Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32602047 0.45% SOD CHLOR $ 32.25 32517153 0.62 X 6" K WIRE" $ 188.00 32601924 0.9% SOD. CHLOR. 4000 $ 65.90 32201543 0/P INFUSION HYDRATION-INITIAL$ 278.00 96360 40759268 1/2 NS 500ML BAG $ 32.95 32602021 10% DEXTRAN 40NS $ 56.85 31202799 1010 STERI DRAPE $ 39.40 31202781 1015-U DRAPE $ 62.35 31202773 1017 STERI DRAPE $ 16.20 39400080 17 HYDROXY PROG $ 108.50 83498 39407902 1GG,CSF $ 62.75 82784 31500648 2.0 SILK SUTURE $ 18.05 31502859 2.0 SILK SUTURE - X $ 18.05 32635311 2.0 SILK SUTURE - X $ 18.05 32517195 20 FR SAFETY PULL PEG KIT $ 281.35 32601841 20-52020-PRIM.SET $ 20.25 39904362 24HR. URINE BUN $ 72.25 84540 39904453 24HR. URINE GLUCOSE $ 68.25 82947 39904545 24HR. URINE MAGNES $ 59.50 83785 31203581 26F GASTRO TUBE $ 390.00 32511032 26FR KNIFE ELECTRODE $ 388.85 32600108 2A0063 D5W 500CC $ 33.80 32600249 2A0164 D10W 1000CC $ 33.80 32600306 2A0213 20% D INJ 500 $ 33.80 32699910 2A-02-53- D-50-W $ 57.40 32600280 2A0263 50% D INJ 500 $ 33.80 32600264 2A0264 50% DEXTROSE $ 35.50 32600504 2A1062 D5% 0.9% NS 250 $ 33.80 32600801 2A1353 3% SC 500 $ 33.80 32600827 2A1833 5% S CARB500 $ 33.80 32600447 2A2013 2.5%D .5R 500 $ 33.80 32600462 2A2022 2.5%D .5R 250 $ 35.50 32600488 2A2023 2.5%D .5R 500 $ 33.80 32600363 2A2323 LAC. RING 500 $ 33.80 32600868 2A2374 10% FRYE 1000 $ 35.50 32600900 2A2574PLASLUTE561000 $ 27.80 32600942 2A4264 10%TRA E31000 $ 33.80 32600967 2A5043 10% GENT 500 $ 94.30 32600983 2A5053 10% GENT 40 500 $ 137.85 32600124 2B0061 D5W 150CC $ 33.80 32699993 2B1357 0.45NS 20KCL $ 37.05 32600843 2B1803 SOD.LAC IN500 $ 33.80 32600884 2B2504 PLAS LYTE 1000 $ 35.50 32601221 2D5433 OSMITROL 500 $ 95.95 32517989 3 ARM ACCESSORY KIT $ 300.00 31203003 3 IN ONE DRAPE $ 201.95 32635014 3/32 JP DRAIN $ 49.05 32517179 3/32 JP DRAIN" $ 49.05 31203433 30% ULTRASONIC TIP $ 175.65 31505027 34CC IAB CATHETER $ 1,504.90 31505035 40CC IAB CATHETER $ 1,504.90 40601213 5 MCG SINCALIDE OR KINEVAC $ 150.00 J2805 31505720 5LB. DISP. SAND BAG X $ 27.00 31505019 5LB. DISP. SANDD BAG $ 28.50 31505498 6 FR CATHETER $ 62.90 31505589 6 FR MUTIPACK CATHETER $ 188.50 41601622 6 MIN WALK PULM STRESS TEST $ 229.00 94618 40871709 6 MINUTE WALK TEST $ 229.00 94618 32529810 7 FR. INTRODUCER SET $ 263.20 39506127 A. ALTERNATA $ 13.00 86003

1 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39506622 A. FUMIGATUS $ 13.00 86003 31532920 ABD PARACENTESIS $ 1,658.00 49082 31532821 ABD PARACENTESIS W/IMAGING$ 1,535.00 49083 40403941 ABDOMEN 2 VIEWS $ 259.00 74019 40400079 ABDOMEN COMPLETE $ 223.00 74022 40500258 ABDOMEN COMPLETE $ 340.00 76700 40400087 ABDOMEN FLAT AND UPRIGHT $ 259.00 74021 40400095 ABDOMEN FLAT OR KUB $ 135.00 74018 41000571 ABDOMEN WWO AND 3 PHASE LIVER$ 629.25 74170 41004339 ABDOMEN WWO THREE PHASE ABDOME$ 629.25 74170 40500860 ABDOMINAL AORTIC ANEURYSM $SCRE 247.00 76706 32510117 ABDOMINAL BINDER $ 142.85 32635410 ABDOMINAL BINDER $ 142.85 32513046 ABLATION SYSTEM, HTA $ 2,016.00 C1727 40200222 ABO AND RH $ 17.25 40100026 ABORH $ 35.00 86900 42614153 ABRAXANE 1 MG $ 45.00 J9264JG 42622865 ABRAXANE 1 MG JW $ 45.00 J9264JGJW 39500012 ABSCESS CULTURE $ 55.75 87070 32533598 ABSORPTION MAT $ 132.20 40401861 AC JOINTS $ 137.75 73050 40872501 ACAPELLA DEVICE $ 204.00 32510976 ACCESS WIRE GUIDE $ 496.30 40763773 ACCOLATE 20MG TAB $ 3.25 40759755 ACCUPRIL 10MG TABLET $ 3.25 40759706 ACCUPRIL 20 MG TAB $ 3.25 31401235 ACCURATOME $ 251.00 32533861 ACCURATOME $ 293.10 32510620 ACE BANDAGE STERILE $ 25.40 31304858 ACE BANDAGE STERILE $ 25.40 32612244 ACE BANDAGE STERILE $ 25.40 32512329 ACE TABULAR COMPONEN $ 660.45 40766834 ACEON 4MG $ 4.00 32516478 ACETABULAR RINGLOC LINER $ 1,625.00 32635113 ACETABULAR RINGLOC LINER $ 1,625.00 39900105 ACETAMINOPHEN $ 119.25 80307 40700825 ACETAMINOPHEN SUPP 120 MG $ 4.55 40756413 ACETAMINOPHEN SUPP 325 MG $ 4.55 40756421 ACETAMINOPHEN SUPP 650 MG $ 4.55 40761959 ACETIC ACID/ALUMINUM $ 15.95 39900196 ACETONE $ 23.50 82009 39400981 ACETYLCHOLINE ANTIBO $ 238.50 84238 39412648 ACETYLCHOLINE REC BLOCK AB $ 238.00 83519 39413242 AchR MODULATING AB $ 188.00 83516 39400106 ACID FAST OTHER $ 79.25 87116 39400197 ACID FAST SMEAR $ 19.75 87206 39402839 ACID FAST SPUTUM $ 65.25 87206 39900287 ACID PHOS $ 53.25 84060 39407385 ACID PHOSPHATASE $ 43.25 84060 32515132 ACL KIT $ 381.35 C1769 32514762 ACROMIOBLASTER $ 164.85 42610984 ACTEMRA 1 MG $ 17.00 J3262JG 42620093 ACTEMRA 1 MG MG JW $ 17.00 J3262JGJW 39400288 ACTH $ 151.25 82024 40724692 ACTIDOSE LIQUID 50GM TUBE $ 19.65 40772840 ACTIVASE 100MG VIAL $ 324.00 J2997JG 40768954 ACTIVASE 50MG/50ML VIAL $ 324.00 J2997JG 30900435 ACTIVATED CLOT DETECTION $ 18.75 85347 31010283 ACTIVATED CLOT DETECTION $ 19.75 85347 40765877 ACTOS 15MG TAB $ 9.70

2 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40759359 ACULAR-OPTHT 0.5% $ 80.15 32517146 ACUMED REAMER $ 307.50 40771651 ACYCLOVIR 400MG TAB $ 6.50 32500019 ADAPTOR CATH. 2C4004 $ 12.45 32508459 ADD-A-LINE 20 DROP $ 23.80 32500043 ADD-A-LINE, 60 DROP $ 12.95 40404311 ADDITIONAL CYST ASPIRATION $ 254.40 19001 40773137 ADENOSINE 12MG/4ML VIAL $ 41.00 40754137 ADENOSINE 6MG/2ML VIAL $ 59.55 J0153 39408458 ADENOVIRUS AB, RSV $ 160.00 87807 40107401 ADENOVIRUS ANTIBODY $ 128.00 86603 39408546 ADENOVIRUS BY PCR $ 394.00 87798 39402201 ADH $ 435.25 84588 32532657 ADHESION BARRIER $ 355.05 C1765 32639172 ADHESION BARRIER $ 448.00 C1765 33301831 ADJ TISSUE <10 SQ CM $ 3,122.00 14040 33453018 ADJ TISSUE ADDL 30 SQ CN $ 2,211.00 14302 33300395 ADJ TISSUE CHIN<10CM $ 3,122.00 14041 33300403 ADJ TISSUE EYE <10CM $ 3,122.00 14060 33300411 ADJ TISSUE EYE 10.1-30 $ 3,122.00 14061 33300429 ADJ TISSUE EYE 30.1 - 60 SQ CM$ 2,211.00 14302 33300379 ADJ TISSUE SCALP <10CM $ 3,122.00 14020 33300387 ADJ TISSUE SCALP 10-30CM $ 3,122.00 14021 33300353 ADJ TISSUE TRUNK <10CM $ 3,122.00 14000 33300361 ADJ TISSUE TRUNK 10-30CM $ 3,122.00 14001 40900136 ADL $ 106.50 97535GP 40920136 ADL 15MIN $ 106.50 97535GO 50710299 ADM FLU VACCINE $ 76.00 G0008 30200901 ADM FLU VACCINE $ 130.00 G0008 30200885 ADM PNEUMOCOCCAL VACCINE $ 68.00 G0009 42613360 ADM; EA ADDTL VACCINE $ 170.00 90472 40750978 ADMINISTRATION FEE HOME MED$ EA 3.25 32504169 ADMISSION KIT $ 43.75 40763393 ADRIAMYCIN PFS 50MG $ 652.25 J9000 40733263 ADRIAMYCIN RDF VIAL $ 117.95 J0202 40750804 ADRIAMYCIN RDF VIAL $ 418.10 40733271 ADRIAMYCIN RDF VIAL $ 571.55 J0202 40764391 ADRIAMYCINPES 200MG VIAL/CHEMO$ 2,168.10 J9000 40767592 ADVAIR 100/50 MCG INHALER $ 248.00 40767618 ADVAIR 500/50 MCG INHALER $ 357.50 40758468 AEROCHAMBER MASK, MEDIUM $ 120.00 40755332 AEROCHAMBER W/MASK, SMALL $ 73.60 33303860 AEROSOL INHALE INIT $ 406.00 94664 33303886 AEROSOL INHALE SUBSQ $ 406.00 94640 39404140 AFP SERUM $ 125.00 82105 39476051 AFP TUMOR MARKER $ 38.25 82105 39403787 AFPMAT ESTRIOL $ 38.25 82677 39403969 AFPMAT HCG $ 38.25 84702 39404058 AFPMAT INHIBIN A $ 38.25 86336 39404504 AFPMAT-TETRA $ 153.00 82105 40717860 AFRIN 0.05% NASAL SPR 15ML BT$ 9.90 40778879 AGGRASTAT 5MG/100ML PREMIX$ BAG 804.00 J3246 40766842 AGGRENOX 200/25 MG CAPSULE$ 6.00 40767816 AHF, HUMAN/VWF HUMAN 600 IU$ 1,186.50 J7184 32500068 AIR MATTRESS DAILY $ 11.20 32500050 AIR MATTRESS SET UP $ 116.90 32513053 AIRWAY BASKET $ 615.20 31902810 AIRWAY NASAL $ 41.95 31700998 AIRWAY NASAL $ 41.95 31700899 AIRWAY NASAL $ 41.95

3 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31539355 AIRWAY NASAL $ 41.95 31302680 AIRWAY NASAL $ 41.95 32634915 AIRWAY NASAL $ 41.95 31904683 AIRWAY NASAL $ 42.00 31405361 AIRWAY NASAL $ 42.00 31902802 AIRWAY ORAL $ 7.60 31548661 AIRWAY ORAL $ 7.60 40773038 AKTEN 3.5% 1 ML OPTH GEL DROPS$ 86.50 39405196 ALANINE $ 268.25 82131 39900469RP ALBUMIN $ 4.25 82040 3990046914 ALBUMIN $ 6.75 82040 39900469HF ALBUMIN $ 9.00 82040 39900469 ALBUMIN $ 39.50 82040 42609602 ALBUMIN 12.5GM $ 320.75 P9047JG 40779275 ALBUMIN 25% 100ml 25gm /100ml$ 781.50 P9047 40779176 ALBUMIN 25% 25gm/100ml IV 50ML$ 391.00 P9047 40769176 ALBUMIN 25% SOL 12.5GM/50ML$ 298.00 P9047JG 39405766 ALBUMIN MICROURINARY $ 27.50 82043 40107732 ALBUMIN, URINE/OTHER $ 39.50 82042 40805350 ALBUTEROL 0.083% 2.5MG/3ML AMP$ 6.50 40805806 ALBUTEROL 5MG/ML UD $ 6.50 40771172 ALBUTEROL 8GM VENTOLIN INHALER$ 61.00 40871602 ALBUTEROL SOLN 1.25MG/3ML NEB$ 10.00 40752248 ALBUTEROL SYRUP 2MG/5ML UDC$ 3.40 40752818 ALCAINE 0.5% OPTH DROP 15ML$ BT 4.55 40700098 ALDACTONE 25 MG TABLET $ 3.25 39400379 ALDOLASE $ 59.00 82085 40700122 ALDOMET TAB 250MG $ 3.25 39400460 ALDOSTERONE $ 166.50 82088 39400064 ALDOSTERONE 24 U $ 149.50 82088 40769838 ALFUZOSIN ER 10MG TABLET $ 6.50 42605686 ALIMTA 10 MG $ 243.00 J9305JG 42622172 ALIMTA 10 MG JW $ 243.00 J9305JGJW 39413440 ALK FRAC ISOENZYMES MASTER $ 145.00 39400551 ALK PHOS FRACT $ 94.25 84080 39413440A ALKALINE PHOS ISO $ 39.00 84075 3990091514 ALKALINE PHOSPHATASE $ 6.75 84075 39900915HF ALKALINE PHOSPHATASE $ 9.00 84075 39900915 ALKALINE PHOSPHATASE $ 50.25 84075 40770711 ALKERAN 2MG TAB $ 18.00 40768772 ALLEGRA 180MG TAB $ 8.00 40764516 ALLEGRA 60MG CAPSULE $ 4.55 32517237 ALLODERM 50 SQ CM $ 1,985.00 Q4116 32517245 ALLODERM 72 SQ SM $ 2,542.50 Q4116 32517252 ALLOGRAFT CARTILAGE DE NOVO$ NT 4,937.50 J3590 32516668 ALLOGRAFT-WHOLE PATELLA TENDON$ 3,838.75 C1762 40768723 ALOCRIL 2% DROPS $ 227.00 42603045 ALOXI .25 MG $ 1,740.00 J2469JG 40775018 ALOXI 0.25MG/5ML VIAL $ 1,245.00 J2469 39400734 ALPHA 1 ANTITRIPSIN $ 65.50 82103 40769788 ALPHA 1 PROTEINASE 1000MCG/VIA$ 1,036.00 J0256 39403720 ALPHA I ANTI PHENO $ 154.50 82104 42603791 ALPHA-1 PROTEIN INHIBIT 1000MG$ 1,088.00 J0256 39478724 ALPHA-2 MACROGLOBULIN $ 134.00 83883 40768616 ALPHAGAN P 0.15% DROPS 5ML BT$ 118.00 40755233 ALPHA-KERI BATH OIL $ 23.85 3990449514 ALT $ 6.75 84460 39904495HF ALT $ 9.25 84460 39904495 ALT $ 60.75 84460 40754814 ALTACE CAP 2.5MG $ 5.70

4 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39400585 ALTERNARIA-RAST $ 28.75 86003 39402292 ALUMINUM $ 127.00 82108 31202682 ALUMINUM BAND $ 125.70 40714024 AMANTADINE CAP 100MG $ 3.40 40763732 AMARYL 2MG TAB $ 3.25 40759797 AMBIEN 5MG TABLET $ 4.55 40804346 AMBU MASK $ 16.50 39506226 AMERICAN ELM $ 13.00 86003 40752065 AMIDATE 2MG/1ML 40MG/20ML VIAL$ 65.85 42601781 AMIFOSTINE 500MG $ 1,338.00 J0207JG 39400825 AMIKACIN LEVEL $ 49.50 80150 40733339 AMIKIN SULF 500MG/2ML VIAL $ 155.50 J0278 39402383 AMINO ACID SCREEN. $ 59.75 82128 40733313 AMINOCAPROIC ACID 250MG/ML $VIA 31.75 40766156 AMINO-CERV TOPICAL CREAM $ 56.20 40756827 AMINOPHYLLINE 500MG/20ML VIAL$ 18.15 J0280 32601023 AMINOSYN 3.5% 1000CC $ 91.15 39404017 AMIODARONE $ 161.00 80299 40759730 AMIODARONE 150MG/3ML VIAL $ 40.65 J0282 40769168 AMIODARONE 900MG/18ML VIAL$ 244.00 J0282 39407002 AMITRIPTYLINE $ 191.00 80307 40704579 AMITRIPTYLINE 10MG TABLET $ 3.25 40704587 AMITRIPTYLINE TAB 25MG $ 3.25 40754962 AMMONIA AROMATIC INH $ 4.50 39901277 AMMONIA BLOOD $ 43.00 82140 32201014 AMNIHOOK $ 14.75 32201030 AMNIOCENTESIS $ 53.25 41467028 AmnioExcel per 1 sq cm $ 500.00 Q4137 40770299 AMOXCICILLIN 875MG TAB $ 3.25 40700262 AMOXICILLIN 250MG CAPSULE $ 3.25 40775315 Amoxicillin 400mg/5ml Bottle $ 24.50 40753717 AMOXICILLIN TRIHYD C 500MG $ 3.40 40724775 AMOXIL 250MG/5ML BOTTLE $ 22.70 40770257 AMPICILLIN 250MG VIAL $ 10.50 40759854 AMPICILLIN 2GM VIAL $ 17.05 J0290 40733412 AMPICILLIN SODIUM 500MG VIAL$ 24.00 J0290 40700296 AMPICILLIN TRIHYD 500MG CAP $ 3.40 40700288 AMPICILLIN TRIHYD CAP 250MG $ 3.25 40733420 AMPICILLIN VIAL 1GM VIAL $ 26.10 J0290 31500713 AMPLATZ 1 $ 92.85 C1725 31500721 AMPLATZ 2 $ 92.85 C1725 31500739 AMPLATZ 3 $ 92.85 C1725 32515819 AMPLATZ MICROSNARE $ 868.55 C1773 31500747 AMPLATZ RIGHT MODIFIED $ 92.85 C1725 31505860 AMPLATZ SUPERSTIFF WIRE - X $ 527.15 C1769 31543018 AMPLATZ SUPERSTIFF WIRE - X $ 528.00 C1769 31537969 AMPLATZ SUPERSTIFF WIRE - X $ 528.00 C1769 41459405 AMPUTA TOE INTERPHALANG JT $ 3,869.00 28825 41463563 AMPUTATE METATAR W/TOE SING$ 3,778.50 28810 41459603 AMPUTATE TOE MTP JOINT $ 3,778.50 28820 40763898 AMVISC 0.5ML SYRINGE $ 217.20 40718009 AMYL NITRITE AMP $ 6.80 39901459 AMYLASE $ 27.25 82150 39901020 AMYLASE 24 HR URINE $ 68.25 82150 39905930 AMYLASE ISO $ 90.00 82150 39905930A AMYLASE ISO I $ 45.00 82150 39905930B AMYLASE ISO II $ 45.00 82150 39900931 AMYLASE UR RANDOM $ 45.25 82150 39401005 ANA $ 59.00 86038 39413143 ANA W/ TITER $ 125.00 86038

5 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39500558 ANAEROBIC CULTURE $ 59.50 87075 40106973 ANAEROBIC ISOLATE(EA) $ 44.25 87076 40755308 ANAPROX DS 550MG TABLET $ 6.80 32515793 ANASTOCLIP APPLIER $ 466.65 32515785 ANASTOCLIP REMOVER SURG $ 427.10 39403746 ANCA MASTER $ 243.00 39403746A ANCA MYELOPEROXIDASE $ 121.50 83516 39403746B ANCA PROTEINASE 3 $ 121.50 83516 40750705 ANCEF 1GM/100ML PREMIX BAG $ 21.55 J0690 40757072 ANCEF 500 MG VIAL $ 14.75 42609699 ANCEF 500MG $ 21.55 J0690 40774424 ANCEF PBACK 2GM/100ML $ 24.00 40773236 ANCEF PBACK 2GM/100ML $ 24.00 J0690 32514531 ANCHOR , MULTIFIX 5.5 $ 490.00 C1713 32605908 ANCHOR , MULTIFIX 6.5 $ 490.00 C1713 32516528 ANCHOR SUTURE MICROMAX $ 557.00 32516544 ANCHOR THREADLESS KNOT $ 454.95 32514523 ANCHOR TISSUE ORTHO $ 490.35 C1713 32514283 ANCHOR TWIN FIX SUTURE $ 320.25 C1713 32511685 ANDREWS PAT CARE KIT $ 201.95 32612343 ANDREWS PAT CARE KIT $ 201.95 40107781 ANDROSTENEDIANE $ 184.00 82157 40107203 ANDROSTENEDIANE $ 184.00 82157 40755605 ANECTINE VIAL 200MG/10ML VIAL$ 60.50 J0330 32201154 ANESTHESIA EPIDURAL $ 413.25 32201188 ANESTHESIA LOCAL $ 124.00 31900012 ANESTHESIA MAJOR I $ 634.00 31900020 ANESTHESIA MAJOR II $ 1,097.00 32201162 ANESTHESIA SADDLE BLOCK $ 424.50 31900962 ANESTHETIC DRUG CHARGE $ 273.75 31500150 ANG F/U EM/INFUS NOT THROMBO$ 1,856.00 75898 32529836 ANGIO CATH.HEPARINIZ $ 173.95 40481758 ANGIO COMPLETE EVAL AV SHUNT$ 1,488.00 39402110 ANGIO CONV ENZ $ 75.25 82164 31521482 ANGIO RENAL BIL SUP SEL W S&I$ 5,782.00 36254 31521284 ANGIO RENAL BILAT W/S&I $ 5,782.00 36252 31521383 ANGIO RENAL UNI SUP SEL W S&I$ 8,609.00 36253 31521185 ANGIO RENAL, UNILAT W/S&I $ 5,782.00 36251 31500754 ANGIO SYRINGE $ 49.40 31505811 ANGIO SYRINGE X $ 46.50 32517229 ANGIOCATH 14GA X 5 1/2 IN $ 54.65 31500010 ANGIOG. ADDT. VESSEL SELECT $ 1,208.00 75774 31500028 ANGIOG. BRACHIAL RETROGRADE$ 5,782.00 75710 31500093 ANGIOG. EXTERMITY, BILATERAL$ 5,782.00 75716 31500101 ANGIOG. EXTREMITY, UNILATERAL$ 5,782.00 75710 31500119 ANGIOG. PELVIC, SEL./SUPRA:S $ 8,609.00 75736 31500770 ANGIOGRAPHIC DRAPE $ 68.90 31505902 ANGIOGRAPHIC DRAPE X $ 65.10 31543414 ANGIOJET CATH OTW $ 4,020.00 C1757 32512949 ANGIOJET CATH OTW $ 4,020.85 C1757 31545691 ANGIOJET PUMP SET $ 550.00 32512931 ANGIOJET PUMP SET $ 551.25 40769697 ANGIOMAX 250MG VIAL $ 1,483.00 J0583 31505423 ANGLE GLIDE WIRE $ 197.40 C1769 61502230 ANGLE GLIDEWIRE - X $ 197.40 C1769 32532236 ANGLED LOOP STORZ $ 225.15 39403191 ANITBODY:EPSTEIN BAR $ 54.75 86665 40401622 ANKLE AP AND LATERAL RIGHT $ 101.10 73600 32516221 ANKLE CLAMP $ 1,613.00 C1713 40401614 ANKLE RIGHT 4 VIEWS $ 137.00 73610

6 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33303217 ANOSCOPY, DIAG $ 292.00 46600 33301021 ANOSCOPY, W/RMV FOREIGN $ 1,836.00 46608 40700338 ANTABUSE TAB $ 3.40 40105454 ANTEPARTUM RHOGAM WK $ 44.75 86850 32507873 ANTERIOR EYE CANULA $ 18.00 39400338 ANTI C3 $ 70.25 86160 39405915 ANTI GAD ANTIBODY $ 171.00 83519 39600200 ANTI PROTEIN C RESISTANCE $ 130.50 85307 39405659 ANTI SCL-70 $ 70.25 86235 39405741 ANTI STRIATED MUSCLE $ 79.25 86255 39402029 ANTI THY AB $ 59.75 86376 39407166 ANTIBASEMENT MEMBRANE $ 163.50 83520 39401021 ANTIBODY CYTOMEGALOV $ 88.75 86644 40200149 ANTIBODY INDENT $ 239.00 86870 40100323 ANTIBODY SCREEN $ 44.00 86850 40201865 ANTIBODY TITER $ 129.00 86886 39401112 ANTIBODY: BLASTOMYCE $ 26.00 86157 39407035 ANTICARDIOLIPIN AB IG-G $ 116.00 86147 39407048 ANTICARDIOLIPIN AB IGM $ 116.00 86147 39401633 ANTICARDIOLIPIN ANTI $ 234.00 86147 39409183 ANTI-CCP $ 23.00 86200 39403910 ANTI-CENTROMENE $ 99.00 86256 39405501 ANTI-CHROMATIN AB $ 59.00 83516 39478229 Anti-Cv2 $ 605.00 84182 39412351 ANTIGEN ID 2 $ 80.00 86902 39412450 ANTIGEN ID 3 $ 100.00 86902 39412549 ANTIGEN ID 4 $ 120.00 86902 40200198 ANTIGEN SCREENING $ 80.00 86905 39479219 ANTIGLIADIN AB MASTER $ 45.00 83516 39479219A ANTIGLIADIN IGA $ 22.50 83516 39479219B ANTIGLIADIN IGG $ 22.50 83516 39477932 Anti-Hu $ 387.00 86256 39405022 ANTI-ISLET $ 158.00 86341 39478625 Anti-JCV $ 515.00 87798 40733446 ANTILIBRIUM 2MG/2ML AMP $ 56.70 39406921 ANTI-MAG $ 188.00 39906623 Anti-Mullerian Hormone $ 39.00 82397 39406467 ANTIMYOCARD ABIGG $ 36.00 86255 39406558 ANTIMYOCORD ABIGM $ 36.00 86256 39477041 Anti-parietal Cell Anitbody $ 148.75 83516 39478130 Anti-RI $ 387.00 86256 39404272 ANTI-SSA $ 59.75 86235 39404363 ANTI-SSB $ 59.75 86235 39402094 ANTITHOMBIN III $ 62.00 85300 39406400 ANTITHYROGLOBULIN $ 64.00 86800 40733461 ANTIVENIN LATRODECTUS MACTANS$ 166.35 40754202 ANTIVERT 12.5 MG TAB $ 3.25 40754210 ANTIVERT 25MG TAB $ 3.25 39478031 Anti-Yo $ 387.00 86256 40752800 ANUSOL HC 2.5% CREAM 30GM TUBE$ 51.15 40730939 ANUSOL HC 25MG SUPP $ 4.60 40500217 AORTIC ANEURYSM $ 362.00 76775 31500168 AORTOG., ABD. W/SERIAL FLUSH$ 5,782.00 75625 31500176 AORTOG., ABD., BILAT/FEM. $ 5,782.00 75630 31500184 AORTOG., THORACIC W/SERIAL $ 8,609.00 75605 31511900 AORTOGRAPHY W/HEART CATH $ 125.00 93567 39413440B AP FRACTIONATED ISOENZYMES$ 106.00 84080 32515157 APC ENTERASCOPE $ 390.60 32515140 APC FLEX PROBE $ 330.75 32515165 APC MEMBRANE FILTER $ 40.70

7 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32515173 APC OMEGA PAD $ 18.90 40915185 APHASIA ASSESSMENT $ 258.00 96105GN 32507832 APLIGRAF 44 SQ CM $ 1,749.00 Q4101 41454257 APLIGRAFT SKIN SUB DISC SQ CM$ 101.33 Q4101JW 41454158 APLIGRAFT SKIN SUB PER 1 SQ CM$ 101.33 Q4101 39412945 APLIPO a+b $ 146.00 40762982 APLISOL 5 ML VIAL $ 143.51 86580 39412747 APOLIPROTEIN A $ 73.00 82172 39412846 APOLIPROTEIN B $ 73.00 82172 41457821 APP SKN SUB 100 SQ CM CHILD $ 5,072.70 15273 41462276 APP SKN SUB 1ST 100 SQ CM FEET$ 955.00 C5277 41461979 APP SKN SUB 1ST 100 SQ CM LEGS$ 3,123.00 C5273 41462573 APP SKN SUB 1ST 25 SCM FEET ME$ 955.00 C5275 41462078 APP SKN SUB ADD 25 SCM FEET ME$ 313.28 C5276 41457920 APP SKN SUB ADDL 100 SQ CM CHI$ 616.00 15274 41462177 APP SKN SUB ADDL 25 SCM LEGS$ M 313.28 C5272 41462474 APP SKN SUB E ADD 100 SQ CM LE$ 1,967.13 C5274 41462375 APP SKN SUB E ADD SQ CM FEET$ M 587.35 C5278 41458217 APP SKN SUB NT TRK/EXT 100SQCM$ 3,077.08 15277 41458019 APP SKN SUB NT TRK/EXT 25 SQ $C 3,077.08 15275 41458316 APP SKN SUB NT TRK/EXT ADD 100$ 614.00 15278 41458118 APP SKN SUB NT TRK/EXT ADDL $25 246.00 15276 41457722 APP SKN SUB T/A/L ADDL 25 SQ $C 226.00 15272 41457623 APP SKN SUB T/A/L/25 SQ CM $ 3,077.08 15271 41461385 APP SKN SUB-1ST 25 SQ SM; TOT$ 955.00 C5271 33302771 APPLICATION ELB FINGER CAST $ 495.00 29075 33302805 APPLICATION FINGER SPLINT $ 77.00 29130 33300890 APPLICATION FINGER SPLINT $ 116.00 29131 33300874 APPLICATION FOREARM TO HAND$ 495.00 29085 33304272 APPLICATION LONG ARM CAST $ 495.00 29065 40924646 APPLICATION OF MULTI-LAYER VEN$ 198.00 29581GO 40901357 APPLICATION OF MULTI-LAYER VEN$ 198.00 29581GP 33300882 APPLICATION SHORT ARM SPLINT$ 116.00 29126 33302813 APPLICATION SHORT LEG CAST $ 495.00 29405 40733503 APRESOLINE 20MG/1ML VIAL $ 23.85 J0360 40706061 APRESOLINE 25 MG TABLET $ 3.25 32517336 AQUAMANTYS SEALER $ 719.00 40755373 AQUA-MEPHTON 1MG/0.5 ML AMPULE$ 14.10 J3430 42605598 AQUAMEPHYTON 10MG AMP $ 22.00 J3430 40733537 AQUA-MEPHYTON 10MG/1ML AMP$ 130.00 J3430 40770166 AQUAPHOR OINTMENT $ 24.50 40901258 AQUATIC THERAPY $ 132.50 97113GP 40921258 AQUATIC THERAPY 15MIN $ 102.00 97113GO 32516957 AQUATRACK GLIDEWIRE - ANGLE$ 138.00 C1769 32516940 AQUATRACK GLIDEWIRE - STRAIGHT$ 111.00 C1769 42609240 ARALAST 1000MG $ 1,036.00 J0256JG 42623954 ARANESP 1 MCG JW $ 29.00 J0881JGJW 42626726 ARANESP 10 MCG $ 290.00 J0881JG 42624647 ARANESP 100 MCG $ 2,900.00 J0881JG 42629696 ARANESP 150 MCG $ 4,350.00 J0881JG 42624944 ARANESP 25 MCG $ 725.00 J0881JG 42625142 ARANESP 300 MCG $ 8,700.00 J0881JG 42624845 ARANESP 60 MCG $ 1,740.00 J0881JG 40768566 ARGATROBAN 250mg/2.5ml VIAL$ 5.00 J0583JG 40764276 ARICEPT 5MG TABLET $ 8.90 31200702 ARM CAST $ 87.60 32529232 ARM SLING & SWATHE $ 59.50 32508350 ARM SLING PADDED LG $ 31.95 31550542 ARM SLING PADDED LG $ 32.00 32508343 ARM SLING PADDED MED $ 31.95

8 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32508368 ARM SLING PADDED XLG $ 31.95 32509432 ARM SLING PED $ 35.45 32529216 ARM SLING, CAST $ 57.50 32529224 ARM SLING,PADDED SM $ 35.45 40714792 ARMOUR THYROID 60 MG TABLET$ 3.25 39400692 ARSENIC $ 168.00 82175 40700429 ARTANE TAB 2MG $ 3.40 39901426 ARTERIAL BLOOD GAS $ 232.00 36600 39901541 ARTERIAL BLOOD GASES $ 97.00 82805 33300965 ARTERIAL CATHETER/MON CUTDO$ 384.00 36625 33300957 ARTERIAL CATHETER/PERCUT $ 199.00 36620 30500078 ARTERIAL LINE DAILY $ 46.00 31900921 ARTERIAL LINE SET UP $ 56.50 31510019 ARTERIAL LINE SET UP $ 56.90 30500060 ARTERIAL LINE SET UP $ 106.00 31010002 ARTERIAL LINE SETUP $ 46.25 31511769 ARTERIAL MECH THROM 1ST VESSEL$ 8,609.00 37184 31511850 ARTERIAL MECH THROM ADD'L VESS$ 7,934.00 37185 31500788 ARTERIAL NEEDLE $ 20.95 31505993 ARTERIAL NEEDLE X $ 19.50 39901178 ARTERIAL PUNCTURE CHARGE $ 232.00 36600 33303076 ARTERIAL PUNCTURE OF BLOOD $ 232.00 36600 40500928 ARTERIAL UNILATERAL LIMITED LE$ 364.00 93926LT 40504549 ARTERIAL UNILATERAL LIMITED RI$ 364.00 93926 31522967 ARTERIAL UNILATERAL/LIMITED $ 364.00 93926 40770281 ARTHRICREAM 85GM TUBE $ 9.50 31203219 ARTHRO FLO IRRIGATOR $ 559.95 33301930 ARTHRO INTERM JOINT $ 469.00 20605 31202948 ARTHRO KNIFE BLADE $ 230.95 33301948 ARTHRO MAJOR JOINT $ 469.00 20610 40478788 ARTHROGRAM LEFT HIP $ 751.00 73525 40404568 ARTHROGRAM LEFT KNEE $ 633.20 73580LT 40478689 ARTHROGRAM RIGHT HIP $ 751.00 73525 40404386 ARTHROGRAM RIGHT KNEE $ 633.20 73580RT 31202195 ARTHROSCOPY PACK $ 527.30 32532772 ARTHTOWAND $ 585.00 40723280 ARTIFIC TEARS 1.4%OPTH 30ML $BT 18.20 40755969 ARTIFICIAL TEARS 3.5 GM TUBE $ 13.00 40764953 ASACOL 400MG TAB $ 3.25 40764359 ASCORBIC ACID 500MG/ML VIAL$ 13.50 39400601 ASO $ 114.25 86060 39401039 ASPERGILLUS AB $ 52.00 86606 31531534 ASPIRATE PLEURA W/IMAGING $ 1,502.00 32555 31531633 ASPIRATE PLEURA W/O IMAGING$ 1,501.00 32554 33455691 ASPIRATE/INJ GANGLION CYST $ 534.00 20612 32527038 ASPIRATION NEEDLE $ 207.30 32507642 ASPIRATION TUBING, STERILE $ 33.50 40730905 ASPIRIN 300MG SUPPOSITORY $ 4.55 33100348 ASSIST WITH I&D $ 312.00 40931711 ASSMT & CARE PLN PT COG IMP $ 418.00 99483GN 40921594 ASST TECH ASSESS $ 106.50 97755GO 40901431 ASST TECH ASSESS $ 106.50 97755GP 3990440414 AST $ 6.75 84450 39904404HF AST $ 9.00 84450 39904404 AST $ 40.75 84450 40765901 ATACAND 16MG TABS $ 3.70 40716235 ATARAX 25MG TAB $ 3.25 Q0177 40724866 ATARAX SYRUP 10MG/5ML UDC $ 3.40 31520195 ATHERECTOMY EA ADDL TIB/PERONE$ 24,076.00 37233 31519799 ATHERECTOMY TIBIOPERONEAL $ 32,429.00 37229

9 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31520690 ATHERECTOMY, ABDOMINAL AORTA$ 21,395.00 0236T 31520789 ATHERECTOMY, BRACHI TRK & BRAN$ 21,395.00 0237T 31519304 ATHERECTOMY, ILIAC $ 32,429.00 0238T 31520492 ATHERECTOMY, RENAL $ 21,395.00 0234T 31520591 ATHERECTOMY, VISCERAL NO RENAL$ 28,287.50 0235T 31519502 ATHERECTOMY,FEMORAL/POPLITEAL$ 24,076.00 37225 31520393 ATHERECTOMY+STENT EA ADDL $TIBP 10,438.00 37235 31519700 ATHERECTOMY+STENT FEMORAL-POPL$ 38,379.00 37227 31519997 ATHERECTOMY+STENT,TIBIOPERONEA$ 38,379.00 37231 39403811 ATIVAN $ 108.50 G0483 40700510 ATIVAN TAB 1MG $ 3.25 31905188 ATOMIZER, LARYNGO-TRACHEAL$ 45.00 42602813 ATROPINE 0.4 MG/ML $ 20.00 J0461 40733586 ATROPINE 0.4MG/1ML VIAL $ 20.00 J0461 40756322 ATROPINE 0.4MG/20ML VIAL $ 20.00 J0461 40757338 ATROPINE 1MG/10ML SYR $ 50.00 J0461 40782245 Atropine 1mg/ml 1ml vial $ 45.00 40718082 ATROPINE SULF 1% OPH 5ML BOTTL$ 29.50 40765091 ATUSS DM 5ML $ 3.25 40763120 AUGMENTIN 400MG/5ML BOTTLE$ 62.85 40768467 AUGMENTIN 600MG-42.9MG/5ML$ BT 176.50 40766339 AUGMENTIN 875-125MG TABLET $ 17.30 40763112 AUGMETIN 200-28.5MG/5ML BOTTLE$ 33.00 40750481 AUGUMENTIN 250 TAB $ 5.50 40750887 AUGUMENTIN 500-125MG TAB $ 6.40 32507063 AUTO SONIX TRIGGER $ 92.55 40200255 AUTOLOGOUS PREDEPOSI $ 210.50 86890 40201394 AUTOPSY - HEAD $ 931.50 40201303 AUTOPSY -TRUNK $ 1,397.25 32511651 AUTOSUTURE N. 120MM $ 127.65 32511669 AUTOSUTURE N. 150MM $ 131.75 32573061 AUTOTOME SPHIN. $ 441.00 32513384 AUTOTOME SPHINCTERTOME ERCP$ 516.60 32513616 AUTOTRANSFUSION ADDED HRS$ 157.50 32513608 AUTOTRANSFUSION STANDBY $ 612.15 40764854 AVANDIA 4MG TABLET $ 5.40 40764946 AVAPRO 150MG TABLET $ 3.25 42607290 AVASTIN 10 MG $ 279.00 J9035JG 42618212 AVASTIN 10MG JW $ 279.00 J9035JGJW 31502966 AVE 17MM STENT - X $ 2,085.70 C1876 31535989 AVF / CENTRAL / PTA $ 300.00 36907 31536979 AVF / CENTRAL / STENT $ 450.00 36908 31536880 AVF / PTA $ 10,586.00 36902 31536781 AVF / STENT $ 21,395.00 36903 31537375 AVF / THROMBECTOMY $ 10,586.00 36904 31537474 AVF / THROMBECTOMY / PTA $ 21,395.00 36905 31536385 AVF / THROMBECTOMY / STENT $ 32,430.00 36906 31537078 AVF IMAGING $ 1,501.00 36901 32533531 AVITENE POWDER $ 322.20 40768608 AVODART 0.5MG CAP $ 8.50 33301401 AVUL NAIL SIMPLE $ 331.00 11730 33300262 AVUL OF NAIL SIMPLE $ 188.00 11732 41453366 AVULSION NAIL PLATE EA ADD'L $ 188.00 11732 41453267 AVULSION NAIL PLATE SIMP 1 $ 331.00 11730 40763062 AXID 150MG CAP $ 4.55 31200165 AXIOM DUAL PUMP $ 124.15 40757189 AZACTAM 1 GM VIAL $ 36.75 40770901 AZACTAM 1GM/100ML NS PREMIX$ 100.00 40757247 AZACTAM 2 GM VIAL $ 73.45 40767808 AZITHROMYCIN 100MG/5ML 15ML$ BT 104.50

10 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40772212 AZITHROMYCIN 500MG/250ML PRMIX$ 95.00 J0456 40754160 AZMACORT ARED INH $ 98.35 40700585 AZULFIDINE 500 MG TABLET $ 3.25 40107229A B. BENSELAE 1GG $ 59.50 86611 40107229D B. BENSELAE 1GM $ 59.50 86611 40107229C B. QUINTANA 1GG $ 59.50 86611 40107229B B. QUINTANA 1GM $ 59.50 86611 39407928A B.BURGDOFERI TEST1 $ 80.00 86617 39407928B B.BURGDOFERI TEST2 $ 80.00 86617 39405014 B-2 MICROGLOB UR $ 74.00 82232 39406368 B-2 MICROGLOBULIN $ 79.25 82232 32500209 BABY BOTTLES $ 3.55 32509374 BABY CARE KIT $ 62.35 32500225 BABY OIL $ 7.00 32509382 BABY WIPES $ 17.85 40765174 BACITRACIN 50,000 UNITS/VIAL $ 24.20 40770612 BACITRACIN 500 UNITS/GM PACKET$ 3.25 40718314 BACITRACIN OINT 30 GM TUBE $ 5.70 40782740 BACITRACIN OPTH OINT $ 385.00 40766297 BACLOFEN REFIL KIT 200MCG $ 640.45 C9009 40755720 BACTERIOSTATIC 30ML VIAL $ 14.10 40752933 BACTROBAN 2% OINT 22 GM TUBE$ 37.50 32515942 BAG AMBU-BREATHE $ 45.00 32513319 BAG BOWEL TRANSPORT $ 25.40 32531659 BAG, URODRAIN $ 88.40 32518276 BAKRI BALLOON $ 222.00 40733990 BAL IN OIL DIMERCAPR $ 101.55 J0470 40752628 BAL SALT SOLUTION + SE $ 79.40 40771768 BALANCED SALT 15ML IRR SOLN$ 24.50 32602542 BALLON, DISSECTING $ 426.77 31201528 BALLOON CATH SET $ 750.70 32512873 BALLOON CORONARY $ 672.90 C1725 31552423 BALLOON CORONARY $ 673.00 C1725 32512907 BALLOON CUTTING $ 2,694.00 C1725 31201593 BALLOON DILATOR $ 536.40 C1726 32516908 BALLOON POWER FLEX EXTREME$ 360.00 C1725 32533903 BALLOON PULMONARY $ 945.90 C1726 32512824 BALLOON PULMONARY TAM. $ 352.60 C1726 31502636 BALLOON PVD - X $ 672.90 C1725 31551730 BALLOON PVD - X $ 673.00 C1725 32513392 BALLOON RETRIEVAL ERCP $ 336.70 32533739 BALLOON TISSUE DISECTOR $ 3,345.25 C1727 31401383 BALOON DILATION $ 517.50 40755084 BANALG LINIMENT $ 7.95 40769994 BANANNA BAG D5-NS 1000 ML BAG$ 208.00 40769986 BANANNA BAG IN 1000ML SALINE$ 208.00 31401912 BAND LIG. VARICIES $ 682.00 32500589 BANDAGE COBAN 3 inch $ 15.05 32500605 BANDAGE COBAN 4 inch $ 17.25 32500621 BANDAGE COBAN 6 inch $ 17.25 32500506 BANDAGE ELASTIC 2 inch $ 21.80 32500522 BANDAGE ELASTIC 3 inch $ 29.20 32500548 BANDAGE ELASTIC 4 inch $ 39.40 32500563 BANDAGE ELASTIC 6 inch $ 49.35 32510018 BANDAGE ESMARK 4 IN $ 116.40 32510026 BANDAGE ESMARK 6 IN $ 145.60 39401906 BARBITURATE LEVEL $ 130.50 G0483 40400665 BARIUM ENEMA $ 297.25 74270 32513350 BARIUM SULFATE STERILE $ 163.80 40400509 BARIUM SWALLOW $ 221.50 74220

11 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32517732 BARRIER, ADAPT RING $ 10.50 A4411 40107229A1 BART AB1 $ 59.50 86611 40107229A2 BART AB2 $ 59.50 86611-91 40107229A3 BART AB3 $ 59.50 86611-91 40107229A4 BART AB4 $ 59.50 86611-91 40107229 BARTONELLA AB PANEL $ 238.00 86611 31902661 BASE UNITS $ 43.00 41293090 BASIC DOSIMETRY $ 165.00 77300 40804676 BASIC SPIROMETRY, TC ONLY $ 297.00 94010 42601013 BCG LIVE 1MG $ 13.00 J9030 42617024 BCG LIVE 1MG JW $ 13.00 J9030JGJW 40400673 BE WITH AIR $ 390.75 74280 32507212 BEAD LARGE KIT 25CC $ 1,165.15 32507204 BEAD MINI KIT 5CC $ 670.85 32500340 BED NET ADULT $ 290.60 32500266 BED PAN $ 7.90 31548859 BED PAN $ 8.00 32500282 BED PAN FRACTURE $ 7.00 32529109 BEDBOARD $ 3.55 40931414 BEHAVIORAL & QUALITATIVE ANALY$ 213.75 92524GN 40769754 BELLADONNA & OPIUM SUPPOSITORY$ 11.00 31200710 BELOW KNEE CAST $ 85.95 32612442 BELOW KNEE CAST $ 85.95 42601641 BENADRYL 25MG/1ML 1ML VIAL $ 15.90 J1200 42601153 BENADRYL 50MG PO $ 6.50 Q0163 40734006 BENADRYL 50MG/1ML VIAL $ 17.05 J1200 40752206 BENADRYL CREAM 28.4 GM TUBE$ 8.85 40725103 BENADRYL ELIXIR 25 MG/10ML UDC$ 3.40 40701187 BENEMID 500 MG TAB $ 3.40 40769911 BENICAR 20MG TABLET $ 5.50 33300460 BENIGN /PREMAL LESION $ 324.00 17000 33300163 BENIGN LESON <0.5 ARM $ 1,834.00 11420 33300205 BENIGN LESON > 4.0 ARM $ 4,047.00 11426 33300155 BENIGN LESON >4.0 $ 2,976.00 11406 33300171 BENIGN LESON 0.6-1.0 ARM $ 1,834.00 11421 33300122 BENIGN LESON 1.1-2.0 $ 840.00 11402 33300130 BENIGN LESON 2.1-3.0 $ 1,834.00 11403 33300189 BENIGN LESON 2.1-3.0 ARM $ 2,976.00 11423 33300148 BENIGN LESON 3.1-4.0 $ 2,976.00 11404 33300197 BENIGN LESON 3.1-4.0 ARM $ 2,976.00 11424 42612370 BENLYSTA 10MG $ 157.00 J0490JG 42619796 BENLYSTA 10MG JW $ 157.00 J0490JGJW 40768814 BENTYL 10MG/5ML UDC $ 3.25 40753725 BENTYL 20MG TAB $ 3.25 40769564 BENTYL 20MG/2ML AMP. $ 32.50 40749038 BENZOIN TINC 4OZ 118ML BTL $ 20.30 39505434 BERMUDA GRASS ALLERGEN $ 13.00 86003 39400403 BERMUDA GRASS RAST $ 28.75 86003 39401995 BETA 1 C GLOBULIN $ 52.00 86329 39901723 BETA HCG $ 60.75 84702 40107039 BETA HYDROXYBUTYRIC A $ 122.00 82010 32509564 BETADINE 4 OZ. $ 7.90 32634618 BETADINE 4 OZ. $ 7.90 42010561 BETADINE 4 OZ. $ 8.00 40406910 BETADINE 4 OZ. $ 8.00 40507519 BETADINE 4 OZ. $ 8.00 40758526 BETADINE 5% OPTH SOL 30ML BT$ 17.05 40748790 BETADINE PERI WASH 8OZ EACH$ 11.35 40759904 BETAMETHASONE DIPROP $ 14.60 40761975 BETAMETHASONE.01%60G $ 25.95

12 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40759912 BETAMETHOSONE DIPROP $ 32.70 40759102 BETAPACE 80 MG TABLET $ 4.55 40751554 BETAXOLOL HCL 0.5% O $ 49.55 40768327 BETOPTICS 0.25% DROPS OPHT $SUS 122.50 42603527 BIAFINE 1.65 OZ $ 30.00 42603615 BIAFINE 3.3 OZ $ 52.00 40759292 BIAXIN 125MG 5ML SUS $ 62.05 40759300 BIAXIN 250MG 5ML SUS $ 118.20 40763211 BIAXIN 500 MG TAB $ 7.60 40780364 BICALUTAMIDE 50MG TAB $ 54.00 32640360 BICEPS TENDON REPAIR KIT $ 1,300.00 40767782 BICILLIN CR 1,200,000U/2ML SYR$ 70.00 J0558 40734071 BICILLIN L-A 1.2M UNIT/2ML SYR$ 36.75 J0558 32514119 BIER BLOCK SUPPLIES $ 42.00 40480768 BIL HIPS W OR WOUT PELVIS 3-4$ 223.00 73522 40480669 BILAT HIPS W OR WO PELVIS 2 VI$ 223.00 73521 31506058 BILAT RENAL VENOGRAM - SELECT$ 5,782.00 75833 40404006 BILAT STERNOCLAVICULAR JOINTS$ 125.00 71130 39406459 BILE ACIDS $ 98.00 32100323 BILI BLANKET $ 56.25 39901392 BILI, NEONATAL $ 90.50 82247 31401516 BILIARY DIL CATH $ 115.00 32532798 BILIARY DIL. CATH. $ 134.70 31200181 BILIARY FOR. BALPROBE $ 180.10 40603398 BILIARY TRACT NO EF $ 827.88 78226 40600579 BILIARY TRACT STUDY $ 827.88 78227 32100737 BILICHEK $ 10.00 88720 32100026 BILIMASK $ 7.75 39901905 BILIRUBIN DIRECT $ 45.75 82248 39901996 BILIRUBIN TOTAL $ 45.75 82247 39901905HF BILIRUBIN, DIRECT $ 9.00 82248 3990199614 BILIRUBIN, TOTAL $ 6.75 82247 39901996HF BILIRUBIN, TOTAL $ 9.00 82247 32517211 BIO A FISTULA PLUG $ 1,118.75 32612541 BIO A FISTULA PLUG $ 1,118.75 32509895 BIO NEUTRALIZER $ 12.85 32517161 BIOCOMPOSITE SWIVEL LOCK $ 750.00 32507089 BIO-COMPRESSION SCREW $ 553.60 40921316 BIOFEEDBACK TRAINING 15MIN $ 92.00 90901GO 40901316 BIOFEEDBACK TRAINING ANY MODAL$ 92.50 90901GP 41210510 BIOFINE RE CREAM 1.65OZ $ 30.00 41210609 BIOFINE RE CREAM 3.3OZ $ 51.00 40500639 BIOPHYSICAL FETAL PROFILE $ 299.25 76818 32605809 BIOPSY FORCEP, PULMONARY $ 132.00 32511784 BIOPSY FORCEPS RADIAL $ 372.65 32515520 BIOPSY KIT $ 146.85 31541533 BIOPSY KIT $ 147.00 40475917 BIOPSY MUSCLE DEEP $ 2,684.92 20205 41000923 BIOPSY NEEDLE DEVICE BARD $ 125.00 40402869 BIOPSY TISSUE $ 959.00 76098 42010066 BIOPSY TISSUE EXAM $ 959.00 76098 32507030 BIOPSY VALVE $ 17.00 32517476 BIOPSY, PUNCH DISPOSABLE $ 6.65 31544899 BIOPSY, PUNCH DISPOSABLE $ 7.00 41295082 BIOSPY OF SKIN (PUNCH) $ 212.00 41295170 BIOSPY OF SKIN (PUNCH) $ 499.00 11104 41295357 BIOSPY OF SKIN (PUNCH) $ 499.00 11104 41295533 BIOSPY OF SKIN EA ADDL LESION$ 163.00 31203268 BIPOLAR CABLE $ 53.40 31203250 BIPOLAR FORCEPS $ 70.90

13 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32511909 BIPOLAR FORCEPS LAP $ 296.75 32634420 BIPOLAR FORCEPS LAP $ 296.75 32533069 BIPOLAR PROBE COLON $ 418.00 C1765 31401789 BI-POLAR PROBE COLON $ 457.50 32532970 BIPOLAR PROBE EGD $ 563.70 31401698 BI-POLAR PROBE EGD $ 482.00 39506721 BIRCH SILVER ALLERGEN $ 13.00 86003 32513079 BITE BLOCK $ 69.50 31543216 BITE BLOCK $ 70.00 40108005 BK Quant PCR $ 409.00 87799 32515454 BLADDER EVACUATOR $ 72.90 32634816 BLADDER EVACUATOR $ 72.90 40500704 BLADDER US $ 203.00 76857 32514754 BLADE ACROMIO $ 156.45 32507006 BLADE CLIPPER SURGICAL $ 40.00 32514184 BLADE CRESCENTIC $ 342.30 32514309 BLADE CUTTING $ 156.45 31202971 BLADE ELECTRO SURG $ 161.70 32632143 BLADE ELECTRO SURG $ 161.70 32532954 BLADE INCISOR $ 219.90 32513822 BLADE INTUBATION $ 15.75 32500688 BLADE KNIFE $ 3.95 32516015 BLADE LARYNGEAL $ 206.00 32503229 BLADE RADNOID PED $ 216.00 32510513 BLADE TOTAL KNEE $ 289.50 32532863 BLADE TRICUT $ 341.20 32513210 BLADE TURBINATE $ 335.00 32511065 BLADE, BEAVER $ 7.50 31546681 BLADE, BEAVER $ 8.00 32640162 BLADE, PRECISION THIS $ 170.00 32512782 BLADE, SINUS SHAVER $ 329.00 32634519 BLADE, SINUS SHAVER $ 329.00 31208242 BLADE, TRUCLEAR 2.9 $ 749.00 31203441 BLADES 15% $ 58.65 32507485 BLAKE DRAIN $ 112.60 39402367 BLASTOMYCES AB $ 174.00 86612 39800388 BLD INTERP,PERP SMEAR $ 103.25 85060 39800289 BLEEDING TIME IVEY $ 61.75 85002 42619895 BLEOMYCIN 15 JW $ 133.00 J9040JW 42601195 BLEOMYCIN 15 UNITS $ 133.00 J9040 40734105 BLEOMYCIN SULF 15 UNIT VIAL $ 676.10 J9040 40722993 BLEPH-10 OPHT SOL 15ML BOTTLE$ 24.95 40718421 BLISTEX OINT $ 4.50 31700800 BLOCK, NERVE, INTERCOSTAL $ 1,491.00 64421 32500365 BLOOD ADMIN SET $ 22.35 32500464 BLOOD COLLECT 2C3002 $ 18.45 32601817 BLOOD COMPONENT SET $ 13.20 39501556 BLOOD CULTURE $ 41.75 87040 41361727 BLOOD DRAW VENOUS DEVICE $ 220.00 36591 32500407 BLOOD FILTER $ 35.50 32500480 BLOOD FILTER ULTIPOR $ 42.45 32500423 BLOOD FILTER W/SET $ 23.10 32201287 BLOOD PATCH $ 157.25 32601981 BLOOD SET $ 26.00 32500381 BLOOD SET 2C2037 $ 23.10 31903594 BLOOD SET, Y-TYPE $ 30.00 40000036 BLOOD SMEAR INTERP $ 103.25 85060 31505845 BLUE MAX BALLOON $ 594.50 C1725 32515322 BLUE VISION DYE $ 135.60 39400536 BLUEGRASS $ 22.00 86003

14 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40000093 BM BPSY INTERP $ 188.25 85305 40000085 BM BPSY NEEDLE&TROCH $ 3,127.00 38221 40000044 BM SMEAR ASP $ 2,083.00 38220 40000051 BM SMEAR INTERP $ 974.00 85097 39800297 BODY FLD HEME $ 33.75 89051 39500129 BODY FLUID CULTURE $ 83.50 87070 39902119 BODY FLUID GLUCOSE $ 26.00 82945 39902028 BODY FLUID PROTEIN $ 28.75 84157 32504326 BODY POSITIONER $ 17.25 32510042 BODY WEDGE $ 55.15 32513863 BOLT LOCKING $ 405.00 31204217 BONANO CATH. $ 343.65 40401010 BONE AGE $ 101.10 77072 32532632 BONE ANCHOR DEVICE $ 644.00 C1713 32634717 BONE ANCHOR DEVICE $ 644.00 C1713 32513582 BONE BLOCK LARGE EBI $ 669.90 32513574 BONE BLOCK SMALL EBI $ 435.75 C1713 32517583 BONE CANCELLANOUS CHIPS 60ML$ 812.50 C1713 32634123 BONE CANCELLANOUS CHIPS 60ML$ 812.50 C1713 32517567 BONE CANCELLOUS CHIPS 15 ML$ 375.00 C1713 32517575 BONE CANCELLOUS CHIPS 30 ML$ 585.00 C1713 32513533 BONE CYLINDER EBI $ 870.45 C1713 32512212 BONE DOWEL 12MM $ 1,024.05 C1713 32512410 BONE DOWEL 14MM $ 1,048.90 C1713 32506990 BONE DOWEL LUMBAR $ 2,313.00 C1713 32513111 BONE DOWEL LUMBAR 1/PK $ 2,312.50 C1713 32533697 BONE FREEZEDRIED MATCHSTICKS$ 796.95 C1762 31202187 BONE GRAFT $ 1,102.80 C1762 32513541 BONE GRANNULES 10CC EBI $ 763.35 32513558 BONE GRANULES 20CC EBI $ 937.65 32513566 BONE GRANULES 50CC EBI $ 2,259.60 32515231 BONE GROWTH STIM.IMPLANT $ 6,808.85 C1763 33100272 BONE MARROW $ 2,994.00 38221 40479580 BONE MARROW ASPIRATE AND BIOPS$ 2,940.00 38222 40479382 BONE MARROW ASPIRATION $ 2,083.00 38220 33451009 BONE MARROW ASSIST,ER CLINIC$ 2,994.00 38221 40479481 BONE MARROW BIOPSY $ 2,994.00 38221 41357250 BONE MARROW BX (INPATIENT) $ 169.00 38221 41357074 BONE MARROW BX (PROF) $ 169.00 38221 41357162 BONE MARROW BX (TECH) $ 2,994.00 38221 41356986 BONE MARROW BX ONLY CC $ 1,607.00 41356535 BONE MARROW BX&ASP (INPATIENT)$ 189.50 32510240 BONE MARROW NEEDLE $ 83.00 32507113 BONE PASTE 5CC $ 3,001.05 32507196 BONE PASTE 5CC OSTEOCEL $ 2,471.45 32512915 BONE PLUG $ 152.15 31202989 BONE PREP KIT $ 450.00 32533333 BONE PUTTY $ 513.00 32612640 BONE PUTTY $ 513.00 32533242 BONE PUTTY 0.5CC $ 254.30 32533515 BONE PUTTY 10CC $ 1,674.50 32513509 BONE PUTTY 3CC $ 572.25 32533424 BONE PUTTY 5CC $ 1,076.55 40600306 BONE SCAN BODY $ 737.45 78306 32514564 BONE SCREW TAP $ 180.60 40600876 BONE SPECT $ 2,807.00 78803 40600868 BONE SPOT MULTI $ 737.45 78305 40600850 BONE SPOT SINGLE $ 737.45 78300 32595900 BONE TAMP LUMBAR $ 4,906.00 32595801 BONE TAMP THORACIC $ 4,906.00

15 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32533606 BONE, FEMORALHEAD F.F. $ 1,943.60 C1713 32508038 BONGORT BAG $ 11.75 32510125 BONGORT BAG LG $ 280.30 40778483 BOOSTRIX TDAP 0.5ML VIAL $ 147.00 90715 40107286B BORD - 1 GG $ 77.00 86615 40107286A BORD - 1GM $ 77.00 86615 39407937 BORDETELLA 1GM $ 73.50 86615 40107286 BORDETELLA 1GM/1GG $ 154.00 39407948 BORDETELLA BY PCR $ 195.00 87801 39407948A BORDETELLA ORGAN 1PROB $ 183.75 87798 39407948B BORDETELLA ORGAN 2PROB $ 183.75 87798 39407849 BORDETRELLA 1GG $ 52.50 86615 32508269 BORNING PAD $ 52.05 39404579 BORRELIA AB IQM $ 36.00 86618 39408819AA BORRELIA AB1 $ 54.00 86617 39408819AB BORRELIA AB2 $ 54.00 86617-91 40480570 BOTH HIPS W OR WO PELVIS MIN$ 5 424.00 73523 40771511 BOTOX 100 UNIT/VIAL $ 20.82 J0585 31502578 BOVIE $ 93.00 32515553 BOVIE TIP EXT. BLADE $ 21.60 32605512 BOWL, STERILE $ 13.00 32509614 BP CUFF NEONAT SIZE 1 $ 77.85 32509622 BP CUFF NEONATE SIZE 2 $ 51.85 32509630 BP CUFF NEONATE SIZE 3 $ 59.50 32509648 BP CUFF NEONATE SIZE 4 $ 51.85 32509655 BP CUFF NEONATE SIZE 5 $ 70.60 32509325 BP CUFF SIZE A $ 26.10 32509333 BP CUFF SIZE B $ 32.30 32509341 BP CUFF SIZE C $ 16.20 30200372 BP MONITOR $ 41.20 31700040 BP MONITOR $ 70.90 31500796 BRACHIAL DRAPE 32X34 $ 44.15 31547770 BRACHIAL DRAPE 32X34 $ 45.00 31505357 BRACHIAL DRAPE 32X34 X $ 41.95 31540444 BRACHIAL DRAPE 32X34 X $ 42.00 39406186 BRAIN NATRIURETIC PEPTIDO $ 161.25 83880 32515587 BREAST MARKER $ 187.55 C1819 32500324 BREAST PUMP $ 105.20 39902101 BREATH ALC SCH $ 50.25 82075 39902192 BREATH ALC UNSCH $ 106.50 82075 31903495 BREATHING CIRCUIT EXT $ 15.00 31900863 BREATHING CIRCUIT, CH $ 82.25 31904386 BREATHING CIRCUIT, CH $ 83.00 31900178 BREATHING CIRCUITS $ 76.10 40750598 BRETHINE 1MG/1ML AMP $ 15.80 J3105 40701245 BRETHINE 2.5 MG TABLET $ 3.25 40749640 BRETYLIUM TOSYLATE S $ 95.05 40759193 BREVIBLOC 250MG/ML $ 173.90 40780562 Bridion 200mg/2ml SDV $ 370.50 40772105 BRILINTA 90 MG TAB $ 14.50 31401250 BRONCH THERAPEUTIC $ 1,449.00 31401169 BRONCH THROUGH TRACH $ 1,360.25 31401946 BRONCH W/BIOPSY $ 85.00 31401433 BRONCH WITH BAL $ 1,449.00 31401342 BRONCH WITH BRUSHING $ 1,449.00 31401706 BRONCH WITH DILATION $ 1,449.00 31401797 BRONCH WITH DILATION $ 1,449.00 31401615 BRONCH WITH NEEDLE BX $ 1,449.00 31401888 BRONCH WITH REMOVAL FB $ 1,449.00 31401524 BRONCH WITH TRANSBROCHEAL$ BX 1,449.00

16 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32529869 BRONCHIAL TRACH $ 353.45 33302979 BRONCHO,DIAG, W/WO WA $ 2,341.00 31622 31401649 BRONCHOSCOPY $ 1,275.50 31401979 BRONCHOSCOPY W/HEMOSTASIS$ BLEE 479.00 40766602 BRONCHOSCQA, KIT INJECTION $ 32.40 40805475 BROVANA 15MCG/2ML $ 17.50 40774820 BROVANA 15MCG/2ML VIAL NEB $ 17.50 39404728 BRUCELES ABORTUS $ 20.75 86622 31200207 BRUSH BIOPSY SET $ 67.05 31202716 BRUSH IM $ 73.85 32634222 BRUSH IM $ 73.85 32516262 BRUSH STERILE DRY $ 5.00 32633925 BRUSH STERILE DRY $ 5.00 32519935 BRUSH, FEMORAL CANAL $ 33.53 30255664 BS-CP, ADL 0-1, NR 1 $ 425.00 BA1 30255565 BS-CP, ADL 0-1, NR 2 $ 445.00 BA2 30258535 BS-CP, ADL 2-5, NR 1 $ 510.00 BB1 30258634 BS-CP, ADL 2-5, NR 2 $ 533.00 BB2 31203664 BSS 15 ML $ 19.10 31203672 BSS 500ML $ 141.05 40100026A BT-ABO $ 17.50 86900 40100026B BT-RH $ 17.50 86901 40854510 BUBBLE STUDY SUPPLIES $ 25.50 40758179 BUCET (GENERIC) $ 3.40 40900532 BUCKS TRACTION SINGL $ 86.50 40751141 BUMEX 1MG TAB $ 3.25 40751133 BUMEX 1MG/4ML VIAL $ 18.15 40771826 BUMEX 2.5MG/10ML VIAL $ 32.50 39902085RP BUN $ 4.25 84520 39902085C8 BUN $ 6.25 84520 3990208514 BUN $ 6.75 84520 39902085 BUN $ 53.75 84520 40753139 BUPRENEX 0.3MG/1ML AMP $ 18.15 J0592 32511412 BUR HALL DERMABRADER $ 261.75 41457524 BURN LG OR >10% BSA $ 628.00 16030 32514242 BURR ACORN $ 224.70 32514234 BURR BALL CUTTER $ 56.70 32507592 BURR BARRELL 4.0MM $ 128.00 32532780 BURR CARBIDE OVAL $ 296.10 32514218 BURR CROSSCUT $ 252.00 32514192 BURR OTOFLEX CARBIDE $ 313.95 32514226 BURR STRYKER CROSSCUT $ 42.00 32532871 BURR, ANSPACH $ 356.00 32514176 BURR/BLADE, ARTHROSCOPY $ 140.00 31544404 BURR/BLADE, ARTHROSCOPY $ 140.00 39404090 BURRELIA AB IQG $ 36.00 86618 40763310 BUSPAR 5MG TABLET $ 3.35 40770091 BUSULFAN 2MG TAB $ 9.00 40701336 BUTISOL 30 MG TAB $ 3.25 40772113 BUTOPHANOL 1MG/ML VIAL $ 5.50 41457326 BX BONE TROCAR OR NED SUPERF$ 1,566.00 20220 41003844 BX DEEP BONE CT $ 2,572.50 20225 41005230 BX PANCREAS PERC NEEDLE $ 2,336.00 48102 41003745 BX PER SUPERFICIAL LYMPH NODE$ 2,083.00 38505 41004240 BX PERC ABD OR RETROPERITONEA$ 2,336.00 49180 41003943 BX SUPERFICIAL BONE CT $ 1,566.00 20220 40771180 BYSTOLIC 5MG TAB $ 6.50 39405774 C ESTERASE INHIBITOR $ 48.50 86160 39402664 C PEPTIDE $ 53.25 84681 41462870 C REP S/A/L:1.1-2.5 CM $ 948.00 13120

17 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40402059 C SPINE FLEX AND EXT 6 OR MORE$ 170.35 72052 32512048 C TAPER HEAD $ 1,183.75 C1776 32615016 C TAPER HEAD $ 1,183.75 C1776 39905304 C TELOPEPTIDE $ 181.00 82523 40107138 C, ESKRA SC $ 104.00 86160 39402086 C.DIFFICILE CULTURE $ 50.75 87075 39402177 C.DIFFICILE TOXIN $ 69.75 87230 39505533 C.HERBARUM $ 13.00 86003 40803819 C.T. ORAL SUCT.KIT $ 46.50 39402268 C'3 $ 72.75 86161 39402359 C'4 COMPLEMENT $ 95.25 86161 39400034 CA 125 $ 79.25 86304 39901715 CA 27.29 $ 83.75 86300 39404264 CA15-3 $ 108.50 86300 39404173 CA19-9 $ 75.25 86301 32533929 CABLE ORTHO S. STEEL $ 396.00 32634321 CABLE ORTHO S. STEEL $ 396.00 32533564 CABLE/SLEEVE COMBO $ 556.00 32634024 CABLE/SLEEVE COMBO $ 556.00 40106841 CACC/DS $ 51.50 32507246 CAF - GEL $ 41.80 40763153 CAFFIENE NA/BENZOATE $ 20.95 J0706 40780760 Caffine Citrate 60mg/3ml vial $ 78.00 40718645 CALADRYL LOTION $ 10.65 40756082 CALAMINE LOTION $ 5.70 40769712 CALAMINE LOTION 177ML BT $ 4.50 40754194 CALAN 120 MG TAB $ 3.40 40749848 CALAN 80 MG TABLET $ 3.25 40752347 CALAN SR 120 MG TABLET $ 4.55 40755480 CALAN SR 180 MG TABLET $ 4.55 40751810 CALAN SR 240MG TAB $ 4.55 40764607 CALCIJEX 1MG/ML $ 32.40 J0636 40754020 CALCIMAR VIAL $ 136.10 39400874 CALCITONIN $ 279.25 82308 39902440RP CALCIUM $ 4.25 82310 39902440C8 CALCIUM $ 6.25 82310 3990244014 CALCIUM $ 6.75 82310 39902440 CALCIUM $ 53.75 82310 39900840 CALCIUM 24 HR. URINE $ 74.25 82340 40768640 CALCIUM 600MG TAB $ 3.25 40760050 CALCIUM CARBONATE $ 3.25 40751612 CALCIUM CARBONATE TA $ 3.40 40771297 CALCIUM CHLOR 1000MG/10ML VIAL$ 32.50 40767105 CALCIUM CITRATE + D3 TABLET $ 3.25 40734527 CALCIUM CL 1000MG/10ML SYR $ 31.75 40734543 CALCIUM DISODIUM VER $ 113.40 40734535 CALCIUM GLUCON 1000MG/10ML$ VIA 17.00 J0610 42608975 CALCIUM GLUCONATE 10 ML INJ $ 27.00 J0610 40701872 CALCIUM GLUCONATE TA $ 3.25 39901384 CALCIUM UR RANDOM $ 46.25 82340 39900485 CALCIUM, IONOIZED $ 79.25 82330 39478922 CALPROTECTIN $ 300.00 83993 40702193 CAMPAZINE 5 MG TAB $ 3.25 42601435 CAMPTOSAR 20MG $ 24.00 J9206 42620885 CAMPTOSAR 20MG JW $ 24.00 J9206JW 40108401 CAMPY QUICK TEST $ 40.00 87899 39404611 CAMPYLOBACTER AB $ 36.00 86625 32529935 CANAL VISION TIP $ 276.40 40771321 CANASA 1000MG SUPP $ 48.00 40768749 CANASA 500MG SUPP $ 14.50

18 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32512147 CANC CORT CHIPS 15CC $ 768.45 32633727 CANC CORT CHIPS 15CC $ 768.45 32512154 CANC CORT CHIPS 30CC $ 864.65 32512170 CANC.CORT.GRAN.15CC $ 720.45 32512188 CANC.CORT.GRAN.30CC $ 941.45 31202229 CANCELLOUS SCREWS $ 232.70 32633826 CANCELLOUS SCREWS $ 232.70 40771073 CANCIDAS 50MG VIAL $ 137.20 J0637 40759284 CANDIDA 1/100 1ML $ 34.60 32515009 CANISTER ATS WOUND $ 142.80 32603201 CANISTER,TRUCLEAR $ 19.00 40800161 CANNULA $ 5.00 41357349 CANNULA (NASAL) $ 5.00 41294906 CANNULA (NASAL) $ 5.00 32516510 CANNULA AQUALOC $ 214.00 32513400 CANNULA ERCP $ 201.60 32533184 CANNULA INNER TRACH $ 20.40 32533051 CANNULA NASAL $ 4.65 32612739 CANNULA NASAL $ 4.65 32514010 CANNULA ORTHO $ 81.35 32514549 CANNULA ORTHO $ 81.35 40406811 CANNULA SET $ 111.00 40406712 CANNULA SET $ 111.00 41108189 CANNULA SET $ 111.00 40604289 CANNULA SET $ 111.00 40604190 CANNULA SET $ 111.00 31203482 CANNULA SET $ 111.10 31203292 CANNULA SET $ 129.35 32514614 CANNULA SHOEHORN $ 81.35 32510869 CANNULA TOME II PAP $ 518.10 32514259 CANNULA TWIST-IN $ 108.00 32604126 CANNULA, ARTHROSCOPY, PASSPORT$ 64.00 31406054 CANNULA, CO2 $ 10.00 32510679 CANNULATED INTER SCR $ 590.80 31203409 CANNULATED SCREW $ 567.00 32516130 CAP INJECTION SEALING $ 6.00 32516171 CAP STAYSAFE $ 5.00 39902531 CAPILLARY BLD GASES $ 97.00 82805 32518268 CAPNOLINE,SMART $ 40.00 40702227 CAPOTEN TAB $ 3.40 32508004 CAPS, ISOLATION $ 60.40 40760076 CAPSAICIN 0.025% $ 38.90 32516239 CAPSULAR TENSION RING $ 375.00 31201734 CAPSULE POLISHER $ 29.20 40750721 CAPTOPRIL 12.5 MG TABLET $ 3.40 40750309 CARAFATE 1 GM TAB $ 3.40 32532822 CARAKLENZ CLEANSER $ 29.00 39902622 CARBON DIOXIDE $ 14.00 82374 39902622E CARBON DIOXIDE $ 16.25 82374 40753444 CARBOPLATIN 150MG $ 582.15 J9045 40754988 CARBOPLATIN 450MG/45ML VIAL$ 1,744.20 J9045 42620192 CARBOPLATIN 50 MG JW $ 28.00 J9045JW 42601377 CARBOPLATIN 50MG $ 28.00 J9045 40754988G CARBOPLATIN 50MG $ 193.85 J9045 40754988H CARBOPLATIN 50MG $ 193.85 J9045 40754988C CARBOPLATIN 50MG $ 193.85 J9045 40754988F CARBOPLATIN 50MG $ 193.85 J9045 40754988E CARBOPLATIN 50MG $ 193.85 J9045 40754988D CARBOPLATIN 50MG $ 193.85 J9045 40754988A CARBOPLATIN 50MG $ 193.85 J9045

19 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40754988B CARBOPLATIN 50MG $ 193.85 J9045 40754988I CARBOPLATIN 50MG $ 193.85 J9045 40753444C CARBOPLATIN 50MG $ 194.05 J9045 40753444A CARBOPLATIN 50MG $ 194.05 J9045 40753444B CARBOPLATIN 50MG $ 194.05 J9045 39901087 CARBOXY HEMOGLOBIN $ 50.25 82375 40771263 CARDEC DM SYRUP $ 8.50 40753378 CARDENE CAP $ 3.40 40753360 CARDENE CAP $ 3.40 40850769 CARDIAC ECHO FEBRUARY $ 125.00 30200380 CARDIAC MONITOR $ 79.15 31546087 CARDIAC OUTPUT TUBING $ 98.00 31500804 CARDIAC OUTPUT TUBING $ 98.05 71601009 CARDIAC REHAB I $ 66.00 71601058 CARDIAC REHAB II $ 242.00 93798 33303803 CARDIO ARRYT, EXTERNAL $ 1,146.00 92960 31206658 CARDIO PULMONAR RES $ 352.00 31402292 CARDIO PULMONARY RES $ 352.00 39479318A CARDIOLIPIN IGG $ 35.00 86147 39479318B CARDIOLIPIN IGM $ 35.00 86147 39479318 CARDIOLIPIN MASTER $ 70.00 31502347 CARDIOVERSION $ 1,146.00 92960 30900203 CARDIOVERSION $ 1,146.00 92960 31510282 CARDIOVERSION SUPPLIES $ 102.00 40771107 CARDIZEM 100MG/100ML PREMIX$ 42.00 40758385 CARDIZEM 25MG/5ML VIAL $ 32.95 40751315 CARDIZEM 30MG TAB $ 3.25 40758542 CARDIZEM CD 120 MG CAPSULE $ 3.25 40759805 CARDIZEM CD 180MG CAPSULE $ 13.00 40764250 CARDIZEM CD 240MG CAPSULE $ 3.40 40754582 CARDIZEM SR CAP $ 4.55 40758500 CARDIZEM SR CAPSULE $ 3.40 40752099 CARDIZEM TAB $ 3.40 40754558 CARDURA 1MG TABLET $ 3.25 40754590 CARDURA TABLET $ 3.40 31202476 C-ARM DRAPE $ 91.00 31542523 C-ARM DRAPE $ 91.00 40500118 CAROTID $ 420.80 93880 40503163 CAROTID US FEBRUARY $ 75.00 40751000 CARRINGTON CARA-KLEN $ 34.05 40751018 CARRINGTON GEL $ 34.05 40754632 CARRINGTON INCONT KIT $ 25.45 40754640 CARRINGTON MOIST BAR $ 26.50 32517120 CARTICAL SCREW ACUMED $ 218.00 40728834 CASANTHRANOL-DOCUSAT $ 3.25 40758211 CASCARA SAGRADA AROM $ 3.25 31203458 CASSETTE PK WITH TIP $ 415.10 32633529 CASSETTE PK WITH TIP $ 415.10 32529588 CAST ARM LONG ADULT $ 168.30 32529570 CAST ARM LONG CHILD $ 87.60 32529554 CAST ARM SHORT ADULT $ 141.55 32529562 CAST ARM SHORT CHILD $ 70.90 32529646 CAST BODY $ 416.65 32508392 CAST BOOT LG $ 134.25 L3265 32529273 CAST BOOT SMALL $ 115.40 L3265 32508400 CAST BOOT XLG $ 96.65 L3265 32508384 CAST BOOT, MED $ 129.35 L3265 32529638 CAST LEG LONG ADULT $ 258.50 32529620 CAST LEG LONG CHILD $ 129.50 32529612 CAST LEG SHORT ADULT $ 186.55

