106560501_CDM_All_2007

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					OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  200   INTENSIVE CARE GENERAL              50.3020       30340   INTENSIVE CARE UNIT OJAI                     2,362.00
  200   INTENSIVE CARE GENERAL              50.3020       32101   ICU DEF OBS UNIT                             1,842.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32110   BRONCHOSCOPY                                   297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32115   CHEST TUBE INSERTION                           214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32120   COLONOSCOPY                                    297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32121   BONE MARROW ASPIRATION                         214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32130   EGD W-SCHLEROSING THERAPY                      214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32132   GROSHONG CATHETER INSERTION                    297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32134   LIVER BIOPSY                                   214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32135   ELECTIVE CARDIOVERSION                         420.00                        92960           1
  490   AMB SURGICAL CARE GENERAL           50.3020       32136   LUMBAR PUNCTURE                                214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32137   MINOR PROCEDURE                                214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32139   MINOR PROCEDURE TIME CHARGE                     46.00
  490   AMB SURGICAL CARE GENERAL           50.3020       32144   PICC LINE INSERTION                            504.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32146   QUINTON CATHETER INSERTION                     297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32148   RADIUM SEED IMPLANT                            297.00                                        1
  230   INCREM NURS CHG GENERAL             50.3020       32155   POST OP RECOVERY-1ST HOUR                      364.00                                        1
  230   INCREM NURS CHG GENERAL             50.3020       32160   POST OP RECOVERY-TIME CHARGE                    77.00
  490   AMB SURGICAL CARE GENERAL           50.3020       32170   SWAN GANZ CATH INSERTION                       297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32175   TEMPORARY PACER INSERTION                      297.00                                        1
  710   RECOVERY ROOM GENERAL               50.3020       32176   RECOVERY SERVICES 30MINS TO 1                  277.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32177   RECOVERY SERVICES 1 TO 2 HOURS                 455.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32178   RECOVERY SERVICES 2 TO 3 HOURS                 638.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32179   RECOVERY SERVICES 3 TO 4 HOURS                 817.00   Z7512                                1
  490   AMB SURGICAL CARE GENERAL           50.3020       32180   TRACHEOSTOMY                                   214.00                                        1
  710   RECOVERY ROOM GENERAL               50.3020       32181   RECOVERY SERVICES 4 TO 8 HOURS               1,274.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32182   RECOVERY SERVICES 8 TO 12 HOUR               1,636.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32183   RECOVERY SERVICES 12 TO 18 HOU               2,000.00   Z7512                                1
  710   RECOVERY ROOM GENERAL               50.3020       32184   RECOVERY SERVICES 18 TO 24 HOU               2,362.00   Z7512                                1
  490   AMB SURGICAL CARE GENERAL           50.3020       32185   RN TRANSPORT                                   214.00
  710   RECOVERY ROOM GENERAL               50.3020       32186   RECOVERY SVCS-4HR INCREM>24HRS                 277.00   Z7512
  490   AMB SURGICAL CARE GENERAL           50.3020       32187   ENDOTRACHEAL INTUBATION                        214.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32188   THORACENTESIS                                  214.00                                        1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32194   BLOOD TRANSFUSION 4 TO 8 HOURS                 911.00                        36430           1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32195   BLOOD TRANSFUSION 8 TO 12 HOUR               1,090.00                        36430           1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32196   BLOOD TRANSFUSION 12 TO 18 HOU               1,274.00                        36430           1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32197   BLOOD TRANSFUSION 18 TO 24 HOU               1,454.00                        36430           1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32198   BLOOD TRANSFUSION-4HR INCREM>2                 277.00                        36430
  490   AMB SURGICAL CARE GENERAL           50.3020       32301   OBSERVATION SERVICES 0 TO 4 HO                 941.00                                        1
  762   TREAT/OBS RM OBSERVATION            50.3020       32302   OBSERVATION SERVICES 4 TO 8 HO               1,274.00                                        1
  762   TREAT/OBS RM OBSERVATION            50.3020       32303   OBSERVATION SERVICES 8 TO 12 H               1,636.00                                        1
  762   TREAT/OBS RM OBSERVATION            50.3020       32304   OBSERVATION SERVICES 12 TO 18                2,000.00                                        1
  762   TREAT/OBS RM OBSERVATION            50.3020       32306   OBSERVATION SVCS-4HR INCREM>24                 277.00
  490   AMB SURGICAL CARE GENERAL           50.3020       32310   BRONCHOSCOPY                                   297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32320   COLONOSCOPY                                    297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32330   EGD W-SCHLEROSING THERAPY                      214.00                                        1
  480   CARDIOLOGY GENERAL                  50.3020       32335   ELECTIVE CARDIOVERSION                         420.00                        92960           1
  490   AMB SURGICAL CARE GENERAL           50.3020       32344   PICC LINE INSERTION                            504.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32346   QUINTON CATHETER INSERTION                     297.00                                        1
  490   AMB SURGICAL CARE GENERAL           50.3020       32348   RADIUM SEED IMPLANT                            297.00                                        1
  719   RECOVERY ROOM OTHER                 50.3020       32355   POST OP RECOVERY-1ST HOUR                      364.00   Z7512                                1
  230   INCREM NURS CHG GENERAL             50.3020       32360   POST OP RECOVERY-TIME CHARGE                    77.00   Z7512

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            1 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL       CPT-4      HCPCS      RVU
  490   AMB SURGICAL CARE GENERAL           50.3020       32370   SWAN GANZ CATH INSERTION                        297.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3020       32375   TEMPORARY PACER INSERTION                       297.00                                           1
  710   RECOVERY ROOM GENERAL               50.3020       32376   RECOVERY SERVICES 30MINS TO 1                   277.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32377   RECOVERY SERVICES 1 TO 2 HOURS                  455.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32378   RECOVERY SERVICES 2 TO 3 HOURS                  638.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32379   RECOVERY SERVICES 3 TO 4 HOURS                  817.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3020       32380   TRACHEOSTOMY                                    214.00                                           1
  710   RECOVERY ROOM GENERAL               50.3020       32381   RECOVERY SERVICES 4 TO 8 HOURS                1,274.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32382   RECOVERY SERVICES 8 TO 12 HOUR                1,636.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32383   RECOVERY SERVICES 12 TO 18 HOU                2,000.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3020       32384   RECOVERY SERVICES 18 TO 24 HOU                2,362.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3020       32385   RN TRANSPORT                                    214.00
  710   RECOVERY ROOM GENERAL               50.3020       32386   RECOVERY SVCS-4HR INCREM>24HRS                  277.00 Z7512
  490   AMB SURGICAL CARE GENERAL           50.3020       32387   ENDOTRACHEAL INTUBATION                         214.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3020       32388   THORACENTESIS                                   214.00                                           1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32394   BLOOD TRANSFUSION 4 TO 8 HOURS                  911.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32395   BLOOD TRANSFUSION 8 TO 12 HOUR                1,090.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32396   BLOOD TRANSFUSION 12 TO 18 HOU                1,274.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32397   BLOOD TRANSFUSION 18 TO 24 HOU                1,454.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3020       32398   BLOOD TRANSFUSION-4HR INCREM>2                  277.00                             36430
  230   INCREM NURS CHG GENERAL             50.3020       32399   CCU HBA MISC CHARGE                         misc charge bsd on cost at time of svcs
  120   SEMI-PRIVATE ROOM & BOARD           50.3177       30311   MED SURGICAL SEMI PVT                           852.00
  110   PRIVATE ROOM & BOARD                50.3177       30321   MED SURGICAL PRIVATE                            978.00
  111   PRIVATE MED/SURG/GYN                50.3177       30336   MED SURGICAL ISOLATION                        1,103.00                                           1
  130   SEMI-PRIV 3/4 BED GENERAL           50.3177       30370   MED SURGICAL WARD BED                           756.00                                           1
  710   RECOVERY ROOM GENERAL               50.3177       32420   RECOVERY SERVICES-INTERM                        529.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3177       32421   BONE MARROW ASPIRATION                          209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32423   BRONCHOSCOPY                                    291.00                                           1
  480   CARDIOLOGY GENERAL                  50.3177       32425   CARDIOVERSION                                   413.00                             92960         1
  490   AMB SURGICAL CARE GENERAL           50.3177       32427   COLONOSCOPY                                     291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32429   EGD W/SCHLEROSING THERAPY                       209.00                                           1
  710   RECOVERY ROOM GENERAL               50.3177       32430   RECOVERY SERVICES-MAJOR                         690.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3177       32432   GROSHONG CATHETER INSERTION                     291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32434   LIVER BIOPSY                                    209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32436   LUMBAR PUNCTURE                                 209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32437   MINOR PROCEDURE                                 209.00 Z7506                                     1
  490   AMB SURGICAL CARE GENERAL           50.3177       32439   MINOR PROCEDURE-TIME CHARGE                       46.00 Z7508
  490   AMB SURGICAL CARE GENERAL           50.3177       32444   PICC LINE INSERTION                             493.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32446   QUINTON CATHETER INSERTION                      291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32448   RADIUM SEED IMPLANT                             291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32452   THORACENTHESIS                                  209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3177       32455   CHEST TUBE INSERTION                            209.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32470   OBSERVATION SERVICES 0 TO 4 HR                  921.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32471   OBSERVATION SERVICES 4 TO 8 HR                1,434.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32472   OBSERVATION SERVICES 8 TO 12 H                1,842.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32473   OBSERVATION SERVICES 12 TO 18                 2,252.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32474   OBSERVATION SERVICES 18 TO 24                 2,658.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       32475   OBSERVATION SVCS - 4HR INCREM>                  270.00
  391   BLOOD STOR/PROC ADMINIS             50.3177       32477   BLOOD TRANSFUSION 30MINS TO 1                   270.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32478   BLOOD TRANSFUSION 1 TO 2 HOURS                  360.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32479   BLOOD TRANSFUSION 2 TO 3 HOURS                  447.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32480   BLOOD TRANSFUSION 3 TO 4 HOURS                  538.00                             36430         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                2 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL       CPT-4      HCPCS      RVU
  391   BLOOD STOR/PROC ADMINIS             50.3177       32481   BLOOD TRANSFUSION 4 TO 8 HRS                    894.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32482   BLOOD TRANSFUSION 8 TO 12 HRS                 1,069.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32483   BLOOD TRANSFUSION 12 TO 18 HRS                1,246.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32484   BLOOD TRANSFUSION 18 TO 24 HRS                1,424.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3177       32485   BLOOD TRANSFUSION-4 HR INCREM>                  270.00                             36430
  490   AMB SURGICAL CARE GENERAL           50.3177       32486   PROSTATHERAPIES                              11,681.00                             53850         3
  490   AMB SURGICAL CARE GENERAL           50.3177       32487   PROSTATHERAPIES                              11,681.00                             53850
  762   TREAT/OBS RM OBSERVATION            50.3177       35310   4TH-OBSERVATION CHARGE                          894.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3177       36104   OBSERVATION SERVICES 0-4 HRS                    941.00                                           1
  999   PT CONVEN OTHER                     50.3177       98701   PRIVATE SITTER CHARGE                       misc charge bsd on cost at time of svcs              1
  270   M/S SUPPLY GENERAL                  50.3178       29201   3CC NACL PRESSURE MONITOR SYRI                    80.00
  270   M/S SUPPLY GENERAL                  50.3178       29202   QUICK PRESSURE MONITOR PACK                     343.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.3178       29203   STEINMAN PIN                                    343.00                                           1
  270   M/S SUPPLY GENERAL                  50.3178       29204   TRACTION BOWS                                   674.00                                           1
  761   TREAT/OBS RM TREATMENT RM           50.3178       29205   MINOR PROCEDURE                                 671.00                                           1
  120   SEMI-PRIVATE ROOM & BOARD           50.3178       30335   MED SURGICAL SWING BED                          567.00
  710   RECOVERY ROOM GENERAL               50.3178       32507   RECOVERY SERVICES 30 MINS TO 1                  309.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32508   RECOVERY SERVICES 1 TO 2 HOURS                  513.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32509   RECOVERY SERVICES 2 TO 3 HOURS                  719.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32510   RECOVERY SERVICES 3 TO 4 HRS                    921.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32511   RECOVERY SERVICES 4 TO 8 HRS                  1,434.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32512   RECOVERY SERVICES 8 TO 12 HRS                 1,844.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32513   RECOVERY SERVICES 12 TO 18 HRS                2,252.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32514   RECOVERY SERVICES 18 TO 24 HRS                2,658.00 Z7512                                     1
  710   RECOVERY ROOM GENERAL               50.3178       32515   RECOVERY SERVICES-4HOUR INCREM                  309.00 Z7512
  710   RECOVERY ROOM GENERAL               50.3178       32520   RECOVERY SERVICES-INTERM                        529.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3178       32521   BONE MARROW ASPIRATION                          209.00                                           1
  480   CARDIOLOGY GENERAL                  50.3178       32525   CARDIOVERSION                                   413.00                             92960         1
  490   AMB SURGICAL CARE GENERAL           50.3178       32527   COLONOSCOPY                                     291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32529   EGD W/SCHLEROSING THERAPY                       209.00                                           1
  710   RECOVERY ROOM GENERAL               50.3178       32530   RECOVERY SERVICES - MAJOR                       690.00 Z7512                                     1
  490   AMB SURGICAL CARE GENERAL           50.3178       32532   GROSHONG CATHETER INSERTION                     291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32534   LIVER BIOPSY                                    209.00                                           1
  230   INCREM NURS CHG GENERAL             50.3178       32535   PRE-OPERATIVE SERVICES                          207.00
  490   AMB SURGICAL CARE GENERAL           50.3178       32536   LUMBAR PUNCTURE                                 209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32537   MINOR PROCEDURE                                 209.00 Z7506                                     1
  490   AMB SURGICAL CARE GENERAL           50.3178       32539   MINOR PROCEDURE-TIME CHARGE                       46.00 Z7508
  490   AMB SURGICAL CARE GENERAL           50.3178       32540   PARACENTHESIS                                   209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32544   PICC LINE INSERTION                             493.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32546   QUINTON CATHETER INSERTION                      291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32548   RADIUM SEED IMPLANT                             291.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32552   THORACENTHESIS                                  209.00                                           1
  490   AMB SURGICAL CARE GENERAL           50.3178       32555   CHEST TUBE INSERTION                            209.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32570   OBSERVATION SERVICES 0 TO 4 HR                  802.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32571   OBSERVATION SERVICES 4 TO 8 HR                1,246.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32572   OBSERVATION SERVICES 8 TO 12 H                1,602.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32573   OBSERVATION SERVICES 12 TO 18                 1,957.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32574   OBSERVATION SERVICES 18 TO 24                 2,312.00                                           1
  762   TREAT/OBS RM OBSERVATION            50.3178       32575   OBSERVATION SVCS - 4 HR INCREM                  270.00
  391   BLOOD STOR/PROC ADMINIS             50.3178       32577   BLOOD TRANSFUSION 30MINS TO 1                   270.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32578   BLOOD TRANSFUSION 1 TO 2 HOURS                  360.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32579   BLOOD TRANSFUSION 2 TO 3 HOURS                  447.00                             36430         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                3 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                      CHARGE
 CHG          CATEGORY AND NAME              DPT       CODE                    DESCRIPTION                     CHARGE       MCAL       CPT-4      HCPCS      RVU
  391   BLOOD STOR/PROC ADMINIS             50.3178       32580   BLOOD TRANSFUSION 3 TO 4 HRS                    538.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32581   BLOOD TRANSFUSION 4 TO 8 HRS                    894.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32582   BLOOD TRANSFUSION 8 TO 12 HRS                 1,069.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32583   BLOOD TRANSFUSION 12 TO 18 HRS                1,246.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32584   BLOOD TRANSFUSION 18 TO 24 HRS                1,424.00                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.3178       32585   BLOOD TRANSFUSION-4 HR INCREM>                  270.00                             36430
  230   INCREM NURS CHG GENERAL             50.3178       32599   5TH FLOOR HBA MISC CHARGE                   misc charge bsd on cost at time of svcs
  762   TREAT/OBS RM OBSERVATION            50.3178       35311   5TH FLOOR-OBSERVATION CHARGE                    894.00                                           1
  185   LV OF ABS NURSING HOME              50.3580       30401   SNF BEDHOLD SEMI                                299.00                                           1
  185   LV OF ABS NURSING HOME              50.3580       30402   SNF BEHOLD WARD                                 285.00                                           1
  120   SEMI-PRIVATE ROOM & BOARD           50.3580       30403   SNF SEMI PRIVATE                                324.00                                           1
  130   SEMI-PRIV 3/4 BED GENERAL           50.3580       30404   SNF WARD                                        305.00                                           1
  110   PRIVATE ROOM & BOARD                50.3580       30405   SNF PRIVATE                                     351.00                                           1
  450   EMERGENCY ROOM GENERAL              50.4010       60001   EMERG DEPT-BRIEF SERVICE                        151.20 Z7502                       99281         1
  450   EMERGENCY ROOM GENERAL              50.4010       60002   EMERG DEPT-BASIC SERVICE                        287.30 Z7502           99282       99282         1
  450   EMERGENCY ROOM GENERAL              50.4010       60003   EMERG DEPT-INTERMEDIATE SERVIC                  520.60 Z7502                       99283         1
  450   EMERGENCY ROOM GENERAL              50.4010       60004   EMERG DEPT-EXTENDED SERVICE                     862.95 Z7502                       99284         1
  450   EMERGENCY ROOM GENERAL              50.4010       60005   EMERG DEPT-COMPLEX SERVICE                    1,596.25 Z7502                       99285         1
  450   EMERGENCY ROOM GENERAL              50.4010       60006   EMERG DEPT-CRITICAL CARE                      2,390.05 Z7502                       99291         1
  391   BLOOD STOR/PROC ADMINIS             50.4010       60008   BLOOD TRANSFUSION OUT PATIENT                 1,366.20                             36430         1
  450   EMERGENCY ROOM GENERAL              50.4010       60009   IPECAC ADMINISTRATION HOSP                      156.60                 99195       99195
  450   EMERGENCY ROOM GENERAL              50.4010       60010   CARDIO PULMONARY RESUSCITATION                1,715.05 Z7502                       92950         1
  450   EMERGENCY ROOM GENERAL              50.4010       60011   ED BASIC OBSERVATION-1/2 HOUR                     74.55 Z7502                  G0244
  450   EMERGENCY ROOM GENERAL              50.4010       60021   ED CRITICAL OBSERVATION-1/2 HO                  100.45 Z7502                   G0244
  450   EMERGENCY ROOM GENERAL              50.4010       60031   ER MINOR PROCEDURE                              178.20                                           1
  450   EMERGENCY ROOM GENERAL              50.4010       60032   ER INTERMEDIATE PROCEDURE                       237.60                                           1
  450   EMERGENCY ROOM GENERAL              50.4010       60033   ER MAJOR PROCEDURE                              653.40                                           1
  450   EMERGENCY ROOM GENERAL              50.4010       60099   ED HBA MISC CHARGE                          misc charge bsd on cost at time of svcs
  762   TREAT/OBS RM OBSERVATION            50.4010       60126   ER OBSERVATION EA ADD 4HOUR IN                  411.50 Z7502
  450   EMERGENCY ROOM GENERAL              50.4010       60129   EAR IRRIGATION BY NURSE                           67.00                                          1
  450   EMERGENCY ROOM GENERAL              50.4010       60130   EYE IRRIGATION BY NURSE                           67.00                                          1
  450   EMERGENCY ROOM GENERAL              50.4010       60131   FOLEY CATH INSERTION BY NURSE                     67.00
  450   EMERGENCY ROOM GENERAL              50.4010       60132   GASTRIC LAVAGE BY NURSE                         445.00                             91105         1
  450   EMERGENCY ROOM GENERAL              50.4010       60133   IV INJECTIONS                                   234.40            C8952            90774         1
  450   EMERGENCY ROOM GENERAL              50.4010       60134   N/G TUBE INSERTION                                67.00                                          1
  450   EMERGENCY ROOM GENERAL              50.4010       60135   TRANSPORT CRITICAL CARE                           67.00                                          1
  270   M/S SUPPLY GENERAL                  50.4010       60136   ORTHO-GLASS SPLINTING MATERIAL                    92.90
  269   IV THERAPY OTHER                    50.4010       60138   IV INFUSION ADMIN                               623.20            C8950            90765         1
  450   EMERGENCY ROOM GENERAL              50.4010       60140   INJECTION OF ANTIBIOTIC                         263.55     90772                   90772         1
  450   EMERGENCY ROOM GENERAL              50.4010       60141   DERMABOND                                       204.15            G0168
  480   CARDIOLOGY GENERAL                  50.4010       60142   CARDIOVERSION                                   412.60                             92960
  450   EMERGENCY ROOM GENERAL              50.4010       60143   IMMUN/VACINE INJECTION                            89.65                                          1
  301   LABORATORY CHEMISTRY                50.4010       60144   URINE PREG TEST BY VIS COLOR                      35.65                            81025         1
  300   LABORATORY GENERAL                  50.4010       60145   CATH FOR URINE SPEC COLLECTION                    71.30           P9612
  460   PULMONARY FUNCTION GENERAL          50.4010       60146   PULSE OX A/P                                    295.95                             94761         1
  269   IV THERAPY OTHER                    50.4010       60147   IV INFUSION EACH ADD HOUR                         10.80           C8951            90766         1
  450   EMERGENCY ROOM GENERAL              50.4010       60155   IV INJECTION SUBSEQUENT                         127.62     90775       90775       90775         1
  450   EMERGENCY ROOM GENERAL              50.4010       60156   IV MED INFUSION CONCURRENT                      108.79     90768       90768       90768         1
  450   EMERGENCY ROOM GENERAL              50.4010       60157   IV MED INFUSION ADD SEQ TO 1HR                  194.94     90767       90767       90767         1
  460   PULMONARY FUNCTION GENERAL          50.4010       61045   PULSE OXIMETER SINGLE                           141.50                             94760         1
  636   DRUG SPEC ID DETAIL CODING          50.4010 DIPER         DIPHTHERIA TETANUS TOXOID                         88.60                            90718         1
  981   PROF FEES EMERGENCY ROOM            50.4011       66000   MINIMAL SERVICE - PROF                            42.30                            99281

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                4 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL       CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66001   BRIEF SERVICE - PROF                            72.50                           99281
  981   PROF FEES EMERGENCY ROOM            50.4011       66002   LIMITED SERVICE - PROF                         105.75                           99282
  981   PROF FEES EMERGENCY ROOM            50.4011       66003   INTERMEDIATE SERVICE - PROF                    178.30                           99283
  981   PROF FEES EMERGENCY ROOM            50.4011       66004   EXTENDED SERVICE - PROF                        270.30                           99284
  981   PROF FEES EMERGENCY ROOM            50.4011       66005   COMPREHENSIVE SERVICE - PROF                   422.30                           99285
  981   PROF FEES EMERGENCY ROOM            50.4011       66007   BRIEF SERVICE- PROF                             72.50      99281              9928125
  981   PROF FEES EMERGENCY ROOM            50.4011       66008   LIMITED SERVICE - PROF                         105.75    9928225              9928225
  981   PROF FEES EMERGENCY ROOM            50.4011       66009   INTERMEDIATE SERVICE- PROF                     178.30    9928325              9928325
  981   PROF FEES EMERGENCY ROOM            50.4011       66010   EXTENDED SERVICE- PROF                         270.30    9928425              9928425
  981   PROF FEES EMERGENCY ROOM            50.4011       66011   COMPREHENSIVE SERVICE- PROF                    422.30    9928525              9928525
  981   PROF FEES EMERGENCY ROOM            50.4011       66012   OPHTHALMOLOGICAL EXAM ESTAB PA                 114.80                           92012
  981   PROF FEES EMERGENCY ROOM            50.4011       66013   DENTAL BLOCK,INJ TRIG N BRANCH                 106.70      64400                64400
  981   PROF FEES EMERGENCY ROOM            50.4011       66020   ANALYSIS OF ARTERIAL BLOOD - P                  96.70                         8280326
  981   PROF FEES EMERGENCY ROOM            50.4011       66021   URINALYSIS DIP STICK4.54                        12.10                         8100126
  985   PROF FEES EKG                       50.4011       66022   RHYTHM ECG 1 TO 3 LEADS - PROF                  45.35    9304226                93042
  981   PROF FEES EMERGENCY ROOM            50.4011       66024   PREL RHYTHM STP INTERP - PROF2                  15.00                         9304026
  981   PROF FEES EMERGENCY ROOM            50.4011       66041   TISSUE ADHESIVE WOUND REPAIR                   105.75                           12011
  981   PROF FEES EMERGENCY ROOM            50.4011       66042   INPATIENT EXAM,LIMTD - PROF                     81.55                           99231
  981   PROF FEES EMERGENCY ROOM            50.4011       66043   INPATIENT EXAM INTERM - PROF                   121.45                           99232
  981   PROF FEES EMERGENCY ROOM            50.4011       66044   INPATIENT EXAM,EXT - PROF                      182.85                           99233
  981   PROF FEES EMERGENCY ROOM            50.4011       66050   CONSULTATION,LIMTD - PROF                      141.90                           99251
  981   PROF FEES EMERGENCY ROOM            50.4011       66052   CONSULTATION,INTERM - PROF                     200.90                           99252
  981   PROF FEES EMERGENCY ROOM            50.4011       66054   CONSULTATION,EXT - PROF                        224.95                           99253
  981   PROF FEES EMERGENCY ROOM            50.4011       66062   CPR,STANDARD - PROF                            557.35                           92950
  981   PROF FEES EMERGENCY ROOM            50.4011       66064   CPR,PROLONGED - PROF                           556.60                           92950
  981   PROF FEES EMERGENCY ROOM            50.4011       66068   CRITICAL CARE 30-74 MIN-PROF                   572.65    9929125              9929125
  981   PROF FEES EMERGENCY ROOM            50.4011       66069   CRIT CARE EACH ADD'L 30 MIN                    224.95    9929225              9929225
  981   PROF FEES EMERGENCY ROOM            50.4011       66070   CRITICAL CARE 30-74 MIN                        572.65                           99291
  981   PROF FEES EMERGENCY ROOM            50.4011       66071   CRITICAL CARE EACH ADDL 30 MIN                 224.95                           99292
  981   PROF FEES EMERGENCY ROOM            50.4011       66072   DETENTION TIME,30 MIN - PROF                   136.00                           99354
  981   PROF FEES EMERGENCY ROOM            50.4011       66074   DETENTION TIME,1 HR - PROF                     271.90                           99356
  981   PROF FEES EMERGENCY ROOM            50.4011       66076   INITIAL HOSPITAL CARE                           89.10                           99221
  981   PROF FEES EMERGENCY ROOM            50.4011       66081   CRITIAL CARE SUB BRIEF EXAM                     90.65    9929152              9929152
  981   PROF FEES EMERGENCY ROOM            50.4011       66082   CRITICAL CARE SUB LIMITED EXAM                 123.90    9929152              9929152
  981   PROF FEES EMERGENCY ROOM            50.4011       66083   CRITICAL CARE SUB INTERMED EXA                 157.10                           99291
  981   PROF FEES EMERGENCY ROOM            50.4011       66084   CRITICAL CARE SUB EXT RE-EXAM                  226.55                           99291
  981   PROF FEES EMERGENCY ROOM            50.4011       66085   CONSCIOUS SEDATION:ORAL/RECTAL                 155.40                           99142
  981   PROF FEES EMERGENCY ROOM            50.4011       66086   THORACOTOMY, MAJOR, WITH CARD                2,692.65    3216054              3216054
  981   PROF FEES EMERGENCY ROOM            50.4011       66087   THORACOTOMY MAJOR                            2,692.65    3211054              3211054
  981   PROF FEES EMERGENCY ROOM            50.4011       66088   INSERT TIMP CARDIAC ELECTRODE                1,042.05                           33210
  981   PROF FEES EMERGENCY ROOM            50.4011       66089   CONSCIOUS SEDATION: IV/IM/INHA                 181.30                           99141
  981   PROF FEES EMERGENCY ROOM            50.4011       66090   TEMPORARY TRANSCUTANEOUS PACIN                 450.10                           92953
  981   PROF FEES EMERGENCY ROOM            50.4011       66091   THROMBOLYSIS CEREBRAL                          725.25                           37195
  981   PROF FEES EMERGENCY ROOM            50.4011       66092   THROMBOLYSIS CORONARY                          149.55                         9297752
  981   PROF FEES EMERGENCY ROOM            50.4011       66094   THROMBOLYSIS CORONARY                          299.05                           92977
  981   PROF FEES EMERGENCY ROOM            50.4011       66098   THORACENTESIS INSERT OF TUBE                   431.95                           32002
  981   PROF FEES EMERGENCY ROOM            50.4011       66100   GASTRIC INTUBATION & LAVAGE -                  185.85   91105ZK                 91105
  981   PROF FEES EMERGENCY ROOM            50.4011       66101   TRACHEOSTOMY REPLACEMENT - PRO                 561.45   31603ZK               3160352
  981   PROF FEES EMERGENCY ROOM            50.4011       66102   ENDOTRACHEAL INTUBATION - PROF                 274.85   31500ZK                 31500
  981   PROF FEES EMERGENCY ROOM            50.4011       66103   PLACEMENT VENOUS CATH PERCUTAN                 252.25                           36488
  981   PROF FEES EMERGENCY ROOM            50.4011       66104   CVP PLACEMENT PERCUTANEOUS>AGE                 252.25   36571ZK                 36571
  981   PROF FEES EMERGENCY ROOM            50.4011       66105   PERITONEOCENTESIS INITIAL                      190.40   49080ZK                 49080

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           5 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL       CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66106   CVP PLACE VIA CUTDOWN > AGE 2                 367.05                           36568
  981   PROF FEES EMERGENCY ROOM            50.4011       66107   PERITONEOCENTESIS SUBSEQUENT                  190.40                           49081
  981   PROF FEES EMERGENCY ROOM            50.4011       66108   PERITONEAL LAVAGE - PROF                      284.45                           49420
  981   PROF FEES EMERGENCY ROOM            50.4011       66109   PLACEMENT VENOUS CATHETER CUTD                367.05                           36490
  981   PROF FEES EMERGENCY ROOM            50.4011       66110   CLOSED TUBE THORACOSTOMY - PRO                502.45   32020ZK                 32020
  981   PROF FEES EMERGENCY ROOM            50.4011       66112   GASTRIC LAVAGE - PROF                         153.25                           91055
  981   PROF FEES EMERGENCY ROOM            50.4011       66114   NG TUBE PLACEMENT - PROF0.00                   39.70   91299ZK                 91299
  981   PROF FEES EMERGENCY ROOM            50.4011       66116   CARDIOVERSION ARRHYTHMIA - PRO                450.10                           92960
  981   PROF FEES EMERGENCY ROOM            50.4011       66117   PERICARDIOCENTESIS INITIAL - P                288.60   33010ZK                 33010
  981   PROF FEES EMERGENCY ROOM            50.4011       66118   VAGINAL DELIVERY - PROF                       768.70      59410                59410
  981   PROF FEES EMERGENCY ROOM            50.4011       66119   LARYNGOSCOPY FLEX REM FOREIGN                 356.15                           31577
  981   PROF FEES EMERGENCY ROOM            50.4011       66120   REM CONJCT FB - PROF                           75.45   65205ZK                 65205
  981   PROF FEES EMERGENCY ROOM            50.4011       66121   DELIVERY OF PLACENTA                          154.10                           59414
  981   PROF FEES EMERGENCY ROOM            50.4011       66122   REM EMB CONJCT FB - PROF                       84.60                           65210
  981   PROF FEES EMERGENCY ROOM            50.4011       66124   REM EMB CORNEAL FB - PROF                      77.45   65220ZK                 65220
  981   PROF FEES EMERGENCY ROOM            50.4011       66126   REM EMB CORNL FB, SLIT LAMP -                 113.40   65222ZK                 65222
  981   PROF FEES EMERGENCY ROOM            50.4011       66127   PELVIC EXAM NOT UNDER ANESTHES                 68.05    5741052              5741052
  981   PROF FEES EMERGENCY ROOM            50.4011       66128   REM FB EXT AUD CANAL - PROF                   117.00   69200ZK                 69200
  981   PROF FEES EMERGENCY ROOM            50.4011       66129   INTROD HEMOSTATIC AGENT                       120.85                           57180
  981   PROF FEES EMERGENCY ROOM            50.4011       66130   REMOVE IMP CERUMEN - PROF                      87.65   69210ZK                 69210
  981   PROF FEES EMERGENCY ROOM            50.4011       66131   CHANGE OF GASTROSTOMY TUBE                    137.35   43760ZK                 43760
  981   PROF FEES EMERGENCY ROOM            50.4011       66132   REMOVE FB,NASAL - PROF                        116.95   30300ZK                 30300
  981   PROF FEES EMERGENCY ROOM            50.4011       66134   ANT EPISTAXIS SIMPLE                          136.80   30901ZK                 30901
  981   PROF FEES EMERGENCY ROOM            50.4011       66135   LARYNGOSCOPY FLEXIBLE                         184.25                           31575
  981   PROF FEES EMERGENCY ROOM            50.4011       66136   NASAL HEMORRAGE, POSTERIOR INI                367.05   30905ZK                 30905
  981   PROF FEES EMERGENCY ROOM            50.4011       66137   LARYNGOSCOPY DIRECT DIAGNOSTIC                584.45                           31525
  981   PROF FEES EMERGENCY ROOM            50.4011       66138   REMOVE FB, MOUTH - PROF                       251.50                           40804
  981   PROF FEES EMERGENCY ROOM            50.4011       66139   LARYNGOSCOPY DIRECT                           184.25                           31515
  981   PROF FEES EMERGENCY ROOM            50.4011       66140   DRAIN ABSCESS,MOUTH - PROF                     54.40                           40800
  981   PROF FEES EMERGENCY ROOM            50.4011       66141   POST DENTAL HEMORRHAGE - PROF                 130.35                           41899
  981   PROF FEES EMERGENCY ROOM            50.4011       66142   POST TONSIL HEMORRHAGE - PROF                 222.00                           42960
  981   PROF FEES EMERGENCY ROOM            50.4011       66143   LARYNGOSCOPY,INDIRECT - PROF                  132.95   31505ZK                 31505
  981   PROF FEES EMERGENCY ROOM            50.4011       66144   LARYNGOSCOPY,REM FB - PROF                    191.75                           31511
  981   PROF FEES EMERGENCY ROOM            50.4011       66145   LARYNGOSCOPY,DIRECT,REM FB - P                238.95                           31530
  981   PROF FEES EMERGENCY ROOM            50.4011       66146   ANOSCOPY W/REMOVAL OF FOREIGN                 182.90   46608ZK                 46608
  981   PROF FEES EMERGENCY ROOM            50.4011       66147   I & D ABSCESS,PERIANAL - PROF                 191.20                           46050
  981   PROF FEES EMERGENCY ROOM            50.4011       66148   CONDYLOMATA,ANAL - PROF                        54.40                           46900
  981   PROF FEES EMERGENCY ROOM            50.4011       66149   INCISION OF THROMBOTIC HEMORRH                219.75                           46083
  981   PROF FEES EMERGENCY ROOM            50.4011       66150   OCCULT BLOOD - PROF                            19.65                           82270
  981   PROF FEES EMERGENCY ROOM            50.4011       66151   BLADDER ASPIRATION BY NEEDLE -                 92.60                           51000
  981   PROF FEES EMERGENCY ROOM            50.4011       66152   URETHERAL CATH,SIMPLE - PROF                   57.95   51702ZK                 51702
  981   PROF FEES EMERGENCY ROOM            50.4011       66153   URETHERAL CATH,COMPL - PROF                   164.35                           51703
  981   PROF FEES EMERGENCY ROOM            50.4011       66154   COLPOCENTESIS - PROF                          131.40   57020ZK                 57020
  981   PROF FEES EMERGENCY ROOM            50.4011       66155   CYSTOGRAM INJ - PROF                           48.30                           51600
  981   PROF FEES EMERGENCY ROOM            50.4011       66156   VENIPUNCTURE/IV > 3 YRS                        42.30   36410ZK                 36410
  981   PROF FEES EMERGENCY ROOM            50.4011       66157   ANOSCOPY DIAGNOSTIC                            90.65   46600ZK                 46600
  981   PROF FEES EMERGENCY ROOM            50.4011       66158   IV, 3 YRS - PROF                               71.05                           36400
  981   PROF FEES EMERGENCY ROOM            50.4011       66159   ASPIRATION OF BLADDER BY TROCA                169.20                           51005
  981   PROF FEES EMERGENCY ROOM            50.4011       66160   IV CUTDOWN,<1 YR - PROF                       169.20                           36420
  981   PROF FEES EMERGENCY ROOM            50.4011       66161   IV CUTDOWN,>1 YR - PROF                       169.20                           36425
  981   PROF FEES EMERGENCY ROOM            50.4011       66162   ARTERIAL PUNCTURE - PROF                       49.90   36600ZK                 36600
  981   PROF FEES EMERGENCY ROOM            50.4011       66163   ASPIRATN BLDDR INSRT SUPRAPUBI                253.75                           51010

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                          6 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE       MCAL      CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66164   LUMBAR PUNCTURE - PROF                        164.60   62270ZK                 62270
  981   PROF FEES EMERGENCY ROOM            50.4011       66165   INJ ANESTH AGENT,PERI NERVE -                 133.10   64450ZM                 64450
  981   PROF FEES EMERGENCY ROOM            50.4011       66166   BURN,1ST DEGREE,INIT - PROF                    95.80   16000ZK                 16000
  981   PROF FEES EMERGENCY ROOM            50.4011       66167   BURN,W/O ANESTH, SMALL <9% - P                 89.10   16020ZK                 16020
  981   PROF FEES EMERGENCY ROOM            50.4011       66168   BURN,W/O ANESTH, MED 9%-18% -                 206.40   16025ZK                 16025
  981   PROF FEES EMERGENCY ROOM            50.4011       66169   REMOVE FB VAGINA - PROF                       322.20   57415ZK                 57415
  981   PROF FEES EMERGENCY ROOM            50.4011       66170   REMOVE FB,SUBCUTANEOUS, SIMPLE                154.75   10120ZK                 10120
  981   PROF FEES EMERGENCY ROOM            50.4011       66171   DEBRIDEMENT,SKIN,PARTIAL THICK                 87.65   11040ZK                 11040
  981   PROF FEES EMERGENCY ROOM            50.4011       66172   REMOVE FB,MUSCLE,SIMPLE - PROF                382.75   20520ZK                 20520
  981   PROF FEES EMERGENCY ROOM            50.4011       66173   REMOVE IUD - PROF                             119.65                           58301
  981   PROF FEES EMERGENCY ROOM            50.4011       66174   AVULSION NAIL PLATE, SINGLE -                 130.50   11730ZK                 11730
  981   PROF FEES EMERGENCY ROOM            50.4011       66175   AVULSION 2ND NAIL PLATE - PROF                 66.35                           11732
  981   PROF FEES EMERGENCY ROOM            50.4011       66176   AVULSION EA ADD NAIL PLATE - P                 66.35                           11732
  981   PROF FEES EMERGENCY ROOM            50.4011       66177   BURN DRESSINGS SML <9%                        138.95                           16010
  981   PROF FEES EMERGENCY ROOM            50.4011       66178   PINCH GRAFT,SINGLE - PROF                     173.90                           15050
  981   PROF FEES EMERGENCY ROOM            50.4011       66179   IPECAC ADMINISTRATION                         102.75                 99175     99175
  981   PROF FEES EMERGENCY ROOM            50.4011       66180   I & D CYST - PROF                             145.20   10060ZK                 10060
  981   PROF FEES EMERGENCY ROOM            50.4011       66181   PHLEBOTOMY THERAPEUTIC                         42.30                           99195
  981   PROF FEES EMERGENCY ROOM            50.4011       66182   I & D FURUNCLE - PROF                          87.65   10060ZK                 10060
  981   PROF FEES EMERGENCY ROOM            50.4011       66183   I & D BARTHOLINS ABSCESS - PRO                199.40   56420ZK                 56420
  981   PROF FEES EMERGENCY ROOM            50.4011       66184   I & D ABSCESS, SIMPLE - PROF                  145.20   10060ZK                 10060
  981   PROF FEES EMERGENCY ROOM            50.4011       66185   I & D ONYCHIA, SINGLE/SIMPLE -                145.20   10060ZK                 10060
  981   PROF FEES EMERGENCY ROOM            50.4011       66186   I & D HEMATOMA, SIMPLE - PROF                 191.75   10140ZK                 10140
  981   PROF FEES EMERGENCY ROOM            50.4011       66187   PUNCTURE ASPIRATION - PROF                    155.45   10160ZK                 10160
  981   PROF FEES EMERGENCY ROOM            50.4011       66188   DEBRIDE INFECT SKIN - 10%                      87.65                           11000
  981   PROF FEES EMERGENCY ROOM            50.4011       66190   BLADDER IRRIGATION SIMPLE                      48.30                           51700
  981   PROF FEES EMERGENCY ROOM            50.4011       66191   CHANGE OF CYSTOSTOMY TUBE                      69.55                           51705
  981   PROF FEES EMERGENCY ROOM            50.4011       66192   PASSAGE OF FILIFORM                           140.55                           53620
  981   PROF FEES EMERGENCY ROOM            50.4011       66193   NONINVASIVE PULSE OXIMETRY MUL                 45.35    9476126              9476126
  981   PROF FEES EMERGENCY ROOM            50.4011       66194   DRAINAGE OF SCROTAL WALL ABSCE                120.85                           55100
  981   PROF FEES EMERGENCY ROOM            50.4011       66195   INCISION & DRAINAGE PERINEAL A                133.10                           56405
  981   PROF FEES EMERGENCY ROOM            50.4011       66196   INCISION & DRAINAGE ABSCESS OF                138.95                           56405
  981   PROF FEES EMERGENCY ROOM            50.4011       66199   BRONCHOSPASM EVAL                              80.15    9406026              9406026
  981   PROF FEES EMERGENCY ROOM            50.4011       66201   LACR,SIMP,OTHR THAN FAC,2.5CM                 211.05                           12001
  981   PROF FEES EMERGENCY ROOM            50.4011       66202   LACR,SIMP,OTHR THN FAC,2.6-7.5                231.85                           12002
  981   PROF FEES EMERGENCY ROOM            50.4011       66203   COMPLEX LAC SCALP,ARM,LEG EA A                339.90                           13122
  981   PROF FEES EMERGENCY ROOM            50.4011       66204   LACR,SIMP,OTHR THN FAC,7.6-12.                278.75                           12004
  981   PROF FEES EMERGENCY ROOM            50.4011       66205   LACR,SIMP,OTHR FAC,12.6-20.0CM                356.60                           12005
  981   PROF FEES EMERGENCY ROOM            50.4011       66206   LACR,SIMP,OTHR FAC,20.1-30.0CM                478.50                           12006
  981   PROF FEES EMERGENCY ROOM            50.4011       66207   LACR SIMP OTHR THAN FAC OVER 3                515.70                           12007
  981   PROF FEES EMERGENCY ROOM            50.4011       66208   LACR COMPLX TRNK,LIMBS EACH AD                365.45                           13122
  981   PROF FEES EMERGENCY ROOM            50.4011       66209   LACR CMPLX FACE HND FT EA ADD                 400.25                           13133
  981   PROF FEES EMERGENCY ROOM            50.4011       66210   LACR CMPLX LID NOSE EAR EAC AD                455.35                           13153
  981   PROF FEES EMERGENCY ROOM            50.4011       66211   LACR,SIMP,FACIAL,TO 2.5CM - PR                220.75                           12011
  981   PROF FEES EMERGENCY ROOM            50.4011       66213   LACR,SIMP,FACIAL,2.6-5.0CM - P                250.55                           12013
  981   PROF FEES EMERGENCY ROOM            50.4011       66214   LACR,SIMP,FACIAL,5.1-7.5CM - P                308.10                           12014
  981   PROF FEES EMERGENCY ROOM            50.4011       66215   LACR,SIMP,FACIAL,7.6-12.5CM -                 392.65                           12015
  981   PROF FEES EMERGENCY ROOM            50.4011       66216   LACR,SIMP,FACIAL,12.5-20.0 CM                 617.65                           12016
  981   PROF FEES EMERGENCY ROOM            50.4011       66217   LACR SIMP FACIAL 20.1 TO 30.0                 841.60                           12017
  981   PROF FEES EMERGENCY ROOM            50.4011       66218   LACR SIMP FACIAL OVER 30.0 CM                 971.05                           12018
  981   PROF FEES EMERGENCY ROOM            50.4011       66231   LACR,INTER,SCALP,TRNK,EXT,2.5C                266.10                           12031
  981   PROF FEES EMERGENCY ROOM            50.4011       66232   LACR,INT,SCLP,TRNK,EXT,2.6-7.5                301.05                           12032

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                          7 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL     CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66234   LACR,INT,SCLP,TRNK,EXT,7.6-12.                 374.15                        12034
  981   PROF FEES EMERGENCY ROOM            50.4011       66235   LACR,INT,SCLP,TRNK,EXT12.6-20.                 392.65                        12035
  981   PROF FEES EMERGENCY ROOM            50.4011       66236   LACR,INT,SCLP,TRNK,EXT20.1-30.                 505.95                        12036
  981   PROF FEES EMERGENCY ROOM            50.4011       66237   LACR INTER SCALP TRUNK EXT OVE                 619.25                        12037
  981   PROF FEES EMERGENCY ROOM            50.4011       66241   LACR,INTER,NECK,ETC,TO 2.5CM -                 290.80                        12041
  981   PROF FEES EMERGENCY ROOM            50.4011       66242   LACR,INTER,NECK,ETC,2.6-7.5CM                  334.05                        12042
  981   PROF FEES EMERGENCY ROOM            50.4011       66244   LACR,INTER,NECK,ETC,7.6-12.5CM                 364.00                        12044
  981   PROF FEES EMERGENCY ROOM            50.4011       66245   LACR,INTER,NECK,ETC,12.6-20.0C                 477.25                        12045
  981   PROF FEES EMERGENCY ROOM            50.4011       66246   LACR,INTER,NECK,ETC,20.1-30.0C                 646.45                        12046
  981   PROF FEES EMERGENCY ROOM            50.4011       66247   LACR INTER NECK ETC OVER 30.0                  799.55                        12047
  981   PROF FEES EMERGENCY ROOM            50.4011       66251   LACR,INTER,FACIAL,TO 2.5CM - P                 309.45                        12051
  981   PROF FEES EMERGENCY ROOM            50.4011       66252   LACR,INTER,FACIAL,2.6-5.0CM -                  308.10 12052ZK                12052
  981   PROF FEES EMERGENCY ROOM            50.4011       66253   LACR,INTER,FACIAL,5.1-7.5CM -                  392.65 12053ZK                12053
  981   PROF FEES EMERGENCY ROOM            50.4011       66254   LACR,INTER,FACIAL,7.6-12.5CM -                 617.65                        12054
  981   PROF FEES EMERGENCY ROOM            50.4011       66255   LACR,INTER,FACIAL,12.6-20.0CM                  928.80                        12055
  981   PROF FEES EMERGENCY ROOM            50.4011       66256   LACR INTER FACIAL 20.1 TO 30.0                 936.85                        12056
  981   PROF FEES EMERGENCY ROOM            50.4011       66257   LACR INTER FACIAL OVER 30.0 CM               1,222.90                        12057
  981   PROF FEES EMERGENCY ROOM            50.4011       66260   LACR,CMPLX,TRUNK,1.1-2.5 CM PR                 396.10                        13100
  981   PROF FEES EMERGENCY ROOM            50.4011       66261   LACR,CMPLX,TRUNK,2.6-7.5CM - P                 501.80                        13101
  981   PROF FEES EMERGENCY ROOM            50.4011       66262   LACR,CMPLX,SCALP,ARM,1.1-2.5 C                 417.60                        13120
  981   PROF FEES EMERGENCY ROOM            50.4011       66264   LACR,CMPLX,SCALP,ARM,2.6-7.5CM                 730.85                        13121
  981   PROF FEES EMERGENCY ROOM            50.4011       66265   ASPIRATION OF BLADDER BY NEEDL                 169.20                        51000
  981   PROF FEES EMERGENCY ROOM            50.4011       66266   LACR,CMPLX,FRHD,ETC,1.1-2.5CM                  448.55                        13131
  981   PROF FEES EMERGENCY ROOM            50.4011       66268   LACR,CMPLX,FRHD,ETC,2.6-7.5CM                  800.40                        13132
  981   PROF FEES EMERGENCY ROOM            50.4011       66270   LACR,CMPLX,EYLD,ETC,1.0 CM OR                  535.45                        13150
  981   PROF FEES EMERGENCY ROOM            50.4011       66272   LACR,CMPLX,EYLD,ETC,1.1-2.5CM                  563.40                        13151
  981   PROF FEES EMERGENCY ROOM            50.4011       66274   LACR,CMPLX,EYLD,ETC,2.6-7.5CM                  910.70                        13152
  981   PROF FEES EMERGENCY ROOM            50.4011       66275   REPAIR UNUSUAL COMPLICATED >7.               1,149.50                        13300
  981   PROF FEES EMERGENCY ROOM            50.4011       66276   LAC 2.5CM FLR MOUTH-ANT 2/3 TO                 293.25                        41250
  981   PROF FEES EMERGENCY ROOM            50.4011       66277   LAC POST 1/3 TONGUE TO 2.5CM                   385.30                        41251
  981   PROF FEES EMERGENCY ROOM            50.4011       66278   LAC TONG/FLR MTH >2.5CM OR COM                 455.80                        41252
  981   PROF FEES EMERGENCY ROOM            50.4011       66279   TREATMENT SUPERFICIAL WOUND DE                 222.00                        12020
  981   PROF FEES EMERGENCY ROOM            50.4011       66280   SECONDARY CLOSURE SURG WOUND D                 345.85                        13160
  981   PROF FEES EMERGENCY ROOM            50.4011       66281   FOREARM OR WRIST REPAIR PRIMAR                 913.70                        25270
  981   PROF FEES EMERGENCY ROOM            50.4011       66282   EXTENSOR TENDON REPAIR DORSUM                1,424.25 2641054              2641054
  981   PROF FEES EMERGENCY ROOM            50.4011       66283   EXTENSOR TENDON REPAIR DORSUM                1,374.40 2641854              2641854
  981   PROF FEES EMERGENCY ROOM            50.4011       66284   REPAIR EXTENSOR TENDON LEG PRI                 595.00                        27664
  981   PROF FEES EMERGENCY ROOM            50.4011       66285   REPAIR XTENSOR TENDON FOOT SIN                 808.65 2820854              2820854
  981   PROF FEES EMERGENCY ROOM            50.4011       66286   LIGATION MAJOR ARTERY                          441.00                        37618
  981   PROF FEES EMERGENCY ROOM            50.4011       66300   INCISION ABSCESS - PROF                        264.90                        20000
  981   PROF FEES EMERGENCY ROOM            50.4011       66301   I & D INFECTED BURSA - PROF                     79.35                        20600
  981   PROF FEES EMERGENCY ROOM            50.4011       66302   I & D FINGER FELON - PROF                      596.20                        26011
  981   PROF FEES EMERGENCY ROOM            50.4011       66303   TREATMENT CLOSED SKULL FRACTUR                 179.70                        21300
  981   PROF FEES EMERGENCY ROOM            50.4011       66304   INJ TENDON SHEATH - PROF                        90.85                        20550
  981   PROF FEES EMERGENCY ROOM            50.4011       66305   ARTHOCENT,ASPIR,INJ SML JT - P                  72.50                        20600
  981   PROF FEES EMERGENCY ROOM            50.4011       66306   ARTHROCENT,ASPIR,INJ INTERM JT                  83.15                        20605
  981   PROF FEES EMERGENCY ROOM            50.4011       66307   TREATMENT FRACTURE OF ORBIT                    178.30                        21400
  981   PROF FEES EMERGENCY ROOM            50.4011       66308   ARTHROCENT,ASPIR,INJ MAJOR JT                  109.05                        20610
  981   PROF FEES EMERGENCY ROOM            50.4011       66309   NASAL FX - W/O MANIPULATION -                  223.60 2145054              2131054
  981   PROF FEES EMERGENCY ROOM            50.4011       66311   NASAL FX REDUCTION - PROF                      246.75                        21315
  981   PROF FEES EMERGENCY ROOM            50.4011       66312   ORBITAL FX - PROF                               81.80                        21385
  981   PROF FEES EMERGENCY ROOM            50.4011       66313   MANDIBULAR FX, W/O MANIPULATIO                 223.60 2148054              2145054

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                        8 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL       CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66314   RIB FX,EACH- PROF                              164.85   2180054              2180054
  981   PROF FEES EMERGENCY ROOM            50.4011       66315   UNCMPL TRTMNT TEMPOROMANDIBULA                 332.30                        2148054
  981   PROF FEES EMERGENCY ROOM            50.4011       66316   VERTEBRAL FX W/O MANIPULATION                  206.95   2231054              2231054
  981   PROF FEES EMERGENCY ROOM            50.4011       66317   CLAVICULAR FX W/O MANIPULATION                 373.95   2350054              2350054
  981   PROF FEES EMERGENCY ROOM            50.4011       66318   ACROMIOCLAVICLR DISLOC W/O MAN                 383.00   2354054              2354054
  981   PROF FEES EMERGENCY ROOM            50.4011       66319   TREATMENT OF STERNUM FRACTURE                  238.05                          21820
  981   PROF FEES EMERGENCY ROOM            50.4011       66320   SCAPULAR FX W/O MANIPULATION -                 396.30                          23570
  981   PROF FEES EMERGENCY ROOM            50.4011       66321   HUMERAL NECK FX W/O MANIPULATI                 553.25   2360054              2360054
  981   PROF FEES EMERGENCY ROOM            50.4011       66322   GREATER TUBEROSITY FX,W/O MANI                 453.30                          23620
  981   PROF FEES EMERGENCY ROOM            50.4011       66323   CLOSED TREATMENT VERTEBRAL PRO                 354.15                          22305
  981   PROF FEES EMERGENCY ROOM            50.4011       66324   HUMERAL SHAFT FX W/O MANIP - P                 550.50                          24500
  981   PROF FEES EMERGENCY ROOM            50.4011       66325   SUPRACONDYLAR FX W/O MANIP-PRO                 676.20   2453054              2453054
  981   PROF FEES EMERGENCY ROOM            50.4011       66326   EPICONDYLAR FX W/O MANIP - PRO                 182.85                          24560
  981   PROF FEES EMERGENCY ROOM            50.4011       66327   TRTMNT CLOSED CLAVICULAR FRAC                  628.55                          23505
  981   PROF FEES EMERGENCY ROOM            50.4011       66328   RAD HEAD,NECK FX W/O MANIP - P                 397.10   2465054              2465054
  981   PROF FEES EMERGENCY ROOM            50.4011       66329   ULNAR FX, OLECRANON W/O MANIP                  462.35   2467054              2467054
  981   PROF FEES EMERGENCY ROOM            50.4011       66330   RADIAL SHAFT FX W/O MANIP-PROF                 424.45                          25500
  981   PROF FEES EMERGENCY ROOM            50.4011       66331   CLSD STERNOCLAVICLR DISL W/O M                 375.95                          23520
  981   PROF FEES EMERGENCY ROOM            50.4011       66332   CLSD STERNOCLAVICLR DSLC W/MAN                 305.10                          23525
  981   PROF FEES EMERGENCY ROOM            50.4011       66333   TRTMNT CLSD ACROMIOCLAVCLR DSL                 551.65                          23545
  981   PROF FEES EMERGENCY ROOM            50.4011       66334   ULNAR SHAFT FX W/O MANIP - PRO                 992.70   2553054              2553054
  981   PROF FEES EMERGENCY ROOM            50.4011       66335   TRTMNT CLSD HUMERAL SHFT W/MAN                 992.70                          24505
  981   PROF FEES EMERGENCY ROOM            50.4011       66336   RADIAL&ULNAR SHAFT FX W/O MANI                 448.35   2556054              2556054
  981   PROF FEES EMERGENCY ROOM            50.4011       66337   DISTAL RADIAL FX W/O MANIP - P                 457.00   2560054              2560054
  981   PROF FEES EMERGENCY ROOM            50.4011       66338   CARPAL BONE FX W/O MANIP - PRO                 475.95                          25630
  981   PROF FEES EMERGENCY ROOM            50.4011       66339   TRTMNT CLSD CONDYLAR W/O MANIP                 505.35                          24576
  981   PROF FEES EMERGENCY ROOM            50.4011       66340   METACARPAL FX W/O MANIP - PROF                 365.60   2660054              2660054
  981   PROF FEES EMERGENCY ROOM            50.4011       66341   MULTI METACARPAL FX - PROF                   1,078.20                          26615
  981   PROF FEES EMERGENCY ROOM            50.4011       66342   BENNETT FX W/MANIP - PROF                      356.50                          26645
  981   PROF FEES EMERGENCY ROOM            50.4011       66343   TRTMNT CLSD ELBOW DISLOC REQ A                 834.10   2460554              2460554
  981   PROF FEES EMERGENCY ROOM            50.4011       66344   PHALANGEAL SHAFT FX W/O MANIP                  258.90   2672054              2672054
  981   PROF FEES EMERGENCY ROOM            50.4011       66345   PHALANGEAL SHFT FX,DIST W/O MA                 309.35   2675054              2675054
  981   PROF FEES EMERGENCY ROOM            50.4011       66346   SACRAL FX - PROF                               882.90                          27193
  981   PROF FEES EMERGENCY ROOM            50.4011       66347   TRTMNT CLSD DISTAL RADIAL W/MA                 989.40                          25605
  981   PROF FEES EMERGENCY ROOM            50.4011       66348   COCCYGEAL FX - PROF                            304.80   2720054              2720054
  981   PROF FEES EMERGENCY ROOM            50.4011       66349   ILIAC,PUBIC,ISCHIAL FX - PROF                  882.90                          27193
  981   PROF FEES EMERGENCY ROOM            50.4011       66350   FEMORAL SHAFT FX - PROF                        129.95                          27500
  981   PROF FEES EMERGENCY ROOM            50.4011       66351   TRTMNT CLSD CARPAL SCAPHOID W/                 447.90   2562254              2562254
  981   PROF FEES EMERGENCY ROOM            50.4011       66352   FEMORAL FX,PROX - PROF                         129.95                          27230
  981   PROF FEES EMERGENCY ROOM            50.4011       66353   PATELLAR FX - W/O MANIP-PROF                   527.15   2752054              2752054
  981   PROF FEES EMERGENCY ROOM            50.4011       66354   TIBIAL FX,PROX W/O MANIP-PROF                  685.05                          27530
  981   PROF FEES EMERGENCY ROOM            50.4011       66355   TRTMNT CLSD ULNAR STYLOID                      498.10                          25650
  981   PROF FEES EMERGENCY ROOM            50.4011       66356   TIBIAL SHAFT FX - W/O MANIP-PR                 206.95                          27750
  981   PROF FEES EMERGENCY ROOM            50.4011       66357   DISTAL TIBIAL FX - W/O MANIP-P                 537.00   2776054              2776054
  981   PROF FEES EMERGENCY ROOM            50.4011       66358   PROX FIBULA,SHAFT FX W/O MANIP                 485.00   2778054              2778054
  981   PROF FEES EMERGENCY ROOM            50.4011       66359   TRTMNT CLSD RADIOCARPAL W/MANI                 804.75                          25660
  981   PROF FEES EMERGENCY ROOM            50.4011       66360   DISTAL FIBULA FX W/O MANIP-PRO                 516.25   2778654              2778654
  981   PROF FEES EMERGENCY ROOM            50.4011       66361   TIBIA W/WO FIBULA FX W/O MANIP                 612.80   2775054              2775054
  981   PROF FEES EMERGENCY ROOM            50.4011       66362   BIMALLEOLAR ANKLE FX W/O MANIP                 206.95                          27808
  981   PROF FEES EMERGENCY ROOM            50.4011       66363   TRIMALLEOLAR ANKLE FX W/O MANI                 206.95                          27816
  981   PROF FEES EMERGENCY ROOM            50.4011       66364   CALCANEAL FX W/O MANIP-PROF                    519.55                          28400
  981   PROF FEES EMERGENCY ROOM            50.4011       66365   TALUS FX W/O MANIP-PROF                        479.80                          28430

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                          9 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL     CPT-4       HCPCS     RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66366   TRTMNT OF CLSD METACARPAL W/MA                 549.00                          26605
  981   PROF FEES EMERGENCY ROOM            50.4011       66367   TARSAL BONE FX W/O MANIP-PROF                  447.05                          28450
  981   PROF FEES EMERGENCY ROOM            50.4011       66368   GREAT TOE FX W/O MANIP-PROF                    234.95 2849054                2849054
  981   PROF FEES EMERGENCY ROOM            50.4011       66369   METATARSAL FX - W/O MANIP-PROF                 408.60 2847054                2847054
  981   PROF FEES EMERGENCY ROOM            50.4011       66370   TRTMNT CARPOMETACARPAL DISLOC                  675.10                          26641
  981   PROF FEES EMERGENCY ROOM            50.4011       66371   INTERPHALANGEAL DISLOC TOE W/O                 277.85 2866054                2866054
  981   PROF FEES EMERGENCY ROOM            50.4011       66372   TMJ DISLOCATION                                415.35 2148054                2148054
  981   PROF FEES EMERGENCY ROOM            50.4011       66373   SHOULDER DISLOC W/MANIP W/O AN                 553.75 2365054                2365054
  981   PROF FEES EMERGENCY ROOM            50.4011       66374   TRTMNT CLSD SHOULDER DISLC REQ                 724.70 2365554                2365554
  981   PROF FEES EMERGENCY ROOM            50.4011       66375   ELBOW DISLOC W/O ANESTH - PROF                 735.20 2460054                2460054
  981   PROF FEES EMERGENCY ROOM            50.4011       66376   PHALANGEAL SHFT FX PROX W/MANI                 504.60                          26725
  981   PROF FEES EMERGENCY ROOM            50.4011       66377   PHALANGEAL SHFT FX,DISTAL W/MA                 480.35                          26755
  981   PROF FEES EMERGENCY ROOM            50.4011       66378   SUBLUXATION,RADIAL HEAD W/MANI                 240.75                          24640
  981   PROF FEES EMERGENCY ROOM            50.4011       66379   PATELLAR DISLOC -W/O ANESTH -                  616.55 2775605            4   2756054
  981   PROF FEES EMERGENCY ROOM            50.4011       66380   ANKLE DISLOC - W/O ANESTH                      796.60 2784054                2784054
  981   PROF FEES EMERGENCY ROOM            50.4011       66381   TARSOMETATARSL JT DISL W/O ANE                 430.00                          28600
  981   PROF FEES EMERGENCY ROOM            50.4011       66382   TMNT CLSD CARPOMETACRPL DSLC W                 640.50                          26670
  981   PROF FEES EMERGENCY ROOM            50.4011       66383   LONG ARM SPLINT - PROF                         101.20                          29105
  981   PROF FEES EMERGENCY ROOM            50.4011       66384   SHORT ARM SPLINT - PROF                         90.65                          29125
  981   PROF FEES EMERGENCY ROOM            50.4011       66385   VELPEAU SPLINT - PROF                          103.50                          29058
  981   PROF FEES EMERGENCY ROOM            50.4011       66386   TRTMNT CLSD CARPOMETACRPL DLC                  315.60                          26675
  981   PROF FEES EMERGENCY ROOM            50.4011       66387   LONG LEG SPLINT - PROF                         126.85                          29505
  981   PROF FEES EMERGENCY ROOM            50.4011       66388   SHORT LEG SPLINT - PROF                        104.25                          29515
  981   PROF FEES EMERGENCY ROOM            50.4011       66390   LONG ARM CAST - PROF                           123.90                          29065
  981   PROF FEES EMERGENCY ROOM            50.4011       66391   TMNT CLSD METACARPOPHALGL DSL                  517.20 2670054                2670054
  981   PROF FEES EMERGENCY ROOM            50.4011       66392   SHORT ARM CAST - PROF                           95.25                          29075
  981   PROF FEES EMERGENCY ROOM            50.4011       66393   TMNT CLSD METACARPOPHALGL DSLC                 668.15 2670554                2670554
  981   PROF FEES EMERGENCY ROOM            50.4011       66394   LONG LEG CAST - PROF                           181.25                          29345
  981   PROF FEES EMERGENCY ROOM            50.4011       66395   TMNT OPEN METACARPOPHALANGEAL                1,104.00                          26715
  981   PROF FEES EMERGENCY ROOM            50.4011       66396   SHORT LEG CAST - PROF                          137.50                          29405
  981   PROF FEES EMERGENCY ROOM            50.4011       66397   TRTMNT OPEN PHALANGEAL SHAFT F               1,136.40                          26735
  981   PROF FEES EMERGENCY ROOM            50.4011       66398   TRTMNT CLSD ARTICULAR FRAC W/O                 338.20                          26740
  981   PROF FEES EMERGENCY ROOM            50.4011       66399   TRTMNT OPEN DISTAL PHALANGEAL                  890.85                          26765
  981   PROF FEES EMERGENCY ROOM            50.4011       66400   CRICOTHYROIDOTOMY - PROF                       747.55 31605ZK                  31605
  981   PROF FEES EMERGENCY ROOM            50.4011       66401   TMNT CLSD INTERPHALANGEAL DSLC                 438.60 2677054                2677054
  981   PROF FEES EMERGENCY ROOM            50.4011       66402   TMNT CLSD INTERPHALANGEAL DSLC                 589.55                          26775
  981   PROF FEES EMERGENCY ROOM            50.4011       66403   TMNT OPEN INTERPHALANGEAL JOIN                 901.00                          26785
  981   PROF FEES EMERGENCY ROOM            50.4011       66404   AMPUTATION FINGER OR THUMB                     646.45                          26951
  981   PROF FEES EMERGENCY ROOM            50.4011       66405   TMNT CLSD HIP DSLC W/O ANESTH                1,058.35                        2725054
  981   PROF FEES EMERGENCY ROOM            50.4011       66406   TRTMNT CLSD HIP DSLC REQ ANEST               1,519.60                          27252
  981   PROF FEES EMERGENCY ROOM            50.4011       66407   TRTMNT CLSD KNEE DLSC W/O ANES                 923.95 2755054                2755054
  981   PROF FEES EMERGENCY ROOM            50.4011       66408   TRTMNT CLSD KNEE DSLC REQ ANES               1,263.20 2755254                2755254
  981   PROF FEES EMERGENCY ROOM            50.4011       66409   TRTMNT ANKLE DISLOC REQ ANESTH                 907.70 2784254                2784254
  981   PROF FEES EMERGENCY ROOM            50.4011       66410   VAGINAL DELIVERY - PROF                      1,778.95                          59409
  981   PROF FEES EMERGENCY ROOM            50.4011       66411   TRTMNT CLSD PATELLAR DISLC REQ                 971.30                          27562
  981   PROF FEES EMERGENCY ROOM            50.4011       66412   TRTMNT CLSD METATARSAL FRACT W                 564.60                          28475
  981   PROF FEES EMERGENCY ROOM            50.4011       66413   TRTMNT CLSD FRACT GRT TOE W/MA                 282.45 2849554                2849554
  981   PROF FEES EMERGENCY ROOM            50.4011       66414   TRTMNT CLSD FRAC PHALANX W/O M                 233.15 2851054                2851054
  981   PROF FEES EMERGENCY ROOM            50.4011       66415   TRTMNT CLSD FRACT PHALANX W/MA                 269.20 2851554                2851554
  981   PROF FEES EMERGENCY ROOM            50.4011       66416   TRTMNT OPEN FRACT PHALANX                      712.40                          28525
  981   PROF FEES EMERGENCY ROOM            50.4011       66417   TMNT CLSD TARSAL BONE DISLC W/                 399.25                          28540
  981   PROF FEES EMERGENCY ROOM            50.4011       66418   TMNT CLD METATARSOPHALGL DSLC                  289.95 2863054                2863054

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                        10 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL      CPT-4     HCPCS      RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66419   TMNT CLSD INTERPHALANGEAL DSLC                342.75                          28665
  981   PROF FEES EMERGENCY ROOM            50.4011       66420   INTRO NEEDLE                                   63.50                          36000
  981   PROF FEES EMERGENCY ROOM            50.4011       66421   TMNT OPEN INTERPHALANGEAL JOIN                617.20                          28675
  981   PROF FEES EMERGENCY ROOM            50.4011       66422   APPLIC OF SPLINT FINGER                        62.50                          29130
  981   PROF FEES EMERGENCY ROOM            50.4011       66425   TRANSFUSION BLOOD OR COMPONENT                 90.65   36430ZK                36430
  981   PROF FEES EMERGENCY ROOM            50.4011       66427   ARTERIAL CATHETERIZATION PERCU                190.40   36620ZK                36620
  981   PROF FEES EMERGENCY ROOM            50.4011       66428   ARTERIAL CATHETERIZATION CUTDO                311.15                          36625
  981   PROF FEES EMERGENCY ROOM            50.4011       66430   PLACE NEEDLE INTRAOSSEOUS INFU                168.50   36680ZK                36680
  981   PROF FEES EMERGENCY ROOM            50.4011       66432   IV INFUSION THERAPY UP TO ONE                 100.10                          90780
  981   PROF FEES EMERGENCY ROOM            50.4011       66435   BURN DRESSINGS W/ANES >9%                     276.40                          16015
  981   PROF FEES EMERGENCY ROOM            50.4011       66440   BURN DRESSINGS W/O ANES >18%                  276.40   16030ZK                16030
  981   PROF FEES EMERGENCY ROOM            50.4011       66442   REM FOR BODY SUBCUTANEOUS COMP                357.35   10121ZK                10121
  981   PROF FEES EMERGENCY ROOM            50.4011       66444   REM FOR BODY MUSCLE COMPLEX                   623.40                          20525
  981   PROF FEES EMERGENCY ROOM            50.4011       66446   REM FOR BODY FOOT DEEP                        774.65                          28192
  981   PROF FEES EMERGENCY ROOM            50.4011       66447   REM FOR BODY PHARYNX                          279.80   42809ZK                42809
  981   PROF FEES EMERGENCY ROOM            50.4011       66449   REM EMB FOREIGN BODY EYELID                   150.65   67938ZK                67938
  981   PROF FEES EMERGENCY ROOM            50.4011       66450   FECAL IMPACTION REMOVAL W/ANES                257.30   45915ZK                45915
  981   PROF FEES EMERGENCY ROOM            50.4011       66452   ANT EPISTAXIS COMPLEX                         179.70   30903ZK                30903
  981   PROF FEES EMERGENCY ROOM            50.4011       66453   CONTROL NASAL HEMORRHAGE POST                 317.15                          30906
  981   PROF FEES EMERGENCY ROOM            50.4011       66455   INJ ANESTHETIC FACIAL NERVE                   147.55                          64402
  981   PROF FEES EMERGENCY ROOM            50.4011       66457   INJ ANESTHETIC AXILLARY NERVE                 155.90                          64417
  981   PROF FEES EMERGENCY ROOM            50.4011       66459   INJ ANESTHETC INTERCOSTAL NERV                130.65                          64420
  981   PROF FEES EMERGENCY ROOM            50.4011       66460   INJ ANESTHETC INTERCOSTAL NERV                338.35                          64421
  981   PROF FEES EMERGENCY ROOM            50.4011       66462   THERAP DIAG INJ                                42.30                          90774
  981   PROF FEES EMERGENCY ROOM            50.4011       66464   INC & DRAIN INF CYST SECOND LE                282.70                          10061
  981   PROF FEES EMERGENCY ROOM            50.4011       66465   INC & DRAIN INF EPITH CYST                    282.70                          10061
  981   PROF FEES EMERGENCY ROOM            50.4011       66467   ABSCESS COMPLICATED                           282.70   10061ZK                10061
  981   PROF FEES EMERGENCY ROOM            50.4011       66468   I & D PILONIDAL CYST, SIMPLE                  149.30   10080ZK                10080
  981   PROF FEES EMERGENCY ROOM            50.4011       66472   DEBRIDE SKIN INFECTED ADD 10%                  42.30                          11001
  981   PROF FEES EMERGENCY ROOM            50.4011       66473   DEBRIDE SKIN INFECTED FULL THI                122.40                          11041
  981   PROF FEES EMERGENCY ROOM            50.4011       66475   HEMATOMA COMPLICATED                          175.20                          10140
  981   PROF FEES EMERGENCY ROOM            50.4011       66477   DEBRIDE SKIN & SUBCUT TISSUE                  137.50   11042ZK                11042
  981   PROF FEES EMERGENCY ROOM            50.4011       66479   DEBRIDE SKIN SUBQ AND MUSCLE                  337.40   11043ZK                11043
  981   PROF FEES EMERGENCY ROOM            50.4011       66480   DEBRIDE SKIN INFECTED AND BONE                206.95                          11044
  981   PROF FEES EMERGENCY ROOM            50.4011       66482   PARING OR CURETTEMENT                          81.55                          11055
  981   PROF FEES EMERGENCY ROOM            50.4011       66483   PINCH GRAFT SINGLE OR MULTI                   271.90                          15050
  981   PROF FEES EMERGENCY ROOM            50.4011       66486   INCISION & DRAINAGE ONYCHIA MU                282.70                          10061
  981   PROF FEES EMERGENCY ROOM            50.4011       66487   EVACUATION SUBUNGUAL HEMATOMA                  45.00   11740ZK                11740
  981   PROF FEES EMERGENCY ROOM            50.4011       66488   REPAIR NAIL BED SIMPLE LACERAT                222.95   11760ZK                11760
  981   PROF FEES EMERGENCY ROOM            50.4011       66490   RECONST NAIL BED COMPLICATED                  348.90                          11762
  981   PROF FEES EMERGENCY ROOM            50.4011       66492   WEDGE EXC SKIN OF NAIL FOLD                   166.20   11765ZK                11765
  981   PROF FEES EMERGENCY ROOM            50.4011       66493   DRAINAGE ABSCESS NASAL                        240.15                          30000
  981   PROF FEES EMERGENCY ROOM            50.4011       66495   DRAINAGE ABSCESS NASAL SEPTUM                 268.90                          30020
  981   PROF FEES EMERGENCY ROOM            50.4011       66497   DRAINAGE ABSCESS CYST HEMATOMA                192.80                          41800
  981   PROF FEES EMERGENCY ROOM            50.4011       66498   DRAINAGE EXT EAR                              162.50                          69000
  981   PROF FEES EMERGENCY ROOM            50.4011       66499   DRAINAGE EXT AUDITORY CANAL                    87.65                          69020
  981   PROF FEES EMERGENCY ROOM            50.4011       66500   STRAPPING THORAX                               55.90                          29200
  981   PROF FEES EMERGENCY ROOM            50.4011       66501   STRAPPING LOW BACK                             69.55                          29220
  981   PROF FEES EMERGENCY ROOM            50.4011       66502   STRAPPING SHOULDER                             83.15                          29240
  981   PROF FEES EMERGENCY ROOM            50.4011       66503   STRAPPING ELBOW OR WRIST                       42.30                          29260
  981   PROF FEES EMERGENCY ROOM            50.4011       66504   STRAPPING HAND OR FINGER                       42.30                          29280
  981   PROF FEES EMERGENCY ROOM            50.4011       66505   STRAPPING KNEE                                 55.90                          29530

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                         11 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                   OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG          CATEGORY AND NAME              DPT        CODE                    DESCRIPTION                   CHARGE     MCAL   CPT-4    HCPCS    RVU
  981   PROF FEES EMERGENCY ROOM            50.4011       66506   STRAPPING ANKLE                                48.30                     29540
  981   PROF FEES EMERGENCY ROOM            50.4011       66507   STRAPPING TOES                                 42.30                     29550
  981   PROF FEES EMERGENCY ROOM            50.4011       66508   STRAPPING UNNA BOOT                            74.05                     29580
  981   PROF FEES EMERGENCY ROOM            50.4011       66510   CAST REMOVAL GAUNTLET BOOT OR                  75.55                     29700
  981   PROF FEES EMERGENCY ROOM            50.4011       66511   CAST REMOVE/BIVALVE FULLL ARM                  97.35                     29705
  981   PROF FEES EMERGENCY ROOM            50.4011       66512   WINDOWING OF CAST                              93.95                     29730
  981   PROF FEES EMERGENCY ROOM            50.4011       66513   WEDGING OF CAST                               136.65                     29740
  981   PROF FEES EMERGENCY ROOM            50.4011       66520   APPL CASTS HAND&LOWER FOREARM                 111.90                     29085
  981   PROF FEES EMERGENCY ROOM            50.4011       66521   APPL CAST LONG LEG WALKER                     237.05                     29355
  981   PROF FEES EMERGENCY ROOM            50.4011       66522   APPL CASTS CYLINDER                           159.95                     29365
  981   PROF FEES EMERGENCY ROOM            50.4011       66523   APPL CASTS SHORT LEG WALKING                  167.70                     29425
  981   PROF FEES EMERGENCY ROOM            50.4011       66524   ADDING WALKER TO PREVSLY APPLI                 72.80                     29440
  969   PROF FEES OTHER                     50.4012       66998   ANESTHESIA BY OUTSIDE MD                      300.00
  511   CLINIC CHRONIC PAIN CENTER          50.4085       74999   KC NEW PT MODERATE COMPLEXITY                 275.00    99204   99204    99204
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78499   KC NEW PATIENT MOD COMPLEXITY                 275.00                     99204      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78500   KC INITIAL ASSESSMENT                         330.00    99205   99205    99205      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78501   KC ESTAB HIGH COMPLEXITY                      220.00    99215   99215    99215      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78502   KC ESTAB MOD COMPLEXITY                       165.00    99214   99214    99214      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78503   KC ESTAB LOW COMPLEXITY                        82.50    99213   99213    99213      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78505   KC BIOFEEDBACK INITIAL                         82.50    90901   90901    90901      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78506   KC BIOFEEDBACK ADDTL SVCS                     165.00    90901   90901    90901      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78507   KC NUTRITION INIT ASSESS 15M                   66.00    97802   97802    97802      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78508   KC INDIV NUTRITION F/U 15 MIN                  40.00    97803   97803    97803      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78509   KC ACUPUNCTURE EA ADDTL 15 MIN                 55.00    97814   97814    97814
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78510   KC MASSAGE THERAPY                            132.00    97124   97124    97124      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78511   KC INDIVID YOGA THERAPY 15MIN                  33.00    97139   97139    96153      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78512   KC YOGA CLASS PER 15 MIM                       20.00    97150   97150    96153      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78513   KC PT INITIAL EVALUATION                                              P
                                                                                                                132.00 97001 G P 97001 G 97001 GP     1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78514   KC PT RE-EVALUATION                                                   P
                                                                                                                 82.50 97002 G P 97002 G 97002 GP     1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78516   KC INJECTION SQ/IM                            106.00    90772   90772    90772      1
  250   PHARMACY GENERAL                    50.4085       78517   KC DEPACON 100MG/ML                            53.20
  250   PHARMACY GENERAL                    50.4085       78518   KC DHE                                         69.05
  250   PHARMACY GENERAL                    50.4085       78519   KC IMITREX 6MG                                 42.65
  250   PHARMACY GENERAL                    50.4085       78520   KC GEODON 20MG/ML                             113.30
  250   PHARMACY GENERAL                    50.4085       78521   KC MYOBLOC 2500 UNIT                          399.30
  250   PHARMACY GENERAL                    50.4085       78522   KC MYOBLOC 5000 UNIT                          798.60
  250   PHARMACY GENERAL                    50.4085       78523   KC TORADOL 30MG                                88.55
  250   PHARMACY GENERAL                    50.4085       78524   KC SOLU-MEDROL 40MG                            36.85
  250   PHARMACY GENERAL                    50.4085       78525   KC SOLU-MEDROL 1GM                             73.30
  250   PHARMACY GENERAL                    50.4085       78526   KC MARCAINE 0.5% 30ML                          66.30
  250   PHARMACY GENERAL                    50.4085       78527   KC KENALOG 40MG                                51.45
  250   PHARMACY GENERAL                    50.4085       78528   KC ZOFRAN 4MG/2ML                              81.40
  250   PHARMACY GENERAL                    50.4085       78529   KC COMPAZINE 10MG/2ML                          39.35
  250   PHARMACY GENERAL                    50.4085       78530   KC PHENERGAN 25MG/ML                           36.30
  250   PHARMACY GENERAL                    50.4085       78531   KC PHENERGAN 50MG/ML                           42.10
  250   PHARMACY GENERAL                    50.4085       78532   KC TRIMETHOBENZAMIDE                           42.90
  250   PHARMACY GENERAL                    50.4085       78533   KC REGLAN 10MG/ML                              45.10
  250   PHARMACY GENERAL                    50.4085       78534   KC COMPAZINE 5MG TAB                            7.70
  273   M/S SUPPLY TAKE-HOME SUP            50.4085       78536   KC NUTRITIONAL GROUP THERAPY                   33.00    97804   97804    97804      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78537   KC EDUCATIONAL THERAPY GROUP                   33.00    99078   99078    99078      1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78538   KC IV HYDRATION 1ST HOUR                       53.35    90774   90760    90760      1
  259   PHARMACY OTHER                      50.4085       78539   KC IV INFUSION SET                             17.60    99070   99070 A4550

