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WESTERN-LaPaz-Mohave-Yuma

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					DATE RECEIVED:                                                              12/5/2011

DHS License Number#:                                                        OTC 0744
Facility Name:                                                  La Paz County Health Department


Physical Street Address:                                          1112 Josuha Avenue Suite 206

City:                                                                         Parker
State:                                                                        Arizona
Zip:                                                                          85344
County:
Facility Mailing Address':
City:
State:

Zip:
Phone #:                                                                  928-669-1100
NPI #:                                                                     1184828469
AHCCCS #:                                              AHCCCS number is for immunizations billing 197740
Medicare Certified: Yes/No                                                      No
Medicare Number:                                                               N/A
Administrator:                                                            Marion Shontz
  Phone #:                                                                928-669-1100
  Email Address:                                                    mshontz@co.la-paz.az.us
Chief Financial Officer:                                                  Mary Bierbrodt
  Phone #:                                                                928-669-1100
  Email Address:                                                   mbierbrodt@co.la-paz.az.us
Person Providing Information:                                              Diana Grazier
  Phone #:                                                                928-669-1100
  Email Address:                                                   dgrazier@co.la-paz.az.us
Implementation Date:                                                    Revised 12 - 1- 2011


        TABLE OF CONTENTS       Service Code                      Discription of Charge


                                We use no codes   Children's Vaccines
                                                  Adult Vaccines (19 years and older):
                                                  Adult Tdap
                                                  Td
                                                  Hepatitis A
                                                  Hepatitis B
                                                  Twinrix (Hep A & B Combo
                                                  MMR
                                                  TB Skin test for employment and Immigration
                                                  Influenza Vaccination
                                                  Pneumovax Vaccine
                                                  Varavax (Chicken Pox)
Shingles: Refer to Safeway Pharmacy
Head Lice Crème Rinse (NIX)
FAMILY PLANNING FEES
Title V (150% or under poverty level)
Over 150%:
Depo Provera
Oral Contraceptives
Pap Smear (Well Woman)
STD Exam by Nurse Practitioner
STD Urine Testing
HIV Testing
Pregnancy Tests AHCCCS
Pregnancy Testings Non-AHCCCS
Plan B Emergency Contraception
Ortho-Evra Patch
NeuvoRing
MISCELLANEOUS LAB FEES
Syphillis/HIV Combonation
Basic Metabolic Panel
CBC
Comprehensive Metabolic Panel
Culture, Group B Strep
Culture, Herpes w/rfx typing
Culture, Herpes w/o rfx Typing
Culture, Urine
hCG Qualitative
hCG Quantatative
Hemoglobin A1c
Hepatic Function Panel
Hepatitis Panel, Acute
Hepatitis Panel, Screen
Lead, Blood
Lipid Panel
Thyroid Panel with TSH
Uric Acid
Urinalysis
Urinalysis w'rfx to Culture
Urinalysis, Micro
Varicella Zoster IgG Antibody
Syphilis
`
                                                                      2/17/2011

                                                                       OTC0660
partment                                                       AIMS URGENT CARE CENTER


te 206                                                         3636 STOCKTON HILL ROAD
                                                                      KINGMAN
                                                                       ARIZONA
                                                                        86409


                                                               3636 STOCKTON HILL ROAD
                                                                      KINGMAN
                                                                       ARIZONA
                                                                        86409
                                                                     928-757-3680
                                                                      1881680122
ons billing 197740                                                      167933


                                                                        73725
                                                                      Shah Salim
                                                                     928-757-3636
z.us




.az.us
                                                                     Cynthia Mirza
                                                                     310-534-1141
az.us                                                             mirza@pmsigroup.com
11


                      Rate of Charge            Service Code


               Free                                10021
               According to vaccine                10060
               $                       40.00       10140
               $                       25.00       11042
               $                       30.00       11401
               $                       35.00       12002
               $                       60.00       15100
               $                       55.00       16020
               $                       10.00       20552
               Donation Only                       20610
               $                       50.00       24600
               $                       110.00      27096
unavailable                      36415
$                         8.50   62311
                                 65205
Free                             69210
                                 70210
$                     30.00      71020
$20.00/pack                      71100
$                     60.00      72040
$                     20.00      72070
$                     20.00      72100
$                     15.00      72170
$                         5.00   73030
Donation Only                    73110
$                     30.00      73130
$30.00/cycle                     73500
$20.00 cycle/$60.00 box          73562
Cost + $5.00/visit               74000
$                     14.00      74022
$                         4.50   74400
$                         3.50   76000
$                         5.00   77003
$                     12.50      81002
$                     25.00      81025
$                     17.50      82948
$                     15.00      83036
$                         8.00   86403
$                         8.00   90470
$                         7.50   90471
$                         4.00   90658
$                     40.00      90701
$                     40.00      90703
$                         8.00   93000
$                         5.00   94010
$                     12.00      94640
$                         4.00   96372
$                         5.00   99203
$                     15.00      99204
$                         5.00   99212
$                     13.00      99213
$                         6.00   99214
                                 99215
                                 99354
                                 99355
                                 99396
A4565
A4570
A6450
A6451
J0690
J0696
J1030
J1051
J1055
J1100
J1644
J1885
J2175
J2550
J3301
J3410
J7610
J7644
                                      2/17/2011

                                        OTC0660
                            AIMS URGENT CARE CENTER                                           B


                            3636 STOCKTON HILL ROAD
                                      KINGMAN
                                       ARIZONA
                                         86409


                            3636 STOCKTON HILL ROAD
                                      KINGMAN
                                       ARIZONA
                                         86409
                                    928-757-3680
                                      1881680122
                                        167933


                                         73725
                                      Shah Salim
                                    928-757-3636




                                     Cynthia Mirza
                                     310-534-1141
                                 mirza@pmsigroup.com




                             Discription of Charge         Rate of Charge      Service Code


NDL Aspiration w/o IMG Guidance                        $              350.00     674100
Incision & Drainage of Abscess                         $              100.00     685200
Incision & Drainage of Hematoma                        $              500.00     684200
Debridement; Skin & Subct Tissue                       $              250.00     684300
Exc of lesion 0.6-1.0 cm trunk, arms legs              $              320.00     675100
Rep Lac 2.6cm-7.5cm hands, feet, sclp                  $              300.00     309400
Split Thk Auto graft 1st 100sq cm or less              $            1,500.00     645500
Drsng and/or Debridement of par thkness                $               65.00     513700
Inj(s):sgle or mul trig pts one or two mus             $              150.00     425801
Arthctsis, Aspr and/or Inj Mj Jt or Bursa              $               80.00     318800
Trtmt of cls elbw dislo w/out anesthesia               $              500.00     446001
G0260 for MCR Inj for Sac Jt athro anes                $              400.00     510500
Blood draw only                               $    15.00   504900
Lumbar, Sacral Single Injection               $   700.00   683200
Rml Frgn frm ext eye, conj superficial        $   100.00   600400
Ear wax removal                               $    90.00   600700
Rad exm,sinus,paranasal,less than 3v          $    65.00   310700
Rad exm,chest,2v frontal and lateral          $    85.00   310800
Rad exm,ribs,unilateral,2v                    $   130.00   600900
Xray;C-Spine 3v                               $   130.00   468001
Xray;T-Spine 2v                               $   125.00   601000
Xray;L-Spine 3v                               $   118.00   601100
Xray;Pelvis only 1v                           $   100.00   462301
Xray;Shoulder 3v                              $   125.00   632200
Xray;Wrist 3v                                 $    95.00   405703
Rad exm,hand,min 3v                           $    60.00   400701
Xray;Hip 1v                                   $    88.00   601500
Rad exm,knee,3v                               $    70.00   311400
Rad exm,ABD,sngl Anteroposterior view         $    40.00   683400
Xray;ABD & Chest 3v                           $    60.00   601900
Urography,IVP, Intra w/wo KUB, Tomgrh         $   250.00   300300
Fluroscopy,up to 1hr Phy time other than      $   200.00   306300
Fluroscopic Gud and Loc NDL or Cath SP        $   150.00   300400
Urin Dip Stick or Tab Rgnt Non-Auto           $    25.00   300600
Urin Preg Test by vis color compr methds      $    25.00   309600
Blood reagent strip                           $    15.00   300700
Glycosylated                                  $    40.00   314400
Quick Strep Test                              $    30.00   314500
H1N1 Immunization Adminstration               $    35.00   300800
Immunization Adminstration-IM                 $    30.00   648500
Influenza vir vac,split vir, 3yrs and older   $    30.00   311600
Diptheria, Tet Tox, whl cell Pertussis Vac    $    15.00   311500
Tet tox absrd, intramuscular use              $    30.00   480201
Electrocardiogram                             $    50.00   625600
Quick Flow FLU Test                           $    70.00   801307
Press or nonpres inhal tx for acute awy ob    $    30.00   436101
Therapeutic,prophy diagn inj intra-arterial   $    40.00   602300
Office or other Outpat New Pat Lv3            $   140.00   436601
Office or other Outpat New Pat Lv4            $   180.00   401404
Office or other Outpat Est Pat Lv2            $    75.00   466801
Office or other Outpat Est Pat Lv3            $   120.00   462501
Office or other Outpat Est Pat Lv4            $   180.00   462701
Office or other Outpat Est Pat Lv5            $   240.00   602400
Prolonged Phy serv in Off serv First hour     $   160.00   602500
Prolonged Phy serv in Off each add 30min      $   155.00   677500
Periodic Comp prev med reeval 40-64           $   160.00   602600
Sling                                                                            $                 15.00        602700
Splint                                                                           $                 30.00        678100
Light compression Bandage                                                        $                 25.00        100200
Moderate compression bandage                                                     $                  5.00        100201
Ancef (Kefzol) 500mg                                                             $                 20.00        100203
Inj, Ceftriaxone Sodium, per 250mg Rocep                                         $                 45.00        100202
Depomedrol 40mg                                                                  $                 40.00        100204
Inj, Medroxyprogesterone 50mg Depro-Ver                                          $                 65.00        100205
Inj,Medroxyprogesterone 150mg                                                    $                 75.00        682100
Inj dexamethaso sod phosht DECADRON                                              $                 10.00        302900
Heparin,Sodium per 1000units                                                     $                 20.00        316500
Inj,Ketorolac Tromethamine TORADEL 15mg                                          $                 35.00        649000
Inj,Meperidine Hydrochl,DEMEROL 100mg                                            $                 50.00        649100
Inj,Promethazine HCI, 50mg PHENEGAN                                              $                 40.00        642100
Inj,Triam acetonide 10mg KENELOG                                                 $                  5.00        681800
Inj,Vistaril Hyrdroxyzine HCL 25mg                                               $                 25.00        602800
Albuterol inhal, concent from 1mg                                                $                 25.00        671200
Atrovent Inhal non compd unit does per mg                                        $                  5.00        428315
                                                                                                                482601
CYTOPATHOLOGY, cervical or vaginal (Pap Smear)                                   $                 70.00        482701
CYTOPATHOLOGY, SLIDES,CERVICAL OR VAGINAL (PAP SMEAR)                            $                 60.00        482801
                                                              $            200.00
DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE                                 482901
                                                             $           1,500.00
DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING                                     483001
debridement, partial thickness                                                   $                150.00        483101
DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE                                       $               250.00         483201
DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE                               $               470.00         483601
                                                                                $
Debridgement of skin,subcutaneous tissue,muscle and fascia for necrotizing soft tissue infection1,050.00        483401
                                                                                  $                30.00         483501
Demonstration/or evaluation of patient utilization of an aerosol generator,nebulizer,metered dose inhaler or IPPB device
DENTAL CARRIES                                                          $            1,325.00
                                    PER AAHCCCS REP UPDATED REV CODE FROM 0361 TO 0490. JL 7/22/09 483301
DEPOMEDROL 20MG                                                                  $                 40.00        483701
DEPOMEDROL 40mg                                                                  $                 40.00        483801
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY                      $                125.00        466501
DESTRUCTION (LASER,ELECTRO,CRYO,CHEMO SURGICAL)                                  $                125.00        433001
                                                                $             20.00
DESTRUCTION ADD 2-14 (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,                             402401
                                                               $
DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM                             1,760.00        402501
DEXTROSE / NORMAL SALINE 500                                                     $                  5.00        603000
                                                              $            8
DIALTION OF ESOPHAGUS BY UNGUIDED SOIND OR BOUGIE, SINGLE OR MULTIPLE PASSES00.00                               602900
                                                            OR
DILATION OF ESOPHAGUS W/BALLOON FOR SCHALASIA 30MM DIAMETER $ LARGER                            1,310.00        207100
                                                              $
DIPHTHERIA, TETANUS TOXOIDS, AND WHOLE CELL PERTUSSIS VACCINE (DTP)                                30.00        205400
DOT PHYSICAL EXAM                                                                $                 55.00        446802
                                                              $           2,500.00    625400
DRAINAGE OF PERITONEAL ABCESS OR LOCALIZED PERITONITIS EXCLUSIVE OF APPENDICAL ABCESS;OPEN
DRAINAGE OF SCROTAL WALL ABCESS                                                  $              1,430.00        310900
DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABCESS                                $              2,400.00        673100
DRESSING 16" OR LESS, W/O ADHESIVE                                               $                  5.00        485101
DRESSING/ADHESIVE BANDAGE/SUTURES                                                $                  25.00        485201
DRUG SCREENING                                                                   $                  50.00        484301
DtaP IMMUNIZATION                                                                $                  40.00        500600
EACH ADDITIONAL                                                                  $                750.00         482301
EACH ADDITIONAL                                                                  $                  46.00        482401
each additional hour                                                             $                  50.00        486101
EACH ADDITIONAL HOUR                                                             $                  32.00        603500
EACH ADDITIONAL HOUR                                                             $                  42.00        603600
Each addt'l 5cm or less                                                          $                350.00         207200
EAR WAY REMOVAL                                                                  $                  90.00        206100
ELBOW THREE VIEWS                                                                $                 103.00        425903
ELBOW TWO VIEWS                                                                  $                  95.00        470501
ELECTROCARDIOGRAM                                                                $                  50.00        425702
Emergency department visit for the evaluation and management of a patient        $                  35.00        468101
Emergency department visit for the evaluation and management of a patient        $                  65.00        423001
Emergency department visit for the evaluation and management of a patient        $                 185.00        603900
Emergency department visit for the evaluation and management of a patient,       $                 105.00        512900
Emergency department visit for the evaluation and management of a patient,       $                 190.00        604300
                                                                                 $                875.00          604400
Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure)
                                                              $         1,100.00
ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS                                      465401
                                                          $          1,120.00
ENTEROENSTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT CUTANEOUS                                          462601
ENTEROLYSIS                                                                      $               1,950.00        469001
                                                                $
EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT ) REDUCIBLE SEPARATE PROCEDURE                          3,055.00        430202
EPINEPHRINE 1ML                                                                  $                  25.00        466401
ERCP WITH REMOVAL/CHANGE TUBE,STENT OR FOREIGN OBJECT                            $               2,200.00        683900
                                                                $
ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, BELSEY IV, HILL PROCEDURES)                             4,800.00        683500
                                                             $
ESOPHAGOGASTRIC FUNDOPLASTY; WITH FUNDIC PATCH (THAL-NISSEN PROCEDURE)                           4,500.00        604800
                                                                                   $               1,305.00        604700
Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION                          $               1,305.00        308800
Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent        $               1,965.00        308900
Evacuation of subungual hematoma                                                 $                200.00         316300
Excised diameter 0.6 to 1.0 cm                                                   $                490.00         675400
Excised diameter 3.1 to 4.0cm                                                    $               1,935.00        621300
EXCISION DIAMETER 2.1 TO 3.0cm                                                   $                580.00         311900
EXCISION MAJOR PERIPHERAL NERVE EXCEPT SCIATIC                                   $               1,720.00        683800
                                                            $
EXCISION MALIGNANT LESION INCLUDING MARGINS TRUNK ARM OR LEGS EXCISED                             490.00         605000
Excision of bone cyst or benign tumor                                            $               2,930.00        312000
                                                              OF        2,305.00
EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT$ RADIOLGICAL                                      317500
                                                             TUMOR,ABERRANT BREAST TISSUE.
EXCISION OF CYST,FIRBROADENOMA, OR OTHER BENIGN OR MALIGNANT $         2,305.00     631100
EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY                           $               2,040.00        605200
Excision of hydrocele of spermatic cord, unilateral (separate procedure)         $               2,375.00        605400
Excision of hydrocele; unilateral                                                $               2,700.00        626000
excision of lesion, 0.6-1.0 cm trunk, arms, legs                                 $                320.00         625900
                                                              $
EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE NOT REQUIRING 760.00                                 622500
                                                              $           4,500.00    FACIAL
EXCISION OF PAROTID TUMOR OR GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF 670500 NERVE
EXCISION OF PILONDIAL CYST OR SINUS; COMPLICATED                 $           2,325.00    670800
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE                   $           2,325.00    605300
EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH                     $           2,500.00    636800
Excision of rib, partial                                         $           2,460.00    605500
                                                            $
EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS,AXILLARY           2,140.00    311800
                                                               $          2,000.00
EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; DEEP, SUBFASCIAL, INTRAMUSCULAR           686000
EXCISION TUMOR, SOFT TISSUE UPPER ARM OR ELBOW                   $             800.00    304700
Excision, abdominal wall tumor                                   $           2,670.00    310600
EXCISION, BENIGN LESION INCLUDING MARGINS, 3.1-4.0               $           1,850.00    480102
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG       $           1,940.00    605600
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG       $             345.00    605800
                                                               $          1,800.00
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTEDOVER 4.0        680500
                                                                $
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 3.1-4.0           1,750.00    638800
Excision, excess skin and subcutaneous tissue, abdomen           $           2,325.00    605700
EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST          $           2,330.00    621900
                                                                $
EXCISION, MALIGNANT LESION INC MARGINS, TRUNK, ARMS, OR LEGS; 3.1 TO 4.0      1,100.00   622000
                                                               $
EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS;550.00     682500
                                                               $             550.00
EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS;2.1-3.0    682800
                                                              $
EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET       2,140.00    684000
                                                              $
EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS,FEET 1.1-2.0 400.00     681100
                                                              $
EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS2.1 TO 3.0 675.00      683600
EXCISION, OLECRANON BURSA                                        $           2,200.00    606100
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS                  $           2,040.00    606200
                                                             $
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE),1,315.00       606300
EXCISION, SOFT TISSUE TUMOR, SHOULDER AREA; SUBCUTANEOUS         $           2,000.00    635200
EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK                    $           2,000.00    635100
Excison diameter 1.1 to 2.0                                      $             500.00    635000
Excison,malignant lesion trunk excised diameter over 4.0cm       $           1,940.00    606000
EXPLORATION OF PENETRATING WOUND, NECK                           $           1,500.00    622200
                                                              $           860.00
EXPLORATION, RETROPERITONEAL AREA WITH OR WITHOUT BIOPSY(S) (SEPARATE PROCEDURE)         606400
EXPLORATORY LAPAROTOMY                                           $           1,500.00    619600
EXTRCTRATIONERUPTED TOOTH OR EXPOSED ROOT                        $             500.00    620400
FINE NEEDLE ASPIRATIOM W/O IMAGING GUIDANCE                      $             150.00    642300
FINGERS 2VIEWS                                                   $              75.00    605900
Fissurectomy, with or without sphincterotomy                     $           2,200.00    606500
                                                               $
FLUOROSCOPY ( SEPARATE PROCEDURE) ,UP TO ONE HOUR PHYSICIAN TIME OTHER THAN 200.00       467101
                                                             $
FLUROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE.     150.00    468901
FOREARM TWO VIEWS                                                $              90.00    648000
GARDISIL (FEMALE TEEN VACCINE) NOC, ANTINEOPLASTIC DRUG          $              45.00    422401
GASTROJEJUNOSTOMY WITHOUT VAGOTOMY                               $           1,200.00    422901
                                                             $            1,160.00
GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCER, WOUND, OR INJURY          682000
gauze, 16" or less                                               $               5.00    671800
GLOBAL SURGERY COMPLICATD OR MULTIPLE                            $             400.00    308100
GLUCOSE,QUANTITIVE,BLOOD(EXECPT REAGENT STRIP)                                   $                  15.00        437601
                                                                               $
Glycosylated(hemoglobin analysis by chromatography in the setting of a hemoglobin variant.          40.00        404601
HAND 2VIEWS                                                                      $                  85.00        606900
                                                                                to
Handling and/or conveyance of specimen for transfer from the physician's office $ a labortory.      25.00        680600
heel loop/holder with or w/o strap                                               $                  60.00        607000
                                                            $
HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE                                    2,740.00        463303
                                                            $           2,400.00
HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; WITH FISSURECTOMY                                 432203
HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE;                                 $               2,390.00        466701
HEMORRHOIDECTOMY,INTERNAL AND EXTERNAL,COMPLEX OR EXTENSIVE$                                     2,390.00        442701
                                                             $
HEMORRHOIDOPEXY (EG, FOR PROLAPSING INTERNAL HEMORRHOIDS) BY STAPLING                            4,100.00        502600
HEP A IMMUNIZATION-PEDIATRIC                                                     $                  90.00        681900
HEP B IMMUNIZATION/ PED/ ADOLESCENT                                              $                  90.00        502700
HEPARIN FLUSH                                                                    $                  10.00        502800
HEPATITIS B TITER 4DOSE                                                          $                 100.00        447501
                                                               $
HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR INTRAMUSCULAR USE                            50.00        463101
Hepatitis B vaccine, adult dosage for intramuscular                              $                  60.00        462901
HETEROPHILE ANTIBODIES, MONOSPOT TEST                                            $                  65.00        405201
Hib IMMUNIZATION                                                                 $                  35.00        462902
Hib-HBV IMMUNIZATION                                                             $                 150.00        405202
HIP XRAY BILATERAL                                                               $                  80.00        464401
                                                                                 $               125.00         684400
History and examination of the normal newborn infant, including the preparation of medical records. (This code should only be used for newborns asse
History and examination of the normal newborn infant, initiation of diagnostic and$                95.00       468701
                                                                                   treatment programs and preparation of hospital records. (This cod
Hospital discharge day management                                                $                 115.00        468801
Hospital discharge day management                                                $                 160.00        800101
HUBER NEEDLE NO 20                                                               $                  30.00        800102
HUMURUS TWO VIEWS                                                                $                 100.00        625000
I/V INFUSION 1000 ML                                                             $                  40.00        464201
IILEOSTOMY OR JEJUNOSTOMY , NON TUBE                                             $               1,800.00        486001
IMMUNIZATION ADMIN BY INTRANASAL OR ORAL ROUTE                                   $                  10.00        608000
IMMUNIZATION ADMIN-EACH ADDITIONAL ORAL/INTRANASAL                               $                  10.00        459803
IMMUNIZATION ADMINISTRATION-EACH ADDITIONAL VACCINE-IM                           $                  30.00        310500
IMMUNIZATION ADMINISTRATION-IM                                                   $                  30.00        318600
Implantation of mesh or other prosthesis for incisional or ventral hernia repair or$              1,500.00       315600
                                                                                    mesh for closure of debridement for necrotizing soft tissue infect
                                                             $          3,055.00     POSTCONCEPTION AGE AND YOU
INCARCERATED OR STANGULATED HERNIA REPIRE DONE ON PRETERM INFANTS OLDER THAN 50 WEEK 486201
INCARCERATED OR STRANGULATED                                                     $               5,110.00        486301
Incarcerated or strangulated                                                     $               5,110.00        405402
                                                               $
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS                         400.00         463001
                                                            $
INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION                                     500.00         312100
                                                                                 $              2,200.00
Incision and drainage of intramural,intramusclular or submucosal abscess,transanal, under anesthesia             312200
                                                             $
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS                                  2,390.00        625200
                                                             $          2,200.00
INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY                                   621400
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED                             $                550.00         309000
                                                            $
INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION                                    2,025.00        683100
INCISION AND DRAINAGE, LEG OR ANKLE ABSCESS OR HEMATOMA                          $               2,025.00        480001
Incision and drainage, upper arm or elbow area:deep abscess or hematoma              $               1,700.00        677700
Incision and removal of foreign body, subcutaneous tissues: simple                   $                400.00          468201
Influenza A virus detection                                                          $                  35.00        677800
INFLUENZA B VIRUS DETECTION                                                          $                  35.00        608400
Influenza virus vaccine,split virus, 3yrs and older                                  $                  30.00        608300
INFLUENZA VIRUS VACCINE-6-35 MONTHS-IM                                               $                  25.00        679000
INFUSION THERAPY                                                                     $              2,745.00         679200
INFUSION, NORMAL SALINE SOLUTION , 1000 CC                                           $                   5.00         679100
                                                            $          2,560.00
INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUETS NODE (SEPARATE                                        480401
                                                                                $                  125.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender622300
                                                                                $                  130.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender670400
                                                                                $                  115.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender670700
                                                                                $                  125.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender677600
                                                                                $                  167.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender629900
                                                                                $                  186.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender647900
                                                                                $                  198.00        appropriate history, examination, co
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender647800
Initial hospital care, per day, for the evaluation and management of a patient       $                 150.00        608500
Initial hospital care, per day, for the evaluation and management of a patient       $                205.00         608700
Initial hospital care, per day, for the evaluation and management of a patient       $                300.00          513800
Initial inpatient consultation for a new or established patient                      $                  80.00         317400
Initial inpatient consultation for a new or established patient                      $                 125.00        608900
Initial inpatient consultation for a new or established patient                      $                250.00          609100
Initial inpatient consultation for a new or established patient                      $                240.00         683700
Initial inpatient consultation for a new or established patient,                     $                280.00         609000
                                                                                   $                 1,500.00         485501
Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less
                                                                                    $                 ill infant    485601
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically1,300.00 or young child, 29 days through 24 months
Initial observation care, per day, for the evaluation and management of a patient $                    110.00         484201
Initial observation care, per day, for the evaluation and management of a patient $                   224.00          461603
Initial observation care, per day, for the evaluation and management of a patient, $                   180.00        682400
INITIAL PREV VISIT, FIRST 12 MONTHS OF MCR ELIG                                      $                200.00         206800
INJ ZOFRAN / INJECTION 1 MG                                                          $                  10.00        609300
Injection dexamethasone sodium phosphate (DECADRON)                                  $                  10.00         314800
                                                            $
INJECTION MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE,150mg                                       75.00         314700
injection potassium chloride, per 2 mEq                                              $                   1.00        680800
                                                             ANESTHETIC STERIOD
INJECTION PROCEDURE FOR SACROILIAC JOINT,ARTHROGRAPHY AND OR $           400.00                                      609800
                                                             ANESTHETIC STERIOD
INJECTION PROCEDURE FOR SACROILIAC JOINT,ARTHROGRAPHY AND OR $           400.00                                       601700
Injection(s):single or multiple trigger points, one or two muscles                   $                 150.00         601800
INJECTION, (COMPAZINE) PROCHIORPERAZINE, UP TO 10MG                                  $                  35.00         625100
INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE                                 $                 190.00         601600
                                                              $
INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES                                     400.00         622600
                                                               $
INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, REGIONAL BLOCK 1,130.00                                    480901
INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH $                                       400.00          480801
Injection, anesthetic agent; stellate ganglion (cervical sympathetic)                $               1,250.00        439705
INJECTION, CEFTRIAXONE SODIUM,PER 250 MG ( ROCEPHIN)                                 $                  45.00        406304
INJECTION, COSYNTROPIN, PER 0.25MG                                           $            25.00      443604
INJECTION, DEPO-ESTRADIOL CYPIONATE,UP TO 5MG                                $            40.00      685300
INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH                                  $          400.00        312900
INJECTION, ESTRADIOL VALERATE,UP TO 40MG                                     $            25.00       312400
INJECTION, ESTROGEN CONJUGATED,PER 25 MG                                     $            45.00       312600
Injection, fentanyl citratge, 0.1mg (Sublimaze) for sedation                 $            15.00       312300
INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100mg                      $            20.00       685100
Injection, lincomycin HCI,up to 300mg                                        $            15.00       312800
Injection, medroxyprogesterone acetate for contraceptive ,50mg ,Depro-vera   $            65.00       312700
INJECTION, MEPERIDINE HYDROCHLORIDE,PER,DEMEROL 100mg                        $            50.00      609200
INJECTION, METHYLPREDNISOLONE ACETATE, 80MG                                  $            25.00      682300
INJECTION, PHYTONADIONE VITAMIN K 1mg                                        $             5.00       313100
Injection, testosterone cypionate, up to 100mg                               $            50.00       314100
Injection, vitamin B-12 cyanocobalamin, up to 1000mcg                        $            25.00       211900
INJECTION,BETAMETHASONE SODIUM PHOSPHATE, PER 4MG                            $            25.00       211200
INJECTION,CEPHALOTHIN SODIUM,UP TO 1G,(KEFLIN)                               $            80.00       211300
Injection,clindamycin phosphate,300mg                                        $            30.00       212100
INJECTION,GAMMA GLOBULIN, INTRAMUSCULAR, 4CC                                 $            35.00       211400
INJECTION,KETOROLAC TROMETHAMINE,PER 15MG (TORADEL)                          $            35.00       212000
INJECTION,MIDAZOLAM HCI,PER1mg (Versed)                                      $            15.00      207300
INJECTION,PROMETHAZINE HCI,UP TO 50mg (PHEREGAN)                             $            40.00      220000
                                                            $
INJECTION,SOLUMEDRAL , METHYLPREDNISOLONE SODIUM SUCCINATE,UP TO 125mg                    25.00       671100
                                                                    when drug administered under the direct supervision of a physician,
INJECTION,SUMATRIPTAN SUCCINATE, 6mg (code may be used for medicare $                80.00       314000
INJECTION,TESTOSTERONE CYPIONATE, 1cc, 200mg                                 $            60.00      456904
Injection,triamcinolone acetonide, per 10mg (KENELOG 10)                     $             5.00       465901
                                                            $           1,000.00
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5+                          443101
INSERTION OF TUNNELED CENTRALLY INSERTED AGE 5YRS OR OLDER                   $         2,635.00       482501
                                                             $          3,500.00    431202
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PUMP
Insufficient Funds (Fee)                                                     $            25.00       312500
Intercostal nerve, single                                                    $          570.00        313000
INTRAVENOOUS INFUSION HYDRATION, 31 MIN TO 1 HR                              $           112.00       313200
IPPB MACHINE,ALL TYPES, WITH BUILT-IN NEBULIZATION                           $            35.00       311000
IPV IMMUNIZATION                                                             $            36.00       315700
Iron-Dextran 165/ 50mg                                                       $            15.00       315800
itermediate repair, single layer, neck,hands,feet,genitalia 2.6to 7.5 cm     $          400.00        421701
IV INFUSION FOR THERAPY, PROPHYLAXIS OR DIAGNOSIS                            $           132.00       406801
IV infusion, hydration, initial, 31 min to 1 hour                            $           150.00      206900
IV PUSH                                                                      $           108.00       214500
                                                               $          1,800.00
LAPAROSCOPY , SURGICAL ENTEROLYSIS( FREEING OF INTESTINAL AHESION) SEPARATE PE                        214000
                                                           $         2,855.00     610600
LAPAROSCOPY ABDOMEN,PERITONNEUM, OMENTUM, DIAGNOSTIC WITH OR WITH WITHOUT COLLECTION OF SPECIMENS BY BRUSHING
LAPAROSCOPY, SURGICAL, APPENDECTOMY                                          $         1,050.00       319000
                                                            $
LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE5,700.00                      463601
                                                             $           900.00
LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT BIOPSY                       463201
                                                              $          2,400.00     611200
LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL) OOPHORECTOMY OR SALPINGECTOMY
                                                              $           350.00     680400
LAPROSCOPEY ,SURGICAL MOBILIZATION OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY
                                                             $
LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; FOR ASPIRATION                               1,645.00       458806
                                                                $           1,020.00
LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS OVER 30.0CM                            311100
LAYER CLOSURE SCALP, TRUNK, EXTREMITIES 2.6-7.5                                 $                380.00        685000
Levalbuterol, inhalation solution, compunded, 0.5 mg                            $                 25.00         470201
LIDOCAINE 1% 3CC                                                                $                  15.00        484601
LIGATION OR BIOPSY TEMPORAL ARTERY                                              $                750.00         484701
LIGHT COMPRESSION BANDAGE                                                       $                 25.00         484401
LUMBAR OR SACRAL, SINGLE LEVEL                                                  $               1,250.00        484501
LUMBAR,SACRAL SINGLE INJECTION                                                  $                700.00         469201
                                                            OR        2,000.00
MANAGEMENT OF LIVE HEMORRHAGE,COMPLEX SUTURE OF LIVER WOUND $ INJURY WITH                                       611500
MARCAINE 30 ML/30 CC                                                            $                 40.00         611700
MASTECTOMY                                                                      $              2,000.00         461301
MASTECTOMY FOR GYNECOMASTIA                                                     $              2,530.00         442901
MASTECTOMY, PARTIAL                                                             $              2,305.00         612000
                                                             $          3,600.00
MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);                                 408201
Mastectomy, simple                                                              $              3,500.00        459902
MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS                               $              2,025.00        684500
                                                              $             100.00
MENACTRA,MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W-135 (TETRAVALENT), 466002
MISCELLANEOUS SUPPLIES                                                          $                 30.00         466001
MMR IMMUNIZATION                                                                $                 50.00         465501
MMR, VACCINE, LIVE, SUBCUTANEOUS                                                $                 50.00        682600
MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED                           $                130.00        684700
moderate comression bandage                                                     $                   5.00        313400
morphine sulfate                                                                $                  10.00        467201
MULTI VITAMIN                                                                   $                 40.00         423701
NECK BRACE                                                                      $                 40.00         466301
NECK COLLAR                                                                     $                 30.00         467301
Noninvasive ear or pulse oximetry for oxygen saturation                         $                 25.00         467901
                                                                                 $                  of baby    466101
Normal newborn care in other than hospital or birthing room setting, including physical examination145.00 and conference(s) with parent(s)
Novolog 5 units                                                                 $                 30.00         612200
Observation care discharge day management                                       $                 115.00       409403
                                                                                 $                 115.00        470701
Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date
                                                                                 $                 280.00        463501
Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date
                                                                                 $                 350.00        318900
Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date
Office consultation for a new or established patient                            $                 85.00         612400
Office consultation for a new or established patient                            $                215.00         470801
Office consultation for a new or established patient                            $                315.00         612600
Office consultation for a new or established patient                            $                385.00         513500
Office consultation for a new or established patient,                           $                160.00         513400
                                                                                 $
Office or other outpatient visit for the evaluation and management of a new patient               70.00         313600
                                                                                 $
Office or other outpatient visit for the evaluation and management of a new patient              120.00         421802
                                                                                 $
Office or other outpatient visit for the evaluation and management of a new patient              180.00        684900
                                                                                 $
Office or other outpatient visit for the evaluation and management of a new patient              215.00         613000
                                                                                 $
Office or other outpatient visit for the evaluation and management of a new patient                240.00         466201
                                                                                 $
Office or other outpatient visit for the evaluation and management of an established patient         40.00        637700
                                                                                 $
Office or other outpatient visit for the evaluation and management of an established patient         75.00        613100
                                                                                 $
Office or other outpatient visit for the evaluation and management of an established patient        120.00        303200
                                                                                 $
Office or other outpatient visit for the evaluation and management of an established patient        180.00        310100
                                                                                 $
Office or other outpatient visit for the evaluation and management of an established patient       240.00         311200
Omentectomy, epiploectomy, resection of omentum                                   $               1,500.00        311300
OOPHORECTOMY                                                                      $               1,820.00        613200
OPEN REPAIR LARGE INTESTINE W/COLOSTOMY                                           $              2,500.00         310300
OptiRay Iodine Dye                                                                $                   5.00        316700
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT)                                          $                  45.00        317200
Osteopathic manipulative tx 3 to 4 body regions involved                          $                  90.00        309300
Oxygen contents, gaseous,1unit equals 1cubic foot                                 $                  15.00        464801
Pap Smear and Breast Exam                                                         $                  70.00        314900
                                                            $
PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY                             2,000.00         428701
PCV-PNEUMOCOCCAL CONJUGATE VACCINE-YOUNGER THAN 5 YEAS-IM                         $                 140.00        637800
                                                                               $                 160.00
Periodic comprehensive preventive medicine reevaluation and management of an individual 65 or older               613300
                                                                               $                   4
Periodic comprehensive preventive medicine reevaluation and management of an individual age of 1 -175.00          627200
                                                                               $                  - 17
Periodic comprehensive preventive medicine reevaluation and management of an individual age of 12145.00           453301
                                                                               $                 160.00
Periodic comprehensive preventive medicine reevaluation and management of an individual age of 180-039            315400
                                                                               $                 160.00
Periodic comprehensive preventive medicine reevaluation and management of an individual age of 40 - 64            315000
                                                                               $                 160.00
Periodic comprehensive preventive medicine reevaluation and management of an individual age of 5 through 11       613400
                                                                               $                 190.00
Periodic comprehensive preventive medicine reevaluation and management of an individual under 1 year of age       626100
                                                             $
PERITONEOCENTIESIS, ABDOMINAL PARACENTESIS, OR PERTONEAL LAVAGE                                    855.00         463401
Pneumococcal polysaccharide vaccine                                               $                  40.00        465601
Pressurized or nonpressurized inhalation tx for acute airway obstruction.         $                  30.00        466601
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE                                     $              2,500.00         512500
                                                                                   $                  beyond      512300
Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact140.00 the usual service (eg, maternal fetal monit
                                                                                   $                  beyond      512400
Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact140.00 the usual service (eg, maternal fetal monit
                                                                                   $                155.00         467001
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
                                                                                   $                160.00        444502
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
PROTHROMBIN TIME                                                                  $                  20.00        681700
Psychological testing with professional interpretation and report                 $                 100.00        467401
PULPOTOMIY, FORMOCRESAL                                                           $                200.00         613800
PULPPAL DEBRIDEMENT PRIMARY AND PERM TEETH                                        $                 150.00        626800
PURETONE AUDIOM                                                                   $                  65.00        613600
                                                                           $                  70.00         measurements,with or without maxi
QUICK FLOW FLU TEST/Spirometry,including graphic record,total and timed vital capacity,expiratory flow rate680700
QUICK STREP TEST                                                                  $                  30.00        613900
Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or thorax$              3,375.00         644200
RADIOLOGIC EXAM MIN 3 VIEWS                                                       $                 150.00        514000
RADIOLOGIC EXAM RIBS & CHEST                                                      $                 150.00        508000
Radiologic exam, knee,three views                                                 $                  70.00        614300
Radiologic exam,chest,two views,frontal and lateral                               $                  85.00        314300
Radiologic exam,ribs,unilateral;two views                                         $                 130.00        637500
Radiologic exam,sinuses,paranasal, less than three views                           $               65.00      614400
                                                           $
RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND ADDITIONAL OBLIQUE 40.00                                 303400
                                                           $
RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW                                       40.00      316600
RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS                                           $               35.00      317000
Radiologic examination, hip, unilateral; complete, minimum of two views            $               70.00      309200
                                                             $
RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR VIEWS                                     60.00       317100
Radiologic examination,hand,minimum 3 views                                        $               60.00      303600
Radiologic examination,neck,soft tissue                                            $               80.00      404001
Radiologic examination;tibia and fibula,two views                                  $               60.00      673400
RADIOLOGICAL EXAM, SURGICAL SPECIMEN                                               $               40.00      614600
REFILLING AND MAINTENANCE OF PORTABLE PUMP                                         $              480.00      318700
                                                            $           125.00
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA                                 314600
                                                              $          2,000.00
REMOVAL OF ALL REMAINING THYROID TISSUE AFTER PREV REMOVAL OF PORTION OF THYROID                              309500
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY UNDER ANESTHESIA $                                     900.00      664500
                                                              $
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON, DEEP OR COMPLICATED                                 1,200.00     614700
                                                                 $            2
REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR,600.00                        484801
REMOVAL OF PROSTHETIC MATERIAL OR MESH                                             $             1,500.00     485301
Removal of tunneled central venous access device, w/subcutaneious port or pump $                 1,400.00     485401
                                                           $           OR PUMP
REMOVAL OF TUNNELED CENTRAL VENOUSE CATHETER,WITHOUT SUBCUTANEOUS PORT 1,190.00                               484901
Repair comples, scalp, arms, and /or legs 2.6cm to 7.5cm                           $              450.00      485001
                                                                 $          1,500.00
REPAIR COMPLEX FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, FEET 2.6-7.5 411501
                                                                 $             FEET         318100
REPAIR COMPLEX FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, 450.00ADD 5 CM OR LESS
Repair hands feet trunk and extremities 2.6cm to 5.0cm                             $              200.00      614800
repair inguinal hernia 6 mo. to 5 yrs.                                             $             1,000.00     630700
Repair inguinal hernia any age incarcerated or strangulated                        $             5,110.00     630500
Repair initial incisional or ventral hernia;reducible                              $             3,055.00     682200
                                                                $
REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED                                5,110.00     681300
Repair initial inguinal hernia, age 5years or older:reducible                      $             3,055.00     684100
                                                                $
REPAIR INTERMEDIATE SCALP, AXILLAE, TRUNK, INCLUDING HANDS & FEET                                 400.00      684800
                                                                                   $
Repair laceration 2.6cm to 7.5cm hands, feet, neck scalp axillae,external genitalia, and trunk    200.00      684600
                                                               $           340.00
REPAIR LAYER CLOSURE OF WOUNDS FACE,EARS,EYELIDS,NOSE,LIPS AND OR MUCOUS MEMBRANE                             452601
Repair lip                                                                         $             1,645.00     683300
Repair of nail bed                                                                 $              340.00       411601
Repair of porta catheter without replacing any parts                               $             1,520.00     480501
REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA REDUCIBLE                            $             3,055.00     643200
REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE                               $             4,000.00     615500
                                                                $
REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED OR STRANGULATED 5,110.00                           315500
Repair umbilical hernia, age 5years or older; reducible                            $             2,920.00     637900
Repair umbilical hernia, under age 5 years; reducible                              $             3,050.00     682900
                                                              $              2.6-7.5
REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA;150.00                            682700
                                                                $            495.00
REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/ OR EXTREMITIES 7.6-12.5                            683000
                                                                                 $              2,630.00        313800
Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access
RESIN COMPOSITE 1 SURFACE, ANTERIOR                                                $               100.00     313900
RESIN COMPOSITE 1 SURFACE, POSTERIOR                                               $               100.00     615700
RESIN COMPOSITE 2 SURFACES, ANTERIOR                                               $                100.00         615800
RESIN COMPOSITE 2 SURFACES, POSTERIOR                                              $                100.00         616000
RESIN COMPOSITE 3 SURFACES, ANTERIOR                                               $                100.00         615900
RESIN COMPOSITE 3 SURFACES, POSTERIOR                                              $                100.00         616400
RESIN COMPOSITE 4 OR MORE SURFACES, ANTERIOR                                       $                100.00         308300
RESIN COMPOSITE 4 OR MORE SURFACES, POSTERIOR                                      $                100.00         100100
RESIN COMPOSITE CROWN, ANTERIOR                                                    $                100.00         100101
                                                                $           2,000.00
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE)                                   100103
                                                             $          4,000.00
REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE)                                    100102
                                                               $           6,700.00    100104
REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTIBLE DEVICE
RINGER LACTATE INFUSION 1000 ML                                                    $                   5.00        100105
ROTAVIRUS VACCINE                                                                  $                 35.00         616700
RUPTURE APPENDIX WITH ABCESS OR GENERALIZED PERITONITIS                            $              1,400.00         424104
SALINE, FLUSH 10 ML                                                                $                  10.00        677900
SCAPULA                                                                            $                 115.00        678000
SCREENING PAPANICOLAOU SMEAR                                                       $                 50.00         672100
SEALANT PER TOOTH                                                                  $                200.00         667800
                                                               $            30.00
SERVICES PROVIDED IN THE OFFICE AT TIMES OTHER THAN REGULARLY SCHEDULED OFFICE                                     616300
SHOULDER THREE VIEWS                                                               $                125.00         638100
SHOULDER TWO VIEWS                                                                 $                 98.00         616800
SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE                           $               1,100.00        317700
                                                                 $
SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION1,315.00                               308000
SIGMOIDOSCOPY,FLEXIBLE                                                             $                355.00         314200
simple repair scalp, neck, genitalia, trunk 2.5 cm or less                         $                200.00         617000
simple wound repair, scalp, neck, genitalia, trunk, extremities 20.1 to 30.0 cm    $                320.00         617100
Sling                                                                              $                  15.00        429701
Specialty absorptive dressing                                                      $                  15.00        673800
                                                              $
SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)                                  2,400.00         625800
SPINAL PUNCTURE,LUMBAR,DIAGNOSTIC                                                  $                570.00         675000
Spinal puncture,therapeutic, for drainage of cerebrospinal fluid                   $                570.00         617600
SPLINT                                                                             $                 30.00         622400
SPORT TRAINING EVALUATION                                                          $                 20.00         670300
                                                             $
STAINLESS STEEL CROWN, PRIMARY TOOTH, ANTERIOR TOOTH, WITH RESIN WINDOW 100.00                                     670600
STAINLESS STEEL CROWN, PRIMARY TOOTH, MOLAR                                        $                100.00         617200
Streptococcus                                                                      $                 20.00         617400
                                                                              $
Subsequent hospital care, for the evaluation and management of a normal newborn, per day             50.00         617500
                                                                                $
Subsequent hospital care, per day, for the evaluation and management of a patient                    60.00         681400
                                                                                $
Subsequent hospital care, per day, for the evaluation and management of a patient                    110.00        413410
                                                                                $
Subsequent hospital care, per day, for the evaluation and management of a patient                   160.00         680900
                                                                                  $                650.00            28 days
Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate,617700 of age or less
                                                                                  $                640.00            681000
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 m
                                                                                $                 weight       (present
Subsequent intensive care, per day, for the evaluation and management of the recovering low birth205.00 infant 461803 body weight of 1500-2500
                                                                                $                birth weight infant (present body weight less than
Subsequent intensive care, per day, for the evaluation and management of the recovering very low 225.00         485801
SURGICAL TRAY                                                                      $                 50.00         620000
                                                            $
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); COMPLEX                               2,860.00         617900
                                                            $          2,680.00
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBMUSCULAR                                            618000
                                                               $
SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM1,500.00                                    633600
                                                              $           2,500.00    685700
SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND ,INJURY,OR RUPTURE SINGEL PERFO
SUTURE REMOVAL                                                                       $                  20.00         422802
Suture, secondary, of abdominal wall for evisceration or dehiscence                  $               2,800.00         618100
Synagis                                                                              $                    -           303500
Tendon sheath incision(eg, for tigger finger)                                        $               1,950.00         681200
                                                            $
TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; SINGLE TENDON (SEPARATE 2,330.00                                       485701
                                                           $             7YEARS OR 484101
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED WHEN ADMINISTERED TO INDIVIDUALS35.00      ORDER,INTRAMUSCULAR USE
Tetanus toxoid adsorbed, for intramuscular use                                       $                  30.00         483901
Therapeutic, prophylactic, or diagnostic injection intra-arterial                    $                  40.00         484001
Therapeutic, prophylactic, or diagnostic injection subcutaneous or IM                $                  40.00         618200
Therapeutic,prophyiactic or diagnostic injection subcutaneous or intramuscular       $                  40.00
THREE OR MORE VIEWS                                                                  $                 130.00
Thumb repair (includes muscle)                                                       $               2,140.00
                                                           $
THYROID LOBECTOMY, UNILATERAL, WITH OR WITHOUT ISTHMESECTOMY                                         1,450.00
TIGAN 200mg                                                                          $                  10.00
toe (2) minumum of two view                                                          $                  50.00
TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX),                                    $               1,000.00
                                                             $          3,000.00
TUBE THORACOSTOMY , INCLUDES WATER SEAL (EG FOR ABCESS,HEMOTHORAX EMPYEMA ) WHEN PERFORMED ( SEPARATE PROCEDURE )
Tuberculosis, intraderal                                                             $                  20.00
TYMPANOGRAM TESTING                                                                  $                  45.00
UNLISTED PROCEDURE ,RECTUM                                                           $                 750.00
Unlisted procedure inner ear                                                         $                 200.00
Unspecified pulmonary procedure.                                                     $                  20.00
                                                               SNARE
UPPER GASTRO ENDOSCOPY WITH REMOVAL OF TIMOR, POLYP, LESION BY $                                       600.00
                                                           $           THE
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS STOMACH AND ETHER 1,635.00
                                                           $
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH                                        1,635.00
                                                           $
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH                                        1,635.00
                                                                               $              jejunum.
Upper gastrointestinal endoscopy including esophagus, stomach,and either the duodenum and /or 1,300.00
URETEROLYSIS FPR OVARIAN VEIN SYNDROME                                               $               2,500.00
                                                                $              10.00
URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, K
                                                                                    $                   25.00
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any
URINE CATHERIZATION                                                                  $                  30.00
Urine pregnancy test, by visual color comparison methods                             $                  25.00
                                                            $           250.00
UROGRAPHY(PYLELOGRAPHY) INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY
VARICELLA IMMUNIZATION                                                               $                  75.00
Vasectomy                                                                            $               2,190.00
VISION TEST                                                                          $                  20.00
VISTARIL /INJECTION,HYDROXYZINE HCL,UP TO 25mg                                       $                  25.00
WITH BIOPSY,SINGLE OR MULTIPLE                                                       $               1,635.00
WITH COLOPROCTOSTOMY                                                                 $               3,000.00
WITH COLOPROCTOSTOMY(LOW PELVIC ANASTOMOSIS)                                         $               3,600.00
With direct placement of percutaneous gastrostomy tube   $   1,635.00
WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT         $   3,000.00
With removal of foreign body                             $   1,305.00
With removal of foreign body                             $   1,635.00
WRIST 3 VIEWS                                            $     95.00
WRIST TWO VIEWS                                          $     95.00
XRAY CALCANEUS, MIN 2 VIEWS                              $     40.00
XRAY TOES                                                $     50.00
XRAY; ABD & CHEST 3 VIEWS                                $     180.00
XRAY; ANKLE 2 VIEWS                                      $     95.00
XRAY; ANKLE 3 VIEWS                                      $     110.00
XRAY; C-SPINE 3 VIEWS                                    $     130.00
XRAY; C-SPINE 5 VIEWS                                    $     165.00
XRAY; C-SPINE COMP 7 VIEWS                               $     190.00
XRAY; ENTIRE SPINE                                       $    240.00
XRAY; FOOT 2 VIEWS                                       $     60.00
XRAY; FOOT 3 VIEWS                                       $     125.00
XRAY; HIP 1 VIEW                                         $     88.00
XRAY; KNEE 4 VIEWS                                       $     125.00
XRAY; L-SPINE & FLEX 7 VIEWS                             $    200.00
XRAY; L-SPINE COMP 5 VIEWS                               $     170.00
XRAY; L-SPINE LTD 3 VIEWS                                $     118.00
XRAY; PELVIS COMP 3 VIEWS                                $     135.00
XRAY; PELVIS ONLY 1 VIEW                                 $     100.00
XRAY; SACRUM & COCCYX                                    $     115.00
XRAY; SPINE                                              $     100.00
XRAY; T-SPINE 2 VIEWS                                    $     125.00
XRAY; T-SPINE COMP 3 VIEWS                               $     130.00
XRAY; THOR-LUM AP & LAT                                  $     130.00
XRAY; THORACO/LUMBER                                     $     125.00
XRAYS; KNEE 2 VIEWS                                      $     95.00
XRAYS; MANDIBLE MIN OF 4 VIEWS                           $     135.00
                             2/20/2012                                                                  11/28/2011

                              OTC-4808                                                                   OTC-3489
                    BMA BULLHEAD CITY DIALYSIS                                                      Bullhead Urgent Ca
                                                                                    Donald Wagner, D.O, dba; Bullhead
                        2650 MIRACLE MILE                                                         1355 Ramar Road, Sui
                           BULLHEAD CITY                                                                Bullhead City
                              ARIZONA                                                                       AZ
                                  86442                                                                    86442


                                  SAME                                                                     SAME




                                                                                                       928-704-9202
                             1669584462                                                                 1225158470
                                 325705                                                                 685399001
                                  YES                                                                       YES
                                 03 2558                                                                   76322
                         ADRIENNE ADKINS                                                               Donald Wagner
                            928-763-5550                                                               928-704-9202
                     adrienne.adkins@FMC-NA.com                                               bullheadurgentcare@npgc
                                 JAY RAY                                                               Donald Wagner
                            480-458-9600                                                               928-704-9202
                         jay.ray@FMC-NA.com                                                   bullheadurgentcare@npgc
                         VALERIE KNUEVEN                                                               Sandy Lubinski
                            928-763-5550                                                               928-704-9202
                     valerie.knueven@FMC-NA.com                                                   urgentcare@npgcable
                                                                                                         11/3/2008


                       Discription of Charge          Rate of Charge     Service Code


HEP B SURFACE AB (ANTI-HBS)                       $             163.91      10060
2 HR DIALYSATE UREA                               $              60.18      10061
2HR DIAL TOTAL PROTEIN                            $             55.90       10080
4HR DIAL TOTAL PROTEIN                            $             55.90       10120
ABO GROUPING                                      $             45.53       10121
ABO TYPING                                        $             177.00      10140
ABSOLUTE - LYMPHOCYTES                            $             38.84       10160
ACCESS FLOW TEST                                  $             127.91      11040
ACETAMINOPHEN (PO) 325 MG          PO             $               0.49      11041
ACID ELUTION                                      $             48.76       11042
ADENOSINE 6 MG              IV                    $             328.17      11055
ADMIN SUPPLY - IV                                 $             52.00       11100
ADMIN SUPPLY INJECTION - IVP              $     52.00    11101
AEROBIC ORGANISM IDENTIFICATION #3        $    123.30    11200
ALBUMIN, SERUM                            $     75.55    11400
ALKALINE PHOSPHATASE                      $     78.88    11401
ALPHA-1 ANTITRYPSIN; TOTAL                $    385.01    11406
ALPHA-1 ANTITRYPSIN; TOTAL PHENOTYPE      $    253.36    11443
ALT - SGPT                                $     80.75    11720
ALUM HYDROXIDE (PO) 320 MG           PO   $       0.81   11730
ALUMINUM SERUM, STIMULATED (W/DFO)        $    388.46    11732
ALUMINUM SERUM,UNSTIMULATED W/0 DFO       $    388.46    11740
AMIKACIN SULFATE 100 MG             IV    $       9.91   11740
AMIODARONE HYDROCHLORIDE(CORDARONE)       $     161.86   11750
AMPHOTERICIN B 50 MG            IV        $     82.68    11752
AMPICILLIN 500 MG          IV             $     20.18    11760
AMYLASE LEVEL                             $     98.83    11765
ANA (ANTINUCLEAR ANTIBODIES)              $    266.26    12001
ANAEROBIC BACTERIAL ID #1                 $    123.30    12002
ANTI NUCLEAR ANTIBODY                     $    170.20    12004
ANTIBODY ELUTION, RBC                     $    567.88    12006
ANTIBODY IDENTIFICATION                   $   1,055.90   12007
ANTIBODY SCREENING                        $    394.06    12011
ANTIGEN SCREENING                         $    194.39    12013
ANTIGEN SCREENING (REGENT)                $    376.77    12014
ANTIGEN TYPING                            $    330.08    12015
ANTIHUMAN GLOBULIN QUAL., INDIRECT        $    524.98    12031
ANTIHUMAN GLOBULIN TITER, INDIRECT        $     255.11   12032
ANTIHUMAN GLOBULIN, DIRECT                $    187.23    12034
ANTI-NEUTROPHILCYTOPLASMIC TITER          $    229.67    12036
ANTISTREPTOLYSIN-O; SCREEN                $     110.16   12041
ANTISTREPTOLYSIN-O;TITER                  $    196.57    12042
APLISOL-5TU 1 ML          IV              $     22.14    12044
APTT                                      $     91.57    12051
ARANESP 1 MCG                             $      51.13   12052
ASCORBIC ACID 70 MG            IV         $      2.08    13120
AST - GOT                                 $     78.75    13121
ATENOLOL (PO) 25 MG            PO         $      6.77    13132
ATROPINE SULFATE 0.1 MG IV                $      8.53    16000
ATTAPULGITE (P0) 750 MG         PO        $       1.44   16020
AZITHROMYCIN 500 MG             IV        $    214.82    17000
AZTREONAM 500 MG                          $     89.45    17110
BETA 2 MICROGLOBULIN                      $    246.64    17250
BICARBONATE                               $     74.57    20550
BICARBONATE (POST)                        $     74.57    20551
BILIRUBIN, DIRECT                         $     76.55    20552
BILIRUBIN, TOTAL                                  $     76.55    20553
BI-PTH                                            $    629.80    20600
BKP CONVENTIONAL HEMODIALYSIS                     $   2,935.00   20605
BKP CONVENTNL/CATHETER HEMODIALYSIS               $   2,935.00   20610
BKP HIGH EFF/CATHETER HEMODIALYSIS                $   2,935.00   20612
BKP HIGH EFFICIENCY HEMODIALYSIS                  $   2,935.00   24640
BKP HIGH FLUX HEMODIALYSIS                        $   2,935.00   26770
BKP HIGH FUX/CATHETER HEMODIALYSIS                $   2,935.00   26775
BLOOD COUNT, SMEAR, MICROSCOPIC W/O MANUAL DIFF   $     52.46    27096
BLOOD SUPPLIES                                    $     32.76    29105
BLOOD, TUBING FILTER                              $     90.55    29125
BUN, ARTERIAL                                     $      60.12   29130
BUN, PERIPHERAL                                   $      60.12   29505
BUN, POST, SERUM                                  $      60.12   29515
BUN, PRE (BLOOD UREA NITROGEN)                    $      60.12   29550
BUN, SERUM                                        $      60.12   30000
BUN, VENOUS                                       $      60.12   30020
CALCITRIOL 0.1 MCG           IV                   $     22.00    30300
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   30901
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   30903
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   31033
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   31525
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   36000
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   36415
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   40800
CALCITRIOL CAPSULES .25 MCG       PO              $       1.12   45900
CALCITRIOL CAPSULES .5 MCG        PO              $       2.11   46083
CALCITRIOL CAPSULES .5 MCG        PO              $       2.11   46230
CALCITRIOL CAPSULES .50 MCG       PO              $       2.11   46250
CALCITRIOL ORL SOL 1 MCG        PO                $      11.14   46320
CALCITRIOL ORL SOL 1 MCG        PO                $      11.14   46600
CALCIUM ACETATE PO 667 MG         PO              $       1.25   46608
CALCIUM CARBONATE (PO) 500 MG          PO         $       0.81   51700
CALCIUM CHLORIDE 10/ML 13.5 MEQ IV                $      10.15   51701
CALCIUM GLUCONATE 10 ML/4.65 MEQ                  $       7.38   51702
CALCIUM IONIZED                                   $    208.24    56420
CALCIUM, TOTAL, SERUM                             $     78.55    57415
CAPD METHOD 1                                     $   1,329.00   64450
CAPD TRAINING                                     $   3,605.00   64472
CAPTOPRIL (PO) 25 MG       PO                     $       6.45   64475
CARBAMAZEPHINE                                    $     221.93   64479
CARCINOEMBRYONIC ANTIGEN (CEA)                    $    422.72    65205
CARNITINE, FREE                                   $    255.79    65210
CARNITOR ORAL SOL 100 MG          PO              $       0.52   65220
CARNITOR SF ORL SOL 100 MG             PO              $       0.52   65220
CARNITOR TABLETS 330 MG               PO               $       1.50   69200
Catheter Care-incl Dressing Change                     $      85.10   69210
CATHFLO ACTIVASE DECLOT 1 MG [Note: VIAL SIZE 2 MG]    $    492.00    70110
CATHFLO ACTIVASE DWELL 1 MG [Note: VIAL SIZE 2 MG]     $    492.00    70140
CATHFLO ACTIVASE PACKING 1 MG [Note: VIAL SIZE 2 MG]   $    492.00    70150
CBC W/ DIFFERENTIAL                                    $     118.61   70200
CBC W/O DIFFERENTIAL                                   $      85.16   70220
CCPD METHOD 1                                          $   1,446.00   70250
CCPD TRAINING                                          $   3,605.00   70360
CEFAZOLIN 500 MG                 IV                    $     33.57    71010
CEFEPIME 500 MG                                        $     75.07    71020
CEFTAZEDIME 500 MG               IM                    $     89.56    71110
CEFTIZOXIME SODIUM 500 MG                  IV          $      94.17   71111
CEFTRIAXONE      250 MG     IV                         $     58.98    71120
CELL COUNT OF PERITONEAL FLUID                         $     72.04    71130
CENT CATH DRESSNG CHNG BL                              $      85.10   72050
CHLORIDE, BLOOD                                        $     70.04    72052
CHOLESTEROL, TOTAL, SERUM                              $     66.40    72100
CIMETIDINE 300 MG                IV                    $      12.18   72110
CIPROFLOXACIN LACTA 200 MG                 IV          $     119.15   72114
CITRATE 4% CATHLOCK                                    $    270.32    72170
CLONIDINE HCL (PO) 0.1 MG             PO               $       1.99   72190
CLONIDINE PATCH 0.3 MG                                 $    225.49    72220
CLOSTRIDIUM DIFFICILE TOXIN A                          $     168.03   73000
CLOSTRIDIUM DIFFICILE TOXIN B                          $     301.26   73010
CMV ANTIBODY                                           $     219.62   73030
CMV IGM ANTIBODY                                       $    257.08    73050
COMPATIBILITY TEST, ANTIGLOBULIN TECH                  $    325.27    73060
COMPATIBILITY TEST, IMMEDIATE SPIN                     $     417.09   73070
COMPATIBILITY TEST, INCUBATION                         $     417.09   73080
COMPLEMENT C3, SERUM                                   $     182.99   73090
COMPLEMENT C4                                          $     182.99   73100
COMPLEMENT FIXATION; EACH ANTIGEN                      $    729.50    73110
CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENT         $     101.88   73120
CORTISOL TOTAL, BLOOD                                  $    248.78    73130
COUNTERIMMUNOELECTROPHORESIS ANTIGEN                   $      55.31   73140
COURIER/STAT TRANSPORTATION FEE                        $     139.30   73510
C-REACTIVE PROTEIN                                     $     78.88    73520
CREATINE PHOSPHOKINASE, (CPK)                          $     99.39    73550
CREATININE CLEARANCE                                   $     144.05   73560
CREATININE DIALYSATE                                   $     78.88    73564
CREATININE DIALYSATE C GLUCOSE                         $     78.88    73590
CREATININE OF PD FLUID                                 $     78.88    73600
CREATININE OF PD FLUID - 24HR                  $    78.88   73610
CREATININE OF PD FLUID - OVERNIGHT             $    78.88   73610
CREATININE, BLOOD                              $    77.98   73620
CREATININE, POST, BLOOD                        $    77.98   73650
CREATININE, URINE                              $    78.88   73660
C-REATIVE PROTEIN                              $   251.97   74000
CRIT-LINE O2 SATURATION                        $   174.13   74020
CROSSMATCH, IMMEDIATE SPIN                     $   417.09   74022
CRYOPRECIPITATE                                $   325.44   80051
CUBICIN 1 MG                                   $     4.12   80053
CULTURE & SENSITIVITY                          $   131.27   80061
CULTURE & SENSITIVITY, BLOOD                   $   157.38   80074
CULTURE & SENSITIVITY, CVC EXIT SITE           $   131.28   80076
CULTURE & SENSITIVITY, PD CATHETER EXIT SITE   $   131.28   80100
CULTURE & SENSITIVITY, PD FLUID                $   131.28   80101
CULTURE & SENSITIVITY, STOOL                   $   248.95   81002
CULTURE & SENSITIVITY, URINE                   $   254.80   81025
CULTURE ACID FAST BACILLUS                     $   164.89   82075
CULTURE AEROBIC FLUID                          $   131.35   82150
CULTURE STOOL, AEROBIC ADDITIONAL PATHOGENS    $   143.89   82272
CULTURE STOOL,YERSINIA                         $   143.89   82273
CULTURE TYPING AGGLUTINATION #2                $    79.00   82550
CULTURE, AEROBIC                               $   157.38   82565
CULTURE, ANAEROBIC                             $   144.26   82607
CULTURE, FUNGAL                                $   128.05   82728
CULTURE, FUNGI, ISOLATION, BLOOD               $   137.43   82746
CULTURE, FUNGI, ISOLATION, OTHER               $   128.05   82951
CULTURE, FUNGI, ISOLATION, SKIN                $   128.05   82962
CULTURE, ROUTINE                               $   131.28   83036
CULTURE, SPUTUM                                $   131.28   83540
CULTURE, STOOL                                 $   248.96   83690
CULTURE, THROAT                                $   131.28   84439
CULTURE, URINE                                 $   254.80   84443
CULTURE, URINE COMPLETE                        $   123.31   84479
CULTURE, WOUND (SWAB)                          $   131.28   84484
CYCLOSPORIN                                    $   275.53   84520
CYPROHEPTADINE (PO) 4 MG         PO            $     3.57   84550
DEFEROXAMINE       500 MG   IV                 $    98.86   85025
DEPAKOTE LEVEL                                 $   149.19   85045
DEXTROSE (D50W) VL 50 ML         IV            $     8.51   85610
DEXTROSE (D50W) SYG 50 ML             IV       $    53.67   85652
DIFFERENTIAL WBC MANUAL                        $    52.46   85730
DIFFERENTIAL, AUTOMATED                        $    52.50   86060
DIFFICULT X-MATCH PROBLEM EVALUAT.             $   255.86   86140
DIGOXIN (PO) 0.125MG              PO                  $      2.67    86141
DIGOXIN 0.5 MG               IV                       $     22.99    86308
DIGOXIN LEVEL                                         $    202.40    86431
DILANTIN-FREE                                         $    202.09    86580
DILANTIN-TOTAL                                        $    202.08    86701
DILTIAZEM IV 50 MG            IV                      $     33.72    86704
DIPHENHYDRAMINE 50 MG                  IV             $     10.02    86735
DIPHENOXLAT/ATRO PO 2.5 MG              PO            $      3.95    86762
DIPHENYDRAMINE (PO) 25 MG              PO             $      0.49    86765
DRESSING CHANGE                                       $     85.10    86787
DRUG SCREEN, URINE                                    $    221.84    86803
EKG                                                   $    433.40    87070
EKG RHYTHM STRIP                                      $    433.40    87086
ENALAPRIL (PO) 2.5 MG         PO                      $      6.37    87491
ENALAPRILAT IV 1.25 MG            IV                  $     46.63    87804
ENGERIX-B 20 MCG       SYG         IM                 $    615.00    87880
ENGERIX-B 20 MCG     VL                               $    615.00    90471
ENGERIX-B 40 MCG       SYG         IM                 $   1,230.00   90658
ENGERIX-B 40 MCG     VL                               $   1,230.00   90703
ENOXAPARIN SODIUM 10 MG                IV             $     151.64   90718
EOSINOPHIL (ABSOLUTE)                                 $     38.77    90732
EPINEPHRINE 1:1,000 1 MG/ML             AMP           $      6.24    90736
EPINEPHRINE 1:10,000 1MG/10ML          SYG            $     28.71    90746
EPO < 10,000 UNITS (10 MG)                            $       1.98   90760
EPO > 10,000 UNITS (10 MG)                            $       1.98   90761
ESR                                                   $     54.17    90772
ESTROGENS CONJUGATE 25 MG                   IV        $    493.94    90774
FERAHEME IV 1MG SDV       *Restricted Use Pharmacy*   $     24.31    90774
FERRITIN                                              $    207.68    90775
FERRLECIT 12.5 MG IV                                  $     151.40   90775
FIBRINOGEN                                            $    930.53    90784
FILTER, LEUKOPOOR                                     $     41.79    92551
FLOW CYTOMETRY                                        $    538.84    93000
FLU VACCINE - FLUARIX 0.5 ML IM                       $    139.50    93000
FLU VACCINE - FLUZONE 0.5 ML IM                       $    139.50    93010
FLU VACCINE 0.5 ML            IM                      $    139.50    93040
FLUCONAZOLE IV 200 MG              IV                 $    806.64    94640
FLUORESCENT ANTIBODY SCREEN                           $    445.36    94664
FLUORESCENT ANTIBODY TITER                            $    374.92    94760
FOLATE, SERUM                                         $    224.13    94761
FOLLICLE STIMULATING HORMONE (FSH)                    $    283.61    94799
FROZEN PREP/FREEZING & THAWING                        $    586.70    95937
FUNGUS IDENTIFICATION, YEAST                          $    157.47    96372
GANCICLOVIR SODIUM 500 MG              IV             $    306.73    97010
GENTAMICIN PEAK                       $    250.09    97010
GENTAMICIN SULFATE 80 MG         IV   $       6.71   97124
GENTAMICIN TROUGH                     $    250.09    97535
GENTAMYCIN LEVEL                      $    250.09    97597
GGT (GAMMA GLUTAMYL TRANSFERASE)      $     109.21   97598
GLUCOMETER                            $     33.09    97598
GLUCOMETER (POST)                     $     33.09    97602
GLUCOMETER (PRE)                      $     33.09    97760
GLUCOSE GEL 15 GM      (PO)           $     34.98    97762
GLUCOSE OF PD FLUID                   $     59.85    98925
GLUCOSE OF PD FLUID - 24HR            $     59.85    98925
GLUCOSE OF PD FLUID - OVERNIGHT       $     59.85    98926
GLUCOSE PRECISION                     $     33.09    98926
GLUCOSE, BLOOD (ACCUCHECK)            $     33.09    98927
GLUCOSE, BLOOD (ACCUCHECK) POST       $     33.09    98927
GLUCOSE, BLOOD (ACCUCHECK) PRE        $     33.09    98928
GLUCOSE, SERUM                        $     59.78    98929
GRAM STAIN                            $     65.09    99000
H1N1 ADMINISTRATION FEE               $     84.77    99050
HANDLING AND PREPARATION FEES         $     48.76    99051
HAPTOGLOBIN                           $     192.00   99070
HCT - HEMATOCORIT                     $     36.07    99070
HCV RNA BY PCR QUALITATIVE            $    535.53    99080
HDL CHOLESTEROL                       $     124.77   99090
HECTOROL CAPSULES .5 MCG      PO      $       8.76   99173
HECTOROL CAPSULES 1 MCG       PO      $      17.45   99201
HECTOROL CAPSULES 2.5 MCG     PO      $     30.29    99202
HECTOROL IV 1 MCG IV                  $     69.30    99203
HELICOBACTER PYLORI ANTIBODY          $     221.42   99204
HEMO TRAINING                         $   3,605.00   99205
HEMOGLOBIN, AIC                       $     148.02   99211
HEMOLYSINS & AGGLUT. INCUBATED        $    279.57    99212
HEMOLYSINS & AGGLUT. SCREEN           $     152.89   99213
HEP A AB IGM (IGM ANTI-HAV)           $     106.24   99214
HEP B SURFACE AG (HBSAG)              $     157.38   99215
HEP BCORELGM (IGM ANTI-HBC)           $     179.45   99354
HEP BE AB (ANTI-HBE)                  $     176.27   99355
HEP BE AG (HBEAG)                     $     175.60   99382
HEP C VIRUS AB (ANTI-HCV)             $     183.76   99383
HEP C VIRUS AB (ANTI-HCV)             $     217.62   99384
HEPARIN HOME 1,000 UNITS 30 ML VIAL   $     53.95    99385
HEPARIN HOME 5,000 UNITS 10 ML VIAL   $     53.95    99386
HEPARIN-PORK 10,000 UNITS/ 0.1 ML     $     53.95    99387
HEPARIN-PORK 1000 UNITS/ 0.1 ML       $       5.40   99391
HEPARIN-PORK 5000 UNITS/ 0.1 ML                    $     26.98    99394
HEPATIC FUNCTION PANEL- Organ or Disease Panel     $     124.66   99395
HEPATITIS A ANTIBODY (HAAB)                        $     196.57   99396
HEPATITIS B CORE ANTIBODY (HBCAB)                  $     161.90   99397
HEPATITIS B SURFACE ANTIBODY HBSAB                 $    283.94    99406
HEPATITIS B SURFACE ANTIGEN (HBSAG)                $    283.94    99407
HEPATITIS B VIRAL DNA QUANTITATIVE                 $     653.51   99408
HEPATITIS BE ANTIBODY (HBEAB)                      $     144.15   99455
HEPATITIS BE ANTIGEN (HBEAG)                       $     144.15   4158f
HGB - HEMOGLOBIN                                   $     36.07    A4216
HIV 1                                              $     135.42   A4217
HIV ANTIGEN                                        $     519.83   A4351
HIV-1 & HIV-2 ASSAY                                $    378.90    A4352
Home Hemo - RN Staff Assist MI_per 15 minute       $      31.92   A4353
Home Hemo - RN Staff Assist_per 15 minute          $      31.92   A4358
Home Hemo Dialysis Aide _per 15 minute             $      19.15   A4460
Home Hemo Dialysis Aide MI _per 15 minute          $      19.15   A4550
Home Hemo LPN/LVN Staff Assist _per 15 minute      $      31.92   A4565
Home Hemo LPN/LVN Staff Assist MI _per 15 minute   $      31.92   A4570
HOME HEMODIALYSIS                                  $   2,935.00   A4570
HOME HEMODIALYSIS - NXSTAGE                        $   2,935.00   A4615
HOMOCYSTEINE                                       $     257.13   A6200
HTLV ANTIBODY                                      $     413.36   A6219
HYDRALAZINE HCL 20 MG             IV               $     124.05   A6260
HYDROCORTIS NA SUCC 100 MG             IV          $      18.95   A6430
HYDROXYZINE (PO) 25 MG            PO               $       2.57   A6442
HYDROXYZINE PAMOATE 25 MG PO                       $       2.57   A6442
IBUPROFEN (PO) 600 MG          PO                  $       2.36   A6443
IGM ANTIBODY - HEPATITIS B                         $     87.37    A6443
IGM ANTIBODY- HEPATITIS A                          $     87.37    A6444
IMMUNOASSAY INFECT. AGENT ANTIBODY                 $    267.57    A6448
IMMUNOASSAY, ANALYZE BY RIA                        $     441.20   A6448
IMMUNOCYTOCHEMISTRY                                $     721.72   A6449
IMMUNOFLUORESCENT ANTIBODY                         $    494.28    A6449
INFED 50 MG     IV *Restricted Use Pharmacy        $    442.87    A6450
INSULIN (HUMAN) 10 UNITS            IV             $       2.31   A6453
IPD INCENTER TREATMENT                             $   2,935.00   A6453
IPD INCENTER TREATMENT - STAFF ASSIST              $   2,935.00   A6454
IPD TRAINING                                       $   3,605.00   A6454
IRON                                               $     98.72    A6457
IRRADIATION FEE                                    $     34.83    A7003
ISOPROTERENOL HCL .2 MG           IV               $     28.27    A9150
LABETALOL IV 5 MG            IV                    $       4.97   E0100
LDH                                                $      92.11   E0114
LDL, DIRECT                                 $    554.56     G0008
LEPIRUDIN 50 MG              IV             $   2,047.99    G0008
LEUKOCYTE ANTIBODY DETECTION                $    374.24     G0101
LEVETIRACETAM (KEPPRA)                      $     161.86    H0048
LEVOCARNITINE (CARNITOR) 1 G                $    540.00    IV Insert
LEVOCARNITINE TABLT 330 MG             PO   $       1.01    J0170
LEVOCARNITINE TABLT 330 MG             PO   $       1.01    J0500
LEVOCARNTNE ORL SOL 100 MG             PO   $       0.40    J0696
LEVOCARNTNE ORL SOL 100 MG             PO   $       0.40    J0698
LEVOFLOXACIN 250 MG           IV            $    342.22     J0735
LIPASE                                      $     105.01    J0780
LITHIUM                                     $     100.72    J1100
LOPERAMIDE (PO) 2 MG         PO             $       5.62    J1200
MAGNESIUM SULFATE 0.5 GM               IV   $       4.80    J1815
MAGNESIUM, SERUM                            $     102.13    J1885
MANNITOL 25% 50 ML            IV            $      16.70    J2360
MERREM     100 MG     IV                    $     57.09     J2550
METHADONE QUALITATIVE, SERUM                $     210.14    J2765
METHYLPREDNI NA SUC 125 MG             IV   $     28.04     J2920
METHYLPREDNI NA SUC 40 MG          IV       $      17.38    J2930
METOCLOPRAMIDE HCL 10 MG           IV       $       6.94    J3250
MIC #3                                      $     131.87    J3301
MICROALBUMIN, URINE                         $     88.30     J3490
MICROSOMAL ANTIBODY                         $     317.14     J644
MIDODRINE HCL (PO) 5 MG           PO        $      19.93    J7030
MUMPS VACCINE 1 ML           IV             $     114.35    J7040
MUPIROCIN 2% OINTME 1 GM                    $      16.47    J7120
NA POLYSTYRENE (PO) 15 GM         PO        $      58.13    J7030
NADOLOL (PO) 20 MG           PO             $       7.26    J7506
NALOXONE HCL 1 MG            IV             $      20.61    J7506
NAPA                                        $    255.36     J7603
NITROGLYCERIN (SL) 0.4 MG          SL       $       0.81    J7605
NITROGLYCERIN 2% 0.5 INCH                   $       2.08    J7614
NOREPINEPHERINE BIT 4 MG           IV       $     107.83    J7620
NUCLEIC ACID TESTING (NAT)                  $     174.13    J7638
OCCULT BLOOD, FECES                         $      38.61    L0120
ONDANSETRON HCL 1 MG                        $      53.01    L0120
OVA-PARASITE STOOL                          $     135.69    L0172
Oxygen Cannula                              $      18.46    L0625
Oxygen Mask                                 $      18.46    L1800
PARTICLE AGGLUT. ANTIBODY                   $    404.07     L1810
PENTAMIDINE 300 MG            IV            $     441.86    L1815
PHENCYCLIDINE (PCP), SERUM                  $     210.14    L1820
PHENOBARBITOL                               $     174.61    L1830
PHENTOIN SODIUM 50 MG           IV        $      4.75    L1901
PHOSPHORUS, POST                          $     72.37    L1902
PHOSPHORUS, SERUM                         $     72.37    L1906
PLASMA, FRESH FROZEN                      $   1,074.60   L2425
PLASMA, PROTEIN, FRACTION                 $    442.94    L3260
PLATELET ANTIBODY DETECTION               $   1,055.90   L3265
PLATELET ASSOC IMMUNOGLOBULIN ASSAY       $    659.61    L3650
PLATELET COUNT                            $     68.17    L3670
PLATELET RICH PLASMA                      $    442.94    L3701
PLATELET, PHERESIS                        $    442.94    L3807
PLATELET, PHERESIS - LEUKOCYTE REDUCED    $   1,144.07   L3807
PLATELETS                                 $    930.53    L3906
PNEUMO VAC 23-VALEN 0.5 ML           IM   $    129.25    L3908
POOLING OF PLATELETS OR OTHER BLOOD       $    231.62    L3914
POTASSIUM CHLORIDE 2 MEQ                  $       0.61   L4350
POTASSIUM, POST                           $     70.04    L4360
POTASSIUM, SERUM                          $     70.04     NSF
PREALBUMIN                                $    222.37    Q0091
PREDNISONE (PO) 5 MG         PO           $      0.49    Q0111
PRETREAT RBC BY DIFF RC ABSORPTION        $    567.88    Q4022
PRETREATMENT OF RBC AB DETECTION          $    288.70    Q4046
PROCAINAMIDE                              $    255.36    S0020
PROCAINAMIDE AND NAPA                     $    255.36    S0612
PROCAINAMIDE HCL 1 GM           IV        $      11.18   S0622
PROCHLORPERAZINE IV 10 MG            IV   $     42.66    S0630
PROCHLORPERAZINE PO 5 MG             PO   $      4.97    S8110
PROF. FEE-HEPATITIS B/RECOMBIVAX          $     84.76    S8110
PROF. FEE-INFLUENZA                       $     84.76    S8120
PROF. FEE-PNEUMOCOCCAL                    $     84.76    S8450
PROMETHAZINE HCL PO 25 MG            PO   $      4.24    S9088
PROMETHZNE HYDROCHL UP TO 50 MG           $     19.74    S9452
PROPOXYPHENE (DARVON), QUANTITATIVE       $    296.87    S9460
PROPRANOLOL 1 MG           IV             $     118.02
PROTEIN ELECTROPHORESES                   $    163.69
PROTEIN S (TOTAL)                         $     55.92
PSA DIAGNOSTIC (PROC SPEC ANTI)           $    280.38
PSA SCREENING (PROC SPEC ANTI)            $    280.38
PT - PROTHROMBIN TIME                     $     59.89
PTH INTACT (PLASMA)                       $    629.80
PULSE OXIMETRY MULTIPLE READINGS          $    127.69
PULSE OXIMETRY SINGLE READING             $     46.43
QUINIDINE                                 $    222.47
RBC ANTIBODY IDENT.                       $    714.92
RBC COUNT                                 $     45.89
RBC FOLATE                                     $    262.62
RBC, (PACKED RED BLOOD CELLS)                  $   1,581.80
RBC, DEGLYCERIZED                              $   1,047.51
RBC, IRRADIATED                                $   1,047.51
RBC, LEUKOCYTES REDUCED                        $   1,047.51
RBC, LEUKOREDUCED, IRRADIATED                  $   1,047.51
RBC, WASHED                                    $   1,615.18
RECOMBIVAX 40 MCG             IM               $   1,625.00
RETIC HGB (CHr)                                $     122.21
RETICULOCYTE COUNT                             $      61.11
RETICULOCYTE SEPARATION                        $     90.55
RH PHENOTYPING COMPLETE                        $     122.15
RH TYPE                                        $     122.15
RH TYPE                                        $    179.22
RHEUMATOID FACTOR                              $     86.58
ROCALTROL CAPSULES .25 MCG         PO          $      2.55
ROCALTROL CAPSULES .25 MCG         PO          $      2.55
ROCALTROL CAPSULES .25 MCG         PO          $      2.55
ROCALTROL CAPSULES .5 MCG          PO          $       4.01
ROCALTROL ORL SOL 1 MCG         PO             $     20.98
ROCEPHINE     250 MG      IV                   $     77.80
ROUTINE TRANSPORT FEE                          $     55.72
RPR                                            $     65.09
RUBELLA ANTIBODY                               $    219.37
RUBEOLA ANTIBODY                               $    147.36
SEDIMENTATION RATE, AUTOMATED                  $      41.17
SENS ORGANISM THREE(MIC)                       $     131.87
SENSITIVITY STAPH AUREUS VANCOMYCIN            $     72.41
SEPARATION BY ELECTROPHORESIS #1               $      61.13
SEPARATION BY ELECTROPHORESIS #3               $      61.13
SILVER NITRATE 10 GM                           $      0.44
SMEAR WET MOUNT, INDIA INK PREPARATION         $     65.10
SODIUM BICARB 50 ML           IV               $     19.02
SODIUM THIOSULFATE 50 GM                       $    243.13
SODIUM, POST                                   $     66.63
SODIUM, SERUM                                  $     66.63
SPLITTING OF BLOOD                             $    241.69
STOOL FOR WHITE BLOOD CELLS                    $     65.09
Susceptibility BETA LACTAMASE #1               $     72.41
Susceptibility MIC #2                          $     131.87
SUSCEPTIBILITY STUDY, AGAR DIFFUSSION METHOD   $     72.41
SYPHILLIS QUAL. (VDRL, RPR)                    $    128.07
SYPHILLIS QUANT.                               $     48.05
T3 (RIA)                                       $    216.33
T3 (UPTAKE)                           $     98.72
T4 FREE                               $     137.43
T-4 THYROXINE                         $     104.80
THEOPHYLLINE                          $     215.75
THYROGLOBULIN QUANT                   $     331.55
TMT CONVENTIONAL HEMODIALYSIS         $   2,935.00
TMT CONVENTNL/CATHETER HEMODIALYSIS   $   2,935.00
TMT HIGH EFF/CATHETER HEMODIALYSIS    $   2,935.00
TMT HIGH EFFICIENCY HEMODIALYSIS      $   2,935.00
TMT HIGH FLUX HEMODIALYSIS            $   2,935.00
TMT HIGH FLUX/CATHETER HEMODIALYSIS   $   2,935.00
TOBRAMYCIN                            $    245.94
TOBRAMYCIN 80 MG                IV    $      51.42
TOBRAMYCIN PEAK                       $    245.93
TOBRAMYCIN TROUGH                     $    245.93
TOTAL PROTEIN (FLUID)                 $      55.91
TOTAL PROTEIN DIALYSATE PD            $     55.92
TOTAL TESTOSTERONE LEVEL              $    394.02
TOXIC SCREEN                          $     221.91
TRANSFERRIN                           $     194.68
TRANSFUSION ADMIN FEE 1 PER TMT       $     696.51
TRANSFUSION REACTION                  $    665.77
TREPONEMA PALLIDUM (FTA-ABA)          $    252.57
TRIGLYCERIDES                         $     87.70
TSH-THYROID STIMULATING HORMONE       $    256.00
TUBERSOL- 5TU 0.1ML                   $      11.33
UIBC                                  $     133.23
UREA NITROGEN DIALYSATE               $      60.12
UREA NITROGEN, 24-HOUR URINE          $     72.45
UREA NITROGEN, URINE                  $     72.45
UREA OF PD FLUID                      $      60.12
UREA OF PD FLUID - 24 HR              $      60.12
UREA OF PD FLUID - OVERNIGHT          $      60.12
Urea-N clearance test                 $     28.00
URIC ACID, BLOOD                      $     68.94
URINALYSIS                            $     48.20
URINALYSIS, MICROSCOPIC ONLY          $     46.29
VANCOMYCIN 500 MG               IV    $     189.75
VANCOMYCIN PEAK                       $     149.02
VANCOMYCIN RANDOM                     $     149.02
VANCOMYCIN TROUGH                     $     149.02
VENOFER 1 MG               IV         $      12.25
VENOFER 1 MG               IV         $      12.25
VERICELLA-ZOSTER                      $     196.45
VITAMIN B12                             $    229.75
VITAMIN D (CALCIFEROL LEVEL)            $     491.16
VITAMIN D 1,25 DIHYDROXY LEVEL          $    586.68
Vitamin d, 25 hydroxy                   $    453.19
VITAMIN K 1 MG                IV        $       4.31
WHITE BLOOD COUNT (WBC)                 $     38.84
WHOLE BLOOD                             $   1,038.74
YEAST IDENTIFICATION #1                 $    157.47
ZEMPLAR 1 MCG IV        MDV             $     95.00
ZEMPLAR CAPSULES 1 MCG             PO   $      11.70
ZEMPLAR CAPSULES 2 MCG             PO   $     23.29
ZEMPLAR CAPSULES 4 MCG             PO   $     46.48
ZINC                                    $     173.61
                        11/28/2011                                                        11/2/2011

                         OTC-3489                                                          OTC-5109
                 Bullhead Urgent Care                                           CANYONLANDS- BEAVER DAM
Donald Wagner, D.O, dba; Bullhead Urgent Care Center                           NW Arizona Regional Health Center
               1355 Ramar Road, Suite 11                                             3272 . Rio Virgin Road
                        Bullhead City                                                      Littlefield
                            AZ                                                              Arizona
                           86442                                                          86432-3200
                                                                                            Mohave
                           SAME                                                           PO Box 1625
                                                                                              Page
                                                                                            Arizona
                                                                                          86040-1625
                       928-704-9202                                                      928-645-9675
                        1225158470                                                        1780653741
                        685399001                                                           432857
                            YES                                                               Yes
                           76322                                                        PTAZ # Z67338
                       Donald Wagner                                                 Elizabeth Latham, CEO
                       928-704-9202                                                 928-645-9675 Ext 5507
            bullheadurgentcare@npgcable.com                                           l.latham@cchcaz,org
                       Donald Wagner                                                 Jaree Chambers, CFO
                       928-704-9202                                                 928-645-9675 Ext 5500
            bullheadurgentcare@npgcable.com                                          j.chambers@cchcaz,org
                       Sandy Lubinski                                             Belinda Bates Billing Manager
                       928-704-9202                                                 928-645-9675 Ext 5521
               urgentcare@npgcable.com                                                b.bates@cchcaz.org
                         11/3/2008                                                         4/1/2006


                Discription of Charge         Rate of Charge    Service Code


      I&D                                     $        125.00      10021
      I&D Mult/comp                           $        225.00      10060
      Pilonidal Cyst                          $        160.00      10061
      FB Removal- Simple Skin                 $        175.00      10120
      FB removal comp                         $        305.00      10160
      Drainage Hematoma                       $        165.00      10180
      Puncture drainage of skin lesion        $        140.00      11000
      Debridement, partial thickness          $         65.00      11001
      Debridement, full thickness             $         75.00      11042
      Debridement, incl SQ tissue             $         80.00      11055
      Paring/cut lesion (corn), 1             $         75.00      11056
      Biopsy skin lesion                      $        100.00      11057
Additional biospy                     $    35.00   11100
Removal skin tags- up to 15           $   100.00   11101
Remove lesion, trunk/arm/leg          $   125.00   11200
Lesion Removal 1.0 cm                 $   160.00   11201
Remove lesion, trunk/arm/leg >4cm     $   300.00   11300
Remove lesion 2.1-3.0 face/lid/eye    $   220.00   11301
Nail Debride 1-5 nails, any method    $    35.00   11302
Nail plate avulsion, simple           $   110.00   11303
Nail Plate, ea add removal prtl       $    52.00   11305
Nail drain                            $   160.00   11306
Nail Drain Hematoma                   $    40.00   11307
Nail Matrix remove                    $   190.00   11308
Nail bed/finger tip, excis,           $   285.00   11310
Nail bed, Repair of                   $   210.00   11311
Nail, toe; ingrown, excise skin       $   120.00   11312
Lac Simple 0cm-2.5cm                  $   180.00   11313
Laceration, simple 2.6-7.5            $   201.00   11400
Lac Simple 7.6cm-12.5cm               $   225.00   11401
Lac Simple 20.1cm-30cm                $   310.00   11402
Lac Simple >30cm                      $   325.00   11403
Laceration, face 0-2.5, simple        $   200.00   11404
Lac Face 2.6-5.0cm                    $   220.00   11406
Lac Face 5.1cm-7.5cm                  $   240.00   11420
Lac Face 7.6cm-12.5 Simple            $   240.00   11421
Lac Scalp, Trunk, Extremity, Itrm     $   225.00   11422
Lac Scalp, Trunk, Extremity, Itrm     $   275.00   11423
Lac Scalp, Trunk, Extremity 7.6       $   270.00   11424
Lac Intermediate 20.1-30 cm           $   435.00   11426
Lac Neck, Hand, Feet, Itrm, 0cm       $   255.00   11440
Lac Neck, Hand Feet, Itrm 2.5 cm      $   302.00   11441
Lac Neck, Hand, Feet, Itrm, 7.6 cm    $   313.00   11442
Lac Face, eye, lips 0cm-2.5           $   292.00   11443
Lac Face 2.6-5.0cm                    $   265.00   11444
Lac Repair complex wound              $   460.00   11446
Repair Complex Wound                  $   465.00   11606
lac, repair complex wound             $   575.00   11719
Burn, Intial Treatment                $    75.00   11720
Burn, debridement partial thickness   $    96.00   11721
Destroy benign/premalig lesion        $    75.00   11730
Destruction of Lesion                 $    70.00   11732
Chemical Cautery                      $    75.00   11740
TP, tendon/sheath, ligament           $   103.00   11750
TP, tendon/ligament, origin           $   100.00   11975
TP, muscle 1-2 injections             $    98.00   11976
TP, muscle 3=> multiple               $   110.00   12001
Arthrocentesis; Drain/inject minor    $    70.00   12002
Arhrocentesis; intermediate joint     $    80.00   12004
Arhrocentesis; major joint            $    90.00   12005
Ganglion Cyst (s) Aspiration/inject   $   200.00   12006
Nurse Maids elbow reduction           $   206.00   12011
Reduce IP joint                       $   322.00   12013
Reduct Finger Disl w anesth           $   445.00   12014
injection, sacroilliac joint          $   175.00   12015
Splint- Long arm application          $   125.00   12016
Splint- Short arm application         $    70.00   12031
Finger splint application             $    50.00   12032
Splint long leg application           $    95.00   12034
Splint- Short leg application         $    90.00   12035
Buddy Tape; Toes                      $    63.00   12041
Drainage of nose abscess              $   250.00   12042
Drainage of nasal septum lesion       $   250.00   12044
FB Removal-Nasal                      $   276.00   12045
Control Epitaxis 1                    $   100.00   12051
Control Epitaxis 2                    $   175.00   12052
Chem Panel                            $    20.00   12053
Laryngoscopy direct, diagnostic       $   310.00   12054
IV, needles/catheter in vein          $    45.00   12055
Venipuncture                          $    20.00   15839
Drainage of mouth lesion              $   200.00   16000
Reduction of rectal prolapse          $   225.00   16020
Incision of external hemorrhoid       $   190.00   16025
I&D Hemorrhoid                        $   289.00   16030
Removal of external hemorrhoid        $   395.00   16035
Enucleation of hemorrhoid clot        $   180.00   17000
Anoscopy                              $   102.00   17003
Anoscopy FB Removal                   $   290.00   17004
Irrigation of bladder, simple         $   110.00   17110
Urinary Cath- straight                $    75.00   17111
Urinary Cath- foley                   $   115.00   17250
Drainage of vulva gland abscess       $   180.00   19000
FB removal, vag                       $   182.00   19100
Nerve block                           $   110.00   20550
TP inject paraver, cerv/thor, ea      $   175.00   20551
Inject paraver, lumb/sacral, singl    $   265.00   20552
Inject foramin, cerv/thor singl       $   300.00   20553
FB Removal Conjunctival-simp          $    65.00   20600
FB Removal conj embedded              $    82.00   20605
FB removal slitL                      $    66.00   20610
FB Removal- corneal w/o slit   $   66.00    21800
FB Removal- Ear                $   60.00    23500
EAR LAV                        $   65.00    23600
Jaw mandible- complete         $   65.00    25560
Facial bones, 1-2 views        $   50.00    25600
Facial bones Complete          $   60.00    26600
Orbits complete                $   80.00    26750
Sinuses, 3 views               $   85.00    27750
Skull, 4 views                 $   120.00   27786
Soft tissue neck, 2 views      $   75.00    28470
Chest, PA                      $   75.00    29065
Chest, PA nad Lateral          $   125.00   29075
Ribs, bilat, 3 view            $   90.00    29105
Ribs both sides w PA Chest     $   125.00   29125
Sternum, 2+ views              $   75.00    29130
Sternoclav Joint(s) 3 view     $   85.00    29405
C Spine w/ obliques            $   110.00   29425
C Spine Complete               $   115.00   29440
L Spine 2 or 3 veiws           $   110.00   29515
L Spine w/obliques             $   125.00   29580
L Spine Complete               $   125.00   29705
Pelvis 1-2 Veiws               $   90.00    30300
Pelvis Complete                $   100.00   30901
Sacrum and Coccyx              $   70.00    30903
Clavicle, 2 views              $   60.00    30905
Scapula, 2 views               $   70.00    31500
Shoulder, 2 views              $   70.00    32421
Shoulder, AC joints            $   60.00    36415
Humerus, 2 views               $   75.00    36416
Elbow, 2 views                 $   65.00    36510
Elbow, 3 view                  $   75.00    41115
Forearm                        $   75.00    43235
Wrist, 2 views                 $   70.00    44144
Wrist, 3 views                 $   85.00    44145
Hand, 2 views                  $   70.00    44160
Hand, 3+ views                 $   85.00    44960
Finger, minimum 2 views        $   70.00    45378
Hip, Complete, 2 views         $   85.00    45380
Hips Bilateral w/ pelvis       $   110.00   45402
Femur, 2 views                 $   75.00    46083
Knee, 2 views                  $   70.00    46320
Knee, 4+ views                 $   90.00    46600
Tibia/Fibula 2 views           $   75.00    46916
Ankle, 2 views                 $   70.00    46924
Ankle, 3 views                  $    85.00   46934
Foot, 3 views                   $    85.00   46935
Foot, 2 views                   $    70.00   47600
Calcaneus, 2 views              $    55.00   47610
Toe, 2 or 3 views               $    70.00   49000
KUB                             $    45.00   49080
Abdomen Complete                $   100.00   49320
Acute Abdomen Series            $   110.00   49322
BMP                             $    20.00   49505
CMP                             $    25.00   50947
Lipid Panel                     $    50.00   51500
HEP Panel Acute                 $   250.00   51701
Hepatic Profile                 $    20.00   51702
Drug Screen, Qual, mlt cls      $    45.00   51725
Urine Drug Screen               $    40.00   51860
UA DIP                          $    20.00   51880
HCG                             $    15.00   52260
Alcohol Breath Test             $    20.00   52282
Amylase                         $    30.00   52285
OCC BLD                         $     7.00   54050
Occt Blood Gastro               $    15.00   54056
CPK in blood                    $    20.00   54065
Creatinine, Blood               $    20.00   54150
Vitamin B-12                    $    90.00   54152
Ferritin                        $    60.00   55250
Folate                          $    70.00   56420
BS Blood Sugar Check            $     5.00   56501
Accucheck                       $    20.00   56515
Hgb A1C                         $    60.00   56620
Serum Iron                      $    15.00   56700
Lipase                          $    35.00   56821
T4 Free                         $    75.00   57061
TSH                             $    40.00   57100
T3 Uptake, FFS                  $    35.00   57105
Troponin                        $    55.00   57160
BUN                             $    20.00   57200
Uric acid, blood                $    15.00   57240
CBC                             $    20.00   57250
Reticulocyte count              $    15.00   57260
Protime                         $    18.00   57265
Sedimentation rate, automated   $    20.00   57267
FFA PTT                         $    28.00   57283
Arthritic Profile               $    50.00   57288
CRP                             $    45.00   57295
CRP, high sensitivity               $    50.00   57410
Monospot                            $    15.00   57420
Rheumatoid factor                   $    35.00   57452
PPD Skin Test                       $    45.00   57454
HIV-1 AB                            $    60.00   57460
Hep B Core Antibody                 $   150.00   57500
Mumps, Titer                        $    90.00   57505
Rubella, Titer                      $    60.00   57511
Rubeola, Titer                      $    80.00   57520
Varicella IgG AB                    $    50.00   57522
Antibody, Hep C                     $    80.00   57720
Culture Wound/NP                    $    65.00   58100
Urine Culture & Sens                $    40.00   58120
GC & Chlamydia                      $   140.00   58140
Influenza Quickvue                  $    25.00   58145
Strep Screen                        $    22.00   58146
IM Vaccine Inject                   $    22.00   58150
FLU VACC                            $    30.00   58180
Tetanus IM                          $    40.00   58260
TD Adult                            $    25.00   58262
Pneumo Vacc                         $    45.00   58270
Zoster Vacc, Sc                     $   220.00   58290
Hep B vac, adult, intramusc         $   100.00   58291
IV treatment 1st Hour               $    80.00   58300
IV Treatment 2nd Hour               $    25.00   58301
IM/SQ Injection                     $    25.00   58340
IV PUSH                             $    60.00   58350
IV injection (IV Push)              $    60.00   58353
IV Push Add                         $    30.00   58550
IV injection (IV Push) Additional   $    30.00   58552
IV Push treatment                   $     3.00   58554
Screening test, hearing             $    15.00   58555
EKG other                           $    50.00   58558
EKG w/Interprt                      $    50.00   58562
EKG INT                             $    25.00   58563
ECG additional reports              $    25.00   58565
Nebulizer treatment                 $    20.00   58600
SVN or inhaler, Demo                $    24.00   58605
O2 sat                              $     5.00   58611
Pulse Ox-multiple                   $     7.00   58660
UDS Pre-employment                  $    40.00   58661
Neuromuscular junction test         $    65.00   58662
IM Inj                              $    28.00   58670
Hot packs                           $    20.00   58671
Hot or Cold packs therapy               $    25.00   58673
Massage Therapy                         $    36.00   58700
Teaching self care/home mgt             $    35.00   58720
Debridement, selective </=20 cm         $    60.00   58740
Remov DevitT                            $    75.00   58925
Debridement, selective >20 cm           $    75.00   58940
Debridement, non selective              $    50.00   58956
Orthotic Mgt and Train                  $    50.00   59000
F/U Orthotic/Proth use                  $    50.00   59020
OMT 1-2                                 $    45.00   59025
OMT 1-2 Areas                           $    45.00   59120
OMT 3-4                                 $    60.00   59121
OMT 3-4 body regions                    $    60.00   59151
OMT 5-6                                 $    68.25   59160
OMT 5-6 body regions                    $    70.00   59320
OMT 7-8 body regions                    $    82.00   59325
OMT 9-10 body regions                   $    92.50   59400
Specimen handling/transport             $    12.00   59409
Afer hours, services                    $    75.00   59410
Med serv, eve/wkend/Hol                 $    35.00   59412
Materials above                         $    50.00   59425
Supplies/materials above & beyond       $    50.00   59426
Special reports/insurance forms         $    45.00   59510
Computer data analysis                  $    35.00   59514
Visual Acuity                           $    20.00   59515
office visit, new pt. level 1           $    80.00   59525
office visit, new pt. level 2           $   100.00   59610
office visit, new pt. level 3           $   135.00   59618
office visit, new pt. level 4           $   190.00   59812
office visit, new pt. level 5           $   255.00   59820
office visit, established pt. level 1   $    35.00   59821
office visit, established pt. level 2   $    60.00   59830
office visit, established pt. level 3   $    80.00   62270
office visit, established pt. level 4   $   125.00   65205
office visit, established pt. level 5   $   165.00   65210
Extended visit 30-74 min                $   126.00   65220
Extended visit 75-104 min               $   124.00   65222
Preventative checkup, new, 1-4 yrs      $   151.00   69200
Preventatative checkup, new 5-11 yrs    $   150.00   69210
Preventative checkup, new 12-17 yrs     $   160.00   74740
Preventative checkup, new 18-39 yrs     $   160.00   80101
Preventative checkup, new 40-64 yrs     $   189.00   81003
Preventative checkup, new 65+yrs        $   150.00   81025
Preventative checkup, est, 5-11 yrs     $   100.00   82270
Preventative checkup, est, 12-17 yrs   $   100.00   82947
Preventative checkup, est, 18-39 yrs   $   100.00   83036
Preventative checkup, est, 40-64 yrs   $   110.00   85018
Preventative checkup, est, 65+yrs      $   125.00   85610
Smoking Council                        $    15.00   86580
Smoking Counseling >10 min             $   30.00    87220
Alcohol/substance abuse counseling     $    15.00   87807
DOT physical                           $   135.00   87880
Education, risk of alcohol             $    15.00   90470
Sterile water/saline, 10 ml            $     2.00   90471
Sterile water saline, 500 ml           $     3.15   90472
Catheter, urine, straight tip          $    15.00   90473
Catheter, urine, Coude tip             $   40.00    90632
Catheter supplies, urine               $     8.00   90633
Leg bag, urinary                       $   20.00    90636
Elastic Bandage                        $     5.00   90647
Suture Tray                            $    15.00   90648
Sling                                  $    16.00   90649
splint supply                          $   20.00    90655
Slpint supplies/finger splints         $   20.00    90656
Cannula nasal                          $     5.00   90657
Bandage, Ointment dsg <16 in           $    10.00   90658
Gauze <=16 sq in w/adh border          $     2.00   90662
Wound cleaners                         $    10.00   90669
Bandage, light compression >5 in       $     7.00   90670
Bandage, non sterile                   $     2.00   90680
Bandage, nonsterile <3 in              $     2.00   90681
Bandage non sterile 3-5 in             $     3.00   90691
Bandage, nonsterile 3-5 in             $     3.00   90698
Bandage, nonsterile >/=5 in            $     2.00   90700
Ace <3 in                              $     2.00   90702
Ace wrap <3 in                         $     2.00   90707
Ace 3-5 in                             $    10.00   90710
Ace wrap 3-5 in                        $    10.00   90713
Ace >5in                               $    15.00   90715
Coban <3 in                            $     2.00   90716
Coban <3 in                            $     2.00   90718
Coban 3-5 in                           $     2.00   90720
Bandage, Coban 3-5 "                   $     2.00   90723
Bandage, Tubular                       $     2.00   90732
Nebulizer administration set           $     5.00   90733
Medicaions, non-prescription           $     2.00   90734
Cane adjust/fixed w/ tip               $   45.00    90736
Crutches                               $   50.00    90743
Flu inject                           $   20.00    90744
IM injec MC FLU admin                $   20.00    90746
Pelvic/Breast exam, CA screen        $   55.00    90748
UDSE, chain of custody col           $   40.00    92551
IV insert only                       $   150.00   92552
Epinephrine Injection                $   20.00    93000
Dicyclomine Injection                $     5.00   93018
Rocephin (ceftriaxone) per 250       $     6.00   93040
Claforan                             $    10.00   93350
Clonidine hydrochloride              $    10.00   93922
Compazine 10mg                       $    15.00   93924
Decadron                             $     3.00   94010
Benadryl IM/IV 50mg                  $     2.00   94060
Insulin Injection                    $   20.00    94370
Toradol per 15mg IV/IM               $     5.00   94640
Norflex                              $   30.00    94664
Phenergan IV/IM up to 50             $     4.50   95115
Metoclopramide 10 mg, Reglan         $     2.00   95117
Solumedrol 40 mg                     $     5.00   95130
Solumedrol 125 mg                    $     5.25   96360
Tigan                                $   30.00    96361
Kenalog                              $     5.00   96365
Medication, misc.                    $     4.00   96366
Atrovent inhalation per unit dose    $     3.00   96372
NS 1000cc                            $     6.00   96374
Normal Saline IV 500mls              $     5.00   97597
LR Infusion                          $     6.00   97598
NS Infusion 1000cc                   $     4.00   98925
Prednisone 5 mg po                   $     2.00   98926
Prednisone 5 mg elix                 $     1.00   99000
Albuterol inhalation per unit dose   $     2.00   99050
Brovana (Arformoterol 15mcg)         $     3.50   99070
Xopenex                              $     8.50   99195
(Duoneb) Atrovent/Albuterol          $     2.00   99201
Dexamethasone                        $     2.00   99202
Cervical Collar                      $   35.00    99203
Cervical Collar, soft                $   35.00    99204
Cervical Collar, phil                $   40.00    99205
Abdominal Binder                     $   50.00    99211
Knee Buttress w/o joints             $   124.00   99212
Knee, elastic with joints            $   75.00    99213
Short Runner                         $   140.00   99214
Short Runner (PTO airmesh)           $   145.00   99215
Knee Immob                           $   90.00    99217
Ankle gaunlet/neoprene               $    40.00   99218
Ankle Lace-up                        $    90.00   99219
Ankle strup/laces                    $    90.00   99220
Knee disc/dial lock/adj flex         $    25.00   99221
Post-OP Shoe                         $    32.00   99222
Boot, Rocker Cast                    $    30.00   99223
Clavicle Support                     $    70.00   99231
Arm Sling and Swathe                 $   136.00   99232
Elbow Sleeve                         $    30.00   99233
Knuckle Brace                        $    60.00   99234
Thumb spica splint, prefab           $   120.00   99235
Finger Guard                         $    60.00   99236
Splint Cock up , wrist               $    65.00   99238
Finger splint                        $     1.00   99239
Walking Boot, Tall                   $   350.00   99241
Walking Boot, Short                  $   180.00   99242
Insufficent Funds                    $    25.00   99251
Pap smear specimen collect           $    35.00   99252
Wet mounts w/ preparations           $    20.00   99253
MC Splint, short arm                 $    22.00   99254
MC Splint, short leg                 $    22.00   99281
Bupivicaine up to 30 ml              $     4.00   99282
Annual gynecological exam            $    45.00   99283
Physical (school, work, insurance)   $    75.00   99284
Suture removal/other doc             $    35.00   99285
Peak flow                            $    20.00   99291
Peak expiratory flow rate            $    20.00   99292
Oxygen per unit                      $     5.00   99295
Splint digit, padded                 $     5.00   99304
Services provided in urgent          $    35.00   99305
Teaching Instruction; Nutritional    $    35.00   99307
Teaching Instruction; Diabetic       $    45.00   99308
                                                  99341
                                                  99343
                                                  99347
                                                  99348
                                                  99349
                                                  99381
                                                  99382
                                                  99383
                                                  99384
                                                  99385
                                                  99386
                                                  99387
 99391
 99392
 99393
 99394
 99395
 99396
 99397
 99435
 99460
 99462
 99463
 99465
 47562
 47605
4761280
 49320
 49322
 52000
 57240
 57250
 57260
5726780
 57288
 58140
 58150
 58260
 58270
 58550
 58552
 58555
 58565
 58600
 59514
5952580
 90470
 90471
 90471
 90471
 90472
 90472
 90473
 90473
 90633
 90647
90648
90649SL
90655SL
90656SL
90657
90658
90663
90669
90670SL
90680
90696
90698
90700
 90701
90702
90707
 90710
 90713
 90715
 90716
 90718
90723
90732
90734
90743
90744
90748
99385
99386
99387
99394
99395
99396
99397
 A4315
A4338
A4358
A4460
A4550
 A4561
A4562
A4565
A4570
 A4614
A6448
A6449
80100
99384
80100
80100
D0120
D0140
D0150
D0160
D0210
D0220
D0230
D0240
D0270
D0272
D0274
D1110
D1120
D1203
D1204
D1206
D1330
D1351
D1510
D1515
D1520
D1550
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2644
D2710
D2740
D2750
D2751
D2752
D2790
D2791
D2792
D2910
D2920
D2930
D2931
D2940
D2950
D2951
D2954
D2970
D2980
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3346
D4231
D4249
D4341
D4342
D4355
D4910
D5110
D5120
D5130
D5140
D5211
D5213
D5214
D5225
D5226
D5410
D5650
D5710
D5750
D5761
D5820
D5821
D5850
D5862
D5875
D5999
D6212
D6242
D6245
D6545
D6740
D6750
D6752
D6792
D6940
D6950
D7111
D7140
D7210
D7220
D7250
D7270
D7310
D7510
80100
D9110
D9230
D9430
D9440
D9930
99382
99383
99385
99392
99393
99394
99395
D9940
D9941
D9970
D9971
D9972
D9973
D9974
Dive PE
99385
99386
99387
99395
99396
99397
80100
J0150
J0171
J0295
J0530
J0540
J0558
J0561
J0690
J0696
J0704
J0780
J1000
J1030
J1040
J1055
J1070
J1080
J1100
J1110
J1200
J1380
J1440
J1670
J1710
J1815
J1885
J1940
J2001
J2060
J2270
J2300
J2405
J2510
J2550
J2675
J2765
J2790
J2930
J3030
J3301
J3360
J3370
J3410
J3411
J3420
J3430
J3480
J7300
J7302
J7307
J7316
J7317
J7319
J7320
J7325
J7510
J7610
J7613
J7614
J7620
J7645
J9213
J9260
L0120
L0180
L0220
L0625
L1810
L1830
L1834
L1845
L1902
L2000
L2114
L3260
L3265
L3650
L3701
L3800
L3908
L3914
L3923
L3999
L4350
L4386
82947
Q0091
S0020
S0180
                           11/2/2011                                                            2/22/2011

