272 $167.70 $0.00

5082219 MESH GRAPH DUAL 8.0X12.X1 278 $4,056.75 $0.00

5082482 CPM MACHINE FLAT FEE 271 $120.00 $0.00

5082490 KIT DANNINGER CPM 271 $42.50 $0.00

5082664 STENT VISION 4.0 18 278 C1876 $10,956.00 $0.00

5082904 CATH BALL MAVERICK 2.0 9 272 C1725 $897.75 $0.00

5083035 BALLOON UT SDS 4X2X75 272 C1725 $701.75 $0.00

5083571 GUIDEWIRE GLIDE STRAIGHT 272 C1769 $131.75 $0.00

5083647 CANNULA TWIST 6X7 272 $96.00 $0.00

5083654 CANNULA TWIST 6MMX9MM 272 $96.00 $0.00

5083704 NEEDLE BIOPSY ASAP 18X21C 272 $169.25 $0.00

5083712 NEEDLE BIOPSY ASAP 18X10C 272 $169.25 $0.00

5084587 STENT LIBERTE 3.5 8 278 C1876 $8,360.00 $0.00

5085667 CATH GUIDE RWY 6FR JL4.5 272 C1887 $246.75 $0.00

5085683 CATH GUIDE RUNWAY 6F IM85 272 C1887 $290.25 $0.00

5085691 CATH GUIDE RWY 6FR AR2 272 C1887 $246.75 $0.00

5085709 CATH GUIDE RWY 6FR JL5 272 C1887 $246.75 $0.00

5085717 CATH GUIDE RWY 6FR JR5 272 C1887 $246.75 $0.00

5086137 GUIDEWIRE SHINOBI 300CM 272 C1769 $384.50 $0.00

5086152 CATH 5FR COBRA 2 272 C1887 $62.75 $0.00

5086236 CATH 5FR AR2 272 C1887 $39.50 $0.00

5086244 CATH 5FR RCB 272 C1887 $39.50 $0.00

5086251 CATH 5FR LCB 272 C1887 $39.50 $0.00

5086269 CATH 5FR MP2 272 C1887 $39.50 $0.00

5086764 GUIDEWIRE JAG STRAIGHT 272 C1769 $574.75 $0.00

5086921 SHEATH 6FR UP & OV 272 $217.25 $0.00

5086947 BLADE OSCILLATING 1/2" UN 272 $496.00 $0.00

5086954 CATH HICKMAN 9.6 SURECUFF 272 C1751 $480.50 $0.00



Page 54 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5087960 R&B 2HTU ICU MINI 10FR

CATH PIGTAIL 272 $284.50 $0.00

5088042 HEMO VALVE/TORQUE 272 $80.75 $0.00

5088141 CATH GUIDE RUNWAY 6F Q4 272 C1887 $246.75 $0.00

5088190 CATH GUIDE 6FR AR1 272 C1887 $173.00 $0.00

5088208 CATH URINARY ICN NSY 5.0F 272 $19.50 $0.00

5088455 CATH GUIDE RWY 6FR JR3.5 272 C1887 $246.75 $0.00

5088539 SHEATH SUPER 9FR 272 C1766 $43.25 $0.00

5088646 CATH POWER FLX BALLN5605V 272 $427.75 $0.00

5088703 SHEETING GEL SILICONE 271 $95.75 $0.00

5088778 SHEARS ULTRA AUTO SONIC 5 272 $1,084.25 $0.00

5088885 CATH VITEK 5FR 272 $59.50 $0.00

5089644 STENT SENTINOL 8X60X135 278 C1876 $10,560.00 $0.00

5089669 KIT TRANSDUCE COVER ULTRS 272 $48.50 $0.00

5089842 TRAY PROC GROSHONG 5.0 FR 272 $460.75 $0.00

5090840 HARNESS STERNUM SUPPRT RG 271 $307.50 $0.00

5090857 HARNESS STERNUM SUPPRT LG 271 $307.50 $0.00

5090931 SHEATH FLEX 7FR 24CM 272 $178.50 $0.00

5091376 BLADE STONE CUTTR 4.0MM V 272 $83.00 $0.00

5091426 SUCTION SURGIWAND II 5MMV 272 $98.50 $0.00

5091541 ELECTRODE VAPOR 90 DEGR V 272 $207.50 $0.00

5091822 BLADE PADGETT HOOD 252 V 272 $22.25 $0.00

5091848 BLADE ARTH/STONE CUT 4.0V 272 $83.00 $0.00

5091855 BLADE ARTH/STONE CUT 5.5V 272 $83.00 $0.00

5091871 BLADE INCISOR 5.5MM V 272 $83.00 $0.00

5091897 BLADE INCISOR PLUS 4.5MM 272 $83.00 $0.00

5091905 BLADE INCISOR PLUS 5.5MMV 272 $100.00 $0.00

5091954 FORCEP LG CAP W/NDL 240CV 272 $53.25 $0.00

5091962 FORCEP LG CAP W/O NDL 240 272 $53.25 $0.00

5091970 FORCEP LG CAP W/NDL 160CM 272 $53.25 $0.00

5092028 BLADE ARTH/ABR NBLAST 5.5 272 $83.00 $0.00

5092051 BLADE ARTH/FULL RADIUS 4. 272 $83.00 $0.00

5092119 BLADE MINI ART/FULL 3410V 272 $68.50 $0.00

5092259 BLADE RD IRRIGATED BUR V 272 $84.00 $0.00

5092549 BALLOON NC RANGR 4.0 15MV 272 C1725 $1,075.75 $0.00

5092572 BALLOON Q RANGER 2.5 20 V 272 C1725 $1,075.75 $0.00

5092754 SHEARS LAB DISP 5MM 272 $97.00 $0.00

5092770 LIGACLIP MCS SMALL 20/20 278 $192.25 $0.00

5092929 CATH THERMO 6FR 272 C1751 $177.50 $0.00

5093018 SLIPPER COMPRESSION REG 272 $100.25 $0.00

5093034 KIT ENDO MISC 272 $1,318.25 $0.00

5093570 CATH 5FR WILLIAMS RIGHT 272 C1887 $39.50 $0.00

5093711 ENDO BABCOCK LAP DISP 272 $97.00 $0.00

5093729 INSTR DISP DISSECT 5MM V 272 $97.00 $0.00

5094040 TOURNIQUET STERILE 8" 272 $37.50 $0.00

5094362 DEVICE INFLAT/MONARCH 25 272 $87.50 $0.00

5094388 SUCTION SURGIWAND II 5MM 272 $55.75 $0.00

5094636 ELECTRODE ROUND 3" 900 S 271 $35.50 $0.00

5095708 BLADE ARTHRO FULL RAD 5.5 272 $83.00 $0.00

5095716 BLADE ARTHRO INCISOR 4.5M 272 $83.00 $0.00



Page 55 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5096110 R&B 2HTU ICU 10F RD HUBLES

DRAIN BLAKE 272 $58.75 $0.00

5096177 TRAY PIE GROSHONG 4F INTR 272 C1751 $373.00 $0.00

5096185 INTRODUCER MICRO/RAD 4.5 272 $146.00 $0.00

5096367 DEVICE PERCUSSION LOW FLW 271 $150.00 $0.00

5096375 DEVICE PERCUSSION HI/FLOW 271 $150.00 $0.00

5096458 INSTR VASC GOOSEN PUNCH 272 $139.00 $0.00

5096813 STENT URETERAL POLAR 6X26 278 C2617 $1,425.50 $0.00

5096862 WIRE TEMP PACING 272 $237.00 $0.00

5096946 TROCAR VERSAPORT SLEEVE 5 272 $76.25 $0.00

5096953 TROCAR VERSAPORT RADIO 5M 272 $142.25 $0.00

5097019 DEVICE LASER DEL ENDSTAT 272 $107.75 $0.00

5097134 CATH STONE BASKET 2X4 272 $1,285.75 $0.00

5097449 GRAFT MESH LARGE 278 $2,595.75 $0.00

5097456 ROD 3.0 GUIDE STR BALL TP 272 $386.50 $0.00

5097480 GRAFT MESH EXTENDED 278 $2,751.50 $0.00

5097498 STENT BILIARY CLSO10-5 278 C2617 $446.75 $0.00

5097589 TUBING INTELIJET PUMP V 272 $76.75 $0.00

5098157 SUTURE/ETHBND 3-0 SH 30"V 272 $4.00 $0.00

5098439 TROCAR VRSPT RADIO 5-12MV 272 $153.75 $0.00

5098587 FOOT COVER COMPRESS LG V 272 $100.25 $0.00

5098595 MASK BIPAP FULL FACE-MED 271 $94.75 $0.00

5098603 MASK BIPAR FULL FACE-LG 271 $88.50 $0.00

5098629 DRAPE MICROSCOPE 272 $44.75 $0.00

5098884 CATH GUIDE 6FR JL3.5SH 272 C1887 $250.00 $0.00

5100169 STENT SENTINOL 10X21X75 278 C2625 $10,560.00 $0.00

5100250 DRAPE IOBAN C-ARM ATIM 2V 272 $40.75 $0.00

5100318 STENT LIBERTE 3.0 12 278 C1876 $8,360.00 $0.00

5100326 STENT LIBERTE 3.0 20 278 C1876 $8,360.00 $0.00

5100334 STENT LIBERTE 3.5 12 278 C1876 $8,360.00 $0.00

5100359 STENT LIBERTE 4.0 12 278 C1876 $8,360.00 $0.00

5100367 STENT LIBERTE 4.0 20 278 C1876 $8,360.00 $0.00

5100391 SEALS SCOPE WARMER DISP 272 $16.25 $0.00

5100805 DRAIN BLAKE 19F R HUBLESS 272 $65.75 $0.00

5100813 BLADE GRAFT HARVST SAW #8 272 $498.25 $0.00

5100862 BLADE GRAFT HARVST SAW#11 272 $429.00 $0.00

5100870 HALTER HEAD UNIVERSAL 272 $78.25 $0.00

5100953 GLOVE EDEMA L SMALL 271 $16.25 $0.00

5101159 PROBE ABLATOR 90 DEGREE 272 $610.00 $0.00

5101167 COIL INTRAVASCLR 6 40 2.4 278 $484.00 $0.00

5101209 COIL INTRAVASCLR 4 30 2.9 278 $484.00 $0.00

5101233 SUTURE GUIDE GABBAY-FRATE 272 $218.75 $0.00

5101423 INSTRUMENT PUNCH GOOSEN 4 272 $141.50 $0.00

5101522 HOOD O2 DISPOS W/DIFFUSER 271 $40.75 $0.00

5101647 BLANKET CARDIAC - STERILE 272 $111.25 $0.00

5101910 COTTON ROLL 6X9 STERILE 272 $23.25 $0.00

5101936 SLEEVES SCD THIGH V 271 $46.50 $0.00

5101944 INSTRUMENT DSP GRASP II V 272 $392.65 $0.00

5101951 SUCTION/IRRIGATOR 272 $349.25 $0.00

5102033 SUTURE PRLN 6-0 BV-1 24"V 272 $4.00 $0.00



Page 56 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5102058 R&B 2HTU ICU

ELECTRODE LEEP BALL 12CMV 272 $35.75 $0.00

5102082 CATH GUIDE RWY 6FR JR3.5S 272 C1887 $246.75 $0.00

5102090 CATH GUIDE RWY 6FR JL4SH 272 C1887 $246.75 $0.00

5102108 CATH GUIDE RWY 6FR JL3.5S 272 C1887 $246.75 $0.00

5102116 CATH GUIDE RWY 6FR JR4SH 272 C1887 $246.75 $0.00

5102124 CATH GUIDE RUNWAY 6F Q4SH 272 C1887 $290.25 $0.00

5102132 CATH GUIDE RUNWAY 6F MPSH 272 C1887 $290.25 $0.00

5102140 CATH GUIDE RUNWAY 6F HSSH 272 C1887 $290.25 $0.00

5102280 SUTURE SILK 0 CT-1 30" V 272 $4.00 $0.00

5102421 GUIDEWIRE GLIDE FIRM ANGL 272 C1769 $182.25 $0.00

5102488 STENT SENTINOL 7X39X135 278 C2625 $10,560.00 $0.00

5103080 CATH PICC LINE 4 FR 50CM 272 C1751 $190.00 $0.00

5103114 CANNULA RETRO/CARDIOPLEG 272 $379.00 $0.00

5103221 KIT TRTREY TRANSTIBL ACLV 272 $250.00 $0.00

5103262 SUTURE TICRON 2-0 Y-31 272 $210.75 $0.00

5103452 TOTE INTUBATION 271 $0.00 $0.00

5103486 SHEATH SUPER 10FR 272 C1766 $65.50 $0.00

5103494 SHEATH SUPER 10FR 25CM 272 C1766 $146.00 $0.00

5103502 SHEATH SUPER 11FR 272 C1766 $65.50 $0.00

5103510 SHEATH SUPER 11FR 25CM 272 C1766 $146.00 $0.00

5103643 NEEDLE BIOP SYS 18GA 10CM 272 $169.25 $0.00

5103650 NEEDLE BIOP SYS 18GA 15CM 272 $169.25 $0.00

5103775 SENSOR DIGITAL I20 INFANT 272 $47.25 $0.00

5103783 SENSOR DIGITAL D20 PEDIE 272 $36.25 $0.00

5103791 SENSOR DEGITAL D25 ADULT 272 $36.25 $0.00

5103809 SENSOR DIGITAL N25 NEONAT 272 $47.25 $0.00

5103817 BARS TEETH ARCH/BANDS STR 272 $68.00 $0.00

5103841 SUTURE CAPIO 48" 272 $63.50 $0.00

5103858 DEVICE CAPIO SUTURE CAPT 278 $2,035.00 $0.00

5104187 CATH PACING 5FR CURVE 275 $396.50 $0.00

5104237 CABLE SURGICAL DISP 4042 272 $115.25 $0.00

5104336 ELECTRODE SUCTION VAPOR90 272 $757.25 $0.00

5104385 GUIDEWIRE 038"STIFF 3CM T 272 C1769 $53.75 $0.00

5104393 CATH URET OPEN END 6FR 272 $48.50 $0.00

5104401 INFLATOR LEVEEN 10CC 272 $206.75 $0.00

5105093 SHEATH 6FR COBRA 272 $251.75 $0.00

5105101 FILTER OPTEASE VENA CAVA 278 $13,156.00 $0.00

5105382 GUIDEWIRE GRAPHIX PT 272 C1769 $346.00 $0.00

5105515 CATH BALL MAVERICK 4.0 12 272 C1725 $897.75 $0.00

5105523 CATH BALL MAVERICK 3.5 15 272 C1725 $897.75 $0.00

5105531 CATH BALL MAVERICK 4.0 15 272 C1725 $897.75 $0.00

5105549 CATH BALL MAVERICK 3.0 15 272 C1725 $897.75 $0.00

5105556 CATH BALL MAVERICK 2.5 15 272 C1725 $897.75 $0.00

5105606 PACK VASCULAR 272 $305.25 $0.00

5105622 NEEDLE BX SP/CUT DSP 16X1 272 $134.50 $0.00

5105663 VEIN HARVESTER SAPHLITE 272 $1,200.50 $0.00

5105747 DEVICE BONE TUNNEL CUFF L 272 $1,200.50 $0.00

5106042 BALLOON CUTTING 2.5 10 272 C1725 $3,426.75 $0.00

5106067 BALLOON CUTTING 2.5 15 272 C1725 $3,426.75 $0.00



Page 57 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5106075 BALLOON ICU

R&B 2HTU CUTTING 2.75 10 272 C1725 $2,741.50 $0.00

5106091 BALLOON CUTTING 3.0 10 272 C1725 $3,426.75 $0.00

5106653 CATH GUIDE 6FR EBU 3.5 272 C1887 $720.25 $0.00

5106760 CATH GUIDE RWY 6FR AL1SH 272 C1887 $246.75 $0.00

5106802 BAG TRU CLOSE W/EMPTY PRT 272 $96.00 $0.00

5106828 NEEDLE EPIDURAL T WNG 6" 272 $97.20 $0.00

5106869 CATH GUIDE RUNWAY 6F ART4 272 C1887 $246.75 $0.00

5106877 CATH GUIDE RUNW 6F ART4SH 272 C1887 $290.25 $0.00

5107081 ELECTRODE COAGULATION TIS 272 $529.50 $0.00

5107362 CATH BALL MAVERICK 2.0 30 272 C1725 $897.75 $0.00

5107370 CATH BALL MAVERICK 2.5 30 272 C1725 $897.75 $0.00

5107388 CATH BALL MAVERICK 3.0 30 272 C1725 $897.75 $0.00

5107396 CATH BALL MAVERICK 3.5 30 272 C1725 $897.75 $0.00

5107404 CATH BALL MAVERICK 4.0 30 272 C1725 $897.75 $0.00

5107412 STENT PROTEGE 7X40X80 6FR 278 C1876 $11,440.00 $0.00

5107594 BALL EXERCISE 29" BLUE 271 $96.00 $0.00

5107834 NEEDLE SPINAL ULTRS 22G6" 272 $97.20 $0.00

5107867 STENT LIBERTE 3.5 24 278 C1876 $8,360.00 $0.00

5108154 KIT QUICK PRESSURE MONITR 272 $298.50 $0.00

5108188 STENT EXP MONO 6.0 14 278 C1876 $10,560.00 $0.00

5108204 WIRE V 18 200 272 $360.75 $0.00

5108303 HEMO DISC SQUARE 272 $16.25 $0.00

5108329 GUIDEWIRE RADIAL .018 272 C1769 $150.50 $0.00

5108337 SHEATH SUPER 6FR 25CM 272 C1766 $146.00 $0.00

5108352 STENT EXP MONO 5.0 15 278 C1876 $10,560.00 $0.00

5108360 STENT EXP MONO 4.0 19 278 C1876 $10,560.00 $0.00

5108386 STENT EXP MONO 6.0 18 278 C1876 $10,560.00 $0.00

5108394 STENT EXP MONO 7.0 15 278 C1876 $10,560.00 $0.00

5108428 HEMOSTAT NU KNIT 1"X3 1/2 272 $113.00 $0.00

5108436 MASSAGER WAND RECHARGEABL 272 $138.25 $0.00

5108444 STENT EXP MONO 5.0 19 278 C1876 $10,560.00 $0.00

5108469 BALLOON UT SDS 7X4X50 272 C1725 $701.75 $0.00

5108477 BALLOON UT SDS 8X4X50 272 C1725 $701.75 $0.00

5109483 CATH GUIDE BRITE 6FR LCB 272 C1725 $250.00 $0.00

5109491 CATH GUIDE BRITE 6FR XB4 272 C1725 $250.00 $0.00

5109517 CATH GUIDE BRITE 6FR ALI 272 C1725 $250.00 $0.00

5109525 CATH GUIDE BRITE 6FR AL2 272 C1725 $250.00 $0.00

5109533 CATH GUIDE BRITE 6FR JL5 272 C1725 $250.00 $0.00

5109541 CATH GUIDE BRITE 6F ALISH 272 C1725 $250.00 $0.00

5109715 GLIDEWIRE STRAIGHT .020 V 272 $116.00 $0.00

5109731 TROCAR NEEDLE 146 STEP 272 $81.00 $0.00

5109756 CANNULA & DILATOR 3/BX 272 $194.25 $0.00

5109764 TROCAR CANNULA 12MM STEP 272 $415.75 $0.00

5109806 STAPLER PRIM CEEA 25 DSPV 278 $1,012.00 $0.00

5109830 CATH GUIDE BRITE 6F JL4SH 272 C1725 $250.00 $0.00

5109848 CATH GUIDE BRITE 6F JR4SH 272 C1725 $250.00 $0.00

5109855 CATH GUIDE BRITE 6FR JR4 272 C1725 $250.00 $0.00

5109863 CATH GUIDE BRITE 6FR JL4 272 C1725 $250.00 $0.00

5109889 CATH GUIDE BRITE 6FR IM 272 C1725 $250.00 $0.00



Page 58 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5109905 R&B 2HTU ICU

CATH GUIDE BRITE 6F XB3.5 272 C1725 $250.00 $0.00

5109962 BALLOON UT SDS 6X4X50 272 C1725 $701.75 $0.00

5110077 KNIFE COLD HALF SINGLE 272 $430.25 $0.00

5110176 KNIFE COLD 272 $356.25 $0.00

5110192 SPLINT PIL-O ELBOW SUPPRT 274 L3700 $237.25 $0.00

5110200 SET AXIUS XPOSE STABILIZE 272 $2,507.00 $0.00

5110242 HEMO BAND RADSTAT LONG 272 $103.75 $0.00

5110291 STABILIZER SYSTEM 272 $3,950.00 $0.00

5110325 KNIFE RESECTOSCOPE 24F TU 272 $303.75 $0.00

5110333 LOOPS RESECTOSCOPE 27FR 272 $280.50 $0.00

5110341 ROLLERBALL 3MM 272 $318.75 $0.00

5110358 ROLLERBAR 3MM 272 $280.50 $0.00

5110390 MASK LARGENGEAL LMA FX S2 271 $55.25 $0.00

5110473 STOCKING STUMP 4" 272 $84.50 $0.00

5110598 SUTURE ENDOSURGERY 5MM SY 271 $1,209.25 $0.00

5110606 SUTURE ETHIBND EXCL OEEN6 272 $146.75 $0.00

5111257 CATH INLINE 5FR 272 $55.75 $0.00

5111265 CATH INLINE 6FR 272 $50.25 $0.00

5111273 CATH INLINE 8FR 272 $50.25 $0.00

5111299 LOOP RESECTION CUTTNG 24F 272 $318.75 $0.00

5111349 SET INTRODUCER 6FR 13CMRD 272 $177.25 $0.00

5111356 CATH GUIDE BRITE 6F JR3.5 272 C1725 $250.00 $0.00

5111380 CATH GUIDE BRITE 6F JL3.5 272 C1725 $250.00 $0.00

5111398 GUIDEWIRE FORTE W/MARKRS 272 C1769 $346.00 $0.00

5111422 SUTURE FIBER WIRE 2 38" 272 $59.50 $0.00

5111497 CATH SERVANTA 272 $51.50 $0.00

5111760 MASK LARGYNGEAL LMA SZ5 D 272 $52.25 $0.00

5111877 RESERVOIR 400C JCKS/PRT V 272 $18.25 $0.00

5111893 SURGINEEDLE 120MM V 272 $26.75 $0.00

5111935 BALLOON DILATR 240CM12/15 272 $352.25 $0.00

5112263 FORCEPS BIPOLAR CUTTNG 5M 272 $1,178.25 $0.00

5112271 FORCEPS BIPOLAR CUTTNG 10 272 $1,104.50 $0.00

5112362 CIRCUIT CPAP INF 4C HEATR 271 $93.00 $0.00

5112396 CATH FALLER PERITONIAL TU 272 $695.25 $0.00

5112404 SPLINT NASAL DENVER SM/ME 271 $150.00 $0.00

5112412 SPLINT NASAL DENVER LG 271 $150.00 $0.00

5112552 CUP CURRETTE 272 $127.00 $0.00

5112578 HANDPC SFT PALLETTE DL ND 272 $1,140.50 $0.00

5112735 CATH STRAIGHT 6FR 40CM 272 C1751 $76.00 $0.00

5113279 EZ PAP WITH MOUTHPIECE 271 $55.75 $0.00

5113287 GENERATOR INFANT CPAP 271 $155.75 $0.00

5113360 SET RIGHT HEART ASSIST 272 $3,589.25 $0.00

5114202 RETRIEVER SEGURA BKT 3.0 272 $794.00 $0.00

5114210 INFLATOR ENCORE OR CYSTO 272 $326.75 $0.00

5114236 RETRACTOR STONE ZERO TIP 272 $831.00 $0.00

5114269 GUIDEWIRE SENSOR 035X3CM 272 C1769 $145.25 $0.00

5114277 DILATOR CO-AXIAL 8/10 272 $138.50 $0.00

5114319 STENT URETERL POLARIS5X22 278 C2617 $1,320.00 $0.00

5114327 STENT URETERAL POLARS5X24 278 C2617 $1,320.00 $0.00



Page 59 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5114335 R&B 2HTU ICU

STENT URETERAL POLARS5X26 278 C2617 $1,425.50 $0.00

5114392 PAD DISP KNEE TRIANGLE 272 $69.25 $0.00

5114400 ADAPTER TROCAR PORT 5MM 272 $115.25 $0.00

5114467 CATH ANGIO KUMPE ACCESS 272 $66.25 $0.00

5114665 CARD TEST HTT 271 $182.00 $0.00

5114749 GUIDEWIRE ST .021 272 C1769 $64.25 $0.00

5114897 INSTRUMENT SCALPEL HARMNC 272 $1,323.50 $0.00

5115175 MESH COMPOSIX 7"X9" 278 $10,252.00 $0.00

5115183 MESH COMPOSIX 8"X10" 278 $13,173.50 $0.00

5115191 MESH KUGEL HERNIA 11X14 P 278 $7,488.75 $0.00

5115217 MESH PERFIX PLUG MED 278 C1781 $1,931.50 $0.00

5115225 MESH PERFIC PLUG SM 278 $1,821.50 $0.00

5115241 MILK BREAST 270 $12.00 $0.00

5115357 FORTIFIER HUMAN MILK SMLC 270 $4.00 $0.00

5115381 BALLOON RETRIEVAL RX 8.5M 272 $573.00 $0.00

5115423 KIT DRESSING VAC TRAC MED 272 $119.50 $0.00

5115431 KIT DRESSING VAC TRAC LG 272 $144.25 $0.00

5115449 KIT DRESSING VAC TRAC SM 272 $94.75 $0.00

5115456 KIT CANISTER VAC STSW ISO 272 $133.25 $0.00

5115472 PAD TRAC 272 $67.25 $0.00

5115480 AUTO TOME RX30MM 272 $1,026.75 $0.00

5115498 AUTO TOME RX 20MM 272 $1,026.75 $0.00

5115506 SPHINCTEROTOME RX20MM 272 $698.00 $0.00

5115522 SPHINCTEROTOME NEEDLKNF X 272 $698.00 $0.00

5115530 BASKET RETRVAL TRAPZD 2X4 272 $1,030.50 $0.00

5115548 BASKET RETRVL TRAP 2.5X4C 272 $1,030.50 $0.00

5115555 GUIDEWIRE JAGTAIL 035 272 C1769 $329.75 $0.00

5115563 GUIDEWIRE JAGWIRE 035 272 C1769 $517.25 $0.00

5115571 CANNULA TAPERED RAPID EXC 272 $250.00 $0.00

5115589 CANNULA TAPERED RAPD EX/X 272 $296.00 $0.00

5115613 GUIDEWIRE J .038" X 70CM 272 C1769 $347.00 $0.00

5115621 STAPLER PREM/PLS CEEA 31V 278 $923.50 $0.00

5115647 DILATOR SHEATH 16FR 272 C1892 $347.00 $0.00

5115654 CATH DIALYSIS 19CM 272 C1750 $347.00 $0.00

5115662 CATH DIALYSIS 28CM 272 C1750 $347.00 $0.00

5115670 CATH DIALYSIS 23CM 272 C1750 $347.00 $0.00

5115696 BALLOON PEDIATRC 12FR 5CC 272 $149.00 $0.00

5115704 NEEDLE INSUL STIMPLX 21GX 272 $41.75 $0.00

5115720 COMP CATH 12FR #2951 272 C1751 $204.50 $0.00

5115738 COMP GUIDEWIRE J STRGHT 272 $204.50 $0.00

5115761 KIT ORTHO PAT PROCESSING 272 $2,082.50 $0.00

5115779 SPLINT ELBOW KNEE SOFT M 274 L3999 $86.25 $0.00

5115803 PATCH HERNIA COMPOSX SM O 278 $5,073.25 $0.00

5115811 PATCH HERNIA COMPOSX SM C 278 $4,158.00 $0.00

5116140 TUBE TRACH SIZE 8 PERC 272 $161.00 $0.00

5116298 GLOVE EDEMA LARGE RT 271 L3999 $17.25 $0.00

5116330 STENT LIBERTE 4.0 28 278 C1876 $8,360.00 $0.00

5116355 KIT BLOWER/MISTER 272 $230.75 $0.00

5116405 CATH CENTRAL LINE 6FR 272 $843.50 $0.00



Page 60 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5116462 R&B 2HTU OPENSAIL 2.0 10

BALLOON ICU 272 C1725 $923.50 $0.00

5116470 BALLOON OPENSAIL 2.5 10 272 C1725 $923.50 $0.00

5116488 BALLOON OPENSAIL 3.0 10 272 C1725 $923.50 $0.00

5116538 BALLOON OPENSAIL 3.0 15 272 C1725 $923.50 $0.00

5116546 BALLOON OPENSAIL 3.5 15 272 C1725 $923.50 $0.00

5116595 INSTRUMENT ENDOGIA VERSFR 272 $384.50 $0.00

5116611 DRESSING SINUSTENT DRWSTR 272 $62.00 $0.00

5116710 TRAY LUMBAR PUNCT C ADULT 272 $46.50 $0.00

5116892 FILTER VENA CAVA TULIP JG 278 $8,910.00 $0.00

5116918 STENT SMART 8X60X80 278 C1876 $14,476.00 $0.00

5116926 STENT SMART 7X40X80 278 C1876 $14,476.00 $0.00

5117098 CATH 6FR 3DRC 272 C1887 $41.50 $0.00

5117106 BALLOON CONQUEST 12X4X75 272 C1725 $814.50 $0.00

5117312 MASK LARYNGEAL LMA FLX .5 272 $38.75 $0.00

5117411 TRAP FINGER XL STRL DBL 272 $100.00 $0.00

5117510 SHEARS LCS 5MM KNIFE DWNV 272 $615.25 $0.00

5117932 COMP CATH 12 FR #11792 272 $204.50 $0.00

5117957 COMP GUIDEWIRE J STRGT 272 $204.50 $0.00

5118013 BAG REPLACEMENT WASTE 272 $45.75 $0.00

5118252 STENT EXPRESS 2 2.75 8 278 C1876 $8,360.00 $0.00

5118278 STENT LIBERTE 4.5 28 278 C1876 $8,360.00 $0.00

5118286 STENT LIBERTE 4.5 32 278 C1876 $8,360.00 $0.00

5118310 STENT LIBERTE 5.0 32 278 C1876 $8,360.00 $0.00

5118369 STENT LIBERTE 2.75 20 278 C1876 $8,360.00 $0.00

5118377 STENT EXPRESS 2 2.25 12 278 C1876 $8,360.00 $0.00

5118476 CANNULA NONVENT CONCT 20F 272 $151.75 $0.00

5118492 HEEL LIFT DISP 99200 272 $109.25 $0.00

5118542 LINE POST OP 272 $44.75 $0.00

5118963 INSERT RETRACT SUT HOLD 272 $192.25 $0.00

5119268 KIT PAT WILSON FRAME 271 $118.00 $0.00

5119276 SCALPEL HARMONIC CURV SHR 272 $1,260.50 $0.00

5119458 TUBE TRACH REPL PERFIT #7 272 $489.00 $0.00

5119482 PIN DISTRACTION 16MM 272 $198.00 $0.00

5119490 SLEEVE SCD THIGH LARGE 271 $211.75 $0.00

5119516 PRESSURIZER FEMORAL SM 272 $64.00 $0.00

5119607 DVC CAPIO SUTUR CAPTURE V 272 $939.50 $0.00

5119664 POWDER ARGLAES 272 $173.75 $0.00

5119680 CATH GUIDE BRITE 6FR RCBS 272 C1725 $250.00 $0.00

5119698 CATH GUIDE BRITE 6FR ARI 272 C1725 $250.00 $0.00

5119706 CATH GUIDE BRITE 6FR AR2 272 C1725 $250.00 $0.00

5119763 SET SPLIT BACK PAD SM 272 $672.75 $0.00

5119771 SET SPLIT BACK PAD MED 272 $672.75 $0.00

5119938 PACKS STEINMAN DRILL 272 $849.50 $0.00

5119953 STENT EXPRESS LD 6X40X75 278 C1876 $12,276.00 $0.00

5119979 STENT EXPRESS LD 7X40X75 278 C1876 $12,276.00 $0.00

5120076 SEALANT HEMO MATRIX FLOSL 272 $615.25 $0.00

5120191 PACK CYSTO 272 $171.25 $0.00

5120209 PACK ENT 272 $157.00 $0.00

5120217 PACK D AND C 272 $112.00 $0.00



Page 61 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5120225 R&B 2HTU ICU

PACK EXTREMITY 272 $225.00 $0.00

5120233 PACK VAG HYST 272 $199.75 $0.00

5120241 PACK BASIC 272 $140.50 $0.00

5120258 PACK LAPAROTOMY 272 $194.25 $0.00

5120423 CATH GUIDE BRITE 6FRXBLAD 272 C1725 $250.00 $0.00

5120431 CATH GUIDE BRITE 6FR JL6 272 C1725 $250.00 $0.00

5120449 STENT EXPRESS LD 8X30X75 278 C1876 $12,276.00 $0.00

5120456 STENT EXPRESS LD 7X30X75 278 C1876 $12,276.00 $0.00

5120555 STENT EXPRESS LD 6X30X75 278 C1876 $12,276.00 $0.00

5120605 STENT EXPRESS LD 7X60X75 278 C1876 $13,156.00 $0.00

5120647 STAPLER TR DST 45 3.5 272 $833.50 $0.00

5120654 LOAD UNIT TA DST 45 3.5 272 $217.75 $0.00

5120688 TRAY PICC NEO 2.8 272 $220.00 $0.00

5120779 SLEEVE SCP THIG LG V 272 $55.25 $0.00

5120837 STAPLER TA DST 45 4.8 278 $1,985.75 $0.00

5120886 BALLOON CONQUEST 6X4X50 272 C1725 $978.75 $0.00

5120894 BALLOON CONQUEST 7X4X50 272 C1725 $978.75 $0.00

5120902 BALLOON CONQUEST 8X4X50 272 C1725 $814.50 $0.00

5120928 CATH GUIDE RWY 6FR CLS4 272 C1887 $246.75 $0.00

5120936 CATH GUIDE RWY 6FR AR2SH 272 C1887 $246.75 $0.00

5120944 CATH GUIDE RWY 6FR VL4 272 C1887 $246.75 $0.00

5120951 CATH GUIDE RWY 6FR VL4SH 272 C1887 $246.75 $0.00

5120969 ELASTIC STAYS 5MM 272 $169.25 $0.00

5121199 BALLOON QMAV 2.0 8 272 C1725 $1,385.00 $0.00

5121207 BALLOON QMAV 2.5 8 272 C1725 $969.50 $0.00

5121215 BALLOON QMAV 2.0 12 272 C1725 $969.50 $0.00

5121223 BALLOON QMAV 2.5 15 272 C1725 $969.50 $0.00

5121231 BALLOON QMAV 3.0 15 272 C1725 $969.50 $0.00

5121249 BALLOON QMAV 4.0 15 272 C1725 $969.50 $0.00

5121256 INTRODUCER RAABE 6FR 55CM 272 $198.00 $0.00

5121314 BALLOON QMAV 3.0 8 272 C1725 $969.50 $0.00

5121322 BALLOON QMAV 3.5 8 272 C1725 $969.50 $0.00

5121348 BALLOON QMAV 2.5 12 272 C1725 $969.50 $0.00

5121355 BALLOON QMAV 3.0 12 272 C1725 $969.50 $0.00

5121363 BALLOON QMAV 3.5 12 272 C1725 $969.50 $0.00

5121371 BALLOON QMAV 4.0 12 272 C1725 $969.50 $0.00

5121389 BALLOON QMAV 2.0 15 272 C1725 $969.50 $0.00

5121397 BALLOON QMAV 3.5 15 272 C1725 $2,206.25 $0.00

5121439 BALLOON QMAV 3.5 20 272 C1725 $2,206.25 $0.00

5121447 BALLOON QMAV 4.0 20 272 C1725 $2,206.25 $0.00

5121520 CATH 5FR SLIP VERT 272 C1887 $134.50 $0.00

5121629 STENT ASPIRE 10X5X100 278 C2625 $17,160.00 $0.00

5121678 PATCH HERNIA LARGE OVAL 274 $9,495.25 $0.00

5121694 ELECTRODE SIDE EFFECT 3.5 271 $207.50 $0.00

5121751 BRACE ANK/FT WLKR HI SM 274 L4386 $258.25 $0.00

5121769 BRACE ANK/FT WLKR HI MED 274 L4386 $277.25 $0.00

5121777 BRACE ANK/FT WLKR HI LG 274 L4386 $277.25 $0.00

5121785 STABILIZER VEGA PATELLA S 274 L1815 $545.25 $0.00

5121793 STABILIZER VEGA PATELLA M 274 L1815 $545.25 $0.00



Page 62 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5121801 R&B 2HTU ICU