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                    12 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG          CATEGORY AND NAME              DPT        CODE                   DESCRIPTION                    CHARGE    MCAL       CPT-4      HCPCS     RVU
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78540   KC INFUSION THERAPY 1ST HOUR                  576.40 Q0081        90765       90765          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78541   KC INJECTION SQ OR IM                         106.70    90772     90772       90772          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78542   KC INJECTION OTHER                             82.50    90779     90779       90779          1
  301   LABORATORY CHEMISTRY                50.4085       78543   KC VENIPUNCTURE                                15.40    36415     36415       36415
  306   LAB BACTERIOLOGY/MICROBIO           50.4085       78544   KC LAB HANDLING FEE                            16.50    99000     99000       99000
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78545   KC SPINAL TAP DRAINAGE FLUID                  220.00    62272     62272       62272          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78546   KC SPINAL TAP LUMBAR                          198.00    62270     62270       62270          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78547   KC NEUROLOGIC CONSULT LOW COMP                200.00    99241     99241       99241          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78548   KC NEUROLOGIC CONSULT MOD COMP                250.00    99242     99242       99242          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78549   KC NEUROLOGIC CONSULT HI COMP                 300.00    99243     99243       99243          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78550   KC INTER TELEPHONE CONSULT                     82.50    99372     99372       99372
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78551   KC ACUPUNCTURE INITIAL 15 MIN                 132.00    97813     97813       97813
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78552   KC COUNSELING INDIVIDUAL 45MIN                180.00    99403     99403       99403
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78553   KC COUNSELING INDIVIDUAL 60MIN                280.00    99404     99404       99404
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78554   KC COUNSELING GROUP 60 MINUTES                 90.00    99412     99412       99412
  250   PHARMACY GENERAL                    50.4085       78559   KC BENADRYL 50MG                               40.00
  250   PHARMACY GENERAL                    50.4085       78560   KC THORAZINE 25MG                              56.00
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78565   KC MANUAL THERAPY EA 15 MIN                    82.50               97140                     1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78566   KC NEW PT OV PROBLEM FOCUSED                  150.00                          99201          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78567   KC NEW PT EXPANDED PROB FOCUS                 190.00                          99202          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78568   LOW COMPLEXITY (DETAILED)                     225.00                          99203          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78569   ESTABLISHED PT PROBLEM FOCUSED                 55.00                          99211          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78570   KC NEURO CONSULT MOD-HI COMPLX                330.00                          99244          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78571   KC NEURO HIGH COMPLEXITY                      350.00                          99245          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78572   KC MINDFUL STRESS RELIEF 15MIN                 70.00                          96152          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78574   KC HOMECARE TRAINING PER 15MIN                 70.00                          97535          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78575   KC CHEMODENERV CERVICAL SP                    800.14                          64613          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78576   KC CHEMODENERV FACIAL                         748.82                          64612          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78577   KC TRIGGER PT(S) 1-2 MUSCLES                  237.58                          20552          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78578   KC TRIGGER PT 3 OR MORE MUSCLE                267.12                          20553          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78579   KC OSTEOPATH MANIP 1-2 REGIONS                129.04                          98295
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78580   KC OSTEOPATH MANIP 3-4 REGIONS                177.72                          98926
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78581   KC OSTEOPATH MANIP 5-6 REGIONS                228.55                          98927
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78582   KC INITIAL ASSESS W/MD 1-2 HRS                669.90                          90801          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78583   KC INDIVID THER 45-50 MIN W/MD                445.57                          90807          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78584   KC INDIVID THER 20-30 MIN W/MD                311.62                          90805          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78585   KC BRIEF MED/DRUG MGMT COUNSEL                233.32                          90862          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78586   KC INDIVIDUAL COUNSELING 45MIN                408.97                          99403
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78587   KC GROUP COUNSELING 60 MINUTES                 86.60                          99412
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78588   KC TRIGEMINAL NERVE BLOCK                     516.52                          64400          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78589   KC FACIAL NERVE BLOCK                         500.52                          64402          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78590   KC GREATER OCCIPITAL NERVE BLK                476.40                          64405          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78591   KC INDIVIDUAL COUNSELING 60MIN                524.30                          99404
  250   PHARMACY GENERAL                    50.4085       78592   NORMAL SALINE 50CC                             10.63                       J7050
  250   PHARMACY GENERAL                    50.4085       78593   NORMAL SALINE 100CC                            21.25                       J7050
  250   PHARMACY GENERAL                    50.4085       78594   NORMAL SALINE 250CC                            53.13                       J7050
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78595   KC IV PUSH FIRST MED                          283.67                          90774          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78596   KC IV PUSH ADDTL MED                          127.62                          90775          1
  259   PHARMACY OTHER                      50.4085       78597   KC SPINAL TAP TRAY                            151.50                       A4550
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78598   KC TELEPHONE CONSULT INTERMED                  82.50                          99372          1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78599   KC IND BEHAV HEALTH 20-30 MIN                 190.00               90804                     1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78600   KC IND BEHAV HEALTH 45-50 MIN                 210.00               90806                     1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            13 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG          CATEGORY AND NAME              DPT        CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS     RVU
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78601   KC THERAP EXERCISE PER 15 MIN                     60.00                97110
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78602   KC IV HYDRATION EACH ADDL HR                      54.00                90761                    1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78603   KC IV INFUSION EACH ADDL HR                     400.00                 90766                    1
  511   CLINIC CHRONIC PAIN CENTER          50.4085       78673   EST PT EXPANDED PROBLEM FOCUS                     65.00                           99212
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410        5816   ESSURE SYSTEM                                 4,773.40
  360   OR SVCS GENERAL                     50.4410       50231   MISC. O.R. CHARGE SDC                       misc chrg determined at time of svcs                1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       50233   MISC IMPLANTS SDC                           misc chrg determined at time of svcs                1
  270   M/S SUPPLY GENERAL                  50.4410       50235   ARGON GAS                                     1,166.65
  270   M/S SUPPLY GENERAL                  50.4410       50236   HELIUM GAS                                      813.15
  279   M/S OTHER SUPPLIES/DEVICES          50.4410       50237   PROBE CRYOABLATION                            6,460.45            C2618
  279   M/S OTHER SUPPLIES/DEVICES          50.4410       50238   GUIDEWIRE CYRO                                  570.15
  279   M/S OTHER SUPPLIES/DEVICES          50.4410       50239   PROBE TEMPROBES                               1,140.20
  270   M/S SUPPLY GENERAL                  50.4410       50241   TROCARE NEEDLES                                 190.20
  490   AMB SURGICAL CARE GENERAL           50.4410       56001   CANCELLATION FEE                                909.20
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56003   TROCHAR APPLE                                 1,100.90
  490   AMB SURGICAL CARE GENERAL           50.4410       56004   ADVANCEMENT FLAP SMALL                        4,751.80                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56006   ANAL FISS/FISTULA CLOSURE                     6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56009   APPLICATION CAST OTHER                        4,751.80                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56010   ARTHROSCOPY UNILATERAL                        8,895.40                            28296         1
  490   AMB SURGICAL CARE GENERAL           50.4410       56011   ARTHROSCOPY BILATERAL                         9,907.45                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56013   LAPOROSCOPY /D&C                              8,895.40                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56022   AMPUTATION DIGIT                              6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56025   ARTHROPLASTY TMJ MAJOR                        9,907.45                                          1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56026   ARCH BAR                                          63.35
  490   AMB SURGICAL CARE GENERAL           50.4410       56027   ARCH BARS REMOVAL                             4,751.80                                          1
  360   OR SVCS GENERAL                     50.4410       56028   ELECTRODE RESECTOSCOPE                          644.35
  490   AMB SURGICAL CARE GENERAL           50.4410       56034   BARTHOLIN CYST                                6,067.60
  360   OR SVCS GENERAL                     50.4410       56035   OPR RM MAJOR FIRST HOUR                      10,692.00 Z7506
  360   OR SVCS GENERAL                     50.4410       56036   OPR RM MAJOR B FIRST HOUR                     4,429.35 Z7506
  490   AMB SURGICAL CARE GENERAL           50.4410       56037   BLEPHAROPLASTY UPPER X1                       6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56038   BLEPHAROPLASTY UPPER X2                       6,833.75                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56039   BLEPHAROPLASTY LOWER X1                       6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56041   BLEPHAROPLASTY X4                             7,875.95                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56048   BRACHIOPLASTY BILATERAL                       7,875.95                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56049   BREAST IMPLANT REMOVAL UNILA                  6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56050   BREAST IMPLANT REMOVAL BILA                   7,875.95                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56051   BRONCHOSCOPY FLEXIBLE                         5,183.75                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56052   BRONCH FLEX/RIGID FS                          5,417.40                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56061   BUNIONECTOMY-UNILATERAL                       8,895.40                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56062   BUNIONECTOMY BILATERAL                        9,907.45                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56063   BX BREAST UNI+BIL LOCAL                       5,417.40                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56064   BX BREAST FS UNI+BIL LOCAL                    5,736.15                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56065   BX BREAST UNI+BIL GENERAL                     6,529.25                                          1
  270   M/S SUPPLY GENERAL                  50.4410       56081   ANES MASK                                         48.60
  270   M/S SUPPLY GENERAL                  50.4410       56082   ANES BREATHING CIRCUIT                          253.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56083   EDITH ENGSTROM                                    42.40                       A4483
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56085   SPONGES LAP                                     108.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56086   TROCAR VERSAPORT 10 LONG                        579.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56087   STERI DRAPE 1000                                  42.40
  360   OR SVCS GENERAL                     50.4410       56089   DERMABOND                                       203.75            G0168       G0168
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56090   SUTURE EYE/MICRO                                178.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56091   SUTURE POP-OFF/MS                               151.90

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               14 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56092   SUTURE DOUBLE-ARMED                            108.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56093   SUTURE VASCULAR                                277.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56094   SUTURE ENDOLOOP CHROMIC                        428.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56095   SUTURE ENDOLOOP VICRYL                         211.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56096   SUTURE GENERAL                                  65.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56097   SUTURE UROLOGY                                 139.00
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56098   SUTURE TIES                                     72.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56099   SKIN STAPLER                                   302.20
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56100   CORD BIPOLAR                                    72.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56101   STOCKINETTE IMPERVIOUS                         145.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56126   GRAFT TRANZ PERICARDIUM                        957.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56127   VALVE BEARVELDT                              2,796.45
  278   M/S OTHER IMPLANTS                  50.4410       56128   CORNEA                                      11,006.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56129   VALVE AHMED                                  2,684.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56130   SILICONE OIL                                 1,691.30
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56131   SHUNT EXPRESS MINI                           4,453.20
  490   AMB SURGICAL CARE GENERAL           50.4410       56141   ANESTHESIA PAIN MANAGEMENT                     136.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56145   DRILL BIT ZIM                                  282.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56147   GUIDE PIN/K-WIRE ZIM                            25.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56148   NUT/WASHER ZIM                                  65.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56149   PLATE ZIM 2361-4,2420 & 60                     157.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56150   PLATE ZIM 2419 & 58-59                         129.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56151   PLATE ZIM 2429 & 54 & 62                       363.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56152   PLATE ZIM 2449-52 & 63                         731.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56154   SCREW ZIM LG FRAG                               77.20
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56155   SCREW ZIM MINI & SM FRAG                        51.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56156   TAP ZIM                                        471.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56157   GRAFTON PUTTY 5CC                            3,071.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56158   GRAFTON PUTTY 10CC                           4,745.00
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56160   PACK HERNIA E                                  488.40
  490   AMB SURGICAL CARE GENERAL           50.4410       56161   CRYOPEXY UNI                                 6,529.25                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56163   J-P RESERVOIR                                  193.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56164   SKIN MARKER                                     24.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56165   DRAPE SNAP COVER                                48.60
  360   OR SVCS GENERAL                     50.4410       56166   OPR RM MINOR FIRST HOUR                      5,108.40 Z7506                                 1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56167   DRAPE TOWEL                                     18.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56169   HYSTEROSCOPY INSTR                           2,290.10                   A4550
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56170   *HYSTER/RESEC INSTR                          4,586.80                   A4550               1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56173   STERI DRAPE 1000                                42.40
  360   OR SVCS GENERAL                     50.4410       56174   STERI DRAPE 1020                                72.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56175   STERI DRAPE 1050                               133.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56176   STERI DRAPE 1060                               205.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56183   IMPLANT FINGER W/GROMMET                     2,030.85                   L8630               1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56184   IMPLANT TOE W/GROMMET                        2,030.85                   L8641
  360   OR SVCS GENERAL                     50.4410       56188   OPR RM MINOR B FIRST HOUR                    1,342.40 Z7506
  360   OR SVCS GENERAL                     50.4410       56189   OR TIME CHARGE-MAJOR 30 MIN                  4,237.20 Z7508
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56197   PROBE CRYO ABALATION 3MM                     5,356.45          C2618
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56198   PROBE CRYO TEMPERATURE                         945.35
  360   OR SVCS GENERAL                     50.4410       56199   KIT CRYO URETHRAL WARMING                    2,205.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56200   ENDOCLIP APPLIER                             1,885.25
  276   M/S SUPPLY INTEROC LENS             50.4410       56201   IOL INTRAOCULAR LENS                         1,271.60          C1780
  276   M/S SUPPLY INTEROC LENS             50.4410       56202   AGUAFLOW CGDD LENS                           3,528.85                   C1783

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           15 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  490   AMB SURGICAL CARE GENERAL           50.4410       56210   EUA                                          4,751.80                                       1
  360   OR SVCS GENERAL                     50.4410       56226   OR TIME CHARGE-MAJOR B QUARTER                 738.45 Z7508
  360   OR SVCS GENERAL                     50.4410       56229   OR TIME CHARGE-MINOR 30 MIN                  2,024.44 Z7508
  360   OR SVCS GENERAL                     50.4410       56231   OR TIME CHARGE-MINOR B QUARTER                 470.05 Z7508
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56236   GYN LAPAROSCOPY                              2,633.55
  360   OR SVCS GENERAL                     50.4410       56237   NEEDLE BIPOLAR CUT                             637.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56238   BALLOON STRUCTURAL                             717.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56239   BALLOON DISTENTION                           1,012.55
  270   M/S SUPPLY GENERAL                  50.4410       56240   CATH SUPRAPUBIC MIVA                           550.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56243   CANNULA ARTHREX SHOULDER                       177.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56244   EXTRACTOR ARTHREX FASTACK                      604.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56245   HARVESTER ARTHREX AUTOGRAFT                  3,825.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56246   IMPLANT TRANSFIX 3X50MM                        700.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56247   KIT ARTHREX ACL DISP                         1,046.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56248   SUTURE ARTHREX LASSO                         1,311.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56249   SUTURE ARTHREX KNOT PUSHER                     604.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56250   KIT ARTHREX TRACTION                           523.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56251   SCREW ARTHREX ACL BIO                          725.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56253   SET ARTHREX TRANSFIX GUIDE                     420.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56254   SPEAR ARTHREX FASTAK                           350.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56255   PUNCH BARRON VACUUM                            483.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56256   TREPHINE KATINA                                499.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56257   SCREW CAN CORTEX LAG                           303.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56258   PROBE ORATEC ABLATOR                         1,006.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56259   PROBE ORATEC TAC                             2,375.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56260   MESH PROLENE 3X6                               323.60                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56261   MESH PROLENE 6X6                               373.55                   C1718
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56262   MESH PROLENE 12X12                             856.20                   C1718
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56263   MESH MERSILENE 12X12                           892.70                   C1718               1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56264   MESH MARLEX 1X4                                424.95                   C1718
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56265   GRAFT IMPRA CENTERFLEX                       2,217.70                   L8670
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56266   GRAFT IMPRA VENAFLO                          2,857.15                   L8670
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56267   SUTURE-VASCULAR                                365.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56269   MESH PROLENE HERNIA SYS                        758.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56271   PROBE ORATEC LIG CHISEL                        886.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56272   SILASTIC SHEETING .005",10601,                 251.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56273   SILASTIC SHEETING .020",10601,                 288.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56274   SILASTIC SHEETING .080",10601,                 397.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56275   KIT MENISECTOMY                                427.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56276   BRACE BLEDSOE KNEE                             839.50
  360   OR SVCS GENERAL                     50.4410       56277   WIRE K-PLAIN 9",10601,56277"                    21.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56278   TREPHINE XOMED                                 247.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56279   WIRE TONSIL SNARE                               56.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56280   SHOW POSTOP BUNION WOODEN                       56.25
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56281   SCREW HERBERT BONE                             708.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56282   CANNULA GREENBAUM                               53.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56283   CAPSULE POLISHER TERRY SQUEEZE                  42.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56284   CASSETTE MAX VAC NO TIP                        531.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56285   KIT TURBOSONICS PARTS BLUE                     235.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56286   KIT TURBOSONICS PARTS PURPLE                   177.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56287   PERFLUARON 5ML                               1,691.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56288   PROBE IRRIGATING OCUTOME                     1,331.55

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           16 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56289   VESSEL LOOP                                     14.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56290   CASSETTE DIAPHRAMATIC SITE                     428.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56291   BAG LAP SPEC 10MM                              668.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56293   BLADE SAW 238, 262                             148.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56298   BUR 228, 236                                   250.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56299   BUR ROUND LONG                                 592.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56300   DRILL WIRE PASS                                309.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56301   BUR 224                                        166.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56302   KIT MENISECTOMY ELECTRODE                      427.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56308   IMPLANT TI RADIAL HEAD                       4,785.20
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56311   KIT SHOULDER CANNULA                           153.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56313   PATCH GORTEX 5X10CM                          1,550.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56314   PATCH GORTEX 10X15CM                         3,034.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56315   PATCH KUGEL HERNIA                             931.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56316   MESH PERFIX PLUG                               695.20                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56317   MESH TRELEX 1X4",10601,56317"                  541.00                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56318   MESH TRELEX 2X4",10601,56318"                  502.80                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56319   MESH TRELEX 10X14",10601,56319               1,576.25                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56324   MESH VICRYL 6X6",10601,56324"                1,217.30                   C1781
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56334   FORCEPS BIPOLAR CUTTING 10MM                 1,602.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56335   FORCEPS BIPOLAR CUTTING 5MM                  1,763.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56336   CANNULA DUAL MODE                            1,006.85
  276   M/S SUPPLY INTEROC LENS             50.4410       56337   CORNEA                                      18,884.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56338   CANNULA INFUSION                               102.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56339   ERASER WETFIELD HEMOSTATIC 186                  51.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56340   ERASER WETFIELD HEMOSTATIC 236                 262.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56341   MANIPULATOR INFINITECK TISSUE                  875.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56342   PROBE INFINITECH ENDO-OCULAR                   906.10
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56346   MEMBRANE ILLUMINATED                           354.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56348   SOLUTION ANTIFOG                               151.45                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56349   TUBING NEZHAT GEN                              646.85                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56350   TUBING NEZHAT GYN                              583.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56351   SPRING GRIP                                     59.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56352   TROCAR VERSAPORT 5MM                           477.10                   A4270
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56353   TROCAR VERSAPORT 5-10MM                        579.50                   A4270
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56354   TROCAR VERSAPORT 5-11MM                        601.15                   A4270
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56355   TROCAR VERSAPORT 5-12MM                        485.75                   A4270
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56356   TROCAR VERSAPORT 5-12MM BLUNT                  794.15                   A4270
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56357   CHOLANGIOCATH EXAMINE                          501.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56358   CHOLANGIOCATH TAUT                             247.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56359   CHOLANGIOCATH RABINOV                          308.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56360   FORCEPS BIPOLAR CUT 5MM                      1,763.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56361   FORCEPS BIPOLAR CUT 10MM                     1,602.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56362   TONSIL SPONGES                                  31.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56363   STRIPPER VEIN DISPOSABLE                       137.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56364   CYSTOTOME SMALL                                467.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56365   KIT SHOULDER TRACTION MCCON                    282.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56366   KIT MAMMARY FILL MCGHAN                         80.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56367   KIT MAMMARY FILL MENTOR                        131.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56368   DRAPE LASER ARTICULATED ARM                     60.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56369   BLADE BEAVER 6400                               29.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56370   BLADE BEAVER 7120                               65.15

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           17 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56372   BLADE BEAVER 5700                               99.00
  360   OR SVCS GENERAL                     50.4410       56373   BRACE BLEDSOE KNEE 26",10601,5                 839.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56374   TIP BOVIE BLADE TEFLON                          46.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56375   CIRCUIT ANES BREATHING PEDS                    139.60                   L8699
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56376   CIRCUIT ANES BREATHING ADULT L                  74.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56377   DRAIN J-P                                       67.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56378   DRAPE U ORTHO                                   52.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56379   BAND FALLOPE RING                              163.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56383   DRAPE MICROSCOPE 5952                          132.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56384   GAUZE OWENS                                     23.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56385   DRESSING AIRSTRIP SMALL                          5.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56386   E-PACK HERNIA CUSTOM                           385.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56387   ENDOCATCH                                      568.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56388   ENDOCLOSE                                      213.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56389   ENDOSHEAR 5MM LONG                             680.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56390   MESH MARLEX 10 X14",10601,5639                 374.00                   C1718
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56393   INJECTOR UTERINE KRONER                        229.20
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56394   TUBING IV VENOSET 72 STERILE"                   49.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56395   SHIELD PRO-12                                   77.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56396   BLADE SLIT KNIFE ANGLED                        123.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56398   BLADE SLIT KNIFE CRESCENT                       91.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56401   LENS GLIDE SHEETS 3M VISION                     32.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56403   NEEDLE SOFT TIP 20GA                            77.55
  490   AMB SURGICAL CARE GENERAL           50.4410       56404   *LARYNGOSCOPY BIOPSY FS                      5,417.40                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56405   TIP TURBO ABS                                  402.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56407   SUTURE-UROLOGY                                 182.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56409   CATH W/PORT MRI SINGLE                       2,735.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56411   CATH W/PORT MRI DOUBLE                       3,151.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56414   TIP TURBO KELMAN 1.1MM                         499.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56416   TIP TURBO 0.9MM                                362.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56418   TIP TURBO ROUND 1.1                            435.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56419   BLADE SAW 233, 260                              79.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56421   BLADE SAW 264                                  127.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56423   BLADE SAW 63,64                                174.20
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56424   BUR 202, 225                                   493.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56425   BUR 106, 226                                   133.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56426   BUR 243, 266,268                               319.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56427   RASP 82                                        411.00
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56428   STETHESCOPE ESOPHAGEAL                          12.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56429   TUBE ENDOTRACHEAL MAGILL                        19.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56430   AIRWAY NASOPHARYNGEAL                          102.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56431   PATCH GORTEX 20X30CM                        11,671.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56432   BREAST IMP STYLE 2500                        4,902.00                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56433   BREAST IMP STYLE 1400, 2700                  3,501.45                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56434   BREAST IMP STYLE 2400, SILTEX                3,968.30                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56435   BREAST IMP STYLE 1600                        2,567.70                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56436   BREAST IMP STYLE 163, 363                    3,734.75                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56437   TISSUE EXP STYLE 133, 2200                   5,485.45                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56438   BREAST IMP STYLE 168, 2600                   2,801.15                   L8600
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56439   BREAST IMP STYLE 468, 2900                   3,034.60                   L8600
  360   OR SVCS GENERAL                     50.4410       56443   ULTRASLING                                     319.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56444   SHOE POST-OP WOODEN                             56.25

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           18 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56445   ANES CIRCUIT PEDS                               63.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56446   BLADE DERMATOME BROWN                           84.70
  360   OR SVCS GENERAL                     50.4410       56448   NEEDLE SPINAL 3.5",10601,56448                  12.15
  360   OR SVCS GENERAL                     50.4410       56451   NEEDLE SPINAL 7",10601,56451"                   41.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56457   DRAPE PROBE                                    101.85
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56458   NEEDLE SPINAL WHITACRE                          50.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56459   SHEET BILAT EXTREMITY                           50.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56460   TIP BOVIE BLADE TEFLON                          46.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56461   SURGINEEDLE                                    176.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56463   TIP BOVIE EXTENDED                              33.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56464   TIP VACURETTE                                   33.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56465   TUBE ENDO TRACH MURPHY                          19.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56466   TUBE SPIROMETER DBL LUMEN                       35.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56467   TUBE TRACH MURPHY LO-PRO                        94.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56468   TUBE TRACH ORAL RAE                             78.70
  360   OR SVCS GENERAL                     50.4410       56471   TIP BOVIE TEFLON MICROTINE                     110.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56472   URINE METER 400CC                               66.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56473   WIRE NASAL SNARE #5                             10.85
  360   OR SVCS GENERAL                     50.4410       56474   WRAP HONEYCOMB ACE 4",10601,56                   8.90
  360   OR SVCS GENERAL                     50.4410       56475   WRAP HONEYCOMB ACE 6",10601,56                  15.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56476   BLADE ARTHRO SHAVER STR                        443.10
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56477   BLADE ARTHRO SHAVER CVD                        555.95
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56479   FOOT STRAP ANKLE DISTRACT S&N                  279.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56481   KIT ECTRA II CARPAL TUNNEL                   1,361.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56482   KIT SHOULDER TRACTION DYONICS                  401.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56483   SUTURE RETRIEVER                               214.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56484   SUTURE BAR T-FIX                               233.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56485   COVER MICROSCOPE ENT                            77.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56487   BLADE SKIN GRAFT KNIFE                          37.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56488   PACK DELUXE POSTERIOR VITRECT                1,476.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56489   PROBE STRAIGHT LASER                           761.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56490   ELECTRODE BALL & LOOP                          115.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56491   CYSTOTOME VISITEC                               23.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56492   NEEDLE RETROBULBAR                              29.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56493   NUCLEUS HYSTRODISSECTOR                         37.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56494   VITREORETINAL MICROPICK                         80.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56496   BLADE DERMATOME AIR                            151.00
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56497   DERMACARRIER                                   113.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56498   TUBING ARTHROSCOPY PUMP                        967.05
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56500   ENDOSHEARS 5MM                                 738.20
  360   OR SVCS GENERAL                     50.4410       56501   BLADE BEAVER 6900                              211.80
  270   M/S SUPPLY GENERAL                  50.4410       56502   DOLPHIN PUMP SUMP TUBING                       629.90
  270   M/S SUPPLY GENERAL                  50.4410       56503   DOLPHIN PUMP CANISTER                           33.50
  270   M/S SUPPLY GENERAL                  50.4410       56504   BLADE SHAVER 345                               579.50
  270   M/S SUPPLY GENERAL                  50.4410       56505   DRAIN BLAKE 10FR                               216.35
  270   M/S SUPPLY GENERAL                  50.4410       56506   DRAPE IOBAN 6650                               106.15
  270   M/S SUPPLY GENERAL                  50.4410       56507   DRESSING INTERCEED                           1,114.95
  270   M/S SUPPLY GENERAL                  50.4410       56508   TUBING WECK SUCTION/COAG                       105.00
  270   M/S SUPPLY GENERAL                  50.4410       56509   DRAPE OPMI MICROSCOPE                           28.10
  270   M/S SUPPLY GENERAL                  50.4410       56510   LITE GLOVE HANDLE                               40.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56511   ANCHOR MITE KNOTLESS                           365.30
  270   M/S SUPPLY GENERAL                  50.4410       56512   SOLUTION BSS EYE                               382.85

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       19 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4410       56513   STERI DRAPE 1015                                61.45
  270   M/S SUPPLY GENERAL                  50.4410       56514   IRRI NS 1000CC BOT                               7.30
  270   M/S SUPPLY GENERAL                  50.4410       56516   TUBING BERKELY SUCTION                          44.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56517   MESH MESILENE 2.5X4.5                          370.95                   C1781
  360   OR SVCS GENERAL                     50.4410       56518   DRILL BIT SYN                                  385.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56519   K WIRE SYN                                      44.25
  360   OR SVCS GENERAL                     50.4410       56520   TAP SYN                                        697.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56521   WASHER SYN                                     118.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56522   PLATE SYN 223.56-59                            719.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56523   PLATE SYN 241.13-15                            601.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56524   PLATE SYN 241.23-25                          1,031.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56525   PLATE SYN 241.33-40                            313.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56526   PLATE SYN 241.83,84                          1,433.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56527   SCREW SYN SM FRAG STD                           88.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56528   PIN SYN BUTTRESS 1.8MM                         285.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56529   PLATE SYN CONDYLAR                           1,433.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56530   PLATE SYN H                                  1,107.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56531   PLATE SYN LCC-DLP 2.0MM                      1,308.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56532   PLATE SYN LC-DCP 2.4MM                       1,745.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56534   PLATE SYN STR 6 HOLE                         1,010.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56535   PLATE SYN STR 12 HOLE                        1,213.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56536   PLATE SYN T,V 1.3-.5MM                       1,087.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56537   PLATE SYN T,V 2.0-.4MM                       1,236.75
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56538   SCREW SYN 1.5,2.0MM                            305.80
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56539   SCREW SYN 1.0,1.3,2.4MM                        467.25
  360   OR SVCS GENERAL                     50.4410       56555   THERMACHOICE II BALLOON                      5,181.70                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56556   TVT DEVICE IMPLANT                           5,198.90          C2631                        1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56557   PATCH VENTRALEX CIRCLE 4CM                   2,109.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56558   PATCH VENTRALEX CIRCLE 6.4CM                 2,520.70
  270   M/S SUPPLY GENERAL                  50.4410       56559   DRAPE URO GYN                                  182.90
  360   OR SVCS GENERAL                     50.4410       56580   SUPER LANCE 19 GA                               26.65
  270   M/S SUPPLY GENERAL                  50.4410       56581   KNIFE LASER EDGE MICROSURG                     251.30
  270   M/S SUPPLY GENERAL                  50.4410       56582   GUILLOTINE CUTTER 20 GA                        133.00
  270   M/S SUPPLY GENERAL                  50.4410       56583   PROBE ENDO ILLUMINATOR                         143.65
  270   M/S SUPPLY GENERAL                  50.4410       56584   CAUTERY C LINE ACCUTEMP                        560.55
  270   M/S SUPPLY GENERAL                  50.4410       56585   CARTRIDGE MONARCH 10L                           79.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56586   TUBE LACRIMAL DUCT                             279.65
  270   M/S SUPPLY GENERAL                  50.4410       56610   RETRACTOR IRIS                                 119.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56615   SCLERAL BUCKLE MIRA BAND                        45.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56616   SCLERAL BUCKLE MIRA SLEEVE                      31.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56617   SCLERAL BUCKLE MIRA SPONGE                     177.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56618   SCLERAL BUCKLE MIRA STRIP                       49.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56619   SCLERAL BUCKLE MIRA TIRE                        69.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56620   SCLERAL BUCKLE MIRA WEDGE                       85.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56621   SCLERAL BUCKLE STORZ BAND                       43.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56622   SCLERAL BUCKLE STORZ SLEEVE                     24.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56623   SCLERAL BUCKLE STORZ SPONGE                    206.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56624   SCLERAL BUCKLE STORZ STRIP                      46.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56625   SCLERAL BUCKLE STORZ TIRE                       61.70
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56626   IMPLANT ORBITAL SPHERE                          67.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56627   CONFORMER W/HOLES                               89.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56628   CONFORMER W/HOLES AND SPHERE                   278.75

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           20 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4410       56629   VERSAPOINT SPRING TIP 5MM                    1,478.85
  360   OR SVCS GENERAL                     50.4410       56630   VERSAPOINT PADDLE                            1,478.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56631   MESH MICROMESH 5X15MM                          993.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56701   SCREW BIOABSORB 2.7MM                          671.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56702   PIN BIOABSORB 1.5MM                            551.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56703   ROD BIABSORB PLA 2.0 MM                        560.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56704   MENISCUS ARROW 1.1 MM                          560.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56705   PIN ORTHOSORB 40 MM                          1,587.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56706   PIN ORTHOSORB 50 MM                            443.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56707   SCREW ARTHREX ACL FT                           418.95
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56708   SCREW ARTHREX ACL W/S                          472.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56709   ANCHOR BIO FASTAK                              291.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56710   ANCHOR BIO CORKSCREW                           312.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56711   ANCHOR FASTAK 2.4 MM                           630.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56712   ANCHOR CORKSCREW 5.0 MM                        770.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56713   GUIDE PINS ARTHREX                             201.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56714   CURVTEK DRILL CARTRIDGE                      3,087.90
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56715   CURVTEK DRILL NEEDLE                            48.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56716   REAMER CANNULATED CORING                     2,375.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56718   SUTURE ANCHOR MITEK GII/RC                     882.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56719   SUTURE ANCHOR MITEK MINI                       896.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56720   SCREW REVO                                     751.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56721   SHUTTLE REALY                                  163.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56722   MENISCAL DART 1.3MM                            443.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56723   MENISCAL DART PROBE                            362.70
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56724   MENISCAL DART CANNULA                          185.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56725   BLADE PARALLEL GRAFT KNIFE                     362.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56749   TUBE VENT XOMED                                 67.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56750   TUBE VENT S&N REG                               57.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56751   TUBE VENT S&N REUT-BOB                         139.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56752   HOUSEWIRE OTOMED                                97.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56753   HOUSEWIRE S&N                                  238.75
  360   OR SVCS GENERAL                     50.4410       56754   SHEATH HYSTERSCOPE 2.5 MM                      108.85
  360   OR SVCS GENERAL                     50.4410       56755   VERSAPORT 5-10 MM LONG                         456.65
  270   M/S SUPPLY GENERAL                  50.4410       56756   DRAIN PENROSE 1X36"                             35.55
  270   M/S SUPPLY GENERAL                  50.4410       56757   DRAPE BUR PROBE COVER                           57.80
  270   M/S SUPPLY GENERAL                  50.4410       56760   SOL NS IRRI DOUBLE PORT BAG                     12.30
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56764   PACK SET-UP BASIC                              139.00
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56765   PACK LAP CHOLE                               5,108.40
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56766   PACK GYN LAPAROSCOPY                           249.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56767   PACK MAJOR                                     520.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56768   PACK PERI/GYN                                  145.15
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56769   PACK MINOR                                     298.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56770   DRAPE LAPAROTOMY SHEET                         199.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56771   DRAPE MICROVASIVE PELVIC                        45.55
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56772   DRAPE TRANSVERSE LAP SHEET                     199.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56775   DRAPE BACK TABLE COVER                          48.75
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56776   DRAPE FANFOLD SHEET                             30.60
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56777   DRAPE MAYO STAND COVER                          36.35
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56778   DRAPE PEDIATRIC                                163.25
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56779   DRAPE SPLIT SHEET                              169.65
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56780   PACK VAGINAL                                   724.55

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       21 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56781   PACK EYE                                       392.45
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56782   PACK SHOULDER ARTHROSCOPY                      779.80
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56783   PACK EXTREMITY                                 401.50
  272   M/S SUPPLY STERILE SUPPLY           50.4410       56784   PACK KNEE ARTHROSCOPY                          472.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56786   PATCH COMPOSIX OVAL 8X12CM                   1,929.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56787   PATCH COMPOSIX OVAL 14X18CM                  3,143.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56788   PATCH COMPOSIX CIRCLE 8X8CM                  1,375.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56789   PATCH COMPOSIX OVAL 11X14CM                  2,481.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56790   PATCH COMPOSIX OVAL 8X10                    10,082.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56791   PATCH COMPOSIX OVAL 7X9                      8,557.65
  270   M/S SUPPLY GENERAL                  50.4410       56792   CAST ADULT BODY                                350.65
  270   M/S SUPPLY GENERAL                  50.4410       56793   CAST ADULT LONG ARM                            127.05
  270   M/S SUPPLY GENERAL                  50.4410       56794   CAST ADULT LONG LEG                            169.60
  270   M/S SUPPLY GENERAL                  50.4410       56795   CAST ADULT SHORT ARM                            84.85
  270   M/S SUPPLY GENERAL                  50.4410       56796   CAST ADULT SHORT LEG                           121.15
  270   M/S SUPPLY GENERAL                  50.4410       56797   CAST CHILD BODY                                272.00
  270   M/S SUPPLY GENERAL                  50.4410       56798   CAST CHILD LONG ARM                             84.85
  270   M/S SUPPLY GENERAL                  50.4410       56799   CAST CHILD LONG LEG                            127.05
  270   M/S SUPPLY GENERAL                  50.4410       56800   CAST CHILD SHORT ARM                            48.60
  270   M/S SUPPLY GENERAL                  50.4410       56801   CAST CHILD SHORT LEG                           103.00
  270   M/S SUPPLY GENERAL                  50.4410       56802   SPLINT FINGER OR HAND                           48.60
  270   M/S SUPPLY GENERAL                  50.4410       56803   SPLINT PLASTER                                  48.60
  360   OR SVCS GENERAL                     50.4410       56804   BLADE I KNIFE                                   32.25                                       1
  270   M/S SUPPLY GENERAL                  50.4410       56805   BLADE SAW 2296 SERIES                          221.95
  270   M/S SUPPLY GENERAL                  50.4410       56806   BLADE SAW 5100-137-133                         463.90
  270   M/S SUPPLY GENERAL                  50.4410       56807   BUR MICRO DRILL 277-10-230                     206.75
  270   M/S SUPPLY GENERAL                  50.4410       56808   BUR MICRO DRILL 1607-2-35                      373.20
  270   M/S SUPPLY GENERAL                  50.4410       56809   BUR MICRO DRILL 1607-2-107                      50.45
  360   OR SVCS GENERAL                     50.4410       56810   DRILL WIRE PASS 1608-2-63                      398.40
  270   M/S SUPPLY GENERAL                  50.4410       56811   RASP RECIP SAW 5100-37-113                     785.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56812   MESH PROLENE 1X4"                              362.10
  360   OR SVCS GENERAL                     50.4410       56813   SET BLOOD FLUID WARMING                        261.40
  270   M/S SUPPLY GENERAL                  50.4410       56814   PACK LITHOTOMY MINOR                           276.25
  270   M/S SUPPLY GENERAL                  50.4410       56815   PACK T AND A                                   123.45
  360   OR SVCS GENERAL                     50.4410       56817   VERSAPOINT SHEATH                              464.70
  360   OR SVCS GENERAL                     50.4410       56818   SUTURE PASSER LINVATEC                         277.70
  360   OR SVCS GENERAL                     50.4410       56819   CORD MONOPLAR DISP                              38.40
  273   M/S SUPPLY TAKE-HOME SUP            50.4410       56820   MEDPOR SHEET                                 1,266.45
  360   OR SVCS GENERAL                     50.4410       56821   LONESTAR STAYS                                 175.40
  360   OR SVCS GENERAL                     50.4410       56822   SHIELD WHITE PLASTIC EYE                         8.55
  360   OR SVCS GENERAL                     50.4410       56823   BLADE BANANA KNIFE                             229.00
  360   OR SVCS GENERAL                     50.4410       56824   STACKHOUSE TUBING                               51.20
  360   OR SVCS GENERAL                     50.4410       56825   STACKHOUSE FILTER                              110.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56826   PATCH MODIFIED KUGEL SM                      1,022.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56827   PATCH MODIFIED KUGEL MED                     1,193.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4410       56828   PATCH MODIFIED KUGEL LG                      1,412.55
  360   OR SVCS GENERAL                     50.4410       56830   KIT PERCUTANEOUS INTRO                         306.90
  490   AMB SURGICAL CARE GENERAL           50.4410       56901   SAME DAY SURGERY - CATEGORY 1                4,270.60                                       1
  490   AMB SURGICAL CARE GENERAL           50.4410       56902   SAME DAY SURGERY - CATEGORY 2                4,751.80                                       1
  490   AMB SURGICAL CARE GENERAL           50.4410       56903   SAME DAY SURGERY - CATEGORY 3                5,183.75                                       1
  490   AMB SURGICAL CARE GENERAL           50.4410       56904   SAME DAY SURGERY - CATEGORY 4                5,417.40                                       1
  490   AMB SURGICAL CARE GENERAL           50.4410       56905   SAME DAY SURGERY - CATEGORY 5                5,736.15                                       1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           22 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS     RVU
  490   AMB SURGICAL CARE GENERAL           50.4410       56906   SAME DAY SURGERY - CATEGORY 6                 6,529.25                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56907   SAME DAY SURGERY - CATEGORY 7                 6,833.75                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56908   SAME DAY SURGERY - CATEGORY 8                 7,875.95                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56909   SAME DAY SURGERY - CATEGORY 9                 8,174.45                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56910   SAME DAY SURGERY - CATEGORY 10                8,895.40                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56911   SAME DAY SURGERY - CATEGORY 11                8,354.75                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56912   SAME DAY SURGERY - CATEGORY 12                9,907.45                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56914   SAME DAY SURGERY - CATEGORY 14               11,633.95                                          1
  490   AMB SURGICAL CARE GENERAL           50.4410       56921   MISC CATEGORY 1 - 50 PERCENT                  2,131.70
  490   AMB SURGICAL CARE GENERAL           50.4410       56922   MISC CATEGORY 2 - 50 PERCENT                  2,379.60
  490   AMB SURGICAL CARE GENERAL           50.4410       56923   MISC CATEGORY 3 - 50 PERCENT                  2,592.00
  490   AMB SURGICAL CARE GENERAL           50.4410       56924   MISC CATEGORY 4 - 50 PERCENT                  2,712.40
  490   AMB SURGICAL CARE GENERAL           50.4410       56925   MISC CATEGORY 5 - 50 PERCENT                  2,861.25
  490   AMB SURGICAL CARE GENERAL           50.4410       56926   MISC CATEGORY 6 - 50 PERCENT                  3,264.95
  490   AMB SURGICAL CARE GENERAL           50.4410       56927   MISC CATEGORY 7 - 50 PERCENT                  3,413.10
  490   AMB SURGICAL CARE GENERAL           50.4410       56928   MISC CATEGORY 8 - 50 PERCENT                  3,938.25
  360   OR SVCS GENERAL                     50.4410       56929   BOVIE FOOT CONTROL                                14.35
  490   AMB SURGICAL CARE GENERAL           50.4410       56930   MISC CATEGORY 10 - 50 PERCENT                 4,450.95
  490   AMB SURGICAL CARE GENERAL           50.4410       56932   MISC CATEGORY 12 - 50 PERCENT                 4,957.35
  490   AMB SURGICAL CARE GENERAL           50.4410       56933   MISC CATEGORY 13 - 50 PERCENT                 5,102.70
  490   AMB SURGICAL CARE GENERAL           50.4410       56934   MISC CATEGORY 14 - 50 PERCENT                 5,823.80
  490   AMB SURGICAL CARE GENERAL           50.4410       56935   MISC CATEGORY 15 - 50 PERCENT                 6,850.35
  360   OR SVCS GENERAL                     50.4420       32363   LONESTAR RETRACTOR STAYS                        304.55
  480   CARDIOLOGY GENERAL                  50.4420       32725   CARDIOVERSION - PACU                            469.45                 92960      92960         1
  360   OR SVCS GENERAL                     50.4420       50001   OPR RM MINOR FIRST HOUR                       5,108.40                                          1
  360   OR SVCS GENERAL                     50.4420       50002   OPR RM MINOR B FIRST HOUR                     4,870.80                                          1
  360   OR SVCS GENERAL                     50.4420       50003   OPR RM MINOR C FIRST HOUR                     4,752.00                                          1
  360   OR SVCS GENERAL                     50.4420       50005   OPR RM MAJ AA FIRST HOUR                     11,880.00                                          1
  360   OR SVCS GENERAL                     50.4420       50008   OPR MAJ AA-AFTER HRS FIRST HOU               14,850.00                                          1
  360   OR SVCS GENERAL                     50.4420       50010   OPR RM MAJ FIRST HOUR                        10,692.00                                          1
  360   OR SVCS GENERAL                     50.4420       50011   OPR RM MAJ B FIRST HOUR                       9,979.20                                          1
  360   OR SVCS GENERAL                     50.4420       50012   OR TIME CHARGE-MAJ EA.ADD 30M                 4,237.20                                          1
  360   OR SVCS GENERAL                     50.4420       50014   OR TIME CHGE-MAJ AA EA 30 MIN                 5,885.00                                          1
  360   OR SVCS GENERAL                     50.4420       50016   OR TIME MAJ AA-AFTHR EACH ADD                 1,613.45
  360   OR SVCS GENERAL                     50.4420       50018   OR TIME CHARGE-MIN EA.ADD 30M                 2,024.44                                          1
  710   RECOVERY ROOM GENERAL               50.4420       50100   RECOVERY ROOM-MAJ AA,1ST HR                     909.20
  710   RECOVERY ROOM GENERAL               50.4420       50105   RECOVERY RM TIME CHG-MAJ AA,QT                  184.15
  360   OR SVCS GENERAL                     50.4420       50210   MISC. O.R. CHARGE (ONE)                            5.75
  360   OR SVCS GENERAL                     50.4420       50220   MISC. O.R. CHARGE (FIVE)                          27.05
  360   OR SVCS GENERAL                     50.4420       50230   MISC. O.R. CHARGE                           misc chrg determined at time of svcs
  360   OR SVCS GENERAL                     50.4420       50240   MISC. O.R. CHARGE (FIFTY)                       269.90
  360   OR SVCS GENERAL                     50.4420       50250   MISC. O.R. CHARGE (ONE HUNDRED                  539.60
  360   OR SVCS GENERAL                     50.4420       50260   MISC. O.R. CHARGE (FIVE HUNDRE                2,697.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50310   PROSTHETIC DEVICE (ONE)                            1.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50320   PROSTHETIC DEVICE (FIVE)                           5.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50330   PROSTHETIC DEVICE (TEN)                           11.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50340   PROSTHETIC DEVICE (FIFTY)                         59.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50342   INVANCE SLING KIT                            14,685.25                        C1771             1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50350   PROSTHETIC DEVICE (ONE HUNDRED                  469.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50360   MISC. IMPLANT                               misc chrg determined at time of svcs
  360   OR SVCS GENERAL                     50.4420       50400   STERIL AIR                                    1,571.00
  360   OR SVCS GENERAL                     50.4420       50405   STERIL AIR-NO HOODS                             604.30

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               23 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       50410   STONE RETRIEVAL HILICAL BASKET               1,673.75
  360   OR SVCS GENERAL                     50.4420       50411   DRAPE MICROVASIVE                               45.55                                       1
  360   OR SVCS GENERAL                     50.4420       50412   SHEET THYROID DRAPE                             58.25
  360   OR SVCS GENERAL                     50.4420       50413   STONE BASKET, PURSER 3FRX90CN                1,172.75
  360   OR SVCS GENERAL                     50.4420       50414   PURSUER CBD MINI BASKET                      2,005.95
  360   OR SVCS GENERAL                     50.4420       50415   STONE BSKT (SEGURA)                          1,722.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50416   DRESSING AIR STRIP (HEART)                      42.40
  360   OR SVCS GENERAL                     50.4420       50417   DRESSING MEDI-RIP 6",10601,504                  48.60
  360   OR SVCS GENERAL                     50.4420       50418   BANDAGE HONEYCOMB 6 W/VELCRO"                   57.15
  360   OR SVCS GENERAL                     50.4420       50419   STENT URETERAL HYDROPLUS                     1,359.50
  360   OR SVCS GENERAL                     50.4420       50420   DRAPE SHEET                                     30.60
  360   OR SVCS GENERAL                     50.4420       50421   DRAPE UTILITY C TAPE                           139.00
  360   OR SVCS GENERAL                     50.4420       50422   DRAPE PED LAPAROTOMY                           163.25
  360   OR SVCS GENERAL                     50.4420       50423   SHEET LAPAROTOMY TRANSVERSE                    199.45
  360   OR SVCS GENERAL                     50.4420       50424   SHEET SPLIT                                    169.60
  360   OR SVCS GENERAL                     50.4420       50425   PACK C SECTION                                 961.20
  270   M/S SUPPLY GENERAL                  50.4420       50426   KIT SITE RIBE SHEATH                            47.30
  360   OR SVCS GENERAL                     50.4420       50427   COVER MAYO                                      36.35
  360   OR SVCS GENERAL                     50.4420       50428   COVER X-RAY CASSETTE                            66.70
  360   OR SVCS GENERAL                     50.4420       50429   BOVIE SUCTION/CAUTERY                          139.00
  360   OR SVCS GENERAL                     50.4420       50430   CONCEPT MINI-KIT & ELECTRODE                   580.10
  360   OR SVCS GENERAL                     50.4420       50431   CONCEPT UNIVERSAL CANNULA                      211.80
  360   OR SVCS GENERAL                     50.4420       50432   CONCEPT ELECTRODE LONG HOOK                    501.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50433   IMPRA VAS GRAFT 4-7 TAPERED                  4,255.75
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50435   SCREW, ACE CANNULATED                        1,099.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50436   PIN, GUIDE KEN NAIL/ACE                        105.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50437   ACE WASHER                                     210.40
  360   OR SVCS GENERAL                     50.4420       50438   SHEET PED TRANS LAP                            132.00                                       1
  360   OR SVCS GENERAL                     50.4420       50439   SHEET NEONATE LAP                              108.90                                       1
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50440   IM MIN CANNULATED SCREW                        386.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50441   IM GUIDE PIN                                    42.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50442   IM WASHER                                       63.35
  270   M/S SUPPLY GENERAL                  50.4420       50443   NEEDLE PROSTATE SEEDING SINGLE                  34.15
  270   M/S SUPPLY GENERAL                  50.4420       50444   NEEDLE PROSTATE SEEDING 5PK                    170.25
  360   OR SVCS GENERAL                     50.4420       50445   PASTE TEFLON                                   634.40
  360   OR SVCS GENERAL                     50.4420       50446   BUR HALL CARBIDE 1.5 X 7.5                     374.75
  360   OR SVCS GENERAL                     50.4420       50447   CANNULA CLEARTRAC THREADED 5MM                 229.20
  360   OR SVCS GENERAL                     50.4420       50448   CANNULA CANNULOC THREADED 8.4M                 277.95
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50449   SCREW REVO                                   1,211.35                                       1
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50450   SUTURE CONCEPT SHUTTLE RELAY                   305.60                                       1
  360   OR SVCS GENERAL                     50.4420       50451   SET PATIL CRICO CATH                           338.50
  360   OR SVCS GENERAL                     50.4420       50452   SET RETRO INTUBATION                           338.50
  360   OR SVCS GENERAL                     50.4420       50453   CATH AIRWAY EXCHANGE                           233.85
  360   OR SVCS GENERAL                     50.4420       50454   SET MELKER CRICO CATH                          604.30
  270   M/S SUPPLY GENERAL                  50.4420       50455   BASKET SUR-CATCH NT STONE                      913.85
  360   OR SVCS GENERAL                     50.4420       50456   CANNULA CRYSTAL 5.75X7CM                       134.55
  360   OR SVCS GENERAL                     50.4420       50501   CANNULA-OPERATIVE CHOLANGIO                    501.90
  360   OR SVCS GENERAL                     50.4420       50502   DRAPE LASER MICROSCOPE                         308.50
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50503   SCREW, RICHARDS 4.0 CANNULATED                 944.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50504   SCREW,CANNULATED 4.0 - 12MM                  1,045.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50505   SCREW,CANNULATED 4.0 - 14MM                    909.20
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50506   SCREW, CANNULATED 4.0 - 16MM                 1,045.60

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           24 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50507   SCREW,CANNULATED 4.0 - 18MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50508   SCREW,CANNULATED 4.0 - 20MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50509   SCREW, CANNULATED 4.0 - 22MM                 1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50510   SCREW, CANNULATED 4.0 - 24MM                 1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50512   SCREW,CANNULATED 4.0 - 26MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50513   SCREW, CANNULATED 4.0 - 28MM                 1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50514   SCREW, CANNULATED 4.0 - 30MM                 1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50515   SCREW,CANNULATED 4.0 - 35MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50516   SCREW,CANNULATED 4.0 - 40MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50517   SCREW,CANNULATED 4.0 - 45MM                  1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50518   SCREW,CANNULATED 4.0 - 50MM                  1,045.60
  360   OR SVCS GENERAL                     50.4420       50519   CATHETER BROVIAC 2.7FR                       1,363.95                                       1
  360   OR SVCS GENERAL                     50.4420       50520   CATHETER BROVIAC 4.2FR                       2,005.25                                       1
  360   OR SVCS GENERAL                     50.4420       50521   CATHETER HICKMAN 7.0FR                       2,117.20
  360   OR SVCS GENERAL                     50.4420       50522   KIT BROVIAC REPAIR 2.7/4.2                     885.80                                       1
  360   OR SVCS GENERAL                     50.4420       50523   KIT HICKMAN REPAIR 7.0                         987.55                                       1
  360   OR SVCS GENERAL                     50.4420       50524   INTRODUCER SYSTEM 4.2/7.0                    1,114.80                                       1
  360   OR SVCS GENERAL                     50.4420       50525   PROBE ORATEC ABLATOR                         1,006.85
  360   OR SVCS GENERAL                     50.4420       50526   PROBE ORATEC TAC                             2,375.85
  360   OR SVCS GENERAL                     50.4420       50527   PROBE ORATEC CHISEL                            886.10
  360   OR SVCS GENERAL                     50.4420       50528   WAND TURBOVAC 90DEG                          1,002.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50529   TOTAL KNEE W/POLY CAP                       22,443.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50530   PRIMARY TOTAL KNEE CAP                      18,893.05                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50531   TOTAL HIP HYBRID CAP                        22,793.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50532   UNIPOLAR HEMIARTHOPLASTY CAP                 4,384.45                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50533   BIPOLAR HEMIARTHROPLASTY CAP                 7,538.35                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50534   PRIMARY TOTAL SHOULDER CAP                  10,692.50                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50535   TOTAL HIP HYB W/POLY CAP                    25,328.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50536   TOTAL HIP POROUS CAP                        24,873.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50537   TOTAL HIP POR W/POLY CAP                    21,067.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50538   ALLOPAK 50CC                                 5,545.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50541   TOTAL HIP HYBRID W/TRAB CAP                 22,221.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50542   TOTAL HIP POROUS W/TRAB CAP                 24,857.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50543   TOTAL KNEE POROUS CAP                       28,876.10                                       1
  360   OR SVCS GENERAL                     50.4420       50550   CANNULA, SCOTT 8FR X 8CM                       677.05
  360   OR SVCS GENERAL                     50.4420       50551   CSF EDM DRAINAGE SET                           966.65
  360   OR SVCS GENERAL                     50.4420       50552   CSF EDM DRAINAGE BAG                           173.40
  360   OR SVCS GENERAL                     50.4420       50555   SAPHENOUS VEIN CNULA                            72.85
  360   OR SVCS GENERAL                     50.4420       50560   ARCH BAR                                        72.85
  360   OR SVCS GENERAL                     50.4420       50562   TIP VITAL VIEW EXT 12FR                        635.00
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50563   TROCAR VERSAPORT 5MM                           477.10
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50564   TROCAR VERSAPORT 5-10MM                        579.50
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50565   STAPLER, ENDO MULTIFIED HERNIA               2,658.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50566   COMPNT, FEM STEM CENTRALIGN SI              19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50567   COMPNT, FEM STEM CENTRALIGN SI              19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50568   COMPNT, FEM STEM CENTRALIGN SI              19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50569   COMPNT, FEM STEM CENTRALIGN SI              19,863.60
  360   OR SVCS GENERAL                     50.4420       50570   HUMIDIFER F-P WATER BAGS                        42.40
  360   OR SVCS GENERAL                     50.4420       50571   ENDO THREADS - 5MM                             103.00
  360   OR SVCS GENERAL                     50.4420       50572   ENDO THREADS - 10MM                            103.00
  360   OR SVCS GENERAL                     50.4420       50573   REDUCER CAPP                                    78.55
  360   OR SVCS GENERAL                     50.4420       50574   TROCAR - 5MM                                 1,389.70

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           25 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50575   TROCAR VERSAPORT BLUNT 5-12MM                  794.15
  360   OR SVCS GENERAL                     50.4420       50576   SURGINEEDLE 120MM                              197.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50577   TROCAR VERSAPORT 12MM                          485.75
  360   OR SVCS GENERAL                     50.4420       50578   BIPOLAR LAP CUTTING NEEDLE                   1,221.40
  360   OR SVCS GENERAL                     50.4420       50579   TROCAR FLEXIPATH 15MM                          569.65
  369   OR SVCS OTHER OR SVCS               50.4420       50580   LASER-MAJOR                                  3,073.55
  369   OR SVCS OTHER OR SVCS               50.4420       50581   LASER-MINOR                                  1,534.10
  360   OR SVCS GENERAL                     50.4420       50582   LASER SOFTWEAR                                 634.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50583   VALTRAC,DIAM 25MM,GAP 2.5MM                  3,625.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50584   VALTRAC,DIAM 25MM,GAP 2.0                    3,625.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50585   VALTRAC,DIAM 28MM,GAP 2.0                    3,625.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50586   VALTRAC,DIAM 31MM,GAP 2.0                    3,625.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50587   VALTRAC,DIAM 34MM,GAP 2.0                    3,625.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50588   VALTRAC,DIAM 34MM,GAP 2.5MM                  3,625.05
  360   OR SVCS GENERAL                     50.4420       50589   DRAP DISP. ORTHO #8476                         103.00
  360   OR SVCS GENERAL                     50.4420       50590   STERI DRAPE 1015                               229.75
  360   OR SVCS GENERAL                     50.4420       50591   STERI DRAPE 1050                               133.30
  360   OR SVCS GENERAL                     50.4420       50592   STERI DRAPE 1051                               253.80
  360   OR SVCS GENERAL                     50.4420       50593   VI DRAPE INTESTINAL BAG                         92.20
  360   OR SVCS GENERAL                     50.4420       50594   STERI DRAPE 1060                               205.75
  360   OR SVCS GENERAL                     50.4420       50595   STERI DRAPE 5208                               169.60
  360   OR SVCS GENERAL                     50.4420       50596   STERI DRAPE 1000                                42.40
  360   OR SVCS GENERAL                     50.4420       50597   STERI DRAPE 1071                               139.00
  360   OR SVCS GENERAL                     50.4420       50598   STERI DRAPE 1020                                72.85
  360   OR SVCS GENERAL                     50.4420       50599   DRAPE TAPE                                      18.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50600   UROPASS STENT                                  641.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50601   UROPASS OBST-STENT                           1,292.45
  360   OR SVCS GENERAL                     50.4420       50602   CATHETER REDDICK                             1,045.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50605   UROPASS STENT KIT                            1,965.15
  360   OR SVCS GENERAL                     50.4420       50606   BLANKET, WARMING, ADULT                        277.95
  360   OR SVCS GENERAL                     50.4420       50607   AIRWAY NASAL DISP                               90.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50610   STENT POST URETERO                             483.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50615   STENT POST NEPHRO                            2,127.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50616   COMPONENT MED NECK PIUS 3.5 28               4,302.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50617   COMPONENT SHORT NECK PIUS 3.5                4,302.95
  360   OR SVCS GENERAL                     50.4420       50620   FOLLOWER ATALA-SHEPARD BALLOON                 699.45
  360   OR SVCS GENERAL                     50.4420       50621   STONE EVA N-CIRCLE TIPLESS                   1,240.00
  360   OR SVCS GENERAL                     50.4420       50622   KIT KUMPE ACCESS STD                           144.75
  360   OR SVCS GENERAL                     50.4420       50623   GUIDE WIRE AMPLATE .038"                       175.80
  360   OR SVCS GENERAL                     50.4420       50624   SET BEAGHLER PERE ENTRY                        861.85
  360   OR SVCS GENERAL                     50.4420       50625   KIT KUMPE ACCESS BEACON                        177.65
  270   M/S SUPPLY GENERAL                  50.4420       50626   CATH FLEX-TIP DURAL LUMEN                      206.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50627   KIT SPARL SLING                              4,726.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50628   SLING REPLIFORM 2X7 CM                       2,410.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50629   KIT PRECISION TWIST                          2,668.15                   C2631
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50630   UROPLASTY DILATATION CATH                    4,854.55
  360   OR SVCS GENERAL                     50.4420       50631   UROPLASTY CALIBRATION CATH                     465.45
  360   OR SVCS GENERAL                     50.4420       50632   UROPLASTY INFLATION DEVICE                     918.35
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50634   BRACHYTX PALLADIUM BEST 103                    260.55          C1720
  272   M/S SUPPLY STERILE SUPPLY           50.4420       50635   PROSTASEED MODLE I 125                         211.60                   C1718
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50636   RESERVOIR BIOFLEX 100CC PENILE               7,586.45
  369   OR SVCS OTHER OR SVCS               50.4420       50640   YAG LASER/W/TECH.                            2,443.10

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       26 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION      CHARGE       MCAL    CPT-4     HCPCS      RVU
  369   OR SVCS OTHER OR SVCS               50.4420       50641   CO2 LASER W/TECH                1,658.80
  369   OR SVCS OTHER OR SVCS               50.4420       50642   STANDBY/TECH                      347.00
  369   OR SVCS OTHER OR SVCS               50.4420       50643   EMERGENCY/RENTAL                1,050.95
  369   OR SVCS OTHER OR SVCS               50.4420       50644   CANDELA PULSE DYE/W/VIDEO/CAME 10,470.75
  369   OR SVCS OTHER OR SVCS               50.4420       50645   STANDBY/TECH/CANDELA            3,136.55
  369   OR SVCS OTHER OR SVCS               50.4420       50646   EMERGENCY/CANDELA               1,397.50
  369   OR SVCS OTHER OR SVCS               50.4420       50647   K.P. (DUAL WAVE LENGTH) YAG &   2,789.75
  369   OR SVCS OTHER OR SVCS               50.4420       50648   LAPAROSCOPIC                    5,931.70
  369   OR SVCS OTHER OR SVCS               50.4420       50649   LAPOROSCOPIC INST/VIDEO/CAMERA  1,744.50
  369   OR SVCS OTHER OR SVCS               50.4420       50650   PELVISCOPY INST.                1,050.95
  369   OR SVCS OTHER OR SVCS               50.4420       50651   HYSTERSCOPY INSTS               2,290.10                    A4550
  369   OR SVCS OTHER OR SVCS               50.4420       50652   GYN/LAPOROTOMY/HEMORRHOIDECTOM    210.30
  369   OR SVCS OTHER OR SVCS               50.4420       50653   COLPOSCOPY INST                   525.45
  369   OR SVCS OTHER OR SVCS               50.4420       50654   HYSTEROSCOPE/W/RESECTOSCOPE &   4,586.80                    A4550
  369   OR SVCS OTHER OR SVCS               50.4420       50655   HYSTERSCOPE INST/LASER          1,050.95
  369   OR SVCS OTHER OR SVCS               50.4420       50656   SINOSCOPY INST/PER DAY          1,744.50
  369   OR SVCS OTHER OR SVCS               50.4420       50657   SINOSCOPY INST/W/VIDEO/TECH     3,136.55
  369   OR SVCS OTHER OR SVCS               50.4420       50658   CANCELLATION FEE                  909.20
  369   OR SVCS OTHER OR SVCS               50.4420       50665   PROBE SCAPEL EA(SAPHIRE TIP)      698.90
  369   OR SVCS OTHER OR SVCS               50.4420       50666   BARE FIBER/SFEO-6ND. YAG.       1,324.15
  369   OR SVCS OTHER OR SVCS               50.4420       50667   HANDPIECES                      1,607.60
  369   OR SVCS OTHER OR SVCS               50.4420       50668   NEZHAT IRRIGATION TUBING          210.30
  369   OR SVCS OTHER OR SVCS               50.4420       50669   PFIZER/SUCTION/IRRIGATION/INSU    630.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50700   COMPRESSION PLATE Z             1,854.70
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50701   LAG SCREW Z                     2,930.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50702   PIN ASSEMBLY Z                    457.30
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50703   COMPRESSION BONE SCREW Z          266.15
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50704   CORTICAL BONE SCREW Z             199.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50705   CYLINDER SET WITH PUMP         19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50706   ASSEMBLY KIT 94805X2            2,054.20
  360   OR SVCS GENERAL                     50.4420       50707   RESERVOR BIOCLEX 60CC & 75CC    5,860.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50708   SCROTAL KIT MARK II\9720S      19,863.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50710   R/AMBI LAY SCREW                1,323.25
  360   OR SVCS GENERAL                     50.4420       50711   CATHETER,ALL SILICONE,FOLEY 12    139.00
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       50715   SCREW CLAVICULAR                  543.90
  360   OR SVCS GENERAL                     50.4420       50716   HOLDER WELL LEG                   211.80
  360   OR SVCS GENERAL                     50.4420       50850   DRAPE OVERHEAD TABLE              211.80
  360   OR SVCS GENERAL                     50.4420       50851   TABLE COVER                        48.60
  360   OR SVCS GENERAL                     50.4420       50852   CLAMP SIDE BITE INSERTS 75MM      320.35
  360   OR SVCS GENERAL                     50.4420       50853   CLAMP 61MM                        253.80
  360   OR SVCS GENERAL                     50.4420       50860   ATHLETIC SUPPORT                  121.15
  360   OR SVCS GENERAL                     50.4420       50898   LEMAITRE VALVNLOTOME DISP       3,282.70
  360   OR SVCS GENERAL                     50.4420       50899   LEMAITRE VALVNLOTOME EXPAND     4,503.90
  360   OR SVCS GENERAL                     50.4420       50900   VEIN STRIPPER DISP                253.80
  360   OR SVCS GENERAL                     50.4420       50901   INJECTION CARTRIDGE KIT Z         380.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50905   HARRIS FEMORAL STEM            16,317.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50910   WEBB BOLT                         289.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50916   MULTIPOLAR BIPOLAR CUPS 40 - 4  7,465.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50917   MULTIPOLAR BIPOLAR CUPS 46 - 5  7,911.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       50918   MULTIPOLAR BIPOLAR CUPS 52 - 6  8,558.10
  360   OR SVCS GENERAL                     50.4420       50920   PULSEVAC SUCTION/IRRIGATOR        628.65
  360   OR SVCS GENERAL                     50.4420       50921   TIP SET S & I SHOWERHEAD          217.40

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                           27 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       50922   TIP SET S & I FEMORAL                          236.05
  360   OR SVCS GENERAL                     50.4420       50923   ELVIS DEFOGGER                                 151.45
  360   OR SVCS GENERAL                     50.4420       51000   HEART-LUNG MACHINE                          13,400.45
  360   OR SVCS GENERAL                     50.4420       51003   JAW SPRING CLIP                                 84.85
  360   OR SVCS GENERAL                     50.4420       51005   FOAM HEADREST                                   30.60
  360   OR SVCS GENERAL                     50.4420       51006   INSERT CUSHION PRONE VIEW                      154.35
  360   OR SVCS GENERAL                     50.4420       51007   BRUSH URETERO-CYSTO                            501.90
  360   OR SVCS GENERAL                     50.4420       51010   CATH FOG IRR 4-6-10F                           320.35
  360   OR SVCS GENERAL                     50.4420       51025   CATH URETERAL DILATION BALLOON               3,037.35
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51026   SCREW CORTICAL 3.5 50-16-35                    489.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51027   SCREW CORTICAL 3.5 50-18-35                    489.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51028   SCREW CORTICAL 3.5 50-14-35                    489.60
  360   OR SVCS GENERAL                     50.4420       51030   CATH-BILIARY STENOSIS                          876.10
  360   OR SVCS GENERAL                     50.4420       51040   CATH FOG BIL 5-6 FR                            556.20
  360   OR SVCS GENERAL                     50.4420       51041   MALLENKRODT ESOPHEGAL TEMP PRO                 217.40
  360   OR SVCS GENERAL                     50.4420       51042   FOLEY CATH W-TEMP PROBE                        368.80
  360   OR SVCS GENERAL                     50.4420       51045   CATH FOG CHOLO                                 320.35
  360   OR SVCS GENERAL                     50.4420       51046   GRAFT GORETEX 10CM                           1,510.45
  360   OR SVCS GENERAL                     50.4420       51065   CANNULA CORONARY ARTERY S M                    954.40
  360   OR SVCS GENERAL                     50.4420       51066   PERCUTANEOUS INTRO-8.5 KIT                     459.35
  360   OR SVCS GENERAL                     50.4420       51067   DRAIN JACKSON-PRATT HUBLESS FL                 151.45
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51068   SCREW - CANCELLOUS 6.5 X 85                    163.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51069   CABLE-READY TROCH DEVICE LG                  2,407.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51070   CABLE-READY TROCH CABLE                      1,369.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51071   CABLE-READY CERCLAGE CABLE                   1,348.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51072   CABLE READY PLATE CABLE                        924.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51073   CABLE-READY BONE PLATE, 6 HOLE               2,647.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51074   CABLE-READY BONE PLATE, 8 HOLE               3,229.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51075   CABLE-READY BONE PLATE, 10 HOL               3,987.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51076   CABLE-READY TROCH DEVICE SH                  1,986.65
  360   OR SVCS GENERAL                     50.4420       51080   STIMUPLEX NEEDLE 50MM                           43.75
  360   OR SVCS GENERAL                     50.4420       51081   STIMUPLEX NEEDLE 80MM                           57.50
  360   OR SVCS GENERAL                     50.4420       51082   CONTIPLEX NERVE BLOCK SET                      128.45
  360   OR SVCS GENERAL                     50.4420       51083   CATH PEDIATRIC STAMEY                          169.00
  360   OR SVCS GENERAL                     50.4420       51084   CATH REENTRY MALECOT                           373.50
  360   OR SVCS GENERAL                     50.4420       51085   LITHO PROBE PNEUMATIC 1.0MM                  1,092.35
  360   OR SVCS GENERAL                     50.4420       51086   LITHO PROBE ULTRASONIC 3.8MM                   560.15
  360   OR SVCS GENERAL                     50.4420       51087   LITHO STONE CATCHER                            224.10
  360   OR SVCS GENERAL                     50.4420       51100   PUDENZ TH&SD ST CONN                           223.85
  360   OR SVCS GENERAL                     50.4420       51105   CATH VENTRICULAR (NEURO)                       616.60
  360   OR SVCS GENERAL                     50.4420       51106   ATRIUM DOUBLE CHAMBER                        1,347.50
  360   OR SVCS GENERAL                     50.4420       51107   KIT - CRANIOTOMY                             2,827.90
  360   OR SVCS GENERAL                     50.4420       51110   CATH RED RUBBER 12-14-16                        96.55
  360   OR SVCS GENERAL                     50.4420       51115   CATH SCOTT VENT (DISP)                         465.45
  360   OR SVCS GENERAL                     50.4420       51120   CATH VENT                                      507.80
  360   OR SVCS GENERAL                     50.4420       51130   SILVERSTONE CLAMP                            2,948.25
  360   OR SVCS GENERAL                     50.4420       51140   SILVERSTONE CLAMP 2                            894.30
  360   OR SVCS GENERAL                     50.4420       51150   PUDENZ CARDIAC END                             834.00
  360   OR SVCS GENERAL                     50.4420       51151   SLEEVE, SCLERAL BUCKLE                          65.25
  360   OR SVCS GENERAL                     50.4420       51152   KIT RANEY CLIP GUN                           1,746.40
  360   OR SVCS GENERAL                     50.4420       51153   BOVIE TIP TEFLON BLADE                          51.90
  360   OR SVCS GENERAL                     50.4420       51170   CLIP APPLIER WECK                              707.05

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       28 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       51179   RANEY CLIP GUN MAGAZINE                         80.60
  360   OR SVCS GENERAL                     50.4420       51180   CLIP NEURO-RAINEY                              108.90
  360   OR SVCS GENERAL                     50.4420       51181   MIDAS REX B-1 DISSECTING TOOL                  874.30
  360   OR SVCS GENERAL                     50.4420       51182   MIDAS REX M-3 DISSECTING TOOL                  744.80
  360   OR SVCS GENERAL                     50.4420       51183   MIDAS REX M-5 DISSECTING TOOL                  879.65
  360   OR SVCS GENERAL                     50.4420       51184   MIDAS REX AM-11 DISSECTING TOO               1,128.35
  360   OR SVCS GENERAL                     50.4420       51185   MIDAS REX M-52 BUR                           1,159.85
  360   OR SVCS GENERAL                     50.4420       51188   GRAFT PATCH VELOUR 4X4                         368.80
  360   OR SVCS GENERAL                     50.4420       51190   CLIP VENA CAVA                                 374.75
  360   OR SVCS GENERAL                     50.4420       51200   CLIP I C ANEUR                               1,619.25
  360   OR SVCS GENERAL                     50.4420       51213   BAG, SPECIMEN 10MM TROCAR                      749.75
  360   OR SVCS GENERAL                     50.4420       51220   PISTON MCGEE                                   725.15
  360   OR SVCS GENERAL                     50.4420       51221   REUTER BIVALUE SPLINT                          392.80
  360   OR SVCS GENERAL                     50.4420       51230   BUTTON TODD                                    242.00
  360   OR SVCS GENERAL                     50.4420       51231   BRACE LATERAL SHOULDER ABDUCTI               2,622.40
  270   M/S SUPPLY GENERAL                  50.4420       51232   ABD BINDER 3-4 PANEL                           128.45                   A4462
  360   OR SVCS GENERAL                     50.4420       51233   ABD BINDER 4 PANEL 60-75",1060                 153.25
  360   OR SVCS GENERAL                     50.4420       51235   TORP                                         1,347.50
  360   OR SVCS GENERAL                     50.4420       51250   TUBE LARYN                                     851.65
  270   M/S SUPPLY GENERAL                  50.4420       51251   TUBING - INSUFFLATOR                           332.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51252   MITRAL RING 32MM                            18,387.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51253   MITRAL RING 34MM                            18,387.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51254   RING, TRICUSPID 34MM                        18,387.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51255   RING TRICUSPID 36MM                         18,387.55
  360   OR SVCS GENERAL                     50.4420       51256   CARDIOPLEGIA ADAPTER                           323.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51257   PERICARDIAL MEMBRANE                         4,127.90
  360   OR SVCS GENERAL                     50.4420       51258   C-LINE ACCTEMP CAUTERY                         159.45
  360   OR SVCS GENERAL                     50.4420       51259   ADAPTER ANTE/RETRO GRADE                       291.60
  360   OR SVCS GENERAL                     50.4420       51260   PERISTRIPS X2                                3,002.65
  360   OR SVCS GENERAL                     50.4420       51261   PERISTRIPS X5                                6,870.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51262   PRECLUDE IMA SLEEVE                          2,876.55                                       1
  360   OR SVCS GENERAL                     50.4420       51263   TUBING STORE INSUFFLATION                       46.15
  360   OR SVCS GENERAL                     50.4420       51278   TIRE 278, SCLERAL BUCKLE                       152.80
  360   OR SVCS GENERAL                     50.4420       51279   SLEEVE, SCLERAL BUCKLE                         101.90
  360   OR SVCS GENERAL                     50.4420       51280   BAND, SCLERAL BUCKLE                            93.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51281   STAPLE-BONE CARTRDIGE-7x10                   1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51282   STAPLE,BONE CARTRIDGE-7x7                    1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51283   STAPLE, BONE CARTRIDGE-16x25                 1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51284   STAPLE, BONE CARTRIDGE - 16x20               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51285   STAPLE, BONE CARTRIDGE - 16x15               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51286   STAPLE, BONE CARTRIDGE - 16x10               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51287   STAPLE, BONE CARTRDIGE - 18x20               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51288   STAPLE, BONE CARTRIDGE - 13x15               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51289   STAPLE, BONE CARTRIDGE - 13x10               1,649.70
  360   OR SVCS GENERAL                     50.4420       51290   TIRE, SCLERAL BUCKLE                           134.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51291   WASHER, 4.0/6.5 CANNULATED                     128.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51292   STAPLE, BONE CARTRIDGE - 13x7                1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51293   STAPLE, BONE CARTRIDGE - 10x15               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51294   STAPLE, BONE CARTRIDGE - 10x10               1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51296   STAPLE, BONE CARTRIDGE - 10x7                1,649.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51297   BLADE-4.5 CURVED INCISOR                     1,418.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51298   BLADE - 4.5 CURVED SYNOVATOR                 1,418.50

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           29 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       51300   ARGON LASER UNIT                             1,015.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51301   GRAFT GORETEX STRETCH 4X7                    4,878.45
  360   OR SVCS GENERAL                     50.4420       51305   ARGON LASER PROBE                            1,655.60
  360   OR SVCS GENERAL                     50.4420       51306   ARGON LASER ABC HANDPIECE NOZZ                 356.80
  360   OR SVCS GENERAL                     50.4420       51325   IRRIGATION SET                                  84.85
  360   OR SVCS GENERAL                     50.4420       51326   STONE RETRIEVAL HILICAL BASKET               1,673.75
  360   OR SVCS GENERAL                     50.4420       51327   DILATOR, 6FR X 70CM                            388.30
  360   OR SVCS GENERAL                     50.4420       51328   PROBE ELECT LITH 7FR                         2,640.60
  360   OR SVCS GENERAL                     50.4420       51330   CRYOPHAKE                                      659.05
  360   OR SVCS GENERAL                     50.4420       51331   CATHETER,CV L.A. LINE                        5,860.60
  360   OR SVCS GENERAL                     50.4420       51340   DERMA CARRIER                                  157.25
  360   OR SVCS GENERAL                     50.4420       51341   HEART, AORTIC PUNCH                            296.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51342   SM SELF COMPRESSION PLATE                      562.45
  360   OR SVCS GENERAL                     50.4420       51345   DERMASTRIP REESE                               477.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51346   BONE - CORTICAL/CANC CRUSHED                 3,336.15
  360   OR SVCS GENERAL                     50.4420       51347   BONE CHIPS MTF                               2,018.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51348   GRAFT FASCIA LATA 10CM                         611.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51349   GRAFT FASCIA LATA 15CM                         854.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51351   STAPLE, BONE FIXATION                          701.45
  360   OR SVCS GENERAL                     50.4420       51355   PREP TRAY SCRUB                                 66.70
  360   OR SVCS GENERAL                     50.4420       51357   URINE METER #6530                              399.20
  360   OR SVCS GENERAL                     50.4420       51358   CATHETER SPINAL                                659.05
  360   OR SVCS GENERAL                     50.4420       51359   C J V NEEDLE INSYTE - A                         78.55
  360   OR SVCS GENERAL                     50.4420       51360   CATHETER TRAY - DUAL LUMEN                   1,673.75
  360   OR SVCS GENERAL                     50.4420       51361   CATH QUINTON DUAL LUMEN 13.5                 1,673.75
  360   OR SVCS GENERAL                     50.4420       51365   SPLINT PLASTER                                  48.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51370   STAPLE, BONE TABLE/OSTEOTOMY                   896.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51371   STAPLER LINEAR PROXIMATE                     1,099.95
  360   OR SVCS GENERAL                     50.4420       51375   SPLINT FINGER METAL                             12.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51380   STAPLE ST TABLE S                              173.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51381   RUSH PINS ASST SIZES                           336.45
  360   OR SVCS GENERAL                     50.4420       51383   PROBE CORSON DISP SUCTION IRRI               1,239.00
  360   OR SVCS GENERAL                     50.4420       51391   PROBE CORSON DISP SUCTION/IR                 1,239.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51394   PLATE CLOVERLEAF T                           1,150.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51400   PLATE COMP 2 1/2                               310.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51410   PLATE COMP 3-3 1/2                             588.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51420   PLATE COMP 4                                   336.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51421   DOWEL,CLOWARD - 14x26CM                      3,036.50
  360   OR SVCS GENERAL                     50.4420       51422   TROCAR THORACOPORT                             182.55
  360   OR SVCS GENERAL                     50.4420       51423   TROCAR THORA CO PORT 15MM                      489.60
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51424   STAPLER ENDO GIA 60-3.5                      2,606.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51425   PLATE SMALL FRAGMENT -Z                        347.15
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51426   STAPLES ENDO GIA 60-3.5                        928.55
  360   OR SVCS GENERAL                     50.4420       51427   TROCAR, SURGIPORT 15MM                       2,024.15
  360   OR SVCS GENERAL                     50.4420       51428   TROCAR APPLE                                 1,100.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51429   CAGES, RAY THREADED FUSION                  19,863.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51430   PLATE EC -Z                                    967.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51431   PLATE EC-Z SEMI TUBULAR                        347.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51432   PLATE EC -Z SCP FOREARM                        683.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51433   WASHER Z                                       136.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51434   EBI STIMULATOR SPF - 2T/C                   19,863.60                   E0749
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51435   SCREW CLIP AMBI                                483.65

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           30 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51436   SUPER LAG SCREW AMBI                         2,036.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51437   SCREW PLATE 2 HOLE AMBI                      2,548.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51438   SCREW PLATE 3 HOLE AMBI                      2,679.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51439   SCREW PLATE 4-5-6 HOLE AMBI                  2,937.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51440   SCREW PLATE 10 HOLE AMBI                     4,843.80
  360   OR SVCS GENERAL                     50.4420       51441   Z/X-RAY ALIGMENT PAD                           296.30
  360   OR SVCS GENERAL                     50.4420       51442   DISP LAMARK BANDAGE STERILE                    236.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51443   PLATE SUPRACONDYLAR AMBI 8/90                3,036.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51444   PLATE SUPRACONDYLAR AMBI 10/90               3,430.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51445   PLATE SUPRACONDYLAR AMBI 12/90               5,421.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51446   SCREW ACUFEX ACL                             1,017.95
  360   OR SVCS GENERAL                     50.4420       51447   CLIP EDSLAB JAW SPRING 6MM                     103.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51448   SUTURE, T-FIX                                  442.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51450   PIN KNOWLES                                    347.15
  360   OR SVCS GENERAL                     50.4420       51451   TUBING MALIS IRRIG+BIPOLAR COR                 586.25
  360   OR SVCS GENERAL                     50.4420       51452   TOURNIQUET DISP CUFF 18",10601                 305.60
  360   OR SVCS GENERAL                     50.4420       51453   TOURNIQUET DISP CUFF 24",10601                 340.80
  360   OR SVCS GENERAL                     50.4420       51454   TOURNIQUET DISP CUFF 34",10601                 392.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51460   COMPONENT FEMORAL NEXGEN                    12,809.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51461   COMPONENT TIB PLATE NEXGEN                   8,708.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51462   COMPONENT ART SURF NEXGEN CB                 4,427.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51463   COMPONENT ART SURF NEXGEN PS                 4,427.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51464   COMPONENT PATELLAR NEXGEN                    3,048.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51465   ILIUM TRICORTICAL BONE STRIP 2               9,981.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51469   COMP DISTAL CENTRALIZER VERSYS                 350.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51470   COMPONENT FEM HEAD VERSYS                    2,124.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51471   COMPONENT FEM STEM CEMENTED VE              11,203.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51472   COMPONENT SHELL TRILOGY                      6,852.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51473   COMPONENT 10 DEG LINER TRIOLOG               3,618.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51474   COMPONENT 20 DEG LINER TRILOGY               3,772.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51475   COMPONENT BONE SCREW TRILOGY                   619.55
  360   OR SVCS GENERAL                     50.4420       51476   DRAIN MALECOT 4 WING 16FR                      296.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51477   BAR-COLLES FRACTURE FEXATION                 4,607.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51478   PIN COLLES SKELETAL FRACTURE                   378.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51479   METACARPAL SCREW COLLES FRACTI                 341.50
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51480   SCREW SET-COLLES FRACTURE                       78.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51491   Z TUBE PLATE 2-3 HOLE                        1,718.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51492   Z TUBE PLATE 4-5-6 HOLE                      1,854.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51493   PLATE SYN PELVIC RECON                         903.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51494   SCREW SYN PELVIC CORTEX                         70.20
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51495   SCREW, SYN SM, FRAG                             86.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51496   SCREW, SYN LG. FRAG                            155.30
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51497   SCREW, WOODRUFF STD/HEAVY                      216.35
  360   OR SVCS GENERAL                     50.4420       51498   PIN ASSEMBLY Z                                 525.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51499   GUILDE PIN T T TIP Z                           231.40
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51510   SCREW OLECRANAN                                574.20
  360   OR SVCS GENERAL                     50.4420       51511   SCISSORS,ETHICON,DISPOSABLE                  1,395.55
  360   OR SVCS GENERAL                     50.4420       51512   ENDOCATCH                                      767.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51513   TUBE GASTROENTERIC -BALLOON #1               1,510.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51514   TUBE GASTROENTERIC-BALLOON #18               1,510.45
  360   OR SVCS GENERAL                     50.4420       51515   AIRWAY NASOPHARYNGEAL                          211.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51516   TUBE MOSS GASTROSTOMY 18 FR                  2,839.70