20 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32529604 CAST LEG SHORT CHILD $ 93.35 41454851 CAST LEG TOTAL CONT RIGID APP$ 512.68 29445 40754996 CASTOR OIL 60ML BT $ 4.55 39400262 CAT EPITHELIA $ 22.00 86003 39506325 CAT EPITHELIAL ALLERGEN $ 13.00 86003 31505282 CAT EXT. 10BR. HP LINE RA X" $ 43.50 31500836 CAT EXT. 10BR.HP LINE RA" $ 45.70 39400171 CAT HAIR - RAST $ 28.75 86003 39405733 CAT SCRATCH DISEASE $ 259.00 86609 40752107 CATAPRES 0.1 MG TAB $ 3.40 42608084 CATAPRES TAB $ 3.40 40702391 CATAPRES TAB $ 3.40 39400122 CATCHOL URINE FRACT $ 103.00 82384 39400213 CATCHOL-PLASMA FRAC $ 187.00 82384 32500126 CATH CARE KIT $ 17.25 32638776 CATH CHOLANGIOGRAM $ 549.00 32603829 CATH CHOLANGIOGRAM X LONG$ 54.00 32638677 CATH CHOLANGIOGRAM X LONG$ 54.00 32511768 CATH COMBO #1635 $ 308.40 32508905 CATH COUDE 14FR 5CC $ 76.35 32508913 CATH COUDE 16FR 5CC $ 93.35 32508921 CATH COUDE 18FR 5CC $ 76.35 32508939 CATH COUDE 20FR 5CC $ 76.35 32508947 CATH COUDE 22FR 5CC $ 104.95 32508954 CATH COUDE 24FR 5CC $ 104.95 31305056 CATH COUDE 24FR 5CC $ 104.95 32612838 CATH COUDE 24FR 5CC $ 104.95 31511454 CATH DELIVERY SYSTEM 8 FR $ 725.00 C1894 32511495 CATH FOGARTY ADHEREN $ 696.00 C1757 32500977 CATH FOLEY 10FR 5CC $ 36.80 31304165 CATH FOLEY 10FR 5CC $ 36.80 32612937 CATH FOLEY 10FR 5CC $ 36.80 40483844 CATH FOLEY 10FR 5CC $ 37.00 32500993 CATH FOLEY 12FR 5CC $ 22.30 31303769 CATH FOLEY 12FR 5CC $ 22.30 32613036 CATH FOLEY 12FR 5CC $ 22.30 40483745 CATH FOLEY 12FR 5CC $ 23.00 31549849 CATH FOLEY 14FR 5CC $ 22.00 32501017 CATH FOLEY 14FR 5CC $ 22.30 32501033 CATH FOLEY 16FR 5CC $ 27.30 31303670 CATH FOLEY 16FR 5CC $ 27.30 32613135 CATH FOLEY 16FR 5CC $ 27.30 40483646 CATH FOLEY 16FR 5CC $ 28.00 31550740 CATH FOLEY 16FR 5CC $ 28.00 32501157 CATH FOLEY 18FR 30CC $ 47.95 31304957 CATH FOLEY 18FR 30CC $ 47.95 32613234 CATH FOLEY 18FR 30CC $ 47.95 31552027 CATH FOLEY 18FR 30CC $ 48.00 32501058 CATH FOLEY 18FR 5CC $ 22.30 32501074 CATH FOLEY 20FR 5CC $ 27.30 31549354 CATH FOLEY 20FR 5CC $ 28.00 32501173 CATH FOLEY 22FR 30CC $ 41.75 32501090 CATH FOLEY 22FR 5CC $ 27.30 31551235 CATH FOLEY 22FR 5CC $ 28.00 32506701 CATH FOLEY 24F 3-WAY $ 81.40 31304660 CATH FOLEY 24F 3-WAY $ 81.40 32613333 CATH FOLEY 24F 3-WAY $ 81.40 31551433 CATH FOLEY 24F 3-WAY $ 82.00 32501199 CATH FOLEY 24FR 30CC $ 58.65 31552324 CATH FOLEY 24FR 30CC $ 59.00

21 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32501116 CATH FOLEY 24FR 5CC $ 33.05 32509481 CATH FOLEY 26FR 5 CC $ 36.80 32509051 CATH FOLEY 28FR 5CC $ 69.20 31304759 CATH FOLEY 28FR 5CC $ 69.20 32613432 CATH FOLEY 28FR 5CC $ 69.20 32501132 CATH FOLEY 30FR 5CC $ 64.45 32510232 CATH FOLEY 6FR PED $ 100.55 32515975 CATH FOLEY 75CC $ 78.00 32500936 CATH FOLEY 8FR 3CC $ 102.90 33100579 CATH FOR U/A $ 48.00 P9612 33451097 CATH FOR UA, ER CLINIC $ 48.00 P9612 32509515 CATH IUP $ 258.25 32509705 CATH KIT MULTILUMEN $ 331.45 C1751 31549651 CATH KIT MULTILUMEN $ 332.00 C1751 32509465 CATH KT DBL LUMEN $ 128.70 C1751 32533465 CATH MELKER EMERGENCY $ 299.90 32501298 CATH MUSHROOM 18FR $ 25.40 32501314 CATH MUSHROOM 20 FR $ 25.40 32501330 CATH MUSHROOM 22 FR $ 25.40 32501355 CATH MUSHROOM 24FR $ 25.40 32501371 CATH MUSHROOM 26 FR $ 25.40 32501397 CATH MUSHROOM 28FR $ 25.40 32501413 CATH MUSHROOM 30FR $ 25.40 32633133 CATH MUSHROOM 30FR $ 25.40 31500812 CATH PACK $ 165.30 C1769 31540939 CATH PACK $ 166.00 C1769 32640459 CATH PRESSURE MONITOR $ 548.00 32501454 CATH ROBINSON 10 FR $ 34.70 32501470 CATH ROBINSON 12 FR $ 15.05 32501496 CATH ROBINSON 14 FR $ 15.05 32501512 CATH ROBINSON 16 FR $ 15.05 32501538 CATH ROBINSON 18 FR $ 15.05 32501553 CATH ROBINSON 20FR $ 15.05 32501579 CATH ROBINSON 20FR $ 38.20 32501520 CATH ROBINSON 22 FR $ 15.05 31302977 CATH ROBINSON 22 FR $ 15.05 32633628 CATH ROBINSON 22 FR $ 15.05 32501546 CATH ROBINSON 24 FR $ 15.05 32501439 CATH ROBINSON 8FR $ 15.05 32508525 CATH SIL 20 FR 5CC $ 66.60 32509044 CATH SIL. 18FR 30CC $ 66.60 31302581 CATH SIL. 18FR 30CC $ 66.60 32633430 CATH SIL. 18FR 30CC $ 66.60 32501256 CATH SILICONE 16FR 5CC $ 56.20 32501231 CATH SILICONE 18FR 5CC $ 50.55 32501272 CATH SILICONE 22FR 5CC $ 50.55 32509291 CATH SUCTION 10FR $ 7.00 32500852 CATH SUCTION 14 FR. $ 10.30 32509317 CATH SUCTION 16FR $ 12.10 32509309 CATH SUCTION 18FR $ 10.45 32613531 CATH SUCTION 18FR $ 10.45 32509358 CATH SUCTION 5 FR $ 7.00 32509366 CATH SUCTION 8 FR $ 5.30 32501595 CATH THORACIC $ 64.20 32501611 CATH THORACIC 28FR $ 64.20 32501637 CATH THORACIC 32FR $ 64.20 32501678 CATH THORACIC 36FR $ 64.20 32501652 CATH THORACIC 40 FR $ 64.20 32512808 CATH TRAY QUAD LUMEN $ 291.60 31200595 CATH URETHRAL $ 157.45

22 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32638974 CATH URETHRAL OPEN END $ 43.00 32501694 CATH WHISTLE TIP 10 $ 9.30 32501710 CATH WHISTLE TIP 12 $ 9.30 32613630 CATH WHISTLE TIP 12 $ 9.30 32501736 CATH WHISTLE TIP 14 $ 9.30 32501751 CATH WHISTLE TIP 16 $ 15.05 32501777 CATH WHISTLE TIP 18 $ 15.05 32604225 CATH, PERM PACK $ 147.00 32633232 CATH, PERM PACK $ 147.00 32508517 CATH.FOLEY 30FR30CC $ 72.20 32508533 CATH.SIL.24FR 5CC $ 56.20 32508541 CATH.SIL.26FR.5CC $ 62.15 32508558 CATH.SIL.30FR 5CC $ 56.20 32500910 CATHETER A.P. $ 3.55 32500829 CATHETER ADAPTOR $ 11.75 31301591 CATHETER ADAPTOR $ 11.75 32633331 CATHETER ADAPTOR $ 11.75 32532715 CATHETER AORTIC OCCULUSION$ 284.15 C1757 32632440 CATHETER AORTIC OCCULUSION$ 284.15 C1757 32500837 CATHETER ASP 10-12 $ 5.85 32500878 CATHETER ASP 16-18 $ 5.85 32594217 CATHETER BANANO $ 343.65 32632935 CATHETER BANANO $ 343.65 32507725 CATHETER BILIARY DRAMAR $ 203.00 C1729 31402688 CATHETER BIPOLAR GOLD PROBE$ 280.00 32512865 CATHETER CORONARY GUIDING $ 343.95 C1887 31551928 CATHETER CORONARY GUIDING $ 344.00 C1887 31501349 CATHETER CORONARY LF BYPASS$ 92.85 C1725 31501539 CATHETER CORONARY RT BYPASS$ 92.85 C1725 31501307 CATHETER DIAGNOSTIC $ 92.85 31547968 CATHETER DIAGNOSTIC $ 92.85 31501299 CATHETER DIAGNOSTIC - X $ 92.85 31542028 CATHETER DIAGNOSTIC - X $ 93.00 32601791 CATHETER DIALYSIS $ 37.05 32516841 CATHETER EAGLE EYE GOLD $ 775.00 C1753 31547176 CATHETER EAGLE EYE GOLD $ 775.00 C1753 31500820 CATHETER EXTENSION 48 inch $ 18.80 31545790 CATHETER EXTENSION 48 inch $ 19.00 31505373 CATHETER EXTENSION 48 X" $ 17.35 31200926 CATHETER FOGERTY EMBOLECTOMY$ 183.65 C1757 32515736 CATHETER H/S HYSTEROSALPING$ 87.80 32603928 CATHETER HICKMAN 6FR TRIPLE $LU 560.00 31544998 CATHETER HICKMAN 6FR TRIPLE $LU 560.00 32516189 CATHETER HICKMAN 9.6 SINGLE$ 320.00 32515272 CATHETER HURRICANE DIL $ 408.45 C1726 32515710 CATHETER INTUBATION $ 139.00 32532624 CATHETER KIT AORTIC OCCULUSION$ 343.95 32613729 CATHETER KIT AORTIC OCCULUSION$ 343.95 32507816 CATHETER KMP $ 70.00 32507899 CATHETER MALEROT $ 43.00 32511321 CATHETER PRUITT IRR $ 216.45 32516858 CATHETER PV VISIO-.018 $ 775.00 C1753 31540642 CATHETER PV VISIO-.018 $ 775.00 C1753 31502537 CATHETER PVD GUIDING - X $ 343.95 C1725 31551631 CATHETER PVD GUIDING - X $ 344.00 C1725 31551037 CATHETER PVD GUIDING - X $ 345.00 C1725 33303084 CATHETER UMB NEWBORN $ 240.00 36660 33303266 CATHETER URETH COMPLICATED$ 251.00 51703 33303254 CATHETER URETH SIMPLE $ 292.00 51701 31208836 CATHETER, 3 WAY COUVELAIRE $ 185.00

23 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32509416 CATHETER, FLEXIMA $ 494.60 32512790 CATHETER, GRAHAM $ 206.10 32532368 CATHETER, PERITONEAL DIALYSIS$ 261.50 C1752 32603136 CATHETER, PTA DILATION $ 515.00 C1725 42606311 CATHFLO ACTIVASE 2MG $ 265.00 J2997 40768277 CATHFLO ACTIVASE 2MG/2ML VIAL$ 126.00 J2997 32500951 CATH-FOLEY 10FR 3CC $ 60.30 31547077 CATH-FOLEY 10FR 3CC $ 61.00 31505431 CATHPACK X $ 157.10 C1769 31544008 CATHPACK X $ 158.00 C1769 32500175 CATH-ROBINSON 30FR $ 15.05 31302284 CATH-ROBINSON 30FR $ 15.05 32632737 CATH-ROBINSON 30FR $ 15.05 32516866 CATHTER PV VISIO-.82 $ 1,062.00 C1753 41454752 CAUTERIZATION CHEM GRAN TISSUE$ 331.00 17250 32532012 CAUTERY TIP LAPAROSCOPIC $ 153.85 32511313 CAUTERY, HOT TEMP $ 54.90 32635212 CAUTERY, HOT TEMP $ 54.90 32507477 CAVILON LOTION $ 30.15 41355184 CBC $ 20.00 85025 39800370 CBC (WHEN ORD W MANDIFF) $ 61.75 85027 39800479 CBC NO DIFF $ 35.00 85027 39800461 CBC WITH DIFF $ 80.25 85025 30256555 CC-DEPRESSED, ADL 0-1 $ 504.00 CA2 30256258 CC-DEPRESSED, ADL 11-14 $ 727.00 CD2 30255862 CC-DEPRESSED, ADL 15-16 $ 766.00 CE2 30255763 CC-DEPRESSED, ADL 2-5 $ 592.00 CB2 30256357 CC-DEPRESSED, ADL 6-10 $ 638.00 CC2 30256456 CC-NOT DEPRESSED, ADL 0-1 $ 471.00 CA1 30256060 CC-NOT DEPRESSED, ADL 11-14 $ 668.00 CD1 30255961 CC-NOT DEPRESSED, ADL 15-16 $ 707.00 CE1 30256654 CC-NOT DEPRESSED, ADL 2-5 $ 550.00 CB1 30256159 CC-NOT DEPRESSED, ADL 6-10 $ 592.00 CC1 33104850 CD TX FEMUR FX W MAN W/WO TRAX$ 1,260.00 27240 39402060 CD3 POS LYMPH FLOW CYTOMETRY$ 38.50 88184 40107179 CD4, ABSOLUTE $ 105.00 86361 39404629 CD4/CD8 RATIO $ 199.50 86360 39403712 CD8,ABSOLUTE $ 77.00 86360 39403803 CD8+HLA+LYMPHS $ 38.50 86812 31500846 CD-R DISK $ 68.90 31502719 CD-R DISK - X $ 68.90 39901830 CEA $ 65.75 82378 40702409 CECLOR CAP $ 5.05 40725517 CECLOR SUSP 125MG/5M $ 35.50 40725509 CECLOR SUSP 250MG/5M $ 65.85 40764102 CEDAX 400MG CAP $ 15.35 40763104 CEDAX 90MG/5ML $ 51.75 40751901 CEENU CAP $ 9.85 40756223 CEENU CAP $ 30.90 40756215 CEENU CAP $ 58.65 40734584 CEFADYL PBACK $ 17.05 40734592 CEFADYL PBACK $ 23.85 40700973 CEFADYL VIAL $ 14.55 J0710 40756835 CEFADYL VIAL $ 17.05 40756843 CEFADYL VIAL $ 24.70 40750697 CEFAZOLIN 1GM VIAL $ 15.00 J0690 40775216 CEFAZOLIN 2GM/100ML PREMIX $ 45.00 J0690 40775711 Cefepime 1 Gm Vial $ 25.00 J0692 40772741 CEFEPIME 2GM VIAL $ 145.00 J0692 42629993 CEFEPIME 500MG $ 9.00 J0692

24 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 42630191 CEFEPIME 500MG JW $ 9.00 J0692JW 40781255 Cefepime -NS 2gm/50ml $ 61.50 J0692 40781156 Cefepime-NS 1gm/50ml $ 40.50 J0692 40760100 CEFOBID 1GM PB $ 38.90 40760118 CEFOBID PIGGYBK 2GM $ 76.70 40738353 CEFOBID VIAL $ 38.90 40738379 CEFOBID VIAL $ 76.70 40752826 CEFOTAN PBACK $ 32.95 40757221 CEFOTAN VIAL $ 32.95 40757239 CEFOTAN VIAL $ 49.70 40765224 CEFOTAXIME SODIUM 2GM $ 78.00 J0694 40770810 CEFOXITIN 1 GM/100 ML IVPB $ 75.50 40770380 CEFOXITIN 2GM/50ML DUPLEX $ 68.00 40770828 CEFOXITIN SOD 2GM/100ML PREMIX$ 111.00 40759011 CEFPROZIL 125MG SUSP $ 32.30 40759029 CEFPROZIL 250MG/5ML BOTTLE $ 59.95 40755001 CEFTAZIDIME 1GM VIAL $ 93.00 J0713 40769796 CEFTAZIDIME 2GM VIAL $ 92.50 J0713 40764748 CEFTIN 125MG/5ML $ 33.30 40752784 CEFTIN 250MG TAB $ 12.40 40764755 CEFTIN 250MG/5ML 50ML BT $ 57.65 40752792 CEFTIN TAB $ 14.35 40765406 CEFTRIAXONE SODIUM 1GM $ 216.00 J0696 40765497 CEFTRIAXONE SODIUM 2GM $ 432.00 J0696 40765315 CEFTRIAXONE SODIUM 500MG $ 108.00 J0696 40765588 CEFUROXIME SODIUM 1.5GM $ 45.00 J0697 40764847 CELEBREX 100 MG CAPSULE $ 3.25 40769549 CELEBREX 200MG CAPSULE $ 10.50 40766164 CELESTONE MDV IV $ 15.15 40754533 CELESTONE SOLUSP 12MG/2ML SYR$ 18.40 J0702 40765661 CELEXA 20MG TABLET $ 4.90 39407761 CELIAC DISEASE PANEL $ 383.25 32514507 CELLFACTOR APPLICATOR KIT $ 118.65 32514515 CELLFACTOR APPLICATOR TIP $ 110.25 31202724 CEMENT BONE $ 505.00 32632836 CEMENT BONE $ 505.00 31202732 CEMENT BOWL $ 218.95 32633034 CEMENT BOWL $ 218.95 31202740 CEMENT MIXER $ 372.00 32511644 CEMENT PALACOS R $ 286.50 32632341 CEMENT PALACOS R $ 286.50 32596098 CEMENT, KYPHOPLASTY $ 315.00 32632539 CEMENT, KYPHOPLASTY $ 315.00 30901201 CEN VEN CATH NONTNLD 5 YRS>$ 1,907.00 36556 40768392 CENESTIN 0.9MG TAB $ 3.50 40916340 CENT NERV SYS ASSESS/TESTS $ 280.00 96125GN 31700206 CENTRAL LINE INSERTION $ 1,895.00 31547671 CENTRAL SUPPLY $ 15.00 31502396 CENTRAL VENOUS CATH PLACEMENT$ 283.00 40718686 CEPACOL 0.05% MWSH $ 5.40 40718702 CEPACOL LOZENGE $ 6.80 40765950 CEREBYX 100MG/2ML VIAL $ 52.90 Q2009 39400395 CERULOPLASM $ 63.00 82390 32510786 CERVICAL COLLAR INF $ 37.15 L0120 32529240 CERVICAL COLLAR PED $ 33.30 L0120 32508467 CERVICAL COLLAR SM $ 43.00 L0120 32508475 CERVICAL COLLAR UNIV $ 53.40 L0120 40401366 CERVICAL MYELOGRAM $ 1,477.00 62302 40403875 CERVICAL SPINE 1 VIEW $ 193.70 72020 40402026 CERVICAL SPINE 2 OR 3 VIEWS $ 117.00 72040

25 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40900342 CERVICAL TX. $ 136.00 97012GP 40764722 CERVIDIL VAG SUPP 10MG $ 388.20 31903172 CESAREAN SECTION $ 606.50 40755423 CETACAINE SPRAY $ 86.20 39402540 CF HHV IGG $ 38.50 86790 39402151 CF LYMPH $ 38.50 85009 39403621 CFCD4 $ 38.50 86361 39402243 CFEBVEAG $ 38.50 86663 39402458 CFEBVNA $ 38.50 86664 39402631 CFHHV IGM $ 38.50 86790 39403530 CFLYMTRN $ 38.50 86353 39403894 CFT4T8 $ 37.75 86360 39403357 CFTOTLYM $ 38.50 86359 39402334 CFVCA IGG $ 38.50 86665 39402425 CFVCA IGM $ 38.50 86665 39401971 CFWBC $ 38.50 85048 40106866I CG MCG;INT AND REPORT $ 155.30 88291 39401658 CH' 100 $ 98.00 86162 39400486 CH'50 (TOTAL) $ 95.25 86162 32507345 CHAMBER POLYPTRAP $ 24.80 32632242 CHAMBER POLYPTRAP $ 24.80 31202757 CHAMBER SYRINGE $ 116.90 33303159 CHANGE GASTROSTOMY TUBE $ 433.00 43762 40770661 CHANTIX 0.5MG (VARENICLINE)TAB$ 6.50 40759839 CHARCOAL 50GM TUBE $ 18.25 33301898 CHEM CAUT OF GRANLTJ TISSUE$ 331.00 17250 32600116 CHEM.THY IV. SET-UP $ 59.05 39900998 CHEMISTRY 14 $ 94.50 80053 39903349 CHEMISTRY 8 $ 50.00 80048 42602672 CHEMO ADM. INTRALESIONAL (7)$ 221.00 96405 42602102 CHEMO BLADDER INSTIL $ 549.00 51720 42602367 CHEMO BY INFUSION EA ADD'L HR.$ 133.00 96415 42602276 CHEMO BY INFUSION UP TO 1 HR.$ 263.00 96413 32500084 CHEMO CAP $ 15.05 40750507 CHEMO FLUID SET CHAR $ 48.60 42602490 CHEMO INFUSION,PROLONGED PUMP$ 554.00 96416 42623459 CHEMO INFUSION,PROLONGED PUMP$ 613.00 G0498 41358163 CHEMO INTRATHECAL (PROF) $ 98.00 96450 41358262 CHEMO INTRATHECAL (TECH AND$ PR 769.00 41358361 CHEMO INTRATHECAL (TECH) $ 672.00 96450 42615737 CHEMO IV INFUSION SEQUENTIAL$ U 94.00 96417 42607113 CHEMO IV PUSH ADD'L DRUG $ 244.00 96411 42602581 CHEMO IV PUSH SINGLE DRUG $ 221.00 96409 40751786 CHEMO PREPARATION FE $ 27.85 42604515 CHEMO SQ OR IM HORMONAL $ 338.00 96402 42604603 CHEMO SQ OR IM NONHORMONAL$ 338.00 96401 32100034 CHEMSTRIP BG $ 18.00 82948 40477204 CHEST 2 VIEW APICAL LORDOTIC$ 135.00 71047 40482755 CHEST 3 VIEWS $ 135.00 71047 40482656 CHEST 4 VIEWS OR MORE $ 259.00 71048 40505935 CHEST COMPLETE $ 299.00 76604 40400046 CHEST FLUOROSCOPY $ 497.00 76000 40404345 CHEST LATERAL ONLY $ 135.00 71045 40403974 CHEST LT DECUBITIS $ 135.00 71046 40400012 CHEST PA AND LATERAL $ 135.00 71046 40400020 CHEST PA OR AP $ 135.00 71045 40400038 CHEST PORTABLE $ 135.00 71045 40402919 CHEST RIGHT DECUBITUS $ 135.00 71046 32527111 CHEST SUCTION/THORO $ 90.20 32529976 CHIBA NEEDLES $ 39.00

26 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31542127 CHIBA NEEDLES $ 39.00 30700009 CHILDBIRTH CLASS $ 10.00 Z5267 50710057 CHILDBIRTH CLASSES $ 30.00 98962 40753618 CHILDREN'S ADVIL 100MG/5ML UDC$ 4.55 32507543 CHIN IMPLANT $ 250.00 32533192 CHITO-SEAL PAD $ 220.50 39404702 CHLAMYDIA AB IQG $ 36.00 86631 39404793 CHLAMYDIA AB IQM $ 36.00 86632 40107088A CHLAMYDIA AMP $ 50.00 87491 39400663 CHLAMYDIA CULTURE $ 65.25 86631 40107692A CHLAMYDIA CYTYC $ 62.25 87491 39407201 CHLAMYDIA DNA PROBE $ 62.25 87490 40107658 CHLAMYDIA TRACH AB/GM $ 122.00 86632 40107088 CHLAMYDIA/GG AMP $ 100.00 40107385 CHLAMYDIN PSITTACI $ 128.00 86631 40704728 CHLORAL HYDRATE SYRP $ 3.40 40756587 CHLORAL HYDRATE SYRU $ 3.40 40702045 CHLORAMPHENICOL CAP $ 4.55 40750366 CHLORASEPTIC THROAT SPRAY $ 9.10 40772055 CHLORHEXIDINE GLUC 15ML UDC$ 4.00 39903430RP CHLORIDE $ 4.25 82435 39903430C8 CHLORIDE $ 6.25 82435 3990343014 CHLORIDE $ 6.75 82435 39903430E CHLORIDE $ 16.25 82435 39903430 CHLORIDE $ 16.25 82435 40734626 CHLOROMYCETIN STERI $ 18.20 40748527 CHLOROMYCETIN SUSP B $ 29.40 40753014 CHLOROPTIC 0.5% OPTH $ 34.90 40757254 CHLOROPTIC S.O.P. 1% $ 32.30 40702060 CHLORPHENIRAMINE MAL $ 3.25 40702086 CHLOR-TREMETON TAB $ 3.25 40770331 CHLORTRIMETON 4MG TAB $ 3.25 40725434 CHLOR-TRIMETON SYRUP $ 3.40 40702078 CHLOR-TRIMETON TAB S $ 3.25 39903521 CHOL. SCREEN $ 9.50 31201262 CHOLANG 10 CATH $ 30.90 39903612LP CHOLESTEROL $ 32.25 82465 39903612 CHOLESTEROL $ 53.75 82465 40725459 CHOLESTYRAMINE 4GM PACKET $ 3.40 40601122 CHOLETEC $ 118.75 A9537 39401054 CHOLINESTERASE $ 161.25 82480 32507097 CHONDRAL DART $ 273.45 C1713 40765125 CHROMAGEN **** $ 3.25 J8499 40107062 CHROMOGRANIN A $ 158.00 86316 40759367 CILOXAN-OPTHT 0.3% 5ML BT $ 28.10 40756108 CIMETIDINE VIAL $ 51.05 42625736 CIMZIA 1 MG $ 66.00 J0717JG 42621182 CIMZIA 1MG JW $ 66.00 J0717JGJW 40752941 CIPRO 250MG TAB $ 6.80 40772048 CIPRO 400MG/200ML PREMIX $ 24.00 40767931 CIPRO HC OTIC SUSP 10 ML BT $ 256.00 40753113 CIPRO TAB $ 8.10 40754889 CIPROFLOXACIN 400MG/40ML VIAL$ 79.40 J0744 40770216 CIPRPFLOXACIN 500MG TAB $ 18.00 40872600 CIRCUIT, COMFORT FLOW $ 76.00 40872303 CIRCUIT, HW NIV $ 96.00 40872204 CIRCUIT, HW, DUAL W/TRAPS $ 76.00 32532111 CIRCULAR STAPLER $ 1,034.25 32101020 CIRCUMCISION $ 700.00 54150 30501020 CIRCUMCISION $ 700.00 54150

27 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30301020 CIRCUMCISION $ 700.00 54150 40725467 CIRTATE OF MAG 300ML BT/EACH$ 3.40 40760157 CISPLATIN 100MG/100ML VIAL $ 936.40 42601559 CISPLATIN 10MG $ 16.00 J9060 40734675 CISPLATIN 10MG $ 77.80 J9060 42619598 CISPLATIN 10MG JW $ 16.00 J9060JW 40703647 CISPLATIN 50MG $ 359.65 J9060 40773731 Citalopram 10mg Tab $ 6.00 40775513 Citalopram 10mg Tab $ 8.00 39400841 CITRATE 24HR. URINE $ 184.50 82507 40757171 CITRIC ACID-SOD CITR 30 ML UDC$ 4.55 40759110 CITRISOURCE LIQUID $ 8.65 40766826 CITRUCEL PKT $ 3.25 39900030 CKMB CONFIRM $ 42.50 82553 39402912 CL 24 HR URINE $ 70.25 82436 33100793 CL TREAT FEMUR FX NECK W/O MAN$ 474.00 27230 33302011 CL TREAT PROX HUMERA $ 474.00 23600 33302029 CL TREAT SHOULDER DI $ 546.00 23650 33455592 CL TX SHDR DL W NK FX W/MANI$ 2,944.00 23675 33105269 CL TX FX/DIS PIP JOINT HAND $ 2,424.00 26742 33455790 CL TX POSTOP HIP DISLOC W ANES$ 2,944.00 27266 33456285 CL TX THIGH FX W/MNPJ $ 1,712.00 27268 39479417D CLA CARDIOLIPIN $ 40.75 86147 39479417 CLA MASTER $ 163.00 39479417A CLA PT $ 40.75 85610 39479417B CLA PTT $ 40.75 85730 39479417C CLA RUSSELL VIPER VENOM $ 40.75 85613 39400676 CLADOSPORIUM-RAST $ 28.75 86003 42612568 CLADRIBINE 10MG $ 1,790.00 J9065JG 40757163 CLAFORAN 1 GM VIAL $ 38.60 J0715 40770745 CLAFORAN 1 GRAM PREMIS $ 67.50 42603164 CLAFORAN 1GRAM $ 41.00 J0698 40769648 CLAFORAN 1GRAM ADD VANTAGE$ 38.50 40764334 CLAFORAN 2GM VIAL $ 43.55 40770752 CLAFORAN 2GM/100NS PREMIX $ 107.00 40751422 CLAFORAN IBTL $ 49.90 40764037 CLARITAN D 12 HR. TAB $ 5.25 40763492 CLARITIN 10MG TABLET $ 4.65 32508434 CLAVICAL SPLINT LG $ 69.90 32508426 CLAVICAL SPLINT MED $ 69.90 32508418 CLAVICAL SPLINT SM $ 69.90 32508442 CLAVICAL SPLINT XLG $ 72.85 32529265 CLAVICAL SPLINT, INF $ 98.70 L3650 32509879 CLAVICLE SPLINT PED $ 71.60 L3650 32509721 CLAVICLE SPLINT UNIV $ 70.90 L3650 32517203 CLEANING BRUSH $ 15.00 32511818 CLEANSER PERINEAL $ 49.20 31502958 CLENCHER $ 110.00 31502065 CLENCHER - X $ 110.00 40702110 CLEOCIN 150 MG CAPSULE $ 3.40 40734691 CLEOCIN 30MG/2ML VIAL $ 25.50 40770844 CLEOCIN 600MG/100ML NS PREMIX$ 78.50 40703738 CLEOCIN 600MG/4ML VIAL $ 34.05 40770851 CLEOCIN 900MG/100NS PREMIX $ 80.50 40753196 CLEOCIN 900MG/6ML VIAL $ 46.50 40764482 CLIMARA 0.05MG PATCH.TDWK $ 12.15 40764490 CLIMARA 0.1MG PATCH.TDWK $ 12.75 40771867 CLINDAMYCIN 300MG/100ML PREMIX$ 59.50 40702136 CLINORIL TAB $ 4.55 40702128 CLINORIL TAB $ 4.55

28 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31203821 CLIP APPLIER $ 296.45 31404272 CLIP, DURACLIP $ 700.00 31402490 CLIP, RESOLUTION 360 $ 328.00 31203920 CLIPPER BLADE $ 28.00 31547374 CLIPPER BLADE $ 28.00 40759417 CLONIDINE HCL .03MG PATCH.TDWK$ 48.60 40759615 CLONIDINE HCL 0.1MG PATCH.TDWK$ 24.30 40759623 CLONIDINE HCL 0.2MG PATCH.TDWK$ 41.05 40702185 CLONIDINE-CHLORTHALI $ 3.25 39403001 CLONOPIN $ 56.75 80299 40770075 CLORPACTIN WCS-90 2GRAM POWDER$ 14.00 40747230 CLORPACTIN WCS-90 PW $ 20.45 33300288 CLOSE FACE >30.0CM $ 781.00 12018 33300767 CLOSE TREAT TIBIAL F $ 2,911.00 27532 33300833 CLOSE TX MATATAR FX $ 704.00 28475 33300809 CLOSE TX MEDICAL MALL $ 2,911.00 27762 33300791 CLOSE TX TIBAL SHAFT $ 2,911.00 27752 33300817 CLOSE TX TRIMALL ANK $ 1,840.00 27818 31700172 CLOSED RED ANKLE FX $ 262.50 40803801 CLOSED TRACH.SUCT $ 48.50 32517468 CLOSURE DEVICE DISP PUNCTURE$ 87.00 31551829 CLOSURE DEVICE DISP PUNCTURE$ 87.00 32510802 CLOTEST $ 64.25 39400593 CLOTTING FACTOR VIII $ 96.25 85240 33452820 CLTX DISL POST H/ARTHRO W/O $AN 537.00 27265 40106866G CML-ADDTL KARYOTYPE 1 EACH $ 155.30 88280 40106866H CML-CA KARYOTYPE 2 $ 155.30 88280 40106866B CML-CHROM ANAL 20-25 CELLS $ 155.30 88264 40106866A CML-CHROMOSOME 10-30 $ 155.30 88273 40106866D CML-DNA PROBE 2 $ 356.00 88271 40106866 CMLFISH & CHROMOSOMES $ 1,553.00 40106866E CML-INSITU HYBRID 10-30 CELL $ 155.30 88273 40106866F CML-INTERPHASE 100-300 CELLS$ 155.30 88275 40106866J CML-INTERPT REPORT 2 $ 155.30 88291 39407585A CMV AB Ig G $ 140.00 86644 39407585B CMV AB Ig M $ 140.00 86645 39400932 CMV CULTURE $ 153.50 86644 39407585 CMV GROUP $ 280.00 40201238 CMV NEGATIVE CHARGE $ 42.00 87271 41502557 CNH - HOSPICE RTN $ 155.00 33302896 CNTL NASAL HEM CAUTHE $ 654.00 30905 33302888 CNTL NASAL HEM COMPL $ 347.00 30903 33302870 CNTL NASAL HEM SIMPL $ 344.00 30901 39902622RP CO2 $ 4.25 82374 39902622C8 CO2 $ 6.25 82374 3990262214 CO2 $ 6.75 82374 31200215 COBAN 3-4 IN $ 19.70 31542820 COBAN 3-4 IN $ 20.00 31201155 COBAN 6 IN $ 25.40 31302086 COBAN 6 IN $ 25.40 32632638 COBAN 6 IN $ 25.40 40743601 COCAINE HCL 10% SOLN $ 96.40 39401575 COCCIDIOIDES AB $ 54.75 86612 40401937 COCCYX $ 158.00 72220 39505236 COCKROACH GERM $ 13.00 86003 40745150 CODEINE PHOSPHATE IN $ 12.15 40745168 CODEINE PHOSPHATE IN $ 13.35 40745192 CODEINE PHOSPHATE TA $ 3.40 40745184 CODEINE SULFATE TAB $ 3.40 40702151 COGENTIN 1 MG TABLET $ 3.25

29 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40734717 COGENTIN AMP $ 21.55 J0515 40725483 COLACE SYRUP 100 MG/10 ML UDC$ 3.40 40702169 COLCHICINE TAB $ 3.25 40771933 COLCRYS 0.6 MG TAB $ 19.50 40718793 COLD CREAM CREM $ 9.10 32511040 COLD KNIFE STR BLADE $ 525.90 40920086 COLD PACK $ 66.25 97010GO 40900086 COLD PACK $ 66.25 97010GP 32506057 COLD PERINEAL PACK $ 17.85 40770026 COLESTID HCL 1GM TABLET $ 3.25 32506974 COLLAR BOBBIN VENT TUBE $ 131.90 32508483 COLLAR EXO STAT MED $ 213.95 32529257 COLLAR EXO STAT SM $ 213.95 32508491 COLLAR EXO-STAT LG $ 213.95 40760217 COLLODION FLEXIBLE $ 12.85 31401136 COLON W/BIOPSY $ 99.00 31401045 COLON W/FOREIGN BODY $ 224.00 31401227 COLON W/HEMOSTAT BLE $ 479.00 31401318 COLON W/HOT BIOPSY $ 357.00 31401409 COLON W/POLYPECTOMY $ 424.00 31401458 COLONOSCOPY $ 1,539.00 31201791 COLONOSCOPY PROC $ 958.00 31403777 COLONOSCOPY W/ BALLOON DILATIO$ 2,042.00 45340 40764961 COLY MYCIN OTIC $ 27.00 40718819 COLY-MYCIN S DROP $ 31.70 40751679 COLYTE SOLUTION 4000ML/JUG $ 35.35 40766362 COMBIVENT INHALER $ 151.20 32511800 COMBO CATH $ 320.00 40500324 COMMON BILE DUCT $ 299.25 76705 32518003 COMPANION POST PLATE $ 5,687.50 C1713 40734741 COMPAZINE 10 MG/2 ML AMP $ 23.85 J0780 40731226 COMPAZINE 25MG SUPP $ 7.85 40751851 COMPAZINE CAP SA $ 4.55 42603703 COMPAZINE IV $ 26.00 J0780 40731200 COMPAZINE SUPP $ 5.70 33301807 COMPCL EYELIDS, 1.1-2.5 $ 954.00 13151 33301815 COMPCL EYELIDS, 2.6-7 $ 1,035.00 13152 33301773 COMPCL FOREHEAD, 1.1-2.5 $ 617.00 13131 33301781 COMPCL FOREHEAD, 2.6- $ 1,307.00 13132 33301989 COMPCL MANI TREAT T-M $ 4,317.00 21485 33301757 COMPCL SCALP 1.1-2.5 $ 948.00 13120 33301765 COMPCL SCALP 2.6-7.5 $ 1,136.00 13121 33301740 COMPCL TRUNK, 2.5-7.5 $ 954.00 13101 40107492 COMPLEMENT C19,QN $ 50.00 86160 40805525 COMPLETE EEG AW/ASLEEP PC $ 139.00 95819 40805616 COMPLETE EEG AW/DROWSY PC $ 139.00 95816 40805798 COMPLETE EEG SLEEP DEPRIVED$ PC 139.00 95816 40805707 COMPLETE EEG SLEEP ONLY PC $ 139.00 95822 40805087 COMPLETE EEG-AW/ASLEEP $ 543.00 95819 40805178 COMPLETE EEG-AW/DROWSY $ 543.00 95816 40805434 COMPLETE EEG-SLEEP DEPRIVED$ 543.00 95816 40805319 COMPLETE EEG-SLEEP ONLY $ 543.00 95822 40500092 COMPLETE PREGNANCY >14 WEEKS$ 414.00 76805 40804734 COMPLETE SPIROMETRY, TC ONLY$ 543.00 94060 33304348 COMPLX REPAIR WOUND,FACE, +5CM$ 403.00 13133 33304256 COMPLX REPAIR WOUND,SCALP,+5CM$ 265.00 13122 33304165 COMPLX REPR WOUND TRNK, +5CM$ 229.00 13102 40766578 COMPOUND MIXTURE $ 21.60 31201395 COMPRESSION SCREW $ 58.65 33306556 COMPX RPR TONGUE MOUTH >2.6$ 449.00 41252

30 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33304439 COMPX RPR WND,EYE,NOS,LIP,+5CM$ 1,035.00 13153 40766941 COMTAN 200MG TABLET $ 6.00 40803843 CONCHA 1500ML $ 12.75 40803850 CONCHA COLUMN $ 39.50 42607544 CONCURRENT NON-CHEMO INFUSION$ 122.00 96368 32510646 CONDULAR BUTTRESS PL $ 448.60 40406514 CONED COMPRESSION MAMMO BILAT$ 432.00 77066 40406019 CONED COMPRESSION MAMMO LT$ UNI 216.00 77065LT 40406415 CONED COMPRESSION MAMMO RT$ UNI 216.00 77065RT 31202153 CONNECTING BAR $ 123.00 32630955 CONNECTING BAR $ 123.00 32516072 CONNECTOR 5 IN 1 $ 5.00 32601866 CONNECTOR REPAIR KIT $ 47.25 40000408 CONS ON REF SL W/PRE $ 291.00 88323 40000424 CONSULT / SURG TOUCHPREP $ 1,353.00 88333 40350100A CONSULT 15 $ 92.00 99241GT 40350200A CONSULT 30 $ 114.00 99242GT 40350300A CONSULT 30 MCR $ 120.00 G0425GT 40350400A CONSULT 40 $ 138.00 99243GT 40350500A CONSULT 50 MCR $ 163.00 G0426GT 40350600A CONSULT 60 $ 172.00 99244GT 40350700A CONSULT 70 MCR $ 242.00 G0427GT 40350800A CONSULT 80 $ 230.00 99245GT 40350100 CONSULT ED 15 MASTER $ 152.00 40350200 CONSULT ED 30 MASTER $ 199.00 40350300 CONSULT ED 30 MASTER MCR $ 205.00 40350400 CONSULT ED 40 MASTER $ 240.00 40350500 CONSULT ED 50 MASTER MCR $ 282.00 40350600 CONSULT ED 60 MASTER $ 308.00 40350700 CONSULT ED 70 MASTER MCR $ 395.00 40350800 CONSULT ED 80 MASTER $ 400.00 40000416 CONSULT ON REF. COMP $ 370.25 88325 40000390 CONSULT ON REFERRED $ 201.00 88321 40000440 CONSULT SRG W/ADD FS $ 161.00 88332 40000432 CONSULT SURG W/FS $ 320.75 88331 40805699 CONT. HHN TX EA ADD HR. $ 36.00 94645 32505257 CONTAINER STERILE 4OZ $ 21.80 32631846 CONTAINER STERILE 4OZ $ 21.80 41210168 CONTINUING PHYSIC CONSULTATION$ 390.00 77336 40805608 CONTINUOUS HHN TX 1ST HR. $ 230.00 94644 40900987 CONTRAST BATH 15 MIN $ 89.00 97034GP 40920987 CONTRAST BATH 15MIN $ 89.00 97034GO 32513475 CONTRAST SAVER TUBING W/SPIKE$ 57.05 31548364 CONTRAST SAVER TUBING W/SPIKE$ 58.00 31505464 CONTRAST SPIKE & TUBING X $ 22.55 31544503 CONTRAST SPIKE & TUBING X $ 23.00 31500853 CONTRAST SPIKE&TUBING $ 24.00 31500861 CONTRAST TRANSFER SET $ 9.85 31505522 CONTRAST TRANSFER SET X $ 9.10 31530742 CONTRAST XR GALLBLADDER $ 247.00 74290 40484933 CONTRAST X-RAY URINARY TRACT$ 840.00 74425 31535296 CONVERSION EXT BIL DRNG CATH$ 6,280.00 47535 31534801 CONVERT NEPHROSTOMY CATH $ 1,205.00 50434 31503188 COOK 6FRX90CM RB SHEATH $ 324.75 C1894 31503196 COOK 6FRX90CM RB SHEATH-X $ 324.75 C1894 31551334 COOK CROSSOVER SHEATH $ 160.00 C1894 31502602 COOK CROSSOVER SHEATH $ 160.10 C1894 31502164 COOK CROSSOVER SHEATH - X $ 160.10 C1894 40100950 COOMBS TEST DIRECT $ 40.00 86880 39401237 COPPER $ 104.75 82525

31 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 42629399 COPPER CHLORIDE 1MG $ 8.00 J3490 42629498 COPPER CHLORIDE 1MG JW $ 8.00 J3490JW 39401419 COPPER-URINE $ 67.75 82525 40767121 CO-Q10 10MG $ 3.25 40767089 CO-Q10 30MG $ 3.25 40767113 CO-Q10 50MG CAPSULE $ 3.25 39900451 CORD BLOOD GASES $ 97.00 82805 40755118 CORDAN 0.05% LOTION $ 27.25 40754947 CORDARONE 200 MG TAB $ 7.05 31502750 CORDIS BILIARY STENT $ 1,609.55 C1877 40701039 CORDRAN 0.05% LOTION $ 70.10 40769937 COREG 12.5MG TAB $ 6.50 40773929 COREG 3.125 MG TABLET $ 6.00 40767097 COREG 3.125MG $ 5.30 40764581 COREG 6.25MG TABLET $ 5.95 40751620 CORGARD 40 MG TAB $ 3.40 31502990 CORINTHIAN IQ-X $ 2,233.70 C1876 40766271 CORLOPAM 10MG/1ML AMP $ 896.40 31203656 CORNEAL IMPLANT $ 4,615.40 C1762 32515439 CORNEAL PROTECTOR $ 31.20 32517849 CORONARY BALLOON $ 637.50 C1725 31511942 CORONARY THROMBECTOMY $ 4,765.00 92973 40702243 CORRECTOL TAB $ 3.25 40768137 CORTANE-B EAR DROPS $ 52.00 40702268 CORTEF 10 MG TABLET $ 3.25 40756124 CORTENEMA ENEM $ 19.80 32512196 CORTICAL POWDER 15CC $ 864.65 32512204 CORTICAL POWDER 30CC $ 1,123.85 32512162 CORTICAL STRIPS $ 1,008.70 39401203 CORTISOL SERUM,TOTAL $ 65.50 82533 39401500 CORTISOL-UR,FREE $ 104.00 82530 40718876 CORTISPORIN OINT $ 38.90 40704710 CORTISPORIN OPHT SUSP 7.5ML $BT 70.75 40718850 CORTISPORIN OTIC SOLN 10ML BT$ 49.80 40758757 CORTISPORIN OTIC SUS 2.5ML BT$ 44.00 40764656 COSOPT 2-0.5% OPHT SOL 10ML$ BT 95.15 40760233 COSYNTROPIN 0.25MG/ML VIAL $ 32.95 39413044 COTININE $ 103.50 80307 32501215 COUDE CATH 12FR 5CC $ 74.75 40769309 COUMADIN 1MG TAB $ 3.25 40702300 COUMADIN 2 MG TABLET $ 3.25 40756462 COUMADIN 2.5MG TAB $ 3.25 40702318 COUMADIN 5 MG TABLET $ 3.25 40702326 COUMADIN 7.5MG TAB $ 3.25 40702334 COUMADIN TAB (BULK) $ 3.25 31201643 COUNCILL CATH $ 50.90 32513988 COUPLER LUMBAR $ 795.90 40769416 COVERT 1 MG/10 ML VIAL $ 940.50 J1742 39905392 COXSACKIE $ 35.00 86658 39401294 COXSACKIE CULTURE $ 114.75 86658 40763765 COZAAR 50MG TAB $ 3.25 40000143 CP NON-GYN CONC $ 144.00 88108 40000127 CP, NON-GYN FILTER $ 131.25 88106 40000192 CP, OTHER, EXTCL $ 209.50 88162 40000184 CP, OTHER, P,S,I $ 120.00 88161 40000176 CP, OTHER, SCREEN $ 95.25 88160 40001026 CP,CER SCREEN/PHYS INTERP $ 14.25 P3001 40000978 CP,CER-VAG DIAG/PHYS INTERP $ 41.00 88141 40000887 CP,CER-VAG DIAG/RE-SCREEN $ 44.00 88165 40000168 CP,CER-VAG SMEAR DIAG $ 44.00 88164

32 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40000994 CP,CER-VAG SMEAR SCREEN $ 44.00 P3000 40000119 CP,FLDS,WASH,BRUSH $ 137.75 88104 40000135 CP,NON-GYN SMEAR,FIL $ 144.50 88106 40803793 CPAP CANNULA $ 32.50 40872105 CPAP DEVICE, FLOSAFE $ 200.00 40800195 CPAP PER DAY $ 406.00 94660 39403209 C-PEPTIDE $ 53.25 84681 39903976 CPK - TOTAL $ 28.50 82550 39401385 CPK ISOENZYMES ELECT $ 96.00 82552 39904156 CPK-MB $ 49.00 82553 40900904 CPM DAILY (EQUIP) $ 106.00 40900896 CPM SETUP (EQUIP) $ 283.25 31902844 CPR $ 352.00 40800203 CPR $ 358.00 33304116 CPR $ 528.00 92950 31500192 CPR $ 528.00 92950 32510661 CRAIG WORM HOOK $ 216.45 32201311 CRASH CART $ 400.00 32100299 CRASH CART $ 400.00 31700099 CRASH CART $ 400.00 31204191 CRASH CART $ 400.00 31010366 CRASH CART $ 400.00 30900385 CRASH CART $ 400.00 30300180 CRASH CART $ 400.00 30210117 CRASH CART $ 400.00 30200117 CRASH CART $ 400.00 33100173 CRASH CART $ 401.00 31510373 CRASH CART $ 468.05 31701493 CRASH CART $ 468.05 31303175 CRASH CART $ 468.05 32632044 CRASH CART $ 468.05 31405757 CRASH CART $ 469.00 31401870 CRASH CART SUPPLIES $ 400.00 31300106 CRASH CART SUPPLIES $ 400.00 30500276 CRASH CART SUPPLIES $ 400.00 32511826 CREAM BARRIER $ 36.20 32529984 C-REAMER CONCEPT $ 429.15 39900667 CREAT 24 HR URINE $ 68.25 82570 39401849 CREAT/PROT RATIO $ 9.25 81050 39904248RP CREATININE $ 4.25 82565 39904248C8 CREATININE $ 6.25 82565 3990424814 CREATININE $ 6.75 82565 39904248 CREATININE $ 36.00 82565 39904339 CREATININE CLEARANCE $ 65.00 82575 39603436 C-REATIVE PROTEIN $ 46.00 86140 40772022 CRESTOR 10MG TAB $ 17.50 40772030 CRESTOR 20MG TAB $ 17.50 40772006 CRESTOR 40MG TABLET $ 17.50 33100538 CRIT CARE INT EACH ADD'L 30MIN$ 160.00 99292 33100553 CRITICAL CARE $ 1,457.00 99291 40762247 CRITICARE HN $ 16.60 40764573 CRIXIVAN 400MG CAPSULE $ 5.60 31902729 CRNA 15 MIN $ 25.50 31900509 CRNA 15 MIN $ 25.50 40733453 CROFAB 1GM VIAL $ 523.80 J0840 32509408 CROPPING SHEARS $ 14.15 40101040 CROSSMATCH $ 100.50 86920 40200313 CROSSMATCH ADD'L $ 100.50 86920 32510489 CRUTCHES ADULT $ 100.15 32510463 CRUTCHES MED $ 100.15

33 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32510471 CRUTCHES YOUTH $ 100.15 32531527 CRYO CUFF $ 187.05 32500647 CRYO UNIT/CUFF $ 329.85 39401476 CRYOGLOBULIN $ 21.75 82595 40200560 CRYOPRECIPITATE HANDLING $ 45.00 P9012 31200322 CRYOSTYLET EYE $ 69.90 39401591 CRYPTOCOCCAL ANT SPF $ 67.25 86641 39800206 CRYSTAL ID $ 42.50 89060 39401567 CRYTO ANTIGEN SERUM $ 50.25 86641 39407140 CRYTOCOCCUS AG, SERUM $ 22.25 87899 40402018 CSPINE OBLIQUE 4 OR 5 VIEWS $ 221.50 72050 41000076 CSPINE WOUT CONTRAST $ 939.00 72125 41003646 CSPINE WWO CONTRAST $ 753.95 72127 41003052 CT ABD AND PELVIS W CONTRAST$ 1,310.00 74177 41003250 CT ABD AND PELVIS WO CONTRAST$ 914.00 74176 41003151 CT ABD AND PELVIS WWO CONTRAST$ 1,310.00 74178 41000050 CT ABDOMEN WITH CONTRAST $ 1,162.00 74160 41000043 CT ABDOMEN WOUT CONTRAST $ 698.00 74150 41000068 CT ABDOMEN WWO CONTRAST $ 1,188.00 74170 41003349 CT ANGIO ABD AND PELVIS $ 1,572.00 74174 41001408 CT ANGIO ABD ARTERIES RUNOFF$ 763.87 75635 41001311 CT ANGIO ABDOMEN $ 763.87 74175 41002386 CT ANGIO CHEST $ 849.00 71275 41002209 CT ANGIO HEAD $ 763.87 70496 41001223 CT ANGIO LEFT LOWER EXTREMITY$ 763.87 73706LT 41001135 CT ANGIO LEFT UPPER EXTREMITY$ 763.87 73206LT 41002298 CT ANGIO NECK $ 763.87 70498 41001047 CT ANGIO PELVIS $ 763.87 72191 41005131 CT ANGIO RIGHT LOWER EXTREMITY$ 763.87 73706RT 41005032 CT ANGIO RIGHT UPPER EXTREMITY$ 763.87 73206RT 41000472 CT BONE DENSITY STUDY $ 404.00 77078 41005329 CT BX MUSCLE, PERC NEEDLE $ 2,336.00 20206 41003448 CT CA SCORE SCREEN FEB $ 90.00 41002953 CT CARDIAC TRIPLE RULE OUT $ 1,737.00 41006419 CT CHEST ABD PELVIS W MASTER$ 2,159.00 41006420 CT CHEST ABD PELVIS WO MASTER$ 1,441.00 41006418 CT CHEST ABD PELVIS WWO MASTER$ 2,228.00 41006121 CT CHEST HIGH RESOLUTION $ 527.00 71250 41000209 CT CHEST WITH CONTRAST $ 849.00 71260 41000191 CT CHEST WOUT CONTRAST $ 527.00 71250 41000217 CT CHEST WWO CONTRAST $ 918.00 71270 41001933 CT CORONARY ANGIO WWO CALCIUM$ 993.00 75574 41003547 CT CSPINE W CONTRAST $ 678.15 72126 41293013 CT GUIDANCE FOR RTX $ 120.00 77014 41210015 CT GUIDANCE FOR THERAPY GUIDE$ 269.00 77014 41000480 CT GUIDE FOR NEEDLE PLACEMENT$ 1,107.00 77012 41000027 CT HEAD WITH CONTRAST $ 865.00 70460 41000019 CT HEAD WOUT CONTRAST $ 626.00 70450 41000035 CT HEAD WWO CONTRAST $ 1,271.00 70470 41001496 CT HEART WO CONTRAST CALCIUM$ S 130.00 75571 41000548 CT INJECTION LIVER BIOPSY $ 2,336.00 47000 41000324 CT LEFT LOWER EXT WITH CONT$ 889.00 73701LT 41000332 CT LEFT LOWER EXT WWO CONT$ 944.00 73702LT 41000290 CT LEFT UPPER EXT WITH CONT $ 902.00 73201LT 41000282 CT LEFT UPPER EXT WO CONT $ 666.00 73200LT 41000308 CT LEFT UPPER EXT WWO CONT $ 944.00 73202LT 41000274 CT LIMITED STUDY $ 552.00 76380 41005725 CT OMNIPAQUE 300MG 100ML $ 300.00 Q9967 41005923 CT OMNIPAQUE 300MG 50 ML $ 150.00 Q9967 41000175 CT PELVIS WITH CONTRAST $ 865.00 72193

34 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41000167 CT PELVIS WOUT CONTRAST $ 626.00 72192 41000183 CT PELVIS WWO CONTRAST $ 1,257.00 72194 41000688 CT PERICENTESIS ABDOMEN $ 1,535.00 49083 41004537 CT RIGHT LOWER EXT WO CONT $ 556.00 73700RT 41004636 CT RIGHT LOWER EXT WWO CONT$ 944.00 73702RT 41004438 CT RIGHT LOWER EXTREMITY W CON$ 889.00 73701RT 41004933 CT RIGHT UPPER EXT WITH CONT$ 902.00 73201RT 41004834 CT RIGHT UPPER EXT WO CONT $ 666.00 73200RT 41004735 CT RIGHT UPPER EXT WWO CONT$ 944.00 73202RT 41000959 CT TEMPORAL BONE W CONTRAST$ 840.00 70481 41000931 CT TEMPORAL BONES WO CONTRAST$ 772.00 70480 41000670 CT THORAX ANGIO WWO CONTRAST$ 1,215.00 71275 41006022 CT VISIPAQUE 320MG 100ML $ 300.00 Q9967 41005824 CT VISIPAQUE 320MG 150ML $ 450.00 Q9967 39409678 C-TELOPEPTIDE $ 157.50 82523 40758450 CTM/VISXYL/DONN/5CC $ 7.60 39502216 CULTURE ROUTINE $ 46.00 87070 32514994 CUP SPILL PROOF $ 6.30 40748998 CUPRIMINE CAP $ 4.55 32513285 CURETTE VACUUM $ 13.25 32532475 CURRETTE ADENOID $ 109.65 31202807 CURVED REMOVAL CORE $ 111.10 31201585 CURVED WIRE GUIDE $ 72.20 32511727 CUTTER DISP VALVE $ 255.55 31514164 CVD FLURO GUIDANCE P'MENT $ 260.00 77001 31536583 CVD PORTOGRAM $ 395.00 36598 31514252 CVD REMOVE TUNNEL NO PORT/PUMP$ 1,501.00 36589 31514439 CVD REMOVE TUNNEL PORT $ 2,162.00 36590 31514340 CVD REMOVE TUNNEL PUMP $ 2,162.00 36590 31513801 CVD REPLACE NONTUNNEL $ 1,872.00 36580 31513890 CVD REPLACE TUNNEL NO PORT/PUM$ 5,179.00 36581 31513988 CVD REPLACE TUNNEL PORT $ 5,179.00 36582 31514076 CVD REPLACE TUNNEL PUMP $ 8,609.00 36583 31512901 CVDI NONTUNNEL $ 1,907.00 36556 31513086 CVDI TUNNEL NO PORT/PUMP $ 5,178.00 36558 31513262 CVDI TUNNEL PORT $ 5,265.00 36561 31513350 CVDI TUNNEL PUMP $ 8,609.00 36563 32501793 CVP SET UP $ 69.90 31203300 C-WIRE SERTER KIT $ 208.40 39401682 CYANIDE $ 141.50 82600 40762551 CYANIDE ANTIDOTE PKG $ 395.30 31505753 CYBER CATHETER - X $ 286.45 40768558 CYCLOCORT 30GM OINTMENT $ 100.00 40750317 CYCLOGYL 1% OPH. DROP 2.5ML$ BT 4.55 40749970 CYCLOGYL 2% OPH DROP $ 4.55 40776503 CYCLOMYDRIL OPTH. DROP $ 127.00 42601914 CYCLOPHOSPHAMIDE 100 MG $ 264.00 J9070JG 42619994 CYCLOPHOSPHAMIDE 100MG JW $ 264.00 J9070JGJW 39401922 CYCLOSPORIN $ 111.25 80158 40770687 CYMBATTA 30MG CAPSULE $ 14.00 42616529 CYRAMZA 5 MG $ 206.00 J9308JG 42618905 CYRAMZA 5 MG JW $ 206.00 J9308JGJW 40107757 CYSTIC FIBROSIS $ 143.00 89230 39401799 CYSTINE AMINO ACIDS $ 70.25 82127 31202674 CYSTO PACK $ 93.75 32529927 CYSTO SPLASH DRAPE $ 87.15 32631747 CYSTO SPLASH DRAPE $ 87.15 31200314 CYSTO, TUBING $ 53.40 32631945 CYSTO, TUBING $ 53.40 40483448 CYSTO, TUBING $ 54.00

35 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40400301 CYSTOGRAM $ 431.00 74430 40400319 CYSTOGRAM VOIDING $ 481.75 74455 40749319 CYTADREN TAB $ 3.40 31401953 CYTOLOGY BRUSH $ 49.00 32532251 CYTOLOGY BRUSH $ 380.00 32631549 CYTOLOGY BRUSH $ 380.00 32513418 CYTOLOGY BRUSH ERCP $ 268.80 32631648 CYTOLOGY BRUSH ERCP $ 268.80 40201949 CYTO-MOL, INTERP REPORT $ 87.25 88291 39407019 CYTOPLAMIC ANCA (C-ANCA) $ 52.25 86225 40734808 CYTOSAR-U 100MG $ 25.50 J9100 40755035 CYTOSAR-U 1GM $ 121.00 J9100 40755043 CYTOSAR-U 2GM $ 236.55 J9100 40755050 CYTOSAR-U 500MG $ 63.75 J9100 40765943 CYTOTEC 100MCG TAB $ 3.25 40766347 CYTOTEC 25MCG TAB $ 3.25 40753501 CYTOTEC TAB 200MCG TABLET $ 3.40 40765786 CYTOVENE 500MG VIAL $ 68.70 40782047 Cytovene 500mg vial $ 379.50 J1570 40706020 CYTOXAN 1GM $ 114.50 J9070 40702805 CYTOXAN 200MG $ 34.00 J9070 40704918 CYTOXAN 500MG VIAL $ 57.25 J9070 40702383 CYTOXAN 50MG $ 7.30 J9070 40805129 D&/OR EVAL TX/DAY $ 406.00 94664 39506523 D.FARINAE ALLERGEN $ 13.00 86003 40735227 D.H.E. 45 1MG/1ML AMP $ 34.00 39505731 D.PTERONYSSINUS $ 13.00 86003 40769515 D10 1/2 NS 1000ML BAG $ 28.00 40769713 D5 0.5NS 1L 20 PIT 20 9M MAG $ 96.00 40768095 D5 1/2NS 10MEQ KCL 1000ML BAG$ 50.00 40768889 D5 1/4NS 10MEQ KCL 1000ML BAG$ 25.00 40768897 D5 1/4NS 20MEQ KCL 1000ML BAG$ 25.00 42602011 DACARBAZINE 100MG $ 230.00 J9130 42619400 DACARBAZINE 100MG JW $ 230.00 J9130JW 40754541 DACARBAZINE 200MG VIAL $ 58.00 J9130 42623558 DACOGEN 1MG $ 131.00 J0894JG 42623657 DACOGEN 1MG JW $ 131.00 J0894JGJW 32532061 DAILY LATEX FREE SUPPLIES $ 37.45 42011254 DAILY LATEX FREE SUPPLIES $ 38.00 40407108 DAILY LATEX FREE SUPPLIES $ 38.00 40755886 DAKIN'S 0.25% SOLN 473ML BT $ 31.55 40770943 DAKINS SOLUTION 0.5% 473ML BOT$ 125.00 40754566 DALGAN VIAL 1ML $ 27.05 40745341 DALMANE CAP $ 3.40 40745358 DALMANE CAP $ 3.40 40780166 Dalvance 500mg $ 5,721.00 J0875JG 40760241 D-AMPHETAMINE SULFAT $ 3.25 40755597 DANTRIUM IV VIAL $ 135.00 40770059 DAPSONE 100MG TAB $ 3.25 40770497 DAPTOMYCIN 500MG vIAL $ 1,737.00 J0878JG 40702946 DARVOCET-N 100 TAB $ 3.25 40746398 DARVON CAP $ 3.25 40746380 DARVON COMPOUND-65 $ 3.25 42615440 DARZALEX 10 MG $ 178.00 J9145JG 42620588 DARZALEX 10 MG JW $ 178.00 J9145JGJW 40107278 DATE RAPE - GHB $ 110.00 82542 32517997 DBM INTEGRO PUTTY $ 870.00 C9359 42631478 DC CHEMO PUMP $ 408.00 96521 40750960 DDAVP 4MCG/ML AMP $ 124.75 J2597 42610885 DDAVP DESMOPRESSIN 4 MCG/ML$ 24.00 J2597JG

36 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40753907 DDAVP NASAL SPRAY $ 261.95 39408722 D-DIMER $ 153.00 85379 33300049 DEB INFECT ADDL 10% $ 71.00 11001 33301294 DEB INFECT SKIN 10% $ 628.00 11000 33300247 DEB NAILS 1-5 $ 188.00 11720 33300254 DEB NAILS 6 OR MORE $ 188.00 11721 33300064 DEB REMOVE MUS FASCI $ 840.00 11011 33300072 DEB REMOVE MUS&BONE $ 4,716.00 11012 33300056 DEB REMOVE SUB TISSUE $ 1,834.00 11010 33301328 DEB SKIN MUSCLE BONE $ 1,834.00 11044 33301310 DEB SKIN TISSUE MUSC $ 628.00 11042 33301302 DEB WND SEL ADDL 20 CM $ 309.00 97598 33305269 DEB WND SLTV 20 CM OR < $ 331.00 97597 33300098 DEB,SKIN TISSUE&MUSCLE $ 628.00 11043 41451881 DEBRIDEMENT BONE 1ST =<20 SQCM$ 1,834.00 11044 41452178 DEBRIDEMENT BONE ADD'L 20SQCM$ 1,754.90 11047 41452079 DEBRIDEMENT MUS/FAS ADD'L 20$ 564.50 11046 41451782 DEBRIDEMENT MUSC/FAS =< 20SQCM$ 628.00 11043 41453069 DEBRIDEMENT NAIL 1-5 NAILS $ 188.00 11720 41453168 DEBRIDEMENT NAILS 6 OR MORE$ 188.00 11721 41451188 DEBRIDEMENT NON-SEL NO ANEST$ 324.00 97602 41451485 DEBRIDEMENT OW =<1ST 20 SQ$ CM 331.00 97597 41451584 DEBRIDEMENT OW ADD'L 20 SQ $CM 309.00 97598 41451980 DEBRIDEMENT SQ ADD'L<= 20SQCM$ 564.50 11045 41451683 DEBRIDEMENT SUBQ <=1ST 20 SQCM$ 628.00 11042 40733756 DEBROX EAR DROP $ 10.00 40719114 DEBROX OTIC DROP $ 14.75 40763534 DECA-DEURABOLIN $ 45.20 40764441 DECADOAN 0.5MG/5ML ELIXIV $ 3.40 40751158 DECADRON & NEOMYCIN $ 10.80 40719122 DECADRON (GEN) OPH D $ 24.95 40719130 DECADRON (GEN) OPH O $ 12.50 40703068 DECADRON 0.75MG TAB $ 3.25 40763906 DECADRON 20 MG/5 ML VIAL $ 19.45 J1100 40702979 DECADRON 4 MG TAB $ 4.15 40735276 DECADRON 4MG/1ML VIAL $ 4.00 J1100 40735250 DECADRON-LA VIAL $ 31.75 J1094 40000309 DECALCIFY TISSUE $ 43.00 88311 31201890 DECANTING SET $ 77.85 40702987 DECLOMYCIN 150 MG TABLET $ 10.40 31517819 DECLOT VASCULAR DEVICE $ 5,179.00 36595 42607632 DECLOTTING OF IMPLANT VAS DEV$ 318.50 36593 31404173 DEFECT CLOSURE SYS COLON $ 899.00 31404074 DEFECT CLOSURE SYS EGD $ 899.00 31523264 DEFIB CARDIOVERT EP EVAL SINGL$ 1,902.00 93642 33100314 DEFIB PADS $ 126.00 31010275 DEFIB PADS $ 126.00 30210562 DEFIB PADS $ 126.00 30200562 DEFIB PADS $ 126.00 32532996 DEFIBRILLATOR - PHOTON DUAL$ 70,965.00 C1721 32533366 DEFIBRILLATOR BI-VENT $ 88,946.00 C1882 31538563 DEFIBRILLATOR BI-VENT $ 89,000.00 C1882 31549156 DEFIBRILLATOR BI-VENT $ 89,000.00 C1882 32532244 DEFIBRILLATOR PADS $ 126.00 31701394 DEFIBRILLATOR PADS $ 126.00 31405856 DEFIBRILLATOR PADS $ 126.00 31303076 DEFIBRILLATOR PADS $ 126.00 32631450 DEFIBRILLATOR PADS $ 126.00 32531972 DEFIBRILLATOR VR $ 59,600.00 C1722 31548958 DEFIBRILLATOR VR $ 59,600.00 C1722

37 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40770109 DEHYDRATED ALCOHOL 1ML AMP$ 26.50 32201204 DELIVERY /RECOVERY $ 300.00 32509929 DELIVERY EXTRACTOR $ 153.00 33303399 DELIVERY OF PLACENTA $ 4,095.00 59414 32201048 DELIVERY ROOM SET UP $ 786.00 40767766 DELSYM SYRUP $ 3.30 40756967 DELTASONE 5MG TAB $ 3.25 J7512 40748931 DELTASONE TAB $ 3.25 42602029 DEMADEX 10MG IV $ 25.00 J3265 40763641 DEMADEX 10MG TAB $ 3.25 40766867 DEMADEX 20MG $ 3.25 40763542 DEMADEX 20MG CAP $ 4.35 40769580 DEMADEX 20MG TAB $ 3.25 40764870 DEMADEX IV 20MG/20ML AMPS $ 14.75 J3265 42602482 DEMEROL 50MG TUBEX $ 38.00 J2180 40754269 DEMEROL PCA 300MG/30ML PCA $PMP 70.00 J2175 32517765 DEODORANT ADAPT LUBRICATING$ 1.20 A4394 32502262 DEODORANT, AIRKEM $ 11.75 40758146 DEPAKENE SYRP 250 MG/5 ML UDC$ 4.55 40763443 DEPAKOTE 250 MG TAB $ 4.60 32516734 DEPLOYMENT GUIDE $ 488.60 40766776 DEPOMEDROL 40MG/1ML VIAL $ 23.10 J1030 40752123 DEPO-MEDROL VIAL $ 31.75 J1040 40750739 DERIFIL TAB $ 3.25 33100306 DERM SKIN CLOSURE <2.5CM $ 263.00 33304371 DERM SKIN CLOSURE > 2.6CM $ 361.00 G0168 31201866 DERMA CARRIER $ 111.10 32533853 DERMABOND SKIN CLOSURE $ 94.30 32631054 DERMABOND SKIN CLOSURE $ 94.30 31546285 DERMABOND SKIN CLOSURE $ 95.00 33100546 DERMABOND SKIN CLOSURE >2.6CM$ 361.00 G0168 41454653 DERMAGRA SKIN SUB DIS POR SQCM$ 119.20 Q4106JW 41453861 DERMAGRAFT APP ADD'L 100 SQ $CM 653.33 15366 41454554 DERMAGRAFT SKIN SUB PER SQ $CM 119.20 Q4106 32502296 DERMATONE HEAD $ 116.75 32631351 DERMATONE HEAD $ 116.75 31201007 DERMATONE TAPE EXTRA $ 224.20 39400312 DERMATOPHAGOIDES-RAS $ 28.75 86003 40719221 DERMOPLAST SPRAY 2 OUNCE EACH$ 9.10 40735367 DESFERAL MESYLATE VI $ 34.00 J0895 39402102 DESIPRAMINE $ 76.00 G0483 40768202 DESIPRAMINE 50MG $ 3.25 40780265 Desmopressin 40 mcg/10ml vial $ 2,321.50 J2597 33300478 DEST WARTS 1-14 LESION $ 218.00 17110 41459801 DESTRU CUTAN VAS PROLIF LES $ 616.70 17106 41459900 DESTRUCT B9 LESION 1-14 $ 218.00 17110 40749715 DESYREL 50 MG TAB $ 3.40 40765679 DETROL 1MG TABLET $ 3.25 40766875 DETROL 2MG $ 6.00 40766883 DETROL LA 2MG CAPSULE $ 9.50 40768236 DETROL LA 4MG TAB $ 10.00 31520987 DEVICE CHRONIC TOTAL OCCLUSION$ 2,744.00 C2628 40757395 DEX 5%-1/4NS 250ML $ 22.70 40768012 DEXAMETH SOD/PHO 120MG/30ML$ VI 33.00 J1100 42601302 DEXAMETHASONE 1MG $ 5.00 J1100 40748303 DEXAMETHASONE SODIUM $ 18.25 40770505 DEXTROSE 10% - 0.25NS 250ML$ 25.00 40757411 DEXTROSE 10% 1000ML BAG $ 32.95 40757429 DEXTROSE 10% 500ML BAG $ 32.95 40757437 DEXTROSE 20% IVSL $ 52.35

38 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40771040 DEXTROSE 30% 1000 ML BAG $ 40.50 40757478 DEXTROSE 5% 1000ML BAG $ 32.95 J7070 40757452 DEXTROSE 5% 250ML BAG $ 32.95 40757460 DEXTROSE 5% 500ML BAG $ 7.60 40756371 DEXTROSE 5% 100ML BAG $ 28.55 40757445 DEXTROSE 5% 150ML BT $ 32.95 40700783 DEXTROSE 5% 50ML BAG $ 34.00 40754277 DEXTROSE 5%-1/2 NS 1000ML BAG$ 32.95 40757361 DEXTROSE 5%-1/2NS $ 22.70 40757379 DEXTROSE 5%-1/2NS $ 32.95 40757387 DEXTROSE 5%-1/4NS 1000ML BAG$ 34.00 40757403 DEXTROSE 5%-1/4NS IV 500ML BAG$ 22.70 40757486 DEXTROSE 5%-LR 1000ML BAG $ 32.95 40757494 DEXTROSE 5%-LR 500ML BAG $ 32.95 40757510 DEXTROSE 5%-NS 0.9% $ 32.95 40757502 DEXTROSE 5%-NS 0.9% 1000ML$ BAG 32.95 40757528 DEXTROSE 5%-NS 0.9% 500ML BAG$ 32.95 40753394 DEXTROSE 50% 50 ML SYRINGE $ 42.15 40757346 DEXTROSE 50% 50 ML VIAL $ 17.65 40757700 DEXTROSE 50% INJECTI $ 73.45 40756116 DEXTROSE 50%-WATER 500ML IVSOL$ 69.50 42602128 DEXTROSE FE 50MG $ 75.00 J1750 40756058 DEXTROSE-WATER 70% 500ML BT$ 3.25 40107187 DHEA $ 204.00 82626 39402193 DHEA-S DEHYDROEPI $ 133.25 82627 40703076 DIABINESE TAB $ 3.40 40748022 DIABINESE TAB $ 3.40 39501457 DIAGNOSTIC OCCULT BLOOD $ 31.50 82272 39901269 DIAGNOSTIC PSA $ 69.50 84153 32601635 DIAL A FLOW EXT. $ 25.05 32601759 DIALYSIS ADMIN SET $ 25.25 32638479 DIALYSIS CATH CHRONIC $ 850.00 C1750 32532459 DIALYSIS CATH CHRONIC $ 851.80 C1750 31539553 DIALYSIS CATH CHRONIC $ 852.00 C1750 32601734 DIALYSIS CATHETER $ 37.05 32601742 DIALYSIS DRAIN BAG $ 13.70 32601767 DIALYSIS TRAY $ 84.30 33100165 DIALYSIS TRAY $ 343.00 40703126 DIAMOX 250 MG TAB $ 3.40 40735391 DIAMOX 500 MG VIAL $ 83.00 40758229 DIAMOX SEQUELS $ 3.40 32601718 DIANEAL 1.5% $ 20.25 32601726 DIANEAL 4.25% $ 20.25 40760191 DIAP. RASH OINT 120G $ 6.75 32511735 DIAPER ADULT XL $ 53.90 32506040 DIAPERS ADULT $ 23.85 32509390 DIAPERS PREMATURE $ 47.65 32508020 DIAPERS, CRAWLER $ 58.65 32508012 DIAPERS, INFANT 1 $ 43.80 32508202 DIAPERS, WALKER 2 $ 62.75 40921175 DIATHERMY $ 92.00 97024GO 40901175 DIATHERMY $ 92.00 97024GP 40760258 DIATRIZOATE SODIUM $ 41.30 40703159 DIBENZYLINE 10 MG CAP $ 3.25 39901624 DIBYDROTESTOSTERONE $ 225.00 80307 40725830 DICLOXACILLIN SODIUM $ 22.70 50710011 DIETARY CONSULT INIT EA 15MIN$ 60.00 97802 50710065 DIETARY CONSULT NON-INIT 15MIN$ 56.00 97803 40703183 DIETHYLSTILBESTROL T $ 3.25 40601734 DIFF QUANTITATIVE LUNG SCAN$ 903.50 78597

39 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39800735 DIFFERENTIAL COUNT $ 46.25 85007 40754129 DIFLUCAN 100 MG TABLET $ 28.50 40763476 DIFLUCAN 10MG/ML 35ML BOTTLE$ 220.60 40767519 DIFLUCAN 150MG TABLET $ 41.25 40755811 DIGIBIND 40MG VIAL $ 12,265.50 J1162 32506982 DIGIT TRAP $ 78.00 40404477 DIGITAL DIAG MAMMO LEFT UNILAT$ 216.00 77065LT 40404451 DIGITAL DIAG MAMMO RT UNILAT$ 216.00 77065RT 40404444 DIGITAL DIAGNOSTIC MAMMO BILAT$ 432.00 77066 41362519 DIGITAL RECTAL EXAM $ 11.00 G0102 40405128 DIGITAL SCREENING MAMMOGRAM$ 238.00 77067 39900063 DIGOXIN LEVEL $ 53.50 80162 40729569 DIHISTINE $ 3.25 40759128 DILACOR XR CAPSULE $ 3.40 40703217 DILANTIN 100 MG CAPSULE $ 3.25 40755316 DILANTIN TAB CHEW $ 4.55 39900154 DILANTIN(PHENYTOIN) $ 65.25 80185 40725723 DILANTIN-125 SUSP $ 3.40 40751398 DILANTIN-30 PEDIATRI $ 4.55 40758427 DILATERIA (WICK) $ 17.85 40758765 DILATERIA (WICK) $ 17.85 33303241 DILATION URETH FILI MALE $ 3,225.00 53620 33303233 DILATION URETH MALE $ 474.00 53600 31500879 DILATOR 5FR $ 32.00 31505704 DILATOR 5FR. X $ 27.00 31500887 DILATOR 6FR $ 32.00 31505613 DILATOR 6FR. X $ 27.00 31505068 DILATOR 7FR $ 32.00 31505795 DILATOR 7FR. X $ 27.00 31500895 DILATOR 8FR $ 32.00 31505886 DILATOR 8FR. X $ 27.00 31402589 DILATOR BALLOON CRE PRO $ 335.00 32515645 DILATOR SHEATH SET $ 407.90 32517898 DILATOR WITH SHEATH $ 106.00 42604305 DILAUDID 2MG $ 18.00 J1170 40781552 Dilaudid 1mg/ml 1ml syringe $ 17.00 40766701 DILAUDID 1MG/ML AMP. $ 18.40 40745432 DILAUDID 2 MG TAB $ 3.40 40745457 DILAUDID 2 MG/1ML VIAL $ 17.05 40766610 DILAUDID 4MG AMP $ 6.50 J1170 40777691 Dilaudid 6mg/30ml PCA Syringe $ 70.00 40766628 DILAUDID PCA $ 54.00 40750374 DILAUDID TAB $ 3.40 32507741 DILETER 9FR $ 37.00 40769341 DILTIAZEM 100MG/100ML ADVANTAG$ 42.00 40769481 DIMENHYDRINATE 50MG/ML VIAL$ 29.10 40703290 DIMETAPP TAB SA $ 3.25 40764862 DIOVAN 80MG TABLET $ 3.25 40108203 DIPHTHERIA AB $ 113.00 86317 40754459 DIPRIVAN 200MG/20ML VIAL $ 48.60 40759177C DIPYRIDAMOLE 10MG $ 65.32 J1245 40759177E DIPYRIDAMOLE 10MG $ 65.32 J1245 40759177B DIPYRIDAMOLE 10MG $ 65.32 J1245 40759177D DIPYRIDAMOLE 10MG $ 65.32 J1245 40759177A DIPYRIDAMOLE 10MG $ 65.32 J1245 40759177 DIPYRIDAMOLE 50MG/10ML VIAL$ 326.60 J1245 40764227 DIPYRIDAMOLE 5MG/2ML AMP $ 65.32 J1245 40757726 DIPYRIDAMOLE AMP $ 108.75 31010655 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379 30900690 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379