STABILIZER VEGA PATELLA L 274 L1815 $545.25 $0.00

5121819 STABILIZER VEGA PATELL XL 274 L1815 $545.25 $0.00

5121827 STABILIZER VEGA PATEL XXL 274 L1815 $545.25 $0.00

5121876 INTRODUCER HEMOSTATC L 7F 272 $250.00 $0.00

5121884 INTRODUCER HEMOSTATC L 9F 272 $325.25 $0.00

5121900 SPLINT THUMB SUEDE 7 1/2" 274 L3913 $61.25 $0.00

5121926 SPLINT FOOT ANKLE RT SM 274 L4398 $256.25 $0.00

5121934 SPLINT FOOT ANKLE RT MED 274 L4398 $258.75 $0.00

5121942 SPLINT FOOT ANKLE RT LG 274 L4398 $376.50 $0.00

5122049 SCREW DELTA 9MM 278 $1,707.25 $0.00

5122056 SCREW DELTA 10MM 278 $1,707.25 $0.00

5122064 SCRE DELTA 11MM 278 $1,707.25 $0.00

5122080 SCREW BIO 7MM 278 $1,249.50 $0.00

5122098 SCREW BIO 8MM 278 $1,249.50 $0.00

5122106 SCREW BIO 9MM 278 $1,249.50 $0.00

5122114 SCREW BIO 10MM 278 $1,249.50 $0.00

5122122 SCREW BIO CORKSCREW 5.0MM 278 $2,244.00 $0.00

5122270 SPLINT ULNAR DEVIAT RT ME 274 A4570 $197.50 $0.00

5122312 SYRINGE PRESSURE MONITRNG 272 $265.25 $0.00

5122320 SET NEEDLE DISCOG DOCKING 272 $77.00 $0.00

5122338 KIT NEEDLE SET DISCOGRAM 272 $40.50 $0.00

5122528 FILTER WIRE 300CM 272 $4,671.25 $0.00

5122700 KIT TISSEEL SEALANT 2ML 272 $722.75 $0.00

5122734 KIT TISSEEL SEALANT 5ML 272 $1,760.00 $0.00

5122742 SET SPRAY TISSEEL 272 $153.75 $0.00

5122759 COSEAL PREMIX 4ML 272 $1,717.50 $0.00

5122767 SHEATH 6FR AN L2 272 C1893 $251.75 $0.00

5122783 KIT PAT CARE JACKSON TABL 272 $141.50 $0.00

5122791 MASK NASAL CPAP SMALL 271 $55.75 $0.00

5122809 MASK NASAL CPAP LARGE 271 $55.75 $0.00

5122858 HANDPIECE TURBOVAC WAND90 272 $687.00 $0.00

5123450 SUTURE FIBERWIRE 2 C-13 3 272 $59.50 $0.00

5123492 MASK LMA FASTRACH SZ 3 272 $99.00 $0.00

5123591 CATH GUIDE BRITE 6FR XBLA 272 C1725 $250.00 $0.00

5124060 BLADE GRAFT HARVEST SAW#6 272 $498.25 $0.00

5124078 BLADE GRAFT HARVEST SAW#7 272 $498.25 $0.00

5124110 CATH 5FR CARDMULTI ANG 272 C1887 $113.25 $0.00

5124128 CATH 5FR CARDMULTI STRA 272 C1887 $127.00 $0.00

5124292 SCREW IMPLANT 5.5MM BIO T 278 $1,892.00 $0.00

5124318 SCREW IMPLANT 7MM BIO TNO 278 $1,980.00 $0.00

5124326 SCREW IMPLANT 8MM BIO TNO 278 $1,716.00 $0.00

5124334 SCREW IMPLANT 9MM BIO TNO 278 $1,980.00 $0.00

5124359 LOAD UNIT ENDO GIAII 30 3 278 $595.50 $0.00

5124698 STENT URET POLARIS 6X28 278 C2617 $622.75 $0.00

5124987 TUBE TRACHEOSTOMY BVN 9.0 272 A7521 $671.25 $0.00

5125109 STENT SMART 10X60X80 278 C1876 $14,476.00 $0.00

5125141 CATH 4FR CARD MULTI ANG 272 C1887 $161.50 $0.00

5125158 CATH 4FR PIG ANG 272 C1887 $53.75 $0.00

5125166 CATH 4FR JR4 272 C1887 $53.75 $0.00



Page 63 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5125174 R&B 2HTUJL4

CATH 4FR ICU 272 C1887 $53.75 $0.00

5125240 BALLOON CUTTING 2.5 6 272 C1725 $3,426.75 $0.00

5125372 SYRINGE CORD BLOOD DRAWIN 272 $52.25 $0.00

5125422 SUTURE FASTACK FIBERWIRE 272 $576.75 $0.00

5125497 CATH AIRWAY EXCHANGE 7MM 272 $139.25 $0.00

5125562 NEEDLE SMART 272 $326.75 $0.00

5125695 PADS DEFIB RADIOLUCENT 271 $177.75 $0.00

5125927 ELECTRODE 2X2 271 $1.50 $0.00

5125935 ELECTRODE ROUND 2 3/4" 271 $19.00 $0.00

5126040 CEMENT SIMPLEX W/TOBRAMYC 278 $4,180.00 $0.00

5126115 NEEDLE SHEATH NEOPIC 2.8 272 $90.00 $0.00

5126123 NEEDLE SHEATH NEOPIC 1.9 272 $90.00 $0.00

5126180 CATH GUIDE OPTIMA 6FR JL4 272 C1887 $173.00 $0.00

5126206 CATH GUIDE OPTIMA 6FR JL4 272 C1887 $173.00 $0.00

5126305 CATH GUIDE OPTIMA 6FR SHA 272 C1887 $173.00 $0.00

5126321 CATH GUIDE OPTIMA 6FR JR5 272 C1887 $173.00 $0.00

5126339 CATH GUIDE OPTIMA 6FR ALI 272 C1887 $173.00 $0.00

5126354 CATH GUIDE OPTIMA 6FR AL2 272 C1887 $173.00 $0.00

5126388 CATH GUIDE OPTIMA 6FR ARI 272 C1887 $173.00 $0.00

5126420 CATH GUIDE OPTIMA 6FR LCB 272 C1887 $173.00 $0.00

5126438 CATH GUIDE OPTIMA 6FR LCB 272 C1887 $173.00 $0.00

5126453 CATH GUIDE OPTIMA 6FR HS 272 C1887 $173.00 $0.00

5126461 CATH GUIDE OPTIMA 6FR HSS 272 C1887 $173.00 $0.00

5126479 CATH GUIDE OPTIMA 6FR IM 272 C1887 $173.00 $0.00

5126495 CATH GUIDE OPTIMA 6FR MP 272 C1887 $173.00 $0.00

5126768 HANDLE IMPLANT MAGNUM/KNT 278 $3,520.00 $0.00

5126776 CONNECTOR MAGNUM NEEDL/GR 272 $480.50 $0.00

5126792 SUTURE CARTRIDGE GREEN 278 $1,276.00 $0.00

5126818 SUTURE BIO ANCHOR#2 FIBRW 278 $1,980.00 $0.00

5126826 TUBE SUCTION MINI 272 $127.00 $0.00

5126859 CATH GUIDE VIKING 7F JLH 272 C1887 $173.00 $0.00

5126958 SHUNT INTRACORONARY 1.25M 272 $288.25 $0.00

5127048 CATH GUIDE VIKING 8FR JL4 272 C1887 $173.00 $0.00

5127113 STENT TAXUS 2.5 8 278 C1874 $25,960.00 $0.00

5127121 STENT TAXUS 2.5 12 278 C1874 $25,960.00 $0.00

5127139 STENT TAXUS 2.5 16 278 C1874 $25,960.00 $0.00

5127147 STENT TAXUS 2.5 20 278 C1874 $25,960.00 $0.00

5127154 STENT TAXUS 2.5 24 278 C1874 $25,960.00 $0.00

5127162 STENT TAXUS 2.75 8 278 C1874 $25,960.00 $0.00

5127170 STENT TAXUS 2.75 12 278 C1874 $25,960.00 $0.00

5127188 STENT TAXUS 2.75 16 278 C1874 $25,960.00 $0.00

5127196 STENT TAXUS 2.75 20 278 C1874 $25,960.00 $0.00

5127204 STENT TAXUS 2.75 24 278 C1874 $25,960.00 $0.00

5127212 STENT TAXUS 2.75 28 278 C1874 $25,960.00 $0.00

5127220 STENT TAXUS 2.75 32 278 C1874 $25,960.00 $0.00

5127238 STENT TAXUS 3.0 8 278 C1874 $25,960.00 $0.00

5127246 STENT TAXUS 3.0 12 278 C1874 $25,960.00 $0.00

5127253 STENT TAXUS 3.0 16 278 C1874 $25,960.00 $0.00

5127261 STENT TAXUS 3.0 20 278 C1874 $25,960.00 $0.00



Page 64 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5127279 R&B 2HTU ICU3.0 24

STENT TAXUS 278 C1874 $25,960.00 $0.00

5127287 STENT TAXUS 3.0 28 278 C1874 $25,960.00 $0.00

5127295 STENT TAXUS 3.0 32 278 C1874 $25,960.00 $0.00

5127303 STENT TAXUS 3.5 8 278 C1874 $25,960.00 $0.00

5127311 STENT TAXUS 3.5 12 278 C1874 $25,960.00 $0.00

5127329 STENT TAXUS 3.5 16 278 C1874 $25,960.00 $0.00

5127337 STENT TAXUS 3.5 20 278 C1874 $25,960.00 $0.00

5127345 STENT TAXUS 3.5 24 278 C1874 $25,960.00 $0.00

5127394 BLADE MANDIBULAR UNDERM D 272 $242.25 $0.00

5127402 BLADE MANDIBULAR RECIPROC 272 $280.00 $0.00

5127428 BLADE MINI MANDIBLR 16.OM 272 $280.00 $0.00

5127477 CATH 4FR ARI 272 C1887 $53.75 $0.00

5127501 CATH 4FR IM 272 C1887 $53.75 $0.00

5127519 CATH 4FR MP2 272 C1887 $53.75 $0.00

5127527 CATH 4FR ALI 272 C1887 $53.75 $0.00

5127535 CATH 4FR JL3.5 272 C1887 $53.75 $0.00

5127592 ELECTRODE RADIUS 2.5X1.0 272 $73.75 $0.00

5127758 BLADE SAGITTAL .97 THICK 272 $188.25 $0.00

5127766 BLADE SAGITTAL 1.27 THICK 272 $188.25 $0.00

5127774 BLADE RECIPRORATING 70.0M 272 $171.75 $0.00

5127808 SENSOR FOREHEAD PULSE OXI 271 $77.00 $0.00

5127873 CATH 4FR JL5 272 C1887 $53.75 $0.00

5127881 TUBING INTEGRATED 272 $346.00 $0.00

5128038 BLADE SAGITTAL 18.0 272 $188.25 $0.00

5128046 BLADE SAGITTAL 25.0 MM 272 $188.25 $0.00

5128137 BLADE SAGITTAL W/10MM STP 272 $142.75 $0.00

5128145 BLADE LONG MEDIUM 272 $165.25 $0.00

5128152 BLADE SAGITTAL W/80MM STP 272 $142.75 $0.00

5128160 BLADE SAGITTAL W/120MM ST 272 $142.75 $0.00

5128178 FORCEP RADIAL JAW BIOPSY 272 $250.00 $0.00

5128467 BALLOON QMAV 5.0 8 272 C1725 $969.50 $0.00

5128475 BALLOON QMAV 5.0 12 272 C1725 $969.50 $0.00

5128491 BALLOON QMAV 5.0 20 272 C1725 $969.50 $0.00

5128681 STENT WAVEMAX 5X17X75 278 C1876 $11,000.00 $0.00

5128699 STENT WAVEMAX 6X12X75 278 C1876 $11,000.00 $0.00

5128707 STENT WAVEMAX 6X38X75 278 C1876 $11,000.00 $0.00

5128715 STENT WAVEMAX 8X17X75 278 C1876 $11,000.00 $0.00

5128723 STENT WAVEMAX 6X28X75 278 C1876 $11,000.00 $0.00

5128731 STENT WAVEMAX 6X17X75 278 C1876 $11,000.00 $0.00

5129036 NEEDLE NITINO SUTURNG LP 272 $384.50 $0.00

5129044 NEEDLE JAMSHIDI DISP 11GX 272 $104.75 $0.00

5129069 STENT WAVEMAX 5X38X75 278 C1876 $11,000.00 $0.00

5129085 CATH PORTA XPORT 8FR 1 LU 272 C1751 $1,311.25 $0.00

5129267 FORCEP RADIAL JAW BIOPSY 272 $53.25 $0.00

5129978 CEMENT BONE 40 GRAM 278 $703.50 $0.00

5129986 CEMENT BONE SMART SET MV 278 $709.25 $0.00

5129994 DILATOR CANNULA MINST7/8 272 $255.00 $0.00

5130109 NEEDLE BASE PLATE 18G 272 $12.50 $0.00

5130117 SNARE GOOSENECK 2MM 200CM 272 $2,236.50 $0.00



Page 65 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5130125 R&B 2HTU ICU

SNARE GOOSENECK 4MM 200CM 272 $2,236.50 $0.00

5130133 SNARE GOOSENECK 7MM 200CM 272 $2,236.50 $0.00

5130281 EXTRACTOR RX TRVL 9.0 12. 272 $622.75 $0.00

5130299 EXTRACTOR RX RTVL 12. 15. 272 $622.75 $0.00

5130489 SNARE GOOSENECK AMPLTZ 20 272 $1,015.75 $0.00

5130497 SNARE GOOSENECK AMPLTZ 30 272 $1,015.75 $0.00

5130505 CATH PERITONEAL 2 CUFF62C 272 $275.25 $0.00

5130513 BAG BLOOD WARMER HG/FLOW 272 $102.00 $0.00

5130844 STENT WAVEMAX 5X28X75 278 C1876 $11,000.00 $0.00

5130851 STENT WAVEMAX 10X28X75 278 C1876 $11,000.00 $0.00

5130877 STENT WAVEMAX 10X38X75 278 C1876 $11,000.00 $0.00

5130885 STENT WAVEMAX 12X38X75 278 C1876 $11,000.00 $0.00

5130893 BALLOON FOX 12X20X75 272 $701.75 $0.00

5130901 BALLOON FOX 12X40X135 272 $701.75 $0.00

5130919 BALLOON FOX 12X60X75 272 $701.75 $0.00

5130943 MASK LARYNGEAL LMA SZ2 DS 272 $54.75 $0.00

5130950 MASK LARYNGEAL LMA SZ2.5D 272 $54.75 $0.00

5130976 SPLINT ULNAR DEVIATION WF 274 A4570 $253.00 $0.00

5130984 CATH GUIDE RWY 6FR JL3.5S 272 C1887 $246.75 $0.00

5130992 CATH GUIDE RWY 6FR JL4ST 272 C1887 $246.75 $0.00

5131008 CATH GUIDE RWY 6FR JL6 272 C1887 $246.75 $0.00

5131016 CATH GUIDE RUNWAY 6FR ARI 272 C1887 $246.75 $0.00

5131024 CATH GUIDE RUNWAY 6FR ART 272 C1887 $290.25 $0.00

5131032 CATH GUIDE RUNWAY 6F ART3 272 C1887 $290.25 $0.00

5131040 CATH GUIDE RUNWAY 6F Q3.5 272 C1887 $246.75 $0.00

5131057 CATH GUIDE RUNWAY 6F Q3.5 272 C1887 $246.75 $0.00

5131065 CATH GUIDE RUNWAY 6FKIMNY 272 C1887 $290.25 $0.00

5131156 FILTER ULPA OPTIMUM SMOKE 272 $378.00 $0.00

5131164 ATTACHMENT SMOKE EVAC OPT 272 $50.00 $0.00

5131198 CATH X SIZER 4.5 135 272 $5,050.00 $0.00

5131206 CATH X SIZER 5.5 135 272 $5,050.00 $0.00

5131214 GUIDEWIRE AQ ANGLED 272 C1769 $173.00 $0.00

5131222 GUIDEWIRE AQ ANGLED EXCH 272 C1769 $211.50 $0.00

5131230 GUIDEWIRE AQ STIFF ANGLED 272 C1769 $219.25 $0.00

5131248 GUIDEWIRE AQ STIFF ANG/EX 272 C1769 $269.25 $0.00

5131255 BALLOON CUTTING PERIP 5X2 272 C1725 $2,885.75 $0.00

5131263 BALLOON CUTTING PERIP 6X2 272 C1725 $2,885.75 $0.00

5131271 BALLOON CUTTNG PERIP 7X2X 272 C1725 $2,885.75 $0.00

5131289 BALLOON CUTTNG PERIP 8X2X 272 C1725 $2,885.75 $0.00

5131297 CATH GUIDE PERIP MACH1 6L 272 C1887 $307.50 $0.00

5131305 CATH GUIDE PERIP MACH1 6R 272 C1887 $307.50 $0.00

5131313 CATH GUIDE PERIP MACH1 7L 272 C1887 $307.50 $0.00

5131321 CATH GUIDE PERIP MACH1 7R 272 C1887 $307.50 $0.00

5131362 ELECTRODE RADIUS 1.0X.7V 271 $21.50 $0.00

5131370 ELECTRODE RADIUW 1.0X1.0V 271 $21.50 $0.00

5131388 ELECTRODE RADIUS 2.OX1.0V 271 $21.50 $0.00

5131396 SET OPCABMULTI VESSEL V 272 $842.25 $0.00

5131404 SET AXIUS STABILZR DP/BLV 272 $842.25 $0.00

5131412 PROBE LITHOTRIPTOR 3F V 272 $160.75 $0.00



Page 66 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5131503 R&B 2HTU ICU JEJUNAL 8.5F

TUBE FEEDING 272 $480.50 $0.00

5131552 MASK LARYNGEAL LMA AIRWAY 271 $46.50 $0.00

5131560 ELECTRODE STANDARD DISP 272 $707.00 $0.00

5131586 INTRODUCER W/BXNDL 196/10 272 $158.50 $0.00

5131651 BALLOON OPENSAIL 1.5 10 272 C1725 $923.50 $0.00

5131669 CATH GUIDE RWY CLS3.5SH 272 C1887 $246.75 $0.00

5131677 CATH GUIDE RWY CLS4SH 272 C1887 $246.75 $0.00

5131685 CATH GUIDE RWY 6FR WR 272 C1887 $246.75 $0.00

5131693 CATH GUIDE RWY 6FR WRSH 272 C1887 $246.75 $0.00

5131701 CATH GUIDE RWY 6FR JL3 272 C1887 $246.75 $0.00

5131719 CATH GUIDE RWY 6FR AL.75 272 C1887 $246.75 $0.00

5131735 DEVICE RETRIEVAL ROTH NET 272 $288.25 $0.00

5131743 GUIDEWIRE IQ W/O MARKERS 272 C1769 $346.00 $0.00

5131750 CATH GUIDE RUNWAY 6F LCBS 272 C1887 $246.75 $0.00

5131768 CATH GUIDE RUNWY 6F RCBSH 272 C1887 $246.75 $0.00

5131776 CATH GUIDE RWY 6FR AL1.5 272 C1887 $246.75 $0.00

5131784 CATH GUIDE RWY 6FR CLS4.5 272 C1887 $246.75 $0.00

5131792 CATH GUIDE RWY 6FR ART4.5 272 C1887 $246.75 $0.00

5131800 CATH GUIDE RWY 6FR Q4.5 272 C1887 $246.75 $0.00

5131818 CATH GUIDE RWY 6FR JR3 272 C1887 $246.75 $0.00

5131826 CATH GUIDE RWY 6FR CLS3.5 272 C1887 $246.75 $0.00

5131834 CATH GUIDE MACH1 7F LCBSH 272 C1887 $246.75 $0.00

5131842 CATH GUIDE MACH1 7FR RCB 272 C1887 $246.75 $0.00

5131859 CATH GUIDE MACH1 7F RCBSH 272 C1887 $246.75 $0.00

5131883 CATH GUIDE OPTIMA 6F GL3. 272 C1887 $173.00 $0.00

5131891 CATH GUIDE OPTIMA 6FGL3.5 272 C1887 $173.00 $0.00

5131909 CATH GUIDE OPTIMA 6FR GL4 272 C1887 $173.00 $0.00

5131917 CATH GUIDE OPTIMA 6FGL4SH 272 C1887 $173.00 $0.00

5131925 CATH GUIDE OPTIMA 6F JL4S 272 C1887 $157.00 $0.00

5131990 STENT PROTEGE 7X20X80 6FR 278 C1876 $11,440.00 $0.00

5132147 BALLOON SYMONORAIL 4X15X9 272 $1,108.00 $0.00

5132154 BALLOON SYMONORAIL 7X2X90 272 $1,005.25 $0.00

5132162 BALLOON SYMONORL 5X1.5X90 272 $1,108.00 $0.00

5132170 BALLOON SYMONORAIL 5X2X90 272 $1,108.00 $0.00

5132188 BALLOON SYMONORL 6X1.5X90 272 $1,108.00 $0.00

5132196 BALLOON SYMONORAIL 6X2X90 272 $1,108.00 $0.00

5132204 BALLOON SYMONORL 7X1.5X90 272 $1,108.00 $0.00

5132212 BALLOON SYMONORAIL 7X2X90 272 $1,108.00 $0.00

5132220 BALLOON POLAR 4X20X120 272 $2,164.25 $0.00

5132238 BALLOON POLAR 4X40X120 272 $2,164.25 $0.00

5132246 BALLOON POLAR 4X60X120 272 $2,164.25 $0.00

5132253 BALLOON POLAR 5X60X120 272 $2,164.25 $0.00

5132261 BALLOON POLAR 6X60X120 272 $2,164.25 $0.00

5132279 BALLOON POLAR 7X60X120 272 $2,164.25 $0.00

5132311 CARTRIDGE NITROUS OXIDE 271 $1,846.75 $0.00

5132345 STENT XCEED 6X8X120 278 C1876 $12,760.00 $0.00

5132352 STENT WAVEMAX 7X38X75 278 C1876 $11,000.00 $0.00

5132360 CATH 4FR JL6 272 C1887 $53.75 $0.00

5132378 CATH 4FR AL2 272 C1887 $53.75 $0.00



Page 67 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5132386 CATH 4FR ICU

R&B 2HTUAL3 272 C1887 $53.75 $0.00

5132394 CATH 4FR AR2 272 C1887 $53.75 $0.00

5132469 INTRODUCER TRACH TUBE L5F 272 $192.25 $0.00

5132527 CATH MOTARJEME 4FR 65CM 272 $68.25 $0.00

5132543 CATH GUIDE PERIPH MACH 16 272 C1887 $307.50 $0.00

5132550 PUMP FEMOSTOP 271 $480.50 $0.00

5132568 DEVICE FEMOSTOP PLUS 272 $286.50 $0.00

5132576 BALLOON FOX 3X2X75 272 $701.75 $0.00

5132584 STENT WAVEMAX 8X38X75 278 C1876 $11,000.00 $0.00

5132618 PINS DISTRACTION 14MM 272 $198.00 $0.00

5132782 TRAY DIALYS CATH/CHRON 19 272 $1,145.00 $0.00

5132790 TRAY DIALYSIS CHRONIC 28C 272 $1,145.00 $0.00

5132808 TRAY DIALYSIS CHRONIC 23C 272 $1,145.00 $0.00

5133004 FORCEP POT BIOPSY SING/U 272 $250.00 $0.00

5133020 DEVICE FEMOSTOP HD 272 $294.25 $0.00

5133038 PAD ARTIC UNIVERSAL SMALL 272 $611.00 $0.00

5133053 TRAY DIALYSIS 37CM METAL 272 $1,143.25 $0.00

5133061 VALVE SHEATH FLOW GUARD/P 272 $115.25 $0.00

5133079 TRAY DIALYSIS 50CM 272 $1,616.75 $0.00

5133186 GUIDEWIRE ASAHI PROWATER 272 C1769 $346.00 $0.00

5133194 GUIDEWIRE ASAHI GRAND SLM 272 C1769 $250.00 $0.00

5133202 GUIDEWIRE ASAHI MIRCLEBR3 272 C1769 $442.25 $0.00

5133210 GUIDEWIRE ASAHI MIRCLBR4. 272 C1769 $442.25 $0.00

5133228 GUIDEWIRE ASAHI MIRCLBR 6 272 C1769 $442.25 $0.00

5133236 CATH GUIDE BRITE 6FR RB 272 C1725 $250.00 $0.00

5133285 CATH GUIDE BRITE 6F 3DRCS 272 C1725 $250.00 $0.00

5133293 CATH GUIDE BRITE 6F MPSH 272 C1725 $250.00 $0.00

5133301 CATH GUIDE BRITE 6F MP 272 C1725 $250.00 $0.00

5133319 CATH GUIDE BRITE 6F ARISH 272 C1725 $250.00 $0.00

5133327 CATH GUIDE BRITE 6F XB4SH 272 C1725 $250.00 $0.00

5133335 CATH GUIDE BRITE 6F HS 272 C1725 $250.00 $0.00

5133343 CATH GUIDE BRITE HSSH 272 C1887 $250.00 $0.00

5133350 CATH GUIDE BRITE 6F ZBC4 272 C1725 $250.00 $0.00

5133368 CATH GUIDE BRITE 6F 3DRC 272 C1725 $250.00 $0.00

5133376 CATH GUIDE BRITE 6F XBC3. 272 C1725 $250.00 $0.00

5133384 CATH GUIDE BRITE 6F XBRCA 272 C1887 $250.00 $0.00

5133392 CATH GUIDE BRITE 6F IMVBI 272 C1725 $250.00 $0.00

5133400 CATH GUIDE BRITE 6F JL4.5 272 C1725 $250.00 $0.00

5133442 STENT WAVEMAX 8X28X75 278 C1876 $11,000.00 $0.00

5133459 STENT WAVEMAX 7X28X75 278 C1876 $11,000.00 $0.00

5133657 APPLIER MENISCAL DSP R/LK 272 $419.00 $0.00

5133665 SUTURE MENISCAL REP PLA#0 272 $672.75 $0.00

5133673 SUTURE MENISCL REP PLA#27 272 $672.75 $0.00

5133681 SUTURE MENISCL REP PLA#12 272 $672.75 $0.00

5133699 CATH PICC 1.9FR 272 C1751 $134.50 $0.00

5133707 KIT CATHETER PICC 1.9FR 272 $123.00 $0.00

5133715 INTRODUCER PICC 1.9FR 272 $168.75 $0.00

5133731 DEVICE ULTRASOUND SLED 272 $134.50 $0.00

5133749 BALLOON FOX 6X2X135 272 $701.75 $0.00



Page 68 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5133764 R&B 2HTU ICU RENAL 7F MP

SHEATH GUIDE 272 $288.25 $0.00

5133871 CATH 5FR FLUSH 90CM 272 C1887 $82.75 $0.00

5133889 CATH 4FR 30RC 272 C1887 $53.75 $0.00

5133897 CATH 4FR LCB 272 C1887 $53.75 $0.00

5133905 CATH 4FR RCB 272 C1887 $53.75 $0.00

5134226 FORCEP BOT BIOPSY S/U V 272 $67.75 $0.00

5134259 STENT XPERT 6X40X120 278 C1876 $15,840.00 $0.00

5134267 STENT XPERT 6X60X120 278 C1876 $15,840.00 $0.00

5134275 STENT XPERT 6X60X80 278 C1876 $15,840.00 $0.00

5134283 STENT XPERT 6X40X80 278 C1876 $15,840.00 $0.00

5134341 SPLINT WRIST BL 8" RT SM 274 L3914 $79.75 $0.00

5134358 INSTRUMENT FRCP LIGASURE 272 $923.50 $0.00

5134366 BRACE ANK/FT WLKR HI XLG 274 L4386 $389.75 $0.00

5134374 BRACE ANK/FT WLKR HI XSM 274 L4386 $362.75 $0.00

5134440 SPLINT WRIST THMB LEFT LG 274 L3984 $158.25 $0.00

5134457 SPLINT WRIST THMB LEFT MD 274 L3984 $158.25 $0.00

5134465 SPLINT WRIST THUMB RT MED 274 L3984 $158.25 $0.00

5134473 SPLINT WRIST THMB LEFT SM 274 L3984 $158.25 $0.00

5134481 SPLINT WRIST THUMB RT SM 274 L3984 $158.25 $0.00

5134499 SPLINT WRIST THMB LFT XLG 274 L3984 $158.25 $0.00

5134507 SPLINT WRIST THUMB RT XLG 274 L3984 $158.25 $0.00

5134515 SPLINT WRIST THUMB RT XSM 274 L3984 $163.25 $0.00

5134523 SPLINT WRIST THUMB RT XXL 274 L3984 $163.25 $0.00

5134531 SPLINT WRIST THUMB RT LG 274 L3984 $158.25 $0.00

5134549 SPLINT WRIST THMB LFT XSM 274 L3984 $163.25 $0.00

5134556 MASK NASAL CPAP MED SZ 1 271 $55.75 $0.00

5134572 NEEDLE JAMSHIDI 8GA 4" 272 $104.75 $0.00

5134580 NEEDLE JAMSHIDI 13GA 2" 272 $57.25 $0.00

5134598 NEEDLE JAMSHIDI 13G 3 1/2 272 $104.75 $0.00

5134630 TRAY EPIDURAL 25GA OB 272 $120.75 $0.00

5134648 TRAY SPINAL 27GA OB 272 $126.00 $0.00

5134739 SUTURE FASTAKE ANCHOR W/H 272 $692.00 $0.00

5134861 BURR EGG 272 $242.25 $0.00

5134879 BURR PEAR 272 $242.25 $0.00

5134887 BURR ROUND FAST CUTTING 272 $215.25 $0.00

5134903 BURR FASTCUTTING 7.1MM RD 272 $215.25 $0.00

5134911 BLADE DRILL WIRE PASS 272 $258.50 $0.00

5134945 TIP BONE CLEANING 272 $50.25 $0.00

5134952 BRUSH FEMORAL 272 $50.25 $0.00

5134960 BLADE LARGE THIN SAFEDGE 272 $201.75 $0.00

5134978 BLADE RECIPROCATING LG33. 272 $280.00 $0.00

5134994 PROBE DILATOR PARSONNETT 272 $76.75 $0.00

5135009 PROBE HOOK ULTRASNC DEV V 272 $248.50 $0.00

5135017 TROCAR CANNULEA 10MM STPV 272 $113.25 $0.00

5135108 STENT EXP MONO 6.0 18/50 278 C1876 $10,560.00 $0.00

5135330 KIT EMERGENCY CRICO/TRCHD 272 $438.25 $0.00

5135348 MASK LARING FASTRAC LM4 U 272 $1,902.25 $0.00

5135355 MASK LARING FASTRAC LMA5U 272 $1,902.25 $0.00

5135363 MASK LARING PROSEAL LMA4U 272 $941.75 $0.00



Page 69 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5135371 R&B 2HTU ICU PROSEAL LMA5U

MASK LARYNG 272 $941.75 $0.00

5135389 TRAY COMBI TUBE 41FR 272 $267.25 $0.00

5135397 TRAY COMBI TUBE 37FR 272 $267.25 $0.00

5135405 PATCH ACTION 272 $33.05 $0.00

5135413 STABILIZER ACROBAT VACM/S 272 $3,950.00 $0.00

5135421 KIT CATH PREMICATH 27GA S 272 $205.75 $0.00

5135496 PROBE ABLATION MICROW FLX 272 $9,919.75 $0.00

5135504 CATH EPIDURAL 21GX24" 272 $242.25 $0.00

5135512 PROBE ABLATION MICRW FL10 272 $15,330.50 $0.00

5135553 APPLICATOR TIP DUAL C 20G 272 $70.75 $0.00

5135561 TIP DUAL SPRAY PLATELT GL 272 $70.75 $0.00

5135579 APPLICATOR RATIO PLATLT G 272 $80.75 $0.00

5135603 SYSTEM INJ RAPID REFILL 272 $84.25 $0.00

5135652 NEEDLE EPIDURAL STRGT 18G 272 $57.00 $0.00

5135660 NEEDLE EPIDURAL STR 18GX3 272 $55.50 $0.00

5135744 DRESSING ACTICOAT ABSRB4X 272 $186.50 $0.00

5135769 DRAPE MICROSCOPE DISP 272 $200.00 $0.00

5135793 SEAL HEARTSTRING PRX 4.3M 272 $1,662.00 $0.00

5135801 DEVICE HEARTSTRING PRX SL 272 $1,403.50 $0.00

5135827 CIRCUIT HEATED HIGHFLOW I 271 $141.25 $0.00

5135850 BAG COLLECTOR FLUID STERL 272 $95.50 $0.00

5135876 COVER C ARM DISP 271 $61.50 $0.00

5135900 INSTR VESSEL SEALING 20CM 272 $1,358.50 $0.00

5136064 LEAD EXTRACTION SYSTEM 5 272 $26,981.75 $0.00

5136080 CANNULA WITH TROCAR 272 $96.00 $0.00

5136106 DEVICE LEAD CLIPPER 272 $180.75 $0.00

5136114 DILATOR SHEATH SS SZ A 272 $684.25 $0.00

5136122 INTRODUCER PEEL AWAY 14FR 272 $233.50 $0.00

5136130 INTRODUCER PEEL AWAY 12FR 272 $233.50 $0.00

5136148 DILATOR SHEATH 11.5FR 272 $403.75 $0.00

5136155 INTRODUCER PEEL AWAY 9FR 272 $233.50 $0.00

5136163 INTRODUCER PEEL AWAY 10FR 272 $233.50 $0.00

5136171 INTRODUCER PEEL AWAY 7FR 272 $233.50 $0.00

5136189 SHEATH CURVED FEMORL 16FR 272 C1894 $1,263.25 $0.00

5136197 SHEATH CURVED FEMRL 12FR 272 C1894 $526.75 $0.00

5136205 SNARE 20MM W/12FR ST SHEA 272 C1773 $1,532.75 $0.00

5136213 SNARE 20MM 272 C1894 $2,388.00 $0.00

5136221 SNARE 13MM W/12F ST SHEAT 272 C1773 $1,532.75 $0.00

5136239 SNARE 13MM 272 C1894 $2,388.00 $0.00

5136247 DILATOR SHEATH SS SZ C 272 $684.25 $0.00

5136254 DILATOR SHEATH SS SZ B 272 $684.25 $0.00

5136262 DILATOR SHEATH 10FR 272 $403.75 $0.00

5136270 DILATOR SHEATH TEF SET C 272 $453.75 $0.00

5136288 DILATOR SHEATH TEF SET C 272 $403.75 $0.00

5136296 DILATOR SHEATH 8.5FR EXLG 272 $453.75 $0.00

5136304 DILATOR SHEATH TEF S/B EX 272 $453.75 $0.00

5136312 DILATOR SHEATH 8.5FR 272 $403.75 $0.00

5136320 DILATOR SHEATH TEF SET B 272 $403.75 $0.00

5136338 DILATOR SHEATH 13FR EXLON 272 $453.75 $0.00



Page 70 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5136346 R&B 2HTU ICU

DILATOR SHEATH 7FR EXLONG 272 $453.75 $0.00

5136353 DILATOR SHEATH 13FR 272 $403.75 $0.00

5136361 DILATOR SHEATH 7FR 272 $403.75 $0.00

5136379 DEVICE LOCKNG STYLT .016 272 C1773 $1,455.25 $0.00

5136387 DILATOR SHEATH 11.5 EXLNG 272 $453.75 $0.00

5136395 DILATOR SHEATH 10FR EXLNG 272 $453.75 $0.00

5136403 DEVICE PIN WISE 272 $211.50 $0.00

5136411 GUIDEWIRE STYLET 272 C1769 $134.50 $0.00

5136437 DEVICE SOF GRIP HEMOSTAT 272 $184.50 $0.00

5136445 DEVICE COIL EXPANDER 272 $192.25 $0.00

5136601 PACK PACEMAKER 272 $167.50 $0.00

5136627 CATH EXTRACTION PRON 272 $1,828.25 $0.00

5136635 SET INTRODUCER MICROPUN 5 272 $111.50 $0.00

5136668 TRAY CATH PIC 2 LUMEN 5FR 272 C1751 $181.50 $0.00

5136734 CATH 4FR JOG MULTI ANG 272 C1887 $109.50 $0.00

5136742 CATH 4FR JOG JL3.5 272 C1887 $37.25 $0.00

5136759 CATH 4FR JOG JL4 272 C1887 $37.25 $0.00

5136767 CATH 4FR JOG JL5 272 C1887 $37.25 $0.00

5136775 CATH 4FR JOG JR3.5 272 C1887 $37.25 $0.00

5136783 CATH 4FR JOG JR4 272 C1887 $37.25 $0.00

5136791 CATH 4FR JOG JR5 272 C1887 $37.25 $0.00

5136809 CATH 4FR JOG PROGRESSV RT 272 C1887 $37.25 $0.00

5136817 CATH 4FR JOG PIG ANG 272 C1887 $37.25 $0.00

5136825 CATH 4FR JOG ALI 272 C1887 $37.25 $0.00

5136833 CATH 4FR JOG AL2 272 C1887 $37.25 $0.00

5136841 CATH 4FR JOG ARI 272 C1887 $37.25 $0.00

5136858 CATH 4FR JOG AR2 272 C1887 $37.25 $0.00

5136866 CATH 4FR JAG IMA 272 C1887 $37.25 $0.00

5136874 CATH 4FR JOG RCB 272 C1887 $37.25 $0.00

5136882 CATH 4FR JOG LCB 272 C1887 $37.25 $0.00

5136890 CATH 4FR JOG MPA2 272 C1887 $37.25 $0.00

5136908 CANNULA 100MM CURV 20G 10 272 $122.75 $0.00

5136916 CANNULA 150MM CURVED 20G 272 $159.25 $0.00

5136924 ELECTRODE PAD SELF ADHESV 272 $81.75 $0.00

5136932 CATH 4FR JOG PIG ST 272 C1887 $34.00 $0.00

5136973 NASAL CPAP ADULT SMALL 271 $96.00 $0.00

5136981 NASAL CPAP ADULT MEDIUM 271 $96.00 $0.00

5136999 NASAL CPAP ADULT LARGE 271 $96.00 $0.00

5137005 NASAL CPAP ADULT XLARGE 271 $96.00 $0.00

5137088 CATH GUIDE BRITE 6F XBRCA 272 C1887 $250.00 $0.00

5137096 NEEDLE ACTIVE TIP CURV5.0 272 $102.25 $0.00

5137104 NEEDLE ACTIVE TIP STRG4.0 272 $102.25 $0.00

5137120 GUIDEWIRE SENSOR .038 STR 272 C1769 $180.75 $0.00

5137138 GUIDEWIRE .025 STRAIGHT 272 C1769 $157.75 $0.00

5137146 GUIDEWIRE SUPERSTIFF .35A 272 C1769 $246.00 $0.00

5137153 GUIDEWIRE SUPERSTIFF .035 272 C1769 $246.00 $0.00

5137187 BANDAGES TRANSELAST CLASS 271 A4460 $2.25 $0.00

5137195 BANDAGES KIDNEY F/RUBB SM 271 A5126 $8.75 $0.00

5137203 BANDAGES KIDNEY F/RUBB LG 271 A5126 $15.25 $0.00



Page 71 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5137245 R&B 2HTU ICU

TRAY THORA/PARACENTESIS 272 $217.25 $0.00

5137336 FORCEP GRASPING 2.6FX90CM 272 $812.50 $0.00

5137344 FORCEP GRASPING 3.2FX90CM 272 $812.50 $0.00

5137351 RETRIEVER STONE 3FX90CM 272 $764.50 $0.00

5137369 RETRIEVER STONE BSKT NITI 272 $831.00 $0.00

5137385 DRESSING VAC ATS WHITE LG 272 $153.25 $0.00

5137401 SLEEVE SCD STERILE THGH L 272 $148.75 $0.00

5137419 SLEEVE SCD KNEE LENGTH 271 $114.75 $0.00

5137427 SLEEVE SCD THIGH MEDIUM 271 $176.75 $0.00

5137435 SLEEVE SCD THIGH LARGE 271 $211.75 $0.00

5137476 KIT NERVE BLOCK 22GA X 8" 272 $55.50 $0.00

5137484 KIT NERVE BLOCK 25GA X 6" 272 $51.75 $0.00

5137492 STENT XCEED 6X40X120 278 C1876 $12,760.00 $0.00

5137500 STENT XCEED 7X80X120 278 C1876 $12,760.00 $0.00

5137518 STENT XCEED 7X40X120 278 C1876 $12,760.00 $0.00

5137526 CATH 6FR PIG DUAL LUMEN 272 C1887 $496.00 $0.00

5137732 SLEEVE TROCAR 5MM 272 $90.75 $0.00

5137740 BLADE LNG RECIP SHRT 33.5 272 $301.50 $0.00

5137757 BLADE SHRT TAPRD LNG 27.0 272 $266.75 $0.00

5137765 BLADE LG TR ACRS CUT RASP 272 $501.25 $0.00

5137773 BLADE SAFDGE LG/SHRT 23.0 272 $301.50 $0.00

5137781 BLADE MINI RECP SHRT 27.0 272 $266.75 $0.00

5137799 BLADE MINI RECP SHRT 14.5 272 $301.50 $0.00

5137807 BLADE CORE INTRA ORL 12.0 272 $382.75 $0.00

5137815 BLADE CORE INTRA ORAL 7.0 272 $382.75 $0.00

5137831 BLADE AGGRESIVE 4.0 SINUS 272 $366.75 $0.00

5137856 STENT XCEED 6X60X120 278 C1876 $12,760.00 $0.00

5137864 STENT XCEED 7X60X120 278 C1876 $12,760.00 $0.00

5137872 BALLOON FOX 4X40X135 272 $701.75 $0.00

5137880 BALLOON FOX 5X40X135 272 $701.75 $0.00

5137898 BALLOON FOX 6X40X135 272 $701.75 $0.00

5137914 CATH GUIDE BRITE XB4 272 C1887 $250.00 $0.00

5138250 SUTURE CAPIO PROL D TAPER 272 $88.00 $0.00

5138375 STENT LIBERTE 3.0 8 278 C1876 $8,360.00 $0.00

5138383 STENT LIBERTE 2.75 8 278 C1876 $8,360.00 $0.00

5138474 CATH STONE BASKET 1.5X3 272 $1,087.75 $0.00

5138482 SHEATH 12FR 30CM 272 $256.00 $0.00

5138490 SHEATH 14FR 30CM 272 $256.00 $0.00

5138508 CATH DRAINAGE 12FR 25CM 272 $263.50 $0.00

5138516 CATH DRAINAGE 14FR 25CM 272 $263.50 $0.00

5138524 CATH STONE BASKET 1.8X2.5 272 $1,458.00 $0.00

5138532 ELECTRODES VALUTRADE 271 $3.75 $0.00

5138540 CANNULA 410 CU 20GA 7.5MM 272 $122.75 $0.00

5138557 SET ESPOCAN SPIRAL EPIDUR 272 $67.75 $0.00

5138631 BRACE BACK PROLIGN SM 274 L0628 $910.75 $0.00

5138649 BRACE BACK PROLIGN MED 274 L0628 $910.75 $0.00

5138656 BRACE BACK PROLIGN LG 274 L0628 $910.75 $0.00

5138664 BRACE BACK PROLIGN XL 274 L0628 $910.75 $0.00

5138672 BRACE BACK PROLIGN XXL 274 L0628 $910.75 $0.00



Page 72 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5138680 R&B 2HTU ICU