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       31 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       51517   TUBE, BAKER 20FR                             1,450.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51518   TUBE TRI FUNNEL GASTRO                         246.25
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51530   SCREW SYN PERC REDUCTION                       288.55
  360   OR SVCS GENERAL                     50.4420       51590   HEMOVAC MINI SNYDER                            422.95
  360   OR SVCS GENERAL                     50.4420       51600   HEMOVAC UNIV CONN                               96.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51601   SCREW,CANNULATED,4.0,55MM                      909.20
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51602   SCREW,CANNULATED,4.0,60MM                    1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51603   SCREW,CANNULATED,4.0,65MM                    1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51604   SCREW,CANNULATED,4.0,70MM                    1,045.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51605   HIP LAG SCREW                                1,280.95
  360   OR SVCS GENERAL                     50.4420       51606   HIP PACK                                       422.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51607   RICHARDS HIP PLATE                           1,623.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51608   SCREW CANCELOUS 6.5X85                         133.30
  360   OR SVCS GENERAL                     50.4420       51610   DRAIN TUBE-HEM VAC                              65.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51611   STEFFIE PLATE                                4,529.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51612   STEFFIE SCREW                                  956.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51613   STEFFIE WASHER                                 184.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51615   COMPONENT, ACETABULAR 64MM                  10,071.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51616   WIRE, ACL GUIDE                                567.60
  272   M/S SUPPLY STERILE SUPPLY           50.4420       51617   WIRE, 4.0/6.5 GUIDE                            172.05
  360   OR SVCS GENERAL                     50.4420       51618   VIA-GUARD SUCTION SET                           90.70
  270   M/S SUPPLY GENERAL                  50.4420       51619   SUGICAL TOWELS WHITE                            40.80
  360   OR SVCS GENERAL                     50.4420       51620   CAST SH ARM CHILD                               48.60
  360   OR SVCS GENERAL                     50.4420       51630   CAST SH ARM ADULT                               84.85
  360   OR SVCS GENERAL                     50.4420       51640   CAST L ARM CHILD                                84.85
  360   OR SVCS GENERAL                     50.4420       51650   CAST L ARM ADULT                               127.05
  360   OR SVCS GENERAL                     50.4420       51660   CAST S LEG CHILD                               103.00
  360   OR SVCS GENERAL                     50.4420       51670   CAST S LEG ADULT                               121.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51677   MITRAL VALVE CARP/EDW ALL SIZE              32,310.65
  360   OR SVCS GENERAL                     50.4420       51680   CAST L LEG CHILD                               127.05
  360   OR SVCS GENERAL                     50.4420       51690   CAST L LEG ADULT                               169.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51691   WIRE LUGUE                                     194.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51692   WIRE-LUQUE - 1292-73                           194.65
  360   OR SVCS GENERAL                     50.4420       51700   CAST BODY CHILD                                272.00
  360   OR SVCS GENERAL                     50.4420       51701   ELECTRODE,SUCTION/IRRIGATION C                 785.75
  360   OR SVCS GENERAL                     50.4420       51702   COAG ELECTRODE (BROWN BALL) #2                 725.15
  360   OR SVCS GENERAL                     50.4420       51703   COAG. ELETRODE (BROWN COLLINS)                 725.15
  360   OR SVCS GENERAL                     50.4420       51704   COAG. ELECTROE (YELLOW BALLS)                  725.15
  360   OR SVCS GENERAL                     50.4420       51705   COAG. ELECTRODE (YELLOW COLLIN                 725.15
  360   OR SVCS GENERAL                     50.4420       51706   CUTTING LOOP YELLOW #24FR                      665.05
  360   OR SVCS GENERAL                     50.4420       51708   CUTTING LOOP BROWN #27FR                       665.05
  360   OR SVCS GENERAL                     50.4420       51710   CAST BODY ADULT                                350.65
  360   OR SVCS GENERAL                     50.4420       51715   CAST CYLINDER                                   48.60
  360   OR SVCS GENERAL                     50.4420       51716   TUBE,TRACH,REINFORCED-8.5                      260.10
  360   OR SVCS GENERAL                     50.4420       51717   TUBE,TRACH,REINFORCED-9.0                      260.10
  360   OR SVCS GENERAL                     50.4420       51720   CAST FINGER CH & AD                          2,054.25
  360   OR SVCS GENERAL                     50.4420       51721   APPLIER ENDO CLIP 176615                     3,075.60
  360   OR SVCS GENERAL                     50.4420       51722   ACCESSORY KIT EC10                           6,361.75
  360   OR SVCS GENERAL                     50.4420       51723   SET TRUMPET VALVE CONT FLUID                   646.85
  360   OR SVCS GENERAL                     50.4420       51724   GUIDE WIRE ANES                                151.45
  360   OR SVCS GENERAL                     50.4420       51725   CARDIOPLEGIA SHILEY                          1,589.15
  360   OR SVCS GENERAL                     50.4420       51726   GUIDE WIRE ARROW .025"                          64.70                                       1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           32 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       51727   HUMI UTERINE MANIPULATOR                       186.90
  360   OR SVCS GENERAL                     50.4420       51728   DRESSING INTERCEED 3X4"                      1,137.90
  360   OR SVCS GENERAL                     50.4420       51729   TRIVEX RESECTOR                              1,521.95
  270   M/S SUPPLY GENERAL                  50.4420       51730   TRIVEX TUBING                                  244.10
  270   M/S SUPPLY GENERAL                  50.4420       51731   DRAIN PENROSE 1X36"                             35.55
  360   OR SVCS GENERAL                     50.4420       51732   SMOKE EVAI CAUTERY PENCIL                      123.55
  360   OR SVCS GENERAL                     50.4420       51733   SMOKE EVAC LAP TUBING                           13.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51734   PATCH KUGEL MED OVAL                         1,407.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51735   PATCH KUGEL LG OVAL                          1,729.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51736   PATCH KUGEL SM CIRCLE                        1,354.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51737   PATCH KUGEL LG CIRCLE                        1,519.75
  360   OR SVCS GENERAL                     50.4420       51740   STERILE SETUP CC                               145.15
  360   OR SVCS GENERAL                     50.4420       51741   INTRODUCER, IMPLANT AID LEAD                   967.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51746   PLATE AESCULAP CX 4 HOLE                     3,062.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51747   PLATE AESCULAP CX 6 HOLE                     3,667.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51748   PLATE AESCULAP CX 8 HOLE                     4,411.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51749   PLATE AESCULAP CX 10 HOLE                    4,808.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51750   PLATE AESCULAP CX 12 HOLE                    5,762.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51751   SCREW AESCULAP CX                            2,268.35
  360   OR SVCS GENERAL                     50.4420       51752   PIN AESCULAP CX FIXATION                       387.80
  360   OR SVCS GENERAL                     50.4420       51753   DRILL BIT AESCULAP CX                        1,464.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51754   PLATE SYN CX SM 1-2 LEVEL                    3,241.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51755   PLATE SYN CX SM 3-4 LEVEL                    3,412.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51756   PLATE, SYNTHES CX 1-2 LEVEL                  3,982.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51757   PLATE, SYNTHES CX 3-4 LEVEL                  4,602.30                                       1
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51758   SCREW, SYNTHES CX EXPANSION                  1,117.45                                       1
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51759   SCREW, SYNTHES CX LOCKING                      190.20                                       1
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51760   SCREW, SYN DHS COMPRESSION                     188.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51761   PLATE, SYNTHES DHS                           2,540.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51762   PLATE, SYNTHES DCS                           3,850.05
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51763   SCREW, SYNTHES DHS LAG                       1,679.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51764   SCREW, SYNTHES DHS BONE                         91.95
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51765   SCREW, SYNTHES 7.0 CANNULATED                1,221.40
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51766   SCREW, SYNTHES 4.5 CANNULATED                  946.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51767   SCREW, SYNTHES 7.3 CANNULATED                1,313.15                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51770   ST CAGE BAK PROXIMITY                       13,304.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51771   ST CAGE BAK STANDARD                        11,490.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51772   ST CAGE BAK END CAP                            605.00
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51775   ST PED SCREW FIXED                           2,815.15
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51776   ST PED SCREW POYAXIAL                        4,005.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51777   ST PED ROD 10CM                                748.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51778   ST PED ROD 20CM                              1,094.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51779   ST PED ROD 47CM                              1,440.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51780   ST PED LOCKING NUT                             489.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51781   ST PED TRANS CONN                            1,152.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51782   ST PED TRANS CONN NUT                          230.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51783   ST PED TRANS CONN INSERT                       345.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51785   SYN PED SCREW 5.0MM                          2,088.10
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51786   SYN PED SCREW 6-7.0MM                        2,201.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51787   SYN PED ROD 50MM                               408.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51788   SYN PED ROD 75MM                               614.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51789   SYN PED ROD 100-500MM                          811.95

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           33 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51790   SYN PED COLLAR STD                             411.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51791   SYN PED NUT                                    164.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51792   SYN PED TCC BODY                               817.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51793   SYN PED TCC COLLAR                             411.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51794   SYN PED TCC BAR                                175.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51795   SYN PED TRANSVERSE                             614.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51796   SYN PED SCREW VARIANGLE                      3,217.40
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51800   SW PED SCREW MULTIANGLE                      2,838.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51801   SW PED ROD                                     685.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51802   SW PED LOCKING CAP                             685.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51803   SW PED CROSS BAR CLAMP                         823.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51804   SW PED TRANSVERSE ROD                          548.70
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51805   SW PED SCREW STD                             2,208.15
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51810   AT PED SCREW STD                             2,176.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51811   AT PED LINK                                  1,508.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51812   AT PED ROD 5-11CM                              548.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51813   AT PED ROD 13-45CM                             713.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51814   AT PED NUT/WASHER                               68.80
  360   OR SVCS GENERAL                     50.4420       51815   AT PED TAP                                   1,419.65
  360   OR SVCS GENERAL                     50.4420       51816   AT PED K-WIRE                                   75.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51817   AT PED BRIDGES                               1,508.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51818   SYN PED SCREW STD 50-60M                     2,281.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51819   SYN PED SCREW VA 50-60M                      3,232.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51820   SYN TRANSCONN 15-30.5 MM                     3,244.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51821   SYN TRANSCONN 31.5-83 MM                     3,501.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51822   SYN ROD CURVED                               1,442.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51823   SYN CLICK X 6.2,7.0 30-45                    3,403.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51824   SYN CLICK X 6.2,7.0 50-55                    3,736.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51825   SYN CLICK X 8.0 30-45                        3,486.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51826   SYN CLICK X 8.0 50-60                        3,826.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51827   SYN LOCKING CAP                              1,442.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51828   SYN 3-D HEAD                                 3,306.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51829   GRAFT FEMORAL RING                          20,171.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51830   PLATE SYNTHES VA CX 1L                       6,495.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51831   PLATE SYNTHES VA CX 2L                       6,675.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51832   PLATE SYNTHES VA CX 3L                       7,652.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51833   GRAFT DBX PUTTY 5CC                          4,041.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51834   GRAFT DBX PUTTY 10CC                         6,231.80
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51835   DAN PED TSRH-3D SCREW                        2,128.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51838   DAN PED SET SCREW                              239.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51839   DAN PED TSRH 3-D CONN                        4,949.40
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51840   DAN PED EXL POST SCREW                       2,232.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51841   DAN PED STR ROD                              1,753.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51842   DAN PED PREBENT ROD                          1,393.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51844   DAN PED STD CROSS PLATE                      5,517.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51845   DAN PED MS CROSS PLATE                       6,370.45
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51846   DAN PED CROSS SET SCREW                        741.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51847   DAN PED ROD TEMPLATE                           513.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51848   GRAFT OSTEOFIL 10CC                          6,585.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51849   PLATE DAN CX 19-50MM                         7,514.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51850   PLATE DAN CX 52.5-65MM                       7,867.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51851   PLATE DAN CX 67.5-77.5MM                     8,408.35

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       34 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51852   PLATE DAN CX 80-110MM                        8,845.10
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51853   SCREW DAN CX 4.0MM                           1,873.45
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51855   SCREW DAN CX 4.5MM                           2,311.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51856   DRILL BIT DAN CX 13MM                        1,407.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51857   GRAFT ACF SPACER                             4,740.00
  270   M/S SUPPLY GENERAL                  50.4420       51860   PACK SHOULDER ARTHRO                           771.80
  270   M/S SUPPLY GENERAL                  50.4420       51865   DRAIN BLAKE 1 OFR                              216.35
  270   M/S SUPPLY GENERAL                  50.4420       51866   ANSPACH ACORN ROUTER                           566.10
  270   M/S SUPPLY GENERAL                  50.4420       51867   ANSPACH MATCHSTICK                             574.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51868   PLATE OSTEO CRANI SBR 2H                       242.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51869   SCREW OSTEO CRANI                              215.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51870   MESH OSTEO CRANI LARGE                       3,119.40                   C1718
  270   M/S SUPPLY GENERAL                  50.4420       51871   DRAPE CRANIAL/INCISE                           295.10
  270   M/S SUPPLY GENERAL                  50.4420       51872   SPONGES BABY LAP                                 7.45
  360   OR SVCS GENERAL                     50.4420       51874   CATH URETERAL AXXESS                            75.45
  270   M/S SUPPLY GENERAL                  50.4420       51875   BAG URO DRAIN                                  103.00
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51876   SCREW SYN CORBEX 2.4MM                         219.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51877   PIN SYN BUTTRESS                               152.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       51878   SCREW SYN 3.5MM SELF TAP                       101.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51879   WASHER SYN SPIKED                              192.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51880   PLATE SYN DORSAL RADIUS                      3,050.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       51881   PLATE SYN VOLAR RADIUS                       2,516.35
  360   OR SVCS GENERAL                     50.4420       51905   STOCKINET IMP                                  145.15
  360   OR SVCS GENERAL                     50.4420       51906   KIT ENDOSCOPIC LAP CHOLI CUSTO               6,839.25
  360   OR SVCS GENERAL                     50.4420       51907   LAP NISSAN EXPOSE RETRACTOR                  1,537.65
  360   OR SVCS GENERAL                     50.4420       52010   BERKELEY TUBE                                  121.15
  360   OR SVCS GENERAL                     50.4420       52015   REINFRCD TRACHEAL TB                           386.95
  360   OR SVCS GENERAL                     50.4420       52016   STONE RETRIEVAL HILICAL BASKET               1,673.75
  270   M/S SUPPLY GENERAL                  50.4420       52017   LAPAROSCOPIC SUCTION/IRRIGATIO               3,141.60
  360   OR SVCS GENERAL                     50.4420       52020   TUR EXT                                         48.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52021   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52022   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52023   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52024   CLIP,SUGITA,LG-ANEUR #07-940-3               1,991.40
  360   OR SVCS GENERAL                     50.4420       52025   TUR SYSTEM                                     145.15
  360   OR SVCS GENERAL                     50.4420       52026   SPINAL CATHETER                                598.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52028   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52029   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52030   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52031   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52032   CLIP,SUGITA,FEN,LG-ANEUR #07-9               1,024.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52033   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52034   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52035   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52036   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52037   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52038   CLIP,SUGITA ANEURYSM ALL                     1,558.55
  360   OR SVCS GENERAL                     50.4420       52040   SNYDER FLOW CONTORL                            399.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52041   CLIP,SUGITA ANEURYSM ALL                     1,792.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52042   CLIP,SUGITA,STAND-ANEUR #07-94               1,639.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52043   CLIP,SUGITA,STAND,ANEUR #07-94               1,639.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52044   CLIP,SUGITA,STAND-ANEUR #07-94               1,639.35

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       35 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52045   CLIP,SUGITA,STAND-ANEUR #07-94               1,639.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52046   CLIP,SUGITA,STAND-ANEUR #07-94               1,639.35
  360   OR SVCS GENERAL                     50.4420       52047   STENT DOUBLE J 7X22                          3,347.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52048   CLIP,SUGITA,LG-ANEUR #07-940-1               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52049   CLIP,SUGITA,LG-ANEUR #07-940-1               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52051   CLIP,SUGITA,LG-ANEUR #07-940-1               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52052   CLIP,SUGITA,LG-ANEUR #07-940-1               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52053   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52054   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52056   CLIP,SUGITA,LG-ANEUR #07-940-2               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52057   CLIP,SURGITA,LG-ANEUR #07-940-               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52058   CLIP,SURGITA,LG-ANEUR #07-940-               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52059   CLIP,SURGITA,LG-ANEUR #07-940-               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52060   COMPRESSION SCREW                              252.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52061   CLIP,SURGITA,LG-ANEUR #07-940-               1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52062   COMP ENDO FEM STEM VERSYS                    4,084.65
  360   OR SVCS GENERAL                     50.4420       52063   PENCIL 45 ANGI ABC FOOT SWITCH                 918.35
  360   OR SVCS GENERAL                     50.4420       52064   CATHETER, URETERAL SPIRAL TIP                  175.65
  360   OR SVCS GENERAL                     50.4420       52065   ELECTRODE, LAP SOLID SHAFT L-H               1,153.95
  360   OR SVCS GENERAL                     50.4420       52066   CATHETER VENTRICULAR                         1,268.75
  360   OR SVCS GENERAL                     50.4420       52067   DELTA VALVE SNAP ASSE LEVEL 1                8,373.80
  360   OR SVCS GENERAL                     50.4420       52068   DELTA VALVE SNAP ASSE LEVEL 2                8,373.80
  360   OR SVCS GENERAL                     50.4420       52069   CATHETER VENTRICULAR 41406                   1,268.75
  360   OR SVCS GENERAL                     50.4420       52070   CATHETER VENTRICULAR 41409                   1,268.75
  360   OR SVCS GENERAL                     50.4420       52071   CATHETER VENTRICULAR 41408                   1,268.75
  360   OR SVCS GENERAL                     50.4420       52144   ATS DRAINAGE SET                               338.20
  360   OR SVCS GENERAL                     50.4420       52145   ATS RECPTAL UNIT                               374.75
  360   OR SVCS GENERAL                     50.4420       52146   ISOTAC TOOL DIG                                616.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52148   SUTURE PROXIMATE PSD                           210.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52150   SUTURE PROXIMATE PPR 15                        362.95
  360   OR SVCS GENERAL                     50.4420       52151   BURR HOLE, DELTA 12MM LEVEL 2                8,567.10
  360   OR SVCS GENERAL                     50.4420       52153   PLC 50                                       1,661.80
  360   OR SVCS GENERAL                     50.4420       52154   PLCUR 50                                       677.05
  360   OR SVCS GENERAL                     50.4420       52155   SUTURE PROXIMATE                               302.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52156   SUTURE AUTO LOADING UNIT (META               1,891.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52207   BRENER BYPASS TUBE                             530.80
  360   OR SVCS GENERAL                     50.4420       52208   SHUNT BRENNER T                                731.20
  360   OR SVCS GENERAL                     50.4420       52209   INFUSION T                                      78.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52210   SAFE T SHUNT                                   472.95
  360   OR SVCS GENERAL                     50.4420       52211   VESSEL TIP                                     157.25
  360   OR SVCS GENERAL                     50.4420       52212   HICKS FRAME WEDGE                              169.60
  360   OR SVCS GENERAL                     50.4420       52213   DIAFLEX URETERAL DILATOR                     1,323.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52235   CEMENT RESTRIC BUCK                            588.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52311   STENT URETERAL 6,7FR                           834.45                                       1
  360   OR SVCS GENERAL                     50.4420       52312   CATH BROVIAC                                   689.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52314   GRAFT - TUTOPLAST DURA                       7,339.50
  360   OR SVCS GENERAL                     50.4420       52315   HICKMAN REPAIR KIT                             731.20
  360   OR SVCS GENERAL                     50.4420       52316   HICKMAN INTRODUCER KIT                         556.20
  360   OR SVCS GENERAL                     50.4420       52317   CONSTAVAC PVC DRAIN - 3/16",10                 302.20
  360   OR SVCS GENERAL                     50.4420       52318   TUBING, ARTHROSCOPY SET                        967.05
  360   OR SVCS GENERAL                     50.4420       52319   SUTURE, GORE-TEX                               242.00
  360   OR SVCS GENERAL                     50.4420       52320   ENDOSTITCH SUTURE                              232.10

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           36 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       52321   PERFUSION SET-UP                            11,600.10
  360   OR SVCS GENERAL                     50.4420       52322   CELL SAVER SET-UP                            2,815.40
  360   OR SVCS GENERAL                     50.4420       52323   ENDOLOOPS, VICRYL                              211.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52324   STENT URETERAL CONTOUR                       1,434.10                   C2617               1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52325   HICKMAN SUBCUTANEOUS PORT                    5,684.45
  360   OR SVCS GENERAL                     50.4420       52326   URETERAL STENT SET W/FADER TIP               3,456.05
  360   OR SVCS GENERAL                     50.4420       52327   URETERAL STENT SET W/FADER TIP               3,456.05
  360   OR SVCS GENERAL                     50.4420       52328   URETERAL STENT SET W/FADER TIP               3,456.05
  360   OR SVCS GENERAL                     50.4420       52329   URETERAL STENT SET W/FADER TIP               3,456.05
  360   OR SVCS GENERAL                     50.4420       52330   URETERAL STENT SET W/FADER TIP               3,456.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52331   STENT URETERAL PERCUFLEX                       834.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52332   STENT URETERAL 4.8FR                           921.50
  360   OR SVCS GENERAL                     50.4420       52333   TANDEM BALLOON                               4,272.55
  360   OR SVCS GENERAL                     50.4420       52334   UROMAX II PLUS BALLOON                       3,641.45
  360   OR SVCS GENERAL                     50.4420       52335   OCCLUSION BALLOON                            1,780.15
  360   OR SVCS GENERAL                     50.4420       52336   KAM VAC SUCTION TUBE                           307.60
  360   OR SVCS GENERAL                     50.4420       52337   TRILOGY BALLOON                              3,495.80
  360   OR SVCS GENERAL                     50.4420       52338   URETERAL DILATOR/SHEATH                      2,265.80
  360   OR SVCS GENERAL                     50.4420       52339   URETERAL DILATOR                               971.10
  360   OR SVCS GENERAL                     50.4420       52340   GEMINI BASKET                                2,589.45
  360   OR SVCS GENERAL                     50.4420       52341   GRASPER, 3 PRONG                             2,330.30
  360   OR SVCS GENERAL                     50.4420       52342   LOOP RETRIEVER                               1,780.15
  360   OR SVCS GENERAL                     50.4420       52343   CATHETER DUAL LUMEN                            696.35
  360   OR SVCS GENERAL                     50.4420       52344   CATHETER SUPRAPUBIC 14FR                     1,116.70
  360   OR SVCS GENERAL                     50.4420       52345   CYTOLOGY BRUSH 510-101                         809.45
  360   OR SVCS GENERAL                     50.4420       52346   CYTOLOGY BRUSH 510-103                       1,133.00
  360   OR SVCS GENERAL                     50.4420       52347   GUIDE WIRE,URETERAL, ZEBRA .03                 647.80
  360   OR SVCS GENERAL                     50.4420       52348   SPRINGE IRRIGATOR                              696.35
  360   OR SVCS GENERAL                     50.4420       52349   EVACUABOR UROVAC BLADDER                       125.15
  360   OR SVCS GENERAL                     50.4420       52350   LASER FIBER 200 MICRON                       2,060.75
  360   OR SVCS GENERAL                     50.4420       52351   LASER FIBER 300, 1000MIC                     1,873.45
  360   OR SVCS GENERAL                     50.4420       52352   LASER FIBER 365, 500 MIC                       616.95
  360   OR SVCS GENERAL                     50.4420       52353   BALLOON NEPHROMAX                            1,564.35
  360   OR SVCS GENERAL                     50.4420       52354   SET AMPLATE SHEATH/DILATOR                   1,434.95
  360   OR SVCS GENERAL                     50.4420       52355   BASKET ZEROTIP 3FR                           1,192.10
  360   OR SVCS GENERAL                     50.4420       52356   CATH MALECOT NEPHROSTOMY                       450.10
  360   OR SVCS GENERAL                     50.4420       52357   SET TLA NEEDLE & SHEATH                        228.45
  360   OR SVCS GENERAL                     50.4420       52358   KIT NEPH PERC ACCESS                           978.50
  360   OR SVCS GENERAL                     50.4420       52359   SHEATH CLEAR RENAL                             326.30
  360   OR SVCS GENERAL                     50.4420       52360   DEVICE ENCORE INFLABION                        362.45
  360   OR SVCS GENERAL                     50.4420       52361   CATH BERN-IMAGER II 5FR                        111.00
  360   OR SVCS GENERAL                     50.4420       52362   SET CHIOU SP TUBE INTRO                        582.75
  360   OR SVCS GENERAL                     50.4420       52363   LONESTAR RETRACTOR STAYS                       304.55
  360   OR SVCS GENERAL                     50.4420       52565   CATH RABINOV                                   308.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52570   6X16 WOVEN KRAFT-DEBAKEY                     2,154.30
  360   OR SVCS GENERAL                     50.4420       52571   DRAPE UNIVERSAL X-RAY EQUIP                    163.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52580   GRAFT GORTEX ONE CM                            268.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52583   GRAFT GORETEX 40CM                           3,856.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52585   GRAFT GORTEX 70 CM                           6,829.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52590   GRAFT GORETEX 80 CM                          7,711.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52595   GRAFT GORETEX 90CM                           8,771.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52600   GRAFT GORETEX TAPER 4.5-6.5MM                6,651.75

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           37 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       52602   ADAPTER UNIPOLAR                             1,468.35
  360   OR SVCS GENERAL                     50.4420       52603   RETRACTOR VAGITRAC                             521.90
  360   OR SVCS GENERAL                     50.4420       52604   FORCEPS PIRANHA BIOPSY                       2,152.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52605   GRAFT GORETEX RING TAPER                     6,257.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       52607   GRAFT IMPRA RINGED FLEX 70CM                 9,073.00
  360   OR SVCS GENERAL                     50.4420       52608   GUIDEWIRE TIP STRAIGHT 630-100                 525.95
  360   OR SVCS GENERAL                     50.4420       52609   BASKET URETERAL PURSUER                      1,276.55                                       1
  360   OR SVCS GENERAL                     50.4420       52620   OXYGEN TRANSDUCER                              223.85
  360   OR SVCS GENERAL                     50.4420       52701   AUTOSUTURE V-ROTICULATING 30\4               2,580.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52702   STAPLER ROT. TA 30,55-3.5,4.8                2,412.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52703   AUTOSUTURE AUTOMATIC CLIP                    1,504.85
  360   OR SVCS GENERAL                     50.4420       52704   AUTOSUTURE PURSE STRING INST                 1,395.55
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52705   STAPLES GIA 60-3.8                             595.65
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52706   STAPLER TA 30,55-3.5,4.8                     1,104.10
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52707   STAPLES TA 55-3.5,4.8                          561.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52708   STAPLER TA LONG 90-3.5,4.8                   1,191.35
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52709   STAPLER GIA 60-3.8                           1,102.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52710   STAPLES TA 30-3.5,4.8                          521.70
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52711   STAPLER ROT. TA 30-V3                        2,485.50
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52712   STAPLER TA LONG 30-V3                        1,181.90
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52713   AUTOSUTURE DISP TA90 B UNITS                 5,654.90
  360   OR SVCS GENERAL                     50.4420       52715   IRRIGATION TUBING Z OSTEON                     634.40
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52716   STAPLER GIA 80-3.8                           1,737.65
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52717   STAPLES GIA 80-3.5                             886.10
  360   OR SVCS GENERAL                     50.4420       52720   AUTOSUTURE EEA CRV                           4,066.25
  360   OR SVCS GENERAL                     50.4420       52721   CLAMP-ATRAUMAX SURG INSERT 86M                 253.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52728   STAPLER CEEA PLUS 25-34                      3,424.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       52729   AUTO SUTURE STAPLER LDS DISP                 3,371.35
  360   OR SVCS GENERAL                     50.4420       52730   ENDO-CLOSE                                     276.25
  270   M/S SUPPLY GENERAL                  50.4420       52731   ETHICON HERNIA STAPLER                       3,236.85
  270   M/S SUPPLY GENERAL                  50.4420       52732   LAPAROSCOPIC HERNIA KIT                      8,183.05
  360   OR SVCS GENERAL                     50.4420       52733   LAP HERNIA BALLOON OMS-TIOSB                 1,374.10
  360   OR SVCS GENERAL                     50.4420       52734   INSURG CBD GUIDEWIRE                           699.55
  360   OR SVCS GENERAL                     50.4420       52735   WIRE, GUIDE .038X145                            80.30
  360   OR SVCS GENERAL                     50.4420       52736   TORQUE VISE                                     79.20
  360   OR SVCS GENERAL                     50.4420       52737   LAP HERNIA TACKER TUBE                       1,628.55
  360   OR SVCS GENERAL                     50.4420       52738   LAP HERNIA TACKER HANDLE                       814.60
  360   OR SVCS GENERAL                     50.4420       52739   LAP HERNIA BALLOON OMS-PDB52                 2,305.50
  360   OR SVCS GENERAL                     50.4420       52740   NEEDLE LAP BIOPSY 18 GA                        322.35
  360   OR SVCS GENERAL                     50.4420       52800   ARTHRO CUTTER DI SP                            906.70
  360   OR SVCS GENERAL                     50.4420       52801   SUCTION,IRRIG,CAUTERY                        1,885.25
  360   OR SVCS GENERAL                     50.4420       52802   ENDOCLIP APPLIER                             1,885.25
  360   OR SVCS GENERAL                     50.4420       52921   PERFUSION SET-UP                            11,600.10
  360   OR SVCS GENERAL                     50.4420       52922   GUIDEWIRE,STIFF,SHAFT, ANGLED                  858.25
  360   OR SVCS GENERAL                     50.4420       52923   GUIDEWIRE C 035X150                            217.90
  360   OR SVCS GENERAL                     50.4420       52924   CARSON ZEROTIP 4x6                           5,341.10
  360   OR SVCS GENERAL                     50.4420       52925   STENT MARDIS GUIDEWIRE 6x28                  2,580.20
  360   OR SVCS GENERAL                     50.4420       52926   STENT MARDIS GUIDEWIRE 6x26                  2,580.20
  360   OR SVCS GENERAL                     50.4420       52927   STENT MARDIS SET & GUIDEWIRE 6               2,580.20
  360   OR SVCS GENERAL                     50.4420       52928   PORT BIOPSY W/CONN                             188.05
  360   OR SVCS GENERAL                     50.4420       52929   BLADE EXTENDER LARYNG                           80.15
  360   OR SVCS GENERAL                     50.4420       52976   TUBING,HEMOVAC,WOUND DRAIN 1/4                 429.00

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           38 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       52977   TUBING,HEMOVAC,HYDROCOAT WD DR                 429.00
  360   OR SVCS GENERAL                     50.4420       52978   TUBING,HEMOVAC,WOUND DRAIN 1/8                 429.00
  360   OR SVCS GENERAL                     50.4420       53040   DISP COLLECTION SET                            127.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       53110   INTRALUMINAL STAPLER (ILP)                   2,314.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53125   IMPLANT TRAPEZIUM                            1,959.75
  360   OR SVCS GENERAL                     50.4420       53195   DRAIN JACKS PRT RES                            193.55
  360   OR SVCS GENERAL                     50.4420       53196   DRAIN JACKS PRT SUCT                           193.55
  360   OR SVCS GENERAL                     50.4420       53199   SHUNT JAVID                                    598.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53593   GRAFTON PUTTY 5CC                            3,071.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53594   GRAFTON PUTTY 10CC                           4,745.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53595   GRAFT BONE DOWEL ARC                         3,940.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53596   PLUG BONE SO CAL                             3,940.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53597   WEDGE BONE SO CAL                            5,779.05
  360   OR SVCS GENERAL                     50.4420       53598   DURA GUARD 6CM X 8CM                         2,751.45
  360   OR SVCS GENERAL                     50.4420       53605   MENTOR INSERTER                                308.50
  360   OR SVCS GENERAL                     50.4420       53609   PUMP SYSTEM VANTEC                             501.90
  360   OR SVCS GENERAL                     50.4420       53610   BUNDLE IMAGING                               1,057.30
  360   OR SVCS GENERAL                     50.4420       53611   LOOP RETRIEVER 90CM 115CM                    1,123.80
  360   OR SVCS GENERAL                     50.4420       53612   LOOP RETRIEVER 60CM                            997.20
  360   OR SVCS GENERAL                     50.4420       53613   FORCEPS GRASPING                             1,462.20
  360   OR SVCS GENERAL                     50.4420       53614   LOOP RETRACTOR                               2,181.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       53615   GUIDEWIRE 620-101                              101.75
  360   OR SVCS GENERAL                     50.4420       53616   IRRIGATION SHEATH URETEROSCOPE                 659.05
  360   OR SVCS GENERAL                     50.4420       53617   GUIDE WIRE TEFLON COATED                       181.40
  360   OR SVCS GENERAL                     50.4420       53618   GUIDE WIRE BENSON                              302.20
  360   OR SVCS GENERAL                     50.4420       53619   FORCEPS GRASPING DEFLECT-ROTAT               2,580.20
  360   OR SVCS GENERAL                     50.4420       53620   LEVEEN PRESSURE SYRINGE                        465.45
  360   OR SVCS GENERAL                     50.4420       53621   PRESSURE GAUGE DISP                            422.95
  360   OR SVCS GENERAL                     50.4420       53622   URETERAL ACCESS SET                          1,347.50
  360   OR SVCS GENERAL                     50.4420       53623   HUNTER ACCESS SET                            1,921.40
  360   OR SVCS GENERAL                     50.4420       53624   BRUSH CYTOLOGY URETERAL                        543.90
  360   OR SVCS GENERAL                     50.4420       53625   BRUSH CYTOLOGY RENAL                           689.00
  360   OR SVCS GENERAL                     50.4420       53626   CYSTO PEEL AWAY SHEATH                         284.20
  360   OR SVCS GENERAL                     50.4420       53627   CYSTO SHEATH SET                               543.90
  360   OR SVCS GENERAL                     50.4420       53628   CATH TAUT CHOL CATHL                           247.85
  360   OR SVCS GENERAL                     50.4420       53629   STONE EXTRACTOR HELICAL-COOK                 1,257.15
  360   OR SVCS GENERAL                     50.4420       53630   STONE EXTRACTOR HELICAL BARD                 2,042.35
  360   OR SVCS GENERAL                     50.4420       53631   STONE EXTRACTOR FLAT WIRE                    1,988.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53632   BRACE BLEDSOE SYSTEM                         1,466.10 L1880             L1880
  360   OR SVCS GENERAL                     50.4420       53633   RETAINER,MCNEELY(FISH)-LARGE                   374.75
  360   OR SVCS GENERAL                     50.4420       53634   RETAINER,MCNEELY(FISH)MEDIUM                   374.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53640   FEMORAL HEAD W/O TROCANTER ARC               5,128.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53641   FEMORAL HEAD W/TROCANTER/FROZE              10,572.85
  272   M/S SUPPLY STERILE SUPPLY           50.4420       53665   GAUZE OWENS                                     42.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53675   PROS PATELLA                                 2,800.10 L8640             L8640
  360   OR SVCS GENERAL                     50.4420       53679   NEURO BIOPSY KIT #12A                        5,099.15
  360   OR SVCS GENERAL                     50.4420       53680   NEURO BIOPSY KIT #3                          1,462.20
  360   OR SVCS GENERAL                     50.4420       53681   FING GUARD                                      78.55
  360   OR SVCS GENERAL                     50.4420       53682   DRAPE MICROSCOPE 3598                          380.95
  360   OR SVCS GENERAL                     50.4420       53685   GUARD ASSEMBLY                                 761.05
  360   OR SVCS GENERAL                     50.4420       53686   CUSA PACK                                    3,111.55
  360   OR SVCS GENERAL                     50.4420       53687   CUSA SPECIMAN TRAP                             133.30

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       39 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       53688   ASPIRATION BOTTLE 1500CC                       332.40
  360   OR SVCS GENERAL                     50.4420       53689   NEUCLEATOME DISP KIT DISCECTOM               8,078.05
  360   OR SVCS GENERAL                     50.4420       53690   SPONGE, SCLERAL BUCKLE                         366.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       53691   SCREW KUROSAKA FIXATION                      1,250.70
  360   OR SVCS GENERAL                     50.4420       53775   PISTONS                                        634.40
  360   OR SVCS GENERAL                     50.4420       53795   PORP                                         1,437.95
  360   OR SVCS GENERAL                     50.4420       53861   KIT, DISP. TWIST DRILL PROCEDU               3,053.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53930   IMPLANT ULNAR HEAD                           2,243.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       53935   IMPLANT RADIAL HEAD                          1,959.75
  360   OR SVCS GENERAL                     50.4420       54055   DRAIN ABRAMSON TRIPLE LUMEN                    242.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54057   MITEK ANCHOR SUTURE                          1,628.70
  360   OR SVCS GENERAL                     50.4420       54058   DRAPE, C-ARM DELUXE                            175.65
  360   OR SVCS GENERAL                     50.4420       54060   DRAIN TRIPLE LUMEN SUMP                        399.20
  360   OR SVCS GENERAL                     50.4420       54061   SUTURE, CHROMIC ENDO LOOPS                     428.75
  360   OR SVCS GENERAL                     50.4420       54062   SUTURE BOOTS                                    16.20
  360   OR SVCS GENERAL                     50.4420       54063   DERMABOND                                      203.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54135   SCHNEIDER ROD                                1,571.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54136   INSERT POLY-AML 28MM                         3,709.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54137   HIP COMPONENT SELF CENTERING                 6,104.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       54138   SCREWS AML NK CEMENTED HIP                     888.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54139   STEM,DE PUY, AML PORO COAT                  19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54140   LINER AML NEUTRAL                            4,139.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54141   BALL HIP CERAMIC AML 32MM                   11,363.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54142   BALL HIP METAL-AML 28MM & 32MM               3,861.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54143   COMP ENDO HEAD ADAPTOR VERSYS                  599.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54144   COMP ENDO FEM HEAD VERSYS                    1,470.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54145   DURA LOC 1200 CUP AML                       10,759.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54146   AML DURA LOC 300 SERIES                      9,708.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54147   DURALOC LINER 10 LIP AML                     4,250.35
  360   OR SVCS GENERAL                     50.4420       54375   CATH STONE FIXATION BALLOON                  1,057.30
  360   OR SVCS GENERAL                     50.4420       54380   CATH VAN TECH DILATION BALLOON               1,522.70
  272   M/S SUPPLY STERILE SUPPLY           50.4420       54384   CATHETER URETERAL 3FR X 70CM                    49.10
  360   OR SVCS GENERAL                     50.4420       54385   OLIVE TIP URETERAL CATH 6 FR                   169.60
  360   OR SVCS GENERAL                     50.4420       54386   DRAIN URETERAL BAG                             127.05
  360   OR SVCS GENERAL                     50.4420       54387   URETERAL CATH FLEXI FR3                        175.65
  360   OR SVCS GENERAL                     50.4420       54388   URETERAL CATH CONNECTOR                         18.25
  360   OR SVCS GENERAL                     50.4420       54389   INTERCIED                                    1,999.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54405   GRAFT GORETEX RING 4MM X 15CM                3,096.10
  360   OR SVCS GENERAL                     50.4420       54415   BLADE VASCULAR PUNCH                           392.80
  360   OR SVCS GENERAL                     50.4420       54451   TUBE ARMSTRONG VENT                            266.15
  360   OR SVCS GENERAL                     50.4420       54452   VESSEL LOOP                                    127.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54461   PLATE SYN 242.03-.08                           210.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54462   PLATE SYN 242.33-.41,243                       162.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54463   PLATE SYN 241.61-.65 SERIES                  2,337.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54464   PLATE, SYN 222, 241.02-.08                     252.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54465   PLATE SYN, 224, 241.13-.15, 24                 593.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54466   PLATE SYN 226, 241.23,241.25 S                 898.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54467   PLATE,SYN 240 SERIES                         1,301.25
  360   OR SVCS GENERAL                     50.4420       54468   DRUKKM SYN BIT/TAP REGULAR                     315.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       54469   DRILL SYN BIT/TAP CANNULATED                 1,730.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54470   WASHERS SYNTHES                                101.95
  279   M/S OTHER SUPPLIES/DEVICES          50.4420       54471   WIRE, SYNTHES K- & GUIDE                        75.55

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           40 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54472   PLATE, BUTTRESS, SYN                           557.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54510   CEMENT CRANIOPLASTIC                         2,574.50
  270   M/S SUPPLY GENERAL                  50.4420       54511   MERSILENE STRIP                                429.00
  360   OR SVCS GENERAL                     50.4420       54512   FROCEPS, FRASPING DISP 3-NAIL                2,743.25
  360   OR SVCS GENERAL                     50.4420       54513   FORCEPS, ALLIGATOR LAP CHOLE                 5,860.60
  360   OR SVCS GENERAL                     50.4420       54514   FORCEPS CUP BIOPSY 3FR                       5,967.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54515   MESH MARLEX                                  1,466.10                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54516   MESH, TRELEX 1X4                               541.00                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54517   MESH, TRELEX 2X4                               502.80                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54518   MESH, TRELEX 10X14                           1,576.25                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54519   MESH PROLENE 1X4"                              362.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54520   MESH PROLENE 3X6"                              331.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54521   MESH PROLENE 6X6"                              383.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54522   MESH PROLENE 12X12                             877.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54540   PLUG ILIUM BONE                              4,034.90
  272   M/S SUPPLY STERILE SUPPLY           50.4420       54541   STAPLES, REFILL MULTIFIRE 55                 1,522.70
  360   OR SVCS GENERAL                     50.4420       54542   ANGIOCATH 12GA. 3IN(28302)                     828.05
  360   OR SVCS GENERAL                     50.4420       54543   JELCO 16GA X 1 1/4                              22.15 X7700
  360   OR SVCS GENERAL                     50.4420       54590   TUBE PARASOL                                   308.50
  360   OR SVCS GENERAL                     50.4420       54620   MONOMER EVAC SYSTEM                            199.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54630   BAND FLORIO                                    840.90
  360   OR SVCS GENERAL                     50.4420       54635   BARRIER DRAPE FXHIP                            453.50
  360   OR SVCS GENERAL                     50.4420       54636   3M IOBAN #6635                                 302.20
  360   OR SVCS GENERAL                     50.4420       54637   3M IOBAN #6651                               1,607.00
  360   OR SVCS GENERAL                     50.4420       54640   PACK PERI - GYN                                145.15
  360   OR SVCS GENERAL                     50.4420       54650   PACK ARTHRDSCOPY                               392.80
  360   OR SVCS GENERAL                     50.4420       54652   PACK C V                                       882.25
  360   OR SVCS GENERAL                     50.4420       54654   PACK BASIC                                     139.00
  360   OR SVCS GENERAL                     50.4420       54657   STERI-STRIP LAP WOUND CLOSURE                  108.90
  360   OR SVCS GENERAL                     50.4420       54658   TUBING IRRIGATION MALIS DESIGN                 586.25
  360   OR SVCS GENERAL                     50.4420       54660   COUDE TIP CATH                                 223.85
  360   OR SVCS GENERAL                     50.4420       54665   CATH DOVER PEDIATRIC                           199.45
  360   OR SVCS GENERAL                     50.4420       54666   COBAN WRAP (STERILE)                            84.85
  360   OR SVCS GENERAL                     50.4420       54670   COVER MICROSCOPE-S                             181.40
  360   OR SVCS GENERAL                     50.4420       54680   COVER MICROSCOPE-W                             459.35
  360   OR SVCS GENERAL                     50.4420       54681   CATHETER ARTERIAL INSYTE                        78.55
  360   OR SVCS GENERAL                     50.4420       54690   HEMOCLIP CART                                  344.70
  360   OR SVCS GENERAL                     50.4420       54700   WARMING BLANKET                                453.50
  360   OR SVCS GENERAL                     50.4420       54701   Y ADAPTER-CORONARY PERF                        145.15
  360   OR SVCS GENERAL                     50.4420       54702   WHITE Y CONNECTOR                              115.25
  360   OR SVCS GENERAL                     50.4420       54727   CATHETER BARTHOLIN GLAN                        223.85
  360   OR SVCS GENERAL                     50.4420       54730   INJECT,HARRIS UTERIN                           659.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       54871   MESH OSTEO CRANI SM                          1,873.50                   C1781
  360   OR SVCS GENERAL                     50.4420       55005   DRAIN RELIAVAC                                 483.80
  360   OR SVCS GENERAL                     50.4420       55017   DRAIN VENTRICLE EXT                            737.45
  360   OR SVCS GENERAL                     50.4420       55020   CATH THOR ST                                   145.15
  360   OR SVCS GENERAL                     50.4420       55025   BIFURCATED SUCTION DRAIN                       108.90
  360   OR SVCS GENERAL                     50.4420       55026   SUMP DRAIN TRIPLE LUMEN                        362.95
  360   OR SVCS GENERAL                     50.4420       55030   CATH THOR CVD                                  236.05
  360   OR SVCS GENERAL                     50.4420       55040   CATH CYSTO                                     520.00
  360   OR SVCS GENERAL                     50.4420       55045   CATHETER EPIDURAL                              199.45
  360   OR SVCS GENERAL                     50.4420       55046   MOISTURIZER ENGSTROM EDITH                      42.40

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       41 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55050   TUBE DONALDSON EUST                            266.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55051   GRAFT, VELEX, STRAIGHT-VO1120                3,036.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55052   GRAFT,VELEX,STRAIGHT V01122                  3,036.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55053   GRAFT, VELEX, STRAIGHT V01124                3,036.50
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55055   KIT VIVONEX JEJUNOSTOMY                      1,239.00
  360   OR SVCS GENERAL                     50.4420       55060   TUBE PERLEE EUST                               350.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55061   CLIP, SUGITA,STAND - ANEUR #0                1,450.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55062   CLIP,SUGITA,STAND-ANEUR #07-94               1,639.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55063   CLIP,SUGITA,STAND-ANEUR #07-94               1,638.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55064   CLIP,SUGITA,LG-ANEUR #07-940-1               1,991.40
  360   OR SVCS GENERAL                     50.4420       55065   TUBE HYS-T DRAIN                               392.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55066   CLIP,SUGITA,FEN,LG-ANEUR #07-9               2,059.65
  360   OR SVCS GENERAL                     50.4420       55070   TUBE STRAIGHT                                   42.40
  360   OR SVCS GENERAL                     50.4420       55075   TUBE SUMP SARATOGA                             211.80
  360   OR SVCS GENERAL                     50.4420       55080   TUBE Y                                         139.00
  360   OR SVCS GENERAL                     50.4420       55081   T TUBE WHELAN MOSS                             266.15
  360   OR SVCS GENERAL                     50.4420       55082   T TUBE BARD                                    193.55
  360   OR SVCS GENERAL                     50.4420       55083   PACK MINOR                                     378.90
  360   OR SVCS GENERAL                     50.4420       55084   LAPAROSCOPY PACK                               286.85
  360   OR SVCS GENERAL                     50.4420       55085   PACK TOTAL KNEE                              2,251.00
  360   OR SVCS GENERAL                     50.4420       55086   PACK LAMI                                    1,397.50
  360   OR SVCS GENERAL                     50.4420       55087   PACK LAP CHOLE                               5,108.40
  360   OR SVCS GENERAL                     50.4420       55088   PACK MAJOR LAPAROTOMY                          950.40
  360   OR SVCS GENERAL                     50.4420       55089   PACK TOTAL HIP                               2,187.00
  360   OR SVCS GENERAL                     50.4420       55090   PACK LAMI ENCOMPASS                          2,680.85
  360   OR SVCS GENERAL                     50.4420       55091   PACK CRANI ENCOMPASS                         3,116.75
  360   OR SVCS GENERAL                     50.4420       55092   PACK ACIF ENCOMPASS                          2,321.85
  360   OR SVCS GENERAL                     50.4420       55093   PACK ACIF W/ICBG ENCOMPASS                   1,112.25
  360   OR SVCS GENERAL                     50.4420       55094   PACK ORTHO LX FUSION                         1,014.40
  360   OR SVCS GENERAL                     50.4420       55095   PACK ORTHO LAMI DISC                           464.55
  360   OR SVCS GENERAL                     50.4420       55096   PACK ORTHO PEDICLE SCREW                     1,692.20
  360   OR SVCS GENERAL                     50.4420       55097   PACK CEMENT ACCESSORY                        1,225.00
  360   OR SVCS GENERAL                     50.4420       55098   PACK KNEE ARTHROSCOPY                        1,044.10
  360   OR SVCS GENERAL                     50.4420       55120   TUBE GOODE T                                   308.50
  360   OR SVCS GENERAL                     50.4420       55166   STERI DRAPE 1016                               205.75
  360   OR SVCS GENERAL                     50.4420       55167   DRAPE PROBE                                    108.45
  360   OR SVCS GENERAL                     50.4420       55180   CATH FOG EMBOL 3 FR                            592.45
  360   OR SVCS GENERAL                     50.4420       55190   CATH FOG EMBOL 4-5-6                           574.20
  360   OR SVCS GENERAL                     50.4420       55191   CATHETER FOGARTY GRAFT THROM                 4,962.05                                       1
  360   OR SVCS GENERAL                     50.4420       55192   CATHETER FOGARTY TL EMBOL 4-5                1,106.95                                       1
  360   OR SVCS GENERAL                     50.4420       55193   CATHETER FOGARTY TL EMBOL 6                    801.65
  360   OR SVCS GENERAL                     50.4420       55200   CATH BYPASS                                    392.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55201   SHUNT PRUITT INAHARA CAROTIO                 1,407.35
  360   OR SVCS GENERAL                     50.4420       55205   CATHETER MUSHROOM                              211.80
  360   OR SVCS GENERAL                     50.4420       55210   CATH MALECOT                                   277.95
  360   OR SVCS GENERAL                     50.4420       55225   CATH CAROTID BYPASS 8F                         586.25
  360   OR SVCS GENERAL                     50.4420       55237   CONNECTOR Y OH                                  84.85
  360   OR SVCS GENERAL                     50.4420       55238   CEMENT SCULPT KIT                              233.20
  360   OR SVCS GENERAL                     50.4420       55239   CEMENT INJECTOR 90 DEG                         123.25
  360   OR SVCS GENERAL                     50.4420       55240   CEMENT INJECTOR SET                            247.85
  360   OR SVCS GENERAL                     50.4420       55241   BECTOL CEMENT HOOK                              24.50
  360   OR SVCS GENERAL                     50.4420       55242   IABP SET UP                                  1,414.35

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           42 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55243   IABP TECH 1HR                                  332.40
  360   OR SVCS GENERAL                     50.4420       55244   IABP STANDBY 1HR                               332.40
  360   OR SVCS GENERAL                     50.4420       55245   CELL SAVER                                   2,181.20
  360   OR SVCS GENERAL                     50.4420       55246   A.C.T.S.                                        78.55
  360   OR SVCS GENERAL                     50.4420       55247   PERFUSIONIST                                 5,757.80
  360   OR SVCS GENERAL                     50.4420       55248   AUTOTRANSFUSION                              2,477.45
  360   OR SVCS GENERAL                     50.4420       55249   PERFUSIONIST ST BY ANGIOPLASTY               2,646.55
  360   OR SVCS GENERAL                     50.4420       55251   AUTOTRANSFUSION STANDBY                        882.25
  360   OR SVCS GENERAL                     50.4420       55252   AUTOTRANSFUSION TECH                           332.40
  360   OR SVCS GENERAL                     50.4420       55253   CELL SAVER MACHINE RENTAL                    1,522.70
  360   OR SVCS GENERAL                     50.4420       55254   IABP TECH - PER HOUR                           308.50
  360   OR SVCS GENERAL                     50.4420       55255   PERFUSION DETENTION - PER HOUR                 308.50
  360   OR SVCS GENERAL                     50.4420       55256   CELL SORER HI-SPEED                          1,196.25
  360   OR SVCS GENERAL                     50.4420       55257   TUBING SFC-04/SHC-04                           175.65
  360   OR SVCS GENERAL                     50.4420       55258   SILASTIC SHEETING                              465.45
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55260   SCREW BLUE                                     525.95
  360   OR SVCS GENERAL                     50.4420       55261   LVAD SET-UP                                  2,205.50
  360   OR SVCS GENERAL                     50.4420       55262   RVAD SET-UP                                  2,205.50
  360   OR SVCS GENERAL                     50.4420       55263   BIVAD MONITORING                               707.05
  360   OR SVCS GENERAL                     50.4420       55264   VAD RENTAL                                   2,205.50
  360   OR SVCS GENERAL                     50.4420       55265   DISCOGRAPHY TRAY SYSTEM                        737.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55270   NAIL, KEN HIP                                2,168.35
  360   OR SVCS GENERAL                     50.4420       55271   SLEEVE FOR KEN NAIL                            411.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55272   PLATE,AMBI,4-SLOT,100MM                      2,842.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55280   POROUS FEMORAL COMPONENT SMALL              15,776.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55282   TIBIAL ARTICULATING SURFACE                  5,159.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55284   TIBIAL STEM EXTENSION                        4,029.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55286   FEMORAL COMPONENT PRECOAT RT&L              13,013.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55287   PATELLA DOME-MILLER GALANTE                  3,026.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55288   TIBIAL PLATE PRECOAT REG & LG                9,608.90
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55295   SCREW HI-TORGUE                                223.85
  360   OR SVCS GENERAL                     50.4420       55296   SUTURE RETRIEVER                               374.75
  360   OR SVCS GENERAL                     50.4420       55297   TENDON LEADER                                  356.80
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55298   SCREW, HERBERT                               1,666.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55300   PROS THOMPSON                                5,516.30
  270   M/S SUPPLY GENERAL                  50.4420       55310   PLAIN, K-WIRE & STEINMAN PIN                    54.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55311   STAPLES - ENDO GIA REFILLS                   2,936.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55312   STAPLER ENDO GIA 3.5 INSTR                   8,712.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55315   WIRE J                                         194.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55320   THREADED, K-WIRE & STEINMAN PI                 105.05
  360   OR SVCS GENERAL                     50.4420       55321   CATHETER INTRASIL LONG PERIPHE                 586.25
  360   OR SVCS GENERAL                     50.4420       55324   ESOPH STETH, DISP                               84.85
  360   OR SVCS GENERAL                     50.4420       55325   ESOPH STETH T PROBE                            193.55
  360   OR SVCS GENERAL                     50.4420       55326   ARTHROSCOPY CAMERA DRAPE                       205.75
  360   OR SVCS GENERAL                     50.4420       55327   EXTREMITY DRAPE                                193.55
  360   OR SVCS GENERAL                     50.4420       55328   EXTREMITY DRAPE BIL                            229.75
  360   OR SVCS GENERAL                     50.4420       55329   CATH 9.5 CURVED LF HEART VENT                  374.75
  360   OR SVCS GENERAL                     50.4420       55333   FEMORAL BONE BRUSH                             217.40
  360   OR SVCS GENERAL                     50.4420       55335   FALOPE RING                                    326.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55340   ACE CUP                                      1,944.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55341   ACETABULAR CUP T1 BAC                       11,347.75
  360   OR SVCS GENERAL                     50.4420       55342   ACETABULAR PRESURIZR                           562.20

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       43 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55343   FORCEPS STONE RETRIEVAL GRASPI               2,827.90
  360   OR SVCS GENERAL                     50.4420       55345   ADAPTER DOUBLE MALE                             30.60
  360   OR SVCS GENERAL                     50.4420       55346   BLADE - RAZOR CUTTER 4.5                     1,298.95
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55350   CEMENT BONE                                    707.05
  360   OR SVCS GENERAL                     50.4420       55351   C-ARM COVER                                     48.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55355   BONE CEMENT-HLF SZ                             551.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55356   BONE CEMENT LVC                                845.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55357   CEMENT BONE SIMPLEX P                          599.15
  360   OR SVCS GENERAL                     50.4420       55358   CARDIOTRONICS EXT DEFIB PATCHE                 634.40
  360   OR SVCS GENERAL                     50.4420       55360   MIXIVAC II STRYKER                             598.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55365   GRAFT BIFUR                                  3,725.10
  360   OR SVCS GENERAL                     50.4420       55367   SUTURE PASSER ALL SIZES                        737.45
  360   OR SVCS GENERAL                     50.4420       55368   SUTURE, PASSER, LARGE                          737.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55370   WIRE, STAINLESS STEEL MONO                      37.75
  360   OR SVCS GENERAL                     50.4420       55371   WIRE MESH STAINLESS                            737.45
  360   OR SVCS GENERAL                     50.4420       55375   NASAL TRANSDUCER                               374.75
  360   OR SVCS GENERAL                     50.4420       55378   MRI MARKERS                                     21.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55379   CSF SHUNT KIT 4/6CM                          4,248.40                                       1
  360   OR SVCS GENERAL                     50.4420       55380   SENSOR GAS STAT                              1,401.95
  360   OR SVCS GENERAL                     50.4420       55381   WIRE, GUIDE 021 15CM                           127.05
  360   OR SVCS GENERAL                     50.4420       55382   CSF VENTRICULAR CATH FLANGED                 1,782.55
  360   OR SVCS GENERAL                     50.4420       55383   CSF FLOW CONTROL VALVE 12MM LO               6,283.60
  360   OR SVCS GENERAL                     50.4420       55384   CSF FLOW CONTROL VALVE 12MM ME               3,975.50
  360   OR SVCS GENERAL                     50.4420       55385   CSF FLOW CONTROL VALVE 12MM HI               3,975.50
  360   OR SVCS GENERAL                     50.4420       55388   CSF FLOW CONTROL VALVE 16MM HI               3,975.50
  360   OR SVCS GENERAL                     50.4420       55389   CSF CARDIAC/PERITONEAL CATH ST               1,365.50
  360   OR SVCS GENERAL                     50.4420       55390   CSF VENTRICULAR RESERVOIR 28MM               2,622.40
  360   OR SVCS GENERAL                     50.4420       55391   CSF LUMBOPERITONEAL CATH                     4,815.30
  360   OR SVCS GENERAL                     50.4420       55392   CSF CATH CONNECTOR STRAIGHT                    356.80
  360   OR SVCS GENERAL                     50.4420       55393   CSF CATH CONNECTOR RT ANGLE                    417.45
  360   OR SVCS GENERAL                     50.4420       55394   CSF CATH CONNECTOR 3-WAY                     1,510.45
  360   OR SVCS GENERAL                     50.4420       55395   CATH BECKER EDMS VENT 20CM                     773.50
  360   OR SVCS GENERAL                     50.4420       55396   PASSER, SHUNT 60CM                             586.25
  360   OR SVCS GENERAL                     50.4420       55397   CSF FLOW CONTROL VALVE 12MM ME               9,419.00
  360   OR SVCS GENERAL                     50.4420       55400   CSF VENTRICULAR CATH RT ANGLE                1,153.95
  360   OR SVCS GENERAL                     50.4420       55401   CSF VENTRICULAR CATH RT ANGLE                1,153.95
  360   OR SVCS GENERAL                     50.4420       55402   CSF VENTRICULAR CATH RT ANGLE                1,153.95
  360   OR SVCS GENERAL                     50.4420       55430   VACURETTE                                      133.30
  360   OR SVCS GENERAL                     50.4420       55440   CATH CHOLO                                     151.45
  360   OR SVCS GENERAL                     50.4420       55445   KIT CHOLANGIOGRAPHIC                           525.95
  360   OR SVCS GENERAL                     50.4420       55460   CATH M P F                                   1,033.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55470   PUDENZ VALVE 16MM HP                         1,439.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55471   PUDENZ VALVE L6MM MP                         2,075.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55472   PUDENZ VALVE 12MM MP                         2,196.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55473   PUDENZ VALVE 12MM HP                         2,075.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55474   PUDENZ VALVE 16MM LP                         2,196.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55475   PUDENZ VALVE 12MM LP                         2,164.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55476   PUDENZ VALVE ANTISIPHON                      3,073.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55478   PUDENZ VALVE (ACCUFLO)                         772.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55479   GRAFT GORETEX STRETCH 70CM                   7,148.95
  360   OR SVCS GENERAL                     50.4420       55480   CATH RAIMOND SPR                             1,697.95
  360   OR SVCS GENERAL                     50.4420       55481   MENISCECTOMY KIT-DYONICS                       797.60

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           44 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55485   CATH PERITONEAL REFLUX                       1,486.35
  360   OR SVCS GENERAL                     50.4420       55486   TUBING, HUMIDIFIER ANAMED                      392.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55510   PROS TEST GEL                                4,964.60
  360   OR SVCS GENERAL                     50.4420       55511   WIRE DRILL TIP GUIDE                           628.65
  360   OR SVCS GENERAL                     50.4420       55512   WIRE, ISOTAC PILOT                             489.60
  360   OR SVCS GENERAL                     50.4420       55513   PIN,3MM SPADE TIP,PASSING                    1,304.95
  360   OR SVCS GENERAL                     50.4420       55514   GUIDE PIN ARTHREX                              201.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55515   SCREW ARTHREX ACL W/S                          472.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55516   SCREW ARTHREX ACL FT                           418.95
  360   OR SVCS GENERAL                     50.4420       55517   KIT ARTHREX ACL DISP                         1,570.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55518   SUTURE ANCHOR CORKSCREW                        770.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55519   SUTURE ANCHOR CORKSCREW W/WIRE               1,008.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55520   STAPES PROS-HOUSE LOOPS                        247.10
  360   OR SVCS GENERAL                     50.4420       55521   REUTEN BOBBIN W-FLANGE HOLES                   296.30
  360   OR SVCS GENERAL                     50.4420       55522   VENOSET 72 W- CAIR                             103.00
  360   OR SVCS GENERAL                     50.4420       55523   POPE OTO WICKE                                  30.60
  360   OR SVCS GENERAL                     50.4420       55525   KITTNER ENDOSCOPIC 5MM                         412.35
  360   OR SVCS GENERAL                     50.4420       55526   SURGIGRIP                                      145.15
  360   OR SVCS GENERAL                     50.4420       55527   CONVERTOR 3.5                                  121.15
  279   M/S OTHER SUPPLIES/DEVICES          50.4420       55528   ENDO-CLIP II                                 1,010.95
  360   OR SVCS GENERAL                     50.4420       55529   SURGINEEDLE VERUS DISP                         368.80
  360   OR SVCS GENERAL                     50.4420       55530   FORCEPS BIPOLAR CUT 10MM                     1,602.85
  360   OR SVCS GENERAL                     50.4420       55531   FORCEPS BIPOLAR CUT 5 MM                     1,763.80
  360   OR SVCS GENERAL                     50.4420       55540   PACER LEAD EXTENDER                          1,123.80
  360   OR SVCS GENERAL                     50.4420       55555   NEEDLE, REGIONAL BLOCK 22GAX1.                  54.55
  360   OR SVCS GENERAL                     50.4420       55557   PAK CYSTO                                      217.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55559   ANCHOR MITEK KNOTLESS                        1,497.40
  360   OR SVCS GENERAL                     50.4420       55560   SUTURELESS LEADS                             7,086.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55561   SUTURE MITEK #2 ANCHOR                       1,628.70
  360   OR SVCS GENERAL                     50.4420       55562   ARTHRO KNIFE                                   471.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55563   SUTURE MITEK SUPER ANCHOR                    1,649.70                                       1
  360   OR SVCS GENERAL                     50.4420       55564   MINI CABG RETRACTOR 3 CM                     1,376.90
  360   OR SVCS GENERAL                     50.4420       55565   MINI CABG RETRACTOR 5CM                      1,439.25
  360   OR SVCS GENERAL                     50.4420       55566   MINI CABG SITE RETRACTOR 3CM                 1,689.70
  360   OR SVCS GENERAL                     50.4420       55567   MINI CABG SITE RETRACTOR 15CM                1,752.10
  360   OR SVCS GENERAL                     50.4420       55568   MINI CABG BASE RETRACTOR 15CM                3,504.20
  360   OR SVCS GENERAL                     50.4420       55569   MINI CABG HEART STABILIZER                   3,128.80
  360   OR SVCS GENERAL                     50.4420       55570   MINI CABG HEART STABLIZER LG                 3,358.05
  360   OR SVCS GENERAL                     50.4420       55571   MINI CABG SITE MANIPULATOR                   2,690.70
  360   OR SVCS GENERAL                     50.4420       55572   MINI CABG SITE MANIPULATOR LG                2,815.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55580   AORTIC MEDTRONIC 20MM PART B                19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55581   AORTIC ST JUDE ALL SIZES PART               19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55582   MITRAL ST JUDE ALL SIZES PART               19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55583   AORTIC CARP-EDW PERI ALL SIZES              19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55584   MITRAL CARP-EDW ALL SIZES PART              19,863.60
  360   OR SVCS GENERAL                     50.4420       55585   CUXTM MONITORING KIT                           495.50
  360   OR SVCS GENERAL                     50.4420       55587   CV INCISE SHEET                                477.60
  360   OR SVCS GENERAL                     50.4420       55590   CATH CVP DRUM                                  211.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55591   VALVE MITRAL ST JUDE ALL SIZE               19,863.60
  360   OR SVCS GENERAL                     50.4420       55595   TRAY BLITT                                     447.50
  360   OR SVCS GENERAL                     50.4420       55596   PERICARDIAL SUMP                               160.55
  360   OR SVCS GENERAL                     50.4420       55598   VENOUS CANNULATION KIT                       2,900.25

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           45 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55600   SILASTIC SCLERAL SPG                           520.00
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55601   SCREW, R-T LOCKING 5.0 MM                      888.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55602   SCREW, R-T STEP 5.0/6.4MM                    1,020.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55603   NAIL, R-T SUPRACONDYLAR                      7,139.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55604   DRILL BIT, R-T 4.0X305MM                     1,218.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55605   TROCAR PIN, R-T 4.0X240MM                      671.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55606   GUIDEWIRE, R-T 3.2X305MM                       712.25
  360   OR SVCS GENERAL                     50.4420       55666   BUR MICRO 100 SHORT                            121.80                                       1
  360   OR SVCS GENERAL                     50.4420       55667   BUR MICRO 100 MED/LONG                         178.15
  270   M/S SUPPLY GENERAL                  50.4420       55668   BLADE SHAVER 345                               579.50
  360   OR SVCS GENERAL                     50.4420       55669   BLADE SHAVER 324-30,MINI                       536.65
  360   OR SVCS GENERAL                     50.4420       55670   BLADE SHAVER 305-16                            688.40
  360   OR SVCS GENERAL                     50.4420       55671   BLADE SHAVER 320, 332-4                        863.65                                       1
  360   OR SVCS GENERAL                     50.4420       55672   SHEATH, SHAVER SHORT BURR                    1,376.90                                       1
  360   OR SVCS GENERAL                     50.4420       55673   BLADE STRYKER STERNAL SAW                      340.90
  360   OR SVCS GENERAL                     50.4420       55674   BLADE ZIMMER MICRO SAW                         152.30
  360   OR SVCS GENERAL                     50.4420       55675   BLADE ZIMMER OSC/RECIP SAW                     170.70
  360   OR SVCS GENERAL                     50.4420       55676   BLADE STRYKER 2108 SERIES                      268.65
  360   OR SVCS GENERAL                     50.4420       55677   BLADE STRYKER 277 SERIES                       281.45
  360   OR SVCS GENERAL                     50.4420       55680   BLADE GIGLI                                    247.85
  360   OR SVCS GENERAL                     50.4420       55681   BLADE ZIMMER BRZL OSC SAW HIP                  597.80
  360   OR SVCS GENERAL                     50.4420       55682   BLADE ZIMMER BRZL OSC SAW KNEE                 726.85
  360   OR SVCS GENERAL                     50.4420       55683   BLADE NEURAIRTOME                              719.30
  360   OR SVCS GENERAL                     50.4420       55684   BLADE CRANIOTOME DISP                          453.50
  360   OR SVCS GENERAL                     50.4420       55685   BLADE REESE DERMATONE                          422.95
  360   OR SVCS GENERAL                     50.4420       55686   PERFORATOR NEURO DISP                        1,257.15
  360   OR SVCS GENERAL                     50.4420       55689   ENDOSHEARS LONG 5MM                            946.65
  360   OR SVCS GENERAL                     50.4420       55690   BLADE DERMATOME                                236.05
  360   OR SVCS GENERAL                     50.4420       55691   BLADE MAMMOPLASTY                              211.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55692   STAPLER FIXATION SYSTEM                        863.95
  360   OR SVCS GENERAL                     50.4420       55694   TREPHINE BLADES DISP                           489.60
  360   OR SVCS GENERAL                     50.4420       55695   TEMP PROBE MYOCRDIAL                           151.45
  360   OR SVCS GENERAL                     50.4420       55696   ESOPH TEMP PROBE PED                           133.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55700   PROS SIL FINGER                              1,896.65 L8658             L8658
  360   OR SVCS GENERAL                     50.4420       55702   SURGIGRIP SLEEVE - 10MM                        145.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55704   PROS HINGE TOE                               1,896.65 L8641             L8641
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55705   PROS GREAT TOE                               1,959.75 L8641             L8641
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55706   PROSTHESIS AUSTIN MOORE                      8,069.30
  360   OR SVCS GENERAL                     50.4420       55708   BOVINE PERICARDIUM                           2,779.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55709   CASPER DISTRACTION PINS                      1,576.25
  360   OR SVCS GENERAL                     50.4420       55712   ICP PRESSURE MONITORING KIT                  4,664.70
  360   OR SVCS GENERAL                     50.4420       55713   ENDO BABCOCK                                   897.90
  360   OR SVCS GENERAL                     50.4420       55714   ENDO STITCH DEVICE                           1,215.20
  360   OR SVCS GENERAL                     50.4420       55715   ARTERIAL LINES ALL                              84.85
  360   OR SVCS GENERAL                     50.4420       55716   MANIFOLD ALL                                   175.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55720   FEMORAL COMPONENT IB                        12,551.25
  360   OR SVCS GENERAL                     50.4420       55721   LIGHT 10 FLEXI-LUM SURGICAL"                   392.80
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55722   SCREW, RICARDS, 6.5 CANNULATED               1,323.25
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55723   SCREW CANNULATED 6.5 X 50                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55724   SCREW CANNULATED 6.5 X 60                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55725   SCREW CANNULATED 6.5 X 65                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55726   SCREW CANNULATED 6.5 X 70                    1,504.85

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           46 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55727   TOURNIQUET,RUMMEL                              211.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55728   GRAFT 4X7 IMPRA                              7,402.40
  360   OR SVCS GENERAL                     50.4420       55730   KIT ACUFEX TRACTION                            356.80
  360   OR SVCS GENERAL                     50.4420       55731   KIT MCCONNEL TRACTION                          282.05
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55732   SCREW CANNULATED 6.5 X 80                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55733   SCREW CANNULATED 6.5 X 85                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55734   SCREW CANNULATED 6.5 X 90                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55735   SCREW CANNULATED 6.5 X 95                    1,504.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55736   SCREW CANNULATED 6.5 X 100                   1,504.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55737   GRAFT - 18X9 WOVEN DBLE VELOUR               4,302.95
  360   OR SVCS GENERAL                     50.4420       55740   CATH BONANNO                                   580.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55742   PATCH KUGEL HERNIA                             931.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55743   MESH PERFIX PLUG                               695.20                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55744   MESH VICRYL 6 X 6",22801,55744               1,399.85                   C1781
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55745   VALVE MULTI PURPOSE                          3,919.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55746   VALVE LOW PRESSURE                           3,992.85
  360   OR SVCS GENERAL                     50.4420       55747   CATH PASSER UNI SHUNT                          501.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55748   MESH MARLEX 1 X 4",22801,55748               1,234.80                   C1781
  360   OR SVCS GENERAL                     50.4420       55749   PATCH-HERNIA GORTEX-5x10                     1,782.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55750   CATH AORTIC BALLOON                          7,176.40
  360   OR SVCS GENERAL                     50.4420       55751   HEPARIN COATED GUIDE WIRE                      260.10
  360   OR SVCS GENERAL                     50.4420       55752   KIT,ARROW,INTERNAL JUGULAR                     767.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55753   TRUMPET VALVE IRRIG & EVAC SYS               2,217.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55754   STAPLER,ENDO GIA 30V                         5,727.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55755   GRAFT GORETEX RING 8MM X 80CM               10,029.00
  360   OR SVCS GENERAL                     50.4420       55756   CATH BALOON DIL VPI                          1,190.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55760   GRAFT DEBAKEY 8-10                           2,506.25
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55761   STAPLER ENDO GIA 30-2.5,3.5                  2,193.95
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55762   STAPLES ENDO GIA 30-2.5,3.5                    983.60
  360   OR SVCS GENERAL                     50.4420       55763   MULTIFIRE ENDO GIA-030805                    2,719.05
  360   OR SVCS GENERAL                     50.4420       55764   ENDOGAUGE INSTR.                               338.20
  360   OR SVCS GENERAL                     50.4420       55765   SURGIPORT, TROCAR-12mm                       1,824.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55766   SURGIWIP SUTURE, LIGATURE                      289.05
  360   OR SVCS GENERAL                     50.4420       55767   ENDOSHEARS 5MM                                 738.20
  360   OR SVCS GENERAL                     50.4420       55768   FEMORAL VENOUS CATHETER 28FR                 1,311.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55770   GRAFT DEBAKEY 12-14                          2,646.55
  360   OR SVCS GENERAL                     50.4420       55771   PIN TIP,THREADED GUIDE-3.2x2.3                  18.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55780   GRAFT DEBAKEY 16-20                          2,506.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55783   PATCH VASCUGARD 2X9CM                        1,327.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55785   GRAFT, 0.4MM 2X9 GORETEX PATCH               2,469.30
  360   OR SVCS GENERAL                     50.4420       55786   SURGIGRIP SLEEVE - 12MM                        121.15
  360   OR SVCS GENERAL                     50.4420       55787   ENDO RETRACT MAXI                            1,324.90
  360   OR SVCS GENERAL                     50.4420       55788   ENDO RETRACT II                              1,826.40
  360   OR SVCS GENERAL                     50.4420       55789   AUTO SONIX UTRASHEAR 5MM                     2,247.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55790   PATCH GORETEX 5X10CM                         1,093.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55791   PATCH GORETEX 10X15CM                        5,642.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55792   PATCH GORTEX 20 X 30CM                      19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55793   PATCH GORTEX 15 X 20MM                      11,510.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55794   GRAFT GORTEX PATCH 2 X 9CM                   1,670.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55795   GRAFT INTRALUMINAL ALL SIZES                 5,800.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55796   GRAFT IMPRA CENTERFLEX                       2,217.70 L8670             L8670
  360   OR SVCS GENERAL                     50.4420       55797   GRAFT IMPRA VENAFLO                          3,285.75 L8670             L8670

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           47 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55799   REINFORED VENAUS CANNULA -RM36                 284.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55800   GRAFT MEADOX PATCH 6X6                         436.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55801   DURALOC LOCK RING 60MM                         661.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55802   DURALOC LOCK RING 62MM                         609.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55803   DURALOC LOCK RING 64MM                         609.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55804   DURALOC LOCK RING 66MM                         661.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55805   DURALOC LOCK RING 68MM                         661.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55806   DURALOC LOCK RING 70MM                         609.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55807   DURALOC LOCK RING 72MM                         661.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55808   DURALOC LOCK RING 74MM                         661.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55810   GRAFT BIFUR MEADOX                           4,045.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55815   GRAFT MEADOX STRAIGHT ALL SIZE               2,773.95
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55817   KIT PERMCATH HEMODIAL                        2,319.95
  360   OR SVCS GENERAL                     50.4420       55818   HEMOVAC AUTOTRANSFUSION SYSTEM               1,226.50
  360   OR SVCS GENERAL                     50.4420       55819   PAD COLD THERAPY                               569.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55820   SHUNT THOMAS FEM                             3,514.90
  360   OR SVCS GENERAL                     50.4420       55821   SHEATH, PEEL-AWAY 11FR                         778.70
  360   OR SVCS GENERAL                     50.4420       55822   SHEATH KIT, PEEL-AWAY                          809.45
  360   OR SVCS GENERAL                     50.4420       55823   VESSEL DILATOR 8,10,11FR                       106.90
  360   OR SVCS GENERAL                     50.4420       55825   SIGMOIDOSCOPE DISP                              42.40
  360   OR SVCS GENERAL                     50.4420       55830   LINE 6FT 4FT ARTERL                             84.85
  360   OR SVCS GENERAL                     50.4420       55831   COBE LINE-1FT                                   54.55
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55832   SCREW BOLT W/HEX 12-9068                     1,280.95
  360   OR SVCS GENERAL                     50.4420       55840   TUBE PVC EXTENSION                              90.70
  360   OR SVCS GENERAL                     50.4420       55841   HEMOSEAL HS7                                   362.95
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55843   SCREW BOLT W/HEX 12-9060                     1,282.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55844   SCREW BOLT W/HEX 12-9062                     1,280.95
  360   OR SVCS GENERAL                     50.4420       55850   MANIFOLD 5 STOPCOCK                            175.65
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55851   SCREW - CANCELLOUS 6.5X90                      163.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55852   PLATE - T, 4 HOLES                           1,991.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55853   TEMPLATE - RED SM FRAG                         131.65
  360   OR SVCS GENERAL                     50.4420       55855   CATH STAMEY                                    411.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55856   GRAFT GORETEX RING 5MM X 70CM                7,692.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55857   VALVE AORTIC 20MM MEDTRONIC PA              19,863.60
  360   OR SVCS GENERAL                     50.4420       55860   CATH SUBCLAVIAN                                 78.55
  360   OR SVCS GENERAL                     50.4420       55861   FACE SOFT                                      108.90
  360   OR SVCS GENERAL                     50.4420       55862   KIT UNIV CANNULA W/OBTR TROCAR                 253.80
  360   OR SVCS GENERAL                     50.4420       55863   KIT UNIV CANNULA W/OBTR TROCAR                 253.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55865   CATH TENCKHOFF                                 761.05
  360   OR SVCS GENERAL                     50.4420       55866   LOOPS,WIRE,LUQUE                               284.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55867   STAPLER,ROTICULTATING,                       1,450.30
  360   OR SVCS GENERAL                     50.4420       55868   FILTER FLUID LEVEL 1                           101.00
  360   OR SVCS GENERAL                     50.4420       55869   TUBING FLUID LEVEL 1                           471.80
  360   OR SVCS GENERAL                     50.4420       55871   HAND ACCESSORIES,MULTILOK                      320.35
  360   OR SVCS GENERAL                     50.4420       55872   PIN SKULL                                      435.25
  360   OR SVCS GENERAL                     50.4420       55873   SHEATH PERITONEAL INTRO LG.                    172.55
  360   OR SVCS GENERAL                     50.4420       55875   BLD PUMP SET Y TUBNG                           247.85
  360   OR SVCS GENERAL                     50.4420       55880   BAG BLOOD DONOR                                 72.85
  360   OR SVCS GENERAL                     50.4420       55881   CATHETER,DAVOL,SINGLE PORT                   6,791.35
  360   OR SVCS GENERAL                     50.4420       55882   PIN THREADED STEINMAN 5/64IN                   205.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55883   DURAN FLEX ANNULOPLASTY RINGS               13,133.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55884   HEMASHIELD WOVEN VELOUR GRAFT                4,268.60

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       48 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55885   HEMASHIELD WOVEN VELOUR GRAFT                5,910.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55886   ANNULOPASTY RING MODEL 4450                 19,863.60                                       1
  360   OR SVCS GENERAL                     50.4420       55887   STERNAL BANDS                                  407.40
  360   OR SVCS GENERAL                     50.4420       55888   PACK HERNIA E                                  488.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55890   PLATE LOCKING                                   47.45
  360   OR SVCS GENERAL                     50.4420       55891   CATHETER,DAVOL,DBL PORT                      6,331.90
  360   OR SVCS GENERAL                     50.4420       55892   WIRE THREADED KIRSCHNER .062                   205.75
  360   OR SVCS GENERAL                     50.4420       55893   WIRE THREADED KIRSCHNER .045                   205.75
  360   OR SVCS GENERAL                     50.4420       55894   WIRE THREADED KIRSCHNER .035                   205.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55895   PLATE T ZIMMER                                 829.95
  360   OR SVCS GENERAL                     50.4420       55896   PALSTIC TUBING IV VENA CAVA                     96.55
  360   OR SVCS GENERAL                     50.4420       55897   INDIFLATOR/SM. 2000                            961.20
  360   OR SVCS GENERAL                     50.4420       55898   CATHETER-MOCA                                4,434.70
  360   OR SVCS GENERAL                     50.4420       55899   TUBING CLEAR FOR TRANSDUCERS                   374.75
  360   OR SVCS GENERAL                     50.4420       55900   BLADE ZIMMER STERNAL SAW                       453.45
  360   OR SVCS GENERAL                     50.4420       55901   SUTURE POP OFF/MS                              152.10
  360   OR SVCS GENERAL                     50.4420       55902   SUTURE DOUBLE ARMED                             65.65
  360   OR SVCS GENERAL                     50.4420       55903   CANNULA 2 STAGE VENOUS                         308.50
  360   OR SVCS GENERAL                     50.4420       55904   FILTER VENA CAVA GREENFIELD                  7,600.45
  360   OR SVCS GENERAL                     50.4420       55905   RING PROSTATIC CARPINTIER                   11,799.40
  360   OR SVCS GENERAL                     50.4420       55906   SUTURE-GENERAL                                 108.90
  360   OR SVCS GENERAL                     50.4420       55907   SUTURE-SPECIAL                                  72.85
  360   OR SVCS GENERAL                     50.4420       55908   SUTURE-HEART                                   277.95
  360   OR SVCS GENERAL                     50.4420       55909   SUTURE-VASCULAR                                277.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55910   AORTIC VALVE CARP/ED PERI ALL               34,631.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55911   VALVE, MITRAL, RING                         18,387.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55912   VALVE AORTIC ST JUDE ALL SIZE               19,863.60
  360   OR SVCS GENERAL                     50.4420       55913   ARGYLE TONSIL SUCTION TIP                       18.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55914   RING ANNULOPLASTIC 32mm                     18,387.55
  360   OR SVCS GENERAL                     50.4420       55915   LEG WRAP-COBAN-MEDI RIP                         36.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55916   GRAFTS XTRA LONG WVN LOW PORO                2,269.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55917   FILTER VENA CAVA GREENFIELD                  6,609.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55918   GRAFT CONDINT ST JUDE                       19,863.60
  360   OR SVCS GENERAL                     50.4420       55919   ADAPTER MULTIFLO W-INJ SITE                     72.85
  360   OR SVCS GENERAL                     50.4420       55920   WIRE TEMP PACING                               211.80
  360   OR SVCS GENERAL                     50.4420       55921   SUTURE-UROLOGY                                 139.00
  360   OR SVCS GENERAL                     50.4420       55922   SUTURE-EYE/MICRO                               178.65
  360   OR SVCS GENERAL                     50.4420       55923   CATHETER VENOUS RETURN AORTIC                  556.20
  360   OR SVCS GENERAL                     50.4420       55924   CATHETER-VV365 1L VENTRICULA                   296.30
  360   OR SVCS GENERAL                     50.4420       55925   LINE CUSTOM PACK                               495.50
  360   OR SVCS GENERAL                     50.4420       55926   CARTRIDGE RED OR SILVER                        229.75
  360   OR SVCS GENERAL                     50.4420       55927   CATHETER LEFT ATRIAL VENT                      302.20
  360   OR SVCS GENERAL                     50.4420       55928   CANNULA V.A.D. AORTIC                          368.80
  360   OR SVCS GENERAL                     50.4420       55929   CORONARY PERFUSION CANNULA 14F                 247.85
  360   OR SVCS GENERAL                     50.4420       55930   LINE 8 FT ARTERIAL                              96.55
  360   OR SVCS GENERAL                     50.4420       55931   PACK,LAPAROSCOPY                               350.65
  360   OR SVCS GENERAL                     50.4420       55932   LINE ASPIRATION                                392.80
  360   OR SVCS GENERAL                     50.4420       55933   CONNECTORS ASSORT-PLASTIC                       84.85
  360   OR SVCS GENERAL                     50.4420       55934   CORONARY PERFUSION CANNULA 12F                 247.85
  360   OR SVCS GENERAL                     50.4420       55935   MODIFIER/C.A.T.R. PAC                          538.00
  360   OR SVCS GENERAL                     50.4420       55936   HEADS PUMP DISPOSABLE (CONE)                 1,827.45
  360   OR SVCS GENERAL                     50.4420       55937   OXYGENATOR BLOOD COBE CML                    5,528.25

