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2018 ALL HOSPITAL CHARGES 2018 Charge Description CPT-4 code Price "L" PLATES - LEFT C1713 $ 645.47 (PT) CONTACT PRODUCT 85730 $ 16.32 (TB) DIRECT SMEAR 87206 $ 14.63 **FB REMOVAL RECTUM 45307 $ 6,123.85 .062 X 7 LONG GUIDE WIRE C1713 $ 86.25 .99MM TURBO ELITE LASER CATH C1885 $ 3,150.00 .99MM TURBO ELITE LASER CATHETER C1887 $ 2,200.00 0 27 GUT CHROMIC SH $ 14.87 0 30 ETHIBOND BRAIDED CT-1 $ 103.50 0 30 PROLENE MONO CTX $ 105.10 0 36 ETHIBOND BRAIDED V-7 $ 310.52 0 54 COATED VICRYL $ 33.80 0 54 GUT CHROMIC $ 33.02 0 54 GUT CHROMIC PLAIN $ 54.98 0 8-18 ETHIBOND EXTRA GRN MO-7 $ 240.30 0 8-18ETHIBOND EXTRA GRN CT-2 $ 206.51 0 PROLENE BL SH $ 129.30 0 SILK SUTUPAK 13 STRANDS 24 C1713 $ 35.55 0.8MM OFFSET PLATE C1713 $ 636.00 0.9MM CATH RAPD-EXCHANGE 150CM C1885 $ 3,150.00 0.9MM CATH X-80, CONT.ON RAPID-EXCHG 150 C1885 $ 3,150.00 02 SATURATION DIRECT 82810 $ 23.69 1 25-OH2D 82652 $ 104.57 1 27 GUT CHROMIC CT-1 $ 155.71 1 30 ETHIBOND BRAIDED DS-8 $ 157.52 1 30ETHIBOND BRAIDED CT-1 $ 87.92 1 36 GUT CHROMIC CTX $ 120.57 1 36 IN COATED VICRYL CTX $ 96.06 1 36 PDS II MONO CT $ 85.41 1 PDS II MONON TP-1 $ 72.48 1 PROLENE CTX $ 103.46 1 VERT MUSCLE 67314 $ 4,790.26 1 VICRYL 27CTB-1 $ 143.21 1.0MM 4 HOLE LARGE XLONG GAP C1713 $ 1,006.50 1.0MM 7HOLE PLATE STRGHT PLATE C1713 $ 1,158.00 1.1MM GUIDE WIRE C1713 $ 43.04 1.2 GUIDEWIRE C1713 $ 322.50 1.3 GUIDE PIN C1713 $ 30.12 1.3MM DRILL BIT MINI QC 55MM X C1713 $ 169.50 1.3MM TI T-PLATE C1713 $ 469.50 1.3MMTPLATE4HOLEHEAD/8HOLESHFT C1713 $ 562.50 1.4MM CATH 80HZ, CONT.ON RAPID-EX 150CM C1885 $ 4,200.00 1.4MM CATH OTW LASER 157L C1885 $ 3,150.00 1.4MM CATH RAPD-EXCHANGE 150CM C1885 $ 4,200.00 1.4MM CATHETER OTW LASER 157L C1885 $ 3,150.00 1.5 MM X50MM 5MM STOP BIT C1713 $ 78.75 1.6x150MM WIRE C1713 $ 469.50 1.7 SUTUREFIX DISPOS DRILL BIT C1713 $ 338.34 1.7MM CATH 80HZ CONT.ON RAPID-EX RX 150C C1885 $ 3,150.00 1.7MM CATH 80HZ, CONT.ON OTW 150CM C1885 $ 3,150.00 1.7MM CATH OVER THE WIRE 150CM C1885 $ 3,150.00 Page 1 2018 1.7MM CATH RAPD-EXCHANGE 150CM C1885 $ 3,150.00 1.8M OLIVE WIRES C1713 $ 44.00 1.8MM SMOOTH WIRE 3/PK C1713 $ 111.00 1/2 CIRCLE TAPER NEEDLE MALE C2618 $ 494.96 1/2 CIRCLE VICRYL#1 SUTURE C1713 $ 225.92 1/2 CYLINDER 5MM-SILICONE SPONGE IMPLANT C1784 $ 75.90 1/2 NORMAL SALINE 250ML IV Acquisition cost 1/2 NS+D5%W+K.PO420MEQ+K.ACETATE20MEQ Acquisition cost 1/3 RING - LARGE C1713 $ 1,228.50 1/8 X3 GEN TROCER PINS C1713 $ 34.92 1-0 30" ETHIBOND BRAIDED DS C1713 $ 157.52 10 HOLE CLAMP C1713 $ 1,263.38 10 X 20 WALL STENT Acquisition cost 10 X 39 WALL STENT Acquisition cost 10-0 PROLENE BL MONO SUTURE C1713 $ 63.07 100MM CURVED CANNULA 10/BX A4615 $ 531.00 10CC SLS 21G 1 1/2 $ 0.99 10CC SLS ONLY $ 0.38 10CC VITOSS C1713 $ 7,110.45 10F NEPH CATHETER C1726 $ 114.98 10FR 97CM TRIPLE LUMEN CATH C1757 $ 656.93 10FR PINN INTRO SHEATH W/POUCH C1769 $ 321.75 10FR24CM DBLE PIGTAIL STNT SET C2617 $ 191.40 10FR26CM DBLE PIGTAIL STNT SET C2617 $ 167.64 10MM HUMERAL STEM Acquisition cost 10MM X 285 CANNULATED TIBIA Acquisition cost 10MM X 300 CANNULATED TIBIA Acquisition cost 10MM/130 LEFT TROCH FIXATION NAIL C1713 $ 1,959.00 10MM/130 X 360MM TROCH NAIL Acquisition cost 10MMX20MMX75 UNISTEP PLUS Acquisition cost 10MMX42MM/75CM/100CM WALL STEN Acquisition cost 10MMX68MM/75CM/100CM Acquisition cost 10x23 BIO INT SCREW C1713 $ 346.50 1-131 NAI ORAL SOLN EACH ADL 1 MCI A9529 $ 107.25 11MM TI CANN TROCH FIXATION NAIL C1713 $ 2,124.00 11MM/130 CANNUL TROCHANTERIC FIX NAIL Acquisition cost 11MM/130 X 170MM TROCH FIX NAIL C1713 $ 1,989.00 11x235MM TI CANN TRACH NAIL STRL C1713 $ 1,602.00 12 X 125MM, 26MM HEAD NEER C1776 $ 3,157.50 12 X 40 WALL STENTS Acquisition cost 12 X 60MM WALL STENT Acquisition cost 12/14 FEMORAL HEAD 36MM C1776 $ 1,564.50 12/14 TO TAPER SLEEVE C1776 $ 140.40 12FR SS JUGULAR SYS. GREENFIELD FILTER Acquisition cost 12MM NONBIAS SCREW C1713 $ 1,049.20 12MM SELF DRILL/ST SCREW C1713 $ 150.00 12MM SELF DRILLING SCREW C1713 $ 217.50 12MM SPIN SCREW C1713 $ 300.00 12MM VARIABLE SCREWS C1713 $ 300.00 12X12 COATED VICRYL MESH KNITTED C1781 $ 3,697.43 12X12 COATED VICRYL MESH WOVEN C1781 $ 3,697.43 12X12X7 PEEK C1713 $ 1,492.50 12X20/8FR UNI PLUS HALO 100CM C1876 Acquisition cost 12X20X80 PTA BAL CATH OTW VASC C1725 $ 510.00 12X40/8FR UNI PLUS HALO 100CM C1876 Acquisition cost 12X60/8FR UNI PLUS HALO 100CM Acquisition cost Page 2 2018 13.5 X 21MM CAGE C1713 $ 2,700.00 132 NECK ANGLE HIP STEM C1776 $ 3,600.00 14 DISTAL CENTRALIZER C1776 $ 147.15 14 HOLE PLATE C1713 $ 399.72 14 X 40 STENT (WALL) Acquisition cost 14-HOLE STEM C1713 $ 399.72 14MM SCREW C1713 $ 217.50 14MM SPHERE C1713 $ 780.00 14MM TRINICA VARABLE SCREW C1713 $ 300.00 14X40/9FR UNI PLUS 100CM Acquisition cost 150MM CRVE CANN W/ACTVE TIP C1725 $ 652.50 15CC MACRO MORSELS VITOSS C1713 $ 1,327.50 15MM ENDOBUTTON ULTRA CLFIXBUT C1749 $ 494.55 16 SYNERGY STEM C1776 $ 5,852.25 16 X 40 STENT (WALL) Acquisition cost 16FREPLACE GTUBE STRGHT ENTRL A4616 $ 51.65 16x3.0MM CANNULATED SCREW C1713 $ 429.00 17 - HYDROXYCORTICOSTEROIDS 24 HR URINE 83491 $ 47.61 17 HYDROXY PROGESTERONE 83498 $ 73.79 17 KETOGENIC STEROID/URINE 83582 $ 38.50 17 KETOSTEROIDS/URINE 83586 $ 34.76 17 OH 83491 $ 47.61 17MM WASHER C1713 $ 399.00 17-OH-PREGNENOLONE 84143 $ 61.95 18 - HYDROXYCORTICOSTERONE 82528 $ 61.16 18 X 40 STENT (WALL) Acquisition cost 18 X 60MM. WALL STENT Acquisition cost 18FR SIGMOIDOSCOPIC SUCT INSTR A4624 $ 61.50 18G X0.038 ANGIOGRAPHIC NEEDLE C2618 $ 78.38 18-OH-CORTICOSTERONE 82528 $ 61.16 1CC SLS INSULIN 29GX1/2 $ 0.24 1CC SLS TUBERCULIN 25GX5/8 $ 0.28 1ST /SBSQ PSYC COLLAB CARE 99494 $ 275.00 1ST DEGREE BURN-INIT TX 16000 $ 446.80 1ST PSYC COLLAB CARE MGMT 99492 $ 275.00 1ST PSYC COLLAB CARE MGMT YR 2 99492 $ 275.00 1STG DSTL HYPSPAD REP W/SIMP MEATL ADV 54322 $ 4,484.35 1x8 SUBCOMPACT LEAD KIT C1778 $ 3,585.00 2 30ETHIBOND BRAIDED LR LR $ 112.22 2 PAIRED SUBDERM ELECTROD-EAR A4556 $ 138.00 2' REPR/SUTR LEG FLEXOR TENDON 27659 $ 14,826.61 2 Single Stinging Insect Venoms 95146 $ 97.92 2.0 CARBIDE BURR C1713 $ 413.13 2.0 KWIRE C1713 $ 13.40 2.0 LCKING PLATE L, 2/4 HOLE; RIGHT/LEFT C1713 $ 558.00 2.0 X 14 LOCKING SCREWS C1713 $ 550.50 2.0 X 10MM SCREW C1713 $ 225.00 2.0MM CATH (OTW) 150CM C1885 $ 4,200.00 2.0MM CATH RAPID-EXCHANG 150CM C1885 $ 3,150.00 2.0MM CATHETER 80HZ CONT.ON OTW 150CM C1885 $ 4,200.00 2.0MM LCP PLATE 7HOLES SHAFT C1713 $ 607.50 2.0MM NON-LOCKING SCREW C1713 $ 787.50 2.0MM X 8MM NONLOCKING SCREW C1713 $ 133.50 2.15MM FLUTED ROUTER CUT BURS C1713 $ 149.04 2.2 DRILL BIT C1713 $ 175.50 2.2MM DRILL C1713 $ 393.00 Page 3 2018 2.3 PENCIL BURR C1713 $ 159.08 2.3 SUTURE ANCHR W1 UB COBRAID C1713 $ 508.31 2.3 X 12MM NON LOCKING SCREW C1713 $ 177.00 2.3MM CATH OTW LASER ABLAT TUBO ELITE C1885 $ 3,150.00 2.3MM CATH OTW LASER ABLATION C1885 $ 3,150.00 2.3MM DURG BURR DIA HEAD HILAN C1713 $ 142.10 2.5 DRILL BIT C1713 $ 642.00 2.5 WER PLATE C1713 $ 963.00 2.5 WER PLATE C1713 $ 963.00 2.5" MED MESH SURG HERN PTCH C1781 $ 1,117.50 2.5FIXOS MARK TIP TROCAR KWIRE C1769 $ 55.12 2.5MM DIAMOND C1725 $ 139.73 2.5MM T PLATE C1713 $ 865.50 2.5MM TURBO ELITE LASER CATH C1885 $ 3,000.00 2.5MM TURBO ELITE LASER CATHETER C1887 $ 3,000.00 2.5X100 POLAR DCATH BALLOON C1725 $ 1,350.00 2.5X100 POLAR DCATH BALLOON, EA C1725 $ 1,350.00 2.6 DRILL C1713 $ 211.50 2.7FR SINGLE LUMEN CV CATHETER C1757 $ 312.08 2.7MM CORTICAL BONE SCREW X C1713 $ 124.32 2.7MM CORTICAL BONE SCREW x VARIOUS C1713 $ 1,456.37 2.7MM DRILL BIT C1713 $ 136.29 2.7MM LOCK SCREW, 20MM C1713 $ 118.13 2.7MM LOCKING SCREW 18MM C1713 $ 241.50 2.7MM LOCKING SCREW X 18MM C1713 $ 195.00 2.7MM LOCKING SCREWS C1713 $ 241.50 2.7MM LOCKING SCREWS 36MM C1713 $ 157.50 2.7MM X 18MM MD SCREW C1713 $ 327.00 2.9MM LOCKING SCREW C1713 $ 315.00 2/0 18 ETHILON MONO PS $ 187.37 2/0 27 CHROMIC SH $ 106.92 2/0 27 GUT CHROMIC CT-1 $ 102.08 2/0 27COATED VICRYL 0S-6 $ 123.47 2/0 30 ETHIBOND BRAIDE $ 155.03 2/0 30 ETHIBOND BRAIDED CT-1 $ 104.84 2/0 30 PROLENE MONO SH $ 119.85 2/0 30ETHICON MONO KS,628H $ 75.74 2/0 30SILK BRAIDED KS $ 1.94 2/0 36 PDS II MONO CT $ 138.11 2/0 36PROLENE MONO $ 256.27 2/0 48PROLENE MONO SHSH $ 205.95 2/0 54 GUT CHROMIC $ 64.20 2/0 54 GUT PLAIN $ 39.20 2/0 54COATED VICRYL $ 30.86 2-0 18" SILK BLACK BRAID PS-2 C1713 $ 159.10 2-0 30 ETHIBOND BRAID LRX496T C1713 $ 112.22 2-0 30" ETHIBOND BRAIDED CT-1 C1713 $ 104.84 2-0 30" V-7 SUTURE SILK NDL B C1713 $ 134.26 2-0 36" GUT CHROMIC #903H $ 105.71 2-0 COATED VICRYL RAPIDE 27 $ 42.54 2-0 COATED VICRYL RAPIDE 36 $ 45.30 20 DEGREE ELEVATED RIM LINER C1776 Acquisition cost 2-0 FS SILK NEEDLE BLK BRD C2618 $ 84.14 2-0 SILK BLK BRD 24" SH NEEDLE C2618 $ 171.56 2-0 SILK BLK BRD CP-1 36MM CI C1713 $ 73.36 2-0 SILK PS NEEDLE 18"-45CM BL C2618 $ 186.29 Page 4 2018 2-0 SILK PSLX $ 5.95 2-0 SILK SH $ 135.47 2-0 SILK' SUTUPAK 13 STRAND 34 C1713 $ 106.65 2-0 SILK TIES $ 64.49 2-0 TAPER T-12 SUTURES W/FIBER C1713 $ 33.00 20 X 24G ANGLED STEPPED PROBE C2618 $ 290.00 20MM CERVICAL PLATE C1713 $ 1,425.00 20MM ENDOBUTTON C1749 $ 494.55 20MM MINI AT2 SCREW C1713 $ 792.00 20MM TRINICA PLATE C1713 $ 1,500.00 2-0VICRYL +CIRCLE VIOLET BRAID C1713 $ 188.30 21MM ARTICULAR SURFACE Acquisition cost 22MM LINER Acquisition cost 22MM STANDARD AT2 SCREW C1713 $ 792.00 22MM TRINICA PLATE C1713 $ 1,500.00 22MM X 44MM HUMERAL HEAD C1776 Acquisition cost 23G ADJST INTUTVE LASRPROBE C2618 $ 315.00 23G VALVED ENTRY SYSTEM 4MM C1713 $ 864.00 23G X 3/4 C2618 $ 0.10 24MM CERVICAL PLATE C1713 $ 1,650.00 24MM HD LFT ANATOMIC RAD HD SYS CHROMIUM C1776 $ 3,000.00 24MM LOCKING SCREW C1713 $ 210.19 24MM TRINICA PLATE C1713 $ 1,875.00 25.4MM DIAMOND DISC C1713 $ 393.75 25G 8.0 SOFT TIP NEEDLE 10/BX C2618 $ 300.00 25-OHD 82306 $ 80.41 25TUB INFLOW SET FLUID MGMT A4624 $ 97.65 26MM PLATE C1713 $ 1,725.00 28-30MM CROSSLINK C1713 $ 1,996.50 28MM +0 TAPER FEMORAL HEAD C1776 $ 781.65 28MM +4 FEMORAL HEAD C1776 $ 1,500.00 28MM +8 TAPER FEMORAL HEAD C1776 $ 781.65 28MM 12/14 TAPER FEMORAL HEAD C1776 $ 781.65 28MM 20 D ACETABULAR LINER C1776 Acquisition cost 28MM ACETABULAR LINER SIZE 45 C1776 Acquisition cost 28MM ACP PLATE Acquisition cost 28MM MODULAR HEAD COMPONENT C1776 Acquisition cost 2MM CATH 80HZ CONT.CON RAPID-EX 150CM C1885 $ 3,150.00 2ND CLOS SURG WND/DEH; EXTENS 13160 $ 4,147.84 2PC INTRATHECAL CATHETER C1755 $ 1,042.50 2W FOLEY CATHETER 16FR 12/BX A4344 $ 16.15 2-WAY FOLEY 5CC, 16FR COUDE TIP C2627 $ 185.90 2WAY FOLEY CATH SILICON 12/BX A4344 $ 59.40 2X2+2HOLES, 3D PLATE C1713 $ 1,125.60 3 GUIDEWIRE 300CMX.014 5/BX C1769 $ 213.00 3 HOLE PLATE C1713 $ 1,520.44 3 HOLE PLATE HOMERUS L8699 $ 1,520.45 3 PIECE ASPHERIC IOL C1780 $ 120.00 3 Single Stinging Insect Venoms 95147 $ 153.91 3.0 CARBIDE BURR C1713 $ 413.13 3.0 GUIDE ROAD 950MM C1713 $ 222.00 3.0 MATCHSTICK BURR C1713 $ 413.13 3.0 X 32MM SCREW C1713 $ 442.50 3.0MM BIOCOMP SUTRETAK 5BX; EA C1713 $ 687.00 3.0MM TITANIUM ELASTIC NAIL C1713 $ 432.00 3.2MM CALIBRATED GUIDE WIRE C1769 $ 181.33 Page 5 2018 3.2MM KWIRE C1713 $ 67.89 3.2X 450 K-WIRE C1713 $ 135.00 3.3 X 25MM DRILLS C1713 $ 121.50 3.5 CORTICAL SCREW 14MM C1713 $ 25.88 3.5 CORTICAL SCREW X 14 C1713 $ 135.00 3.5 CORTICAL SCREW x VARIOUS C1713 $ 1,948.50 3.5 LOCKING SCREW C1713 $ 213.75 3.5 LOCKING SCREW X C1713 $ 311.62 3.5 X SCREW C1713 $ 627.00 3.5 X14MM TI SYNAPSE SCREW C1713 $ 1,575.00 3.5MM CORTEX SCREW SELFTAP C1713 $ 31.97 3.5MM CORTEX SCREW SELF-TAPPING 10MM C1713 $ 58.50 3.5MM CORTEX SCRW SELF-TAPP C1713 $ 58.50 3.5MM LOCKING COMPRESSION PLATE 9-HOLE C1713 $ 1,291.20 3.5MM LOCKING SCREW C1713 $ 517.50 3.5MM LOW PROF NON-LOCK SCREW C1713 $ 213.75 3.5MM NON-LOCKING SCREW X C1713 $ 121.50 3.5MM NONLOCKING x VARIOUS C1713 $ 240.00 3.5MM SELF TAPPING LOCKING SCREW C1713 $ 259.50 3.5MM SHAFT SCREW C1713 $ 30.75 3.5MM TIBIA PLATE 4 HOLES Acquisition cost 3.5MM TIBIA PLATE 6 HOLES Acquisition cost 3.5MM TIBIA PLATE 6HOLE/LEFT Acquisition cost 3.5MM TIBIA PLATE 8 HOLES/LT Acquisition cost 3.5MM TIBIA PLATE 8 HOLES/RT C1713 Acquisition cost 3.5X 14MM CONT C1713 $ 118.12 3.7 X 32 SCREW C1713 $ 1,453.50 3/0 18 PDS II MONO PS-2 $ 76.98 3/0 18ETHILON MONO PS-2 $ 164.98 3/0 27 GUT CHROMIC SH $ 152.87 3/0 27 IN PDS II MONO RB-1 $ 130.95 3/0 27GUT PLAIN CT-1 $ 129.11 3/0 27GUT PLAIN FS-2 $ 131.97 3/0 30 EHTIBOND BRAIDED SH $ 103.65 3/0 30 ETHILON MONO KS $ 76.01 3/0 30 ETHILON MONO RS $ 165.16 3/0 54 COATED VICRYL $ 33.01 3/0 54 GUT CHROMIC $ 37.67 3/0 8-18 SILK BRAIDED SH $ 134.61 3-0 30" SILK BRAIDED KS#622H $ 2.22 3-0 COAT VICRYLPLS SUTRE ANTIB C1713 $ 94.05 3-0 MONOCRYL PS1 $ 225.00 3-0 NEUROLON 8-18" BLACK BRAID C1713 $ 253.34 3-0 NUROLON 8-18" SH NDL SUTRE C1713 $ 186.19 3-0 PROLENE SH SH $ 201.75 3-0 PROLENE SUTURES 8632G C1713 $ 80.04 3-0 SILK BLKBRD SUTUPK 13 STR C1713 $ 106.65 3-0 SILK RB-1 $ 151.19 3-0 SILK TIES $ 76.60 30 STRGHT 5BX PERIPH GUIDEWIRE C1769 $ 1,350.00 3-0 TAPER SUTURES C1713 $ 33.00 3-0 VICRYL + 18SH VIOLT BRAID C1713 $ 192.38 3-0 VICRYL CT2 18 VIOLET BRAID C1713 $ 185.90 3-0 VICRYL PS-2 $ 176.90 30CCLIVER CATH.LATEX MED.POLYO C1887 $ 174.78 3-0CT UNDYE VICRYL RAPD NEEDLE C2618 $ 89.22 Page 6 2018 30GA CANNULA AIR C2618 $ 27.00 3-0GUT CHROM 27"STRGHT60MM CUT C1769 $ 163.80 30MM INTRAFIX TIBIAL SHEATH C1713 $ 502.50 30MM SHPERILAR SCREW L8699 $ 192.00 36CM PERMA CATHETER KIT Acquisition cost 36MMX10 POLYETHYL INSERT LINER C1713 $ 1,200.00 38MM LEVEL PLATE C1713 $ 1,950.00 38MM TRINICA PLATE C1713 $ 1,875.00 39X34 3MM ORBITAL PLATE Acquisition cost 3CC SLS 21GX1 1/2 $ 0.22 3CMEXTRA STIFF GUIDWIRE FLXTIP C1773 $ 94.11 3D MAX LIGHT MESH C1781 $ 315.90 3D MAX LIGHT MESH MED 3.1X5.3 C1781 $ 472.50 3D MAXLGHT MESH LRGE RT4.1X6.2 C1781 $ 500.85 3MM BIOCOMPOSITE SUTURETAK #2FWTW C1713 $ 480.00 3MM FLUTED MATCHSTICK BURR C1713 $ 282.00 3MM T WRENCH C1713 $ 434.40 3WAY FOL LUBRICATH MED RD TIP A4346 $ 400.68 3WAY FOLEY 24FR RND TIP CATH A4340 $ 153.90 3WAY FOLEY LUBRICATH RND TIP A4346 $ 160.92 3WAY FOLEY ROUND TIP CATH12/BX A4346 $ 292.81 3WAY FOLEY ROUND TIP CATH12/CS A4346 $ 26.24 3-WAYFOL CATH LUBRI MED RD TIP A4346 $ 157.50 3WAYFOL CATH LUBRI MED RND TIP A4346 $ 157.50 3X100 POLARCATH BALLOON, EA C1725 $ 1,296.00 3X1000MM WIRE GUIDE C1713 $ 285.91 4 DISTAL CONTRACTOR C1776 $ 147.15 4 HOLE LEFT ANT LAT DISTAL TIBIAL PLATE C1713 $ 2,283.00 4 HOLE PLATE C1713 $ 1,006.50 4 HOLE PRE BENT C1713 $ 1,006.50 4 Single Stinging Insect Venoms 95148 $ 153.91 4 X 13 INSERT Acquisition cost 4.0 CANNULATED SCREW X C1713 $ 146.25 4.0 CARBIDE BURR C1713 $ 413.13 4.0MM CANCELLOUS BONE SCRW C1713 $ 37.29 4.0MM CANNUL SCREWSHORT THREAD C1713 $ 358.05 4.0X 12 SCREW VARIABLE C1713 $ 217.50 4.0x100 SCHANZ SCREW C1713 $ 178.50 4.5 CONN C1713 $ 1,321.75 4.5 MED PROX TIBIA PLATE 6HOLE C1776 $ 2,272.50 4.5 TWINFIX ULTRA PK C1713 $ 352.50 4.5MM MEDIAL PROXIMAL TIB PLATE; 6 HOLES C1713 $ 2,272.50 4.5MM TIBIA PLATE 2 HOLES/LT C1713 Acquisition cost 4.5MM TIBIA PLATE 2 HOLES/RT C1713 Acquisition cost 4.5MM TIBIA PLATE 4 HOLES/LT C1713 Acquisition cost 4.5MM TIBIA PLATE 4 HOLES/RT C1713 Acquisition cost 4.5MM TIBIA PLATE 6 HOLES/LT C1713 Acquisition cost 4.5MM TIBIA PLATE 6 HOLES/RT C1713 Acquisition cost 4.8FR CLOSED TIP URETERAL STENT, 24CM C2617 $ 255.00 4/0 18 COATED VICRYL P-3 $ 60.57 4/0 18 ETHILON MONO $ 165.62 4/0 18 ETHILON MONO PS-2 $ 165.62 4/0 18 PDS II MONO P-3 $ 81.32 4/0 18 PROLENE MONO P-3 $ 77.27 4/0 18MONOCRYL UNDYED MONO P-3 $ 77.63 4/0 18RAPIDE P-3 $ 78.68 Page 7 2018 4/0 18SILK BRAIDED $ 89.94 4/0 27 GUT CHROMIC RB-1 $ 132.93 4/0 27COATED VICRYL RB-1 $ 80.48 4/0 27GUT CHROMIC $ 111.72 4/0 27GUT PLAIN RB-1 $ 134.00 4/0 27PDS II MONO RB-1 $ 126.06 4/0 30 ETHIBOND BRAIDED V-5 $ 290.87 4/0 30 ETHILON MONO RS $ 86.94 4/0 36 PROLENE MONO RB-1 RB-1 $ 271.69 4/0 8-18 SILK BRAIDED SH $ 160.37 4/0 8-18SILK BRAIDED SH $ 5.62 4-0 8-18" SILK BRAID SH CO14D C1713 $ 160.37 4-0 CHROMIC GUT SUTURE 12/BX' C1713 $ 108.32 40 DLP VENA CAVA FILTER SYS C1880 Acquisition cost 4-0 IN COATED VICRYL PS-2 $ 82.76 4-0 MONOCRYL PS-2 $ 225.00 4-0 SILK BKL P-3 $ 56.13 4-0 SILK SUTUPAK 13 STRAND 24 C1713 $ 105.08 4-0 TAPR SUTRE W/FIBRWIRE NEED C1769 $ 33.00 4-0 VICRYL REEL $ 31.04 40MM ENDOBUTTON C1749 $ 483.22 40MM EXTENSION C1776 $ 5,359.20 40MM PLATE C1713 $ 1,875.00 4-0NUR SUTRE NYLN BL RB1 NEEDL C1713 $ 236.18 41 BIPOLAR SHELL Acquisition cost 43-46, 28MM BIPOLAR C1776 $ 199.80 43-46, 28MM BIPOLAR C1776 $ 199.80 44 BIPOLAR HEAD C1713 $ 1,123.20 45MM CERVICAL PLATE C1713 $ 1,950.00 45MM LCP CURVED CONDULR PLATE 14HOLE C1713 $ 4,018.50 45MM PERMA CATHETER Acquisition cost 46MM CUP Acquisition cost 480MM ROD; EXPEDIUM PLUS TI C1713 $ 588.75 49MM BIOPOLAR SHELL C1776 $ 1,123.20 4F NEFF SET $ 7,125.00 4FR PINNACLE INTRODUCER SHEATH C1894 $ 32.18 4FRENCH OMNI FLUSH CATHETER C1887 $ 975.00 4HOLE LCP PROX MEDIAL TIB PLATE C1713 $ 2,041.50 4-HOLE PLATE C1713 $ 1,029.37 4-HOLE PLATE C1713 $ 1,029.38 4PAIR SUBDERM ELECTROD-PAROTID A4556 $ 207.00 4x40MM CANNULATED SCREW C1713 $ 429.00 4X5 DURA GRAFT SINGLE SPONGE C1768 $ 1,924.44 5 - HYDROXYINDOLEACETIC ACID 24 HR URINE 83497 $ 35.02 5 ETHIBOND LR LR $ 132.50 5 HOLE CLAMP C1713 $ 864.45 5 HOLE PLATE C1713 $ 1,081.50 5% DEXTROSE/WATER 500ML J7060 $ 5.14 5.0 CARBIDE BURR C1713 $ 413.13 5.0MM LOCKING SCREW - SYNTHES BRAND C1713 $ 247.67 5.0x150MM SELF-DRILLING SCREW C1713 $ 261.00 5.0x175 SELF DRILLING SCHANE SCREW C1713 $ 261.00 5.0x200MM PIN C1713 $ 201.00 5.5 MM X 45MM LORDOCTIC ROD C1713 $ 495.00 5.5 SPEEDSCREW IMPLANT C1713 $ 682.50 5.5 SWIVEL LOCK C1713 $ 600.00 Page 8 2018 5.5 X 50 POLY SCREW C1713 $ 937.50 5.5 X 50MM SCREW C1713 $ 1,321.75 5.5 X 8MM ROD C1713 $ 337.50 5.5MM X 45 POLY SCREW C1713 $ 937.50 5.5MM X 50MM SCREW C1713 $ 937.50 5/0 18 EHTILON MONO PS-3 $ 162.38 5/0 18 PDS II MONO PS-2 $ 77.57 5/0 18 RAPIDE P-3 $ 77.85 5/0 18COATED VICRYL P-3 $ 182.97 5/0 18GUT PLAIN P-3 $ 77.63 5/0 18SILK BRAIDED PS-2 $ 60.71 5/0 27 GUT CHROMIC RB-1 $ 160.64 5/0 30 ETHIBOND BRAIDED C-1 $ 310.37 5/0 30SILK BRAIDED RB-1 $ 68.36 5/0 36 ETHIBOND BRAIDED RB-1 $ 230.76 5/BX SUPER STIFF EX GUIDEWIRE C1769 $ 324.90 5-0 18" SUTURE BLACK 36/BX C1713 $ 165.56 5-0 18"PROLENE MONO C-1 C-1 $ 9.54 5-0 27" GUT.CHR E-812H 36/BX* C1713 $ 4.18 5-0 MONOCRYL PC-3 $ 82.17 5-0 PDS RB-1 TAPERED NEEDLE C2618 $ 119.35 50MM REFLECTION SHELL C1776 $ 2,250.00 5-0PROLENE SUT MONO RB1 NEEDLE C2618 $ 130.28 51 BIPOLAR SHELL C1713 $ 435.00 51 BIPOLAR SHELL C1776 $ 1,123.20 52 POROUS COATED HEAD SHELL Acquisition cost 55MM LORDOTIC BULLETED ROD C1713 $ 300.00 58MM,SP 3 HOLE REFLEXION L8699 $ 2,782.50 5CC BDM PUTTY C1713 $ 217.50 5CC LIVER 16F POLYCATH LATEX C1887 $ 223.38 5CC LIVER 18F POLYCATH LATEX C1887 $ 223.38 5CC SLS 21G 1 1/2 $ 0.42 5CC SLS ONLY $ 0.39 5CCLIVER 22F CATH.LATEX MED.PO C1887 $ 212.22 5CCLIVER POLYCATH.RED LATEX CO C1887 $ 223.38 5F EXPO MULTIPK 5FR FL4 FR4 ANGIOGRAPHIC $ 83.13 5F EXPO MULTIPK 5FR FL4 FR4 DIAGNOSTIC C $ 83.13 5F EXPO MULTIPK 5FR FL6 ANGIOGRPH CATH D $ 83.13 5FR STRAIGHT GLIDECATH 5/BX C1787 $ 90.30 5FRENCH INTRODUCER SHEATH C1894 $ 31.01 5-HIAA 83497 $ 35.02 5-HOLE CLAMP C1713 $ 864.45 5MM ALLOGRFT CANCELOUS CORE BONE 14x12MM C1713 $ 1,425.00 5MM BALL ELECTRODES 5/CS A4556 $ 24.28 5MM HALF PIN 165x25MM C1713 $ 157.50 5MMENDPTHEXCEL OPTVIEW BLADLSS C1713 $ 69.44 5'-NUCLEOTIDASE 83915 $ 30.29 5-ROM STEM 18X13 Acquisition cost 5-TIER H/A MONITNG 99213 $ 538.00 5-TIER H/A MONITORG 99214 $ 538.00 5-TIER H/A COUNSEL 99403 $ 587.50 5-TIER H/A COUNSELING 99401 $ 587.50 5-TIER H/A COUNSELING ONLY (NO TEST) 99402 $ 587.50 5-TIER H/A COUNSLIG 99404 $ 587.50 5-TIER H/A MONIT 99215 $ 538.00 5-TIER H/A MONITOR 99212 $ 538.00 Page 9 2018 5-TIER H/A MONITORING 99211 $ 538.00 5-TIER H/A NEG 99404 $ 587.50 5-TIER H/A NEGAT 99402 $ 587.50 5-TIER H/A NEGATIVE 99401 $ 587.50 5-TIER H/A NEGATVE 99403 $ 587.50 5-TIER H/A NEW PAT COMPREHENSIVE 99205 $ 398.00 5-TIER H/A NEW PT COMPR 99201 $ 300.00 5-TIER H/A NEW PT COMPRE 99202 $ 315.00 5-TIER H/A NEW PT COMPREH 99203 $ 343.00 5-TIER H/A NEW PT COMPREHE 99204 $ 370.00 5-TIER H/A POS 99402 $ 587.50 5-TIER H/A POSIT 99404 $ 587.50 5-TIER H/A POSITIVE 99401 $ 587.50 5-TIER H/A POSITVE 99404 $ 587.50 5-TIER H/A TEST / CONSL 99403 $ 587.50 5-TIER H/A TEST RESULT POSITIVE 99403 $ 587.50 5-TIER H/A TESTING / COUNSEL 99402 $ 587.50 5-TIER H/A TESTING / COUNSEL. 99404 $ 587.50 5-TIER H/A TESTING / COUNSELING 99401 $ 587.50 5X5CM PLASTIC SURGERY MATRIX C1763 $ 724.50 6 ACCC CEMENTED HIP STEM C1776 $ 2,325.00 6 DEGREE FEMORAL HEAD 28MM C1776 $ 1,560.55 6 HOLE PLATE C1713 $ 1,067.62 6 HOLE PLATE CURVED C1713 $ 1,067.63 6""X8"" SEPRAMESH C1781 Acquisition cost 6.0 CARBIDE BURR C1713 $ 413.13 6.5 SCREW X C1713 $ 386.32 6.5 SCREW x VARIOUS C1776 $ 687.00 6.5 X 40MM MULTI AXIAL SCREW Acquisition cost 6.5 X 55MM SCREW C1713 $ 1,312.50 6.5MM POLY SCREW C1713 $ 1,050.00 6.5X35 EXPEDIUM SCREW C1713 $ 1,582.50 6/0 18 PROLENE MONO BV-1 BV-1 $ 560.69 6/0 24 ETHIBOND BRAIDED BV-1 $ 479.93 6/0 27GUT CHROMIC FS-2 $ 44.22 6/0 36 ETHIBOND BRAIDED C-1 $ 318.44 6/127 NECK ANGLE HIP STEM C1776 $ 3,600.00 6-0 18" SUTURE SILK BLCK BRAID C1713 $ 15.68 6-0 NYLON P-1 $ 165.62 6-0COAT VICRYL CT VIOLET BRAID C1713 $ 176.78 60MM SP3 SHELL C1776 $ 1,200.00 60MM SP3 SHELL C1776 $ 1,200.00 6FR CLOSE TIP URETERL STNT KIT C2617 $ 202.71 6FR PINNACLE INTRO SHEATH 10BX C1894 $ 32.17 6-HOLE PLATE C1713 $ 1,067.63 6MM ALLOGRFT CANCELOUS CORE BONE 14x12MM C1713 $ 1,425.00 6MM ALLOGRFT CANCELOUS CORE BONE;14x12MM C1713 $ 1,425.00 6MM FLUTED BALL C1725 $ 149.04 6MM FLUTED BALL CUTTING BURS C1713 $ 183.38 6MM FULL CONE X25CM Acquisition cost 6MM X 100 GORETEX VASCULAR GRA C1768 Acquisition cost 6MMX20MM X75 6F UNISTEP PLUS Acquisition cost 7 HOLE PLATE C1713 $ 684.68 7 TIER EST PAT VIST LEVL 1 INF THERP 99211 $ 587.50 7 TIER EST PAT VIST LEVL 2 INF THERP 99212 $ 587.50 7 TIER EST PAT VIST LEVL 3 INF THERP 99213 $ 587.50 Page 10 2018 7 TIER EST PAT VIST LEVL 5 INF THERP 99215 $ 587.50 7 TIER- NEW PAT VIST LEVL 1 99201 $ 587.50 7 TIER- NEW PAT VIST LEVL 2 99202 $ 587.50 7 TIER- NEW PAT VIST LEVL 3 99203 $ 587.50 7 TIER- NEW PAT VIST LEVL 4 99204 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 1 99211 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 2 99212 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 3 99213 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 4 99214 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 4 - F/U EXT 99214 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 4-INF THERP 99214 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 5 - COMPRH 99215 $ 587.50 7 TIER-OFF EST PAT VIST LEVL 5 - F/U EXT 99215 $ 587.50 7 TIER-OFF EST PAT VIST LVL 1 99211 $ 587.50 7 TIER-OFF EST PAT VIST LVL 2 99212 $ 587.50 7 TIER-OFF EST PAT VIST LVL 2 - F/U EXT 99212 $ 587.50 7 TIER-OFF EST PAT VIST LVL 3 99213 $ 587.50 7 TIER-OFF EST PAT VST LEVL 1 - F/U EXT 99211 $ 587.50 7 TIER-OFF EST PAT VST LEVL 4 99214 $ 587.50 7 TIER-OFF EST PAT VST LEVL 4 - COMPRH 99214 $ 587.50 7 TIER-OFF EST PT VIST LEVL 2 - COMPRH 99212 $ 587.50 7 TIER-OFF EST PT VIST LEVL 3 99213 $ 587.50 7 TIER-OFF EST PT VIST LEVL 5 99215 $ 587.50 7 TIER-OFF EST PT VIST LVL 5 99215 $ 587.50 7 TIER-OFF ET PAT VIST LEVL 1 - COMPRH 99211 $ 587.50 7 TIER-OFF ET PT VIST LEVL 3 - COMPRH 99213 $ 587.50 7 TIER-OFF NEW PAT LEVL 1 VIST 99201 $ 587.50 7 TIER-OFF NEW PAT LEVL 2 VIST 99202 $ 587.50 7 TIER-OFF NEW PAT LEVL 3 VIST 99203 $ 587.50 7 TIER-OFF NEW PAT LEVL 4 VIST 99204 $ 587.50 7 TIER-OFF NEW PAT LEVL 5 VIST 99205 $ 587.50 7 TIER-OFF NEW PAT VIST LEVL 5 99205 $ 587.50 7.0 TRACH A4624 $ 161.85 7.0x150 HUMERAL NAIL C1776 $ 1,575.00 7.5 X 45MM SCREW C1713 $ 937.50 7/0 18 PROLENE MONO BV-1 BV-1 $ 503.09 7/0 18ETHIBOND BRAIDED BV-1 $ 510.33 7/0 30PROLENE MONO C-1 C-1 $ 334.37 70MM K-WIRE C1713 $ 36.12 70MM K-WIRE C1713 $ 36.12 7FR 65CM DUAL LUMEN CATH C1887 $ 485.93 7FR DRAIN WITH TROCAR 10/CS C1729 $ 216.00 7FR GUID CATH TURBO ELITE 3/BX C1887 $ 750.00 7FR GUIDE CATH 1.4&1.7 TURBO ELITE, C1885 $ 750.00 7FR GUIDING CATH 1.4&1.7 TURBO ELITE C1885 $ 750.00 7FR SILICONE DRAIN 10/CS C1729 $ 165.00 7-HOLE, NARROW T-PLATE C1713 $ 114.75 7MM L BIO-ACF SPACER Acquisition cost 7MM OP SHT ROTAT STOPCOCK&26163DO OB C1894 $ 1,098.00 7MM S BIO-ACF SPACER Acquisition cost 7X35 EXPEDIUM SCREW C1713 $ 1,125.00 8 X 20 WALL STENT Acquisition cost 8 X 32 WALL STENT Acquisition cost 8" REVERSE CUT CHROM GUT SUTUR C1713 $ 100.50 8""X12"" SEPRAMESH C1781 Acquisition cost 8.0 TRACH A4624 $ 114.68 Page 11 2018 8-0 NYLON SUTURE 12/BX" C1713 $ 17.21 8MM S BIO-ACF TM SPACER Acquisition cost 8MM X 65MM CAN C1713 $ 392.62 8MMX20MM WALL STENT Acquisition cost 8MMX40MM-75CM 6F UNISTEP PLUS C1876 Acquisition cost 8MMX60CM STRETCH GRAFT Acquisition cost 8MMX60MM-75CM-100CM WALL STENT Acquisition cost 8X20MM BIOSURE REGENESORB SCRW C1713 $ 492.00 8x65MM CANNULATED SCREW C1713 $ 24.00 9 ROUND BUR 4.0MM C1713 $ 48.65 9 X 18 WALL STENT Acquisition cost 9 X 35 WALL STENT Acquisition cost 9.0 X 115 MM FEMORAL STEM Acquisition cost 9-0 VICRYL SUTURE TG140-8 12/BX C1713 $ 234.75 9FR 65CM DUAL LUMEN CATHETER C1757 $ 454.58 9FR EHL PROBE FOR AEH-4 3/BX C2618 $ 977.37 9-HOLE LEFT DISTAL FEMUR Acquisition cost 9MM SL GRFTCH LORD CORT SPACER L8670 $ 1,434.37 9MM TI CANNULATED HUMERAL NAIL C1713 $ 2,683.50 9POLY TIB INSRT TOT STAB TRIAT C1776 $ 3,450.00 A&D OINTMENT Acquisition cost AB ID; LEUKOCYTE AB 86021 $ 40.90 AB ID; PLATELET AB 86022 $ 49.90 AB ID; PLATELET IG ASSAY 86023 $ 33.84 AB ISOAGGLUT'N TITER 86940 $ 22.29 AB SCREEN BY IF 86022 $ 49.90 AB SCREEN-SPECIAL METHOD 86970 $ 84.11 AB SH; NOT AUTOG 36830 $ 11,279.00 AB TO EA-EB VIRUS 86663 $ 35.64 AB TO EBNA 86664 $ 41.54 AB; CMV IGM 86645 $ 45.76 AB; COCCIDIOIDES 86635 $ 31.17 AB; EB VCA 86665 $ 49.28 AB; FUNGUS NES 86671 $ 33.29 AB; HELICOBACTER PYLORI 86677 $ 39.40 AB; HELMINTH NES 86682 $ 35.33 AB; HIV-1 & HIV-2 SGL ASSAY 86703 $ 37.22 AB; HSV NON-SPECIFIC 86694 $ 39.09 AB; HTLV OR HIV WB 86689 $ 52.58 AB; LYME'S DISEASE 86618 $ 46.24 AB; RSV 86756 $ 35.00 AB; TETANUS 86774 $ 40.19 AB; TOXOPLASMA 86777 $ 39.09 AB; TOXOPLASMA IGM 86778 $ 39.12 ABACAVIE/LAMIVUDINE/ZIDOVUDINE Acquisition cost ABACAVIR 20MG/ML ORAL LIQ Acquisition cost ABACAVIR SULFATE 100MG/5ML SOL Acquisition cost ABACAVIR/LAMIVUD/ZIDOVUDINE Acquisition cost ABACAVIR-LAMIVUDINE 600/300 TB Acquisition cost ABARELIX 100MG IM Acquisition cost ABBOKINASE 250.000UNITS INJ 5ML VIA J3365 Acquisition cost ABBOKINASE 5000UNITS INJ 1ML VIAL J3364 Acquisition cost ABCIXIMAB 10MG INJ J0130 $ 3,559.20 ABD 8.5CM LONG STRGHT CUTNEEDL C2618 $ 494.96 ABD PARACENTESIS (DX/TX); WO IMG GUIDE 49082 $ 1,966.21 ABD PARACENTESIS;DX/TX;W IMG G 49083 $ 1,966.21 Page 12 2018 ABD US B-SCAN COMPLETE 76700 $ 302.70 ABD US W/CONTRAST C9744 $ 668.38 ABDMINAL PARACNTESIS W IMAGE 49083 $ 1,966.21 ABDOM HYSTCTMY INC P/ VAGNCTMY 58200 $ 2,939.35 ABDOM PARACENTESIS; DX/TX 49082 $ 1,966.21 ABDOMEN MRA / MRCP 74185 $ 195.43 ABDOMEN MRI WITH AND WITHOUT CONTRAST 74183 $ 1,206.90 ABDOMEN MRI WITH CONTRAST 74182 $ 1,206.90 ABDOMEN MRI WITHOUT CONTRAST 74181 $ 614.37 ABDOMEN AP/ KUB 74018 $ 159.39 ABDOMEN COMPLETE US 76700 $ 302.70 ABDOMEN CT WITH AND WITHOUT CONTRAST 74170 $ 668.38 ABDOMEN CT WITH CONTRAST 74160 $ 668.38 ABDOMEN CT WITHOUT CONTRAST 74150 $ 302.70 ABDOMEN FLAT / UPRIGHT/SERIES 74022 $ 302.70 ABDOMEN LIMITED (SINGLE ORGAN) US 76705 $ 302.70 Abdomen MRA 74185 $ 195.43 Abdomen MRCP 74185 $ 195.43 ABDOMEN OBLIQUE 74010 $ 159.39 ABDOMEN RETROPERITONEAL /LIMITED US 76775 $ 302.70 ABDOMEN RETROPERITONEAL / COMPLETE US 76770 $ 302.70 ABDOMENCOMPLETE 74021 $ 159.39 ABDOMINAL DUPLEX PELVIC 93975 $ 614.37 ABDOMINAL HYSTERECTOMY 58150 $ 2,171.38 ABDUCTION PILLOW-CATEG 1 Acquisition cost ABILIFY MAINTENA - 300MG INJ EXT REL J0401 $ 4,098.60 ABILIFY MAINTENA - 400MG INJ EXT REL J0401 $ 5,464.80 ABILIFY MAINTENA 300MG INJ J0401 Acquisition cost ABLAT SOFT TIS INF TURBNTES; UNI/BILAT 30802 $ 3,010.00 ABLATE INF TURBINATE; SUPERFIC 30801 $ 3,010.00 ABLATE SOFT TIS INF TURBNTE; SUPRFCL 30801 $ 3,010.00 ABO TYPE 86900 $ 277.79 ABO/RH CORD BLOODPANEL Acquisition cost ABORTION BY 1+ INJ 59850 $ 802.05 ABORTION BY 1+ INJ; W D&C 59851 $ 841.72 ABORTION BY 1+ ; W D&C 59856 $ 1,029.75 ABORTION BY 1+ 59855 $ 876.96 ABP MONITORING 24+ HRS; RECORDING 93786 $ 277.79 ABP MONITORING 24+ HRS; SCAN ANALYSIS 93788 $ 277.79 ABRADER 2.9MM BURR 6/BX C1713 $ 716.63 ABRADER STRGHT BURRS C1713 $ 106.31 ABRASION OF SINGLE LESION 15786 $ 446.80 ABRASION; EA ADDITIONAL, 4 les or less 15787 $ 38.83 ABRAXANE 100MG J9264 $ 35.16 ABSCESS CULTURE 87070 $ 23.41 ABSCESS IMAGING, LTD. AREA 78805 $ 3,180.58 ABSCESS IMAGING, WHOLE BODY (3D) 78806 $ 3,180.58 ABSCESS NUCLEAR LOCALIZATION 78807 $ 1,198.21 ABSORB ADHES BARRIER INTERCEED GYNECARE C1765 $ 489.13 ABSORB ADHES BARRIER INTERCEED GYN C1765 $ 489.13 Abtmt supp cast mtl crown-base D6063 $ 420.00 Abtmt supp cast mtl crown-hinob D6062 $ 420.00 Abtmt supp cast mtl crown-noble D6064 $ 420.00 Abtmt supp porc fused to hi-nob D6059 $ 420.00 Abtmt supp porc fused-mtl crown D6061 $ 420.00 Abtmt supp ret for porc/cer FPD D6068 $ 1,330.00 Page 13 2018 Abut sup ret-cast mtl FPD-base D6073 $ 1,330.00 Abut sup ret-cast mtl FPD-hinob D6072 $ 1,330.00 Abut sup ret-cast mtl FPD-noble D6074 $ 1,330.00 Abut sup ret-cast mtl FPD-titan D6194 $ 1,130.00 Abut sup ret-porc fsd mtl FPDbm D6070 $ 1,330.00 Abut sup ret-porc fsd mtl FPDhn D6069 $ 1,330.00 Abut sup ret-porc fsd mtl FPDno D6071 $ 1,330.00 ABUT SUPP PORCELAIN FUSED METAL CROWN D6060 $ 420.00 ABUTMENT FLX LOCK-CATEG 1 Acquisition cost ABUTMENT SUP PORCLN FUSED METAL CROWN D6060 $ 420.00 Abutment supp crown - titanium D6094 $ 1,096.00 Abutment supported porc/cer crn D6058 $ 420.00 AC GRAFTROPE C1768 $ 1,042.50 ACAMPROSATE 333MG TAB Acquisition cost ACANTHAMOEBA 87102 $ 22.84 ACARBOSE 50 MG TABLETS Acquisition cost ACC 2.0MM COCR CABLE & W/CLAMP C1713 $ 506.10 ACCESS SHEATH DILATORS C1714 $ 207.00 ACCOLADE #2 STEM 30MMx127 DEGREE NECK C1776 $ 3,450.00 ACCOLADE #4.5 TMZ PLUS HIP STEM 35x129MM C1776 $ 75.00 ACCOLADE HFX SIZE #1 C1776 $ 2,011.35 ACCOLADE HFX SIZE#2 C1776 $ 2,011.35 ACCOLADE PLUS TMZF HIP STEM C1776 $ 3,450.00 ACCOLADE PLUS TMZF HIP STEM #3.5 C1776 $ 75.00 ACCOLADE STEM 127 DEG NECK- C1776 $ 3,450.00 ACCOLADE TMZ PLUZ HIP STEM C1776 $ 3,450.00 ACCOLADE TMZ+HIP STEM#3 ALUMINA SHEL INS C1768 $ 2,010.00 ACCOLADE#4 TMZ PLUZ HIP STM V40TM 35MMx C1776 $ 75.00 ACCOLDE STEM TRIDENT CUP LFTHD C1776 $ 5,933.61 ACCUDRAIN EXT CSF DRAIN SYSTEM C1729 $ 385.46 ACCUPRIL 10MG TAB Acquisition cost ACCUPRIL 20MG TAB Acquisition cost ACCURUS ANT PK 30K 0.9ABS FLARED C1780 $ 367.50 ACCURUS SURG CHANDELIER WIDE C1713 $ 2,291.58 ACCURUS TOT+VITRECTOMY W/PROBE C2618 $ 478.50 ACETABLAR SHLL; PSL HA CLUSTR 52MM C1776 $ 1,200.00 ACETABLR SHLL, TRIDNT PSL HA CLUSTR 50MM C1776 $ 1,200.00 ACETABULAR CUP OSTEOME IN SYS 56MM C1776 $ 389.70 ACETABULAR DRILL SCREW 15CM C1713 $ 138.60 ACETABULAR LINER C1776 Acquisition cost ACETABULAR LINER - 32MM C1776 $ 1,102.50 ACETABULAR LINER 28MM C1776 Acquisition cost ACETABULAR LINER 32MM C1776 $ 1,102.50 ACETABULAR LINER METAL/METAL C1776 Acquisition cost ACETABULAR LINER SIZE 24 C1776 Acquisition cost ACETABULAR LINER SIZE 46 C1776 Acquisition cost ACETABULAR SCREW C1713 $ 172.20 ACETABULAR SHELL C1776 Acquisition cost ACETABULAR SHELL C1713 $ 1,200.00 ACETABULAR SHELL 54MM C1776 Acquisition cost ACETABULAR SHELL METAL/METAL C1776 Acquisition cost ACETABULAR SHELL; VARIOUS SZ C1776 $ 1,171.50 ACETABUR CUP OSTEOTOME INS SYS C1713 $ 389.70 ACETAMINOPHEN 80329 $ 61.20 ACETAMINOPHEN 1000MG/100ML INJ Acquisition cost ACETAMINOPHEN 120MG SUPPOS Acquisition cost Page 14 2018 ACETAMINOPHEN 160MG/3.75ML Acquisition cost ACETAMINOPHEN 160MG/5ML SUSP PO Acquisition cost Acetaminophen 325 mg. Suppository Acquisition cost ACETAMINOPHEN 325MG TAB Acquisition cost ACETAMINOPHEN 650MG SUPPOS Acquisition cost ACETAMINOPHEN 80MG SUPPOS Acquisition cost ACETAMINOPHEN 80MG/2.5 ML. SYRINGE PO Acquisition cost ACETAMINOPHEN INFANT DROPS $ 2.82 ACETAMINOPHEN IV (<50KG) J0131 Acquisition cost ACETAMINOPHENSUSP 160MG/5ML Acquisition cost ACETAMNPHEN 160MG/5ML LIQ $ 2.82 ACETAMNPHEN 325MG TAB $ 0.16 ACETAMNPHEN SUPP 120MG $ 0.82 ACETAZLMIDE 250MG TAB J8499 $ 8.25 ACETAZOLAMIDE 250MG TAB Acquisition cost ACETAZOLAMIDE 500MG INJECTION J1120 Acquisition cost ACETAZOLAMIDE 500MG SEQ CAP Acquisition cost 0.25% IRRIGATION $ 11.95 ACETIC ACID 1% EXTERNAL SOL Acquisition cost ACETIC ACID 2% OTIC Acquisition cost ACETIC ACID 3% EXTERNAL SOL Acquisition cost ACETIC ACID 5% $ 154.40 ACETIC ACID EXTERNAL 1000ML Acquisition cost ACETIC ACID GLACIAL 500ML BOT Acquisition cost ACETONE 82009 $ 12.28 ACETYCHOLINESTERASE 82013 $ 30.34 ACETYLCHOLINE AB 84238 $ 99.31 ACETYLCHOLINE CL 1% Acquisition cost ACETYLCHOL-RECPTR AB 86256 $ 32.74 ACETYLCISTEINE 200MG/ML IV J0132 Acquisition cost ACETYLCYSTEIN IV 20% (50MG/ML) J7608 Acquisition cost ACETYLCYSTEIN IV 20% (7MG/ML) J7608 Acquisition cost ACETYLCYSTEINE 10% Acquisition cost ACETYLCYSTEINE NON-COMP 1GM J7608 $ 9.17 ACETYLCYSTEINE SOL 20% 30ML J7608 Acquisition cost ACETYLCYSTINE 10% 30 ML. FOR Acquisition cost ACG UP TO 48 HRS RECORD SCAN STOR 93224 $ 132.00 ACHALASIA BALLOON CATHETER #40 Acquisition cost ACHILL ALLGRFT TEND W/CALC BNE C1713 $ 2,227.50 ACHILLES TENDON W/CALCANEUS L8699 $ 2,227.50 ACID FAST STAIN 87206 $ 14.63 ACID PHOSPHATASE STAIN 84066 $ 26.25 ACID P'TASE PROST 84066 $ 26.25 ACID P'TASE TOTAL 84060 $ 20.06 ACITRETIN 10MG CAP Acquisition cost ACITRETIN 25MG CAP Acquisition cost ACL KIT REAMER LOW PROFILE C1713 $ 418.50 ACL TIGHT ROPE RIGHT C1713 $ 1,320.00 ACMI CYSTOURETHROSCOPE SHEATH 23FR C1894 $ 737.10 ACMI MASTOID DIAM SURG CUT BUR C1713 $ 77.66 ACNE SURG 10040 $ 446.80 ACOUSTIC REFLEX DECAY TEST 92750 $ 360.51 ACOUSTIC REFLEX TESTING 92568 $ 84.11 ACOUSTIC, REFLEX DECAY TEST 92570 $ 360.51 ACOUSTIC, REFLEX TESTING 92568 $ 84.11 ACRAGUN ACRACLIP SCALP CLIP SYS C1713 $ 60.00 Page 15 2018 ACRMIOPLSTY SURETAC II PAC FIX DEV SHLDR C1713 $ 340.59 ACRMIOPLSTY/ACRMIONCTMY; PART 23130 $ 6,995.52 ACROM-CLAV. JTS 73050 $ 164.27 ACRYSOF IOL TORIC LENSE 1.5D V2787 $ 742.50 ACRYSOF IOL TORIC LENSE 2.25D V2787 $ 742.50 ACRYSOF IOL TORIC LENSE 3.00D V2787 $ 742.50 ACRYSOF IOL TORIC LENSE 3.75D V2787 $ 742.50 ACRYSOF SPHERIC IOL V2632 $ 120.00 ACTEAMINOPHEN INFANT 80MG/0.6ML Acquisition cost ACTH 82024 $ 104.90 ACTH STIMULATION TEST 82533 $ 44.26 ACTH STIMULATION TEST 80400 $ 88.59 ACTH.C34 82024 $ 104.90 ACTHAR H.P. 80U/ML IM 5ML J0800 Acquisition cost ACTINOTHERAPY 96900 $ 84.11 ACTIVASE 100MG INJ J2997 Acquisition cost ACTIVATED CLOTTING TIME 85730 $ 16.32 ACTIVATED PROTEIN C RESISTANCE 85307 $ 41.62 ACTOS 30MG TABLETS Acquisition cost ACTOSN 15MG TABLETS Acquisition cost ACTV THER-PT W/MENTL PROB 45>M G0176 $ 275.00 ACUJECT VARIABLE INJ NEEDLE C2618 $ 52.50 ACUPUNTURE W/O ELEC STIM 15 MIN 97810 $ 96.00 ACUPUNTURE W/O ELEC STIM EA ADD 15 MIN 97811 $ 30.00 ACUTE HEPATITIS PANEL 80074 $ 129.38 ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE 78456 $ 3,180.58 ACUTRAK 2 MINI .045 K-WIRE C1713 $ 22.50 ACUTRAK 2 MINI BONE SCREW 22MM C1713 $ 784.50 ACUTRAK 2 MINI BONE SCREW 30MM C1713 $ 438.00 ACUTRAK 2 MINI BONE SCREW 30MM C1713 $ 687.00 ACUTRAK 2 MINI BONE SCREW 30MM STERILE C1713 $ 438.00 ACUTRAK 2 MINI GUIDEWIRE C1713 $ 22.50 ACUTRAK 2 STAND 22MM BONE SCRW C1713 $ 784.50 ACUTRAK FUSION SCREW WASTED 32MM C1713 $ 492.00 ACUTRAK FUSION SCRW WASTE 32MM C1713 $ 492.00 ACUTRAK2 FIX SYS MINI DRIL BIT C1713 $ 438.00 ACYCLOVIR 10 MG INJ J0133 Acquisition cost ACYCLOVIR 200MG/5ML ORAL SYR Acquisition cost ACYCLOVIR 400MG U-D Acquisition cost ACYCLOVIR LEVEL 80299 $ 41.01 ADAPTER LOCK CONT FLOW C1713 $ 393.12 ADAPTER TUOY-BORST-CATEG 1 Acquisition cost ADATO SILICONE SIL-OL 5000 1ML C1780 $ 628.43 Add clasp, exist part denture D5660 $ 239.00 ADD EVAL EPISODE, SAME SITE 88177 $ 50.29 ADD JNT UP EXTRM ORTHSIS,ANY MATRL;PR JT L3956 $ 220.00 ADD LW EXT DRSFLX/PLNTR ASST EA JNT L2220 $ 95.80 ADD LW EXT FT PLAT MOLD PT STIRUP L2250 $ 801.90 Add tooth to exist part denture D5650 $ 168.00 ADDITIONAL SPINE FUSION 22585 $ 699.91 ADDITIONAL TOUCH PREP 88334 $ 87.34 ADD'L SLIDES MULT. 5 88162 $ 118.21 ADEFOVIR (HESPERA) 10 MG. PO Acquisition cost ADENOCARD 3MG/ML IV 2ML J0153 Acquisition cost ADENOIDECTMY;SCNDRY;UNDER 12 42835 $ 5,815.59 ADENOIDECTOMY PRIM; UNDER AGE 12 42830 $ 5,815.59 Page 16 2018 ADENOIDECTOMY;2NDARY;AGE12< 42836 $ 5,815.59 ADENOIDECTOMY;PRIMARY;12/ 14020 $ 4,147.84 ADJ TIS TRAN S/A/L; D 10.1-30 SQ CM 14021 $ 4,147.84 ADJ TIS TRAN TRUNK; D 10 SQ CM/> 14000 $ 4,147.84 ADJ TIS TRNSFR; ANY 30.1-60.0 SQ CM 14301 $ 7,168.06 ADJ TIS TRNSFR; TRUNK 10.1-30.0 SQ CM 14001 $ 4,147.84 ADJ TRANS CHIN AX&/FT;10.1-30. 