40 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30500474 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379 30300651 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379 30210877 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379 30200877 DIRECT ADM OBS MEDICARE 1XONLY$ 1,063.00 G0379 40200206 DIRECT DONATION FEE $ 62.75 39402284 DIRECTIGEN $ 216.75 87450 40804296 DISABILITY BASIC $ 297.00 94010 40804247 DISABILITY COMPLETE $ 543.00 94060 40804288 DISABILITY DIFFUSION $ 144.00 94729 40703308 DISALCID TAB $ 3.25 40752883 DISALCID TAB $ 3.25 40803785 DISP AMBU, INFANT $ 156.25 40803876 DISP AMBU,PEDIATRIC $ 156.25 32529745 DISP ICE BAG $ 15.05 40803777 DISP.AMBU,ADULT $ 156.25 42602110 DISPOSABLE AMBU-ADULT $ 158.00 32511578 DISSECTOR ENDO DISP $ 288.95 32507378 DISTAL RADIUS STD $ 934.80 C1713 40758088 DITROPAN 5 MG TAB $ 4.55 40768053 DITROPAN XL 10MG TABLET $ 9.50 40768111 DITROPAN XL 5MG TAB $ 10.00 40765984 DIURIL 500MG VIAL $ 151.74 J1205 40753733 DIURIL TAB $ 3.25 40804908 DLCO, TC ONLY $ 144.00 94729 39401278 DNA NATIVE FARR $ 79.25 86226 39407638 DNA URINE TRICH $ 204.75 87299 40603002 DOBUTAMINE MYOCARDIAL PERF$ 1,517.60 78452 40765117 DOBUTREX 500MG/250ML PREMIX$ 330.25 40749558 DOBUTREX VIAL 20ML $ 119.90 39506820 DOG DANDER $ 13.00 86003 39400221 DOG EPITHELIAL RAST $ 28.75 86003 40752602 DOLOBID TAB $ 4.55 40702821 DOMEBORO PACK $ 3.25 40759698 DONNAGEL 120ML $ 8.50 40725806 DONNAGEL SUSP $ 3.25 40703340 DONNATAL 16.2MG TAB $ 3.25 40725814 DONNATAL ELIXIR 16.2MG/5ML UDC$ 3.40 32511305 DONOR CORNEA PUNCH $ 268.55 32631153 DONOR CORNEA PUNCH $ 268.55 40750028 DOPAMINE 400MG IN IV $ 54.95 40767527 DOPAMINE 400MG/250ML PREMIX$ IV 60.00 40782443 Dopamine 800mg/250ml premixed$ 75.00 40750010 DOPAMINE HCL VIAL $ 60.50 31502495 DOPPLER NEEDLE $ 306.55 31546582 DOPPLER NEEDLE $ 307.00 31502404 DOPPLER NEEDLE-X $ 306.55 40772204 DORIBAX 250MG/100ML NS PREMIX$ 98.52 J1267 40771065 DORIBAX 500MG VIAL PIGGYBACK$ 156.00 J1267 33304884 DORSAL SLIT $ 3,613.00 54001 40402034 DORSAL SPINE $ 150.50 72072 41210068 DOSIMETRY BASIC $ 259.00 77300 39600028 DOUBLE STRANDED ADNA $ 47.00 86225 40771628 DOXAZOSIN MESYLATE 4 MG TABLET$ 3.50 40765133 DOXEPIN 10MG CAPSULE $ 3.25 J8499 40769507 DOXEPINE 10MG/ML BOTTLE $ 3.25 40703415 DOXIDAN CAP $ 3.25 42601476 DOXORUBICIN 10MG $ 27.00 J9000 42618014 DOXORUBICIN 10MG JW $ 27.00 J9000JW 40768905 DR. CASSIDY'S PASTE $ 58.00 32511248 DR. FOG $ 66.05

41 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33300981 DRAIN ABSCESS EXTERNAL $ 806.00 42320 33454602 DRAIN ABSCESS NASAL INTERNAL$ 288.00 30000 33303126 DRAIN ABSCESS PERITO $ 806.00 42700 33303118 DRAIN ABSCESS SUBLIN $ 806.00 42310 33303100 DRAIN ABSCESS SYST $ 1,183.00 40800 33302292 DRAIN FINGER, COMPLICATED $ 1,921.00 26011 33302284 DRAIN FINGER, SIMPLE $ 359.00 26010 33303175 DRAIN ISCHIORECTAL $ 3,228.00 46040 32639370 DRAIN JACKSON PRATT $ 418.00 33303183 DRAIN PERIANAL ABSCESS $ 982.00 46050 33303308 DRAIN SCROTAL WALL $ 1,921.00 55100 32629173 DRAIN SILICONE $ 52.00 32507139 DRAIN SILICONE $ 52.20 32512634 DRAIN VALVE HEIMLICH $ 92.30 31208737 DRAIN, 10FR ROUND $ 20.00 32603334 DRAIN, TRIPLE LUMEN $ 62.00 33304728 DRAINAGE ABSCESS EXTERNAL EAR$ 359.00 69020 33304876 DRAINAGE ABSCESS GUM $ 359.00 41800 32516684 DRAINAGE BAG CONNECTOR CT SCAN$ 43.50 32507675 DRAINAGE BAG TUBES $ 41.00 31549948 DRAINAGE BAG TUBES $ 41.00 32502304 DRAINAGE BOTTLE, DUAL $ 208.40 32508210 DRAINAGE BOTTLE, SING $ 128.45 31533019 DRAINAGE CATH UNDER XR $ 381.00 75989 31532722 DRAINAGE CATH UNDER XR $ 381.00 75989 31511173 DRAINAGE CATHETER CHANGE S&I$ 227.50 75984 32509861 DRAINAGE PLEURA VAC $ 389.10 32507758 DRAINAGE POUCH SET $ 70.00 40703423 DRAMAMINE 50 MG TABLET $ 3.25 40735441 DRAMAMINE AMP $ 20.45 J1240 32533002 DRAPE BUTTOCKS $ 9.60 32514150 DRAPE CHEST $ 42.00 32631252 DRAPE CHEST $ 42.00 32500308 DRAPE ENDOSCOPY $ 115.55 32515959 DRAPE KNEE ARTHO $ 127.00 31538167 DRAPE KNEE ARTHO $ 127.00 42010462 DRAPE STERILE SURGICAL $ 66.00 40507618 DRAPE STERILE SURGICAL $ 66.00 32512840 DRAPE STERILE SURGICAL $ 66.15 31549057 DRAPE STERILE SURGICAL $ 67.00 32607492 DRAPE UNIVERSAL 4 PACK $ 50.00 32517823 DRAPE, UNDER BUTTOCKS $ 52.50 32517096 DREAMTOME $ 546.00 41457227 DRESS AND/OR DEBR BURN MEDIUM$ 331.00 16025 41457128 DRESS AND/OR DEBR BURN SAMLL$ 331.00 16020 33301880 DRESS DEB LARGE $ 628.00 16030 33301872 DRESS,DEB MEDIUM $ 331.00 16025 33301864 DRESS,DEB SMALL $ 331.00 16020 31203052 DRESSING (JONES) $ 109.65 32502049 DRESSING 2X5 STERILE $ 9.05 32502064 DRESSING 4X5 STERILE $ 10.45 32502148 DRESSING BANDAID 4X6 $ 5.30 32517591 DRESSING CENTRAL LINE $ 49.50 31904188 DRESSING CENTRAL LINE $ 50.00 32510505 DRESSING DUODERM 4X4 $ 86.55 32510497 DRESSING DUODERM 8X8 $ 106.05 31301789 DRESSING DUODERM 8X8 $ 108.00 32630856 DRESSING DUODERM 8X8 $ 108.00 32533663 DRESSING FLUFF $ 7.10 32502080 DRESSING HEAVY DRAIN $ 12.55

42 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32529703 DRESSING IODOFORM $ 11.50 32502122 DRESSING KERLIX ROLL $ 12.10 32514986 DRESSING KIT WOUND $ 225.75 32517864 DRESSING MEPILEX BORDER $ 25.52 A6213 32603730 DRESSING SILVERLON $ 54.00 32630658 DRESSING SILVERLON $ 54.00 32502221 DRESSING TELFA $ 3.55 42010363 DRESSING TELFA $ 4.00 32630559 DRESSING TELFA $ 4.00 32509739 DRESSING TELFA 3X4 $ 3.30 42010957 DRESSING TELFA 3X4 $ 4.00 32630460 DRESSING TELFA 3X4 $ 4.00 32502163 DRESSING XEROFOAM 1X8 $ 11.50 32630361 DRESSING XEROFOAM 1X8 $ 12.00 32594811 DRESSING, OPEN WOUND $ 515.20 32502189 DRESSING, PROCELLERA $ 138.00 A6207 32517856 DRESSING, SILVER BORDER $ 430.50 A6213 32595405 DRESSING, WOUND VAC, STICKY$ 22.00 A6550 32502023 DRESSINGS ADAPTIC $ 10.30 32514903 DRILL BIT 1.0-2.8 $ 158.20 32514937 DRILL BIT 11.0 MM $ 341.10 32514945 DRILL BIT 13.0MM $ 578.70 32514911 DRILL BIT 3.0-3.5 $ 211.20 32514929 DRILL BIT 4.0-5.5 $ 346.50 32516981 DRILL BIT CALIBRATED $ 486.00 32513871 DRILL BIT CALIBRATED $ 593.00 32514317 DRILL BIT CANNULATED $ 1,575.00 32630262 DRILL BIT CANNULATED $ 1,575.00 32514200 DRILL BIT CORNERSTONE $ 419.00 32514895 DRILL BIT TAP $ 142.80 31203243 DRILL BITS $ 291.90 32529992 DRILL BITS ACL $ 875.00 32512477 DRILL LONG TWIST $ 309.30 32512519 DRILL, SHORT $ 434.85 32630163 DRILL, SHORT $ 440.00 32517674 DRILL,CALIBRATED $ 230.00 32517351 DRILLBIT $ 218.00 C1713 42602904 DROPERIDOL UP TO 5MG $ 7.00 J1790 40107070 DRUG PROFILE BLOOD $ 454.00 80307 39403761 DRUG SCREEN COLLECTION $ 20.75 39900519 DRUG SCREEN SP.COLL. $ 20.75 39406111 DS DOT $ 56.00 80307 39406202 DS NON DOT $ 45.50 80307 40755589 DTIC-DOME IV 100MG VIAL $ 37.25 40601296 DTPA $ 64.50 A9539 40603596 DTPA NO CODE $ 65.00 31502222 DUAL INFUSAPORT-BARD $ 901.65 31502503 DUAL LEAD INSERT ONLY P/ICD $ 15,305.00 33217 31505605 DUAL PACE GEN INS/RPL W/EXISTI$ 20,652.00 33213 40731440 DULCOLAX 10 MG SUPP $ 4.55 40770034 DULEXETINE HCL 60MG DR CAP $ 12.50 40402836 DUPLICATE FILM 10X12 $ 12.00 40402828 DUPLICATE FILM 14X17 $ 14.25 32530008 DURA FILM $ 205.80 32514572 DURA NEEDLE $ 10.50 31500903 DURA PREP SYRINGES $ 49.40 31548166 DURA PREP SYRINGES $ 50.00 31505977 DURA PREP SYRINGES X $ 46.50 32604522 DURAGEN $ 419.00 32630064 DURAGEN $ 419.00

43 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40765000 DURAGESIC 100MCG/HR TD PATCH$ 75.60 40760357 DURAGESIC 50MCG/HR PATCH TD.72$ 36.30 40766024 DURAGESIC 75MCG/HR PATCH.TD72$ 110.70 40755688 DURAGESIC-25MCG/HR PATCH TD.72$ 24.25 32512360 DURALOC 1200 SERIES $ 2,605.40 40751976 DURAMORPH 5MG/10ML AMP $ 37.80 J2274 32513632 DURAPREP REMOVER $ 3.70 40756231 DURATEARS OINT $ 21.60 40703498 DURICEF CAP $ 7.60 40749160 DURICEF SUSP $ 22.70 40749178 DURICEF SUSP 250MG/5ML BOTTLE$ 36.30 40703464 DYAZIDE CAP $ 3.25 40759391 DYLINE-GG 100 $ 3.70 40780958 Dyloject 37.5mg/ml vial $ 61.50 40754681 DYNACIRC CR 2.5MG CAP $ 4.55 40703480 DYNAPEN 250 MG CAPSULE $ 3.40 40767022 DYNAPEN 500MG $ 3.25 32507022 DYONICS ADAPTER $ 20.00 40703993 E.E.S. 400 TAB $ 3.40 40726036 E.E.S. GRANULES SUSP $ 22.70 32527210 E.R. PACK $ 45.60 40927339 E0100- Cane New $ 59.00 E0100 40927240 E0114 - Crutches New $ 113.00 E0114 40927141 E0135 - Standard Walker - New $ 121.00 E0135 40927042 E0143 - Walker w/Wheels - New $ 127.00 E0143 31900087 EA ADD 15 MIN MAJ2 $ 99.25 31200082 EA ADD 30 MIN MAJOR $ 503.00 31900079 EA. ADD. 15 MIN.-MAJ1 $ 57.50 31401094 EA.ADD 15 MIN. $ 58.00 31200058 EA.ADD.30MIN.MINOR $ 311.00 39500780 EAR CULTURE $ 79.25 87070 32507667 EAR CURETTE $ 18.00 40804189 EASY CAP ETCO2 MON. $ 51.00 32516114 EASY PLUG & PATCH $ 528.00 C1781 32510927 EBL12 ESCORT BALLOON $ 405.30 C1726 32510943 EBL8.5 ESCORT BALLON $ 405.30 C1726 40108698 EBV AB VCA IGG $ 50.00 86665 40108797 EBV AB VCA IGM $ 50.00 86665 39405402 EBV ANTI-VCA-IGG AB $ 73.00 86665 40108500 EBV EARLY AG $ 38.00 86663 39403282 EBV EARLY ANTIGEN $ 85.25 86663 39405493 EBV IGM AB $ 73.00 86665 40108599 EBV NUCLEAR AB $ 43.00 86664 39405311 EBV NUCLEAR AG AB $ 73.00 86664 40108896 EBV PANEL MASTER $ 181.00 40854668 ECHO CONTRAST STUDY $ 120.50 A9700 40850613 ECHO DOPPLER $ 200.00 93320 40850670 ECHO DOPPLER LIMITED $ 326.49 93321 40850654 ECHO LIMITED;TRANSTHORACIC$ 499.00 93308 40850647 ECHO STRESS $ 987.00 93350 40850662 ECHO TEE $ 1,306.00 93312TC 40850605 ECHO WITH OR WITHOUT M-MODE$ 1,061.00 93306 40850621 ECHO,COLOR DOPPLER FLOW $ 356.77 93325 40872996 EEG, EXTENDED 41-60 MIN $ 543.00 95812 40873095 EEG, OVER 1 Hr. $ 543.00 95813 40350035 EEG-CEREBRAL DEATH $ 487.00 95824 40768160 EFFEXOR 37.5MG TAB $ 5.00 40765695 EFFEXOR XR 150MG CAPSULE $ 5.85 40765190 EFFEXOR XR 37.5MG CAPSULE $ 4.85 40766172 EFFEXOR XR 75MG CAPSULE $ 8.15

44 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40771537 EFFIENT 10MG TAB $ 22.50 31401631 EGD $ 1,402.00 31201833 EGD PROCEDURE $ 687.00 31401920 EGD W/BALLOON DILATION $ 224.00 31401656 EGD W/BAND LIGATION $ 372.00 31401474 EGD W/BIOPSY $ 71.00 31401748 EGD W/DILATION $ 174.00 31401300 EGD W/HEMOSTASIS BLE $ 479.00 31401128 EGD W/HOT BIOPSY $ 240.00 31401037 EGD W/PEG $ 478.00 31401219 EGD W/POLYPECTOMY $ 289.00 31401839 EGD W/REMOVAL FOREIGN BODY$ 518.00 31401565 EGD W/SCLEROTHERAPY $ 469.00 32518144 EGGCRATE BED PAD $ 34.00 40300014 EKG 12 LEAD $ 111.00 40805814 EKG 12 LEAD IN ER $ 111.00 40874283 EKG 12 LEAD IN ER PROFESSIONAL$ 36.00 93010 40874382 EKG 12 LEAD IN ER TRACING ONLY$ 122.00 93005 40874085 EKG 12 LEAD PROFESSIONAL $ 36.00 93010 40874976 EKG 12 LEAD PROFESSIONAL IPPE$ 36.00 G0403 40874184 EKG 12 LEAD TRACING ONLY $ 122.00 93005 40874877 EKG 12 LEAD TRACING ONLY IPPE$ 122.00 G0403 41355459 EKG -TRACING ONLY - 12 LEADS$ 122.00 93005 40805012 EKG WITH MAGNET $ 111.00 40874679 EKG WITH MAGNET PROFESSIONAL$ 36.00 93010 40874580 EKG WITH MAGNET TRACING ONLY$ 122.00 93005 40805095 EKG WITHOUT MAGNET $ 111.00 40874778 EKG WITHOUT MAGNET PROFESSIONA$ 36.00 93010 40874481 EKG WITHOUT MAGNET TRACING$ ONL 122.00 93005 40753485 ELASE OINT $ 36.30 32509523 ELASTIKON 2 INCH $ 27.00 32509531 ELASTIKON 3 INCH $ 36.80 32509549 ELASTIKON 4 INCH $ 38.50 40762064 ELDEPRYL 5 MG $ 4.90 40900052 ELECTRIC STIM-CONSTANT AT 15$ 119.00 97032GP 40920052 ELECTRIC STIM-CONSTANT EA 15MI$ 119.00 97032GO 40912305 ELECTRIC STIM-STAGE 3/4 WOUND,$ 113.25 G0281GP 40920060 ELECTRIC STIM-SUPERVISED $ 113.25 G0283GO 40900060 ELECTRIC STIM-SUPERVISED $ 113.25 G0283GP 40931002 ELECTRIC STIM-WOUND, STG 3/4$ S 113.25 G0281GO 32517955 ELECTRO LUBE $ 147.00 31202633 ELECTRO SURG. PENCIL $ 45.60 31401011 ELECTROCOAGULATION $ 54.00 30200315 ELECTROCOAGULATION $ 56.20 32629965 ELECTROCOAGULATION $ 57.00 32517047 ELECTRODE BUTTON OR LOOP $ 726.00 32517831 ELECTRODE DEVICE LOOP $ 22.00 32517492 ELECTRODE FULGURATING $ 500.00 32515298 ELECTRODE MENISCUS $ 101.70 31902778 ELECTRODES EKG $ 13.55 39901574 ELECTROLYTES $ 62.75 80051 40770372 ELECTROLYTE-S SOLN 1000ML BAG$ 332.50 32515447 ELETROSURGICAL HANDPIECE BUTTO$ 57.15 32629866 ELETROSURGICAL HANDPIECE BUTTO$ 58.00 40769242 ELIDEL 1% CREAM 30GM TUBE $ 188.00 40755324 ELIMITE 5% CREAM 60GM TUBE $ 46.05 40776206 Eliquis 2.5mg tablet $ 16.00 40776305 ELIQUIS 5 MG TABLET $ 16.00 40778978 ELITEK 1.5 MG VIAL $ 2,809.00 J2783 39400353 ELM TREE $ 22.00 86003

45 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40768590 ELOXATIN 50MG VIAL $ 3,102.20 J9263 40768590H ELOXATIN 5MG VIAL $ 310.22 J9263 40768590G ELOXATIN 5MG VIAL $ 310.22 J9263 40768590B ELOXATIN 5MG VIAL $ 310.22 J9263 40768590C ELOXATIN 5MG VIAL $ 310.22 J9263 40768590J ELOXATIN 5MG VIAL $ 310.22 J9263 40768590D ELOXATIN 5MG VIAL $ 310.22 J9263 40768590A ELOXATIN 5MG VIAL $ 310.22 J9263 40768590I ELOXATIN 5MG VIAL $ 310.22 J9263 40768590F ELOXATIN 5MG VIAL $ 310.22 J9263 40768590E ELOXATIN 5MG VIAL $ 310.22 J9263 40200677 ELUTION $ 78.75 86860 31517720 EMBOLIZATION THERAPEUTIC PERCU$ 17,425.00 37204 31533217 Embozene 500 mcg $ 330.00 31533118 Embozene 700 mcg $ 330.00 31533712 Embozene 900 mcg $ 330.00 42628904 EMEND 40MG ORAL $ 413.00 J8501JG 42628805 EMEND ORAL 80MG $ 765.00 J8501JG 42626033 EMEND-FOSAPREPITANT 150 MG$ SD 1,200.00 J1453JG 41221301 Emergency Outpatient Hemodialy$ 1,362.00 G0257 32512667 EMERSON PUMP SETUP $ 200.15 40762395 EMLA 2.5%-2.5% 30 GM TUBE $ 17.75 40759649 EMPTY BAG/ANY SIZE $ 36.75 32514093 END CAP ORTHO $ 352.80 32613828 END CAP ORTHO $ 353.00 40763096 ENDAL HG LIQUID $ 3.40 40704108 ENDAL TAB SA $ 3.25 32516460 ENDO 11 TAPER INSERT $ 181.00 32514275 ENDO BUTTON DRILL BIT $ 168.00 32514267 ENDO BUTTON FIXATION $ 383.25 C1713 31203730 ENDO CLIP APPLIER $ 977.80 32516783 ENDO GIA 60-3.5MM ROTIC REINFO$ 549.55 31203755 ENDO LOOPS $ 125.15 32629767 ENDO LOOPS $ 126.00 32516353 ENDO MINI SHEARS $ 154.00 32629668 ENDO MINI SHEARS $ 154.00 31401060 ENDO SINGLE LIGATOR $ 445.00 31401003 ENDO SURG FEE $ 91.00 32509846 ENDO TUBE HOLDER $ 42.45 32613927 ENDO TUBE HOLDER $ 43.00 32515181 ENDO TUBING/CAP SET $ 63.00 32507956 ENDOBRONCHIAL TUBE $ 128.00 31403084 ENDOGATOR KIT $ 66.00 32511891 ENDOKNOT $ 121.50 31535593 ENDOLUMINAL BX URTR RNL PLVS$ 386.00 50606 39407761C ENDOMYSIAL AB $ 78.75 83516 39404777 ENDOMYSIAL AB, 1GA $ 178.00 86255 39408634 ENDOMYSIAL AB, IGA $ 178.00 86255 32511586 ENDOPATH DISP BABCOC $ 476.05 32511222 ENDOPOUCH $ 355.75 32609076 ENDOPOUCH, CONMED $ 422.00 32516833 ENDOSCOPIC CARPAL TUN REL INST$ 337.50 32531964 ENDOSTITCH DEVICE $ 455.35 32531873 ENDOSTITCH SURGIDAC $ 132.00 31902927 ENDOTRACHEAL INTUBATION BY $CRN 312.00 31500 40803702 ENDOTRACHEAL TUBE $ 31.25 31900186 ENDOTRACHIAL TUBE $ 39.40 40804239 ENDTIDAL CO2 MON. $ 543.00 94770 40804221 ENDTIDAL CO2 SET-UP $ 46.50 32502437 ENEMA BUCKET $ 8.80

46 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32502478 ENEMA, OIL RETENTION $ 10.65 32502452 ENEMA, PHOSPHATE $ 7.00 40755159 ENERGIX 20MCG VACCIN $ 130.80 39400445 ENGLISH PLANTAIN $ 22.00 86003 40751893 ENKAID CAP $ 3.40 40743056 ENLON 150MG/15ML VIAL $ 250.00 40768400 ENOXAPARIN SOD 100MG/1ML SYR$ 208.00 J1650 40773632 ENOXAPARIN SOD 120MG/0.8ML $SYR 122.00 J1650 40773533 ENOXAPARIN SOD 150MG/1ML SYR$ 162.00 J1650 40759425 ENOXAPARIN SOD 30MG/0.3ML SYR$ 84.42 J1650 40768426 ENOXAPARIN SOD 40MG/0.4ML SYR$ 112.56 J1650 40768434 ENOXAPARIN SOD 60MG/0.6ML SYR$ 168.84 J1650 40768442 ENOXAPARIN SOD 80MG/0.8ML SYR$ 225.12 J1650 40768418 ENOXAPARIN SODIUM SYR. 100MG$ 208.00 J1650 32515801 ENSNARE SYSTEM $ 529.90 C1773 40754335 ENSURE LIQUID $ 4.55 40754442 ENSURE PLUS HN (SUB) $ 5.70 40771354 ENTEREG 12MG CAP $ 254.00 40107583 ENTEROVIRUS AB PROFILE $ 252.00 39400239 ENTEROVIRUS CULTURE $ 101.00 87250 40107583A ENTEROVIRUS EA AB 1 $ 36.00 86658 40107583B ENTEROVIRUS EA AB 2 $ 36.00 86658 40107583C ENTEROVIRUS EA AB 3 $ 36.00 86658 40107583D ENTEROVIRUS EA AB 4 $ 36.00 86658 40107583E ENTEROVIRUS EA AB 5 $ 36.00 86658 40107583F ENTEROVIRUS EA AB 6 $ 36.00 86658 40107583G ENTEROVIRUS EA AB 7 $ 36.00 86658 40754699 ENTEX CAP $ 4.55 40749913 ENTEX LA TAB $ 4.55 40763575 ENTEX SYRUP 5/100/20 $ 3.50 40401317 ENTIRE SPINE MYELOGRAM $ 1,477.00 62305 40782938 ENTRESTO 100MG (49MG/51MG)$ TAB 33.50 40782839 ENTRESTO 200MG (97MG/103MG)$ TA 33.50 31534405 ENTUIT START GASTRO SET $ 192.00 42616331 ENTYVIO 1 MG $ 67.00 J3380JG 42618806 ENTYVIO 1 MG JW $ 67.00 J3380JGJW 33303209 ENUCLEATION, EXT THRO $ 3,228.00 46320 39701362 EOSINOPHILS URINE $ 38.50 89050 40735912 EPHEDRINE SULF 50MG/1ML 10/BX$ 60.50 32533846 EPI - FILM $ 208.90 41466533 EPICORD 1 SQ CM $ 570.00 Q4187 41465444 EPIDRM A-GRAFT FACE/NCK/HF/G$ 1 3,120.00 15115 41465345 EPIDRM A-GRFT FACE/NCK/HF/G100$ 3,120.00 15110 33454404 EPIDURAL BLOOD OR CLOT PATCH$ 1,503.00 62273 31700115 EPIDURAL INFUSION(LINE INSERT)$ 318.75 31300650 EPIDURAL INJECTION, STERIOD $ 1,294.00 62311 31700545 EPIDURAL INJECTION, STEROID $ 1,294.00 62322 32510448 EPIDURAL KIT $ 127.00 32509424 EPIDURAL TRAY $ 194.50 32629569 EPIDURAL TRAY $ 195.00 40484240 EPIDURAL TRAY $ 220.00 40484438 EPIDURAL TRAY $ 220.00 31900871 EPIDURAL TRAY $ 221.95 31904881 EPIDURAL TRAY $ 222.00 32629470 EPIDURAL TRAY $ 222.00 41466830 EpiFix per 1 sq cm $ 400.00 Q4186 40748436 EPIFRIN 0.5% OPH DRO $ 80.30 40719452 EPIFRIN 2% OPHTH DROP $ 81.50 40760316 EPINEPHRINE $ 20.00 40735920 EPINEPHRINE 1MG/10ML SYR $ 36.30

47 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40700809 EPINEPHRINE 1MG/1ML AMP $ 15.90 J0171 40771156 EPINEPHRINE 1MG/ML INJ $ 14.50 40754848 EPINEPHRINE 30MG/30ML VIAL $ 32.90 42603888 EPIRUBRICIN 50MG VIAL - BU=2MG$ 600.00 J9178 40763401 EPIVIR 150MG TAB $ 10.40 40757742B EPOETIN 1,000 UNITS $ 27.25 j0885 40757742 EPOETIN 2,000 UNITS $ 54.45 J0885 40758831 EPOETIN ALFA 10,000U $ 259.20 40765810Z EPOETIN ALPHA 1,000 UNITS $ 24.30 J0885 40765810W EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810I EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AB EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AL EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AG EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810U EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810T EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810A EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810R EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810S EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AC EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810O EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AE EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810P EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AM EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810K EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810X EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AI EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810C EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810D EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810B EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810N EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810Q EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AJ EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810F EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810G EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810E EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AF EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810Y EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810J EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810H EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810V EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810M EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AD EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AH EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810L EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AK EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AN EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40765810AA EPOETIN ALPHA 1,000 UNITS $ 24.35 J0885 40763021J EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021I EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021A EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021G EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021F EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021C EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021H EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021B EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021D EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40763021E EPOETIN ALPHA 1,000 UNITS $ 25.95 J0885 40764599A EPOETIN ALPHA 1,000 UNITS $ 26.75 J0885 40764599C EPOETIN ALPHA 1,000 UNITS $ 26.75 J0885

48 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40764599B EPOETIN ALPHA 1,000 UNITS $ 26.75 J0885 40764599D EPOETIN ALPHA 1,000 UNITS $ 26.75 J0885 40757734A EPOETIN ALPHA 1,000 UNITS $ 27.25 J0885 40757734B EPOETIN ALPHA 1,000 UNITS $ 27.25 J0885 40763021 EPOETIN ALPHA 10,000 UNITS/ML$ 259.20 J0885 42602631 EPOETIN ALPHA 1000UNITS $ 90.00 J0885JG 40757734 EPOETIN ALPHA 2000UNITS/1ML $VI 54.45 J0885 40765810 EPOETIN ALPHA 40,000U/ML VIAL$ 972.85 J0885 40764599 EPOETIN ALPHA 4000UNIT/ML VIAL$ 106.95 J0885 40769846 EPOPROSTENOL SODIUM 0.5MG VIAL$ 72.50 33100207 ER CLINIC I $ 226.00 G0463 33100215 ER CLINIC II $ 226.00 G0463 39406384 ERA $ 489.50 84233 31203508 ERASER CAUTERY $ 77.85 40771123 ERAXIS 1MG $ 731.00 J0348 42602326 ERBITUX (CETUXIMAB) 10MG $ 215.00 J9055JG 42618707 ERBITUX (CETUXIMAB) 10MG JW$ 215.00 J9055JGJW 31401722 ERCP $ 1,633.00 40403289 ERCP BILIARY AND PANCREAS $ 1,065.00 74330 40403263 ERCP BILIARY ONLY $ 907.25 74328 32510968 ERCP CANNULAS $ 238.95 40403271 ERCP PANCREAS ONLY $ 907.25 74329 31402094 ERCP PURCHASED $ 3,014.00 31401391 ERCP W/BIOPSY $ 71.00 31401938 ERCP W/DILATION OF $ 313.00 31401755 ERCP W/INSERTION STE $ 276.00 31401664 ERCP W/LITHROTRIPSY $ 380.00 31401573 ERCP W/REMOVAL STONE $ 593.00 31401482 ERCP W/SPHINCTEROTOMY $ 479.00 31401847 ERCP W/STENT REMOVAL $ 150.00 40756504 ERYTHROCIN STEARA TA $ 3.25 40719478 ERYTHROMYCIN 0.5% OPHT 1G TUBE$ 10.60 40748410 ERYTHROMYCIN 1GM VIAL $ 49.70 J1364 40735946 ERYTHROMYCIN 500MG VIAL $ 244.00 J1364 40704009 ERYTHROMYCIN BASE TABLET $ 3.25 39400320 ERYTHROPOIETIN $ 136.00 82668 40709081 ESGIC 325/50/40MG TABLET $ 3.40 40758963 ESMOLOL HCL 100MG/10ML VIAL$ 70.35 33303142 ESOPHAG, FIBER, DIAG $ 1,654.00 43200 31401284 ESOPHAGEAL DILATION $ 137.00 32510984 ESOPHAGEAL DILATOR $ 405.30 32515371 ESOPHAGEAL OVERTUBE GUARDUS$ 282.45 32507220 ESOPHAGEAL STENT $ 2,622.75 C1877 31900855 ESOPHAGEAL STETHESCOPE $ 59.50 32515991 ESOPHAGEAL TUBE $ 445.00 31401961 ESOPHAGOSCOPY $ 1,042.00 41351728 ESTAB PT. OFFICE VISIT LEVEL 1$ 42.00 99211 41351810 ESTAB PT. OFFICE VISIT LEVEL 2$ 56.00 99212 41351909 ESTAB PT. OFFICE VISIT LEVEL 3$ 69.00 99213 41351997 ESTAB PT. OFFICE VISIT LEVEL 4$ 87.00 99214 41352085 ESTAB PT. OFFICE VISIT LEVEL 5$ 136.00 99215 40767949 ESTER C 500MG $ 3.75 40921068 E-STIM/US COMB. 15MIN $ 119.00 97032GO 40901068 E-STIM/US COMB. 15MIN $ 119.00 97032GP 40758674 ESTRADERM 0.05 PATCH $ 6.45 39401856 ESTRADIOL $ 23.00 82670 40766180 ESTRADIOL 1MG TABLET $ 3.55 39401864 ESTRADIOL SENSITIVE $ 150.00 82670 39400411 ESTRIOL SERUM $ 72.25 82677 39406012 ESTRIOL TRIPLE SCR $ 33.75 82677

49 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39401955 ESTROGEN SERUM $ 67.00 82670 39400502 ESTROGEN URINE $ 239.00 82672 40803892 ET TUBE HOLDER $ 24.00 39900550 ETHANOL $ 114.25 80307 40760332 ETHANOLAMINE OLEATE $ 62.65 Q2007 40768756 ETHEZYME OINTMENT 30GM $ 160.00 40754426 ETHMOZINE TAB $ 3.25 40755639 ETHRANE SINGLE DOSE $ 54.45 40755647 ETHRANE SINGLE DOSE $ 91.85 40754798 ETHYL CHLORIDE SPRAY 120ML CAN$ 31.75 39406095 ETHYLENE GLYCOL $ 70.25 82693 40763807 ETOPOSIDE 100MG VIAL $ 432.00 J9181 42601831 ETOPOSIDE 10MG $ 48.00 J9181 42621281 ETOPOSIDE 10MG JW $ 48.00 J9181JW 32512295 EUDURON POLYTHYLENE $ 1,111.30 40754491 EVACUATED CONTAINER 1000ML$ BT 40.45 40757619 EVACUATED CONTAINER 500ML BT$ 36.75 33301427 EVACUATION OF HEMATOMA $ 116.00 11740 32515561 EVACUATOR BULB $ 66.75 40916241 EVAL AUDI REHAB EA ADD'L 15MIN$ 54.00 92627GN 40916142 EVAL AUDI REHAB STATUS 1ST 1HR$ 262.60 92626GN 40916043 EVAL CENT AUDI FUNC EA ADD 15M$ 54.00 92621GN 40915944 EVAL CENT AUDIT FUNC INI 60MIN$ 227.00 92620GN 40915647 EVAL FOR SPEECH DEVICE RX 1 HR$ 416.65 92607GN 40915746 EVAL SPEECH DEV EA ADD'L 30MIN$ 126.00 92608GN 40931315 EVAL SPEECH FLUENCY $ 270.00 92521GN 40931216 EVAL SPEECH SOUND LANGUAGE,$ CO 469.00 92523GN 40931117 EVAL SPEECH SOUND PRODUCTION$ 220.73 92522GN 40915450 EVAL SWALLOWING DYSPHAGIA $ 205.00 92610GN 31204142 EVANS-SPEC.T-TUBES $ 171.70 39479021 EVEROLIMUS $ 275.00 80169 40765687 EVISTA 60MG TABLET $ 4.90 41460494 EX MAL LES INCL MARG,T, A, L, $ 755.00 11601 41460791 EXC BEN LES .6-1.0CM $ 840.00 11401 41463365 EXC BEN LES S/N/EX G:0.5CM/<$ 1,834.00 11420 41462672 EXC BLES S/N/EX G:1.1-2.0 CM $ 1,438.00 11422 41463167 EXC F/E/E/N/L MAL +MRG 0.5CM<$ 1,438.25 11640 41463068 EXC F/E/E/N/L MAL +MRG 0.6-1 $ 1,438.25 11641 41463266 EXC F/E/E/N/L MAL +MRG 1.1-2.0$ 1,438.25 11642 41453465 EXC ISION OF NAIL & NAIL MATRI$ 1,051.00 11750 41460692 EXC TR-EXT B9+MARG $ 840.00 11400 41465147 EXC TR-EXT MAL+MARG 0.5

50 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40872897 EXERCISE CHALLENGE TEST $ 229.00 94617 40704231 EX-LAX TAB CHEW $ 3.25 40768541 EXOXAC 30MG CAP $ 5.50 33304702 EXP. PENETRATE WOUND,EXTREMITY$ 1,921.00 20103 40776602 EXPAREL 266mg/20ml Vial $ 1,151.62 33100694 EXPL PENETRATING WND ABDBKFLNK$ 3,122.00 20102 33100488 EXPL PENETRATING WOUND CHEST$ 3,122.00 20101 33100709 EXPL PENETRATING WOUND NECK$ 1,435.00 20100 30254377 EXT SER- INFECTION ISOLATION$ 976.00 ES1 30254476 EXT SER-TRACH & VENT or RESP $C 1,390.00 ES3 30254575 EXT SER-TRACH or VENT or RESP$ 1,091.00 ES2 32529760 EXT SET WITH T $ 20.50 31505555 EXT. PACING ELECTRODES X $ 218.35 31404866 EXT. PACING ELECTRODES X $ 220.00 31302185 EXT. PACING ELECTRODES X $ 220.00 32629371 EXT. PACING ELECTRODES X $ 220.00 31500911 EXT.PACING ELECTRODES $ 229.65 33300684 EXTENSOR TENDON/HAND $ 4,903.00 26412 31010457 EXTERIOR PACING $ 186.00 31510464 EXTERIOR PACING $ 228.15 39401187 EXTRAC NUC ANTI $ 125.50 86235 31203185 EXTRACTOR $ 33.35 31202955 EXTREMITY DRAPE $ 123.35 31201049 EYE CAUTERY $ 70.90 32515462 EYE CORNEAL SHIELD $ 73.50 39500343 EYE CULTURE $ 69.00 87070 31200231 EYE DRAPE $ 86.05 40719494 EYE IRRIGATION 120 ML BOTTLE$ 28.90 31203649 EYE PACK $ 906.95 31200330 EYE SHIELD $ 7.35 32629272 EYE SOLUTION ADDT'L $ 384.00 31203813 EYE SOLUTION ADDT'L $ 428.00 32515876 EYE SPHERE $ 112.65 40804924 EZPAP SET-UP $ 72.00 40804742 EZPAP TX INITIAL $ 229.00 94667 40804833 EZPAP TX SUBSEQUENT $ 229.00 94668 31401995 F.B. REMOVAL $ 544.00 32532210 F.B. RETRIEVER $ 385.35 39476150 f5 gene, variants. FAC V LEIDE $ 152.25 81241 40477402 FACIAL BONE 3 VIEWS OR LESS $ 101.10 70140 40402547 FACIAL BONES $ 158.00 70150 32507865 FACIAL SUPPORT WEAR $ 68.00 39404454 FACT 8 RELATE ANTIGE $ 40.00 85244 39407182 FACTOR 2 GENE ANALYSIS $ 246.00 81240 40107344 FACTOR IX ACTIVITY $ 239.00 85250 39407732 FACTOR V $ 175.50 85220 39407829 FACTOR VII $ 175.50 85230 39407917 FACTOR VIII $ 175.50 85244 39479120 FACTOR XIII $ 326.00 85291 40763336 FACTREL 100MCG $ 170.35 J1620 32513343 FALOPE GUIDE ASSEMBLY $ 135.65 32629074 FALOPE GUIDE ASSEMBLY $ 136.00 32532723 FALOPE-RING BAND KIT $ 261.45 32628975 FALOPE-RING BAND KIT $ 262.00 39400627 FALSE RAGWEED RAST $ 28.75 86003 40772170 FAMOTIDINE 20MG/50ML PREMIX$ 22.50 40767154 FAMVIR 250MG $ 11.30 40767576 FAMVIR 500MG $ 22.60 42626132 FASLODEX 250 MG $ 7,160.00 J9395JG 42621083 FASLODEX 25MG JW $ 716.00 J9395JW

51 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40767980 FASLODEX 50MG/ML 5ML SYRINGE$ 2,996.50 J9395 32514838 FASTFIX NEEDLE DEL SYSTEM $ 588.00 40748899 FAT EMULSIONS 20% IV 500ML BAG$ 249.50 39400684 FAT FECES FREE SUDAN $ 27.00 82710 41116258 FDG UNIT DOSE $ 882.00 A9552 39400775 FDP $ 153.00 85379 32502601 FEEDING BAG FLIP TOP $ 23.10 32507147 FEEDING TUBE MIC $ 450.80 40931513 FEES W CINE OR VIDEO $ 441.00 92612GN 40749863 FELDENE CAP $ 6.10 32532293 FELT VAS TEFLON $ 291.80 31502776 FEM. WOUND CLOSURE $ 714.75 C1760 31549255 FEM. WOUND CLOSURE $ 715.00 C1760 31502867 FEM. WOUND CLOSURE - X $ 714.75 C1760 32509440 FEMALE CATH KIT $ 25.40 32513335 FEMORAL ATERIAL TRAY $ 149.50 32507337 FEMORAL IRRIGATING TIP $ 51.00 31502313 FEM-O-STOP $ 219.90 31540048 FEM-O-STOP $ 220.00 31010374 FEMOSTOP/MANOMETER $ 207.00 31502040 FEM-O-STOP-X $ 219.90 40769739 FENOFIBRATE,MICRON 145MG TAB$ 11.50 40751927 FENTANYL 100MCG/2ML AMP $ 22.70 J3010 40772147 FENTANYL 12 MICROGRAMS PATCH$ 61.00 40751927A FENTANYL 1ML $ 12.45 J3010 40751927B FENTANYL 1ML $ 16.75 J3010 40758492 FENTANYL 20ML/2.0MG $ 63.75 J3010 40751117 FENTANYL 250MCG/5ML AMP $ 24.70 J3010 40758492P FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492E FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492D FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492M FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492K FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492B FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492F FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492C FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492A FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492J FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492L FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492R FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492G FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492O FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492T FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492S FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492N FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492H FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492Q FENTANYL 2ML/2.0MG $ 3.20 J3010 40758492I FENTANYL 2ML/2.0MG $ 3.20 J3010 40751117C FENTANYL 33.3MCG $ 8.25 J3010 40751117A FENTANYL 33.3MCG $ 8.25 J3010 40751117B FENTANYL 33.3MCG $ 8.25 J3010 40760340 FEOCYTE FA $ 3.25 42630389 FERAHEME 1MG $ 6.00 Q0138JG 40726341 FER-IN-SOL DROP 50ML $ 22.00 40757759 FER-IN-SOL SYRUP (NF $ 3.25 39901053 FERRITIN $ 72.50 82728 40753675 FERROUS GLUCONATE 324MG TAB$ 3.25 40726333 FERROUS SULFATE 220 MG/5ML UDC$ 3.25 40704769 FERROUS SULFATE CPSA $ 3.25 40500027 FETAL BPD $ 299.25 76815

52 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39405667 FETAL LUNG SURF $ 70.50 83661 32201089 FETAL MONITOR 1ST HR $ 117.75 30300339 FETAL MONITOR 1ST HR $ 118.00 30300420 FETAL MONITOR EA ADDL HR $ 91.00 32201097 FETAL MONITOR EA ADDL HR $ 91.25 40500407 FETAL POSITION $ 299.25 76815 40200685 FETAL SCREEN $ 61.75 83033 40200263 FFP THAWING $ 463.00 86927 32514580 FIBER STICK $ 118.65 C1762 31902836 FIBEROPTIC ADAPTER $ 32.50 39802806 FIBRINOGEN $ 67.00 85385 39479516C FIBROSURE CHEMISTRY $ 209.00 82397 39479516B FIBROSURE IMMUNOASSAY $ 208.00 83520 39479516 FIBROSURE MASTER $ 625.00 39479516A FIBROSURE NEPHELOMETRY $ 208.00 83883 32517138 FIBULA DRILL BIT $ 218.00 32517112 FIBULA ROD IMPLANT $ 2,243.75 32507923 FIDUCIAL GOLD MARKER $ 434.00 A4648 40501140 FIDUCIAL MARKER PROSTATE $ 2,305.00 55876 41295710 FIDUCIAL MKR BREAST MASTER $ 813.00 41295710C FIDUCIAL MKR CT GUIDE BREAST$ 285.00 77012 41295808C FIDUCIAL MKR CT GUIDE HD & NK$ 285.00 77012 41295896C FIDUCIAL MKR CT GYN $ 285.00 77012 41295896 FIDUCIAL MKR GYN MASTER $ 813.00 41295808 FIDUCIAL MKR HD & NK MASTER$ 813.00 41295710B FIDUCIAL MKR PLACE BREAST DOC$ 164.00 19499 41295896B FIDUCIAL MKR PLACE GYN DOC $ 164.00 58999 41295808B FIDUCIAL MKR PLACE HD & NK DOC$ 164.00 21899 41295621B FIDUCIAL MKR PLACE PROSTAT DOC$ 164.00 55876 41295621 FIDUCIAL MKR PROSTATE MASTER$ 813.00 41295621C FIDUCIAL MKR U/S GUIDE PROSTAT$ 285.00 76942 40764615 FILGRASTIM 480MCG $ 1,020.60 J1442 42602722 FILGRASTIM 1 MCG $ 4.00 J1442JG 40755092 FILGRASTIM 300MCG/ML VIAL $ 646.95 J1442 42630587 FILGRASTIM JW 1 MCG $ 4.00 J1442JGJW 31201304 FILIFORMS-FOLLOWERS $ 45.30 32628876 FILIFORMS-FOLLOWERS $ 46.00 32603003 FILTER 0.2 MICRON $ 33.30 32511743 FILTER PLATELET $ 176.05 32603235 FILTER, SUMP DRAIN $ 23.00 32513236 FILTERWIRE EX EMBOLIC $ 1,920.35 31548562 FILTERWIRE EX EMBOLIC - X $ 1,920.00 32518565 FILTERWIRE EX EMBOLIC - X $ 1,920.35 40000234 FINE NEEDLE ASP, I&R $ 271.25 88173 40000226 FINE NEEDLE ASP,EVAL $ 174.75 88172 40000200 FINE NEEDLE ASP. SUP $ 218.00 10021 41296266A FINE NEEDLE ASPIRATION $ 153.00 10021 41296266B FINE NEEDLE ASPIRATION $ 218.00 10021 40501326 FINE NEEDLE ASPIRATION BIOPSY$ 1,261.00 10005 41006618 FINE NEEDLE ASPIRATION BX INCL$ 1,261.00 10009 41006519 FINE NEEDLE ASPIRATION BX WITH$ 121.00 10010 40506232 FINE NEEDLE ASPIRATION BX WITH$ 121.00 10006 41296266 FINE NEEDLE ASPIRATION MASTER$ 371.00 32501827 FINGER COT $ 11.75 32501835 FINGER PROTECTOR $ 12.30 32515546 FINGER SHIELD $ 17.85 40931011 FINGER SPLINT-DYNAMIC $ 122.00 29131GO 40931010 FINGER SPLINT-STATIC $ 97.03 29130GO 32529968 FINGER TRAPS $ 144.35 40745663 FIORINAL TAB $ 3.40

53 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40760209 FIORINAL W/ COD #3 CAPSULE $ 3.25 40107609 FISH BCR/ABL CML TRANSCRIPT $ 620.95 40405821 FISHER STEREO LEFT LOC 1ST LES$ 1,063.00 19283LT 40405920 FISHER STEREO LEFT LOC ADDED$ L 121.00 19284LT 41250099 FISHER STEREO RIGHT LOC 1ST $LE 1,063.00 19283RT 41250396 FISHER STEREO RIGHT LOC ADDED$ 121.00 19284RT 32515082 FIXATION EXTERNAL LEVEL 1 $ 2,929.50 32628777 FIXATION EXTERNAL LEVEL 1 $ 2,930.00 31202542 FIXATION EXTERNAL LEVEL 2 $ 4,000.35 31202534 FIXATION EXTERNAL LEVEL 3 $ 5,464.60 32515090 FIXATION EXTERNAL LEVEL 4 $ 8,603.00 32628381 FIXATION EXTERNAL LEVEL 4 $ 8,603.00 32515041 FIXATION INTERNAL LEVEL 1 $ 892.50 32628678 FIXATION INTERNAL LEVEL 1 $ 893.00 32515058 FIXATION INTERNAL LEVEL 2 $ 1,260.00 32628579 FIXATION INTERNAL LEVEL 2 $ 1,260.00 32515066 FIXATION INTERNAL LEVEL 3 $ 1,890.00 32515074 FIXATION INTERNAL LEVEL 4 $ 2,625.00 32628480 FIXATION INTERNAL LEVEL 4 $ 2,625.00 40768129 FLAGYL 500MG TABLET $ 3.25 40748865 FLAGYL 500MG/100ML PREMIX 24/C$ 77.80 39406541 FLECAINIDE $ 84.00 80299 40757114 FLEET PHOSPHO-SODA F $ 3.25 32529794 FLEX FINDER GUIDEWIRE $ 289.50 41291141 FLEX LARYNGOSCOPY FIBEROPTIC$ 334.00 31575 33302300 FLEX TENDON REPAIR EA $ 4,903.00 26350 40704850 FLEXERIL 10MG TAB $ 3.25 31203110 FLEXIFLO GASTRO KIT $ 343.65 33300668 FLEXOR REPAIR PRIMARY $ 4,903.00 26356 33300650 FLEXOR TENDON SECOND $ 4,903.00 26352 33300676 FLEXOR TENDON SECOND $ 4,903.00 26357 40769853 FLOLAN DILUENT 50ML $ 76.50 40764524 FLOMAX 0.4 MG CAPSULE $ 4.55 40764045 FLONASE 0.05% NAS SPRY 16GM$ BT 97.20 40770554 FLORA-Q 230MG CAPSULE $ 3.25 40764979 FLORINEF 0.1MG TABLET $ 3.25 J8499 32532665 FLOSEAL $ 361.20 32628282 FLOSEAL $ 581.00 40763278 FLOVENT 44MCG INHALE $ 117.20 40763229 FLOVENT INH. 110MCG $ 118.80 40803900 FLOWMETER $ 24.00 31505852 FLOWSWITCH - X $ 32.30 40759672 FLOXIN 200MG TAB $ 7.55 40758534 FLOXIN 400MG INJ. $ 59.90 40759664 FLOXIN 400MG TAB $ 9.45 40766107 FLOXIN OTIC DROP 0.3% 5ML BT$ 122.05 42601575 FLOXURIDINE (FUDR) 500MG $ 524.00 J9200 40108897 FLU A AMPLIFIED PROBE $ 120.00 87502 39905841AA FLU A SCRN $ 50.50 87804 40108699 FLU A/B AMPLIFIED PROBE $ 240.00 87502 40108798 FLU B AMPLIFIED PROBE $ 120.00 87502 39905841BB FLU B SCRN $ 50.50 87804 39905841 FLU DIFF A & B SCRN $ 101.00 87804 40771438 FLU VACCINE $ 32.00 Q2038 40771503 FLU VACCINE MASTER $ 50.00 50710200 FLU VACCINE MASTER $ 169.00 40777394 FLUARIX FLU VACCINE MASTER $ 223.00 50710398 FLUARIX QUADVALENT FLU VACCIN$ 93.00 90686 40777493 Flucelvax 45mcg/0.5ml Trivalen $ 60.00 90661 40777592 Flucelvax Master $ 78.00

54 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40754871 FLUCONAZOLE 200MG/100ML PRM$ IV 184.85 J1450 42603439 FLUCONAZOLE 200MG/200ML $ 128.00 J1450 42603340 FLUCONAZOLE 400MG/200ML $ 128.00 J1450 40769044 FLUCONAZOLE 400MG/200ML PRMIX$ 508.50 J1450 42601211 FLUDARABINE 50MG $ 1,044.00 J9185JG 42617123 FLUDARABINE 50MG JW $ 1,044.00 J9185JGJW 40761991 FLUDARABINE PHOSPHAT $ 407.20 J9185 31500929 FLUID DELIVERY SET $ 31.45 31904782 FLUID DELIVERY SET $ 32.00 31543909 FLUID DELIVERY SET $ 32.90 31505647 FLUID DELIVERY SET X $ 30.00 31904485 FLUID DELIVERY SET X $ 30.00 40500134 FLUID LOCALIZATION $ 381.00 76942 40920912 FLUIDOTHERAPY $ 150.75 97022GO 40900912 FLUIDOTHERAPY $ 150.75 97022GP 40763740 FLUMADINE 100MG TAB $ 4.55 40763781 FLUMADINE SYR 50MG $ 4.45 40762015 FLUOCINONIDE 0.05% $ 38.80 40767584 FLUOCINONIDE 60GM $ 66.00 40758591 FLUORESCEIN NA 1MG STRIP $ 30.65 40400574 FLUORO AND INJECT ABCESS COLONIC$ 495.00FISTULAGRAM 49465 40482451 FLUORO AND INJECT BILAT FACET$ 1,466.00 64493 40481857 FLUORO AND INJECT VASCULAR ACC$ 395.00 36598 31533613 FLUORO FOR VEIN DEVICE $ 260.00 77001 40482352 FLUORO GUIDANCE FOR NASO OR$ OR 579.00 43752 40402984 FLUORO GUIDANCE/NEEDLE PLACEME$ 344.00 77002 40481659 FLUORO NEPHROSTOMY TUBE $ 2,762.00 40400186 FLUORO UP TO 1 HOUR $ 502.00 76000 40405529 FLUORO VAS ACCESS DEV GUIDE$ 260.00 77001 40477501 FLUORO/INJ PEG TUBE SM BOWEL$ 495.00 49465 42601393 FLUOROURACIL 500MG $ 10.00 J9190 42620786 FLUOROURACIL 500MG JW $ 10.00 J9190JW 42621974 FLUOROURACIL 500MG JW $ 10.00 J9190JW 40736365 FLUOROURACIL 500MG/10ML VIAL$ 14.75 J9190 31500218 FLURO UP TO 1 HOUR $ 497.00 76000 40778681 FLUZONE QUAD VACCINE MASTER$ 149.00 40776899 FLUZONE QUAD 60MCG/0.5ML SYR$ 93.00 90686 40719692 FML OPHTH GTT 0.1% 5 $ 38.80 39407079B FOALTE RBC $ 34.00 82747 31201239 FOG. IRRIG. CATH $ 178.30 32531907 FOGARTY HYDROGRIP CLAMP $ 92.65 32531998 FOGARTY HYDROJAW INSERT $ 88.20 32532087 FOGARTY SOFTJAW INSERT $ 49.65 39407079A FOLATE HCT $ 34.00 85014 39407079 FOLATE,RBC $ 65.00 82747 33451185 FOLEY CATH INSERT,ER CLINIC $ 292.00 51702 32516635 FOLEY SECUREMENT DEVICE $ 9.00 39900295 FOLIC ACID $ 47.75 82746 40704876 FOLIC ACID 1 MG TABLET $ 3.25 42609338 FOLIC ACID 1MG TABLET $ 3.25 40750846 FOLIC ACID 50 MG/10 ML VIAL $ 32.95 40500498 FOLLOW UP STUDY $ 203.48 76970 40768335 FOLTX TABLETS $ 3.25 40767998 FORADIL 12MCG/PER CAP INHALER$ 98.00 40755670 FORANE SINGLE DOSE $ 48.80 32640558 FORCEP BIOPSY CUP $ 506.00 32640657 FORCEP BIOPSY BIGopsy $ 570.00 32515223 FORCEP BIOPSY DISP $ 115.50 32514366 FORCEP BIOSPY PIRANHA $ 601.65 32640756 FORCEP BIOSPY PIRANHA $ 602.00

55 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32514358 FORCEP GRASPING DISP. $ 344.05 31401607 FORCEP, MULTI BITE $ 184.00 31403381 FORCEPS, BIOPSY JUMBO $ 150.00 31403975 FORCEPS, BIOPSY PEDIATRIC $ 180.00 40476214 FOREIGN BODY EYE $ 101.10 70030 33304157 FOREIGN BODY REMOVAL, DEEP $ 4,047.00 20525 42602052 FORTAZ 1 GM $ 49.00 J0713 40770885 FORTAZ 1GM/100NS PREMIX $ 84.00 40770893 FORTAZ 2GM/100ML NS PREMX IVPB$ 123.50 40764474 FOSAMAX 10MG TAB $ 4.25 40771990 FOSPHENTOIN 500MG/10ML VIAL$ 85.50 Q2009 39407596 FRAC BILE ACIDS $ 163.00 83789 39407158 FREE CATECHOLAMINE $ 98.25 82384 39406939 FREE HYSROXY PROLINE $ 100.75 83500 39406194 FREE T3 $ 42.50 84481 39406277 FREE T4 INDEX $ 27.75 84439 39402227 FREE(FT4) THYROXINE $ 67.25 84439 32100638 FRENOTOMY $ 1,120.00 41010 32531626 FRIM. KAR. PAPILLOTOME $ 254.30 32515777 FRONTRUNNER CTD CATHETER $ 1,475.85 C1887 39405865 FRUCTOSAMINE $ 60.50 82985 39402938 FRUCTOSE-SEMEN $ 44.25 82757 39901327 FSH SERUM $ 101.75 83001 31203367 FT. CONTROL SUCT. COAG $ 76.10 39406723 FTA-CSF $ 55.25 86780 32502643 FULLER SHIELD $ 21.95 40759441 FULVICIN P/G TAB $ 4.55 40931009 FUNCTIONAL CAPACITY EVAL EA $15 106.50 97750GO 39407125 FUNGAL SENSITIVITY $ 44.25 87186 40703696 FUNGIZONE IV 50MG VIAL $ 87.55 J0285 39401310 FUNGUS CULTURE $ 65.50 87101 40767709 FURACIN 0.2% 454GM $ 308.00 40719718 FURACIN SOL. DRESSING $ 31.75 40704900 FURADANTIN TAB $ 3.25 40779374 Furosemide 100mg/NS 100ml IV $ 118.50 42628706 FUROSEMIDE 20MG IV $ 46.00 J1940 42612766 FUSILEV 0.5 MG $ 7.00 J0641JG 42621875 FUSILEV 0.5 MG JW $ 7.00 J0641JGJW 39401948 G6PD GLUCOSE 6 PHOS $ 46.25 82955 4061460 GA 67 PER MCI $ 46.50 Q3002 40601460 GA 67 PER MCI $ 46.50 A9556 40770562 GABAPENTIN 400MG CAP $ 5.50 41107595 GADAVIST 10 MMOL/10 ML VIAL $ 470.00 A9585 41107694 GADAVIST 2.0 MMOL/2.0 ML VIAL$ 64.00 A9585 41107496 GADAVIST 7.5 MMOL/7.5 ML VIAL$ 371.00 A9585 40920177 GAIT TRAINING 15 MIN $ 72.00 97116GO 40900177 GAIT TRAINING 15MIN $ 72.00 97116GP 40500159 GALLBLADDER ULTRASOUND $ 299.25 76705 40600157 GALLIUM SCAN $ 2,638.05 78804 39406228 GAMMA HYDROX BUTYRIC ACD,S$ 210.00 82542 32516429 GAMMA NAIL KIT $ 2,897.50 42624350 GAMMAGARD 10 G VIAL $ 5,020.00 J1569JG 42624251 GAMMAGARD 20 G Vial $ 10,040.00 J1569JG 42627023 GAMMAGARD 5 G VIAL $ 2,510.00 J1569JG 42613757 GAMUNEX - C 1GRAM $ 180.00 J1561JG 40770695 GAMUNEX 10 GRAMS VIAL $ 3,048.40 J1561 40770695Q GAMUNEX 500MG $ 152.42 Q4092 40726580 GANTRISIN PEDIATRIC $ 3.40 40705428 GANTRISIN TAB $ 3.25 40719932 GARAMYCIN 0.1% OINT $ 39.50

56 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40719965 GARAMYCIN OPTH DROP 5 ML BOTTL$ 35.75 40756496 GARAMYCIN SULF 80 MG/2 ML VIAL$ 17.65 40600835 GASTRIC EMPTYING $ 725.58 78264 40603695 GASTRIC EMPTYING WITH SMALL$ BO 735.00 78265 33303787 GASTRIC INTUBATION $ 366.00 43753 31401466 GASTRIC LAVAGE $ 544.00 32514713 GASTRIC LAVAGE KIT $ 80.80 39501093 GASTRIC OCCULT BLOOD $ 32.25 82271 39501184 GASTRIC PH $ 17.25 83986 39401401 GASTRIN ANALYSIS $ 69.75 82941 31534306 GASTRO ANCHOR SET $ 226.00 40475116 GASTROGRAFIN GI $ 402.00 74240 40481461 GASTROGRAPHIN SMALL BOWEL $ 402.00 74248 40403792 GASTROGRAPHIN UGI WO KUB $ 253.00 74240 40705436 GAVISCON X-STR TAB C $ 3.25 42615935 GAZYVA 10 MG $ 215.00 J9301JG 42620984 GAZYVA 10 MG JW $ 215.00 J9301JGJW 40107088B GC AMP $ 50.00 87591 40107692 GC AND CHLYMYDIA CYTIC MASTER$ 124.50 40107692B GC CYTYC $ 62.25 87591 32517906 GEL BLADE STOP $ 592.00 40748113 GELATION SPONGE, 12-7MM/EACH$ 14.80 32532509 GELFILM $ 378.75 40759185 GELFILM LARGE 50 SQ CM $ 405.60 40759169 GELFILM OPTH $ 43.20 32533754 GELFOAM - LG. $ 521.10 32628183 GELFOAM - LG. $ 522.00 32532517 GELFOAM - SMALL $ 131.55 32628084 GELFOAM - SMALL $ 132.00 32594514 GELPORT $ 656.25 31511090 GEMINI/PHOTON DIL. CATHETER$ 549.00 31511082 GEMINI/PHOTON DIL. CATHETER-X$ 549.00 42601401 GEMZAR 200MG $ 411.00 J9201 42621677 GEMZAR 200MG JW $ 411.00 J9201JW 40764367 GENASAL(AFRINE) NASAL 30 ML $ 8.10 39502323 GENITAL CULTURE $ 69.00 87070 40775414 Gentamicin 20mg/2ml vial $ 17.00 40770232 GENTAMICIN 40MG 2ML VIAL $ 3.25 40765141 GENTAMICIN 80MG/100ML PREMIX$ 29.55 J1580 40767634 GENTAMICIN OPHT OINT 3.5GM TUB$ 8.04 40718660 GENTAMICIN OPHTH OIN $ 31.20 40762031 GENTAMICIN SULF.0.1% $ 7.80 42602946 GENTAMYCIN 80MG $ 18.00 J1580 39901681 GENTAMYCIN LEVEL $ 89.75 80170 40755787 GENTIAN VIOLET 1% SO $ 4.50 40779572 GEODON 20MG/ML SINGLE DOSE$ VIA 113.00 J3486 40764821 GEREF DIAGNOSTIC $ 49.05 39901210 GEST DIABETES SCREEN $ 57.50 82950 40758476 GEVRABON LIQUID $ 4.90 39406996 GG DNA PROBE $ 62.25 87490 39401492 GGT GAMMA GLUTAMYL P $ 22.00 82977 40400541 GI AND SMALL BOWEL $ 467.00 74246 40600355 GI BLEEDING SCAN $ 725.58 78278 39401583 GIARDIA ANTIGEN $ 219.75 87329 39480011 GIARDIA FOR STOOL $ 38.00 87269 39480110 GIARDIA STOOL $ 38.00 87269 31201015 GIGLI SAW BLADES $ 58.65 32627985 GIGLI SAW BLADES $ 59.00 32515728 GIRDLE ABOVE KNEE $ 165.00 32515355 GIRDLE-SM-MED-LG $ 156.45

57 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32515868 GLASSCOCK EAR DRESSING $ 47.45 40719445 GLAUCON 1% OPHTH DROP $ 52.00 39407761A GLIADEN 1GA $ 78.75 83516 39408005 GLIADEN 1GA $ 78.75 83516 39408093 GLIADEN 1GG $ 78.75 83516 39407761B GLIADEN 1GG $ 78.75 83516 32517260 GLIDE CATH AQUATRACK TEMP STR$ 140.00 32513491 GLIDE CATHETER $ 140.70 C1887 32529893 GLIDE WIRE 630-100 $ 194.55 C1769 31505506 GLIDEWIRE $ 177.30 C1769 31502768 GLIDEWIRE - X $ 177.30 C1769 31542919 GLIDEWIRE - X $ 178.00 C1769 32614818 GLIDEWIRE - X $ 178.00 C1769 31502271 GLIDEWIRE GOLD - X $ 390.90 C1769 40762007 GLIPIZIDE XL 5MG TABLET $ 3.25 32513038 GLOVE RADIATION $ 120.00 32627886 GLOVE RADIATION $ 120.00 32508608 GLOVE SIZE 8 1/2 $ 3.55 31541434 GLOVE SIZE 8 1/2 $ 4.00 32502817 GLOVE STERILE $ 3.55 31542721 GLOVE STERILE $ 4.00 32502833 GLOVE SURG SIZE 6 $ 5.20 32508566 GLOVE SURG SIZE 6 1/2 $ 3.55 31538860 GLOVE SURG SIZE 6 1/2 $ 4.00 32508574 GLOVE SURG SIZE 7 $ 3.55 42010660 GLOVE SURG SIZE 7 $ 4.00 40407405 GLOVE SURG SIZE 7 $ 4.00 40507123 GLOVE SURG SIZE 7 $ 4.00 31543315 GLOVE SURG SIZE 7 $ 4.00 32627787 GLOVE SURG SIZE 7 $ 4.00 32508582 GLOVE SURG SIZE 7 1/2 $ 3.55 31545889 GLOVE SURG SIZE 7 1/2 $ 4.00 32508590 GLOVE SURG SIZE 8 $ 3.55 42011056 GLOVE SURG SIZE 8 $ 4.00 40407306 GLOVE SURG SIZE 8 $ 4.00 41108090 GLOVE SURG SIZE 8 $ 4.00 40507222 GLOVE SURG SIZE 8 $ 4.00 40484339 GLOVE SURG SIZE 8 $ 4.00 31543513 GLOVE SURG SIZE 8 $ 4.00 32627688 GLOVE SURG SIZE 8 $ 4.00 32507980 GLOVE SURGICAL SPECIALTY $ 9.95 31541830 GLOVE SURGICAL SPECIALTY $ 10.00 32513590 GLOW AND TELL TAPE $ 119.30 31543117 GLOW AND TELL TAPE $ 120.00 40107518 GLUCAGON $ 175.00 82943 40754228 GLUCAGON 1MG VIAL $ 669.50 J1610 40760225 GLUCATROL XL 10MG $ 3.25 40603992 GLUCERNA 1.5 $ 12.00 32602938 GLUCERNA 1.5 $ 12.00 40766305 GLUCERNA SHAKE $ 5.70 40754327 GLUCERNA VANILLA LIQ $ 4.50 40763294 GLUCOPHAGE 500MG TABLET $ 3.35 40766032 GLUCOPHAGE 850MG TABLET $ 4.35 40766693 GLUCOPHAGE XR 500MG TAB $ 18.90 41355000 GLUCOSE $ 18.00 82948 39902135 GLUCOSE 2HR TOLERANC $ 79.25 82951 40759383 GLUCOSE 31GM TUBE $ 14.30 39902226 GLUCOSE 3HR TOLERANC $ 122.75 82951 39902317 GLUCOSE 5HR TOLERANC $ 153.75 82951 39901863RP GLUCOSE BLOOD $ 4.25 82947

58 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39901863C8 GLUCOSE BLOOD $ 6.25 82947 3990186314 GLUCOSE BLOOD $ 6.75 82947 39901863 GLUCOSE BLOOD $ 38.50 82947 39701099 GLUCOSE DIPSTICK $ 15.75 81002 41455742 GLUCOSE SCREEN $ 18.00 82948 39902044 GLUCOSE SCREEN $ 18.00 82948 31011198 GLUCOSE SCREEN $ 18.00 82948 30901399 GLUCOSE SCREEN $ 18.00 82948 33100660 GLUCOSE SCREEN COLLECT IN E/R$ 18.00 82948 30500653 GLUCOSE SCREEN COLLECT/PEDS$ 18.00 82948 32201345 GLUCOSE SCREEN COLLECT-OB $ 18.00 82948 39900113 GLUCOSE UR RANDOM $ 17.75 82947 40751307 GLUCOTROL 5 MG TAB $ 3.40 40759003 GLYBURIDE $ 5.70 40755548 GLYBURIDE 2.5 MG TABLET $ 4.55 40750424 GLYBURIDE 5 MG TABLET $ 3.25 40762056 GLYCERIN $ 17.45 40770992 GLYCERIN 2GM SUPP ADULT $ 3.25 40719999 GLYCERIN SUPP ADULT $ 4.55 40756645 GLYCERIN SUPP PED 1.2GM $ 4.55 32601205 GLYCINE 4000 $ 100.60 40107633 GLYCOMARK $ 100.00 84378 40769366 GLYCOPYRROLATE 0.2MG/1ML VIAL$ 60.50 40783037 GLYDO 2% JELLY (LIDOCAINE) SPR$ 21.00 32514689 GOLD PROBE HEMOSTASIS $ 529.90 39402730 GOLDEN ROD $ 19.75 86003 40762197 GONISOL 2.5 %(GONAK) $ 28.40 32509952 GOWN, ISOLATION $ 72.35 32507972 GOWN, ISOLATION $ 81.40 41466731 Grafix per 1 sq cm $ 330.00 Q4133 32533085 GRAFT AAA $ 838.40 C1768 32511123 GRAFT AAA $ 1,316.85 C1768 32533176 GRAFT AAA VELOUR ST. 092222 $ 838.40 C1768 32533267 GRAFT AAA VELOUR ST. 092224 $ 838.40 C1768 31200132 GRAFT ARTERIAL $ 304.35 C1768 32627589 GRAFT ARTERIAL $ 305.00 C1768 32511156 GRAFT DIALYSIS $ 1,071.35 C1768 32532731 GRAFT PELVICOL COLLAGEN $ 831.30 C1768 31201759 GRAFT SOFT TISSUE (Gortex) $ 470.80 C1768 32595009 GRAFT STRETCH STD 4-7x48 $ 1,044.00 C1768 32533382 GRAFT VASC STR 10CM X 6CM $ 392.00 C1768 32511081 GRAFT, BIFEMORAL SB16 $ 1,375.95 C1768 32627490 GRAFT, BIFEMORAL SB16 $ 1,376.00 C1768 31200173 GRAFT, BIFERCATED $ 536.30 C1768 32604819 GRAFT, VASCULAR, PROPATEN $ 2,894.00 C1768 32627391 GRAFT, VASCULAR, PROPATEN $ 2,895.00 C1768 32511149 GRAFT-AXILLO-BIF-EMRNG 8-70-90$ 3,760.20 C1768 32511164 GRAFT-STR-BIF-STDWALL 24-12-40$ 1,420.40 C1768 32511099 GRAFT-STR-BIF-THINWAL 16-08-40$ 1,420.40 C1768 32627292 GRAFT-STR-BIF-THINWAL 16-08-40$ 1,421.00 C1768 32511107 GRAFT-STR-BIT-THINWAL 20-10-40$ 1,420.40 C1768 32627193 GRAFT-STR-BIT-THINWAL 20-10-40$ 1,421.00 C1768 32511115 GRAFT-STR-RING-THINWALL 6-70$ 2,126.90 C1768 32511073 GRAFT-STR-RING-THINWALL 8-50$ 1,788.70 C1768 32511230 GRAFT-STR-RING-THINWALL 8-50$ 3,037.00 C1768 39500897 GRAM STAIN $ 22.00 87205 40720013 GRANULEX SPRAY $ 31.75 40769010 GRANULEX SPRAY 56.7 GM CAN $ 49.50 31403282 GRASPER, RAPTOR $ 495.00 40754731 GREEN COCKTAIL 30ML UDC $ 3.25

59 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40766545 GREEN COCKTAIL SUSPENSION(SELL$ 16.20 40755795 GREEN SOAP TINC 480ML BT $ 15.75 32510737 GREENFIELD CATH FEMORAL $ 2,757.45 C1880 32511206 GREENFIELD CATH JUGULAR $ 2,042.85 C1880 41458613 GRFT PINCH SING/MULTI $ 954.00 15050 41458712 GRFT SKIN SPL THICKNESS GRAFT$ 5,072.00 15120 40752891 GRIFULVIN V 500MG TAB $ 4.05 31201767 GROSHONG CATHETER $ 728.95 C1751 31502669 GROSHONG CATHETER $ 729.00 C1751 31202641 GROUNDING PAD $ 43.30 31544800 GROUNDING PAD $ 44.00 40921365 GROUP THERAPY $ 49.00 97150GO 40901365 GROUP THERAPY $ 49.00 97150GP 39401393 GROWTH HORMONE $ 75.25 83003 32510877 GT ERCP CANNULA/STD $ 236.50 32510885 GT ERCP CANNULA/TAPE $ 192.75 39901483 GTT ADDITIONAL SPEC $ 16.50 82952 40729451 GUAIFENESIN SYRUP @B $ 9.10 40766131 GUIATEX PSE TAB $ 3.55 40500746 GUIDANCE FOR NEEDLE PLACEMENT$ 381.00 76942 32507154 GUIDE CATH $ 203.40 C1887 31201403 GUIDE PIN $ 196.00 31202500 GUIDE PINS TIP THREA $ 299.00 32512543 GUIDE RODS $ 430.00 31500952 GUIDE WIRE .035 150 CM J $ 70.35 C1769 31500960 GUIDE WIRE .035 150 CM J X $ 70.35 C1769 31500937 GUIDE WIRE .035 150 CM ST $ 80.00 C1769 31500945 GUIDE WIRE .035 150 CM ST X $ 70.35 C1769 31501141 GUIDE WIRE .035 260 CM J $ 110.00 C1769 31501158 GUIDE WIRE .035 260 CM J X $ 135.05 C1769 31501166 GUIDE WIRE .035 260 CM ST $ 110.00 C1769 31501174 GUIDE WIRE .035 260 CM ST X $ 110.00 C1769 31501182 GUIDE WIRE .038 145 CM JX $ 65.10 C1769 32511339 GUIDE WIRE TRACER SL $ 338.15 C1769 32512535 GUIDEPINS TAPERPOINT $ 48.20 41240495 GUIDEWIRE $ 70.00 C1769 32517682 GUIDEWIRE $ 70.00 C1769 32517344 GUIDEWIRE $ 132.00 C1713 32627094 GUIDEWIRE $ 132.00 C1713 32500937 GUIDEWIRE .035 MOVEABLE CORE$ 55.75 31505100 GUIDEWIRE .038 150 ST $ 42.70 C1769 31505084 GUIDEWIRE .038 150CM J $ 42.70 C1769 31505142 GUIDEWIRE .038 150CM J X $ 42.70 C1769 31505167 GUIDEWIRE .038 150ST X $ 42.70 C1769 31505126 GUIDEWIRE .038 175CM J $ 53.25 C1769 31505183 GUIDEWIRE .038 175CM J X $ 53.25 C1769 31505092 GUIDEWIRE .038 260CM J $ 62.20 C1769 31505159 GUIDEWIRE .038 260CM J X $ 62.20 C1769 31505118 GUIDEWIRE .038 260CM ST $ 62.20 C1769 31505175 GUIDEWIRE .038 260CM ST X $ 62.20 C1769 32513940 GUIDEWIRE AQUATRACK $ 144.00 32626995 GUIDEWIRE AQUATRACK $ 144.00 32512881 GUIDEWIRE CORONARY $ 431.30 C1769 31538959 GUIDEWIRE CORONARY $ 432.00 C1769 32511610 GUIDEWIRE ENTRY NEED $ 318.30 C1769 31505688 GUIDEWIRE J $ 152.65 C1769 31540246 GUIDEWIRE J $ 153.00 C1769 31502057 GUIDEWIRE J - X $ 152.65 C1769 31546978 GUIDEWIRE J - X $ 153.00 C1769 32510604 GUIDEWIRE J TIP $ 58.65 C1769

60 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32533911 GUIDEWIRE JAG $ 282.10 C1769 32515116 GUIDEWIRE ORTHO $ 42.00 32513913 GUIDEWIRE ORTHO $ 314.00 C1769 32516064 GUIDEWIRE SMOOTH $ 323.00 C1769 31201577 GUIDEWIRE STRAIGHT $ 116.10 C1769 31541236 GUIDEWIRE STRAIGHT $ 120.00 C1769 32595108 GUIDEWIRE, STEERABLE $ 135.00 C1769 32532384 GUIDWIRE SUPERSTIFF $ 319.20 C1769 40850030 GXT - PLAIN $ 510.00 93017 40850246 GXT DOBUTAMINE/STRESS ECHO$ 510.00 93017 40602804 GXT MYOCARDIAL PERF $ 1,517.60 78452 40850212 GXT-CARD/DOBUTAMINE $ 510.00 93017 40850204 GXT-CARDIOLYTE $ 510.00 93017 40850220 GXT-PERSANTINE $ 510.00 93017 40850238 GXT-STRESS ECHO $ 510.00 93017 40757718 GYNE-LOTRIMIN 1% CRM $ 31.10 40731853 GYNE-LOTRIMIN VAG $ 24.40 40106999 H PYLORI 1GM $ 56.00 86677 39402755 H PYLORI ANTIBODY $ 107.00 86677 39402953 H. INFLUENZA GRP. B $ 50.25 87899 40107021 H. PYLORI ANTIGEN STOOL $ 169.00 87338 42617222 HALAVEN (ERIBULIN) 0. $ 397.00 J9179JGJW 42614549 HALAVEN (ERIBULIN) 0.1MG $ 397.00 J9179JG 40751042 HALCION 0.125 MG TABLET $ 3.25 40752578 HALCION TAB $ 3.25 40705980 HALDOL 1 MG TABLET $ 3.25 40706137 HALDOL 5 MG TABLET $ 3.40 40737272 HALDOL 5MG/1ML AMP $ 25.50 40771834 HALDOL 5MG/ML 10ML VIAL $ 90.00 40705972 HALDOL TAB $ 3.25 40705998 HALDOL TAB $ 3.25 40726820 HALOPERIDOL LACTATE $ 36.30 40755662 HALOTHANE LIQUID $ 98.80 40755654 HALOTHANE LIQUID $ 191.20 32510182 HAND CONTROL MITT $ 21.40 32532194 HANDLE NEO PROBE $ 427.20 40200040 HANDLING FEE FFP $ 40.00 P9017 32533010 HANDPORT COLECTOMY $ 1,163.15 39402037 HAPTOGLOBIN $ 40.25 83010 32531782 HARMONIC SCAPEL TIPS $ 930.30 39402482 HAV IGM $ 42.75 86709 39402573 HB CONE ABIQG IQM $ 52.25 86705 39401344 HBCAB IGM $ 42.75 86704 40762163 H-BIG 5ML $ 126.40 C9105 41451089 HBO 106 MINUTE SESSION FOR BC$ 1,259.90 99183 41463761 HBO 30 MINUTE SESSION FOR MEDI$ 315.00 G0277 41457029 HBO 30 MINUTE SESSION FOR MEDI$ 315.00 C1300 39403555 HBSAB $ 42.75 86706 40107708 HBV DNA PCR $ 298.00 87516 40000374 HC DET OF ENZYMES $ 31.25 88319 40000382 HC DET OF ENZYMES $ 109.25 88319 39405832 HCG TRIPLE SCREEN $ 33.75 84702 40748097 HCTZ 25 MG TABLET $ 3.25 39902580LP HDL $ 32.25 83718 39902580 HDL $ 62.50 83718 40101784 HDN #2 $ 72.75 32516486 HEAD - MODULAR $ 721.00 31902794 HEAD CRADLE $ 19.50 32529299 HEAD HALTER UPPER 7 $ 42.45 32529281 HEAD HALTER-DISP. $ 23.10