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           49 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  360   OR SVCS GENERAL                     50.4420       55938   CARDIOPLEGIA SET /105                          665.05
  360   OR SVCS GENERAL                     50.4420       55939   SENSOR C.D.I. 6600                           1,093.35
  360   OR SVCS GENERAL                     50.4420       55940   CELL SAVER PEDIATRIC UNIT                    1,142.05
  360   OR SVCS GENERAL                     50.4420       55941   HEART PACK                                   3,891.00
  360   OR SVCS GENERAL                     50.4420       55942   BASIN SET HEART                                435.25
  360   OR SVCS GENERAL                     50.4420       55943   SUTURES E PACK-T                             5,919.70
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55944   SCREW,CANNULATED,UNIVERSAL                   1,002.95
  360   OR SVCS GENERAL                     50.4420       55945   CANNUIA AORTIC/VENOUS #007186                  332.40
  360   OR SVCS GENERAL                     50.4420       55946   DRAIN AXION-SILLICONE                          253.80
  360   OR SVCS GENERAL                     50.4420       55947   SQUARES, DACTON, TEFLON, FELT                  979.05
  360   OR SVCS GENERAL                     50.4420       55948   MICRO SHARP SYSTEMS #75                         84.85
  360   OR SVCS GENERAL                     50.4420       55949   INSERTS FOGORTY CROSS CLAMP 86                 221.10
  360   OR SVCS GENERAL                     50.4420       55950   PUNCH AORTIC                                   520.00
  360   OR SVCS GENERAL                     50.4420       55952   L.A. LINE 16ga X 24",10601,559                 773.50
  360   OR SVCS GENERAL                     50.4420       55954   TUBING TRANSDUCER                              411.00
  360   OR SVCS GENERAL                     50.4420       55955   LEAD, PACER, SUTURLESS                       6,162.50
  360   OR SVCS GENERAL                     50.4420       55956   NEEDLE, COOK D.C.M. #18                        115.25
  360   OR SVCS GENERAL                     50.4420       55957   WIRE MYO TEMP PACING                           199.45
  360   OR SVCS GENERAL                     50.4420       55958   VENT, LEFT VENTRICULAR                         308.50
  360   OR SVCS GENERAL                     50.4420       55959   QUICK PRIME LINE BPL-48Y                       260.10
  360   OR SVCS GENERAL                     50.4420       55960   CATH MED-TEC                                 1,504.85
  360   OR SVCS GENERAL                     50.4420       55961   HEADS, PUMP DISP. (CONE)                     1,945.75
  360   OR SVCS GENERAL                     50.4420       55962   CML EXCELL MEMBRANE                          5,582.75
  360   OR SVCS GENERAL                     50.4420       55963   CUSTOM TUBE PACK CMH                         2,719.05
  360   OR SVCS GENERAL                     50.4420       55964   CELL SAVER PAC                               1,153.95
  360   OR SVCS GENERAL                     50.4420       55965   HEMOCOR-HEMOCONCENTRATION                    1,359.50
  360   OR SVCS GENERAL                     50.4420       55966   JUGULAR PUNCTURE KIT AK-4000                   260.10
  360   OR SVCS GENERAL                     50.4420       55967   TISSUE EXPANDER 800CC FILL                   4,029.90
  360   OR SVCS GENERAL                     50.4420       55968   AORTA VEIN PUNCH 4.0                           652.70
  360   OR SVCS GENERAL                     50.4420       55969   AORTA VEIN PUNCH 4.4                           677.05
  360   OR SVCS GENERAL                     50.4420       55970   STER NERVE STIMULATE                           374.75
  360   OR SVCS GENERAL                     50.4420       55971   DACRON FABRIC 6 X 6                            888.45
  360   OR SVCS GENERAL                     50.4420       55972   GUNDY RETRAGRADE CS PERFUSION                  761.05
  360   OR SVCS GENERAL                     50.4420       55973   GUNDY RCSP PERFUSION ADAPTER                    72.85
  360   OR SVCS GENERAL                     50.4420       55974   ASPERATING NEEDLE 16 GD                        151.45
  360   OR SVCS GENERAL                     50.4420       55975   INSYTE-A CATH UNIT                             127.05
  360   OR SVCS GENERAL                     50.4420       55976   SYST IRRIG & EUAGUATION                        876.10
  360   OR SVCS GENERAL                     50.4420       55977   CANNULA OPER CHOLE                             332.40
  360   OR SVCS GENERAL                     50.4420       55978   THORASEAL SYSTEM                               320.35
  360   OR SVCS GENERAL                     50.4420       55979   AUTO TRANSFUSION ACCESSORY                     531.80
  360   OR SVCS GENERAL                     50.4420       55980   KIT,AUTOTRANSFUSION,DAVOL                      979.05
  360   OR SVCS GENERAL                     50.4420       55981   FRAME,ANDREWS,BOOTIES & BELT                   417.45
  360   OR SVCS GENERAL                     50.4420       55983   DISPOSABLE BIPOLAR CORD                         72.85
  360   OR SVCS GENERAL                     50.4420       55985   PHANTOM CBD BALLOON 4CM X 6MM                2,643.30
  360   OR SVCS GENERAL                     50.4420       55986   CATH BRONCH DISPOSABLE                         991.30
  360   OR SVCS GENERAL                     50.4420       55987   CATH ARROW RADIAL ARTERY SET                   169.60
  360   OR SVCS GENERAL                     50.4420       55988   VENOUS CANNULATION KIT ARTERIA               2,900.25
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       55989   STAPLE,FIXATION,SM-SHORT                       630.50
  360   OR SVCS GENERAL                     50.4420       55990   MANIFOLD 3 STOPCOCK                            169.60
  360   OR SVCS GENERAL                     50.4420       55991   KIT, URETERAL BALOON                         2,459.20
  360   OR SVCS GENERAL                     50.4420       55992   CATHETER, ARG/SHERWOOD SILIC 8                 211.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       55993   STAPLER, ROTICULATOR 55 POLY                 5,437.75

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       50 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                      CHARGE       MCAL        CPT-4     HCPCS   RVU
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       55994   SCREW,CANNULATED,UNIVERSAL                    1,002.95
  360   OR SVCS GENERAL                     50.4420       55995   TRANSFUSION AUTO BBL                          1,063.40
  360   OR SVCS GENERAL                     50.4420       55996   CARDIOTOMY RESEIROIS BCR 3538                 1,233.00
  360   OR SVCS GENERAL                     50.4420       55997   TRANSFUSION AUTO PCK                          1,027.25
  360   OR SVCS GENERAL                     50.4420       55998   INTERNAL DEFIB                                    72.85
  360   OR SVCS GENERAL                     50.4420       55999   SURGERY HBA MISC CHARGE                     misc chrg determined at time of svcs
  360   OR SVCS GENERAL                     50.4420       56735   HOLAP ABLATION OF PROSTATE                   19,156.50            C9713
  360   OR SVCS GENERAL                     50.4420       57365   REDUCER CAP FOR 18MM TROCAR                       29.75
  360   OR SVCS GENERAL                     50.4420       57366   ENDOSCOPIC CLIP APPLIER 5MM                   1,715.75
  360   OR SVCS GENERAL                     50.4420       57367   ENDOPOUCH 10MM                                  516.35
  360   OR SVCS GENERAL                     50.4420       57368   LINEAR CUTTER 75MM STD                          880.15
  360   OR SVCS GENERAL                     50.4420       57369   LINEAR CUTTER 75MM TIMEK                        940.10
  360   OR SVCS GENERAL                     50.4420       57370   CUTTER CARTRIDGE 75MM                           469.45
  360   OR SVCS GENERAL                     50.4420       57371   INSERTS ENDO BABCOCK 5MM                        170.50
  360   OR SVCS GENERAL                     50.4420       57372   VERSAPOINT ELECTRODE                          1,285.90
  360   OR SVCS GENERAL                     50.4420       57373   VERSAPOINT SHEATH                               464.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57374   PATCH MODIFIED KUGEL SM                       1,022.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57375   PATCH MODIFIED KUGEL MED                      1,193.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57376   PATCH MODIFIED KUGEL LG                       1,412.55
  360   OR SVCS GENERAL                     50.4420       57510   ARGON BEAM LAP. PROBE 10MM                    1,278.45
  360   OR SVCS GENERAL                     50.4420       57511   SCISSORS, DISP, ETHICON                       2,096.70
  360   OR SVCS GENERAL                     50.4420       57512   BAG,GALLBLADDER SPEC RETRIEVAL                1,257.15
  360   OR SVCS GENERAL                     50.4420       57513   TUBE, GASTROENTERIC & BALOON 1                1,994.20
  360   OR SVCS GENERAL                     50.4420       57514   TUBE,GASTROENTERIC & BALOON 18                1,994.20
  360   OR SVCS GENERAL                     50.4420       57515   BAGS DISP. PRESSURE                             344.70
  360   OR SVCS GENERAL                     50.4420       57516   PENCIL TRIPLE OPTION HAND CONT                  525.95
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57517   SCREW AMBI COMP HIP PLT 145,5                 3,304.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57518   SCREW AMBI COMP HIP PLT 140, 5                3,304.85
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57519   SCREW AMBI COMP HIP PLT 145, 4                3,184.00
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57520   SCREW AMBI COMP HIP PLT 145, 6                3,377.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57521   SCREW SUPER LAG 105MM                         2,036.15
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57522   SCREW AMBI COMP HIP PLT 140, 6                3,377.60
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57523   SCREW 6.5 UNIV CANN                           1,649.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57524   WIRES THREADED KIRSCHNER .035                   131.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57525   WIRES THREADED KIRSCHNER .045                   131.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57526   WIRES THREADED KIRSCHNER .062                   131.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57527   BURR HOLE 12MM LEVEL ONE                      5,464.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57528   VALVE DELTA REG                               6,372.65
  360   OR SVCS GENERAL                     50.4420       57529   URET STENT SET W/FADER TIP 6X2                3,456.05
  360   OR SVCS GENERAL                     50.4420       57530   FORCEP GRASPING 3 PRONG 4.5X60                2,301.90
  360   OR SVCS GENERAL                     50.4420       57531   SEGURA BASKET 4 WIRE O TIP                    2,827.90
  360   OR SVCS GENERAL                     50.4420       57532   RINGERS LACTATE CONTAINERS                        48.60
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57533   STAPLER GIA 60 4.8                            7,920.65
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57534   STAPLES GIA 60 4.8 REFILLS                    2,936.45
  360   OR SVCS GENERAL                     50.4420       57536   RINGERS LACTATE SOLUTION 3000C                  151.45
  360   OR SVCS GENERAL                     50.4420       57537   INJECTOR UTERINE HUI                            580.10
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57538   SCREW NUT-STEFFIE 5/16 IN LOCK                  127.05
  273   M/S SUPPLY TAKE-HOME SUP            50.4420       57539   SCREW NUT-STEFFIE 3/8 IN TAPER                  193.55
  360   OR SVCS GENERAL                     50.4420       57540   MINI SUCKER                                     230.85
  360   OR SVCS GENERAL                     50.4420       57541   AUTO INFLATING CANNULA 15FR                     110.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57542   CATHETER CURL PERITNEAL DIALY                   828.05
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57543   CATHETER CURL PERITNEAL DIALY                   828.05

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                          51 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57544   TROCAR VERSAPORT LONG 5-10 MM                  579.50
  360   OR SVCS GENERAL                     50.4420       57545   AORTIC CANNULA 8MM                             388.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57546   STAPLE, BONE CARTRIDGE 10X10                 1,502.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57547   EBI WRIST FIXATOR                            6,956.10
  360   OR SVCS GENERAL                     50.4420       57548   ADAPTER RETROGRADE STOPCOCK                    326.70
  360   OR SVCS GENERAL                     50.4420       57549   CATHETER VENTRICULAR EDM 35CM                  906.70
  360   OR SVCS GENERAL                     50.4420       57550   DRAIN 10MM FLAT BLAKE                          417.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57551   SYNTHES WRIST EX FIX                         9,666.15
  360   OR SVCS GENERAL                     50.4420       57552   PALL OXYGENATOR FILTER                          73.85
  360   OR SVCS GENERAL                     50.4420       57553   PIN, EBI FIXATOR                               661.75
  360   OR SVCS GENERAL                     50.4420       57554   SURGIGRIP 10.5 MM                              127.05
  360   OR SVCS GENERAL                     50.4420       57555   SPRING-GRIP                                     59.90
  360   OR SVCS GENERAL                     50.4420       57556   SURGIPATCH 10.5                                145.15
  360   OR SVCS GENERAL                     50.4420       57557   SURGIPATCH 5MM                                 145.15
  360   OR SVCS GENERAL                     50.4420       57558   AIRSTRIP 37.5 X 12CM                           133.30
  360   OR SVCS GENERAL                     50.4420       57559   ADHERENT CLOT CATHETER                       2,985.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57560   KIT CURL PERIDIAL                              992.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57561   PATCH COMPOSIX OVAL 8 X 12CM                 1,677.90
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57562   PATCH COMPOSIX OVAL 14 X 18CM                3,143.10
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57563   PATCH COMPOSIX CIRCLE 8X8CM                  1,375.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57564   PATCH COMPOSIX OVAL 11X14CM                  2,481.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57565   PATCH COMPOSIX OVAL 8X10                    10,082.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57566   PATCH COMPOSIX OVAL 7X9                      8,557.65
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57567   PATCH VENTRALEX CIRCLE 4CM                   2,109.75
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57568   PATCH VENTRALEX CIRCLE 6.4CM                 2,520.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57569   T PLIF SPACER                               16,877.35
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57571   PUTTY DBX MIX 10CC                           7,685.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57572   PUTTY DBX 1CC                                  918.70
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57573   PUTTY DBX 2.5CC                              2,050.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57574   PRECLUDE DURA SUB 4X4CM                        974.20
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57575   PRECLUDE DURA SUB 6X10CM                     3,117.35
  360   OR SVCS GENERAL                     50.4420       57576   LAP DISC                                     2,744.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57577   STAPLER PPH                                  2,044.55
  360   OR SVCS GENERAL                     50.4420       57578   DRAIN BLAKE 19FR ROUND                         141.55
  270   M/S SUPPLY GENERAL                  50.4420       57580   TROCAR BLADELESS 5MM                           724.80
  270   M/S SUPPLY GENERAL                  50.4420       57581   TROCAR BLADELESS 10/11/12MM                    874.35
  270   M/S SUPPLY GENERAL                  50.4420       57582   STABILITY SLEEVE 5MM                           389.00
  270   M/S SUPPLY GENERAL                  50.4420       57583   STABILITY SLEEVE 10/11/12MM                    453.80
  270   M/S SUPPLY GENERAL                  50.4420       57584   TROCAR DILATING TIP 10/12MM                    904.90
  270   M/S SUPPLY GENERAL                  50.4420       57585   STABILITY THREAD 5/12MM                        104.30
  270   M/S SUPPLY GENERAL                  50.4420       57586   CAP REDUCER 5-12MM                              69.75
  270   M/S SUPPLY GENERAL                  50.4420       57587   CAUTERY PROBE HAND CONTROL                     877.15
  270   M/S SUPPLY GENERAL                  50.4420       57588   CAUTERY PROBE HOOK 5MM                         458.75
  270   M/S SUPPLY GENERAL                  50.4420       57589   TROCAR TRANSPARENT 18MM                      1,160.45
  270   M/S SUPPLY GENERAL                  50.4420       57590   ENDOSCOPIC CLIP APPLIER                      1,392.20
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57591   STAPLER FLEXIBLE ENDO 45MM                   3,910.45
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57592   CARTRIDGE ENDO STAPLER 45-2.5                1,316.10
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57593   CARTRIDGE ENDO STAPLER 45-3.5                1,513.50
  270   M/S SUPPLY GENERAL                  50.4420       57594   TUBING PRESSURIZED IRRIGATION                  206.60
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57595   STAPLER 55-4.5                               1,397.25
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57596   STAPLER 55-2.5                               1,482.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57597   RELOAD STAPLES 55-4.5                          748.85

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                       52 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order              OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION         CHARGE       MCAL       CPT-4      HCPCS     RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57598   RELOAD STAPLES 55-2.5              826.45
  270   M/S SUPPLY GENERAL                  50.4420       57599   NEEDLE VEREES 150MM                119.75
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57600   STAPLER ENDO 35MM                1,576.85
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57601   CARTRIDGE ENDO STAPLER 35MM        565.60
  270   M/S SUPPLY GENERAL                  50.4420       57602   SUTURE ENDO ETHIBOND               239.40
  270   M/S SUPPLY GENERAL                  50.4420       57603   TUBE ADULT GASTRIC                   96.40
  360   OR SVCS GENERAL                     50.4420       57604   SHEARS ULTRACISION CVD 5MM       2,007.10
  360   OR SVCS GENERAL                     50.4420       57605   APPLICATOR FIBRIN GLUE EXT         252.15
  360   OR SVCS GENERAL                     50.4420       57606   LAP BAND SYSTEM                 16,776.30
  360   OR SVCS GENERAL                     50.4420       57607   LAP BAND ACCESS PORT KIT         3,332.90                                           1
  360   OR SVCS GENERAL                     50.4420       57608   LAP BAND TUBING ACCESSORY KIT      700.25
  360   OR SVCS GENERAL                     50.4420       57609   LAP BAND SUCTION CATHETER          756.30
  272   M/S SUPPLY STERILE SUPPLY           50.4420       57610   STAPLER PROTACK HERNIA 5MM       1,584.70
  360   OR SVCS GENERAL                     50.4420       57611   BALLOON BLUE MAX DILATION        1,195.35
  360   OR SVCS GENERAL                     50.4420       57612   TRAY HEMOSPLIT CATH              2,021.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57613   GRAFT HEMASHIELD STRAIGHT        1,967.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57614   GRAFT HEMASHIELD BIFURCATED      2,810.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57615   GRAFT HEMASHIELD MICROVEL        1,808.30
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57616   GRAFT IMPA TW 6MMX10CM             608.70
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57617   GRAFT IMPRA TW 6MMX30CM          1,778.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57618   GRAFT IMPRA TW 6MMX40CM          1,958.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57619   GRAFT IMPRA RINGED 6MMX40CM      2,580.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57620   GRAFT IMPRA RINGED 6MMX70CM      4,093.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57621   GRAFT IMPRA RINGED 8MMX50CM      3,364.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57622   GRAFT IMPRA TAPER 4-7MMX45CM     2,074.60
  360   OR SVCS GENERAL                     50.4420       57623   CATH LEMAITRE FOG EMBOLECTOMY      138.85
  360   OR SVCS GENERAL                     50.4420       57624   CATH PRUITT IRRI/OCCI              379.95
  360   OR SVCS GENERAL                     50.4420       57625   CATH PRUITT OCCLUSION              336.10
  360   OR SVCS GENERAL                     50.4420       57626   DRAPE LOBAN 6651 EZ                  75.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4420       57627   PATCH CAROTID 8X75MM               675.15
  360   OR SVCS GENERAL                     50.4420       57628   GLIDEWIRE ANGLED 0.35X180CM        241.95
  360   OR SVCS GENERAL                     50.4420       57629   GUIDEWIRE STARTED ROSEN 180CM        76.75
  360   OR SVCS GENERAL                     50.4420       57630   FLOWSWITCH                           55.60
  360   OR SVCS GENERAL                     50.4420       57631   SHEATH PINNACLE INTRO                90.15
  270   M/S SUPPLY GENERAL                  50.4420       57632   TAPE GLOW N TELL                     96.25
  360   OR SVCS GENERAL                     50.4420       57633   SHUNT OUTLYING CAROTID             920.60
  360   OR SVCS GENERAL                     50.4420       57634   VALVULOTOME LEMAITRE 1.8MM         535.80
  272   M/S SUPPLY STERILE SUPPLY           50.4420       58069   SKIN STAPLER 35W                   302.95                                           1
  360   OR SVCS GENERAL                     50.4420       58208   PACK MAJOR LAPAROTOMY              647.50                                           1
  272   M/S SUPPLY STERILE SUPPLY           50.4420       58800   BRACHYTX SEED IODINE 125           250.90                         C1718
  272   M/S SUPPLY STERILE SUPPLY           50.4420       58801   BRACHYTX SEED PALLADIUM 103        337.20                         C1720
  360   OR SVCS GENERAL                     50.4420       63001   AMBULATORY SERVICE ROOM CHARGE   1,188.00
  999   PT CONVEN OTHER                     50.4420       91998   HBA OTHER                      misc charge bsd on cost at time of svcs
  710   RECOVERY ROOM GENERAL               50.4422       50200   RECOVERY ROOM-ROUTINE,1ST HR       609.65                                           1
  710   RECOVERY ROOM GENERAL               50.4422       50205   RECOVERY RM TIME CHG-ROUT,Q15M     121.10                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       10185   FOREIGN BODY REMOVAL               213.85                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       10190   ESOPHAGEAL DILT WIRE GUIDED        835.95                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       10235   PERCUTANEOUS ENDOSCOPIC GASTRO   1,220.55                                           1
  270   M/S SUPPLY GENERAL                  50.4430       10236   P.E.G. KIT                       1,961.25                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       10300   COLONOSCOPY                        562.55                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       10900   ENDOSCOPIC BIOPSY                  360.35                                           1
  750   GASTROINTENTINAL GENERAL            50.4430       11200   ESOPHAGO GASTRO-DUOD               520.35                                           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                   53 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG          CATEGORY AND NAME              DPT        CODE                   DESCRIPTION                    CHARGE      MCAL      CPT-4     HCPCS      RVU
  750   GASTROINTENTINAL GENERAL            50.4430       12400   POLYPECTOMY                                    519.20                                         1
  750   GASTROINTENTINAL GENERAL            50.4430       12850   FLEX SIGMOIDOSCOPY                             519.20                                         1
  270   M/S SUPPLY GENERAL                  50.4430       12915   BICAP PROBE                                  4,140.20                                         1
  750   GASTROINTENTINAL GENERAL            50.4430       12920   ENDOSCLEROTHERAPY                              885.05                                         1
  750   GASTROINTENTINAL GENERAL            50.4430       12925   ESOPHAGEAL LIGATION PROCEDURE                  885.05                                         1
  750   GASTROINTENTINAL GENERAL            50.4430       12926   ESOPHAGEAL LIGATION DEVICE                   3,128.80                                         1
  761   TREAT/OBS RM TREATMENT RM           50.4430       36016   LUMBAR PUNCTURE                                324.35                                         1
  490   AMB SURGICAL CARE GENERAL           50.4430       36018   MINOR PROCEDURE                                324.35                                         1
  761   TREAT/OBS RM TREATMENT RM           50.4430       36022   PARACENTHESIS                                  413.45                                         1
  761   TREAT/OBS RM TREATMENT RM           50.4430       36024   PICC LINE INSERTION                            769.85                                         8
  761   TREAT/OBS RM TREATMENT RM           50.4430       36030   THORACENTHESIS                                 413.45                                         1
  762   TREAT/OBS RM OBSERVATION            50.4430       36108   OBSERVATION SERVICES 4-8 HRS                 1,272.35                                         1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36301   BLOOD TRANSFUSION 30 MINS TO 1                 420.55    36430      36430     36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36302   BLOOD TRANSFUSION 1-2 HRS                      557.20                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36303   BLOOD TRANSFUSION 2-3 HRS                      696.20                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36304   BLOOD TRANSFUSION 3-4 HRS                      838.75                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36308   BLOOD TRANSFUSION 4-8 HRS                    1,395.90                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36312   BLOOD TRANSFUSION 8-12 HRS                   1,671.55                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36318   BLOOD TRANSFUSION 12-18 HRS                  1,953.10                         36430           1
  391   BLOOD STOR/PROC ADMINIS             50.4430       36324   BLOOD TRANSFUSION 18-24 HRS                  2,228.70                         36430           1
  761   TREAT/OBS RM TREATMENT RM           50.4430       37002   BONE MARROW ASPIRATION                         413.45                                         1
  490   AMB SURGICAL CARE GENERAL           50.4430       37016   GROSHONG CATHETER INSERTION                    499.00                                         1
  710   RECOVERY ROOM GENERAL               50.4430       56000   RECOVERY ROOM FIRST HOUR                       497.80                                         1
  490   AMB SURGICAL CARE GENERAL           50.4430       56002   PRE OP HOLDING                                 402.90                                         1
  710   RECOVERY ROOM GENERAL               50.4430       56005   RECOVERY ROOM QUARTER HOUR                      67.40
  490   AMB SURGICAL CARE GENERAL           50.4430       56007   EPIDURAL LUMBAR/CERVICAL                     2,147.55
  761   TREAT/OBS RM TREATMENT RM           50.4430       56067   BX OTHER LOCAL                                 543.90                                         1
  450   EMERGENCY ROOM GENERAL              50.4430       60137   INJECTION IM/SC ALL                            158.00                         90772           1
  301   LABORATORY CHEMISTRY                50.4430       60139   VENIPUNCTURE                                    16.65    36415      36415     36415           1
  761   TREAT/OBS RM TREATMENT RM           50.4430       60148   BLOOD DRAW FROM VASCULAR DEV                    65.35
  480   CARDIOLOGY GENERAL                  50.4430       60149   ECHO COLOR FLOW MAPP                           272.65    93325      93325     93325
  480   CARDIOLOGY GENERAL                  50.4430       60150   ECHO DOPPLER                                   378.40    93320      93320     93320
  480   CARDIOLOGY GENERAL                  50.4430       60151   ECHO 2D M-MODE                                 567.90    93307      93307     93307
  482   CARDIOLOGY STRESS TEST              50.4430       60152   STRESS TEST W/ DOBUTAMINE                      665.30    93017      93017     93017
  260   IV THERAPY GENERAL                  50.4430       60153   INFUSION THERAPY INITIAL HOUR                  152.10    90780      90780     90780
  260   IV THERAPY GENERAL                  50.4430       60154   INFUSION THERAPY EA ADDTL HOUR                 223.95    90781      90781     90766
  920   OTHER DIAG GENERAL                  50.4430       63070   ANTIBIOTIC IM ADMIN                            317.20                                         1
  369   OR SVCS OTHER OR SVCS               50.4432       14214   ARGON LASER TREATMENT                        2,010.10                                         1
  369   OR SVCS OTHER OR SVCS               50.4432       14215   YAG LASER TREATMENT                          2,435.40                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       60891   MAJOR PROCEDURE                              2,075.45                                         3
  490   AMB SURGICAL CARE GENERAL           50.4432       63000   AMBULATORY SERVICES ROOM CHARG                 944.50                                         1
  230   INCREM NURS CHG GENERAL             50.4432       63010   POST PROCEDURE SERVICES-MINOR                  281.60                                         1
  230   INCREM NURS CHG GENERAL             50.4432       63020   POST PROCEDURE SERVICES-INTERM               1,122.70                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63030   POST PROCEDURE SERVICES-MAJOR                1,947.15                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63040   MINOR PROCEDURE                                317.20                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63050   MINOR PROCEDURE ADDITIONAL                      66.55
  490   AMB SURGICAL CARE GENERAL           50.4432       63075   ULTRASOUND LIVER BX                            810.25                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63076   INJECTION PROCEDURE                            272.05                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63081   PM MINOR PROCEDURE                           1,476.70                                         1
  490   AMB SURGICAL CARE GENERAL           50.4432       63082   PM AMBULATORY SERVICES                         403.95                                         1
  710   RECOVERY ROOM GENERAL               50.4432       63083   PM RECOVERY SERVICES 1/2 HOUR                  403.95                                         1
  710   RECOVERY ROOM GENERAL               50.4432       63084   PM RECOVERY SERVICES 1/4 HOUR                   67.75                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             54 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                     DESCRIPTION                   CHARGE       MCAL       CPT-4      HCPCS      RVU
  490   AMB SURGICAL CARE GENERAL           50.4432       63085   PM EPIDURAL LUMBAR/CERVICAL                   2,147.90                                           1
  230   INCREM NURS CHG GENERAL             50.4432       63099   AMBULATORY SERV HBA MISC CHARG              misc charge bsd on cost at time of svcs
  710   RECOVERY ROOM GENERAL               50.4432       63112   RECOVERY SERVICES 30MINS TO 1                   411.05                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63114   RECOVERY SERVICES 1 TO 2 HOURS                  680.75                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63116   RECOVERY SERVICES 2 TO 3 HOURS                  956.35                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63118   RECOVERY SERVICES 3 TO 4 HOURS                1,226.05                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63120   RECOVERY SERVICES 4 TO 8 HOURS                1,911.50                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63122   RECOVERY SERVICES 8 TO 12 HOUR                2,456.80                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63124   RECOVERY SERVICES 12 TO 18 HOU                3,002.10                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63126   RECOVERY SERVICES 18 TO 24 HOU                3,547.40                                           1
  710   RECOVERY ROOM GENERAL               50.4432       63128   RECOVERY SVCS-4HR INCREM>24HRS                  411.05
  391   BLOOD STOR/PROC ADMINIS             50.4432       63130   BLOOD TRANSFUSION 30MINS TO 1                   411.05                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63132   BLOOD TRANSFUSION 1 TO 2 HOURS                  545.30                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63134   BLOOD TRANSFUSION 2 TO 3 HOURS                  680.75                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63136   BLOOD TRANSFUSION 3 TO 4 HOURS                  820.95                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63138   BLOOD TRANSFUSION 4 TO 8 HOURS                1,366.20                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63140   BLOOD TRANSFUSION 8 TO 12 HOUR                1,635.90                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63142   BLOOD TRANSFUSION 12 TO 18 HOU                1,911.50                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63144   BLOOD TRANSFUSION 18 TO 24 HOU                2,181.20                             36430         1
  391   BLOOD STOR/PROC ADMINIS             50.4432       63146   BLOOD TRANSFUSION-4HR INCREM>2                  411.05                             36430
  949   OTHER THERAPY OTHER                 50.4432       90930   ENTEROSTOMAL THERAPY                            431.25                             97535
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470        2371   VAS CATH SLIM ST 15CM                           286.75
  270   M/S SUPPLY GENERAL                  50.4470        2416   FEMSTOP PLUS                                    160.95
  272   M/S SUPPLY STERILE SUPPLY           50.4470       20076   EPIDURAL TRAY/EPIDURAL CERV                     121.80
  258   PHARMACY IV SOLUTIONS               50.4470       21004   IV D 5 L R S 500CC                              249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21005   IV D 5 L R S 1000CC                             249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21006   IV SOD CHL 45 100 ML                            249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21007   IV SOD CHL 45 500                               249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21008   IV WATER IRRIG 500ML                              39.60 X7700                                    1
  258   PHARMACY IV SOLUTIONS               50.4470       21009   D-5-1/4 SAL. 500                                242.70 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21010   IV D 5-1/2 S 1000 CC                            249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21011   IV D 5-1/2 S 500CC                              249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21012   IV D 5 S 1000CC                                 249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21013   IV D 5 S 500CC                                  249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21018   IV D 5 W 1000CC                                 249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21019   IV D 5 W 500CC                                  249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21020   IV D 5 W 250                                    249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21021   IV D 10 W 1000CC                                249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21022   IV D 10 W 500CC                                 249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21023   IV D10W 250 ML                                  249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21029   IV L R S 1000CC                                 249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21030   IV L R S 500CC                                  249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21035   IV NORMOSOL M-D5W 1000ML                        249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21036   IV IONOSOL MB                                   249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21041   IV MANNITOL 20 500CC                            259.60 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21044   IV RINGERS INJ. 500                             249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21046   IV 5 SOD BIC W 500CC                            249.30 X7700                                     1
  270   M/S SUPPLY GENERAL                  50.4470       21047   NORMAL SALINE 50ML                                21.80 X7700                                    1
  270   M/S SUPPLY GENERAL                  50.4470       21048   NORMAL SALINE 100ML                               21.25 X7700                                    1
  258   PHARMACY IV SOLUTIONS               50.4470       21049   IV NORM SALINE 1000                             249.30 X7700                                     1
  258   PHARMACY IV SOLUTIONS               50.4470       21050   IV NORM SALINE 500C                             249.30 X7700                   J7040             1
  258   PHARMACY IV SOLUTIONS               50.4470       21051   IV NORM SALINE 250CC                            249.30 X7700                                     1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                55 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE       MCAL      CPT-4     HCPCS      RVU
  258   PHARMACY IV SOLUTIONS               50.4470       21052   IV SOD CHL .45 1000                           249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21053   IV SOD CHL 5 500CC                            249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21059   IV-WATER IRRIG 1000                           249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21060   IV-WATER INJ 250CC                            120.70   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21062   IV-WATER INJ 1000cc                           249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21063   IV-N SAL-IRR 1000CC                           249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21064   IV-N.SAL.IRR.3000                             249.30   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21065   I.V.N. SAL.IRR 250                             72.85   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21066   IV-EMP EVAC CONT 500                          198.95   X7700                                   1
  258   PHARMACY IV SOLUTIONS               50.4470       21067   IV-EM EVAC CONT 1000                          198.95   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21068   TRANS PACK MONITORING KIT                     164.35   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21069   MALE ADAPTER PLUG                              45.85   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21070   DONOR SET                                      39.60      21070                                1
  270   M/S SUPPLY GENERAL                  50.4470       21072   BLOOD SET Y PEDEATRIC                         200.20   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       21073   NON-VENTED SECONDARY                           11.10   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21074   BLOOD SET Y                                    61.35   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21075   BLOOD SET Y PUMP                               67.65   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21076   NON-VENTED SECONDARY SET                       11.10   Z7610                                   1
  272   M/S SUPPLY STERILE SUPPLY           50.4470       21077   BLOOD SET Y PEDIATRIC                          89.45
  270   M/S SUPPLY GENERAL                  50.4470       21078   VENOSET Y TYPE                                 62.35   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21079   PLAT RECIP S-HB 182                           124.00   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21080   IV PRIMARY PIGGYBACK PUMP SET                 183.25   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21081   EXTENSION T SET                                31.10   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21082   PUMP SET Z MALE ADAPTER                       353.30   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21084   I V SET                                        23.95   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21085   NONVENTED CATH SET                            313.20   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21088   PVC EXTENSION TUBE                             91.05   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21089   MICROBORE TUBING                               65.95   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21090   EXT T SET MACRO                                20.95   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21093   DUAL INJ SITE                                  67.00   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21094   OMNI-FLOW PRIMARY IV SET                      485.75   X7702                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21095   OMNI-FLOW SECONDARY SET                        54.55   X7702                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21096   PROVIDER CARTRIGE                             392.80   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21097   TRIFUSE ADMINISTRATION SET NIC                 41.80   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       21107   ANGIO. 14 GA 2 1/4IN                           42.75   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21108   ANGIO. 14 GA 5 1/2IN                           62.60   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21109   ANGIO. 16 GA 5 1/2IN                           62.60   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21111   ANGIO. 20 GA 1 1/4IN                           29.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21112   NEEDLE NON-CORING                              94.30   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21113   BUTTERFLY 19 GA                                 9.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21114   BUTTERFLY 21 GA                                 9.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21115   BUTTERFLY 23 GA                                 9.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21116   BUTTERFLY 25 GA                                 9.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21117   INTRA CATH 14 GA 2IN                          119.90   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21118   INTRA CATH 17 GA 2IN                          101.90   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21119   INTRA CATH 19 GA 2IN                          101.90   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21120   ANGIO CATH 20 FR 2IN                           29.15   Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21121   JELCO 22 GA                                    54.55   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21122   JELCO 14 GA                                    54.55   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21123   JELCO 16 GA                                    54.55   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21124   JELCO 18 GA                                    54.55   X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       21125   JELCO 20 GA                                    54.55   X7700                                   1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              56 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       21126   QUIK-CATH 24 FR. JELCO                          72.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21127   EPIDURAL CATHETER                              294.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21128   JELCO 18X1 3/4 GA                               51.30   X7700                                1
  270   M/S SUPPLY GENERAL                  50.4470       21129   TWIN-CATHETER                                  196.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21130   C V P INFUSSOR                                 239.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21131   VENOUS MONITOR 5700                            401.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21132   ANAEROBIC SPEC COLLR                           109.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21133   BIOPSY NEEDLE DISP                             485.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21134   TROCATH V 4900                                 415.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21135   INTRA-FLO SYSTEM                               261.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21136   TRU CUT NEEDLE - 4 1/2IN                       389.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21137   24 GA JELCO W/O WINGS                            4.60
  270   M/S SUPPLY GENERAL                  50.4470       21138   22 GA JELCO W/WINGS                              5.75
  270   M/S SUPPLY GENERAL                  50.4470       21139   22 GA JELCO W/O WINGS                            5.75
  270   M/S SUPPLY GENERAL                  50.4470       21140   HEMOVAC 2505                                   404.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21141   D5-1/4 SALINE 1000CC                           228.95   X7702                                1
  270   M/S SUPPLY GENERAL                  50.4470       21142   HEMOVAC 2500                                   389.80   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21144   HEMOVAC 2510                                   495.90   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21146   TRANSFER PACK TA 1                             100.60   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21147   HEMOVAC 2507                                   528.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21150   INTRA CATH 16 GA 12IN                           50.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21151   PLAT INF SET                                    67.65   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21152   UMBILICAL ARTERY CAT 3.5 FR                    277.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21153   UMBILICAL VESSEL CATH - 5FR                    213.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21154   UMBILICAL VESSEL CATHETER - 8F                 213.95                                        1
  258   PHARMACY IV SOLUTIONS               50.4470       21155   D 5 W 100 ML                                   161.15   X7700                                1
  258   PHARMACY IV SOLUTIONS               50.4470       21156   D 5 W 50 ML                                    124.40   X7700                                1
  270   M/S SUPPLY GENERAL                  50.4470       21159   BUNETTE SET-MICRO DRIP                          62.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21160   INLINE METRI SET                               100.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21162   MENGHINI NEEDLE DISP                           394.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21163   DISP MENGHIN NEEDLE - 17ga.                    311.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21164   HIGH FLOW RATE EXT SET                          49.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21165   I V FLOW CONTROL                               130.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21166   THORASEAL AUTOTRANSFUSION                      782.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21167   THORASEAL ACCESSORY                            714.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21168   ATRIUM                                       1,089.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21169   THERA-SEAL DRAINAGE UNIT                       301.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21172   STIFCOR BRONCHIAL NEEDLE 1400                  867.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21173   SOFCOR BIOPSY NEEDLE 1100                      867.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21175   SCLEROTHEROPY NEEDLE                           503.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21176   GROS. DB. L. REPAIR RED                         63.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21177   GROS. DB.L. REPAIR WHITE                        63.90   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       21179   MINI BORE CONNECTOR TUBING 7",                  21.90   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       21180   STAT LOCK PLUS                                  14.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       21181   MICROINTRODUCER 4.5 FR PICC                     55.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       22119   SCOTCH CAST 2 IN                               144.35   Z7610                                1
  999   PT CONVEN OTHER                     50.4470       22120   TOOTHETTE - PKG                                 43.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       22125   VAG PACKING - 3'                                73.55   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       22126   VAG PACKING - 12'                               95.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       22127   VAG PACKING                                    101.80   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       22128   PACKETS,LEMON-GLY                                5.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       22131   OPSITE WOUND DRESSING 11X6                      76.75   Z7610                                1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            57 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       22132   OPSITE POST-UP DRESSING 5 1/2X                116.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22133   OP-SITE 30 X 28                               136.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22134   STRAPS MONTGOMERY                              67.00   Z7610                                 1
  999   PT CONVEN OTHER                     50.4470       22135   COTTON BALLS - PKG                             19.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22136   COTTON ROLL                                   314.00   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22137   BIO PATCH                                      13.75
  270   M/S SUPPLY GENERAL                  50.4470       22138   ACE BANDAGE 2IN BD                             33.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22139   ACE BANDAGE 3",10601,22139"                    22.15   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       22140   ACE BANDAGE 4IN                                28.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22141   ACE BANDAGE 6IN                                44.50   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22142   TEGADERM 1 3/4 X 1 3/4                          2.40   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22143   KLING 1IN                                      14.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22144   KLING 2IN                                      14.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22145   KLING GAUZE 3IN                                17.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22146   LISTER DRESS HEAVY                             61.75   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22148   EYE SHIELD FOX                                 27.95   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22149   WECK PLA EYE SHIELD                            54.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22154   MEDI PREP 3X3                                  19.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22155   BANAID DR. 8 X 6                               31.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22156   VASELINE-G 1 X 8                               25.40   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22157   VASELINE-G 3 X 9                               35.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22158   NEW GAUZE STP 1/4IN                           114.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22160   NEW GAUZE STP 1IN                             129.30   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22161   IODAFORM 1/4IN                                123.85   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22162   IODAFORM 1/2 X 5IN                            130.00   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22163   IODAFORM 1IN                                  140.75   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22164   VASELINE GAUZE 1/2                             54.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22166   PADS A R D                                    156.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22167   KLING-G 4IN                                    31.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22168   VASELINE GAUZE 3X18                            22.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22170   MEDI PREP 3X8                                  48.60   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22172   ELASTIKON TAPE 2 IN                            71.25   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22173   ELASTIKON TAPE 3 IN                           106.80   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22174   CAIRPAD                                        91.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22175   PATIENT UNDERPADS(5)                           12.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22176   TELFA                                           9.85   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22177   A.B.D. - 5X9                                    9.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22181   SUTURE PKG                                    117.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22182   EYE DRESSING KIT                              152.80   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22183   STERI STRIP 1 X 5                              83.60   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22184   STERI STRIP 1X8 X3                             33.80   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22186   STERI-STRIP 4X3                                77.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22190   CONFORM BANDAGE 2IN                            13.85   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22191   CONFORM BANDAGE 3IN                            16.45   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22192   CONFORM BANDAGE 4IN                            19.40   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22193   CONFORM BANDAGE 6IN                            33.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22194   CASTING TAPE 3IN 3M                           163.25   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22195   4X4 GAUZE PKG                                  19.40   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22196   BRIEF INCONTINENT LG                          135.25   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22198   CASTING TAPE 4IN                              263.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22199   BRIEF INCONTINENT MED                          94.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       22200   SCOTCHCAST 5IN                                304.95   Z7610                                 1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            58 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL      CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       22230   INCONTINENT PADS                                28.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23002   EX TRANSFUSION                               1,016.90                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23003   DISP. BONE MARROW TRAY                         755.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23004   LUMBAR TR. 18 GA                               377.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23005   LUMBAR PUN 20 GA                               377.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23006   LUMBAR PUN-INFANT                              378.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23007   MYLOGRAM TRAYS                                 433.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23008   THORACENTESIS TRAY                             421.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23009   TRACH CARE TR                                  109.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23010   MONITORING LN 1FTINJ                            79.60    90799                                1
  270   M/S SUPPLY GENERAL                  50.4470       23011   BONE MARROW BIOPSY NEEDLE 8 GA                 605.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23012   BONE MARROW BIOPSY NEEDLE 11 G                 605.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23013   BONE MORROW SET                                508.20                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23014   CUT DOWN TRAY                                  342.50                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23015   EYE TRAY                                       171.45 X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       23016   ANESTHESIA EPIDURAL TRAY                        63.45
  270   M/S SUPPLY GENERAL                  50.4470       23017   IRRIGATION TRAY                                 50.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23018   LIVER BIOPSY SET                               285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23022   PARA-THORACENTESTS                             285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23023   PLASTIC REPAIR TRAY                            285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23025   SPECIAL SUTURE TRAY                            285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23028   SM. SUTURE SET                                 254.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23029   PICC NEEDLE                                    282.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23030   LARGE SUTURE SET                               289.50                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23031   SPEC. PROCEDURE TRAY ER                        340.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23032   TRACHEOTOMY TRAY                               514.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23033   SALPINGIOGRAPH TRAY                            254.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23035   TUBE THORACOSTOMY TR                           285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23038   POST PARTUM KIT                                240.85                                         1
  999   PT CONVEN OTHER                     50.4470       23039   ADMIT KIT                                      102.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23041   VAG EXAM TRAY                                  101.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23042   AMNIOCENTESIS TRAY                             400.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23043   ISOLATION SETUP                                586.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23044   DECLOTTING TRAY                                308.50                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23045   THORACENTESIS TRAY AND CATHETE                 479.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23046   PICC KIT                                     1,543.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23047   SPING WIRE GUIDE .25X60CM                       48.30 X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       23048   COBE ARTERIAL KIT SINGLE                       330.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23049   COBE PA-CVP KIT                              1,005.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23050   PERVENOUS LEADS 6F                             857.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23052   A.V.P. CATH INTRODUCER SET                     510.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23053   PERC CATH INTRODR 6F                           466.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23054   THERMADILUTION CATH                          1,006.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23056   GERSHONG SINGLE LUMEN 3FR                      248.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23057   VENOUS CATH INTRO 7F                           386.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23062   CARDIAC PACING LEADS                         1,179.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23063   BIOPLAR PACING ELEC                          1,182.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23064   COOK NEEDLE 18 T                                84.70 X7700                                   1
  270   M/S SUPPLY GENERAL                  50.4470       23065   PRESSURE RELIEF VALV                           120.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23066   ACCU SET                                       294.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23067   WIRE GUIDE J                                   346.45                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23068   5 FR DILATOR                                   149.45                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             59 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL      CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       23069   RADIAL ARTERY CATH SET                         155.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23070   ULTRA-PACE I ELECTRO                         1,899.95                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23071   WIRE GUIDE TSCF                                300.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23074   PNEUMOTHORAX SET                             1,362.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23075   LUNG BIOPSY NEEDLE                             347.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23076   CO-SET                                         492.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23077   FEMORAL ARTERY TRAY                            604.30                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23078   PRESSURE MONITORING TRAY                       563.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23079   HEIMLICH CHEST DRAIN VALVE                     270.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23080   PACING ELECTRODE - 6FR                       1,528.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23081   PACING ELECTRODE - 7FR                       1,528.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23082   ESOPHAGEAL/RECTAL PROBE                         25.50
  270   M/S SUPPLY GENERAL                  50.4470       23083   SKIN SURFACE TEMP PROBE                         24.15
  270   M/S SUPPLY GENERAL                  50.4470       23084   MICROBORE EXT SET                                3.55
  270   M/S SUPPLY GENERAL                  50.4470       23085   EPIDURAL CATH SET 19GA X 12"                   161.25
  270   M/S SUPPLY GENERAL                  50.4470       23086   PUMP REFILL KIT                                 58.65
  270   M/S SUPPLY GENERAL                  50.4470       23087   NERVE BLOCK W/18GA X 3 1/2                      77.40
  270   M/S SUPPLY GENERAL                  50.4470       23088   INTRA AORTIC BALLOON 8FR 34CC                5,153.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23089   INTRA AORTIC BALLOON 8FR 40CC                5,153.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23090   BALLOON PACING CATHETER                      1,454.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23091   MULTI-MED CATHETER KIT                         638.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23093   V-PACKING PROBE TRAY                         1,912.20                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23094   PACEPORT CATHETER CCU                        1,546.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23095   NEEDLE INSULATED 22 GA X 2"                     39.70
  270   M/S SUPPLY GENERAL                  50.4470       23096   QUINTON FEMORAL 195MM                        1,179.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23097   QUINTON SUBCLAVIAN 135MM                     1,179.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23098   INTRA AORTIC CATH 8.5FR.                     9,217.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23099   INTRA AORTIC CATH 10.5FR.                   11,086.25                                         1
  272   M/S SUPPLY STERILE SUPPLY           50.4470       23100   GROSHONG CATH KIT                            3,560.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23101   GROSHONG CATH 8FR.                           2,461.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23102   GROSHOWG CATH 5.5 FR.                        1,468.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23103   GROSHONG REPAIR KIT                            218.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23104   GROSHONG INJ. CAP                               59.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23105   DUAL LUMEN GROSHONG CATH                     3,809.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23106   DATASCOPE INSERTION KIT                      1,840.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23108   A-V SEQUENTIAL PACING ELECT.                 4,232.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23112   PERC. SHEATH INTRODUCER SET                    374.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23113   ARROW TUOHY BORST ADAPTER                      216.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23114   CORDIS CATH SHEATH INTRODUCER                  480.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23115   CORDIS CATH SHEATH INTRODUCER                  480.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23116   LIFEMED CONNECTOR 1 3-8IN                       21.90 Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       23117   LIFEMED CONNECTOR 1IN                           16.85 Z7610                                   1
  270   M/S SUPPLY GENERAL                  50.4470       23118   LIFEMED INFUSION T TUBE                        102.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23119   QUINTON INJ CAP                                 36.35    90799                                1
  270   M/S SUPPLY GENERAL                  50.4470       23120   HICKMAN INJ CAP                                 34.95    90799                                1
  270   M/S SUPPLY GENERAL                  50.4470       23121   PERCUTANEOUS SHEATH TRAY                       830.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23122   OPTICATH                                     2,724.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23123   MULTI-PURPOSE-BIOPSY-TRAY                      503.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23124   VAS-CATH LEFT 8",10601,23124"                1,031.90
  270   M/S SUPPLY GENERAL                  50.4470       23125   VAS-CATH RIGHT 6",10601,23125"               1,031.90
  270   M/S SUPPLY GENERAL                  50.4470       23126   PERICARDIOCENTESIS                           2,334.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       23127   MEDCOMP DUAL/LUMAN LOFT                      1,137.40                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             60 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG          CATEGORY AND NAME              DPT        CODE                  DESCRIPTION                     CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       23128   MEDCOMP DUAL LUMAN RIGHT                     1,137.40                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23129   MEDCOMP LFT SUBELAVIAN 20CM                  1,037.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23130   VAS CATH LEFT OR RIGHT                       1,171.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23131   MEDLINE PIC KIT 3FR                            649.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23132   MEDLINE PIC KIT 4FR                            649.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23134   X-RAY CASSETTS HOLDER                           30.70   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       23135   ESMARK 4",10601,23135"                          47.65   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       23136   ESMARK 6",10601,23136"                          26.15   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       23137   ASEPTO SYRINGE                                   9.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       23138   COBAN                                           18.25   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       23139   BONANNO CATHETER                               320.95   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       23141   GROUNDING PAD                                   20.80   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       23143   CATH ASH SPLINT 14FR X 32CM                  2,297.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23144   SURGICAL BLADE CLIPPER                          25.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23145   ABC LAPAROSCOPIC HANDPIECE                     454.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23146   ABC 45 DEG ANGLE HANDPICE                      253.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23147   DELUXE C ARM DRAPE                              53.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23148   DRAIN ABRAMSON SUMP                            264.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23149   CATH ASH SPLINT 14FRX28CM                    2,297.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23150   DRAIN BLAKE FLAT 10MM                          137.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23151   ANGIO CATH 10 GA X 3",10601,23                  57.65
  270   M/S SUPPLY GENERAL                  50.4470       23152   ANGIO CATH 12 GA X 3",10601,23                  54.95
  270   M/S SUPPLY GENERAL                  50.4470       23153   RETAINER MCGLASS VIS FISH LG                   129.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23154   TOURNIQUET DISP CUFF 18",10601                 281.30
  270   M/S SUPPLY GENERAL                  50.4470       23155   TOURNIQUET DISP CUFF 24",10601                 313.40
  270   M/S SUPPLY GENERAL                  50.4470       23156   TOURNIQUET DISP CUFF 34",10601                 361.45
  270   M/S SUPPLY GENERAL                  50.4470       23157   BAG URETERAL CATHETER                           40.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23158   KIT VIVONEX JEJUNOSTOMY                        371.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23159   ABC GROUDING PAD                                21.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23160   SURGICAL BLADE CLIPPER                          25.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23161   COMPRESSOR COMFORT DISC                         33.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23162   DISP Y CONNECTOR 3/8 3/8 3/8                    28.70
  270   M/S SUPPLY GENERAL                  50.4470       23163   BOVIE                                           16.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23164   20 EXT T"                                        1.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23165   DISP CHILD BLOOD PRESSURE CUFF                  19.45
  270   M/S SUPPLY GENERAL                  50.4470       23167   DISP LG ADULT BLOOD PRESSURE                    25.25
  270   M/S SUPPLY GENERAL                  50.4470       23168   DISP THIGH BLOOD PRESSURE CUFF                  33.60
  270   M/S SUPPLY GENERAL                  50.4470       23169   VAS CATH SLIM CVD/SCM                          329.80
  270   M/S SUPPLY GENERAL                  50.4470       23170   VAS CATH SLIM CVD 20CM                         329.80
  270   M/S SUPPLY GENERAL                  50.4470       23171   VAS CATH SLIM ST 15CM                          369.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       23172   VAS CATH SLIM ST 20CM                          329.80
  270   M/S SUPPLY GENERAL                  50.4470       23173   VAS CATH SLIM ST 24CM                          329.80
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       23174   INFUSION PUMP SINGLE 2.5                       305.95
  261   IV THERAPY INFUSION PUMP            50.4470       23175   INFUSION PUMP DUAL 2.5                         527.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       23176   INFUSION PUMP DUAL 5.0                         522.40
  261   IV THERAPY INFUSION PUMP            50.4470       23177   INFUSION PUMP SINGLE 5                         497.00
  270   M/S SUPPLY GENERAL                  50.4470       24001   BILE BAGS-SM.                                  171.50   A7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24002   BAGS BILE-REG.                                 213.95   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24003   3-WAY STOPCOCK - PT                             28.10   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24005   PLEUR-EVAC BIL                               1,187.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24006   BELT ABDOMINAL                                   8.55
  270   M/S SUPPLY GENERAL                  50.4470       24007   CULTURETTE                                      12.50   Z7610                                1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            61 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       24009   PADS CONTOUR BREAST                            34.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24010   PALL BLD TRANS FILTR                          239.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24011   FOAM RING                                     364.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24012   SITZ BATH                                      69.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24014   SHIELD BR EZE-NURS                             96.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24015   SUSPENSORIES SCR ME                           180.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24016   SUSPENSORIES SCR LA                           180.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24018   3 PC. EYE SET                                  56.00   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24019   SPUTUM COL SYSTEM                              47.30   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24020   COMB & BRUSH                                   30.60   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24021   BACTERIA FILTER                                43.65   Z7610                                 1
  999   PT CONVEN OTHER                     50.4470       24022   DRY SHAMPOO                                    76.55   Z7610                                 1
  999   PT CONVEN OTHER                     50.4470       24023   BREAST PUMP MEDELA                            325.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24025   SUSPENSORIES SM                               209.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24026   SUSPENSORIES SCR XL                           276.25   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24027   DOUCHE                                         66.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24028   LINER RECEPTAL 1000CC                           5.30
  270   M/S SUPPLY GENERAL                  50.4470       24029   FACE MASK MED ADULT                             8.55
  270   M/S SUPPLY GENERAL                  50.4470       24030   LENS MORGAN                                   398.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24031   NASOSTAT                                      575.45   Z7610                                 1
  999   PT CONVEN OTHER                     50.4470       24032   PERSONAL SHAVE KIT                             65.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24033   DISP BULB SYR. - 3 OZ.                         22.30   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24034   ANESTHESIA CIRCUITS                            13.65
  270   M/S SUPPLY GENERAL                  50.4470       24035   INFANT TRANSDUCER                             512.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24036   02 CONNECTING TUBE NSY                          8.50   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24037   PREMI-PROBE                                   308.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24038   HARVARD MICRO HIGH FLOW SET O.                106.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24039   ICE PACK                                       36.45   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24040   STARTER SNS                                   105.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24041   FETAL SCALP ELECTRODE                         186.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       24042   DEBUSK TEMPERATURE SYS                         26.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24043   OB VACUUM DELIVERY SYS                        447.90                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24044   EPCOM INTRAUTERINE CATH SET                   156.45                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24045   BURRON BLOC EPIDURAL CATH.                    304.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24046   PHOTO EYE SHIELD NSY                           28.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24047   HYPERINFLATION W/02 PRESSURE                   11.50                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24048   BREAST SHELL                                  196.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24049   NSY NUTRITION SYSTEM                          504.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24051   02 TRANSDUCER-OXISENSOR                       394.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24052   DISP SKIN STAPLER                             258.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24053   C\SECT. BASIC PK.                             889.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24054   DISP PREP TRAY                                 85.45                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24055   TUBAL BASIC PACK                              158.90                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24056   GYN PACK                                      170.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24057   M-STYLE VACUUM DEL KIT                        530.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24058   OMEDA EASY PROBE NSY                          535.45                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24059   I.U.P. 400                                    422.95                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24060   OXISENSOR PEDIATRIC                           394.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24061   OXISENSOR N-25 NEONATAL                       127.35
  270   M/S SUPPLY GENERAL                  50.4470       24062   VAGINAL DELIVERY PACK                         206.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24063   D & PACK                                      152.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       24064   TUBAL LIGATION PACK                           242.70                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            62 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       24088   CORE BIOPSY SYS GI                             212.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24089   G.I. STOMATE KIT                             1,434.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24096   BRONCH BIOPSY FORCEP.DISP.                     543.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24097   MICROBIOLOGY BRUSH                             372.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24098   CYTOLOGY BRUSH - 1601                          243.40                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24099   FEEDING ADAPTER G I                             34.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24100   QUIK-PACE PACING ELECTRODE                     905.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24101   PT. RETURN ELECTRODE GI                        120.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24102   FAST-PATCH ELECTRODE                           421.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24103   CYTOLOGY BRUSH GI LAB                          378.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24104   QUICK COMBO RTS                                 14.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24106   POPE OTOWICK EAR ER                             37.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24107   STARI STAT NOSE ER                              69.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24108   ACCU TEMP. COUTERY ER                           80.30   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24109   R 2 PADS E.R.                                  457.25   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24110   DEFIB ELECTRODE ER                             587.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24111   MECONIUM ASPIRATOR                             109.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24112   PALL SET SAVER                                 119.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24113   SENTRY-SILVER-SIRCUIT                          101.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24115   ZEROWET SPLASHIELD                              34.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24200   LITHOTRIPSY KIT                                372.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24201   VAGINAL SPECULUM MED.                           31.20   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24202   TIS-U-TRAP 4MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24203   TIS-U-TRAP 5MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24204   TIS-U-TRAP 6MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24205   TIS-U-TRAP 7MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24206   TIS-U-TRAP 8MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24207   TIS-U-TRAP 9MM                                 290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24208   TIS-U-TRAP 10MM                                290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24209   TIS-U-TRAP 11MM                                290.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24210   RESTOCK-GOWNS                                  219.30                                        1
  999   PT CONVEN OTHER                     50.4470       24211   TOOTHBRUSH & PASTE                              16.20                                        1
  999   PT CONVEN OTHER                     50.4470       24212   ALOE PERINEAL SOLUTION                          14.50                                        1
  999   PT CONVEN OTHER                     50.4470       24213   BABY POWDER                                     14.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24214   RAPID RHINO 5.5 CM                              64.30                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24215   RAPID RHINO 7.5CM                               67.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24216   KATZ EXTRACTOR                                 122.15                                        1
  999   PT CONVEN OTHER                     50.4470       24297   SINGLE BREAST PUMP                              35.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24298   TRAY UMBILICAL INSERTION 5 FR                  473.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24299   TRAY UMBILICAL INSERTION 3.5 F                 473.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24301   BREAST PUMP DOUBLE                             325.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24302   CATH UMBILICAL DUAL                            157.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24303   PHOTO EYE SHIELD PRIMI                          28.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24304   PHOTO EYE SHIELD PRIMI SM                       28.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24305   TRAY TWO LUMEN 5 FR                            422.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24306   TRAY TWO LUMEN 4 FR                            422.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24307   CATH UMBILICAL VESSEL 5FR                      157.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24308   CATH UMBILICAL VESSEL 3.5                      157.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24309   ABBOCATH 26 GAGE                                25.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24310   NEONATAL L P TRAY                              128.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24311   DRAINAGE CHEST                                 580.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24312   V-CATH-ACCESSORIES                             672.65                                        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            63 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       24313   V-CATH INTRODUCER                              450.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24318   DUAL EXT T SET                                  39.95   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24319   MASK INFLATABLE #1                              59.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24320   MASK INFLATABLE #2                              59.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24321   MASK INFATABELE # 3                             59.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24322   DUAL MACRO BORE TUBING                          36.00
  270   M/S SUPPLY GENERAL                  50.4470       24323   R T BAG HYPERINFLATION                          86.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24324   MASK PREMI                                      14.70   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24325   STEAMLINE 24 GAGE                               25.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24326   NEO CARE PICC PEELAWAY CATH                    308.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24327   NEO CARE PICC CATHETER                         344.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24328   GEL-E-DONUT                                     34.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24329   SKIN TEMPERATURE SENSOR                         39.45   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24330   SKIN TEMPERATURE WHITE                          32.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24331   REPAIR KIT MINI PICC                           415.80
  270   M/S SUPPLY GENERAL                  50.4470       24332   NEOPICC INTRODUCER SHEATH                       80.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24333   FUHRMAN PLUENAL DRAINAGE                       233.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24334   3.7FR UAC NEOTREND                              46.95
  270   M/S SUPPLY GENERAL                  50.4470       24339   PIC KIT SINGLE-LUMEN 2 FR                      429.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24340   PIC PE 28 TRAY                                 696.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24341   PIC PE 24 TRAY                                 696.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24345   INTRO EZE INTRODUCER 4.2 FR                    892.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24346   REPAIR KIT 4.2 FR                            1,064.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24347   BROVIAC CATH KIT 2.7 FR                      1,638.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24348   BROVIAC CATH KIT 4.2 FR                      2,408.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24349   REPAIR KIT 2.7 FR                            1,064.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       24350   TUBE FEED 6.5 FR SILICONE                       86.55   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       24351   TUBE FEED 8 FR SILICONE                         86.55   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25001   SPIROMETRICS                                   298.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25002   PALL HEAT FILTER                               104.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25003   CATH SUCTION 10 FR.                             12.20   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25004   CATH SUCTION 14FR                               13.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25005   REGU VAC SUC. 5FR                               13.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25006   REGU VAC SUC. 6 1/2 FR                          13.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25007   REGU VAC SUC.8FR                                13.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25008   PORTEX CATH-14 FR.                              25.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25009   DEELEE CATH + MUCUS                            129.30   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25010   REGU VAC SUC.18FR                               13.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25011   TRACHEOSTOMY TUBE                              454.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25012   ENEMA BUCKETS                                   47.70   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25013   ENDO TRACH T #1-182                             93.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25014   SILVER TRACHEA TUBE                            752.15   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25015   SUCTION CATH LOOPED                             19.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25016   SHILEY TRACH TUBE                              743.85   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25018   SCUTION KIT 10/PKG                             192.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25020   HUMIDIFIER WATER                                97.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25021   FIO2 NEBULIZER                                  50.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25022   VENTILATOR ELBOW                                11.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25023   TRACH SUCTION SYSTEM                           331.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25024   IPPB SET UPS                                    56.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25025   BLOOD GAS KITS                                  25.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25026   PALL PRO-TAL FILTER                            203.55   Z7610                                1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            64 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE        MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       25027   CONNECTING TUBE                                 13.85   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25028   ADULT 02 MASK                                   19.50   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25029   UP DRAFT NEBUILIZER                             30.60   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25031   AEROTRACH BAG                                   40.50   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25032   TRIFLOW                                        110.00   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25033   VENTILATOR SET RESP.                            66.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25034   VENTURI MASK                                    40.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25035   NON BREATH MASK                                 32.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25036   TRACHEOSTOMY MASK                               31.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25037   PEDS 02 CANNULA                                 31.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25038   BBG NASAL ASPIRATOR                             49.00
  270   M/S SUPPLY GENERAL                  50.4470       25039   PEDS 02 MASK                                    25.70   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25040   AEROVENT P. T.                                 160.80   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25041   AEROSOL MASK                                    11.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25042   Y ADAPT VENTILATOR                              24.50   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25043   CAM TENT                                       243.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25044   PEDS NON REBREATHER MASK                         9.45   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25045   WATER INHALATION                                78.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25046   NEBULIZER WATER                                132.20   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25049   ACON NEB SYS. RESP.                            203.55   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25050   RT CONCHA CARTRIDGE                            161.15   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25051   RT WATER 1500                                   62.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25052   TRACH SPEAKING 9.0                             748.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25053   RESUSCITATOR W/MASK                            516.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25054   FACE MASK 5250                                 110.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25055   NASAL AIRWAY 7MM                               141.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25056   NASAL AIRWAY 8MM                               141.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25057   NASAL AIRWAY 9MM                               141.10   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25058   TRACH TUBE HOLDER                               88.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25059   ENDO TRACH TUBE HOLDER                         101.75   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25060   ENDO TRACH TUBE 2.5 PED.                        83.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25061   ENDO TRACH TUBE 3.0 PED.                        93.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25062   ENDO TRACH TUBE 3.5 PED                         93.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25063   ENDO TRACH TUBE 4.0 PED                         93.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25064   ENDO TRACH TUBE 4.5 PED                         93.05   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25065   ENDO TRACH TUBE 5.0                             99.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25066   ENDO TRACH TUBE 5.5 PORTEX                      99.35   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25067   ENDO TRACH 2.0                                  41.60   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25068   R T MASK RESUSCITATION                         267.05   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       25069   EASY CAP CO2 DETECTOR                           54.65   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25070   ENDO TRACH TUBE 6.0                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25071   ENDO TRACH TUBE 6.5                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25072   ENDO TRACH TUBE 7.0                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25073   ENDO TRACH TUBE 7.5                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25074   ENDO TRACH TUBE 8.0                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25075   ENDO TRACH TUBE 8.5                             72.90   Z7610                                 1
  270   M/S SUPPLY GENERAL                  50.4470       25077   PORTEX X LG 8MM                              1,198.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25080   TRACH TUBE PORTEX 6MM                          612.90                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25081   TRACH TUBE PORTEX 7MM                          612.90                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25082   TRACH TUBE PORTEX 8MM                          677.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25083   TRACH TUBE PORTEX 9MM                          677.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       25085   SHILEY TRACH FENESTRATED 4                     814.60                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             65 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE       MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       25086   SHILEY TRACH FENESTRATED 6                     823.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25087   SHILEY TRACH FENESTRATED 8                     823.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25088   SHILEY TRACH FENESTRATED 10                    795.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25089   SHILEY TRACH TUBE 4                            743.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25090   SHILEY TRACH TUBE 6                            813.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25091   SHILEY TRACH TUBE 8                            813.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25092   SHILEY TRACH TUBE 10                           790.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25093   SHILEY INNER CANNULA                            76.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25094   SHILEY INNER CANNULA #6                        101.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25095   SHILEY INNER CANNULA #8                        101.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25096   SHILEY INNER CANNULA #10                       101.75   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25097   AMBU BAG ADULT                                 108.30   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       25098   AMBU BAG PEDIATRIC                             149.20   Z7610
  270   M/S SUPPLY GENERAL                  50.4470       25099   HOPE NEBULIZER                                  63.25   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25100   CONCH COLUMN                                    46.95   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25101   NEONATAL NEBULIZER                              13.45   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25102   CANNULA SALTER NEONATE                          17.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25103   CANNULA PREMI NASAL                             17.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25104   CANNULA SALTER INTERMEDIATE                     15.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25105   BALLARD SERVANTA CATH 5FR                       80.00   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25106   BALLARD TRACH CARE 6FR                          94.15   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25107   BALLRD TRACH CARE 8FR                           98.25   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25108   AQUA PAK BOTTLES                                32.55   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25109   NEONATAL HEATED - WIRE CIRCUIT                  91.40   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25110   AQUA PAK ADAPTOR                                17.15   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25111   PASSY MUIR VALVE                               299.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       25112   FLOW SENSOR                                     11.45   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25113   SILVER CIRCUIT ELECTRODES                        4.70   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25114   BALLARD IN-LINE TRACH SUCTION                  111.30   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       25194   SHILEY XLT TRACH TUBE DISTAL                   383.90
  270   M/S SUPPLY GENERAL                  50.4470       25195   SHILEY XLT TRACH TUBE PROXIMAL                 383.90
  270   M/S SUPPLY GENERAL                  50.4470       25196   DISP INNER CANNUAL/XLT TRACH                    31.00
  270   M/S SUPPLY GENERAL                  50.4470       26002   SHIRLEY DRAINS                                 333.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26006   ESOPH. NASOG. TUBE                           1,947.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26007   LINTON TUBE                                  2,702.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26008   FEED TUBE 5-15IN                                33.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26009   FEED TUBE 8-15IN                                33.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26010   FEED TUBES 8-42IN                               33.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26014   M-A TUBE 16FR                                  831.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26016   LEVINE PLAST. 12FR                              31.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26017   LEVINE PLAST. 14FR                              31.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26018   PLASTIC 16FR                                    33.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26019   PLASTIC 18 FR                                   33.90                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26021   LEVINE TUBE 12 FR                              186.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26022   LEVINE TUBE 14 FR                              186.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26023   LEVINE TUBE 16 FR                              179.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26024   LEVINE TUBE 18 FR                              171.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26025   FLEXIFLO 10FR                                  239.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26026   FLEXIFLO 12FR                                  239.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26027   TOPTAINER, KANG                                 45.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26028   PUMP SET TUBE, KANG                             44.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26029   Y PORT CONNECTOR                               126.10                                        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            66 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       26032   ASPIR TUBES 3 1/4                              64.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26036   KANGAROO FEED SET                             108.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26037   CANTOR TUBES 16FR                             615.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       26039   ANTI-REFLUX VALVES                            119.15   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26040   PENROSE TUBING                                 16.85   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26045   LAVAGE KIT ER                                 401.90   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26046   LAVAGE TUBING 18FR ER                         143.65   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26047   LAVAGE TUBING 24FR ER                         151.45   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26048   LAVAGE TUBING 32 FR ER                        143.65   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26049   LAVAGE TUBING 36FR ER                         151.45   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       26050   LAVAGE TUBING 40FR ER                         151.45   z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27001   URINARY DRAIN SET                             112.30   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27002   DISP A LEG BAG                                 91.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27003   U BAG-24 HR                                    44.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27006   CATH CAUDE-12 FR                              149.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27007   CATH CAUDE-14 FR                              149.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27008   CATH CAUDE-16 FR                              149.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27009   CATH CAUDE-18 FR                              149.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27010   CATH FOLEY C 14/5                             348.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27011   CATH FOLEY 12/5                               171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27012   CATH FOLEY 14/5                               184.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27013   CATH FOLEY 16/5                               184.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27014   CATH FOLEY 18/5                               168.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27015   CATH FOLEY 20/5                               171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27016   CATH FOLEY 22/5                               171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27017   CATH FOLEY 24/5                               171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27018   CATH FOLEY 26/5                               171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27019   CATH FOLEY 14/30                              214.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27020   CATH FOLEY 16/30                              214.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27021   CATH FOLEY 18/30                              214.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27022   CATH FOLEY 20/30                              199.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27023   CATH FOLEY 22/30                              199.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27024   CATH FOLEY 24/30                              199.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27025   CATH FOLEY 26/30                              199.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27026   CATH CAUDE 20FR                                59.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27027   CATH CAUDE 22FR                                59.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27028   FOL CATH CONT 20/30                           296.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27029   FOL CATH CONT 22/30                           318.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27030   FOL CATH CONT 24/30                           318.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27031   FOL CATH CONT 26/30                           318.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27032   FEMALE CATH KIT                                43.50   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27033   CATH KIT INFANT/PEDS                           49.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27035   ROBINSON CATHETER 8FR                          26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27036   ROBINSON CATHETER 10FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27037   ROBINSON CATHETER 12FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27038   ROBINSON CATHETER 14FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27039   ROBINSON CATHETER 16FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27040   ROBINSON CATHETER 18FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27041   ROBINSON CATHETER 20FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27042   ROBINSON CATHETER 22FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27043   ROBINSON CATHETER 24FR                         26.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27044   ROBINSON CATHETER 26FR                         26.15                                        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           67 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  270   M/S SUPPLY GENERAL                  50.4470       27045   TROCAN CATH 8FR                               179.40                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27047   T.V.R. SET & POUCH                            200.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27048   CYSTOSCOPY IRRIG SET                          128.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27049   T.V.R. EXTENSION                               77.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27050   T.V.R. Y SET                                  213.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27051   TROCAR CATH 10 FR                             455.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27052   TOCAR CATH 12 FR                              455.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27053   TROCAR CATH 16 FR                             455.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27054   TROCAR CATH 20 FR                             455.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27055   TROCAR CATH 28 FR                             455.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27056   TROCAR CATH 32 FR                             455.85   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27057   DISP CATH A TRAY                               84.70   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27058   TRAY CATH 16 FR                               242.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27059   TRAY CATH 18 FR                               242.05   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27060   MID STREAM                                     35.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27061   URINARY DR TUBES                               39.95   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27062   URI METER                                     228.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27063   URO SHEATH                                    126.10   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27064   MALE EXT CATH                                  29.15   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27066   FOL CATH CONT 18/30                           318.35   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27067   ADD-A-FOLEY TRAY                              178.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27068   CATHETER 30-30                                199.60   Z7610                                1
  270   M/S SUPPLY GENERAL                  50.4470       27069   CATHETER 30-75                                417.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27070   URINE METER, FOLEY - 16FR                     329.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27071   URINE METER, FOLEY - 18FR                     329.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27072   CATH FOLEY 12 FR5CC SILICONE                   32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27073   CATH FOLEY 14FR 5CC SILICONE                   32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27074   CATH FOLEY 16FR5CC SILICONE                    32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27075   CATH FOLEY 18FR5CC SILOCINE                    32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27076   CATH FOLEY 20FR 5CC SILICONE                   32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27077   CATH FOLEY 22FR 5CC SILICONE                   32.55
  270   M/S SUPPLY GENERAL                  50.4470       27078   CATH FOLEY 24FR 5 CC SILICONE                  32.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27079   CATH FOLEY 26FR 5CC SILICONE                   32.55
  270   M/S SUPPLY GENERAL                  50.4470       27087   HOLLISTER DRAIN 7327                           50.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27092   HOLLI BAG 41/2 7347                            48.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27093   HOLLI GASK 41/2 7345                          114.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27095   HOLLI BELT MED 7320                           133.30                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27097   STOMA POUCH KURAYA 1 3-4 PKG                  206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27098   STOMA POUCH KURAYA 1 1-4 PKG                  206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27099   STOMA POUCH KURAYA 2 1-2 PKG                  206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27101   STOMA POUCH KURAYA 1IN PKG                    206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27109   ADHESIVE STOMA                                 67.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27111   IRRIG CONE SET                                757.30                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27113   CATH FOLEY CAUDE 16/                          323.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27114   CATH FOLEY CAUDE 18/                          323.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27115   CATH CAUDE 12/5CC                             323.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27116   FOLEY CATH 8/3CC                              356.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27117   FOLEY CATH 10/3CC                             356.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27118   STOMA POUCH KURAYA 2IN PKG                    206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27119   STOMA POUCH KURAYA 3IN PKG                    206.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27120   STOMA BAG KARYA 3IN                            23.95                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27121   CATH FOLEY CAUDE20/5                          323.85                                        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           68 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS   RVU
  270   M/S SUPPLY GENERAL                  50.4470       27122   CATH FOLEY CAUDE22/5                            323.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27124   STOMAHESIVE WAFER SQUIBB                          67.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27125   UROSTOMY POUCH                                    67.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27126   STOMA POUCH KURAYA 1 1-2 PKG                    206.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27127   1 1/2IN UROSTOMY POUCH SQUIBB                     67.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27128   1 3/4IN UROSTOMY POUCH SQUIBB                     67.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27129   2 1/4IN UROSTOMY POUCH SQUIBB                     67.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27131   1 1/2IN STOMA WAFER SQUIBB                        67.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27132   1 3/4IN STOMA WAFER SQUIBB                        67.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27133   2 1/4IN STOMA WAFER SQUIBB                        67.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27134   WOUND MANAGER 4X9                               317.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27135   WOUND DRAINAGE BAG                              243.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27136   HYDRON WOUND DRAINAGE 3GM                       222.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27137   UROSTOMY STYSTEM 1 3/4",10601,                    98.25
  270   M/S SUPPLY GENERAL                  50.4470       27140   UNIDERM MOISTURIZER                             100.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27141   STOMA PASTE SQUIBB                              194.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27142   STOMA POWDER SQUIBB                             133.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27143   UNISALVE OINTMENT                               123.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27144   SKIN BARRIER 2 3/4IN                              90.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27145   SKIN BARRIER 4IN                                123.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27146   POUCH FLANGE 2 3/4IN                              50.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27147   POUCH FLANGE 4IN                                  44.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27148   IRRIG DRAIN FLANGE 2 3/4IN                        82.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27149   IRRIG DRAIN FLANGE 4IN                            94.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27150   UROSHOMY POUCH 2 3/4                              70.55                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27151   ONE-PIECE DRAIN POUCH SQUIBB                      65.85                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27152   IRRIG SLEEVE SQUIBB                             100.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27153   POUCH - FLANGE 1 1/2IN                            47.70                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27154   POUCH - FLANGE 1 3/4IN                            47.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27155   STAMEY SUPERPUBIC CATH                          544.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27156   UROSTOMY POSTOPERATIVE SYS                      179.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       27157   OSTOMY BELT                                       46.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       27158   CONE IRRIGATION KIT                             170.70
  270   M/S SUPPLY GENERAL                  50.4470       27159   IRRIGATION SLEEVE 3",10601,271                    11.10
  270   M/S SUPPLY GENERAL                  50.4470       27777   CENTRAL SUPPLY MISC                         misc chrg determined at time of svcs               1
  270   M/S SUPPLY GENERAL                  50.4470       28001   RIB BELT WOMEN                                  147.45 L0210                                   1
  270   M/S SUPPLY GENERAL                  50.4470       28011   RIB BELT-MALE                                   147.45 L0210                                   1
  270   M/S SUPPLY GENERAL                  50.4470       28012   SCULT. BINDER                                   188.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28014   ABD BINDER                                        31.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       28015   ABDOMINAL BINDER 28IN-32IN                      366.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28016   ABDOMINAL BINDER 32IN-36IN                      366.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28017   ABDOMINAL BINDER 36IN-42IN                      366.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28018   ABDOMINAL BINDER 42IN-48IN                      366.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28019   ABDOMINAL BINDER 48IN-54IN                      366.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       28020   ABD BINDER 50-56                                366.85                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28100   HALO BRACE                                   19,863.60                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28101   SHOULDER BRACE                                2,460.20                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28102   NECK BRACE                                    7,380.75                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28103   S.L.C.CAST BRACE                              8,746.85                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28104   PANTY COMP STOCK                              2,079.85                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28105   TAYLOR KNIGHT BRACE                           5,237.25                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28106   AFO L1940 PROSTHESIS                          4,281.50                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              69 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28107   LUMBAR BRACE                                 1,988.15                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28108   MRI DUAL PORT CATHETER                      10,638.65                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28109   BLEDSOE BRACE                                3,356.45                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28110   LUMBAR-SACRAL CORSET                         1,180.80                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28111   LONG LEG CAST, BRACE                        19,863.60                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28112   BODY JACKET                                  9,107.95                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28113   T.L.S.O. BRACE                              12,423.20                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28114   A.F.O. LEFT BRACE                           12,509.30                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28115   K.A.F.O. RIGHT BRACE                        13,966.35                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28116   STOCKING                                     1,153.85                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28117   A.F.O. BRACE - L & R                         9,900.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28118   HALO BRACE                                  19,863.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28119   STUMP PROSTHESIS                            10,704.00                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28120   JEWETT KNEE BRACE                            4,910.45                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28121   A.K. STUMP SHRINKER                          3,583.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28122   L F CORSET                                   1,971.00                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28123   C0MP STOCKING                                1,547.70                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28124   HYPEREXTENSION ORTHOSIS                      5,714.40                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28125   CERVICAL BRACE                               2,274.05                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28126   L.S. CORSET                                  1,239.25                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28127   SWANSON TOE IMPLANT G426-010                 2,854.45                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28128   TLSO PROSTHESIS                             19,863.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28129   CHAIR BACK BRACE                             3,492.95                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28130   STOCKING                                     2,907.55                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28131   LUMBAR CORSET                                2,378.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28132   ADJUST TO HIP ORTHESIS                         578.25                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28133   POTLICK HARNESS                              1,685.50                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28134   KNEE BRACE B                                 4,471.65                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28135   HALO BRACE                                  19,863.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28136   LEFT AKA STUMP SHRINKER                        708.35                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28137   JEWETT HYPEREXTENSION BRACE                  4,910.45                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28138   POST OP BODY JACKET                         17,873.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28139   JOBST STOCKING                               1,363.00                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28140   TLSO BODY JACKET                            12,003.70                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28141   ANKLE FOOT ORTHOSIS                          8,997.80                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28142   COMPRESSION SLEEVE & GLOVE                   1,860.15                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28143   HIP ABDUC ORTHO                             19,504.75                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28144   KAM WALKER                                   1,285.55                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28145   COLLAR                                       1,186.35                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28146   AFO WALKER LINER                             1,841.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28147   FRACTURE BRACE                               3,638.00
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28148   SIGVARIUS STOCKING                           1,834.80
  270   M/S SUPPLY GENERAL                  50.4470       28149   SHOE LIFT                                    1,279.30                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28151   TAYLOR BRACE                                 6,079.70                                       1
  270   M/S SUPPLY GENERAL                  50.4470       28153   CERVICAL COLLAR                              1,549.05                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28154   PELVIC EXTENTION                            11,120.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28155   ANKLE BRACE                                    840.55                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28156   HIP ABD BRACE                               11,429.75                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28157   BK PROSTHESIS                               12,504.60                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28158   KNEE BRACE A                                12,183.50                                       1
  460   PULMONARY FUNCTION GENERAL          50.4470       28159   PNEUMOGRAM                                   8,031.75             94772     94772           1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28160   AFO PROSTHESIS                               7,947.65                                       1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           70 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4     HCPCS      RVU
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28161   WRIST SPLINT                                 1,000.05
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28162   LSO BRACE                                    4,330.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28163   ORTHO SOCK                                   4,283.55
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28164   K.H.F.O. KNEE                               19,863.60
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28165   ADJ. FOOT DROP SPUNT                           782.45
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28166   STUMP SHRINKER W ACCESSORIES                 5,495.60
  270   M/S SUPPLY GENERAL                  50.4470       28167   SOMI BRACE                                   6,347.50
  270   M/S SUPPLY GENERAL                  50.4470       28168   WALKING CAST BOOT                            3,356.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       28169   SOFT WRIST SPLINT                            1,150.10
  270   M/S SUPPLY GENERAL                  50.4470       28170   AFO BRACE W VELCRO                           2,727.85                                        1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28171   SIGVARUS STOCKING, CALF                        630.50
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28172   TLSO HYPEREXTENSION ORTHOSIS                 3,496.05                                        1
  279   M/S OTHER SUPPLIES/DEVICES          50.4470       28173   HEMOVAC WOUND DRAINAGE SYSTEM                  417.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       28174   WOUND VAC SMALL DRESSING                        91.10
  270   M/S SUPPLY GENERAL                  50.4470       28175   WOUND VAC MEDIUM DRESSING                      114.75
  270   M/S SUPPLY GENERAL                  50.4470       28176   WOUND VAC LARGE DRESSING                       138.35
  270   M/S SUPPLY GENERAL                  50.4470       28177   WOUND VAC CANNISTER                            103.40
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28180   BONE STIMULATION DEVICE (A)                 19,715.35                                        1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4470       28181   BONE STIMULATION DEVICE (B)                 19,715.35
  270   M/S SUPPLY GENERAL                  50.4470       28182   KAM BOOT                                       311.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29001   SHOES BUNNION                                  191.45   L3215                                1
  270   M/S SUPPLY GENERAL                  50.4470       29002   BUNNION SHOE, WOMEN MED                        191.45   L3215                                1
  270   M/S SUPPLY GENERAL                  50.4470       29003   BUNNION SHOE, WOMEN, LARGE                     191.45   L3215                                1
  270   M/S SUPPLY GENERAL                  50.4470       29004   BUNNION SHOE, MEN, SMALL                       191.45   L3219                                1
  270   M/S SUPPLY GENERAL                  50.4470       29005   BUNNION SHOE, MEN, MED                         191.45   L3219                                1
  270   M/S SUPPLY GENERAL                  50.4470       29006   BUNNION SHOE, MEN LARGE                        191.45   L3219                                1
  270   M/S SUPPLY GENERAL                  50.4470       29007   SHOULDER AMMOBILIZER SM                         94.30   L3650                                1
  270   M/S SUPPLY GENERAL                  50.4470       29008   SHOULDER EMMOBILIZER MED                        94.30   L3650                                1
  270   M/S SUPPLY GENERAL                  50.4470       29009   SHOULDER EMMOBILIZER LG                         94.30   L3650                                1
  270   M/S SUPPLY GENERAL                  50.4470       29012   FOREARM SPLINT, RIGHT                          361.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29013   FOREARM SPLINT ER                              361.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29014   HEEL PROTECTOR FOAM                            364.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29015   CPM                                          1,524.05                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29016   C P M SHEEP SKIN                               538.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29018   TRAPEEZE                                       254.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29024   HYPER HYPOTHERMIA                              703.60                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29025   AQUAMATIC MACH                                 254.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29026   DUO THERM BLANKET 24X60                        445.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29027   DUO THERM BLANKET 24X30                        445.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29028   EMERSON PUMP                                   914.65                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29029   EMERSON TUBING SET                             641.10                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29031   GASTRIC SUC MACHINE - PER DAY                  171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29032   EMERSON PUMP BOTTLE                            804.20                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29033   ORAL SUC MACH - 22.55                          171.45                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29035   HUMIDIFIER MACHINE                              86.00                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29036   STOCK BIAS 2IN                                  13.40                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29037   STOCK BIAS 3IN                                  19.40                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29038   STOCK BIAS 4IN                                  20.80                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29039   STOCK BIAS 6IN                                  37.35                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29040   BRONCHOSCOPY CART                              514.15                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29041   ANKLE BRACE, RIGHT                             510.85   L4350                                1
  270   M/S SUPPLY GENERAL                  50.4470       29047   ARM SPLINT ADULT                               290.40                                        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            71 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                      CHARGE       MCAL        CPT-4     HCPCS   RVU
  270   M/S SUPPLY GENERAL                  50.4470       29048   ARM SPLINT CHILD LEFT                           290.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29049   ARM SPLINT CHILD RIGHT                          290.40                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29050   ARM SLING                                         42.75                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29051   ANKLE AIR CAST                                  510.85 L4350                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29052   CRUSHED-FINGER SPLINT                             87.50                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29054   FINGER SPLINT SM                                182.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29055   FINGER SPLINT LG                                182.55                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29056   CLAVICLE SPLINT                                 335.45 L3660                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29057   CRUTCHES                                        321.60 E0111Y2                                 1
  270   M/S SUPPLY GENERAL                  50.4470       29058   EGG CRATE PAD                                   183.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29059   ORTHOPEDIC ARM SLING ADULT                        92.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29060   ORTHOPEDIC ARM SLING YOUTH                        92.25                                        1
  292   DURAB MED EQUIP PURCH NEW           50.4470       29061   CANE                                            459.50                        E0100            1
  270   M/S SUPPLY GENERAL                  50.4470       29062   ORTHOPEDIC ARM SLING CHILD                        92.25                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29064   IMMOBILIZING SLING                              242.00                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29065   SIGMOID SCOPE MACH                              285.70                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29066   PAD SHEEPSKIN                                   227.25                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29067   PELVIC TRACTION BELT                            563.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29068   CRUTCHES - SMALL                                321.60                        E0114            1
  270   M/S SUPPLY GENERAL                  50.4470       29069   CRUTCHES - MEDIUM                               321.60 E0111Y2                                 1
  270   M/S SUPPLY GENERAL                  50.4470       29070   CRUTCHES - LARGE                                321.60 E0114Y2                                 1
  270   M/S SUPPLY GENERAL                  50.4470       29071   CRUTCHES, CHILD                                 321.60                        E0111            1
  270   M/S SUPPLY GENERAL                  50.4470       29072   HEEL LIFT                                       495.85                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29073   HEEL PROTECTOR                                  130.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29074   CUTAWAY SHOULDER IM ER                          156.45                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29076   UNIVRSL SLING/SWATHE                            362.05                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29077   SHOULDER IM ELASTIC SM                          194.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29078   SHOULDER IM ELASTIC MED                         194.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29079   SHOULDER IM ELASTIC LG                          194.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29080   SHOULDER IM ELASTIC X-LG                        194.75                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29081   ABDUCTION PILLOW                                550.80                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29082   BUCKS BOOT                                      498.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29083   KNEE IMMOBILIZER 19IN                           641.70 L1830                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29084   KNEE IMMOBILIZER 24IN                           759.15 L1830                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29085   CAST SHOE                                       349.15                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29086   FLOATATION EGG CRATE                            414.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29087   BUCK BOOT SM                                    442.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29088   BUCK BOOT MED                                   442.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29089   BUCK BOOT LG                                    442.35                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29091   CAST SHOE SANDAL SM                             216.35 L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29092   CAST SHOE SANDAL MED                            216.35 L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29093   CAST SHOE SANDAL                                216.35 L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29094   CAST SHOE SEMI CLOSED                           252.65                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29095   CLAVICLE SPLINT CHILD                           156.10 L3660                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29096   CLAVICLE SPLINT MEDIUM                          156.10 L3660                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29097   CLAVCLE SPLINT LG                               156.10                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29099   CENTRAL HBA MISC CHARGE                     misc chrg determined at time of svcs               1
  270   M/S SUPPLY GENERAL                  50.4470       29101   STOCK TUBE 6IN                                    69.35 Z7610                                  1
  270   M/S SUPPLY GENERAL                  50.4470       29102   STOCK TUBE 4IN                                    47.30                                        1
  270   M/S SUPPLY GENERAL                  50.4470       29103   KANGAROO FEED PUMP                              228.95                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29108   DUO PADS 18X24                                  139.60                                         1
  270   M/S SUPPLY GENERAL                  50.4470       29109   DUO PADS 12X17                                  119.15                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              72 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                      CHARGE
 CHG         CATEGORY AND NAME               DPT       CODE                   DESCRIPTION                     CHARGE       MCAL       CPT-4     HCPCS      RVU
  947   OTHER THER MED EQP ANCILL           50.4470       29110   ZONEAIR BED                                  1,051.30                                           1
  947   OTHER THER MED EQP ANCILL           50.4470       29111   FLEXICARE BED #2                             1,051.30                                           1
  947   OTHER THER MED EQP ANCILL           50.4470       29113   REST CUE BED                                 1,848.65                                           1
  946   OTHER THER MED EQP ROUTINE          50.4470       29115   ACU-CARE BED                                   736.30                                           1
  760   TREAT/OBS RM GENERAL                50.4470       29117   CLENSICAIR BED                                 968.35
  270   M/S SUPPLY GENERAL                  50.4470       29118   J.J. ORTHO SORB PIN KIT                      5,627.60                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29119   J.J. ORTHO SORB PIN                          2,227.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29120   ORTHO ABSORBABLE PIN                         1,876.00                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29121   CARPAL TUNNEL KIT                            1,333.35                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29122   FINGER SPLINT CRUSHED MED                       87.50                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29123   FINGER SPLINT CRUSHED SM                        87.50                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29125   CLINITRON ELEXIS BED                         1,444.95                                           1
  947   OTHER THER MED EQP ANCILL           50.4470       29126   MAGNUM BED                                     684.15                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29127   COLD THERAPY MACHINE                           288.05                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29128   COLD THERAPY PAD                               319.40                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29129   HEPA-CARE FILTER MACHINE                       167.10                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29130   EMERSON PUMP - PER DAY                         195.80                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29131   GASTRIC SUC MACHINE - PER DAY                  176.65                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29132   ORAL SUC MACHINE - PER DAY                     176.65                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29133   K-PAD MACHINE - PER DAY                        117.35                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29135   KANGAROO FEED PUMP - PER DAY                   211.60                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29139   PCA INFUSER                                    597.80                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29150   PHILADELPHIA COLLAR,SM. 3 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29151   PHILADELPHIA COLLAR,MED. 3 1/4                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29152   PHILADELPHIA COLLAR,LG. 3 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29153   PHILADELPHIA COLLAR,SM. 4 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29154   PHILADELPHIA COLLAR,MED. 4 1/4                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29155   PHILADELPHIA COLLAR,LG. 4 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29156   PHILADELPHIA COLLAR,SM. 5 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29157   PHILADELPHIA COLLAR,MED 5 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29158   PHILADELPHIA COLLAR,LG, 5 1/4"                 411.75   L0150
  270   M/S SUPPLY GENERAL                  50.4470       29159   CAST SHOE SEMI CLOSED SM                       175.25   L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29160   CAST SHOE SEMI CLOSED MED                      175.25   L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29161   CAST SHOE SEMI CLOSED LG                       175.25   L3540                                   1
  270   M/S SUPPLY GENERAL                  50.4470       29164   CERVICAL COLLAR 3 1/2",10601,2                  61.15
  270   M/S SUPPLY GENERAL                  50.4470       29165   CERVICAL COLLAR SM 2.5 IN                       99.35                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29166   CERVICAL COLLAR SM 3 IN                        106.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29167   CERVICAL COLLAR MED 3 IN                       106.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29168   CERVICAL COLLAR MED 3.75 IN                    106.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29169   CERVICAL COLLAR LG 3 IN                        106.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29170   CERVICAL COLLAR LG 4.25 IN                     106.70                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29171   ULTRA SLING X-LG                               747.40                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29172   ULTRA SLING STD                                747.40                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29173   SUPPORT ELBOW SMALL 5M                         227.20                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29174   SUPPORT ELBOW MED                              227.20                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29175   SUPPORT ELBOW LG                               227.20                                           1
  270   M/S SUPPLY GENERAL                  50.4470       29200   EOA KIT                                      1,066.35                                           1
  360   OR SVCS GENERAL                     50.4470       51165   STERI-STRIP                                     18.25
  302   LABORATORY IMMUNOLOGY               50.4470 86631A        CHLAMYDIA IgG IFA BY ARUP                       38.80   86631ZS                 86631           1
  300   LABORATORY GENERAL                  50.4500       46062   FROZ BLOOD, THAW                                24.95      86927      86927     86927
  300   LABORATORY GENERAL                  50.4500       46069   RBC ANTIGEN SCREEN                              64.15      86903      86903     86903
  300   LABORATORY GENERAL                  50.4500       46070   ANTIBODY ID,COMPLEX                            673.60      86870      86870     86870