14041 $ 4,147.84 ADJ TRANS EYELD/&LIP; 10 SQ CM 14060 $ 4,147.84 ADJUSTABLE CLAMP C1713 $ 600.00 ADJUSTABLE SUTURE 67335 $ 323.07 ADJUSTMENT - COMPLETE/DENTURE MAND. D5411 $ 80.00 ADJUSTMENT - COMPLETE/DENTURE MAX. D5410 $ 80.00 ADJUSTMENT - PARTIAL / DENTURE MAND. D5422 $ 80.00 ADJUSTMENT - PARTIAL / DENTURE MAX. D5421 $ 80.00 ADMIN OF HEPATITIS B VACCINE MCARE 90471 $ 13.23 ADMIN OF INFLUENZA VIRUS VACCINE MCARE 90471 $ 13.23 ADMIN OF PNEUMOCCAL VACCINE MCARE 90471 $ 13.23 ADMIRAL PTA BALL CATH OTW C1725 $ 202.50 ADMIRAL PTA BALL CATH OTW VASC C1725 $ 202.50 ADMIRAL PTA BALL CATH OTW0.035 C1725 $ 510.00 ADMIRAL PTA BALL CATH0.035 OTW C1725 $ 225.00 ADMIRAL VASC PTA BALL CATH-OTW C1725 $ 225.00 ADMISSION CHARGE $ 3,250.00 ADMN FLU VAC NO FEE SCHED SAME DAY G0008 $ 97.92 ADMN HEP B VAC NO FEE SCHD SAME DAY 90471 $ 97.92 ADMN PNEUMCOC VAC NO FEE SCHED DAY 90471 $ 97.92 ADMN PNEUMCOC VAC NO FEE SCHED DAY-CLINC 90471 $ 97.92 ADOMINIAL/PELVIC DUPLEX US 93976 $ 302.70 ADOMINIAL/PELVIC DUPX US 93976 $ 302.70 ADRENAL, CORTEX AND/OR MEDULLA 78075 $ 3,180.58 ADRENALECTOMY/EXPL; TRANS ABD/LMB/DORS 60540 $ 2,285.43 ADRENALIN 1:1000 IV 30ML J0171 Acquisition cost ADULT KIT (TENOFOVIR/COMBIVIR) Acquisition cost ADV CAR PLAN DISCSSION DOCMNTED IN MR 1158F Acquisition cost ADV CAR PLAN IN MED RECRD 1157F Acquisition cost ADV MALE SLING SYS CX C1813 $ 6,150.00 ADVANCE 18LP PTA BALL CATH RE C1725 $ 472.50 ADVANCE MALE SLING KIT C1771 $ 7,282.50 ADVANCE MALE SLING SYSTEM CX C1813 $ 6,150.00 ADVANCE PTA BALL CATHETER C1725 $ 618.75 ADVIL (IBUPROFEN) 200 MG TAB Acquisition cost ADVNCE MALE SLING KIT C1771 $ 7,282.50 AEROSOL INHALA PENTAMIDINE PC PNEUM 94642 $ 492.89 AEROSOL MASK 94640 $ 492.89 Page 17 2018 AEROSOL/VAPOR INHALA; INIT DEMO // EVAL 94664 $ 492.89 AEROSOL/VAPOR INHALA; SUBSQT 94640 $ 492.89 AF02 LEGEND (B-1) 2.4MM STEM C1776 $ 1,679.18 AFFINITY SR PMKR C1786 Acquisition cost AFP (MATERNAL)-SERUM 82105 $ 45.56 AFP (TUMOR MARKER) 86316 $ 56.54 AFP(MATERNAL)-AMN FL 82106 $ 45.56 AGENERASE 15 MG/ML SOL Acquisition cost AGENERASE 150MG Acquisition cost AGENERASE 50MG CAPSULE Acquisition cost AHG ANTIGEN TYPING 86905 $ 569.71 AHMED GLAUCOMA VALVE ADLT FLEX PLATE C1783 $ 892.50 AIR MATTRESS (DISP) $ 260.67 AIRWAY COBRAPLA-CATEG 1 Acquisition cost AIRWAY NASOPHAR-CATEG 1 Acquisition cost AIRWAY NASOPHAR-CATEG 2 Acquisition cost AIRWAY ORAL-CATEG 1 Acquisition cost AIRWAY PHARYNGEAL PAXPRESS-CATEG 1 Acquisition cost AIRWAY RESISTANCE. 94726 $ 658.04 AIRWAY TRAY $ 71.50 AIRWAY TUBE 10FR $ 2.97 AIRWAY TUBE 3FR $ 2.77 AIRWAY TUBE 4FR $ 2.77 AIRWAY TUBE 5FR $ 19.20 AIRWAY TUBE 6FR $ 0.55 AIRWAY TUBE 7FR $ 2.97 AIRWAY TUBE 8FR $ 2.97 AIRWAY TUBE 9FR $ 0.48 AKREOS POSTERIOR CHAMBER IOL V2632 $ 262.50 ALBATE BONE TUMOR(S) PERQ 20982 $ 14,826.61 ALBENDAZOLE 200MG. PO TABLET Acquisition cost ALBUEROL 0.083% INHALATION SOL J7609 $ 0.97 ALBUMIN 82040 $ 13.44 ALBUMIN (HUMAN) 25%, 20ML P9046 $ 49.48 ALBUMIN (HUMAN) 25%, 50ML P9047 $ 117.57 ALBUMIN (HUMAN) 5%, 250ML P9045 $ 120.38 ALBUMIN (HUMAN) 5%, 50ML P9041 $ 25.96 ALBUMIN 25% IV 100ML Acquisition cost ALBUMIN 25% IV 50ML P9047 Acquisition cost ALBUMIN 5% IV 250ML P9045 Acquisition cost ALBUMIN 5% IV 50ML P9041 Acquisition cost ALBUMIN BF 82040 $ 13.44 ALBUMIN BF... 82042 $ 17.12 ALBUMIN BOVINE-CATEG 1 Acquisition cost ALBUMIN(MICRO) URINE 82043 $ 15.71 ALBUMIN. 82040 $ 13.44 ALBUMIN; QUAN 82042 $ 17.12 ALBUMIN; URIN/OTH SOURCE QUAN EA SPECMN 82042 $ 17.12 ALBUT SUL / IPRAT Acquisition cost ALBUT SUL 3 mg/ IPRAT 0.5mg (DuoNeb) $ 0.10 ALBUTEROL 2.5MG & IPRATROPIUM 0.5MG J7620 $ 4.82 ALBUTEROL 5 MG/ML Acquisition cost Albuterol 5mg/ml 20 ml for inhalation J7611 Acquisition cost ALBUTEROL 90 MCG (PROVENTIL) Acquisition cost ALBUTEROL 90MCG INH PED USE Acquisition cost ALBUTEROL 90MCG INHALER J7613 $ 63.36 Page 18 2018 ALBUTEROL HFA MDI INHALER J7620 $ 6.51 ALBUTEROL INHAL SOL CONC-1/0.5 MG J7613 $ 2.71 ALBUTEROL SULF SOLUTION Acquisition cost ALBUTERSOL SULF 2MG/ML ORAL SYRUP Acquisition cost ALC ASSMT-PSY/OTH OP-BEHV MOD/ 90791 $ 290.00 ALC IND--PSY/OTH OP-BEHV MOD/S 90832 $ 290.00 ALC IND-PSY/OTH OP-BEHV MOD/SU 90834 $ 290.00 ALC/DRUG GROUP COUNSELING 90853 $ 290.00 ALC/DRUG GROUP COUNSELING H00 90853 $ 275.00 ALC/DRUG INTERVENTION PER 15MI 99408 $ 275.00 ALC/SUBS ABUSE COUNSELING 99408 $ 275.00 ALC-GROUP PSYCHOTHERAPY 90853 $ 290.00 ALCHL/DRUG SCREEN >30 MINS 99409 $ 300.00 ALCHL/DRUG SCREEN 15 TO30 MIN 99408 $ 300.00 ALCHOL/SUBS INTER >30 MIN G0397 $ 190.26 ALCHOL/SUBS INTER 13-30 MIN G0396 $ 80.45 ALCLOMETASONE 0.05% CR TOP Acquisition cost ALCOHOL AND/OR DRUG SCREENING 90791 $ 275.00 ALCOHOL ETHYL 80320 $ 11.00 ALCOHOL OR DRUG ASSESSMENT 90791 $ 275.00 ALCOHOL PADS Acquisition cost ALCOHOL/DRUG SCREEN 15 MINS 99408 $ 275.00 ALCOHOL/DRUG SCREENING >30MINS 99409 $ 275.00 ALCOHOL/DRUG SCREENING 15 TO 3 99408 $ 275.00 ALCOHOL/DRUG SERVICES H0014 $ 275.00 ALDACTONE 50 MG TAB Acquisition cost ALDESLEUKIN 22MMU VIAL J9015 Acquisition cost ALDESLEUKIN,SINGLE USE VIAL J9015 $ 10,306.34 ALDOLASE 82085 $ 26.38 ALDOSTERONE SERUM 82088 $ 110.68 ALDOSTERONE SUPPRESSION EVAL PANEL 80408 $ 340.87 ALDOSTERONE URINE 82088 $ 110.68 ALEMTUZUMAB 10MG/ML AMPULE J0202 Acquisition cost ALENDRONATE 5MG TAB Acquisition cost ALENDRONATE 70MG TABLET Acquisition cost ALENDRONATE SODIUM 70MG TAB Acquisition cost ALFENTANIL 500MCG/ML Acquisition cost ALFENTANIL 500MCG/ML - 5ML Acquisition cost ALGINATE DRESSING<=16 SQ IN A6196 Acquisition cost ALIMTA 10MG INJECCT J9305 $ 178.60 ALISKIREN (TEKTURA) 150MG. PO Acquisition cost ALK PHOS ISOENZYMES 84080 $ 40.15 ALKALINE P'TASE 84075 $ 14.06 ALKERAN 2MG TAB J9245 Acquisition cost ALL DRESS 4X4 $ 13.50 ALL DRESS 6X6 $ 21.84 ALL DRESS 6X8 $ 30.45 ALL POLY PATELLA L8699 $ 1,084.20 ALL POLY PATELLA STNDRD SZ#29 8MM THICK C1776 $ 1,414.53 ALL POLY PATELLA SZ.32MM Acquisition cost ALLERCAN SILICONE BREAST IMP 120-550 C1789 $ 1,390.50 ALLERG SP IGE; QUAN OR SEMIQUAN 86003 $ 14.17 ALLERGAN BRST IMP SILICONE SMOOTH RD C1789 $ 1,350.00 ALLERGAN SILICONE BREAST IMPL C1789 $ 1,350.00 ALLERGAN SILICONE BRST IMP STYLE C1789 $ 1,350.00 ALLERGEN IMMN 1INSECT VENOM 95130 $ 20.92 Page 19 2018 ALLERGEN IMMN 2 INSECT VENOMS 95131 $ 29.19 ALLERGEN IMMN 3 INSECT VENOMS 95132 $ 33.57 ALLERGEN IMMN 4 INSECT VENOMS 95133 $ 37.93 ALLERGEN IMMUN 5 INSECT VENOMS 95134 $ 42.28 ALLERGY TSTS,INTRDRML,ALERGENC 95028 $ 84.11 ALLO MATRIX INJECTABLE PUTTY Acquisition cost ALLOGRFT, STRUCTRL, SPINE ONLY; ADD-ON 20931 $ 236.32 ALLOMATRIX 3CC BOND PUTTY C9359 $ 1,816.50 ALLOSKIN PER 1 SQ CM Q4115 $ 10.09 ALLPORT LS 5MM CLIP APPLIER 1 Acquisition cost ALOE VEA 16 OZ Acquisition cost ALOE VESTA(2% NITRATE+ALOE) Acquisition cost ALOMIDE 0.1% OPHT SOL 10ML Acquisition cost ALOPURINOL 100MG TAB Acquisition cost ALOPURINOL 300MG TAB Acquisition cost ALPHA 1 ANTITRYPSIN 82104 $ 39.29 ALPHA SUBUNIT 83519 $ 40.48 ALPHA SUBUNIT(A-PGH) 83520 $ 37.99 ALPHA THALASSEMIA, DNA, NYPANEL Acquisition cost ALPHA-1 ANTITRYPSIN. 82103 $ 36.50 ALPHA-1-ANTITRYPSIN 82103 $ 36.50 ALPHA-1-ANTITRYPSIN PHENOTYPE 82104 $ 39.29 ALPHACOR DEVICE L8610 $ 10,425.00 ALPHACOR DEVICE L8610 $ 10,425.00 ALPHA-FETOPROTEIN AMNIOTIC 82106 $ 45.56 ALPRAZOLAM 0.25MG TAB Acquisition cost ALPRAZOLAM 0.25MG TABLET Acquisition cost ALPRAZOLAM 0.5MG TAB Acquisition cost ALPRAZOLAM 0.5MG TABLET Acquisition cost ALPRAZOLAM 1MG TAB PO Acquisition cost ALT 84460 $ 14.39 ALTEPLASE (ACTIVASE) 50MG J2997 Acquisition cost ALTEPLASE 10 MG/50 ML NS SYRINGE $ 0.10 ALTEPLASE 2MG INJ J2997 Acquisition cost ALUMINUM (SERUM) 82108 $ 69.21 ALUMINUM CARB 400MG/5ML PO SUSP Acquisition cost ALUMINUM CARB 400MG/5ML SUSP Acquisition cost ALUMINUM CARBONATE 500MG CAP Acquisition cost ALUMINUM CARBONATE 500MG TABL Acquisition cost ALUMINUM HYDROX 300MG TABLET Acquisition cost ALUMINUM HYDROX 320MG/ML ORAL SUSP Acquisition cost ALUMINUM HYDROX 600MG TABLET Acquisition cost ALUMINUM STIMULATION TEST 82108 $ 69.21 ALUPENT 0.6% NEBU SOL 2.5ML J7669 Acquisition cost ALUPENT 200PU INHALER 14GM J7668 Acquisition cost ALVEOLOPLASTY EA QUADRANT 41874 $ 5,815.59 Alveoloplasty w/ext 1-3 th/quad D7311 $ 262.00 Alveoloplsty w/o ex 1-3 th/quad D7321 $ 412.00 ALVEOLUS CLOSED REDUCTN STABILZN TEETH D7771 $ 2,204.00 ALVEOLUS CLSD REDUCTN MAY INC STAB TEETH D7670 $ 1,413.00 Alveolus-open reduction D7671 $ 2,661.00 Alveolus-stabilize teeth, open D7770 $ 2,856.00 ALVEOPLASTY - PER QUARDANT D7310 $ 364.00 AMALGAM -1 SURFACE D2140 $ 154.00 AMALGAM 4 SURFACES D2161 $ 252.00 AMALGAM-THREE SURFACES D2160 $ 210.00 Page 20 2018 AMALGAM-THREE SURFACES, D2160 $ 210.00 AMALGAM-TWO SURFACES D2150 $ 175.00 AMANTADINE 50 MG/5 ML G9017 Acquisition cost AMANTADINE 100MG CAP G9017 Acquisition cost AMARYL (GLIMEPIRIDE) 1 MG TAB Acquisition cost AMBIODRY HUM AMNIO MEMB 2X3CM GRAFT V2790 $ 892.50 AMBISONE 10MG IV J0289 Acquisition cost AMBULATORY SURG BOOT EA L3260 $ 106.65 AMBULATORY SURGERY UNIT 106 - 120 MINS $ 3,960.00 AMBULATORY SURGERY UNIT 121 - 135 MINS $ 3,274.43 AMBULATORY SURGERY UNIT 136 - 150 MINS $ 4,950.00 AMBULATORY SURGERY UNIT 151 - 165 MINS $ 5,445.00 AMBULATORY SURGERY UNIT 16 - 30 MINS $ 727.65 AMBULATORY SURGERY UNIT 166 - 180 MINS $ 5,940.00 AMBULATORY SURGERY UNIT 181 - 195 MINS $ 6,435.00 AMBULATORY SURGERY UNIT 196 - 210 MINS $ 6,930.00 AMBULATORY SURGERY UNIT 211 - 225 MINS $ 7,425.00 AMBULATORY SURGERY UNIT 226 - 240 MINS $ 7,920.00 AMBULATORY SURGERY UNIT 241 - 255 MINS $ 8,415.00 AMBULATORY SURGERY UNIT 256 - 270 MINS $ 8,910.00 AMBULATORY SURGERY UNIT 271 - 285 MINS $ 9,405.00 AMBULATORY SURGERY UNIT 286 - 300 MINS $ 9,900.00 AMBULATORY SURGERY UNIT 301 - 315 MINS $ 10,395.00 AMBULATORY SURGERY UNIT 31 - 45 MINS $ 1,091.48 AMBULATORY SURGERY UNIT 316 - 330 MINS $ 10,890.00 AMBULATORY SURGERY UNIT 331 - 345 MINS $ 11,385.00 AMBULATORY SURGERY UNIT 346 - 360 MINS $ 11,880.00 AMBULATORY SURGERY UNIT 361 - 375 MINS $ 12,375.00 AMBULATORY SURGERY UNIT 376 - 390 MINS $ 12,870.00 AMBULATORY SURGERY UNIT 391 - 405 MINS $ 13,365.00 AMBULATORY SURGERY UNIT 406 - 415 MINS $ 13,860.00 AMBULATORY SURGERY UNIT 416 - 430 MINS $ 14,355.00 AMBULATORY SURGERY UNIT 431 - 445 MINS $ 14,850.00 AMBULATORY SURGERY UNIT 446 - 460 MINS $ 15,345.00 AMBULATORY SURGERY UNIT 46 - 60 MINS $ 1,455.30 AMBULATORY SURGERY UNIT 461 - 475 MINS $ 15,840.00 AMBULATORY SURGERY UNIT 476 - 495 MINS $ 16,335.00 AMBULATORY SURGERY UNIT 496 - 510 MINS $ 16,830.00 AMBULATORY SURGERY UNIT 511 - 525 MINS $ 17,325.00 AMBULATORY SURGERY UNIT 526 - 540 MINS $ 17,820.00 AMBULATORY SURGERY UNIT 541 - 555 MINS $ 18,315.00 AMBULATORY SURGERY UNIT 556 - 570 MINS $ 18,810.00 AMBULATORY SURGERY UNIT 571 - 585 MINS $ 19,305.00 AMBULATORY SURGERY UNIT 586 - 600 MINS $ 19,800.00 AMBULATORY SURGERY UNIT 61 - 75 MINS $ 1,819.13 AMBULATORY SURGERY UNIT 76 - 90 MINS $ 2,182.95 AMBULATORY SURGERY UNIT 91 - 105 MINS $ 2,546.78 AMBULATORY SURGERY UNIT < 15 MINS $ 363.83 AMEBIASIS SEROLOGY 87449 $ 32.56 AMICAR 250MG/ML SYRUP Acquisition cost AMIDATE 2MG/ML 10ML IV Acquisition cost AMIFOSTINE 500MG INJ J0207 Acquisition cost AMIKACIN 80150 $ 40.94 AMIKACIN 100MG/2ML IV Acquisition cost AMIKACIN 500mg/100ml IV BAG J0278 Acquisition cost AMIKACIN 500MG/2ML IV J0278 Acquisition cost Page 21 2018 AMIKACIN INTRAVITREAL INJ Acquisition cost AMILORIDE 5MG TAB Acquisition cost AMINO ACID QUANTITATIVE 82139 $ 45.83 AMINO ACID SCREEN 82131 $ 50.56 AMINO ACID SCREEN(B) 82128 $ 37.69 AMINO ACID SCREEN(U) 82128 $ 37.69 AMINO ACIDS; SINGLE QUAL EA 82127 $ 37.69 AMINOCAPROIC ACID 250MG/ML IV Acquisition cost AMINOCAPROIC ACID 500 MG TABLET Acquisition cost AMINOCENTESIS TRAY $ 133.59 AMINOGLUTETHIMIDE 250MG Acquisition cost AMINOLEVULINIC ACID 82135 $ 44.68 AMINOPHYLLIN 5MG/ML NICU Acquisition cost AMINOPHYLLINE 100MG TAB Acquisition cost AMINOPHYLLINE 250MG/10ML IV J0280 Acquisition cost AMINOSALICYLIC ACID 4GM PACLET Acquisition cost AMIODARONE 80299 $ 41.01 AMIODARONE 150MG IV, PER 30MG J0282 $ 18.33 AMIODARONE 150mg/100ml IV SOLUTION J0282 Acquisition cost AMIODARONE 360MG/200ML PREMIX J0282 Acquisition cost AMIODARONE 5MG/ML ORAL SYRINGE Acquisition cost AMIODARONE HCL 200MG TAB J0282 Acquisition cost AMIODARONE HCL INJ, PER 30MG J0282 $ 18.33 AMIODARONE PRE-MIXED IV Acquisition cost AMITIZA 8 MCG. PO Acquisition cost AMITRIPTYLINE 80335 $ 11.00 AMITRIPTYLINE 100MG TAB Acquisition cost AMITRIPTYLINE 10MG TAB Acquisition cost AMITRIPTYLINE 25MG TAB Acquisition cost AMITRIPTYLINE 50MG TAB Acquisition cost AMITRIPTYLINE 75MG TAB Acquisition cost AMLODIPINE 1MG/ML NICU CHR SY Acquisition cost AMLODIPINE/BENAZEPRIL10MG/20MG CAP Acquisition cost AMMONIA 82140 $ 39.58 AMMONIA AROM SPIRIT 30ML Acquisition cost AMMONIA N-13 <=40MCI A9526 Acquisition cost AMNIO MEMBRANE AMNIOGRAFT SZ-B 2x1.5CM L8610 $ 1,342.50 AMNIO MEMBRNE; AMNIOGRFT SZ C 3.5x3.5CM L8610 $ 1,342.50 AMNIOCENTESIS ANY METHD 59000 $ 1,522.22 AMNIOCENTESIS; TX FLUID REDUCTION 59001 $ 709.68 AMNIOTIC FLUID SCAN 82143 $ 20.57 AMNIOTIC FLUID SPECTROPH 82143 $ 20.57 AMNIOTIC MEMBRANE F, SIZE A (THICKER) V2790 $ 1,155.00 AMNIOTIC MEMBRANE F, SIZE A THICKER V2790 $ 1,155.00 AMOBARBITAL LEVEL URINE 80345 $ 11.00 AMODARONE HCL 50MG/ML IV J0282 Acquisition cost AMOX TRI/CLAVUL ES 600 125ML Acquisition cost AMOX TRI/CLAVUL ES 600 75ML Acquisition cost AMOXAPINE 50MG TAB Acquisition cost AMOXICILLIN 250MG/5ML - 150ML Acquisition cost AMOXICILLIN 125MG/5ML-150ML Acquisition cost AMOXICILLIN 250MG UD CAPSULE Acquisition cost AMOXICILLIN 500MG CAPSULE Acquisition cost AMOXICILLIN 500-MG CAPSULE J8499 $ 2.13 AMOXICILLIN SUSP 125MG/5ML Acquisition cost AMPH DEEP PTA BALL CATHOTWVASC C1725 $ 457.50 Page 22 2018 AMPHET ASP/AMPHET/D-AMPHET 5MG Acquisition cost AMPHET ASP/AMPHET/D-AMPHET10MG Acquisition cost AMPHET ASP/AMPHET/D-AMPHET20MG Acquisition cost AMPHET ASP/AMPHET/D-AMPHET30MG Acquisition cost AMPHETAMINE LEVEL 80324 $ 11.00 AMPHETAMINE QUANT URINE 80324 $ 11.00 AMPHETAMINE/METHAMPHETAMINE 80324 $ 11.00 AMPHI DEEP PTA BALL CATH OTW C1725 $ 457.00 AMPHI DEEP BALL CATH PTA OTW C1725 $ 517.50 AMPHIRI DEEP PTA BALL CATH OTW C1725 $ 510.00 AMPHOGEL 675MG/5ML 30ML UD Acquisition cost AMPHOTERICIN PO LIQ 100MG/ML Acquisition cost AMPHOTERICIN B 0.5MG/ML EYE DROP Acquisition cost AMPHOTERICIN B 0.5mcg/ml (OPH) $ 0.10 AMPHOTERICIN B 1.5MG/ML EYE DROP Acquisition cost AMPHOTERICIN B INJ J0285 Acquisition cost AMPHOTERICIN LEVEL PEAK 80299 $ 41.01 AMPHOTERICIN LEVEL RANDOM 80299 $ 41.01 AMPHOTERICIN LEVEL TROUGH 80299 $ 41.01 AMPICILLIN 125MG/5ML SUSP Acquisition cost AMPICILLIN 1GM ADD VANTAGE Acquisition cost AMPICILLIN 1GM IV J0290 Acquisition cost AMPICILLIN 250MG CAPSULE Acquisition cost AMPICILLIN 2GM ADD VANTAGE Acquisition cost AMPICILLIN 2GM IV J0290 Acquisition cost AMPICILLIN 500MG CAPSULE Acquisition cost AMPICILLIN 500MG IV J0290 Acquisition cost AMPICILLIN SODIUM 250MG VIAL J0290 Acquisition cost AMPICILLIN TRIH 250MG/5ML PO Acquisition cost AMPICILLIN/SULB 1.5GM ADD VANT Acquisition cost AMPICILLIN/SULB 3GM ADD VANT Acquisition cost AMPLATZ CORONARY-CATEG 1 Acquisition cost AMPLATZ RENAL SHEATH DILATOR C1725 $ 329.64 AMPLATZ SUPER STIFF GW XCH 035/180 C1769 $ 310.65 AMPLATZ SUPER STIFF GW XCH 035/260 C1769 $ 310.65 AMPLATZ SUPER STIFF J TIP GW C1769 $ 315.11 AMPLATZ SUPER STIFF-CATEG 1 C1769 Acquisition cost AMPLATZ SUPER STIFF-CATEG 2 C1769 Acquisition cost AMPLATZ SUPER TORQUE-CATEG 1 C1769 Acquisition cost AMPLATZ TYPE 30FR RENAL SHEATH C1894 $ 59.04 AMPLATZ-CATEG 1 C1769 Acquisition cost AMPLATZER VASC PLUG II SIZE 20 C1781 $ 1,575.00 AMPLIF NA PROBE NOS AGENT 87798 $ 95.33 AMPLIFIED PROBE TECHNIQUE EA ORG 87798 $ 95.33 AMP-RT ASSAY 82030 $ 70.07 AMPUTA FING/TH SGL;W DIR CLOSE 26951 $ 6,995.52 AMPUTATE FING/TH SGL; W LOC ADV FLAP 26952 $ 6,995.52 AMPUTATE FNG/TH; SING; DIRECT CLOS 26951 $ 6,995.52 AMPUTATE FOOT; TRANSMETATARSAL 28805 $ 6,995.52 AMPUTATE METATARSAL W TOE; SINGLE 28810 $ 6,995.52 AMPUTATE PENIS; PARTIAL 54120 $ 9,800.87 AMPUTATE TOE; MTP JOINT 28820 $ 3,570.03 AMPUTATE TOE;IP JOINT 28825 $ 3,570.03 AMPUTATION OF CERVIX 57530 $ 6,010.51 AMYLASE 82150 $ 17.60 AMYLASE BF 82150 $ 17.60 Page 23 2018 AMYLASE ISOENZYME 82664 $ 135.30 AMYLASE UR HR 82150 $ 17.60 AMYLASE UR RANDOM 82150 $ 17.60 AMYLASE/LIPASE/PROTEASE $ 0.10 ANA (SCREEN) 86038 $ 32.82 ANA (TITER) 86039 $ 30.32 ANA CROWN EXP 4 OR> PER QUAD D4230 $ 550.00 ANAER ABCESS CULT 87075 $ 25.72 ANAER BODY FL CULT 87075 $ 25.72 ANAER SENSITIVITY 87186 $ 23.47 ANAER TISSUE CULT 87075 $ 25.72 ANAEROB BACT CULTURE W ID 87075 $ 25.72 ANAEROBIC WOUND CULT 87075 $ 25.72 ANAGESIC BALM Acquisition cost ANAGRELIDE 0.5 MG. PO Acquisition cost Anagrelide 1 mg. po tablet Acquisition cost ANAL PUMP W/O REPROGRAM 62367 $ 692.58 ANAL PUMP W/ REPROGRAM 62368 $ 692.58 ANAL PUMP W/ REPROGRAMING 62368 $ 692.58 ANAL PUMP WO REPROGRAM 62367 $ 692.58 ANALGESIA, NITROUS OXIDE D9230 $ 280.00 ANALYS INFORM DATA STORED-COMP 59899 $ 424.97 ANASTROZOLE 1MG (ARIMIDEX) TAB Acquisition cost ANCA 86021 $ 40.90 ANCHOR PANALOK-CATEG 1 Acquisition cost ANCHOR PHANTOM-CATEG 1 Acquisition cost ANCHOR PHANTOM-CATEG 2 Acquisition cost ANCHOR SHOULDER-CATEG 1 Acquisition cost ANCHOR SPACER 7MM C1713 $ 4,447.92 ANCHOR SUPER-CATEG 1 C1713 Acquisition cost ANCHOR, BIOFASTIN-CATEG 1 C1713 Acquisition cost ANDROGEL 1.62% Acquisition cost ANDROGEN RECEPTORS 84235 $ 156.71 ANDROSTANEDIOL GLUCU 82154 $ 78.32 ANDROSTENEDIONE 82157 $ 79.51 ANDROSTENEDIONE 82157 $ 79.51 ANESTHESIA TIME 106 - 120 MINUTES $ 440.00 ANESTHESIA TIME 121 - 135 MINUTES $ 495.00 ANESTHESIA TIME 136 - 150 MINUTES $ 550.00 ANESTHESIA TIME 151 - 165 MINUTES $ 605.00 ANESTHESIA TIME 16 - 30 MINUTES $ 110.00 ANESTHESIA TIME 166 - 180 MINUTES $ 660.00 ANESTHESIA TIME 181 - 195 MINUTES $ 715.00 ANESTHESIA TIME 196 - 210 MINUTES $ 770.00 ANESTHESIA TIME 211 - 225 MINUTES $ 825.00 ANESTHESIA TIME 226 - 240 MINUTES $ 880.00 ANESTHESIA TIME 241 - 255 MINUTES $ 935.00 ANESTHESIA TIME 256 - 270 MINUTES $ 990.00 ANESTHESIA TIME 271 - 285 MINUTES $ 1,045.00 ANESTHESIA TIME 286 - 300 MINUTES $ 1,100.00 ANESTHESIA TIME 301 - 315 MINUTES $ 1,155.00 ANESTHESIA TIME 31 - 45 MINUTES $ 165.00 ANESTHESIA TIME 316 - 330 MINUTES $ 1,210.00 ANESTHESIA TIME 331 - 345 MINUTES $ 1,265.00 ANESTHESIA TIME 346 - 360 MINUTES $ 1,320.00 ANESTHESIA TIME 361 - 375 MINUTES $ 1,375.00 Page 24 2018 ANESTHESIA TIME 376 - 390 MINUTES $ 1,430.00 ANESTHESIA TIME 391 - 405 MINUTES $ 1,485.00 ANESTHESIA TIME 406 - 415 MINUTES $ 1,540.00 ANESTHESIA TIME 416 - 430 MINUTES $ 1,595.00 ANESTHESIA TIME 431 - 445 MINUTES $ 1,650.00 ANESTHESIA TIME 446 - 460 MINUTES $ 1,705.00 ANESTHESIA TIME 46 - 60 MINUTES $ 220.00 ANESTHESIA TIME 461 - 475 MINUTES $ 1,760.00 ANESTHESIA TIME 476 - 495 MINUTES $ 1,815.00 ANESTHESIA TIME 496 - 510 MINUTES $ 1,870.00 ANESTHESIA TIME 511 - 525 MINUTES $ 1,925.00 ANESTHESIA TIME 526 - 540 MINUTES $ 1,980.00 ANESTHESIA TIME 541 - 555 MINUTES $ 2,035.00 ANESTHESIA TIME 556 - 570 MINUTES $ 2,090.00 ANESTHESIA TIME 571 - 585 MINUTES $ 2,145.00 ANESTHESIA TIME 586 - 600 MINUTES $ 2,200.00 ANESTHESIA TIME 61 - 75 MINUTES $ 275.00 ANESTHESIA TIME 76 - 90 MINUTES $ 330.00 ANESTHESIA TIME 91 - 105 MINUTES $ 385.00 ANESTHESIA TIME < 15 MINUTES $ 55.00 ANGIO 6FR PTA 120CM DILAT CATH C1725 $ 397.50 ANGIO 6FR PTA 50CM DILAT CATH C1725 $ 382.50 ANGIO 6FR PTA 75CMD ILAT CATH C1725 $ 544.50 ANGIO ADRENAL BILAT SELECT-RAD S / I 75733 $ 6,592.23 ANGIO ADRENAL UNILAT SELECT-RAD S / I 75731 $ 1,619.99 ANGIO BRACHIAL RETROGRADE-RAD S / I 75658 $ 6,285.47 ANGIO INT MAMMARY-RAD S / I 75756 $ 6,592.23 ANGIO PULM-NONSELECT CATH-RAD S / I 75746 $ 2,599.54 ANGIO SEAL-CATEG 1 C1760 Acquisition cost ANGIO SELECT EA ADD VESSEL-S/I 75774 $ 37.44 ANGIO SPINAL SELECT-RAD S / I 75705 $ 11,279.00 ANGIO THRU EXISTING CATH 75898 $ 2,599.54 ANGIOFILL-CATEG 1 Acquisition cost ANGIOGRAPH DISP-CATEG 1 Acquisition cost ANGIOGRAPHY /NECK CT W/W/O CONTRAST 70498 $ 668.38 ANGIOMAX 250MG J0583 Acquisition cost ANGIOOPTIC ST STRGHT CATH 10BX C1887 $ 234.00 ANGIOSEAL C1760 $ 4,350.00 ANGIOTENSIN II (GIAPEZA) 2.5MG/ML $ 0.10 ANGIOTENSION CONV ENZYME 82164 $ 39.67 ANGLE GLDECATH 5FR/65CM HYDROPHLC COATED C1887 $ 536.25 ANGLE GLIDEWIRE .035/150CM C1769 $ 282.89 ANGLE GLIDEWIRE .035/150CM - 3CM TIP C1769 $ 282.89 ANGLED SELECT CATH 4FR 5/BX C1887 $ 135.00 ANION GAP $ 16.01 ANK-FT ORTHOSIS PLSTC CUST-FAB L1940 $ 43.98 ANK-FT ORTHOSIS PLSTC PREFAB L1930 $ 43.98 ANKLE AP / LAT 73600 $ 164.27 ANKLE COMPLETE 73610 $ 164.27 ANKLE/FOOT STRAPPING 29540 $ 358.14 ANKLET COMPRESSION-CATEG 1 Acquisition cost ANNA-1 (ANTI-HU) 86255 $ 32.74 ANNA-2 (ANTI-RI) 86255 $ 32.74 ANOPLASTY FOR STRICTURE; ADULT 46700 $ 6,123.85 ANORECTAL MANOMETRY 91122 $ 607.00 ANOSCOPY DX W/WO SPECIMENS 46600 $ 277.79 Page 25 2018 ANOSCOPY W DILATION 46604 $ 2,476.36 ANOSCOPY W DILATION 46604 $ 2,476.36 ANOSCOPY W REM FB 46608 $ 1,877.59 ANOSCOPY; DX W/WO SPECIMENS 46600 $ 277.79 ANOSCOPY; REM SING T/P/L; SNARE 46611 $ 1,877.59 ANOSCOPY; W BX;SING/MULTI 46606 $ 2,476.36 ANOSCOPY; W REM FB 46608 $ 1,877.59 ANOSCOPY;SNARE TO REM TUM/POL 46611 $ 1,877.59 ANOSCOPY;W BLEED CONTROL 46614 $ 2,476.36 ANOSCOPY;W REM MULTI TUM/POL/L 46615 $ 6,123.85 ANOSCOPY;W REM TUM/POL/LES;HBF 46610 $ 6,123.85 ANOSCPY W ABLATION OF T/P/L 46615 $ 6,123.85 ANOSCPY W BLEED CONTROL 46614 $ 2,476.36 ANOSCPY W BX; SING/MULTI 46606 $ 2,476.36 ANOSCPY W REM MULTI T/P/L; ANY TECHNQ 46612 $ 6,123.85 ANOSCPY W REM T/P/L; HBX/BIP CAUT 46610 $ 6,123.85 ANOSCPY;W REM MULTI T/P/L;HBF/ 46612 $ 6,123.85 ANT COLPORRHAPHY REP CYSTOCELE 57240 $ 10,873.98 ANT TAP 65800 $ 5,080.46 ANT TIBIAL TUBERCLEPASTY 27418 $ 14,826.61 ANT VESICOURETHROPEXY; SIMPLE 51840 $ 1,433.37 ANT. STROMAL PUNCT 65600 $ 4,790.26 ANTEGRA SACRAL 41MM PLATE C1713 $ 8,662.50 ANTERIOR CHAMBER CANNULA 23G A4615 $ 27.00 ANTERIOR COMPOSITE RESIN - 3 SURFACE D2332 $ 224.00 ANTERIOR COMPOSITE RESIN - 4 SURFACE D2335 $ 280.00 ANTERIOR COMPOSITE RESIN - 1 SURFACE D2330 $ 175.00 ANTERIOR COMPOSITE RESIN - 2 SURFACES D2331 $ 189.00 ANTHRAX VACCINE,SUBCUT CLINIC 90581 $ 99.99 ANTI ENA (SM+RNP) 86235 $ 48.71 ANTI ENDOMYSIAL AB 86256 $ 32.74 ANTI GLIADIN AB 86256 $ 32.74 ANTI HYALURONIDASE 83519 $ 40.48 ANTI ISLET CELL AB 86341 $ 53.75 ANTI JO-1 AB 86235 $ 48.71 ANTI PLATELET AB 86022 $ 49.90 ANTI RNP 86235 $ 48.71 ANTI SCL-70 AB 80299 $ 41.01 ANTI SM-MUSCLE AB 86256 $ 32.74 ANTI STRIATIONAL MUSCLE 86256 $ 32.74 ANTI TPO 86376 $ 39.51 ANTI-ADREANL AB 86256 $ 32.74 ANTIB HTLV HIV ANTIB CNFRM TEST 86689 $ 52.58 ANTIB; HTLV I 86687 $ 22.79 ANTIB; HTLV/HIV ANTIB CONFIRM TEST 86689 $ 52.58 ANTIB; HTLV-II 86688 $ 38.04 ANTIB; TOXOPLASMA IGM 86778 $ 39.12 BLD LEVEL 80299 $ 41.01 Antiboby TETANUS 86774 $ 40.19 ANTIBODY ABSORPTION 86978 $ 84.11 ANTIBODY ID COLD 86970 $ 84.11 ANTIBODY ID ENZYME 86971 $ 569.71 ANTIBODY ID ROUTINE 86870 $ 569.71 ANTIBODY ID WARM 86970 $ 84.11 ANTIBODY IDENTIFICATION PANEL Acquisition cost ANTIBODY ID-SPECIAL METHOD 86970 $ 84.11 Page 26 2018 Antibody Inhibition- 86977 $ 341.62 ANTI-CARDIOLIPIN 86147 $ 69.12 ANTI-DNA AB 86225 $ 37.33 ANTIDNASE B TITER 86215 $ 35.97 ANTIGEN SCREEN CHG 86902 $ 569.71 ANTIGEN THERAPY SERVICES 5 VENOMS 95149 $ 153.91 ANTIGENS;WH BODY EXTRBITING IN 95170 $ 97.92 ANTIGENS-ALLERGEN IMMUN;SGL/MUL 95165 $ 97.92 ANTIGENTYPING-UNIT 86902 $ 569.71 ANTIGLOMERULAR BASEMNT MEMBRANE ANTIBODY 83520 $ 37.99 ANTI-HISTONE AB 86235 $ 48.71 ANTI-LA TEST (SSB) 86235 $ 48.71 ANTI-LIVER/KIDNEY AB 86376 $ 39.51 ANTI-MITO AB 86256 $ 32.74 ANTI-MYOCARDIAL ANTIBODY 86255 $ 32.74 ANTI-NEUTROPHIL AB 86021 $ 40.90 ANTIPARIETAL CELL ABS 83516 $ 31.33 ANTI-PHOSPHATIDYLSERINE AB 86148 $ 43.65 ANTIPYRINE/BZOCAIN/GLY EAR DROP Acquisition cost ANTI-RIBONUCLEOPROTEIN ANTIBODY $ 11.00 ANTI-RO TEST (SSB) 86235 $ 48.71 ANTI-SPERM AB IGA 89325 $ 29.00 ANTI-SPERM AB IGG 89325 $ 29.00 ANTI-SPERM AB IGM 89325 $ 29.00 ANTITHROMBIN 111 ACTIVITY 85300 $ 32.19 ANTI-THROMBIN III ANTIGEN 85301 $ 29.37 ANTITHROMBIN III(HUMAN),PER IU J7197 $ 10.25 ANTI-THYROGLOBULIN 86800 $ 43.21 ANTITHYROGLOBULIN AB 86800 $ 43.21 ANUSOL 1% OINTMENT Acquisition cost ANUSOL HC 2.5% Acquisition cost AORTA IVC DUPLEX US 93979 $ 302.70 AORTA IVC DUPX US 93979 $ 302.70 AORTOGRAM, ABDOMINAL 75625 $ 6,592.23 AORTOGRAM, THORACIC 75605 $ 11,279.00 AORTOGRAPHY ABD+BIL ILIOFEM-S / I 75630 $ 6,592.23 AORTOGRPHY THORACIC WO SERIALOG-S/I 75600 $ 6,592.23 AP ALLERGAN IMPLANT LAP BAND SMALL L8699 $ 4,960.50 AP IMPLANT LAP BAND LARGE ALLERGAN L8699 $ 4,960.50 APAP/CODEINE#2 300-15MG TAB Acquisition cost APC RESISTANCE 85307 $ 41.62 Apexification/recalcif, final D3353 $ 315.00 Apexification/recalcif, initial D3351 $ 280.00 Apexification/recalcif, interim D3352 $ 98.00 Apically positioned flap D4245 $ 420.00 APICOECTOMY - ANTERIOR D3410 $ 420.00 APICOECTOMY-BICUSPID, FIRST ROOT D3421 $ 420.00 APICOECTOMY-MOLAR, FIRST ROOT D3425 $ 525.00 APIXABAN 2.5MG TAB Acquisition cost APIXABAN 5MG TABLETS Acquisition cost APLIGRAF SOFT WOUNT HEALING THERAPY Q4101 $ 2,461.50 APOGEE W/INTEXN; PORCINE CLLGN MTRX CAPE C1763 $ 3,580.50 APOLIPOPROTEIN A-1 82172 $ 46.40 APOLIPOPROTEIN B 82172 $ 46.40 APOLIPOPROTEIN E 82172 $ 46.40 APOLIPOPROTEIN EACH 82172 $ 46.40 Page 27 2018 APP CHILD F/N/H/F/G SKN SUB GFT 15277 $ 4,147.84 APP F/N/H/F/G SKN SUB GFT 15275 $ 4,147.84 APPL LONG LEG SPLINT 29505 $ 358.14 APPL SHORT LEG SPLINT 29515 $ 358.14 APPL SKIN GFT SUB; T/A/L ADD ON 15272 $ 38.28 APPL SURFACE NEUROSIMULATOR 64550 $ 38.81 APPL TRNSCUTANEOUS NEUROSIMULATOR 64550 $ 38.81 APPLIANCE REMOVAL INC REMOVAL OF ARCHBAR D7997 $ 377.00 APPLIC CLUBFOOT CAST W/MOLD/MANIP 29450 $ 358.14 APPLIC CYLIND CAST 29365 $ 627.51 APPLIC CYLINDER CAST 29365 $ 627.51 APPLIC FINGER SPLINT; STATIC 29130 $ 147.99 APPLIC LONG LEG CAST 29345 $ 627.51 APPLIC LONG LEG CAST BRACE 29358 $ 627.51 APPLIC LONG LEG SPLINT 29505 $ 358.14 APPLIC MODAL 1/> AREA; VASPNEU DVC 97016 $ 34.30 APPLIC MODAL 1/> AREAS; ELEC STIM 97032 $ 33.81 APPLIC MODAL 1/> AREAS; ELEC STIM-UNATND 97014 $ 32.03 APPLIC MODAL 1/> AREAS; HOT/CO 97010 $ 126.01 APPLIC MODAL 1/> AREAS; HUBBRD TANK 97036 $ 76.82 APPLIC MODAL 1/> AREAS; IONTOPHORES 97033 $ 45.14 APPLIC MODAL 1/> AREAS; PARAFFIN BATH 97018 $ 18.77 APPLIC MODAL 1/> AREAS; TRACTION-MECH 97012 $ 32.32 APPLIC MODAL 1/> AREAS; ULTRASOUND 97035 $ 29.15 APPLIC MODAL 1/> AREAS; WHIRLPOOL 97022 $ 41.03 APPLIC MODAL 1/>AREAS;HOT/COLD 97010 $ 126.01 APPLIC SHORT LEG CAST 29405 $ 627.51 APPLIC SHORT LEG CAST; WALKING/AMB TYPE 29425 $ 627.51 APPLIC SHORT LEG SPLINT 29515 $ 358.14 APPLIC; ELBOW TO FINGER 29075 $ 627.51 APPLIC; ELBOW TO FNGER 29075 $ 627.51 APPLIC; HAND / LOWER FOREARM 29085 $ 358.14 APPLIC; PLASTER VELPEAU 29058 $ 627.51 APPLIC; SHLDER SPICA 29055 $ 627.51 APPLIC; SHLDER TO HAND 29065 $ 627.51 APPLIC; SHOULDER SPICA 29055 $ 627.51 APPLIC; SHOULDER TO HAND 29065 $ 627.51 APPLICATION OF MODALITIES HTCL 97010 $ 126.01 APPLICATION SHORT LEG CAST WALKING 29425 $ 627.51 APPLIER CLIP-CATEG 1 Acquisition cost APPLIER CLIP-CATEG 2 Acquisition cost APPLIER CLIP-CATEG 3 Acquisition cost APPLIER MULTICLIP-CATEG 1 Acquisition cost APPLY BONE FIX DEV; 1< PLANE 20692 $ 26,770.83 APPLY BONE FIX DEVICE, 1 PLANE 20690 $ 14,826.61 APPLY BONE FIX DEVICE; 1 PLANE 20690 $ 14,826.61 APPLY CAST ELBOW TO FINGER 29075 $ 627.51 APPLY CAST- GAUNTLET 29085 $ 358.14 APPLY CHLD F/N/H/F/G SKN SUB GFT ADD 15278 $ 123.99 APPLY CLUBFT CAST W MLD/MANIP; LNG/SHRT 29450 $ 358.14 APPLY F/N/H/F/G SKN SUB GFT ADD-ON 15276 $ 55.22 APPLY FING SPLINT-STATIC 29130 $ 147.99 APPLY FINGER CAST 29086 $ 358.14 APPLY FINGER SPLINT DYNAMIC 29131 $ 147.99 APPLY FINGER SPLINT; STATIC 29130 $ 147.99 APPLY GAUNTLET CAST 29085 $ 358.14 Page 28 2018 APPLY INTERDENTAL FIX DEVICE 21110 $ 3,010.00 APPLY INTERDENTAL FIXATION DEVICE 21110 $ 3,010.00 APPLY LONG ARM CAST 29065 $ 627.51 APPLY LONG ARM SPLINT 29105 $ 358.14 APPLY LONG LEG CAST 29345 $ 627.51 APPLY LONG-ARM CAST 29065 $ 627.51 APPLY LONG-ARM SPLINT 29105 $ 358.14 APPLY MULTILAY COMPRSSION SYS; LWR LEG 29581 $ 358.14 APPLY MULTILAYER COMPRS SYST; LWR LEG 29581 $ 358.14 APPLY RIGID TOTAL CONTACT LEG CAST 29445 $ 627.51 APPLY SHORT ARM CAST 29075 $ 627.51 APPLY SHORT ARM SPLINT 29125 $ 277.79 APPLY SHORT ARM SPLINT; DYNAMIC 29126 $ 277.79 APPLY SHORT ARM SPLINT; STATIC 29125 $ 277.79 APPLY SHORT LEG CAST 29405 $ 627.51 APPLY SHORT LEG SPLINT 29515 $ 358.14 APPLY SHRT ARM SPLINT; DYNAMIC 29126 $ 277.79 APPLY SHRT ARM SPLINT; STATIC 29125 $ 277.79 APPLY SHRT ARM SPLNT - DYNAMIC 29126 $ 277.79 APPLY SKIN GFT SUB; T/A/L 15271 $ 4,147.84 APPLY SPLING SHORT LEG 29515 $ 358.14 APPLY SPLINT LONG LEG 29505 $ 358.14 APPLY SPLINT SHLDR TO HAND 29105 $ 358.14 APPLY SPLINT; THIGH TO ANKLE/TOES 29505 $ 358.14 APPLY STATIC FINGER SPLINT 29130 $ 147.99 APPLY-GAUNTLET CAST 29085 $ 358.14 APPROACH CTO WIRE GUIDE 300CM C1713 $ 229.50 APPROACH CTO WIREGUIDE 190CM C1713 $ 229.50 APRACLONIDINE HCL 1% $ 190.89 APREPITANT 125MG CAP Acquisition cost APREPITANT 80MG CAP Acquisition cost APRIPIPRAZOLE 5MG/5ML ORAL Acquisition cost APTT 85730 $ 16.32 AQUANOT RNDDISC FLOOR SUCT DEV A4624 $ 296.96 AQUATIC THERAPEUTIC EXERCISE, EA 15 MIN. 97113 $ 84.85 AQUEOUS SHUNT EYE W/O GRAFT 66179 $ 9,548.90 AQUEOUS SHUNT-EXTRAOCULAR RESE 66180 $ 9,548.90 AR GUIDE C1769 $ 3,505.50 ARANESP 1MCG INJECT (NON ESRD) J0881 $ 20.43 ARANESP 40 MCG. Acquisition cost ARDUAN 10MG VIAL 10ML Acquisition cost AREDIA 30MG VIAL IV J2430 Acquisition cost AREDIA 60MG VIAL IV J2430 Acquisition cost AREDIA 90MG VIAL IV J2430 Acquisition cost ARENA L 11MM IMPLANT C1713 $ 4,650.00 ARGATROBAN 100MG/ML 2.5 ML VIAL Acquisition cost ARGATROBAN 125MG/125ML NORMAL SALINE Acquisition cost ARGATROBAN 250/2.5 MG PO Acquisition cost ARGATROBAN 250/2.5 MG. PO Acquisition cost ARGATROBAN 50MG/50mL INJ Acquisition cost ARGYLE SALEM SUMP TUBE 6FR PED A4624 $ 73.50 ARGYLE TROCAR CATHETER10FR C1887 $ 295.95 ARICEPT 5MG UD TAB Acquisition cost ARIPIPRAZOLE 10 MG (ABILIFY) TAB PO Acquisition cost ARIPIPRAZOLE 15MG (ABILIFY) TAB PO Acquisition cost ARIPIPRAZOLE 20MG (ABILIFY) TAB PO Acquisition cost Page 29 2018 ARIPIPRAZOLE 20MG TABLET J8499 Acquisition cost ARIPIPRAZOLE 2MG TABLET Acquisition cost ARIPIPRAZOLE 5MG (ABILIFY) TAB PO Acquisition cost ARIPIPRAZOLE MAINTENA 400MG INJ J0401 Acquisition cost ARIPIPRAZOLE30MG (ABILIFY) TAB PO Acquisition cost ARISTOCORT/KENALOG 0.5% 15GM Acquisition cost ARMADA 14 PTA DILAT CATH C1725 $ 637.50 ARMADA 35 PTA DILAT CATH C1725 $ 300.00 ARMADA BDC LL PTA DILAT CATH C1725 $ 412.50 ARMADA PTA DILATATION CATHETER C1725 $ 487.50 ARMSTRONG VENT TUBE W/WIRE A4624 $ 44.10 ARPIPRAZOE 0.75 MG/1.3 ML INJ. Acquisition cost ARSENIC (BLOOD) 82175 $ 51.52 ARSENIC (URINE) 82175 $ 51.52 ART CATH PROLONG INFUS TX CUTDN 36640 $ 6,592.23 ART CATH-SAMPL-SEP PROC; PERQ 36620 $ 97.26 ART EMBOLECTOMY CATH 5FR/80CM C1757 $ 39.00 ART INSEM/INTRA UTER 58322 $ 424.97 ART OCCLUSIVE DEVICE PLCMT G0269 $ 267.30 ART PRESSURE WAVEFORM ANALYS 93050 $ 84.11 ART PUNCT WITHDRAWAL BLD DX 36600 $ 277.79 ART SURF; STRIPED YLW - 10MM H C1776 $ 6,155.58 ARTERIAL BLOOD GAS 36600 $ 277.79 ARTERIAL BLOOD GAS. 94690 $ 84.11 ARTERIAL PUNCTURE 36600 $ 277.79 ARTERIOGRAM BILATERAL EXTREMITY 75716 $ 6,592.23 ARTERIOGRAM UNILATERAL EXTREMITY 75710 $ 6,592.23 ARTERIOGRAM VISCERAL 75726 $ 11,279.00 ARTERIOVENOUS DIALYSIS SHUNT 75791 $ 1,789.85 ARTESUNATE Acquisition cost ARTHOCARE 2.8MM Q-FIX SUTURE C1713 $ 919.50 ARTHODESIS; TRIPLE 28715 $ 26,770.83 ARTHRCNTSIS ASPIR INJ SM JNT 20600 $ 647.13 ARTHREX 2.9MM DISP KIT PUSHLCK C1713 $ 262.50 ARTHREX NEEDLE #2 FIBER LOOP C1713 $ 75.00 ARTHREX PERCUT INSERT PUSHLOCK C1713 $ 330.00 ARTHRO GHJ HEMIARTHOPLASTY 23470 $ 26,770.83 ARTHRO GT IP JNT W EHL TRANSFER 28760 $ 14,826.61 