61 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40756991 HEALON OPHTH $ 192.80 31900806 HEAT HUMITY CIRC $ 305.55 40805111 HEAT WIRE VENT CIRCUIT $ 52.50 40107351 HEAVY METAL SCREEN $ 213.00 39402128 HEAVY METALS, URINE $ 202.75 83015 32502940 HEEL PROTECTORS $ 25.70 32514341 HEEL SUSPENSION BOOT $ 94.50 32513905 HELICAL BLADE $ 1,177.00 C1713 40763591 HEMABATE 250MCG/ML AMPULE $ 966.00 32533317 HEMASHIELD FINESSE $ 100.00 39800826 HEMATOCRIT $ 16.75 85014 40106924 HEMOCHROMOTOSIS PROFILE $ 310.00 32510521 HEMOCLIP $ 48.35 32626896 HEMOCLIP $ 49.00 32514671 HEMOCLIP ENDO $ 105.65 31401243 HEMOCULT $ 46.00 82270 32532525 HEMOCULT KIT $ 39.00 40768152 HEMOCYLE PLUS CAP $ 3.25 41220104 HEMODIALYSIS $ 580.00 39800917 HEMOGLOBIN $ 25.50 85018 39402219 HEMOGLOBIN ELECTRO $ 87.00 83020 42604876 HEMOPHILUS FLU B VACCINE $ 513.00 90648 42604964 HEMOPHILUS VACCINE ADMIN $ 170.00 90471 31403579 HEMORRHOID, EXT THROMBOSED$ 474.00 46083 31403480 HEMORRHOID, INTERNAL DESTRUCTI$ 1,465.00 46930 31401052 HEMORRHOIDECTOMY SNGL LIGATION$ 600.00 31203276 HEMOVAC 100ML $ 270.95 31200272 HEMOVAC 400 $ 178.30 31201692 HEMOVAC 800 $ 229.95 39403647 HEP B ANTIG (HBEAG) $ 42.50 87350 40769390 HEP B IMM GLOB 220U/0.5ML SYR$ 256.00 90744 39402300 HEP B SCREEN $ 127.00 82108 42612172 HEP B VAC ENERGIX-B(2-10MCG $VI 69.45 90746 42612271 HEP B VACCINE ADMIN $ 94.23 G0010 39403738 HEP BE ANTIB (HBEAB) $ 42.50 86707 40106916 HEP BE ANTIBODY $ 134.00 86707 40107005 HEP BE ANTIGEN $ 40.00 87350 39480209 HEP C QUANT VIRAL LOAD $ 170.00 87522 39401666 HEP C RIBA $ 111.25 87521 39403456 HEP DELTA $ 134.25 86692 40751166 HEP LOCK FLUSH 100UNIT/ML VIAL$ 11.75 33100652 HEP LOCK INS $ 38.00 31903198 HEP LOCK INSERTION $ 36.75 31700255 HEP LOCK INSERTION $ 36.75 40107120A HEP PCR AMP PROBE 1 $ 123.00 87529 40107120B HEP PCR AMP PROBE 2 $ 123.00 87529 39404355 HEP. B VIRAL DNA $ 332.50 87516 40737298 HEPARIN 1,000 UNIT/1ML VIAL $ 5.68 J1644 40756850 HEPARIN 10,000 UNIT/1ML VIAL $ 17.05 J1644 40771909 HEPARIN 100 UNITS/1ML 5 ML SYR$ 3.25 42601849 HEPARIN 1000 UNITS $ 5.00 J1644 40756868 HEPARIN 5000U/1ML VIAL 25/BX$ 8.75 J1644 39407453 HEPARIN ANTI XA $ 222.75 85520 39476843 HEPARIN INDUCED PLT AB $ 278.00 86022 42601179 HEPARIN LOCK FLUSH $ 8.00 J1642 40757122 HEPARIN LOCK FLUSH $ 15.30 40757130 HEPARIN LOCK VIAL $ 12.95 40770976 HEPARIN LOCKFLUSH 10ML VIAL$ 6.00 40752669 HEPARIN/D5W 25000U/250ML PRMIX$ 55.10 31511793 HEPATIC VENOGRAPHY - S&I $ 5,782.00 75889

62 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39400072 HEPATITIS A ANTIBODY $ 133.50 86709 39400072HE HEPATITIS A ANTIBODY IGM $ 42.50 86709 39405147 HEPATITIS A IGG $ 55.00 86708 40771255 HEPATITIS B 20MCG/1ML VIAL $ 210.50 40771248 HEPATITIS B 5MCG 0.5ML VIAL $ 93.75 39400163 HEPATITIS B CORE ANT $ 73.00 86704 39400163HE HEPATITIS B CORE ANTIBODY $ 42.50 86704 39400254 HEPATITIS B SURF AG $ 65.50 87340 39400254HE HEPATITIS B SURFACE AN $ 42.50 87340 40758195 HEPATITIS B VAC 10MCG/0.5ML VI$ 53.20 90744 39402391 HEPATITIS C AB $ 62.75 86803 39406657 HEPATITIS C ANTIBODI $ 62.75 86317 39406657HE HEPATITIS C ANTIBODY $ 42.50 86317 39403449 HEPATITIS C BY RNA $ 508.25 87520 40108104 HEPATITIS C SCREEN $ 63.00 G0472 39406483 HEPATITIS PROFILE $ 169.25 80074 39476348 HEPC VIR GENOTYPE $ 472.00 87902 40767535 HEPLOCK 10U/ML $ 4.50 33451273 HEPLOCK INSERTION, ER CLINIC$ 38.00 39409777 HER HEMOCHROMATOSIS $ 149.88 42601948 HERCEPTIN 10MG $ 354.00 J9355JG 42621776 HERCEPTIN 10MG JW $ 354.00 J9355JGJW 40765992AR HERCEPTIN 10MG KIT $ 182.90 J9355 40765992AJ HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AE HERCEPTIN 10MG KIT $ 183.15 J9355 40765992Z HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AP HERCEPTIN 10MG KIT $ 183.15 J9355 40765992A HERCEPTIN 10MG KIT $ 183.15 J9355 40765992V HERCEPTIN 10MG KIT $ 183.15 J9355 40765992J HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AN HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AQ HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AM HERCEPTIN 10MG KIT $ 183.15 J9355 40765992O HERCEPTIN 10MG KIT $ 183.15 J9355 40765992L HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AA HERCEPTIN 10MG KIT $ 183.15 J9355 40765992H HERCEPTIN 10MG KIT $ 183.15 J9355 40765992N HERCEPTIN 10MG KIT $ 183.15 J9355 40765992X HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AK HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AI HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AC HERCEPTIN 10MG KIT $ 183.15 J9355 40765992M HERCEPTIN 10MG KIT $ 183.15 J9355 40765992K HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AD HERCEPTIN 10MG KIT $ 183.15 J9355 40765992E HERCEPTIN 10MG KIT $ 183.15 J9355 40765992T HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AL HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AO HERCEPTIN 10MG KIT $ 183.15 J9355 40765992F HERCEPTIN 10MG KIT $ 183.15 J9355 40765992G HERCEPTIN 10MG KIT $ 183.15 J9355 40765992U HERCEPTIN 10MG KIT $ 183.15 J9355 40765992Q HERCEPTIN 10MG KIT $ 183.15 J9355 40765992I HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AF HERCEPTIN 10MG KIT $ 183.15 J9355 40765992R HERCEPTIN 10MG KIT $ 183.15 J9355 40765992D HERCEPTIN 10MG KIT $ 183.15 J9355 40765992S HERCEPTIN 10MG KIT $ 183.15 J9355 40765992P HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AH HERCEPTIN 10MG KIT $ 183.15 J9355

63 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40765992B HERCEPTIN 10MG KIT $ 183.15 J9355 40765992C HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AG HERCEPTIN 10MG KIT $ 183.15 J9355 40765992AB HERCEPTIN 10MG KIT $ 183.15 J9355 40765992W HERCEPTIN 10MG KIT $ 183.15 J9355 40765992Y HERCEPTIN 10MG KIT $ 183.15 J9355 40765992 HERCEPTIN 440MG KIT $ 8,056.80 J9355 32511982 HERNIA KIT $ 1,555.80 39404199 HERP I WB $ 125.00 84182 39404280 HERP II WB $ 125.00 84182 40107591 HERPES AB 1GG $ 65.25 86694 40107500 HERPES AB 1GM $ 65.25 86694 40107120 HERPES BY PCR $ 246.00 39403639 HERPES CULTURE $ 130.00 87252 39400437 HERPES SIMPLEX TITER $ 72.75 86694 39400528 HERPES VIRUS CULTURE $ 40.00 87255 40107161 HERPES VIRUS I 1GG $ 44.00 86695 40107245 HERPES VIRUS II 1GG $ 64.00 86696 39400619 HERPES ZOSTER TITER $ 120.75 86787 40759276 HESPAN IV BAG 500ML 6-0.9% $ 152.45 39400700 HETEROPHILE $ 49.00 86308 39905489 HETEROPHILE AB $ 64.00 86308 31204159 HEWSON BREAKAWAY PIN $ 497.40 32532608 HF ELECTRODE LOOP $ 315.00 40200362 HF-CRYO $ 34.25 39478427 HFE , DNA.GENE VARIANTS $ 600.00 81256 39400791 HGB A1C,HEMOGLOBIN $ 45.00 83036 39906227 HHM GLU/CHOL/HDL SCREEN $ 10.00 40805335 HIGH FLOW CANNULA $ 10.00 40805400 HIGH FLOW HUMIDIFIER $ 20.00 31505456 HIGH PRESSURE INJ LINE 30 X" $ 37.45 31505050 HIGH PRESSURE INJ. LINE 30 in $ 39.70 30201015 HINI VACCINE ADMIN $ 170.00 90471 40771560 HINI VACCINE AND ADMIN $ 170.00 90471 32509853 HIP ABDUCTION PILLOW $ 133.20 32626797 HIP ABDUCTION PILLOW $ 134.00 32517518 HIP OR KNEE REVISION LEVEL 1 $ 2,201.00 C1776 32517526 HIP OR KNEE REVISION LEVEL 2 $ 10,070.00 C1776 32517534 HIP OR KNEE REVISION LEVEL 3 $ 20,893.00 C1776 32614917 HIP OR KNEE REVISION LEVEL 3 $ 20,893.00 C1776 32517542 HIP OR KNEE REVISION LEVEL 4 $ 34,654.00 C1776 32513764 HIP REPLACEMENT LEVEL 1 $ 4,725.00 C1776 32513772 HIP REPLACEMENT LEVEL 2 $ 6,930.00 C1776 32513780 HIP REPLACEMENT LEVEL 3 $ 8,400.00 C1776 32614620 HIP REPLACEMENT LEVEL 3 $ 8,400.00 C1776 32513798 HIP REPLACEMENT LEVEL 4 $ 9,975.00 C1776 32513806 HIP REPLACEMENT LEVEL 5 $ 12,075.00 C1776 32513814 HIP REPLACEMENT LEVEL 6 $ 15,750.00 C1776 31202401 HIP, PLATE $ 665.30 32626698 HIP, PLATE $ 666.00 40754780 HISMANAL TAB $ 6.80 40737363 HISTAMINE PHOSPHATE $ 22.70 40709909 HISTASPAN-PLUS CAP S $ 3.25 40766388 HISTEX PD LIQUID $ 4.35 39478823 HISTONE AB $ 124.00 86235 39401484 HISTOPLASMA AB $ 54.75 86698 40737330 HISTOPLASMIN TEST $ 91.80 39405303 HIV 1 & 2 $ 62.75 86703 39400882 HIV ANTIBODY-HTLVIII $ 87.00 86701 39400973 HIV ANTIGEN $ 178.25 87390

64 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39476447 HIV SCREEN FOR MEDICARE $ 87.00 G0432 40106858 HIV1 & 2 $ 90.00 86703 40763963 HIVID .375MG TABLET $ 4.35 39401062 HLA_B27 $ 127.75 86812 40107351A HM ARSEPIC $ 86.00 82175 40107351B HM LEAD $ 52.00 83655 40107351C HM MERCURY $ 75.00 83825 40479679 HOCM CYSTOGRAFIN 85MG/ML IODIN$ 2.00 Q9958 40479778 HOCM GASTROGRAFIN 367MG/ML$ IOD 2.00 Q9963 41355811 HOME HEALTH RECERTIFICATION$ 100.00 G0179 41355908 HOME HEALTH START OF CARE $ 132.00 G0180 39406566 HOMOCYSTEINE $ 130.25 83090 32602443 HOOK, L, LAPARSCOPIC $ 42.76 32603696 HOOK, SINSKEY $ 46.00 32517872 HOOKS TLC STAY $ 37.63 41355996 HOSPICE PLAN OF CARE $ 250.00 G0182 41292178 HOSPITAL DISCHARGE < 30 MIN.$ 101.00 99238 41353087 HOSPITAL DISCHARGE <30 MINUTES$ 101.00 99238 41292180 HOSPITAL DISCHARGE > 30 MIN.$ 135.00 99239 41353175 HOSPITAL DISCHARGE >30 MINUTES$ 135.00 99239 32507295 HOT LOOP CUTTER $ 113.00 40920029 HOT PACK I $ 66.25 97010GO 40900029 HOT PACKS $ 66.25 97010GP 39402466 HOUSE DUST $ 18.50 86003 40201402A HPV TEST (HUMAN PAP VIRUS) $ 127.00 87624 40201402B HPV TEST (HUMAN PAP VIRUS) $ 127.00 87624 40201402 HPV TEST (HUMAN PAP VIRUS) $ 254.00 87624 39407109 HS CRP $ 49.00 86141 39402417 HSV AB GROUP $ 98.00 86694 39404710 HTLV2 $ 291.00 86688 32509184 HUBER BENT 22/1 $ 11.75 40766354 HUMALOG $ 162.00 40764631 HUMALOG VIAL $ 60.65 40766784O HUMAN IMGLOB WIN RHO D $ 5.62 J2792 40766784E HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784J HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784G HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784I HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784B HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784A HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784K HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784M HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784H HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784F HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784L HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784N HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784C HUMAN IMGLOB WIN RHO D $ 5.67 J2792 40766784 HUMAN IMGLOB WIN RHO D $ 85.00 J2792 40763815 HUMIBID DM 600/30 MG TABLET$ 3.25 40753626 HUMIBID LA 600 MG TABLET $ 3.40 40800476 HUMIDIFIER 340 $ 8.75 42608446 HUMIRA(ADALIMUMAB) 40MG $ 2,533.50 J0135JG 40763872 HUMULIN 50/50 INSULIN $ 21.90 40753238 HUMULIN 70/30 VIAL $ 45.40 40765166 HUMUN REG INSULIN (1 DOSE) $ 12.15 J1815 40768103 HYCAMTIN 4MG VIAL $ 2,601.00 J9350 40764060 HYCODAN SYRUP 5CC $ 3.55 40750911 HYDERGINE LC CAP $ 3.25 40706046 HYDERGINE TAB $ 3.25 40706053 HYDRALAZINE 10 MG TABLET $ 3.25

65 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40754384 HYDREA CAP $ 4.55 40765893 HYDROCAINE SUPP $ 37.80 40753741 HYDROCHLOROTHIAZIDE $ 3.25 40773830 HYDROCHLOROTHIZE 12.5MG CAPSUL$ 3.25 40765067 HYDROCORTISOME 1% CR 30GM$ TUBE 6.70 40754038 HYDROCORTISONE 0.5% 30GM TUBE$ 27.95 40762189 HYDROCORTISONE 2.5% 20GM TUBE$ 10.15 40770463 HYDROMORPHONE 0.2MG/ML 50MLBAG$ 114.00 40745440 HYDROMORPHONE SYRING $ 17.05 40745465 HYDROMORPHONE SYRING $ 17.05 39401153 HYDROXPROLINE $ 461.25 83505 39401336 HYDROXYCORTICOST $ 87.50 83491 39401245 HYDROXY-INDOL AC A-5 $ 119.75 83497 40767303 HYDROXYUREA 500MG CAPSULE $ 4.00 40771230 HYDROXYZINE 10MG TAB $ 3.25 40767659 HYDROXYZINE 10MG/5ML $ 4.01 40771453 HYGROTON 25MG TABLET $ 3.25 40748832 HYGROTON TAB $ 3.25 40771396 HYPERRAB 300 IU/1ML Rabies Imm$ 2,769.50 90375 40783136 HyperRab 300 IU/ml 5ml Rabies $ 12,641.00 90375 40737371 HYPERSTAT I.V. AMP $ 256.00 J1730 40737348 HYPER-TET 250 UNIT SYRINGE $ 56.20 J1670 40762171 HYTONE 2.5% $ 73.50 40755621 HYTRIN 1MG CAPSULE $ 3.40 40759714 HYTRIN 5 MG CAP $ 4.55 40758112 HYTRIN TAB $ 4.55 40758104 HYTRIN TAB $ 4.55 40107435B I - MEASLES $ 40.00 86765 40107435A I - MUMPS $ 40.00 86735 40107435C I - RUBELLA $ 40.00 86762 33304843 I & D, EYELID $ 662.00 67700 40601106 I 123 PER UCI $ 77.00 A9516 40601833 I 131 LESS THAN 100 MICROCURIE$ 37.50 A9531 31505449 I I COVER X $ 12.05 41452376 I&D ABSCESS COMPLEX MULTIPLE$ 559.00 10061 41452277 I&D ABSCESS SIMPLE SINGLE $ 359.00 10060 33300023 I&D ABSCESS, COMPLICA $ 559.00 10061 33451361 I&D ASSIST, ER CLINIC $ 312.00 33303332 I&D BARTHOLIN GLAND $ 291.00 56420 33454899 I&D BURSA UPPER ARM/ELBOW $ 2,714.00 23931 41459702 I&D CPLX POSTOP WND INF $ 3,522.08 10180 33300031 I&D CYST, COMPLICATED $ 1,921.00 10081 33303290 I&D EPIDIDYMIS $ 3,805.00 54700 33304108 I&D EXTERNAL EAR $ 359.00 69000 41462969 I&D HEMATOMA/FLUID $ 2,713.00 10140 31533811 I&D HEMATOMA/FLUID $ 2,713.00 10140 33303316 I&D PERONEAL ABSCESS $ 502.00 56405 32602179 I.V. CATHETER $ 17.65 31501208 IAB INTRODUCER $ 208.70 C1766 31505043 IABP 6 EXTENTION TUBING" $ 40.45 31500226 IABP INSERTION $ 1,003.00 41000431 IACS ORBIT POSTERIOR FOSSA WOU$ 772.00 70480 41000449 IACS WITH CONTRAST $ 840.00 70481 41000498 IACS WWO CONTRAST $ 993.00 70482 42615044 IBANDRONATE SODIUM INJ 1 MG$ (B 960.00 J1740JG 40765042 IBERET FOLIC 500 $ 3.25 J8499 40107112B IBP - FUNG 1GA $ 138.00 86671 40107112A IBP - FUNG 1GG $ 185.00 86671 40107112C IBP - NONINF 1D $ 138.00 86256 31511835 IC INFUSION THROMBOLYSIS $ 897.00 92975

66 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40766891 ICARC CAPSULE $ 3.25 40000457 ICC IMMUNOPEROXIDOSE $ 363.75 88344 31522076 ICD GEN INSER W EX MULTI LDS$ 66,971.00 33231 31521977 ICD GEN INSER W EX SING LD $ 65,663.00 33240 31522274 ICD GEN REM & REP DUAL LD $ 65,663.00 33263 31522373 ICD GEN REM & REP MULTI LD $ 66,971.00 33264 31522175 ICD GEN REM & REPLACE SING LD$ 65,663.00 33262 31511397 ICD GENERATOR REMOVAL S/D $ 5,615.00 33241 32508376 ICE BAG LARGE $ 29.20 32529133 ICE BAG SMALL $ 29.20 40720500 ICHTH 3% IN ZNO $ 6.50 40756330 ICHTHAMMOL 10% 1 OZ. $ 5.70 30900013 ICU ROOM $ 1,100.00 39500822 ID - URINE $ 44.25 87088 39500913 ID ANAEROBE $ 44.25 87076 40000465 IF EACH ABODY DIRECR $ 199.50 88346 40000473 IF INDIRECT 1ST STAIN $ 199.50 88346 42611578 IFEX 1GM VIAL OR 1000 MG $ 232.00 J9208 39479615B IGA IN QIMG $ 21.00 82784 40107690 IGD $ 85.00 82784 39401609 IGE $ 72.75 82785 39505929 IGE RAP 6 $ 13.00 82785 39409579 IGF1 $ 30.00 84305 39479615A IGG IN QIMG $ 21.00 82784 39401732 IGG1 $ 78.75 82787 39403829 IGG2 $ 82.75 82787 39401914 IGG3 $ 78.75 82787 39404033 IGG4 $ 78.75 82787 39479615C IGM IN QIMG $ 21.00 82784 39479714B IGM MAG AB $ 94.00 83516 31501216 II COVER $ 12.85 31401441 ILEOSCOPY THROUGH A STOMA $ 1,278.00 44380 31519205 ILIAC EA ADD'L W ANGIO & STENT$ 11,340.00 37223 31519106 ILIAC, EA ADDL W ANGIOPLASTY$ 11,340.00 37222 31511215 ILLIAC ANGIOGRAPH7Y W/LHC $ 42.00 G0278 40703563 ILOSONE SUSPENSION $ 22.70 39401211 IM A $ 30.25 82784 39401120 IM G $ 30.25 82784 39401302 IM M $ 30.25 82784 40774028 IMDUR 30 MG TABLET $ 6.00 40763435 IMDUR 60MG TABLET $ 3.55 42629201 IMFINZI 10MG $ 273.00 J9173TB 42629300 IMFINZI 10MG JW $ 273.00 J9173TBJW 40751208 IMIPENEM 500MG $ 61.60 J0743 39405824 IMIPRAMINE LEVEL $ 181.00 80307 40772154 IMITREX 25 MG TABLET $ 9.00 40766909 IMITREX 25MG $ 62.50 40758567 IMITREX 6MG/0.5ML VIAL $ 94.00 40762855 IMITREX KIT REFILL $ 175.00 J3030 32510711 IMMOBILIZER ARM LG $ 53.30 L3650 32510695 IMMOBILIZER ARM SM $ 50.00 L3650 32510729 IMMOBILIZER ARM XLG $ 64.70 L3650 32510703 IMMOBILIZER ARM, MED $ 53.10 L3650 40778384 IMMUNE GLOBULI 10GM/100ML VIAL$ 6,000.00 J1569 40760308 IMMUNE GLOBULIN 5GM $ 1,524.20 J1569 40107435 IMMUNITY PROFILE $ 120.00 39407174 IMMUNOCYTOCHEM ANTIBODY $ 116.00 88342 39401963 IMMUNOELECTRO SERUM $ 101.75 86320 39402052 IMMUNOELECTRO-URINE $ 141.25 86335 39402078B IMMUNOFIXATION ELECTRO $ 45.00 86334

67 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39408273 IMMUNOGLOBULIN D $ 40.00 82784 39402409 IMMUNOGLOBULIN D $ 80.00 82784 39402144 IMMUNOGLOBULINS $ 101.75 82784 40202048 IMMUNOHISTO CHEM per sp each$ 115.50 88341 40201619 IMMUNOHISTO CHEMISTRY PER SPECIMEN,1ST$ 209.00 STAIN 88342 40754418 IMODIUM A-D 1MG/5ML UDC $ 3.40 40766248 IMPACT ORAL NUTRITION $ 38.70 32516346 IMPACT SEALER $ 922.00 32501843 IMPACTION $ 42.45 32509093 IMPERVIOUS STOCKINET $ 44.10 32531709 IMPLANT JOINT $ 1,491.25 C1776 32518086 IMPLANT, SMART TOE $ 1,244.00 C1776 40505539 IMPLANTABLE TISSUE MARKER $ 434.00 A4648 31200652 IMPRA GRAFT 50CM $ 2,416.90 C1768 41296552 IMRT DELIVERY COMPLES $ 1,126.35 77386 41210368 IMRT DELIVERY SIMPLE $ 1,126.35 77385 41293281 IMRT PLANNING $ 1,274.00 77301 41210370A IMRT PLANNING & PREP - PROF $ 499.00 77301 41210370 IMRT PLANNING & PREP MASTER$ 2,803.00 41210370B IMRT PLANNING & PREP -TECH $ 2,304.00 77301 40752131 IMURAN 50MG TAB $ 5.70 40751968 INAPSINE 5MG/2ML AMP $ 21.55 J1790 33301260 INC RMV SUBCUTAN,COM $ 2,976.00 10121 33301278 INC/DRAIN HEMAT,SIMP $ 2,713.00 10140 33301245 INC/DRAIN PILONDIAL $ 1,183.00 10080 33301252 INC/RMV,SUBCUT SIMPL $ 628.00 10120 40800542 INCENTIVE SPIROMETER S/U $ 46.25 33301237 INCIS/DRAIN,ABSC,SIM $ 359.00 10060 33452919 INCISEL/REL SCAR CONTX F/S/E/M$ 954.00 15004 33105006 INCISEL/REL SCAR CONTX T/A/L$ 3,120.00 15002 32527418 INCISION & DRAINAGE $ 34.50 33303191 INCISION THROMBOSED $ 475.00 46083 41466137 Incisional bioposy of skin sin $ 683.00 11106 41466038 Incisional biopsy of skin each $ 78.00 11107 39500459 INDENTIFY (CULTURE) $ 44.25 87077 40706673 INDERAL 10 MG TABLET $ 3.25 40706681 INDERAL 20 MG TABLET $ 3.25 40706699 INDERAL 40 MG TABLET $ 3.40 40737827 INDERAL AMP $ 23.05 J1800 40758732 INDERAL LA 60MG CAP $ 3.40 40753758 INDERAL LA CAP $ 3.40 40753766 INDERAL LA CAP $ 3.40 39500376 INDIA INK $ 19.75 87210 40737843 INDIGO CARMINE 40 MG/5 ML AMP$ 27.05 41201768 INDIUM-111 5mCi $ 2,486.00 A9542 40706715 INDOCIN 25MG CAP $ 3.25 40764664 INDOCIN 50MG SUPP $ 13.00 40771479 INDOCIN 50MG SUPPOSITORY $ 32.00 40744963 INDOCIN SR CAP $ 3.40 33451909 INF THERAPY,ER CLI 1ST HR $ 407.00 96365 31522769 INF VENA CAVA LIGA $ 8,609.00 37619 32100158 INF WARMER EA ADDL HR $ 14.00 40754400 INFANT FORMULA W-IRO $ 9.90 32515389 INFANT HEEL WARMER $ 4.20 32201212 INFANT WARMER RENT $ 57.00 31201874 INFL.GAUGE W/CON.TUB $ 90.20 32626599 INFL.GAUGE W/CON.TUB $ 91.00 31402787 INFLATION DEVICE - X $ 218.00 31505415 INFLATION DEVICE - X $ 218.35 32626500 INFLATION DEVICE - X $ 219.00

68 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31548760 INFLATION DEVICE - X $ 220.00 31201536 INFLATION DEVICE GI $ 253.60 32533820 INFLATION ESSENTIAL KIT $ 145.75 32516049 INFLATOR W/GUAGE LEVEEN $ 124.00 42630488 Inflectra 10mg biosmilar Infli $ 428.00 Q5103TB 42630686 Inflectra 10mg JW biosmilar In $ 428.00 Q5103TBJW 39905577AA INFLU A AB $ 91.50 86710 39905577BB INFLU B AB $ 91.50 86710 40107328 INFLUENZA A/B $ 50.50 87804 39905577 INFLUENZA ANTIBODIES $ 193.00 41293555 INFLUENZA VACCINE $ 93.00 90686 42604788 INFLUENZA VACCINE $ 93.00 90686 42604064 INFLUENZA VACCINE ADM $ 76.00 G0008 40736357 INFLUENZA VIRUS TRIV $ 31.20 Q2038 40933095 INFRARED $ 15.00 97026GO 40924270 INFRARED $ 15.00 97026GP 32512766 INFUSAID REFILL KIT $ 129.95 31502131 INFUSAPORT-SINGLE $ 747.55 C1788 40601395 INFUSE RADIOACTIVE MATERIALS$ 874.00 77750 41292011 INFUSED RADIOACTIVE MATERIAL$ 874.00 77750 32503054 INFUSION ADAPTIC 19G $ 9.30 32503096 INFUSION ADAPTIC 21G $ 9.30 32503070 INFUSION ADAPTIC 23G $ 9.30 32503112 INFUSION ADAPTIC 25G $ 9.30 32503153 INFUSION BUTTERFLY 25 $ 9.30 32503138 INFUSION BUTTERFLY23 $ 9.30 41108387 INFUSION CATHETER KIT $ 637.00 31505225 INFUSION CATHETER KIT $ 637.00 31552126 INFUSION CATHETER KIT $ 637.00 31505258 INFUSION CATHETER KIT X $ 637.00 31550146 INFUSION CATHETER KIT X $ 637.00 42602185 INFUSION EACH ADD'L HR. $ 122.00 96366 42606937 INFUSION HYDRATE 1ST HR $ 278.00 96360 42607025 INFUSION HYDRATE ADD'L HR $ 61.00 96361 41201767 INFUSION OF RADIOACTIVE MASTER$ 1,726.00 41296081 INFUSION OF RADIOACTIVE MAT$ 1,726.00 41210356 INFUSION RADIOACTIVE MATERIAL$ 874.00 77750 42615836 INFUSION SEQUENTIAL UP TO 1 HR$ 119.00 96367 42602094 INFUSION UP TO 1 HR $ 407.00 96365 40800013 INHALATION TREATMENT $ 406.00 94640 40107096 INHIBIN B $ 270.00 83520 33301138 INIT OBSERV CARE LV1 30 MI BSD$ 142.00 99218 33301146 INIT OBSERV CARE LV2 50 MI BSD$ 179.00 99219 33301153 INIT OBSERV CARE LV3 70 MI BSD$ 261.00 99220 33301856 INIT TREAT 1ST DEGREE $ 218.00 16000 41356084 INITIAL HOSP CARE LEVEL 1 $ 220.00 99221 41356172 INITIAL HOSP CARE LEVEL 2 $ 302.00 99222 41356260 INITIAL HOSP CARE LEVEL 3 $ 447.00 99223 33105071 INJ ANES OTH PRPH NRV/BRANCH$ 827.00 64450 31500234 INJ AORTOGRAM $ 71.00 40480273 INJ ARTHROGRAM ELBOW $ 168.00 24220 40403479 INJ ARTHROGRAM SHOULDER $ 362.25 23350 31534207 INJ CHOLANGIOGM/EXIST ACCESS$ 6,280.00 47531 31534108 INJ CHOLANGIOGRM/NEW ACCESS$ 6,280.00 47532 40476016 INJ EPIDURAL STEROID WITH FLUO$ 1,180.00 62323 40503955 INJ INTERMEDIATE JT $ 469.00 20605 42602003 INJ IV PUSH FIRST $ 395.00 96374 42606849 INJ IV PUSH/ADD DIFF MED $ 121.00 96375 33100991 INJ IV PUSH/ADD DIFF MED $ 121.00 96375 33452622 INJ IV PUSH/ADD DIFF MED ERCLI$ 121.00 96375

69 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 42608534 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 33100959 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 33400959 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 32201741 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 31300502 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 30500268 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 30300768 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 30210794 INJ IV PUSH/ADD SAME MED>30MIN$ 121.00 96376 33301914 INJ LIGA TRIGGER POI $ 2,683.00 20550 31536286 INJ NEPH/URTR GRAM EXISTING $ 1,205.00 50431 31536088 INJ NEPH/URTR GRAM NEW ACCES$ 1,205.00 50430 40603200 INJ PROC SENTINEL LYMPH NODE$ 822.00 38792 31500275 INJ PULM. ANGIO $ 113.00 93568 40479184 INJ SACROILIAC JOINT $ 1,491.00 G0260 40403529 INJ SALPINGOGRAM $ 436.75 58340 33301922 INJ SMALL JOINT $ 469.00 20600 40504054 INJ SMALL JT $ 469.00 20600 42601989 INJ SQ OR 1M $ 204.00 96372 41455841 INJ THERA IM OR SQ $ 204.00 96372 40485032 INJ TO SEE ILEAL CONDUIT $ 31.00 50690 40476610 INJ WRIST ARTHROGRAM $ 200.00 25246 33451636 INJ, IM/SUBQ,ER CLINIC $ 204.00 96372 33451724 INJ, IV PUSH,ER CLINIC-INITIAL $ 395.00 96374 33456483 INJ, RABIES $ 170.00 90471 33456384 INJ, RABIES,ER CLINIC $ 170.00 90471 33451812 INJ, TETANUS,ER CLINIC $ 170.00 90471 33456582 INJ, VACCINE ADDITIONAL $ 170.00 90472 31505480 INJ. BILAT. PULMONARY ARTERY $ 667.00 31505308 INJ. MAIN PULMONARY ARTERY $ 498.00 31505399 INJ. UNILAT. PULMONARY ARTERY$ 533.00 31502156 INJ. VENOGRAM - X $ 166.00 33304645 INJ;TRIGGER POINT, 1/2 MUSCLES$ 469.00 20552 31537771 INJCT L VENTRIC/ATRIAL ANGIO $ 110.00 93565 31537672 INJCT R VENTRIC/ATRIAL ANGIO$ 110.00 93566 31537870 INJECT CONGENITAL CARD CATH$ 140.00 93563 42624053 INJECTAFER SDV 750MG $ 3,740.00 J1439JG 40478590 INJECTION ARTHROGRAM HIP $ 171.00 27093 40404493 INJECTION CYSTOGRAM VCUG $ 103.50 51600 40481263 INJECTION FOR CHOLANGIOGRAM$ 6,280.00 47531 40404329 INJECTION FOR DUCTOGRAM $ 240.00 19030 33100256 INJECTION IM OR SUBQ NON ANTIB$ 204.00 96372 41465642 INJECTION INTO SKIN LESIOS=<7$ 368.00 11900 33100108 INJECTION IV PUSH-INITIAL $ 395.00 96374 40503856 INJECTION MAJOR JT W/O US $ 469.00 20610 32513269 INJECTION NEEDLE $ 105.35 31401334 INJECTION NEEDLE $ 141.00 32602096 INJECTION SITE NF $ 9.60 32531949 INK SPOT MARKER $ 68.40 40753337 INOCOR AMP $ 155.55 41291075 INPATIENT CONSULT LEVEL 2 $ 140.00 99252 41291087 INPATIENT CONSULT LEVEL 3 $ 163.00 99253 41291099 INPATIENT CONSULT LEVEL 4 $ 215.00 99254 41291104 INPATIENT CONSULT LEVEL 5 $ 293.00 99255 41352173 INPATIENT PT. CONSULT LEVEL 2$ 140.00 99252 41352261 INPATIENT PT. CONSULT LEVEL 3$ 163.00 99253 41352350 INPATIENT PT. CONSULT LEVEL 4$ 215.00 99254 41352442 INPATIENT PT. CONSULT LEVEL 5$ 293.00 99255 41355547 INPT VISIT SUBSEQ LEVEL 1 $ 85.00 99231 41355635 INPT VISIT SUBSEQ LEVEL 2 $ 153.00 99232 41355723 INPT VISIT SUBSEQ LEVEL 3 $ 219.00 99234

70 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31511348 INS ELECTRODE LV PACING ATTACH$ 29,353.00 33224 31532425 INS TUN IP CATH-DIAL OPEN $ 6,280.00 49421 31530940 INS/REPLAC SQ DEFIBRILLATOR $ 68,392.00 33270 31505787 INS/RPL SING PULSE GENERATOR$ 18,180.00 33212 31532029 INSERT CATH PLEURA W/O IMAGE$ 2,928.00 32556 31531930 INSERT CATH W/ IMAGE $ 1,501.00 32557 31515966 INSERT DUAL CHAMBER TRAN ELECT$ 15,305.00 33217 31511447 INSERT DUAL ICD SYSTEM $ 72,136.50 33249 31511785 INSERT DUAL PACE & ATR/VEN LEA$ 23,761.00 33208 31511439 INSERT LV LEAD PACE/ICD $ 29,353.00 33225 31511421 INSERT NEW OR REPLACE OF PPM$ W 21,571.00 33206 31511264 INSERT OF REPLACED DUAL ICD $GE 65,663.00 33230 31511389 INSERT OF REPLACED SING ICD GE$ 65,663.00 33240 31514888 INSERT PICC W/PORT $ 5,179.00 36571 31532524 INSERT PLEURAL CATH $ 6,280.00 32550 31511603 INSERT SING PACE & VENT LEAD$ 21,571.00 33207 31511355 INSERT SINGLE ICD SYSTEM $ 72,136.00 33249 31515878 INSERT SNGL CHAMBER TRAN ELECT$ 15,305.00 33216 31553017 INSERT SQ CARD RHYTHM MONITR$ 16,117.00 33285 31530841 INSERT SQ DEFIB ELECTRODE $ 15,305.00 33271 33303027 INSERT TEMP PACEMAKER $ 14,520.00 33210 33100264 INSERTION FOLEY CATH $ 292.00 51702 33100413 INSERTION FOLEY CATHETER $ 292.00 51702 40201857 IN-SITU HYBR 25-99 CELLS $ 278.00 88274 40755134 INSPIREASE KIT $ 42.15 40769325 INSPRA 25MG TAB $ 12.50 32507360 INSTRUMENT DISP KIT $ 376.60 32533671 INSUFFLATION NEEDLE $ 199.15 31203870 INSUFFLATION TUBING $ 84.85 39400114 INSULIN ANTIBODY $ 108.25 86337 40757288 INSULIN HUMAN NPH $ 45.40 40757296 INSULIN HUMAN REG RE $ 45.40 40757312 INSULIN LENTE (BEEF) $ 41.05 40758344 INSULIN LENTE VIAL $ 46.45 40753279 INSULIN NPH (BEEF) $ 41.05 40753303 INSULIN NPH (PORK) $ 69.15 40753204 INSULIN NPH 100 UNITS/1ML VIAL$ 35.65 40757270 INSULIN REG 100U/1ML 10ML VIAL$ 46.45 J1815 42606135 INSULIN REG VIAL $ 49.00 J1815 40757304 INSULIN REG. (BEEF) $ 41.05 40757320 INSULIN SEMILENTE $ 32.95 40753329 INSULIN ULTRALENTE $ 45.40 39400023 INSULIN,TOTAL $ 40.25 83525 33300346 INT CLS FACE > 30.0CM $ 1,071.00 12057 33300338 INT CLS FACE 20.1-30 $ 893.00 12056 33301724 INT REPAIR 12.6-20CM $ 793.00 12055 31500341 INT. MAMMARY INJECTION: S $ 6,011.00 75756 40753998 INTAL 14.2GM INHALER $ 142.60 40751885 INTAL 8.1GM INHALER $ 89.60 40755803 INTAL NEBA $ 3.25 33301682 INTCL, FACE <2.5CM $ 488.00 12051 33301690 INTCL, FACE 2.6-5.0CM $ 488.00 12052 33301716 INTCL, FACE EARS 7.6 $ 726.00 12054 33301708 INTCL, FACE EARS, EYELID $ 488.00 12053 33300320 INTCL, NECK . 30.0CM $ 3,134.00 12047 33301641 INTCL, NECK <2.5 CM $ 488.00 12041 33301674 INTCL, NECK 12.6-20.0CM $ 542.00 12045 33301658 INTCL, NECK 2.6-7.5CM $ 488.00 12042 33300312 INTCL, NECK 20.1-30CM $ 557.00 12046 33301666 INTCL, NECK 7.6-12.5 $ 488.00 12044

71 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33301609 INTCL, SCALP <2.5CM $ 488.00 12031 33300304 INTCL, SCALP >30.0 CM $ 3,120.00 12037 33301633 INTCL, SCALP 12.6-20 $ 954.00 12035 33301617 INTCL, SCALP 2.6-7.5CM $ 488.00 12032 33300296 INTCL, SCALP 20.1-30 $ 954.00 12036 33301625 INTCL, SCALP 7.6-12.5 $ 488.00 12034 40764714 INTEGRILIN 75MG/100ML VIAL $ 342.20 J1327JG 40764706 INTEGRILIN 20MG/10ML VIAL/EACH$ 162.00 J1327JG 42603039 INTERFERON 3 MILLION UNITS $ 1,834.00 J9213 40757783 INTERFERON ALFA-2A,R $ 439.60 31501224 INTERNAL MAMMARY $ 92.85 31502941 INTERNAL MAMMARY - X $ 88.25 32512121 INTERPORE BLOCK 10CC $ 2,213.90 32512113 INTERPORE BLOCK 2.4C $ 817.65 32512576 INTERPORE GRANULES 15CC $ 1,472.00 32512584 INTERPORE GRANULES 30CC $ 1,908.95 32512097 INTERPORE GRANULES 5CC $ 1,158.60 32512105 INTERPORE SYRINGE/BONE $ 1,062.45 41462771 INTMD WND REPAIR S/A/T/EXT $ 488.00 12031 32503179 INTRACATH SMALL 8 inch $ 20.75 31500309 INTRACORONARY TPA INJ. $ 1,660.00 40768178 INTRALIPID 10% BTL $ 288.00 40775909 Intralipids 20% 250mg blttle $ 288.00 31903081 INTRAPERITONEAL $ 606.50 32509234 INTRAUTERINE KIT $ 62.15 39406632 INTRINSIC FAC BL AB $ 70.25 86340 33300932 INTRO CATHETER/AORTA $ 479.00 36200 31500333 INTRO. NEEDLE/INTRACA., CA/VE$ 1,245.00 31905584 INTRODCR, ET TUBE, FLEX GUID $ 40.00 32511628 INTRODUCER $ 111.45 31540840 INTRODUCER $ 112.00 32532418 INTRODUCER PEELAWAY $ 237.35 C1892 32509978 INTRODUCER SET 13 FR $ 290.60 C1893 31505365 INTRODUCER SHEATH $ 139.15 C1893 31505894 INTRODUCER SHEATH - X $ 139.15 31545295 INTRODUCER SHEATH - X $ 140.00 32511016 INTRODUCER STENT SET $ 254.60 32517740 INTRODUCER, ET TUBE, FLEX GUID$ 40.00 32639271 INTRODUCER, SP SET $ 210.00 31511256 INTRODUCTION OF NEEDLE OR CATH$ 42.00 33304363 INTRODUCTION OF NEEDLE/CATHET$ 35.00 40756256 INTROPIN VIAL 5ML $ 14.10 33302904 INTUBATION E/R PROCEDURE $ 312.00 31500 32516288 INTUBATION TUBE LMA $ 35.00 40771958 INVANZ 1GM VIAL $ 250.50 J1335 40763427 INVIRASE 200MG CAPSULE $ 5.75 31202518 IOBAN DRAPE $ 121.30 31547572 IOBAN DRAPE $ 122.00 31500317 IOC, AORTA $ 1,745.00 31518512 IOC, CORONARIES ONLY $ 8,180.00 93454 31518611 IOC, CORONARIES+ BYPASS GRFTS$ 8,180.00 93455 31500374 IOC, EXTREMITY ARTERY $ 1,448.00 31500382 IOC, RETROGRADE BRACHIAL $ 1,683.00 40107898 IODINE $ 150.00 83789 40727588 IODINE 7% TINC 60ML BOTTLE $ 3.40 31200835 IODOFORM $ 53.40 33451450 IODOFORM, DSG, ER CLINIC $ 12.00 40900854 IONTOPHORESIS 15 MIN $ 120.75 97033GP 40920854 IONTOPHORESIS 15MIN $ 120.75 97033GO 40758245 IOPIDINE 1%OPH GTT U $ 13.50

72 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33303910 IPECAC INDIVID EMESI $ 110.00 99175 40704397 IPECAC SYRUP $ 4.65 40871610 IPR/ALB 0.5/2.5MG 3ML NEB $ 16.50 39405212 IQG-CSF $ 62.75 82784 40805442 IRATROPIUM 500MCG/2.5ML UD NEB$ 6.50 40737793 IRON DEXTRAN 100MG/2ML VIAL$ 79.30 J1750 42602573 IRON DEXTRAN 50 MG $ 48.00 J1750JG 42619499 IRON DEXTRAN 50MG JW $ 48.00 J1750JGJW 39904742 IRON SERUM $ 25.50 83540 40201766 IRRADIATION CHARGE $ 55.00 86945 33303282 IRRIGATE CORPORA $ 536.00 54220 31201841 IRRIGATING VECTIS $ 25.40 32516403 IRRIGATION FLUID WARMING SET$ 130.00 32510760 IRRIGATION LENS $ 116.40 40803926 IRRIGATION SOLUTION $ 5.75 31403183 IRRIGATION VALVE $ 18.00 40107112 IRRITABLE BOWEL PROFILE $ 461.00 40754285 ISOCAL LIQUID $ 5.15 41210105 ISODOSE PLAN - COMPLEX - MASTE$ 428.16 77307 41210105A ISODOSE PLAN - COMPLEX (PROF)$ 181.00 77307 41210105B ISODOSE PLAN - COMPLEX (TECH)$ 345.00 77307 41210093 ISODOSE PLAN - INTERMEDIATE $1 336.43 77306 41296651 ISODOSE PLAN - INTERMEDIATE $-C 428.00 41210093A ISODOSE PLAN - INTERMEDIATE $SI 87.00 77306 41210093B ISODOSE PLAN - INTERMEDIATE $SI 251.03 77306 40921282 ISOKINECTIC EXCERCISE 15MIN $ 106.50 97530GO 40921191 ISOKINECTIC TEST 15MIN $ 106.50 97750GO 40901282 ISOKINETIC EXCERCISE 15MIN $ 106.50 97530GP 40901191 ISOKINETIC TEST 15MIN $ 106.50 97750GP 30200059 ISOLATION ROOM 2 EAST $ 213.00 30210059 ISOLATION ROOM OVERFLOW $ 213.00 30210141 ISOLATION SET-UP $ 26.00 30200141 ISOLATION SET-UP $ 26.00 32100067 ISOLETTE INCUB $ 33.25 32602039 ISOLYTE $ 32.15 40768996 ISOLYTE/P/DEXTROSE 5% 500ML$ BA 75.50 40759342 ISOMIL RTF $ 11.55 40709917 ISONIAZID 300 MG TABLET $ 3.25 40737959 ISOPROTERENOL SYRING $ 35.65 40722357 ISOPTO CARPINE 1% DR $ 58.95 40722365 ISOPTO CARPINE 2% DR $ 30.40 40722373 ISOPTO CARPINE 3% DR $ 37.30 40722381 ISOPTO CARPINE 4% DR $ 32.40 40722399 ISOPTO CARPINE 6% DR $ 36.45 40750275 ISORDIL 20 MG TAB $ 3.25 40713752 ISOSORBIDE DINITRATE $ 3.25 40713794 ISOSORBIDE DINITRATE 10 MG TAB$ 3.25 40713810 ISOSORBIDE DINITRATE 40 MG TAB$ 3.40 40758161 ISOSORBIDE MONO 20 MG TABLET$ 3.40 40767030 ISOSORBIDE MONOTRATE ER 30MG$ 3.25 40776701 ISOSULFAN BLUE 50 MG/5 ML VIAL$ 2,914.00 40720526 ISUPREL 0.25% INHALE $ 55.25 31900822 IV CHARGE $ 94.50 33452246 IV INF HYDRA 1ST HR ERCLINIC $ 278.00 96360 33452534 IV INF HYDRA ADD'L HR ERCLINIC$ 72.00 96361 31511744 IV INFUSION - THROMBOLYSIS $ 677.00 92977 33100249 IV INFUSION 1ST HOUR $ 407.00 96365 33100322 IV INFUSION ADD'L HR $ 122.00 96366 33100926 IV INFUSION CONCURRENT $ 119.00 96367 33100801 IV INFUSION HYDRA 1ST HR $ 278.00 96360

73 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33100868 IV INFUSION HYDRA ADD'L HR $ 61.00 96361 40750200 IV PUSH $ 4.55 33451997 IV, INF > 1 HR,ER CLINIC $ 122.00 96366 40757064 IVA $ 6.80 42611776 IVANZ 1 GM VIAL $ 250.50 J1335 31522472 IVC FILT INSER PERC W RAD S&I$ 8,609.00 37191 31522571 IVC FILT REPOSI W RAD S&I $ 5,746.00 37192 32601452 IVEX HP FILTER $ 24.15 40400285 IVP HYPERTENSIVE $ 601.00 74400 40476412 IVP W TOMO BEFORE AND AFTER$ CONT 601.00 74400 40400251 IVP W TOMOGRAMS $ 601.00 74400 40400269 IVP WO TOMOGRAMS $ 601.00 74400 31535692 IVUS, NC 1ST $ 223.00 37252 31535791 IVUS, NC ADD'L $ 178.00 37253 31516122 IVUS/OCT,CORONARY 1ST VESSEL$ 500.00 92978 31516190 IVUS/OCT,CORONARY ADDL VESSL$ 500.00 92979 31516289 IVUS-FFR, 1ST VESSEL $ 500.00 93571 31516357 IVUS-FFR, ADD'L VESSEL $ 500.00 93572 42631280 IXEMPRA 1 MG JW $ 341.00 J9207JGJW 42631181 IXEMPRA 1MG $ 341.00 J9207JG 32531899 JAG WIRE $ 373.80 32514382 JAG WIRE HYDRA $ 586.05 C1769 31401680 JAG-WIRE $ 320.00 32513376 JAGWIRE ERCP $ 507.15 C1769 39476249 JAK2 GENE ANALYSIS $ 563.00 81270 32508327 JAMSHIDI BN.MRW.NEED. $ 17.25 31204209 JARED CARD. BYP.SHUNT $ 136.45 40765802 JEVITY/JEVITY PLUS $ 3.25 42629003 JEVTANA 1MG $ 633.00 J9043JG 42629102 JEVTANA 1MG JW $ 633.00 J9043JGJW 39405550 JO-1 ANTIBODY $ 132.50 86235 32513954 JOSTENT GRAFTMASTER $ 3,382.60 C1876 31501232 JUDKINS L 5FR JL 3.5 $ 92.85 31501240 JUDKINS L 5FR JL 4.0 $ 92.85 31501257 JUDKINS L 5FR JL 4.5 $ 92.85 31501265 JUDKINS L 5FR JL 5.0 $ 92.85 31501273 JUDKINS L 5FR JL 6.0 $ 92.85 31501281 JUDKINS R 5FR JR 3.5 $ 92.85 31501315 JUDKINS R 5FR JR 4.5 $ 92.85 31501323 JUDKINS R 5FR JR 5.0 $ 92.85 31501331 JUDKINS R 5FR JR 6.0 $ 92.85 32510745 JUGULAR NEEDLE KIT $ 343.15 39400494 JUNE GRASS-RAST $ 28.75 86003 31503006 JUPITER PTA SYSTEM-X $ 732.70 C1725 32533234 JURGAN PIN $ 53.50 32626401 JURGAN PIN $ 54.00 32533770 JURGAN PIN BALL $ 53.50 40771388 JUVEN HMB PACKET $ 8.00 39501440 K O H PREP $ 16.50 87220 31202484 K WIRE $ 138.50 42631775 KADCYLA 1 MG JW $ 118.00 J9354JGJW 42631676 KADCYLA 1MG $ 118.00 J9354JG 40707374 KANTREX CAP $ 4.70 40756546 KAON-CL 20% LIQUID $ 19.95 40727273 KAPECTOLIN SUSP 262MG/15ML $ 3.25 32517716 KARAYA PASTE $ 59.22 32508053 KARAYA POWDER $ 22.55 32517724 KARAYA POWDER $ 58.90 40747347 KAYEXALATE 15 GM/60 ML BOTTLE$ 20.00 40756942 KAYEXALATE PWD $ 17.05

74 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40781948 Kcentra 1,000 Unit Kit $ 8,860.00 C9132JG 40771032 KCL 10 MEQ/100 ML IVPB $ 3.25 40756512 K-DUR TAB SA $ 3.40 40707390 KEFLEX 500MG CAP $ 5.85 40707382 KEFLEX CAP $ 3.40 40727307 KEFLEX SUSP 100ML $ 28.95 40753055 KEFLEX SUSP 250MG/5ML 100ML$ BT 54.45 40718058 KENALOG 0.1% CREAM 15GM TUBE$ 24.85 40738411 KENALOG 40MG/1ML VIAL $ 40.85 J3302 40756652 KENALOG DENTAL PST 0.1% 5GM$ TU 28.00 40107765 KEPPRA $ 147.00 82542 40766479 KEPPRA 500MG TAB $ 6.05 40772089 KEPPRA 500MG/5ML VIAL $ 135.00 J1953 40107476 KEPPRA LEVEL $ 147.00 82542 40776998 KEPPRA SOLUTION 500MG/5ML UDC$ 25.50 40705113 KERI LOTION $ 13.05 40758864 KETAMINE HCL 500 MG/10 ML VIAL$ 48.45 40769259 KETOCENAZOLE 2% SHAMP 120ML$ BT 85.50 39400205 KETOGENIC STEROID-17 $ 66.00 83582 40764425 KETORALAC 30MG/1ML VIAL 25/BX$ 60.50 J1885 40782641 Ketorolac 0.5% Opth Drop $ 343.00 39400295 KETOSTEROIDS-17 $ 57.75 83586 42615638 KEYTRUDA 1 MG $ 171.00 J9271JG 42619697 KEYTRUDA 1 MG JW $ 171.00 J9271JGJW 31401144 KINEVAC $ 108.00 32511420 KIT ACUFORM NASAL SP $ 115.80 31501190 KIT BALLOON INSERTION $ 1,270.50 C1766 32515702 KIT BIO-TENODESIS $ 338.95 32517757 KIT COLOSTOMY 2 3/4 inch $ 18.40 A4414 32517773 KIT COLOSTOMY 4 inch $ 23.25 A5063 32513699 KIT CRUCIATE $ 339.15 32533622 KIT FATHERS DELIVERY $ 21.45 32511552 KIT GLASSCOCK EAR AD $ 94.85 31202336 KIT JET VAC HIP $ 187.95 32516585 KIT LIGHTROPE SYNDESMOSIS $ 665.80 32516494 KIT MICROMAX $ 464.25 32507782 KIT MRI MAMMOTOME $ 821.00 C1819 32507907 KIT O RING $ 7.00 32532681 KIT PAIN INFUSION $ 530.00 32515348 KIT PASSPORT BALLOON $ 569.45 C1725 32504144 KIT PERI LAVAGE $ 235.60 32533630 KIT PILOT BALLOON REPAIR $ 27.15 32515835 KIT PROLIFT A/P $ 1,765.35 C1771 32508509 KIT TEP $ 395.65 32516569 KIT THERMOFLEX WARMING BLANKET$ 22.70 32529919 KIT TRACH CARE $ 12.10 32509101 KIT, CAVITY DRAINAGE $ 230.95 32533895 KIT, INLET CLOSURE $ 879.35 32509259 KIT, MENISECTOMY $ 232.95 32533804 KIT, METRA-PS $ 1,397.30 32603300 KIT, PROCEDURE, TRUCLEAR $ 448.00 32511198 KIT,BOWER-RING PEG $ 547.20 40201196 KLEIHAUER BETKE $ 117.75 85460 40748626 KLONOPIN 0.5 MG TABLET $ 3.25 40704405 K-LOR PACK $ 3.40 32532350 KNEE CRUTCH PAD $ 47.95 32508798 KNEE IMMOB. 18 inch $ 303.65 L1830 32508335 KNEE IMMOB. 19 inch $ 183.10 32508251 KNEE IMMOB.UNIV.23 inch $ 387.25 L1830 32510372 KNEE IMOBILIZER 13 inch $ 190.95 L1830

75 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32508244 KNEE IMOBILIZER-CHU $ 69.90 32515421 KNEE NAIL GOLD $ 2,238.45 32515637 KNEE POSITIONER $ 302.80 32513707 KNEE REPLACEMENT LEVEL 1 $ 4,725.00 C1776 32513715 KNEE REPLACEMENT LEVEL 2 $ 6,930.00 C1776 32614719 KNEE REPLACEMENT LEVEL 2 $ 6,930.00 C1776 32513723 KNEE REPLACEMENT LEVEL 3 $ 8,400.00 C1776 32513731 KNEE REPLACEMENT LEVEL 4 $ 9,975.00 C1776 32513749 KNEE REPLACEMENT LEVEL 5 $ 12,075.00 C1776 32513756 KNEE REPLACEMENT LEVEL 6 $ 15,750.00 C1776 32529877 KNEE SLING $ 210.50 32507444 KNEE TOTAL LEVEL 7 $ 20,000.00 C1776 40402935 KNEES AP STANDING $ 101.10 73565 32507394 KNIFE ACL $ 182.95 32515256 KNIFE BAYONET $ 461.50 31501430 KNIFE BLADE $ 53.25 42010165 KNIFE BLADE - X $ 50.00 40506628 KNIFE BLADE - X $ 50.00 31506009 KNIFE BLADE - X $ 50.25 32626302 KNIFE BLADE - X $ 51.00 31203524 KNIFE CRESCENT $ 116.40 32515967 KNIFE CURVED $ 284.00 32516007 KNIFE FLAP DISP $ 130.00 32507626 KNIFE LIGHT CARPEL $ 181.00 32510539 KNIFE MICROSURGERY $ 252.85 32626203 KNIFE MICROSURGERY $ 253.00 32514085 KNIFE TRIANGLE $ 327.60 32532962 KNIFE TULIP $ 188.50 32533499 KNIFE ULTRACISION $ 857.25 32514325 KNIFE VASCULAR $ 136.50 31202302 KNIFE, MYRINGOTOMY $ 102.50 32511289 KNIFE, ULTRA SHARP $ 221.95 31203532 KNIFE,SLIT (PHACO) $ 129.35 32514853 KNOT PUSHER $ 280.00 32510075 KOALAKIAR $ 323.70 32501124 K-PAD W/PUMP SET-UP $ 58.20 40767204 K-PHOS 500MG TABLET $ 3.30 32515496 KUGEL HERNIA MESH $ 2,482.00 C1781 40720765 KWELL 1% LOTION $ 19.30 40720773 KWELL 1% SHAMPOO $ 24.20 32516213 KWIRE $ 303.00 32507584 K-WIRE DBL TROCAR $ 36.00 40479085 KYPHOPLASTY EACH ADDED BODY$ 546.00 22515 40478986 KYPHOPLASTY LUMBAR $ 14,032.00 22514 40478887 KYPHOPLASTY THORACIC $ 14,032.00 22513 32531840 KYPHX BONE ACCESS DRIVE $ 75.00 32514044 KYPHX BONE BIOPSY KIT $ 1,765.05 32531758 KYPHX BONE BIOSPY DEVICE $ 308.70 32531931 KYPHX BONE FILLER DEVICE $ 196.25 32532848 KYPHX BONE TAMP XPAND $ 1,551.90 32514051 KYPHX INFLATION SYRINGE $ 257.25 32532020 KYPHX OSTED BONE SYSTEM $ 1,609.65 32532939 KYPHX TRAY 1ST FX $ 4,877.25 32533028 KYPHX TRAY 2ND FX $ 3,288.60 42613261 KYPROLIS 1 MG $ 126.00 J9047JG 42617321 KYPROLIS 1 MG JW $ 126.00 J9047JGJW 40767642 KYTRIL 1MG TAB $ 147.58 40476313 L KNEE STANDING LAT $ 131.75 73560LT 40477006 L RIBS NO CHEST $ 124.50 71100LT 39402920 L/S RATIO $ 92.75 83661

76 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40926646 L0460 - TLSO, 2shells, prefab $ 2,449.00 L0460 40926943 L0472 - TLSO, Triplane, Hypere $ 1,045.00 L0472 40926844 L0648 - LSO, Custom Prefab - E $ 2,504.00 L0648 40926745 L0650 - LSO, Custom Prefab - E $ 3,321.00 L0650 40924745 L3760 - ELB ADJ JT PREFAB CUST$ 1,110.00 L3760GO 40933689 L3806-WHFO W/JOINT(S) CF $ 1,009.00 L3806GO 40924864 L3806-WHFO W/JOINT(S) CF $ 1,009.00 L3806GP 40924963 L3808 - WRIST HAND FINGER ORTH$ 742.00 L3808GP 40934580 L3808-WHFO W/O JOINTS $ 742.00 L3808GO 40925062 L3809 - WRIST HAND FINGER ORTH$ 555.00 L3809GP 40934679 L3809-WHFO W/O JOINTS PRE OTS$ 555.00 L3809GO 40925359 L3905 - WHO W/NONTORSION JNT(S$ 2,202.00 L3905GP 40933788 L3905-WHO W/NONTORSION JNT(S)$ 2,202.00 L3905GO 40925161 L3906 - WHO W/O JOINTS CF $ 937.00 L3906GP 40933887 L3906-WHO W/O JOINTS CF $ 937.00 L3906GO 40925755 L3908 - WHO COCK-UP NONMOLDED$ 133.00 L3908GP 40934481 L3908-WHO COCK-UP NONMOLDED$ PR 133.00 L3908GO 40925458 L3912 - HFO FLEXION GLOVE PRE$ 213.00 L3912GP 40935273 L3912-HFO FLEXION GLOVE PRE $OT 213.00 L3912GO 40925557 L3913 - HFO W/O JOINTS CF $ 601.00 L3913GP 40935372 L3913-HFO W/O JOINTS CF $ 601.00 L3913GO 40925854 L3916 - WHO NONTORSION JNTS$ PR 1,180.00 L3916GP 40934283 L3916-WHO NONTORSION JNTS PRE$ 1,180.00 L3916GO 40925656 L3918 - METACARP FX ORTHOSIS$ P 235.00 L3918GP 40934382 L3918-METACARP FX ORTHOSIS PRE$ 235.00 L3918GO 40926052 L3919 - HO W/O JOINTS CF $ 601.00 L3919GP 40934976 L3919-HO W/O JOINTS CF $ 601.00 L3919GO 40926448 L3921 - HFO W/ JOINT(S) CF $ 713.00 L3921GP 40935174 L3921-HFO W/JOINT(S) CF $ 713.00 L3921GO 40926151 L3924 - HFO WITHOUT JOINTS PRE$ 193.00 L3924GP 40934778 L3924-HFO WITHOUT JOINTS PRE$ O 193.00 L3924GO 40925953 L3925 - FO PIP DIP JNT/SPRING $ 117.00 L3925GP 40935075 L3925-FO PIP DIP JNT/SPRNG PRE$ 117.00 L3925GO 40926547 L3927 - FO PIP DIP NO JT SPR P $ 78.00 L3927GP 40934184 L3927-FO PIP DIP NO JT SPR PRE$ 140.00 L3927GO 40926250 L3930 - HFO NONTORSION JNTS $PR 187.00 L3930GP 40925260 L3931 - WHFO NONTORSION JOINT$ 452.00 L3931GP 40934085 L3931-WHFO NONTORSION JOINT$ PR 452.00 L3931GO 40926349 L3933 - FO W/O JOINTS CF $ 474.00 L3933GP 40934877 L3933-FO W/O JOINTS CF $ 474.00 L3933GO 40933986 L393O-HFO NONTORSION JNTS PRE$ 187.00 L3930GO 32600181 L5100 D5W 1000CC $ 30.90 32600165 L5101 D5W 500CC $ 37.65 32600140 L5102 D5W 250CC $ 30.90 32600223 L5200 D10W 1000CC $ 27.00 32600207 L5201 D10W 500CC $ 30.90 32600546 L6100 D5% .9% NS 1000 $ 20.30 32600520 L6101 D5% 0.9 NS 500 $ 26.50 32600603 L6120 D5 0.45NS1000 $ 24.85 32600587 L6121 D5 0.45NS 500 $ 24.85 32600561 L6122 D5 0.45% NS 250 $ 30.15 32600660 L6160 D5 0.2NS 1000 $ 20.30 32600645 L6161 D5 0.2NS 500 $ 30.30 32600629 L6162 D5 0.2NS 250 $ 25.95 32600702 L6220 D10 0.45NS 100ML $ 33.80 32601643 L6250 5% DEX 20 KCL $ 30.30 32601668 L6280 5% DEX 40 KCL $ 24.85 32601676 L6340 5% D0.45SC10KCL $ 24.85 32601684 L6350 5%DO.45SC20KCL $ 37.05 32601692 L6360 5%DO 45SC30KCL $ 20.30

77 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32601700 L6380 5%DO 45SC40KCL $ 20.30 32602328 L6450 D5 0.2NS 20KCL $ 37.05 32602195 L6520 D5NS20 KCL $ 35.25 32602419 L7070 ISOLYTE S $ 24.85 32600421 L7500 LAC RING 1000 $ 45.05 32600405 L7501 LAC RING 500 $ 24.85 32600389 L7502 LAC. RING 250 $ 25.95 32600348 L7510 D5 LACTATE R $ 45.05 32600322 L7511 5% D L R 500 $ 45.05 32600785 L8000 0.9% SC 1000 $ 24.85 32600769 L8001 0.9% SC 500 $ 20.30 32600744 L8002 0.9% SC 250 $ 24.85 32600728 L8020 0.45% NS 1000 $ 20.30 32602237 L8650 0.9% SC 20KCL $ 37.05 40769283 LABETALOL 20MG/4ML $ 61.00 40752032 LABETALOL HCL 100MG/20ML VIAL$ 77.55 40750564 LABETALOL HCL 200MG TABLET $ 3.25 32201261 LABOR PIT $ 690.00 32201238 LABOR/PRG RM EA HR $ 35.00 40770273 LAC HYDRIN 12% LOTION 225GM$ BT 59.50 32509788 LACERATION TRAY $ 100.70 31541632 LACERATION TRAY $ 110.00 40764136 LAC-HYDRIN 12% LOTION $ 101.40 39477734 LACOSAMIDE $ 265.00 82542 40756157 LACRILUBE (GEN) OPH $ 8.20 32529901 LACRIMAL INTUB. SET $ 315.65 42608622 LACTATED RINGERS $ 32.95 J7120 40757536 LACTATED RINGERS 1000ML BAG$ 32.95 40757551 LACTATED RINGERS SOL 500ML BAG$ 32.95 J7120 39402326 LACTIC ACID $ 36.50 83605 40752594 LACTICARE-HC 1% LOTN $ 37.90 40727505 LACTINEX PACKET $ 3.40 40755209 LACTINEX TAB CHEW $ 3.25 40749673 LACTULOSE 20GM/30ML UDC $ 6.80 40752230 LACTULOSE ENEMA $ 76.00 32516437 LAG SCREW FOR GAMMA NAIL $ 786.00 39411262 LAMBDA LT CHAINS $ 80.00 83883 40757809 LAMB'S WOOL $ 5.70 40767220 LAMICTAL 100MG TABLET $ 9.60 40769432 LAMISIL 250MG TAB $ 29.50 39411757 LAMOTRIGINE $ 146.00 G0483 39400015 LAMOTRIGINE $ 156.50 80299 39408996 LAMOTRIGINE $ 160.00 82542 31204449 LANDMARK IMAGE GUIDANCE SYS$ 1,323.00 61795 40720989 LANOLIN OINT 28 GM TUBE/EACH$ 12.50 40750465 LANOXICAPS CAP $ 3.25 40751240 LANOXICAPS CAP $ 3.25 40707929 LANOXIN 0.125 MG TABLET $ 3.25 40707937 LANOXIN 0.25 MG TABLET $ 3.25 40704314 LANOXIN 0.5MG/2ML AMP $ 19.30 40751059 LANOXIN PEDIATRIC EL $ 28.10 42631379 LANREOTIDE ACETATE 1MG $ 255.00 J1930JG 40767873 LANTUS INSULIN 100U/ML $ 144.00 39400098 LAP $ 42.75 83670 32517302 LAP CHOLE PK SURGITRAK CASSIDY$ 1,173.50 31201098 LAP SPONGE ACCU SORB $ 45.60 32516791 LARGE CAPACITY FORCEP - EGD $ 36.75 32510398 LARGE VEST RESTRAINT $ 92.30 33302920 LARNGO INDIR RMV BODY $ 334.00 31511 33302953 LARYNGO DIAG $ 334.00 31575

78 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33302946 LARYNGO DIR DIAG $ 2,794.00 31525 33302938 LARYNGO DIR W/O TRAC $ 2,794.00 31515 33300924 LARYNGO FLEX W/RMVL FB $ 887.00 31577 33302912 LARYNGO INDIR DIAG $ 334.00 31505 41210381B LARYNGOSCOPY FLEX PROFESSIONAL$ 321.00 31575 32515017 LASER FIBER $ 1,145.95 32606601 LASER FIBER, FLEXIVA 1000 $ 890.00 32606304 LASER FIBER, FLEXIVA TRACTIP 2$ 625.00 32606403 LASER FIBER, SIDELITE $ 1,660.00 32606106 LASER FIBER, SLIMLINE 1000 $ 1,300.00 32606502 LASER FIBER, SLIMLINE EZ365 $ 450.00 32606205 LASER FIBER, SLIMLINE EZ550 $ 550.00 32514812 LASER NON CONTACT $ 1,271.05 31201650 LASER SURGERY $ 1,001.00 40704322 LASIX 100 MG/10 ML VIAL $ 23.85 40758682 LASIX 10MG/CC LIQUID $ 38.20 40707952 LASIX 20 MG TAB $ 3.25 40747792 LASIX 40 MG TAB $ 3.25 40738841 LASIX 40 MG/4 ML VIAL $ 17.05 40707978 LASIX TAB $ 3.25 40738833 LASIX VIAL 20MG/2ML VIAL $ 15.90 32532269 LATERAL HIP POSITIONER $ 124.25 32503625 LAVACUATOR $ 92.30 40759458 LAXATIVE OF CHOICE $ 3.25 41006220 LDCT FOR LUNG CA SCREEN $ 135.00 G0297 39900352 LDH $ 28.50 83615 39400189 LDH ISOENZYMES $ 44.25 83625 39404082 LDH-CL $ 36.75 83615 39403993 LDH-CSF $ 31.25 83615 39406913 LDL DIRECT $ 50.75 83721 39400270 LEAD - BLOOD $ 40.25 83655 31511637 LEAD ADAPTOR - BIVENTRICULAR$ 725.00 C1893 32533549 LEAD BI-VENT C.S. $ 7,001.40 C1900 31547869 LEAD BI-VENT C.S. $ 7,100.00 C1900 32533457 LEAD BI-VENT SCREW-IN $ 24,979.50 C1900 31200439 LEAD CAPSURE FIX SCREW-IN $ 1,898.55 C1898 31200512 LEAD CAPSURE SP-TINED $ 1,898.55 C1898 32531733 LEAD DEFIB SCREW IN $ 7,001.40 C1777 32531024 LEAD DEFIB SPL SP02 $ 7,001.40 C1895 32533887 LEAD PASSIVE PLUS DX TINED $ 1,898.55 C1898 32531550 LEAD TENDRIL DX SCREW-IN $ 1,898.55 C1898 40404097 LEFT ANKLE 4 VIEWS $ 137.00 73610 40404105 LEFT ANKLE AP AND LATERAL $ 101.10 73600 40405623 LEFT BREAST LOC 1ST LESION MAM$ 1,063.00 19281LT 40405722 LEFT BREAST LOC ADDED LESION$ I 120.00 19282LT 40480174 LEFT ELBOW ARTHROGRAM $ 847.00 73085LT 40500779 LEFT EYE US $ 299.25 76512 40480372 LEFT FEMUR 1 VIEW $ 134.42 73551LT 40481164 LEFT FEMUR 2 VIEWS $ 134.42 73552LT 40403818 LEFT FOOT AP AND LATERAL $ 120.00 73620 40403909 LEFT HAND 2 VIEWS $ 120.00 73120 40403859 LEFT HIP 2 VIEWS $ 134.00 73502 41000316 LEFT LOWER EXT WOUT $ 556.00 73700LT 40403024 LEFT MAMMO DUCTOGRAM $ 533.55 77053LT 40404303 LEFT PUNCTURE CYST ASPIRATION$ 722.20 19000LT 40402992 LEFT SHOULDER ARTHROGRAM $ 633.20 73040 40403990 LEFT STERNOCLAVICULAR JOINT$ 125.00 71130 40404113 LEFT TIBIA FIBULA $ 124.50 73590 40405705 LEFT WRIST ARTHROGRAM $ 751.52 73115LT 32503633 LEG BAG DISPOSABLE $ 45.60

79 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31304264 LEG BAG DISPOSABLE $ 46.00 32614026 LEG BAG DISPOSABLE $ 46.00 32510281 LEG STRAP CATH $ 23.85 31304363 LEG STRAP CATH $ 24.00 32614125 LEG STRAP CATH $ 24.00 32533747 LEGGINGS STERILE $ 15.75 39400361 LEGION ANTIBODY $ 111.25 86713 39400452 LEGION DIRECT IF $ 49.00 86255 39402276 LEGIONELLA AGLENINE $ 213.00 87541 40107567 LEGIONELLAPMEU URINE AG $ 117.00 87449 31201445 LENS INTRAOCULAR $ 1,036.00 C1780 32626104 LENS INTRAOCULAR $ 1,036.00 C1780 32507428A LENS RESTOR MULTIFOCAL INS CHG$ 1,036.00 C1780 32626005 LENS RESTOR MULTIFOCAL INS CHG$ 1,036.00 C1780 32507428 LENS RESTOR MULTIFOCAL MASTER$ 1,846.00 32507428B LENS RESTOR MULTIFOCAL PAT CHG$ 810.00 31549552 LENS RESTOR MULTIFOCAL PAT CHG$ 810.00 32614224 LENS RESTOR MULTIFOCAL PAT CHG$ 810.00 32507402A LENS TORIC ASTIG INS CHG $ 1,036.00 C1780 32625906 LENS TORIC ASTIG INS CHG $ 1,036.00 C1780 32507402 LENS TORIC ASTIG MASTER $ 1,446.00 32507402B LENS TORIC ASTIG PAT CHARGE $ 410.00 39475952 Leptospira IgM $ 94.00 86720 40763997 LESCAL 20MG $ 4.35 33300239 LESION FACE >4.0 $ 4,047.00 11446 33300213 LESION FACE 2.1-3.0 $ 1,834.00 11443 33300221 LESION FACE 3.1-4.0 $ 1,834.00 11444 40754772 LEUCOVORIN 350MG VIAL $ 453.60 J0640 40754772F LEUCOVORIN 50MG $ 64.80 J0640 40754772A LEUCOVORIN 50MG $ 64.80 J0640 40754772E LEUCOVORIN 50MG $ 64.80 J0640 40754772B LEUCOVORIN 50MG $ 64.80 J0640 40754772G LEUCOVORIN 50MG $ 64.80 J0640 40754772D LEUCOVORIN 50MG $ 64.80 J0640 40754772C LEUCOVORIN 50MG $ 64.80 J0640 42630092 LEUCOVORIN 50MG $ 384.00 J0640 40748717 LEUCOVORIN 50MG $ 384.00 J0640 42622073 LEUCOVORIN 50MG JW $ 384.00 J0640JW 40768806 LEUCOVORIN CALCIUM 5MG TAB$ 7.00 40755571 LEUKERAN TAB $ 3.40 40759219 LEUKINE 250MCG $ 261.40 J2820 40759219A LEUKINE 50MCG $ 52.30 J2820 40759219C LEUKINE 50MCG $ 52.30 J2820 40759219D LEUKINE 50MCG $ 52.30 J2820 40759219B LEUKINE 50MCG $ 52.30 J2820 40759219E LEUKINE 50MCG $ 52.30 J2820 42602235 LEUKINE(SARGRAMOSTIM) 500 MCG$ 838.00 J2820 40204140 LEUKORED RBC HANDLING $ 211.00 P9016 40201493 LEUKOREDUCED RBC HANDLING $ 189.50 P9016 39407117 LEVA DOPA $ 163.50 80299 40774325 Levaquin 250mg Tab $ 17.00 40763823 LEVAQUIN 500MG TAB $ 16.70 40768376 LEVAQUIN 750MG/150ML PRMX 24/C$ 169.00 J1956 40766404 LEVBID 0.125MG CAP $ 3.25 33100017 LEVEL 1 $ 200.00 99281 33100181 LEVEL 2 $ 400.00 99282 33100124 LEVEL 3 $ 700.00 99283 32100539 LEVEL 3 - MEDICAID $ 700.00 33100199 LEVEL 4 $ 1,150.00 99284 33100132 LEVEL 5 $ 1,700.00 99285

80 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40771677 LEVEMIR 100 UNITS/1ML VIAL $ 42.35 39407468 LEVETIRACETAM $ 117.75 80299 40783334 Levetiracetam 500mg/100ml NS $ 169.50 40766412 LEVID 0.375MG EX TAB $ 3.25 40751687 LEVOBUNOLOL HCL 0.5% 100GTTS/B$ 43.20 40763856B LEVOFLOXACIN 250MG IV $ 56.33 J1956 40766818 LEVOFLOXACIN 250MG/50ML PREMIX$ 56.33 J1956 42607819 LEVOFLOXACIN 500MG IV $ 112.66 J1956 40763856 LEVOFLOXACIN 500MG/100ML PRMIX$ 112.66 J1956 42627122 LEVOFLOXACIN 750MG IV $ 688.00 J1956 40772063 LEVOFLOXACIN 750MG TAB $ 82.00 40758443 LEVOPHED 4MG/4ML AMPULE 10/BX$ 34.60 40767238 LEVOTHROID 0.125MG $ 4.00 40772303 LEVOTHYROXINE 500MCG VIAL $ 195.00 40762262 LEVOTHYROXINE SOD 50 MCG TAB$ 3.25 40767196 LEVOTHYROXINE SODIUM 88MCG$ TAB 3.90 40756132 LEVOXINE 25MCG TAB $ 3.40 40766438 LEVSIN DROPS 0.125MG/ML BOTTLE$ 3.50 40768574 LEXAPRO 10MG TAB $ 8.00 40772939 LEXISCAN 0.4MG/5ML SYRINGE $ 206.00 J2785 40603101 LEXISCAN MYOCARDIAL PERF $ 1,517.60 78452 39900626 LH $ 101.75 83002 31517918 LHC + CORONARIES $ 8,180.00 93458 31518017 LHC + CORONARIES + BYPASS GRFT$ 8,180.00 93459 31518215 LHC + RHC + CORONARIES $ 8,180.00 93460 31518314 LHC W/VENTRICULOGRAPHY $ 8,180.00 93452 31518413 LHC+RHC W/VENTRICU NO CORONAR$ 8,180.00 93453 31520888 LHC+RHC+CORONARIES+BYPASS$ GRPH 7,530.00 93461 40708018 LIBRAX 5/2.5MG CAP $ 3.25 40708042 LIBRIUM 25MG CAP $ 3.25 40708026 LIBRIUM 5 MG CAPSULE $ 3.25 40738874 LIBRIUM AMP $ 35.65 40708034 LIBRIUM CAP $ 3.25 40753493 LIDEX 0.05% CREAM $ 40.80 40755761 LIDO/EPI 2% (200MG/20ML) VIAL$ 17.65 40783235 LIDOCAIN 5% CREAM 30 GRAM $ 51.00 39405048 LIDOCAINE $ 62.00 80176 42602912 LIDOCAINE 1% $ 8.00 40762312 LIDOCAINE 10MG/1ML 25/BX $ 14.10 40762361 LIDOCAINE 200MG/10ML VIAL $ 11.75 40762320 LIDOCAINE 20MG/ML $ 17.05 40759037 LIDOCAINE 4% TOPICAL $ 16.00 40771149 LIDOCAINE 40MG/5ML AMP $ 3.25 40762270 LIDOCAINE 40MG/ML $ 15.30 40783433 LIDOCAINE 5% PATCH $ 30.50 40755613 LIDOCAINE 5%/DEXTROS $ 27.05 40762379 LIDOCAINE HCL .5/EPI 50ML VIAL$ 17.65 40738882 LIDOCAINE HCL 2% 100MG/5ML $SYR 34.00 40762338 LIDOCAINE HCL 2% 200MG/10ML$ VI 15.30 40762296 LIDOCAINE HCL 5% $ 13.50 40762288 LIDOCAINE HCL2% JELLY 5ML TUBE$ 17.35 40752412 LIDOCAINE/D5W 2GM/500ML PREMIX$ 51.60 40781057 Lidocaine/phenylephrine PF Syr $ 81.50 32516361 LIGASURE 10MM ATLAS $ 625.00 32516338 LIGASURE ADVANCE $ 1,100.00 32605710 LIGASURE BLUNT TIP DIVIDER $ 1,088.00 32605611 LIGASURE CURVED SM JAW $ 978.00 32516379 LIGASURE MAX $ 350.00 31534009 LIGATION ARTERY EXTREMITY $ 917.00 37618 33304975 LIGATION MAJOR ARTERY EXTMTY$ 917.00 37618