                            OTC-5109                                                            OTC-4324
               CANYONLANDS- BEAVER DAM                                                  EXPRESS MEDICAL CARE
             NW Arizona Regional Health Center                                           Jose Gochoco D.O.PLLC
                     3272 . Rio Virgin Road                                       2002 Stockton Hill Rd. Suite 102Kingman
                            Littlefield                                                          Kingman
                             Arizona                                                               AZ
                           86432-3200                                                             86401
                             Mohave
                           PO Box 1625                                                         P.O. Box 631
                                 Page                                                            Kingman
                             Arizona                                                               AZ
                           86040-1625                                                             86402
                          928-645-9675                                                        928-718-4375
                           1780653741
                             432857                                                              295487
                                 Yes                                                               yes
                        PTAZ # Z67338                                                            Z118144
                     Elizabeth Latham, CEO                                                  Jose Gochoco, D.O.
                   928-645-9675 Ext 5507                                                      928-718-4375
                      l.latham@cchcaz,org                                                 j_gochoco@yahoo.com
                     Jaree Chambers, CFO                                                    Jose Gochoco D.O.
                    928-645-9675 Ext 5500                                                     928-718-4375
                    j.chambers@cchcaz,org                                                 j_gochoco@yahoo.com
                 Belinda Bates Billing Manager                                              Jose Gochoco D.O.
                    928-645-9675 Ext 5521                                                     928-718-4375
                      b.bates@cchcaz.org                                                  j_gochoco@yahoo.com
                            4/1/2006                                                            11/1/2007


                   Discription of Charge         Rate of Charge    Service Code         Discription of Charge


Fine Ndle Aspir; W/o Imaging G                   $        215.00      J3301         INJ TRIAM 10 MG
I&d Abscess; Simpl/sngl                          $        190.00      99213         OV LEVEL III EP
I&d Abscess; Complic/mx                          $       320.00       J1100         INJ DEXAMETHASO
Incs & Remov Fb Subq Tiss; Sim                   $       222.00       96372         THERAPEUTIC INJ
Punct Aspir Absces/hemat/bulla                   $        190.00      J0696         INJ ROCEPH 250M
I&d Complx Postop Wound Infec                    $       325.00       99214         OV LEVEL IV ESP
Debrid Exten Infec Skin; To 10                   $        94.00       S9088         URGENT CARE SVC
Debrid Exten Infec Skin; Ea Ad                   $        33.00       99203         OV LEVEL III NP
Debrid; Skin & Subq Tiss                         $        109.00      99204         OV LEVEL IV NP
Paring/cutting Ben Les; 1 Les                    $        77.00       81002         UA W/O SCOPE
Paring/cutting Ben Les; 2-4 Le                   $        105.00      J1885         INJ TORADOL 15M
Paring/cutting Ben Les; > 4 Le                   $        111.00      S9083         GLOBAL FEE URGE
Bx Skin/subq Tiss (sep Pro); 1   $   183.00   J0704   INJ BETAMETHASO
Bx Skin/subq Tiss (sep Pro); E   $    57.00   81025   UA PREGNANCY
Remov Skin Tags; To & Incl 15    $   139.00   J3420   INJECTION B 12
Remov Skin Tags; Ea Add 10 Les   $    32.00   86403   STREP SCREEN
Shaving 1 Les Trunk; 0.5 Cm/le   $   116.00   93000   ECG RESTING
Shaving 1 Les Trunk; 0.6 To 1.   $   161.00   99215   OV LEVEL V ESP
Shaving 1 Les Trunk; 1.1 To 2.   $   192.00   99394   PREVCAR 12-17EP
Shaving 1 Les Trunk; Over 2.0    $   225.00   J2550   INJ PHENER 50 M
Shaving 1 Les Scalp; 0.5cm/les   $   122.00   11010   DEBRIDEMENT OF
Shaving 1 Les Scalp; 0.6 To 1.   $   168.00   69210   REMOVE IMPACTED
Shaving 1 Les Scalp; 1.1 To 2.   $   196.00   87400   INFECT ANTIGEN
Shaving 1 Les Scalp; Over 2.0    $   219.00   11750   EX NAIL MATRIX
Shaving 1 Les Face; 0.5 Cm/les   $   145.00   99212   OV LEVEL II ESP
Shaving 1 Les Face; 0.6 To 1.0   $   168.00   82948   STICK ASSAY OF
Shaving 1 Les Face; 1.1 To 2.0   $   194.00   01462   DIGITAL BLOCK
Shaving 1 Les Face; Over 2.0 C   $   263.00   S8451   WRIST/ANKLE SPL
Exc Ben Les Trunk; 0.5 Cm/less   $   189.00   J7611   ALBUTEROL CON 1
Exc Ben Les Trunk; 0.6 To 1.0    $   238.00   86308   HETEROPHILE ANT
Exc Ben Les Trunk; 1.1 To 2.0    $   266.00   94640   INHALATION TRMT
Exc Ben Les Trunk; 2.1 To 3.0    $   305.00   20005   INCISION OF ABS
Exc Ben Les Trunk; 3.1 To 4.0    $   346.00   90703   TETANUS IMMUNIZ
Exc Ben Les Trunk; Over 4.0 Cm   $   493.00   99384   PREVCARE 12-17N
Exc Ben Les Scalp; 0.5 Cm/less   $   196.00   99395   PRECARE 18-39EP
Exc Ben Les Scalp; 0.6 To 1.0    $   255.00   E0110   CRUTCHES
Exc Ben Les Scalp; 1.1 To 2.0    $   286.00   J1040   INJ DEPO MEDROL
Exc Ben Les Scalp; 2.1 To 3.0    $   330.00   20000   INCISION OF ABS
Exc Ben Les Scalp; 3.1 To 4.0    $   381.00   Q4021   SHORT ARM SPLIN
Exc Ben Les Scalp; Over 4.0 Cm   $   543.00   99386   PREVCARE 40-64N
Exc Ben Les Face; 0.5 Cm/less    $   209.00   99396   PRECARE 40-64EP
Exc Ben Les Face; 0.6 To 1.0 C   $   242.00   99385   PREVCARE 18-39N
Exc Ben Les Face; 1.1 To 2.0 C   $   273.00   15851   REMOVAL OF SUTU
Exc Ben Les Face; 2.1 To 3.0 C   $   324.00   11765   EX INGROWN NAIL
Exc Ben Les Face; 3.1 To 4.0 C   $   404.00   99393   PREVCARE 5-11EP
Exc Ben Les Face; Over 4.0 Cm    $   551.00   86580   TB INTRADERMAL
Exc Malig Les Trunk; Over 4.0    $   615.00   J0970   INJ DELESTROGEN
Trim Nondystrophic Nails-any N   $    30.00   80100   DRUG TESTING, M
Debrid Nail(s) Any Methd(s); 1   $    75.00   A4565   SLING
Debrid Nail(s) Any Methd(s); 6   $   100.00   16025   BURN TREATMENT
Avulsion Plate Part/complt Sim   $   173.00   99383   PREV CARE 5-11N
Avulsion Plate Part/complt Smp   $    80.00   J1200   INJ BENADRYL 50
Evacuation Subungual Hematoma    $    73.00   99397   PRECARE 65+ EP
Exc Nail/matrix Part/complt Pe   $   375.00   11400   EX LES <.5 CM
Insrt Implnt Contraceptive Cap   $   215.00   16020   BURN TREATMENT
Remov Implnt Contraceptive Cap   $   250.00   99205   OV LEVEL V NP
Simpl Repr Sclp/trunk; 2.5 Cm/   $    242.00    A4204   ABSORTIVE DRESS
Simpl Repr Sclp/trunk; 2.6-7.5   $    259.00    12001   REPAIR SIMPLE
Simpl Repr Sclp/trunk; 7.6-12.   $    306.00    L1830   KNEE IMMOBILIZE
Simpl Repr Sclp/trunk; 12.6-20   $    381.00    Q4045   SHORT LEG SPLIN
Simpl Repr Sclp/trunk; 20.1-30   $    363.00    23931   DRAIN INFECTED
Simpl Repr Face/mucous; 2.5/le   $    259.00    99202   OV LEVEL II NP
Simpl Repr Face/mucous; 2.6-5.   $    287.00    29130   APPLY FINGER SP
Simpl Repr Face/mucous; 5.1-7.   $    307.00    20552   INJECTION SNGL/
Simpl Repr Face/mucous; 7.6-12   $    364.00    51702   INSERT TEMP IND
Simpl Repr Face/mucous; 12.6-2   $    443.00    99243   OFF CONS LEVIII
Layer Clo Sclp/trunk; 2.5 Cm/l   $    288.00    99291   INT CRIT CARE,
Layer Clo Sclp/trunk; 2.6 To 7   $    340.00    26770   TREAT FINGER DI
Layer Clo Sclp/trunk; 7.6 To 1   $    442.00    99000   SPECIMEN HANDLE
Layer Clo Sclp/trunk; 12.6 To    $    518.00    20600   SMALL JOINT INJ
Layer Clo Neck/ft/genit; 2.5cm   $    275.00    17250   CHEMICAL CAUTER
Layer Clo Neck/ft/genit; 2.6 T   $    325.00    15850   REMOVAL OF SUTU
Layer Clo Neck/ft/genit; 7.6-1   $    430.00    11740   EV SUB HEMATOMA
Layer Clo Neck/ft/genit; 12.6-   $    512.00    11200   REM SKINTAG <15
Layer Clo Face/lips; 2.5 Cm/le   $    355.00    20612   ASPIRATE/INJECT
Layer Clo Face/lips; 2.6 To 5.   $    390.00    10120   REM FORIEGN BOD
Layer Clo Face/lips; 5.1 To 7.   $    458.00    16035   REMOVAL OF BURN
Layer Clo Face/lips; 7.6 To 12   $    554.00    46083   INC EXT HEMORRH
Layer Clo Face/lips; 12.6 To 2   $    651.00    99211   OV LEVEL I ESP
Exc Excess Skin/subq Tiss; Oth   $   1,250.00   13131   REPAIR COMPLEX
Init Tx 1st Degree Burn W/loca   $     114.00   12002   REP SIM TO 7.5C
Dsg/debrid Init/subsqt; Wo Ane   $    134.00    46320   REMOVE HEMORRHO
Dsg/debrid Init/subsqt; Wo Ane   $    243.00    99407   TOBACCO USE CES
Dsg/debrid Init/subsqt; Wo Ane   $    296.00    53670   URINARY CATHETE
Escharotomy                      $    365.00
Destrct-any Methd-ben Les; W/a   $    139.00
Destrct-any Methd-ben Les; 2-1   $     26.00
Destrct-any Methd-ben Les 15/>   $    294.00
Destrct Warts/molluscum To 14    $    169.00
Destrct Warts/molluscum; 15/>    $    218.00
Chem Caut Granulation Tiss       $    126.00
Punct Aspirat Cyst Breast        $     171.00
Bx Breast; Needle Core (sep Pr   $    265.00
Inj Tendon Sheath/lig/trig Pt/   $     99.00
Injection; Tendon Origin/inser   $     99.00
Inj; 1/mx Trig Point 1/two Mus   $     87.00
Inj; 1/mx Trig Point 3/> Musc    $     96.00
Arthrocentesis/aspir/inj; Sm J   $     94.00
Arthrocentesis/aspir/inj; Inte   $     101.00
Arthrocentesis/aspir/inj; Majo   $    133.00
Clo Tx Rib Fx Uncomp Ea                              $     146.00
Clo Tx Clav Fx; Wo Manip                             $     341.00
Clo Tx Prox Humeral Fx; Wo Man                       $    525.00
Clo Tx Rad & Ulna Shaft Fx; Wo                       $     418.00
Clo Tx Dist Rad Fx; Wo Manip                         $    457.00
Clo Tx Metacarp Fx 1; Wo Manip                       $    394.00
Clo Tx Dist Phalangeal Fx; Wo                        $    248.00
Clo Tx Tibial Shaft Fx; Wo Man                       $    660.00
Clo Tx Distal Fibular Fx; Wo M                       $    499.00
Clo Tx Metatarsal Fx; Wo Manip                       $    298.00
Applic; Shoulder To Hand                             $     155.00
Applic; Elbow To Finger                              $     144.00
Applic Long Arm Splint                               $     140.00
Applic Short Arm Splint; Stati                       $     110.00
Applic Finger Splint; Static                         $     67.00
Applic Short Leg Cast                                $     148.00
Applic Short Leg Cast; Walking                       $     160.00
Add Walker To Prev Applic Cast                       $     75.00
Applic Short Leg Splint                              $     120.00
Strapping; Unna Boot                                 $     89.00
Remov/bivalv; Full Arm/leg Cas                       $     111.00
Remov Fb Intranasal; Offic Pro                       $    366.00
Contrl Nasal Hemorr-ant-simpl                        $     154.00
Contrl Nasal Hemorr-ant-complx                       $    300.00
Contrl Nasal Hemorr-post; Init                       $    368.00
Intubation Endotracheal Emer P                       $    300.00
Thoracentesis, puncture of pleural cavity for aspi   $    275.00
Routine Venipunct/finger/heel                        $      13.00
collecton capillary blood spec                       $      16.00
Cath Umbilical Vein Dx/therap                        $    206.00
Frenectomy Exc Lingual Frenum                        $     412.00
Ugi Endo; Dx W/wo Collec Specm                       $    475.00
Colectomy Part; W/resect & Muc                       $   1,005.00
Colectomy Part; W/coloproctost                       $    945.00
Colectomy W/remov Term Ileum                         $   2,063.00
Appy; Rupt W/abscess/gen Perit                       $    322.00
Colonoscopy Flex; Dx (sep Pro)                       $    625.00
Colonoscopy Flex; W/bx 1/mx                          $    755.00
Laparoscopy, surgical; proctopexy (for prolapse),    $    875.00
Incs Thrombosed Hemorrhoid Ext                       $    265.00
Enucleation Ext Thrombotic Hem                       $     251.00
Anoscopy; Dx W/wo Specmn (sep                        $     133.00
Destrct Les Anus Simpl; Cryosu                       $    352.00
Destrct Les Anus Exten Any Met                       $    770.00
Destrct Hemorrhoids Any Methd;                       $    583.00
Destrct Hemorrhoids Any Methd;                       $    439.00
Choley                                               $    446.00
Choley W/explor Common Duct                          $    665.00
Explor Laparotomy W/wo Bx (sep                       $   1,290.00
Peritoneocentesis; Init                              $    296.00
Lap Surg-abd; Dx-w/wo Specmn (                       $    550.00
Lap Surg-abd Peritnm; W/aspir                        $    626.00
Repr Init Ing Hernia 5yr/more;                       $    273.00
Lap Surg; Ureterneocystost W/s                       $   2,100.00
Exc Urachal Cyst W/wo Hernia R                       $   1,040.00
insertion non-indwll bladder c                       $    106.00
insert temp indwll bladd cath;                       $    139.00
Simpl Cystometrogram                                 $    397.00
Cystorrhaphy Wound/rupt; Simpl                       $   1,225.00
Clo Cystostomy (separt Proc)                         $    892.00
Cystourethroscpy W/dilat; Gen                        $    364.00
Cystourethscpy W/insrt Ureth S                       $    659.00
Cystourethroscpy Tx Fe Urethrl                       $    494.00
Destrct Les Penis Simpl; Chem                        $    209.00
Destrct Les Penis Simpl; Cryos                       $    248.00
Destrct Les Penis Exten Any Me                       $    357.00
Circumcision Using Clamp; Nb                         $    300.00
Circumcision Using Clamp; Ex N                       $    200.00
Vasectomy (sep Pro) W/postop S                       $    767.00
I&d Bartholin's Gland Abscess                        $    208.00
Destrct Les Vulva; Simpl Any M                       $    198.00
Destrct Les Vulva; Exten Any M                       $    338.00
Vulvectomy Simpl; Part                               $    800.00
Part Hymenectomy/revis Hymenal                       $    285.00
colposcopy of the vulva; w/bio                       $    223.00
Destrct Vag Les; Simpl Any Met                       $    198.00
Bx Vag Mucos; Simpl (separt Pr                       $    154.00
Bx Vag Mucos; Exten Req Suture                       $    205.00
Fit/insrt Pessary-oth Support                        $    137.00
Colporrhaphy Suture Injury Vag                       $    524.00
Ant Colporrhaphy Repr Cystocel                       $   1,053.00
Post Colporrhaphy Repr Rectoce                       $   1,025.00
Combo Anteroposterior Colporrh                       $   1,425.00
Combo A-p Colporrhaphy; W/ente                       $   1,935.00
Insertion of mesh or other prosthesis for repair O   $    397.00
Colpopexy, Vaginal; Intra-peritoneal Approach        $   1,040.00
Sling Operation For Stress Inc                       $   1,490.00
Revision (or Removal) of prosthetic vaginal          $    857.00
Pelvic Exam Under Anes           $     191.00
colpscpy entire vag w/cerv if    $     176.00
Colposcopy; (separt Proc)        $     192.00
Colposcopy; W/bx-cerv &/or End   $    269.00
Colposcopy; W/loop Electrd Exc   $     501.00
Bx 1/mx Local Exc Les (separt    $    202.00
Endocervical Curet               $     177.00
Caut Cerv; Cryocautery Init/re   $    252.00
Conization Cerv W/wo D&c; Knif   $    533.00
Coniza Cerv W/wo D&c; Loop Ele   $    457.00
Trachelorrhaphy Repr Cerv-vag    $    465.00
Endomet Bx W/wo Endocerv Bx (s   $     192.00
D&c Dx &/or Therap (non Ob)      $    446.00
Myomectomy Sngl/mx (sep Pro);    $   1,594.00
Myomectomy Sngl/mx (sep Pro);    $     812.00
myomect 5/>myoma&/tot wt>250 g   $   1,600.00
Tah W/wo Remov Tube(s) - Ovary   $   1,723.00
Supracerv Abd Hyst W/wo Remov    $   1,655.00
Vag Hyst                         $   1,438.00
Vag Hyst; W/remov Tube &/or Ov   $   1,372.00
Vag Hyst; W/repr Enterocele      $   2,128.00
vag hyst uterus > 250 grams;     $   2,006.00
vag hyst utrus>250 gms; remv t   $   2,590.00
Insrt Intrauterine Device        $     118.00
Remov Intrauterine Device        $     166.00
Cath-intro/inj Hysterosono/sal   $     216.00
Chromotubation Oviduct Incl Ma   $     215.00
Endomet Ablat Therm Wo Scop Gu   $   1,906.00
Lap Surg; W/vag Hyst W/wo Remo   $   2,418.00
lap vag hyst utrus 250 gms/<;    $   1,686.00
lap vag hyst utrus>250 gm;remv   $   2,254.00
Hysteroscopy Dx (separt Proc)    $    437.00
Hysteroscpy Surg; W/samp/polyp   $    775.00
Hysteroscopy Surg; W/remov Fb    $    544.00
Hysteroscopy Surg; W/endo Abla   $   2,971.00
Hysteroscopy, Sterilization      $   3,380.00
Lig/transect Fallopian Tube Ab   $    635.00
Lig Fallopian-same Hosp (sep P   $    575.00
Lig Fallopian-w/c-sect/intra-a   $     137.00
Lap Surg; W/lysis Adhes (sep P   $   1,173.00
Lap Surg; W/remov Adnexal Stru   $   1,119.00
Lap Surg; W/fulg/excis Les-ova   $   1,049.00
Lap Surg; W/fulg Oviducts        $    549.00
Lap Surg; W/occlus Oviducts-de   $    827.00
Lap Surg; W/salpingostomy                            $   1,401.00
Salpingectomy Complt/part (sep                       $   1,335.00
Salpingo-oophorectomy (separt                        $   1,249.00
Lysis Adhesions                                      $   1,518.00
Ovarian Cystectomy Unilat/bila                       $   1,277.00
Oophorectomy Part/tot Unilat/b                       $    879.00
Bilateral salpingo-oophorectomy with total omentec   $   2,445.00
Amniocentesis Any Methd                              $    226.00
Fetal Contraction Stress Test                        $     163.00
Fetal Non-stress Test                                $     88.00
Surg Tx Ectopic Pg; Req Salpin                       $   1,392.00
Surg Tx Ectopic Pg; Wo Salping                       $   1,155.00
Lap Tx Ectopic Pg; W/salpingec                       $   1,097.00
Curet Pp                                             $     731.00
Cerclage Cerv During Pg; Vag                         $    235.00
Cerclage Cerv During Pg; Abd                         $    375.00
Routine Ob Care Incl Vag Del                         $   3,121.00
Vag Deliv Only                                       $   1,372.00
Vag Deliv Only; Incl Pp Care                         $   1,596.00
Ext Cephalic Version W/wo Toco                       $     185.00
Antepartum Care Only; 4-6 Visi                       $    780.00
Antepartum Care Only; 7/more V                       $   1,400.00
Routine Ob Care Incl C Sect                          $   3,536.00
C Deliv Only;                                        $   1,627.00
C Deliv Only; Incl Pp Care                           $   1,919.00
Subtl/tot Hyst After Cesarean                        $   1,005.00
Rout Ob Care-vag Deliv-prev C                        $   3,298.00
Rout Ob Care-c Deliv-vag Try-p                       $   3,635.00
Tx Incompl Ab Any Trimes Compl                       $    568.00
Tx Missed Ab Compl Surg; 1st T                       $    653.00
Tx Missed Ab Compl Surg; 2nd T                       $    905.00
Tx Septic Ab Complt Surgically                       $    675.00
Spinal Punct Lumbar Dx                               $     221.00
Remov Fb Ext Eye; Conjunc Supe                       $     88.00
Remov Fb Ext Eye; Conjunc Embe                       $     107.00
Remov Fb Ext Eye; Corneal Wo L                       $      81.00
Remov Fb Ext Eye; Corneal W/la                       $     125.00
Remov Fb-ext Audit Canal; Wo A                       $    200.00
Remov Impacted Cerumen (sep Pr                       $     83.00
Hysterosalpingography-rad S &                        $     134.00
Drug Screen; Sngl Drug Class E                       $     175.00
Ua Dip Stik/tablet; Wo Micro A                       $      10.00
Urin Pg Test Visual Color Comp                       $     20.00
Bld Occult; Feces 1-3 Simult D                       $      10.00
Glu; Quan                                            $    14.00
Hgb; Glycated                                        $    21.00
Bld Ct; Hgb                                          $    12.00
Prothrombin Time                                     $    13.00
Skin Test; Tuberculosis Intrad                       $   26.00
Tiss Exam Fungi                                      $    12.00
Agt-immunassay Dir Obs; RSV                          $   25.00
Agt-immunassay Dir Obs; Strep                        $   22.00
Immuniz Admin/H1N1                                   $   25.00
Immuniz Admin; 1/combo Vacc/to                       $   25.00
Immuniz Admin; 2/> Sing/comb V                       $    15.00
Immu Admn Intranasal/oral; 1 V                       $    19.00
Hepatitis A Vaccine Adult Dose                       $   89.00
Hep A Vaccine Ped/adoles Dose-                       $   35.00
Hep A-hep B Vaccine Adult Dose                       $   30.00
Hemophil Flu B Vacc Prp-omp Co                       $   35.00
Hemophil Flu B Vacc Prp-t Conj                       $   30.00
Gardisil                                             $   168.00
Flu Virus Vacc-split 6-35 Mo                         $   20.00
Flu Vir Vacc-split 3 Yr & > Im                       $   20.00
Flu Virus Vacc-split 6-35 Mo I                       $   20.00
Flu Vir Vacc-split 3 Yr & > Im                       $   20.00
Flu Vacc HIg Dose 65 Yrs +                           $    31.00
Pneumococcal Vacc-polyvalent-i                       $   97.00
Pneumococcal conjugate vaccine, 13 valent, for int   $   150.00
Rotavirus Vacc Pentavlnt-live-                       $   95.00
Rotarix                                              $    15.00
Typhoid Vaccine-vicps-im Use                         $   65.00
DTaP - Hib - IPV                                     $    12.00
Diphth/tet Tox/acell Pertuss V                       $   32.00
Diphth & Tet Tox -ped Use-im U                       $   20.00
Measles/mumps/rubella Vac Live                       $   65.00
Measles/mumps/rubella/varcella                       $   145.00
Poliovirus Vac Inactivated-sub                       $   30.00
Tetanus, Diphtheria Vaccine                          $   48.00
Varicella Virus Vac Live-subq                        $   100.00
Tetanus/diphth Tox-adult-im/je                       $   23.00
Dipth/tet/whle Cell Pertuss/in                       $    31.00
Dtap-hep B-ipv Inactivated-im                        $   92.00
Pneumococcal Polysacch Vac-adu                       $   60.00
Meningocococcal Polysacch Vac-                       $   111.00
Meningococcal Vaccine                                $   108.00
OZostavax                                            $   215.00
Hepatitis B Vac Adolescent-im                        $   27.00
Hepatitis B Vac Ped/adoles Dos                    $    21.00
Hepatitis B Vac Adult Dose-im                     $   100.00
Hep B/hemophilus Influ B Vac-i                    $    67.00
Screening Test Pure Tone Air O                    $    17.00
Pure Tone Audiometry; Air Only                    $    17.00
Ecg-routine 12 Lead; W/intrpt                     $    40.00
Cv Stress; Interpt & Reprt Onl                    $    31.00
Rhythm Ecg 1-3 Lead; W/intrpt-                    $    22.00
Echo W/rest & Stress-interp &                     $   454.00
Noninvasv Stdy-up/lo Extm Art                     $   175.00
Noninvasiv Physiol Stdy-lo Ext                    $    45.00
Spiromtry W/recrd-vc-expir Flo                    $    63.00
Bronchospsm Eval: Spiro-bronch                    $   114.00
Determ Airway Clo Volum 1 Brea                    $    60.00
Airway Inhalation Treatment                       $    33.00
Airway Inhalation Education Demo                  $    33.00
Prof Immunotx Wo Extrct; 1 Inj                    $    17.00
Prof Immunotx Wo Extract; 2/>                     $    22.00
Prof Immunotx W/extract; 1 Ins                    $    15.00
Intrav. Infusion Up To 1 Hr                       $   105.00
Each Additional Hr                                $    30.00
IV Infusion/w Meds Up To 1 Hr                     $   128.00
IV Infusion/w Meds Ea Add't Hr                    $    40.00
Ther., Prophy., Or Diagnostic Inj                 $    21.00
Ther/proph/diag Inj - IV Push                     $    70.00
Partial Thickness Removal of devitalized tissue   $   105.00
Full Thickness Removal of devitalized tissue      $   135.00
Osteopath Manip Tx; 1-2 Bod Re                    $    51.00
Osteopath Manip Tx; 3-4 Bod Re                    $    71.00
Handl/convey Specmn-offic To L                    $    25.00
Serv Request Aftr Hrs Add To B                    $    61.00
Suppl/mat Provid-phys Not W/visit                 $    44.00
Phlebotomy Therap (separt Proc                    $    50.00
Offic/outpt E&m New Minor 10mi                    $    69.00
Offic/outpt E&m New Low-mod 20                    $    89.00
Offic/outpt E&m New Mod Sever                     $   126.00
Offic/outpt E&m New Mod-hi 45                     $   179.00
Offic/outpt E&m New Mod-hi 60                     $   228.00
Offic/outpt E&m Estab 5 Min                       $    28.00
Offic/outpt E&m Estab Minor 10                    $    54.00
Offic/outpt E&m Estab Low-mod                     $    77.00
Offic/outpt E&m Estab Mod-hi 2                    $   115.00
Offic/outpt E&m Estab Mod-hi 4                    $   166.00
Obsrv Care D/c Da Mgmt                            $   124.00
Init Obsrv Care-da E&m Low Sev                   $    103.00
Init Obsrv Care-da E&m Mod Sev                   $    190.00
Init Obsrv Care-da E&m Hi Seve                   $    267.00
Init Hosp-da E&m Low Severity                    $    168.00
Init Hosp-da E&m Mod Severity                    $    227.00
Init Hosp-da E&m Hi Severity 7                   $    335.00
Subsqt Hosp-da E&m Stable 15 M                   $     69.00
Subsqt Hosp-da E&m Minr Compl                    $    124.00
Subsqt Hosp-da E&m Sig Compl 3                   $    178.00
Obsrv/inpt Hosp Care E&m Low S                   $    233.00
Obsrv/inpt Hosp Care E&m Mod S                   $    306.00
Obsrv/inpt Hosp Care E&m High                    $    341.00
Hosp D/c Da Mgmt; 30 Min/less                    $    122.00
Hosp D/c Da Mgmt; More Than 30                   $    178.00
Offic Cons New/estab Minor 15                    $     91.00
Offic Cons New/estab Low 30 Mi                   $    170.00
Init Inpt Cons New/estab Minr                    $     91.00
Init Inpt Cons New/estab Low 4                   $    140.00
Init Inpt Cons New/estab Mod 5                   $    214.00
Init Inpt Cons New/est Mod-hi                    $    255.00
Emer Visit E&m Self Limited/mi                   $     74.00
Emer Visit E&m Low-moderat Sev                   $     117.00
Emer Dept Visit E&m Moderate S                   $    196.00
Emer Visit E&m Hi Sever Urgent                   $    295.00
Er E&m Hi Sever Immed Signif T                   $    434.00
Crit Care E&m-unstable Pt; 1st                   $    469.00
Crit Care E&m; Ea Add 30 Min                     $    214.00
Init Nicu Care/da-e&m-admissio                   $   1,627.00
Initial nursing facility care, Low Comp 25 Min   $    136.00
Initial nursing facility care, Mod Sev 35 Min    $    189.00
Subs nursing facility care, Stable 10 Min        $     87.00
Subst nursing facility care, Minor Comp 15 Min   $    102.00
Home Visit E&m New Pt Lo Sev-2                   $     90.00
Home Visit E&m New Pt Mod-hi-4                   $    245.00
Home Visit E&m Estab Minor-15                    $     88.00
Home Visit E&m Estab Low-mod 2                   $    132.00
Home Visit E&m Estab Mod-hi 40                   $     191.00
Init Preven Meds New Under 1 Yr                  $     151.00
Init Preven Meds New 1-4 Yrs                     $    165.00
Init Preven Meds New 5-11 Yrs                    $    169.00
Init Preven Meds New 12-17 yrs                   $    179.00
Init Preven Meds New 18-39 Yrs                   $    179.00
Init Preven Meds New 40-64 Yrs                   $    209.00
Init Preven Meds New 65+ Yrs                     $    229.00
Preven Meds Estab Under 1 Yr                         $    129.00
Preven Meds Estab 1-4 Yrs                            $    144.00
Preven Meds Estab 5-11 Yrs                           $    149.00
Preven Meds Estab 12-17 Yrs                          $    157.00
Preven Meds Estab 18-39 Yrs                          $    158.00
Preven Meds Estab 40-64 Yrs                          $    173.00
Preven Meds Estab 65+ Yrs                            $    194.00
Hx & Exam Normal Nb-d/c Same D                       $    139.00
Hx/exam Norm Nb Init Dx/tx/pre                       $    100.00
Subsqt Hosp Care E&m Norm Nb-d                       $     75.00
Hx & Exam Normal Nb-d/c Same D                       $    139.00
Delivery/birthing room resuscitation, provision of   $    200.00
Lap Surg; Cholecystectomy                            $    420.00
Choley; W/cholangiography                            $    446.00
Choley W/explor Duct; Choledoc                       $    675.00
Lap Surg-abd; Dx-w/wo Specmn (                       $    220.00
Lap Surg-abd Peritnm; W/aspir                        $    250.00
Cystourethroscopy (separt Proc                       $    512.00
Ant Colporrhaphy Repr Cystocel                       $    420.00
Post Colporrhaphy Repr Rectoce                       $    410.00
Combo Anteroposterior Colporrh                       $    570.00
Insertion of mesh or other prosthesis for repair O   $    158.00
Sling Operation For Stress Inc                       $    595.00
Myomectomy Sngl/mx (sep Pro);                        $    637.00
Tah W/wo Remov Tube(s) - Ovary                       $    690.00
Vag Hyst                                             $    575.00
Vag Hyst; W/repr Enterocele                          $    851.00
Lap Surg; W/vag Hyst W/wo Remo                       $    967.00
lap vag hyst utrus 250 gms/<;                        $    674.00
Hysteroscopy Dx (separt Proc)                        $    175.00
Hysteroscopy, Sterilization                          $   1,352.00
Lig/transect Fallopian Tube Ab                       $    254.00
C Deliv Only;                                        $   1,415.00
Subtl/tot Hyst After Cesarean                        $    400.00
Immuniz Admin/H1N1                                   $     15.00
Immuniz Admin; 1/combo Vacc/to                       $     12.00
Immuniz Admin; 1/combo Vacc/to                       $     15.00
Immuniz Admin; 1/combo Vacc/to                       $     15.00
Immuniz Admin; 2/> Sing/comb V                       $     15.00
Immuniz Admin; 2/> Sing/comb V                       $     15.00
Immu Admn Intranasal/oral; 1 V                       $     12.00
Immu Admn Intranasal/oral; 1 V                       $     15.00
Hep A Vaccine Ped/adoles Dose-                       $     15.00
Hemophil Flu B Vacc Prp-omp Co                       $     15.00
Hemophil Flu B Vacc Prp-t Conj                       $   15.00
Gardisil                                             $   15.00
Flu Virus Vacc-split 6-35 Mo                         $   15.00
Flu Vir Vacc-split 3 Yr & > Im                       $   15.00
Flu Virus Vacc-split 6-35 Mo I                       $   15.00
Flu Vir Vacc-split 3 Yr & > Im                       $   15.00
Influenza virus vaccine, pandemic formulation        $   15.00
Pneumococcal Vacc-polyvalent-i                       $   15.00
Pneumococcal conjugate vaccine, 13 valent, for int   $   15.00
Rotavirus Vacc Pentavlnt-live-                       $   15.00
Dip,tet,acellular pertus&polio,Dtap-IPV 4-6 Yrs      $   15.00
DTaP - Hib - IPV                                     $   15.00
Diphth/tet Tox/acell Pertuss V                       $   15.00
Diph/tet/whole Cell Pertuss Va                       $   12.00
Diphth & Tet Tox -ped Use-im U                       $   12.00
Measles/mumps/rubella Vac Live                       $   15.00
Measles/mumps/rubella/varcella                       $   15.00
Poliovirus Vac Inactivated-sub                       $   15.00
Tetanus, Diphtheria Vaccine                          $   15.00
Varicella Virus Vac Live-subq                        $   15.00
Tetanus/diphth Tox-adult-im/je                       $   15.00
Dtap-hep B-ipv Inactivated-im                        $   15.00
Pneumococcal Polysacch Vac-adu                       $   15.00
Meningococcal Vaccine                                $   15.00
Hepatitis B Vac Adolescent-im                        $   15.00
Hepatitis B Vac Ped/adoles Dos                       $   15.00
Hep B/hemophilus Influ B Vac-i                       $   15.00
Init Preven Meds New 18-39 Yrs                       $   110.00
Init Preven Meds New 40-64 Yrs                       $   110.00
Init Preven Meds New 65+ Yrs                         $   110.00
Preven Meds Estab 12-17 Yrs                          $   110.00
Preven Meds Estab 18-39 Yrs                          $   110.00
Preven Meds Estab 40-64 Yrs                          $   110.00
Preven Meds Estab 65+ Yrs                            $   110.00
Insert Tray W/drbg & Indw Cath                       $   21.00
Indw Cath Foley 2 Way Ltx W/co                       $    5.00
Urinary Leg Bag Vinyl W/wo Tub                       $   15.00
Elas Band /roll (compres Band)                       $    5.00
Surgical Trays                                       $   25.00
Pessary Rubber                                       $   75.00
Pessary Non Rubber                                   $   62.00
Slings                                               $    5.00
Splints                                              $   12.00
Peak Expir Flow Meter Hand Hel                       $   20.00
Ace Bandage < 3 Inches           $     5.00
Ace Bandage 3-5" In Width"       $     5.00
Drug Screen; Mx Drug Classes E   $    56.00
Init Preven Meds New 12-17 yrs   $    85.00
Drug Screen; Mx Drug Classes E   $    17.00
Drug Screen; Mx Drug Classes E   $    21.00
Periodic Oral Examination        $    37.00
Limit Oral Eval-prob Focused     $    63.00
Comprehensive Oral Evaluation    $    64.00
Detail & Exten Oral Eval, Br     $    90.00
Intraor Complt (incl Bitewings   $   104.00
Intraoral Periapical First Fil   $    21.00
Intraor Periapical Ea Add Film   $    18.00
Intraoral Occlusal Film          $    24.00
Bitewing Single Film             $    22.00
Bitewings Two Films              $    32.00
Bitewings Four Films             $    47.00
Prophylaxis Adult                $    77.00
Prophylaxis Child                $    54.00
Top Fluoride (prophyl Not Incl   $    29.00
Top Fluoride-adult               $    29.00
Topical Fluride Varnish          $    45.00
Oral Hygiene Instruction         $    38.00
Sealant Per Tooth                $    40.00
Space Maintainer Fixed Unilate   $   274.00
Space Maintainer Fixed Bilater   $   332.00
Space Maintainer Remov Unilat    $   325.00
Recementation Of Space Maintai   $    52.00
Amalgam One Surface Permanent    $    92.00
Amalgam Two Surfaces Permanent   $   121.00
Amalgam Three Surfaces Permane   $   144.00
Amalgam 4/more Surfaces Perman   $   171.00
Resin One Surface Anterior       $    96.00
Resin Two Surfaces Anterior      $   122.00
Resin Three Surfaces Anterior    $   173.00
Resin 4/more Surfaces/incisal    $   215.00
Posterior 1 Surface              $   140.00
Posterior 2 Surface Resin        $   166.00
Posterior 3 Surface Resin        $   223.00
Posterior 4 Surface              $   261.00
Onlay-porcelain/ceramic>=4 Sur   $   761.00
Crown Resin (laboratory)         $   349.00
Crown Porcelain Ceramic Substr   $   780.00
Crown Porc Fused High Noble Me   $   770.00
Crown Porc Fused Predom Base M                     $    716.00
Crown Porc Fused Noble Metal                       $    734.00
Crown Full Cast High Noble Met                     $    739.00
Crown Full Cast Predom Base Me                     $    704.00
Crown Full Cast Noble Metal                        $    716.00
Recement Inlay                                     $     78.00
Recement Crown                                     $     63.00
Prefab Ststl Crown Prim Tooth                      $    172.00
Prefab Ststl Crown Perm Tooth                      $    231.00
Sedative Filling                                   $     66.00
Core Build Up Including Any Pi                     $    164.00
Pin Retention/tooth-add-restor                     $     49.00
Prefab Post & Core In Add To C                     $    245.00
Temporary (fractured Tooth)                        $     161.00
Crown Repair By Report                             $     115.00
Pulp Cap Dir (excld Final Rest                     $     48.00
Pulp Cap Indir (excld Final Re                     $     39.00
Therap Pulpotomy (excld Fnl Re                     $     111.00
Pulpal Debridement                                 $    122.00
Pulpal Therap-ant Prim Tth                         $    228.00
Pulpal Therap-post Prim Tth                        $    228.00
Anterior (excld Final Restor)                      $    471.00
Bicuspid (excld Final Restor)                      $    564.00
Molar (excluding Final Restora                     $    745.00
Retreat Previous Rcnl Therap-a                     $    640.00
Anatomical crown expos, 1-3 teeth per              $    443.00
Clin Crown Lengthening-hard Ti                     $    475.00
P'dontal Scaling & Root Plan /                     $    183.00
Periodontal scaling & root planing 1-3, Per Quad   $     110.00
Full Mouth Debridement                             $    122.00
P'dontal Maint Proc (aftr Act                      $    107.00
Complete Denture Maxillary                         $   1,035.00
Complete Denture Mandibular                        $   1,035.00
Immediate Denture Maxillary                        $   1,175.00
Immediate Denture Mandibular                       $   1,128.00
Maxillary Partial Dent-resin B                     $    764.00
Maxil Part Dent-cast Metal W/r                     $    975.00
Mandib Part Dent-cast Metal W/                     $   1,243.00
Maxillary partial denture - flexible base          $    750.00
Mandibular partial denture - flexible base         $    850.00
Adjust Complete Denture-maxill                     $     63.00
Add Tooth Existing Partial Den                     $     110.00
Rebase Complete Maxillary Dent                     $    454.00
Reline Maxil Complt Dent (lab)                     $    350.00
Reline Mandib Part Dent (lab)                        $   342.00
Interim Partial Denture (maxil                       $   350.00
Interim Partial Denture (mandi                       $   377.00
Tissue Conditioning, Maxillary                       $   142.00
Precision Attachment By Report                       $   364.00
Modification of removable prosthesis following imp   $   172.00
Unspec Maxil'facial Prosth Br                        $   200.00
Pontic Cast Noble Metal                              $   595.00
Pontic Porc Fused Noble Metal                        $   711.00
Pontic - porcelain/ceramic                           $   725.00
Retain-mtl-resin Bonded Fix Pr                       $   285.00
Crown Partial - porcelain/ceramic                    $   775.00
Crown Partial Porc Fused High Noble Me               $   735.00
Crown Porc Fused To Noble Meta                       $   746.00
Crown Full Cast Noble Metal                          $   595.00
Stress Breaker                                       $   188.00
Precision Attachement                                $   317.00
Coronal Remnants                                     $    72.00
Extract Erupted Tooth                                $    92.00
Remov Erptd Tth W/flp Bon/tth                        $   153.00
Removal Impacted Tooth Soft Ti                       $   225.00
Surg Remov Tooth Roots (cut Pr                       $   190.00
Tth Replnt/stab Accdnt Tth/alv                       $   321.00
Alveoloplasty W/extractions/qu                       $   210.00
I&d Absc Intraoral Soft Tiss                         $   133.00
Drug Screen; Mx Drug Classes E                       $    23.00
Pall (er) Tx Dental Pain Minor                       $    86.00
Analgesia                                            $    46.00
Offic Visit Obsrv (reg Hours O                       $    40.00
Offic Visit Aft Reg Sched Hour                       $    72.00
Tx Complic (post Surg) Unusual                       $    65.00
Init Preven Meds New 1-4 Yrs                         $    25.00
Init Preven Meds New 5-11 Yrs                        $    25.00
Init Preven Meds New 18-39 Yrs                       $    25.00
Preven Meds Estab 1-4 Yrs                            $    25.00
Preven Meds Estab 5-11 Yrs                           $    25.00
Preven Meds Estab 12-17 Yrs                          $    25.00
Preven Meds Estab 18-39 Yrs                          $    25.00
Occlusal Guard, By Report                            $   385.00
Fabrication Of Athletic Mouthg                       $   110.00
Enamel Microabrasion                                 $    40.00
Odontoplasty 1-2 teeth; includes removal of enamel   $    40.00
External bleaching - per arch                        $   215.00
External Bleaching - Per Tooth                       $    70.00
Internal bleaching - per tooth               $   165.00
Dive Physical                                $   650.00
Init Preven Meds New 18-39 Yrs               $   145.00
Init Preven Meds New 40-64 Yrs               $   145.00
Init Preven Meds New 65+ Yrs                 $   145.00
Preven Meds Estab 18-39 Yrs                  $   145.00
Preven Meds Estab 40-64 Yrs                  $   145.00
Preven Meds Estab 65+ Yrs                    $   145.00
Drug Screen; Mx Drug Classes E               $    25.00
Inj Adenosine 6 Mg (see Also A               $    56.00
Inj Epinephrine Adrenaline <=1               $    22.00
Inj Ampicillin Sodium 1.5 Gm                 $    16.00
Inj Pen G Benz/pro To 600,000                $    22.00
Inj Pen G Benz/pro To 1,200,00               $    30.00
Inj Pen G Benz/Pro 100,000                   $     4.00
Inj Pen G Benz 100,000                       $     8.00
Inj Cefazolin Sodium To 500 Mg               $    25.00
Inj Rocephin / Ceftriaxone Sodium Per 250    $    24.00
Betamethasone Na Phosphate/4 M               $    39.00
Inj Prochlorperazine To 10 Mg                $    14.00
Inj Depo-estradiol Cypionate To 5            $     9.00
Inj Methylprednisolone Acetate-40            $    14.00
Inj Methylprednisolone Acetate-80            $    24.00
Inj Medroxypro Acetate-contra-150            $    76.00
Inj Depo-Testosterone To 100                 $     7.00
Inj Depo-Testosterone To 200                 $    24.00
Dexamethasone Na Phospate-4 Mg               $    22.00
Inj Dihydroergotamine Mesylate               $    59.55
Inj Diphenhydramine Hcl To 50                $     5.00
Inj Delestrogen To 10 M                      $    37.00
Inj Filgrastim 300 Mcg                       $   285.00
Tetanus Immune Globulin Human-               $    23.00
Hydrocortisone Na Phosphate-50               $     9.00
Inj Insulin Regular                          $     5.00
Inj Toradol / Ketorolac Tromethamine 15 Mg   $    12.00
Inj Furosemide To 20 Mg                      $    12.00
Inj. lidocaine, 10mg                         $     5.00
Inj Lorazepam 2mg                            $    17.00
Inj Morphine Sulfate To 10 Mg                $    15.00
Inj, Nalbuphine Hcl, Per 10 Mg               $     5.50
Inj Zofran 1mg / Ondansetron                 $    42.00
Pen G Procaine Aqueous-600,000               $    11.00
Inj Promethazine Hcl To 50 Mg                $     5.00
Inj Progesterone Per 50 Mg                   $    56.00
Inj Metoclopramide Hcl To 10 M                       $    17.35
Rho D Ig Human 1 Dose Pkg                            $   157.00
Methylpred Na Succinate To 125                       $     9.00
Inj Sumatriptan Succinate 6 Mg                       $    85.00
Inj Kenalog 10mg / Triamcinolone Acetonide/10 Mg     $     7.00
Inj Valium 5 Mg / Diazepam To 5 Mg                   $    11.00
Inj Vancomycin Hcl To 500 Mg                         $     7.00
Inj Hydroxyzine Hcl To 25 Mg                         $    25.00
Thiamine HC1 100mg                                   $     5.00
Vit B-12 Cyanocobalamin-1000 M                       $     5.00
Inj Phytonadione (vit K) Per 1                       $    21.00
Inj, Potassuim Chloride/2 Meq                        $    15.00
Intrauterine Copper Contracept                       $   395.00
Mirena IUD                                           $   577.00
Etonogestrel implant system, incl Supplies           $   735.00
Hyalgan (Soduim Hyaluronate)                         $   180.00
Hyalgan (Sodium Hyaluronate)                         $   180.00
sodium hyaluronate/derivative intra-articular Inj    $   380.00
Hylan G-f 20 16 Mg Intra Art I                       $   302.00
Hyaluronan or derivative, 16 Mg Synvisc or Synvisc   $   310.00
Prednisolone Oral, Per 5 Mg                          $     5.00
Albuterol concentrated form, 1 mg                    $     5.00
Albuterol Sulfate 0.083% Inhalation                  $     7.00
Xopenex/Levalbuterol .5 Mg                           $     7.00
Albuterol Sulfate 0.083%                             $    10.00
Ipratropium Bromide 0.02%/ml Inhalation              $     5.00
Interferon,alfa-2a,recomb/3 Mi                       $    68.00
Methotrexate Sodium 50 Mg                            $    11.00
Cerv Flex Non Adjus (foam Coll                       $    15.00
Mx Post Collr Occip/mandib                           $    23.00
Thoracic Rib Belt Custom Fabri                       $    10.00
Lumbar Support                                       $    25.00
Ko Elastic W/joints                                  $    30.00
Ko Immobilizer Canvas Longitud                       $    31.00
Ko Wo Joint Rgd Mold/pt Model                        $    75.00
Ko Uprt Thigh/calf Adjus Flex                        $   800.00
Afo Ankle Gauntlet                                   $    15.00
Kafo Sngl Uprt Free K/a Sld St                       $    95.00
Afo-fx/tib Fx Orthosis-semi-ri                       $    92.00
Ambulatory Surg Boot Ea                              $     8.00
Plastazote Sandal Ea                                 $    10.00
So Fig 8 Design Abduct Restrai                       $    12.00
Elbow Sleeve                                         $    12.00
Whfo Short Opponens No Attach                        $    28.00
Who Wrist Exten Cock-up Nonmol      $    26.00
Who Wrist Extension Cock-up         $    12.00
Hand finger orthosis (HFO),         $    11.00
Upper Limb Orthosis Nos             $    12.00
Pneumatic Ankle Contrl & Splin      $    45.00
Range Walker,                       $    94.00
Glu; Quan                           $    19.00
Screen Pap Obtain Prep Convey       $    55.00
Injection, bupivicaine HCl, 30 ml   $     5.00
Etonogestrel implant system         $   735.00
/2011                                                                      12/9/2011

-4324                                                                      OTC-4814
EDICAL CARE                                                          Fastrax Urgent Care
co D.O.PLLC
Rd. Suite 102Kingman                                             2002 Stockton Hill Rd Ste 103
gman                                                                        Kigman
AZ                                                                            AZ

6401                                                                         86401


Box 631                                                              1739 Beverly Ave #201
gman                                                                        Kingman
AZ                                                                            AZ

402                                                                          86409
18-4375                                                                  928-753-3303
                                                                          1265423917
5487                                                                        533201
yes                                                                           yes
8144                                                                        Z23101
choco, D.O.                                                               Brian Turney
18-4375                                                                  928-757-0602

@yahoo.com                                                            bturney@azkrmc.com
choco D.O.                                                               Tim Blanchard
18-4375                                                                  928-681-8668
@yahoo.com                                                          tblanchard@azkrmc.com

choco D.O.                                                              Rebecca Barnes
18-4375                                                                  928-681-8655
@yahoo.com                                                           rbarnes@azkrmc.com
/2007                                                                      7/1/2010


                  Rate of Charge     Service Code                   Discription of Charge            Rate of Charge


              $              10.00      10060       DRAINAGE OF SKIN ABSCESS                     $            238.00
              $              89.00      10061       DRAINAGE OF SKIN ABSCESS                     $            437.00
              $               5.00      11080       DRAINAGE OF PILONIDAL CYST                   $            360.00
              $              30.00      10120       REMOVE FOREIGN BODY                          $            303.00
              $              10.00      10121       REMOVE FOREIGN BODY                          $            583.00
              $             135.00      10140       DRAINAGE OF HEMATOMA/FLUID                   $            364.00
              $              50.00      10160       PUNCTURE DRAINAGE OF LESION                  $            293.00
              $             138.00      11000       DEBRIDE INFECTED SKIN; UP TO 10% TBS         $             117.00
              $             210.00      11043       DEBRIDE TISSUE/MUSCLE                        $             941.00
              $              17.00      11044       DEBRIDE TISSUE/MUSCLE/BONE                   $            680.00
              $              10.00      11200       REMOVAL OF SKIN TAGS                         $             174.00
              $             240.00      11201       REMOVE SKIN TAGS ADD-ON                      $             42.00
$     2.00   11310   SHAVE SKIN LESION                               $    200.00
$    26.00   11401   EXC TR-EXT B9+MARG 0.6-1 CM                     $    309.00
$    12.00   11423   EXC H-F-NK-SP B9+MARG 2.1-3                     $    445.00
$    30.00   11719   TRIM NAIL(S)                                    $       -
$    75.00   11720   DEBRIDE NAIL, 1-5                               $     76.00
$   183.00   11730   REMOVAL OF NAIL PLATE                           $    215.00
$   149.00   11732   REMOVE NAIL PLATE, ADD-ON                       $     101.00
$    13.00   11740   DRAIN BLOOD FROM UNDER NAIL                     $     74.00
$   627.00   11765   EXCISION OF NAIL FOLD, TOE                      $    333.00
$   108.00   12001   REPAIR SUPERFICIAL WOUND(S)                     $    332.00
$    30.00   12002   REPAIR SUPERFICIAL WOUND(S)                     $    353.00
$   450.00   12004   REPAIR SUPERFICIAL WOUND(S)                     $    353.00
$    55.00   12005   REPAIR SUPERFICIAL WOUND(S)                     $    518.00
$    16.00   12011   REPAIR SUPERFICIAL WOUND(S)                     $    352.00
$      -     12013   REPAIR SUPERFICIAL WOUND(S)                     $    388.00
$    30.00   12014   REPAIR SUPERFICIAL WOUND(S)                     $    457.00
$      -     12015   REPAIR SUPERFICIAL WOUND(S)                     $    575.00
$     9.00   12016   REPAIR SUPERFICIAL WOUND(S)                     $    683.00
$    42.00   12017   REPAIR SUPERFICIAL WOUND(S)                     $    613.00
$   403.00   12018   REPAIR SUPERFICIAL WOUND(S)                     $    772.00
$    34.00   12031   LAYER CLOSURE OF WOUND(S)<2.5 cm                $    590.00
$   144.00   12032   LAYER CLOSURE OF WOUND(S) 2.6 cm to 7.5 cm      $    736.00
$   157.00   12034   LAYER CLOSURE OF WOUND(S) 7.6cm -12.5cm         $    728.00
$   124.00   12035   LAYER CLOSURE OF WOUND(S) 12.6 cm to 20.0 com   $    853.00
$    10.00   12036   LAYER CLOSURE OF WOUND(S) 20.1 cm to 30.0 cm    $    931.00
$   277.00   12037   LAYER CLOSURE OF WOUND(S)> 30.0 cm              $   1,053.00
$    30.00   12041   LAYER CLOSURE OF WOUND(S)                       $    604.00
$   212.00   12042   LAYER CLOSURE OF WOUND(S)                       $    696.00
$   165.00   12044   LAYER CLOSURE OF WOUND(S)                       $    822.00
$   204.00   12045   LAYER CLOSURE OF WOUND(S)                       $    854.00
$   131.00   12046   LAYER CLOSURE OF WOUND(S)                       $   1,005.00
$   164.00   12047   LAYER CLOSURE OF WOUND(S)                       $   1,095.00
$   141.00   12051   LAYER CLOSURE OF WOUND(S)                       $    636.00
$    14.00   12052   LAYER CLOSURE OF WOUND(S)                       $    735.00
$      -     12053   LAYER CLOSURE OF WOUND(S)                       $    855.00
$    30.00   12054   LAYER CLOSURE OF WOUND(S)                       $    855.00
$    30.00   12055   LAYER CLOSURE OF WOUND(S)                       $   1,018.00
$   203.00   13100   REPAIR OF WOUND OR LESION                       $    744.00
$   172.00   13101   REPAIR OF WOUND OR LESION                       $    953.00
$     5.00   13102   REPAIR WOUND/LESION ADD-ON                      $    256.00
$   173.00   13120   REPAIR OF WOUND OR LESION                       $    772.00
$   144.00   13121   REPAIR OF WOUND OR LESION                       $   1,064.00
$   110.00   13122   REPAIR WOUND/LESION ADD-ON                      $    278.00
$   263.00   13131   REPAIR OF WOUND OR LESION                       $    854.00
$      -     13132   REPAIR OF WOUND OR LESION             $   1,387.00
$   218.00   13133   REPAIR WOUND/LESION ADD-ON            $    403.00
$   172.00   13150   REPAIR OF WOUND OR LESION             $    834.00
$    30.00   13151   REPAIR OF WOUND OR LESION             $    970.00
$   392.00   13152   REPAIR OF WOUND OR LESION             $   1,348.00
$    93.00   13153   REPAIR WOUND/LESION ADD-ON            $    441.00
$    55.00   16000   INITIAL TREATMENT OF BURN(S)          $    157.00
$    70.00   16020   DRESS/DEBRID P-THICK BURN, S          $    185.00
$   128.00   16025   DRESS/DEBRID P-THICK BURN, M          $    330.00
$   173.00   16030   DRESS/DEBRID P-THICK BURN, L          $    396.00
$   384.00   20520   REMOVAL OF FOREIGN BODY               $    247.00
$   345.00   20550   INJ TENDON SHEATH/LIGAMENT            $    134.00
$    21.00   20552   INJ TRIGGER POINT, 1/2 MUSCL          $    212.00
$    84.00   20533   INJECT TRIGGER POINTS, =/> 3          $    135.00
$    95.00   20600   DRAIN/INJECT, JOINT/BURSA             $    125.00
$      -     20605   DRAIN/INJECT, JOINT/BURSA             $    134.00
$    59.00   20610   DRAIN/INJECT, JOINT/BURSA             $    177.00
$   126.00   23650   TREAT SHOULDER DISLOCATION            $    647.00
$   100.00   24640   TREAT ELBOW DISLOCATION               $    270.00
$   133.00   29105   APPLY LONG ARM SPLINT                 $     191.00
$   296.00   29125   APPLY FOREARM SPLINT                  $    147.00
$   222.00   29130   29130 -Application of finger splint   $     90.00
$    30.00   29505   29505 -APPLICATION, LONG LEG SPLINT   $    169.00
$   377.00   29515   29515 -APPLICATION LOWER LEG SPLINT   $    154.00
$   218.00   29580   29580 -APPLICATION OF PASTE BOOT      $     116.00
$   285.00   30300   30300 - REMOVE NASAL FOREIGN BODY     $    498.00
$    47.00   30901   30901 - CONTROL OF NOSEBLEED          $    235.00
$   124.00   30905   30905 - CONTROL OF NOSEBLEED          $    522.00
             30906   30906 - REPEAT CONTROL OF NOSEBLEED   $    600.00
             36415   36415- Routine Venipuncture           $     15.00
             40652   40652- REPAIR LIP                     $   1,087.00
             40654   REPAIR LIP                            $   1,291.00
             46083   NCISE EXTERNAL HEMORRHOID             $    290.00
             46608   ANOSCOPY, REMOVE FOR BODY             $    480.00
             51702   INSERT TEMP BLADDER CATH              $    212.00
             56420   DRAINAGE OF GLAND ABSCESS             $    290.00
             64402   N BLOCK INJ, FACIAL                   $    280.00
             64450   N BLOCK, OTHER PERIPHERAL             $    280.00
             65205   REMOVE FOREIGN BODY FROM EYE          $     112.00
             65220   REMOVE FOREIGN BODY FROM EYE          $    130.00
             65222   REMOVE FOREIGN BODY FROM EYE          $     161.00
             69200   CLEAR OUTER EAR CANAL                 $    261.00
             69210   REMOVE IMPACTED EAR WAX               $    150.00
             71020   CHEST X-RAY                           $    104.00
73030   X-RAY EXAM OF SHOULDER                                 $   108.00
73080   X-RAY EXAM OF ELBOW                                    $    96.00
73100   X-RAY EXAM OF WRIST                                    $    79.00
73110   X-RAY EXAM OF WRIST                                    $    91.00
73130   X-RAY EXAM OF HAND                                     $    90.00
73140   X-RAY EXAM OF FINGER(S)                                $    67.00
73562   X-RAY EXAM OF KNEE, 3                                  $   100.00
73590   X-RAY EXAM OF LOWER LEG                                $    88.00
73610   X-RAY EXAM OF ANKLE                                    $    93.00
73630   X-RAY EXAM OF FOOT                                     $    92.00
73660   X-RAY EXAM OF TOE(S)                                   $    75.00
80047   QW - METABOLIC PANEL IONIZED CA                        $    54.00
80048   METABOLIC PANEL TOTAL CA                               $    54.00
80100   DRUG SCREEN, QUALITATE/MULTI                           $    56.00
82948   REAGENT STRIP/BLOOD GLUCOSE                            $    19.00
83037   QW - GLYCOSYLATED HB, HOME DEVICE                      $    64.00
86580   TB INTRADERMAL TEST                                    $    29.00
87804   QW - INFLUENZA ASSAY W/OPTIC                           $    38.00
87880   STREP A ASSAY W/OPTIC                                  $    25.00
87880   QW- STREPAASSAYW/OPTIC                                 $    34.00
90470   H1N1 vaccine administration                            $    40.00
90471   Immunization Adminstration, First Vaccine, No Counse   $    25.00
90472   Immunization Administration, each additional, No Cou   $    18.00
90473   Immunization Administration, Oral, First, No Counsel   $    20.00
90658   FLU VACCINE, 3 YRS &>, IM                              $    40.00
90660   FLU VACCINE, intranasal                                $    40.00
90696   DTAP-IPV VACC 4-6 YR IM                                $    90.00
90714   TD VACCINE NO PRSRV >/ = 7 IM                          $    23.00
90715   TDAP                                                   $    90.00
90718   TD VACCINE> 7, IM                                      $    33.00
90732   PNEUMOCOCCAL VAC > 2yrs old                            $    65.00
90736   Zoster (shingles) vaccine, live, for subcutaneous in   $   235.00
92140   GLAUCOMA PROVOCATIVE TESTS                             $   102.00
93000   ELECTROCARDIOGRAM, COMPLETE                            $    59.00
93010   ELECTROCARDIOGRAM REPORT                               $    21.00
98925   OSTEOPATHIC MANIPULATION                               $    45.00
98926   OSTEOPATHIC MANIPULATION                               $    62.00
98927   OSTEOPATHIC MANIPULATION                               $    80.00
98928   OSTEOPATHIC MANIPULATION                               $    95.00
98929   OSTEOPATHIC MANIPULATION                               $   109.00
98940   chiropractic manipulation                              $    40.00
98941   chiropractic manipulation                              $    55.00
98942   chiropractic manipulation                              $    71.00
99000   SPECIMEN HANDLING                                      $    45.00
99051   MED SERV, EVE/WKEND/HOLIDAY                       $    95.00
99058   OFFICE EMERGENCY CARE                             $   100.00
99070   SPECIAL SUPPLIES                                  $    25.00
99080   SPECIAL REPORTS OR FORMS                          $    30.00
99175   INDUCTION OF VOMITING                             $   108.00
99201   OFFICE/OUTPATIENT VISIT, NEW                      $    92.00
99202   OFFICE/OUTPATIENT VISIT, NEW                      $   158.00
99203   OFFICE/OUTPATIENT VISIT, NEW                      $   227.00
99204   OFFICE/OUTPATIENT VISIT, NEW                      $   348.00
99205   OFFICE/OUTPATIENT VISIT, NEW                      $   440.00
99211   OFFICE/OUTPATIENT VISIT, EST                      $    53.00
99212   OFFICE/OUTPATIENT VISIT, EST                      $    92.00
99213   OFFICE/OUTPATIENT VISIT, EST                      $   153.00
99214   OFFICE/OUTPATIENT VISIT, EST                      $   229.00
99215   OFFICE/OUTPATIENT VISIT, EST                      $   308.00
99385   PREV VISIT, NEW, AGE 18-39                        $   270.00
99386   PREV VISIT, NEW, AGE 40-64                        $   315.00
99387   INIT PM E/M, NEW PAT 65+ YRS                      $   347.00
99395   PREV VISIT, EST, AGE 18-39                        $   271.00
99396   PREV VISIT, EST, AGE 40-64                        $   294.00
99406   BEHAV CHNG SMOKING 3-10 MIN                       $    30.00
99407   BEHAV CHNG SMOKING <10 MIN                        $    35.00
A4316   Cath w/drainage 3-way                             $    60.00
A4550   Surgical trays                                    $    36.00
A4565   Slings                                            $    50.00
A6219   Gauze<= 16 sq in w/border                         $    12.00
A6449   Lt compres band >=3' <5'/yd                       $     9.00
A7003   Nebulizer administration set                      $     9.00
        CDLPHY - CDL physicial                            $    90.00
E0110   Crutch forearm pair                               $   110.00
E0111   Crutch forearm each                               $    55.00
E0112   Crutch underarm pair wood                         $   110.00
E0113   Crutch underarm each wood                         $    55.00
E0114   Crutch underarm pair no wood                      $   110.00
E0116   Crutch underarm each no wood                      $    55.00
E0140   Walker w trunk support                            $   327.00
G0008   Admin influenza virus vac                         $    20.00
G0009   Admin pneumococcal vaccine                        $    25.00
G9141   Influenza A H1N1 Vaccine w/Physician counseling   $    40.00
J0170   Adrenalin epinephrin inject                       $     2.00
J0690   Cefazolin sodium injection                        $     4.00
J0696   Ceftriaxone sodium injection                      $    25.00
J0698   Cefotaxime sodium injection                       $    24.00
J1100   Dexamethasone sodium phos                         $    10.00
J1120   Acetazolamid sodium injectio                   $    10.00
J1885   Ketorolactromethamine inj                      $     3.00
J2001   Lidocaine injection for Intravenous infusion   $    25.00
J2175   Meperidine hydrochl/100 MG                     $    30.00
J2180   Meperidine/promethazine inj                    $    42.00
J2270   Morphine sulfate injection                     $    30.00
J2550   Promethazine hcl injection                     $    20.00
J2920   Methylprednisolone injection                   $    20.00
J2930   Methylprednisolone injection                   $    10.00
J3250   Trimethobenzamide hcl inj                      $    12.00
J3301   Triamcinolone acetonide inj                    $    10.00
J3410   Hydroxyzine hcl injection                      $     3.00
J3420   Vitamin b12 injection                          $    20.00
J7030   Normal saline solution infus                   $     8.00
J7506   Prednisone oral                                $     6.00
J7620   Albuterol ipratrop non-comp                    $    25.00
J7644   Ipratropium bromide non-comp                   $    25.00
L0120   Cerv flexible non-adjustable                   $    60.00
L0140   Cervical semi-rigid adjustab                   $   103.00
L1830   Ko immobilizer canvas longit                   $    75.00
L1902   Afo ankle gauntlet                             $    99.00
L1906   Afo multiligamentus ankle su                   $   204.00
L2112   Afo tibial fracture soft                       $   889.00
L3260   Ambulatory surgical boot eac                   $    44.00
L3651   Prefab shoulder orthosis                       $   101.00
L3660   Abduct restrainer canvas&web                   $   158.00
L3800   Whfo short opponen no attach                   $   307.00
L3807   WHFO,no joint, prefabricated                   $   207.00
L3808   WHFO, rigid w/ojoints                          $   549.00
L3908   Wrist cock-up non-molded                       $    99.00
L3930   Finger extension with wrist                    $   117.00
L4386   Non-pneum walk boot prefab                     $   268.00
S9083   Urgent care center global                      $   200.00
S9088   Services provided in urgent                    $    55.00


98928   Osteopathic manip, 7-8 body regions            $    95.00
98929   Osteopathic manip, 9-10 body region            $   109.00
98940   CMT, spinal, 1-2 regions                       $    40.00
98941   CMT, spinal, 3-4 regions                       $    55.00
98942   CMT, spinal, 5 regions                         $    71.00
99000   Handling Specimen for Transfer                 $    45.00
99051   MED SERV, EVE/WKEND/HOLIDAY                    $    95.00
99058   Disrution Code                                 $    41.00
99070   Misc. Med. Supplies                            $    25.00
99080   Special reports/insurance forms        $    30.00
99175   Induction of vomiting                  $   108.00
99201   Patient Visit 1                        $    92.00
99202   Patient Visit 2                        $   158.00
99203   Patient Visit 3                        $   227.00
99204   Patient Visit 4                        $   348.00
99205   Patient Visit 5                        $   440.00
99211   Established 1 Nurse Visit              $    53.00
99212   Established 2                          $    92.00
99213   Established 3                          $   153.00
99214   Established 4                          $   229.00
99215   Established 5                          $   308.00
99291   Critical care, 30 - 74 min             $   627.00
99406   BEHAV CHNG SMOKING 3-10 MIN            $    30.00
99407   BEHAV CHNG SMOKING < 10 MIN            $    35.00
99499   CDL/Employment Physical                $    90.00
A4316   Cath w/drainage 3-way                  $    60.00
A4550   Eye,Ear,Nasal,I.V.,and Lac. Tray       $    36.00
A4565   Arm Sling                              $    50.00
A6219   Dress Wound                            $    12.00
A6449   ACE Wrap 3" to 5"                      $     9.00
A7003   Nebulizer administration set           $    25.00
E0114   Crutches                               $    95.00
G0008   Flu Vaccine(Admin Medicare Only        $    20.00
g0009   Admin pneumococcal vaccine Medicare    $    25.00
G9141   Medicare H1N1 Vaccine administration   $    40.00
J0170   Epinephrine 1:1000                     $     2.00
J0690   Ancef 500mg                            $     4.00
J0696   Rocephin 250 mg                        $    25.00
J0698   Claforan 1 gm                          $    24.00
J1100   Decadron 1mg                           $    10.00
J1200   Benadryl 50MG                          $    10.00
J1885   Toradol 15mg                           $     3.00
J2001   Lidocaine injection                    $    25.00
J2550   Phenergan 50mg                         $    20.00
J3250   Tigan 200mg                            $    12.00
J3301   Kenalog 10mg                           $    10.00
J3410   Hydroxyzine 25mg                       $     3.00
J7030   Normal Saline 1000 cc                  $     8.00
J7506   Prednisone 5mg                         $     6.00
J7620   Albuterol 2.5 mg/0.5 mg                $    25.00
J7644   Ipatroprium 1mg                        $    25.00
L0120   Soft C collar                          $    60.00
L0140   Rigid C collar                         $   103.00
  L1830      Knee Immobilizer              $   148.00
  L1906      Ankle Strrup                  $   204.00
  L2112      FX Walker                     $   889.42
  L3260      Post Op Shoe                  $    44.00
  L3651      Shoulder Imm                  $   101.12
  L3660      Clavicle splint               $   157.94
  L3808      Thumb Spica                   $   549.00
  L3908      Wrist Splint                  $    99.00


  S9083      Aetna/Humana                  $   173.00
  S9088      Services provided in urgent   $    60.00
 z-sports    Sports Physical               $    35.00
z-sportsUA                                 $    35.00
                                      12/9/2011                                                          2

                                     OTC - 5058                                                           O
                              FASTRAX URGENT CARE                                            FRESENIUS ME


                                 4995 W. Highway 68                                           1739 BEVERLY
                                    Golden Valley                                                         K
                                         AZ                                                               A

                                        86413


                               1739 Beverly Ave #201
                                       Kingman
                                         AZ

                                       86409
                                    928-718-5200                                                        928
                                     1265423917                                                          14
                                       533201
                                         yes
                                       Z23101
                                     Brian Turney                                                    ADRIE
                                    928-757-0602                                                        928

                                bturney@azkrmc.com                                               adrienne.a
                                    Tim Blanchard                                                         J
                                    928-681-8668                                                        480
                               tblanchard@azkrmc.com                                                jay.ray

                                   Rebecca Barnes                                                    VALER
                                    928-681-8655                                                        928
                                rbarnes@azkrmc.com                                              valerie.knue
                                      7/1/2010


Service Code                   Discription of Charge       Rate of Charge     Service Code


   10060       DRAINAGE OF SKIN ABSCESS                $            238.00      674100
   10061       DRAINAGE OF SKIN ABSCESS                $            437.00      685200
   11080       DRAINAGE OF PILONIDAL CYST              $            360.00      684200
   10120       REMOVE FOREIGN BODY                     $            303.00      684300
   10121       REMOVE FOREIGN BODY                     $            583.00      675100
   10140       DRAINAGE OF HEMATOMA/FLUID              $            364.00      309400
   10160       PUNCTURE DRAINAGE OF LESION             $            293.00      645500
   11000       DEBRIDE INFECTED SKIN; UP TO 10% TBS    $             117.00     513700
   11043       DEBRIDE TISSUE/MUSCLE                   $             941.00     425801
   11044       DEBRIDE TISSUE/MUSCLE/BONE              $            680.00      318800
   11200       REMOVAL OF SKIN TAGS                    $             174.00     446001
   11201       REMOVE SKIN TAGS ADD-ON                 $             42.00      510500
11310   SHAVE SKIN LESION                               $    200.00    504900
11401   EXC TR-EXT B9+MARG 0.6-1 CM                     $    309.00    683200
11423   EXC H-F-NK-SP B9+MARG 2.1-3                     $    445.00    600400
11719   TRIM NAIL(S)                                    $       -      600700
11720   DEBRIDE NAIL, 1-5                               $     76.00    310700
11730   REMOVAL OF NAIL PLATE                           $    215.00    310800
11732   REMOVE NAIL PLATE, ADD-ON                       $     101.00   600900
11740   DRAIN BLOOD FROM UNDER NAIL                     $     74.00    468001
11765   EXCISION OF NAIL FOLD, TOE                      $    333.00    601000
12001   REPAIR SUPERFICIAL WOUND(S)                     $    332.00    601100
12002   REPAIR SUPERFICIAL WOUND(S)                     $    353.00    462301
12004   REPAIR SUPERFICIAL WOUND(S)                     $    353.00    632200
12005   REPAIR SUPERFICIAL WOUND(S)                     $    518.00    405703
12011   REPAIR SUPERFICIAL WOUND(S)                     $    352.00    400701
12013   REPAIR SUPERFICIAL WOUND(S)                     $    388.00    601500
12014   REPAIR SUPERFICIAL WOUND(S)                     $    457.00    311400
12015   REPAIR SUPERFICIAL WOUND(S)                     $    575.00    683400
12016   REPAIR SUPERFICIAL WOUND(S)                     $    683.00    601900
12017   REPAIR SUPERFICIAL WOUND(S)                     $    613.00    300300
12018   REPAIR SUPERFICIAL WOUND(S)                     $    772.00    306300
12031   LAYER CLOSURE OF WOUND(S)<2.5 cm                $    590.00    300400
12032   LAYER CLOSURE OF WOUND(S) 2.6 cm to 7.5 cm      $    736.00    300600
12034   LAYER CLOSURE OF WOUND(S) 7.6cm -12.5cm         $    728.00    309600
12035   LAYER CLOSURE OF WOUND(S) 12.6 cm to 20.0 com   $    853.00    300700
12036   LAYER CLOSURE OF WOUND(S) 20.1 cm to 30.0 cm    $    931.00    314400
12037   LAYER CLOSURE OF WOUND(S)> 30.0 cm              $   1,053.00   314500
12041   LAYER CLOSURE OF WOUND(S)                       $    604.00    300800
12042   LAYER CLOSURE OF WOUND(S)                       $    696.00    648500
12044   LAYER CLOSURE OF WOUND(S)                       $    822.00    311600
12045   LAYER CLOSURE OF WOUND(S)                       $    854.00    311500
12046   LAYER CLOSURE OF WOUND(S)                       $   1,005.00   480201
12047   LAYER CLOSURE OF WOUND(S)                       $   1,095.00   625600
12051   LAYER CLOSURE OF WOUND(S)                       $    636.00    801307
12052   LAYER CLOSURE OF WOUND(S)                       $    735.00    436101
12053   LAYER CLOSURE OF WOUND(S)                       $    855.00    602300
12054   LAYER CLOSURE OF WOUND(S)                       $    855.00    436601
12055   LAYER CLOSURE OF WOUND(S)                       $   1,018.00   401404
13100   REPAIR OF WOUND OR LESION                       $    744.00    466801
13101   REPAIR OF WOUND OR LESION                       $    953.00    462501
13102   REPAIR WOUND/LESION ADD-ON                      $    256.00    462701
13120   REPAIR OF WOUND OR LESION                       $    772.00    602400
13121   REPAIR OF WOUND OR LESION                       $   1,064.00   602500
13122   REPAIR WOUND/LESION ADD-ON                      $    278.00    677500
13131   REPAIR OF WOUND OR LESION                       $    854.00    602600
13132   REPAIR OF WOUND OR LESION             $   1,387.00   602700
13133   REPAIR WOUND/LESION ADD-ON            $    403.00    678100
13150   REPAIR OF WOUND OR LESION             $    834.00    100200
13151   REPAIR OF WOUND OR LESION             $    970.00    100201
13152   REPAIR OF WOUND OR LESION             $   1,348.00   100203
13153   REPAIR WOUND/LESION ADD-ON            $    441.00    100202
16000   INITIAL TREATMENT OF BURN(S)          $    157.00    100204
16020   DRESS/DEBRID P-THICK BURN, S          $    185.00    100205
16025   DRESS/DEBRID P-THICK BURN, M          $    330.00    682100
16030   DRESS/DEBRID P-THICK BURN, L          $    396.00    302900
20520   REMOVAL OF FOREIGN BODY               $    247.00    316500
20550   INJ TENDON SHEATH/LIGAMENT            $    134.00    649000
20552   INJ TRIGGER POINT, 1/2 MUSCL          $    212.00    649100
20533   INJECT TRIGGER POINTS, =/> 3          $    135.00    642100
20600   DRAIN/INJECT, JOINT/BURSA             $    125.00    681800
20605   DRAIN/INJECT, JOINT/BURSA             $    134.00    602800
20610   DRAIN/INJECT, JOINT/BURSA             $    177.00    671200
23650   TREAT SHOULDER DISLOCATION            $    647.00    428315
24640   TREAT ELBOW DISLOCATION               $    270.00    482601
29105   APPLY LONG ARM SPLINT                 $     191.00   482701
29125   APPLY FOREARM SPLINT                  $    147.00    482801
29130   29130 -Application of finger splint   $     90.00    482901
29505   29505 -APPLICATION, LONG LEG SPLINT   $    169.00    483001
29515   29515 -APPLICATION LOWER LEG SPLINT   $    154.00    483101
29580   29580 -APPLICATION OF PASTE BOOT      $     116.00   483201
30300   30300 - REMOVE NASAL FOREIGN BODY     $    498.00    483601
30901   30901 - CONTROL OF NOSEBLEED          $    235.00    483401
30905   30905 - CONTROL OF NOSEBLEED          $    522.00    483501
30906   30906 - REPEAT CONTROL OF NOSEBLEED   $    600.00    483301
36415   36415- Routine Venipuncture           $     15.00    483701
40652   40652- REPAIR LIP                     $   1,087.00   483801
40654   REPAIR LIP                            $   1,291.00   466501
46083   NCISE EXTERNAL HEMORRHOID             $    290.00    433001
46608   ANOSCOPY, REMOVE FOR BODY             $    480.00    402401
51702   INSERT TEMP BLADDER CATH              $    212.00    402501
56420   DRAINAGE OF GLAND ABSCESS             $    290.00    603000
64402   N BLOCK INJ, FACIAL                   $    280.00    602900
64450   N BLOCK, OTHER PERIPHERAL             $    280.00    207100
65205   REMOVE FOREIGN BODY FROM EYE          $     112.00   205400
65220   REMOVE FOREIGN BODY FROM EYE          $    130.00    446802
65222   REMOVE FOREIGN BODY FROM EYE          $     161.00   625400
69200   CLEAR OUTER EAR CANAL                 $    261.00    310900
69210   REMOVE IMPACTED EAR WAX               $    150.00    673100
71020   CHEST X-RAY                           $    104.00    485101
73030   X-RAY EXAM OF SHOULDER                                 $   108.00   485201
73080   X-RAY EXAM OF ELBOW                                    $    96.00   484301
73100   X-RAY EXAM OF WRIST                                    $    79.00   500600
73110   X-RAY EXAM OF WRIST                                    $    91.00   482301
73130   X-RAY EXAM OF HAND                                     $    90.00   482401
73140   X-RAY EXAM OF FINGER(S)                                $    67.00   486101
73562   X-RAY EXAM OF KNEE, 3                                  $   100.00   603500
73590   X-RAY EXAM OF LOWER LEG                                $    88.00   603600
73610   X-RAY EXAM OF ANKLE                                    $    93.00   207200
73630   X-RAY EXAM OF FOOT                                     $    92.00   206100
73660   X-RAY EXAM OF TOE(S)                                   $    75.00   425903
80047   QW - METABOLIC PANEL IONIZED CA                        $    54.00   470501
80048   METABOLIC PANEL TOTAL CA                               $    54.00   425702
80100   DRUG SCREEN, QUALITATE/MULTI                           $    56.00   468101
82948   REAGENT STRIP/BLOOD GLUCOSE                            $    19.00   423001
83037   QW - GLYCOSYLATED HB, HOME DEVICE                      $    64.00   603900
86580   TB INTRADERMAL TEST                                    $    29.00   512900
87804   QW - INFLUENZA ASSAY W/OPTIC                           $    38.00   604300
87880   STREP A ASSAY W/OPTIC                                  $    25.00   604400
87880   QW- STREPAASSAYW/OPTIC                                 $    34.00   465401
90470   H1N1 vaccine administration                            $    40.00   462601
90471   Immunization Adminstration, First Vaccine, No Counse   $    25.00   469001
90472   Immunization Administration, each additional, No Cou   $    18.00   430202
90473   Immunization Administration, Oral, First, No Counsel   $    20.00   466401
90658   FLU VACCINE, 3 YRS &>, IM                              $    40.00   683900
90660   FLU VACCINE, intranasal                                $    40.00   683500
90696   DTAP-IPV VACC 4-6 YR IM                                $    90.00   604800
90714   TD VACCINE NO PRSRV >/ = 7 IM                          $    23.00   604700
90715   TDAP                                                   $    90.00   308800
90718   TD VACCINE> 7, IM                                      $    33.00   308900
90732   PNEUMOCOCCAL VAC > 2yrs old                            $    65.00   316300
90736   Zoster (shingles) vaccine, live, for subcutaneous in   $   235.00   675400
92140   GLAUCOMA PROVOCATIVE TESTS                             $   102.00   621300
93000   ELECTROCARDIOGRAM, COMPLETE                            $    59.00   311900
93010   ELECTROCARDIOGRAM REPORT                               $    21.00   683800
98925   OSTEOPATHIC MANIPULATION                               $    45.00   605000
98926   OSTEOPATHIC MANIPULATION                               $    62.00   312000
98927   OSTEOPATHIC MANIPULATION                               $    80.00   317500
98928   OSTEOPATHIC MANIPULATION                               $    95.00   631100
98929   OSTEOPATHIC MANIPULATION                               $   109.00   605200
98940   chiropractic manipulation                              $    40.00   605400
98941   chiropractic manipulation                              $    55.00   626000
98942   chiropractic manipulation                              $    71.00   625900
99000   SPECIMEN HANDLING                                      $    45.00   622500
99051   MED SERV, EVE/WKEND/HOLIDAY                       $    95.00   670500
99058   OFFICE EMERGENCY CARE                             $   100.00   670800
99070   SPECIAL SUPPLIES                                  $    25.00   605300
99080   SPECIAL REPORTS OR FORMS                          $    30.00   636800
99175   INDUCTION OF VOMITING                             $   108.00   605500
99201   OFFICE/OUTPATIENT VISIT, NEW                      $    92.00   311800
99202   OFFICE/OUTPATIENT VISIT, NEW                      $   158.00   686000
99203   OFFICE/OUTPATIENT VISIT, NEW                      $   227.00   304700
99204   OFFICE/OUTPATIENT VISIT, NEW                      $   348.00   310600
99205   OFFICE/OUTPATIENT VISIT, NEW                      $   440.00   480102
99211   OFFICE/OUTPATIENT VISIT, EST                      $    53.00   605600
99212   OFFICE/OUTPATIENT VISIT, EST                      $    92.00   605800
99213   OFFICE/OUTPATIENT VISIT, EST                      $   153.00   680500
99214   OFFICE/OUTPATIENT VISIT, EST                      $   229.00   638800
99215   OFFICE/OUTPATIENT VISIT, EST                      $   308.00   605700
99385   PREV VISIT, NEW, AGE 18-39                        $   270.00   621900
99386   PREV VISIT, NEW, AGE 40-64                        $   315.00   622000
99387   INIT PM E/M, NEW PAT 65+ YRS                      $   347.00   682500
99395   PREV VISIT, EST, AGE 18-39                        $   271.00   682800
99396   PREV VISIT, EST, AGE 40-64                        $   294.00   684000
99406   BEHAV CHNG SMOKING 3-10 MIN                       $    30.00   681100
99407   BEHAV CHNG SMOKING <10 MIN                        $    35.00   683600
A4316   Cath w/drainage 3-way                             $    60.00   606100
A4550   Surgical trays                                    $    36.00   606200
A4565   Slings                                            $    50.00   606300
A6219   Gauze<= 16 sq in w/border                         $    12.00   635200
A6449   Lt compres band >=3' <5'/yd                       $     9.00   635100
A7003   Nebulizer administration set                      $     9.00   635000
        CDLPHY - CDL physicial                            $    90.00   606000
E0110   Crutch forearm pair                               $   110.00   622200
E0111   Crutch forearm each                               $    55.00   606400
E0112   Crutch underarm pair wood                         $   110.00   619600
E0113   Crutch underarm each wood                         $    55.00   620400
E0114   Crutch underarm pair no wood                      $   110.00   642300
E0116   Crutch underarm each no wood                      $    55.00   605900
E0140   Walker w trunk support                            $   327.00   606500
G0008   Admin influenza virus vac                         $    20.00   467101
G0009   Admin pneumococcal vaccine                        $    25.00   468901
G9141   Influenza A H1N1 Vaccine w/Physician counseling   $    40.00   648000
J0170   Adrenalin epinephrin inject                       $     2.00   422401
J0690   Cefazolin sodium injection                        $     4.00   422901
J0696   Ceftriaxone sodium injection                      $    25.00   682000
J0698   Cefotaxime sodium injection                       $    24.00   671800
J1100   Dexamethasone sodium phos                         $    10.00   308100
J1120   Acetazolamid sodium injectio                   $    10.00   437601
J1885   Ketorolactromethamine inj                      $     3.00   404601
J2001   Lidocaine injection for Intravenous infusion   $    25.00   606900
J2175   Meperidine hydrochl/100 MG                     $    30.00   680600
J2180   Meperidine/promethazine inj                    $    42.00   607000
J2270   Morphine sulfate injection                     $    30.00   463303
J2550   Promethazine hcl injection                     $    20.00   432203
J2920   Methylprednisolone injection                   $    20.00   466701
J2930   Methylprednisolone injection                   $    10.00   442701
J3250   Trimethobenzamide hcl inj                      $    12.00   502600
J3301   Triamcinolone acetonide inj                    $    10.00   681900
J3410   Hydroxyzine hcl injection                      $     3.00   502700
J3420   Vitamin b12 injection                          $    20.00   502800
J7030   Normal saline solution infus                   $     8.00   447501
J7506   Prednisone oral                                $     6.00   463101
J7620   Albuterol ipratrop non-comp                    $    25.00   462901
J7644   Ipratropium bromide non-comp                   $    25.00   405201
L0120   Cerv flexible non-adjustable                   $    60.00   462902
L0140   Cervical semi-rigid adjustab                   $   103.00   405202
L1830   Ko immobilizer canvas longit                   $    75.00   464401
L1902   Afo ankle gauntlet                             $    99.00   684400
L1906   Afo multiligamentus ankle su                   $   204.00   468701
L2112   Afo tibial fracture soft                       $   889.00   468801
L3260   Ambulatory surgical boot eac                   $    44.00   800101
L3651   Prefab shoulder orthosis                       $   101.00   800102
L3660   Abduct restrainer canvas&web                   $   158.00   625000
L3800   Whfo short opponen no attach                   $   307.00   464201
L3807   WHFO,no joint, prefabricated                   $   207.00   486001
L3808   WHFO, rigid w/ojoints                          $   549.00   608000
L3908   Wrist cock-up non-molded                       $    99.00   459803
L3930   Finger extension with wrist                    $   117.00   310500
L4386   Non-pneum walk boot prefab                     $   268.00   318600
S9083   Urgent care center global                      $   200.00   315600
S9088   Services provided in urgent                    $    55.00   486201
                                                                    486301
98928   Osteopathic manip, 7-8 body regions            $    95.00   405402
98929   Osteopathic manip, 9-10 body region            $   109.00   463001
98940   CMT, spinal, 1-2 regions                       $    40.00   312100
98941   CMT, spinal, 3-4 regions                       $    55.00   312200
98942   CMT, spinal, 5 regions                         $    71.00   625200
99000   Handling Specimen for Transfer                 $    45.00   621400
99051   MED SERV, EVE/WKEND/HOLIDAY                    $    95.00   309000
99058   Disrution Code                                 $    41.00   683100
99070   Misc. Med. Supplies                            $    25.00   480001
99080   Special reports/insurance forms        $    30.00   677700
99175   Induction of vomiting                  $   108.00   468201
99201   Patient Visit 1                        $    92.00   677800
99202   Patient Visit 2                        $   158.00   608400
99203   Patient Visit 3                        $   227.00   608300
99204   Patient Visit 4                        $   348.00   679000
99205   Patient Visit 5                        $   440.00   679200
99211   Established 1 Nurse Visit              $    53.00   679100
99212   Established 2                          $    92.00   480401
99213   Established 3                          $   153.00   622300
99214   Established 4                          $   229.00   670400
99215   Established 5                          $   308.00   670700
99291   Critical care, 30 - 74 min             $   627.00   677600
99406   BEHAV CHNG SMOKING 3-10 MIN            $    30.00   629900
99407   BEHAV CHNG SMOKING < 10 MIN            $    35.00   647900
99499   CDL/Employment Physical                $    90.00   647800
A4316   Cath w/drainage 3-way                  $    60.00   608500
A4550   Eye,Ear,Nasal,I.V.,and Lac. Tray       $    36.00   608700
A4565   Arm Sling                              $    50.00   513800
A6219   Dress Wound                            $    12.00   317400
A6449   ACE Wrap 3" to 5"                      $     9.00   608900
A7003   Nebulizer administration set           $    25.00   609100
E0114   Crutches                               $    95.00   683700
G0008   Flu Vaccine(Admin Medicare Only        $    20.00   609000
g0009   Admin pneumococcal vaccine Medicare    $    25.00   485501
G9141   Medicare H1N1 Vaccine administration   $    40.00   485601
J0170   Epinephrine 1:1000                     $     2.00   484201
J0690   Ancef 500mg                            $     4.00   461603
J0696   Rocephin 250 mg                        $    25.00   682400
J0698   Claforan 1 gm                          $    24.00   206800
J1100   Decadron 1mg                           $    10.00   609300
J1200   Benadryl 50MG                          $    10.00   314800
J1885   Toradol 15mg                           $     3.00   314700
J2001   Lidocaine injection                    $    25.00   680800
J2550   Phenergan 50mg                         $    20.00   609800
J3250   Tigan 200mg                            $    12.00   601700
J3301   Kenalog 10mg                           $    10.00   601800
J3410   Hydroxyzine 25mg                       $     3.00   625100
J7030   Normal Saline 1000 cc                  $     8.00   601600
J7506   Prednisone 5mg                         $     6.00   622600
J7620   Albuterol 2.5 mg/0.5 mg                $    25.00   480901
J7644   Ipatroprium 1mg                        $    25.00   480801
L0120   Soft C collar                          $    60.00   439705
L0140   Rigid C collar                         $   103.00   406304
  L1830      Knee Immobilizer              $   148.00   443604
  L1906      Ankle Strrup                  $   204.00   685300
  L2112      FX Walker                     $   889.42   312900
  L3260      Post Op Shoe                  $    44.00   312400
  L3651      Shoulder Imm                  $   101.12   312600
  L3660      Clavicle splint               $   157.94   312300
  L3808      Thumb Spica                   $   549.00   685100
  L3908      Wrist Splint                  $    99.00   312800
                                                        312700
  S9083      Aetna/Humana                  $   173.00   609200
  S9088      Services provided in urgent   $    60.00   682300
 z-sports    Sports Physical               $    35.00   313100
z-sportsUA                                 $    35.00   314100
                                                        211900
                                                        211200
                                                        211300
                                                        212100
                                                        211400
                                                        212000
                                                        207300
                                                        220000
                                                        671100
                                                        314000
                                                        456904
                                                        465901
                                                        443101
                                                        482501
                                                        431202
                                                        312500
                                                        313000
                                                        313200
                                                        311000
                                                        315700
                                                        315800
                                                        421701
                                                        406801
                                                        206900
                                                        214500
                                                        214000
                                                        610600
                                                        319000
                                                        463601
                                                        463201
                                                        611200
680400
458806
311100
685000
470201
484601
484701
484401
484501
469201
611500
611700
461301
442901
612000
408201
459902
684500
466002
466001
465501
682600
684700
313400
467201
423701
466301
467301
467901
466101
612200
409403
470701
463501
318900
612400
470801
612600
513500
513400
313600
421802
684900
613000
466201
637700
613100
303200
310100
311200
311300
613200
310300
316700
317200
309300
464801
314900
428701
637800
613300
627200
453301
315400
315000
613400
626100
463401
465601
466601
512500
512300
512400
467001
444502
681700
467401
613800
626800
613600
680700
613900
644200
514000
508000
614300
314300
637500
614400
303400
316600
317000
309200
317100
303600
404001
673400
614600
318700
314600
309500
664500
614700
484801
485301
485401
484901
485001
411501
318100
614800
630700
630500
682200
681300
684100
684800
684600
452601
683300
411601
480501
643200
615500
315500
637900
682900
682700
683000
313800
313900
615700
615800
616000
615900
616400
308300
100100
100101
100103
100102
100104
100105
616700
424104
677900
678000
672100
667800
616300
638100
616800
317700
308000
314200
617000
617100
429701
673800
625800
675000
617600
622400
670300
670600
617200
617400
617500
681400
413410
680900
617700
681000
461803
485801
620000
617900
618000
633600
685700
422802
618100
303500
681200
485701
484101
483901
484001
618200
                    2/20/2012                                                              3/5/2012

                    OTC-4621                                                               OTC-0710
     FRESENIUS MEDICAL CARE KINGMAN                                            Heart Instirute of Northern Arizona


       1739 BEVERLY AVENUE SUITE 208                                                 1753 Airway Ave, Ste B
                    KINGMAN                                                                 Kingman
                    ARIZONA                                                                    AZ

                      86401                                                                  86409
                                                                                             Mohave
                      SAME                                                               Same as above




                  928-681-4300                                                            928 6926200
                    1487818076                                                            1922089416
                                                                                             197211

                       YES                                                                     no
                     03 2628                                                                Z-25383
               ADRIENNE ADKINS                                                         A Paul Kalanithi.MD
                  928-681-4300                                                           928 757 4359

          adrienne.adkins@fmc-na.com                                                  skalanithi@yahoo.com
                     JAY RAY                                                              Sue Kalanithi
                 480-458-9600                                                            928 757 4359
               jay.ray@FMC-NA.com                                                     skalanithi@yahoo.com

               VALERIE KNUEVEN                                                           ShirleyHaskett
                 928-763-5550                                                            928 757 4359
         valerie.knueven@FMC-NA.com                                                 shaskett50@frontier.com