CATH DRAIN SUPRPUBIC ROBV 272 $113.25 $0.00

5138698 INSTRUMENT FRCP LIGASUREV 272 $755.75 $0.00

5138706 LOOPS RESECT CUT 24FRV 272 $290.00 $0.00

5138722 STENT LIBERTE 3.5 16 278 C1876 $8,360.00 $0.00

5138789 STENT LIBERTE 4.5 12 278 C1876 $8,360.00 $0.00

5138797 SET FILTERLINE H ADLT/PED 271 $47.25 $0.00

5138805 SET FILTERLINE INFANT/NEO 271 $47.25 $0.00

5138961 SENSOR OXYCLIQ NEONATAL 271 $32.50 $0.00

5138995 INTRODUCER PEEL AWAY 16FR 272 C1892 $184.50 $0.00

5139001 INTRODUCER PEEL AWAY 20FR 272 C1892 $147.75 $0.00

5139019 INTRODUCER PEEL AWAY 22FR 272 C1892 $147.75 $0.00

5139043 CATH GUIDE BRI 6FR XB 4.5 272 C1887 $250.00 $0.00

5139050 CATH GUIDE BRITE 6FR AL3 272 C1887 $250.00 $0.00

5139068 CATH GUI BRI 6F XBLAD 4.5 272 C1887 $250.00 $0.00

5139076 SPLINT NGHT DORSAL PF-MED 274 L1930 $138.50 $0.00

5139084 SPLINT NGHT DORSAL PF-LG 274 L1930 $316.75 $0.00

5139092 PAD CPM KNEE DANNIGER 400 271 A9900 $43.50 $0.00

5139100 CABLE CATH LAB DISP PCMKR 272 $115.25 $0.00

5139118 STENT LIBERTE 2.75 12 278 C1876 $8,360.00 $0.00

5139126 STENT LIBERTE 2.75 16 278 C1876 $8,360.00 $0.00

5139134 STENT LIBERTE 3.5 20 278 C1876 $8,360.00 $0.00

5139142 STENT LIBERTE 4.0 8 278 C1876 $8,360.00 $0.00

5139159 STENT LIBERTE 4.5 16 278 C1876 $8,360.00 $0.00

5139167 STENT LIBERTE 5.0 12 278 C1876 $8,360.00 $0.00

5139175 STENT LIBERTE 5.0 16 278 C1876 $8,360.00 $0.00

5139258 KIT PLNTR FACI NIGHT MED 274 $1,186.50 $0.00

5139266 KIT PLNTR FACI NIGHT LG 274 $1,186.50 $0.00

5139274 CUP HEEL SILICONE MED 271 $90.25 $0.00

5139282 CUP HEEL SILICONE MED 271 $90.25 $0.00

5139290 STRAP FOOT CONTROL 271 $117.50 $0.00

5139308 HOOKS ELAS STAY 12MM BLNT 272 $169.25 $0.00

5139332 SENSOR DIGI OXICLIQ ADULT 272 $26.75 $0.00

5139340 SENSOR DIGI OXICLIQ INFNT 272 $32.50 $0.00

5139357 SENSOR DIGI OXICLIQ PEDS 272 $26.75 $0.00

5139464 STENT EXPRESS LD 5X17X75 278 C1876 $11,396.00 $0.00

5139472 GUIDEWIRE GLIDE ANGLD 260 272 C1769 $131.75 $0.00

5139506 IMMOBILIZER SHOULDER UNIV 274 L3650 $96.75 $0.00

5139514 COLLAR CERVICAL ADJUSTABL 274 L0172 $321.50 $0.00

5139522 SPLINT ACROMIO CLAVICULAR 274 L3670 $180.75 $0.00

5139530 SPLINT FINGER 274 L3932 $104.00 $0.00

5139548 SPLINT FINGER EXTN ASSIST 274 L3932 $82.25 $0.00

5139555 SPLINT WRST & THMB LT XXL 274 L3908 $163.25 $0.00

5139563 PAD II SHOULDER SMALL 274 L3660 $396.75 $0.00

5139571 PAD II SHOULDER MEDIUM 274 L3660 $396.75 $0.00

5139589 PAD II SHOULDER LARGE 274 L3660 $396.75 $0.00

5139597 SPLINT TENNIS ELBOW XSML 274 L3701 $84.25 $0.00

5139605 SPLINT TENNIS ELBOW SML 274 L3701 $84.25 $0.00

5139613 SPLINT TENNIS ELBOW MED 274 L3701 $84.25 $0.00

5139621 SPLINT TENNIS ELBOW LG 274 L3701 $84.25 $0.00



Page 73 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5139639 R&B 2HTU ICU ELBOW XL

SPLINT TENNIS 274 L3701 $84.25 $0.00

5139647 SPLINT TENNIS ELBOW XXL 274 L3701 $84.25 $0.00

5139654 SPLINT TENNIS ELBOW UNIV 274 L3701 $58.00 $0.00

5139662 SPLINTSRITE SMALL 274 L4386 $524.25 $0.00

5139670 SPLINTSRITE MEDIUM 274 L4386 $524.25 $0.00

5139688 SPLINTSRITE LARGE 274 L4386 $524.25 $0.00

5139696 SPLINTSRITE XLARGE 274 L4386 $524.25 $0.00

5139704 BRACE ANK/FT WLKR LO SML 274 L4386 $261.50 $0.00

5139712 BRACE ANK/FT WLKR LO MED 274 L4386 $261.50 $0.00

5139720 BRACE ANK/FT WLKR LO LG 274 L4386 $261.50 $0.00

5139779 STENT EXP MONO 4.0 15 278 C1876 $10,560.00 $0.00

5139787 SHEATH SUPER 7FR 25CM 272 C1766 $146.00 $0.00

5139845 BRACE ANK/FT WKR WRAP SM 274 L4386 $258.25 $0.00

5139852 BRACE ANK/FT WKR WRAP MED 274 L4386 $258.25 $0.00

5139860 BRACE ANK/FT WKR WRAP LG 274 L4386 $258.25 $0.00

5139936 STENT LIBERTE 2.75 24 278 C1876 $8,360.00 $0.00

5139944 STENT LIBERTE 2.75 28 278 C1876 $8,360.00 $0.00

5139951 STENT LIBERTE 2.75 32 278 C1876 $8,360.00 $0.00

5139969 STENT LIBERTE 3.0 24 278 C1876 $8,360.00 $0.00

5139977 STENT LIBERTE 3.0 28 278 C1876 $8,360.00 $0.00

5139985 STENT LIBERTE 3.0 32 278 C1876 $8,360.00 $0.00

5139993 STENT LIBERTE 3.5 28 278 C1876 $8,360.00 $0.00

5140009 STENT LIBERTE 3.5 32 278 C1876 $8,360.00 $0.00

5140017 STENT LIBERTE 4.5 20 278 C1876 $8,360.00 $0.00

5140025 STENT LIBERTE 4.5 24 278 C1876 $8,360.00 $0.00

5140033 STENT LIBERTE 5.0 20 278 C1876 $8,360.00 $0.00

5140041 STENT LIBERTE 5.0 24 278 C1876 $8,360.00 $0.00

5140058 STENT LIBERTE 5.0 28 278 C1876 $8,360.00 $0.00

5140074 GLIDEWIRE .018 272 C1769 $233.00 $0.00

5140082 CATH BALL OCCLUDER OCCLUS 272 C2628 $298.00 $0.00

5140090 WIRE SENSOR STRAIGHT .035 272 $180.75 $0.00

5140108 WIRE SENSOR ANGLED .035 272 $180.75 $0.00

5140116 GLIDEWIRE .025 272 C1769 $246.00 $0.00

5140124 CATH NEHP MALECOT 20FR 272 C1729 $296.00 $0.00

5140132 CATH NEPH RNTRY MLCT 20FR 272 C1729 $307.50 $0.00

5140140 CATH NEPH MALECOT 16FR 272 C1729 $307.50 $0.00

5140157 CATCHER ULTRASOUND STONE 272 $269.00 $0.00

5140165 CATH BERN TIP ACCESS 272 $77.00 $0.00

5140173 KIT PUNCTURE MARDIS II 272 $288.25 $0.00

5140181 SHEATH RENAL CLEAR 272 $223.00 $0.00

5140199 CATH BALL NEPHROMAX 272 C1726 $1,015.75 $0.00

5140207 DILATOR AMPLATZ & SHEATH 272 $941.75 $0.00

5140215 PROBE US 3.8MM 300X330 272 $1,957.50 $0.00

5140223 NEEDLE PERC ACCESS 18G 272 $142.25 $0.00

5140231 PROBE PNEUMATIC 497MM 272 $831.00 $0.00

5140249 PROBE US 3.8MM 400X3MM 272 $1,957.50 $0.00

5140256 PROBE PNEUMATIC 570MM 272 $831.00 $0.00

5140264 ELECTRODE NEUROLINE CUP 271 $34.25 $0.00

5140371 KIT FECAL MGT SYSTEM 271 $1,108.00 $0.00



Page 74 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5140397 R&B 2HTU ICU

SUTURE CAP POL MONO OTC36 272 $94.50 $0.00

5140405 TUBE FEEDING WEIGHTED 6FR 272 $51.25 $0.00

5140413 SET SUCTION INTROPERATIVE 272 $72.75 $0.00

5140447 TUBE ENDOTRACH CHNGR STRL 272 $52.75 $0.00

5140462 CATH PICC DUAL LUMEN 5FR 272 C1751 $190.25 $0.00

5140470 STENT EXP MONO 6.0 14 150 278 C1876 $10,560.00 $0.00

5140488 CATH BALL STRLING 7X2X135 272 C1725 $1,717.50 $0.00

5140603 CATH PICC LINE KIT 3FR 272 C1751 $151.75 $0.00

5140629 INST DISC LAP HND ACC DEV 272 $1,873.25 $0.00

5140637 INSTR DISC LAP MED SLEEVE 272 $1,873.25 $0.00

5500103 PERFUSION CIRCUIT 270 $3,012.55 $0.00

5500186 LABOR SUPPLIES 272 $265.70 $0.00

5500301 SUCTION/INTERMITTENT 271 $38.00 $0.00

5500319 ELECTRONIC SUCTION 271 $83.50 $0.00

5500327 TOILET EXTENDER 271 $22.80 $0.00

5500343 AMNIOCENTESIS TRAY 272 $122.45 $0.00

5500350 ASPIRATING TRAY 272 $91.10 $0.00

5500368 BONE MARROW TRAY 272 $91.10 $0.00

5500376 CHEMOTHERAPY TRAY 272 $38.00 $0.00

5500384 CHEST TUBE INSERTION TRAY 272 $519.90 $0.00

5500392 CULDOCENTESIS TRAY 272 $68.35 $0.00

5500400 CUTDOWN TRAY 272 $512.70 $0.00

5500418 D*C SET - UCC 272 $213.90 $0.00

5500434 TRACTION TONGS TRAY G/W 272 $180.80 $0.00

5500442 HYSTEROSALPINGOGRAM TRAY 272 $121.45 $0.00

5500459 HYSTEROSALPINGOGRAM TRAY 272 $121.45 $0.00

5500467 INCISION & DRAINAGE TRAY 272 $91.10 $0.00

5500475 MASTOID TRAY 272 $68.35 $0.00

5500483 NOSE BLEED TRAY 272 $91.10 $0.00

5500491 OPEN CHEST EMERGENCY TRAY 272 $1,137.10 $0.00

5500509 PARACENTESIS TRAY 272 $75.90 $0.00

5500517 PELVIC TRAY 272 $68.35 $0.00

5500525 RENAL BIOPSY TRAY 272 $98.70 $0.00

5500533 SIGMOIDOSCOPE/PRCTCP TRAY 272 $129.05 $0.00

5500541 SMR TRAY 272 $91.10 $0.00

5500558 STAPEDECTOMY TRAY 272 $68.35 $0.00

5500566 SUTURE LINE TRAY 272 $292.55 $0.00

5500574 SUTURE TRAY - SMALL 272 $300.85 $0.00

5500582 SUTURE TRAY - LARGE 272 $301.55 $0.00

5500590 THORACENTESIS TRAY 272 $124.90 $0.00

5500608 TRACHEOTOMY TRAY 272 $512.70 $0.00

5500616 TROCAR SP NEEDLE W/OBTURT 272 $68.35 $0.00

5500624 TYMPANOPLSTY TRAY 272 $68.35 $0.00

5500632 LOCAL SET - CS 272 $270.60 $0.00

5500640 CHEST TUBE REMOVAL SET 272 $120.80 $0.00

5500657 NOSE BLEED LOCAL SET 272 $271.50 $0.00

5500665 ISOLATION CARTS 272 $75.90 $0.00

5500673 CRASH CART 272 $531.30 $0.00

5500681 BRONCHOSCOPE 272 $531.30 $0.00



Page 75 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5500699 R&B 2HTU ICU

CAST/ARM ABOVE ELBOW 271 $227.70 $0.00

5500707 CAST/ARM BELOW ELBOW 271 $151.80 $0.00

5500715 CAST/BODY ADULT 271 $455.40 $0.00

5500723 CAST/BODY CHILD 271 $341.60 $0.00

5500731 CAST/LEG LONG 271 $379.50 $0.00

5500749 CAST/LEG SHORT 271 $303.60 $0.00

5500756 CAST/SPLINT ARM P 271 $30.70 $0.00

5500764 CAST/SPLINT LEG P 271 $24.50 $0.00

5500772 TRAY PERICARDIOCENTIS 272 $759.70 $0.00

5500780 TRAY PERICARDIAL DRAIN 272 $98.70 $0.00

5500798 STEIMAN PIN ON TRAY 278 $292.25 $0.00

5500806 TONSIL/TRAY HEMORRHAGE 272 $75.90 $0.00

5500814 EXERCISER STANDARD 271 $65.60 $0.00

5500822 TRACTION HIP & LEG EXERC 271 $227.70 $0.00

5500830 TRACTION/BUCKS 271 $106.25 $0.00

5500848 TRACTION/OVERHEAD FRAME 271 $189.80 $0.00

5500855 TRACTION/CERVICAL 271 $138.00 $0.00

5500863 TRACTION/PELVIC 271 $151.80 $0.00

5500871 TRACTION/HAACHER SLING 271 $213.10 $0.00

5500905 CART CRASH FLAT FEE 272 $552.00 $0.00

5500913 KIT ENTRY NEO NATE 272 $103.50 $0.00

5500939 TRAY UMBILICAL 272 $517.80 $0.00

5500947 TRY RESUSCITATION 272 $207.00 $0.00

5500954 CATH BAL DILAT XXL 272 $1,483.85 $0.00

5500962 STENT BILLIARY (ENDO) 278 C1887 $466.90 $0.00

5500970 STAINLESS STEEL WIRE 278 $135.66 $0.00

5501010 L5688 BK WAIST BELT WEB 274 L5688 $0.00 $0.00

5501051 PROSTHESIS TOTAL HIP 278 $0.00 $0.00

5501069 SLING FIXT/URINARY INCONT 271 $0.00 $0.00

5501382 MISC VASCULAR GRAFT 30 35 278 $0.00 $0.00

5501390 MISC VASC GRAFT 40 45 O50 278 $0.00 $0.00

5501408 SYNTHETIC TISSUE IMPLNTS 278 $0.00 $0.00

5501416 COCHLEAR IMPLANT SYSTEM 278 L8614 $0.00 $0.00

5501424 JOINT DEVICE 274 $0.00 $0.00

5501440 PROSORBA SUPPLIES 272 $5,096.00 $0.00

5501457 L0859 MRI COMPATIBLE SYST 274 L0859 $0.00 $0.00

5501465 L3980 ORTHOSIS HUMERO FX 274 L3980 $0.00 $0.00

5501473 L3995 ORTHOSIS HUMERO FX 274 L3995 $0.00 $0.00

5501481 L3660 SQ FIG-8 ABDCT CANV 274 L3660 $0.00 $0.00

5501499 L0210 THORACIC RIB BELT 274 L0210 $0.00 $0.00

5501507 COMPRESION STOCKING BK18 274 L8100 $956.00 $0.00

5501515 L0180 MULTI POST CERV COL 274 $0.00 $0.00

5501523 L2182 DROP KNEE JOINT 274 L2182 $0.00 $0.00

5501549 L2850 FEM LNGT INTERF/SCK 274 L2850 $0.00 $0.00

5501564 L2340 CUSTOM FABR PRE/TIB 274 L2340 $0.00 $0.00

5501580 L2350 CUSTOM FABRC PTB/SC 274 L2350 $0.00 $0.00

5501598 L2126 THEMOPLST KAFO FR/P 274 L2126 $0.00 $0.00

5501606 L1970 CUSTOM FABRICATES A 274 L1970 $0.00 $0.00

5501614 A6531 BELOW KNEE COMPR/ST 272 A6531 $0.00 $0.00



Page 76 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5501622 R&B 2HTU ICU AB/KNEE S

L8430 MULTI PLY 274 L8430 $0.00 $0.00

5501630 L5668 MOLDED DISTAL CUSHN 274 L5668 $0.00 $0.00

5501648 L1800 ORTH ELAST/KNEE W/S 274 L1800 $0.00 $0.00

5501663 L3999 ORTHOSES UNDER SLEE 274 L3999 $0.00 $0.00

5501671 L3807 ORTHOSIS WRST/HND/F 274 L3807 $0.00 $0.00

5501697 L2134 ORTHOTIC SEMI/RGD F 274 L2134 $0.00 $0.00

5501713 L3985 ORTHOSIS WRT FRCT W 274 L3985 $0.00 $0.00

5501721 L0627 LO SAG RIGID PNL PF 274 L0627 $0.00 $0.00

5501739 L0637 LSO SAG-CRNL PNL PF 274 L0637 $0.00 $0.00

5501747 L2184 LIM MOT ADJ KNEE JT 274 L2184 $0.00 $0.00

5502018 CORNEAL TISSUE PROCESSING 278 V2785 $0.00 $0.00

5502026 L0621 SACRO FLEX SURG SUP 274 L0621 $0.00 $0.00

5502034 L3914 WHFO BILA WRIST EXT 274 L3914 $0.00 $0.00

5502042 L1830 CANVAS KO IMMOB PRE 274 L1830 $0.00 $0.00

5502059 L0628 LO FLX WO RGD ST PR 274 L0628 $0.00 $0.00

5502067 L3650 SO PRE FIG 8 RSTRAN 274 L3650 $0.00 $0.00

5551007 MISC STERILE SUPPLIES 272 $0.00 $0.00

5551015 MISC NON-STERILE SUPPL 271 $0.00 $0.00

5551049 MISC PROSTHETIC/ORTH DEV 274 $0.00 $0.00

5551064 MISC INTRAOCULAR LENS150 NT 276 $0.00 $0.00

5551122 MISC PACEMAKER DUAL CHAMB 275 C1785 $0.00 $0.00

5551148 MISC PACEMAKER SNGL/CHAMB 275 C1786 $0.00 $0.00

5551163 MISC LEAD PACEMAKER 275 $0.00 $0.00

5551189 MISC BREAST IMPLANTS 278 $0.00 $0.00

5551197 MISC BLADDER SLNG FX/W SM 278 $0.00 $0.00

5551205 MISC HUMAN TISSUE IMPLANT 278 $0.00 $0.00

5551221 MISC LEAD DEFIBR ENDOC SC 275 C1777 $0.00 $0.00

5551247 MISC CARDIVT/DEFIB OTH/T 275 C1882 $0.00 $0.00

5551262 MISC LEAD DEFIB OTH/T EN 275 C1896 $0.00 $0.00

5551288 MISC LEAD PACEMK/DEFIB C 275 C1899 $0.00 $0.00

5551296 MISC LEAD LT VENT COR SYS 275 C1900 $0.00 $0.00

5551320 MISC DEBIBRILLT DUAL/CHMB 275 C1721 $0.00 $0.00

5551346 MISC DEFIBRILLT SGL/CHAMB 275 C1722 $0.00 $0.00

5551361 MISC DEFIBRILLT NOT SGL/D 275 C1882 $0.00 $0.00

5551379 MISC LEAD DEFIBR ENDC D/C 275 C1895 $0.00 $0.00

5551387 MISC LEAD PACEMK TRN VDD 275 C1779 $0.00 $0.00

5551395 MISC PACEMK S/CHAMB N-RR 275 C2620 $0.00 $0.00

5551411 L0174 CERVICAL COLLAR S/R 274 L0174 $0.00 $0.00

5551429 L4396 STATIC AFO INCL SFT 274 L4396 $0.00 $0.00

5551437 L0810 CERV HALO INCORP JK 274 L0810 $0.00 $0.00

5551445 L1832 KO ADJ KNEE JT RG S 274 L1832 $0.00 $0.00

5551452 L0120 CERV FLX NONADJ FM 274 L0120 $0.00 $0.00

5551478 L8440 PROSTH SHRINKR B/KN 274 L8440 $0.00 $0.00

5551486 L5460 IMMED PST SUR N/WGT 274 L5460 $0.00 $0.00

5551510 L3670 SO ACRM CLV CANVS W 274 L3670 $0.00 $0.00

5551528 L8460 PROSTH SHRNK ABV/KN 274 L8460 $0.00 $0.00



Page 77 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5551536 R&B 2HTU ICU CNTRL HIP

L1686 HO ABDUC 274 L1686 $0.00 $0.00

5551544 L4360 PNEUMTC WLKNG SPLNT 274 L4360 $0.00 $0.00

5551551 L0172 CERV COLLAR SRGD FM 274 L0172 $0.00 $0.00

5551569 L2624 ADD TO LWR EXTRM PV 274 L2624 $0.00 $0.00

5551585 L3908 WHO WRIST EXT CNTRL 274 L3908 $0.00 $0.00

5551593 L1930 AFO CUSTOM FIT PLST 274 L1930 $0.00 $0.00

5551601 L5400 POSTOP DRSS&CASTNG 274 L5400 $0.00 $0.00

5551627 L1960 ORTHOSIS AFO P/ANKL 274 L1960 $0.00 $0.00

5551635 L2275 PLAST/MOD LW EXT PD 274 L2275 $0.00 $0.00

5551643 L2820 SOFT INTERF BLW KNE 274 L2820 $0.00 $0.00

5551650 L5530 BELOW KNEE PROSTH 274 L5530 $0.00 $0.00

5551668 L5620 TEST SOCKET BLW/KNE 274 L5620 $0.00 $0.00

5551676 L5637 BELOW KNEE TOT/CONT 274 L5637 $0.00 $0.00

5551684 L5666 BELOW KNEE CUFF/SUS 274 L5666 $0.00 $0.00

5551692 L8420 PROSTH SOCK MULTI/P 274 L8420 $0.00 $0.00

5551700 L1940 AFO MOLD PAT/PLASTC 274 L1940 $0.00 $0.00

5551718 L2770 LOWER EXT ORTH P/BR 274 L2770 $0.00 $0.00

5551726 L2270 VARUS/VALGUS STRP P 274 L2270 $0.00 $0.00

5551734 L4205 ORTHO DVC REPAIR 274 L4205 $0.00 $0.00

5551742 L4210 REPLACE PLATE/SCRWH 274 L4210 $0.00 $0.00

5551759 L0140 CERVICAL SEMI-RIGID 274 L0140 $0.00 $0.00

5551767 L4350 PNEUMATIC ANKL/C SP 274 L4350 $0.00 $0.00

5551783 LSO APL 2 PC/CONSTRUCTION 274 $11,810.00 $0.00

5551791 L5450 POST OP APP N-WGTBR 274 L5450 $0.00 $0.00

5551809 L2136 FEM CAST RGD PREF/I 274 L2136 $0.00 $0.00

5551817 L2180 PLST SHOE INC W/KNE 274 L2180 $0.00 $0.00

5551825 L2186 KNEE/JT ADJUST/MOTN 274 L2186 $0.00 $0.00

5551833 L2188 QUADRILATERAL BRIM 274 L2188 $0.00 $0.00

5551841 L2850 FEMORAL LENGHT SOCK 274 L2850 $0.00 $0.00

5551858 L2830 THIGH SECTN/INTERF 274 L2830 $0.00 $0.00

5551866 L0486 TLSO 2 SHELLS RIG/S 274 L0486 $0.00 $0.00

5551882 L2200 JOINTS 274 L2200 $0.00 $0.00

5551890 L2999 NEOPRENE HIGH SLEEV 274 L2999 $0.00 $0.00

5551908 L3982 RADIUS/ULNR FRCT OR 274 L3982 $0.00 $0.00

5551916 L5690 PADD/CSTM WAIST BLT 274 L5690 $0.00 $0.00

5551924 L1680 HIP/ABD ORTH W/H JT 274 L1680 $0.00 $0.00

5551932 L0472 TLSO ANT FRAME HYPX 274 L0472 $0.00 $0.00

5551940 L2128 KAFO FX ORTHOSIS C/ 274 L2128 $0.00 $0.00

5551957 L8010 MASTECTOMY SLEEVE 274 L8010 $0.00 $0.00

5551973 L2132 HIP FAX ORTHOSIS 274 L2132 $0.00 $0.00

5551981 L4386 WALKING SPLINT O/SH 274 L4386 $0.00 $0.00

5552005 MISC LEAD PACEMK NOT TRAN 275 C1898 $0.00 $0.00

5552021 MISC PACEMK DL CHAMBER NR 275 C2619 $0.00 $0.00

5552047 MISC PACEMAKER ADAPTER 275 C1883 $0.00 $0.00

5552062 MISC INTRO/SHEATH FIX P/A 272 C1892 $0.00 $0.00

5552088 MISC INTRO/SHEATH FIC N/P 272 C1893 $0.00 $0.00

5552104 MISC INTRO/SHEATH FIX N/L 272 C1894 $0.00 $0.00

5552120 MISC INTR/SHEATH STEERB N 272 C1766 $0.00 $0.00

5552146 MISC GUIDE WIRE 272 C1769 $0.00 $0.00



Page 78 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

5552161 R&B 2HTU ICU DEVICE VASCL

MISC CLOSURE 272 C1760 $0.00 $0.00

5552187 MISC CATH EP 19 OR LESS E 272 C1730 $0.00 $0.00

5552203 MISC CATH EP 20 OR MORE E 272 C1731 $0.00 $0.00

5552229 MISC CATH EP NOT COOL TIP 272 C1733 $0.00 $0.00

5552245 MISC PACEMK NOT SNGL OR D 275 C2621 $0.00 $0.00

5552260 MISC CATH GUIDING 272 C1887 $0.00 $0.00

5552286 MISC EVENT RECORDR CARDIA 275 C1764 $0.00 $0.00

5552302 L0460 TLSO 2 SHELL LINER 274 L0460 $0.00 $0.00

5552328 L2860 TORSION MECH/ADJUST 274 L2860 $0.00 $0.00

5552344 L1499 PADS REPL PHIL COLL 274 L1499 $0.00 $0.00

5599709 SPLINT FABRICATION I 271 99070 $52.50 $0.00

5599717 SPLINT FABRICATION II 271 99070 $71.50 $0.00

5599725 SPLINT FABRICATION III 271 99070 $216.75 $0.00

6100143 LITHOTRIPSY UNILATERAL 790 MULTI $19,857.95 $0.00

6100150 LITHOTRIPSY BILATERAL 790 MULTI $23,810.45 $0.00

6100168 URETEROSCOPE 360 $1,772.65 $0.00

6100184 EP EVAL INT IMPLANT/REPL 480 93640 $3,125.00 $0.00

6100192 EP EVAL INT IMPL/REPL TST 480 93641 $3,125.00 $0.00

6101000 SURGERY MINUTE LV1 360 $76.50 $0.00

6101026 SURGERY MINUTE LV2 360 $128.00 $0.00

6101042 SURGERY MINUTE LV3 360 $179.45 $0.00

6101067 SURGERY MINUTE LV1 (AH) 360 $93.95 $0.00

6101075 SURGERY MINUTE LV2 (AH) 360 $162.80 $0.00

6101083 SURGERY MINUTE LV3 (AH) 360 $231.70 $0.00

6101208 SURGERY MINUTE LV S 360 $118.20 $0.00

6101224 SURGERY MINUTE LV S (AH) 360 $149.45 $0.00

6101505 ALBUMIN ADMINISTRATION 391 36430 $550.00 $0.00

6101513 SURGERY OUT PATIENT VISIT 510 99211 $41.25 $0.00

6101539 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00

6101554 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

6101570 HYDRATE IV INFUSON ADD-ON 260 90761 $231.00 $0.00

6101596 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

6101612 THER/PROPH/DIAG INJ SC/IM 940 90772 $247.50 $0.00

6101620 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

6101638 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

6101646 TH/PR/DX INJ SC/IM EA ADD 940 9077276 $206.25 $0.00

6101661 LITHOTRIPSY EQUIP RENTAL 790 $750.00 $0.00

6106454 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

6106462 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

6106470 CYST/INS INDWL URTR STENT 360 52332 $2,000.00 $0.00

6150445 KIRSCHNER WIRES 272 $28.55 $0.00

6150536 MESH GRAFT 278 $264.55 $0.00

6150809 STAINLESS STEEL WIRE 278 $186.55 $0.00

6150817 STEINMAN PINS 278 $69.20 $0.00

6150825 STEINMAN PINS (THREADED) 278 $68.45 $0.00

6200109 OPEN HEART SUR/MINUTE LV3 360 $179.45 $0.00

6200125 TRANSESOPHAGEAL TEE 483 93318 $2,475.00 $0.00

6300081 O2 ADMIN 1/2 HR 272 $19.95 $0.00

6300099 O2 ADMIN 1 HR 272 $39.90 $0.00



Page 79 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

6300107 R&B 2HTU ICU

RECOVERY OTHERS 710 $68.30 $0.00

6300115 RCVRY - SCH PROCEDURE 360 $1,214.40 $0.00

6300206 RECOVERY RM MINUTE LV1 710 $8.25 $0.00

6300214 RECOVERY RM MINUTE LV2 710 $16.50 $0.00

6300222 RECOVERY RM MINUTE LVFLR 710 $1.75 $0.00

6300305 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00

6300313 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

6300321 HYDRATE IV INFUSON ADD-ON 260 90761 $231.00 $0.00

6300339 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

6300347 THER/PROPH/DIAG INJ SC/IM 940 90772 $247.50 $0.00

6300354 TH/PR/DX INJ SC/IM EA ADD 940 9077276 $206.25 $0.00

6300362 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

6300370 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

6300388 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

6300396 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

6400014 ANESTHESIA 1 HR 370 $973.45 $0.00

6400022 ANESTHESIA 2HRS 370 $1,946.90 $0.00

6400030 ANESTHESIA 3HRS 370 $2,920.25 $0.00

6400048 ANESTHESIA 4HRS 370 $3,893.70 $0.00

6400055 ANESTHESIA 5HRS 370 $4,867.05 $0.00

6400063 ANESTHESIA 1/2 HR 370 $487.65 $0.00

6400071 SPINAL ANESTHESIA 370 $586.30 $0.00

6400089 LOCAL TRAY 272 $398.50 $0.00

6400097 BRACH BK 370 $586.30 $0.00

6400105 INF BK 370 $586.30 $0.00

6400113 ANES ATTENDED 1HR 370 $973.45 $0.00

6400121 ANES ATTENDED 2HR 370 $1,946.90 $0.00

6400139 ANES ATTENDED 1/2 370 $487.65 $0.00

6400204 ANESTHESIA GEN/ATTND MIN 370 $16.25 $0.00

6500011 GEN ANES 1HR 370 $973.45 $0.00

6500029 GEN ANES 2HR 370 $1,946.90 $0.00

6500037 GEN ANES 3HR 370 $2,920.25 $0.00

6500045 GEN ANES 4HR 370 $3,893.70 $0.00

6500052 GEN ANES 1/2HR 370 $487.65 $0.00

6500060 SPINAL ANESTHESIA 370 $586.30 $0.00

6500078 LOCAL TRAY 272 $398.50 $0.00

6500086 INF BK 370 $586.30 $0.00

6500094 ANES ATTENDED 1HR 370 $973.45 $0.00

6500102 ANES ATTENDED 2HR 370 $1,946.90 $0.00

6500110 ANES ATTENDED 1/2 370 $487.65 $0.00

6500128 SURGERY 1 HR 360 $3,723.30 $0.00

6500243 FLUORO, UP TO 1 HOUR 320 76000 $982.95 $0.00

6501001 SURGERY MINUTE LV1 360 $65.25 $0.00

6501027 SURGERY MINUTE LV2 360 $116.75 $0.00

6501506 RECOVERY RM MINUTE LV1 710 $8.25 $0.00

6501522 RECOVERY RM MINUTE LV2 710 $16.50 $0.00

6501704 ANESTHESIA GEN/ATTND MIN 370 $16.25 $0.00

6502009 ALBUMIN ADMINISTRATION 391 36430 $550.00 $0.00

6502017 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00



Page 80 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

6502033 R&B 2HTU ICU IV INF INIT

THER/PRO/DIAG 260 90765 $247.50 $0.00

6502058 HYDRATE IV INFUSON ADD-ON 260 90761 $231.00 $0.00

6502074 THER/PRO/DX IV INF ADD-ON 260 90766 $231.00 $0.00

6502090 THER/PROPH/DIAG INJ SC/IM 940 90772 $247.50 $0.00

6502116 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

6502124 SHORT STAY OP VISIT/CONSL 510 99211 $48.15 $0.00

6502132 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

6502140 SHORT STAY OUT PAT VISIT 510 9921125 $41.25 $0.00

6502157 TH/PR/DX INJ SC/IM EA ADD 940 9077276 $206.25 $0.00

6502165 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

6502173 LITHOTRIPSY UNILATERAL 790 MULTI $19,857.95 $0.00

6502181 LITHOTRIPSY BILATERAL 790 MULTI $23,810.45 $0.00

6502199 LITHOTRIPSY EQUIP RENTAL 790 $750.00 $0.00

6502207 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

6605000 DISCOGRAM CERV/THOR INIT 320 72285 $4,210.25 $0.00

6605026 DISCOGRAM CERV/THR EA ADD 320 7228576 $4,210.25 $0.00

6605042 DISCOGRAM LUMBAR INITIAL 320 72295 $4,210.25 $0.00

6605067 DISCOGRAM LUMBAR EA ADD 320 7229576 $4,210.25 $0.00

6605083 FLUORO NDL LOC SPINAL INJ 320 76005 $1,200.00 $0.00

6605109 FLUORO GUIDED NDL PLCMNT 320 76003 $1,200.00 $0.00

6605125 DISCOGRAM INJ CRV/TH INIT 361 62291 $1,711.25 $0.00

6605141 DISCGRAM INJ CV/TH EA ADD 361 6229176 $762.50 $0.00

6605166 DISCOGRAM INJ LUMBAR INIT 361 62290 $1,711.25 $0.00

6605182 DISCOGRAM INJ LUMB EA ADD 361 6229076 $762.50 $0.00

6605208 EPID INJ CERV/THOR W/SED 361 62310 $5,483.50 $0.00

6605224 EPID INJ CERV/THR W/O SED 361 62310 $5,483.50 $0.00

6605240 EPID INJ LUMB/SAC W/SED 361 62311 $5,483.50 $0.00

6605265 EPID INJ LUMB/SAC W/O SED 361 62311 $5,483.50 $0.00

6605281 EPID INJ BLOOD/CLOT PATCH 361 62273 $3,960.00 $0.00

6605307 INJ STELLATE GANGL W/SED 361 64510 $5,483.50 $0.00

6605323 INJ STELATE GANGL W/O SED 361 64510 $5,483.50 $0.00

6605349 INJ FCTS CR/TH S/LV W/SED 361 64470 $1,524.15 $0.00

6605364 INJ FCTS CR/TH S/L WO SED 361 64470 $1,524.15 $0.00

6605372 INJ TNSF EP CV SG LV WSED 361 64479 $5,482.50 $0.00

6605380 INJ FCTS CR/TH EA ADD LVL 361 64472 $762.50 $0.00

6605398 IN TNSF EP CV SG LV WOSED 361 64479 $5,482.50 $0.00

6605406 INJ FCTS LM/SC S/LV W/SED 361 64475 $1,524.15 $0.00

6605414 INJ TRNSF EPI CV EA AD LV 361 64480 $812.50 $0.00

6605422 INJ FCTS L/SC S/LV WO SED 361 64475 $1,524.15 $0.00

6605430 INJ TNSF EP LS SG LV WSED 361 64483 $5,482.50 $0.00

6605448 INJ FCTS LM/SAC EA ADD LV 361 64476 $762.50 $0.00

6605455 IN TNSF EP LS SG LV WOSED 361 64483 $5,482.50 $0.00

6605463 PRHRL NRV BRNCH BLK W/SED 361 64450 $1,524.15 $0.00

6605471 INJ TRNSF EPI LS EA AD LV 361 64484 $812.50 $0.00

6605489 PRHL NRV BRNCH BLK WO SED 361 64450 $1,524.15 $0.00

6605505 SYMPTH NRV INJ LUMB W/SED 361 64520 $1,524.15 $0.00

6605521 SYMPT NRV INJ LUMB WO SED 361 64520 $1,524.15 $0.00

6605547 INTCSTL NRV BLK SGL W/SED 361 64420 $1,524.15 $0.00

6605562 INTCSTL NV BLK SGL WO SED 361 64420 $1,524.15 $0.00



Page 81 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

6605588 R&B 2HTU ICU RG BL W/SED

ITCSTL NV MLT 361 64421 $3,125.00 $0.00

6605604 ITCSTL NV MT RG BL WO SED 361 64421 $3,125.00 $0.00

6605620 INTARTCLR S/H/K INJ W/SED 361 20610 $1,238.40 $0.00

6605646 INTRTCLR S/H/K INJ WO SED 361 20610 $1,238.40 $0.00

6605661 PIRIFORMIS W/SED 361 20610 $1,238.40 $0.00

6605687 PIRIFORMIS W/O SED 361 20610 $1,238.40 $0.00

6605703 NRV BLK CERV PLEXUS W/SED 361 64413 $1,238.40 $0.00

6605729 NRV BLK CRV PLXUS W/O SED 361 64413 $1,238.40 $0.00

6605745 NRV BLK GTR/OCCIPTL W/SED 361 64405 $1,238.40 $0.00

6605760 NRV BLK GTR/OCPTL W/O SED 361 64405 $1,238.40 $0.00

6605786 SACROILIAC JNT INJ W/SED 361 27096 $1,238.40 $0.00

6605802 SACROILAC JNT INJ W/O SED 361 27096 $1,238.40 $0.00

6605828 NV DST NER AG ILNGL W/SED 361 64622 $2,573.75 $0.00

6605844 NV DST NR AG ILNGL WO SED 361 64622 $2,573.75 $0.00

6605869 NV DST NR AG LM LV1 W/SED 361 64622 $2,573.75 $0.00

6605885 NV DST NR AG LM L1 WO SED 361 64622 $2,573.75 $0.00

6605901 NV DST NR AG LUMB ADD LVL 361 64623 $812.50 $0.00

6605927 NV DST NR AG CV LV1 W/SED 361 64626 $2,573.75 $0.00

6605943 NV DST NR AG CV L1 WO SED 361 64626 $2,573.75 $0.00

6605968 NV DST NR AG CERV ADD LVL 361 64627 $812.50 $0.00

6605984 NPLSTY DCMPRS DISK W/SED 361 62287 $6,397.40 $0.00

6606008 NPLSTY DCMPRS DSK W/O SED 361 62287 $6,397.40 $0.00

6606024 TPTS 1-2 MUSCLE(S) W/SED 361 20552 $1,625.00 $0.00

6606040 TPTS 1-2 MUSCLE(S) WO SED 361 20552 $1,625.00 $0.00

6606065 TPTS 3/> MUSCLE(S) W/SED 361 20553 $3,125.00 $0.00

6606081 TPTS 3/> MUSCLE(S) WO SED 361 20553 $3,125.00 $0.00

6606107 RECOVERY PAIN MGMT LV1 710 $8.25 $0.00

6606123 RECOVERY PAIN MGMT LV2 710 $16.50 $0.00

6606149 TH/PR/DX INJ IV PUSH INIT 940 90774 $247.50 $0.00

6606164 THER/PRO/DIAG IV INF INIT 260 90765 $247.50 $0.00

6606180 MOD CS BY SAME PHYS 5YRS+ 370 99144 $458.50 $0.00

6606206 THER/PRO/DIAG INJ, SC/IM 940 90772 $247.50 $0.00

6606222 MOD CS BY SAME PHY ADD-ON 370 99145 $229.25 $0.00

6606248 TPDX IV PUSH NEW SUB INIT 940 90775 $206.25 $0.00

6606255 TPDX IV PSH NEW SUB E-ADD 940 9077576 $206.25 $0.00

6606263 TH/PR/DX IV PUSH EA ADD 940 9077476 $206.25 $0.00

6606289 HYDRATION IV INFUSION INI 260 90760 $247.50 $0.00

6606305 SPINAL LUMB PUNCT W/SED 361 62270 $788.55 $0.00

6606321 SPINAL LUMB PUNCT W/O SED 361 62270 $785.55 $0.00

7900038 LIDOCAINE/D5W 2GM/500ML P 250 J2001 $113.00 $0.00

7900046 SOD CHLORIDE 0.45% INJ 10 250 J7030 $65.92 $0.00

7900053 SOD CHLORIDE 0.45% INJ 50 250 J7040 $65.29 $0.00

7900095 SOD CHLORIDE 0.9% INJ 100 250 J7030 $65.78 $0.00

7900111 SODIUM CHLORIDE 0.9% INJ 250 J7050 $64.95 $0.00

7900129 SODIUM CHLORIDE 0.9% INJ 250 J7040 $65.75 $0.00

7900178 SODIUM CHLORIDE 0.9% IRRI 250 $67.40 $0.00

7900186 SODIUM CHLORIDE 0.9% IRRI 250 $68.21 $0.00

7900202 AMINOSYN 10% INJ 500MLS 250 $438.45 $0.00

7900210 AMINOSYN II 10% INJ 1000M 250 $495.48 $0.00



Page 82 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7900228 R&B 2HTU ICU