ARTHRO KNEE W IMPL AUTOGRFT 29866 $ 14,826.61 ARTHRO POST CRUCIATE LIG REP/AUG/RECON 29889 $ 26,770.83 ARTHRO WRIST; W RLS TRNSV CARP LIG 29848 $ 3,570.03 ARTHROCEN ASPIR//INJ; INTERMED JNT 20605 $ 647.13 ARTHROCENTESIS D7870 $ 344.00 ARTHROCENTESIS ASPIR//INJ; SM JNT 20600 $ 647.13 ARTHROCENTESIS/ASPIR/INJ; MAJOR JT/BURSA 20610 $ 647.13 ARTHROD IP JNT W AUTOGFT 26862 $ 6,995.52 ARTHROD IP JOINT W/WO FIXATION 26860 $ 6,995.52 ARTHROD IP JOINT; EA ADDTL IP JNT 26861 $ 222.40 ARTHROD MCP JNT W AUTOGFT 26852 $ 14,826.61 ARTHROD MCP JNT; W/WO INT FIX 26850 $ 14,826.61 ARTHROD MT/TMT; W OSTEOTOMY 28735 $ 26,770.83 ARTHRODESIS GREAT TOE; MTP JOINT 28750 $ 14,826.61 ARTHRODESIS MT OR TME; SINGLE JOINT 28740 $ 14,826.61 ARTHRODESIS W TNDN LENGTH, MIDTRSL 28737 $ 26,770.83 ARTHRODESIS, WRST; LMTD WO BN GRFT 25820 $ 14,826.61 ARTHRODSIS; MT/TNT, MULTI/TRANSV 28730 $ 26,770.83 Page 30 2018 ARTHROPL GHJ TOT SHLDR REPL 23472 $ 3,844.62 Arthroplasty D7865 $ 10,434.00 ARTHROPLASTY ANKLE 27700 $ 14,826.61 ARTHROPLASTY MCP JOINT; EA JOINT 26530 $ 6,995.52 ARTHROPLASTY PATELLA; W PROSTH C1713 Acquisition cost ARTHROPLASTY PATELLA; W PROSTH 27438 $ 26,770.83 ARTHROSC KNEE; DRILL FOR OD LES 29886 $ 6,995.52 ARTHROSC KNEE; DRILL OD LES W INT FIX 29887 $ 14,826.61 ARTHROSC KNEE; EXC OSCHON DEFECT 29891 $ 6,995.52 ARTHROSC KNEE; FOR INF/LAVAGE/DRAIN 29871 $ 6,995.52 ARTHROSC KNEE; W MEN REP MED/LAT 29882 $ 6,995.52 ARTHROSC; SHLDR; W LYSIS OF ADH 29825 $ 6,995.52 ARTHROSCOP ANKLE; PART SYNOVECTOMY 29895 $ 6,995.52 ARTHROSCOP KNEE; W MEN REP MED&LAT 29883 $ 6,995.52 ARTHROSCOP YANKLE; EXT DEBRIDEM 29898 $ 6,995.52 ARTHROSCOPY ANKLE; SMPL DEBRID 29897 $ 6,995.52 ARTHROSCOPY ANKLE; W REM FB 29894 $ 6,995.52 ARTHROSCOPY KNEE; W FEM FB/LB 29874 $ 6,995.52 ARTHROSCOPY SHLDR; W REM FB/LB 29819 $ 6,995.52 ARTHROSCOPY WRIST; EXC/REP CARTILAGE 29846 $ 6,995.52 ARTHROSCOPY/SURGERY; KNEE 29881 $ 6,995.52 ARTHROSCOPY; BICEPS TENDOESIS 29828 $ 14,826.61 Arthroscopy-diag, w/ w/o biopsy D7872 $ 3,681.00 Arthroscopy-surgic: debridement D7877 $ 6,626.00 Arthroscopy-surgic: synovectomy D7875 $ 6,964.00 Arthroscopy-surgical: adhesions D7873 $ 4,432.00 Arthroscopy-surgical: disc rep D7874 $ 6,357.00 Arthroscopy-surgical:discectomy D7876 $ 7,508.00 ARTHROSCPY ELBOW; DEBRID LIMITED 29837 $ 6,995.52 ARTHROSCPY KNEE; LIM SYNOVECTOMY 29875 $ 6,995.52 ARTHROSCPY SHLDR; DEBRID EXTENS 29823 $ 6,995.52 ARTHROSCPY SHOULDER; SYNOVEC PARTL 29820 $ 14,826.61 ARTHROSIS ANKLE/FOOT-CATEG 1 Acquisition cost ARTHROT KNEE W MENISC; MED & LAT 27333 $ 6,995.52 ARTHROT KNEE W MENISC;MED OR LAT 27332 $ 6,995.52 ARTHROT KNEE; JNT EXPL/BX/REM FB 27331 $ 6,995.52 ARTHROTOMY ANKLE W SYNOVECTOMY 27625 $ 6,995.52 ARTHROTOMY OPEN TMJ SURGERY D7860 $ 6,475.00 ARTHROTOMY W BIOPSY; HIP JNT 27052 $ 3,570.03 ARTHROTOMY W SYNOVCTMY; KNEE, ANT/POST 27334 $ 6,995.52 ARTHRPLSTY KNEE, C&P; MED.LAT 27446 $ 26,770.83 ARTHRPLSTY, IP JOINT; W PROSTH IMP, EA 26536 $ 14,826.61 ARTHRSCPY SHLDR; DEBRID LIMITED 29822 $ 6,995.52 ARTHRSCPY SHLDR; SYNOVEC COMPL 29821 $ 6,995.52 ARTHSCPY AIDED ACL REPR/AUG/RE 29888 $ 14,826.61 ARTICULAR HIP BALL 28MM+5 Acquisition cost ARTICULAR SURFACE Acquisition cost ARTICULAR SURFACE SIZE; C1776 $ 2,434.50 ARTICULAR SURFACE SZ. 12MM Acquisition cost ARTICULAR SURFACE SZ-YWL/C.D 12MM Acquisition cost ARTICULATING PIN CLAMP C1713 $ 697.50 ARTIFICIAL ANTERIOR CHAMBER C1780 $ 168.00 ARTIFICIAL INSEMINATION 58322 $ 424.97 ARTIFICIAL INSEMINATION; INTRA-CERV 58321 $ 709.68 ARTIFICIAL LARYNX ANY TYPE L8500 $ 225.00 ARTIFICIAL TEARS $ 3.04 Page 31 2018 ASAHI ASTATO 300CM PERI GWIRE C1713 $ 1,350.00 ASAHI MIRACLEBROS 3 GW C1769 $ 213.00 ASCLERA (POLIDOCANOL ) 1 % AMPULES Acquisition cost ASCLERA (POLIDOCANOL) 0.5% AMPULES Acquisition cost ASCORBIC ACID (VIT C) 82180 $ 26.84 ASCORBIC ACID INJ 500MG/ML $ 0.10 ASENAPINE 5MG TAB Acquisition cost ASIALO GM1 IGG 83520 $ 37.99 ASIALO GM1 IGM 83520 $ 37.99 ASLO 86060 $ 19.82 ASNISIII 4MM THREAD GUIDEWIRE C1713 $ 178.87 ASP BY PATHOLOGIST 10021 $ 821.94 ASP INTERMED JT/BURSA 20605 $ 647.13 ASPARAGINASE 10,000 UNIT INJ J9020 Acquisition cost ASPARAGINASE, 10,000 UNITS J9020 $ 133.00 ASPERGILLUS IMM DIF 86606 $ 40.90 ASPERGILLUS ANTIBODY IGG + IGM 86606 $ 40.90 ASPERGILLUS ANTIBODY IGG CONVALEST TITER 86606 $ 40.90 ASPERGILLUS ANTIBODY IGM ACUTE TITER 86606 $ 40.90 ASPIR HYDROCELE 55000 $ 1,514.94 ASPIR/INJ; THYROID CYST 60300 $ 1,514.94 ASPIRAT &/OR INJ THYROID CYST 60300 $ 1,514.94 ASPIRAT BLADDER BY NEEDLE 51100 $ 1,495.78 ASPIRAT BLADDER; BY TROCAR/INTRACATHETER 51101 $ 2,387.99 ASPIRAT BLADDER; W/INSRT SUPRAPUBIC CATH 51102 $ 4,484.35 ASPIRAT BLDR; W/INS SUPRAPUBIC 51102 $ 4,484.35 ASPIRAT VITREOUS/SUBRETINAL FL 67015 $ 5,080.46 ASPIRAT//INJ RENAL CYST/PELV-NEEDLE 50390 $ 1,514.94 ASPIRATE FOR O/P 87177 $ 24.18 ASPIRATE PLEURA; W IMAGING GUIDE 32555 $ 1,619.99 ASPIRATE PLEURA; W/ IMAGING GUIDE 32555 $ 1,619.99 ASPIRATE PLEURA; W/O IMAGE 32554 $ 1,619.99 ASPIRATE PLEURA; WO IMAGE 32554 $ 1,619.99 ASPIRATE/INJ GANGLION CYST 20612 $ 647.13 ASPIRATING LASER PROBE STRGHT C2618 $ 1,890.00 ASPIRATION-ASSISTED 88172 $ 341.62 ASPIRIN 300MG SUPP Acquisition cost ASPIRIN 325MG TAB Acquisition cost ASPIRIN 325MG TABLET U-D Acquisition cost ASPIRIN 81MG CHEWABLE TAB $ 0.09 ASPIRIN CHEWABLE 81MG TAB Acquisition cost ASPIRIN DESENSITIZATION Acquisition cost ASPIRIN EC 81MG TABLET Acquisition cost ASPIRIN ENTERIC COATED 81MG TAB $ 0.05 ASPIRIN/DIPYRIDAMOL 25-200 MG. Acquisition cost ASPI-UNASSISTED 88173 $ 118.21 ASP-MAJOR JT/BURSA 20610 $ 647.13 ASPRATE/INJ GANGLION CYST 20612 $ 647.13 ASPRATE/INJECT GANGLION CYST 20612 $ 647.13 ASPRN 325MG TAB J8499 $ 0.39 ASP-SM JT/BURSA/GANGLION 20600 $ 647.13 ASSAY FOR CALPROTECTIN FECAL 83993 $ 53.33 ASSAY IGA/IGD/IGG/IGM EACH 82784 $ 25.26 ASSAY OF IGE 82785 $ 44.70 ASSAY OF SERUM ALBUMIN 82040 $ 13.44 ASSAY OF THIAMINE (VITAMIN B-1) 84425 $ 57.66 Page 32 2018 ASSESS APHASIA W/I/R PER HR 96105 $ 266.53 ASSESS HLTH/BEHAV, INIT 96150 $ 275.00 ASSESS HLTH/BEHAV, SUBSEQ 96151 $ 275.00 ASSURANT COBALT STENT C2625 $ 2,167.50 ASSURANT COBALT STENT 30CM LNG C1876 $ 2,092.50 AST, DISK METHOD 87184 $ 18.72 ASTHMA ED; 2-4 PATS, PER 30MIN 98961 $ 24.20 ASTHMA ED; 5-8 PATS, PER 30MIN 98962 $ 24.20 ASTHMA ED; INDIV PAT, PER 30MIN 98960 $ 44.00 ASYMM PATELLA TRIATHLON X3 C1776 $ 715.50 ASYMMETRIC PATELLA X3 11MMxA38 C1776 $ 715.50 ASYMMETRIC PATELLA X3 11MMxA40 C1776 $ 715.50 ASYMMETRIC PATELLA X3 TRIATH C1776 $ 715.50 ASYMMETRIC PATELLA X3 TRIATHION 9MMxA29 C1776 $ 715.50 ATARAX 50MG/ML INJ 1ML J3410 Acquisition cost ATAZANAVIR (REYATAZ) 300MG. Acquisition cost ATAZANAVIR 100MG (REYATAZ) CAP PO Acquisition cost ATAZANAVIR 150MG CAP Acquisition cost ATAZANAVIR 200MG (REYATAZ) CAP PO Acquisition cost ATAZANAVIR-COBICISTAT300-150MG(Evotaz) Acquisition cost ATENOLOL 100MG TAB J8499 $ 2.44 ATENOLOL 100MG. PO Acquisition cost ATENOLOL 25MG TAB PO Acquisition cost ATENOLOL 50MG TAB Acquisition cost ATENOLOL 50MG. PO Acquisition cost ATGAM INJECTION Acquisition cost ATHERECTOMY, ILIAC ARTERY 0238T $ 42,367.14 ATIVAN 0.5MG TABLET Acquisition cost ATOMOXETINE 10MG (STRATTERA) CAP Acquisition cost ATOMOXETINE 18MG (STRATTERA) CAP Acquisition cost ATOMOXETINE 25MG (STRATTERA) CAP Acquisition cost ATOMOXETINE 40MG (STRATTERA) CAP Acquisition cost ATOMOXETINE 60MG (STRATTERA) CAP Acquisition cost ATORPINE 1MG AMP. INJ. J0461 $ 0.97 ATOVAQUONE PO SUSP 750MG/5ML Acquisition cost ATOVAQUONE/PROGU (MALARONE)250/100 Acquisition cost ATOVAQUONE/PROGU (MALARONE)62.5/25 Acquisition cost ATR LEAD Acquisition cost ATRIAL LEAD M/N 1388/T52 Acquisition cost ATRIAL LEAD MODEL #1388T/52 Acquisition cost ATRIAL LEAD MODEL 1188T/52 Acquisition cost ATROPINE 0.1MG INJ./1ML 10ML ABBOJECT J0461 $ 2.42 ATROPINE 0.4MG INJ, 1ML VIAL J0461 $ 0.97 ATROPINE SULFATE 0.3 MG/ML 10ML J0461 Acquisition cost ATROPINE SULFATE 0.4MG/ML 1ML J0461 Acquisition cost ATROPINE SULFATE 0.4MG/ML SYRINGE Acquisition cost ATROPINE SULFATE 1% OPTH 15ML Acquisition cost ATROPINE SULFATE 1% OPTH 3.5GM Acquisition cost ATROPINE SULFATE 1%/5ML J0461 $ 56.10 ATROVENT INHALER 200 PUFF 14GM Acquisition cost ATROVENT NEBU SOL 0.02% 2.5ML J7644 Acquisition cost ATT F/M/C/G/H/F/N/A; D 10 SQ CM/> 14040 $ 4,147.84 ATTENTION CURRENT STATUS G9165 Acquisition cost ATTENTION DISCHARGE STATUS G9167 Acquisition cost ATTENTION GOAL STATUS G9166 Acquisition cost ATTENUATION PET W/ CT. LIMITED 78814 $ 3,642.17 Page 33 2018 AUDIOMETRY AIR AND BONE 92553 $ 360.51 AUDIOMETRY, AIR AND BONE 92553 $ 360.51 AUDITORY EVOKED POTENTIAL CMPRHNSV 92585 $ 658.04 AUDITORY EVOKED POTENTIAL, CMPRHNSV 92585 $ 658.04 AUDITORY EVOKED POTENTIAL, LIMITED 92586 $ 360.51 AUGMENTIN 125MG/5ML SUSP 75ML Acquisition cost AUGMENTIN 200MG/5ML SUSP 100ML Acquisition cost AUGMENTIN 250MG TAB Acquisition cost AUGMENTIN 250MG/5ML SUSP 75ML Acquisition cost AUGMENTIN 400MG/5ML SUSP 100ML Acquisition cost AUGMENTIN 500MG TAB Acquisition cost AUGMENTIN 875MG TAB Acquisition cost AUGMENTIN ES 600MG. Acquisition cost AUTO CRYO FIBRIN GLU 86890 $ 569.71 AUTOGENOUS HARVEST BONE GRAFT MAJOR 20902 $ 14,826.61 AUTOLOGOUS SURCHARGE 86890 $ 569.71 AUTOLOGOUSPROCESSFEE 86890 $ 569.71 AUTOMATED DIFFERENTIAL 85025 $ 21.10 AV - SHUNT 36821 $ 6,592.23 AVA10DK VARE ANGLE DK DRILL C1713 $ 4,579.80 AVANCE NERV GRFT 2-3 MMDIA30MM C1768 $ 3,637.50 AVANCE NERV GRFT 3-4MM DIA50MM C1768 $ 5,737.50 AVANCE NERVE GRAFT 3-4 MM DIA C1768 $ 5,437.50 AVANCE NERVE GRAFT 4-5 MM DIA C1768 $ 2,925.00 AVANCE NERVE GRAFT 4-5 MM DIA C1768 $ 7,237.50 AVANDIA 2 MG TAB Acquisition cost AVANDIA 8 MG TAB Acquisition cost AVEENO BATH TREATMENT Acquisition cost AVEENO SOAP Acquisition cost AVENTYL/PAMELOR 10MG/5ML Acquisition cost AVIATOR PLATE 26MM C1713 $ 1,712.35 AVIATOR PLATE 30MM C1713 $ 1,969.56 AVITENE FLOUR 1 GRAM 6/CS** C1760 $ 190.06 AVONEX 30MCG INJ Q3027 Acquisition cost AVUL NAIL PLAT PART/CMPL SMPL; 11730 $ 446.80 AVUL NAIL PLAT PART/CMPL SMPL; ONE 11730 $ 446.80 AVUL NAIL PLATE SMPL-1 11730 $ 446.80 AVUL PLAT PART/CMPL SMPL;EA ADD 11732 $ 39.03 AVULSION NAIL PLATE; PART/COMP; EA 11732 $ 39.03 AWV PPPS SUBSEQ VISIT; MCARE O G0439 $ 252.16 AX-BI RING GRAFT 8MM/70CM Acquisition cost AXILLARY FEM VASC GRAFT 8MMx70CM C1768 $ 3,180.00 AXILLARY LYMPHADENECTOMY; COMPLETE 38745 $ 11,870.65 AXILLARY LYMPHADENECTOMY; SUPERFICIAL 38740 $ 11,870.65 AXILLARY NERVE BLOCK 64417 $ 1,777.62 AXLE C1713 $ 1,816.80 AXLLRY NERVE BLOCK 64417 $ 1,777.62 AXOGUARD NERV PROT PERIPHERAL C1714 $ 2,587.50 AXOGUARD NERV PROTECT PERIPHER C1714 $ 3,075.00 AXOGUARD NERV PROTECTR PERIPH C1714 $ 3,075.00 AXT ARTIC BLCK W/REINFRCE 6BX C1713 $ 5,830.83 AYR NASAL DROP 50 ML Acquisition cost AZACTAM 2 GM INJECTION Acquisition cost AZACTAM 500 MG VIAL Acquisition cost AZATHIOPRINE,PARENTERAL,100 MG J7501 $ 660.00 AZATHIOPRINE-ORAL,TAB,50 MG J7500 $ 4.64 Page 34 2018 AZELASTINE 137MCG Acquisition cost AZITHROMYCIN 1G PACKET Q0144 Acquisition cost AZITHROMYCIN 1GRAM PACKET Q0144 $ 68.51 AZITHROMYCIN 250MG TAB Q0144 Acquisition cost AZITHROMYCIN 250-MG TAB Q0144 $ 68.51 AZITHROMYCIN 500MG INJ J0456 Acquisition cost AZITHROMYCIN 500MG. PO (FOR SCC ONLY) Q0144 Acquisition cost AZITHROMYCIN ADDVANTAGE BAG Acquisition cost AZITHROMYCIN ADDVANTAGE VIAL 500MG. J0456 Acquisition cost AZITHROMYCIN OPH.DROP (AZASITE) Acquisition cost AZMACORT 75MCG INHALER Acquisition cost AZMACORT INHALER 20GM J3301 Acquisition cost AZTREONAM 1GM IV Acquisition cost AZTREONAM 1GM. FOR INJECTION Acquisition cost AZTREONAM 2GM IV Acquisition cost B-2 MICROGLOBULIN 82232 $ 43.93 BABCOCK-CATEG 1 Acquisition cost BABY Acquisition cost BACID (FOR SCC ONLY) Acquisition cost BACID (LACTOBACILLUS) CAP Acquisition cost BACITRACIN 500 UNIT/1GM OPHTH. $ 0.53 BACITRACIN 50000U VIAL IV Acquisition cost BACITRACIN OPTH OINT 3.5GM Acquisition cost BACITRACIN ZINC OINT PACKET Acquisition cost BACITRACIN ZNC OINT. FOIL/PKT/GROSS/BOX $ 0.53 BACITRACIN/ Acquisition cost BACLOFEN (LIORISAL) INTRATHECAL KIT J0475 Acquisition cost BACLOFEN 20MG TAB Acquisition cost BACT CULT AER ISOL ADDL 87077 $ 21.93 BACT CULTURE - URINE; QUAN COUNT 87086 $ 21.91 BACTERIAL AG DETECT 86403 $ 27.68 BACTERIAL CULTURE - OTHR SOURCE 87070 $ 23.41 BACTERIOLOGY SENS 87184 $ 18.72 BACTISEAL CLEAR EVD CATH SET C1751 $ 1,140.00 BACTISEAL CLEAR W/BARIUM CATH C1751 $ 1,086.90 BACTISEAL PERITON DISTL CATH C1887 $ 759.00 BACTOCILL 2 GM J2700 Acquisition cost BACTRIM DS PO Acquisition cost BACTRIM/SEPTRA(200MG/40MG/5ML) Acquisition cost BACTROBAN 2% NASAL 15MG Acquisition cost BACTROBAN 2% OINTMENT 15MG Acquisition cost BAHA RENTAL DRILL KIT C1713 $ 1,650.00 BALL DISSECTOR VEIN STRP 240CC A4344 $ 540.75 BALL ELECTRODE 3MM 5/CS A4556 $ 138.00 BALL TIPPED GUIDE WIRE C1713 $ 106.53 BALLOON CATH 5.8FR, 75CM 7MMx4 C1725 $ 549.00 BALLOON CATHETER C1725 $ 406.50 BALLOON DILAT CATH 6MM SHRT DIALYSIS C1725 $ 400.50 BALLOON DILATION CATH C1725 $ 408.32 BALLOON DILATION CATH KIT 4CMx24FR C1726 $ 523.05 BALLOON, UDT-CATEG 1 Acquisition cost BANDAGE -CATEG 2 Acquisition cost BANDAGE PLASTER 2 A4580 $ 27.75 BANDAGE PLASTER 3 A4580 $ 27.75 BANDAGE PLASTER 4 A4580 $ 27.75 BANDAGE PLASTER 5 A4580 $ 27.75 Page 35 2018 BANDAGE PLASTER 6 A4580 $ 27.75 BANDAGE PLASTER-CATEG 1 Acquisition cost BANDAGE WEBRIL 2X4 $ 25.01 BANDAGE WEBRIL 3X4 $ 16.95 BANDAGE WEBRIL 4X4 $ 24.95 BANDAGE WEBRIL 6X4 $ 20.24 BANGAY OINTMENT Acquisition cost BAR TO BAR COUPLING C1713 $ 813.76 BARACLUDE 1 MG. PO Acquisition cost BARBITURATE SCREEN URINE 80307 $ 158.03 BARBITURATES 80307 $ 158.03 BARD BIOPSY INSTRUMNT 14GX10CM $ 900.00 BARD COLLAMEND IMPLANT 7"X9", C1781 $ 9,037.50 BARD COLLAMEND IMPLANT PATCH 6"X8", C1763 $ 5,787.00 BARD COLLAMEND PATCH IMPLANT 8"X10", C1763 $ 8,533.50 BARD COLLMEND IMPLANT 4"X6" C1763 $ 3,654.00 BARD COLLMEND IMPLANT 4"X6", C1763 $ 3,654.00 BARD COMPOSIX KUGEL 10X13CM C1781 Acquisition cost BARD COMPOSIX KUGEL 11X14CM C1781 Acquisition cost BARD COMPOSIX KUGEL 12X12CM C1781 Acquisition cost BARD COMPOSIX KUGEL 14X18CM C1781 Acquisition cost BARD COMPOSIX KUGEL 7""X9"" C1781 Acquisition cost BARD COMPOSIX KUGEL 8X10CM C1781 Acquisition cost BARD COMPOSIX L/P MESH 8"X10", 1/CS C1781 $ 2,394.00 BARD COMPOSIX MESH 6X8 C1781 Acquisition cost BARD COMPOSIX MESH 8X10 C1781 Acquisition cost BARD DULEX 26X34CM C1781 Acquisition cost BARD IMPLANT MRI LOW PROFILE PORT 6.6F C1788 $ 451.92 BARD MESH FLAT SHEET 6 X 6" C1781 $ 253.12 BARD MESH FLAT SHEET 6 X 6" C1781 $ 253.13 BARD RECONIX 15CMX20CM RECT C1781 Acquisition cost BARD RECONIX 20CMX30CM RECT C1781 Acquisition cost BARD RECONIX 26CMX34CM OVAL C1781 Acquisition cost BARD RECONIX-CATEG 1 C1781 Acquisition cost BARD SOFT MESH C1781 $ 288.00 BARD URETEX SLING KIT C1771 $ 975.00 BARD VASCULAR IMPLANT SUPPLIES C1874 $ 195.00 BARDEX LUBCATH FOL CATH 14/5CC A4344 $ 5.07 BARDEX LUBRICATH FOLEY CATH A4340 $ 60.84 BARE METAL STENT C1876 $ 1,567.50 BARIUM 2.1% ADULT 750ML PO Acquisition cost BARIUM 2.1% PED 250ML PO Acquisition cost BARIUM R/O INTUSSUSCEPTION 74283 $ 668.38 BARIUM ENEMA WITH AIR 74280 $ 668.38 BARIUM ENEMA/KUB 74270 $ 668.38 BARIUM SULFATE (MAXIBAR) Acquisition cost Barium Sulfate (Digibar) Acquisition cost BARIUM SULFATE (ENTERO-H) 1900 ML Acquisition cost BARIUM SULFATE (E-Z PASTE CREAM) Acquisition cost Barium Sulfate 60% Cream Acquisition cost BARIUM SULFATE (E-Z DOSE) Acquisition cost BARIUM SWALLOW 74230 $ 302.70 BARREL BURR 2.9 6/BX C1713 $ 1,246.50 BARTONELLA HENSELEA IGG 86609 $ 34.98 BARTONELLA HENSELEA IGM 86609 $ 34.98 BARTONELLA QUINTANA IGG 86609 $ 34.98 Page 36 2018 BARTONELLA QUINTANA IGM 86609 $ 34.98 BASEPLATE Acquisition cost BASIC LIFE //OR DISABILITY EXAM 99450 Acquisition cost BASIC METABOLIC PANEL 80048 $ 22.97 BASIC METABOLIC PANEL W/CA 80048 $ 22.97 BASIC METABOLIC PANEL. 80048 $ 22.97 BASIC METABOLIC PANEL; IONIZED CA 80047 $ 30.21 BASIC PACK I $ 263.79 BASIC PACK II $ 460.38 BASIC RAD DOSIMETRY CALCULAT-BY MD 77300 $ 331.50 BASIC VESTIBULAR EVALUATION 92540 $ 360.51 BASKET SEGURA-CATEG 1 Acquisition cost BAYER STUDY #100039 CAPSULE Acquisition cost BAYER STUDY #100039 IV Acquisition cost BAYER STUDY #100039IV Acquisition cost B-CELL EVAL-FLOW CYTOMETRY $ 36.30 BCG LIVE (INTRAVESICAL),PER VI J9031 $ 414.65 BCG VACCINE, PERCUT 90585 $ 383.20 BCG VACCINE,INTRAVESICAL,BLADR CA CLINIC 90586 $ 383.20 BCG VACCINE,PERCUT,TB CLINIC 90585 $ 383.20 BCR/ABL GENE, QN, PCE W RFLPANEL Acquisition cost BD SPINAL QINCKE NEEDLE 22GX7 C2618 $ 544.98 BD VISITEC SINSKEY IOL MANIPUL V2630 $ 29.34 BE COLORECTAL CA SCREENING G0106 $ 668.38 BEADED CABLE/SLEEVE SET 2.0MM C1713 $ 574.35 BECLOVENT/VANCERIL PER MG Acquisition cost BECONASE/VANCENASE AQ Acquisition cost BEEPEN-VK 125MG/5ML SUSP 100ML Acquisition cost BEHAV CHANGE 3 TO 10 M 99406 $ 67.97 BEHAV CHNG SMOKING > 10 MIN 99407 $ 67.97 BEHAV CHNG SMOKING>10 MIN GROU 99407 $ 67.97 BEHAVRL/QUALIT ANALYS OF VOICE 92524 $ 191.31 BEKESY AUDIOMETRY, DIAGNOSIS 92561 $ 277.79 BEKESY AUDIOMETRY, SCREEN 92560 $ 118.00 BELIMUMAB 120MG VIAL J0490 Acquisition cost BELIMUMAB 400MG VIAL J0490 Acquisition cost BELIMUMAB INJECTION 10MG J0490 $ 112.32 BELLADONNA ALK/PHENOBARB 5ML ELIX Acquisition cost BELLADONNA ALKA/PHENOBAR Acquisition cost BELOTERO BALANCE 1ML INJ Acquisition cost BELOW KNEE CAST 29355 $ 627.51 BENADRYL 12.5MG/5ML ELIXER UD Acquisition cost BENADRYL 50MG/ML INJ 1ML J1200 Acquisition cost BENAMUSTINE 100 MG. INJ. (TREANDA) Acquisition cost BENAMUSTINE 25MG. INJ. (TREANDA) Acquisition cost BENAZEPRIL 40MG TAB Acquisition cost BENCE JONES PROTEIN URINE 86335 $ 79.71 BENDAMUSTINE 100mg INJ J9033 Acquisition cost BENDAMUSTINE INJ 1 MG J9033 $ 78.45 BENEFIBER Acquisition cost BENEFIBER 1 GM Acquisition cost BENEMID 500MG TAB Acquisition cost BENZAGEL 5% GEL Acquisition cost BENZAMYCIN GEL 23.30GM Acquisition cost BENZOCA/LANOL/ALO SPRAY Acquisition cost BENZOCAINE (HURRICANE) 20% $ 20.39 Page 37 2018 BENZOCAINE GEL (TOPICALE) 3/PAK $ 20.39 BENZODIAZEPINES 80346 $ 11.00 BENZOIN COMPOUND TINCT 60ML Acquisition cost BENZOIN OF SWABSTICKS 50/BX $ 11.79 BENZONATATE 100MG CAP Acquisition cost BENZOYL PEROXIDE 10% GEL42.5GM Acquisition cost BENZOYL PEROXIDE 3% CLEANSER 6 OZ. Acquisition cost BENZOYL PEROXIDE 5% GEL 42.5GM Acquisition cost BENZOYL PEROXIDE 5% GEL 45ML Acquisition cost BENZTROPINE 1MG/ML INJ 2ML J0515 Acquisition cost BENZTROPINE MESYL 0.5MG TAB Acquisition cost BENZTROPINE MESYLATE Acquisition cost BENZTROPINE MESYLATE 1MG TAB Acquisition cost BENZTROPINE MESYLATE 2MG TAB Acquisition cost BERACTANT (SURVANTA) 4ML Acquisition cost BERENSTEIN CATHETER C1887 $ 135.00 BETA 2 GLYCOPROTEIN I AB EA 86146 $ 69.12 BETA-2-GLYCO-PROTEIN-1 LGG 86147 $ 69.12 BETADINE MEDICATED 30ML Acquisition cost BETAMETH DIPRO/PROP GLY 0.05% OINT Acquisition cost 0.1% CREAM 15GM Acquisition cost BETAMETHASONE 6MG/ML INJ. J0702 Acquisition cost BETAMETHASONE DIPROP 0.05% CR Acquisition cost BETAMETHASONE DIPROP 0.5% OINT Acquisition cost BETAMETHASONE DIPROP OINT .05% Acquisition cost BETHANECHOL 10MG TAB Acquisition cost BETHANECHOL 25MG TAB Acquisition cost BETHANECHOL 5MG TAB Acquisition cost BETHANECHOL 5MG.ML INJ 1ML J0520 Acquisition cost BETOPTIC 0.5% OPTH DROPS 5ML Acquisition cost BETOPTIC S 0.25% OPTH SUSP 5ML Acquisition cost BEVACIZUMAB 10MG/ML IV J9035 $ 205.26 BEVACIZUMAB 25MG/ML IV J9035 Acquisition cost BEVEL GROMMET TUBE FLUROPLASTC A4624 $ 1,765.50 BEVEZISUMIDE (AVASTIN) Acquisition cost BEXSERO 90620 $ 436.59 B-HEXOSAMINIDASE, EA ASSAY 83080 $ 45.83 B-HEXOSAMINIDASE, EA ASSAY 88189 $ 190.32 B-HYDROXYBUTYRIC ACID 82010 $ 22.20 BIAXIN 125MG/5ML 100ML SUSP Acquisition cost BIAXIN 250MG TAB Acquisition cost BIAXIN 250MG/5ML 100ML SUSP Acquisition cost BIAXIN 500MG TAB Acquisition cost BICALUTAMIDE 50MG TAB Acquisition cost BICILLIN CR 1.2MU TUBEX IM J0558 Acquisition cost BICILLIN CR 2.4 M UNITS J0558 $ 40.20 BICILLIN CR 2.4MU TUBEX IM 4ML Acquisition cost BICILLIN CR 600,000U TUBEX IM J0558 Acquisition cost BICILLIN LA 100000 IM TUBEX 2ML J0561 Acquisition cost BICILLIN LA 2.4MU TUBEX IM 4ML J0561 Acquisition cost BICILLIN LA 600,000U TUBEX 1ML J0558 Acquisition cost BICILLLIN LA 600,000 UNITS/1ML J0561 $ 39.97 BIKTARVY $ 0.10 BILATERAL PULMONARY ANGIO 75743 $ 6,592.23 BILE ACIDS 82239 $ 46.51 BILE BAG $ 9.70 Page 38 2018 BILE STOOL 82252 $ 12.39 BILI DUCT STONE EXTRACT VIA T- 47544 $ 353.56 BILI ENDO VIA T-TBE; W/ STENT 47556 $ 11,870.65 BILI ENDO VIA T-TBE; WO STENT 47555 $ 7,698.79 BILIARY BALLOON 4X4" C1726 $ 427.50 BILIARY BALLOON 6X4" C1726 $ 427.50 BILIARY BALLOON 6X4" C1726 $ 427.50 BILIARY BIOPSY (ENDOSCOPY CODE 47553 $ 7,698.79 BILIARY ENDO;PRECU VIA T-TUBE; 47552 $ 7,698.79 BILIARY ENDOSCOPY WITH REMOVAL 47554 $ 11,870.65 BILIARY STENT NHS/8-23/7/75 Acquisition cost BILILRUBIN TOTAL, BG 82247 $ 13.62 BILIRUBIN DIRECT 82248 $ 13.62 BILIRUBIN DIRECT BF 82248 $ 13.62 BILIRUBIN INDIRECT 82248 $ 13.62 BILIRUBIN TOTAL 82247 $ 13.62 BILIRUBIN TOTAL BF 82247 $ 13.62 BIMAN IRRIG CANN 21G OPEN TIP C1713 $ 79.95 BIMANUAL ASPIRATION CANNULA A4615 $ 135.90 BIMATOPROST 0.01% OPHTHALMIC DROPS Acquisition cost BIMATOPROST 0.03% OPH DROP Acquisition cost BIMETRIC FEMORAL STEM SIZE 15M Acquisition cost BIMETRIC FEMORAL STEM SIZE 9MM Acquisition cost BINDER ABDOM-CATEG 1 Acquisition cost BINDER ABDOM-CATEG 2 Acquisition cost BIO COMPOSITE 5.5 SWIVELOCK C1713 $ 705.00 BIO COMPOSITE 5.5 SWIVELOCK C1713 $ 705.00 BIO COMPOSITE INTERFSCREW C1713 $ 405.00 BIO COMPOSITE SCREW 9x23 C1713 $ 405.00 BIO INTERFERENCE SCREW 8x23" C1713 $ 405.00 BIO INTERFERENCE SCREW 9x23" C1713 $ 405.00 Bio mat, sft&osseous tiss regen D4265 $ 210.00 BIO MODULAR HUMERUS HEAD Acquisition cost BIO MODULAR SHOULDER 10 MX 115 Acquisition cost BIO SURE SCREW C1713 $ 492.00 BIO-A FIST PLUS9CM TUBES; 16MM DISK IMP C1781 $ 1,263.00 BIO-A FISTULA PLUG SIX 9CM TU C1781 $ 1,263.00 BIOCAPTOR 2.9MM W/1 ULTRABRAID C1713 $ 445.17 BIOCELLULOSE MASK Acquisition cost BIOCELLULOSE MSK $ 132.00 BIOCOMPOSITE PUCHLCK 2.9MM C1713 $ 600.00 BIOCOMPOSITE SWIVELCK C6.25MM C1713 $ 600.00 BIOCOMPRESSION SYSTEMS Acquisition cost BIODESIGN HERN GRFT SRGISIS 13x15 C1763 $ 6,838.50 BIODESIGN SURGISIS FISTULA RECTAL PLUG C1763 $ 1,612.50 BIOFASTIN ANCHOR C1713 $ 382.50 BIOFEEDBACK TRAIN-ANORECTAL W/EMG 90911 $ 347.69 BIOFEEDBACK TRAINING-ANY MODALITY 90901 $ 95.63 BIOFEEDBACK, ANY MODALITY 90901 $ 93.26 BIOLOX CERAM FEM HD SYS TAPER C1776 $ 3,462.78 BIOMODULAR HEAD Acquisition cost BIOMODULAR HUMERAL STEM Acquisition cost BIOP OF PENIS (SEP PROC) 54100 $ 3,564.97 BIOP, NAIL UNIT, ANY METHOD 11755 $ 1,514.94 BIOPRAPTOR KNOTLSS SUTRE ANCHR C1713 $ 598.50 BIOPST, INTRANASAL 30100 $ 3,010.00 Page 39 2018 BIOPSY - CORNEA 65410 $ 4,790.26 BIOPSY (1) GROSS / MICRO 88304 $ 118.21 BIOPSY (2) GROSS / MICRO 88305 $ 118.21 BIOPSY (3) GROSS / MICRO 88307 $ 569.71 BIOPSY (4+) GROSS & MICRO 88309 $ 1,430.62 BIOPSY EAR 69100 $ 1,216.16 BIOPSY EXTERNAL AUDITORY CANAL 69105 $ 3,010.00 BIOPSY EXTERNAL EAR 69100 $ 1,216.16 BIOPSY FOR O+P 87210 $ 12.80 BIOPSY LIP 40490 $ 472.05 BIOPSY MUSCLE DEEP 20205 $ 6,148.30 BIOPSY MUSCLE SUPERFIC 20200 $ 3,564.97 BIOPSY NERVE 64795 $ 4,259.09 BIOPSY OF LIP 40490 $ 472.05 BIOPSY OF CONJUNCTIVA 68100 $ 4,790.26 BIOPSY OF EYELID 67810 $ 707.85 BIOPSY OF FLOOR OF MOUTH 41108 $ 3,564.97 BIOPSY OF PALATE, UVULA 42100 $ 3,010.00 BIOPSY OF PENIS (SEP PROC) 54100 $ 3,564.97 BIOPSY OF TISSUE/HARD D7285 $ 910.00 BIOPSY OF URETHRASTATE DILATIO 53200 $ 7,131.78 BIOPSY SOFT TISSUE SHOULDER, S 23065 $ 3,564.97 BIOPSY THYROID; PERCUTANEOUS NEEDLE 60100 $ 1,514.94 BIOPSY TONGUE;ANT 2/3 41100 $ 1,216.16 BIOPSY, DEEP CERVICAL LYMPH NO 38510 $ 7,213.98 BIOPSY, MOUTH, FLOOR 41108 $ 3,564.97 BIOPSY, NAIL UNIT, ANY METHOD 11755 $ 1,514.94 BIOPSY, PALATE, UVULA 42100 $ 3,010.00 BIOPSY, SOFT TISSUE NECK 21550 $ 3,564.97 BIOPSY, TONGUE POSTERIOR ONE-THIRD 41105 $ 5,815.59 BIOPSY, TONGUE; POST ONE-THIRD 41105 $ 5,815.59 BIOPSY, VESTIBLE, MOUTH 40808 $ 1,216.16 BIOPSY, VESTIBULE, MOUTH 40808 $ 1,216.16 BIORAPTOR KNOTLESS SUTRE ANCHR C1713 $ 631.58 BIORAPTR 2.3MM CURV ULTRABRAID C1713 $ 499.50 BIOSURE 10X25MM REGENSOR SCREW C1713 $ 492.00 BIOSURE HA 10X30MM INTER SCREW C1713 $ 409.31 BIOSURE HA 8X30MM INTERFE SCRW C1713 $ 396.90 BIOSURE HA INTEFERENCE SCREW C1713 $ 396.90 BIOSURE HA INTERFERENCE SCREW C1713 $ 396.90 BIOSURE SYNC 9MM X 10MM C1713 $ 331.50 BIOSURE-HA 10MM X 25MM C1713 $ 396.90 BIOSURE-HA 7MM X 20MM C1713 $ 492.00 BIOSURE-HA 7MM X 25MM C1713 $ 396.90 BIOSUREHA INTRFRNCE SCRW TAPER C1713 $ 396.90 BIOTENE ORAL RINSE 60ML Acquisition cost BIO-TISSUE 3.5X3.5CM Acquisition cost BIPAP 94660 $ 492.89 BIPOLAR 46MM Acquisition cost BIPOLAR ACETABULAR CUP C1776 Acquisition cost BIPOLAR CHIP SHELL 22MM C1776 $ 675.00 BIPOLAR CONVENE LINER 43-48 C1776 $ 199.80 BIPOLAR CUP 49MM C1776 $ 1,150.50 BIPOLAR CUP SHELL 28MM C1776 $ 43.04 BIPOLAR CUP SHELL 28MM C1776 $ 709.50 BIPOLAR CUP SHELL 43MM C1776 $ 675.00 Page 40 2018 BIPOLAR CUP SHELL 46MM C1776 $ 1,203.00 BIPOLAR CUP SHELL SZ 46MM C1776 $ 1,203.00 BIPOLAR CUP SIZE 46 C1776 Acquisition cost BIPOLAR FEMORAL CUP C1776 Acquisition cost BIPOLAR HEAD C1776 Acquisition cost BIPOLAR LINER 50MM TANDEM, 28 ID C1776 $ 577.50 BIPOLAR MODULAR HEAD 45MM C1776 Acquisition cost BIPOLAR SHELL 44MM C1776 $ 1,123.20 BIPOLAR SHELL 47MM C1776 $ 1,123.20 BIPOLAR SHELL 47MM C1776 $ 1,123.20 BI-POLAR SHELL 50MM/ C1776 Acquisition cost BIPOLAR SHELL LINEAR 47-51 C1776 $ 199.80 BIPOLAR SHELL LINEAR 47-51 C1776 $ 199.80 BIPOLAR SHELL SIZE 52MM C1776 Acquisition cost BIPOLAR SHELL SIZE 44MM C1776 $ 1,123.20 BIPOLAR STEM 45MM C1776 $ 1,123.20 BIPOLAR STEM 45MM C1776 $ 1,123.20 BIPOLAR/UNIVERSAL HEAD C1776 $ 1,050.00 BIPOLR SEALR DISP ELETRSRG DEV A4649 $ 769.50 BISACODYL 10MG SUPP Acquisition cost BISACODYL 5MG TAB Acquisition cost BISMUTH SUBSALICYLATE PO SUSP Acquisition cost BIT PERFORATOR LARGE 14/11MM^ C1713 $ 322.88 BIVALRUDIN PER 1MG J0583 $ 4.64 BIVONA CUFFED PEDS TRACH TUBE A4624 $ 268.62 BIVONA LARYNGECTOMY TUBE NS+ A7520 $ 151.53 BIVONA LARYNGECTOMY TUBE NS+ A7520 $ 151.53 BIVONA LARYNGECTOMY TUBE NS+ A7520 $ 151.53 BL DRAW <3 YRS SCALP VEIN 36405 $ 6.60 BLADDER INSTIL ANTI CAR AGENT 51720 $ 607.00 Bladder instillation of anticarcinogenic 51720 $ 607.00 BLADDER IRRIGATION 51700 $ 607.00 BLADDER IRRIGATION SIMPLE 51700 $ 607.00 BLADE RUNNER C1713 $ 249.50 BLAKE DRAIN 10 FR ROUND 1/8 C1729 $ 887.52 BLASTOMYCES IMM DIF 86612 $ 35.05 BLD BANK STUD-OTHER 86999 $ 46.20 BLD CT; HG / PLATELET CT AUTOMATED 85027 $ 17.56 BLD CT; HG AUTO / MANUL DIFF WBC CT $ 19.80 BLD CT; HG/PLATELET AUTO/PART WBC 85025 $ 21.10 BLD OCCLT PEROX ACTV; QUAL FECES 82270 $ 9.64 BLD SMEAR PERIPHRL INTRPT W/REPORT 85060 $ 54.65 BLD TYPE; RBC AG NOT ABO/RHD 86905 $ 569.71 BLEACHING PER ARCH D9972 $ 284.00 BLEACHING PER TOOTH D9973 $ 32.00 BLEEDING TIME 85002 $ 12.25 BLEEDINGTIME 85002 $ 12.25 BLEOMYCIN 15 UNIT INJ J9040 Acquisition cost BLEOMYCIN SULFATE, 15 UNITS J9040 $ 151.00 BLEPHAMIDE 0.2% OPTH DROPS 5ML Acquisition cost BLEPHAROPL LL; W EXT HERN FAT PAD 15821 $ 4,147.84 BLEPHAROPL UL; W EXCESS SKIN 15823 $ 4,147.84 BLEPHAROPLASTY LOWER EYELID 15820 $ 4,147.84 BLEPHAROPLASTY UPPER EYELID 15822 $ 4,147.84 BLEPHAROPLASTY; UPPR EYELID 15822 $ 4,147.84 BLEPHAROTOMY DRAIN ABSC EYELID 67700 $ 707.85 Page 41 2018 BLEPHAROTOMY, DRAIN ABSC; EYELID 67700 $ 707.85 BLEPHAROTOMY; DRAIN ABSC, EYELID 67700 $ 707.85 BLOOD Acquisition cost BLOOD (WHOLE) FOR TRANSFUSION PER UNIT P9010 $ 345.22 BLOOD COLLECTION 36415 $ 6.60 BLOOD CULTURE 87040 $ 28.03 BLOOD GAS 82803 $ 57.35 BLOOD GAS 82803 $ 57.35 BLOOD GAS ANAL CSICU 94690 $ 84.11 BLOOD GAS ANAL MSICU 94690 $ 84.11 BLOOD GAS ANAL OR 94690 $ 84.11 BLOOD GAS ANAL OTHER 94690 $ 84.11 BLOOD GAS ANAL PCU 94690 $ 84.11 BLOOD GAS ANAL PICU 94690 $ 84.11 BLOOD GAS ANAL RESPI 94690 $ 84.11 BLOOD GAS ANALYSIS. 94690 $ 84.11 BLOOD GAS HAECOM 94690 $ 84.11 BLOOD GAS/CO-OX VENOUS 82805 $ 173.29 BLOOD GAS/CO-OX ARTERIAL 82805 $ 173.29 BLOOD PARASITES 87207 $ 16.28 BLOOD PLASMA-CATEG 1 Acquisition cost BLOOD PLASMA-CATEG 2 Acquisition cost BLOOD PLATELETS Acquisition cost BLOOD RED BLOOD CELLS Acquisition cost BLOOD TYPE ABO/RH TYPINGPANEL Acquisition cost BLOOD TYPING; ABO 86900 $ 277.79 BLOOD TYPING; RH D 86901 $ 84.11 BLOOD UA $ 4.90 BLOOD UNIT Acquisition cost BLOOD YTYPE SET #1873-68 $ 5.89 BLOOD(SPLIT UNIT),PER ML P9011 $ 225.90 BLOOD, L/R, CMV-NEG, UNIT P9051 $ 423.87 BLOOD, L/R, FROZEN/DEGLY/WASHED, UNIT P9054 $ 623.70 BLOOD, L/R, IRRADIATED, UNIT P9056 $ 341.53 BLOOD, SPLIT UNIT P9011 $ 225.90 BLOOD/COMP ADMIN.FEE 36430 $ 991.89 BLOOD/COMP TRANSFUSION 36430 $ 991.89 BLOODCOMP/ADMINFEE 36430 $ 991.89 BLUE CANNULA 5 X 76MM 10/BX A4615 $ 396.90 BLUEMAX BALLOON CATH 5.8FR C1725 $ 330.00 BLUNT DISSECT PROBE W/RND HNDL C2618 $ 159.75 BLUNT TIP-CATEG 1 Acquisition cost BNE IMPL, TEMPRL; PERQ ATTCH SPCH/COCHLR 69714 $ 26,770.83 BODY FLUID-CYTOLOGY 89051 $ 14.96 BODY POS DISCHARGE STATUS - OT G8983 Acquisition cost BODY POS DISCHARGE STATUS - PT G8983 Acquisition cost BODY POSITION CURRENT STATUS - OT G8981 Acquisition cost BODY POSITION CURRENT STATUS - PT G8981 Acquisition cost BODY POSITION GOAL STATUS - OT G8982 Acquisition cost BODY POSITION GOAL STATUS - PT G8982 Acquisition cost BOLD 14CM CANNULATED SCREW C1713 $ 386.30 BOLT LOCKING-CATEG 1 Acquisition cost BONANO SUPRA BLADR DRAIN CATH C1729 $ 419.10 BONE AGE STUDY 77072 $ 302.70 BONE BIOPSY OPEN DEEP 20245 $ 6,148.30 BONE DENSITY STUDY 77078 $ 164.27 Page 42 2018 BONE DENSITY; SPA 78350 $ 88.00 BONE GRAFT TO HOLE OR MAXILLA 21210 $ 11,474.25 BONE GRAFT; MINOR/SM 20900 $ 14,826.61 BONE GRFT INECTABLE MIIGX3; 15CC C1713 $ 3,742.50 BONE GRFT; FEM HD, NECK, IT OR ST 27170 $ 2,524.85 BONE IMAGING LIMITED AREA 78300 $ 924.11 BONE IMAGING, (3D) 78320 $ 1,198.21 BONE IMAGING, 3 PHASE 78315 $ 924.11 BONE IMAGING, WHOLE BODY 78306 $ 924.11 BONE JOINT MULTIPLE AREAS 78305 $ 924.11 BONE LENGTH 77073 $ 302.70 BONE MARROW BIOP; NDLE/TROCR 38221 $ 3,564.97 BONE MARROW BX NEEDLE/TROCAR 38221 $ 3,564.97 BONE MARROW IMAGING LTD 78102 $ 924.11 BONE MARROW IMAGING, BODY 78104 $ 924.11 BONE MARROW IMAGING, MULT 78103 $ 924.11 BONE MARROW PREP 38220 $ 3,564.97 BONE MARROW; ASPIRAT ONLY - CLINIC 38220 $ 3,564.97 BONE MARROW; ASPIRAT ONLY 3100 38220 $ 3,564.97 BONE PLATE 1/3TUBULAT SMLL FRG C1713 $ 149.62 Bone repl grft ridge prsv/site D7953 $ 210.00 Bone replace graft-1st site/qu D4263 $ 420.00 Bone replace graft-each add/qu D4264 $ 210.00 BONE SCREW 80/35 C1713 $ 237.60 BONE SCREW 6.5MM 25MM C1713 $ 241.50 BONE SCREW 6.5x25MM C1713 $ 241.50 BONE SCREWS 2.3x8MM C1713 $ 241.50 BONE SURVEY COMPLETE 77075 $ 302.70 BONE SURVEY INFANT 77076 $ 302.70 BONE SURVEY LIMITED 77074 $ 302.70 BONE WEDGES (ATSI HTO WEDGE) Acquisition cost BOOT CANVAS CAST-CATEG 1 Acquisition cost BOOT FLEX-CATEG 1 Acquisition cost BOOT UNNA-CATEG 1 Acquisition cost BORDETELLA PERTUSSIS ANTIBODY 86615 $ 35.82 Acquisition cost BORRELIA SEROLOGY 86619 $ 36.34 BORTEZOMIB 3.5 MG. (VELCADE) INJ. Acquisition cost BOTOX 10UNITS/0.2ML SYRINGE J0585 Acquisition cost BOTOX 50UNITS/VIAL J0585 Acquisition cost BOTULINUM TOXIN - TYPE A, PER UNIT J0585 $ 15.87 BOTULIUM TOXIN A (BOTOX COSMETIC) 100U Acquisition cost BOVIE PAD-CATEG 1 Acquisition cost BPAS GFT OTH THN VEIN AORTLIAC 35637 $ 3,690.81 BPAS GFT OTH THN VEIN ILIOFEMO 35665 $ 2,518.76 BPAS GFT OTH THN VEIN SBCLVAUX 35616 $ 2,354.24 BPAS GFT OTH THN VEIN; AORTFEM 35646 $ 3,682.54 BPAS GFT OTH THN VEIN; FEMORAL 35656 $ 2,324.12 BPAS GFT OTHR THN VEIN SUBCLAV 35612 $ 2,229.30 BRA SUPPORT-CATEG 1 Acquisition cost BRACE ABDUCTION-CATEG 1 Acquisition cost BRACE ABDUCTION-CATEG 2 Acquisition cost BRACE ANKLE-CATEG 1 Acquisition cost BRACE HIP-CATEG 1 Acquisition cost BRACE PATELLA/FEM-CATEG 1 Acquisition cost BRACE WRIST-CATEG 1 Acquisition cost Page 43 2018 BRACHIAL PLEXUS 64415 $ 1,777.62 BRAIN CT WITH CONTRAST 70460 $ 668.38 BRAIN CT WITH AND WITHOUT CONTRAST 70470 $ 668.38 BRAIN CT WITHOUT CONTRAST 70450 $ 302.70 BRAIN FLOW IMAGING ONLY 78610 $ 1,198.21 BRAIN IMAGING (3D) STATIC 78607 $ 3,180.58 BRAIN IMAGING COMP / FLOW STATIC 78606 $ 1,198.21 BRAIN IMAGING COMPLT STUDY; STATIC 78605 $ 1,198.21 BRAIN IMAGING, LIMITED PROC; W VASC FLOW 78601 $ 924.11 BRAIN IMAGING, LIMITED PROCEDURE; STATIC 78600 $ 924.11 Brain MR Venogram without Contrast 70551 $ 614.37 BRAIN MRI WITH AND WITHOUT CONTRAST 70553 $ 1,206.90 BRAIN MRI WITH CONTRAST 70552 $ 668.38 BRAIN MRI WITHOUT CONTRAST 70551 $ 614.37 BRAIN/INTER AUDITORY CANAL MRI W/O CONTR 70551 $ 614.37 BRAIN/INTER AUDITORY CANAL MRI W/W/OCONT 70553 $ 1,206.90 BRAIN/INTERNAL AUDITORY CANAL MRI W/CONT 70552 $ 668.38 BREAST / MIRALUMA SCAN 78801 $ 924.11 BREAST ASPIRATION MAMMO 19000 $ 1,514.94 BREAST IMPL SILCN RND 600CC; STYLE 120 C1789 $ 1,390.50 BREAST IMPLANT SILICONE C1789 $ 1,390.50 Breast MRI w/w/o Contrast bilateral 77059 $ 1,206.90 Breast MRI w/w/o Contrast Unilateral 77058 $ 178.49 BREAST MRI with CONTRAST; BILATERAL 77059 $ 178.49 BREAST MRI with CONTRAST; UNILATERAL 77058 $ 178.49 BREAST MRI without CONTRAST; BILATERAL 77059 $ 178.49 BREAST MRI without CONTRAST; UNILATERAL 77058 $ 178.49 BREAST PUMP ALL TYPES E0602 Acquisition cost BREAST RECONST W TIS EXPAN 19357 $ 30,117.89 BREAST RECONSTRUCT W OTHR 19366 $ 12,725.37 BREAST ROUND SILICON-45 460CC C1789 $ 1,162.50 BREATH PATTERN RECORDING, INFANT 94772 $ 1,175.22 BREATHING RESPONSE TO CO2 94400 $ 571.25 BRETHINE 1MG/ML AMP INJ 1ML J3105 Acquisition cost BRETHINE 5MG TAB Acquisition cost BRETYLOL 500MG VIAL 10ML INJ Acquisition cost BRIDGE PORCELAIN/CERAMIC D6245 $ 644.00 BRIEF EMOTINAL/BEHAV ASSMNT 96127 $ 34.03 BRILINTA (TICAGRELOR) 90mg Acquisition cost BRIMONIDINE 0.2% EYE DROP Acquisition cost BRIMONIDINE TART 0.15% EYE DR Acquisition cost BRIMONIDINE TARTRATE 0.15% $ 39.89 BRINZOLAMIDE 1% OPHTHALMIC DROPS Acquisition cost BROAD BONE PLATE 6.5 C1713 $ 901.95 BROAD BONE PLATE SIZE 10" C1713 $ 901.95 BRONCH EBUS DX/TX PERIPH LES 31654 $ 148.90 BRONCH EBUS SAMPL; 3+ NODES 31653 $ 6,919.73 BRONCH EBUS SAMPLE; 1-2 NODES 31652 $ 6,919.73 BRONCH, RIGD/FLEX W RAD GUIDANCE 31645 $ 3,500.62 BRONCH/ BRONCHIAL ALVEOLAR LA 31624 $ 3,500.62 BRONCH/ DESTR TUMOR, CRYOTHERPA 31641 $ 6,919.73 BRONCHOSCOPY REMOVAL FB 31635 $ 3,500.62 