          Discription of Charge         Rate of Charge          Service Code


HEP B SURFACE AB (ANTI-HBS)                         163.91       78452-TC
2 HR DIALYSATE UREA                                  60.18       78451-TC
2HR DIAL TOTAL PROTEIN                                   55.9      93015
4HR DIAL TOTAL PROTEIN                                   55.9      93017
ABO GROUPING                                         45.53         93016
ABO TYPING                                               177       93018
ABSOLUTE - LYMPHOCYTES                               38.84        A9500
ACCESS FLOW TEST                                    127.91        A9505
ACETAMINOPHEN (PO) 325 MG          PO                    0.49      J0280
ACID ELUTION                                         48.76         J1245
ADENOSINE 6 MG                IV                    328.17         J1250
ADMIN SUPPLY - IV                                         52       J2785
ADMIN SUPPLY INJECTION - IVP                 52    95805-TC
AEROBIC ORGANISM IDENTIFICATION #3         123.3   95810-TC
ALBUMIN, SERUM                             75.55   95811-TC
ALKALINE PHOSPHATASE                       78.88   93458-TC
ALPHA-1 ANTITRYPSIN; TOTAL                385.01    93459
ALPHA-1 ANTITRYPSIN; TOTAL PHENOTYPE      253.36    93567
ALT - SGPT                                 80.75   93451-TC
ALUM HYDROXIDE (PO) 320 MG           PO     0.81   93460-TC
ALUMINUM SERUM, STIMULATED (W/DFO)        388.46   93461-TC
ALUMINUM SERUM,UNSTIMULATED W/0 DFO       388.46   93454-TC
AMIKACIN SULFATE 100 MG             IV      9.91   93455-TC
AMIODARONE HYDROCHLORIDE(CORDARONE)       161.86   75605-TC
AMPHOTERICIN B 50 MG            IV         82.68   75625-TC
AMPICILLIN 500 MG          IV              20.18   75630-TC
AMYLASE LEVEL                              98.83   75650-TC
ANA (ANTINUCLEAR ANTIBODIES)              266.26   75665-TC
ANAEROBIC BACTERIAL ID #1                  123.3   75671-TC
ANTI NUCLEAR ANTIBODY                      170.2   75676-TC
ANTIBODY ELUTION, RBC                     567.88   75680-TC
ANTIBODY IDENTIFICATION                   1055.9   75685-TC
ANTIBODY SCREENING                        394.06   75710-TC
ANTIGEN SCREENING                         194.39   75716-TC
ANTIGEN SCREENING (REGENT)                376.77   75736-TC
ANTIGEN TYPING                            330.08   75741-TC
ANTIHUMAN GLOBULIN QUAL., INDIRECT        524.98   75743-TC
ANTIHUMAN GLOBULIN TITER, INDIRECT        255.11   75746-TC
ANTIHUMAN GLOBULIN, DIRECT                187.23   75756-TC
ANTI-NEUTROPHILCYTOPLASMIC TITER          229.67   75774-TC
ANTISTREPTOLYSIN-O; SCREEN                110.16    36252
ANTISTREPTOLYSIN-O;TITER                  196.57    36254
APLISOL-5TU 1 ML          IV               22.14    Q9950
APTT                                       91.57
ARANESP 1 MCG                              51.13
ASCORBIC ACID 70 MG            IV           2.08
AST - GOT                                  78.75
ATENOLOL (PO) 25 MG            PO           6.77
ATROPINE SULFATE 0.1 MG IV                  8.53
ATTAPULGITE (P0) 750 MG         PO          1.44
AZITHROMYCIN 500 MG             IV        214.82
AZTREONAM 500 MG                           89.45
BETA 2 MICROGLOBULIN                      246.64
BICARBONATE                                74.57
BICARBONATE (POST)                         74.57
BILIRUBIN, DIRECT                          76.55
BILIRUBIN, TOTAL                                   76.55
BI-PTH                                             629.8
BKP CONVENTIONAL HEMODIALYSIS                      2935
BKP CONVENTNL/CATHETER HEMODIALYSIS                2935
BKP HIGH EFF/CATHETER HEMODIALYSIS                 2935
BKP HIGH EFFICIENCY HEMODIALYSIS                   2935
BKP HIGH FLUX HEMODIALYSIS                         2935
BKP HIGH FUX/CATHETER HEMODIALYSIS                 2935
BLOOD COUNT, SMEAR, MICROSCOPIC W/O MANUAL DIFF    52.46
BLOOD SUPPLIES                                     32.76
BLOOD, TUBING FILTER                               90.55
BUN, ARTERIAL                                      60.12
BUN, PERIPHERAL                                    60.12
BUN, POST, SERUM                                   60.12
BUN, PRE (BLOOD UREA NITROGEN)                     60.12
BUN, SERUM                                         60.12
BUN, VENOUS                                        60.12
CALCITRIOL 0.1 MCG           IV                       22
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .25 MCG       PO                 1.12
CALCITRIOL CAPSULES .5 MCG        PO                 2.11
CALCITRIOL CAPSULES .5 MCG        PO                 2.11
CALCITRIOL CAPSULES .50 MCG       PO                 2.11
CALCITRIOL ORL SOL 1 MCG        PO                  11.14
CALCITRIOL ORL SOL 1 MCG        PO                  11.14
CALCIUM ACETATE PO 667 MG         PO                1.25
CALCIUM CARBONATE (PO) 500 MG          PO           0.81
CALCIUM CHLORIDE 10/ML 13.5 MEQ IV                 10.15
CALCIUM GLUCONATE 10 ML/4.65 MEQ                    7.38
CALCIUM IONIZED                                   208.24
CALCIUM, TOTAL, SERUM                              78.55
CAPD METHOD 1                                      1329
CAPD TRAINING                                      3605
CAPTOPRIL (PO) 25 MG       PO                       6.45
CARBAMAZEPHINE                                    221.93
CARCINOEMBRYONIC ANTIGEN (CEA)                    422.72
CARNITINE, FREE                                   255.79
CARNITOR ORAL SOL 100 MG          PO                0.52
CARNITOR SF ORL SOL 100 MG             PO                0.52
CARNITOR TABLETS 330 MG               PO                  1.5
Catheter Care-incl Dressing Change                       85.1
CATHFLO ACTIVASE DECLOT 1 MG [Note: VIAL SIZE 2 MG]      492
CATHFLO ACTIVASE DWELL 1 MG [Note: VIAL SIZE 2 MG]       492
CATHFLO ACTIVASE PACKING 1 MG [Note: VIAL SIZE 2 MG]     492
CBC W/ DIFFERENTIAL                                    118.61
CBC W/O DIFFERENTIAL                                    85.16
CCPD METHOD 1                                           1446
CCPD TRAINING                                           3605
CEFAZOLIN 500 MG                 IV                     33.57
CEFEPIME 500 MG                                         75.07
CEFTAZEDIME 500 MG               IM                     89.56
CEFTIZOXIME SODIUM 500 MG                  IV           94.17
CEFTRIAXONE      250 MG     IV                          58.98
CELL COUNT OF PERITONEAL FLUID                          72.04
CENT CATH DRESSNG CHNG BL                                85.1
CHLORIDE, BLOOD                                         70.04
CHOLESTEROL, TOTAL, SERUM                                66.4
CIMETIDINE 300 MG                IV                     12.18
CIPROFLOXACIN LACTA 200 MG                 IV          119.15
CITRATE 4% CATHLOCK                                    270.32
CLONIDINE HCL (PO) 0.1 MG             PO                 1.99
CLONIDINE PATCH 0.3 MG                                 225.49
CLOSTRIDIUM DIFFICILE TOXIN A                          168.03
CLOSTRIDIUM DIFFICILE TOXIN B                          301.26
CMV ANTIBODY                                           219.62
CMV IGM ANTIBODY                                       257.08
COMPATIBILITY TEST, ANTIGLOBULIN TECH                  325.27
COMPATIBILITY TEST, IMMEDIATE SPIN                     417.09
COMPATIBILITY TEST, INCUBATION                         417.09
COMPLEMENT C3, SERUM                                   182.99
COMPLEMENT C4                                          182.99
COMPLEMENT FIXATION; EACH ANTIGEN                       729.5
CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENT         101.88
CORTISOL TOTAL, BLOOD                                  248.78
COUNTERIMMUNOELECTROPHORESIS ANTIGEN                    55.31
COURIER/STAT TRANSPORTATION FEE                         139.3
C-REACTIVE PROTEIN                                      78.88
CREATINE PHOSPHOKINASE, (CPK)                           99.39
CREATININE CLEARANCE                                   144.05
CREATININE DIALYSATE                                    78.88
CREATININE DIALYSATE C GLUCOSE                          78.88
CREATININE OF PD FLUID                                  78.88
CREATININE OF PD FLUID - 24HR                   78.88
CREATININE OF PD FLUID - OVERNIGHT              78.88
CREATININE, BLOOD                               77.98
CREATININE, POST, BLOOD                         77.98
CREATININE, URINE                               78.88
C-REATIVE PROTEIN                              251.97
CRIT-LINE O2 SATURATION                        174.13
CROSSMATCH, IMMEDIATE SPIN                     417.09
CRYOPRECIPITATE                                325.44
CUBICIN 1 MG                                     4.12
CULTURE & SENSITIVITY                          131.27
CULTURE & SENSITIVITY, BLOOD                   157.38
CULTURE & SENSITIVITY, CVC EXIT SITE           131.28
CULTURE & SENSITIVITY, PD CATHETER EXIT SITE   131.28
CULTURE & SENSITIVITY, PD FLUID                131.28
CULTURE & SENSITIVITY, STOOL                   248.95
CULTURE & SENSITIVITY, URINE                    254.8
CULTURE ACID FAST BACILLUS                     164.89
CULTURE AEROBIC FLUID                          131.35
CULTURE STOOL, AEROBIC ADDITIONAL PATHOGENS    143.89
CULTURE STOOL,YERSINIA                         143.89
CULTURE TYPING AGGLUTINATION #2                   79
CULTURE, AEROBIC                               157.38
CULTURE, ANAEROBIC                             144.26
CULTURE, FUNGAL                                128.05
CULTURE, FUNGI, ISOLATION, BLOOD               137.43
CULTURE, FUNGI, ISOLATION, OTHER               128.05
CULTURE, FUNGI, ISOLATION, SKIN                128.05
CULTURE, ROUTINE                               131.28
CULTURE, SPUTUM                                131.28
CULTURE, STOOL                                 248.96
CULTURE, THROAT                                131.28
CULTURE, URINE                                  254.8
CULTURE, URINE COMPLETE                        123.31
CULTURE, WOUND (SWAB)                          131.28
CYCLOSPORIN                                    275.53
CYPROHEPTADINE (PO) 4 MG         PO              3.57
DEFEROXAMINE       500 MG   IV                  98.86
DEPAKOTE LEVEL                                 149.19
DEXTROSE (D50W) VL 50 ML         IV              8.51
DEXTROSE (D50W) SYG 50 ML             IV        53.67
DIFFERENTIAL WBC MANUAL                         52.46
DIFFERENTIAL, AUTOMATED                          52.5
DIFFICULT X-MATCH PROBLEM EVALUAT.             255.86
DIGOXIN (PO) 0.125MG              PO                    2.67
DIGOXIN 0.5 MG               IV                        22.99
DIGOXIN LEVEL                                          202.4
DILANTIN-FREE                                         202.09
DILANTIN-TOTAL                                        202.08
DILTIAZEM IV 50 MG            IV                       33.72
DIPHENHYDRAMINE 50 MG                  IV              10.02
DIPHENOXLAT/ATRO PO 2.5 MG              PO              3.95
DIPHENYDRAMINE (PO) 25 MG              PO               0.49
DRESSING CHANGE                                         85.1
DRUG SCREEN, URINE                                    221.84
EKG                                                    433.4
EKG RHYTHM STRIP                                       433.4
ENALAPRIL (PO) 2.5 MG         PO                        6.37
ENALAPRILAT IV 1.25 MG            IV                   46.63
ENGERIX-B 20 MCG       SYG         IM                   615
ENGERIX-B 20 MCG     VL                                 615
ENGERIX-B 40 MCG       SYG         IM                  1230
ENGERIX-B 40 MCG     VL                                1230
ENOXAPARIN SODIUM 10 MG                IV             151.64
EOSINOPHIL (ABSOLUTE)                                  38.77
EPINEPHRINE 1:1,000 1 MG/ML             AMP             6.24
EPINEPHRINE 1:10,000 1MG/10ML          SYG             28.71
EPO < 10,000 UNITS (10 MG)                              1.98
EPO > 10,000 UNITS (10 MG)                              1.98
ESR                                                    54.17
ESTROGENS CONJUGATE 25 MG                   IV        493.94
FERAHEME IV 1MG SDV       *Restricted Use Pharmacy*    24.31
FERRITIN                                              207.68
FERRLECIT 12.5 MG IV                                   151.4
FIBRINOGEN                                            930.53
FILTER, LEUKOPOOR                                      41.79
FLOW CYTOMETRY                                        538.84
FLU VACCINE - FLUARIX 0.5 ML IM                        139.5
FLU VACCINE - FLUZONE 0.5 ML IM                        139.5
FLU VACCINE 0.5 ML            IM                       139.5
FLUCONAZOLE IV 200 MG              IV                 806.64
FLUORESCENT ANTIBODY SCREEN                           445.36
FLUORESCENT ANTIBODY TITER                            374.92
FOLATE, SERUM                                         224.13
FOLLICLE STIMULATING HORMONE (FSH)                    283.61
FROZEN PREP/FREEZING & THAWING                         586.7
FUNGUS IDENTIFICATION, YEAST                          157.47
GANCICLOVIR SODIUM 500 MG              IV             306.73
GENTAMICIN PEAK                       250.09
GENTAMICIN SULFATE 80 MG         IV     6.71
GENTAMICIN TROUGH                     250.09
GENTAMYCIN LEVEL                      250.09
GGT (GAMMA GLUTAMYL TRANSFERASE)      109.21
GLUCOMETER                             33.09
GLUCOMETER (POST)                      33.09
GLUCOMETER (PRE)                       33.09
GLUCOSE GEL 15 GM      (PO)            34.98
GLUCOSE OF PD FLUID                    59.85
GLUCOSE OF PD FLUID - 24HR             59.85
GLUCOSE OF PD FLUID - OVERNIGHT        59.85
GLUCOSE PRECISION                      33.09
GLUCOSE, BLOOD (ACCUCHECK)             33.09
GLUCOSE, BLOOD (ACCUCHECK) POST        33.09
GLUCOSE, BLOOD (ACCUCHECK) PRE         33.09
GLUCOSE, SERUM                         59.78
GRAM STAIN                             65.09
H1N1 ADMINISTRATION FEE                84.77
HANDLING AND PREPARATION FEES          48.76
HAPTOGLOBIN                             192
HCT - HEMATOCORIT                      36.07
HCV RNA BY PCR QUALITATIVE            535.53
HDL CHOLESTEROL                       124.77
HECTOROL CAPSULES .5 MCG      PO        8.76
HECTOROL CAPSULES 1 MCG       PO       17.45
HECTOROL CAPSULES 2.5 MCG     PO       30.29
HECTOROL IV 1 MCG IV                    69.3
HELICOBACTER PYLORI ANTIBODY          221.42
HEMO TRAINING                          3605
HEMOGLOBIN, AIC                       148.02
HEMOLYSINS & AGGLUT. INCUBATED        279.57
HEMOLYSINS & AGGLUT. SCREEN           152.89
HEP A AB IGM (IGM ANTI-HAV)           106.24
HEP B SURFACE AG (HBSAG)              157.38
HEP BCORELGM (IGM ANTI-HBC)           179.45
HEP BE AB (ANTI-HBE)                  176.27
HEP BE AG (HBEAG)                      175.6
HEP C VIRUS AB (ANTI-HCV)             183.76
HEP C VIRUS AB (ANTI-HCV)             217.62
HEPARIN HOME 1,000 UNITS 30 ML VIAL    53.95
HEPARIN HOME 5,000 UNITS 10 ML VIAL    53.95
HEPARIN-PORK 10,000 UNITS/ 0.1 ML      53.95
HEPARIN-PORK 1000 UNITS/ 0.1 ML          5.4
HEPARIN-PORK 5000 UNITS/ 0.1 ML                     26.98
HEPATIC FUNCTION PANEL- Organ or Disease Panel     124.66
HEPATITIS A ANTIBODY (HAAB)                        196.57
HEPATITIS B CORE ANTIBODY (HBCAB)                   161.9
HEPATITIS B SURFACE ANTIBODY HBSAB                 283.94
HEPATITIS B SURFACE ANTIGEN (HBSAG)                283.94
HEPATITIS B VIRAL DNA QUANTITATIVE                 653.51
HEPATITIS BE ANTIBODY (HBEAB)                      144.15
HEPATITIS BE ANTIGEN (HBEAG)                       144.15
HGB - HEMOGLOBIN                                    36.07
HIV 1                                              135.42
HIV ANTIGEN                                        519.83
HIV-1 & HIV-2 ASSAY                                 378.9
Home Hemo - RN Staff Assist MI_per 15 minute        31.92
Home Hemo - RN Staff Assist_per 15 minute           31.92
Home Hemo Dialysis Aide _per 15 minute              19.15
Home Hemo Dialysis Aide MI _per 15 minute           19.15
Home Hemo LPN/LVN Staff Assist _per 15 minute       31.92
Home Hemo LPN/LVN Staff Assist MI _per 15 minute    31.92
HOME HEMODIALYSIS                                   2935
HOME HEMODIALYSIS - NXSTAGE                         2935
HOMOCYSTEINE                                       257.13
HTLV ANTIBODY                                      413.36
HYDRALAZINE HCL 20 MG             IV               124.05
HYDROCORTIS NA SUCC 100 MG             IV           18.95
HYDROXYZINE (PO) 25 MG            PO                 2.57
HYDROXYZINE PAMOATE 25 MG PO                         2.57
IBUPROFEN (PO) 600 MG          PO                    2.36
IGM ANTIBODY - HEPATITIS B                          87.37
IGM ANTIBODY- HEPATITIS A                           87.37
IMMUNOASSAY INFECT. AGENT ANTIBODY                 267.57
IMMUNOASSAY, ANALYZE BY RIA                         441.2
IMMUNOCYTOCHEMISTRY                                721.72
IMMUNOFLUORESCENT ANTIBODY                         494.28
INFED 50 MG     IV *Restricted Use Pharmacy        442.87
INSULIN (HUMAN) 10 UNITS            IV               2.31
IPD INCENTER TREATMENT                              2935
IPD INCENTER TREATMENT - STAFF ASSIST               2935
IPD TRAINING                                        3605
IRON                                                98.72
IRRADIATION FEE                                     34.83
ISOPROTERENOL HCL .2 MG           IV                28.27
LABETALOL IV 5 MG            IV                      4.97
LDH                                                 92.11
LDL, DIRECT                                  554.56
LEPIRUDIN 50 MG              IV             2047.99
LEUKOCYTE ANTIBODY DETECTION                 374.24
LEVETIRACETAM (KEPPRA)                       161.86
LEVOCARNITINE (CARNITOR) 1 G                   540
LEVOCARNITINE TABLT 330 MG             PO      1.01
LEVOCARNITINE TABLT 330 MG             PO      1.01
LEVOCARNTNE ORL SOL 100 MG             PO       0.4
LEVOCARNTNE ORL SOL 100 MG             PO       0.4
LEVOFLOXACIN 250 MG           IV             342.22
LIPASE                                       105.01
LITHIUM                                      100.72
LOPERAMIDE (PO) 2 MG         PO                5.62
MAGNESIUM SULFATE 0.5 GM               IV       4.8
MAGNESIUM, SERUM                             102.13
MANNITOL 25% 50 ML            IV               16.7
MERREM     100 MG     IV                      57.09
METHADONE QUALITATIVE, SERUM                 210.14
METHYLPREDNI NA SUC 125 MG             IV     28.04
METHYLPREDNI NA SUC 40 MG          IV         17.38
METOCLOPRAMIDE HCL 10 MG           IV          6.94
MIC #3                                       131.87
MICROALBUMIN, URINE                            88.3
MICROSOMAL ANTIBODY                          317.14
MIDODRINE HCL (PO) 5 MG           PO          19.93
MUMPS VACCINE 1 ML           IV              114.35
MUPIROCIN 2% OINTME 1 GM                      16.47
NA POLYSTYRENE (PO) 15 GM         PO          58.13
NADOLOL (PO) 20 MG           PO                7.26
NALOXONE HCL 1 MG            IV               20.61
NAPA                                         255.36
NITROGLYCERIN (SL) 0.4 MG          SL          0.81
NITROGLYCERIN 2% 0.5 INCH                      2.08
NOREPINEPHERINE BIT 4 MG           IV        107.83
NUCLEIC ACID TESTING (NAT)                   174.13
OCCULT BLOOD, FECES                           38.61
ONDANSETRON HCL 1 MG                          53.01
OVA-PARASITE STOOL                           135.69
Oxygen Cannula                                18.46
Oxygen Mask                                   18.46
PARTICLE AGGLUT. ANTIBODY                    404.07
PENTAMIDINE 300 MG            IV             441.86
PHENCYCLIDINE (PCP), SERUM                   210.14
PHENOBARBITOL                                174.61
PHENTOIN SODIUM 50 MG           IV          4.75
PHOSPHORUS, POST                           72.37
PHOSPHORUS, SERUM                          72.37
PLASMA, FRESH FROZEN                      1074.6
PLASMA, PROTEIN, FRACTION                 442.94
PLATELET ANTIBODY DETECTION               1055.9
PLATELET ASSOC IMMUNOGLOBULIN ASSAY       659.61
PLATELET COUNT                              68.17
PLATELET RICH PLASMA                      442.94
PLATELET, PHERESIS                        442.94
PLATELET, PHERESIS - LEUKOCYTE REDUCED    1144.07
PLATELETS                                 930.53
PNEUMO VAC 23-VALEN 0.5 ML           IM   129.25
POOLING OF PLATELETS OR OTHER BLOOD       231.62
POTASSIUM CHLORIDE 2 MEQ                     0.61
POTASSIUM, POST                            70.04
POTASSIUM, SERUM                           70.04
PREALBUMIN                                222.37
PREDNISONE (PO) 5 MG         PO             0.49
PRETREAT RBC BY DIFF RC ABSORPTION        567.88
PRETREATMENT OF RBC AB DETECTION           288.7
PROCAINAMIDE                              255.36
PROCAINAMIDE AND NAPA                     255.36
PROCAINAMIDE HCL 1 GM           IV          11.18
PROCHLORPERAZINE IV 10 MG            IV    42.66
PROCHLORPERAZINE PO 5 MG             PO     4.97
PROF. FEE-HEPATITIS B/RECOMBIVAX           84.76
PROF. FEE-INFLUENZA                        84.76
PROF. FEE-PNEUMOCOCCAL                     84.76
PROMETHAZINE HCL PO 25 MG            PO     4.24
PROMETHZNE HYDROCHL UP TO 50 MG             19.74
PROPOXYPHENE (DARVON), QUANTITATIVE       296.87
PROPRANOLOL 1 MG           IV              118.02
PROTEIN ELECTROPHORESES                   163.69
PROTEIN S (TOTAL)                          55.92
PSA DIAGNOSTIC (PROC SPEC ANTI)           280.38
PSA SCREENING (PROC SPEC ANTI)            280.38
PT - PROTHROMBIN TIME                      59.89
PTH INTACT (PLASMA)                        629.8
PULSE OXIMETRY MULTIPLE READINGS          127.69
PULSE OXIMETRY SINGLE READING              46.43
QUINIDINE                                 222.47
RBC ANTIBODY IDENT.                       714.92
RBC COUNT                                  45.89
RBC FOLATE                                     262.62
RBC, (PACKED RED BLOOD CELLS)                   1581.8
RBC, DEGLYCERIZED                              1047.51
RBC, IRRADIATED                                1047.51
RBC, LEUKOCYTES REDUCED                        1047.51
RBC, LEUKOREDUCED, IRRADIATED                  1047.51
RBC, WASHED                                    1615.18
RECOMBIVAX 40 MCG             IM                 1625
RETIC HGB (CHr)                                 122.21
RETICULOCYTE COUNT                               61.11
RETICULOCYTE SEPARATION                         90.55
RH PHENOTYPING COMPLETE                         122.15
RH TYPE                                         122.15
RH TYPE                                        179.22
RHEUMATOID FACTOR                               86.58
ROCALTROL CAPSULES .25 MCG         PO            2.55
ROCALTROL CAPSULES .25 MCG         PO            2.55
ROCALTROL CAPSULES .25 MCG         PO            2.55
ROCALTROL CAPSULES .5 MCG          PO             4.01
ROCALTROL ORL SOL 1 MCG         PO              20.98
ROCEPHINE     250 MG      IV                     77.8
ROUTINE TRANSPORT FEE                           55.72
RPR                                             65.09
RUBELLA ANTIBODY                               219.37
RUBEOLA ANTIBODY                               147.36
SEDIMENTATION RATE, AUTOMATED                    41.17
SENS ORGANISM THREE(MIC)                        131.87
SENSITIVITY STAPH AUREUS VANCOMYCIN              72.41
SEPARATION BY ELECTROPHORESIS #1                 61.13
SEPARATION BY ELECTROPHORESIS #3                 61.13
SILVER NITRATE 10 GM                             0.44
SMEAR WET MOUNT, INDIA INK PREPARATION            65.1
SODIUM BICARB 50 ML           IV                 19.02
SODIUM THIOSULFATE 50 GM                       243.13
SODIUM, POST                                    66.63
SODIUM, SERUM                                   66.63
SPLITTING OF BLOOD                             241.69
STOOL FOR WHITE BLOOD CELLS                     65.09
Susceptibility BETA LACTAMASE #1                 72.41
Susceptibility MIC #2                           131.87
SUSCEPTIBILITY STUDY, AGAR DIFFUSSION METHOD     72.41
SYPHILLIS QUAL. (VDRL, RPR)                    128.07
SYPHILLIS QUANT.                                48.05
T3 (RIA)                                       216.33
T3 (UPTAKE)                            98.72
T4 FREE                               137.43
T-4 THYROXINE                          104.8
THEOPHYLLINE                          215.75
THYROGLOBULIN QUANT                   331.55
TMT CONVENTIONAL HEMODIALYSIS          2935
TMT CONVENTNL/CATHETER HEMODIALYSIS    2935
TMT HIGH EFF/CATHETER HEMODIALYSIS     2935
TMT HIGH EFFICIENCY HEMODIALYSIS       2935
TMT HIGH FLUX HEMODIALYSIS             2935
TMT HIGH FLUX/CATHETER HEMODIALYSIS    2935
TOBRAMYCIN                            245.94
TOBRAMYCIN 80 MG                IV     51.42
TOBRAMYCIN PEAK                       245.93
TOBRAMYCIN TROUGH                     245.93
TOTAL PROTEIN (FLUID)                  55.91
TOTAL PROTEIN DIALYSATE PD             55.92
TOTAL TESTOSTERONE LEVEL              394.02
TOXIC SCREEN                          221.91
TRANSFERRIN                           194.68
TRANSFUSION ADMIN FEE 1 PER TMT       696.51
TRANSFUSION REACTION                  665.77
TREPONEMA PALLIDUM (FTA-ABA)          252.57
TRIGLYCERIDES                           87.7
TSH-THYROID STIMULATING HORMONE         256
TUBERSOL- 5TU 0.1ML                    11.33
UIBC                                  133.23
UREA NITROGEN DIALYSATE                60.12
UREA NITROGEN, 24-HOUR URINE           72.45
UREA NITROGEN, URINE                   72.45
UREA OF PD FLUID                       60.12
UREA OF PD FLUID - 24 HR               60.12
UREA OF PD FLUID - OVERNIGHT           60.12
Urea-N clearance test                    28
URIC ACID, BLOOD                       68.94
URINALYSIS                              48.2
URINALYSIS, MICROSCOPIC ONLY           46.29
VANCOMYCIN 500 MG               IV    189.75
VANCOMYCIN PEAK                       149.02
VANCOMYCIN RANDOM                     149.02
VANCOMYCIN TROUGH                     149.02
VENOFER 1 MG               IV          12.25
VENOFER 1 MG               IV          12.25
VERICELLA-ZOSTER                      196.45
VITAMIN B12                             229.75
VITAMIN D (CALCIFEROL LEVEL)             491.16
VITAMIN D 1,25 DIHYDROXY LEVEL          586.68
Vitamin d, 25 hydroxy                    453.19
VITAMIN K 1 MG                IV           4.31
WHITE BLOOD COUNT (WBC)                  38.84
WHOLE BLOOD                             1038.74
YEAST IDENTIFICATION #1                  157.47
ZEMPLAR 1 MCG IV        MDV                 95
ZEMPLAR CAPSULES 1 MCG             PO      11.7
ZEMPLAR CAPSULES 2 MCG             PO    23.29
ZEMPLAR CAPSULES 4 MCG             PO    46.48
ZINC                                     173.61
                       3/5/2012                                                               2/22/2012

                      OTC-0710                                                                 OTC-4787
       Heart Instirute of Northern Arizona                                                   Express Care


              1753 Airway Ave, Ste B                                                     45 Capri Blvd, Suite G
                       Kingman                                                             Lake Havasu City
                          AZ                                                                    Arizona
                         86409                                                                  86403
                         Mohave                                                                 Mojave
                     Same as above                                                           P. O. Box 3030
                                                                                           Lake Havasu City
                                                                                                Arizona
                                                                                                86405
                     928 6926200                                                             928-505-1030
                     1922089416
                         197211                                                                 499918
                           no                                                                     Yes
                       Z-25383                                                                  z136841
                A Paul Kalanithi.MD                                                       Sandra Podley - CEO
                     928 757 4359                                                            928-855-8185
               skalanithi@yahoo.com
                     Sue Kalanithi                                                        Christopher Flores
                     928 757 4359                                                            928-855-8185
               skalanithi@yahoo.com                                                      Chris.flores@Lpnt.net
                  ShirleyHaskett                                                               Linda Toy
                     928 757 4359                                                            928-505-5761
            shaskett50@frontier.com                                                       linda.toy@lpnt.net
                                                                                               1/9/2012


            Discription of Charge                Rate of Charge     Service Code       Discription of Charge


Myocardial Perfusion,Multiple Studies        $             462.00     116927       ABDOMEN
Myocardial Perfusion,Single Study            $             298.00     116928       AC JOINTS BIL W/WO W
Cardiovascular Stress test                   $             140.00     116931       ABDOMEN COMPLETE
CV Stress-tracing only                       $              80.00     116932       ABD COMP W/DECUB A/O
CV Stress-physician Supervision              $              35.00     116933       ABDOMEN LIMITED
CV Stress Interpretation & Report            $              35.00     116934       ANKLE AP & LAT
TechnithiumTC-99M sestambili                 $             125.00     116935       ANKLE COMP MIN 3 VWS
Thallium TL-201 Thallous chloride            $              65.00     116936       ABDOMEN SERIES W/PA
Aminophylline upto 250mg                     $              40.00     116937       HIPS BIL MN 2 V W/AP
Diyridamole per 10mg                         $              20.00     116938       BONE AGE STUDY
Dobutamine HCL per 250mg                     $              25.00     116939       BONE LENGTH STUDY
Lexiscan per 0.1mg                           $              70.00     116940       RIBS BIL 3 VWS
Multiple Sleep Latency Testing               $    406.00    116942   RIB BIL&PA CHEST MN
polysomnography, sleep staging               $    872.00    116943   BONE SURVEY COMP
Polysomnography with CPAP                    $    872.00    116944   BONE SURVEY INFANT
Cath Placement with LHC                      $   1,090.00   116945   BONE SURVEY LTD MET
Cath Placemnt with LHC & LV Inj              $   1,200.00   116946   CHEST 1 VW
Inj procedure for Supravalvular aortogram    $    225.00    116947   CHEST 2 VWA PA & LAT
RHC with Oxy sat & Cardiac output            $    788.00    116948   CHEST CMP MN 4 V W/F
Cath Placemnt with LHC & LV Inj              $   1,285.00   116949   CLAVICLE
cath Placement with R& LHC Bypass Gr         $   1,477.00   116951   CRV SP CP W/OB/FLX A
Cath Placement for Coronary Angio & Inj      $    900.00    116953   CERV SPINE 1 VW
Cath Placement in Coronary Art & Bypass Gr   $   1,050.00   116954   CERV SPINE AP & LAT
Thoracic Aortogram                           $     179.00   116955   CERV SPINE MN 4 VWS
Abdominal Aortogram                          $     175.00   116956   CHEST SP VWS-LAT DCM
Abdominal Aortogram with Lower Extrem        $     182.00   116957   EYE FOR FB PRE-MRI
Cervico Cerebral Angiogram                   $    259.00    116958   ELBOW AP & LAT
Unil Carotid,Cerebral Angiogram              $    270.00    116959   ELBOW COMP MN 3VWS
Bilateral Carotid,Cerebral Angiogram         $     315.00   116961   FINGER(S) MN 2 VWS
Unil Carotid,Carotid,Cervical Angiogram      $     315.00   116962   EYE FOR FOREIGN BODY
Bil Carotid,Cervical Angiogram               $    277.00    116964   FACIAL BONES <3 VWS
Vertebral Angiogram                          $    263.00    116965   FACIAL BONE COMP MN
Unilateral Extremity Angiogram               $    252.00    116966   FEMUR AP & LAT
Bilateral Extremity Angiogram                $    300.00    116967   FOREARM AP & LAT
Pelvic Angiogram                             $    256.00    116968   FOOT AP & LAT
Unilateral Pulmonary Angio                   $    242.00    116969   FOOT COMP MN 3 WVS
bilateral Pulmonary Angio                    $    270.00    116970   HIP UNIL 1VW
Pulmonary Angio by Cath or Venous            $    249.00    116972   HIPUNIL COMP MN 2 V
Internal Mammory Angio                       $    263.00    116973   HAND 2 VWS
Selective Angio,cath additional              $     179.00   116975   HAND MN 3 VWS
Selective Cath Placement-renal-bil           $   1,905.00   116976   CALCANEUS MN 2 VWS
Selective Cath Placement 2nd order renal     $   2,757.00   116977   HUMERUS MN 2 VWS
Contrast Media                               $       1.00   116978   INFANT HIPS LTD/STAT
                                                            116979   KNEE AP & LAT
                                                            116980   KNEE AP&LAT W/OBL MN
                                                            116981   KNEE CP W/OB+TL/PT A
                                                            116982   LUMBAR SPINE 1VW
                                                            116983   L-S SPINE AP & LAT
                                                            116984   L-S SPINE BND ONL MN
                                                            116986   L-S SPINE COMP W/BEN
                                                            116987   L-S SPINE COMP W/OBL
                                                            116988   MANDIBLE < 4 VWS
                                                            116989   MANDIBLE COMP MN 4 V
                                                            116990   NASAL BONES COMP MN
                                                            116991   NECK SOFT TISSUE
                                                            116992   PELVIS AP ONLY
116993   PELVIS COMP MN 3 VWS
116994   SINUSES PARANASAL <
116995   SINUS PARANSL CP MN
116997   SPINE 1 VW
116998   SCAPULA
116999   SACRUM & COCCYX MN 2
117001   STRNOCLVCLR JT/JTS M
117002   SHOULDER 1VW
117003   SJOULDER COMPL MN 2
117004   SACROILIAC JOINTS <
117005   SACROILIAC JOINTS 3
117006   SKULL <4VWS
117007   SKULL COMP MIN 4 VWS
117008   SPINE SURVY ENTIRE A
117009   STERNUM MN 2 VWS
117010   TOES(S) MIN 2 VWS
117013   THORACOLUMBR SPINE A
117014   THORAC SPIN AP&LT W/
117015   THORACIC SPINE 1 VW
117016   THORA SPN CP W/OBL M
117017   UPPER EXT INFANT MN
117018   RIBS UNL 2 VWS
117019   RIB UNI&PA CHEST MN
117020   WRIST AP & LAT
117021   WRIST COMP MN 3 VWS
117151   VISIT LEVEL I
117152   VISIT LEVEL 2
117153   VISIT LEVEL 3
117154   VISIT LEVEL 4
117155   VISIT LEVEL 5
117156   I&D SIMPLE
117157   I&D SIMPLE PILO CYST
117158   I&D SIMPLE LESION
117159   I&D COMPLEX
117160   NAIL DEBRIDEMENT
117161   NAIL DRAIN BLOOD
117162   NAIL AVULS SINGLE
117163   NAIL AVULS EA ADD
117164   NAIL EXCISN W/AMPUT
117165   TX BURN MED W/O ANES
117166   CAUTERY CHEMICAL
117167   DEBR SKIN PART/FULL
117169   TX BURN 1ST DEGREE
117170   TX BURN SML W/O ANES
117171   TX BURN LG W/O ANES
117172   DEBRIDE SKIN TISSUE
117173   NAIL & MATRIX EXCISN
117174   FB REM MUSC/TEN SMP
117176   FB REM DEEP TISSUE
117177   DRAIN/INJECT JOINT
117178   DEFIBRILLATION
117182   IV INF TX/DX 1ST HR
117183   IV INF TX/DX ADD HR
117186   FECAL IMPACT REMOVAL
117187   FB REM CORNEA W/SL
117188   FB REM CORNEA W/O SL
117189   LAC REP SIMPLE TI
117190   REP WND 2.6-7.5 SIMP
117193   REP END TYP2 SIMP
117194   REP WND 2.6-5.0 SMP
117195   REP WND 2.5-7.5 SMP
117196   REP END 7.6-12.5 SMP
117197   LAC REP DERMABOND
117199   FB REM EAR
117202   REM IMPACTED CERUM
117203   PPD SKIN TEST
117205   UA DIPSTICK
117206   BLD GLUC REG STRIP
117207   INJ VACC 1ST VACC
117208   INJ VACC EA ADD INJ
117209   TET/DIPT <7YRS
117210   TET/DIPT >7 YRS
117211   TET TOXOID
117213   INJECT SUBQ/IM
117214   IV PUSH INITIAL
117216   EPISTAXIS CONTROL
117217   REM NASAL FB
117218   FB REM MOUTH/NOSE
117219   CLSD TX FX NOSE
117221   SPLT APP LOWER LEG
117222   STRPG APP KNEE
117223   STRPG APP KNEE
117227   STRPG TOES
117228   SPLT APP LONG ARM
117229   SPLT APP FOREARM
117231   APLT APP FINGER
117232   STRPG APP SHOULDER
117233   STRPG APP ELBOW
117234   STRPG APP HAND/FING
117235   CAST APP SHORT LEG
117236   REM FB SUBSQ
117238   VENIPUNCTURE
117242   INFUS SEQUEN
117243   IV PUSH EA ADDL
117244   HEP B VACC ADMIN
117245   INFLU VACC ADM
117246   PNEUM VACC ADM
117247   ADD SEQUEN IV PUSH
117249   DRN/INJ BURSA INT
117251   DRN/INJ BURSA MAJ JT
117252   CLSD TX CLAV FX W/O
117253   TX DISL SHLDER W/O
117254   CLOSED TX ULN/RAD HD
117255   CLSD TX RAD HD SUBLX
117256   CLSD TX RAD SHFT FX
117257   CLSD TX ULNAR SHAFT
117258   CLSD TX RAD/ULNA FX
117261   CLSD TX METACARP FX
117263   CLSD TX METATARS FX
117264   CLSD TX METATARS FX
117265   GLUCOMETER
117266   I&D VULVA/PERINLABSC
117267   H1N1 VACC ADMIN
117268   ALLERGY INJECTION
117307   RHYTHM ECG TRACING
117308   LEVEL 1 PULMONARY TX
118782   UC-INFLUA&B
118784   UC-URINEPREG
118785   UC-STREP A
118787   UC-RSV
125583   TIBIA/FIBULA 2V RT
125709   TIBIA/FIBULA 2V LT
126973   VAC INFLUENZA ADMIN
128222   EST PT LEVEL 1
128223   EST PT LEVEL 2
128224   EST PT LEVEL 3
128226   EST PT LEVEL 4
128227   EST PT LEVEL 5
/2012                                                      2/17/2011

4787                                                        OTC-2527
ss Care                                             KINGMAN KIDNEY CLINIC


vd, Suite G                                         4055 STOCKTON HILL RD
vasu City                                                  KINGMAN
zona                                                           AZ
403                                                          86409
jave
ox 3030                                             10917 72 ND ROAD, STE 6-R
vasu City                                                FOREST HILLS
zona                                                           NY
405                                                           11375
05-1030                                                   718-268-7347
                                                           1447338710
9918                                                         510934
es                                                            YES
6841                                                        032-582
dley - CEO                                               RAMESH SARVA
55-8185                                                   718-268-7347
                                                        Ramesh@Sarva.Org
her Flores                                               RAMESH SARVA
55-8185                                                   718-268-4933
s@Lpnt.net                                              Ramesh@Sarva.Org
a Toy                                                    SHAILA SARVA
05-5761                                                   718-268-7347
@lpnt.net                                           Shaila@softtechsource.com
2012


                  Rate of Charge     Service Code


              $             345.60      77421
              $             304.90      90658
              $             693.00      90732
              $             510.80      90746
              $             345.60      90747
              $             242.55      90935
              $             351.40      90937
              $             693.00      90999
              $             536.80      90989
              $             330.95      99910
              $             653.45     Q4081
              $             601.20     Q0163
$   745.85   G0008
$   744.10   G0009
$   721.85   G0010
$   980.85   J0635
$   275.75   J0690
$   342.75   J0698
$   968.15   J0713
$   273.45   J0715
$   684.65   J0735
$   243.25   J0780
$   473.25   J0885
$   699.95   J0886
$   275.75   J1270
$   549.80   J1580
$   273.45   J1642
$   349.95   J1644
$   242.55   J1720
$   549.80   J1756
$   349.95    J1815
$   551.55   J1955
$   345.60   J2501
$   311.55   J2550
$   273.45   J2912
$   349.95   J2916
$   242.55   J2930
$   444.40   J3370
$   273.45   J7050
$   349.95   M0982
$   351.40   M0986
$   376.25   Q9920
$   360.35   V5364
$   354.05   J7050
$   444.40   J0698
$   444.40   J2930
$   231.60   J2997
$   551.55   A4657
$   639.85   A4660
$   772.15   A4755
$   551.55   A4913
$   436.50
$   551.55
$   362.65
$   221.50
$   434.00
$    577.20
$    404.50
$     551.55
$     231.60
$    396.75
$     375.10
$    395.60
$    253.55
$    434.00
$     485.10
$    577.20
$    436.05
$    577.20
$   1,174.10
$     415.50
$    273.45
$     531.30
$     630.10
$     231.60
$    698.75
$     228.15
$    490.30
$     561.95
$     301.00
$    507.30
$     78.00
$     88.00
$     150.00
$    200.00
$    250.00
$     170.00
$    263.00
$     122.00
$    340.00
$     103.00
$     117.95
$     174.00
$     66.00
$   4,557.90
$    295.45
$   3,703.70
$     159.89
$     113.00
$     132.00
$    336.85
$     110.42
$     117.50
$    303.00
$    494.00
$    140.00
$     711.95
$    518.85
$    155.20
$    402.15
$     86.00
$     86.00
$    290.00
$    308.00
$      3.48
$    488.00
$    498.00
$    502.00
$       4.61
$    242.00
$     98.00
$     39.95
$     29.50
$     15.45
$     39.15
$     39.15
$    223.80
$    223.80
$    223.80
$     39.15
$    129.55
$    375.10
$     214.15
$     214.15
$   1,233.70
$    147.00
$       1.61
$     161.20
$    146.35
$    276.20
$    133.00
$     78.00
$    224.90
$    169.95
$     161.20
$    271.45
$    536.40
$     12.40
$    106.47
$    106.47
$     35.00
$     35.00
$     35.00
$    106.47
$     94.00
$     113.00
$    319.00
$    537.00
$   2,100.50
$    344.25
$    737.30
$    598.40
$    735.95
$    622.05
$    818.65
$    599.75
$     21.00
$     181.00
$     35.00
$     35.00
$    292.80
$     87.72
$     39.75
$      9.30
$     39.75
$     39.75
$    363.00
$    363.00
$     10.00
$     50.35
$     80.85
$     90.30
$    156.45
$    252.00
                                        2/17/2011

                                        OTC-2527
                                KINGMAN KIDNEY CLINIC


                                 4055 STOCKTON HILL RD
                                        KINGMAN
                                            AZ
                                          86409


                                10917 72 ND ROAD, STE 6-R
                                      FOREST HILLS
                                            NY
                                           11375
                                       718-268-7347
                                        1447338710
                                          510934
                                           YES
                                         032-582
                                     RAMESH SARVA
                                       718-268-7347
                                    Ramesh@Sarva.Org
                                     RAMESH SARVA
                                       718-268-4933
                                    Ramesh@Sarva.Org
                                      SHAILA SARVA
                                       718-268-7347
                                 Shaila@softtechsource.com




                                Discription of Charge            Rate of Charge


STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TA           $              350.00
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR USE IN I           $               13.22
PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT, AD           $               17.32
HEPATITIS B VACCINE, ADULT                                   $               59.65
HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED            $               119.41
HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALU           $              410.00
HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION         $              820.00
UNLISTED DIALYSIS PROCEDURE, INPATIENT OR OUTPATIENT         $              236.00
DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHEN TRAINING   $              200.00
CCPD SUP                                                     $               85.00
EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS                $                1.00
DIPHENHYDRAMINE, HCI 50MG                                    $                0.10
ADMINISTRATION OF INFLUENZA VIRUS VACCINE            $    18.57
ADMINISTRATION OF PNEUMOCOCCAL VACCINE               $    18.57
ADMINISTRATION OF HEPATITIS B VACCINE                $    18.57
INJECTION, CALCIJEX, 1 MCG AMP.                      $     0.46
INJECTION, ANCEF 500 MG                              $     0.68
INJECTION, CEFOTAXIME SODIUM, PER GM                 $     4.55
FORTAZ, PER 500 MG                                   $     2.21
INJECTION, CEFTIZOXIME SODIUM, PER 500 MG            $     3.25
Clonidine Hydrochloride, 1MG                         $    77.48
INJECTION, COMPAZINE, UP TO 10 MG                    $     1.86
Epoetin alfa 1000- ESRD                              $     9.65
INJECTION, DARBEPOETIN ALFA, 1000 UNITS-ESRD         $     9.96
HECTOROL 2MCG                                        $     3.20
GENTAMYCIN, UP TO 80 MG                              $     0.87
INJ HEPARIN SODIUM PER 10 UNITS                      $     0.16
INJ HEPARIN SODIUM PER 100 UNITS                     $     0.44
INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO    $     3.30
INJECTION,VENOFER, 1 MG                              $     0.36
INSULIN INJECTION, 5 UNITS                           $     0.66
INJECTION, LEVOCARNITINE, PER 1 GM                   $     5.60
PARICALCITOL, 1MCG                                   $     3.50
PHENERGAN, UP TO 50 MG                               $     1.64
INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML           $     0.50
Na FERRIC GLUCONATE COMPLEX, 12.5 MG                 $     6.60
INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP   $     2.59
INJECTION, VANCOMYCIN HCL, 500 MG                    $     3.30
INFUSION, NORMAL SALINE SOLUTION 250 CC              $     0.28
CCPD TRN                                             $   200.00
CAPD TRN                                             $   236.00
INJECTION OF EPO, PER 1000 UNITS, AT PATIENT HCT O   $    10.00
DYSPHAGIA SCREENING                                  $    10.51
INJECTION,VENOFER, 1 MG                              $     0.50
INFUSION, NORMAL SALINE SOLUTION 250 CC              $     0.26
INJECTION, CEFOTAXIME SODIUM, PER GM                 $     4.55
ALTEPASE RECOMBINANT 1MG                             $    37.87
SYRINGE, WITH OR WITHOUT NEEDLE, EACH                $     0.50
SPHYGMOMANOMETER/BLOOD PRESSURE APPARATUS WITH CUF   $     0.50
BLOOD TUBING, ARTERIAL AND VENOUS COMBINED, FOR HE   $     6.00
MISCELLANEOUS DIALYSIS SUPPLIES, NOT OTHERWISE SPE   $     0.50
                                           3/21/2012                                                                          2/

                                            OTC-3231                                                                           O
                         Anasazi Healthcare, Inc. dba Lake Hills Inn                                           Mohave County De


                                        2781 Osborn Drive                                                                 1222 H
                                        Lake Havasu City                                                                     Bul
                                             Arizona
                                              86406


                                        2781 Osborn Drive
                                        Lake Havasu City
                                             Arizona
                                              86406
                                          928-505-5552                                                                       928
                                           1063411981                                                                         174
                                             371899
                                                yes
                                              35240                                                                           174
                                          Janet Lumpkin                                                                       Pa
                                          928-505-5552                                                                       928
                                    jlumpkin@cghealthinc.net                                                          patty.mead
                                           Krissi Elliott                                                                  Jenn
                                          970-516-1404                                                                       928
                                    kelliott@cghealthinc.net                                                        jennifer.mcna
                                          Peggy Rossiter                                                                   Christ
                                          970-533-1404                                                                       928
                                   prossiter@cghealthinc.net                                                      christine.brons
                                              Aug-11                                                                           7


Service Code                      Discription of Charge                    Rate of Charge       Service Code


   97001       PT Evaluation                                           $               87.44
   97002       PT Re-Evaluation                                        $               48.52
   97003       OT Evaluation                                           $               97.82
   97004       Re-Evaluation                                           $                60.11
   97012       Mechanical Traction Therapy Supv                        $                18.61
   97016       Vasopneumatic Device Therapy Supv                       $               21.74
   97018       Paraffin Bath Therapy Supv                              $               12.05
   97022       Whirlpool Therapy Supv                                  $               26.14
   97024       Diathermy/Microwave                                     $                7.66
   97026       Infrared Therapy Supv                                   $                6.86
   97028       Ultraviolet Therapy Supv                                $                8.47
   97032       Electrical Stimulation                                  $               21.82
97033   Electric Current Therapy                 $   36.20
97034   Contrast Bath Therapy                    $    20.17
97035   Ultrasound Therapy                       $    14.58
97036   Hydrotherapy                             $   36.62
97110   Therapeutic Exercises                    $   36.37
97112   Neuromuscular Reeducation                $   37.97
97113   Aquatic Therapy/Exercises                $   48.35
97116   Gait Training Therapy                    $   32.33
97124   Massage Therapy                          $   29.89
97140   Manual Therapy                           $   33.96
97150   Group Therapeutic Procedures 2 or more   $   23.42
97530   Therapeutic Activities                   $   39.96
97532   Cognitive Skills Development             $   30.37
97533   Sensory Integration                      $   33.56
97535   Self Care/ADLs                           $   39.56
97537   Community/Work Reintegration             $   34.38
97542   Wheelchair Mangement Training            $    35.17
97597   X Active Wound Care (20cm or Less)       $    88.81
97598   Active Wound Care                        $   29.42
97605   Negative Pressure Wound <50cm -          $   48.55
97606   Negative Pressure Wound >50cm -          $    51.82
97750   Physical Performance Test                $   38.40
97755   Assistive Technology Assessment          $    41.75
97760   Orthotic Management and Training         $   43.60
97761   Prosthetic Training                      $   38.00
97762   Orthotic/Prosthetic Checkout             $    52.18
G0281   E-Stim - Stage 3-4 Wound                 $    15.76
G0283   E-Stim - Other than Wound                $    15.76
29065   Application of Long Arm Cast             $   113.27
29075   Application of Forearm cast              $   105.96
29085   Apply Hand/Wrist Cast                    $   111.65
29105   Apply Long Arm Splint                    $   102.85
29125   Apply Forearm Splint                     $   75.67
29126   Apply Forearm Splint                     $   90.24
29130   Application of Finger Splint             $   47.69
29131   Application of Finger Splint             $    61.33
29200   Strapping of Chest                       $    61.38
29240   Strapping of Shoulder                    $   66.62
29260   Strapping of Elbow or Wrist              $   60.89
29280   Strapping of Hand or Finger              $   58.84
29345   Application of Long Leg Cast             $   160.66
29365   Application of Long Leg Cast             $   144.42
29405   Apply Short Leg Cast                     $    97.15
29425   Apply Short Leg Cast                     $   94.34
 29435     Apply Short Leg Cast                              $   141.22
 29440     Addition of Walker to Cast                        $    66.95
 29445     Apply Rigid Leg Cast                              $   162.95
 29450     Application of Leg Cast                           $   171.58
 29505     Application Long Leg Splint                       $    94.66
 29515     Application Lower Leg Splint                      $    83.50 * These services offered on sliding fee sc
 29520     Strapping of Hip                                  $    58.07
 29530     Strapping of Knee                                 $    60.91
 29540     Strapping of Ankle or Foot                        $    43.14
 29550     Strapping of Toes                                 $    36.19
 29580     Application of Paste Boot                         $    61.72
 29590     Application of Foot Splint                        $    62.28
70371 26   Speech Evaluation, Complex Video                  $    47.89
70371 TC   Speech Evaluation, Complex Video                  $    57.96
 70371     Speech Evaluation, Complex Video                  $   112.67
74230 26   Cinema Xray Throat/Esophagus Mod barium swallow   $    31.26
74230 TC   Cinema Xray Throat/Esophagus Mod barium swallow   $    68.32
 74230     Cinema Xray Throat/Esophagus Mod barium swallow   $   110.78
 92506     Speech & Hearing Eval                             $   194.99
 92507     Speech/Hearing Therapy                            $    89.16
 92508     Speech/Hearing Therapy Group, 2+                  $    26.68
 92520     Laryngeal Function Studies                        $    83.42
 92526     Swallow TX                                        $    98.78
 92607     Eval of Speech Device                             $   169.19
 92608     Eval of Speech Device - Add'l x 30                $    54.61
 92609     Training and Fitting - Device                     $   120.10
 92610     Swallow Function Eval                             $   106.33
 92611     Motion Fluoroscopy/Swallow Study                  $   116.77
 92612     Endoscopy Swallow                                 $   200.58
 92613     Endoscopy Swallow                                 $    45.04
 92614     Laryngoscopic Sensory Test                        $   179.81
 92615     Evaluate Laryngoscopic Test                       $    40.16
 92616     Fees w/Laryngeal Sense Test                       $   241.52
 92617     Interpret Fees w/Laryngeal Test                   $    49.50
 93922     Extremity Study                                   $   122.50
93922 TC   Extremity Study                                   $   119.70
93922 26   Extremity Study                                   $    14.36
 95831     Limb Muscle Testing, Manual Excl hand             $    33.46
 95832     Hand Muscle Testing, Manual                       $    31.46
 95833     Body Muscle Testing, Manual Excl hands            $    43.98
 95834     Body Muscle Testing, Manual Incl hands            $    57.31
 95851     ROM Meas - Each Extremity Excl hands              $    21.34
 95852     ROM Meas - Hand                                   $    18.89
 96105     Assessment of Aphasia x 60                        $   121.07
96125   Cognitive Test by HC Professional   $   117.88
                     2/23/2012                                                                       2/23/2012

                      OTC-3464                                                                       OTC-3465
     Mohave County Department of Public Health                                        Mohave County Department of Public Health


                 1222 Hancock Road                                                           2001 College Drive Suite 115
                   Bullhead City                                                                  Lake Havasu City
                        AZ                                                                               AZ
                       86442                                                                           86403




                   928-758-0703                                                                    928-453-0703
                    1740326727                                                                      1740326727




                    1740326727                                                                      1740326727
                     Patty Mead                                                                      Patty Mead
                   928-753-0743                                                                    928-753-0743
            patty.mead@co.mohave.az.us                                                       patty.mead@co.mohave.az.us
                 Jennifer McNally                                                                 Jennifer McNally
                   928-753-0743                                                                    928-753-0743
          jennifer.mcnally@co.mohave.az.us                                                 jennifer.mcnally@co.mohave.az.us
                 Christine Bronston                                                               Christine Bronston
                   928-753-0714                                                                     928-753-0714
        christine.bronston@co.mohave.az.us                                               christine.bronston@co.mohave.az.us
                      7/1/2011                                                                        7/1/2011


              Discription of Charge                  Rate of Charge    Service Code


TB
Skin Test                                        $            26.00
Symptom Review Care                              $            28.00
Chest X-ray                                      $            117.00
Reproductive Health
Pregnancy Test                                   $             21.00
Condoms                                          $              1.00
Vaginits Treatment                               $             3.00
UTI Screening/Treatment                          $            48.00
Reproductive Health
Income Above 150 FPL
Annual Exam                                      $            113.00
Repeat Pap                                  $          43.00
Depo Provera Injection                      $          32.00
Oral Contraceptives                         $           5.00
IUD (Procedure Only)                        $          93.00
IUD (Procedure Only)                            Not Offered
Diaphragm                                       Not Offered
Reproductive Health
Income Below 150 FPL (see attached chart)
Sexually Transmitted Disease
STD Evaluation                                       74.00 *
STD Treatment - Add on to RH                $          19.00
STD Treatment - Bicillin                              10.00 *
STD Treatment - Other                                  4.00 *
HPV Treatment                                         41.00 *
HSV Testing (Herpes)                            Not Offered
HIV Prevention
HIV Counseling & Testing - 14 Day               Not Available
HIV Counseling & Testing - 1 Day                     94.00 *
Adult Immunizations
TD                                          $          52.00
Hepatitis A                                 $          64.00
Hepatitis B                                 $          60.00
MMR                                         $          82.00
Varicella                                   $         118.00
Manactra (meningococcal Vaccine)            $         137.00
Menomune (Meningococcal Vaccine)            $         139.00
Twinrix *Hepatitis A & B Combination)       $          78.00
Immune Globulin                                 Not Available
Rabies (Imovax)                             $         223.00
Adacel (Adult Pertussis)                    $          65.00
Influenza                                   $          32.00
Pneumonia                                   $          63.00
Hepatitis B Titer                           $          79.00
Varicella Titer                             $          85.00
Measles Mumps Rubella Titer                 $         156.00
Rabies Titer                                $         117.00
HPV Treatment                               $         167.00
Shingles                                    $         198.00
MMR VAR                                         Not Available
Imms Admin Fee - Adults                     $          29.00
NICP Program Services                             No Charge
Health Start Program Services                     No Charge
Childhood Immunization Program                    No Charge
HIV Surveillance Program                          No Charge
              Ryan White Program Services                            No Charge
              Communicable Disease Control                           No Charge
              Child Care Health Consultation                         No Charge
              Teen Pregnancy Prevention Program                      No Charge


se services offered on sliding fee scale based upon patient income          * These services offered on sliding fee scale based upon patient income
                        2/23/2012                                                                    2/22/2012

                         OTC-3465                                                                    OTC - 3466
      Mohave County Department of Public Health                                       Mohave County Department of Public Health


                2001 College Drive Suite 115                                                        20 S. Colvin
                      Lake Havasu City                                                              Colorado City
                            AZ                                                                           AZ
                          86403                                                                         86021


                                                                                                    P.O. Box 2038
                                                                                                    Colorado City
                                                                                                         AZ
                                                                                                        86021
                       928-453-0703                                                                928-875-8960
                        1740326727                                                                  1740326727




                        1740326727                                                                  1740326727
                        Patty Mead                                                                   Patty Mead
                       928-753-0743                                                                928-753-0743
                patty.mead@co.mohave.az.us                                                   patty.mead@co.mohave.az.us
                      Jennifer McNally                                                            Jennifer McNally
                       928-753-0743                                                                928-753-0743
              jennifer.mcnally@co.mohave.az.us                                             jennifer.mcnally@co.mohave.az.us
                     Christine Bronston                                                           Christine Bronston
                       928-753-0714                                                                 928-753-0714
            christine.bronston@co.mohave.az.us                                           christine.bronston@co.mohave.az.us
                         7/1/2011                                                                     7/1/2011


              Discription of Charge                  Rate of Charge    Service Code


TB
Skin Test                                        $            26.00
Symptom Review Care                              $            28.00
Chest X-ray                                      $           102.00
Reproductive Health
Pregnancy Test                                   $             21.00
Condoms                                          $              1.00
Vaginits Treatment                               $             3.00
UTI Screening/Treatment                          $            48.00
Reproductive Health
Income Above 150 FPL
Annual Exam                                      $            113.00
Repeat Pap                                  $          43.00
Depo Provera Injection                      $          32.00
Oral Contraceptives                         $           5.00
IUD (Procedure Only)                        $          93.00
IUD (Procedure Only)                            Not Offered
Diaphragm                                       Not Offered
Reproductive Health
Income Below 150 FPL (see attached chart)
Sexually Transmitted Disease
STD Evaluation                                       74.00 *
STD Treatment - Add on to RH                          19.00 *
STD Treatment - Bicillin                              10.00 *
STD Treatment - Other                                  4.00 *
HPV Treatment                                         41.00 *
HSV Testing (Herpes)                            Not Offered
HIV Prevention
HIV Counseling & Testing - 14 Day               Not Available
HIV Counseling & Testing - 1 Day                     94.00 *
Adult Immunizations
TD                                          $          52.00
Hepatitis A                                 $          64.00
Hepatitis B                                 $          60.00
MMR                                         $          82.00
Varicella                                   $         118.00
Manactra (meningococcal Vaccine)            $         137.00
Menomune (Meningococcal Vaccine)            $         139.00
Twinrix *Hepatitis A & B Combination)       $          78.00
Immune Globulin                                 Not Available
Rabies (Imovax)                             $         223.00
Adacel (Adult Pertussis)                    $          65.00
Influenza                                   $          32.00
Pneumonia                                   $          63.00
Hepatitis B Titer                           $          79.00
Varicella Titer                             $          85.00
Measles Mumps Rubella Titer                 $         156.00
Rabies Titer                                $         117.00
HPV Treatment                               $         167.00
Shingles                                    $         198.00
MMR VAR                                         Not Available
Imms Admin Fee- Adults                      $          29.00
NICP Program Services                             No Charge
Health Start Program Services                     No Charge
Childhood Immunization Program                    No Charge
HIV Surveillance Program                          No Charge
              Ryan White Program Services                             No Charge
              Communicable Disease Control                            No Charge
              Child Care Health Consultation                          No Charge
              Teen Pregnancy Prevention Program                       No Charge


ese services offered on sliding fee scale based upon patient income
                    2/22/2012                                                                    2/23/2012

                    OTC - 3466                                                                    OTC-3853
  Mohave County Department of Public Health                                       Mohave County Department of Public Health


                   20 S. Colvin                                                             700 West Beale Street
                   Colorado City                                                                   Kingman
                        AZ                                                                           AZ
                       86021                                                                        86401


                   P.O. Box 2038                                                                P.O. Box 7000
                   Colorado City                                                                   Kingman
                        AZ                                                                           AZ
                       86021                                                                       86402
                  928-875-8960                                                                  928-753-0714
                   1740326727                                                                   1740326727




                   1740326727                                                                   1740326727
                    Patty Mead                                                                   Patty Mead
                  928-753-0743                                                                 928-753-0743
            patty.mead@co.mohave.az.us                                                   patty.mead@co.mohave.az.us
                 Jennifer McNally                                                             Jennifer McNally
                  928-753-0743                                                                 928-753-0743
        jennifer.mcnally@co.mohave.az.us                                               jennifer.mcnally@co.mohave.az.us
                 Christine Bronston                                                           Christine Bronston
                   928-753-0714                                                                 928-753-0714
      christine.bronston@co.mohave.az.us                                             christine.bronston@co.mohave.az.us
                      7/1/2011                                                                    7/1/2011


            Discription of Charge              Rate of Charge      Service Code


TB
Skin Test                                  $               26.00
Symptom Review Care                        $               28.00
Chest X-ray                                $               57.00
Reproductive Health
Pregnancy Test                             $               21.00
Condoms                                    $                1.00
Adult Immunizations
TD                                         $               52.00
Hepatitis A                                $               64.00
Hepatitis B                                $               60.00
MMR                                        $               82.00
Varicella                               $               118.00
Manactra (meningococcal Vaccine)        $               137.00
Menomune (Meningococcal Vaccine)        $               139.00
Twinrix *Hepatitis A & B Combination)   $                78.00
Immune Globulin                         Not Available
Rabies (Imovax)                         $               223.00
Adacel (Adult Pertussis)                $                65.00
Influenza                               $                32.00
Pneumonia                               $                63.00
Hepatitis B Titer                       $                79.00
Varicella Titer                         $                85.00
Measles Mumps Rubella Titer             $               156.00
Rabies Titer                            $               117.00
HPV                                     $               167.00
Shingles                                $               198.00
MMR VAR                                 Not Available
Imms Cost (without vaccine)             $                29.00




Rabies Titer                            $               128.00
Childhood Immunizations                 No Charge
Communicable Disease Control            No Charge
* These services offered on sliding fee scale based upon patient income
                    2/23/2012

                    OTC-3853
 Mohave County Department of Public Health                                          North Co


              700 West Beale Street                                                   2585
                      Kingman
                        AZ
                       86401


                  P.O. Box 7000
                      Kingman
                        AZ
                       86402
                  928-753-0714
                   1740326727




                   1740326727
                   Patty Mead
                  928-753-0743
            patty.mead@co.mohave.az.us                                              aroggen
                 Jennifer McNally
                  928-753-0743
       jennifer.mcnally@co.mohave.az.us                                              jyoungb
                Christine Bronston
                  928-753-0714
     christine.bronston@co.mohave.az.us                                               kbradi
                      7/1/2011


              Discription of Charge              Rate of Charge      Service Code


TB                                                                      Code
Skin Test                                    $               26.00      10180
Symptom Review Care                          $               28.00      11040
Chest X-ray                                  $               90.00      11601
Reproductive Health                                                     11603
Pregnancy Test                               $               21.00      11976
Condoms                                      $                1.00      11981
Vaginits Treatment                           $                3.00      17260
UTI Screening/Treatment                      $               48.00      94620
Reproductive Health                                                     10040
Income Above 150 FPL                                                    10060
Annual Exam                                  $              113.00      10061
Repeat Pap                                  $                43.00   10080
Depo Provera Injection                      $                32.00   10120
Oral Contraceptives                         $                 5.00   10140
IUD (Procedure Only)                        $                93.00   10160
IUD                                         Not Offered              11004
Diaphragm                                   Not Offered              11042
Reproductive Health                                                  11055
Income Below 150 FPL (see attached chart)                            11100
Sexually Transmitted Disease                                         11101
STD Evaluation                              74.00 *                  11200
STD Treatment - Add on to RH                $                19.00   11201
STD Treatment - Bicillin                    10.00 *                  11300
STD Treatment - Other                       4.00 *                   11301
HPV Treatment                               41.00 *                  11302
HSV Testing (Herpes)                        Not Offered              11303
HIV Prevention                                                       11305
HIV Counseling & Testing - 14 Day           Not Available            11306
HIV Counseling & Testing - 1 Day            94.00 *                  11307
Adult Immunizations                                                  11310
TD                                          $                52.00   11311
Hepatitis A                                 $                64.00   11312
Hepatitis B                                 $                60.00   11313
MMR                                         $                82.00   11400
Varicella                                   $               118.00   11401
Manactra (Meningococcal vaccine)            $               137.00   11402
Menomune (Meningococcal vaccine)            $               139.00   11403
Twinrix *Hepatitis A & B Combination)       $                78.00   11404
Immune Globulin                             Not Available            11406
Rabies (Imovax)                             $               223.00   11420
Adacel (Adult Pertussis)                    $                65.00   11421
Influenza                                   $                32.00   11422
Pneumonia                                   $                63.00   11423
Hepatitis B Titer                           $                79.00   11424
Varicella Titer                             $                85.00   11426
Measles Mumps Rubella Titer                 $               156.00   11440
Rabies Titer                                $               117.00   11441
HPV Treatment                               $               167.00   11442
Shingles                                    $               198.00   11443
MMR VAR                                     Not Available            11444
Imms Admin Fee - Adults                     $                29.00   11602
NICP Program Services                       No Charge                11643
Health Start Program Services               No Charge                11719
Childhood Immunization Program              No Charge                11720
HIV Surveillance Program                    No Charge                11721
              Ryan White Program Services                       No Charge   11730
              Communicable Disease Control                      No Charge   11732
              Child Care Health Consultation                    No Charge   11740
              Teen Pregnancy Prevention Program                 No Charge   11750
rvices offered on sliding fee scale based upon patient income               11765
                                                                            11900
                                                                            11901
                                                                            12001
                                                                            12002
                                                                            12004
                                                                            12005
                                                                            12011
                                                                            12013
                                                                            12014
                                                                            12020
                                                                            12021
                                                                            12031
                                                                            12032
                                                                            12034
                                                                            12035
                                                                            12041
                                                                            12042
                                                                            12052
                                                                            15850
                                                                            15851
                                                                            16020
                                                                            16025
                                                                            16030
                                                                            17000
                                                                            17003
                                                                            17004
                                                                            17106
                                                                            17107
                                                                            17108
                                                                            17110
                                                                            17111
                                                                            17250
                                                                            19000
                                                                            19105
                                                                            19120
                                                                            20520
                                                                            20526
                                                                            20550
                                                                            20551
20552
20553
20555
20600
20605
20610
20612
23065
23071
23600
24500
24640
25028
25075
25500
25560
25600
26010
26700
26770
27603
27613
27786
29065
29075
29085
29105
29125
29126
29130
29365
29405
29425
29505
29515
29700
29705
30300
30901
36000
36410
36415
36416
36620
40800
45378
46083
46250
46600
47562
49322
49402
49505
51701
51702
54056
54115
54150
54160
54450
56420
56440
56501
56605
57061
57065
57100
57160
57170
57240
57267
57282
57288
57420
57421
57452
57454
57455
57456
57460
57461
57500
57505
57520
57522
58100
58120
58140
58150
58152
58180
58260
58262
58267
58300
58301
58350
58558
58563
58600
58605
58611
58661
58662
58670
58671
58720
58925
58940
59000
59025
59120
59150
59160
59200
59400
59409
59410
59412
59425
59426
59430
59510
59514
59515
59612
59618
59620
59812
59820
62270
64405
64435
65205
67700
69200
69210
70100
70140
70150
70160
70200
70220
70250
70260
71010
71020
71021
71022
71030
71100
71101
72020
72040
72050
72070
72200
72220
73000
73010
73020
73030
73060
73070
73080
73090
73100
73110
73120
73130
73140
73500
73510
73520
73550
73560
73562
73564
73590
73592
73600
73610
73620
73630
73650
73660
74000
74020
76010
76645
76700
76770
76801
76805
76810
76813
76815
76816
76817
76818
76819
76830
76831
76856
76857
76946
76977
86580
88112
88141
88305
88312
90460
90461
90470
90471
90472
90473
90474
90632
90633
90647
90648
90649
90655
90657
90658
90660
90669
90670
90680
90696
90698
90700
90701
90702
90703
90705
90706
90707
90708
90710
90712
90713
90714
90715
90716
90718
90720
90721
90723
90732
90733
90734
90736
90743
90744
90746
90748
92551
92552
92567
92582
92587
93000
93005
93965
94010
94150
94640
94644
94760
95115
95117
96150
96151
96152
96153
96154
97001
97002
97010
97014
97032
97035
97036
97110
97112
97116
97124
97140
97530
97802
97810
97811
98925
98926
99000
99173
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99291
99292
99354
99355
99356
99358
99359
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99420
99441
99442
99443
99460
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480
                                                               2/27/2012

                                                                OTC 4981
                                              North Country HealthCare - Bullhead City


                                                  2585 Miracle Mile Suite 114, 115, 116
                                                              Bullhead City
                                                                    AZ
                                                              86442-7553
                                                                 Mohave
                                                              PO Box 3630
                                                                Flagstaff
                                                                    AZ
                                                              86003-3630
                                                              928-704-1221
                                                              1760798680
                                                                 433079
                                                                   Yes
                                                          A: 031888; B: z70394
                                                             Ann Roggenbuck
                                                             928-774-8325
                                               aroggenbuck@northcountryhealthcare.org
                                                           Jennifer Youngberg
                                                              928-213-6162
                                                jyoungberg@northcountryhealthcare.org
                                                              Kelly Bradish
                                                              928-213-6111
                                                 kbradish@northcountryhealthcare.org
                                                               2/27/2012


                                                       Discription of Charge


Description
Incision and drainage, complex, postoperative wound infeciton
Debridement, skin, partial thickness
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0
Removal, implantable contraceptive capsules
Insertion, non-biodegradable drug delivery implant
Destruction, malignant lesion trunk, arms, legs; lesion diameter 0.5 cm or less
Pulmonary stress test/simple
Acne surgery
Incision and drainage of abscess; simple or single
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicat
Incision and drainage of pilonidal cyst; simple
Foreign Body Removal (simple)
Incision and drainage of hematoma, seroma or fluid collection
Puncture aspiration of abscess, hematoma, bulla, or cyst
Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
Debridement; skin, and subcutaneous tissue
Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); single lesion
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); each separate/
Removal of skin tags, any area, up to and including 15 lesions.
each additional 10 lesions, or part thereof (list separately in addtion to code for primary procedure)
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm
Trimming of nondystrophic nails, any number
Debridement of nail(s) by any method(s); one to five
Debridement of nail(s) by any method(s); six or more
Avulsion of nail plate, partial or complete, simple; single
Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)
Evacuation of subungual hematoma
Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal;
Wedge excision of skin of nail fold (eg for ingrown toenail)
Injection, intralesional; up to and including seven lesions
Injection, intralesional; more than seven lesions
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm
Treatment of superficial wound dehiscence; simple closure
Treatment of superficial wound dehiscence; with packing
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Removal of sutures under anesthesia (other than local), same surgeon
Removal of sutures under anesthesia (other than local), other surgeon
Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small
Dressings and/or debridement, initial or subsequent; without anesthesia, medium (eg, whole face or whole extremity)
Dressings and/or debridement, initial or subsequent; without anesthesia, large (eg, more than one extremity)
Destruction of all benign or premalignant lesions
Destruction of all benign or premalignant lesions; second through 14 lesions
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic kerat
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 - 50.0 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
Wart Removal (up to 14 lesions)
Wart Removal (15 or more)
Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)
Puncture aspiration of cyst of breast;
Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open,
Removal of foreign body in muscle or tendon sheath; simple
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
Tendon Injection
Injection; tendon origin/insertion
One or two muscle injections
Three or more muscle injections
Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent t
Small Joint Injections
Medium Joint Injections
Large Joint Injections
aspiration/inj ganlion cyst
Biopsy, soft tissue of shoulder area; superficial
Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater
Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation
Closed treatment of humeral shaft fracture; without manipulation
Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation
Incision and drainage, forearm and/or wrist; deep abscess or hematoma
Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous
Closed treatment of radial shaft fracture; without manipulation
Closed treatment of radial and ulnar shaft fractures; without manipulation
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid; without manip
Drainage of finger abscess; simple
Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia
Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia
Incision and drainage, leg or ankle; deep abscess or hematoma
Biopsy, soft tissue of leg or ankle area; superficial
Closed treatment of distal fibular fracture (lateral malleolus); without manipulation
Application, cast; shoulder to hand (long arm)
Application, cast; elbow to finger (short arm)
Application, cast; hand and lower forearm (gauntlet)
Application of long arm splint (shoulder to hand)
Application of short arm splint (forearm to hand); static
Application of short arm splint (forearm to hand); dynamic
Application of finger splint
Application of cylinder cast (thigh to ankle)
Application of short leg cast (below knee to toes);
Application of short leg cast (below knee to toes); walking or ambulatory type
Application of long leg splint (thigh to ankle or toes)
Application of short leg splint (calf to foot)
Removal or bivalving; gauntlet, boot or body cast
Cast Removal
Removal foreign body, intranasal; office type procedure
Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method
Introduction of needle or intracatheter, vein
Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes. Not to be u
Venipuncture Lab
Collection of capillary blood speciman ( eg, finger, heel, ear stick)
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous
Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon d
Incision of thrombosed hemorrhoid, external
Hemorrhoidectomy, external, complete
Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
Laparoscopy, surgical; cholecystectomy
Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)
removal of perioneal foriegn body form pertioneal cavity
Repair initial inguinal hernia, age 5 years or over; reducible
Insertion of non-indwelling bladder catheter
Insertion of temporary indwelling bladder catheter; simple
Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery
Removal foreign body from deep penile tissue (eg, plastic implant)
Circumcision, using clamp or other device; newborn
Circumcision, surgical excision other than clamp, device or dorsal slit; newborn
Foreskin manipulation including lysis of preputial adhesions and stretching
Incision and drainage of Bartholin's gland abscess
Marsupialization of Bartholin's gland cyst
Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Biopsy of vulva or perineum (separate procedure); one lesion
Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Biopsy of vaginal mucosa; simple (separate procedure)
Fitting and insertion of pessary or other intravaginal support device
Diaphragm or cervical cap fitting with instructions
Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele
Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately
Sacrospinous ligament fixation for prolapse of vagina
Sling operation for stress incontinence (eg, fascia or synthetic)
Colposcopy of the entire vagina, with cervix if present
Colposcopy with biopsy(s) of vagina/cervix
Colposcopy of the cervix including upper/adjacent vagina;
Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix
Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)
Endocervical curettage
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision
Endometrial biopsy
Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)
Myomectomy, excision of leiomyomata of uterus, single or multiple (separate procedure); abdominal approach
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystope
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
Vaginal hysterectomy, for uterus 250 g or less;
Vaginal hysterectomy; with removal of tube(s), and/or ovary(s)
Vaginal hysterectomy; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type, with or without endoscopic control)
Insertion of intrauterine device (IUD)
Removal of intrauterine device (IUD)
Chromotubation of oviduct, including materials
Polypectomy - Uterus
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate pr
Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List se
Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
Ovarian cystectomy, unilateral or bilateral
Oophorectomy, partial or total, unilateral or bilateral;
Amniocentesis; diagnostic
Fetal non-stress test
Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach
Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy
Curettage, postpartum
Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure)
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
Vaginal delivery only (with or without episiotomy and/or forceps);
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
External cephalic version, with or without tocolysis
Antepartum care only; 4-6 visits
Antepartum care only; 7 or more visits
Postpartum care only (separate procedure)
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
Cesarean delivery only;
Cesarean delivery only; including postpartum care
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarea
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;
Treatment of incomplete abortion, any trimester, completed surgically
Treatment of missed abortion, completed surgically; first trimester
Spinal puncture, lumbar, diagnostic
Injection, anesthetic agent; greater occipital nerve
Injection, anesthetic agent; paracervical (uterine) nerve
Removal of foreign body, external eye; conjunctival superficial
Blepharotomy, drainage of abscess, eyelid
Removal foreign body from external auditory canal; without general anesthesia
Removal of Impacted Cermen
Radiologic examination, mandible; partial, less than four views
Radiologic examination, facial bones; less than three views
Radiologic examination, facial bones; complete, minimum of three views
Radiologic examination, nasal bones, complete, minimum of three views
Radiologic examination; orbits, complete, minimum of four views
Radiologic examination, sinuses, paranasal, complete, minimum of three views
Radiologic examination, skull; less than four views, with or without stereo
Radiologic examination, skull; complete, minimum of four views, with or without stereo
Radiologic examination, chest; single view, frontal
Chest X-Ray
Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure
Radiologic examination, chest, two views, frontal and lateral; with oblique projections
Radiologic examination, chest, complete, minimum of four views;
Radiologic examination, ribs, unilateral; two views
Radiologic examination of ribs
Radiologic examination of spine
Radiologic examination, spine, cervical; two or three views
Radiologic examination of spine
Radiologic examination, spine; thoracic, two views
Radiologic examination, sacroiliac joints; less than three views
Radiologic examination, sacrum and coccyx, minimum of two views
Radiologic examination; clavicle, complete
Radiologic examination; scapula, complete
Radiologic examination, shoulder; one view
Radiologic examination of shoulder
Radiologic examination of humerus
Radiologic examination, elbow; two views
Radiologic examination, elbow; complete, minimum of three views
Radiologic examination of forearm
Radiologic examination, wrist; two views
Radiologic examination of wrist, min. 3 views
Radiologic examination, hand; two views
Radiologic examination of hand
Radiologic examination of finger(s)
Radiologic examination, hip, unilateral; one view
Radiologic examination of hip
Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis
Radiologic examination of femur
Radiologic examination of knee
Radiologic examination of knee
Radiologic examination, knee; complete, four or more views
Radiologic examination, tibia and fibula, 2 views
Radiologic examination; lower extremity, infant, minimum of two views
Radiologic examination, ankle; two views
Radiologic examination of ankle
Radiologic examination, foot; two views
Radiologic examination of foot
Radiologic examination; calcaneus, minimum of two views
Radiologic examination of toe(s)
Radiologic examination single view of abdomen
Radiologic examination of abdomen; multiple views
Radiologic examination from nose to rectum for foreign body, single view, child
Ultrasound, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation
Abdominal Ultrasound
Renal ultrasound
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal ap
Pregnant uterus ultrasound
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal and maternal evaluation), multiple gestation
fetal nuchal translucency measurement, first trimester
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart beat, placental location, fetal position, or em
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat
Ultrasound, pregnant uterus, real time with image documentation, transvaginal
Fetal biophysical profile; with non-stress testing
Fetal biophysical profile; without non-stress testing
Ultrasound, transvaginal
Hysterosonography
Pelvic ultrasound
Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up (eg, for follicles)
Ultrasonic guidance for amniocentesis, imaging supervision and interpretation
Ultrasound bone density measurement and interpretation, peripheral site(s), any method
TB Skin Test
Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical servic
Level IV - Surgical pathology, gross and microscopic examination Abortion - Spontaneous/Missed Artery, Biopsy Bone Marrow, Biopsy Bone Exostosis
Special stains (List separately in addition to code for surgical pathology examination); Group I for microorganisms (eg, Gridley, acid fast, methenamin
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profe
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profe
H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
Immunization administration; one vaccine
Immunization administration for multiple vaccinations
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to c
Hepatitis A vaccine (over 12 years) 0.5 ml
Hepatitis A vaccine (peds/adolescent)
Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use
Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use
Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use
Influenza virus vaccine, live, for intranasal use
Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
Rotavirus vaccine, tetravalent, live, for oral use
Diphtheria, tetanus toxoids, acellar petussis vaccine, poliovirus vaccine,inactivated (DTap-IPV) for intramuscular use
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intra
DTAP Vaccine <7 yrs old
DTP Vaccine
Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than seven years, for intramuscular use
Tetanus shot by injection
Measles virus vaccine, live, for subcutaneous or jet injection use
Rubella virus vaccine, live, for subcutaneous or jet injection use
Measles, mumps and rubella virus vaccine
Measles and rubella virus vaccine, live, for subcutaneous or jet injection use
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
Poliovirus vaccine
Poliovirus vaccine SQ/IM
Diptheria/tetanus >7 yrs old IM
Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals seven years or older, for intramuscular use
Varicella virus vaccine
Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection
Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use
Pediatrix - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscula
Pneumonia vaccine
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use
Zoster (shingles) vaccine, live, for subcutaneous injection
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
Hepatitis B vaccine (19 years and under)
Hepatitis B vaccine (20 years and older)
Hemophilus influenza B vaccine
Screening test, pure tone, air only
Pure tone audiometry (threshold): air only
Tympanometry (impedance testing)
Conditioning play audiometry
Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
Electrocardiogram, routine ECG with at least 12 leads
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other
Pulmonary Function Test
Vital capacity, total (separate procedure)
Respiratory Therapy
Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour
Pulse oximetry
Single injectionj; Professional services for allergen immunotherapy not including provision of allergenic extracts
Two or more injections; Professional services for allergen immunotherapy not including provision of allergenic extracts
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
Health and behavior intervention, each 15 minutes, face-to-face; individual
Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)
Physical therapy evaluation
Physical therapy re-evaluation
Application of a modality to one or more areas; hot or cold packs
Application of a modality to one or more areas; electrical stimulation (unattended)
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; ultrasound, each 15 minutes
Application of a modality to one or more areas; Hubbard tank, each 15 minutes
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, postur
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, perc
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 min
Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
Acupuncture, first 15 min
Acupuncture, each add'l 15 min
Osteopathic Manipulative Treatment
Osteopathic Manipulative Treatment
Spec. Handling/Trans.
Screening test of visual acuity, quantitative, bilateral
New Patient E&M Focused
New Patient E&M Expanded
New Patient E&M Detailed
New Patient E&M Moderate
New Patient E&M High Complexity
Established Patient Visit
Established Patient Visit
Established Patient Visit
Established Patient Visit
Established Patient Visit
Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge fro
Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehe
Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive histor
Initial Hospital Visit
Initial Hospital Visit
Initial Hospital Visit
Initial Hospital Visit
Subsequent Hospital Visit
Subsequent Hospital Visit
Subsequent Hospital Visit
Observation/Discharge Hospital Visit
Observation/Discharge Hospital Visit
Observation/Discharge Hospital Visit
Hospital Discharge
Hospital Discharge
Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused exam
Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded
Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and med
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
Initial inpatient consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focu
Initial inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an e
Initial inpatient consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination;
Initial inpatient consultation for a new or established patient, which requires three key components: a comprehensive history; a comprehensive exami
Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem focused history;
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detaile
Critical Care Hospital Visit
Critical Care Hospital Visit
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monit
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, comm
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, comm
Initial comprehensive preventive medicine evaluation and management of an individual; infant (age under 1 year)
Initial comprehensive preventive medicine evaluyation and management of an individual; early childhood (age 1 through 4 years)
Initial comprehensive preventivemedicine evaluation and management of an individual; age 5 through 11 years
Initial comprehensive preventive medicine evaluation and management of an individual; age 12 through 17 years
Initial comprehensive preventive medicine evaluation and management of an individual; 18-39 years.
Initial comprehensive preventive medicine evaluation and management of an individual; 40-64 years.
Initial comprehensive preventive medicine evaluation and management of an individual; 65 years and over.
Periodic comprehensive preventive medicine reevaluation and management of an individual; infant (age under 1 year)
Periodic comprehensive preventive medicine reevaluation and management of an individual; early childhood (age 1 through 4 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; late childhood (age 5 through 11 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; adolescent (age 12 through 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual; 65 years and over
Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)
Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M
11-20 minutes of medical discussion
Telephone Evaluation and Management:21-30 minutes f medical discussion
Initial hospital, per day, for evaluation and management of normal newborn infant
Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
Subsequen hospital care, per day, for evaluation and management of normal newborn
Initial hospital, per day, for evaluation and management of normal newborn infant admitted and discharged on the same day
Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn
Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventila
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 m
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of a
Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequ
Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than
Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500
Subsequent intensive care, per day, for the evaluation and management of the recovering infant (presen body weight of 2501-5000 grams)
                                                       2/23/2012

                                                        OTC 4587
                                       North Country HealthCare - Lake Havasu City


                                              2090 Smoketree Avenue North
                                                     Lake Havasu City
                                                           AZ
                                                       86403-5806
                                                         Mohave
                                                      PO Box 3630
                                                        Flagstaff
                                                           AZ
                                                       86003-3630
                                                      928-854-1800
                                                      1033359468
                                                         433079
                                                           Yes
                                                  A: 031875; B: Z70394
                                                     Ann Roggenbuck
                                                     928-774-8325
                                         aroggenbuck@northcountryhealthcare.org
                                                   Jennifer Youngberg
                                                      928-213-6162
                                          jyoungberg@northcountryhealthcare.org
                                                      Kelly Bradish
                                                      928-213-6111
                                           kbradish@northcountryhealthcare.org
                                                       2/27/2012


    Rate of Charge      Service Code


Fee                        Code
$             409.00       10180
$              64.00       11040
$             387.00       11601
$             481.00       11603
$             252.00       11976
$             233.50       11981
$             164.00       17260
$              111.00      94620
$             177.00       10040
$             190.00       10060
$             317.00       10061
$    291.00    10080
$    234.50    10120
$    269.00    10140
$    218.00    10160
$   1,022.50   11004
$     151.50   11042
$     83.50    11055
$    178.50    11100
$     57.00    11101
$    146.00    11200
$     32.50    11201
$     118.00   11300
$    160.50    11301
$    192.00    11302
$    226.00    11303
$     118.00   11305
$    164.00    11306
$    194.00    11307
$    146.00    11310
$    184.00    11311
$    214.50    11312
$    266.00    11313
$    204.50    11400
$    250.00    11401
$    278.50    11402
$    320.00    11403
$    364.00    11404
$    519.00    11406
$    203.50    11420
$    265.00    11421
$    295.00    11422
$    342.00    11423
$    393.00    11424
$    562.50    11426
$    225.00    11440
$    283.00    11441
$    319.50    11442
$    380.50    11443
$    478.50    11444
$    423.50    11602
$    550.00    11643
$     37.00    11719
$     53.50    11720
$     73.00    11721
$     164.00   11730
$     75.00    11732
$     79.50    11740
$    370.50    11750
$    233.50    11765
$     97.00    11900
$     122.50   11901
$     167.00   12001
$     196.00   12002
$    233.00    12004
$    300.00    12005
$    200.00    12011
$     215.00   12013
$    254.50    12014
$    463.00    12020
$    275.50    12021
$     419.00   12031
$    528.00    12032
$    526.50    12034
$    639.00    12035
$    437.50    12041
$     501.00   12042
$    528.50    12052
$     149.00   15850
$     163.50   15851
$     142.00   16020
$    254.50    16025
$    306.50    16030
$     139.00   17000
$      12.50   17003
$    300.50    17004
$    592.50    17106
$    769.00    17107
$   1,098.50   17108
$     189.50   17110
$    225.50    17111
$     130.50   17250
$     190.00   19000
$   3,557.00   19105
$     819.00   19120
$    334.50    20520
$     129.00   20526
$     98.00    20550
$     100.00   20551
$    91.50   20552
$   103.50   20553
$   575.50   20555
$    92.50   20600
$   101.00   20605
$   134.00   20610
$   100.50   20612
$   371.50   23065
$   740.00   23071
$   541.00   23600
$   590.00   24500
$   214.50   24640
$   888.50   25028
$   824.00   25075
$   444.00   25500
$   451.50   25560
$   485.50   25600
$   433.50   26010
$   528.00   26700
$   449.50   26770
$   915.00   27603
$   432.50   27613
$   528.00   27786
$   159.50   29065
$   149.00   29075
$   158.00   29085
$   145.00   29105
$   116.00   29125
$   132.00   29126
$    68.50   29130
$   206.00   29365
$   149.00   29405
$   159.00   29425
$   130.00   29505
$   121.00   29515
$   110.50   29700
$   113.00   29705
$   394.50   30300
$   167.50   30901
$    44.00   36000
$    32.00   36410
$    19.00   36415
$    19.00   36416
$    89.00   36620
$    356.50    40800
$    692.00    45378
$    297.00    46083
$    756.50    46250
$    143.50    46600
$   1,278.50   47562
$    642.50    49322
$   1,471.00   49402
$    886.50    49505
$    104.50    51701
$    135.00    51702
$    246.50    54056
$    816.00    54115
$    294.50    54150
$    409.00    54160
$    129.00    54450
$    217.50    56420
$    323.00    56440
$    230.00    56501
$    145.50    56605
$    200.00    57061
$    336.50    57065
$    154.50    57100
$    135.00    57160
$     114.00   57170
$   1,175.00   57240
$    459.00    57267
$    886.50    57282
$   1,259.50   57288
$    203.00    57420
$    273.50    57421
$    190.50    57452
$    240.00    57454
$    196.00    57455
$    237.50    57456
$     511.50   57460
$    575.50    57461
$    228.50    57500
$    178.50    57505
$    479.00    57520
$    428.50    57522
$    193.00    58100
$    383.50    58120
$   1,618.00   58140
$   1,753.00   58150
$   2,200.50   58152
$   1,685.00   58180
$   1,459.50   58260
$   1,628.00   58262
$   1,863.50   58267
$     126.00   58300
$     168.50   58301
$     170.50   58350
$    472.00    58558
$    607.50    58563
$    642.50    58600
$    580.50    58605
$     137.00   58611
$   1,135.00   58661
$   1,243.50   58662
$    645.00    58670
$    644.50    58671
$   1,270.00   58720
$   1,301.00   58925
$    904.50    58940
$    225.00    59000
$     82.50    59025
$   1,414.00   59120
$   1,367.50   59150
$     314.50   59160
$      81.00   59200
$   3,325.50   59400
$   1,306.50   59409
$   1,656.00   59410
$     168.50   59412
$    740.00    59425
$   1,322.50   59426
$    225.00    59430
$   3,703.00   59510
$   1,482.50   59514
$   2,006.50   59515
$   1,472.50   59612
$   3,772.00   59618
$   1,544.50   59620
$    523.00    59812
$    630.00    59820
$     271.50   62270
$     196.50   64405
$   246.50   64435
$    94.00   65205
$   442.50   67700
$   214.00   69200
$    87.50   69210
$    58.00   70100
$    53.50   70140
$    75.50   70150
$    58.00   70160
$    78.00   70200
$    68.50   70220
$    65.50   70250
$    83.00   70260
$    41.50   71010
$    54.50   71020
$    67.00   71021
$    82.00   71022
$    81.50   71030
$    57.00   71100
$    69.50   71101
$    42.00   72020
$    69.00   72040
$    93.00   72050
$    60.00   72070
$    52.50   72200
$    51.50   72220
$    50.50   73000
$    54.00   73010
$    41.50   73020
$    54.50   73030
$    51.50   73060
$    50.00   73070
$    60.00   73080
$    49.50   73090
$    54.50   73100
$    64.00   73110
$    48.50   73120
$    56.50   73130
$    55.00   73140
$    47.50   73500
$    68.50   73510
$    72.00   73520
$    50.50   73550
$    54.00   73560
$    64.50   73562
$    74.00   73564
$    48.50   73590
$    54.50   73592
$    50.00   73600
$    57.00   73610
$    48.00   73620
$    56.00   73630
$    49.50   73650
$    51.50   73660
$    44.00   74000
$    70.50   74020
$    48.50   76010
$   168.50   76645
$   247.00   76700
$   234.50   76770
$   228.50   76801
$   262.00   76805
$   171.50   76810
$   222.50   76813
$   160.50   76815
$   205.50   76816
$   181.50   76817
$   215.00   76818
$   161.50   76819
$   219.50   76830
$   220.50   76831
$   219.00   76856
$   178.00   76857
$    66.50   76946
$    18.50   76977
$    13.00   86580
$   179.50   88112
$    50.50   88141
$   185.50   88305
$   186.50   88312
$    40.50   90460
$    20.00   90461
$    35.50   90470
$    40.50   90471
$    20.00   90472
$    40.50   90473
$    20.00   90474
$    26.00   90632
$    74.00   90633
$    25.00   90647
$   106.00   90648
$   160.00   90649
$    21.00   90655
$    22.00   90657
$    25.00   90658
$    25.00   90660
$   113.00   90669
$   141.00   90670
$   115.00   90680
$    43.00   90696
$    67.00   90698
$    36.00   90700
$    45.00   90701
$    31.00   90702
$    26.00   90703
$    46.00   90705
$    47.00   90706
$    62.00   90707
$    64.00   90708
$    73.00   90710
$    41.00   90712
$    48.00   90713
$    31.00   90714
$    49.00   90715
$    95.00   90716
$    29.00   90718
$    52.00   90720
$    65.00   90721
$    88.00   90723
$    49.00   90732
$   114.00   90733
$   133.00   90734
$   268.00   90736
$    81.00   90743
$   103.00   90744
$    67.00   90746
$    89.00   90748
$    20.00   92551
$    44.50   92552
$    26.50   92567
$    89.50   92582
$    64.50   92587
$    34.50   93000
$    19.00   93005
$   221.50   93965
$    62.00   94010
$    42.00   94150
$    28.00   94640
$    70.00   94644
$     5.00   94760
$    18.00   95115
$    22.00   95117
$    37.00   96150
$    35.50   96151
$    34.00   96152
$     8.50   96153
$    33.50   96154
$   126.50   97001
$    70.00   97002
$     9.50   97010
$    25.50   97014
$    31.00   97032
$    21.00   97035
$    51.00   97036
$    51.50   97110
$    54.00   97112
$    45.50   97116
$    42.00   97124
$    48.50   97140
$    56.50   97530
$    56.00   97802
$    62.50   97810
$    47.50   97811
$    53.00   98925
$    70.50   98926
$    43.00   99000
$     5.00   99173
$    72.00   99201
$   124.00   99202
$   180.00   99203
$   276.50   99204
$   344.50   99205
$    34.50   99211
$    72.50   99212
$   120.50   99213
$   178.50   99214
$   240.50   99215
$   121.00   99217
$   112.00   99218
$   187.50   99219
$   262.50   99220
$   170.00   99221
$   231.00   99222
$   339.00   99223
$    67.00   99231
$   121.00   99232
$   174.00   99233
$   230.00   99234
$   301.00   99235
$   374.00   99236
$   120.50   99238
$   177.00   99239
$    56.50   99241
$   118.00   99242
$   164.50   99243
$   309.00   99244
$   377.50   99245
$    82.50   99251
$   127.00   99252
$   193.50   99253
$   279.00   99254
$   337.50   99255
$    36.00   99281
$    70.50   99282
$   107.00   99283
$   202.00   99284
$   379.50   99291
$   190.50   99292
$   167.00   99354
$   165.00   99355
$   152.50   99356
$   188.00   99358
$    91.00   99359
$   105.50   99381
$   177.50   99382
$   177.00   99383
$   192.50   99384
$   192.50   99385
$   224.00   99386
$   247.00   99387
$    138.50    99391
$    154.00    99392
$    153.00    99393
$    167.50    99394
$    168.00    99395
$    183.50    99396
$    206.50    99397
$     18.00    99420
$     24.50    99441
$     46.50    99442
$     68.50    99443
$     101.00   99460
$    159.00    99461
$     54.50    99462
$    138.50    99463
$    125.50    99464
$    242.50    99465
$    462.50    99466
$    207.00    99467
$   1,570.50   99468
$    684.00    99469
$   1,353.50   99471
$    681.00    99472
$    956.50    99475
$    579.50    99476
$    604.00    99477
$    240.00    99478
$    220.50    99479
$    205.50    99480
                                                 2/23/2012

                                                 OTC 4587
                             North Country HealthCare - Lake Havasu City


                                       2090 Smoketree Avenue North
                                              Lake Havasu City
                                                     AZ
                                                86403-5806
                                                   Mohave
                                                PO Box 3630
                                                  Flagstaff
                                                     AZ
                                                86003-3630
                                               928-854-1800
                                                1033359468
                                                   433079
                                                     Yes
                                           A: 031875; B: Z70394
                                              Ann Roggenbuck
                                               928-774-8325
                                 aroggenbuck@northcountryhealthcare.org
                                            Jennifer Youngberg
                                               928-213-6162
                                 jyoungberg@northcountryhealthcare.org
                                                Kelly Bradish
                                                928-213-6111
                                  kbradish@northcountryhealthcare.org
                                                 2/27/2012


                                        Discription of Charge                                             Rate of Charge


Description                                                                                         Fee
Incision and drainage, complex, postoperative wound infeciton                                       $                409.00
Debridement, skin, partial thickness                                                                $                  64.00
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0                        $                387.00
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0                        $                 481.00
Removal, implantable contraceptive capsules                                                         $                252.00
Insertion, non-biodegradable drug delivery implant                                                  $                233.50
Destruction, malignant lesion trunk, arms, legs; lesion diameter 0.5 cm or less                     $                 164.00
Pulmonary stress test/simple                                                                        $                  111.00
Acne surgery                                                                                        $                 177.00
Incision and drainage of abscess; simple or single                                                  $                 190.00
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous$                 317.00
                                                                                                     abscess, cyst, furuncle, or paronychia); complicat
Incision and drainage of pilonidal cyst; simple                                                         $                  291.00
Foreign Body Removal (simple)                                                                           $                  234.50
Incision and drainage of hematoma, seroma or fluid collection                                           $                  269.00
Puncture aspiration of abscess, hematoma, bulla, or cyst                                                $                  218.00
                                                                                                    $                1,022.50
Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
Debridement; skin, and subcutaneous tissue                                                              $                  151.50
Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion                   $                   83.50
                                                                                                   $                 178.50
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); single lesion
                                                                                                   $                  57.00
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); each separate/
Removal of skin tags, any area, up to and including 15 lesions.                                         $                  146.00
each additional 10 lesions, or part thereof (list separately in addtion to code for primary procedure) $                    32.50
                                                                                                       $
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less                  118.00
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm$                  160.50
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm$                  192.00
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm $                   226.00
                                                                                                         $
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 118.00
                                                                                                         $
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm   164.00
                                                                                                         $
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm   194.00
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane;$                146.00
                                                                                                        lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane;$                184.00
                                                                                                        lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane;$                 214.50
                                                                                                        lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane;$                266.00
                                                                                                        lesion diameter over 2.0 cm
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less 204.50
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm     250.00
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm     278.50
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm     320.00
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm     364.00
                                                                                                       $
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm       519.00
                                                                                                          $               203.50
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
                                                                                                          $               265.00
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
                                                                                                          $                295.00
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
                                                                                                          $               342.00
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
                                                                                                          $               393.00
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
                                                                                                          $               562.50
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm
                                                                                                       $                225.00
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
                                                                                                       $                283.00
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
                                                                                                       $                319.50
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
                                                                                                       $                380.50
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
                                                                                                       $                478.50
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm                         $                  423.50
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm              $                  550.00
Trimming of nondystrophic nails, any number                                                             $                   37.00
Debridement of nail(s) by any method(s); one to five                                                    $                   53.50
Debridement of nail(s) by any method(s); six or more                                                    $                   73.00
Avulsion of nail plate, partial or complete, simple; single                                             $                 164.00
                                                                                                           $                 75.00
Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)
Evacuation of subungual hematoma                                                                        $                  79.50
                                                                                                      $
Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal;             370.50
Wedge excision of skin of nail fold (eg for ingrown toenail)                                            $                233.50
Injection, intralesional; up to and including seven lesions                                             $                  97.00
Injection, intralesional; more than seven lesions                                                       $                 122.50
                                                                                                       $                 167.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
                                                                                                       $                 196.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
                                                                                                       $                 233.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
                                                                                                       $                 300.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm
                                                                                                     $
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less           200.00
                                                                                                     $
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm          215.00
                                                                                                     $
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm         254.50
Treatment of superficial wound dehiscence; simple closure                                               $                463.00
Treatment of superficial wound dehiscence; with packing                                                 $                275.50
                                                                                                     $
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less            419.00
                                                                                                     $
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm         528.00
                                                                                                     $
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm        526.50
                                                                                                     $
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm       639.00
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less                  $                437.50
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm                $                 501.00
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm$                    528.50
Removal of sutures under anesthesia (other than local), same surgeon                                    $                 149.00
Removal of sutures under anesthesia (other than local), other surgeon                                   $                 163.50
Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small      $                 142.00
                                                                                                   $
Dressings and/or debridement, initial or subsequent; without anesthesia, medium (eg, whole face or whole extremity)254.50
                                                                                                    $
Dressings and/or debridement, initial or subsequent; without anesthesia, large (eg, more than one extremity)             306.50
Destruction of all benign or premalignant lesions                                                       $                 139.00
Destruction of all benign or premalignant lesions; second through 14 lesions                            $                  12.50
                                                                                                   $                300.50
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic kerat
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm       $                592.50
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 - 50.0 sq cm        $                769.00
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm          $               1,098.50
Wart Removal (up to 14 lesions)                                                                         $                 189.50
Wart Removal (15 or more)                                                                               $                225.50
Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)                            $                 130.50
Puncture aspiration of cyst of breast;                                                                  $                 190.00
Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma               $              3,557.00
                                                                                                    $                  819.00
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open,
Removal of foreign body in muscle or tendon sheath; simple                                              $                334.50
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel                            $                 129.00
Tendon Injection                                                                                        $                  98.00
Injection; tendon origin/insertion                                                                      $                 100.00
One or two muscle injections                                                                         $                  91.50
Three or more muscle injections                                                                      $                 103.50
                                                                                                    $                 (at the
Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application575.50 time of or subsequent t
Small Joint Injections                                                                               $                  92.50
Medium Joint Injections                                                                              $                 101.00
Large Joint Injections                                                                               $                 134.00
aspiration/inj ganlion cyst                                                                          $                 100.50
Biopsy, soft tissue of shoulder area; superficial                                                    $                 371.50
Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater                         $                740.00
Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation    $                 541.00
Closed treatment of humeral shaft fracture; without manipulation                                     $                590.00
Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation             $                 214.50
Incision and drainage, forearm and/or wrist; deep abscess or hematoma                                $                888.50
Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous                              $                824.00
Closed treatment of radial shaft fracture; without manipulation                                      $                444.00
Closed treatment of radial and ulnar shaft fractures; without manipulation                           $                 451.50
                                                                                                      $               485.50
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid; without manip
Drainage of finger abscess; simple                                                                   $                433.50
Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia $                  528.00
Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia $                449.50
Incision and drainage, leg or ankle; deep abscess or hematoma                                        $                 915.00
Biopsy, soft tissue of leg or ankle area; superficial                                                $                432.50
Closed treatment of distal fibular fracture (lateral malleolus); without manipulation                $                528.00
Application, cast; shoulder to hand (long arm)                                                       $                 159.50
Application, cast; elbow to finger (short arm)                                                       $                 149.00
Application, cast; hand and lower forearm (gauntlet)                                                 $                 158.00
Application of long arm splint (shoulder to hand)                                                    $                 145.00
Application of short arm splint (forearm to hand); static                                            $                 116.00
Application of short arm splint (forearm to hand); dynamic                                           $                 132.00
Application of finger splint                                                                         $                  68.50
Application of cylinder cast (thigh to ankle)                                                        $                206.00
Application of short leg cast (below knee to toes);                                                  $                 149.00
Application of short leg cast (below knee to toes); walking or ambulatory type                       $                 159.00
Application of long leg splint (thigh to ankle or toes)                                              $                 130.00
Application of short leg splint (calf to foot)                                                       $                 121.00
Removal or bivalving; gauntlet, boot or body cast                                                    $                 110.50
Cast Removal                                                                                         $                 113.00
Removal foreign body, intranasal; office type procedure                                              $                394.50
Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method               $                 167.50
Introduction of needle or intracatheter, vein                                                        $                  44.00
                                                                                                       $                 32.00
Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes. Not to be u
Venipuncture Lab                                                                                     $                  19.00
Collection of capillary blood speciman ( eg, finger, heel, ear stick)                                $                  19.00
                                                                                                    $
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous      89.00
Drainage of abscess, cyst, hematoma, vestibule of mouth; simple                                        $                356.50
                                                                                                       $                 washing,
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or692.00 with or without colon d
Incision of thrombosed hemorrhoid, external                                                            $                297.00
Hemorrhoidectomy, external, complete                                                                   $                756.50
                                                                                                    $
Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)             143.50
Laparoscopy, surgical; cholecystectomy                                                                 $              1,278.50
Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)       $                642.50
removal of perioneal foriegn body form pertioneal cavity                                               $               1,471.00
Repair initial inguinal hernia, age 5 years or over; reducible                                         $                886.50
Insertion of non-indwelling bladder catheter                                                           $                104.50
Insertion of temporary indwelling bladder catheter; simple                                             $                135.00
                                                                                                       $               2
Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery 46.50
Removal foreign body from deep penile tissue (eg, plastic implant)                                     $                816.00
Circumcision, using clamp or other device; newborn                                                     $                294.50
Circumcision, surgical excision other than clamp, device or dorsal slit; newborn                       $                409.00
Foreskin manipulation including lysis of preputial adhesions and stretching                            $                129.00
Incision and drainage of Bartholin's gland abscess                                                     $                217.50
Marsupialization of Bartholin's gland cyst                                                             $                323.00
                                                                                                     $
Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)                  230.00
Biopsy of vulva or perineum (separate procedure); one lesion                                           $                145.50
                                                                                                     $
Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)                 200.00
                                                                                                     $
Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)              336.50
Biopsy of vaginal mucosa; simple (separate procedure)                                                  $                154.50
Fitting and insertion of pessary or other intravaginal support device                                  $                135.00
Diaphragm or cervical cap fitting with instructions                                                    $                 114.00
Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele                       $               1,175.00
                                                                                                      $               vaginal
Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), 459.00 approach (List separately
Sacrospinous ligament fixation for prolapse of vagina                                                  $                886.50
Sling operation for stress incontinence (eg, fascia or synthetic)                                      $              1,259.50
Colposcopy of the entire vagina, with cervix if present                                                $                203.00
Colposcopy with biopsy(s) of vagina/cervix                                                             $                273.50
Colposcopy of the cervix including upper/adjacent vagina;                                              $                190.50
Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage                   $                240.00
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix                 $                196.00
Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage                  $                237.50
Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix                         $                 511.50
                                                                                                     $
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix                  575.50
                                                                                                        $
Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)               228.50
Endocervical curettage                                                                                 $                178.50
                                                                                                      $                 479.00
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser
                                                                                                      $                 428.50
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision
Endometrial biopsy                                                                                     $                193.00
Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)                                 $                383.50
                                                                                                  $
Myomectomy, excision of leiomyomata of uterus, single or multiple (separate procedure); abdominal approach             1,618.00
                                                                                                   $              1,753.00
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
                                                                                                   $              2,200.50
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystope
                                                                                                  with or without1,685.00 of ovary(s)
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), $               removal
Vaginal hysterectomy, for uterus 250 g or less;                                                        $              1,459.50
Vaginal hysterectomy; with removal of tube(s), and/or ovary(s)                                         $              1,628.00
                                                                                                 with or without1,863.50
Vaginal hysterectomy; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type, $               endoscopic control)
Insertion of intrauterine device (IUD)                                                                 $                126.00
Removal of intrauterine device (IUD)                                                                   $                168.50
Chromotubation of oviduct, including materials                                                         $                170.50
Polypectomy - Uterus                                                                                   $                472.00
                                                                                                     $                6
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) 07.50
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral   $                642.50
                                                                                                       $                  580.50
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate pr
                                                                                                     $                137.00
Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List se
                                                                                                    $
Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)         1,135.00
                                                                                                        $               1,243.50
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
Laparoscopy, surgical; with fulguration of oviducts (with or without transection)                      $                645.00
Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)           $                644.50
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)               $              1,270.00
Ovarian cystectomy, unilateral or bilateral                                                            $               1,301.00
Oophorectomy, partial or total, unilateral or bilateral;                                               $                904.50
Amniocentesis; diagnostic                                                                              $                225.00
Fetal non-stress test                                                                                  $                 82.50
                                                                                                   $              1,414.00
Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach
Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy                 $              1,367.50
Curettage, postpartum                                                                                  $                314.50
Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure)                      $                  81.00
                                                                                                     $              postpartum care
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and 3,325.50
Vaginal delivery only (with or without episiotomy and/or forceps);                                     $              1,306.50
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care           $              1,656.00
External cephalic version, with or without tocolysis                                                   $                168.50
Antepartum care only; 4-6 visits                                                                       $                740.00
Antepartum care only; 7 or more visits                                                                 $              1,322.50
Postpartum care only (separate procedure)                                                              $                225.00
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care               $              3,703.00
Cesarean delivery only;                                                                                $              1,482.50
Cesarean delivery only; including postpartum care                                                      $              2,006.50
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); $                1,472.50
                                                                                                    $             3,772.00
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarea
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;         $              1,544.50
Treatment of incomplete abortion, any trimester, completed surgically                                  $                523.00
Treatment of missed abortion, completed surgically; first trimester                                    $                630.00
Spinal puncture, lumbar, diagnostic                                                                    $                271.50
Injection, anesthetic agent; greater occipital nerve                                                   $                196.50
Injection, anesthetic agent; paracervical (uterine) nerve                                             $               246.50
Removal of foreign body, external eye; conjunctival superficial                                       $                94.00
Blepharotomy, drainage of abscess, eyelid                                                             $               442.50
Removal foreign body from external auditory canal; without general anesthesia                         $               214.00
Removal of Impacted Cermen                                                                            $                87.50
Radiologic examination, mandible; partial, less than four views                                       $                58.00
Radiologic examination, facial bones; less than three views                                           $                53.50
Radiologic examination, facial bones; complete, minimum of three views                                $                75.50
Radiologic examination, nasal bones, complete, minimum of three views                                 $                58.00
Radiologic examination; orbits, complete, minimum of four views                                       $                78.00
Radiologic examination, sinuses, paranasal, complete, minimum of three views                          $                68.50
Radiologic examination, skull; less than four views, with or without stereo                           $                65.50
Radiologic examination, skull; complete, minimum of four views, with or without stereo                $                83.00
Radiologic examination, chest; single view, frontal                                                   $                41.50
Chest X-Ray                                                                                           $                54.50
Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure         $                67.00
Radiologic examination, chest, two views, frontal and lateral; with oblique projections               $                82.00
Radiologic examination, chest, complete, minimum of four views;                                       $                81.50
Radiologic examination, ribs, unilateral; two views                                                   $                57.00
Radiologic examination of ribs                                                                        $                69.50
Radiologic examination of spine                                                                       $                42.00
Radiologic examination, spine, cervical; two or three views                                           $                69.00
Radiologic examination of spine                                                                       $                93.00
Radiologic examination, spine; thoracic, two views                                                    $                60.00
Radiologic examination, sacroiliac joints; less than three views                                      $                52.50
Radiologic examination, sacrum and coccyx, minimum of two views                                       $                51.50
Radiologic examination; clavicle, complete                                                            $                50.50
Radiologic examination; scapula, complete                                                             $                54.00
Radiologic examination, shoulder; one view                                                            $                41.50
Radiologic examination of shoulder                                                                    $                54.50
Radiologic examination of humerus                                                                     $                51.50
Radiologic examination, elbow; two views                                                              $                50.00
Radiologic examination, elbow; complete, minimum of three views                                       $                60.00
Radiologic examination of forearm                                                                     $                49.50
Radiologic examination, wrist; two views                                                              $                54.50
Radiologic examination of wrist, min. 3 views                                                         $                64.00
Radiologic examination, hand; two views                                                               $                48.50
Radiologic examination of hand                                                                        $                56.50
Radiologic examination of finger(s)                                                                   $                55.00
Radiologic examination, hip, unilateral; one view                                                     $                47.50
Radiologic examination of hip                                                                         $                68.50
                                                                                                      $
Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis    72.00
Radiologic examination of femur                                                                       $                50.50
Radiologic examination of knee                                                                        $                54.00
Radiologic examination of knee                                                                        $                  64.50
Radiologic examination, knee; complete, four or more views                                            $                  74.00
Radiologic examination, tibia and fibula, 2 views                                                     $                  48.50
Radiologic examination; lower extremity, infant, minimum of two views                                 $                  54.50
Radiologic examination, ankle; two views                                                              $                  50.00
Radiologic examination of ankle                                                                       $                  57.00
Radiologic examination, foot; two views                                                               $                  48.00
Radiologic examination of foot                                                                        $                  56.00
Radiologic examination; calcaneus, minimum of two views                                               $                  49.50
Radiologic examination of toe(s)                                                                      $                  51.50
Radiologic examination single view of abdomen                                                         $                  44.00
Radiologic examination of abdomen; multiple views                                                     $                  70.50
Radiologic examination from nose to rectum for foreign body, single view, child                       $                  48.50
Ultrasound, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation     $                 168.50
Abdominal Ultrasound                                                                                  $                 247.00
Renal ultrasound                                                                                      $                 234.50
                                                                                                    $                228.50
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal ap
Pregnant uterus ultrasound                                                                            $                 262.00
                                                                                                  fetal and maternal evaluation), multiple gestation
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete (complete $               171.50
fetal nuchal translucency measurement, first trimester                                                $                 222.50
                                                                                                    $                 160.50
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart beat, placental location, fetal position, or em
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat $                    205.50
Ultrasound, pregnant uterus, real time with image documentation, transvaginal                         $                  181.50
Fetal biophysical profile; with non-stress testing                                                    $                 215.00
Fetal biophysical profile; without non-stress testing                                                 $                  161.50
Ultrasound, transvaginal                                                                              $                 219.50
Hysterosonography                                                                                     $                 220.50
Pelvic ultrasound                                                                                     $                 219.00
                                                                                                     $                  178.00
Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up (eg, for follicles)
Ultrasonic guidance for amniocentesis, imaging supervision and interpretation                         $                  66.50
Ultrasound bone density measurement and interpretation, peripheral site(s), any method                $                  18.50
TB Skin Test                                                                                          $                  13.00
                                                                                                     $               179.50
Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
                                                                                                       separately in addition to code for technical servic
Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List $                  50.50
                                                                                                 $                 Marrow,
Level IV - Surgical pathology, gross and microscopic examination Abortion - Spontaneous/Missed Artery, Biopsy Bone 185.50 Biopsy Bone Exostosis
                                                                                                      $                186.50
Special stains (List separately in addition to code for surgical pathology examination); Group I for microorganisms (eg, Gridley, acid fast, methenamin
                                                                                                                       40.50
Immunization administration through 18 years of age via any route of administration, with counseling$by physician or other qualified health care profe
                                                                                                                       20.00
Immunization administration through 18 years of age via any route of administration, with counseling$by physician or other qualified health care profe
H1N1 immunization administration (intramuscular, intranasal), including counseling when performed $                      35.50
Immunization administration; one vaccine                                                              $                  40.50
Immunization administration for multiple vaccinations                                                 $                  20.00
                                                                                                     $
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)              40.50
                                                                                                      $                 20.00
Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to c
Hepatitis A vaccine (over 12 years) 0.5 ml                                                            $                  26.00
Hepatitis A vaccine (peds/adolescent)                                                                 $                 74.00
Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use $                      25.00
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use        $                106.00
                                                                                                      $
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use        160.00
                                                                                                      $
Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use          21.00
Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use      $                 22.00
Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use $                25.00
Influenza virus vaccine, live, for intranasal use                                                     $                 25.00
Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use      $                 113.00
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use                                      $                 141.00
Rotavirus vaccine, tetravalent, live, for oral use                                                    $                 115.00
                                                                                                       $
Diphtheria, tetanus toxoids, acellar petussis vaccine, poliovirus vaccine,inactivated (DTap-IPV) for intramuscular use 43.00
                                                                                                      vaccine, inactivated (DTaP - Hib - IPV), for intra
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus$                 67.00
DTAP Vaccine <7 yrs old                                                                               $                 36.00
DTP Vaccine                                                                                           $                 45.00
                                                                                                    $
Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than seven years, for intramuscular use      31.00
Tetanus shot by injection                                                                             $                 26.00
Measles virus vaccine, live, for subcutaneous or jet injection use                                    $                 46.00
Rubella virus vaccine, live, for subcutaneous or jet injection use                                    $                 47.00
Measles, mumps and rubella virus vaccine                                                              $                 62.00
Measles and rubella virus vaccine, live, for subcutaneous or jet injection use                        $                 64.00
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use                     $                 73.00
Poliovirus vaccine                                                                                    $                  41.00
Poliovirus vaccine SQ/IM                                                                              $                 48.00
Diptheria/tetanus >7 yrs old IM                                                                       $                  31.00
                                                                                                       or                49.00
Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals seven years $ older, for intramuscular use
Varicella virus vaccine                                                                               $                 95.00
                                                                                                    $                   29.00
Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection
                                                                                                    $                 52.00
Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
                                                                                                    $                  65.00
Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use
                                                                                                        $                  88.00
Pediatrix - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscula
Pneumonia vaccine                                                                                     $                 49.00
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use            $                 114.00
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use $                   133.00
Zoster (shingles) vaccine, live, for subcutaneous injection                                           $                268.00
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use                              $                  81.00
Hepatitis B vaccine (19 years and under)                                                              $                103.00
Hepatitis B vaccine (20 years and older)                                                              $                 67.00
Hemophilus influenza B vaccine                                                                        $                 89.00
Screening test, pure tone, air only                                                                   $                 20.00
Pure tone audiometry (threshold): air only                                                            $                 44.50
Tympanometry (impedance testing)                                                                      $                 26.50
Conditioning play audiometry                                                                          $                 89.50
Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) $                64.50
Electrocardiogram, routine ECG with at least 12 leads                                                 $                 34.50
                                                                                                     $
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report                  19.00
                                                                                                    analysis with responses to compression and other
Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform $                221.50
Pulmonary Function Test                                                                               $                 62.00
Vital capacity, total (separate procedure)                                                            $                 42.00
Respiratory Therapy                                                                                   $                 28.00
Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour      $                 70.00
Pulse oximetry                                                                                        $                  5.00
                                                                                                      $
Single injectionj; Professional services for allergen immunotherapy not including provision of allergenic extracts      18.00
                                                                                                     $
Two or more injections; Professional services for allergen immunotherapy not including provision of allergenic extracts22.00
                                                                                                    $                 37.00
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
                                                                                                    $                 35.50
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
Health and behavior intervention, each 15 minutes, face-to-face; individual                           $                 34.00
Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)           $                  8.50
Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) $                    33.50
Physical therapy evaluation                                                                           $                126.50
Physical therapy re-evaluation                                                                        $                 70.00
Application of a modality to one or more areas; hot or cold packs                                     $                  9.50
Application of a modality to one or more areas; electrical stimulation (unattended)                   $                 25.50
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes      $                 31.00
Application of a modality to one or more areas; ultrasound, each 15 minutes                           $                 21.00
Application of a modality to one or more areas; Hubbard tank, each 15 minutes                         $                 51.00
                                                                                                  $                 range
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, 51.50 of motion and flexibility
                                                                                                $                  54.00
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, postur
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)    $                 45.50
                                                                                                   $               42.00
Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, perc
                                                                                                    $                 48.50
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
                                                                                                     $                  56.50
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 min
                                                                                                       $                 56.00
Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
Acupuncture, first 15 min                                                                             $                 62.50
Acupuncture, each add'l 15 min                                                                        $                 47.50
Osteopathic Manipulative Treatment                                                                    $                 53.00
Osteopathic Manipulative Treatment                                                                    $                 70.50
Spec. Handling/Trans.                                                                                 $                 43.00
Screening test of visual acuity, quantitative, bilateral                                              $                  5.00
New Patient E&M Focused                                                                               $                 72.00
New Patient E&M Expanded                                                                              $                124.00
New Patient E&M Detailed                                                                              $                180.00
New Patient E&M Moderate                                                                              $               276.50
New Patient E&M High Complexity                                                                       $               344.50
Established Patient Visit                                                                             $                 34.50
Established Patient Visit                                                                             $                 72.50
Established Patient Visit                                                                             $                120.50
Established Patient Visit                                                                             $                178.50
Established Patient Visit                                                                            $                 240.50
                                                                                                   $                 121.00
Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge fro
                                                                                                    $                112.00
Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehe
                                                                                                     $               187.50
Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive histor
Initial Hospital Visit                                                                               $                 262.50
Initial Hospital Visit                                                                               $                 170.00
Initial Hospital Visit                                                                               $                 231.00
Initial Hospital Visit                                                                               $                 339.00
Subsequent Hospital Visit                                                                            $                  67.00
Subsequent Hospital Visit                                                                            $                 121.00
Subsequent Hospital Visit                                                                            $                 174.00
Observation/Discharge Hospital Visit                                                                 $                 230.00
Observation/Discharge Hospital Visit                                                                 $                 301.00
Observation/Discharge Hospital Visit                                                                 $                 374.00
Hospital Discharge                                                                                   $                 120.50
Hospital Discharge                                                                                   $                 177.00
                                                                                                   $                56.50
Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused exam
Office consultation for a new or established patient, which requires these three key components: an$               118.00
                                                                                                    expanded problem focused history; an expanded
                                                                                                   $                 164.50
Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and med
                                                                                                   $               309.00
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
                                                                                                   $               377.50
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
                                                                                                     $                 82.50
Initial inpatient consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focu
                                                                                                     $               127.00
Initial inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an e
                                                                                                     $                 history;
Initial inpatient consultation for a new or established patient, which requires these three key components: a detailed 193.50 a detailed examination;
                                                                                                      a              history;
Initial inpatient consultation for a new or established patient, which requires three key components:$ comprehensive279.00 a comprehensive exami
                                                                                                     $               337.50
Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive
                                                                                                 $                36.00
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem focused history;
                                                                                                 $                70.50
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
                                                                                                 $               107.00
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
                                                                                                 $               202.00
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detaile
Critical Care Hospital Visit                                                                         $                 379.50
Critical Care Hospital Visit                                                                         $                 190.50
                                                                                                      patient contact beyond the usual service (eg, pro
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) $                167.00
                                                                                                      patient contact beyond the usual service (eg, pro
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) $                165.00
                                                                                                      $                 152.50
Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monit
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care$                 188.00
                                                                                                   (eg, review of extensive records and tests, comm
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care$                  91.00
                                                                                                   (eg, review of extensive records and tests, comm
                                                                                                    $
Initial comprehensive preventive medicine evaluation and management of an individual; infant (age under 1 year)        105.50
                                                                                                    $                 4 years)
Initial comprehensive preventive medicine evaluyation and management of an individual; early childhood (age 1 through177.50
                                                                                                   11
Initial comprehensive preventivemedicine evaluation and management of an individual; age 5 through $ years             177.00
                                                                                                   $
Initial comprehensive preventive medicine evaluation and management of an individual; age 12 through 17 years          192.50
Initial comprehensive preventive medicine evaluation and management of an individual; 18-39 years. $                   192.50
Initial comprehensive preventive medicine evaluation and management of an individual; 40-64 years. $                   224.00
                                                                                                   $
Initial comprehensive preventive medicine evaluation and management of an individual; 65 years and over.               247.00
                                                                                                   $
Periodic comprehensive preventive medicine reevaluation and management of an individual; infant (age under 1 year)          138.50
                                                                                                   $                154.00
Periodic comprehensive preventive medicine reevaluation and management of an individual; early childhood (age 1 through 4 years)
                                                                                                   $                153.00
Periodic comprehensive preventive medicine reevaluation and management of an individual; late childhood (age 5 through 11 years)
                                                                                                  $                 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; adolescent (age 12 through167.50
                                                                                                  $
Periodic comprehensive preventive medicine reevaluation and management of an individual; 18-39 years                        168.00
                                                                                                  $
Periodic comprehensive preventive medicine reevaluation and management of an individual; 40-64 years                        183.50
                                                                                                  $
Periodic comprehensive preventive medicine reevaluation and management of an individual; 65 years and over                  206.50
                                                                                                   $
Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)                          18.00
                                                                                                   $                 24.50
Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M
11-20 minutes of medical discussion                                                                       $                  46.50
Telephone Evaluation and Management:21-30 minutes f medical discussion                                    $                  68.50
Initial hospital, per day, for evaluation and management of normal newborn infant                         $                  101.00
                                                                                                    $                 159.00
Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
Subsequen hospital care, per day, for evaluation and management of normal newborn                         $                  54.50
                                                                                                   $                138.50
Initial hospital, per day, for evaluation and management of normal newborn infant admitted and discharged on the same day
                                                                                                     $
Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn                    125.50
                                                                                                    $                 242.50
Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventila
                                                                                                        $                    462.50
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
                                                                                                        $                    207.00
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
                                                                                                          $              1,570.50
Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
                                                                                                     $                  684.00
Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
                                                                                                          $               child, 29
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young 1,353.50 days through 24 months
                                                                                                     $                   681.00
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 m
                                                                                                          $                956.50
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
                                                                                                     $                   579.50
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of a
                                                                                                     $               604.00
Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequ
                                                                                                  $                240.00
Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than
                                                                                                  $                 220.50
Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500
                                                                                                  $                of 2501-5000 grams)
Subsequent intensive care, per day, for the evaluation and management of the recovering infant (presen body weight205.50
                             2/23/2012