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               73 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4     HCPCS      RVU
  300   LABORATORY GENERAL                  50.4500       46080   ANTIBODY PANEL                                139.00       86870     86870      86870
  301   LABORATORY CHEMISTRY                50.4500       52652   VITAMIN D 1,26 DILYD BY REFERE                 *        82652ZS                 82652           1
  300   LABORATORY GENERAL                  50.4500       80031   FLECAINIDE BY REFERENCE                        *        80299ZS                 80299           1
  301   LABORATORY CHEMISTRY                50.4500       80074   HEPATITIS PANEL ACUTE BY REFER                 *        80074ZS                 80074           1
  301   LABORATORY CHEMISTRY                50.4500       80101   CAMABINOIDS BY REFERENCE                        88.40   80101ZS                 80101           1
  301   LABORATORY CHEMISTRY                50.4500       80152   ELAVIL BY REFERENCE                            *        80152ZS                 80152           1
  301   LABORATORY CHEMISTRY                50.4500       80153   AMYTRIPTYLINE/NORTRIPTYLINE                    *        80152ZS                 80152           1
  301   LABORATORY CHEMISTRY                50.4500       80154   CLONAZEPAM BY REFERENCE                        *        80154ZS                 80154           1
  301   LABORATORY CHEMISTRY                50.4500       80158   CYCLOSPORINE A BY REFERENCE                    *        80158ZS                 80158           1
  301   LABORATORY CHEMISTRY                50.4500       80160   NORPRAMINE BY REFERENCE                        *        80160ZS                 80160           1
  301   LABORATORY CHEMISTRY                50.4500       80168   ETHOSUXIMIDE BY REFERENCE                      *        80168ZS                 80168           1
  301   LABORATORY CHEMISTRY                50.4500       80173   HALDOL BY REFERENCE                            *        80173ZS                 80173           1
  301   LABORATORY CHEMISTRY                50.4500       80174   TOFRANIL BY REFERENCE                          *        80174ZS                 80174           1
  301   LABORATORY CHEMISTRY                50.4500       80182   NORTRIPTYLINE BY REFERENCE                     *        80182ZS                 80182           1
  301   LABORATORY CHEMISTRY                50.4500       80197   TACROLIMUS PROGAF                               91.25   80197ZS                 80197           1
  301   LABORATORY CHEMISTRY                50.4500       80299   METHOTREXATE BY REFERENCE                      *        80299ZS                 80299           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       81090   CHLAMIDIA TRACHOMATIS DFA                       76.75   87206ZS                 87206           1
  301   LABORATORY CHEMISTRY                50.4500       82024   ACTH BY REFERENCE LAB                         359.65    82024ZS                 82024           1
  301   LABORATORY CHEMISTRY                50.4500       82043   MICROALBUMIN BY ARUP                            19.30   82043ZS                 82043           1
  301   LABORATORY CHEMISTRY                50.4500       82085   ALDOLASE BY REFERENCE                          *        82085ZS                 82085           1
  301   LABORATORY CHEMISTRY                50.4500       82088   ALDOSTERONE PLASMA BY REFERENC                327.65    82088ZS                 82088           1
FOR     CHARGE EXPLOSION ONLY               50.4500       82102   ALPHA 1 ANTITRYPSIN PHENO ARUP                  19.80   82103ZS                 82103           1
  301   LABORATORY CHEMISTRY                50.4500       82103   ALPHA 1 ANTIRYPSIN BY REF                      *        82103ZS                 82103           1
  301   LABORATORY CHEMISTRY                50.4500       82104   ALPHA 1 ANTITRYPSIN PHENOTYPE                   14.10   82104ZS                 82104           1
  301   LABORATORY CHEMISTRY                50.4500       82105   ALPHA FETOPROTEIN BY REF                       *        82105ZS                 82105           1
  301   LABORATORY CHEMISTRY                50.4500       82128   INBORN ERRORS OF METAB BY REFE                 *        82128ZS                 82128           1
  301   LABORATORY CHEMISTRY                50.4500       82139   AMINO ACIDS PLASMA BY REF                      *        82139ZS                 82136           1
  301   LABORATORY CHEMISTRY                50.4500       82143   AMNIOTIC FLUID SCAN BY REF                      79.40   82143ZS                 82143           1
  301   LABORATORY CHEMISTRY                50.4500       82154   ANDOSTANEDIOL GLUCURONIDE BY R                 *        82154ZS                 82154           1
  301   LABORATORY CHEMISTRY                50.4500       82157   ANDROSTENEDIONE                                 48.35   82157ZS                 82157           1
  301   LABORATORY CHEMISTRY                50.4500       82163   ANGIOTENSIN CON ENZ BY REFEREN                  95.05   82164ZS                 82164           1
  301   LABORATORY CHEMISTRY                50.4500       82164   ACE BY REFER                                   *        82164ZS                 82164           1
  301   LABORATORY CHEMISTRY                50.4500       82172   LIPOPROTEIN BY REFERENCE                       *           82172                82172           1
  301   LABORATORY CHEMISTRY                50.4500       82175   ARSENIC BLOOD/URINE BY REFERRE                  24.95   82175ZS                 82175           1
  301   LABORATORY CHEMISTRY                50.4500       82180   VITAMIN C PLASMA BY REFERENCE                  *        82180ZS                 82180           1
  301   LABORATORY CHEMISTRY                50.4500       82205   NEMBUTAL BY REFERENCE                          *        82205ZS                 82205           1
  301   LABORATORY CHEMISTRY                50.4500       82232   BETA 2 MICROGLOB SERUM BY REFE                 *        82232ZS                 82232           1
  301   LABORATORY CHEMISTRY                50.4500       82300   CADMIUM URINE BY REFERENCE                      35.65      82300                82300           1
  301   LABORATORY CHEMISTRY                50.4500       82306   VITAMIN D 25 HYDROXY BY REFERE                 *        82306ZS                 82306           1
  301   LABORATORY CHEMISTRY                50.4500       82308   CALCITONIN BY REFERENCE                         56.90   82308ZS                 82308           1
  301   LABORATORY CHEMISTRY                50.4500       82378   CEA BY REFERRENCE                              *        82378ZS                 82378           1
  301   LABORATORY CHEMISTRY                50.4500       82379   CARNITINE FREE & TOT                            78.55   82379ZS                 82379           1
  301   LABORATORY CHEMISTRY                50.4500       82380   CAROTENE BY REFERENCE                          *        82380ZS                 82380           1
  301   LABORATORY CHEMISTRY                50.4500       82384   CATECHOLAMINES FRAC BY REFEREN                  77.85   82384ZS                 82384           1
  301   LABORATORY CHEMISTRY                50.4500       82480   CHOLINESTERASE SERUM BY REFERE                 *        82480ZS                 82480           1
  301   LABORATORY CHEMISTRY                50.4500       82490   GABAPENTIN                                      60.45   82491ZS                 82491           1
  301   LABORATORY CHEMISTRY                50.4500       82491   CLONIDINE BY REFERENCE                         *        82491ZS                 82491           1
  301   LABORATORY CHEMISTRY                50.4500       82492   PROZAC BY REFERENCE                            *        82492ZS                 82492           1
  301   LABORATORY CHEMISTRY                50.4500       82493   AMIDARONE & METABOL                             52.45      82492                82492           1
  301   LABORATORY CHEMISTRY                50.4500       82495   CHROMIUM SERUM/URIN BY REFEREN                 *        82495ZS                 82495           1
  301   LABORATORY CHEMISTRY                50.4500       82507   CITRIC,ACID,URINE BY REFERENCE                  15.20   82507ZS                 82507           1
  301   LABORATORY CHEMISTRY                50.4500       82523   CROSS LINKED N TELOP BY REF                    *        82523ZS                 82523           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               74 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL      CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4500       82530   CORTISOL FREE                                   16.60               82530      82530
  301   LABORATORY CHEMISTRY                50.4500       82534   CORTISOL-URINE BY REFERENCE                    *        82533ZS                82533           1
  301   LABORATORY CHEMISTRY                50.4500       82542   QUANT,SINGLE SAT & MOBILE PHAS                  68.90                82542     82542
  301   LABORATORY CHEMISTRY                50.4500       82595   CRYOGLOBULIN QUAL                               15.10   82595ZS                82595           1
  301   LABORATORY CHEMISTRY                50.4500       82607   VITAMIN B12 BY REFERENCE                       *        82607ZS                82607           1
  301   LABORATORY CHEMISTRY                50.4500       82608   B12 BINDING CAP BY REFERENCE                   *        82608ZS                82608           1
  301   LABORATORY CHEMISTRY                50.4500       82626   DEHYDROEPI SERUM BY REFERENCE                  *        82626ZS                82626           1
  301   LABORATORY CHEMISTRY                50.4500       82627   DEHYDROEP SULFATE SERUM BY REF                 *        82627ZS                82627           1
  301   LABORATORY CHEMISTRY                50.4500       82638   CHOLINESTERASE SERUM DIB BY RE                 *        82638ZS                82638           1
  301   LABORATORY CHEMISTRY                50.4500       82664   ELECTROPHORETIC TECHN BY REF                    79.40   82664ZS                82664           1
  301   LABORATORY CHEMISTRY                50.4500       82668   ERYTHROPOIETIN                                  51.35   82668ZS                82668           1
  301   LABORATORY CHEMISTRY                50.4500       82677   ESTRIOL SERUM BY REFERENCE                     *        82677ZS                82677           1
  301   LABORATORY CHEMISTRY                50.4500       82679   ESTRONE SERUM BY REFERENCE                     *        82679ZS                82679           1
  301   LABORATORY CHEMISTRY                50.4500       82705   FAT,FECAL QUALITATIVE                           28.10   82705ZS                82705           1
  301   LABORATORY CHEMISTRY                50.4500       82710   FAT,FECAL,QUANTIVATIVE BY REFE                 *        82710ZS                82710           1
  301   LABORATORY CHEMISTRY                50.4500       82715   LIPIDS FAT FECES BY REFERENCE                  *        82715ZS                82715           1
  301   LABORATORY CHEMISTRY                50.4500       82746   FOLIC ACID BLOOD BY REFERENCE                  *        82746ZS                82746           1
  301   LABORATORY CHEMISTRY                50.4500       82787   IgG SUBCLASSES BY REFERENCE                    *        82787ZS                82787           1
  301   LABORATORY CHEMISTRY                50.4500       82941   GASTRIN BY REFERENCE                           *        82941ZS                82941           1
  301   LABORATORY CHEMISTRY                50.4500       82955   GLUCOSE 6 PDH BY REFERENCE                     *        82955ZS                82955           1
  301   LABORATORY CHEMISTRY                50.4500       82985   FRUCTOSAMINE BY REFERENCE                      *        82985ZS                82985           1
  301   LABORATORY CHEMISTRY                50.4500       83003   GROWTH HORMONE RANDOM BY REFER                 *        83003ZS                83003           1
  301   LABORATORY CHEMISTRY                50.4500       83015   METALS HEAVY SCREEN BY REFEREN                 *        83015ZS                83015           1
  301   LABORATORY CHEMISTRY                50.4500       83036   HEM A1C BY REFERENCE                           *        83036ZS                83036           1
  301   LABORATORY CHEMISTRY                50.4500       83050   METHEMOGLOBIN BY REFERENCE                     *        83050ZS                83050           1
  301   LABORATORY CHEMISTRY                50.4500       83088   HISTAMINE WHOLE BLOOD BY REFER                 *        83088ZS                83088           1
  301   LABORATORY CHEMISTRY                50.4500       83090   HOMOCYSTEINE TOTAL BY REFERENC                 *        83090ZS                83090           1
  301   LABORATORY CHEMISTRY                50.4500       83150   HOMOVANILLIC ACID URINE BY REF                 *        83150ZS                83150           1
  301   LABORATORY CHEMISTRY                50.4500       83497   SEROTONIN 5HIAA BY REFERENCE                   *        83497ZS                83497           1
  301   LABORATORY CHEMISTRY                50.4500       83515   MITOCHON ANTIBODY                               24.35   83516ZS                83516           1
  301   LABORATORY CHEMISTRY                50.4500       83517   GLIADIN AB IgA/IgB                              72.45   83516ZS                83516           1
  301   LABORATORY CHEMISTRY                50.4500       83518   BLADDER TUMOR ASSOC ANTI BY RE                 *        83518ZS                86294           1
  301   LABORATORY CHEMISTRY                50.4500       83519   ACETYLCHOLINE REC PANEL BY REF                 *        83519ZS                83519           1
  301   LABORATORY CHEMISTRY                50.4500       83520   NEURONAL CELL ANTI SERUM BY RE                 *        83520ZS                83520           1
  301   LABORATORY CHEMISTRY                50.4500       83525   INSULIN BLOOD BY REFERENCE                     *        83525ZS                83525           1
  301   LABORATORY CHEMISTRY                50.4500       83582   17 KETOGENIC STER BY REFERENCE                 *        83582ZS                83582           1
  301   LABORATORY CHEMISTRY                50.4500       83587   17 KETOSTEROIDS FRAC BY REFERE                 *        83593ZS                83593           1
  301   LABORATORY CHEMISTRY                50.4500       83630   LACTOFERRIN (FECAL)                             30.90   83630ZS      83630     83630           1
  301   LABORATORY CHEMISTRY                50.4500       83655   LEAD QUANT BLOOD/UA BY REFEREN                 *        83655ZS                83655           1
  301   LABORATORY CHEMISTRY                50.4500       83670   LEUCINE AMINO (LAP) BY REFEREN                 *        83670ZS                83670           1
  301   LABORATORY CHEMISTRY                50.4500       83700   LIPIDS TOTAL                                  117.45    84999ZS      83700     84999           1
  300   LABORATORY GENERAL                  50.4500       83725   LITHIUM BLOOD BY REFERENCE                      98.30   80178ZS                80178           1
  301   LABORATORY CHEMISTRY                50.4500       83835   MATANEPHRINES URINE BY REFER                   *        83835ZS                83835           1
  301   LABORATORY CHEMISTRY                50.4500       83872   ROPES TEST                                      18.05                83872     83872           1
  301   LABORATORY CHEMISTRY                50.4500       83880   B NATURETIC PEPTIDE                           230.65                           83880           1
  301   LABORATORY CHEMISTRY                50.4500       83883   KAPPA/LAMBDA LCR BY REFERENCE                  *        83883ZS                83883           1
  301   LABORATORY CHEMISTRY                50.4500       83885   NICKEL SERUM BY REFERENCE                      *        83885ZS                83885           1
  301   LABORATORY CHEMISTRY                50.4500       83890   MOLECULAR EXTRACTION BY ARUP                    27.20   83890ZS                83890           1
  301   LABORATORY CHEMISTRY                50.4500       83892   ENZYMATIC DIAGESTION                            82.40   83892ZS                83892           1
  301   LABORATORY CHEMISTRY                50.4500       83896   NUCLEIC ACID PROBE EACH                         82.40   83896ZS                83896           1
  301   LABORATORY CHEMISTRY                50.4500       83898   PCR AMPLIFICATION BY ARUP                       27.20   83898ZS                83898           1
  301   LABORATORY CHEMISTRY                50.4500       83900   AMP OF PT NUC ACID MULTIPLEX                    52.38                          83900           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              75 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                           OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL       CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4500       83901   AMP OF PT NUCLEIC ACID                          38.65   83901ZS                  83901           1
  301   LABORATORY CHEMISTRY                50.4500       83902   REVERSE TRANSCRIPTION                         128.45    83902ZS                  83902           1
  301   LABORATORY CHEMISTRY                50.4500       83903   MUTATION SCANNING                               82.40   83903ZS                  83903           1
  301   LABORATORY CHEMISTRY                50.4500       83904   MUTATION ID SINGLE SEGMENT                    128.45    83904ZS                  83904           1
  301   LABORATORY CHEMISTRY                50.4500       83905   5' NUCLEOTIDASE BY REFERENCE L                  97.70   83915ZS                  83915           1
  301   LABORATORY CHEMISTRY                50.4500       83909   SEP AND IDENTI BY HIGH RESOLU                   52.38                            83909
  301   LABORATORY CHEMISTRY                50.4500       83912   INTREPRETATION AND REPORT/ARUP                  27.20   83912ZS                  83912           1
  301   LABORATORY CHEMISTRY                50.4500       83915   5 NUCLEOTIDASE BY REFERENCE                    *        83915ZS                  83915           1
  301   LABORATORY CHEMISTRY                50.4500       83916   MS PANEL                                      131.20    83916ZS                  83916           1
  301   LABORATORY CHEMISTRY                50.4500       83921   METHYLMALONIC ACID SERUM BY RE                 *           83921                 83921           1
  301   LABORATORY CHEMISTRY                50.4500       83945   OXALATE URINE BY REFERENCE                     *        83945ZS                  83945           1
  301   LABORATORY CHEMISTRY                50.4500       84031   PHENYLALANINE QNT BY REFERENCE                 *        84030ZS                  84030           1
  301   LABORATORY CHEMISTRY                50.4500       84066   PROSTATICS SPECIFIC AG BY REFE                  39.80   84153ZS                  84153           1
  302   LABORATORY IMMUNOLOGY               50.4500       84090   PHOSPHOLIPIDS BY REFERENCE                     *        86147ZS                  86147           1
  301   LABORATORY CHEMISTRY                50.4500       84120   PORPHYRINS URINE BY REFERENCE                  *        84120ZS                  84120           1
  301   LABORATORY CHEMISTRY                50.4500       84140   PREGNENOLONE BY REFERENCE                      *        84140ZS                  84140           1
  301   LABORATORY CHEMISTRY                50.4500       84144   PROGESTERONE                                  220.35    84144ZS                  84144           1
  301   LABORATORY CHEMISTRY                50.4500       84202   ZINC WHOLE BLOOD BY REFERENCE                  *        84630ZS                  84630           1
  301   LABORATORY CHEMISTRY                50.4500       84206   PROINSULIN BY REFERENCE                        *        84206ZS                  84206           1
  301   LABORATORY CHEMISTRY                50.4500       84207   VITAMIN B6 TOTAL PLASMA BY REF                 *        84207ZS                  84207           1
  301   LABORATORY CHEMISTRY                50.4500       84210   PYRUVATE BY REFERENCE                          *        84210ZS                  84210           1
  301   LABORATORY CHEMISTRY                50.4500       84238   NON-ENDOCHRINE RECEP BY ARUP                    69.25   84238ZS                  84238           1
  301   LABORATORY CHEMISTRY                50.4500       84244   RENIN BLOOD BY REFERENCE                       *        84244ZS                  84244           1
  301   LABORATORY CHEMISTRY                50.4500       84252   VITAMIN B2 BY REFERENCE                        *        84252ZS                  84252           1
  301   LABORATORY CHEMISTRY                50.4500       84260   SEROTONIN SERUM BY REFERENCE                   *        84260ZS                  84260           1
  301   LABORATORY CHEMISTRY                50.4500       84270   SEX HORM BINDING GLOB BY REFER                 *        84270ZS                  84270           1
  301   LABORATORY CHEMISTRY                50.4500       84305   IGF-1 BY REFERENCE                             *        84305ZS                  84305           1
  301   LABORATORY CHEMISTRY                50.4500       84311   CARNITINE TOTAL BY REFERENCE                   *        82379ZS                  82379           1
  301   LABORATORY CHEMISTRY                50.4500       84402   TESTOSTERONE FREE BY REFERENCE                 *        84402ZS                  84402           1
  301   LABORATORY CHEMISTRY                50.4500       84403   TESTOSTERONE                                    66.70   84403ZS                  84403           1
  301   LABORATORY CHEMISTRY                50.4500       84425   VITAMIN B1 PLASMA BY REFERENCE                 *        84425ZS                  84425           1
  301   LABORATORY CHEMISTRY                50.4500       84432   THYROGLOBULIN                                   53.45        27.4                84432           1
  301   LABORATORY CHEMISTRY                50.4500       84442   TBG BY REFERENCE                               *        84442ZS                  84442           1
  301   LABORATORY CHEMISTRY                50.4500       84445   THYROID STIM IMMUNOGLOB BY REF                 *        84445ZS                  84445           1
  301   LABORATORY CHEMISTRY                50.4500       84466   TRANSFERRIN SERUM BY REFERENCE                 *        84466ZS                  84466           1
  301   LABORATORY CHEMISTRY                50.4500       84480   T3 TOTAL BY REFERENCE                          *        84480ZS                  84480           1
  301   LABORATORY CHEMISTRY                50.4500       84481   T3 FREE BY REFERENCE                           *        84481ZS                  84481           1
  301   LABORATORY CHEMISTRY                50.4500       84482   REVERSE T3 BY REFERENCE                        *        84482ZS                  84482           1
  301   LABORATORY CHEMISTRY                50.4500       84585   VAMILYLMANDELIC ACID UR BY REF                 *        84585ZS                  84585           1
  301   LABORATORY CHEMISTRY                50.4500       84586   VMA URINE BY REFERENCE                         *        84585ZS                  84585           1
  301   LABORATORY CHEMISTRY                50.4500       84588   ANTIDIURETIC HORM PLASMA BY RE                 *        84588ZS                  84588           1
  301   LABORATORY CHEMISTRY                50.4500       84597   VITAMIN K1 BY REFERENCE                        *        84597ZS                  84597           1
  301   LABORATORY CHEMISTRY                50.4500       84600   VOLATILES BY REFERENCE                         *        84600ZS                  84600           1
  301   LABORATORY CHEMISTRY                50.4500       84681   C PEPTIDE SERUM BY REFERRENCE                  *        84681ZS                  84681           1
  301   LABORATORY CHEMISTRY                50.4500       84702   GANADOTROPIN BY REF                             38.40   84702ZS                  84702           1
  302   LABORATORY IMMUNOLOGY               50.4500       84998   THYROID ANTIBODY BY REFERENCE                  *        86800ZS                  86800           1
  301   LABORATORY CHEMISTRY                50.4500       85003   HUMAN GROWTH HORMONE RAN BY RE                 *        83003ZS                  83003           1
  305   LAB HEMATOLOGY                      50.4500       85220   FACTOR V BY REFERENCE                          *        85220ZS                  85220           1
  305   LAB HEMATOLOGY                      50.4500       85245   RISTOCETIN COFACTOR BY REFEREN                 *        85245ZS                  85245           1
  305   LAB HEMATOLOGY                      50.4500       85260   FACTOR X BY REFERENCE                          *        85260ZS                  85260           1
  305   LAB HEMATOLOGY                      50.4500       85301   ATIII ANTIGEN BY ARUP                           45.10   85301ZS                  85301           1
  305   LAB HEMATOLOGY                      50.4500       85302   PROTEIN C TOTAL BY REFERENCE                   *        85302ZS                  85302           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                76 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                   CHARGE        MCAL      CPT-4     HCPCS      RVU
  305   LAB HEMATOLOGY                      50.4500       85305   PROTEIN S TOTAL BY REFERENCE                   *        85305ZS                 85305           1
  305   LAB HEMATOLOGY                      50.4500       85335   FACTOR VIII ANTIBODY BY REFERE                 *        85335ZS                 85335           1
  305   LAB HEMATOLOGY                      50.4500       85420   PLASMINOGEN BY REFERENCE                       *        85420ZS                 85420           1
  305   LAB HEMATOLOGY                      50.4500       85540   WBC PHOSPHOTASE BY REFERENCE                   *        85540ZS                 85540           1
  305   LAB HEMATOLOGY                      50.4500       85613   DILUTE RUSSELL VENOM TIME BY R                 *        85613ZS                 85613           1
  305   LAB HEMATOLOGY                      50.4500       85810   VISCOSITY SERUM BY REFERENCE                   *        85810ZS                 85810           1
  302   LABORATORY IMMUNOLOGY               50.4500       86003   SOUTHWEST ADULT PROFILE                       308.25    86003ZS                 86003           1
  302   LABORATORY IMMUNOLOGY               50.4500       86021   ANTI-NEUTROPHIL ANTIBODY BY RE                 *        86021ZS                 86021           1
  302   LABORATORY IMMUNOLOGY               50.4500       86022   HEPARIN ASSOC ANTI DETEC BY RE                 *        86022ZS                 86022           1
  302   LABORATORY IMMUNOLOGY               50.4500       86023   PLATELET ASSOC ANTIB BY REFERE                 *        86023ZS                 86023           1
  302   LABORATORY IMMUNOLOGY               50.4500       86038   ANA REFLEX PANEL                                73.70   86038ZS                 86038           1
  302   LABORATORY IMMUNOLOGY               50.4500       86039   ANTINUCLEAR ANTIBODY POS BY RE                 *        86039ZS                 86039           1
  302   LABORATORY IMMUNOLOGY               50.4500       86140   CREACTIVE PROT HI SENS BY REFE                 *        86141ZS                 86141           1
  302   LABORATORY IMMUNOLOGY               50.4500       86162   CH 50 BY REFERENCE                             *        86162ZS                 86162           1
  302   LABORATORY IMMUNOLOGY               50.4500       86215   ANTI DNA AB BY REFERENCE                       *        86215ZS                 86215           1
  302   LABORATORY IMMUNOLOGY               50.4500       86225   Anti-dsDNA ANTIBODY, IgG BY RE                 *        86225ZS                 86225           1
  302   LABORATORY IMMUNOLOGY               50.4500       86233   SCLERODERMA AB IgG                              33.45   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500       86234   JO 1 ANTIBODY IgG                               45.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500       86236   SJOGRENS ANTIBODIES                             66.45   86235ZS                 86235           1
  301   LABORATORY CHEMISTRY                50.4500       86244   ALPHA FETO PROTEIN BY REFERENC                 *        82105ZS                 82105           1
  302   LABORATORY IMMUNOLOGY               50.4500       86253   SMOOTH MUSCLE Ab                                14.15   86255ZS                 86255           1
  301   LABORATORY CHEMISTRY                50.4500       86286   ALPHA FETOPROTEIN BY REFERENCE                136.95    82105ZS                 82105           1
  302   LABORATORY IMMUNOLOGY               50.4500       86288   ANTI HBS BY REFERENCE                         180.70    86706ZS                 86706           1
  302   LABORATORY IMMUNOLOGY               50.4500       86289   HBC CORE BY REFERENCE                         180.70    86704ZS                 86704           1
  302   LABORATORY IMMUNOLOGY               50.4500       86295   HEPATITIS BE AB BY REFERENCE                   *        86705ZS                 86707           1
  302   LABORATORY IMMUNOLOGY               50.4500       86298   HEPATITIS A IgG/IgM BY REFEREN                 *        86296ZS                 86296           1
  302   LABORATORY IMMUNOLOGY               50.4500       86300   CA 15-3 /CA 27-29 BY REFERRENC                 *        86300ZS                 86300           1
  302   LABORATORY IMMUNOLOGY               50.4500       86301   CA 19-9 BY REFERRENCE                          *        86301ZS                 86301           1
  302   LABORATORY IMMUNOLOGY               50.4500       86304   CA 125 BY REFERRENCE                           *           86304                86304           1
  302   LABORATORY IMMUNOLOGY               50.4500       86316   CA 72-4 BY REFERENCE                           *        86316ZS                 86316           1
  302   LABORATORY IMMUNOLOGY               50.4500       86317   PNEUMOCOCAL ANTIBODIES BY REFE                 *        86317ZS                 86317           1
  302   LABORATORY IMMUNOLOGY               50.4500       86328   TEICHOIC ACID AB                                29.25   86329ZS                 86329           1
  302   LABORATORY IMMUNOLOGY               50.4500       86332   IMMUNE COMPLEX ASSAY BY REFERE                 *           86332                86332           1
  302   LABORATORY IMMUNOLOGY               50.4500       86335   IMMUNO FIX FLUIDS                               97.45   86335ZS       86335     86335           1
  302   LABORATORY IMMUNOLOGY               50.4500       86337   INSULIN ANTI HUMAN BY REFERENC                 *           86337                86337           1
  302   LABORATORY IMMUNOLOGY               50.4500       86341   ANTIISLET CELL ANTI IgG BY REF                 *        86341ZS                 86341           1
  302   LABORATORY IMMUNOLOGY               50.4500       86359   T CELL TOTAL COUNT BY REF                      *        86359ZS                 86359           1
  302   LABORATORY IMMUNOLOGY               50.4500       86360   ABSOLUTE CD4 & CD8 BY REF                       85.95   86360ZS                 86360           1
  302   LABORATORY IMMUNOLOGY               50.4500       86361   CD4 ABSOLUTE COUNT BY REF                      *        86361ZS                 86361           1
  302   LABORATORY IMMUNOLOGY               50.4500       86376   ANTI MICROSOMAL AB BY REFERENC                  28.65   86376ZS                 86376           1
  302   LABORATORY IMMUNOLOGY               50.4500       86384   NITROBLUE TETRAXOLIUM BY REFER                 *        86384ZS                 86384           1
  302   LABORATORY IMMUNOLOGY               50.4500       86516   ENDOMYSIAL Ab IgA BY ARUP                       12.75   83516ZS                 83516           1
  302   LABORATORY IMMUNOLOGY               50.4500       86611   CAT SCRATCH FEVER ANTIB BY REF                 *        86611ZS                 86611           1
  302   LABORATORY IMMUNOLOGY               50.4500       86618   LYME ANTIBODIES DET BY REFEREN                 *        86618ZS                 86618           1
  302   LABORATORY IMMUNOLOGY               50.4500       86628   CANDIDA AB,ID                                   26.85   86628ZS                 86628           1
  302   LABORATORY IMMUNOLOGY               50.4500       86641   CRYPTOCOCCUS ANTIBODY                         101.95    86641ZS                 86641           1
FOR     CHARGE EXPLOSION ONLY               50.4500       86643   CMV Ab IgG & IgM BY ARUP                       *        86644ZS                 86644           1
  302   LABORATORY IMMUNOLOGY               50.4500       86644   CYTOMEGALOVIRUS ANTI IgG BY RE                 *        86644ZS                 86644           1
  302   LABORATORY IMMUNOLOGY               50.4500       86645   CMV,ANTIBODY,IgM BY REFERENCE                  *        86645ZS                 86645           1
  302   LABORATORY IMMUNOLOGY               50.4500       86658   COXASACKIE A VIRUS BY REFERENC                 *        82523ZS                 86658           1
FOR     CHARGE EXPLOSION ONLY               50.4500       86660   EBV PANEL I BY ARUP                            *                                                1
  302   LABORATORY IMMUNOLOGY               50.4500       86663   EBV EARLY Ag BY ARUP                            19.15   86663ZS                 86663           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               77 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4     HCPCS      RVU
  302   LABORATORY IMMUNOLOGY               50.4500       86664   EBV NUCLEAR Ag BY ARUP                          19.15   86663ZS                 86663           1
  302   LABORATORY IMMUNOLOGY               50.4500       86674   GIARDIA ANTIBODY IFA BY REFERE                 *        86674ZS                 86674           1
  302   LABORATORY IMMUNOLOGY               50.4500       86682   ECHINOCCOCUS ANTIBODY BY REF                   *        86682ZS                 86682           1
  302   LABORATORY IMMUNOLOGY               50.4500       86689   HIV 1 ANTIBOD CONFIRM BY REFER                 *        86689ZS                 86689           1
  302   LABORATORY IMMUNOLOGY               50.4500       86695   HERPES SIMPLEX VIRUS I BY REFE                 *        86695ZS                 86695           1
  302   LABORATORY IMMUNOLOGY               50.4500       86696   HERPES SIMPLEX VIRUS II BY REF                 *        86696ZS                 86696           1
  302   LABORATORY IMMUNOLOGY               50.4500       86698   HISTOPLASMA ANTIBODIES BY REFE                 *        86698ZS                 86698           1
  301   LABORATORY CHEMISTRY                50.4500       86701   SCREEN HIV                                      41.55                 86701     86701           1
  302   LABORATORY IMMUNOLOGY               50.4500       86704   HEPATITIS B CORE ANTIB BY REFE                 *        86704ZS                 86704           1
  302   LABORATORY IMMUNOLOGY               50.4500       86705   HEPATITIS B CORE ANTIB IgM BY                  *        86705ZS                 86705           1
  302   LABORATORY IMMUNOLOGY               50.4500       86706   HEPATITIS B SURFACE ANTI BY RE                 *        86706ZS                 86706           1
  302   LABORATORY IMMUNOLOGY               50.4500       86707   HEPATITIS Be ANTIBODY BY REFER                 *        86707ZS                 86707           1
  302   LABORATORY IMMUNOLOGY               50.4500       86708   HEPATITIS A ANTIBODIES BY REFE                 *        86708ZS                 86708           1
  302   LABORATORY IMMUNOLOGY               50.4500       86709   HEPATITIS A ANTIBODY IgM BY RE                 *        86709ZS                 86709           1
  302   LABORATORY IMMUNOLOGY               50.4500       86713   LEGIONELLA PNEUMO ANTI BY REFE                 *        86713ZS                 86713           1
  302   LABORATORY IMMUNOLOGY               50.4500       86735   MUMPS VIRUS ANTIBODY IgG BY RE                 *        86735ZS                 86735           1
  302   LABORATORY IMMUNOLOGY               50.4500       86738   MYCROPLASMA PNEUM ANTI BY REFE                 *        86738ZS                 86738           1
  302   LABORATORY IMMUNOLOGY               50.4500       86747   PARVOVIRUS B19 ANTI BY REFEREN                 *        86747ZS                 86747           1
  302   LABORATORY IMMUNOLOGY               50.4500       86753   AMEBIASIS ANTIBODY BY REF                      *        86753ZS                 86753           1
  302   LABORATORY IMMUNOLOGY               50.4500       86762   RUBELLA ANTI IgG & IgM BY REFE                 *        86762ZS                 86762           1
  302   LABORATORY IMMUNOLOGY               50.4500       86765   MEASLES ANTIBODIES BY REFERENC                 *           86765                86765           1
  302   LABORATORY IMMUNOLOGY               50.4500       86777   TOXOPLASMA ANTI IgG BY REFEREN                 *        86777ZS                 86777           1
  302   LABORATORY IMMUNOLOGY               50.4500       86778   TOXOPLASMA ANTIB IgM BY REFERE                 *           86778                86778           1
  302   LABORATORY IMMUNOLOGY               50.4500       86787   VARICELLA ZOSTER VIR ANTI BY R                 *        86787ZS                 86787           1
  302   LABORATORY IMMUNOLOGY               50.4500       86789   HERPESVIRUS 6 IGG & M                         303.45    86790ZS                 86790           1
  302   LABORATORY IMMUNOLOGY               50.4500       86790   DENGUE FEVER VIRUS BY REFERENC                 *        86790ZS                 86790           1
  302   LABORATORY IMMUNOLOGY               50.4500       86793   YERSINIA ANTIBODIES BY REFEREN                 *        86793ZS                 86793           1
  300   LABORATORY GENERAL                  50.4500       86800   ANTI THYROID AB BY REFERENCE                   *           86800                86800           1
  302   LABORATORY IMMUNOLOGY               50.4500       86803   HEPATITIS C ANTIBODY BY REFERE                 *        86803ZS                 86803           1
  302   LABORATORY IMMUNOLOGY               50.4500       86807   HLA ANTIBODY DETEC ASSAY BY RE                 *        86807ZS                 86807           1
  302   LABORATORY IMMUNOLOGY               50.4500       86812   HLA B27 BY REFERENCE                           *        86812ZS                 86812           1
  302   LABORATORY IMMUNOLOGY               50.4500       86941   SUCROSE HEM SCREEN                              59.55   86941ZS                 86941           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87110   CHLAMYDIA CULTURE BY REFERENCE                 *        87110ZS                 87110           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87252   VIRAL CULTURE BY REFERENCE                     *        87252ZS                 87252           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87270   CHLAMYDIA TRACH DFA BY REFERE                  *        87490ZS                 87490           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87281   PNEUMOCYSTIS CARINII BY REFERE                 *        87281ZS                 87281           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87328   GIARDIA ANTIGEN BY EIA BY REFE                 *        87328ZS                 87328           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87427   E.COLI(0157:H7) SHIGA LIKE TOX                  42.10   87427ZS                 87427           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87449   CRYPTOCOCCUS ANTIGEN BY REF                    *           87449                87449           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87476   BORRELIA BURGDORFEN BY REFERE                  *        87476ZS                 87476
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87490   CLAMYDIA TRACHOMATIS DIRECT                     14.15   87490ZS                 87490           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87491   CHLAMYDIA TRACH BY LCR BY REF                  *        87491ZS                 87491           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87496   CMV BY PCR BY ARUP                            384.30    87496ZS                 87496           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87516   HEPATITIS B VIRAL DNA BY REFER                 *        87516ZS                 87516           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87517   HEPATITIS B VIRAL DNA QUAN BY                  *        87517ZS                 87517           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87522   HEPATITIS C VIRUS RNA QUANT BY                 *        87522ZS                 87522           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87529   HERPES SIMP VIRUS BY PCR BY RE                 *        87529ZS                 87529           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87536   HIV 1 RNA QUANT BY PCR BY REFE                 *        87536ZS                 87536           1
  302   LABORATORY IMMUNOLOGY               50.4500       87556   MYCOBACTERIAL PCR                             454.95    87556ZS                 87556           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87590   NEISSERIA GONORRHOEAE DIRECT                    14.15   87590ZS                 87590           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87621   HPV DNA PROBE BY REFERENCE                     *        87621ZS                 87621           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4500       87801   CHLAMYDIA/NEISSER AMP DET ARUP                  76.30   87801ZS                 87801           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               78 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                   DESCRIPTION                     CHARGE        MCAL      CPT-4     HCPCS      RVU
  306   LAB BACTERIOLOGY/MICROBIO           50.4500          87899   CANDIDA ANTIGEN                                 81.65   87899ZS                 87899           1
  311   LAB PATHOLOGY CYTOLOGY              50.4500          88180   CD3 BY REFERRENCE                              *        88184ZS                 88184           1
  310   LAB PATHOLOGY GENERAL               50.4500          88185   FLOW CYTOMETRY EA ADD MARKER                     2.00      88185      88185     88185           1
  310   LAB PATHOLOGY GENERAL               50.4500          88230   TISSUE CULTURE NON NEOPL/ARUP                 143.50    88230ZS                 88230           1
  310   LAB PATHOLOGY GENERAL               50.4500          88233   TISSUE CULTURE NON-NEO BY ARUP                430.40       88233                88233           1
FOR     CHARGE EXPLOSION ONLY               50.4500          88255   CHROMOSOME ANALY AMNIO BY ARUP                 *                                                1
FOR     CHARGE EXPLOSION ONLY               50.4500          88258   CHROMOSOME ANAL LEUK BLD/ARUP                  *                                                1
FOR     CHARGE EXPLOSION ONLY               50.4500          88259   CHROMOSOME ANALY HI RESOL/ARUP                 *                                                1
FOR     CHARGE EXPLOSION ONLY               50.4500          88260   CHROMOSOME ANAL PD CONCEP/ARUP                 *                                                1
FOR     CHARGE EXPLOSION ONLY               50.4500          88262   CHROMOSOME ANAL WHOLE BLD/ARUP                 *        88262ZS                 88262           1
  310   LAB PATHOLOGY GENERAL               50.4500          88264   CHROMOSOME ANAL 20-25 BY ARUP                 352.55    88264ZS                 88264           1
  302   LABORATORY IMMUNOLOGY               50.4500          88269   CHROMOSOME ANALY IN SITU/ARUP                 245.95    88269ZS                 88269           1
  310   LAB PATHOLOGY GENERAL               50.4500          88271   MOLECULAR CYTOGENETICS DNA                    125.00       88271      88271     88271           1
  310   LAB PATHOLOGY GENERAL               50.4500          88275   INTERPHASE IN SITU HYBRID                     125.00       88275      88275     88275           1
  310   LAB PATHOLOGY GENERAL               50.4500          88289   ADD HIGH RESOLUTION/ARUP                      136.65    88289ZS                 88289           1
  301   LABORATORY CHEMISTRY                50.4500    82947ER       GLUCOSE FBS/24HRP/CSF                           30.80   82947ZS                 82947
  301   LABORATORY CHEMISTRY                50.4500    83516A        IMMUNOASSY MULTI STEP BY ARUP                   77.65   83516ZS                 83516           1
  300   LABORATORY GENERAL                  50.4500    83880ER       BNP                                           220.30    83880ZS       83880     83880           1
  301   LABORATORY CHEMISTRY                50.4500    83890A        MOLECULAR EXTRACTION BY ARUP                    69.45   83890ZS                 83890           1
  301   LABORATORY CHEMISTRY                50.4500    83892A        ENZYMATIC DIGESTION BY ARUP                     65.05   83892ZS                 83892           1
  301   LABORATORY CHEMISTRY                50.4500    83892B        ENZYMATIC DIGESTION BY ARUP                     65.05   83892ZS                 83892           1
  301   LABORATORY CHEMISTRY                50.4500    83892C        ENZYMATIC DIGESTION BY ARUP                     65.05   83892ZS                 83892           1
  301   LABORATORY CHEMISTRY                50.4500    83894A        GEL ELECTROPHORESIS SEPAR/ARUP                  65.05   83894ZS                 83894           1
  301   LABORATORY CHEMISTRY                50.4500    83894B        GEL ELECTROPHORESIS SEPAR/ARUP                  65.05      83894                83894           1
  301   LABORATORY CHEMISTRY                50.4500    83894C        GEL ELECTROPHORESIS SEPAR/ARUP                  65.05      83894                83894           1
  301   LABORATORY CHEMISTRY                50.4500    83896A        NUCLEIC ACID PROBE BY ARUP                      27.20   83896ZS                 83896           1
  301   LABORATORY CHEMISTRY                50.4500    83896B        NUCLEIC ACID PROBE BY ARUP                      27.20   83896ZS                 83896           1
  301   LABORATORY CHEMISTRY                50.4500    84238B        NON ENDOCHRINE RECEP BY ARUP                    69.25   84238ZS                 84238           1
  301   LABORATORY CHEMISTRY                50.4500    84238C        NON ENDOCHRINE RECEPT BY ARUP                   69.25   84238ZS                 84238           1
  305   LAB HEMATOLOGY                      50.4500    85300A        INHIBITORS ATIII ACT BY ARUP                    45.10   85300ZS                 85300           1
  300   LABORATORY GENERAL                  50.4500    85379ER       D-DIMER                                         68.55      85379      85379     85379           1
  302   LABORATORY IMMUNOLOGY               50.4500    86147A        CARDIOLIPIN IgG BY ARUP                         28.70   86147ZS                 86147           1
  302   LABORATORY IMMUNOLOGY               50.4500    86147B        CARDIOLIPIN IgM BY ARUP                         28.70   86147ZS                 86147           1
  302   LABORATORY IMMUNOLOGY               50.4500    86160A        COMPLEMENT Ag (C3) BY ARUP                      14.85   86160ZS                 86160           1
  302   LABORATORY IMMUNOLOGY               50.4500    86160B        COMPLEMENT Ag (C4) BY ARUP                      14.85   86160ZS                 86160           1
  302   LABORATORY IMMUNOLOGY               50.4500    86235A        EXTRACTABLE NUC AgAb RNP/ARUP                   23.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500    86235B        EXTRACTABLE NUC AgAb SM/ARUP                    23.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500    86235C        EXTRACTABLE NUC AgAb SCLE/ARUP                  23.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500    86235D        EXTRACTABLE NUC AgAb SSA/ARUP                   23.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500    86235E        EXTRACTABLE NUC AgAb SSB/ARUP                   23.40   86235ZS                 86235           1
  302   LABORATORY IMMUNOLOGY               50.4500    86255A        FLUORESCENT Ab SCREEN BY ARUP                   77.65   86255ZS                 86255           1
  302   LABORATORY IMMUNOLOGY               50.4500    86255B        FLUORESCENT Ab SCREEN BY ARUP                   77.65   86255ZS                 86255           1
  302   LABORATORY IMMUNOLOGY               50.4500    86516A        ENDOMYSIAL Ab IgA TITER/ARUP                    46.70   86256ZS                 86256           1
  302   LABORATORY IMMUNOLOGY               50.4500    86606A        ASPERGILLUS BY ARUP                             21.40   86606ZS                 86606           1
  302   LABORATORY IMMUNOLOGY               50.4500    86612A        BLASTOMYCES BY ARUP                             21.40   86612ZS                 86612           1
  302   LABORATORY IMMUNOLOGY               50.4500    86615A        BORDETELLA IgG BY ARUP                          36.05   86615ZS                 86615           1
  302   LABORATORY IMMUNOLOGY               50.4500    86615B        BORDETELLA IgA BY ARUP                          36.05   86615ZS                 86615           1
  302   LABORATORY IMMUNOLOGY               50.4500    86615C        BORDETELLA IgM BY ARUP                          36.05   86615ZS                 86615           1
  302   LABORATORY IMMUNOLOGY               50.4500    86632B        CHLAMYDIA IgM IFA BY ARUP                       91.85   86632ZS                 86632           1
  302   LABORATORY IMMUNOLOGY               50.4500    86635A        COCCIDIODES Ab (CF) BY ARUP                     12.75   86635ZS                 86635           1
  302   LABORATORY IMMUNOLOGY               50.4500    86635B        COCCIDIODES Ab (ID) BY ARUP                     12.75   86635ZS                 86635           1
  302   LABORATORY IMMUNOLOGY               50.4500    86635C        COCCIDIODES Ab (IgG EIA)/ARUP                   12.75   86635ZS                 86635           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                 79 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                    CHARGE       MCAL      CPT-4     HCPCS      RVU
  302   LABORATORY IMMUNOLOGY               50.4500    86635D        COCCIDIODES Ab(IgM EIA)/ARUP                   12.75      86635                86635           1
  302   LABORATORY IMMUNOLOGY               50.4500    86644A        CMV Ab IgG BY ARUP                             12.40   86644ZS                 86644           1
  302   LABORATORY IMMUNOLOGY               50.4500    86645A        CMV Ab IgM BY ARUP                             14.00   86645ZS                 86645           1
  302   LABORATORY IMMUNOLOGY               50.4500    86665A        EBV CAPSID BY ARUP                             19.15   86665ZS                 86665           1
  302   LABORATORY IMMUNOLOGY               50.4500    86665B        EBV CAPSID BY ARUP                             19.15   86665ZS                 86665           1
  302   LABORATORY IMMUNOLOGY               50.4500    86698A        HISTOPLASMA BY ARUP                            30.10   86698ZS                 86698           1
  302   LABORATORY IMMUNOLOGY               50.4500    86698B        HISTOPLASMA BY ARUP                            21.40   86698ZS                 86698           1
  302   LABORATORY IMMUNOLOGY               50.4500    88235A        TISSUE CULTURE AMNIO FLD/ARUP                 245.95   88235ZS                 88235           1
  310   LAB PATHOLOGY GENERAL               50.4500    88237A        TISSUE CULTURE NEOPLASTIC/ARUP                351.20      88237                88237           1
  310   LAB PATHOLOGY GENERAL               50.4500    88262A        CHROMOSOME ANALY 15-20 CELLS                  143.50   88262ZS                 88262           1
  302   LABORATORY IMMUNOLOGY               50.4500    88280A        CHROMOSOME ANAL ADD KARYO/ARUP                245.95   88280ZS                 88280           1
  301   LABORATORY CHEMISTRY                50.4502          82585   CRYOFIBRINOGEN BLOOD                          152.80   82585ZS                 82585           1
  301   LABORATORY CHEMISTRY                50.4502          82596   CRYOGLOBULINS BLOOD                           152.80   82595ZS                 82595           1
  305   LAB HEMATOLOGY                      50.4502          83052   83052/SICKLE TEST CHEMICAL                    250.40   85660ZS                 85660           1
  305   LAB HEMATOLOGY                      50.4502          85005   BASOPHIC COUNT                                183.25   85048ZS                 85048           1
  305   LAB HEMATOLOGY                      50.4502          85007   DIFF                                           85.95   85007ZS                 85007           1
  305   LAB HEMATOLOGY                      50.4502          85012   EOSINOPHIL COUNT                              183.25   89190ZS                 89190           1
  305   LAB HEMATOLOGY                      50.4502          85014   HEMATOCRIT                                     36.45   85014ZS                 85014           1
  305   LAB HEMATOLOGY                      50.4502          85018   HEMOGLOBIN                                     36.45   85018ZS                 85018           1
  305   LAB HEMATOLOGY                      50.4502          85021   CBC W/O DIFF                                  250.40   85027ZS                 85027           1
  305   LAB HEMATOLOGY                      50.4502          85022   CBC W/DIFF                                    439.80   85023ZS                 85025           2
  305   LAB HEMATOLOGY                      50.4502          85023   CBC WITH MANUAL DIFFERENTIAL                  390.65   85025ZS                 85025           2
  305   LAB HEMATOLOGY                      50.4502          85024   CBC WITHOUT DIFFERENTIAL                      195.20   85027ZS                 85027           1
  305   LAB HEMATOLOGY                      50.4502          85025   CBC WITH AUTOMATED DIFF                       390.65   85025ZS                 85025           2
  305   LAB HEMATOLOGY                      50.4502          85029   ADDITIONAL AUTOMATED INDICES                   67.00   85029ZS                 85029           1
  305   LAB HEMATOLOGY                      50.4502          85044   RETICULOCYTE COUNT                            225.90   85044ZS                 85044           1
  305   LAB HEMATOLOGY                      50.4502          85112   PRENATAL W/DRAW                               604.30   80055ZS                 80055           1
  305   LAB HEMATOLOGY                      50.4502          85113   PRENATAL W/O DRAW                             433.00   85999ZS                 85999           1
  305   LAB HEMATOLOGY                      50.4502          85441   HEINZ BODIES                                  183.25   85441ZS                 85441           1
  305   LAB HEMATOLOGY                      50.4502          85535   SIDEROCYTES                                   122.20   85536ZS                 85536           1
  305   LAB HEMATOLOGY                      50.4502          85545   L E CELL PREP                                 335.90   86344ZS                 86344           1
  305   LAB HEMATOLOGY                      50.4502          85557   RBC FRAGILITY                                 409.00   85557ZS                 85557           1
  312   LAB PATHOLOGY HISTOLOGY             50.4502          85560   PEROXIDASE STAINS                             152.80   88319TC                 88319           1
  305   LAB HEMATOLOGY                      50.4502          85650   SED. RATE                                     146.60   85651ZS                 85651           1
  305   LAB HEMATOLOGY                      50.4502          85997   JOINT FLD PNL 80112                           720.35   85999ZS                 85999           1
  305   LAB HEMATOLOGY                      50.4502          85998   SUCROSE HEMOLYSIN SC                          409.00   86941ZS                 86941           1
  302   LABORATORY IMMUNOLOGY               50.4502          86004   AUTO HEMOLYSINS                               409.00   86940ZS                 86940           1
  309   LAB OTHER                           50.4502          87165   CRYSTAL EXAM JT FLD                           106.35   89060ZS                 89060           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4502          87208   MALARIAL SMEAR                                190.60   87207ZS                 87207           1
  305   LAB HEMATOLOGY                      50.4502          89005   LAB HANDLING CHARGE                           152.80                           99001
  300   LABORATORY GENERAL                  50.4502          89013   VENIPUNCTURE OUTPATIENT                        30.70              G0001        36415           1
  300   LABORATORY GENERAL                  50.4502          89014   VENIPUNCTURE (OUTPATIENT)                      42.90                 36415     36415           1
  309   LAB OTHER                           50.4502          89050   CELL CNT(CSF)MISC BF                          180.70   89050ZS                 89050           1
  309   LAB OTHER                           50.4502          89051   DIFF (CSF)MISC BD FL                          101.25   89051ZS                 89051           1
  309   LAB OTHER                           50.4502          89300   SEMEN POST VAS                                112.75   89300ZS                 89300           1
  309   LAB OTHER                           50.4502          89320   SEMEN COMPLETE                                445.90   89320ZS                 89320           1
  305   LAB HEMATOLOGY                      50.4502    85025ER       CBC WITH AUTOMATED DIFF                        76.90   85025ZS                 85025
  312   LAB PATHOLOGY HISTOLOGY             50.4504          80313   TRICHROME STAIN                               165.05   88313ZS                 88313           1
  301   LABORATORY CHEMISTRY                50.4504          82270   OCCULT BLOD SCREEN - X 3                      329.80      82270                82270           3
  306   LAB BACTERIOLOGY/MICROBIO           50.4504          87005   BLOOD CULTURE ONE BOTTLE                      470.25   87040ZS                 87040           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504          87040   CULTURE BLOOD AER-ANAER                       823.75   87040ZS                 87040           2
  306   LAB BACTERIOLOGY/MICROBIO           50.4504          87042   CLOSTRIDIA DIFFICLE TOXIN                     695.75   87230ZS                 87230           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                80 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL     CPT-4     HCPCS      RVU
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87055   CULTURE DEFIN-STOOL                            470.25   87045ZS                87045           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87070   CULTURE-OTHER SOURCE                           470.25   87070ZS                87070           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87072   CSF CULTURE                                    470.25   87070ZS                87070           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87075   CUL ANAEROBIC ANYSOU                           543.50   87075ZS                87075           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87081   BETA STREP SCREEN                              110.00   87081ZS                87081           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87082   CULTURE NEISSERIA ONLY                         256.35   87081ZS                87081           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87083   GC & GROUP B STREP SCREEN                      110.00   87083ZS                87083           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87086   URINE CULTURE & IDEN                           415.00   87086ZS                87086           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87088   IDENTIFICATION, URINE                          122.20                                          1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87102   CULTURE FUNGUS OTHER SOURCE                    360.35   87102ZS                87102           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87106   CULTURE,FUNGUS:IDENT                           360.35   87106ZS                87106           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87117   CULTURE AFB/CONC/ISO                           427.20   87015ZS                87015           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87147   SEROLOGICAL TYPING                             201.60   87147ZS                87147           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87162   YERSINIA CULTURE                               262.50   87081ZS                87081           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87164   VIBRIO CULTURE                                 262.50   87081ZS                87081           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87177   OVA & PARASITES                                677.35   87177ZS                87177           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87184   ANTIOBIOTIC SENSITIVI                          470.25   87184ZS                87184           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87185   MIC SENSITIVITY, URINE                         390.65   87186ZS                87186           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87186   SENSITIVITY-MIC                                506.60   87186ZS                87186           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87205   SMEAR-GRAM STAIN                               140.60   87205ZS                87205           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87206   SMEAR-ACID FASTSTAIN                           256.35   87206ZS                87206           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87207   GIEMSA STAIN                                   225.90   87207ZS                87207           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87210   FUNGUS WET MT/INDINK                           122.20   87210ZS                87210           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87211   OVA&PARA-WET/PIN/TAP                           225.90   87172ZS                87172           1
  310   LAB PATHOLOGY GENERAL               50.4504       87312   TRICHROME/FE HEMO                              250.40   88312TC                88313           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       87991   BLOOD CULTURE W ARD 2 BOTTLES                1,012.75   87040ZS                87040           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4504       89001   LAB HANDLING CHARGE                            152.80                          99001
  309   LAB OTHER                           50.4504       89125   FECAL FAT                                      207.85   89125ZS                89125           1
  309   LAB OTHER                           50.4504       89160   FECAL FIBER                                    122.20   89160ZS                89160           1
  301   LABORATORY CHEMISTRY                50.4504       89205   STOOL & OCCULT BLOOD                           110.00   82270ZS                82270           1
  301   LABORATORY CHEMISTRY                50.4506       80005   LIVER 5 PANEL                                   92.40   80005ZS                80005           1
  301   LABORATORY CHEMISTRY                50.4506       80021   CHEST PAIN ER                                  734.40   80016ZS                80016           1
  301   LABORATORY CHEMISTRY                50.4506       80049   BASIC METABOLIC PANEL                           53.50   80048ZS                80048           1
  301   LABORATORY CHEMISTRY                50.4506       80054   COMPREHENSIVE METABOLIC PANEL                  192.10   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       80058   HEPATIC FUNCTION PANEL                          26.00   80076ZS                80076           1
  301   LABORATORY CHEMISTRY                50.4506       80059   HEPATIIS PANEL ACUTE                           139.50   80074ZS                80074
  301   LABORATORY CHEMISTRY                50.4506       80104   LIVER PANEL                                    653.30   80076ZS                80076           1
  301   LABORATORY CHEMISTRY                50.4506       80112   KIDNEY PANEL                                   585.60   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       80113   TPN PANEL                                      506.60   80048ZS                80048           1
  301   LABORATORY CHEMISTRY                50.4506       80115   CARDIAC RISK PROFILE                            74.80   80061ZS                80061
  301   LABORATORY CHEMISTRY                50.4506       80118   GEN CHEM PANEL                                 817.70   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       80119   INDUST HLTH-CBC,CHEM PANEL,UA                  232.00   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       80120   ELECTRLYTES 82439,82374,84132,                 841.90   80051ZS                80051           1
  301   LABORATORY CHEMISTRY                50.4506       80121   CARDIAC PANEL 84450,82550                      640.80   80002ZS                80002           1
  301   LABORATORY CHEMISTRY                50.4506       80122   INDUST HLTH-CBC,CHEM PANEL                     177.05   80119ZS                80119           1
  301   LABORATORY CHEMISTRY                50.4506       80125   ARTHRITIS PANEL                                653.30   86430ZS                86430           1
  301   LABORATORY CHEMISTRY                50.4506       80126   CMH V 48 TEST PANEL                            640.80   80019ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       80143   CMH VI PANEL                                   466.05   80053ZS                80053           4
  301   LABORATORY CHEMISTRY                50.4506       80178   LITHIUM                                        219.75   80178ZS                80178           1
  301   LABORATORY CHEMISTRY                50.4506       81207   CMH - 4                                        866.85   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       81209   CMHIII 39TESTS                                 744.80   80053ZS                80053           1
  301   LABORATORY CHEMISTRY                50.4506       81215   CMH II 25 TEST PANEL                           341.55   80053ZS                80053           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              81 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4506       81219   CMH I 22 TEST PANEL                            293.20   80053ZS                 80053           1
  301   LABORATORY CHEMISTRY                50.4506       81225   LIVER PANEL 13TESTS                          1,238.65   80116ZS                 80116           1
  301   LABORATORY CHEMISTRY                50.4506       81228   LIVER PANEL 9TESTS                           1,104.35   80112ZS                 80112           1
  301   LABORATORY CHEMISTRY                50.4506       81253   GLUCOSE TOL 6 HR                             1,153.75   80112ZS                 80112           1
  301   LABORATORY CHEMISTRY                50.4506       81254   GLUCOSE TOL 5 HR                             1,006.95   82952ZS                 82952           1
  301   LABORATORY CHEMISTRY                50.4506       81255   GLUCOSE TOL 4 HR                               860.15   80105ZS                 80105           1
  301   LABORATORY CHEMISTRY                50.4506       81256   GLUCOSE TOL 3 HR                               720.35   82951ZS                 82951           1
  301   LABORATORY CHEMISTRY                50.4506       81323   CARDIAC RISK PANEL                             720.35   80061ZS                 80061           1
  301   LABORATORY CHEMISTRY                50.4506       81359   DERM I PANEL                                   257.20   81359ZS                 81359           4
  301   LABORATORY CHEMISTRY                50.4506       81360   DERM 2 WITH HCG                                381.50   81360ZS                 81360           5
  309   LAB OTHER                           50.4506       81361   INDUSTRIAL BODY FLUID EXPOSURE                 616.90   89060ZS                 89060           5
  301   LABORATORY CHEMISTRY                50.4506       81362   INDUSTRIAL HEALTH EXPOSURE SOU                 498.65   81362ZS                 81362           4
  301   LABORATORY CHEMISTRY                50.4506       82004   ACETAMINOPHEN                                  543.50   82003ZS                 82003           1
  301   LABORATORY CHEMISTRY                50.4506       82010   ACETONE SERUM                                  183.25   82010ZS                 82010           1
  301   LABORATORY CHEMISTRY                50.4506       82011   SALICYLATE                                     250.40   80196ZS                 80196           1
  301   LABORATORY CHEMISTRY                50.4506       82040   ALBUMIN                                        183.25   82040ZS                 82040           1
  301   LABORATORY CHEMISTRY                50.4506       82055   ETOH                                           335.90   82055ZS                 82055           1
  301   LABORATORY CHEMISTRY                50.4506       82140   AMMONIA                                        390.65   82140ZS                 82140           1
  301   LABORATORY CHEMISTRY                50.4506       82150   AMYLASE SERUM                                  299.25   82150ZS                 82150           1
  301   LABORATORY CHEMISTRY                50.4506       82206   PHENOBARBITAL QUAN                             366.30   82205ZS                 82205           1
  301   LABORATORY CHEMISTRY                50.4506       82207   CARBAMAZEPINE QUAN                             512.80   80156ZS                 80156           1
  301   LABORATORY CHEMISTRY                50.4506       82208   PRIMIDONE QUAN                                 451.80   80188ZS                 80188           1
  301   LABORATORY CHEMISTRY                50.4506       82250   BILIRUBIN TOTAL                                195.20   82247ZS                 82247           1
  301   LABORATORY CHEMISTRY                50.4506       82255   BILIRUBIN DIRECT                               195.20   82248ZS                 82248           1
  301   LABORATORY CHEMISTRY                50.4506       82258   BILIRUBIN TOTAL,DIRECT,INDIREC                 378.60   82247ZS                 82247           1
  301   LABORATORY CHEMISTRY                50.4506       82310   CALCIUM                                        268.65   82310ZS                 82310           1
  301   LABORATORY CHEMISTRY                50.4506       82311   IONIZED CALCIUM                                835.95   82330ZS                 82330           1
  301   LABORATORY CHEMISTRY                50.4506       82340   CALCIUM URINE 24HR                             250.40   82340ZS                 82340           1
  301   LABORATORY CHEMISTRY                50.4506       82374   CO2/BICARBONATE                                274.65   82374ZS                 82374           1
  301   LABORATORY CHEMISTRY                50.4506       82390   CERULOPLASMIN                                   27.25   82390ZS                 82390           1
  301   LABORATORY CHEMISTRY                50.4506       82439   CHLORIDE BLD                                   274.65   82435ZS                 82435           1
  301   LABORATORY CHEMISTRY                50.4506       82465   CHOLESTEROL TOTAL                              207.85   82465ZS                 82465           1
  301   LABORATORY CHEMISTRY                50.4506       82533   CORTISOL TOTAL SERUM                           512.80   82533ZS                 82533           1
  301   LABORATORY CHEMISTRY                50.4506       82550   CPK                                            304.95   82550ZS                 82550           1
  301   LABORATORY CHEMISTRY                50.4506       82552   CPK ISOENZYMES                                 616.60   82552ZS                 82552           1
  301   LABORATORY CHEMISTRY                50.4506       82553   CK MB                                          757.05   82553ZS                 82553           1
  301   LABORATORY CHEMISTRY                50.4506       82565   CREATININE SER/UA                              330.00   82565ZS                 82565           1
  301   LABORATORY CHEMISTRY                50.4506       82575   CREATININE CLR 24 HR                           366.30   82575ZS                 82575           1
  301   LABORATORY CHEMISTRY                50.4506       82643   DIGOXIN ANY SOURCE                             396.60   80162ZS                 80162           1
  301   LABORATORY CHEMISTRY                50.4506       82655   DILANTIN                                       366.30   80185ZS                 80185           1
  301   LABORATORY CHEMISTRY                50.4506       82670   ESTRADIOL                                      494.25   82670ZS                 82670           1
  301   LABORATORY CHEMISTRY                50.4506       82731   FETAL FIBRONECTIN                              370.50      82731                82731           1
  301   LABORATORY CHEMISTRY                50.4506       82774   SEMEN FRUCTOSE                                 494.25   82757ZS                 82757           1
  301   LABORATORY CHEMISTRY                50.4506       82785   IMMUNO-GLOB IG D/E                             268.65   82785ZS                 82785           1
  301   LABORATORY CHEMISTRY                50.4506       82800   PH ARTERIAL/VENOUS                             225.90   82800ZS                 82800           1
  300   LABORATORY GENERAL                  50.4506       82801   PC02                                           250.40   82803ZS                 82803           1
  300   LABORATORY GENERAL                  50.4506       82803   PO2 PCO2 PH ART BLD                            580.10   82803ZS                 82803           1
  300   LABORATORY GENERAL                  50.4506       82804   PO2                                            250.40   82803ZS                 82803           1
  301   LABORATORY CHEMISTRY                50.4506       82947   GLUCOSE FBS/2HRP/CSF                           262.50   82947ZS                 82947           1
  301   LABORATORY CHEMISTRY                50.4506       82951   GLUCOSE TOL 2 HR                               567.40   82951ZS                 82951           1
  301   LABORATORY CHEMISTRY                50.4506       82952   GLUCOSE TOL EA ADDHR                           146.60   82952ZS                 82952           1
  301   LABORATORY CHEMISTRY                50.4506       82954   URINE QUAN 12-24 HR                            304.95   82945ZS                 82945           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               82 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE       MCAL      CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4506       82980   GGT                                           335.90   82977ZS                 82977           1
  301   LABORATORY CHEMISTRY                50.4506       82996   HCG BETA-SUBUNIT QUANTITATIVE                 360.35   84702ZS                 84702           1
  301   LABORATORY CHEMISTRY                50.4506       82997   HCG QUANT B SUB                               585.60   84702ZS                 84702           1
  301   LABORATORY CHEMISTRY                50.4506       83001   FSH-FOLLICLE STIMULATING HORMO                253.30   83001ZS                 83001           1
  301   LABORATORY CHEMISTRY                50.4506       83002   LUTINIZING HORMONE                            494.25   83002ZS                 83002           1
  301   LABORATORY CHEMISTRY                50.4506       83010   HAPTOGLOBIN BLOOD                             409.00   83010ZS                 83010           1
  301   LABORATORY CHEMISTRY                50.4506       83020   HEMOGLOBIN ELECTROPH                          512.80   83020ZS                 83020           1
  301   LABORATORY CHEMISTRY                50.4506       83037   GLYCATED HEMOGLOBIN                           274.65   83036ZS                 83036           1
  301   LABORATORY CHEMISTRY                50.4506       83125   FITNESS LAB PANEL WITH UA                     268.65   80119ZS                 80119           1
  301   LABORATORY CHEMISTRY                50.4506       83537   T4                                            183.25   84436ZS                 84436           1
  301   LABORATORY CHEMISTRY                50.4506       83540   IRON                                          225.90   83540ZS                 83540           1
  301   LABORATORY CHEMISTRY                50.4506       83550   IRON BINDING CAPACITY                         451.80   83550ZS                 83550           1
  301   LABORATORY CHEMISTRY                50.4506       83605   LACTATE BLOOD                                 304.95   83605ZS                 83605           1
  301   LABORATORY CHEMISTRY                50.4506       83615   LDH                                           304.95   83615ZS                 83615           1
  301   LABORATORY CHEMISTRY                50.4506       83625   LDH ISOENZYMES                                360.35   83625ZS                 83625           1
  301   LABORATORY CHEMISTRY                50.4506       83626   LDH ISOENZYME INCLUDES TOTAL L                671.45   83625ZS                 83625           1
  301   LABORATORY CHEMISTRY                50.4506       83690   LIPASE                                        286.85   83690ZS                 83690           1
  301   LABORATORY CHEMISTRY                50.4506       83715   LIPID PENOTYPE                                720.35   83715ZS                 83715           1
  301   LABORATORY CHEMISTRY                50.4506       83717   HDL                                           207.85   83718ZS                 83718           1
  301   LABORATORY CHEMISTRY                50.4506       83735   MAGNESIUM                                     207.85   83735ZS                 83735           1
  301   LABORATORY CHEMISTRY                50.4506       83875   MYOGLOBIN                                     543.50   83874ZS                 83874           1
  301   LABORATORY CHEMISTRY                50.4506       83930   OSMOLALITY BLD/UA                             304.95   83930ZS                 83930           1
  301   LABORATORY CHEMISTRY                50.4506       84000   PHENOPTHALINE                                 366.30   84311ZS                 84311           1
  301   LABORATORY CHEMISTRY                50.4506       84022   PHENOTHIAZINE QUANT                           152.80   84022ZS                 84022           1
  301   LABORATORY CHEMISTRY                50.4506       84060   PHOSPHATASE ACID                              250.40   84060ZS                 84060           1
  301   LABORATORY CHEMISTRY                50.4506       84075   PHOSPHATASE ALKALINE                          250.40   84075ZS                 84075           1
  301   LABORATORY CHEMISTRY                50.4506       84080   ALKALINE PHOS ISO                             512.80   84080ZS                 84080           1
  301   LABORATORY CHEMISTRY                50.4506       84081   ALK PHOS ISO INCLUDES TOTAL AL                757.05   84080ZS                 84080           1
  301   LABORATORY CHEMISTRY                50.4506       84100   PHOSPHOROUS SERUM/UA                          207.85   84100ZS                 84100           1
  301   LABORATORY CHEMISTRY                50.4506       84109   PORPHOBIL/PORPHY SCN                          207.85   84106ZS                 84106           1
  301   LABORATORY CHEMISTRY                50.4506       84132   POTASSIUM BLD                                 238.10   84132ZS                 84132           1
  301   LABORATORY CHEMISTRY                50.4506       84133   POTASSIUM 24HR URINE                          202.55      84133                84133           1
  301   LABORATORY CHEMISTRY                50.4506       84134   PREALBUMIN                                     50.75   84134ZS                 84134           1
  301   LABORATORY CHEMISTRY                50.4506       84142   PROCAINAMIDE                                  543.50   80192ZS                 80192           1
  301   LABORATORY CHEMISTRY                50.4506       84146   PROLACTIN                                     253.30   84146ZS                 84146           1
  301   LABORATORY CHEMISTRY                50.4506       84153   PROSTATIC SPECIFIC ANTIGEN                    311.45   84153ZS                 84153           1
  301   LABORATORY CHEMISTRY                50.4506       84154   PROSTATE SPECIFIC AG - FREE                    96.95   84154ZS                 84154
  301   LABORATORY CHEMISTRY                50.4506       84155   TOTAL PROTEIN SERUM                           183.25   84155ZS                 84155           1
  301   LABORATORY CHEMISTRY                50.4506       84156   URINE IMMUNO ELECT                             45.25   84156TC       84156     84156           1
  301   LABORATORY CHEMISTRY                50.4506       84160   PROTEIN ELECT-SERUM                            13.30   84160TC       84160     84160           1
  301   LABORATORY CHEMISTRY                50.4506       84165   PROTEIN ELECTROPHRO                           409.00   84165ZS                 84165           1
  301   LABORATORY CHEMISTRY                50.4506       84166   PROTEIN ELECTRO INCLUDES TOTAL                591.95   84166ZS                 84166           1
  301   LABORATORY CHEMISTRY                50.4506       84175   PROT UA/24HR/JTFL QU                          250.40   84155ZS                 84155           1
  301   LABORATORY CHEMISTRY                50.4506       84190   CSF ELECTROPHORESIS                           512.80   84165ZS                 84165           1
  301   LABORATORY CHEMISTRY                50.4506       84191   URINE ELECTROPHORESIS                         512.80   84165ZS                 84165           1
  301   LABORATORY CHEMISTRY                50.4506       84195   PROTEIN SPINAL FLUID                          268.65   84155ZS                 84155           1
  301   LABORATORY CHEMISTRY                50.4506       84225   VACOMYCIN                                     543.50   80202ZS                 80202           1
  301   LABORATORY CHEMISTRY                50.4506       84226   METHOTREXATE                                  677.35   80299ZS                 80299           1
  301   LABORATORY CHEMISTRY                50.4506       84227   AMIKACIN                                      543.50   80150ZS                 80150           1
  301   LABORATORY CHEMISTRY                50.4506       84228   GENTAMYCIN                                    543.50   80170ZS                 80170           1
  301   LABORATORY CHEMISTRY                50.4506       84229   TOBRAMYCIN                                    543.50   80200ZS                 80200           1
  301   LABORATORY CHEMISTRY                50.4506       84230   QUINIDINE                                     543.50   80194ZS                 80194           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              83 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                    CHARGE       MCAL      CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4506          84231   FERRITIN                                      512.80   82728ZS                 82728           1
  301   LABORATORY CHEMISTRY                50.4506          84250   T 3 % UPTAKE                                  183.25   84479zs                 84479           1
  301   LABORATORY CHEMISTRY                50.4506          84251   THY SCRN 84435/84436                          366.30   84436ZS                 84436           1
  301   LABORATORY CHEMISTRY                50.4506          84295   SODIUM SERUM                                  268.65   84295ZS                 84295           1
  301   LABORATORY CHEMISTRY                50.4506          84420   THEOPHYLLINE                                  421.45   80198ZS                 80198           1
  301   LABORATORY CHEMISTRY                50.4506          84426   VALPROIC ACID                                 543.50   80164ZS                 80164           1
  301   LABORATORY CHEMISTRY                50.4506          84439   FREE THYROXINE                                253.30   84439ZS                 84439           1
  301   LABORATORY CHEMISTRY                50.4506          84443   TSH THYROID STIMULATING HORMO                 543.50   84443QW                 84443           1
  301   LABORATORY CHEMISTRY                50.4506          84450   SGOT                                          286.85   84450QW                 84450           1
  301   LABORATORY CHEMISTRY                50.4506          84460   SGPT                                          330.00   84460ZS                 84460           1
  301   LABORATORY CHEMISTRY                50.4506          84475   TRIGLYCERIDES                                 250.40   84478ZS                 84478           1
  301   LABORATORY CHEMISTRY                50.4506          84484   TROPONIN-I                                    757.05   84484ZS                 84484           1
  301   LABORATORY CHEMISTRY                50.4506          84520   UREA NITROGEN                                 256.35   84520ZS                 84520           1
  301   LABORATORY CHEMISTRY                50.4506          84550   URIC ACID                                     207.85   84550ZS                 84550           1
  301   LABORATORY CHEMISTRY                50.4506          84580   UROBILINOGEN QUANT                            225.90   84580ZS                 84580           1
  301   LABORATORY CHEMISTRY                50.4506          84625   LIDOCAINE                                     543.50   80176ZS                 80176           1
  301   LABORATORY CHEMISTRY                50.4506          84703   HCG QUALITATIVE                               144.35   84703ZS                 84703           1
  301   LABORATORY CHEMISTRY                50.4506          84997   UNSUAL SERV STAT                              207.85   84999ZS                 84999           1
  301   LABORATORY CHEMISTRY                50.4506          86151   CEA                                           653.30   82378ZS                 82378           1
  302   LABORATORY IMMUNOLOGY               50.4506          86170   HIV ANTIBODY                                  152.80   86701ZS                 86701           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4506          86287   HBS AG                                        335.90   87340ZS                 87340           1
  302   LABORATORY IMMUNOLOGY               50.4506          86291   HEPATITIS B SURFACE AB                        274.65   86706ZS                 86706           1
  302   LABORATORY IMMUNOLOGY               50.4506          86320   IMMUNOELECTROPHORSIS                          512.80   86320ZS                 86320           1
  302   LABORATORY IMMUNOLOGY               50.4506          86329   IMMUNO/GAMC3                                  265.40   86329ZS                 86329           1
  301   LABORATORY CHEMISTRY                50.4506          86334   IMMUNOFIX ELECTROPH                            19.15   86334TC       86334     86334           1
  302   LABORATORY IMMUNOLOGY               50.4506          86650   FTA ABSORBED                                  268.65   86650ZS                 86781           1
  301   LABORATORY CHEMISTRY                50.4506          87225   VANCOMYCIN                                    543.50   80202ZS                 80202           1
  301   LABORATORY CHEMISTRY                50.4506          89009   LAB HANDLING CHARGE                            66.45                           99001
  301   LABORATORY CHEMISTRY                50.4506          89015   LAB HANDLING -MAYO                             18.40                           99009
  309   LAB OTHER                           50.4506          89130   DUODENAL CONTENTS PH                          101.25   89130ZS                 89130           1
  309   LAB OTHER                           50.4506          89135   GASTRIC ANALYSIS                               95.65   89135ZS                 89135           1
  309   LAB OTHER                           50.4506          89140   GASTRIC HISTALOG                              355.60   89140ZS                 89140           1
  301   LABORATORY CHEMISTRY                50.4506    80100A        DRUG ANALYSIS SERUM BY ARUP                    26.30      80100                80100           1
  301   LABORATORY CHEMISTRY                50.4506    80100B        DRUG ANALYSIS SERUM BY ARUP                    26.30      80100                80100           1
  301   LABORATORY CHEMISTRY                50.4506    80100C        DRUG ANALYSIS SERUM BY ARUP                    26.30   80100ZS                 80100           1
  301   LABORATORY CHEMISTRY                50.4506    80100D        DRUG ANALYSIS SERUM BY ARUP                    26.30   80100ZS                 80100           1
  301   LABORATORY CHEMISTRY                50.4506    80120ER       ELECTRLYTES                                    76.90   80051ZS                 80051           1
  301   LABORATORY CHEMISTRY                50.4506    82150ER       AMYLASE BLOOD                                  76.90   82150ZS                 82150
  301   LABORATORY CHEMISTRY                50.4506    82250ER       TOTAL BILIRUBIN                                30.80   82247ZS                 82247
  301   LABORATORY CHEMISTRY                50.4506    82310ER       CALCIUM                                        30.80   82310ZS                 82310
  301   LABORATORY CHEMISTRY                50.4506    82465ER       CHOLESTEROL TOTAL                              30.80   82465ZS                 82465
  301   LABORATORY CHEMISTRY                50.4506    82550ER       CPK                                            30.80   82550ZS                 82550
  301   LABORATORY CHEMISTRY                50.4506    82553ER       CK MB                                          74.10   82553ZS                 82553
  301   LABORATORY CHEMISTRY                50.4506    82565ER       CREATININE SER/UA                              30.80   82565ZS                 82565
  301   LABORATORY CHEMISTRY                50.4506    83615ER       LDH                                            30.80   83615ZS                 83615
  301   LABORATORY CHEMISTRY                50.4506    83735ER       MAGNESIUM                                      87.70   83735ZS                 83735
  301   LABORATORY CHEMISTRY                50.4506    83874ER       MYOGLOBIN                                      82.85   83874ZS       83874     83874           1
  301   LABORATORY CHEMISTRY                50.4506    84075ER       ALK PHOS                                       30.80   84075ZS                 84075
  301   LABORATORY CHEMISTRY                50.4506    84155ER       PROTEIN TOTAL                                  30.80   84155ZS                 84155
  301   LABORATORY CHEMISTRY                50.4506    84450ER       SGOT                                           30.80   84450QW                 84450
  301   LABORATORY CHEMISTRY                50.4506    84460ER       SGPT                                           30.80   84460ZS                 84460
  301   LABORATORY CHEMISTRY                50.4506    84484ER       TROPONIN-1                                     63.20   84484ZS                 84484