BRONCHOSCOPY W NEEDLE BX ADD 31633 $ 139.83 BRONCHOSCOPY WITH BIOPSY 31625 $ 3,500.62 BRONCHOSCOPY WITH BRUSHING 31623 $ 3,500.62 BRONCHOSCOPY WITH NDL ASP 31629 $ 6,919.73 Page 44 2018 BRONCHOSCOPY/ TRACH DILIT/STE 31631 $ 12,863.66 BRONCHOSCOPY/LUNG BIOPSY; SING 31628 $ 6,919.73 BRONCHOSCOPY; W/BX 31625 $ 3,500.62 BRONCHOSCOPY; W/LUNG BX W/WO FLUORO 31628 $ 6,919.73 BRONCHOSCP W FLOURO GUIDE W/LUNG BX ADD 31632 $ 108.68 BRONCHOSCPY FLEXI W/WO CELLWASH 31622 $ 3,500.62 BRONCHOSPASM EVAL W/SPIROMETRY 94070 $ 658.04 BRONCHOSPSM EVAL: SPIRO-BRONCHODILT 94060 $ 658.04 BRONXHSCPY; FLEXI DX W/WO CELLWSH 31622 $ 3,500.62 BROVIAC SNGL LUM CENTRLVENCATH C1757 $ 411.83 BRST RECONST W FREE FLAP 19364 $ 5,939.69 BRUCELLA 86622 $ 24.27 BRUCELLA ANTIBODY 86622 $ 24.27 BRUCELLA ANTIBODY TITER 86622 $ 24.27 Brush biopsy-transepith sample D7288 $ 112.00 BRUSH/WASH, SIMPLE FILTER 88106 $ 46.20 BRUSH/WSH, SIMPLE FILTER 88106 $ 46.20 BRUSHES 88104 $ 84.11 B-SCAN PELV US-COMPLETE 76856 $ 302.70 BSS 15ML J3490 $ 30.73 BSS 30ML J3490 $ 30.73 BSS OPTH SALT SOL 500ML Acquisition cost BSS OPTH SOL 15ML Acquisition cost BSS PLUS SOL 500ML Acquisition cost BSS SOL 500ML-CATEG 1 Acquisition cost BTB TIGHTROPE C1713 $ 637.50 BUDEPRION XL 300MG. PO Acquisition cost BUDES/FORMOT FUM 160/4.5 MCG. Acquisition cost BUDES/FORMOT FUM 80/4.5 MCG. Acquisition cost BUDESONIDE {PULMICORT}INHAL J7626 Acquisition cost BUDESONIDE 200MCG MDI Acquisition cost BUDESONIDE 3MG CAPSULE PO Acquisition cost BUDESONIDE INHAL 0.5MG/2ML J7626 Acquisition cost BUDNESONIDE 32MCG NSL SPR Acquisition cost BUFFY COAT-ABN.CELLS 85009 $ 11.15 BUGBEE ELECTRODE 5FR 58CM 2/PK A4556 $ 175.50 BULSULFAN,ORAL,2MG J8510 $ 61.83 BUMETADINE 25MG/ML INJ Acquisition cost BUMETANIDE 0.5MG TAB Acquisition cost BUMETANIDE 1MG TAB Acquisition cost BUMETANIDE 2MG (BUMEX) TAB PO Acquisition cost BUNION CORRECT W MTRSLBONE INC 28296 $ 6,995.52 BUNION CORRECTION 28297 $ 14,826.61 BUNION; BY PHALYNX OSTEOTOMY 28298 $ 14,826.61 BUPIVACAINE 0.25% INJ Acquisition cost BUPIVACAINE 0.5% INJ Acquisition cost BUPIVACAINE 0.5% INJ J3490 $ 11.51 BUPIVACAINE 0.75% INJ Acquisition cost BUPIVACAINE/EPINEPH 0.25% INJ Acquisition cost BUPIVCAINE LIPOSML (EXPAREL) 1.3% INJ Acquisition cost BUPREN HCL/ NALOX 2MG-0.5MG TAB Acquisition cost BUPREN HCL/ NALOX 8MG-2MG TAB Acquisition cost BUPRENORPHINE 80348 $ 11.00 BUPRENORPHINE 0.3MG/ML INJ. J0592 Acquisition cost BUPROPION 100MG TAB Acquisition cost BUPROPION 150MG TAB Acquisition cost Page 45 2018 BUPROPION 300MG XL J8499 Acquisition cost BUPROPION SR 150MG TAB Acquisition cost BUPROPION XL 150MG TAB Acquisition cost BUR BARREL-CATEG 1 Acquisition cost BUR CARB FG 330PEAR SHPE 100PK C1713 $ 26.91 BUR CARB FG CLINIC #6RD 100/BG C1713 $ 184.79 BUR CARB FG CLINIC 2RND 100/BG C1713 $ 217.07 BUR CARB FG CLNC #4 RND 100/BG C1713 $ 184.79 BUR CARB FG CLNC 169L TAPR FIS C1713 $ 181.34 BUR CARB FG CLNC 330PEAR 100BG C1713 $ 217.07 BUR CARB HP/RA #4 RND 100/BG C1713 $ 224.10 BUR CARB HP/RA #6 RND 100/BX C1713 $ 177.60 BUR CARB HP/RA #8 RND 100/BG C1713 $ 180.00 BUR CARBIDE FG PEAR 10/PK MW C1713 $ 19.88 BUR CARBIDE RA #6 RD 10/PK C1713 $ 24.60 BUR PRECISION ROUND C1713 $ 375.63 BUR SURG 3MM RND DIAM EXTRA C1713 $ 212.09 BUR SURG HEAD TAPR RND DIAM C1776 $ 212.09 BUR SURG HEAD TAPR RND EXT SFT C1776 $ 212.09 BUR SURG NEURO 3.0MM DIA ROUND C1713 $ 294.05 BUR SURG NEURO DIA STRYKR CORE C1713 $ 287.28 BUR SURG OVAL EGG 4MM DIA C1713 $ 21.75 BUR SURG RD FLUTEX10 SFT TOUCH C1713 $ 212.09 BUR SURG ROUTER TAPR STRLE C1713 $ 191.64 BUR SURG1.1X6.0MM STRGHT ROUTR C1713 $ 212.09 BUR SURGICAL 5.0M COARSE DIAM C1713 $ 212.09 BUR TAPER CARBIDE 1.6 CYL RD C1713 $ 7.43 BUR TRANSNASAL 3MM MATCHSTICK C1713 $ 671.79 BUR TRANSNASAL 3MM ROUND FLUTE C1713 $ 671.79 BUR TRANSNASAL 3MMRND DIAM CRS C1713 $ 671.79 BUR TRANSNASAL 4.5MM RND DIAM C1713 $ 671.79 BUR TRANSNASAL 4MM ROUND FLUTE C1713 $ 671.79 BUR TRANSNASAL 4MMRND DIAM CRS C1713 $ 671.79 BURN DSG/DEBR S ANES-LG 16030 $ 821.94 BURN DSG/DEBR S ANES-MED 16025 $ 446.80 BURN DSG/DEBR S ANES-SM 16020 $ 446.80 BURN PACK / BLANKET $ 99.00 BUROWS SOLUTION 480ML Acquisition cost BURR 3MM FLUTE MATCHSTICK BURR C1713 $ 351.00 BURR SURG 80MM MAST DIAM DRLL C1713 $ 77.66 BURS CARBIDE SURG FG 702 10/PK C1713 $ 43.28 BUSPERONE 10MG TABLET Acquisition cost BUSPERONE 5MG TABLET Acquisition cost BUSPIRONE 15MG TABLET Acquisition cost BUTFLY SL BLOOD COL.25G(SH) $ 1.92 BUTOCONAZOLE 2% VAG CREAM Acquisition cost BUTORPHANOL (STADOL) 1MG/1ML Acquisition cost BUTORPHANOL 2MG/ML INJ Acquisition cost BUTRFLY SL BLOOD COL.23G $ 1.92 BUTRFLY SL BLOOD COL.25G $ 1.92 BUTRFLY SL BLOOD COL21G $ 1.92 BUTTON-CATEG 1 Acquisition cost BX ABD/RETROPERITON MASS PERQ 49180 $ 3,564.97 BX BONE TROCAR/NEEDLE; DEEP 20225 $ 3,564.97 BX BONE TROCAR/NEEDLE; SUPERF 20220 $ 3,564.97 BX BREAST; OP INCIS 19101 $ 7,213.98 Page 46 2018 BX BREAST; PERQ W/O GUID -SEP PROC 19100 $ 3,564.97 BX BRST W DVCE; 1ST LESION, MR IMAG 19085 $ 3,564.97 BX BRST W DVCE; 1ST LESION, STEREO GUIDE 19081 $ 3,564.97 BX BRST W DVCE; 1ST LESION, US 19083 $ 3,564.97 BX BRST W DVCE; EA ADD LES, MR IMAG 19086 $ 202.84 BX BRST W DVCE; EA ADD LES, STEREO GUIDE 19082 $ 185.53 BX BRST W DVCE; EA ADD LES, US 19084 $ 173.18 BX CONJUNC 68100 $ 4,790.26 BX DONE W COLPOSCOPY ADD-ON 58110 $ 88.26 BX EYELID 67810 $ 707.85 BX LACRIMAL GLAND 68510 $ 4,790.26 BX LIVER NDLE; DONE W/OTH MAJ 47001 $ 222.84 BX LIVER NEEDLE; PERCUT 47000 $ 3,564.97 BX LUNG/MEDIASTINUM PERCUT NEE 32405 $ 3,564.97 BX MUSCL PERCUT NEEDLE 20206 $ 3,564.97 BX NAIL UNIT 11755 $ 1,514.94 BX OF LIVER; WEDGE 47100 $ 1,804.68 BX OF TESTIS; NEEDLE 54500 $ 6,148.30 BX OVARY UNILAT/BILAT (SEPART PROC) 58900 $ 6,010.51 BX PANCREAS PERCUT NEEDLE 48102 $ 3,564.97 BX PLEURA; PERCUT NEEDLE 32400 $ 3,564.97 BX PROS; NDLE/PUNCH 1/MX ANY APPRCH 55700 $ 4,484.35 BX PROS; NDLE/PUNCH ANY APPRCH 55700 $ 4,484.35 BX SALIVARY GLAND; INCS 42405 $ 5,815.59 BX SIGLE/MX/LOC EXC LES W/WO FULG 57500 $ 1,522.22 BX SINGLE/MX/LOC EXC LES W/WO 57500 $ 1,522.22 BX SKIN//SUBQ TISS (SEP PRO); 1 LES 11100 $ 821.94 BX SKIN//SUBQ TISS (SEP PRO);EA ADD 11101 $ 54.10 BX SKIN/SUBQ TIS/MUCS MEMBRN; EACH 11101 $ 54.10 BX SKN SQ/MM; SING 11100 $ 821.94 BX SOFT TISS LEG/ANK AREA; SUPERF 27613 $ 3,564.97 BX SOFT TISSUE, HIP/PEL DEEP 27041 $ 3,564.97 BX SOFT TISSUE, HIP/PEL SUPERF 27040 $ 3,564.97 BX SPINAL CORD PERCUT NEEDLE 62269 $ 3,564.97 BX THYROID PERCUT CORE NEEDLE 60100 $ 1,514.94 BX TONGUE; ANT TWO-THIRDS 41100 $ 1,216.16 BX VAG MUCOS; EXTEN REQUIRING 57105 $ 6,010.51 BX VAG MUCOS; SIMPL (SEPART PROC) 57100 $ 1,522.22 BX VAGINA, EXTENSIVE; REQUIRING SUTURE 57105 $ 6,010.51 BX VAGINAL MUCOSA; SIMPLE 57100 $ 1,522.22 BX VUL/PERIN, EA ADDTL 56606 $ 63.89 BX VULVA/PERINEUM (S/ PROC); 1 56605 $ 1,522.22 BX VULVA/PERINEUM (SEPART PROC); 1 LES 56605 $ 1,522.22 BX, INTRANASAL 30100 $ 3,010.00 BX, VUL/ PERIN, EA ADDTL 56606 $ 63.89 BX/EXC LN; DEEP CERV W EXC SFP 38520 $ 7,213.98 BX/EXC LYMPH NODE BY NEEDLE SUPERF 38505 $ 3,564.97 BX/EXC LYMPH NODE OP; INT MAMMARY NODE 38530 $ 7,213.98 BX/EXC LYMPH NODE(S) OP; SUPER 38500 $ 7,213.98 BX/EXC LYMPH NODE; BY NEEDLE S 38505 $ 3,564.97 BX; NASOPHARYNX VISIBLE LES SIMPL 42804 $ 5,815.59 BX; OPEN SUPFIC BONE 20240 $ 6,148.30 BX; OROPHARYNX 42800 $ 5,815.59 BX; PROSTATE SATURAT SAMPLING 55706 $ 7,131.78 BX;NASOPHARYNX UNKNOWN PRIMRY 42806 $ 5,815.59 BX-SKN SQ/MM; SINGLE 11100 $ 821.94 Page 47 2018 C REP F G H F 1-2.5CM 13131 $ 821.94 C REP F G H F 2.6-7.5CM 13132 $ 1,291.09 C REP TRUNK 1.1 CM TO 2.5CM 13100 $ 1,291.09 C REP TRUNK 2.6-7.5CM 13101 $ 1,291.09 C REP TRUNK, EA ADDTL 5 CM OR LESS 13102 $ 160.78 C.DIFF.LATEX TEST 87230 $ 53.61 C.F OUTER SHEATH C1892 $ 1,521.00 C1-C2 PUNCTURE; WO INJECTION 61050 $ 647.13 C1INHIBIT-ESTERASE 86160 $ 32.58 C1Q BINDING 86332 $ 66.20 C1Q IMMUNE COMPLEX DETECTION 86332 $ 66.20 C3A COMPLEMENT PROTEIN 86160 $ 32.58 C4 COMPONENT 86161 $ 32.58 C5 COMPLEMENT 86160 $ 32.58 CA 125. 86316 $ 56.54 CA 125... 86304 $ 56.54 CA 15-3. 86316 $ 56.54 CA 15-3... 86300 $ 56.54 CA 19-9. 86316 $ 56.54 CA 19-9... 86301 $ 56.54 CA 27.29 86316 $ 56.54 CA 27.29.. 86300 $ 56.54 CABAZITAXEL 60MG/1.5MLVIAL J9043 Acquisition cost CABAZITAXEL INJ 1MG J9043 $ 461.03 CABERGOLINE 0.5 MG. PO Acquisition cost CABERGOLINE 0.5 MG.TABLET Acquisition cost CABLE GRIP-CATEG 1 Acquisition cost CABLE GRIP-CATEG 2 Acquisition cost CABLE PLUG C1713 $ 100.41 CABLE SLEEVE-CATEG 1 Acquisition cost CABLE SLEEVE-CATEG 2 Acquisition cost CABLE-CATEG 1 Acquisition cost CABLE-CATEG 2 Acquisition cost CABLE-CATEG 3 Acquisition cost CAD/CAM NON-STERILE HIP STEM Acquisition cost CADMIUM LEVEL 82300 $ 62.88 CAFERGOT SUPP 12 PACK Acquisition cost CAFFEINE 20MG/ML ORAL SYR Acquisition cost CAFFEINE CIT 2MG/ML IV 5ML SYR Acquisition cost CAFFEINE CITR 20MG/ML IV J0706 Acquisition cost CAFFEINE CITR 20MG/ML ORAL SOL Acquisition cost CAFFEINE CITRATE 5MG/ML IV 2ML SYRINGE J0706 Acquisition cost CAL. GLUCONATE 1g,/D10%W 250ML Acquisition cost CAL. GLUCONATE 1g,/D5%W 250ML Acquisition cost CAL. GLUCONATE 500MG/D10%W Acquisition cost CALAMINE LOTION $ 5.17 CALAMINE LOTION 120ML Acquisition cost CALAMN LOTION $ 5.17 CALC GLUBION 1.8GM/5ML OR SYR Acquisition cost CALCANEAL PLATE - SM PARAMETER FRACTURE C1713 $ 1,707.00 CALCANEAL PLATE SMLL PARAFRACT C1713 $ 1,707.00 CALCANEUS 73650 $ 164.27 CALCANEUS MESH PLATE, MEDIUM C1781 $ 1,327.50 CALCELLOUS SCREW FTH 4.0 X NON-LOCKING C1713 $ 60.00 CALCIJEX 0.1MCG/ML AMP 1ML INJ J0636 Acquisition cost CALCIMAR 200U/ML 2ML VIAL INJ J0630 Acquisition cost Page 48 2018 CALCIPOTRIENE 0.005% CREAM Acquisition cost CALCIPOTRIENE 0.005% TOPICAL SOLUTION Acquisition cost CALCITONIN 82308 $ 72.78 CALCIUM 82310 $ 14.01 CALCIUM ACETATE Acquisition cost CALCIUM ACETATE 667MG TAB Acquisition cost CALCIUM ACETATE 667MG TAB PO Acquisition cost CALCIUM ACETATE CAPSULE Acquisition cost CALCIUM BF 82310 $ 14.01 CALCIUM CAR W/VIT D 250-125 TAB Acquisition cost CALCIUM CARBONATE 1250MG/5ML SUSPENSION Acquisition cost CALCIUM CARBONATE 600MG TAB Acquisition cost CALCIUM CARBONATE 650MG TAB PO Acquisition cost CALCIUM CHLORD 1000MG/10ML VIAL INJ $ 17.60 CALCIUM CHLORIDE 10% ABBOJECT Acquisition cost CALCIUM CHLORIDE ABBOJET 10ML Acquisition cost CALCIUM CITRATE 950 MG. PO Acquisition cost CALCIUM GLUC 10% 10ML VIAL INJ J0610 Acquisition cost CALCIUM GLUC 10% 50ML VIAL J0610 Acquisition cost CALCIUM GLUC10% 100ML FOR TPN J0610 Acquisition cost CALCIUM GLUCINATE 500MG NICU Acquisition cost CALCIUM GLUCONATE 10% 100ML J0610 Acquisition cost CALCIUM GLUCONATE 1000MG NICU Acquisition cost CALCIUM GLUCONATE 500MG TAB Acquisition cost CALCIUM GLUCONATE100MG/ML NICU Acquisition cost CALCIUM LEVEL BODY FLUID 82310 $ 14.01 CALCIUM UR RANDOM 82340 $ 16.37 CALCIUM UR T.V. 82340 $ 16.37 CALCIUM; TOTAL 82310 $ 14.01 CALCU; X-RAY DIFFRACTION 82370 $ 34.01 CALDESENE 10% 2.5 OZ POWDER Acquisition cost CALDWELL-LUC WO REM ANTROCH POLYPS 31030 $ 11,474.25 CALDWELL-LUC; W REM ANTROCH POLYPS 31032 $ 11,474.25 CALIBRATED REAMER 2MM C1713 $ 489.00 CALORIC VESTBLR TEST; BITHERMAL 92537 $ 360.51 CALORIC VESTBLR TEST; MONOTHERMAL 92538 $ 360.51 CALORIC VESTIBULAR TEST 92533 $ 33.00 CAMPYLOBACTER PYLO 86625 $ 35.64 CAN SHRT CRVD LUER LOCKW/THUMB C1713 $ 78.75 CANAGLIFLOZIN 300MG TABLET Acquisition cost CANALITH REPOSITIONING PROC 95992 $ 94.38 CANCELLOUS BONE CHIPS 15CC C1713 $ 371.25 CANCELLOUS BONE CHIPS 30CC C1713 $ 573.75 CANCELLOUS BONE CHIPS 5CC C1713 $ 189.00 CANCELLOUS BONE SCREW C1713 $ 162.90 CANCELLOUS BONE SCREW 6.5x25MM C1713 $ 162.90 CANCELLOUS BONE SCREW FULLY THREADED C1713 $ 37.29 CANCELLOUS SCREW 6.5MM X C1713 $ 61.20 CANCELLOUS SCREW 6.5MM x VARIOUS C1713 $ 162.90 CANCELOUS BONE CHIP 15CC; MTF FREEZE DRY C1713 $ 459.00 CANDESARTAN 16MG TABLET PO Acquisition cost CANDESARTAN 32MG TAB PO Acquisition cost CANDESARTAN 4MG TABLET PO Acquisition cost CANDESARTAN 8MG TABLET PO Acquisition cost CANDESARTAN/HCTZ 16-12.5 Acquisition cost CANDESARTAN/HCTZ 32-12.5 Acquisition cost Page 49 2018 CANDIA ALBICANS SKIN TEST 1ML Acquisition cost CANDIDA AB DETECT 86628 $ 32.60 CANDIDA ANTIGEN 87449 $ 32.56 CANDIDIASIS ANTIBODY 86628 $ 32.60 CANE ALL MATERIAL ADJUSTABLE/FIXED W/TIP E0100 $ 7.52 CANE QUAD/3-PRONG ALL MATL W/TIPS E0105 $ 29.62 CANE WOODEN-CATEG 1 Acquisition cost CANE WOODEN-CATEG 2 Acquisition cost CANE WOODEN-CATEG 3 Acquisition cost CANE WOODEN-CATEG 4 Acquisition cost CANN 40CM W/CURV INTRD 5FRCATH C1713 $ 136.97 CANN SCRW 6.5MM C1713 $ 386.32 CANNUL COMPRESN SCRW 2.5X 28MM C1713 $ 571.50 CANNULA 20G X 1-1/8IN, FLUTED A4615 $ 59.67 CANNULA 20ML SYR 3K TIP CURVE A4615 $ 135.00 CANNULA 5.5 X 72MM A4615 $ 781.05 CANNULA 5.75 X 7" A4615 $ 187.50 CANNULA 7MM X 7CM W/ TWIST-IN A4615 $ 37.50 CANNULA 8.25 X 7" A4615 $ 63.00 CANNULA 8.5 X 90MM 10/BX A4615 $ 491.40 CANNULA ANT CHAMBER-CATEG 1 Acquisition cost CANNULA ASPIR BIMAN-CATEG 1 Acquisition cost CANNULA BEND-CATEG 1 Acquisition cost CANNULA BISHOP HARM-CATEG 1 Acquisition cost CANNULA CLEAR TRAC-CATEG 1 Acquisition cost CANNULA CLEAR-CATEG 1 Acquisition cost CANNULA COBRA K ALUM HANDLE A4615 $ 240.00 CANNULA COBRAK + - CATEG 1 Acquisition cost CANNULA COBRAK-CATEG 1 Acquisition cost CANNULA CRVD OD LUER LCK A4615 $ 67.50 CANNULA CYCLODIALYSIS-CATEG 1 Acquisition cost CANNULA DISP INNER-CATEG 1 Acquisition cost CANNULA DISP-CATEG 1 Acquisition cost CANNULA DISP-CATEG 2 Acquisition cost CANNULA FLUTE-CATEG 1 Acquisition cost CANNULA H.F DGNST RTBL DBL VLV A4615 $ 1,176.00 CANNULA HYDRODISS-CATEG 1 Acquisition cost CANNULA INFANT NASAL-CATEG 1 Acquisition cost CANNULA INFANT W/TUBING-CATEG 1 Acquisition cost CANNULA INFILTR-CATEG 1 Acquisition cost CANNULA INFUSION-CATEG 1 Acquisition cost CANNULA INNER-CATEG 1 Acquisition cost CANNULA INTERLINK LVR-CATEG 1 Acquisition cost CANNULA IRRIG BIMAN-CATEG 1 Acquisition cost CANNULA IRRIG-CATEG 1 Acquisition cost CANNULA J-SHAPED-CATEG 1 Acquisition cost CANNULA LACRIMAL-CATEG 1 Acquisition cost CANNULA LACRIMAL-CATEG 2 Acquisition cost CANNULA NASAL PED-CATEG 1 Acquisition cost CANNULA NASAL-CATEG 1 Acquisition cost CANNULA NAVY-CATEG 1 Acquisition cost CANNULA NEONATAL-CATEG 1 Acquisition cost CANNULA NEONATE W/TUBING-CATEG 1 Acquisition cost CANNULA PED NASAL-CATEG 1 Acquisition cost CANNULA REGULAR-CATEG 1 Acquisition cost CANNULA STAR TIP-CATEG 1 Acquisition cost Page 50 2018 CANNULA SUBRETINAL-CATEG 1 Acquisition cost CANNULA VISCOAT-CATEG 1 Acquisition cost CANNULA/DILATOR-CATEG 1 Acquisition cost CANNULA-CATEG 1 Acquisition cost CANNULATED BIT C1713 $ 151.05 CANNULATED COMPRESSION SCREW C1713 $ 571.50 CANNULATED DRILL 3.5 X 60MM C1713 $ 693.00 CANNULATED DRILL BIT 4.4MM C1713 $ 243.00 CANNULATED DRILL W/AO COUPLING C1713 $ 518.62 CANNULATED LOCKING SCREW 4.0x40MM C1713 $ 490.50 CANNULATED LOCKING SCREW 4MMxVARIOUS C1713 $ 490.50 CANNULATED LOCKING SCREW 5.0MM C1713 $ 286.50 CANNULATED LOCKING SCREW; SIZE=VARIOUS C1713 $ 490.50 CANNULATED SCREW 3.5x36MM C1713 $ 146.25 CANNULATED SCREW 3.75 X 36MM C1713 $ 429.00 CANNULATED SCREW 4.0MM C1713 $ 291.37 CANNULATED SCREW 4.0MM Xvarious C1713 $ 490.50 CANNULATED TIB NAIL 10MM TP C1713 $ 2,124.00 CANTHOPLASTY 67950 $ 4,790.26 CANTHOTOMY 67715 $ 4,790.26 CAP END-CATEG 1 Acquisition cost CAP ULNA THREADED-CATEG 1 C1757 Acquisition cost CAPCALCITRIOL 0.25MG CAP Acquisition cost CAPECITABINE ORAL 500 MG J8521 $ 86.06 CAPECITABINE,ORAL,150MG J8520 $ 25.82 CAPIO SLIM SUTURE CAPTUR DEV C1713 $ 779.63 CAPREOMYCIN 1 GM. Acquisition cost CAPREOMYCIN SULF 1GM INJ Acquisition cost CAPSAICIN 0.025% CREAM TOP Acquisition cost Capsaicin Cream 0.025% 60 Gm. Cream Acquisition cost CAPSLCTMY/CAPSLTMY; INTERPHALNGL JNT 26525 $ 3,570.03 CAPSLRRHAPHY, GLENOHUMRL JNT; POSTERIOR 23465 $ 14,826.61 CAPSULORRHAPHY ANT; W CPT 23462 $ 14,826.61 CAPSULOTOMY; IP JOINT; EACH 28272 $ 3,570.03 CAPTOPRIL 12.5 MG TAB J8499 $ 2.44 CAPTOPRIL 12.5MG TAB Acquisition cost CAPTOPRIL 25MG P.O. J8499 $ 2.44 CAPTOPRIL 25MG TAB Acquisition cost CAPTOPRIL 50MG TAB Acquisition cost CAPTOPRIL 50MG/ML NICU PO SUS Acquisition cost CAPUSULORRHAPHY; BANKART 23455 $ 14,826.61 CAPUSULORRHAPHY; PUTTI-PLATT/MAGNUS 23450 $ 14,826.61 CARAFATE 1GM TAB Acquisition cost CARAFATE SUSP 1GM/10ML UD Acquisition cost CARBAMAZEPINE 80156 $ 39.56 CARBAMAZEPINE 200MG TAB Acquisition cost CARBAMAZEPINE 100MG/5ML LIQ Acquisition cost CARBAMAZEPINE XR 200MG Acquisition cost CARBAMIDE 6.5% OTIC DROPS Acquisition cost CARBIDE ROUND 44.5MM X 1.2MM C1713 $ 7.88 CARBIDOPA/LEVADOPA ER 25MG/100MG TAB Acquisition cost CARBIDOPA/LEVADOPA ER 50MG/200MG TAB Acquisition cost CARBIDOPA/LEVODOPA 10-100MG TAB Acquisition cost CARBIDOPA/LEVODOPA 25-100MG TAB Acquisition cost CARBIDOPA/LEVODOPA 25-250MG TAB Acquisition cost CARBOCAINE 3% CARTRIDGE 50/BOX J3490 $ 3.82 Page 51 2018 CARBOLIC ACID SOLUTION 100ML Acquisition cost CARBON CONNECTING ROD; 200MM C1713 $ 333.00 CARBON CONNECTING ROD; 350MM C1713 $ 333.00 CARBON MONOXIDE DIFFUSING CAPACITY 94729 $ 20.04 CARBOPLATIN 450MG INJ J9045 Acquisition cost CARBOPLATIN 50MG INJ J9045 Acquisition cost CARBOPLATIN, 50 MG J9045 $ 95.37 CARBOPROST 250MCG/1ML Acquisition cost CARBOXYHEMOGLOBIN 82375 $ 33.46 CARD PLANAR 1ST PASS MULTI 78483 $ 1,198.21 CARD.PET PERFUS; MULTIPLE 78492 $ 3,642.17 CARDCATH REDUCE TIP BAR IMPREG C1887 $ 345.60 CARDIAC BLD POOL IMAG; MX STUDIES 78473 $ 924.11 CARDIAC CARE UNIT (CCU) $ 3,375.00 CARDIAC CATH LAB 106 - 120 MINUTES $ 3,960.00 CARDIAC CATH LAB 121 - 135 MINUTES $ 4,455.00 CARDIAC CATH LAB 136 - 150 MINUTES $ 4,950.00 CARDIAC CATH LAB 151 - 165 MINUTES $ 5,445.00 CARDIAC CATH LAB 16 - 30 MINUTES $ 990.00 CARDIAC CATH LAB 166 - 180 MINUTES $ 5,940.00 CARDIAC CATH LAB 181 - 195 MINUTES $ 6,435.00 CARDIAC CATH LAB 196 - 210 MINUTES $ 6,930.00 CARDIAC CATH LAB 211 - 225 MINUTES $ 7,425.00 CARDIAC CATH LAB 226 - 240 MINUTES $ 7,920.00 CARDIAC CATH LAB 241 - 255 MINUTES $ 8,415.00 CARDIAC CATH LAB 256 - 270 MINUTES $ 8,910.00 CARDIAC CATH LAB 271 - 285 MINUTES $ 9,405.00 CARDIAC CATH LAB 286 - 300 MINUTES $ 9,900.00 CARDIAC CATH LAB 301 - 315 MINUTES $ 10,395.00 CARDIAC CATH LAB 31 - 45 MINUTES $ 1,485.00 CARDIAC CATH LAB 316 - 330 MINUTES $ 10,890.00 CARDIAC CATH LAB 331 - 345 MINUTES $ 11,385.00 CARDIAC CATH LAB 346 - 360 MINUTES $ 11,880.00 CARDIAC CATH LAB 361 - 375 MINUTES $ 12,375.00 CARDIAC CATH LAB 376 - 390 MINUTES $ 12,870.00 CARDIAC CATH LAB 391 - 405 MINUTES $ 13,365.00 CARDIAC CATH LAB 406 - 415 MINUTES $ 13,860.00 CARDIAC CATH LAB 416 - 430 MINUTES $ 14,355.00 CARDIAC CATH LAB 431 - 445 MINUTES $ 14,850.00 CARDIAC CATH LAB 446 - 460 MINUTES $ 15,345.00 CARDIAC CATH LAB 46 - 60 MINUTES $ 1,980.00 CARDIAC CATH LAB 461 - 475 MINUTES $ 15,840.00 CARDIAC CATH LAB 476 - 495 MINUTES $ 16,335.00 CARDIAC CATH LAB 496 - 510 MINUTES $ 16,830.00 CARDIAC CATH LAB 511 - 525 MINUTES $ 17,325.00 CARDIAC CATH LAB 526 - 540 MINUTES $ 17,820.00 CARDIAC CATH LAB 541 - 555 MINUTES $ 18,315.00 CARDIAC CATH LAB 556 - 570 MINUTES $ 18,810.00 CARDIAC CATH LAB 571 - 585 MINUTES $ 19,305.00 CARDIAC CATH LAB 586 - 600 MINUTES $ 19,800.00 CARDIAC CATH LAB 61 - 75 MINUTES $ 2,475.00 CARDIAC CATH LAB 76 - 90 MINUTES $ 2,970.00 CARDIAC CATH LAB 91 - 105 MINUTES $ 3,465.00 CARDIAC CATH LAB < 15 MINUTES $ 495.00 CARDIAC CATH PACK $ 402.60 CARDIAC GUIDE WIRE C1769 $ 170.50 Page 52 2018 CARDIAC SHUNT DETECTION 78428 $ 924.11 CARDIOLIPIN ANTIBODY SCREEN 86147 $ 69.12 CARDIOPULMONARY RESUSCITATION 92950 $ 658.04 CARDIOVERS ELEC-CONVER ARRHY; EXT 92960 $ 1,355.77 CARDIZEM (DILTIAZEM) 90 MG TAB Acquisition cost CARDON FIBER ROD 11x0250MM C1713 $ 303.00 CARDURA 1MG TAB Acquisition cost CARDURA 2MG TAB Acquisition cost CARDURA 4MG TAB Acquisition cost CARDURA 8MG TAB Acquisition cost CARE MGMT SVC BHVL HLTH COND 99484 $ 80.45 CARE OF VESTICOT 53899 $ 607.00 CARMUSTINE 100MG INJECTION J9050 Acquisition cost CARMUSTINE, 100 MG J9050 $ 452.51 CARNITINE 82131 $ 50.56 CARNITINE... 82379 $ 45.83 CARNITOR 100MG/ML 118ML Acquisition cost CAROT ARTRY STNT SHNT KIT TBE C2625 $ 519.03 CAROTENE 82380 $ 25.06 CAROTID SINUS BLOCK 64508 $ 647.13 CARPAL EXC CRPL SCAPHD WO MNP 25630 $ 568.33 CARPAL SCAPHOID FX WO MANIPUL 25622 $ 568.33 CARPECTOMY; ALL BNS PROXML ROW 25215 $ 6,995.52 CARRY CURRENT STATUS - OT G8984 Acquisition cost CARRY CURRENT STATUS - PT G8984 Acquisition cost CARRY DISCHARGE STATUS - OT G8986 Acquisition cost CARRY DISCHARGE STATUS - PT G8986 Acquisition cost CARRY GOAL STATUS - OT G8985 Acquisition cost CARRY GOAL STATUS - PT G8985 Acquisition cost CARTILAGE GRFT; NAS SEPT 20912 $ 7,168.06 CARVEDILOL 1.56MG TABLET J3490 Acquisition cost CARVEDILOL 12.5MG TABLET Acquisition cost CARVEDILOL 25MG TAB (COREG) Acquisition cost CARVEDILOL 3.125MG TAB Acquisition cost CARVEDILOL 6.25MG TAB Acquisition cost CASCARA 450 MG. PO Acquisition cost CASCARA 450MG. CASULE (FOR SCC ONLY) Acquisition cost CASCARA SAGRADA FL EXTR Acquisition cost CASCARA SAGRADA TABLET Acquisition cost CASE MANAGE MONTHLY T2022 $ 225.00 CASE MANAGE PER MONTH T2022 $ 225.00 CASE MANAGE PER-MONTH T2022 $ 225.00 CASE MANAGE PER-MONTH T2022 $ 225.00 CASE MANAGEMENT MONTHLY T2022 $ 225.00 CASE MANAGEMENT PER MONTH T2022 $ 225.00 CASE MANAGEMENT PER/MONTH T2022 $ 225.00 CASE MANAGEMENT PER-MONTH T2022 $ 225.00 CASE MANAGEMENT, PER MONTH T2022 $ 225.00 CASE MANAGEMENT-PER MONTH T2022 $ 225.00 CASE MGMT PER MONTH T2022 $ 225.00 CASE-MANAGEMENT PER MONTH T2022 $ 225.00 CASPOFUNGIN 50MG (CANCIDIS) VIAL IV J0637 Acquisition cost CASPOFUNGIN 70MG VIAL IV J0637 Acquisition cost CASSETT W/MD-30PLATE # 408708 Acquisition cost CAST POST / CORE IN ADD'N TO CROWN D2952 $ 427.00 CAST RETAINER ACID ETCH BRIDGE D6545 $ 840.00 Page 53 2018 CAST SHOE-CATEG 1 Acquisition cost CASTING 29799 $ 358.14 CASTOR OIL 60ML Acquisition cost CATAPRES 0.2MG TAB J0735 Acquisition cost CATARACT SURGE W IOL; 1 STAGE; INTRACAP 66983 $ 5,080.46 CATARACT SURGERY COMPLEX 66982 $ 5,080.46 CATECHOL TOTAL 82384 $ 68.60 CATECHOLAMINES FRACTIONATED 82384 $ 68.60 CATECHOLAMINES TOTAL URINE 82382 $ 60.06 CATECHOLAMINES; BLD 82383 $ 68.05 CATECHOLAMINES-BLOOD(FRACTIONATED) 82384 $ 68.60 CATECHOLAMINES-URINE(FRACTIONATED) 82384 $ 68.60 CATH & INJ CONTR/SALIN; HYSTEROS/SIS 58340 $ 125.58 CATH 5FR ANGLE GLIDECATH 100CM C1713 $ 536.25 CATH 8FR 2.7MM, 23CM LONG C1751 $ 295.95 CATH OPEN END TIP URETERAL C1758 $ 290.28 CATH PLATFRM DBX SOLID CROWN C1714 $ 4,942.50 CATH PLCMT, SUBCLAV ARTERY (LIMA INJ) 36215 $ 464.33 CATH SET-PIGTAIL, LCA, RCA $ 385.00 CATH SOFT VU PIGTAIL CATH 10BX C1887 $ 291.37 CATH SOFT-VU SOS OMNI 2 5FX80C C1887 $ 135.00 CATH URETH W/WHISTLE TIP 10/CS C1758 $ 125.55 CATH URETHRA; SIMPL 51701 $ 277.79 CATH URETHRAL SELF, MALE 30CS C1758 $ 21.93 CATH VENTRICULAR ANTIMICROBIAL C1751 $ 664.50 CATH&INJ CONTR/SALIN; HYSTEROS/SIS 58340 $ 125.58 CATHER BH-CATEG 1 Acquisition cost CATHETER 2 CHNL DISP-CATEG 1 C1750 Acquisition cost CATHETER 2 SENSOR DISP-CATEG 1 C1750 Acquisition cost CATHETER 2 WAY AB PRESS-CATEG 1 Acquisition cost CATHETER 4 CHNL WATER PERF-CATEG 1 Acquisition cost CATHETER 4FR ALI 100CM C1887 $ 18.75 CATHETER ABCESS DRAIN 8/10 FR C1729 $ 600.00 CATHETER ABCSS DRAINAGE-CATEG 1 C1729 Acquisition cost CATHETER ALL PURPOSE DRAIN-CATEG 1 C1729 Acquisition cost CATHETER ALL PURPOSE-CATEG 1 C1758 Acquisition cost CATHETER ANGIO-CATEG 1 C1885 Acquisition cost CATHETER ANGIO-CATEG 2 C1885 Acquisition cost CATHETER ANGIO-CATEG 3 C1885 Acquisition cost CATHETER ANTIMONY-CATEG 1 Acquisition cost CATHETER ARROW HOWES MULTI LUM-CATEG 1 Acquisition cost CATHETER ARTERIAL VENOUS-CATEG 1 C1876 Acquisition cost CATHETER BALKIN-CATEG 1 Acquisition cost CATHETER BALLOON ACHALASIA-CATEG 1 Acquisition cost CATHETER BALLOON AVIATOR-CATEG 1 Acquisition cost CATHETER BALLOON COUDE TIP-CATEG 1 Acquisition cost CATHETER BALLOON COUDE TIP-CATEG 2 Acquisition cost CATHETER BALLOON DIAMOND-CATEG 1 Acquisition cost CATHETER BALLOON DIL MAXFORCE-CATEG 1 Acquisition cost CATHETER BALLOON DILATION-CATEG 1 C1752 Acquisition cost CATHETER BALLOON HYST-SAPN-CATEG 1 Acquisition cost CATHETER BALLOON INTRA AORTIC-CATEG 1 Acquisition cost CATHETER BALLOON INTRA AORTIC-CATEG 2 Acquisition cost CATHETER BALLOON OPTA LP-CATEG 1 C1725 Acquisition cost CATHETER BALLOON RETRIEVAL-CATEG 1 Acquisition cost CATHETER BALLOON SYMMETRY-CATEG 1 C1725 Acquisition cost Page 54 2018 CATHETER BALLOON TEGWIRE-CATEG 1 Acquisition cost CATHETER BALLOON ULTR ENDO-CATEG 1 C1726 Acquisition cost CATHETER BALLOON VIPER-CATEG 1 Acquisition cost CATHETER BALLOON WORKHORSE-CATEG 1 Acquisition cost CATHETER BALLOON-CATEG 1 Acquisition cost CATHETER BALLOON-CATEG 2 C1725 Acquisition cost CATHETER BALLOON-CATEG 3 C1725 Acquisition cost CATHETER BALLOON-CATEG 4 Acquisition cost CATHETER BARD/DAVOL-CATEG 1 Acquisition cost CATHETER BARD/DAVOL-CATEG 2 Acquisition cost CATHETER BARTHOLIN-CATEG 1 Acquisition cost CATHETER BENTSON-CATEG 1 Acquisition cost CATHETER BERENSTEIN-CATEG 1 C1887 Acquisition cost CATHETER BH-CATEG 1 Acquisition cost CATHETER BILIARY-CATEG 1 C1726 Acquisition cost CATHETER BLUE MAX-CATEG 1 Acquisition cost CATHETER BLUE MAX-CATEG 2 C1725 Acquisition cost CATHETER BROVIAC-CATEG 1 C1751 Acquisition cost CATHETER C2-CATEG 1 Acquisition cost CATHETER CARDIO/PERIT-CATEG 1 Acquisition cost CATHETER CHUANG 'B'-CATEG 1 Acquisition cost CATHETER CHUANG 'C'-CATEG 1 C1713 Acquisition cost CATHETER CHUANG 'D'CATEG 1 Acquisition cost CATHETER CI 65-CATEG 1 C1751 Acquisition cost CATHETER CLOSE TIP-CATEG 1 Acquisition cost CATHETER CLOSED SUCTION-CATEG 1 Acquisition cost CATHETER CNTRL VENOUS SILICN-CATEG 1 C1751 Acquisition cost CATHETER COBRA-CATEG 1 C1729 Acquisition cost CATHETER CONE TIP-CATEG 1 Acquisition cost CATHETER CONTRAST EASE-CATEG 1 Acquisition cost CATHETER COONS DILATOR-CATEG 1 Acquisition cost CATHETER CORDIS-CATEG 1 Acquisition cost CATHETER CORONARY-CATEG 1 Acquisition cost CATHETER CORONARY-CATEG 2 Acquisition cost CATHETER CORONARY-CATEG 3 Acquisition cost CATHETER COUDE TIP-CATEG 1 Acquisition cost CATHETER COUDE-CATEG 1 A4344 Acquisition cost CATHETER CVP-CATEG 1 Acquisition cost CATHETER CYBER GUIDING-CATEG 1 Acquisition cost CATHETER DBL LUMEN-CATEG 1 C1751 Acquisition cost CATHETER DBL LUMEN-CATEG 2 C1751 Acquisition cost CATHETER DBL LUMEN-CATEG 3 C1751 Acquisition cost CATHETER DIAMOND BLN-CATEG 1 C1725 Acquisition cost CATHETER DILATOR-CATEG 1 Acquisition cost CATHETER DILATOR-CATEG 2 Acquisition cost CATHETER DRAIN BILL-CATEG 1 C1729 Acquisition cost CATHETER DRAINAGE-CATEG 1 C1729 Acquisition cost CATHETER D-TIP W/T PC-CATEG 1 Acquisition cost CATHETER D-TIP-CATEG 1 Acquisition cost CATHETER DUAL LUMEN ANG EMB-CATEG 1 Acquisition cost CATHETER DUAL LUMEN RECTAL-CATEG 1 Acquisition cost CATHETER EMBOLECTOMY-CATEG 1 Acquisition cost CATHETER EMBOLECTOMY-CATEG 2 Acquisition cost CATHETER ENDO-CATEG 1 Acquisition cost CATHETER FIXATION DEVICE C1755 $ 847.50 CATHETER FIXATION DEVICE-CATEG 1 C1755 Acquisition cost Page 55 2018 CATHETER FLEXIPATH-CATEG 1 Acquisition cost CATHETER FLUSH-CATEG 1 Acquisition cost CATHETER FOGARTY EMBOL-CATEG 1 Acquisition cost CATHETER FOGARTY GRFT THRMBCT-CATEG 1 Acquisition cost CATHETER FOGARTY IRRIG-CATEG 1 Acquisition cost CATHETER FOGARTY THRU LUMN-CATEG 1 C1757 Acquisition cost CATHETER FOGARTY-CATEG 1 Acquisition cost CATHETER FOGARTY-CATEG 2 Acquisition cost CATHETER FOLEY 2W-CATEG 1 A4344 Acquisition cost CATHETER FOLEY 2W-CATEG 2 Acquisition cost CATHETER FOLEY 2W-CATEG 3 Acquisition cost CATHETER FOLEY 3W-CATEG 1 A4346 Acquisition cost CATHETER FOLEY 3W-CATEG 2 A4340 Acquisition cost CATHETER FOLEY 3W-CATEG 3 Acquisition cost CATHETER FOLEY COUDE-CATEG 1 A4340 Acquisition cost CATHETER FOLEY COUDE-CATEG 2 Acquisition cost CATHETER FOLEY LATEX FREE-CATEG 1 A4344 Acquisition cost CATHETER FOLEY W/STYLET-CATEG 1 A4338 Acquisition cost CATHETER FOLEY-CATEG 1 A4338 Acquisition cost CATHETER FOLEY-CATEG 2 Acquisition cost CATHETER GENL-CATEG 1 C1725 Acquisition cost CATHETER GLIDE-CATEG 1 Acquisition cost CATHETER GOLDSTEIN-CATEG 1 Acquisition cost CATHETER GUIDING-CATEG 1 C1887 Acquisition cost CATHETER H STICK-CATEG 1 Acquisition cost CATHETER HEADHUNTER-CATEG 1 C1887 Acquisition cost CATHETER HI-CATEG 1 Acquisition cost CATHETER HICKMAN SINGLE LUMN-CATEG 1 C1751 Acquisition cost CATHETER HICKMAN-CATEG 1 C1751 Acquisition cost CATHETER HOCKEYSTICK-CATEG 1 Acquisition cost CATHETER IMPLANT 62350 $ 12,238.01 CATHETER IMPRSL-CATEG 1 Acquisition cost CATHETER INFINITI-CATEG 1 Acquisition cost CATHETER INFUSION-CATEG 1 C1751 Acquisition cost CATHETER INFUSION-CATEG 2 C1751 Acquisition cost CATHETER INTRA UTERINE-CATEG 1 Acquisition cost CATHETER INTRODUCER PERIT-CATEG 1 Acquisition cost CATHETER IRRIGATION-CATEG 1 Acquisition cost CATHETER IV RADIOPAQUE-CATEG 1 Acquisition cost CATHETER IV-CATEG 1 Acquisition cost CATHETER JEJUNOSTOMY-CATEG 1 Acquisition cost CATHETER JIM-CATEG 1 Acquisition cost CATHETER JUDKINS-CATEG 1 Acquisition cost CATHETER JUDKINS-CATEG 2 Acquisition cost CATHETER KUMPE-CATEG 1 Acquisition cost CATHETER KUMPE-CATEG 2 Acquisition cost CATHETER LUER LOCK-CATEG 1 Acquisition cost CATHETER MALECOT-CATEG 1 Acquisition cost CATHETER MAMMARY-CATEG 1 Acquisition cost CATHETER MAN-CATEG 1 Acquisition cost CATHETER MANI-CATEG 1 Acquisition cost CATHETER MARSHALL BLN-CATEG 1 Acquisition cost CATHETER MECONIUM SUCT-CATEG 1 Acquisition cost CATHETER MEWISSEN-CATEG 1 Acquisition cost CATHETER MICRO-CATEG 1 Acquisition cost CATHETER MONTEFIORE-CATEG 1 Acquisition cost Page 56 2018 CATHETER MPA 100-CATEG 1 Acquisition cost CATHETER MULTI-LUMEN-CATEG 1 Acquisition cost CATHETER MULTI-LUMEN-CATEG 2 Acquisition cost CATHETER MULTI-PURPOSE-CATEG 1 Acquisition cost CATHETER NEFF-CATEG 1 Acquisition cost CATHETER NEONATAL SILICONE-CATEG 1 Acquisition cost CATHETER NEPHROSTOMY-CATEG 1 C1729 Acquisition cost CATHETER NIGHTHAWK TENNIS-CATEG 1 Acquisition cost CATHETER OMNI FLUSH-CATEG 1 Acquisition cost CATHETER OMNI-CATEG 1 C1887 Acquisition cost CATHETER OPERATIVE CHOLANG-CATEG 1 Acquisition cost CATHETER OPUS VENT-CATEG 1 Acquisition cost CATHETER PEDS SUCTIONCATEG 1 Acquisition cost CATHETER PERCU SUPRA-CATEG 1 Acquisition cost CATHETER PERMA-CATEG 1 Acquisition cost CATHETER PH-CATEG 1 Acquisition cost CATHETER PIGTAIL-CATEG 1 Acquisition cost CATHETER PIGTAIL-CATEG 2 C1729 Acquisition cost CATHETER PIGTAIL-CATEG 3 C1887 Acquisition cost CATHETER PLATINUM PLUS-CATEG 1 Acquisition cost CATHETER PLUG-CATEG 1 Acquisition cost CATHETER POWERFLEX-CATEG 1 C1713 Acquisition cost CATHETER POWERFLEX-CATEG 2 Acquisition cost CATHETER PREMI-CATEG 1 Acquisition cost CATHETER PREMI-CATEG 2 Acquisition cost CATHETER PTA OPTAS-CATEG 1 Acquisition cost CATHETER PTA POWERFLEX-CATEG 1 C1725 Acquisition cost CATHETER PTA SAVVY-CATEG 1 Acquisition cost CATHETER PV-CATEG 1 Acquisition cost CATHETER RED RUBBER-CATEG 1 Acquisition cost CATHETER RETRIEVAL BALLOON-CATEG 1 Acquisition cost CATHETER SHOLKOFF-CATEG 1 Acquisition cost CATHETER SHORT-CATEG 1 Acquisition cost CATHETER SIM 2-CATEG 1 Acquisition cost CATHETER SIMI-CATEG 1 Acquisition cost CATHETER SIMMONS-CATEG 1 Acquisition cost CATHETER SIMMONS-CATEG 2 Acquisition cost CATHETER SINGLE LUMEN-CATEG 1 C1751 Acquisition cost CATHETER SINGLE LUMEN-CATEG 2 C1751 Acquisition cost CATHETER SINGLE LUMEN-CATEG 3 C1751 Acquisition cost CATHETER SINGLE LUMEN-CATEG 4 C1751 Acquisition cost CATHETER SKATER DRAIN-CATEG 1 C1729 Acquisition cost CATHETER STRAIGHT-CATEG 1 C1887 Acquisition cost CATHETER SUCTION-CATEG 1 Acquisition cost CATHETER SUCTION-CATEG 2 Acquisition cost CATHETER SUPRA PUBIC-CATEG 1 Acquisition cost CATHETER SYMMETRY-CATEG 1 C1725 Acquisition cost CATHETER TAD II-CATEG 1 Acquisition cost CATHETER TAD II-CATEG 2 Acquisition cost CATHETER TENCKOFF PERIT-CATEG 1 Acquisition cost CATHETER TESIO-CATEG 1 C1750 Acquisition cost CATHETER TFE-CATEG 1 Acquisition cost CATHETER THORACIC-CATEG 1 C1887 Acquisition cost CATHETER THORACIC-CATEG 2 Acquisition cost CATHETER THROMBECTOMY-CATEG 1 C1757 Acquisition cost CATHETER TIEMANN FOLEY-CATEG 1 Acquisition cost Page 57 2018 CATHETER TORCON ANGIO-CATEG 1 Acquisition cost CATHETER TORCON-CATEG 1 Acquisition cost CATHETER TRACH-CATEG 1 Acquisition cost CATHETER TRACH-CATEG 2 Acquisition cost CATHETER TRANSEM-CATEG 1 Acquisition cost CATHETER TROCAR-CATEG 1 Acquisition cost CATHETER TROCAR-CATEG 2 Acquisition cost CATHETER TROCAR-CATEG 3 Acquisition cost CATHETER TROCAR-CATEG 4 Acquisition cost CATHETER TURBOTRACKER-CATEG 1 Acquisition cost CATHETER TWO LUMEN-CATEG 1 Acquisition cost CATHETER ULTRA THIN-CATEG 1 C1725 Acquisition cost CATHETER UMBILICAL-CATEG 1 Acquisition cost CATHETER UMBILICAL-CATEG 2 Acquisition cost CATHETER URETERAL-CATEG 1 C1758 Acquisition cost CATHETER URETHRAL CONE TIP-CATEG 1 C1758 Acquisition cost CATHETER URETHRAL-CATEG 1 C1758 Acquisition cost CATHETER URETHRAL-CATEG 2 C1758 Acquisition cost CATHETER URODYNMC DUAL LUM-CATEG 1 Acquisition cost CATHETER URODYNMC TRIPLE LUM-CATEG 1 C1751 Acquisition cost CATHETER UROLOGICAL-CATEG 1 Acquisition cost CATHETER VISCERAL-CATEG 1 Acquisition cost CATHETER VISCERAL-CATEG 2 Acquisition cost CATHETER YANKAUER-CATEG 1 Acquisition cost CATHETER-CATEG 1 Acquisition cost CATHETER-CATEG 2 Acquisition cost CATHETER-CATEG 3 C1714 Acquisition cost CATHETER-CATEG 4 Acquisition cost CATHETER-CATEG 5 Acquisition cost CATHETER-CATEG 6 Acquisition cost CATHETER-CATEG 7 Acquisition cost CATHETER-CATEG 8 Acquisition cost CATHETERIZATION BLADDER INSERT 51701 $ 277.79 CATHETERIZATION,AD/PED W/CORON 36830 $ 11,279.00 CATHETER-PTA SAVVY-CATEG 1 Acquisition cost CATOPRIL, 12.5 MG $ 3.44 CAUT CERV CRYOCAUTERY INIT/REPT 57511 $ 709.68 CAUT CERV CRYTERY INIT/RPT 57511 $ 709.68 CAUT CERV; CRYOCAUTERY INIT/REPEAT 57511 $ 709.68 CAUTERIZATION OF CERVIX 57510 $ 6,010.51 CAUTERY OF CERVIX; LASER ABLATION 57513 $ 6,010.51 CAUTERY TYMPANIC MEMB 69610 $ 5,815.59 CAVERNOSOMETRY DYNAMICY, PROCE 54231 $ 4,484.35 CBC MANUAL DIFF 85007 $ 9.33 CBC ROUTINE 85025 $ 21.10 CBC W/ INDICES & DIFF 85025 $ 21.10 CBT EACH ADDL HOUR 94645 $ 16.63 C-COLLAR ADJSTBL-CATEG 1 Acquisition cost C-COLLAR FIRM CONTOURED-CATEG 1 Acquisition cost C-COLLAR FOAM LOW