81 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32532343 LIGATOR MULTIBAND $ 209.35 32514408 LIGATOR SPEEDBAND $ 470.60 32533648 LIGHT HANDLE COVERS $ 10.90 31547275 LIGHT HANDLE COVERS $ 11.00 32503658 LIMB HOLDERS $ 34.95 32625807 LIMB HOLDERS $ 35.00 32531519 LINEAR CUTTER $ 848.40 32625708 LINEAR CUTTER $ 849.00 31208539 LINEAR CUTTER $ 850.00 32507469 LINEAR STAPLER TA $ 231.90 40751323 LIORESAL 10MG TAB $ 3.25 39900097 LIPASE $ 50.25 83690 39905128 LIPID PRO MARKETING SCR $ 15.00 39900808 LIPID PROFILE $ 96.25 80061 40763864 LIPITOR 10MG TAB $ 4.95 40776107 Lipitor 20 mg Tab $ 16.00 40775612 LIPITOR 40mg TAB $ 18.00 40774721 Lipitor 40mg Tablet $ 18.00 39406830 LIPOPROTEIN A $ 101.25 83695 39406822 LIPOPROTEIN ELECTROPHERSIS $ 88.75 83700 39407062 LIPOPROTEIN, HIGH RES-VAP $ 114.75 83701 39600119 LISTECIA ANTIBODY $ 145.00 86723 40721037 LISTERINE ANTISEPTIC $ 5.75 39900899 LITHIUM BLOOD $ 45.25 80178 33303274 LITHO&EXTRAC STONE $ 4,625.00 52317 40751513 LITHONATE 300 MG CAPSULE $ 3.40 32515025 LITHOTRIPSY ESW $ 6,405.00 32511792 LITHOTRIPSY PROBE $ 761.60 40500167 LIVER $ 299.25 76705 40600561 LIVER AND SPLEEN SCAN $ 827.88 78215 39900980 LIVER PROFILE $ 62.50 80076 40600033 LIVER SCAN $ 827.88 78201 40600827 LIVER SPECT $ 2,807.00 78803 31203763 LLC CHLANGIOCATH $ 131.50 31200108 LOCAL ANES SUP $ 87.60 31404965 LOCAL ANES SUP $ 88.00 32625609 LOCAL ANES SUP $ 88.00 31203342 LOCKING SCREW $ 440.00 32513996 LOCKNUT LUMBAR $ 127.05 40708075 LOMOTIL 2.5/0.025MG TAB $ 3.25 40771339 LONAZEPAM 2MG/ML 10ML $ 16.50 33304074 LONG ARM POST SPLINT $ 284.00 29105 40931003 LONG ARM SPLINT APP $ 281.50 29105GO 40401028 LONG BONES $ 101.10 77074 31200736 LONG LEG CAST $ 105.20 33302821 LONG LEG SPLINT $ 584.00 29505 40507420 LONG US TRANSDUCER COVER $ 18.00 32517054 LONG US TRANSDUCER COVER $ 18.25 31903891 LONG US TRANSDUCER COVER $ 19.00 32625510 LONG US TRANSDUCER COVER $ 19.00 40758856 LOPID 600MG TABLET $ 3.40 40774523 LOPRESSOR 50 MG TABLET $ 3.25 40708083 LOPRESSOR 50 MG TABLET $ 3.25 40751109 LOPRESSOR 5MG/5ML VIAL $ 21.55 40751380 LOPROX 1% CREAM $ 25.80 40755779 LOPROX 1% LOTION 30M $ 50.70 40758872 LORABID 100MG/5C SUS $ 32.55 40758690 LORABID 200MG/5C SUS $ 54.35 40758989 LORACARBEF $ 7.15 40749897 LORAZEPAM 0.5MG TABLET $ 3.25

82 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40701690 LORAZEPAM 2 MG/1ML VIAL 10/BX$ 36.30 42601492 LORAZEPAM 2MG/2ML $ 27.00 J2060 40763799 LORTAB 2.5-108MG/5ML SOLUTION$ 5.65 40758351 LORTAB 5-325MG TABLET $ 3.40 40753477 LORTAB 7.5-325MG TABLET $ 3.40 40758781 LORTAB LIQUID $ 6.80 40759722 LOTENSIN 10MG TAB $ 3.25 40755027 LOTRIMIN 1% CREAM $ 45.20 40721094 LOTRIMIN 1% CREAM 15 GM TUBE$ 26.65 40721060 LOTRIMIN 1% SOLN 10M $ 23.45 40751273 LOTRISONE CREAM 15 GM TUBE $ 45.00 42626627 LOVENOX 60MG $ 252.00 J1650 42626231 LOVENOX 80MG $ 61.00 J1650 40401812 LOWER EXTREMITY CHILD $ 200.00 77076 40752958 LOZOL 1.25 MG TABLET $ 3.40 40402109 LS SPINE FLEX AND EXTENSION$ 170.35 72114 39403019 LS/PG PHOSPHATIDYL $ 78.00 84081 40474819 LSPINE FLEX AND EXT VIEWS ONLY$ 103.50 72120 40477600 LSPINE ONE VIEW $ 193.70 72020 41000456 LSPINE WITH CONTRAST $ 986.00 72132 41000100 LSPINE WOUT CONTRAST $ 939.00 72131 41000464 LSPINE WWOUT CONTRAST $ 1,402.00 72133 40404204 LT CALCANEUS $ 101.10 73650 40403982 LT CLAVICLE $ 124.50 73000 40404246 LT ELBOW 4 VIEWS $ 124.50 73080 40404253 LT ELBOW AP AND LAT $ 101.10 73070 41000745 LT ELBOW WOUT $ 666.00 73200LT 41000753 LT ELBOW WWO $ 944.00 73202LT 40500563 LT EYE FOREIGN BODY $ 299.25 76529 40404220 LT FINGERS $ 103.25 73140 40404170 LT FOOT 3 VIEWS $ 124.50 73630 41000907 LT FOOT ANKLE WO $ 556.00 73700LT 41000915 LT FOOT ANKLE WWO $ 944.00 73702LT 40404212 LT FOREARM $ 124.50 73090 40404238 LT HAND 3 VIEWS $ 124.50 73130 41000788 LT HAND WRIST WO $ 666.00 73200LT 41000796 LT HAND WRIST WWO $ 944.00 73202LT 40404071 LT HIP 1 VIEW $ 134.00 73501 41000820 LT HIP WO $ 556.00 73700LT 41000837 LT HIP WWO $ 944.00 73702LT 40404279 LT HUMERUS $ 124.50 73060 40404139 LT KNEE 4 VIEWS $ 150.50 73564 40404147 LT KNEE AP AND LATERAL $ 124.50 73560 40404121 LT KNEE W PATELLA SUNRISE $ 101.10 73564 40404154 LT KNEE W TUNNEL $ 101.10 73564 41000864 LT KNEE WO $ 556.00 73700LT 41000872 LT KNEE WWO $ 944.00 73702LT 40404063 LT RIBS $ 194.75 71101 40404055 LT SCAPULA $ 124.50 73010 40404048 LT SHOULDER 1 VIEW $ 101.10 73020 40404022 LT SHOULDER 2 VIEWS $ 136.00 73030 41000704 LT SHOULDER WOUT CONTRAST $ 666.00 73200LT 41000712 LT SHOULDER WWO CONTRAST $ 944.00 73202LT 40404196 LT TOES $ 103.25 73660 40401713 LT WRIST 4 VIEWS $ 124.50 73110 40403917 LT WRIST AP AND LATERAL $ 101.10 73100 31900830 LTA KIT $ 22.30 40758880 LUBRICATING JELLY UD $ 3.25 40758252 LUBRIDERM LOTION $ 18.45 40755266 LUDIOMIL TAB $ 3.40

83 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33452085 LUMB PUNCT ASSIST,ER CLINIC $ 1,294.00 62270 40401358 LUMBAR MYELOGRAM $ 1,477.00 62304 31700297 LUMBAR PUNCTURE $ 318.75 42602300 LUMBAR PUNCTURE $ 1,294.00 62270 33100280 LUMBAR PUNCTURE $ 1,294.00 62270 32513525 LUMBAR SPACER PLIF $ 2,754.15 C1763 40475818 LUMBAR SPINAL PUNCTURE $ 1,294.00 62270 40402091 LUMBAR SPINE AP LAT $ 103.25 72100 40402083 LUMBAR SPINE OBLIQUE $ 206.00 72110 40900367 LUMBAR TX $ 136.00 97012GP 32529331 LUMBO-SACRAL SUPPORT $ 111.10 40768210 LUMIGAN 0.01% OPTH DROP 5ML$ BT 363.00 41000530 LUNG MEDIASTINUM PERC BX $ 1,700.50 32405 40106940B LUP PTT $ 36.00 85732 40106940C LUP RUSSELL VIPER $ 61.00 85613 40106940A LUP THROMBOINHIB $ 57.00 85705 40106940D LUP TROMBIA TIME $ 36.00 85670 42625043 LUPRON 11.25 MG $ 12,060.00 J1950JG 42629894 LUPRON 22.5MG $ 15,366.00 J9217JG 40759151 LUPRON 3.75 MG $ 1,286.20 J1950 42602060 LUPRON 3.75 MG $ 4,020.00 J1950JG 40759748A LUPRON 3.75MG $ 835.95 J1950 40759748B LUPRON 3.75MG $ 835.95 J1950 42624449 LUPRON 30MG $ 19,164.00 J9217JG 42624548 LUPRON 45MG $ 28,746.00 J9217JG 40759748 LUPRON 7.5MG $ 1,563.85 J1950 42602557 LUPRON 7.5MG $ 4,791.00 J9217JG 42624746 LUPRON 7.5MG $ 8,040.00 J1950JG 40763526 LUPRON DEPOT 11.25MG $ 2,855.55 J1950 40763526A LUPRON DEPOT 3.75MG $ 951.85 J1950 40763526C LUPRON DEPOT 3.75MG $ 951.85 J1950 40763526B LUPRON DEPOT 3.75MG $ 951.85 J1950 39406103 LUPUS ANTICOAGULANT $ 125.00 85705 40106940 LUPUS ANTICOAGULANT $ 190.00 31533910 LUTONIX CATH, TRANSLUMIN, DRUG$ 2,062.00 C2623 39476744 LYME CSF WB $ 304.00 39476546 LYME CSF WB A $ 152.00 86617 39476645 LYME CSF WB B $ 152.00 86617 39400635 LYME DISEASE $ 153.75 86618 39408819 LYME DISEASE BY WEST BLOT $ 108.00 86617 39410767 LYME DISEASE WB $ 75.36 86617 40601650 LYMPHATICS AND LYMPH GLANDS$ 820.23 78195 32531832 LYMPHAZURIN BLUE 10 10 MG VIAL$ 643.50 Q9968 40764151 LYMPHAZURINL INJ $ 206.05 39407928 LYNE DISEASE BY WB $ 159.75 86617 40770935 LYRICA 100MG CAPSULE $ 8.00 40770208 LYRICA 25MG CAP $ 7.00 39477536 M .TUBERCULOSIS BY PCR DNA $ 441.25 87556 39475764A M.HOMINIS AMP.DNA PROBE $ 109.33 87798 40754517 M.T.E. 10 ML VIAL $ 18.15 40748972 M.V.I. 12 10 ML VIAL $ 15.80 42607996 M.V.I. 12 10ML VIAL $ 15.80 40756728 MAALOX 30 ML UDC $ 3.25 40755241 MAALOX PLUS SUSP $ 5.70 40727794 MAALOX SUSP $ 6.50 40754624 MAALOX TC SUSP $ 3.40 40754616 MAALOX TC SUSP $ 16.95 40708646 MACRODANTIN 50MG CAP $ 3.40 40601478 MAG 3 $ 304.25 A9562 39479714 MAG ANTIBODY MASTER $ 188.00

84 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39479714A MAG IGG $ 94.00 83516 40755977 MAGIC LOTION $ 16.20 40751067 MAGIC MOUTHWASH $ 32.40 40769457 MAGIC MOUTHWASH SOLN 5ML UDC$ 11.00 31505514 MAGIC TORQUE GUIDEWIRE $ 204.25 C1769 31502321 MAGIC TORQUE GUIDEWIRE - X $ 204.25 C1769 40755126 MAGNEFIST 10MM/20ML VIAL $ 279.00 39901079 MAGNESIUM BLOOD $ 32.25 83735 40759094 MAGNESIUM CHLORIDE 64MG CR$ TAB 3.25 40766792 MAGNESIUM INFUSION 4GM/250ML$ 153.50 39475863 MAGNESIUM RBC $ 42.25 83735 40770620 MAGNESIUM SULF 1GM/100ML BOLUS$ 52.00 40770679 MAGNESIUM SULF 2GM/50ML BOLUS$ 62.00 40766800 MAGNESIUM SULF 40GM/1000ML$ BAG 253.50 40772162 MAGNESIUM SULF 6GM/100 ML BAG$ 63.50 40739336 MAGNESIUM SULFATE 1GM/2ML VIAL$ 5.30 J3475 42609151 MAGNESIUM SULFATE 2GM $ 62.00 J3475 32699902 MAGNESIUM SULFATE 4GM 100ML$ 50.65 42609063 MAGNESIUM SULFATE 4GM/100ML$ 50.65 J3475 40739344 MAGNESIUM SULFATE 5GM/10ML$ VIA 12.15 J3475 39901749 MAGNESIUM UR $ 44.25 83735 31203698 MAGNETIC MAT $ 43.80 32639073 MAGNETIC MAT $ 43.80 40406316 MAGNIFICATION VIEW MAMMO BILAT$ 432.00 77066 40406217 MAGNIFICATION VIEW MAMMO LT$ UN 216.00 77065LT 40406118 MAGNIFICATION VIEW MAMMO RT$ UN 216.00 77065RT 32516601 MAGNUM MODULAR HEAD 50DM $ 1,593.85 32516593 MAGNUM PF CUP $ 4,203.15 32516619 MAGNUM TAPER ADAPTOR $ 494.10 40763831 MAG-OX 400 MG TABLET $ 3.25 32511263 MAINTAINER ANT CHAMB $ 280.25 39800115 MALARIA $ 46.50 87207 32503781 MALE INCONTINENT BAG $ 15.05 31200561 MALECOT $ 44.75 40755258 MALTSUPEX PWD $ 82.85 32533168 MAMMARY BOTTLE $ 69.20 32512774 MAMMARY BRA $ 266.25 32532897 MAMMARY FILL KITS $ 109.45 32507493 MAMMARY GEL IMPLANT $ 1,210.50 C1789 32514374 MAMMARY GEL SIZERS $ 338.95 C1789 32532806 MAMMARY GIROLE $ 150.65 32532988 MAMMARY IMPLANT $ 1,098.95 C1789 32533077 MAMMARY SUCTION TUBING $ 57.70 32533259 MAMMARY TISSUE EXPANDER $ 2,342.35 C1789 32507253 MAMMOSITE APPLICATOR $ 3,698.75 C1728 32517278 MAMMOSITE MULTILUMEN $ 3,562.50 C1728 32515579 MAMMOTONE PROBE $ 587.50 C1819 42011551 MAMMOTONE PROBE $ 588.00 C1819 40507717 MAMMOTONE PROBE $ 588.00 C1819 41293193 MANAGEMENT OF COURSE 1 OR 2$ FX 79.00 77431 40402539 MANDIBLE $ 103.25 70110 40477303 MANDIBLE LESS THAN 4 VIEWS $ 101.10 70100 40769200 MANGANESE SULF 4GM/100ML BAG$ 63.50 31501372 MANIFOLD KIT $ 124.25 31548067 MANIFOLD KIT $ 125.00 31505829 MANIFOLD KIT X $ 118.20 31544305 MANIFOLD KIT X $ 120.00 42601674 MANNITOL 12.5GM $ 23.00 J2150 40739385 MANNITOL 25% 250MG/ML VIAL $ 18.15 40900995 MANUAL TECHNIQUES JOINT $ 118.75 97140GP

85 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39505137 MAPLE BOX ELDER $ 13.00 86003 40753063 MARAX TAB $ 3.40 40775810 MARCAINE SPINL 0.75% 5MG/2ML$ V 25.00 40769291 MARINOL 2.5MG CAPSULE $ 52.00 32507790 MARKER MRI MAMMOTONE $ 202.00 C1819 39506028 MARSH ELDER ALLERGEN $ 13.00 86003 31505662 MARSHALL BALLOON $ 585.45 C1725 40800773 MASK AEROSOL $ 5.00 40800781 MASK OTFM $ 8.25 32533143 MASK OXYGEN/AEROSOL $ 4.65 31542226 MASK OXYGEN/AEROSOL $ 5.00 40800799 MASK SIMPLE $ 5.75 31903396 MASK, CO2 $ 38.00 32507998 MASK, ISOLATION $ 45.90 31546483 MASK, ISOLATION $ 46.00 40803934 MASK, NON-REBREATH. $ 5.75 40800807 MASK, TRACH $ 7.25 40800815 MASK, VENTURI $ 11.25 40900045 MASSAGE 15 MIN $ 72.00 97124GP 40932996 MASSAGE 15 MIN $ 72.00 97124GO 33304926 MASTOTOMY $ 3,629.00 19020 32510414 MATRESS DECUB - (DAILY) $ 53.90 41000415 MAXILLOFACIAL W CONTRAST $ 1,179.00 70487 41000407 MAXILLOFACIAL WOUT CONTRAST$ 722.00 70486 41000423 MAXILLOFACIAL WWO $ 1,358.00 70488 40721359 MAXITROL OPHT DROP 5ML BOTTLE$ 48.60 40721367 MAXITROL OPHT OINT 3.5GM TUBE$ 48.60 40750937 MAXZIDE 37.5/25MG TAB $ 3.25 31202450 MAYO COVER (DISPO.) $ 21.80 32625411 MAYO COVER (DISPO.) $ 22.00 40900847 MB/TRACTION CK DAILY, EQUIP $ 18.75 40755274 MCT OIL 946ML BOTTLE $ 128.50 40804635 MDI TREATMENT $ 406.00 94640 40601031 MDP $ 49.75 A9503 40600553 MECKELS BOWEL IMAGING $ 725.58 78290 32509796 MECONIUM ASPIRATOR $ 23.60 40107724 MECONIUM DRUG $ 140.00 80307 30259030 MEDICAL MANAGEMENT KLAA1 $ 1,940.00 40762783 MEDICATED BLUE 210GM $ 9.80 32507550 MEDNEXT DISSECTING BURR $ 155.00 31501398 MEDRAD SYRINGE $ 49.00 31501380 MEDRAD SYRINGE X $ 59.85 31540147 MEDRAD SYRINGE X $ 60.00 40708745 MEDROL 4 MG TABLET $ 3.25 40762445 MEDROL 4MG DOSEPAK $ 30.85 42616727 MEDROXYPROGESTERONE 150 MG/ML$ 313.00 J1050 40768459 MEDROXY-PROGESTERONE 5MG TAB$ 3.25 40754764 MEDS USED IN PHACO P $ 453.90 40804619 MEDS/NACL FOR TX $ 10.00 40756561 MEFOXIN 1GM VIAL $ 27.05 40764409 MEFOXIN 2GM VIAL $ 43.75 40704462 MEFOXIN IBTL $ 34.00 40704470 MEFOXIN IBTL $ 49.70 40764540 MEGACE 400 MG/10 ML UDC $ 273.65 40708786 MEGACE TAB $ 5.70 31502545 MEGALINK BILIARY STENT-X $ 2,429.60 C1877 31502693 MEGALINK STENT $ 1,738.95 C1877 40758419 MEGESTROL ACETATE 40 MG TAB$ 6.80 40776404 Melatonin 3mg Tab $ 3.25 40708810 MELLARIL 25MG TAB $ 3.25

86 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40755464 MELLARIL CONC $ 33.00 40758377 MELLARIL CONC $ 77.95 40753774 MELLARIL TAB $ 3.40 32511537 MEMORY BASKET $ 671.15 40769036 MENINGOCOCCAL VACC 1 VIAL $ 261.50 42605052 MENINGOCOCCAL VACCINE $ 85.00 90733 42605149 MENINGOCOCCAL VACCINE ADMIN$ 170.00 90471 32516031 MENISCAL DART $ 75.00 31203284 MENISCAL REPAIR KIT $ 1,104.50 32533325 MENISCUS ARROWS $ 493.45 40756140 MENTHOL CRY $ 11.15 40752503 MEPERGAN FORTIS 50-2 $ 4.55 40770489 MEPERIDINE 10MG/ML 50ML BAG$ 114.00 40745408 MEPERIDINE 50MG TAB $ 4.55 40745374 MEPERIDINE 75MG TUBE $ 17.05 40745366 MEPERIDINE HCL 100MG/ML AMP$ 17.05 40745390 MEPERIDINE HCL 25MG/0.5ML AMP$ 17.05 40745382 MEPERIDINE HCL 50MG/ML AMP $ 17.05 40762411 MEPIVACAINE 1.5% 30ML SING DOS$ 27.05 40708851 MEPROBAMATE TAB $ 3.25 40704173 MEPROBAMATE W/ASA TA $ 3.25 39400718 MERCURY $ 101.25 83825 40769184 MEROPENEM 1 GRAM VIAL $ 186.50 40764177 MERREN 1 GM VIAL $ 113.55 40764169 MERREN 500 MG VIAL $ 56.00 32533721 MESH COMPOSIX $ 626.60 C1781 32532921 MESH DUAL PLUS 15X19 $ 2,552.00 C1781 32514069 MESH DUAL PLUS 18X24 $ 1,765.35 C1781 32514077 MESH DUAL PLUS 20X30 $ 2,700.25 C1781 32506925 MESH MOSAIC 10X8 $ 1,760.00 C1781 32516106 MESH MOSAIC 4X6 $ 550.00 C1781 32516197 MESH MOSAIC 6X8 $ 1,086.80 32607096 MESH MOSAIC 6X9 $ 1,030.00 C1781 32606997 MESH MOSAIC 9X9 $ 450.00 C1781 32607195 MESH PARIETENE 20X20 $ 120.00 C1781 32606898 MESH PARIETENE15X10 $ 130.00 C1781 32607690 MESH PATCH CIRCLE LARGE $ 923.00 C1781 32607789 MESH PATCH CIRCLE MED $ 700.00 C1781 32607888 MESH PATCH CIRCLE SMALL $ 585.00 C1781 31206856 MESH RESTORELLE Y $ 1,150.00 32502700 MESH ROLLS, FINE $ 7.00 32625312 MESH ROLLS, FINE $ 7.00 32512592 MESH SOFT TISSUE $ 376.65 C1781 32610066 MESH, 10x14 BARD 0112660 $ 401.00 C1781 32609472 MESH, 3D MAXX, LEFT LARGE $ 788.00 C1781 32609571 MESH, 3D MAXX, LEFT MEDIUM $ 567.00 C1781 32609274 MESH, 3D MAXX, RIGHT LARGE $ 786.00 C1781 32609373 MESH, 3D MAXX, RIGHT MEDIUM$ 729.00 C1781 32610561 MESH, 6x6 BARD 012720 $ 702.00 C1781 32532830 MESH, CENTRIFX $ 325.00 C1781 32638578 MESH, CENTRIFX $ 325.00 C1781 32610264 MESH, CIRCLE VENTRIO 4.5 X 4.5$ 3,150.00 C1781 31200256 MESH, FINE $ 10.45 31200579 MESH, MARLEX $ 497.40 C1781 32608284 MESH, OVAL LARGE $ 1,763.00 C1781 32610363 MESH, OVAL LARGE VENTRIO $ 3,738.00 C1781 32608185 MESH, OVAL MED $ 1,350.00 C1781 32607591 MESH, OVAL SMALL $ 915.00 C1781 32610165 MESH, OVAL VENTRIO 10.8 X 13.7$ 3,435.00 C1781 32610462 MESH, OVAL VENTRIO 8.7 X 10.7$ 2,745.00 C1781

87 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32607987 MESH, OVAL XL $ 2,325.00 C1781 31201163 MESH, PLUG EXTENDED $ 655.00 C1781 32605314 MESH, POLYFORM $ 600.00 32605116 MESH, POLYPROPYLENE $ 400.00 C1781 32603631 MESH, ROLL, FINE $ 8.61 32608086 MESH, SELF FIXATING $ 787.00 32610759 MESH, SOFT 12X12 $ 608.00 C1781 32610660 MESH, SOFT 6x6 $ 891.00 C1781 32609868 MESH, VENTRALIGHT ST 10x13 $ 2,543.00 32609670 MESH, VENTRALIGHT ST SYS 4X6$ 885.00 C1781 32609967 MESH, VENTRALIGHT ST SYS 6X8$ 1,050.00 C1781 32517880 MESH, XENFORM $ 2,422.00 C1781 31201858 MESH-GRAFT 2 DERMAT $ 72.85 C1781 42611677 MESNA 200 MG - MULTI $ 253.00 J9209 40403073 METABOLIC BONE SURVEY $ 294.00 77075 40727877 METAMUCIL 3.4 GM PACKET $ 3.25 40756736 METAMUCIL SUNRISE SM $ 3.40 39400726 METANEPHRINES $ 72.75 83835 40749129 METAPREL SYRP $ 3.40 40751950 METARAMINOL BITARTRALE 100MG$ 32.95 J0380 40751950J METARAMINOL BITARTRALE 10MG$ 3.29 J0380 40751950G METARAMINOL BITARTRALE 10MG$ 3.29 J0380 40751950H METARAMINOL BITARTRALE 10MG$ 3.29 J0380 40751950I METARAMINOL BITARTRALE 10MG$ 3.29 J0380 40751950F METARAMINOL BITARTRALE 10MG$ 3.29 J0380 40751950A METARAMINOL BITARTRALE 10MG$ 3.30 J0380 40751950E METARAMINOL BITARTRALE 10MG$ 3.30 J0380 40751950D METARAMINOL BITARTRALE 10MG$ 3.30 J0380 40751950B METARAMINOL BITARTRALE 10MG$ 3.30 J0380 40751950C METARAMINOL BITARTRALE 10MG$ 3.30 J0380 40401036 METASTATIC BONE SURVEY $ 194.00 77075 40107310 METHADONE $ 176.00 80307 40767691 METHADONE 10MG $ 4.50 40745499 METHADONE 5 MG TABLET $ 3.40 40107716 METHANOL $ 50.00 84600 39406004 METHANOL $ 119.75 84600 40708869 METHERGINE 0.2 MG TAB $ 3.25 40739401 METHERGINE 0.2 MG/ML AMP $ 15.80 42601930 METHOTREX 50MG $ 145.00 J9260 39405287 METHOTREXATE $ 116.00 80299 40708877 METHOTREXATE 2.5 MG TABLET $ 10.25 42601757 METHOTREXATE 250 MG SINGLE $USE 50.00 J9250 40739427 METHOTREXATE 500/50MG $ 18.20 J9260 42602375 METHYL PRED UP TO 125MG $ 8.00 J2930 40739435 METHYLENE BLUE 1 ML VIAL $ 34.05 40758583 METHYLENE BLUE 1% 10ML AMP $ 32.95 39402185 METHYLMELONIC ACID $ 238.75 82542 40708844 METIMYD 0.5% OPH DRO $ 60.85 40721409 METIMYD 0.5% OPH OIN $ 56.70 40107864 METONEPHEINCS PLASMA $ 315.00 83835 40765968 METROGEL 0.75% 45G TUBE $ 144.30 40704843 METRONIDAZOLE 250MG TAB $ 3.25 40753782 METRONIDAZOLE TAB $ 4.55 32514630 METRX QUADRANT ILLUM $ 932.10 32533473 METRX RAD ILLUM $ 1,456.35 32514978 METRX RAD ILLUM II $ 2,088.45 40754251 MEVACOR TAB $ 5.70 40753964 MEZLIN PBACK $ 27.05 40755506 MEZLIN PBACK $ 32.95 40753972 MEZLIN PBACK $ 43.10

88 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40763518 MIACALCIN 200 units/,l 2ml via $ 6,929.50 J0630 40768079 MIACALCIN SPRAY 200 UNIT/SPRAY$ 114.00 39502448 MIC $ 56.75 87186 39406673 MIC, 2 DRUGS $ 28.25 87184 40768228 MICARDIS 80MG TAB $ 5.50 40701401 MICONAZOLE NIT CRM 14GM TUBE$ 28.35 40764730 MICONOZOLE -7 VAGINAL SUPP $ 27.00 32515769 MICRO GUIDE CATH $ 404.00 C1887 40756439 MICRO K 8MEQ TABLET $ 3.25 39406582 MICROALBUMIN,24 HR $ 35.00 82043 32516726 MICROFLOW SPACER $ 993.75 40701351 MICRO-K 10 MEQ TABLET $ 3.25 40755076 MICRONEFRIN 2.25% SO $ 34.05 32516452 MICROPLASTY ZEMORAL $ 5,737.00 40767063 MIDODRINE HCL 5MG TABLET $ 7.60 40771578 MIHOXIDIL 2.5MG TAB $ 3.25 40756744 MILK OF MAGNESIA 30 ML UDC $ 3.25 40727885 MILK OF MAGNESIA SUS $ 3.25 40777988 MILRINONE/D5W 20MG/100ML BAG$ 144.95 J2260 40756751 MINERAL OIL $ 3.40 40729964 MINERAL OIL $ 6.40 40753691 MINERAL OIL 2 ML VIAL $ 11.35 40727893 MINERAL OIL 30 ML UDC $ 4.50 32532434 MINI BAND LIGATOR $ 520.35 32531717 MINI TOME $ 254.30 40708919 MINIPRESS 1MG CAP $ 3.40 40749343 MINIPRESS CAP $ 3.40 31401417 MINI-TOME $ 218.00 40748212 MINIZIDE 1 CAP $ 3.25 40708927 MINOCYCLINE 50MG CAP $ 4.55 40767246 MINOXIDIL 10MG $ 5.30 31203680 MIOSTAT $ 134.25 40749228 MIOSTAT OPHTH 0.01% 1.5ML INJ$ 63.75 40766586 MIRALAX 17GM PACKET $ 6.50 40600983 MIRALUMA DOSE $ 311.75 A9500 40766537 MIRAPEK 0.125MG TABLET $ 3.25 40769358 MIRAPEX 0.25MG TAB $ 4.50 40804361 MISC. ADAPTER/CONN. $ 10.00 40804510 MISCELLANEOUS FILTER $ 15.00 31203888 MITEK G2 SNAP PAK $ 794.35 C1713 31203896 MITEK QUICK ANCHOR $ 660.00 C1713 32625213 MITEK QUICK ANCHOR $ 660.00 C1713 40759540 MITHRACIN VIAL $ 192.25 39401369 MITOCHRONDIALAB $ 63.00 86256 42601963 MITOMYCIN 20MG $ 803.00 J9280JG 42614351 MITOXANTORNE 5MG INJ $ 126.00 J9293JG 40758617 MIVACRON 100C INF BA $ 39.70 40758625 MIVACRON 10ML VIAL $ 39.70 30258931 MJR JOINT REPL OR SPINAL SX $ 1,980.00 41296354B MLC FOR IMRT DESIGN - FACILITY$ 594.45 77338 41296354A MLC FOR IMRT DESIGN - PHYSICIA$ 268.00 77338 41296354 MLC FOR IMRT DESIGN AND CONSTR$ 844.00 77338 41296453B MLC IMRT NEW BOOST PLAN FACILI$ 442.50 7733859 41296453 MLC IMRT NEW BOOST PLAN MASTER$ 856.00 41296453A MLC IMRT NEW BOOST PLAN PHYS$ 413.50 7733859 40107252B MMR MEASLES $ 40.00 86765 40107252A MMR MUMPS $ 40.00 86735 40107252C MMR RUBELLA $ 40.00 86762 42628112 MMR VACCINE $ 256.00 90707 42627617 MMR VACCINE ADMIN $ 170.00 90471

89 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40767253 MOBIC 7.5MG TABLET $ 8.10 40753790 MOBIDIN TAB $ 3.40 40920995 MOBILIZATION 15MIN $ 118.75 97140GO 33456087 MOD SED SAME PHY/QHP <5 YRS$ 61.00 99151 33456186 MOD SED SAME PHY/QHP >5 YRS$ 30.00 99152 33455988 MOD SED SAME PHY/QP ADDL 15$ MI 24.00 99153 40708943 MODANE TAB $ 3.25 40403461 MODIFIED BARIUM SWALLOW $ 615.50 74230 40915361 MODIFIED BARIUM SWALLOW EVAL$ 268.45 92611GN 40749814 MODURETIC TAB $ 3.25 40106866C MOL CYTO GENE-DNA PROBE EA$ 356.00 88271 40201584 MOL. CYTO DNA PROBE 1 $ 356.00 88271 40201675 MOL. CYTO DNA PROBE 2 $ 356.00 88271 40735318 MOM 30CC+CASCARA 5CC $ 3.40 40721433 MONISTAT 7 2% CREAM 30G TUBE$ 39.70 40754046 MONISTAT 7 SUPP $ 6.80 32604621 Monitor, Compartmental Pressur $ 174.00 31700362 MONITORED NERVE BLOCK $ 318.75 32201303 MONITORING LEG PLATE $ 59.50 40900318 MONKEY BAR SET UP, EQUIP $ 81.00 39601901 MONO TEST $ 48.25 86308 32510935 MONOFILAMENT CANNULA $ 487.20 40757775 MONOPRIL 10 MG TABLET $ 4.55 31203912 MONOPTY BIO. NEEDLE $ 555.00 32503807 MONTGOMERY STRAP $ 14.50 32625114 MONTGOMERY STRAP $ 15.00 40000869 MOR/TUMOR IMMUNO $ 103.00 88360 32603102 MORCELLATOR, ROTARY $ 1,049.00 32518060 MORCELLEX $ 937.50 C1782 40777295 Morphine 2mg syringe $ 17.00 40777196 Morphine 4mg/1ml VIAL 25/BX $ 17.00 40759466 MORPHINE IMMED. REL. $ 4.55 40703597 MORPHINE SULF 20MG/1ML ORAL$ CN 7.55 42606498 MORPHINE SULF 4MG/ML VIAL $ 8.00 40745978 MORPHINE SULF 8MG/1ML 1ML/VIAL$ 17.05 40763666 MORPHINE SULF IMMED $ 4.55 40777889 MORPHINE SULF/NS 30MG/30ML $PCA 114.00 J2770 40762528 MORPHINE SULFATE $ 32.95 40759078 MORPHINE SULFATE .5M $ 27.05 42602995 MORPHINE SULFATE 10MG $ 7.00 J2270 40745986 MORPHINE SULFATE 10MG/1ML VIAL$ 17.05 40770471 MORPHINE SULFATE 1MG/ML 50MLBA$ 114.00 40745994 MORPHINE SULFATE INJ $ 17.05 40770455 MORPHINE SULFATE INJ 5MG/ML$ VI 3.25 40752370 MORPHINE SULFATE PF $ 37.80 40753097 MORPHINE SULFATE SYR $ 17.05 40753402 MORRHUATE SODIUM VIA $ 135.00 40753527 MOTRIN (ADVIL) 200 MG TABLET$ 3.25 40708976 MOTRIN 400 MG TABLET $ 3.25 40703555 MOTRIN 600 MG TAB $ 3.40 39507216 MOUNTAIN JUNIPER $ 13.00 86003 39505632 MOUSE URINE ALLERGEN $ 13.00 86003 33304066 MOUTH LACERATION $ 288.00 41250 41101259 MR GUIDED NEEDLE PLACEMENT$ 752.00 77021 41100835 MRA ABD W CONTRAST $ 2,068.00 C8900 41100306 MRA ABD WO CONTRAST $ 2,068.00 C8901 41100926 MRA ABD WWO CONTRAST $ 3,732.00 C8902 41106902 MRA BILAT LOWER EXT WWO CONT$ 3,732.00 C8914 41100470 MRA BRAIN W CONTRAST $ 1,902.00 70545 41100462 MRA BRAIN WOUT CONTRAST $ 1,585.00 70544

90 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41100488 MRA BRAIN WWO CONTRAST $ 3,358.00 70546 41100652 MRA CHEST W CONTRAST $ 2,068.00 C8909 41100264 MRA CHEST WOUT CONTRAST $ 2,047.00 C8910 41100744 MRA CHEST WWO CONTRAST $ 3,732.00 C8911 41100678 MRA LEFT LOW EXT W CONT $ 2,068.00 C8912 41100298 MRA LEFT LOW EXT WOUT CONT $ 2,047.00 C8913 41100850 MRA LEFT LOW EXT WWO CONT $ 3,732.00 C8914 41103734 MRA LEFT UPPER EXT W CONT $ 1,179.00 C8934 41103833 MRA LEFT UPPER EXT WO CONT $ 964.20 C8935 41103635 MRA LEFT UPPER EXT WWO CONT$ 1,445.00 C8936 41100421 MRA NECK W CONTRAST $ 1,902.00 70548 41100439 MRA NECK WOUT CONTRAST $ 1,585.00 70547 41100256 MRA NECK WWO CONTRAST $ 2,027.00 70549 41103338 MRA PELVIS W CONTRAST $ 1,179.00 C8918 41103041 MRA PELVIS W CONTRAST $ 1,207.00 C8918 41100314 MRA PELVIS W OR WOUT CONTRAST$ 2,037.00 C8920 41103437 MRA PELVIS WO CONTRAST $ 1,729.00 C8919 41103140 MRA PELVIS WWO CONTRAST $ 729.00 C8919 41105021 MRA RIGHT LOW EXT W CONTRAST$ 2,068.00 C8912RT 41104922 MRA RIGHT LOW EXT WO CONT $ 2,047.00 C8913RT 41105318 MRA RIGHT LOW EXT WWO CONT$ 3,732.00 C8914RT 41105219 MRA RIGHT UPPER EXT W CONT $ 1,179.00 C8934RT 41105120 MRA RIGHT UPPER EXT WO CONT$ 964.20 C8935RT 41105813 MRA RIGHT UPPER EXT WWO CONT$ 1,445.00 C8936RT 41103239 MRA VENOGRAM $ 1,585.00 70544 41100413 MRI ABDOMEN W CONTRAST $ 2,179.00 74182 41100173 MRI ABDOMEN WOUT CONTRAST$ 2,051.00 74181 41100447 MRI ABDOMEN WWO CONTRAST $ 3,732.00 74183 41102060 MRI BILAT BREAST WWO CONTRAST$ 2,494.00 C8908 41101796 MRI BILATERAL BREAST WO CONTRA$ 1,906.00 77047 41100041 MRI BRAIN W CONTRAST $ 2,893.00 70552 41102942 MRI BRAIN W MRA WO BUNDLE $ 4,478.00 70552 41100033 MRI BRAIN WOUT CONTRAST $ 2,051.00 70551 41100215 MRI BRAIN WWO CONTRAST $ 3,732.00 70553 41102854 MRI BRAIN WWO MRA WO BUNDLE$ 5,317.00 70553 41100074 MRI CERVICAL SPINE W CONTRAST$ 2,893.00 72142 41100066 MRI CERVICAL SPINE WO CONTRAST$ 2,051.00 72141 41100454 MRI CHEST W CONTRAST $ 2,893.00 71551 41100058 MRI CHEST WOUT CONTRAST $ 2,029.00 71550 41100496 MRI CHEST WWO CONTRAST $ 3,732.00 71552 41100223 MRI CSPINE WWO CONTRAST $ 3,732.00 72156 41100363 MRI IACS WITH CONTRAST $ 2,893.00 70552 41100595 MRI IACS WOUT CONT $ 2,051.00 70551 41100587 MRI IACS WWO CONTRAST $ 3,732.00 70553 41101083 MRI L HAND WOUT CONTRAST $ 2,051.00 73218LT 41101091 MRI LEFT ACHILLES TENDON WOUT$ 2,051.00 73721LT 41101347 MRI LEFT BREAST W CONTRAST $ 984.00 C8903 41101611 MRI LEFT BREAST WO CONTRAST$ 953.00 77046 41101884 MRI LEFT BREAST WWO CONTRAST$ 1,247.00 C8905 41101075 MRI LEFT FOOT WOUT CONTRAST$ 2,051.00 73718LT 41100934 MRI LEFT HUMERUS WOUT CONT$ 2,029.00 73218LT 41100942 MRI LEFT HUMERUS WWO CONT $ 3,732.00 73220LT 41100405 MRI LEFT LOW EXT JOINT W CONTR$ 2,179.00 73722 41100165 MRI LEFT LOW EXT JT WOUT CONT$ 2,051.00 73721 41100512 MRI LEFT LOW EXT JT WWO CONT$ 3,732.00 73723 41100397 MRI LEFT LOW EXT NON JT W CONT$ 2,179.00 73719 41100157 MRI LEFT LOW EXT NON JT WOUT$ C 2,051.00 73718 41100504 MRI LEFT LOW EXT NONJT WWO $CON 3,732.00 73720 41100389 MRI LEFT UPPER EXT JT W CONT$ 2,179.00 73222 41100140 MRI LEFT UPPER EXT JT WOUT CO$ 2,051.00 73221

91 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41100132 MRI LEFT UPPER EXT NON JT WOU$ 2,029.00 73218 41100579 MRI LEFT UPPER EXT JT WWO CONT$ 3,732.00 73223 41100371 MRI LEFT UPPER EXT NON JT W CO$ 2,157.00 73219 41100561 MRI LEFT UPPER EXT NON JT WWO$ 3,732.00 73220 41100751 MRI LEFT WRIST WWO $ 3,732.00 73223LT 41100231 MRI LSPINE WWO CONTRAST $ 3,732.00 72158 41100884 MRI LT ANKLE WOUT $ 2,051.00 73721 41100892 MRI LT ANKLE WWO $ 3,732.00 73723 41101059 MRI LT CALF WO $ 2,051.00 73718 41101067 MRI LT CALF WWO $ 3,732.00 73720 41100694 MRI LT ELBOW WOUT $ 2,051.00 73221 41100702 MRI LT ELBOW WWO $ 3,732.00 73223 41100975 MRI LT FOREARM WOUT $ 2,029.00 73218 41100983 MRI LT FOREARM WWO $ 3,732.00 73220 41100785 MRI LT HIP WOUT $ 2,051.00 73721 41100793 MRI LT HIP WWO $ 3,732.00 73723 41100827 MRI LT KNEE WOUT $ 2,051.00 73721 41100843 MRI LT KNEE WWO $ 3,732.00 73723 41100629 MRI LT SHOULDER WOUT $ 2,051.00 73221 41100637 MRI LT SHOULDER WWO $ 3,732.00 73223 41101016 MRI LT THIGH WOUT $ 2,051.00 73718 41101024 MRI LT THIGH WWO $ 3,732.00 73720 41100736 MRI LT WRIST WOUT $ 2,051.00 73221 41100116 MRI LUMBAR SPINE W CONTRAST$ 2,893.00 72149 41100108 MRI LUMBAR SPINE WO CONTRAST$ 2,051.00 72148 41102698 MRI MRA BRAIN W CONT BUNDLE$ 4,795.00 70552 41102786 MRI MRA BRAIN WO CONT BUNDLE$ 3,636.00 70551 41102600 MRI MRA BRAIN WWO CONT BUNDLE$ 7,090.00 70553 41100520 MRI MYOCARDIUM W CONTRAST$ 1,909.00 41100181 MRI MYOCARDIUM WOUT CONTRAST$ 2,029.00 41100538 MRI ORBIT FACE NECK WITH CONT$ 2,893.00 70542 41100025 MRI ORBIT FACE NECK WO CONTRAS$ 2,051.00 70540 41100546 MRI ORBIT FACE NECK WWO CONTRA$ 3,732.00 70543 41100124 MRI PELVIS W CONTRAST $ 2,893.00 72196 41100553 MRI PELVIS WOUT CONTRAST $ 2,051.00 72195 41100330 MRI PELVIS WWO CONTRAST $ 3,055.00 72197 41105516 MRI R FOOT WOUT CONTRAST $ 2,051.00 73718RT 41105417 MRI R HAND WOUT CONTRAST $ 2,029.00 73218RT 41106506 MRI RIGHT ACHILLES TENDON WOUT$ 2,051.00 73721RT 41101435 MRI RIGHT BREAST W CONTRAST$ 984.00 C8903 41101708 MRI RIGHT BREAST WO CONTRAST$ 953.00 77046 41101972 MRI RIGHT BREAST WWO CONT $ 1,247.00 C8905 41104130 MRI RIGHT LOW EXT JOINT W CONT$ 2,179.00 73722RT 41104031 MRI RIGHT LOW EXT JT WWO CONT$ 3,732.00 73723RT 41105714 MRI RIGHT LOW EXT NON JT W CON$ 2,179.00 73719RT 41105615 MRI RIGHT LOW EXT NON JT WO $CO 2,051.00 73718RT 41103932 MRI RIGHT LOW EXT NON JT WWO$ C 3,732.00 73720RT 41106407 MRI RIGHT LOWER EXT JT WO CONT$ 2,051.00 73721RT 41106011 MRI RIGHT UPPER EXT JT W CONT$ 2,179.00 73222RT 41106704 MRI RIGHT UPPER EXT JT WO CONT$ 2,051.00 73221RT 41106110 MRI RIGHT UPPER EXT JT WWO CON$ 3,732.00 73223RT 41106308 MRI RIGHT UPPER EXT NON JT W$ C 2,157.00 73219RT 41105912 MRI RIGHT UPPER EXT NON JT WO$ 2,029.00 73218RT 41106209 MRI RIGHT UPPER EXT NON JT WWO$ 3,732.00 73220RT 41100868 MRI RT ANKLE WOUT $ 2,051.00 73721 41100876 MRI RT ANKLE WWO $ 3,732.00 73723 41101032 MRI RT CALF WO $ 2,051.00 73718 41101040 MRI RT CALF WWO $ 3,732.00 73720 41100660 MRI RT ELBOW WOUT $ 2,051.00 73221 41100686 MRI RT ELBOW WWO $ 3,732.00 73223

92 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41100959 MRI RT FOREARM WOUT $ 2,029.00 73218 41100967 MRI RT FOREARM WWO $ 3,732.00 73220 41100769 MRI RT HIP WOUT $ 2,051.00 73721 41100777 MRI RT HIP WWO $ 3,732.00 73723 41100900 MRI RT HUMERUS WOUT $ 2,029.00 73218RT 41100918 MRI RT HUMERUS WWO $ 3,732.00 73220RT 41100801 MRI RT KNEE WOUT $ 2,051.00 73721 41100819 MRI RT KNEE WWO $ 3,732.00 73723 41100603 MRI RT SHOULDER WOUT $ 2,051.00 73221 41100611 MRI RT SHOULDER WWO $ 3,732.00 73223 41100991 MRI RT THIGH WOUT $ 2,051.00 73718 41101008 MRI RT THIGH WWO $ 3,732.00 73720 41100710 MRI RT WRIST WOUT $ 2,051.00 73221 41100728 MRI RT WRIST WWO $ 3,732.00 73223 41100355 MRI SELLA WO CONTRAST $ 2,051.00 70551 41100348 MRI SELLA WWO CONTRAST $ 3,732.00 70553 41100090 MRI THORACIC SPINE W CONTRAST$ 2,863.00 72147 41100082 MRI THORACIC SPINE WOUT CONTRA$ 2,051.00 72146 41100249 MRI TSPINE WWO CONTRAST $ 3,732.00 72157 40106874 MRO SERVICE $ 7.25 41102511 MRV LEFT LOWER EXTREMITY W $CON 2,068.00 C8912 41106803 MRV PELVIS WWO CONTRAST $ 2,037.00 C8920 41106605 MRV RIGHT LOWER EXT W CONTRAST$ 2,068.00 C8912RT 40753535 MS 30mg/ml PCA Syringe $ 70.00 40762510 MS CONTIN $ 20.65 40759235 MS CONTIN 100MG $ 11.25 40759227 MS CONTIN SR 15 MG TABLET $ 4.55 40776800 MS CONTIN SR 30MG TAB $ 11.00 40759243 MS CONTIN SR 60MG TABLET $ 7.60 40754053 MS CONTIN TBSA $ 6.25 40754208 MSLT STUDY $ 1,935.00 95805 40755677 MSLT STUDY < 4 Naps $ 1,935.00 95805 40804759 MUCOMYST 20% (800MG/4ML) VIAL$ 6.50 40756272 MUCOMYST 20% 6000MG/30ML VIAL$ 153.65 40752859 MUCOMYST 20% 800MG/4ML VIAL$ 56.10 32504581 MUCOUS SPECIMEN TRAP $ 25.70 32625015 MUCOUS SPECIMEN TRAP $ 26.00 40600637 MUGA SCAN $ 730.00 78472 39505038 MULBERRY ALLERGEN $ 13.00 86003 40771487 MULTAG 400MG $ 15.00 32532889 MULTI BITE FORCEP $ 215.45 32624916 MULTI BITE FORCEP $ 216.00 31501406 MULTI PACK CATHETER $ 370.15 C1885 31505910 MULTI PACK CATHETER X $ 352.25 C1885 40763583 MULTI VITA LIQ 5ML UDC $ 3.25 31401151 MULTIBAND LIGATOR $ 445.00 31401102 MULTIPLE BIOPSIES $ 67.00 31401193 MULTIPLE POLYPECTOMY $ 91.00 31505134 MULTIPURPOSE A1 $ 62.90 C1885 31505191 MULTIPURPOSE A1 X $ 62.90 C1885 31501414 MULTIPURPOSE C $ 92.85 C1885 31501422 MULTIPURPOSE X $ 92.85 C1885 32532590 MULTISEAL CAP $ 37.35 31505951 MULTITORQUE VISE - X $ 42.70 40770398 MULTIVITAMIN ADULT TAB $ 3.25 39403472 MUMPS $ 50.75 86735 39407726 MUMPS 1GG $ 39.00 86735 39408185 MUMPS 1GM $ 42.00 86735 40107252 MUMPS,MEASLES,RUBELLA $ 120.00 40930891 MUSCLE TEST W/ NERVE TEST, COM$ 225.00 95886

93 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40930792 MUSCLE TEST W/ NERVE TEST, LIM$ 145.00 95885 40107625 MUSK ANTIBODIES $ 1,761.00 83519 40106908 MUSK HB $ 685.00 83519 40739518 MUSTARGEN VIAL $ 45.40 J9230 40756280 MUTAMYCIN 20MG VIAL $ 2,300.50 J9280 40739492 MUTAMYCIN 5MG $ 298.10 J9280 40755281 MWT STUDY $ 1,936.00 95805 40709008 MYAMBUTOL 100 MG TABLET $ 3.25 40763955 Myambutol 400mg tab $ 3.45 40772394 MYCAMINE 100MG VIAL $ 760.00 J2248 40767923 MYCELEX 10MG TAB $ 5.00 40751430 MYCELEX TROCHE $ 4.55 40107427A MYCO/UREA AMPLIFICATION $ 109.33 87798 39475764B MYCO/UREA AMPLIFICATION $ 109.33 87798 40107427C MYCO/UREA AMPLIFIED PROBE $ 109.33 87798 40721474 MYCOLOG II CREAM $ 32.85 39477437 MYCOPHENOLIC ACID $ 200.00 80180 39400817 MYCOPLASMA GROUP $ 119.25 86738 39475764 MYCOPLASMA/UREA URINE NA $ 219.00 40107427B MYCOPLASMA/UREAPLASMA Amplifca$ 109.33 87798 40107427 MYCOPLASMA/UREAPLASMA PCR $ 328.00 40756660 MYCOSTATIN 10,000U/G $ 26.20 40721441 MYCOSTATIN 100 MU/GM 15GM TUBE$ 26.20 40728214 MYCOSTATIN 100,000U/ $ 4.15 40728222 MYCOSTATIN 100000U/1ML 60ML$ BT 49.55 40755357 MYCOSTATIN POWDER 15 GM BOTTLE$ 54.90 40732356 MYCOSTATIN VAG TAB $ 4.55 40749988 MYDFRIN 2.5% 2.5ML BOTTLE $ 4.55 40763708 MYDRIACYL 1% 1 DROP $ 5.65 40749962 MYDRIACYL 1% OPHTH $ 64.15 39405113 MYELIN BASIC PROTEIN $ 24.25 83873 40727919 MYLANTA (GEN) UD 30M $ 3.25 40767683 MYLANTA 355ML $ 8.41 40758286 MYLANTA DOUBLE STR L $ 13.25 40758294 MYLANTA II 30ML UDC $ 3.25 40758278 MYLANTA II LIQ 5 OZ. $ 7.15 40727943 MYLANTA LIQUID $ 7.95 40727950 MYLICON DROP 40MG/0.6ML BOTTLE$ 24.95 40709057 MYLICON-80MG TAB CHEW $ 3.25 40600736 MYOCARDIAL PERF MULT $ 1,705.75 78452 40600744 MYOCARDIAL PERF SINGLE $ 2,531.08 78451 40739500 MYOCHRISINE 50 MG INJ $ 34.00 40739505 MYOCHRYSINE AMP $ 34.00 40921027 MYOFASCIAL MOBILIZATION 15MIN$ 118.75 97140GO 40901027 MYOFASCIAL MOBILIZATION 15MIN$ 118.75 97140GP 39400808 MYOGLOBIN $ 146.75 83874 40709073 MYSOLINE 250MG TAB $ 3.40 40770422 MYSOLINE 50MG TAB $ 3.25 39403043 N. MENINGITIDIS GRPA $ 32.25 87899 39403134 N. MENINGITIDIS GRPB $ 32.25 87899 39403225 N. MENINGITIDIS GRPC $ 32.25 87899 40763914 NA BICARB 50MEQ/50ML VIAL 10/P$ 17.05 40769887 NA CHLOR BABY NASAL DROP $ 8.00 40771941 NA CHLORIDE 10% 15 ML VIAL NEB$ 3.25 40704686 NAFCILLIN SOD 2 GM VIAL $ 34.00 32516056 NAIL ANKLE $ 3,311.00 C1713 32531881 NAIL FEMEROL SUPRA CONDYLOR$ 2,763.00 32517419 NAIL FEMORAL DISTAL $ 3,847.00 C1713 32515249 NAIL FEMORAL PERCUTANEOUS $ 2,382.70 32531790 NAIL FEMORAL RETROGRADE $ 1,883.85

94 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32513855 NAIL HUMERAL PROXINAL $ 2,677.00 32516999 NAIL HUMERAL TITANIUM $ 2,497.50 C1713 32517617 NAIL KIT, GAMMA, LONG $ 3,778.75 C1713 32516296 NAIL RECONSTRUCTION $ 3,128.00 32515678 NAIL REVISION $ 2,824.50 32517484 NAIL SUPRA CONDYLAR 10 X 170MM$ 3,235.00 32514135 NAIL TIBIAL GOLD DISTAL $ 2,111.35 32507659 NAIL TIBIAL META $ 2,521.00 C1713 32516023 NAIL TITANIUM ELASTIC $ 526.00 C1713 32513889 NAIL TROCH FIXATION $ 2,662.00 32517294 NAIL TROCHANTER RT< ASST SZ$ 2,384.00 C1713 32624817 NAIL TROCHANTER RT< ASST SZ$ 2,384.00 C1713 32512451 NAIL, DELTA FEMORAL $ 1,496.25 32512436 NAIL, DELTA TIBIAL $ 2,554.67 C1713 32624718 NAIL, DELTA TIBIAL $ 2,555.00 C1713 40709594 NALFON CAP $ 4.55 40772386 NALOXONE 2MG/2ML SYR $ 28.00 40770182 NALTREXONE 50MG TAB $ 17.50 40769929 NAMENDA 10MG TAB $ 8.00 39402003 NAPA $ 63.75 80192 40752511 NAPHCON FORTE 0.1% D $ 34.85 40758898 NAPROSYN 500 MG TAB $ 4.55 40709610 NAPROSYN TAB $ 3.40 42606047 NARCAN 0.4MG VIAL $ 29.00 40739914 NARCAN 0.4MG/1ML VIAL $ 27.25 40739906 NARCAN NEONATAL AMP $ 27.05 40765208 NAROPIN 0.2% 40 MG/20 ML AMP$ 16.20 40771735 NAROPIN 0.5% 100 MG/20 ML AMP$ 65.00 40765216 NAROPIN 0.5% 150MG/30ML VIAL$ 30.25 40777790 NAROPIN 20MG/10ML AMP $ 17.00 J2795 40766727 NAROPIN 2MG/ML 100ML BTL $ 65.30 J2795 40768871 NAROPIN 400MG/200ML BOTTLE $ 119.00 32503955 NASAL BALLOON $ 111.10 40402497 NASAL BONE $ 170.35 70160 33300486 NASAL BONE W/O MANIP $ 476.00 21310 33300494 NASAL BONE W/O STABI $ 2,810.00 21315 41357437 NASAL O2 1-3 HRS $ 53.50 41294994 NASAL O2 1-3 HRS $ 53.50 31900517 NASAL O2 CANNULA $ 32.00 32510364 NASAL PACKING $ 56.20 32532152 NASAL PACKING $ 350.00 32513368 NASAL SEPTAL BUTTON $ 341.25 32614323 NASAL SEPTAL BUTTON $ 342.00 32512626 NASAL SPLINT $ 147.65 32624619 NASAL SPLINT $ 148.00 40751026 NASALCROM 4% NASAL S $ 92.60 40752453 NASALIDE 0.025% NASA $ 78.95 40768830 NASAREL 29MCG SPRAY $ 196.00 40763922 NASONEX NASAL SPRAY $ 112.50 40805038 NASOPHARYNGEAL AIRWAYS $ 11.75 41295905 NASOPHARYNGOSCOPY $ 395.00 41295905A NASOPHARYNGOSCOPY FACILITY$ 338.00 92511 41295905B NASOPHARYNGOSCOPY PROFESSIONAL$ 57.00 92511 39503438 NASOPHARYNX CULTURE $ 74.00 87070 32100315 NATUS NB HEARING SCREEN $ 487.00 92585 40750853 NAVANE CAP $ 3.40 40758120 NAVANE CAP $ 4.55 42601021 NAVELBINE 10MG $ 69.00 J9390 42617519 NAVELBINE 10MG JW $ 69.00 J9390JW 32100018 NB - LEVEL 1 (ROUTINE) $ 650.00

95 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30500466 NB - LEVEL 2 (LBW) $ 410.00 32100364 NB - LEVEL 2 (LBW) $ 700.00 30300362 NB - LEVEL 2 (LBW) $ 700.00 30500554 NB - LEVEL 3 (SICK) $ 462.00 32100455 NB - LEVEL 3 (SICK) $ 750.00 30300453 NB - LEVEL 3 (SICK) $ 750.00 32100059 NB - LEVEL 4 (ICU) $ 540.75 32100273 NB - ROOM - IN $ 550.00 40106569 NB BLD.COLL.DEV $ 29.75 39400999 NB SCREEN-ABN. HGB. $ 20.50 83020 40106544 NB SCREEN-ABN. HGB. $ 25.50 83060 40106528 NB SCREEN-PKU $ 25.50 84030 39401088 NB SCREEN-PKU(PHENY) $ 20.50 83030 39401179 NB SCREEN-T4 $ 20.50 84437 40106536 NB SCREEN-T4 $ 25.50 84437 40768061 NEAMYCIN SULFATE 10GM POWDER$ 3.50 40800872 NEBULIZER, 700ML $ 14.75 40402042 NECK FOR SOFT TISSUE $ 186.00 70360 42011452 NEEDLE BIOSPY $ 97.00 40406613 NEEDLE BIOSPY $ 97.00 40507321 NEEDLE BIOSPY $ 97.00 32515884 NEEDLE BIOSPY $ 97.00 32624520 NEEDLE BIOSPY $ 97.00 32533507 NEEDLE COUNTER $ 8.10 32624421 NEEDLE COUNTER $ 9.00 32507857 NEEDLE HAWKINS $ 71.00 32510356 NEEDLE HUBER ST 22/1 $ 20.10 32509192 NEEDLE HUBERBENT 22/1 $ 30.90 32509671 NEEDLE HUBERBENT 20/1 $ 26.75 31532623 NEEDLE LOCALIZATION BY XR $ 344.00 77002 32604918 NEEDLE PASSER, FIRST PASS $ 400.00 32509960 NEEDLE PORT-A-CATH $ 70.90 32516155 NEEDLE POWER LOC $ 35.00 31902828 NEEDLE REGIONAL BLOCK $ 22.55 32624322 NEEDLE REGIONAL BLOCK $ 23.00 32515339 NEEDLE RESECTION $ 139.00 32515397 NEEDLE SCORPION $ 316.05 32531584 NEEDLE SUTURE PASSER $ 405.00 32639964 NEEDLE SUTURE PASSER $ 644.00 32515405 NEEDLE TRANSURETHRAL $ 96.60 41006717 NEEDLE TROCOR $ 47.00 40506331 NEEDLE TROCOR $ 47.00 32507717 NEEDLE TVOCOR $ 47.00 32513152 NEEDLE UTERINE $ 22.05 31403876 NEEDLE, INJECTION, ARTICULATIN$ 115.00 32518078 NEEDLE, SPINAL $ 101.00 41463860 NEG PRE WOUND <=50 SQ CM $ 642.00 97607 41463662 NEG PRES WOUND >50 SQ CM $ 642.00 97608 41451287 NEG PRES WT <=50 SQ CM $ 219.00 97605 41451386 NEG PRES WT > 50 SQ CM $ 330.75 97606 40753188 NEMBUTAL CAP $ 3.40 40746158 NEMBUTAL CAP $ 4.55 40751794 NEMBUTAL ELIXIR $ 6.80 40721714 NEODECADRON DROP $ 35.30 40721722 NEODECADRON OINT $ 15.20 40755340 NEOMYCIN POWDER $ 13.65 40709669 NEOMYCIN SULFATE 500 MG TAB$ 3.25 40721755 NEOSPORIN G.U. IRRIG 1ML AMP$ 26.10 40770174 NEOSPORIN GUIRRIGENT $ 58.00 40721763 NEOSPORIN OINT 15GM TUBE $ 11.35

96 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40753923 NEOSPORIN OINT UD PACKET $ 4.50 40721771 NEOSPORIN OPHT OINT 3.5GM TUBE$ 36.60 40721789 NEOSPORIN OPHTH GTTS 10ML SOLN$ 36.60 40741167 NEOSTIGMINE METH 10MG/10ML$ VIA 372.00 40721854 NEO-SYNEPHRINE 0.125 $ 8.00 40721847 NEO-SYNEPHRINE 0.25% $ 8.00 40721813 NEO-SYNEPHRINE 0.25% $ 9.10 40721839 NEO-SYNEPHRINE 0.5% $ 8.60 40721805 NEO-SYNEPHRINE 0.5% SPRAY 15ML$ 9.10 40739948 NEO-SYNEPHRINE 10MG/1ML VIAL$ 60.50 32507683 NEPHROSTOMY CATHETER $ 190.00 31541929 NEPHROSTOMY CATHETER $ 190.00 40765703 NEPHRO-VITE TAB $ 3.25 40764094 NEPRO RENAL NUTRI 237ML CAN$ 10.00 40751356 NEPTAZANE TAB $ 3.40 40930297 NERVE CONDUCTION STUDIES, 1-2$ 300.00 95907 40930495 NERVE CONDUCTION STUDY, 11-12$ 995.00 95912 40930594 NERVE CONDUCTION STUDY, 13 $OR 995.00 95913 40930198 NERVE CONDUCTION STUDY, 3-4$ ST 550.00 95908 40930099 NERVE CONDUCTION STUDY, 5-6$ ST 550.00 95909 40930396 NERVE CONDUCTION STUDY, 7-8$ ST 550.00 95910 40930693 NERVE CONDUCTION STUDY, 9-10$ S 995.00 95911 31200421 NERVE STIMULATOR $ 41.60 40766495 NESIRITIDE 1.5MG VIAL $ 1,722.45 J2325 32513137 NETTERVILLE BLOCK $ 502.75 42603013 NEULASTA 6MG $ 20,768.00 J2505JG 42618608 NEULASTA 6MG JW $ 20,768.00 J2505JW 40767972 NEULASTA 6MG/0.6ML SYR $ 8,840.00 J2505 42602730 NEUMEGA 5MG $ 782.00 J2355 40757767 NEUPOGEN 480MCG/1.6ML VIAL $ 708.75 J1442 40921332 NEUROMUSC REED 15MIN $ 83.00 97112GO 40901332 NEUROMUSCULAR REDUCTION 15MIN$ 83.00 97112GP 39403092 NEURONTIN $ 165.25 80299 40763302 NEURONTIN 100MG CAPSULE $ 3.35 40766255 NEURONTIN 300MG CAPSULE $ 3.25 32516676 NEUROVISION M5 MEP MODULE $ 2,517.50 40760324 NEUTRA-PHOS PACKET $ 3.25 41292035 NEW PATIENT OFFICE VISIT LEV $2 77.00 99202 41292047 NEW PATIENT OFFICE VISIT LEV $3 111.00 99203 41292059 NEW PATIENT OFFICE VISIT LEV $4 154.00 99204 41292064 NEW PATIENT OFFICE VISIT LEV $5 231.00 99205 41351369 NEW PT. OFFICE VISIT LEVEL 2 $ 77.00 99202 41351452 NEW PT. OFFICE VISIT LEVEL 3 $ 111.00 99203 41351544 NEW PT. OFFICE VISIT LEVEL 4 $ 154.00 99204 41351636 NEW PT. OFFICE VISIT LEVEL 5 $ 231.00 99205 40766925 NEXIUM 20MG $ 14.50 40770067 NEXIUM 40 MG VIAL $ 89.50 40779671 Nexterone 360mg/200ml IV Bag $ 141.50 J0282 40769556 NIACIN 500MG TAB $ 3.25 40709727 NIACIN TAB $ 3.25 40772261 NICARDIPINE 25MG/10ML VIAL $ 92.50 40751844 NICORETTE 2MG GUM $ 10.85 40755852 NICOTENE 14MG/24HR TD PATCH$ 11.75 40755878 NICOTENE 21MG/24HR TD PATCH$ 8.25 40755860 NICOTINE 7MG/24HR TD PATCH $ 8.35 40768764 NIFEREX FORTE 150MG CAP $ 3.25 40766446 NILANDRON 150MG TAB $ 29.70 40763013 NIMBEX @MG?ML INJ $ 56.80 40765851 NIMBEX 20MG/10ML VIAL $ 116.30 32512964 NIMS EMG TUBE $ 551.25

97 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32512956 NIMS PROBELELECTRODE $ 370.45 32503914 NIPPLE SHIELD $ 29.20 32201329 NIPPLE STIMULATION TEST $ 198.00 59020 30300511 NIPPLE STIMULATION TEST $ 198.00 59020 40762627 NITRAZINE PAPER 15 inch $ 47.40 40749798 NITRO 0.2MG/HR TD PATCH $ 7.95 40757015 NITRO 0.4MG/HR TD PATCH $ 7.95 40766669 NITRO 50MG/D5W/250 ML BOTTLE$ 67.00 32602005 NITRO SET $ 42.85 40757023 NITRO-DUR 0.1MG/HR TD PATCH$ 7.95 40758906 NITRO-DUR 0.6MG/HR $ 7.95 40756603 NITROGLYCERIN 0.4MG SL TABLET$ 15.40 40700346 NITROGLYCERIN 50MG/10ML VIAL$ 56.70 40749855 NITROGLYCERIN OINT 1GM PACK$ 4.50 40756595 NITROGLYCERIN TABLET $ 11.80 40756611 NITROGLYCERIN TABLET $ 15.40 40751729 NITROL 2% OINT $ 15.05 40768384 NITROLINGUAL 0.4MG 4.9GM SPRAY$ 129.00 40739963 NITROPRUSSIDE SOD 50MG/2ML$ VIA 2,863.00 40709776 NITROSTAT 0.15MG TABLETS $ 11.80 40701617 NITROSTAT TAB SL $ 3.25 40756454 NITROSTAT TAB SL $ 3.75 40752982 NIX 1% LIQUID $ 22.70 40753956 NIZORAL 2% CREAM 15GM TUBE$ 36.95 40735433 NIZORAL 200MG TAB $ 7.80 40602705 NM HEMANGIOMA $ 2,807.00 78803 40601643 NM LUNG PERFUSION WITH VENT$ 977.20 78582 40600181 NM LUNG SCAN PERFUSION $ 701.03 78580 40600694 NM RENOGRAM $ 933.53 78707 40600645 NM RENOGRAM CAPTOPRIL $ 933.53 78708 40602111 NM RENOGRAM LASIX $ 933.53 78708 40602408 NM THYROID SCAN $ 421.48 78013 40602507 NM THYROID UPTAKE $ 419.78 78012 39411163 NMR LIPID PANEL $ 23.00 80061 39411064 NMR LIPO PARTICLE $ 72.22 83704 39410965 NMR LIPOPROTEIN $ 95.22 40751463 NOCTEC CAP $ 3.25 40709800 NOLVADEX 10MG TAB $ 3.40 40757817 NON FORMULARY $2.00 $ 3.25 31523812 NON SCP THORACIC AORTA $ 5,782.00 36221 40931008 NON SELECTIVE DEBRIDEMENT $ 160.63 97602GO 40912203 NON SELECTIVE DEBRIDEMENT $ 160.63 97602GP 40931612 NON-ELEC OSCILLATORY PEP DVC$ 104.00 E0484GN 41221400 Non-ESRD Pt w acute renal fail $ 1,362.00 90935 40757825 NONFORMUALARY $12.00 $ 14.60 40757841 NONFORMUALRY $5.00 D $ 6.10 40757858 NONFORMULARY $10.00 $ 12.15 40757874 NONFORMULARY $14.00 $ 16.50 40757882 NONFORMULARY $16.00 $ 19.45 40757916 NONFORMULARY $3.00 D $ 4.55 40757973 NONFORMULARY $6.00 D $ 7.30 40757999 NONFORMULARY $7.00 D $ 8.50 40758013 NONFORMULARY $8.00 D $ 9.75 40758039 NONFORMULARY $9.00 D $ 10.95 40758070 NONFORMULARY RX $4.0 $ 5.75 41463464 NONINVAS VASC DX STUDY PROC$ 49.60 93998 71601127 NON-MONITORED ECG $ 242.00 93797 30258733 NONORTH SX+ACUTENEURO OLAA1$ 1,943.00 31530247 NONSELECTIVE CATH AORTA $ 479.00 36200 32201121 NON-STRESS TEST $ 228.50 59025

98 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30300784 NON-STRESS TEST INPT $ 228.00 59025 30300602 NON-STRESS TEST OUTPT $ 228.00 59025 40768657 NORCO 10-325MG TABLET $ 3.25 42604152 NORCO 10MG TABLET $ 3.25 40755472 NORCURON 10 MG VIAL $ 63.20 40779473 Norepinephrine 4mg/D5W 250ml $I 110.00 40769572 NORFLEX 30MG/1ML AMP 10/BX$ 37.00 40739971 NORFLEX AMP $ 21.85 32503930 NORMAL SALINE 1000CC $ 8.45 31905386 NORMAL SALINE 1000CC $ 9.00 31701889 NORMAL SALINE 1000CC $ 9.00 31550839 NORMAL SALINE 1000CC $ 9.00 31406252 NORMAL SALINE 1000CC $ 9.00 31303868 NORMAL SALINE 1000CC $ 9.00 32614422 NORMAL SALINE 1000CC $ 9.00 40757585 NORMAL SALINE 500ML BAG $ 32.95 40756389 NORMAL SALINE 50ML BAG $ 28.55 32508186 NORMAL SALINE 5OOCC $ 15.35 31552621 NORMAL SALINE 5OOCC $ 16.00 40752149 NOROXIN TAB $ 5.80 39401260 NORPACE $ 60.00 80299 40709842 NORPACE CAP $ 3.40 40709859 NORPACE CAP $ 3.40 40709867 NORPRAMIN TAB $ 3.25 40762577 NORTRIPTYLINE HCL 25MG CAPSULE$ 3.25 39406376 NORTRIPTYLLINE $ 194.00 80307 40774127 Norvasc 2.5mg Tab $ 6.50 40759250 NORVASC 5 MG TABLET $ 5.40 42604339 NORVASC 5MG TABLET $ 6.00 32501850 NOSE STOP $ 70.75 40748352 NOVAFED CAP SA $ 3.25 42601203 NOVANTRONE 25MG $ 4,500.00 J9293 40753550 NOVATRONE VIAL $ 1,634.05 J9293 40771685 NOVOLIN 70/30 100 UNITS/ML VIA$ 21.00 40771669 NOVOLOG 100 UNITS/ 1 ML VIAL$ 42.35 40771099 NOVOLOG 70/30 100U/1ML 10ML$ EA 42.35 40766008 NOVOSEVEN 1.2MG $ 3,297.25 Q0187 32509747 NOZ STOP NAS CAT KIT $ 147.15 40772543 NPLATE 250 MCG $ 4,265.00 J2796 42625835 NPLATE 250 MCG $ 6,352.00 J2796JG 42625934 NPLATE 500 MCG $ 12,704.00 J2796JG 40772642 NPLATE 500MCG VIAL $ 8,530.00 J2796 40804437 NPPV CIRCUIT $ 32.50 40804593 NPPV INITIAL SETUP $ 193.00 40804452 NPPV PER DAY $ 406.00 94660 40768913 NS 0.9% ADD-VANTAGE BAG 100ML$ 34.50 40767964 NS 1000ML 20MEQ KCL BAG $ 28.00 31208044 NS IMP ELECT NEUROSTIM STAGE$ I 33,020.68 31207549 NS IMP ELECT NEUROSTIM STAGE$ I RE14,019.70 64581 31207450 NS IMP NEUROSTIM ELEC, SACRAL$ 12,609.00 64561 31207648 NS IMP NEUROSTIM GEN $ 17,789.15 64590 31207351 NS IMP SAC NEUROMOD TEST ELECT$ 9,648.15 64561 31208143 NS IMP STAGE I NEUROSTIM MASTER$ 18,545.70 31207747 NS IMP, FULL SYS SACRO NEURO$ M 51,566.38 32518745 NS KIT, LEAD INTRODUCER $ 420.00 C1894 32518448 NS Lead Interstim permanant $ 4,106.00 C1778 32518646 NS LEAD, TEST INTERSTIM $ 840.00 C1897 31207252 NS LEVEL II ELECT ANAL OF DEVI$ 250.00 95972 32518547 NS Neurostimulator, Interstim $ 13,494.00 C1767 32518349 NS Programmer, Interstim $ 1,487.00 C1787

99 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31207846 NS TEST LEAD NEURO SAC MOD $MASTER 13,449.00 40769499 NS-40MEQ KCL 1000ML BAG $ 28.00 39409381 N-TERMINAL PROPEPTIDE $ 208.69 82523 40106890 N-TERMINAL PROPEPTIDE TYPE I$ 261.00 82523 40753105 NTG SPRAY $ 61.20 40764078 NUBAIN 10MG/ML MDV $ 17.05 40764086 NUBAIN 10MG/ML SDV $ 17.05 40766073 NUBAIN 20MG/1ML AMP $ 7.80 42617618 NUCALA 1 MG JW $ 99.00 J2182JGJW 42627221 NUCALA 100 MG $ 9,990.00 J2182TB 32514747 NUGAUZE PACKING $ 16.80 40721896 NUPERCAINAL 1% OINT $ 8.55 32100265 NURSERY ROOM PAC PATIENT $ 408.00 40762205 NUTRAMIGEN $ 13.30 40754368 NUTRAMIGEN 20 CAL/OZ $ 15.70 40709768 NUTRAMIGEN POWDER $ 54.40 40769820 NUTRIHEP $ 53.50 40727034 NYSTATIN 100,000U/ML $ 8.25 40762585 NYSTATIN OINT 15 GM TUBE $ 8.55 31204282 O.R. MINOR 1/2 HOUR $ 501.00 31200025 O.R. MINOR I 1ST HR. $ 1,268.00 31300049 O/P ENDOSCOPY RECOVERY ROOM/HR$ 37.00 30900922 O/P INF HYDRA/ADD HR $ 61.00 96361 30900864 O/P INF HYDRA/INITIAL $ 278.00 96360 32201634 O/P INF HYDRATE/ADD $ 61.00 96361 31010937 O/P INF HYDRATE/ADD HR $ 61.00 96361 30500508 O/P INF HYDRATE/ADD HR $ 61.00 96361 30200927 O/P INF HYDRATE/ADD HR $ 61.00 96361 30300925 O/P INF HYDRATE/ADD HR N/A $ 61.00 96361 31010846 O/P INF HYDRATE/INITIAL $ 278.00 96360 32210543 O/P INF HYDRATE/INITIAL $ 278.00 96360 30500441 O/P INF HYDRATE/INITIAL $ 278.00 96360 30200869 O/P INF HYDRATE/INITIAL $ 278.00 96360 30300867 O/P INF HYDRATE/INITIAL N/A $ 278.00 96360 31300205 O/P INF NON-CHEM EACH ADDL HR$ 122.00 96366 30900617 O/P INF NON-CHEMO 1ST HR $ 407.00 96365 30901102 O/P INF NON-CHEMO 2ND IV SITE$ 122.00 96368 31011000 O/P INF NON-CHEMO EACH ADDL$ HR 122.00 96366 30900625 O/P INF NON-CHEMO EACH ADDL$ HR 122.00 96366 32210642 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 31301195 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 31011099 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 30901300 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 30501119 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 30301218 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 30201114 O/P INF NON-CHEMO SEQ DIF MED$ 119.00 96367 32201428 O/P INFUS NONCHEMO EA ADD HR$ 122.00 96366 30500342 O/P INFUS NONCHEMO EA ADD HR$ 122.00 96366 30300248 O/P INFUS NONCHEMO EA ADD HR$ 122.00 96366 30210588 O/P INFUS NON-CHEMO EA ADD HR$ 122.00 96366 30200588 O/P INFUS NON-CHEMO EA ADD HR$ 122.00 96366 31300932 O/P INFUSION HYDRA/ADD'L HR $ 61.00 96361 31300866 O/P INFUSION HYDRATE/INITIAL$ 278.00 96360 30211141 O/P INFUSION HYDRATION ADDL$ HR 61.00 96361 30211053 O/P INFUSION HYDRATION-INITIAL$ 278.00 96360 31010556 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 32201410 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 31300296 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 30500334 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 30300230 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365