                             OTC-4413
                North Country HealthCare - Kingman


                    1510 North Stockton Hill Road
                              Kingman
                                 AZ
                            86401-5173
                              Mohave
                            PO Box 3630
                              Flagstaff
                                 AZ
                            86003-3630
                           928-753-1177
                            1336329788
                              433079
                                Yes
                       A: 031870; B: Z70394
                          Ann Roggenbuck
                           928-774-8325
               aroggenbuck@northcountryhealthcare.org
                         Jennifer Youngberg
                           928-213-6162
               jyoungberg@northcountryhealthcare.org
                            Kelly Bradish
                            928-213-6111
                kbradish@northcountryhealthcare.org
                             9/13/2011


Service Code


   Code
   10180
   11040
   11601
   11603
   11976
   11981
   17260
   94620
   10040
   10060
   10061
10080
10120
10140
10160
11004
11042
11055
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
11307
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11602
11643
11719
11720
11721
11730
11732
11740
11750
11765
11900
11901
12001
12002
12004
12005
12011
12013
12014
12020
12021
12031
12032
12034
12035
12041
12042
12052
15850
15851
16020
16025
16030
17000
17003
17004
17106
17107
17108
17110
17111
17250
19000
19105
19120
20520
20526
20550
20551
20552
20553
20555
20600
20605
20610
20612
23065
23071
23600
24500
24640
25028
25075
25500
25560
25600
26010
26700
26770
27603
27613
27786
29065
29075
29085
29105
29125
29126
29130
29365
29405
29425
29505
29515
29700
29705
30300
30901
36000
36410
36415
36416
36620
40800
45378
46083
46250
46600
47562
49322
49402
49505
51701
51702
54056
54115
54150
54160
54450
56420
56440
56501
56605
57061
57065
57100
57160
57170
57240
57267
57282
57288
57420
57421
57452
57454
57455
57456
57460
57461
57500
57505
57520
57522
58100
58120
58140
58150
58152
58180
58260
58262
58267
58300
58301
58350
58558
58563
58600
58605
58611
58661
58662
58670
58671
58720
58925
58940
59000
59025
59120
59150
59160
59200
59400
59409
59410
59412
59425
59426
59430
59510
59514
59515
59612
59618
59620
59812
59820
62270
64405
64435
65205
67700
69200
69210
70100
70140
70150
70160
70200
70220
70250
70260
71010
71020
71021
71022
71030
71100
71101
72020
72040
72050
72070
72200
72220
73000
73010
73020
73030
73060
73070
73080
73090
73100
73110
73120
73130
73140
73500
73510
73520
73550
73560
73562
73564
73590
73592
73600
73610
73620
73630
73650
73660
74000
74020
76010
76645
76700
76770
76801
76805
76810
76813
76815
76816
76817
76818
76819
76830
76831
76856
76857
76946
76977
86580
88112
88141
88305
88312
90460
90461
90470
90471
90472
90473
90474
90632
90633
90647
90648
90649
90655
90657
90658
90660
90669
90670
90680
90696
90698
90700
90701
90702
90703
90705
90706
90707
90708
90710
90712
90713
90714
90715
90716
90718
90720
90721
90723
90732
90733
90734
90736
90743
90744
90746
90748
92551
92552
92567
92582
92587
93000
93005
93965
94010
94150
94640
94644
94760
95115
95117
96150
96151
96152
96153
96154
97001
97002
97010
97014
97032
97035
97036
97110
97112
97116
97124
97140
97530
97802
97810
97811
98925
98926
99000
99173
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99291
99292
99354
99355
99356
99358
99359
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99420
99441
99442
99443
99460
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480
                                                                   2/23/2012

                                                                    OTC-4413
                                                      North Country HealthCare - Kingman


                                                          1510 North Stockton Hill Road
                                                                     Kingman
                                                                        AZ
                                                                   86401-5173
                                                                     Mohave
                                                                  PO Box 3630
                                                                    Flagstaff
                                                                        AZ
                                                                   86003-3630
                                                                  928-753-1177
                                                                  1336329788
                                                                     433079
                                                                       Yes
                                                             A: 031870; B: Z70394
                                                                 Ann Roggenbuck
                                                                 928-774-8325
                                                     aroggenbuck@northcountryhealthcare.org
                                                               Jennifer Youngberg
                                                                  928-213-6162
                                                     jyoungberg@northcountryhealthcare.org
                                                                  Kelly Bradish
                                                                  928-213-6111
                                                      kbradish@northcountryhealthcare.org
                                                                    9/13/2011


                                                          Discription of Charge


Description
Incision and drainage, complex, postoperative wound infeciton
Debridement, skin, partial thickness
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0
Removal, implantable contraceptive capsules
Insertion, non-biodegradable drug delivery implant
Destruction, malignant lesion trunk, arms, legs; lesion diameter 0.5 cm or less
Pulmonary stress test/simple
Acne surgery
Incision and drainage of abscess; simple or single
Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicat
Incision and drainage of pilonidal cyst; simple
Foreign Body Removal (simple)
Incision and drainage of hematoma, seroma or fluid collection
Puncture aspiration of abscess, hematoma, bulla, or cyst
Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
Debridement; skin, and subcutaneous tissue
Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); single lesion
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); each separate/
Removal of skin tags, any area, up to and including 15 lesions.
each additional 10 lesions, or part thereof (list separately in addtion to code for primary procedure)
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm
Trimming of nondystrophic nails, any number
Debridement of nail(s) by any method(s); one to five
Debridement of nail(s) by any method(s); six or more
Avulsion of nail plate, partial or complete, simple; single
Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)
Evacuation of subungual hematoma
Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal;
Wedge excision of skin of nail fold (eg for ingrown toenail)
Injection, intralesional; up to and including seven lesions
Injection, intralesional; more than seven lesions
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm
Treatment of superficial wound dehiscence; simple closure
Treatment of superficial wound dehiscence; with packing
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm
Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Removal of sutures under anesthesia (other than local), same surgeon
Removal of sutures under anesthesia (other than local), other surgeon
Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small
Dressings and/or debridement, initial or subsequent; without anesthesia, medium (eg, whole face or whole extremity)
Dressings and/or debridement, initial or subsequent; without anesthesia, large (eg, more than one extremity)
Destruction of all benign or premalignant lesions
Destruction of all benign or premalignant lesions; second through 14 lesions
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic kerat
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 - 50.0 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
Wart Removal (up to 14 lesions)
Wart Removal (15 or more)
Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)
Puncture aspiration of cyst of breast;
Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open,
Removal of foreign body in muscle or tendon sheath; simple
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
Tendon Injection
Injection; tendon origin/insertion
One or two muscle injections
Three or more muscle injections
Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent t
Small Joint Injections
Medium Joint Injections
Large Joint Injections
aspiration/inj ganlion cyst
Biopsy, soft tissue of shoulder area; superficial
Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater
Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation
Closed treatment of humeral shaft fracture; without manipulation
Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation
Incision and drainage, forearm and/or wrist; deep abscess or hematoma
Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous
Closed treatment of radial shaft fracture; without manipulation
Closed treatment of radial and ulnar shaft fractures; without manipulation
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid; without manip
Drainage of finger abscess; simple
Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia
Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia
Incision and drainage, leg or ankle; deep abscess or hematoma
Biopsy, soft tissue of leg or ankle area; superficial
Closed treatment of distal fibular fracture (lateral malleolus); without manipulation
Application, cast; shoulder to hand (long arm)
Application, cast; elbow to finger (short arm)
Application, cast; hand and lower forearm (gauntlet)
Application of long arm splint (shoulder to hand)
Application of short arm splint (forearm to hand); static
Application of short arm splint (forearm to hand); dynamic
Application of finger splint
Application of cylinder cast (thigh to ankle)
Application of short leg cast (below knee to toes);
Application of short leg cast (below knee to toes); walking or ambulatory type
Application of long leg splint (thigh to ankle or toes)
Application of short leg splint (calf to foot)
Removal or bivalving; gauntlet, boot or body cast
Cast Removal
Removal foreign body, intranasal; office type procedure
Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method
Introduction of needle or intracatheter, vein
Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes. Not to be u
Venipuncture Lab
Collection of capillary blood speciman ( eg, finger, heel, ear stick)
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous
Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon d
Incision of thrombosed hemorrhoid, external
Hemorrhoidectomy, external, complete
Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
Laparoscopy, surgical; cholecystectomy
Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)
removal of perioneal foriegn body form pertioneal cavity
Repair initial inguinal hernia, age 5 years or over; reducible
Insertion of non-indwelling bladder catheter
Insertion of temporary indwelling bladder catheter; simple
Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery
Removal foreign body from deep penile tissue (eg, plastic implant)
Circumcision, using clamp or other device; newborn
Circumcision, surgical excision other than clamp, device or dorsal slit; newborn
Foreskin manipulation including lysis of preputial adhesions and stretching
Incision and drainage of Bartholin's gland abscess
Marsupialization of Bartholin's gland cyst
Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Biopsy of vulva or perineum (separate procedure); one lesion
Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Biopsy of vaginal mucosa; simple (separate procedure)
Fitting and insertion of pessary or other intravaginal support device
Diaphragm or cervical cap fitting with instructions
Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele
Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately
Sacrospinous ligament fixation for prolapse of vagina
Sling operation for stress incontinence (eg, fascia or synthetic)
Colposcopy of the entire vagina, with cervix if present
Colposcopy with biopsy(s) of vagina/cervix
Colposcopy of the cervix including upper/adjacent vagina;
Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix
Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)
Endocervical curettage
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision
Endometrial biopsy
Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)
Myomectomy, excision of leiomyomata of uterus, single or multiple (separate procedure); abdominal approach
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystope
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
Vaginal hysterectomy, for uterus 250 g or less;
Vaginal hysterectomy; with removal of tube(s), and/or ovary(s)
Vaginal hysterectomy; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type, with or without endoscopic control)
Insertion of intrauterine device (IUD)
Removal of intrauterine device (IUD)
Chromotubation of oviduct, including materials
Polypectomy - Uterus
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate pr
Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List se
Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
Ovarian cystectomy, unilateral or bilateral
Oophorectomy, partial or total, unilateral or bilateral;
Amniocentesis; diagnostic
Fetal non-stress test
Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach
Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy
Curettage, postpartum
Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure)
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
Vaginal delivery only (with or without episiotomy and/or forceps);
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
External cephalic version, with or without tocolysis
Antepartum care only; 4-6 visits
Antepartum care only; 7 or more visits
Postpartum care only (separate procedure)
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
Cesarean delivery only;
Cesarean delivery only; including postpartum care
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarea
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;
Treatment of incomplete abortion, any trimester, completed surgically
Treatment of missed abortion, completed surgically; first trimester
Spinal puncture, lumbar, diagnostic
Injection, anesthetic agent; greater occipital nerve
Injection, anesthetic agent; paracervical (uterine) nerve
Removal of foreign body, external eye; conjunctival superficial
Blepharotomy, drainage of abscess, eyelid
Removal foreign body from external auditory canal; without general anesthesia
Removal of Impacted Cermen
Radiologic examination, mandible; partial, less than four views
Radiologic examination, facial bones; less than three views
Radiologic examination, facial bones; complete, minimum of three views
Radiologic examination, nasal bones, complete, minimum of three views
Radiologic examination; orbits, complete, minimum of four views
Radiologic examination, sinuses, paranasal, complete, minimum of three views
Radiologic examination, skull; less than four views, with or without stereo
Radiologic examination, skull; complete, minimum of four views, with or without stereo
Radiologic examination, chest; single view, frontal
Chest X-Ray
Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure
Radiologic examination, chest, two views, frontal and lateral; with oblique projections
Radiologic examination, chest, complete, minimum of four views;
Radiologic examination, ribs, unilateral; two views
Radiologic examination of ribs
Radiologic examination of spine
Radiologic examination, spine, cervical; two or three views
Radiologic examination of spine
Radiologic examination, spine; thoracic, two views
Radiologic examination, sacroiliac joints; less than three views
Radiologic examination, sacrum and coccyx, minimum of two views
Radiologic examination; clavicle, complete
Radiologic examination; scapula, complete
Radiologic examination, shoulder; one view
Radiologic examination of shoulder
Radiologic examination of humerus
Radiologic examination, elbow; two views
Radiologic examination, elbow; complete, minimum of three views
Radiologic examination of forearm
Radiologic examination, wrist; two views
Radiologic examination of wrist, min. 3 views
Radiologic examination, hand; two views
Radiologic examination of hand
Radiologic examination of finger(s)
Radiologic examination, hip, unilateral; one view
Radiologic examination of hip
Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis
Radiologic examination of femur
Radiologic examination of knee
Radiologic examination of knee
Radiologic examination, knee; complete, four or more views
Radiologic examination, tibia and fibula, 2 views
Radiologic examination; lower extremity, infant, minimum of two views
Radiologic examination, ankle; two views
Radiologic examination of ankle
Radiologic examination, foot; two views
Radiologic examination of foot
Radiologic examination; calcaneus, minimum of two views
Radiologic examination of toe(s)
Radiologic examination single view of abdomen
Radiologic examination of abdomen; multiple views
Radiologic examination from nose to rectum for foreign body, single view, child
Ultrasound, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation
Abdominal Ultrasound
Renal ultrasound
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal ap
Pregnant uterus ultrasound
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal and maternal evaluation), multiple gestation
fetal nuchal translucency measurement, first trimester
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart beat, placental location, fetal position, or em
Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat
Ultrasound, pregnant uterus, real time with image documentation, transvaginal
Fetal biophysical profile; with non-stress testing
Fetal biophysical profile; without non-stress testing
Ultrasound, transvaginal
Hysterosonography
Pelvic ultrasound
Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up (eg, for follicles)
Ultrasonic guidance for amniocentesis, imaging supervision and interpretation
Ultrasound bone density measurement and interpretation, peripheral site(s), any method
TB Skin Test
Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical servic
Level IV - Surgical pathology, gross and microscopic examination Abortion - Spontaneous/Missed Artery, Biopsy Bone Marrow, Biopsy Bone Exostosis
Special stains (List separately in addition to code for surgical pathology examination); Group I for microorganisms (eg, Gridley, acid fast, methenamin
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profe
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profe
H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
Immunization administration; one vaccine
Immunization administration for multiple vaccinations
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to c
Hepatitis A vaccine (over 12 years) 0.5 ml
Hepatitis A vaccine (peds/adolescent)
Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use
Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use
Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use
Influenza virus vaccine, live, for intranasal use
Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
Rotavirus vaccine, tetravalent, live, for oral use
Diphtheria, tetanus toxoids, acellar petussis vaccine, poliovirus vaccine,inactivated (DTap-IPV) for intramuscular use
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intra
DTAP Vaccine <7 yrs old
DTP Vaccine
Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than seven years, for intramuscular use
Tetanus shot by injection
Measles virus vaccine, live, for subcutaneous or jet injection use
Rubella virus vaccine, live, for subcutaneous or jet injection use
Measles, mumps and rubella virus vaccine
Measles and rubella virus vaccine, live, for subcutaneous or jet injection use
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
Poliovirus vaccine
Poliovirus vaccine SQ/IM
Diptheria/tetanus >7 yrs old IM
Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals seven years or older, for intramuscular use
Varicella virus vaccine
Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection
Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use
Pediatrix - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscula
Pneumonia vaccine
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use
Zoster (shingles) vaccine, live, for subcutaneous injection
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
Hepatitis B vaccine (19 years and under)
Hepatitis B vaccine (20 years and older)
Hemophilus influenza B vaccine
Screening test, pure tone, air only
Pure tone audiometry (threshold): air only
Tympanometry (impedance testing)
Conditioning play audiometry
Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
Electrocardiogram, routine ECG with at least 12 leads
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other
Pulmonary Function Test
Vital capacity, total (separate procedure)
Respiratory Therapy
Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour
Pulse oximetry
Single injectionj; Professional services for allergen immunotherapy not including provision of allergenic extracts
Two or more injections; Professional services for allergen immunotherapy not including provision of allergenic extracts
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysicological monitoring, health-oriented ques
Health and behavior intervention, each 15 minutes, face-to-face; individual
Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)
Physical therapy evaluation
Physical therapy re-evaluation
Application of a modality to one or more areas; hot or cold packs
Application of a modality to one or more areas; electrical stimulation (unattended)
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; ultrasound, each 15 minutes
Application of a modality to one or more areas; Hubbard tank, each 15 minutes
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, postur
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, perc
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 min
Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
Acupuncture, first 15 min
Acupuncture, each add'l 15 min
Osteopathic Manipulative Treatment
Osteopathic Manipulative Treatment
Spec. Handling/Trans.
Screening test of visual acuity, quantitative, bilateral
New Patient E&M Focused
New Patient E&M Expanded
New Patient E&M Detailed
New Patient E&M Moderate
New Patient E&M High Complexity
Established Patient Visit
Established Patient Visit
Established Patient Visit
Established Patient Visit
Established Patient Visit
Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge fro
Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehe
Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive histor
Initial Hospital Visit
Initial Hospital Visit
Initial Hospital Visit
Initial Hospital Visit
Subsequent Hospital Visit
Subsequent Hospital Visit
Subsequent Hospital Visit
Observation/Discharge Hospital Visit
Observation/Discharge Hospital Visit
Observation/Discharge Hospital Visit
Hospital Discharge
Hospital Discharge
Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused exam
Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded
Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and med
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examinat
Initial inpatient consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focu
Initial inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an e
Initial inpatient consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination;
Initial inpatient consultation for a new or established patient, which requires three key components: a comprehensive history; a comprehensive exami
Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem focused history;
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focus
Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detaile
Critical Care Hospital Visit
Critical Care Hospital Visit
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, pro
Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monit
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, comm
Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, comm
Initial comprehensive preventive medicine evaluation and management of an individual; infant (age under 1 year)
Initial comprehensive preventive medicine evaluyation and management of an individual; early childhood (age 1 through 4 years)
Initial comprehensive preventivemedicine evaluation and management of an individual; age 5 through 11 years
Initial comprehensive preventive medicine evaluation and management of an individual; age 12 through 17 years
Initial comprehensive preventive medicine evaluation and management of an individual; 18-39 years.
Initial comprehensive preventive medicine evaluation and management of an individual; 40-64 years.
Initial comprehensive preventive medicine evaluation and management of an individual; 65 years and over.
Periodic comprehensive preventive medicine reevaluation and management of an individual; infant (age under 1 year)
Periodic comprehensive preventive medicine reevaluation and management of an individual; early childhood (age 1 through 4 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; late childhood (age 5 through 11 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; adolescent (age 12 through 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual; 65 years and over
Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)
Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M
11-20 minutes of medical discussion
Telephone Evaluation and Management:21-30 minutes f medical discussion
Initial hospital, per day, for evaluation and management of normal newborn infant
Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
Subsequen hospital care, per day, for evaluation and management of normal newborn
Initial hospital, per day, for evaluation and management of normal newborn infant admitted and discharged on the same day
Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn
Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventila
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24
Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 m
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of a
Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequ
Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than
Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500
Subsequent intensive care, per day, for the evaluation and management of the recovering infant (presen body weight of 2501-5000 grams)
                                                                    6/12/2012

                                                                     OTC-2076
                                                         Palo Verde Physical Therapy, PC


                                                                3003 HWY 95, #61
                                                                    Bullhead City
                                                                      Arizona
                                                                       86442
                                                                      Mohave
                                                                3003 HWY 95, #61
                                                                    Bullhead City
                                                                      Arizona
                                                                       86442
                                                                   928-758-0029
                                                                    1225033483
                                                                      782848
                                                                        Yes
                                                                    36580.000
                                                                     Carol Diehl
                                                                   928-758-0029
                                                                pvpt@frontiernet.net
                                                                     Carol Diehl
                                                                   928-758-0029
                                                                pvpt@frontiernet.net
                                                                     Carol Diehl
                                                                   928-758-0029
                                                               pvpt@frontiernet.net




      Rate of Charge        Service Code                    Discription of Charge              Rate of Charge


Fee                            97001        Physical Therapy Evaluation                    $               80.00
$                409.00        97002        Physical Therapy Re-Evaluation                 $               42.00
$                 64.00        97010        Hot/Cold Packs                                 $               18.00
$                387.00        97012        Mechanical Traction                            $               32.00
$                481.00    970104 (G0283) Electrical Stimulation (unattended)              $               25.00
$                252.00        97018        Paraffin Bath                                  $               20.00
$                233.50        97032        Electrical Stimulation (monitored)             $               38.00
$                164.00        97033        Iontophoresis                                  $               52.00
$                 111.00       97035        Ultrasound                                     $               32.00
$                177.00        97039        Unlisted Modality                              $               25.00
$                190.00        97110        Therapeutic exercise (per 15 min)              $               32.00
$                317.00        97112        Neuromuscular Re-Education                     $               25.00
$    291.00    97116   Gait Training                                  $   30.00
$    234.50    97124   Massage                                        $   32.00
$    269.00    97139   Unlisted Modality                              $   25.00
$    218.00    97140   Manual Therapy Techniques                      $   40.00
$   1,022.50   97150   Group Therapeutic Exercise                     $   25.00
$     151.50   97504   Orthotics Fitting and Training (each 15 min)   $   32.00
$     83.50    97533   Sensory Integration                            $   32.00
$    178.50    97535   Self-Care/Home Training in ADL's               $   24.00
$     57.00
$    146.00
$     32.50
$     118.00
$    160.50
$    192.00
$    226.00
$     118.00
$    164.00
$    194.00
$    146.00
$    184.00
$    214.50
$    266.00
$    204.50
$    250.00
$    278.50
$    320.00
$    364.00
$    519.00
$    203.50
$    265.00
$    295.00
$    342.00
$    393.00
$    562.50
$    225.00
$    283.00
$    319.50
$    380.50
$    478.50
$    423.50
$    550.00
$     37.00
$     53.50
$     73.00
$     164.00
$     75.00
$     79.50
$    370.50
$    233.50
$     97.00
$     122.50
$     167.00
$     196.00
$    233.00
$    300.00
$    200.00
$     215.00
$    254.50
$    463.00
$    275.50
$     419.00
$    528.00
$    526.50
$    639.00
$    437.50
$     501.00
$    528.50
$     149.00
$     163.50
$     142.00
$    254.50
$    306.50
$     139.00
$      12.50
$    300.50
$    592.50
$    769.00
$   1,098.50
$     189.50
$    225.50
$     130.50
$     190.00
$   3,557.00
$     819.00
$    334.50
$     129.00
$     98.00
$     100.00
$    91.50
$   103.50
$   575.50
$    92.50
$   101.00
$   134.00
$   100.50
$   371.50
$   740.00
$   541.00
$   590.00
$   214.50
$   888.50
$   824.00
$   444.00
$   451.50
$   485.50
$   433.50
$   528.00
$   449.50
$   915.00
$   432.50
$   528.00
$   159.50
$   149.00
$   158.00
$   145.00
$   116.00
$   132.00
$    68.50
$   206.00
$   149.00
$   159.00
$   130.00
$   121.00
$   110.50
$   113.00
$   394.50
$   167.50
$    44.00
$    32.00
$    19.00
$    19.00
$    89.00
$    356.50
$    692.00
$    297.00
$    756.50
$    143.50
$   1,278.50
$    642.50
$   1,471.00
$    886.50
$    104.50
$    135.00
$    246.50
$    816.00
$    294.50
$    409.00
$    129.00
$    217.50
$    323.00
$    230.00
$    145.50
$    200.00
$    336.50
$    154.50
$    135.00
$     114.00
$   1,175.00
$    459.00
$    886.50
$   1,259.50
$    203.00
$    273.50
$    190.50
$    240.00
$    196.00
$    237.50
$     511.50
$    575.50
$    228.50
$    178.50
$    479.00
$    428.50
$    193.00
$    383.50
$   1,618.00
$   1,753.00
$   2,200.50
$   1,685.00
$   1,459.50
$   1,628.00
$   1,863.50
$     126.00
$     168.50
$     170.50
$    472.00
$    607.50
$    642.50
$    580.50
$     137.00
$   1,135.00
$   1,243.50
$    645.00
$    644.50
$   1,270.00
$   1,301.00
$    904.50
$    225.00
$     82.50
$   1,414.00
$   1,367.50
$     314.50
$      81.00
$   3,325.50
$   1,306.50
$   1,656.00
$     168.50
$    740.00
$   1,322.50
$    225.00
$   3,703.00
$   1,482.50
$   2,006.50
$   1,472.50
$   3,772.00
$   1,544.50
$    523.00
$    630.00
$     271.50
$     196.50
$   246.50
$    94.00
$   442.50
$   214.00
$    87.50
$    58.00
$    53.50
$    75.50
$    58.00
$    78.00
$    68.50
$    65.50
$    83.00
$    41.50
$    54.50
$    67.00
$    82.00
$    81.50
$    57.00
$    69.50
$    42.00
$    69.00
$    93.00
$    60.00
$    52.50
$    51.50
$    50.50
$    54.00
$    41.50
$    54.50
$    51.50
$    50.00
$    60.00
$    49.50
$    54.50
$    64.00
$    48.50
$    56.50
$    55.00
$    47.50
$    68.50
$    72.00
$    50.50
$    54.00
$    64.50
$    74.00
$    48.50
$    54.50
$    50.00
$    57.00
$    48.00
$    56.00
$    49.50
$    51.50
$    44.00
$    70.50
$    48.50
$   168.50
$   247.00
$   234.50
$   228.50
$   262.00
$   171.50
$   222.50
$   160.50
$   205.50
$   181.50
$   215.00
$   161.50
$   219.50
$   220.50
$   219.00
$   178.00
$    66.50
$    18.50
$    13.00
$   179.50
$    50.50
$   185.50
$   186.50
$    40.50
$    20.00
$    35.50
$    40.50
$    20.00
$    40.50
$    20.00
$    26.00
$    74.00
$    25.00
$   106.00
$   160.00
$    21.00
$    22.00
$    25.00
$    25.00
$   113.00
$   141.00
$   115.00
$    43.00
$    67.00
$    36.00
$    45.00
$    31.00
$    26.00
$    46.00
$    47.00
$    62.00
$    64.00
$    73.00
$    41.00
$    48.00
$    31.00
$    49.00
$    95.00
$    29.00
$    52.00
$    65.00
$    88.00
$    49.00
$   114.00
$   133.00
$   268.00
$    81.00
$   103.00
$    67.00
$    89.00
$    20.00
$    44.50
$    26.50
$    89.50
$    64.50
$    34.50
$    19.00
$   221.50
$    62.00
$    42.00
$    28.00
$    70.00
$     5.00
$    18.00
$    22.00
$    37.00
$    35.50
$    34.00
$     8.50
$    33.50
$   126.50
$    70.00
$     9.50
$    25.50
$    31.00
$    21.00
$    51.00
$    51.50
$    54.00
$    45.50
$    42.00
$    48.50
$    56.50
$    56.00
$    62.50
$    47.50
$    53.00
$    70.50
$    43.00
$     5.00
$    72.00
$   124.00
$   180.00
$   276.50
$   344.50
$    34.50
$    72.50
$   120.50
$   178.50
$   240.50
$   121.00
$   112.00
$   187.50
$   262.50
$   170.00
$   231.00
$   339.00
$    67.00
$   121.00
$   174.00
$   230.00
$   301.00
$   374.00
$   120.50
$   177.00
$    56.50
$   118.00
$   164.50
$   309.00
$   377.50
$    82.50
$   127.00
$   193.50
$   279.00
$   337.50
$    36.00
$    70.50
$   107.00
$   202.00
$   379.50
$   190.50
$   167.00
$   165.00
$   152.50
$   188.00
$    91.00
$   105.50
$   177.50
$   177.00
$   192.50
$   192.50
$   224.00
$   247.00
$    138.50
$    154.00
$    153.00
$    167.50
$    168.00
$    183.50
$    206.50
$     18.00
$     24.50
$     46.50
$     68.50
$     101.00
$    159.00
$     54.50
$    138.50
$    125.50
$    242.50
$    462.50
$    207.00
$   1,570.50
$    684.00
$   1,353.50
$    681.00
$    956.50
$    579.50
$    604.00
$    240.00
$    220.50
$    205.50
                                   9/15/2011                                                                   2/23/2012

                                    OTC-4743                                                                   OTC-4335
                 PARAGON HEALTHCARE OF ARIZONA, LLC                                             Physiotherapy Associates, Inc.-


                          2585 Miracle Mile, Suite 107                                                      2120 Airway Ave
                                   Bullhead City                                                                Kingman
                                       Arizona                                                                     AZ
                                       86442                                                                  86409-3027


                                       Mohave                                                        1025 E. Broadway Rd., suite 2
                          2585 Miracle Mile, Suite 107                                                           Tempe
                                   Bullhead City                                                                   AZ
                                       Arizona                                                                   85282
                                       86442                                                                 (928)757-1211
                                  928-444-8168                                                                1528130663
                                   1477786226                                                                      n/a
                                       591126                                                                     Yes
                                       Part B                                                                   03-6550
                                                                                                              Dustin Brisco
                               Roxanne Pincombe, PT                                                          (928)757-1211
                                  928-444-8168                                                       dustin.brisco@physiocorp.co
                        roxannep@paragonhealthcare.org                                                       Andrew LaVoe
                                    Sam Spear                                                                (610)644-7824
                                  702-528-3999                                                        andrew.lavoe@physiocorp.co
                               samspear2@aol.com                                                              Becky Rigsby
                                  Diane Seaney                                                          (469)467-8705 ext 8094
                                 928-444-8168                                                        becky.rigsby@physiocorp.co
                         dianes@paragonhealthcare.org                                                           1/3/2012


Service Code              Discription of Charge              Rate of Charge      Service Code


   97001       Physical Therapy Evaluation               $              110.00      97001
   97002       Physical Therapy Re-Evaluation            $               70.00      97002
   97110       Therapeutic Procure, 1 or more areas      $               55.00      97003
   97112       Ther oricedure, neuromuscelar re-educ     $               55.00      97004
   97116       Gait Training                             $               55.00      97010
   97140       Manual Therapy Technique                  $               55.00      97012
   97530       Therapeutic Activities, direct            $               55.00      97014
   95831       Muscle testing manual                     $               70.00      97016
   95851       Range of Motion measurements              $               70.00      97018
   97010       Hot or cold pack therapy                  $               55.00      97022
   97014       Electrical Stimulation, unattended        $               55.00      97026
   97032       Electrical Stimulation, Manual            $               55.00      97032
97035   Ultrasound   $   55.00   97033
                                 97034
                                 97035
                                 97110
                                 97112
                                 97113
                                 97116
                                 97124
                                 97140
                                 97150
                                 97530
                                 97532
                                 97533
                                 97535
                                 97537
                                 97542
                                 97545
                                 97546
                                 97597
                                 97598
                                 97602
                                 97750
                                 97760
                                 97761
                                 97762
                    2/23/2012                                                                         2/28/2012

                     OTC-4335                                                                        OTC - 4046
   Physiotherapy Associates, Inc.- Kingman                                          RENAL CARE GROUP ARIZONA, LLC - LAKE HAVASU


                  2120 Airway Ave                                                           1761 MCCULLOCH BLVD SUITE F
                      Kingman                                                                    LAKE HAVASU CITY
                         AZ                                                                           ARIZONA
                    86409-3027                                                                          86403
                                                                                                        SAME
           1025 E. Broadway Rd., suite 201
                       Tempe
                         AZ
                       85282
                   (928)757-1211                                                                    928-680-4748
                    1528130663                                                                       1588776397
                        n/a                                                                            466989
                        Yes                                                                              YES
                      03-6550                                                                          03 2544
                    Dustin Brisco                                                                ADRIENNE ADKINS
                   (928)757-1211                                                                    928-680-4748
           dustin.brisco@physiocorp.com                                                       adrienne adkins@fmc-na.com
                   Andrew LaVoe                                                                        JAY RAY
                   (610)644-7824                                                                    480-458-9600
           andrew.lavoe@physiocorp.com                                                           jay.ray@FMC-NA.com
                    Becky Rigsby                                                                  VALERIE KNUEVEN
              (469)467-8705 ext 8094                                                                928-763-5550
           becky.rigsby@physiocorp.com                                                        valerie.knueven@FMC-NA.com
                     1/3/2012


            Discription of Charge                Rate of Charge      Service Code


Physical Therapy Evaluation                  $              198.00       821
Physical Therapy Re-Evaluation               $               99.00       831
Occupational Therapy Evaluation              $              205.00       841
Occupational Therapy Re-Evaluation           $              114.00       851
Hot/Cold Pack                                $               50.00       841
Traction                                     $               57.00       851
Electrical Stimulation, unattented           $               69.00      J0882
Vasopneumatic devices                        $               64.00      J2997
Paraffin Bath                                $               57.00      J0690
Whirlpool/Fluidotherapy                      $               57.00      90740
Infrared Therapy                             $               57.00      J0886
Manual Electrical Stimulation                $               71.00      J2916
Iontophoresis (15 min)                $    92.00   90658
Contrast Bath Therapy                 $    64.00   J1580
Ultrasound (15 min)                   $    64.00   J1270
Theraputic exercise (15 min)          $    86.00   J1955
Neuromuscular re-ed                   $    76.00   90732
Aquatic Therapy w/exercise            $    90.00   J0780
Gait training                         $    65.00   90740
Massage                               $    64.00   J3370
Manual Techniques                     $    81.00   J1756
Therapeutic procedure (group)         $    46.00   93005
Theraputic Activities (15 min)        $    79.00   93005
Cognitive skills development          $    86.00   A4657
Sensory integration                   $    68.00   A4913
Self Care Managment Training          $    79.00   G0008
Community/work integration            $    82.00   G0009
Wheelchair Management Training        $    71.00   G0010
Work Hardening (2 hours)              $   262.00
Work Hardening (each additional hr)   $   106.00
Removal of tissue <20 cm              $   155.00
Removal of tissue >20 cm              $   189.00
Wound care non-selective              $    57.00
Physical Test w/report (15 min)       $    99.00
Orthotic Managment & Training         $    88.00
Prosthetic Training (15 min)          $    79.00
Checkout for Orthotic Prosthetic      $    92.00
                    2/28/2012                                                                    11/3/2011

                    OTC - 4046                                                                   OTC-3000
RENAL CARE GROUP ARIZONA, LLC - LAKE HAVASU                                                SILVER CREEK MRI
                                                                                     Western Arizona Medical Center
           1761 MCCULLOCH BLVD SUITE F                                                    2735 Silver Creed Rd
                LAKE HAVASU CITY                                                                Bullhead City
                     ARIZONA                                                                         AZ
                       86403                                                                       86442
                       SAME
                                                                                               P.O. Box 847173
                                                                                                   Dallas
                                                                                                     TX
                                                                                                75284-7173
                   928-680-4748                                                                928-763-2273
                    1588776397                                                                  1790724185
                       466989                                                                      308118
                        YES                                                                          Y
                       03 2544                                                                    Z121216
                ADRIENNE ADKINS                                                                Barry Schneider
                   928-680-4748                                                                928-763-0201
             adrienne adkins@fmc-na.com                                                 barry_schneider@chs.net
                     JAY RAY                                                                   Marty Brockman
                   480-458-9600                                                                928-763-0270
                jay.ray@FMC-NA.com                                                      marty_brockman@chs.net
                VALERIE KNUEVEN                                                                Marty Brockman
                  928-763-5550                                                                 928-763-0270
            valerie.knueven@FMC-NA.com                                                  marty_brockman@chs.net
                                                                                                 10/21/2011


            Discription of Charge             Rate of Charge       Service Code        Discription of Charge


DIALYSIS                                  $              136.85     2070233       NEG PRESS 50 CM OR LT
DIALYSIS                                  $              136.85     2070234       NEG PRESS 50 CM OR GT
DIALYSIS                                  $               58.65      2070201      LEVEL 1 EP
DIALYSIS                                  $               58.65     2070202       LEVEL 2 EP
DIALYSIS TRAINING                         $              148.25     2070203       LEVEL 3 EP
DIALYSIS TRAINING                         $              155.85     2070204       LEVEL 4 EP
ARANESP 1 MCG                             $                2.69     2070205       LEVEL 5 EP
CATHFLO ACTIVASE 1MG                      $                31.16     2070211      LEVEL 1 NP
CEFAZOLIN 500 MG IV                       $                0.52      2070212      LEVEL 2 NP
ENGERIX-B 40 MCG VL                       $              108.78      2070213      LEVEL 3 NP
EPO<10,000 UNITS (1000 units)             $                9.50      2070214      LEVEL 4 NP
FERRLECIT 12.5 MG IV                      $                4.64      207015       LEVEL 5 NP
FLU VACCINE 0.5 ML IM                $    12.56   2070230   DEBRIDE LE 20 SQ CM
GENTAMICIN SULFATE 80 MG IV          $     0.88   2070232   NON SELECTIVE DEBRID
HECTOROL IV 1 MCG IV                 $     2.86   2070222   PROC CLINIC SIMPLE
LEVOCARNITINE (CARNITOR) 1G          $     6.28   2070223   PROC CLINIC MINOR
PNEUMO VAC 23-VALEN 0.5ML IM         $    31.07   2070224   PROC CLINIC INTERM
PROCHLORPERAZINE IV 10 MG IV         $     1.55   2070225   PROC CLINIC MAJOR
RECOMBIVAX 40 MCG IM                 $   108.78   2072333   DEBRIDE EA ADD 20 CM
VANCOMYCIN 500 MG IV                 $     2.94   1822132   MULTI COMP LWR LEG A
VENOFER 1 MG IV                      $     0.33   1852100   CAST AP LG ARM S-H
EKG                                  $    16.73   1852101   CAST AP SHRT ARM E-F
EKG RHYTHM STRIP                     $    16.73   1852102   CAST APP GAUNTLET
ADMIN SUPPLY INJECTION - IVP         $     0.49   1852104   SPLNT LONG ARM S-H
ADMIN SUPPLY - IV                    $     2.85   1852105   SPINT SHRT ARM STATC
PROF. FEE-INFLUENZA                  $     7.68   1852106   SPLNT SHRT ARM DYNAM
PROF. FEE - PNEUMOCOCCAL             $     7.68   1852107   SPLNT FINGER STATIC
PROF. FEE - HEPATITIS B/RECOMBIVAX   $     7.68   1852108   SPLNT FINGER DYNAM
                                                  1852111   STRAPPING SHOULDER
                                                  1852112   STRAPPPLING ELBO-WRIST
                                                  1852113   STRAPPING HAND-FLING
                                                  1852127   DENIS-BROWNE SPL=STR
                                                  1852129   BIOFDBK ANY MOD-VIS
                                                  1852130   BIOFDBK ANORCTL-VIS
                                                  1852223   MUSL TST W-R EXT
                                                  1852224   MUSL TST W-R HAND
                                                  1852225   MUSL TST W-R BDY-HND
                                                  1852226   MUSL TST W-R BDY+HND
                                                  1852228   ROM W-R HND W-WO COM
                                                  1852231   DEV TST EXT W-RPT-HR
                                                  1852234   OT EVAL VISIT
                                                  1852235   OT RE-EVAL VISIT
                                                  1852238   HOT-COLD PACKS
                                                  1852239   MECH TRACTION-VISIT
                                                  1852241   VASPNEUMATIC DEV-VIS
                                                  1852242   PARAFFIN BATH-VIST
                                                  1852243   WHIRLPOOL THRPY-VIST
                                                  1852247   ELECT STIM-MAN-15 MIN
                                                  1852248   IONTOPHORESIS-15 MIN
                                                  1852249   CONTRAST BATH-15 MIN
                                                  1852250   ULTRASOUND-15 MIN
                                                  1852252   UNLIST MODALITY-VST
                                                  1852253   THERAP EXERCS-15 MIN
                                                  1852254   NEURO RE-ED 15 MIN
                                                  1852257   MASSAGE THRPY-15 MIN
                                                  1852258   UNLIST THERP-15 MIN
1852260   MANUAL THRPY-15 MIN
1852261   GROUP THRP PROC-VIST
1852262   THERAP ACTVTS-15 MIN
1852263   COG SKILL DEV-15 MIN
1852264   SENSORY INTEG-15 MIN
1852265   SELF CARE MGT-15 MIN
1852266   COM-WRK REINT-15 MIN
1852267   WHEELCHR MGT-15 MIN
1852268   WRK HER-CND 1ST 2 HRS
1852269   WRK HAR-CND-ADD HR
1852273   DEBRIDE NON-SELC VIS
1852276   PHYSICAL PERF-15 MIN
1852278   ORTHOTIC TRAIN-15 MI
1852279   PROSTH TRAIN-15 MIN
1852280   PROS-ORTH CHK-15 MIN
1852303   ELEC STIM UNATTND-VI
1852132   MULTI COMP LWR LEG A
1872332   STD COG TEST PERHOUR
1872166   TYPANOMETRY-IMPED
1872133   EVAL SPEECH-HEAR-VST
1872134   SP-HEAR-TX-INDI VIST
1872136   AU NASOPHARYNGOSCOPE
1872179   AUDITORY EVP-EVR-CNS
1872202   SP EVAL SWL WO RADOP
1872205   EVAL SWALLO W-RADOPQ
1872213   AUDITORY FUNC, 60 MIN
1872214   AUDIT FUNC, +15 MIN
1872229   APHASIA ASSESS-HOUR
1872230   DEV TST LIM W-RPT-V
1872263   COG SKILL DEV-15 MIN
1872307   EVAL SPEECH-LANG-VST
1872309   SP-HEAR-GROUP-VIST
1872314   ORAL FUNCTION TX-VIS
1872308   SP-HEAR-GROUP-VIST
1872310   SP NASOPHARYNGOSCOPE
1872311   AU NASAL FUNCT STUDY
1872313   LARYNGEAL FUN STU-VI
1872321   AU UNLIST OTORHINOLS
1892132   MULTI COMP LWR LEG A
1141031   GI LAB LEV 1 1ST 15
1141032   GI LAB LEV 2 1ST 15
1141033   GI LAB LEV 3 1ST 15
1141034   GI LAB LEV 4 1ST 15
1141041   GI LEV 1 EA ADD MIN
1141042   GI LEV 2 EA ADD MIN
1141043   GI LEV 3 EA ADD MIN
1141044   GI LEV 4 EA ADD MIN
1140121   ANES LV 1 INI 15 MIN
1140122   ANES LV 2 INI 15 MIN
1140131   ANES LV 1 EA ADD MIN
1140132   ANES LV 2 EA ADD MIN
1140161   PACU LEV 1 INI 15 MN
1140162   PACU LEV 2 INI 15 MIN
1140163   PACU LEV 3 INI 15 MIN
1140171   PACU LEV 1 EA ADD MN
1140172   PACU LEV 2 EA ADD MN
1140173   PACU LEV 3 EA ADD MN
1140201   PAIN MGMNT LEVEL 1
1140211   OR LEV 1 INI 15 MIN
1140212   OR LEV 2 INI 15 MIN
1140213   OR LEV 3 INI 15 MIN
1140221   OR LEV 1 EA ADD MIN
1140222   OR LEV 2 EA ADD MIN
1140223   OR LEV 3 EA ADD MIN
1140243   LITHOTRIPSY
1140123   ANES LV 3 INI 15 MIN
1140133   ANES LV 3 EA ADD MIN
1140124   ANES LV 4 INI 15 MIN
1140134   ANES LV 4 EA ADD MIN
1140164   PACU LEV 4 INI 15 MN
1140174   PACU LEV 4 EA ADD MIN
1140214   OR LEV 4 INI 15 MIN
1140215   OR LEV 5 INI 15 MIN
1140216   OR LEV 6 INI 15 MIN
1140224   OR LEV 4 EA ADD MIN
1140225   OR LEV 5 EA ADD MIN
1140226   OR LEV 6 EA ADD MIN
1681007   HE-EYE (FOREIGNBODY)
1681069   CH-ABDOMEN 1V
1681153   CH-ABD W-DEC-ERECT
1681188   HE-MANDIBLE 4V+
1681190   HE-FACIAL BONES LIMI
1681191   HE-FACIAL BONES 3 V+
1681192   HE-NASAL BONES
1681193   HE-ORBITS 4V
1681194   HE-SINUSES LIMITED
1681195   HE-SINUSES 3V+
1681196   HE-SKULL LIMITED
1681197   HE-SKULL 4V+
1681200   SP-NECK, SOFT TISSUE
1681201   CH-CHEST 1V
1681202   CH-CHEST 2V
1681203   CH-CHEST 2V+APICLORD
1681204   CH-CHEST 2V+OBLIQUES
1681205   CH-RIBS UNILATERAL
1681206   HE-MANDIBLE LIMITED
1681207   CH-RIBS UNI-PA CHEST
1681208   CH-RIBS BILATERAL
1681209   CH-RIBS BILAT-PA CHE
1681210   CH-STERNUM
1681211   CH-STERNOCLAV JOINTS
1681213   SP-CERVICAL SPIN2-3V
1681214   SP-CERVICAL SPIN 4V+
1681215   SP-CERV SP FLEX /EXT
1681219   SP-SPINE-SCOLIO W-UP
1681220   SP-LS SPINE 2-3V
1681221   SP-LS SPINE 4V+
1681222   SP-LS SPINE W-BEND
1681223   LE-PELVIS
1681225   SP-SACRUM-COCCYX 2V
1681226   UE-AC JTS BILATRAL
1681227   LE-HIP UNILATERAL 1V
1681228   LE-HIP UNILATERAL 2V+
1681229   LE-HIP BILAT W-PELVI
1681230   LE-KNEE BILAT AP STA
1681231   CH-ABD SER W-PA CXR
1681234   UE-CLAVICLE
1681235   UE-CLAVICLE BILAT
1681236   UE-SCAPULA
1681237   UE-SCAPUAL BILAT
1681238   UE-SHOULDER 1V
1681242   UE-HUMERUS
1681243   UE-HUMERUS BILAT
1681244   UE-ELBOW 2V
1681245   UE-ELBOW 2VIEW BILAT
1681246   UE-ELBOW 3V
1681247   UE-ELBOW 3VIEW BILAT
1681248   UE-FOREARM 2V
1681249   UE-FOREARM 2VW BILAT
1681255   UE-HAND 2V
1681256   UE-HAND 2VIEW BILAT
1681257   UE-HAND 3V
1681258   UE-HAND 3 VIEW BILAT
1681259   UE-FINGER (S) 2V+
1681261   LE-FEMUR 2V
1681262   LE-FEMUR 2VIEW BILAT
1681263   LE-KNEE 1-2V
1681264   LE-KNEE 1-2VW BILAT
1681265   LE-KNEE 3V
1681266   LE-KNEE 3VIEW BILAT
1681267   LE-KNEE 4V+
1681268   LE-KNEE 4+VIEW BILAT
1681271   LE-ANKLE 2V
1681272   LE-ANKLE 2VIEW BILAT
1681273   LE-ANKLE 3V+
1681274   LE-ANKLE 3+VW BILAT
1681275   LE-FOOT 2 V
1681276   LE-FOOT 2VIEW BILAT
1681277   LE-FOOT 3V+
1681278   LE-FOOT 3VIEW+ BILAT
1681279   LE-CALCANEOUS 2V+
1681280   LE-CALCANEOUS 2V BILA
1681300   HE-MASTOIDS 3V+
1681301   CH-CHEST SPEC VIEWS
1681302   SP-SI JOINTS 3V+
1681303   UE-INFANT BILAT
1681304   UE-UP EXTREM INFANT
1681305   LE-HIP PELVIS PEDIAT
1681306   LE-LW EXTRE INFA BIL
1681307   LE-LOWER EXTREM INFA
1681199   HE-TMJ BILATERAL
1681212   SP-SPINE-SINGLE VIEW
1681216   SP-THORACIC SPINE 2V
1681217   SP-THORACIC SPINE 3 V
1681250   UE-WRIST 2V
1681251   UE-WRIST 2VIEW BILAT
1681253   UE-WRIST 3 V+
1681254   UE-WRIST 3+VW BILAT
1681269   LE-TUBIA-FIBULA 2V
1681270   LE-TIBIA-FIBLA 2V BI
1681281   LE-TOE (S) 2V+
1681282   LE-TOE (S) 2+VW BILAT
1681240   UE-SHOULDER 2V+
1681241   UE-SHLDR 2+VWS BILAT
1374114   HEPATITIS ACUTE PANE
1374143   ANGIOTENSIN CONV ENZ
1374156   BLD OCCULT FECES 1-3
1374176   CARCINOEMBRYONIC AG
1374207   CORTISOL TOTAL
1374223   VITAMIN B-12
1374234   DIHYDROXY VITAMIN D
1374254   FERRITIN
1374258   FOLIC ACID SERUM
1374266   GAMMALGLOBULIN IGE
1374297   FOLLICLE STIM HORM
1374298   LEUTEINIZING HORMONE
1374340   IRON
1374341   IRON BINDING CAPACIT
1374343   KETOGENIC STERIODS
1374406   OSMOLATLITY, URNIE
1374441   PROLACTIN
1374444   PSA, TOTAL
1374445   PSA, FREE
1374448   PROTEINELECTR FR-QNT
1374470   SODIUM, URINE RANDOM
1374482   TESTOSTERONE, TOTAL
1374486   THYROXINE T 4, TOTAL
1374488   THYROXINE T 4, FREE
1374496   TRANSFERRIN
1374560   PSA, SCREENING
1374562   ALLERGEN IGE QUANT
1374567   ANA
1374639   RHEUMATOID FACT QUAN
1374689   HERPES SIMP TYPE 1
1374709   MUMPS AB
1374719   RUBELLA AB IGG
1374720   RUBELOLA AB
1374728   VARICELLA-ZOSTER AB
1374844   CULT STL BACT W-ISOL
1374845   CULT STL BACT EA ADD
1374846   CULTURE BACTERIA OTH
1375029   URINE PREG TEST QL
1375674   UDS QL MULTI CHROMAT
1374855   CULT URINE W-P ID
1374877   OVA-PARASITES SMEARS
1374918   CLOSTRIDIUM DIF TOXN
1376342   BASIC METABO CA TOTA
1376361   HCG QUANT
1374030   DIGOXIN
1674031   VALPROIC ACID
1374048   SALICYLATE
1374097   ACETAMINOPHEN
1374105   ALBUMIN SERUM
1374109   ELECTROLYTE PANEL
1374113   RENAL FUNCTION PANEL
1374152   BILIRUBIN TOTAL
1374153   BILIRUBIN DIRECT
1374164   CALCIUM DIOXIDE C02
1374173   CARBON DIOXIDE CO2
1374186   CHLORIDE BLOOD
1374213   CPK
1374280   GLUCOSE, QUANT
1374292   GGT
1374346   LACTIC ACID
1374347   LACTATE DEHYDROLDH
1374358   LIPASE
1374365   MAGNESIUM
1374419   PHOSPHATASE, ALKALINE
1374425   PHOSPHORUS, BLOOD
1374433   POTASSIUM SER PL WB
1374446   PROTEIN TOT SER PLWB
1374490   THYROID STIM TSH
1374494   TRANSFERASE AST
1374495   TRANSFERASE ALT
1374497   TRIGLYCERIDES
1374508   UREA NITROGEN, QUAN
1374512   URIC ACID, BLOOD
1374529   HCG, QUAL
1374571   C-REACTIVE PROTEIN
1374594   RSV ASSAY W-OPTIC
1374609   HETEROPHILE AB SCREE
1374746   BLEEDING TIME
1374751   HEMATOCRIT, OTHER
1374752   HEMOGLOBIN
1374753   CBC W-PLT AUTO COMPD
1374755   RBC COUNT
1374759   WBC COUNT
1374797   D-DIMER, QUANT
1374891   SMEARWET MOUNT SAL-I
1374934   INFLUENZA A-B AG, EIA
1374938   STREP A AG, EIA
1375022   UA, AUTO W-SCOPE
1375079   CBC-PLT AUTORP CDM
1375675   UDS CHEM ANALYZER
1376362   GLU, HOME USE DIAGNOS
1375015   INFLUENZA ASSAY W-OP
1375000   N.GONORRHO, DNA, AMPPR
1374999   N.GONORRHEA, DNA, DIR
1374716   RSV AB
1663413   FL-NEDL GUIDE FLUORO
1663061   US-ENCEPHALOGRAM
1663409   BR-DIG MAMMO BILAT
1663408   BR-DIG MAMMO SCRN BI
1663410   BR-DIG MAMMO UNILAT
1663549   BR-DIG MAMMO SCRN UN
1663002   CT-PELVIS WITHOUT
1663003   CT-PELVIS WITH
1663004   CT-PELVIS W-WO
1663032   CT-CHEST WITHOUT
1663033   CT-CHEST WITH
1663034   CT-CHEST W-WO
1663053   CT-ABDOMEN WITHOUT
1663054   CT-ABDOMEN WITH
1663055   CT-ABDOMEN W-WO
1669916   CTCHABD WITH
1669917   CTCHABD WITHOUT
1669918   CTCHABD WO-W
1663001   CTA-PELVIS
1663035   CTA-CHEST
1663056   CTA-ABDOMEN
1663601   CT-ABD PELVIS WO
1663602   CT-ABD PELVIS WITH
1663603   CT-ABD PELV WO-W
1663604   US-EXAM EXTREMITY
1663605   US-XTR NON-VASC LMTD
1669926   CT-CHABDPEL WITHOUT
1669927   CT-CHABDPEL WITH
1669928   CT-CHABDPEL WO-W
1663000   LE-LW EXTRE INFA BILL
1663016   CT-RAD TX TREAT PLAN
1663017   CT-LIMITED-FOLLOW-UP
1663018   CT-HEAD WITHOUT
1663019   CT-HEAD WITH
1663020   CT-HEAD W-WO
1663021   CT-ORBIT-EAR WITHOUT
1663022   CT-ORBIT-EAR WITH
1663023   CT-ORBIT-EAR W-WO
1663024   CT-MAXILLOFACIL WO
1663025   CT-MAXILLOFACIL WITH
1663026   CT-MAXILLOFACIL W-WO
1663027   CT-NECK SOFT TIS WO
1663028   CT-NECK SOFT TIS W
1663029   CT-NECK SOFT TS W-WO
1663030   CTA-HEAD
1663031   CTA-NECK
1663036   CT-CERV SPIN WITHOUT
1663037   CT-CERV SPIN WITH
1663038   CT-CERV SPIN W-WO
1663039   CT-THOR SPIN WITHOUT
1663040   CT-THOR SPIN WITH
1663041   CT-THOR SPIN W-WO
1663042   CT-LUMB SPIN WITHOUT
1663043   CT-LUMB SPIN WITH
1663044   CT-LUMB SPIN W-WO
1663045   CT-UP EXT WITHOUT
1663046   CT-UP EXT WITH
1663047   CT-UP EXT W-WO
1663048   CTA-UPPER EXTR
1663049   CTA-LW EXT WITHOUT
1663050   CT-LW EXT WITH
1663051   CT-LW EXT W-WO
1663052   CTA-LOWER EXTR
1663057   CTA-ABDOM ARTERIES
1663068   US-HEAD-NECK SFT TIS
1663070   US-BREAST UNI-BILAT
1663071   US-ABDOMEN
1663072   US-ABDOMEN SNGL ORG
1663073   US-ABDOMEN RETROPER
1663074   US-ABDOMEN RETRO LMT
1663076   US-SPINAL CANAL
1663077   US-PELVIS PREG
1663078   US-PELVIS PREG-2NDTR+
1663079   US-PELVS PREG LIMITD
1663087   US-TRANSVAGINAL
1663089   US-PELVIS (NON-OB)
1663090   US-PELVIS (NON-OB) F-U
1663091   US-SCROTUM
1663092   US-TRANSRECTAL
1663096   US-HIPS INFANT NO MA
1663101   US-GUIDE NEEDLE PLAC
1663103   US-GUIDE AMNIOCENT
1663111   US-ULTRASOUND UNLSTD
1663113   US-CAROTID DPLX SCAN
1663114   US-EXT VEINS DPLX WC
1663115   US-ARTERIAL
1663116   US-EXT LOWR DPLX LMT
1663118   US-NON-INV ARTER EXT
1663119   US-EXT VEINS DPX LIM
1663121   US-EXT LOWR DPLX ART
1663122   US-CAROTID DUP-DOPL
1663123   US-EXT UPPR DPLX ART
1663126   US-LMTD DPLX ART EXT
1663136   US-PELV PREG-14 WKS
1663137   US-PLV PRG-14 WKS +G
1663138   US-PLV PRG 2-T DETAIL
1663139   UD-PLV PRG-2T DETADD
1663140   US-PLV PRG F-U TRNSV
1663144   US-BIL EXT VEIN STDY
1663233   HE-EYE (FOREIGNBODY)
1663234   HE-MANDIBLE LIMITED
1663235   HE-MANDIBLE 4V+
1663237   HE-MASTOIDS 3V+
1663239   HE-FACIAL BONES LIMI
1663240   HE-FACIAL BONES 3V+
1663241   HE-NASAL BONES
1663243   HE-ORBITS 4V
1663244   HE-SINUSES LIMITED
1663245   HE-SINUSES 3V+
1663246   HE-SELLA TURCICA
1663247   HE-SKULL LIMITED
1663248   HE-SKULL 4V+
1663253   HE-TMJ BILATERAL
1663256   SP-NECK, SOFT TISSUE
1663261   CH-CHEST 1 V
1663263   CH-CHEST 2V
1663264   CH-CHEST 2 V
1663265   CH-CHEST 2 V +APICLORD
1663269   CH-CHEST 2V+OBLIQUES
1663270   CH-RIBS UNILATERAL
1663271   CH-RIBS UNI-PA CHEST
1663272   CH-RIBS BILATERAL
1663273   CH-RIBS BILAT-PA CHE
1663274   CH-STERNUM
1663275   CH-STERNOCLAV JOINTS
1663276   SP-COMP SPINE SURVEY
1663277   SP-SPINE-SINGLE VIEW
1663278   SP-CERVICAL SPIN2-3V
1663279   SP-CERVICAL SPIN 4V+
1663280   SP-CERV SP FLEX-EXT
1663282   SP-THORACIC SPINE 2V
1663283   SP-THORACIC SPINE 3V
1663285   SP-THORACOLUMBAR 2V
1663286   SP-SPINE-SCOLIO W-UP
1663287   SP-LS SPINE 2-3V
1663288   SP-LS SPINE 4V
1663289   SP-LS SPINE W-BEND
1663291   LE-PELVIS
1663294   SP-SI JOINTS 3V+
1663295   SP-SACRUM-COCCYX 2V
1663296   UE-CLAVICLE
1663297   UE-CLAVICLE BILAT
1663298   UE-SCAPULA
1663299   UE-SCAPULA BILAT
1663300   UE-SHLDR 1VIEW BILAT
1663301   UE-SHOULDER 1V
1663302   UE-SHLDR 2+VWS BILAT
1663303   UE-SHOULDER 2V+
1663304   UE-AC JTS BILATRAL
1663305   UE-HUMERUS
1663306   UE-HUMERUS BILAT
1663307   UE-ELBOW 2V
1663308   UE-ELBOW 2 VIEW BILAT
1663309   UE-ELBOW 3V
1663310   UE-FOREARM 2V
1663311   UE-FOREARM 2VW BILAT
1663312   UE-INFANT BILAT
1663313   UE-UP EXTREM INFANT
1663314   UE-WRIST 2V
1663315   UE-WRIST 2VIEW BILAT
1663316   UE-WRIST 3+VW BILAT
1663317   UE-WRIST 3V+
1663318   UE-HAND 2V
1663319   UE-HAND 2VIEW BILAT
1663320   UE-HAND 3V
1663321   UE-HAND 3 VIEW BILAT
1663322   UE-FINGER (S) 2V+
1663324   LE-HIP UNILATERAL 1 V
1663325   LE-HIP UNILATER 2V+
1663326   LE-HIP BILAT W-PELVI
1663327   LE-HIP PELVIS PEDIAT
1663328   LE-FEMUR 2V
1663329   LE-FEMUR 2VIEW BILAT
1663330   LE-KNEE 1-2 V
1663331   LE-KNEE 1-2 VW BILAT
1663332   LE-KNEE 3V
1663333   LE-KNEE 3VIEW BILAT
1663334   LE-KNEE 4+VIEW BILAT
1663335   LE-KNEE 4V+
1663336   LE-KNEE BILAT AP STA
1663337   LE-TIBIA-FIBLA 2V BI
1663338   LE-TIBIA-TIBULA 2V
1663339   LE-LOWER EXTREM INFA
1663340   LE-ANKLE 2V
1663341   LE-ANKLE 2VIEW BILAT
1663342   LE-ANKLE 3+VW BILAT
1663343   LE-ANKLE 3V+
1663344   LE-FOOT 2V
1663345   LE-FOOT 2VIEW BILAT
1663346   LE-FOOT 3V+
1663347   LE-FOOT 3VIEW+ BILAT
1663348   LE-CALCANEOUS 2 V+
1663349   LE-CALCNEOUS 2V BILA
1663350   LE-TOE (S) 2+VW BILAT
1663351   LE-TOES (S) 2V+
1663355   CH-ABDOMEN 1V
1663354   CH-ABD W-DEC-ERECT
1663355   CH-ABD SER W-PA CXR
1663357   FL-ESOPHAGUS
1663360   FL-GI SERIES W-KUB
1663361   FL-GI W-SM BOWEL
1663363   FL-GI AIR W-KUB
1663364   FL-GI AIR W-SM BOWEL
1663365   FL-SMALL BOWEL
1663368   FL-BARIUM ENEMA
1663369   FL-BARIUM ENEMA AIR
1663370   FL-ENEMA-THERAPEUTIC
1663371   FL-GALLBLADDER ORAL
1663376   FL-IVP
1663377   FL-UROGRAPHY
1663380   FL-UROGRAPHY ANTE
1663385   CH-BABYGRAM-FB
1663386   BONE AGE STUDY
1663387   BONE SRVY LIM-METS
1663388   BONE SRVY LIM-METS
1663389   BONE SRVY COMP-METS
1663391   JOINT SURVEY 1V
1663392   TOMOGRAM-SINGL PLANE
1663399   UNLISTED RAD EXAM
1663403   BR-MAMMOGRAM UNILAT
1663405   BR-MAMMOGRAM BILAT
1663406   BR-MAMMGRM SCRN BILA
1663407   BR-MAMMO SCRN UNI
1663426   CT-3D RED W-O POSTP
1663428   UE-ELBOW 3VIEW BILAT
1663429   BR-NEEDLE LOC BREAST
1663466   FL-FLUORO 1 HOUR
1663467   FL-FLUORO 1+ HOUR
1663487   US-STD LE STRS-REST
1663494   BR-DUCT-GALBRM MULT
1663495   BR-DUCT-GALGRM UNI
1663505   BR-STEREO BX BREAST
1663135   EXAM SURGSPECIMEN
2011                                                               4/3/2012

3000                                                               OTC-4182                                                                O
REEK MRI                                                   SILVER CREEK OPEN MRI                                             SLEEP WAKE DISO
a Medical Center                                         Western Arizona Medical Center
r Creed Rd                                                 1245 B East Hancock Road                                               1720 MESQU
ad City                                                           Bullhead City                                                        LAKE
Z                                                                      AZ
442                                                                  86442
                                                                     Mojave
    847173                                                    2735 Silver Creek Rd                                                1720 MESQU
las                                                               Bullhead City                                                        LAKE
X                                                                      AZ
-7173                                                                86442
3-2273                                                           928-763-2273                                                            92
24185                                                             1255302766                                                              1
118                                                                  531237
Y                                                                      Yes
1216                                                                  30101
chneider                                                        Elmer Hyde, ICEO                                                         SA
3-0201                                                           928-763-2273                                                            92
der@chs.net                                                   Elmer_Hyde@chs.net                                                   SAUL@SL
rockman                                                         Marty Brockman                                                           SA
3-0270                                                           928-763-2273                                                            92
man@chs.net                                                 Marty_Brockman@chs.net                                                 SAUL@SL
rockman                                                           Judy Kosters                                                           KA
3-0270                                                           928-763-0230                                                            92
man@chs.net                                                  Judy_Kosters@chs.net                                                 SATORI@S
/2011                                                              3/29/2012                                                               6


                   Rate of Charge       Service Code       Discription of Charge          Rate of Charge      Service Code


              $               793.16      1641034      MR-BREAST UNI WITH             $            5,295.60      99202
              $              1,016.23     1641035      MR-BREAST UNI WO               $            4,077.18      99203
              $               225.25      1641036      MR-BREAST UNI W-WO             $            5,735.84      99204
              $               284.09      1641037      MR-BREAT BILL WITH             $            5,371.57      99205
              $               284.09      1641038      MR-BREAST BIL WO               $            4,634.62      99213
              $               369.70      1641039      MR-BREAST BIL W-WO             $            5,735.84      99214
              $               467.85      1641029      MR-GUIDE NEEDLE PLAC           $            4,876.17      99215
              $               225.25      1641108      MRA-SPINAL CNL WITH            $            7,000.78      95810
              $               284.09      1641109      MRA-SPINAL CNL WO              $            5,992.12      95811
              $               369.70      1641110      MRA-SPINAL CNL WO-W            $            7,434.62      95811
              $               467.85      1641111      MRA-UPPER EXTR WITH            $            5,184.06      95805
              $               666.09      1641112      MRA-UPPER EXTR WO              $            4,240.88      95807
$   412.83   164113    MRA-UPPER EXTR WO-W    $   6,262.40   94660
$   225.36   1641114   MRA-UP EXTR WITH BI    $   7,434.62   G0399
$   190.54   1641115   MR-UP EXTR WO BI       $   6,262.40   E0601
$   328.11   1641116   MRA-UP EXTR WO-W BI    $   8,526.42   E0601
$   534.45   1641000   MR-UP EXTR WITHOUT     $   5,060.08   E0470
$   909.05   1641001   MR-UP EXTR WITH        $   5,781.74   E0470
$   206.70   1641003   MR-UP JOINT WITHOUT    $   5,784.53   E0471
$    86.19   1641004   MR-UP JOINT WITH       $   5,781.74   E0471
$   370.26   1641005   MR-UP JOINT W-WO       $   6,262.40   A7031
$   334.61   1641007   MRA-NECK WITHOUT       $   5,505.88   A7032
$   353.22   1641008   MRA-NECK WITH          $   5,505.88   A7033
$   353.22   1641009   MRA-NECK W-WO          $   5,505.88   A7034
$   266.44   1641010   MR-CHEST WITHOUT       $   5,905.75   A7035
$   385.76   1641011   MR-CHEST WITH          $   5,505.88   A7036
$   212.21   1641012   MR-CHEST W-WO          $   8,190.58   A7037
$   334.61   1641014   MR-LW EXTR WITHOUT     $   5,060.08   A7038
$   316.03   1641015   MR-LW EXTR WITH        $   5,781.74   A7039
$   244.76   1641016   MR-LW EXTR W-WO        $   5,075.41   E0562
$   266.44   1641017   MR-LW JOINT WITHOUT    $   5,784.53   E0562
$   244.76   1641018   MR-LW JOINT WITH       $   5,781.74   A7046
$   195.19   1641019   MR-LW JOINT W-WO       $   6,262.40
$   316.03   1641020   MR-ABDOMEN WITHOUT     $   5,905.75
$   158.01   1641021   MR-ABDOMEN WITH        $   5,781.74
$   212.21   1641022   MR-ABDOMEN W-WO        $   6,262.40
$   212.21   1641023   MR-CARD MORP WITHOUT   $   5,911.31
$   212.21   1641024   MR-CARD MORP W-WO      $   6,376.62
$   140.96   1641031   MR-ABDOMEN WITH        $   5,781.74
$   316.03   1641032   MR-ABDOMEN WITHOUT     $   5,060.08
$   477.14   1641033   MR-ABDOMEN W-WO        $   6,011.62
$   229.27   1641043   MRA-LW EXTR WITH       $   5,184.06
$    34.08   1641044   MR-LW EXTR WO          $   4,240.88
$   212.21   1641046   MR-ORBT-FACE-NECK WO   $   5,837.47
$   235.47   1641047   MR-ORBT-FACE-NECK W    $   5,344.29
$   201.40   1641048   MR-ORBT-FAC-NCK W-W    $   5,344.29
$   316.03   1641049   MRA-HEAD WITHOUT       $   5,505.88
$   212.21   1641050   MRA-HEAD WITH          $   5,505.88
$   339.26   1641051   MRA-HEAD W-WO          $   5,505.88
$   224.61   1641052   MR-BRAIN WITHOUT       $   5,837.47
$   161.12   1641053   MR-BRAIN WITH          $   7,000.78
$   175.83   1641054   MR-BRAIN W-WO          $   7,434.62
$   195.19   1641055   MR-CERV SPINE WO       $   5,905.75
$   235.47   1641056   MR-CERV SPINE WITH     $   7,088.56
$   140.96   1641057   MR-THOR SPINE WO       $   6,449.07
$   175.06   1641058   MR-THOR SPINE WITH     $   7,088.56
$     258.70    1641059   MR-LUM SPINE WO      $   6,379.43
$      195.19   1641060   MR-LUM SPINE WITH    $   7,000.78
$     215.33    1641061   MR-CERV SPINE W-WO   $   7,509.85
$     203.92    1641062   MR-THOR SPINE W-WO   $   7,509.85
$     175.06    1641063   MR-LUMB SPINE W-WO   $   7,434.62
$     198.29    1641065   MR-PELVIS WITHOUT    $   5,411.16
$     175.06    1641066   MR-PELVIS WITH       $   5,905.75
$     224.61    1641067   MR-PELVIS W-WO       $   8,190.58
$     597.97    1641069   MRA-PELVIS WITHOUT   $   4,668.58
$     298.99    1641070   MRA-PELVIS W-WO      $   5,530.97
$     175.06    1641079   MR-TMJS              $   5,784.53
$      212.21   1641002   MR-UP EXTR W-WO      $   6,262.40
$     188.99
$     235.35
$     140.96
$      212.21
$      86.19
$     295.60
$      43.45
$     272.38
$     233.93
$      114.63
$      161.12
$     601.08
$     658.39
$     481.77
$      119.28
$     316.03
$     175.06
$     203.92
$     286.59
$     436.86
$     278.85
$     233.93
$      114.63
$      114.63
$     164.20
$     134.34
$      86.19
$   3,089.01
$   5,561.45
$   7,724.06
$   10,813.06
$      30.96
$      54.23
$      75.91
$     106.88
$     388.83
$     582.48
$      12.40
$      18.58
$   1,924.04
$   2,886.08
$   3,849.62
$      49.57
$      74.37
$      99.15
$    2,951.14
$   2,498.79
$   3,332.23
$    4,164.10
$      79.01
$     105.34
$      130.13
$   12,712.90
$     776.12
$      24.79
$     969.77
$      30.96
$    4,811.66
$     123.94
$   4,997.55
$   5,831.00
$   6,662.90
$     156.46
$     182.79
$     209.14
$     410.99
$     429.08
$     555.73
$     540.44
$     550.31
$     710.53
$     421.43
$     728.64
$     481.48
$     634.34
$     534.98
$    759.89
$    370.12
$    407.24
$    430.17
$    498.76
$    498.76
$    583.02
$    433.44
$    583.02
$    834.53
$    692.20
$    478.21
$    579.58
$    519.70
$    683.47
$    930.66
$    654.80
$    548.08
$    751.16
$   1,051.86
$    421.43
$    453.10
$    488.03
$    371.21
$    447.64
$    883.28
$    379.95
$    663.81
$    412.70
$    613.00
$    433.28
$    704.95
$    355.93
$    417.07
$    755.10
$    373.40
$    674.31
$    381.04
$    688.24
$    379.95
$    688.24
$    376.67
$    681.27
$    396.32
$   640.89
$   380.34
$   417.07
$   798.32
$   389.77
$   704.95
$   425.80
$   693.29
$   478.21
$   862.39
$   376.67
$   681.27
$   396.32
$   711.92
$   376.67
$   681.27
$   396.32
$   640.89
$   414.48
$   658.98
$   377.76
$   440.24
$   495.68
$   615.80
$   439.89
$   534.99
$   681.27
$   417.95
$   660.54
$   352.48
$   533.89
$   650.62
$   417.95
$   681.27
$   429.08
$   640.89
$   389.77
$   634.34
$   315.53
$   509.91
$   421.43
$   548.08
$   635.15
$   261.81
$     79.01
$    373.35
$    196.74
$    195.19
$    848.94
$    384.19
$    182.79
$    207.58
$    221.54
$    247.86
$    250.66
$    347.17
$    386.07
$    105.15
$    254.96
$    404.79
$    227.61
$    463.85
$    312.59
$    319.80
$    325.55
$    116.68
$    194.48
$    435.31
$   1,753.12
$    110.92
$    300.53
$    236.25
$    769.93
$    143.38
$    630.50
$    288.12
$    563.36
$    582.14
$    483.34
$     75.91
$    317.58
$    175.74
$    545.97
$     77.79
$    384.19
$    439.36
$    334.61
$    167.31
$   373.35
$   426.01
$   336.17
$   601.08
$   597.97
$   305.16
$   362.50
$   325.31
$   188.99
$   185.90
$   460.09
$   300.53
$   373.35
$   152.69
$   278.03
$   399.02
$   262.18
$   312.59
$   204.56
$   295.31
$   302.51
$   590.62
$   275.13
$   275.13
$   410.56
$   316.92
$   347.17
$   234.81
$   244.89
$   872.18
$   365.90
$   301.08
$   288.12
$   122.44
$   278.03
$   182.93
$   127.02
$   340.81
$   175.74
$    84.67
$   204.56
$   257.87
$   197.87
$   109.99
$     56.75
$     84.67
$     84.80
$     93.64
$     811.03
$   1,214.06
$    357.23
$    582.35
$    497.87
$    433.52
$    497.87
$   3,340.88
$   3,807.59
$   4,578.02
$   3,389.64
$   3,956.66
$   4,832.99
$   3,293.52
$   3,569.36
$   4,690.87
$       -
$       -
$       -
$   3,807.59
$   3,958.05
$   3,873.07
$   6,634.54
$   7,376.54
$   9,268.64
$   1,061.60
$    530.80
$       -
$       -
$       -
$     681.27
$   1,472.59
$   2,191.51
$   2,654.04
$   3,257.27
$   3,977.55
$   2,929.89
$   3,406.35
$   4,087.64
$   2,837.93
$   3,357.59
$   4,072.32
$   2,929.89
$   3,406.35
$   4,084.84
$   3,257.27
$   3,406.35
$   3,389.64
$   3,942.73
$   4,079.28
$   3,389.64
$   3,942.73
$   4,711.77
$   3,389.64
$   3,942.73
$   5,418.13
$   2,908.98
$   3,389.64
$   4,098.77
$   3,389.64
$   2,908.98
$   3,389.64
$   4,098.77
$   3,389.64
$   4,679.74
$   1,039.32
$     861.00
$   1,462.85
$   1,061.60
$   1,419.67
$   1,056.05
$    937.62
$   1,650.93
$   3,372.92
$   1,103.41
$   1,184.22
$   1,184.22
$    746.74
$   1,142.43
$     691.04
$    959.93
$   1,199.54
$    964.08
$    664.55
$   2,061.93
$   2,478.49
$     815.00
$   1,494.91
$   1,519.96
$   1,650.93
$   2,237.46
$   1,372.30
$   2,113.46
$   1,801.41
$   1,273.38
$   1,273.38
$    959.93
$    268.89
$   1,029.58
$     913.92
$     410.99
$    482.05
$    600.47
$     419.35
$     550.31
$     710.53
$     468.12
$    728.64
$    534.99
$    704.95
$    477.86
$    594.89
$    844.27
$    734.20
$     410.99
$    452.80
$    573.99
$    498.76
$    498.76
$    440.24
$    647.84
$    647.84
$    834.53
$    769.03
$     530.81
$    579.58
$     951.55
$    352.48
$    519.67
$    759.30
$    930.66
$    593.50
$    650.62
$    607.42
$    654.80
$    607.42
$    834.53
$   1,051.86
$    468.12
$    550.31
$    502.94
$    458.35
$    613.00
$    433.28
$    704.95
$    395.67
$    395.67
$    608.82
$    468.12
$    541.96
$    463.94
$    755.10
$    415.19
$    674.31
$    423.54
$    422.16
$    688.24
$    615.80
$    409.59
$    417.95
$    681.27
$    711.92
$    476.46
$    417.95
$    681.27
$    440.24
$    711.92
$    380.34
$    412.38
$    497.37
$    883.28
$    534.99
$    463.94
$    798.32
$    433.28
$    704.95
$    473.69
$    770.44
$    862.39
$     530.81
$     422.16
$    704.95
$    433.28
$     417.95
$     417.95
$     681.27
$     711.92
$    440.24
$     417.95
$     681.27
$    440.24
$     711.92
$    404.03
$    658.98
$     509.91
$     351.08
$    476.46
$     617.20
$     737.01
$   1,132.66
$   1,519.96
$   2,258.36
$   1,591.03
$   2,374.00
$   1,209.30
$   1,656.52
$   2,237.46
$   2,117.65
$     737.01
$   1,469.82
$   1,277.53
$     991.96
$    476.46
$   1,490.72
$     841.49
$   1,106.19
$   1,490.72
$   1,297.07
$   1,273.38
$     447.21
$    242.09
$     310.29
$    243.94
$    243.94
$   1,688.55
$    423.54
$    628.34
$    834.53
$   1,178.65
$   1,628.65
$   2,680.50
$   1,950.46
$   2,817.03
$    344.77
                    2/8/2011                                                              2/3/2012

                   OTC-3548                                                               OTC-4263
  SLEEP WAKE DISORDER CENTER OF HAVASU                                            Troyer Urgent Care, Inc.


       1720 MESQUITE AVE, SUITE 201                                                1810 Mesquite Ave. Ste. B
             LAKE HAVASU CITY                                                          Lake Havasu City
                      AZ                                                                   Arizona
                     86403                                                                  86403


       1720 MESQUITE AVE, SUITE 201                                                1810 Mesquite Ave. Ste. B
             LAKE HAVASU CITY                                                          Lake Havasu City
                      AZ                                                                   Arizona
                     86403                                                                  86403
                  928 855-7570                                                          928-453-4600
                   1265447718                                                            1639374317
                    881525                                                                 260741
                      YES
                     71482                                                                 Z116757
                 SAUL ALVAREZ                                                        Randal L Troyer, MD
                  928 246-0500                                                          928-453-4600
         SAUL@SLEEPRESOURCE.ORG                                                  troyerurgentcare@hotmail.com
                 SAUL ALVAREZ                                                            Greg Troyer
                  928 246-0500                                                          928-453-4600
         SAUL@SLEEPRESOURCE.ORG                                                   greg@troyerurgentcare.com
                 KAREN MILLER                                                            Greg Troyer
                  928 855-7076                                                          928-453-4600
        SATORI@SLEEPRESOURCE.ORG                                                  greg@troyerurgentcare.com
                   6/27/1905                                                             10/10/2007


          Discription of Charge           Rate of Charge      Service Code


INITIAL OFFICE VISIT EXPANDED         $              124.00              10021
INITIAL OFFICE VISIT DETAILED         $              184.00      10060
INITIAL OFFICE VISIT EXTENDED         $              279.00      10061
INITIAL VISIT COMPREHENSIVE           $              351.00      10080
FOLLOW UP VISIT                       $              119.00      10081
FOLLOW UP VISIT DETAILED              $              180.00      10120
FOLLOW UP VISIT COMPREHENSIVE         $              244.00      10121
DIAGNOSTIC SLEEP STUDY                $            1,900.00      10140
CPAP TITRATION                        $            2,000.00      10160
SPLIT NIGHT STUDY                     $            2,000.00      10180
MSLT SLEEP STUDY                      $            1,400.00      11040
CPAP DESENSITIZATION (PAP-NAP)        $            1,200.00      11041
CPAP INITIATION AND MANAGEMENT    $     80.00    11042
HOME SLEEP STUDY, UNATTENDED      $    500.00    11043
STANDARD CPAP RENTAL              $     140.00   11055
STANDARD CPAP PURCHASE            $    600.00    11056
STANDARD BI-LEVEL RENTAL          $     218.00   11057
STANDARD BI-LEVEL PURCHASE        $   1,200.00   11100
BI-LEVEL WITH RATE/ASV RENTAL     $    600.00    11200
BI-LEVEL WITH RATE/ASV PURCHASE   $   3,640.00   11201
FULL FACE MASK                    $    226.37    11300
NASAL CUSHION                     $     48.64    11301
NASAL PILLOWS                     $     34.08    11302
NASAL INTERFACE                   $     141.17   11303
HEADGEAR                          $     50.00    11305
CHINSTRAP                         $     25.95    11306
TUBING 6'                         $     53.00    11307
DISPOSABLE FILTER                 $       6.47   11308
NON-DISPOSABLE FILTER             $      18.40   11310
HUMIDIFIER-HEATED RENTAL          $     40.00    11311
HUMIDIFIER-HEATED PURCHASE        $    400.00    11312
REPLACEMENT HUMIDIFIER CHAMBER    $     50.00    11313
                                                 11400
                                                 11401
                                                 11402
                                                 11403
                                                 11404
                                                 11406
                                                 11420
                                                 11421
                                                 11422
                                                 11423
                                                 11424
                                                 11426
                                                 11440
                                                 11441
                                                 11442
                                                 11443
                                                 11444
                                                 11446
                                                 11600
                                                 11601
                                                 11602
                                                 11603
                                                 11604
                                                 11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11730
11732
11740
11750
11755
11760
11765
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14040
16000
16020
16025
16030
17000
17003
17004
17110
17250
20100
20101
20102
20103
20520
20525
20526
20550
20551
20552
20553
20600
20605
20610
20612
21337
23500
23505
23650
23930
23931
24500
24505
24560
24600
24620
24640
24670
24675
25500
25505
25520
25530
25535
25560
25565
25600
25605
25622
25624
25630
25635
25650
25660
25675
25680
25690
26010
26011
26020
26025
26030
26340
26350
26600
26605
26607
26641
26645
26700
26705
26720
26725
26740
26742
26750
26755
26770
26775
27560
27750
27760
27780
27808
27816
27824
27840
28190
28400
28430
28470
28490
28510
28515
28530
28570
28600
28630
28660
29105
29125
29130
29505
29515
29580
29700
29705
30300
30901
30903
36415
36416
40650
40652
40654
40800
40801
40804
40805
41000
41005
41006
41007
41008
41009
41250
41251
41252
41800
42000
42300
42305
42310
42320
42700
45990
46250
46320
46600
46608
51701
51702
56405
56420
56740
57415
64450
65205
65210
65220
69000
69005
69020
69200
69210
70030
70110
70150
70160
70210
70220
70250
70260
70330
70360
71010
71020
71022
71030
71035
71100
71101
71110
71111
71120
71130
72040
72050
72052
72070
72080
72100
72110
72170
72190
72202
72220
73000
73010
73030
73050
73060
73070
73080
73090
73100
73110
73120
73130
73140
73510
73520
73550
73560
73562
73564
73590
73600
73610
73620
73630
73650
73660
74000
74020
74022
80047
80048
80050
80051
80053
80061
80074
80076
80100
80100
80162
80185
81001
81002
81003
81025
82075
82150
82465
82947
82948
82962
83036
83690
83721
83735
84132
84153
84436
84439
84443
84479
84481
84702
85018
85025
85610
85651
85730
86308
86490
86580
86580
86592
86635
86703
86706
86706
86762
86765
86787
86804
87045
87070
87081
87086
87177
87210
87220
87255
87274
87491
87591
87804
87880
88164
88165
90471
90472
90656
90658
90663
90703
90746
90746
90760
90761
90772
90774
92081
92283
93000
93922
94150
94640
94750
94760
96360
96361
96372
96374
97005
97124
97602
98925
99000
99050
99058
99070
99173
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99354
99355
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99408
99409
99455
99455
A4565
A6449
A6450
A7003
E0114
G0001
G0101
G0102
G0107
G0344
G0366
G0396
G0397
H0048
J0170
J0570
J0696
J0698
J1030
J1100
J1200
J1885
J2001
J2360
J2405
J2550
J2920
J2930
J3301
J3420
J7030
J7040
J7620
J7644
L0120
L1810
L1930
L3260
L3700
L3908
L3999
L4350
S9083
S9088
                                    2/3/2012                                                       10/25/2011

                                   OTC-4263                                                         OTC-4868
                          Troyer Urgent Care, Inc.                                          TrueRehab of Arizona, LLC


                          1810 Mesquite Ave. Ste. B                                         297 Lake Havasu Ave S #102
                              Lake Havasu City                                                   Lake Havasu City
                                     Arizona                                                         Arizona
                                     86403                                                            86403
                                                                                                     Mohave
                          1810 Mesquite Ave. Ste. B                                                   same
                              Lake Havasu City                                                        same
                                     Arizona                                                          same
                                     86403                                                            86403
                               928-453-4600                                                       928-453-0201
                                   1639374317                                                      1801941992
                                     260741                                                          924292
                                                                                                       yes
                                    Z116757                                                          Z109060
                             Randal L Troyer, MD                                                 Thomas Bennetch
                               928-453-4600                                                       928-453-0501
                      troyerurgentcare@hotmail.com                                          trurrehab@frontiernet.net
                                   Greg Troyer                                                     Susan Fosher
                               928-453-4600                                                       928-453-0501
                        greg@troyerurgentcare.com                                           truerehab@frontiernet.net
                                   Greg Troyer                                                     Susan Fosher
                               928-453-4600                                                       928-453-0501
                       greg@troyerurgentcare.com                                            truerehab@frontiernet.net
                                   10/10/2007                                                       10/1/2007