DEXTROSE 10%/NACL 0.9% IN 250 $90.60 $0.00

7900236 D10W INJ 250MLS 250 $69.10 $0.00

7900244 DEXTROSE 10% INJ 500MLS 250 J7040 $68.57 $0.00

7900269 HEPARIN/D5W 12,500 UNITS/ 250 J1644 $85.54 $0.00

7900277 LIPOSYN II 20% INJ 500MLS 250 $510.87 $0.00

7900285 DEXTROSE 20% INJ 500MLS 250 $75.26 $0.00

7900293 MANNITOL 20% INJ 250MLS 250 J2150 $113.65 $0.00

7900343 MAGNESIUM SULF 40MG/ML IN 250 J3475 $51.75 $0.00

7900350 MAGNESIUM SULF 40MG/ML 10 250 J3475 $93.42 $0.00

7900376 D5W INJ 100MLS 250 J7060 $98.71 $0.00

7900400 D5W INJ 50MLS 250 J7060 $98.18 $0.00

7900426 D5W ADV 100MLS 250 J7060 $69.19 $0.00

7900442 D5W ADV 50ML 250 J7060 $21.18 $0.00

7900459 D5LR INJ 1000MLS 250 $68.67 $0.00

7900467 D5LR INJ 500MLS 250 $69.20 $0.00

7900475 D5W/RINGER'S INJ 1000MLS 250 $71.28 $0.00

7900483 D5W/NACL 0.225% INJ 1000M 250 J7042 $66.63 $0.00

7900491 D5W/NACL 0.225% INJ 250ML 250 J7042 $65.75 $0.00

7900509 D5W/NACL 0.225% INJ 500ML 250 J7042 $65.75 $0.00

7900517 D5W/NACL 0.3% INJ 500MLS 250 J7042 $66.10 $0.00

7900525 D5W/NACL 0.45% INJ 1000ML 250 J7042 $68.60 $0.00

7900533 D5W/NACL 0.45% INJ 250MLS 250 J7042 $65.75 $0.00

7900541 D5W/NACL 0.45% INJ 500MLS 250 J7042 $67.69 $0.00

7900558 D5W/0.9NS WITH 20MEQ KCL 250 J7040 $70.22 $0.00

7900566 D5W/NACL 0.9% INJ 1000MLS 250 J7042 $67.26 $0.00

7900574 D5W/NACL 0.9% INJ 500MLS 250 J7042 $65.75 $0.00

7900582 ALCOHOL/D5W 5% INJ 1000ML 250 J7040 $118.53 $0.00

7900590 SODIUM BICARB 5% INJ 500M 250 J7040 $57.59 $0.00

7900624 DEXTROSE 50% INJ 500MLS 250 $115.78 $0.00

7900632 NITROGLYCERIN 50MG/D5W 25 250 $43.83 $0.00

7900640 AMINO ACID 7% INJ (AMINOS 250 $612.62 $0.00

7900657 DEXTROSE 70% INJ 1000MLS 250 J7040 $173.97 $0.00

7900673 TRAVASOL 8.5% INJ 500MLS 250 $636.15 $0.00

7900723 ACETAMINOPHEN 100MG/ML IN 250 $39.85 $0.00

7900731 ACETAMINOPHEN CHLD 160/5M 250 $37.15 $0.00

7900756 ACETAMINOPHEN 120MG SUPP 250 $9.64 $0.00

7900764 ACETAMINOPHEN 325MG SUPP 250 $10.11 $0.00

7900772 ACETAMINOPHEN 650MG SUPP 250 $10.72 $0.00

7900780 ACETAMINOPHEN 325MG TAB 250 $7.10 $0.00

7900798 APAP/CODEINE 300-15MG TAB 250 $11.09 $0.00

7900814 APAP/CODEINE 300-60MG TAB 250 $13.45 $0.00

7900822 APAP/CODEINE 300-30MG TAB 250 $11.34 $0.00

7900830 AcetaZOLAMIDE 250MG TAB ( 250 $8.97 $0.00

7900848 AcetaZOLAMIDE 500MG INJ 250 J1120 $126.02 $0.00

7900855 AcetaZOLAMIDE 500MG CAP(D 250 $16.88 $0.00

7900897 ACETYLCHOLINE 20MG INJ (M 250 $209.34 $0.00

7900905 ACETYLCYSTEINE 20% (MUCOM 250 J7608 $101.02 $0.00

7900913 ACTIDOSE/SORBITOL 50GM/24 250 $112.79 $0.00

7900921 ACYCLOVIR 200MG CAP (ZOVI 250 $24.39 $0.00



Page 83 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7900947 R&B 2HTU ICU

ACYCLOVIR 800MG TAB (ZOVI 250 $35.49 $0.00

7900996 ALBUTEIN 25% INJ 100MLS 250 P9046 $642.40 $0.00

7901002 ALBUTEIN 25% INJ 50MLS 250 P9046 $324.70 $0.00

7901010 ALBUTEIN 5% INJ 250MLS ( 250 P9041 $324.70 $0.00

7901028 ALBUTEIN 5% INJ 500MLS (A 250 P9041 $642.40 $0.00

7901036 PLASBUMIN-5 5% INJ 50MLS 250 P9041 $87.99 $0.00

7901044 ALBUTEROL 2MG TAB 250 $8.66 $0.00

7901051 ALBUTEROL 90MCG INH (VENT 250 $209.87 $0.00

7901077 ALBUTEROL 0.083% NEB 3ML 250 J7613 $15.53 $0.00

7901093 ALBUTEROL 2MG/5ML SYRUP ( 250 $9.85 $0.00

7901119 ALFENTANIL 500MCG/ML INJ 250 $108.71 $0.00

7901143 ALLOPURINOL 100MG TAB 250 $8.30 $0.00

7901150 ALLOPURINOL 300MG TAB 250 $10.13 $0.00

7901176 AlPRAZolam 0.5MG TAB (XAN 250 $12.23 $0.00

7901184 AlPRAZolam 0.25MG TAB (XA 250 $11.48 $0.00

7901192 ALPROSTADIL 500MCG INJ 250 J0270 $448.25 $0.00

7901242 ALUM-HYDROXIDE 400MG CAP 250 $8.38 $0.00

7901283 GAVISCON FOAM TAB 250 $7.62 $0.00

7901291 GENATON SUSP 360ML (GAVIS 250 $7.09 $0.00

7901341 AMANTADINE 100MG CAP (SYM 250 $11.21 $0.00

7901366 AMIKACIN 500MG/2ML INJ 250 $40.26 $0.00

7901374 AMILORIDE 5MG TAB (MIDAMO 250 $11.06 $0.00

7901390 AMINOCAPROIC ACID 500MG T 250 $21.44 $0.00

7901408 AMINOCAPROIC ACID 250MG/M 250 $25.95 $0.00

7901432 AMINOPHYLLINE 25MG/ML INJ 250 J0280 $13.25 $0.00

7901457 AMIODARONE 200MG TAB (COR 250 $37.84 $0.00

7901481 AMITRIPTYLINE 10MG TAB (E 250 $8.27 $0.00

7901499 AMITRIPTYLINE 25MG TAB (E 250 $9.57 $0.00

7901507 AMLODIPINE 5MG TAB (NORVA 250 $19.61 $0.00

7901515 AMMONIA AROMATIC 0.33ML I 250 $9.18 $0.00

7901531 AMOXAPINE 50MG TAB (ASEND 250 $14.04 $0.00

7901556 AMOX/CLAV 125MG/5ML SUSP 250 $9.54 $0.00

7901564 AMOX/CLAV 250MG/5ML SUSP 250 $11.85 $0.00

7901598 AMOXIL 50MG/ML DROP 15ML 250 $7.84 $0.00

7901614 AMOXIL 125MG/5ML SUSPENSI 250 $7.83 $0.00

7901622 AMOXICILLIN 250MG/5ML SUS 250 $7.33 $0.00

7901630 AMOXICILLIN 250MG CAP (T 250 $8.75 $0.00

7901648 AMOXICILLIN 500MG CAP (TR 250 $10.45 $0.00

7901655 AMOX/CLAV 250MG TAB (AUGM 250 $32.75 $0.00

7901663 AMOX/CLAV 500MG TAB (AUGM 250 $35.44 $0.00

7901689 UNASYN 1.5GM ADV INJ 250 J0295 $57.77 $0.00

7901697 UNASYN 3GM ADV INJ 250 J0295 $100.23 $0.00

7901705 AMPHOTERICIN 3% CREAM (FU 250 $180.03 $0.00

7901713 AMPHOTERICIN 50MG INJ (FU 250 J0285 $112.16 $0.00

7901739 AMPICILLIN 500MG CAP (PRI 250 $9.81 $0.00

7901754 AMPICILLIN 1GM INJ (PRINC 250 J0290 $52.70 $0.00

7901762 AMPICILLIN 1GM ADV (PRIN 250 J0290 $61.80 $0.00

7901770 AMPICILLIN 250MG INJ (PRI 250 J0290 $36.54 $0.00

7901804 AMPICILLIN 500MG INJ 250 J0290 $38.09 $0.00



Page 84 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7901812 R&B 2HTU ICU

PRINCIPEN 125MG/5ML SUSP 250 $7.32 $0.00

7901820 PRINCIPEN 250MG/5ML SUSP 250 $7.55 $0.00

7901838 AMPICILLIN 250MG CAP (PRI 250 $8.65 $0.00

7901853 UNASYN 1.5GM INJ 250 J0295 $54.84 $0.00

7901861 AMP/SULBACTAM 3GM INJ. (U 250 J0295 $97.32 $0.00

7901895 ANTICOAG CITRATE DEXTROSE 250 $41.80 $0.00

7901911 AURODEX OTIC SOLN 15ML (A 250 $25.68 $0.00

7901929 ANTIVENIN LATRODECTUS KIT 250 $178.39 $0.00

7901945 AQUAPHOR OINTMENT 396GM 250 $77.36 $0.00

7901978 CECON 90MG/ML SOLN 50ML 250 $127.66 $0.00

7901994 VITAMIN C 500MG TAB 250 $7.47 $0.00

7902018 ASPIRIN 81MG CHEW TAB 250 $7.28 $0.00

7902034 ASPIRIN 325MG EC TAB (ECO 250 $7.50 $0.00

7902042 ASPIRIN 300MG SUPPOSITORY 250 $10.55 $0.00

7902059 ASPIRIN 600MG SUPPOSITORY 250 $10.64 $0.00

7902067 ASPIRIN 325MG TAB 250 $7.14 $0.00

7902075 ASPIRIN/ANTACID TAB (ASCR 250 $7.26 $0.00

7902083 ASA/CODEINE 325-30MG TAB 250 $10.14 $0.00

7902091 ASA/CODEINE 325-60MG TAB 250 $10.81 $0.00

7902109 ATENOLOL 50MG TAB (TENORM 250 $12.88 $0.00

7902141 ATRACURIUM 10MG/ML INJ 10 250 $63.60 $0.00

7902158 ATROPINE SULF 1% OP OINT 250 $34.82 $0.00

7902174 ATROPINE SULF 0.4MG/ML IN 250 J0460 $10.08 $0.00

7902182 ATROPINE SULF 0.05MG/ML I 250 J0460 $40.06 $0.00

7902190 ATROPINE SULF 0.1MG/ML IN 250 J0460 $32.20 $0.00

7902216 ISOPTO ATROPINE 1% OP SOL 250 $122.05 $0.00

7902224 ATROPINE SULF 1% OPHTH. S 250 $27.72 $0.00

7902240 AZATHIOPRINE 50MG TAB (IM 250 J7500 $16.24 $0.00

7902273 BAC/POLY/NEO/HC OP OINT 3 250 $93.38 $0.00

7902281 BACITRACIN 50000U INJ 250 $73.54 $0.00

7902299 BACITRACIN ZINC 500U/GM O 250 $27.44 $0.00

7902307 BACITRACIN OP OINTMENT 3. 250 $40.48 $0.00

7902323 BACLOFEN 10MG TAB 250 $9.89 $0.00

7902349 BECLOMETHASONE NS SPR (BE 250 $373.97 $0.00

7902356 BECLOMETHASONE INH (BECON 250 $179.66 $0.00

7902364 BECLOMETHASONE DIP INH (V 250 $271.02 $0.00

7902398 BENAZEPRIL 5MG TAB (LOTEN 250 $15.23 $0.00

7902406 BENAZEPRIL 20MG TAB (LOTE 250 $15.23 $0.00

7902414 BENZO/TETRA/BUTAME ORAL ( 250 $215.95 $0.00

7902422 HURRICAINE 20% AER 60GM 250 $160.35 $0.00

7902430 DERMOPLAST 20% AER 250 $36.04 $0.00

7902448 BENZONATATE 100MG CAP 250 $12.44 $0.00

7902471 BENZTROPINE 1MG/ML INJ (C 250 J0515 $50.47 $0.00

7902489 BENZTROPINE 0.5MG TAB (CO 250 $8.83 $0.00

7902497 BENZTROPINE 2MG TAB (COGE 250 $9.25 $0.00

7902505 BETAMETHASONE VAL 0.1% CR 250 $39.05 $0.00

7902513 BETAMETHASONE SOLUSPA 6MG 250 J0702 $172.57 $0.00

7902521 BETAMETHASONE AUG 0.05% O 250 $120.57 $0.00

7902539 BETAMETHASONE VAL 0.1% OI 250 $40.38 $0.00



Page 85 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7902547 R&B 2HTU ICU

BETAXOLOL 0.25% OP SUSP ( 250 $260.28 $0.00

7902570 URECHOLINE 5MG/ML INJ 1ML 250 J0520 $36.71 $0.00

7902588 BETHANECHOL 10MG TAB (URE 250 $17.54 $0.00

7902596 BETHANECHOL 25MG TAB (URE 250 $23.16 $0.00

7902604 BISACODYL 10MG SUPP 250 $8.29 $0.00

7902612 BISACODYL 5MG EC TAB 250 $7.58 $0.00

7902620 PINK BISMUTH 527MG/30ML S 250 $7.05 $0.00

7902653 FLEET PREP #1 KIT 250 $42.25 $0.00

7902679 BROMOCRIPTIN 2.5MG TAB 250 $22.43 $0.00

7902687 DIMETAPP ELIXIR 118ML 250 $8.54 $0.00

7902703 BUMETANIDE 1MG TAB (BUMEX 250 $10.52 $0.00

7902711 BUMETANIDE 0.25MG/ML INJ 250 $19.33 $0.00

7902737 BUPIVACAINE/EPI .25% INJ 250 $36.87 $0.00

7902745 BUPI-MPF/EPI 0.5% (SENSOR 250 $52.70 $0.00

7902760 BUPIVACAINE 0.25% INJ 10M 250 $26.12 $0.00

7902778 BUPIVACAINE MPF.25% INJ ( 250 $52.66 $0.00

7902794 BUPIVACAINE 0.5% INJ 30ML 250 $21.80 $0.00

7902810 BuPROPion 75MG TAB (WELLB 250 $18.81 $0.00

7902828 BusPIRone 5MG TAB (BUSPAR 250 $13.89 $0.00

7902836 BUSULFAN 2MG TAB (MYLERAN 250 J8510 $26.07 $0.00

7902844 BUTALBITAL COMPOUND TAB ( 250 $7.47 $0.00

7902869 FIORICET TAB 250 $14.72 $0.00

7902885 FIORINAL/COD 30MG CAP 250 $26.44 $0.00

7902893 BUTORPHANOL 2MG/ML INJ 1M 250 J0595 $52.59 $0.00

7902901 CALAMINE LOTION 120ML 250 $19.62 $0.00

7902919 CALAMINE/PRAMOX LOTION 18 250 $29.48 $0.00

7902927 CALCITONIN 200IU/A SPR (M 250 J0630 $213.73 $0.00

7902935 CALCITRIOL 0.25MCG CAP (R 250 $17.02 $0.00

7902950 CALCIUM CARB 500MG CHW TA 250 $10.40 $0.00

7902976 CALCIUM CHL 10% INJ 10ML 250 $12.55 $0.00

7902984 CALCIUM CHLORIDE 10% INJ 250 $32.73 $0.00

7902992 CALCIUM GLUCONATE 10% INJ 250 J0610 $13.25 $0.00

7903008 CALCIUM GLUCONATE 500MG T 250 $8.73 $0.00

7903024 OYSTER SHELL-CALCIUM W/D 250 $7.18 $0.00

7903040 CAPTOPRIL 25MG TAB 250 $12.88 $0.00

7903057 CAPTOPRIL/HCTZ 25/15MG TA 250 $17.21 $0.00

7903065 CARBASTAT 0.01% OP SOL (M 250 $169.00 $0.00

7903073 CARBACHOL 1.5% OP SOLN 15 250 $215.95 $0.00

7903081 CARBACHOL 3% OP SOLN 15ML 250 $245.73 $0.00

7903099 CARBAMAZEPINE 100MG/5ML S 250 $7.77 $0.00

7903115 CARBAMAZEPINE 200MG TAB ( 250 $12.36 $0.00

7903123 EAR WAX REMOVER OTIC SOLN 250 $28.07 $0.00

7903131 CARBIDOPA/LEVO 10-100MG T 250 $11.99 $0.00

7903149 CARBIDOPA/LEVO 25-100MG T 250 $12.64 $0.00

7903156 CARBIDOPA/LEVO 25-250MG T 250 $14.18 $0.00

7903164 CARBIDOPA/LEVO ER 50-200M 250 $21.74 $0.00

7903172 RONDEC DM DROP (CARDEC) 3 250 $8.40 $0.00

7903180 CARBOPLATIN 150MG INJ (PA 250 J9045 $1,293.41 $0.00

7903198 CARBOPLATIN 450MG INJ (PA 250 J9045 $5,490.47 $0.00



Page 86 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7903206 R&B 2HTU ICU 50MG INJ (PAR

CARBOPLATIN 250 J9045 $671.17 $0.00

7903214 CARBOPROST 250MCG INJ (HE 250 $240.29 $0.00

7903255 CASTOR 95% OIL 120ML 250 $7.15 $0.00

7903263 CEFACLOR 250MG CAP (CECLO 250 $23.43 $0.00

7903271 CEFACLOR 125MG/5ML SUSP 7 250 $8.32 $0.00

7903289 CEFACLOR 250MG/5ML SUSP 7 250 $9.45 $0.00

7903297 CEFADROXIL 500MG CAP 250 $33.51 $0.00

7903339 CEFAZOLIN 1GM INJ (ANCEF) 250 J0690 $26.38 $0.00

7903347 CEFAZOLIN 1GM INJ (KEFZOL 250 J0690 $30.68 $0.00

7903370 CEFOTAXIME 1GM INJ (CLAFO 250 J0698 $59.96 $0.00

7903396 CEFOTAXIME 2GM INJ (CLAFO 250 J0698 $124.63 $0.00

7903412 CEFOTETAN 1GM INJ (CEFOTA 250 $71.00 $0.00

7903438 CEFOXITIN 1GM INJ (MEFOXI 250 J0694 $70.36 $0.00

7903453 CEFOXITIN 2GM INJ (MEFOXI 250 J0694 $133.28 $0.00

7903479 CEFTAZIDIME 1GM INJ 250 J0713 $65.49 $0.00

7903487 CEFTAZIDIME 1GM ADV (FORT 250 J0713 $84.80 $0.00

7903495 CEFTAZIDIME 2GM INJ 250 J0713 $123.99 $0.00

7903503 CEFTAZIDIME 2GM ADV (FORT 250 J0713 $160.06 $0.00

7903529 CEFTIZOXIME 1GM INJ (CEFI 250 J0715 $67.25 $0.00

7903537 CEFTRIAXONE 1GM INJ (ROCE 250 J0696 $187.42 $0.00

7903545 CEFTRIAXONE 1GM ADV (ROCE 250 J0696 $193.26 $0.00

7903552 CEFTRIAXONE 2GM INJ (ROCE 250 J0696 $365.52 $0.00

7903560 CEFTRIAXONE 2GM ADV (ROCE 250 J0696 $374.85 $0.00

7903578 CEFUROXIME 250MG TAB (CEF 250 J0697 $48.63 $0.00

7903586 CEFUROXIME 1.5GM ADV (ZIN 250 J0697 $48.70 $0.00

7903594 CEFUROXIME 750MG INJ (ZIN 250 J0697 $32.63 $0.00

7903602 CEFUROXIME 750MG ADV (ZIN 250 J0697 $35.15 $0.00

7903651 CEPHALEXIN 250MG CAP (KEF 250 $12.93 $0.00

7903669 CEPHALEXIN 500MG CAP (KEF 250 $19.19 $0.00

7903677 CEPACOL LOZENGE 250 $10.12 $0.00

7903693 CHLORAL HYDRATE 500MG/5ML 250 $13.51 $0.00

7903768 CHLORDIAZEPOXIDE 10MG CAP 250 $10.51 $0.00

7903776 CHLORDIAZEPOXIDE 25MG CAP 250 $10.58 $0.00

7903784 CHLORDIAZEPOXIDE 5MG CAP 250 $8.35 $0.00

7903792 LIBRAX 5-2.5MG CAP 250 $21.63 $0.00

7903800 CLIDINIUM/CPD CAP (LIBRA 250 $10.31 $0.00

7903818 CHLOROPROCAINE 1% INJ (NE 250 J2400 $126.28 $0.00

7903826 CHLOROPROCAINE-MPF 2% INJ 250 J2400 $147.92 $0.00

7903834 CHLOROPROCAINE-MPF 3% INJ 250 J2400 $155.01 $0.00

7903842 CHLOROTHIAZIDE 250MG/5ML 250 $7.36 $0.00

7903859 CHLOROTHIAZIDE 500MG INJ 250 J1205 $60.58 $0.00

7903909 CHLORPHENIRAMINE 2MG/5ML 250 $7.96 $0.00

7903917 CHLORPHENIRAMINE 4MG TAB 250 $7.31 $0.00

7903941 ChlorproMAZINE 30MG/ML CO 250 $7.35 $0.00

7903958 ChlorproMAZINE 25MG/ML IN 250 J3230 $39.69 $0.00

7903974 ChlorproMAZINE 25MG TAB ( 250 Q0172 $10.75 $0.00

7903982 ChlorproPAMIDE 100MG TAB 250 $9.40 $0.00

7904006 ChlorproPAMIDE 250MG TAB 250 $11.88 $0.00

7904014 CHLORTHALIDONE 25MG TAB 250 $8.27 $0.00



Page 87 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7904022 R&B 2HTU ICU