DENSITY-CATEG 1 Acquisition cost C-COLLAR FOAM UNIV-CATEG 1 Acquisition cost C-COLLAR SOFT-CATEG 1 Acquisition cost C-COLLAR SOFT-CATEG 2 Acquisition cost CCP 86235 $ 48.71 CCP ANTIBODY 86200 $ 35.16 CCTA W/ WO DYE 75574 $ 668.38 Page 58 2018 CCTA W/ WO QUAN CALCIUM 75574 $ 668.38 CCTA W/ WO, DISEASE STRXR 75573 $ 668.38 CCTA W/ WO, STRXR 75574 $ 668.38 CCTA W/ WO, STRXR QUAN CALC 75574 $ 668.38 CCULT BLOOD, QUAL-FECES 82270 $ 9.64 CE FERULIC Acquisition cost CE FRULIC $ 204.60 CEA 82378 $ 51.50 CEFACLOR (CECLOR) 250MG CAP Acquisition cost CEFACLOR (CECLOR) 500MG CAP Acquisition cost CEFADROXIL 500MG CAP Acquisition cost CEFADROXIL 500MG. PO Acquisition cost CEFALEXIN 125MG/5ML PO SUSP Acquisition cost CEFALEXIN 250MG/5ML PO SUSP Acquisition cost CEFAZOLIN 1GM ADD VANTAGE J0690 Acquisition cost Cefazolin 1Gm in 10ml IV Syringe Acquisition cost CEFAZOLIN 1GM INJ J0690 Acquisition cost CEFAZOLIN 500 MG NICU INJ J0690 Acquisition cost CEFAZOLIN SODIUM 1GM/50ML J0690 Acquisition cost CEFAZOLINE 1GM ADDVANTAGE INJ J0690 $ 3.26 CEFAZOLINE 1GM/10ML INTELIFIL SYRINGE Acquisition cost CEFAZOLINE 2G/50ml IV BAG J0690 Acquisition cost CEFEPIME 100MG/ML NICU SYR Acquisition cost CEFEPIME 1GM ADD VANTAGE J0692 Acquisition cost CEFEPIME 2GM ADD VANTAGE J0692 Acquisition cost CEFEPIME 500 MG/ML NICU SYR J0692 Acquisition cost CEFEPINE 1 GM. VIAL Acquisition cost CEFOTAXIME 10GM VIAL J0698 Acquisition cost CEFOTAXIME 2GM ADD VANTAGE J0698 Acquisition cost CEFOTAXIME 500MG VIAL J0698 Acquisition cost CEFOTAXIME 50MG/ML 3ML PEDS J0698 Acquisition cost CEFOTAXIME SODIUM PER GM J0698 $ 9.13 CEFOTETAN 1GM INJ Acquisition cost CEFOTETAN 2GM INJ Acquisition cost CEFOXITIN 1GM INJ J0694 Acquisition cost CEFOXITIN 1GM/50ML DEXTROSE BAG J0694 Acquisition cost CEFOXITIN 2GM INJ J0694 Acquisition cost CEFOXITIN 2GM/50ML DEXTROSE BAG J0694 Acquisition cost CEFPODOXOPIME 100MG/5ML SUSP Acquisition cost CEFPODOXOPIME 50MG/5ML SUSP Acquisition cost CEFTAROLINE 400MG VIAL J0712 Acquisition cost CEFTAROLINE 600MG VIAL J0712 Acquisition cost CEFTAZEDIME 1GM ADD VANTAGE Acquisition cost CEFTAZEDIME 2GM ADD VANTAGE Acquisition cost CEFTAZIDIME 50MG/ML 2ML PEDS J0713 Acquisition cost CEFTAZIDIME INTRAVITREAL 2MG/0.1ML Acquisition cost CEFTAZIDIME&AVIBACTAM 2.5g VIAL(Avycaz) $ 0.10 CEFTAZIDINE 2G ADDVANTAGE VIAL Acquisition cost CEFTIN 250MG UD TAB Acquisition cost CEFTIN 500MG UD TAB Acquisition cost CEFTOLOXANE/TAZOBACTUM 1.5GRAM $ 0.10 CEFTRIAXONE 1GM ADD VANTAGE J0696 Acquisition cost CEFTRIAXONE 1GM INJ J0696 $ 25.15 CEFTRIAXONE 1GM/10ML NS SYR $ 0.10 CEFTRIAXONE 1MG INJ J0696 Acquisition cost CEFTRIAXONE 250MG INJ J0696 Acquisition cost Page 59 2018 CEFTRIAXONE 2GM ADD VANTAGE J0696 Acquisition cost CEFTRIAXONE 2GM INJ J0696 $ 14.78 CEFTRIAXONE 2MG INJ J0696 Acquisition cost CEFTRIAXONE 500MG J0696 $ 25.15 CEFTRIAXONE 500MG INJ J0696 Acquisition cost CEFUROXIME 1.5GM ADDVANTAGE Acquisition cost CEFUROXIME 1.5GM INJ J0697 Acquisition cost CEFUROXIME 1.5GM INJ J0697 Acquisition cost CEFUROXIME 1.5GM INJECTION J0697 Acquisition cost CEFUROXIME 1MG/0.1ML OPTHALMIC SYRINGE Acquisition cost CEFUROXIME 750MG ADDVANTAGE J0697 Acquisition cost CEFUROXIME 750MG INJ J0697 Acquisition cost CELEBREX 100MG CAPSULE Acquisition cost CELEBREX 200MG CAPSULE Acquisition cost CELEXA 20MG TAB Acquisition cost CELIAC PANEL, ADULTQPANEL Acquisition cost CELIAC PANEL, INFANTQPANEL Acquisition cost CELIAC PLEXUS NV DSTR SYMP NRV 64680 $ 1,777.62 CELL BLOCK 88305 $ 118.21 CELLCEPT 200MG/ML ORAL SUSPENSION Acquisition cost CELLCEPT 250 MG CAP J7517 Acquisition cost CELLCEPT 500MG. PO J7517 Acquisition cost CELLUVISC 0.01 OZ OPTH Acquisition cost CELONTIN 80339 $ 44.79 CEMENTED TIBIAL KNEE Acquisition cost CENT VENOUS CATH TRAY 3FR 8CM C1751 $ 90.75 CENT VENOUS CATH TRAY 5FR 15CM C1751 $ 99.28 CENTRAL C-V HEMODYNAMICS 78414 $ 1,198.21 CENTRAL VENUS CATHETER PLMT PERCUTANEOUS 36569 $ 2,599.54 CENTRALIZER DISTAL POST-CATEG 1 C1713 Acquisition cost CENTRALIZER DISTAL POST-CATEG 2 C1713 Acquisition cost CENTRALIZER DISTAL-CATEG 1 C1713 Acquisition cost CEPHALEXIN 250MG CAP Acquisition cost CEPHALEXIN 500MG CAPSULE J8499 $ 2.44 CEPHALOGRAM, ORTHODONTIC 70350 $ 164.27 CERAMIC FEM HEAD BIOLOX DELTA S-ROM 32MM C1776 $ 3,103.20 CERAMIC FEMOR HEAD BIOLOX 32MM C1776 $ 3,103.20 CERAMIC FEMORAL HIP Acquisition cost CERAMIC ON POLY CASE STEM SYS C1776 $ 8,250.00 CERAMIC ON POLY CASE STEM SYS C1776 $ 8,250.00 CERAMIC RETAINER FOR BONDED PROSTHETICS D6548 $ 531.00 CERAMIC V40 FEMORAL HEAD 28MM C1776 $ 1,200.00 CERAMIC X3; ACCCOLADE STM/TRIDNT INS HIP C1776 $ 7,241.51 CERAX3ACCOL STM/TRI INS HP CUP C1776 $ 7,241.50 CERCLAGE CERV DURING PG; VAG 59320 $ 6,010.51 CERCLAGE UTERINE CERV NON-OB 57700 $ 6,010.51 CEREBR SEIZURE 16\>CH; EA 24 HRS 95951 $ 2,387.99 CEREBRAL BLOOD FLOW IMAGING 78610 $ 1,198.21 CEREBROSP FL FLOW IMAG; CISTERNGRPH 78630 $ 1,198.21 CEREBROSP FL FLOW IMAG; SHNT EVAL 78645 $ 1,198.21 CERULOPLASMIN 82390 $ 29.17 CERV COLLR SEMI-RIGD FOAM 2 PIECE L0172 $ 287.10 CERV COLP W EC CURETT 57456 $ 709.68 CERV CONIZATOIN; COLD KNIFE LASER 57520 $ 6,010.51 CERV MX POST COLLR SUPPS ADJ L0180 $ 311.30 CERV/VAG CANCR SCR;PELV/CLN BRST EX G0101 $ 190.26 Page 60 2018 CERVIC COLP W CERVIX BX 57455 $ 709.68 CERVICAL COLPOSCOPY; LEEP; W BX 57460 $ 6,010.51 CERVICAL DISC PROSTHESIS C1713 $ 6,750.00 CERVICAL FLEXIBLE NONADJUSTABLE L0120 $ 45.99 CERVICAL LYMPHADENECTOMY 38724 $ 3,106.18 CERVICAL PLATE 38MM C1713 $ 1,425.00 CERVICAL SPINE MRI W/W/O CONTRAST 72156 $ 1,206.90 CERVICAL SPINE MRI WITH CONTRAST 72142 $ 1,206.90 CERVICAL SPINE MRI WITHOUT CONTRAST 72141 $ 614.37 CERVICAL SPINE 2 VIEWS 72040 $ 164.27 CERVICAL SPINE COMPLETE 4 VIEWS 72050 $ 302.70 CERVICAL SPINE CT WITH CONTRAST 72126 $ 1,206.90 CERVICAL SPINE CT WITH/WITHOUT CONTRAST 72127 $ 668.38 CERVICAL SPINE CT WITHOUT CONTRAST 72125 $ 302.70 CERVICAL SPINE FLEXION / EXTENSION 72052 $ 302.70 CERVICAL SPINE OBLIQUE 72052 $ 302.70 CERVICOPLASTY 15819 $ 4,147.84 CERVIDIL Acquisition cost CESAREAN DELIVERY ONLY 59514 $ 1,938.66 CETAPHIL CREAM Acquisition cost CETAPHIL LOTION Acquisition cost CETIRIZINE 1MG/ML ORAL SYR PO Acquisition cost CETIRIZINE HCL 10MG TAB Acquisition cost CETIRIZINE HCL 5MG TAB Acquisition cost CETIRIZINE HCL 5MG TABS Acquisition cost CETUXIMAB 100MG/50ML IV Acquisition cost CF CARRIER SCREEN (NY)QPANEL Acquisition cost CFS W/VENT CATH EXT DRAIN SYS C1729 $ 241.50 CG MCG; INT & REP 88291 $ 72.23 CHALAZION EXC, MULTIPLE, DIFFERENT LIDS 67805 $ 707.85 CHALAZION EXCISION SINGLE 67800 $ 707.85 CHALAZION EXCISION, MULTIPLE, SAME LID 67801 $ 2,137.81 CHAN CLEAN TUBE PROX CON WASH A4616 $ 133.86 CHANGE CYSTOST TUBE; SIMPLE 51705 $ 607.00 CHANGE CYSTOSTOMY TUBE; SIMPL 51705 $ 607.00 CHANGE EXT/INT URETER STENT; PERQ 50387 $ 4,484.35 CHANGE GASTROSTOMY TUBE 43760 $ 607.00 CHANGE NEPHROSTOMY/PYELOSTOMY TUBE 50435 $ 4,484.35 CHANGE URETER STENT; PERQ 50382 $ 4,484.35 CHANGE URETEROSTOMY TUBE 50688 $ 4,484.35 CHAPSTICK Acquisition cost CHARCOAL 260 MG CAP Acquisition cost CHARCOAL WITH SORBITOL 50 GM. Acquisition cost CHECK FLO PERFORM 5FR INTRO C1887 $ 52.02 CHECKFLO PERFORM 5FR GUID SHTH C1887 $ 52.02 CHECK-FLO PERFORMER-CATEG 1 Acquisition cost CHECKOUT ORTHO/PROSTH USE-1 UNIT 97762 $ 124.06 CHECKOUT ORTHTC /PRSTHTC USE, EA 15 MIN. 97762 $ 124.06 CHELATION BAND KEROPATHY 65436 $ 4,790.26 CHEM CAUT GRANULATION TIS 17250 $ 446.80 CHEM CAUT GRANULATION TISS 17250 $ 446.80 CHEM CAUT GRANULATION TISSUE 17250 $ 446.80 CHEM CAUTERIZATION > 4 LESSIO 11057 $ 446.80 CHEM CAUTERIZATION (1 LESION) 11055 $ 446.80 CHEM PEEL, FACIAL; EPIDERML 15788 $ 446.80 CHEM PEEL; NONFACIAL, EPIDERMAL 15792 $ 821.94 Page 61 2018 CHEM PLEURODESIS 32560 $ 1,619.99 CHEMICAL CAUT GRAN TISSUE 17250 $ 446.80 CHEMICAL PEEL; FACIAL, DERMAL 15789 $ 1,291.09 CHEMICAL PEEL; NONFACIAL, DERMAL 15793 $ 821.94 CHEMICL PEEL, FACIAL; EPIDERML 15788 $ 446.80 CHEMO DENERV MUSC IN NERV FACIAL NRV 64612 $ 647.13 CHEMO HORMON ANTINEOPL, SQ/IM 96402 $ 153.91 CHEMO IV INFUS EACH ADDL SEQ=<1 HR 96417 $ 153.91 CHEMO, ANTI-NEOPL, SQ/IM 96401 $ 153.91 CHEMO, IV PUSH, ADDL DRUG 96411 $ 153.91 CHEMODENERV TRUNK MUSC; 1-5 MUSC 64646 $ 1,437.02 CHEMODENERV TRUNK MUSC; 6+ MUSC 64647 $ 1,437.02 CHEMODENERV 1 EXTREM, EA AD; 5+ MUSC 64645 $ 177.36 CHEMODENERV 1 EXTREM; 5+ MUSC 64644 $ 1,437.02 CHEMODENERV ECCRINE GLANDS BOTH AXILLAE 64650 $ 647.13 CHEMODENERV ECCRINE GLANDS OTH AREAS 64653 $ 647.13 CHEMODENERV MUSC; INNERV FACIAL NRV 64612 $ 647.13 CHEMODENERV; 1 EXTREM EA AD 1-4 MUSC 64643 $ 154.57 CHEMODENERV; 1 EXTREM; 1-4 MUSC 64642 $ 1,437.02 CHEMODENERVATION - ANAL MUSCLE 46505 $ 2,476.36 CHEMODENERVATION EXTRAOCULAR MUSCL 67345 $ 707.85 CHEMODENRV MUSC; MIGRAINE, BILAT 64615 $ 647.13 CHEMODENRVTION-EXTRAOCULAR MUSCLE 67345 $ 707.85 CHEMOTHERAPY ADMIN CNS W/LUMB 96450 $ 786.94 CHEMOTHERAPY ADMIN, INTRA-ARTR <=1 HR 96422 $ 505.36 CHEMOTHERAPY REGIMEN Acquisition cost CHEMOTX ADM IV INFUS W/PUMP 96416 $ 786.94 CHEMOTX ADMIN INTRA-ART; PUSH TECH 96420 $ 786.94 CHEMOTX ADMIN IV; INFUSION TECH UP-1 HR 96413 $ 726.57 CHEMOTX ADMIN IV; PUSH TECH 96409 $ 505.36 CHEMOTX INJ SUBARACH-1/MX AGENTS 96542 $ 505.36 CHEMOTX INTRA-ART; 1-8 HR EA ADD HR 96423 $ 97.92 CHEMOTX INTRA-ART;PROLONGED W/PUMP>8 HRS 96425 $ 786.94 CHERRY SYRUP Acquisition cost CHERRY SYRUP 480ML Acquisition cost CHEST CT WITHOUT CONTRAST 71250 $ 302.70 CHEST CT WITH CONTRAST 71260 $ 668.38 CHEST MRI WITH AND WITHOUT CONTRAST 71552 $ 1,206.90 CHEST MRI WITH CONTRAST 71551 $ 1,803.27 CHEST MRI WITHOUT CONTRAST 71550 $ 614.37 CHEST 1 VIEW AP/ PA 71045 $ 159.39 CHEST COMPLETE 71048 $ 159.39 CHEST CT WITH AND WITHOUT CONTRAST 71270 $ 668.38 CHEST DRAINAGE UNIT $ 374.00 CHEST DRAINGE/CLOSED $ 80.00 CHEST MRA WITH CONTRAST 71555 $ 196.50 CHEST MRA WITHOUT CONTRAST 71555 $ 196.50 CHEST PA / LAT 71046 $ 159.39 CHEST PA / RIBS BILATERAL 71111 $ 302.70 CHEST PA / RIBS UNILATERAL 71101 $ 302.70 CHEST PHYSIOTHERAPY (CPT) 94667 $ 277.79 CHEST STEREO FRONTAL 71015 $ 159.39 CHEST US 76604 $ 302.70 CHEST WALL MANIPULATION, SUBSEQUENT 94668 $ 277.79 CHEST/APICAL LORDOTIC 71021 $ 159.39 CHEST/DECUBITUS 71035 $ 159.39 Page 62 2018 CHEST/OBLIQUE 71022 $ 159.39 CHILD APPLY SKIN GFT SUB; T/A/L 15273 $ 7,168.06 CHILD DT - COLLATERAL 90847 $ 290.00 CHILDRENS PEG-CATEG 1 Acquisition cost CHLAMYDIA ANTIBODY 86631 $ 32.12 CHLAMYDIA CULTURE 87110 $ 53.22 CHLAMYDIA DNA PROBE 87490 $ 54.47 CHLAMYDIA ISOLATION 87110 $ 53.22 CHLAMYDIA T AMPLIF NA PROBE 87491 $ 95.33 CHLAMYDIA T DIR NA PROBE 87490 $ 54.47 CHLAMYDIA T, AMPLIF NA PROBE 87491 $ 95.33 CHLAMYDIA TRACHOMATIS IGM 86631 $ 32.12 CHLORAL HYDR 500MG/5ML ORAL SYRP Acquisition cost 82415 $ 34.41 CHLORAMPHENICOL LEV 82415 $ 34.41 CHLORAPROMAZINE HCL, 5MG ORAL Q0161 $ 7.28 CHLORASEPTIC SPRAY Acquisition cost CHLORDIAZEPOXIDE 10MG CAP Acquisition cost CHLORDIAZEPOXIDE 25MG CAP Acquisition cost CHLORDIAZEPOXIDE 5MG CAP Acquisition cost CHLORDIAZEPOXIDE HCL 25MG Acquisition cost CHLORHEXADINE GLUCONATAE 480ML $ 1.98 GLU CLEANSER Acquisition cost CHLORIDE 82435 $ 12.50 CHLORIDE STOOL 82438 $ 13.27 CHLORIDE FLUID 82438 $ 13.27 CHLORIDE UR RAN 82436 $ 13.66 CHLORIDE UR TV 82436 $ 13.66 CHLORIDE; BLOOD 82435 $ 12.50 CHLOROMYCETIN 1GM VIAL INJ J0720 Acquisition cost CHLOROPROMAZINE 50MG ORAL SYR Acquisition cost CHLOROQUINE PHOS 500MG TAB Acquisition cost CHLORPHENIRAMINE MAL 4MG TAB Acquisition cost CHLORPROMAZINE 80299 $ 41.01 CHLORPROMAZINE 50MG/0.5ML ORAL SYR Acquisition cost CHLORPROMAZINE HCL 100MG TAB Q0161 Acquisition cost CHLORPROMAZINE HCL 200MG TAB Acquisition cost CHLORPROMAZINE HCL 50MG TAB Q0161 Acquisition cost CHLORPROMAZINE HCL, 5MG TAB Q0161 Acquisition cost CHLORPROMAZINE HCL; 5MG TAB Q0161 Acquisition cost CHLORTHALIDONE 25MG TAB Acquisition cost CHLORTHALIDONE 50MG TAB Acquisition cost CHMDNRVTN MUSC(S);CRVCL SPNL MUSC(S) 64616 $ 647.13 CHMDNRVTN OF MUSC(S);CRVCL SPNL MUSC(S) 64616 $ 647.13 CHMOTX ADM IV INFUS 1-8 HR 96415 $ 153.91 CHNG G-TUBE - G/J-TUBE; PERQ 49446 $ 3,774.85 CHNG NEPHROSTOMY/PYELOSTOMY TU 50435 $ 4,484.35 CHOLANG CATH 5.5 FR TIP/18 INCH LGT C1887 $ 585.00 CHOLANGIOGRAM CATHETER C1887 $ 585.00 CHOLANGIOGRAPHY; INTRAOP-RAD S / I 74300 $ 39.71 CHOLANGIOGRPHY; ADD SET-INTRAOP-S/I 74301 $ 22.84 CHOLECYSTECTOMY 47600 $ 2,279.20 CHOLECYSTOGRAPHY ORAL CONTRAST 74290 $ 668.38 CHOLEDOCHOTOMY; WO TD SPHINCTRTMY 47420 $ 2,860.88 CHOLERA VACCINE (Vaxchora) $ 0.10 CHOLERA VACCINE LIVE ORAL 90625 $ 594.00 Page 63 2018 CHOLESTEROL 82465 $ 11.81 CHOLESTEROL LDL 83721 $ 25.92 CHOLESTEROL-HDL 83718 $ 22.26 CHOLESTYRAMINE/SUCR 4GM Acquisition cost CHOLESTYRAMINE-QUESTRAN 4 GM Acquisition cost CHOLINE MAG TRISALICYL 500MG TAB Acquisition cost CHOLINE MAG TRISALICYL 750MG TAB Acquisition cost CHOLINEMAGNESIUM TRISALIYLATE LIQ (SCC) Acquisition cost CHOMOSOME ANALY;ADD HIGH RESOLUTION STUD 88289 $ 93.52 CHONDROITIN/SOD HYALURON KIT Acquisition cost CHORIONIC VILLUS SAMPLE 59015 $ 1,522.22 CHROM ANAL BL-BKG 88245 $ 470.36 CHROM ANAL BL-FX 88248 $ 470.36 CHROM ANAL BL-KAR STD 88262 $ 338.54 CHROM ANAL BL-LEUK 88280 $ 73.63 CHROM ANAL BL-MOSAIC 88248 $ 470.36 CHROM ANAL BL-STD 88230 $ 316.40 CHROM ANAL FLUID 88239 $ 400.66 CHROM ANAL;CT 45 CEL MOSA 2 KARYO W/BAND 88263 $ 408.19 CHROM ANAL-45 CELL 88263 $ 408.19 CHROM ANAL-ADD CELL 88285 $ 59.20 CHROM ANAL-ADD KARY 88285 $ 59.20 CHROM ANAL-BONE 88237 $ 343.05 CHROM ANAL-HIGH RES ST 88289 $ 93.52 CHROM ANAL-SPEC STAIN 88283 $ 186.32 CHROM ANAL-TISSUE 88233 $ 382.23 CHROM ANALY BASELINE BREAKAGE 88248 $ 470.36 CHROM ANALY BREAK SYDROME;SCE 20-25 CELL 88245 $ 470.36 CHROM ANALY; 15-20 CELLS 88262 $ 338.54 CHROM ANALY; 20-25 CELLS 88264 $ 338.54 CHROM ANALY; ADD CELLS COUNTED EA STUDY 88285 $ 59.20 CHROM ANALY; ADD KARYOTYPES EA STUDY 88280 $ 73.63 CHROM ANALY; ADD SPECIALIZED BANDING TEC 88283 $ 186.32 CHROM ANALY; ADDTL KARYOT EA STUDY 88280 $ 73.63 CHROM ANALY; SITU AF CELLS FROM 6-12 COL 88269 $ 451.75 CHROM ANALY;CT 15-20 CELL 2 KARYO W/BAND 88262 $ 338.54 CHROMIUM (BLOOD) 82495 $ 55.09 CHROMIUM (URINE) 82495 $ 55.09 CHROMIUM 4MCG/ML IV Acquisition cost CHROMO ANALY; CT 15-20 CELL 2 KARYO 88262 $ 338.54 CHROMOGENIC SUBSTRATE ASSAY 85130 $ 32.30 CHROMOGRANIN A 83519 $ 40.48 CHROMOSOME ANAL(AM FL) 88262 $ 338.54 CHROMOSOME ANALYSIS 88230 $ 316.40 CHROMOSOME ANALYSIS 88262 $ 338.54 CHROMOSOME ANALYSIS FOR AF/CVF 88267 $ 488.29 CHROMOSOMES, AFPQPANEL Acquisition cost CHROMOSOMES, BLOODQPANEL Acquisition cost CHROMOSOMES, HEMATOLOGICQPANEL Acquisition cost CHROMOSOMES, TISSUEQPANEL Acquisition cost CHROMOTUBATION OVIDUCT INCL MA 58350 $ 10,873.98 CICLOPIROX 0.77% CREAM TOP Acquisition cost CIDEX $ 12.38 CIDOFOVIR 75MG/ML VIAL J0740 Acquisition cost CILIARY BDY DESTRUC; CYCLOPHOT 66710 $ 4,790.26 CILIARY BODY DESTRCT; CRYOTHER 66720 $ 4,790.26 Page 64 2018 CILOSTAZOL 100MG (PLETAL) TAB Acquisition cost CILOSTAZOL 100MG TAB Acquisition cost CILOSTAZOL 50MG (PLETAL) TAB Acquisition cost CILOXAN 0.3% OPTH DROPS 5ML Acquisition cost CIMETIDINE 300MG. PO Acquisition cost CIMETIDINE 300MG/5ML PO LIQ Acquisition cost CIMETIDINE 400MG TAB Acquisition cost CIMETIDINE 800MG TAB Acquisition cost CINACALCET 30MG TAB Acquisition cost CINACALCET 60MG TAB Acquisition cost CINACALCET 60MG TABLET Acquisition cost CINACALCET 90MG TAB Acquisition cost CINERADIOGRAPHY EX WHERE SPEC INCL 76120 $ 302.70 CINERADIOGRAPHY-COMPLEMENT ROUTINE EXAM 76125 $ 30.60 CIPRO 400MG IV J0744 $ 5.72 CIPRO 500MG TAB J8499 $ 8.25 CIPRODEX OTIC SOLUTION 0.3% $ 463.32 250 MG/ML J0744 Acquisition cost CIPROFLOXACIN 250MG TAB Acquisition cost CIPROFLOXACIN 500MG TAB Acquisition cost CIPROFLOXACIN 750MG TAB Acquisition cost CIPROFLOXACIN HC SUSP OTIC Acquisition cost CIPROFLOXACIN/D5W 200MG IV J0744 Acquisition cost CIPROFLOXACIN/D5W 400MG IV J0744 Acquisition cost CIPROFLOXACIN/DEXA.0.3-0.1% OTIC SUSP. Acquisition cost CIRC NO CLAMP/DORSL SLIT; NOT 54161 $ 4,484.35 CIRC NOT CLAMP DEVC/DORSL SLIT; NB 54160 $ 4,484.35 CIRC USING CLAMP/OTH DEVICE; NOT NB 54150 $ 4,484.35 CIRCUMCISION NEONATAL; 28 DAYS OR LESS 54160 $ 4,484.35 CIRCUMCISION W REGIONAL BLCK 54150 $ 4,484.35 CISPLATIN 10 MG J9060 $ 10.65 CISPLATIN 100MG/100ML AQ J9060 Acquisition cost CISPLATIN 50MG/50ML AQ J9060 Acquisition cost CISPLATIN,POWDER OR SOL, 10 MG J9060 $ 10.65 CISTERNAL PUNCT; W/INJ DRUG/OT 61055 $ 647.13 CISTERNOGRAPHY POS CONTRAST-RAD S / I 70015 $ 1,803.27 CITALOPRAM 10MG TAB O Acquisition cost CITALOPRAM 10MG/5ML PO SOL Acquisition cost CITALOPRAM 40MG TABLET Acquisition cost CITRATE (SERUM) 82507 $ 75.53 CITRATE (URINE) 82507 $ 75.53 CITRATE OF MAGNESIA ORAL SOLN Acquisition cost CITRIC ACID/SOD CITRAT PO SOL Acquisition cost CITROCARBONATE (E-Z GAS II ) PACKET Acquisition cost CK MBPANEL Acquisition cost CK-MB (IMMUNO) 82553 $ 31.37 CK-MB INDEX $ 26.39 CL LACERAT MOUTH VESTIB;2.5CM 40831 $ 1,216.16 CL LACERATION MOUTH VESTIB;2.5 40830 $ 472.05 CL TX "NURSEMAID ELBOW" W MANIP; CHILD 24640 $ 568.33 CL TX 1 MP DISLOC S ANES 26700 $ 568.33 CL TX ACLAV DISLOC; W MANIP 23545 $ 568.33 CL TX ANKLE DISLOC W ANESTH 27842 $ 3,570.03 CL TX ANKLE DISLOC; WO ANESTH 27840 $ 568.33 CL TX ART FX MCP/IP JNT; WO MANIP 26740 $ 568.33 CL TX ARTFX, MCP/IP JNT; W MANIP 26742 $ 3,570.03 Page 65 2018 CL TX ARTIC FX MCP/IP JNT; W MANIP; EA 26742 $ 3,570.03 CL TX BIMALLE ANKL FRACT WOMNP 27808 $ 568.32 CL TX C HUMERUS FX; MED/LAT; W MANIP 24577 $ 3,570.03 CL TX C HUMERUS RX W MANIP 24577 $ 3,570.03 CL TX CALCAN FX-NO MANIP 28400 $ 568.33 CL TX CALCANEAL FRACT; W MANIP 28405 $ 568.33 CL TX CALCANEAL FX; W MANIP 28405 $ 568.33 CL TX CARPAL BNE FX WO MANIP; EA 25630 $ 568.33 CL TX CARPL BONE FX W MANIP; EA 25635 $ 3,570.03 CL TX CLAVICULAR FX; W MANIP 23505 $ 3,570.03 CL TX CMC DISLOC THUMB W MANIP 26641 $ 568.32 CL TX CMC DISLOC THUMB; W MANIP 26641 $ 568.33 CL TX CMC DISLOC, W MANIP; WO ANESTH 26670 $ 568.33 CL TX CMC FX DISLOC; THUMB; W MANIP 26645 $ 3,570.03 CL TX D PHAL FX, FGR/THMB; WO MANIP 26750 $ 568.33 CL TX DISL IP JNT W MANIP; W ANESTH 26775 $ 627.51 CL TX DISLOC THUMB CMC FX; W MANIP 26645 $ 3,570.03 CL TX DIST FIB FX; W MANIP 27788 $ 568.33 CL TX DIST PHAL FX, FINGR/THMB; W MANIP 26755 $ 568.33 CL TX DIST TIB ; WO MANIP; W/WO ANESTH 27824 $ 568.33 CL TX DISTL PHAL FX; FNGR/THMB W MANIP 26755 $ 568.33 CL TX DSTL FIB FX WO MANIP 27786 $ 568.33 CL TX DSTL RADIAL FX/EPIPHYSL SEP W MNP 25605 $ 3,570.03 CL TX DSTL RADIOULNAR DISLOC W MANIP 25675 $ 568.33 CL TX EC HUMERUS FX; WO MANIP 24560 $ 568.33 CL TX ELBOW DISLOC; WO ANESTH 24600 $ 568.33 CL TX FINGR/THMB DIST PHAL FX; WO MANIP 26750 $ 568.33 CL TX FX GRT PHALANX; WO MANIP 28490 $ 568.33 CL TX FX, EC HUMERUS; W MANIP 24565 $ 3,570.03 CL TX FX, NASAL BONE; W STABLIZ 21320 $ 5,815.59 CL TX FX, PHALNX/PHALANG WO MANIP 28510 $ 568.33 CL TX FX, PROX HUMRL; W MANIP 23605 $ 3,570.03 CL TX HUMERUS FX W MANIP 24505 $ 3,570.03 CL TX HUMERUS FX WO MANIP 24500 $ 568.33 CL TX HUMRL CONDYL FX; WO MANIP 24576 $ 568.33 CL TX IP JNT DISL W MANIP; SING 26770 $ 568.33 CL TX IP JOINT DISL WO ANESTH 28660 $ 568.33 CL TX KNEE DISLOC; W ANESTH 27552 $ 3,570.03 CL TX KNEE DISLOC; WO ANESTH 27550 $ 568.33 CL TX LUNATE DISLOC W MANIP 25690 $ 3,570.02 CL TX MAND/MAXILL AL VEOLAR RIDGE FX 21440 $ 5,815.59 CL TX MC FX SING; WO MANIP EA BONE 26600 $ 568.33 CL TX MC FX, SGL; W MANIP 26605 $ 568.33 CL TX MCP DISLOC W MANIP; SINGLE 26700 $ 568.33 CL TX MCP DISLOC W MANIP; W/ ANESTH 26705 $ 3,570.03 CL TX MCP DISLOC, SING W MANIP; W ANESTH 26705 $ 3,570.03 CL TX MED MALL FX S MANP 27760 $ 568.33 CL TX MED MALLEOLUS FX; W MANIP 27762 $ 3,570.03 CL TX MEDIAL ANKLE FX; WO MANIP 27760 $ 568.33 CL TX METACARPL FX W MANIP; EXT FIX; EA 26607 $ 3,570.03 CL TX METATARSAL FX; W MANIP 28475 $ 568.33 CL TX METATARSAL FX; WO MANIP 28470 $ 568.33 CL TX MTP JNT DISLOC WO ANESTH 28630 $ 568.33 CL TX MTP JOINT DISLOC; WITH ANESTH 28635 $ 3,570.03 CL TX NAS FX W/WO STABIL 21337 $ 5,815.59 CL TX NASAL BONE FX WO MANIPULATION 21310 $ 568.33 Page 66 2018 CL TX NASAL BONE FX; W/STABILIZ 21320 $ 5,815.59 CL TX NASAL SEPTAL FX 21337 $ 5,815.59 CL TX NAVICULAR FX; WO MANIP 25622 $ 568.33 CL TX OF MALLET FINGER 26432 $ 3,570.03 CL TX OF MAND FX W ID FIX 21453 $ 11,474.25 CL TX PAT DISLOC-NO ANES 27560 $ 568.33 CL TX PATELLAR DISLOC; WO ANESTH 27560 $ 568.33 CL TX PHAL SHAFT FX; W MANIPULATION 26725 $ 568.33 CL TX PHALNX/PHALNG FX, WO MANIP; EA 28510 $ 568.33 CL TX PHANG SHAFT FX; W MANIP 26725 $ 568.33 CL TX POST ANKLE FX W/MNPJ 27768 $ 3,570.02 CL TX POST HIP DISLC WO ANESTH 27265 $ 568.33 CL TX POST MALLEOLUS FX; WO MANIP 27767 $ 568.33 CL TX POSTOP HIP DISLOC W ANESTH 27266 $ 3,570.03 CL TX PROX FIB/SHAFT FX WO MAN 27780 $ 568.32 CL TX PROX FIB/SHFT FX; W MANIP 27781 $ 3,570.03 CL TX PROX HUMERAL FX; W MANIP 23605 $ 3,570.03 CL TX PROX HUMERAL FX; W/O MANIP 23600 $ 568.33 CL TX PROX HUMERAL FX; WO MANIP 23600 $ 568.33 CL TX PROX TIBIAL FX W SK TRACTION 27752 $ 3,570.03 CL TX PROX TIBIAL FX; WO MANIP 27530 $ 568.33 CL TX RAD HD/NCK FX; WO MANIP 24650 $ 568.33 CL TX RADIAL & ULNAR SHFT FX; WO MNP 25560 $ 568.33 CL TX RADIAL HD/NECK FX; W MANIP 24655 $ 3,570.03 CL TX RADIAL/ULNR FX W MANIP 25565 $ 3,570.03 CL TX RADIO/INTRCRPL DISLC; 1+ BNS W MNP 25660 $ 568.33 CL TX SC/TC HUM SHFT FX; W MANIP 24535 $ 3,570.03 CL TX SC/TC HUMERUS FX; WO MANIP 24530 $ 568.33 CL TX SCAPULAR FX; WITH MANIP 23575 $ 3,570.03 CL TX SCAPULAR FX; WO MANIP 23570 $ 568.33 CL TX SHLDR DISL W MANIP W ANESTH 23665 $ 3,570.03 CL TX SHLDR DISL W MANIP; W ANESTH 23655 $ 3,570.03 CL TX SHLDR DISLOC W GT FX; W/MANIP 23665 $ 3,570.03 CL TX SHLDR DISLOC W MANIP; WO ANESTH 23650 $ 568.33 CL TX SHLDR DISLOC; W NK FX, W MANIP 23675 $ 3,570.03 CL TX TALUS FX; W MANIP 28435 $ 3,570.03 CL TX TIB SHFT FX; WO MANIP 27750 $ 568.33 CL TX TIBIAL SHFT FX; W MANIP 27752 $ 3,570.03 CL TX TMT JNT DISLOC; WO ANESTH 28600 $ 568.33 CL TX TRAUMTIC HIP DISLOC; WO ANESTH 27250 $ 568.33 CL TX TRIMALL ANKLE FX WO MANIP 27816 $ 568.33 CL TX TRIMALLEOLAR FX; WO MANIP 27816 $ 568.33 CL TX TRIMALLR ANKLE FX; W MANIP 27818 $ 3,570.03 CL TX TRNS-SCPLR FX/DISLOC; W MANIP 25680 $ 568.33 CL TX ULNAR FX, PROXML END W MANIP 24675 $ 3,570.03 CL TX ULNAR SHFT FX W MANIP 25535 $ 568.33 CL TX ULNAR SHFT FX W/MANIP 25535 $ 568.33 CL TX ULNAR SHFT FX; WO MANIP 25530 $ 568.33 CL TX ULNAR STYLOID FX 25650 $ 568.33 CL TX WB DISTL TIB, W MANIP; W/WO ANESTH 27824 $ 568.33 CL TX WB TIB FX W/WO ANESTH; W MANIP 27825 $ 3,570.03 CL WND SUCT EVAC 100CC W/Y CON A4624 $ 8.01 CLADRIBINE 1MG/ML INJ Acquisition cost CLAFORAN 1GM VIAL INJ J0698 Acquisition cost CLAFORAN 2GM VIAL INJ J0698 Acquisition cost CLAMP ADJUST-CATEG 1 Acquisition cost Page 67 2018 CLAMP BABCOCK ENDODISP-CATEG 1 Acquisition cost CLAMP BOWEL ENDODISP-CATEG 1 Acquisition cost CLAMP COMBINA-CATEG 1 Acquisition cost CLAMP GLASSMAN ENDODISP-CATEG 1 Acquisition cost CLAMP KELLY ENDODISP-CAQTEG 1 Acquisition cost CLAMP ZEPPELIN-CATEG 1 Acquisition cost CLAMP, RING-TO-ROD-CATEG 1 Acquisition cost CLAMP-CATEG 1 Acquisition cost CLARFYING CLAY MASQUE $ 134.20 CLARIFYING CLAY MASQUE Acquisition cost CLARITIN 10 MG TAB Acquisition cost CLASS I MALOCCLUSION D8070 $ 2,100.00 CLASS II MALOCCLUSION D8080 $ 2,100.00 CLASS II MALOCCLUSION_ D8080 $ 2,100.00 CLASS III MALOCCLUSION D8090 $ 2,100.00 CLAVE EXT W/T-CONNCTOR C1751 $ 562.32 CLAVE EXT W/T-CONNECTOR-CATEG 1 Acquisition cost CLAVE EXTENSION SET C1751 $ 544.79 CLAVE EXTENSION SET#12241-01 $ 2.00 CLAVE MALE ADAPTER#11956-01 $ 1.32 CLAVE OMNI-FLOW #11820-01 $ 4.66 CLAVE OMNI-FLOW-CATEG 1 Acquisition cost CLAVE PIGGYBACK MICRO#11962-68 $ 7.78 CLAVE PIGGYBACK MICRO-CATEG 1 Acquisition cost CLAVE PLUM W/FILTER#11947-12 $ 5.87 CLAVE PLUM W/FILTER-CATEG 1 Acquisition cost CLAVE PLUMSET#11943-12 $ 4.66 CLAVE PLUMSET-CATEG 1 Acquisition cost CLAVE PRIM PIGGYBACK-CATEG 1 Acquisition cost CLAVE PRIM. PIGGYBACK#11961-68 $ 7.05 CLAVE SOLUSET#11964-02 $ 587.52 CLAVE SOLUSET-CATEG 1 Acquisition cost CLAVICLE 73000 $ 164.27 CLAVICULECTOMY; PARTIAL 23120 $ 6,995.52 CLEANERXT THROMBCTOMY CATH C1757 $ 825.00 CLEARVIEW MANDIBLE C1713 $ 4,509.00 CLEOCIN 1% TOPICAL SOL 30ML Acquisition cost CLEOCIN 600MG IN 50ML D5W INJ Acquisition cost CLEUPREX 100ML Acquisition cost CLINDAMYCIN 150 MG CAPSULE J8499 $ 2.44 CLINDAMYCIN 150MG CAP Acquisition cost CLINDAMYCIN 1MG/0.1ML Acquisition cost CLINDAMYCIN 300MG ADD VANTAG S0077 Acquisition cost CLINDAMYCIN 300MG ADDVANTAGE INJ S0077 $ 5.80 CLINDAMYCIN 300MG/2ML INJ Acquisition cost CLINDAMYCIN 300MG/50ML D5W Acquisition cost CLINDAMYCIN 300MG/50ML IV S0077 $ 12.10 CLINDAMYCIN 600 MG ADDVANTAGE INJ S0077 $ 10.03 CLINDAMYCIN 600MG 4ML VIAL Acquisition cost CLINDAMYCIN 600MG ADD VANTAG Acquisition cost CLINDAMYCIN 600MG ADD VANTAG Acquisition cost CLINDAMYCIN 600MG/4ML INJ Acquisition cost CLINDAMYCIN 600MG/50ML IV S0077 $ 18.15 CLINDAMYCIN 75MG/ML ORAL SOL Acquisition cost CLINDAMYCIN 900MG ADD VANT Acquisition cost CLINDAMYCIN 900MG/50ML D5W Acquisition cost Page 68 2018 CLINDAMYCIN 900MG/6ML INJ Acquisition cost CLINDAMYCIN PHOS 300MG/2ML Acquisition cost CLING BANDAGE $ 15.40 CLINIC GROUP SESSION (7) 90853 $ 290.00 CLINICAL EVAL OF SWALLOWING FUNCTION 92610 $ 186.30 CLIP ENDO ROTATE-CATEG 1 Acquisition cost CLIP HADA-CATEG 1 Acquisition cost CLIP RANEY-CATEG 1 Acquisition cost CLIP RETENTION-CATEG 1 Acquisition cost CLIP STANDARD-CATEG 1 Acquisition cost CLIP TITAN-CATEG 1 Acquisition cost CLNSCOPY VIA STOM;W TUM REM SN 44394 $ 2,476.36 CLO LACRIMAL PUNCTUM; BY PLUG EA 68761 $ 707.85 CLO LACRIMAL PUNCTUM; THERMOCAUT 68760 $ 707.85 CLO TX MC FX SING; W MANIP EA 26605 $ 568.33 CLO TX NASAL BONE FX; W/STABIL 21320 $ 5,815.59 CLO TX NASAL BONE FX; WO STAB 21315 $ 3,010.00 CLO TX PHAL SHAFT FX; WO MANIP 26720 $ 568.33 CLO TX RADIAL & ULNAR FX; W MNP 25565 $ 3,570.03 CLO TX SHOULDER DISLOC W/MANIP; WO ANES 23650 $ 568.33 CLOBAZAM 10MG TABLETS Acquisition cost CLOBAZAM 5MG TABLETS Acquisition cost CLOBETASOL 0.05% CREAM(G Acquisition cost CLOBETASOL PROP 0.05% CREAM Acquisition cost CLOMIPRAMINE 80299 $ 41.01 CLOMIPRAMINE 75MG CAP Acquisition cost CLOMIPRAMINE HCL 25MG CAPSULE Acquisition cost CLOMIPRAMINE HCL 50MG CAPSULE Acquisition cost CLONAZEPAM 80299 $ 41.01 CLONAZEPAM 0.5MG TAB Acquisition cost CLONAZEPAM 0.5MG TABLET BULK Acquisition cost CLONAZEPAM 1MG TAB Acquisition cost CLONAZEPAM 1MG TABLET BULK Acquisition cost CLONAZEPAM ORAL SOL CHERRY Acquisition cost CLONAZEPAM ORAL SOL ORASWEET Acquisition cost CLONIDINE 0.1MG TAB J8499 $ 2.44 CLONIDINE 0.2MG TAB J8499 $ 2.44 CLONIDINE 1MG TAB J0735 Acquisition cost CLONIDINE HCL 0.2MG TABLET J0735 Acquisition cost CLONIDINE HCL 0.3MG TABLET U-D J0735 Acquisition cost CLONIDINE TTS1 PATCH J0735 Acquisition cost CLONIDINE TTS2 PATCH J0735 Acquisition cost CLONIDINE TTS3 PATCH J0735 Acquisition cost CLOPIDODREL TAB - 300MG J8499 $ 34.47 CLOPIDODREL TAB - 75MG J8499 $ 2.13 CLOPIDOGREL 75MG TAB Acquisition cost CLORAX SOLUTION 3840ML Acquisition cost CLORAZEPATE DIP 7.5MG TAB PO Acquisition cost CLORAZEPATE LEVEL 80346 $ 11.00 CLOS RECTOVAGNL FIST; VAG/TRNSANAL APPR 57300 $ 6,010.51 CLOS TX ANKLE DISLOC; WO ANESTH 27840 $ 568.33 CLOS TX CMC DISLOC; W MANIP; W ANESTH 26675 $ 3,570.03 CLOS TX DIST RADIAL FX; REQ MANIP 25605 $ 3,570.03 CLOS TX DISTAL FIB FX; WO MANIP 27786 $ 568.33 CLOS TX EC HUMERUS FX; W MANIP 24565 $ 3,570.03 CLOS TX FX GRT PHALANX; W MANIP 28495 $ 568.33 Page 69 2018 CLOS TX NASAL BN FX; WO MANIP 21310 $ 568.33 CLOS TX PATELLAR FX; WO MANIP 27520 $ 568.33 CLOS TX RADIAL HEAD SUBLUX CHILD 24640 $ 568.33 CLOS TX VERT BDY FX NO MANIP W/CAST 22310 $ 568.33 CLOS TX VERT FX/DISLOC W/CAST MANIP 22315 $ 3,570.03 CLOS URETHROSTOMY FISTULA; MALE 53520 $ 9,800.87 CLOSE GASTROSTOMY; SURG 43870 $ 7,255.23 CLOSE LACRIMAL FISTULA 68770 $ 4,790.26 CLOSE VESICOVAGINL FISTULA; VAGINAL 57320 $ 10,873.98 CLOSED DRAINAGE FOLEY SYS 16FR A4340 $ 20.27 CLOSED MAXILLA FRACTURE D7560 $ 3,037.00 CLOSED RED DISLOCATION D7820 $ 885.00 CLOSED RED MANDIBLE FX D7640 $ 4,052.00 CLOSED RED MANDIBLE FX COMPD D7740 $ 4,130.00 CLOSED TC TMJ DISLOC; INITIAL 21480 $ 568.33 CLOSED THOROCOTOMY TRAY $ 71.50 CLOSED TREAT NASAL BONE FRAC W/O STABILN 21315 $ 3,010.00 CLOSED TREATMENT OF DISTAL FIBULAR 27788 $ 568.33 CLOSED TX FEMORAL FX; WO MANIP 27508 $ 568.33 CLOSED TX PHALAX 28515 $ 568.33 CLOSED TX ULNAR FR PROXIM END WO MNP 24670 $ 568.33 CLOSED TX ULNR STYLOID FX 25650 $ 568.33 CLOSURE LAC VESTIBULE OF MOUTH 40830 $ 472.05 CLOSURE OF SALIVARY FISTULA D7983 $ 2,677.00 CLOSURE SALIVARY FISTULA 42600 $ 5,815.59 CLOT RETRACTION 85170 $ 35.86 CLOTRIMAZOLE 1% CREAM 15GM Acquisition cost CLOTRIMAZOLE 10MG TROCHE Acquisition cost CLOTRIMAZOLE/BETAMETHASONE 1/0.05% CREAM Acquisition cost CLOTTING FUNCT ACTIVITY 85397 $ 67.89 CLOTTING INHIBITOR PROTEIN S FREE 85306 $ 41.62 CLOTTING; FACTOR II PROTHROMBIN SPECIF 85210 $ 35.27 CLOTTING; FACTOR IX 85250 $ 51.72 CLOTTING; FACTOR V 85220 $ 47.94 CLOTTING; FACTOR XIII - FS 85290 $ 44.37 CLOTTING; FACTOR XIII SCREEN SOLUBLE 85291 $ 24.16 CLOZAPINE 80159 $ 50.23 CLOZAPINE 50MG TABLET J3490 Acquisition cost CLOZAPINE LEVEL 80346 $ 11.00 CLOZARIL 100MG TAB Acquisition cost CLOZARIL 25MG TAB Acquisition cost CLSD DRAINAGE BAG $ 3.59 CLSD TX ACLAV DISLOC; W/ MANIP 23545 $ 568.33 CLSD TX CLAV FX NO MANIP 23500 $ 568.33 CLSD TX FING FX-NO MANIP 26720 $ 568.33 CLSD TX IP DISLOC W ANES 26775 $ 627.51 CLSD TX MT FX W/O MANIP 28470 $ 568.33 CLSD TX SCAPH FX W MANIP 25624 $ 3,570.03 CLSD TX TMJ DISLOCATION 21480 $ 568.33 CLTX CARPL BONE EX W MNP EA BONE 25635 $ 3,570.03 CLTX DSTL RADIAL FX/EPIPHYSL SEP WO MNP 25600 $ 568.33 CLTX MED ANKLE FX; W MANIP 27762 $ 3,570.03 CLTX POST HIP ARTHRPLSTY DISLC WO ANESTH 27265 $ 568.33 CLUBFT CAST W MLD/MANIP; LNG/SHRT LEG 29450 $ 358.14 CLUSTER ACETA HIP SHELL GCUP C1776 $ 1,200.00 CLUSTER ACETABULAR SHELL C1776 $ 1,200.00 Page 70 2018 CLUSTER ACETABULAR SHELL 48MM D CUP C1776 $ 1,200.00 CLUSTER ACETABULAR SHELL 54MM F CUP C1776 $ 1,200.00 CLUSTER ACETABULAR SHELL 58MM G CUP C1776 $ 1,200.00 CMC TENDON TRNSFR/TRNSPLNT 26480 $ 6,995.52 CMCQ (CYTOMEGALOVIRUS CULT)PANEL Acquisition cost CMPL BI D SCAN EXT VEIN 93970 $ 614.37 CMPLX REP E/N/E/L; 1.1-2.5CM 13151 $ 1,291.09 CMPLX REP E/N/E/L; 2.6-7.5CM 13152 $ 1,291.09 CMPLX REP F/G/H/F; 1.1-2.5CM 13131 $ 821.94 CMPLX REP F/G/H/F; 2.6-7.5CM 13132 $ 1,291.09 CMPLX REP H/A/G/EXTR; EA ADD 5CM/LESS 13133 $ 284.55 CMPLX REP S/A/L; 1.1-2.5CM 13120 $ 1,291.09 CMPLX REP TRUNK; 1.1-2.5 CM 13100 $ 1,291.09 CMPLX REP; S/A/L 2.6-7.5CM 13121 $ 1,291.09 CMPLX RPR S/A/L; 1.1-2.5CM 13120 $ 1,291.09 CMPLX RPR S/A/L; 2.6-7.5CM 13121 $ 1,291.09 CMPLX RPR TRUNK; 1.1-2.5CM 13100 $ 1,291.09 CMPLX RPR TRUNK; 2.6-7.5CM 13101 $ 1,291.09 CMPLX SUTURE LIV WND/INJ 47360 $ 4,005.85 CMPTR OPHTH DX IMG ANT SEGMT 92132 $ 147.99 CMV ANTIBODY 86644 $ 39.09 CMV CULTURE 87254 $ 53.13 CMV DNA BY PCR 87496 $ 95.33 CMV IGG 86644 $ 39.09 CMV IGM IFA 86645 $ 45.76 CMV NEG &/OR SIC NEG UNITS 86644 $ 39.09 CMV-CF 86644 $ 39.09 CMV-NEG LR IRRAD RBC, EA PEDS P9058 $ 523.71 CMVNEGATIVEUNIT 86644 $ 39.09 CNTRL NASL HEMOR POSTR INITIAL 30905 $ 277.79 CNTRL NASL HEMOR POSTR INTIAL 30905 $ 277.79 CNTRL NASL HEMR ANTER CMPLEX 30903 $ 277.79 CNTRL NASL HEMR ANTER COMPLEX 30903 $ 277.79 CNTRL NOSE BLEED-ANT/SMP 30901 $ 277.79 CNTRL OROPHARYN HEMORRH; COMP 42961 $ 901.91 CNTRL OROPHARYNGEAL HEM;REQ SU 42962 $ 5,815.59 CNTRL OROPHARYNGEAL HEMORRH;SI 42960 $ 1,216.16 CNTRL VEN CATH TRY 3FR 8CM C1751 $ 90.77 CNTRL VEN CATH TRY 5FR 15CM C1751 $ 99.29 CO DIFFUSING CAPACITY 94729 $ 20.04 CO2 82374 $ 13.27 CO2 BF 82374 $ 13.27 CO2 BREATHING RESPONSE CURVE 94400 $ 360.51 CO2 DETERMINATION 94400 $ 360.51 CO2 EXPIRED GAS DETERM-INFRARED 94770 $ 658.04 CO2 OMNIGUIDE LASER C1713 $ 1,567.50 COAGULATOR BIPOLAR-CATEG 1 Acquisition cost COAPTITE INJECTABLE 1ML SYRINGE L8606 $ 549.45 COARSE BUR, EXTRA SHORT 7.0MM C1713 $ 151.20 COARSE DIAM BUR SUPER LNG 4.0M C1713 $ 178.82 COARSE DIAMON BUR SUPER LONG C1713 $ 178.82 COARSE DIAMON BUR, SHORT 5.0MM C1713 $ 142.50 COARSE DIAMOND BUR, SHORT C1713 $ 142.50 COAT GUIDEWIRE STRGHT FLEX TIP C1713 $ 16.47 COBICISTAT 150MG TABLET Acquisition cost COBRA GLIDE CATH 4FRXC2 65CM C1769 $ 536.25 Page 71 2018 COBRA IMAGER CATH II 5FR C1758 $ 135.30 10% TOPICAL SOL 4ML Acquisition cost COCAINE HCL 4% SOLUTION 4ML Acquisition cost COCAINE OR METABOLITE ASSAY 80353 $ 11.00 COCAINE W/ METABOLITES 80307 $ 158.03 COCCIDIOIDES IMM DIF 86635 $ 31.17 COCCYX CUSHION-CATEG 1 Acquisition cost COCHLEAR IMPL EXAM&PROG; <7 YRS 92601 $ 360.51 COCHLEAR IMPL EXAM&PROG; 7+ YRS 92603 $ 360.51 COCHLEAR IMPL REPROG; <7 YRS 92602 $ 360.51 COCHLEAR IMPL REPROG; 7+ YRS 92604 $ 360.51 CODA BALL CATH.035 COMPL POST C1725 $ 664.50 CODA BALLOON CATHETER 10FR C1725 $ 664.50 CODEINE PHOS 30MG/ML INJ J0745 Acquisition cost CODEINE PHOS/APAP 120MG/12MG 5ML Acquisition cost CODEINE PHOS/APAP 30-300MG #3 TAB Acquisition cost CODEINE PHOSPHATE 12-120MG/5 E Acquisition cost CODEINE PHOSPHATE/APAP30-300MG Acquisition cost CODEINE SCREEN URINE 80307 $ 158.03 CODEINE SULFATE 15MG TAB Acquisition cost CODEINE SULFATE 30MG TAT Acquisition cost CODMAN MIRCO SENSOR SKULL BOLT C1713 $ 1,110.08 CO-ENZYME Q-10 Acquisition cost COFIELD 2 HUMERAL STEM C1776 $ 3,832.50 COFIELD HUM STEM 6MMx115MM C1776 $ 3,832.50 COGNEX (TACRINE) 10 MG CAP Acquisition cost COGNEX (TACRINE) 20 MG CAP Acquisition cost COGNITIVE SKILLS DEV 23 TO 37 MIN. 97532 $ 65.69 COGNITIVE SKILLS DEV 38 TO 52 MIN. 97532 $ 65.69 COGNITIVE SKILLS DEV 8 TO 22 MIN. 97532 $ 65.69 COGNITIVE SKILLS DEVELOPMENT EA 15 MINS 97532 $ 65.69 COGNITIVE TEST BY HC PRO 96125 $ 373.00 COLACE 100MG/10ML UD LIQ Acquisition cost COLCHICINE 80299 $ 41.01 COLCHICINE 0.5MG/ML2ML INJ Acquisition cost COLCHICINE 0.6MG TAB Acquisition cost COLD AGGLUTININ 86940 $ 22.29 COLD AGGLUTININ TITER 86157 $ 21.89 COLD AGGLUTININS 86738 $ 35.95 COLD AGGLUTININS TITER 86738 $ 35.95 COLD AGGLUT'N SCREEN 86156 $ 18.19 COLD AGGLUT'N TITER 86157 $ 21.89 COLD STOOL FOR O+P 87177 $ 24.18 COLLAGEN CROSS LINKS 82523 $ 50.75 COLLAGEN CROSS LINKS ANY METHOD 82523 $ 50.75 COLLAGEN DRESSING<=16 SQ IN A6021 Acquisition cost COLLAGEN SYRINGE (COSMODERM) 0.5 ML Acquisition cost COLLAGEN SYRINGE (COSMODERM) 1 ML Acquisition cost COLLAR HEALING TITANIUM-CATEG 1 Acquisition