100 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30210570 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 30200570 O/P INFUSION NON-CHEMO 1ST HR$ 407.00 96365 30900484 O/P INJ IM/SUB Q $ 204.00 96372 30200794 O/P INJ IV PUSH/AD SAME MED>30$ 121.00 96376 32201725 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 31300809 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 31010754 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 30900807 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 30500433 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 30300800 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 30210965 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 30200810 O/P INJ IV PUSH/ADD DIFF MED $ 121.00 96375 31010218 O/P INJ IV PUSH/ADD SAME MED>3$ 121.00 96376 31010911 O/P INJ IV PUSH/INITIAL $ 395.00 96374 30900633 O/P INJ IV PUSH/INITIAL $ 395.00 96374 30300255 O/P INJ IV PUSH/INITIAL $ 395.00 96374 30200596 O/P INJ IV PUSH/INITIAL $ 395.00 96374 30900823 O/P INJ IV PUSH/SAME MED>30 $ 121.00 96376 30200711 O/P INJ SQ OR IM $ 204.00 96372 30210711 O/P INJ SQ OR IM $ 395.00 96374 31301096 O/P INJ. BY I.V. PUSH INITIAL $ 395.00 96374 31010739 O/P INJ. IM/SUB Q $ 204.00 96372 31300924 O/P INJ. SQ OR IM $ 204.00 96372 30210596 O/P INJECT BY IV PUSH-INITIAL $ 395.00 96374 30500359 O/P INJECT IV PUSH/INITIAL $ 395.00 96374 32201451 O/P INJECT SQ OR IM $ 204.00 96372 30500375 O/P INJECT SQ OR IM $ 204.00 96372 32201436 O/P INJECTION IV PUSH/INITIAL$ 395.00 96374 30300271 O/P INJECTION SQ OR IM $ 204.00 96372 30500482 O/P IV INFUSION TX 1ST HR $ 407.00 96365 30500490 O/P IV INFUSION TX ADD'L HR $ 122.00 96366 31204480 O/P LEVEL I NURSING $ 159.00 99203 32201386 O/P LEVEL I NURSING $ 226.00 G0463 31700677 O/P LEVEL I NURSING $ 226.00 G0463 31401714 O/P LEVEL I NURSING $ 226.00 G0463 31300759 O/P LEVEL I NURSING $ 226.00 G0463 31010382 O/P LEVEL I NURSING $ 226.00 G0463 30900757 O/P LEVEL I NURSING $ 226.00 G0463 30500300 O/P LEVEL I NURSING $ 226.00 G0463 30300206 O/P LEVEL I NURSING $ 226.00 G0463 30210653 O/P LEVEL I NURSING $ 226.00 G0463 30200653 O/P LEVEL I NURSING $ 226.00 G0463 32201394 O/P LEVEL II NURSING $ 226.00 G0463 31010473 O/P LEVEL II NURSING $ 226.00 G0463 30900849 O/P LEVEL II NURSING $ 226.00 G0463 30500318 O/P LEVEL II NURSING $ 226.00 G0463 30300214 O/P LEVEL II NURSING $ 226.00 G0463 30210661 O/P LEVEL II NURSING $ 226.00 G0463 30200661 O/P LEVEL II NURSING $ 226.00 G0463 32201402 O/P LEVEL III NURSING $ 226.00 G0463 31010564 O/P LEVEL III NURSING $ 226.00 G0463 30900948 O/P LEVEL III NURSING $ 226.00 G0463 30500326 O/P LEVEL III NURSING $ 226.00 G0463 30300222 O/P LEVEL III NURSING $ 226.00 G0463 30210679 O/P LEVEL III NURSING $ 226.00 G0463 30200679 O/P LEVEL III NURSING $ 226.00 G0463 30300123 O/P OBSERVATION/3RD MS/PER $HR 30.00 G0378 33105368 O/P OBSERVATION/ER/PER HOUR$ 30.00 G0378 32201378 O/P OBSERVATION/HR $ 30.00 G0378 30900328 O/P OBSERVATION/ICU/PER HOUR$ 30.00 G0378

101 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30200240 O/P OBSERVATION/MS/PER HOUR$ 30.00 G0378 30210240 O/P OBSERVATION/OF/PER HOUR$ 30.00 G0378 30500250 O/P OBSERVATION/PEDS/PER HOUR$ 30.00 G0378 31000052 O/P OBSERVATION/SD/PER HOUR$ 30.00 G0378 31010028 O/P RECOVERY PER HR $ 36.00 30500227 O/P RECOVERY PER HR $ 36.00 31300031 O/P RECOVERY ROOM/HR $ 36.00 30210224 O/P RECOVERY ROOM/HR $ 36.00 30200224 O/P RECOVERY ROOM/HR $ 36.00 32201360 O/P RECOVERY/HR $ 36.00 30300156 O/P RECOVERY/HR $ 36.00 30900971 O/P RECOVERY/ICU $ 36.00 30200729 O/P TRANSFUSION 1 UNIT BLOOD$ 827.00 36430 32201469 O/P TRANSFUSION 1 UNIT BLOOD$ 828.00 36430 30500383 O/P TRANSFUSION 1 UNIT BLOOD$ 828.00 36430 30300289 O/P TRANSFUSION 1 UNIT BLOOD$ 828.00 36430 30210729 O/P TRANSFUSION 1 UNIT BLOOD$ 828.00 36430 31300387 O/P TRANSFUSION 1U BLOOD $ 827.00 36430 31010119 O/P TRANSFUSION 1U BLOOD $ 827.00 36430 30900641 O/P TRANSFUSION 1U BLOOD $ 828.00 36430 32201477 O/P TRANSFUSION 2 UNITS BLOOD$ 1,653.00 36430 30500391 O/P TRANSFUSION 2 UNITS BLOOD$ 1,653.00 36430 30300297 O/P TRANSFUSION 2 UNITS BLOOD$ 1,653.00 36430 30210737 O/P TRANSFUSION 2 UNITS BLOOD$ 1,653.00 36430 30200737 O/P TRANSFUSION 2 UNITS BLOOD$ 1,653.00 36430 31300478 O/P TRANSFUSION 2U BLOOD $ 1,653.00 36430 31010200 O/P TRANSFUSION 2U BLOOD $ 1,653.00 36430 30900773 O/P TRANSFUSION 2U BLOOD $ 1,653.00 36430 32201485 O/P TRANSFUSION 3 UNITS BLOOD$ 2,480.00 36430 30500409 O/P TRANSFUSION 3 UNITS BLOOD$ 2,480.00 36430 30300305 O/P TRANSFUSION 3 UNITS BLOOD$ 2,480.00 36430 30210745 O/P TRANSFUSION 3 UNITS BLOOD$ 2,480.00 36430 30200745 O/P TRANSFUSION 3 UNITS BLOOD$ 2,480.00 36430 31010390 O/P TRANSFUSION 3U BLOOD $ 2,480.00 36430 30900815 O/P TRANSFUSION 3U BLOOD $ 2,480.00 36430 31300569 O/P TRANSFUSION 3U BLOOD $ 2,482.00 36430 32201493 O/P TRANSFUSION 4 UNITS BLOOD$ 3,306.00 36430 30500417 O/P TRANSFUSION 4 UNITS BLOOD$ 3,306.00 36430 30300313 O/P TRANSFUSION 4 UNITS BLOOD$ 3,306.00 36430 30210752 O/P TRANSFUSION 4 UNITS BLOOD$ 3,306.00 36430 30200752 O/P TRANSFUSION 4 UNITS BLOOD$ 3,306.00 36430 31010481 O/P TRANSFUSION 4U BLOOD $ 3,306.00 36430 30900930 O/P TRANSFUSION 4U BLOOD $ 3,306.00 36430 32201501 O/P TRANSFUSION 5 UNITS BLOOD$ 4,133.00 36430 30500425 O/P TRANSFUSION 5 UNITS BLOOD$ 4,133.00 36430 30300321 O/P TRANSFUSION 5 UNITS BLOOD$ 4,133.00 36430 30210760 O/P TRANSFUSION 5 UNITS BLOOD$ 4,133.00 36430 30200760 O/P TRANSFUSION 5 UNITS BLOOD$ 4,133.00 36430 31010572 O/P TRANSFUSION 5U BLOOD $ 4,133.00 36430 30901003 O/P TRANSFUSION 5U BLOOD $ 4,133.00 36430 42602748 O2 1-3 HRS AND SET-UP $ 54.00 42602565 O2 CANNULA $ 7.00 40804718 O2 FIXATION DEVICE $ 5.25 42602474 O2 MASK, NON-REBREATHER $ 7.00 42602037 O2 PER SHIFT $ 29.00 42602839 O2 SUPPLY TUBING $ 6.00 42602920 O2 TUBING CONNECTOR $ 7.00 39507018 OAK ALLERGEN $ 13.00 86003 39400767 OAK TREE-RAST $ 29.00 86003 41454455 OASIS SKIN SUB DISC PER SQ CM$ 13.00 Q4102JW

102 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41454356 OASIS SKIN SUB PER 1 SQ CM $ 20.00 Q4102 32532814 OASIS WOUND DRESSING 7X10 $ 194.00 32532905 OASIS WOUND DRESSING 7X20 $ 284.00 31502933 OASIS-VENOUS THROMBECTOMY$ 2,199.00 32527707 OB PACK, EMERGENCY $ 78.00 31201122 OBGYN PACK $ 123.00 32509283 OBGYN PACKS $ 130.00 32100422 OBSERV HF,CP, OR ASTHMA =>8HRS$ 819.00 31501448 OBTURATOR $ 34.00 31505290 OBTURATOR - X $ 31.00 31501455 OBTURATOR 6FR $ 34.00 31505381 OBTURATOR 6FR. X $ 31.00 31505076 OBTURATOR 7FR $ 31.00 31505472 OBTURATOR 7FR. X $ 31.00 32532202 OBTURATOR CENTRAL LINE $ 13.00 32515504 OCCLUSION CATHETER $ 343.00 C1757 39502539 OCCULT BLOOD $ 32.25 82270 40751232 OCEAN NASAL SPRAY 44ML BT/EACH$ 9.10 32534335 OCELOT $ 5,250.00 42613657 OCREVUS 1MG $ 208.00 J2350TB 42613756 OCREVUS 1MG JW $ 208.00 J2350TBJW 42623162 OCTREOTIDE 1 MG JW $ 678.00 J2353JGJW 42603976 OCTREOTIDE 1MG $ 678.00 J2353JG 42605774 OCTREOTIDE 25 MCG INJ $ 26.00 J2354 42622964 OCTREOTIDE 25 MCG JW $ 26.00 J2354JW 42625241 OCTREOTIDE 30 MG $ 20,340.00 J2353 40751836 OCUFEN 0.03% DROP 2.5ML EACH$ 4.55 40766115 OCUFLOX 0.3% OPHT SOL 5ML BT$ 117.75 41450594 OFFICE/OUTPT VISIT EST LEV1 $ 157.10 41450693 OFFICE/OUTPT VISIT EST LEV2 $ 225.40 41450792 OFFICE/OUTPT VISIT EST LEV3 $ 225.40 41450891 OFFICE/OUTPT VISIT EST LEV4 $ 299.15 41450990 OFFICE/OUTPT VISIT EST LEV5 $ 385.45 41450099 OFFICE/OUTPT VISIT NEW LEV1 $ 157.10 41450396 OFFICE/OUTPT VISIT NEW LEV4 $ 385.45 41450198 OFFICE/OUTPT VISIT NEW LEV2 $ 225.40 41450297 OFFICE/OUTPT VISIT NEW LEV3 $ 299.15 41450495 OFFICE/OUTPT VISIT NEW LEV5 $ 506.78 40779869 OFIRMEV 1,000 MG VIAL $ 136.00 J0131 39405477 OLIGO ALB $ 24.25 82040 39405386 OLIGO BANDS $ 24.25 83916 39405568 OLIGO IGG $ 24.25 82784 39405204 OLIGO PROTEIN $ 24.25 84157 39400569 OLIGOCLONAL BAND $ 72.25 83916 40769978 OMALIZUMAB 150MG VIAL $ 1,930.50 J2357 40769978S OMALIZUMAB 5MG $ 64.35 J2357 40769978I OMALIZUMAB 5MG $ 64.35 J2357 40769978P OMALIZUMAB 5MG $ 64.35 J2357 40769978E OMALIZUMAB 5MG $ 64.35 J2357 40769978Q OMALIZUMAB 5MG $ 64.35 J2357 40769978C OMALIZUMAB 5MG $ 64.35 J2357 40769978H OMALIZUMAB 5MG $ 64.35 J2357 40769978V OMALIZUMAB 5MG $ 64.35 J2357 40769978J OMALIZUMAB 5MG $ 64.35 J2357 40769978R OMALIZUMAB 5MG $ 64.35 J2357 40769978X OMALIZUMAB 5MG $ 64.35 J2357 40769978W OMALIZUMAB 5MG $ 64.35 J2357 40769978U OMALIZUMAB 5MG $ 64.35 J2357 40769978L OMALIZUMAB 5MG $ 64.35 J2357 40769978N OMALIZUMAB 5MG $ 64.35 J2357

103 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40769978AB OMALIZUMAB 5MG $ 64.35 J2357 40769978O OMALIZUMAB 5MG $ 64.35 J2357 40769978K OMALIZUMAB 5MG $ 64.35 J2357 40769978B OMALIZUMAB 5MG $ 64.35 J2357 40769978A OMALIZUMAB 5MG $ 64.35 J2357 40769978Y OMALIZUMAB 5MG $ 64.35 J2357 40769978AA OMALIZUMAB 5MG $ 64.35 J2357 40769978F OMALIZUMAB 5MG $ 64.35 J2357 40769978G OMALIZUMAB 5MG $ 64.35 J2357 40769978AC OMALIZUMAB 5MG $ 64.35 J2357 40769978M OMALIZUMAB 5MG $ 64.35 J2357 40769978D OMALIZUMAB 5MG $ 64.35 J2357 40769978T OMALIZUMAB 5MG $ 64.35 J2357 40769978AD OMALIZUMAB 5MG $ 64.35 J2357 40769978Z OMALIZUMAB 5MG $ 64.35 J2357 32500241 OMNI JUG $ 85.90 31404767 OMNI JUG $ 86.00 32624223 OMNI JUG $ 86.00 40782146 Omnicef 300mg capsule $ 17.00 40767857 OMNICEF SUSP 125 MG/5ML BOTTLE$ 222.00 40482253 OMNIPAQUE 240 50ML $ 100.00 Q9966 31208440 OMNIPAQUE 240 50ML $ 100.00 Q9966 32516551 OMNIPAQUE 300/ML $ 0.60 Q9967 40482055 OMNIPAQUE 300MG 100ML $ 200.00 Q9967 41006319 OMNIPAQUE 300MG 30ML $ 60.00 Q9967 40482154 OMNIPAQUE 300MG 50ML $ 100.00 Q9967 31511629 OMNIPAQUE 350/ML $ 2.00 Q9967 41107298 OMNISCAN 287MG 10ML $ 218.00 A9579 41107199 OMNISCAN 287MG 20ML $ 400.00 A9579 41107397 OMNISCAN 287MG 5ML $ 218.00 A9579 42629795 ON BODY INJECTOR $ 59.00 96377 40756249 ONCOVIN VIAL 2MG/2ML $ 174.65 40759144D ONDANSETRON 1MG $ 21.38 J2405 42626330 ONDANSETRON 1MG $ 23.00 J2405 42602771 ONDANSETRON 32MG $ 492.00 J2405 42612667 ONDANSETRON 4 MG TAB $ 71.00 40771586 ONDANSETRON 4MG TAB $ 81.00 40759144 ONDANSETRON 4MG/2ML VIAL $ 85.52 J2405 42626429 ONDANSETRON 8 MG TAB $ 129.00 42615341 ONIVYDE 1MG $ 145.00 J9205TB 42617420 ONIVYDE 1MG JW $ 145.00 J9205TBJW 42621380 ONIVYDE 1MG JW $ 145.00 J9205JW 31300015 OP SURG CTR STAGING $ 108.00 31300023 OP SURGE CTR EA ADD HR $ 17.00 42614846 OPDIVO 1 MG $ 96.00 J9299JG 42617717 OPDIVO 1 MG JW $ 96.00 J9299JGJW 33300858 OPEN TX OF FX PHALAN $ 4,531.00 28525 33300841 OPEN TX OF FX TOE $ 4,531.00 28505 40766750 OPENEX 0.63MG/3ML $ 176.00 40400889 OPERATIVE CHOLANGIOGRAM $ 418.00 74300 39403852 OPIATES $ 180.00 80307 40771081 OPIUM/BELLADONNA 60MG SUPPOSIT$ 12.00 31503097 OPTA PTA SYSTEM-X $ 505.00 C1725 31201676 OPTICAL URETHROTOME $ 59.00 40751372 OPTICROM 4% DROP $ 87.55 40770596 OPTIMENTAL VANILLA $ 26.00 32517609 OPUS MAGNUM/SMART STITCH $ 450.00 C1713 31200066 OR MAJOR I 1ST HR $ 1,712.00 40763849 ORABASE-B W/BENZOCAINE PASTE$ 8.40 32100224 ORAL GASTRIC FEEDING $ 27.00

104 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40779077 Orbactiv 1200mg (3x400mg vials$ 11,136.00 J2407JG 40402513 ORBITS $ 112.00 70200 42607908 ORENCIA (ABATACEPT) 10 MG $ 143.00 J0129 42618410 ORENCIA (ABATACEPT) 10 MG JW$ 143.00 J0129JW 39404108 ORGANIC ACID URINE $ 230.50 83918 39403928 ORGANIC ACID-PLASMA $ 223.75 83918 40728495 ORGANIDIN CONC SOL. $ 66.15 40728503 ORGANIDIN ELIXIR $ 3.40 40750903 ORGANIDIN TAB $ 3.25 39407133 ORGANISM ID, YEAST $ 92.75 87106 39401104 ORGANOPHOSPHATES $ 183.75 83918 40710444 ORNADE 75-12 CAP SA $ 3.25 32510067 ORTH. DRESSING $ 32.30 40924250 ORTHC/PROSTC MGMT SBSQ ENC$ 15 113.00 97763GO 40901654 ORTHC/PROSTC MGMT SBSQ ENC$ 15 113.00 97763GP 32594415 ORTHO LIGHT ILLUMINATOR $ 143.00 40921159 ORTHOTIC MNGT/TRAIN 15 MIN $ 110.00 97760GO 40901159 ORTHOTIC MNGT/TRAIN 15 MIN $ 110.00 97760GP 40753808 ORUDIS CAP $ 4.55 40751745 ORUDIS CAP $ 4.55 40702052 OS-CAL 500 MG TABLET $ 3.25 40763559 OSMITROL 20% 500CC $ 129.90 39401351 OSMOLALITY - BLOOD $ 30.00 83930 39400783 OSMOLARITY SERUM $ 31.50 83930 39401773 OSMOLARITY URINE $ 42.75 83935 40754319 OSMOLITE 8OZ $ 3.60 40768251 OSMOLITE HN 23/ML CAN $ 8.00 39401443 OSMOTIC FRAGILITY $ 48.25 85555 32507105 OSTEOCHONDRAL KIT $ 734.40 32517039 OSTEOSET RESORB BEAD KIT $ 1,618.75 32508046 OSTOMY POUCH w/ FILTER $ 8.75 32507170 OSTOMY BRIDGE LOOP $ 5.85 31302482 OSTOMY BRIDGE LOOP $ 6.00 32624124 OSTOMY BRIDGE LOOP $ 6.00 32606007 OSTOMY POUCH $ 5.00 31303967 OSTOMY POUCH $ 5.00 32614521 OSTOMY POUCH $ 5.00 40933293 OT EVAL HIGH COMPLEXITY $ 370.00 97167GO 40933590 OT EVAL LOW COMPLEXITY $ 214.00 97165GO 40933491 OT EVAL MOD COMPLEXITY $ 278.00 97166GO 40933392 OT RE-EVAL EST POC $ 145.00 97168GO 30258832 OTHER ORTHOPEDIC GLAA1 $ 1,960.00 40700411 OTOBIOTIC DROP $ 44.50 41351001 OUTPATIENT CONSULT LEVEL 2 $ 140.00 99242 41291014 OUTPATIENT CONSULT LEVEL 2 $ 140.00 99242 41351093 OUTPATIENT CONSULT LEVEL 3 $ 165.00 99243 41291026 OUTPATIENT CONSULT LEVEL 3 $ 165.00 99243 41351185 OUTPATIENT CONSULT LEVEL 4 $ 213.00 99244 41291038 OUTPATIENT CONSULT LEVEL 4 $ 213.00 99244 41351277 OUTPATIENT CONSULT LEVEL 5 $ 265.00 99245 41291040 OUTPATIENT CONSULT LEVEL 5 $ 265.00 99245 41296178 OUTPATIENT CONSULT LEVEL I $ 78.00 99241 39401534 OVA & PARASITES $ 42.50 87177 40765869 OVRAL 1 KIT TABLET $ 7.90 40741142 OXACILLIN 1GM VIAL $ 31.75 J2700 40750184 OXACILLIN 2GM VIAL $ 43.10 J2700 40711657 OXACILLIN CAP $ 3.25 39401625 OXALATE URINE $ 72.75 83945 42607201 OXALIPLATIN 0.5 MG $ 3.00 J9263 42620390 OXALIPLATIN 0.5 MG JW $ 3.00 J9263JW

105 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40770588 OXEPA UNFLAVORED $ 37.00 31903297 OXISENSOR, CEREBRAL $ 138.00 40769523 OXYCONTIN CR 20MG TAB $ 11.00 40763468 OXYCONTIN CR 40MG TABLET $ 8.65 40763450 OXYCONTIN HCL CR 10MG TABLET$ 4.35 40800930 OXYGEN 1-3 & SET-UP $ 53.50 40803678 OXYGEN 1-3 ONLY $ 30.50 40804601 OXYGEN PER SHIFT $ 27.50 40803942 OXYHOOD $ 60.00 40766149 OXYIR 5MG TAB $ 3.55 30300693 OXYTOCAV CHALLENGE TEST $ 198.00 59020 32201063 OXYTOCIN CHALLENGE TEST $ 198.00 59020 31401557 P.E.G. $ 879.00 39504840 P.NOTATUM $ 13.00 86003 39412054 P2Y12 (PLATELET FUNCTION) $ 154.00 85576 31501463 PA CATHETER C $ 136.15 C1725 31501471 PA CATHETER X $ 136.15 C1725 32532566 PACEMAKER BIVENT $ 21,828.00 C2621 32533481 PACEMAKER CABLE $ 101.25 31539751 PACEMAKER CABLE $ 110.00 31511728 PACEMAKER CABLE - BIVENTRICULA$ 83.00 31010721 PACEMAKER CHECK $ 83.00 31510738 PACEMAKER CHECK SUPPLIES $ 102.50 32533796 PACEMAKER DUAL DR $ 17,496.15 C1785 31550938 PACEMAKER DUAL DR $ 17,500.00 C1785 31511306 PACEMAKER GENERATOR REMOVAL$ 15,305.00 33233 31511819 PACEMAKER LEAD - OSCOR $ 1,014.00 C1898 32531618 PACEMAKER SINGLE SR $ 14,576.55 C1786 31541137 PACEMAKER SINGLE SR $ 14,700.00 C1786 32511974 PACEMAKER VVI $ 6,727.90 C2620 32509663 PACIFIER $ 3.25 31501489 PACING ELECTRODE 5FR $ 277.45 31545592 PACING ELECTRODE 5FR $ 280.00 31501497 PACING ELECTRODE 6FR $ 277.45 31540345 PACING ELECTRODE 6FR $ 280.00 32533713 PACK BASIC SETUP $ 28.55 32533309 PACK C-SECTION $ 188.50 32517328 PACK LAPORSCOPIC $ 148.00 32624025 PACK LAPORSCOPIC $ 148.00 32532327 PACK LAVH $ 113.15 32533689 PACK MAJOR ORTHO $ 135.65 32517310 PACK OPEN $ 126.50 32513681 PACK PACEMAKER $ 118.65 31541335 PACK PACEMAKER $ 120.00 31203847 PACK SHOULDER ARTHRO $ 358.20 32511057 PACK, KENNEDY SINUS $ 83.35 32596197 PACK, PERM CATH $ 147.00 31546879 PACK, PERM CATH $ 147.00 32623827 PACK, PERM CATH $ 147.00 42601385 PACLITAXEL 1MG $ 3.00 J9267 42619103 PACLITAXEL 1MG JW $ 3.00 J9267JW 31502107 PAD GROUNDING $ 43.50 31544107 PAD GROUNDING $ 44.00 41606000 PAD REHAB PER SESSION - SET $ 122.00 93668 32529158 PADS FOOT M $ 247.40 32504102 PADS INCONTINENT $ 24.00 32504128 PADS, SANITARY $ 15.35 31303571 PADS, SANITARY $ 16.00 32623926 PADS, SANITARY $ 16.00 40766370 PALGIC DS SYRUP $ 3.25

106 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40765158 PAMELOR 50MG **** $ 3.25 J8499 40750879 PAMELOR CAPSULE $ 3.25 42601146 PAMIDRONATE 30MG $ 104.00 J2430 40500175 PANCREAS $ 299.25 76705 40778186 PANCRELIPASE 5000 U CAPSULE $ 3.25 40765729 PANCRELIPASE 8000 $ 3.25 40770083 PANOKASE 1MG TAB $ 3.25 40722316 PANTHODERM CREAM $ 35.05 32513327 PANTIE MESH $ 13.25 40766206 PANTOPRAZOLE 40MG VIAL(PROTONI$ 117.00 C9113 40201758 PAP,TP $ 86.50 G0123 40201311 PAP,TP DIAG DR. INTERP $ 64.25 88141 40201220 PAP,TP DIAGNOSTIC $ 86.50 88142 40201931 PAP,TP SCREEN/RESCM DR.INTERP$ 64.25 88141 40201840 PAP,TP SCREEN/RESCRN $ 86.50 G0143 40740797 PAPAVERINE AMP $ 18.15 40758922 PAPAVERINE HCL 10ML $ 36.75 42602664 PARACENTESIS INI WO IMAG GUIDE$ 1,658.00 49082 42602847 PARACENTESIS SUBSEQ WO IMAG$ GU 1,658.00 49082 31402193 PARACENTESIS W IMAGING GUIDE$ 1,535.00 49083 33453216 PARACENTESIS W/ IMAGING $ 1,535.00 49083 33253117 PARACENTESIS W/O IMAGING $ 97.00 49082 33453117 PARACENTESIS W/O IMAGING $ 1,658.00 49082 31401201 PARACENTESIS WO IMAGING GUID$ 1,658.00 49082 40920078 PARAFFIN $ 51.50 97018GO 40900078 PARAFFIN $ 51.50 97018GP 40711053 PARAFON FORTE DSC TA $ 3.40 39478328 Paraneoplastic Profile $ 1,161.00 40753451 PARAPLATIN 50MG $ 194.40 J9045 40600710 PARATHYROID SCAN $ 625.83 78070 39404819 PARATYPHOID A $ 20.75 86000 39402508 PARATYPHOID B $ 20.75 86000 41452673 PARE/CUT BENIGN HYPERK LES >4$ 330.75 11057 41452574 PARE/CUT BENIGN HYPERK LES 2-4$ 324.00 11056 41452475 PARE/CUT BENIGN HYPERKER LES$ 1 219.00 11055 40728768 PAREGORIC LIQU $ 3.40 40756769 PAREGORIC LIQUID $ 3.40 40754525 PARENTAL AMINO ACID 1000ML IV$ 199.80 B5000 40871907 PARI LCD NEBULIZER $ 30.00 40872006 PARI MASK $ 22.00 40711061 PARLODEL TAB $ 4.55 41466929 Part Exc Bone Finger $ 2,860.00 26236 39405592 PARVOVIRUS B19 IGG $ 84.50 86747 39405683 PARVOVIRUS B19 IGM $ 84.50 86747 32509754 PAS SET UP $ 351.00 32510687 PAS SLEEVES ADD $ 178.30 32514291 PASSING PIN $ 148.05 40805723 PASSY-MUIR PMV 007 (AQUA) KIT$ 200.00 40768509 PATANOL 0.1% OPHT SOL 5ML BT$ 196.30 32513228 PATCH SYVEK NT $ 201.75 32513251 PATCH SYVEK NT - X $ 201.75 32511131 PATCH, CV 0.8 X 7.5 X 0.5 $ 588.95 C1781 32511172 PATCH, CV 2.5 X 15.0 X 0.5 $ 588.95 C1781 32517021 PATELLA TENDON ALLOGRAFT $ 2,868.75 32623728 PATELLA TENDON ALLOGRAFT $ 2,869.00 40000028 PATH CONS-COMP(CLIN) $ 227.50 80502 40000010 PATH CONS-LIMIT(CLIN $ 76.00 80500 32504367 PATIENT GOWNS ST. $ 11.85 40752040 PAVULON VIAL $ 36.40 40763260 PAXIL 20 MG TAB $ 5.70

107 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40753519 PCA PUMP CHARGE $ 113.40 40751778 PCE TAB $ 3.25 31521581 PCMKR GEN NEW W EX MUL LEADS$ 36,784.00 33221 31521779 PCMKR REM & REP GEN DUAL LEAD$ 20,652.00 33228 31521680 PCMKR REM & REP GEN SING LD $ 17,847.00 33227 31521878 PCMKR REM & REP GEN W MUL LD$ 36,784.00 33229 39901798 PCO2 $ 35.50 82803 40804254 PEAK FLOW METER $ 42.50 39507117 PECAN HICKORY ALLERGEN $ 13.00 86003 30500052 PED ICU ROOM $ 715.00 30500284 PED SEDATION ROOM $ 57.00 32100091 PED URINE COLLECTOR $ 4.00 40755449 PEDIAPRED SOLUTION $ 33.50 40770604 PEDIASURE 237ML CAN $ 8.00 40764235 PEDIASURE 8OZ CAN $ 4.10 40804627 PEDIATRIC 12 LEAD EKG $ 122.00 93005 30500260 PEDIATRIC NURSERY $ 331.00 39901889 PEDIATRIC PANEL $ 45.75 80048 32501868 PEDIATRIC URINE COL $ 5.85 40748949 PEDIAZOLE SUSP $ 37.80 40753543 PEDIOTIC SUSP $ 62.20 40764219 PEDTRACE $ 10.50 32510851 PEEL AWAY CATH 5/BOX $ 754.95 32511008 PEG TRAY SILICONE $ 603.50 33100298 PEG TUBE REPLACEMENT $ 433.00 43762 32529349 PELVIC BELT DOUBLE $ 111.10 33100033 PELVIC EXAM $ 14.00 40500183 PELVIC ULTRASOUND $ 300.50 76856 40401945 PELVIS $ 170.35 72170 40401994 PELVIS LEFT HIP MIN 4 VIEWS $ 222.62 73503LT 40477897 PELVIS RIGHT HIP MIN 4 VIEWS $ 222.62 73503RT 32507535 PEN MARKING SKIN $ 15.00 31538266 PEN MARKING SKIN $ 15.00 31502198 PENCIL, BOVIE $ 45.70 31548463 PENCIL, BOVIE $ 46.00 32594910 PENCIL, PLUME EVACUATING $ 135.00 40740821 PENICILLIN G 5 MU VIAL $ 15.90 40740813 PENICILLIN G POTASSI $ 12.50 40755563 PENICILLIN G POTASSI $ 31.75 40740888 PENICILLIN G SODIUM $ 58.00 49082 40711129 PENICILLIN V POTASSI $ 3.25 40728818 PENICILLIN VK 125MG/ $ 11.35 40756777 PENICILLIN VK 250MG/ $ 8.20 32504227 PENROSE DRAIN $ 23.10 32623629 PENROSE DRAIN $ 24.00 40765083 PENTASA 250MG $ 3.25 J8499 40758641 PENTOTHAL 400MG SYR $ 34.00 40711137 PEN-VEE K 500MG TAB $ 3.25 40872699 PEP INITIAL THERAPY $ 229.00 94667 40872798 PEP THERAPY SUBSEQUENT $ 229.00 94668 40763657 PEPCID 10MG TAB $ 3.25 40754079 PEPCID 20 MG/2 ML VIAL $ 22.70 40763039 PEPCID 20MG $ 4.45 40753915 PEPCID TAB $ 6.90 40759930 PEPTO BISMOL(240ML LIQUID) $ 11.90 41005527 PERC ASP OR INJ OF RENAL CYST/$ 2,336.00 50390 40507816 PERC BX OR EXC LYMPH NODE $ 2,994.00 38505 41004042 PERC DRAINAGE BY CATH CT GUIDE$ 2,745.10 49405 41004141 PERC PERI OR RETROPERI DRAIN$ B 2,745.10 49406 31201924 PERC.S/P CATH TRAY $ 177.20

108 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40746356 PERCOCET 5/325 MG TAB $ 4.55 42631577 PERCOCET 5/325 TABLET $ 4.55 40780661 Percocet 7.5/325 tablet $ 9.00 40777097 Percocet 7.5mg/325mg tablet $ 9.00 40746364 PERCODAN TAB $ 4.55 31501505 PERCUFLEX CATH CUFF KIT $ 74.15 31530544 PERCUTANEOUS CHOLECYSTOSTOMY$ 6,280.00 47490 40756488 PERDIEM $ 10.15 40703654 PERDIEM FIBER GRANUL $ 13.10 40758815 PERI COLACE LIQUID $ 3.25 40728826 PERIACTIN 2 MG/5 ML UDC $ 22.70 40703662 PERIACTIN 4 MG TABLET $ 3.25 40500274 PERICARDIAL EFFUSION $ 299.00 76604 31502586 PERICARDIAL WINDOW/DRAIN $ 3,140.00 31505233 PERICARDIALCENTESIS KIT $ 438.15 31502677 PERICARDIO CENTESIS $ 459.00 40759821 PERICOLACE SYRUP $ 10.85 40763625 PERIDEX MOUTHWASH 473ML BT$ 27.00 39407023 PERINUCLEAR ANCA (P-ANCA) $ 52.25 86225 41201009 PERITONEAL DIALYSIS CAPD $ 859.00 90945 41221103 PERITONEAL DIALYSIS CCPD $ 859.00 90945 33453315 PERITONEAL LAVAGE W/WO IMAGING$ 1,086.00 49084 33253315 PERITONEAL LAVAGE W/WO IMAGING$ 1,086.00 49084 40711210 PERITRATE SA TAB $ 3.40 40711202 PERITRATE TAB $ 3.25 42617915 PERJETA (PERTUZUMAB) 1MG JW$ 41.00 J9306JGJW 42613558 PERJETA (PERTUZUMAB) 1MG $ 41.00 J9306JG 32504300 PEROXIDE $ 3.55 31904287 PEROXIDE $ 4.00 31405460 PEROXIDE $ 4.00 32623530 PEROXIDE $ 4.00 42011650 PEROXIDE $ 7.00 41007014 PEROXIDE $ 7.00 40483250 PEROXIDE $ 7.00 32509556 PEROXIDE $ 7.00 31904089 PEROXIDE $ 7.00 31404668 PEROXIDE $ 7.00 32623431 PEROXIDE $ 7.00 40768244 PERPHENAZINE 2MG TABLET $ 3.25 40711178 PERSANTINE 25 MG TABLET $ 3.25 40602903 PERSANTINE MYOCARDIAL PERF $ 1,517.60 78452 40748824 PERSANTINE TAB $ 3.25 40748816 PERSANTINE TAB $ 3.25 31511801 PERT ASP/INJ RENAL CYST NEEDLE$ 2,336.00 50390 31511868 PERT TRANSHEPATIC S&I PORTO$ 1,836.00 75887 39479813 PERTUSSIS AB MASTER $ 261.00 39407673 PERTUSSIS CULTURE $ 63.00 87070 39479813B PERTUSSIS IGA $ 87.00 86615 39479813A PERTUSSIS IGG $ 87.00 86615 39479813C PERTUSSIS IGM $ 87.00 86615 41116445 PET LIMITED AREA $ 3,859.00 78811 41116544 PET SCAN BRAIN ALZHEIMER EVAL$ 2,816.00 78608 41116346 PET SKULL TO THIGH $ 3,859.00 78812 41116278 PET WHOLE BODY SCAN $ 3,859.00 78813 32515926 PEZZER CATHETER $ 55.00 40803959 PFT, NEBULIZER $ 19.50 40107666 PH ASSOC AUTOANTIBODY PANEL$ 330.00 86022 40107666C PH ASSOC IA/IIA $ 110.00 86022 40107666B PH ASSOC IB/1X $ 110.00 86022 40107666A PH ASSOC IIB/IIIA $ 110.00 86022

109 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39901970 PH BLOOD $ 17.25 83986 32533358 PHACO CARTRIDGE $ 7.95 31529554 PHARMA AGENT ADMIN $ 240.00 93463 40479283 PHARYNX OR LARYNX W FLUORO$ 354.02 70370 40765919 PHAZYME $ 3.25 40711251 PHAZYME 125 MG CAPSULE $ 3.25 39701453 PH-BDY FLD $ 14.00 83986 40728875 PHENER W COD 6.25/10MG/5ML $UDC 4.55 40711285 PHENERGAN 12.5MG UPP $ 6.35 40732554 PHENERGAN 25 MG SUPPOSITORY$ 7.30 42602144 PHENERGAN 25MG AMP $ 17.00 J2550 42627815 PHENERGAN 25MG TABLET $ 3.25 Q0169 42627419 PHENERGAN 25MG TABLET $ 3.25 40711293 PHENERGAN 25MG TABLET $ 3.25 40740904 PHENERGAN 25MG/1ML AMP 25/BX$ 17.05 40749384 PHENERGAN 50MG/1ML AMP $ 15.90 40728842 PHENERGAN 6.25 MG/5 ML UDC $ 3.40 40732562 PHENERGAN SUPP $ 8.80 40728859 PHENERGAN VC SYRUP $ 3.40 40728867 PHENERGAN VC W/COD 5ML UDC$ 3.40 40728883 PHENERGAN W/DEXTROM $ 3.25 40711335 PHENOBARBITAL 32.4 MG TAB $ 3.25 40764003 PHENOBARBITAL ELIXAR 30MG/7.5M$ 4.60 40740912 PHENOBARBITAL ELIXIR $ 3.40 39902069 PHENOBARBITAL LEVEL $ 65.25 80184 40740920 PHENOBARBITAL SOD 130MG/ML$ VIA 17.05 40756876 PHENOBARBITAL SOD 65MG/ML VIAL$ 15.90 40711350 PHENOBARBITAL TAB $ 3.25 40711327 PHENOBARBITAL TAB $ 3.25 40711343 PHENOBARBITAL TAB $ 3.25 40756165 PHENOL LIQUID $ 32.40 40759771 PHENYTOIN 125MG/5ML UDC $ 3.40 40735409 PHENYTOIN SODIUM 100MG/2ML$ VIA 10.82 J1165 40753576 PHENYTOIN SODIUM 250MG/5ML$ VIA 27.05 J1165 32515744 PHERIPHERAL CATHETER $ 3,523.60 C1714 31545493 PHERIPHERAL CATHETER $ 3,600.00 C1714 32509218 PHIL COLLAR MED $ 158.20 L0172 32532376 PHIL. COLLAR INFANT $ 168.30 L0172 32532285 PHIL. COLLAR PEDIATRIC $ 168.30 L0172 32509200 PHIL. COLLAR SMALL $ 168.30 L0172 32509226 PHIL. COLLLAR LARGE $ 129.65 L0172 40722332 PHISOHEX 3% LIQUID $ 28.40 40200131 PHLEBOTOMY $ 175.00 99195 42602227 PHLEBOTOMY THERAPEUTIC $ 175.00 99195 33303928 PHLEBOTOMY THERAPEUTIC $ 175.00 99195 40920961 PHONOPHORESIS I 15MIN $ 104.00 97035GO 40900961 PHONOPHORESIS I 15MIN $ 104.00 97035GP 40765034 PHOSLO 667MG TABLET $ 3.25 J8499 39405758 PHOSPHATIDYL QLY $ 70.50 84081 40107013 PHOSPHOLIPIDS $ 34.00 84311 39902150RP PHOSPHORUS $ 4.25 84100 39902150 PHOSPHORUS - SERUM $ 30.00 84100 39901129 PHOSPHORUS 24 HR.URI $ 68.25 84105 30500169 PHOTOTHERAPY DAILY $ 25.00 32100109 PHOTOTHERAPY DAILY $ 46.00 97028 32100257 PHOTOTHERAPY DOUBLE $ 46.00 97028 30500177 PHOTOTHERAPY DOUBLE $ 46.00 40201485 PHYS BB SERV,AUTH DE $ 74.00 86079 40200305 PHYS BB SERV,AUTH DE $ 74.00 86079 40201576 PHYS BB SERV,TRAN RE $ 137.75 86078

110 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40200297 PHYS BB SERV,TRAN RE $ 137.75 86078 40200289 PHYS BB SERVICE DIFF $ 100.50 86077 40201667 PHYS BB SERVICE DIFF $ 137.75 86077 39403365 PHYTANATE $ 295.00 82542 39402995 PHYTOHEMAGGLUTINN $ 179.00 86353 32595603 PICC LINE 5FR $ 190.00 31545097 PICC LINE 5FR $ 190.00 32531857 PICC LINE INTRODUCER $ 73.30 31546780 PICC LINE INTRODUCER $ 74.00 32623332 PICC LINE INTRODUCER $ 74.00 31514703 PICC PLACE 5Y+ NO FLUORO $ 2,381.00 36569 31552720 PICC PLACE 5Y+ RS&I $ 2,383.00 36573 31515240 PICC REPLAC SAME VEIN RS&I $ 2,381.00 36584 31515152 PICC W/PORT PART, REPLACE $ 5,179.00 36578 31501513 PIGTAIL $ 92.85 31538761 PIGTAIL $ 93.00 31401425 PIGTAIL STENT $ 102.00 32532707 PIGTAIL STENT $ 119.65 31501521 PIGTAIL STRAIGHT $ 92.85 31505639 PIGTAIL STRAIGHT X $ 88.25 31505548 PIGTAIL X $ 88.25 31542424 PIGTAIL X $ 90.00 39506424 PIGWEED ALLERGEN $ 13.00 86003 39400940 PIGWEED-RAST $ 28.75 86003 32504342 PILLOWCASES, STERILE $ 8.00 40758716 PILOCARPINE 0.5% OPH $ 25.15 40768350 PIMA SYRUP 325MG/5ML $ 3.25 32516536 PIN BI-PASS NITINOL $ 232.00 32534127 PIN FIXATION TEMPORARY $ 250.00 C1713 32507931 PIN GUARD ORTHO $ 15.00 32511636 PIN,ORTHOSORB $ 299.10 C1713 33301849 PINCH FRAFT OPEN AREA $ 954.00 15050 40728925 PINK COCKTAIL $ 4.35 32512550 PINS, ZIMMER-RUSCH $ 200.05 32623233 PINS, ZIMMER-RUSCH $ 201.00 32534226 PIONEER PLUS CATHETER $ 3,375.00 C1758 40764771 PIPERACIL/TAZO SOD 3.375GM VIA$ 56.53 J2543 40766511 PIPERACILIN/TAZ SOD 4.5GM VIAL$ 67.00 J2543 40764763 PIPERACILIN/TAZO SOD. 2.25GM$ 37.69 J2543 40764417 PIPRACIL 3GM VIAL $ 43.45 40749699 PIPRACIL IBTL $ 34.00 40749707 PIPRACIL IBTL $ 46.05 49082 40717936 PIPRACIL IBTL $ 61.60 40757007 PIPRACIL VIAL $ 31.75 40740946 PITOCIN 10 UNITS/1 ML VIAL $ 15.90 40769705 PITOCIN/LR 20 UNITS/1000ML BAG$ 63.50 40770570 PIVOT 1.5 CAL 237 ML LIQUID $ 29.00 39401716 PKU $ 27.50 31531336 PLACE GASTROSTOMY TUBE PERC$ 2,928.00 49440 33303092 PLACE NEEDLE INTROAS $ 292.00 36680 31534999 PLACE NEPHROS CATHETER $ 3,609.00 50432 31535098 PLACE NEPHROURETERAL CATH $ 3,608.00 50433 40711376 PLACEBO CAPSULE $ 3.25 40740995 PLACEBO INJ $ 10.80 40711400 PLAQUENIL 200MG TAB $ 3.40 39407086 PLASMINOGEN ASSAY $ 68.75 85420 32529547 PLASTER ROLLS $ 11.50 31201320 PLASTIC CONNECTOR $ 4.05 32507709 PLATE 1/3 TUB W/COLLAR $ 138.00 C1713 32514457 PLATE 10-14 HOLE $ 677.00

111 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32517625 PLATE CALCANEAL $ 2,118.75 C1713 32513939 PLATE CERV SPINE ALL $ 1,975.00 32514432 PLATE CHS 4-8 HOLE $ 619.00 32517559 PLATE CLAVICLE $ 1,531.00 C1713 32507600 PLATE CLOVERLEAF $ 638.00 32623134 PLATE CLOVERLEAF $ 638.00 32514416 PLATE COMP 5-7 HOLE $ 1,105.65 32623035 PLATE COMP 5-7 HOLE $ 1,106.00 32514424 PLATE COMP 9-11 HOLE $ 1,328.25 32514887 PLATE DCP $ 318.00 32514952 PLATE DCP NARROW $ 210.00 32514440 PLATE FEMORAL $ 1,816.20 32517633 PLATE HOOK $ 875.00 C1713 32602344 PLATE LOCK FLARED $ 4,062.00 C1713 32622936 PLATE LOCK FLARED $ 4,062.00 C1713 32507618 PLATE OBLIQUE T1 $ 371.00 32515124 PLATE ORTHO $ 840.00 31202567 PLATE SMALL FRAG. $ 331.00 32640063 PLATE SMALL FRAG. $ 465.00 32507519 PLATE STRAIGHT $ 307.00 32622837 PLATE STRAIGHT $ 307.00 32533838 PLATE TIBIAL STEMED $ 2,252.25 32622738 PLATE TIBIAL STEMED $ 2,253.00 32514879 PLATE TUBULAR $ 401.00 32517385 PLATE VOLAR RADIUS $ 1,306.00 C1713 32514481 PLATE Y CALCANEAL $ 558.35 31202559 PLATE, BASIC FRG $ 559.25 32517708 PLATE, LCP CONDYLOR $ 2,276.25 C1713 32517377 PLATE, LEFT VDR $ 1,306.00 C1713 32518011 PLATE, LOCK $ 3,750.00 C1713 31202575 PLATE, MINI FRAG $ 401.00 32532178 PLATE, RECONSTRUCTION $ 672.90 40107369 PLATELET AB DIRECT $ 265.00 86022 40107450 PLATELET AB PANEL $ 560.00 86022 39801451 PLATELET COUNT $ 16.75 85049 40107450A PLATELET PANEL 1 $ 140.00 86022 40107450B PLATELET PANEL 2 $ 140.00 86022 40107450C PLATELET PANEL 3 $ 140.00 86022 40107450D PLATELET PANEL 4 $ 140.00 86022 31505597 PLATINUM GUIDE WIRE $ 315.60 C1769 31502149 PLATINUM GUIDEWIRE - X $ 315.60 C1769 40764284 PLAVIX 75 MG TABLET $ 6.65 40765059 PLENDIL ER 5MG TABLET $ 3.25 J8499 40765927 PLETAL 100MG TABLET $ 4.30 39502992 PLEURAL FLUID CULTUR $ 65.75 87070 31533514 PleurX Catheter Kit $ 1,060.00 31537177 PLMT BILI DRAIN CATH INT/EXT $ 6,280.00 47534 31535197 PLMT BILIARY DRAIN CATH EXT $ 6,280.00 47533 31534504 PLMT URETERAL STENT/EXISTING$ 5,578.00 50693 31534603 PLMT URTRL STENT/NEW ACCESS$ 5,578.00 50694 31534702 PLMT URTRL STNT/NEW/SEP CATH$ 5,578.00 50695 39401724 PLT AB DIRECT $ 182.50 86023 39406273 PLT AB INDIRECT $ 182.50 86022 40200057 PLT CONCENTRATE HANDLING $ 41.00 P9019 40200693 PLT PHERESIS $ 32.00 86999 40200230 PLT PHERESIS HANDLING $ 495.00 P9034 42605237 PNEUMOCOCCAL VACCINE $ 134.00 90732 42605325 PNEUMOCOCCAL VACCINE ADMIN$ 68.00 G0009 40771495 PNEUMONIA VACC 25MCG/0.5ML $VIA 134.00 90732 32533093 PNEUMOTHORAX KIT $ 183.10

112 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31511967 POCKET REVISION ICD S/D $ 3,273.00 33223 31511876 POCKET REVISION PACE S/D $ 3,273.00 33222 32512683 POLAR PAD TMJ $ 120.15 40728933 POLARAMINE SYRUP $ 28.40 32515629 POLARUS NAIL $ 2,000.00 42623360 POLIO VACCINE $ 91.00 90713 42622766 POLIO VACCINE ADMIN $ 170.00 90471 40754376 POLYCOSE LIQUID $ 4.75 40756298 POLYCOSE POWDER $ 15.45 40750606 POLYMOX SUSP $ 5.10 40724767 POLYMOX SUSP $ 22.70 40778087 POLYMYXIN B 500,000 UNIT/VIAL$ 37.00 40759045 POLYMYXIN B SULFATE $ 55.10 40768731 POLYSACCHARIDE IRON 150MG $ 3.25 40759862 POLYSPORIN OINTMENT 15 GM TUBE$ 5.20 40754574 POLYTRIM DROP $ 50.85 40756686 POLYVINYL ALCOHOL 1. $ 21.85 40728941 POLY-VI-SOL DROP $ 26.95 40728958 POLY-VI-SOL W/FE DROP $ 26.95 40770364 PONTOCAINE 2% 30ML VIAL $ 60.50 39401807 PORPHOBILINOGEN QUAL $ 44.25 84106 39408908 PORPHYRINS 24HR UR $ 118.00 84120 39407644 PORPHYRINS,QT $ 55.75 84120 41361628 PORT BLOOD DRAW $ 220.00 36591 32595702 PORT POWER 8FR REG $ 963.00 32507311 PORT Y PEG ACCESSORY $ 30.00 31201882 PORT-A-CATH $ 1,599.45 C1788 31550344 PORT-A-CATH $ 1,600.00 C1788 40755225 PORTAGEN POWDER $ 50.55 31203318 PORTAL ROD $ 26.10 32606799 POSITIONER, WING PAD $ 125.00 32531923 POSITIONING PADS $ 64.20 32622639 POSITIONING PADS $ 65.00 32510349 POST OP SHOE F/LG $ 102.90 32510331 POST OP SHOE F/MED $ 64.45 32510323 POST OP SHOE F/SM $ 84.75 32510315 POST OP SHOE M/LG $ 90.05 32510307 POST OP SHOE M/MED $ 90.05 32610858 POST OP SHOE M/MED $ 91.00 32510299 POST OP SHOE M/SM $ 73.55 32532533 POST OP SHOE M/XL $ 90.05 32602245 POST PLATE FLARED COMPONENT$ 6,950.00 C1713 32622540 POST PLATE FLARED COMPONENT$ 6,950.00 C1713 39902424RP POTASSIUM $ 4.25 84132 39902424E POTASSIUM - SERUM $ 16.25 84132 39902424 POTASSIUM - SERUM $ 19.50 84132 39900758 POTASSIUM 24 HR URIN $ 68.25 84133 40749525 POTASSIUM ACE 40MEQ/20ML VIAL$ 17.05 40768970 POTASSIUM CHL 20MEQ/100ML IVPB$ 25.50 40768988 POTASSIUM CHL 40MEQ/100ML BAG$ 25.50 40756553 POTASSIUM CHLOR 20MEQ/15ML$ UDC 3.40 40780463 POTASSIUM CHLORIDE 20 MEQ POWD$ 20.00 40749376 POTASSIUM CHLORIDE V $ 12.15 40741027 POTASSIUM CHLORIDE V $ 17.05 42601690 POTASSIUM CL 2MG $ 8.00 J3480 40767774 POTASSIUM CLOR 20mEq/10ML VIAL$ 11.40 J3480 40741035 POTASSIUM PHOS 45MM/15ML VIAL$ 13.35 39902424C8 POTASSIUM SERUM $ 6.25 84132 42630290 POTASSIUM TABLET 10MEQ $ 3.25 3990242414 POTASSIUM, SERUM $ 6.75 84132

113 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31202765 POWER PACK SYRINGE $ 445.35 32201139 PP MATERNITY CARE KIT $ 65.25 39406749 PRA $ 497.25 84234 40771917 PRADAXA 150MG CAPSULE $ 13.50 40771925 PRADAXA 75 MG CAP $ 13.50 40764193 PRANDIN 1MG TAB $ 4.65 40763682 PRAVACHOL 10MG $ 4.55 31700107 PRE OP RECOVERY $ 95.25 39401898 PREALBUMIN $ 61.75 84134 40805251 PRE-BRONCHOSCOPY TX & S/U $ 406.00 94640 32533150 PRECUT PAPILLOTONE $ 254.30 31401508 PRE-CUT PAPILLOTONE $ 218.00 40722423 PRED FORTE 1% OPHT 5ML BT $ 34.75 40770349 PREDNISONE 10MG TAB $ 3.50 J7512 40708885 PREDNISONE 1MG TABLET $ 3.25 40756959 PREDNISONE 20MG TABLET $ 3.50 J7512 40756975 PREDNISONE 50MG TABLET $ 3.25 J7512 40770141 PREGABALIN 50MG CAP $ 7.00 40770158 PREGABALIN 75MG CAP $ 7.00 40729006 PREGESTIMIL 454 GM CAN $ 59.40 39902606 PREGNANCY SERUM $ 60.75 84702 39602081 PREGNANCY URINE $ 43.00 81025 40751182 PRELONE SYRUP 15MG/5ML UDC $ 3.25 40711467 PREMARIN 0.625MG TAB $ 3.25 40741043 PREMARIN 25MG/5ML VIAL $ 103.70 J1410 40759433 PREMARIN TAB $ 3.25 40711475 PREMARIN TAB $ 3.40 40722449 PREMARIN VAG CREAM 45GM TUBE$ 1,321.00 52410008 PRENATAL EDUCATION $ 10.00 Z5267 40748220 PRENATAL-S TAB $ 3.25 40921373 PRE-OP REHAB $ 106.50 97535GO 40901373 PRE-OP REHAB 15 MIN $ 106.50 97535GP 31202666 PREP TRAY $ 53.40 31502289 PREP TRAY $ 53.90 40754186 PREPARATION H SUPP $ 4.55 40722456 PREPARATION-H OINT 1oz TUBE $ 9.10 40758518 PREPIDIL GEL 0.5MG $ 278.60 32516643 PRESHAPED ACHILLES TENDON $ 3,625.00 C1762 32640855 PRESS MONTR INTRACOMPART $ 510.00 C1888 31902893 PRESSURE INFUSION BAG 500CC$ 71.25 32515264 PRESSURE INFUSOR $ 89.05 31505001 PRESSURE INFUSOR $ 89.05 32531451 PRESSURE MONITOR INTRA-COMPART$ 216.00 C1888 32507386 PRESTOP ARTHROERESIS $ 1,546.75 40763674 PREVACID 15 MG $ 8.75 40771461 PREVACID 15MG CAPSULE $ 16.00 40771776 PREVACID 15MG SOLU TAB $ 21.50 40769275 PREVACID 15MG/PACKET $ 15.50 40763633 PREVACID 30MG CAP $ 9.95 40768285 PREVACID 30MG PACKET $ 15.50 40769465 PREVACID 30MG VIAL $ 69.00 42614747 PREVNAR 13 $ 601.00 90670 40778582 Prevnar13 Pneum Vacc 0.5ML SYR$ 601.00 90670 40754103 PRILOSEC CAPSULE $ 8.25 40764839 PRIMACOR $ 290.00 40765794 PRIMACOR 10MG/10ML VIAL $ 144.95 J2260 41454852 PRIMATRIX PER 1 SQ CM $ 752.00 Q4110 40772253 PRIMAXIN 250MG /100ML IVPB $ 98.50 J0743 40772329 PRIMAXIN 500MG VIAL $ 156.00 J0743 40757155 PRIMAXIN 500MG/100ML NS PREMIX$ 57.90 J0743

114 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40751190 PRIMAXIN PBACK $ 33.50 J0743 40757148 PRIMAXIN VIAL $ 32.95 J0743 32516874 PRIME WIRE VOLCANO $ 750.00 C1769 32516882 PRIME WIRE VOLCANO-J $ 750.00 C1769 39401989 PRIMIDONE (MYSOLINE) $ 77.00 80188 40771446 PRIMIDONE 250MG TAB $ 3.50 40754483 PRINIVIL 10 MG TAB $ 4.55 40774226 Prinivil 5mg Tab $ 3.25 40766933 PRINZIDE 20-25MG $ 4.50 40751455 PRISCOLINE AMP $ 56.70 30500011A PRIVATE ROOM $ 455.00 30500011 PRIVATE ROOM $ 700.00 30200612 PRIVATE ROOM 2 EAST $ 455.00 30200612A PRIVATE ROOM 2 EAST $ 455.00 30200018A PRIVATE ROOM 2 EAST $ 455.00 30200018 PRIVATE ROOM 2 EAST $ 700.00 30300016 PRIVATE ROOM 3RD FLOOR $ 455.00 30300016A PRIVATE ROOM 3RD FLOOR $ 700.00 30210018 PRIVATE ROOM ROUTINE OVERFLOW$ 700.00 31000029 PRIVATE ROOM STEP DOWN $ 455.00 31000029A PRIVATE ROOM STEP DOWN $ 700.00 39402169 PRO ELECTRO - URINE $ 54.00 84166 39801543 PRO TIME $ 39.75 85610 32533291 PROBE ABC GI $ 401.10 32622441 PROBE ABC GI $ 402.00 32533374 PROBE COVER STERILE $ 71.70 31548265 PROBE COVER STERILE $ 72.00 32533101 PROBE LAP ABC $ 198.45 32509689 PROBE OXISENSOR ADULT $ 82.25 31539454 PROBE OXISENSOR ADULT $ 83.00 32509903 PROBE OXISENSOR INF. $ 160.05 32509945 PROBE OXISENSOR NEON $ 160.05 32509697 PROBE OXISENSOR PED $ 187.40 32509606 PROBE RECTAL $ 83.65 32509598 PROBE, SKIN $ 69.90 32511461 PROBES PARSONET VASC $ 266.75 39477239 ProBNP $ 200.00 83880 40763724 PROCAINAMIDE 250 MG $ 3.25 40762718 PROCAINAMIDE HCL $ 3.25 40741084 PROCAINAMIDE HCL 100MG/10ML$ VI 82.65 40749434 PROCAINAMIDE TAB SA $ 3.25 39402250 PROCAINAMIDE W/METOB $ 47.00 80192 40755894 PROCALAMINE 3% 1000ML IV SOLN$ 118.80 39478526 Procalcitonin $ 91.00 84145 40762726 PROCAN SR 500MG $ 3.25 40749491 PROCARDIA 10 MG CAPSULE $ 3.25 42608897 PROCARDIA 10MG $ 3.25 40753592 PROCARDIA XL 30 MG TABLET $ 4.55 40756819 PROCHLORPERAZINE MAL $ 5.65 40768855 PROCTASOL-HC CREAM $ 81.50 33301005 PROCTO W/RMV FOR BODY $ 3,677.00 45307 40753600 PROCTOCREAM-HC 1% CR 30GM $TUBE 44.20 40751216 PROCTOFOAM 1% SPRAY 0.5OZ 12/C$ 36.00 40722472 PROCTOFOAM-HC 1%/1% $ 76.10 33303167 PROCTOSIGMOID DIAG $ 1,095.00 45300 39400650 PROGESTERONE $ 114.25 84144 40107153 PROINSULIN $ 199.00 84206 39407556 PROINSULIN $ 244.75 84206 39400833 PROLACTIN $ 114.25 84146 42626825 PROLIA 60MG $ 3,960.00 J0897JG

115 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40711566 PROLIXIN TAB $ 3.25 40711582 PROLOID TAB $ 3.25 40728891 PROMETHAZINE W/CODEINE $ 5.75 39402342 PRONESTYL $ 65.50 80190 40711608 PRONESTYL CAP $ 3.25 40752222 PRONESTYL CAP $ 3.40 40752842 PRONESTYL VIAL $ 82.65 39407297 PROPADFENONE LEVEL $ 182.75 82542 40751497 PROPINE 0.1% OPHTH $ 37.65 40771362 PROPOFOL 1000MG/100ML $ 217.50 40759086 PROPULSID 10MG TAB $ 3.25 40763252 PROPULSID 1MG/ML SUS $ 6.75 40711632 PROPYLTHIOURACIL 50 MG TABLET$ 3.25 40763757 PROSCAR 5MG TAB $ 4.55 40756884 PROSTAPHLIN VIAL $ 31.75 40771347 PRO-STAT 64 LIQUID 30ML $ 40.00 40502371 PROSTATE BIOPSY IN US $ 3,245.00 55700 39903323 PROSTATIC SPEC.ANTIG $ 69.50 G0103 32511545 PROSTHESIS DRUM STAPE $ 564.80 40921241 PROSTHETIC TRAIN 15MIN $ 95.00 97761GO 40901241 PROSTHETIC TRAIN 15MIN $ 95.00 97761GP 40732570 PROSTIN E2 VAG SUPP $ 655.70 40758310 PROSTIN VR PED 500 MCG/ML AMP$ 466.60 39402433 PROT,ELEC,INTERP,SER $ 76.00 84165 39402441 PROT,ELEC,INTERP,URI $ 76.00 84166 40741183 PROTAMINE SULF 10MG/1ML VIAL$ 21.55 32510893 PROTECTOR WIREGUIDE $ 405.30 39400049 PROTEIN C $ 117.75 85302 39411955 PROTEIN C FUNCTIONAL $ 161.00 85303 39402078A PROTEIN ELECTROPHORESIS FRACTI$ 38.00 84165 40766552 PROTEIN POWDER $ 8.10 39400130 PROTEIN S $ 157.50 39480506 PROTEIN S FREE $ 155.00 85306 39903596 PROTEIN SERUM $ 29.00 84155 39402532 PROTEIN URINE QUANT $ 52.00 84156 3990359614 PROTEIN, TOTAL $ 6.75 84155 39402078C PROTEIN, TOTAL $ 7.50 84155 39903596HF PROTEIN, TOTAL $ 8.75 84155 39402599 PROTEUS OX-19 $ 20.75 86000 39402680 PROTEUS OX-2 $ 20.75 86000 40107906 PROTHROMBIA MIXING $ 114.00 40772279 PROTONIX 40 MG VIAL $ 117.00 C9113 40765711 PROTONIX 40MG TAB $ 6.95 42627518 PROTONIX 40MG TAB $ 7.00 40741191 PROTOPAM CHLORIDE 1GM VIAL $ 116.80 J2730 39402623 PROTOPORPHYRINS FEP $ 57.75 84120 39400130B PROTS FREE AG $ 78.75 85306 39400130A PROTS TOT AG $ 78.75 85305 40756066 PROVENTIL SOLN $ 36.85 40716169 PROVENTIL TAB $ 3.25 40749665 PROVENTIL TAB $ 3.25 40754145 PROVENTIL TAB SA $ 4.55 40711681 PROVERA 10 MG TABLET $ 4.55 32516387 PROWICK SHOULDER DRESSING $ 130.00 40722480 PROXIGEL ANTISEP 11% $ 25.65 32516411 PROXIMAL FEBIA NAIL, TITANIUM$ 2,336.00 31200447 PROXIMATE SKIN STAPLE $ 170.10 40763328 PROZAC 10MG CAPSULE $ 6.40 40753634 PROZAC CAP $ 5.70 39901533 PSA FREE/TOT $ 138.00 84153

116 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40107419A PSA AG $ 73.50 84153 40107419B PSA FREE $ 73.50 84154 39905030 PSA MARKETING SCR $ 10.00 40107419 PSA TOTAL & FREE $ 147.00 39409480 PSA, COMPLEXED $ 32.22 84152 39903471 PSA,FREE $ 153.75 84154 40500753 PSEUDO ANEURYSM US $ 1,117.00 76936 39402714 PSEUDOCHOLINESTERASE $ 20.75 82480 40751006 PSG-SLEEP STUDY $ 2,146.00 95810 40755380 PSG-SLEEP STUDY <6 Hrs. $ 2,146.00 95810 40755479 PSG-SLEEP STUDY UNATTENDED$ 408.00 95806 40752059 PSG-SLEEP STUDY W/CPAP $ 2,724.00 95811 40755578 PSG-SLEEP STUDY W/CPAP < 6Hrs.$ 2,724.00 95811 40753091 PSG-SPLIT NIGHT STUDY $ 2,724.00 95811 40755776 PSG-SPLIT NIGHT STUDY <6hrs. $ 2,724.00 9581152 40107906A PT - PT $ 57.00 85610 40107906B PT - SUBS PI:FRACTIONS $ 57.00 85611 40924666 PT EVAL HIGH COMPLEXITY $ 382.00 97163GP 40924765 PT EVAL LOW COMPLEXITY $ 198.00 97161GP 40924468 PT EVAL MOD COMPLEXITY $ 286.00 97162GP 40924567 PT RE-EVAL EST PLAN CARE $ 134.00 97164GP 31536682 PTA / ARTERIAL / ADDL $ 423.00 37247 31537276 PTA / ARTERIAL / INITIAL $ 10,586.00 37246 31536484 PTA / VENOUS / ADDL $ 360.00 37249 31536187 PTA / VENOUS / INITIAL $ 10,586.00 37248 31520096 PTA TIB/PER, EA ADDL VESSEL $ 10,438.00 37232 31502469 PTA TIBIOPERONEAL $ 21,395.00 37228 31519403 PTA, FEMORAL/POPLITEAL $ 10,585.00 37224 31518908 PTA, ILIAC $ 10,586.00 37220 31525693 PTCA, EA ADD'L BRANCH CX $ 4,516.00 31525792 PTCA, EA ADD'L BRANCH LAD $ 4,516.00 31525891 PTCA, EA ADD'L BRANCH RCA $ 4,516.00 31525594 PTCA, EA ADD'L BRANCH RI $ 4,516.00 31524703 PTCA, MAJOR CORONARY, LAD $ 9,032.00 31524901 PTCA, MAJOR CORONARY, LM $ 9,032.00 31524802 PTCA, MAJOR CORONARY, RCA $ 9,032.00 31525000 PTCA, MAJOR CORONARY, RI $ 9,032.00 31524604 PTCA, MAJOR CORONARY,CX $ 9,032.00 39406814 PTH CALCIUM $ 20.75 82310 39402805 PTH INTACT $ 25.00 83970 39407752 PTH MID MOLECULE $ 124.00 83970 39480605 PTH RELATED PROTEIN $ 155.00 82542 39402821 PTH-C-TERMINAL $ 174.75 83970 39402649 PTH-N-TERMINAL $ 295.00 83970 39801634 PTT $ 39.75 85730 31500416 PULM. ANGIOG., BILATERAL: S $ 5,782.00 75743 31500424 PULM. ANGIOG., NONSEL: S $ 6,011.00 75746 31500432 PULM. ANGIOG., UNILATERAL:S $ 5,782.00 75741 40768665 PULMICORT 0.25MG/2ML NEB $ 15.50 40805269 PULMICORT 0.5MG/2ML AMPULE $ 15.75 40768673 PULMICORT 0.5MG/2ML NEB $ 15.50 40768004 PULMICORT TURBUHALER 200MCG$ 476.00 41601424 PULMO FUNC THERA (15 MIN) $ 116.23 G0238 41601226 PULMO REHAB W EXERCISE $ 116.23 G0424 40751257 PULMOCARE LIQUID 240ML CAN $ 6.10 40804932 PULMOCORT 0.25MG/2ML AMP $ 15.75 41000563 PULMONARY ANGIO $ 849.00 71275 40600611 PULMONARY VENTILATION IMAGING$ 701.03 78579 33303894 PULSE OXI FOR OXYGEN $ 23.00 94760 32500134 PULSED FOOT SYSTEM $ 329.85

117 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31202369 PULSED IRRIGATION SY $ 577.10 32622342 PULSED IRRIGATION SY $ 578.00 32507014 PUMP TUBING ARTHREX $ 132.00 32607294 PUMP TUBING SMITH NEPHEW $ 120.00 33301286 PUNC ABSESS HEMATOMA $ 359.00 10160 41465939 Punch biopsy of skin each addi $ 65.00 11105 41465741 Punch biopsy of skin single le $ 384.00 11104 32516809 PUNCH BIOSPY DISPOSABLE $ 31.20 41460593 PUNCT ASP ABSCESS,HEMATOMA,$ BU 359.00 10160 33301906 PUNCT CYST OF BREAST $ 1,081.00 19000 32603498 PUPIL EXPANDER $ 270.00 41466236 PURAPLY XT 1 SQ CM $ 298.00 Q4197 41466434 PURAPLY AM 1 SQ CM $ 298.00 Q4196 39405675 PURE ISOLATE ID ARL $ 32.50 87070 40711707 PYRIDIUM 100 MG TAB $ 3.25 40752495 PYRIDOXINE 50 MG TABLET $ 3.25 40601023 PYROPHOSPHATE $ 85.50 A9538 40603794 PYROPHOSPHATE $ 86.00 39404009 QFEVER $ 30.50 86000 39479615 QIMG MASTER $ 63.00 31201775 QUAD LUMEN DRAIN $ 217.20 39480308 QUAD SCREEN $ 113.00 81511 39477635 QuantiFERON TB Gold Incubate $ 283.75 86480 40755019 QUESTRAN LIGHT PWD $ 87.90 32531634 QUICK ANCHOR PLUS, MINILOK $ 730.00 C1713 32531725 QUICK ANCHOR PLUS, ROTATOR $CUF 730.00 C1713 31505266 QUICK COMBO RTS $ 193.70 31546186 QUICK COMBO RTS $ 194.00 32514820 QUIKCROSS CATHETER $ 316.40 31546384 QUIKCROSS CATHETER $ 320.00 32514846 QUIKSILVER COAG PROBE $ 362.25 40753683 QUINAGLUTE TAB SA $ 3.25 39402896 QUINDINE $ 50.75 80194 40712259 QUINIDEX TAB SA $ 3.25 40712291 QUINIDINE TAB $ 3.40 40768020 QUININE SULFATE 325 MG CAPSULE$ 6.50 40712283 QUININE TAB $ 3.25 40768301 QVAR 40MCG INHALER $ 156.17 40769382 QVAR 80 MEQ INHALER $ 233.50 40476907 R RIBS NO CHEST $ 124.50 71100RT 31700016 R.R. 1ST HR $ 500.00 31700024 R.R.EA ADDL 15 MIN $ 150.00 39405139 RA - RHOE 18 $ 18.25 86431 39602172 RA TEST $ 48.25 86431 40764128 RABIES IMMUNE GLOB 150IU/ML$ 1,793.10 40759789 RABIES VACCINE 2.5 UNIT VIAL $ 1,390.00 90675 40805715 RACEMIC EPI 2.25% 11.25MG/ML$ 6.50 40768780 RACEPINEPHRINE UD VIALS $ 4.50 41210250 RAD TX 2 AREAS UP TO 5 MEV $ 261.00 77407 41210293 RAD TX 3 AREAS OR > UP TO 5MEV$ 261.00 77412 41210329 RAD TX DELIVERY $ 428.68 77412 41210207 RAD TX SUPERFICIAL $ 261.00 77401 32507949 RADIAL ARTERY CATH SET $ 33.00 41294818 RADIAPLEX RX 0.5 OZ. $ 11.01 41294721 RADIAPLEX RX 6 OZ. $ 63.05 40294094 RADIATION HANDLING & SUPER $ 118.00 77790 41000605 RADIOLOGICAL GUIDANCE FOR CATH$ 554.00 41210331 RADIOLOGY PORT FILM $ 75.00 77417 41292023 RADIOLOGY PORT FILM(BCBS) $ 75.00 77417 41294457 RADIOPHARM MONOCL AB $ 1,370.00

118 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41294633 RADIOPHARM MONOCL AB (PROF)$ 535.00 79403 41294545 RADIOPHARM MONOCL AB (TECH)$ 835.00 79403 41210393 RADIOPHARMACENTICAL THERAPY$ 868.00 79005 41294182 RADIOPHRAM ADMIN IV $ 226.00 41294369 RADIOPHRAM ADMIN IV (PROF) $ 116.00 79101 39505830 RAGWEED ALLERGEN $ 13.00 86003 39400858 RAGWEED-RAST $ 28.75 86003 39901475 RANDOM URINE POTASS $ 32.25 84133 39901566 RANDOM URINE SODIUM $ 32.25 84300 40770430 RANEXA 500MG TAB $ 11.50 32515199 RANEY CLIP KIT $ 121.60 32517070 RANEY CLIP RELOAD $ 46.65 40763286 RANITIDINE HCL 150MG/10ML UDC$ 20.45 32501876 RAPE KIT $ 152.30 40764938 RAPLON 100MG $ 41.05 42615242 RASBURICASE 1.5MG VIAL $ 2,810.00 J2783JG 39403076 RAST 2 PANEL (PED) $ 255.00 86003 39402987 RAST PANEL FOODS $ 146.25 86003 39405105 RAST-SE REGION $ 255.00 86003 32504458 RAZOR DISP $ 7.90 31544602 RAZOR DISP $ 8.00 40204239 RBC LEUK. REDUCED IRRADIATED$ 271.00 P9040 40200024 RBC WASHED PROCESSIN $ 271.00 32518094 REAMER $ 300.00 32512501 REAMER CANN/HEADED $ 309.30 42623063 RECLAST 1 MG JW $ 643.00 J3489JW 42625637 RECLAST 5 MG $ 3,215.00 J3489 33301450 RECON NAIL BED W GRAFT $ 3,122.00 11762 32512139 RECT. BLOCK 30X8X8MM $ 720.45 33100041 RECTAL EXAM $ 11.00 39503982 RECTAL SWAB CULTURE $ 65.75 87045 40200015 RED BLOOD CELL HANDLING $ 188.00 P9021 32511503 REDDICK CYSTIC DUCT $ 298.35 33301971 REDUCT DIS T-M JOINT $ 288.00 21480 39480704 REDUCTASE MTHFR GENE $ 275.00 81291 32515751 RE-ENTRY CATHETER $ 2,866.90 C1887 31550245 RE-ENTRY CATHETER $ 2,900.00 C1887 40200180 REF. LAB CHARGE $ 134.75 32517062 REG US TRANSDUCER COVER $ 6.50 39504939 REGIONAL ALLERGEY PANEL 6 $ 312.00 31900848 REGIONAL DRUG CHARGE $ 165.25 40741993 REGITINE 5MG/2ML VIAL $ 1,739.00 J2760 42628409 REGLAN 10 MG $ 4.00 J2765 40749145 REGLAN 10MG TAB $ 3.40 40703613 REGLAN 10MG/2ML VIAL 25/PACK$ 18.15 J2765 40774622 REGLAN 5 MG TAB $ 6.00 40752990 REGLAN SYRUP 10 MG/10 ML UDC$ 3.40 40753816 REGLAN TAB $ 3.40 30254773 REHAB HIGH, ADL 0-5 $ 731.00 RHA 30255466 REHAB HIGH, ADL 11-16 $ 908.00 RHC 30254674 REHAB HIGH, ALD 6-10 $ 823.00 RHB 30253387 REHAB HIGH+ES, ADL11-16 $ 1,269.00 RHX 30253288 REHAB HIGH+ES, ADL2-10 $ 1,138.00 RHL 30254971 REHAB LOW, ADL 0-10 $ 495.00 RLA 30255169 REHAB LOW, ADL 11-16 $ 754.00 RLB 30252991 REHAB LOW+ES, ADL 2-16 $ 1,004.00 RLX 30255070 REHAB MEDIUM, ADL 0-5 $ 618.00 RMA 30254872 REHAB MEDIUM, ADL 11-16 $ 789.00 RMC 30255268 REHAB MEDIUM, ADL 6-10 $ 743.00 RMB 30253189 REHAB MEDIUM+ES, ADL 11-16 $ 1,153.00 RMX

119 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30253090 REHAB MEDIUM+ES, ADL 2-10 $ 1,061.00 RML 30252694 REHAB ULTRA HIGH, ADL 0-5 $ 1,061.00 RUA 30252892 REHAB ULTRA HIGH, ADL 11-16 $ 1,249.00 RUC 30252793 REHAB ULTRA HIGH, ADL 6-10 $ 1,249.00 RUB 30252100 REHAB ULTRA HIGH+ES, ADL 11-16$ 1,613.00 RUX 30252199 REHAB ULTRA HIGH+ES, ADL 2-10$ 1,580.00 RUL 30255367 REHAB VERY HIGH, ADL 0-5 $ 922.00 RVA 30252496 REHAB VERY HIGH, ADL 11-16 $ 1,056.00 RVC 30252595 REHAB VERY HIGH, ADL 6-10 $ 925.00 RVB 30252397 REHAB VERY HIGH+ES, ADL 11-16$ 1,417.00 RVX 30253486 REHAB VERY HIGH+ES, ADL 2-10$ 1,279.00 RVL 33100561 REINSERTION OF SUPRAPUBIC CATH$ 474.00 51705 40764698 RELAFEN 500MG TABLET $ 4.55 32509242 RELIEF VALVE $ 108.70 40782542 Relistor 12mg syringe $ 425.50 J2212 32507766 RELOAD VERSATACK $ 181.00 32531600 RELOADS, CONTOUR $ 402.20 33304082 REM OF FB CORNEA $ 224.00 65220 41465048 REM SKIN TAGS<=15 LESIONS $ 219.00 11200 40764987 REMERON 15MG TABLET $ 4.90 J8499 42601880 REMICADE 10 MG $ 428.00 J1745JG 40764649 REMICADE 100MG VIAL $ 1,539.00 J1745 40764649D REMICADE 10MG $ 153.90 J1745 40764649I REMICADE 10MG $ 153.90 J1745 40764649A REMICADE 10MG $ 153.90 J1745 40764649H REMICADE 10MG $ 153.90 J1745 40764649J REMICADE 10MG $ 153.90 J1745 40764649E REMICADE 10MG $ 153.90 J1745 40764649F REMICADE 10MG $ 153.90 J1745 40764649B REMICADE 10MG $ 153.90 J1745 40764649G REMICADE 10MG $ 153.90 J1745 40764649C REMICADE 10MG $ 153.90 J1745 42616925 REMICADE 10MG JW $ 428.00 J1745JGJW 40769002 REMINYL 4MG TAB $ 9.00 40769135 REMINYL 8MG TAB $ 9.00 31511249 REMOVAL DUAL LEAD ICD SYS $ 5,615.00 33244 33304025 REMOVAL FB EXTERNAL AUD CANAL$ 292.00 69200 33304041 REMOVAL FB EYE $ 224.00 65205 33304181 REMOVAL FB FOOT, COMPLICATED$ 1,834.00 28193 33304793 REMOVAL FB FOOT, DEEP $ 2,576.00 28192 33454701 REMOVAL IMPACTED CERUMEN $ 120.00 69209 41455643 REMOVAL IMPACTED EARWAX UNI$ 139.00 69210 31512362 REMOVAL NEPH TUBE W/STENT $ 1,218.00 50389 41458415 REMOVAL OF FOREIGN BODY $ 628.00 10120 33304090 REMOVAL OF IMPACT CEREMEN $ 139.00 69210 31511157 REMOVAL SING LEAD ICD SYS $ 5,615.00 33244 33304553 REMOVAL SUPERFICIAL FB, EYELID$ 662.00 67938 32517922 REMOVAL SYSTEM TISSUE TX1 $ 861.00 33454800 REMOVAL TNL CV CATH $ 1,501.00 36589 31534900 REMOVE BILIARY DRNG CATH $ 1,535.00 47537 31511579 REMOVE DUAL LEAD SYS PACEMAKER$ 5,615.00 33235 33304637 REMOVE FB CORNEA W/SPLIT LAMP$ 224.00 65222 33304611 REMOVE FB MUSCLE/TENDON,SIMPLE$ 1,834.00 20520 33301955 REMOVE IMPLANT SUPER $ 2,976.00 20670 33300908 REMOVE OF BIVALVE ARM $ 495.00 29705 31515427 REMOVE PICC W/PORT $ 2,162.00 36590 31531435 REMOVE PLEURAL CATH $ 1,501.00 32552 33104983 REMOVE RECTAL OBSTRUCTION $ 3,228.00 45915 31511330 REMOVE SING GEN & INSERT DUAL$ 26,190.00 33214 31511488 REMOVE SING LEAD SYS PACEMAKER$ 5,615.00 33234