                          Discription of Charge           Rate of Charge     Service Code


Fine ndle asprtn w/o imaging guide                    $             212.00      97001
I&D Abscess                                           $             174.00      97002
I&D abscess Mult/complicated                          $             337.00      97010
I&D Pilonidal Cyst                                    $             249.00      97012
Drainage of pilonidal cyst, complicated               $             347.00   97014/G0283
FB Removal- Simple Skin                               $             196.00      97026
FB Removal Complicated Skin                           $             441.00      97032
Drainage hematoma/seroma                              $             226.00      98033
Puncture drainage of skin lesion                      $             158.00      97035
Drain comp) postop wound infected                     $             403.00      97110
Debridement Skin                                      $              75.00      97112
Debridement, skin, full thickness                     $             109.00      97116
Debridement of skin/tissue                                    $    75.00   97124
Debridement of tissue/muscle                                  $   109.00   97140
Paring/cut lesion (corn), 1                                   $    59.00   97150
Paring/cut benign skin lesion, 2-4                            $    72.00   G0283
Paring/cut benign skin lesion, 4-1                            $    89.00   29540
Biopsy of skin lesion                                         $   112.00   64550
Removal skin tags- up to 15                                   $   142.00
Removal of each add'l 10 skin tags                            $    53.00
Shave skin lesion, trunk/arm/leg 0.5 cm                       $   109.00
Shave skin lesion 0.6-1.0cm                                   $   146.00
Shave skin lesion 1.1-2.0cm                                   $   171.00
Shave skin lesion, over 2.0cm                                 $   205.00
Shave lesion, scalp/neck/hand/foot 0.5 cm                     $   110.00
Shave lesion, scalp/neck/hand/foot 0.6-1.0 cm                 $   151.00
Shave lesion, scalp/neck/hand/foot 1.1-2.0 cm                 $   176.00
Shave lesion, scalp/neck/hand/foot over 2.0 cm                $   208.00
Shave lesion, face/lid/ear/nose/lip 0.5 cm                    $   134.00
Shave lesion, face/lid/ear/nose/lip 0.6-1.0 cm                $   166.00
Shave lesion, face/lid/ear/nose/lip 1.1-2.0cm                 $   192.00
Shave lesion, face/lid/ear/nose/lip over 2.0 cm               $   251.00
Remove lesion, trunk/arm/leg 0.5 cm or less                   $   196.00
Remove lesion to 1.0 cm                                       $   239.00
Remove lesion, trunk/arm/leg 1.1-2.0 cm                       $   273.00
Remove lesion, trunk/arm/leg 2.1-3.0 cm                       $   317.00
Remove lesion, trunk/arm/leg 3.1-4.0 cm                       $   418.00
Rem lesion, trunk/arm/leg >4cm                                $   557.00
Remove lesion, scalp/neck/hand/foot/genitaoia 0.5cm or less   $   199.00
Remove lesion, scalp/neck/hand/foot/genitalia 0.6 -1.0 cm     $   254.00
Remove lesion, scalp/neck/hand/foot/genitalia 1.1-2.0 cm      $   284.00
Remove lesion, scalp/neck/hand/foot/genitlia 2.1-3.0 cm       $   387.00
Remove lesion, scalp/neck/hand/foot/genitalia 3.1-4.0 cm      $   441.00
Remove lesion, scalp/neck/hand/foot/genitalia 4.1 cm +        $   619.00
Remove lesion,face/lid/ear/nose/lip/eyelids 0.5 cm or less    $   240.00
Remove lesion,face/lid/ear/nose/lip/eyelids 0.6-1.0 cm        $   281.00
Remove lesion,face/lid/ear/nose/lip/eyelids 1.1-2.0 cm        $   345.00
Remove lesion,face/lid/ear/nose/lip/eyelids 2.1-3.0 cm        $   426.00
Remove lesion,face/lid/ear/nose/lip/eyelids 3.1-4.0 cm        $   526.00
Remove lesion,face/lid/ear/nose/lip/eyelids 4.1 cm +          $   712.00
Remove malig lesion, trunk/arm/leg 0.5cm or less              $   265.00
Remove malig lesion, trunk/arm/leg 0.6-1.0 cm                 $   327.00
Remove malig lesion, trunk/arm/leg 1.1-2.0 cm                 $   349.00
Remove malig lesion, trunk/arm/leg 2.1-3.0 cm                 $   385.00
Remove malig lesion, trunk/arm/leg 3.1-4.0 cm                 $   446.00
Remove malig lesion, trunk/arm/leg 4.1 cm +                   $   578.00
Remove malig lesion, head/hand/foot 0.5 cm or less   $   274.00
Remove malig lesion, head/hand/foot 0.6-1.0 cm       $   325.00
Remove malig lesion, head/hand/foot 1.1-2.0 cm       $   369.00
Remove malig lesion, head/hand/foot 2.1-3.0 cm       $   439.00
Remove malig lesion, head/hand/foot 3.1-4.0 cm       $   506.00
Remove malig lesion, head/hand/foot 4.1 cm +         $   659.00
Remove malig lesion, face/nose/lips 0.5cm or less    $   291.00
Remove malig lesion, face/nose/lips 0.6-1.0 cm       $   349.00
Remove malig lesion, face/nose/lips 1.1-2.0 cm       $   438.00
Remove malig lesion, face/nose/lips 2.1-3.0 cm       $   507.00
Remove malig lesion, face/nose/lips 3.1-4.0 cm       $   614.00
Remove malig lesion, face/nose/lips 4.1 cm +         $   863.00
Nail Plate Removal                                   $   167.00
Nail Plate Removal each additional                   $    81.00
Nail Drain Hematoma                                  $    88.00
Nail Matrix Removal                                  $   294.00
Biopsy of Nail                                       $   185.00
Repair of nail bed                                   $   338.00
Excise skin wedge, ingrown toenail                   $   162.00
Lac Simple 0cm - 2.5cm                               $   271.00
Lac Simple 2.6cm - 7.5cm                             $   302.00
Lac Simple 7.6cm - 12.5cm                            $   375.00
Repair superficial wounds, trunk 12.6-20.0 cm        $   420.00
Repair superficial wounds, trunk 20.1-30.0 cm        $   479.00
Repair superficial wounds, trunk 30.1cm +            $   548.00
Lac Face 0cm - 2.5cm Simple                          $   302.00
Lac Face 2.6cm - 5.0cm Simple                        $   355.00
Lac Face 5.1cm - 7.5cm Simple                        $   375.00
Lac Face 7.6cm - 12.5 Simple                         $   459.00
Repair superficial wounds, face 12.6-20.0 cm         $   667.00
Repair superficial wounds, face 20.1-30.0 cm         $   834.00
Repair superficial wounds, face 30.1 cm +            $   657.00
Closure of split wound, simple                       $   386.00
Closure of split wound w/packing                     $   302.00
Lac Scalp,Trunk,Extremity, Itrm, 2.5 cm or less      $   281.00
Lac Scalp,Trunk,Extremity, Itrm, 2.6-7.5 cm          $   360.00
Lac Scalp,Trunk,Extremity, Itrm, 7.6-12.5 cm         $   445.00
Layer closure of wounds, trunk 12.6-20.0 cm          $   533.00
Lac Scalp,Trunk,Extremity, Itrm, 20.1-30.0 cm        $   655.00
Layer closure of wounds, trunk 30.1 cm +             $   712.00
Lac Neck, Hand, Feet, Itrm, 2.5 cm or less           $   324.00
Lac Neck, Hand, Feet, Itrm, 2.6-7.5 cm               $   390.00
Lac Neck, Hand, Feet, Itrm, 7.6-12.5 cm              $   465.00
Layer closure of wounds, hands/feet 12.6-20.0 cm     $   594.00
Layer closure of wounds, hands/feet 20.1-30.0 cm             $    769.00
Layer closure of wounds, hands/feet 30.1 cm +                $    712.00
Lac Face 0cm - 2.5 Intm                                      $    390.00
Lac Face 2.6cm - 5.0cm Intm                                  $    437.00
Lac Face 5.1cm - 7.5cm Intm                                  $    507.00
Layer closure of wounds, face/ears 7.6-12.5 cm               $    629.00
Layer closure of wounds, face/ears 12.6-20.0 cm              $    839.00
Layer closure of wounds, face/ears 20.1-30.0 cm              $    979.00
Layer closure of wounds, face/ears 30.1 cm +                 $    885.00
Repair complex wound, trunk 11-2.5 cm                        $    393.00
Repair complex wound, trunk 2.6-7.5 cm                       $    524.00
Repair, complex, trunk add 5cm or less                       $    187.00
Repair complex wound, scalp/arrm/leg 1.1-2.5 cm              $    414.00
Repair complex wound, scalp/arrm/leg 2.6-7.5 cm              $    635.00
Repair complex wound, scalp/arrm/leg ech add. 5 cm           $    256.00
Repair complex wound,face/hand/foot/genitalia 1.1-2.5 cm     $    543.00
Repair complex wound,face/hand/foot/genitalia 2.6-7.5 cm     $    939.00
Repair complx face/hnd/ft add. 5 cm or less                  $    373.00
Repair complex wound, nose/ear/lips/eyelids 1.0 cm or less   $    469.00
Repair complex wound, nose/ear/lips/eyelids 1.1-2.5 cm       $    695.00
Repair complex wound, nose/ear/lips/eyelids 2.6-7.5 cm       $   1,187.00
Repair cmplx nose/ear/lip add. 5cm or less                   $    467.00
Secondary closure of sugical wound                           $   1,055.00
Tissue transfer, face/hands/feet                             $   1,228.00
Initial Treatment to Burn                                    $     94.00
Debridement Small Burn                                       $    137.00
Burn treatment w/o anesth, medium                            $    217.00
Burn treatment w/o anesth, large                             $    321.00
Destroy Premalignant Lesion, 1st                             $     114.00
Destroy Premalignant Lesion 2-14                             $     23.00
Destroy Premalignant Lesion 15 +                             $    373.00
Destroy Benign Lesion 1 to 14                                $    135.00
Chemical Cautery                                             $    120.00
Explore penetrating wound, neck                              $   1,218.00
Explore penetrating wound, chest                             $   1,065.00
Explore penetrating wnd, abdmn/back                          $   1,096.00
Explore penetrating wnd, arm/leg                             $   1,157.00
Remove object, muscle/tendon, simple                         $    373.00
Remove object, muscle/tendon, complex                        $    970.00
Inject, therapeutic, carpal tunnel                           $    152.00
Trigger Point Single Tendon or Ligament                      $    130.00
Injection, tendon origin/insertion                           $    130.00
Inject sngl/mlt trig pt 1-2 msclgrp                          $    137.00
Inject sngl/mlt trig pt 3+ msclgrp                           $     118.00
Drain/inject minor joint                          $    107.00
Drain/inject intermed joint                       $    130.00
Drain/inject major joint or bursa                 $    145.00
Aspiration and/or injection of ganglion cyst(s)   $     115.00
Closed Treat Nasal Septal Fracture                $    775.00
Treat clavicle fracture                           $    432.00
Treat clavicle Fx w/manipulation                  $    823.00
Reduct Shoulder Disl                              $    588.00
Upper Arm or Elbow I&D Abscess                    $    736.00
Drainage of arm bursa                             $    736.00
Clsd trtmnt hmrl shft Fx w/o manipulation         $    725.00
Clsd trtmnt hmrl shft Fx w/manipulation           $   1,107.00
Clsd trtmnt hmrl epicondylar Fx                   $    705.00
Treat elbow dislocation                           $    719.00
Treat elbow Fx/disloc, Monteggi                   $   1,409.00
Treat "Nursemaid Elbow"                           $    262.00
Treat ulnar fracture                              $    684.00
Treat ulnar Fx w/manipulation                     $   1,127.00
Clsd trtmnt rdl shaft Fx w/o manipulation         $    564.00
Clsd trtmnt rdl shaft Fx w/manipulation           $   1,093.00
Clsd trtmnt Galaezzi Fx/dislocation               $   1,264.00
Clsd trtmnt ulnar shft Fx w/o manipulation        $    564.00
Clsd trtmnt ulnar shft Fx w/manipulation          $   1,025.00
Clsd trtmnt rdl/ulna Fx w/o manipulation          $    615.00
Clsd trtmnt rdl/ulna Fx w/manipulation            $   1,230.00
Clsd trtmnt distal rdl Fx w/o manipulation        $    649.00
Clsd trtmnt distal rdl Fx w/manipulation          $   1,196.00
Clsd trtmnt crpl scaph Fx w/o manipulation        $    684.00
Clsd trtmnt crpl scaph Fx w/manipulation          $    892.00
Clsd trtmnt crpl bone Fx w/o manipulation         $    615.00
Clsd trtmnt crpl bone Fx w/manipulation           $    940.00
Clsd trtmnt ulnar styloid fracture                $    718.00
Clsd trtmnt wrist dsloc w manipulation            $    759.00
Clsd trtmnt radulnr dsloc w/manipulation          $    888.00
Clad trtmnt wrist Fx dsloc w/manipulation         $    957.00
Clsd trtmnt lunate dsloc, w/manipulation          $   1,093.00
Drainage of finger abscess, simple                $    532.00
Drainage of finger abscess, complex               $    827.00
Drain hand/digit tendon sheath, each              $   1,292.00
Drainage of palmer bursa, single                  $   1,292.00
Drainage of palmer bursa, multiple                $   1,525.00
Manip fngr joint under anes, each joint           $    905.00
Rpr flexor tndn, w/o grft, ea tendon              $   2,118.00
Clsd trtmnt mtcrpl Fx sng w/o manipulation        $    490.00
Metacarpal Fracture with manipulation         $    608.00
Clsd trtmnt mtcrpl Fx w/manip/fxtn            $   1,309.00
Clad trtmnt,thumb dsloc w/manipulation        $    670.00
Clsd trtmnt thumb Fx dsloc w/manipulation     $    865.00
Clsd trtmnt knuckle dsloc w/o anes            $    610.00
Clsd trtmnt knuckle dsloc w/anes              $    767.00
Clsd trtmnt fngr/thumb Fx w/o manipulation    $    356.00
Clsd trtmnt fngr/thumb Fx w/manipulation      $    667.00
Clsd trtmnt artclr Fx w/o manipulation        $    538.00
Clsd trtmnt artclr Fx w/manipulation each     $    795.00
Clsd trtmnt dstl fngr Fx w/o manipulation     $    351.00
Clsd trtmnt dstl fngr Fx w/manipulation       $    595.00
Reduce IP joint                               $    500.00
Reduct Finger Disl w/ anesth                  $    709.00
Treat kneecap dislocation                     $    686.00
Treat tibia shaft fracture                    $    732.00
Treat ankle fracture                          $    694.00
Treat fibula fracture                         $    551.00
Treat bimalleolar ankle fracture              $    694.00
Treat trimalleolar ankle fracture             $    655.00
Treat lower leg fracture                      $    694.00
Treat ankle dislocation                       $    732.00
Remove object from foot, subcutaneous         $    312.60
Heel fracture                                 $    608.00
Treatment of closed talus fracture            $    569.00
Treat metatarsal fracture                     $    455.00
Treat great toe fracture                      $    256.00
Treatment of toe fracture                     $    247.00
Treatment of toe Fx w/manipulaion             $    313.00
Treat sesamoid bone fracture                  $    304.00
Treat talotarsal joint dislocation            $    304.00
Treat tarsometatarsal joint dislocation       $    417.00
Treat metatarsophalangeal joint dislocation   $    304.00
Treat interphalangeal joint dislocation       $    228.00
Splint Application Long arm                   $    166.00
Splint Application Short arm                  $    128.00
Splint Application Finger                     $     77.00
Splint Application Long leg                   $    179.00
Splint Application Short leg                  $    130.00
Application of Una Boot                       $     101.00
Remove / Revise Una Boot                      $     101.00
Cast Removal Arm or Leg                       $    129.00
FB Removal- Nasal                             $    333.00
Control Epitaxis 1                            $    188.00
Control Epitaxis 2                                 $    313.00
Veinpuncture Fee                                   $     14.00
Capillary Blood Collection                         $     15.00
Repair lip vermilion                               $    857.00
Repair lip, up to 1/2 vertical height              $   1,042.00
Repair lip, over 1/2 or complex                    $   1,484.00
Drainage of mouth lesion, simply                   $    365.00
Drain mouth lesion, complicated                    $    853.00
Remove foreign body, mouth, simple                 $    391.00
Remove foreign body, mouth, complicated            $    758.00
Drain mouth lesion, lingual                        $    306.00
Drain mouth lesion,subling,superficial             $    402.00
Drain mouth lesion, subling, deep                  $    686.00
Drain mouth lesion, submental space                $    694.00
Drain mouth lesion, submandib space                $    697.00
Drain mouth lesion,masticator space                $    744.00
Repair tongue/mouth laceration                     $    410.00
Repair tongue/mouth laceration posterior 1/3       $    461.00
Repair tongue/mouth laceration over 2.6 cm         $   1,089.00
Drainage of gum lesion                             $    362.00
Drainage of mouth roof lesion                      $    313.00
Drainage of salivary gland abscess, simple         $    397.00
Drainage of salivary gland abscess, complicated    $    883.00
Drainage of salivary gland abscess, intaoral       $    316.00
Drainage of salivary gland abscess, external       $    474.00
Drainage of tonsil abscess                         $    358.00
Rectum Exam, Digital                               $     10.00
Removal of multiple external hemorrhoids           $    972.00
Excision of External Hemroid                       $    281.00
Anoscopy                                           $    169.00
Anoscopy FB Removal                                $    483.00
Cath insert (straight)                             $    150.00
Cath insert (foley)                                $    152.00
Drainage of vulva/perineum abscess                 $    284.00
Incision & drainage of Bartholin's gland abscess   $    312.00
Excision of Bartholin's Cyst                       $    444.00
FB Removal, vaginal                                $    381.00
Inject nerve block, peripheral                     $    295.00
FB Removal Conjunctival- Simp                      $    129.00
FB Removal conj embedded                           $    140.00
FB Removal- Corneal w/o slit                       $     151.00
Drain external ear lesion, simple                  $    251.00
Drain external ear lesion, complicated             $    670.00
Drain outer ear canal lesion                       $    284.00
FB Removal- Ear                        $   205.00
Ear Lavage                             $    83.00
X-ray exam of eye for foreign body     $   152.00
X-Ray exam of jaw complete             $   151.00
X-ray exam of facial bones,complete    $   166.00
X-ray exam of nasal bones, cornplete   $   100.00
X-ray exam of sinuses                  $   110.00
X-ray exam of sinuses, complete        $   190.00
X-ray exam of skull, partial           $   138.00
X-ray exam of skull, complete          $   196.00
X-ray exam of jaw joints               $   198.00
X-ray exam of neck tissue              $   117.00
Chest x-ray, single view, frontal      $   132.00
Chest x-ray, PA Lateral                $   154.00
Chest x-ray, PA Lat Obliques           $   206.00
Chest x-ray, 4 view                    $   212.00
Chest x-ray, special views             $   131.00
X-ray exam of ribs, one side           $   154.00
X-ray exam of ribs, chest, one side    $   182.00
X-ray exam of ribs, both sides         $   199.00
X-ray exam of ribs,chest,both sides    $   229.00
X-ray exam of breastbone, 2+ views     $   153.00
X-ray exam of sternoclav joint(s)      $   170.00
X-ray exam of neck spine 2-3 views     $   144.00
X-ray exam of neck spine, 4+ views     $   200.00
X-ray exam of neck spine, complete     $   233.00
X-ray exam of thoracic spine 2 views   $   143.00
X-ray exam of trunk spine 2 views      $   154.00
X-ray exam lower spine 2-3 views       $   145.00
X-ray exam lwr spine, min 4 views      $   209.00
X-ray exam of pelvis, 1-2 views        $   150.00
X-ray exam of pelvis, complete         $   185.00
X-ray exam of sacroiliac joints        $   175.00
X-ray exam of tailbone, 2+ views       $   155.00
X-ray exam of collarbone, complete     $   118.00
X-ray of shoulder blade, complete      $   137.00
X-ray exam of shoulder, complete       $   145.00
X-ray exam of shoulder joints          $   148.00
X-ray exam of humerus, 2+ views        $   132.00
X-ray exam of elbow, 2 views           $   110.00
X-ray exam of elbow, complete          $   127.00
X-ray exam of forearm, 2 views         $   113.00
X-ray exam of wrist, 2 views           $   107.00
X-ray exam of wrist, complete          $   123.00
X-ray exam of hand, 2 views            $   105.00
X-ray exam of hand, 3+ views           $   121.00
X-ray exam of finger(s), 2+ views      $    89.00
X-ray exam of hip, complete            $   138.00
X-ray exam of hips, 2+ views           $   169.00
X-ray exam of thigh, 2 views           $   221.00
X-ray exam of knee, 1 or 2 views       $   116.00
X-ray exam of knee, 3 views            $   128.00
X-ray exam of knee, 4+ views           $   155.00
X-ray exam tib/fib, 2 views            $   115.00
X-ray exam of ankle, AP/LAT            $   106.00
X-ray exam of ankle, complete          $   121.00
X-ray exam of foot, 2 views            $   105.00
X-ray exam of foot, complete           $   118.00
X-ray exam of heel, 2+ views           $   104.00
X-ray exam of toe(s), 2+ views         $    96.00
X-ray exam of abdomen, single view     $   138.00
X-ray exam of abdomen, complete        $   177.00
X-ray exam series, abdomen             $   192.00
i-STAT Chem-8 Panel                    $    49.00
Basic Metabolic Panel                  $    49.00
CMP, CBC, TSH General Health           $   159.00
Electrolyte panel                      $    41.00
Complete Metabolic Panel               $    57.00
Lipid Profile                          $    66.00
Hep Panel Acute                        $   270.00
Hepatic profile                        $    58.00
Drug Screen - 5 or 10 Panel            $    87.00
Drug Screen - 5 or 10 Panel            $    51.00
Digoxin                                $    49.00
Assay, Phenytoin, total                $    53.00
Urinalysis, complete with microscope   $    19.00
UA Dipstick                            $    15.00
UA Dipstick - automated                $    15.00
Urine Preg Test                        $    28.00
Breath Alcohol Test                    $    35.00
Amylase,                               $    28.00
Assay, cholest, serum/whole bld ttl    $    22.00
Glucose Plasma                         $    25.00
Blood Sugar Check (Reagent Strip)      $    22.00
Blood Sugar Check                      $    22.00
Hemoglobin Al-C                        $    58.00
Lipase                                 $    47.00
LDL Cholesterol                        $    43.00
Assay, Blood Magnesium                  $   39.00
Assay, Blood Potassium                  $    21.00
Assay, PSA, total                       $   63.00
Thyroid Panel                           $   39.00
Thyroxine, T4 Free                      $   70.00
TSH                                     $    91.00
Assay, Thyroid Hormone                  $   39.00
T3 Free                                 $   115.00
HCG Quant                               $   83.00
Hemoglobin count                        $    17.00
CBC                                     $   34.00
Protime                                 $   20.00
RBC sedimentation rate, non-automated   $   28.00
PTT                                     $   25.00
Monospot                                $   34.00
Cocci Skin Test                         $   55.00
TB Skin Test                            $   25.00
TB Skin Test                            $   28.00
RPR (Syphilis)                          $   37.00
Cocci IGG/IGM                           $   97.00
HIV-1 and HIV-2 Single Assay            $   86.00
Hepatitis B Titer                       $   67.00
Hepatitis B Titer                       $   56.00
Antibody, Rubella                       $   58.00
Antibody, rubeola                       $   103.00
Varicella Zoster Titer                  $   126.00
Hep CAB                                 $   167.00
Feces culture for bacteria              $   54.00
Culture Wound, Aerobic                  $   59.00
Strep A Culture                         $   54.00
Urine Culture & Sens                    $   54.00
Ova and Parasite Smears                 $   49.00
Wet Prep                                $   46.00
Tissue exam for fungi/ova/mites         $   28.00
HSV culture-rapid                       $    91.00
HSV/VZV virus culture                   $   45.00
Chlamydia probe                         $   128.00
Gonorrhea probe                         $   128.00
Influenza A and B Assay                 $   43.00
Strep Screen                            $   40.00
PAP                                     $   64.00
Rescreening FFS PAP                     $   70.00
Inject - Vaccine                        $   29.00
Each Additional Vaccine                 $   27.00
Syringe - Flu Vaccine 3 year and older   $    25.00
Vial - Flu Vaccine 3 year and older      $    35.00
H1N1 Flue Vaccine                        $    15.43
Tetanus Intramuscular                    $    31.00
Hepatitis B Adult                        $    51.00
Hepatitis B Adult                        $    94.00
IV Hydration therapy, 1 hour             $   188.00
IV Hydration, each additional hour       $    49.00
Injection Fee                            $    29.00
THER/PROPH/DIAG INJ, IV PU               $    91.00
Visual field exam(s), limited            $    84.00
Vision - Color Testing, Ishihara         $     8.00
EKG w/ lnterprt                          $    75.00
Physiologic extremity study              $   283.00
Vital capacity test                      $    63.00
Nebulizer Treatment (SVN)                $    39.00
Pulmonary compliance study               $   174.00
Pulse Ox                                 $    10.00
IV Hydration therapy, 1 hour             $   188.00
IV Hydration, each additional hour       $    49.00
Injection Fee                            $    29.00
THER/PROPH/DIAG INJ, IV PU               $    91.00
Sports Physical                          $    89.00
Massage Therapy                          $    42.00
Removal of tissue, new bandage           $    52.00
OMT 1-2 Areas                            $    57.00
Specimen handling/transport              $    18.00
Stat Fee                                 $    85.00
After Hours Office Visit                 $    85.00
Medical Supplies                         $    57.00
Visual acuity- Snellen chart             $    25.00
New Patient Visit Level 1                $    83.00
New Patient Visit Level 2                $   105.00
New Patient Visit Level 3                $   150.00
New Patient Visit Level 4                $   200.00
New Patient Visit Level 5                $   260.00
Established Patient Visit Level 1        $    50.00
Established Patient Visit Level 2        $    70.00
Established Patient Visit Level 3        $    95.00
Established Patient Visit Level 4        $   150.00
Established Patient Visit Level 5        $   224.00
Extended Visit 30-74 min                 $   224.00
Extended Visit 75-104 min                $   170.00
Preventive checkup, new, infant          $   130.00
Preventive checkup, new, 1-4 yr           $   140.00
Preventive checkup, new 5-11 y            $   150.00
Preventive checkup, new, 12-17            $   160.00
Preventive checkup, new, 18-39            $   215.00
Preventive checkup, new, 40-64            $   235.00
Preventive checkup, new, 65+ yrs          $   265.00
Preventive checkup, est, infant           $   110.00
Preventive checkup, est, 1-4 yrs          $   115.00
Preventive checkup, est, 5-11 yr          $   125.00
Preventive checkup, est, 12-17            $   135.00
Preventive checkup, est, 18-39            $   145.00
Preventive checkup, est, 40-64            $   160.00
Preventive checkup, est, 65+ yrs          $   180.00
Alcohol/Substance Counsel 15-30 min.      $    75.00
Alcohol/Substance Counsel, over 30 min.   $   154.00
DOT / Employment Physical                 $    78.00
DOT / Employment Physical                 $   149.00
Arm Sling                                 $    15.56
ACE Wrap 3" to 5"                         $     5.00
ACE Wrap 6"                               $     9.00
Nebulizer Administration Kit              $     5.00
Crutches, Alumiinum                       $    57.00
Venipuncture                              $     5.00
Screening Breast/Pelvic                   $    60.00
Screening DRE                             $    32.00
Screening fecal-occult                    $    15.00
Initial preventative exam                 $   150.00
ECG w/initial exam                        $    60.00
Alcohol/Substance Counsel, 15-30 min.     $    75.00
Alcohol/Substance Counsel, over 30 min.   $   154.00
Breath Alcohol Test                       $    35.00
Adrenalin Epinephrin Injectable           $   150.00
Bicillin LA IM Injectable                 $    65.00
Rocephin IM per 250 mg                    $    25.00
Claforan up to 1 g                        $    25.00
Depo-Medrol IM 40 mg                      $    20.00
Decadron IM per 1mg                       $     2.50
Benadryl IM up to 50mg                    $    25.00
Toradol IM per 15 mg                      $    15.00
Lidocaine                                 $    10.00
Norflex up to 60 mg                       $    35.00
Zofran per l mg                           $     8.00
Phenergan IM up to 50 mg                  $    15.00
Solumedrol IM 40 mg                       $     5.00
Solu-Medrol IM to 125mg         $   25.00
Kenalog IM per 10 mg            $     9.00
Vitamin B12 injection           $    15.00
Normal Saline Solution 1000cc   $   20.00
Normal Saline Solution 500cc    $    12.00
Albuterol up to 2.5mg           $     8.00
Atrovent                        $     8.00
Cervical Soft Collar            $   38.00
Patella Knee Wrap               $   60.00
Tibia/Fibula Splint             $   58.00
Post OP Shoe                    $   49.00
Tennis Elbow Support            $   26.00
Wrist, Hand, Finger Support     $   58.00
Arm Splint / Support            $   29.00
Ankle Splint / Support          $   100.00
Urgent Care - CIGNA & HUMAN     $   105.00
Urgent Care Facility Fee        $   25.00
               10/25/2011

                OTC-4868
    TrueRehab of Arizona, LLC


   297 Lake Havasu Ave S #102
           Lake Havasu City
                 Arizona
                  86403
                 Mohave
                  same
                  same
                  same
                  86403
             928-453-0201
               1801941992
                 924292
                   yes
                Z109060
           Thomas Bennetch
             928-453-0501
       trurrehab@frontiernet.net
               Susan Fosher
             928-453-0501
    truerehab@frontiernet.net
               Susan Fosher
             928-453-0501
    truerehab@frontiernet.net
                10/1/2007


       Discription of Charge           Rate of Charge


Initial Eval                       $             125.00
Reevaluation                       $              70.00
H/C Pac                            $              21.25
Traction                           $              37.50
Stim                               $              40.00
Infrared                           $              26.75
E-Stim                             $              36.50
Ionto                              $              38.25
Ultrasound                         $              38.25
Exercise                           $              49.75
Neuro                              $              46.50
Gait                               $              49.75
Massage            $   51.75
Manual             $   51.75
Group              $   38.00
E-Stim             $   40.00
Strapping/Taping   $   24.00
TENS               $   34.50
`
                                                                       3/16/2012


DHS License Number#:                                                    OTC4675
             Facility Name:                                      5 Minute Walk-in Clinic


Physical Street Address:                                  1962 E. Juan Sanchez Blvd Suite C-2
City:                                                                   San Luis
State:                                                                     AZ
Zip:                                                                     85349
County:                                                                   Yuma
Facility Mailing Address':                                            P.O Box 7290
City:                                                                   San Luis
State:                                                                     AZ

Zip:                                                                     85349
Phone #:                                                             (928)627-4825
NPI #:                                                                 1285664151
AHCCCS #:                                                              1.00281E+11
Medicare Certified: Yes/No                                                 Yes
Medicare Number:                                                         113381
Administrator:                                                        Gilbert Vega
  Phone #:                                                           (928)627-4825
  Email Address:                                              5minutewalkinclinic@gmail.com
Chief Financial Officer:                                              Gilbert Vega
  Phone #:                                                           (928)627-4825
  Email Address:                                              5minutewalkinclinic@gmail.com
Person Providing Information:                                        Yuliana Lagarda
  Phone #:                                                           (928)627-4825
  Email Address:                                                 yulianna_04@yahoo.com
Implementation Date:                                                   3/15/2012


TABLE OF CONTENTS               Service Code                   Discription of Charge


                                   99201       Very Limited
                                   99202       Limited
                                   99203       Expanded
                                   99204       Detail
                                   99205       Comprehensive
                                   99211       Very Limited
                                   99212       Limited
                                   99213       Expanded
                                   99214       Detail
                                   99215       Comprehensive
                                   99217       DOT
                                   99429       employment exam
   99430      sport exam
   92552      audiometry
   94010      spirometry
   94760      Pulse Oxymetry
   99172      Visual Acuity Screening
93000/A4849   EKG (12 lead)
  A4649       Supplies
   94840      Neubolizer treatment
   J7611      albuterol solution
  J7644       race/Epi
   E0441      oxygen
   A4616      O2 tubing
   A4615      O2 cannula
   A4617      O2 mask
   94150      peak flow
   46600      anoscopy
   96372      IM/SQ therapeutic medication
   95117      allergy inj. Admin. Two or more
   95115      allergy inj. Admin.
  J0290       ampicillin 1gm IM
  J0690       ancef 500-1000mg x_units
  J3420       B12 up to 1000mcg
   J1200      benedryl 50mg x_units
  J0540       bicillin CR 1.2 mg
  J0580       bicillin LA 1.2 mg
  J0696       claforan 1gm IM
   J1100      decadron 4mg x_units
   J1030      depomedrol 40mg x_units
  J8499       diazeparm/vallium 5mg/2ml (0833)
   J0170      epinephrine 1 ML amp
  J8499       GI cocktall
   J3410      visteril/hydroxyrine 25mg x_units
   J3301      kenelog 10mg x_units
   J2001      lidocaine/xylocaine 1.2% per 1cc
   J2150      marcaine
  J2300       nubein 10mg x_units
  J2550       phenergan 25-50mg x_units
  J0696       rocephin 500mg x_units
  J2930       solumedrol 125mg
  J0009       sladol mg x_units
   J1885      toradol 15mg x_units
  J3360       valium /diazepam
   96374      Iv/drug injection
   36000      IV/insertion vein
96365   IV/infusion up to 1 hr
A4212   IV needle/catheter
A4750   IV tubing
J7040   IV solution 500cc
J7030   IV solution 1000cc
20612   aspiration & or inj of ganglion cyst
20550   injection, tendon, shealth or trg pts
20810   Large Joint
20805   Medium Joint
20600   Small Joint
20552   tigger point injection
99024   Initial Surgical Visit (W/C Only)
30905   Control Nasal Hemorrhage/any method
11000   debridement of ext. infected skin
11040   debridement , skin (partial thickness)
17000   destruction benign lesion, first
17004   destructionlesion 15 or more
17003   destruction lesion 2-14 each
17110   estruction of wart-molluscum
64450   digital block
30901   epistaxis, anterior simple
10060   I&D abscess, peronychie, cyst
46320   I&D hemorrhoid
10080   I&D pilonidal cyst simple
11740   I&D subungual hematioma
11750   removal ingrown nail/complicated
11730   removal ingrown nail/uncomplicated
11760   nailbed repair
65205   removal FB, conjunctival
65220   removal FB, cornea
65222   removal FB, corneal (n/still lamp)
69200   removal FB, ear
30300   removal FB. Nose
10120   removal FB, simple
10121   removal FB, complicated
69210   removal impacted cerumen
11200   removal skin tags (up to 15)
A6266   beladine/wound prep
A6404   large
A6403   medium
A6402   small
A6250   dermanbond supplies
A6196   dressing, wound cover
A6410   eye patch/pad
A6209   foam dressing
A6449   lodoform
A4322   irrigation solution
A4320   irrigation tray
A4216   saline/water, sterile
J5499   Silver Nitrate Aplicator
A4930   sterile gloves
A6251   steri-strips
99070   supplies and materials
A4585   Surgical Tray
S0630   Suture Removal
A4450   Tape, Non-Water proof


G0008   Flu Vaccine Adsmistration
90632   hep A adult
90746   hep B adult
90472   immun, admin 2 or moore
86580   PPD
90703   tetanus
L1902   Ankle Supp. Elastic
A6452   ACE Bandage Large
A6443   ACE Bandage SM Medium
L4350   Ankle-gelcast
L0500   back brace-dual support
L3260   Cast shoe/boot/post up
L0120   cervical collar
A6444   Coband
E0114   crutches
E0191   elastic elbow support/L
L1825   elastic knee support/L
L3700   elbow band/strap-tennis
L3701   elbow sleeve/support
E1826   fabricated finger splint
E1825   frog spling/support
L1830   sknee-molizer
L1810   knee supp-hinged
L0210   rib bell-universal
L0900   coller c-spine support
12001   up to 2.5cm
12002   2.6 to 2.5cm
12004   7.6 to 12.5cm
12005   12.6 to 20cm
12011   up to 2.5cm
12013   2.6 to 6.0cm
12014   5.1 to 7.5cm
12015   7.6 to 12.5cm
12016   12.6 to 20cm
12031   up to 2.5cm
12032   2.6 to 7.5cm
12034   7.6 to 12.5cm
12035   12.6 to 20cm
12041   up to 2.5cm
12042   2.6 to 7.5cm
12044   7.6 to 12.5cm
12046   12.0 to 20cm
12051   up to 2.5cm
12052   2.6 to 5.0cm
12053   5.1 to 7.5cm
12054   7.6 to 12.5cm
12055   12.6 to 20cm
13100   trunk 1.1 to 2.5cm
13101   trunk to 2.6 to 5.0cm
13120   scalp, arm/leg 1.1-2.5cm
13121   scalp, arm/leg 2.6-7.5cm
13131   face,ax hand/ft 1.1-2.5cm
13132   face, ax hand/ft 2.6-7.6cm
13151   lids, nose, ears, lip 1.1-2.5cm
13152   lids, nose, ears, lip 2.6-7.5cm
A4570   splinting materials/supplies
29130   finger splint
29105   liong arm
29505   long leg
29125   short arm fabricate
29515   short leg
J8499   nitroglycerin 0.4mg
J8499   aspirin 81 mg
J8499   aceteminophen 325mg tab
J8499   admin of an oral drug non-chemo
J8499   apap 325mg tab
J8499   carisoprodol 350mg
J8499   cephalexin 250-500mg cap
J8499   diphenhydramine 25mg
J8499   erythromycin opth oint
J8499   gentamicin suffate 0.3%
J8499   hydrocortisone 1% crm
J8499   hydroxyzine hct 25mg tab
J8499   ibuprofen 800mg
A9150   nonprescription drug
J8499   prednisone 5-20mg
J8499   propoxacel N-100mg
J8499   silver sulfadizine 1% crm
52959   SMZ-TMP DS tab 9-01442)
J8499   tylenol #3
J8499   vallium 5-10mg tab
52950   zirthromax 250mg tab (-05050)
74000   abdominal/KUB
47022   abdominal series
73050   AC joint w/wo wts. Bilateral
73610   ankle, complete
73600   ankle, 2 views
72052   c spine complete
72040   c spine limited 2 views
72050   cervical spine 4-5 views
71010   chest 1 view
71020   chest 2 view
73000   clavicle complete
73080   elbow complete
70150   facial complete
73550   femur
73140   finger complete
73620   foot 3 views
73630   foot complete
73090   forearm complete
73120   hand 2 view
73130   hand complete
73650   heel-calcaneous
73510   hip unilateral complete
73080   humerous complete
73562   knee 3 view
73564   knee complete 5 view
73560   knee ulimited 2 views
72110   LS spine-complete
72100   LS spine-limited
70110   mandible complete
70100   mandible limited 3 view
70160   nasal complete 3 view
70200   orbit
72170   pelvic(AP)
72190   pelvis comp. 3 views
71100   ribs 2 views
71111   ribs bilateral complete
71101   ribs unilateral 3 views
72220   sacrum/coccyx
73010   scapula
73030   shoulder complete
70220   sinuses 3 views
70250   skull PA/Lat 3 views
70260   skull complete
71120   slernum/minimum 2 views
72070   T spine A/P & lateral
72080   throaco lumbar spine 2 views
73590   tib/fib complete
73660   toe complete
73110   wrist complete
73100   wrist limited 2 view
99000   collection & handiling fee
36415   venipunction
99073   basic metabolic panel
82948   blood sugar-glucouse
86901   blood type(abo rh)
G0101   cervical or vaginal cancer screen
85025   complete blood count
80053   comprehensive metabolic-cmp
82962   glucose
80061   lipid screening
80053   liver function test
86308   monospot test
88141   pap smear
84153   psa screening
87880   repid strep
82270   stool occult blood
84443   tsh screening
86580   PPD
81002   urine dipstick, non-automated
81025   urine pregnancy
Q0112   wet mount/KOH
                                                                          9/12/2011


                                                                          OTC-2699
inic                                                FOOTHILLS WALK-IN MEDICAL CARE (URGENT CARE CTR)


Suite C-2                                                     11274 South Fortuna Road, Suite I-4
                                                                             Yuma
                                                                           Arizona
                                                                            85367


                                                              11274 South Fortuna Road, Suite I-4
                                                                             Yuma
                                                                           Arizona
                                                                            85367
                                                                        928 345-2150
                                                                         1023041654
                                                                           855059
                                                                             Yes
                                                                           Z28500
                                                                        David E. Smock
                                                                        831-596-1629
ail.com                                                          foothillswalkin@earthlink.net
                                                                        David E. Smock
                                                                        831-596-1629
ail.com                                                          foothillswalkin@earthlink.net
                                                                        David E. Smock
                                                                        831-596-1629
com                                                              foothillswalkin@earthlink.net




                Rate of Charge       Service Code


            $               97.00       99203
            $              150.00       99204
            $              200.00       99205
            $              250.00       99211
            $               300.00      99214
            $                85.00      99215
            $                95.00      86687
            $              150.00       86735
            $              165.00       86765
            $              220.00       86790
            $               110.00   5295903351
            $               110.00      29130
$   45.00      29305
$   40.00      29105
$   50.00      29505
$   20.00      29125
$     5.00     29515
$   70.00      80074
$    10.00   A4565
$   45.00      20605
$   20.00      20610
$     6.00     20600
$    15.00     20612
$   25.00    280200024
$    10.00     92589
$    15.00     11730
$   34.00    J3420
$   80.00      82055
$   30.00      82075
$   40.00    L0500
$   30.00    K0634
$   70.00    L0625
$   35.00      80048
$   20.00    A4246
$   20.00    J0580
$   75.00      82270
$   75.00      94060
$   45.00     9907082
$   20.00       11100
$   35.00       11101
$   20.00    A4615
$   30.00    5295900263
$   35.00    A4590
$   25.00      85025
$   30.00    5295900302
$    10.00     82465
$    14.00     82482
$   25.00      82480
$   25.00      25605
$   130.00     26775
$   35.00      26770
$   20.00      24620
$   35.00      26605
$   20.00      26725
$   35.00      23650
$   36.00      36416
$    85.00       36415
$    20.00       92283
$    23.00      9907034
$    40.00       80053
$    45.00       30901
$   184.00       30905
$   173.00      801005
$   151.00       80111
$   125.00   ESCREEN
$   162.00      801002
$   224.00       80100
$    50.00       11040
$   300.00       11000
$   115.00    5504532420
$   115.00     517493025
$    60.00   DHL0000000
$   300.00    J3360
$    90.00     409127332
$    83.00    5295900482
$   120.00    5295900432
$   150.00      9907000
$   165.00        1111
$   200.00    A6196
$   169.00       16025
$   145.00       16020
$   450.00       80102
$   165.00       17000
$   230.00       17003
$    70.00       17110
$    90.00    L1825
$   180.00    L3908
$   115.00    L3701
$   217.00       46320
$   180.00    L3700
$   310.00     168007038
$    65.00       11740
$   150.00       11750
$     8.00       11222
$    12.00    A6403
$    11.00    A6402
$     9.00    A6404
$     5.00       80170
$    10.00    6131463305
$    10.00    5456912290
$    40.00       82962
$    10.00      801003
$    10.00      8010003
$    18.00       99000
$     8.00       86706
$    40.00       98070
$    15.00       90746
$    25.00       90744
$     5.00       86804
$    45.00    5295900390
$    20.00    5295900742
$     8.00       10061
                 10060
$    16.00       10140
$   115.00       10081
$   110.00       10080
$    12.00       87880
$    35.00    J2999I
$    35.00       10121
$    35.00       10120
$    12.00       87084
$     8.00    4037F
$    30.00    J1094
$    30.00    J1200
$    40.00    J0690
$    40.00    J1885
$     8.00    J3301
$    48.00       51701
$    15.00       51703
$    40.00   INSTACHECK
$    48.00       50393
$    30.00    4950268526
$    15.00    A4320
$    15.00       96360
$    55.00       96361
$    98.00    A4223
$    30.00       90761
$    25.00      990701
$   205.00      302932
$   245.00    6467907580
$   255.00     1659001382
$   265.00      9907065
$   245.00    L1815
$   393.00    L1830
$    394.00       83655
$    394.00      9907004
$    394.00     409427701
$    405.00       80061
$    405.00       12051
$    420.00       12052
$    463.00       12053
$    376.00       12054
$    412.00       12057
$    456.00       12045
$    456.00       12041
$    456.00       12042
$    515.00       12046
$    679.00       12044
$    679.00       12047
$    679.00       12035
$    395.00       12031
$    544.00       12032
$    500.00       12036
$    704.00       12034
$    624.00       12037
$    971.00      9907090
$    760.00     99070000
$   1,202.00      94760
$    430.00       64450
$     45.00    J2999NI
$     90.00       20551
$     110.00      20550
$     90.00       20552
$     110.00      20553
$     10.00       99211
$      5.00       99214
$     10.00       99215
$     10.00       99213
$      4.00       99201
$      5.00       99202
$      5.00       99203
$      5.00       99204
$      4.00       99205
$      4.00    A6250
$      3.00       98925
$      5.00       98926
$      5.00       98927
$     10.00       11055
$     5.00     11056
$     5.00     11057
$     5.00     99396
$     3.00     99008
$    10.00   J2550
$    10.00     97750
$     5.00     99455
$    90.00     90732
$   160.00     10160
$   120.00     99024
$   105.00   5295902202
$   100.00     94640
$   240.00     95115
$   110.00     95117
$   180.00   641149535
$    90.00   5295903352
$   115.00     84153
$   105.00     92552
$   105.00     73610
$   130.00     73650
$    90.00     71010
$    90.00     71020
$    90.00     73000
$    95.00     73080
$    90.00     73090
$    90.00     70150
$    95.00     73550
$    90.00     73140
$   105.00     73620
$    95.00     73630
$   110.00     73120
$   115.00     73130
$    95.00     73510
$   160.00     73060
$   155.00     73560
$   105.00     73562
$    90.00     73564
$    95.00     70110
$   130.00     70100
$    95.00     70160
$   100.00     70200
$   100.00     72170
$   155.00     72190
$   115.00      71111
$   85.00      71100
$   90.00       71101
$   95.00      72220
$   120.00     73010
$   160.00     70240
$   160.00     73030
$   110.00     70220
$   110.00     70250
$   105.00     70260
$   95.00      72040
$   90.00      72050
$   100.00     72100
$   90.00      72110
$    15.00     72080
$   25.00      72070
$   68.00      71120
$   22.00      73590
$   30.00      73660
$   65.00      73100
$   68.00      73110
$   68.00       11111
$   25.00      11042
$   50.00      93041
$   85.00    A4572
$   30.00      69210
$   110.00      11201
$   72.00      11200
$   56.00      29705
$   20.00      29700
$   120.00   6050507520
$   35.00    6467909830
$   22.00    J0696
$   32.00      13132
$   25.00      11760
               80196
               99173
             L3265
               95926
                11310
                11311
                11312
                11313
               11305
               11306
  11307
  11308
  11300
   11301
  11302
  11303
1287000011
5295906355
   12011
  12013
  12014
  12015
  12001
  12002
  12004
  87210
5295901442
J7030
264780000
3027F
  94010
3023F
A4570
  99384
4988406003
  990709
2420807250
603728041
  99053
  86592
 9907052
  86580
  90703
A4616
  12020
  12021
 9907033
  81025
  81002
  36515
 9907032
1055F
2010F
L3800
   84630
  9907080
  9907078
  9907081
 5295903023
 5295900031
   94642
L1902
   82044
   82042
 4950269724
   J7613
   Q4093
   J7602
 143992490
                                  9/12/2011


                                  OTC-2699
        FOOTHILLS WALK-IN MEDICAL CARE (URGENT CARE CTR)                                          Mo


                     11274 South Fortuna Road, Suite I-4
                                    Yuma
                                   Arizona
                                    85367


                     11274 South Fortuna Road, Suite I-4
                                    Yuma
                                   Arizona
                                    85367
                                928 345-2150
                                 1023041654
                                   855059
                                     Yes
                                   Z28500
                                David E. Smock
                                831-596-1629
                         foothillswalkin@earthlink.net
                                David E. Smock
                                831-596-1629
                         foothillswalkin@earthlink.net
                                David E. Smock
                                831-596-1629
                         foothillswalkin@earthlink.net




                           Discription of Charge               Rate of Charge      Service Code


INITIAL VISIT DETAILED                                     $              160.00      99203
INITIAL VISIT COMPREHENSIVE                                $              200.00      99204
INITIAL VISIT GH COMPLEXITY                                $              265.00      99213
NO PHYSICIAN VISIT                                         $               35.00      99214
ESTABLISHED VISIT DETAILED                                 $              150.00
ESTABLISHED VISIT COMPREHENSIVE                            $              220.00
ANTB HTLV-I                                                $              120.00
ANTB MUMPS                                                 $              120.00
ANTB RUBEOLA                                               $              120.00
ANTB VIRUS NES MEASLES                                     $              120.00
APAP/PROPOXYPHENE 650mg/100mg #15                          $               33.80
APPL FNGR SPLNT STATIC                                     $               40.00
APPL HIP SPICA CST 1 LEG                   $    50.00
APPL LONG ARM SPLNT SHO HAND               $    49.80
APPL LONG LEG SPLNT THI ANKLE/TOES         $    65.00
APPL SHORT ARM SPLNT F/ARM-HAND STATIC     $    42.70
APPL SHORT LEG SPLNT CALF FOOT             $    86.00
AQT HEP PANEL                              $   130.00
ARM SLING/CLINIC                           $    25.00
ARTHROCNTS ASPIR&/NJX INTRM JT/BURSA       $    68.00
ARTHROCNTS ASPIR&/NJX MAJOR JT/BURSA       $    95.00
ARTHROCNTS ASPIR&/NJX SM JT/BURSA          $    54.00
ASPIR&/NJX GANGLION CST ANY LOCATION       $   295.00
ASPIRIN                                    $     2.00
AUDIO                                      $    15.00
AVLSN NAIL PLATE PRTL/COMPL SMPL 1         $   156.00
B-12 INJECTION                             $     2.00
B.A.T. CONFIRMATION                        $    15.00
B.A.T. TESTING/ ALCOHOL                    $    25.00
BACK BRACE                                 $    45.00
BACK SUPPORT                               $    40.00
BACK SUPPORT                               $    54.15
BASIC METAB PANEL                          $    35.00
BETADINE SOAK                              $    12.00
BICILLIUN                                  $    40.00
BLD OCLT PROXIDASE ACTV QUAL FECES 1 DET   $    35.00
BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILA   $    25.00
BURN TRAY                                  $    25.00
BX SKN SUBQ/MUC MEMB 1 LESION              $   138.00
BX SKN SUBQ/MUC MEMB EA SPX ADDL LESION    $    70.00
CANNULA                                    $    15.00
CARISOPRODOL 350 MG # 30                   $     4.17
CASTING MATERIAL                           $    30.00
CBC SCREENING                              $    27.00
CEPHALEXIN/ KEFLEX 250 MG # 28             $     2.14
CHOLESTEROL SERUM/WHL BLD TOT              $     4.57
CHOLINESTERASE RBC                         $    22.83
CHOLINESTERASE SERUM                       $    65.00
CLTX DSTL RDL FX/EPIPHYSL SEP +-W/MNPJ     $   656.00
CLTX IPHAL JT DISLC 1 W/MNPJ REQ ANES      $   211.02
CLTX IPHAL JT DISLC 1 W/MNPJ W/O ANES      $   236.30
CLTX MONTGG TYP FX DISLC ELBW W/MNPJ       $   149.25
CLTX MTCRPL FX 1 W/MNPJ EA B1              $   313.00
LTX PHLNGL FX PROX/MIDDLE PX/F/T W/MNPJ    $   273.00
CLTX SHO DISLC W/MNPJ W/O ANES             $   307.00
COLLJ CAPILLARY BLD SPEC                   $    10.00
COLLJ VEN BLD VNPNXR                       $     10.00
COLOR VIS XM EXTND ANOMALOSCOPE/EQUIV      $     12.00
COMP. METABOLIC PANEL                      $     35.00
COMPRE METAB PANEL                         $     65.00
CTRL NSL HEMRRG ANT SMPL LMTD CAUT&/PACK   $     42.70
CTRL NSL HEMRRG PST PST NSL PACKS&/CAUT    $    184.90
D/S COLLECTION ONLY                        $     15.00
D/S CONFIRMATION SENT TO LAB               $     35.00
D/S E-SCREEN/WALMART                       $     21.00
D/S NIDA                                   $     35.00
D/S NON NIDA                               $     35.00
DBRDMT SKN PRTL THKNS                      $    100.00
DBRDMT X10SV ECZMT/INFCT SKN UP 10% BDY    $    100.00
DEPO MEDROL INJ.55045324205                $     10.00
DEXAMETHASONE 30 ML                        $      9.69
DHL CHARGES                                $    100.00
DIAZEPAM (VALIUM)                          $     10.00
DIAZEPAM/ VALIUM                           $     46.50
DICLOXACILLIN 250 MG # 28                  $       1.08
DIPENHYDRAMINE 25MG#20                     $       1.00
DMV PHYSICAL                               $     45.00
DR SERVICES                                $   1,600.00
DRESSING,WOUND COVER                       $     10.00
DRS&/DBRDMT PRTL-THKNS BRNS 1ST/SBSQ MED   $    150.00
DRS&/DBRDMT PRTL-THKNS BRNS 1ST/SBSQ SM    $     65.00
DRUG CONFIRMATION EA PX                    $     35.00
DSTRJ ALL PRMLG 1ST LES                    $     72.81
DSTRJ ALL PRMLG 2-14 EA                    $      19.13
DSTRJ B9 SK TGS/CUTAN VASC UP 14 <         $     54.00
ELASTIC KNEE SUPPORT,L                     $     60.00
ELASTIC WRIST,RT,L 79-87077-004            $     64.00
ELBOW SUPPORT ELASTIC,                     $     25.00
ENCL/EXC XTRNL THROMBOTIC HEMORRHOID       $    132.00
EO ELAST W/STAYS PREFAB                    $     69.01
ERYTHROMICIN OINT. OPHT.                   $     20.00
EVAC SUBUNGUAL HMTMA                       $     70.00
EXC NAIL MATRIX PRM RMVL                   $     199.10
FLU SHOTS                                  $     25.00
GAUZ NON-IMPREG STREL 16=48SQ              $     15.00
GAUZ NON-IMPREG STREL 16Q                  $     10.00
GAUZ NON-IMPREG STREL 48SQ NO ADHES        $     15.00
GENTAMICIN                                 $     14.00
GENTAMICIN SULFATE OPHT. 5ML               $     20.80
GENTAMYCIN OPHTH OIN 3.5 GMS               $      7.09
GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC    $    25.00
HAIR ANALYSIS IN HOUSE ONLY                $    75.00
HAIR COLLECTION ONLY                       $    35.00
HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE    $    13.00
HEP B SURF ANTB HBSAB                      $   150.00
HEP B TITER                                $    50.00
HEP B VACC ADLT IM                         $    65.00
HEP B VACC PED/ADOL 3 DOSE SCHED IM        $    75.00
HEP C ANTB CONFIRMATORY TST                $    50.00
HYDROCORTISONE 1% CREAM W/ALOE             $    16.00
HYDROXYZINE / ATARAX 25MG #20              $    22.00
I&D ABSC COMP/MLT                          $   375.00
I&D ABSC SMPL/1                            $   175.00
I&D HMTMA SEROMA/FLU COLLJ                 $   150.00
I&D PILONIDAL CST COMP                     $   250.00
&D PILONIDAL CST SMPL                      $   175.00
IAADIADOO STREPTOCOCCUS GRP                $    50.00
IBUROFEN 800MG TAB                         $    15.00
INC&RMVL FB SUBQ TISS COMP                 $   260.00
INC&RMVL FB SUBQ TISS SMPL                 $   200.00
INFLUENZA A/B RAPID                        $    48.00
INFLUENZA IMMUNIZATION ORDERED OR ADMINI   $    30.00
INJ DEXAMETHASONE 1MG PER UNIT             $     1.00
INJECTION BENADRYL 50MG                    $     4.00
INJECTION CEFAZOLIN SODIUM 500 MG (ANCEF   $     2.00
INJECTION TORADOL 15MG                     $    17.00
INJECTION TRIAMCINOLONE 10MG (KENALOG)     $     2.00
INSJ NON-NDWELLG BLDR CATH SIMPLE          $    83.00
INSJ TEMP NDWELLG BLDR CATH COMP           $   170.00
INSTA/CHECK RAPID                          $    25.00
INTRO URTRL CATH/STENT THRU PELVIS DRG&/   $   215.00
IPRATROPIUM BROMIDE 0.02% 0.5 MG/2.5ML     $    15.00
IRRIG TRAY W/BULB/PISTON/ SYRINGE          $    25.00
IV HYDRATION 1st HR.                       $    73.00
IV HYDRATION ADDITONAL HR.                 $    29.00
IV INFUSION SUPPLIES                       $     7.40
IV NFUS HYDRATION EA HR                    $    29.00
J-MARR HAND GRIP                           $    15.00
KENALOG 40MG/ML 00003029328                $    19.26
KETORALAC INJ64679075802 30MG/ML           $     5.50
KETOROLAC 10 MG #20                        $     7.70
KNEE SUPPORT ELASTIC                       $    50.00
KO ELAS OTH ELAS MATL                      $   102.45
KO IMMOBLIZER CANVAS PREFAB                $    90.02
LEAD                                       $     40.00
LEAD, BLOOD                                $     40.00
LIDOCAINE                                  $      3.00
LIPID PANEL                                $     25.00
LYR CLSR F/E/E/N/L/M&/MUC 2.5 CM/<         $    358.00
LYR CLSR F/E/E/N/L/M&/MUC 2.6 CM-5.0 CM    $    373.00
LYR CLSR F/E/E/N/L/M&/MUC 5.1 CM-7.5 CM    $    455.00
LYR CLSR F/E/E/N/L/M&/MUC 7.6 CM-12.5 CM   $    501.00
LYR CLSR F/E/E/N/L/M&/MUC > 30.0 CM        $   1,500.00
LYR CLSR N/H/F/XTRNL GENT 12.6 CM-20.0 C   $    525.00
LYR CLSR N/H/F/XTRNL GENT 2.5 CM/<         $    375.00
LYR CLSR N/H/F/XTRNL GENT 2.6 CM-7.5 CM    $    342.00
LYR CLSR N/H/F/XTRNL GENT 20.1 CM-30.0 C   $    700.00
LYR CLSR N/H/F/XTRNL GENT 7.6 CM-12.5 CM   $    450.00
LYR CLSR N/H/F/XTRNL GENT > 30.0 CM        $    800.00
LYR CLSR S/A/T/E 12.6 CM-20.0 CM           $    550.00
LYR CLSR S/A/T/E 2.5 CM/<                  $    350.00
LYR CLSR S/A/T/E 2.6 CM-7.5 CM             $    342.00
LYR CLSR S/A/T/E 20.1 CM-30.0 CM           $    750.00
LYR CLSR S/A/T/E 7.6 CM-12.5 CM            $    550.00
LYR CLSR S/A/T/E > 30.0 CM                 $    800.00
MRO REVIEW                                 $     25.00
MRO SIGNATURE                              $     10.00
N-INVAS EAR/PLS OXIMTRY F/O2 SAT 1 DETER   $     34.00
NERVE/DIGITAL BLOCK                        $    200.00
NITROGLYCERIN                              $     10.00
NJX 1 TDN ORIGIN/INSJ                      $     25.00
NJX 1 TDN SHTH/LIGM APONEUROSIS            $    105.00
NJX 1/MLT TRIGGER POINT 1/2 MUSC           $     98.00
NJX 1/MLT TRIGGER POINT 3/> MUSC           $     98.00
OFFICE O/P EST 5 MIN                       $     35.00
OFFICE OUTPT EST 25 MIN                    $    150.00
OFFICE OUTPT EST 40 MIN                    $    160.00
OFFICE OUTPT EST15 MIN                     $     71.00
OFFICE OUTPT NEW 10 MIN                    $     91.00
OFFICE OUTPT NEW 20 MINUTES                $     90.00
OFFICE OUTPT NEW 30 MIN                    $    160.00
OFFICE OUTPT NEW 45 MIN                    $    200.00
OFFICE OUTPT NEW 60 MIN                    $    265.00
OINTMENT                                   $     12.00
OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGI   $     59.00
OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGI   $     55.00
OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGI   $     73.00
PARING/CUTTING B9 HYPRKERATOTIC LES 1 LE   $     90.00
PARING/CUTTING B9 HYPRKERATOTIC LES 2-4    $   115.00
PARING/CUTTING B9 HYPRKERATOTIC LES >4     $   145.00
PDIC COMPRE PREV MED REE/M EST PT 40-64    $   45.00
PFT MEDICAL QUESTIONAIRE                   $    15.00
PHENERGAN 50MG                             $     4.00
PHYSICAL PERFORMANCE TST/MEAS W/RPRT 15    $   25.00
PHYSICAL WORK RELATED                      $   45.00
PNCCAL POLYSAC 23-V ADLT/IMMUNSUP SUBQ/I   $   20.00
PNXR ASPIR ABSC HMTMA BULLA/CST            $   120.00
PO F-UP VST RELATED TO ORIGINAL PX         $   151.00
PREDNISONE 5MG # 21/52959022021            $     0.70
PRESS/N-PRESS INHLJ TX F/AAO/SPTM INDCTJ   $   46.00
PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTR   $   60.00
PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTR   $   40.00
PROMETHAZINE/PHENEGRAN 25MG/ML             $     9.71
PROPOXYPH.NAP/W/ACET 100/650MG#20          $     1.69
PRST8 SPEC AG TOT                          $   75.00
PURE TONE AUDIOMTRY AIR ONLY               $   30.00
RADEX ANKLE COMPL MINIMUM 3 VIEWS          $   85.00
RADEX CALCANEUS MINIMUM 2 VIEWS            $   60.00
RADEX CH 1 VIEW FRNT                       $   75.00
RADEX CH 2 VIEWS FRNT&LAT                  $   80.00
RADEX CLAV COMPL                           $   80.00
RADEX ELBW COMPL MINIMUM 3 VIEWS           $   70.00
RADEX F/ARM 2 VIEWS                        $   70.00
RADEX FACIAL B1S COMPL MINIMUM 3 VIEWS     $   105.00
RADEX FEMUR 2 VIEWS                        $   90.00
RADEX FNGR MINIMUM 2 VIEWS                 $   60.00
RADEX FOOT 2 VIEWS                         $   80.00
RADEX FOOT COMPL MINIMUM 3 VIEWS           $   80.00
RADEX HAND 2 VIEWS                         $   70.00
RADEX HAND MINIMUM 3 VIEWS                 $   85.00
RADEX HIP UNI COMPL MINIMUM 2 VIEWS        $   70.00
RADEX HUM MINIMUM 2 VIEWS                  $   67.00
RADEX KNE 1/2 VIEWS                        $   60.00
RADEX KNE 3 VIEWS                          $   75.00
RADEX KNE COMPL 4/MORE VIEWS               $   70.00
RADEX MNDBL COMPL MINIMUM 4 VIEWS          $   90.00
RADEX MNDBL PRTL < 4 VIEWS                 $   70.00
RADEX NSL B1S COMPL MINIMUM 3 VIEWS        $   95.00
RADEX ORBITS COMPL MINIMUM 4 VIEWS         $   100.00
RADEX PELVIS 1/2 VIEWS                     $   72.00
RADEX PELVIS COMPL MINIMUM 3 VIEWS         $   87.00
RADEX RIBS BI W/POSTEROANT CH MINIMUM 4    $   125.00
RADEX RIBS UNI 2 VIEWS                     $    50.00
RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3   $   120.00
RADEX SACRUM&COCCYX MINIMUM 2 VIEWS        $    80.00
RADEX SCAPULA COMPL                        $    80.00
RADEX SELLA TURCICA                        $    80.00
RADEX SHO COMPL MINIMUM 2 VIEWS            $    75.00
RADEX SINUSES PARANSL COMPL MINIMUM 3 VI   $    90.00
RADEX SKL < 4 VIEWS                        $   115.00
RADEX SKL COMPL MINIMUM 4 VIEWS            $   150.00
RADEX SPI CRV 2/3 VIEWS                    $    80.00
RADEX SPI CRV MINIMUM 4 VIEWS              $   125.00
RADEX SPI LUMBOSAC 2/3 VIEWS               $    95.00
RADEX SPI LUMBOSAC MINIMUM 4 VIEWS         $   134.00
RADEX SPI THORACOLMBR 2 VIEWS              $    95.00
RADEX SPI THRC 2 VIEWS                     $    80.00
RADEX STERNUM MINIMUM 2 VIEWS              $    80.00
RADEX TIBFIB 2 VIEWS                       $    70.00
RADEX TOE MINIMUM 2 VIEWS                  $    60.00
RADEX WRST 2 VIEWS                         $    70.00
RADEX WRST COMPL MINIMUM 3 VIEWS           $    73.00
RANDOM PULL FEE                            $    25.00
REMOVAL OF DAMAGED SKIN AND UNDERLYING T   $   315.00
RHYTHM ECG 1-3 LDS TRCG ONLY W/O I&R       $    18.00
RIB/BELT/SUPPORT                           $    45.00
RMVL IMPACTED CERUMEN SPX 1/BTH EARS       $    40.00
MVL SK TGS MLT FIBRQ TAGS ANY AREA EA 1    $    50.00
RMVL SK TGS MLT FIBRQ TAGS ANY AREA UP&W   $   130.00
RMVL/BIVALV FULL ARM/FULL LEG CST          $    50.00
RMVL/BIVALV GAUNTLET BOOT/BDY CST          $   110.00
ROCEPHIN IGM/ CEFTRIAXONE 60505075204      $    75.00
ROCEPHIN/64679098302                       $    75.00
ROCHEPIN 250MG                             $    16.00
RPR CPLX F/C/C/M/N/AX/G/H/F 2.6 CM-7.5 C   $   700.00
RPR NAIL BED                               $   228.40
SALICYLATE                                 $     2.00
SCREENING                                  $    56.00
SHOE CAST                                  $    25.00
SHORT-LATENCY SOMATOSENS EP STD LWR LIMB   $    45.00
SHVG SKN LES 1 LES F/E/E/N/L/M DIAM 0.5    $   115.00
SHVG SKN LES 1 LES F/E/E/N/L/M DIAM 0.6-   $   175.00
SHVG SKN LES 1 LES F/E/E/N/L/M DIAM 1.1-   $   230.00
SHVG SKN LES 1 LES F/E/E/N/L/M LES DIAM    $   288.00
SHVG SKN LES 1 LES S/N/H/F/G DIAM 0.5 CM   $   115.00
SHVG SKN LES 1 LES S/N/H/F/G DIAM 0.6-1.   $   175.00
SHVG SKN LES 1 LES S/N/H/F/G DIAM 1.1-2.   $   230.00
SHVG SKN LES 1 LES S/N/H/F/G DIAM > 2.0    $   288.00
SHVG SKN LES 1 LES T/A/L DIAM 0.5 CM/<     $    98.00
SHVG SKN LES 1 LES T/A/L DIAM 0.6-1.0 CM   $   110.00
SHVG SKN LES 1 LES T/A/L DIAM 1.1-2.0 CM   $   120.00
SHVG SKN LES 1 LES T/A/L DIAM > 2.0 CM     $   173.00
SILVER NITRATE APPLICATORS                 $    40.00
SILVER SULFADIAZINE 1% CREAM/50 MG         $    17.00
SMPL RPR SUPFC F/E/E/N/L/M 2.5CM/<         $   218.00
SMPL RPR SUPFC F/E/E/N/L/M 2.6CM-5.0CM     $   264.00
SMPL RPR SUPFC F/E/E/N/L/M 5.1CM-7.5CM     $   311.00
SMPL RPR SUPFC F/E/E/N/L/M 7.6CM-12.5CM    $   358.00
SMPL RPR SUPFC S/N/AX/G/T 2.5CM/<          $   206.00
SMPL RPR SUPFC S/N/AX/G/T 2.6CM-7.5CM      $   278.00
SMPL RPR SUPFC S/N/AX/G/T 7.6CM-12.5CM     $   350.00
SMR PRIM SRC WET MOUNT NFCT AGT            $    25.00
SMZ/BACTRIM DS 20 800mg-160mg              $     1.67
SODIUM CHLORIDE 0.9% 1000cc                $     5.20
SODIUM CHLORIDE 0.9% 1000cc                $     5.20
SPIROM FEV/FVC>=70% W/O COPD               $    25.00
SPIROMETRY                                 $    25.00
SPIROMETRY RESULTS DOCUMENTED AND REVIEW   $    30.00
SPLINTS/SUPPORTS                           $    15.00
SPORTS PHYSICAL                            $    30.00
SSD 1% / 50 GRAMS                          $    18.50
STERI STRIP                                $     5.00
STERILE EYE lubricant (naphazoline hcl)    $    15.41
SULFACETAMIDE OPTH 10%                     $    17.50
SVC PRV BTW 10 PM&8 AM AT 24-HR FAC        $   100.00
SYPHILIS TST QUAL                          $    24.50
TAKE HOME GAUZE                            $    10.00
TB TES-PPD                                 $    25.00
TETANUS TOXOID ADSORBED IM                 $    25.00
TUBING PER FOOT                            $    16.00
TX SUPFC DEHSN SMPL CLSR                   $   350.00
TX SUPFC DEHSN W/PACKING                   $   200.00
UA WITH MICRO                              $    20.00
URINE PREGNANCY TST VIS COLOR CMPRSN MET   $    25.00
URNLS DIP STICK/TABLET RGNT NON-AUTO W/O   $    10.00
VENIPUNCTURE                               $    20.00
VISION TEST                                $    15.00
VISUAL FUNCTIONAL STATUS ASSESSED          $    15.00
VITAL SIGNS RECORDED                       $    20.00
WHFO SHRT OPPONENS                         $   179.99
ZINC                                     $         100.00
ACE BANDAGE 3"                           $           5.50
ACE BANDAGE 6"                           $           8.75
ACE WRAP 2"                              $           3.75
ACETAMINOPHEN 325 MG #30                 0.83 EA
ACETAMINOPHEN W/COD 300/30MG #15         2.23 EA
AERSL INHLJ PENTAMIDINE F/PCP TX/PROPH   $         50.00
AFO ANK GAUNTLT PREFAB W/FIT ADJ         $         85.03
ALBUMIN URINE MICROALBUMIN SEMIQUAN      $           2.20
ALBUMIN URINE/OTH SRC QUAN EA SPEC       $           -
ALBUTEROL SULFATE 0.083% 2.5 MG/3ML      $          15.00
ALBUTEROL UNIT DOSE 1 MG                 $           0.88
ALBUTEROL UNIT DOSE 1MG                  $          10.00
ALBUTEROL UNIT DOSE 1MG                  $          10.00
   ANCEF/ CEFAZOLIN 1GM INJECTION        $          15.00
                          2/23/2012                                                                 2/16/2012


                           OTC-5218                                                                  OTC-4102
              Mountain Health & Wellness of Yuma                                          Northside Medical Clinic/W


                1210 West 24th Street, Suite 2                                                 1394 West 16th Stre
                             Yuma                                                                      Yuma
                            Arizona                                                                   Arizona
                             85364                                                                     85364
                              Pinal
                         P.O. Box 3160                                                               PO Box 3
                        Apache Junction                                                                Yuma
                            Arizona                                                                   Arizona
                             85117                                                                     85366
                         480-983-0065                                                              928-539-0055
                          1205103322                                                                1245226398
                            659979                                                                    918518
                              Yes                                                                       Yes
                           Z135586                                                                   Z102887
                        Rob Evans, CEO                                                          Daniel R. Ortiz, PA-C
                         480-983-0065                                                              928-539-0055
                        robe@mhwaz.org                                                    nsmc@northsidemedicalyu
                         Marge Walter                                                           Daniel R. Ortiz, PA-C
                                                                                                   928-539-0055
                      margew@mhwaz.org                                                    nsmc@northsidemedicalyu
                         Ramsey Riddell                                                         Daniel R. Ortiz, PA-C
                         480-474-5606                                                              928-539-0055
                      ramseyr@mhwaz.org                                                   nsmc@northsidemedicalyum
                            2-Nov-11                                                                 10/1/2010


                 Discription of Charge                 Rate of Charge      Service Code


New Patient BASIC Exam/Walk-In Visit               $              120.00
New Patient ENHANCED Exam/Walk-in Visit            $              170.00      99201
Established Patient BASIC Follow-Up                $               70.00      99202
Establised Patient ENHANCED Follow-Up              $              100.00      99203
No-Show Fee                                        $               20.00      99204
                                                                              99205


                                                                              99211
                                                                              99212
                                                                              99213
                                                                              99214
                                                                              99215
99217
99429
99430


92552
94010
94760
99172
93000
A4649
94640
J7611
J7644
E0441
A4616
A4615
A4617
94150
46600


96372
95117
95115
J0290
J0690
J3420
J1200
J0540
J0580
J0698
J1100
J1030
J8499
J0170
J8499
J3410
J3301
J2001
J2150
J2300
J2550
J0696
J2930
J0009
J1885
J3360


96374
36000
96365
A4212
A4750
J7040
J7030


20612
20550
20610
20605
20600
20552




99024
30905
11000
11040
17000
17004
17003
17110
64450
30901
10060
46320
10080
11740
11750
11730
11760
65205
65220
65222
69200
30300
10120
10121
69210
11200


A6266
A6404
A6403
A6402
A6250
A6196
A6410
A6209
A6449
A4322
A4320
A4216
J8499
A4930
A6251
99070
A4565
S0630
A4450


G0008
90632
90746
90472
86580
90703


L1902
A6452
A6443
L4350
L0500
L3260
L0120
A6444
E0114
E0191
L1825
L3700
L3701
E1826
E1825
L1830
L1810
L0210
L0900




12001
12002
12004
12005


12011
12013
12014
12015
12016




12031
12032
12034
12035


12041
12042
12044
12045


12051
12052
12053
12054
12055


13100
13101
13120
13121
13131
13132
13151
13152
A4570
29130
29105
29505
29125
29515


J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
A9150
J8499
J8499
J8499
52959
J8499
J8499
52959




74000
74022
73050
73610
73600
72052
72040
72050
71010
71020
73000
73080
70150
73550
73140
73620
73630
73090
73120
73130
73650
73510
73060
73562
73564
73560
72110
72100
70110
70100
70160
70200
72170
72190
71100
71111
71101
72220
73010
73030
70220
70250
70260
71120
72070
72080
73590
73660
73110
73100


99000
36415
99073
82948
86901
G0101
85025
80053
82962
80061
80053
86308
88141
84153
87880
82270
84443
86580
81002
81025
Q0112




70220
70250
70260
71120
72070
72080
73590
73660
73110
73100
 CPT
99000
36415
99073
82948
86900
G0101
82480
85025
80053
82947
98070
86687
83655
80061
80053
86308
88141
84153
85210
87880
82270
84443
86580
81002
81025
87220
 CPT
 QW
 25
99050
99054




 CPT
93000
A4649
99024
94760
 CPT
99024
J7603
A7016
94640
94760
J7699
A4616
 CPT
64450
J2001
99024
 CPT


A6266
10121
A6196
69200
A4649
30300
10120
 CPT
69210
A4217
A4322
A4320
A4616
 CPT
96365
36000
A4212
J7030
J7040
A4750
 CPT
A4615
E0441
A4617
A4611
A4616
94150
 CPT


65205
65220
A4217
A6410
A4649
99024
 CPT
99000
36415


 CPT




29075
A6451
E0114
E1825
L1830
L3260
A4565
A4570
L3909
                          2/16/2012                                                               8/1/2011


                          OTC-4102                                                                OTC-4451
               Northside Medical Clinic/Walk-In                                             Pinnacel Medical Group


                    1394 West 16th Street                                                     4343 E 31st Place
                            Yuma                                                                    Yuma
                           Arizona                                                                   AZ
                            85364                                                                  85365


                           PO Box 3                                                           4343 E 31st Place
                            Yuma                                                                    Yuma
                           Arizona                                                                   AZ
                            85366                                                                  85365
                        928-539-0055                                                            928-341-4544
                         1245226398                                                              1578660718
                            918518                                                                  N/A
                             Yes                                                                     yes
                           Z102887                                                                 72684
                     Daniel R. Ortiz, PA-C                                                      Tami Harmon
                        928-539-0055                                                            928-341-4544
                nsmc@northsidemedicalyuma.com                                            tami.harmon@pinnacleweb.com
                     Daniel R. Ortiz, PA-C                                                          N/A
                        928-539-0055                                                                N/A
                nsmc@northsidemedicalyuma.com                                                       N/A
                     Daniel R. Ortiz, PA-C                                                      Tami Harmon
                        928-539-0055                                                            928-341-4544
                nsmc@northsidemedicalyuma.com                                            tami.harmon@pinnacleweb.com
                          10/1/2010                                                              11/2/2002


                 Discription of Charge                Rate of Charge      Service Code


OV NEW PATIENT                                                               99201
Very Limited                                      $               97.00      99202
Limited                                           $              150.00      99203
Expanded                                          $              200.00      99204
Detailed                                          $              250.00     99429
Comprehensive                                     $              306.00     92552
OV ESTABLISHED PATIENT                                                      93000
Very Limited                                      $               65.00      94540
Limited                                           $               95.00      20600
Expanded                                          $              150.00     A4570
Detailed                                          $              185.00      11750
Comprehensive                                     $              220.00      11040
PREVENTATIVE MED                                       17110
DOT                                       $   110.00   10060
Employment Exam                           $   110.00   11740
Sports Exam                               $   45.00        65220
MEDICAL PROCEDURE                                      69200
Audiometry                                $   40.00    10120
Spirometry                                $   50.00    12001
Pulse Oxymetry                            $   20.00    12002
Visual Acuity Screening                   $     5.00   12004
EKG(12-Lead)                              $   70.00    12005
Supplies                                  $    10.00   12011
Nebulizer Treatment                       $   45.00    12013
Albuterol Solution                        $   20.00    12014
RaceEpi                                   $     6.00   12015
Oxygen                                    $    15.00   12031
O2 Tubing                                 $   25.00    12032
O2 Cannula                                $    10.00   12034
O2 Mask                                   $    15.00   12051
Peak Flow                                 $   34.00    12052
Anoscopy                                  $   80.00    12054
INJECTIONS                                             A6260
IM/SQ Therapeutic Medication              $   30.00    A6402
Allergy Inj. Admin. Two or more           $   40.00    A4550
Allegry Inj. Admin.                       $   30.00    A4649
Ampicillin 1 gm IM                        $   70.00    74000
Ancef 500-1000 mg x __units               $   35.00    74002
B12 up to 1000 mcg                        $   20.00    73610
Benadryl 50 mg x ____ units               $   20.00    72052
Bicillin CR 1.2 mu                        $   75.00    71020
Bicillin LA 1.2 mu                        $   75.00    73000
Claforan 1 gm IM                          $   45.00    73080
Decadron 4 mg x ____ units                $   20.00    70150
Depomedrol 40 mg x ____units              $   35.00    73140
Diazepam/Valium 5 mg/2ml (-0833)          $   20.00    73630
Epinephrine 1 ml Amp                      $   30.00    73090
GI Cocktail                               $   35.00    73130
Vistaril/Hydroxyrine 25 mg x ____ units   $   25.00    73650
Kenalog 10 mg x ____ units                $   30.00    73510
Lidocaine/Xylocaine 1-2% per 1 CC         $    10.00   73060
Marcaine                                  $    14.00   73564
Nubain 10 mg x ____ units                 $   25.00    72110
Phenergan 25-50 mg x ____units            $   25.00    70110
Rocephin 500mg x ____units                $   130.00   70160
Solumedrol 125 mg                         $   35.00    70200
Stadol mg x ____ units                   $    20.00    72170
Toradol 15 mg x ____ units               $    35.00    71111
Valium/Diazepam                          $    20.00    72220
IV INJECTION AND SUPPLIES                              73010
IV/Drug Injection                        $    35.00    73030
IV/Insertion Vein                        $    36.00    70220
IV/Infusion up to 1 Hr                   $    85.00    70260
IV Needle / Catheter                     $    20.00    71120
IV Tubing                                $    23.00    72070
IV Solution 500 cc                       $    40.00    73590
IV Solution 1000 cc                      $    45.00    73660
ARTHROCENTESIS                                         73110
Aspiration &/or Inj. Of Ganglion Cys     $   184.00    90471
Injection, Tendon, Shealth, or Trg Pts   $   173.00    90632
Large Joint                              $   151.00    90746
Medium Joint                             $   125.00    90658
Small Joint                              $   162.00    90718
Trigger Point Injection                  $   224.00    90788
                                                       90782
SURGICAL VISITS                          $             99000
Initial Surgical Visit (w/c only)        $    50.00    36415
Control Nasal Hemorrhage/any method      $   300.00    86580
Debridement of Ext. Infected Skin        $   115.00    81000
Debridement, Skin (partial thickness)    $   115.00    81025
Destruction Benign Lesion, First         $    60.00    82075
Destruction Lesion 15 or more            $   300.00    80100
Destruction Lesion 2-14 each             $    90.00   80100-90
Destruction of Wart-Molluscum            $    63.00    82480
Digital Block                            $   120.00
Epistaxis, Anterior Simple               $   150.00
I&D Abscess, Paronychia, Cyst            $   165.00
I&D Hemorrhoid                           $   200.00
I&D Pilonidal Cyst-Simple                $   169.00
I&D Subungual Hematoma                   $   145.00
Removal Ingrown Nail / Complicated       $   450.00
Removal Ingrown Nail / Uncomplicated     $   155.00
Nailbed Repair                           $   230.00
Removal FB, Conjunctival                 $    70.00
Removal FB, Cornea                       $    90.00
Removal FB, Corneal (w/Slit Lamp)        $   180.00
Removal FB, Ear                          $   115.00
Removal FB, Nose                         $   217.00
Removal Foreign Body, Simple             $   180.00
Removal Foreign Body, Complicated        $   310.00
Removal Impacted Cerumen       $   65.00
Removal Skin Tags (up to 15)   $   150.00
SURGICAL SUPPLIES
Betadine / Wound Prep          $     8.00
Large                          $    12.00
Medium                         $    11.00
Small                          $     9.00
Dermabond Supplies             $     5.00
Dressing, Wound Cover          $    10.00
Eye Patch / Pad                $    10.00
Foam Dressing                  $   40.00
Iodoform                       $    10.00
Irrigation Solution            $    10.00
Irrigation Tray                $    18.00
Saline/Water, Sterile          $     8.00
Silver Nitrate Applicators     $   40.00
Sterile Gloves                 $    15.00
Steri-Strips                   $   25.00
Supplies and Materials         $     5.00
Surgical Tray                  $   45.00
Suture Removal                 $   20.00
Tape, Non-Waterproof           $     8.00
IMMUNIZATIONS
Flu Vaccine Administration     $    15.00
Hep A Adult                    $   115.00
Hep B Adult                    $   110.00
Immun. Admin. 2 or more        $    12.00
PPD                            $   35.00
Tetanus                        $   35.00
SUPPLIES
Ankle Supp. -Elastic           $   35.00
ACE Bandage Large              $    12.00
ACE Bandage Sm-Med             $     8.00
Ankle - Gelcast                $   30.00
Back Brace - Dual Support      $   30.00
Cast Shoe / Boot / Post-op     $   40.00
Cervical Collar                $   40.00
Coband                         $     8.00
Crutches                       $   48.00
Elastic Elbow Support/L        $    15.00
Elastic Knee Support/L         $   40.00
Elbow Band/Strap-Tennis        $   48.00
Elbow Sleeve / Support         $   30.00
Fabricated Finger Splint       $    15.00
Frog Splint / Support               $     15.00
Knee - Mobilizer                    $     55.00
Knee Supp. - Hinged                 $     98.00
Rib Belt-Universal                  $     30.00
Collar C-Spine Support              $     25.00
SIMPLE LACERATIONS                  $
SCALP, NECK, EXT GEN, TRUNK EXT
Up to 2.5 cm                        $    205.00
2.6 to 7.5 cm                       $    245.00
7.6 to 12.5 cm                      $    255.00
12.6 to 20 cm                       $    265.00
FACE, EARS, MUCOUS MEMBRANES
Up to 2.5 cm                        $    245.00
2.6 to 5.0 cm                       $    393.00
5.1 to 7.5 cm                       $    394.00
7.6 to 12.5 cm                      $    394.00
12.6 to 20 cm                       $    394.00
INTERMEDIATE LACERATION
SCALP, TRUNK, EXTREMITIES
Up to 2.5 cm                        $    405.00
2.6 to 7.5 cm                       $    405.00
7.6 to 12.5 cm                      $    420.00
12.6 to 20 cm                       $    463.00
NECK, HANDS, FEET, EXT GEN
Up to 2.5 cm                        $    375.00
2.6 to 7.5 cm                       $    412.00
7.6 to 12.5 cm                      $    456.00
12.6 to 20 cm                       $    456.00
FACE, EARS, MUCOUS MEMBRANES
Up to 2.5 cm                        $    456.00
2.6 to 5.0 cm                       $    515.00
5.1 to 7.5 cm                       $    679.00
7.6 to 12.5 cm                      $    679.00
12.6 to 20 cm                       $    679.00
COMPLEX LACERATIONS
Trunk 1.1 to 2.5 cm                 $    395.00
Trunk 2.6 to 5.0 cm                 $    544.00
Scalp, Arm/Leg 1.1-2.5 cm           $    500.00
Scalp, Arm/Leg 2.6-7.5 cm           $    704.00
Face, Ax, Hand/Ft 1.1-2.5 cm        $    624.00
Face, Ax, Hand/Ft 2.6-7.5 cm        $    971.00
Lids, Nose, Ears, Lips 1.1-2.5 cm   $    760.00
Lids, Nose, Ears, Lips 2.6-7.5 cm   $   1,202.00
Other
Location _______________
Length ________________
APPLICATION OF SPLINTS
Splinting Materials / Supplies    $    30.00
Finger Splint                     $    45.00
Long Arm                          $    90.00
Long Leg                          $   110.00
Short Arm                         $    90.00
Short Leg                         $   110.00
ORAL MEDICATION
Nitroglycerin 0.4 mg              $    10.00
Aspirin 81 mg                     $     5.00
Acetaminophen 325 mg tab          $    10.00
Admin of an Oral Drug Non-Chemo   $    10.00
Apap 325 mg tab                   $     4.00
Carisoprodol 350 mg               $     5.00
Cephalexin 250-500 mg Cap         $     5.00
Diphenhydramine 25 mg             $     5.00
Erythromycin Opth Oint            $     4.00
Gentamicin Suffate 0.3%           $     4.00
Hydrocortisone 1% Crm             $     3.00
Hydroxyzine Hcl 25 mg tab         $     5.00
Ibuprofen 800mg                   $     5.00
Nonprescription Drug              $    10.00
Prednisone 5 -20 mg               $     5.00
Propoxacet N- 100 mg              $     5.00
Silver Sulfadizine 1% Crm         $     5.00
SMZ-TMP DS tab (-01442)           $     3.00
Tylenol #3                        $    10.00
Valium 5 - 10 mg tab              $    10.00
Zithromax 250 mg tab (-05050)     $     5.00


RADIOLOGY                         $
Abdominal/KUB                     $    90.00
Abdominal Series                  $   160.00
AC Joint w/wo wts. Bilateral      $   120.00
Ankle, Complete                   $   105.00
Ankle, 2 Views                    $   100.00
C Spine-Complete                  $   240.00
C-Spine-Limited 2 Views           $   110.00
Cervical Spine 4-5 Views          $   180.00
Chest 1 View                      $    90.00
Chest 2 View                      $   115.00
Clavicle Complete                 $   105.00
Elbow Complete                 $   105.00
Facial Complete                $   130.00
Femur                          $   90.00
Finger Complete                $   90.00
Foot 2 Views                   $   90.00
Foot Complete                  $   95.00
Forearm Complete               $   90.00
Hand 2 Views                   $   90.00
Hand Complete                  $   95.00
Heel / Calcaneous              $   90.00
Hip Unilateral Complete        $   105.00
Humerous Complete              $   95.00
Knee 3 Views                   $   110.00
Knee Complete 5 Views          $   115.00
Knee Limited 2 Views           $   95.00
LS Spine-Complete              $   160.00
LS Spine-Limited               $   155.00
Mandible Complete              $   105.00
Mandible Limited 3 Views       $   90.00
Nasal Complete 3 Views         $   95.00
Orbit                          $   130.00
Pelvic (AP)                    $   95.00
Pelvis Comp 3 Views            $   100.00
Ribs 2 Views                   $   100.00
Ribs: Bilateral Complete       $   155.00
Ribs: Unilateral, 3V           $   115.00
Sacrum/Coccyx                  $   85.00
Scapula                        $   90.00
Shoulder Complete              $   95.00
Sinuses 3 View                 $   120.00
Skull AP/Lat 3 Views           $   160.00
Skull Complete                 $   160.00
Sternum / Minimum 2 Views      $   110.00
T Spine A/P & Lateral          $   110.00
Thoraco Lumbar Spine 2 Views   $   105.00
Tib/Fib Complete               $   95.00
Toe Complete                   $   90.00
Wrist Complete                 $   100.00
Wrist Limited 2 Views          $   90.00
LABORATORY
Collection & Handling Fee      $    15.00
Venipuncture                   $   25.00
Basic Metabolic Panel          $   68.00
Blood Sugar / Glucose          $   22.00
Blood Type (ABO RH)              $       30.00
Cervical or Vaginal Cancer Scn   $       85.00
Complete Blood Count             $       68.00
Comprehensive Metabolic - CMP    $       68.00
Glucose                          $       25.00
Lipid Screening                  $       50.00
Liver Function Test              $       85.00
MonoSpot Test                    $       30.00
PAP Smear                        $       110.00
PSA Screening                    $       72.00
Rapid Strep                      $       56.00
Stool Occult Blood               $       20.00
TSH Screening                    $       120.00
Tuberculosis / PPD               $       35.00
Urine Dipstick, Non-Automated    $       22.00
Urine Pregnancy                  $       32.00
Wet Mount / KOH                  $       25.00


Other Orders/Misc.
Sinuses 3 View                   $       120.00
Skull AP/Lat 3 Views             $       160.00
Skull Complete                   $       160.00
Sternum / Minimum 2 Views        $       110.00
Thoracic Spine 2 Views           $       110.00
Thoracolumbar 2 Views            $       105.00
Tib/Fib Complete                 $       95.00
Toe Complete                     $       90.00
Wrist Complete                   $       100.00
Wrist Limited 2 Views            $       90.00
LABORATORY                       Price
Collection & Handling Fee        $        15.00
Venipuncture                     $       20.00
Basic Metabolic Panel            $       40.00
Blood Sugar / Glucose            $       22.00
Blood Type (ABO & RH)            $       60.00
Cervical or Vaginal Cancer Scn   $       80.00
Cholinesterase RBC/Serum         $       50.00
Complete Blood Count             $       68.00
Comprehensive Metabolic - CMP    $       35.00
Glucose                          $        10.00
Hep B Titer Fraw                 $       50.00
HTLV-1                           $       80.00
Lead/ZPP (Zinc)                  $       45.00
Lipid Panel                      $       35.00
Hepatic Function/Liver Profile   $       35.00
MonoSpot Test                    $       30.00
PAP Smear                        $       100.00
PSA Screening                    $       50.00
PT/INR                           $       20.00
Rapid Strep                      $       45.00
Hemoccult                        $        15.00
TSH Screening                    $       50.00
Tuberculosis / PPD               $       35.00
Urine Dipstick, Non-Automated    $       22.00
Urine Pregnancy                  $       25.00
Wet Mount / KOH                  $       25.00
MODIFIERS                        Price
In House Lab Order
Procedure w Injection
Services after 8PM               $       50.00
Sunday/Holiday                   $       80.00




Other Orders/Misc.
EKG
EKG
Supplies
Procedure
Pulse Ox
BREATHING TREATMENT
Visit / Procedure
Albuterol
Mouthpiece
Nebulizer
Pulse Ox
Racepinephrine
Tubing
DIGITAL BLOCK
Digital Block
Lidocaine/Xylocaine 1-2%/1 CC
Visit W/ Procedure
FOREIGN BODY
Location
Bedatine
Complicated
Dressing, Wound Cover
Ear
I&D / Suture Setup
Nose
Simple
EAR IRRIGATION
Ear Irrigation
Solution
Syringe
Tray
Tubing
IV INFUSION
IV Infusion up to one
IV Insertion
IV Needle / Cath
IV Solution 1000cc
IV Solution 500cc
IV Tubing
OXYGEN
O2 Cannula
Oxygen Contents
Oxygen Mask
Oxygen Medication / Supply
Oxygen Tubing
Peak Flow
FOREIGN BODY REMOVAL-EYE
Location
Conjunctival
Cornea
Eye Irrigation
Eye Patch
Eye Tray
Visit W/ Procedure
ANY IN HOUSE LAB ORDERS
Collection & Handling
Venipuncture
Labs or Specific Lab Order
SPLINTS
Splint Location
Fab / Prefab
Splint Application
Ace Wrap (One or Two)
Crutches
Frog Splint
Knee Immobilizer
Ortho Shoe
Sling
Supplies
Wrist Immobilizer
                            8/1/2011                                                              2/17/


                            OTC-4451                                                               OTC-
                      Pinnacel Medical Group                                                Planned Pare


                        4343 E 31st Place                                                   1455 W. 16t
                              Yuma                                                                   Yu
                               AZ                                                                   Ariz
                              85365                                                                  853


                        4343 E 31st Place                                                        Same a
                              Yuma
                               AZ
                              85365
                           928-341-4544                                                          855-20
                           1578660718                                                             11242
                               N/A                                                                  188
                               yes                                                                     N
                              72684                                                                   N
                           Tami Harmon                                                          Heather
                           928-341-4544                                                          928-34
                tami.harmon@pinnacleweb.com                                                    hgeorge@
                               N/A                                                               Patrici
                               N/A                                                               602-26
                               N/A                                                              pgross@
                           Tami Harmon                                                          Cynthia
                           928-341-4544                                                          602-26
               tami.harmon@pinnacleweb.com                                                      clocke@
                            11/2/2002                                                               1-Fe


                Discription of Charge              Rate of Charge          Service Code


Simple Office Visit                            $               60.00    11981/99212/j7307
Expanded Office Visit                          $               76.00    11983/99212/j7303
Detailed Office Visit                          $               101.00   58300/99202/j7307
Comprehensive Office Visit                     $               112.00   58300/99203/j7302
DMV Physical                                   $                75.00   58300/99212/j7302
Audiometry                                     $                40.00   58300/99203/j7300
EKG                                            $                65.00   58300/99212/j7300
Nebulizer Treatment                            $               27.00    11982/99212/j7307
Small Joint Arthrocentesis                     $               55.00    11982/99212/j7307
Small Splint Application                       $               38.00       58301/99202
Nail Removal                                   $              240.00       58301/99212
Skin Debridement                               $               56.00          99211
Wart Destruction                        $    63.00         99212
I & D abscess, cyst                     $    48.00         99213
I & D Subungual Hematoma                $    68.00         99214
FB Removal Cornea                       $    88.00         99215
FB Removal Ear                          $    85.00   80048/36415/99000
FB Removal, Simple                      $   148.00      88104/99000
Simple Laceration, up to 2.5 cm         $    94.00      88305/9900
Simple Laceration, 2.5-7.5 cm           $   114.00      85025/36415
Simple Laceration 7.6-12.5 cm           $   174.00      81003/99000
Simple Laceration over 12.6 cm          $   282.00   87491/87591/99000
Facial/Ear Laceration                   $   128.00      87491/99000
Facial/Ear Laceration, 2.6-5.0 cm       $   170.00      87491/99000
Facial/Ear Laceration, 5.1-75 cm        $   239.00      82465/36415
Facial/Ear Laceration, > 7.6cm          $   303.00      80053/36415
Intermediate Laceration up to 2.5 cm    $   130.00      58100/99000
Intermediate Laceration, 2.6-7.5 cm     $   175.00      83001/36415
Intermediate Laceration, 7.6-12.5 cm    $   230.00     87070/99000
Hand/Feet/Neck Laceration               $   155.00     82947/364/15
Hand/Feet/Neck Laceration, 2.6-7.5 cm   $   226.00      87591/99000
Hand/Feet/Neck Laceration >7.6 cm       $   475.00   87491/87591/99000
Betadine/Wound Prep                     $     4.00      85013/99000
Small Dressing                          $     4.00     82270/99000
Surgical Tray                           $    35.00     80074/364145
Eye/Ear Tray                            $    10.00      86706/36415
Abdominal/KUB x-ray                     $    65.00      86694/36415
Abdominal x-ray series                  $    95.00     87273/99000
Ankle x-ray, Complete                   $    68.00      86701/36416
C-Spine, Complete                       $   115.00   86701/36415/99000
Chest X-Ray                             $    98.00      87621/99000
Clavicle X-ray                          $    72.00     83002/364145
Elbow X-Ray                             $    62.00      80061/36415
Facial X-ray                            $    95.00      88142/99000
Finger X-ray                            $    48.00      84703/36415
Foot, Complete X-ray                    $    70.00      84702/36415
Forearm, Complete X-ray                 $    70.00         81025
Hand X-ray                              $    68.00      84164/36415
Heel X-ray                              $    60.00         86901
Hip, Unilateral X-ray                   $    72.00      j2788/96372
Humerus X-ray                           $    78.00      j2709/96372
Knee, 3 view X-ray                      $    78.00      86762/36415
LS Spine                                $   110.00      89310/99000
Mandible                                $   110.00      86592/36415
Nasal Bones                             $    65.00        86580
Orbit X-ray                             $   100.00      84497/36415
Pelvic X-ray                   $   78.00      84443/36415
Rib X-ray                      $   100.00     81003/99000
Sacrum/Coccyx                  $   75.00      87088/99000
Scapula X-ray                  $   95.00      87081/99000
Shoulder, Complete X-ray       $   68.00          87210
Sinuses X-ray                  $   110.00         99201
Skull X-ray                    $   110.00        99202
Sternum X-ray                  $   75.00         99203
T-Spine X-ray                  $   85.00         99204
Tib/Fib X-ray                  $   90.00         99205
Toe X-ray                      $   40.00         99384
Wrist X-ray                    $   75.00         99385
Immunization Administration    $   24.00         99385a
Hep A Immunization             $   80.00         99386
Hep B Immunization             $   85.00         99387
Influenza Immunization         $   35.00         99394
Tetanus Immunization           $   27.00         99395
IM/SQ abx administration       $   24.00         99395a
IM/SQ Therapeutic Medication   $    18.00        99396
Collection and Handling ree    $    15.00        99379
Venipuncture                   $    16.00      76815/99201
PPD                            $   20.00       99211/76815
Urinalysis                     $    16.00      76817/99201
Urine Pregnancy Test           $   25.00       99201/76817
Breath Alcohol Test            $   25.00    90417/90649/99201
Drug Screen Collection         $   20.00    90649/90472/99211
DOT/Non-DOT Drug Screen        $   55.00    90632/90471/00201
Cholinesterase                 $   85.00    90632/90472/99211
                                            90471/90746/99201
                                            90472/90746/99211
                                            90471/90636/99201
                                            90472/90636/99211
                                              54056/99202
                                              54065/99203
                                              56501/99202
                                              56515/99203
                                              99203/SO190
                                                5984106
                                                 5984110
                                                 5984112
                                                 5984114
                                                 5984116
                                                 5984118
                                                4984120
    57454/88305/99202
    57456/88305/99202
       57511/99202
87491/87591/86592/uhv86701
87491/87591/86592/uhv86701
87491/87591/86592/uhv86701
87491/87591/86592/bhv86701
                 2/17/2012                                                                   2/17/2


                 OTC-0740                                                                     OTC-36
         Planned Parenthood Yuma                                                         PrimeCare F


          1455 W. 16th St. Suite C                                                     11142 S. Scott
                     Yuma                                                                       Yuma
                    Arizona                                                                    Arizo
                     85364                                                                      8536


               Same as Above                                                             2377 S. 22N
                                                                                                YUM
                                                                                              ARIZO
                                                                                                8536
               855-207-7526                                                                 928-343-
                1124273818
                    188806                                                                     48330
                      No                                                                         YES
                     N/A                                                                      ZWDB
              Heather George                                                             DR JOHN C
               928-343-4860                                                                 928-343-
             hgeorge@ppaz.org
               Patricia Gross                                                                   SAM
               602-263-4275                                                                     SAM
              pgross@ppaz.org
              Cynthia K. Locke                                                             KELLEY PA
               602-263-2237                                                                 928-343-
              clocke@ppaz.org                                                        K.PATTON@YUMA
                    1-Feb-12                                                                  2/17/2


                     Discription of Charge       Rate of Charge       Service Code


Implanon Insertion                           $              895.00       10060
Implanon Removal and Insertion, Est.         $             1,045.00      10061
Implanon Removal and Insertion , New         $             1,065.00      10080
Mirena Insertion, New                        $             1,200.00      10120
Mirena Insertion, Est.                       $             1,170.00      10140
Paragard Insertion, New                      $              800.00       10160
Paragard Insertion, Est.                     $              255.00       10180
Implanon Removal , New                       $             1,065.00      11040
Implanon Removal, Est.                       $             1,045.00      11041
IUC Removal, New                             $              165.00       11100
IUC Removal, Est.                            $              145.00       11200
Visit Limited or Minor, Est.                 $               36.00       11201
Visit Low Severity, Est.                   $   44.00    11400
Visit Moderate Severity, Est.              $   75.00    11401
Visit Moderatet/High Severity, Est.        $   88.00    11402
Visit High Severity, Est.                  $   120.00   11403
Basic Metabolic Panel                      $   48.00    11404
Breast Smear                               $   148.00   11422
Biopsy                                     $   66.00    11423
Complete Blood Count                       $   44.00    11426
Chemstrip (Urine)                          $    16.00   11441
Chlamydia/Gonorrhea (Urine or Gen Probe)   $   44.00    11442
Chlamydia - Gen-Probe                      $   26.00    11446
Chlamydia - Urine                          $   26.00    11730
Cholestrol                                 $   32.00    11740
Complete Metabolic Panel                   $   48.00    11750
Endometrial Biopsy                         $   132.00   11760
FSH                                        $   44.00    11765
Genital Culture                            $   60.00    12001
Glucose - Fasting                          $   32.00    12002
Gonorrhea (Urine or Gen Probe)             $   26.00    12004
Gonorrhea / Chlamydia                      $   52.00    12005
Hematocrit                                 $   20.00    12006
Hemoccult                                  $     8.00   12007
Hep Panel                                  $   64.00    12011
Hep B titer                                $   44.00    12013
Herpes Blood                               $   64.00    12031
Herpes Culture                             $   44.00    12034
HIV - Unigold                              $   52.00    13121
HIV - Blood                                $   64.00    16000
HPV                                        $   72.00    16020
LH                                         $   44.00    16025
Lipid Panel                                $   40.00    16030
Pap Sure/Sure Path                         $   40.00    17000
Pregnancy Test - Serum Qualitative         $   44.00    20550
Pregnancy Test - Serum Quantitative        $   44.00    20600
Pregnancy Test - Urine                     $   20.00    20650
Pro Lactin                                 $   44.00    20610
RH Screen                                  $   20.00    21337
Rohgam Injection (Micro)                   $   65.00    21480
Rhogam Injection                           $   95.00    23520
Rubella                                    $   44.00    23540
Semen Analysis with Count                  $   44.00    23650
Syphilis                                   $   40.00    24600
TB Screen                                  $    12.00   24640
Thyroid (T3 or T4)                         $   48.00    25675
TSH                                 $     48.00    26010
Urine - Chemstrip                   $     16.00    26011
Urine Bacterial Culture             $     36.00    26605
Vaginal Culture                     $     44.00    26641
Wet Mount                           $     16.00    26725
Visit Limited or Minor, New         $     56.00    27560
Visit Low Severity, New             $     64.00    28190
Visit Moderate Severity, New        $    105.00    30300
Visit Moderate/High Severity. New   $     112.00   30901
Visit High Severity, New            $    132.00    30903
Pre visit, new, age 12-17           $     112.00   30905
Pre visit, new, age 18-20           $    128.00    36415
Pre visit, new, age 21- 39          $    128.00    40800
Pre visit, new, age 40-64           $    135.00    42700
Pre visit, new, age 65 +            $    135.00    42809
Pre visit, est. , age 12-17         $    106.00    46083
Pre visit, est, age 18-20           $     114.00   51702
Pre visit, est, age 21- 39          $     114.00   56420
Pre visit, est, age 40-64           $     114.00   65205
Pre visit, est, age 65 +            $    122.00    65220
Ultrasound - Abdominal, New         $    176.00    69200
Ultrasound - Abdominal, Est         $    124.00    69210
Ultrasound - Tran Vaginal , New     $    188.00    70140
Ultrasound - Transvaginal, Est.     $     111.00   70160
Gardasil #1                         $    217.00    70330
Gardasil #2 & 3                     $    188.00    71010
Hep A # 1                           $     141.00   71020
Hep A # 2                           $     112.00   71100
Hep B # 1                           $     113.00   71120
Hep B # 2& 3                        $     84.00    72020
Hep A & B #1                        $    189.00    72040
HepA & B # 2 & 3                    $    160.00    72050
Destruction of penis lesion < 5     $    188.00    72070
Destruction of penis lesion >5      $    281.00    72072
Destruction of vulva lesion <5      $    180.00    72100
Detruction of vulva lesion >5       $    281.00    72110
Abortion by Pill                    $    525.00    72170
Abortion 5- 9.6 wks                 $    525.00    72190
Abortion 10 - 11.6 wks              $    525.00    73000
Abortion 12 - 13.6 wks              $    800.00    73020
Abortion 14 - 15.6 weeks            $    950.00    73030
Abortion 16 - 17.5 wks              $   1,225.00   73050
Abortion 18 -19.5 wks               $   1,605.00   73060
Abortion 20- 24.6 weeks             $   1,900.00   73070
Colposcopy Biopsy                            $   230.00   73080
Colposcopy Endocervix                        $   230.00   73090
Cryosurgery                                  $   244.00   73100
Chlamydia/Gonorrhea/HIV-Uni-gold/Syphillis   $   136.00   73110
Chlamydia/Gonorrhea/HIV - blood/Syphillis    $   148.00   73120
Full screen STI                              $   136.00   73130
Full screen STI blood                        $   148.00   73140
                                             $    25.00   73500
                                             $    40.00   73510
                                             $    40.00   73550
                                             $    10.00   73560
                                             $    15.00   73564
                                             $    35.00   73590
                                             $    30.00   73600
                                             $    30.00   73620
                                             $    20.00   73650
                                             $    30.00   73660
                                             $    38.00   74000
                                             $    20.00   74022
                                             $    20.00   80100
                                             $    75.00   81002
                                             $    30.00   81025
                                             $    30.00   82947
                                             $    20.00   86308
                                             $    20.00   86580
                                             $    10.00   87430
                                             $    30.00   87804
                                             $    30.00   90471
                                             $    35.00   90658
                                             $    35.00   90718
                                             $    40.00   90744
                                             $    30.00   92551
                                             $    25.00   92950
                                             $    35.00   93000
                                             $    25.00   94010
                                             $    25.00   94640
                                             $    30.00   96360
                                             $    35.00   96372
                                             $    20.00   96374
                                             $    35.00   99201
                                             $    35.00   99202
                                             $    30.00   99203
                                             $   130.00   99204
                                             $    35.00   99205
$    25.00    99211
$    50.00    99212
$    15.00    99213
$     0.25    99214
$    80.00    99215
$    80.00   A4310
$    40.00   A4314
$    50.00   A4466
$    35.00   A4565
$   340.00   A4570
$    50.00   A4570
$     2.50   A4570.2
$    15.00   A6220
$    15.00   A6251
$    12.00   A6449
$    10.00    E0116
             G0168
             J0170
             J0540
             J0561
             J0696
             J0698
             J0780
              J1100
             J1200
             J1460
             J1885
             J2300
             J2550
             J2930
             J3301
             J3410
             J7040
              L1830
             L3260
             L3909
             Q4046
             Q4048
             45999
             46050
             46083
             46320
             46600
             46608
46945
51702
53670
56420
65205
65220
65222
67700
69200
69210
70100
70110
70130
70140
70150
70160
70190
70200
70210
70220
70250
70260
70330
70360
71010
71020
71021
71030
71100
71101
71110
71111
71120
71130
72020
72040
72052
72070
72072
72080
72100
72110
72120
72170
72190
72202
72220
73000
73010
73020
73030
73050
73060
73070
73080
73090
73100
73110
73120
73130
73140
73500
73510
73520
73550
73560
73562
73564
73590
73600
73610
73620
73630
73650
73660
74000
74020
74022
80100
81002
81025
82055
82270
82480
82947
82948
82962
83655
86663
87430
87804
90732
90774
92551
92950
93000
94010
94640
94664
94760
96372
97028
98925
99202
99203
99204
99205
99212
99213
99214
99215
                            2/17/2012                                                            2/


                            OTC-3676                                                             O
                        PrimeCare Foothills                                                 PRIMECA


                     11142 S. Scottsdale Drive                                              284 W.
                               Yuma
                             Arizona                                                             A
                              85367


                       2377 S. 22ND DRIVE                                                    2377 S
                              YUMA
                            ARIZONA                                                              A
                              85364
                          928-343-0488                                                         928
                                                                                                121
                             483302                                                                  4
                               YES
                            ZWDBYN                                                               Z
                        DR JOHN CARSON                                                       DR JO
                          928-343-0488                                                         928


                              SAME
                              SAME


                         KELLEY PATTON                                                        KELL
                          928-343-0488                                                         928
                  K.PATTON@YUMA.TWCBC.COM                                                K.PATTON@
                            2/17/2012                                                            2/