cost COLLAR HEALING-CATEG 1 Acquisition cost COLLAR STIFF NECK EXTRICATION-CATEG 1 Acquisition cost COLLAR TRACH-CATEG 1 Acquisition cost COLLAR-CATEG 1 Acquisition cost COLLODION FLEXIBLE LIQ Acquisition cost COLON SCRN; BE ALTERN TO COLONOSCOPY G0120 $ 668.38 COLONIC STENT Acquisition cost Page 72 2018 COLONOS W HOT BX BIPOLAR 45384 $ 2,476.36 COLONOSCOPY FLEX; DX-SEP PROC 45378 $ 1,877.59 COLONOSCOPY FLEX; W/BX 1/MX 45380 $ 2,476.36 COLONOSCOPY FLEX; W/REMV LES-S 45385 $ 2,476.36 COLONOSCOPY LASER BIOPSY 45382 $ 2,476.36 COLONOSCOPY STOMA 44388 $ 1,877.59 COLONOSCOPY THRU COLOST COMPL 44388 $ 1,877.59 COLONOSCOPY VIA STOMA;WBX;SING 44389 $ 2,476.36 COLONOSCOPY W BALLOON DIL;1/CM 13133 $ 284.55 COMP REP S/A/L; EA ADD 5CM OR LESS 13122 $ 185.55 COMP SCREEN MAMMOGRAM ADD-ON 77067 $ 83.14 COMP URETHRAL CATH 51703 $ 360.51 COMPAT TEST EA UNIT; IMMED SPIN TECH 86920 $ 341.62 COMPL REP S/A/L; 2.6-7.5 CM 13121 $ 1,291.09 COMPLEMENT 86162 $ 55.20 COMPLEMENT; AG EA 86160 $ 32.58 COMPLERA 25MG/200MG/300MG. PO Acquisition cost COMPLETE CATARACT PIKPAK EYE PAK C1780 $ 433.88 COMPLETE CATRACT, C1780 $ 438.77 COMPLETE CATRACT, 4/BX C1780 $ 438.77 COMPLETE LOWER DENTURE D5120 $ 1,400.00 COMPLETE PEDIATRIC ECHO 93303 $ 1,287.09 COMPLETE SE STENT 60MM LONG C1876 $ 1,612.50 COMPLETE SE STENT LONG 100MM C1876 $ 1,762.50 COMPLETE SE VASC 6X40MM STENT C1876 $ 1,612.50 COMPLETE UPPER DENTURE D5110 $ 1,400.00 COMPLEX CARE COORDINATION; 5 MIN 90882 $ 87.00 COMPLEX CYSTO 51726 $ 1,495.78 Complex Cysto w/voiding pressure study 51728 $ 1,495.78 COMPLEX CYSTOMETROGRAM 51726 $ 1,495.78 COMPLEX FX W/MULT APPROACHES D7780 $ 12,275.00 COMPLEX REP TRUNK; 2.6-7.5CM 13101 $ 1,291.09 COMPLEX REPAIR TRUNK; EA ADD 5> CM 13102 $ 160.78 COMPLICATED SYTURE - UP TO 5CM D7911 $ 525.00 COMPLX UROFLOWMETRY 51741 $ 360.51 COMPONENT FEM KNEE-CATEG 1 Acquisition cost COMPONENT HEAD-CATEG 1 C1776 Acquisition cost COMPONENT HEAD-CATEG 2 Acquisition cost COMPONENT HEAD-CATEG 3 C1776 Acquisition cost COMPONENT PATELLAR-CATEG 1 C1776 Acquisition cost COMPONENT STEM-CATEG 1 Acquisition cost COMPONENT STEM-CATEG 2 Acquisition cost COMPONENT TIBIA-CATEG 1 Acquisition cost COMPOS MESH LOW PROF POLY&PTFE C1781 $ 570.00 COMPOSITE MESH TEFLON/POLYPRO C1781 Acquisition cost COMPOSIX 7.2X9.2 C1781 $ 1,863.00 COMPOSIX 7.2X9.2 C1781 $ 1,986.00 COMPOUND BENZOIN TINCTURE Acquisition cost COMPREHENSIVE - HEARING TEST 92557 $ 360.51 COMPREHENSIVE HEARING TEST 92557 $ 360.51 COMPREHENSIVE METABOLIC PANEL 80053 $ 28.69 COMPREHENSIVE METABOLIC PANEL 80053 $ 28.69 COMPREHENSIVE ORAL EVALUATION D0150 $ 252.00 COMPREHENSIVE ORAL EXAM D0160 $ 224.00 Page 74 2018 COMPREHENSIVE PERIDONTAL EVALUA D0180 $ 252.00 COMPRESS-CATEG 1 Acquisition cost COMPRESSION GUIDE C1713 $ 645.46 COMPRESSION SCREW C1713 $ 37.50 COMPRESSION SCREWS HEADLESS 30x22MM C1713 $ 630.00 COMPRESSOR AIR POWER SOURCE EQUIPMENT E0565 $ 9.00 COMPUTER DX MAMMOGRAM ADD-ON 77065 $ 89.08 COMRESSION SCRW HEADLESS3.0MM C1713 $ 399.00 CONDITIONING PLAY - AUDIOMETRY 92582 $ 360.51 CONDITIONING PLAY AUDIOMETRY 92582 $ 360.51 CONDUIT TCP 30CC C1713 $ 1,890.00 Condylectomy D7840 $ 7,361.00 CONE BEAM CT CAPT & INTERP D0364 Acquisition cost CONE BEAM CT CAPT BOTH JAWS D0383 Acquisition cost CONE BEAM CT CAPT LIMITED D0380 Acquisition cost CONE BEAM CT CAPT MANDIBLE D0381 Acquisition cost CONE BEAM CT CAPT MAXILLA D0382 Acquisition cost CONE BEAM CT CAPTURE TMJ D0384 Acquisition cost CONE BEAM CT INTERP BOTH JAW D0367 Acquisition cost CONE BEAM CT INTERPRETE MAN D0365 Acquisition cost CONE BEAM CT INTERPRETE MAX D0366 Acquisition cost CONE BEAM CT INTERPRETE TMJ D0368 Acquisition cost CONE TIP 5FR URET CATH POLY C1758 $ 131.25 CONE-CATEG 1 Acquisition cost CONFIDENCE SPINAL CEMENT SYST C1713 $ 4,995.00 CONGESTIVE SKILLS DVLPMT, EA 15 MIN. 97532 $ 65.69 CONIZA CERV W/WO D/C; LOOP ELEC EXC 57522 $ 6,010.51 CONIZATION CERV W/WO D/C; KNIF/LASR 57520 $ 6,010.51 CONIZATION CERVIX W SCOPE; LEEP 57461 $ 6,010.51 CONIZATION CERVIX; LEEP 57522 $ 6,010.51 CONIZATION CERVX W/ SCOPE; LEEP 57461 $ 6,010.51 CONJ ESTROGENS INJECT-25MG J1410 Acquisition cost CONJ FLAP PATIAL 68360 $ 7,805.64 CONJ FLAP TOTAL 68362 $ 4,790.26 CONJUCTIVAL GRAFT 68320 $ 4,790.26 CONJUNCTIVORHINOSTOMY; WO TUBE INS 68745 $ 7,805.64 CONJUNCTVPLSTY; W GFT/REARRANGMNT 68326 $ 7,805.64 CONNECTIVE TISSUE/IMPLANT REPAIR C1763 Acquisition cost Connector bar D6920 $ 350.00 CONNECTOR-CATEG 1 Acquisition cost CONNECTOR-CATEG 2 Acquisition cost CONNOR ANESTHESIA CANNULA 27GA A4615 $ 31.50 CONNOR CANNULA SUB-TENON ANEST A4615 $ 276.00 CONQUEST FEM STEM 13 C1776 $ 2,470.50 CONQUEST FEM STEM SZ13 C1776 $ 2,470.50 CONQUEST FX - STEM SZ 12 C1776 $ 2,470.50 CONQUEST FX - STEM SZ 18 C1776 $ 2,470.50 CONQUEST FX STEAM 18 C1776 $ 2,470.50 CONQUEST FX STEM SZ#14 C1776 $ 2,470.50 CONQUEST FX, STEM 12 Acquisition cost CONSTELL SYS 25GA TROCAR PLUGS C1781 $ 468.00 CONSTR IM ADHES MED TARSORRHAPH 67880 $ 4,790.26 CONSTRUCT INTERMARGINAL ADHESI 67880 $ 4,790.26 CONSULT-REF SLIDES 88325 $ 118.21 CONSULT-REF SLIDES PREP ELSW 88321 $ 84.11 CONSULT-SLIDES ONLY 88321 $ 84.11 Page 75 2018 CONSULT-WET TISSUE 88323 $ 118.21 CONT EAR PULSE OXIMETRY 94762 $ 360.51 CONT EAR/PULSE OXIMETRY 94762 $ 360.51 CONT ECG MONITOR-24 HR 93224 $ 132.00 CONT GLUC MNTR PT PROV EQP 95249 $ 147.99 CONT INHALATION TRTMT, 1ST HOUR 94644 $ 277.79 CONT INTRAOP NEURO MONITOR; OR 15 MIN 95940 $ 70.95 CONT MED PHYSICS CNSLT PER WK TX 77336 $ 331.50 CONTACT EMG ENDOTRACH TUBE 8MM A4624 $ 454.50 CONTACT LENS FITTING; TX 92071 $ 74.07 CONTACT LENS PMM BIFOCAL V2502 $ 281.60 CONTIGEN BARD COLLAGEN IMPLANT INJ L8603 $ 524.93 CONTOUR PROFILE NATURAL SALINE Acquisition cost CONTRAST BATH, EA 15 MIN. 97034 $ 32.91 CONTRAST INJ EVAL CVAD 36598 $ 505.36 CONTRAST MEDIA Acquisition cost CONTRL NASAL HEMORR-ANT-SIMPL ANY METHD 30901 $ 277.79 CONTROL BONE SCREW 80/35 C1713 $ 1,134.00 CONTROL BONE SCREW 80/35 C1713 $ 1,134.00 CONTROL NASAL HEMORRH ANT; COMPLX 30903 $ 277.79 CONTROL NASAL HEMORRH; ANT; SIMPLE 30901 $ 277.79 CONTROL OROPHARYGNEAL HEMRHGE PRIM/SEC 42960 $ 1,216.16 CONTROL OROPHARYNGEAL HEMORRH; SIMPLE 42960 $ 1,216.16 CONTRST INJ ABSC PREV CATH SEP PROC 49424 $ 83.80 COOMBS TEST (AHG TITER-NON-PREG ONLY) 86886 $ 341.62 COOMBS TEST (AHG TITER-PREG. ONLY) 86886 $ 341.62 COOMBS TEST INDIRECT TITER 86886 $ 341.62 COOMBS; DIRECT 86880 $ 84.11 COORDINATION EXERCISES, EA 15 MIN. 97112 $ 75.90 COPAXONE J1595 Acquisition cost COPPER 82525 $ 33.70 COPPER BLOOD 82525 $ 33.70 COPPER IN RBC'S 82525 $ 33.70 CORACOACROMIAL LIGAMENT RELEAS 23415 $ 13,808.82 CORDIS STENT GENESIS 5MMX15MM Acquisition cost CORDIS STENT GENESIS 5MMX18MM Acquisition cost CORE BUILDS UP WITH PINS D2950 $ 280.00 CORING TUBING A4624 $ 697.50 CORKSCREW 3.5MM SUTURE ANCHOR#2 C1713 $ 292.50 CORKSCRW,SUTRE ANCHR,FIBRWRE C1713 $ 292.50 CORNEA V2785 $ 292.50 CORNEA OPH BURR 0.5MM COMP SET C1713 $ 262.50 CORNEAL RELAXING INCS-ASTIGMAT 65772 $ 2,137.81 CORNEAL TISSUE-CATEG 1 Acquisition cost CORNEAL TOPOGRAPHY 92025 $ 147.99 CORNEAL TRANSPLANT; ANT LAMELLAR 65710 $ 9,548.90 CORNEAL TRANSPLNT; IN APHAKIA 65750 $ 9,548.90 CORNEAL TRNSPL ENDOTHELIAL 65756 $ 9,548.90 CORNEAL TRNSPLNT; IN PSEUDOPHAKIA 65755 $ 9,548.90 CORNEL TOPOGRAPHY 92499 $ 46.20 COROENT XL 10X18X55 C1713 $ 8,205.60 COROENT XL 10X22X50 C1713 $ 11,121.00 CORONARY ART/GRFT ANGIO S&I 93455 $ 7,440.77 CORONARY ARTERY ANGIO S&I 93454 $ 7,440.77 Coronoidectomy D7991 $ 6,076.00 CORONOIDECTOMY 21070 $ 11,474.25 Page 76 2018 CORPORA CAVERNOSOGRAPHY-RAD S / I 74445 $ 302.70 CORRECT BUNION W/WO SESMDCTMY 28299 $ 6,995.52 CORRECT COCKUP 5TH TOE W PLSTC CL 28286 $ 3,570.03 CORRECT EVERTED PUNCTUM CAUTERY 68705 $ 707.85 CORRECT EYELID W IMPLANT 67912 $ 4,790.26 CORRECT HAMMERTOE 28285 $ 6,995.52 CORRECT LID RETRACTION 67911 $ 4,790.26 CORRECT TRICHIASIS; EPILAT-FORCEPS 67820 $ 277.79 CORTEF 10MG/5ML SUSP 120ML Acquisition cost CORTENEMA 100MG/60ML 60ML Acquisition cost CORTEX SCREW 2.4, 20MM C1713 Acquisition cost CORTEX SCREW 2.4/20MM C1713 $ 96.75 CORTEX SCREW 2.4x18MM C1713 $ 159.00 CORTEX SCREW 3.5 C1713 $ 159.00 CORTEX SCREW 3.5MM C1713 $ 25.88 CORTEX SCREW 3.5MM SELF-TAPPING 30MM C1713 $ 32.63 CORTEX SCREW 3.5MM SELF-TAPPING 36MM C1713 $ 28.47 CORTEX SCREW 3.5MM SELF-TAPPING 40MM C1713 $ 32.63 CORTEX SCREW 3.5MMx12MM C1713 $ 267.75 CORTEX SCREW 3.5x20MM C1713 $ 28.50 CORTEX SCREW 3.5x28MM C1713 $ 25.88 CORTEX SCREW 4.5MMx36MM C1713 $ 30.75 CORTEX SCREW 4.5MMx40MM C1713 $ 39.38 CORTEX SCREW 4.5x90MM C1713 $ 360.00 CORTEX SCREW SELF-TAPPING 3.5x26MM C1713 $ 60.38 CORTEX SCREW SS 2.4MMx34MM C1713 $ 96.75 CORTICAL BLCK SPINALGRAFT TECH C1768 $ 1,582.50 CORTICAL BONE SCREW 120/40MM C1713 $ 192.00 CORTICAL BONE SCREW 2.3MM C1713 $ 237.60 CORTICAL BONE SCREW 3.5 X C1713 $ 118.12 CORTICAL BONE SCREW 3.5x28MM C1713 $ 237.60 CORTICAL BONE SCREW 70/20 C1713 $ 237.60 CORTICAL BONE SCREW 90 X C1713 $ 237.60 CORTICAL BONE SCREW 90xVARIOUS C1713 $ 237.60 CORTICAL SCREW 1.7MM X C1713 $ 124.32 CORTICAL SCREW 2.4x12MM C1713 $ 237.60 CORTICAL SCREW 2.5x10MM C1713 $ 237.60 CORTICAL SCREW 3.2 C1713 $ 255.00 CORTICAL SCREW 3.5 X 14 C1713 $ 70.12 CORTICAL SCREW 3.5 X VARIOUS C1713 $ 37.29 CORTICAL SCREW 3.5MMx36MM C1713 $ 37.29 CORTICAL SCREW NON-LOCKING 3.5MMxVARIOUS C1713 $ 59.40 CORTICAL SCREW SELF TAP 4.5MM C1713 $ 46.86 CORTICAL SCRW NONLOCKING 3.5MM C1713 $ 76.80 CORTICAL SCRW SS SELF TAP 2.7 C1713 $ 40.17 CORTICOSTERONE 82528 $ 61.16 CORTISOL 82533 $ 44.26 CORTISOL FREE (URINE) 82530 $ 45.39 CORTISOL/PLASMA 82533 $ 44.26 CORTISOL/PLASMA OTHE 82533 $ 44.26 CORTISOL; FREE 82530 $ 45.39 CORTISOL; FREE. 82530 $ 45.39 CORTISONE ACETATE 10MG TABLET Acquisition cost CORTROSYN 0.25 MG(FOR IV PUSH ONLY) J0834 $ 281.38 CORTROSYN 0.25MG VAIL J0834 Acquisition cost COSMOS PMKR M/N 284-05 Acquisition cost Page 77 2018 COTAZYM CAP Acquisition cost COUMADIN 80299 $ 41.01 COUMADIN 10MG TAB Acquisition cost COUMADIN 1MG TAB Acquisition cost COUMADIN 2.5MG TAB Acquisition cost COUMADIN 2MG TAB Acquisition cost COUMADIN 5MG TAB Acquisition cost COVER EYE W AMNIOTIC MEMBRNE W SUTURE 65779 $ 7,805.64 COVER EYE W/ MEMBRANE 65778 $ 2,137.81 COXSACKIE A IGG 86658 $ 35.38 COXSACKIE A IGM 86658 $ 35.38 COXSACKIE A VIRUS ANTIBODY 86658 $ 35.38 COXSACKIE B IGG 86658 $ 35.38 COXSACKIE B IGM 86658 $ 35.38 COXSACKIE B VIRUS ANTIBODY 86658 $ 35.38 CPAP VENTILATION INIT/MANAGEMENT 94660 $ 492.89 CPEP BRIEF EVALUATION E&M SF L 99281 $ 1,175.00 CPEP BRIEF EVALUATION E/M LOW 99282 $ 1,175.00 CPEP CRISIS OTRCH E/M HIGH SEV 99284 $ 1,175.00 CPEP CRISIS OTRCH E/M HIGH SEV 99285 $ 1,175.00 CPEP CRISIS OTRCH E/M MOD SV 99283 $ 1,175.00 CPEP FULL EVAL E/M HIGH SER UR 99284 $ 1,175.00 CPEP FULL EVAL E/M HIGH SEV SI 99285 $ 1,175.00 CPEP FULL EVAL E/M MOD SERVER 99283 $ 1,175.00 CPEP INTERIM CRISIS E/M HGH SE 99285 $ 1,175.00 CPEP INTERIM CRISIS E/M HIGH S 99284 $ 1,175.00 CPEP INTERIM CRISIS E/M MOD SE 99283 $ 1,175.00 C-PEPTIDE 84681 $ 56.54 CPK 82550 $ 17.69 CPK ISOENZYME 82552 $ 36.37 CPK ISOENZYMES 82550 $ 17.69 CPK: MB FRACTION ONLY 82553 $ 31.37 CPK; TOTAL 82550 $ 17.69 CPK-MB ISOENZYME 82553 $ 31.37 CPLX REP E/N/E/L; 2.6-7.5CM 13152 $ 1,291.09 CPR 92950 $ 658.04 CPR RESPONSE 92950 $ 658.04 CRANBERRY 450 MG TAB Acquisition cost CRANIECTOMY W EXC TUM/BONE LES 61500 $ 2,788.54 CRANIOPLASTY FOR SKULL DFCT W REP 62145 $ 2,960.56 CRANIOTOME HANDPIECE BUR, MED C1713 $ 148.50 CRE WIRE GUIDED BALOON DILAT 15-18MM C1726 $ 348.81 CRE WIRE GUIDED BALOON DILATOR 10-12MM C1726 $ 339.27 CRE WIRE GUIDED BALOON DILATOR 15-18MM C1726 $ 348.81 C-REACTIVE PROTEIN 86140 $ 14.06 C-REACTIVE PROTEIN HS 86141 $ 35.16 CREATE AV FISTULA-SP; AUTOG GF 36825 $ 11,279.00 CREATE PERICARDIAL WINDOW/PART RESECT 33025 $ 1,701.83 CREATININE 82565 $ 13.93 CREATININE (BF) 82570 $ 14.06 CREATININE BODY FLUID 82570 $ 14.06 CREATININE CLEAR 82575 $ 25.67 CREATININE UR RANDOM 82570 $ 14.06 CREATININE UR T.V. 82570 $ 14.06 CREATININE; NOT BLOOD 82570 $ 14.06 CRESTOR 10 MG. PO Acquisition cost Page 78 2018 CRESTOR 20 MG. PO Acquisition cost CREWIRE GUID ESO/PYL BALL DILA C1726 $ 348.81 CRICOTHROIDOTOMY TRAY $ 93.50 CRISIS INTERV/15 MIN 90839 $ 70.40 CRISIS INTERVENT/ PER HOUR 90839 $ 1,175.00 CRISIS INTERVENT/15 MIN 90839 $ 70.40 CRISIS INTERVENT/PER IEM 90840 $ 1,175.00 CRISIS INTERVENTION/ PER HR 90839 $ 1,175.00 CRISIS INTERVENTION/DIEM 90840 $ 1,175.00 CRISIS INTERVENTION;PER 15MIN 90839 $ 1,175.00 CRISIS INTERVENTION;PER HOUR 90839 $ 1,175.00 CRISIS INTERVENTION-PER 15MIN 90839 $ 1,175.00 CRISIS INTERVENTION-PER HOUR 90839 $ 1,175.00 CRITICAL CARE E&M; 1ST 30-74 M 99291 $ 2,251.00 CRITICAL CARE EVAL/MGMNT; 1ST 99291 $ 2,251.00 CRITICAL CARE-1ST 30-74 99291 $ 2,251.00 CRITICAL CARE-ADDL 30 99292 $ 425.00 CROMOLYN OPHTH SOL 4% Acquisition cost CROMOLYN SODIUM 4% DROPS 10ML Acquisition cost CROSS 50DEGREE PROBE W/SUCT C2618 $ 305.55 CROSS MATCH 86805 $ 416.92 CROSS MATCH TEST. 86922 $ 341.62 CROSSCUT FISSRE RNDTIP CARBBUR C1713 $ 12.42 CROSSEROTW RECANALIZATION CATH C1887 $ 4,458.00 CROSSMATCH DTT 86999 $ 46.20 CROSSMATCH SEMIFINAL LRD 86999 $ 46.20 CROSSMATCH-AHG 86922 $ 341.62 CROSSMATCH-CAD FINAL 86999 $ 46.20 CROSSMATCH-IS 86920 $ 341.62 CROSSMATCH-LRD 86805 $ 416.92 CROSSMATCH-LRD FINAL 86999 $ 46.20 CROSSPIN SELF TAP LOCK SCREW C1713 $ 138.99 CROSSPIN SELFTAP 2.0X5MM SCREW C1713 $ 76.59 CROSSPIN SLFTAP 2.3X8M LCKSCRW C1713 $ 93.62 CROSSPIN SLFTAP EMERGLCKSCRW C1713 $ 178.71 CROSSPN SELF TAP EMERG SCREW C1713 $ 99.29 CROSSPN SELF TAP SCRW 1.2X10MM C1713 $ 95.03 CROSSPN SLFTAP 2.7X8M EMERSCRW C1713 $ 104.96 CROWN 3/4 CAST BASED METAL D6781 $ 630.00 CROWN 3/4 CAST NOBLE METAL D6782 $ 630.00 CROWN 3/4 PORCELAIN/CERAMIC D6783 $ 630.00 CROWN BUILDUP W/PINS D2980 $ 140.00 CROWN FULL CAST D2790 $ 980.00 CROWN FULL CAST D6790 $ 1,264.00 CROWN LENGTHENING HARD TISSUE D4249 $ 630.00 CROWN PORCELAIN/CERAMIC D6740 $ 565.00 CROWN RESIN/LAB D2710 $ 399.00 CROWN TITANIUM D2794 $ 770.00 CROWN TITANIUM RETAINER D6794 $ 784.00 Crown-3/4 resin-based comp-ind D2712 $ 420.00 Crown-full cast noble metal D2792 $ 840.00 CROWN-PFM D2750 $ 1,120.00 Crown-porcelain/ceramic D6740 $ 791.00 Crown-porcelain/ceramic substr D2740 $ 980.00 CRTCHES FORARM VARIOUS MATL PAIR E0110 $ 27.35 CRTCHES UNDARM OTH THAN WOOD PAIR E0114 $ 129.20 Page 79 2018 CRTCHS UNDARM WOOD PAIR ADJSTBL/FIX E0112 $ 27.35 CRUCIATE RETAINING FEMORAL RIGHT SZ#3 C1776 $ 1,400.28 CRUTCH ATTACHMENT WALKER EA E0157 $ 105.80 CRUTCHES ADULT-CATEG 1 Acquisition cost CRUTCHES CHILD-CATEG 2 Acquisition cost CRUTCHES LAMIN WD ADLT-CATEG 1 Acquisition cost CRUTCHES LAMIN WD ADLT-MED-CATEG 1 Acquisition cost CRUTCHES LAMIN WD CHILD-CATEG 1 Acquisition cost CRUTCHES LARGE-CATEG 1 Acquisition cost CRUTCHES MED-CATEG 1 Acquisition cost CRUTCHES SMALL-CATEG 1 Acquisition cost CRUTCHES TALL-CATEG 1 Acquisition cost CRUTCHES YOUTH-CATEG 1 Acquisition cost CRYO DEPLT FROZ PLAS P9017 $ 159.30 CRYOFIBRINOGEN 82595 $ 17.56 CRYOGLOBULIN 82595 $ 17.56 CRYOGLOBULIN - QUAL/SEMI QUAN 82595 $ 17.56 CRYOGLOBULINS UR/BLD 82595 $ 17.56 CRYOPRECIPITATE 82595 $ 17.56 CRYOPRECIPITATE REDUCED PLASMA, UNIT P9044 $ 232.19 CRYOPRECIPITATE, UNIT P9012 $ 96.82 CRYOPRESERVE-FREEZE-STORE EA CELL LINE 88240 $ 28.75 CRYOTHERAPY-ACNE 17340 $ 84.11 CRYPTOCOCCAL ANTIBODY 86641 $ 39.14 CRYPTOCOCCAL ANTIGEN 86403 $ 27.68 CRYPTOCOCCAL CSF 86403 $ 27.68 CRYPTOCOCCAL TITER 86406 $ 28.89 CRYPTOCOCCUS NEOFORM AG EIA 87327 $ 32.56 CRYPTOSPORIDIUM Ag 87272 $ 32.56 CRYSTALIDENT 89060 $ 19.43 CSD SCRW 14MM TI ANT CRV PLATE C1713 $ 394.87 CSF 89051 $ 14.96 CSF ALBUMIN 86329 $ 38.15 CSF CULTURE 87070 $ 23.41 CSF FLOW VENTRICULOGRAPHY 78635 $ 1,198.21 CSF LEAKAGE IMAGING 78650 $ 3,180.58 CSF SPECT 78647 $ 3,180.58 CSF-OLIGOCLONAL BAND 83916 $ 60.26 CSLP SMALL STATURE PLATE C1713 $ 1,537.50 CT ABD & PELVIS W/O CONTRAST 74176 $ 614.37 CT ABD&PELVIS 1+SECTION/REGNS W/O CONT 74178 $ 668.38 CT ABDOMEN & PELVIS W/CONTRAST 74177 $ 668.38 CT ANGIOGRAPHY / PELVIS W/W/O CONTRAST 72191 $ 668.38 CT ANGIOGRAPHY /ABDOMEN W / W/O CONTRAST 74175 $ 668.38 CT ANGIOGRAPHY/CHEST W / W/O CONTRAST 71275 $ 668.38 CT ANGIOGRAPHY/EXTREMITY W/ W/O CONTRAST 73202 $ 668.38 CT ANGIOGRAPHY/HEAD W/W/O CONTRAST 70496 $ 668.38 CT GUIDANCE FOR PERCUTANEOUS DRAINAGE 75989 $ 127.36 CT GUIDANCE STEREOTACTIC LOCALIZ 77011 $ 136.47 CT GUIDANCE/ PLACEMENT RAD THERAPY FIELD 77014 $ 97.04 CT GUIDANCE; TISSUE ABLATION 77013 $ 421.65 CT GUIDED ASPIRATION 77012 $ 125.27 CT GUIDED BIOPSY 77012 $ 125.27 CT GUIDED LOCALIZATION AND INJECTION 77012 $ 125.27 CT HEAD W/O CONTRAST; STROKE PROTOCOL 70450 $ 302.70 CT HEART FUNCT ADD-ON 75571 $ 164.27 Page 80 2018 CT HEART W/ WO DYE FUNCT 75572 $ 668.38 CT HEART WO DYE;QUAL CALC CALCIUM SCOR 75571 $ 164.27 CT IMAGE RENDER W POSTPROCESS 76377 $ 86.75 CT IMAGE RENDER W/O POSTPROCESS 76376 $ 21.58 CT LIMITED / LOCALIZATION FOLLOW UP 76380 $ 164.27 CT PERFUSION W/CONTRAST 0042T Acquisition cost CT TX CMC DISLOC; W MANIP; NO ANESTH 26670 $ 568.33 CTA ABD-AIFP-RAD S/I-W/WO CONTRAST 75635 $ 668.38 CTA CHEST W/ CONTRAST; PE PROTOCOL 71275 $ 668.38 CTA LWR EXTREM W AND WO CONTR 73706 $ 668.38 CTA UP EXTREM W/ / WO CONTRAST 73206 $ 668.38 C-TAPER LFIT HEAD 26MM C1776 $ 1,500.00 C-TAPERED HEAD Acquisition cost CTGQPANEL Acquisition cost CTRY/ABLTN SPF MCSA INF TURBNT UNIL BIL 30801 $ 3,010.00 CUFFED FLEX DIC TRACH 10MM ID A4624 $ 39.50 CUFFED FLEX DIC TRACH 6MM ID A4624 $ 39.50 CUFFED FLEX DIC TRACH 7MM ID A4624 $ 39.50 CUFFED FLEX DIC TRACH 9MM ID A4624 $ 39.50 CULT TB/AFB ANY SOURCE W/ISOL / ID 87116 $ 29.35 CULTURE R/O MRSA 87081 $ 18.00 CULTURE OTHER (C. DIPTHERIAE CULTURE) 87070 $ 23.41 CULTURE OTHER (THROAT) 87070 $ 23.41 CULTURE P PATHOG - SCREEN 87081 $ 18.00 CULTURE; IF EA ANTISERUM 87140 $ 15.14 CUP BIPOLAR ACET-CATEG 1 Acquisition cost CUP BIPOLAR FEM-CATEG 1 Acquisition cost CUP BIPOLAR-CATEG 1 Acquisition cost CUP SUCTION-CATEG 1 Acquisition cost CURETTAGE POSTPARTUM 59160 $ 6,010.51 CURV VACURETTE SUCT TIP 12MM A4624 $ 15.07 CURVE VACURETTE SUCT TIP 9MM A4624 $ 10.27 CURVED CEMENTED STEM C1776 $ 4,950.00 CURVED TIP NEEDLE C2618 $ 67.50 CURVED VACURETTE SUCT TIP A4624 $ 10.27 CURVED VACURETTE SUCT TIP 14MM A4624 $ 87.38 CUSHING INTERVERTEBRAL-CATEG 1 Acquisition cost CUSHIONS HEEL-CATEG 1 Acquisition cost CUST ARTHROSCOPY PACK $ 219.29 CUST BASIC EYE PACK $ 462.00 CUST BASIC PACK $ 80.67 CUST C-SECTION PACK $ 274.14 CUST CYSTO PACK $ 302.34 CUST LITHOTOMY PACK $ 53.10 CUST LOWER EXTERMITY PACK $ 192.62 CUST OB/GYN PACK $ 308.25 CUST PEDIATRIC SHEET $ 114.60 CUSTOM ABUTMENT - INCLUDES PLACEMENT D6057 $ 560.00 CUSTOM LAPAROSCOPY PACKS $ 648.27 CUT WIRE 2.4MM MAX VITAL DBLE C1769 $ 766.38 CV STRESS TEST W/TREADMILL; TRACING ONLY 93017 $ 658.04 CV STRESS TST W/PHARM; INTRPT / RPT 93015 $ 132.00 CV-2 THX 26 SUTURE, 12/BX C1713 $ 450.00 CV6 SUTRE NDLE 76MM TAPR SUTRE C2618 $ 1,291.50 CV-6 TTC-09 TAPER SUTURE 12/BX C1713 $ 481.50 CV-7 TT-13 SUTURE 3DZ/BX C1713 $ 1,305.00 Page 81 2018 CVC 4FR TWO LUMEN CATH C1752 $ 45.06 CVC 4FR TWO LUMEN CATH 5/BX C1887 $ 45.06 CXI SUP CATH 2.6FR 150CM ANGL C1887 $ 277.50 CXI SUPP CATH 2.6FR 90CM ANGLE C1887 $ 277.50 CXI SUPP CATH 2.6FR90CM STRGHT C1887 $ 277.50 CXI SUPP CATH 4.0FR STRAIGHT C1887 $ 277.50 CXI SUPPORT CATH 150CM STRGHT C1714 $ 277.50 CXI SUPPORT CATH 2.3FR STRGHT C1887 $ 277.50 CXI SUPPORT CATH 4.0FR ANGLED C1887 $ 277.50 CYANIDE 82600 $ 52.69 CYANOCOBALAMIN 100MCG/ML 1ML J3420 Acquisition cost CYANOCOBALAMINE 1000MCG. PO Acquisition cost CYANOKIT 5G KIT J3490 Acquisition cost CYCLIC AMP 82030 $ 70.07 CYCLIC AMP URINE 82030 $ 70.07 CYCLIC CITRULLINE PEP IGG 83520 $ 37.99 CYCLOBENZAPRIL 5 MG. PO Acquisition cost CYCLOBENZAPRINE 10MG TAB Acquisition cost CYCLOGYL 0.5% OPTH DROPS 2ML Acquisition cost CYCLOGYL 1% OPTH DROPS 5ML Acquisition cost CYCLOMIDRIL (CYLOPEN PHENYL) 2ML $ 69.30 CYCLOPENTOLATE HCL 1% DROPS $ 32.49 CYCLOPENTOLATE HCL 2% 2ML Acquisition cost CYCLOPHOSPHAMIDE 1 G J9070 $ 181.30 CYCLOPHOSPHAMIDE 2 G J9070 $ 181.30 CYCLOPHOSPHAMIDE 200 MG J9070 $ 181.30 CYCLOPHOSPHAMIDE 25MG TAB J8530 Acquisition cost CYCLOPHOSPHAMIDE 500 MG J9070 $ 181.30 CYCLOPHOSPHAMIDE 500MG INJ J9070 Acquisition cost CYCLOPHOSPHAMIDE 50MG TAB J8530 Acquisition cost CYCLOPHOSPHAMIDE LYOPHI 200 MG J9070 $ 181.30 CYCLOPHOSPHAMIDE LYOPHI 500 MG J9070 $ 181.30 CYCLOPHOSPHAMIDE LYOPHILIZ 2 G J9070 $ 181.30 CYCLOPHOSPHAMIDE LYOPHILIZED 1 G J9070 $ 181.30 CYCLOPHOSPHAMIDE ORAL 25 MG J8530 $ 20.59 CYCLOPHOSPHAMIDE, 100MG J9070 $ 181.30 CYCLOPHOSPHAMIDE, LYOPH 100 MG J9070 $ 181.30 CYCLOPHOTOCOAGULATION*CB 66710 $ 4,790.26 CYCLOSPORIN 0.05% EYE DROPS Acquisition cost CYCLOSPORIN 100 MG CAP J7502 Acquisition cost CYCLOSPORIN 100MG CAP J7502 Acquisition cost CYCLOSPORINE 80158 $ 49.02 CYCLOSPORINE 100MG (SANDIMMUNE) CAP Acquisition cost CYCLOSPORINE 250MG AMPULE Acquisition cost CYCLOSPORINE 25MG (SANDIMMUNE) CAP Acquisition cost CYCLOSPORINE 50MG/ML (SANDIMMUNE) IV Acquisition cost CYCLOSPORINE,ORAL, 100 MG J7502 $ 12.09 CYCTITIS BLADDER IRRIGATION Acquisition cost CYPROHEPTADINE HCL 4MG TAB Acquisition cost CYRAMZA 5MG/10ML J9308 $ 146.48 CYRAMZA 5MG/50ML J9308 $ 146.48 CYST W INS OF INDWELLING URETER STENT 52332 $ 7,131.78 CYSTICERCOSIS AB 86682 $ 35.33 CYSTICERCOSIS ABS 86682 $ 35.33 CYSTINE 24 HOUR URINE 82131 $ 50.56 CYSTINE RANDOMURINE 82615 $ 22.18 Page 82 2018 CYSTO TX FEMALE URETHRL SYNDROME 52285 $ 4,484.35 CYSTO W BIOPSY/FULG URET/RENAL LES 52354 $ 9,800.87 CYSTO W CALCULUS REM 52320 $ 9,800.87 CYSTO W CHEMODENERVATION BLADDER 52287 $ 4,484.35 CYSTO W DIL OF URETHRL STRICTURE 52281 $ 4,484.35 CYSTO W DIL URETHRAL STRICTURE 52281 $ 4,484.35 CYSTO W DILATION BLDR; GEN ANESTH 52260 $ 4,484.35 CYSTO W DIR VISION INT URETHROTOMY 52276 $ 4,484.35 CYSTO W FRAGMENT OF CALCULUS 52325 $ 9,800.87 CYSTO W FULG BLADDR TUM; 2.0-5.0CM 52235 $ 7,131.78 CYSTO W FULG BLDR TUM; 0.5 < 2CM 52234 $ 7,131.78 CYSTO W FULG MINOR LES; 0.5CM/> 52224 $ 4,484.35 CYSTO W FULGRTN LRG BLDR TUM 52240 $ 9,800.87 CYSTO W INJ IMPL MATERIAL 52327 $ 9,800.87 CYSTO W INT URETHROTOMY; MALE 52275 $ 4,484.35 CYSTO W LITHOTRIPSY 52353 $ 9,800.87 CYSTO W REM FB//STNT; URET/BLDR; COMP 52315 $ 4,484.35 cysto w rem fb/stnt ureth/bldr; simple 52310 $ 4,484.35 CYSTO W REM FB/STNT; URETH/BLDR; SIMP 52310 $ 4,484.35 CYSTO W RESCT/FULG ECTOP URETEROCELE 52301 $ 7,131.78 CYSTO W STEROID INJ INTO STRICTURE 52283 $ 4,484.35 CYSTO W UP STICTURE TX 52342 $ 9,800.87 CYSTO W URET CATH & BRUSH BX 52007 $ 7,131.78 CYSTO W URETER STRICTURE TX 52341 $ 4,484.35 CYSTO W URETOSC W URETR STRCITRE TX 52344 $ 7,131.78 CYSTOGRAFIN 18% 300ML BOTTLE Acquisition cost CYSTOGRAPHY MINI 3 VIEWS-RAD S / I 74430 $ 668.38 CYSTOGRFIN 18%/300 ML Q9958 $ 0.28 CYSTOLITHOTOMY; W REM STONE; WO VN RES 51050 $ 9,800.87 CYSTOMETROGRAM W URETHRAL PRES 51727 $ 1,495.78 CYSTOMETROGRAM W/ URETHRAL PRESSRE 51727 $ 1,495.78 CYSTOMETROGRAM W/VP 51728 $ 1,495.78 CYSTOMETROGRM W/VP & UP 51729 $ 1,495.78 CYSTORRHAPHY; SUTURE BLADDER; SIMP 51860 $ 9,800.87 CYSTOSCOPIC 5FR INJECT NEEDLE C2618 $ 31.05 CYSTOSTMY W DRAINAGE 51040 $ 4,484.35 CYSTOSTOMY CYSTOTOMY W/DRAINAGE 51040 $ 4,484.35 CYSTOSTOMY TUBE CHANGE, COMPLI 51710 $ 1,495.78 CYSTOTOMY W INS URETERAL CATH/STNT 51045 $ 4,484.35 CYSTOURETHROSCOPY 52204 $ 4,484.35 CYSTOURETHROSCOPY (SEP PROC) 52000 $ 1,495.78 CYSTOURETHROSCOPY (SEPART PROC 52000 $ 1,495.78 CYSTOURETHROSCOPY W/INSRT STEN 52332 $ 7,131.78 CYSTOURETHROSCOPY W/URETERAL C 52005 $ 4,484.35 CYSTOURETHROSCOPY WITH REMOVAL 52352 $ 9,800.87 CYSTOURETHROSCOPY, WITH BIOPSY 52282 $ 7,131.78 CYSTOURETHROSCOPY-SEP PROC; SI 52310 $ 4,484.35 CYSTOURETHROSCPY; W MEATOTMY; UNI/BI 52290 $ 4,484.35 CYSTOURETHRSCOPY,FULGURATN TRGN 52214 $ 4,484.35 CYSTOURETHRSCPY W INSRT GW THRU KIDNEY 52334 $ 7,131.78 CYSTOURETHRSCPY,FULGURATN TRGN 52214 $ 4,484.35 CYSTOURTHRSCPY W URETRSCPY, TX STRICTURE 52345 $ 9,800.87 CYSTOURTHRSCPY, URETR/PYELSCPY W/REM TUM 52355 $ 9,800.87 CYSTOURTHRSCPY, URETR/PYELSCPY W/STNT 52356 $ 9,800.87 CYST-RES/FULG ORTH URET UNI/BI 52300 $ 7,131.78 CYSTROGRAFIN 30% 300ML BOTTLE Acquisition cost Page 83 2018 CYTARABINE 100MG J9100 $ 2.75 CYTARABINE 500 MG J9100 $ 13.79 CYTARABINE LIPOSOMAL,10MG J9098 $ 1,564.99 CYTOGENETICS ANLZ 3-5 CEL FISH 88272 $ 89.54 CYTOGENETICS DNA PROBE FISH 88271 $ 58.17 CYTOGENICS 89240 $ 118.21 CYTOGENTC ANLZ 100-300 CEL FSH 88275 $ 112.62 CYTOGENTCS ANLZ 10-30 CEL FISH 88273 $ 87.25 CYTOGENTCS ANLZ 25-99 CEL FISH 88274 $ 94.56 CYTOLOGY (EACH) 88161 $ 84.11 CYTOLOGY MULTIPLE STAINS (3+) 88162 $ 118.21 CYTOLOGY OF WASHES 88104 $ 84.11 CYTOMEGALOVIRUS DFA 87271 $ 32.56 CYTOMEGALOVIRUS NA QUAN 87497 $ 116.34 CYTOPATH CONC TECH SMERS/INTEPR-CELL BLK 88108 $ 84.11 CYTOSAR-U 100MG VIAL J9100 Acquisition cost CYTOSMEAR SCRN/INTERP 88160 $ 46.20 CYTOSMEAR, SCREEN/INTERP 88160 $ 46.20 CYTOTOXIC AB SCREENING 86807 $ 173.03 CYTOVENE 500MG CAPSULE Acquisition cost CYTPTH SLIDE CERV/VAG; MNL-SUPRVS 88150 $ 32.23 CYTRA-K SOLUTION Acquisition cost D 5% 0.45% NS WITH KCL 30 MEQ 1000 ML J3480 Acquisition cost D 5% 0.45% NS WITH KCL 40 MEQ 1000 ML Acquisition cost D10%W+NS+K.PO4+K.ACETATE 20MEQ. 1000ML Acquisition cost D11% W 1000 ML Acquisition cost D3.5% WITH ELECTROLYTE 1000 ML Acquisition cost D5% 1/2 NS + 30MEQ KCLàLVP 1000 ML Acquisition cost D5% 1/2 NS WITH 10 MEQ. KCL 1000 ML Acquisition cost D5% 1/3 NS + KCL 10 meq. 1000 ml/bag Acquisition cost D5%0.45% NS+20meq KPhos+20meq K Acet Acquisition cost D5%W + 0.45%NS +KCL 10 MEQ. 1000 ML. Acquisition cost D5%W 100 ML ADDVANTAGE BAG Acquisition cost D5%W 250 ML ADDVANTAGE BAG Acquisition cost D5%W 50ML ADDVANTAGE BAG Acquisition cost DABIGATRAN (PRADAXA) 150 MG Acquisition cost DABIGATRAN (PRADAXA) 75MG. PO Acquisition cost DACARBAZINE 200 MG J9130 $ 21.67 DACARBAZINE, 100 MG INJ J9130 $ 249.48 DACLATASVIR 60MG TAB Acquisition cost DACRIOSE IRRIGATION 15ML OPHTH $ 9.39 DACRO SILICONE REINFORCED OPEN-CATEG 1 Acquisition cost DACRYOCYSTOGRAPHY NLD RAD S/I 70170 $ 614.37 DACTINOMYCIN 0.5MG VIAL J9120 Acquisition cost DACTINOMYCIN, 0.5MG J9120 $ 4,460.17 DAKINS FULL STRENGTH SOLUTION Acquisition cost DAKIN'S HALF STRENGTH SOLUTION Acquisition cost DALTEPARIN 2500 UNITS SQ J1645 Acquisition cost DALTEPARIN SODIUM 5000U/.2 J1645 Acquisition cost D-AMPHETAMINE 10MG (DEXADRINE) TAB PO Acquisition cost D-AMPHETAMINE SULF 5MG TAB Acquisition cost DANOCRINE 200MG CAP Acquisition cost DANTROLENE 250 MG (Ryanodex) $ 0.10 DANTROLENE 25MG CAP Acquisition cost DANTROLENE SOD. 20MG/VIAL INJ. Acquisition cost DANTROLENE SODIUM 20MG VIAL Acquisition cost Page 84 2018 DAPSONE 100MG TABLET Acquisition cost DAPSONE 25MG TABLET Acquisition cost DAPTOMYCIN 500MG. VIAL INJ. Acquisition cost DARAPRIM 25MG TAB Acquisition cost DARBEPOETIN 100MCG/ML Acquisition cost DARBEPOETIN 25MCG/ML Acquisition cost DARBEPOETIN 300MCG/ML Acquisition cost DARBEPOETIN 60MCG/ML Acquisition cost DARK ADAPTATION EXAM W/I/R 92284 $ 872.74 DARK FIELD EX SRC; INCL SPEC CLCT 87164 $ 29.17 DARK FLD EX SRC INCL SPEC CLCT 87164 $ 29.17 DARTFIRE COMPRS SCRW; HDLSS 3.0x24MM C1713 $ 592.50 DARUNAVIR Acquisition cost DARUNAVIR 400MG. TABLET Acquisition cost DARUNAVIR 600MG. TABLET Acquisition cost DARVOCET N-100 Acquisition cost DAUNORUBICIN 5MG/ML 10ML VIAL J9150 Acquisition cost DAUNORUBICIN CITR LIPO FORM 10 MG J9151 $ 607.20 DAUNORUBICIN HCL, 10MG J9150 $ 177.06 DAUNOXOME 2MG/ML 25ML J9151 Acquisition cost DAVOL DULEX PATCH 1/CS C1781 $ 2,526.00 DAVOL DULEX PATCH 3.1 X 3.9 C1781 $ 360.00 DAVOL DULEX PATCH 3.1 X 4.7 C1781 $ 463.50 DAVOL DULEX PATCH 3.1 X 4.7 C1781 $ 463.50 DAVOL DULEX PATCH 3.1x3.9 C1781 $ 360.00 DAVOL DULEX PATCH 5.9 X 7.5 C1781 $ 1,207.50 DAVOL DULEX PATCH 5.9 X 7.5 C1781 $ 1,207.50 DAVOL DULEX PATCH 7.9"x11.8" C1781 $ 2,526.00 DBL.REFR.BODY 81000 $ 8.84 DBX PUTTY 10CC C1713 $ 2,340.00 DBX PUTTY 5CC** C1713 $ 1,387.50 DCR 68720 $ 7,805.64 DDAVP 0.1% NASAL SPRAY 5ML Acquisition cost DDAVP 4MCG/ML INJ 1ML J2597 Acquisition cost DDI/VIDEX 10MG/ML PED 200ML Acquisition cost D-DIMER FDP 85362 $ 18.72 DEB BONE 20 CM OR LESS 11044 $ 3,564.97 DEB MUSC/FASCIA 20 SQ CM/< 11043 $ 1,291.09 DEB SKIN BONE AT FX SITE 11012 $ 6,148.30 DEBR INFECT SKIN-10% BDY 11000 $ 1,291.09 DEBR NECROTIZ STISS-ABD WALL 11005 $ 1,239.05 DEBRDMNT SUBQ TIS; 20 CM SQ OR LESS 11042 $ 821.94 DEBRID EXT ECZEM/INF SKIN;TO 10% 11000 $ 1,291.09 DEBRID MAST CAVITY COML 69222 $ 1,216.16 DEBRID MASTOIDEC CAVITY SIMPL 69220 $ 446.80 DEBRID NAIL(S) ANY METHD(S); 6 OR MORE 11721 $ 147.99 DEBRID NAIL(S) ANY METHD(S); ONE TO FIVE 11720 $ 147.99 DEBRID NAIL(S) ANY METHD(S); SIX OR MORE 11721 $ 147.99 DEBRID; SKIN & SUBQ TISS 11042 $ 821.94 DEBRIDE NAIL; 1 - 5 11720 $ 147.99 DEBRIDE SKIN AT FX SITE 11010 $ 1,514.94 DEBRIDE/REM FB AT FX SITE 11010 $ 1,514.94 DEBRIDE; SKIN TO MUSCLE 11043 $ 1,291.09 DEBRIDEMENT OF SKIN & SUBQ TISSUE 11042 $ 821.94 DEBRIDEMENT SYSTEM-CATEG 1 Acquisition cost DEBRIDESUBCU MUSCLE 11043 $ 1,291.09 Page 85 2018 DEBRIDMNT EXZ/INF SKIN; UP TO 10% BS 11000 $ 1,291.09 DEBROX OTIC SOL Acquisition cost DECADRON 0.5MG/5ML LIQID UD J8540 Acquisition cost DECADRON 10MG/ML 10ML VIAL J1100 Acquisition cost DECADRON 4MG TAB J8540 Acquisition cost DECADRON 4MG/ML 1ML VIAL J1100 Acquisition cost DECA-DURABOLIN 200MG/ML 1ML Acquisition cost DECALCIFICATION 88311 $ 28.51 DECARBAZINE 200MG INJ J9130 Acquisition cost DECLOMYCIN 300MG TAB Acquisition cost DECLOTTING BY THROMBOLYTIC AGENT 36593 $ 786.94 DECOFED/SUDAFED 30MG/ML Acquisition cost DECOMPRESS FASCIOTOMY 27603 $ 6,148.30 DECOMPRESS SPINAL CORD; ADD-ON 63057 $ 679.58 DECOMPRESS SPINAL CORD; LUMBAR 63056 $ 14,826.61 DEEP FB REM-FOREARM/WRIST 25248 $ 3,570.02 DEEP INC FOOT; BONE CORTEX 28005 $ 6,995.52 DEEP INC HAND/FINGER 26034 $ 3,570.03 DEEP INC SOFT TISS ABSC 20005 $ 3,564.97 DEEP PTA BALL CATH OTW VASC C1725 $ 510.00 DEEP PTA BALL CATH OTW0.014VAS C1725 $ 600.00 DEEP ROOT SCALING/PER Q D4341 $ 266.00 DEEP SED/GEN ANESTH-EA 15MN INCREMENT D9223 $ 182.00 DEF ANAER ID-EA ORG 87076 $ 21.93 DEF BACT ID-EACH ORG 87077 $ 21.93 DEF FUNG ID-EACH ORG 87106 $ 28.03 DEF MYCO ID-EACH ORG 87118 $ 32.14 DEF URIN ID-EACH ORG 87088 $ 21.98 DEFIB/PACING PAD $ 849.78 DEFICID (FIDAXOMICIN) 200MG PO Acquisition cost DEFINITY (REFRIGERATED) Q9957 $ 49.50 DEGARELIX INJ 1 MG J9155 $ 16.11 DEGLYCING CHARGE 86931 $ 569.71 DEHYDRATED ALCOHOL 98% 1ML INJ Acquisition cost DEKTA CERANUC V40 FEMORAL HEAD 36MM C1776 $ 1,960.20 DELAVIRDINE 100MG TAB PO Acquisition cost DELAVIRDINE 100MG TAB Acquisition cost DELAVIRDINE 200MG. Acquisition cost DELAVIRIDINE MES 200MG PO Acquisition cost DELAY FLAP; SCALP/ARMS/LEGS 15610 $ 4,147.84 DELFLEX 1.5% 2000 CC $ 9.08 DELFLEX 4.25% 2000 CC $ 49.50 DELFLEX-CATEG 1 Acquisition cost DELFLEX-CATEG 2 Acquisition cost DELFLEX-CATEG 3 Acquisition cost DELIVER PLACENTA 59414 $ 6,010.51 DELIVERY OF PLACENTA 59414 $ 6,010.51 DELTA 16MM C1713 $ 129.15 DELTA AMINOLEVULINIC ACID 82135 $ 44.68 DELTA CERAMIC V40 HEAD 36MM C1776 $ 1,200.00 DELTA V40 CERAM HEAD 36MM-0MM C1776 $ 1,200.00 DELTA V40 CERAMIC HEAD 32MM C1776 $ 2,041.88 DELTASONE 50MG TAB, PER 1MG J7512 Acquisition cost DELTASONE 5MG/5ML ORAL SOLTN; PER 1MG J7512 Acquisition cost DELYD INSERT BRST PROSTHESIS 19342 $ 19,537.41 DEMECLOCYCLINE 10MG CAPS Acquisition cost Page 86 2018 DENILEUKIN DIFTITOX, 300MCG J9160 $ 683.32 DENT APPL DESENSITIZING MED D9910 $ 21.00 DENTAL - FOLLOW-UP D9430 $ 130.00 DENTAL ADHESIVE CREAM Acquisition cost DENTAL AMALGAM-FOUR SURFACES D2161 $ 252.00 DENTAL AMALGAM-ONE SURFACE,PER D2140 $ 154.00 DENTAL AMALGAM-TWO SURFACES,PER D2150 $ 175.00 DENTAL DIAGNOSTIC CASTS D0470 $ 140.00 DENTAL EMERGENCY VISIT D0140 $ 139.00 DENTAL IMPLANT SUPPORTED CONN BAR D6055 $ 420.00 DENTAL RADIOGRAPHS BITE WINGS-1 D0270 $ 49.00 DENTAL RADIOGRAPHS BITE WINGS-2 D0272 $ 76.00 DENTAL RADIOGRAPHS BITE WINGS-3 D0273 $ 36.00 DENTAL RADIOGRAPHS BITE WINGS-4 D0274 $ 106.00 DENTAL RADIOGRAPHS CEPHALOMETR D0340 $ 154.00 DENTAL RADIOGRAPHS OCCLUSAL D0240 $ 60.00 DENTAL RADIOGRAPHS PANORAMIC D0330 $ 70.00 DENTAL RADIOGRAPHS-COMPLETE SE D0210 $ 252.00 DENTAL SPEC A 41800 $ 277.79 DENTAL-ALVEOPLASTY D7320 $ 525.00 DENTAL-BIOPSY SOFT TISSUE D7286 $ 490.00 DENTAL-CONSULTATION D9310 $ 100.00 DENTAL-CONTINUING TREATMENT D8690 $ 1,400.00 DENTAL-CROWN-PFM D6750 $ 1,310.00 DENTAL-FIXED APPLAINCE THERAPY D8220 $ 1,365.00 DENTAL-GENL ANESTHESIA, FIRST 30 MINS. D9220 $ 361.00 DENTAL-GENL ANSTHESIA, EA. ADDL 15 MINS. D9221 $ 130.00 DENTAL-HOSPITAL VISIT D9420 $ 200.00 DENTAL-PALLIATIVE TREATMENT (E D9110 $ 90.00 DENTAL-RADIOGRAPHS PERIAP/EACH D0230 $ 32.00 DENTAL-RADIOGRAPHS PERIAP/FIRS D0220 $ 41.00 DENTURE CLEANER Acquisition cost DEOXYCORTICOSTERONE 82633 $ 84.15 DEOXYCORTISOL-11 82634 $ 79.51 DEPAKOTE 250MG TAB Acquisition cost DEPAKOTE 250MG. DELAYED RELEASE CAPSULE Acquisition cost DEPAKOTE 250MG. ERT TABLET Acquisition cost DEPAKOTE 500MG TAB Acquisition cost DEPHENHYDRAMINE 50MG CAP Q0163 Acquisition cost DEPO 40MG J1030 $ 27.92 DEPO 80MG J1040 $ 48.42 DEPODUR 10MG/ML Acquisition cost DEPOTESTOSTERONE, PER 1 MG J1071 $ 0.31 DEPOTESTOSTERONE, PER 1MG J1071 $ 0.31 DEPUY MITEK LOCKING BONE SCREW C1713 $ 340.50 DERM MATRIX ALLOGRFT 12x16CM Q4128 $ 9,952.50 DERM MATRIX ALLOGRFT 6x12CM Q4128 $ 3,619.50 DERM MATRIX ALLOGRFT 8x16CM Q4128 $ 6,258.00 DERMABRASION; SEGMENTAL, FACE 15781 $ 1,514.94 DERMABRASION; SUPERFICIAL, ANY SITE 15783 $ 821.94 DERMABRASION; TOTAL FACE 15780 $ 6,148.30 DERMA-FAT-FASCIA GRAFT 15770 $ 7,168.06 DERMAGRAFT PER 1 SQ CM Q4106 $ 44.97 DERMA-PHOR Acquisition cost DERMICEL TAPE 1 A4450 $ 0.71 DERMICEL TAPE 2 A4450 $ 1.42 Page 87 2018 DERMICEL TAPE 3 A4450 $ 2.14 DES CUT VASC LES <10SQ CM LASER 17106 $ 821.94 DESCEND THOR AORTA GRAFT W/WO BYPS 33875 $ 5,863.53 DESCOVY 200/25MG TABLET Acquisition cost DESENSITIZ BACTRIM 0.02/0.004MG Acquisition cost DESENSITIZAT BACTRIM 2/0.4MG Acquisition cost DESENSITIZATION PCN 0.5MG/ML Acquisition cost DESENSITIZATION PCN 5MG/ML Acquisition cost DESFERAL 500MG INJ VIAL J0895 Acquisition cost DESFLURANE LIQUID 240ML Acquisition cost DESIPRAMINE 80335 $ 11.00 DESIPRAMINE 50MG TAB Acquisition cost DESIPRAMINE HCL 25MG TAB Acquisition cost DESIPRAMINE HCL 75MG TAB Acquisition cost DESITIN OINTMENT Acquisition cost DESMOPRESSIN 0.1MG. TABLET Acquisition cost DESMOPRESSIN 