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                84 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                      CHARGE
 CHG         CATEGORY AND NAME               DPT       CODE                    DESCRIPTION                    CHARGE        MCAL      CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4506 84520ER       UREA NITROGEN                                   30.80   84520ZS                 84520
  302   LABORATORY IMMUNOLOGY               50.4508       86000   FEBRILE AGGLUTINA EA                           110.00   86000ZS                 86000           1
  302   LABORATORY IMMUNOLOGY               50.4508       86002   FEBRILE AGGLUT PANEL                           512.80   86000ZS                 86000           1
  302   LABORATORY IMMUNOLOGY               50.4508       86006   C REACTIVE PROTEIN SCREEN                      207.85   86140ZS                 86140           1
  302   LABORATORY IMMUNOLOGY               50.4508       86007   DIRECT GROUP A BETA STREP AG S                 286.85   87430ZS                 87430           1
  302   LABORATORY IMMUNOLOGY               50.4508       86009   RHEUMATOID FACTOR TITER                        262.50   86430ZS                 86430           1
  302   LABORATORY IMMUNOLOGY               50.4508       86060   ASO TITER QUANT                                225.90   86060ZS                 86060           1
  302   LABORATORY IMMUNOLOGY               50.4508       86061   ASO SCREEN                                     152.80   86063ZS                 86063           1
  302   LABORATORY IMMUNOLOGY               50.4508       86255   ANA FLOURESCENT                                390.65   86256ZS                 86255           1
  302   LABORATORY IMMUNOLOGY               50.4508       86256   ANA SCREEN                                     195.20   86038ZS                 86038           1
  302   LABORATORY IMMUNOLOGY               50.4508       86280   RUBELLA SCREEN                                 219.75   86762ZS                 86762           1
  302   LABORATORY IMMUNOLOGY               50.4508       86308   HETEROPHILE ANTIBODIES;SCREEN                  207.85      86308                86308           1
  302   LABORATORY IMMUNOLOGY               50.4508       86430   RHEUMATOID FACTOR;QUAL                         207.85      86430                86430           1
  302   LABORATORY IMMUNOLOGY               50.4508       86490   COCCIDIOIDOMYCOSIS                             207.85   86490ZS                 86490           1
  302   LABORATORY IMMUNOLOGY               50.4508       86510   HISTOPLASMOSIS                                 207.85   86510ZS                 86510           1
  302   LABORATORY IMMUNOLOGY               50.4508       86540   MUMPS VIRAL ANTIBODY                           207.85   86735ZS                 86735           1
  302   LABORATORY IMMUNOLOGY               50.4508       86592   RPR SCREEN                                     219.75   86592ZS                 86592           1
  302   LABORATORY IMMUNOLOGY               50.4508       86756   RESPIRATORY SYNCYTIAL VIRUS SC                 207.85   86756ZS                 86756           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4508       87804   INFLUENZA AG A&B DIRECT                        215.25   87804ZS                 87804           1
  302   LABORATORY IMMUNOLOGY               50.4508       89008   LAB HANDLING CHARGE                            152.80                           99001
  307   LAB UROLOGY                         50.4510       81000   URIN ROUTINE                                   315.75   81001ZS                 81001           1
  307   LAB UROLOGY                         50.4510       81005   URINALYSIS CHEMICAL STRIP ONLY                 133.85   81003ZS                 81003           1
  307   LAB UROLOGY                         50.4510       81015   MICROSCOPIC URINE                               98.60   81015ZS                 81015           1
  307   LAB UROLOGY                         50.4510       81016   INDUST HLTH-UA                                  98.60   81016ZS                 81016           1
  301   LABORATORY CHEMISTRY                50.4510       82009   ACETONE URINE                                   67.00   81005ZS                 81005           1
  301   LABORATORY CHEMISTRY                50.4510       82370   CALCULUS STONE ANAL                            304.95   82370ZS                 82370           1
  301   LABORATORY CHEMISTRY                50.4510       82998   PREG TEST QUAL IMMUN                           268.65   84703ZS                 84703           1
  301   LABORATORY CHEMISTRY                50.4510       83070   HEMOSIDERIN                                    183.25   83070ZS                 83070           1
  307   LAB UROLOGY                         50.4510       84185   PROTEIN BENCE JONES                            175.70   84185ZS                 84185           1
  307   LAB UROLOGY                         50.4510       84315   SPECIFIC GRAVITY OLY                            56.25   81002ZS                 81002           1
  301   LABORATORY CHEMISTRY                50.4510       84581   UROBILINOGEN SCREEN                             67.00   84583ZS                 84583           1
  307   LAB UROLOGY                         50.4510       89003   LAB HANDLING CHARGE                            175.70                           99001
  305   LAB HEMATOLOGY                      50.4512       85002   BLEEDING TIME IVY                              304.95   85002ZS                 85002           1
  305   LAB HEMATOLOGY                      50.4512       85165   PETECHIOMETER                                  134.65   85999ZS                 85999           1
  305   LAB HEMATOLOGY                      50.4512       85170   CLOT RETRACTION                                158.85   85170ZS                 85170           1
  305   LAB HEMATOLOGY                      50.4512       85240   FACTOR VIII ASSAY                              616.60      85240                85240           1
  305   LAB HEMATOLOGY                      50.4512       85345   COAG (LEE WHITE)                               183.25   85345ZS                 85345           1
  305   LAB HEMATOLOGY                      50.4512       85360   EUGLOBULIN LYSIS                               304.95   85360ZS                 85360           1
  305   LAB HEMATOLOGY                      50.4512       85364   FDP                                            207.85   85370ZS                 85370           1
  305   LAB HEMATOLOGY                      50.4512       85368   PROTAMINE SULFATE                              304.95   85366ZS                 85366           1
  305   LAB HEMATOLOGY                      50.4512       85376   FIBRINOGEN                                     304.95   85384ZS                 85384           1
  305   LAB HEMATOLOGY                      50.4512       85610   PROTHROMBIN TIME                               225.90   85610ZS                 85610           1
  305   LAB HEMATOLOGY                      50.4512       85670   THROMBIN TIME                                  207.85   85670ZS                 85670           1
  305   LAB HEMATOLOGY                      50.4512       85700   PROTHROMBIN GEN                                616.60   85999ZS                 85999           1
  305   LAB HEMATOLOGY                      50.4512       85730   P.T.T.                                         353.90   85730ZS                 85730           1
  305   LAB HEMATOLOGY                      50.4512       85995   DIC PANEL 80112                              1,446.25   85999ZS                 85999           1
  305   LAB HEMATOLOGY                      50.4512       85996   COAG PNL 85610/85730                           726.50                           85999           1
  305   LAB HEMATOLOGY                      50.4512       89004   LAB HANDLING CHARGE                            152.80                           99001
  301   LABORATORY CHEMISTRY                50.4514       87995   GALACTOSE                                       76.90   82760ZS                 82760           1
  301   LABORATORY CHEMISTRY                50.4514       87996   REPEAT T4                                       54.50   84436ZS                 84436           1
  301   LABORATORY CHEMISTRY                50.4514       87997   REPEAT PKU                                      58.75   84030ZS                 84030           1
  306   LAB BACTERIOLOGY/MICROBIO           50.4514       87998   NEONATAL SCREEN                                 91.50   87999ZS                 87999           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               85 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                    CHARGE       MCAL       CPT-4     HCPCS      RVU
  301   LABORATORY CHEMISTRY                50.4514          89007   LAB HANDLING CHARGE NBS                         11.75                           99001
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81104   CYP NON-OBGYN FLUIDS-HOSP                      128.25   88104TC                 88104           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81106   CYP FILTER METHOD INTRP-HOSP                   128.25   88106TC                 88106           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81107   CYP SMEARS FLTR INTRP-HOSP                     134.65   88107TC                 88107           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81108   CYP CONCENT SMEAR INT-HOSP                     134.65   88112TC                 88112           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81142   THIN PREP CYTOPATHOLOGY CERV/V                  80.10      88142                88142           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81150   SMEARS PAP-HOSP                                 42.90   88150TC                 88150           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81151   BETHESDA PAP 1 SLIDE MD                         36.60   88164ZS                 88164           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81155   CERVAG HORMNAL INTERP-HOSP                      79.50   88155TC                 88155           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81156   PAP SMEAR (VAG/CX) 1 SLIDE                      36.60   88164TC                 88164           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81157   BETHESDA PAP EXTENDED 2 SLIDES                  61.15                           88150           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81160   CYP OTHER SCRG INTERP-HOSP                     140.60   88160TC                 88160           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81161   CYP OTHER PREP SCRG INT-HOSP                   146.60   88161TC                 88161           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81162   CYP OVER 5 SLIDES STUDY-HOSP                   207.85   88162TC                 88162           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81170   FNA SUPERFICIAL TISSUE-HOSP                    274.65   88170TC                 88170           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81171   FNA DEEP IMAGE GUIDED-HOSP                     274.65   88171TC                 88171           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81172   FNA IMMEDT PRELIM EVAL-HOSP                    152.80   88172TC                 88172           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          81173   FNA INTERP & REPORT-HOSP                       323.60   88173TC                 88173           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          86064   B CELLS TOTAL                                  125.25   86064ZS    86064        86064           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          86379   NK CELLS                                       125.25   86379ZS    86379        86379
  311   LAB PATHOLOGY CYTOLOGY              50.4516          86587   CD 34 TOTAL                                    125.25   86587ZS    86587        86587           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          88143   PAP TLP SCREEN                                  36.60   88142ZS G0123           88142           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516          89006   LAB HANDLING CHARGE                            152.80                           99001
  311   LAB PATHOLOGY CYTOLOGY              50.4516    A1104         CYP BRONCH BRUSHINGS-HOSP                      134.65   88104TC                 88104           1
  309   LAB OTHER                           50.4516    A9060         CRYSTAL ID ANY FLUID (EX URINE                 122.20   89060ZS                 89060           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516    B1104         CYP BRONCH WASHINGS-HOSP                       134.65   88104TC                 88104           1
  311   LAB PATHOLOGY CYTOLOGY              50.4516    C1104         CYP FLD PREP INTERPT-HOSP                      140.60   88104TC                 88104           1
  310   LAB PATHOLOGY GENERAL               50.4520          81020   NECROPSY GROSS MICRO-HOSP                    1,995.50   88020TC                 88020           1
  310   LAB PATHOLOGY GENERAL               50.4520          81025   NECROPSY GROSS MICRO BRN-HOSP                2,269.60   88025TC                 88025           1
  310   LAB PATHOLOGY GENERAL               50.4520          81029   NECROPSY STILLBORN NEWBORN-HOS               1,519.60   88029TC                 88029           1
  310   LAB PATHOLOGY GENERAL               50.4520          81036   NECRPOSY LIMITED-HOSP                        1,665.85   88036TC                 88036           1
  310   LAB PATHOLOGY GENERAL               50.4520          81037   NECROPSY SINGLE ORGAN-HOSP                   1,360.70   88037TC                 88037           1
  310   LAB PATHOLOGY GENERAL               50.4520          81060   BLOOD SMEAR MD INTERP-HOSP                      67.00   85060ZS                 85060           1
  310   LAB PATHOLOGY GENERAL               50.4520          81078   TRANSF RX INVESTIGATION-HOSP                   225.90   86078ZS                 86078           1
  361   OR SVCS MINOR SURGERY               50.4520          81095   BONE MARROW ASP ONLY-HOSP                      274.65   38220ZS                 38220           1
  310   LAB PATHOLOGY GENERAL               50.4520          81097   BONE MARROW SMEAR INT-HOSP                     323.60   85097ZS                 85097           1
  310   LAB PATHOLOGY GENERAL               50.4520          81100   BONE MARROW ASP & INT-HOSP                     378.60   85095ZS                 85095           1
  361   OR SVCS MINOR SURGERY               50.4520          81102   BONE MARROW NEEDLE BIOPSY-HOSP                 238.90   38221ZS                 38221           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81103   BONE MARROW STAIN & INT-HOSP                   366.30   88305TC                 88305           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81105   BONE MARROW BX INTER ONLY-HOSP                 390.65   88305TC                 88305           1
  311   LAB PATHOLOGY CYTOLOGY              50.4520          81109   MARROW BX STAIN & PREP-HOSP                    286.85   88104TC                 88104           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81300   SURG PATH GROSS EXAM - HOSP                     79.50   88300TC                 88300           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81302   SURGICAL PATHOLOGY LEVEL 11                    134.65   88302TC                 88302           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81304   DIAG EXAM SML UNCOMP - HOSP                    256.35   88304TC                 88304           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81305   SURGICAL PATHOLOGY LEVEL IV                    390.65   88305TC                 88305           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81307   SURGICAL PATHOLOGY LEVEL V                     506.60   88307TC                 88307           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81309   SURGICAL PATHOLOGY LEVEL VI                    720.35   88309TC                 88309           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81311   DECALCIFIC PROCEDURE-HOSP                       42.90   88311TC                 88311           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81312   SPEC STAIN I MICRORGN-HOSP                      55.35   88312TC                 88312           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81313   SPEC STAIN II OTHER-HOSP                        42.90   88313TC                 88313           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81314   IMMUNO STAIN AGM-HOS                           225.90   88342TC                 88342           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81321   CONSULT OUTSIDE SLIDES-HOSP                    225.90   88321TC                 88321           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                 86 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                     DESCRIPTION                   CHARGE        MCAL     CPT-4     HCPCS      RVU
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81325   CONSULT CMPRH REVIEW RCDS-HOSP                 360.35   88325TC                88325           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81329   CONSULT DURING SURGERY-HOSP                    183.25   88329TC                88329           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81331   CONSULT FROZEN SECTION-HOSP                    360.35   88331TC                88331           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81332   EA ADD FROZEN SECTION-HOSP                     207.85   88332TC                88332           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81342   IMMUNOSTAIN EA ANTIBODY-HOSP                   146.60   88342TC                88342           1
  312   LAB PATHOLOGY HISTOLOGY             50.4520          81346   IMMUNOFLUORESCENCE-HOSP                        183.25   88346TC                88346           1
  310   LAB PATHOLOGY GENERAL               50.4520          81500   CP CONSULT LIMITED-HOSP                        110.00   80500ZS                80500           1
  310   LAB PATHOLOGY GENERAL               50.4520          81502   CP CONSULT COMPREHEN-HOSP                      286.85   80502ZS                80502           1
  310   LAB PATHOLOGY GENERAL               50.4520          88365   HER 2 BY FISH METHOD BY ARUP                   475.20   88365TC                88365
  310   LAB PATHOLOGY GENERAL               50.4520          89011   LAB HANDLING CHARGE                            152.80   99001ZS                99001
  272   M/S SUPPLY STERILE SUPPLY           50.4520          89012   SURGICAL TRAY                                  196.45                                          1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    A1304         SURGICAL PATHOLOGY LEVEL 111                   256.35   88305TC               88305            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    A1312         SPEC STAIN I PAS FUNGUS-HOSP                    55.35   88312TC               88312            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    A1313         STAIN II GIEMSA HEME-HOSP                       49.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    A1323         CONSULT OUTSIDE SLIDES PREP RP                 323.60   88323TC               88323            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    A1342         IMMUNOSTAIN EA ANTIBODY 2-HOSP                 152.80   88342TC               88342            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    B1312         SPEC STAIN I AFB MYCO                           67.00   88312TC               88312            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    B1313         STAIN II IRON STORES-HOSP                       49.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    B1342         IMMUNOSTAIN EA ANTIBODY 3-HOSP                 152.80   88342TC               88342            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    C1312         STAIN I GIEMSA HELICO-HOSP                      67.00   88312TC               88312            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    C1313         STAIN II PAS MUCI BM RT-HOSP                    55.35   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    C1342         IMMUNOSTAIN EA ANTIBODY 4-HOSP                 158.85   88342TC               88342            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    D1312         STAIN I GMS FUNG PCP-HOSP                       67.00   88312TC               88312            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    D1313         STAIN II TRICHROME-HOSP                         55.35   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    E1312         SPEC STAIN I COMPLEX-HOSP                       73.55   88312TC               88312            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    E1313         STAIN II MUCICARMIN-HOSP                        67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    F1313         STAIN II OILREDO FAT-HOSP                       67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    G1313         STAIN II RETIC FIBER-HOSP                       67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    H1313         STAIN II DPAS GLYCGN-HOSP                       67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    J1313         STAIN II ELASTIC FIBERS-HOSP                    67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    K1313         STAIN II PTAH-HOSP                              67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    L1313         STAIN II VONKOS CALC-HOSP                       67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    M1313         STAIN II AMYLOID-HOSP                           67.00   88313TC               88313            1
  312   LAB PATHOLOGY HISTOLOGY             50.4520    N1313         SPEC STAIN II COMPLICATED-HOSP                  67.00   88313TC               88313            1
  971   PROF FEES LABORATORY                50.4530          88151   BETHESDA PAP 1 SLIDE MD27.51                    12.55   88141ZS             8814126
  381   BLOOD PACKED RED CELLS              50.4540          46010   BLD RED CELLS                                  351.65   P9021     P9021    P9021
  383   BLOOD PLASMA                        50.4540          46018   BLD PLSMA FROZEN                               125.35   P9017     P9017    P9017
  386   BLOOD OTHER COMPONENTS              50.4540          46032   BLD AUTOLOGOUS                                 479.95   P9021     P9021    P9021
  384   BLOOD PLATELETS                     50.4540          46060   PLATELETPHERESIS                               905.85   P9034     P9034    P9034
  390   BLOOD STOR/PROC GENERAL             50.4540          80000   PROCESS FEE FRESH FROZEN PLASM                  85.55                      P9017
  390   BLOOD STOR/PROC GENERAL             50.4540          80001   PROCESS FEE CRYOPRECIPITATED A                  77.25                      P9012
  390   BLOOD STOR/PROC GENERAL             50.4540          80002   PROCESS FEE PLATELETS UBS                      141.80                      P9031
  390   BLOOD STOR/PROC GENERAL             50.4540          80003   PROCESS FEE FROZEN RBCS UBS                  1,008.00
  390   BLOOD STOR/PROC GENERAL             50.4540          80009   PROCESS FEE PLATELETPHERESIS S                 653.40                      P9035
  636   DRUG SPEC ID DETAIL CODING          50.4540          80011   RH IMMUNE GLOBULIN                             286.85   J2790              J2790               1
  270   M/S SUPPLY GENERAL                  50.4540          80012   PLATELET WBC FILTER                            290.40                                          1
  270   M/S SUPPLY GENERAL                  50.4540          80013   RED CELL WBC FILTER                             89.25                                          1
  390   BLOOD STOR/PROC GENERAL             50.4540          80020   ANTIHEM FACTOR-HEAT TREATED PE                   5.35   86240ZS                86240           1
  390   BLOOD STOR/PROC GENERAL             50.4540          80040   PLASMA PROTEIN FRAC                            212.55             P9048                        1
  390   BLOOD STOR/PROC GENERAL             50.4540          80041   SER ALBUMIN-25%/50ML                           244.35   82040ZS            P9047               1
  390   BLOOD STOR/PROC GENERAL             50.4540          80042   BLOOD SPLIT UNIT                               211.75             P9011    P9011               1
  390   BLOOD STOR/PROC GENERAL             50.4540          80050   PROCESS FEE RED BLOOD CELLS UB                 268.50                      P9016

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                87 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE       MCAL      CPT-4    HCPCS       RVU
  390   BLOOD STOR/PROC GENERAL             50.4540       80051   RECIPIENT SPECIFIC-AUTOLOGOUS                  503.90                      P9016               1
  390   BLOOD STOR/PROC GENERAL             50.4540       80055   PROCESS FEE WASHED RBCS UBS                    392.05                      P9022
  390   BLOOD STOR/PROC GENERAL             50.4540       80060   PROCESS FEE WHOLE BLOOD UBS                    392.05                      P9010
  636   DRUG SPEC ID DETAIL CODING          50.4540       80080   KONYNE                                           1.05   J7194              J7194               1
  636   DRUG SPEC ID DETAIL CODING          50.4540       80090   MICRHOGAM                                      191.15   J2788              J2788               1
  305   LAB HEMATOLOGY                      50.4540       85460   SCREEN FOR FETAL HEMOGLOBIN                    225.90   85460ZS               85460            1
  302   LABORATORY IMMUNOLOGY               50.4540       86005   RH TITER SCREEN                                134.65   86886ZS               86886            1
  302   LABORATORY IMMUNOLOGY               50.4540       86008   RH TITER QUANTATIVE                            238.10   86886ZS               86886            1
  302   LABORATORY IMMUNOLOGY               50.4540       86012   COLD AGGLUTINS QUANT                           219.75   86157ZS               86157            1
  302   LABORATORY IMMUNOLOGY               50.4540       86013   ANTIBODY ABSORPTION                            195.20   86978ZS               86978            1
  302   LABORATORY IMMUNOLOGY               50.4540       86016   ANTIBODY SCREEN                                318.55   86850ZS               86850            1
  302   LABORATORY IMMUNOLOGY               50.4540       86017   ABO,RH,ANTIBODY SCREEN                         561.75   86850ZS               86850            1
  302   LABORATORY IMMUNOLOGY               50.4540       86018   ENZYME TECHNIQUE                               195.20   86971ZS               86971            1
  302   LABORATORY IMMUNOLOGY               50.4540       86019   ELUTION ANY METHOD                             274.65   86860ZS               86860            1
  302   LABORATORY IMMUNOLOGY               50.4540       86024   ANTIBODY QUANT PANEL                           396.60   86886ZS               86886            1
  302   LABORATORY IMMUNOLOGY               50.4540       86031   COOMBS TEST DIRECT                             152.80   86880ZS               86880            1
  302   LABORATORY IMMUNOLOGY               50.4540       86032   COOMBS TEST INDIRECT                           152.80   86885ZS               86885            1
  302   LABORATORY IMMUNOLOGY               50.4540       86069   BLOOD X-MATCH 1 UNIT                           402.95   86922ZS               86922            1
  302   LABORATORY IMMUNOLOGY               50.4540       86073   SCREEN FOR COMP UNIT                            79.50   86903ZS               86903            1
  302   LABORATORY IMMUNOLOGY               50.4540       86075   RHO IMMUN PNL XMATCH                           396.60   86886ZS               86886            1
  302   LABORATORY IMMUNOLOGY               50.4540       86076   MINOR X-MATCH EACH                             128.25   86880ZS               86880            1
  302   LABORATORY IMMUNOLOGY               50.4540       86080   BLOOD GROUPING A&B                             183.25   86900ZS               86900            1
  302   LABORATORY IMMUNOLOGY               50.4540       86082   ABO,RH TYPE                                    274.65   86900ZS               86900            1
  302   LABORATORY IMMUNOLOGY               50.4540       86095   RBC ANTIGENS/DU                                122.20   86905ZS               86905            1
  302   LABORATORY IMMUNOLOGY               50.4540       86096   RH SUBTYPES EACH                               140.60   86906ZS               86906            1
  302   LABORATORY IMMUNOLOGY               50.4540       86100   RH TYPING                                      183.25   86901ZS               86901            1
  302   LABORATORY IMMUNOLOGY               50.4540       86202   CRYOPPT THAW/POOL 10                           286.85   86965ZS               86965            1
  302   LABORATORY IMMUNOLOGY               50.4540       86385   PATERN TEST PER INDV                         2,361.35   86910ZS               86910            1
  302   LABORATORY IMMUNOLOGY               50.4540       86393   PLATELET POOL/10 UNT                           286.85   86965ZS               86965            1
  302   LABORATORY IMMUNOLOGY               50.4540       86985   ALIQUOTING BLOOD                               175.40   86985ZS               86985            1
  302   LABORATORY IMMUNOLOGY               50.4540       86998   FFP THAW                                        73.55   86927ZS               86927            1
  305   LAB HEMATOLOGY                      50.4540       89002   LAB HANDLING CHARGE                            122.20                         99001            1
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1083   E P CATHETER                                   621.50             C173X
  270   M/S SUPPLY GENERAL                  50.4570        1084   TIPPS KIT                                    1,852.45
  270   M/S SUPPLY GENERAL                  50.4570        1085   ADVANCER                                       710.30
  270   M/S SUPPLY GENERAL                  50.4570        1086   EXCHANGE CATHETER                              781.30
  270   M/S SUPPLY GENERAL                  50.4570        1087   ROTOBUR                                      3,887.35
  270   M/S SUPPLY GENERAL                  50.4570        1088   EXCHANGE WIRE 014                              497.20                                              * Test done by outside reference lab. Pric
  270   M/S SUPPLY GENERAL                  50.4570        1089   ROTOWIRE                                       497.20                                              determined based on reference lab charge
  320   RADIOLOGY DIAG GENERAL              50.4570        1093   VERTEBROPLASTY RADI SUPER/INTE               4,418.95                          72291           2
  490   AMB SURGICAL CARE GENERAL           50.4570        1094   VERTEBRALPLASTY                             18,559.10                          22521           2
  270   M/S SUPPLY GENERAL                  50.4570        1095   ACRYLIC RESIN                                  760.10
  270   M/S SUPPLY GENERAL                  50.4570        1096   BONE CEMENT                                    608.10
  270   M/S SUPPLY GENERAL                  50.4570        1097   DELIVERY SYSTEM KIT                          2,759.05
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1101   ROTOBLADE ADVANCER                           1,234.95             C1043
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1102   ROTOBLADE BURR                               6,760.65             C1043
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1103   ROTOWIRE                                       864.65
  270   M/S SUPPLY GENERAL                  50.4570        1104   QUADRIPOLAR CATHETHER                          833.65
  270   M/S SUPPLY GENERAL                  50.4570        1105   DECAPOLAR/CSL                                2,531.50
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1106   LIVEWIRE DECK                                2,315.40             C1730
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1107   LIVEWIRE DUO/DECK                            7,378.10             C1731
  270   M/S SUPPLY GENERAL                  50.4570        1108   DUO/TRIO SHEATH                                222.50

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                            88 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS     RVU
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1109   EP GUIDING CATHETHER                          3,231.70                        C1004
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1111   ABLATION CATHETHER CONDUCTOR                  4,013.30                                0
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1112   ABLATION CATHETHER PERFORMER                  4,013.30            C1757
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1113   ABLATION CATHETHER RF MARINR C                4,013.30                        C1757
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1114   ROTOBLADER SYSTEM                            13,518.45                                0
  272   M/S SUPPLY STERILE SUPPLY           50.4570        1115   PERCLOSE                                      1,185.15            C1760
  270   M/S SUPPLY GENERAL                  50.4570        1121   NITROUS OXIDE CATRIDGE                          255.45
  270   M/S SUPPLY GENERAL                  50.4570        1122   INFLATION UNIT                                4,853.00
  270   M/S SUPPLY GENERAL                  50.4570        1123   POLAR CATH 014                                4,086.75
  270   M/S SUPPLY GENERAL                  50.4570        1124   POLAR CATH 035                                3,065.05
  481   CARDIOLOGY CARDIAC CATH             50.4570        5500   COR ANG W-CINE-HOSP                           3,770.50
  481   CARDIOLOGY CARDIAC CATH             50.4570        5606   BIOPSY MYOCARDIUM                             4,997.70                                          1
  270   M/S SUPPLY GENERAL                  50.4570        6910   MAGNET                                          898.25                                          1
  270   M/S SUPPLY GENERAL                  50.4570        6911   MOTOR DRIVE                                     808.45                                          1
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7029   INTRAVASCULAR CATHETER                        6,875.55            C1980
  481   CARDIOLOGY CARDIAC CATH             50.4570        7051   ABLATION SVT                                 22,357.15                            93651         2
  481   CARDIOLOGY CARDIAC CATH             50.4570        7053   ABLATION V-TACH                              22,357.15                            93652         2
  481   CARDIOLOGY CARDIAC CATH             50.4570        7055   INTRA A OR V MAPPING                          1,543.60                            93609         1
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7057   ROTOBLADE                                    21,745.60                                          1
  270   M/S SUPPLY GENERAL                  50.4570        7300   COIL                                            617.75
  270   M/S SUPPLY GENERAL                  50.4570        7301   COIL PUSHER                                     617.75
  270   M/S SUPPLY GENERAL                  50.4570        7302   CONTOUR GEL                                     586.75
  270   M/S SUPPLY GENERAL                  50.4570        7303   COIL WIRE                                       111.35 Z7610
  270   M/S SUPPLY GENERAL                  50.4570        7304   BIOPSY NEEDLE                                     61.90 Z7610
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7305   CENTRAL LINE                                    536.75            C1750
  278   M/S OTHER IMPLANTS                  50.4570        7306   PORTA CATH                                    5,062.85            C1788
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7307   NITINOL WIRE 018 LONG                         1,008.60            C1769
  270   M/S SUPPLY GENERAL                  50.4570        7308   NITINOL 018 SHORT                               779.45
  270   M/S SUPPLY GENERAL                  50.4570        7309   HEMOBAND                                          37.25
  270   M/S SUPPLY GENERAL                  50.4570        7315   PTD DEVICE                                    3,704.60
  270   M/S SUPPLY GENERAL                  50.4570        7370   CAMERA DRAPE                                      61.90
  270   M/S SUPPLY GENERAL                  50.4570        7371   LONG GLIDEWIRE                                  309.00
  270   M/S SUPPLY GENERAL                  50.4570        7372   KATZEN WIRE                                     586.75
  270   M/S SUPPLY GENERAL                  50.4570        7373   FLEX SHEATH                                     123.80 Z7610
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7374   PICC LINE SINGLE                                646.55                                0
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7375   STERILE SLEEVE                                    49.60
  270   M/S SUPPLY GENERAL                  50.4570        7376   SHORT SHEATH                                    123.80 Z7610
  270   M/S SUPPLY GENERAL                  50.4570        7377   TURBO TRACKER                                 1,821.50
  272   M/S SUPPLY STERILE SUPPLY           50.4570        7378   PICC LINE DOUBLE                                646.55                                0
  329   RADIOLOGY DIAG OTHER                50.4570        7399   CATH LAB HBA MISC CHARGE                    misc chrg determined at time of svcs
  270   M/S SUPPLY GENERAL                  50.4570        9606   NITINOL 035 SHORT                               220.30            C1769
  272   M/S SUPPLY STERILE SUPPLY           50.4570        9607   NITINOL 035 LONG                                440.15            C1769
  270   M/S SUPPLY GENERAL                  50.4570       25115   SENSOR ABDOMINAL                                137.70
  323   RADIOLOGY DIAG ARTERIOGR            50.4570       77584   CATHETER MAIN - PA/RV                         1,387.25      36013
  361   OR SVCS MINOR SURGERY               50.4570       77586   CATHETER SELECTIVE PA                         1,387.25      36014                 36014
  361   OR SVCS MINOR SURGERY               50.4570       77587   CATHETER SUBSELECTIVE PA                      1,387.25      36015                 36015
  361   OR SVCS MINOR SURGERY               50.4570       77606   SECOND ORDER THORACIC BRACH                   1,679.00      36216                 36216
  361   OR SVCS MINOR SURGERY               50.4570       77607   THIRD ORDER THORACIC BRACH                    1,679.00      36217                 36217
  361   OR SVCS MINOR SURGERY               50.4570       77608   ADDITIONAL THORACIC BRACH                     1,679.00                            36218
  361   OR SVCS MINOR SURGERY               50.4570       77762   SELECTIVE ABD PELVIS LOWER EXT                1,387.25                            36245
  361   OR SVCS MINOR SURGERY               50.4570       77764   INITIAL THIRD ORDER ABD BELOW                 1,387.25                            36247
  361   OR SVCS MINOR SURGERY               50.4570       77765   ADDITIONAL ABD BELOW                          1,387.25                            36248

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               89 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL      CPT-4     HCPCS      RVU
  361   OR SVCS MINOR SURGERY               50.4570       77790   INTRO NEEDLE EXTREMITY ARTERIA               1,530.55    36140                36140
  323   RADIOLOGY DIAG ARTERIOGR            50.4570       77947   CATHETER SELECTIVE VENOUS                    1,244.05    36011
  323   RADIOLOGY DIAG ARTERIOGR            50.4570       77948   CATHETER SUBSELECTIVE VENOUS                 1,244.05    36012
  270   M/S SUPPLY GENERAL                  50.4572        6908   MICROPUNTURE KIT                               192.10
  270   M/S SUPPLY GENERAL                  50.4572        6909   ULTRAFUSE X                                  1,835.60                                         1
  270   M/S SUPPLY GENERAL                  50.4572        6912   HEMOSTATIC VALVE                               450.70                                         1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        6913   9 FR GUIDER                                    634.30                              0
  636   DRUG SPEC ID DETAIL CODING          50.4572        6916   VISIPAQUE 200CC                              1,088.70            Q9945
  636   DRUG SPEC ID DETAIL CODING          50.4572        6917   VISIPAQUE 100 CC                             1,088.70            Q9945
  255   PHARMACY INCID TO RAD               50.4572        6918   VISIPAQUE 50 CC                              1,088.70            Q9945
  270   M/S SUPPLY GENERAL                  50.4572        6919   INFUSION CATHETER                              584.15
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        6920   VENA CAVA FILTER (FEMERAL/JUGU               8,168.50                     C1880               1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        6921   STENT NIR WITH SOX                          12,441.35
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        6922   MULTILINK STENT TETRA                       11,212.95
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        6923   MUTILINK STENT 15 MM                         9,620.00                                         1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        6962   DRUG ELUDING STENT                          16,346.90            C1876                        1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7310   PEDS SHEATH                                    126.45                              0          1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        7311   AMPLATZ THROMBECTOMY DEVICE LA               5,677.65            C1757
  272   M/S SUPPLY STERILE SUPPLY           50.4572        7312   AMPLATZ THROMBECTOMY SMALL/OAS               6,053.40                              0
  490   AMB SURGICAL CARE GENERAL           50.4572        7313   CENTRAL LINE PLACEMENT                       4,112.25                                         1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        7314   LOOP SNARE                                   1,419.65            C1773
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7320   BOWEL BAG DRAPE                                210.30                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7330   BOVIE PENCIL                                   141.95                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7340   GROUNDING PAD                                   84.05                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7360   NDM ELECTRODES - SET                           136.85                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7361   DEFIBRILATION ELECTRODES                       341.50                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7400   SHEATH SETS                                    451.95                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7420   DILATOR                                        173.40                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7440   PACEMAKER INTRODUCER                           788.45                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7450   OCCLUDING SPRINGS                              525.45                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7461   DISP 3 RING SYRINGE                            141.95                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7465   SYRINGES, MEDRAD DISPOSABLE                    157.80                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7470   SUTURE WITH NEEDLE                              89.55                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7480   SUTURE NO NEEDLE                                47.65                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7490   PRESSURE LINE                                   84.05                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7501   DISP 1 WAY STOPCOCK                             36.95                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7510   CONTRAST SPIKE                                  94.70                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7540   ROSEN GUIDEWIRE                                431.00                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7550   STEERING DEVICE                                215.55                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7560   ARROW CATHETER GUARD                           184.15                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7570   INJECTOR TUBING                                100.15                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        7590   MANIFOLD                                       289.20                                         1
  636   DRUG SPEC ID DETAIL CODING          50.4572        7620   OMNIPAQUE 300 CONTRAST 100ML                   793.55            Q9958    A4641               1
  636   DRUG SPEC ID DETAIL CODING          50.4572        7630   OMNIPAQUE CONTRAST 50ML                        793.55            Q9958    A4641               1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8610   GUIDING CATHETER PTCA                        1,308.55            C1887                        1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8615   CORONARY BALLOON-ON WIRE                    10,775.20            C1725                        1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8620   CORONARY BALLOON-OVER WIRE                   6,845.50            C1725                        1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8630   GUIDEWIRE PTCA AS,IM,BMW,HW                  1,970.25                     C1769               1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8631   GUIDEWIRE PTCA CROSS IT                      1,970.25
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8632   GUIDEWIRE PTCA CHOICE                        1,970.25            C1769
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8650   INDEFLATOR PTCA                              1,607.60                                         1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8660   REPLACEMENT Y CONNECTOR PTCA                   573.20                                         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             90 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8670   GUIDING CATHETER SHEATH PTCA                   798.70                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        8671   INTRACORONARY STENT                         14,116.40          C1874                        1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        8672   ROTABLATION BURR                            12,775.55                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8673   PTD KIT                                      3,154.40                                       1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8674   PTD MOTOR DRIVE                                631.05                                       1
  275   M/S SUPPLY PACEMAKER                50.4572        8680   PACEMAKER                                      **              C1785                        1
  275   M/S SUPPLY PACEMAKER                50.4572        8681   PACEMAKER KAPPA 700 DR                         **                       C2621               1
  275   M/S SUPPLY PACEMAKER                50.4572        8682   PACEMAKER KAPPA 600 DR                         **                       C1785               1
  275   M/S SUPPLY PACEMAKER                50.4572        8683   PACEMAKER SIGMA 300 DR                         **              C1118                        1
  275   M/S SUPPLY PACEMAKER                50.4572        8684   PACEMAKER GENERATOR KAPPA 700                  **              C1127                        1
  275   M/S SUPPLY PACEMAKER                50.4572        8685   PACEMAKER GENERATOR SIGMA 300                  **                       C1785               1
  278   M/S OTHER IMPLANTS                  50.4572        8686   PACEMAKER LEADS CAPSURE SP                     **                       C1898               1
  278   M/S OTHER IMPLANTS                  50.4572        8687   PACEMAKER LEAD CAPSURE FIX                     **                       C1898               1
  275   M/S SUPPLY PACEMAKER                50.4572        8688   PACEMAKER GENRATOR DISCOVER DR                 **                       C1785
  275   M/S SUPPLY PACEMAKER                50.4572        8689   PACEMAKER GENERATOR PULSAR MAX                 **                                           1
  278   M/S OTHER IMPLANTS                  50.4572        8690   PACEMAKER LEAD                                 **                       C1898               1
  275   M/S SUPPLY PACEMAKER                50.4572        8691   IMPLANTABLE DEFIBRILATOR                       **                                           1
  275   M/S SUPPLY PACEMAKER                50.4572        8692   IMPLANTABLE DEFIBRILATOR GEM D                 **                                0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8693   IMPLANTABLE DEFIBRILATOR GEM 7                 **              C1121                        1
  275   M/S SUPPLY PACEMAKER                50.4572        8694   IMPLANTABLE DEFIBRI MICRO JEWE                 **                       C1882               1
  275   M/S SUPPLY PACEMAKER                50.4572        8695   IMPLANTABLE DEFIBRILATOR VENTA                 **                                0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8696   IMPLANTABLE DEFIB VENTAK VR PR                 **                                0          1
  278   M/S OTHER IMPLANTS                  50.4572        8697   IMPLANTBLE DEFIB VENTAK PRIZM                  **                                0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8698   IMPLANTABLE DEFIB CONTOUR MD S                 **              C1148                        1
  278   M/S OTHER IMPLANTS                  50.4572        8701   PACEMAKER LEAD 5038S,5038,5038                 **                       C1898               1
  278   M/S OTHER IMPLANTS                  50.4572        8702   PACEMAKER LEAD SPINT6932,6943                  **                       C1777               1
  278   M/S OTHER IMPLANTS                  50.4572        8703   PACEMAKER LEAD SPRINT6942,6945                 **                       C1895               1
  275   M/S SUPPLY PACEMAKER                50.4572        8704   IMPLANTABLE DEFIBRILATOR GEM I                 **                                0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8705   PACEMAKER GEN ADDVENT MOD 2060                 **                       C2621               1
  275   M/S SUPPLY PACEMAKER                50.4572        8706   PACEMAKER GENERATOR AFNTY SP 5                 **                                           1
  278   M/S OTHER IMPLANTS                  50.4572        8707   PACEMAKER LEAD AV PLUS DX 1368                 **              C1147                        1
  275   M/S SUPPLY PACEMAKER                50.4572        8708   PACEMAKER ENTITY DC 5226R                      **                       C2619               1
  278   M/S OTHER IMPLANTS                  50.4572        8709   PACEMAKER LEAD PASSIVEPLUS DX                  **                       C1898               1
  278   M/S OTHER IMPLANTS                  50.4572        8710   PACEMAKER LEAD PASVE+DXLEAD 13                 **                                0          1
  278   M/S OTHER IMPLANTS                  50.4572        8711   PACEMAKER LEAD REGENCY SC+2402                 **                       C1779               1
  275   M/S SUPPLY PACEMAKER                50.4572        8712   PACEMAKER GEN TR1102TRSR+2260L                 **                       C1785               1
  275   M/S SUPPLY PACEMAKER                50.4572        8713   PACEMAKER GEN TRILOGY DCT 23/8                 **                       C2619               1
  278   M/S OTHER IMPLANTS                  50.4572        8714   PACEMAKER LEAD AICD TVL SV01,S                 **              C1158                        1
  278   M/S OTHER IMPLANTS                  50.4572        8715   PACEMAKER LEAD AICD TVL RV02 R                 **                       C1899               1
  278   M/S OTHER IMPLANTS                  50.4572        8716   PACEMAKER LEAD AICD TVL ADX 15                 **                       C1899               1
  278   M/S OTHER IMPLANTS                  50.4572        8717   PACEMAKER LEAD TENDRIL DX 1388                 **                                0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8718   PACEMAKER GEN TEMPO DR TRILOGY                 **                       C1785               1
  278   M/S OTHER IMPLANTS                  50.4572        8719   PACEMAKER LEAD SDX 488T                        **                       C1898               1
  278   M/S OTHER IMPLANTS                  50.4572        8720   PACEMAKER LEAD AICD ENDO,TAK E                 **                       C1895               1
  275   M/S SUPPLY PACEMAKER                50.4572        8721   PACEMAKER GEN PLUSAR DDD                       **                       C2619               1
  278   M/S OTHER IMPLANTS                  50.4572        8722   ACID LEAD ENDOTAK END RX                       **                       C1895
  278   M/S OTHER IMPLANTS                  50.4572        8723   ACID LEAD ENDOTAK DSP                          **                       C1895
  278   M/S OTHER IMPLANTS                  50.4572        8724   AICD GENERATOR GEM2 VR                         **              C1722             0
  278   M/S OTHER IMPLANTS                  50.4572        8725   AICD GENERATOR GEM DR/GEM 2 DR                 **              C1722             0
  278   M/S OTHER IMPLANTS                  50.4572        8726   AICD GENERATOR VENTAK MINI                     **              C1722             0
  275   M/S SUPPLY PACEMAKER                50.4572        8727   PACEMAKER GENERATOR SIGMA 300                  **
  275   M/S SUPPLY PACEMAKER                50.4572        8728   PACEMAKER GENERATOR KAPPA 700D                 **                       C1785

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           91 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                    DESCRIPTION                    CHARGE      MCAL    CPT-4    HCPCS      RVU
  275   M/S SUPPLY PACEMAKER                50.4572        8729   PACEMAKER GENERATOR KAPPA 400V                  **
  275   M/S SUPPLY PACEMAKER                50.4572        8730   PACEMAKER GENERATOR DISCOVER S                  **
  275   M/S SUPPLY PACEMAKER                50.4572        8731   PACEMAKER GENERATOR PULSAR MAX                  **                       C1785
  275   M/S SUPPLY PACEMAKER                50.4572        8732   PACEMAKER GENERATOR AFFINITY D                  **                       C1785
  278   M/S OTHER IMPLANTS                  50.4572        8733   PACEMAKER LEAD CASURE SP                        **                       C1898
  275   M/S SUPPLY PACEMAKER                50.4572        8734   PACEMAKER GENERATOR KAPPA 400                   **                       C1785
  275   M/S SUPPLY PACEMAKER                50.4572        8735   PACMAKER GENERATOR ENTITY 5326                  **                               0
  278   M/S OTHER IMPLANTS                  50.4572        8736   AICD LEAD CAPTURE FX 6940/4068                  **                       C1896
  275   M/S SUPPLY PACEMAKER                50.4572        8737   AICD PHOTON DR V-230HV3                         **              C1721    C1721              1
  278   M/S OTHER IMPLANTS                  50.4572        8738   DEFIBULATOR LEAD TVL-ADX 1559/                  **                       C1899              1
  278   M/S OTHER IMPLANTS                  50.4572        8739   AICD LEAD TENDRIL SDX 1488TC/5                  **                       C1898              1
  278   M/S OTHER IMPLANTS                  50.4572        8740   AICD GEM III DURAL CHAMBER DR                   **              C1721
  278   M/S OTHER IMPLANTS                  50.4572        8741   LOOP RECORDER                                   **                       C1764              1
  275   M/S SUPPLY PACEMAKER                50.4572        8742   MARQUIS DR AICD GENERATOR                   103,445.10                           0          1
  275   M/S SUPPLY PACEMAKER                50.4572        8743   INSYNC BI-VEN GENERATOR                      52,361.10                   C2621              1
  278   M/S OTHER IMPLANTS                  50.4572        8744   BI-VEN LEAD 4193                             17,138.90                   C1898              1
  270   M/S SUPPLY GENERAL                  50.4572        8745   VENOGRAM BALLOON CATH                           836.10                                      1
  270   M/S SUPPLY GENERAL                  50.4572        8746   ATTAIN CATH SYSTEM                            5,016.35                                      1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        8800   CORONARY BALLOON-PERFUSION                    9,052.15          C1725                       1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8910   PIGTAIL CORONARY CATHETER                       462.55                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8950   SELECTIVE PERIPH PIGTAIL CATHE                  362.95                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        8951   AUROUS MEASURE CATH                           1,061.70                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9000   SELECTIVE CORONARY CATHETER                     462.55                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9050   J GUIDEWIRE                                     304.90                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9100   LT/LLT GUIDEWIRE                                241.90                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9110   GLIDEWIRE                                       551.75                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9120   MOVEABLE CORE GUIDEWIRE                         289.20                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9130   EXCHANGE GUIDEWIRE                              446.60                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9140   TIP DEFLECTING GUIDEWIRE                        861.90                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9160   BENTSON GUIDEWIRE                               373.00                                      1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572        9402   QUAD POLAR ELECTROPHYSIO CATHE                  840.75                                      1
  272   M/S SUPPLY STERILE SUPPLY           50.4572        9601   PTA BALLOON CATH MRSHAL,BLU MA                2,884.70          C1725                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        9602   WALLSTENT BIL,ENDO SYMPHONY                  10,288.05                   C2617              1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        9603   WALLSTENT BIL ENDO                           10,288.05                   C2617              1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572        9604   WALLSTENT BIL ENDO PALMAZ                    10,288.05                   C2617              1
  320   RADIOLOGY DIAG GENERAL              50.4572        9605   PERCUTAN TRANSHPT                               765.85 74320TC              74320           1
  279   M/S OTHER SUPPLIES/DEVICES          50.4572       23250   FILTER WIRE                                   8,486.00          C1884
  490   AMB SURGICAL CARE GENERAL           50.4572       37026   PICC LINE INSERTION                           1,462.25                                      1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4572       50434   VENA CAVA FILTER                              8,168.50          C1880       75961           1
  361   OR SVCS MINOR SURGERY               50.4572       79605   PERCUTAN TRANSHPT INJUECTION P                  258.40                      47500           1
  320   RADIOLOGY DIAG GENERAL              50.4573        1090   PACER INSERT TE-HOSP                          2,334.00                                      1
  481   CARDIOLOGY CARDIAC CATH             50.4573        1091   PACER INSERT PE-HOSP                          4,116.85                                      1
  360   OR SVCS GENERAL                     50.4574        2289   OCCLUSIVE DEVICE PLACE POST OP                  297.00          G0269                       1
  320   RADIOLOGY DIAG GENERAL              50.4574        2290   DISKOGRAM L-SPINE                               987.55 72295TC              72295           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4574        5598   PERICARDIOCENTESIS                            5,106.30                      76930           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        6905   ATHERECTOMY-COR SINGLE VESSEL                22,218.30                                      1
  481   CARDIOLOGY CARDIAC CATH             50.4574        6907   ATHERECTOMY-COR ADDL VESSEL                   9,469.70                                      1
  272   M/S SUPPLY STERILE SUPPLY           50.4574        6914   BANTAM CUTTER                                14,252.55                           0          1
  270   M/S SUPPLY GENERAL                  50.4574        6915   7 FR INTRO GUIDER                               167.10                                      1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7000   RT HRT CATH                                   5,730.90    93501             93501           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7002   SWAN GANZ CATH                                3,346.35                      93503           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7006   INTRACORONARY THROMBOLYSIS                    1,226.20                      92975           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           92 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE       MCAL       CPT-4     HCPCS      RVU
  481   CARDIOLOGY CARDIAC CATH             50.4574        7008   INTRA AORTIC BALLOON                         4,746.50                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7010   LEFT HEART-ANGIO-VGRAM                      10,606.10                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7012   LT HEART-ANGIO-VGRAM-ROOT                   11,489.10                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7014   LT-RT HEART-ANGIO-VGRAM                     10,606.10                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7016   LT-RT HEART-ANGIO-VGRAM-GRAFTS              18,046.35                           93527           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7018   BYPASS GRAFTS ANGIO                          3,037.00                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7020   LEFT HEART ANGIO-VGRAM-GRAFTS               14,244.45                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7022   LT HEART-ANGIO-VGRAM-ROOT-GRAF              15,133.15                           93510           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7026   LT HEART CATH                                6,185.85                           93510           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7027   INTRAVASCULAR ULTRASOUND IVUS                6,168.40
  481   CARDIOLOGY CARDIAC CATH             50.4574        7028   CORONARY ANGIO                               4,240.15                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7030   AORTIC ROOT                                  2,637.55                           76499           1
  272   M/S SUPPLY STERILE SUPPLY           50.4574        7041   HEART CATH CUSTOM PACK                         470.25
  481   CARDIOLOGY CARDIAC CATH             50.4574        7050   COMPREH ELECTRPHYSIO EVAL.                  18,135.95                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7052   PROG STIM/PACING W/DRUG INFUSI               5,781.40                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7054   ELECTRO PHYSIO EVAL OF LEAD/DE               8,671.95                                           1
  481   CARDIOLOGY CARDIAC CATH             50.4574        7056   ABLATION AV NODE                            22,843.15                           93650           2
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77582   STENT INSERTION (NON CORONARY)               4,234.65                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77583   ANGIO PULMONARY BILATERAL                    2,963.90   75743TC       75743     75743           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77585   ANGIO PULMONARY UNILATERAL                   2,620.65                                           1
  361   OR SVCS MINOR SURGERY               50.4576       77605   SELECTIVE THORACIC BRACHEOCEPH               1,715.50      36215                36215           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77630   ANGIO EXT CAROTID UNILATERAL                 3,419.35                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77631   ANGIO CAROTID CEREBRAL UNILATE               3,655.35                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77635   ANGIO EXT CAROTID BILATERAL                  3,785.00                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77636   ANGIO CAROTID CEREBRAL BILATER               4,347.20                           75671           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77639   ANGIO VERTEBRAL/INTRACRANIAL                 3,785.00                           75685           1
  489   CARDIOLOGY OTHER                    50.4576       77760   INTRO CATHETER AORTA                         1,383.45      36200                36200           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77761   PELVIC ANGIO                                 2,963.90      75736                75736           1
  361   OR SVCS MINOR SURGERY               50.4576       77763   INITIAL SECOND ORDER ABD BELOW               1,417.45                           36246
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77766   ANGIO VISCERAL W OR W/O AORTOG               4,527.05                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77767   ANGIO EACH ADDITIONAL                        1,271.05                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77768   ANGIO CERVICOCEREBRAL                        3,762.75                           75650           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77769   AORTOGRAPHY THORACIC W/O SERIA               3,312.70                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77770   AORTOGRAPHY THORACIC W/SERIAL                4,004.10                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77772   AORTOGRAPHY ABD BY SERIAL                    3,655.35                           75625           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77775   AORTOGRAPHY ABD-ILIOFEMORAL                  2,963.90                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77779   ANGIOPLASTY VENOUS                           6,579.85      75978                75978           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77780   ANGIOPLASTY PERIPHERAL ART                   6,579.85      75962                75962           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77781   ANGIOPLASTY ADDITIONAL ART                   2,221.70                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77787   ANGIO EXTREMITY UNILATERAL                   3,312.70   75710TC                 75710           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77789   ANGIO EXTREMITY BILATERAL                    3,655.35   75716TC                 75716           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77905   VENOGRAPHY SVC                               2,963.90                           75825           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77906   EMBOLIZATION                                 1,794.35                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77910   THROMBOLYSIS NON CORONARY                    1,226.20   75896TC                 75896           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77945   VENOGRAPHY IVC                               2,963.90                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77946   CATHETER IVC/SVC                             1,271.05      36010                                1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77950   ANGIO F/U STUDY                              1,321.90                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77955   FILTER PLACEMENT                             2,497.30                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77959   PTA RENAL/VISCERAL                           2,823.40      35471                                1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77960   ANGIO RENAL UNILATERAL                       2,963.90                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77961   ANGIOPLASTY RENAL ARTERY                     6,579.85                                           1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77962   ANGIO RENAL BILATERAL                        3,312.70   75724TC                 75724           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               93 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                      CHARGE
 CHG         CATEGORY AND NAME               DPT       CODE                  DESCRIPTION                       CHARGE       MCAL        CPT-4     HCPCS     RVU
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77963 ANGIOPLASTY ADDITIONAL RENAL                    2,221.70                                          1
  490   AMB SURGICAL CARE GENERAL           50.4576       77964 PTA ILIAC                                       2,823.40      35473                               1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77965 PTA FEMORAL-POPLITEAL                           2,823.40      35474                               1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77966 PTA VENOUS                                      2,823.40      35476                               1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77967 ANGIO A/V SHUNT                                 2,963.90 75790TC                    75790         1
  489   CARDIOLOGY OTHER                    50.4576       77968 INTRO NEEDLE SHUNT                              1,271.05                                          1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77969 VENOGRAPHY EXTREMITY UNILATERA                  2,963.90      75820                 75820         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77970 VENOGRAPHY EXTREMITY BILATERAL                  3,110.00 75822TC                    75822         1
  489   CARDIOLOGY OTHER                    50.4576       77971 INTRO NEEDLE EXTREMITY VENOUS                   1,271.05      36000                 36000         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77977 ANGIO ABDOMINAL AORTA                           3,312.70 75625TC                    75625         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77978 ANGIO STENT PLACEMENT                           3,312.70 75960TC                    75960         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77979 ANGIOPLASTY EXTREMITY                           3,312.70 75962TC                    75962         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576       77980 ANGIOPLASTY EXTREMITY VENOUS                    2,159.15 75978TC                    75978         1
  323   RADIOLOGY DIAG ARTERIOGR            50.4576 L7969       VENOGRAPHY EXTREM UNILAT LT                     2,963.90 75820LT TC 75820LT     75820LT           1
  730   EKG/ECG GENERAL                     50.4590       14201 EKG 12 LEAD-HOSP ROUTINE23.42                     415.75 93005TC                    93005         1
  482   CARDIOLOGY STRESS TEST              50.4590       14202 TREADSTRESS TEST-HOSP76.97                      1,615.00 93017TC                    93017         1
  730   EKG/ECG GENERAL                     50.4590       14203 EKG-3 LEAD - HOSP7.64                             587.05 93041TC                    93041         1
  730   EKG/ECG GENERAL                     50.4590       14204 EKG/INDUSTRIAL23.42                               244.35 93005TC                    93005         1
  730   EKG/ECG GENERAL                     50.4590       14205 SIGNAL AVERAGE EKG98.03                           773.95 93278TC                    93278         1
  731   EKG/ECG HOLTER MONITOR              50.4590       14208 24-HR DCG-HOSP119.67                            2,040.70 93236TC                    93236         1
  480   CARDIOLOGY GENERAL                  50.4590       14211 2-DIMEN ECHO-HOSP203.85                         3,297.10 93307TC                    93307         1
  730   EKG/ECG GENERAL                     50.4590       14212 RHYTHM STRIP 1 LEAD7.64                           197.45 93041TC                    93041
  480   CARDIOLOGY GENERAL                  50.4590       14213 2 DIMEN ECHO LIMITED/FU                         1,648.60 93308TC         93308      93308         1
  480   CARDIOLOGY GENERAL                  50.4590       14216 CARDIAC DOPPLER STUDY90.82                        426.10      93320                 93320         1
  480   CARDIOLOGY GENERAL                  50.4590       14217 CARDIAC DOPPLER HOSP LIMITED                      401.85 93321TC         93321      93321         1
  480   CARDIOLOGY GENERAL                  50.4590       14231 TRANSESOPHAGEAL 2D ECHO - TEE1                  4,585.00 93312TC                    93312         1
  480   CARDIOLOGY GENERAL                  50.4590       14232 STRESS 2D ECHOCARDIOGRAM94.03                   4,289.00 93350TC                    93350         1
  482   CARDIOLOGY STRESS TEST              50.4590       14233 PERSANTINE MP EXERCISE76.97                     1,718.60 93017TC                    93017         1
  480   CARDIOLOGY GENERAL                  50.4590       14234 TILT TABLE TEST-HOSP                            1,718.60      93660                 93660         1
  480   CARDIOLOGY GENERAL                  50.4590       14235 COLOR DOPPLER/CARDIAC133.59                       301.50 93325TC                    93325         1
  480   CARDIOLOGY GENERAL                  50.4590       14238 NST OB TECH                                       427.05
  730   EKG/ECG GENERAL                     50.4590       14299 PHYSIOLOGY HBA MISC CHARGE                    misc chrg determined at time of svcs
  985   PROF FEES EKG                       50.4591       15230 2-DIMEN ECHO-M. WILKINSON203.8                    152.25                          9330726
  985   PROF FEES EKG                       50.4591       15231 2-DIMEN ECHO - N. MAYER203.85                     152.25                          9330726
  985   PROF FEES EKG                       50.4591       15232 2D ECHO GINKEL203.85                              152.25                          9330726
  985   PROF FEES EKG                       50.4591       15233 2-DIMEN ECHO - T. KONG203.85                      152.25                          9330726
  985   PROF FEES EKG                       50.4591       15234 2D ECHO BRACKETT203.85                            152.25 9330726                  9330726
  985   PROF FEES EKG                       50.4591       15235 2-DIMEN ECHO - N. J. FRIEDMAN2                    152.25                          9330726
  985   PROF FEES EKG                       50.4591       15236 2-DIMEN ECHO - DR. BROOKS203.8                    152.25                          9330726
  985   PROF FEES EKG                       50.4591       15237 2-DIMEN ECHO - DR S. STORZ203.                    152.25                          9330726
  985   PROF FEES EKG                       50.4591       15238 2-DIMEN ECHO - G. MITCHELL203.                    152.25 9330726                  9330726
  985   PROF FEES EKG                       50.4591       15239 2-DIMEN ECHO - DR MANSOUR                         152.25 9330726                  9330726
  985   PROF FEES EKG                       50.4591       15240 TREADM STR TST - WILKINSON35.8                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15241 TREADM STR TST - N. MAYER35.84                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15242 TREADMILL STRESS TEST GINKEL35                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15243 TREADM STR TST - T. KONG35.84                     132.00                            93018
  985   PROF FEES EKG                       50.4591       15244 TREADMILL STRESS DR BRACKETT35                    132.00      93018                 93018
  985   PROF FEES EKG                       50.4591       15245 TREADM STR TST - N. J. FRIEDMA                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15246 TREADM STR TST - D. BROOKS35.8                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15247 TREADM STR TST - S. STORZ35.84                    132.00                            93018
  985   PROF FEES EKG                       50.4591       15248 TREADM STR TST - G. MITCHELL35                    132.00 93018TC                    93018
  985   PROF FEES EKG                       50.4591       15249 TREADM STR TST - DR MANSOUR                       132.00 93018TC                    93018

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               94 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE      MCAL       CPT-4     HCPCS      RVU
  985   PROF FEES EKG                       50.4591       15250   FITNESS TREADMILL STR TST - PR                  132.00   9301526                93015
  985   PROF FEES EKG                       50.4591       15251   FITNESS TREADMILL -PROF-NO CHA              no charge    9301526                93015
  985   PROF FEES EKG                       50.4591       15270   ROUT EKG 12LEAD - WILKINSON17.                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15271   ROUT EKG 12LEAD - N. MAYER17.1                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15272   EKG 12 LEAD GINKEL17.14                          29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15273   ROUT EKG 12LEAD - T. KONG17.14                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15274   EKG-12 LEAD-DR BRACKETT17.14                     29.00     93010                93010
  985   PROF FEES EKG                       50.4591       15275   ROUT EKG 12LEAD - N. J. FRIEDM                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15276   ROUT EKG 12LEAD - D. BROOKS17.                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15277   ROUT EKG 12LEAD - S. STORZ17.1                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15278   ROUT EKG 12LEAD - G. MITCHELL1                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15279   ROUTINE EKG 12LEAD - DR MANSOU                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15290   24 HR DCG - WILKINSON48.98                      115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15291   24 HR DCG - N. MAYER48.98                       115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15292   24 HR DCG GINKEL48.98                           115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15293   24 HR DCG - T. KONG48.98                        115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15294   24 HOUR DCG BRACKETT48.98                       115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15295   24 HR DCG - N. J. FRIEDMAN48.9                  115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15296   24 HR DCG - D. BROOKS48.98                      115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15297   24 HR DCG - S. STORZ48.98                       115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15298   24 HR DCG - G. MITCHELL48.98                    115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15299   24 HR DCG - DR MANSOUR                          115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15300   FITNESS EKG - PROF17.14                          29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15301   FITNESS EKG - PROF-NO CHARGE17              no charge                           93010
  985   PROF FEES EKG                       50.4591       15511   ROUT EKG 12 LEAD-C.D. GOYSAYNI                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15513   ROUT EKG 12 LEAD-T. KONG17.14                    29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15515   ROUT EKG 12 LEAD-N.J. FRIEDMAN                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15516   ROUT EKG 12 LEAD-D. BROOKS17.1                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15517   ROUT EKG 12 LEAD-S. STORZ17.14                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15518   ROUT EKG 12 LEAD - G. MITCHELL                   29.00   9301026                93010
  985   PROF FEES EKG                       50.4591       15521   TREADM STR TST-C.D. GOSAYNIE35                  132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15523   TREADM STR TST-T. KONG35.84                     132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15525   TREADM STR TST-N.J. FRIEDMAN35                  132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15526   TREADM STR TST-D. BROOKS35.84                   132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15527   TREADM STR TST-S. STORZ35.84                    132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15528   TREADM STR TST - G. MITCHELL35                  132.00   9301826                93018
  985   PROF FEES EKG                       50.4591       15561   24 HR DCG-C.D GOSAYNIE48.98                     115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15563   24 HR DCG-T. KONG48.98                          115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15565   24 HR DCG-N.J. FRIEDMAN48.98                    115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15566   24 HR DCG-D. BROOKS48.98                        115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15567   24 HR DCG-S. STORZ48.98                         115.50   9323726                93237
  985   PROF FEES EKG                       50.4591       15710   CARDIAC DOPPLER - WILKINSON90.                   53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15711   CARDIAC DOPPLER - N. MAYER90.8                   53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15712   CARDIAC DOPPLER GINKEL90.82                      53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15713   CARDIAC DOPPLER - KONG90.82                      53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15714   CARDIAC DOPPLER DR BRACKETT90.                   53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15715   CARDIAC DOPPLER - FRIEDMAN90.8                   53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15716   CARDIAC DOPPLER - BROOKS90.82                    53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15717   CARDIAC DOPPLER - STORZ90.82                     53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15718   CARDIAC DOPPLER - MITCHELL90.8                   53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15719   CARDIAC DOPPLER -DR MANSOUR                      53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591       15720   SIGNAL AVG EKG - WILKINSON98.0                   66.00   9327826              9327826

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           95 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE     MCAL      CPT-4     HCPCS      RVU
  985   PROF FEES EKG                       50.4591       15721   SIGNAL AVG EKG -N. MAYER98.03                  66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15722   SIGNAL AVG ECG GINKEL98.03                     66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15723   SIGNAL AVG EKG - KONG98.03                     66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15724   SIGNAL AVERAGE EKG DR BRACKETT                 66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15725   SIGNAL AVG EKG - FRIEDMAN98.03                 66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15726   SIGNAL AVG EKG - BROOKS98.03                   66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15727   SIGNAL AVG EKG - STORZ98.03                    66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15728   SIGNAL AVG EKG - MITCHELL98.03                 66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15729   SIGNAL AVG EKG - DR MANSOUR                    66.00 9327826               9327826
  985   PROF FEES EKG                       50.4591       15731   TRANSESOPHAGEAL 2D MAYER172.36                400.00    93312                93312
  985   PROF FEES EKG                       50.4591       15732   TRANSESOPHAGEAL-N. MAYER                      400.00                                         1
  985   PROF FEES EKG                       50.4591       15733   TRANSESOPHAGEAL 2D KONG172.36                 400.00 9331226               9331226
  985   PROF FEES EKG                       50.4591       15734   TRANSESOPHO ECHO DR BRACKETT17                400.00    93312                93312
  985   PROF FEES EKG                       50.4591       15735   TRANSESOPHAGEAL 2D FRIEDMAN172                400.00 9331226               9331226
  985   PROF FEES EKG                       50.4591       15736   TRANSESOPHAGEAL 2D BROOKS172.3                400.00 9331226               9331226
  985   PROF FEES EKG                       50.4591       15737   TRANSESOPHAGEAL 2D STORZ172.36                400.00 9331226               9331226
  985   PROF FEES EKG                       50.4591       15738   TRANSESOPHAGEAL 2D MITCHELL172                400.00 9331226               9331226
  985   PROF FEES EKG                       50.4591       15740   STRESS 2D ECHO - WILKINSON                    220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15741   STRESS ECHO -N. MAYER                         220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15742   STRESS 2D ECHO GINKEL                         220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15743   STRESS 2D ECHO - KONG                         220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15744   STRESS 2D ECHO DR BRACKETT94.0                220.00    93350                93350
  985   PROF FEES EKG                       50.4591       15745   STRESS 2D ECHO - FRIEDMAN                     220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15746   STRESS 2D ECHO - BROOKS                       220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15747   STRESS 2D ECHO - STORZ                        220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15748   STRESS 2D ECHO - MITCHELL                     220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15749   STRESS 2D ECHO - DR MANSOUR                   220.00 9335026               9335026
  985   PROF FEES EKG                       50.4591       15750   PERSANTINE THLL WILKINSON35.84                132.00                         93018
  985   PROF FEES EKG                       50.4591       15751   ADENOSINE MYOCARDIAL-N. MAYER3                132.00                         93018
  985   PROF FEES EKG                       50.4591       15752   ADENOSINE STRESS TEST GINKEL16                132.00    93015                93015
  985   PROF FEES EKG                       50.4591       15753   PERSANTINE THALL - KONG35.84                  132.00                         93018
  985   PROF FEES EKG                       50.4591       15754   MPS ADENO/DOB DR BRACKETT35.84                132.00    93018                93018
  985   PROF FEES EKG                       50.4591       15755   PERSANTINE THALL - FRIEDMAN35.                132.00                         93018
  985   PROF FEES EKG                       50.4591       15756   PERSANTINE THALL - BROOKS35.84                132.00                         93018
  985   PROF FEES EKG                       50.4591       15757   PERSANTINE THALL - STORZ35.84                 132.00                         93018
  985   PROF FEES EKG                       50.4591       15758   PERSANTINE THALL - MITCHELL35.                132.00 93018TC                 93018
  985   PROF FEES EKG                       50.4591       15759   PERSANTINE THALL - DR MANSOUR                 132.00 93018TC                 93018
  985   PROF FEES EKG                       50.4591       15760   TILT TABLE TEST - WILKINSON                   152.00 9366026               9366026
  985   PROF FEES EKG                       50.4591       15761   TILT TABLE TEST,PROF-N. MAYER                 152.00                         93660
  985   PROF FEES EKG                       50.4591       15762   TILT TABLE TEST GINKEL                        152.00 9366026               9366026
  985   PROF FEES EKG                       50.4591       15763   TILT TABLE TEST, PROF-KONG                    152.00 9366026               9366026
  985   PROF FEES EKG                       50.4591       15764   TILT TABLE TEST DR BRACKETT                   152.00    93660                93660
  985   PROF FEES EKG                       50.4591       15765   TILT TABLE TEST, PROF-FRIEDMAN                152.00 9366026               9366026
  985   PROF FEES EKG                       50.4591       15766   TILT TABLE TEST, PROF-BROOKS                  152.00
  985   PROF FEES EKG                       50.4591       15767   TILT TABLE TEST, PROF-STORZ                   152.00 9366026               9366026
  985   PROF FEES EKG                       50.4591       15768   TILT TABLE TEST - G. MITCHELL                 152.00 9372826                 93660
  985   PROF FEES EKG                       50.4591       15769   TILT TABLE TEST - DR MANSOUR                  152.00 9372826                 93660
  985   PROF FEES EKG                       50.4591       15775   INTRO ENDOSCOPIC TRANSDCR-FRIE                357.00 9331326               9331326
  985   PROF FEES EKG                       50.4591       15780   COLOR DOPPLER/DR. WILKINSON133                 65.00                       9332526
  985   PROF FEES EKG                       50.4591       15781   COLOR DOPPLER -N. MAYER133.59                  65.00 9332526               9332526
  986   PROF FEES EEG                       50.4591       15782   COLOR DOPPLER GINKEL                           65.00 9332526               9332526
  985   PROF FEES EKG                       50.4591       15783   COLOR DOPPLER/DR. KONG133.59                   65.00 9332526               9332526