                   Discription of Charge             Rate of Charge       Service Code


I&D CYST SIMPLE                                  $              288.00       10060
I&D CYST COMP                                    $              307.50       10061
I&D PILONIDAL CYST                               $              299.00       10080
F/B REMOVAL SUB-Q SIMPLE                         $              241.00       10120
PUNCTURE HEMATOMA                                $              239.50       10140
PUNCTURE HEMATOMA                                $              201.50       10160
PUNCTURE ASPIRATION ABSCESS                      $              437.00       10180
DEBRIDEMENT PARTIAL                              $               141.00      11040
DEBRIDEMENT FULL THICKNESS                       $              203.50       11041
BIOPSY, SUB-Q                                    $              169.50       11100
REMOVAL SKIN TAGS                                $              148.50       11200
REMOVAL SKIN TAGS, OVER 20                       $               76.50       11201
EXCISION, BENIGN LESION          $   209.00   11400
EXCISION, LESIONS                $   262.00   11401
EXCISION LESION, ARMS, LEGS      $   333.00   11402
EXCISIONS, LESIONS TRUNK         $   430.00   11403
EXCISION, 3-4 CM                 $   340.00   11404
EXCISION BENIGN, SCALP, FEET     $   372.00   11422
EXCISION GENITALIA               $   484.50   11423
EXCISION BEN NECK, HANDS         $   862.00   11426
EXCISION FACIAL                  $   405.00   11441
EXCISION LESION, FACIAL, EARS    $   441.00   11442
EXCISION, LESIONS, FACIAL, EYE   $   613.00   11446
NAIL PLATE AVULSION, SIMPLE      $   172.00   11730
PUNCTURE-NAIL HEMATOMA           $   130.00   11740
EXCISION NAIL INGROWN NAIL       $   306.50   11750
NAIL BED REPAIR                  $   382.00   11760
WEDGE EXCISION                   $   193.00   11765
REPAIR SIMPLE SCALP              $   263.00   12001
REPAIR SIMP, SCALP NECK          $   304.00   12002
REPAIR SIMP NECK TRUNK           $   325.00   12004
REPAIR SIMP EXTREMITIES          $   493.00   12005
REPAIR SIMP SCALP                $   507.00   12006
REPAIR SIMP TRUNK                $   734.00   12007
REPAIR SIMP FACIAL               $   291.00   12011
REPAIR SIMP FACIAL               $   421.00   12013
REPAIR INTERM TRUNK              $   315.00   12031
REPAIR LAYERED TRUNK             $   435.00   12034
REPAIR COMP SCALP                $   647.00   13121
BURN TX LOCAL                    $   138.00   16000
BURN TX SMALL                    $   145.00   16020
BURN TX MEDIUM                   $   261.00   16025
BURN TX LARGE                    $   367.00   16030
LESION DESTRUCTION               $   124.00   17000
INJECT/TRIGGER PT                $   132.50   20550
INJECT/ASPIRATE SMALL JOINT      $   120.00   20600
INJECT/ASPIRATE INTER JOINT      $   132.50   20650
INJECT/ASPIRATE MAJOR JOINT      $   153.00   20610
REDUCE CLOSED NASAL FX           $   621.00   21337
REDUCE BILT TEMPEROMAND JOINT    $   238.50   21480
REDUCE STERNOCLAVICULAR          $   367.00   23520
REDUCE ACROMIOCLAVICULAR         $   369.00   23540
REDUCE SHOULDER                  $   508.00   23650
REDUCE ELBOW                     $   385.00   24600
REDUCE RADIAL HEAD-CHILD         $   216.00   24640
REDUCE DISTAL RADIOULNAR         $   748.00   25675
I&D FINGER ABSCESS SIMP     $   623.00   26010
I&D FELON                   $   772.00   26011
REDUCE METACARPAL           $   541.00   26605
REDUCE THUMB                $   607.00   26641
REDUCE PHALANX              $   591.00   26725
REDUCE PATELLA              $   636.00   27560
F/B REMOVAL SUB-Q SIMPLE    $   425.00   28190
F/B REMOVAL NOSE, SIMPLE    $   490.00   30300
CAUTERIZATION-ANT NASAL     $   246.00   30901
CAUTERIZATION ANT COMPLEX   $   352.00   30903
CAUTERIZATION POST NASAL    $   598.00   30905
DRAW FEE                    $    21.00   36415
I&D ABSCESS MOUTH           $   387.00   40800
I&D ABSCESS PERITONSILLAR   $   508.00   42700
F/B REMOVAL PHARYNX         $   391.00   42809
I&D HEMORROID               $   578.00   46083
CATHETER INSERTION          $   179.00   51702
I&D BARTHOLIN'S CYST        $   315.00   56420
F/B REMOVAL EXT. EYE        $   173.00   65205
F/B REMOVAL CORNEA          $   104.00   65220
F/B REMOVAL EAR             $   219.00   69200
REMOVAL IMPACTED CERUMEN    $    95.50   69210
XRAY FACIAL BONES           $   140.00   70140
XRAY NASAL BONES            $   138.00   70160
XRAY MANDIBULAR JOINT       $    84.00   70330
XRAY CHEST (1)              $   107.00   71010
XRAY CHEST (2)              $   132.50   71020
XRAY RIBS (2)               $   173.00   71100
XRAY STERNUM (2)            $   137.00   71120
XRAY SPINE (2)              $   146.00   72020
XRAY CERVICAL SPINE (2)     $   159.00   72040
XRAY CERVICAL SPINE (4)     $   213.00   72050
XRAY THORACIC SPINE (2)     $   158.00   72070
XRAY THORACIC SPINE (3)     $   175.00   72072
XRAY LUMBAR SPINE (2)       $   176.00   72100
XRAY LUMBAR SPINE (4)       $   219.50   72110
XRAY PELVIS (1)             $   117.00   72170
XRAY PELVIS (3)             $   128.00   72190
XRAY CLAVICLE               $   120.00   73000
XRAY SHOULDER (1)           $   121.00   73020
XRAY SHOULDER (2)           $   128.00   73030
XRAY A/C JOINTS BILATERAL   $   148.50   73050
XRAY HUMERUS (2)            $   117.00   73060
XRAY ELBOW (2)              $   150.00   73070
XRAY ELBOW (3)                  $   124.00   73080
XRAY FOREARM (2)                $   105.00   73090
XRAY WRIST (2)                  $   102.00   73100
XRAY WRIST (3)                  $   112.00   73110
XRAY HAND (2)                   $   106.00   73120
XRAY HAND (3)                   $   115.50   73130
XRAY FINGER (2)                 $    89.00   73140
XRAY HIP UNI (1)                $   125.00   73500
XRAY HIP (2)                    $   136.00   73510
XRAY FEMUR                      $   127.00   73550
XRAY KNEE (2)                   $   112.00   73560
XRAY KNEE COMPLETE              $   151.50   73564
XRAY TIB-FIB (2)                $    93.00   73590
XRAY ANKLE (3)                  $   103.00   73600
XRAY FOOT (3)                   $    95.50   73620
XRAY CALCANEUS (2)              $    80.50   73650
XRAY TOES (2)                   $    91.00   73660
XRAY ABDOMEN (1)                $   125.00   74000
XRAY ABDOMEN COMPLETE           $   195.00   74022
DRUG TEST U/A                   $    38.00   80100
URINALYSIS DIP STICK            $    21.00   81002
PREGNANCY TEST                  $    34.00   81025
GLUCOSE STICK TEST              $    24.00   82947
MONO SPOT TEST                  $    96.00   86308
T.B. TEST INTRADERMAL           $    34.00   86580
STREP SCREEN                    $    48.00   87430
FLU VAX TEST                    $    29.00   87804
TETANUS                         $    34.00   90471
INFLUENZA VACCINE               $    26.50   90658
TETANUS ADULT                   $    37.00   90718
HEPATITIS B PEDS/ADULT          $    64.00   90744
AUDIOMETRY                      $    33.00   92551
CARDIOPULMONARY RESUSCITATION   $   752.00   92950
EKG                             $   106.00   93000
SPIROMETRY                      $   109.00   94010
SVN TREATMENT                   $    65.00   94640
I.V. SET UP                     $   220.50   96360
INJ ADMINISTRATION              $    34.00   96372
INTRAVENOUS ADMIN               $    60.00   96374
OV E&M NP LEVEL 1               $    97.00   99201
OV E&M NP LEVEL 2               $   130.00   99202
OV E&M NP LEVEL 3               $   193.00   99203
OV E&M NP LEVEL 4               $   272.00   99204
OV E&M NP LEVEL 5               $   347.00   99205
OV E&M EP LEVEL 1                   $    54.00    99211
OV E&M EP LEVEL 2                   $    82.00    99212
OV E&M EP LEVEL 3                   $   118.00    99213
OV E&M EP LEVEL 4                   $   164.00    99214
OV E&M EP LEVEL 5                   $   240.00    99215
FOLEY CATHETER TUBE                 $    42.50   A4310
FOLEY CATHETER BAG                  $    42.50   A4314
ACE WRAP, FROG SPLINT               $    15.00   A4466
ARM SLING                           $    13.00   A4565
SPLINT THUMB                        $    42.50   A4570
WRIST IMMOBILIZER                   $    32.00   A4570
SPLINT SHORT ARM                    $    72.00   A4570.2
DRESSING MEDIUM                     $    16.00   A6220
NASAL PACKING                       $    32.00   A6251
ACE WRAP                            $     8.50   A6449
CRUTCHES                            $    44.50    E0116
DERMABOND                           $    64.00   G0168
EPINEPHRINE                         $    24.00   J0170
PENICILLIN 1.2 UNITS                $    42.50   J0540
BICILLIN 1.2 IM                     $    75.00   J0561
ROCEPHIN 250 MG IM                  $    22.50   J0696
CLAFARON                            $    48.00   J0698
COMPAZINE                           $    13.50   J0780
DECADROM 4 MG IM                    $    32.00    J1100
BENADRYL                            $    16.00   J1200
HEPATITIS A VACCINE                 $    64.00   J1460
TORRADOL 60 MG                      $    42.50   J1885
NUBAIN 10 MG                        $    24.00   J2300
PHENERGAN 50 MG                     $    26.50   J2550
SOLUMEDROL 125 MG                   $    38.00   J2930
KENALOG 40 MG                       $    32.00   J3301
VISTARIL 50 MG                      $    80.50   J3410
NORMAL SALINE IV 500 CC             $    37.00   J7040
KNEE IMMOBILIZER                    $    53.00    L1830
ORTHOPEDIC SHOE                     $    34.00   L3260
VELCRO HAND SPLINTS                 $    40.00   L3909
LEG SPLINT ADULT SHORT              $    72.00   Q4046
LEG SPLINT CHILD SHORT              $    40.00   Q4048
Remove Fecal Impact                 $    53.00   45999
I&D Perianal Abscess, Superficial   $   329.00   46050
I&D Thromosed Hemorroid External    $   578.00   46083
Excisioln-Thrombosed Hemmoroid      $   339.00   46320
Anoscopy                            $   144.00   46600
F/B Removal w/ Anoscopy             $   414.00   46608
Ligation-Internal Hemorrhoids/Single              $   382.00   46945
Bladder Catheter (Foley) Insertion                $   179.00   51702
Bladder Catheter Insertion                        $   148.00   53670
I&D Bartholin's Cyst                              $   315.00   56420
F/B Removal External Eye                          $   173.00   65205
F/B Removal Cornea w/o Slit Lamp                  $   104.00   65220
F/B Removal w/Slit Lamp                           $   261.00   65222
I&D Drainage of Abcess, Eyelid                    $   507.00   67700
F/B Removal Ear                                   $   219.00   69200
Removal Impacted Cerumen                          $    95.50   69210
X-Ray- Mandible 3V                                $   146.00   70100
X-Ray-Mandible 4v min                             $   174.00   70110
Xray-Mastoids; Min of 3V                          $   195.00   70130
Xray- Facial Bones 3V                             $   140.00   70140
Xray- Facial Bonhes Min 3V                        $   140.00   70150
Xray- Nasal Bones 3V                              $   138.00   70160
Xray-Optic Formina                                $   106.00   70190
Xray-Orbits, Complete Min. 4V                     $   114.50   70200
Xray-Sinus 1-2V                                   $   103.00   70210
Xray-Sinus 3V                                     $   173.00   70220
Xray-Skull Less 4V                                $   159.00   70250
Xray- Skull Complete Min 4V                       $   174.00   70260
Xray-Temporomandibular Joint (TMJ) Bilateral      $    84.00   70330
Xray-Neck, Soft Tissue                            $   128.00   70360
Xray- Chest 1V                                    $   107.00   71010
Xray- Chest 2V                                    $   132.50   71020
Xray-Chest w/Apical Lordotic Pro                  $   168.50   71021
Xray-Chest 4V Complete                            $   163.00   71030
Xray-Ribs 2V                                      $   173.00   71100
Xray-Ribs,Chest 3V                                $   159.00   71101
Xray-Ribs, Bilateral 3V                           $   173.00   71110
Xray-Ribs Posteroanterior Chest Min 4V            $   183.00   71111
Xray- Sternum 2V                                  $   137.00   71120
Xray-Sternum Sternoclavicular Joints Min 3V       $   141.00   71130
Xray-Spine Single Cies Spec Level                 $   146.00   72020
Xray-Cervical Spine 2V                            $   159.00   72040
Xray-Cervical Complete Oblique and Flexion        $   227.00   72052
Xray-Thoratic Spine 2V                            $   158.00   72070
Xray-Thoracic Spine 3V                            $   175.00   72072
Xray-Thoracolumbar, Anteroposterior and Laterat   $   154.00   72080
Xray-Lumbar Spine Complete 2V                     $   176.00   72100
Xray-Lumbar Spine Complete 4V                     $   219.50   72110
Xray Spine Lumbosacral Bend view 4V               $   214.00   72120
Xray-Pelvis 1V                                    $   117.00   72170
Xray-Pelvis Complete Min 3V       $   128.00   72190
Xray-Sacroiliac Joints 3V         $   95.50    72202
Xray-Sacrium and Coccyx 2V        $   128.00   72220
Xray-Clavical Complete            $   120.00   73000
Xray-Scapula Complete             $   122.00   73010
Xray-Shoulder 1V                  $   121.00   73020
Xray-Shoulder 2V                  $   128.00   73030
Xray-A/C Joint, B/L               $   148.50   73050
Xray-Humerus 2V                   $   117.00   73060
Xray-Elbow 2V                     $   150.00   73070
Xray-Elbow 3V                     $   124.00   73080
Xray-forearm 2V                   $   105.00   73090
Xray-Wrist 2V                     $   102.00   73100
Xray-Wrist 3V                     $   112.00   73110
Xray-Hand 2V                      $   106.00   73120
Xray-Hand 3V                      $   115.50   73130
Xay-Finger 2V                     $   89.00    73140
Xray-Hip Unilateral 1V            $   125.00   73500
Xray- Hip 2V                      $   136.00   73510
Xray-Hip Bilateral 2V             $   167.50   73520
Xray-Femur 2V                     $   127.00   73550
Xray-Knee 2V                      $   112.00   73560
Xray-Knee 3V                      $   150.50   73562
Xray-Knee Complete                $   151.50   73564
Xray-Leg (Tib/Fib) 2V             $   93.00    73590
Xray-Ankle 3V                     $   103.00   73600
Xray-Ankle 3V Complete            $   124.00   73610
Xray-Foot 3V                      $   95.50    73620
Xray-Foot 3V Complete             $   95.50    73630
Xray-Calcaneus 2V                 $   80.50    73650
Xray-Toe(s) 2V                    $    91.00   73660
Xray-Abdomen 1V (KUB)             $   125.00   74000
Xray- Abdomen 2V                  $   176.00   74020
Xray-Abdomen Series Complete      $   195.00   74022
Drug Test-UA                      $   38.00    80100
Urinalysis-Dip Stick              $    21.00   81002
Urinalysis-Pregnancy Test         $   34.00    81025
Drug Test-UA with Alcohol         $   38.00    82055
Hemoccult-Blood Feces Screening   $   22.00    82270
Cholinesterase Plasma             $   44.50    82480
Glucose Test                      $   24.00    82947
Glucose Reagent Strip             $   26.50    82948
Glucose Stick Test                $   24.00    82962
Lead with OSHA (Blood)            $   119.00   83655
Mononucleosis Spot Test                    $    96.00   86663
Strep Screen                               $    48.00   87430
Flu Vax Test                               $    29.00   87804
Inj-Admin Pneumo Vac                       $    69.00   90732
Inj-Intravenous Admin                      $    60.00   90774
Audiometry-Screening                       $    33.00   92551
Cardiopulmonary Resucitation               $   752.00   92950
EKG                                        $   106.00   93000
Spirometry-Peak Flow                       $   109.00   94010
SVN Treatment                              $    65.00   94640
SVN Treatment                              $    65.00   94664
Oximetry Pulse                             $    48.00   94760
Inj-Intramuscular Admin                    $    34.00   96372
F/B-Ultraviolet Application                $    17.00   97028
Osteo Manipulation Tx                      $    64.00   98925
Office Visit E&M New Patient Level 2       $   130.00   99202
Office Visit E&M New Patient Level 3       $   193.00   99203
Office Visit E&M New Patient Level 4       $   272.00   99204
Office Visit E&M New Patient Level 5       $   347.00   99205
Office Visit Established Patient Level 2   $    82.00   99212
Office Visit E&M Established Level 3       $   118.00   99213
Office Visit E&M Esablished Level 4        $   164.00   99214
Office Visit E&M Established Level 5       $   240.00   99215
                            2/17/2012                                                       2/17/20


                            OTC-1175                                                        OTC-36
                     PRIMECARE CENTRAL                                                  PRIMECARE


                      284 W. 32ND STREET                                                2377 S. 22ND
                              YUMA                                                            YUMA
                            ARIZONA                                                         ARIZON
                              85364                                                           85364


                       2377 S. 22ND DRIVE                                               2377 S. 22ND
                              YUMA                                                            YUMA
                            ARIZONA                                                         ARIZON
                              85364                                                           85364
                          928-343-0488                                                    928-343-0
                           1215054309                                                      1013034
                             483302
                               YES                                                             YES
                            ZWDBYN                                                           ZWDBY
                        DR JOHN CARSON                                                  DR JOHN CA
                          928-343-0488                                                    928-343-0


                              SAME                                                            SAME
                              SAME                                                            SAME


                         KELLEY PATTON                                                   KELLEY PA
                          928-343-0488                                                    928-343-0
                  K.PATTON@YUMA.TWCBC.COM                                           K.PATTON@YUMA
                            2/17/2012                                                       2/16/20


                   Discription of Charge        Rate of Charge       Service Code


I&D CYST SIMPLE                             $              288.00       10060
I&D CYST COMP                               $              307.50       10061
I&D PILONIDAL CYST                          $              299.00       10080
F/B REMOVAL SUB-Q SIMPLE                    $              241.00       10120
PUNCTURE HEMATOMA                           $              239.50       10140
PUNCTURE HEMATOMA                           $              201.50       10160
PUNCTURE ASPIRATION ABSCESS                 $              437.00       10180
DEBRIDEMENT PARTIAL                         $               141.00      11040
DEBRIDEMENT FULL THICKNESS                  $              203.50       11041
BIOPSY, SUB-Q                               $              169.50       11100
REMOVAL SKIN TAGS                           $              148.50       11200
REMOVAL SKIN TAGS, OVER 20                  $               76.50       11201
EXCISION, BENIGN LESION          $   209.00   11400
EXCISION, LESIONS                $   262.00   11401
EXCISION LESION, ARMS, LEGS      $   333.00   11402
EXCISIONS, LESIONS TRUNK         $   430.00   11403
EXCISION, 3-4 CM                 $   340.00   11404
EXCISION BENIGN, SCALP, FEET     $   372.00   11422
EXCISION GENITALIA               $   484.50   11423
EXCISION BEN NECK, HANDS         $   862.00   11426
EXCISION FACIAL                  $   405.00   11441
EXCISION LESION, FACIAL, EARS    $   441.00   11442
EXCISION, LESIONS, FACIAL, EYE   $   613.00   11446
NAIL PLATE AVULSION, SIMPLE      $   172.00   11730
PUNCTURE-NAIL HEMATOMA           $   130.00   11740
EXCISION NAIL INGROWN NAIL       $   306.50   11750
NAIL BED REPAIR                  $   382.00   11760
WEDGE EXCISION                   $   193.00   11765
REPAIR SIMPLE SCALP              $   263.00   12001
REPAIR SIMP, SCALP NECK          $   304.00   12002
REPAIR SIMP NECK TRUNK           $   325.00   12004
REPAIR SIMP EXTREMITIES          $   493.00   12005
REPAIR SIMP SCALP                $   507.00   12006
REPAIR SIMP TRUNK                $   734.00   12007
REPAIR SIMP FACIAL               $   291.00   12011
REPAIR SIMP FACIAL               $   421.00   12013
REPAIR INTERM TRUNK              $   315.00   12031
REPAIR LAYERED TRUNK             $   435.00   12034
REPAIR COMP SCALP                $   647.00   13121
BURN TX LOCAL                    $   138.00   16000
BURN TX SMALL                    $   145.00   16020
BURN TX MEDIUM                   $   261.00   16025
BURN TX LARGE                    $   367.00   16030
LESION DESTRUCTION               $   124.00   17000
INJECT/TRIGGER PT                $   132.50   20550
INJECT/ASPIRATE SMALL JOINT      $   120.00   20600
INJECT/ASPIRATE INTER JOINT      $   132.50   20650
INJECT/ASPIRATE MAJOR JOINT      $   153.00   20610
REDUCE CLOSED NASAL FX           $   621.00   21337
REDUCE BILT TEMPEROMAND JOINT    $   238.50   21480
REDUCE STERNOCLAVICULAR          $   367.00   23520
REDUCE ACROMIOCLAVICULAR         $   369.00   23540
REDUCE SHOULDER                  $   508.00   23650
REDUCE ELBOW                     $   385.00   24600
REDUCE RADIAL HEAD-CHILD         $   216.00   24640
REDUCE DISTAL RADIOULNAR         $   748.00   25675
I&D FINGER ABSCESS SIMP     $   623.00   26010
I&D FELON                   $   772.00   26011
REDUCE METACARPAL           $   541.00   26605
REDUCE THUMB                $   607.00   26641
REDUCE PHALANX              $   591.00   26725
REDUCE PATELLA              $   636.00   27560
F/B REMOVAL SUB-Q SIMPLE    $   425.00   28190
F/B REMOVAL NOSE, SIMPLE    $   490.00   30300
CAUTERIZATION-ANT NASAL     $   246.00   30901
CAUTERIZATION ANT COMPLEX   $   352.00   30903
CAUTERIZATION POST NASAL    $   598.00   30905
DRAW FEE                    $    21.00   36415
I&D ABSCESS MOUTH           $   387.00   40800
I&D ABSCESS PERITONSILLAR   $   508.00   42700
F/B REMOVAL PHARYNX         $   391.00   42809
I&D HEMORROID               $   578.00   46083
CATHETER INSERTION          $   179.00   51702
I&D BARTHOLIN'S CYST        $   315.00   56420
F/B REMOVAL EXT. EYE        $   173.00   65205
F/B REMOVAL CORNEA          $   104.00   65220
F/B REMOVAL EAR             $   219.00   69200
REMOVAL IMPACTED CERUMEN    $    95.50   69210
XRAY FACIAL BONES           $   140.00   70140
XRAY NASAL BONES            $   138.00   70160
XRAY MANDIBULAR JOINT       $    84.00   70330
XRAY CHEST (1)              $   107.00   71010
XRAY CHEST (2)              $   132.50   71020
XRAY RIBS (2)               $   173.00   71100
XRAY STERNUM (2)            $   137.00   71120
XRAY SPINE (2)              $   146.00   72020
XRAY CERVICAL SPINE (2)     $   159.00   72040
XRAY CERVICAL SPINE (4)     $   213.00   72050
XRAY THORACIC SPINE (2)     $   158.00   72070
XRAY THORACIC SPINE (3)     $   175.00   72072
XRAY LUMBAR SPINE (2)       $   176.00   72100
XRAY LUMBAR SPINE (4)       $   219.50   72110
XRAY PELVIS (1)             $   117.00   72170
XRAY PELVIS (3)             $   128.00   72190
XRAY CLAVICLE               $   120.00   73000
XRAY SHOULDER (1)           $   121.00   73020
XRAY SHOULDER (2)           $   128.00   73030
XRAY A/C JOINTS BILATERAL   $   148.50   73050
XRAY HUMERUS (2)            $   117.00   73060
XRAY ELBOW (2)              $   150.00   73070
XRAY ELBOW (3)                  $   124.00   73080
XRAY FOREARM (2)                $   105.00   73090
XRAY WRIST (2)                  $   102.00   73100
XRAY WRIST (3)                  $   112.00   73110
XRAY HAND (2)                   $   106.00   73120
XRAY HAND (3)                   $   115.50   73130
XRAY FINGER (2)                 $    89.00   73140
XRAY HIP UNI (1)                $   125.00   73500
XRAY HIP (2)                    $   136.00   73510
XRAY FEMUR                      $   127.00   73550
XRAY KNEE (2)                   $   112.00   73560
XRAY KNEE COMPLETE              $   151.50   73564
XRAY TIB-FIB (2)                $    93.00   73590
XRAY ANKLE (3)                  $   103.00   73600
XRAY FOOT (3)                   $    95.50   73620
XRAY CALCANEUS (2)              $    80.50   73650
XRAY TOES (2)                   $    91.00   73660
XRAY ABDOMEN (1)                $   125.00   74000
XRAY ABDOMEN COMPLETE           $   195.00   74022
DRUG TEST U/A                   $    38.00   80100
URINALYSIS DIP STICK            $    21.00   81002
PREGNANCY TEST                  $    34.00   81025
GLUCOSE STICK TEST              $    24.00   82947
MONO SPOT TEST                  $    96.00   86308
T.B. TEST INTRADERMAL           $    34.00   86580
STREP SCREEN                    $    48.00   87430
FLU VAX TEST                    $    29.00   87804
TETANUS                         $    34.00   90471
INFLUENZA VACCINE               $    26.50   90658
TETANUS ADULT                   $    37.00   90718
HEPATITIS B PEDS/ADULT          $    64.00   90744
AUDIOMETRY                      $    33.00   92551
CARDIOPULMONARY RESUSCITATION   $   752.00   92950
EKG                             $   106.00   93000
SPIROMETRY                      $   109.00   94010
SVN TREATMENT                   $    65.00   94640
I.V. SET UP                     $   220.50   96360
INJ ADMINISTRATION              $    34.00   96372
INTRAVENOUS ADMIN               $    60.00   96374
OV E&M NP LEVEL 1               $    97.00   99201
OV E&M NP LEVEL 2               $   130.00   99202
OV E&M NP LEVEL 3               $   193.00   99203
OV E&M NP LEVEL 4               $   272.00   99204
OV E&M NP LEVEL 5               $   347.00   99205
OV E&M EP LEVEL 1                   $    54.00    99211
OV E&M EP LEVEL 2                   $    82.00    99212
OV E&M EP LEVEL 3                   $   118.00    99213
OV E&M EP LEVEL 4                   $   164.00    99214
OV E&M EP LEVEL 5                   $   240.00    99215
FOLEY CATHETER TUBE                 $    42.50   A4310
FOLEY CATHETER BAG                  $    42.50   A4314
ACE WRAP, FROG SPLINT               $    15.00   A4466
ARM SLING                           $    13.00   A4565
SPLINT THUMB                        $    42.50   A4570
WRIST IMMOBILIZER                   $    32.00   A4570
SPLINT SHORT ARM                    $    72.00   A4570.2
DRESSING MEDIUM                     $    16.00   A6220
NASAL PACKING                       $    32.00   A6251
ACE WRAP                            $     8.50   A6449
CRUTCHES                            $    44.50    E0116
DERMABOND                           $    64.00   G0168
EPINEPHRINE                         $    24.00   J0170
PENICILLIN 1.2 UNITS                $    42.50   J0540
BICILLIN 1.2 IM                     $    75.00   J0561
ROCEPHIN 250 MG IM                  $    22.50   J0696
CLAFARON                            $    48.00   J0698
COMPAZINE                           $    13.50   J0780
DECADROM 4 MG IM                    $    32.00    J1100
BENADRYL                            $    16.00   J1200
HEPATITIS A VACCINE                 $    64.00   J1460
TORRADOL 60 MG                      $    42.50   J1885
NUBAIN 10 MG                        $    24.00   J2300
PHENERGAN 50 MG                     $    26.50   J2550
SOLUMEDROL 125 MG                   $    38.00   J2930
KENALOG 40 MG                       $    32.00   J3301
VISTARIL 50 MG                      $    80.50   J3410
NORMAL SALINE IV 500 CC             $    37.00   J7040
KNEE IMMOBILIZER                    $    53.00    L1830
ORTHOPEDIC SHOE                     $    34.00   L3260
VELCRO HAND SPLINTS                 $    40.00   L3909
LEG SPLINT ADULT SHORT              $    72.00   Q4046
LEG SPLINT CHILD SHORT              $    40.00   Q4048
Remove Fecal Impact                 $    53.00
I&D Perianal Abscess, Superficial   $   329.00
I&D Thromosed Hemorroid External    $   578.00
Excisioln-Thrombosed Hemmoroid      $   339.00
Anoscopy                            $   144.00
F/B Removal w/ Anoscopy             $   414.00
Ligation-Internal Hemorrhoids/Single              $   382.00
Bladder Catheter (Foley) Insertion                $   179.00
Bladder Catheter Insertion                        $   148.00
I&D Bartholin's Cyst                              $   315.00
F/B Removal External Eye                          $   173.00
F/B Removal Cornea w/o Slit Lamp                  $   104.00
F/B Removal w/Slit Lamp                           $   261.00
I&D Drainage of Abcess, Eyelid                    $   507.00
F/B Removal Ear                                   $   219.00
Removal Impacted Cerumen                          $    95.50
X-Ray- Mandible 3V                                $   146.00
X-Ray-Mandible 4v min                             $   174.00
Xray-Mastoids; Min of 3V                          $   195.00
Xray- Facial Bones 3V                             $   140.00
Xray- Facial Bonhes Min 3V                        $   140.00
Xray- Nasal Bones 3V                              $   138.00
Xray-Optic Formina                                $   106.00
Xray-Orbits, Complete Min. 4V                     $   114.50
Xray-Sinus 1-2V                                   $   103.00
Xray-Sinus 3V                                     $   173.00
Xray-Skull Less 4V                                $   159.00
Xray- Skull Complete Min 4V                       $   174.00
Xray-Temporomandibular Joint (TMJ) Bilateral      $    84.00
Xray-Neck, Soft Tissue                            $   128.00
Xray- Chest 1V                                    $   107.00
Xray- Chest 2V                                    $   132.50
Xray-Chest w/Apical Lordotic Pro                  $   168.50
Xray-Chest 4V Complete                            $   163.00
Xray-Ribs 2V                                      $   173.00
Xray-Ribs,Chest 3V                                $   159.00
Xray-Ribs, Bilateral 3V                           $   173.00
Xray-Ribs Posteroanterior Chest Min 4V            $   183.00
Xray- Sternum 2V                                  $   137.00
Xray-Sternum Sternoclavicular Joints Min 3V       $   141.00
Xray-Spine Single Cies Spec Level                 $   146.00
Xray-Cervical Spine 2V                            $   159.00
Xray-Cervical Complete Oblique and Flexion        $   227.00
Xray-Thoratic Spine 2V                            $   158.00
Xray-Thoracic Spine 3V                            $   175.00
Xray-Thoracolumbar, Anteroposterior and Laterat   $   154.00
Xray-Lumbar Spine Complete 2V                     $   176.00
Xray-Lumbar Spine Complete 4V                     $   219.50
Xray Spine Lumbosacral Bend view 4V               $   214.00
Xray-Pelvis 1V                                    $   117.00
Xray-Pelvis Complete Min 3V       $   128.00
Xray-Sacroiliac Joints 3V         $   95.50
Xray-Sacrium and Coccyx 2V        $   128.00
Xray-Clavical Complete            $   120.00
Xray-Scapula Complete             $   122.00
Xray-Shoulder 1V                  $   121.00
Xray-Shoulder 2V                  $   128.00
Xray-A/C Joint, B/L               $   148.50
Xray-Humerus 2V                   $   117.00
Xray-Elbow 2V                     $   150.00
Xray-Elbow 3V                     $   124.00
Xray-forearm 2V                   $   105.00
Xray-Wrist 2V                     $   102.00
Xray-Wrist 3V                     $   112.00
Xray-Hand 2V                      $   106.00
Xray-Hand 3V                      $   115.50
Xay-Finger 2V                     $   89.00
Xray-Hip Unilateral 1V            $   125.00
Xray- Hip 2V                      $   136.00
Xray-Hip Bilateral 2V             $   167.50
Xray-Femur 2V                     $   127.00
Xray-Knee 2V                      $   112.00
Xray-Knee 3V                      $   150.50
Xray-Knee Complete                $   151.50
Xray-Leg (Tib/Fib) 2V             $   93.00
Xray-Ankle 3V                     $   103.00
Xray-Ankle 3V Complete            $   124.00
Xray-Foot 3V                      $   95.50
Xray-Foot 3V Complete             $   95.50
Xray-Calcaneus 2V                 $   80.50
Xray-Toe(s) 2V                    $    91.00
Xray-Abdomen 1V (KUB)             $   125.00
Xray- Abdomen 2V                  $   176.00
Xray-Abdomen Series Complete      $   195.00
Drug Test-UA                      $   38.00
Urinalysis-Dip Stick              $    21.00
Urinalysis-Pregnancy Test         $   34.00
Drug Test-UA with Alcohol         $   38.00
Hemoccult-Blood Feces Screening   $   22.00
Cholinesterase Plasma             $   44.50
Glucose Test                      $   24.00
Glucose Reagent Strip             $   26.50
Glucose Stick Test                $   24.00
Lead with OSHA (Blood)            $   119.00
Mononucleosis Spot Test                    $    96.00
Strep Screen                               $    48.00
Flu Vax Test                               $    29.00
Inj-Admin Pneumo Vac                       $    69.00
Inj-Intravenous Admin                      $    60.00
Audiometry-Screening                       $    33.00
Cardiopulmonary Resucitation               $   752.00
EKG                                        $   106.00
Spirometry-Peak Flow                       $   109.00
SVN Treatment                              $    65.00
SVN Treatment                              $    65.00
Oximetry Pulse                             $    48.00
Inj-Intramuscular Admin                    $    34.00
F/B-Ultraviolet Application                $    17.00
Osteo Manipulation Tx                      $    64.00
Office Visit E&M New Patient Level 2       $   130.00
Office Visit E&M New Patient Level 3       $   193.00
Office Visit E&M New Patient Level 4       $   272.00
Office Visit E&M New Patient Level 5       $   347.00
Office Visit Established Patient Level 2   $    82.00
Office Visit E&M Established Level 3       $   118.00
Office Visit E&M Esablished Level 4        $   164.00
Office Visit E&M Established Level 5       $   240.00
                         2/17/2012


                         OTC-3678                                                         OTC-3905
                    PRIMECARE VALLEY                                 REGIONAL CENTER FOR BORDER HEALTH MOBILE CLI


                    2377 S. 22ND DRIVE                                            1896 EAST BABBIT LANE
                           YUMA
                         ARIZONA
                           85364


                    2377 S. 22ND DRIVE
                           YUMA
                         ARIZONA
                           85364
                       928-343-0488
                        1013034776


                            YES
                         ZWDBYN
                     DR JOHN CARSON
                       928-343-0488


                           SAME
                           SAME


                      KELLEY PATTON
                       928-343-0488
           K.PATTON@YUMA.TWCBC.COM
                         2/16/2012


                Discription of Charge        Rate of Charge       Service Code   Discription of Charge


I&D CYST SIMPLE                          $              288.00
I&D CYST COMP                            $              307.50
I&D PILONIDAL CYST                       $              299.00
F/B REMOVAL SUB-Q SIMPLE                 $              241.00
PUNCTURE HEMATOMA                        $              239.50
PUNCTURE HEMATOMA                        $              201.50
PUNCTURE ASPIRATION ABSCESS              $              437.00
DEBRIDEMENT PARTIAL                      $               141.00
DEBRIDEMENT FULL THICKNESS               $              203.50
BIOPSY, SUB-Q                            $              169.50
REMOVAL SKIN TAGS                        $              148.50
REMOVAL SKIN TAGS, OVER 20               $               76.50
EXCISION, BENIGN LESION          $   209.00
EXCISION, LESIONS                $   262.00
EXCISION LESION, ARMS, LEGS      $   333.00
EXCISIONS, LESIONS TRUNK         $   430.00
EXCISION, 3-4 CM                 $   340.00
EXCISION BENIGN, SCALP, FEET     $   372.00
EXCISION GENITALIA               $   484.50
EXCISION BEN NECK, HANDS         $   862.00
EXCISION FACIAL                  $   405.00
EXCISION LESION, FACIAL, EARS    $   441.00
EXCISION, LESIONS, FACIAL, EYE   $   613.00
NAIL PLATE AVULSION, SIMPLE      $   172.00
PUNCTURE-NAIL HEMATOMA           $   130.00
EXCISION NAIL INGROWN NAIL       $   306.50
NAIL BED REPAIR                  $   382.00
WEDGE EXCISION                   $   193.00
REPAIR SIMPLE SCALP              $   263.00
REPAIR SIMP, SCALP NECK          $   304.00
REPAIR SIMP NECK TRUNK           $   325.00
REPAIR SIMP EXTREMITIES          $   493.00
REPAIR SIMP SCALP                $   507.00
REPAIR SIMP TRUNK                $   734.00
REPAIR SIMP FACIAL               $   291.00
REPAIR SIMP FACIAL               $   421.00
REPAIR INTERM TRUNK              $   315.00
REPAIR LAYERED TRUNK             $   435.00
REPAIR COMP SCALP                $   647.00
BURN TX LOCAL                    $   138.00
BURN TX SMALL                    $   145.00
BURN TX MEDIUM                   $   261.00
BURN TX LARGE                    $   367.00
LESION DESTRUCTION               $   124.00
INJECT/TRIGGER PT                $   132.50
INJECT/ASPIRATE SMALL JOINT      $   120.00
INJECT/ASPIRATE INTER JOINT      $   132.50
INJECT/ASPIRATE MAJOR JOINT      $   153.00
REDUCE CLOSED NASAL FX           $   621.00
REDUCE BILT TEMPEROMAND JOINT    $   238.50
REDUCE STERNOCLAVICULAR          $   367.00
REDUCE ACROMIOCLAVICULAR         $   369.00
REDUCE SHOULDER                  $   508.00
REDUCE ELBOW                     $   385.00
REDUCE RADIAL HEAD-CHILD         $   216.00
REDUCE DISTAL RADIOULNAR         $   748.00
I&D FINGER ABSCESS SIMP     $   623.00
I&D FELON                   $   772.00
REDUCE METACARPAL           $   541.00
REDUCE THUMB                $   607.00
REDUCE PHALANX              $   591.00
REDUCE PATELLA              $   636.00
F/B REMOVAL SUB-Q SIMPLE    $   425.00
F/B REMOVAL NOSE, SIMPLE    $   490.00
CAUTERIZATION-ANT NASAL     $   246.00
CAUTERIZATION ANT COMPLEX   $   352.00
CAUTERIZATION POST NASAL    $   598.00
DRAW FEE                    $    21.00
I&D ABSCESS MOUTH           $   387.00
I&D ABSCESS PERITONSILLAR   $   508.00
F/B REMOVAL PHARYNX         $   391.00
I&D HEMORROID               $   578.00
CATHETER INSERTION          $   179.00
I&D BARTHOLIN'S CYST        $   315.00
F/B REMOVAL EXT. EYE        $   173.00
F/B REMOVAL CORNEA          $   104.00
F/B REMOVAL EAR             $   219.00
REMOVAL IMPACTED CERUMEN    $    95.50
XRAY FACIAL BONES           $   140.00
XRAY NASAL BONES            $   138.00
XRAY MANDIBULAR JOINT       $    84.00
XRAY CHEST (1)              $   107.00
XRAY CHEST (2)              $   132.50
XRAY RIBS (2)               $   173.00
XRAY STERNUM (2)            $   137.00
XRAY SPINE (2)              $   146.00
XRAY CERVICAL SPINE (2)     $   159.00
XRAY CERVICAL SPINE (4)     $   213.00
XRAY THORACIC SPINE (2)     $   158.00
XRAY THORACIC SPINE (3)     $   175.00
XRAY LUMBAR SPINE (2)       $   176.00
XRAY LUMBAR SPINE (4)       $   219.50
XRAY PELVIS (1)             $   117.00
XRAY PELVIS (3)             $   128.00
XRAY CLAVICLE               $   120.00
XRAY SHOULDER (1)           $   121.00
XRAY SHOULDER (2)           $   128.00
XRAY A/C JOINTS BILATERAL   $   148.50
XRAY HUMERUS (2)            $   117.00
XRAY ELBOW (2)              $   150.00
XRAY ELBOW (3)                  $   124.00
XRAY FOREARM (2)                $   105.00
XRAY WRIST (2)                  $   102.00
XRAY WRIST (3)                  $   112.00
XRAY HAND (2)                   $   106.00
XRAY HAND (3)                   $   115.50
XRAY FINGER (2)                 $    89.00
XRAY HIP UNI (1)                $   125.00
XRAY HIP (2)                    $   136.00
XRAY FEMUR                      $   127.00
XRAY KNEE (2)                   $   112.00
XRAY KNEE COMPLETE              $   151.50
XRAY TIB-FIB (2)                $    93.00
XRAY ANKLE (3)                  $   103.00
XRAY FOOT (3)                   $    95.50
XRAY CALCANEUS (2)              $    80.50
XRAY TOES (2)                   $    91.00
XRAY ABDOMEN (1)                $   125.00
XRAY ABDOMEN COMPLETE           $   195.00
DRUG TEST U/A                   $    38.00
URINALYSIS DIP STICK            $    21.00
PREGNANCY TEST                  $    34.00
GLUCOSE STICK TEST              $    24.00
MONO SPOT TEST                  $    96.00
T.B. TEST INTRADERMAL           $    34.00
STREP SCREEN                    $    48.00
FLU VAX TEST                    $    29.00
TETANUS                         $    34.00
INFLUENZA VACCINE               $    26.50
TETANUS ADULT                   $    37.00
HEPATITIS B PEDS/ADULT          $    64.00
AUDIOMETRY                      $    33.00
CARDIOPULMONARY RESUSCITATION   $   752.00
EKG                             $   106.00
SPIROMETRY                      $   109.00
SVN TREATMENT                   $    65.00
I.V. SET UP                     $   220.50
INJ ADMINISTRATION              $    34.00
INTRAVENOUS ADMIN               $    60.00
OV E&M NP LEVEL 1               $    97.00
OV E&M NP LEVEL 2               $   130.00
OV E&M NP LEVEL 3               $   193.00
OV E&M NP LEVEL 4               $   272.00
OV E&M NP LEVEL 5               $   347.00
OV E&M EP LEVEL 1         $    54.00
OV E&M EP LEVEL 2         $    82.00
OV E&M EP LEVEL 3         $   118.00
OV E&M EP LEVEL 4         $   164.00
OV E&M EP LEVEL 5         $   240.00
FOLEY CATHETER TUBE       $    42.50
FOLEY CATHETER BAG        $    42.50
ACE WRAP, FROG SPLINT     $    15.00
ARM SLING                 $    13.00
SPLINT THUMB              $    42.50
WRIST IMMOBILIZER         $    32.00
SPLINT SHORT ARM          $    72.00
DRESSING MEDIUM           $    16.00
NASAL PACKING             $    32.00
ACE WRAP                  $     8.50
CRUTCHES                  $    44.50
DERMABOND                 $    64.00
EPINEPHRINE               $    24.00
PENICILLIN 1.2 UNITS      $    42.50
BICILLIN 1.2 IM           $    75.00
ROCEPHIN 250 MG IM        $    22.50
CLAFARON                  $    48.00
COMPAZINE                 $    13.50
DECADROM 4 MG IM          $    32.00
BENADRYL                  $    16.00
HEPATITIS A VACCINE       $    64.00
TORRADOL 60 MG            $    42.50
NUBAIN 10 MG              $    24.00
PHENERGAN 50 MG           $    26.50
SOLUMEDROL 125 MG         $    38.00
KENALOG 40 MG             $    32.00
VISTARIL 50 MG            $    80.50
NORMAL SALINE IV 500 CC   $    37.00
KNEE IMMOBILIZER          $    53.00
ORTHOPEDIC SHOE           $    34.00
VELCRO HAND SPLINTS       $    40.00
LEG SPLINT ADULT SHORT    $    72.00
LEG SPLINT CHILD SHORT    $    40.00
                                                                 3/30/2010                                                            3/7


TC-3905                                                          OTC- 3969                                                            OTC
ORDER HEALTH MOBILE CLINIC                           San Luis Walk-In Clinic, Inc.                                           San Luis Walk


T BABBIT LANE                                               214 W. MAIN STREET                                                      P. O. B
                                                                 Somerton                                                         1896 Ba
                                                                 ARIZONA                                                               San
                                                                    85350                                                             ARI


                                                                P. O. Box 617                                                           85
                                                                 Somerton                                                           P. O. B
                                                                    Arizona                                                            Sa
                                                                    85350                                                              Ar
                                                              (928) 627-9222                                                            85
                                                                1003991506                                                         (928) 6
                                                                    836512                                                           1003
                                                                                                                                       83
                                                                  76154AZ                                                              761
                                                               Tuly B. Medina                                                       Tuly B
                                                              (928) 627-9222                                                       (928) 6
                                                            tulymedina@rcfbh.org                                                 tulymedin
                                                               Ilian Marquez                                                        Ilian
                                                              (928) 627-9222                                                       (928) 6
                                                               ilian@rcfbh.org                                                      ilian@r
                                                               Tuly B. Medina                                                       Tuly B
                                                              (928) 627-9222                                                       (928) 6
                                                            tulymedina@rcfbh.org                                                 tulymedin
                                                                 5/1/2006                                                             6/1


                Rate of Charge   Service Code         Discription of Charge              Rate of Charge       Service Code


                                                Office Visit, New
                                    99202       Focused                              $               84.00       99202
                                    99203       Expanded                             $              125.00       99203
                                    99204       Detailed                             $              180.00       99204
                                   99205        Comprehensive                        $               225.00     99205
                                                Office Visit, Established
                                    99211       Mini Serv                            $                35.00      99211
                                    99212       Focused                              $               65.00       99212
                                    99213       Expanded                             $               84.00       99213
                                    99214       Detailed                             $               110.00      99214
                                    99215       Comprehensive                        $              160.00       99215
                                                Preventive Medicine, New
99381   1 yr                        $   150.00   99381
99382   1-4 yrs                     $   155.00   99382
99383   5-11 yrs                    $   150.00   99383
99384   12-17 yrs                   $   160.00   99384
99385   18-21 yrs                   $   160.00   99385
99385   18-39 yrs                   $   160.00   99385
99386   40 -64 yrs                  $   185.00   99386
99387   65 and over                 $   200.00   99387
        Preventive Medicine, Est.
99391   1 yr                        $   115.00   99391
99392   1-4 yrs                     $   120.00   99392
99393   5-11 yrs                    $   120.00   99393
99394   12-17 yrs                   $   160.00   99394
99395   18-21 yrs                   $   155.00   99395
99395   18-39 yrs                   $   155.00   99395
99396   40-64 yrs                   $   155.00   99396
99397   65 and over                 $   155.00   99397
        CLIA Waived Tests
82962   Glucometer                  $    15.00   82962
82270   Fecal Occult Blood          $    15.00   82270
82948   Glucose strip               $    15.00   82948
85014   Hematrocrit                 $    20.00   85014
85014   Hemoglobin                  $    20.00   85014
86308   Mononucleosis                            86308
87880   Rapid strep test            $    30.00   87880
81000   Urine dipstick              $    15.00   81000
81025   Urine pregnancy             $    15.00   81025
        Blood Draw
99211   Nurse service               $    35.00   99211
36415   Draw fee                    $    12.00   36415
99000   HANDL/Convery SPECMN        $    25.00   99000
        Office Procedures
11750   Removal Toe Nail            $   280.00   11750
A6430   Ace w rap                   $    10.00   A6430
93000   EKG                         $    50.00   93000
92552   Pure tone aud/omer          $    35.00   92552
94760   Pulse OX 1                  $    35.00   94760
94664   SVN Treatment               $    45.00   94664
A4565   Sling - Elbow, Arm, etc     $    20.00   A4565
88142   Papsmear                    $    50.00   88142
        Wrist brace
        Removal Foreign Body
65205   Eye, External, Cornea       $   120.00   65205
28190   Foot                        $   190.00   28190
30300   Nose                       $   145.00   30300
69210   Ear Wax                    $   60.00    69210
        Splint Aplication
        Well Women Check
88142   Papsmear                   $   50.00    88142
        Injections-IM
J1100   Decadron 1mg               $     5.00   J1100
J2550   Phenergan 50 mg            $   40.00    J2550
J1885   Toradol 15 mg              $    10.00   J1885
J0696   Rocephin units             $   40.00    J0696
        Vaccines(s)
90700   DTaP< 7 yrs old            $   30.00    90700
90723   DTaP-HepB-IPV Pediarix     $   95.00    90723
90715   TdaP                       $   45.00    90715
90714   Tetanus (Td)               $   55.00    90714
90718   Td > 7 yrs old             $   25.00    90718
90655   Flu, 6-35 months of age    $   25.00    90655
90656   Flu vaccine                $   25.00    90656
90633   Hep A                      $   70.00    90633
90743   Hep B                      $   80.00    90743
90746   Hep B adult                $   75.00    90746
90713   IPV                        $   45.00    90713
90669   Pheumococcal Prevnar       $   98.00    90669
90707   MMR                        $   65.00    90707
90710   MMRV (Proquad)             $   55.00    90710
90716   Varicella                  $   95.00    90716
90648   HIB                        $   50.00    90648
86580   PPD                        $    11.00   86580
90680   Rotavirus                  $   60.00    90680
90732   Pheumovac 23 > 2 yrs old   $   30.00    90732
90649   HPV vaccine                $   195.00   90649
90734   Menactra                   $   100.00   90734
                 3/7/2012                                                                        3/1/2012


                 OTC-3530                                                                        OTC-5045
     San Luis Walk-In Clinic, Inc.                                           SCHC SCH HEALTH PRGM WELLTON/MOHAWK MO


               P. O. Box 1669                                                                 2060 W 24th St
             1896 Babbitt Lane                                                                     Yuma
                  San Luis                                                                          AZ
                 ARIZONA


                    85349                                                                     2060 W 24th St
               P. O. Box 1669                                                                      Yuma
                  San Luis                                                                          AZ
                    Arizona                                                                        85364
                    85349                                                                      928-373-6187
              (928) 627-9222                                                                    1063433720
                1003991506                                                                        430661
                    836512                                                                          YES
                  76154AZ                                                                       1063433720
               Tuly B. Medina                                                                   David Rogers
              (928) 627-9222                                                                   928-819-8802
            tulymedina@rcfbh.org                                                           drogers@sunset-chc.org
               Ilian Marquez                                                                   Whitney Sims
              (928) 627-9222
               ilian@rcfbh.org                                                              wsims@sunset-chc.org
               Tuly B. Medina                                                                  Shaunna Ruis
              (928) 627-9222                                                                   928-373-6187
            tulymedina@rcfbh.org                                                            sruis@sunset-chc.org
                 6/1/2004                                                                        1/1/2012


      Discription of Charge              Rate of Charge       Service Code


Office Visit, New                                                11900
Focused                              $               70.00       11900
Expanded                             $              125.00       11901
Detailed                             $              180.00       11901
Comprehensive                        $              225.00       11975
Office Visit, Established                                        11975
Mini Serv                            $               35.00       11976
Focused                              $               50.00       11976
Expanded                             $               70.00       11977
Detailed                             $               110.00      11977
Comprehensive                        $              160.00       12001
Preventive Medicine, New                                         12001
1 yr                        $   150.00   12002
1-4 yrs                     $   155.00   12002
5-11 yrs                    $   150.00   12011
12-17 yrs                   $   160.00   12011
18-21 yrs                   $   160.00   12013
18-39 yrs                   $   160.00   12013
40 -64 yrs                  $   185.00   12021
65 and over                 $   200.00   13132
Preventive Medicine, Est.                13160
1 yr                        $   115.00   13160
1-4 yrs                     $   120.00   15833
5-11 yrs                    $   120.00   15850
12-17 yrs                   $   160.00   15850
18-21 yrs                   $   155.00   16020
18-39 yrs                   $   155.00   16020
40-64 yrs                   $   145.00   17000
65 and over                 $   150.00   17000
CLIA Waived Tests                        17003
Glucometer                  $    15.00   17110
Fecal Occult Blood          $    15.00   17110
Glucose strip               $    15.00   17250
Hematrocrit                 $    20.00   17340
Hemoglobin                  $    20.00   17340
Mononucleosis                            19000
Rapid strep test            $    30.00   19000
Urine dipstick              $    15.00   19020
Urine pregnancy             $    20.00   19103
Blood Draw                               19120
Nurse service               $    35.00   19120
Draw fee                    $    12.00   20526
HANDL/Convery SPECMN        $    25.00   20550
Office Procedures                        20550
Removal Toe Nail            $   280.00   20552
Ace w rap                   $    10.00   20600
EKG                         $    50.00   20600
Pure tone aud/omer          $    35.00   20605
Pulse OX 1                  $    35.00   20605
SVN Treatment               $    45.00   20610
Sling - Elbow, Arm, etc     $    20.00   20610
Papsmear                    $    50.00   23500
Wrist brace                              23500
Removal Foreign Body                     24530
Eye, External, Cornea       $   120.00   24530
Foot                        $   190.00   25530
Nose                       $   145.00   25530
Ear Wax                    $   60.00    25560
Splint Aplication                       25560
Well Women Check                        25600
Papsmear                   $   50.00    25600
Injections-IM                           25680
Decadron 1mg               $     5.00   25680
Phenergan 50 mg            $   40.00    26600
Toradol 15 mg              $    10.00   26600
Rocephin units             $   40.00    27780
Vaccines(s)                             27780
DTaP< 7 yrs old            $   30.00    27816
DTaP-HepB-IPV Pediarix     $   95.00    27816
TdaP                       $   45.00    28190
Tetanus (Td)               $   55.00    28190
Td > 7 yrs old             $   25.00    28400
Flu, 6-35 months of age    $   25.00    28400
Flu vaccine                $   25.00    28470
Hep A                      $   70.00    28470
Hep B                      $   80.00    29055
Hep B adult                $   75.00    29055
IPV                        $   45.00    29065
Pheumococcal Prevnar       $   98.00    29065
MMR                        $   65.00    29075
MMRV (Proquad)             $   55.00    29075
Varicella                  $   95.00    29085
HIB                        $   50.00    29085
PPD                        $   25.00    29105
Rotavirus                  $   60.00    29105
Pheumovac 23 > 2 yrs old   $   30.00    29105
HPV vaccine                $   195.00   29125
Menactra                   $   100.00   29125
                                        29130
                                        29130
                                        29405
                                        29405
                                        29425
                                        29425
                                        29515
                                        29515
                                        29540
                                        29540
                                        29580
                                        29580
29590
29590
30300
30300
30901
30901
36000
36415
36415
36556
36556
36571
36571
38500
44005
44005
44140
44180
44180
44955
45330
45330
45562
45562
45915
45915
46083
46083
46600
46600
46922
46922
46935
46935
47563
47563
49000
49000
49002
49002
49200
49200
49203
49255
49320
49320
49321
49321
49322
49323
49323
49560
49585
49585
50400
50400
50785
50785
51600
51600
51700
51700
51701
51701
51702
51702
51726
51726
51727
51729
51736
51736
51741
51741
51772
51772
51795
51795
51797
51797
51797
51798
51840
51840
51845
51845
51865
51865
51990
51990
52000
52000
53230
53230
53270
53270
54150
54150
54152
54152
56405
56405
56420
56420
56440
56440
56501
56501
56515
56515
56605
56605
56606
56606
56700
56740
56740
56810
56810
56820
56820
57000
57000
57010
57010
57020
57020
57022
57022
57061
57061
57065
57065
57100
57100
57105
57105
57120
57120
57130
57130
57135
57135
57160
57160
57170
57170
57210
57210
57220
57220
57240
57240
57250
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57260
57265
57265
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57268
57268
57280
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57283
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57287
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57288
57300
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57320
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57410
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57452
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57456
57460
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57461
57461
57500
57500
57505
57505
57510
57510
57511
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57520
57520
57522
57700
57700
57720
57800
57800
58100
58100
58120
58120
58140
58140
58145
58145
58150
58150
58152
58152
58180
58180
58200
58200
58260
58260
58262
58262
58263
58263
58270
58290
58290
58291
58291
58300
58300
58301
58301
58340
58340
58350
58350
58550
58550
58552
58552
58553
58553
58554
58554
58555
58555
58558
58558
58559
58559
58561
58562
58563
58563
58605
58605
58611
58611
58615
58615
58660
58660
58661
58661
58662
58662
58670
58670
58671
58671
58679
58700
58700
58720
58720
58740
58740
58750
58750
58805
58805
58925
58925
58940
58940
58953
58953
59000
59000
59025
59025
59100
59120
59120
59151
59151
59160
59160
59200
59200
59300
59300
59320
59320
59350
59350
59400
59400
59409
59409
59410
59410
59412
59412
59414
59414
59425
59425
59426
59430
59430
59510
59510
59514
59514
59515
59515
59525
59525
59610
59610
59612
59612
59614
59812
59812
59820
59820
59830
59841
59841
59855
59855
59870
59871
59871
59899
59899
61000
61000
62270
62270
62272
64435
64435
64774
64774
65205
65205
65220
65220
65222
65222
69200
69200
69210
69210
70100
70100
70150
70150
70160
70160
70220
70220
70250
70250
70260
70260
70328
70328
70360
70360
70450
70450
70460
70470
70470
70486
70486
70488
70488
70491
70491
70543
70543
70551
70551
70553
70553
71020
71020
71100
71100
71101
71101
71260
71260
72040
72040
72050
72050
72069
72069
72070
72070
72072
72074
72074
72100
72100
72110
72110
72114
72114
72125
72125
72128
72128
72131
72131
72141
72141
72146
72146
72148
72148
72158
72158
72170
72170
72192
72192
72193
72193
72202
73000
73000
73010
73010
73030
73030
73050
73050
73060
73060
73070
73070
73080
73080
73090
73090
73100
73100
73110
73110
73120
73120
73130
73130
73140
73140
73200
73200
73201
73220
73221
73221
73510
73510
73520
73540
73540
73550
73550
73560
73560
73562
73562
73564
73564
73565
73565
73590
73590
73600
73600
73610
73610
73620
73620
73630
73630
73650
73650
73660
73701
73721
73725
74000
74000
74020
74020
74022
74022
74150
74150
74160
74170
74170
74183
74220
74230
74241
74241
74246
74246
74247
74247
74280
74280
74400
74400
74455
74455
76020
76020
76062
76062
76075
76075
76082
76082
76083
76083
76090
76090
76091
76091
76092
76092
76098
76506
76506
76536
76645
76645
76700
76705
76770
76770
76775
76775
76805
76810
76815
76815
76817
76830
76830
76856
76856
76857
76857
76870
76870
76872
76880
76880
76885
76885
76942
76942
76998
77055
77055
77056
77056
77057
77057
77080
77080
78000
78001
78003
78007
78007
78290
78607
78607
78709
78709
80051
80051
80053
80053
80055
80055
80061
80061
80069
80069
80074
80074
80076
80076
80100
80100
80102
80102
80152
80152
80156
80156
80158
80158
80160
80160
80162
80162
80164
80164
80174
80174
80178
80178
80184
80184
80185
80185
80188
80188
80190
80190
80194
80194
80196
80196
80198
80198
80202
80202
80299
80299
81000
81000
81001
81001
81002
81002
81015
81015
81025
81099
81099
82009
82009
82024
82024
82040
82040
82042
82042
82043
82043
82055
82055
82085
82085
82088
82088
82104
82104
82105
82105
82131
82131
82135
82135
82140
82140
82150
82150
82164
82164
82240
82240
82247
82247
82270
82270
82310
82310
82340
82340
82365
82365
82374
82374
82375
82375
82376
82376
82378
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82383
82383
82390
82390
82435
82435
82465
82465
82482
82482
82486
82486
82489
82489
82491
82491
82525
82525
82530
82530
82533
82533
82543
82543
82550
82550
82552
82552
82565
82565
82570
82570
82575
82575
82595
82595
82607
82607
82615
82615
82626
82626
82627
82627
82634
82634
82670
82670
82671
82671
82710
82710
82728
82728
82731
82746
82746
82784
82784
82805
82805
82941
82941
82947
82947
82947
82948
82948
82950
82950
82951
82951
82952
82952
82955
82955
82960
82960
82962
82962
82977
82977
82985
82985
83001
83001
83002
83002
83003
83003
83010
83010
83015
83015
83020
83020
83036
83036
83037
83037
83050
83050
83070
83070
83491
83491
83518
83518
83525
83525
83540
83540
83550
83550
83605
83605
83615
83615
83655
83655
83690
83690
83718
83718
83735
83735
83825
83825
83835
83835
83880
83880
83890
83890
83891
83891
83894
83894
83898
83898
83915
83915
83918
83918
83930
83930
83935
83935
83945
83945
83970
83970
84030
84030
84060
84060
84066
84066
84075
84075
84078
84078
84080
84080
84100
84100
84105
84105
84110
84110
84120
84120
84132
84132
84133
84133
84144
84144
84146
84146
84153
84153
84155
84155
84165
84165
84182
84182
84202
84202
84206
84206
84233
84233
84238
84238
84295
84295
84300
84300
84305
84305
84403
84403
84436
84439
84443
84446
84450
84460
84460
84478
84478
84479
84479
84480
84480
84481
84481
84484
84484
84520
84520
84550
84550
84585
84585
84620
84620
84681
84681
84702
84702
84703
84703
85002
85002
85018
85018
85018
85025
85025
85044
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85060
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85220
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88342
89051
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90460
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90465
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90471a
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90632
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 99220
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 99224
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 99232
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 99310
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99431
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99440
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99460
99462
99463
99464
99465
A4561
A4561
A4565
A4565
A4641
A4641
C9003
C9003
G0008
G0009
G0010
G0179
G0180
G0181
G0202
G0204
G0206
G0394
G0396
G0397
G9141
G9142
J0170
J0280
J0460
J0530
J0540
J0550
J0560
J0570
J0580
J0696
J0704
J0735
J0780
J0885
J0970
J1000
J1030
J1055
J1055
J1056
J1060
J1100
J1200
J1460
J1470
J1500
J1510
J1520
J1580
J1630
J1631
J1720
J1815
J1885
J1940
J1950
J2001
J2060
J2175
J2180
J2270
J2510
J2540
J2550
J2680
J2788
J2788
J2790
J2790
J2910
J2920
J2930
J3130
J3150
J3250
J3301
J3302
J3360
J3360
J3410
J3420
J3430
J3490A
J3490A
J7030
J7300
J7300
J7302
J7307
J7506
J7603
J7609
J7613
J7633
J7644
J9202
J9213
J9214
J9216
J9217
J9260
Q0091
Q0091
Q0114
Q2038
S0180
S0181
S9075
                                 3/1/2012


                                 OTC-5045                                                                  OT
          SCHC SCH HEALTH PRGM WELLTON/MOHAWK MOBILE UNIT                              SCHC SCH HEALTH PROGRAM


                               2060 W 24th St                                                       600 SOUTH
                                   Yuma                                                                      Y
                                     AZ
                                                                                                            8


                               2060 W 24th St
                                   Yuma
                                     AZ
                                   85364
                               928-373-6187                                                               9288
                                1063433720
                                  430661
                                    YES
                                1063433720                                                          2060 WEST
                                David Rogers                                                              David
                               928-819-8802
                           drogers@sunset-chc.org
                               Whitney Sims


                            wsims@sunset-chc.org
                                Shaunna Ruis
                               928-373-6187
                            sruis@sunset-chc.org
                                  1/1/2012