1 MCG/ML VIAL INJ J2597 Acquisition cost DESMOPRESSIN ACETATE 0.2MG Acquisition cost DESONIDE 0.05% CREAM Acquisition cost DESONIDE 0.05% OINT 60 GM Acquisition cost DESOXYCORTICOSTERONE (DOC) 82633 $ 84.15 DEST IN HEMORRHOIDS W THERM EN 46930 $ 2,476.36 DEST LES PENIS SIMPLE; LASER 54057 $ 4,147.84 DEST LES/SCAR PHYS METH;VESTIB 40820 $ 5,815.59 DEST RETNA LES LCL; CRYOTX/DTHRM; 1+SES 67208 $ 707.85 DEST VAGINAL LES; SIMP 57061 $ 6,010.51 DEST W NEUROLYTIC; OTHER PERIPH NRV 64640 $ 1,777.62 DEST W/AGENT; SUP HYPOGASTRC PLXUS 64681 $ 1,777.62 DEST. FACET CERV/ THOR 64633 $ 4,259.09 DEST. PARAVERT ECH. ADD 64636 $ 130.72 DESTCT W AGNT; TRIGEMINAL NERVE 64600 $ 1,777.62 DESTINATION GUIDE SHEATH 1/BX C1887 $ 214.50 DESTR LES PENIS; SIMPLE; SURG EXC 54060 $ 4,147.84 DESTR MAL LES FCE ERS; > 4.0 CM 17286 $ 1,291.09 DESTR MAL LES FCE ERS; 0.5 CM/< 17280 $ 446.80 DESTR MAL LES FCE ERS; 0.6-1.0 CM 17281 $ 821.94 DESTR MAL LES FCE ERS; 1.1-2.0 CM 17282 $ 821.94 DESTR MAL LES FCE ERS; 2.1-3.0 CM 17283 $ 821.94 DESTR MAL LES FCE ERS; 3.1-4.0 CM 17284 $ 1,291.09 DESTR MAL LES SCLP; 0.5 CM/LESS 17270 $ 446.80 DESTR MAL LES SCLP; 0.6-1.0 CM 17271 $ 446.80 DESTR MAL LES SCLP; 1.1-2.0 CM 17272 $ 446.80 DESTR MAL LES SCLP; 2.1-3.0 CM 17273 $ 821.94 DESTR MAL LES SCLP; 3.1-4.0 CM 17274 $ 821.94 DESTR MAL LES SCLP; MORE 4.0 CM 17276 $ 821.94 DESTR MALIG LES TRUNK; > 4.0 CM 17266 $ 821.94 DESTR MALIG LES TRUNK; 0.5 CM/< 17260 $ 446.80 DESTR MALIG LES TRUNK; 0.6-1.0 CM 17261 $ 446.80 DESTR MALIG LES TRUNK; 1.1-2.0 CM 17262 $ 446.80 DESTR MALIG LES TRUNK; 2.1-3.0 CM 17263 $ 446.80 DESTR MALIG LES TRUNK; 3.1-4.0 CM 17264 $ 821.94 DESTR NEUROLYTIC AGNT INTERCOSTAL 64620 $ 1,777.62 DESTR PENIS LESION(S); EXTENSIVE 54065 $ 4,147.84 DESTR W NEUROLYTIC; CELIAC PLEXUS 64680 $ 1,777.62 DESTR WART MOLLUSC/MILIA; UP 14 17110 $ 446.80 DESTR. INTERCOSTAL 64620 $ 1,777.62 Page 88 2018 DESTR. NEUROLYTIC 64610 $ 4,259.09 DESTR. PARAVERTEBRAL 64635 $ 4,259.09 DESTRCT BEN/PREMALIG LES; 2-14 EA 17003 $ 5.15 DESTRCT LES ANUS SIMPL; CHEM 46900 $ 821.94 DESTRCT LES CORNEA-CRYOTHERAPY 65450 $ 707.85 DESTRCT LES LID MARGIN 67850 $ 2,137.81 DESTRCT LES PENIS SIMPL; CRYOSURGERY 54056 $ 446.80 DESTRCT LES PENIS SIMPL; LASER SURG 54057 $ 4,147.84 DESTRCT LES RETINA; CRYOTHERAPY 67208 $ 707.85 DESTRCT LES RETINA; PHOTOCOAGULAT 67210 $ 1,290.50 DESTRCT LES VULVA; SIMPL ANY METHD 56501 $ 4,147.84 DESTRCT RETINOPATHY; CRYOTHERA 67227 $ 7,805.64 DESTRCT RETINOPATHY; PHOTOCOAGULAT 67228 $ 1,290.50 DESTRCT VAG LES; SIMPL ANY METHD 57061 $ 6,010.51 DESTRCT, ANAL LESION,ELECTROD 46910 $ 4,147.84 DESTRCT, RECTAL TUMOR,ANY MTD 45190 $ 6,123.85 DESTRCT,ANAL LESION CRYOSURGY 46916 $ 446.80 DESTRCT,ANAL LESION EXTENSIVE 46924 $ 6,123.85 DESTRCT,ANAL LESION,LASER SURG 46917 $ 6,123.85 DESTRCT,ANAL LESION,SURGL EXCS 46922 $ 6,123.85 DESTRCT,PENILE LESION, CHEMCL 54050 $ 821.94 DESTRCT,PENILE LESION,ELECTROD 54055 $ 4,147.84 DESTRCT,PENILE LESION,EXTENSVE 54065 $ 4,147.84 DESTRCT,VAGINAL LESION EXTENSV 57065 $ 6,010.51 DESTROY ANAL LESION SIMPLE; CHEMICAL 46900 $ 821.94 DESTROY VULVA LESIONS; SIMPLE 56501 $ 4,147.84 DESTRU LESION, 15 OR MORE 17111 $ 446.80 DESTRUC BEN/PREMALIG LES; 1 LES 17000 $ 446.80 DESTRUC BEN/PREMALIG LES; 15/> LES 17004 $ 821.94 DESTRUC BEN/PREMALIG LES; 2-14 EA 17003 $ 5.15 DESTRUC MAL LES FCE ERS; > 4.0 CM 17286 $ 1,291.09 DESTRUC MAL LES FCE ERS; 0.5 CM/< 17280 $ 446.80 DESTRUC MAL LES FCE ERS; 0.6-1.0 CM 17281 $ 821.94 DESTRUC MAL LES FCE ERS; 1.1-2.0 CM 17282 $ 821.94 DESTRUC MAL LES FCE ERS; 2.1-3.0 CM 17283 $ 821.94 DESTRUC MAL LES FCE ERS; 3.1-4.0 CM 17284 $ 1,291.09 DESTRUC MAL LES SCLP; 0.5 CM/LESS 17270 $ 446.80 DESTRUC MAL LES SCLP; 0.6-1.0 CM 17271 $ 446.80 DESTRUC MAL LES SCLP; 1.1-2.0 CM 17272 $ 446.80 DESTRUC MAL LES SCLP; 2.1-3.0 CM 17273 $ 821.94 DESTRUC MAL LES SCLP; 3.1-4.0 CM 17274 $ 821.94 DESTRUC MAL LES SCLP; MORE 4.0 CM 17276 $ 821.94 DESTRUC MALIG LES TRUNK; > 4.0 CM 17266 $ 821.94 DESTRUC MALIG LES TRUNK; 0.5 CM/< 17260 $ 446.80 DESTRUC MALIG LES TRUNK; 0.6-1.0 CM 17261 $ 446.80 DESTRUC MALIG LES TRUNK; 1.1-2.0 CM 17262 $ 446.80 DESTRUC MALIG LES TRUNK; 2.1-3.0 CM 17263 $ 446.80 DESTRUC MALIG LES TRUNK; 3.1-4.0 CM 17264 $ 821.94 DESTRUC WART MOLLUSC/MILIA; UP 14 17110 $ 446.80 DESTRUCT BENIGN LES; UP TO 14 LESIONS 17110 $ 446.80 DESTRUCT LES PENIS SIMPL; CRYOSURGERY 54056 $ 446.80 DESTRUCT LESION 15 OR MORE 17111 $ 446.80 Destruct lesion-phys/chem B/R D7465 $ 613.00 DESTRUCT OF VULVA LESIONS EXTE 56515 $ 4,147.84 DESTRUCT OF VULVA LESIONS EXTENSV 56515 $ 4,147.84 DESTRUCT RECTAL TUMORANY MTD 45190 $ 6,123.85 Page 89 2018 DESTRUCT WART MOLLUSC MILIA; UP 14 17110 $ 446.80 DESTRUCT, ANAL LESION,ELECTROD 46910 $ 4,147.84 DESTRUCT,ANAL LESION CRYOSURGY 46916 $ 446.80 DESTRUCT,ANAL LESION EXTENSIVE 46924 $ 6,123.85 DESTRUCT,ANAL LESION,LASER SURG 46917 $ 6,123.85 DESTRUCT,ANAL LESION,SURGL EXCS 46922 $ 6,123.85 DESTRUCT,PENILE LESION, CHEMCL 54050 $ 821.94 DESTRUCT,PENILE LESION,ELECTROD 54055 $ 4,147.84 DESTRUCT,PENILE LESION,EXTENSVE 54065 $ 4,147.84 DESTRUCT,VAGINAL LESION EXTENSV 57065 $ 6,010.51 DESTRUCTION LESION CHOROID 67220 $ 1,290.50 DETERM ARWAY CLO VOL 1 BREATH TESTS 94726 $ 658.04 DETERM MALDISTRIBUTION INSPIRED GAS 94727 $ 360.51 DETERM REFRACTIVE STATE 92015 $ 318.00 DETOXIFICATION PRIVATE ROOM $ 1,900.00 DETOXIFICATION SEMI PRIVATE ROOM $ 950.00 DETROL (TOLTERODINE) 1 MG TAB Acquisition cost DETROL (TOLTERODINE) 2 MG TAB Acquisition cost DETROL LA 2mg Acquisition cost DEVELOPMENTAL TESTING; LTD W/I 96110 $ 224.50 DEVMENTAL TEST LTD W/IR 96110 $ 224.50 DEVMENTAL TESTING;LTD W/IR 96110 $ 275.00 DEVMTAL TESTING;LTD W/I/R 96110 $ 275.00 DEVMTAL TST EXT W/I/R PER HR 96111 $ 373.00 DEX 10% INJ 1000 #7930-09 $ 1.43 DEX 10% INJ 500 #7930-03 $ 1.21 DEX 5% INJ 100 #7923-37 $ 1.39 DEX 5% INJ 250 #1522-02 $ 5.30 DEX 5% INJ 50 #7923-13 $ 1.39 DEX 5% LCT RG 1000 #7929-09 $ 1.53 DEX 5% LCT RG 500 #7929-03 $ 1.26 DEX 5% WTR 1000 #7922-09 $ 1.25 DEX 5% WTR 250 #7922-02 $ 1.25 DEX 5% WTR 500 #7922-03 $ 1.13 DEX 5%/.9% CL 1000 #7941-09 $ 1.41 DEX 5%/.9% CL 500 #7941-03 $ 1.16 DEX 5%/45% CL 1000#7926-09 $ 1.46 DEX 5%/45% CL 500 #7926-03 $ 1.16 DEXA 1/MORE SITES; APPENDICULAR SKELETON 77081 $ 164.27 DEXA BONE DENSITY / BMD 77080 $ 302.70 DEXA, BODY COMP, 1/> SITES 76499 $ 164.27 DEXAMETH SOD PHOS 0.05% EYE OINT Acquisition cost DEXAMETHAS PHOS 0.1% EYE DROP Acquisition cost 4MG TAB Acquisition cost DEXAMETHASONE 0.25MG TAB J8540 $ 3.85 DEXAMETHASONE 0.4MG/0.1ML Acquisition cost DEXAMETHASONE 0.75 MG. PO J8540 Acquisition cost DEXAMETHASONE 1 MG TAB J8540 Acquisition cost DEXAMETHASONE 10MG IV J1100 Acquisition cost DEXAMETHASONE 10MG/2.5ML SOLUTION J1100 Acquisition cost DEXAMETHASONE 1MG/ML INTELEFILL SYR Acquisition cost DEXAMETHASONE 2 MG TAB J8540 Acquisition cost DEXAMETHASONE 4MG/50ML PRE MIXED Acquisition cost DEXAMETHASONE PO TAPER DOSE Acquisition cost DEXAMETHASONE SOD. PHOSP 4MG/ML VIAL J1100 $ 1.39 DEXAMETHASONE SUPPRESSION TEST 82533 $ 44.26 Page 90 2018 DEXAMETHASONEINJ 4MG PREPACK J1100 Acquisition cost Dexferrum 100mg/2ml Injection Acquisition cost DEXMETOMIDINE Acquisition cost DEXMOPRESSIN 0.2 MG. PO Acquisition cost DEXRAZOXANE 500MG INJ J1190 Acquisition cost DEXT 5% 100ML ADV#7100-23 $ 1.80 DEXT 5% 250ML ADV#7100-02 $ 2.57 DEXT 5% 50ML ADV#7100-13 $ 1.80 DEXTRAN 40 IN D5W J7100 Acquisition cost DEXTRAN 40/NACL .9% 10-0.9% J7100 Acquisition cost DEXTRAN70/DEXTROS10% WATER 100ML J7110 Acquisition cost DEXTROMETHORPHAN 80299 $ 41.01 DEXTROSE 10% #7930-CATEG 1 Acquisition cost DEXTROSE 10% 0.225NS IV Acquisition cost DEXTROSE 10% 0.45%NS IV Acquisition cost DEXTROSE 10% 1000 #7930-09-CATEG 1 Acquisition cost DEXTROSE 10% 1000mL IV bag Acquisition cost DEXTROSE 10% EL NO.48 250ML IV Acquisition cost DEXTROSE 10% IN 0.25% SALINE IVSL IV Acquisition cost DEXTROSE 10% IN WATER Acquisition cost DEXTROSE 10% IN WATER SOLN 250 ML Acquisition cost DEXTROSE 10% WATER 1L IV Acquisition cost DEXTROSE 10% WATER 500ML IV Acquisition cost DEXTROSE 10%/SODIUM CHLORIDE 0.9% 1000mL Acquisition cost DEXTROSE 12.5% / ELEC 48 250ML Acquisition cost DEXTROSE 12.5% WATER IV Acquisition cost DEXTROSE 15% / ELEC 48 250ML Acquisition cost DEXTROSE 15% WATER IV Acquisition cost DEXTROSE 17.5% / ELEC 48 250ML Acquisition cost DEXTROSE 17.5% WATER IV Acquisition cost DEXTROSE 20% / ELEC 48 250ML Acquisition cost DEXTROSE 20% WATER IV Acquisition cost DEXTROSE 25% ABBOJECT SYR 10ML Acquisition cost DEXTROSE 3% WATER IV Acquisition cost DEXTROSE 3.5% WATER IV Acquisition cost DEXTROSE 4% WATER IV Acquisition cost DEXTROSE 5% #1522-CATEG 1 Acquisition cost DEXTROSE 5% #7923-CATEG 1 Acquisition cost DEXTROSE 5% & ELECTROLYTE NO.48 Acquisition cost DEXTROSE 5% ADV #7100-CATEG 1 Acquisition cost DEXTROSE 5% AND ELECTROLYTE-CATEG 1 Acquisition cost Dextrose 5% in Water for IV Room Acquisition cost DEXTROSE 5% LCT RG 1000 #7929-09-CATEG 1 Acquisition cost DEXTROSE 5% LR #7929-CATEG 1 Acquisition cost DEXTROSE 5% NS 0.33% (D51/3NS) 1L IV Acquisition cost DEXTROSE 5% WATER 100ML IV Acquisition cost DEXTROSE 5% WATER 1L IV Acquisition cost Dextrose 5% Water 250ml Bag J7060 Acquisition cost DEXTROSE 5% WATER 250ML IV Acquisition cost Dextrose 5% Water 50 ml Bag Acquisition cost DEXTROSE 5% WATER 500ML IV Acquisition cost DEXTROSE 5% WATER 50ML IV J7060 Acquisition cost DEXTROSE 5% WTR #7922-CATEG 1 Acquisition cost Dextrose 5%/0.45% Sod Chlor+40meq KCL J3480 Acquisition cost Dextrose 5%/0.45% Sod. Chlo.+10meq. KCL Acquisition cost Dextrose 5%/0.9% Sod Chlor+40meq KCL J3480 Acquisition cost Page 91 2018 DEXTROSE 5%/45% CL 1000-CATEG 1 Acquisition cost DEXTROSE 5%/45% CL-CATEG 1 Acquisition cost DEXTROSE 5%/9% CL #7941-CATEG 1 Acquisition cost DEXTROSE 5%/9% CL 1000-CATEG 1 Acquisition cost DEXTROSE 5%-0.45% SALINE INJ J7799 Acquisition cost DEXTROSE 5%-1/4NS IV SOL Acquisition cost DEXTROSE 5%-LACTATED RINGERS J7042 Acquisition cost DEXTROSE 5%-NORMAL SAL .9% INJ J7042 Acquisition cost DEXTROSE 5%-WATER IV SOLN. J7060 Acquisition cost DEXTROSE 50% 50ML-CATEG 1 Acquisition cost DEXTROSE 50% ABBOJECT Acquisition cost DEXTROSE 50% ABBOJECT SYR 50ML J7799 Acquisition cost DEXTROSE 50% INJ 50ML VIAL Acquisition cost DEXTROSE 50% SYRINGE J3490 $ 16.55 DEXTROSE 50%/WATER 50% INJ ABBOJECT J7060 $ 16.55 DEXTROSE 6% WATER IV Acquisition cost DEXTROSE 7.5% WATER IV Acquisition cost DEXTROSE 70% (HI CONC)-CATEG 1 Acquisition cost DEXTROSE 8% WATER IV Acquisition cost DEXTROSE 9% WATER IV Acquisition cost DEXTROSE IN WATER 20% 500ML. Acquisition cost DEXTRUS BI-POSTV VENTRICULAR LEAD C1900 $ 2,268.75 DH-ACTV THER-PT W/MENTL PROB 4 G0176 $ 275.00 DHEA 82626 $ 68.64 DHEA-S 82627 $ 60.39 DH-GROUP PSYCHOTHERAPY______G0410 $ 275.00 DIABETIC TUSSIN DM EXPECTRORANT Acquisition cost DIABETIC TUSSIN EXPECTORANT Acquisition cost DIAG PAP SCREENED + RESCREENED BETHESDA 88165 $ 92.88 DIAG PAP SCREENED BETHESDA 88164 $ 32.23 DIAG TUBE 1 BLCK CHROMPLTE TIP A4624 $ 72.00 DIAGNOSTIC ANOSCOPY 46601 $ 277.79 DIAGNOSTIC ANOSCOPY & BIOPSY 46607 $ 2,476.36 DIAGNOSTIC ANOSCOPY & BIOPSY 46607 $ 2,476.36 DIAGNOSTIC ANOSCOPY SPX 46600 $ 277.79 DIALATION OF ESOPHAGUS (BOUGIE 43450 $ 1,966.21 DIAM 3.0MM CUT DCR BURR 18DEG C1713 $ 560.25 DIAM SOLO DISP RND END TAP C1725 $ 47.35 DIAMND BACK CATH FOR ATHERECT C1725 $ 4,492.50 DIAMND BALLOON CATH 40CM 5MMx10/5FR C1725 $ 324.00 DIAMND BALLOON CATH 75CM 5MMx10/5FR C1725 $ 406.50 DIAMND BALLOON CATH 75CM 5MMx2/5FR C1725 $ 406.50 DIAMND BALLOON CATH 75CM 6MMx2/5FR C1725 $ 324.00 DIAMON BALL CATH 75CM6MMX6/5FR C1725 $ 324.00 DIAMOND 3.0MM CUTTING DCR BURR C1713 $ 594.14 DIAMOND BACK CATH FOR ATHERECT C1714 $ 4,492.50 DIAMOND BACK CATH.014VIPERWIRE C1713 $ 255.00 DIAMOND BALL CATH C1725 $ 317.52 DIAMOND BALLOON CATH C1725 $ 324.00 DIAMOND BALLOON CATH C1725 $ 406.50 DIAMOND BALLOON CATH 75CM C1725 $ 406.50 DIAMOND BALLOON CATH 75CM 6MMX6/5FR C1725 $ 324.00 DIAMOND BALLOON CATH 75CM 8MMX8/5.8FR C1727 $ 324.00 DIAMOND BALLOON CATH 75CM 9MMx4/5.8FR C1725 $ 406.50 DIAMOND DT C1725 $ 324.00 DIAMOND DT 10X4X75 7FR C1725 $ 324.00 Page 92 2018 DIAMOND DT 7X4X75 6FR C1725 $ 324.00 DIAMOND FG 855 C 6 TPR RD 5PK C1769 $ 33.15 DIAMOND PREDATOR CATHETER C1724 $ 4,492.50 DIAMONDBACK 360MICRO CROWN 4FR C1714 $ 5,092.50 DIAMOX 500MG INJ Acquisition cost DIAPHRAGM/CERV CAP FITTING W/INSTRUC 57170 $ 424.97 DIAPHRAGM-CATEG 1 Acquisition cost DIAPHRAGMS CAP-CATEG 1 Acquisition cost DIAST BP .= 90 MM HG 3080F $ 0.10 DIAST BP < 80 MM HG 3078F $ 0.10 DIAST BP 80-89 MM HG 3079F $ 0.10 DIATR MEG/DIAT SOD6%-10% SOL Acquisition cost DIATRIZOATE 30% 250ML Acquisition cost DIATRIZOATE MEGLUMINE 20% 100ML Acquisition cost DIATRIZOATE MEGLUMINE 30% 300ML Acquisition cost DIATRIZOATE MEGLUMINE 50% 50ML Acquisition cost DIATRIZOATE MEGLUMINE 60% 50ML Acquisition cost DIATRIZOATE MEGULMINE18%-300ML Acquisition cost DIATRIZOATE ORAL SOL Acquisition cost DIAZEPAM - 5MG TAB J8499 $ 2.13 DIAZEPAM 2MG TAB Acquisition cost DIAZEPAM 2MG TABLET BULK Acquisition cost DIAZEPAM 5 MG/2 ML (VALIUM) INJ J3360 Acquisition cost DIAZEPAM 5MG TAB Acquisition cost DIAZEPAM 5MG TABLET BULK Acquisition cost DIAZEPAM 5MG/5ML SOLN Acquisition cost DIAZEPAM LEVEL 80346 $ 11.00 DIAZEPAM ORAL LIQ 5MG/5ML Acquisition cost DIAZEPAM RECTAL BEL 10 MG Acquisition cost DIAZEPAM RECTAL GEL 2.5 MG Acquisition cost DIAZEPAM RECTAL GEL 5MG Acquisition cost DIAZOXIDE (PROGLYCEM) ORAL SUSPENSION Acquisition cost DIAZOXIDE 300MG/20ML AMP 20ML J1730 Acquisition cost DIBUCAINE 1% OINTMENT 30GM Acquisition cost DICLOFENAC 1% GEL Acquisition cost DICLOXACILLIN 250MG CAP Acquisition cost DICLOXACILLIN 500MG CAP Acquisition cost DICLOXACILLIN 62.5MG/5ML ORAL SUSP Acquisition cost DICYCLOMINE 10MG CAPSULE Acquisition cost DIDAN/CAL CB(ALK)MG SL 50MG CHEW Acquisition cost DIDANOSINE EC TABLET 200 MG Acquisition cost DIDANOSINE (VIDEX) 150 MG Acquisition cost DIDANOSINE 100MG CHEW TAB Acquisition cost DIDANOSINE 10MG/ML PEDS SUSP Acquisition cost DIDANOSINE 25MG CHEW TAB Acquisition cost DIDANOSINE CHEW TABLET 200MG Acquisition cost DIDANOSINE EC 200MG CAP PO Acquisition cost DIDANOSINE EC 250MG CAP PO Acquisition cost DIDANOSINE EC TABLET 125 MG Acquisition cost DIDANOSINE EC TABLET 400 MG Acquisition cost DIFFERENTIAL MANUAL 85007 $ 9.33 DIFLORASONE DIAC 0.05% TOP Acquisition cost DIFLORAZONE OINTMENT Acquisition cost DIFLUCAN 100MG TAB J1450 Acquisition cost DIFLUCAN 150MG TAB J1450 Acquisition cost DIFLUCAN 200MG IV BAG 100ML J1450 Acquisition cost Page 93 2018 DIFLUCAN 200MG TAB J1450 Acquisition cost DIFLUCAN 400MG IV BAG 200ML J1450 Acquisition cost DIFLUCAN 40MG/ML SUSP 35ML J1450 Acquisition cost DIFLUCAN 50MG TAB J1450 Acquisition cost DIGIBIND INJ J1162 Acquisition cost DIGITAL ANALYSIS OF EEG 95957 $ 228.21 DIGITAL ANLYS EEG; PRMRY PROCED CD 95957 $ 228.21 DIGITAL BRST TOMOSYNTHSIS, BILAT ADDON 77063 $ 65.49 DIGOXIN 80162 $ 36.06 DIGOXIN IMM FAB(OVINE)PER VIAL J1162 $ 9,372.00 DIHYDROERGOTAMINE 1MG/ML INJECTION Acquisition cost DIHYDROTESTOSTERONE. 80327 $ 78.06 DIL & CURETTAGE OF CERVICAL STUMP 57558 $ 6,010.51 DIL URETH STRICT MALE INIT FIL 53620 $ 1,495.78 DIL URETH STRICT MALE SUBS FIL 53621 $ 607.00 DIL URETHRAL STRICTR ; MALE W ANESTH 53605 $ 4,484.35 DILANTIN 80185 $ 35.99 DILANTIN 100MG CAP Acquisition cost DILANTIN 250MG/5ML INJ 5ML J1165 Acquisition cost DILANTIN 50MG SUSP J1165 Acquisition cost DILANTIN 50MG TAB Acquisition cost DILANTIN 50MG/ML 2ML AMP J1165 Acquisition cost DILAT & CATH SALIVARY DUCT W/W 42660 $ 1,216.16 DILAT & CURET DX &/OR THERAP ( 58120 $ 6,010.51 DILAT ESOPH OVER GUIDE WIRE 43453 $ 3,774.85 DILAT LACRIMAL PUNCTUM W/WO IRRIGA 68801 $ 872.74 DILAT NEPHROST/URETERS/URETHRA-S/I 74485 $ 4,484.35 DILAT URETHRAL STRICT-MALE; SUBSQT 53601 $ 277.79 DILAT URETHRAL STRICTURE-INIT MALE 53600 $ 607.00 DILAT URETHRAL STRICTURE-MALE; INIT 53600 $ 607.00 DILATE ANAL SPHNCTER UNDER ANESTH 45905 $ 2,476.36 DILATE ESOPHAGUS;BALLOON/DILAT 43213 $ 3,774.85 DILATING TIP-CATEG 1 Acquisition cost DILATION 57800 $ 6,010.51 DILATION CATETHER 7FR, 200CM C1725 $ 85.85 DILATION CERVICAL CANAL; INSTRUMENT 57800 $ 6,010.51 DILATION OF RECTAL NARROWING 45910 $ 2,476.36 DILATOR-CATEG 1 Acquisition cost DILAUDID 2MG TAB BULK Acquisition cost DILTIAZEM CD 120MG CAP Acquisition cost DILTIAZEM 100MG IV ADVANTAGE Acquisition cost DILTIAZEM 25MG/5ML INJ 10ML Acquisition cost DILTIAZEM 25MG/5ML INJ 5ML Acquisition cost DILTIAZEM 30MG TAB Acquisition cost DILTIAZEM 360MG 24HR CAP CD PO Acquisition cost DILTIAZEM 60MG ER CAP PO Acquisition cost DILTIAZEM 60MG TAB Acquisition cost DILTIAZEM CD 240MG/24H TAB Acquisition cost DILTIAZEM CD 180MG CAP Acquisition cost DILTIAZEM CD 300MG CAP Acquisition cost DILTIAZEM PREMIX BAG 100MG/100ml IV Acquisition cost DILUENT FOR ALLERGNIC EXTRACT Acquisition cost DILUTE PROTHROMBIN TIME 85611 $ 10.71 DILUTION DROP (PE/TROP/CYCLO/KETOR) 1ML Acquisition cost DIMETHICONE/PETROLATUM,WHITE Acquisition cost DINOPROSTONE 0.5MG/3GM Acquisition cost Page 94 2018 DIOVAN HCTZ 320/25 MG. PO Acquisition cost DIP/PERT/TET/HAEM VACCINE Acquisition cost DIPENHYDRAMINE 25MG INJ J1200 $ 2.16 DIPENHYDRAMINE 50MG CAP Q0163 $ 0.29 DIPENHYDRAMINE 50MG/ML VIAL J1200 $ 2.16 DIPHEN HYDROCH 50MG ORAL ANTEM Q0163 $ 0.29 DIPHENHYDRAM 12.5MG/5ML ELIX Acquisition cost DIPHENHYDRAMINE 25MG CAP Q0163 Acquisition cost DIPHENHYDRAMINE 50MG CAP Q0163 Acquisition cost Diphenhydramine 50mg in 50ml N.S. Acquisition cost DIPHENHYDRAMINE HCL 5ML ELIXIR Q0163 $ 3.76 DIPHENHYDRMINE 50MG TAB Q0163 $ 0.29 DIPHENHYDRMINE 50MG TABLET Q0163 $ 0.29 DIPHENOXYL W/ATROPINE TAB Acquisition cost DIPHENOXYLATE HCL SULF 2.5-.0 Acquisition cost DIPHTH/PERTUS ACELEL/TET PED Acquisition cost DIPHTH/TET TOX/ACELL PERTUS DTAP CLINIC 90700 $ 75.00 DIPHTH/TET TOX/ACELL PERTUSS VAC-IM 90700 $ 75.00 DIPHTHER,PERTUSS,TETANUS PEDS >7YRS 90700 Acquisition cost DIPIVEFRIN HCL 0.1% EYE DROP Acquisition cost DIPROSONE 0.05% LOT Acquisition cost DIPTH/TETANUS/TET VACCINE Acquisition cost DIPTHERIA AB 86648 $ 41.29 DIPYRIDAMOL 5MG/ML 10ML J1245 Acquisition cost DIPYRIDAMOLE 10MG J1245 $ 2.58 DIPYRIDAMOLE 25MG TAB Acquisition cost DIR REP ANEUR; OCCL DZ ABD AORTA 35081 $ 3,727.99 DIRECT ADMIT TO OBSERVATION ST G0379 $ 1,377.42 DIRECT ANTIGEN TYPING 86905 $ 569.71 DIRECT COOMBS 86880 $ 84.11 DIRECT GROUP A TEST 87880 $ 36.37 DIREXION+FATHOM GW C1763 $ 1,396.50 Disc repair D7852 $ 7,279.00 DISCISSION 2ND CATARACT; LASER 66821 $ 1,290.50 DISCISSION 2ND CATARACT; STAB INCS 66820 $ 5,080.46 DISCISSION VITREOUS STRNDS; PARS PLA 67030 $ 5,080.46 DISKOGRAPHY CERV/THOR RAD S/I 72285 $ 4,259.09 DISKOGRAPHY LUMBAR-RAD S / I 72295 $ 4,259.09 DISOPYRAMIDE 100MG. PO Acquisition cost DISOPYRAMIDE LEVEL 80299 $ 41.01 DISP SNAP Y SET $ 69.75 DISPOSABLE CANNULA 9MM A4615 $ 49.50 DISPOSABLE TUBING KIT 18"&72" A4331 $ 24.44 DISTAFLO MINICUFF BYPASS GRAFT C1768 $ 4,185.00 DISTAL CENTRALIZER 13MM C1776 $ 171.00 DISTAL CENTRALIZER 9MM C1776 $ 147.15 DISTAL FEMORAL COMPONENT GMRS C1776 $ 12,662.40 DISTAL OR PRIMARY WEDGE D4274 $ 490.00 DISTAL RADIOUS FIXATOR & DIST MODULE C1776 $ 3,937.17 DISTAL RADIUS FIXAT W/DISTRACT C1713 $ 3,937.17 DISTAL RADIUS FIXATOR W/T WIND Acquisition cost DISTAL RADIUS KIT Acquisition cost DISTRACT PIN SCREW STERLE 12MM C1713 $ 795.00 DISTRACT PIN SCREWS STER 10BX C1713 $ 795.00 DISTRACT PIN SCREWS STERL 16MM C1713 $ 292.50 DISTRACTION PIN SCREWS 14MM; STEALTH C1713 $ 795.00 Page 95 2018 DISULFIRAM 250MG TAB Acquisition cost DIVALPROEX 125MG TAB Acquisition cost DIVALPROEX SOD 500MG ER TAB Acquisition cost DIVALPROEX SPRINKLE 125MG Acquisition cost DIVIDEBLOODCOMPONENT 86985 $ 341.62 DM SLF-MGMT TRN SRVC GRP-30 MIN G0109 $ 31.55 DM SLF-MGMT TRN SRVC INDV-30 MIN G0108 $ 116.05 DM SS BEAD CABLE/SLEEVE SET C1713 $ 382.90 DMSA VIAL <= 10 MCI A9551 $ 160.99 DNA AB 86215 $ 35.97 DNA IMAGE ANALYSIS 88358 $ 569.71 DNU FORTIFIED Acquisition cost DNU VANCO Acquisition cost DOBUTAMINE 500MG/250ML D5W IV J1250 Acquisition cost DOBUTAMINE 60MG/100ML IV J1250 Acquisition cost DOBUTAMNE HCL 12.5/ML INJ J1250 $ 3.68 DOBUTREX 250MG/20ML INJ J1250 Acquisition cost DOCETAXEL INJECTION J9171 Acquisition cost DOCETAXEL, 1 MG J9171 $ 26.40 DOCUSATE 50MG CAP Acquisition cost DOCUSATE SODIUM 100MG CAP Acquisition cost DOFETILIDE 0.125MG CAPSULE Acquisition cost DOFETILIDE 0.25MG CAPSULE Acquisition cost DOFETILIDE 0.5MG CAPSULE Acquisition cost DOLASETRON 100MG Q0180 Acquisition cost DOLASETRON MESYLATE 100MG Q0180 $ 380.44 DOLOPHINE 10MG TAB Acquisition cost DOLOPHINE 10MG/ML INJ 20ML J1230 Acquisition cost DOLOPHINE 5MG TABLET Acquisition cost DOLUTEGRAVIR 50MG TABLETS Acquisition cost DONEPEZIL 10MG TAB Acquisition cost DONNATAL TAB Acquisition cost DONOVON BODY TEST 87205 $ 11.59 DOPAMINE 1600MG/ML BAG J1265 $ 1.40 DOPAMINE 400MG IV BAG PER 40MG J1265 $ 1.40 DOPAMINE 400MG IV PB J1265 Acquisition cost DOPAMINE 60MG/100ML D5W NICUIV J1265 Acquisition cost DOPPLER ECHO COLOR FLOW VELOCITY MAPPING 93325 $ 7.04 DOPPLER ECHO CONT WAVE; CMPL 93320 $ 40.35 DOPPLER ECHO CONT WAVE; F/U-LTD 93321 $ 16.10 DOPPLER ECHO FETAL-CV SYS; CMPL 76827 $ 302.70 DOPPLER ECHO FETAL-CV SYS; REPEAT 76828 $ 302.70 DOPPLER PROBE PENCIL 11.5CM C2618 $ 1,642.50 DOPPLER, UMBILICAL ARTERY 76820 $ 302.70 DORADO PTA 5X4CM DILATAT CATH C1752 $ 307.50 DORNASE 5 MG/ 50ML NS SYRINGE $ 0.10 DORSAL DISTAL RADIUS PLATE C1713 $ 849.00 DORZOLAMIDE HCL 2% EYE DROP Acquisition cost DORZOLOMIDE HCL EYE DROPS 2% $ 146.96 DOUBLE J STENT 6FX26 C2617 $ 202.71 DOUBLE J STENT 6FX28 C2617 $ 202.71 DOUBLE STRANDED DNA 86225 $ 37.33 DOVONEX 0.005% OINT 30GM Acquisition cost DOXEPIN (SINEQUAN) 80335 $ 11.00 DOXEPIN HCL 100MG CAP Acquisition cost DOXEPIN HCL 10MG CAP Acquisition cost Page 96 2018 DOXEPIN HCL 25MG CAP Acquisition cost DOXEPIN HCL 75MG CAP Acquisition cost DOXERCALCIFEROL 2.5MCG Acquisition cost DOXORUBICIN HCL 10MG IV J9000 Acquisition cost DOXORUBICIN HCL 50MG IV J9000 Acquisition cost DOXORUBICIN HCL LIPOSOME10MG/ML Q2050 Acquisition cost DOXORUBICIN HCL, 10 MG J9000 $ 127.82 DOXORUBICIN HCL,HCL LIPID,10MG Q2050 $ 1,549.46 DOXYCYCLINE 100 MG CAPS J8499 $ 8.25 DOXYCYCLINE 100MG CAP Acquisition cost DOXYCYCLINE 100MG/100ML D5W BNRY CONNCTR J3490 Acquisition cost DOXYCYCLINE 25MG/5ML 60 ML ORAL LIQUID Acquisition cost DOXYCYCLINE 50 MG CAP Acquisition cost DOXYCYCLINE 50MG CAP Acquisition cost DOXYCYCLINE ORAL SUSP 25MG/5ML Acquisition cost DP(A) POLIO/HB (PENTACEL) Acquisition cost DR ABSC CYST HEMAT-MOUTH; COMPLICATED 40801 $ 1,216.16 DR ABSC, CYST, HEMATOM - DENTOALVEOLAR 41800 $ 277.79 DR ABSC,CYST, HEMAT-MOUTH; SIMPLE 40800 $ 1,514.94 DR EXT EAR ABSCESS/HEMATOMA; COMPLIC 69005 $ 3,564.97 DRAIN 15FR RND HUBLESS TROCAR C1729 $ 887.52 DRAIN ABRAMSON TRIPLE LUMEN-CATEG 1 Acquisition cost DRAIN ABSC/HEMATMA; NASAL INTRNL APPRCH 30000 $ 472.05 DRAIN ABSC/HEMATOMA NASAL INT APPROACH 30000 $ 472.05 DRAIN BLAKE-CATEG 1 Acquisition cost DRAIN BLDR; W CATH INSERTION 51102 $ 4,484.35 DRAIN CATHETER VARIOUS C1729 $ 720.00 DRAIN END PERFORATED-CATEG 1 Acquisition cost DRAIN EXT AUDITORY CANAL ABSC 69020 $ 1,514.94 DRAIN EXT EAR ABSC/HEMA; SIMP 69000 $ 1,514.94 DRAIN FINGER ABSC; SIMPLE 26010 $ 446.80 DRAIN FLAT-CATEG 1 Acquisition cost DRAIN FLAT-CATEG 2 Acquisition cost DRAIN FNGR ABSC; COMPLICATED 26011 $ 3,564.97 DRAIN HEMATOMA/ABSC NASAL; INT APPR 30000 $ 472.05 DRAIN J-VAC-CATEG 1 Acquisition cost DRAIN LN ASCESS/; EXTNSIVE 38305 $ 3,564.97 DRAIN MAJOR JOINT/BURSA W US GUIDE 20611 $ 647.13 DRAIN MAJOR JOINT/BURSA W/ US GUIDE 20611 $ 647.13 DRAIN MALECOT-CATEG 1 Acquisition cost DRAIN OVARIAN ABSC; VAG APPROACH OPEN 58820 $ 6,010.51 DRAIN PALMAR BURSA; SNGL BURSA 26025 $ 3,570.03 DRAIN PENROSE-CATEG 1 Acquisition cost DRAIN PERIRENAL/RENAL ABSC; OPEN 50020 $ 7,131.78 DRAIN PERITONEAL ABSC; OPEN 49020 $ 3,401.86 DRAIN RETROPERITONEAL ABSC; OP 49060 $ 2,354.18 DRAIN SILIC 19FR RND,FUL FLUTE C1729 $ 796.29 DRAIN SILICONE TROCAR-CATEG 1 Acquisition cost DRAIN SILICONE-CATEG 1 Acquisition cost DRAIN SUBDIAPHRAGMATIC ABSC; O 49040 $ 2,137.78 DRAIN TRPL LUMEN SUMP-CATEG 1 Acquisition cost DRAIN TUBING 3/8 12L C1729 $ 138.00 DRAIN TUBING 5/8 12IN 50BX 4CS C1729 $ 138.00 DRAIN/INJ INTER JOINT/BURSA W/US 20606 $ 1,437.02 DRAIN/INJ INTERM JNT/BURSA 20605 $ 647.13 DRAIN/INJ MAJOR JNT/BURSA 20610 $ 647.13 Page 97 2018 DRAIN/INJ MAJOR JOINT/BURSA W/O US 20610 $ 647.13 DRAINAGE CATH 8F-16F C1729 $ 570.00 DRAINAGE DEEP ABSCESS THIGH OR 27301 $ 6,148.30 DRAINAGE EXT AUDITORY CANAL ABSCES 69020 $ 1,514.94 DRAINAGE EXT AUDITORY CANAL ABSCESS 69020 $ 1,514.94 DRAINAGE FINGER ABSCESS; SIMPL 26010 $ 446.80 DRAINAGE LYMPH NODE ABSCESS; SMPL 38300 $ 3,564.97 DRAINAGE OVARIAN ABSCESS; ABD APPROACH 58822 $ 1,488.96 DRAINAGE PERIVESICAL/PREVESICA 51080 $ 6,148.30 DRAINAGE SCROTAL WALL ABSC 55100 $ 3,564.97 DRAINAGE SYSTEM EXTERNAL-CATEG 1 Acquisition cost DRAINAGE SYSTEM THORAKLEX-CATEG 1 Acquisition cost DRAINAGE SYSTEM THORAKLEX-CATEG 2 Acquisition cost DRAIN-CATEG 1 Acquisition cost DRAING ABSC/HEMTMA,NASL SEPTM 30020 $ 1,216.16 DRAING ABSCS/HEMTMA,NASL SEPTM 30020 $ 1,216.16 DRAW BLOOD FROM PICC 36592 $ 277.79 DRAW BLOOD FROM VAD 36591 $ 277.79 DRESS EZ DERM MESHED 3X4 SHEET C1781 $ 558.36 DRESS EZ DERM XENOGRFT SHEET C1781 $ 770.19 DRESS/DEBRD PART-THICK BURN; <5% BS 16020 $ 446.80 DRESS/DEBRID P THICK BURN L 16030 $ 821.94 DRESSING Acquisition cost DRESSING ALGINATE-CATEG 1 Acquisition cost DRESSING ALGINATE-CATEG 2 Acquisition cost DRESSING CHANGE 15852 $ 1,291.09 DRESSING MEROCEL NASAL-CATEG 1 Acquisition cost DRESSING MESALT-CATEG 1 Acquisition cost DRESSING MESALT-CATEG 2 Acquisition cost DRESSING TEGADERM-CATEG 1 Acquisition cost DRESSING TEGADERM-CATEG 2 Acquisition cost DRESSING TELFA-CATEG 1 Acquisition cost DRESSING TRANSPARENT-CATEG 1 Acquisition cost DRIL, UPPER EXTRM HEMODIALYSIS ACCSS 36838 $ 11,279.00 DRILL BIT C1713 $ 260.10 DRILL BIT 1.6 C1713 $ 397.50 DRILL BIT 1/8TH C1713 $ 386.10 DRILL BIT 10MM C1713 $ 489.60 DRILL BIT 2.0MM C1713 $ 200.82 DRILL BIT 2.1 C1713 $ 185.74 DRILL BIT 2.5MM C1713 $ 181.69 DRILL BIT 2.5MM C1713 $ 257.20 DRILL BIT 3.2 C1713 $ 242.90 DRILL BIT 3.2MM C1713 $ 262.02 DRILL BIT 3.2MM SHORT C1713 $ 262.02 DRILL BIT 3.5 X 60 C1713 $ 531.00 DRILL BIT 3.5MM C1713 $ 181.69 DRILL BIT 3.5MM, AO DIA SCALED C1713 $ 417.00 DRILL BIT 4.5MM LONG C1713 $ 293.63 DRILL BIT FLEX 2.3 CURVED C1713 $ 219.96 DRILL BIT LONG C1713 $ 438.00 DRILL BIT QUICKREAD CONNECT C1713 $ 136.13 DRILL GUIDE 2.0MM C1713 $ 180.00 DRILL PIN 3.7MM C1713 $ 750.00 DRILL TIP GUIDEWIRE 2.5 C1769 $ 99.45 DRILLBIT AO DIA2.6X135MM SCALE C1713 $ 438.00 Page 98 2018 DRILLGUIDE CURVE FOR 2.3 SA C1713 $ 831.00 DRN OVAR CYST UNI/BIL-SEP PROC 58805 $ 6,010.51 DRN OVAR CYST UNI/BIL-SEP PROC; VAG 58800 $ 6,010.51 DRONABINOL 2.5MG ANTI-EMETIC Q0167 $ 13.49 DRONABINOL 5MG CAPSULE PO Acquisition cost DROTRECOGIN 20MG (XIGRIS) VIAL Acquisition cost DRRESSING CHG NOT FOR BURN 15852 $ 1,291.09 DRS/DEBRID PART-THICK BURN; MEDIUM 16025 $ 446.80 DRUG ADMIN & HEMODYNMIC MEAS 93463 $ 215.69 DRUG SCREEN SGL CLASS 80307 $ 158.03 DRUG SCRN 1+ CLASS NONCHROMO 80307 $ 158.03 DRUG-ELUTING STENT C1874 $ 2,692.50 DSCHRG MED/CURRENT MED MERGE 1111F $ 0.10 DSG//DEBRID INIT/SUBSQT;W/O ANES SM 16020 $ 446.80 DT ADSORBED-USE INDIVID < 7 YRS-IM 90702 $ 125.04 DT ADSORBED-USE INDIVID <7 YRS-IM CLINIC 90702 $ 125.04 DTaP VACCINE, LESS THAN 7 YRS, IM 90700 $ 75.00 DTAP-HEPB-IPV,IM CLINIC 90723 $ 94.68 DTAP-HEPB-IPV,IM CLINIC (ADULT) 90723 $ 94.68 DTAP-HEPB-IPV,IM CLINIC (IMMUNOSUPPRESD) 90723 $ 94.68 DTAP-HEPB-IPV,IM CLINIC (PEDS/ADOLES) 90723 $ 94.68 DTAP-HIB IP VACCINE, IM 90698 $ 218.78 DTAP-IPV VACC 4-6 YR IM 90696 $ 128.96 DUAL LUMEN 5FR CATHETER C1757 $ 372.00 DUAL LUMEN CATH C1887 $ 337.50 DUAL LUMEN CATHETER C1758 $ 337.50 DUAL LUMEN GASTRIC TUBES 8FR B4087 $ 88.71 DUAL LUMEN URETERAL CATH C1757 $ 47.82 DUAL MESH PLUS 26CMX34CM Acquisition cost DUAL PORT ACCESS 10FR ST405L A4301 $ 771.11 DUAL URETER CATH UDEX10X150MM C1758 $ 104.55 DUET EXTERNAL DRAINAGE &MONITR C1729 $ 599.04 DULERA 100/5 INH J3535 Acquisition cost DULERA 200/5 INH J3535 Acquisition cost DULOXETINE 20MG CAPSULE Acquisition cost DULOXETINE 30MG CAPSULE Acquisition cost DULOXETINE 60MG CAPSULE Acquisition cost DUOCAINE INJ 50CC J2001 Acquisition cost DUODERM GEL 5 PACK Acquisition cost DUO-TRACH KIT 5 EA Acquisition cost DUPLEX SCAN AORTA/GFTS; CMPL 93978 $ 614.37 DUPLEX SCAN LOWR EXT ART; UNI/LTD 93926 $ 302.70 DUPLEX SCAN LOWR EXTREM ART; CMPL 93925 $ 614.37 DUPLEX SCAN PENIL VES; F/U-LTD STDY 93981 $ 302.70 DUPLEX SCAN PENILE VESSELS; CMPL 93980 $ 302.70 DUPLEX SCAN UPPR EXT ART; UNI/LTD 93931 $ 302.70 DUPLEX SCAN UPPR EXTREM ART; CMPL 93930 $ 614.37 DURA GLIDE-CATEG 1 Acquisition cost DURABLE MEDICAL EQUPMENT MISCELLANEOUS E1399 Acquisition cost DURAFLOW PRE-CURVE KIT CATH 15.5X32CM C1730 $ 450.00 DURAFLOW 15.5FR X 28CM BASIC STRG KIT CA C1881 $ 358.50 DURAFLOW 15.5FR X 32CM BASIC STRG KIT CA C1881 $ 358.50 DURAFLOW BASIC PRE-CURVE CATH 15.5FR X32 C1730 $ 450.00 DURAFORM 1X3 SPONGE DURAL GRFT C1768 $ 2,443.47 DURAFORM 2X2 SPONGE DURAL GRFT C1768 $ 2,756.31 DURAFORM 3X3 DURAL GRAFT SPONG C1768 $ 5,228.22 Page 99 2018 DURAGEN SUTUR DURAL REGEN 1X3" C1713 $ 724.77 DURAGEN SUTUR DURAL REGEN 2X2" C1713 $ 759.95 DURAGEN SUTUR DURAL REGEN 3X3" C1713 $ 1,380.93 DURAGEN SUTUR DURAL REGEN 4X5" C1713 $ 2,322.08 DURAMAX 24/20CM STACK TIP STRG C1887 $ 1,875.00 DURAMAX STACK TIP STRGHT CATH C1887 $ 1,875.00 DURAMAX STRGHT DIALYSIS CATH C1887 $ 1,875.00 DURASEAL SPINE SEALANT BRAIN A4649 $ 7,498.50 DURVALUMAB 10MG, INJ. C9492 $ 185.06 DUTASTERIDE (AVODAR) 0.5 MG. Acquisition cost DUTASTERIDE 0.5MG CAPS Acquisition cost DVLPMENTL TST; EXT W/I/R PER HOUR 96111 $ 347.69 DVLPMNTL TST EXT W/I/R PER HR 96111 $ 373.00 DVLPTL TST EXT W/I/R PER HR 96111 $ 347.69 DVR ANATOMIC DVRA PLATE SYS C1713 $ 1,268.40 DVR ANATOMIC; DVRA PLATE SYSTEM C1713 $ 1,268.40 DVR CROSSLOCK WIDE PLATE RIGHT C1713 $ 1,665.00 DVR LOCK NARROW L C1713 $ 1,665.00 DVR LOCK STANDARD L C1713 $ 1,665.00 DW 5% IV BAG FOR FLOOR STOCK Acquisition cost DX BRONCHOSCOPE/BRUSH 31623 $ 3,500.62 DX BRONCHOSCOPE/LAVAGE 31624 $ 3,500.62 DX BRONCHOSCOPE/WASH 31622 $ 3,500.62 DX CYSTO W URETER/PYELO 52351 $ 4,484.35 DX DIG BRST TMSYNTHSIS; ADD-ON 77061 $ 65.32 DX DIG BRST TOMOSYNTHESIS; BILAT 77062 $ 65.32 DX KNEE ARTHROSCOPY 29870 $ 6,995.52 DX LARYNGOSCOPY; EXCLD NEWBORN 31525 $ 3,500.62 DX; HYSTEROSCOPY 58555 $ 6,010.51 DX; SPINAL PUNCTURE - LUMBAR 62270 $ 1,437.02 DX;PROCTOSIGMOIDOSCOPY; RIGID 45300 $ 1,877.59 DXA BONE STUDY; AXIAL SKLTON, 1+ SITES 77085 $ 302.70 DXTIC LUMB SPINAL PUNCT 62270 $ 1,437.02 D-XYLOSE 84620 $ 32.19 D-XYLOSE POWDER 25GM Acquisition cost DYCLONINE HCL 0.5% SOL Acquisition cost DYNACAST EXTRA-CATEG 1 Acquisition cost DYNAMIC FINGER SPLINT 29131 $ 147.99 DYNAMIC MESH RIGID 90 X 90 X 6 Acquisition cost DYNAMIC SPLINT 29126 $ 277.79 DYNAMIC SPLINT; SHORT ARM 29126 $ 277.79 DYNAMO 90 PROBE 3.5MMX5.5MM C2618 $ 305.55 DYONIC RF RND 60 DEGREE PROBE C2618 $ 291.00 DYONICS ELITE ABRADER BURR C1713 $ 733.95 DYRENIUM 50 MG. PO Acquisition cost E 904H GUT CHR $ 120.35 E LUMINEX VASC/BILLARY STNT C1877 $ 1,650.00 E LUMINEXX VASC& BILLARY STENT C1876 $ 1,650.00 E LUMINEXX VASC& BILLARY STENT C1876 $ 1,650.00 E. D. - RABIES VACCINE-IM USE 90675 $ 632.04 E. D. - SIMPL REPR SCLP//TRUNK; < 2.5 CM 12001 $ 446.80 E. D. - TX CLO ELBOW DISLOC; WO ANES 24600 $ 568.33 E. D.-SIMPL REPR FACE//MUCOUS; < 2.5 CM 12011 $ 446.80 E. HYSTOLYTICA ANTIGEN 87336 $ 35.20 E.D - CNTRL NASL HEMOR POSTR INITIAL 30905 $ 277.79 E.D - CNTRL NASL HEMR ANTER COMPLEX 30903 $ 277.79 Page 100 2018 E.D - EVACUATION SUBUNGUAL HEMATOMA 11740 $ 277.79 E.D. - SPIROMETRY 94010 $ 360.51 E.D. - TBE THORACOSTMY W/WO WATR SEAL 32551 $ 2,599.54 E.E.S. 200MG/5ML 100ML Acquisition cost EA. ADDLT 64634 $ 149.60 Each + prefab post-same tooth D2957 $ 176.00 EAR / THROAT EXAM UNDER ANESTH 92502 $ 1,216.16 EAR CULTURE 87070 $ 23.41 EAR MICROSCOPY EXAMINATION 92504 $ 20.75 EAR PIERCING 69090 $ 150.00 EAR PROTECTOR EVALUATION 92596 $ 84.11 EARS CT WITH AND WITHOUT CONTRAST 70482 $ 668.38 EARS CT WITH CONTRAST 70481 $ 668.38 EARS CT WITHOUT CONTRAST 70480 $ 302.70 ECF3 CEMENTED FEMORAL 15.0X155 Acquisition cost ECG - MONITORING & ANAYLSIS 93271 $ 304.61 ECG UP TO 48 HRS SCAN ANALYSIS REPORT 93226 $ 277.79 ECG UP TO 48 HRS; RECORDING 93225 $ 277.79 ECG W 12 LEADS TRACE ONLY NO INTRPRT/RPT 93005 $ 147.99 ECG-ROUTINE 12 LEAD; W/INTRPT / RPT 93000 $ 33.00 ECHINOCOCCUS ANTIBODY 86003 $ 14.17 ECHO FETAL-CV SYS-REAL TIME W/DOC 76825 $ 1,287.09 ECHO FETAL-CV SYS-REAL TIME; REPT 76826 $ 614.37 ECHO TIP ULTRA 25 GAUGE NEEDLE C2618 $ 345.00 ECHO TRANSESOPH; PLCMT PROBE O 93313 $ 1,287.09 ECHO TRANSESOPHAGEAL; I&R ONLY 93314 $ 198.92 ECHO TRANSESOPHGL; PROBE PLACE ONLY 93313 $ 1,287.09 ECHO TRNSESOPH; W/PROBE PLCMT-REPRT 93312 $ 1,287.09 ECHO TRNSTHORAC REAL-TIME; CMPL 93307 $ 1,287.09 ECHO TRNSTHORAC REAL-TIME; F/U-LTD 93308 $ 614.37 ECHO W/REST / STRESS-INTERP / RPT 93350 $ 1,287.09 ECOTRIN EC 325MG TAB Acquisition cost ECX SUBMANDIBULAR GLAND 42440 $ 11,474.25 ED VISIT E/M - LOW MODALITY SE 99282 $ 530.00 ED VISIT E/M - MODERATOR SERVE 99283 $ 663.00 EDETATE CALC DISODIUM 200MG ML J0600 Acquisition cost EDOXABAN (SAVAYSA) 15MG TABLET Acquisition cost EDOXABAN (SAVAYSA) 30MG TABLET Acquisition cost EDOXABAN (SAVAYSA) 45MG TABLET Acquisition cost EDS CSF EXT DRAIN SYS W/0 CATH C1729 $ 340.50 EDS LUMBAR EXTERNAL CATH DRAIN C1729 $ 337.50 EDS3 DRAIN SYS W/CLR VENT CATH C1729 $ 474.00 EDS3 LEVEL DEV; EXT DRAIN SYS C1729 $ 60.00 EDS3 LUMBAR CATHETER KIT II C1887 $ 811.50 EDUCAT SUPPL PROVID-PHYS @ COS 99071 Acquisition cost EECP PER TREATMENT G0166 $ 277.79 EEG ALL NIGHT SLEEP ONLY 95827 $ 1,175.22 EEG ASLEEP ONLY 95822 $ 658.04 EEG BRAIN DEATH EVALUATION 95824 $ 1,175.22 EEG DURING NONINTRACRANIAL SURGERY 95955 $ 118.47 EEG EXTEND MONITOR; UP TO 1 HR 95812 $ 658.04 EEG INCL RECORDING AWAKE/DROWSY 95816 $ 658.04 EEG MONITORING >ONE HOUR 95813 $ 658.04 EEG RCRD/INTRPRT-PRTBL,EA 24HR 95953 $ 1,175.22 EEG RCRDNG/INTRPRTN EA 24HR 95950 $ 1,175.22 EEG WITH MEDICATIONS 95954 $ 1,175.22 Page 101 2018 EEG; ALL NIGHT RECORDING 95827 $ 1,175.22 EFAV/EMTRICITABINE/TENOFOVIR600/200/300 Acquisition cost EFAVIRENZ 100MG CAP Acquisition cost EFAVIRENZ 200MG CAP Acquisition cost EFAVIRENZ 600 TAB PO Acquisition cost EFFERDENT TAB Acquisition cost EFFIENT 5 mg. Acquisition cost EFUDEX 5% CR 25 GMS Acquisition cost EGD BALLOON DIL ESOPH 30+MM 43233 $ 3,774.85 EGD ENDO-MUCOSAL RESECTION 43254 $ 3,774.85 EGD ENDOSCOPIC STENT PLACE 43266 $ 11,354.79 EGD FOR GT PLACEMENT 43246 $ 3,774.85 EGD W/ ENDO MUCOSAL RESECTION 43254 $ 3,774.85 EGD WITH BIOPSY OF SMALL INTESTINE 44100 $ 1,966.21 EGD WITH LASER ABLATION OF TUM 43270 $ 3,774.85 EGD WITH POLYPECTOMY 43251 $ 3,774.85 EGD, FLEX; DX, BRUSH/WASH 43235 $ 1,966.21 EGD, FLEX; ESOPH DILAT W/BALLN 43233 $ 3,774.85 EGG BUR 4.0MM^* C1713 $ 96.41 EIA ANA SCREEN 86235 $ 48.71 EIA ANTI-HBS 86706 $ 29.17 EIA FOR HBEAG 87350 $ 31.31 EIA FOR HBSAG 87340 $ 28.05 EIA HTLV-1 86687 $ 22.79 EIA-ANTI-HBC 86704 $ 32.74 EIA-ANTI-HBE 86707 $ 31.42 EIA-HEPT A ANTI-HAV-IGG 86708 $ 33.64 EIA-HEPT A-IGM 86709 $ 30.58 EIA-HIV-1/HIV-2 AB 86703 $ 37.22 EKG TRACING 93005 $ 147.99 EKG/ECG ELECTRODE A4556 $ 80.58 ELASTIC BANDAGE 2 $ 0.47 ELASTIC BANDAGE 3 $ 0.62 ELASTIC BANDAGE 4 $ 0.74 ELASTIC BANDAGE 6 A6450 $ 1.08 ELASTOPLAST-CATEG 1 Acquisition cost ELASTOPLAST-CATEG 2 Acquisition cost ELASTOPLAST-CATEG 3 Acquisition cost ELAVIL 10MG/ML INJ 10ML VIAL J1320 Acquisition cost ELBOW AP / LAT 73070 $ 164.27 ELBOW COMPLETE 73080 $ 164.27 ELBOW SPLINT 29260 $ 84.11 ELBOW/WRIST STRAPPING 29260 $ 84.11 ELCTRO ANLYS SPNE INF PUMP W/RPRG&RFIL 62370 $ 692.58 ELDEPRYL 5MG CAP Acquisition cost ELEC STIM 1 OR MORE AREA PRT THPY PLAN 97014 $ 32.03 ELEC-M / 3.5% DEXTROSE IV Acquisition cost ELEC-M / 7.5% DEXTROSE IV Acquisition cost ELEC-OCULOGRAPHY W/I/R 92270 $ 277.79 ELECT ANAL NEUROSTIM 95970 $ 277.79 ELECT ANAL NEUROSTIM WITH PROG 95971 $ 304.61 ELECTIVE EXT CARDIOVERS 92960 $ 1,355.77 ELECTRICAL STIMULATION 97014 $ 34.72 ELECTRICAL STIMULATION- ATT., EA 15 MIN. 97032 $ 33.81 ELECTRICAL STIMULATOR GUIDANCE, CHEMOD 95873 $ 44.07 ELECTRO HEARING AID TEST- BOTH EARS 92595 $ 210.00 Page 102 2018 ELECTRO HEARING AID TEST- ONE EAR 92594 $ 118.00 ELECTRO HEARING AID TEST, BOTH EARS 92595 $ 210.00 ELECTRO HEARING AID TEST, ONE EAR 92594 $ 118.00 ELECTRO STIM BONE; INVASIVE 20975 $ 380.73 ELECTROCARDIOLOGY PANEL Acquisition cost ELECTROCEPHALOGRAM 95819 $ 658.04 ELECTROCOCHLEOGRAPHY 92584 $ 360.51 ELECTROCOCHLEOGRAPHY, 92584 $ 360.51 ELECTROCORTICOGM AT SURG S/PRC 95829 $ 733.92 ELECTROCORTIGRAM AT SURGERY 95829 $ 733.92 ELECTRODE PCO2. 