CHLORTHALIDONE 50MG TAB ( 250 $8.33 $0.00

7904055 CHLORZOXAZONE 500MG TAB ( 250 $10.48 $0.00

7904063 CHOLESTYRAMINE 4GM POWD 250 $21.88 $0.00

7904071 CHOLINE MAG TRISAL 750MG 250 $12.73 $0.00

7904089 CIMETIDINE 200MG TAB 250 $12.63 $0.00

7904105 CIMETIDINE 150MG/ML INJ 2 250 $14.75 $0.00

7904121 CIMETIDINE 300MG TAB 250 $14.24 $0.00

7904162 CIPROFLOXACIN 10MG/ML INJ 250 J0744 $159.41 $0.00

7904170 CIPROFLOXACIN 0.3% OP SOL 250 $154.11 $0.00

7904188 CIPROFLOXACIN 250MG TAB ( 250 $34.97 $0.00

7904196 CIPROFLOXACIN 500MG TAB ( 250 $39.66 $0.00

7904204 CIPROFLOXACIN 750MG TAB ( 250 $41.25 $0.00

7904212 CISPLATIN AQ 50MG INJ (PL 250 J9062 $915.87 $0.00

7904220 MAGNESIUM CITRATE SOLN 30 250 $18.84 $0.00

7904238 CLARITHROMYCIN 500MG TAB 250 $34.50 $0.00

7904261 CLINDAMYCIN 600MG INJ (CL 250 $55.59 $0.00

7904279 CLINDAMYCIN 600MG INJ (CL 250 $25.11 $0.00

7904287 CLINDAMYCIN 75MG/5ML SUSP 250 $17.79 $0.00

7904295 CLINDAMYCIN 150MG CAP (CL 250 $29.10 $0.00

7904329 CLONAZEPAM 1MG TAB 250 $13.02 $0.00

7904345 CLONIDINE 0.1/24HR PATCH 250 $108.05 $0.00

7904352 CLONIDINE 0.2/24HR PATCH 250 $177.11 $0.00

7904360 CLONIDINE 0.3/24HR PATCH 250 $243.01 $0.00

7904378 CLONIDINE 0.1MG TAB 250 $8.66 $0.00

7904386 CLONIDINE 0.2MG TAB 250 $9.28 $0.00

7904410 CLORAZEPATE DIP 3.75MG TA 250 $23.40 $0.00

7904428 CLOTRIMAZOLE 10MG TROCHE 250 $21.26 $0.00

7904444 CLOTRIMAZOLE 1% VAG CREAM 250 $70.48 $0.00

7904469 LOTRISONE CREAM 15GM 250 $178.81 $0.00

7904519 CODEINE PHOS 30MG/2ML INJ 250 J0745 $14.98 $0.00

7904535 CODEINE SULF 30MG TAB 250 $12.59 $0.00

7904543 COLCHICINE 0.6MG TAB 250 $8.36 $0.00

7904550 COLCHICINE 1MG/2ML INJ 2M 250 J0760 $47.99 $0.00

7904568 COLESTID 5GM POWD 250 $242.41 $0.00

7904584 COLLODION FLEXIBLE 120ML 250 $82.54 $0.00

7904600 CONJ,ESTROGENS 0.3MG TAB 250 $16.02 $0.00

7904626 CONJ,ESTROGENS 0.9MG TAB 250 $16.41 $0.00

7904659 CONJ,ESTROGEN 25MG INJ (P 250 J1410 $256.07 $0.00

7904667 CONJ,ESTROGENS 0.625MG TA 250 $14.81 $0.00

7904675 CONJ,ESTROGENS 1.25MG TAB 250 $16.41 $0.00

7904683 CONJ,ESTROGEN 0.625MG CRE 250 $284.10 $0.00

7904691 CONRAY 60% INJ 50ML 250 $74.77 $0.00

7904725 CORTISONE AC 10MG TAB (CO 250 $9.96 $0.00

7904758 CROMOLYN 5.2/ACT AER (NAS 250 J7631 $52.28 $0.00

7904766 CROMOLYN SOD 20MG/2ML NEB 250 J7631 $11.93 $0.00

7904774 CYANOCOBALAMIN 1000MCG/1M 250 J3420 $11.49 $0.00

7904790 CYCLOBENZAPRINE 10MG TAB 250 $13.83 $0.00

7904808 CYCLOPENTOLATE 1% OPHTH S 250 $88.36 $0.00

7904816 CYCLOPENTOLATE HCL OP 2% 250 $113.48 $0.00



Page 88 of 129

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12427

7904824 R&B 2HTU ICU

CYCLOPEN 0.2%/PHENYLEP 1% 250 $92.32 $0.00

7904832 CYCLOPHOSPHAMIDE 50MG TAB 250 J8530 $36.21 $0.00

7904857 CYCLOPHOSPHAMIDE 1GM INJ 250 J9096 $329.90 $0.00

7904865 CYCLOPHOSPAMIDE 500MG INJ 250 J9095 $199.30 $0.00

7904873 CycloSPORINE 50MG/ML 5ML 250 J7516 $161.24 $0.00

7904881 CycloSPORINE 100MG/ML SOL 250 J7502 $47.03 $0.00

7904899 CYPROHEPTADINE 4MG TAB 250 $10.01 $0.00

7904907 CYSTO-CONRAY II 17.2% INJ 250 $7.56 $0.00

7904915 CYTARABINE 100MG INJ (CYT 250 J9100 $40.06 $0.00

7904923 CYTARABINE 500MG INJ (CYT 250 J9110 $118.34 $0.00

7904931 DACARBAZINE 100MG INJ 250 J9130 $131.24 $0.00

7904949 DACARBAZINE 200MG INJ (DT 250 J9140 $215.42 $0.00

7904964 DANAZOL 100MG CAP (DANOCR 250 $27.19 $0.00

7904972 DANTROLENE SODIUM 25MG CA 250 $15.89 $0.00

7904980 DANTROLENE 20MG INJ (DANT 250 $368.61 $0.00

7904998 DAPSONE 100MG TAB 250 $8.50 $0.00

7905003 DAUNOrubicin 20MG INJ 250 J9150 $643.39 $0.00

7905029 DEFEROXAMINE 500MG INJ (D 250 J0895 $128.67 $0.00

7905037 DEMECLOCYCLINE 150MG TAB 250 $69.17 $0.00

7905045 DEMECLOCYCLINE 300MG TAB 250 $119.55 $0.00

7905078 DESIPRAMINE 25MG TAB (NOR 250 $10.11 $0.00

7905086 DESMOPRESSIN 4MCG/ML INJ 250 J2597 $748.12 $0.00

7905094 DESMOPRESSIN 0.01% SOL (D 250 $392.82 $0.00

7905102 DESOXIMETASONE 0.25% CREA 250 $143.79 $0.00

7905110 NEO/POLY/DEX 0.1% OP OINT 250 $49.31 $0.00

7905128 NEO/POLY/DEX 0.1% OP SUSP 250 $49.32 $0.00

7905136 DEXAMETHASONE 0.5MG TAB 250 $8.33 $0.00

7905144 DEXAMETHASON 0.5MG/5ML EL 250 $14.14 $0.00

7905151 DEXAMETHASONE 0.75MG TAB 250 $9.33 $0.00

7905219 DEXAMETHASONE 0.1% OP SUS 250 $227.85 $0.00

7905243 DEXAMETHASONE 4MG TAB (DE 250 $11.37 $0.00

7905268 DEXPANTHENOL 250MG/ML INJ 250 $35.63 $0.00

7905276 DEXTRAN 40 LMW 10% 500ML 250 J7100 $195.18 $0.00

7905284 DEXTRAN 70 HMW 32% 100ML 250 J7110 $156.58 $0.00

7905318 GLUTOSE 40% GEL 15GM 250 $29.91 $0.00

7905334 DEXTROSE 50% SYRINGE 50ML 250 $36.17 $0.00

7905391 DIAZEPAM 5MG/ML INJ 2ML ( 250 J3360 $24.85 $0.00

7905409 DIAZEPAM 10MG TAB (VALIUM 250 $9.68 $0.00

7905417 DIAZEPAM 2MG TAB (VALIUM) 250 $8.70 $0.00

7905425 DIAZEPAM 5MG TAB (VALIUM) 250 $9.26 $0.00

7905433 DIDUCAINE 1% OINTMENT 30G 250 $32.73 $0.00

7905441 DICLOFENAC 25MG EC TAB (V 250 $15.24 $0.00

7905490 DICYCLOMINE 10MG CAP (BE 250 $8.87 $0.00

7905508 DICYCLOMINE 10MG/ML INJ ( 250 J0500 $121.95 $0.00

7905516 DIDANOSINE 100MG CHW TAB 250 $25.02 $0.00

7905557 DIFLUNISAL 250MG TAB (DO 250 $14.19 $0.00

7905565 DIFLUNISAL 500MG TAB (DOL 250 $17.48 $0.00

7905573 DIGOXIN 0.125MG TAB (LANO 250 $9.59 $0.00

7905615 DIGOXIN 0.25MG/ML INJ 2ML 250 J1160 $20.22 $0.00



Page 89 of 129

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12427

7905656 R&B 2HTU ICU TAB (LANOX

DIGOXIN 0.25MG 250 $9.59 $0.00

7905664 DIHYDROERGOTAMINE 1MG/ML 250 J1110 $198.50 $0.00

7905698 DILTIAZEM 60MG TAB (CARD 250 $10.91 $0.00

7905706 DILTIAZEM CD 120MG CAP (C 250 $17.90 $0.00

7905714 DILTIAZEM CD 180MG CAP (C 250 $19.88 $0.00

7905722 DILTIAZEM CD 240MG CAP (C 250 $25.29 $0.00

7905730 DILTIAZEM CD 300MG CAP (C 250 $30.96 $0.00

7905771 DILTIAZEM 30MG TAB (CARDI 250 $10.16 $0.00

7905789 DILUENT SOL 250 $7.16 $0.00

7905797 DimenhyDRINATE 50MG TAB 250 J1240 $7.22 $0.00

7905813 DINOPROSTONE .5MG/3GM GEL 250 $833.44 $0.00

7905821 PROSTIN E2 20MG VAG SUPP 250 $2,822.37 $0.00

7905839 TRIPEDIA INJ 0.5ML 250 $145.49 $0.00

7905847 DIP/TET PED 0.5ML SYRINGE 250 $35.29 $0.00

7905862 DIPHENHYDRAMINE 25MG CAP 250 Q0163 $4.65 $0.00

7905888 DiphenhydrAMINE 50MG/1ML 250 J1200 $18.90 $0.00

7905912 DiphenhydrAMINE 50MG CAP 250 Q0163 $7.63 $0.00

7905920 LONOX 2.5MG TAB 250 $10.37 $0.00

7905926 ISOSORB DIN 5MG TAB 250 $8.50 $0.00

7905938 DIPHENOXYLATE/ATROPINE 2. 250 $7.95 $0.00

7905946 DIPHENOXYLATE/ATROPINE 2. 250 $10.36 $0.00

7905953 DIPIVEFRIN 0.1% OP SOLN 5 250 $81.58 $0.00

7905979 DIPYRIDAMOLE 25MG TAB (P 250 $8.90 $0.00

7905995 DISOPYRAMIDE 150MG SA CAP 250 $17.03 $0.00

7906001 DISOPYRAMIDE 100MG CAP (N 250 $11.89 $0.00

7906019 DISOPYRAMIDE 150MG CAP (N 250 $11.81 $0.00

7906035 DIVALPROEX 250MG E TAB (D 250 $17.97 $0.00

7906043 DOBUTamine 250MG/20ML INJ 250 J1250 $70.48 $0.00

7906050 DOCUSATE CALCIUM 240MG CA 250 $7.80 $0.00

7906076 DOCUSATE SOD 100MG CAP 250 $7.80 $0.00

7906092 DOMEBORO 2% OTIC SOL 60ML 250 $104.65 $0.00

7906126 DOXAPRAM 20MG/ML INJ (DOP 250 $350.75 $0.00

7906134 DOXAZOSIN 2MG TAB (CARDUR 250 $16.79 $0.00

7906167 DOXEPIN HCL 10MG CAP 250 $9.28 $0.00

7906175 DOXEPIN HCL 25MG CAP 250 $10.02 $0.00

7906183 DOXOrubicin 2MG/ML INJ 5M 250 J9000 $128.26 $0.00

7906191 DOXOrubicin 2MG/ML INJ 25 250 J9000 $249.66 $0.00

7906225 DOXYCYCLINE HYC 100MG INJ 250 $85.02 $0.00

7906233 DOXYCYCLINE 100MG CAP 250 $16.75 $0.00

7906274 ECHOTHIOPHATE 0.03% OP SO 250 $166.44 $0.00

7906290 ECHOTHIOPHATE 0.125% OP S 250 $266.91 $0.00

7906316 CALCIUM DISOD 200MG/ML IN 250 J0600 $262.79 $0.00

7906324 EDROPHONIUM/ATROPINE INJ 250 $114.25 $0.00

7906332 EVAC EMPTY CONTAINER 1000 250 $15.70 $0.00

7906340 EVAC EMPTY CONTAINER GLAS 250 $14.64 $0.00

7906357 EVAC EMPTY CONTAINER 500M 250 $15.31 $0.00

7906365 ENALAPRIL 10MG TAB (VASOT 250 $15.80 $0.00

7906381 ENALAPRIL 5MG TAB (VASOTE 250 $15.33 $0.00

7906449 EPHEDrine SULF 50MG/ML IN 250 $12.55 $0.00



Page 90 of 129

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12427

7906456 R&B 2HTU ICU

EPINEPHRINE 1MG/ML INJ 1M 250 J0170 $11.05 $0.00

7906464 EPINEPHrine 0.1MG/ML SYR 250 J0170 $24.80 $0.00

7906530 ERGOCALCIFEROL ORAL DROP 250 $16.53 $0.00

7906589 ERGOLOID MESYLATES 1MG TA 250 $15.09 $0.00

7906597 CAFERGOT 2/100 SUPP 250 J1330 $49.45 $0.00

7906621 ERYTHROMYCIN 200MG/5ML SU 250 $7.35 $0.00

7906647 ERYTHROMYCIN 400MG/5ML SU 250 $7.63 $0.00

7906654 ERYTHROMYCIN 1000MG INJ ( 250 J1364 $47.46 $0.00

7906662 ERYTHROMYCIN 1000MG ADV ( 250 J1364 $99.14 $0.00

7906670 ERYTHROMYCIN LAC 500MG AD 250 J1364 $54.67 $0.00

7906696 ERYTHROMYCIN 250MG TAB (E 250 $9.04 $0.00

7906704 EES/SULFISOX 200-600 SUSP 250 $7.88 $0.00

7906712 ESMOLOL 10MG/ML INJ (BREV 250 $119.46 $0.00

7906720 ESMOLOL 250MG/ML INJ (BRE 250 $464.84 $0.00

7906738 ESTRADIOL 1MG TAB 250 $9.43 $0.00

7906746 ESTRADIOL 0.05MG PATCH (C 250 $60.64 $0.00

7906753 ESTRADIOL 0.1MG PATCH (CL 250 $60.64 $0.00

7906761 ESTRADIOL 40MG/ML INJ (DE 250 J0970 $505.61 $0.00

7906787 ESTROPIPATE 0.75 TAB (OGE 250 $14.46 $0.00

7906795 ETHACRYNIC ACID 50MG INJ 250 $132.90 $0.00

7906811 ETHAMBUTOL 100MG TAB (MYA 250 $11.77 $0.00

7906837 ETHAMBUTOL 400MG TAB (MYA 250 $22.95 $0.00

7906878 ETIDRONATE 200MG TAB (DID 250 $33.63 $0.00

7906894 ETODOLAC 300MG CAP (LODIN 250 $19.39 $0.00

7906928 ETOPOSIDE 20MG/ML INJ (VE 250 J9182 $413.50 $0.00

7906944 FAMOTIDINE 20MG TAB (PEPC 250 $21.29 $0.00

7906969 FAMOTIDINE 20MG/2ML INJ ( 250 $40.37 $0.00

7906977 FELODIPINE 5MG CR TAB (PL 250 $18.17 $0.00

7906993 FENTANYL CIT 250MCG/5ML I 250 J3010 $33.18 $0.00

7907009 FENTANYL 25MCG/HR PATCH ( 250 $97.93 $0.00

7907017 FENTANYL 50MCG/HR PATCH ( 250 $171.62 $0.00

7907025 FENTANYL 75MCG/HR PATCH ( 250 $257.09 $0.00

7907066 FERROUS GLUCONATE 300MG T 250 $7.68 $0.00

7907074 FERROUS SULF 220MG/5ML EL 250 $7.35 $0.00

7907108 FERROUS SULFATE 325MG TAB 250 $7.34 $0.00

7907124 FILGRASTIM 300MCG/ML INJ 250 J1440 $863.90 $0.00

7907132 FINASTERIDE 5MG TAB (PROS 250 $31.51 $0.00

7907157 FLECAINIDE 50MG TAB (TAMB 250 $22.34 $0.00

7907165 FLOXURIDINE 0.5GM INJ (FU 250 J9200 $550.17 $0.00

7907173 FLUCONAZOLE 200MG/100ML P 250 J1450 $435.44 $0.00

7907181 FLUCONAZOLE 100MG TAB (DI 250 $61.32 $0.00

7907199 FLUCYTOSINE 500MG CAP (AN 250 $62.66 $0.00

7907207 FLUDARABINE 50MG INJ (FLU 250 J9185 $1,418.30 $0.00

7907215 FLUDROCORTISONE 0.1MG TAB 250 $13.22 $0.00

7907231 FLUNISOLIDE 250MCG INH (A 250 $321.45 $0.00

7907249 FLUNISOLIDE 0.025% SPR (N 250 $191.40 $0.00

7907264 FLUOCINOLONE 0.025% CREAM 250 $28.50 $0.00

7907272 FLUOCINOLONE 0.025% OINT 250 $36.61 $0.00

7907280 FLUOCINOLONE 0.01% SOLN 6 250 $65.18 $0.00



Page 91 of 129

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12427

7907298 R&B 2HTU ICU 0.05% CREAM

FLUOCINONIDE 250 $85.02 $0.00

7907314 FLUORESCITE 10% OP INJ 5M 250 $141.89 $0.00

7907322 FLUORESCEIN 9MG OP TEST 250 $8.82 $0.00

7907348 FLUOROMETHOLONE 0.1% OP S 250 $86.50 $0.00

7907355 FLUOROURACIL 50MG/ML INJ 250 J9190 $91.31 $0.00

7907363 FLUOXETINE 20MG CAP (PROZ 250 $34.30 $0.00

7907389 FLUPHENAZINE 1MG TAB (PRO 250 $10.87 $0.00

7907397 PROLIXIN-DEC 25MG/ML INJ 250 J2680 $449.83 $0.00

7907413 FLUPHENAZINE 25MG/10ML IN 250 J2680 $294.48 $0.00

7907421 FLURANDRENOLIDE 0.05% LOT 250 $337.93 $0.00

7907454 FLURAZEPAM 15MG CAP (DALM 250 $9.25 $0.00

7907470 FLURBIPROFEN 0.03% OP SOL 250 $53.18 $0.00

7907504 FOLIC ACID 5MG/ML INJ 10 250 $15.81 $0.00

7907512 FOLIC ACID 1MG TAB 250 $8.59 $0.00

7907538 FOSINOPRIL 10MG TAB (MONO 250 $17.57 $0.00

7907546 FOSINOPRIL 20MG TAB (MONO 250 $16.97 $0.00

7907579 FUROSEMIDE 100MG/10ML INJ 250 J1940 $23.12 $0.00

7907587 FUROSEMIDE 40MG/4ML INJ ( 250 J1940 $17.13 $0.00

7907603 FUROSEMIDE 10MG/ML SOLN 6 250 $8.22 $0.00

7907611 FUROSEMIDE 20MG TAB (LAS 250 $8.20 $0.00

7907629 FUROSEMIDE 40MG TAB (LAS 250 $8.18 $0.00

7907652 GELFOAM SPONGE 12/7MM 250 $56.65 $0.00

7907660 GELFOAM SPONGE 100MM 250 $305.96 $0.00

7907678 GELFOAM SPONGE 50MM 250 $168.01 $0.00

7907686 GELFILM OP FILM ABSORBABL 250 $225.41 $0.00

7907694 GEMFIBROZIL 600MG TAB (LO 250 $15.78 $0.00

7907702 GENTAMICIN 0.1% CREAM 15G 250 $33.22 $0.00

7907710 GENTAMICIN 10MG/ML INJ 2M 250 J1580 $15.72 $0.00

7907728 GENTAMICIN 40MG/ML INJ 2M 250 J1580 $12.90 $0.00

7907736 GENTAMICIN 0.3% OP OINT 3 250 $87.19 $0.00

7907744 GENTAMICIN 0.3% OP SOLN 5 250 $57.25 $0.00

7907769 GlipiZIDE 10MG TAB (GLUCO 250 $11.49 $0.00

7907777 GlipiZIDE 5MG TAB (GLUCOT 250 $9.36 $0.00

7907785 CALCIUM GLUBIONATE 1.8GM/ 250 $7.36 $0.00

7907793 GLUCAGON 1MG KIT 250 J1610 $282.79 $0.00

7907892 GlyBURIDE 2.5MG TAB (MICR 250 $9.15 $0.00

7907900 GlyBURIDE 5MG TAB (MICRON 250 $10.70 $0.00

7907918 GLYCERIN 1.5GM PEDIATRIC 250 $8.21 $0.00

7907926 GLYCERIN 3GM ADULT SUPP 250 $8.79 $0.00

7907934 GLYCOPYRROLATE 2MG TAB (R 250 $14.02 $0.00

7907942 GLYCOPYRROLATE 0.2MG/M IN 250 $15.96 $0.00

7908072 GUANABENZ 4MG TAB (WYTANS 250 $13.90 $0.00

7908080 GUANADREL 10MG TAB (HYLOR 250 $21.08 $0.00

7908098 GUANFACINE 1MG TAB (TENEX 250 $13.14 $0.00

7908130 HALOPERIDOL 2MG/ML CONC L 250 J1630 $9.48 $0.00

7908189 TRINSICON CAP 250 $14.12 $0.00

7908205 HEMORRHOIDAL SUPP 250 $8.73 $0.00

7908213 HYDROCORTISONE AC 25MG SU 250 $13.14 $0.00

7908221 HEPARIN SOD 1,000 UNITS/M 250 J1644 $31.67 $0.00



Page 92 of 129

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12427

7908239 R&B 2HTU ICU1,000 UNITS/M

HEPARIN SOD 250 J1644 $16.95 $0.00

7908247 HEPARIN SOD 10,000 UNITS/ 250 J1644 $18.89 $0.00

7908262 HEPARIN LOCK 100 UNITS/ML 250 J1642 $10.87 $0.00

7908304 HEPATITIS B INJ 5ML (NABI 250 90371 $2,478.00 $0.00

7908338 HETASTARCH 6%/NACL PREMIX 250 $207.35 $0.00

7908353 HEXACHLOROPHENE 3% LIQ (P 250 $120.73 $0.00

7908379 HISTOPLASMIN 1U INJ 250 $382.06 $0.00

7908411 HydrALAZINE 20MG/1ML INJ 250 J0360 $106.18 $0.00

7908429 HydrALAZINE 10MG TAB 250 $8.53 $0.00

7908437 HydrALAZINE 25MG TAB 250 $9.49 $0.00

7908445 HydrALAZINE 50MG TAB 250 $10.10 $0.00

7908478 HYDROCHLOROTHIAZIDE 25MG 250 $7.71 $0.00

7908486 HYDROCHLOROTHIAZIDE 50MG 250 $7.86 $0.00

7908510 HYDROCODONE/APAP 7.5/500M 250 $16.21 $0.00

7908544 HYDROCODONE/APAP 5-500MG 250 $11.70 $0.00

7908551 TUSSIONEX SUSPENSION 250 $26.18 $0.00

7908577 CODAMINE SYRUP 473ML 250 $9.20 $0.00

7908585 HYDROCORTISONE 10MG TAB ( 250 $10.21 $0.00

7908601 HYDROCORTISONE 0.5% CREAM 250 $22.53 $0.00

7908619 HYDROCORTISONE 1% CREAM 2 250 $28.18 $0.00

7908635 HYDROCORTISONE 100MG INJ 250 J1720 $24.89 $0.00

7908643 HYDROCORTISONE 250MG INJ 250 J1720 $38.58 $0.00

7908650 HYDROCORTISONE 500MG INJ 250 J1720 $76.63 $0.00

7908676 HYDROCORTISONE 0.5% OINT 250 $22.53 $0.00

7908684 HYDROCORTISONE 1% OINT 28 250 $28.18 $0.00

7908692 HYDROCORTISONE 100MG ENEM 250 $66.06 $0.00

7908700 HYDROmorphone 2MG/ML INJ 250 J1170 $16.47 $0.00

7908718 HYDROmorphone 4MG/1ML INJ 250 J1170 $17.32 $0.00

7908726 HYDROmorphone 2MG TAB (D 250 $12.27 $0.00

7908734 HYDROmorphone 4MG TAB (DI 250 $14.00 $0.00

7908742 HYDROXYCHLOROQUINE 200MG 250 $14.72 $0.00

7908767 HYDROXYUREA 500MG CAP (HY 250 J9340 $17.00 $0.00

7908775 HydrOXYzine HCL 10MG TAB 250 $7.71 $0.00

7908809 HydrOXYzine HCL 10MG/5ML 250 $7.32 $0.00

7908825 HydrOXYzine PAM 25MG CAP 250 Q0177 $10.12 $0.00

7908833 IBUPROFEN (MOTRIN) 100MG/ 250 $51.96 $0.00

7908874 IBUPROFEN 800MG TAB 250 $9.04 $0.00

7908882 IBUPROFEN 200MG TAB 250 $7.48 $0.00

7908890 IBUPROFEN 400MG TAB (MOT 250 $8.51 $0.00

7908908 IBUPROFEN 600MG TAB 250 $9.14 $0.00

7908924 IDARUBICIN 5MG/5ML INJ 250 J9211 $1,629.15 $0.00

7908965 PRIMAXIN IV 500MG ADV 250 J0743 $208.80 $0.00

7908973 IMIPRAMINE HCL 10MG TAB 250 $10.02 $0.00

7908981 IMIPRAMINE HCL 25MG TAB 250 $12.05 $0.00

7909054 INDAPAMIDE 2.5MG TAB (LOZ 250 $15.64 $0.00

7909062 INDIGO CARMINE 8MG/ML INJ 250 $54.61 $0.00

7909096 INDOMETHACIN 1MG INJ (IND 250 $2,213.25 $0.00

7909104 INDOMETHACIN 75MG ER CAP 250 $19.84 $0.00

7909112 INDOMETHACIN 25MG CAP 250 $10.87 $0.00



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12427

7909120 R&B 2HTU ICU 50MG CAP

INDOMETHACIN 250 $11.78 $0.00

7909146 INSULIN LENTE INJ (HUMULI 250 J1815 $37.50 $0.00

7909153 NPH INSULIN INJ (NOVOLIN 250 J1815 $37.50 $0.00

7909161 70/30 NPH/REG INSULIN INJ 250 J1815 $37.50 $0.00

7909179 REG INSULIN (NOVOLIN R) B 250 J1815 $37.50 $0.00

7909252 SUMMERS EVE 0.3% SOL 250 $23.76 $0.00

7909260 POVIDONE-IODINE 10% OINT 250 $57.30 $0.00

7909286 POVIDONE-IODINE 10% OINT 250 $7.73 $0.00

7909294 IODINE STRONG SOLN 480ML 250 $138.29 $0.00

7909351 FERROUS SULF 15MG/0.6ML D 250 $38.86 $0.00

7909377 ISONIAZID 100MG TAB 250 $7.57 $0.00

7909393 ISONIAZID 50MG/5ML SYP 47 250 $7.50 $0.00

7909401 ISONIAZID 300MG TAB 250 $8.06 $0.00

7909435 ISOPROTERENOL 0.2MG/ML IN 250 $41.81 $0.00

7909443 ISOPROTERENOL 0.2MG/M SYR 250 $36.22 $0.00

7909476 ISOSORBIDE MONO 20MG TAB 250 $17.07 $0.00

7909484 ISOSORBIDE 2.5MG SL TAB ( 250 $9.25 $0.00

7909492 ISOSORBIDE DIN 5MG SL TAB 250 $8.45 $0.00

7909500 ISOSORB DIN 40MG ER TAB 250 $12.96 $0.00

7909518 ISOSORBIDE DIN 10MG TAB 250 $8.28 $0.00

7909575 K-PHOS NEUTRAL TAB 250 $8.30 $0.00

7909583 K-Y GEL 113.5GM 250 $7.17 $0.00

7909591 KANAMYCIN 1GM/3ML INJ (KA 250 J1840 $43.65 $0.00

7909625 KETAMINE 100MG/ML INJ 5ML 250 $60.92 $0.00

7909633 KETOCONAZOLE 2% CREAM (NI 250 $117.87 $0.00

7909641 KETOCONAZOLE 200MG TAB (N 250 $40.44 $0.00

7909666 KETOPROFEN 50MG CAP (ORUD 250 $15.65 $0.00

7909674 KETOPROFEN 75MG CAP (ORUD 250 $16.62 $0.00

7909682 KETOROLAC 10MG TAB 250 $14.19 $0.00

7909732 LABETALOL 200MG TAB (NORM 250 $13.24 $0.00

7909740 LABETALOL 5MG/ML INJ (TRA 250 $106.18 $0.00

7909757 LABETALOL 100MG TAB (TRAN 250 $12.28 $0.00

7909773 LACTATED RINGERS INJ 1000 250 J7120 $65.92 $0.00

7909781 LACTATED RINGERS INJ 500 250 J7120 $67.69 $0.00

7909799 LACTINEX CHW TAB 250 $8.00 $0.00

7909849 LEUCOVORIN CAL 5MG TAB 250 $21.44 $0.00

7909872 LEVOBUNOLOL 0.5% OP SOLN 250 $94.81 $0.00

7909898 LEVOTHYROXINE 25MCG TAB ( 250 $9.30 $0.00

7909914 LEVOTHROID 75MCG TAB 250 $8.88 $0.00

7909955 LEVOTHYROXINE 300MCG TAB 250 $12.79 $0.00

7909963 LEVOTHYROXIN 500MCG INJ 250 $46.67 $0.00

7909971 LEVOTHROID 50MCG TAB 250 $8.70 $0.00

7909989 LEVOTHROID 125MCG TAB 250 $9.25 $0.00

7909997 LEVOTHYROXINE 150MCG TAB 250 $10.81 $0.00

7910003 LEVOTHYROXINE 100MCG TAB 250 $10.19 $0.00

7910011 LEVOTHYROXINE 200MCG TAB 250 $11.58 $0.00

7910029 LIDOCAINE 4% SOLN 50ML 250 $55.45 $0.00

7910037 LIDOCAINE-MPF 4% INJ (XYL 250 J2001 $48.58 $0.00

7910045 LIDOCAINE 0.5% INJ 50ML 250 J2001 $24.09 $0.00



Page 94 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7910052 R&B 2HTU ICU MDV INJ 20ML