120 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 33300114 REMOVE SKIN ADDL 10 $ 60.00 11201 31552819 REMOVE SQ CARD RHYTHM MONITR$ 1,261.00 33286 31530445 REMOVE SQ DEFIB ELECTRODE $ 5,615.00 33272 31531831 REMOVE TUNNELED IP CATH $ 5,179.00 49422 40722704 RENACIDIN POWDER $ 117.75 40769473 RENAGEL 800MG TABLET $ 5.00 40766503 RENAGEL CAPSULES $ 3.25 40500761 RENAL BIOPSY BY NEEDLE $ 2,336.00 50200 32507287 RENAL DILATOR SET $ 334.10 40500266 RENAL MASS PUNCTURE $ 345.00 76770 41000555 RENAL NEEDLE TROCAR BX $ 2,336.00 50200 39901442 RENAL PROFILE $ 42.00 80069 40600074 RENAL SCAN $ 933.53 78700 40600926 RENAL SPECT $ 2,807.00 78803 40500191 RENAL US $ 362.25 76775 39403167 RENIN $ 87.00 84244 40778780 Reopro 10mg/5ml Vial $ 3,691.50 J0130 33301732 REP COMPL TRUNK 1.1 $ 3,120.00 13100 41459306 REP, SMP SUP WND > 30 CM $ 593.00 12007 41458811 REP, SMP SUP WND 12.6 CM TO 20$ 371.00 12005 41459009 REP, SMP SUP WND 2.6 CM to 7.5$ 192.50 12002 41459108 REP, SMP SUP WND 20.1 CM TO 30$ 488.00 12006 41459207 REP, SMP SUP WND 7.6 CM TO 12.$ 289.00 12004 41458910 REP,SMP SUP WND 2.5 CM OR LESS$ 218.00 12001 41464256 REPAIR BLD VESSEL DIRECT;LWR$ E 1,834.00 35226 33301443 REPAIR NAIL BED $ 488.00 11760 31514976 REPAIR PICC NO PORT/PUMP $ 1,501.00 36575 31515064 REPAIR PICC W/PORT $ 2,162.00 36576 33302854 REPAIR SPICA CAST $ 284.00 29720 33455493 REPAIR SUTURE RECTUM $ 1,548.00 45999 33302151 REPAIR TEN,FOREARM,W $ 5,772.00 25260 33300601 REPAIR TENDION /MUSCLE $ 5,772.00 25263 33300619 REPAIR TENDON /MUSCLE SEC $ 5,772.00 25272 33300643 REPAIR TENDON FOREARM/WRIST$ 5,772.00 25270 31552918 REPLAC PEG NO REV GT TRACT $ 504.00 43762 31553116 REPLAC PEG REVISE GT TRACT $ 504.00 43763 31532227 REPLACE G/C TUBE PERC $ 1,535.00 49450 31530643 REPOSIT IMP SQ ICD ELECTRODE$ 5,615.00 33273 31515691 REPOSITION ICD RA/RVLEAD $ 5,179.00 33215 31515780 REPOSITION LV LEAD PACE/ICD $ 5,179.00 33226 31512355 REPOSITION PACE RA/RV LEAD $ 5,179.00 33215 40771743 REQUIP 0.5MG TAB $ 9.00 40764292 REQULIN 200MG $ 6.65 40201139 RE-SCREEN/PHYS INTERP $ 14.25 P3001 32514697 RESOLUTION CLIP $ 338.95 40768715 RESOURCE ARGINAID PACKET $ 8.00 40754343 RESOURCE LIQUID $ 3.65 41601523 RESP FUNC/STRENG >2 PEOP $ 80.00 G0239 41601325 RESP MUSCLE THERA (15 MIN) $ 116.23 G0237 41210864 RESPIRATORY MOTION MANAGMENT$ S 965.00 77293 41296750 RESPIRATORY MOTION SIMULATION$ 128.00 77293 40749392 RESTORIL 15MG CAP $ 3.40 40749400 RESTORIL CAP $ 3.40 40765828A RETAVASE KIT(2VIALS) 18.1MG $ 1,589.25 J2993 40765828B RETAVASE KIT(2VIALS) 18.1MG $ 5,754.78 J2993 40765828 RETAVASE KIT(2VIALS) 36MG $ 3,178.45 J2993 39407761D RETICULIN 1GA $ 73.50 86255 39407761E RETICULIN 1GG $ 73.50 86255 39801725 RETICULOCYTE COUNT $ 22.00 85044 32511511 RETRACTOR FAN $ 467.50

121 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32511271 RETRACTOR FLEX IRIS $ 119.60 31208935 RETRACTOR FLEX IRIS $ 540.00 32515207 RETRACTOR VAGINAL $ 232.00 32507527 RETRACTOR, WOUND, HIP $ 350.00 31505209 RETREIVAL SNARE CORONAR $ 1,298.55 C1773 31505217 RETREIVAL SNARE VASCULAR $ 585.45 C1773 31505241 RETREIVAL SNARE VASCULAR X $ 585.45 C1773 31541731 RETREIVAL SNARE VASCULAR X $ 600.00 C1773 31522670 RETRIEV IVC FILTER $ 5,746.00 37193 315525396 RETRIEVE FB $ 5,226.00 37197 31525495 RETRIEVE FB $ 5,266.00 37197 32514796 RETRIEVER GRASPIT $ 364.35 32514739 RETRIEVER POLYGRAB $ 158.55 32514788 RETRIEVER STONE CONE $ 373.60 32513434 RETRIEVER, SUTURE $ 140.00 31203490 RETRO-BULBAR NEEDLE $ 43.30 40400210 RETROGRADE PYELOGRAM $ 416.75 74420 40402885 RETROGRADE URETHROGRAM $ 367.50 74450 40500209 RETROPERITONEUM COMPLETE SCAN$ 345.00 76770 40763419 RETROVIR 100MG CAP $ 4.35 40763971 RETROVIR 100MG CAPSULE $ 4.35 41292066 RETURN OFFICE VISIT LEVEL 1 $ 42.00 99211 41292078 RETURN OFFICE VISIT LEVEL 2 $ 56.00 99212 41292080 RETURN OFFICE VISIT LEVEL 3 $ 69.00 99213 41292091 RETURN OFFICE VISIT LEVEL 4 $ 87.00 99214 41292103 RETURN OFFICE VISIT LEVEL 5 $ 136.00 99215 31202963 REUTER BIVALVE $ 247.35 31526881 REVASC, ACUTE OCC,AMI,SNGL,CX$ 13,719.00 31527772 REVASC,ACUTE OCC,AMI,SNGL,LAD$ 13,719.00 31527970 REVASC,ACUTE OCC,AMI,SNGL,LM$ 13,719.00 31527871 REVASC,ACUTE OCC,AMI,SNGL,RCA$ 13,719.00 31528069 REVASC,ACUTE OCC,AMI,SNGL,RI$ 13,719.00 31527376 REVASC,COR GRFT, EA ADD'L,CX$ 6,859.00 31527475 REVASC,COR GRFT,EA ADD'L,LAD$ 6,859.00 31527474 REVASC,COR GRFT,EA ADD'L,RCA$ 6,859.00 31527673 REVASC,COR GRFT,EA ADD'L,RI $ 6,859.00 31526980 REVASC,COR GRFT,SNGL,CX $ 13,719.00 31527079 REVASC,COR GRFT,SNGL,LAD $ 13,719.00 31527178 REVASC,COR GRFT,SNGL,RCA $ 13,719.00 31527277 REVASC,COR GRFT,SNGL,RI $ 13,719.00 31528762 REVASC,CTO,ADDL CORONARY,CX$ 6,859.00 31529059 REVASC,CTO,ADDL, CORONARY,RI$ 6,859.00 31528861 REVASC,CTO,ADDL,CORONARY,LAD$ 6,859.00 31529158 REVASC,CTO,ADDL,CORONARY,LM$ 6,859.00 31528960 REVASC,CTO,ADDL,CORONARY,RCA$ 6,859.00 31528168 REVASC,CTO,CORONARY,SNGL,CX$ 13,719.00 31528267 REVASC,CTO,CORONARY,SNGL,LAD$ 13,719.00 31528465 REVASC,CTO,CORONARY,SNGL,LM$ 13,719.00 31528366 REVASC,CTO,CORONARY,SNGL,RCA$ 13,719.00 31528663 REVASC,CTO,CORONARY,SNGL,RI$ 13,719.00 40770968 REVATIO 20MG TAB $ 41.00 31511363 REVEAL DEVICE $ 14,908.00 C1764 39406285 REVERSE T3 $ 250.25 84482 40101115 RH FACTOR $ 21.50 86901 31500440 RHC $ 6,216.00 93451 31537573 RHC & RETROGR LHC CONGENITAL$ 6,219.00 93531 31518710 RHC + CORONARIES $ 8,180.00 93456 31518809 RHC+ CORONARIES+ BYPASS GRAFTS$ 8,180.00 93457 40768863 RHINOCORT AQUA SPRAY $ 232.00 40200107 RHO GAM $ 234.00 J2790

122 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 42606223 RHYTHM STRIP 3 LEAD $ 120.00 93041 32508970 RIB BELT FEMALE LG. $ 75.90 32508962 RIB BELT FEMALE MED $ 75.90 32509509 RIB BELT FEMALE UNIV $ 43.30 32508988 RIB BELT FEMALE XLG $ 75.90 32509010 RIB BELT MALE LARGE $ 75.90 32509002 RIB BELT MALE MED $ 75.90 32508996 RIB BELT MALE SMALL $ 75.90 32509499 RIB BELT MALE UNIV $ 49.35 32509028 RIB BELT MALE XLARGE $ 75.90 32509036 RIB BELT MALE XXLG $ 75.90 32529307 RIB BELT SM FEMALE $ 75.90 40476709 RIBS BILATERAL NO CHEST $ 124.00 71110 40401960 RIBS BILATERAL PA CHEST $ 236.25 71111 32510653 RICHARD RODS $ 274.60 32515983 RICHARDS PROTHESIS $ 250.00 39403340 RICKETTSIAL PANEL $ 374.75 86317 40758740 RIFAMPIN 600 MG VIAL $ 198.45 41240198 RIGHT BREAST LOC 1ST LESION $MA 1,063.00 19281RT 41240099 RIGHT BREAST LOC ADDED LESION$ 120.00 19282RT 40480075 RIGHT ELBOW ARTHROGRAM $ 847.00 73085RT 40500555 RIGHT EYE US $ 299.25 76512 40480471 RIGHT FEMUR 1 VIEW $ 134.42 73551RT 40480867 RIGHT FEMUR 2 VIEWS $ 134.42 73552RT 40478392 RIGHT FOOT AP AND LATERAL $ 120.00 73620RT 40403842 RIGHT HAND 2 VIEWS $ 120.00 73120 40404485 RIGHT HIP 2 VIEWS $ 134.00 73502 40478095 RIGHT KNEE STANDING LAT $ 131.75 73560RT 41240396 RIGHT MAMMO DUCTOGRAM $ 533.55 77053RT 41240297 RIGHT PUNCTURE CYST ASPIRATION$ 722.20 19000RT 40404030 RIGHT SHOULDER 1 VIEW $ 101.10 73020 40478293 RIGHT SHOULDER ARTHROGRAM$ 633.20 73040RT 40401879 RIGHT STERNOCLAVICULAR JT $ 125.00 71130RT 40401648 RIGHT TIBIA FIBULA $ 124.50 73590 40402067 RIGHT WRIST AP AND LATERAL $ 101.10 73100 40477996 RIGHT WRIST ARTHROGRAM $ 751.52 73115RT 40712838 RIMACTANE 300 MG CAPSULE $ 4.90 32517332 RING ADAPT BARRIER $ 10.48 40729436 RIOPAN PLUS SUSP $ 11.15 40712853 RIOPAN PLUS TAB CHEW $ 3.25 40729410 RIOPAN SUSP $ 10.10 40764466 RISPERDAL 1MG TABLET $ 5.05 40767758 RISPERDAL 2MG $ 15.28 39404546 RISTOCETIN COFACTOR $ 155.75 85245 39404637 RISTOCETIN PLATELET $ 218.25 85245 40764318 RITALIN 10MG TAB $ 3.40 40746554 RITALIN 10MG TABLET $ 5.70 40763567 RITALIN 5MG TABLET $ 3.25 40762437 RITALIN-SR 20MG CAPSULE $ 3.25 40764508 RITUXAN 100MG/10ML VIAL $ 910.15 J9312 40764433 RITUXAN 500MG/50ML VIAL $ 4,550.60 42601526 RITUXIMAB 10MG $ 361.00 J9312JG 42618311 RITUXIMAB 10MG JW $ 361.00 J9312JGJW 33302847 RMV BIVALVE BODY CAST $ 284.00 29700 33302649 RMV FOR BODY FOOT $ 1,834.00 28190 33302862 RMV FOR BODY INTRANA $ 292.00 30300 33303134 RMV FOREIGN BODY PHA $ 292.00 42809 33300973 RMV FOREIGN BODY/MOUT $ 292.00 40804 33303357 RMV INTRAUTERINE DEV $ 502.00 58301 33455394 RMVL FOREIGN BODY RECTUM $ 1,548.00 45999

123 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40483151 RMVL TUNLD CVAD W PORT/PUMP$ (CENTRAL 2,162.00 VENOUS ACCESS36590 DEVICE) 33455295 RMVL TUNNELED CVAD W PORT/PUMP$ 2,162.00 36590 31401862 ROAD RUNNER WIRE $ 328.00 32532079 ROADRUNNER WIRE $ 382.85 C1769 40769689 ROBAXIN 500MG TAB $ 3.25 40753824 ROBAXIN TAB $ 3.25 40742009 ROBAXIN VIAL $ 18.20 40712879 ROBAXIN-750 TAB $ 3.25 42609963 ROBINUL $ 22.00 40751984 ROBINUL 5MG/20ML VIAL $ 125.50 40755142 ROBITUSSIN AC 10-100MG/5ML UDC$ 3.40 40756785 ROBITUSSIN SYRUP 5ML $ 3.40 40729469 ROBITUSSIN-DAC SYRUP $ 4.65 40729477 ROBITUSSIN-DM 200-20MG/10ML$ UD 3.25 31204579 ROBOT USE $ 1,000.00 31204678 ROBOTIC CHOLECYSTEC COMBO $CHG 5,000.00 32518037 ROBOTIC CHOLECYSTECTOMY SUPPLY$ 4,000.00 31204876 ROBOTIC DX LAP COMBO CHG $ 4,500.00 32517807 ROBOTIC DX LAPOROSC SUPPLIES$ 3,500.00 31204777 ROBOTIC HYST W/WO BSO COMBO$ CH 4,500.00 32518102 ROBOTIC HYST W/WO BSO SUPPLIES$ 3,500.00 31205074 ROBOTIC INCIS VEN HERN COMBO$ 5,000.00 32511775 ROBOTIC INCIS VEN HERN SUPPLIE$ 4,000.00 31204975 ROBOTIC OOP W/WO SALP COMBO$ CG 4,500.00 31207153 ROBOTIC PROSTATECTOMY COMBO$ CH 4,293.00 32594316 ROBOTIC PROSTATECTOMY SUPPLIES$ 3,293.00 31206955 ROBOTIC SACRAL COLPOPEXY COMBO$ 4,500.00 31207054 ROBOTIC SACRAL COLPOPEXY SUPPL$ 3,500.00 32517815 ROBOTIC SALPIN/OOPH SUPPLIES$ 3,500.00 31206757 ROBOTIC SPLENECTOMY COMBO $CHG 5,000.00 32518250 ROBOTIC SPLENECTOMY SUPPLIES$ 4,000.00 31205173 ROBOTIC TRANSVERSE COLON COMBO$ 5,000.00 32518169 ROBOTIC TRANSVERSE COLON SUPPL$ 4,000.00 40766974 ROCALTROL 0.25MCG CAPSULE $ 4.30 42628508 ROCEPHIN 1G $ 33.00 J0696 40753071 ROCEPHIN 1GM VIAL $ 81.00 40770778 ROCEPHIN 1GM/100ML NS PREMIX$ 68.00 40769630 ROCEPHIN 1GRAM ADD VANTAGE$ 171.50 40753170 ROCEPHIN 2 GM VIAL $ 166.35 40753030 ROCEPHIN 250 MG VIAL $ 32.95 40771875 ROCEPHIN 2GM/100ML IVPB $ 188.50 J0696 40769622 ROCEPHIN 2GRAM ADD VANTAGE$ 328.50 40753048 ROCEPHIN 500 MG VIAL $ 51.40 40757262 ROCEPHIN VIAL $ 84.25 39403431 ROCKY MT.SPOTTED FEV $ 134.00 86000 39905665 ROCKY MTN 1GM $ 106.00 86757 32513962 ROD LUMBAR $ 404.25 32513897 ROD REAMING $ 400.00 32511024 ROLLER BALL ELECTROD $ 388.85 32622243 ROLLER BALL ELECTROD $ 389.00 40921324 ROM EXT OR TRUNK EACH $ 47.00 95851GO 40901324 ROM EXT OR TRUNK EACH $ 47.00 95851GP 40921415 ROM HAND $ 42.00 95852GO 40901415 ROM HAND $ 42.00 95852GP 40754913 ROMAZICON 0.5MG/5ML VIAL $ 76.70 31010648 ROOKE BOOT $ 183.00 32532186 ROOKE BOOT $ 224.35 39403522 ROTAVIRUS $ 87.00 86759 40764789 ROWASA 60ML $ 25.10 40764805 ROWASA SUPP $ 22.70

124 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30257941 RPF, ADL 0-1, NR-1 (DEFAULT) $ 392.00 PA1 30257842 RPF, ADL 0-1, NR-2 $ 409.00 PA2 30258238 RPF, ADL 11-14, NR-1 $ 635.00 PD1 30257743 RPF, ADL 11-14, NR-2 $ 668.00 PD2 30257644 RPF, ADL 15-16, NR-1 $ 674.00 PE1 30258436 RPF, ADL 15-16, NR-2 $ 707.00 PE2 30258139 RPF, ADL 2-5, NR-1 $ 471.00 PB1 30258040 RPF, ADL 2-5, NR-2 $ 491.00 PB2 30257545 RPF, ADL 6-10, NR-1 $ 550.00 PC1 30258337 RPF, ADL 6-10, NR-2 $ 576.00 PC2 39603071 RPR ROUTINE $ 26.00 86592 39403613 RSV ANTIGEN $ 123.00 86256 39407830 RSV BY E/A $ 31.00 87807 39406731 RSV CULTURE FINAL $ 54.00 87252 39406640 RSV CULTURE PRELIM $ 52.25 87253 40401739 RT CALCANEUS $ 101.10 73650 40401853 RT CLAVICLE $ 124.50 73000 40401788 RT ELBOW 4 VIEWS $ 124.50 73080 40401796 RT ELBOW AP AND LATERAL $ 101.10 73070 41000720 RT ELBOW WOUT $ 666.00 73200RT 41000737 RT ELBOW WWO $ 944.00 73202RT 40500787 RT EYE FOREIGN BODY $ 299.25 76529 40401754 RT FINGERS $ 103.25 73140 40401705 RT FOOT 3 VIEWS $ 124.50 73630 41000880 RT FOOT ANKLE WO $ 556.00 73700RT 41000899 RT FOOT ANKLE WWO $ 944.00 73702RT 40401747 RT FOREARM $ 124.50 73090 40401762 RT HAND 3 VIEWS $ 124.50 73130 41000761 RT HAND WRIST WO $ 666.00 73200RT 41000770 RT HAND WRIST WWO $ 944.00 73200RT 40401986 RT HIP 1 VIEW $ 134.00 73501 41000804 RT HIP WO $ 556.00 73700RT 41000812 RT HIP WWO $ 944.00 73702RT 40401846 RT HUMERUS $ 124.50 73060 40401663 RT KNEE 4 VIEWS $ 150.50 73564 40401671 RT KNEE AP AND LATERAL $ 124.50 73560 40401655 RT KNEE W PATELLA SUNRISE $ 101.10 73564 40401689 RT KNEE W TUNNEL $ 101.10 73564 41000845 RT KNEE WO $ 556.00 73700RT 41000856 RT KNEE WWO $ 944.00 73702LT 40401952 RT RIBS $ 194.75 71101 40401903 RT SCAPULA $ 124.50 73010 40401895 RT SHOULDER 2 VIEWS $ 136.00 73030 41000589 RT SHOULDER WOUT CONTRAST $ 666.00 73200RT 41000597 RT SHOULDER WWO CONTRAST $ 944.00 73202RT 40401721 RT TOES $ 103.25 73660 40482484 RT TOES 4TH CLINIC $ 56.74 73660 40404188 RT WRIST 4 VIEWS $ 124.50 73110 39904131 RUB.ANTIBODY $ 60.75 86762 32502668 RUBBER RING $ 50.25 39403563 RUBELLA $ 50.75 86762 39403381 RUBEOLA $ 50.75 86765 30252001 RUG Level 1 $ 500.00 40500084 RULEOUT FETAL DEATH $ 299.25 76815 32517104 RX RETRIEVAL BALLOON $ 300.00 40752305 RYNATAN SUSP PED $ 4.55 40752917 RYNATAN TAB $ 4.55 40758724 RYTHMOL 150MG TABLET $ 4.55 31502305 S&I ADDN'L STENT PLACEMENT $ 830.00 31511223 S&I ANTIGRADE UROGRAPHY $ 987.00 74425

125 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31502826 S&I AORTA $ 1,363.00 31511405 S&I DILATION NEPH/URE/URETHRA$ 3,608.00 74485 31502644 S&I RENAL OR VISCERAL $ 2,525.00 31502214 S&I STENT PLACEMENT $ 1,662.00 31511702 S&I TRANSCATHETER BIOPSY $ 840.00 75970 31502842 S&I VEIN SHEATH/NEEDLE $ 86.00 31511934 S&I VENOUS - BILATERAL $ 1,984.00 75822 31512443 S&I VISCERAL ANGIOGRAPHY $ 10,129.00 75726 31502479 S&I, VENOUS - UNILATERAL $ 1,984.00 75820 39403316 S. PNEUMONIA $ 32.25 87899 40804700 S/U-AEROECLIPSE NEB. $ 26.25 40804973 S/U-CONT. AEROSOL /USN $ 42.00 40805301 S/U-MINI-HEART NEB. $ 26.25 40805145 S/U-MV W/CONCHA INITIAL $ 223.50 40805228 S/U-MV W/HME INITIAL $ 176.75 40804767 S/U-MV W/HWIRE INITIAL $ 251.75 40805293 S/U-PARI LC PLUS NEB. $ 45.25 39402722 S102 $ 151.25 86353 32601650 S6270 5% DEX 30KCL $ 33.80 40401929 SACRO ILIAC JOINTS $ 157.50 72202 40401911 SACRUM AND OR COCCYX $ 158.00 72220 39904222 SALICYLATES $ 79.50 80307 40768681 SALINE 3ML NEB $ 3.25 40767717 SALINE FLUSH 10ML SYR $ 3.25 40729709 SALINE NOSE SPRAY 30ML $ 10.50 39404165 SALMONELLA AB IQA $ 36.00 86768 39403985 SALMONELLA AB IQG $ 36.00 86768 39404074 SALMONELLA AB IQM $ 36.00 86768 40402216 SALPINGOGRAM $ 533.55 74740 40703621 SALUTENSIN 50/0.125 $ 3.40 40755365 SANDOSTATIN 100MCG/1ML 10/BX$ 59.50 J2354 40766263 SANTYL OINT $ 193.35 40772246 SANTYL OINTMENT 30 GM TUBE $ 652.50 32512899 SAPS IRRIGATION SYSTEM $ 169.55 42603069G SARGRAMOSTIM 50 MCG $ 83.80 J2820JG 42603069D SARGRAMOSTIM 50 MCG $ 83.80 J2820 42603069 SARGRAMOSTIM 500 MCG VIAL $ 838.00 J2820 40759136 SARGRAMOSTIM 500MCG VIAL $ 797.70 J2820 40759136D SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136I SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136G SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136C SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136F SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136J SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136E SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136A SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136H SARGRAMOSTIM 50MCG $ 79.77 J2820 40759136B SARGRAMOSTIM 50MCG $ 79.77 J2820 31203235 SAW BLADES $ 385.50 30253981 SC HIGH, DEPRESSED, ADL 11-14$ 884.00 HD2 30253882 SC HIGH, DEPRESSED, ADL 15-16$ 944.00 HE2 30253783 SC HIGH, DEPRESSED, ADL 2-5 $ 825.00 HB2 30253684 SC HIGH, DEPRESSED, ADL 6-10$ 835.00 HC2 30254179 SC HIGH, NOT DEPRESSED, ADL $11 740.00 HD1 30254278 SC HIGH, NOT DEPRESSED, ADL $15 786.00 HE1 30253585 SC HIGH, NOT DEPRESSED, ADL $2- 694.00 HB1 30254080 SC HIGH, NOT DEPRESSED, ADL $6- 701.00 HC1 30256753 SC LOW, DEPRESSED, ADL 11-14$ 825.00 LD2 30257050 SC LOW, DEPRESSED, ADL 15-16$ 858.00 LE2 30257347 SC LOW, DEPRESSED, ADL 2-5 $ 691.00 LB2

126 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 30257446 SC LOW, DEPRESSED, ADL 6-10 $ 727.00 LC2 30257248 SC LOW, NOT DEPRESSED, ADL 11-$ 694.00 LD1 30256852 SC LOW, NOT DEPRESSED, ADL 15-$ 720.00 LE1 30256951 SC LOW, NOT DEPRESSED, ADL 2-5$ 589.00 LB1 30257149 SC LOW, NOT DEPRESSED, ADL 6-1$ 615.00 LC1 32532616 SCHLEROTHERAPY NEEDLE $ 164.55 31200884 SCHNEIDER NAIL $ 591.35 32622144 SCHNEIDER NAIL $ 592.00 32512618 SCISSOR TIP $ 259.65 32622045 SCISSOR TIP $ 260.00 32533762 SCISSORS ENDO DISP $ 263.50 32509168 SCISSORS STERILE $ 24.00 31401375 SCLEROTHERAPY $ 454.00 40481065 SCOLIOSIS SERIES 2 OR 3 VIEWS$ 533.55 72082 40480966 SCOLIOSIS SERIES 4 OR 5 VIEWS$ 533.55 72083 32515280 SCOPE INTRODUCER $ 59.35 31500499 SCP, 1ST ORDER,AO $ 1,517.00 31500507 SCP, 2ND ORDER,AO $ 1,517.00 31500556 SCP, 2ND ORDER,AP $ 1,809.00 31500515 SCP, 3RD ORDER,AO $ 1,908.00 31500564 SCP, 3RD ORDER,AP $ 1,862.00 31500523 SCP, ABDM, PELVIC $ 1,876.00 31500531 SCP, ADDITIONAL,AO $ 813.00 31500549 SCP, ADDL AP $ 1,580.00 31524406 SCP, ECA, UNILAT $ 275.00 36227 31523911 SCP, ICA, UNILAT $ 10,129.00 36224 31524208 SCP, SC/INA,UNILATERAL $ 5,782.00 36225 31524505 SCP, VERT, UNILATERAL $ 10,129.00 36226 31524109 SCP,CC/INA,UNILAT,EXTRACRANIAL$ 5,782.00 36222 31524010 SCP,CC/INA,UNILAT,INTRACRANIAL$ 8,609.00 36223 31524307 SCP,INTRA BCH,ICA,VERT,UNILATE$ 562.00 36228 31503121 SCP-SUBCLAVIAN $ 833.00 36215 32512311 SCREW $ 192.80 32610957 SCREW $ 193.00 32514333 SCREW ACUTRAK $ 608.40 32621946 SCREW ACUTRAK $ 609.00 32514598 SCREW BIO-INTERFER $ 330.75 C1713 32515694 SCREW BIO-TENODESIS $ 466.65 C1713 32515108 SCREW BONE $ 190.00 32513921 SCREW BONE CERV $ 392.70 32621847 SCREW BONE CERV $ 393.00 32517666 SCREW CANNULATED $ 300.00 C1713 31203419 SCREW CANNULATED $ 357.00 C1713 32517690 SCREW CANNULATED LOCKING $ 476.00 C1713 32517658 SCREW CORTEX $ 105.00 C1713 32507568 SCREW CORTEX FACIAL $ 62.65 C1713 32507576 SCREW CORTICAL $ 94.00 32621748 SCREW CORTICAL $ 94.00 32639667 SCREW CORTICAL $ 203.00 32517369 SCREW CORTICAL $ 218.00 C1713 32514606 SCREW FEMORAL RETRO $ 418.05 32514143 SCREW HEX CAP $ 354.75 32621649 SCREW HEX CAP $ 355.00 31203128 SCREW LAG/COMP $ 448.00 32517401 SCREW LOCKING $ 218.00 C1713 32514105 SCREW LOCKING $ 341.25 C1713 32516973 SCREW LOCKING $ 346.00 C1713 32514101 SCREW LOCKING TITANIUM $ 428.00 32621550 SCREW LOCKING TITANIUM $ 428.00 32513947 SCREW SELF DRILLING $ 522.90

127 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31200480 SCREW SELF TAPPING $ 94.00 32621451 SCREW SELF TAPPING $ 94.00 32513970 SCREW SPONOY LUMBAR $ 1,234.80 31202377 SCREW SUPER LAG $ 556.25 31202070 SCREW VASIC LAG $ 63.55 32517641 SCREW, LOCKING $ 220.00 C1713 325176141 SCREW, LOCKING $ 220.00 C1713 32503342 SCREW, LOCKING $ 409.50 C1713 32518029 SCREW, UNIVERSAL $ 585.00 C1713 31202609 SCREWS MINI $ 130.00 32621352 SCREWS MINI $ 340.00 31202591 SCREWS SM $ 67.60 31202583 SCREWS, BASIC $ 53.40 40758096 SCROTAL SUPPORT $ 19.65 40500357 SCROTUM ULTRASOUND $ 299.25 76870 32506727 SCRUB SKIN CLEANSER $ 16.55 31301492 SCRUB SKIN CLEANSER $ 17.00 32621253 SCRUB SKIN CLEANSER $ 17.00 32518136 SEAL, SCOPE WARMER $ 19.00 32621154 SEAL, SCOPE WARMER $ 19.00 32532756 SEAMGUARD BIO-ABSORB $ 430.00 C1781 40752198 SEBUTONE LOTION SHAM $ 15.05 31523713 SEC ART M-TROMBECT ADD-ON $ 7,184.00 37186 40766123 SECONAL 100MG CAP $ 3.55 40775117 SECURESEAL LIQUID $ 79.50 39801816 SEDIMENTATION RATE $ 33.75 85651 31530346 SEL.CATH ART-BRACH-CEPH;2ND$ OR 665.00 36216 40751646 SELDANE TAB $ 3.40 32529802 SELDINGER NEEDLE $ 37.95 31511777 SELECTIVE UNILATERAL RENAL VEN$ 5,782.00 75831 39405840 SELENIUM $ 106.50 84255 40901506 SELFCARE TRAINING/INSTR 15MIN$ 106.50 97535GP 40402430 SELLA TURSICA $ 101.75 70240 40722910 SELSUN BLUE 1% SHAM $ 7.65 39801907 SEMEN ANALYSIS $ 91.50 89320 32507055 SEMI T" TENDON" $ 1,610.00 C1762 30200026A SEMI-PRI RM 2 EAST $ 410.00 30200026 SEMI-PRI RM 2 EAST $ 410.00 30500029A SEMI-PRIVATE ROOM $ 410.00 30500029 SEMI-PRIVATE ROOM $ 410.00 30300024A SEMI-PVT 3RD FLOOR $ 410.00 30300024 SEMI-PVT ROOM 3RD FLOOR $ 410.00 40759581 SENEKOT-S TABLETS $ 6.40 40713489 SENOKOT 8.6MG TAB $ 3.25 40729717 SENOKOT GRAN $ 38.40 40759201 SENOKOT SYRUP $ 38.00 39500103 SENSITIVITIES $ 49.00 87186 32516148 SENSOR FLOTRAC STERILE $ 550.00 40759960 SENSORCAINE .25% 10ML VIAL $ 15.30 40759953 SENSORCAINE .25% 30ML VIAL $ 17.65 40759995 SENSORCAINE .5 50ML $ 27.05 40760019 SENSORCAINE .5% W/EPI 50ML MDV$ 32.95 40759946 SENSORCAINE .75 $ 22.35 40759979 SENSORCAINE 0.25% 50ML MDV$ 27.05 40758799 SENSORCAINE 0.75%+EP $ 22.35 40760001 SENSORCAINE-EPI 50ML MDV $ 27.05 40760027 SENSORCAINE-EPI/MPF 30ML VIAL$ 22.35 40759987 SENSORCAINE-MPF 0.5% 30ML VIAL$ 20.00 40924151 SENSORY INT 15MIN $ 81.00 97533GO 40701112 SEPTRA DS 800-160MG TAB $ 4.55

128 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40749368 SEPTRA SUSP $ 3.80 40763146 SEPTRA SUSP 10ML $ 3.80 40725079 SEPTRA SUSP 200-40MG/5ML UDC$ 7.90 40758393 SER-AP-ES TAB $ 3.25 40713505 SERAX 10 MG CAPSULE $ 3.25 40713513 SERAX 15 MG CAP $ 3.25 40713521 SERAX CAP $ 3.25 40762767 SEREVENT 6.5GM $ 71.15 40768582 SEREVENT DISKUS 50MCG INHALER$ 7.00 40767329 SERONE 250MG $ 5.85 40767899 SEROQUEL 100MG TAB $ 9.50 40767360 SEROQUEL 25MG TABLET $ 4.81 39403704 SEROTONIN $ 311.75 83497 39480407 SERUM IEP $ 70.00 86334 40767071 SERZONE HCI 100MG $ 5.00 32601908 SET 60 DROP VENTED $ 20.25 32601940 SET DECANTING $ 63.90 32602120 SET EXT. STRAIGHT $ 20.65 32509937 SET FEED ROSS PUMP $ 36.60 32601874 SET FLUID COLLECTION $ 17.15 32529786 SET FLUID/BLOOD WARMING $ 26.90 32507881 SET IRRIGATION TUBING $ 64.00 32611056 SET IRRIGATION TUBING $ 64.00 32507691 SET LIVER ACCESS & BIOPSY $ 609.00 32601882 SET MASS INFUSION $ 52.95 32513517 SET MICROPUNCTURE $ 112.35 31543612 SET MICROPUNCTURE $ 115.00 31208638 SET MICROPUNCTURE $ 115.00 32531287 SET PRESSURE MONITOR $ 181.50 31905485 SET PRESSURE MONITOR $ 182.00 32611155 SET PRESSURE MONITOR $ 182.00 32601825 SET PRIM LATEX FREE $ 29.65 32601965 SET PUMP BLOOD Y $ 27.80 42601617 SET TAXOL $ 31.00 32602138 SET TAXOL $ 110.95 32511214 SET UROMAV II217/122 $ 641.40 32601890 SET Y BLOOD 82 IN $ 22.55 32601809 SET Y TYPE COMPONENT $ 20.65 32601916 SET, BURETROL METRISET $ 33.80 32602070 SET, EXTENSION NF $ 12.10 32601932 SET, PCA INFUSER $ 40.60 32602054 SET, PRIMARY SETUP $ 80.35 32602062 SET, SECONDARY NF $ 12.10 32602088 SET, SECONDARY Y NF $ 20.65 32510216 SET/PRESSURE MONITOR $ 249.55 32510224 SET/SLIT CATH $ 190.20 39407541 SEX HORMONE BINDING GLOB $ 110.25 84270 32509267 SHAMPOO $ 6.45 41463959 SHAVE LES T/A/L;0.6-1.0CM $ 324.18 11301 31203227 SHAVER/BLADES $ 523.55 32621055 SHAVER/BLADES $ 524.00 32518573 SHEATCH RETRIEVAL EX - X $ 178.00 32509473 SHEATH INTRODUCER KIT $ 180.10 32513244 SHEATH RETRIEVAL EX $ 178.00 32511719 SHEATH TUNNEL B TIP $ 124.90 31501547 SHEATH W/O WIRE 11 CM 5FR $ 53.25 C1894 31501554 SHEATH W/O WIRE 11 CM 6FR $ 53.25 C1894 31501562 SHEATH W/O WIRE 11 CM 8FR $ 53.25 C1894 31505621 SHEATH W/O WIRE 11CM 5FR. X $ 50.25 C1894 31505712 SHEATH W/O WIRE 11CM 6FR. X $ 50.25 C1894

129 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31505803 SHEATH W/O WIRE 11CM 8FR. X $ 50.25 C1894 31501570 SHEATH W/O WIRE 23 CM 5FR $ 146.55 C1894 31501588 SHEATH W/O WIRE 23 CM 6FR $ 146.55 C1894 31501596 SHEATH W/O WIRE 23 CM 8FR $ 146.55 C1894 31505985 SHEATH W/O WIRE 23CM 6FR. X $ 139.15 C1894 32504821 SHEETS STERILE $ 13.15 39404520 SHIQELLA ABIGG $ 36.00 86771 33302797 SHORT ARM SPLINT HAND $ 292.00 29125 40931005 SHORT ARM SPLINT-DYNAMIC $ 224.75 29126GO 40931004 SHORT ARM SPLINT-STATIC $ 150.20 29125GO 33302839 SHORT LEG SPLINT CALF $ 284.00 29515 32510257 SHOULDER ABDU PILLOW $ 338.15 32529315 SHOULDER IMMOB PED $ 126.50 L3650 32510091 SHOULDER IMMOB. INF $ 111.05 L3650 31543711 SHOULDER IMMOB., UNV. $ 100.00 L3650 32508806 SHOULDER IMMOB., UNV. $ 100.15 L3650 40403016 SHOULDER OBLIQUE AXILLARY $ 136.00 73030 32533341 SHOULDER SUSPENSION KIT $ 298.10 31202625 SHOULDER TOTAL REPLACE $ 7,176.45 C1776 32595504 SHOULDER TOTAL REPLACE BIOMET$ 8,915.00 C1776 32533135 SHUNT CAROTID $ 382.85 32511446 SHUNT SUNDT EXT CARD $ 343.65 32516932 SI BRITE TIP L $ 108.00 C1894 39403886 SICKLE CELL SCREEN $ 22.00 85660 32510950 SIDE ARM ADAPTOR $ 60.30 31401490 SIGMIOD W/BIOPSY $ 71.00 31401581 SIGMIOD W/FOREIGN BD $ 224.00 31401763 SIGMIOD W/HEMOST BLD $ 479.00 31401672 SIGMIOD W/HOT BIOPSY $ 240.00 31401540 SIGMIODOSCOPY $ 995.00 31403678 SIGMIODOSCOPY W/ BALLOON DILIT$ 2,042.00 45386 31401854 SIGMOID W/POLYPECTOMY $ 289.00 31200843 SILASTIC FOLEY CATH $ 47.95 40769879 SILDENAFIL 50MG TAB $ 36.50 39402813 SILICONE $ 154.50 86353 39402904 SILICONE GEL $ 151.25 86353 40756306 SILVADENE 1% CREAM $ 7.90 40722936 SILVADENE 1% CREAM 400GM TUBE$ 85.90 40722928 SILVADENE 1% CREAM 50GM TUBE$ 16.80 40755522 SILVER NITR W/APP 1 EACH STICK$ 14.80 31502362 SIMMONS CATHETER - X $ 61.80 33301476 SIMPCL CL, SCALP <2.5 $ 218.00 12001 33301534 SIMPCL FACE <2.5 CM $ 252.00 12011 33301575 SIMPCL FACE 12.6-20 $ 728.00 12016 33301542 SIMPCL FACE 2.6-5.0CM $ 297.00 12013 33100603 SIMPCL FACE 20.1-30.0 CM $ 767.00 12017 33301559 SIMPCL FACE 5.1-7.5CM $ 375.00 12014 33301567 SIMPCL FACE 7.6-12.5 $ 483.00 12015 33301526 SIMPCL SCALP >30.CM $ 593.00 12007 33301518 SIMPCL SCALP 20.1-30 $ 488.00 12006 33301500 SIMPL SCALP 12.6-20.0 $ 371.00 12005 33301492 SIMPL SCALP 7.6-12.5 $ 289.00 12004 31300577 SIMPLE NERVE BLOCK $ 263.00 33301484 SIMPLE SCALP 2.6-7.5 $ 252.00 12002 42613955 SIMPONI 1MG $ 122.00 J1602JG 42623756 SIMPONI 1MG JW $ 122.00 J1602JGJW 41293088 SIMULATION - 3D $ 361.00 77295 41210056 SIMULATION - 3-D $ 2,326.00 77295 41293076 SIMULATION - COMPLEX $ 323.00 77290 41210044 SIMULATION - COMPLEX $ 699.00 77290

130 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41293064 SIMULATION - INTERMEDIATE $ 195.00 77285 41210039 SIMULATION - INTERMEDIATE $ 699.00 77285 41293052 SIMULATION - SIMPLE $ 171.00 77280 41210027 SIMULATION - SIMPLE $ 555.00 77280 40770042 SIMVASTATIN 20MG TABLET $ 18.00 40760084 SINEMET CR 25/100MG TABLET $ 3.25 40713570 SINEMET-10/100 TAB $ 3.25 40749202 SINEMET-25/100 TAB $ 3.40 40713588 SINEMET-25/250 TAB $ 3.25 40713604 SINEQUAN 25 MG CAPSULE $ 3.25 31401813 SINGLE BIOPSY $ 67.00 31502412 SINGLE LEAD INSERT ONLY P/ICD$ 15,305.00 33216 31401904 SINGLE POLYP $ 91.00 32515827 SINGLE PORT A CATH $ 692.00 C1788 40756629 SINGLET TAB $ 13.75 40765026 SINGULAR 10MG TABLET $ 4.90 J8499 40755191 SINOGRAFIN VIAL $ 80.30 32516718 SINUS BALLON CATHETER $ 855.00 32516700 SINUS BALLON INFLATION DEVICE$ 149.10 32516742 SINUS BALLOON CATH $ 901.25 32595207 SINUS BALLOON CATH (0014842)$ 2,320.00 C1726 32516759 SINUS CATHETER GUIDE $ 577.20 32516775 SINUS GUIDE HANDLE $ 132.00 32516692 SINUS ILLUMINATING SYSTEM $ 530.60 32640261 SINUS IMPLANT $ 1,315.00 C2625 32516767 SINUS IRRIGATION CATH $ 250.00 40402422 SINUSES $ 158.00 70220 41000373 SINUSES ROUTINE WOUT CONTRAST$ 939.00 70486 41000639 SINUSES WITH CONTRAST $ 1,179.00 70487 41000647 SINUSES WWO CONTRAST $ 1,358.00 70488 32504565 SITZ BATH DISP $ 26.10 32201220 SITZ/PERINEAL DAILY $ 43.00 32517914 SIZER FINGER JOINT IMPLANT $ 959.00 39402797 SJOGREN'S ANTIBODIES $ 159.00 86325 40770117 SKELAXIN 800MG TABLET $ 3.83 32508061 SKIN BARRIER 4X4 $ 11.85 32508079 SKIN BARRIER 8X8 $ 28.30 32508087 SKIN BARRIER FLANGE $ 10.45 32501934 SKIN STAPLE REMOVER $ 67.45 31302878 SKIN STAPLE REMOVER $ 68.00 32620956 SKIN STAPLE REMOVER $ 68.00 40402414 SKULL $ 186.00 70260 40400137 SKULL AP AND LAT $ 124.50 70250 32513020 SLATER SLEEVE $ 11.05 32510562 SLEEVES PNEUMATIC $ 525.90 31405262 SLEEVES PNEUMATIC $ 526.00 31302383 SLEEVES PNEUMATIC $ 526.00 32620857 SLEEVES PNEUMATIC $ 526.00 40764326 SLELAXIN 400MG TAB $ 3.40 39901806 SLIDE FOR SCABIES $ 16.50 87220 40001067 SLIDE PREP,CONSULT/REPORT $ 74.40 88323 32603038 SLING, URETHRAL, ALTIS $ 1,800.00 C1771 32511404 SLIPPERS $ 7.20 40749756 SLO-BID 100MG TAB $ 3.25 40703241 SLO-BID 125 CAP SA $ 3.25 40748576 SLO-BID 200 MG TABLET $ 3.25 40715021 SLO-BID 300 MG SR TABLET $ 3.25 40751703 SLO-BID 50 CAP SA $ 3.25 40758435 SLO-BID 75 CAP SA $ 3.40 40756793 SLO-PHYLLIN 80MG/15ML UDC $ 3.40

131 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40729733 SLO-PHYLLIN GG SYRUP $ 3.40 31511686 SLP VENOUS 1ST ORDER $ 853.00 36011 31511512 SLP VENOUS 2ND ORDER OR ADD'L$ 816.00 36012 39403084 SM/RNP $ 86.50 86235 40400558 SMALL BOWEL $ 193.70 74250 40481362 SMALL BOWEL VIA ENTEROCLYSIS$ T 424.42 74251 31501604 SMALL SHIELD COVER $ 12.85 32510380 SMALL VEST RESTRAINT $ 108.70 39801998 SMEAR FOR INCLUSION $ 75.50 87207 39401450 SMOOTH MUSCLE $ 69.00 86256 32514390 SNARE BASKET FB $ 170.10 C1773 31505670 SNARE CATHETER -X $ 824.70 C1773 31538662 SNARE CATHETER -X $ 825.00 C1773 32510844 SNARE POLYP $ 186.00 C1773 32620758 SNARE POLYP $ 186.00 C1773 32510836 SNARE ROTATABLE $ 110.25 C1773 32514721 SNARE SOFT OVAL $ 59.35 C1773 31406153 SNARE, 33MM $ 72.00 40742447 SOD BICARBONATE 50MEQ/50ML$ SYR 50.80 40757569 SOD CHLORIDE 0.9% 1000ML BAG$ 32.95 40772287 SOD CHLORIDE 3% 500 ML IV SOLN$ 23.50 40722985 SOD SULAMYD 30% DROP $ 55.90 39904586RP SODIUM $ 4.25 84295 39904586C8 SODIUM - SERUM $ 6.25 84295 3990458614 SODIUM - SERUM $ 6.75 84295 39904586E SODIUM - SERUM $ 16.25 84295 39904586 SODIUM - SERUM $ 16.25 84295 40755696 SODIUM ACETATE 40MEQ/20ML VIAL$ 14.10 40763989 SODIUM BICABONATE 7.5% $ 17.05 40754475 SODIUM BICARB 650MG TABLET $ 4.55 40755399 SODIUM BICARBONATE P $ 4.50 40757577 SODIUM CHL 0.9% 250ML BAG $ 32.95 J7050 40755704 SODIUM CHLOR 120MEQ/30ML VIAL$ 12.95 40756181 SODIUM CHLORIDE 0.9% $ 12.50 40755712 SODIUM CHLORIDE 0.9% $ 12.95 40755738 SODIUM CHLORIDE 0.9% 100ML $BT 32.95 40753832 SODIUM CHLORIDE 1 GM TABLET$ 3.25 42629597 SODIUM CHLORIDE 1MG JW $ 8.00 J3490JW 40750416 SODIUM CHLORIDE 3% $ 34.00 40757593 SODIUM CL 0.45% 1000 ML BAG$ 32.95 40756405 SODIUM CL 0.9% 10 $ 34.45 40757601 SODIUM CL 0.9% 15 $ 32.95 40756397 SODIUM CL 0.9% 25ML BAG $ 37.90 40804999 SODIUM CL 0.9% UD 3ML VIAL.NEB$ 4.75 40748774 SODIUM PHOS 45MM/15ML VIAL $ 28.35 40747354 SODIUM POLYSTYRENE S $ 45.50 40505737 SOFT TISSUE HEAD AND NECK $ 299.25 76536 41000357 SOFT TISSUE NECK W CONTRAST$ 866.00 70491 41000343 SOFT TISSUE NECK WOUT CONTRAST$ 626.00 70490 41000365 SOFT TISSUE NECK WWO CONTRAST$ 1,259.00 70492 32500159 SOL ADMIN SET $ 10.55 32602682 SOL D5 100ML $ 36.25 32602591 SOL D5 50ML $ 36.25 32602773 SOL NACL 100ML $ 36.25 32602864 SOL NACL 50ML $ 36.25 42627914 SOLU MEDROL 125 MG $ 34.00 J2930 42628211 SOLU MEDROL 1G $ 147.00 J1720 40742488 SOLU-CORTEF 100 MG VIAL $ 19.30 42616628 SOLU-CORTEF 100MG VIAL $ 36.00 J1720 42628310 SOLU-CORTEF 100MG VIAL $ 47.00 J1720

132 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40742496 SOLU-CORTEF 500MG/4ML VIAL $ 37.70 40755175 SOLU-CORTEF VIAL $ 68.05 40742538 SOLU-MEDROL 1 GM VIAL $ 74.55 40742512 SOLU-MEDROL 125MG/2ML VIAL $ 23.85 40742504 SOLU-MEDROL 40 MG VIAL $ 21.55 40742520 SOLU-MEDROL 500 MG VIAL $ 51.05 40752214 SOMA 350MG TABLET $ 4.10 39401435 SOMATOMEDINC $ 250.25 84305 40754608 SORBITOL 70% SOLN 30 ML UDC$ 10.25 40755407 SORBITOL 70% SOLUTIO $ 27.05 40713778 SORBITRATE TAB $ 3.25 40713760 SORBITRATE TBSL $ 3.25 32512642 SORENSON PUMP SETUP $ 74.85 32514002 SPACER CERVICAL $ 2,000.00 31502446 SPARTA WIRE - X $ 299.10 C1769 39402078 SPE MASTER $ 90.50 32504805 SPECI PAN $ 9.45 31203102 SPECI. COLLEC. FILTER $ 73.55 40763070 SPECIAL CMPD PCA SYR $ 135.00 41293149 SPECIAL DOSIMETRY (TLD) $ 174.00 77331 41210129 SPECIAL DOSIMETRY (TLD) $ 390.00 77331 41293137 SPECIAL ISODOSE PORT PLAN $ 226.00 77321 41210117 SPECIAL ISODOSE PORT PLAN $ 699.00 77321 41210171 SPECIAL PHYSICS CONSULTATION$ 377.00 77370 41293217 SPECIAL RADIATION TX PROCEDURE$ 259.00 77470 40001166 SPECIAL STAINS G 2 $ 136.82 88313 40000325 SPECIAL STAINS GP 2 $ 72.75 88313 40000968 SPECIAL STAINS, G 1 $ 141.75 88312 40000317 SPECIAL STAINS, GP 1 $ 117.75 88312 40000333 SPECIAL STAINS,HC,FS $ 36.75 88314 40000347 SPECIAL STAINS,HC,FS $ 109.25 88314 41210344 SPECIAL TX PROCEDURE $ 928.00 77470 32512816 SPECIMEN BRUSH $ 203.45 40704934 SPECTROBID TAB $ 5.55 39407050 SPECTROPHOTO. ANALYTE NES $ 57.50 84311 40916439 SPEECH THERAPY RE-EVAL $ 115.25 32516502 SPEED PASS LARIET $ 464.85 39802087 SPERM COUNT $ 61.75 89310 31208341 SPHENOCATH $ 200.00 32532160 SPHINCTERTONE KNIFE $ 254.30 31203854 SPICA CAST $ 216.45 32602013 SPIKE ADAPTER IRRIG $ 5.85 32601999 SPIKE ADAPTER VEN.IV $ 9.35 32201295 SPINAL ANALGESIA $ 522.25 31900970 SPINAL ANES. TRAY $ 102.90 31904584 SPINAL ANES. TRAY $ 103.00 31700701 SPINAL BLOOD PATCH $ 1,503.00 62273 31300742 SPINAL BLOOD PATCH $ 1,503.00 62273 39502554 SPINAL FLUID CULTURE $ 46.00 87070 39802178 SPINAL FLUID EXAM $ 67.00 89051 33303407 SPINAL LUMBAR DIAG $ 1,294.00 62270 40481956 SPINAL PUNCTURE FOR CHEMOTHERA$ 614.00 96450 32507071 SPINCTEROTOME PRELOADED $ 671.55 32201170 SPIRAL ELECTRODE $ 47.25 40769440 SPIRIVA 18MCG INHALER $ 103.50 40756363 SPIRONOLACTONE W/HCT $ 3.25 32529414 SPL KNEE SM.CHILD-OP $ 247.25 32529406 SPL KNEE,SM.CHILD-IP $ 81.40 40600058 SPLEEN SCAN $ 820.23 78185 32504599 SPLINT ALUMAFOAM FIN $ 15.35

133 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32620659 SPLINT ALUMAFOAM FIN $ 16.00 32510794 SPLINT ANKLE UNV. $ 151.95 L1906 32501918 SPLINT BASEBALL $ 21.80 32501900 SPLINT BASSWOOD $ 5.85 32501892 SPLINT BRANT $ 12.45 31203607 SPLINT CAST $ 245.55 32510174 SPLINT COCKUP LF MED $ 152.90 L3908 32510158 SPLINT COCKUP LF SM $ 138.50 L3908 32620560 SPLINT COCKUP LF SM $ 139.00 L3908 32510273 SPLINT COCKUP LT LG $ 132.90 L3908 32510265 SPLINT COCKUP RT LG $ 146.50 L3908 32510166 SPLINT COCKUP RT MED $ 138.50 L3908 32510141 SPLINT COCKUP RT SM $ 138.50 L3908 32509085 SPLINT FOREARM LT AD $ 113.20 32509069 SPLINT FOREARM LT CH $ 119.05 32509077 SPLINT FOREARM LT Y $ 113.20 32529398 SPLINT FOREARM RT.AD $ 119.05 32529372 SPLINT FOREARM RT.CH $ 139.80 32529380 SPLINT FOREARM RT.YO $ 119.05 33100140 SPLINT HARE TRACTION $ 208.00 32529513 SPLINT HIP LG $ 219.20 32529729 SPLINT HIP MED $ 322.95 32529711 SPLINT HIP SM CHILD $ 301.85 32529497 SPLINT HIP SMALL $ 395.75 32529463 SPLINT KNEE ADULT -IP $ 161.45 32529422 SPLINT KNEE CHILD -IP $ 91.70 32529471 SPLINT KNEE LG $ 347.85 32529455 SPLINT KNEE MED $ 241.35 32529430 SPLINT KNEE SMALL $ 259.65 32529448 SPLINT KNEE YOUTH-IP $ 138.50 32529505 SPLINT LEG ADULT IP $ 199.20 32529489 SPLINT LEG CHILD IP $ 158.20 32529521 SPLINT LEG THOMAS IP $ 276.90 32529539 SPLINT LEG THOMAS OP $ 276.90 32529596 SPLINT PLASTER $ 140.30 32508855 SPLINT W/F LT PED $ 141.05 L3908 32508814 SPLINT W/F LT SMALL $ 127.00 32508848 SPLINT W/F LT X-LARGE $ 127.00 32508889 SPLINT W/F LT. LARGE $ 127.00 32529323 SPLINT- W/F R-PED $ 138.25 L3908 32508897 SPLINT W/F RT XLG $ 127.00 32508830 SPLINT W/F RT. LARGE $ 127.00 32620461 SPLINT W/F RT. LARGE $ 127.00 32508863 SPLINT W/F RT. SMALL $ 111.10 32508871 SPLINT WRIST UNV.LT. $ 141.05 L3908 32508822 SPLINT WRIST UNV.RT. $ 141.05 L3908 32529356 SPLINT, COLLES $ 50.55 32508293 SPLINT, PLASATUME $ 7.90 31202526 SPLINT,REUTER $ 183.10 39406293 SPLIT SPECIMEN TEST $ 156.25 32533416 SPONGE COUNT BAG $ 19.60 32516080 SPONGE SURGICAL WECK $ 5.00 32504706 SPONGES 4X4 STERILE $ 3.55 42010264 SPONGES 4X4 STERILE $ 4.00 40407009 SPONGES 4X4 STERILE $ 4.00 41006816 SPONGES 4X4 STERILE $ 4.00 40506430 SPONGES 4X4 STERILE $ 4.00 40483943 SPONGES 4X4 STERILE $ 4.00 31539949 SPONGES 4X4 STERILE $ 4.00 31404470 SPONGES 4X4 STERILE $ 4.00

134 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32620263 SPONGES 4X4 STERILE $ 4.00 32504680 SPONGES 4X4 TRAYS $ 6.45 31544206 SPONGES 4X4 TRAYS $ 8.00 31203383 SPONGES PEANUT $ 6.45 31203391 SPONGES TONSIL $ 25.40 31203375 SPONGES, NEURO $ 26.75 32620164 SPONGES, NEURO $ 27.00 31203425 SPONGES, XRAY DETECTABLE $ 9.05 31545394 SPONGES, XRAY DETECTABLE $ 10.00 40763344 SPORANOX $ 13.00 40767345 SPORANOX 100MG $ 25.60 32639469 SPRING CLIP $ 50.00 40800039 SPUTUM COLLECTION $ 282.00 89220 39503545 SPUTUM CULTURE $ 38.00 87070 31533316 SQ ICD $ 31,250.00 41464355 SREP F/E/N/L/MM; 2.5CM/< $ 252.00 12011 41294006 SRT BODY MGMT $ 1,515.00 77435 40729741 SSKI SOLUTION 30ML BOTTLE $ 28.00 32601122 ST.WATER 1000.IRRIG $ 39.00 32601148 ST.WATER 4000.IRRIG. $ 67.80 40701682 STADOL 2MG/ML VIAL $ 27.05 40764144 STADOL NASAL SPRAY 10MG/ML $ 162.50 32609175 STALOCK $ 19.00 31201783 STAMEY CATH TRAY $ 177.20 31204225 STAMEY NEEDLES $ 335.35 32515686 STAPLER $ 459.55 32595306 STAPLER CONTOUR $ 585.00 32510752 STAPLER HERNIA $ 927.95 32532541 STAPLER LINEAR $ 750.55 32511354 STAPLER RELOAD $ 498.35 32620065 STAPLER RELOAD $ 499.00 32507238 STAPLER VERSATACK $ 365.00 32511362 STAPLER, CURVED CONTOUR $ 862.35 32511388 STAPLES PI 90 $ 217.20 32511602 STAPLES RICH TAB MED $ 362.50 32619966 STAPLES RICH TAB MED $ 363.00 32511594 STAPLES RICHARDS TAB $ 317.05 32619867 STAPLES RICHARDS TAB $ 318.00 32511396 STAPLES, PI 30 $ 175.65 32511370 STAPLES, PI-55 $ 185.50 32517450 STAPLING DEV REL ARTIC VAS 45$ 391.00 32517443 STAPLING DEV RELOAD ARTIC 45MM$ 306.00 32517435 STAPLING DEV RELOAD ARTIC 60MM$ 430.00 32517427 STAPLING DEV STD 4 HANDLE LAP$ 244.00 40766289 STARLIX 60MG TABLET $ 3.25 32510919 STD WIRE GUIDE $ 247.35 C1769 31502727 STEELCORE GUIDE WIRE $ 284.15 C1769 31202179 STEINMAN PIN $ 139.00 32619768 STEINMAN PIN $ 139.00 42631082 STELARA 1MG $ 47.00 J3358JG 42630983 STELARA 1MG JW $ 47.00 J3358JGJW 32513426 STENT BILIARY ERCP $ 291.90 C1877 32510992 STENT BILLARY $ 205.60 C1877 31505407 STENT CORONARY COATED $ 2,493.90 C1874 31550047 STENT CORONARY COATED $ 2,500.00 C1874 32512857 STENT CORONARY NON-COATED$ 2,305.35 C1876 31550641 STENT CORONARY NON-COATED$ 2,310.00 C1876 32513103 STENT DRUG ELUTING $ 7,579.70 C1874 31550443 STENT DRUG ELUTING $ 7,600.00 C1874 32513467 STENT INTRACOIL $ 1,694.70 C1874

135 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32507733 STENT NEPHROURETEROSTOMY $ 254.00 C1877 32513624 STENT PARAMOUNT BILIARY $ 2,047.50 C1877 32516247 STENT PERIPHERAL $ 3,400.00 C1877 31551532 STENT PERIPHERAL $ 3,400.00 C1877 32512923 STENT PERMALUME BIL $ 3,969.00 C1877 32513459 STENT PROTEGE 150 $ 2,471.45 C1874 32513442 STENT PROTEGE 30-80 $ 1,412.25 C1874 32533812 STENT PULMONARY $ 5,407.40 C2625 31502784 STENT PVD - X $ 2,579.15 C1876 31549750 STENT PVD - X $ 2,600.00 C1876 32516924 STENT SMART 6 X 80 $ 1,700.00 C1876 32516916 STENT SMART 6X20 $ 1,281.25 C1876 31502909 STENT SMART 7X30 X $ 2,794.40 C1876 31551136 STENT SMART 7X30 X $ 2,800.00 C1876 31519888 STENT TIBIOPERONEAL INC ANGIO$ 32,429.00 37230 32507808 STENT URETERAL $ 347.00 C1877 32606700 STENT URETERAL POSITIONER $ 40.00 31201742 STENT, DOUBLE J $ 638.00 C1877 32605413 STENT, DOUBLE J PERCUFLEX $ 230.00 C1877 31526485 STENT, EA ADD'L BRANCH CX $ 6,859.00 31526584 STENT, EA ADD'L BRANCH LAD $ 6,859.00 31526683 STENT, EA ADD'L BRANCH RCA $ 6,859.00 31526782 STENT, EA ADD'L BRANCH RI $ 6,859.00 31520294 STENT, EA ADDL TIB/PERONEAL $ 10,438.00 37234 31519007 STENT, ILIAC (INCLUDES ANGIO)$ 21,395.00 37221 31525990 STENT, MAJOR CORONARY,CX $ 13,719.00 31501909 STENT, MICRO OCULAR $ 2,220.00 32607393 STENT, MICRO OCULAR $ 2,220.00 C1783 32602641 STENT, VIABAHN, 6MM $ 3,678.00 32602740 STENT, VIABAHN, 8MM $ 4,200.00 31529950 STENT,ARTERY,ADDL" $ 9,897.00 37237 31529752 STENT,ARTERY,INITIAL $ 21,395.00 37236 31519601 STENT,FEMORAL-POPLITEAL $ 24,076.00 37226 31526386 STENT,MAJOR CORONARY RI $ 13,719.00 31526089 STENT,MAJOR CORONARY,LAD $ 13,719.00 31526287 STENT,MAJOR CORONARY,LM $ 13,719.00 31526188 STENT,MAJOR CORONARY,RCA $ 13,719.00 31529653 STENT,VEIN,ADD'L $ 9,897.00 37239 31529851 STENT,VEIN,INITIAL $ 21,395.00 37238 31000011A STEP DOWN ROOM $ 680.00 31000011 STEP DOWN ROOM $ 1,050.00 40405524 STEREO LEFT LOC 1ST LESION $ 1,575.50 19081LT 40405425 STEREO LEFT LOC ADDED LESION$ 207.00 19082LT 41250198 STEREO RIGHT LOC 1ST LESION $ 1,575.50 19081RT 41250297 STEREO RIGHT LOC ADDED LESION$ 207.00 19082RT 41293643 STEREOSCOPIC GUIDE RAD/THER$ PR 18.75 77421 41210697 STEREOSCOPIC GUIDE VOL RAD/THR$ 129.20 41280099 STEREOSCOPIC X-RAY GUIDANCE$ 23.00 G6002 41210765 STEREOSCOPIC X-RAY GUIDANCE$ 58.00 77387 31200496 STERI DRAPE $ 31.95 31200504 STERI STRIP $ 53.40 32619669 STERI STRIP $ 54.00 31203557 STERILE ACE BANDAGE $ 53.40 32500092 STERILE BASIN $ 14.35 31203094 STERILE SLEEVE, GLIDESCOPE $ 69.00 32502320 STERILE WATER 1000CC $ 15.35 31905287 STERILE WATER 1000CC $ 16.00 31701988 STERILE WATER 1000CC $ 16.00 31406351 STERILE WATER 1000CC $ 16.00 31304561 STERILE WATER 1000CC $ 16.00

136 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32611254 STERILE WATER 1000CC $ 16.00 40755837 STERILE WATER 1000ML BAG $ 32.95 32508194 STERILE WATER 500CC $ 11.50 31552225 STERILE WATER 500CC $ 12.00 32509572 STERISTRIP 3 INCH $ 15.35 31541038 STERISTRIP 3 INCH $ 16.00 32619570 STERISTRIP 3 INCH $ 16.00 42011353 STERISTRIP 4 INCH $ 18.00 32509580 STERISTRIP 4 INCH $ 18.00 32619471 STERISTRIP 4 INCH $ 18.00 40401887 STERNUM $ 124.50 71120 32509986 STOCKINET 3 STERILE" $ 36.40 32619372 STOCKINET 3" STERILE $ 37.00 32619273 STOCKINET 4 STERILE $ 36.00 32509994 STOCKINET 4 STERILE" $ 35.45 32510000 STOCKINET 6 STERILE" $ 45.60 40752354 STOMAHESIVE PASTE $ 21.75 39400387 STONE ANALYSIS MASTER $ 120.50 82360 32638875 STONE BASKET EXTRACTOR $ 714.00 31201338 STONE BASKET EXTRACTOR $ 714.35 32531808 STONE TOME $ 649.75 31401599 STONETOME $ 555.00 39504535 STOOL CULTURE PLATE 1 $ 20.50 87045 39504741 STOOL CULTURE PLATE 2 $ 20.50 87046 40107617 STOOL FORFAT,QL $ 60.00 82705 39500194 STOOL LEUKOCYTES $ 22.00 87205 39403274 STOOL LYTES $ 312.50 32515660 STOPCORK $ 18.00 31538068 STOPCORK $ 18.00 40931016 STRAPPING HAND/FINGER $ 87.75 29280GO 40931012 STRAPPING- HIP $ 105.00 29520GO 40901480 STRAPPING KNEE $ 88.58 29530GP 40931013 STRAPPING- TOES $ 82.25 29550GO 40901399 STRAPPING, ANKLE/FOOT $ 62.00 29540GP 40924161 STRAPPING, HIP $ 105.00 29520GP 40912191 STRAPPING; ELBOW/WRIST $ 93.75 29260GP 40912192 STRAPPING; HAND/FINGER $ 87.75 29280GP 40921181 STRAPPING; SHOULDER $ 115.00 29240GP 40924171 STRAPPING; TOES $ 82.25 29550GP 40931015 STRAPPING-ELBOW/WRIST $ 93.75 29260GO 40931014 STRAPPING-SHOULDER $ 115.00 29240GO 40108996 STREP A AMPLIFIED PROBE $ 97.00 87651 39603345 STREP A SCREEN $ 54.25 87449 40763187 STREPTOKINASE 1.5MM $ 1,172.90 31501943 STREPTOKINASE 250 UNITS $ 365.00 40763161 STREPTOKINASE 250M $ 264.60 J2995 40763179 STREPTOKINASE 750M $ 583.20 39503107 STREPTOZYME $ 63.75 86590 40713893 STRESS 600 TAB $ 3.40 32532129 STUMP STOCKING $ 87.15 32516122 STYLET STRAIGHTENING $ 252.00 31905079 STYLET, ADULT $ 17.00 31904980 STYLET, PEDI $ 11.00 39411856 STYPVEN TIME $ 175.00 85612 32527863 SUBCLAVIAN CHANGE $ 28.95 33204868 SUBSEQUENT HOSP CARE 2-DIST$ PX 151.25 99232-59 41292142 SUBSEQUENT HOSP VISIT LEVEL $1 85.00 99231 41292154 SUBSEQUENT HOSP VISIT LEVEL $2 153.00 99232 41292166 SUBSEQUENT HOSP VISIT LEVEL $3 119.00 99233 40805053 SUBSQ. INHALATION TX $ 406.00 94640

137 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32501884 SUCTION CAN. W/TUBING $ 23.85 32509127 SUCTION CANNISTER/OR $ 39.85 42010759 SUCTION CANNISTER/OR $ 40.00 41006915 SUCTION CANNISTER/OR $ 40.00 40506529 SUCTION CANNISTER/OR $ 40.00 40484636 SUCTION CANNISTER/OR $ 40.00 31701097 SUCTION CANNISTER/OR $ 40.00 31539652 SUCTION CANNISTER/OR $ 40.00 31404569 SUCTION CANNISTER/OR $ 40.00 31301393 SUCTION CANNISTER/OR $ 40.00 32619174 SUCTION CANNISTER/OR $ 40.00 32509135 SUCTION INFANT DELEE $ 20.85 31203771 SUCTION IRR. SET LAP $ 414.45 32619075 SUCTION IRR. SET LAP $ 415.00 31203797 SUCTION IRRIG. TIP $ 83.65 32504664 SUCTION KITS 10 PKG $ 28.05 32504649 SUCTION KITS 10 PKG $ 75.90 32529174 SUCTION PUMP SET-UP $ 31.40 32529190 SUCTION THERM SET UP $ 51.00 32513277 SUCTION Y SWIVEL $ 20.65 40752016 SUFENTA 50MCG/1ML 2ML AMP $ 58.90 40756199 SUGAR $ 3.40 40767378 SULAR 10MG $ 3.65 40771750 SULAR 20MG TAB $ 8.50 40767352 SULAR 30MG $ 3.65 40767865 SULAR 40MG $ 3.70 40756983 SULFAMETHOXA-TRIMETH $ 3.80 40601387 SULFUR COLLOID $ 49.75 A9541 32533440 SUMPDRAIN, TRIPLELUONER $ 241.35 40714677 SUMYCIN 250 CAP $ 3.25 33300569 SUP OR TRAM FRAC $ 1,179.00 24535 32516205 SUPERCHONDRYL BOLT $ 320.00 C1713 33301583 SUPERFIC WOUND SIMPLE $ 954.00 12020 33301591 SUPERFIC WOUND W/PACKING $ 488.00 12021 40764680 SUPLENA 8OZ CANS 237ML LIQUID$ 6.05 32100190 SUPPLIES CIRCUMCISION $ 110.00 30500292 SUPPLIES CIRCUMCISION $ 110.00 30301119 SUPPLIES CIRCUMCISION $ 110.00 32507188 SUPPORT CATHETER $ 316.35 C1725 40900227 SUPPORT MEASURE 15 MIN $ 110.00 97760GP 40920227 SUPPORT MEASURE EA 15 MIN $ 110.00 97760GO 31502810 SUPRACORE GUIDE WIRE-X $ 329.00 C1769 40758658 SUPRANE SINGLE DOSE $ 41.40 31202492 SUPRAPUBIC CATH TRAY $ 160.05 C2627 40754434 SUPRAX 100MG/5ML UDC $ 11.35 40767261 SUPRAX 400MG $ 27.00 40756090 SUPRAX SUSP 50ML BLK $ 70.25 32514770 SURESEAL VALVE $ 47.45 32513848 SURETAC DELIVERY SYSTEM $ 329.95 32513830 SURETAC III FIXATOR $ 432.60 40000259 SURG PATH G&M LV 2 $ 82.00 88302 40000267 SURG PATH, G&M LV 3 $ 117.75 88304 40000275 SURG PATH, G&M LV 4 $ 251.00 88305 40000283 SURG PATH, G&M LV 5 $ 437.00 88307 40000291 SURG PATH, G&M LV 6 $ 482.00 88309 40000242 SURG PATH,GROSS,LV 1 $ 70.50 88300 42011155 SURGI CLIP $ 240.35 31202872 SURGI CLIP $ 240.35 32618976 SURGI CLIP $ 241.00 31501612 SURGICAL GOWN $ 39.70

138 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 31545988 SURGICAL GOWN $ 40.00 32618877 SURGICAL GOWN $ 40.00 31505563 SURGICAL GOWN X $ 37.45 32618778 SURGICAL GOWN X $ 38.00 31540543 SURGICAL GOWN X $ 40.00 31200397 SURGICEL $ 116.40 32532145 SURGICEL FIBRILLAR $ 158.60 32517005 SURGICEL NU-KNIT 3 x 4 $ 123.50 32618679 SURGICEL NU-KNIT 3 x 4 $ 124.00 32517013 SURGICEL NU-KNIT 6 X 9 $ 294.50 32618580 SURGICEL NU-KNIT 6 X 9 $ 295.00 32516098 SURGIMESH 14X15CM $ 942.00 C1781 32516312 SURGIWAND $ 371.00 32504730 SUSPENSORY 0.16 $ 17.25 32504714 SUSPENSORY 0.2 $ 28.95 32511859 SUSPENSORY LG $ 57.75 32511842 SUSPENSORY MED $ 57.75 32511867 SUSPENSORY XLG $ 57.75 40742637 SUS-PHRINE 1:200 AMP $ 20.65 40755217 SUSTACAL PUDDING $ 3.40 40754301 SUSTACAL VANILLA PUD $ 4.55 32518625 SUTURE ANCHOR 3.0MM BIOCOMPOSI$ 455.00 32511453 SUTURE BOOTS $ 15.25 32514804 SUTURE CAPTURE DEVICE $ 942.00 32531543 SUTURE GRASPER 60 DEGREES $ 388.80 32533788 SUTURE GRASPER, 30 DEGREES $ 388.80 32533879 SUTURE GRASPER, 45 DEGREES $ 388.80 33302441 SUTURE INFRAPATELLAR $ 5,772.00 27380 32516817 SUTURE KIT, BIO $ 320.00 32514556 SUTURE LASSO ORTHO $ 316.35 32603597 SUTURE PASSER $ 375.00 32504623 SUTURE REMOVAL KIT $ 12.10 31305155 SUTURE REMOVAL KIT $ 13.00 32611353 SUTURE REMOVAL KIT $ 13.00 32514648 SUTURE SHUTTLE $ 282.45 33302656 SUTURE TENDON FOOT $ 3,868.00 28200 33302540 SUTURE TENDON LEG EA $ 5,772.00 27664 31200967 SUTURE, FIBER WIRE $ 130.00 32604720 SUTURE, MONODEK $ 117.00 32618481 SUTURE, MONODEK $ 118.00 32605215 SUTURE, ULTRA BRAID $ 69.00 32605017 SUTURE, ULTRA TAPE $ 56.00 32502338 SUTURES CATAGORY A $ 18.00 31201056 SUTURES CATAGORY A $ 18.00 32618382 SUTURES CATAGORY A $ 18.00 32618283 SUTURES CATAGORY A $ 18.00 31201064 SUTURES CATAGORY B $ 21.80 32618184 SUTURES CATAGORY B $ 22.00 31201080 SUTURES CATAGORY D $ 53.40 31201106 SUTURES CATAGORY F $ 105.20 31201114 SUTURES CATAGORY G $ 248.00 32618085 SUTURES CATAGORY G $ 248.00 31201817 SUTURES CATAGORY H $ 227.30 31202831 SUTURES EEA $ 1,385.20 31202849 SUTURES GIA 50 $ 531.80 31202823 SUTURES TA 90 $ 434.35 31202815 SUTURES TA-55 $ 361.80 32617986 SUTURES TA-55 $ 362.00 31201072 SUTURES-CATEGORY C $ 19.75 32617887 SUTURES-CATEGORY C $ 20.00

139 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32514622 SUTURING NEEDLE $ 214.70 32594712 SWABS, PROCTO $ 20.00 31501638 SWAN GANZ CATHETER $ 542.45 C1751 31549453 SWAN GANZ CATHETER $ 550.00 C1751 31500572 SWAN GANZ INSERTION $ 3,420.00 93503 31900939 SWAN GANZ SET UP $ 267.25 30900054 SWAN GANZ SET-UP $ 383.00 39802350 SWEAT TEST $ 133.25 89230 31505571 SYMMETRY BALLON - X $ 787.25 C1725 31500571 SYMMETRY BALLOON $ 675.00 32506099 SYN LONG ARM CAST A $ 168.30 32508103 SYN LONG ARM CAST Y $ 96.00 32506073 SYN LONG LEG CAST A $ 245.55 32611452 SYN LONG LEG CAST A $ 246.00 32508129 SYN LONG LEG CAST Y $ 196.90 32506107 SYN SHORT ARM CAST A $ 128.75 32611551 SYN SHORT ARM CAST A $ 129.00 32508095 SYN SHORT ARM CAST Y $ 82.70 32506081 SYN SHORT LEG CAST A $ 212.80 32508111 SYN SHORT LEG CAST Y $ 196.00 40720260 SYNACORT 1% CREM $ 12.85 40723058 SYNALAR 0.01% CREAM $ 30.65 40753469 SYNALAR 0.025% CREAM $ 32.40 32508137 SYNETHETIC ROLL 2 inch $ 44.75 39802442 SYNOVIAL FLUID EXAM $ 45.75 32508145 SYNTHETIC ROLL 3inch $ 66.60 32508152 SYNTHETIC ROLL 4 inch $ 75.05 32508160 SYNTHETIC ROLL 5 inch $ 77.85 40714008 SYNTHROID 100 MCG TABLET $ 3.25 40750572 SYNTHROID 100MCG VIAL $ 131.55 32504763 SYRINGE 60CC $ 3.55 41107892 SYRINGE 60CC $ 4.00 41007311 SYRINGE 60CC $ 4.00 40484042 SYRINGE 60CC $ 4.00 31903990 SYRINGE 60CC $ 4.00 31701196 SYRINGE 60CC $ 4.00 31543810 SYRINGE 60CC $ 4.00 31405658 SYRINGE 60CC $ 4.00 31302779 SYRINGE 60CC $ 4.00 32617788 SYRINGE 60CC $ 4.00 32515413 SYRINGE IMPLANT $ 553.35 L8603 32504789 SYRINGE IRR BULB $ 15.35 32611650 SYRINGE IRR BULB $ 16.00 32514127 SYRINGE PUMP SUPPLIES $ 42.00 32504722 SYRINGE, 20CC $ 3.55 32504748 SYRINGE, 30CC $ 3.55 39401138 T. Pallidum SYPHILIS IgG $ 23.00 86780 39402565 T3 - TOTAL $ 46.50 84480 39904099 T3 TOTAL $ 52.00 84480 39903190 T3 UPTAKE $ 50.25 84479 39903281 T4 $ 60.75 84436 39904008 T4 - FREE $ 53.50 84439 39405121 T4/T8 CELL RATIO $ 241.25 86360 31202468 TABLE COVER $ 29.20 31538464 TABLE COVER $ 30.00 32617689 TABLE COVER $ 30.00 32533556 TACK LABRIAL $ 427.80 32517393 TACK, PLATE $ 218.00 C1713 32635806 TACKER OPTIFIX OPEN $ 735.00 32635608 TACKER SORBAFIX $ 775.00