                        Discription of Charge                   Rate of Charge       Service Code


INJECTION INTO SKIN LESIONS                                 $               30.00
INJECTION INTO SKIN LESIONS                                 $               82.00
ADDED SKIN LESIONS INJECTION                                $              102.00
ADDED SKIN LESIONS INJECTION                                $              102.00
INSERT CONTRACEPTIVE CAP                                    $               525.00
INSERT CONTRACEPTIVE CAP                                    $               150.00
REMOVAL OF CONTRACEPTIVE CAP                                $               200.00
REMOVAL OF CONTRACEPTIVE CAP                                $              241.00
REMOVAL/REINSERT CONTRA CAP                                 $              380.00
REMOVAL/REINSERT CONTRA CAP                                 $              405.00
REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, S/N/T/E             $              105.00
REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, S/N/T/E             $              247.00
REPAIR SUPERFICIAL WOUND(S)2.6-7.5CM                 $    145.00
REPAIR SUPERFICIAL WOUND(S)2.6-7.5CM                 $    262.00
REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, F/E/EYE/N/   $    125.00
REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, F/E/EYE/N/   $    261.00
REPAIR SUPERFICIAL WOUND(S) 2.6-5.0 CM               $    190.00
REPAIR SUPERFICIAL WOUND(S) 2.6-5.0 CM               $    287.00
CLOSURE OF SPLIT WOUND, W/PACKING                    $    175.00
REPAIR OF WOUND OR LESION                            $    856.00
LATE CLOSURE OF WOUND                                $    805.00
LATE CLOSURE OF WOUND                                $   1,322.00
EXCISE EXCESSIVE SKIN TISSUE                         $   1,250.00
REMOVAL OF SUTURES                                   $    107.00
REMOVAL OF SUTURES                                   $    125.00
DRESS/DEBRID P-THICK BURN, S                         $     75.00
DRESS/DEBRID P-THICK BURN, S                         $    140.00
DESTRUCT PREMALG LESION                              $     83.00
DESTRUCT PREMALG LESION                              $     114.00
DESTRUCT PREMALG LES, 2-14                           $      11.00
DESTRUCT B9 LESION, 1-14                             $    134.00
DESTRUCT B9 LESION, 1-14                             $    157.00
CHEMICAL CAUTERY, TISSUE                             $     75.00
CRYOTHERAPY OF SKIN                                  $     58.00
CRYOTHERAPY OF SKIN                                  $     74.00
DRAINAGE OF BREAST LESION                            $     51.00
DRAINAGE OF BREAST LESION                            $    189.00
INCISION OF BREAST LESION                            $    480.00
BX BREAST PERCUT W/DEVICE                            $    538.38
REMOVAL OF BREAST LESION                             $    850.00
REMOVAL OF BREAST LESION                             $    850.00
THER INJECTION, CARP TUNNEL                          $     75.00
INJ TENDON SHEATH/LIGAMENT                           $     65.00
INJ TENDON SHEATH/LIGAMENT                           $     99.00
INJ TRIGGER POINT, 1/2 MUSCL                         $     75.00
DRAIN/INJECT, JOINT/BURSA                            $     38.00
DRAIN/INJECT, JOINT/BURSA                            $     91.00
DRAIN/INJECT, JOINT/BURSA                            $     61.50
DRAIN/INJECT, JOINT/BURSA                            $     99.00
DRAIN/INJECT, JOINT/BURSA                            $     85.00
DRAIN/INJECT, JOINT/BURSA                            $    123.00
TREAT CLAVICLE FRACTURE                              $    321.00
TREAT CLAVICLE FRACTURE                              $    343.00
TREAT HUMERUS FRACTURE                               $    503.00
TREAT HUMERUS FRACTURE                               $    604.00
TREAT FRACTURE OF ULNA                               $    471.00
TREAT FRACTURE OF ULNA         $   471.00
TREAT FRACTURE RADIUS & ULNA   $   437.00
TREAT FRACTURE RADIUS & ULNA   $   471.00
TREAT FRACTURE RADIUS/ULNA     $   200.00
TREAT FRACTURE RADIUS/ULNA     $   466.00
TREAT WRIST FRACTURE           $   650.00
TREAT WRIST FRACTURE           $   745.00
TREAT METACARPAL FRACTURE      $   302.00
TREAT METACARPAL FRACTURE      $   423.00
TREATMENT OF FIBULA FRACTURE   $   360.00
TREATMENT OF FIBULA FRACTURE   $   475.00
TREATMENT OF ANKLE FRACTURE    $   579.00
TREATMENT OF ANKLE FRACTURE    $   591.00
REMOVAL OF FOOT FOREIGN BODY   $   217.80
REMOVAL OF FOOT FOREIGN BODY   $   378.00
TREATMENT OF HEEL FRACTURE     $   514.00
TREATMENT OF HEEL FRACTURE     $   404.00
TREAT METATARSAL FRACTURE      $   350.00
TREAT METATARSAL FRACTURE      $   395.00
APPLICATION OF SHOULDER CAST   $   270.00
APPLICATION OF SHOULDER CAST   $   331.00
APPLICATION OF LONG ARM CAST   $   180.00
APPLICATION OF LONG ARM CAST   $   215.00
APPLICATION OF FOREARM CAST    $   105.00
APPLICATION OF FOREARM CAST    $   141.00
APPLY HAND/WRIST CAST          $   151.00
APPLY HAND/WRIST CAST          $   185.00
APPLY LONG ARM SPLINT          $    45.00
APPLY LONG ARM SPLINT          $   125.00
APPLY LONG ARM SPLINT          $   143.00
APPLY FOREARM SPLINT           $    40.00
APPLY FOREARM SPLINT           $   110.00
APPLICATION OF FINGER SPLINT   $    30.00
APPLICATION OF FINGER SPLINT   $    66.00
APPLY SHORT LEG CAST           $   135.00
APPLY SHORT LEG CAST           $   145.00
APPLY SHORT LEG CAST           $    84.00
APPLY SHORT LEG CAST           $   156.00
APPLICATION LOWER LEG SPLINT   $    75.00
APPLICATION LOWER LEG SPLINT   $   112.00
STRAPPING OF ANKLE AND/OR FT   $    55.00
STRAPPING OF ANKLE AND/OR FT   $    66.00
APPLICATION OF PASTE BOOT      $    70.00
APPLICATION OF PASTE BOOT      $    84.00
APPLICATION OF FOOT SPLINT     $      71.00
APPLICATION OF FOOT SPLINT     $     89.00
REMOVE NASAL FOREIGN BODY      $     48.00
REMOVE NASAL FOREIGN BODY      $    376.00
CONTROL OF NOSEBLEED           $     42.00
CONTROL OF NOSEBLEED           $     172.00
PLACE NEEDLE IN VEIN           $     75.00
ROUTINE VENIPUNCTURE           $       5.00
ROUTINE VENIPUNCTURE           $       8.00
INSERT NON-TUNNEL CV CATH      $     120.00
INSERT NON-TUNNEL CV CATH      $     135.00
INSERT PICVAD CATH             $   2,865.00
INSERT PICVAD CATH             $   2,950.00
BIOPSY/REMOVAL, LYMPH NODES    $     517.00
FREEING OF BOWEL ADHESION      $    800.00
FREEING OF BOWEL ADHESION      $   1,736.00
PARTIAL REMOVAL OF COLON       $   1,300.00
LAP, ENTEROLYSIS               $   2,974.00
LAP, ENTEROLYSIS               $   2,974.00
APPENDECTOMY ADD-ON            $     125.00
DIAGNOSTIC SIGMOIDOSCOPY       $    225.00
DIAGNOSTIC SIGMOIDOSCOPY       $    345.00
EXPLORATION/REPAIR OF RECTUM   $   2,080.00
EXPLORATION/REPAIR OF RECTUM   $   2,250.00
REMOVE RECTAL OBSTRUCTION      $    452.00
REMOVE RECTAL OBSTRUCTION      $    507.00
INCISE EXTERNAL HEMORRHOID     $     112.00
INCISE EXTERNAL HEMORRHOID     $    266.00
DIAGNOSTIC ANOSCOPY            $     35.00
DIAGNOSTIC ANOSCOPY            $     138.00
EXCISION OF ANAL LESION(S)     $    345.00
EXCISION OF ANAL LESION(S)     $    367.00
DESTRUCTION OF HEMORRHOIDS     $    292.00
DESTRUCTION OF HEMORRHOIDS     $    405.00
LAPARO CHOLECYSTECTOMY/GRAPH   $   2,750.00
LAPARO CHOLECYSTECTOMY/GRAPH   $   2,850.00
EXPLORATION OF ABDOMEN         $    900.00
EXPLORATION OF ABDOMEN         $   1,234.00
REOPENING OF ABDOMEN           $   2,450.00
REOPENING OF ABDOMEN           $   2,750.00
REMOVAL OF ABDOMINAL LESION    $   2,385.00
REMOVAL OF ABDOMINAL LESION    $   2,650.00
EXC ABD TUM 5 CM OR LESS       $   2,500.00
REMOVAL OF OMENTUM             $    750.00
DIAG LAPARO SEPARATE PROC      $    989.00
DIAG LAPARO SEPARATE PROC      $   1,150.00
LAPAROSCOPY, BIOPSY            $   1,055.00
LAPAROSCOPY, BIOPSY            $   1,225.00
LAPAROSCOPY, ASPIRATION        $     613.00
LAPARO DRAIN LYMPHOCELE        $   1,990.00
LAPARO DRAIN LYMPHOCELE        $   2,110.00
RPR VENTRAL HERN INIT, REDUC   $   1,180.00
RPR UMBIL HERN, REDUC > 5 YR   $    980.00
RPR UMBIL HERN, REDUC > 5 YR   $   1,205.00
REVISION OF KIDNEY/URETER      $     130.00
REVISION OF KIDNEY/URETER      $   1,986.00
REIMPLANT URETER IN BLADDER    $   1,765.85
REIMPLANT URETER IN BLADDER    $   2,072.00
INJECTION FOR BLADDER X-RAY    $     210.00
INJECTION FOR BLADDER X-RAY    $    384.00
IRRIGATION OF BLADDER          $     42.00
IRRIGATION OF BLADDER          $     165.00
INSERT BLADDER CATHETER        $     120.00
INSERT BLADDER CATHETER        $     132.00
INSERT TEMP BLADDER CATH       $     120.00
INSERT TEMP BLADDER CATH       $     165.00
COMPLEX CYSTOMETROGRAM         $    545.00
COMPLEX CYSTOMETROGRAM         $    375.00
CYSTOMETROGRAM W/UP            $     315.00
CYSTOMETROGRAM W/VP&UP         $    350.00
URINE FLOW MEASUREMENT         $     97.00
URINE FLOW MEASUREMENT         $     85.00
ELECTRO-UROFLOWMETRY, FIRST    $     121.00
ELECTRO-UROFLOWMETRY, FIRST    $     125.00
URETHRA PRESSURE PROFILE       $    425.00
URETHRA PRESSURE PROFILE       $    300.00
URINE VOIDING PRESSURE STUDY   $    525.00
URINE VOIDING PRESSURE STUDY   $    350.00
INTRAABDOMINAL PRESSURE TEST   $    228.00
INTRAABDOMINAL PRESSURE TEST   $    439.00
INTRAABDOMINAL PRESSURE TEST   $    250.00
US URINE CAPACITY MEASURE      $     40.00
ATTACH BLADDER/URETHRA         $   1,025.00
ATTACH BLADDER/URETHRA         $   1,150.00
REPAIR BLADDER NECK            $   2,290.00
REPAIR BLADDER NECK            $   3,005.00
REPAIR OF BLADDER WOUND        $   3,047.00
REPAIR OF BLADDER WOUND        $   3,075.00
LAPARO URETHRAL SUSPENSION     $   2,420.00
LAPARO URETHRAL SUSPENSION     $   2,475.00
CYSTOSCOPY                     $    326.00
CYSTOSCOPY                     $    378.00
REMOVAL OF URETHRA LESION      $   1,838.00
REMOVAL OF URETHRA LESION      $   1,975.00
REMOVAL OF URETHRA GLAND       $    809.00
REMOVAL OF URETHRA GLAND       $    925.00
CIRCUMCISION W/REGIONL BLOCK   $    300.00
CIRCUMCISION W/REGIONL BLOCK   $    300.00
CIRCUMCISION                   $     170.00
CIRCUMCISION                   $    200.00
I & D OF VULVA/PERINEUM        $     190.00
I & D OF VULVA/PERINEUM        $     215.00
DRAINAGE OF GLAND ABSCESS      $    205.00
DRAINAGE OF GLAND ABSCESS      $    239.00
SURGERY FOR VULVA LESION       $    545.00
SURGERY FOR VULVA LESION       $    555.00
DESTROY, VULVA LESIONS, SIM    $    200.00
DESTROY, VULVA LESIONS, SIM    $    226.00
DESTROY VULVA LESION/S COMPL   $    539.00
DESTROY VULVA LESION/S COMPL   $    574.00
BIOPSY OF VULVA/PERINEUM       $     160.00
BIOPSY OF VULVA/PERINEUM       $     174.00
BIOPSY OF VULVA/PERINEUM       $     111.00
BIOPSY OF VULVA/PERINEUM       $     127.00
PARTIAL REMOVAL OF HYMEN       $     315.00
REMOVE VAGINA GLAND LESION     $    703.00
REMOVE VAGINA GLAND LESION     $    722.00
REPAIR OF PERINEUM             $   1,080.00
REPAIR OF PERINEUM             $   1,125.00
EXAM OF VULVA W/SCOPE          $    242.00
EXAM OF VULVA W/SCOPE          $    265.00
EXPLORATION OF VAGINA          $    690.00
EXPLORATION OF VAGINA          $    735.00
DRAINAGE OF PELVIC ABSCESS     $   1,238.00
DRAINAGE OF PELVIC ABSCESS     $   1,375.00
DRAINAGE OF PELVIC FLUID       $     175.00
DRAINAGE OF PELVIC FLUID       $    220.00
I & D VAGINAL HEMATOMA, PP     $     410.00
I & D VAGINAL HEMATOMA, PP     $    454.00
DESTROY VAG LESIONS, SIMPLE    $    200.00
DESTROY VAG LESIONS, SIMPLE    $    235.00
DESTROY VAG LESIONS, COMPLEX   $    800.00
DESTROY VAG LESIONS, COMPLEX   $    875.00
BIOPSY OF VAGINA               $     175.00
BIOPSY OF VAGINA               $     215.00
BIOPSY OF VAGINA               $    296.00
BIOPSY OF VAGINA               $     312.00
CLOSURE OF VAGINA              $   1,718.00
CLOSURE OF VAGINA              $   1,935.00
REMOVE VAGINA LESION           $     615.00
REMOVE VAGINA LESION           $    635.00
REMOVE VAGINA LESION           $    520.00
REMOVE VAGINA LESION           $    537.00
INSERT PESSARY/OTHER DEVICE    $     120.00
INSERT PESSARY/OTHER DEVICE    $     131.00
FITTING OF DIAPHRAGM/CAP       $     120.00
FITTING OF DIAPHRAGM/CAP       $     149.00
REPAIR VAGINA/PERINEUM         $    722.00
REPAIR VAGINA/PERINEUM         $    765.00
REVISION OF URETHRA            $   1,076.00
REVISION OF URETHRA            $   1,150.00
REPAIR BLADDER & VAGINA        $    900.00
REPAIR BLADDER & VAGINA        $   1,031.00
REPAIR RECTUM & VAGINA         $    750.00
REPAIR RECTUM & VAGINA         $   1,014.00
REPAIR OF VAGINA               $   1,200.00
REPAIR OF VAGINA               $   1,295.00
EXTENSIVE REPAIR OF VAGINA     $   2,238.00
EXTENSIVE REPAIR OF VAGINA     $   2,375.00
INSERT MESH/PELVIC FLR ADDON   $   1,195.00
REPAIR OF BOWEL BULGE          $   1,908.00
REPAIR OF BOWEL BULGE          $   1,364.00
SUSPENSION OF VAGINA           $   2,005.00
SUSPENSION OF VAGINA           $   2,085.00
COLPOPEXY, EXTRAPERITONEAL     $   1,921.00
COLPOPEXY, EXTRAPERITONEAL     $   1,321.00
COLPOPEXY, INTRAPERITONEAL     $    900.00
REPAIR PARAVAG DEFECT, OPEN    $   3,088.00
REPAIR PARAVAG DEFECT, OPEN    $   3,115.00
REVISE/REMOVE SLING REPAIR     $   1,810.00
REVISE/REMOVE SLING REPAIR     $   1,235.00
REPAIR BLADDER DEFECT          $   3,640.00
REPAIR BLADDER DEFECT          $   3,712.00
REPAIR RECTUM-VAGINA FISTULA   $    750.00
REPAIR RECTUM-VAGINA FISTULA   $    883.00
REPAIR BLADDER-VAGINA LESION   $   1,200.00
REPAIR BLADDER-VAGINA LESION   $   1,375.00
PELVIC EXAMINATION             $    240.00
PELVIC EXAMINATION             $    255.00
EXAM OF VAGINA W/SCOPE         $     125.00
EXAM OF CERVIX W/SCOPE         $     175.00
EXAM OF CERVIX W/SCOPE         $     190.00
BX/CURETT OF CERVIX W/SCOPE    $    200.00
BX/CURETT OF CERVIX W/SCOPE    $     175.00
BIOPSY OF CERVIX W/SCOPE       $     165.00
ENDOCERV CURETTAGE W/SCOPE     $     150.00
BX OF CERVIX W/SCOPE, LEEP     $    375.00
BX OF CERVIX W/SCOPE, LEEP     $    568.00
CONZ OF CERVIX W/SCOPE, LEEP   $   1,262.00
CONZ OF CERVIX W/SCOPE, LEEP   $   1,347.00
BIOPSY OF CERVIX               $     180.00
BIOPSY OF CERVIX               $    245.00
ENDOCERVICAL CURETTAGE         $    300.00
ENDOCERVICAL CURETTAGE         $     125.00
CAUTERIZATION OF CERVIX        $    289.00
CAUTERIZATION OF CERVIX        $    327.00
CRYOCAUTERY OF CERVIX          $     210.00
CRYOCAUTERY OF CERVIX          $    254.00
CONIZATION OF CERVIX           $    650.00
CONIZATION OF CERVIX           $    650.00
CONIZATION OF CERVIX           $    275.00
REVISION OF CERVIX             $   1,108.00
REVISION OF CERVIX             $   1,238.00
REVISION OF CERVIX             $    325.00
DILATION OF CERVICAL CANAL     $     121.00
DILATION OF CERVICAL CANAL     $     148.00
BIOPSY OF UTERUS LINING        $     185.00
BIOPSY OF UTERUS LINING        $     193.00
DILATION AND CURETTAGE         $     716.00
DILATION AND CURETTAGE         $    865.00
MYOMECTOMY ABDOM METHOD        $   1,500.00
MYOMECTOMY ABDOM METHOD        $   1,560.00
MYOMECTOMY VAG METHOD          $   1,440.00
MYOMECTOMY VAG METHOD          $   1,625.00
TOTAL HYSTERECTOMY             $   1,875.00
TOTAL HYSTERECTOMY             $   1,875.00
TOTAL HYSTERECTOMY             $   1,875.00
TOTAL HYSTERECTOMY             $   2,150.00
PARTIAL HYSTERECTOMY           $   4,755.00
PARTIAL HYSTERECTOMY           $   4,755.00
EXTENSIVE HYSTERECTOMY         $   5,938.00
EXTENSIVE HYSTERECTOMY         $   6,120.00
VAGINAL HYSTERECTOMY           $   2,795.00
VAGINAL HYSTERECTOMY           $   2,795.00
VAG HYST INCLUDING T/O         $   2,950.00
VAG HYST INCLUDING T/O         $   2,950.00
VAG HYST W/T/O & VAG REPAIR    $   3,002.00
VAG HYST W/T/O & VAG REPAIR    $   3,045.00
VAG HYST W/ENTEROCELE REPAIR   $   3,200.00
VAG HYST COMPLEX               $   4,042.00
VAG HYST COMPLEX               $   4,075.00
VAG HYST INCL T/O, COMPLEX     $   4,350.00
VAG HYST INCL T/O, COMPLEX     $   4,440.00
INSERT INTRAUTERINE DEVICE     $     150.00
INSERT INTRAUTERINE DEVICE     $     150.00
REMOVE INTRAUTERINE DEVICE     $     150.00
REMOVE INTRAUTERINE DEVICE     $     173.00
CATHETER FOR HYSTEROGRAPHY     $     75.00
CATHETER FOR HYSTEROGRAPHY     $    257.00
REOPEN FALLOPIAN TUBE          $     318.00
REOPEN FALLOPIAN TUBE          $    337.00
LAPARO-ASST VAG HYSTERECTOMY   $   2,472.00
LAPARO-ASST VAG HYSTERECTOMY   $   2,624.00
LAPARO-VAG HYST INCL T/O       $   3,331.00
LAPARO-VAG HYST INCL T/O       $   3,422.00
LAPARO-VAG HYST, COMPLEX       $   3,660.00
LAPARO-VAG HYST, COMPLEX       $   3,700.00
LAPARO-VAG HYST W/T/O, COMPL   $   5,037.00
LAPARO-VAG HYST W/T/O, COMPL   $   5,150.00
HYSTEROSCOPY, DX, SEP PROC     $    650.00
HYSTEROSCOPY, DX, SEP PROC     $    725.00
HYSTEROSCOPY, BIOPSY           $     810.00
HYSTEROSCOPY, BIOPSY           $    925.00
HYSTEROSCOPY, LYSIS            $   2,252.00
HYSTEROSCOPY, LYSIS            $   2,445.00
HYSTEROSCOPY, REMOVE MYOMA     $    800.00
HYSTEROSCOPY, REMOVE FB        $    350.00
HYSTEROSCOPY, ABLATION         $   2,100.00
HYSTEROSCOPY, ABLATION         $   3,915.00
DIVISION OF FALLOPIAN TUBE     $   1,150.00
DIVISION OF FALLOPIAN TUBE     $   1,275.00
LIGATE OVIDUCT(S) ADD-ON       $    575.00
LIGATE OVIDUCT(S) ADD-ON       $    635.00
OCCLUDE FALLOPIAN TUBE(S)      $   1,324.00
OCCLUDE FALLOPIAN TUBE(S)      $   1,614.00
LAPAROSCOPY, LYSIS             $   2,000.00
LAPAROSCOPY, LYSIS             $   2,000.00
LAPAROSCOPY, REMOVE ADNEXA     $   2,000.00
LAPAROSCOPY, REMOVE ADNEXA     $   2,000.00
LAPAROSCOPY, EXCISE LESIONS    $   2,100.00
LAPAROSCOPY, EXCISE LESIONS    $   2,225.00
LAPAROSCOPY, TUBAL CAUTERY     $   1,420.00
LAPAROSCOPY, TUBAL CAUTERY     $   1,670.00
LAPAROSCOPY, TUBAL BLOCK       $   1,530.00
LAPAROSCOPY, TUBAL BLOCK       $   1,620.00
LAPARO PROC, OVIDUCT-OVARY     $    550.00
REMOVAL OF FALLOPIAN TUBE      $   1,700.00
REMOVAL OF FALLOPIAN TUBE      $   1,810.00
REMOVAL OF OVARY/TUBE(S)       $   2,945.00
REMOVAL OF OVARY/TUBE(S)       $   3,002.00
Lysis Of Adhesions             $   2,080.00
Lysis Of Adhesions             $   2,125.00
REPAIR OVIDUCT                 $   2,561.00
REPAIR OVIDUCT                 $   2,635.00
DRAINAGE OF OVARIAN CYST(S)    $   1,448.00
DRAINAGE OF OVARIAN CYST(S)    $   1,535.00
REMOVAL OF OVARIAN CYST(S)     $   1,800.00
REMOVAL OF OVARIAN CYST(S)     $   1,925.00
REMOVAL OF OVARY(S)            $   1,800.00
REMOVAL OF OVARY(S)            $   1,625.00
TAH, RAD DISSECT FOR DEBULK    $   9,826.00
TAH, RAD DISSECT FOR DEBULK    $   9,925.00
AMNIOCENTESIS, DIAGNOSTIC      $    275.00
AMNIOCENTESIS, DIAGNOSTIC      $    325.00
FETAL NON-STRESS TEST          $     130.00
FETAL NON-STRESS TEST          $     152.00
REMOVE UTERUS LESION           $   1,000.00
TREAT ECTOPIC PREGNANCY        $   1,900.00
TREAT ECTOPIC PREGNANCY        $   2,100.00
TREAT ECTOPIC PREGNANCY        $   3,350.00
TREAT ECTOPIC PREGNANCY        $   4,475.00
D & C AFTER DELIVERY           $    660.00
D & C AFTER DELIVERY           $    720.00
INSERT CERVICAL DILATOR        $    230.00
INSERT CERVICAL DILATOR        $    245.00
EPISIOTOMY OR VAGINAL REPAIR   $    480.00
EPISIOTOMY OR VAGINAL REPAIR   $    528.00
REVISION OF CERVIX             $    890.00
REVISION OF CERVIX             $    934.00
REPAIR OF UTERUS               $   1,774.00
REPAIR OF UTERUS               $   1,924.00
OBSTETRICAL CARE               $   2,000.00
OBSTETRICAL CARE               $   2,500.00
OBSTETRICAL CARE               $   1,150.00
OBSTETRICAL CARE               $   1,500.00
OBSTETRICAL CARE               $   1,125.00
OBSTETRICAL CARE               $   1,600.00
ANTEPARTUM MANIPULATION        $    490.00
ANTEPARTUM MANIPULATION        $    520.00
DELIVER PLACENTA               $    457.38
DELIVER PLACENTA               $    524.00
ANTEPARTUM CARE ONLY           $    670.00
ANTEPARTUM CARE ONLY           $    749.00
ANTEPARTUM CARE ONLY           $   1,000.00
CARE AFTER DELIVERY            $    230.00
CARE AFTER DELIVERY            $    248.00
CESAREAN DELIVERY              $   2,500.00
CESAREAN DELIVERY              $   2,600.00
CESAREAN DELIVERY ONLY         $   2,500.00
CESAREAN DELIVERY ONLY         $   2,200.00
CESAREAN DELIVERY              $   2,500.00
CESAREAN DELIVERY              $   2,300.00
REMOVE UTERUS AFTER CESAREAN   $   1,456.00
REMOVE UTERUS AFTER CESAREAN   $   1,625.00
VBAC DELIVERY                  $   2,000.00
VBAC DELIVERY                  $   2,600.00
VBAC DELIVERY ONLY             $   1,150.00
VBAC DELIVERY ONLY             $   1,600.00
VBAC CARE AFTER DELIVERY       $   1,700.00
TREATMENT OF MISCARRIAGE       $    720.00
TREATMENT OF MISCARRIAGE       $    765.00
CARE OF MISCARRIAGE            $    780.00
CARE OF MISCARRIAGE            $    825.00
TREAT UTERUS INFECTION         $    725.00
ABORTION                       $    680.00
ABORTION                       $    725.00
ABORTION                       $   1,209.00
ABORTION                       $   1,540.00
EVACUATE MOLE OF UTERUS        $    575.00
REMOVE CERCLAGE SUTURE         $    258.00
REMOVE CERCLAGE SUTURE         $    273.00
MATERNITY CARE PROCEDURE       $     65.00
MATERNITY CARE PROCEDURE       $     85.00
REMOVE CRANIAL CAVITY FLUID    $    554.00
REMOVE CRANIAL CAVITY FLUID    $    584.00
SPINAL FLUID TAP, DIAGNOSTIC   $    180.00
SPINAL FLUID TAP, DIAGNOSTIC   $    281.00
DRAIN CEREBRO SPINAL FLUID     $    185.00
N BLOCK INJ, PARACERVICAL      $     88.00
N BLOCK INJ, PARACERVICAL      $    262.00
REMOVE SKIN NERVE LESION       $    921.00
REMOVE SKIN NERVE LESION       $    982.00
REMOVE FOREIGN BODY FROM EYE   $    200.00
REMOVE FOREIGN BODY FROM EYE   $    220.00
REMOVE FOREIGN BODY FROM EYE   $    220.00
REMOVE FOREIGN BODY FROM EYE   $    240.00
REMOVE FOREIGN BODY FROM EYE   $    200.00
REMOVE FOREIGN BODY FROM EYE   $    220.00
CLEAR OUTER EAR CANAL          $    100.00
CLEAR OUTER EAR CANAL          $    207.00
REMOVE IMPACTED EAR WAX        $     70.00
REMOVE IMPACTED EAR WAX        $     82.00
X-RAY EXAM OF JAW              $     110.00
X-RAY EXAM OF JAW              $    122.00
X-RAY EXAM OF FACIAL BONES     $    233.00
X-RAY EXAM OF FACIAL BONES     $    245.00
X-RAY EXAM OF NASAL BONES      $    142.00
X-RAY EXAM OF NASAL BONES      $    174.00
X-RAY EXAM OF SINUSES          $    222.00
X-RAY EXAM OF SINUSES          $    233.00
X-RAY EXAM OF SKULL            $    136.00
X-RAY EXAM OF SKULL            $    154.00
X-RAY EXAM OF SKULL            $    247.00
X-RAY EXAM OF SKULL            $    264.00
X-RAY EXAM OF JAW JOINT        $    106.00
X-RAY EXAM OF JAW JOINT        $    124.00
X-RAY EXAM OF NECK             $    153.00
X-RAY EXAM OF NECK             $    167.00
CT HEAD/BRAIN W/O DYE          $    470.00
CT HEAD/BRAIN W/O DYE          $    489.00
CT HEAD/BRAIN W/DYE            $    771.00
CT HEAD/BRAIN W/O & W/DYE      $    787.00
CT HEAD/BRAIN W/O & W/DYE      $     911.00
CT MAXILLOFACIAL W/O DYE       $    461.00
CT MAXILLOFACIAL W/O DYE       $    472.00
CT MAXILLOFACIAL W/O & W/DYE   $   1,446.00
CT MAXILLOFACIAL W/O & W/DYE   $   1,522.00
CT SOFT TISSUE NECK W/DYE      $    808.00
CT SOFT TISSUE NECK W/DYE      $    817.00
MRI ORBT/FAC/NCK W/O & W/DYE   $   2,478.10
MRI ORBT/FAC/NCK W/O & W/DYE   $   2,512.00
MRI BRAIN W/O DYE              $   1,190.00
MRI BRAIN W/O DYE              $   1,225.00
MRI BRAIN W/O & W/DYE          $   1,675.00
MRI BRAIN W/O & W/DYE          $   1,725.00
CHEST X-RAY                    $    135.00
CHEST X-RAY                    $    182.00
X-RAY EXAM OF RIBS             $    126.00
X-RAY EXAM OF RIBS             $    154.00
X-RAY EXAM OF RIBS/CHEST       $    202.80
X-RAY EXAM OF RIBS/CHEST       $    227.00
CT THORAX W/DYE                $    884.00
CT THORAX W/DYE                $    935.00
X-RAY EXAM OF NECK SPINE       $     92.00
X-RAY EXAM OF NECK SPINE       $    107.00
X-RAY EXAM OF NECK SPINE       $    208.00
X-RAY EXAM OF NECK SPINE       $    227.00
X-RAY EXAM OF TRUNK SPINE      $    132.00
X-RAY EXAM OF TRUNK SPINE      $    149.00
X-RAY EXAM OF THORACIC SPINE   $    149.00
X-RAY EXAM OF THORACIC SPINE   $    157.00
X-RAY EXAM OF THORACIC SPINE   $     94.00
X-RAY EXAM OF THORACIC SPINE   $    175.00
X-RAY EXAM OF THORACIC SPINE   $    205.00
X-RAY EXAM OF LOWER SPINE      $    153.00
X-RAY EXAM OF LOWER SPINE      $    180.00
X-RAY EXAM OF LOWER SPINE      $    257.00
X-RAY EXAM OF LOWER SPINE      $    265.00
X-RAY EXAM OF LOWER SPINE      $     62.18
X-RAY EXAM OF LOWER SPINE      $    120.00
CT NECK SPINE W/O DYE          $    802.00
CT NECK SPINE W/O DYE          $    837.00
CT CHEST SPINE W/O DYE         $   1,227.00
CT CHEST SPINE W/O DYE         $   1,375.00
CT LUMBAR SPINE W/O DYE        $   1,062.00
CT LUMBAR SPINE W/O DYE        $   1,295.00
MRI NECK SPINE W/O DYE         $   1,139.00
MRI NECK SPINE W/O DYE         $   1,285.00
MRI CHEST SPINE W/O DYE        $   1,139.00
MRI CHEST SPINE W/O DYE        $   1,285.00
MRI LUMBAR SPINE W/O DYE       $   1,190.00
MRI LUMBAR SPINE W/O DYE       $   1,232.00
MRI LUMBAR SPINE W/O & W/DYE   $   1,038.71
MRI LUMBAR SPINE W/O & W/DYE   $   1,836.00
X-RAY EXAM OF PELVIS           $     143.00
X-RAY EXAM OF PELVIS           $     162.00
CT PELVIS W/O DYE              $    892.00
CT PELVIS W/O DYE              $    923.00
CT PELVIS W/DYE                $   1,115.00
CT PELVIS W/DYE                $   1,210.00
X-RAY EXAM SACROILIAC JOINTS   $    399.90
X-RAY EXAM OF COLLAR BONE      $     216.00
X-RAY EXAM OF COLLAR BONE      $    234.00
X-RAY EXAM OF SHOULDER BLADE   $     65.00
X-RAY EXAM OF SHOULDER BLADE   $     79.00
X-RAY EXAM OF SHOULDER         $     132.00
X-RAY EXAM OF SHOULDER         $     154.00
X-RAY EXAM OF SHOULDERS        $     176.00
X-RAY EXAM OF SHOULDERS        $     194.00
X-RAY EXAM OF HUMERUS          $     110.00
X-RAY EXAM OF HUMERUS          $     137.00
X-RAY EXAM OF ELBOW            $     82.00
X-RAY EXAM OF ELBOW            $     102.00
X-RAY EXAM OF ELBOW            $     93.00
X-RAY EXAM OF ELBOW            $     105.00
X-RAY EXAM OF FOREARM          $     103.00
X-RAY EXAM OF FOREARM          $     111.00
X-RAY EXAM OF WRIST            $     73.00
X-RAY EXAM OF WRIST            $     92.00
X-RAY EXAM OF WRIST            $     121.00
X-RAY EXAM OF WRIST            $     134.00
X-RAY EXAM OF HAND             $     184.00
X-RAY EXAM OF HAND             $     197.00
X-RAY EXAM OF HAND             $    242.00
X-RAY EXAM OF HAND             $    263.00
X-RAY EXAM OF FINGER(S)        $      81.00
X-RAY EXAM OF FINGER(S)        $     92.00
CT UPPER EXTREMITY W/O DYE     $    766.00
CT UPPER EXTREMITY W/O DYE     $    823.00
CT UPPER EXTREMITY W/DYE       $    375.00
MRI UPPR EXTREMITY W/O&W/DYE   $   3,500.00
MRI JOINT UPR EXTREM W/O DYE   $   1,190.00
MRI JOINT UPR EXTREM W/O DYE   $   1,235.00
X-RAY EXAM OF HIP              $    206.00
X-RAY EXAM OF HIP              $    238.00
X-RAY EXAM OF HIPS             $    105.00
X-RAY EXAM OF PELVIS & HIPS    $     99.00
X-RAY EXAM OF PELVIS & HIPS    $     114.00
X-RAY EXAM OF THIGH            $     58.00
X-RAY EXAM OF THIGH            $     72.00
X-RAY EXAM OF KNEE, 1 OR 2     $     60.00
X-RAY EXAM OF KNEE, 1 OR 2     $     75.00
X-RAY EXAM OF KNEE, 3          $    276.00
X-RAY EXAM OF KNEE, 3          $    321.00
X-RAY EXAM, KNEE, 4 OR MORE    $    206.00
X-RAY EXAM, KNEE, 4 OR MORE    $    234.00
X-RAY EXAM OF KNEES            $     60.00
X-RAY EXAM OF KNEES            $     72.00
X-RAY EXAM OF LOWER LEG        $    226.00
X-RAY EXAM OF LOWER LEG        $    226.00
X-RAY EXAM OF ANKLE            $    105.00
X-RAY EXAM OF ANKLE            $    120.00
X-RAY EXAM OF ANKLE            $    125.00
X-RAY EXAM OF ANKLE            $    132.00
X-RAY EXAM OF FOOT             $     55.00
X-RAY EXAM OF FOOT             $     73.00
X-RAY EXAM OF FOOT             $     118.00
X-RAY EXAM OF FOOT             $    132.00
X-RAY EXAM OF HEEL             $     93.00
X-RAY EXAM OF HEEL             $     112.00
X-RAY EXAM OF TOE(S)           $     48.00
CT LOWER EXTREMITY W/DYE       $    375.00
MRI JNT OF LWR EXTRE W/O DYE   $   1,190.00
MR ANG LWR EXT W OR W/O DYE    $    650.00
X-RAY EXAM OF ABDOMEN          $     92.00
X-RAY EXAM OF ABDOMEN          $     113.00
X-RAY EXAM OF ABDOMEN          $    186.00
X-RAY EXAM OF ABDOMEN          $    201.00
X-RAY EXAM SERIES, ABDOMEN     $    249.00
X-RAY EXAM SERIES, ABDOMEN     $    261.00
CT ABDOMEN W/O DYE             $    892.00
CT ABDOMEN W/O DYE             $    921.00
CT ABDOMEN W/DYE               $    450.00
CT ABDOMEN W/O & W/DYE         $   1,062.00
CT ABDOMEN W/O & W/DYE         $   1,087.00
MRI ABDOMEN W/O & W/DYE        $    734.43
CONTRAST X-RAY, ESOPHAGUS      $    284.00
CINE/VID X-RAY, THROAT/ESOPH   $    385.00
X-RAY EXAM, UPPER GI TRACT     $   362.00
X-RAY EXAM, UPPER GI TRACT     $   372.00
CONTRST X-RAY UPPR GI TRACT    $   366.00
CONTRST X-RAY UPPR GI TRACT    $   375.00
CONTRST X-RAY UPPR GI TRACT    $   422.00
CONTRST X-RAY UPPR GI TRACT    $   436.00
CONTRAST X-RAY EXAM OF COLON   $   381.00
CONTRAST X-RAY EXAM OF COLON   $   396.00
CONTRST X-RAY, URINARY TRACT   $   372.00
CONTRST X-RAY, URINARY TRACT   $   385.00
X-RAY, URETHRA/BLADDER         $   297.00
X-RAY, URETHRA/BLADDER         $   356.00
X-RAYS FOR BONE AGE            $   129.00
X-RAYS FOR BONE AGE            $   164.00
X-RAYS, BONE SURVEY            $   193.00
X-RAYS, BONE SURVEY            $   210.00
DXA BONE DENSITY, AXIAL        $   233.00
DXA BONE DENSITY, AXIAL        $   254.00
COMPUTER MAMMOGRAM ADD-ON      $    65.50
COMPUTER MAMMOGRAM ADD-ON      $    79.00
COMPUTER MAMMOGRAM ADD-ON      $    56.00
COMPUTER MAMMOGRAM ADD-ON      $    72.00
MAMMOGRAM, ONE BREAST          $    83.20
MAMMOGRAM, ONE BREAST          $   102.00
MAMMOGRAM, BOTH BREASTS        $   145.40
MAMMOGRAM, BOTH BREASTS        $   156.00
MAMMOGRAM, SCREENING           $   106.90
MAMMOGRAM, SCREENING           $   124.00
X-RAY EXAM, BREAST SPECIMEN    $   156.40
ECHO EXAM OF HEAD              $   167.00
ECHO EXAM OF HEAD              $   179.00
US EXAM OF HEAD AND NECK       $   352.00
US EXAM, BREAST(S)             $   345.00
US EXAM, BREAST(S)             $   682.70
US EXAM, ABDOM, COMPLETE       $   345.00
ECHO EXAM OF ABDOMEN           $   185.00
US EXAM ABDO BACK WALL, COMP   $   345.00
US EXAM ABDO BACK WALL, COMP   $   354.00
US EXAM ABDO BACK WALL, LIM    $   352.00
US EXAM ABDO BACK WALL, LIM    $   368.00
OB US >/= 14 WKS, SNGL FETUS   $   150.00
OB US >/= 14 WKS, ADDL FETUS   $   272.00
OB US, LIMITED, FETUS(S)       $   150.00
OB US, LIMITED, FETUS(S)       $   176.00
TRANSVAGINAL US, OBSTETRIC       $   150.00
TRANSVAGINAL/PELVIC US, NON-OB   $   185.00
TRANSVAGINAL/PELVIC US, NON-OB   $   150.00
US EXAM, PELVIC, COMPLETE        $   187.00
US EXAM, PELVIC, COMPLETE        $   125.00
US EXAM, PELVIC, LIMITED         $   215.00
US EXAM, PELVIC, LIMITED         $   256.00
US EXAM, SCROTUM                 $   172.00
US EXAM, SCROTUM                 $   182.00
US, TRANSRECTAL                  $   289.00
US EXAM, EXTREMITY               $   161.00
US EXAM, EXTREMITY               $   161.00
US EXAM INFANT HIPS, DYNAMIC     $   426.30
US EXAM INFANT HIPS, DYNAMIC     $   458.00
ECHO GUIDE FOR BIOPSY            $   434.00
ECHO GUIDE FOR BIOPSY            $   475.00
US GUIDE, INTRAOP                $   210.00
MAMMOGRAM, ONE BREAST            $   111.20
MAMMOGRAM, ONE BREAST            $   134.00
MAMMOGRAM, BOTH BREASTS          $   170.50
MAMMOGRAM, BOTH BREASTS          $   182.00
MAMMOGRAM, SCREENING             $   114.50
MAMMOGRAM, SCREENING             $   114.50
DXA BONE DENSITY, AXIAL          $   311.60
DXA BONE DENSITY, AXIAL          $   325.00
THYROID, SINGLE UPTAKE           $   200.00
THYROID, MULTIPLE UPTAKES        $   225.00
THYROID SUPPRESS/STIMUL          $   200.00
THYROID IMAGE, MULT UPTAKES      $   299.00
THYROID IMAGE, MULT UPTAKES      $   342.00
MECKEL'S DIVERT EXAM             $   100.00
BRAIN IMAGING (3D)               $   540.00
BRAIN IMAGING (3D)               $   703.00
K FLOW/FUNCT IMAGE, MULTIPLE     $   617.00
K FLOW/FUNCT IMAGE, MULTIPLE     $   638.00
ELECTROLYTE PANEL                $    25.00
ELECTROLYTE PANEL                $    25.00
COMPREHEN METABOLIC PANEL        $    31.76
COMPREHEN METABOLIC PANEL        $    35.00
OBSTETRIC PANEL                  $    80.00
OBSTETRIC PANEL                  $    80.00
LIPID PANEL                      $    55.00
LIPID PANEL                      $    72.00
RENAL FUNCTION PANEL             $    35.00
RENAL FUNCTION PANEL           $    43.00
ACUTE HEPATITIS PANEL          $   277.98
ACUTE HEPATITIS PANEL          $   312.00
HEPATIC FUNCTION PANEL         $    30.00
HEPATIC FUNCTION PANEL         $    35.00
DRUG SCREEN, QUALITATE/MULTI   $    65.00
DRUG SCREEN, QUALITATE/MULTI   $    70.00
DRUG CONFIRMATION              $    75.00
DRUG CONFIRMATION              $    82.00
ASSAY OF AMITRIPTYLINE         $   106.70
ASSAY OF AMITRIPTYLINE         $   115.00
ASSAY, CARBAMAZEPINE, TOTAL    $    60.00
ASSAY, CARBAMAZEPINE, TOTAL    $    71.00
ASSAY OF CYCLOSPORINE          $   225.00
ASSAY OF CYCLOSPORINE          $   245.00
ASSAY OF DESIPRAMINE           $    75.00
ASSAY OF DESIPRAMINE           $    90.00
ASSAY OF DIGOXIN               $    55.00
ASSAY OF DIGOXIN               $    62.00
ASSAY, DIPROPYLACETIC ACID     $    60.00
ASSAY, DIPROPYLACETIC ACID     $    68.00
ASSAY OF IMIPRAMINE            $    75.00
ASSAY OF IMIPRAMINE            $    82.00
ASSAY OF LITHIUM               $    35.00
ASSAY OF LITHIUM               $    40.00
ASSAY OF PHENOBARBITAL         $    60.00
ASSAY OF PHENOBARBITAL         $    65.00
ASSAY OF PHENYTOIN, TOTAL      $    55.00
ASSAY OF PHENYTOIN, TOTAL      $    62.00
ASSAY OF PRIMIDONE             $    60.00
ASSAY OF PRIMIDONE             $    68.00
ASSAY OF PROCAINAMIDE          $    60.00
ASSAY OF PROCAINAMIDE          $    65.00
ASSAY OF QUINIDINE             $    60.00
ASSAY OF QUINIDINE             $    65.00
ASSAY OF SALICYLATE            $    37.00
ASSAY OF SALICYLATE            $    45.00
ASSAY OF THEOPHYLLINE          $    55.00
ASSAY OF THEOPHYLLINE          $    60.00
ASSAY OF VANCOMYCIN            $    79.45
ASSAY OF VANCOMYCIN            $    85.00
QUANTITATIVE ASSAY, DRUG       $   157.25
QUANTITATIVE ASSAY, DRUG       $   172.00
URINALYSIS, NONAUTO W/SCOPE    $     5.00
URINALYSIS, NONAUTO W/SCOPE    $     5.00
URINALYSIS, AUTO W/SCOPE       $    22.00
URINALYSIS, AUTO W/SCOPE       $    27.00
URINALYSIS NONAUTO W/O SCOPE   $    18.00
URINALYSIS NONAUTO W/O SCOPE   $    22.00
MICROSCOPIC EXAM OF URINE      $     8.00
MICROSCOPIC EXAM OF URINE      $    10.00
URINE PREGNANCY TEST           $    20.00
URINALYSIS TEST PROCEDURE      $    15.00
URINALYSIS TEST PROCEDURE      $    20.00
TEST FOR ACETONE/KETONES       $    15.00
TEST FOR ACETONE/KETONES       $    18.00
ASSAY OF ACTH                  $   228.80
ASSAY OF ACTH                  $   245.00
ASSAY OF SERUM ALBUMIN         $    23.90
ASSAY OF SERUM ALBUMIN         $    28.00
ASSAY OF URINE ALBUMIN         $    38.20
ASSAY OF URINE ALBUMIN         $    42.00
MICROALBUMIN, QUANTITATIVE     $    50.00
MICROALBUMIN, QUANTITATIVE     $    57.00
ASSAY OF ETHANOL               $    71.15
ASSAY OF ETHANOL               $    75.00
ASSAY OF ALDOLASE              $    56.45
ASSAY OF ALDOLASE              $    58.00
ASSAY OF ALDOSTERONE           $   215.60
ASSAY OF ALDOSTERONE           $   220.00
ALPHA-1-ANTITRYPSIN, PHENO     $   144.90
ALPHA-1-ANTITRYPSIN, PHENO     $   150.00
ALPHA-FETOPROTEIN, SERUM       $    94.30
ALPHA-FETOPROTEIN, SERUM       $   100.00
AMINO ACIDS, SINGLE QUANT      $   100.00
AMINO ACIDS, SINGLE QUANT      $   110.00
ASSAY, AMINOLEVULINIC ACID     $    60.00
ASSAY, AMINOLEVULINIC ACID     $    66.00
ASSAY OF AMMONIA               $   113.85
ASSAY OF AMMONIA               $   120.00
ASSAY OF AMYLASE               $    37.45
ASSAY OF AMYLASE               $    45.00
ANGIOTENSIN I ENZYME TEST      $    87.30
ANGIOTENSIN I ENZYME TEST      $    95.00
BILE ACIDS, CHOLYLGLYCINE      $    80.00
BILE ACIDS, CHOLYLGLYCINE      $    87.00
BILIRUBIN, TOTAL               $    66.41
BILIRUBIN, TOTAL               $    70.00
OCCULT BLOOD, FECES            $    15.00
OCCULT BLOOD, FECES            $   20.00
ASSAY OF CALCIUM               $   20.00
ASSAY OF CALCIUM               $   22.00
ASSAY OF CALCIUM IN URINE      $   20.00
ASSAY OF CALCIUM IN URINE      $   22.00
CALCULUS SPECTROSCOPY          $   55.00
CALCULUS SPECTROSCOPY          $   62.00
ASSAY, BLOOD CARBON DIOXIDE    $   20.00
ASSAY, BLOOD CARBON DIOXIDE    $   23.00
ASSAY, BLOOD CARBON MONOXIDE   $   30.00
ASSAY, BLOOD CARBON MONOXIDE   $   33.00
TEST FOR CARBON MONOXIDE       $   30.00
TEST FOR CARBON MONOXIDE       $   33.00
CARCINOEMBRYONIC ANTIGEN       $   75.00
CARCINOEMBRYONIC ANTIGEN       $   80.00
ASSAY, BLOOD CATECHOLAMINES    $   109.00
ASSAY, BLOOD CATECHOLAMINES    $   115.00
ASSAY OF CERULOPLASMIN         $   45.00
ASSAY OF CERULOPLASMIN         $   50.00
ASSAY OF BLOOD CHLORIDE        $   20.00
ASSAY OF BLOOD CHLORIDE        $   25.00
ASSAY, BLD/SERUM CHOLESTEROL   $   20.00
ASSAY, BLD/SERUM CHOLESTEROL   $   25.00
ASSAY, RBC CHOLINESTERASE      $   30.00
ASSAY, RBC CHOLINESTERASE      $   33.00
GAS/LIQUID CHROMATOGRAPHY      $   80.00
GAS/LIQUID CHROMATOGRAPHY      $   88.00
THIN LAYER CHROMATOGRAPHY      $   40.00
THIN LAYER CHROMATOGRAPHY      $   44.00
CHROMOTOGRAPHY, QUANT, SING    $   45.00
CHROMOTOGRAPHY, QUANT, SING    $   48.00
ASSAY OF COPPER                $   35.00
ASSAY OF COPPER                $   38.00
CORTISOL, FREE                 $   68.00
CORTISOL, FREE                 $   72.00
TOTAL CORTISOL                 $   70.00
TOTAL CORTISOL                 $   73.00
COLUMN CHROMOTOGRAPH/ISOTOPE   $   150.00
COLUMN CHROMOTOGRAPH/ISOTOPE   $   165.00
ASSAY OF CK (CPK)              $   20.00
ASSAY OF CK (CPK)              $   23.00
ASSAY OF CPK IN BLOOD          $   50.00
ASSAY OF CPK IN BLOOD          $   56.00
ASSAY OF CREATININE            $   20.00
ASSAY OF CREATININE            $   24.00
ASSAY OF URINE CREATININE      $   20.00
ASSAY OF URINE CREATININE      $   24.00
CREATININE CLEARANCE TEST      $   40.00
CREATININE CLEARANCE TEST      $   46.00
ASSAY OF CRYOGLOBULIN          $   25.00
ASSAY OF CRYOGLOBULIN          $   28.00
VITAMIN B-12                   $   55.00
VITAMIN B-12                   $   60.00
TEST FOR URINE CYSTINES        $   39.00
TEST FOR URINE CYSTINES        $   45.00
DEHYDROEPIANDROSTERONE         $   90.00
DEHYDROEPIANDROSTERONE         $   95.00
DEHYDROEPIANDROSTERONE         $   80.00
DEHYDROEPIANDROSTERONE         $   85.00
DEOXYCORTISOL                  $   100.00
DEOXYCORTISOL                  $   115.00
ASSAY OF ESTRADIOL             $   90.00
ASSAY OF ESTRADIOL             $   97.00
ASSAY OF ESTROGENS             $   55.00
ASSAY OF ESTROGENS             $   62.00
FATS/LIPIDS, FECES, QUANT      $   60.00
FATS/LIPIDS, FECES, QUANT      $   65.00
ASSAY OF FERRITIN              $   42.75
ASSAY OF FERRITIN              $   47.00
ASSAY OF FETAL FIBRONECTIN     $   50.00
BLOOD FOLIC ACID SERUM         $   55.00
BLOOD FOLIC ACID SERUM         $   60.00
ASSAY OF GAMMAGLOBULIN IGM     $    67.10
ASSAY OF GAMMAGLOBULIN IGM     $   70.00
BLOOD GASES W/O2 SATURATION    $   60.00
BLOOD GASES W/O2 SATURATION    $   63.00
ASSAY OF GASTRIN               $   39.00
ASSAY OF GASTRIN               $   44.00
ASSAY, GLUCOSE, BLOOD QUANT    $    16.00
ASSAY, GLUCOSE, BLOOD QUANT    $   20.00
ASSAY, GLUCOSE, BLOOD QUANT    $   20.00
REAGENT STRIP/BLOOD GLUCOSE    $    12.00
REAGENT STRIP/BLOOD GLUCOSE    $    15.00
GLUCOSE TEST                   $   22.00
GLUCOSE TEST                   $   25.00
GLUCOSE TOLERANCE TEST (GTT)   $   47.00
GLUCOSE TOLERANCE TEST (GTT)   $   50.00
GTT-ADDED SAMPLES              $   40.00
GTT-ADDED SAMPLES              $   44.00
ASSAY OF G6PD ENZYME           $   25.00
ASSAY OF G6PD ENZYME           $   28.00
TEST FOR G6PD ENZYME           $   19.50
TEST FOR G6PD ENZYME           $   23.00
GLUCOSE BLOOD TEST             $   12.00
GLUCOSE BLOOD TEST             $   12.00
ASSAY OF GGT                   $   25.00
ASSAY OF GGT                   $   25.00
GLYCATED PROTEIN               $   30.00
GLYCATED PROTEIN               $   33.00
GONADOTROPIN (FSH)             $   70.00
GONADOTROPIN (FSH)             $   76.00
GONADOTROPIN (LH)              $   70.00
GONADOTROPIN (LH)              $   76.00
ASSAY, GROWTH HORMONE (HGH)    $   57.25
ASSAY, GROWTH HORMONE (HGH)    $   65.00
ASSAY OF HAPTOGLOBIN, QUANT    $   45.00
ASSAY OF HAPTOGLOBIN, QUANT    $   50.00
HEAVY METAL SCREEN             $   40.00
HEAVY METAL SCREEN             $   44.00
HEMOGLOBIN ELECTROPHORESIS     $   35.00
HEMOGLOBIN ELECTROPHORESIS     $   40.00
GLYCOSYLATED HEMOGLOBIN TEST   $   53.64
GLYCOSYLATED HEMOGLOBIN TEST   $   57.00
GLYCOSYLATED HB, HOME DEVICE   $   35.00
GLYCOSYLATED HB, HOME DEVICE   $   35.00
BLOOD METHEMOGLOBIN ASSAY      $   46.60
BLOOD METHEMOGLOBIN ASSAY      $   50.00
ASSAY OF HEMOSIDERIN, QUAL     $   20.00
ASSAY OF HEMOSIDERIN, QUAL     $   23.00
ASSAY OF CORTICOSTEROIDS       $   70.00
ASSAY OF CORTICOSTEROIDS       $   75.00
IMMUNOASSAY, DIPSTICK          $   32.00
IMMUNOASSAY, DIPSTICK          $   35.00
ASSAY OF INSULIN               $   45.00
ASSAY OF INSULIN               $   48.00
ASSAY OF IRON                  $   35.00
ASSAY OF IRON                  $   38.00
IRON BINDING TEST              $   35.00
IRON BINDING TEST              $   40.00
ASSAY OF LACTIC ACID           $   28.50
ASSAY OF LACTIC ACID           $   30.00
LACTATE (LD) (LDH) ENZYME      $    19.95
LACTATE (LD) (LDH) ENZYME      $    25.00
ASSAY OF LEAD                  $    45.00
ASSAY OF LEAD                  $    50.00
ASSAY OF LIPASE                $    30.00
ASSAY OF LIPASE                $    34.00
ASSAY OF LIPOPROTEIN           $    57.00
ASSAY OF LIPOPROTEIN           $    62.00
ASSAY OF MAGNESIUM             $    23.00
ASSAY OF MAGNESIUM             $    28.00
ASSAY OF MERCURY               $    73.00
ASSAY OF MERCURY               $    75.00
ASSAY OF METANEPHRINES         $    72.00
ASSAY OF METANEPHRINES         $    77.00
NATRIURETIC PEPTIDE            $   171.46
NATRIURETIC PEPTIDE            $   195.00
MOLECULE ISOLATE               $   249.00
MOLECULE ISOLATE               $   265.00
MOLECULE ISOLATE NUCLEIC       $   310.00
MOLECULE ISOLATE NUCLEIC       $   315.00
MOLECULE GEL ELECTROPHOR       $   310.00
MOLECULE GEL ELECTROPHOR       $   325.00
MOLECULE NUCLEIC AMPLI, EACH   $   310.00
MOLECULE NUCLEIC AMPLI, EACH   $   325.00
ASSAY OF NUCLEOTIDASE          $    40.00
ASSAY OF NUCLEOTIDASE          $    47.00
ORGANIC ACIDS, TOTAL, QUANT    $   350.00
ORGANIC ACIDS, TOTAL, QUANT    $   365.00
ASSAY OF BLOOD OSMOLALITY      $    24.00
ASSAY OF BLOOD OSMOLALITY      $    28.00
ASSAY OF URINE OSMOLALITY      $    30.00
ASSAY OF URINE OSMOLALITY      $    35.00
ASSAY OF OXALATE               $    30.00
ASSAY OF OXALATE               $    35.00
ASSAY OF PARATHORMONE          $   115.00
ASSAY OF PARATHORMONE          $   124.00
ASSAY OF BLOOD PKU             $    25.00
ASSAY OF BLOOD PKU             $    28.00
ASSAY ACID PHOSPHATASE         $    48.30
ASSAY ACID PHOSPHATASE         $    52.00
ASSAY PROSTATE PHOSPHATASE     $    46.00
ASSAY PROSTATE PHOSPHATASE     $    53.00
ASSAY ALKALINE PHOSPHATASE     $    79.35
ASSAY ALKALINE PHOSPHATASE     $    85.00
ASSAY ALKALINE PHOSPHATASE     $    30.00
ASSAY ALKALINE PHOSPHATASE     $    34.00
ASSAY ALKALINE PHOSPHATASES    $    60.00
ASSAY ALKALINE PHOSPHATASES    $    65.00
ASSAY OF PHOSPHORUS            $    20.00
ASSAY OF PHOSPHORUS            $    25.00
ASSAY OF URINE PHOSPHORUS      $    15.00
ASSAY OF URINE PHOSPHORUS      $    20.00
ASSAY OF PORPHOBILINOGEN       $    20.00
ASSAY OF PORPHOBILINOGEN       $    22.00
ASSAY OF URINE PORPHYRINS      $    40.00
ASSAY OF URINE PORPHYRINS      $    44.00
ASSAY OF SERUM POTASSIUM       $    20.00
ASSAY OF SERUM POTASSIUM       $    24.00
ASSAY OF URINE POTASSIUM       $    11.40
ASSAY OF URINE POTASSIUM       $    15.00
ASSAY OF PROGESTERONE          $    50.00
ASSAY OF PROGESTERONE          $    54.00
ASSAY OF PROLACTIN             $   142.50
ASSAY OF PROLACTIN             $   150.00
ASSAY OF PSA, TOTAL            $    31.39
ASSAY OF PSA, TOTAL            $    35.00
ASSAY OF PROTEIN, SERUM        $    20.00
ASSAY OF PROTEIN, SERUM        $    22.00
PROTEIN E-PHORESIS, SERUM      $    50.00
PROTEIN E-PHORESIS, SERUM      $    54.00
PROTEIN, WESTERN BLOT TEST     $    40.00
PROTEIN, WESTERN BLOT TEST     $    44.00
ASSAY RBC PROTOPORPHYRIN       $    16.80
ASSAY RBC PROTOPORPHYRIN       $    24.00
ASSAY OF PROINSULIN            $   255.60
ASSAY OF PROINSULIN            $   260.00
ASSAY OF ESTROGEN              $   100.00
ASSAY OF ESTROGEN              $   105.00
ASSAY, NONENDOCRINE RECEPTOR   $   223.10
ASSAY, NONENDOCRINE RECEPTOR   $   230.00
ASSAY OF SERUM SODIUM          $    20.00
ASSAY OF SERUM SODIUM          $    22.00
ASSAY OF URINE SODIUM          $    11.40
ASSAY OF URINE SODIUM          $    15.00
ASSAY OF SOMATOMEDIN           $   104.00
ASSAY OF SOMATOMEDIN           $   112.00
ASSAY OF TOTAL TESTOSTERONE    $   100.00
ASSAY OF TOTAL TESTOSTERONE    $   115.00
ASSAY OF TOTAL THYROXINE       $   25.00
ASSAY OF FREE THYROXINE        $   47.39
ASSAY THYROID STIM HORMONE     $   60.00
ASSAY OF VITAMIN E             $   50.00
TRANSFERASE (AST) (SGOT)       $   20.00
ALANINE AMINO (ALT) (SGPT)     $   20.00
ALANINE AMINO (ALT) (SGPT)     $   23.00
ASSAY OF TRIGLYCERIDES         $   20.00
ASSAY OF TRIGLYCERIDES         $   23.00
ASSAY OF THYROID (T3 OR T4)    $   25.00
ASSAY OF THYROID (T3 OR T4)    $   30.00
ASSAY, TRIIODOTHYRONINE (T3)   $   50.00
ASSAY, TRIIODOTHYRONINE (T3)   $   55.00
FREE ASSAY (FT-3)              $   102.90
FREE ASSAY (FT-3)              $   115.00
ASSAY OF TROPONIN, QUANT       $   130.25
ASSAY OF TROPONIN, QUANT       $   146.00
ASSAY OF UREA NITROGEN         $    16.00
ASSAY OF UREA NITROGEN         $   22.00
ASSAY OF BLOOD/URIC ACID       $    16.00
ASSAY OF BLOOD/URIC ACID       $   22.00
ASSAY OF URINE VMA             $   63.00
ASSAY OF URINE VMA             $   68.00
XYLOSE TOLERANCE TEST          $   28.00
XYLOSE TOLERANCE TEST          $   32.00
ASSAY OF C-PEPTIDE             $    91.00
ASSAY OF C-PEPTIDE             $   95.00
CHORIONIC GONADOTROPIN TEST    $    51.00
CHORIONIC GONADOTROPIN TEST    $   56.00
CHORIONIC GONADOTROPIN ASSAY   $   30.00
CHORIONIC GONADOTROPIN ASSAY   $   35.00
BLEEDING TIME TEST             $   28.00
BLEEDING TIME TEST             $   33.00
HEMOGLOBIN                     $   30.00
HEMOGLOBIN                     $   35.00
HEMOGLOBIN                     $   35.00
COMPLETE CBC W/AUTO DIFF WBC   $   30.00
COMPLETE CBC W/AUTO DIFF WBC   $   35.00
MANUAL RETICULOCYTE COUNT      $    10.00
MANUAL RETICULOCYTE COUNT      $    15.00
AUTOMATED LEUKOCYTE COUNT      $    14.00
AUTOMATED LEUKOCYTE COUNT      $   20.00
BLOOD SMEAR INTERPRETATION     $     6.19
BLOOD SMEAR INTERPRETATION     $   40.00
BLOOD CLOT FACTOR V TEST       $    84.00
BLOOD CLOT FACTOR V TEST       $    90.00
BLOOD CLOT FACTOR VIII TEST    $    99.75
BLOOD CLOT FACTOR VIII TEST    $   108.00
BLOOD CLOT FACTOR VIII TEST    $   189.00
BLOOD CLOT FACTOR VIII TEST    $   192.00
BLOOD CLOT FACTOR VIII TEST    $   302.45
BLOOD CLOT FACTOR VIII TEST    $   315.00
BLOOD CLOT FACTOR X TEST       $    84.00
BLOOD CLOT FACTOR X TEST       $    90.00
BLOOD CLOT FACTOR XIII TEST    $    55.00
BLOOD CLOT FACTOR XIII TEST    $    60.00
ANTITHROMBIN III TEST          $    38.00
ANTITHROMBIN III TEST          $    43.00
COAGULATION TIME               $    10.00
COAGULATION TIME               $    13.00
FIBRIN DEGRADATION PRODUCTS    $    24.00
FIBRIN DEGRADATION PRODUCTS    $    30.00
FIBRIN DEGRADE, SEMIQUANT      $    55.15
FIBRIN DEGRADE, SEMIQUANT      $    60.00
FIBRINOGEN                     $    24.00
FIBRINOGEN                     $    26.00
HEMOGLOBIN, FETAL              $    14.60
HEMOGLOBIN, FETAL              $    18.00
PROTHROMBIN TIME               $    24.43
PROTHROMBIN TIME               $    28.00
RUSSELL VIPER VENOM, DILUTED   $    41.64
RUSSELL VIPER VENOM, DILUTED   $    45.00
RBC SED RATE, NONAUTOMATED     $    15.00
RBC SED RATE, NONAUTOMATED     $    18.00
RBC SED RATE, AUTOMATED        $    27.51
RBC SED RATE, AUTOMATED        $    32.00
RBC SICKLE CELL TEST           $    20.00
RBC SICKLE CELL TEST           $    26.00
THROMBOPLASTIN INHIBITION      $    50.00
THROMBOPLASTIN INHIBITION      $    60.00
THROMBOPLASTIN TIME, PARTIAL   $    25.00
THROMBOPLASTIN TIME, PARTIAL   $    32.00
HEMATOLOGY PROCEDURE           $    17.20
HEMATOLOGY PROCEDURE           $    22.00
PLATELET ANTIBODIES            $   290.00
PLATELET ANTIBODIES            $   315.00
ANTINUCLEAR ANTIBODIES         $    62.55
ANTINUCLEAR ANTIBODIES         $    65.00
ANTISTREPTOLYSIN O, SCREEN     $   25.00
ANTISTREPTOLYSIN O, SCREEN     $   28.00
C-REACTIVE PROTEIN             $   28.00
C-REACTIVE PROTEIN             $   30.00
CARDIOLIPIN ANTIBODY           $   98.28
CARDIOLIPIN ANTIBODY           $   102.00
COLD AGGLUTININ, SCREEN        $   25.00
COLD AGGLUTININ, SCREEN        $   28.00
COMPLEMENT, ANTIGEN            $   60.00
COMPLEMENT, ANTIGEN            $   65.00
COMPLEMENT, TOTAL (CH50)       $   85.00
COMPLEMENT, TOTAL (CH50)       $   92.00
COMPLEMENT FIXATION, EACH      $   20.00
COMPLEMENT FIXATION, EACH      $   24.00
DNA ANTIBODY                   $   85.45
DNA ANTIBODY                   $   90.00
NUCLEAR ANTIGEN ANTIBODY       $   55.00
NUCLEAR ANTIGEN ANTIBODY       $   62.00
FLUORESCENT ANTIBODY, SCREEN   $   48.00
FLUORESCENT ANTIBODY, SCREEN   $   52.00
FLUORESCENT ANTIBODY, TITER    $   59.00
FLUORESCENT ANTIBODY, TITER    $   64.00
HEMAGGLUTINATION INHIBITION    $   45.00
HEMAGGLUTINATION INHIBITION    $   50.00
IMMUNOASSAY, TUMOR, CA 125     $   125.65
IMMUNOASSAY, TUMOR, CA 125     $   143.00
HETEROPHILE ANTIBODIES         $   53.25
HETEROPHILE ANTIBODIES         $   59.00
IMMUNOASSAY, TUMOR OTHER       $   80.00
IMMUNOASSAY, TUMOR OTHER       $   86.00
IMMUNOASSAY,INFECTIOUS AGENT   $   50.00
IMMUNOASSAY,INFECTIOUS AGENT   $   54.00
IMMUNOASSAY,INFECTIOUS AGENT   $   40.00
IMMUNOASSAY,INFECTIOUS AGENT   $   44.00
SERUM IMMUNOELECTROPHORESIS    $   60.00
SERUM IMMUNOELECTROPHORESIS    $   66.00
IMMUNODIFFUSION                $   70.00
IMMUNODIFFUSION                $   76.00
IMMUNODIFFUSION OUCHTERLONY    $   28.00
IMMUNODIFFUSION OUCHTERLONY    $    31.00
INSULIN ANTIBODIES             $    91.00
INSULIN ANTIBODIES             $   95.00
INTRINSIC FACTOR ANTIBODY      $   25.00
INTRINSIC FACTOR ANTIBODY      $   32.00
MICROSOMAL ANTIBODY            $   55.00
MICROSOMAL ANTIBODY            $   62.00
PARTICLE AGGLUTINATION TEST    $   20.00
PARTICLE AGGLUTINATION TEST    $   23.00
RHEUMATOID FACTOR TEST         $   25.00
RHEUMATOID FACTOR TEST         $   28.00
SKIN TEST, CANDIDA             $   60.00
SKIN TEST, CANDIDA             $   64.00
COCCIDIOIDOMYCOSIS SKIN TEST   $   23.00
COCCIDIOIDOMYCOSIS SKIN TEST   $   28.00
TB INTRADERMAL TEST            $   25.00
TB INTRADERMAL TEST            $   28.00
SKIN TEST, UNLISTED            $   20.00
SKIN TEST, UNLISTED            $   24.00
BLOOD SEROLOGY, QUALITATIVE    $   26.55
BLOOD SEROLOGY, QUALITATIVE    $   30.00
BLOOD SEROLOGY, QUANTITATIVE   $    18.00
BLOOD SEROLOGY, QUANTITATIVE   $   22.00
LYME DISEASE ANTIBODY          $   85.00
LYME DISEASE ANTIBODY          $   88.00
COCCIDIOIDES ANTIBODY          $    61.00
COCCIDIOIDES ANTIBODY          $   65.00
CRYPTOCOCCUS ANTIBODY          $   28.00
CRYPTOCOCCUS ANTIBODY          $   32.00
EPSTEIN-BARR ANTIBODY          $   75.00
EPSTEIN-BARR ANTIBODY          $   82.00
HELICOBACTER PYLORI            $   129.00
HELICOBACTER PYLORI            $   135.00
HTLV/HIV CONFIRMATORY TEST     $   70.00
HTLV/HIV CONFIRMATORY TEST     $   76.00
HIV-1                          $    55.21
HIV-1                          $   58.00
MUMPS ANTIBODY                 $    51.00
MUMPS ANTIBODY                 $   55.00
MYCOPLASMA ANTIBODY            $   198.00
MYCOPLASMA ANTIBODY            $   210.00
RUBEOLA ANTIBODY               $    84.14
RUBEOLA ANTIBODY               $   90.00
TREPONEMA PALLIDUM, CONFIRM    $   45.00
TREPONEMA PALLIDUM, CONFIRM    $   50.00
VARICELLA-ZOSTER ANTIBODY      $   66.62
VARICELLA-ZOSTER ANTIBODY      $   70.00
VIRUS ANTIBODY NOS             $   27.00
VIRUS ANTIBODY NOS             $   30.00
THYROGLOBULIN ANTIBODY         $    55.00
THYROGLOBULIN ANTIBODY         $    60.00
HEPATITIS C AB TEST            $    62.00
HEPATITIS C AB TEST            $    65.00
HLA TYPING, A, B, OR C         $   112.50
HLA TYPING, A, B, OR C         $   120.00
IMMUNOLOGY PROCEDURE           $   205.00
IMMUNOLOGY PROCEDURE           $   220.00
COOMBS TEST, DIRECT            $    20.00
COOMBS TEST, DIRECT            $    24.00
COOMBS TEST, INDIRECT, TITER   $    23.00
COOMBS TEST, INDIRECT, TITER   $    26.00
BLOOD TYPING, ABO              $    16.15
BLOOD TYPING, ABO              $    20.00
BLOOD TYPING, RH (D)           $    13.00
BLOOD TYPING, RH (D)           $    15.00
BLOOD TYPING, RBC ANTIGENS     $    32.00
BLOOD TYPING, RBC ANTIGENS     $    35.00
TRANSFUSION PROCEDURE          $   132.00
TRANSFUSION PROCEDURE          $   140.00
SPECIMEN CONCENTRATION         $    20.00
SPECIMEN CONCENTRATION         $    24.00
BLOOD CULTURE FOR BACTERIA     $    35.00
BLOOD CULTURE FOR BACTERIA     $    38.00
FECES CULTURE, BACTERIA        $    40.00
FECES CULTURE, BACTERIA        $    44.00
CULTURE, BACTERIA, OTHER       $    22.00
CULTURE, BACTERIA, OTHER       $    25.00
CULTURE SCREEN ONLY            $    25.00
CULTURE SCREEN ONLY            $    28.00
URINE CULTURE/COLONY COUNT     $    31.00
URINE CULTURE/COLONY COUNT     $    35.00
SKIN FUNGI CULTURE             $    27.00
SKIN FUNGI CULTURE             $    30.00
FUNGUS ISOLATION CULTURE       $    27.00
FUNGUS ISOLATION CULTURE       $    30.00
FUNGI IDENTIFICATION, YEAST    $    40.00
FUNGI IDENTIFICATION, YEAST    $    45.00
CHLAMYDIA CULTURE              $    65.00
CHLAMYDIA CULTURE              $    70.00
OVA AND PARASITES SMEARS       $    22.80
OVA AND PARASITES SMEARS       $    25.00
MICROBE SUSCEPTIBLE, DISK      $    25.00
MICROBE SUSCEPTIBLE, DISK      $    28.00
SMEAR, GRAM STAIN              $    15.00
SMEAR, GRAM STAIN              $    18.00
SMEAR, FLUORESCENT/ACID STAI   $    24.00
SMEAR, FLUORESCENT/ACID STAI   $    29.00
SMEAR, SPECIAL STAIN           $    15.00
SMEAR, SPECIAL STAIN           $    33.00
SMEAR, WET MOUNT, SALINE/INK   $    26.55
SMEAR, WET MOUNT, SALINE/INK   $    32.00
SMEAR, WET MOUNT, SALINE/INK   $    32.00
TISSUE EXAM FOR FUNGI          $    15.00
TISSUE EXAM FOR FUNGI          $    18.00
ASSAY, TOXIN OR ANTITOXIN      $    75.00
ASSAY, TOXIN OR ANTITOXIN      $    83.00
VIRUS INOCULATE, EGGS/ANIMAL   $    75.00
VIRUS INOCULATE, EGGS/ANIMAL   $    82.00
VIRUS INOCULATION, TISSUE      $    64.00
VIRUS INOCULATION, TISSUE      $    68.00
HERPES SIMPLEX 2, AG, IF       $    56.00
HERPES SIMPLEX 2, AG, IF       $    60.00
HERPES SIMPLEX 1, AG, IF       $    69.00
HERPES SIMPLEX 1, AG, IF       $    76.00
CHYLMD TRACH, DNA, AMP PROBE   $    75.00
CHYLMD TRACH, DNA, AMP PROBE   $    81.00
HEPATITIS C, RNA, AMP PROBE    $   277.15
HEPATITIS C, RNA, AMP PROBE    $   290.00
HEPATITIS C, RNA, QUANT        $   334.25
HEPATITIS C, RNA, QUANT        $   345.00
N.GONORRHOEAE, DNA, AMP PROB   $   111.00
N.GONORRHOEAE, DNA, AMP PROB   $   120.00
HPV, DNA, AMP PROBE            $   110.30
HPV, DNA, AMP PROBE            $   125.00
STREP A ASSAY W/OPTIC          $    44.00
STREP A ASSAY W/OPTIC          $    44.00
CYTOPATH, CONCENTRATE TECH     $    95.00
CYTOPATH, CONCENTRATE TECH     $   123.00
CYTOPATH, CELL ENHANCE TECH    $   158.00
CYTOPATH, C/V, THIN LAYER      $    60.00
CYTOPATH, C/V, THIN LAYER      $    65.00
CYTOPATH TBS, C/V, MANUAL      $    45.00
CYTOPATH TBS, C/V, MANUAL      $    52.00
TISSUE CULTURE, LYMPHOCYTE     $   310.00
TISSUE CULTURE, LYMPHOCYTE     $   325.00
CHROMOSOME ANALYSIS, 15-20     $   310.00
CHROMOSOME ANALYSIS, 15-20     $   325.00
CHROMOSOME STUDY, ADDITIONAL           $   310.00
CHROMOSOME STUDY, ADDITIONAL           $   325.00
CYTO/MOLECULAR REPORT                  $   310.00
CYTO/MOLECULAR REPORT                  $   325.00
TISSUE EXAM BY PATHOLOGIST             $    92.00
TISSUE EXAM BY PATHOLOGIST             $   109.00
TISSUE EXAM BY PATHOLOGIST             $   256.90
SPECIAL STAINS                         $    69.00
SPECIAL STAINS                         $   113.00
IMMUNOHISTOCHEMISTRY                   $   102.60
BODY FLUID CELL COUNT                  $    26.00
BODY FLUID CELL COUNT                  $    28.00
LEUKOCYTE ASSESSMENT, FECAL            $    37.45
LEUKOCYTE ASSESSMENT, FECAL            $    40.00
EXAM,SYNOVIAL FLUID CRYSTALS           $    26.00
EXAM,SYNOVIAL FLUID CRYSTALS           $    33.00
NASAL SMEAR FOR EOSINOPHILS            $    15.00
NASAL SMEAR FOR EOSINOPHILS            $    18.00
SEMEN ANAL VOL/COUNT/MOT               $    25.00
SEMEN ANAL VOL/COUNT/MOT               $    29.00
IMADM ANY ROUTE 1ST VAC/TOX            $    24.00
INADM ANY ROUTE ADDL VAC/TOX           $    22.00
IMMUNE ADMIN 1 INJ, < 8 YRS            $    25.00
IMMUNE ADMIN 1 INJ, < 8 YRS            $    35.00
IMMUNE ADMIN ADDL INJ, < 8 Y           $    25.00
IMMUNE ADMIN ADDL INJ, < 8 Y           $    25.00
H1N1 Administration                    $    15.00
IMMUNIZATION ADMIN                     $    25.00
IMMUNIZATION ADMIN                     $    26.50
Administration Fee For Etorogesterel   $   150.00
IMMUNIZATION ADMIN, EACH ADD           $    25.00
IMMUNIZATION ADMIN, EACH ADD           $    25.00
HEP A VACCINE, ADULT IM                $    65.00
HEP A VACCINE, ADULT IM                $    65.00
HEP A VACC, PED/ADOL, 2 DOSE           $    53.00
HEP A VACC, PED/ADOL, 2 DOSE           $    53.00
HEP A VACC, PED/ADOL, 2 DOSE           $    10.00
HEP A VACC, PED/ADOL, 2 DOSE           $    14.00
HEP A VACC, PED/ADOL, 2 DOSE           $    16.00
HEP A/HEP B VACC, ADULT IM             $   140.00
HIB VACCINE, HBOC, IM                  $    82.00
HIB VACCINE, PRP-OMP, IM               $    16.00
HIB VACCINE, PRP-OMP, IM               $    82.00
HIB VACCINE, PRP-OMP, IM               $    82.00
HIB VACCINE, PRP-OMP, IM       $    10.00
HIB VACCINE, PRP-OMP, IM       $    14.00
HIB VACCINE, PRP-T, IM         $    16.00
HIB VACCINE, PRP-T, IM         $    32.00
HIB VACCINE, PRP-T, IM         $    82.00
HIB VACCINE, PRP-T, IM         $    10.00
HIB VACCINE, PRP-T, IM         $    14.00
H PAPILLOMA VACC 3 DOSE IM     $   195.00
H PAPILLOMA VACC 3 DOSE IM     $   205.00
H PAPILLOMA VACC 3 DOSE IM     $    10.00
H PAPILLOMA VACC 3 DOSE IM     $    14.00
H PAPILLOMA VACC 3 DOSE IM     $    16.00
FLU VACCINE NO PRESERV 6-35M   $    30.00
FLU VACCINE NO PRESERV 6-35M   $    30.00
FLU VACCINE NO PRESERV 6-35M   $    10.00
FLU VACCINE NO PRESERV 6-35M   $    14.00
FLU VACCINE NO PRESERV 6-35M   $    16.00
FLU VACCINE NO PRESERV 3 & >   $    30.00
FLU VACCINE NO PRESERV 3 & >   $    30.00
FLU VACCINE NO PRESERV 3 & >   $    14.00
FLU VACCINE NO PRESERV 3 & >   $    16.00
FLU VACCINE, 3 YRS, IM         $    30.00
FLU VACCINE, 3 YRS, IM         $    30.00
FLU VACCINE, 3 YRS, IM         $    10.00
FLU VACCINE, 3 YRS, IM         $    14.00
FLU VACCINE, 3 YRS, IM         $    16.00
FLU VACCINE, 3 YRS & >, IM     $    30.00
FLU VACCINE, 3 YRS & >, IM     $    30.00
FLU VACCINE, 3 YRS & >, IM     $    30.00
FLU VACCINE, 3 YRS & >, IM     $    30.00
FLU VACCINE, 3 YRS & >, IM     $    10.00
FLU VACCINE, 3 YRS & >, IM     $    14.00
FLU VACCINE, 3 YRS & >, IM     $    16.00
FLU VACCINE, NASAL             $    30.00
FLU VACCINE, NASAL             $    14.00
FLU VACCINE, NASAL             $    16.00
H1N1 Vaccination               $    15.00
PNEUMOCOCCAL VACC, PED <5      $    90.37
PNEUMOCOCCAL VACC, PED <5      $   105.00
PNEUMOCOCCAL VACC, PED <5      $    10.00
PNEUMOCOCCAL VACC, PED <5      $    14.00
PNEUMOCOCCAL VACC, PED <5      $    16.00
PNEUMOCOCCAL VACC, 13 VAL IM   $   165.00
PNEUMOCOCCAL VACC, 13 VAL IM   $    14.00
PNEUMOCOCCAL VACC, 13 VAL IM   $    16.00
ROTOVIRUS VACC 3 DOSE, ORAL    $   105.33
ROTOVIRUS VACC 3 DOSE, ORAL    $   112.00
ROTOVIRUS VACC 3 DOSE, ORAL    $    10.00
ROTOVIRUS VACC 3 DOSE, ORAL    $    14.00
ROTOVIRUS VACC 3 DOSE, ORAL    $    16.00
ROTAVIRUS VACC 2 DOSE ORAL     $   85.00
ROTAVIRUS VACC 2 DOSE ORAL     $    14.00
ROTAVIRUS VACC 2 DOSE ORAL     $    16.00
DTAP-IPV VACC 4-6 YR IM        $   40.00
DTAP-IPV VACC 4-6 YR IM        $    14.00
DTAP-IPV VACC 4-6 YR IM        $    16.00
DTAP-HIB-IP VACCINE, IM        $   35.00
DTAP-HIB-IP VACCINE, IM        $    14.00
DTAP-HIB-IP VACCINE, IM        $    16.00
DTAP VACCINE, < 7 YRS, IM      $   40.00
DTAP VACCINE, < 7 YRS, IM      $   40.00
DTAP VACCINE, < 7 YRS, IM      $    10.00
DTAP VACCINE, < 7 YRS, IM      $    14.00
DTAP VACCINE, < 7 YRS, IM      $    16.00
DTP VACCINE, IM                $   40.00
DTP VACCINE, IM                $   40.00
DT VACCINE < 7, IM             $   25.00
DT VACCINE < 7, IM             $   25.00
DT VACCINE < 7, IM             $    14.00
DT VACCINE < 7, IM             $    16.00
TETANUS VACCINE, IM            $    31.00
TETANUS VACCINE, IM            $   35.00
MUMPS VACCINE, SC              $   25.00
MUMPS VACCINE, SC              $   25.00
MEASLES VACCINE, SC            $   27.00
MEASLES VACCINE, SC            $   27.00
MMR VACCINE, SC                $   40.00
MMR VACCINE, SC                $   40.00
MMR VACCINE, SC                $    10.00
MMR VACCINE, SC                $    14.00
MMR VACCINE, SC                $    16.00
MMRV VACCINE, SC               $   54.00
MMRV VACCINE, SC               $   54.00
MMRV VACCINE, SC               $    10.00
MMRV VACCINE, SC               $    14.00
MMRV VACCINE, SC               $    16.00
ORAL POLIOVIRUS VACCINE        $   28.00
ORAL POLIOVIRUS VACCINE        $   28.00
POLIOVIRUS, IPV, SC/IM         $    16.00
POLIOVIRUS, IPV, SC/IM         $    28.00
POLIOVIRUS, IPV, SC/IM         $    28.00
POLIOVIRUS, IPV, SC/IM         $    10.00
POLIOVIRUS, IPV, SC/IM         $    14.00
TD VACCINE NO PRSRV >/= 7 IM   $    50.00
TD VACCINE NO PRSRV >/= 7 IM   $    50.00
TD VACCINE NO PRSRV >/= 7 IM   $    14.00
TD VACCINE NO PRSRV >/= 7 IM   $    16.00
TDAP VACCINE >7 IM             $    59.00
TDAP VACCINE >7 IM             $    59.00
TDAP VACCINE >7 IM             $    10.00
TDAP VACCINE >7 IM             $    14.00
TDAP VACCINE >7 IM             $    16.00
CHICKEN POX VACCINE, SC        $    96.00
CHICKEN POX VACCINE, SC        $    96.00
CHICKEN POX VACCINE, SC        $    10.00
CHICKEN POX VACCINE, SC        $    14.00
CHICKEN POX VACCINE, SC        $    16.00
TD VACCINE > 7, IM             $    20.00
TD VACCINE > 7, IM             $    30.00
DTP/HIB VACCINE, IM            $    82.00
DTP/HIB VACCINE, IM            $    82.00
DTAP-HEP B-IPV VACCINE, IM     $   150.00
DTAP-HEP B-IPV VACCINE, IM     $   150.00
DTAP-HEP B-IPV VACCINE, IM     $    10.00
DTAP-HEP B-IPV VACCINE, IM     $    14.00
DTAP-HEP B-IPV VACCINE, IM     $    16.00
PNEUMOCOCCAL VACCINE           $    45.00
PNEUMOCOCCAL VACCINE           $    14.00
PNEUMOCOCCAL VACCINE           $    16.00
Pneumonia Shot                 $    30.00
MENINGOCOCCAL VACCINE, IM      $   114.00
MENINGOCOCCAL VACCINE, IM      $    10.00
MENINGOCOCCAL VACCINE, IM      $    14.00
MENINGOCOCCAL VACCINE, IM      $    16.00
ZOSTER VACC, SC                $   225.00
HEP B VACC, ADOL, 2 DOSE, IM   $    82.00
HEP B VACC, ADOL, 2 DOSE, IM   $    14.00
HEP B VACC, ADOL, 2 DOSE, IM   $    16.00
HEPB VACC PED/ADOL 3 DOSE IM   $    78.00
HEPB VACC PED/ADOL 3 DOSE IM   $    10.00
HEPB VACC PED/ADOL 3 DOSE IM   $    14.00
HEPB VACC PED/ADOL 3 DOSE IM   $    16.00
HEP B VACCINE, ADULT, IM       $   84.00
HEPB VACC, ILL PAT 4 DOSE IM   $   130.00
HEP B/HIB VACCINE, IM          $   65.00
HEP B/HIB VACCINE, IM          $    14.00
HEP B/HIB VACCINE, IM          $    16.00
VACCINE TOXOID                 $   75.00
HYDRATION IV INFUSION, INIT    $   80.00
HYDRATION IV INFUSION, INIT    $   110.00
HYDRATE IV INFUSION, ADD-ON    $   35.00
THER/PROPH/DIAG INJ, SC/IM     $   20.00
THER/PROPH/DIAG INJ, SC/IM     $   35.00
GROUP PSYCHOTHERAPY            $   50.00
GROUP PSYCHOTHERAPY            $   55.00
MEDICATION MANAGEMENT          $   60.00
MEDICATION MANAGEMENT          $    91.00
EYE EXAM, NEW PATIENT          $   75.00
EYE EXAM, NEW PATIENT          $   121.00
EYE EXAM, NEW PATIENT          $   120.00
EYE EXAM, NEW PATIENT          $   218.00
EYE EXAM ESTABLISHED PAT       $   65.00
EYE EXAM ESTABLISHED PAT       $   111.00
EYE EXAM & TREATMENT           $   80.00
EYE EXAM & TREATMENT           $   164.00
VISUAL FIELD EXAMINATION(S)    $   64.00
VISUAL FIELD EXAMINATION(S)    $   88.00
PURE TONE HEARING TEST, AIR    $   33.00
PURE TONE HEARING TEST, AIR    $   33.00
PURE TONE AUDIOMETRY, AIR      $   36.00
PURE TONE AUDIOMETRY, AIR      $   36.00
AUDIOMETRY, AIR & BONE         $   40.00
AUDIOMETRY, AIR & BONE         $   50.00
SPEECH THRESHOLD AUDIOMETRY    $   30.00
SPEECH THRESHOLD AUDIOMETRY    $   30.00
COMPREHENSIVE HEARING TEST     $   75.00
COMPREHENSIVE HEARING TEST     $    91.00
TYMPANOMETRY                   $   105.00
TYMPANOMETRY                   $   125.00
ACOUSTIC REFL THRESHOLD TST    $   34.00
ACOUSTIC REFL THRESHOLD TST    $   42.00
ACOUSTIC REFLEX DECAY TEST     $   34.00
ACOUSTIC REFLEX DECAY TEST     $   42.00
CONDITIONING PLAY AUDIOMETRY   $   57.00
CONDITIONING PLAY AUDIOMETRY   $   60.00
ELECTROCARDIOGRAM, COMPLETE    $   70.00
ELECTROCARDIOGRAM, COMPLETE    $    70.00
ELECTROCARDIOGRAM, TRACING     $    66.00
ELECTROCARDIOGRAM, TRACING     $    66.00
ECHO EXAM OF HEART             $   301.00
ECHO EXAM OF HEART             $   353.00
DOPPLER ECHO EXAM, HEART       $   148.00
DOPPLER ECHO EXAM, HEART       $   156.00
DOPPLER COLOR FLOW ADD-ON      $   161.00
DOPPLER COLOR FLOW ADD-ON      $   180.00
EXTRACRANIAL STUDY             $   404.00
EXTRACRANIAL STUDY             $   449.00
EXTREMITY STUDY                $   550.00
LOWER EXTREMITY STUDY          $   300.00
UPPER EXTREMITY STUDY          $   226.00
EXTREMITY STUDY                $   405.00
EXTREMITY STUDY                $   443.00
EXTREMITY STUDY                $   369.00
EXTREMITY STUDY                $   375.00
VASCULAR STUDY                 $   528.00
VASCULAR STUDY                 $   678.00
EVALUATION OF WHEEZING         $   150.00
EVALUATION OF WHEEZING         $   750.00
VITAL CAPACITY TEST            $    26.00
VITAL CAPACITY TEST            $    32.00
AIRWAY INHALATION TREATMENT    $    40.00
AIRWAY INHALATION TREATMENT    $    40.00
MEASURE BLOOD OXYGEN LEVEL     $    13.35
MEASURE BLOOD OXYGEN LEVEL     $    15.00
MEASURE BLOOD OXYGEN LEVEL     $    13.35
MEASURE BLOOD OXYGEN LEVEL     $    15.00
IMMUNOTHERAPY, ONE INJECTION   $    10.00
IMMUNOTHERAPY, ONE INJECTION   $    25.00
EEG, AWAKE AND DROWSY          $   257.00
EEG, AWAKE AND DROWSY          $   356.00
DEVELOPMENTAL TEST, LIM        $    28.12
OFFICE EMERGENCY CARE          $    48.00
OFFICE EMERGENCY CARE          $    52.00
SPECIAL SUPPLIES               $     3.50
SPECIAL SUPPLIES               $     5.00
VISUAL ACUITY SCREEN           $    20.00
OFFICE/OUTPATIENT VISIT, NEW   $    60.00
OFFICE/OUTPATIENT VISIT, NEW   $    64.00
OFFICE/OUTPATIENT VISIT, NEW   $    60.00
OFFICE/OUTPATIENT VISIT, NEW   $    64.00
OFFICE/OUTPATIENT VISIT, NEW   $    90.00
OFFICE/OUTPATIENT VISIT, NEW   $   112.00
OFFICE/OUTPATIENT VISIT, NEW   $    90.00
OFFICE/OUTPATIENT VISIT, NEW   $   112.00
OFFICE/OUTPATIENT VISIT, NEW   $   120.00
OFFICE/OUTPATIENT VISIT, NEW   $   166.00
OFFICE/OUTPATIENT VISIT, NEW   $   120.00
OFFICE/OUTPATIENT VISIT, NEW   $   166.00
OFFICE/OUTPATIENT VISIT, NEW   $   150.00
OFFICE/OUTPATIENT VISIT, NEW   $   252.00
OFFICE/OUTPATIENT VISIT, NEW   $   150.00
OFFICE/OUTPATIENT VISIT, NEW   $   252.00
OFFICE/OUTPATIENT VISIT, NEW   $   200.00
OFFICE/OUTPATIENT VISIT, NEW   $   316.00
OFFICE/OUTPATIENT VISIT, NEW   $   200.00
OFFICE/OUTPATIENT VISIT, NEW   $   316.00
OFFICE/OUTPATIENT VISIT, EST   $    30.00
OFFICE/OUTPATIENT VISIT, EST   $    36.00
OFFICE/OUTPATIENT VISIT, EST   $    30.00
OFFICE/OUTPATIENT VISIT, EST   $    36.00
OFFICE/OUTPATIENT VISIT, EST   $    50.00
OFFICE/OUTPATIENT VISIT, EST   $    66.00
OFFICE/OUTPATIENT VISIT, EST   $    50.00
OFFICE/OUTPATIENT VISIT, EST   $    66.00
OFFICE/OUTPATIENT VISIT, EST   $    65.00
OFFICE/OUTPATIENT VISIT, EST   $   107.00
OFFICE/OUTPATIENT VISIT, EST   $    65.00
OFFICE/OUTPATIENT VISIT, EST   $   107.00
OFFICE/OUTPATIENT VISIT, EST   $    95.00
OFFICE/OUTPATIENT VISIT, EST   $   162.00
OFFICE/OUTPATIENT VISIT, EST   $    95.00
OFFICE/OUTPATIENT VISIT, EST   $   162.00
OFFICE/OUTPATIENT VISIT, EST   $   150.00
OFFICE/OUTPATIENT VISIT, EST   $   219.00
OFFICE/OUTPATIENT VISIT, EST   $   150.00
OFFICE/OUTPATIENT VISIT, EST   $   219.00
OBSERVATION CARE DISCHARGE     $   100.00
OBSERVATION CARE DISCHARGE     $   119.00
OBSERVATION CARE               $   120.00
OBSERVATION CARE               $   137.00
OBSERVATION CARE               $   120.00
OBSERVATION CARE               $   137.00
OBSERVATION CARE               $   175.00
OBSERVATION CARE               $   185.00
OBSERVATION CARE                $   200.00
OBSERVATION CARE                $   261.00
INITIAL HOSPITAL CARE           $   130.00
INITIAL HOSPITAL CARE           $   153.00
INITIAL HOSPITAL CARE, LOW      $   130.00
INITIAL HOSPITAL CARE, LOW      $   153.00
INITIAL HOSPITAL CARE           $   165.00
INITIAL HOSPITAL CARE           $   214.00
INITAL HOSPITAL CARE, MED       $   165.00
INITAL HOSPITAL CARE, MED       $   214.00
INITIAL HOSPITAL CARE           $   200.00
INITIAL HOSPITAL CARE           $   312.00
INITIAL HOSPITAL CARE, HIGH     $   200.00
INITIAL HOSPITAL CARE, HIGH     $   312.00
SUBSEQUENT OBSERVATION CARE     $    75.00
SUBSEQUENT OBSERVATION CARE     $   105.00
SUBSEQUENT OBSERVATION CARE     $   135.00
SUBSEQUENT HOSPITAL CARE        $    75.00
SUBSEQUENT HOSPITAL CARE        $    85.00
SUBSEQUENT HOSPITAL CARE, LOW   $    75.00
SUBSEQUENT HOSPITAL CARE, LOW   $    85.00
SUBSEQUENT HOSPITAL CARE        $   100.00
SUBSEQUENT HOSPITAL CARE        $   115.00
SUBSEQUENT HOSPITAL CARE, MED   $   100.00
SUBSEQUENT HOSPITAL CARE, MED   $   115.00
SUBSEQUENT HOSPITAL CARE        $   140.00
SUBSEQUENT HOSPITAL CARE        $   164.00
SUBSEQUENT HOSPITAL CARE        $   164.00
OBSERV/HOSP SAME DATE           $   165.00
OBSERV/HOSP SAME DATE           $   225.00
OBSERV/HOSP SAME DATE           $   220.00
OBSERV/HOSP SAME DATE           $   297.00
OBSERV/HOSP SAME DATE           $   260.00
OBSERV/HOSP SAME DATE           $   370.00
HOSPITAL DISCHARGE DAY          $    95.00
HOSPITAL DISCHARGE DAY          $   118.00
HOSPITAL DISCHARGE DAY          $    95.00
HOSPITAL DISCHARGE DAY          $   118.00
HOSPITAL DISCHARGE DAY          $   140.00
HOSPITAL DISCHARGE DAY          $   171.00
OFFICE CONSULTATION             $   100.00
OFFICE CONSULTATION             $   110.00
OFFICE CONSULTATION             $   140.00
OFFICE CONSULTATION             $   161.00
OFFICE CONSULTATION            $    170.00
OFFICE CONSULTATION            $    220.00
OFFICE CONSULTATION            $    225.00
OFFICE CONSULTATION            $    323.00
OFFICE CONSULTATION            $    290.00
OFFICE CONSULTATION            $    401.00
INPATIENT CONSULTATION         $     115.00
INPATIENT CONSULTATION         $    150.00
INPATIENT CONSULTATION         $    185.00
INPATIENT CONSULTATION         $    196.00
INPATIENT CONSULTATION         $    240.00
INPATIENT CONSULTATION         $    282.00
INPATIENT CONSULTATION         $    280.00
INPATIENT CONSULTATION         $    351.00
EMERGENCY DEPT VISIT           $     70.00
EMERGENCY DEPT VISIT           $    100.00
EMERGENCY DEPT VISIT           $    130.00
EMERGENCY DEPT VISIT           $    200.00
EMERGENCY DEPT VISIT           $    280.00
EMERGENCY DEPT VISIT           $    298.00
CRITICAL CARE, FIRST HOUR      $    300.00
CRITICAL CARE, FIRST HOUR      $    461.00
CRITICAL CARE, FIRST HOUR      $    300.00
CRITICAL CARE, ADD'L 30 MIN    $    150.00
CRITICAL CARE, ADD'L 30 MIN    $    206.00
CRITIAL CARE, ADDL 30 MIN      $    150.00
NEONATE CRIT CARE, INITIAL     $   1,130.00
NEONATE CRIT CARE, INITIAL     $   1,564.00
NEONATE CRITICAL CARE SUBSEQ   $    753.00
NURSING FACILITY CARE, INIT    $     90.00
NURSING FACILITY CARE, INIT    $     110.00
NURSING FACILITY CARE, INIT    $    120.00
NURSING FACILITY CARE, INIT    $    146.00
NURSING FACILITY CARE, INIT    $    160.00
NURSING FACILITY CARE, INIT    $    179.00
NURSING FAC CARE, SUBSEQ       $    190.00
NURSING FAC CARE, SUBSEQ       $     80.00
NURSING FAC CARE, SUBSEQ       $     95.00
NURSING FAC CARE, SUBSEQ       $     80.00
NURSING FAC CARE, SUBSEQ       $    133.00
NURSING FAC CARE, SUBSEQ       $     110.00
NURSING FAC CARE, SUBSEQ       $    166.00
NURSING FAC DISCHARGE DAY      $     90.00
NURSING FAC DISCHARGE DAY      $    103.00
NURSING FAC DISCHARGE DAY      $   120.00
NURSING FAC DISCHARGE DAY      $   135.00
ANNUAL NURSING FAC ASSESSMNT   $   105.00
ANNUAL NURSING FAC ASSESSMNT   $   110.00
HOME VISIT, NEW PATIENT        $    80.00
HOME VISIT, NEW PATIENT        $    98.00
HOME VISIT, NEW PATIENT        $   100.00
HOME VISIT, NEW PATIENT        $   143.00
HOME VISIT, NEW PATIENT        $   160.00
HOME VISIT, NEW PATIENT        $   207.00
PROLONGED SERVICE, OFFICE      $   200.00
PROLONGED SERVICE, OFFICE      $   100.00
PROLONGED SERVICE, OFFICE      $   163.00
PROLONGED SERVICE, INPATIENT   $   225.00
PROLONGED SERVICE, INPATIENT   $   115.00
PROLONGED SERVICE, INPATIENT   $   151.00
PROLONGED SERV, W/O CONTACT    $   125.00
PHYSICIAN STANDBY SERVICES     $    98.00
PHYSICIAN/TEAM CONFERENCE      $   154.00
PHYSICIAN PHONE CONSULTATION   $    40.00
PHYSICIAN PHONE CONSULTATION   $    90.00
INIT PM E/M, NEW PAT, INF      $   150.00
INIT PM E/M, NEW PAT 1-4 YRS   $   160.00
PREV VISIT, NEW, AGE 5-11      $   155.00
PREV VISIT, NEW, AGE 12-17     $   160.00
PREV VISIT, NEW, AGE 18-39     $   175.00
PREV VISIT, NEW, AGE 40-64     $   210.00
INIT PM E/M, NEW PAT 65+ YRS   $   240.00
PER PM REEVAL, EST PAT, INF    $   120.00
PREV VISIT, EST, AGE 1-4       $   140.00
PREV VISIT, EST, AGE 5-11      $   130.00
PREV VISIT, EST, AGE 12-17     $   160.00
PREV VISIT, EST, AGE 18-39     $   160.00
PREV VISIT, EST, AGE 40-64     $   175.00
PER PM REEVAL EST PAT 65+ YR   $   180.00
PREVENTIVE COUNSELING, INDIV   $    50.00
PREVENTIVE COUNSELING, INDIV   $    95.00
PREVENTIVE COUNSELING, INDIV   $   135.00
BEHAV CHNG SMOKING 3-10 MIN    $    45.00
BEHAV CHNG SMOKING >10 MIN     $    60.00
AUDIT/DAST, 15-30 MIN          $    45.00
AUDIT/DAST, OVER 30 MIN        $    55.00
INITIAL CARE, NORMAL NEWBORN   $   150.00
NORMAL NEWBORN CARE/HOSPITAL   $    85.00
NEWBORN DISCHARGE DAY HOSP                     $   175.00
ATTENDANCE, BIRTH                              $   175.00
NEWBORN RESUSCITATION                          $   255.00
PHONE E/M BY PHYS 5-10 MIN                     $    25.00
Init nb em per day, hosp                       $   125.00
Sbsq nb em per day, hosp                       $   100.00
Same day nb discharge                          $   125.00
Attendance At Birth                            $   125.00
Newborn Resucitation                           $   175.00
Pessary rubber, any type                       $    48.00
Pessary rubber, any type                       $    57.00
Slings                                         $     2.99
Slings                                         $     5.00
Radiopharm dx agent noc                        $   128.00
Radiopharm dx agent noc                        $   156.00
Palivizumab, per 50 mg                         $   787.00
Palivizumab, per 50 mg                         $   765.04
Admin influenza virus vac                      $    26.50
Admin pneumococcal vaccine                     $    25.00
Admin hepatitis b vaccine                      $    20.00
MD recertification HHA PT                      $    50.00
MD certification HHA patient                   $    65.00
Home health care supervision                   $   125.00
Screeningmammographydigital                    $   250.00
Diag Mammo Digital Bilateral                   $   383.10
Diag Mammo Digital Unilateral                  $   300.00
Blood occult test,colorectal                   $    20.00
Alcohol/subs interv 15-30mn                    $    45.00
Alcohol/subs interv >30 min                    $    60.00
H1N1 Admninistration                           $    15.00
H1N1 Vaccine                                   $    30.00
Adrenalin epinephrin inject                    $     6.50
Aminophyllin 250 MG inj                        $     6.50
Atropine sulfate injection                     $     6.00
Penicillin g benzathine inj                    $    19.63
Penicillin g benzathine inj                    $    16.50
Penicillin g benzathine inj                    $    33.00
Penicillin g benzathine inj 6000,000 Units     $    12.50
Penicillin g benzathine inj, 1,200,000 Uni     $    18.50
Penicillin g benzathine inj, 2,400,000 Units   $    43.10
Ceftriaxone sodium injection                   $    16.50
Betamethasone sod phosp/4 MG                   $    14.15
Clonidine hydrochloride                        $    80.00
Prochlorperazine injection                     $    12.50
Epoetin alfa, non-esrd                              $    15.00
Estradiol valerate injection                        $    46.00
Depo-estradiol cypionate inj                        $     8.00
Methylprednisolone 40 MG inj                        $     7.00
Medrxyprogester acetate inj                         $    70.00
Medrxyprogester acetate inj                         $    95.00
MA/EC contraceptiveinjection                        $    35.00
Testosterone cypionate 1 ML                         $    11.00
Dexamethasone sodium phos                           $    12.50
Diphenhydramine hcl injectio                        $     6.00
Gamma globulin 1 CC inj                             $    30.00
Gamma globulin 2 CC inj                             $    30.00
Gamma globulin 5 CC inj                             $   100.00
Gamma globulin 6 CC inj                             $   100.00
Gamma globulin 7 CC inj                             $   120.00
Garamycin gentamicin inj                            $     7.50
Haloperidol injection                               $    41.00
Haloperidol decanoate inj                           $    30.00
Hydrocortisone sodium succ i                        $     7.75
Insulin injection                                   $    30.00
Ketorolac tromethamine inj 15mg (use For Toradol)   $    12.50
Furosemide injection                                $     6.00
Leuprolide acetate /3.75 MG                         $   550.00
Lidocaine injection                                 $     6.50
Lorazepam injection                                 $     6.00
Meperidine hydrochl /100 MG                         $     6.00
Meperidine/promethazine inj                         $    12.00
Morphine sulfate injection                          $     6.00
Penicillin g procaine inj                           $    15.00
Penicillin g potassium inj                          $     6.00
Promethazine hcl injection                          $     6.00
Fluphenazine decanoate 25 MG                        $    18.00
Rho d immune globulin 50 mcg                        $    28.00
Rho d immune globulin 50 mcg                        $    35.00
Rho d immune globulin inj                           $   120.00
Rho d immune globulin inj                           $   120.00
Aurothioglucose injeciton                           $    36.00
Methylprednisolone injection                        $     7.00
Methylprednisolone injection                        $    12.50
Testosterone enanthate inj Up To 200mg              $    23.00
Testosteron propionate inj                          $     7.00
Trimethobenzamide hcl inj                           $     6.00
Triamcinolone acetonide inj                         $     9.00
Triamcinolone diacetate inj                         $    20.64
Diazepam injection                            $     6.50
Diazepam injection                            $     8.00
Hydroxyzine hcl injection Up To 25mg          $     6.00
Vitamin b12 injection                         $     7.00
Vitamin k phytonadione inj                    $    10.00
INJ; UNCLSSFD DRG; MARCAIN                    $     1.00
INJ; UNCLSSFD DRG; MARCAIN                    $   150.00
Normal saline solution infus                  $    15.00
Intraut copper contraceptive                  $   621.00
Intraut copper contraceptive                  $   650.00
Levonorgestrel iu contracept                  $   674.00
Etonogestrel implant system                   $   650.00
Prednisone oral                               $     5.00
Albuterol inh non-comp u d                    $     1.00
Albuterol comp unit                           $     1.00
Albuterol unit dose                           $     1.00
Budesonide non-comp con                       $     5.00
Ipratropium bromide non-comp                  $     5.00
Goserelin acetate implant                     $   566.42
Interferon alfa-2a inj                        $    57.00
Interferon alfa-2b inj                        $    37.00
Interferon gamma 1-b inj                      $   150.00
Leuprolide acetate suspnsion                  $   610.00
Methotrexate sodium inj                       $    13.25
Obtaining screen pap smear                    $    48.00
Obtaining screen pap smear                    $    71.00
Fern test                                     $    15.00
Medicare Flu Shot                             $    30.00
Etonogestrel (contraceptive) Implant System   $   650.00
Ondansetron 4 mg                              $    15.00
Smoking cessation treatment                   $    55.00
                      OTC5044                                                  OTC5046
SCHC SCH HEALTH PROGRAM PECAN GROVE (SCHOOL BASED)         SCHC SCHOOL HEALTH PROGRAM CENTER RANCHO VIEJO


              600 SOUTH 21ST AVENUE                                      930 SOUTH AVENUE C
                        YUMA                                                     YUMA
                          AZ                                                       AZ
                        85364                                                    85364




                     9288198999                                               9288198999




              2060 WEST 24TH STREET                                    2060 WEST 24TH STREET
                     David Rogers                                             David Rogers




             Discription of Charge    Rate of Charge   Service Code   Discription of Charge
TC5046                                                     OTC5043
OGRAM CENTER RANCHO VIEJO                   SCHC SCHOOL HEALTH PROGRAM-SAN LUIS


TH AVENUE C                                       1245 NORTH MAIN STREET
YUMA                                                       SAN LUIS
 AZ                                                            AZ
85364                                                        85349




8198999                                                   9288198999




T 24TH STREET
id Rogers                                                 David Rogers




                Rate of Charge   Service Code     Discription of Charge    Rate of Charge    Service Code


                                                                                            54482-0145-08
                                                                                            50383-0172-90
                                                                                            64980-0130-09
                                                                                            54482-0144-07
                                                                                            00054-0007-25
                                                                                            00054-0007-13
                                                                                            30698-0143-01
                                                                                            00093-0658-01
                                                                                            30698-0143-23
                                                                                            30698-0144-01
                                                                                            58468-0120-01
                                                                                            00074-4317-30
00054-3120-41
30698-0911-15
58468-0124-01
53746-0282-01
16252-0516-05
00074-4314-30
58468-0121-01
   82962
00074-4315-30
   85045
   93041
   84540
   82570
   90657
   90658
   85046
   83540
   86580
   87076
   87077
   87070
   99070
   83550
   87075
   87040
   87340
   86706
   86705
   90732
   86704
   84466
   82728
   84134
   82746
   82607
   82379
   82668
   82108
   82306
   93005
   93701
   82652
   83970
   90940
90999
90747
90999
90999
90740
36516
90945
90945
90945
90945
90945
90945
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90993
90993
90999
90993
90993
90993
90993
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
90999
J0171
J7131
A4615
J0694
P9041
J0460
J2916
J2060
J0697
J0698
A4728
J0180
J0696
J3370
J2248
J2270
J0360
J1270
J1170
J1240
J3360
J0692
E0431
E0441
E0443
J1750
C9121
A4216
J0743
J1200
Q4081
Q4081
J3420
J3480
J0610
J2320
J1652
J2765
J1580
J0895
J1335
J0690
J1644
J3410
J1750
J2405
J3250
J2150
J2930
J3120
J3430
J0636
J0878
J2700
J0285
J0744
J2550
J0278
J0637
J7130
J1890
J1631
J1644
J2997
J1955
J3070
J1160
J2020
J0290
J2543
J2310
J0882
J7060
J1945
J9070
J2185
J1885
J2560
J3364
Q0139
J1650
A4657
A4913
Q2035
Q2036
Q2037
Q2038
Q2039
J2920
J3475
J3260
J0713
J1790
J0295
J0715
J2720
J1956
J0780
G0008
G0009
G0010
J2501
J1165
J1590
J3000
J1450
J1364
J1756
Q4081
Q4081
Q4081
Q4081
J0882
J0882
                                                        4/7/2012


                                                        OTC-4721
                                                    South Yuma Dialysis


                                                    3010 S 4th Avenue
                                                           Yuma
                                                            AZ
                                                          85364


                                                    3010 S 4th Avenue
                                                           Yuma
                                                            AZ
                                                          85364
                                                       928-317-0517
                                                       1447223318
                                                          197865
                                                            Yes
                                                         03-2556
                                                      Donna Gebhart
                                                       928-317-0517
                                                 donna.gebhart@davita.com
                                                        Luis Borgen
                                                      (303) 405-2223
                                                  Luis.Borgen@davita.com
                                                      Bridget Cuffie
                                                       615-341-5893
                                                 bridget.cuffie@davita.com
                                                         3/1/2012


                                                 Discription of Charge


CARNITOR ORAL SOLUTION 1GM/10ML, NDC: 54482-0145-08
LEVOCARNITINE TABLETS 330 MG, NDC: 50383-0172-90
LEVOCARNITINE TABLETS 330 MG, NDC: 64980-0130-09
CARNITOR TABLETS 330 MG, NDC: 54482-0144-07
CALCITRIOL CAPSULES 0.25 MCG, NDC: 00054-0007-25
CALCITRIOL CAPSULES 0.25 MCG, NDC: 00054-0007-13
ROCALTROL CAPSULES 0.25 MCG, NDC: 30698-0143-01
CALCITRIOL CAPSULES 0.5 MCG, NDC: 00093-0658-01
ROCALTROL CAPSULES 0.25 MCG, NDC: 30698-0143-23
ROCALTROL CAPSULES 0.5 MCG, NDC: 30698-0144-01
HECTOROL CAPSULES 0.5 MCG, NDC: 58468-0120-01
ZEMPLAR CAPSULES 1 MCG, NDC: 00074-4317-30
CALCITRIOL ORAL SOLUTION 1MCG/ML, NDC: 00054-3120-41
ROCALTROL ORAL SOLUTION 1MCG/ML, NDC: 30698-0911-15
HECTOROL CAPSULES 1 MCG, NDC: 58468-0124-01
BACTRIM TABLET 800MG, NDC: 53746-0282-01
CIPROFLOXACIN TABLET 750MG, NDC: 16252-0516-05
ZEMPLAR CAPSULES 2 MCG, NDC: 00074-4314-30
HECTOROL CAPSULES 2.5 MCG, NDC: 58468-0121-01
BLOOD GLUCOSE TEST 1 EA
ZEMPLAR CAPSULES 4 MCG, NDC: 00074-4315-30
LAB, BLD COUNT, RETICULOCYTE, AUTO
RYTHUM STRIP ONE 1 EA
LAB, UREA NITROGEN, URINE
LAB, CREATININE, OTHER SOURCE
FLU VACCINE, 6-35 MONTHS 1 EA
FLU VACCINE, 3 YEARS AND ABOVE 1 EA
LAB, BLD COUNT, RETICULOCYTE, CHR, AUTO
LAB, IRON
TB TEST PERCUTANEOUS (INTRADERMAL)
LAB, CULTURE, ID DEFINITIVE, ANAEROBIC
LAB, CULTURE, ID DEFINITIVE, AEROBIC
LAB, CULTURE, OTHER, BACTERIAL
DRESSING CHANGE
LAB, IRON BINDING CAPACITY
LAB, CULTURE, NON BLD, BACTERIAL
LAB, CULTURE, BLD, BACTERIAL
LAB, HBSAG, EIA
LAB, HBSAB
LAB, HBCAB, IGM
PNEUMOCOCCAL VACCINE INJ. 1 EA
LAB, HBCAB, TOTAL
LAB, TRANSFERRIN
LAB, FERRITIN
LAB, PREALBUMIN
LAB, FOLIC ACID, SERUM
LAB, VITAMIN B12
LAB, CARNITINE, TOTAL AND FREE
LAB, ERYTHROPOIETIN
LAB, ALUMINUM
LAB, VITAMIN D, 25 HYDROXY
EKG 1 EA
BIOZ ICG MONITOR - TEST
LAB, VITAMIN D, 1, 25 DIHYDROXY
LAB, PARATHORMONE
TRANSONIC MONITORING
HOME HEMO CLINIC VISIT
ENGERIX 40 MCG
CAPD MONTHLY VISIT
CCPD MONTHLY VISIT
RECOMBIVAX 40 MCG
LIPID APHERESIS
CAPD
CCPD
CAPD, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
CCPD, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
CAPD, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
CCPD, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HEMODIALYSIS 1 EA
BACK UP HEMO TREATMENT
HEMODIALYSIS SELF CARE 1 EA
IPD; DAILY TREATMENT
HEMODIALYSIS ULTRAFILTRATION 1 EA
HEMODIALYSIS ULTRAFILTRATION 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HOME HEMO DIALYSIS
HEMO SELF CARE TRAINING 1 EA
NOCTURNAL HEMODIALYSIS
HOME HEMO TRAINING 1 EA
CAPD TRN, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
CCPD TRN, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HOME HEMO DIALYSIS, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
CAPD TRN
CCPD TRN
CAPD TRN, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
CCPD TRN, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HOME HEMO DIALYSIS, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HEMO SELF CARE TRAINING 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HEMODIALYSIS 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
BACK UP HEMO TREATMENT, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HEMODIALYSIS SELF CARE 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
IPD; DAILY TREATMENT, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HEMO SELF CARE TRAINING 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HOME HEMO TRAINING 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
HEMODIALYSIS 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
BACK UP HEMO TREATMENT, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HEMODIALYSIS SELF CARE 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
IPD; DAILY TREATMENT, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
HOME HEMO TRAINING 1 EA, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
NOCTURNAL HEMODIALYSIS, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, AND INJECTABLE VITAMIN D
NOCTURNAL HEMODIALYSIS, DLYS TX RATE INCLUDES TX, ANEMIA MGMT DRUGS, INJECTABLE VITAMIN D AND LABS
ADRENALIN EPINEPHRINE 0.1 MG
HYPERTONIC SALINE 1 ML
CANNULA, NASAL W/TUBING(OXYG ADMIN) 1 EA
MEFOXIN, CEFOXITIN SODIUM 1 G
ALBUMIN 5% 50 ML
ATROPINE SULFATE 0.3 MG
FERRLECIT 12.5 MG
ATIVAN 2 MG
ZINACEF (CEFUROXIME) 750 MG 750 MG
CEFOTAXIME, CLAFORAN 1 G
EXTRANEAL, ICODEXTRIN 500 ML
FABRAZYME, AGALSIDASE BETA 1 MG
ROCEPHIN 250 MG
VANCOMYCIN 500 MG
MICAFUNGIN SODIUM, MYCAMINE 1 MG
MORPHINE 10 MG
HYDRALAZINE HCL, APRESOLINE 20 MG
HECTOROL 1 MCG
DILAUDID (HYDROMORPHONE) 4 MG
DIMENHYDRINATE 50 MG
VALIUM, DIAZEPAM 5 MG
CEFEPIME HCL 500MG
OXYGEN GASEOUS, PORTABLE, RENTAL 1 EA
OXYGEN, GASEOUS, STATIONARY 1 EA
OXYGEN GASEOUS, PORTABLE, OWNED 1 EA
DEXFERRUM 50 MG
ARGATROBAN 5 MG
STERILE H20 10ML(TO DILUTE DRUGS)
PRIMAXIN 250 MG
BENADRYL 50 MG
EPOGEN <10,000 100 UT
                                            EPOGEN >10,000 100 UT
VITAMIN B-12 1000 MCG
POTASSIUM CHLORIDE, KCL 2 MEQ
CALCIUM GLUCONATE 10 ML
NANDROLONE DECANOATE 50 MG
ARIXTRA, FONDAPARINUX SODIUM .5 MG 0.5 MG
REGLAN 10 MG
GENTAMICIN SULFATE 80 MG
DESFERAL 500 MG
ERTAPENEM SODIUM 500 MG
ANCEF 500 MG
HEPARIN PORK 1000 UT
HYDROXYZINE 25 MG
INFED 50 MG
ONDANSETRON OR ZOFRAN 1 MG
TIGAN 200 MG
MANNITOL 50 ML
SOLU MEDROL 125 MG
TESTOSTERONE 100 MG
VITAMIN K 1 MG
CALCITRIOL OR CALCIJEX 0.1 MCG
CUBICIN, DAPTOMYCIN 1 MG 1 MG
OXACILLIN SODIUM 250 MG
AMPHOTERICIN B 50 MG
CIPRO 200 MG
PHENERGAN 50 MG
AMIKACIN SULFATE 100 MG
CANCIDAS, CASPOFUNGIN ACETATE 5 MG
HYPERTONIC SALINE 20 CC
KEFLIN 1 G
HALOPERIDOL 50 MG
HEPARIN BEEF 1000 UT
ACTIVASE (ALTEPLASE RECOMBINANT) 1 MG
CARNITOR 1 G
TALWIN 30 MG
LANOXIN 0.5 MG
ZYVOX, LINEZOLID 200 MG
AMPICILLIN 500 MG
ZOSYN 1 G
NARCAN 1 MG
ARANESP (DARBEPOETIN ALFA) 1 MCG
DEXTROSE 500 ML
REFLUDAN 50 MG
CYTOXAN, CYCLOPHOSPHAMIDE 100 MG
MERREM, MEROPENEM 100 MG
TORADOL IV 15 MG
LUMINAL SODIUM, NEMBUTAL SODIUM 120 MG
UROKINASE 5000 UT
FERUMOXYTOL, FERAHEME
LOVENOX, ENOXAPARIN SODIUM 10 MG
ADMIN DRUG
IV SOLUTION ADMINISTRATION 1 EA
FLU VACCINE, 3 YEARS AND ABOVE - AFLURIA 1 EA
FLU VACCINE, 3 YEARS AND ABOVE - FLULAVAL 1 EA
FLU VACCINE, 3 YEARS AND ABOVE - FLUVIRIN 1 EA
FLU VACCINE, 3 YEARS AND ABOVE - FLUZONE 1 EA
FLU VACCINE, 3 YEARS AND ABOVE - NOS 1 EA
SOLU MEDROL 40 MG
MAGNESIUM SULFATE 500 MG
TOBRAMYCIN SULFATE 80 MG
FORTAZ 500 MG
INAPSINE 5 MG
UNASYN 1.5 G
CEFIZOX 500 MG
PROTAMINE SULFATE 10 MG
LEVAQUIN 250 MG
COMPAZINE (PROCHLORPERAZINE) 10 MG
ADMIN FLU 1 EA
ADMIN PNEUMOCOCCAL 1 EA
ADMIN HEPATITIS
ZEMPLAR 1 MCG
DILANTIN 50 MG
TEQUIN (GATIFLOXACIN) 10 MG
STREPTOMYCIN 1 G
DIFLUCAN 200 MG
ERYTHROMYCIN LACTOBINATE 500 MG
VENOFER (IRON SUCROSE INJECTION) 1 MG
HOME EPOGEN <10,000 100 UT
HOME EPOGEN EMERGENCY RESERVE <10,000 100 UT
HOME EPOGEN >10,000 100 UT
HOME EPOGEN EMERGENCY RESERVE >10,000 100 UT
HOME ARANESP (DARBEPOETIN ALFA) 1 MCG
HOME ARANESP (DARBEPOETIN ALFA) EMERGENCY RESERVE 1 MCG
                                                                  2/16/2012


                                                                  OTC-4965
                                                    Southwest Oncology Centers-Yuma, LLC


                                                           1951 W. 25th St., Suite F
                                                                    Yuma
                                                                      AZ
                                                                    85364
                                                                    Yuma
                                                           1951 W. 25th St., Suite F
                                                                    Yuma
                                                                      AZ
                                                                    85364
                                                                928-317-9200
                                                                 1710201223
                                                                   540528
                                                                     yes
                                                                    140671
                                                               Tami Alexander
                                                                760-912-1878
                                                      talexander@healthwestpartners.net
                                                                 David Cohen
                                                                818-879-9600
                                                           healthwest@earthlink.net
                                                               Tami Alexander
                                                                760-912-1878
                                                      talexander@healthwestpartners.net
                                                                  25-Nov-11


Rate of Charge           Service Code                    Discription of Charge


                 0.41       G0173       RAD TX:STEREOTACTIC RAD SURG THERP
                  1.01      0182T       RAD TX:XOFT BRACHYTHERAPY PER FRACT
                  1.01      G0251       RAD TX:STEREO RADSURG PER SESSION
                  1.11      G0339       RAD TX:STEREO RADSURG THERP 1/1ST S
                 1.34       G0340       RAD TX:STEREO RADSURG PER SES 2-5
                 1.72       J9217       SUP:LEUPROLIDE ACETATE 7.5MG (LUPRO
                  1.81      77013       CT:GUIDE FOR TISSUE ABLATION
                 2.07       77014       CT:SCAN FOR RADIATION THERAPY GUIDE
                 2.15       77261       RAD TX:RADIATION THERAPY PLANNING
                 2.82       77262       RAD TX:RADIATION THERAPY PLANNING
                 9.57       77263       RAD TX:RADIATION THERAPY PLANNING
                 11.66      77280       RAD TX:SET RADIATION THERAPY FIELD
 12.82   77285   RAD TX:SET RADIATION THERAPY FIELD
 15.21   77290   RAD TX:SET RADIATION THERAPY FIELD
 18.87   77295   RAD TX:SET RADIATION THERAPY FIELD
 19.12   77300   RAD TX:RADIATION THERAPY DOSE PLAN
 21.57   77301   RAD TX:RADIOTHERAPY DOSE PLAN IMRT
 22.87   77315   RAD TX:TELETX ISODOSE PLAN COMPLEX
 26.13   77326   RAD TX:BRACHYTX ISODOSE CALC SIMP
 43.35   77331   RAD TX:SPECIAL RADIATION DOSIMETRY
 45.30   77334   RAD TX:RADIATION TREATMENT AID(S)
 51.66   77336   RAD TX:RADIATION PHYSICS CONSULT
 53.70   77338   RAD TX:MLC FOR IMRT PER IMRT PLAN
 61.20   77370   RAD TX:RADIATION PHYSICS CONSULT
 66.69   77372   RAD TX:SRS CERBR LESN ACCELRATR BAS
 67.60   77373   RAD TX:STEROTACTIC TRMT- PER 1+LESN
 67.60   77413   RAD TX:RADIATION TREATMENT DELIVERY
 71.91   77418   RAD TX:RADIATION TX DELIVERY IMRT
 83.52   77427   RAD TX:RADIATION TX MANAGEMENT X5
 87.05   77432   RAD TX:STEREOTACTIC RADIATION TRMT
104.13   77435   RAD TX:STEROTACTIC MGMT- PER 1+LESN
104.13   77470   RAD TX:SPECIAL RADIATION TREATMENT
111.06   96402   SURG PROC:CHEMO INJ SUBCUT/INTRAMUS
 112.3   99201   EVAL & MGMT:OV OR OP VISIT NEW PATI
112.68   99202   EVAL & MGMT:OV OR OP VISIT NEW PATI
121.95   99203   EVAL & MGMT:OV OR OP VISIT NEW PATI
133.11   99204   EVAL & MGMT:OV OR OP VISIT NEW PATI
133.11   99205   EVAL & MGMT:OV OR OP VISIT NEW PATI
138.42   99211   EVAL & MGMT:OV EST CONSULT LEVEL 1
151.74   99212   EVAL & MGMT:OV EST CONSULT LEVEL 2
154.45   99213   EVAL & MGMT:OV EST CONSULT LEVEL 3
155.34   99214   EVAL & MGMT:OV EST CONSULT LEVEL 4
164.61   99215   EVAL & MGMT:OV EST CONSULT LEVEL 5
175.59   99241   EVAL & MGMT:OFFICE CONSULTATION 1
188.01   99242   EVAL & MGMT:OFFICE CONSULTATION 2
189.54   99243   EVAL & MGMT:OFFICE CONSULTATION 3
194.31   99244   EVAL & MGMT:OFFICE CONSULTATION 4
217.44
224.80
328.41
381.60
461.05
480.15
496.26
532.08
632.35
  1296.2
 1411.60
 1533.95
 1533.95
2530.35
30682.15
    1711
    1711
   2021
   2021
 2105.00
 2105.00
   2785
   2785
   2785
   2785
   2785
2884.00
   3068
   3163
   3620
   3898
4047.00
4047.00
4065.00
   4065
   4065
 4131.00
 4131.00
 4194.00
 4714.00
 4714.00
 4714.00
 4714.00
 4714.00
4843.00
4845.00
4937.00
4937.00
4937.00
4937.00
4974.00
5422.00
5645.00
           0.95
           1.80
          10.05
         104.40
         108.95
          11.70
         112.50
         113.20
         117.40
         118.25
          120.8
        1268.60
         127.05
         133.10
          14.70
          14.90
         146.05
         149.30
          15.10
          16.35
          16.35
          16.70
          161.8
          161.8
          161.8
         164.70
         165.90
          17.55
         170.75
          18.10
          18.35
18.35
           2.40
           2.50
         20.90
          21.25
         216.30
         22.35
         23.70
        233.30
        240.65
         25.05
          25.15
         25.65
255.05
275.00
 28.85
 28.90
 28.90
 29.55
 29.55
 29.85
  3.55
 31.35
310.90
320.50
 33.60
 34.55
345.35
 35.00
 36.55
385.55
 39.50
401.95
404.95
 41.15
 41.35
416.15
 45.50
 48.45
 53.70
 53.80
 54.85
558.45
 56.25
 57.50
 58.25
 58.90
596.30
  6.15
 63.90
  67.5
  67.5
 67.60
 67.60
 67.60
 67.60
 67.60
  7.25
  7.90
70.35
75.35
75.85
77.75
78.35
  8.60
834.15
88.60
88.85
88.85
88.85
89.55
  9.20
  9.30
90.50
913.35
95.50
  9.00
 18.35
 18.35
 18.35
 18.35
53.80
53.80
                                                                              2/16/2012


                                                                              OTC- 4028
a, LLC                                                        Southwest PET/CT Institute - Yuma


                                                                   1951 W. 25th Street, Ste G
                                                                                Yuma
                                                                               Arizona
                                                                                85364


                                                                   1951 W. 25th Street, Ste G
                                                                                Yuma
                                                                                 AZ
                                                                                85364
                                                                             928-314-4800
                                                                              103316759
                                                                                991712
                                                                                 Yes
                                                                               Z106077
                                                                          Tami Alexander
                                                                             760-912-1878
net                                                              talexander@healthwestpartners
                                                                             David Cohen
                                                                             818-879-9600
                                                                    Healthwest@earthlink.net
                                                                          Tami Alexander
                                                                             760-912-1878
.net                                                             talexander@healthwestpartners
                                                                               1/1/2012


             Rate of Charge       Service Code                    Discription of Charge               Rate of Charge


         $            6,700.00      A9552        FDG-18                                           $              450.00
         $            4,350.00      A9580        Sodium Fluoride F18                              $              450.00
         $             1,800.00      78814       Ltd. PET/CT Tumor Imaging                        $             6,051.00
         $            6,700.00       78815       PET/CT Tumor Imaging Skull-Thigh                 $            6,087.00
         $            4,700.00       78816       PET/CT Tumor Imaging Full Body                   $            6,096.00
         $              300.00       70450       CT: Head/Brain w/o Dye                           $              720.00
         $             1,366.00      70460       CT: Head/Brain w/ dye                            $              882.00
         $              546.00       70470       CT: Head/Brain w/o + w/ dye                      $             1,080.00
         $              219.00       70480       CT: Orbit/Ear/Fossa w/o Dye                      $              789.00
         $              331.00       70481       CT: Orbit/Ear/Fossa w/ Dye                       $              921.00
         $              491.00       70482       CT: Orbit/Ear/Fossa w/o + w/ Dye                 $             1,107.00
         $              538.00       70486       CT: Maxillofacial w/o Dye                        $              765.00
$    455.00    70487   CT: Maxillofacial w/ Dye                  $    909.00
$   1,476.00   70488   CT: Maxillofacial w/o + w/ Dye            $   1,101.00
$   1,788.00   70490   CT: Soft Tissue Neck w/o Dye              $    789.00
$    207.00    70491   CT: Soft Tissue Neck w/ Dye               $     921.00
$   6,496.00   70492   CT: Soft Tissue Neck w/o + w Dye          $   1,107.00
$    705.00    70496   CTA: Angio Head                           $   1,596.00
$    430.00    70498   CTA: Angio Neck                           $   1,596.00
$    240.00    71250   CT: Thorax w/o Dye                        $     918.00
$    455.00    71260   CT: Thorax w/ Dye                         $   1,074.00
$     160.00   71270   CT: Thorax w/o + w/ Dye                   $   1,317.00
$    633.00    71275   CT: Angio Chest                           $   1,821.00
$    333.00    72125   CT: Neck Spine w/o Dye                    $     918.00
$   2,411.00   72126   CT: Neck Spine w/ Dye                     $   1,071.00
$   2,411.00   72127   CT: Neck Spine w/o + w/ Dye               $   1,302.00
$    633.00    72128   CT: Chest Spine w/o Dye                   $     918.00
$   1,500.00   72129   CT: Chest Spine w/ Dye                    $   1,071.00
$    588.00    72130   CT: Chest Spine w/o + w/ Dye              $   1,302.00
$   1,242.00   72131   CT: Lumbar Spine w/o Dye                  $     918.00
$   2,062.00   72132   CT: Lumbar Spine w/ Dye                   $   1,071.00
$    579.00    72133   CT: Lumbar Spine w/o + w/ Dye             $   1,302.00
$     100.00   72191   CT: Angio Pelv w/o + w/ Dye               $   1,761.00
$     118.00   72192   CT: Pelvis w/o Dye                        $    909.00
$    203.00    72193   CT: Pelvis w/ Dye                         $   1,035.00
$    295.00    72194   CT: Pelvis w/o + w/ Dye                   $   1,245.00
$    459.00    73200   CT: Upper Extremity w/o Dye               $    789.00
$    576.00    73201   CT: Upper Extremity w/ Dye                $     918.00
$     58.00    73202   CT: Upper Extremity w/o + w/ Dye          $   1,116.00
$     118.00   73206   CTA: Angio Upper Extremity w/o + w/ Dye   $   1,632.00
$     197.00   73700   CT: Lower Extremity w/o Dye               $    789.00
$    296.00    73701   CT: Lower Extremity w/ Dye                $     918.00
$    400.00    73702   CT: Lower Extremity w/o + w/ Dye          $   1,116.00
$     118.00   73706   CTA: Angio Lower Extremity w/o + w/ Dye   $   1,647.00
$    203.00    74150   CT: ABD w/o Dye                           $     891.00
$    295.00    74160   CT: ABD w/ Dye                            $   1,160.00
$    459.00    74170   CT: ABD w/o + w/ Dye                      $   1,275.00
               74175   CTA: Angio ABD w/o + w Dye                $   1,776.00
               74176   CT: ABD + Pelvis w/o Dye                  $    640.00
               74177   CT: ABD + Pelvis w/ Dye                   $   1,005.00
               74178   CT: ABD + Pelvis w/o + w/ Dye             $   1,272.00
               75635   CTA: Angio ABD Arteries                   $   2,322.00
               77014   CT: Scan for Radiation Therapy Guide TC   $    546.00
               78459   PET: Heart Muscle Imaging                 $   5,493.00
               78608   PET: Brain Imaging                        $   5,787.00
               Q9967   SUP: LOCM 300-399 MG/ML                   $     50.00
                                               2/17/2011


                                                OTC-3908
                               Sunset Community Health Center, Inc Yuma


                                             2060 W 24th St
                                                  Yuma
                                                   AZ
                                                  85364


                                             2060 W 24th St
                                                  Yuma
                                                   AZ
                                                  85364
                                              928-819-8999
                                               1063433720
                                                 433061
                                                   YES
                                               1063433720
                                               David Rogers
                                              928-819-8802
                                          drogers@sunset-chc.org
                                              Whitney Sims
                                              928-819-8803
                                          wsims@sunset-chc.org
                                              Shaunna Ruis
                                              928-373-6187
                                          sruis@sunset-chc.org




Service Code                           Discription of Charge                  Rate of Charge