LIDOCAINE 1% 250 J2001 $9.82 $0.00

7910094 LIDOCAINE 2% INJ 20ML MDV 250 J2001 $9.90 $0.00

7910128 LIDOCAINE 2% GEL (XYLOCAI 250 $119.41 $0.00

7910144 LIDOCAINE 5% OINT 35.4GM 250 $87.26 $0.00

7910169 LIDOCAINE 2% VISC SOLN 10 250 $8.20 $0.00

7910177 LIDOCAINE/EPI 0.5% INJ 50 250 J2001 $27.88 $0.00

7910185 LIDOCAINE/EPI 1% INJ 20ML 250 J2001 $16.69 $0.00

7910219 LIDOCAINE/EPI 2% INJ 20ML 250 J2001 $19.16 $0.00

7910268 BLISTEX LIP BALM MIS 0.15 250 $14.23 $0.00

7910276 LISINOPRIL 5MG TAB (PRIN 250 $14.61 $0.00

7910284 LISINOPRIL 10MG TAB (PRIN 250 $14.86 $0.00

7910300 LITHIUM CARBONATE 300MG T 250 $8.51 $0.00

7910318 LITHIUM CITRATE 8MEQ/5ML 250 $7.98 $0.00

7910383 LOPERAMIDE 1MG/5ML LIQ 12 250 $8.66 $0.00

7910409 LOPERAMIDE 2MG CAP 250 $11.95 $0.00

7910425 LORazepam 2MG/ML INJ (ATI 250 J2060 $42.43 $0.00

7910433 LORazepam 1MG TAB 250 $13.39 $0.00

7910441 LOVASTATIN 20MG TAB (MEVA 250 $25.58 $0.00

7910458 LOXAPINE 50MG CAP (LOXITA 250 $29.36 $0.00

7910516 MAGNESIUM CHL 64MG TAB (S 250 $7.84 $0.00

7910557 MANNITOL 25% INJ 50ML 250 J2150 $32.11 $0.00

7910581 MD-GASTROVIEW SOL 120ML 250 $8.53 $0.00

7910599 MEBENDAZOLE 100MG CHW TAB 250 $35.14 $0.00

7910623 MECLIZINE 25MG TAB 250 $8.23 $0.00

7910631 MECLOFENAMATE 100MG CAP ( 250 $30.95 $0.00

7910649 MECLOFENAMATE 50MG CAP ( 250 $19.90 $0.00

7910664 MEDIUM CHAIN TRIGLYCERIDE 250 $19.10 $0.00

7910672 MedroxyPROGESTERone 10MG 250 $18.11 $0.00

7910680 MedroxyPROGESTERone 2.5MG 250 $9.18 $0.00

7910698 MedroxyPROGESTERone 5MG T 250 $15.51 $0.00

7910706 MEDROXYPROGESTERONE 400MG 250 J1051 $479.27 $0.00

7910714 MEFANAMIC 250MG CAP (PONS 250 $16.43 $0.00

7910722 MEGESTROL AC 40MG TAB 250 $14.53 $0.00

7910748 BANALG-HS LINIMENT LIQ 60 250 $32.94 $0.00

7910755 MEPERIDINE 100MG/1ML INJ 250 J2175 $13.72 $0.00

7910763 MEPERIDINE 25MG/1ML INJ ( 250 J2175 $12.68 $0.00

7910771 MEPERIDINE 50MG/1ML INJ ( 250 J2175 $13.09 $0.00

7910789 MEPERIDINE 75MG/1ML SYR ( 250 J2175 $13.37 $0.00

7910797 MEPERIDINE 300MG/30ML PCA 250 J2175 $71.37 $0.00

7910813 MEPERIDINE 50MG TAB (DEME 250 $10.94 $0.00

7910839 MEPIVACAINE-MPF 1% INJ (P 250 J0670 $51.96 $0.00

7910847 MEPIVACAINE-MPF 2% INJ (P 250 J0670 $56.93 $0.00

7910854 MEPROBAMATE 400MG TAB 250 $9.42 $0.00

7910870 MERCAPTOPURINE 50MG TAB ( 250 $36.51 $0.00

7910904 METAPROTERENOL 10MG/5ML S 250 $9.34 $0.00

7910920 METAPROTERENOL 65MCG INH 250 $221.82 $0.00

7910938 METAPROTERENOL 5% NEB (AL 250 J7668 $117.24 $0.00

7910946 METAPROTERENOL 0.6% NEB 2 250 J7669 $15.67 $0.00

7910961 METHADONE 5MG/5ML ORAL SO 250 $9.49 $0.00



Page 95 of 129

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12427

7910979 R&B 2HTU ICU

METHADONE 5MG TAB 250 $11.66 $0.00

7910987 METHAZOLAMIDE 50MG TAB 250 $12.56 $0.00

7910995 METHIMAZOLE 10MG TAB (TAP 250 $13.49 $0.00

7911019 METHOCARBAMOL 100MG/ML IJ 250 J2800 $90.42 $0.00

7911027 METHOCARBAMOL 500MG TAB 250 $8.77 $0.00

7911035 METHOHEXITAL 500MG INJ (B 250 $226.56 $0.00

7911043 METHOTREXATE 2.5MG TAB 250 J8610 $33.21 $0.00

7911076 METHOTREXATE 25MG/ML INJ 250 J9260 $102.23 $0.00

7911092 METHYLDOPA 250MG TAB 250 J0210 $9.59 $0.00

7911142 METHYLDOPATE 250MG/5ML IN 250 J0210 $73.12 $0.00

7911159 METHYLENE BLUE 1% INJ 1ML 250 A9535 $48.33 $0.00

7911167 METHYLERGONOVINE 0.2MG/ML 250 J2210 $36.52 $0.00

7911175 METHYLERGONOVINE 0.2MG TA 250 $14.13 $0.00

7911183 METHYLPHENIDATE 5MG TAB 250 $11.30 $0.00

7911191 METHYLPHENIDATE 20MG ER T 250 $16.42 $0.00

7911209 MethylPREDNISolone 125MG 250 J2930 $36.18 $0.00

7911217 MethylPREDNISolone 1000MG 250 J2930 $131.47 $0.00

7911225 MethylPREDNISolone 40MG I 250 J2920 $21.45 $0.00

7911233 MethylPREDNISolone 500MG 250 J2930 $85.50 $0.00

7911258 MethylPREDNISolone 40MG I 250 J1030 $52.17 $0.00

7911266 MethylPREDNISolone 80MG I 250 J1040 $85.34 $0.00

7911274 MethylPREDNISolone 4MG TA 250 J7509 $16.45 $0.00

7911316 METOCLOPRAMIDE 10MG/2ML I 250 J2765 $23.59 $0.00

7911332 METOCLOPRAMIDE 10MG TAB 250 $9.52 $0.00

7911357 METOLAZONE 5MG TAB (ZAROX 250 $19.65 $0.00

7911365 METOLAZONE 2.5MG TAB (ZAR 250 $19.80 $0.00

7911399 METOPROLOL 5MG/5ML INJ (L 250 $39.30 $0.00

7911407 METOPROLOL 100MG TAB (LOP 250 $12.81 $0.00

7911415 METOPROLOL 50MG TAB (LOPR 250 $11.03 $0.00

7911431 METRONIDAZOLE/NACL 500MG 250 $28.59 $0.00

7911449 METRONIDAZOLE 250MG TAB 250 $12.07 $0.00

7911522 MIDAZOLAM 1MG/ML INJ (VER 250 J2250 $45.99 $0.00

7911530 MIDRIN CAP 250 $10.95 $0.00

7911555 MILRINONE 20MG/20ML INJ ( 250 J2260 $608.59 $0.00

7911571 MINERAL OIL (MURI-LUBE) 1 250 $39.73 $0.00

7911589 MINERAL OIL 30ML 250 $10.70 $0.00

7911597 MINOCYCLINE 100MG CAP 250 $24.34 $0.00

7911605 MISOPROSTOL 100MCG TAB (C 250 $15.25 $0.00

7911613 MITOMYCIN 5MG INJ (MUTAMY 250 J9280 $523.23 $0.00

7911621 MITOXANTRONE 2MG/ML INJ ( 250 J9293 $5,409.85 $0.00

7911639 MITOXANTRONE 2MG/ML INJ ( 250 J9293 $6,745.00 $0.00

7911647 MIVACURIUM CHLORIDE 2MG/M 250 $177.54 $0.00

7911662 MORICIZINE 200MG TAB (ETH 250 $16.38 $0.00

7911670 MORICIZINE 300MG TAB (ETH 250 $19.76 $0.00

7911688 MORphine SULFATE 10MG/ML 250 J2270 $15.37 $0.00

7911696 MORphine PF 1MG/ML INJ (D 250 J2275 $57.75 $0.00

7911704 MORphine SULFATE 15MG/ML 250 J2270 $17.05 $0.00

7911712 MORphine SULFATE 15MG/ML 250 J2270 $13.31 $0.00

7911753 MORphine SUL 10MG/5ML SOL 250 $9.49 $0.00



Page 96 of 129

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12427

7911761 MORphine ICU

R&B 2HTU20MG/ML SOLUTION 250 $12.80 $0.00

7911779 MORphine 30MG CR TAB (ORA 250 $24.20 $0.00

7911787 MORRHUAT SOD 5% INJ 250 $227.62 $0.00

7911803 VITAMIN B COMPLEX CAP 250 $7.32 $0.00

7911837 MULTIVIT/MIN THERAPEUTIC 250 $7.56 $0.00

7911845 MULTIVITAMIN THERAPEUTIC 250 $7.52 $0.00

7911852 POLY-VI-FLOR/FE .25MG/ML 250 $77.30 $0.00

7911902 MULTIVITAMIN DROP (VI-DAY 250 $77.78 $0.00

7911910 MULTIVITAMINE LIQ (THERAV 250 $8.70 $0.00

7911951 NABUMETONE 500MG TAB (REL 250 $22.46 $0.00

7911969 NADOLOL 40MG TAB (CORGARD 250 $20.48 $0.00

7912009 NAFCILLIN 1GM INJ 250 $48.52 $0.00

7912025 NAFCILLIN 2GM INJ 250 $87.56 $0.00

7912041 NALBUPHINE 20MG/ML INJ 1M 250 J2300 $17.31 $0.00

7912066 NALOXONE 0.4MG/ML INJ 1M 250 J2310 $16.34 $0.00

7912074 NALOXONE 1MG/ML INJ (NARC 250 J2310 $252.66 $0.00

7912082 NALOXONE 1MG/ML SYR 2ML 250 J2310 $126.25 $0.00

7912090 NALTREXONE 50MG TAB (REVI 250 $33.88 $0.00

7912124 NAPHAZOLINE 0.1% OP SOL 1 250 $36.88 $0.00

7912207 NEOMYCIN SULF POWD (NEO-R 250 $59.23 $0.00

7912215 NEOMYCIN 500MG TAB 250 $20.92 $0.00

7912223 NEOMYCIN/DEX 0.5-0.1 OP S 250 $84.71 $0.00

7912231 NEOSTIGMINE 1MG/ML INJ 10 250 J2710 $67.43 $0.00

7912272 NIACIN 500MG SA CAP 250 $7.79 $0.00

7912280 NIACIN 50MG TAB 250 $7.16 $0.00

7912348 NICOTINE TD 14MG/24HR PAT 250 $40.27 $0.00

7912355 NICOTINE TD 21MG/24HR PAT 250 $42.01 $0.00

7912363 NICOTINE 7MG/24HR PATCH 250 $40.21 $0.00

7912389 NIFEdipine 10MG CAP 250 $11.69 $0.00

7912421 NIMODIPINE 30MG CAP (NIMO 250 $57.38 $0.00

7912439 NITROFURANTOIN MAC 100MG 250 $25.65 $0.00

7912462 NITROFURANTOIN MAC 50MG C 250 $12.17 $0.00

7912470 NITROGLYCERIN 5MG/ML INJ 250 $81.39 $0.00

7912546 NITROGLYCERIN 2.5MG CAP 250 $7.47 $0.00

7912579 NITROGLYCERIN 6.5MG T CAP 250 $8.55 $0.00

7912611 NORMOSOL-R PH 7.4 INJ 100 250 $402.68 $0.00

7912637 NORTRIPTYLINE 10MG CAP (P 250 $12.46 $0.00

7912645 NORTRIPTYLINE 25MG CAP 250 $12.66 $0.00

7912652 NTG 0.1MG/HR PATCH (2.5M 250 $25.06 $0.00

7912660 NTG 0.2MG/HR PATCH (5MG/2 250 $18.39 $0.00

7912678 NTG 0.3MG/HR PATCH (7.5MG 250 $27.54 $0.00

7912686 NTG 0.4MG/HR PATCH (10MG/ 250 $20.01 $0.00

7912694 NTG 0.6MG/HR PATCH (15MG 250 $21.35 $0.00

7912710 NYSTATIN 100000U CREAM 30 250 $38.74 $0.00

7912744 NYSTOP 100000U POWD 15GM 250 $152.26 $0.00

7912769 NYSTATIN 100000U VAG TAB 250 $28.83 $0.00

7912777 NYSTATIN/TRIAMCINOLONE CR 250 $39.43 $0.00

7912785 NYSTATIN/TRIAMCINOLONE OI 250 $39.43 $0.00

7912793 OCTREOTIDE 0.05MG/1ML INJ 250 J2354 $59.76 $0.00



Page 97 of 129

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12427

7912801 R&B 2HTU ICU

OCTREOTIDE 0.1MG/1ML INJ 250 J2354 $109.33 $0.00

7912835 OFLOXACIN 200MG TAB (FLOX 250 $36.77 $0.00

7912843 OLSALAZINE 250MG CAP (DIP 250 $17.04 $0.00

7912868 OMEPRAZOLE 20MG CR CAP (P 250 $39.53 $0.00

7912934 ONE TOUCH HIGH CONTROL TE 250 A4256 $11.43 $0.00

7912942 ONE TOUCH II HOLDERS 250 $7.87 $0.00

7912959 ONE TOUCH LOW CONTROL TES 250 A4256 $11.43 $0.00

7912967 ONE TOUCH STRIPS TEST 250 $8.76 $0.00

7912975 OPHTHALMIC IRRIGATION (BS 250 $43.69 $0.00

7913064 SUSPENDING LIQ 1ML 250 $7.23 $0.00

7913130 OXYBUTYNIN 5MG TAB 250 $10.14 $0.00

7913155 OXYCODONE/ACETAM 5-325MG 250 $10.75 $0.00

7913189 ASA 325MG/OXYCODONE 4.5MG 250 $17.43 $0.00

7913197 OXYMETAZOLINE 0.05% NASAL 250 $21.73 $0.00

7913221 OXYTOCIN 10UNITS/ML INJ ( 250 J2590 $40.04 $0.00

7913239 PACLITAXEL 30MG/5ML INJ ( 250 J9265 $687.62 $0.00

7913247 PAMIDRONATE 30MG INJ (ARE 250 J2430 $994.90 $0.00

7913254 PANCREASE EC CAP 250 $11.22 $0.00

7913270 PAPAVERINE 30MG/ML INJ 10 250 J2440 $96.29 $0.00

7913304 PAROXETINE 20MG TAB (PAXI 250 $30.62 $0.00

7913387 GOLYTELY SOLN 4000MLS 250 $104.52 $0.00

7913403 PEN G BENZ CR 1.2MILL UNI 250 J0540 $114.72 $0.00

7913411 PEN G BENZ CR 600K UNITS 250 J0530 $61.87 $0.00

7913429 PEN G BENZ LA 1.2MMU INJ. 250 J0570 $127.64 $0.00

7913437 PEN G BENZ LA 600K UNITS 250 J0560 $76.66 $0.00

7913460 PEN G POT 20MMU INJ (PFIZ 250 J2540 $63.55 $0.00

7913478 PEN G POT 5MMU INJ (PFIZE 250 J2540 $32.71 $0.00

7913486 PEN G PROCAINE 1.2MMU INJ 250 J2510 $90.88 $0.00

7913502 PEN G PROCAINE 600MU (WYC 250 J2510 $57.38 $0.00

7913510 PENICILLAMINE 250MG CAP ( 250 $15.17 $0.00

7913536 PENICILLN VK 250MG TAB 250 $7.37 $0.00

7913551 PENICILLN VK 500MG TAB 250 $9.81 $0.00

7913585 PENTAMIDINE 300MG INJ 250 $256.68 $0.00

7913601 PENTAZOCINE W/APAP 25MG-6 250 $12.97 $0.00

7913619 TALWIN NX TAB 250 $18.56 $0.00

7913676 PENTOXIFYLLINE 400MG C TA 250 $13.15 $0.00

7913692 PERMETHRIN 1% SOLN (NIX) 250 $55.66 $0.00

7913718 PERPHENAZINE 2MG TAB 250 Q0175 $10.24 $0.00

7913767 PETROLATUM GEL 28.4GM 250 $16.18 $0.00

7913775 DURATEARS OP OINT 3.5GM 250 $75.13 $0.00

7913783 PHENAPHTHAZINE PAPER (NIT 250 $172.10 $0.00

7913791 PHENAZOPYRIDINE 100MG TAB 250 $10.17 $0.00

7913809 PHENAZOPYRIDINE 200MG TAB 250 $12.81 $0.00

7913825 DONNATAL 16MG/5ML ELX 473 250 $9.11 $0.00

7913841 DONNATAL TAB 250 $7.60 $0.00

7913866 PHENOBARBITAL 100MG TAB 250 $9.56 $0.00

7913874 PHENOBARBITAL 15MG TAB 250 $9.02 $0.00

7913908 PHENOBARBITAL 130MG/1ML I 250 J2560 $40.57 $0.00

7913916 PHENOBARBITAL 65MG/ML INJ 250 J2560 $18.98 $0.00



Page 98 of 129

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12427

7913924 R&B 2HTU ICU

PHENOBARBITAL 30MG TAB 250 $9.28 $0.00

7913932 PHENOBARBITAL 60MG TAB 250 $9.43 $0.00

7913957 PHENTOLAMINE MESYLAT INJ 250 J2760 $192.15 $0.00

7913973 PHENYLEPHRINE 10MG/ML INJ 250 J2370 $29.03 $0.00

7913981 NOSE DROPS EX-STR SOLN (N 250 $29.13 $0.00

7914005 PHENYLEPHRINE 0.5% NS SPR 250 $31.60 $0.00

7914013 PHENYLEPHRINE 0.25% NS SP 250 $31.60 $0.00

7914039 MYDFRIN 2.5% OP SOLN 3ML 250 $78.73 $0.00

7914088 PHENYTOIN 50MG CHW TAB (D 250 $10.30 $0.00

7914096 PHENYTOIN 250MG/5ML INJ 250 J1165 $21.45 $0.00

7914104 PHENYTOIN 30MG CAP (DILAN 250 $9.24 $0.00

7914112 PHENYTOIN 125MG/5ML SUSP 250 $7.97 $0.00

7914120 PHENYTOIN 100MG CAP (DILA 250 $9.87 $0.00

7914138 PHOSPHORATED CARB SOLN (E 250 $7.37 $0.00

7914146 PHYSOSTIGMINE 1MG/ML INJ 250 $41.26 $0.00

7914153 PHYTONADIONE 5MG TAB (MEP 250 $11.60 $0.00

7914161 PHYTONADIONE 10MG/ML INJ 250 J3430 $41.31 $0.00

7914203 PILOCARPINE 0.5% OP SOLN 250 $42.01 $0.00

7914211 PILOCARPINE 1% OP SOLN 15 250 $55.66 $0.00

7914229 PILOCARPINE 2% OP SOLN 15 250 $69.42 $0.00

7914237 PILOCARPINE 3% OP SOL 15M 250 $63.49 $0.00

7914245 PILOCARPINE 4% OP SOLN 15 250 $65.98 $0.00

7914252 PILOCARPINE 6% OP SOLN 15 250 $76.82 $0.00

7914344 PIRBUTEROL 200MCG INH (MA 250 $185.33 $0.00

7914351 PIROXICAM 10MG CAP 250 $16.92 $0.00

7914377 PLICAMYCIN 2.5MG INJ (MIT 250 J9270 $417.28 $0.00

7914385 PNEUMOCOCCAL 25MCG/0.5ML 250 $182.95 $0.00

7914401 BACITRACIN/POLYMYXIN OINT 250 $52.57 $0.00

7914419 BACITRACIN/POLYMYXIN OP O 250 $143.32 $0.00

7914427 BAC/NEO/POLY OINT 28.4GM 250 $37.09 $0.00

7914435 NEO/POLY/BACI OP OINT 3.5 250 $38.21 $0.00

7914443 BAC/NEO/POLY OINT 1GM 250 $8.85 $0.00

7914450 CORTISPORIN OINTMENT 15GM 250 $221.72 $0.00

7914468 NEO/POLY/GRAM OP SOLN 10M 250 $165.85 $0.00

7914476 CORTISPORIN OP SUSP 7.5ML 250 $240.65 $0.00

7914484 FIBER CON 625MG TAB 250 $7.99 $0.00

7914500 POLYMYXIN B 500000U INJ 250 $54.61 $0.00

7914518 NEO/POLY/HC OTIC SUSP 10M 250 $169.93 $0.00

7914526 POTASSIUM ACETATE 2MEQ/ML 250 $23.83 $0.00

7914591 POTASSIUM CHLORIDE 2MEQ/M 250 J3480 $10.17 $0.00

7914625 SSKI 1GM/ML SOL 30L 250 $71.00 $0.00

7914633 POTASSIUM PHOS 3MM/ML INJ 250 $11.66 $0.00

7914641 PRALIDOXIME 1GM INJ (PROT 250 J2730 $389.56 $0.00

7914658 PRAMOXINE NS 1% AER (PROC 250 $205.00 $0.00

7914666 PRAMOXINE-HC 1% AER (PROC 250 $207.82 $0.00

7914674 PRAVASTATIN 10MG TAB (PRA 250 $32.18 $0.00

7914716 PRAZOSIN HCL 1MG CAP (MI 250 $9.06 $0.00

7914724 SODIUM BICARB 8.4% ABBOJE 250 $25.68 $0.00

7914740 PrednisoLONE 5MG/5ML SYP 250 J7510 $13.38 $0.00



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12427

7914757 R&B 2HTU ICU

PrednisoLONE 0.12% OP SUS 250 $138.08 $0.00

7914765 PrednisoLONE 1% OP SUSP 5 250 $73.65 $0.00

7914823 PredniSONE 10MG TAB 250 J7506 $7.93 $0.00

7914831 PredniSONE 1MG TAB 250 J7506 $8.64 $0.00

7914849 PredniSONE 20MG TAB 250 J7506 $8.12 $0.00

7914856 PredniSONE 5MG TAB 250 J7510 $7.84 $0.00

7914864 PRIMIDONE 250MG TAB 250 $12.48 $0.00

7914872 PRIMIDONE 50MG TAB (MYSO 250 $10.40 $0.00

7914880 PROBENECID 500MG TAB 250 $13.93 $0.00

7914906 PROBENECID/COLCHICINE 500 250 $12.94 $0.00

7914930 PROCAINAMIDE 100MG/ML INJ 250 J2690 $26.12 $0.00

7914948 PROCAINAMIDE 500MG/ML INJ 250 J2690 $27.97 $0.00

7914955 PROCAINAMIDE 500MG SR TA 250 $12.64 $0.00

7914971 PROCAINAMIDE 750MG SA TA 250 $13.32 $0.00

7915036 PROCARBAZINE 5OMG CAP (MA 250 $203.55 $0.00

7915069 PROCHLORPERAZINE 5MG TAB 250 Q0164 $12.03 $0.00

7915119 PROCHLORPERAZINE 25MG SUP 250 $34.07 $0.00

7915135 PROCHLORPERAZINE 10MG TAB 250 Q0165 $14.78 $0.00

7915192 PROMETHAZINE 50MG/1ML INJ 250 J2550 $28.15 $0.00

7915200 PROMETHAZINE 6.25MG/5ML P 250 $8.39 $0.00

7915218 PROMETHAZINE 12.5MG SUPP 250 $37.83 $0.00

7915226 PROMETHAZINE 25MG SUPP (P 250 $33.52 $0.00

7915242 PHENERGAN 25MG TAB 250 $11.16 $0.00

7915259 PROMETHAZINE VC SYRUP 1ML 250 $9.72 $0.00

7915275 PROMETHAZINE/CODEINE SYRU 250 $9.42 $0.00

7915283 PROMETHAZINE DM SYP 118ML 250 $7.42 $0.00

7915291 PROPAFENONE 150MG TAB (RY 250 $20.85 $0.00

7915309 PROPARACAINE 0.5% OP SOLN 250 $156.44 $0.00

7915325 PROPOFOL 1% 50ML INJ (DIP 250 $264.42 $0.00

7915333 PROPOXYPHENE HCL 65MG CAP 250 $9.34 $0.00

7915366 PROPOXYPHENE/APAP 100-650 250 $9.69 $0.00

7915416 PROPRANOLOL 1MG/ML INJ (I 250 J1800 $105.16 $0.00

7915432 PROPRANOLOL 60MG LA CAP 250 $14.62 $0.00

7915473 PROPRANOLOL 10MG TAB 250 $8.43 $0.00

7915481 PROPRANOLOL 40MG TAB 250 $9.89 $0.00

7915499 INDERIDE 40/25 TAB 250 $18.32 $0.00

7915507 INDERIDE 80/25 TAB 250 $21.70 $0.00

7915523 PROTAMINE 10MG/ML INJ 25 250 J2720 $96.98 $0.00

7915531 PROTAMINE 10MG/ML INJ 5ML 250 J2720 $42.24 $0.00

7915549 PROTRIPTYLINE 10MG TAB (V 250 $19.21 $0.00

7915564 GUAIFEN/PSEUDO/COD LIQ 250 $8.43 $0.00

7915598 PSEUDOEPHEDRINE 30MG TAB 250 $7.50 $0.00

7915606 KONSYL-ORANGE 3.4GM UD PA 250 $8.90 $0.00

7915622 PYRAZINAMIDE 500MG TAB 250 $15.49 $0.00

7915630 PYRIDOSTIGMINE 60MG TAB ( 250 $13.52 $0.00

7915655 PYRIDOXINE 100MG/1ML INJ 250 J3415 $36.36 $0.00

7915671 PYRIDOXINE 50MG TAB (VIT 250 $7.28 $0.00

7915697 QUINIDINE SULFATE 200MG T 250 $8.41 $0.00

7915705 QUINIDINE SULFATE 300MG T 250 $9.72 $0.00



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12427

7915713 R&B 2HTU ICU

QUINIDINE SULFATE 300MG S 250 $9.92 $0.00

7915721 QUINIDINE GLUC 80MG/ML IN 250 $125.81 $0.00

7915747 QUINIDINE GL 324MG CR TAB 250 $16.64 $0.00

7915788 QUININE SULFATE 325MG CAP 250 $12.46 $0.00

7915804 RAMIPRIL 2.5MG CAP (ALTAC 250 $18.44 $0.00

7915820 RANITIDINE 15MG/ML SYRUP 250 $12.22 $0.00

7915846 RANITIDINE 25MG/ML INJ (Z 250 J2780 $55.98 $0.00

7915853 RANITIDINE 150MG TAB (ZAN 250 $29.57 $0.00

7915937 RIFAMPIN 300MG CAP (RIFAD 250 $26.11 $0.00

7915945 RINGERS INJ 1000MLS 250 J7120 $69.45 $0.00

7915952 RUBELLA VACC (MERUVAX) 1M 250 $122.50 $0.00

7915986 SCOPOLAMINE 0.4MG/M INJ 1 250 $36.75 $0.00

7915994 SCOPOLAMINE 0.25% OP SOL 250 $133.96 $0.00

7916000 SCOPOLAMINE 1.5MG PATCH ( 250 $49.70 $0.00

7916034 SENNA 8.6MG TAB (AKA SENO 250 $7.20 $0.00

7916042 SERTRALINE 50MG TAB (ZOLO 250 $28.26 $0.00

7916059 SILVER NITRATE APPLICATOR 250 $7.71 $0.00

7916083 SSD 1% CREAM 400GM 250 $192.52 $0.00

7916091 SSD 1% CREAM 50GM 250 $50.69 $0.00

7916109 SIMITHICONE 40MG/0.6M DRO 250 $32.31 $0.00

7916117 SIMETHICONE 80MG CHW TAB 250 $8.26 $0.00

7916141 SODIUM ACETATE 2MEQ/ML IN 250 $23.83 $0.00

7916166 SODIUM BICARB 8.4% ABBOJE 250 $34.84 $0.00

7916182 SODIUM BICARB 4.2% ABBOJE 250 $29.03 $0.00

7916190 SODIUM BICARB 650MG TAB 250 $7.60 $0.00

7916208 SODIUM CHLORIDE 0.9% NEB 250 $8.02 $0.00

7916216 SODIUM CHLORIDE 1GM TAB 250 $7.46 $0.00

7916232 SOD CHLORIDE 4MEQ/ML(23.4 250 J7130 $17.13 $0.00

7916265 BICITRA SOLN 30ML 250 $16.60 $0.00

7916273 NITROPRUSSIDE 25MG/ML INJ 250 $46.35 $0.00

7916281 SOD PHOSPHAT 3MM/ML INJ 1 250 $22.95 $0.00

7916307 SOD POLY SULF 15GM/60ML 5 250 $37.38 $0.00

7916315 SOD POLYSTYRENE SULF 30GM 250 $111.05 $0.00

7916323 SOD POLYST SULF POWD 454G 250 $242.81 $0.00

7916372 SORBITOL 70% SOLUTION 480 250 $7.04 $0.00

7916380 SOTALOL 80MG TAB (BETAPAC 250 $30.68 $0.00

7916398 SPECTINOMYCIN 2GM INJ (TR 250 J3320 $194.68 $0.00

7916414 SPIRONOLACTONE 25MG TAB 250 $10.01 $0.00

7916448 EYE WASH SOLN 118ML 250 $27.30 $0.00

7916471 STERILE WATER IRRIG SOLN 250 $68.25 $0.00

7916497 STERILE WATER IRRIG SOLN 250 $66.91 $0.00

7916505 STERILE EMPTY 30ML VIAL 250 $8.64 $0.00

7916539 STREPTOZOCIN 1GM INJ (ZAN 250 J9320 $616.35 $0.00

7916554 SUCCINYLCHOLINE 20MG/ML I 250 J0330 $27.45 $0.00

7916570 SUCRALFATE 1GM TAB 250 $12.43 $0.00

7916596 SUFENTANIL 50MCG/ML INJ 2 250 $116.86 $0.00

7916604 SULFACETAMIDE OINT (BLEPH 250 $185.08 $0.00

7916612 SULF/PRED NA OPTH SOLN 10 250 $133.90 $0.00

7916638 SULFACETAMIDE 10% OP SOLN 250 $33.87 $0.00



Page 101 of 129

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12427

7916661 R&B 2HTU ICU 1.05GM VAG

SULFANILAMIDE 250 $28.39 $0.00

7916679 SULFASALAZINE 500MG TAB 250 $8.79 $0.00

7916737 SULINDAC 150MG TAB 250 $13.92 $0.00

7916745 SULINDAC 200MG TAB 250 $15.50 $0.00

7916752 SUMATRIPTAN 6MG/0.5ML INJ 250 J3030 $269.56 $0.00

7916786 TAMOXIFEN 10MG TAB (NOLVA 250 $22.35 $0.00

7916794 AKWA TEARS OP SOLN 15ML 250 $33.01 $0.00

7916802 TEMAZEPAM 15MG CAP 250 $12.03 $0.00

7916810 TERAZOSIN 1MG CAP 250 $18.30 $0.00

7916828 TERAZOSIN 2MG CAP 250 $18.30 $0.00

7916869 TERBUTALINE 1MG/ML INJ (B 250 J3105 $171.97 $0.00

7916877 TERBUTALINE 2.5MG TAB (BR 250 $10.68 $0.00

7916885 TERBUTALINE 5MG TAB (BRET 250 $12.30 $0.00

7916927 TETANUS IMMUNE GLOBULIN(H 250 J1670 $470.31 $0.00

7916950 TETRACAINE 2% SOLN (PONTO 250 $97.35 $0.00

7916968 TETRACYCLINE 125MG/5ML SY 250 $12.57 $0.00

7916976 TETRACYCLINE 250MG CAP (S 250 $7.41 $0.00

7916984 TETRACYCLINE 500MG CAP (S 250 $7.80 $0.00

7917016 TETRAHYDROZOLINE 0.05% OP 250 $20.39 $0.00

7917024 THEOPHYLLINE 80MG/15ML EL 250 $7.08 $0.00

7917032 THEOPHYLLINE 300MG CR CAP 250 $13.87 $0.00

7917040 THEOPHYLLINE 100MG CR CA 250 $10.73 $0.00

7917131 THIABENDAZOLE 500MG CHW T 250 $15.88 $0.00

7917149 THIAMINE HCL 100MG/ML INJ 250 J3411 $43.36 $0.00

7917198 THIOPENTAL 500MG INJ (PEN 250 $57.91 $0.00

7917248 THIORIDAZINE 100MG TAB 250 $11.82 $0.00

7917255 THIORIDAZINE 10MG TAB 250 $9.41 $0.00

7917263 THIORIDAZINE 25MG TAB 250 $10.32 $0.00

7917289 THIOTHIXENE 1MG CAP 250 $8.67 $0.00

7917297 THIOTHIXENE 5MG CAP (NAVA 250 $10.34 $0.00

7917305 THROMBIN-JMI 20000U KIT 250 $1,202.18 $0.00

7917339 THYROID 30MG TAB (ARMOUR 250 $8.02 $0.00

7917370 THYROID 60MG TAB (ARMOUR 250 $8.90 $0.00

7917404 TICLOPIDINE 250MG TAB (TI 250 $26.15 $0.00

7917438 TIMOLOL MAL 0.5% OP SOLN 250 $96.93 $0.00

7917446 TOBRAMYCIN 0.3% OP OINT ( 250 $224.09 $0.00

7917453 TOBRAMYCIN 40MG/ML INJ 2M 250 J3260 $45.53 $0.00

7917461 TOBRAMYCIN 0.3% OP SOLN 5 250 $86.35 $0.00

7917479 TOBRAMYCIN/DEXAMETHASONE 250 $289.85 $0.00

7917487 TOBRA/DEXAMET OP SUSP.(TO 250 $195.48 $0.00

7917511 TOLAZamide 100MG TAB (TOL 250 $10.58 $0.00

7917529 TOLAZamide 250MG TAB (TOL 250 $12.42 $0.00

7917552 TOLBUTamide 500MG TAB (O 250 $9.05 $0.00

7917586 TOLNAFTATE 1% CREAM 15GM 250 $23.92 $0.00

7917594 TOLNAFTATE 1% POWD 45GM 250 $35.13 $0.00

7917602 TOLNAFTATE 1% SOLN 10ML 250 $28.15 $0.00

7917610 TPN ELECTROLYTES 250 $404.58 $0.00

7917636 EMPTY CONTAINER 3000ML PL 250 $19.26 $0.00

7917644 EMPTY CONTAINER 4000ML PL 250 $20.68 $0.00



Page 102 of 129

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12427

7917651 R&B 2HTU ICU

TRACE ELEMENTS INJ 1ML 250 $12.64 $0.00

7917677 TRAZODONE 150MG TAB 250 $17.35 $0.00

7917735 TRIAMCINOLONE INH 20GM (A 250 J7683 $347.43 $0.00

7917743 TRIAMCINOLONE 10MG/ML INJ 250 J3301 $58.10 $0.00

7917750 TRIAMCINOLONE 40MG/1ML IN 250 J3301 $46.56 $0.00

7917768 TRIAMCINOLNE 40MG/ML INJ 250 J3301 $207.08 $0.00

7917792 TRIAMTERENE 100MG CAP (DY 250 $21.31 $0.00

7917800 TRIAMTERENE 50MG CAP (DY 250 $15.24 $0.00

7917834 TRIAMTERENE/HCTZ 75-50MG 250 $13.44 $0.00

7917867 TRIFLUOPERAZINE 2MG TAB 250 $13.23 $0.00

7917917 TRIHEXYPHENIDYL 2MG TAB 250 $8.28 $0.00

7917925 TRIHEXYPHENIDYL 5MG TAB ( 250 $9.56 $0.00

7917941 TRIMETHOBENZAMIDE 100MG C 250 $11.20 $0.00

7917966 TRIMETHOBENZAMIDE 200MG/2 250 J3250 $42.48 $0.00

7917974 TRIMETHOBENZAMIDE 100MG S 250 $16.72 $0.00

7917982 TRIMETHOBENZAMIDE 200MG S 250 $17.79 $0.00

7917990 TRIMETHOPRIM 100MG TAB (P 250 $10.21 $0.00

7918014 TRIMETHOPRIM POLYMYX OP S 250 $99.15 $0.00

7918048 SMZ-TMP INJ 400-80 250 $43.59 $0.00

7918055 SULFATRIM SUSP 100ML 250 $7.89 $0.00

7918063 SMZ/TMP DS 800-160 TAB 250 $15.05 $0.00

7918089 TRIACIN-C SYP 118ML 250 $7.43 $0.00

7918105 TRIPROLIDINE/PSE 1.25/30 250 $7.85 $0.00

7918113 TRIPROLIDINE/PSEUDO 2.5/6 250 $7.27 $0.00

7918139 TROPICAMIDE 0.5% OP SOLN 250 $91.48 $0.00

7918147 TROPICAMIDE 1% OP SOLN 2M 250 $33.60 $0.00

7918162 TUBERCULIN TEST 5U/0.1ML 250 $29.03 $0.00

7918196 TYMPAGESIC OTIC SOLN 13ML 250 $130.36 $0.00

7918238 URSODIOL 300MG CAP (ACTIG 250 $29.19 $0.00

7918253 VALPROIC ACID 250MG/5ML S 250 $10.80 $0.00

7918261 VALPROIC ACID 250MG CAP ( 250 $24.87 $0.00

7918279 VANCOMYCIN 1000MG INJ 250 J3370 $54.21 $0.00

7918287 VANCOMYCIN 500MG INJ 250 J3370 $28.32 $0.00

7918295 VANCOMYCIN 500MG ADV 250 J3370 $38.46 $0.00

7918337 VASOPRESSIN 20U/ML INJ 1M 250 $35.56 $0.00

7918345 VECURONIUM 10MG INJ 250 $41.71 $0.00

7918360 VERAPAMIL 2.5MG/ML INJ 2M 250 $24.18 $0.00

7918378 VERAPAMIL 120MG TAB 250 $11.07 $0.00

7918386 VERAPAMIL SR 180MG TAB (C 250 $22.55 $0.00

7918394 VERAPAMIL SR 240MG TAB ( 250 $15.59 $0.00

7918410 VERAPAMIL 80MG TAB 250 $11.01 $0.00

7918428 VITAMIN B W/C TAB 250 $7.32 $0.00

7918444 VinBLAStine 10MG INJ (VEL 250 J9360 $132.23 $0.00

7918451 VinCRIStine 1MG/1ML INJ ( 250 J9370 $168.25 $0.00

7918485 VITAMIN A D OINTMENT 5GM 250 $7.83 $0.00

7918493 BETA CAROTENE 25000IU CAP 250 $7.42 $0.00

7918501 AQUASOL A 50000/ML INJ 250 $153.36 $0.00

7918519 VITAMIN E 200IU CAP 250 $7.33 $0.00

7918535 VITAMIN E 50IU/ML DROP 12 250 $170.19 $0.00



Page 103 of 129

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12427

7918543 R&B 2HTU ICU

WARFARIN 2.5MG TAB (COUM 250 $13.46 $0.00

7918550 WARFARIN 2MG TAB (COUMAD 250 $13.26 $0.00

7918568 WARFARIN 7.5MG TAB (COUM 250 $15.63 $0.00

7918626 ZIDOVUDINE 100MG CAP (RET 250 $23.74 $0.00

7918634 ZINC OXIDE 20% OINT 454GM 250 $62.54 $0.00

7918642 ZINC OXIDE 20% OINT 60GM 250 $21.09 $0.00

7918659 ZINC OXIDE 40% OINT 120GM 250 $27.37 $0.00

7918675 ZINC SULFATE 220MG CAP 250 $7.41 $0.00

7918709 D5W INJ 1000MLS 250 J7070 $68.74 $0.00

7918758 NEUTRA-PHOS POW 250 $10.85 $0.00

7918816 ANTIBIOTIC MONITORING FEE 250 $250.00 $0.00

7918857 CALCIUM GLUCONATE POWD 50 250 $7.29 $0.00

7918949 LIQUOR 30ML 250 $7.00 $0.00

7918956 MORTAR GLASS 20Z 250 $7.50 $0.00

7918972 SODIUM CHL 0.65% NS SPRAY 250 $21.80 $0.00

7918980 PESTLE GLASS 2OZ 250 $7.50 $0.00

7919012 SULFACETAMIDE 10% OP OINT 250 $49.84 $0.00

7919020 TABLET CRUSHER 250 $7.50 $0.00

7919038 TABLET CUTTER 250 $7.50 $0.00

7919046 COCAINE HCL 10% SOL 4ML 250 $236.47 $0.00

7919137 MORphine 100MG CR TAB (MS 250 $43.76 $0.00

7919145 DILTIAZEM 5MG/ML INJ 5ML 250 $24.62 $0.00

7919152 QUINAPRIL 10MG TAB (ACCUP 250 $17.65 $0.00

7919186 NIZATIDINE 150MG CAP (AXI 250 $28.56 $0.00

7919194 ACETIC ACID GLACIAL SOL 5 250 $115.28 $0.00

7919210 CEFOTETAN 1GM ADV (CEFOTA 250 $87.20 $0.00

7919251 MICONAZOLE 2% CREAM (MONI 250 $70.90 $0.00

7919293 OFLOXACIN 300MG TAB (FLOX 250 $42.43 $0.00

7919327 CHLORASEPTIC THROAT SPRAY 250 $26.87 $0.00

7919335 TERAZOSIN 5MG CAP 250 $18.30 $0.00

7919343 SIMPLE SYRUP 480ML 250 $7.13 $0.00

7919368 CONRAY 60% SYRINGE 30ML 250 $50.64 $0.00

7919384 DOBUTamine/D5W 250MG/250M 250 J1250 $46.11 $0.00

7919400 DEXTROSE 70% INJ 2000MLS 250 J7040 $126.62 $0.00

7919426 AMINOSYN II 10% INJ 2000M 250 $581.69 $0.00

7919434 DIPYRIDAMOLE 5MG/ML INJ ( 250 J1245 $515.32 $0.00

7919442 CLARITHROMYCIN 250MG TAB 250 $34.50 $0.00

7919459 VITAMIN E 400IU CAP 250 $7.45 $0.00

7919467 ISRADIPINE 2.5MG CAP (DYN 250 $13.56 $0.00

7919483 MESALAMINE 400MG EC TAB ( 250 $14.76 $0.00

7919517 ONDANSETRON 4MG/2ML INJ ( 250 J2405 $148.33 $0.00

7919541 ACTIDOSE-AQ 50GM/240ML LI 250 $112.79 $0.00

7919566 TRIAMCIN/ORAB 0.1% PST (K 250 $96.87 $0.00

7919574 ISOSORBIDE 60MG ER TAB (I 250 $24.49 $0.00

7919590 QUININE SULFATE 200MG CAP 250 $10.92 $0.00

7919616 SLOW FE 160MG CR TAB 250 $8.60 $0.00

7919624 ROCURONIUM 10MG/ML INJ (Z 250 $95.03 $0.00

7919665 THEOPHYLLINE 400MG CR TAB 250 $15.34 $0.00

7919699 TRIAMCINOLONE INH (NASACO 250 $218.27 $0.00



Page 104 of 129

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12427

7919707 GENAMIN ICU

R&B 2HTUCOLD SYRUP 120ML 250 $7.15 $0.00

7919723 IPRATROPIUM 0.02% INHAL S 250 J7644 $16.30 $0.00

7919731 NATALCARE PLUS TAB 250 $8.96 $0.00

7919756 TENSILON 10MG/ML INJ 1ML 250 $39.95 $0.00

7919772 RIFAMPIN 600MG INJ (RIFAD 250 $377.43 $0.00

7919798 WARFARIN 10MG TAB (COUMAD 250 $15.96 $0.00

7919806 ALLERGY 2% CREAM 30GM (BE 250 $23.85 $0.00

7919814 LIDOCAINE-MPF 2% INJ (XYL 250 J2001 $27.83 $0.00

7919830 TRIAMTERENE/HCTZ 37.5-25 250 $9.39 $0.00

7919848 CycloSPORINE 100MG CAP (S 250 J7502 $48.21 $0.00

7919855 CHLORAMBUCIL 2MG TAB (LEU 250 J8600 $23.50 $0.00

7919863 MEGESTROL 40MG/ML SUSP (M 250 $11.69 $0.00

7919871 THEOPHYLLINE 200MG CR CAP 250 $12.57 $0.00

7919897 HOMATROPINE 5% OP SOLN 5M 250 $152.47 $0.00

7919905 OPTIPRANOLOL 0.3% OP SOLN 250 $234.36 $0.00

7919913 RAMIPRIL 5MG CAP (ALTACE) 250 $19.23 $0.00

7919921 PHYTONADIONE 1MG/0.5ML SY 250 J3430 $24.95 $0.00

7919939 WARFARIN 1MG TAB (COUMAD 250 $13.00 $0.00

7919947 ASPIRIN 81MG EC TAB 250 $7.18 $0.00

7919970 POTASSIUM CHL 20MEQ TAB 250 $12.17 $0.00

7919988 WARFARIN 5MG TAB (COUMAD 250 $13.74 $0.00

7920010 THEOPHYLLINE 200MG TR CAP 250 $10.45 $0.00

7920028 ERYTHROMYCIN BS 500MG TAB 250 $9.00 $0.00

7920036 SIMVASTATIN 5MG TAB (ZOC 250 $21.43 $0.00

7920085 EPINEPHRINE 30MG/30ML INJ 250 J0170 $55.93 $0.00

7920135 TORSEMIDE 20MG TAB (DEMAD 250 $15.56 $0.00

7920150 FAMCICLOVIR 500MG TAB (FA 250 $46.02 $0.00

7920226 LEVOBUNOLOL 0.25% OP SOL 250 $90.68 $0.00

7920242 GlyBURIDE 3MG TAB (GLYNAS 250 $15.40 $0.00

7920267 ABCIXIMAB 2MG/ML INJ (REO 250 J0130 $2,329.84 $0.00

7920283 PROPOFOL 1% 20ML INJ (DIP 250 $109.84 $0.00

7920291 ALBUTEROL 4MG ER TAB 250 $14.69 $0.00

7920317 GlipiZIDE XL 5MG TAB (GLU 250 $10.82 $0.00

7920333 CycloSPORINE 25MG CAP (SA 250 J7515 $20.75 $0.00

7920358 HEPARIN/NACL 1,000 UNITS/ 250 J1644 $33.43 $0.00

7920366 CALCIUM CARB 1250MG/5ML S 250 $7.17 $0.00

7920374 THROMBIN-JMI 5000U SOL 250 $291.51 $0.00

7920390 TOBRAMYCIN 1.2GM POWDER I 250 J3260 $1,318.14 $0.00

7920424 HYOSCYAMINE 0.125MG SL TA 250 $9.04 $0.00

7920440 ORAJEL 7.5% GEL 9.5GM (B 250 $36.69 $0.00

7920456 VARICELLA VACC INJ (VARIV 250 $320.11 $0.00

7920457 ROWASA 4GM/60ML ENEMA UNI 250 $112.15 $0.00

7920481 OPCON-A OP SOL 15ML 250 $35.13 $0.00

7920499 NEDOCROMIL INH (TILADE) 1 250 $253.60 $0.00

7920507 VENLAFAXINE 75MG TAB (EFF 250 $23.23 $0.00

7920515 METFORMIN 850MG TAB (GLUC 250 $18.14 $0.00

7920523 METFORMIN 500MG TAB (GLUC 250 $13.55 $0.00

7920531 HEPATITIS B 5MCG/0.5ML IN 250 $220.84 $0.00

7920549 ITRACONAZOLE 100MG CAP (S 250 J1835 $61.53 $0.00



Page 105 of 129

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12427

7920572 R&B 2HTU ICU 10MG VAG (CE

DINOPROSTONE 250 $877.78 $0.00

7920606 LEVOTHROID 112MCG TAB 250 $9.10 $0.00

7920614 METHYLENE BLUE 1% INJ 10M 250 $60.82 $0.00

7920622 LEVOCARNITIN 200MG/ML INJ 250 J1955 $218.60 $0.00

7920648 AZITHROMYCIN 1GM POWD (ZI 250 Q0144 $157.48 $0.00

7920655 SODIUM BENZOATE POWD 500G 250 $83.07 $0.00

7920671 LOSARTAN 25MG TAB (COZAAR 250 $20.72 $0.00

7920689 AMIODARONE 50MG/ML INJ (C 250 J0282 $380.16 $0.00

7920697 SEVOFLURANE INHALATION 25 250 $60.47 $0.00

7920705 METHADONE 10MG/ML INJ (DO 250 J1230 $93.00 $0.00

7920721 FAMOTIDINE 40MG/5ML SUSP 250 $22.18 $0.00

7920739 PHENYLEPHRINE 10MG/ML INJ 250 J2370 $89.65 $0.00

7920762 CALCITONIN 200IU/ML INJ ( 250 J0630 $266.42 $0.00

7920796 ACARBOSE 50MG TAB (PRECOS 250 $13.57 $0.00

7920804 PILOCARPINE 4% OP GEL (PI 250 $186.14 $0.00

7920812 METRONIDAZOLE 0.75% TOPIC 250 $289.58 $0.00

7920838 LORATADINE 10MG TAB (CLAR 250 $29.77 $0.00

7920846 METOPROLOL XL 50MG TAB (T 250 $13.82 $0.00

7920879 PROPANTHELINE 15MG TAB 250 $11.96 $0.00

7920895 CISATRACURIUM BESY. 2MG/M 250 $123.12 $0.00

7920903 ISOFLURANE INHALATION SOL 250 $13.52 $0.00

7920937 CHLORHEXIDINE 0.12% SOLN 250 $64.77 $0.00

7920945 CLARITHROMYCIN 250MG/5ML 250 $13.52 $0.00

7920960 ALPRACLONIDINE 0.5% OP SO 250 $295.15 $0.00

7920978 ALENDRONATE 10MG TAB (FOS 250 $28.21 $0.00

7920994 RISPERIDONE 1MG TAB (RISP 250 $36.74 $0.00

7921026 HEPATITIS B IMM GLOB INJ 250 90371 $531.20 $0.00

7921034 ULTRASOUND GEL 250 $7.50 $0.00

7921042 DEXAMETHASONE PHOSPHA POW 250 J1100 $437.66 $0.00

7921075 PROCAINAMIDE 1000MG ER TA 250 $17.57 $0.00

7921083 ALCOHOL ABSOLUTE 480ML 250 $7.50 $0.00

7921117 CEBO #1 CAP 250 $9.66 $0.00

7921133 TRAMADOL 50MG TAB (ULTRAM 250 $16.34 $0.00

7921141 METHADONE 10MG TAB 250 $12.03 $0.00

7921158 GABAPENTIN 400MG CAP (NEU 250 $20.91 $0.00

7921166 IBUTILIDE 0.1MG/ML INJ (C 250 J1742 $1,142.88 $0.00

7921174 BUPIVACAINE MPF 0.5% INJ 250 $56.06 $0.00

7921190 FLUVOXAMINE 50MG TAB (LUV 250 $30.46 $0.00

7921216 ZOLPIDEM 5MG TAB (AMBIEN 250 $22.36 $0.00

7921265 MORphine 15MG CR TAB (ORA 250 $16.58 $0.00

7921281 MYCOPHENOLATE 250MG CAP ( 250 J7517 $29.81 $0.00

7921307 ETHYL CHLOR AER 103.5ML 250 $97.24 $0.00

7921331 SUCRALFATE 1GM/10ML SUS(C 250 $14.88 $0.00

7921349 SODIUM CHLORIDE 3% NEB 15 250 A7019 $7.37 $0.00

7921372 VENLAFAXINE 37.5MG TAB ( 250 $21.86 $0.00

7921380 AMINOSYN-HF 8% SOLN 500ML 250 B4176 $654.01 $0.00

7921398 FLUCONAZOLE 400MG/200ML P 250 J1450 $633.20 $0.00

7921406 FLUOXETINE 20MG/5M LIQ (P 250 $20.44 $0.00

7921414 ENALAPRIL 20MG TAB (VASOT 250 $19.28 $0.00



Page 106 of 129

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12427

7921513 R&B 2HTU ICU 10MG/ML INJ (Z

ROCURONIUM 250 $176.03 $0.00

7921554 PERGOLIDE 0.05MG TAB (PER 250 $15.79 $0.00

7921596 CycloSPORINE 100MG CAP (N 250 J7502 $39.30 $0.00

7921604 MOEXIPRIL 15MG TAB (UNIVA 250 $17.36 $0.00

7921620 FOSPHENYTOIN 50MG/ML INJ 250 Q2009 $143.97 $0.00

7921638 POTASSIUM CHL 20MEQ/100ML 250 J3480 $73.50 $0.00

7921661 AMANTADINE 50MG/5ML SYRUP 250 $8.09 $0.00

7921679 CEFTIZOXIME 1GM ADV (CEFI 250 J0715 $78.09 $0.00

7921687 ANASTROZOLE 1MG TAB (ARIM 250 $55.21 $0.00

7921695 CEFTIZOXIME 2GM ADV (CEFI 250 J0715 $129.53 $0.00

7921703 ZAFIRLUKAST 20MG TAB (ACC 250 $17.78 $0.00

7921711 NEFAZODONE 100MG TAB (SER 250 $19.65 $0.00

7921729 TRAZODONE 100MG TAB 250 $12.18 $0.00

7921752 FLUTICASONE 220MCG INH (F 250 $329.65 $0.00

7921786 LAMIVUDINE 150MG TAB (EPI 250 $39.26 $0.00

7921802 LAMOTRIGINE 100MG TAB (LA 250 $37.77 $0.00

7921810 MESALAMINE 250MG C CAP (P 250 $12.50 $0.00

7921836 GLY-OXIDE 10% SOLN 15ML 250 $39.64 $0.00

7921844 MESNA 1GM INJ (MESNEX) 10 250 J9209 $750.02 $0.00

7921869 LIDOCAINE 2% GEL (XYLOCAI 250 $53.27 $0.00

7921877 CHILDREN'S SUDAFED 15MG/5 250 $41.33 $0.00

7921885 IMPACT 1.5 LIQ 250ML 250 $75.13 $0.00

7921893 ISOSOURC HN LIQ 1000MLS 250 $87.83 $0.00

7921927 BACITRACIN/POLYMYXIN OINT 250 $9.75 $0.00

7921935 PYRIDOSTIGMINE 180MG TAB 250 $17.99 $0.00

7921943 MOLINDONE 10MG TAB (MOBAN 250 $21.84 $0.00

7921950 AMIFOSTINE 500MG INJ (ETH 250 J0207 $1,463.78 $0.00

7921968 TANNIC ACID POWDER 125GM 250 $90.63 $0.00

7921976 DESMOPRESSIN 4MCG/ML INJ 250 J2597 $177.51 $0.00

7921984 CEFUROXIME 1.5GM INJ (ZIN 250 J0697 $78.19 $0.00

7922032 FENTANYL 100MCG PATCH (DU 250 $228.71 $0.00

7922040 MAGNESIUM OXIDE 400MG TAB 250 $7.79 $0.00

7922081 LATANOPROST 0.005% OP (XA 250 $234.15 $0.00

7922099 BICALUTAMIDE 50MG TAB (CA 250 $95.98 $0.00

7922115 OFLOXACIN 0.3% OP SOLN (O 250 $187.31 $0.00

7922123 M.V.I. -12 INJ 10ML 250 $53.65 $0.00

7922149 LEUCOVORIN 100MG INJ 250 J0640 $36.75 $0.00

7922172 OYSTER-CAL 500MG TAB (OS 250 $7.24 $0.00

7922180 OPTICHAMBER FACE MASK 250 $20.00 $0.00

7922198 AMOX/CLAV 875MG TAB (AUGM 250 $44.95 $0.00

7922248 TIMOLOL GEL 0.5% OP SOLN 250 $111.37 $0.00

7922255 INDINAVIR 400MG CAP (CRIX 250 $29.36 $0.00

7922263 REMIFENTANIL INJ 1MG (ULT 250 $83.48 $0.00

7922271 ATORVASTATIN 10MG TAB (LI 250 $27.37 $0.00

7922289 MAGNESIUM SULF 50% INJ 10 250 J3475 $13.61 $0.00

7922305 VALPROATE 100MG/ML INJ (D 250 $92.44 $0.00

7922313 BOTOX 100U INJ 250 J0585 $2,147.06 $0.00

7922354 DICLOFENAC 0.1% OP SOL (V 250 $243.51 $0.00

7922362 CARVEDILOL 3.125MG TAB (C 250 $21.70 $0.00



Page 107 of 129

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12427

7922370 R&B 2HTU ICU 14.7GM

COMBIVENT INH 250 $351.31 $0.00

7922396 ZIAC 5/6.25MG TAB 250 $17.03 $0.00

7922404 OCUPRESS 1% OP SOL 5ML 250 $180.24 $0.00

7922412 AZITHROMYCIN 500MG INJ (Z 250 J0456 $178.90 $0.00

7922420 CHLOROTHIAZIDE 500MG TAB 250 $8.79 $0.00

7922446 KETOROLAC 0.5% OP SOL (AC 250 $254.51 $0.00

7922453 BETAMETHASONE VAL 0.1% CR 250 $54.39 $0.00

7922461 MedroxyPROGESTERone 150MG 250 J1055 $205.06 $0.00

7922479 ENULOSE 10GM/15 SYP 473ML 250 $15.12 $0.00

7922487 ZOSYN 3.375GM INJ. 250 J2543 $107.57 $0.00

7922495 DONEPEZIL 5MG TAB (ARICEP 250 $37.38 $0.00

7922503 LANSOPRAZOLE 15MG DR CAP 250 J1956 $34.58 $0.00

7922529 PRAMIPEXOLE 0.25MG TAB (M 250 $16.26 $0.00

7922537 PERGOLIDE 0.25MG TAB (PER 250 $21.59 $0.00

7922545 LEVOFLOXACIN 500MG TAB (L 250 $71.97 $0.00

7922552 TROPICAMIDE 1% OP SOL (MY 250 $263.24 $0.00

7922560 FLUTICASONE 0.05% SPR (FL 250 $318.27 $0.00

7922586 AMLACTIN 12% CREAM (LAC-H 250 $127.71 $0.00

7922685 OMEPRAZOLE 10MG CR CAP (P 250 $36.14 $0.00

7922735 VALSARTAN 80MG TAB (DIOVA 250 $19.36 $0.00

7922743 GEMCITABINE 200MG INJ (GE 250 J9201 $585.01 $0.00

7922750 GEMCITABINE 1GM INJ (GEMZ 250 J9201 $2,650.06 $0.00

7922768 TOPOTECAN 4MG/ML INJ (HYC 250 J9350 $3,721.95 $0.00

7922776 OLANZAPINE 5MG TAB (ZYPRE 250 $50.03 $0.00

7922792 SOD LACTATE 5MEQ/ML INJ 1 250 $23.21 $0.00

7922800 ONE TOUCH BASIC SYSTEM 250 $70.00 $0.00

7922826 PETROLATUM GEL 5GM 250 $7.73 $0.00

7922834 MINERAL OIL 480ML 250 $7.06 $0.00

7922891 RIFAMPIN 150MG CAP (RIFAD 250 $20.48 $0.00

7922925 OCTREOTIDE 500MCG/1ML INJ 250 J2354 $336.36 $0.00

7922933 FLUTICASONE 44MCG INH (FL 250 $241.36 $0.00

7922941 FLUTICASONE 110MCG INH (F 250 $208.18 $0.00

7922982 BuPROPion 150MG SR TAB (W 250 $27.12 $0.00

7923055 LEVOFLOX/DEX 500MG PREMIX 250 J1956 $248.48 $0.00

7923063 SOD HYPOCHLORITE SOLN 5.2 250 $7.85 $0.00

7923071 LEVOCARNITINE 330MG TAB ( 250 $13.81 $0.00

7923089 CLOBETASOL 0.05% OINT (TE 250 $411.22 $0.00

7923097 CLOBETASOL 0.05% CREAM 30 250 $196.69 $0.00

7923105 DEXAMETHASONE PHOS 4MG/ML 250 J1100 $14.66 $0.00

7923154 DOLASETRON 12.5MG/0.625ML 250 J1260 $165.64 $0.00

7923162 LANSOPRAZOLE 30MG DR CAP 250 $35.11 $0.00

7923188 VITAMIN B-12 500MCG TAB 250 $7.30 $0.00

7923196 NISOLDIPINE 10MG CR TAB ( 250 $16.83 $0.00

7923212 MONTELUKAST 10MG TAB (SIN 250 $32.46 $0.00

7923261 NOREPINEPHRINE 1MG/ML INJ 250 $65.25 $0.00

7923287 MUPIROCIN 2% CREAM (BACTR 250 $224.04 $0.00

7923311 ZIAC 2.5/6.2MG TAB 250 $17.03 $0.00

7923337 RANITIDINE 25MG/ML INJ (Z 250 J2780 $35.13 $0.00

7923352 TOLTERODINE 2MG TAB (DETR 250 $21.82 $0.00



Page 108 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7923410 R&B 2HTU ICU