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            96 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                    CHARGE      MCAL       CPT-4     HCPCS      RVU
  985   PROF FEES EKG                       50.4591          15784   COLOR DOPPLER DR BRACKETT133.5                  65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          15785   COLOR DOPPLER/DR.FRIEDMAN133.5                  65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          15786   COLOR DOPPLER/DR. BROOKS133.59                  65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          15787   COLOR DOPPLER/DR. STORZ133.59                   65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          15788   COLOR DOPPLER-DR. MITCHELL                      65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          15789   COLOR DOPPLER-DR MANSOUR                        65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591          16200   EKG 12 LEAD DR BUCKINGHAM                       29.00              9301026   9301026
  985   PROF FEES EKG                       50.4591          16201   EKG 12 LEAD DR MCMANUS                          29.00   9301026              9301026
  985   PROF FEES EKG                       50.4591          16202   EKG 12 LEAD DR FAUVRE                           29.00   9301026              9301026
  985   PROF FEES EKG                       50.4591    1523B         2D ECHO DR BRACKETT203.85                      152.25   9330726              9330726
  985   PROF FEES EKG                       50.4591    1523M         2D ECHO DR MOUSSAVIAN                          152.25   9330726              9330726
  985   PROF FEES EKG                       50.4591    1523W         2-DIMEN ECHO - DR WILKINSON203                 152.25   9330726              9330726
  985   PROF FEES EKG                       50.4591    1524B         TREADMILL STRESS - DR BRACKETT                 132.00   9301826                93018
  985   PROF FEES EKG                       50.4591    1524M         TREADMILL STRESS DR MOUSSAVIAN                 132.00     93018                93018           1
  985   PROF FEES EKG                       50.4591    1524W         TREADMILL STR TEST - DR WILKIN                 132.00   9301826                93018
  985   PROF FEES EKG                       50.4591    1527B         EKG-12 LEAD-DR BRACKETT                         29.00   9301026                93010
  985   PROF FEES EKG                       50.4591    1527M         EKG-12 LEAD DR MOUSSAVIAN                       29.00   9301026                93010
  985   PROF FEES EKG                       50.4591    1527W         EKG-12LEAD - DR WILKINSON17.14                  29.00   9301026                93010
  985   PROF FEES EKG                       50.4591    1529B         24 HR DCG DR BRACKETT                          115.50   9323726                93237
  985   PROF FEES EKG                       50.4591    1529M         24 HR DCG DR MOUSSAVIAN                        115.50   9323726                93237
  985   PROF FEES EKG                       50.4591    1529W         24 HOUR DCG - DR WILKINSON48.9                 115.50   9323726                93237
  985   PROF FEES EKG                       50.4591    1551W         EKG-12LEAD CR - DR WILKINSON17                  29.00   9301026                93010
  985   PROF FEES EKG                       50.4591    1552W         TREADMILL CR - DR WILKINSON35.                 132.00   9301826                93018
  985   PROF FEES EKG                       50.4591    1556W         24 HR DCG CR - DR WILKINSON48.                 115.00   9323726                93237
  985   PROF FEES EKG                       50.4591    1571B         CARDIAC DOPPLER - DR BRACKETT9                  53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591    1571M         CARDIAC DOPPLER - DR MOUSSAVIA                  53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591    1571W         CARDIAC DOPPLER - WILKINSON90.                  53.00   9332026              9332026
  985   PROF FEES EKG                       50.4591    1572B         SIGNAL AVERAGE EKG-DR BRACKETT                  66.00   9327826              9327826
  981   PROF FEES EMERGENCY ROOM            50.4591    1572M         SIGNAL AVERAGE EKG DR MOUSSAVI                  66.00   9327826              9327826
  985   PROF FEES EKG                       50.4591    1572W         SIGNAL AVG EKG - WILKINSON98.0                  66.00   9327826              9327826
  985   PROF FEES EKG                       50.4591    1573B         TRANSESOPHAGEAL-ECHO BRACKETT1                 400.00   9331226              9331226
  985   PROF FEES EKG                       50.4591    1573M         TRANSESOPHAGEAL ECHO MOUSSAVIA                 400.00   9331226              9331226
  985   PROF FEES EKG                       50.4591    1573W         TRANSESOPHAGEAL 2D WILKINSON17                 400.00   9331226              9331226
  985   PROF FEES EKG                       50.4591    1574B         STRESS 2D ECHO - DR BRACKETT                   220.00   9335026              9335026
  985   PROF FEES EKG                       50.4591    1574M         STRESS 2D ECHO - DR MOUSSAVIAN                 220.00   9335026              9335026
  985   PROF FEES EKG                       50.4591    1574W         STRESS 2D ECHO - WILKINSON                     220.00   9335026              9335026
  985   PROF FEES EKG                       50.4591    1575B         MPS ARDENO/DOB- DR BRACKETT35.                 132.00     93018                93018
  985   PROF FEES EKG                       50.4591    1575M         MPS ARDENO/DOB DR MIOUSSAVIAN                  132.00     93018                93018
  985   PROF FEES EKG                       50.4591    1575W         PERSANTINE THALL - WILKINSON35                 132.00                          93018
  985   PROF FEES EKG                       50.4591    1576B         TILT TABLE TEST - DR BRACKETT                  152.00                          93660
  985   PROF FEES EKG                       50.4591    1576M         TILT TABLE TEST DR MOUSSAVIAN                  152.00   9366026                93660
  985   PROF FEES EKG                       50.4591    1576W         TILT TABLE TEST - DR WILKINSON                 152.00   9366026              9366026
  985   PROF FEES EKG                       50.4591    1578B         COLOR DOPPLER - DR BRACKETT133                  65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591    1578M         COLOR DOPPLER - DR MOUSSAVIAN                   65.00   9332526              9332526
  985   PROF FEES EKG                       50.4591    1578W         COLOR DOPPLER/DR. WILKINSON133                  65.00   9332526              9332526
  740   EEG GENERAL                         50.4610          14302   EEG SLEEP-HOSP97.46                          1,195.15                          95822           1
  740   EEG GENERAL                         50.4610          14303   EEG MED-HOSP                                 1,195.15                          95954           1
  922   OTHER DIAG EMG                      50.4610          14304   EMG ONE EXT-HOSP20.71                          544.60                          95860           1
  922   OTHER DIAG EMG                      50.4610          14305   EMG TWO EXT-HOSP40.27                        1,010.40                          95861           1
  922   OTHER DIAG EMG                      50.4610          14306   EMG THREE EXT-HOSP50.91                      1,485.85                          95863           1
  922   OTHER DIAG EMG                      50.4610          14307   EMG FOUR EXT-HOSP96.32                       1,956.35                          95864           1
  922   OTHER DIAG EMG                      50.4610          14308   NRV CON NEL&SNG-HOSP MOTOR W/O                 396.90                          95900           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                97 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE     MCAL       CPT-4     HCPCS      RVU
  922   OTHER DIAG EMG                      50.4610       14309   NRV CON VEL&SEN-HOSP12.07                     396.90                          95904           1
  922   OTHER DIAG EMG                      50.4610       14310   H-REFLEX NO GASTROC/SOLEUS12.0                396.90                          95934           1
  922   OTHER DIAG EMG                      50.4610       14311   REPETITIVE NERVE STIMULATION16                396.90                          95937           1
  922   OTHER DIAG EMG                      50.4610       14313   H-RELEX GASTROC/SOLEUS15.64                   396.90                          95936           1
  922   OTHER DIAG EMG                      50.4610       14314   F-WAVE STUDY20.28                             396.90                          95903           1
  922   OTHER DIAG EMG                      50.4611       15016   H-REFLEX STUDY NO GASTRO RICHA                 35.25   9593626              9593626
  986   PROF FEES EEG                       50.4611       15312   NRV CON VEL&SNG W/O F-WAVE AMO                 30.00                        9590026
  986   PROF FEES EEG                       50.4611       15314   NRV CON VEL&SNG W/O F-WAVE LEO                 30.00                        9590026
  986   PROF FEES EEG                       50.4611       15315   NRV CON VEL+SNG W/O F-WAVE SHE                 30.00                        9590026
  986   PROF FEES EEG                       50.4611       15316   NVC CON VEL&SNG W/O F WAVE RIC                 30.00   9590026              9590026
  986   PROF FEES EEG                       50.4611       15322   ROUTINE EEG - DR AMORTEGUY                     43.00                        9581926
  986   PROF FEES EEG                       50.4611       15324   ROUTINE EEG - DR LEONARD                       43.00                        9581926
  986   PROF FEES EEG                       50.4611       15325   ROUTINE EEG - DR SHEEHY                        43.00                        9581926
  986   PROF FEES EEG                       50.4611       15326   EEG SLEEP - DR RICHARDSON                      43.00   9582226              9582226
  986   PROF FEES EEG                       50.4611       15332   EEG SLEEP - DR AMORTEGUY                       30.00                        9582226
  986   PROF FEES EEG                       50.4611       15334   EEG SLEEP - DR LEONARD                         30.00                        9582226
  986   PROF FEES EEG                       50.4611       15335   EEG SLEEP - DR SHEEHY                          30.00                        9582226
  986   PROF FEES EEG                       50.4611       15342   EEG MED - DR AMORTEGUY                         43.00                        9595426
  986   PROF FEES EEG                       50.4611       15344   EEG MED - DR LEONARD                           43.00                        9595426
  986   PROF FEES EEG                       50.4611       15345   EEG MED - DR SHEEHY                            43.00                        9595426
  986   PROF FEES EEG                       50.4611       15346   EEG MED-DR RICHARDSON                          43.00   9595426              9595426
  986   PROF FEES EEG                       50.4611       15352   EMG ONE EXT - DR AMORTEGUY                     62.00                        9586026
  986   PROF FEES EEG                       50.4611       15354   EMG ONE EXT - DR LEONARD                       62.00                        9586026
  986   PROF FEES EEG                       50.4611       15355   EMG ONE EXT - DR SHEEHY                        62.00                        9586026
  986   PROF FEES EEG                       50.4611       15356   EMG ONE EXT - DR RICHARDSON                    62.00   9586026              9586026
  986   PROF FEES EEG                       50.4611       15362   EMG TWO EXT - DR AMORTEGUY                    104.00                        9586126
  986   PROF FEES EEG                       50.4611       15364   EMG TWO EXT - DR LEONARD                      104.00                        9586126
  986   PROF FEES EEG                       50.4611       15365   EMG TWO EXT - DR SHEEHY                       104.00                        9586126
  986   PROF FEES EEG                       50.4611       15366   EMG TWO EXT - DR RICHARDSON                   104.00   9586126              9586126
  986   PROF FEES EEG                       50.4611       15372   EMG THREE EXT - DR AMORTEGUY                  143.00                        9586326
  986   PROF FEES EEG                       50.4611       15374   EMG THREE EXT - DR LEONARD                    143.00                        9586326
  986   PROF FEES EEG                       50.4611       15375   EMG THREE EXT - DR SHEEHY                     143.00                        9586326
  986   PROF FEES EEG                       50.4611       15376   EMG THREE EXT - DR RICHARDSON                 143.00   9856326              9586326
  986   PROF FEES EEG                       50.4611       15382   EMG FOUR EXT - DR AMORTEGUY                   189.80                        9586426
  986   PROF FEES EEG                       50.4611       15384   EMG FOUR EXT - DR LEONARD                     189.80                        9586426
  986   PROF FEES EEG                       50.4611       15385   EMG FOUR EXT - DR SHEEHY                      189.80                        9586426
  986   PROF FEES EEG                       50.4611       15386   EMG FOUR EXT - DR RICHARDSON                  189.90   9586426              9586426
  986   PROF FEES EEG                       50.4611       15392   NRV CON VEL&SEN - DR AMORTEGUY                 30.00                        9590426
  986   PROF FEES EEG                       50.4611       15394   NRV CON VEL&SEN - DR LEONARD                   30.00                        9590426
  986   PROF FEES EEG                       50.4611       15395   NRV CON VEL+SEN - DR SHEEHY                    30.00                        9590426
  986   PROF FEES EEG                       50.4611       15396   NRV CON VEL&SEN - DR RICHARDSO                 30.00   9590426              9590426
  922   OTHER DIAG EMG                      50.4611       15813   H-REFLEX GASTROC/SOLEUS SHEEHY                 30.00                          95934
  922   OTHER DIAG EMG                      50.4611       15814   H-REFLEX GASTROC/SOLEUS LEONAR                 35.25                          95934
  922   OTHER DIAG EMG                      50.4611       15823   REP NERVE STIMUATION-SHEEHY16.                 30.00                          95937
  922   OTHER DIAG EMG                      50.4611       15824   REP NERVE STIMULATION-LEONARD1                 35.25                          95937
  922   OTHER DIAG EMG                      50.4611       15828   REP NERVE STIMULATION-RICHARDS                 35.25   9593726              9593726
  969   PROF FEES OTHER                     50.4611       15832   ART ULTRASOUND UPPER EXT DR TE                 87.40                        9393026           1
  986   PROF FEES EEG                       50.4611       15834   F-WAVE STUDY LEONARD                           38.00                        9590326           1
  986   PROF FEES EEG                       50.4611       15835   F-WAVE STUDY SHEEHY                            38.00                        9590326           1
  922   OTHER DIAG EMG                      50.4611       15842   H-REFLEX STUDY NO GASTROC/SOLE                 35.25                          95936           1
  922   OTHER DIAG EMG                      50.4611       15844   H-REFLEX STUDY NO GASTROC/SOLE                 35.25                          95936           1
  922   OTHER DIAG EMG                      50.4611       15845   H-REFLEX STUDY NO GASTROC/SOLE                 35.25                          95936           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                             98 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE       MCAL       CPT-4     HCPCS      RVU
  740   EEG GENERAL                         50.4612       14301   ROUTINE EEG-HOSP73.76                          948.05                           95819           1
  730   EKG/ECG GENERAL                     50.4625       14501   ROUT EKG 12LEAD-HOSP23.42                      424.75   93005TC                 93005           1
  482   CARDIOLOGY STRESS TEST              50.4625       14502   TREADM STR TST-HOSP                          1,650.10   93017TC                 93017           1
  943   OTHER THER CARDIAC REHAB            50.4625       14506   CARDIAC REHAB BRIEF EVAL                       329.20                           93797           1
  943   OTHER THER CARDIAC REHAB            50.4625       14507   EVAL & THERAPY CARDIAC REHAB                   572.35                           93798           1
  320   RADIOLOGY DIAG GENERAL              50.4630          30   EYE FORGN BDY-HOSP                             595.40   70030TC                 70030           1
  320   RADIOLOGY DIAG GENERAL              50.4630          31   FOREIGN BODY SINGLE VIEW CHILD                 276.70   76010TC                 76010           1
  320   RADIOLOGY DIAG GENERAL              50.4630         100   MANDIBLE LIM UNI-HOSP                          411.05   70100TC                 70100           1
  320   RADIOLOGY DIAG GENERAL              50.4630         110   MANDIBLE BILAT-HOSP                            636.70   70110TC                 70110           1
  320   RADIOLOGY DIAG GENERAL              50.4630         130   MASTOIDS-HOSP                                  816.70   70130TC                 70130           1
  320   RADIOLOGY DIAG GENERAL              50.4630         134   INTER AUD MEAST-HOSP                           765.85   70134TC                 70134           1
  320   RADIOLOGY DIAG GENERAL              50.4630         140   FACIAL BONES LIMITED                           503.25   70140TC                 70140           1
  320   RADIOLOGY DIAG GENERAL              50.4630         150   FACIAL BNES COMPLETE                           701.35   70150TC                 70150           1
  320   RADIOLOGY DIAG GENERAL              50.4630         160   NASAL BONES-HOSP                               475.15   70160TC                 70160           1
  320   RADIOLOGY DIAG GENERAL              50.4630         190   OPTIC FORAMINA-HOSP                            411.05   70190TC                 70190           1
  320   RADIOLOGY DIAG GENERAL              50.4630         200   ORBITS                                         521.70   70200TC                 70200           1
  320   RADIOLOGY DIAG GENERAL              50.4630         210   PARANSL SIN LIM-HOSP                           373.85   70210TC                 70210           1
  320   RADIOLOGY DIAG GENERAL              50.4630         211   WATER VIEWS ONL-HOSP                           272.30   70210TC                 70210           1
  320   RADIOLOGY DIAG GENERAL              50.4630         220   PARANSL SIN COMP-HOSP                          756.60   70220TC                 70220           1
  320   RADIOLOGY DIAG GENERAL              50.4630         240   SELLA TURCICA-HOSP                             396.95   70240TC                 70240           1
  320   RADIOLOGY DIAG GENERAL              50.4630         250   SKULL LIMITED-HOSP                             438.75   70250TC                 70250           1
  320   RADIOLOGY DIAG GENERAL              50.4630         260   SKULL COMPLETE-HOSP                            876.55   70260TC                 70260           1
  320   RADIOLOGY DIAG GENERAL              50.4630         300   TEETH SING VW-HOSP                             138.35   70300TC                 70300           1
  320   RADIOLOGY DIAG GENERAL              50.4630         328   TEMPOROMANDIBULAR JOINTS UNILA                 438.75   70328TC                 70328           1
  320   RADIOLOGY DIAG GENERAL              50.4630         330   TEMPOROMND JTS-HOSP                            604.35   70330TC                 70330           1
  320   RADIOLOGY DIAG GENERAL              50.4630         360   NECK SOFT TISS-HOSP                            291.05   70360TC                 70360           1
  320   RADIOLOGY DIAG GENERAL              50.4630         380   SALIVARY GLND-HOSP                             411.05   70380TC                 70380           1
  320   RADIOLOGY DIAG GENERAL              50.4630         390   SIALOGRAPHY                                    401.45   70390TC                 70390           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1008   INDUSTRIAL HEALTH/CHEST 1VIEW                  202.10   71010ZS                 71010           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1009   INDUSTRIAL HEALTH/CHEST 2VIEW                  265.05   71020TC                 71020           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1010   CHEST 1 VIEW-HOSP                              221.80   71010TC                 71010           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1020   CHEST 2 VIEW-HOSP                              272.30   71020TC                 71020           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1021   CHEST 3 VIEW-HOSP                              318.75   71021TC                 71021           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1030   CHEST 4 VIEW-HOSP                              369.35   71030TC                 71030           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1033   INDUSTRIAL HEALTH/CHEST 4VIEW                  340.85   71030TC                 71030           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1034   CHEST 4 VW & FLUORO-HOSP                       913.70   71034TC                 71034           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1035   CHEST SPECIAL VIEW, DECUBITIS                  406.05   71035TC                 71035           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1036   FLUORO GUIDANCE                                411.05   76003TC                 76003           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1037   FLUORO GUIDE VEIN DEVICE                       671.25   75998TC       75998     75998           1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630        1039   CHEST, DECUBITIS VIEW EXTENDED                 507.75   71035TC                 71035           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1040   BRONCHOG UNILATERAL                          1,042.75   71040TC                 71040           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1060   BRONCHOG BILATERAL                           1,407.20   71060TC                 71060           1
  270   M/S SUPPLY GENERAL                  50.4630        1082   ABLATION PROBE                               7,315.45                                           1
  270   M/S SUPPLY GENERAL                  50.4630        1092   GASTRO GJ CATHETER                           1,997.45
  320   RADIOLOGY DIAG GENERAL              50.4630        1100   RIBS UNILAT W/CHEST HOSP                       503.25   71101TC                 71101           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1110   RIBS BILAT W/CHEST HOSP                        581.40   71101TC                 71101           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1120   STERNUM-HOSP                                   411.05   71120TC                 71120           1
  320   RADIOLOGY DIAG GENERAL              50.4630        1130   STERNOCLAV.JTS-HOSP                            411.05   71130TC                 71130           1
  361   OR SVCS MINOR SURGERY               50.4630        1221   INJECTION EXTREMITY VENOGRAPHY                 356.40      36005      36005     36005           1
  320   RADIOLOGY DIAG GENERAL              50.4630        2000   INDUSTRIAL HEALTH/L-SPINE 3VIE                 323.10   72100TC                 72100           1
  320   RADIOLOGY DIAG GENERAL              50.4630        2005   INDUSTRIAL HEALTH/L-SPINE 5VIE                 476.50   72110TC                 72110           1
  320   RADIOLOGY DIAG GENERAL              50.4630        2020   SPINE CERV, LATERAL VIEW ONLY                  194.05   72020TC                 72020           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               99 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4    HCPCS     RVU
  320   RADIOLOGY DIAG GENERAL              50.4630        2021   C-SPINE LATERAL VIEW ONLY EXT                  244.60   72020TC                72020       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2040   SPINE CERV LIM-HOSP                            272.30   72040TC                72040       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2041   SPINE SINGLE VIEW                              263.95   72020TC                72020       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2050   CERV ROUT COMP-HOSP                            535.30   72050TC                72050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2052   CERV & FLEX EXT-HOSP                           775.35   72052TC                72052       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2070   THORACIC SPINE-HOSP 3V                         494.00   72072TC                72072       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2072   T SPINE LIMITED                                300.10   72070TC                72070       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2080   THORACO LUMBAR-HOSP                            494.00   72080TC                72080       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2090   SCOLIOSIS STUDY-HOSP                           411.05   72090TC                72090       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2100   LUMBAR LIMITED-HOSP                            309.20   72100TC                72100       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2110   LUMBAR SPINE-HOSP                              512.05   72110TC                72110       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2170   PELVIS 1 OR 2 VIEW-HOSP                        359.80   72170TC                72170       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2190   PELVIS COMPLETE-HOSP                           567.40   72190TC                72190       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2202   SACRO ILIAC JT-HOSP                            549.35   72202TC                72202       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2220   SACRUM-COCCYX-HOSP                             442.95   72220TC                72220       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2250   MYELOGRAM C-SPINE                            1,259.60   72240TC                72240       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2256   MYELOGRAM T-SPINE                            1,232.10   72255TC                72255       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2266   MYELOGRAM L-SPINE                            1,324.20   72265TC                72265       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2270   MYELOGRAM COMPLETE                           2,113.25   72270TC                72270       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2286   DISKOGRAM C-SPINE                              886.10   72285TC                72285       1
  320   RADIOLOGY DIAG GENERAL              50.4630        2295   FACET INJECTION-HOSP                           950.60                          76005       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3000   CLAVICLE-HOSP RT                               332.40   73000TC             73000RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3010   SCAPULA-HOSP RT                                411.05   73010TC             73010RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3020   SHOULDER LIM-HOSP RT                           327.60   73020TC             73020RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3030   SHOULDER COMP-HOSP RT                          438.75   73030TC             73030RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3040   SHOULDER ARTHROGRAM RT                         567.40   73040TC             73040RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3050   ACROMIO-CLAV JTS-HOSP                          475.15   73050TC                73050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3060   HUMERUS-HOSP RT                                332.40   73060TC             73060RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3061   HUMERUS COMP WITH COMPARISON                   415.25   73060TC                73060       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3070   ELBOW LIMITED-HOSP RT                          304.70   73070TC             73070RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3080   ELBOW COMPLETE-HOSP RT                         411.05   73080TC             73080RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3081   ELBOW COMPLETE WITH COMPARISON                 512.05   73080TC                73080       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3082   ELBOW COMP BILATERAL                           317.80    7308050   TC 73080507308050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3083   ELBOW LTD BILATERAL                            319.60    7307050   TC 73070507307050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3084   FINGER BILATERAL                               199.00    7314050    7314050 TC 7314050
  320   RADIOLOGY DIAG GENERAL              50.4630        3085   FORARM BILATERAL                               338.60    7309050   TC 73090507309050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3086   HAND COMP BILATERAL                            400.40   73130TC       73130    73130       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3087   HAND LTD BILATERAL                             272.05    7312050   TC 73120507312050
  320   RADIOLOGY DIAG GENERAL              50.4630        3088   HUMERUS BILATERAL                              317.80    7306050   TC 73060507306050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3089   SCAPULA BILATERAL                              376.60    7301050   TC 73010507301050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3090   FOREARM-HOSP RT                                323.10   73090TC             73090RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3091   FOREARM WITH COMPARISON                        401.45   73090TC                73090       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3100   WRIST LIMITED-HOSP RT                          396.95   73100TC             73100RT        1
  320   RADIOLOGY DIAG GENERAL              50.4630        3101   SHOULDER COMPLETE BILATERAL                    381.35    7303050   TC 73030    73030       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3102   SHOULDER LTD BILATERAL                         272.05    7302050   TC 73020507302050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3103   UPPER EXT INFANT BILATERAL                     200.20    7309250   TC 73092507309250       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3104   WRIST COMP BILATERAL                           355.85    7311050   TC 73110507311050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3105   WRIST LTD BILATERAL                            272.05    7310050   TC 73100507310050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3106   ANKLE COMP BILATERAL                           355.85    7361050   TC 73610507361050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3107   ANKLE LTD BILATERAL                            285.15    7360050   TC 73600507360050
  320   RADIOLOGY DIAG GENERAL              50.4630        3108   FEMUR BILATERAL                                317.80    7355050   TC 73550507355050       1
  320   RADIOLOGY DIAG GENERAL              50.4630        3109   WRIST ARTHROGRAM RT                            977.95   73115TC             73115RT        1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           100 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4    HCPCS        RVU
  320   RADIOLOGY DIAG GENERAL              50.4630        3110   WRIST COMPLETE-HOSP RT                         535.30   73110TC             73110RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        3111   WRIST COMPLETE WITH COMPARISON                 669.20   73110TC                73110            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3120   HAND LIMITED-HOSP RT                           323.10   73120TC             73120RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        3130   HAND COMPLETE-HOSP RT                          424.75   73130TC             73130RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        3131   HAND COMPLETE WITH COMPARISON                  535.30   73130TC                73130            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3140   FINGER(S)-HOSP RT                              291.05   73140TC             73140RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        3141   FINGER(S) WITH COMPARISON                      364.55   73140TC                73140            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3209   FOOT COMPLETE BILATERAL                        355.85   73630TC       73630    73630            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3210   RIBS BILATERAL                                 321.35    7111050   TC 71110507111050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3211   PELVIS 3 VIEW                                  321.35   72190TC       72190    72190            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3212   T SPINE 4 VIEW                                 335.65   72074TC       72074    72074            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3213   FOOT LTD BILATERAL                             275.65    7362050   TC 73620507362050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3214   HEEL BILATERAL                                 352.85    7365050   TC 73650507365050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3215   HIP BILATERAL COMPLETE                         347.50    7352050   TC 73520507352050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3216   HIP PELVIS INFANT                              240.00   73540TC       73540    73540            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3217   HIP IN SURGERY                                 380.75   73530TC       73530    73530            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3218   KNEE 3 VIEW BILATERAL                          417.00    7356250   TC 73562    73562            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3220   KNEE COMP BILATERAL                            472.85    7356450   TC 73564507356450            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3221   KNEE LTD BILATERAL                             285.15    7356050   TC 73560507356050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3222   LOWER EXT INFANT BILATERAL                     352.85    7359250   TC 73592507359250            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3223   TIBIA FIBULA BILATERAL                         317.80    7359050    7359050 7359050             1
  320   RADIOLOGY DIAG GENERAL              50.4630        3224   TOES BILATERAL                                 285.15    7366050   TC 73660507366050            1
  320   RADIOLOGY DIAG GENERAL              50.4630        3225   BE INTESSUPTION                                657.60   74283TC       74283    74283
  320   RADIOLOGY DIAG GENERAL              50.4630        3226   UPPER GI W/O KUB                               380.75   74240TC       74240    74240            1
  361   OR SVCS MINOR SURGERY               50.4630        3227   ABCESS ABD                                     354.05                                           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3229   ELBOW ANTHROGRAM                               590.45   73085TC       73085      73085          1
  403   OTH IMAG SCREEN MAMMOGRAPH          50.4630        3314   MAMMO SCREENING                                152.70   77057TC       77057      77057          1
  401   OTH IMAG DIAG MAMMOGRAPHY           50.4630        3317   MAMMO SPECIAL                                   59.40                                           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3424   UGI AIR CON/KUB SBWL                           723.50   74249TC       74249      74249          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3500   HIP UNILAT LIM-HOSP RT                         480.20   73500TC               73500RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3510   HIP UNILAT COMP-HOSP RT                        595.40   73510TC               73510RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3520   HIP BILAT PELV-HOSP                            701.35   73520TC                  73520          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3525   HIP ARTHROGRAM-HOSP RT                       1,291.85   73525TC               73525RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3530   HIP OPER PROC-HOSP RT                        1,061.10   73530TC               73530RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3550   FEMUR-HOSP RT                                  411.05   73550TC               73550RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3560   KNEE 1 OR 2 VIEW RT                            373.85   73560TC               73560RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3561   KNEE AP AND LATERAL W/COMP RT2                 466.25   73560TC               7356022RT         1
  320   RADIOLOGY DIAG GENERAL              50.4630        3562   THREE VIEW KNEE RT                             466.25   73562TC               73562RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3570   KNEE WITH SPECIAL VIEWS RT                     581.40   73564TC               73564RT           1
  322   RADIOLOGY DIAG ARTHROGRAPH          50.4630        3580   KNEE ARTHRO-HOSP RT                          1,149.15   73580TC               73580RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3590   TIBIA FIBULA-HOSP RT                           332.40   73590TC               73590RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3591   TIBIA FIBULA WITH COMPARISON                   516.95   73590TC                  73590          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3600   ANKLE LIMITED-HOSP RT                          359.80   73600TC               73600RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3601   ANKLE LIMITED WITH COMPARISON                  447.55   73600TC                  73600          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3610   ANKLE COMPLETE-HOSP RT                         521.70   73610TC               73610RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3611   ANKLE COMPLETE WITH COMPARISON                 655.35   73610TC                  73610          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3615   ANKLE ARTHROGRAM RT                            599.90   73615TC               73615RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3620   FOOT LIMITED-HOSP RT                           318.75   73620TC               73620RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3630   FOOT COMPLETE-HOSP RT                          406.05   73630TC               73630RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3631   FOOT COMPLETE WITH COMPARISON                  507.75   73630TC                  73630          1
  320   RADIOLOGY DIAG GENERAL              50.4630        3650   OS CALIS HEEL-HOSP RT                          291.05   73650TC               73650RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        3660   TOE(S)-HOSP RT                                 254.00   73660TC               73660RT           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               101 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE        MCAL   CPT-4      HCPCS       RVU
  320   RADIOLOGY DIAG GENERAL              50.4630        3661   TOE(S) WITH COMPARISON RT17.93                 313.90   73660TC            73660RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        4000   ABDOMEN 1 VW KUB-HOSP                          369.35   74000TC               74000            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4001   ABDOMEN 1 VIEW 1 EXTENDED                      461.45   74000TC               74000            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4010   ABDOMEN 2 VW -HOSP                             507.75   74010TC               74010            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4011   ABDOMEN 2 VIEW EXTENDED                        641.55   74010TC               74010            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4020   ABDOMEN 3 VW -HOSP                             632.25   74020TC               74020            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4021   ABDOMEN SERIES, 3 VIEW EXTENDE                 784.25   74022TC               74022            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4210   PHARYNX CER ESO VIDEO                          581.40   74210TC               74210            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4215   BARIUM SWALLOW                                 936.65   74230TC               74230            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4220   ESOPHAGUS-HOSP                                 664.50   74220TC               74220            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4241   UGI - UPPER GI                               1,088.70   74241TC               74241            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4242   UGI - UPPER GI WITH AIR CONTRA               1,282.70   74247TC               74247            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4243   UPPER GI BARIATRIC POST OP                   1,088.70   74241TC               74241
  320   RADIOLOGY DIAG GENERAL              50.4630        4244   UGI-SBFT GRASTROGRAFIN GI-SML                1,841.05   74245TC               74245            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4245   UGI + SMALL BOWEL WITH AIR CON               1,564.30   74249TC               74245            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4249   UGI + SMALL BOWEL                            1,384.30   74245TC               74245            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4250   SMALL BOWEL-HOSP                               867.70   74250TC               74250            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4270   COLON BARI ENEMA WITHOUT AIR C                 803.00   74270TC               74270            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4271   BARIUM ENEMA WITHOUT AIR - EXT               1,005.80   74270TC               74270            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4275   COLON W/AIR-HOSP                             1,314.95   74280TC               74280            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4276   BARIUM ENEMA WITH AIR - EXTEND               1,642.40   74280TC               74280            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4290   CHOLECYST ORAL-HOSP                            636.70   74290TC               74290            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4291   CHOLECYST REPT-HOSP                            387.70   74291TC               74291            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4300   CHOLANGIO OPER-HOSP                            881.35   74300TC               74300            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4301   CHOLANGIO OPERATIVE ADDITIONAL                 521.70   74301TC               74301            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4305   CHOLANGIO T-TUBE-HOSP                          658.75   74305TC               74305            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4320   PERCUTAN TRANSHPT                              765.85   74320TC               74320            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4322   X RAY LOWER EXT 2V INFANTS RT                  116.15   73592RT TC         73592RT
  320   RADIOLOGY DIAG GENERAL              50.4630        4323   X RAY UPPER EXT 2V INFANTS RT                  116.15   73092RT TC         73092RT
  320   RADIOLOGY DIAG GENERAL              50.4630        4340   GI TUBE PLACEMNT EG:MILLER-ABB                 512.05   74340TC               74340            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4351   GASTROSTOMY TUBE PLACMNT PERCU                 447.55   74350TC               74350            1
  761   TREAT/OBS RM TREATMENT RM           50.4630        4353   CHANGE OF GASTROSTOMY TUBE                     568.65   43760TC               43760
  320   RADIOLOGY DIAG GENERAL              50.4630        4356   ENTEROCLYSIS STDY/GASTRIC TUBE               1,481.00   74251TC               74355            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4360   BILIARY DUCT STONE REMOVAL                   1,116.85   74327TC               74327            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4399   ERCP                                           927.45   74330TC               74330            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4400   IVP W/O TOMOS-HOSP                           1,259.60   74400TC               74400            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4401   IVP WITHOUT TOMOGRAPHY EXTENDE               1,578.15   74400TC               74400            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4406   IVP WITH TOMOGRAPHY                          1,684.30   74415TC               74415            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4407   IVP WITH TOMOGRAPHY EXTENDED                 2,108.40   74415TC               74415            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4415   NEPHROTOMO INFUSION-DRIP                     1,725.80   74415TC               74415            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4420   UROGRAPHY RETRO-HOSP                           862.90   74420TC               74420            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4430   CYSTOGRAPHY                                    401.45   74430TC               74430            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4455   URETHROCYSTOGRAPHY                             756.60   74455TC               74455            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4470   RENAL CYST PUNCTURE                            544.50   74470TC               74470            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4475   PERCUTANEOUS NEPHROSTOGRAPHY                 1,282.70   74475TC               74475            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4480   URETERAL STENT PLACEMENT                     1,444.15   74480TC               74480            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4710   PELVIMETRY-HOSP                                706.10   74710TC               74710            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4740   HYSTEROSALPIN                                  567.40   74740TC               74740            1
  320   RADIOLOGY DIAG GENERAL              50.4630        4798   NEPHROSTOMY PLC-HOSP                         1,721.00   74475TC               74475            1
  761   TREAT/OBS RM TREATMENT RM           50.4630        4801   CHANGE OF NEPHROSTOMY TUBE                     568.65                         50398
  320   RADIOLOGY DIAG GENERAL              50.4630        5970   VENOGRAPHY UNILATERAL RT                       927.45   75820TC            75820RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630        5971   VENOGRAPHY BILATERAL                         1,393.50   75822TC               75822            1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              102 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS     RVU
  320   RADIOLOGY DIAG GENERAL              50.4630        5980   LYMPHANGIOGRAM UNILATERAL RT                    756.60 75801TC                75801RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630        5982   LYMPHANGIOGRAM BILATERAL                      1,550.20 75803TC                    75803         1
  320   RADIOLOGY DIAG GENERAL              50.4630        5983   BILIARY DRAINAGE PERCUTAN TRAN                1,241.30                            75980         1
  320   RADIOLOGY DIAG GENERAL              50.4630        5985   CHANGE DRAINAGE CATH BILIARY-G                  834.95                            75984         1
  320   RADIOLOGY DIAG GENERAL              50.4630        5990   ABCESS DRAINAGE PERCUTANEOUS                  1,365.50                            75989         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6000   FLUORO CARM UNDER ONE HOUR                      826.05 76005TC                    77003         2
  320   RADIOLOGY DIAG GENERAL              50.4630        6001   FLUORO RM < ONE HOUR                            826.05 76000TC                    76000         3
  320   RADIOLOGY DIAG GENERAL              50.4630        6002   FLUORO RM > ONE HOUR                          1,342.40 76001TC                    76001         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6003   NEEDLE LOCALIZATION                             876.55                            77002         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6004   FLUORO CARM ONE HOUR                          1,342.40                            76000         4
  320   RADIOLOGY DIAG GENERAL              50.4630        6020   BONE AGE STUD-HOSP                              452.45                            76020         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6040   BONE LNGTH STUD-HOSP                            733.90                            77073         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6060   BONE SURVEY-HOSP                              1,001.30                            76062         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6061   BONE SURVEY INFANT HOSP                       1,001.30 76065TC                    76065         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6082   FISTULA-SINOGRAM                                438.75                            76080         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6095   RAD EXAM BREAST SURG SPECIMEN                   217.20 76098ZS                    76098         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6100   LAMINOGRAPHY-HOSP                               945.90                            76100         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6140   WRIT CONSULT-HOSP                               101.90                            76140         1
  402   OTH IMAG ULTRASOUND                 50.4630        6311   ECHO TRANSRECTAL                              1,227.15                            76872         1
  402   OTH IMAG ULTRASOUND                 50.4630        6317   ECHO CAROTIDS RT134.80                        1,107.55 93882TC                93882RT           1
  402   OTH IMAG ULTRASOUND                 50.4630        6731   ECHO RENAL WITH DOPPLER                       1,204.35 93975TC                    93975         1
  402   OTH IMAG ULTRASOUND                 50.4630        6815   LTD PREGNCY STY-HOSP                            392.30 76815TC                    76815         1
  402   OTH IMAG ULTRASOUND                 50.4630        6843   ECHO FOLICULAR STAGING DAY 2                    572.35                            76857         1
  402   OTH IMAG ULTRASOUND                 50.4630        6845   ECHO FOLICULAR STAGING DAY 3                    383.25                            76858         1
  402   OTH IMAG ULTRASOUND                 50.4630        6898   ECHO BREAST-HOSP BILAT45.08                   1,346.95                            76645         1
  402   OTH IMAG ULTRASOUND                 50.4630        6977   ECHO BIOPSY GUIDE RENAL                         687.65                            76942         1
  402   OTH IMAG ULTRASOUND                 50.4630        6978   ECHO BIOPSY GUIDE PANCREAS                      687.65                            76942         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6979   ULTRASONIC GUIDANCE                             630.85                            76942         1
  320   RADIOLOGY DIAG GENERAL              50.4630        6999   RADIOLOGY HBA MISC CHARGE                   misc chrg determined at time of svcs      0
  320   RADIOLOGY DIAG GENERAL              50.4630        9044   PYELOGRAM,ANTE/NEPHRO                           627.30 74425TC         74425      74425         1
  401   OTH IMAG DIAG MAMMOGRAPHY           50.4630        9910   MAMMOGRAM UNILATERL,PROC CHG R                  109.30 77055TC         77055      77055         1
  401   OTH IMAG DIAG MAMMOGRAPHY           50.4630        9920   MAMMOGRAM BILATERL, PRC CHG (D                  205.55 77056TC         77056      77056         1
  320   RADIOLOGY DIAG GENERAL              50.4630        9925   GALACTOGRAPHY-SINGLE DUCT                       335.65 76086TC                    76086         1
  320   RADIOLOGY DIAG GENERAL              50.4630        9926   GALACTOGRAPHY-MULT DUCTS                        297.00                            76088         1
  270   M/S SUPPLY GENERAL                  50.4630       10031   THORACIC VENT FOR PNEMOTHRAX                    591.30
  921   OTHER DIAG PERIPHERAL LAB           50.4630       15421   US VENOUS DUPLEX EXT UPPER RT                 1,083.95                        93971RT           1
  921   OTHER DIAG PERIPHERAL LAB           50.4630       15422   US VENOUS DUPLEX EXT LOWER BIL                1,683.20                            93970         1
  921   OTHER DIAG PERIPHERAL LAB           50.4630       15429   US VENOUS DUPLEX EXT LOWER RT                 1,083.95                        93971RT           1
  320   RADIOLOGY DIAG GENERAL              50.4630       25246   WRIST ARTHROGRAM INJECTION PRO                  473.35      25246                 25246         1
  270   M/S SUPPLY GENERAL                  50.4630       29210   MINI STICK KIT                                  290.85
  270   M/S SUPPLY GENERAL                  50.4630       29211   COOK DUAL LOCK ADAPTER                            15.40
  490   AMB SURGICAL CARE GENERAL           50.4630       36025   CENTRAL LINE PLACEMENT                        4,112.00                                          4
  490   AMB SURGICAL CARE GENERAL           50.4630       36026   PICC LINE INSERTION                           1,462.25                                          1
  420   PHYSICAL THERAPY GENERAL            50.4630       45179   ULTRASOUND GUIDANCE                           1,535.40 76965TC                    76965         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       70390   SIALOGRAPHY INJECTION PROCEDUR                  152.40                            42550         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       71036   BIOPSY PLUERA                                   152.40      32400                 32400         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       72250   MYELOGRAM C-SPINE INJECTION PR                  419.80                            61055         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       72256   MYELOGRAM T-SPINE INJECTION PR                  411.05                            62284         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       72266   MYELOGRAM L-SPINE INJECTION PR                  442.95                            62284         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       72270   MYELOGRAM COMPLETE INJECTION P                  706.10                            62284         1
  761   TREAT/OBS RM TREATMENT RM           50.4630       72286   DISKOGRAM C-SPINE INJECTION PR                  295.50                            62291         1
  361   OR SVCS MINOR SURGERY               50.4630       72290   DISKOGRAM L-SPINE INJECTION PR                  327.60                            62290         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               103 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                    CHARGE       MCAL      CPT-4    HCPCS       RVU
  361   OR SVCS MINOR SURGERY               50.4630          73040   SHOULDER ARTHROGRAM INJECTION                  189.35     23350               23350            1
  361   OR SVCS MINOR SURGERY               50.4630          73615   ANKLE ARTHROGRAM INJECTION PRO                 203.10     27648               27648            1
  361   OR SVCS MINOR SURGERY               50.4630          74320   PERCUTAN TRANSHPT INJECTION PR                 258.40                         47500            1
  361   OR SVCS MINOR SURGERY               50.4630          74351   GASTROSTOMY TUBE PLC PERC INJ                  152.40                         43246            1
  361   OR SVCS MINOR SURGERY               50.4630          74356   ENTEROCYLSIS STDY/SML BOWEL IN                 494.00                         44015            1
  361   OR SVCS MINOR SURGERY               50.4630          74360   BILIARY DUCT STONE REMOVAL INJ                 378.60                         47630            1
  361   OR SVCS MINOR SURGERY               50.4630          74430   CYSTOGRAPHY INJECTION PROC                     152.40                         51600            1
  361   OR SVCS MINOR SURGERY               50.4630          74455   URETHROCYSTOGRAPHY INJECTION P                 258.40                         51600            1
  361   OR SVCS MINOR SURGERY               50.4630          74470   RENAL CYST PUNCTURE INJ/ASP PR                 184.75                         50390            1
  361   OR SVCS MINOR SURGERY               50.4630          74475   PERCUTANEOUS NEPHROSTOGRAPHY I                 438.75                         50394            1
  361   OR SVCS MINOR SURGERY               50.4630          74740   ECHO HYSTROSALINE                              189.35                         58340            1
  361   OR SVCS MINOR SURGERY               50.4630          74801   CHANGE NEPHRO TUBE MONITORING-                 304.95                         75984
  361   OR SVCS MINOR SURGERY               50.4630          75970   VENOGRAPHY UNILATERAL INJ PROC                 309.20     36000               36000            1
  361   OR SVCS MINOR SURGERY               50.4630          75971   VENOGRAPHY BILATERAL INJECTION                 470.80     36000               36000            1
  361   OR SVCS MINOR SURGERY               50.4630          75980   LYMPHANGIOGRAM UNILAT INJECTIO                 254.00                         38790            1
  361   OR SVCS MINOR SURGERY               50.4630          75982   LYMPHANGIOGRAM BILAT INJECTION                 521.70                         38790            1
  361   OR SVCS MINOR SURGERY               50.4630          75983   BILIARY DRAIN PERCUT TRANS INJ                 415.25                         47510            1
  361   OR SVCS MINOR SURGERY               50.4630          75985   CHANGE DRAIN CATH BIL/GU INJ P                 277.15                         47525            1
  361   OR SVCS MINOR SURGERY               50.4630          75990   ABCESS DRAIN PERCUT INJ PROCED                 249.50                         49020            1
  361   OR SVCS MINOR SURGERY               50.4630          76082   FISTULA-SINOGRAM INJ PROC-PROF                 265.80     20501               20501            1
  361   OR SVCS MINOR SURGERY               50.4630          76960   AMINO SURGICAL CODE                            309.20                         59000            1
  361   OR SVCS MINOR SURGERY               50.4630          76965   ECHO PERICARDIOCENTESIS GDE IN                 309.20     33010               33010            1
  361   OR SVCS MINOR SURGERY               50.4630          76977   BIOPSY GUIDE RENAL                             230.85                         50200            1
  361   OR SVCS MINOR SURGERY               50.4630          76978   BIOPSY GUIDE PANCREAS                          230.85                         48102            1
  361   OR SVCS MINOR SURGERY               50.4630          76981   ECHO CYST ASP GUIDE LIVER INJ                  230.85                         47010            1
  361   OR SVCS MINOR SURGERY               50.4630          76982   ABDOMINAL PARACENTESIS                         230.85                         49080            1
  361   OR SVCS MINOR SURGERY               50.4630          76983   ECHO CYST GUIDE PANCREAS INJ P                 230.85                         48500            1
  320   RADIOLOGY DIAG GENERAL              50.4630    L0100         MANDIBLE LIM UNI-HOSP                          411.05   70100TC               70100            1
  320   RADIOLOGY DIAG GENERAL              50.4630    L1100         RIBBS UNILAT W/CHEST HOSP                      503.25   71101TC               71101            1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3000         CLAVICLE-HOSP LT                               332.40   73000TC            73000LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3010         SCAPULA-HOSP LT                                411.05   73010TC            73010LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3020         SHOULDER LIM-HOSP LT                           327.60   73020LT TC         73020LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3030         SHOULDER COMP-HOSP LT                          438.75   73030TC            73030LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3040         SHOULDER ARTHROGRAM LT                         567.40   73040TC            73040LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3060         HUMERUS-HOSP LT                                332.40   73060TC            73060LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3070         ELBOW LIMITED-HOSP LT                          304.70   73070TC            73070LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3080         ELBOW COMPLETE-HOSP LT                         411.05   73080TC            73080LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3090         FOREARM-HOSP LT                                323.10   73090TC            73090LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3100         WRIST LIMITED-HOSP LT                          396.95   73100TC            73100LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3109         WRIST ARTHROGRAM LT                            977.95   73115TC            73115LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3110         WRIST COMPLETE HOSP LT                         535.30   73110TC            73110LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3120         HAND LIMITED-HOSP LT                           323.10   73120TC            73120LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3130         HAND COMPLETE-HOSP LT22.54                     424.75   73130TC            73130LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3140         FINGER(S)-HOSP LT                              291.05   73140TC            73140LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3500         HIP UNILAT LIM-HOSP LT                         480.20   73500TC            73500LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3501         HIP UNILATERAL LIMITED EXT LT                  595.40   73500TC            73500LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3510         HIP UNILAT COMP-HOSP LT                        595.40   73510TC            73510LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3511         HIP UNILATERAL COMPLETE EXT LT                 742.75   73510TC            73510LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3525         HIP ARTHROGRAM-HOSP LT                       1,291.85   73525TC            73525LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3530         HIP OPER PROC-HOSP LT                        1,061.10   73530TC            73530LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3550         FEMUR-HOSP LT                                  411.05   73550TC            73550LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3560         KNEE 1 OR 2 VIEW LT                            373.85   73560TC            73560LT             1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                104 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                           OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                     CHARGE        MCAL   CPT-4       HCPCS       RVU
  320   RADIOLOGY DIAG GENERAL              50.4630    L3561         KNEE AP AND LATERAL W/COMP LT                   466.25   73562TC             73562LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3562         THREE VIEW KNEE LT                              466.25   73562TC             73562LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3570         KNEE WITH SPECIAL VIEW LT                       581.40   73564TC             73564LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3580         KNEE ARTHRO-HOSP LT                           1,149.15   73580TC             73580LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3590         TIBIA FIBULA-HOSP LT                            332.40   73590TC             73590LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3600         ANKLE LIMITED-HOSP LT                           359.80   73600TC             73600LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3610         ANKLE COMPLETE-HOSP LT                          521.70   73610TC             73610LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3615         ANKLE ARTHROGRAM LT                             599.90   73615TC             73615LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3620         FOOT LIMITED-HOSP LT                            318.75   73620TC             73620LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3630         FOOT COMPLETE-HOSP LT                           406.05   73630TC             73630LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3650         OS CALIS HEEL-HOSP LT                           291.05   73650TC             73650LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3660         TOE(S)-HOSP LT                                  254.00   73660TC             73660LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L3661         TOE(S) WITH COMPARISON LT                       313.90   73660TC             73660LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L5970         VENOGRAPHY UNILATERAL LT                        927.45   75820TC             75820LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    L5980         LYMPHANGIOGRAM UNILATERAL LT                    756.60   75801TC             75801LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6306         ECHO DUPLEX LOWER EXT ART UNI1                1,116.85   93926TC             93926LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6308         ECHO DUPLEX UPPER EXT ART UNIL                1,116.85   93931TC             93931LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6313         ECHO VENOUS UNILAT LT150.65                     911.75   93971TC             93971LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6317         ECHO CAROTIDS LT134.80                        1,107.55   93882TC             93882LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6996         ECHO EXTREMITY NON VASC LT                      673.50   76880TC             76880LT             1
  402   OTH IMAG ULTRASOUND                 50.4630    L6998         ECHO BREAST-HOSP LT                             659.25   76645TC             76645LT             1
  324   RADIOLOGY DIAG CHEST XRAY           50.4630    Y1020         CHEST 2 VIEW                                    266.65   71020TC                71020            1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y2120         LUMBAR WITH FLEX/EXTEND                         853.80   72120TC                72120            1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y3523L        KNEE COMPLETE 4 VIEWS                           476.55   73564LT TC          73564LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y352L         KNEE 3 VIEW LT                                  456.35   73562TC             73562LT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y3562         KNEE 3 VIEWS RT                                 456.35   73562TC             73562RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y3563         KNEE COMPLETE 4 VIEWS RT                        476.55   73564RT TC          73564RT             1
  320   RADIOLOGY DIAG GENERAL              50.4630    Y4322         X RAY LOWER EXT 2V INFANT LT                    116.15   73592LT TC          73592LT
  972   PROF FEES RADIOLOGY DIAGN           50.4631           9962   BONE DENSITOMETRY-PROF121.30                     63.80                        7607526
  972   PROF FEES RADIOLOGY DIAGN           50.4631          70005   EXAM CANC OR RESCHLD                        no charge                                0
  972   PROF FEES RADIOLOGY DIAGN           50.4631          71009   INDUSTRIAL HEALTH/CHEST 2VIEW2                   24.20    7102026             7102026
  972   PROF FEES RADIOLOGY DIAGN           50.4631          71033   INDUSTRIAL HEALTH/CHEST 4VIEW3                   31.35    7103026             7103026
  972   PROF FEES RADIOLOGY DIAGN           50.4631          74305   CHOLANGIO T-TUBE-PROF                            75.35                          74305
  972   PROF FEES RADIOLOGY DIAGN           50.4631          76095   SURG SPECIMEN                                    12.10                          76098
  972   PROF FEES RADIOLOGY DIAGN           50.4631          76998   ECHO BREAST-PROF                                 47.45                          76645
  621   MED/SUR SUPP INCID TO RAD           50.4632           6170   SUBTRACT FILM                                   210.25                          76350            1
  270   M/S SUPPLY GENERAL                  50.4632           6171   SINGLE ANGLE BRACKET                            115.40                                           1
  270   M/S SUPPLY GENERAL                  50.4632           6172   NEEDLE GUIDE COVER KIT                           48.30                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           6175   DUPLICATE FILM                                   53.95                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7700   E-Z-EM BIOPSY NEEDLE                            365.15                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7710   LYMPHANGIOGRAM SET                              165.00                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7711   TRU-CUT BX NEEDLE 18GA                          189.20                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7712   TRU-CUT BX NEEDLE 17GA                          220.70                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7713   TRU-CUT BX NEEDLE 14GA                          227.15                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7715   ROTEX II BX NEELDE                              535.70                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7718   MANAN LOCKING BX SYRINGE                         31.70                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7720   TECTMEYER LYMPH CANNULATOR                      366.20                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7730   BILIARY STONE REMOVAL CATH                    2,166.80                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7740   STONE REMOVAL BASKET                          2,160.00                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7750   ANTEGRADE JJ STENT KIT                        2,234.85                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7752   ACCUSTICK INTRODUCER SYSTEM                     673.50                                           1
  621   MED/SUR SUPP INCID TO RAD           50.4632           7760   MEDI-TECH PERC NEPHR SET                      1,320.85                                           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                  105 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  621   MED/SUR SUPP INCID TO RAD           50.4632        7762   NEPHROSTOMY CATHETER WITH TEMP                 821.15                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7770   RENAL DRAINAGE CATH SET                        707.90                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7790   RING BILIARY DRAIN SET                       1,030.10                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7800   COOK BILIARY DRAIN SET                       1,354.95                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7802   TRU-CLOSE GRAVITY DRAINAGE SYS                 110.90                                       1 Price determined at time of
  621   MED/SUR SUPP INCID TO RAD           50.4632        7803   TRU-FIX CATHETER FIXATION KIT                  110.90                                       1 servicebased on cost
  621   MED/SUR SUPP INCID TO RAD           50.4632        7815   BARD BIOPSY NEEDLES (BIOP GUN)                 222.55                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7820   CAREY COONS STENT SET                        1,462.60                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7822   CAREY-ALZATE-COONS GASTROJEJUN               1,522.70
  621   MED/SUR SUPP INCID TO RAD           50.4632        7825   CYSTO AID                                       58.70                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7830   ALL PURPOSE DRAIN SET                          745.40                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7832   ARGON HYSTERO TRAY                              97.00                                       1
  636   DRUG SPEC ID DETAIL CODING          50.4632        7835   OMNIPAQUE 180 20ML                             793.55          Q9958                        1
  636   DRUG SPEC ID DETAIL CODING          50.4632        7837   OMNIPAQUE 240, 150 ml.                         793.55          Q9946                        1
  636   DRUG SPEC ID DETAIL CODING          50.4632        7838   OMNIPAQUE 350 75ML                             793.45          Q9958                        1
  636   DRUG SPEC ID DETAIL CODING          50.4632        7839   OMNIPAQUE 300 50ML                             793.55          Q9958                        1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7840   BUDD PIGTAIL CATHETER                          610.15                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7842   APD (CATHETER ONLY)                            535.70                                       1
  636   DRUG SPEC ID DETAIL CODING          50.4632        7845   OMNIPAQUE 240 20ML                             793.55          Q9958                        1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7855   DUODENAL SET (14F FOR ENTEROC)                 429.65                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7865   FRANSEEN BIOPSY NEEDLE                         114.75                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7868   MEADOX BX GUN                                  283.45                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7869   MEADOX BX NEEDLE 21GA                          251.90                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7870   MEADOX BX NEEDLE 18GA                          189.20                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7875   WESTCOTT BIOPSY NEEDLE                         121.55                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        7885   5-6IN SPINAL NEEDLE                            151.35                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8050   VAN SONNENBURG SUMP KIT                      1,327.75                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8075   EXCHANGE WIRE                                  284.90                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8100   WIRE GUIDE                                     284.90                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8125   RING TORQUE GUIDE                              339.05                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8150   CATH INTRODUCER                                635.70                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8175   COOK COPE LOOP NEPHRO DRAIN                    934.70                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8275   GASTROVIST (PER BOTTLE)                         92.25                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8276   ORAL HYPAQUE (POWDER)                          274.20                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8280   METHYLCELLULOSE                                 62.35                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8290   ENTEROCLYSIS BARIUM                            180.55                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8310   ENTEROCLYSIS CATHETER                          461.30                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8320   ENTEROCLYSIS ADMIN KIT                         100.05                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8322   PNEUMOTHORAX KIT                             1,023.30                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8323   MRI - PROBE FOR RECTAL COIL                    872.40                                       1
  274   M/S SUPPLY PROSTHETHIC DVC          50.4632        8324   BILIARY STENT INTERNAL SSUI                  9,639.80
  621   MED/SUR SUPP INCID TO RAD           50.4632        8325   PANTOPAQUE (PER VIAL)                          352.25                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8400   HUI UTERINE INJECTOR                           361.35                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8425   SIALOGRAM CATHETER                             270.90                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8440   ENTEROCLYSIS CATH / BARIUM                   1,016.00                                       1
  636   DRUG SPEC ID DETAIL CODING          50.4632        8450   OMNIPAQUE 20CC 180MG                           793.55          Q9959    A4644               1
  636   DRUG SPEC ID DETAIL CODING          50.4632        8458   OMNIPAQUE 300 150CC                          2,380.65          Q9958
  636   DRUG SPEC ID DETAIL CODING          50.4632        8459   OMNIPAQUE 300 100CC                          1,587.10          Q9958
  636   DRUG SPEC ID DETAIL CODING          50.4632        8460   OMNIPAQUE 10CC 240MG                           793.55          Q9960    A4645               1
  636   DRUG SPEC ID DETAIL CODING          50.4632        8470   OMNIPAQUE 300 30 CC                            793.55          Q9958    A4641               1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8475   BIOPSY NEEDLE                                  365.15                                       1
  621   MED/SUR SUPP INCID TO RAD           50.4632        8500   BILIARY DRAIN                                1,287.00                                       1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                                      106 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                      Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                   DESCRIPTION                    CHARGE       MCAL      CPT-4     HCPCS      RVU
  621   MED/SUR SUPP INCID TO RAD           50.4632          8550   CHIBA BIOPSY NEEDLE                            174.00                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8552   E-Z-M BONE BIOPSY NEEDLE                       590.65                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8575   SURGI-TECH PERC NEPHRO DRAIN                 1,557.75                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8580   CONTRAST SPIKE                                  94.70                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8590   ZSI HYSTERO TRAY                               298.60                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8600   DILATOR                                        173.40                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          8602   VIDEO TAPE                                      24.60                                          1
  621   MED/SUR SUPP INCID TO RAD           50.4632          9257   MRA RECONSTRUCTION                             577.80                                          1
  320   RADIOLOGY DIAG GENERAL              50.4635          2101   LUMBAR LIMITED HOSPITAL EXT                    379.35   72100TC               72100            1
  320   RADIOLOGY DIAG GENERAL              50.4635    C6000        SPINE INJ LOCALIZATION                         808.45   76005TC               76005            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0030        EYE FOREIGN BODY                               582.70   70030TC               70030            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y006L        HUMERUS COMPLETE W/COMPARISON                  406.50   73060TC            73060LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0100        MANDIBLE UNILATERAL LIMITED RT                 402.35   70100TC               70100            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y010L        MANDIBLE LIM UNILATERAL                        402.35   70100TC               70100            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0110        MANDIBLE BILATERAL                             623.15   70110TC               70110            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0130        MASTOIDS                                       799.50   70130TC               70130            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0134        INTER AUD MEAST                                749.50   70134TC               70134            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0140        FACIAL BONES LIMITED                           492.55   70140TC               70140            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0150        FACIAL BONES COMPLETE                          686.35   70150TC               70150            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0160        NASAL BONES                                    465.10   70160TC               70160            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0190        OPTIC FORAMINA                                 402.35   70190TC               70190            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0200        ORBITS                                         510.55      70200              70200            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0210        PARANSL SIN LIMITED                            365.85   70210TC               70210            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0211        WATER VIEWS ONLY26.30                          266.65   70210TC               70210            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0220        PARANSL SIN COMPLETE                           740.50   70220TC               70220            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0240        SELLA TURCICA                                  388.45   70240TC               70240            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0250        SKULL LIMITED                                  429.35   70250TC               70250            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0260        SKULL COMPLETE                                 857.90   70260TC               70260            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0300        TEETH SINGLE VIEW                              135.55   70300TC               70300            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0328        TEMPOROMANDIBULAR JTS UNILATER                 429.35   70328TC               70328            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0330        TEMPOROMANDIBULAR JOINTS                       591.50   70330TC               70330            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0360        NECK SOFT TISSUE                               284.85   70360TC               70360            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y0380        SALIVARY GLAND                                 402.35   70380TC               70380            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1008        INDUSTRIAL HEALTH/CHEST 1VIEW2                 197.75   71010TC               71010            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1009        INDUSTRIAL HEALTH/CHEST 2VIEW2                 259.45   71020TC               71020            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1010        CHEST 1 VIEW                                   217.10   71010TC               71010            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1014        CHEST 1 VIEW, EXTENDED20.00                    271.15   71010TC               71010            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1021        CHEST 3 VIEW                                   312.05   71021TC               71021            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1030        CHEST 4 VIEW                                   361.50   71030TC               71030            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1033        INDUSTRIAL HEALTH/CHEST 4VIEW3                 333.60    7103052 TC           71030            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1035        CHEST SPECIAL VIEW, DECUBITIS                  397.40   71035TC               71035            1
  324   RADIOLOGY DIAG CHEST XRAY           50.4635    Y1039        CHEST, DECUBITIS VIEW EXTENDED                 497.00   71035TC               71035            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y1100        RIBS UNILAT W/CHEST                            492.55   71101TC               71101            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y110L        RIBS UNILAT W/CHEST                            492.55   71101TC               71101            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y1110        RIBS BILAT W/CHEST                             569.05   71111TC               71111            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y1120        STERNUM                                        402.35   71120TC               71120            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y1130        STERNOCLAV JTS                                 402.35   71130TC               71130            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2000        INDUSTRIAL HEALTH/L-SPINE 3VIE                 316.05                       7210052            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2005        INDUSTRIAL HEALTH/L-SPINE 5VIE                 466.40                         72110            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2020        SPINE CERV LATERAL VIEW ONLY                   189.95   72020TC               72020            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2021        C SPINE LATERAL VIEW ONLY EXT1                 239.50   72020TC               72020            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2040        SPINE CERV LIMITED                             266.65   72040TC               72040            1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                               107 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                        OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                  DESCRIPTION                    CHARGE       MCAL     CPT-4    HCPCS       RVU
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2050       CERVICAL ROUTINE COM/MIN 4 VIE                523.75   72050TC               72050            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2052       CERV & FLEX EXT                               758.90   72052TC               72052            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2070       THORACIC SPINE                                483.55   72072TC               72072            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2072       T SPINE LIMITED                               293.65   72070TC               72070            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2080       THORACO LUMBAR                                483.55   72080TC               72080            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2090       SCOLIOSIS STUDY                               402.35   72090TC               72090            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2100       LUMBAR LIMITED                                302.75   72100TC               72100            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2110       LUMBAR SPINE W/OBLIQUES                       501.25   72110TC               72110            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2170       PELVIS 1 VIEW                                 352.25   72170TC               72170            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2190       PELVIS COMPLETE                               555.40   72190TC               72190            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2202       SACRO ILIAC JOINT                             537.60   72202TC               72202            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y2220       SACRUM COCCYX                                 433.40   72220TC               72220            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3000       CLAVICLE RT                                   325.50   73000TC            73000RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y300L       CLAVICLE LT                                   325.50   73000TC            73000LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3010       SCAPULA RT                                    402.35   73010TC            73010RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y301L       SCAPULA LT                                    402.35   73010TC            73010LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3020       SHOULDER LIMITED RT                           320.55   73020TC            73020RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3021       SHOULDER LIMITED EXT 1 VIEW20.                411.00   73020TC             7302022            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y302L       SHOULDER LIMITED LT 1 VIEW                    320.55   73020TC            73020LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3030       SHOULDER COMPLETE RT MIN 2 VIE                429.35   73030TC            73030RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y303L       SHOULDER COMPLETE LT MIN 2 VIE                429.35   73030TC            73030LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3050       ACROMIO-CLAV JTS                              465.10   73050TC               73050            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3060       HUMERUS RT MIN 2 VIEWS                        325.50   73060TC            73060RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3061       HUMERUS COMP WITH COMPARISON R                406.50   73060TC            73060RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y306L       HUMERUS LT MIN 2 VIEWS                        325.50   73060TC            73060LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3070       ELBOW LIMITED RT                              298.15   73070TC            73070RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y307L       ELBOW LIMITED LT                              298.15   73070TC            73070LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3080       ELBOW COMPLETE RT MIN 3 VIEWS                 402.35   73080TC            73080RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3081       ELBOW COMPLETE WITH COMPARISON                501.25                       7308022            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y308L       ELBOW COMPLETE LT MIN 3 VIEWS                 402.35   73080TC            73080LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3090       FOREARM RT AP AND LAT                         316.05   73090TC            73090RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3091       FOREARM WITH COMPARISON                       392.85   73090TC               73090            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y309L       FOREARM LT AP AND LAT                         316.05   73090TC            73090LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3100       WRIST LIMITED RT AP AND LAT                   388.45   73100TC            73100RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y310L       WRIST LIMITED LT AP AND LAT                   388.45   73100TC            73100LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3110       WRIST COMPLETE RT MIN 3 VIEWS                 523.75   73110TC            73110RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3111       WRIST COMPLETE WITH COMPARISON                654.95                       7311022            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y311L       WRIST COMPLETE LT MIN 3 VIEWS                 523.75   73110TC            73110LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3120       HAND LIMITED RT 2 VIEWS                       316.05   73120TC            73120RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y312L       HAND LIMITED LT 2 VIEWS                       316.05   73120TC            73120LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3130       HAND COMPLETE RT MIN 3 VIEWS                  415.75   73130TC            73130RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3131       HAND COMPLETE WITH COMPARISON2                523.75                       7313022            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y313L       HAND COMPLETE LT MIN 3 VIEWS                  415.75   73130TC            73130LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3140       FINGER(S) RT MIN 2 VIEWS                      284.85   73140TC            73140RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3141       FINGER(S) WITH COMPARISON17.93                356.85                       7314022            1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y314L       FINGER(S) LT MIN 2 VIEWS                      284.85   73140TC            73140LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3500       HIP UNILATERAL LIMITED RT 1 VI                470.05   73500TC            73500RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y350L       HIP UNILATERAL LIMITED LT 1 VI                470.05   73500TC            73500LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3510       HIP UNILAT COMP RT MIN 2 VIEWS                582.70   73510TC            73510RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3511       HIP UNILATERAL COMPLETE EXTEND                727.00                      73510RT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y351L       HIP UNILAT COMP LT MIN 2 VIEWS                582.70   73510TC            73510LT             1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3520       HIP BILATERAL AND PELVIS                      686.35   73520TC               73520            1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                             108 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                      Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                   DESCRIPTION                     CHARGE       MCAL        CPT-4     HCPCS     RVU
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3550        FEMUR RT AP AND LAT                             402.35 73550TC                73550RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y355L        FEMUR LT AP AND LAT                             402.35 73550TC                73550LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3560        KNEE RT 1 OR 2 VIEWS                            365.85 73560TC                73560RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3561        KNEE AP & LATERAL W/COMPARISON                  456.35                          7356022         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3564        KNEE STANDING AP (BOTH)                         373.85 73565TC                    73565         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y356L        KNEE LT 1 OR 2 VIEWS                            365.85 73560TC                73560LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3570        KNEE WITH SPECIAL VIEWS > 4 RT                  569.05 73564TC                73564RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y357L        KNEE WITH SPEC VIEWS > 4 MORE                   569.05 73564TC                73564LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3590        TIBIA FIBULA RT                                 325.50 73590TC                73590RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3591        TIBIA FIBULA WITH COMPARISON22                  505.95                          7359022         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y359L        TIBIA FIBULA LT                                 325.50 73590TC                73590LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3600        ANKLE LIMITED RT AP AND LAT                     352.25 73600TC                73600RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3601        ANKLE LIMITED WITH COMPARISON2                  438.05 73600TC                  7360022         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y360L        ANKLE LIMITED LT AP AND LAT                     352.25                        73600LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3610        ANKLE COMPLETE RT MIN 3 VIEWS                   510.55 73610TC                73610RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y361L        ANKLE COMPLETE LT MIN 3 VIEWS                   510.55 73610TC                73610LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3620        FOOT LIMITED RT AP AND LAT                      312.05 73620TC                73620RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y362L        FOOT LIMITED LT AP AND LAT                      312.05 73620TC                73620LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3630        FOOT COMPLETE RT MIN 3 VIEWS                    397.40 73630TC                73630RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3631        FOOT COMPLETE WITH COMPARISON2                  497.00                            73630         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y363L        FOOT COMPLETE LT MIN 3 VIEWS                    397.40 73630TC                73630LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3650        OS CALIS HEEL RT MIN 3 VIEWS                    284.85 73650TC                73650RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y365L        OS CALIS HEEL LT MIN 3 VIEWS                    284.85 73650TC                73650LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3660        TOE(S) RT MIN 2 VIEWS                           248.65 73660TC                73660RT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y3661        TOE(S) WITH COMPARISON17.93                     307.25                          7366022         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y366L        TOE(S) LT MIN 2 VIEWS                           248.65 73660TC                73660LT           1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4000        ABDOMEN 1 VIEW KUB                              361.50 74000TC                    74000         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4001        ABDOMEN 1 VIEW EXTENDED22.17                    451.70                            74000         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4010        ABDOMEN 2 VIEW                                  497.00 74010TC                    74010         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4020        ABDOMEN 3 VIEW                                  618.70 74020TC                    74020         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4210        PHARYNX CER ESO                                 569.05 74210TC                    74210         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4323        X RAY UPPER EXT 2V INFANT                       116.15 73092TC                    73092
  320   RADIOLOGY DIAG GENERAL              50.4635    Y4710        PELVIMETRY                                      691.00 74710TC                    74710         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6000        SPINE INJ LOCALIZATION                          808.45                            77003         3
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6001        FLUORO CARM ONE HOUR                            928.05                            76000         4
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6020        BONE AGE STUDY                                  442.85                            76020         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6040        BONE LENGTH STUDY                               718.35                            77073         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6060        BONE SURVEY                                     979.90                            76062         1
  320   RADIOLOGY DIAG GENERAL              50.4635    Y6095        RAD EXAM BREAST SURG SPECIMEN                   212.50                            76098         1
  929   OTHER DIAG OTHER                    50.4635    Y6999        RADIOLOGY HBA MISC CHARGE                   misc chrg determined at time of svcs
  402   OTH IMAG ULTRASOUND                 50.4638          3316   STUDY FOLLOW UP                                 190.70 76970TC         76970      76970         1
  402   OTH IMAG ULTRASOUND                 50.4638          3336   ECHO PICC LINE INSERT                           572.05      36569      36569      36569         1
  402   OTH IMAG ULTRASOUND                 50.4638          3337   ECHO LUNG ABCESS                                354.05
  402   OTH IMAG ULTRASOUND                 50.4638          3338   ECHO APPENDIC ABCS                              354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3340   ECHO PANCREAS PSEUDO CYST                       354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3341   ECHO PELVIC ABCESS                              354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3342   ECHO PERITONEAL ABCESS                          354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3343   ECHO RENAL PERIRENAL ABCESS                     354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3344   ECHO RETROPERITONEAL ABCESS                     354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3345   ECHO LOWER LEG ABCESS                           354.05                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3346   LIVER ABCESS                                    604.70                                          1
  402   OTH IMAG ULTRASOUND                 50.4638          3347   THYROID BIPOSY                                  604.70                                          1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                109 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4   HCPCS        RVU
  402   OTH IMAG ULTRASOUND                 50.4638        6301   ECHO BIOPHYSICAL PROFILE                       738.05                      76818             1
  402   OTH IMAG ULTRASOUND                 50.4638        6302   ECHO OB 1ST TRIMESTER                        1,201.20                      76801             1
  402   OTH IMAG ULTRASOUND                 50.4638        6303   ECHO OB 2ND/3RD TRIMESTER                    1,201.20   76805TC            76805             1
  402   OTH IMAG ULTRASOUND                 50.4638        6304   ECHO OB F/U OR REPEAT                        1,201.20                      76816             1
  402   OTH IMAG ULTRASOUND                 50.4638        6305   ECHO DUPLEX LOWER EXT ART BILA               1,517.20                      93925             1
  402   OTH IMAG ULTRASOUND                 50.4638        6306   ECHO DUPLEX LOWER EXT ART UNI1               1,093.00   93926TC         93926RT              1
  402   OTH IMAG ULTRASOUND                 50.4638        6307   ECHO DUPLEX UPPER EXT ART BILA               1,517.20      93930           93930             1
  402   OTH IMAG ULTRASOUND                 50.4638        6308   ECHO DUPLEX UPPER EXT ART UNI1               1,093.00   93931TC         93931RT              1
  402   OTH IMAG ULTRASOUND                 50.4638        6309   ECHO DUPLEX HEMO SHUNT178.86                 1,517.20                      93990             1
  402   OTH IMAG ULTRASOUND                 50.4638        6310   ECHO INFANT HIPS                             1,093.00                      76885             1
  402   OTH IMAG ULTRASOUND                 50.4638        6312   ECHO PSEUDOANEURYSM                          1,093.00                      76936             1
  402   OTH IMAG ULTRASOUND                 50.4638        6313   ECHO VENOUS UNILAT RT178.86                    892.50   93971RT         93971RT              1
  402   OTH IMAG ULTRASOUND                 50.4638        6314   ECHO ABDOMINAL DOPPLER COMP217               1,201.20                      93975             1
  402   OTH IMAG ULTRASOUND                 50.4638        6315   ECHO ABDOMINAL DOPPLER LTD173.                 892.50                      93976             1
  920   OTHER DIAG GENERAL                  50.4638        6316   ECHO CAROTIDS BILAT203.06                    2,167.85      93880           93880             1
  402   OTH IMAG ULTRASOUND                 50.4638        6318   ECHO OB MULTI GEST AFT 1ST TRI               2,459.60   76815TC            76815             2
  402   OTH IMAG ULTRASOUND                 50.4638        6319   ECHO SONOHYSTEROGRAM                           670.95   76831TC            76831             1
  402   OTH IMAG ULTRASOUND                 50.4638        6320   ECHO EXT NON VASCULAR                          614.55                      76880             1
  402   OTH IMAG ULTRASOUND                 50.4638        6321   ECHO OB 1ST TRI MULTI GEST                   1,801.75   76802TC            76802             1
  402   OTH IMAG ULTRASOUND                 50.4638        6330   ECHO DUPLEX UPPER EXT ART BIL                1,517.20      93930           93930             1
  402   OTH IMAG ULTRASOUND                 50.4638        6334   US OB < 14 DAYS TRANSVAGINAL                   282.15   76817 T C 76817    76817
  402   OTH IMAG ULTRASOUND                 50.4638        6343   ECHO OB EACH ADD GESTATION                     900.85   76810TC            76810             1
  402   OTH IMAG ULTRASOUND                 50.4638        6344   ECHO OB TRANSVAGINAL                           343.25   76817TC            76817             1
  402   OTH IMAG ULTRASOUND                 50.4638        6535   ECHO THYROID/SOFT TISSUE HOSP                1,201.20   76536TC            76536             1
  402   OTH IMAG ULTRASOUND                 50.4638        6630   ECHO CHEST                                     735.90                      76604             1
  402   OTH IMAG ULTRASOUND                 50.4638        6700   ABD COMP-HOSP                                1,201.20   76700TC            76700             1
  402   OTH IMAG ULTRASOUND                 50.4638        6703   ECHO ABDOMEN COMPLETE EXTENDED               1,499.40   76700TC            76700             1
  402   OTH IMAG ULTRASOUND                 50.4638        6705   ECHO ABD LTD-FU-HOSP                           677.45                      76705             1
  402   OTH IMAG ULTRASOUND                 50.4638        6720   ECHO GALLBLDR-HOSP                           1,201.20                      76705             1
  402   OTH IMAG ULTRASOUND                 50.4638        6730   ECHO RENAL-HOSP                              1,201.20   76770TC            76770             1
  402   OTH IMAG ULTRASOUND                 50.4638        6765   ECHO ABD AORTA-HOSP/RETROPERI                1,201.20                      76770             1
  402   OTH IMAG ULTRASOUND                 50.4638        6770   ECHO RETRPERIT-HOSP                          1,201.20                      76770             1
  402   OTH IMAG ULTRASOUND                 50.4638        6778   ECHO OF TRANSPL KIDNEY W/WO DO               1,345.95   76778TC            76778             1
  402   OTH IMAG ULTRASOUND                 50.4638        6780   ECHO PELVIS LIMITED                          1,201.20   76857TC            76857             1
  402   OTH IMAG ULTRASOUND                 50.4638        6800   ECHO SPINAL CANAL                            1,201.20                      76800             1
  402   OTH IMAG ULTRASOUND                 50.4638        6801   ECHO GUIDE VEIN DEVICE                         673.00   76937TC   76937    76937             1
  402   OTH IMAG ULTRASOUND                 50.4638        6810   ECHO OB-PREG-FET AGE LTD                       738.05   76815TC            76815             1
  402   OTH IMAG ULTRASOUND                 50.4638        6816   ECHO PREGNANCY, FOLLOW UP OR R                 735.90   76816TC            76816             1
  402   OTH IMAG ULTRASOUND                 50.4638        6830   ECHO TRANSVAGINAL                              343.25   76830TC            76830             1
  402   OTH IMAG ULTRASOUND                 50.4638        6840   ECHO FOLICULAR STAGING DAY 1                   934.90                      76856             1
  402   OTH IMAG ULTRASOUND                 50.4638        6850   ECHO PELV MASS-HOSP                          1,201.20   76856TC            76856             1
  402   OTH IMAG ULTRASOUND                 50.4638        6855   ECHO PELVIC AREA WITH DOPPLER2               1,662.00                      93975             1
  921   OTHER DIAG PERIPHERAL LAB           50.4638        6925   ECHO PERIPHERAL VASCULAR DOPPL               1,683.20                      93970             1
  921   OTHER DIAG PERIPHERAL LAB           50.4638        6926   ECHO ABDOMINAL ARTERIAL                      1,683.20      93978           93978             1
  402   OTH IMAG ULTRASOUND                 50.4638        6928   ECHO ENCEPHALOGRAPHY                         1,093.00                      76506             1
  402   OTH IMAG ULTRASOUND                 50.4638        6960   ECHO BIOPSY GUIDE-AMNIO                        894.25                      76946             1
  402   OTH IMAG ULTRASOUND                 50.4638        6965   ECHO PERICARDIOCENTESIS GUIDE                  894.25                      76930             1
  402   OTH IMAG ULTRASOUND                 50.4638        6970   ECHO THORACENTESIS GUIDE                       894.25                      76942             1
  402   OTH IMAG ULTRASOUND                 50.4638        6975   ECHO NEEDLE BIOPSY GUIDE                       673.00                      76942             1
  402   OTH IMAG ULTRASOUND                 50.4638        6976   ECHO BIOPSY GUIDE LIVER                        673.00                      76942             1
  402   OTH IMAG ULTRASOUND                 50.4638        6980   ECHO CYST OR RENAL PELVIC ASP                  903.20                      76942             1
  402   OTH IMAG ULTRASOUND                 50.4638        6981   ABCESS ASP GUIDE LIVER                         673.00                      76942             1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            110 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                      CHARGE
 CHG         CATEGORY AND NAME               DPT       CODE                 DESCRIPTION                       CHARGE       MCAL       CPT-4    HCPCS       RVU
  402   OTH IMAG ULTRASOUND                 50.4638        6982 ECHO CYST ASP GUIDE BOWEL                        673.00                          76942            1
  402   OTH IMAG ULTRASOUND                 50.4638        6983 ECHO CYST ASP GUIDE PANCREAS                     673.00                          76942            1
  402   OTH IMAG ULTRASOUND                 50.4638        6985 ECHO ABCESS DRAINAGE                             903.20                          76942            1
  402   OTH IMAG ULTRASOUND                 50.4638        6996 ECHO EXTREMITY NON VASC RT                       659.25   76880TC             76880RT             1
  402   OTH IMAG ULTRASOUND                 50.4638        6997 ECHO SCROTUM-HOSP                                659.25                          76870            1
  402   OTH IMAG ULTRASOUND                 50.4638        6998 ECHO BREAST-HOSP RT                              659.25   76645TC             76645RT             1
  401   OTH IMAG DIAG MAMMOGRAPHY           50.4638        9964 ECHO ABLATION LIVER                            4,860.85   76940TC                76940            1
  921   OTHER DIAG PERIPHERAL LAB           50.4638       14404 EXT ART DOPPLER BILATERAL HOSP                   394.40      93923               93923            1
  921   OTHER DIAG PERIPHERAL LAB           50.4638       14419 ECHO ARTERIAL ULTRASOUND                       2,167.85                          93970            1
  490   AMB SURGICAL CARE GENERAL           50.4638       32440 ECHO PARACENTHESIS                               232.10                                           1
  402   OTH IMAG ULTRASOUND                 50.4638       45187 ECHO INTRA OPERATIVE MONITOR                   3,135.10                       76986
  361   OR SVCS MINOR SURGERY               50.4638       76970 THORACENTESIS GUIDE                              302.75      32000            32000               1
  361   OR SVCS MINOR SURGERY               50.4638       76975 NEEDLE BPSY LUNG                                 225.95      32405            32405               1
  361   OR SVCS MINOR SURGERY               50.4638       76976 BIOPSY GUIDE LIVER                               225.95                       47000               1
  402   OTH IMAG ULTRASOUND                 50.4638 L6320       ULTRASOUND EXT NON VASCULAR LT                   614.55                    76880LT
                                                                                                                          76880LT TC 76880LT                      1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3301 LACRIMAL DUCT FLOW                               911.20      78660   78660    78660               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3303 BRAIN IMAGING COMP STAT                        1,002.10   78605TC    78605    78605               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3304 BRAIN IMAGING LTD VAS FLOW                       869.65   78601TC    78601    78601               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3305 COMPUTER EVAL 30 MIN                             497.20      78890   78890    78890               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3306 COMPUTER EVAL 30+ MIN                            654.00      78891   78891    78891               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3307 ESOPHAGEAL MOTILITY                            1,125.65      78258   78258    78258               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3309 MI REST PYP                                    1,372.15      78466   78466    78466               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3310 MYO GATE EQ REST WALL                            853.00      78472   78472    78472               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3311 PULMONARY VENT SCAN                              775.80      78593   78593    78593               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4650        3312 SCHILLING CO 57                                  432.45      78990   78990    78990               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3313 THYROID IMAGING SINGLE                           801.90      78006   78006    78006               1
  340   NUCLEAR MEDICINE GENERAL            50.4650        3315 URETERAL REFLUX STDY                             983.70   78740TC    78740    78740               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91000 THYROID IMAGING; ONLY                          1,003.20                       78010               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91003 THYROID UPTAKE; SINGLE DETERMI                   620.75                       78000               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91004 THYROID IMAGING W/UPT, MULTI                   1,624.45                       78007               2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91006 THYROID UPTAKE; MULTIPLE DETER                   774.60                       78001               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91007 PARATHYROID IMAGING                            2,398.90                       78070               2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91010 RADIOTHEARAPY W MONOCLONAL AB                  2,809.65              79403    79403               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91011 THYROID IMAGING; VASCULAR FLOW                 1,395.25                       78011               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91040 THYROID CA METASTASES; LTD                       933.80                       78015               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91050 THYROID CA METASTASES; WHOLE B                 2,440.55                       78018               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91080 ADRENAL IMAGING                                2,440.55                       78075               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91100 BONE MARROW IMAGING; LIMITED                   2,520.35                       78102               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91103 BONE MARROW IMAGING; MULTIPLE                  2,716.65                       78103               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91106 BONE MARROW IMAGING; WHOLE BOD                 2,716.65                       78104               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91110 PLASMA VOLUME; SEP PROCED; SIN                   658.05                       78110               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91111 PLASMA VLM; MULT; HSA; TAG                       790.85                       78111               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91112 PLASMA VLM; SNGL; CR51; SUB                      307.80                       78110               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91113 PLASMA VLM; MULT; CR51; SUBCRI                   398.25                       78111               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91114 RED CELL VLM; SNGL; CR51; TAG                    658.05                       78120               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91115 RED CELL VLM; MULT; CR51; TAG                    790.85                       78121               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91116 RED CELL VLM; SNGL; HSA; SUB                     307.80                       78120               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91117 RED CELL VLM; MULT; HSA; SUB                     398.25                       78121               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91118 WHOLE BLOOD VLM; HSA; CR51; TA                 1,358.15                       78122               1
  305   LAB HEMATOLOGY                      50.4652       91119 HEMATOCRIT                                        79.80   85013ZS             85013               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91120 RED CELL SURVIVAL STUDY                        1,655.40                       78130               1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91121 RED CELL SPLENIC/HEPATIC SEQST                   939.25                       78140               1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               111 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                     CHARGE      MCAL    CPT-4     HCPCS      RVU
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91130   SPLEEN IMAGING                               1,554.75                       78185           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91139   SPLEEN IMAGING; SPECT                          594.55                       78185           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91140   LYMPHATIC/LYMPH GLANDS IMAG SU               1,660.75                       78195           3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91143   LYMPHATICS & LYMPH GLANDS IMAG               2,334.65                       78195           3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91200   LIVER IMAGING                                1,554.75                       78201           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91203   LIVER IMAGING;VASCULAR FLOW                  2,056.20                       78202           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91210   LIVER AND SPLEEN IMAGING                     1,899.40                       78215           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91213   LIVER AND SPLEEN IMAG; VASC FL               2,627.45                       78216           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91219   LIVER IMAGING SPECT & FLOW                   3,426.90                       78206           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91223   LIVER IMAGING; VASCULAR FLOW                 1,395.25                       78202           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91229   LIVER IMAGING (SPECT)                        2,741.55                       78205           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91240   HEPATOBILIARY DUCT;GALLBLDR;IN               1,294.85                       78223           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91243   HEPATOBILLIARY DUCT;GLBLDR W/C               2,056.20                       78223           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91249   LIVER FUNCT IMAGE W HEPATOBIL                1,827.70                       78205           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91250   SALIVARY GLAND IMAG;SERIAL IMA               1,263.40                       78231           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91263   GASTROESOPHAGEAL REFLUX STUDY                2,339.55                       78262           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91266   GASTRIC EMPTYING STUDY;INITIAL               1,915.20                       78264           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91270   VIT B12 ABSORP;SCHILNG;W/O INT                 472.55                       78270           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91271   VIT B12 ABSORP;SCHILNG W/INTRI                 472.55                       78271           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91280   BOWEL IMAGING;MECKELS;INITIAL                1,029.40                       78290           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91285   PERITONEAL-VEN SHNT PATNCY;INT               1,873.25                       78291           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91290   GASTROINT BLD LOSS; ACUTE;INIT               1,602.45                       78278           3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91295   SHUNT;INTRAARTERIAL;INITIAL                  1,873.25                       78291           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91300   BONE IMAGING;LIMITED AREA                    1,899.40                       78300           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91303   BONE IMAGING; VASCULAR FLOW                    742.75                       78445           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91308   BONE SCAN 3 PHASE                            2,642.10                       78315           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91309   BONE IMAGING;TOMO (SPECT) LIMI               3,655.35                       78320           3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91310   BONE IMAGING;MULTIPLE AREAS                  2,631.60                       78305           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91313   BONE IMAGING;VASCULAR FLOW                     742.75                       78445           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91319   BONE IMAGING;TOMO (SPECT) MULT               3,426.90                       78320           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91320   BONE IMAGING;WHOLE BODY                      2,780.25                       78306           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91323   BONE IMAGING;VASCULAR FLOW                     742.75                       78445           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91329   BONE IMAGING;TOMO (SPECT) WHOL               3,883.85                       78320           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91330   BONE IMAGING;LIMITED;DENTAL VW               2,292.20                       78300           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91340   JOINT IMAGING;LIMITED AREA                   2,966.00                       78300           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91400   CARDIAC SHUNT DETECTION;LEFT-R               1,538.50                       78428           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91403   CARDIAC SHUNT DETECTION;                     1,538.50                       78428           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91410   FIRST PASS AT REST;WALL MOTION               1,416.80                       78481           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91420   FRST PASS TECNQ;RST;SRL;ANY CM               3,024.20                       78483           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91422   GATED EQLBRM;AT RST;WALL MOTIO               1,517.80                       78494           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91428   GATED EQUILBRM;AT RST;QNTWM;W/               2,801.30                       78473           3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91440   MYO PERFUSION PET RST OR STR                11,422.75                       78491           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91441   MYO PERF PET REST AND STR                   15,991.80                       78492           4
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91449   MYOCARDIAL;INFARCT;REST;TOMOGR               2,124.75                       78469           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91450   MYO PERF EXC / OR RD                         1,814.30                       78460           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91453   MYO PERF EXC / OR RD SPECT                   1,814.05                       78464           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91456   MYO PERF EXC AND RD                          1,504.25                       78461           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91459   MYOCARDIAL PERFUSION; SPECT; E               3,198.50                       78465           2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91460   UNLISTED CARDIOVSCLR;PERIPHRL;               1,894.05                       78499           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91462   GATED SPECT                                  1,028.20                       78478           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91464   MYO PERF W EF                                1,028.20                       78480           1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91480   VENOUS THROMBOSIS;UNILATERAL (               1,067.00                       78457           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                           112 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                  DESCRIPTION                      CHARGE       MCAL        CPT-4     HCPCS     RVU
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91483   VENOUS THROMBOSIS;BILATERAL (T                2,056.20                            78456         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91500   LUNG VENT;GAS;SGL BRTH;RBRTH;W                1,925.95                            78594         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91510   LUNG PERFUSION IMAGING;PARTICU                1,873.00                            78580         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91513   VASCULAR FLOW IMAGING;CHEST                   1,395.45                            78445         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91520   LUNG/PULMNRY;PRF/VNT;SNGL,RBRT                3,087.90                            78585         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91527   PULMONARY QUANTIT DIFF FUNCT                  3,426.90                            78596         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91610   BRAIN IMAGING,VASCULAR FLOW                   1,278.65                            78610         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91620   BRAIN IMAGING;COMPLETE;VASCULA                2,056.20                            78606         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91629   TOMOGRAPHIC (ECT);BRAIN;CMPLT                 2,969.95                            78607         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91630   CEREBROSPINAL FLUID FLOW;CSTRN                2,741.55                            78630         3
  761   TREAT/OBS RM TREATMENT RM           50.4652       91631   INJECTION PROC SPINAL FLUID;CI                  277.15                            62270         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91640   CEREBROSPINAL FLUID FLOW;SHUNT                1,819.70                            78645         1
  761   TREAT/OBS RM TREATMENT RM           50.4652       91641   LUMBAR PUNCTURE;INJECTION PROC                  318.65                            62270         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91650   CSF LEAKAGE DETECTION/LOCALIZA                2,170.40                            78650         1
  761   TREAT/OBS RM TREATMENT RM           50.4652       91651   INJECTION PROC FOR SPINAL;CSF                   318.65                            62272         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91693   BRAIN PET PERFUSION                          11,422.75                            78609         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91700   KIDNEY IMAGING;STATIC                         1,491.20                            78700         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91703   KIDNEY VASCULAR FLOW                          1,395.25                            78715         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91720   KIDNEY/RENAL FUNCTION STUDY                   2,627.45                            78707         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91722   KIDNEY/RENAL FUNCTION W/PHARM                 2,924.40 78708TC                    78707         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91723   URINARY BLADDER RESIDUAL STUDY                  509.35                            78730         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91739   KIDNEY/RENAL IMAGING [SPECT]                  1,827.70                            78710         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91760   TESTICULAR IMAGING                            1,608.25                            78760         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91763   TESTICULAR IMAGING;VASCULAR FL                2,969.95                            78761         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91800   RADIONCLDE LOCALZTN;LMT                       2,090.65                            78800         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91809   RADIONCLDE LOCALZTN;LMT/ECT                   3,335.60                            78803         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91810   RADIONCLDE LOCALZTN;MULTI                     3,246.55                            78800         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91819   TUMOR LOCAL MULTI/ECT                         3,986.75                            78803         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91820   RADIONCLDE LOCALZTN;WHOLE BODY                3,141.40                            78802         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91829   RADIONCLDE LOCALZTN;WHOLE BODY                4,386.40                            78802         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91840   BRAIN IMAGINING LIMITED                       1,135.75                            78660         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91850   RADIONCLDE LOCALZTN;IMF PROC W                3,141.40                            78806         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91859   RADIONCLDE LOCALZTN;INF WHLBOD                4,386.40                            78807         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91860   RADIONCLDE LOCALZTN;INFAM PROC                2,398.90                            78805         2
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91869   RADIONCLDE LOCALZTN;IMF PROC L                3,655.35                            78807         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91880   RADNCLD LOCALZN,WHLEBDY,INL CR                1,644.75                            78802         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91889   RADNCLD LOCALZN, WHOLEBODY,ECT                5,254.55                            78803         3
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91903   VASCULAR FLOW IMAGING                           742.75                            78445         1
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91905   WHOLE BODY SCAN MULIT DAYS                      742.75                            78804         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4652       91910   HYPERTHYROIDISM INITIAL                       2,339.90                            79005         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4652       91938   METASTESES THY CA TX                            875.45                 79005      79005
  342   NUCLEAR MEDICINE THERAPEUT          50.4652       91940   POLYCYTHEMIA VERA                               875.45                            79101         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4652       91941   INTRACAVITARY RADIOACTIVE COL                 2,339.90                            79200         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4652       91944   RADIONUCLIDE THRPY - BONE METS                  947.65 79101TC                    79101
  341   NUCLEAR MEDICINE DIAGNOS            50.4652       91999   NUCLEAR MEDICINE HBA MISC CHAR              misc chrg determined at time of svcs
  636   DRUG SPEC ID DETAIL CODING          50.4652       93825   NEUTROSPECT                                   4,086.75                        A4641
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91911   HYPERTHYROIDISM INITIAL                       2,339.90                            79000         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91912   HYPERTHYROIDISM INITIAL                       2,339.90                            79000         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91913   HYPERTHYROIDISM INITIAL                       2,339.90                 79005      79005         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91920   HYPERTHYROIDISM SUBSEQUENT                    1,024.00                            79001         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91921   HYPERTHYROIDISM SUBSEQUENT                    1,024.00                            79001         1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91922   HYPERTHYROIDISM SUBSEQUENT                    1,024.00                            79001         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               113 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                     OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE     MCAL    CPT-4     HCPCS      RVU
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91923   HYPERTHYROIDISM SUBSEQUENT                   1,024.00           79005      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91930   THYROID CA                                   2,341.70                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91932   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91933   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91934   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91935   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91936   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91937   THYROID CARCINOMA ABLATION                   2,339.90                      79005           1
  342   NUCLEAR MEDICINE THERAPEUT          50.4653       91942   P-32 THERAPY FOR CARCINOMA                     875.45                      79400           1
  344   NUC MED/RX RADIOPHARM               50.4653       93944   STRONTIUM-89 PER mCi                         5,919.20                   A9600
  344   NUC MED/RX RADIOPHARM               50.4653       93945   153 SAMARIUM PER 50 mCi                      7,784.75                   A9605
  636   DRUG SPEC ID DETAIL CODING          50.4655       93000   SODIUM IODIDE I-123 CAPS PER 1                 233.40         A9516     A9516
  343   NUC MED/DX RADIOPHARM               50.4655       93003   SODIUM IODID E I-131 CAP PER 1                  39.00                   A9517
  343   NUC MED/DX RADIOPHARM               50.4655       93007   THALLOUS CHLRD TL201-SOD PERT                  933.80         A9505     A9505              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93010   SODIUM PERTECHNETATE TC99M                     313.20                                      1
  343   NUC MED/DX RADIOPHARM               50.4655       93080   1131-MIBG(METAIODOBENZYLGUADID               7,167.45                   A9508
  636   DRUG SPEC ID DETAIL CODING          50.4655       93090   OCTREOTID PER 3mCi                           3,575.10 Q3008   J2353
  636   DRUG SPEC ID DETAIL CODING          50.4655       93110   IC99M ALBUMIN HSA                              419.50                                      1
  344   NUC MED/RX RADIOPHARM               50.4655       93111   IODINATED I-125 ALBUMIN INJECT                 313.20         A9532     A9532              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93114   SODIUM CHROMATE CR51                         1,316.00                   A4641              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93116   SODIUM CHROMATE CR-51 INJECT                 3,225.65                   A4641              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93118   TC99M HSA AND SOD CHR CR51                   1,745.75                   A4641              1
  343   NUC MED/DX RADIOPHARM               50.4655       93130   TECHNETIUM TC99M SULFUR COLLOI                 313.20         A9541     A9541              1
  343   NUC MED/DX RADIOPHARM               50.4655       93140   TECHNETIUM TC99M FILTERED SULF                 551.95                   A9541              1
  343   NUC MED/DX RADIOPHARM               50.4655       93200   TECHNETIUM TC99M SULFUR COLLOI                 313.20                   A9541              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93230   TECHNETIUM TC99M SULF COL/ALBU                 626.35                   A9519              1
  343   NUC MED/DX RADIOPHARM               50.4655       93240   TECHNETIUM TC99M MEBROFENIN                    541.50         A9513     A9537              1
  343   NUC MED/DX RADIOPHARM               50.4655       93270   CYANOCOBALAMIN CO57/VITAMIN B1                 896.95         Q3012     Q3012              1
  343   NUC MED/DX RADIOPHARM               50.4655       93271   CYANOCOBALAMIN CO57/VITAMIN B1                 896.95         Q3012     Q3012              1
  343   NUC MED/DX RADIOPHARM               50.4655       93285   TECHNETIUM TC99M SULFUR COL                    313.20         A9541     A9541              1
  343   NUC MED/DX RADIOPHARM               50.4655       93290   TECHNETIUM TC99M PYROPHOSPHATE                 403.10                   A9514              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93291   TC - ULTRATAG                                   29.35 Q3010   Q3010                        1
  343   NUC MED/DX RADIOPHARM               50.4655       93300   TECHNETIUM TC99M MEDRONATE SOD                 313.20                   A9503              1
  343   NUC MED/DX RADIOPHARM               50.4655       93340   TECHNETIUM TC99M MEDRONATE SOD                 313.20         A9503     A9503              1
  343   NUC MED/DX RADIOPHARM               50.4655       93403   TECHNETIUM TC99M ALBUMIN AGGRE                 313.20         A9519     A9519              1
  343   NUC MED/DX RADIOPHARM               50.4655       93421   TECHNETIUM TC99M PYROPHOSPHATE                 403.10         A9514     A9514              1
  343   NUC MED/DX RADIOPHARM               50.4655       93450   THALLOUS CHLORIDE TL201 PER mC                 415.75                   A9505
  343   NUC MED/DX RADIOPHARM               50.4655       93458   TECHNETIUM TC99M SESTAMIBI                   1,156.70                   A9500              1
  343   NUC MED/DX RADIOPHARM               50.4655       93461   TECHNETIUM TC99M TETROFOSMIN                 1,156.70                   A9502              1
  343   NUC MED/DX RADIOPHARM               50.4655       93483   TECHNETIUM TC99M ACUTECT                     2,838.75                   A9504              1
  343   NUC MED/DX RADIOPHARM               50.4655       93500   XENON XE 133 PER 10mCi                         403.10         A9558                        1
  343   NUC MED/DX RADIOPHARM               50.4655       93510   TECHNETIUM TC99M ALBUMIN AGGRE                  77.85         A9540     A9540              1
  343   NUC MED/DX RADIOPHARM               50.4655       93600   TECHNETIUM TC99M BICISATE                    1,280.40         Q3003                        1
  343   NUC MED/DX RADIOPHARM               50.4655       93610   TECHNETIUM TC99M GLUCEPTATE SO                 366.65         Q3006                        1
  343   NUC MED/DX RADIOPHARM               50.4655       93630   PE NTETATE INDIUM TRISODIUM DT               3,489.75         A9548     A9548              1
  343   NUC MED/DX RADIOPHARM               50.4655       93690   TC HMPAO EXAMETAZIME                         2,928.80         A9521     A9521              1
  343   NUC MED/DX RADIOPHARM               50.4655       93700   TECHNETIUM TC99M GLUCEPTATE SO                 366.65         Q3006     Q3006              1
  343   NUC MED/DX RADIOPHARM               50.4655       93703   TECHNETIUM TC99M GLUCEPTATE SO                 366.65         Q3006     Q3006              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93720   IODOHIPPURATE SODIUM I-131                     785.60                   C1900              1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93730   IODOHIPPURATE SODIUM I-123                   1,793.30                   A4641              1
  343   NUC MED/DX RADIOPHARM               50.4655       93750   TECHNETIUM TC 99M MERTIATIDE P                 151.35 Q3005   Q3005     Q3005
  343   NUC MED/DX RADIOPHARM               50.4655       93760   TC DTPA PENTETATE                              313.20                   A9515              1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                          114 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                       OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE       MCAL    CPT-4       HCPCS     RVU
  343   NUC MED/DX RADIOPHARM               50.4655       93800   GALLIUM CITRATE GA67 PER mCi                    82.20           Q3002
  343   NUC MED/DX RADIOPHARM               50.4655       93850   IODINE HIPP 123                              2,488.30                       A9547            1
  343   NUC MED/DX RADIOPHARM               50.4655       93880   INDIUM IN-111 SATUMOMAB PENDET               9,474.00                       C1066            1
  343   NUC MED/DX RADIOPHARM               50.4655       93881   TEC-CEA                                      9,474.00                       C1122            1
  343   NUC MED/DX RADIOPHARM               50.4655       93882   PROSTASCINT                                  8,647.40                       A9507            1
  343   NUC MED/DX RADIOPHARM               50.4655       93883   TC - NEOTECT                                 3,942.85                       A9511            1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93900   FDG                                          3,941.00           C1775       A4641
  343   NUC MED/DX RADIOPHARM               50.4655       93910   SODIUM IODIDE I-131 SOLUTION P                 457.10                       A9529
  343   NUC MED/DX RADIOPHARM               50.4655       93911   SODIUM IODIDE-131 SOLUTION-010               1,251.95                       A9539            1
  343   NUC MED/DX RADIOPHARM               50.4655       93921   SODIUM IODIDE I-131 SOLUTION-0               1,379.55            A9529      A9529            1
  636   DRUG SPEC ID DETAIL CODING          50.4655       93940   SODIUM PHOSPHATE P-32 PER mCi                  727.65            Q3007
  636   DRUG SPEC ID DETAIL CODING          50.4655       93941   CHROMIC PHOSPHATE P-32 PER mCi               3,868.45   Q3011    Q3011
  610   MRI GENERAL                         50.4660        2955   MRI SHOULDER L ARTHROGRAM W/CO               3,415.50   73222LT TC          73222LT          1
  610   MRI GENERAL                         50.4660        2956   MRI SHOULDER R ARTHROGRAM W/CO               3,415.50   73222RT TC          73222RT          1
  610   MRI GENERAL                         50.4660        2957   MRI LOWER EXT WITH JOINT                     3,602.50   73721TC             73721RT          1
  610   MRI GENERAL                         50.4660        2958   MRI WRIST RT WITHOUT CONTRAST                3,602.50   73221RT TC          73221RT          1
  610   MRI GENERAL                         50.4660        2959   MRI ANKLE RIGHT W/CONTRAST                   1,061.00   73722RT TC          73722RT          1
  610   MRI GENERAL                         50.4660        2960   MRI ANKLE RIGHT W&WOUT CONTRAS               3,885.30   73723RT TC          73723RT          1
  610   MRI GENERAL                         50.4660        2961   MRI WRIST RIGHT WITH CONTRAST                1,061.00   73222RT TC          73222RT          1
  610   MRI GENERAL                         50.4660        2962   MRI WRIST RIGHT W&WO CONTRAST                3,885.30   73223RT TC          73223RT          1
  610   MRI GENERAL                         50.4660        2963   MRI HAND RIGHT WO CONTRAST                   2,934.00   73218RT TC          73218RT          1
  610   MRI GENERAL                         50.4660        2964   MRI HAND RIGHT WITH CONTRAST                 1,061.00   73219RT TC          73219RT          1
  610   MRI GENERAL                         50.4660        2965   MRI HAND RIGHT W&WO CONTRAST                 3,885.30   73220RT TC          73220RT          1
  610   MRI GENERAL                         50.4660        2966   MRI ELBOW RIGHT WO/CONTRAST                  2,934.00   73221RT TC          73221RT          1
  610   MRI GENERAL                         50.4660        2967   MRI ELBOW RIGHT WITH CONTRAST                1,061.00   73222RT TC          73222RT          1
  610   MRI GENERAL                         50.4660        2968   MRI ELBOW RIGHT W&WO/CONTRAST                3,885.30   73223RT TC          73223RT          1
  610   MRI GENERAL                         50.4660        2969   MRI SHOULDER RT WITH CONTRAST                1,061.00   73222RT TC          73222RT          1
  610   MRI GENERAL                         50.4660        2970   MRI SHOULDER RT W&WO/CONTRAST                3,885.30   73223RT TC          73223RT          1
  610   MRI GENERAL                         50.4660        2971   MRI IAC WITH CONTRAST                        1,061.00      70542               70542         1
  610   MRI GENERAL                         50.4660        2972   MRI IAC WITHOUT CONTRAST                     2,934.00      70540               70540         1
  610   MRI GENERAL                         50.4660        2973   MRI IAC WITH & WOUT CONTRAST                 3,885.30      70543               70543         1
  610   MRI GENERAL                         50.4660        2974   MRI ORBITS/FACE/NECK W&WO CONT               3,885.30      70543               70543         1
  610   MRI GENERAL                         50.4660        2975   MRI CHEST W&WO CONTRAST                      3,885.30      71552               71552         1
  610   MRI GENERAL                         50.4660        2976   MRI CERVICAL SPINE W&WO CONTRA               3,885.30      72156               72156         1
  612   MRI SPINAL CORD                     50.4660        3239   MRI T SPINE W/WO CONT SURVEY                 1,386.05   72157TC     72157      72157
  612   MRI SPINAL CORD                     50.4660        3249   MRI L SPINE W/WO CONT SURVEY                 1,386.05   72158TC     72158      72158         1
  610   MRI GENERAL                         50.4660        3348   MRI UPPER EXT NO JNT                         2,583.90   73220TC     73220      73220         1
  610   MRI GENERAL                         50.4660        3349   MRI CARDIAC FOR FUNCTION                     3,038.90      75554    75554      75554         1
  610   MRI GENERAL                         50.4660        3350   MRI CARDIAC MORPH W CONTRAST                 3,038.90   75553TC     75553      75553         1
  610   MRI GENERAL                         50.4660        3351   MRI CARDIAC MORPH W/O CONT                   2,848.85   75552TC     75552      75552         1
  610   MRI GENERAL                         50.4660        3352   MRI CARDIAC VELOCITY FLOW MAP                2,848.85   75555TC     75555      75555         1
  610   MRI GENERAL                         50.4660        3353   MRA ABDOMEN                                  2,848.85   74185TC     74185      74185         1
  610   MRI GENERAL                         50.4660        3354   MRA UPPER EXT W CONT                         2,848.85   73225TC     73225      73225         1
  610   MRI GENERAL                         50.4660        3419   MRA PELVIS W/WO DYE                          3,038.90            C8920      C8920            1
  612   MRI SPINAL CORD                     50.4660        3976   MRI CERVICAL SPINE W/WO CONT S               1,386.05   72156TC     72156      72156         1
  636   DRUG SPEC ID DETAIL CODING          50.4660        8700   PARAMAGNETIC CONTRAST                          778.10            Q9952      A4647            1
  636   DRUG SPEC ID DETAIL CODING          50.4660        8992   MRI CONTRAST M-CAL                             774.45                       Q9952            1
  610   MRI GENERAL                         50.4660        8993   MRI FOOT RT W/CONTRAST                       1,061.00   73719RT TC          73719RT          1
  610   MRI GENERAL                         50.4660        8994   MRI FOOT RIGHT W&WOUT CONTRAST               3,885.30   73720RT TC          73720RT          1
  610   MRI GENERAL                         50.4660        8995   MRI RT FOOT WITHOUT CONTRAST                   992.70   73718RT TC          73718RT          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9005   MRI M.R. ANGIO HEAD                          1,478.00   70544TC                70544         1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9217   MRI BRAIN TREATMENT PLANNING                 1,366.20   70552TC                70552         1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                            115 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL      CPT-4      HCPCS     RVU
  610   MRI GENERAL                         50.4660        9219   MRI BRAIN PITUITARY W/WO CONTR               5,802.50      70553                 70553          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9220   MRI ORBIT / FACE / NECK 3 SEQU               3,602.50   70540TC                  70540          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9221   MRI ORBIT / FACE / NECK 4 SEQU               4,360.90   70540TC                  70540          1
  610   MRI GENERAL                         50.4660        9222   MRI ORBIT,FACE, NECK W/WO CONT               3,602.50   70543TC                  70543          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9223   MRI TMJ                                      3,602.50   70336TC                  70336          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9224   MRI M.R. ANGIO NECK                          1,478.00   70541TC                  70547          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9226   MRI BRAIN WITHOUT CONTRAST 3S                3,602.50   70551TC                  70551          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9227   MRI BRAIN WITH CONTRAST 2 SEQU               3,520.55   70552TC                  70552          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9228   MRI BRAIN WITH CONTRAST 3 SEQU               4,278.85   70552TC                  70551          1
  611   MRI BRAIN (INC BRAINSTEM)           50.4660        9229   MRI BRAIN WITH & WITHOUT CONTR               5,119.40   70553TC                  70553          1
  619   MRI OTHER                           50.4660        9230   MRI CHEST 2 SEQUENCES                        2,843.80   71550TC                  71550          1
  619   MRI OTHER                           50.4660        9231   MRI CHEST W/O CONT                           3,602.50   71550TC                  71550          1
  619   MRI OTHER                           50.4660        9232   MRI M.R. ANGIO CHEST                         1,478.00   71555TC    C8909         71555          1
  612   MRI SPINAL CORD                     50.4660        9234   MRI SPINAL CANAL                             1,478.00   72159TC                  72159
  612   MRI SPINAL CORD                     50.4660        9236   MRI CERVICAL SPINE NO CONT 4S                4,360.90   72141TC                  72141          1
  612   MRI SPINAL CORD                     50.4660        9237   MRI CERVICAL SPINE W CONTR 3S                4,278.85   72142TC                  72142          1
  612   MRI SPINAL CORD                     50.4660        9238   MRI CERVICAL SPINE W CONTR 4S                5,037.45   72142TC                  72142          1
  612   MRI SPINAL CORD                     50.4660        9239   MRI T SPINE W&W/O CON                        5,690.85   72157TC                  72157          1
  612   MRI SPINAL CORD                     50.4660        9241   MRI THORACIC SPINE NO CONTR 3                3,602.50   7216TC                   72146          1
  612   MRI SPINAL CORD                     50.4660        9242   MRI THORACIC SPINE W CONTR 2S                3,520.55   72147TC                  72147          1
  612   MRI SPINAL CORD                     50.4660        9243   MRI THORACIC SPINE W CONTR 3S                4,278.85   72147TC                  72147          1
  612   MRI SPINAL CORD                     50.4660        9245   MRI LUMBAR SPINE NO CONTRAST3                3,602.50   72148TC                  72148          1
  612   MRI SPINAL CORD                     50.4660        9246   MRI LUMBAR SPINE NO CONTRAST4                4,360.90   72148TC                  72148          1
  612   MRI SPINAL CORD                     50.4660        9247   MRI LUMBAR SPINE WITH CONT 3S                4,278.85   72149TC                  72149          1
  612   MRI SPINAL CORD                     50.4660        9248   MRI LUMBAR SPINE WITH CONTR 4                5,037.45   72149TC                  72149          1
  612   MRI SPINAL CORD                     50.4660        9249   MRI L-SPINE WITH & WITHOUT CON               5,690.85   72158TC                  72158          1
  610   MRI GENERAL                         50.4660        9250   MRI PELVIS 2 SEQ WITH CONTRAST               2,843.80   72196TC                  72196          1
  610   MRI GENERAL                         50.4660        9251   MRI PELVIS 3 SEQ WITH CONTRAST               3,602.50   72196TC                  72196          1
  610   MRI GENERAL                         50.4660        9252   MRI SHOULDER RT WOUT CONTRAST                3,602.50   73221RT    TC         73221RT           1
  610   MRI GENERAL                         50.4660        9253   MRI M.R. ANGIO PELVIS                        1,478.00   72198TC    C8918         72198          1
  610   MRI GENERAL                         50.4660        9254   MRI M.R.ANGIO UPPER EXT RT                   1,478.00   73225TC               73225RT           1
  610   MRI GENERAL                         50.4660        9256   MRI UPPER EXTREMITY 3 SEQ RT                 3,602.50   73220TC               73220RT           1
  612   MRI SPINAL CORD                     50.4660        9258   MRI LUMBAR SPINE N/CONT SURVEY               1,188.00   72148TC       72148      72148          1
  612   MRI SPINAL CORD                     50.4660        9259   MRI M.R ANGIO LOWER EXTREMITY                1,478.00   73725TC    C8912      73725RT           1
  610   MRI GENERAL                         50.4660        9261   MRI LOW EXT 3 SEQ RT NOT JOINT               3,602.50   73720TC               73720RT           1
  610   MRI GENERAL                         50.4660        9263   MRI KNEE RT                                  2,934.00   73721RT    TC         73721RT           1
  610   MRI GENERAL                         50.4660        9264   MRI MRA ANGIO ABDOMEN                        1,478.00   74185TC               C8901             1
  610   MRI GENERAL                         50.4660        9265   MRI ABDOMEN 2 SEQ LIMITED EXAM               2,843.80   74181TC                  74181          1
  610   MRI GENERAL                         50.4660        9266   MRI ABD 3 SEQ W/WO CONTRAST                  3,602.50   74183TC                  74183          1
  610   MRI GENERAL                         50.4660        9267   MRI KNEE RT W/CONTRAST                       1,061.00   73722RT    TC         73722RT           1
  610   MRI GENERAL                         50.4660        9268   MRI KNEE RT W&WO/CONTRAST                    3,885.30   73723RT    TC         73723RT           1
  610   MRI GENERAL                         50.4660        9269   MRI LOWER EXT WITH JOINT RT                  2,934.00   73721RT    TC         73721RT           1
  610   MRI GENERAL                         50.4660        9270   MRI HIP RIGHT WITH CONTRAST                  1,061.00   73722RT    TC         73722RT           1
  610   MRI GENERAL                         50.4660        9271   MRI HIP RIGHT W&WO/CONTRAST                  3,885.30   73723RT    TC         73723RT           1
  610   MRI GENERAL                         50.4660        9272   MRI PELVIS WITHOUT CONTRAST                  2,732.40      72195                 72195          1
  610   MRI GENERAL                         50.4660        9273   MRI PELVIS W&WOUT CONTRAST                   3,885.30      72197                 72197          1
  610   MRI GENERAL                         50.4660        9274   MRI ABDOMEN W&WO/CONTRAST                    3,885.30      74183                 74183          1
  621   MED/SUR SUPP INCID TO RAD           50.4660        9277   MRI SUBTRACT FILM                              210.25              76350         76350          1
  610   MRI GENERAL                         50.4660        9302   MRI BREAST UNILAT RT W/WO CONT               2,843.80   76093TC C8903         76093RT
  610   MRI GENERAL                         50.4660        9304   MRI BREAST BILAT W/WOUT CONTRA               3,602.50           C8907            76094          1
  612   MRI SPINAL CORD                     50.4660        9436   MRI CERVICAL SPINE N/CONT SURV               1,188.00   72141TC    72141         72141          1
  612   MRI SPINAL CORD                     50.4660        9437   MRI CERVICAL SPINE W CONT ADD                  198.05   72142TC    72142         72142          1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               116 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                       Department order & then charge code order                           OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                    DESCRIPTION                     CHARGE        MCAL    CPT-4         HCPCS     RVU
  612   MRI SPINAL CORD                     50.4660           9441   MRI THORACTIC SPINE N/CON SURV                1,188.00   72146TC    72146          72146         1
  612   MRI SPINAL CORD                     50.4660           9442   MRI THORACIC SPINE W/CONT ADD                   198.05   72147TC    72147          72147         1
  612   MRI SPINAL CORD                     50.4660           9447   MRI LUMBAR SPINE W CONT ADD                     198.05   72149TC 72149TC           72149         1
  610   MRI GENERAL                         50.4660           9999   MRI REPEAT NO CHARGE                        no charge                                            1
  610   MRI GENERAL                         50.4660          69276   MRI BONE MARROW SPL                           2,583.90   76400TC         76400  76400            1
  610   MRI GENERAL                         50.4660    L2957         MRI ANKLE LT WITHOUT CONTRAST                 3,602.50   73721LT    TC       73721LT             1
  610   MRI GENERAL                         50.4660    L2958         MRI WRIST LT WITHOUT CONTRAST                 3,602.50   73221LT    TC       73221LT             1
  610   MRI GENERAL                         50.4660    L2959         MRI ANKLE LEFT W/CONTRAST                     1,061.00   73722LT    TC       73722LT             1
  610   MRI GENERAL                         50.4660    L2960         MRI ANKLE LEFT W&WOUT CONTRAST                3,885.30   73723LT    TC       73723LT             1
  610   MRI GENERAL                         50.4660    L2961         MRI WRIST LEFT WITH CONTRAST                  1,061.00   73222LT    TC       73222LT             1
  610   MRI GENERAL                         50.4660    L2962         MRI WRIST LEFT W&WO CONTRAST                  3,885.30   73223LT    TC       73223LT             1
  610   MRI GENERAL                         50.4660    L2963         MRI HAND LEFT WO CONTRAST                     2,934.00   73218LT    TC       73218LT             1
  610   MRI GENERAL                         50.4660    L2964         MRI HAND LEFT WITH CONTRAST                   1,061.00   73219LT    TC       73219LT             1
  610   MRI GENERAL                         50.4660    L2965         MRI HAND LEFT W&WO CONTRAST                   3,885.30   73220LT    TC       73220LT             1
  610   MRI GENERAL                         50.4660    L2966         MRI ELBOW LEFT WO/CONTRAST                    2,934.00   73221LT    TC       73221LT             1
  610   MRI GENERAL                         50.4660    L2967         MRI ELBOW LEFT WITH CONTRAST                  1,061.00   73222LT    TC       73222LT             1
  610   MRI GENERAL                         50.4660    L2968         MRI ELBOW LEFT W&WO/CONTRAST                  3,885.30   73223LT    TC       73223LT             1
  610   MRI GENERAL                         50.4660    L2969         MRI SHOULDER LT WITH CONTRAST                 1,061.00   73222LT    TC       73222LT             1
  610   MRI GENERAL                         50.4660    L2970         MRI SHOULDER LT W&WO/CONTRAST                 3,885.30   73223LT    TC       73223LT             1
  610   MRI GENERAL                         50.4660    L8993         MRI FOOT LEFT W/CONTRAST                      1,061.00   73719LT    TC       73719LT             1
  610   MRI GENERAL                         50.4660    L8994         MRI FOOT LEFT W&WOUT CONTRAST                 3,885.30   73720LT    TC       73720LT             1
  610   MRI GENERAL                         50.4660    L8995         MRI LT FOOT WITHOUT CONTRAST                    992.70   73718LT    TC       73718LT             1
  610   MRI GENERAL                         50.4660    L9252         MRI SHOULDER LT WOUT CONTRAST                 3,602.50   73221LT    TC       73221LT             1
  610   MRI GENERAL                         50.4660    L9254         MRA ANGIO UPPER EXTREMITY LT                  1,478.00   73225TC             73225LT             1
  610   MRI GENERAL                         50.4660    L9256         MRI UPPER EXT 3 SQ LT W/WO CON                3,602.50   73220LT    TC       73220LT             1
  610   MRI GENERAL                         50.4660    L9259         MRA ANGIO LOWER EXTREMITY LT                  1,478.00   73725TC    C8912    73725LT             1
  610   MRI GENERAL                         50.4660    L9261         MRI LOWER EXT 3 SQ LT W/WO CON                3,602.50   73720LT    TC       73720LT             1
  610   MRI GENERAL                         50.4660    L9263         MRI KNEE LT                                   2,934.00   73721TC             73721LT             1
  610   MRI GENERAL                         50.4660    L9267         MRI KNEE LT W/CONTRAST                        1,048.70   73722LT    TC       73722LT             1
  610   MRI GENERAL                         50.4660    L9268         MRI KNEE LT W&WO/CONTRAST                     3,885.30   73723LT    TC       73723LT             1
  610   MRI GENERAL                         50.4660    L9269         MRI LOWER EXT WITH JOINT LT                   2,934.00   73721LT    TC       73721LT             1
  610   MRI GENERAL                         50.4660    L9270         MRI HIP LEFT WITH CONTRAST                    1,061.00   73722LT    TC       73722LT             1
  610   MRI GENERAL                         50.4660    L9271         MRI HIP LEFT W&WO CONTRAST                    3,885.30   73723LT    TC       73723LT             1
  610   MRI GENERAL                         50.4660    L9302         MRI BREAST UNILAT LT W/WO CONT                2,843.80   76098LT    TC C8903 76098LT             1
  350   CAT SCAN GENERAL                    50.4680           3320   BREAST BIOPSY                                   592.85      19102      19102    19102            1
  350   CAT SCAN GENERAL                    50.4680           3321   BONE SUPERFCAL BX                               592.85      20220      20220    20220            1
  350   CAT SCAN GENERAL                    50.4680           3322   MUSCLE SOFT TISSUE BIOPSY                       592.85                 20206    20206            1
  350   CAT SCAN GENERAL                    50.4680           3323   CT THYROID BIOPSY                               592.85                                           1
  350   CAT SCAN GENERAL                    50.4680           3324   CT ABDOMINAL ABCESS SURG CODE                   346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3325   CT APPENDICEAL ABCESS                           346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3326   LIVER ABCESS SURG                               346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3327   CT LUNG ABCESS SURG                             346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3328   CT PANC PSEUDO SURG                             346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3329   CT PELV ABCESS SURG                             346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3330   CT PERITONEAL ABCESS                            346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3331   CT RENAL PERI ABCESS                            346.90                                           1
  350   CAT SCAN GENERAL                    50.4680           3332   CT RETROPERI ABCESS                             346.90
  350   CAT SCAN GENERAL                    50.4680           3333   BREAST ASPIRATION                               298.20      19000        19000     19000         1
  350   CAT SCAN GENERAL                    50.4680           3334   BREAST ASP EA ADD                               298.20                   19001     19001         1
  350   CAT SCAN GENERAL                    50.4680           3335   THYROID CYST ASPIRATION                         298.20                   60001     60001         1
  350   CAT SCAN GENERAL                    50.4680           3359   CT BIOPSY ABD/RETROPER                          592.85                                           1
  350   CAT SCAN GENERAL                    50.4680           3416   CT UPPER EXT W/WO CONT RT                     1,883.00                   73202RT
                                                                                                                              73202RT TC 73202RT                      1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                                  117 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                       CHARGE
 CHG         CATEGORY AND NAME               DPT        CODE                   DESCRIPTION                    CHARGE        MCAL   CPT-4   HCPCS          RVU
  350   CAT SCAN GENERAL                    50.4680        3417   CT UPPER EXT WO CONT RT                      1,755.90                   73200RT
                                                                                                                          73200RT TC 73200RT                     1
  350   CAT SCAN GENERAL                    50.4680        3418   ABDOMEN RETRO BIOPSY                           592.85                                          1
  352   CAT SCAN BODY                       50.4680        4792   CT SINUS WITH CONTRAST                       2,341.70   70487TC               70487            1
  352   CAT SCAN BODY                       50.4680        4793   CT SI JOINTS WITH CONTRAST                   2,255.00   72193TC               72193            1
  352   CAT SCAN BODY                       50.4680        4794   CT SI JOINTS W/WITHOUT CONTRAS               2,255.00   72194TC               72194            1
  352   CAT SCAN BODY                       50.4680        4799   CT PELVIS W/WITHOUT CONTRAST                 2,350.90   72194TC               72194            1
  352   CAT SCAN BODY                       50.4680        6430   CT OSTEOPOROSIS-HOSP                           389.25                         76070            1
  352   CAT SCAN BODY                       50.4680        6432   CT ANGIOGRAPHY CHEST                         2,182.55   71275TC               71275            1
  351   CAT SCAN HEAD                       50.4680        6433   CT STEREOTACTIC LOCALIZATION                 1,634.35                         76355            1
  351   CAT SCAN HEAD                       50.4680        6436   CT BRAIN WO CON-HOSP                         1,781.75   70450TC               70450            1
  351   CAT SCAN HEAD                       50.4680        6437   CT BRAIN NO CONTRAST EXTENDED                2,214.55   70450TC               70450            1
  351   CAT SCAN HEAD                       50.4680        6439   CT BRAIN CONTR-HOSP                          2,113.95   70460TC               70460            1
  351   CAT SCAN HEAD                       50.4680        6440   CT BRAIN WITH CONTRAST EXTENDE               2,630.65   70460TC               70460            1
  351   CAT SCAN HEAD                       50.4680        6441   CT BRAIN W WO C-HOSP                         2,724.50   70470TC               70470            1
  351   CAT SCAN HEAD                       50.4680        6442   CT BRAIN W WO CONTRAST EXTENDE               3,127.20   70470TC               70470            1
  352   CAT SCAN BODY                       50.4680        6444   CT C SPINE 3 LV-NO CONTRAST                  2,066.85   72125TC               72125            1
  352   CAT SCAN BODY                       50.4680        6445   CT C-SPINE COMPLETE NO CONTRAS               2,811.85   72125TC               72125            1
  352   CAT SCAN BODY                       50.4680        6446   CT C-SPINE COMPLETE NO CONTRAS               3,516.35   72125TC               72125            1
  352   CAT SCAN BODY                       50.4680        6447   CT C SPINE 4+LV-HOSP                         2,811.85   72125TC               72125            1
  352   CAT SCAN BODY                       50.4680        6448   CT C-SPINE COMPLETE WITH CONE                3,516.35   72126TC               72126            1
  352   CAT SCAN BODY                       50.4680        6450   CT T SPINE 3 LV NO CONTRAST                  2,066.85   72128TC               72128            1
  352   CAT SCAN BODY                       50.4680        6451   CT T-SPINE TO 3 LEVELS WITH CO               2,915.80   72129TC               72129            1
  352   CAT SCAN BODY                       50.4680        6452   CT THORACIC SPINE TO 3 LEVS W/               3,056.55   72130TC               72130            1
  352   CAT SCAN BODY                       50.4680        6454   CT THORACIC SPINE COMPLETE NO                3,593.35   72128TC               72128            1
  352   CAT SCAN BODY                       50.4680        6455   CT T-SPINE COMPLETE NO CON EXT               4,492.75   72128TC               72128            1
  352   CAT SCAN BODY                       50.4680        6456   CT T SPINE COMP WITH CONTRAST                4,341.65   72129TC               72128            1
  352   CAT SCAN BODY                       50.4680        6457   CT THORACIC SPINE COMPL W/WOC                4,653.75   72130TC               72130            1
  352   CAT SCAN BODY                       50.4680        6459   CT L SPINE 3 LV-HOSP NO CONSTR               2,066.85   72131TC               72131            1
  352   CAT SCAN BODY                       50.4680        6462   CT L SPINE COMP HOSP NO CONTRA               2,811.85   72131TC               72131            1
  352   CAT SCAN BODY                       50.4680        6463   CT L-SPINE COMPLETE NO CON EXT               3,516.35   72131TC               72131            1
  352   CAT SCAN BODY                       50.4680        6464   CT LUMBAR SPINE COMPLETE WITH                3,506.15   72132TC               72132            1
  352   CAT SCAN BODY                       50.4680        6465   CT L SPINE COMPLETE W CONTRST                4,381.80   72132TC               72132            1
  351   CAT SCAN HEAD                       50.4680        6468   CT IN/OUT EAR W/WO-HOSP                      3,372.10   70482TC               70482            1
  351   CAT SCAN HEAD                       50.4680        6469   CT ORBITS/SELLA/IAC/M WITH CON               3,942.40   70481TC               70481            1
  351   CAT SCAN HEAD                       50.4680        6470   CT SINUS COMPLETE                            2,034.25   70486TC               70486            1
  351   CAT SCAN HEAD                       50.4680        6471   CT ORBITS/SELLA/IAC WO CONT                  4,174.05   70482TC               70480            1
  351   CAT SCAN HEAD                       50.4680        6472   CT SINUS LIMITED                               617.45   70486TC               70486            1
  351   CAT SCAN HEAD                       50.4680        6473   CT FACIAL STRUCTURES NO CONTRA               2,278.60   70486TC               70486            1
  351   CAT SCAN HEAD                       50.4680        6474   CT FACIAL STRCT NO CON EXTENDE               2,848.70   70486TC               70486            1
  351   CAT SCAN HEAD                       50.4680        6475   CT FACIAL STRUCTURES WITH CONT               3,620.30   70481TC               70481            1
  351   CAT SCAN HEAD                       50.4680        6476   CT FACIAL STRUCTURES W/WO CONT               3,999.25   70488TC               70488            1
  352   CAT SCAN BODY                       50.4680        6477   CT NECK W/WO-HOSP                            3,150.75   70492TC               70492            1
  352   CAT SCAN BODY                       50.4680        6480   CT NECK TISSUES-HOSP NO CONTRA               2,496.45   70490TC               70490            1
  352   CAT SCAN BODY                       50.4680        6481   CT NECK TISSUES WITH CONTRAST                3,217.85   70491TC               70491            1
  352   CAT SCAN BODY                       50.4680        6483   CT LOWER EXTY HOSP NO CONT RT                2,241.35   73700RT TC         73700RT             1
  352   CAT SCAN BODY                       50.4680        6484   CT LOWER EXTREMITY W/CONTRAST                2,945.95   73701TC            73701RT             1
  352   CAT SCAN BODY                       50.4680        6485   CT CHEST WITHOUT CONTRAST                    3,301.85   71250TC               71250            1
  352   CAT SCAN BODY                       50.4680        6486   CT CHEST-HOSP WITH CONTRAST                  3,576.65   71260TC               71260            1
  352   CAT SCAN BODY                       50.4680        6487   CT UPPER EXTREMITY W/O CONT RT               2,305.10   73200TC            73200RT             1
  352   CAT SCAN BODY                       50.4680        6488   CT UPPER EXTREMITY W/CONTRAST                2,966.00   73201TC            73201RT             1
  352   CAT SCAN BODY                       50.4680        6489   CT PELVIS-HOSP WITH CONTRAST                 2,255.00   72193TC               72193            1
  352   CAT SCAN BODY                       50.4680        6490   CT PELVIS WITHOUT CONTRAST                   2,043.55   72192TC               72192            1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                              118 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                    Department order & then charge code order                          OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                     CHARGE
 CHG         CATEGORY AND NAME               DPT       CODE                   DESCRIPTION                     CHARGE        MCAL      CPT-4     HCPCS      RVU
  352   CAT SCAN BODY                       50.4680        6491   CT LIMITED FOLLOW UP                         1,832.15      76380                76380           1
  352   CAT SCAN BODY                       50.4680        6492   CT ABDOMEN LTD-HOSP WITH CONTR               1,972.95   76380TC                 76380           1
  352   CAT SCAN BODY                       50.4680        6493   CT ABDOMEN COMPLETE NO CONTRAS               2,043.55   74150TC                 74150           1
  352   CAT SCAN BODY                       50.4680        6494   CT ABDOMEN COMP. W/WO CONTRAST               2,494.50   74170TC                 74170           1
  352   CAT SCAN BODY                       50.4680        6495   CT ABDOMEN COMP-HOSP WITH CONT               2,255.00   74160TC                 74160           1
  352   CAT SCAN BODY                       50.4680        6496   CT PELVIMETRY LIMITED                        1,183.50   72192TC                 72192           1
  359   CAT SCAN OTHER                      50.4680        6497   CT CYST ASPIRATION BOWEL                     2,244.85                           76360           1
  352   CAT SCAN BODY                       50.4680        6498   CT BIOPSY LUNG                               2,030.10                           77012           1
  359   CAT SCAN OTHER                      50.4680        6499   CT PLACEMENT OF RADIO-THERAPY                1,677.70                           76370           1
  359   CAT SCAN OTHER                      50.4680        6500   CT CYST ASPIRAT LIVER                        2,244.85                           76360           1
  359   CAT SCAN OTHER                      50.4680        6501   CT CYST ASPIRAT RENAL                        2,244.85                           76360           1
  359   CAT SCAN OTHER                      50.4680        6502   CT CYST ASPIRAT PANCREAS                     2,244.85                           76360           1
  359   CAT SCAN OTHER                      50.4680        6503   CT BIOPSY BONE                               2,030.10                           77012           1
  359   CAT SCAN OTHER                      50.4680        6504   CT BIOPSY LIVER                              2,030.10                           76360           1
  359   CAT SCAN OTHER                      50.4680        6505   CYST APSIRATION RENAL                        2,030.10                           76360           1
  359   CAT SCAN OTHER                      50.4680        6506   CYST ASPIRATION PANCREAS                     2,030.10                           76360           1
  359   CAT SCAN OTHER                      50.4680        6507   CT BIOPSY RETROPERIT MASS                    1,812.65                           77012           1
  359   CAT SCAN OTHER                      50.4680        6508   CT ABLATION LIVER                            4,860.85   76362TC                 76362           1
  359   CAT SCAN OTHER                      50.4680        6509   CT 3-D RECONSTRUCTION                          577.80   76376TC                 76376           1
  270   M/S SUPPLY GENERAL                  50.4680        6510   BARD MAX CORE BIOPSY INS                       301.05
  270   M/S SUPPLY GENERAL                  50.4680        6511   BARD COAXIAL BIOPSY NEEDLE                     108.85
  270   M/S SUPPLY GENERAL                  50.4680        6512   PERCUTANEOUS STAY 25/BX                        219.70
  359   CAT SCAN OTHER                      50.4680        6520   CT C-SPINE WITH/WITHOUT CONT                 2,374.25   72127TC                72127            1
  359   CAT SCAN OTHER                      50.4680        6521   CT CHEST WITH/WITHOUT                        3,609.25   71270TC                71270            1
  352   CAT SCAN BODY                       50.4680        6522   CT LOWER EXT WITH/WITHOUT CONT               3,253.30   73702RT TC          73702RT             1
  352   CAT SCAN BODY                       50.4680        6523   CT FACIAL WITH CONTRAST                      2,848.70      70487               70487            1
  352   CAT SCAN BODY                       50.4680        6524   CT LUMBAR SPINE W/WITHOUT CONT               3,813.50   72133TC                72133            1
  272   M/S SUPPLY STERILE SUPPLY           50.4680        6531   DENVER PLEURAL CATH KIT                      1,932.85
  270   M/S SUPPLY GENERAL                  50.4680        6532   DENVER PLEURAL DRAINAGE KIT                  3,054.85
  274   M/S SUPPLY PROSTHETHIC DVC          50.4680        6541   PROBE OERC LUMB DISC                         8,939.70              C22614       62287
  359   CAT SCAN OTHER                      50.4680        6590   CT BIOPSY GUIDED                             2,030.10                           77012           1
  350   CAT SCAN GENERAL                    50.4680        6591   CYST ASPIRATION PANCREAS                       346.90                                           1
  352   CAT SCAN BODY                       50.4680        6592   CT VIRTUAL COLON SCREEN                      1,069.20              0066T    0066T
  352   CAT SCAN BODY                       50.4680       60431   CT ANGIOGRAPHY NECK                          2,182.55   70498TC                70498            1
  352   CAT SCAN BODY                       50.4680       60440   CT ANGIOGRAPHY PELVIS                        2,182.55      72191               72191            1
  352   CAT SCAN BODY                       50.4680       60441   CT ANGIOGRAPHY ABDOMEN                       2,182.55      74175               74175            1
  352   CAT SCAN BODY                       50.4680       60442   CT ANGIO ABD AORTA W/BIL RUN                 2,182.55      75635               75635            1
  352   CAT SCAN BODY                       50.4680       60443   CT ANGIOGRAPHY HEAD                          2,182.55      70496               70496            1
  352   CAT SCAN BODY                       50.4680       60444   CT ANGIOGRAPHY UPPER EXTREMITY               2,837.30   73706TC                73206            1
  352   CAT SCAN BODY                       50.4680       60445   CT ANGIOGRAPHY LOWER EXTREM                  2,837.30   73706TC                73706            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76497   CT CYST ASPIRATION BOWEL INJ P                 751.80      27065               27065            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76498   BIOPSY LUNG                                    678.10      32405               32405            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76500   CT CYST ASPIRATION LIVER INJ P                 751.80                          47010            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76501   CT CYST ASPIRAT RENAL INJ PROC                 751.80                          50390            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76502   CT CYST ASPIRAT PANCREAS INJ P                 751.80                          48500            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76503   BIOPSY BONE INJ PROC                           678.10      20225               20225            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76504   BIOPSY LIVER                                   678.10                          47000            1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76505   CT BIOPSY RENAL INJ PROC                       678.10                          50205            1
  359   CAT SCAN OTHER                      50.4680       76506   CT BIOPSY PANCREAS INJ PROC                    678.10                                           1
  761   TREAT/OBS RM TREATMENT RM           50.4680       76507   BPSY RETROPERIT MASS                           605.20      20225                20225
  351   CAT SCAN HEAD                       50.4680 C6436         CT BRAIN WO CON-HOSP                         1,781.75   70450TC                 70450           1
  351   CAT SCAN HEAD                       50.4680 C6442         CT BRAIN W WO CONTRAST EXTENDE               3,127.20   70470TC                 70470           1