   11900       INJECTION INTO SKIN LESIONS                                $              30.00
   11900       INJECTION INTO SKIN LESIONS                                $              82.00
   11901       ADDED SKIN LESIONS INJECTION                               $             102.00
   11901       ADDED SKIN LESIONS INJECTION                               $             102.00
   11975       INSERT CONTRACEPTIVE CAP                                   $             525.00
   11975       INSERT CONTRACEPTIVE CAP                                   $             150.00
   11976       REMOVAL OF CONTRACEPTIVE CAP                               $             200.00
   11976       REMOVAL OF CONTRACEPTIVE CAP                               $             241.00
   11977       REMOVAL/REINSERT CONTRA CAP                                $             380.00
   11977       REMOVAL/REINSERT CONTRA CAP                                $             405.00
   12001       REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, S/N/T/E            $             105.00
   12001       REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, S/N/T/E            $             247.00
12002   REPAIR SUPERFICIAL WOUND(S)2.6-7.5CM                 $    145.00
12002   REPAIR SUPERFICIAL WOUND(S)2.6-7.5CM                 $    262.00
12011   REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, F/E/EYE/N/   $    125.00
12011   REPAIR SUPERFICIAL WOUND(S)2.5 OR LESS, F/E/EYE/N/   $    261.00
12013   REPAIR SUPERFICIAL WOUND(S) 2.6-5.0 CM               $    190.00
12013   REPAIR SUPERFICIAL WOUND(S) 2.6-5.0 CM               $    287.00
12021   CLOSURE OF SPLIT WOUND, W/PACKING                    $    175.00
13132   REPAIR OF WOUND OR LESION                            $    856.00
13160   LATE CLOSURE OF WOUND                                $    805.00
13160   LATE CLOSURE OF WOUND                                $   1,322.00
15833   EXCISE EXCESSIVE SKIN TISSUE                         $   1,250.00
15850   REMOVAL OF SUTURES                                   $    107.00
15850   REMOVAL OF SUTURES                                   $    125.00
16020   DRESS/DEBRID P-THICK BURN, S                         $     75.00
16020   DRESS/DEBRID P-THICK BURN, S                         $    140.00
17000   DESTRUCT PREMALG LESION                              $     83.00
17000   DESTRUCT PREMALG LESION                              $     114.00
17003   DESTRUCT PREMALG LES, 2-14                           $      11.00
17110   DESTRUCT B9 LESION, 1-14                             $    134.00
17110   DESTRUCT B9 LESION, 1-14                             $    157.00
17250   CHEMICAL CAUTERY, TISSUE                             $     75.00
17340   CRYOTHERAPY OF SKIN                                  $     58.00
17340   CRYOTHERAPY OF SKIN                                  $     74.00
19000   DRAINAGE OF BREAST LESION                            $     51.00
19000   DRAINAGE OF BREAST LESION                            $    189.00
19020   INCISION OF BREAST LESION                            $    480.00
19103   BX BREAST PERCUT W/DEVICE                            $    538.38
19120   REMOVAL OF BREAST LESION                             $    850.00
19120   REMOVAL OF BREAST LESION                             $    850.00
20526   THER INJECTION, CARP TUNNEL                          $     75.00
20550   INJ TENDON SHEATH/LIGAMENT                           $     65.00
20550   INJ TENDON SHEATH/LIGAMENT                           $     99.00
20552   INJ TRIGGER POINT, 1/2 MUSCL                         $     75.00
20600   DRAIN/INJECT, JOINT/BURSA                            $     38.00
20600   DRAIN/INJECT, JOINT/BURSA                            $     91.00
20605   DRAIN/INJECT, JOINT/BURSA                            $     61.50
20605   DRAIN/INJECT, JOINT/BURSA                            $     99.00
20610   DRAIN/INJECT, JOINT/BURSA                            $     85.00
20610   DRAIN/INJECT, JOINT/BURSA                            $    123.00
23500   TREAT CLAVICLE FRACTURE                              $    321.00
23500   TREAT CLAVICLE FRACTURE                              $    343.00
24530   TREAT HUMERUS FRACTURE                               $    503.00
24530   TREAT HUMERUS FRACTURE                               $    604.00
25530   TREAT FRACTURE OF ULNA                               $    471.00
25530   TREAT FRACTURE OF ULNA         $   471.00
25560   TREAT FRACTURE RADIUS & ULNA   $   437.00
25560   TREAT FRACTURE RADIUS & ULNA   $   471.00
25600   TREAT FRACTURE RADIUS/ULNA     $   200.00
25600   TREAT FRACTURE RADIUS/ULNA     $   466.00
25680   TREAT WRIST FRACTURE           $   650.00
25680   TREAT WRIST FRACTURE           $   745.00
26600   TREAT METACARPAL FRACTURE      $   302.00
26600   TREAT METACARPAL FRACTURE      $   423.00
27780   TREATMENT OF FIBULA FRACTURE   $   360.00
27780   TREATMENT OF FIBULA FRACTURE   $   475.00
27816   TREATMENT OF ANKLE FRACTURE    $   579.00
27816   TREATMENT OF ANKLE FRACTURE    $   591.00
28190   REMOVAL OF FOOT FOREIGN BODY   $   217.80
28190   REMOVAL OF FOOT FOREIGN BODY   $   378.00
28400   TREATMENT OF HEEL FRACTURE     $   514.00
28400   TREATMENT OF HEEL FRACTURE     $   404.00
28470   TREAT METATARSAL FRACTURE      $   350.00
28470   TREAT METATARSAL FRACTURE      $   395.00
29055   APPLICATION OF SHOULDER CAST   $   270.00
29055   APPLICATION OF SHOULDER CAST   $   331.00
29065   APPLICATION OF LONG ARM CAST   $   180.00
29065   APPLICATION OF LONG ARM CAST   $   215.00
29075   APPLICATION OF FOREARM CAST    $   105.00
29075   APPLICATION OF FOREARM CAST    $   141.00
29085   APPLY HAND/WRIST CAST          $   151.00
29085   APPLY HAND/WRIST CAST          $   185.00
29105   APPLY LONG ARM SPLINT          $    45.00
29105   APPLY LONG ARM SPLINT          $   125.00
29105   APPLY LONG ARM SPLINT          $   143.00
29125   APPLY FOREARM SPLINT           $    40.00
29125   APPLY FOREARM SPLINT           $   110.00
29130   APPLICATION OF FINGER SPLINT   $    30.00
29130   APPLICATION OF FINGER SPLINT   $    66.00
29405   APPLY SHORT LEG CAST           $   135.00
29405   APPLY SHORT LEG CAST           $   145.00
29425   APPLY SHORT LEG CAST           $    84.00
29425   APPLY SHORT LEG CAST           $   156.00
29515   APPLICATION LOWER LEG SPLINT   $    75.00
29515   APPLICATION LOWER LEG SPLINT   $   112.00
29540   STRAPPING OF ANKLE AND/OR FT   $    55.00
29540   STRAPPING OF ANKLE AND/OR FT   $    66.00
29580   APPLICATION OF PASTE BOOT      $    70.00
29580   APPLICATION OF PASTE BOOT      $    84.00
29590   APPLICATION OF FOOT SPLINT     $      71.00
29590   APPLICATION OF FOOT SPLINT     $     89.00
30300   REMOVE NASAL FOREIGN BODY      $     48.00
30300   REMOVE NASAL FOREIGN BODY      $    376.00
30901   CONTROL OF NOSEBLEED           $     42.00
30901   CONTROL OF NOSEBLEED           $     172.00
36000   PLACE NEEDLE IN VEIN           $     75.00
36415   ROUTINE VENIPUNCTURE           $       5.00
36415   ROUTINE VENIPUNCTURE           $       8.00
36556   INSERT NON-TUNNEL CV CATH      $     120.00
36556   INSERT NON-TUNNEL CV CATH      $     135.00
36571   INSERT PICVAD CATH             $   2,865.00
36571   INSERT PICVAD CATH             $   2,950.00
38500   BIOPSY/REMOVAL, LYMPH NODES    $     517.00
44005   FREEING OF BOWEL ADHESION      $    800.00
44005   FREEING OF BOWEL ADHESION      $   1,736.00
44140   PARTIAL REMOVAL OF COLON       $   1,300.00
44180   LAP, ENTEROLYSIS               $   2,974.00
44180   LAP, ENTEROLYSIS               $   2,974.00
44955   APPENDECTOMY ADD-ON            $     125.00
45330   DIAGNOSTIC SIGMOIDOSCOPY       $    225.00
45330   DIAGNOSTIC SIGMOIDOSCOPY       $    345.00
45562   EXPLORATION/REPAIR OF RECTUM   $   2,080.00
45562   EXPLORATION/REPAIR OF RECTUM   $   2,250.00
45915   REMOVE RECTAL OBSTRUCTION      $    452.00
45915   REMOVE RECTAL OBSTRUCTION      $    507.00
46083   INCISE EXTERNAL HEMORRHOID     $     112.00
46083   INCISE EXTERNAL HEMORRHOID     $    266.00
46600   DIAGNOSTIC ANOSCOPY            $     35.00
46600   DIAGNOSTIC ANOSCOPY            $     138.00
46922   EXCISION OF ANAL LESION(S)     $    345.00
46922   EXCISION OF ANAL LESION(S)     $    367.00
46935   DESTRUCTION OF HEMORRHOIDS     $    292.00
46935   DESTRUCTION OF HEMORRHOIDS     $    405.00
47563   LAPARO CHOLECYSTECTOMY/GRAPH   $   2,750.00
47563   LAPARO CHOLECYSTECTOMY/GRAPH   $   2,850.00
49000   EXPLORATION OF ABDOMEN         $    900.00
49000   EXPLORATION OF ABDOMEN         $   1,234.00
49002   REOPENING OF ABDOMEN           $   2,450.00
49002   REOPENING OF ABDOMEN           $   2,750.00
49200   REMOVAL OF ABDOMINAL LESION    $   2,385.00
49200   REMOVAL OF ABDOMINAL LESION    $   2,650.00
49203   EXC ABD TUM 5 CM OR LESS       $   2,500.00
49255   REMOVAL OF OMENTUM             $    750.00
49320   DIAG LAPARO SEPARATE PROC      $    989.00
49320   DIAG LAPARO SEPARATE PROC      $   1,150.00
49321   LAPAROSCOPY, BIOPSY            $   1,055.00
49321   LAPAROSCOPY, BIOPSY            $   1,225.00
49322   LAPAROSCOPY, ASPIRATION        $     613.00
49323   LAPARO DRAIN LYMPHOCELE        $   1,990.00
49323   LAPARO DRAIN LYMPHOCELE        $   2,110.00
49560   RPR VENTRAL HERN INIT, REDUC   $   1,180.00
49585   RPR UMBIL HERN, REDUC > 5 YR   $    980.00
49585   RPR UMBIL HERN, REDUC > 5 YR   $   1,205.00
50400   REVISION OF KIDNEY/URETER      $     130.00
50400   REVISION OF KIDNEY/URETER      $   1,986.00
50785   REIMPLANT URETER IN BLADDER    $   1,765.85
50785   REIMPLANT URETER IN BLADDER    $   2,072.00
51600   INJECTION FOR BLADDER X-RAY    $     210.00
51600   INJECTION FOR BLADDER X-RAY    $    384.00
51700   IRRIGATION OF BLADDER          $     42.00
51700   IRRIGATION OF BLADDER          $     165.00
51701   INSERT BLADDER CATHETER        $     120.00
51701   INSERT BLADDER CATHETER        $     132.00
51702   INSERT TEMP BLADDER CATH       $     120.00
51702   INSERT TEMP BLADDER CATH       $     165.00
51726   COMPLEX CYSTOMETROGRAM         $    545.00
51726   COMPLEX CYSTOMETROGRAM         $    375.00
51727   CYSTOMETROGRAM W/UP            $     315.00
51729   CYSTOMETROGRAM W/VP&UP         $    350.00
51736   URINE FLOW MEASUREMENT         $     97.00
51736   URINE FLOW MEASUREMENT         $     85.00
51741   ELECTRO-UROFLOWMETRY, FIRST    $     121.00
51741   ELECTRO-UROFLOWMETRY, FIRST    $     125.00
51772   URETHRA PRESSURE PROFILE       $    425.00
51772   URETHRA PRESSURE PROFILE       $    300.00
51795   URINE VOIDING PRESSURE STUDY   $    525.00
51795   URINE VOIDING PRESSURE STUDY   $    350.00
51797   INTRAABDOMINAL PRESSURE TEST   $    228.00
51797   INTRAABDOMINAL PRESSURE TEST   $    439.00
51797   INTRAABDOMINAL PRESSURE TEST   $    250.00
51798   US URINE CAPACITY MEASURE      $     40.00
51840   ATTACH BLADDER/URETHRA         $   1,025.00
51840   ATTACH BLADDER/URETHRA         $   1,150.00
51845   REPAIR BLADDER NECK            $   2,290.00
51845   REPAIR BLADDER NECK            $   3,005.00
51865   REPAIR OF BLADDER WOUND        $   3,047.00
51865   REPAIR OF BLADDER WOUND        $   3,075.00
51990   LAPARO URETHRAL SUSPENSION     $   2,420.00
51990   LAPARO URETHRAL SUSPENSION     $   2,475.00
52000   CYSTOSCOPY                     $    326.00
52000   CYSTOSCOPY                     $    378.00
53230   REMOVAL OF URETHRA LESION      $   1,838.00
53230   REMOVAL OF URETHRA LESION      $   1,975.00
53270   REMOVAL OF URETHRA GLAND       $    809.00
53270   REMOVAL OF URETHRA GLAND       $    925.00
54150   CIRCUMCISION W/REGIONL BLOCK   $    300.00
54150   CIRCUMCISION W/REGIONL BLOCK   $    300.00
54152   CIRCUMCISION                   $     170.00
54152   CIRCUMCISION                   $    200.00
56405   I & D OF VULVA/PERINEUM        $     190.00
56405   I & D OF VULVA/PERINEUM        $     215.00
56420   DRAINAGE OF GLAND ABSCESS      $    205.00
56420   DRAINAGE OF GLAND ABSCESS      $    239.00
56440   SURGERY FOR VULVA LESION       $    545.00
56440   SURGERY FOR VULVA LESION       $    555.00
56501   DESTROY, VULVA LESIONS, SIM    $    200.00
56501   DESTROY, VULVA LESIONS, SIM    $    226.00
56515   DESTROY VULVA LESION/S COMPL   $    539.00
56515   DESTROY VULVA LESION/S COMPL   $    574.00
56605   BIOPSY OF VULVA/PERINEUM       $     160.00
56605   BIOPSY OF VULVA/PERINEUM       $     174.00
56606   BIOPSY OF VULVA/PERINEUM       $     111.00
56606   BIOPSY OF VULVA/PERINEUM       $     127.00
56700   PARTIAL REMOVAL OF HYMEN       $     315.00
56740   REMOVE VAGINA GLAND LESION     $    703.00
56740   REMOVE VAGINA GLAND LESION     $    722.00
56810   REPAIR OF PERINEUM             $   1,080.00
56810   REPAIR OF PERINEUM             $   1,125.00
56820   EXAM OF VULVA W/SCOPE          $    242.00
56820   EXAM OF VULVA W/SCOPE          $    265.00
57000   EXPLORATION OF VAGINA          $    690.00
57000   EXPLORATION OF VAGINA          $    735.00
57010   DRAINAGE OF PELVIC ABSCESS     $   1,238.00
57010   DRAINAGE OF PELVIC ABSCESS     $   1,375.00
57020   DRAINAGE OF PELVIC FLUID       $     175.00
57020   DRAINAGE OF PELVIC FLUID       $    220.00
57022   I & D VAGINAL HEMATOMA, PP     $     410.00
57022   I & D VAGINAL HEMATOMA, PP     $    454.00
57061   DESTROY VAG LESIONS, SIMPLE    $    200.00
57061   DESTROY VAG LESIONS, SIMPLE    $    235.00
57065   DESTROY VAG LESIONS, COMPLEX   $    800.00
57065   DESTROY VAG LESIONS, COMPLEX   $    875.00
57100   BIOPSY OF VAGINA               $     175.00
57100   BIOPSY OF VAGINA               $     215.00
57105   BIOPSY OF VAGINA               $    296.00
57105   BIOPSY OF VAGINA               $     312.00
57120   CLOSURE OF VAGINA              $   1,718.00
57120   CLOSURE OF VAGINA              $   1,935.00
57130   REMOVE VAGINA LESION           $     615.00
57130   REMOVE VAGINA LESION           $    635.00
57135   REMOVE VAGINA LESION           $    520.00
57135   REMOVE VAGINA LESION           $    537.00
57160   INSERT PESSARY/OTHER DEVICE    $     120.00
57160   INSERT PESSARY/OTHER DEVICE    $     131.00
57170   FITTING OF DIAPHRAGM/CAP       $     120.00
57170   FITTING OF DIAPHRAGM/CAP       $     149.00
57210   REPAIR VAGINA/PERINEUM         $    722.00
57210   REPAIR VAGINA/PERINEUM         $    765.00
57220   REVISION OF URETHRA            $   1,076.00
57220   REVISION OF URETHRA            $   1,150.00
57240   REPAIR BLADDER & VAGINA        $    900.00
57240   REPAIR BLADDER & VAGINA        $   1,031.00
57250   REPAIR RECTUM & VAGINA         $    750.00
57250   REPAIR RECTUM & VAGINA         $   1,014.00
57260   REPAIR OF VAGINA               $   1,200.00
57260   REPAIR OF VAGINA               $   1,295.00
57265   EXTENSIVE REPAIR OF VAGINA     $   2,238.00
57265   EXTENSIVE REPAIR OF VAGINA     $   2,375.00
57267   INSERT MESH/PELVIC FLR ADDON   $   1,195.00
57268   REPAIR OF BOWEL BULGE          $   1,908.00
57268   REPAIR OF BOWEL BULGE          $   1,364.00
57280   SUSPENSION OF VAGINA           $   2,005.00
57280   SUSPENSION OF VAGINA           $   2,085.00
57282   COLPOPEXY, EXTRAPERITONEAL     $   1,921.00
57282   COLPOPEXY, EXTRAPERITONEAL     $   1,321.00
57283   COLPOPEXY, INTRAPERITONEAL     $    900.00
57284   REPAIR PARAVAG DEFECT, OPEN    $   3,088.00
57284   REPAIR PARAVAG DEFECT, OPEN    $   3,115.00
57287   REVISE/REMOVE SLING REPAIR     $   1,810.00
57287   REVISE/REMOVE SLING REPAIR     $   1,235.00
57288   REPAIR BLADDER DEFECT          $   3,640.00
57288   REPAIR BLADDER DEFECT          $   3,712.00
57300   REPAIR RECTUM-VAGINA FISTULA   $    750.00
57300   REPAIR RECTUM-VAGINA FISTULA   $    883.00
57320   REPAIR BLADDER-VAGINA LESION   $   1,200.00
57320   REPAIR BLADDER-VAGINA LESION   $   1,375.00
57410   PELVIC EXAMINATION             $    240.00
57410   PELVIC EXAMINATION             $    255.00
57420   EXAM OF VAGINA W/SCOPE         $     125.00
57452   EXAM OF CERVIX W/SCOPE         $     175.00
57452   EXAM OF CERVIX W/SCOPE         $     190.00
57454   BX/CURETT OF CERVIX W/SCOPE    $    200.00
57454   BX/CURETT OF CERVIX W/SCOPE    $     175.00
57455   BIOPSY OF CERVIX W/SCOPE       $     165.00
57456   ENDOCERV CURETTAGE W/SCOPE     $     150.00
57460   BX OF CERVIX W/SCOPE, LEEP     $    375.00
57460   BX OF CERVIX W/SCOPE, LEEP     $    568.00
57461   CONZ OF CERVIX W/SCOPE, LEEP   $   1,262.00
57461   CONZ OF CERVIX W/SCOPE, LEEP   $   1,347.00
57500   BIOPSY OF CERVIX               $     180.00
57500   BIOPSY OF CERVIX               $    245.00
57505   ENDOCERVICAL CURETTAGE         $    300.00
57505   ENDOCERVICAL CURETTAGE         $     125.00
57510   CAUTERIZATION OF CERVIX        $    289.00
57510   CAUTERIZATION OF CERVIX        $    327.00
57511   CRYOCAUTERY OF CERVIX          $     210.00
57511   CRYOCAUTERY OF CERVIX          $    254.00
57520   CONIZATION OF CERVIX           $    650.00
57520   CONIZATION OF CERVIX           $    650.00
57522   CONIZATION OF CERVIX           $    275.00
57700   REVISION OF CERVIX             $   1,108.00
57700   REVISION OF CERVIX             $   1,238.00
57720   REVISION OF CERVIX             $    325.00
57800   DILATION OF CERVICAL CANAL     $     121.00
57800   DILATION OF CERVICAL CANAL     $     148.00
58100   BIOPSY OF UTERUS LINING        $     185.00
58100   BIOPSY OF UTERUS LINING        $     193.00
58120   DILATION AND CURETTAGE         $     716.00
58120   DILATION AND CURETTAGE         $    865.00
58140   MYOMECTOMY ABDOM METHOD        $   1,500.00
58140   MYOMECTOMY ABDOM METHOD        $   1,560.00
58145   MYOMECTOMY VAG METHOD          $   1,440.00
58145   MYOMECTOMY VAG METHOD          $   1,625.00
58150   TOTAL HYSTERECTOMY             $   1,875.00
58150   TOTAL HYSTERECTOMY             $   1,875.00
58152   TOTAL HYSTERECTOMY             $   1,875.00
58152   TOTAL HYSTERECTOMY             $   2,150.00
58180   PARTIAL HYSTERECTOMY           $   4,755.00
58180   PARTIAL HYSTERECTOMY           $   4,755.00
58200   EXTENSIVE HYSTERECTOMY         $   5,938.00
58200   EXTENSIVE HYSTERECTOMY         $   6,120.00
58260   VAGINAL HYSTERECTOMY           $   2,795.00
58260   VAGINAL HYSTERECTOMY           $   2,795.00
58262   VAG HYST INCLUDING T/O         $   2,950.00
58262   VAG HYST INCLUDING T/O         $   2,950.00
58263   VAG HYST W/T/O & VAG REPAIR    $   3,002.00
58263   VAG HYST W/T/O & VAG REPAIR    $   3,045.00
58270   VAG HYST W/ENTEROCELE REPAIR   $   3,200.00
58290   VAG HYST COMPLEX               $   4,042.00
58290   VAG HYST COMPLEX               $   4,075.00
58291   VAG HYST INCL T/O, COMPLEX     $   4,350.00
58291   VAG HYST INCL T/O, COMPLEX     $   4,440.00
58300   INSERT INTRAUTERINE DEVICE     $     150.00
58300   INSERT INTRAUTERINE DEVICE     $     150.00
58301   REMOVE INTRAUTERINE DEVICE     $     150.00
58301   REMOVE INTRAUTERINE DEVICE     $     173.00
58340   CATHETER FOR HYSTEROGRAPHY     $     75.00
58340   CATHETER FOR HYSTEROGRAPHY     $    257.00
58350   REOPEN FALLOPIAN TUBE          $     318.00
58350   REOPEN FALLOPIAN TUBE          $    337.00
58550   LAPARO-ASST VAG HYSTERECTOMY   $   2,472.00
58550   LAPARO-ASST VAG HYSTERECTOMY   $   2,624.00
58552   LAPARO-VAG HYST INCL T/O       $   3,331.00
58552   LAPARO-VAG HYST INCL T/O       $   3,422.00
58553   LAPARO-VAG HYST, COMPLEX       $   3,660.00
58553   LAPARO-VAG HYST, COMPLEX       $   3,700.00
58554   LAPARO-VAG HYST W/T/O, COMPL   $   5,037.00
58554   LAPARO-VAG HYST W/T/O, COMPL   $   5,150.00
58555   HYSTEROSCOPY, DX, SEP PROC     $    650.00
58555   HYSTEROSCOPY, DX, SEP PROC     $    725.00
58558   HYSTEROSCOPY, BIOPSY           $     810.00
58558   HYSTEROSCOPY, BIOPSY           $    925.00
58559   HYSTEROSCOPY, LYSIS            $   2,252.00
58559   HYSTEROSCOPY, LYSIS            $   2,445.00
58561   HYSTEROSCOPY, REMOVE MYOMA     $    800.00
58562   HYSTEROSCOPY, REMOVE FB        $    350.00
58563   HYSTEROSCOPY, ABLATION         $   2,100.00
58563   HYSTEROSCOPY, ABLATION         $   3,915.00
58605   DIVISION OF FALLOPIAN TUBE     $   1,150.00
58605   DIVISION OF FALLOPIAN TUBE     $   1,275.00
58611   LIGATE OVIDUCT(S) ADD-ON       $    575.00
58611   LIGATE OVIDUCT(S) ADD-ON       $    635.00
58615   OCCLUDE FALLOPIAN TUBE(S)      $   1,324.00
58615   OCCLUDE FALLOPIAN TUBE(S)      $   1,614.00
58660   LAPAROSCOPY, LYSIS             $   2,000.00
58660   LAPAROSCOPY, LYSIS             $   2,000.00
58661   LAPAROSCOPY, REMOVE ADNEXA     $   2,000.00
58661   LAPAROSCOPY, REMOVE ADNEXA     $   2,000.00
58662   LAPAROSCOPY, EXCISE LESIONS    $   2,100.00
58662   LAPAROSCOPY, EXCISE LESIONS    $   2,225.00
58670   LAPAROSCOPY, TUBAL CAUTERY     $   1,420.00
58670   LAPAROSCOPY, TUBAL CAUTERY     $   1,670.00
58671   LAPAROSCOPY, TUBAL BLOCK       $   1,530.00
58671   LAPAROSCOPY, TUBAL BLOCK       $   1,620.00
58679   LAPARO PROC, OVIDUCT-OVARY     $    550.00
58700   REMOVAL OF FALLOPIAN TUBE      $   1,700.00
58700   REMOVAL OF FALLOPIAN TUBE      $   1,810.00
58720   REMOVAL OF OVARY/TUBE(S)       $   2,945.00
58720   REMOVAL OF OVARY/TUBE(S)       $   3,002.00
58740   Lysis Of Adhesions             $   2,080.00
58740   Lysis Of Adhesions             $   2,125.00
58750   REPAIR OVIDUCT                 $   2,561.00
58750   REPAIR OVIDUCT                 $   2,635.00
58805   DRAINAGE OF OVARIAN CYST(S)    $   1,448.00
58805   DRAINAGE OF OVARIAN CYST(S)    $   1,535.00
58925   REMOVAL OF OVARIAN CYST(S)     $   1,800.00
58925   REMOVAL OF OVARIAN CYST(S)     $   1,925.00
58940   REMOVAL OF OVARY(S)            $   1,800.00
58940   REMOVAL OF OVARY(S)            $   1,625.00
58953   TAH, RAD DISSECT FOR DEBULK    $   9,826.00
58953   TAH, RAD DISSECT FOR DEBULK    $   9,925.00
59000   AMNIOCENTESIS, DIAGNOSTIC      $    275.00
59000   AMNIOCENTESIS, DIAGNOSTIC      $    325.00
59025   FETAL NON-STRESS TEST          $     130.00
59025   FETAL NON-STRESS TEST          $     152.00
59100   REMOVE UTERUS LESION           $   1,000.00
59120   TREAT ECTOPIC PREGNANCY        $   1,900.00
59120   TREAT ECTOPIC PREGNANCY        $   2,100.00
59151   TREAT ECTOPIC PREGNANCY        $   3,350.00
59151   TREAT ECTOPIC PREGNANCY        $   4,475.00
59160   D & C AFTER DELIVERY           $    660.00
59160   D & C AFTER DELIVERY           $    720.00
59200   INSERT CERVICAL DILATOR        $    230.00
59200   INSERT CERVICAL DILATOR        $    245.00
59300   EPISIOTOMY OR VAGINAL REPAIR   $    480.00
59300   EPISIOTOMY OR VAGINAL REPAIR   $    528.00
59320   REVISION OF CERVIX             $    890.00
59320   REVISION OF CERVIX             $    934.00
59350   REPAIR OF UTERUS               $   1,774.00
59350   REPAIR OF UTERUS               $   1,924.00
59400   OBSTETRICAL CARE               $   2,000.00
59400   OBSTETRICAL CARE               $   2,500.00
59409   OBSTETRICAL CARE               $   1,150.00
59409   OBSTETRICAL CARE               $   1,500.00
59410   OBSTETRICAL CARE               $   1,125.00
59410   OBSTETRICAL CARE               $   1,600.00
59412   ANTEPARTUM MANIPULATION        $    490.00
59412   ANTEPARTUM MANIPULATION        $    520.00
59414   DELIVER PLACENTA               $    457.38
59414   DELIVER PLACENTA               $    524.00
59425   ANTEPARTUM CARE ONLY           $    670.00
59425   ANTEPARTUM CARE ONLY           $    749.00
59426   ANTEPARTUM CARE ONLY           $   1,000.00
59430   CARE AFTER DELIVERY            $    230.00
59430   CARE AFTER DELIVERY            $    248.00
59510   CESAREAN DELIVERY              $   2,500.00
59510   CESAREAN DELIVERY              $   2,600.00
59514   CESAREAN DELIVERY ONLY         $   2,500.00
59514   CESAREAN DELIVERY ONLY         $   2,200.00
59515   CESAREAN DELIVERY              $   2,500.00
59515   CESAREAN DELIVERY              $   2,300.00
59525   REMOVE UTERUS AFTER CESAREAN   $   1,456.00
59525   REMOVE UTERUS AFTER CESAREAN   $   1,625.00
59610   VBAC DELIVERY                  $   2,000.00
59610   VBAC DELIVERY                  $   2,600.00
59612   VBAC DELIVERY ONLY             $   1,150.00
59612   VBAC DELIVERY ONLY             $   1,600.00
59614   VBAC CARE AFTER DELIVERY       $   1,700.00
59812   TREATMENT OF MISCARRIAGE       $    720.00
59812   TREATMENT OF MISCARRIAGE       $    765.00
59820   CARE OF MISCARRIAGE            $    780.00
59820   CARE OF MISCARRIAGE            $    825.00
59830   TREAT UTERUS INFECTION         $    725.00
59841   ABORTION                       $    680.00
59841   ABORTION                       $    725.00
59855   ABORTION                       $   1,209.00
59855   ABORTION                       $   1,540.00
59870   EVACUATE MOLE OF UTERUS        $    575.00
59871   REMOVE CERCLAGE SUTURE         $    258.00
59871   REMOVE CERCLAGE SUTURE         $    273.00
59899   MATERNITY CARE PROCEDURE       $     65.00
59899   MATERNITY CARE PROCEDURE       $     85.00
61000   REMOVE CRANIAL CAVITY FLUID    $    554.00
61000   REMOVE CRANIAL CAVITY FLUID    $    584.00
62270   SPINAL FLUID TAP, DIAGNOSTIC   $    180.00
62270   SPINAL FLUID TAP, DIAGNOSTIC   $    281.00
62272   DRAIN CEREBRO SPINAL FLUID     $    185.00
64435   N BLOCK INJ, PARACERVICAL      $     88.00
64435   N BLOCK INJ, PARACERVICAL      $    262.00
64774   REMOVE SKIN NERVE LESION       $    921.00
64774   REMOVE SKIN NERVE LESION       $    982.00
65205   REMOVE FOREIGN BODY FROM EYE   $    200.00
65205   REMOVE FOREIGN BODY FROM EYE   $    220.00
65220   REMOVE FOREIGN BODY FROM EYE   $    220.00
65220   REMOVE FOREIGN BODY FROM EYE   $    240.00
65222   REMOVE FOREIGN BODY FROM EYE   $    200.00
65222   REMOVE FOREIGN BODY FROM EYE   $    220.00
69200   CLEAR OUTER EAR CANAL          $    100.00
69200   CLEAR OUTER EAR CANAL          $    207.00
69210   REMOVE IMPACTED EAR WAX        $     70.00
69210   REMOVE IMPACTED EAR WAX        $     82.00
70100   X-RAY EXAM OF JAW              $     110.00
70100   X-RAY EXAM OF JAW              $    122.00
70150   X-RAY EXAM OF FACIAL BONES     $    233.00
70150   X-RAY EXAM OF FACIAL BONES     $    245.00
70160   X-RAY EXAM OF NASAL BONES      $    142.00
70160   X-RAY EXAM OF NASAL BONES      $    174.00
70220   X-RAY EXAM OF SINUSES          $    222.00
70220   X-RAY EXAM OF SINUSES          $    233.00
70250   X-RAY EXAM OF SKULL            $    136.00
70250   X-RAY EXAM OF SKULL            $    154.00
70260   X-RAY EXAM OF SKULL            $    247.00
70260   X-RAY EXAM OF SKULL            $    264.00
70328   X-RAY EXAM OF JAW JOINT        $    106.00
70328   X-RAY EXAM OF JAW JOINT        $    124.00
70360   X-RAY EXAM OF NECK             $    153.00
70360   X-RAY EXAM OF NECK             $    167.00
70450   CT HEAD/BRAIN W/O DYE          $    470.00
70450   CT HEAD/BRAIN W/O DYE          $    489.00
70460   CT HEAD/BRAIN W/DYE            $    771.00
70470   CT HEAD/BRAIN W/O & W/DYE      $    787.00
70470   CT HEAD/BRAIN W/O & W/DYE      $     911.00
70486   CT MAXILLOFACIAL W/O DYE       $    461.00
70486   CT MAXILLOFACIAL W/O DYE       $    472.00
70488   CT MAXILLOFACIAL W/O & W/DYE   $   1,446.00
70488   CT MAXILLOFACIAL W/O & W/DYE   $   1,522.00
70491   CT SOFT TISSUE NECK W/DYE      $    808.00
70491   CT SOFT TISSUE NECK W/DYE      $    817.00
70543   MRI ORBT/FAC/NCK W/O & W/DYE   $   2,478.10
70543   MRI ORBT/FAC/NCK W/O & W/DYE   $   2,512.00
70551   MRI BRAIN W/O DYE              $   1,190.00
70551   MRI BRAIN W/O DYE              $   1,225.00
70553   MRI BRAIN W/O & W/DYE          $   1,675.00
70553   MRI BRAIN W/O & W/DYE          $   1,725.00
71020   CHEST X-RAY                    $    135.00
71020   CHEST X-RAY                    $    182.00
71100   X-RAY EXAM OF RIBS             $    126.00
71100   X-RAY EXAM OF RIBS             $    154.00
71101   X-RAY EXAM OF RIBS/CHEST       $    202.80
71101   X-RAY EXAM OF RIBS/CHEST       $    227.00
71260   CT THORAX W/DYE                $    884.00
71260   CT THORAX W/DYE                $    935.00
72040   X-RAY EXAM OF NECK SPINE       $     92.00
72040   X-RAY EXAM OF NECK SPINE       $    107.00
72050   X-RAY EXAM OF NECK SPINE       $    208.00
72050   X-RAY EXAM OF NECK SPINE       $    227.00
72069   X-RAY EXAM OF TRUNK SPINE      $    132.00
72069   X-RAY EXAM OF TRUNK SPINE      $    149.00
72070   X-RAY EXAM OF THORACIC SPINE   $    149.00
72070   X-RAY EXAM OF THORACIC SPINE   $    157.00
72072   X-RAY EXAM OF THORACIC SPINE   $     94.00
72074   X-RAY EXAM OF THORACIC SPINE   $    175.00
72074   X-RAY EXAM OF THORACIC SPINE   $    205.00
72100   X-RAY EXAM OF LOWER SPINE      $    153.00
72100   X-RAY EXAM OF LOWER SPINE      $    180.00
72110   X-RAY EXAM OF LOWER SPINE      $    257.00
72110   X-RAY EXAM OF LOWER SPINE      $    265.00
72114   X-RAY EXAM OF LOWER SPINE      $     62.18
72114   X-RAY EXAM OF LOWER SPINE      $    120.00
72125   CT NECK SPINE W/O DYE          $    802.00
72125   CT NECK SPINE W/O DYE          $    837.00
72128   CT CHEST SPINE W/O DYE         $   1,227.00
72128   CT CHEST SPINE W/O DYE         $   1,375.00
72131   CT LUMBAR SPINE W/O DYE        $   1,062.00
72131   CT LUMBAR SPINE W/O DYE        $   1,295.00
72141   MRI NECK SPINE W/O DYE         $   1,139.00
72141   MRI NECK SPINE W/O DYE         $   1,285.00
72146   MRI CHEST SPINE W/O DYE        $   1,139.00
72146   MRI CHEST SPINE W/O DYE        $   1,285.00
72148   MRI LUMBAR SPINE W/O DYE       $   1,190.00
72148   MRI LUMBAR SPINE W/O DYE       $   1,232.00
72158   MRI LUMBAR SPINE W/O & W/DYE   $   1,038.71
72158   MRI LUMBAR SPINE W/O & W/DYE   $   1,836.00
72170   X-RAY EXAM OF PELVIS           $     143.00
72170   X-RAY EXAM OF PELVIS           $     162.00
72192   CT PELVIS W/O DYE              $    892.00
72192   CT PELVIS W/O DYE              $    923.00
72193   CT PELVIS W/DYE                $   1,115.00
72193   CT PELVIS W/DYE                $   1,210.00
72202   X-RAY EXAM SACROILIAC JOINTS   $    399.90
73000   X-RAY EXAM OF COLLAR BONE      $     216.00
73000   X-RAY EXAM OF COLLAR BONE      $    234.00
73010   X-RAY EXAM OF SHOULDER BLADE   $     65.00
73010   X-RAY EXAM OF SHOULDER BLADE   $     79.00
73030   X-RAY EXAM OF SHOULDER         $     132.00
73030   X-RAY EXAM OF SHOULDER         $     154.00
73050   X-RAY EXAM OF SHOULDERS        $     176.00
73050   X-RAY EXAM OF SHOULDERS        $     194.00
73060   X-RAY EXAM OF HUMERUS          $     110.00
73060   X-RAY EXAM OF HUMERUS          $     137.00
73070   X-RAY EXAM OF ELBOW            $     82.00
73070   X-RAY EXAM OF ELBOW            $     102.00
73080   X-RAY EXAM OF ELBOW            $     93.00
73080   X-RAY EXAM OF ELBOW            $     105.00
73090   X-RAY EXAM OF FOREARM          $     103.00
73090   X-RAY EXAM OF FOREARM          $     111.00
73100   X-RAY EXAM OF WRIST            $     73.00
73100   X-RAY EXAM OF WRIST            $     92.00
73110   X-RAY EXAM OF WRIST            $     121.00
73110   X-RAY EXAM OF WRIST            $     134.00
73120   X-RAY EXAM OF HAND             $     184.00
73120   X-RAY EXAM OF HAND             $     197.00
73130   X-RAY EXAM OF HAND             $    242.00
73130   X-RAY EXAM OF HAND             $    263.00
73140   X-RAY EXAM OF FINGER(S)        $      81.00
73140   X-RAY EXAM OF FINGER(S)        $     92.00
73200   CT UPPER EXTREMITY W/O DYE     $    766.00
73200   CT UPPER EXTREMITY W/O DYE     $    823.00
73201   CT UPPER EXTREMITY W/DYE       $    375.00
73220   MRI UPPR EXTREMITY W/O&W/DYE   $   3,500.00
73221   MRI JOINT UPR EXTREM W/O DYE   $   1,190.00
73221   MRI JOINT UPR EXTREM W/O DYE   $   1,235.00
73510   X-RAY EXAM OF HIP              $    206.00
73510   X-RAY EXAM OF HIP              $    238.00
73520   X-RAY EXAM OF HIPS             $    105.00
73540   X-RAY EXAM OF PELVIS & HIPS    $     99.00
73540   X-RAY EXAM OF PELVIS & HIPS    $     114.00
73550   X-RAY EXAM OF THIGH            $     58.00
73550   X-RAY EXAM OF THIGH            $     72.00
73560   X-RAY EXAM OF KNEE, 1 OR 2     $     60.00
73560   X-RAY EXAM OF KNEE, 1 OR 2     $     75.00
73562   X-RAY EXAM OF KNEE, 3          $    276.00
73562   X-RAY EXAM OF KNEE, 3          $    321.00
73564   X-RAY EXAM, KNEE, 4 OR MORE    $    206.00
73564   X-RAY EXAM, KNEE, 4 OR MORE    $    234.00
73565   X-RAY EXAM OF KNEES            $     60.00
73565   X-RAY EXAM OF KNEES            $     72.00
73590   X-RAY EXAM OF LOWER LEG        $    226.00
73590   X-RAY EXAM OF LOWER LEG        $    226.00
73600   X-RAY EXAM OF ANKLE            $    105.00
73600   X-RAY EXAM OF ANKLE            $    120.00
73610   X-RAY EXAM OF ANKLE            $    125.00
73610   X-RAY EXAM OF ANKLE            $    132.00
73620   X-RAY EXAM OF FOOT             $     55.00
73620   X-RAY EXAM OF FOOT             $     73.00
73630   X-RAY EXAM OF FOOT             $     118.00
73630   X-RAY EXAM OF FOOT             $    132.00
73650   X-RAY EXAM OF HEEL             $     93.00
73650   X-RAY EXAM OF HEEL             $     112.00
73660   X-RAY EXAM OF TOE(S)           $     48.00
73701   CT LOWER EXTREMITY W/DYE       $    375.00
73721   MRI JNT OF LWR EXTRE W/O DYE   $   1,190.00
73725   MR ANG LWR EXT W OR W/O DYE    $    650.00
74000   X-RAY EXAM OF ABDOMEN          $     92.00
74000   X-RAY EXAM OF ABDOMEN          $     113.00
74020   X-RAY EXAM OF ABDOMEN          $    186.00
74020   X-RAY EXAM OF ABDOMEN          $    201.00
74022   X-RAY EXAM SERIES, ABDOMEN     $    249.00
74022   X-RAY EXAM SERIES, ABDOMEN     $    261.00
74150   CT ABDOMEN W/O DYE             $    892.00
74150   CT ABDOMEN W/O DYE             $    921.00
74160   CT ABDOMEN W/DYE               $    450.00
74170   CT ABDOMEN W/O & W/DYE         $   1,062.00
74170   CT ABDOMEN W/O & W/DYE         $   1,087.00
74183   MRI ABDOMEN W/O & W/DYE        $    734.43
74220   CONTRAST X-RAY, ESOPHAGUS      $    284.00
74230   CINE/VID X-RAY, THROAT/ESOPH   $    385.00
74241   X-RAY EXAM, UPPER GI TRACT     $   362.00
74241   X-RAY EXAM, UPPER GI TRACT     $   372.00
74246   CONTRST X-RAY UPPR GI TRACT    $   366.00
74246   CONTRST X-RAY UPPR GI TRACT    $   375.00
74247   CONTRST X-RAY UPPR GI TRACT    $   422.00
74247   CONTRST X-RAY UPPR GI TRACT    $   436.00
74280   CONTRAST X-RAY EXAM OF COLON   $   381.00
74280   CONTRAST X-RAY EXAM OF COLON   $   396.00
74400   CONTRST X-RAY, URINARY TRACT   $   372.00
74400   CONTRST X-RAY, URINARY TRACT   $   385.00
74455   X-RAY, URETHRA/BLADDER         $   297.00
74455   X-RAY, URETHRA/BLADDER         $   356.00
76020   X-RAYS FOR BONE AGE            $   129.00
76020   X-RAYS FOR BONE AGE            $   164.00
76062   X-RAYS, BONE SURVEY            $   193.00
76062   X-RAYS, BONE SURVEY            $   210.00
76075   DXA BONE DENSITY, AXIAL        $   233.00
76075   DXA BONE DENSITY, AXIAL        $   254.00
76082   COMPUTER MAMMOGRAM ADD-ON      $    65.50
76082   COMPUTER MAMMOGRAM ADD-ON      $    79.00
76083   COMPUTER MAMMOGRAM ADD-ON      $    56.00
76083   COMPUTER MAMMOGRAM ADD-ON      $    72.00
76090   MAMMOGRAM, ONE BREAST          $    83.20
76090   MAMMOGRAM, ONE BREAST          $   102.00
76091   MAMMOGRAM, BOTH BREASTS        $   145.40
76091   MAMMOGRAM, BOTH BREASTS        $   156.00
76092   MAMMOGRAM, SCREENING           $   106.90
76092   MAMMOGRAM, SCREENING           $   124.00
76098   X-RAY EXAM, BREAST SPECIMEN    $   156.40
76506   ECHO EXAM OF HEAD              $   167.00
76506   ECHO EXAM OF HEAD              $   179.00
76536   US EXAM OF HEAD AND NECK       $   352.00
76645   US EXAM, BREAST(S)             $   345.00
76645   US EXAM, BREAST(S)             $   682.70
76700   US EXAM, ABDOM, COMPLETE       $   345.00
76705   ECHO EXAM OF ABDOMEN           $   185.00
76770   US EXAM ABDO BACK WALL, COMP   $   345.00
76770   US EXAM ABDO BACK WALL, COMP   $   354.00
76775   US EXAM ABDO BACK WALL, LIM    $   352.00
76775   US EXAM ABDO BACK WALL, LIM    $   368.00
76805   OB US >/= 14 WKS, SNGL FETUS   $   150.00
76810   OB US >/= 14 WKS, ADDL FETUS   $   272.00
76815   OB US, LIMITED, FETUS(S)       $   150.00
76815   OB US, LIMITED, FETUS(S)       $   176.00
76817   TRANSVAGINAL US, OBSTETRIC       $   150.00
76830   TRANSVAGINAL/PELVIC US, NON-OB   $   185.00
76830   TRANSVAGINAL/PELVIC US, NON-OB   $   150.00
76856   US EXAM, PELVIC, COMPLETE        $   187.00
76856   US EXAM, PELVIC, COMPLETE        $   125.00
76857   US EXAM, PELVIC, LIMITED         $   215.00
76857   US EXAM, PELVIC, LIMITED         $   256.00
76870   US EXAM, SCROTUM                 $   172.00
76870   US EXAM, SCROTUM                 $   182.00
76872   US, TRANSRECTAL                  $   289.00
76880   US EXAM, EXTREMITY               $   161.00
76880   US EXAM, EXTREMITY               $   161.00
76885   US EXAM INFANT HIPS, DYNAMIC     $   426.30
76885   US EXAM INFANT HIPS, DYNAMIC     $   458.00
76942   ECHO GUIDE FOR BIOPSY            $   434.00
76942   ECHO GUIDE FOR BIOPSY            $   475.00
76998   US GUIDE, INTRAOP                $   210.00
77055   MAMMOGRAM, ONE BREAST            $   111.20
77055   MAMMOGRAM, ONE BREAST            $   134.00
77056   MAMMOGRAM, BOTH BREASTS          $   170.50
77056   MAMMOGRAM, BOTH BREASTS          $   182.00
77057   MAMMOGRAM, SCREENING             $   114.50
77057   MAMMOGRAM, SCREENING             $   114.50
77080   DXA BONE DENSITY, AXIAL          $   311.60
77080   DXA BONE DENSITY, AXIAL          $   325.00
78000   THYROID, SINGLE UPTAKE           $   200.00
78001   THYROID, MULTIPLE UPTAKES        $   225.00
78003   THYROID SUPPRESS/STIMUL          $   200.00
78007   THYROID IMAGE, MULT UPTAKES      $   299.00
78007   THYROID IMAGE, MULT UPTAKES      $   342.00
78290   MECKEL'S DIVERT EXAM             $   100.00
78607   BRAIN IMAGING (3D)               $   540.00
78607   BRAIN IMAGING (3D)               $   703.00
78709   K FLOW/FUNCT IMAGE, MULTIPLE     $   617.00
78709   K FLOW/FUNCT IMAGE, MULTIPLE     $   638.00
80051   ELECTROLYTE PANEL                $    25.00
80051   ELECTROLYTE PANEL                $    25.00
80053   COMPREHEN METABOLIC PANEL        $    31.76
80053   COMPREHEN METABOLIC PANEL        $    35.00
80055   OBSTETRIC PANEL                  $    80.00
80055   OBSTETRIC PANEL                  $    80.00
80061   LIPID PANEL                      $    55.00
80061   LIPID PANEL                      $    72.00
80069   RENAL FUNCTION PANEL             $    35.00
80069   RENAL FUNCTION PANEL           $    43.00
80074   ACUTE HEPATITIS PANEL          $   277.98
80074   ACUTE HEPATITIS PANEL          $   312.00
80076   HEPATIC FUNCTION PANEL         $    30.00
80076   HEPATIC FUNCTION PANEL         $    35.00
80100   DRUG SCREEN, QUALITATE/MULTI   $    65.00
80100   DRUG SCREEN, QUALITATE/MULTI   $    70.00
80102   DRUG CONFIRMATION              $    75.00
80102   DRUG CONFIRMATION              $    82.00
80152   ASSAY OF AMITRIPTYLINE         $   106.70
80152   ASSAY OF AMITRIPTYLINE         $   115.00
80156   ASSAY, CARBAMAZEPINE, TOTAL    $    60.00
80156   ASSAY, CARBAMAZEPINE, TOTAL    $    71.00
80158   ASSAY OF CYCLOSPORINE          $   225.00
80158   ASSAY OF CYCLOSPORINE          $   245.00
80160   ASSAY OF DESIPRAMINE           $    75.00
80160   ASSAY OF DESIPRAMINE           $    90.00
80162   ASSAY OF DIGOXIN               $    55.00
80162   ASSAY OF DIGOXIN               $    62.00
80164   ASSAY, DIPROPYLACETIC ACID     $    60.00
80164   ASSAY, DIPROPYLACETIC ACID     $    68.00
80174   ASSAY OF IMIPRAMINE            $    75.00
80174   ASSAY OF IMIPRAMINE            $    82.00
80178   ASSAY OF LITHIUM               $    35.00
80178   ASSAY OF LITHIUM               $    40.00
80184   ASSAY OF PHENOBARBITAL         $    60.00
80184   ASSAY OF PHENOBARBITAL         $    65.00
80185   ASSAY OF PHENYTOIN, TOTAL      $    55.00
80185   ASSAY OF PHENYTOIN, TOTAL      $    62.00
80188   ASSAY OF PRIMIDONE             $    60.00
80188   ASSAY OF PRIMIDONE             $    68.00
80190   ASSAY OF PROCAINAMIDE          $    60.00
80190   ASSAY OF PROCAINAMIDE          $    65.00
80194   ASSAY OF QUINIDINE             $    60.00
80194   ASSAY OF QUINIDINE             $    65.00
80196   ASSAY OF SALICYLATE            $    37.00
80196   ASSAY OF SALICYLATE            $    45.00
80198   ASSAY OF THEOPHYLLINE          $    55.00
80198   ASSAY OF THEOPHYLLINE          $    60.00
80202   ASSAY OF VANCOMYCIN            $    79.45
80202   ASSAY OF VANCOMYCIN            $    85.00
80299   QUANTITATIVE ASSAY, DRUG       $   157.25
80299   QUANTITATIVE ASSAY, DRUG       $   172.00
81000   URINALYSIS, NONAUTO W/SCOPE    $     5.00
81000   URINALYSIS, NONAUTO W/SCOPE    $     5.00
81001   URINALYSIS, AUTO W/SCOPE       $    22.00
81001   URINALYSIS, AUTO W/SCOPE       $    27.00
81002   URINALYSIS NONAUTO W/O SCOPE   $    18.00
81002   URINALYSIS NONAUTO W/O SCOPE   $    22.00
81015   MICROSCOPIC EXAM OF URINE      $     8.00
81015   MICROSCOPIC EXAM OF URINE      $    10.00
81025   URINE PREGNANCY TEST           $    20.00
81099   URINALYSIS TEST PROCEDURE      $    15.00
81099   URINALYSIS TEST PROCEDURE      $    20.00
82009   TEST FOR ACETONE/KETONES       $    15.00
82009   TEST FOR ACETONE/KETONES       $    18.00
82024   ASSAY OF ACTH                  $   228.80
82024   ASSAY OF ACTH                  $   245.00
82040   ASSAY OF SERUM ALBUMIN         $    23.90
82040   ASSAY OF SERUM ALBUMIN         $    28.00
82042   ASSAY OF URINE ALBUMIN         $    38.20
82042   ASSAY OF URINE ALBUMIN         $    42.00
82043   MICROALBUMIN, QUANTITATIVE     $    50.00
82043   MICROALBUMIN, QUANTITATIVE     $    57.00
82055   ASSAY OF ETHANOL               $    71.15
82055   ASSAY OF ETHANOL               $    75.00
82085   ASSAY OF ALDOLASE              $    56.45
82085   ASSAY OF ALDOLASE              $    58.00
82088   ASSAY OF ALDOSTERONE           $   215.60
82088   ASSAY OF ALDOSTERONE           $   220.00
82104   ALPHA-1-ANTITRYPSIN, PHENO     $   144.90
82104   ALPHA-1-ANTITRYPSIN, PHENO     $   150.00
82105   ALPHA-FETOPROTEIN, SERUM       $    94.30
82105   ALPHA-FETOPROTEIN, SERUM       $   100.00
82131   AMINO ACIDS, SINGLE QUANT      $   100.00
82131   AMINO ACIDS, SINGLE QUANT      $   110.00
82135   ASSAY, AMINOLEVULINIC ACID     $    60.00
82135   ASSAY, AMINOLEVULINIC ACID     $    66.00
82140   ASSAY OF AMMONIA               $   113.85
82140   ASSAY OF AMMONIA               $   120.00
82150   ASSAY OF AMYLASE               $    37.45
82150   ASSAY OF AMYLASE               $    45.00
82164   ANGIOTENSIN I ENZYME TEST      $    87.30
82164   ANGIOTENSIN I ENZYME TEST      $    95.00
82240   BILE ACIDS, CHOLYLGLYCINE      $    80.00
82240   BILE ACIDS, CHOLYLGLYCINE      $    87.00
82247   BILIRUBIN, TOTAL               $    66.41
82247   BILIRUBIN, TOTAL               $    70.00
82270   OCCULT BLOOD, FECES            $    15.00
82270   OCCULT BLOOD, FECES            $   20.00
82310   ASSAY OF CALCIUM               $   20.00
82310   ASSAY OF CALCIUM               $   22.00
82340   ASSAY OF CALCIUM IN URINE      $   20.00
82340   ASSAY OF CALCIUM IN URINE      $   22.00
82365   CALCULUS SPECTROSCOPY          $   55.00
82365   CALCULUS SPECTROSCOPY          $   62.00
82374   ASSAY, BLOOD CARBON DIOXIDE    $   20.00
82374   ASSAY, BLOOD CARBON DIOXIDE    $   23.00
82375   ASSAY, BLOOD CARBON MONOXIDE   $   30.00
82375   ASSAY, BLOOD CARBON MONOXIDE   $   33.00
82376   TEST FOR CARBON MONOXIDE       $   30.00
82376   TEST FOR CARBON MONOXIDE       $   33.00
82378   CARCINOEMBRYONIC ANTIGEN       $   75.00
82378   CARCINOEMBRYONIC ANTIGEN       $   80.00
82383   ASSAY, BLOOD CATECHOLAMINES    $   109.00
82383   ASSAY, BLOOD CATECHOLAMINES    $   115.00
82390   ASSAY OF CERULOPLASMIN         $   45.00
82390   ASSAY OF CERULOPLASMIN         $   50.00
82435   ASSAY OF BLOOD CHLORIDE        $   20.00
82435   ASSAY OF BLOOD CHLORIDE        $   25.00
82465   ASSAY, BLD/SERUM CHOLESTEROL   $   20.00
82465   ASSAY, BLD/SERUM CHOLESTEROL   $   25.00
82482   ASSAY, RBC CHOLINESTERASE      $   30.00
82482   ASSAY, RBC CHOLINESTERASE      $   33.00
82486   GAS/LIQUID CHROMATOGRAPHY      $   80.00
82486   GAS/LIQUID CHROMATOGRAPHY      $   88.00
82489   THIN LAYER CHROMATOGRAPHY      $   40.00
82489   THIN LAYER CHROMATOGRAPHY      $   44.00
82491   CHROMOTOGRAPHY, QUANT, SING    $   45.00
82491   CHROMOTOGRAPHY, QUANT, SING    $   48.00
82525   ASSAY OF COPPER                $   35.00
82525   ASSAY OF COPPER                $   38.00
82530   CORTISOL, FREE                 $   68.00
82530   CORTISOL, FREE                 $   72.00
82533   TOTAL CORTISOL                 $   70.00
82533   TOTAL CORTISOL                 $   73.00
82543   COLUMN CHROMOTOGRAPH/ISOTOPE   $   150.00
82543   COLUMN CHROMOTOGRAPH/ISOTOPE   $   165.00
82550   ASSAY OF CK (CPK)              $   20.00
82550   ASSAY OF CK (CPK)              $   23.00
82552   ASSAY OF CPK IN BLOOD          $   50.00
82552   ASSAY OF CPK IN BLOOD          $   56.00
82565   ASSAY OF CREATININE            $   20.00
82565   ASSAY OF CREATININE            $   24.00
82570   ASSAY OF URINE CREATININE      $   20.00
82570   ASSAY OF URINE CREATININE      $   24.00
82575   CREATININE CLEARANCE TEST      $   40.00
82575   CREATININE CLEARANCE TEST      $   46.00
82595   ASSAY OF CRYOGLOBULIN          $   25.00
82595   ASSAY OF CRYOGLOBULIN          $   28.00
82607   VITAMIN B-12                   $   55.00
82607   VITAMIN B-12                   $   60.00
82615   TEST FOR URINE CYSTINES        $   39.00
82615   TEST FOR URINE CYSTINES        $   45.00
82626   DEHYDROEPIANDROSTERONE         $   90.00
82626   DEHYDROEPIANDROSTERONE         $   95.00
82627   DEHYDROEPIANDROSTERONE         $   80.00
82627   DEHYDROEPIANDROSTERONE         $   85.00
82634   DEOXYCORTISOL                  $   100.00
82634   DEOXYCORTISOL                  $   115.00
82670   ASSAY OF ESTRADIOL             $   90.00
82670   ASSAY OF ESTRADIOL             $   97.00
82671   ASSAY OF ESTROGENS             $   55.00
82671   ASSAY OF ESTROGENS             $   62.00
82710   FATS/LIPIDS, FECES, QUANT      $   60.00
82710   FATS/LIPIDS, FECES, QUANT      $   65.00
82728   ASSAY OF FERRITIN              $   42.75
82728   ASSAY OF FERRITIN              $   47.00
82731   ASSAY OF FETAL FIBRONECTIN     $   50.00
82746   BLOOD FOLIC ACID SERUM         $   55.00
82746   BLOOD FOLIC ACID SERUM         $   60.00
82784   ASSAY OF GAMMAGLOBULIN IGM     $    67.10
82784   ASSAY OF GAMMAGLOBULIN IGM     $   70.00
82805   BLOOD GASES W/O2 SATURATION    $   60.00
82805   BLOOD GASES W/O2 SATURATION    $   63.00
82941   ASSAY OF GASTRIN               $   39.00
82941   ASSAY OF GASTRIN               $   44.00
82947   ASSAY, GLUCOSE, BLOOD QUANT    $    16.00
82947   ASSAY, GLUCOSE, BLOOD QUANT    $   20.00
82947   ASSAY, GLUCOSE, BLOOD QUANT    $   20.00
82948   REAGENT STRIP/BLOOD GLUCOSE    $    12.00
82948   REAGENT STRIP/BLOOD GLUCOSE    $    15.00
82950   GLUCOSE TEST                   $   22.00
82950   GLUCOSE TEST                   $   25.00
82951   GLUCOSE TOLERANCE TEST (GTT)   $   47.00
82951   GLUCOSE TOLERANCE TEST (GTT)   $   50.00
82952   GTT-ADDED SAMPLES              $   40.00
82952   GTT-ADDED SAMPLES              $   44.00
82955   ASSAY OF G6PD ENZYME           $   25.00
82955   ASSAY OF G6PD ENZYME           $   28.00
82960   TEST FOR G6PD ENZYME           $   19.50
82960   TEST FOR G6PD ENZYME           $   23.00
82962   GLUCOSE BLOOD TEST             $   12.00
82962   GLUCOSE BLOOD TEST             $   12.00
82977   ASSAY OF GGT                   $   25.00
82977   ASSAY OF GGT                   $   25.00
82985   GLYCATED PROTEIN               $   30.00
82985   GLYCATED PROTEIN               $   33.00
83001   GONADOTROPIN (FSH)             $   70.00
83001   GONADOTROPIN (FSH)             $   76.00
83002   GONADOTROPIN (LH)              $   70.00
83002   GONADOTROPIN (LH)              $   76.00
83003   ASSAY, GROWTH HORMONE (HGH)    $   57.25
83003   ASSAY, GROWTH HORMONE (HGH)    $   65.00
83010   ASSAY OF HAPTOGLOBIN, QUANT    $   45.00
83010   ASSAY OF HAPTOGLOBIN, QUANT    $   50.00
83015   HEAVY METAL SCREEN             $   40.00
83015   HEAVY METAL SCREEN             $   44.00
83020   HEMOGLOBIN ELECTROPHORESIS     $   35.00
83020   HEMOGLOBIN ELECTROPHORESIS     $   40.00
83036   GLYCOSYLATED HEMOGLOBIN TEST   $   53.64
83036   GLYCOSYLATED HEMOGLOBIN TEST   $   57.00
83037   GLYCOSYLATED HB, HOME DEVICE   $   35.00
83037   GLYCOSYLATED HB, HOME DEVICE   $   35.00
83050   BLOOD METHEMOGLOBIN ASSAY      $   46.60
83050   BLOOD METHEMOGLOBIN ASSAY      $   50.00
83070   ASSAY OF HEMOSIDERIN, QUAL     $   20.00
83070   ASSAY OF HEMOSIDERIN, QUAL     $   23.00
83491   ASSAY OF CORTICOSTEROIDS       $   70.00
83491   ASSAY OF CORTICOSTEROIDS       $   75.00
83518   IMMUNOASSAY, DIPSTICK          $   32.00
83518   IMMUNOASSAY, DIPSTICK          $   35.00
83525   ASSAY OF INSULIN               $   45.00
83525   ASSAY OF INSULIN               $   48.00
83540   ASSAY OF IRON                  $   35.00
83540   ASSAY OF IRON                  $   38.00
83550   IRON BINDING TEST              $   35.00
83550   IRON BINDING TEST              $   40.00
83605   ASSAY OF LACTIC ACID           $   28.50
83605   ASSAY OF LACTIC ACID           $   30.00
83615   LACTATE (LD) (LDH) ENZYME      $    19.95
83615   LACTATE (LD) (LDH) ENZYME      $    25.00
83655   ASSAY OF LEAD                  $    45.00
83655   ASSAY OF LEAD                  $    50.00
83690   ASSAY OF LIPASE                $    30.00
83690   ASSAY OF LIPASE                $    34.00
83718   ASSAY OF LIPOPROTEIN           $    57.00
83718   ASSAY OF LIPOPROTEIN           $    62.00
83735   ASSAY OF MAGNESIUM             $    23.00
83735   ASSAY OF MAGNESIUM             $    28.00
83825   ASSAY OF MERCURY               $    73.00
83825   ASSAY OF MERCURY               $    75.00
83835   ASSAY OF METANEPHRINES         $    72.00
83835   ASSAY OF METANEPHRINES         $    77.00
83880   NATRIURETIC PEPTIDE            $   171.46
83880   NATRIURETIC PEPTIDE            $   195.00
83890   MOLECULE ISOLATE               $   249.00
83890   MOLECULE ISOLATE               $   265.00
83891   MOLECULE ISOLATE NUCLEIC       $   310.00
83891   MOLECULE ISOLATE NUCLEIC       $   315.00
83894   MOLECULE GEL ELECTROPHOR       $   310.00
83894   MOLECULE GEL ELECTROPHOR       $   325.00
83898   MOLECULE NUCLEIC AMPLI, EACH   $   310.00
83898   MOLECULE NUCLEIC AMPLI, EACH   $   325.00
83915   ASSAY OF NUCLEOTIDASE          $    40.00
83915   ASSAY OF NUCLEOTIDASE          $    47.00
83918   ORGANIC ACIDS, TOTAL, QUANT    $   350.00
83918   ORGANIC ACIDS, TOTAL, QUANT    $   365.00
83930   ASSAY OF BLOOD OSMOLALITY      $    24.00
83930   ASSAY OF BLOOD OSMOLALITY      $    28.00
83935   ASSAY OF URINE OSMOLALITY      $    30.00
83935   ASSAY OF URINE OSMOLALITY      $    35.00
83945   ASSAY OF OXALATE               $    30.00
83945   ASSAY OF OXALATE               $    35.00
83970   ASSAY OF PARATHORMONE          $   115.00
83970   ASSAY OF PARATHORMONE          $   124.00
84030   ASSAY OF BLOOD PKU             $    25.00
84030   ASSAY OF BLOOD PKU             $    28.00
84060   ASSAY ACID PHOSPHATASE         $    48.30
84060   ASSAY ACID PHOSPHATASE         $    52.00
84066   ASSAY PROSTATE PHOSPHATASE     $    46.00
84066   ASSAY PROSTATE PHOSPHATASE     $    53.00
84075   ASSAY ALKALINE PHOSPHATASE     $    79.35
84075   ASSAY ALKALINE PHOSPHATASE     $    85.00
84078   ASSAY ALKALINE PHOSPHATASE     $    30.00
84078   ASSAY ALKALINE PHOSPHATASE     $    34.00
84080   ASSAY ALKALINE PHOSPHATASES    $    60.00
84080   ASSAY ALKALINE PHOSPHATASES    $    65.00
84100   ASSAY OF PHOSPHORUS            $    20.00
84100   ASSAY OF PHOSPHORUS            $    25.00
84105   ASSAY OF URINE PHOSPHORUS      $    15.00
84105   ASSAY OF URINE PHOSPHORUS      $    20.00
84110   ASSAY OF PORPHOBILINOGEN       $    20.00
84110   ASSAY OF PORPHOBILINOGEN       $    22.00
84120   ASSAY OF URINE PORPHYRINS      $    40.00
84120   ASSAY OF URINE PORPHYRINS      $    44.00
84132   ASSAY OF SERUM POTASSIUM       $    20.00
84132   ASSAY OF SERUM POTASSIUM       $    24.00
84133   ASSAY OF URINE POTASSIUM       $    11.40
84133   ASSAY OF URINE POTASSIUM       $    15.00
84144   ASSAY OF PROGESTERONE          $    50.00
84144   ASSAY OF PROGESTERONE          $    54.00
84146   ASSAY OF PROLACTIN             $   142.50
84146   ASSAY OF PROLACTIN             $   150.00
84153   ASSAY OF PSA, TOTAL            $    31.39
84153   ASSAY OF PSA, TOTAL            $    35.00
84155   ASSAY OF PROTEIN, SERUM        $    20.00
84155   ASSAY OF PROTEIN, SERUM        $    22.00
84165   PROTEIN E-PHORESIS, SERUM      $    50.00
84165   PROTEIN E-PHORESIS, SERUM      $    54.00
84182   PROTEIN, WESTERN BLOT TEST     $    40.00
84182   PROTEIN, WESTERN BLOT TEST     $    44.00
84202   ASSAY RBC PROTOPORPHYRIN       $    16.80
84202   ASSAY RBC PROTOPORPHYRIN       $    24.00
84206   ASSAY OF PROINSULIN            $   255.60
84206   ASSAY OF PROINSULIN            $   260.00
84233   ASSAY OF ESTROGEN              $   100.00
84233   ASSAY OF ESTROGEN              $   105.00
84238   ASSAY, NONENDOCRINE RECEPTOR   $   223.10
84238   ASSAY, NONENDOCRINE RECEPTOR   $   230.00
84295   ASSAY OF SERUM SODIUM          $    20.00
84295   ASSAY OF SERUM SODIUM          $    22.00
84300   ASSAY OF URINE SODIUM          $    11.40
84300   ASSAY OF URINE SODIUM          $    15.00
84305   ASSAY OF SOMATOMEDIN           $   104.00
84305   ASSAY OF SOMATOMEDIN           $   112.00
84403   ASSAY OF TOTAL TESTOSTERONE    $   100.00
84403   ASSAY OF TOTAL TESTOSTERONE    $   115.00
84436   ASSAY OF TOTAL THYROXINE       $   25.00
84439   ASSAY OF FREE THYROXINE        $   47.39
84443   ASSAY THYROID STIM HORMONE     $   60.00
84446   ASSAY OF VITAMIN E             $   50.00
84450   TRANSFERASE (AST) (SGOT)       $   20.00
84460   ALANINE AMINO (ALT) (SGPT)     $   20.00
84460   ALANINE AMINO (ALT) (SGPT)     $   23.00
84478   ASSAY OF TRIGLYCERIDES         $   20.00
84478   ASSAY OF TRIGLYCERIDES         $   23.00
84479   ASSAY OF THYROID (T3 OR T4)    $   25.00
84479   ASSAY OF THYROID (T3 OR T4)    $   30.00
84480   ASSAY, TRIIODOTHYRONINE (T3)   $   50.00
84480   ASSAY, TRIIODOTHYRONINE (T3)   $   55.00
84481   FREE ASSAY (FT-3)              $   102.90
84481   FREE ASSAY (FT-3)              $   115.00
84484   ASSAY OF TROPONIN, QUANT       $   130.25
84484   ASSAY OF TROPONIN, QUANT       $   146.00
84520   ASSAY OF UREA NITROGEN         $    16.00
84520   ASSAY OF UREA NITROGEN         $   22.00
84550   ASSAY OF BLOOD/URIC ACID       $    16.00
84550   ASSAY OF BLOOD/URIC ACID       $   22.00
84585   ASSAY OF URINE VMA             $   63.00
84585   ASSAY OF URINE VMA             $   68.00
84620   XYLOSE TOLERANCE TEST          $   28.00
84620   XYLOSE TOLERANCE TEST          $   32.00
84681   ASSAY OF C-PEPTIDE             $    91.00
84681   ASSAY OF C-PEPTIDE             $   95.00
84702   CHORIONIC GONADOTROPIN TEST    $    51.00
84702   CHORIONIC GONADOTROPIN TEST    $   56.00
84703   CHORIONIC GONADOTROPIN ASSAY   $   30.00
84703   CHORIONIC GONADOTROPIN ASSAY   $   35.00
85002   BLEEDING TIME TEST             $   28.00
85002   BLEEDING TIME TEST             $   33.00
85018   HEMOGLOBIN                     $   30.00
85018   HEMOGLOBIN                     $   35.00
85018   HEMOGLOBIN                     $   35.00
85025   COMPLETE CBC W/AUTO DIFF WBC   $   30.00
85025   COMPLETE CBC W/AUTO DIFF WBC   $   35.00
85044   MANUAL RETICULOCYTE COUNT      $    10.00
85044   MANUAL RETICULOCYTE COUNT      $    15.00
85048   AUTOMATED LEUKOCYTE COUNT      $    14.00
85048   AUTOMATED LEUKOCYTE COUNT      $   20.00
85060   BLOOD SMEAR INTERPRETATION     $     6.19
85060   BLOOD SMEAR INTERPRETATION     $   40.00
85220   BLOOD CLOT FACTOR V TEST       $    84.00
85220   BLOOD CLOT FACTOR V TEST       $    90.00
85240   BLOOD CLOT FACTOR VIII TEST    $    99.75
85240   BLOOD CLOT FACTOR VIII TEST    $   108.00
85245   BLOOD CLOT FACTOR VIII TEST    $   189.00
85245   BLOOD CLOT FACTOR VIII TEST    $   192.00
85246   BLOOD CLOT FACTOR VIII TEST    $   302.45
85246   BLOOD CLOT FACTOR VIII TEST    $   315.00
85260   BLOOD CLOT FACTOR X TEST       $    84.00
85260   BLOOD CLOT FACTOR X TEST       $    90.00
85290   BLOOD CLOT FACTOR XIII TEST    $    55.00
85290   BLOOD CLOT FACTOR XIII TEST    $    60.00
85300   ANTITHROMBIN III TEST          $    38.00
85300   ANTITHROMBIN III TEST          $    43.00
85345   COAGULATION TIME               $    10.00
85345   COAGULATION TIME               $    13.00
85362   FIBRIN DEGRADATION PRODUCTS    $    24.00
85362   FIBRIN DEGRADATION PRODUCTS    $    30.00
85378   FIBRIN DEGRADE, SEMIQUANT      $    55.15
85378   FIBRIN DEGRADE, SEMIQUANT      $    60.00
85384   FIBRINOGEN                     $    24.00
85384   FIBRINOGEN                     $    26.00
85460   HEMOGLOBIN, FETAL              $    14.60
85460   HEMOGLOBIN, FETAL              $    18.00
85610   PROTHROMBIN TIME               $    24.43
85610   PROTHROMBIN TIME               $    28.00
85613   RUSSELL VIPER VENOM, DILUTED   $    41.64
85613   RUSSELL VIPER VENOM, DILUTED   $    45.00
85651   RBC SED RATE, NONAUTOMATED     $    15.00
85651   RBC SED RATE, NONAUTOMATED     $    18.00
85652   RBC SED RATE, AUTOMATED        $    27.51
85652   RBC SED RATE, AUTOMATED        $    32.00
85660   RBC SICKLE CELL TEST           $    20.00
85660   RBC SICKLE CELL TEST           $    26.00
85705   THROMBOPLASTIN INHIBITION      $    50.00
85705   THROMBOPLASTIN INHIBITION      $    60.00
85730   THROMBOPLASTIN TIME, PARTIAL   $    25.00
85730   THROMBOPLASTIN TIME, PARTIAL   $    32.00
85999   HEMATOLOGY PROCEDURE           $    17.20
85999   HEMATOLOGY PROCEDURE           $    22.00
86022   PLATELET ANTIBODIES            $   290.00
86022   PLATELET ANTIBODIES            $   315.00
86038   ANTINUCLEAR ANTIBODIES         $    62.55
86038   ANTINUCLEAR ANTIBODIES         $    65.00
86063   ANTISTREPTOLYSIN O, SCREEN     $   25.00
86063   ANTISTREPTOLYSIN O, SCREEN     $   28.00
86140   C-REACTIVE PROTEIN             $   28.00
86140   C-REACTIVE PROTEIN             $   30.00
86147   CARDIOLIPIN ANTIBODY           $   98.28
86147   CARDIOLIPIN ANTIBODY           $   102.00
86156   COLD AGGLUTININ, SCREEN        $   25.00
86156   COLD AGGLUTININ, SCREEN        $   28.00
86160   COMPLEMENT, ANTIGEN            $   60.00
86160   COMPLEMENT, ANTIGEN            $   65.00
86162   COMPLEMENT, TOTAL (CH50)       $   85.00
86162   COMPLEMENT, TOTAL (CH50)       $   92.00
86171   COMPLEMENT FIXATION, EACH      $   20.00
86171   COMPLEMENT FIXATION, EACH      $   24.00
86225   DNA ANTIBODY                   $   85.45
86225   DNA ANTIBODY                   $   90.00
86235   NUCLEAR ANTIGEN ANTIBODY       $   55.00
86235   NUCLEAR ANTIGEN ANTIBODY       $   62.00
86255   FLUORESCENT ANTIBODY, SCREEN   $   48.00
86255   FLUORESCENT ANTIBODY, SCREEN   $   52.00
86256   FLUORESCENT ANTIBODY, TITER    $   59.00
86256   FLUORESCENT ANTIBODY, TITER    $   64.00
86280   HEMAGGLUTINATION INHIBITION    $   45.00
86280   HEMAGGLUTINATION INHIBITION    $   50.00
86304   IMMUNOASSAY, TUMOR, CA 125     $   125.65
86304   IMMUNOASSAY, TUMOR, CA 125     $   143.00
86308   HETEROPHILE ANTIBODIES         $   53.25
86308   HETEROPHILE ANTIBODIES         $   59.00
86316   IMMUNOASSAY, TUMOR OTHER       $   80.00
86316   IMMUNOASSAY, TUMOR OTHER       $   86.00
86317   IMMUNOASSAY,INFECTIOUS AGENT   $   50.00
86317   IMMUNOASSAY,INFECTIOUS AGENT   $   54.00
86318   IMMUNOASSAY,INFECTIOUS AGENT   $   40.00
86318   IMMUNOASSAY,INFECTIOUS AGENT   $   44.00
86320   SERUM IMMUNOELECTROPHORESIS    $   60.00
86320   SERUM IMMUNOELECTROPHORESIS    $   66.00
86329   IMMUNODIFFUSION                $   70.00
86329   IMMUNODIFFUSION                $   76.00
86331   IMMUNODIFFUSION OUCHTERLONY    $   28.00
86331   IMMUNODIFFUSION OUCHTERLONY    $    31.00
86337   INSULIN ANTIBODIES             $    91.00
86337   INSULIN ANTIBODIES             $   95.00
86340   INTRINSIC FACTOR ANTIBODY      $   25.00
86340   INTRINSIC FACTOR ANTIBODY      $   32.00
86376   MICROSOMAL ANTIBODY            $   55.00
86376   MICROSOMAL ANTIBODY            $   62.00
86403   PARTICLE AGGLUTINATION TEST    $   20.00
86403   PARTICLE AGGLUTINATION TEST    $   23.00
86430   RHEUMATOID FACTOR TEST         $   25.00
86430   RHEUMATOID FACTOR TEST         $   28.00
86485   SKIN TEST, CANDIDA             $   60.00
86485   SKIN TEST, CANDIDA             $   64.00
86490   COCCIDIOIDOMYCOSIS SKIN TEST   $   23.00
86490   COCCIDIOIDOMYCOSIS SKIN TEST   $   28.00
86580   TB INTRADERMAL TEST            $   25.00
86580   TB INTRADERMAL TEST            $   28.00
86586   SKIN TEST, UNLISTED            $   20.00
86586   SKIN TEST, UNLISTED            $   24.00
86592   BLOOD SEROLOGY, QUALITATIVE    $   26.55
86592   BLOOD SEROLOGY, QUALITATIVE    $   30.00
86593   BLOOD SEROLOGY, QUANTITATIVE   $    18.00
86593   BLOOD SEROLOGY, QUANTITATIVE   $   22.00
86618   LYME DISEASE ANTIBODY          $   85.00
86618   LYME DISEASE ANTIBODY          $   88.00
86635   COCCIDIOIDES ANTIBODY          $    61.00
86635   COCCIDIOIDES ANTIBODY          $   65.00
86641   CRYPTOCOCCUS ANTIBODY          $   28.00
86641   CRYPTOCOCCUS ANTIBODY          $   32.00
86665   EPSTEIN-BARR ANTIBODY          $   75.00
86665   EPSTEIN-BARR ANTIBODY          $   82.00
86677   HELICOBACTER PYLORI            $   129.00
86677   HELICOBACTER PYLORI            $   135.00
86689   HTLV/HIV CONFIRMATORY TEST     $   70.00
86689   HTLV/HIV CONFIRMATORY TEST     $   76.00
86701   HIV-1                          $    55.21
86701   HIV-1                          $   58.00
86735   MUMPS ANTIBODY                 $    51.00
86735   MUMPS ANTIBODY                 $   55.00
86738   MYCOPLASMA ANTIBODY            $   198.00
86738   MYCOPLASMA ANTIBODY            $   210.00
86765   RUBEOLA ANTIBODY               $    84.14
86765   RUBEOLA ANTIBODY               $   90.00
86781   TREPONEMA PALLIDUM, CONFIRM    $   45.00
86781   TREPONEMA PALLIDUM, CONFIRM    $   50.00
86787   VARICELLA-ZOSTER ANTIBODY      $   66.62
86787   VARICELLA-ZOSTER ANTIBODY      $   70.00
86790   VIRUS ANTIBODY NOS             $   27.00
86790   VIRUS ANTIBODY NOS             $   30.00
86800   THYROGLOBULIN ANTIBODY         $    55.00
86800   THYROGLOBULIN ANTIBODY         $    60.00
86803   HEPATITIS C AB TEST            $    62.00
86803   HEPATITIS C AB TEST            $    65.00
86812   HLA TYPING, A, B, OR C         $   112.50
86812   HLA TYPING, A, B, OR C         $   120.00
86849   IMMUNOLOGY PROCEDURE           $   205.00
86849   IMMUNOLOGY PROCEDURE           $   220.00
86880   COOMBS TEST, DIRECT            $    20.00
86880   COOMBS TEST, DIRECT            $    24.00
86886   COOMBS TEST, INDIRECT, TITER   $    23.00
86886   COOMBS TEST, INDIRECT, TITER   $    26.00
86900   BLOOD TYPING, ABO              $    16.15
86900   BLOOD TYPING, ABO              $    20.00
86901   BLOOD TYPING, RH (D)           $    13.00
86901   BLOOD TYPING, RH (D)           $    15.00
86905   BLOOD TYPING, RBC ANTIGENS     $    32.00
86905   BLOOD TYPING, RBC ANTIGENS     $    35.00
86999   TRANSFUSION PROCEDURE          $   132.00
86999   TRANSFUSION PROCEDURE          $   140.00
87015   SPECIMEN CONCENTRATION         $    20.00
87015   SPECIMEN CONCENTRATION         $    24.00
87040   BLOOD CULTURE FOR BACTERIA     $    35.00
87040   BLOOD CULTURE FOR BACTERIA     $    38.00
87045   FECES CULTURE, BACTERIA        $    40.00
87045   FECES CULTURE, BACTERIA        $    44.00
87070   CULTURE, BACTERIA, OTHER       $    22.00
87070   CULTURE, BACTERIA, OTHER       $    25.00
87081   CULTURE SCREEN ONLY            $    25.00
87081   CULTURE SCREEN ONLY            $    28.00
87086   URINE CULTURE/COLONY COUNT     $    31.00
87086   URINE CULTURE/COLONY COUNT     $    35.00
87101   SKIN FUNGI CULTURE             $    27.00
87101   SKIN FUNGI CULTURE             $    30.00
87102   FUNGUS ISOLATION CULTURE       $    27.00
87102   FUNGUS ISOLATION CULTURE       $    30.00
87106   FUNGI IDENTIFICATION, YEAST    $    40.00
87106   FUNGI IDENTIFICATION, YEAST    $    45.00
87110   CHLAMYDIA CULTURE              $    65.00
87110   CHLAMYDIA CULTURE              $    70.00
87177   OVA AND PARASITES SMEARS       $    22.80
87177   OVA AND PARASITES SMEARS       $    25.00
87184   MICROBE SUSCEPTIBLE, DISK      $    25.00
87184   MICROBE SUSCEPTIBLE, DISK      $    28.00
87205   SMEAR, GRAM STAIN              $    15.00
87205   SMEAR, GRAM STAIN              $    18.00
87206   SMEAR, FLUORESCENT/ACID STAI   $    24.00
87206   SMEAR, FLUORESCENT/ACID STAI   $    29.00
87207   SMEAR, SPECIAL STAIN           $    15.00
87207   SMEAR, SPECIAL STAIN           $    33.00
87210   SMEAR, WET MOUNT, SALINE/INK   $    26.55
87210   SMEAR, WET MOUNT, SALINE/INK   $    32.00
87210   SMEAR, WET MOUNT, SALINE/INK   $    32.00
87220   TISSUE EXAM FOR FUNGI          $    15.00
87220   TISSUE EXAM FOR FUNGI          $    18.00
87230   ASSAY, TOXIN OR ANTITOXIN      $    75.00
87230   ASSAY, TOXIN OR ANTITOXIN      $    83.00
87250   VIRUS INOCULATE, EGGS/ANIMAL   $    75.00
87250   VIRUS INOCULATE, EGGS/ANIMAL   $    82.00
87252   VIRUS INOCULATION, TISSUE      $    64.00
87252   VIRUS INOCULATION, TISSUE      $    68.00
87273   HERPES SIMPLEX 2, AG, IF       $    56.00
87273   HERPES SIMPLEX 2, AG, IF       $    60.00
87274   HERPES SIMPLEX 1, AG, IF       $    69.00
87274   HERPES SIMPLEX 1, AG, IF       $    76.00
87491   CHYLMD TRACH, DNA, AMP PROBE   $    75.00
87491   CHYLMD TRACH, DNA, AMP PROBE   $    81.00
87521   HEPATITIS C, RNA, AMP PROBE    $   277.15
87521   HEPATITIS C, RNA, AMP PROBE    $   290.00
87522   HEPATITIS C, RNA, QUANT        $   334.25
87522   HEPATITIS C, RNA, QUANT        $   345.00
87591   N.GONORRHOEAE, DNA, AMP PROB   $   111.00
87591   N.GONORRHOEAE, DNA, AMP PROB   $   120.00
87621   HPV, DNA, AMP PROBE            $   110.30
87621   HPV, DNA, AMP PROBE            $   125.00
87880   STREP A ASSAY W/OPTIC          $    44.00
87880   STREP A ASSAY W/OPTIC          $    44.00
88108   CYTOPATH, CONCENTRATE TECH     $    95.00
88108   CYTOPATH, CONCENTRATE TECH     $   123.00
88112   CYTOPATH, CELL ENHANCE TECH    $   158.00
88142   CYTOPATH, C/V, THIN LAYER      $    60.00
88142   CYTOPATH, C/V, THIN LAYER      $    65.00
88164   CYTOPATH TBS, C/V, MANUAL      $    45.00
88164   CYTOPATH TBS, C/V, MANUAL      $    52.00
88230   TISSUE CULTURE, LYMPHOCYTE     $   310.00
88230   TISSUE CULTURE, LYMPHOCYTE     $   325.00
88262   CHROMOSOME ANALYSIS, 15-20     $   310.00
88262   CHROMOSOME ANALYSIS, 15-20     $   325.00
88289    CHROMOSOME STUDY, ADDITIONAL           $   310.00
88289    CHROMOSOME STUDY, ADDITIONAL           $   325.00
88291    CYTO/MOLECULAR REPORT                  $   310.00
88291    CYTO/MOLECULAR REPORT                  $   325.00
88304    TISSUE EXAM BY PATHOLOGIST             $    92.00
88304    TISSUE EXAM BY PATHOLOGIST             $   109.00
88305    TISSUE EXAM BY PATHOLOGIST             $   256.90
88313    SPECIAL STAINS                         $    69.00
88313    SPECIAL STAINS                         $   113.00
88342    IMMUNOHISTOCHEMISTRY                   $   102.60
89051    BODY FLUID CELL COUNT                  $    26.00
89051    BODY FLUID CELL COUNT                  $    28.00
89055    LEUKOCYTE ASSESSMENT, FECAL            $    37.45
89055    LEUKOCYTE ASSESSMENT, FECAL            $    40.00
89060    EXAM,SYNOVIAL FLUID CRYSTALS           $    26.00
89060    EXAM,SYNOVIAL FLUID CRYSTALS           $    33.00
89190    NASAL SMEAR FOR EOSINOPHILS            $    15.00
89190    NASAL SMEAR FOR EOSINOPHILS            $    18.00
89320    SEMEN ANAL VOL/COUNT/MOT               $    25.00
89320    SEMEN ANAL VOL/COUNT/MOT               $    29.00
90460    IMADM ANY ROUTE 1ST VAC/TOX            $    24.00
90461    INADM ANY ROUTE ADDL VAC/TOX           $    22.00
90465    IMMUNE ADMIN 1 INJ, < 8 YRS            $    25.00
90465    IMMUNE ADMIN 1 INJ, < 8 YRS            $    35.00
90466    IMMUNE ADMIN ADDL INJ, < 8 Y           $    25.00
90466    IMMUNE ADMIN ADDL INJ, < 8 Y           $    25.00
90470    H1N1 Administration                    $    15.00
90471    IMMUNIZATION ADMIN                     $    25.00
90471    IMMUNIZATION ADMIN                     $    26.50
90471a   Administration Fee For Etorogesterel   $   150.00
90472    IMMUNIZATION ADMIN, EACH ADD           $    25.00
90472    IMMUNIZATION ADMIN, EACH ADD           $    25.00
90632    HEP A VACCINE, ADULT IM                $    65.00
90632    HEP A VACCINE, ADULT IM                $    65.00
90633    HEP A VACC, PED/ADOL, 2 DOSE           $    53.00
90633    HEP A VACC, PED/ADOL, 2 DOSE           $    53.00
90633    HEP A VACC, PED/ADOL, 2 DOSE           $    10.00
90633    HEP A VACC, PED/ADOL, 2 DOSE           $    14.00
90633    HEP A VACC, PED/ADOL, 2 DOSE           $    16.00
90636    HEP A/HEP B VACC, ADULT IM             $   140.00
90645    HIB VACCINE, HBOC, IM                  $    82.00
90647    HIB VACCINE, PRP-OMP, IM               $    16.00
90647    HIB VACCINE, PRP-OMP, IM               $    82.00
90647    HIB VACCINE, PRP-OMP, IM               $    82.00
90647   HIB VACCINE, PRP-OMP, IM       $    10.00
90647   HIB VACCINE, PRP-OMP, IM       $    14.00
90648   HIB VACCINE, PRP-T, IM         $    16.00
90648   HIB VACCINE, PRP-T, IM         $    32.00
90648   HIB VACCINE, PRP-T, IM         $    82.00
90648   HIB VACCINE, PRP-T, IM         $    10.00
90648   HIB VACCINE, PRP-T, IM         $    14.00
90649   H PAPILLOMA VACC 3 DOSE IM     $   195.00
90649   H PAPILLOMA VACC 3 DOSE IM     $   205.00
90649   H PAPILLOMA VACC 3 DOSE IM     $    10.00
90649   H PAPILLOMA VACC 3 DOSE IM     $    14.00
90649   H PAPILLOMA VACC 3 DOSE IM     $    16.00
90655   FLU VACCINE NO PRESERV 6-35M   $    30.00
90655   FLU VACCINE NO PRESERV 6-35M   $    30.00
90655   FLU VACCINE NO PRESERV 6-35M   $    10.00
90655   FLU VACCINE NO PRESERV 6-35M   $    14.00
90655   FLU VACCINE NO PRESERV 6-35M   $    16.00
90656   FLU VACCINE NO PRESERV 3 & >   $    30.00
90656   FLU VACCINE NO PRESERV 3 & >   $    30.00
90656   FLU VACCINE NO PRESERV 3 & >   $    14.00
90656   FLU VACCINE NO PRESERV 3 & >   $    16.00
90657   FLU VACCINE, 3 YRS, IM         $    30.00
90657   FLU VACCINE, 3 YRS, IM         $    30.00
90657   FLU VACCINE, 3 YRS, IM         $    10.00
90657   FLU VACCINE, 3 YRS, IM         $    14.00
90657   FLU VACCINE, 3 YRS, IM         $    16.00
90658   FLU VACCINE, 3 YRS & >, IM     $    30.00
90658   FLU VACCINE, 3 YRS & >, IM     $    30.00
90658   FLU VACCINE, 3 YRS & >, IM     $    30.00
90658   FLU VACCINE, 3 YRS & >, IM     $    30.00
90658   FLU VACCINE, 3 YRS & >, IM     $    10.00
90658   FLU VACCINE, 3 YRS & >, IM     $    14.00
90658   FLU VACCINE, 3 YRS & >, IM     $    16.00
90660   FLU VACCINE, NASAL             $    30.00
90660   FLU VACCINE, NASAL             $    14.00
90660   FLU VACCINE, NASAL             $    16.00
90663   H1N1 Vaccination               $    15.00
90669   PNEUMOCOCCAL VACC, PED <5      $    90.37
90669   PNEUMOCOCCAL VACC, PED <5      $   105.00
90669   PNEUMOCOCCAL VACC, PED <5      $    10.00
90669   PNEUMOCOCCAL VACC, PED <5      $    14.00
90669   PNEUMOCOCCAL VACC, PED <5      $    16.00
90670   PNEUMOCOCCAL VACC, 13 VAL IM   $   165.00
90670   PNEUMOCOCCAL VACC, 13 VAL IM   $    14.00
90670   PNEUMOCOCCAL VACC, 13 VAL IM   $    16.00
90680   ROTOVIRUS VACC 3 DOSE, ORAL    $   105.33
90680   ROTOVIRUS VACC 3 DOSE, ORAL    $   112.00
90680   ROTOVIRUS VACC 3 DOSE, ORAL    $    10.00
90680   ROTOVIRUS VACC 3 DOSE, ORAL    $    14.00
90680   ROTOVIRUS VACC 3 DOSE, ORAL    $    16.00
90681   ROTAVIRUS VACC 2 DOSE ORAL     $   85.00
90681   ROTAVIRUS VACC 2 DOSE ORAL     $    14.00
90681   ROTAVIRUS VACC 2 DOSE ORAL     $    16.00
90696   DTAP-IPV VACC 4-6 YR IM        $   40.00
90696   DTAP-IPV VACC 4-6 YR IM        $    14.00
90696   DTAP-IPV VACC 4-6 YR IM        $    16.00
90698   DTAP-HIB-IP VACCINE, IM        $   35.00
90698   DTAP-HIB-IP VACCINE, IM        $    14.00
90698   DTAP-HIB-IP VACCINE, IM        $    16.00
90700   DTAP VACCINE, < 7 YRS, IM      $   40.00
90700   DTAP VACCINE, < 7 YRS, IM      $   40.00
90700   DTAP VACCINE, < 7 YRS, IM      $    10.00
90700   DTAP VACCINE, < 7 YRS, IM      $    14.00
90700   DTAP VACCINE, < 7 YRS, IM      $    16.00
90701   DTP VACCINE, IM                $   40.00
90701   DTP VACCINE, IM                $   40.00
90702   DT VACCINE < 7, IM             $   25.00
90702   DT VACCINE < 7, IM             $   25.00
90702   DT VACCINE < 7, IM             $    14.00
90702   DT VACCINE < 7, IM             $    16.00
90703   TETANUS VACCINE, IM            $    31.00
90703   TETANUS VACCINE, IM            $   35.00
90704   MUMPS VACCINE, SC              $   25.00
90704   MUMPS VACCINE, SC              $   25.00
90705   MEASLES VACCINE, SC            $   27.00
90705   MEASLES VACCINE, SC            $   27.00
90707   MMR VACCINE, SC                $   40.00
90707   MMR VACCINE, SC                $   40.00
90707   MMR VACCINE, SC                $    10.00
90707   MMR VACCINE, SC                $    14.00
90707   MMR VACCINE, SC                $    16.00
90710   MMRV VACCINE, SC               $   54.00
90710   MMRV VACCINE, SC               $   54.00
90710   MMRV VACCINE, SC               $    10.00
90710   MMRV VACCINE, SC               $    14.00
90710   MMRV VACCINE, SC               $    16.00
90712   ORAL POLIOVIRUS VACCINE        $   28.00
90712   ORAL POLIOVIRUS VACCINE        $   28.00
90713    POLIOVIRUS, IPV, SC/IM         $    16.00
90713    POLIOVIRUS, IPV, SC/IM         $    28.00
90713    POLIOVIRUS, IPV, SC/IM         $    28.00
90713    POLIOVIRUS, IPV, SC/IM         $    10.00
90713    POLIOVIRUS, IPV, SC/IM         $    14.00
90714    TD VACCINE NO PRSRV >/= 7 IM   $    50.00
90714    TD VACCINE NO PRSRV >/= 7 IM   $    50.00
90714    TD VACCINE NO PRSRV >/= 7 IM   $    14.00
90714    TD VACCINE NO PRSRV >/= 7 IM   $    16.00
90715    TDAP VACCINE >7 IM             $    59.00
90715    TDAP VACCINE >7 IM             $    59.00
90715    TDAP VACCINE >7 IM             $    10.00
90715    TDAP VACCINE >7 IM             $    14.00
90715    TDAP VACCINE >7 IM             $    16.00
90716    CHICKEN POX VACCINE, SC        $    96.00
90716    CHICKEN POX VACCINE, SC        $    96.00
90716    CHICKEN POX VACCINE, SC        $    10.00
90716    CHICKEN POX VACCINE, SC        $    14.00
90716    CHICKEN POX VACCINE, SC        $    16.00
90718    TD VACCINE > 7, IM             $    20.00
90718    TD VACCINE > 7, IM             $    30.00
90720    DTP/HIB VACCINE, IM            $    82.00
90720    DTP/HIB VACCINE, IM            $    82.00
90723    DTAP-HEP B-IPV VACCINE, IM     $   150.00
90723    DTAP-HEP B-IPV VACCINE, IM     $   150.00
90723    DTAP-HEP B-IPV VACCINE, IM     $    10.00
90723    DTAP-HEP B-IPV VACCINE, IM     $    14.00
90723    DTAP-HEP B-IPV VACCINE, IM     $    16.00
90732    PNEUMOCOCCAL VACCINE           $    45.00
90732    PNEUMOCOCCAL VACCINE           $    14.00
90732    PNEUMOCOCCAL VACCINE           $    16.00
90732M   Pneumonia Shot                 $    30.00
90734    MENINGOCOCCAL VACCINE, IM      $   114.00
90734    MENINGOCOCCAL VACCINE, IM      $    10.00
90734    MENINGOCOCCAL VACCINE, IM      $    14.00
90734    MENINGOCOCCAL VACCINE, IM      $    16.00
90736    ZOSTER VACC, SC                $   225.00
90743    HEP B VACC, ADOL, 2 DOSE, IM   $    82.00
90743    HEP B VACC, ADOL, 2 DOSE, IM   $    14.00
90743    HEP B VACC, ADOL, 2 DOSE, IM   $    16.00
90744    HEPB VACC PED/ADOL 3 DOSE IM   $    78.00
90744    HEPB VACC PED/ADOL 3 DOSE IM   $    10.00
90744    HEPB VACC PED/ADOL 3 DOSE IM   $    14.00
90744    HEPB VACC PED/ADOL 3 DOSE IM   $    16.00
90746   HEP B VACCINE, ADULT, IM       $   84.00
90747   HEPB VACC, ILL PAT 4 DOSE IM   $   130.00
90748   HEP B/HIB VACCINE, IM          $   65.00
90748   HEP B/HIB VACCINE, IM          $    14.00
90748   HEP B/HIB VACCINE, IM          $    16.00
90749   VACCINE TOXOID                 $   75.00
90760   HYDRATION IV INFUSION, INIT    $   80.00
90760   HYDRATION IV INFUSION, INIT    $   110.00
90761   HYDRATE IV INFUSION, ADD-ON    $   35.00
90772   THER/PROPH/DIAG INJ, SC/IM     $   20.00
90772   THER/PROPH/DIAG INJ, SC/IM     $   35.00
90853   GROUP PSYCHOTHERAPY            $   50.00
90853   GROUP PSYCHOTHERAPY            $   55.00
90862   MEDICATION MANAGEMENT          $   60.00
90862   MEDICATION MANAGEMENT          $    91.00
92002   EYE EXAM, NEW PATIENT          $   75.00
92002   EYE EXAM, NEW PATIENT          $   121.00
92004   EYE EXAM, NEW PATIENT          $   120.00
92004   EYE EXAM, NEW PATIENT          $   218.00
92012   EYE EXAM ESTABLISHED PAT       $   65.00
92012   EYE EXAM ESTABLISHED PAT       $   111.00
92014   EYE EXAM & TREATMENT           $   80.00
92014   EYE EXAM & TREATMENT           $   164.00
92081   VISUAL FIELD EXAMINATION(S)    $   64.00
92081   VISUAL FIELD EXAMINATION(S)    $   88.00
92551   PURE TONE HEARING TEST, AIR    $   33.00
92551   PURE TONE HEARING TEST, AIR    $   33.00
92552   PURE TONE AUDIOMETRY, AIR      $   36.00
92552   PURE TONE AUDIOMETRY, AIR      $   36.00
92553   AUDIOMETRY, AIR & BONE         $   40.00
92553   AUDIOMETRY, AIR & BONE         $   50.00
92555   SPEECH THRESHOLD AUDIOMETRY    $   30.00
92555   SPEECH THRESHOLD AUDIOMETRY    $   30.00
92557   COMPREHENSIVE HEARING TEST     $   75.00
92557   COMPREHENSIVE HEARING TEST     $    91.00
92567   TYMPANOMETRY                   $   105.00
92567   TYMPANOMETRY                   $   125.00
92568   ACOUSTIC REFL THRESHOLD TST    $   34.00
92568   ACOUSTIC REFL THRESHOLD TST    $   42.00
92569   ACOUSTIC REFLEX DECAY TEST     $   34.00
92569   ACOUSTIC REFLEX DECAY TEST     $   42.00
92582   CONDITIONING PLAY AUDIOMETRY   $   57.00
92582   CONDITIONING PLAY AUDIOMETRY   $   60.00
93000   ELECTROCARDIOGRAM, COMPLETE    $   70.00
93000   ELECTROCARDIOGRAM, COMPLETE    $    70.00
93005   ELECTROCARDIOGRAM, TRACING     $    66.00
93005   ELECTROCARDIOGRAM, TRACING     $    66.00
93307   ECHO EXAM OF HEART             $   301.00
93307   ECHO EXAM OF HEART             $   353.00
93320   DOPPLER ECHO EXAM, HEART       $   148.00
93320   DOPPLER ECHO EXAM, HEART       $   156.00
93325   DOPPLER COLOR FLOW ADD-ON      $   161.00
93325   DOPPLER COLOR FLOW ADD-ON      $   180.00
93880   EXTRACRANIAL STUDY             $   404.00
93880   EXTRACRANIAL STUDY             $   449.00
93922   EXTREMITY STUDY                $   550.00
93926   LOWER EXTREMITY STUDY          $   300.00
93931   UPPER EXTREMITY STUDY          $   226.00
93970   EXTREMITY STUDY                $   405.00
93970   EXTREMITY STUDY                $   443.00
93971   EXTREMITY STUDY                $   369.00
93971   EXTREMITY STUDY                $   375.00
93975   VASCULAR STUDY                 $   528.00
93975   VASCULAR STUDY                 $   678.00
94060   EVALUATION OF WHEEZING         $   150.00
94070   EVALUATION OF WHEEZING         $   750.00
94150   VITAL CAPACITY TEST            $    26.00
94150   VITAL CAPACITY TEST            $    32.00
94640   AIRWAY INHALATION TREATMENT    $    40.00
94640   AIRWAY INHALATION TREATMENT    $    40.00
94760   MEASURE BLOOD OXYGEN LEVEL     $    13.35
94760   MEASURE BLOOD OXYGEN LEVEL     $    15.00
94761   MEASURE BLOOD OXYGEN LEVEL     $    13.35
94761   MEASURE BLOOD OXYGEN LEVEL     $    15.00
95115   IMMUNOTHERAPY, ONE INJECTION   $    10.00
95115   IMMUNOTHERAPY, ONE INJECTION   $    25.00
95816   EEG, AWAKE AND DROWSY          $   257.00
95816   EEG, AWAKE AND DROWSY          $   356.00
96110   DEVELOPMENTAL TEST, LIM        $    28.12
99058   OFFICE EMERGENCY CARE          $    48.00
99058   OFFICE EMERGENCY CARE          $    52.00
99070   SPECIAL SUPPLIES               $     3.50
99070   SPECIAL SUPPLIES               $     5.00
99173   VISUAL ACUITY SCREEN           $    20.00
99201   OFFICE/OUTPATIENT VISIT, NEW   $    60.00
99201   OFFICE/OUTPATIENT VISIT, NEW   $    64.00
99201   OFFICE/OUTPATIENT VISIT, NEW   $    60.00
99201   OFFICE/OUTPATIENT VISIT, NEW   $    64.00
99202   OFFICE/OUTPATIENT VISIT, NEW   $    90.00
99202   OFFICE/OUTPATIENT VISIT, NEW   $   112.00
99202   OFFICE/OUTPATIENT VISIT, NEW   $    90.00
99202   OFFICE/OUTPATIENT VISIT, NEW   $   112.00
99203   OFFICE/OUTPATIENT VISIT, NEW   $   120.00
99203   OFFICE/OUTPATIENT VISIT, NEW   $   166.00
99203   OFFICE/OUTPATIENT VISIT, NEW   $   120.00
99203   OFFICE/OUTPATIENT VISIT, NEW   $   166.00
99204   OFFICE/OUTPATIENT VISIT, NEW   $   150.00
99204   OFFICE/OUTPATIENT VISIT, NEW   $   252.00
99204   OFFICE/OUTPATIENT VISIT, NEW   $   150.00
99204   OFFICE/OUTPATIENT VISIT, NEW   $   252.00
99205   OFFICE/OUTPATIENT VISIT, NEW   $   200.00
99205   OFFICE/OUTPATIENT VISIT, NEW   $   316.00
99205   OFFICE/OUTPATIENT VISIT, NEW   $   200.00
99205   OFFICE/OUTPATIENT VISIT, NEW   $   316.00
99211   OFFICE/OUTPATIENT VISIT, EST   $    30.00
99211   OFFICE/OUTPATIENT VISIT, EST   $    36.00
99211   OFFICE/OUTPATIENT VISIT, EST   $    30.00
99211   OFFICE/OUTPATIENT VISIT, EST   $    36.00
99212   OFFICE/OUTPATIENT VISIT, EST   $    50.00
99212   OFFICE/OUTPATIENT VISIT, EST   $    66.00
99212   OFFICE/OUTPATIENT VISIT, EST   $    50.00
99212   OFFICE/OUTPATIENT VISIT, EST   $    66.00
99213   OFFICE/OUTPATIENT VISIT, EST   $    65.00
99213   OFFICE/OUTPATIENT VISIT, EST   $   107.00
99213   OFFICE/OUTPATIENT VISIT, EST   $    65.00
99213   OFFICE/OUTPATIENT VISIT, EST   $   107.00
99214   OFFICE/OUTPATIENT VISIT, EST   $    95.00
99214   OFFICE/OUTPATIENT VISIT, EST   $   162.00
99214   OFFICE/OUTPATIENT VISIT, EST   $    95.00
99214   OFFICE/OUTPATIENT VISIT, EST   $   162.00
99215   OFFICE/OUTPATIENT VISIT, EST   $   150.00
99215   OFFICE/OUTPATIENT VISIT, EST   $   219.00
99215   OFFICE/OUTPATIENT VISIT, EST   $   150.00
99215   OFFICE/OUTPATIENT VISIT, EST   $   219.00
99217   OBSERVATION CARE DISCHARGE     $   100.00
99217   OBSERVATION CARE DISCHARGE     $   119.00
99218   OBSERVATION CARE               $   120.00
99218   OBSERVATION CARE               $   137.00
99218   OBSERVATION CARE               $   120.00
99218   OBSERVATION CARE               $   137.00
99219   OBSERVATION CARE               $   175.00
99219   OBSERVATION CARE               $   185.00
 99220    OBSERVATION CARE                $   200.00
 99220    OBSERVATION CARE                $   261.00
 99221    INITIAL HOSPITAL CARE           $   130.00
 99221    INITIAL HOSPITAL CARE           $   153.00
9922125   INITIAL HOSPITAL CARE, LOW      $   130.00
9922125   INITIAL HOSPITAL CARE, LOW      $   153.00
 99222    INITIAL HOSPITAL CARE           $   165.00
 99222    INITIAL HOSPITAL CARE           $   214.00
9922225   INITAL HOSPITAL CARE, MED       $   165.00
9922225   INITAL HOSPITAL CARE, MED       $   214.00
 99223    INITIAL HOSPITAL CARE           $   200.00
 99223    INITIAL HOSPITAL CARE           $   312.00
9922325   INITIAL HOSPITAL CARE, HIGH     $   200.00
9922325   INITIAL HOSPITAL CARE, HIGH     $   312.00
 99224    SUBSEQUENT OBSERVATION CARE     $    75.00
 99225    SUBSEQUENT OBSERVATION CARE     $   105.00
 99226    SUBSEQUENT OBSERVATION CARE     $   135.00
 99231    SUBSEQUENT HOSPITAL CARE        $    75.00
 99231    SUBSEQUENT HOSPITAL CARE        $    85.00
9923125   SUBSEQUENT HOSPITAL CARE, LOW   $    75.00
9923125   SUBSEQUENT HOSPITAL CARE, LOW   $    85.00
 99232    SUBSEQUENT HOSPITAL CARE        $   100.00
 99232    SUBSEQUENT HOSPITAL CARE        $   115.00
9923225   SUBSEQUENT HOSPITAL CARE, MED   $   100.00
9923225   SUBSEQUENT HOSPITAL CARE, MED   $   115.00
 99233    SUBSEQUENT HOSPITAL CARE        $   140.00
 99233    SUBSEQUENT HOSPITAL CARE        $   164.00
9923325   SUBSEQUENT HOSPITAL CARE        $   164.00
 99234    OBSERV/HOSP SAME DATE           $   165.00
 99234    OBSERV/HOSP SAME DATE           $   225.00
 99235    OBSERV/HOSP SAME DATE           $   220.00
 99235    OBSERV/HOSP SAME DATE           $   297.00
 99236    OBSERV/HOSP SAME DATE           $   260.00
 99236    OBSERV/HOSP SAME DATE           $   370.00
 99238    HOSPITAL DISCHARGE DAY          $    95.00
 99238    HOSPITAL DISCHARGE DAY          $   118.00
9923825   HOSPITAL DISCHARGE DAY          $    95.00
9923825   HOSPITAL DISCHARGE DAY          $   118.00
 99239    HOSPITAL DISCHARGE DAY          $   140.00
 99239    HOSPITAL DISCHARGE DAY          $   171.00
 99241    OFFICE CONSULTATION             $   100.00
 99241    OFFICE CONSULTATION             $   110.00
 99242    OFFICE CONSULTATION             $   140.00
 99242    OFFICE CONSULTATION             $   161.00
 99243    OFFICE CONSULTATION            $    170.00
 99243    OFFICE CONSULTATION            $    220.00
 99244    OFFICE CONSULTATION            $    225.00
 99244    OFFICE CONSULTATION            $    323.00
 99245    OFFICE CONSULTATION            $    290.00
 99245    OFFICE CONSULTATION            $    401.00
 99251    INPATIENT CONSULTATION         $     115.00
 99252    INPATIENT CONSULTATION         $    150.00
 99253    INPATIENT CONSULTATION         $    185.00
 99253    INPATIENT CONSULTATION         $    196.00
 99254    INPATIENT CONSULTATION         $    240.00
 99254    INPATIENT CONSULTATION         $    282.00
 99255    INPATIENT CONSULTATION         $    280.00
 99255    INPATIENT CONSULTATION         $    351.00
 99281    EMERGENCY DEPT VISIT           $     70.00
 99282    EMERGENCY DEPT VISIT           $    100.00
 99283    EMERGENCY DEPT VISIT           $    130.00
 99284    EMERGENCY DEPT VISIT           $    200.00
 99285    EMERGENCY DEPT VISIT           $    280.00
 99285    EMERGENCY DEPT VISIT           $    298.00
 99291    CRITICAL CARE, FIRST HOUR      $    300.00
 99291    CRITICAL CARE, FIRST HOUR      $    461.00
9929125   CRITICAL CARE, FIRST HOUR      $    300.00
 99292    CRITICAL CARE, ADD'L 30 MIN    $    150.00
 99292    CRITICAL CARE, ADD'L 30 MIN    $    206.00
9929225   CRITIAL CARE, ADDL 30 MIN      $    150.00
 99295    NEONATE CRIT CARE, INITIAL     $   1,130.00
 99295    NEONATE CRIT CARE, INITIAL     $   1,564.00
 99296    NEONATE CRITICAL CARE SUBSEQ   $    753.00
 99304    NURSING FACILITY CARE, INIT    $     90.00
 99304    NURSING FACILITY CARE, INIT    $     110.00
 99305    NURSING FACILITY CARE, INIT    $    120.00
 99305    NURSING FACILITY CARE, INIT    $    146.00
 99306    NURSING FACILITY CARE, INIT    $    160.00
 99306    NURSING FACILITY CARE, INIT    $    179.00
 99307    NURSING FAC CARE, SUBSEQ       $    190.00
 99308    NURSING FAC CARE, SUBSEQ       $     80.00
 99308    NURSING FAC CARE, SUBSEQ       $     95.00
 99309    NURSING FAC CARE, SUBSEQ       $     80.00
 99309    NURSING FAC CARE, SUBSEQ       $    133.00
 99310    NURSING FAC CARE, SUBSEQ       $     110.00
 99310    NURSING FAC CARE, SUBSEQ       $    166.00
 99315    NURSING FAC DISCHARGE DAY      $     90.00
 99315    NURSING FAC DISCHARGE DAY      $    103.00
99316   NURSING FAC DISCHARGE DAY      $   120.00
99316   NURSING FAC DISCHARGE DAY      $   135.00
99318   ANNUAL NURSING FAC ASSESSMNT   $   105.00
99318   ANNUAL NURSING FAC ASSESSMNT   $   110.00
99341   HOME VISIT, NEW PATIENT        $    80.00
99341   HOME VISIT, NEW PATIENT        $    98.00
99342   HOME VISIT, NEW PATIENT        $   100.00
99342   HOME VISIT, NEW PATIENT        $   143.00
99343   HOME VISIT, NEW PATIENT        $   160.00
99343   HOME VISIT, NEW PATIENT        $   207.00
99354   PROLONGED SERVICE, OFFICE      $   200.00
99355   PROLONGED SERVICE, OFFICE      $   100.00
99355   PROLONGED SERVICE, OFFICE      $   163.00
99356   PROLONGED SERVICE, INPATIENT   $   225.00
99357   PROLONGED SERVICE, INPATIENT   $   115.00
99357   PROLONGED SERVICE, INPATIENT   $   151.00
99358   PROLONGED SERV, W/O CONTACT    $   125.00
99360   PHYSICIAN STANDBY SERVICES     $    98.00
99362   PHYSICIAN/TEAM CONFERENCE      $   154.00
99372   PHYSICIAN PHONE CONSULTATION   $    40.00
99373   PHYSICIAN PHONE CONSULTATION   $    90.00
99381   INIT PM E/M, NEW PAT, INF      $   150.00
99382   INIT PM E/M, NEW PAT 1-4 YRS   $   160.00
99383   PREV VISIT, NEW, AGE 5-11      $   155.00
99384   PREV VISIT, NEW, AGE 12-17     $   160.00
99385   PREV VISIT, NEW, AGE 18-39     $   175.00
99386   PREV VISIT, NEW, AGE 40-64     $   210.00
99387   INIT PM E/M, NEW PAT 65+ YRS   $   240.00
99391   PER PM REEVAL, EST PAT, INF    $   120.00
99392   PREV VISIT, EST, AGE 1-4       $   140.00
99393   PREV VISIT, EST, AGE 5-11      $   130.00
99394   PREV VISIT, EST, AGE 12-17     $   160.00
99395   PREV VISIT, EST, AGE 18-39     $   160.00
99396   PREV VISIT, EST, AGE 40-64     $   175.00
99397   PER PM REEVAL EST PAT 65+ YR   $   180.00
99401   PREVENTIVE COUNSELING, INDIV   $    50.00
99402   PREVENTIVE COUNSELING, INDIV   $    95.00
99403   PREVENTIVE COUNSELING, INDIV   $   135.00
99406   BEHAV CHNG SMOKING 3-10 MIN    $    45.00
99407   BEHAV CHNG SMOKING >10 MIN     $    60.00
99408   AUDIT/DAST, 15-30 MIN          $    45.00
99409   AUDIT/DAST, OVER 30 MIN        $    55.00
99431   INITIAL CARE, NORMAL NEWBORN   $   150.00
99433   NORMAL NEWBORN CARE/HOSPITAL   $    85.00
99435   NEWBORN DISCHARGE DAY HOSP                     $   175.00
99436   ATTENDANCE, BIRTH                              $   175.00
99440   NEWBORN RESUSCITATION                          $   255.00
99441   PHONE E/M BY PHYS 5-10 MIN                     $    25.00
99460   Init nb em per day, hosp                       $   125.00
99462   Sbsq nb em per day, hosp                       $   100.00
99463   Same day nb discharge                          $   125.00
99464   Attendance At Birth                            $   125.00
99465   Newborn Resucitation                           $   175.00
A4561   Pessary rubber, any type                       $    48.00
A4561   Pessary rubber, any type                       $    57.00
A4565   Slings                                         $     2.99
A4565   Slings                                         $     5.00
A4641   Radiopharm dx agent noc                        $   128.00
A4641   Radiopharm dx agent noc                        $   156.00
C9003   Palivizumab, per 50 mg                         $   787.00
C9003   Palivizumab, per 50 mg                         $   765.04
G0008   Admin influenza virus vac                      $    26.50
G0009   Admin pneumococcal vaccine                     $    25.00
G0010   Admin hepatitis b vaccine                      $    20.00
G0179   MD recertification HHA PT                      $    50.00
G0180   MD certification HHA patient                   $    65.00
G0181   Home health care supervision                   $   125.00
G0202   Screeningmammographydigital                    $   250.00
G0204   Diag Mammo Digital Bilateral                   $   383.10
G0206   Diag Mammo Digital Unilateral                  $   300.00
G0394   Blood occult test,colorectal                   $    20.00
G0396   Alcohol/subs interv 15-30mn                    $    45.00
G0397   Alcohol/subs interv >30 min                    $    60.00
G9141   H1N1 Admninistration                           $    15.00
G9142   H1N1 Vaccine                                   $    30.00
J0170   Adrenalin epinephrin inject                    $     6.50
J0280   Aminophyllin 250 MG inj                        $     6.50
J0460   Atropine sulfate injection                     $     6.00
J0530   Penicillin g benzathine inj                    $    19.63
J0540   Penicillin g benzathine inj                    $    16.50
J0550   Penicillin g benzathine inj                    $    33.00
J0560   Penicillin g benzathine inj 6000,000 Units     $    12.50
J0570   Penicillin g benzathine inj, 1,200,000 Uni     $    18.50
J0580   Penicillin g benzathine inj, 2,400,000 Units   $    43.10
J0696   Ceftriaxone sodium injection                   $    16.50
J0704   Betamethasone sod phosp/4 MG                   $    14.15
J0735   Clonidine hydrochloride                        $    80.00
J0780   Prochlorperazine injection                     $    12.50
J0885   Epoetin alfa, non-esrd                              $    15.00
J0970   Estradiol valerate injection                        $    46.00
J1000   Depo-estradiol cypionate inj                        $     8.00
J1030   Methylprednisolone 40 MG inj                        $     7.00
J1055   Medrxyprogester acetate inj                         $    70.00
J1055   Medrxyprogester acetate inj                         $    95.00
J1056   MA/EC contraceptiveinjection                        $    35.00
J1060   Testosterone cypionate 1 ML                         $    11.00
J1100   Dexamethasone sodium phos                           $    12.50
J1200   Diphenhydramine hcl injectio                        $     6.00
J1460   Gamma globulin 1 CC inj                             $    30.00
J1470   Gamma globulin 2 CC inj                             $    30.00
J1500   Gamma globulin 5 CC inj                             $   100.00
J1510   Gamma globulin 6 CC inj                             $   100.00
J1520   Gamma globulin 7 CC inj                             $   120.00
J1580   Garamycin gentamicin inj                            $     7.50
J1630   Haloperidol injection                               $    41.00
J1631   Haloperidol decanoate inj                           $    30.00
J1720   Hydrocortisone sodium succ i                        $     7.75
J1815   Insulin injection                                   $    30.00
J1885   Ketorolac tromethamine inj 15mg (use For Toradol)   $    12.50
J1940   Furosemide injection                                $     6.00
J1950   Leuprolide acetate /3.75 MG                         $   550.00
J2001   Lidocaine injection                                 $     6.50
J2060   Lorazepam injection                                 $     6.00
J2175   Meperidine hydrochl /100 MG                         $     6.00
J2180   Meperidine/promethazine inj                         $    12.00
J2270   Morphine sulfate injection                          $     6.00
J2510   Penicillin g procaine inj                           $    15.00
J2540   Penicillin g potassium inj                          $     6.00
J2550   Promethazine hcl injection                          $     6.00
J2680   Fluphenazine decanoate 25 MG                        $    18.00
J2788   Rho d immune globulin 50 mcg                        $    28.00
J2788   Rho d immune globulin 50 mcg                        $    35.00
J2790   Rho d immune globulin inj                           $   120.00
J2790   Rho d immune globulin inj                           $   120.00
J2910   Aurothioglucose injeciton                           $    36.00
J2920   Methylprednisolone injection                        $     7.00
J2930   Methylprednisolone injection                        $    12.50
J3130   Testosterone enanthate inj Up To 200mg              $    23.00
J3150   Testosteron propionate inj                          $     7.00
J3250   Trimethobenzamide hcl inj                           $     6.00
J3301   Triamcinolone acetonide inj                         $     9.00
J3302   Triamcinolone diacetate inj                         $    20.64
J3360    Diazepam injection                            $     6.50
J3360    Diazepam injection                            $     8.00
J3410    Hydroxyzine hcl injection Up To 25mg          $     6.00
J3420    Vitamin b12 injection                         $     7.00
J3430    Vitamin k phytonadione inj                    $    10.00
J3490A   INJ; UNCLSSFD DRG; MARCAIN                    $     1.00
J3490A   INJ; UNCLSSFD DRG; MARCAIN                    $   150.00
J7030    Normal saline solution infus                  $    15.00
J7300    Intraut copper contraceptive                  $   621.00
J7300    Intraut copper contraceptive                  $   650.00
J7302    Levonorgestrel iu contracept                  $   674.00
J7307    Etonogestrel implant system                   $   650.00
J7506    Prednisone oral                               $     5.00
J7603    Albuterol inh non-comp u d                    $     1.00
J7609    Albuterol comp unit                           $     1.00
J7613    Albuterol unit dose                           $     1.00
J7633    Budesonide non-comp con                       $     5.00
J7644    Ipratropium bromide non-comp                  $     5.00
J9202    Goserelin acetate implant                     $   566.42
J9213    Interferon alfa-2a inj                        $    57.00
J9214    Interferon alfa-2b inj                        $    37.00
J9216    Interferon gamma 1-b inj                      $   150.00
J9217    Leuprolide acetate suspnsion                  $   610.00
J9260    Methotrexate sodium inj                       $    13.25
Q0091    Obtaining screen pap smear                    $    48.00
Q0091    Obtaining screen pap smear                    $    71.00
Q0114    Fern test                                     $    15.00
Q2038    Medicare Flu Shot                             $    30.00
S0180    Etonogestrel (contraceptive) Implant System   $   650.00
S0181    Ondansetron 4 mg                              $    15.00
S9075    Smoking cessation treatment                   $    55.00
D6241    Pontic, Pfm Non Precious                      $   569.00
D6545    Maryland Bridge                               $   397.00
D6750    Crown, Pfm                                    $   704.00
D6751    Crown, Pfm, Non Precious                      $   658.00
D6790    Crown, Full Gold                              $   680.00
D6791    Crown, Full Cast, Non Precious                $   644.00
D6930    Re-Cement Bridge                              $   105.00
D6930    Re-Cement Bridge                              $   118.40
D7111    Extract Coronal remnants deciduous tooth      $    96.00
D7111    Extract Coronal remnants deciduous tooth      $    85.00
D7140    Extraction erupted tooth or exposed root      $    85.00
D7140    Extraction erupted tooth or exposed root      $    96.00
D7210    Surgical extr erupted tooth                   $   152.00
 D7210     Surgical extr erupted tooth                  $   144.00
 D7220     Extract soft tissue impacted tooth           $   167.00
 D7220     Extract soft tissue impacted tooth           $   216.00
 D7230     Extraction, Partial Bony                     $   288.00
 D7230     Extraction, Partial Bony                     $   218.00
 D7250     Surgical removal of residual roots           $   156.00
 D7270     Tooth Replacement, Per Tooth                 $   305.00
 D7285     Biopsy - Hard                                $   150.00
 D7286     Biopsy - Soft                                $   150.00
 D7310     Alveoloplasty W/Extn.                        $   175.00
 D7310     Alveoloplasty W/Extn.                        $   200.00
 D7320     Alveoloplasty W/O Extn.                      $   240.00
 D7320     Alveoloplasty W/O Extn.                      $   195.00
 D7510     Incision & drainage of soft tissue abscess   $   135.00
 D7997     Band Removal                                 $   150.00
 D8680     Hawley Wire                                  $   230.00
 D9110     Palliative tx dental pain minor proc         $    68.00
 D9430     Office Visit (No Chrg)                       $    32.00
 D9430     Office Visit (No Chrg)                       $    40.00
 D9940     Occlusal Guard                               $   280.00
DMANG      DM - PROMOTORA                               $      -
FreePreg   Free Pregnancy Test                          $      -
 G0008     Admin influenza virus vac                    $    20.00
 G0009     Admin pneumococcal vaccine                   $    25.00
 G0010     Admin hepatitis b vaccine                    $    20.00
 HEAZ      Health-e-Arizona Screening                   $      -
 J0170     Adrenalin epinephrin inject                  $     6.50
 J0280     Aminophyllin 250 MG inj                      $     6.50
 J0460     Atropine sulfate injection                   $     6.00
 J0530     Penicillin g benzathine inj                  $    19.63
 J0540     Penicillin g benzathine inj                  $    16.50
 J0550     Penicillin g benzathine inj                  $    33.00
 J0560     Penicillin g benzathine inj                  $    12.50
 J0570     Penicillin g benzathine inj                  $    18.50
 J0580     Penicillin g benzathine inj                  $    43.10
 J0696     Ceftriaxone sodium injection                 $    16.50
 J0704     Betamethasone sod phosp/4 MG                 $    14.15
 J0735     Clonidine hydrochloride                      $    80.00
 J0780     Prochlorperazine injection                   $    12.50
 J0885     Epoetin alfa, non-esrd                       $    15.00
 J0970     Estradiol valerate injection                 $    46.00
 J1000     Depo-estradiol cypionate inj                 $     8.00
 J1030     Methylprednisolone 40 MG inj                 $     7.00
 J1055     Medrxyprogester acetate inj                  $    70.00
J1055    Medrxyprogester acetate inj         $    95.00
J1056    MA/EC contraceptiveinjection        $    35.00
J1060    Testosterone cypionate 1 ML         $    11.00
J1100    Dexamethasone sodium phos           $    12.50
J1200    Diphenhydramine hcl injectio        $     6.00
J1460    Gamma globulin 1 CC inj             $    30.00
J1470    Gamma globulin 2 CC inj             $    30.00
J1500    Gamma globulin 5 CC inj             $   100.00
J1510    Gamma globulin 6 CC inj             $   100.00
J1520    Gamma globulin 7 CC inj             $   120.00
J1580    Garamycin gentamicin inj            $     7.50
J1630    Haloperidol injection               $    41.00
J1631    Haloperidol decanoate inj           $    30.00
J1720    Hydrocortisone sodium succ i        $     7.75
J1815    Insulin injection                   $    30.00
J1885    Ketorolac tromethamine inj, 15 Mg   $    12.50
J1940    Furosemide injection                $     6.00
J1950    Leuprolide acetate /3.75 MG         $   550.00
J2001    Lidocaine injection                 $     6.50
J2060    Lorazepam injection                 $     6.00
J2175    Meperidine hydrochl /100 MG         $     6.00
J2270    Morphine sulfate injection          $     6.00
J2510    Penicillin g procaine inj           $    15.00
J2540    Penicillin g potassium inj          $     6.00
J2550    Promethazine hcl injection          $     6.00
J2680    Fluphenazine decanoate 25 MG        $    18.00
J2788    Rho d immune globulin 50 mcg        $    28.00
J2788    Rho d immune globulin 50 mcg        $    35.00
J2790    Rho d immune globulin inj           $   120.00
J2790    Rho d immune globulin inj           $   120.00
J2910    Aurothioglucose injeciton           $    36.00
J2920    Methylprednisolone injection        $     7.00
J2930    Methylprednisolone injection        $    12.50
J3130    Testosterone enanthate inj          $    23.00
J3150    Testosteron propionate inj          $     7.00
J3250    Trimethobenzamide hcl inj           $     6.00
J3301    Triamcinolone acetonide inj         $     9.00
J3302    Triamcinolone diacetate inj         $    20.64
J3360    Diazepam injection                  $     6.50
J3360    Diazepam injection                  $     8.00
J3410    Hydroxyzine hcl injection           $     6.00
J3420    Vitamin b12 injection               $     7.00
J3430    Vitamin k phytonadi