140 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32511990 TACKER SYSTEM $ 750.70 32609769 TACKER SYSTEM $ 750.70 32635509 TACKER SYSTEM $ 751.00 32635707 TACKER, CAPSURE $ 458.00 39405410 TACROLIMUS (FK506) $ 91.50 80197 40744914 TAGAMET 300MG/5ML SOLN $ 6.60 40714560 TAGAMET TAB $ 3.25 40703522 TAGAMET TAB $ 3.25 40751752 TAGAMET TAB $ 4.55 40751489 TAGAMET TAB $ 6.20 40751737 TAGAMET VIAL 2ML $ 27.05 40752909 TALACEN CAPLET 25/65 $ 3.40 32513012 TALC STERILE $ 253.60 32617590 TALC STERILE $ 254.00 40746901 TALWIN AMP $ 18.20 40772352 TALWIN NX $ 5.50 40751505 TAMBOCOR 100 MG TAB $ 3.40 40771214 TAMBOCOR 100MG $ 4.50 40768848 TAMBOCOR 50MG TAB $ 6.00 40768038 TAMIFLU 12MG/ML LIQUID $ 91.00 40782344 Tamiflu 1ml 6mg/1ml suspensio $ 10.00 40781651 TAMIFLU 30MG CAPSULE $ 46.50 J8499 40781750 Tamiflu 6mg/1ml 1ml unit dose $ 10.00 40781849 Tamiflu 6mg/ml 60ml bottle $ 592.50 40765075 TAMIFLU 75MG CAPSULE $ 58.00 J8499 41465840 Tangential biopsy of skin each $ 55.00 11103 41466335 TANGENTIAL BIOPSY OF SKIN SING$ 384.00 11102 40764268 TAPAZAK 5MG $ 4.55 40776008 TAPAZOLE 10MG TAB $ 3.25 40768319 TAPAZOLE 10MG TAB $ 3.25 40768087 TARKA 2/240MG TAB $ 6.50 40766982 TARKA 4/240MG $ 6.20 40749426 TAVIST-1 TAB $ 3.25 40753840 TAVIST-D TAB SA $ 4.55 40763237 TAXOL 100MG/16.7ML VIAL $ 1,578.20 J9267 40759532 TAXOL 30MG $ 379.10 J9267 42601955 TAXOTERE 1MG $ 39.00 J9171JG 40764532 TAXOTERE 1MG $ 4,493.00 J9171 42618113 TAXOTERE 1MG JW $ 39.00 J9171JGJW 41358064 TB - PPD $ 28.05 86580 42610502 TB-PPD $ 11.75 86580 40601197 TC 99M MAA $ 53.00 A9540 31511611 TC BIOPSY $ 8,609.00 37200 31525297 TC, A/V INF,THROM,NC,SSQ DAY$ 4,318.00 37213 31525198 TC, CESS. THROMB, CATH REMVL$ 4,318.00 37214 31500622 TC, THER.,NITRO INFUS $ 2,590.00 31525099 TC, VEN INF THROMB,INIT DAY $ 5,779.00 37212 31525396 TC,ART INF THROM,NC,INIT DAY$ 8,609.00 37211 40601924 TC99 PERTECHNETATE $ 60.00 A9512 40603497 TC99 PERTECHNETATE $ 60.00 40603893 TC99 TILMANOCEPT DIAG 0.5 MCi$ 1,370.00 A9520 40601742 TC99M MYOVIEW $ 201.00 A9502 40601288 TC99M SESTAMIBI $ 311.75 A9500 42622667 TDAP VACCINE $ 147.00 90715 42622469 TDAP VACCINE ADMIN $ 170.00 90471 42630785 TECENTRIQ 10MG $ 284.00 J9022JG 42630884 TECENTRIQ 10MG JW $ 284.00 J9022JGJW 32510406 TED HOSE KNEE $ 43.30 31404371 TED HOSE KNEE $ 44.00 31303274 TED HOSE KNEE $ 44.00

141 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32617491 TED HOSE KNEE $ 44.00 32510422 TED HOSE THIGH $ 75.90 40700643 TED KNEE LENGTH $ 15.90 31401730 TEE $ 801.00 93312 40772097 TEFLARO 600 MG VIAL $ 160.00 32506719 TEGADERM 2 inch $ 3.55 31539850 TEGADERM 2 inch $ 4.00 32509150 TEGADERM 4X4 $ 7.00 31544701 TEGADERM 4X4 $ 7.00 40714602 TEGOPEN CAP $ 4.55 40763617 TEGRETOL 100MG CHEW TAB $ 3.25 40714610 TEGRETOL 200MG TAB $ 3.25 40758328 TEGRETOL 200MG/10ML UDC $ 50.15 40771701 TEGRETOL XR 200MG TAB $ 3.50 39904677 TEGRETOL(CARBAMAZEP) $ 65.25 80156 39408361 TEICHOIC ACID AB $ 160.00 86329 39407850 TEICHOIC ACID AB $ 190.25 86329 30900021 TELEMETRY $ 120.00 93041 40757106 TELEPAQUE TAB $ 8.60 50710003 TELEVISION $ 3.50 40770315 TEMOVATE CREAM 0.05% 15GM TUBE$ 224.50 33303795 TEMP TRANSCUT PACING $ 1,044.00 92953 31500598 TEMP. PACER:SINGLE $ 7,838.00 31500580 TEMPORARY PACER $ 61.00 31900236 TEMP-O-STRIP $ 39.40 32513640 TENDON ACHILLE'S LARGE $ 2,928.00 C1762 32532038 TENDON ACHILLE'S PRESHAPED $ 2,605.65 C1762 32514655 TENDON BICEP KIT $ 355.95 32513665 TENDON PATELLA HEMI $ 2,171.40 C1762 32513657 TENDON PATELLA PRESHAPED $ 3,717.00 C1762 32617392 TENDON PATELLA PRESHAPED $ 3,717.00 C1762 33302326 TENDON REPAIR DORS FINGER $ 2,725.00 26418 33302318 TENDON REPAIR DORS HAN $ 2,725.00 26410 40766099 TENECTEPLASE 50MG (TNKASE) KIT$ 185.00 J3101JG 31206361 TENEX ACHILLES TENDON $ 2,236.00 27605 31206559 TENEX ADDUCT &/OR HAMSTR MULTI$ 3,862.00 27307 31206460 TENEX ADDUCT &/OR HAMSTR SING$ 2,232.00 27306 31206064 TENEX ELBOW $ 3,862.00 24357 31206163 TENEX FASCIOTOMY FOOT OR TOE$ 2,236.00 28008 31206262 TENEX PLANTAR FASCIA &/OR MUSC$ 2,236.00 28250 40753857 TENEX TAB $ 3.40 40700171 TENORMIN 50 MG TAB $ 3.40 40769234 TERAZOL 3 VAG CREAM 20GM TUBE$ 142.50 40755415 TERAZOL 7 0.4% CREAM $ 56.65 31501646 TERUMO .035 150 CM J $ 162.35 C1769 31501653 TERUMO .035 150 CM J X $ 162.35 C1769 31501687 TERUMO .035 150 CM ST $ 162.35 C1769 31501661 TERUMO .035 150 CM STX $ 162.35 C1769 31501695 TERUMO .035 250 CM ANGLE $ 260.20 C1769 31501703 TERUMO .035 260 CM ANGLE X $ 260.20 C1769 31501711 TERUMO .035 260 CM ST $ 260.20 C1769 31501729 TERUMO .035 260 CM STX $ 260.20 C1769 31501737 TERUMO .038 150 CM J $ 162.35 C1769 31501745 TERUMO .038 150 CM J X $ 162.35 C1769 31501760 TERUMO .038 150 CM ST $ 162.35 C1769 31501752 TERUMO .038 150 CM STX $ 162.35 C1769 31501778 TERUMO .038 260 CM ANGLE $ 260.20 C1769 31501786 TERUMO .038 260 CM ANGLE X $ 260.20 C1769 31501802 TERUMO .038 260 CM ST $ 260.20 C1769 31501794 TERUMO .038 260 CM STX $ 260.20 C1769

142 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40753709 TESSALON PEARLE 100MG CAP $ 3.40 40762890 TES-TAPE DISPENSER $ 17.30 42605959 TESTOSTERONE 200MG $ 85.00 J1071 39403977 TESTOSTERONE TOTAL $ 126.75 84403 39404066 TESTOSTERONE-FREE $ 232.50 84402 33100777 TETANUS INJECTION $ 170.00 90471 31301294 TETANUS INJECTION $ 170.00 90471 42605413 TETANUS VACCINE $ 74.00 90714 42605501 TETANUS VACCINE ADMINISTRATION$ 204.00 96372 33455889 TETANUS VACCINE UNDER 7 YRS$ IM 74.00 90702 40749095 TETANUS, DIPH TOXIOD $ 20.65 40743098 TETANUS, DIPH TOXOID 0.5ML SYR$ 74.00 90714 40771891 TETRACAINE HCL 10MG/ML AMP $ 9.00 40749582 TETRACYCLINE CAP $ 3.25 39479912A TG AB GROUP $ 30.00 86800 40350100B TH TECHNICAL FEE 15 $ 60.00 Q3014 40350200B TH TECHNICAL FEE 30 $ 85.00 Q3014 40350300B TH TECHNICAL FEE 30 MCR $ 85.00 Q3014 40350400B TH TECHNICAL FEE 40 $ 102.00 Q3014 40350500B TH TECHNICAL FEE 50 MCR $ 119.00 Q3014 40350600B TH TECHNICAL FEE 60 $ 136.00 Q3014 40350700B TH TECHNICAL FEE 70 MCR $ 153.00 Q3014 40350800B TH TECHNICAL FEE 80 $ 170.00 Q3014 40601379 THALLOUS CHLORIDE $ 85.50 A9505 40769614 THEO-24 300MG CAPSULE $ 3.25 40768046 THEO-24 400MG CAPSULE $ 4.00 40730038 THEO-ORGANIDIN ELIXI $ 6.40 39904941 THEOPHYLLINE $ 65.25 80198 40766719 THEOPHYLLINE 800MG/D5W 1000ML$ 70.20 40758153 THEOPHYLLINE ANHYDRO $ 3.25 40769762 THEOPHYLLINE SR 100MG CAPSULE$ 3.25 40730046 THERAGRAN LIQUID $ 12.60 40872402 THERAPEP DEVICE $ 72.00 40901340 THERAPEUTIC ACTIVITY 15MIN $ 106.50 97530GO 40912306 THERAPEUTIC ACTIVITY/TRANS 15M$ 95.00 97530GP 31515603 THERAPEUTIC IV PUSH EA. ADDL$ 121.00 96375 31515515 THERAPEUTIC IV PUSH SGL/INITIA$ 395.00 96374 40915845 THERAPEUTIC SPEECH DEV SERVICE$ 275.33 92609GN 40756348 THERAPEUTIC VIT W/MI TABLET $ 3.25 40921225 THERAPUTIC EXCERCISE 15MIN $ 78.00 97110GO 40901225 THERAPUTIC EXCERCISE 15MIN $ 78.00 97110GP 41466632 Theraskin per 1 sq cm $ 1,055.00 Q4121 32505976 THERMOMETER KIT ORAL $ 23.10 32505992 THERMOMETER KIT RECTAL $ 20.75 40714701 THIAMINE 100 MG TABLET $ 3.25 40743122 THIAMINE 200MG/2ML VIAL $ 13.35 42609426 THIAMINE HCL 100MG VIAL $ 13.35 J3411 40766313 THIOTEPA 15MG INJ $ 401.80 J9340 40762874 THIOTHIXENE $ 3.25 40766917 THIOTHIXENE 5MG $ 3.25 31401078 THORACENTESIS $ 462.00 31300585 THORACENTESIS $ 462.00 40506034 THORACENTESIS WITH US GUIDANCE$ 1,502.00 32555 40805004 THORACIC GAS VOLUME, TC ONLY$ 543.00 94726 40403784 THORACIC MYELOGRAM $ 1,477.00 62303 32507162 THORACIC TROCAR $ 118.85 40506925 THORACIC TROCAR $ 120.00 40764557 THORAZINE 10MG TAB $ 3.40 40759631 THORAZINE 10MG/5CSYR $ 3.25 40714750 THORAZINE 25 MG TABLET $ 3.25

143 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40743148 THORAZINE AMP $ 16.50 J3230 40751083 THORAZINE TAB $ 3.25 31200553 THREE WAY FOLEY CATH $ 39.20 31304462 THREE WAY FOLEY CATH $ 40.00 32611749 THREE WAY FOLEY CATH $ 40.00 39504097 THROAT CULTURE $ 55.75 87070 31531732 THROMBECT AVF DIALYSIS GRAFT$ 8,609.00 36831 31201205 THROMBECTOMY CATH $ 180.10 C1757 32617293 THROMBECTOMY CATH $ 181.00 C1757 32514465 THROMBECTOMY DEVICE $ 1,977.15 31539058 THROMBECTOMY DEVICE $ 1,980.00 32514473 THROMBECTOMY DEVICE - X $ 1,977.15 C1757 31542622 THROMBECTOMY DEVICE - X $ 1,980.00 C1757 31532326 THROMBECTOMY OF A OR V GRAFT$ 8,609.00 35875 40723314 THROMBIN 5000 UNIT VIAL $ 49.00 31517269 THROMBIN INJECT-PSEUDOARYSM$ 1,501.00 36002 39407091 THROMBIN TIME $ 77.25 85670 33303811 THROMBOLYSIS CORNARY $ 677.00 92977 31500606 THROMBOLYSIS IV $ 364.00 40753584 THROMBOSTAT KIT $ 96.50 42602045 THYROGEN 1.1MG $ 2,307.00 J3240JG 39403266 THYROGLOBULIN $ 77.75 86800 39479912 THYROGLOBULIN AB MASTER $ 60.00 39407814 THYROGLOBULIN QT $ 58.50 84432 39401542 THYROID ANTIBOD $ 90.50 86800 39405329 THYROID MICROSOMAL AB $ 65.00 86376 39902564 THYROID PROFILE $ 94.50 40107047 THYROID RECEPTOR AB $ 142.00 83520 39477140 THYROID STIM. IMMUNOGLOBULIN$ 350.00 84445 40600348 THYROID UPTAKE AND SCAN $ 625.83 78014 40500233 THYROID US $ 299.25 76536 40107575 THYROTROPAM RECP AB $ 142.00 83520 39404157 THYROXIN BIND.GLOB. $ 73.00 84442 39902747 TIBC(IRON BINDING) $ 16.25 83550 40758971 TICLOPIDINE HYDROCHL 250MG $TAB 5.70 40753949 TIGAN AMP $ 17.05 40757684 TIGAN SUPP $ 4.55 40755456 TIGAN SUPP $ 4.55 40770125 TIGECYCLINE 50MG VIAL $ 184.00 40766040 TIKOSYN 125MCG CAP $ 5.70 40766057 TIKOSYN 250MCG CAP $ 5.70 40766065 TIKOSYN 500MCG CAP $ 5.70 40759060 TILADE INHALER $ 59.65 40750754 TIMENTIN 3.1GM PB $ 42.85 40757098 TIMENTIN VIAL $ 33.50 40754897 TIMOPTIC 0.5% DROP $ 6.70 40723330 TIMOPTIC 0.5% DROP 2.5ML BOTTL$ 23.50 39505335 TIMOTHY GRASS ALLERGEN $ 13.00 86003 40723322 TIMPOTIC 0.25% OPHT 5ML BOTTLE$ 34.00 40723355 TINACTIN 1% SOULTION $ 10.90 40723348 TINACTIN 1% SPRAY $ 12.50 32532483 TISSEEL APPLICATOR $ 147.00 32617194 TISSEEL APPLICATOR $ 147.00 32532301 TISSEEL VH FIBRIN 2ML $ 370.65 32532392 TISSEEL VH FIBRIN 5ML $ 603.75 32532574 TISSOMAT SPRAY SET $ 136.50 32617095 TISSOMAT SPRAY SET $ 137.00 32507352 TISSUE CHAMBER 1&2 $ 5.00 32513673 TISSUE FEMUR $ 840.00 C1762 32515595 TISSUE FORCEPREUS $ 74.60

144 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40201147 TISSUE INSITA, EA PROBE $ 218.50 88365 32506016 TISSUE WIPES $ 3.55 42010858 TISSUE WIPES $ 4.00 40407207 TISSUE WIPES $ 4.00 41107793 TISSUE WIPES $ 4.00 41007113 TISSUE WIPES $ 4.00 40604091 TISSUE WIPES $ 4.00 40507024 TISSUE WIPES $ 4.00 40483547 TISSUE WIPES $ 4.00 32516650 TITANIUM TIBIAL NAIL $ 2,239.00 41000613 TMJS WITH CONTRAST $ 1,179.00 70487 41000241 TMJS WOUT CONTRAST $ 939.00 70486 41000621 TMJS WWO CONTRAST $ 1,358.00 70488 33302003 TMT CL ACROMIOCLAVI $ 474.00 23540 40759375 TOBRADEX OPHT SUSP 5ML BOTTLE$ 59.40 39404249 TOBRAMYCIN $ 89.75 80200 40763369 TOBRAMYCIN 80MG/2ML VIAL $ 48.60 40763880 TOBRAMYCIN EYE DR .3% 2.5ML $BT 4.55 42602862 TOBRAMYCIN UP TO 80MG $ 52.00 J3260 40750994 TOFRANIL 25MG TAB $ 3.25 40753865 TOFRANIL TAB $ 3.25 32500142 TOGA DRAPE $ 162.00 40758138 TOLECTIN DS CAP $ 4.55 40714883 TOLINASE TAB $ 4.55 40714875 TOLINASE TAB $ 4.55 40723363 TOLNAFTATE 1% CREAM 15GM TUBE$ 15.90 40402752 TOMOGRAM 1 TO 5 IMAGES $ 415.00 74415 40402760 TOMOGRAM 11 TO 20 IMAGES $ 415.00 74415 40401465 TOMOGRAMS 6 TO 10 IMAGES $ 415.00 74415 40750689 TONOCARD TAB $ 3.40 32515470 TOOMEY SYRINGE $ 11.50 32507121 TOOTH PROTECTOR $ 39.05 39405378 TOPAMAX $ 208.50 80201 40767402 TOPAMAX 25MG TAB $ 4.58 40752081 TOPICORT 0.25% CREAM $ 39.40 42601971 TOPOTECAN 4MG $ 2,310.00 J9351 40772345 TOPROL XL 25MG TAB $ 3.25 40766198 TOPROL XL 50MG TABLET $ 3.55 40758484 TORADOL 10 MG TABLET $ 6.15 42628607 TORADOL 30 MG IV/IM $ 22.00 J1885 40754111 TORADOL SYRD $ 22.70 40757353 TORADOL SYRD $ 27.05 39402136 TORCH PANEL $ 200.75 80090 39401880 TORCH RUBELLA $ 57.75 86762 32529828 TORCON BLUE CATH $ 107.75 42614450 TORISEL 1 MG $ 264.00 J9330JG 42622370 TORISEL 1 MG JW $ 264.00 J9330JGJW 31202286 TOTAL JOINT PACK $ 483.60 39700828 TOTAL REDUCING SUB $ 28.75 81002 32510638 TOURNIQUET CUFF $ 220.10 32506032 TOWEL, STERILE $ 10.45 31540741 TOWEL, STERILE $ 11.00 39400890 TOXOPLASMA IGM $ 75.00 86778 39405238 TOXOPLASMOSIS IGG $ 64.00 86777 40766222 TPN ELECTRLYTES INJ. 20ML VIAL$ 6.95 39479912B TPO AB GROUP $ 30.00 86376 31401771 TRACER HYBRID WIRE $ 328.00 32531980 TRACER HYBRIS WIRE $ 224.35 33302961 TRACH E/R PROC $ 1,435.00 31603 33300916 TRACH TUBE CHANCE $ 288.00 31502

145 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32527954 TRACHEOSTOMY POST CAR $ 23.10 32509457 TRACK. TUBE HOLDER $ 23.10 40758633 TRACRIUM INJ MDV 10M $ 118.40 40769671 TRANDOLAPRIL 4MG TAB $ 3.50 40779770 TRANEXAMIC ACID 1000MG/10ML$ VI 100.00 40754095 TRANSDERM-SCOP 1.5MG PATCH$ 9.10 31501810 TRANSDUCER $ 55.40 31501828 TRANSDUCER KIT $ 74.15 32516163 TRANSFER SET STAYSAFE $ 62.00 39404330 TRANSFERRIN ASSAY $ 53.25 84466 42601534 TRANSFUSE 1 UNIT BLOOD $ 828.00 36430 42601625 TRANSFUSE 2 UNITS BLOOD $ 1,653.00 36430 42601716 TRANSFUSE 3 UNITS BLOOD $ 2,482.00 36430 33100355 TRANSFUSION 1 UNIT BLOOD $ 827.00 36430 33100447 TRANSFUSION 2 UNIT BLOOD $ 1,653.00 36430 33100629 TRANSFUSION 3 UNIT BLOOD $ 2,481.00 36430 33100710 TRANSFUSION 4 UNIT BLOOD $ 3,306.00 36430 33100827 TRANSFUSION 5 UNIT BLOOD $ 4,133.00 36430 33303050 TRANSFUSION BLOOD $ 828.00 36430 40500829 TRANSPLANTED KIDNEY US $ 362.00 76776 40200370 TRANSRXN $ 39.75 32514036 TRANSVERSE CONNECTOR $ 227.80 32514028 TRANSVERSE ROD $ 151.85 40751448 TRANXENE T-TAB TAB $ 3.40 32513160 TRAPEASE FILTER 6FR $ 2,596.40 40768822 TRASYLOL 10,000/20ML VIAL $ 1,633.00 40403966 TRAUMA LEFT ANKLE AND MORTISE$ 137.00 73610 40403925 TRAUMA LEFT SHOULDER $ 136.00 73030 40404014 TRAUMA RIGHT ANKLE AND MORTISE$ 137.00 73610 40403867 TRAUMA RIGHT SHOULDER $ 136.00 73030 40770653 TRAVATAN .004% OPTH SOL 5ML$ BT 453.50 32527822 TRAY , SIGMOIDOSCOPE $ 41.75 32505430 TRAY ADD A FOLEY $ 42.65 32527020 TRAY ARTERIOGRAM $ 108.70 32505414 TRAY FOLEY 18FR $ 85.95 32507915 TRAY HIBICLENS 4% $ 5.00 32508780 TRAY LUMBAR ADULT $ 133.75 32505356 TRAY LUMBAR ADULT $ 133.75 32513293 TRAY PARACENTESIS $ 132.30 32505372 TRAY URETHRAL CATH $ 14.50 32517500 TRAY URETHRAL STRICTURE $ 404.96 A4311 32616996 TRAY URETHRAL STRICTURE $ 405.00 A4311 32532640 TRAY UROLOGIST $ 526.94 32527004 TRAY, AMNIOCENTESIS $ 60.80 32505232 TRAY, BONE MARROW $ 247.35 32527129 TRAY, COLOSTOMY CARE $ 20.75 32527186 TRAY, DRESSING $ 19.60 32527996 TRAY, DRESSING $ 28.95 32527137 TRAY, E.R. CUT DOWN $ 38.25 32527228 TRAY, ENDO TRACHEAL $ 66.60 32508228 TRAY, EXCHANGE TRANS $ 414.10 32527202 TRAY, EYE $ 25.40 32505398 TRAY, FOLEY 16FR $ 85.95 32510547 TRAY, HEMODYALISIS CA $ 567.85 32616897 TRAY, HEMODYALISIS CA $ 568.00 32505455 TRAY, IRRIGATION $ 12.85 32611848 TRAY, IRRIGATION $ 13.00 32527095 TRAY, LAVAGE $ 36.80 32527509 TRAY, LIVER BIOPSY $ 179.45 41007212 TRAY, LIVER BIOPSY $ 180.00

146 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40506727 TRAY, LIVER BIOPSY $ 180.00 32505315 TRAY, LUMBAR INFANT $ 52.05 32505331 TRAY, LUMBAR PED $ 62.35 32527608 TRAY, M. A./ CANTOR $ 211.00 32527616 TRAY, MYELOGRAM $ 147.65 32527673 TRAY, NEONATAL RESUS $ 108.70 32527764 TRAY, PELVIC EXAM ER. $ 57.30 32527756 TRAY, PRE-ECLAMPTIC $ 17.25 40484537 TRAY, SALPINGOGRAM $ 84.00 32527806 TRAY, SALPINGOGRAM $ 84.85 32527814 TRAY, SENGSTAKEN $ 661.75 32505273 TRAY, SHAVE PREP $ 11.50 32527830 TRAY, SKINNY NEEDLE $ 66.60 32527855 TRAY, SUBCLAVIAN $ 46.55 40506826 TRAY, THORACENTESIS $ 114.00 32505216 TRAY, THORACENTESIS $ 114.30 32616798 TRAY, THORACENTESIS $ 115.00 32500100 TRAY, TRACHEOSTOMY $ 112.00 32527962 TRAY, TRANSHEPATIC $ 85.90 42613162 TREANDA 1 MG $ 104.00 J9033JG 42619301 TREANDA 1MG JW $ 104.00 J9033JGJW 33300536 TREAT ACRORMI DISLOC $ 790.00 23545 33300635 TREAT CARPAL BONE FR $ 2,424.00 25635 33300627 TREAT CARPAL SCAPHOL $ 1,582.00 25624 33300692 TREAT CL CARPOMETACA $ 375.00 26670 33301997 TREAT CL CLAVICULAR FRACT $ 1,582.00 23505 33100504 TREAT CL.FX DISLOCATION,THUMB$ 2,424.20 26645 33300510 TREAT CLAVICULAR FRA $ 392.00 23500 33100397 TREAT DISLOCATION,THUMB W/MANI$ 474.00 26641 33300734 TREAT DISTAL PHAL FR $ 4,531.00 26765 33302110 TREAT ELBOW W/ANES $ 2,553.00 24605 33302102 TREAT ELBOW W/O ANES $ 537.00 24600 33302094 TREAT HUMERAL COMDYL $ 474.00 24576 33300577 TREAT HUMERAL CONDYL $ 1,084.00 24577 33302086 TREAT HUMERAL EPCI $ 2,424.00 24565 33302078 TREAT HUMERAL EPICON $ 413.00 24560 33300551 TREAT HUMERAL SHAFT $ 1,179.00 24505 33302052 TREAT HUMERAL SUPRA $ 474.00 24530 33302045 TREAT HUMERAL W/O MA $ 474.00 24500 33300742 TREAT INTERPHAL JOINT $ 4,531.00 26785 33301963 TREAT MANDI W/O MANI $ 806.00 21450 33300502 TREAT MANDIBULAR FRA $ 2,810.00 21451 33300544 TREAT PROXIMAL FRAC $ 3,684.00 23605 33300585 TREAT RADIAL HEAD/NECK $ 2,670.00 24655 33302037 TREAT SHOULDER W/ANES $ 2,553.00 23655 33455097 TREAT SHOULDER W/MAN $ 2,672.00 23665 33300528 TREAT STERNOCLAV FRA $ 2,911.00 23520 33300825 TREAT TARSAL BONE FX $ 2,424.00 28455 33300593 TREAT ULNAR FRACTURE $ 2,424.00 24675 41210156 TREATMENT DEVICES - COMPLEX$ 555.00 77334 41210144 TREATMENT DEVICES - INTERMEDIA$ 480.00 77333 41210132 TREATMENT DEVICES - SIMPLE $ 480.00 77332 41210425 TREATMENT DEVICES COMPLEX $ 645.00 77334 41293178 TREATMENT DEVICES, COMPLEX $ 223.00 77334 41293166 TREATMENT DEVICES, INTERMEDIAT$ 155.00 77333 41293154 TREATMENT DEVICES, SIMPLE $ 123.00 77332 41293049 TREATMENT PLANNING COMPLEX$ 665.00 77263 41293037 TREATMENT PLANNING INTERMEDIAT$ 563.00 77262 41293025 TREATMENT PLANNING SIMPLE $ 447.00 77261 40915197 TREATMENT SPEECH LANGUAGE $ 196.00 92507GN

147 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40931018 TREATMENT SPEECH LANGUAGE-GRP$ 63.93 92508GN 40915548 TREATMENT SWALLOWING DYSPHAGIA$ 223.90 92526GN 40750556 TRENTAL 400MG TABLET $ 3.40 31203516 TREPHINE BLADE DISP $ 196.90 32511255 TREPHINE, HESSMAN BA $ 280.25 32616699 TREPHINE, HESSMAN BA $ 281.00 32511297 TREPINE, BARROW RADI $ 298.35 31501836 TRI PACK CATHETER $ 249.05 C1759 31505654 TRI PACK CATHETER X $ 237.05 C1759 40600686 TRI PHASE BONE SCAN $ 737.45 78315 32516890 TRIAD FACET DOWEL $ 1,868.75 40764011 TRIAMANOLON 0.1% OIN 15GM TUBE$ 23.80 41460098 TRIAMCINOLONE ACET INJ NOS 10M$ 32.00 J3301 40756264 TRIAMCINOLONE ACETON $ 17.05 40753873 TRIAVIL 2-10 TAB $ 3.40 40753881 TRIAVIL 2-25 TAB $ 3.40 39501994 TRICH, URINE $ 20.00 87808 40107336 TRICHOMONAS URINE $ 15.00 81015 40770919 TRICHOPHYTON ALLERGENIC EX $2ML 168.50 32514705 TRICLIP ENDO DEVICE $ 425.00 40767410 TRICOR 160MG TAB $ 8.27 40768343 TRICOR 54MG TAB $ 3.50 31900814 TRIFICATED SET $ 42.45 40750267 TRIFLUOPERAZINE TAB $ 3.25 39903018LP TRIGLYCERIDES $ 32.25 84478 39903018 TRIGLYCERIDES $ 44.75 84478 39404132 TRIGLYCERIDES - VAP $ 57.50 84478 40750325 TRILAFON AMP $ 23.05 40107807 TRILEPTAL $ 50.00 82542 40767956 Trileptal 300mg Tablet $ 6.00 39407664 TRILEPTAL(OXCARBAZEPINE) $ 103.00 80299 32507303 TRIM-IT DRILL PIN $ 355.10 41452970 TRIMMING NONDYSTROPIC NAILS$ 136.50 11719 40749079 TRIMPEX TAB $ 4.55 40758849 TRINSICON CAPSULE $ 3.40 40770323 TRIPLE ANTIBIOTIC OINTMENT $ 12.50 40723041 TRIPLE SULFA VAGINAL $ 12.40 32516320 TRIVERSE DEVICE $ 130.00 31203714 TROCAR 10MM $ 594.50 32531691 TROCAR 12MM $ 594.50 32608383 TROCAR 12MM OPTIVIEW $ 131.00 32639766 TROCAR 12MM X 100MM OPTIVIEW$ 131.00 32608581 TROCAR 12MM, AIRSEAL $ 385.00 31203722 TROCAR 5MM $ 459.90 32616600 TROCAR 5MM $ 460.00 32608779 TROCAR 5MM AIRSEAL $ 370.00 32608482 TROCAR 5MM OPTIVIEW $ 104.00 32608977 TROCAR 5MM X 100MM OPTIVIEW$ 104.00 32608878 TROCAR 8MM, AIRSEAL $ 369.00 32533408 TROCAR SLEEVES $ 204.95 32602839 TROCAR, DISSECTING BALLON $ 361.16 32533655 TROCH GRIP $ 628.95 32515850 TROCOR THORAROPORT $ 112.00 40752297 TROLAMINE POLYPEPTID $ 42.75 39901939 TROPONIN I $ 96.00 84484 31201429 TRU-CUT NEEDLE $ 129.35 40766487 TRUSOPT 2% OPTH 2.5ML BOTTLE$ 85.05 39404538 TRYPSINOGEN $ 160.00 84488 39903109 TSH $ 69.50 84443 40477699 TSPINE ONE VIEW $ 193.70 72020

148 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 41000654 TSPINE WITH CONTRAST $ 1,327.00 72129 41000134 TSPINE WOUT CONTRAST $ 939.00 72128 41000662 TSPINE WWO CONTRAST $ 1,533.00 72130 39412153 T-TRANGLUTAMINASE IGA $ 132.00 83516 39412252 T-TRANGLUTAMINASE IGG $ 132.00 83516 39413341 T-TRANSGLUTAMINASE IGA $ 132.00 83516 31200538 T-TUBE &/OR BILE BAG $ 53.60 32616501 T-TUBE &/OR BILE BAG $ 54.00 32511487 TUBE ATRIUM CHEST $ 103.70 32505935 TUBE E-WALD $ 12.60 32601833 TUBE EXTENSION $ 5.50 32505638 TUBE FEED ROSS 10 FR $ 103.70 32509143 TUBE FEEDING ROSS 8FR $ 68.75 31203573 TUBE GASTROSTOMY $ 267.25 31545196 TUBE GASTROSTOMY $ 270.00 32511750 TUBE GAUZE DRESSING $ 8.15 32514861 TUBE JEJUNAL $ 153.70 32533119 TUBE LMA $ 50.95 31202310 TUBE P.E. EAR $ 116.40 32515512 TUBE RECTAL $ 3.75 32505794 TUBE SALEM SUMP 12FR $ 19.60 32508699 TUBE SALEM SUMP 14 FR $ 11.20 32616402 TUBE SALEM SUMP 14 FR $ 12.00 32508707 TUBE SALEM SUMP 16 FR $ 12.85 32508715 TUBE SALEM SUMP 18FR $ 24.00 32511479 TUBE SILICONE SUMP $ 80.15 32611947 TUBE SILICONE SUMP $ 81.00 32500167 TUBE SUCTION CON. 144 $ 25.40 33304967 TUBE THORACOSTOMY W/WO WTRS$ 1,086.00 32551 31402391 TUBE THORACOSTOMY W/WO WTRS$ 1,088.00 32508749 TUBE TRACHEOSTOMY 10 $ 223.80 32533275 TUBE TRACHEOSTOMY 4 $ 223.80 32505893 TUBE TRACHEOSTOMY 6 $ 223.80 32508723 TUBE TRACHEOSTOMY 7 LONG $ 268.55 32508731 TUBE TRACHEOSTOMY 8 $ 223.80 32596296 TUBE, EAR 1.27 TITANIUM $ 92.00 32516254 TUBE, TEFLON $ 462.00 32505950 TUBE, URINARY DRAIN $ 3.55 32505778 TUBE,RECTAL 25FR $ 11.75 40772444 TUBERCULIN 5 UNITS / 0.1ML SYR$ 17.00 86580 32505554 TUBES ENDOTRACHEAL $ 25.40 32505653 TUBES FEEDING 5FR 15 $ 12.55 40483349 TUBES FEEDING 5FR 15 $ 13.00 32505612 TUBES FEEDING 8FR 15 $ 7.00 32505513 TUBES, CANTON $ 149.95 32505737 TUBES, MILLER ABBOTT $ 163.55 32507329 TUBING CAP SET $ 60.10 32514663 TUBING CONN 72IN. $ 5.25 32608680 TUBING, INSUFFLATION AIRSEAL$ 385.00 40756892 TUBOCURARINE CHLORID $ 32.95 40743171 TUBOCURARINE CHLORID $ 32.95 40723413 TUCKS PAD 1 EACH PAD 100/BOX$ 7.30 40601668 TUMOR IMAGING WHOLEBODY 2 $DAY 2,638.05 78804 40601577 TUMOR IMAGING WHOLEBODY SINGLE$ 1,568.38 78802 40758609 TUMS PACK OF 12'S $ 3.25 32508319 TURKEL ASPIRT.NEEDLE $ 28.95 31200413 TURTUBING $ 56.15 40730095 TUSSIONEX SUSP 5ML UDC $ 6.80 40730111 TUSSI-ORGANIDIN DM $ 3.25 40730103 TUSSI-ORGANIDIN LIQ $ 3.25

149 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32532467 TVT DEVICE $ 1,554.00 C1771 32517088 TWISTED 1/2 BASKET $ 142.50 31200587 TWO WAY FOLEY $ 15.75 40769226 TWOCAL AN $ 8.00 33302623 TX ANK DIS W/O ANES $ 474.00 27840 33302631 TX ANKLE DIS W/ANES $ 2,553.00 27842 33302607 TX BILALL ANK, W/MANI $ 1,582.00 27810 33302599 TX BINALL ANK, W/O MANI $ 474.00 27808 33302664 TX CALCANEAL W/O MANI $ 474.00 28400 33302250 TX CARPAL FRAC W/O MANI $ 474.00 25630 33302243 TX CARPAL FRAC W/O MANI $ 474.00 25622 33302581 TX DISTAL FIB W/MANI $ 474.00 27788 33302409 TX DISTAL PHAL W/MANI $ 474.00 26755 33302391 TX DISTAL PHAL, W/O MANI $ 375.00 26750 33302276 TX DISTAL RAD DISLOC $ 474.00 25675 33302573 TX DISTAL TIB W/O MANI $ 474.00 27786 33302474 TX FEMORAL FRAC W/O MANI $ 474.00 27508 33302482 TX FEMORAL FX W/MANI $ 2,672.00 27510 33302466 TX FEMORAL W/ANES $ 2,911.00 27502 33302458 TX FEMORAL W/O ANES $ 474.00 27500 33302235 TX FRAC/EPIPH W/MANI $ 1,582.00 25605 33302227 TX FRAC/EPIPH,W/O MAN $ 608.00 25600 33302706 TX FX GREAT TOE W/MANI $ 474.00 28495 33302698 TX FX GREAT TOE W/O $ 375.00 28490 33305170 TX FX TIB DSTL W/TRACJ/MANIP $F 2,911.00 27825 33302722 TX FX,PHAL W/MANI $ 474.00 28515 33302714 TX FX.PHAL W/O MANI $ 375.00 28510 33302433 TX HIP DIS W/O ANES $ 517.00 27250 33302417 TX INTERPHAL W/MANI $ 375.00 26770 33302763 TX INTERPHAL W/O ANES $ 375.00 28660 33302516 TX KNEE DIS W/O ANES $ 672.00 27550 33302342 TX METACARPAL W/ MANI $ 474.00 26605 33302334 TX METACARPAL W/O MANI $ 474.00 26600 33302367 TX METACARPO W/MANI $ 474.00 26700 33302680 TX METATARSAL W/O MANI $ 474.00 28470 33302748 TX METATERS W/O ANES $ 474.00 28630 33454503 TX MONTEGGIA FX $ 2,911.00 24620 33300726 TX OPEN PHALANG FRACT $ 4,531.00 26735 33302524 TX PATELLAR DIS, W/O ANES $ 385.00 27560 33302490 TX PATELLAR FX, W/MANI $ 474.00 27520 33302383 TX PHALAN SFT W/MANI $ 474.00 26725 33302375 TX PHALAN SFT W/O MANI $ 375.00 26720 33302128 TX RAD HEAD W/MANI $ 474.00 24640 33302136 TX RAD HEAD W/O MANI $ 474.00 24650 33302169 TX RAD SHAFT W/O MAN $ 375.00 25500 33302177 TX RAD SHAFT W/O MAN $ 1,582.00 25505 33302201 TX RAD&ULNAR SHAFT W/O MAN$ 698.00 25560 33302219 TX RAD&ULNARSHAFT W/MAN $ 2,424.00 25565 33302730 TX SESAMIOD FX $ 375.00 28530 33302672 TX TARSAL BONE W/O MANI $ 375.00 28450 33302508 TX TIBIAL FX, W/O MANI $ 474.00 27530 33302557 TX TIBIAL W/O MANI $ 474.00 27750 33302615 TX TRIMALL ANK W/O MANI $ 474.00 27816 33301244 TX ULNAR FRAC W/MANI $ 416.00 24670 33302185 TX ULNAR FRAC W/O MA $ 437.00 25530 33302193 TX ULNAR SHAFT W/MAN $ 580.00 25535 33302268 TX ULNAR STY FRAC $ 474.00 25650 33303340 TX VAGINAL BLEEDING $ 291.00 57180 33302565 TXDISTAL TIB W/O MA $ 474.00 27760 33452721 TXFX TIB DSTL W/TRACJ/MANIP FA$ 2,911.00 27825

150 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40704702 TYLENOL (GEN) DROPS 80MG/0.8ML$ 13.65 40764243 TYLENOL ELIXIR 160MG/5ML $ 3.25 40746372 TYLENOL W/COD #3 300/30MG TAB$ 4.55 40756926 TYLENOL W/COD ELX BL $ 4.55 40756934 TYLENOL/COD 120/12MG/5ML UDC$ 3.40 40200214 TYPE & SCREEN $ 91.00 86850 39402862 TYPHOID H $ 20.75 86000 39402771 TYPHOID O $ 20.75 86000 39404181 TYPHUS FEVER $ 20.75 86000 40763930 TYRAZINAMIDE 500MG TAB $ 3.25 42611875 TYSABRI 1 MG $ 74.00 J2323JG 42620489 TYSABRI 1 MG JW $ 74.00 J2323JGJW 40765885 U.A.C. KIT SALINE 1 EACH KIT $ 27.00 40501975 U/S COMP PREG <14 WEEKS TWINS$ 110.00 76802 40501876 U/S COMP PREGNANCY <14 WEEKS$ 250.00 76801 40502074 U/S COMP PREGNANCY >14 WEEKS$ 110.00 76810 32518177 U/S GUID TENOT ELBOW SUPPIES$ 892.00 32616303 U/S GUID TENOT ELBOW SUPPIES$ 892.00 32518185 U/S GUID TENOT FASIO FOOT SUPP$ 892.00 31205272 U/S GUIDANCE FOR TENOTOMY $ 381.00 76942 31522868 U/S GUIDANCE NEEDLE PLACEMENT$ 381.00 76942 32518201 U/S GUIDE TENOT ACHILLES TEN$ S 892.00 31205767 U/S GUIDE TENOT ACHILLES TEND$ 1,121.00 32518227 U/S GUIDE TENOT ADD OR HAMST$ M 892.00 32518219 U/S GUIDE TENOT ADD OR HAMST$ S 892.00 31205965 U/S GUIDE TENOT ADD OR HMSTR$ M 1,121.00 31205866 U/S GUIDE TENOT ADD OR HMSTR$ S 1,121.00 31205371 U/S GUIDE TENOT ELBOW COMBO$ CO 1,121.00 31205569 U/S GUIDE TENOT FASCI FOOT COM$ 1,121.00 31205668 U/S GUIDE TENOT PLANT AND MSCL$ 1,121.00 32518193 U/S GUIDE TENOT PLANT F & MU$ S 892.00 31533415 U/S GUIDE VAS ACCESS $ 190.00 76937 39409084 UA NO MICRO $ 43.00 81003 39404595 UA REFLEX + DIP $ 43.00 81003 40106957 UD MICROSCOPIC ONLY $ 26.25 81015 40478491 UGI SERIES WITH BA SWALLOW $ 293.00 74246 40476808 UGI SERIES WITH KUB $ 402.00 74246 40400533 UGI SERIES WO KUB $ 293.00 74246 31902786 ULNAR PROTECTORS $ 19.50 40765182 ULTANE 250 ML BOTTLE $ 164.95 32518128 ULTRA PLUME AWAY $ 75.00 40601569 ULTRA TAG $ 137.25 Q3010 40763500 ULTRAM 50MG TABLET $ 3.55 40505044 ULTRASOUND BREAST COMPLETE$ BIL 470.00 40505341 ULTRASOUND BREAST COMPLETE$ LEF 235.00 76641LT 40505440 ULTRASOUND BREAST COMPLETE$ RIG 235.00 76641RT 40505143 ULTRASOUND BREAST LIMITED BIL$ 480.00 76642 40505242 ULTRASOUND BREAST LIMITED LEFT$ 240.00 76642LT 40504945 ULTRASOUND BREAST LIMITED RIGH$ 240.00 76642RT 40505638 ULTRASOUND GUIDANCE RADIATION$ 58.00 77387 40900037 ULTRASOUND I 15 MIN $ 104.00 97035GP 40920037 ULTRASOUND I 15MIN $ 104.00 97035GO 40504747 ULTRASOUND RIGHT UPPER EXT $ART 334.00 93931RT 40504648 ULTRASOUND VENOUS DOPPLER $RIGH 422.25 93971RT 32531535 ULTRATOME $ 517.40 31401326 ULTRATOME XL $ 442.00 40933194 ULTRAVIOLET $ 19.00 97028GO 40924369 ULTRAVIOLET $ 19.00 97028GP 32527103 UMBILICAL ARTERY TRAY $ 178.30 32515934 UMBILICAL CATHETER $ 48.00

151 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32616204 UMBILICAL CATHETER $ 48.00 40770869 UNASYM 1.5GM/100ML NS IVPB $ 68.00 40770877 UNASYM 3GM/100ML NS PREMX IVPB$ 84.00 40757197 UNASYN 1.5GM VIAL $ 30.65 J0295 40757205 UNASYN 3GM VIAL $ 53.00 J0295 40704694 UNIPEN VIAL $ 17.95 40756579 UNIPEN VIAL $ 22.35 40778285 Unisom 25mg Tab $ 3.25 41210183 UNLISTED PROC PHYSICS DOS $ 301.00 77399 41460395 UNLISTED PROCEDURE SKIN MM&$ SQ 136.50 17999 31517621 UNLISTED RADIOLOGY PROC S&I$ 131.00 76499 31511314 UNLISTED URINARY SYST. PROCED$ 474.00 53899 40501063 UNLISTED US PROCEDURE $ 203.00 76999 31517533 UNLISTED VASCULAR PROCEDURE$ 1,907.00 37799 41454950 UNNA BOOT APPLICATION $ 310.38 29580 40924448 UNNA BOOT APPLICATION EACH $ 142.00 29580GO 40901308 UNNA BOOT APPLICATION EACH $ 142.00 29580GP 41455049 UNNA BOOTS APP BILATERAL $ 568.00 2958050 40750929 UNNA FLEX 4 1 EACH BANDAGE" $ 31.00 32594613 UPHOLD VAGINAL SUPPORT SYSTEM$ 2,330.25 C1763 32616105 UPHOLD VAGINAL SUPPORT SYSTEM$ 2,331.00 C1763 40402646 UPPER AIRWAY AP AND LATERAL$ 117.25 70360 40402273 UPPER EXTREMITY CHILD INFANT$ 2 VIEWS 124.50 73092 39401930 UR PROT RANDOM $ 32.25 81050 39901293 UREA UR RANDOM $ 32.25 84540 40715534 URECHOLINE TAB $ 3.25 40743619 URECHOLINE VIAL $ 20.65 31200611 URET CONN TUBE X FIT $ 29.20 32612046 URET CONN TUBE X FIT $ 30.00 31200678 URET LUER LOCK CONN $ 21.35 32616006 URET LUER LOCK CONN $ 22.00 32507279 URETERAL DILATOR SET $ 300.20 32615907 URETERAL DILATOR SET $ 340.00 32515363 URETHRAL CATHETER ILLUMINATING$ 355.95 C1758 32515033 URETHRAL SHEATH $ 226.00 32515314 URETHRAL SHEATH $ 271.15 C1894 32603037 URETHRAL SLING $ 1,531.25 32527848 URETHRAL STICTURE TRAY $ 196.30 39903372 URIC ACID - SERUM $ 53.75 84550 39903463 URIC ACID - URINE $ 52.25 84560 39405220 URIC ACID RHEA 18 $ 18.25 84550 32506149 URINAL, DISP $ 6.45 41107991 URINAL, DISP $ 7.00 41007410 URINAL, DISP $ 7.00 40604388 URINAL, DISP $ 7.00 40484141 URINAL, DISP $ 7.00 31701295 URINAL, DISP $ 7.00 31405064 URINAL, DISP $ 7.00 31301690 URINAL, DISP $ 7.00 32615808 URINAL, DISP $ 7.00 41355092 URINALYSIS $ 18.00 81002 39700109 URINALYSIS WITH MICRO $ 54.00 81001 32506164 URINARY DRAINAGE SET $ 45.60 39404686 URINE BACTERIA SCREEN $ 27.00 81007 39406020 URINE CREATINE $ 40.75 82540 39900394 URINE CREATININE $ 44.25 82570 39502661 URINE CULTURE $ 55.75 87086 39700190 URINE DIPSTICK $ 43.00 81002 32639568 URINE DRAINAGE BAG $ 11.00 40108302 URINE DRUG CONFIRMATION $ 103.25 80307

152 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 39900600 URINE DRUG SCREEN $ 217.00 80307 39700281 URINE GLUCOSE $ 10.25 81002 39405642 URINE HEMOGLOBIN $ 14.50 81003 39700372 URINE KEYTONE $ 7.75 81002 32509713 URINE METER $ 49.35 39477338 Urine NMP22 $ 278.75 86316 40107294 URINE PORPHYRIN $ 57.00 84120 39901756 URINE PROTEIN 24HR $ 52.00 84156 39701180 URINE PROTEIN DIPSTK $ 14.00 81003 39700646 URINE SCREEN $ 30.00 81001 39900576 URINE SODIUM 24 HOUR $ 72.25 84300 39700737 URINE SPECIFIC GRAV. $ 19.75 81005 32506222 URINE STRAINER $ 15.35 40715542 URISED TAB $ 3.25 40715559 URISPAS 100MG TAB $ 3.40 39402011 UROBIL $ 23.00 84120 39903554 UROBILINOGEN $ 21.75 84578 40767444 UROGESIC BLUE TABLET $ 3.25 42601328 UROKINASE 5000IU $ 137.00 J3364 32508764 UROSHEATH LARGE $ 47.95 32508756 UROSHEATH MED $ 31.40 32506248 UROSHEATH SMALL $ 36.25 32510900 UROSTOMY POUCH $ 52.80 32510208 UROSTOMY WAFER @FLAN $ 77.85 39401757 URPROT RANDOL QUANT $ 45.75 84156 40503361 US ABDOMEN LIMITED $ 299.25 76705 40503757 US BREAST WIRE 1ST LESION LEFT$ 1,183.00 19285LT 40503658 US BREAST WIRE ADDED LESION$ LE 106.00 19286LT 40504153 US BREAST WIRE ADDED LESION$ RI 106.00 19286RT 40504252 US BREAST WIRE RIGHT LESION $1 1,183.00 19285RT 40500142 US CHEST EXAM $ 299.00 76604 40502470 US EXT NONVASCULAR REAL TIME$ C 334.00 76881 40503262 US GUIDANCE FOR PARACENTESIS$ 1,535.00 49083 40506133 US GUIDANCE FOR PERC DRAINAGE$ 381.00 75989 40504450 US GUIDE PERCU BREAST 1ST LESI$ 2,714.00 19083RT 40500910 US GUIDE PERCU BREAST 1ST LESI$ 2,714.00 19083LT 40500811 US GUIDE PERCU BREAST 2ND LESI$ 1,954.00 19084LT 40504351 US GUIDE PERCU BREAST 2ND LESI$ 1,954.00 19084RT 40501414 US GUIDED BX PERCU LIVER $ 2,336.00 47000 40501678 US GUIDED DRAINAGE OTHER $ 800.00 40501590 US GUIDED PERCU DRAINAGE ABD$ 1,037.00 40502668 US LOWER EXT BIL ARTERIAL $ 532.00 93925 40502173 US NEEDLE BX PROSTATE SING MUL$ 3,245.00 55700 40502569 US NONVASCULAR LIMIT SPECIFIC$ 211.00 76882 40502272 US PREGNANT UTERUS LIMITED $ 299.25 76815 40500514 US PROSTATE TRANSRECTAL $ 299.25 76872 40500951 US PYLORIC STENOSIS $ 299.25 76705 40500837 US SPLEEN $ 299.25 76705 40500506 US TRANSVAGINAL NONPREGNANT$ 300.50 76830 40501777 US TRANSVAGINAL PREGNANT $ 299.25 76817 40502866 US UPPER EXT ARTERIAL LEFT $ 334.00 93931LT 40502767 US UPPER EXT BILATERAL ARTERIA$ 532.00 93930 31200686 UVAC CANNISTER/TUBING $ 175.65 32615709 UVAC CANNISTER/TUBING $ 176.00 39407990 V,ZOSTER 1GG $ 47.25 86787 31505779 V-18 WIRE - X $ 309.55 32506370 VACUUM BLOOD BOTTLE $ 19.10 31203862 VACUUM TREPHINE $ 270.95 33303365 VAGINAL DEL W/WO FORCEPTS $ 4,095.00 59409 32506354 VAGINAL IRRIG. BAG $ 39.40

153 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32501959 VAGINAL IRRIGATION $ 17.25 32515843 VAGINAL SUPPORT SYSTEM $ 4,025.00 C1771 40744013 VALIUM 10MG/2ML VIAL $ 19.30 40755068 VALIUM 2MG TAB $ 3.40 40716110 VALIUM 5 MG TAB $ 3.40 42607720 VALIUM 5MG PO $ 3.40 40755498 VALIZONE O.1% CREAM $ 31.75 39404421 VALPROIC ACID (DEPAK $ 42.00 80164 42601443 VALRUBICIN INTRAV 200MG $ 1,704.00 J9357JG 40766396 VALTREX 500MG TABLET $ 12.45 32511966 VALVE ANTI REFLUX $ 42.65 32513095 VALVE BIOPSY $ 13.85 31405955 VALVE BIOPSY $ 22.00 31402985 VALVE KIT $ 24.00 32513087 VALVE SUCTION $ 33.10 40753162 VANCENASE AQ 0.042% $ 90.90 40763203 VANCENASE AQ 84MCG C $ 91.80 40749681 VANCENASE NASAL INH $ 80.70 39903737 VANCOMYCIN $ 89.75 80202 42602854 VANCOMYCIN 1.5 GM $ 21.00 J3370 42609514 VANCOMYCIN 1GM $ 85.50 J3370 40755530 VANCOMYCIN 1GM VIAL $ 85.05 J3370 40770786 VANCOMYCIN 1GM/250ML NS IVPB$ 59.00 J3370 40781453 VANCOMYCIN 500MG /100ml IVPB$ 42.52 J3370 40749277 VANCOMYCIN 500MG VIAL $ 42.52 J3370 40781354 VANCOMYCIN 750MG / 250MG IVPB$ 42.52 J3370 39905216 VAP $ 159.50 32532335 VAPOR TROBE ELECTRODE $ 317.05 39403654 VARICELLA ZOST $ 50.75 86787 41455544 VAS STUDY BIL EXTRE COMPLETE$ 319.45 93923 40764052 VASACON A OPHTH GTTS $ 14.05 31530049 VASC EMBOLIZE/OCCLUDE ORGAN$ 21,366.00 37243 40764813 VASCOR 200MG TAB $ 7.60 32533044 VASCULAR ACCESS PORT $ 1,259.70 C1788 33454998 VASCULAR CATH AGE 3 OR OLDER$ 320.00 36410 31300833 VASCULAR CATH AGE 3 OR OLDER$ 320.00 36410 31300213 VASCULAR CATH, UNDER AGE 3 $ 320.00 36400 31200975 VASCULAR GRAFT $ 1,094.50 C1768 32615610 VASCULAR GRAFT $ 1,095.00 C1768 41455346 VASCULAR STUDY LIM BIL EXT 1-2$ 250.00 93922 41455445 VASCULAR STUDY UNILAT LIMITED$ 157.50 9392252 32506396 VASELINE GAUZE 3X9 $ 7.90 32506438 VASELINE TUBES $ 3.55 40763195 VASOCIDIN 10-0.23% OPHT SOLN$ 34.60 40757213 VASOCON (GEN) OPH GT $ 13.50 40716136 VASODILAN TAB $ 3.25 40755936 VASOLINE 1 OZ TUBE $ 4.50 40931000 VASOPNEUMATIC DEVICE $ 66.25 97016GO 40912304 VASOPNEUMATIC DEVICE $ 66.25 97016GP 40752388 VASOPRESSIN 20 UNITS/1 ML VIAL$ 669.50 32533200 VASOSEAL CLOSURE $ 372.75 40759409 VASOTEC 1.25MG/1ML 1ML VIAL/EA$ 32.95 40751364 VASOTEC 5 MG TAB $ 3.40 31513449 VD REPAIR NONTUNNEL NO PORT/PU$ 1,501.00 36575 31513537 VD REPAIR TUNNEL NO PORT/PUMP$ 1,501.00 36575 31513625 VD REPAIR TUNNEL PORT $ 2,162.00 36576 31513713 VD REPAIR TUNNEL PUMP $ 2,162.38 36576 39404751 VDRL $ 17.50 86593 42619202 VECTIBIX 10 MG JW $ 419.00 J9303JW 42611281 VECTIBIX 10MG $ 419.00 J9303

154 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 32510554 VEIN STRIPPER $ 96.55 42604691 VELCADE 0.1 MG $ 176.00 J9041JG 42621479 VELCADE 0.1 MG JW $ 176.00 J9041JGJW 40780859 Velcade 3.5mg Vial $ 5,102.50 J9041 33303043 VEN CATHER 5 YRS OR GREATER$ 1,907.00 36556 33300940 VEN CATHETER > AGE 5 $ 305.00 36491 32513301 VENA CAVA FILTER $ 2,513.70 C1880 31511470 VENA CAVA FILTER - FEMORAL $ 2,759.00 31552522 VENA CAVA FILTER - FEMORAL $ 2,800.00 31511561 VENA CAVA FILTER - JUGULAR $ 2,044.00 41355276 VENIPUNCTURE $ 8.00 36415 40105322 VENIPUNCTURE $ 8.00 36415 33100785 VENIPUNCTURE $ 8.00 36415 33100462 VENIPUNCTURE UNDER AGE 3 $ 320.00 36400 33452173 VENIPUNCTURE,ER CLINIC $ 8.00 36415 40772378 VENOFER 100 MG/5 ML VIAL $ 223.50 J1756 42614054 VENOFER 100MG $ 192.00 J1756 31511108 VENOGRAM - CORONARY SINUS $ 6,011.00 75860 31502420 VENOGRAM INFERIOR CAVAL $ 5,782.00 75825 31502248 VENOGRAM SUPERIOR CAVAL $ 1,984.58 75827 42604427 VENOUS ACCESS DEV IRRIGATION$ 71.00 96523 32512758 VENOUS ACCESS TRAY $ 60.70 33303068 VENOUS CATHER UNDER AGE 5 $ 1,871.00 36555 40500464 VENOUS DOPPLER BILAT $ 635.00 93970 40500852 VENOUS DOPPLER LEFT $ 422.25 93971LT 31511678 VENOUS MECH THROMB SUBSEQ$ DAY 7,934.93 37188 31511587 VENOUS MECHANICAL THROMBECTOMY$ 8,609.00 37187 33303845 VENT MGMT INPT OR OBS 1X PER$ D 183.00 94656 40804197 VENT. HM EXCHANGER $ 26.00 32601858 VENTED ADD. PRIM SET $ 15.25 32601973 VENTED SECONDARY SET $ 5.15 40801417 VENTILATION SUBSEQ. DAY $ 1,005.00 94003 40804072 VENTILATOR INITIATION(1ST DAY)$ 1,005.00 94002 40801441 VENTILATOR MANIFOLD $ 25.50 40748980 VENTOLIN INHALER 90MCG (18GM)$ 3.25 40752255 VENTOLIN SYRUP 5ML $ 62.95 32515488 VENTRALEX HERNIA PATCH $ 1,367.00 C1781 40749459 VERAPAMIL HCL 5MG/2ML VIAL $ 36.30 40767469 VERELAN PM 200MG $ 6.00 31502818 VERIPATH GUIDE CATHETER-X $ 343.95 C1887 40716177 VERMOX TAB CHEW $ 12.55 32511529 VERSA PORT 12MM $ 229.05 32533580 VERSA PORT PLUS 5MM $ 74.35 32615511 VERSA PORT PLUS 5MM $ 75.00 40764672 VERSED 10MG/A0ML $ 65.35 40766735 VERSED 25MG/5ML VIAL $ 124.20 40752115 VERSED 2MG/2ML VIAL $ 21.55 40759334 VERSED 5MG/1ML VIAL $ 32.95 40751570 VERSED 5MG/5ML VIAL $ 32.95 40476115 VERTEBROPLASTY CERVICOTHORACIC$ 5,774.65 22510 40478194 VERTEBROPLASTY EACH ADDED BODY$ 510.20 22512 40477798 VERTEBROPLASTY LUMBOSACRAL$ 5,774.65 22511 31204183 VESSEL CLUDE $ 66.20 32511438 VESSELL HOOPS $ 4.95 32615412 VESSELL HOOPS $ 5.00 32529778 VEST RESTRAINT $ 78.05 39477833 VGCC ANTIBODY $ 516.25 83516 32507501 VHS-VARI-ANGLE PLATE 4HL $ 677.00 31502875 VIA TRAC BALLOON - X $ 711.70 C1725 32602146 VIAL ADAPTER $ 12.45

155 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40767790 VIBRAMYCIN 100MG CAP $ 3.25 40716185 VIBRAMYCIN CAP $ 5.70 40744054 VIBRAMYCIN HYCLATE 100MG VIAL$ 47.80 40804080 VIBROPERC. INITIAL $ 229.00 94667 40801433 VIBROPERC. SUBSEQ. $ 229.00 94668 42611182 VIDAZA 1MG $ 23.00 J9025JG 42619004 VIDAZA 1MG JW $ 23.00 J9025JGJW 42601740 VINBLASTINE 10MG $ 17.00 J9360 42622271 VINBLASTINE 10MG JW $ 17.00 J9360JW 40744047 VINBLASTINE 10MG/10ML VIAL $ 94.00 J9360 42601922 VINCRISTINE 1MG $ 21.00 J9370 42620687 VINCRISTINE 1MG JW $ 21.00 J9370JW 40748188 VINCRISTINE 1MG/ML VIAL $ 91.80 J9370 40765109 VIOXX 25MG $ 5.40 J8499 32516304 VIPERSLIDE LUBRICANT $ 194.00 39404512 VIRAL CULTURE $ 135.50 87252 39401617 VIRAL TITER-ACUTE $ 36.75 86790 39401708 VIRAL TITER-CONV $ 36.75 86790 40751349 VIROPTIC 1% OPHTH GT $ 114.80 32532426 VISCERAL RETAINER $ 95.70 40749590 VISCOAT OPHT SOLN 0.5ML $ 303.50 39400247 VISCOSITY, BLD $ 134.25 85810 40749954 VISCOUS LIDOCANE UD $ 4.55 32515215 VISION BLUE DYE $ 135.45 31511710 VISIPAQUE 320/MG 150/ML $ 450.00 Q9967 31535890 VISIPAQUE 320MG PER ML 500ML$ B 3.00 Q9967 40737868 VISKEN TAB $ 3.40 42602391 VISTARIL 50MG/1CC $ 38.00 J3410 40756918 VISTARIL VIAL $ 12.50 40744062 VISTARIL VIAL $ 12.95 J3410 40733982 VIT B12 INJ 1,000 MCG VIAL $ 15.90 39405576 VIT D 1,25 OH $ 368.75 82652 40107526 VITAMIN A $ 111.00 84590 40767014 VITAMIN A 10,000 CAP $ 3.25 40770307 VITAMIN A AND D OINT 60GM TUBE$ 10.00 40717845 VITAMIN A&D OINT 120GM TUBE$ 7.65 40106932 VITAMIN B $ 110.00 84425 39409282 VITAMIN B1 $ 129.75 84425 39900204 VITAMIN B12 $ 60.75 82607 40767477 VITAMIN B12 100 MCG TABLET $ 3.25 40771883 VITAMIN B12 1000 MCG TAB $ 3.25 42602649 VITAMIN B-12, 1000MCG $ 16.00 J3420 40107740 VITAMIN B6 $ 92.00 84207 40770406 VITAMIN C 500MG TAB $ 43.25 39405485 VITAMIN D, 25 OH $ 269.75 82306 40780067 Vitamin D2 50,000 units tablet $ 3.25 40779968 Vitamin D3 1,000 unit Capsule $ 3.25 40107195 VITAMIN E $ 48.00 84446 40758237 VITAMIN E 400 IU CAPSULE $ 3.40 39905753 VITAMIN K $ 221.00 84597 31200777 VITRECTOR $ 605.25 40755100 VIVONEX CHERRY-VANIL $ 3.25 40757643 VIVONEX LEMON-LIME F $ 17.00 40757650 VIVONEX ORANGE-PINEA $ 17.00 40757668 VIVONEX RASPBERRY FL $ 17.00 40730368 VIVONEX T.E.N. PACK $ 17.05 40768194 VIVONEX TEN PKT $ 24.00 40757676 VIVONEX VANILLA FLAV $ 17.00 39404694 VMA $ 87.00 84585 407685333 VOLMAX 4MG TAB $ 4.00

156 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40767485 VOLTAREN 50MG $ 5.02 39701545 VOLUME MEASURE $ 16.50 81050 39404785 VON WILLEBRAND PANEL $ 477.00 85247 40107799 VON WILLIEBRAND ACTIVITY $ 176.00 85245 40769747 VORICONAZOLE 200MG TAB $ 114.50 40768517 VORICONAZOLE 200MG VIAL $ 345.50 J3465 40750945 VP16 (ETOPOSIDE) 100MG $ 297.25 40750945C VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945E VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945B VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945F VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945J VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945A VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945H VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945I VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945G VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 40750945D VP16 (ETOPOSIDE) 10MG $ 29.75 J9181 32515603 VULCAN BIPOLAR PROBE $ 411.25 32515611 VULCAN ELECTROTHERMAL PROBE$ 472.95 39403100 VW-PH $ 20.75 83986 40901050 WALKER/EQUIP DAILY $ 17.50 32501967 WALKING HEEL ADULT $ 23.10 32501975 WALKING HEEL CHILD $ 11.75 31503048 WALL GRAFT STENT 10X30 $ 3,471.50 C1876 31503055 WALL GRAFT STENT 12X30 $ 3,471.50 C1876 31503030 WALL GRAFT STENT 8X30 $ 3,471.50 C1876 31505936 WALL STENT $ 2,462.50 C1876 39506919 WALNUT TREE ALLERGEN $ 13.00 86003 32516270 WAND COBLATOR ENT $ 315.00 32512832 WANG NEEDLE $ 57.95 31900780 WARMING COVER $ 211.00 31010101 WARMING UNIT/COVER $ 130.00 31510118 WARMING UNIT/COVER $ 159.35 31202617 WASHER $ 121.00 32604027 WASHER, 4.0 CANNULATED SCREW$ 74.00 31501844 WASTE STATION $ 56.90 31505746 WASTE STATION X $ 53.90 32507261 WATER CAP, AQUASHIELD $ 72.00 40755746 WATER FOR IRRIGATION 1000ML$ BT 32.95 31402886 WATER JET CONNECTOR $ 8.00 40757692 WATER, STERILE 10 ML VIAL 25/P$ 11.75 40755845 WATER, STERILE 100ML VIAL $ 15.30 32516965 WATER, STERILE 4000 ML $ 26.00 40755829 WATER,BACTERIOSTATIC 20ML VIAL$ 11.35 32515538 WATERBUG FLOOR SYSTEM $ 144.90 40400244 WATERS VIEW $ 101.10 70210 39802533 WBC COUNT $ 38.00 85048 31202351 WEBRIL,STERILE $ 15.35 33301468 WEDGE EXC INGROWN NAIL $ 324.00 11765 32532699 WEDGE RESECTION ELECTRODE $ 312.55 41293205 WEEKLY TREATMENT MANAGEMENT$ 385.00 77427 40764623 WELLBUTRIN 100MG TAB $ 4.35 40766214 WELLBUTRIN SR 150MG TABLET $ 5.40 40107815A WEST NILE 1GM $ 101.00 86788 40107815B WEST NILE VIR $ 102.00 86789 39476942 West Nile Virus RT PCR $ 332.50 87798 40107815 WEST NILE VIRUS SERUM $ 203.00 32508301 WEST.-JENSEN BN. MRW. $ 29.20 39500285 WET PREP $ 38.00 87210 32506693 WHEELCHAIR RESTRAINT $ 71.85

157 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40921423 WHEELCHAIR TRAINING 15MIN $ 79.00 97542GO 40901423 WHEELCHAIR TRAINING 15MIN $ 79.00 97542GP 40921274 WHIRLPOOL - ATTENDED 15 MIN$ 150.75 97036GO 40901274 WHIRLPOOL - ATTENDED 15 MIN$ 150.75 97036GP 40920292 WHIRLPOOL UNATTENDED $ 150.75 97022GO 40900292 WHIRLPOOL UNATTENDED $ 150.75 97022GP 40200073 WHOLE BLOOD HANDLING $ 554.00 P9010 31501901 WHOLEY WIRE $ 294.65 C1769 31501919 WHOLEY WIRE - X $ 294.65 C1769 31501851 WHOLEY WIRE .035 145 CM $ 225.80 C1769 31501869 WHOLEY WIRE .035 145 CM X $ 225.80 C1769 31501877 WHOLEY WIRE .035 175 CM $ 277.45 C1769 31501893 WHOLEY WIRE .035 175 CM X $ 277.45 C1769 32534434 WILDCAT $ 1,250.00 42610140 WIN RHO 1000mcg / 5000IU $ 4,325.50 J2792JG 42613856 WIN RHO 3000mcg/15000iu $ 12,976.45 J2792 40771636 WINRHO 1500 UNITS/1.3ML VIAL$ 1,313.50 J2790 31501927 WIRE .025 150 CM $ 65.10 C1769 31505837 WIRE .025 150CM X $ 61.35 C1769 31501935 WIRE .025 260 CM $ 92.85 C1769 31505928 WIRE .025 260CM X $ 88.25 C1769 32529844 WIRE CUTTERS $ 27.55 40922097 WORK COND - ADDL HOUR $ 75.50 97546GO 40921043 WORK MOD/TRAIN 15MIN $ 78.00 97537GO 40901043 WORK MOD/TRAIN 15MIN $ 78.00 97537GP 40921035 WORK RECONDITIONING 2HOURS$ 141.50 97545GO 40901035 WORK RECONDITIONING 2HOURS$ 141.50 97545GP 40912303 WORK RECONDITIONING EA ADDT$ HR 75.50 97546GP 41460989 WOUND CARE CLINIC VISIT $ 226.00 G0463 41455247 WOUND COMP SYS APP BK BILATERA$ 568.00 2958150 41455148 WOUND COMP SYS APP MULTI-LA$ BK 284.00 29581 39504642 WOUND CULTURE $ 59.50 87070 40931006 WOUND DEBRIDEMENT <20 $ 246.25 97597GO 40912200 WOUND DEBRIDEMENT <20 $ 246.25 97597GP 40931007 WOUND DEBRIDEMENT >20 $ 246.25 97598GO 40912201 WOUND DEBRIDEMENT >20 $ 246.25 97598GP 32509804 WOUND DRAINAGE BAG $ 64.45 41461483 WOUND PREP F/N/HG/G 100 SQ CM/$ 954.00 15004 32604324 WOUND PROTECTOR, C-SECTION$ 250.00 32604423 WOUND PROTECTOR, SML-MED $ 120.00 32512675 WRAP, FOOT/CALF $ 212.80 32507634 WRIST EXT FIX DISP KIT $ 2,200.00 C1713 31203938 WRIST LACER $ 132.00 40740854 WYCILLIN SYRD $ 15.80 40740870 WYCILLIN SYRD $ 20.65 40740862 WYCILLIN SYRD $ 34.00 40744476 WYDASE STABILIZED SO $ 26.10 40756470 WYGESIC TAB $ 3.25 32515918 X STOP IMPLANT $ 6,221.00 C1713 40766016 XALATAN OPHT SOL.005% 2.5ML$ BT 162.00 39403902 XANAX $ 124.50 80307 40704199 XANAX 0.25 MG TAB $ 3.25 40750432 XANAX 0.5MG TABLET $ 3.25 40772188 XARELTO 10 MG TABLET $ 22.00 40768071 XARELTO 15MG TABLET $ 22.00 40772360 XARELTO TAB 20MG $ 24.00 31200785 XEROFOAM $ 7.90 32615313 XEROFOAM $ 8.00 42627320 XGEVA 120 MG $ 7,800.00 J0897 40766636 XIGRIS 20MG VIAL $ 3,419.30

158 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40766644 XIGRIS 5MG VIAL $ 855.40 42624152 XOLAIR 150MG VIAL $ 3,926.00 J2357JG 42612073 XOLAIR 5 MG $ 126.00 J2357JG 42620291 XOLAIR 5 MG JW $ 126.00 J2357JGJW 40767287 XOPENEX 0.63MG/3ML $ 7.95 40805533 XOPENEX 0.63MG/3ML UD $ 10.00 40806069 XOPENEX 1.25MG/0.5ML VIAL.NEB$ 18.50 40767279 XOPENEX 1.25MG/3ML $ 7.95 40766743 XOPENEX 1.25MG/3ML $ 176.00 40805624 XOPENEX 1.25MG/3ML UD $ 10.00 31502511 XXXL BALLOON $ 695.35 C1725 31502073 XXXL BALLOON - X $ 695.35 C1725 40750218 XYLOCAINE 0.5% VIAL $ 18.20 40762304 XYLOCAINE 10% $ 110.95 40762353 XYLOCAINE 10MG $ 20.00 40757049 XYLOCAINE 2% (400MG/20ML) VIAL$ 15.90 42601088 XYLOCAINE 2% JELLY $ 21.00 40770448 XYLOCAINE 2% JELLY (OPTHALMIC)$ 6.00 40805137 XYLOCAINE 2% TUBE $ 15.75 40762387 XYLOCAINE 2% W/EPI 20MG/ML $VIA 32.95 40762346 XYLOCAINE 20MG $ 22.35 40804866 XYLOCAINE 4% TOPICAL $ 15.75 40748063 XYLOCAINE JELLY 2% 30 ML TUBE$ 38.35 40757031 XYLOCAINE VISCOUS 2% 100ML $BT 35.70 40755753 XYLOCAINE1%-EPI 300MG/30ML $VIA 22.35 31505761 Y ADAPTER - X $ 116.05 31539157 Y ADAPTER - X $ 120.00 32509119 YANK. SUCTION W/TUBING $ 31.95 31903693 YANK. SUCTION W/TUBING $ 32.00 31701691 YANK. SUCTION W/TUBING $ 32.00 31542325 YANK. SUCTION W/TUBING $ 32.00 31405559 YANK. SUCTION W/TUBING $ 32.00 31303373 YANK. SUCTION W/TUBING $ 32.00 32615214 YANK. SUCTION W/TUBING $ 32.00 32506651 YANKEUR TIP $ 8.45 31547473 YANKEUR TIP $ 9.00 39404439 YERSINIA AB IQA $ 36.00 86793 39404256 YERSINIA AB IQG $ 36.00 86793 39404348 YERSINIA AB IQM $ 36.00 86793 42614945 YERVOY 1 MG $ 527.00 J9228 42621578 YERVOY 1 MG JW $ 527.00 J9228JW 40766420 ZANAFLEX 4MG TAB $ 4.35 40766990 ZANAFLEX 4MG TABLET $ 4.60 42627716 ZANTAC 150 MG TABLET $ 5.00 40750044 ZANTAC 150MG TABLET $ 4.55 40763245 ZANTAC 150MG/10ML SY $ 20.45 40769028 ZANTAC 50MG 50ML PREMIXED $ 19.50 40750580 ZANTAC 50MG/2ML VIAL $ 17.05 42603252 ZANTAC 50MG/50ML PREMIX $ 21.00 40763377 ZANTAC 75MG TABLET $ 3.25 40756173 ZANTAC VIAL $ 131.80 39402656 ZARONTIN $ 73.00 80168 40717308 ZAROXOLYN 5 MG TAB $ 3.25 40755290 Z-BEC TAB $ 3.40 31202997 Z-DRAPE $ 27.30 32615115 Z-DRAPE $ 28.00 40767493 ZEBETA 10MG $ 4.25 40769317 ZEBETA 5MG TAB $ 5.00 32511776 ZEBRA WIRES .035INCH $ 449.05 31203466 ZEISS MICRO. DRAPE $ 123.70

159 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40768368 ZELNORM 6MG TAB $ 8.50 40758930 ZEMURON 50MG/5ML VIAL $ 70.35 40768525 ZETIA 10MG TAB $ 8.00 40760266 ZIAC 5/6.25 MG TABLET $ 3.75 40770018 ZILEUTON 600MG TAB (ZYFLO) $ 7.50 32517187 ZIMMER BLOOD REINFUSION W/DRA$ 336.15 31204167 ZIMMER DEMATONE BLADE $ 92.30 40763138 ZINACEF 1.5 GM VIAL $ 37.30 40770794 ZINACEF 1.5GM PREMIX $ 79.00 40763088 ZINACEF 750 MG VIAL $ 24.70 40770802 ZINACEF 750MG PREMIX $ 59.00 39402748 ZINC $ 60.00 84630 40753899 ZINC GLUCONATE TAB $ 3.25 40766461 ZINC OXIDE 28 GM TUBE $ 11.50 40756694 ZINC OXIDE OINT 30 GM TUBE $ 7.95 40724155 ZINC OXIDE OINT 454 GM JAR $ 15.60 41456930 ZINC PASTE W 3-5" / YARD" $ 10.00 40759052 ZINC SULFATE 1MG/ML $ 14.10 40717316 ZINC SULFATE 220 MG CAPSULE $ 3.25 42601500 ZINECARD 250MG $ 653.00 J1190JG 40768170 Zinecard 500mg Vial $ 1,681.00 J1190 40764458 ZITHOMAX 100MG/5ML SUSP $ 57.95 40768808 ZITHROMAX 100MG/5ML $ 104.50 40764201 ZITHROMAX 200MG/5ML 15ML BOTTL$ 62.60 40759607 ZITHROMAX 250 MG TABLET $ 14.05 40765976 ZITHROMAX 500MG VIAL $ 81.00 40766594 ZOCOR 40MG TAB $ 15.00 40754467H ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467C ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467D ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467I ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467B ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467J ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467E ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467F ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467A ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40754467G ZOFRAN 2MG/ML 2ML VIAL $ 52.85 J2405 40771859 ZOFRAN 4MG ODT TAB $ 72.50 40764185 ZOFRAN 8MG TABLET $ 52.75 Q0179 42628013 ZOLADEX 3.6 MG $ 2,323.00 J9202 42623261 ZOLEDRONIC ACID 1 MG JW $ 671.00 J3489JW 42602656 ZOLEDRONIC ACID 4 MG $ 2,684.00 J3489 42626924 ZOLEDRONIC ACID 4 MG $ 2,684.00 J3489 40758914 ZOLOFT TAB 50MG $ 4.60 40766560 ZOMETA 4MG/5ML VIAL $ 2,177.30 J3489 40770190 ZONISAMIDE 25MG CAP $ 3.25 40763716 ZORCOR 10MG TAB $ 4.90 40764797 ZOSTRIX CREAM $ 25.80 40769606 ZOSYN 2.25 GM VIAL $ 39.00 42611479 ZOSYN 3.375G VIAL $ 39.00 J2543 40770760 ZOSYN 3.375GM/100ML PREMIX $ 85.00 40752172 ZOVIRAX 200MG CAP $ 4.55 40705410 ZOVIRAX 5% OINT $ 100.00 40754921 ZOVIRAX 500MG VIAL $ 129.60 40759813 ZOVIRAX SUSP 200MG/5ML UDC $ 4.55 40402562 ZYGOMATIC ARCHES $ 158.00 70150 40717324 ZYLOPRIM 100MG TAB $ 3.25 40717332 ZYLOPRIM 300MG TAB $ 4.55 40766230 ZYPREXA 2.5MG TABLET $ 17.00 40767501 ZYPREXA 5MG $ 19.25

160 Russell Medical Standard Charges December, 2019

CPT/HCPCS CHARGE CODE DESCRIPTION PRICE CODE 40765935 ZYRTEC 10MG TABLET $ 5.10 40768269 ZYRTEC SUSP 10MG/10ML UDC $ 16.25 40764029 ZYTONE 1% CREAM 30MG TUBE $ 64.80 40769218 ZYVOX 600MG TAB $ 200.50 40766685 ZYVOX 600MG/300ML PREMIX BAG$ 257.75 J2020 40766651 ZYVOX SUSP 150ML $ 952.85 J2020

161