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012   charge master v2                                                                                               119 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                        Department order & then charge code order                         OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG         CATEGORY AND NAME               DPT          CODE                     DESCRIPTION                    CHARGE       MCAL      CPT-4      HCPCS     RVU
  352   CAT SCAN BODY                       50.4680    C6496          CT FULL BODY SCAN                              944.50                           76499          1
  352   CAT SCAN BODY                       50.4680    C6497          CT VIRTUAL COLONOSCOPY                       1,069.20                        0067T             2
  352   CAT SCAN BODY                       50.4680    C6501          CT CARDIAC SCORING                             475.20                           76499          1
  352   CAT SCAN BODY                       50.4680    L0444          CT ANGIOGRAPHY UPPER EXT LT                  2,837.30   73206LT   TC         73206LT
                                                                                                                                             73206LT                 1
  350   CAT SCAN GENERAL                    50.4680    L3416          CT UPPER EXT W/WO CONT LT                    1,883.00   73202LT   TC         73202LT
                                                                                                                                             73202LT                 1
  350   CAT SCAN GENERAL                    50.4680    L3417          CT UPPER EXT W/O CONT LT                     1,755.90   73200LT   TC         73200LT
                                                                                                                                             73200LT                 1
  352   CAT SCAN BODY                       50.4680    L6483          CT LOWER EXTY HOSP W/OC CONT L               2,241.35   73700TC              73700LT           1
  352   CAT SCAN BODY                       50.4680    L6484          CT LOWER EXTREMITY W/CONTRAST                2,945.95   73710TC              73701LT           1
  352   CAT SCAN BODY                       50.4680    L6487          CT UPPER EXTREMITY NO CONTRAST               2,305.10   73200TC              73200LT           1
  352   CAT SCAN BODY                       50.4680    L6488          CT UPPER EXTREMITY W/CONTRAST                2,966.35   73201TC              73201LT           1
  352   CAT SCAN BODY                       50.4680    L6522          CT LOWER EXT WITH/WITHOUT CONT               3,253.30   73702LT   TC         73702LT           1
  250   PHARMACY GENERAL                    50.4710           1-Aug   AUGMENTIN 250-125 TAB                           18.38
  250   PHARMACY GENERAL                    50.4710           3-Aug   AUGMENTIN 875-125 TAB                           31.99
  250   PHARMACY GENERAL                    50.4710          14-Aug   AUGMENTIN 250 SUSP                             275.90
  250   PHARMACY GENERAL                    50.4710           53001   SNF PRESCRIPTION                               360.30
  250   PHARMACY GENERAL                    50.4710    2CO10          COCAINE HCL SOLN 4% 4ML                        110.95
  250   PHARMACY GENERAL                    50.4710    2FE31          FENTANYL TRANSDERMAL PATCH 100                 324.01
  250   PHARMACY GENERAL                    50.4710    2FE32          FENTANYL TRANSDERMAL PATCH 25M                 286.03
  250   PHARMACY GENERAL                    50.4710    2FE35          FENTANYL TRANSDERMAL PATCH 50M                 161.80
  250   PHARMACY GENERAL                    50.4710    2FE37          FENTANYL TRANSDERMAL PATCH 75M                 244.99
  250   PHARMACY GENERAL                    50.4710    2HY02          HYDROMORPHONE TAB 2MG                            7.50
  250   PHARMACY GENERAL                    50.4710    2HY54          HYDROMORPHONE INJ 4MG                           39.50
  250   PHARMACY GENERAL                    50.4710    2ME01          METHADONE TAB 10MG                               7.50
  250   PHARMACY GENERAL                    50.4710    2ME02          METHADONE TAB 5MG                                7.50
  250   PHARMACY GENERAL                    50.4710    2ME51          MEPERIDINE INJ 100MG                            39.50
  250   PHARMACY GENERAL                    50.4710    2ME52          MEPERIDINE INJ 25MG                             39.50
  250   PHARMACY GENERAL                    50.4710    2ME55          MEPERIDINE INJ 50MG                             39.50
  250   PHARMACY GENERAL                    50.4710    2ME57          MEPERIDINE INJ 75MG                             39.50
  250   PHARMACY GENERAL                    50.4710    2ME58          METHADONE INJ 10 MG/ML                          33.45
  250   PHARMACY GENERAL                    50.4710    2ME60          MEPERIDINE 500 MG/50 ML CART.                   67.89
  250   PHARMACY GENERAL                    50.4710    2MO04          MORPHINE SULFATE CR TAB 30 MG                   14.89
  250   PHARMACY GENERAL                    50.4710    2MO05          MORPHINE SO4 CR TABLET 15MG                      9.20
  250   PHARMACY GENERAL                    50.4710    2MO06          MORPHINE SO4 CR TABLET 100MG                    38.21
  250   PHARMACY GENERAL                    50.4710    2MO10          MORPHINE SO4 SOLN 10MG/5ML                      13.68
  250   PHARMACY GENERAL                    50.4710    2MO50          MORPHINE SO4 50 MG/50 ML                       136.28
  250   PHARMACY GENERAL                    50.4710    2MO51          MORPHINE SO4 INJ 10MG                           39.50
  250   PHARMACY GENERAL                    50.4710    2MO52          MORPHINE SO4 INJ 2MG                            39.50
  250   PHARMACY GENERAL                    50.4710    2MO54          MORPHINE SO4 INJ 4MG                            39.50
  250   PHARMACY GENERAL                    50.4710    2MO55          MORPHINE SO4 INJ 15MG                           39.50
  250   PHARMACY GENERAL                    50.4710    2MO58          MORPHINE SO4 INJ 250MG/10ML                    213.97
  250   PHARMACY GENERAL                    50.4710    2MO59          MORPHINE SO4 INJ 15MG/ML 20ML                   14.32
  250   PHARMACY GENERAL                    50.4710    2MO63          EPIDURAL MORPHINE 10 MG/10 ML                   75.82
  250   PHARMACY GENERAL                    50.4710    2OX02          OXYCODONE CR TABLET 20MG                        17.69
  250   PHARMACY GENERAL                    50.4710    2OX05          OXYCODONE 5MG CAPSULE IMMED. R                   7.50
  250   PHARMACY GENERAL                    50.4710    2PE02          PERCOCET TAB                                     7.93
  250   PHARMACY GENERAL                    50.4710    2RI01          RITALIN TAB 10MG                                 7.50
  250   PHARMACY GENERAL                    50.4710    2RO10          ROXANOL ORAL SOLN 20MG/1ML 1ML                   7.50
  250   PHARMACY GENERAL                    50.4710    2SU52          SUBLIMAZE INJ 2ML                               39.50
  250   PHARMACY GENERAL                    50.4710    2SU55          SUBLIMAZE INJ 5ML                               41.62
  250   PHARMACY GENERAL                    50.4710    3AC03          ACETAMINOPHEN/CODEINE TAB 30MG                   7.50
  250   PHARMACY GENERAL                    50.4710    3AC04          ACETAMINOPHEN/CODEINE TAB 60MG                   7.50
  250   PHARMACY GENERAL                    50.4710    3AC10          ACETAMINOPHEN/CODEINE ELX 12MG                   7.50

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012     charge master v2                                                                                                120 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                     OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG        CATEGORY AND NAME                DPT          CODE                 DESCRIPTION                     CHARGE     MCAL    CPT-4     HCPCS      RVU
  250   PHARMACY GENERAL                    50.4710    3AC16       APAP/COD 12 MG/5 ML 60 ML                      16.58
  250   PHARMACY GENERAL                    50.4710    3HY10       HYCODAN SYP 5ML                                 5.65
  250   PHARMACY GENERAL                    50.4710    3NO01       NORCO TABLET                                    8.04
  250   PHARMACY GENERAL                    50.4710    3VI01       VICODIN TAB                                     7.50
  250   PHARMACY GENERAL                    50.4710    3VI02       VICODIN ES TABLET                               7.50
  250   PHARMACY GENERAL                    50.4710    4AL02       ALPRAZOLAM TAB 0.25MG                           7.50
  250   PHARMACY GENERAL                    50.4710    4AL05       ALPRAZOLAM TAB 0.5MG                            7.51
  250   PHARMACY GENERAL                    50.4710    4CH02       CHLORDIAZEPOXIDE CAP 25MG                       7.50
  250   PHARMACY GENERAL                    50.4710    4CL07       CLORAZEPATE CAP 7.5MG                          12.94
  250   PHARMACY GENERAL                    50.4710    4DA01       DARVOCET N TAB 100MG                            7.50
  250   PHARMACY GENERAL                    50.4710    4DI05       DIAZEPAM TAB 5MG                                7.50
  250   PHARMACY GENERAL                    50.4710    4DI51       DIAZEPAM INJ 10MG                              39.50
  250   PHARMACY GENERAL                    50.4710    4LO01       LORAZEPAM TAB 1MG                               8.30
  250   PHARMACY GENERAL                    50.4710    4LO02       LORAZEPAM TAB 2MG                              10.46
  250   PHARMACY GENERAL                    50.4710    4LO03       LORAZEPAM TAB 0.5MG                             7.50
  250   PHARMACY GENERAL                    50.4710    4LO10       LORAZEPAM 2 MG/ML ORAL CONC                    11.73
  250   PHARMACY GENERAL                    50.4710    4LO52       LORAZEPAM INJ 2MG                              55.05
  250   PHARMACY GENERAL                    50.4710    4MI10       MIDAZOLAM SYRUP 2MG/1ML                        24.55
  250   PHARMACY GENERAL                    50.4710    4MI53       MIDAZOLAM 2MG/2ML INJ                          42.02
  250   PHARMACY GENERAL                    50.4710    4MI55       MIDAZOLAM INJ 5MG/ML                           39.54
  250   PHARMACY GENERAL                    50.4710    4PH03       PHENOBARBITAL TAB 30MG                          7.50
  250   PHARMACY GENERAL                    50.4710    4PH06       PHENOBARBITAL TAB 60MG                          7.50
  250   PHARMACY GENERAL                    50.4710    4TE01       TEMAZEPAM CAP 15MG                              7.50
  250   PHARMACY GENERAL                    50.4710    4TE07       TEMAZEPAM CAPSULE 7.5MG                         8.35
  250   PHARMACY GENERAL                    50.4710    5LO02       LOMOTIL TAB                                     7.50
  250   PHARMACY GENERAL                    50.4710    5PR10       PROMETHAZINE/CODEINE EXP 5ML                    7.50
  250   PHARMACY GENERAL                    50.4710    5PR60       PROMETHAZINE/CODEINE 60 ML                     46.44
  250   PHARMACY GENERAL                    50.4710    ACA01       ACARBOSE 25 MG TABLET                           7.88
  250   PHARMACY GENERAL                    50.4710    ACC01       QUINAPRIL TABLET 10MG                           9.04
  250   PHARMACY GENERAL                    50.4710    ACC02       QUINAPRIL TABLET 20MG                           9.04
  250   PHARMACY GENERAL                    50.4710    ACC05       QUINAPRIL TABLET 5MG                            9.04
  250   PHARMACY GENERAL                    50.4710    ACE01       ACETAMINOPHEN TAB 300MG                         7.50
  250   PHARMACY GENERAL                    50.4710    ACE06       ACETAMINOPHEN CHEWABLE TAB 80M                  7.50
  250   PHARMACY GENERAL                    50.4710    ACE07       ACETAMINOPHEN TAB 500MG                         7.50
  250   PHARMACY GENERAL                    50.4710    ACE09       ACEBUTOLOL 200 MG CAPSULE                       8.83
  250   PHARMACY GENERAL                    50.4710    ACE10       ACETAMINOPHEN DROPS 15ML                        7.20
  250   PHARMACY GENERAL                    50.4710    ACE11       ACETAMINOPHEN LIQ 160MG                         7.50
  250   PHARMACY GENERAL                    50.4710    ACE12       ACETAMINOPHEN LIQ 325MG                         7.50
  250   PHARMACY GENERAL                    50.4710    ACE13       ACETAMINOPHEN LIQ 650MG                         7.50
  250   PHARMACY GENERAL                    50.4710    ACE20       ACETAMINOPHEN SUPP 125MG                        7.50
  250   PHARMACY GENERAL                    50.4710    ACE21       ACETAMINOPHEN SUPP 325MG                        7.50
  250   PHARMACY GENERAL                    50.4710    ACE22       ACETAMINOPHEN SUPP 650MG                        7.50
  250   PHARMACY GENERAL                    50.4710    ADE50       ADENOSINE INJ 6MG                             295.13
  250   PHARMACY GENERAL                    50.4710    ADV40       ADVAIR DISKUS 100/50 28 DOSES                 295.49
  250   PHARMACY GENERAL                    50.4710    ADV41       ADVAIR DISKUS 250/50 28 DOSES                 359.96
  250   PHARMACY GENERAL                    50.4710    ADV42       ADVAIR DISKUS 500/50 28 DOSES                 498.16
  250   PHARMACY GENERAL                    50.4710    ADV44       ADVAIR DISKUS 250/50 60 DOSES                 725.73
  250   PHARMACY GENERAL                    50.4710    ADV45       ADVAIR DISKUS 500/50 60 DOSES                 994.70
  250   PHARMACY GENERAL                    50.4710    AGG01       AGGRENOX 25MG/200MG CAPSULE                    13.10
  250   PHARMACY GENERAL                    50.4710    ALB40       ALBUTEROL INHALER                             156.12
  250   PHARMACY GENERAL                    50.4710    ALB42       ALBUTEROL INHALANT SOL 0.083%                  11.91
  250   PHARMACY GENERAL                    50.4710    ALB70       ALBUMIN 25% 50ML                              536.02

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                      121 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG        CATEGORY AND NAME                DPT          CODE                   DESCRIPTION                   CHARGE      MCAL    CPT-4     HCPCS      RVU
  250   PHARMACY GENERAL                    50.4710    ALB74       ALBUMIN 25% 100ML                            1,077.14
  250   PHARMACY GENERAL                    50.4710    ALE02       ALENDRONATE TAB 70 MG                           88.90
  250   PHARMACY GENERAL                    50.4710    ALL01       ALLOPURINOL TAB 100MG                            7.50
  250   PHARMACY GENERAL                    50.4710    ALL02       ALLOPURINOL TAB 300MG                            7.50
  250   PHARMACY GENERAL                    50.4710    ALU12       ALUMIN/MAGN OH SUSP 30ML                         7.50
  250   PHARMACY GENERAL                    50.4710    ALU18       ALUMINUM/MAGNESIUM HYDROXIDE 1                   7.50
  250   PHARMACY GENERAL                    50.4710    AMA01       AMANTADINE CAP 100MG                             7.50
  250   PHARMACY GENERAL                    50.4710    AMI04       AMITRIPTYLINE TAB 10MG                           7.50
  250   PHARMACY GENERAL                    50.4710    AMI05       AMITRIPTYLINE TAB 25MG                           7.50
  250   PHARMACY GENERAL                    50.4710    AMI06       AMITRIPTYLINE TAB 50MG                           7.50
  250   PHARMACY GENERAL                    50.4710    AMI09       AMIODARONE TAB 200MG                            19.89
  250   PHARMACY GENERAL                    50.4710    AMI56       AMIODARONE INJ 150MG/3ML                       670.55
  250   PHARMACY GENERAL                    50.4710    AMI72       AMINO ACID 6.5 % 500 ML                        296.01
  250   PHARMACY GENERAL                    50.4710    AMI73       AMINO ACID/DEX 4.25%/10% 500ML                 223.28
  250   PHARMACY GENERAL                    50.4710    AMI74       3.5% AMINOSYN 1000 ML                          236.12
  250   PHARMACY GENERAL                    50.4710    AMI77       AMINO ACIDS 5.2% 500 ML                        113.12
  250   PHARMACY GENERAL                    50.4710    AMI78       8.5% AMINOSYN 500 ML                            85.95
  250   PHARMACY GENERAL                    50.4710    AML01       AMLODIPINE TAB 10MG                             14.95
  250   PHARMACY GENERAL                    50.4710    AML03       AMLODIPINE 2.5MG TAB                            10.94
  250   PHARMACY GENERAL                    50.4710    AML05       AMLODIPINE TAB 5MG                              10.94
  250   PHARMACY GENERAL                    50.4710    AMO01       AMOXICILLIN CAP 250MG                            7.50
  250   PHARMACY GENERAL                    50.4710    AMO02       AMOXICILLIN CAP 500MG                            7.50
  250   PHARMACY GENERAL                    50.4710    AMO12       AMOXICILLIN SUSP 250MG/5ML                      35.68
  250   PHARMACY GENERAL                    50.4710    AMO13       AMOXICILLIN SUSP 250MG/5ML 100                   1.50
  250   PHARMACY GENERAL                    50.4710    ANCEF       ANCEF 1 GRAM IVPB                               76.76
  250   PHARMACY GENERAL                    50.4710    ART01       ARTANE TAB 2MG                                   7.50
  250   PHARMACY GENERAL                    50.4710    ASC02       ASCORBIC ACID TAB 500MG                          7.50
  250   PHARMACY GENERAL                    50.4710    ASP02       ASPIRIN TAB 81MG                                 7.50
  250   PHARMACY GENERAL                    50.4710    ASP03       ASPIRIN TAB 300MG                                7.50
  250   PHARMACY GENERAL                    50.4710    ASP05       ASPIRIN ENTERIC TAB 300MG                        7.50
  250   PHARMACY GENERAL                    50.4710    ASP06       ASPIRIN ENTERIC COATED TAB 81M                   7.50
  250   PHARMACY GENERAL                    50.4710    ATE01       ATENOLOL TAB 25MG                                7.34
  250   PHARMACY GENERAL                    50.4710    ATE02       ATENOLOL TAB 50MG                                8.62
  250   PHARMACY GENERAL                    50.4710    ATO01       ATORVASTATIN 10MG TAB                           14.96
  250   PHARMACY GENERAL                    50.4710    ATO02       ATORVASTATIN 20MG TAB                           20.91
  250   PHARMACY GENERAL                    50.4710    ATO04       ATORVASTATIN 40MG TAB                           21.96
  250   PHARMACY GENERAL                    50.4710    ATR51       ATROPINE INJ 1MG/10ML SYR                       46.37
  250   PHARMACY GENERAL                    50.4710    ATR52       ATROPINE INJ 1MG                                39.50
  250   PHARMACY GENERAL                    50.4710    AUR40       AURALGAN OTIC SOLN 10ML                         38.87
  250   PHARMACY GENERAL                    50.4710    BAC02       BACLOFEN TAB 10MG                                7.50
  250   PHARMACY GENERAL                    50.4710    BAC40       BACITRICIN OPH OINT                             34.45
  250   PHARMACY GENERAL                    50.4710    BAL60       BALMEX OINT 120 GRAMS                           35.17
  250   PHARMACY GENERAL                    50.4710    BEN01       BENADRYL CAP 25MG                                7.50
  250   PHARMACY GENERAL                    50.4710    BEN02       BENADRYL CAP 50MG                                7.50
  250   PHARMACY GENERAL                    50.4710    BEN11       BENADRYL ELIX 10ML                               7.50
  250   PHARMACY GENERAL                    50.4710    BEN38       BENZOCAINE SPRAY 20% 60ML (OR                   85.19
  250   PHARMACY GENERAL                    50.4710    BEN50       BENADRYL INJ 50MG                               38.24
  250   PHARMACY GENERAL                    50.4710    BEN52       BENTYL INJ 20MG                                141.82
  250   PHARMACY GENERAL                    50.4710    BET41       LEVOBUNOLOL OPH SOLN 0.5% 5ML                  126.60
  250   PHARMACY GENERAL                    50.4710    BET42       BETOPTIC-S OPH SUSP 5ML                        132.96
  250   PHARMACY GENERAL                    50.4710    BIA01       CLARITHROMYCIN TAB 500MG                        24.44
  250   PHARMACY GENERAL                    50.4710    BIC54       BICILLIN LA INJ 1,200,000 UNIT                  69.75

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                       122 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                     OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG        CATEGORY AND NAME                DPT          CODE                 DESCRIPTION                     CHARGE     MCAL    CPT-4     HCPCS      RVU
  250   PHARMACY GENERAL                    50.4710    BIS01       BISACODYL TAB 5MG                               7.50
  250   PHARMACY GENERAL                    50.4710    BIS20       BISACODYL SUPP 10MG                             7.50
  250   PHARMACY GENERAL                    50.4710    BSS40       BSS 15 ML                                      42.65
  250   PHARMACY GENERAL                    50.4710    BSS41       BSS PLUS 500ML                                561.41
  250   PHARMACY GENERAL                    50.4710    BUD40       BUDESONIDE 0.5MG/2ML INH SOL                   25.66
  250   PHARMACY GENERAL                    50.4710    BUM01       BUMETANIDE TAB 1 MG                             7.50
  250   PHARMACY GENERAL                    50.4710    BUM51       BUMETANIDE INJ 1MG/4ML                         25.78
  250   PHARMACY GENERAL                    50.4710    BUP52       BUPIVACAINE INJ 0.5%/EPI 10ML                  58.99
  250   PHARMACY GENERAL                    50.4710    BUP55       BUPIVACAINE INJ 0.25%/EPI 10ML                 58.32
  250   PHARMACY GENERAL                    50.4710    BUP56       BUPIVACAINE SPINAL 0.75% M-661                 61.00
  250   PHARMACY GENERAL                    50.4710    BUP57       BUPIVACAINE LOCAL ER 10 ML                     66.94
  250   PHARMACY GENERAL                    50.4710    BUP59       BUPIVACAINE LOCAL 0.5% ER                      43.69
  250   PHARMACY GENERAL                    50.4710    BUS04       BUSPIRONE TAB 15MG                             15.95
  250   PHARMACY GENERAL                    50.4710    CAL40       CALCITONIN NASAL SPRAY (MIACAL                272.46
  250   PHARMACY GENERAL                    50.4710    CAL50       CALCIUM CHLORIDE INJ 1GM SYR                   47.82
  250   PHARMACY GENERAL                    50.4710    CAL52       CALCIMAR INJ 200 UNITS                        189.86
  250   PHARMACY GENERAL                    50.4710    CAN02       ATACAND (CANDESARTAN) 16MG TAB                 11.23
  250   PHARMACY GENERAL                    50.4710    CAP02       CAPTOPRIL TAB 25 MG                             7.61
  250   PHARMACY GENERAL                    50.4710    CAP03       CAPTOPRIL TAB 50MG                              9.46
  250   PHARMACY GENERAL                    50.4710    CAR04       CARBAMAZEPINE TAB 200MG                         7.50
  250   PHARMACY GENERAL                    50.4710    CAR50       NICARDIPINE INJ 25MG/10ML                     215.37
  250   PHARMACY GENERAL                    50.4710    CAT01       CATAPRES TAB 0.1 MG                             7.50
  250   PHARMACY GENERAL                    50.4710    CAT31       CATAPRES-TTS-1                                 59.57
  250   PHARMACY GENERAL                    50.4710    CAT32       CATAPRES-TTS-2                                 97.87
  250   PHARMACY GENERAL                    50.4710    CAT33       CATAPRES-TTS-3                                134.43
  250   PHARMACY GENERAL                    50.4710    CEF01       CEFACLOR CAP 250MG                             16.05
  250   PHARMACY GENERAL                    50.4710    CEF04       CEFUROXIME TAB 500MG                           45.91
  250   PHARMACY GENERAL                    50.4710    CEF54       CEFAZOLIN INJ 1GM                              77.31
  250   PHARMACY GENERAL                    50.4710    CEF59       CEFOTAXIME INJ 1GM                            122.32
  250   PHARMACY GENERAL                    50.4710    CEF65       CEFTRIAXONE INJ 250 MG                        135.47
  250   PHARMACY GENERAL                    50.4710    CEF66       CEFTRIAXONE INJ 500MG                         221.58
  250   PHARMACY GENERAL                    50.4710    CEF67       CEFTRIAXONE INJ 1GM                           363.07
  250   PHARMACY GENERAL                    50.4710    CEF68       CEFTRIAXONE INJ 2GM                           649.88
  250   PHARMACY GENERAL                    50.4710    CEF69       CEFTAZIDIME INJ 1GM                           145.95
  250   PHARMACY GENERAL                    50.4710    CEL02       CELEXOXIB 200MG CAPSULE                        16.79
  250   PHARMACY GENERAL                    50.4710    CEP04       CEPHALEXIN/CEPHRADINE CAP 250M                  7.93
  250   PHARMACY GENERAL                    50.4710    CEP05       CEPHALEXIN/CEPHRADINE CAP 500M                 12.63
  250   PHARMACY GENERAL                    50.4710    CET01       ZYRTEC (CETIRIZINE) 10MG TABLE                 14.26
  250   PHARMACY GENERAL                    50.4710    CHA11       CHARCOAL ORAL SUSP 240ML AQUEO                 13.26
  250   PHARMACY GENERAL                    50.4710    CHA12       ACTIVATED CHARCOAL SUSP 240ML(                 15.05
  250   PHARMACY GENERAL                    50.4710    CHA13       CHARCOAL ORAL SUSP 120ML SORB                  12.89
  250   PHARMACY GENERAL                    50.4710    CHE82       LIFESCAN ONETOUCH STRIP                         8.62
  250   PHARMACY GENERAL                    50.4710    CHL52       CHLORPROMAZINE INJ 25MG                        55.58
  250   PHARMACY GENERAL                    50.4710    CIM01       CIMETIDINE TAB 300MG                            8.14
  250   PHARMACY GENERAL                    50.4710    CIP02       CIPROFLOXACIN TAB 250MG                        25.29
  250   PHARMACY GENERAL                    50.4710    CIP05       CIPROFLOXACIN TAB 500MG                        28.98
  250   PHARMACY GENERAL                    50.4710    CIPRO       CIPRO 400 MG                                  208.77
  250   PHARMACY GENERAL                    50.4710    CIT02       CITALOPRAM 20 MG TAB.                          15.11
  250   PHARMACY GENERAL                    50.4710    CIT10       CITRATE OF MAGNESIA SOLN                       19.33
  250   PHARMACY GENERAL                    50.4710    CIT13       CITRUCEL 10 GMS/1 SCOOP                        18.32
  250   PHARMACY GENERAL                    50.4710    CLI02       CLINDAMYCIN CAP 150mg                          15.06
  250   PHARMACY GENERAL                    50.4710    CLI51       CLINDAMYCIN INJ 300MG                          49.91

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                      123 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                      OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG        CATEGORY AND NAME                DPT          CODE                  DESCRIPTION                    CHARGE      MCAL    CPT-4     HCPCS      RVU
  250   PHARMACY GENERAL                    50.4710    CLI53       CLINDAMYCIN INJ 600MG                           82.69
  250   PHARMACY GENERAL                    50.4710    CLI54       CLINDAMYCIN INJ 900MG                           20.16
  250   PHARMACY GENERAL                    50.4710    CLIN6       CLINDAMYCIN 600 MG                              86.43
  250   PHARMACY GENERAL                    50.4710    CLO02       CLONAZEPAM TAB 0.5MG                             7.72
  250   PHARMACY GENERAL                    50.4710    CLO05       CLONAZEPAM TAB 1MG                               8.30
  250   PHARMACY GENERAL                    50.4710    CLO30       CLOTRIMAZOLE CR 1% 15GM                         62.55
  250   PHARMACY GENERAL                    50.4710    COL03       COLCHICINE TAB 0.6MG                             7.50
  250   PHARMACY GENERAL                    50.4710    COL40       COLMYCIN S OTIC SUSP 5ML                       151.07
  250   PHARMACY GENERAL                    50.4710    COM40       COMBIVENT INHALER                              198.44
  250   PHARMACY GENERAL                    50.4710    COM50       HEP B/HIB CONJ 0.5 ML VACCINE                  386.18
  250   PHARMACY GENERAL                    50.4710    COR03       CARVEDILOL 3.125MG TAB                          12.31
  250   PHARMACY GENERAL                    50.4710    COR06       CARVEDILOL 6.25MG TABLET                        12.31
  250   PHARMACY GENERAL                    50.4710    COR09       CARVEDILOL 12.5 MG TABLET                       12.31
  250   PHARMACY GENERAL                    50.4710    COR40       CORTISPORIN OPH SUSP 7.5ML                     212.65
  250   PHARMACY GENERAL                    50.4710    COR42       CORTISPORIN OTIC SUSP 10ML                     126.75
  250   PHARMACY GENERAL                    50.4710    COR48       CORTISPORIN OTIC SOLN 10ML                      63.69
  250   PHARMACY GENERAL                    50.4710    CYA50       CYANOCOBALAMIN INJ 1000MCG                      14.62
  250   PHARMACY GENERAL                    50.4710    CYC40       CYCLOGYL OPH SOLN 1% 2ML                        62.89
  250   PHARMACY GENERAL                    50.4710    CYT01       CYTOMEL TAB 5MCG                                 7.50
  250   PHARMACY GENERAL                    50.4710    CYT02       CYTOMEL TAB 25MCG                                7.50
  250   PHARMACY GENERAL                    50.4710    DAC40       DACRIOSE OPH SOLN 30ML                          59.31
  250   PHARMACY GENERAL                    50.4710    DAD71       5% DEXTROSE IN WATER 100ML ADD                 125.00
  250   PHARMACY GENERAL                    50.4710    DAP50       DAPTOMYCIN 500 MG INJ                          803.61
  250   PHARMACY GENERAL                    50.4710    DEF50       DEFEROXAMINE MESYLATE INJ 500M                 124.92
  250   PHARMACY GENERAL                    50.4710    DEP01       DIVALPROEX SODIUM 125 MG TAB                     7.51
  250   PHARMACY GENERAL                    50.4710    DEP02       DIVALPROEX SODIUM TAB 250MG                      8.51
  250   PHARMACY GENERAL                    50.4710    DEP03       DIVALPROEX SODIUM TAB 500MG                     12.63
  250   PHARMACY GENERAL                    50.4710    DEP52       DEPO MEDROL INJ 40MG                            73.75
  250   PHARMACY GENERAL                    50.4710    DEP53       DEPO MEDROL INJ 80MG                           128.93
  250   PHARMACY GENERAL                    50.4710    DET02       TOLTERODINE 2 MG TABLET                         12.20
  250   PHARMACY GENERAL                    50.4710    DET04       TOLTERODINE LA 4 MG CAPSULE                     19.11
  250   PHARMACY GENERAL                    50.4710    DEX06       DEXAMETHASONE TAB 4MG                            7.50
  250   PHARMACY GENERAL                    50.4710    DEX51       DEXAMETHASONE INJ 4MG                           35.34
  250   PHARMACY GENERAL                    50.4710    DEX54       DEXAMETHASONE INJ 10MG                          45.03
  250   PHARMACY GENERAL                    50.4710    DEX59       DEXTROSE INJ 50% 50ML                           49.97
  250   PHARMACY GENERAL                    50.4710    DEX70       5% DEXTROSE IN WATER 50ML                      125.00
  250   PHARMACY GENERAL                    50.4710    DEX71       5% DEXTROSE IN WATER 100ML                     125.00
  250   PHARMACY GENERAL                    50.4710    DEX72       5% DEXTROSE IN WATER 250ML                     116.30
  250   PHARMACY GENERAL                    50.4710    DEX73       5% DEXTROSE IN WATER 500ML                     113.19
  250   PHARMACY GENERAL                    50.4710    DEX74       5% DEXTROSE IN WATER 1000 ML                   102.20
  250   PHARMACY GENERAL                    50.4710    DEX75       10% DEXTROSE IN WATER 500 ML                    76.38
  250   PHARMACY GENERAL                    50.4710    DHE50       DHE-45 INJ 1MG                                 136.48
  250   PHARMACY GENERAL                    50.4710    DIG01       DIGOXIN TAB 0.125MG                              7.44
  250   PHARMACY GENERAL                    50.4710    DIG02       DIGOXIN TAB O.25MG                               7.50
  250   PHARMACY GENERAL                    50.4710    DIG12       DIGOXIN ELIX 0.25MG                             12.52
  250   PHARMACY GENERAL                    50.4710    DIG52       DIGOXIN INJ 0.5MG                               39.02
  250   PHARMACY GENERAL                    50.4710    DIG54       DIGIBIND INJ 40MG                            4,475.91
  250   PHARMACY GENERAL                    50.4710    DIL01       DILTIAZEM TAB 30MG                               7.50
  250   PHARMACY GENERAL                    50.4710    DIL02       DILTIAZEM TAB 60MG                               7.50
  250   PHARMACY GENERAL                    50.4710    DIL03       DILTIAZEM TAB 90MG                               8.04
  250   PHARMACY GENERAL                    50.4710    DIL06       DILTIAZEM CD CAP 120MG                          10.52
  250   PHARMACY GENERAL                    50.4710    DIL07       DILTIAZEM CD CAP 180MG                          11.94

460c823b-54be-4840-b24b-96e7760a59d5.xls   8/23/2012    charge master v2                                                                                       124 of 282
OJAI VALLEY COMMUNITY HOSPITAL                                     Department order & then charge code order                     OSHPD Facility # 106560501
CHARGE MASTER, JUNE 2007
                                                         CHARGE
 CHG        CATEGORY AND NAME                DPT          CODE                  DESCRIPTION                    CHARGE     MCAL    CPT-4     HCPCS      RVU
  250   PHARMACY GENERAL                    50.4710    DIL08       DILTIAZEM CD CAP 240MG                         15.47
  250   PHARMACY GENERAL                    50.4710    DIL50       DILTIAZEM INJ 25MG/5ML                         61.73
  250   PHARMACY GENERAL                    50.4710    DIL55       DILTIAZEM INJ 125MG/5ML                       200.22
  250   PHARMACY GENERAL                    50.4710    DIP01       DIPYRIDAMOLE TAB 25MG                           7.50
  250   PHARMACY GENERAL                    50.4710    DIP02       DIPYRIDAMOLE TAB 50MG                           7.50
  250   PHARMACY GENERAL                    50.4710    DIP03       DIPYRIDAMOLE TAB 75MG                           7.50
  250   PHARMACY GENERAL                    50.4710    DIP50       DIPHTHERIA-TETANUS TOXOID ADUL                149.49
  250   PHARMACY GENERAL                    50.4710    DIP51       DIPHTHERIA-TETANUS TOXOID PED                  91.96
  250   PHARMACY GENERAL                    50.4710    DIP56       PROPOFOL INJ 1000MG/100ML                     477.47
  250   PHARMACY GENERAL                    50.4710    DIP59       DIP-TET-ACELL PERTUS 0.5ML                    324.79
  250   PHARMACY GENERAL                    50.4710    DIS72       5% DEXTROSE IN 0.45% NACL 500                 125.00
  250   PHARMACY GENERAL                    50.4710    DIS73       5% DEXTROSE IN 0.45% NACL 1000                113.77
  250   PHARMACY GENERAL                    50.4710    DIS75       5% DEXTROSE IN 0.9% NACL 1000                 118.22
  250   PHARMACY GENERAL                    50.4710    DIT01       DITROPAN TAB 5MG                                7.50
  250   PHARMACY GENERAL                    50.4710    DLR70       5% DEXTROSE IN LR 1000 ML                     103.28
  250   PHARMACY GENERAL                    50.4710    DOB50       DOBUTAMINE INJ 250MG                           95.32
  250   PHARMACY GENERAL                    50.4710    DOC02       DOCUSATE CAP 100MG                              7.57
  250   PHARMACY GENERAL                    50.4710    DOC10       DOCUSATE SYP 100MG/5ML                          7.50
  250   PHARMACY GENERAL                    50.4710    DOL50       DOLASETRON 12.5MG/0.625ML INJE                228.26
  250   PHARMACY GENERAL                    50.4710    DON03       ARICEPT (DONEPEZIL) 5MG TABLET                 28.45
  250   PHARMACY GENERAL                    50.4710    DON04       ARICEPT (DONEPEZIL) 10MG TABLE                 28.45
  250   PHARMACY GENERAL                    50.4710    DON11       DONNATAL ELIX 5ML                              10.30
  250   PHARMACY GENERAL                    50.4710    DON15       DONNATAL ELIXIR 10ML                           17.11
  250   PHARMACY GENERAL                    50.4710    DOP50       DOPAMINE INJ 200MG                             44.63
  250   PHARMACY GENERAL                    50.4710    DOP51       DOPAMINE INJ 400MG                             66.45
  250   PHARMACY GENERAL                    50.4710    DOX02       DOXYCYCLINE CAP 50MG                            7.67
  250   PHARMACY GENERAL                    50.4710    DOX03       DOXYCYCLINE CAP 100MG                           7.50
  250   PHARMACY GENERAL                    50.4710    DOX04       DOXEPIN CAP 25MG                                7.50
  250   PHARMACY GENERAL                    50.47