EURAX 10% CREAM 60GM 250 $77.67 $0.00

7923477 BISOPROLOL FUM 5MG TAB (Z 250 $17.03 $0.00

7923485 ZOSYN 4.5GM ADVANTAGE 250 J2543 $133.76 $0.00

7923493 FLEET PHOS SODA-FL SOLN 4 250 $20.04 $0.00

7923501 FLEET ENEMA 133ML 250 $14.05 $0.00

7923519 ENOXAPARIN 80MG/0.8ML INJ 250 J1650 $225.57 $0.00

7923535 CEFEPIME 1GM INJ (MAXIPIM 250 J0692 $91.32 $0.00

7923543 PYRIDOSTIGMINE 60MG/5M SY 250 $8.12 $0.00

7923584 VITAMIN A D OINTMENT 454G 250 $57.26 $0.00

7923618 ALCOHOL/D5W 10% INJ 1000M 250 $512.99 $0.00

7923626 LEUPROLIDE 3.75MG INJ (LU 250 J1950 $2,236.48 $0.00

7923642 OXAZEPAM 15MG CAP (SERAX) 250 $14.68 $0.00

7923659 SALSALATE 500MG TAB 250 $9.34 $0.00

7923683 TACROLIMUS 1MG CAP (PROGR 250 J7507 $29.92 $0.00

7923691 GLIMEPIRIDE 2MG TAB (AMAR 250 $11.81 $0.00

7923709 RALOXIFENE 60MG TAB (EVIS 250 $30.68 $0.00

7923717 HYDROCODONE/APAP 10-500MG 250 $12.70 $0.00

7923733 SODIUM THIOSULFATE CRYSTA 250 $79.88 $0.00

7923758 POTASSIUM CHL 8MEQ TAB 250 $8.53 $0.00

7923766 POTASSIUM CITRATE 540MG T 250 $9.34 $0.00

7923774 RIMEXOLONE 1% OP SUSP (VE 250 $140.57 $0.00

7923790 IRBESARTAN 150MG TAB (AVA 250 $19.92 $0.00

7923816 TOLTERODINE 1MG TAB (DET 250 $21.44 $0.00

7923824 CARVEDILOL 25MG TAB (CORE 250 $21.70 $0.00

7923832 MINOXIDIL 2.5MG TAB 250 $11.14 $0.00

7923840 PALIVIZUMAB 100MG INJ (SY 250 C9003 $5,386.86 $0.00

7923857 LEVOCARNITINE 100MG/ML SO 250 J1955 $9.06 $0.00

7923865 GLAUCON 2% OP SOLN 10ML 250 $178.92 $0.00

7923873 MIRTAZAPINE 15MG TAB (REM 250 $32.55 $0.00

7923899 EPTIFIBATIDE 20MG/10ML IN 250 J1327 $336.34 $0.00

7923907 EPTIFIBATIDE 75MG/100ML(I 250 J1327 $1,037.72 $0.00

7923915 MIDAZOLAM 2MG/ML SYRUP (V 250 J2250 $15.79 $0.00

7924004 OLOPATADINE 0.1% OP SOLN 250 $310.58 $0.00

7924038 CANDESARTAN 8MG TAB (ATA 250 $19.83 $0.00

7924046 SUMATRIPTAN 20MG NS SPR ( 250 $175.44 $0.00

7924053 HEPATITIS A VACC (HAVRIX) 250 $254.20 $0.00

7924079 CELECOXIB 100MG CAP (CELE 250 $21.96 $0.00

7924087 CELECOXIB 200MG CAP (CELE 250 $31.55 $0.00

7924103 CLOPIDOGREL 75MG TAB (PLA 250 $41.32 $0.00

7924145 DESFLURANE INHALATION 240 250 $55.91 $0.00

7924236 DESONIDE 0.05% OINT 15GM 250 $88.83 $0.00

7924293 PrednisoLONE 15MG/5ML SYR 250 J7510 $28.15 $0.00

7924301 FENOLDOPAM 10MG/ML INJ (C 250 $845.37 $0.00

7924319 ISOXSUPRINE 10MG TAB 250 $9.92 $0.00

7924335 TOPIRAMATE 25MG CAP (TOP 250 $22.96 $0.00

7924343 LAMOTRIGINE 25MG TAB (LAM 250 $36.06 $0.00

7924350 BuPROPion 100MG TAB (WELL 250 $22.75 $0.00

7924376 LEPIRUDIN 50MG INJ (REFLU 250 Q2021 $517.75 $0.00

7924392 BECLOMETHASONE 84MCG INH 250 $101.03 $0.00



Page 109 of 129

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12427

7924400 R&B 2HTU ICU

GABAPENTIN 100MG CAP (NEU 250 $11.63 $0.00

7924426 CEFPODOXIME 200MG TAB (VA 250 $36.19 $0.00

7924434 NAPROXEN 250MG TAB 250 $12.64 $0.00

7924475 GABAPENTIN 300MG CAP (NEU 250 $18.59 $0.00

7924483 ISOSORBIDE MONO 30MG ER T 250 $22.82 $0.00

7924491 MISOPROSTOL 200MCG TAB (C 250 $18.45 $0.00

7924533 TAMSULOSIN 0.4MG CAP (FLO 250 $24.38 $0.00

7924541 LAMISIL AT 1% CRE 12GM 250 $51.91 $0.00

7924616 SUMATRIPTAN 25MG TAB (IMI 250 $118.49 $0.00

7924624 DICLOFENAC 75MG TAB (VOLT 250 $22.58 $0.00

7924665 LEVOTHYROXINE 88MCG TAB 250 $8.97 $0.00

7924814 BRINZOLAMIDE OPTH SUSP 1% 250 $215.32 $0.00

7924855 TELMISARTAN 40MG TAB (MIC 250 $19.14 $0.00

7924863 FLUCONAZOLE 40MG/ML SUSP 250 $122.28 $0.00

7924897 COSOPT 2-.5% OP SOLN 5ML 250 $238.96 $0.00

7924921 OPTISON 3ML INJ 250 $492.37 $0.00

7924947 TERAZOL 3 0.8% VAG CREAM 250 $201.11 $0.00

7924954 MIDODRINE 2.5MG TAB (PROA 250 $17.78 $0.00

7924988 HYZAAR 50-12.5MG TAB 250 $20.72 $0.00

7924996 AMITRIPTYLINE 100MG TAB ( 250 $14.83 $0.00

7925027 FLUCONAZOLE 10MG/ML SUSP 250 $38.74 $0.00

7925068 ALUM HYDROXIDE 320MG/5ML 250 $7.09 $0.00

7925084 PIOGLITAZONE 30MG TAB (AC 250 $40.15 $0.00

7925092 CILOSTAZOL 100MG TAB (PLE 250 $22.72 $0.00

7925118 BROMETANE DX SYP 473ML 250 $7.58 $0.00

7925126 FLUMAZENIL 0.1MG/ML INJ ( 250 $372.63 $0.00

7925134 CITALOPRAM 20MG TAB (CELE 250 $28.67 $0.00

7925142 MOMETASONE NASAL SPRAY (N 250 $280.85 $0.00

7925159 ANAGRELIDE 0.5MG CAP (AGR 250 $41.46 $0.00

7925167 CEFUROXIME 250MG/5ML SUSP 250 $32.70 $0.00

7925191 ROFECOXIB 25MG TAB (VIOXX 250 $29.26 $0.00

7925209 COLESTIPOL 1GM TAB (COLES 250 $11.91 $0.00

7925225 PARICALCITOL 5MCG/1ML INJ 250 J2501 $151.91 $0.00

7925233 DEXAMETHASONE 4MG/ML INJ 250 J1100 $48.46 $0.00

7925241 LEVALBUTEROL 0.63MG NEB ( 250 $29.03 $0.00

7925258 CAFFEINE CITRATE 20MG/ML 250 J0706 $246.05 $0.00

7925308 ENOXAPARIN 60MG/0.6ML INJ 250 J1650 $252.66 $0.00

7925316 ENOXAPARIN 40MG/0.4ML INJ 250 J1650 $170.57 $0.00

7925324 ROSIGLITAZONE 4MG TAB (AV 250 $32.45 $0.00

7925332 IRINOTECAN 20MG/ML INJ (C 250 J9206 $2,776.47 $0.00

7925365 KETOCONAZOLE 2% SHAMPOO ( 250 J1956 $170.35 $0.00

7925373 AMPHOTERICIN B LIPID COMP 250 J0287 $854.20 $0.00

7925399 MOXIFLOXACIN 400MG TAB (A 250 $63.61 $0.00

7925407 MUPIROCIN NASAL 2% OINT ( 250 $47.59 $0.00

7925449 TRIAMCINOLONE 0.1% OINT 4 250 $7.31 $0.00

7925464 LEVALBUTEROL 1.25MG/3ML N 250 $29.03 $0.00

7925472 CYANIDE ANTIDOTE KIT 250 $976.19 $0.00

7925498 ALTEPLASE 50MG INJ (ACTI 250 J2997 $6,376.99 $0.00

7925506 FINGER STICK BLOOD SUGAR 250 $7.50 $0.00



Page 110 of 129

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12427

7925530 R&B 2HTU ICU INJ.

ZOSYN 2.25GM 250 J2543 $74.64 $0.00

7925548 GATIFLOXACIN 10MG/ML INJ 250 J1590 $208.23 $0.00

7925563 METAXALONE 400MG TAB (SKE 250 $16.89 $0.00

7925571 MANNITOL 20% INJ 500MLS 250 J2150 $113.27 $0.00

7925597 CHO MAG TRIS 500MG TAB (T 250 $14.60 $0.00

7925605 QVAR 80MCG AER 250 J7622 $280.36 $0.00

7925621 ENOXAPARIN 100MG/1ML INJ 250 J1650 $280.20 $0.00

7925639 MIDAZOLAM 1MG/ML INJ 2ML 250 J2250 $11.85 $0.00

7925647 QUETIAPINE 25MG TAB (SERO 250 $22.01 $0.00

7925654 PRAZOSIN HCL 2MG CAP 250 $9.69 $0.00

7925696 AGGRENOX 25-200MG CAP 250 $24.34 $0.00

7925704 DIABETIC TUSSIN DM LIQ 11 250 $7.22 $0.00

7925712 PANTOPRAZOLE 40MG TAB (PR 250 $36.78 $0.00

7925720 COMBIVIR TAB 250 $61.44 $0.00

7925738 IMOVAX RABIES 2.5IU/ML IN 250 90675 $698.66 $0.00

7925746 REPAGLINIDE 0.5MG TAB (PR 250 $16.80 $0.00

7925753 LINEZOLID 600MG/300ML INJ 250 J2020 $328.22 $0.00

7925811 RABEPRAZOLE 20MG TAB (ACI 250 $34.88 $0.00

7925837 TOPIRAMATE 25MG TAB (TOPA 250 $20.96 $0.00

7925878 REPAGLINIDE 2MG TAB (PRAN 250 $16.80 $0.00

7925902 HEPARIN SOD 1,000 UNITS/M 250 J1644 $30.79 $0.00

7925936 ALENDRONATE 70MG TAB (FOS 250 $118.48 $0.00

7925951 HALOPERIDOL 5MG TAB (HALD 250 $12.49 $0.00

7925977 PANTOPRAZOLE 40MG INJ (PR 250 C9113 $165.70 $0.00

7926009 OPREVEKIN 5MG INJ (NEUMEG 250 J2355 $1,087.18 $0.00

7926025 VENLAFAXINE 25MG TAB (EFF 250 J2355 $21.43 $0.00

7926033 HUMALOG PEN 75/25 INJ 3ML 250 J1815 $178.06 $0.00

7926058 QUETIAPINE 100MG TAB (SER 250 $32.76 $0.00

7927007 ESTRATEST TAB (1.25/2.5) 250 $26.79 $0.00

7927057 METRONIDAZOLE 0.75% VAG. 250 $295.78 $0.00

7927114 LOTRISONE LOTION 30ML 250 $244.74 $0.00

7927155 OXCARBAZEPINE 300MG TAB ( 250 $25.05 $0.00

7927163 METHENAMINE 1GM TAB 250 $10.73 $0.00

7927254 RISPERIDONE 0.25MG TAB (R 250 $32.49 $0.00

7927551 BUDESONIDE .25MG/2ML RESP 250 J7626 $35.25 $0.00

7927601 BUDESONIDE 0.5MG/2ML RESP 250 J7626 $38.39 $0.00

7927650 CIMETIDINE 150MG/ML INJ 8 250 $42.25 $0.00

7927700 MILK OF MAGNESIA SUSP 30M 250 $9.29 $0.00

7927809 PILOCARPINE 5MG TAB (SALA 250 $19.69 $0.00

7927908 PRAMIPEXOLE 0.125MG TAB ( 250 $14.27 $0.00

7928005 TERCONAZOLE 80MG SUPP (TE 250 $201.11 $0.00

7928021 VENLAFAXINE XR 75MG CAP ( 250 $32.87 $0.00

7928039 OSCAL 500 + D TAB 250 $7.54 $0.00

7928047 GATIFLOXACIN 400MG/200ML 250 J1590 $256.23 $0.00

7928054 VITRON-C TAB 250 $8.11 $0.00

7928062 AMINOPHYLLINE 100MG TAB 250 $7.42 $0.00

7928088 OXYBUTYNIN XL 5MG TAB (DI 250 $32.75 $0.00

7928104 NEPHROCAPS CAP 250 $9.13 $0.00

7928112 GUAIFENESIN 7.5/5ML SYP ( 250 $8.35 $0.00



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12427

7928120 R&B 2HTU ICU TAB

NIACIN 250MG 250 $7.26 $0.00

7928146 B O 16-A SUPPRETTES 250 $34.73 $0.00

7928187 CALCIUM CARB 650MG TAB 250 $7.82 $0.00

7928195 VENLAFAXINE XR 37.5MG CAP 250 $30.08 $0.00

7928203 PATIENTS OWN MED 250 $5.00 $0.00

7928229 RIVASTIGMINE 1.5MG CAP (E 250 $29.92 $0.00

7928310 CALMOSEPTINE OINTMENT 113 250 $42.25 $0.00

7928336 GUAIFEN/PSEUDO 600MG/120M 250 $16.95 $0.00

7928369 WHISKEY 30ML 250 $7.00 $0.00

7928377 COLESEVELAM 625MG TAB (WE 250 $14.40 $0.00

7928385 PERPHENAZINE 16MG TAB 250 Q0176 $17.83 $0.00

7928393 VERAPAMIL SR 120MG TAB (C 250 $19.88 $0.00

7928435 HELIDAC MIS 250 $40.73 $0.00

7928443 OXYCODONE 20MG CR TAB (OX 250 $32.87 $0.00

7928450 HYOSCYAMINE 0.375MG ER TA 250 $17.16 $0.00

7928492 SPIRONOLACTONE 50MG TAB ( 250 $17.23 $0.00

7928500 ATACAND HCT 16-12.5MG TAB 250 $24.37 $0.00

7928518 LEVETIRACETAM 500MG TAB ( 250 $26.75 $0.00

7928534 POLY-VI-SOL/IRON DROPS 50 250 $49.58 $0.00

7928542 ZIAC 10/6.25MG TAB 250 $17.03 $0.00

7928567 PHENOBARBITAL 20MG/5ML EL 250 $10.11 $0.00

7928583 SEVELAMER 800MG TAB (RENA 250 $18.93 $0.00

7928591 QVAR 40MCG AER 250 J7622 $223.91 $0.00

7928609 BuPROPion SR 100MG TAB (W 250 $25.78 $0.00

7928617 FELODIPINE 2.5MG SA TAB ( 250 $15.58 $0.00

7928633 GlipiZIDE XL 2.5MG TAB (G 250 $10.82 $0.00

7928666 LEVOTHROID 137MCG TAB 250 $9.29 $0.00

7928690 THEOPHYLLINE 300MG TR TAB 250 $9.19 $0.00

7928708 THEOPHYLLINE 200MG ER TAB 250 $9.57 $0.00

7928716 TENECTEPLASE 50MG KIT (TN 250 J3100 $10,305.70 $0.00

7928732 CARISOPRODOL 350MG TAB 250 $11.23 $0.00

7928757 CALCIUM CITRATE 200MG TAB 250 $7.31 $0.00

7928765 CLINDAMYCIN 1% LOT (CLEOC 250 $260.59 $0.00

7928773 NATEGLINIDE 120MG TAB (ST 250 $17.18 $0.00

7928799 ESOMEPRAZOLE 40MG CAP (NE 250 $34.89 $0.00

7928815 BACITRACIN ZINC 500U/GM O 250 $8.41 $0.00

7928823 ZOLPIDEM 10MG TAB (AMBIEN 250 $24.99 $0.00

7928831 ENTACAPONE 200MG TAB (COM 250 $24.40 $0.00

7928849 LEUPROLIDE 7.5MG INJ (LUP 250 J1950 $2,676.53 $0.00

7928898 ESOMEPRAZOLE 20MG CAP (N 250 $34.89 $0.00

7928914 FLUOROURACIL 5% CREAM (EF 250 $416.23 $0.00

7928922 ADVAIR DISKUS 100/50 #28 250 $374.43 $0.00

7928930 CLOTRIMAZOLE 1% CREAM 30G 250 $77.88 $0.00

7928963 HEPARIN SOD 1,000 UNITS/M 250 J1644 $32.99 $0.00

7928971 VICOPROFEN 200MG/7.5MG TA 250 $17.11 $0.00

7928989 RACEPINEPHRINE 2.25% INH 250 $8.32 $0.00

7928997 ENOXAPARIN 120MG/0.8ML IN 250 J1650 $334.96 $0.00

7929003 AMMONIUM LACT 12% LOT 225 250 $103.49 $0.00

7929011 ERTAPENEM 1GM INJ (INVANZ 250 $214.74 $0.00



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12427

7929037 R&B 2HTU ICU

BUDESONIDE 32MCG INH (RHI 250 $251.13 $0.00

7929045 HydrOXYzine 25MG/1ML INJ 250 J3410 $12.20 $0.00

7929052 HydrOXYzine 50MG/ML INJ 2 250 J3410 $16.07 $0.00

7929078 MOXIFLOXACIN 400MG INJ (A 250 $238.43 $0.00

7929086 OXYCODONE 10MG CR TAB (OX 250 $21.13 $0.00

7929128 LINEZOLID 100MG/5ML SUSP 250 $23.68 $0.00

7929151 ADVAIR DISKUS 500/50 #28 250 $647.73 $0.00

7929169 KETOROLAC 15MG/1ML INJ 250 J1885 $20.21 $0.00

7929185 KETOROLAC 60MG/2ML INJ 250 J1885 $21.80 $0.00

7929193 KETOROLAC 30MG/1ML INJ 250 J1885 $20.74 $0.00

7929201 THIAMINE HCL 100MG TAB 250 $7.19 $0.00

7929219 POTASSIUM CHL 10% SF LIQ 250 $9.78 $0.00

7929227 PROGESTERONE 50MG/ML INJ 250 J2675 $204.74 $0.00

7929235 PROMETHAZINE 25MG/1ML INJ 250 J2550 $23.83 $0.00

7929250 STREPTOMYCIN 1GM INJ 250 J3000 $58.57 $0.00

7929268 MORphine SULF 2MG/ML INJ 250 J2270 $14.94 $0.00

7929292 METRONIDAZOLE 500MG TAB 250 $15.03 $0.00

7929300 HEPARIN SOD 1,000 UNITS/M 250 J1644 $14.58 $0.00

7929326 BECLOMETHASONE INH (BECON 250 $208.56 $0.00

7929334 CycloSPORINE 25MG CAP (NE 250 J7515 $16.70 $0.00

7929342 NITROGLYCERIN 2% OINT (NI 250 $12.13 $0.00

7929359 PHENYTOIN 100MG/4ML SUSP 250 $16.80 $0.00

7929367 SOD POLYSTYRENE 15GM/60ML 250 $52.75 $0.00

7929383 GUAIFENESIN 100MG/5ML SYP 250 $10.73 $0.00

7929391 LIDOCAINE 2% VISC SOLN 20 250 $15.90 $0.00

7929409 GUAIFENESIN DM SYP (ROBI 250 $9.93 $0.00

7929425 LACTULOSE 20GM/30ML UD SY 250 $28.00 $0.00

7929433 LIOTHYRONINE 5MCG TAB (CY 250 $11.97 $0.00

7929441 ACETYLCYSTEINE 20% (MUCOM 250 J7608 $35.16 $0.00

7929573 KAOLIN/PECT SUSP 30ML 250 $10.45 $0.00

7929581 FIORICET/COD CAP 250 $26.44 $0.00

7929599 GUAIFENESIN W/COD SYRUP 1 250 $10.49 $0.00

7929615 PROMETHAZINE/COD 6.25/10 250 $14.09 $0.00

7929623 HYDROCODONE/APAP 7.5MG/50 250 $30.80 $0.00

7929656 LANSINOH 7GM OINT 250 $17.71 $0.00

7929672 DOCUSATE SOD 100MG/10ML L 250 $10.07 $0.00

7929680 METOCLOPRAMIDE 10MG/10ML 250 $11.36 $0.00

7929698 SUCRALFATE 1GM/10ML UD SU 250 $22.50 $0.00

7929706 HYDROCORTISONE 2.5% CREAM 250 $139.16 $0.00

7929748 VALPROIC ACID 250MG/5ML S 250 $22.23 $0.00

7929755 PRAZOSIN HCL 5MG CAP 250 $11.61 $0.00

7929763 LOPERAMIDE 2MG/10ML LIQ 1 250 $16.65 $0.00

7929789 TETRACAINE 0.5% OP SOLN 2 250 $43.36 $0.00

7929813 ALENDRONATE 35MG TAB (FOS 250 $118.48 $0.00

7929839 MESALAMINE 500MG SUPP (CA 250 $35.65 $0.00

7929847 CARVEDILOL 12.5MG TAB (CO 250 $21.70 $0.00

7929854 CARVEDILOL 6.25MG TAB (C 250 $21.70 $0.00

7929904 SIMVASTATIN 20MG TAB (ZOC 250 $35.92 $0.00

7929912 LYMPHAZURIN 1% INJ 250 $550.62 $0.00



Page 113 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7929920 R&B 2HTU ICU ELIXIR 5ML (

APAP/CODEINE 250 $10.74 $0.00

7929938 ROPINIROLE 0.25MG TAB (RE 250 $21.90 $0.00

7929946 LORazepam 2MG/ML INJ (ATI 250 J2060 $217.59 $0.00

7929961 LIDOCAINE/D5W 2GM/250ML P 250 J2001 $93.55 $0.00

7929987 BUMETANIDE 0.25MG/ML INJ 250 $40.06 $0.00

7930001 OPIUM 10% TINCTURE 250 $13.31 $0.00

7930035 BAYGAM VIAL 10ML 250 J1550 $459.29 $0.00

7930043 HYDROCODONE/APAP 10-325MG 250 $16.70 $0.00

7930068 DiphenhydrAMINE 12.5MG/5M 250 $10.60 $0.00

7930076 AZTREONAM 1GM INJ (AZACTA 250 $153.97 $0.00

7930084 AZTREONAM 2GM INJ (AZACTA 250 $202.79 $0.00

7930092 HALOPERIDOL 1MG TAB (HALD 250 $10.20 $0.00

7930100 CEFAZOLIN 10GM INJ (ANCEF 250 J0690 $19.16 $0.00

7930118 CEPHALEXIN 125MG/5ML SUSP 250 $9.77 $0.00

7930126 CEPHALEXIN 250MG/5ML SUSP 250 $12.55 $0.00

7930134 NITROFURANTOIN 25MG/5ML S 250 $10.01 $0.00

7930142 ALOMIDE 0.1% OP SOLN 10ML 250 $305.28 $0.00

7930159 ENOXAPARIN 30MG/0.3ML INJ 250 J1650 $129.69 $0.00

7930167 NYSTATIN 100000U SUSP 250 $8.99 $0.00

7930183 ERYTHROMYCIN ST 250MG TAB 250 $8.28 $0.00

7930191 POTASSIUM CHL 8MEQ ER T 250 $8.53 $0.00

7930209 BENAZEPRIL 10MG TAB (LOTE 250 $15.23 $0.00

7930225 AMOX/CLAV 200MG/5ML SUSP( 250 $10.62 $0.00

7934250 TIZANIDINE 4MG TAB (ZANAF 250 $18.47 $0.00

7934268 ATENOLOL 25MG TAB (TENORM 250 $18.06 $0.00

7934276 TOPIRAMATE 100MG TAB (TOP 250 $35.54 $0.00

7934292 KALETRA CAP 250 $38.18 $0.00

7934326 MELOXICAM 7.5MG TAB (MOBI 250 $31.82 $0.00

7934342 ADAPALENE 0.1% GEL (DIFFE 250 $230.18 $0.00

7934359 AMOX/CLAV 400MG/5ML SUSP( 250 $13.90 $0.00

7934383 IMATINIB 100MG CAP (GLEEV 250 $119.67 $0.00

7934391 CARBAMAZEPINE 100MG CHW T 250 $8.62 $0.00

7934409 BIMATOPROST 0.03% SOL (LU 250 $253.32 $0.00

7934425 IFOSFAMIDE 1GM INJ (IFEX) 250 J9208 $668.28 $0.00

7934433 DESIPRAMINE 10MG TAB (NOR 250 $12.82 $0.00

7934441 PROPOFOL 1% 100ML INJ (DI 250 $350.60 $0.00

7934466 MONTELUKAST 4MG CHW TAB ( 250 $32.46 $0.00

7934474 BUDESONIDE 200MCG INH (PU 250 $632.90 $0.00

7934482 LISINOPRIL 20MG TAB (ZEST 250 $16.66 $0.00

7934516 VINORELBINE 10MG/ML INJ ( 250 J9390 $2,178.41 $0.00

7934524 RISEDRONATE 5MG TAB (ACTO 250 $28.21 $0.00

7934557 TRAVOPROST 0.004% SOL (TR 250 $253.21 $0.00

7934573 SULFACETAMIDE OP SUSP (BL 250 $189.07 $0.00

7934581 HALOPERIDOL LAC 5MG/ML IN 250 J1630 $46.61 $0.00

7934599 NIASPAN 750MG ER TAB 250 $27.86 $0.00

7934607 RITUXIMAB 100MG INJ (RITU 250 J9310 $2,123.88 $0.00

7934615 ULTRACET 37.5MG/325MG TAB 250 $15.02 $0.00

7934623 DROTRECOGIN 20MG INJ (XIG 250 $4,468.03 $0.00

7934631 TOBRAMYCIN 300MG/5ML NEB 250 J7682 $236.95 $0.00



Page 114 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7934656 R&B 2HTU ICU

GLYCOPPROLATE 1MG TAB (RO 250 $20.46 $0.00

7934664 CLARITHROMYCIN 500MG XL T 250 $36.42 $0.00

7934680 LOTEPREDNOL 0.2% SUSP (AL 250 $191.30 $0.00

7934698 ESTRADIOL 25MCG TAB (VAGI 250 $30.74 $0.00

7934706 MODAFINIL 200MG TAB (PROV 250 $41.12 $0.00

7934714 LOTEPREDNOL 0.5% SUSP (LO 250 $220.98 $0.00

7934722 IMIQUIMOD 5% CREAM (ALDAR 250 $101.64 $0.00

7934763 FOLGARD RX 2.2 TAB 250 $11.47 $0.00

7934789 RIZATRIPTAN 10MG TAB (MAX 250 $115.47 $0.00

7934797 DIVALPROEX SPRINKLE 125MG 250 $12.39 $0.00

7934813 ESTROGEN (MENEST) 0.625MG 250 $12.32 $0.00

7934839 FLUVASTATIN XL 80MG TAB ( 250 $28.35 $0.00

7934854 METOPROLOL XL 25MG TAB (T 250 $13.82 $0.00

7934862 LEUPROLIDE ACETATE 30MG I 250 J1950 $10,438.11 $0.00

7934870 MIRTAZAPINE 30MG TAB (REM 250 $33.31 $0.00

7934888 LIOTHYRONINE 25MCG TAB (C 250 $13.53 $0.00

7934904 LINEZOLID 600MG TAB (ZYVO 250 $257.69 $0.00

7934920 DESMOPRESSIN 0.01% NASAL 250 $512.99 $0.00

7934938 ANGIOMAX 250MG INJ 250 $1,824.95 $0.00

7934946 TOLTERODINE LA 2MG CAP (D 250 $32.05 $0.00

7934953 FEMARA 2.5MG TAB 250 $58.75 $0.00

7934961 IODOSORB GEL CADEXOMER IO 250 $217.98 $0.00

7934987 POTASSIUM CHL 10% SF LIQ 250 $9.99 $0.00

7934995 ALBUTEROL 0.5% NEB 0.5ML 250 J7611 $10.57 $0.00

7935000 HUMALOG MIX 75/25 SUSP 250 J1815 $302.46 $0.00

7935026 CASPOFUNGIN ACETATE 50MG 250 J0637 $1,460.79 $0.00

7935034 GLYCERIN LIQUID 118ML 250 $32.30 $0.00

7935042 DIVALPROEX 125MG EC TAB ( 250 $12.24 $0.00

7935059 ZOLMITRIPTAN 2.5MG TAB (Z 250 $99.66 $0.00

7935075 CAPTOPRIL 12.5MG TAB 250 $12.44 $0.00

7935091 ROFECOXIB 12.5MG TAB (VIO 250 $29.26 $0.00

7935109 BETADINE 5% SPRAY 90GM 250 $52.07 $0.00

7935125 HEPARIN SOD 5,000 UNITS/M 250 J1644 $15.63 $0.00

7935133 VALCYCLOVIR 500MG TAB (VA 250 $38.69 $0.00

7935141 TACROLIMUS 0.1% OINT (PRO 250 $279.33 $0.00

7935166 CUROSURF 240MG/3ML SUSP 250 $2,361.50 $0.00

7935174 CUROSURF 120MG/1.5ML SUS 250 $1,209.67 $0.00

7935182 ClomiPRAMINE 50MG CAP (AN 250 $35.33 $0.00

7935190 LITHIUM CR 450MG TAB (ESK 250 $12.55 $0.00

7935208 POLY-VI-FLOR 0.25MG DROP 250 $77.56 $0.00

7935216 QUINAPRIL 5MG TAB (ACCUPR 250 $17.65 $0.00

7935232 INS GLARGINE 100 UNITS/ML 250 J1815 $281.81 $0.00

7935240 ADVAIR DISKUS 250/50 #28 250 $460.39 $0.00

7935257 LEVOFLOXACIN 250MG TAB (L 250 $63.69 $0.00

7935273 TERBINAFINE 250MG TAB (LA 250 $73.73 $0.00

7935281 RECOMBIVA-HB 10MCG/M PF I 250 $203.89 $0.00

7935299 LEVOFLOX/DEX 250MG PREMIX 250 J1956 $127.77 $0.00

7935331 TRAZODONE 50MG TAB 250 $9.99 $0.00

7935372 MULTITRACE-4 PED INJ 3ML 250 $15.81 $0.00



Page 115 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7935380 R&B 2HTU ICU

OXAZEPAM 10MG CAP (SERAX) 250 $13.13 $0.00

7935398 PROMETHAZINE 50MG SUPP 250 $43.36 $0.00

7935406 IMIPENEM AND CILASTATIN 5 250 J0743 $204.90 $0.00

7935414 DROPERIDOL 2.5MG/ML INJ 2 250 J1790 $16.60 $0.00

7935547 GATIFLOXACIN 200MG TAB (T 250 $63.42 $0.00

7935554 NITROGLYCERIN 0.4MG SL TA 250 $42.04 $0.00

7935570 RIZATRIPTAN 5MG TAB (MAXA 250 $115.47 $0.00

7935588 LEVOXYL 175MCG TAB 250 $9.81 $0.00

7935596 CIPROFLOXACIN OTIC SUSP ( 250 $354.28 $0.00

7935604 METFORMIN 1000MG TAB (GLU 250 $20.50 $0.00

7935612 MICONAZOLE 2% CREAM 30GM 250 $29.56 $0.00

7935646 SUMATRIPTAN 50MG TAB (IMI 250 $110.61 $0.00

7935653 RESERPINE 0.1MG TAB 250 $9.23 $0.00

7935661 ILEX SKIN PROTECT PST 250 $34.92 $0.00

7935679 PHENYTOIN 100MG/2ML INJ ( 250 J1165 $19.33 $0.00

7935687 AVITENE FLOUR POW 250 $389.43 $0.00

7935695 LAC-HYDRIN 12% LOT 400GM 250 $249.20 $0.00

7935703 PROPYLTHIOURACIL 50MG TAB 250 $8.11 $0.00

7935729 MAALOX PLUS X-STR SUS 30M 250 $10.60 $0.00

7935745 CEFTRIAXONE 250MG INJ (RO 250 J0696 $100.79 $0.00

7935752 CEFTRIAXONE 500MG INJ (RO 250 J0696 $171.67 $0.00

7935760 ZIPRASIDONE 40MG CAP (GEO 250 $35.92 $0.00

7935778 METFORMIN XR 500MG TAB (G 250 $13.69 $0.00

7935786 MORphine 60MG CR TAB (ORA 250 $36.29 $0.00

7935802 DICLOXACILLIN 250MG CAP ( 250 $17.76 $0.00

7935828 TENOFOVIR 300MG TAB 250 $104.54 $0.00

7935836 MIGLITOL 25MG TAB (GLYSE 250 $12.83 $0.00

7935919 ACETIC ACID .25% IRRIG SO 250 $40.39 $0.00

7935927 EPINEPHRINE 1:1000 SOL 30 250 $135.97 $0.00

7935968 AVITENE 35X35MM PAD 250 $81.32 $0.00

7935976 PENICILLN VK 250/5ML SOL 250 $7.89 $0.00

7936008 CALCIUM LACTATE 650MG TAB 250 $7.21 $0.00

7936032 COLY-MYCIN-S OTIC SUS 250 $236.48 $0.00

7936073 OPTICHAMBER FACE MA MIS 250 $59.90 $0.00

7936172 SODIUM BICARB POWDER 250 $7.18 $0.00

7936198 ACYCLOVIR 5% OINT (ZOVIRA 250 $309.55 $0.00

7936206 ASCRIPTIN RS TAB 250 $7.52 $0.00

7936222 BISMATROL 262MG CHEWABLE 250 $33.43 $0.00

7936248 CLONAZEPAM 0.5MG TAB 250 $12.62 $0.00

7936263 CONTAC SEVERE COLD FLU TA 250 $9.01 $0.00

7936305 LEUCOVORIN CA 100MG INJ 250 $205.56 $0.00

7936370 GONIOSOL OP SOL 250 $103.01 $0.00

7936388 GRANULEX SPRAY 56.7GM 250 $87.14 $0.00

7936404 IODINE 2% MILD TINCTURE 250 $66.72 $0.00

7936412 IPECAC SYRUP 30ML 250 $17.92 $0.00

7936461 PENICILLN VK 125/5ML SOL 250 $7.58 $0.00

7936529 FLUCONAZOLE 50MG TAB (DIF 250 $41.57 $0.00

7936545 OLANZAPINE (ZYPREXA) 5MG 250 $47.40 $0.00

7936560 ETODOLAC 400MG TAB (LODIN 250 $20.10 $0.00



Page 116 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7936578 R&B 2HTU ICU

IRINOTECAN (CAMPTOSAR) 40 250 J9206 $1,151.85 $0.00

7936586 ALTEPLASE (CATHFLO) 2MG I 250 $297.62 $0.00

7936610 DIP/TET PEDIATRIC INJ 0.5 250 $135.28 $0.00

7936628 PAROXETINE (PAXIL) 10MG T 250 $29.64 $0.00

7936651 HYOSCYAMINE 0.125MG/5ML E 250 $8.93 $0.00

7936669 SUMATRIPTAN (IMITREX) 5MG 250 $175.44 $0.00

7936677 FLUORESCEIN STRIPS OP 250 $8.03 $0.00

7936685 TEARS RENEWED OP SOL 250 $41.82 $0.00

7936693 FACTOR VIII (KOGENATE) 50 250 J7190 $2,137.70 $0.00

7936719 TRI-VIT/FLUORIDE 0.25MG D 250 $51.96 $0.00

7936727 PAROXETINE (PAXIL) CR 12. 250 $30.32 $0.00

7936743 L.E.T. SOLUTION 3ML 250 $54.61 $0.00

7936750 NEDOCROMIL (ALOCRIL) 2% O 250 $314.25 $0.00

7936768 DRONABINOL (MARINOL) 2.5M 250 $40.72 $0.00

7936784 MIDAZOLAM (VERSED) 50MG/1 250 J2250 $180.41 $0.00

7936792 NISOLDIPINE 20MG CR TAB 250 $16.36 $0.00

7936826 DOCUSATE SOD 250MG CAP 250 $7.48 $0.00

7936834 OXALIPLATIN (ELOXATIN) 50 250 J9263 $3,828.41 $0.00

7936842 ETOMIDATE 2MG/ML INJ (AMI 250 $129.33 $0.00

7936859 HYDROCERIN CRE 454GM 250 $62.43 $0.00

7936867 ALCOHOL 98% INJ 5ML 250 $202.06 $0.00

7936875 ZETIA (EZETIMIBE) 10MG TA 250 $28.18 $0.00

7936891 NYSTATIN 500,000U/5ML SUS 250 $15.27 $0.00

7936917 RITUXIMAB 500MG INJ (RITU 250 J9310 $10,344.05 $0.00

7936925 NASACORT AQ 55MCG/SPRAY N 250 $297.09 $0.00

7936933 GATIFLOXACIN 200MG/100ML 250 J1590 $150.22 $0.00

7936958 ISONIAZID (NYDRAZID) 100M 250 $885.97 $0.00

7936966 FML S.O.P. 0.1% OP OIN 250 $186.86 $0.00

7936982 ERYTHROMYCIN OP OIN 3.5GM 250 $37.31 $0.00

7936990 VENOFER 20MG/ML INJ 5ML 250 J1756 $249.86 $0.00

7937006 ATROPINE SUL 0.4MG/ML 20M 250 J0460 $28.15 $0.00

7937014 GENTAMICIN/NACL 80MG/100M 250 J1580 $85.54 $0.00

7937022 MAGNESIUM S04 50% 2ML INJ 250 J3475 $11.14 $0.00

7937030 VHC 2.25 VANILLA LIQ 250 $23.62 $0.00

7937048 JEVITY 1.5 CAL LIQ 1000ML 250 $41.22 $0.00

7937055 PEPTAMEN LIQ 1000ML 250 $215.63 $0.00

7937063 GLUCOSE 5GM TAB 250 $10.80 $0.00

7937071 PEPTAMEN 1.5 LIQ 1000ML 250 $215.83 $0.00

7937089 JEVITY 1.5 CAL LIQ 240ML 250 $16.84 $0.00

7937097 ROPIVACAINE HCL 2MG/ML 0. 250 J2795 $44.25 $0.00

7937105 ROPIVACAINE HCL 5MG/ML 0. 250 J2795 $83.65 $0.00

7937121 NOVOLOG INS ASPART 100 UN 250 J1815 $302.46 $0.00

7937139 CEFDINIR (OMNICEF) 300MG 250 $35.14 $0.00

7937147 QUININE SULFATE 260MG TAB 250 $11.94 $0.00

7937154 PNEUMOCOCCAL VACCINE (INF 250 $616.81 $0.00

7937162 AKWA TEARS OP OIN 3.5 GM 250 $34.35 $0.00

7937170 PIOGLITAZONE 15MG TAB (AC 250 $34.59 $0.00

7937188 FLUOCINONIDE 0.05% SOL 250 $151.25 $0.00

7937196 DiphenhydrAMINE 25MG CAP 250 $7.88 $0.00



Page 117 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7937212 R&B 2HTU ICU

TRIAMCINOLONE 0.5% OINT 1 250 $39.63 $0.00

7937238 DAKIN'S SOLN (FULL STR) 0 250 $39.42 $0.00

7937246 DAKIN'S SOLN (HALF STR) 0 250 $39.42 $0.00

7937253 CEFTIBUTEN 90MG/5ML SUSP 250 $39.27 $0.00

7937261 VORICONAZOLE 200MG INJ (V 250 J3465 $480.92 $0.00

7937279 THYROLAR-1 60MG TAB 250 $12.37 $0.00

7937287 MUPIROCIN 2% OINT (BACTRO 250 $218.98 $0.00

7937295 NUTRADERM THERAPEUTIC LOT 250 $43.20 $0.00

7937311 LOSARTAN 50MG TAB (COZAAR 250 $20.72 $0.00

7937337 HEMORRHOIDAL OINT.(PREPAR 250 $36.54 $0.00

7937345 ClomiPRAMINE 25MG CAP (AN 250 $12.89 $0.00

7937378 AMLODIPINE 10MG TAB (NORV 250 $24.31 $0.00

7937386 ESCITALOPRAM 10MG TAB (LE 250 $27.17 $0.00

7937394 PEN G BENZATHINE 2.4 MMU 250 J0580 $344.58 $0.00

7937428 KENALOG-40 40MG/ML INJ 5M 250 J3301 $207.75 $0.00

7937436 DDAVP 0.1MG TAB (DESMOPRE 250 $32.67 $0.00

7937444 COMPOUNDED MEDICATION 250 $7.00 $0.00

7937451 ARGATROBAN 100MG/ML INJ 2 250 $4,028.87 $0.00

7937469 LAMIVUDINE 100MG TAB (EPI 250 $54.71 $0.00

7937477 TRIAZOLAM 0.125MG TAB 250 $11.51 $0.00

7937485 TPN, ADULT (PER 1000ML) 250 $731.15 $0.00

7937493 TPN, NEONATE (PER 100ML) 250 $642.90 $0.00

7937501 CEFDINIR 125MG/5ML SUSP 250 $36.63 $0.00

7937519 BETAMETHASONE AUG 0.05% C 250 $184.20 $0.00

7937527 TACROLIMIS 0.5MG CAP 250 J7507 $23.00 $0.00

7937535 DIVALPROEX ER 500MG TAB ( 250 $25.11 $0.00

7937550 AMIODARONE 50MG/ML INJ 18 250 J0282 $86.35 $0.00

7937568 VISIPAQUE 320MG/ML INJ 10 250 Q9949 $442.81 $0.00

7937584 EMP PCA VIAL 30ML MIS 250 $55.02 $0.00

7937592 LEFLUNOMIDE 10MG TAB (ARA 250 $111.74 $0.00

7937600 ATORVASTATIN 20MG TAB (LI 250 $37.51 $0.00

7937618 ATORVASTATIN 40MG TAB (LI 250 $36.05 $0.00

7937626 DROTRECOGIN ALFA 5MG INJ 250 $1,122.26 $0.00

7937642 VORICONAZOLE 200MG TAB 250 $211.62 $0.00

7937667 TERAZOL 7 0.4% CREAM 45 G 250 $201.11 $0.00

7937675 BREVIBLOC HCL 2500MG/250M 250 $453.80 $0.00

7937683 POLIOVIRUS VACCINE INACTI 250 $206.85 $0.00

7937691 HAEMOPHILUS B CONJUGATE V 250 $150.04 $0.00

7937709 CEFEPIME HCL 2GM INJ (MAX 250 J0692 $230.78 $0.00

7937717 PEDIARIX 0.5ML INJ 250 $319.08 $0.00

7937733 ASCORBIC ACD 500MG/ML INJ 250 $73.12 $0.00

7937758 CEFTRIAXONE 100MG/ML SYR 250 J0696 $235.42 $0.00

7937774 CEFUROXIME 100MG/ML SYR 250 J0697 $64.48 $0.00

7937782 HYDROCERIN MOISTURIZING C 250 $33.71 $0.00

7937790 LR 1L + PITOCIN 15 UNITS 250 $97.00 $0.00

7937808 DUTASTERIDE 0.5MG CAPULES 250 $29.42 $0.00

7937816 DISTILLED VINEGAR 1 ML 250 $7.02 $0.00

7937824 OXYTOCIN 10UNITS/ML INJ 1 250 J2590 $254.96 $0.00

7937832 LIDOCAINE 5% PATCH 250 $40.17 $0.00



Page 118 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7937840 CALCIUM ICU

R&B 2HTUGLUCONATE 10% INJ 250 $30.08 $0.00

7937857 VITAMIN B-12 100MCG TAB 250 $7.19 $0.00

7937865 MULTITRACE-4 CONC INJ 10 250 $15.76 $0.00

7937881 CASPOFUNGIN 70MG INJ 250 J0637 $1,460.79 $0.00

7937899 LANSOPRAZOLE 15MG SOLUTAB 250 $32.08 $0.00

7937907 LANSOPRAZOLE 30MG SOLUTAB 250 $32.08 $0.00

7937915 BETAXOLOL 0.5% OPHTH. SOL 250 $145.38 $0.00

7937923 METOPROLOL 25MG TAB (LOPR 250 $8.90 $0.00

7937931 ZIPRASIDONE HCL 60MG CAP 250 $38.50 $0.00

7937956 DOLASETRON INJ 100MG/5ML 250 J1260 $618.25 $0.00

7937964 ROSUVASTATIN 20MG TAB (CR 250 $30.14 $0.00

7937972 CYTARABINE 100MG/ML INJ ( 250 $360.00 $0.00

7937980 EDROPHONIUM CL 10MG/ML IN 250 $63.86 $0.00

7937998 TIOTROPIUM BR 18MCG CAP ( 250 $201.93 $0.00

7938004 MEMANTINE 10MG TAB (NAMEN 250 $25.21 $0.00

7938012 CALCIPOTRIENE 0.005% OIN 250 $515.00 $0.00

7938020 CLIMARA 0.075MG/DAY PATCH 250 $60.64 $0.00

7938038 M-M-R II LIVE INJ 250 $194.09 $0.00

7938046 LEVALBUTEROL 1.25MG/0.5ML 250 $29.03 $0.00

7938053 INTERFERON A 18MILLU INJ 250 J9213 $1,084.88 $0.00

7938061 PHENYLEPHRINE 2.5% OPH SO 250 $35.90 $0.00

7938079 PREVACID I.V 30MG INJ 250 $157.50 $0.00

7938087 LIDOCAINE 4% PF SOLN 5ML 250 $23.30 $0.00

7938095 INSULIN ASPART 70/30 10ML 250 J1815 $302.46 $0.00

7938103 TEGASEROD 6MG TAB (ZELNOR 250 $27.70 $0.00

7938111 GUAIFEN/PSEUDO 600MG/30MG 250 $15.05 $0.00

7938137 LEVOFLOXACIN 750MG TAB (L 250 $128.69 $0.00

7938145 LEVOFLOX/D5W 750MG PREMIX 250 J1956 $220.88 $0.00

7938152 PEMETREXED 500MG INJ 250 J9305 $9,046.97 $0.00

7938178 POTASSIUM CHLORIDE 2MEQ/M 250 J3480 $10.96 $0.00

7938186 HALOPERIDOL DECAN 100MG/M 250 J1631 $322.01 $0.00

7938194 GASTROVIEW UD SOLN 5ML 250 $14.66 $0.00

7938202 ROPINIROLE 4MG TAB (REQUI 250 $25.12 $0.00

7938210 CINACALCET 30MG TAB 250 $65.98 $0.00

7938228 SIROLIMUS 1MG TAB (RAPAMU 250 $53.33 $0.00

7938236 ITRACONAZOLE 250MG KIT 250 $791.71 $0.00

7938244 MYCOPHENOLATE 500MG INJ ( 250 $210.37 $0.00

7938251 TACROLIMUS 5MG/ML INJ (PR 250 $609.83 $0.00

7938269 FENTANYL CIT 100MCG/2ML I 250 J3010 $10.34 $0.00

7938277 MORphine SULFATE 4MG/ML I 250 J2270 $14.93 $0.00

7938285 WARFARIN 4MG TAB (COUMADI 250 $13.25 $0.00

7938293 WARFARIN 3MG TAB (COUMADI 250 $13.49 $0.00

7938301 ROPINIROLE 1MG TAB (REQUI 250 $21.90 $0.00

7938319 WARFARIN 6MG TAB (COUMADI 250 $15.68 $0.00

7938327 DIOVAN HCT 80MG/12.5MG TA 250 $20.30 $0.00

7938335 ACETAMINOPHEN 500MG TAB 250 $7.56 $0.00

7938343 ORAJEL 10% GEL 7GM (REG S 250 $40.14 $0.00

7938350 PROMETHAZINE VC/CODEINE S 250 $11.59 $0.00

7938368 CARBAMAZEPINE XR 100MG TA 250 $9.71 $0.00



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12427

7938376 R&B 2HTU ICU 0.25% INJ 30M

BUPIVACAINE 250 $23.30 $0.00

7938384 AEROCHAMBER PLUS MASK (SM 250 $91.64 $0.00

7938392 RANITIDINE IN NS 1MG/ML O 250 $21.06 $0.00

7938400 ENALAPRILAT 25 MCG/ML ORA 250 $32.89 $0.00

7938418 AMLODIPINE ORAL SUSP 1MG/ 250 $29.48 $0.00

7938426 METRONIDAZOLE 50MG/ML SUS 250 $20.84 $0.00

7938434 SPIRONOLACTONE 4MG/ML ORA 250 $13.51 $0.00

7938442 URSODIOL 25MG/ML SUSP 250 $34.25 $0.00

7938459 SPIRONOL/HCTZ 5MG/ML ORAL 250 $36.53 $0.00

7938475 FOLIC ACID 50MCG/ML SUSP 250 $16.44 $0.00

7938483 HYDROCHLOROT 5MG/ML SUSP 250 $22.99 $0.00

7938491 MORphine ORAL SOLN 0.4MG/ 250 $12.83 $0.00

7938509 CAPTOPRIL 1MG/ML SOLN 250 $21.53 $0.00

7938517 LORAZEPAM 0.5MG/ML ORAL S 250 $39.56 $0.00

7938525 VANCOMYCIN 50MG/ML SOLN 250 $30.38 $0.00

7938533 INSULIN REG 1 UNIT/ML INJ 250 J1815 $35.68 $0.00

7938558 CAFFEINE CITRATE ORAL 10M 250 $65.50 $0.00

7938566 EPLERENONE 25MG TAB 250 $34.76 $0.00

7938582 LEVOFLOXACIN 500MG INJ 250 J1956 $248.48 $0.00

7938590 OMEPRAZOLE 2MG/ML SUSPENS 250 $6.44 $0.00

7938608 ARIPIPRAZOLE 10MG TAB (AB 250 $74.77 $0.00

7938616 CycloSPORINE OPHTH. 0.05% 250 $32.94 $0.00

7938624 LANTHANUM CARBONATE 250MG 250 $15.37 $0.00

7938632 HYALURONIDASE 150UNIT/ML 250 J3470 $139.25 $0.00

7938640 LIDO/EPI PF 1.5% 5ML INJ 250 $28.77 $0.00

7938657 TESTOSTERONE TRANSDERMAL 250 $49.63 $0.00

7938665 HYDROCORTISONE IV 1MG/ML 250 $24.72 $0.00

7938673 TIAGABINE 2MG TAB (GABITR 250 $24.62 $0.00

7938681 DOXEPIN HCL 5% CREAM (ZON 250 $270.05 $0.00

7938699 METOCLOPRAMIDE 1MG/1ML OR 250 $8.41 $0.00

7938707 LIDOCAINE 5% IN DEXTROSE 250 $26.03 $0.00

7938715 ABREVA 10% CREAM 2.0GM 250 $79.73 $0.00

7938723 RIFAMPIN 10MG/ML ORAL SUS 250 $24.65 $0.00

7938731 FLOVENT HFA 110MCG INHALA 250 $417.82 $0.00

7938749 FLOVENT HFA 44MCG INHALAT 250 $313.86 $0.00

7938756 FLOVENT HFA 220MCG INHALA 250 $645.08 $0.00

7938764 COLLAGENASE OINTMENT 15GM 250 $194.42 $0.00

7938772 LICE TREATMENT MAXIUM STR 250 $33.97 $0.00

7938798 EPSOM SALT 250 $16.16 $0.00

7938806 HUMATE-P 2000UNIT INJ (F 250 $8,880.00 $0.00

7938814 CIPROFLOXACIN HCL 0.3%OP. 250 $244.85 $0.00

7938822 FENOFIBRATE 48MG TAB (Tri 250 $15.84 $0.00

7938830 HYDROCODONE/GUAIF 5-100/5 250 $10.23 $0.00

7938848 ACETADOTE 200MG/ML INJ. 3 250 $510.02 $0.00

7938855 RISEDRONATE SODIUM 35MG T 250 $118.46 $0.00

7938863 NITROBID 2% OINTMENT 60GM 250 $102.11 $0.00

7938871 DOLASETRON 100MG TAB (ANZ 250 $287.34 $0.00

7938889 MOXIFLOXACIN HCL 0.5% OP. 250 $220.14 $0.00

7938897 PANAFIL SPRAY LIQUID 33ML 250 $317.64 $0.00



Page 120 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7938905 R&B 2HTU ICU

TAMOXIFEN 20MG TAB (NOLVA 250 $33.58 $0.00

7938913 ACCUZYME SPRAY LIQUID 33 250 $199.56 $0.00

7938921 FENT(1MCG/ML)/BUPI 1/8(0. 250 $75.92 $0.00

7938939 FENT(2MCG/ML)/BUPI(1/16)/ 250 $84.66 $0.00

7938947 LAMINARIA JAPONICA CERVIC 250 $65.19 $0.00

7938954 LEVETIRACETAM 100MG/ML OR 250 $10.81 $0.00

7938962 ALBUTEROL 0.042% NEB 3ML 250 $18.70 $0.00

7938970 DAPTOMYCIN 500MG INJ. (CU 250 $721.29 $0.00

7938988 ZOVIA 1/35E TAB 250 $165.05 $0.00

7938996 FERRIC SUBSULFATE SOLUTIO 250 $9.94 $0.00

7939002 KALETRA ORAL SOLN (LOPINA 250 $72.81 $0.00

7939010 MONONINE 1000UNIT INJ (F 250 J7194 $4,419.50 $0.00

7939036 OYST-CAL-D 500MG TAB 250 $7.69 $0.00

7939044 BENICAR 20MG TAB 250 $19.33 $0.00

7939051 INFLIXIMAB 100MG INJ (REM 250 J1745 $2,443.72 $0.00

7939069 CARBIDOPA/LEVODOPA 25MG/1 250 $14.60 $0.00

7939077 UREA 40% CREAM 85.1 GM 250 $230.79 $0.00

7939085 SALMETEROL 50MCG INHALATI 250 $455.31 $0.00

7939093 DIGOXIN ELIXIR 0.05MG/ML 250 $10.96 $0.00

7939101 VITAMIN E 3000IU CREAM 2 250 $33.72 $0.00

7939119 BENGAY VANISHING SCENT NO 250 $30.26 $0.00

7939127 TRIMETHOBENZAMIDE 300MG C 250 $14.91 $0.00

7939135 LUBRISOFT UNSCENTED LOTIO 250 $36.04 $0.00

7939143 ENOXAPARIN 20MG/ML INJ 250 $211.82 $0.00

7939150 PALIVIZUMAB 50MG INJ. (SY 250 $2,856.09 $0.00

7939168 BECAPLERMIN 0.01% GEL (RE 250 $2,161.00 $0.00

7939176 LIDOCAINE/PRILOCAINE 2.5% 250 $49.30 $0.00

7939192 GENTIAN VIOLET 1% TOPICAL 250 $32.23 $0.00

7939200 (AMPHOTERICIN B)LIPOSOME 250 J0289 $699.76 $0.00

7939218 CLEOCIN VAGINAL CREAM 2% 250 $219.96 $0.00

7939226 FLUOCINONIDE 0.05% OINTME 250 $200.12 $0.00

7939234 DERMA-SMOOTHE/FS OIL(Fluo 250 $208.74 $0.00

7939242 DESONIDE 0.05% OINTMENT 6 250 $219.39 $0.00

7939259 DIASTAT 2.5MG RECTAL GEL 250 $940.54 $0.00

7939267 ISOSOR DIN. 20MG/HYDRALA 250 $22.86 $0.00

7939275 ARIPIPRAZOLE 5MG TAB (ABI 250 $74.77 $0.00

7939283 BROMAXEFED DM RF SYRUP (R 250 $14.53 $0.00

7939291 HEPATITIS B INJ. (Nabi-HB 250 $655.42 $0.00

7939309 PREGABALIN 75MG CAPSULE ( 250 $21.54 $0.00

7939317 CONJ.ESTROGENS 0.45MG TAB 250 $17.18 $0.00

7939325 TIGECYCLINE 50MG INJ. (TY 250 $206.57 $0.00

7939333 PEDIACARE 7.5MG/0.8ML DRO 250 $41.33 $0.00

7939341 SALIVART ORAL MOISTURIZER 250 $53.60 $0.00

7939358 TUBERCULIN PPD 5TU/0.1ML 250 $23.03 $0.00

7939366 POLYETHYLENE GLYCOL 3350, 250 $21.88 $0.00

7939374 ZOLEDRONIC ACID INJ. 4MG/ 250 J3487 $3,605.76 $0.00

7939382 PROPAFENONE SR 325MG CAP 250 $43.28 $0.00

7939390 DULOXETINE 60MG CAPSULE ( 250 $35.22 $0.00

7939408 TETANUS TOXOID ADSORBED P 250 $129.00 $0.00



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12427

7939416 R&B 2HTU ICU

MENOMUNE A/C/Y/W 135 INJ 250 $386.93 $0.00

7939432 MUPIROCIN 2% OINTMENT 0.9 250 $15.77 $0.00

7939440 OMNIPAQUE 240MG/M INJ 10 250 Q9947 $191.43 $0.00

7939457 IMMUNE GLOBULIN 6GM INJ. 250 J1566 $2,146.18 $0.00

7939465 IMMUNE GLOBULIN 12GM INJ. 250 J1566 $4,285.36 $0.00

7939473 DOPamine/D5W 400MG/250ML 250 J1265 $94.81 $0.00

7939481 DOPamine 200MG/5ML INJ. 250 J1265 $22.42 $0.00

7939499 DOPamine 800MG/5ML INJ. 250 J1265 $50.04 $0.00

7939507 ACYCLOVIR SODIUM 500MG/10 250 J0133 $20.21 $0.00

7939515 ACYCLOVIR NA 5MG/ML INJ. 250 J0133 $39.75 $0.00

7939523 EPOETIN 4,000 UNITS/ML IN 250 J0886 $214.66 $0.00

7939531 EPOETIN 2,000 UNITS/ML IN 250 J0886 $162.57 $0.00

7939549 EPOETIN 3,000 UNITS/ML IN 250 J0886 $240.44 $0.00

7939556 EPOETIN 10,000 UNITS/ML I 250 J0886 $544.00 $0.00

7939564 EPOETIN 40,000 UNITS/ML I 250 J0886 $2,155.00 $0.00

7939572 FOMEPIZOLE 1GM/ML INJ (A 250 J1451 $4,892.52 $0.00

7939580 DIGOXIN IMMUNE FAB (DIGIF 250 J1162 $2,125.00 $0.00

7939598 APROTININ 10,000KIU/200ML 250 J0365 $2,104.91 $0.00

7939606 APROTININ 10,000KIU/100ML 250 J0365 $1,116.76 $0.00

7939614 EPOETIN 20,000 UNITS/ML I 250 J0885 $1,081.00 $0.00

7939622 NESIRITIDE 1.5MG INJ (NA 250 J2325 $2,027.32 $0.00

7939630 IRON DEXTRAN 50MG/ML INJ 250 J1752 $206.45 $0.00

7939648 IMMUNE GLOBULIN INTRAVENO 250 J1567 $364.41 $0.00

7939655 ADENOSINE 6MG/2ML INJ (AD 250 J0150 $223.56 $0.00

7939663 ADENOSINE 3MG/ML INJ 30ML 250 J0152 $894.40 $0.00

7939671 HEPATITIS B SYRINGE 0.5ML 250 90371 $562.97 $0.00

7939689 OMNIPAQUE 300MG/ML INJ 10 250 Q9949 $212.24 $0.00

7939697 OMNIPAQUE 300MG/ML INJ 5 250 Q9949 $111.74 $0.00

7939705 OMNIPAQUE 350MG/ML INJ 10 250 Q9950 $235.05 $0.00

7939713 OMNIPAQUE 350MG/ML INJ 5 250 Q9950 $121.07 $0.00

7939721 VISIPAQUE 320MG/ML INJ 1 250 Q9950 $608.63 $0.00

7939739 OMNIPAQUE 180MG/ML INJ 1 250 Q9946 $261.20 $0.00

7939747 CALCIUM ACTEATE 667MG GEL 250 $9.39 $0.00

7939754 BACTERIOSTATIC WATER INJ 250 A4216 $10.35 $0.00

7939762 SOD CHLORIDE 0.9% INJ 10M 250 A4216 $9.73 $0.00

7939770 STERIL WATER FOR INJ 10ML 250 A4216 $9.90 $0.00

7939788 SOD CHLORIDE 0.9% BACTERI 250 A4216 $10.70 $0.00

7939796 SALINE FLUSH 0.9% INJ 5ML 250 J2912 $12.11 $0.00

7939804 SALINE FLUSH 0.9% INJ 2.5 250 J2912 $12.11 $0.00

7939812 STERIL WATER FOR INJ 1000 250 A4217 $22.93 $0.00

7939820 SOD CHLORIDE 0.9% INJ 100 250 A4216 $21.89 $0.00

7939838 SOD CHLORIDE 0.9% 50 ML A 250 A4216 $83.70 $0.00

7939846 SOD CHLORIDE 0.45% INJ 50 250 A4216 $26.47 $0.00

7939853 STERIL WATER FOR INJ 250M 250 A4216 $42.25 $0.00

7939861 STERIL WATER FOR INJ 200 250 A4216 $43.06 $0.00

7939879 SODIUM CHLORIDE 0.9% INJ 250 A4216 $22.33 $0.00

7939895 INDOMETHACIN 25MG/5ML SUS 250 $8.50 $0.00

7939903 GATIFLOXACIN 0.3% OPHTH S 250 $220.14 $0.00

7939911 VANCOMYCIN HCL 125MG CAP 250 $92.48 $0.00



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12427

7939929 R&B 2HTU ICU BENZOATE 500

CAFFEINE/SOD 250 $66.51 $0.00

7939937 OMNIPAQUE 240MG/ML 50ML I 250 Q9947 $248.47 $0.00

7939945 PENTOSAN POLYSUL SOD 100M 250 $28.77 $0.00

7939952 ETOPOSIDE 20MG/ML INJ (VE 250 J9181 $469.53 $0.00

7939960 PLEGISOL SOLUTION 1000ML 250 $223.70 $0.00

7939978 CLOZAPINE 200MG TAB (CLOZ 250 $41.45 $0.00

7939986 NALMEFENE HCL 100MCG/ML ( 250 $39.69 $0.00

7939994 STROMECTOL 3MG TAB 250 $35.77 $0.00

7940000 ALBUTEROL 0.5% NEB 0.5ML 250 J7613 $13.34 $0.00

7940018 D5W INJ 500ML BAG 250 J7060 $17.75 $0.00

7940026 LIDOCAINE-MPF/EPI 2% INJ 250 J2001 $93.65 $0.00

7940034 AEROCHAMBER SPACER 250 $54.39 $0.00

7940042 HEPARIN LOCK 10UNT/ML INJ 250 $10.43 $0.00

7940059 SENNA/DSS 8.6-50MG TAB (S 250 $7.85 $0.00

7940067 TARCEVA 100MG TAB 250 $355.44 $0.00

7940075 DOXOrubicin 2MG/ML INJ 1 250 J9000 $121.39 $0.00

7940083 IMMUNE GLOBULIN 5% 10GM ( 250 J1567 $3,819.40 $0.00

7940091 IMMUNE GLOBULIN 5% 5GM (O 250 J1567 $1,913.20 $0.00

7940109 NITROLINGUAL PUMPSPRAY 4. 250 $262.24 $0.00

7940117 NITROLINGUAL PUMPSPRAY (P 250 $59.09 $0.00

7940125 GENGRAF 25MG CAP (CYCLOSP 250 $16.70 $0.00

7940133 DIMETHYL SULFOXIDE IRRIGA 250 J1212 $192.32 $0.00

7940141 SALIVA SUBSTITUTE SOLUTIO 250 $40.98 $0.00

7940158 PILOCARPINE 1% OP SOLN 2M 250 $35.76 $0.00

7940166 OWN MED IV PREPARATION FE 250 $55.00 $0.00

7940174 MORPHINE SULFATE 10MG/5ML 250 $12.40 $0.00

7940182 PREGABALIN 100MG CAP (LYR 250 $21.84 $0.00

7940190 DULOXETINE 20MG CAPSULE 250 $32.15 $0.00

7940208 CALCITRIOL 1MCG/ML IN 1ML 250 J0636 $88.00 $0.00

7940216 LOXAPINE 25MG CAP (LOXITA 250 $24.06 $0.00

7940224 SOD CHLORIDE 0.9% INJ 100 250 A4216 $99.50 $0.00

7940232 ALAVERT ALRGY - SINUS TAB 250 $10.96 $0.00

7940240 NEURONTIN 250MG/5ML SOLUT 250 $8.84 $0.00

7940257 CETIRIZINE HCL 5MG CHEW 250 $24.09 $0.00

7940265 PREADMIN IVIG FEE 260 G0332 $333.92 $0.00

7940273 TRIAMCINOLONE 0.5% CRM 15 250 $34.19 $0.00

7940281 SODIUM BICARB 8.4% INJ 50 250 $11.84 $0.00

7940299 DEXTROSE 50% VIAL 50MLS 250 $15.01 $0.00

7940307 PANCURONIUM 1MG/ML INJ 10 250 $20.48 $0.00

7940315 DULOXETINE 30MG CAPSULE ( 250 $35.22 $0.00

7940323 DEXTROSE 5% INJ 250ML 250 J7060 $90.25 $0.00

7940331 DEXTROSE 5% INJ 500MLS(GL 250 J7060 $90.25 $0.00

7940349 ACYCLOVIR 200MG/5ML SUSP 250 $17.26 $0.00

7940356 MAALOX PLUS SUSPENSION 35 250 $8.60 $0.00

7940364 DOMEBORO PACKETS POWDER 250 $12.13 $0.00

7940372 CROTALIDAE POLYVALENT IMM 250 $3,918.24 $0.00

7940380 BUPIVACAINE 0.75% INJ 10M 250 $22.33 $0.00

7940398 BUPIVACAINE HCL IN DEXTRO 250 $39.69 $0.00

7940406 COSYNTROPIN 0.25MG INJ. ( 250 J0835 $634.06 $0.00



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12427

7940414 R&B 2HTU ICU

HYDRAMINE 12.5MG/5ML ELIX 250 $7.31 $0.00

7940422 ENALAPRILAT 1.25MG/ML INJ 250 $31.18 $0.00

7940430 ERYTHROMYCIN OP OIN 1GM 250 $36.39 $0.00

7940448 FLUOCINOLONE ACET 0.01% C 250 $40.34 $0.00

7940455 FLUOCINONIDE 0.05% OINTME 250 $1,132.18 $0.00

7940463 HYDROCODONE/HOMATROPIN SY 250 $9.29 $0.00

7940471 HydrOXYzine HCL 25MG TAB 250 $13.44 $0.00

7940489 INTERFERON 3MMU/0.2ML INJ 250 J9213 $222.37 $0.00

7940497 INTERFERON 5MMU/0.2ML INJ 250 J9213 $246.54 $0.00

7940505 LIDOCAINE 1% INJ PF 30ML 250 J2001 $11.58 $0.00

7940513 LIDOCAINE 100MG/5ML SYRIN 250 J2001 $32.73 $0.00

7940521 LIDOCAINE-MPF/EPI 1% INJ 250 J2001 $74.34 $0.00

7940539 LIDOCAINE-MPF/EPI 1.5% IN 250 J2001 $82.83 $0.00

7940547 XYLO-MPF/EPI 2% INJ 20ML 250 J2001 $93.65 $0.00

7940554 MAGNESIUM 30MG TAB (MAG G 250 $7.33 $0.00

7940562 MORphine SUL 30MG/30ML PC 250 J2270 $73.45 $0.00

7940570 M.V.I PEDIATRIC INJ 250 $78.68 $0.00

7940588 NYSTATIN 100,000UNIT OINT 250 $44.66 $0.00

7940596 ZOFRAN ODT 8MG TAB 250 $225.25 $0.00

7940604 OXYMETAZOLINE 0.05% NASAL 250 $25.68 $0.00

7940612 CALCIUM CARBONATE 648MG T 250 $7.11 $0.00

7940620 PENICILLIN GK 5MMU INJ 250 J2540 $230.10 $0.00

7940638 PENTAZOCINE LACTATE INJ 3 250 J3070 $54.84 $0.00

7940646 PERMETHRIN 5% CREAM 60GM 250 $161.73 $0.00

7940653 PHENOBARBITAL 20MG/5M ELX 250 $9.55 $0.00

7940661 CROMOLYN SODIUM 800MCG IN 250 $213.18 $0.00

7940679 PILOCARPINE 2% OP SOL 2ML 250 $35.76 $0.00

7940687 POTASSIUM CHLORIDE 10MEQ 250 $9.36 $0.00

7940695 PROCHLORPERAZINE 5MG/ML I 250 J0780 $57.85 $0.00

7940703 PROPRANOLOL HCL LA 80MG C 250 $19.14 $0.00

7940711 SELEGILINE 5MG CAPSULE (E 250 $23.24 $0.00

7940729 DEPO-TESTOSTERONE 200MG/M 250 $143.27 $0.00

7940737 TETANUS/DIPHTHERIA TOXOID 250 $126.02 $0.00

7940745 THEOPHYLLINE 100MG ER TAB 250 $10.86 $0.00

7940752 TIMOLOL MAL 0.25% OPH. SO 250 $86.35 $0.00

7940760 TRIAMCINOLON 0.025% CREAM 250 $28.15 $0.00

7940778 TRIAMCINOLONE 0.1% CREAM 250 $37.41 $0.00

7940786 TRIAMCINOLON 0.025% OINT. 250 $32.38 $0.00

7940794 TRIAMCINOLON 0.1% OINT. 1 250 $32.38 $0.00

7940802 AZITHROMYCIN 250MG TAB (Z 250 $55.45 $0.00

7940810 LOXAPINE 5MG CAP (LOXITA 250 $14.00 $0.00

7940828 DORZOLAMIDE HCL OPHTH SOL 250 $177.12 $0.00

7940836 MEN-PHOR LOTION 222ML 250 $40.41 $0.00

7940844 SOD CHLORIDE 3% INJ 500ML 250 $111.97 $0.00

7940851 MUCINEX 600MG E TAB (SAME 250 $9.84 $0.00

7940869 LACTULOSE 10GM/15 SYP 500 250 $7.77 $0.00

7940877 NIFEdipine 30MG ER TAB 250 $16.33 $0.00

7940885 AZITHROMYCIN 200MG/5ML SU 250 $41.19 $0.00

7940893 SEVELAMER 400MG TAB (RENA 250 $12.96 $0.00



Page 124 of 129

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NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

7940901 CAFFEINE ICU

R&B 2HTU CITRATE 20MG/ML 250 $211.08 $0.00

7940919 ECONAZOLE CREAM 1% 30GM ( 250 $170.61 $0.00

7940927 AEROCHAMBER PLUS MASK (ME 250 $27.50 $0.00

7940935 FLUOXETINE 10MG CAP (PROZ 250 $25.31 $0.00

7940943 FORADIL AEROLIZ CAP 250 $195.37 $0.00

7940950 CLINDAMYCIN 900MG INJ (CL 250 $21.43 $0.00

7940968 GUAIFENESIN 100MG/5ML SYR 250 $7.56 $0.00

7940976 FENOFIBRATE 145MG TAB (TR 250 $33.54 $0.00

7940984 BRIMONIDINE 0.2% OPHTH. S 250 $179.71 $0.00

7940992 HEP FLUSH 10 UNITS/ML 10M 250 J1642 $34.32 $0.00

7941008 CLINDAMYCIN 300MG INJ (CL 250 $24.09 $0.00

7941016 ZOFRAN ODT 4MG TAB 250 $138.03 $0.00

7941024 AMPICILLIN 2GM INJ 250 J0290 $95.60 $0.00

7941032 CARRINGTON SOL 250 $142.37 $0.00

7941040 INFLUENZA VIRUS VACCINE I 250 $62.37 $0.00

7941057 TEMAZEPAM (RESTORIL) 7.5M 250 $35.13 $0.00

7941065 INSULIN REG SLIDING SCALE 250 J1815 $37.50 $0.00

7941073 MAALOX SUSPENSION 355ML 250 $8.63 $0.00

7941081 PENTOBARBITAL INJ. 50MG/M 250 J2515 $47.76 $0.00

7941099 NOVOSEVEN 4800MCG INJ-COA 250 $26,947.96 $0.00

7941107 SOD CHLORIDE 5% OPHTH SOL 250 $71.06 $0.00

7941115 CYTARABINE 1000MG INJ (C 250 J9110 $132.63 $0.00

7941123 ETH-OXYDOSE 20MG/ML CONC. 250 $23.02 $0.00

7941131 HYDROmorphone 50MG/5ML IN 250 J1170 $67.22 $0.00

7941149 UROXATRAL 10MG TAB 250 $24.38 $0.00

7941156 HYDROCHLOROTHIAZIDE 12.5M 250 $10.20 $0.00

7941164 CAPSIUM OLEORESIN 0.075% 250 $70.42 $0.00

7941172 ZIDOVUDINE 10MG/ML 20ML 250 $142.94 $0.00

7941180 SCLEROSOL INTRAPLEURAL AE 250 $359.99 $0.00

7941198 ANIMAL SHAPE /IRON CHW (C 250 $7.31 $0.00

7941206 XIFAXAN 200MG TAB 250 $36.14 $0.00

7941214 PREGABALIN 50MG CAP (LYRI 250 $21.54 $0.00

8000010 DIALYSIS 800 90935 $5,053.95 $0.00

8000028 PERITONEAL DIALYSIS 800 90945 $5,053.95 $0.00

8000044 CLARK HEMOPERF CARTRY XLG 800 90997 $2,805.25 $0.00

8100018 PLASMA PHERESIS 940 36514 $4,083.45 $0.00

8700015 WORK TOLERANCE TESTING 420 97660 $65.00 $0.00

8700064 CARDIAC REHAB WO CONT ECG 420 93797 $81.25 $0.00

8700080 ADVANCED ERGO TESTING 420 97660 $60.00 $0.00

8700106 PHYSICAL AGILITY TEST II 420 97660 $45.00 $0.00

8700122 ASSES/EVAL BRIEF INIT 420 $76.90 $0.00

8700130 ASSES/EVAL LIMITED INITIL 420 $115.30 $0.00

8700148 ASSES/EVAL INTERM/INITIAL 420 $149.90 $0.00

8700155 ASSES/EVAL LIMIT/ESTAB 420 $74.00 $0.00

8700163 ASSES/EVAL INTERM/ESTB 420 $98.05 $0.00

8700189 GAIT TRAINING 15MIN 420 97116 $78.25 $0.00

8700221 CPM SET-UP 420 97110 $88.75 $0.00

8700239 CPM FOLLOW UP 420 97110 $71.00 $0.00

8700247 THERAPEUTIC EX INIT 30MIN 420 $103.80 $0.00



Page 125 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

8700254 R&B 2HTU ICU

KINETIC ACT ADD 15MIN 420 $46.15 $0.00

8700270 ELEC STIM MAN INIT 30MIN 420 $73.05 $0.00

8700288 ORTHOTIC TRAIN INIT 30MIN 420 $124.95 $0.00

8700296 ORTHOTIC TRAIN ADD 15MIN 420 $55.75 $0.00

8700304 PROSTHETIC TRAIN ADD 15MN 420 $63.45 $0.00

8700338 ADL TRAIN INIT 30MIN 420 $103.80 $0.00

8700346 WORK CONDITION INIT 2HR 420 97545 $150.00 $0.00

8700353 WORK CONDITIONING ADD 1HR 420 97546 $73.75 $0.00

8700361 ADL TRAIN ADD 15MIN 420 $46.15 $0.00

8700379 ASSES/EVAL COMP INIT 420 $273.90 $0.00

8700395 ULTRASOUND INIT 30MIN 420 $65.35 $0.00

8700403 ELECTRICAL STIM UNATTEND 420 97014 $57.65 $0.00

8700411 MASSAGE INITIAL 30MIN 420 $69.20 $0.00

8700429 MECHANICAL TRACTION 420 97012 $57.65 $0.00

8700437 MANUAL TRACTION INIT 30MN 420 $63.45 $0.00

8700445 JOINT MOBILIZATION 420 $67.30 $0.00

8700452 IONTOPHERESIS INIT 30MN 420 $94.20 $0.00

8700460 APPLY TENS UNIT 420 64550 $56.90 $0.00

8700478 CONTRAST BATHS INIT 30MIN 420 $63.45 $0.00

8700494 WHRLPOOL SML/PULSE LAVAGE 420 97022 $57.65 $0.00

8700536 GAIT TRAINING INIT 30MIN 420 $84.55 $0.00

8700544 KINETIC ACT INIT 30MIN 420 $103.80 $0.00

8700551 WORK CAPACITY MEASUREMENT 420 97670 $915.00 $0.00

8700577 JOB SITE ANALYSIS 1HR 420 97680 $156.25 $0.00

8700593 LIFTING ASSESSMENT 420 97660 $75.00 $0.00

8700601 PHYSICAL AGILITY TEST III 420 97660 $60.00 $0.00

8700627 POST OFFER EMPLOY TEST 420 97620 $90.00 $0.00

8700635 PHYS PERF TEST INIT 30MIN 420 $127.15 $0.00

8700643 PHYS PERF TEST ADD 15MIN 420 $63.45 $0.00

8700650 ADL/ORTHOTIC/PROSTHETC CK 420 97703 $140.30 $0.00

8700668 ADL/ORT/PROS CK ADD 15MIN 420 $71.15 $0.00

8700684 BIODEX TEST 420 97752 $75.00 $0.00

8700866 GROUP THERAPY 420 97150 $55.30 $0.00

8700908 PROSTHETIC TRAIN INIT 30M 420 $140.30 $0.00

8700924 COMM/WRK RE-INTEGR 15MIN 420 97537 $86.65 $0.00

8700932 PHYS PERFORM TEST 15MIN 420 97750 $94.95 $0.00

8701013 JOBST PUMP 420 97016 $57.65 $0.00

8701104 PT EVALUATION 420 97001 $192.10 $0.00

8701112 PT RE-EVALUATION 420 97002 $96.05 $0.00

8701120 JOBSITE ANALYSIS 2HR 420 97680 $312.50 $0.00

8701138 JOB SITE ANALYSIS 4HR 420 97680 $625.00 $0.00

8701179 MSCL TEST EXTREM OR TRUNK 420 95831 $91.10 $0.00

8701187 MUSCLE TEST HAND 420 95832 $77.10 $0.00

8701195 MSCL TEST TOT BODY W HAND 420 95834 $151.15 $0.00

8701203 ROM EA EXTREM TRNK NT HND 420 95851 $64.40 $0.00

8701211 WLCHR MGT PROP TRAIN 15MN 420 97542 $71.30 $0.00

8701245 MANUAL THERAPY EA 15MIN 420 97140 $67.15 $0.00

8701328 STRAPPING LOW BACK 420 29220 $143.45 $0.00

8701336 STRAPPING SHOULDER 420 29240 $155.20 $0.00



Page 126 of 129

CHARGE REV UNIT ROOM

NUMBER DESCRIPTION CODE CPT CODE PRICE PRICE

12427

8701369 R&B 2HTU ICU

STRAPPING HIP 420 29520 $137.60 $0.00

8701377 STRAPPING KNEE 420 29530 $135.25 $0.00

8701385 STRAPPING ANKLE 420 29540 $94.35 $0.00

8701401 ASSES/EVAL EXTEND/INIT 420 $217.20 $0.00

8701419 ASSES/EVAL EXTEND/ESTB 420 $138.75 $0.00









Page 127 of 129

CHARGE REV CPT UNIT

NUMBER DESCRIPTION DEPT CODE CODE PRICE

3100930 CBC AUTO & AUTO DIFF 31 305 85025 $120.15

250027 FETAL MONITORING P/HOUR 2 720 59050 $40.96

8702409 THERAPEUTIC EXRCISE 15MIN 87 420 97110 $71.00

6605083 FLUORO NDL LOC SPINAL INJ 66 320 76005 $1,200.00

3800026 ECG 12LD ADULT 38 730 93000 $313.50

3300035 METABOLIC COMP PANEL 33 301 80053 $300.30

3300167 LIPID PANEL 33 301 80061 $273.20

200048 NON STRESS TEST 2 920 59025 $1,008.65

3300530 CREATININE 33 301 82565 $123.30

4602587 CREATE AV DIALYSIS SHUNT 46 323 36145 $1,754.50

2000909 CHEST 2 VIEW 20 324 71020 $449.65

3300019 ELECTROLYTE PANEL 33 301 80051 $197.25

3100583 RUBELLA ANTIBODY IGG 31 300 86762 $123.30

3300779 HORMONE TSH 33 301 84443 $231.90

3100351 ANTIBODY SCREEN RBC 31 300 86850 $244.95

6605430 INJ TNSF EP LS SG LV WSED 66 361 64483 $5,482.50

4602504 PTA VENOUS 46 323 35476 $4,000.00

4604302 PERC AVF THROMBECT GRAFT 46 323 36870 $5,337.50

4600342 S&I INJ PLM/BPG/CORO ANGI 46 481 93556 $3,432.00

4600375 INJ SEL LV/LA ANGI W CATH 46 481 93543 $2,638.65

4600359 S&I-INJ VT OR AT ANGIOGR 46 481 93555 $2,897.15

4600474 LHC RETRO PERCUTANEOUS 46 481 93510 $9,376.15

2001378 FLUORO, UP TO 1 HOUR 20 320 76000 $982.95

2000891 CHEST 1 VIEW 20 324 71010 $291.50

6605240 EPID INJ LUMB/SAC W/SED 66 361 62311 $5,483.50

DAMERON HOSPITAL ASSOCIATION

GROSS CHARGE ANALYSIS









JUN04-MAY05 JUN05-MAY06 VAR %









GROSS REV 596,328,225 633,200,768 6.18%



APDS 67,806 66,886 -1.36%



REV/APD 8,795 9,467 7.64%