1304 1306 13 Acquisition cost ELECTRODES (APNEA MONITOR) PER PAIR A4556 $ 24.29 ELECTROENCEPHALOGRM SLEEP ONLY 95822 $ 658.04 ELECTROLYTE PANEL 80051 $ 19.05 ELECTROLYTE PANEL 80051 $ 19.05 ELECTROLYTE-M/5%DEXTROSE IV Acquisition cost ELECTRON MICRO DIAG 88348 $ 1,430.62 ELECTRON MICROSCOPIC STUDY 88348 $ 1,430.62 ELECTRONIC CROSSMATCH 86923 $ 341.62 ELECTROPHORESIS SERUM 84165 $ 29.17 ELECTROPHORESIS UR 84165 $ 29.17 ELECTROPHYSIOLOGY EVAL 93644 $ 330.22 ELECTRORETINOGRAPHY W INT & REP 92275 $ 658.04 ELEMENTAL CALCIUM 500MG Acquisition cost ELEMENTAL CALCIUM 260MG Acquisition cost ELEMENTAL CALCIUM 500MG Acquisition cost ELETROCARDIOGRAM, TRACING 93005 $ 147.99 ELISA FOR ROTAVIRUS 87425 $ 32.56 ELISA VIR AB TEST IGM 86709 $ 30.58 ELIXOPHYLLIN 160MG/30ML 30ML Acquisition cost ELIXOPHYLLIN 80MG/15ML UD 15ML Acquisition cost ELLIPTICAL ST MESH 6X8" W/ECHO C1781 $ 1,952.70 ELUTION PREP/ACID 86860 $ 341.62 EMBOLECTOMY 3FR CATH 6X80CM GW C1757 $ 136.50 EMBOLECTOMY 4FR CATH C1757 $ 39.00 EMBOLECTOMY 4FR CATH 10X80CMGW C1757 $ 136.50 EMBOLECTOMY 5FR PLUS CATHETER C1757 $ 136.50 EMBOLECTOMY 6FR CATH C1757 $ 91.50 EMBOLECTOMY/THROMBECTOMY VENO 34421 $ 6,592.23 EMBOLECTOMY/THROMBECTOMY, ARTE 34203 $ 11,279.00 EMER DEPT VISIT E&M SELF LIMIT 99281 $ 425.00 EMERG DIALYSIS ESRD PATIENT G0257 $ 1,581.54 EMERG DIALYSIS ESRD PT G0257 $ 1,581.54 EMERG ENDOTRACH INTUB 31500 $ 472.05 Emergency tracheotomy D7990 $ 2,454.00 EMG anal or ureteral sphincter 51784 $ 360.51 EMG ANAL SPHINCT NOT NEEDLE 51784 $ 360.51 EMG PATCH 51784 $ 360.51 EMLA CREAM 30GM Acquisition cost EMLA CREAM 5X5GM TUBES Acquisition cost EMLA{LIDO/PRILOCAINE}2.5% CRM, 30GM TUBE $ 18.70 EMP EVC CONT 1000 #1614-05 $ 4.08 EMP EVC CONT 500 #1614-03 $ 1.80 EMP EVC CONT 500 #1614-03-CATEG 1 Acquisition cost EMTRICITAB/TENOFOVIR 200/300 MG Acquisition cost EMTRICITABINE 10MG/ML ORAL SOLUTION J3490 Acquisition cost Page 103 2018 EMTRICITABINE 200MG (EMPRIVA) CAP Acquisition cost ENA ANY METHOD 86235 $ 48.71 ENALAPRIL 1MG/ML NICU BIC/OSW Acquisition cost ENALAPRIL 1.25 MG ML, 2ML INJ $ 10.83 ENALAPRIL 1.25 MG/ML, 1ML INJ $ 10.83 ENALAPRIL 1.25MG INJ - 1ML Acquisition cost ENALAPRIL 10MG TAB Acquisition cost ENALAPRIL 2.5MG TAB Acquisition cost ENALAPRIL 20MG TAB Acquisition cost ENALAPRIL 5 MG TABLET J8499 $ 4.13 ENALAPRIL 5MG TAB Acquisition cost ENALAPRILAT 1.25MG/ML INJ 1ML Acquisition cost Enamel microabrasion D9970 $ 49.00 ENCAINIDE 80299 $ 41.01 END CAP C1713 $ 27.30 ENDEAVOR SPRNT CORNRY STENT 3.0X15MM C1874 $ 2,385.00 ENDEAVOR SPRNT CORNRY STENT 3.0X18MM C1874 $ 2,310.00 ENDEAVOR SPRNT CORNRY STENT 3.5X30MM C1874 $ 2,587.50 ENDO BAG-CATEG 1 Acquisition cost ENDO CATH-BILI DUCTAL SYST-RAD S / I 74328 $ 77.64 ENDO CATH-PANCREAT DUCT SYS-S / I 74329 $ 78.39 ENDO COLON RETRO IMAGING C1749 $ 835.42 ENDO INJ OF IMPLANT MATERIAL 51715 $ 7,131.78 ENDO LIGACLIP ROT MULT CLIP C1713 $ 128.01 ENDO LIGACLP ROT 10MM MULT C1713 $ 417.72 ENDO UGI W REM FB 43247 $ 1,966.21 ENDO UGI; BALLOON DIL ESOPH 30> MM DIAM 43249 $ 3,774.85 ENDO ULTRAVERES NEEDLE 120MM C2618 $ 339.39 ENDO; ESOPHAGUS CAPSULE 91111 $ 1,966.21 ENDO-ANCHOR HERNIA DEVICE 5MM C1713 $ 428.18 ENDO-ANCHOR HERNIA DEVICE 5MM, C1713 $ 428.18 ENDOCERVIC CURETTAGE 57505 $ 1,522.22 ENDOCERVICAL CURET 57505 $ 1,522.22 ENDODONTIC EACH ADDITIONL ROOT D3426 $ 322.00 Endodontic endosseous implant D3460 $ 1,400.00 ENDODONTICS RETREAT ANTERIOR D3346 $ 490.00 ENDODONTICS RETREAT BICUSPID D3347 $ 560.00 ENDODONTICS RETREAT MOLAR D3348 $ 700.00 ENDOLOOP-CATEG 1 Acquisition cost ENDOLYMPHATIC SAC OP; W SHUNT 69806 $ 11,474.25 ENDOMET BX W/WO ENDOCRV BX-SEP 58100 $ 424.97 ENDOMET BX W/WO ENDOCRV BX-SEP PC 58100 $ 424.97 ENDOMETRIAL ASPIRATION 88108 $ 84.11 ENDOMETRIAL BIOPSY WITH COLPO 58110 $ 88.26 ENDOMETRIAL CRYOALBATION W US 58356 $ 10,873.98 ENDOSCOPIC 4.5 DRILL BIT C1713 $ 204.75 ENDOSCOPIC ANTEGRADE URETERAL 50553 $ 9,800.87 ENDOSCOPIC BILLARY STENT SET C1876 $ 780.00 ENDOSCOPIC PANCREATOSCOPY 43273 $ 264.81 ENDOSCOPIC PLANTAR FASCIOTOMY 29893 $ 6,995.52 ENDOSCOPIC US EXAM - UGI 43237 $ 3,774.85 ENDOSCPY; GI TRACT CAPSULE 91110 $ 1,966.21 ENDOSTAT FIBERWIRE STRIPP LASR C1713 $ 337.50 ENDOTOXIN ASSAY (LAL) $ 10.49 ENDOTRCH TUB REINFRC CONTCTTUB A4624 $ 454.50 ENDOTRCT TUB 6.0FR $ 2.99 Page 104 2018 ENDOTRCT TUB 6.5FR $ 2.93 ENDOTRCT TUB 7.0FR $ 3.10 ENDOTRCT TUB 7.5FR $ 2.99 ENDOTRCT TUB 8.0FR $ 2.93 ENDOTRCT TUB 8.5FR $ 2.99 ENDOTRCT TUB 9.0FR $ 11.97 ENDOTRCT TUB 9.5FR $ 2.93 ENDOVASC AAA BIFURCATED GRAFT C1768 $ 3,517.50 ENDOVASC PLCMT ILIAC ARTERY OCCLUS DEV 34808 $ 444.99 ENDOVASC REP THORAC AORTA; INCL SUBCL 33880 $ 3,846.52 ENDOVASC REPR ABD AO ANEUR-RAD S/I 75952 $ 577.65 ENDOVEN ALBATE THER; RF; 1ST VEIN 36475 $ 6,592.23 ENDOVEN ALBTN THER; LASER EXT; 1ST VEIN 36478 $ 6,592.23 ENDOVENOUS ABLAT TX; ADD-ON 36476 $ 291.94 ENDROPHONIUM CL 10MG/ML Acquisition cost ENEMA BAG $ 1.34 ENFLURANE 125ML Acquisition cost ENFUVIRIDE Acquisition cost ENFUVIRTIDE 90MG SQ KIT Acquisition cost ENOXAPARIN 100MG/ML PFS J1650 Acquisition cost ENOXAPARIN 10MG/ML INJ Acquisition cost ENOXAPARIN 60MG/0.6ML SYR INJ J1650 Acquisition cost ENOXAPARIN 80MG/0.8ML SYR INJ J1650 Acquisition cost ENOXPRIN 120MG (LOVENOX) INJ SC J1650 Acquisition cost ENOXPRIN 150MG (LOVENOX) INJ SC J1650 Acquisition cost ENSEAL G2 ARTICULAT TISS SEALR A4649 $ 5,301.33 ENSEAL TRIO 3MM 35CM TISS SEAL A4649 $ 4,680.41 ENT TRAY $ 38.50 ENTACAPONE 200MG TAB Acquisition cost ENTECAVIR 0.5 MG. PO Acquisition cost ENTECAVIR 0.5mg ORAL Acquisition cost ENTECAVIR 1 MG TABLET Acquisition cost ENTERO-H 1900 ML 80% Acquisition cost ENTEROLYSIS 44005 $ 2,340.95 ENTEROSCOPY 44380 $ 1,966.21 ENTEROTEST (GIARDIA) 87177 $ 24.18 ENTEROVIRUS SCREEN 87140 $ 15.14 ENTROPION REPAIR; EXTENSIVE 67924 $ 4,790.26 ENTROSCOPY >2ND DUOD 44360 $ 3,774.85 ENUC EYE; W IMPLANT; WO MSCL ATTCHMNT 65103 $ 7,805.64 ENUCL EYE; W IMP & MUSCLE ATTCHMNT 65105 $ 7,805.64 ENUCLEATE EYE; WO IMPLANT 65101 $ 7,805.64 ENULOSE/CEPHULAC 10GM/15ML480M Acquisition cost ENV INTERVEN-W/AGENCIES/INSTIT 90882 $ 77.00 ENVIRNMENTAL MGEMENT 90882 $ 77.00 ENVIRONMENTAL CULTURE 87081 $ 18.00 ENVIRONMENTAL MANAGEMENT 90882 $ 77.00 ENZ IMM DETECT-RSV 86317 $ 40.70 EO, DBL UPRT FORARM/ARM CUFFS, EXT/FLXN L3730 $ 1,905.18 EO, DBL UPRT FORARM/ARM CUFS, FREE MTN L3720 $ 1,413.28 EODB UPRT 4ARM/ARM CF ADJ+LCK W ACT CTRL L3740 $ 2,139.94 EOM MEASUREMENT (PVT ONLY) 95851 $ 43.23 EOSINOPHIL COUNT 85999 $ 16.50 EOSINOPHIL COUNT-NASAL SMEAR 89190 $ 12.89 EOSINOPHIL SMEAR 85999 $ 16.50 EOSINOPHIL SMEAR FECAL 85999 $ 16.50 Page 105 2018 EOSINOPHIL SMEAR NASAL 89190 $ 12.89 EOSINOPHIL SMEAR SPUTUM 85999 $ 16.50 EOSINOPHIL URINE 81015 $ 8.27 EOSINOPHILES-URINE 87205 $ 11.59 EOVIST 181.43 MG/ML 10ML Acquisition cost EP EVAL CD LEADS; INIT IMPL/REPLACEMNT 93640 $ 385.88 EP STEERABLE GUIDING INTRODUCR/SHEAT C1766 Acquisition cost EPCLUSA Sofosbuvir400mg/Velpatasvir100mg $ 0.10 EPHEDRINE 50MG INJ J3490 $ 29.04 EPHEDRINE SULF 50MG/ML INJ Acquisition cost EPHEDRINE SULFATE 10MG/ML SYRINGE Acquisition cost EPIDURAL/LUMBA/ SACRAL NV DESR 62282 $ 1,777.62 EPIDURL CERVICL THORAC NRV DES 62281 $ 1,777.62 EPIDUROGRAPHY RAD S/I 72275 $ 85.40 EPILATION OF TRICHIASIS 67820 $ 277.79 EPILATION PROC; OTHER THAN FORCEPS 67825 $ 707.85 EPINEPHRINE 0.1MG 1ML, 10MLABB J0171 $ 3.85 EPINEPHRINE 0.1MG/ML ABBO 10ML J0171 Acquisition cost EPINEPHRINE 0.5% EYE DROP Acquisition cost EPINEPHRINE 1% EYE DROP Acquisition cost EPINEPHRINE 1MG / ML INJ J0171 Acquisition cost EPINEPHRINE 1MG/1mL INJ Acquisition cost EPINEPHRINE 1MG/250ML INJECTION Acquisition cost EPINEPHRINE 2% EYE DROP Acquisition cost EPINEPHRINE 4MG/250ML PREMIX Acquisition cost EPIRUBICIN 2MG/ML VIAL INJ. Acquisition cost EPIRUBICIN HCL,2MG J9178 $ 6.16 EPISIOTOMY OR VAGINAL REPAIR 59300 $ 6,010.51 EPIVIR 10MG/ML SOLUTION Acquisition cost EPIVIR 150MG TAB Acquisition cost EPIVIR 300MG. PO (FOR SCC ONLY) Acquisition cost EPLERENONE 25MG. TABLET Acquisition cost EPOETIN ALPHA 20,000 UNITS SQ J0885 Acquisition cost EPOETIN ALPHA 40,000 UNITS INJ Acquisition cost EPOETIN(NON ESRD USE)/1000 UNT J0885 $ 43.78 EPOGEN FOR NICU (PREPARED BY IV DEPART.) J0885 Acquisition cost EPOGEN/PROCRIT 10000U/ML 1ML J0885 Acquisition cost EPOGEN/PROCRIT PER 1000 UNITS Acquisition cost EPOGEN/PROCRIT PER 40,000 UNT(FOR SCC Acquisition cost EPOTIN ALFA (NON ESRD) PER 1000 UNT J0885 $ 67.91 EPSTEIN BARR SCREEN 86663 $ 35.64 EPSTEINBARR-VIRUS AB ASSAY-VCA IGG 86665 $ 49.28 EQUALIZER BALLOONS 33 X 65 C2628 $ 372.00 EQUALIZER BALLOONS 33 X 65 C1726 $ 372.00 ER VISIT E&M HIGH SEVER URGENT 99284 $ 886.00 ER VISIT E&M HIGH-SEVER SIG TH 99285 $ 1,186.00 ERASER SUCTION ASP-CATEG 1 Acquisition cost ERBITUS 10 MG (CETUXIMAB) J9055 $ 160.12 ERCP DUCT STNT PLACEMENT 43274 $ 11,354.79 ERCP EA DUCT/AMPULLA DILATE 43277 $ 7,255.23 ERCP W ALBATION TUM/POLYP/LES 43278 $ 7,255.23 ERCP W BX; SING/MULTI 43261 $ 7,255.23 ERCP W REM FB/STNT; BILARY/PANCR DUCTS 43275 $ 7,255.23 ERCP W REM/EXCH STNT; DILAT, GW PASS 43276 $ 11,354.79 ERCP/ENDOSCOPIC CATH/PANCREAS / BILE 74330 $ 99.97 ERCP; BALLN DILAT AMPULA BILI& 43277 $ 7,255.23 Page 106 2018 ERCP; DESTRUC LITH CALCU/CALCU 43265 $ 11,354.79 ERCP; DX W/WO CLCT SPEC SEP PR 43260 $ 7,255.23 ERCP; REMV CALCU BILI&/PANC DU 43264 $ 7,255.23 ERCP; STENT EXCHNG W/DILATION 43276 $ 11,354.79 ERCP; W/ REM FB PANCREAS DUCT 43275 $ 7,255.23 ERCP; W/SPHINCTEROTOMY/PAPILLO 43262 $ 7,255.23 ERGOCALCIFEROL 200UNIT/DROP Acquisition cost ERGOCALCIFEROL 50,000 INT UNIT CAP Acquisition cost ERGONOVINE MAL 0.2MG/ML INJ J1330 Acquisition cost ERGOTAMINE TART/CAFFEINE TAB Acquisition cost ERTAPENCU 1 GM. J1335 Acquisition cost ERTAPENEM 1 GM. ADDVANTAGE VIAL J1335 Acquisition cost ERYTHROCIN 1GM VIAL INJ J1364 Acquisition cost ERYTHROCIN 500MG VIAL INJ J1364 Acquisition cost ERYTHROMYCIN 1GM ADD VANTAG Acquisition cost ERYTHROMYCIN 250MG TAB Acquisition cost ERYTHROMYCIN 400MG/5ML 100 ML SUSPENSION Acquisition cost ERYTHROMYCIN 500 MG TAB Acquisition cost ERYTHROMYCIN 500MG ADD VANT J1364 Acquisition cost ERYTHROMYCIN BASE EYE OINT Acquisition cost ERYTHROMYCIN EYE OINT 3.5 GM Acquisition cost ERYTHROMYCIN OPHTH. OINT. 0.5% (5MG/G) $ 22.48 ERYTHROPOIETIN 82668 $ 51.04 ERYTHRO-PROTOPORPH 84202 $ 38.96 ES SILVERHAWK PERIPH CATH C1714 $ 5,992.50 ESCALATE LAMINOPLASTY PLATE C1713 $ 1,362.90 ESCITALOPRAM OXALATE 10MG Acquisition cost ESCITALOPRAM OXALATE 20MG Acquisition cost ESKALITH CAPSULES Acquisition cost ESKALITH CR 450 MG TAB Acquisition cost ESL BLOOD COL NDL 21G $ 0.32 ESL BLOOD COL.22GX 1 1/4 $ 0.34 ESMOLOL 10MG/ML 10ML INJ Acquisition cost ESMOLOL 2,500MG/250ML PREMIX Acquisition cost ESMOLOL 250MG/ML 10ML INJ Acquisition cost ESMOLOL HCL 10MG/ML 250ML BAG $ 3.83 ESO REM TUM BY SNARE 43217 $ 3,774.85 ESO W HOT BX/B CAUTERY 43216 $ 3,774.85 ESO W REPAIR BLEED 43227 $ 3,774.85 ESOMEPRAZOLE 20MG (NEXIUM) CAP DR Acquisition cost ESOMEPRAZOLE 40MG (NEXIUM) CAP DR Acquisition cost ESOMPRAZOLE 40MG IV Acquisition cost ESOPH FLEX SPEC COLLECTION 43200 $ 1,966.21 ESOPH MOTILITY 78258 $ 924.11 ESOPH SCOPE W/SUBMUCOUS INJ 43201 $ 3,774.85 ESOPH W BAND LIGAT VARICES 43205 $ 3,774.85 ESOPH W BX SGL/MULTI 43202 $ 3,774.85 ESOPHAGEAL BALLOON DILATION 43220 $ 3,774.85 ESOPHAGEAL CAPSULE ENDO 91111 $ 1,966.21 ESOPHAGEAL STENT Acquisition cost ESOPHAGOGASTROSCOPYBX; SING/MULT 43202 $ 3,774.85 ESOPHAGOSCOPY DIAGNOSTIC 43200 $ 1,966.21 ESOPHAGOSCOPY RIGID/FLEX; W/RE 43215 $ 3,774.85 ESOPHAGOSCOPY W GUIDE WIRE 43226 $ 3,774.85 ESOPHAGOSCOPY W US FNA/BX 43232 $ 3,774.85 ESOPHAGOSCOPY; FLEXIBLE BRUSH 43200 $ 1,966.21 Page 107 2018 ESOPHAGOSCOPY; INSRT TUBE/STEN 43212 $ 11,354.79 ESOPHAGOSCOPY; RIGID, DX 43191 $ 3,774.85 ESOPHAGOSCOPY; W US EXAM 43231 $ 3,774.85 ESOPHAGOSCP GUIDE WIRE DILAT 43196 $ 7,255.23 ESOPHAGOSCP RIG TRNSO BIOPSY 43193 $ 3,774.85 ESOPHAGOSCP RIG TRNSO REM FB 43194 $ 3,774.84 ESOPHAGOSCP RIG TRNSO REM FB 43194 $ 3,774.85 ESOPHAGOSCPY, FLEX; DILAT W/BALLN 43214 $ 3,774.85 ESOPHAGOSCPY; TRNSNASAL, FLEX W BRUSH 43197 $ 1,966.21 ESOPHAGSCOPIC FB REMOVAL 43215 $ 3,774.85 ESOPHAGSCOPY FB REMOVAL 43215 $ 3,774.85 ESOPHAGUS 74220 $ 668.38 ESOPHAGUS ( PHARYNX / CERVICAL) 74210 $ 668.38 ESOPHAGUS MOTILITY STUDY 91010 $ 1,175.22 ESOPHAGUS, UNLISTED PROCEDURE 43499 $ 1,966.21 ESPGHOGEAL SCLEROTHERAPY 43204 $ 3,774.85 ESPOHAGOSCOPY/BX/CYTOLOGY 43202 $ 3,774.85 ESSO X REM TUM/PLP SNARE 43217 $ 3,774.85 EST PAT E/M - 10MIN (PO) 99212 $ 315.00 EST PAT E/M - 15MIN (PO) 99213 $ 343.00 EST PAT E/M - 25MIN (PO) 99214 $ 370.00 EST PAT E/M - 40MIN (PO) 99215 $ 398.00 EST PAT E/M - 5MIN (PO) 99211 $ 300.00 ESTRADERM 0.05MG/24H PATCH Acquisition cost ESTRADERM 0.1 MG PATCH Acquisition cost ESTRADIOL (E2) 82670 $ 75.88 ESTRADIOL 0.01% VAGINAL CR Acquisition cost ESTRADIOL 1MG TABLET Acquisition cost ESTRAMUST PHOS SOD 140MG CAP Acquisition cost ESTRIOL (E3) 82677 $ 65.67 ESTRIOL LEVEL 82677 $ 65.67 ESTRIOL LEVEL URINE 82677 $ 65.67 ESTRIOL, FREE 82677 $ 65.67 ESTROGEN TOTAL 82672 $ 58.92 ESTROGEN + PROGESTERONE RECEP 84233 $ 193.34 ESTROGEN RECEPTOR 84233 $ 193.34 ESTROGENS CONJ 0.3MG TAB Acquisition cost ESTROGENS CONJ 1.25MG TAB Acquisition cost ESTROGENS; FRACTIONATED 82671 $ 87.74 ESTRONE 82679 $ 67.78 ESTRONE E1 82679 $ 67.78 ESZOPICLONE 1 MG. Acquisition cost ESZOPICLONE 2 MG. Acquisition cost ESZOPICLONE 3 MG. Acquisition cost ETHACRYNIC ACID 25 MG. PO Acquisition cost ETHAMBUTOL 100MG TAB Acquisition cost ETHAMBUTOL 400MG TAB Acquisition cost ETHANOLAMINE 5% INJ J1430 $ 564.31 ETHANOLAMINE OLEATE 5% AMPULES J1430 Acquisition cost ETHICON SUTURE C1781 $ 1,911.54 ETHICON ULTRAPRO COMFORT PLUG C1781 $ 1,393.73 ETHICON ULTRAPRO COMFORT PLUG C1781 $ 1,393.73 ETHICON ULTRAPRO MESH 6 X 6" 3/BX C1781 $ 172.50 ETHICON ULTRAPRO MESH 6X6 3/BX C1781 $ 172.49 ETHILON SUTURE 18"(45CM) C1713 $ 54.72 ETHIODIZED OIL 37% INJ. Acquisition cost Page 108 2018 ETHIONAMIDE 250MG SC TABLET Acquisition cost ETHMOIDECT; INTRANASAL; TOTAL 31201 $ 5,815.59 ETHMOIDECTOMY; INTRANASAL; ANTERIOR 31200 $ 11,474.25 ETHOSUXIMIDE 80168 $ 44.37 ETHYL CHLORD SPRAY J3490 $ 77.00 ETHYL CHLORIDE SPRAY 105ML Acquisition cost ETHYLENE GLYCOL LEVEL 82693 $ 40.48 ETHYOL 500MG INJ VIAL J0207 Acquisition cost ETIDRONATE DISODIUM 200MG TAB Acquisition cost ETOMIDATE 2MG/ML INJ J3490 $ 1.94 ETONOGESTREL IMPLANT SYSTEM J7307 $ 2,036.81 ETOPOSIDE 20MG/ML INJ J9181 Acquisition cost ETOPOSIDE 50 MG J9181 $ 2.46 ETOPOSIDE 50MG CAP J8560 Acquisition cost ETOPOSIDE ORAL 50 MG J8560 $ 220.96 ETOPOSIDE, 10MG J9181 $ 2.46 ETRAVIRINE 100MG (INTELENCE) Acquisition cost ETRETINATE 10MG CAP Acquisition cost ETRETINATE 25MG CAP Acquisition cost EUGLOBULIN TIME 85360 $ 22.84 EVAC EXTRNL THROMBOSED HEMORRHOID 46083 $ 607.00 EVAC SUBUNGUAL HEMATOMA 11740 $ 277.79 EVACUATION SUBUNGUAL HEMATOMA 11740 $ 277.79 EVACUATOR COMPACT-CATEG 1 Acquisition cost EVACUATOR -CATEG 1 Acquisition cost EVAL - SPEECH DEVICE; 1HR 92607 $ 284.50 EVAL AND/OR FITTING VOICE PROSTHETIC 92597 $ 156.51 EVAL AUD REHAB STATUS; 1ST HR 92626 $ 360.51 EVAL AUD REHAB STATUS; EA ADDL 15 MIN 92627 Acquisition cost EVAL CARDIOVASC FUNCT W/TILT TABLE 93660 $ 1,175.22 EVAL CENT AUDTRY FUNC W/RPT + ADD 15 MIN 92621 $ 30.00 EVAL CENT AUDTRY FUNC W/RPT INITL 60 MIN 92620 $ 360.51 EVAL FINE NEEDL ASP; INTRPT & REPRT 88173 $ 118.21 EVAL OF SPEECH FLUENCY 92521 $ 247.98 EVAL SPEECH PRODUCTION 92522 $ 199.32 EVAL SPEECH SOUND/LANG COMPREHEN 92523 $ 430.12 EVAL SWALLOWING & ORAL FUNCT-FEEDING 92610 $ 186.30 EVALTO USE/FIT VOICE PROSTH 92597 $ 156.51 EVALUATION OF FINE NEEDLE ASPIRATE (CVS) 88172 $ 341.62 EVENT RECORDER CARDIAC C1764 $ 7,267.50 EVICEL SEALANT C1765 $ 374.93 EVISCERATE OCULAR CONTENTS; W IMP 65093 $ 7,805.64 EVISTA 60MG TABLET Acquisition cost EVOKED AUDITORY TEST- COMPREHENSIVE 92588 $ 658.04 EVOKED AUDITORY TEST- LIMITED 92587 $ 658.04 EVOKED AUDITORY TEST, COMPREHENSIVE 92588 $ 658.04 EVOKED AUDITORY TEST, LIMITED 92587 $ 658.04 EVOLVE - HEAD C1776 $ 2,460.00 EVOLVE - STEM C1776 $ 2,902.50 EX FOR SPEECH DEVICE RX ADDL 92608 $ 114.31 Ex malig tumor-diam <= 1.25 cm D7440 $ 1,898.00 Ex malig tumor-diam > 1.25 cm D7441 $ 2,950.00 EXAM SYNOVIAL FLUID CRYSTALS 89060 $ 19.43 EXC & REPR EYELID; UP TO 1/4 L 67961 $ 4,790.26 EXC / REPR EYELID > 1/4 LID MARGIN 67966 $ 4,790.26 EXC 5. TAG PAPILLECTOMY 46220 $ 2,476.36 Page 109 2018 EXC ABD TUM;OPEN;DIAM 10CM OR 49205 $ 3,767.19 EXC AURAL POLYP 69540 $ 3,010.00 EXC B9 LES FACE/MM; 2.1-3 CM 11443 $ 3,564.97 EXC B9 LES S/N/EX/G; 0.5 CM OR LESS 11420 $ 3,564.97 EXC B9 LESION T/A/L; 3.1-4 CM 11404 $ 3,564.97 EXC B9 LESION TRNK/EXTREM; 1.1-2 CM 11402 $ 1,514.94 EXC B9 TUM/CYST OF MAXILLA/ZYGOMA 21030 $ 11,474.25 EXC B9 TUM; CRANIAL BONE; WO OND 61563 $ 4,157.32 EXC BARTH GLAND/CYST 56740 $ 6,010.51 EXC BEN CYST/TUMOR MANDIB; SIMPL 21040 $ 5,815.59 EXC BEN LES FACE EAR LIP; 0.6-1.0 CM 11441 $ 1,514.94 EXC BEN LES FACE EAR LIP; 1.1-2.0 CM 11442 $ 1,514.94 EXC BEN LES FACE EAR LIP;0.5 CM/LESS 11440 $ 1,514.94 EXC BEN LES FACE/MM; 3.1-4 CM 11444 $ 3,564.97 EXC BEN LES FCE EAR LIP; 0.6-1 11441 $ 1,514.94 EXC BEN LES FCE EAR LIP; 1.1-2 11442 $ 1,514.94 EXC BEN LES FCE EAR LIP; 2.1-3.0 CM 11443 $ 3,564.97 EXC BEN LES FCE EAR LIP; 3.1-4.0 CM 11444 $ 3,564.97 EXC BEN LES FCE EAR LIP; OVR 4.0 CM 11446 $ 6,148.30 EXC BEN LES FCE EAR LIP;0.5 CM 11440 $ 1,514.94 EXC BEN LES FCE EAR LIP;0.5 CM/LESS 11440 $ 1,514.94 EXC BEN LES S/N/EX/G; 0.6-1 CM 11421 $ 1,514.94 EXC BEN LES SCLP HND FT; 0.6-1.0 CM 11421 $ 1,514.94 EXC BEN LES SCLP HND FT; 1.1-2.0 CM 11422 $ 3,564.97 EXC BEN LES SCLP HND FT; 2.1-3.0 CM 11423 $ 3,564.97 EXC BEN LES SCLP HND FT; 3.1-4.0 CM 11424 $ 3,564.97 EXC BEN LES SCLP HND FT; OVR 4.0 CM 11426 $ 6,148.30 EXC BEN LES SCLP HND FT;0.5 CM/LESS 11420 $ 3,564.97 EXC BEN LES T/A/L; 2.1-3 CM 11403 $ 1,514.94 EXC BEN LES TRNK ARM/LEG;0.6-1.0 CM 11401 $ 821.94 EXC BEN LES TRNK ARM/LEG;1.1-2.0 CM 11402 $ 1,514.94 EXC BEN LES TRNK ARM/LEG;2.1-3.0 CM 11403 $ 1,514.94 EXC BEN LES TRNK ARM/LEG;3.1-4.0 CM 11404 $ 3,564.97 EXC BEN LES TRUNK/ARMS/LEGS; 0.5 CM/LESS 11400 $ 1,514.94 EXC BEN LES TRUNK/ARMS/LEGS; OVER 4.0 CM 11406 $ 3,564.97 EXC BEN LESION S/N/EX/G; 3.1-4 CM 11424 $ 3,564.97 EXC BEN MANDIBL TUMR W OSTEOT 21046 $ 11,474.25 EXC BENIGN LES S/N/EX/G; 1.1-2 CM 11422 $ 3,564.97 EXC BENIGN LES TRNK/EXTREM; 0.6-1 CM 11401 $ 821.94 EXC BENIGN LESION FACE/MM; OVER 4 CM 11446 $ 6,148.30 EXC BENIGN LESION S/N/EX/G; OVER 4 CM 11426 $ 6,148.30 EXC BENIGN LESION T/A/L; OVER 4 CM 11406 $ 3,564.97 EXC BENIGN MANDIBL TUMR W EOO 21047 $ 11,474.25 EXC BN CYST/BEN TUM; PHALANGE 28108 $ 3,570.03 EXC BN CYST/TUM; CARPAL BONES 25130 $ 6,995.52 EXC BONE/MANDIBLE OSTEOMYELITIS 21025 $ 11,474.25 EXC BONE; FACIAL BONE 21026 $ 11,474.25 EXC BONE; MANDIBLE 21025 $ 11,474.25 EXC BRANCH CLFT CYST/VEST;BELO 42815 $ 11,474.25 EXC BRANCHIAL CLEFT CYST/VESTI 42810 $ 5,815.59 EXC BRST CYST TUMR/LES OPN M/F 1/> 19120 $ 7,213.98 EXC BRST LES ID RAD MARKR OPN;1 LES 19125 $ 7,213.98 EXC CERVICAL STUMP; VAGINAL APPR 57550 $ 6,010.51 EXC CHALAZION; MX DIFF LIDS 67805 $ 707.85 EXC CHALAZION; MX SAME LID 67801 $ 2,137.81 EXC CHALAZION; SNGL 67800 $ 707.85 Page 110 2018 EXC CHALZION, W ANESTH/HOSP; SNG/MULTI 67808 $ 4,790.26 EXC CHEST WALL TUMOR INCL RIBS 19260 $ 6,148.30 EXC CYST HYGROMA WO DEEP NEUROVASC DISCT 38550 $ 7,213.98 EXC CYST/BENGN TUM; RADIUS 24120 $ 6,995.52 EXC CYST/GANGLION - TOES 28092 $ 3,570.03 EXC CYST/TUM FINGER PHALANX 26210 $ 3,570.03 EXC CYST/TUMOR FING PHALANX W AUTOGRFT 26215 $ 6,995.52 EXC CYST/TUMOR METACRPL 26200 $ 3,570.03 EXC DEEP TMR; FACE/SCLP; 2< CM 21014 $ 6,148.30 EXC DEEP TUM FOOT/TOE; 1.5< CM 28041 $ 6,148.30 EXC DEEP TUM NECK/THORAX; 5< CM 21554 $ 6,148.30 EXC DEEP TUM; FACE/SCLP; <2CM 21013 $ 3,564.97 EXC DEEP TUM; THIGH/KNEE; 5< CM 27339 $ 6,148.30 EXC DEEP TUMOR HAND; 1.5< CM 26113 $ 3,564.97 EXC DEEP TUMOR; BACK; 5CM OR LESS 21932 $ 6,148.30 EXC DEEP TUMOR; PELVIS; 5< CM 27045 $ 6,148.30 EXC EP TESTIS LESION 54512 $ 4,484.35 EXC EXCESS SKIN TISSUE; HIP 15834 $ 6,148.30 EXC EXCESS SKIN; FOREARM/HAND 15837 $ 6,148.30 EXC EXCESSIVE SKIN & SUBQ TISS 15832 $ 6,148.30 EXC EXCESSIVE SKIN / SUBQ TISS; ABD 15830 $ 12,725.37 EXC EXT EAR; PARTIAL, SIMPLE REP 69110 $ 6,148.30 EXC EXTERNAL EAR; PART; SIMP REP 69110 $ 6,148.30 EXC EYELID LES WO CLOSE/SIMP REP 67840 $ 2,137.81 EXC FEMUR BONE CYST/TUMOR 27355 $ 6,995.52 EXC FIBROUS TUBRSITIES 41822 $ 3,010.00 EXC FISTAL ULNA; PART/COMPLTE 25240 $ 6,995.52 EXC FOOT CYST/GANGLION 28090 $ 3,570.03 EXC FOOT/TOE TUMOR; DEEP; 1.5 CM/> 28045 $ 6,148.30 EXC FOREARM/WRST TUM DEEP 3< CM 25073 $ 6,148.30 EXC FRENUM, LABIAL, BUCCAL 40819 $ 3,010.00 EXC GANGLION WRIST; PRIM 25111 $ 3,570.03 EXC HAND LESION; SUBQ; 1.5 CM/> 26115 $ 3,564.97 EXC HAND TUMOR; DEEP; 1.5 CM/> 26116 $ 3,564.97 EXC HEEL TALUS/CALCAN CYST/TUMOR 28100 $ 6,995.52 EXC HIDRAD AXIL; SIMP/INTRMED REPAIR 11450 $ 6,148.30 EXC HIDRAD PERI/UMBIL; S/I REP 11470 $ 6,148.30 EXC HIDRAD UMBLCL; CMPLX 11471 $ 6,148.30 EXC HIDRAD UMBLCL; SIMP/INTERMD 11470 $ 6,148.30 EXC HIDRAD; AXIL; CMPLX REP 11451 $ 6,148.30 EXC HIDRAD; INGUINAL; CMPLX REP 11463 $ 6,148.30 EXC HYDROCEL SPERM CRD UNI-SEP PROC 55500 $ 7,131.78 EXC HYDROCELE OF SPRM CRD; UNILATERAL 55500 $ 7,131.78 EXC HYDROCELE; UNILATERAL 55040 $ 7,698.79 EXC HYPERPLASTIC TISSUE D7970 $ 732.00 EXC I P ULCER W 1' SUTURE 15940 $ 6,148.29 EXC INFECTED GRAFT; EXTREMITY 35903 $ 6,592.23 EXC INTERDIG MORTON NEUROMA; EA SGL 28080 $ 3,570.03 EXC LACRIMAL GLND TUMR;FRNT APPR 68540 $ 4,790.26 EXC LACRIMAL SAC 68520 $ 7,805.64 EXC LACTIFEROUS DUCT FISTULA 19112 $ 7,213.98 EXC LCL LES OF EPIDIDYMIS 54830 $ 4,484.35 EXC LCL;ULCER/BENIGN TUM STOMA 43610 $ 2,090.51 EXC LEG/ANKLE TUM; DEEP; 5CM/> 27619 $ 6,148.30 EXC LEG/ANKLE TUMOR; SUBQ; 3CM/> 27618 $ 3,564.97 EXC LES CONJUNC; UP TO 1 CM 68110 $ 4,790.26 Page 111 2018 EXC LES CORNEA EX PTERYGIUM 65400 $ 2,137.81 EXC LES LID NO CLOS/W SMPL DIR 67840 $ 2,137.81 EXC LES MENISCUS/CAPSULE; KNEE 27347 $ 6,995.52 EXC LES MOUTH VESTI;CPLX W EXC 40816 $ 5,815.48 EXC LES MOUTH VESTIB W CMPLX REP 40814 $ 5,815.59 EXC LES MOUTH VESTIBULE W SIMPLE REPAIR 40812 $ 5,815.59 EXC LES PALATE/UVULA;W LOCAL F 42107 $ 11,474.25 EXC LES/TMR DENTOALVEOLAR W CM 41827 $ 11,474.25 EXC LES/TUM DENTOALVEOLAR W SI 41826 $ 5,815.59 EXC LES; CONJNCTVA W ADJ SCLERA 68130 $ 4,790.26 EXC LES; CONJUNCTIVA; OVER 1CM 68115 $ 4,790.26 EXC LES; MAL S/N/H/F/G/MRG; 1.1-2.0CM 11622 $ 1,514.94 EXC LES; MAL S/N/H/F/G/MRG; 4.0+ CM 11646 $ 6,148.30 EXC LES;MOUTH VEST; SIMP REP 40812 $ 5,815.59 EXC LES;MOUTH VESTIBULE;WO REP 40810 $ 5,815.59 EXC LESION DENOALVEOLAR 41825 $ 5,815.59 EXC LESION OF SPERMATIC CORD 55520 $ 7,131.78 EXC LESION;PALATE/UVULA;WO CLO 42104 $ 5,815.59 EXC LINGUAL FRENUM 41115 $ 3,010.00 EXC LIP; FULL THICK RECONST W LCL FLP 40525 $ 5,815.59 EXC LIP; TRANSVRS WEDGE 40510 $ 5,815.59 EXC LOP;V-EXC W PRIMARY DIR 40520 $ 5,815.59 EXC MAL LES F/E/E/N/L; 1.1-2.0CM 11642 $ 1,514.94 EXC MAL LES F/E/E/N/L; 2.1-3.0CM 11643 $ 3,564.97 EXC MAL LES F/E/E/N/L; 3.1-4.0CM 11644 $ 3,564.97 EXC MAL LES FACE; 0.6 TO 1.0 CM 11641 $ 1,514.94 EXC MAL LES MRG/S/N/H/F/G; 1.1-2CM 11622 $ 1,514.94 EXC MAL LES S/H/N/F/G/MARG; 0.5> CM 11620 $ 3,564.97 EXC MAL LES SCLP/NK/HN/FT/G; 0.6-1.0CM 11621 $ 1,514.94 EXC MAL LES SCLP/NK/HN/FT/G; 2.1-3.0CM 11623 $ 3,564.97 EXC MAL LES SCLP/NK/HN/FT/G; 3.1-4.0CM 11624 $ 3,564.97 EXC MAL LES SCLP/NK/HN/FT/G; 4.0CM < 11626 $ 6,148.30 EXC MAL LES TNK/ARM/LEG; 0.6-1.0 CM 11601 $ 1,514.94 EXC MAL LES TNK/ARM/LEG; 2.1-3.0 CM 11603 $ 1,514.94 EXC MAL LES TNK/ARM/LEG; 4.0CM < 11606 $ 3,564.97 EXC MAL LES TRNK/A/L/MARG; 1.1-2.0 CM 11602 $ 821.94 EXC MAL LES TRUNK; 0.5 CM/LESS 11600 $ 1,514.94 EXC MALG LES TRUNK; 0.6 TO 1.0 CM 11601 $ 1,514.94 EXC MALGNT LES FACE; LESS THAN 0.5CM 11640 $ 1,514.94 EXC MALIG LES FACE; 0.5 CM/LESS 11640 $ 1,514.94 EXC MALIG LES FACE; 0.6 TO 1.0 11641 $ 1,514.94 EXC MALIG LES FACE; 1.1 TO 2.0 11642 $ 1,514.94 EXC MALIG LES FACE; 2.1 TO 3.0 11643 $ 3,564.97 EXC MALIG LES FACE; 3.1 TO 4.0 11644 $ 3,564.97 EXC MALIG LES SCLP; 0.5 CM/LESS 11620 $ 3,564.97 EXC MALIG LES SCLP; 0.6 TO 1.0 CM 11621 $ 1,514.94 EXC MALIG LES SCLP; 2.1 TO 3.0 11623 $ 3,564.97 EXC MALIG LES SCLP; 3.1 TO 4.0 11624 $ 3,564.97 EXC MALIG LES SCLP; OVER 4.0 C 11626 $ 6,148.30 EXC MALIG LES TRUNK; 0.5 CM/LESS 11600 $ 1,514.94 EXC MALIG LES TRUNK; 0.6 TO 1.0 CM 11601 $ 1,514.94 EXC MALIG LES TRUNK; 1.1 TO 2.0 CM 11602 $ 821.94 EXC MALIG LES TRUNK; 2.1 TO 3. 11603 $ 1,514.94 EXC MALIG LES TRUNK; 3.1 TO 4. 11604 $ 1,514.94 EXC MALIG LES TRUNK; OVER 4.0 11606 $ 3,564.97 EXC MAXILLA TUMOR-CMPLX 21048 $ 11,474.25 Page 112 2018 EXC MAXILLARY TORUS PALATINUS 21032 $ 5,815.59 EXC NAIL/MATRIX PART/COMPLT PERM REMOV 11750 $ 821.94 EXC NAIL/MATX PRT/COMP PRM REM 11750 $ 821.94 EXC NASAL POLYP(S); EXTENSIVE 30115 $ 5,815.59 EXC NASAL POLYP(S); SIMPLE 30110 $ 3,010.00 EXC NECK TUM; DEEP; 5 CM/> 21556 $ 6,148.30 EXC NECK TUMOR; SUBQ; 3CM/> 21555 $ 3,564.97 EXC NEUROFBRMA/NERULEMMOMA; EXT 64792 $ 12,238.01 EXC NEUROFIBRO;MAJ PERIPH NRVE 64790 $ 4,259.09 EXC NEUROFIBROMA; CUTANEOUS NERVE 64788 $ 4,259.09 EXC NEUROMA; CUTANEOUS NRV, SURG IDENTIF 64774 $ 4,259.09 EXC NEUROMA; HND/FOOT; NOT DIG NRV 64782 $ 4,259.09 EXC NEUROMA; MAJ PERIPH NRV; NOT SCIATIC 64784 $ 4,259.09 EXC OF TARSAL COALITION 28116 $ 6,995.52 EXC OR FULGURATE; SKENE'S GLANDS 53270 $ 7,131.78 EXC PAROTID TMR/GLND;TOT; W DI 42420 $ 11,474.25 EXC PAROTID TUM/GLAND;LL; W DI 42415 $ 11,474.25 EXC PAROTID TUM/GLND;LL; WO NR 42410 $ 11,474.25 EXC PENILE POST CIRCUMCISION ADHES 54162 $ 4,484.35 EXC PILONDAL CYST/SINUS; COMPLX 11772 $ 6,148.30 EXC PILONID CYST; COMPL 11772 $ 6,148.30 EXC PILONID CYST; SIMPLE 11770 $ 6,148.30 EXC PILONID CYST; SMPLE 11770 $ 6,148.30 EXC PILONIDAL CYST/SINUS; SIMPL 11770 $ 6,148.30 EXC PILONIDAL CYST; EXTENSIVE 11771 $ 6,148.30 EXC PREPATELLAR BURSA 27340 $ 6,995.52 EXC RECTAL TUM;TRANSANAL;FULL 45172 $ 6,123.85 EXC RECTL TUM;TRNSANAL;NO PART 45171 $ 6,123.85 EXC RECURRENT GANGLION WRIST 25112 $ 3,570.03 EXC S P ULCER; W 1' SUTURE 15931 $ 3,564.97 EXC S/N/EX/G B9 & MARGIN; 2.1-3 CM 11423 $ 3,564.97 EXC SFT TIS LES; EXTERN AUD CANAL 69145 $ 6,148.30 EXC SKIN ABD 15830 $ 12,725.37 EXC SKIN ABD ADD-ON 15847 $ 4,305.80 EXC SKIN FOR HIDRAD AXIL; CPLX REP 11451 $ 6,148.30 EXC SKIN HIDRADEN AX; SMPL/INTERMED 11450 $ 6,148.30 EXC SKIN HIDRADEN ING;SMPL/INTERMED 11462 $ 6,148.30 EXC SKIN/SUBQ TIS HIDRADNTITIS; COMP 11463 $ 6,148.30 EXC SKIN/SUBQ TIS HIDRADNTITIS; SIMP 11462 $ 6,148.30 EXC SPERMATOCELE; W/WO EPIDIDIMECTOMY 54840 $ 4,484.35 EXC SUBLINGUAL GLAND 42450 $ 11,474.25 EXC SUBLINGUAL SALIVARY CYST 42408 $ 5,815.59 EXC SUBMANDIBULAR GLAND 42440 $ 11,474.25 EXC SYNOVIAL CYST POPLITEAL SPACE 27345 $ 6,995.52 EXC TALUS/CALCNEUS TUMOR/CYST W ALLGRFT 28103 $ 14,826.61 EXC TARSA/METARS CYST/TUMOR 28104 $ 6,995.52 EXC TEND H/F W ROD; EA 26390 $ 14,826.61 EXC TENDON SHEATH LES; FOREARM/WRST 25110 $ 3,570.03 EXC TENDON SHTH LESION LEG/ANKLE 27630 $ 6,995.52 EXC THYROGLOSSAL DUCT CYST/SINUS 60280 $ 11,870.65 EXC THYROGLOSSAL DUCT CYST/SINUS; RECUR 60281 $ 11,870.65 EXC THYROID CYST/ADENOMA/TRANSEC ISTHM 60200 $ 11,870.65 EXC TIB/FIB BONE CYST/TUMOR 27635 $ 6,995.52 EXC TMR DEEP; SHLDR; 5< CM 23073 $ 6,148.30 EXC TMR FOREARM; LESS THAN 3CM 25075 $ 3,564.97 EXC TMR; ABDOMEN; 3 CM OR LESS 22902 $ 3,564.97 Page 113 2018 EXC TMR; ARM/ELBOW; 3< CM 24071 $ 6,148.30 EXC TMR; FACE/SCALP; 2< CM 21012 $ 3,564.97 EXC TNDN SHEATH LES - HND/FNGR 26160 $ 3,570.03 EXC TONGUE LES W CLOS; ANT2/3 41112 $ 5,815.59 EXC TONGUE LES W CLOS;POST 1/3 41113 $ 5,815.59 EXC TONGUE LES WO CLOSURE 41110 $ 5,815.59 EXC TORUS MANDIBULARIS 21031 $ 5,815.59 EXC TRNK/EXTREM B9 & MARGIN; 0.5 CM/> 11400 $ 1,514.94 EXC TUM ABD WALL; SUBQ; LESS THAN 3CM 22902 $ 3,564.97 EXC TUM BACK/FLANK; SUBQ; LESS THAN 3CM 21930 $ 3,564.97 EXC TUM DEEP; ABDOMEN; 5< CM 22901 $ 6,148.30 EXC TUM DEEP; ARM/ELBOW; 5< CM 24073 $ 6,148.30 EXC TUM DEEP; SHLDR; 5CM OR LESS 23076 $ 6,148.30 EXC TUM FACE/SCLP; SUBQ; LESS THAN 2CM 21011 $ 3,564.97 EXC TUM FOOT/TOE; 1.5< CM 28039 $ 6,148.30 EXC TUM FORARM/WRST; SUBQ; LESS THAN 3CM 25075 $ 3,564.97 EXC TUM FOREARM/WRST DEEP 3< CM 25076 $ 3,564.97 EXC TUM FOREARM; 3< CM 25071 $ 3,564.97 EXC TUM LEG/ANKLE DEEP; 5< CM 27634 $ 6,148.30 EXC TUM LEG/ANKLE; SUBQ; LESS THAN 3CM 27618 $ 3,564.97 EXC TUM NECK; SUBQ; LESS THAN 3CM 21555 $ 3,564.97 EXC TUM PELVIS/HIP; SUBQ; LESS THAN 3CM 27047 $ 6,148.30 EXC TUM PELVIS; 3< CM 27043 $ 6,148.30 EXC TUM SHOULDER; SUBQ; LESS THAN 3CM 23075 $ 3,564.97 EXC TUM THIGH/KNEE; DEEP; 5CM/> 27328 $ 6,148.30 EXC TUM THIGH/KNEE; SUBQ; LESS THAN 3CM 27327 $ 3,564.97 EXC TUM UPARM/ELBOW; SUBQ; LESS THAN 3CM 24075 $ 3,564.97 EXC TUM, SOFT TIS LEG/ANKLE, SUBQ; 3CM < 27632 $ 6,148.30 EXC TUM, SOFT TIS PELVIS/HIP, SUBQ; >3CM 27047 $ 6,148.30 EXC TUM; ABDOMEN; 3< CM 22903 $ 6,148.30 EXC TUM; FACE/SCALP; <2CM 21011 $ 3,564.97 EXC TUM; NECK/THORAX; 3< CM 21552 $ 6,148.30 EXC TUM; THIGH/KNEE; 3< CM 27337 $ 6,148.30 EXC TUMOR ABDOMINAL; DEEP; 5CM/> 22900 $ 6,148.30 EXC TUMOR ARM/ELBOW; DEEP; 5CM/> 24076 $ 6,148.30 EXC TUMOR ARM/ELBOW; SQ; 3CM/> 24075 $ 3,564.97 EXC TUMOR BACK/FLANK; SUBQ; 3CM/> 21930 $ 3,564.97 EXC TUMOR DEEP; BACK; 5< CM 21933 $ 6,148.30 EXC TUMOR HAND; 1.5< CM 26111 $ 3,564.97 EXC TUMOR HIP/PELV; DEEP; 5CM/> 27048 $ 6,148.30 EXC TUMOR SHOULDER; SUBQ; 3>CM 23075 $ 3,564.97 EXC TUMOR THIGH/KNEE; SQ; 3CM/> 27327 $ 3,564.97 EXC TUMOR; BACK; 3< CM 21931 $ 3,564.97 EXC TUMOR; SHLDR; 3< CM 23071 $ 3,564.97 EXC URACHAL CYST/SINUS 51500 $ 11,870.65 EXC URETHRAL DIVERTICULUM; FEMALE 53230 $ 9,800.87 EXC VAGINAL CYST/TUMOR 57135 $ 6,010.51 EXC VARICOCL/LIG SPERM VN;SEP 55530 $ 7,131.78 EXC VARICOCL/LIG SPRM VEIN W/ HERN REP 55540 $ 7,698.79 EXC VARIOCEL/LIG OF SPRM VEIN; ABD APPR 55535 $ 7,698.79 EXC/CURET BONE CYST/B9 TUM RAD/ULNA 25120 $ 6,995.52 EXC/DESTRCT INTRANASAL LES; EXT 30118 $ 5,815.59 EXC/DESTROY PHARYNX LES 42808 $ 5,815.59 EXC/PLANE NOSE FOR RHINOPHYMA 30120 $ 5,815.59 EXC/TRANSPOS PTERYGIUM; W GRAFT 65426 $ 4,790.26 EXC/TRANSPOSITION PTERYGIUM; W 65420 $ 4,790.26 Page 114 2018 EXC; LES PALATE/UVULA; SIMP CL 42106 $ 5,815.59 EXCERCISING STRESS TESTING 94621 $ 658.04 EXCHANGE BILIARY DRAIN CATH; W RAD 47536 $ 7,698.79 EXCHANGE TRANSFUSION; BLOOD; NEWBORN 36450 $ 991.89 EXCHG OF AN IOL 66986 $ 5,080.46 EXCHNG ABSC/CYST CATH-RAD GUID-SP 49423 $ 3,774.85 EXCIS MAL LES TRNK; 3.1 TO 4.0 CM 11604 $ 1,514.94 EXCIS MALIG LES FACE; 0.5 CM/LESS 11640 $ 1,514.94 EXCIS MALIG LES FACE; 1.1 TO 2.0 CM 11642 $ 1,514.94 EXCIS MALIG LES FACE; 2.1 TO 3.0 CM 11643 $ 3,564.97 EXCIS MALIG LES FACE; 3.1 TO 4.0 CM 11644 $ 3,564.97 EXCIS MALIG LES SCLP; 0.5 CM/LESS 11620 $ 3,564.97 EXCIS MALIG LES SCLP; 0.6 TO 1.0 CM 11621 $ 1,514.94 EXCIS MALIG LES SCLP; 2.1 TO 3.0 CM 11623 $ 3,564.97 EXCIS MALIG LES SCLP; 3.1 TO 4.0 CM 11624 $ 3,564.97 EXCIS MALIG LES SCLP; OVER 4.0 CM 11626 $ 6,148.30 EXCIS MALIG LES TRUNK; 1.1 TO 2.0 CM 11602 $ 821.94 EXCIS MALIG LES TRUNK; OVER 4.0 CM 11606 $ 3,564.97 EXCISE EXCESS SKIN TIS; LEG 15833 $ 6,148.30 EXCISE EXCESS SKIN TISSUE; FAT PAD 15838 $ 6,148.30 EXCISE EXCESS SKIN TISSUE; OTHER 15839 $ 6,148.30 EXCISE EXCESS SKIN&TISSUE; ARM 15836 $ 6,148.30 EXCISE EXCESS SKIN&TISSUE; BUTTOCK 15835 $ 6,148.30 EXCISE HYDROCELE; BILATERAL 55041 $ 7,698.79 EXCISE INFERIOR TURBINATE 30130 $ 5,815.59 EXCISE OLECRANON BURSA 24105 $ 6,995.52 EXCISE OR DESTROY LINGUAL TONSIL 42870 $ 11,474.25 EXCISE OSSEOUS TUBEROSITIES DENTOAL V 41823 $ 11,474.25 EXCISE TUMOR 28043 $ 3,564.97 EXCISION AURAL POLYP 69540 $ 3,010.00 EXCISION BARTHOLIN'S GLAND/CYST 56740 $ 6,010.51 EXCISION BENIGN LESION > 1.25CM D7411 $ 1,837.00 Excision benign lesion,complic D7412 $ 2,043.00 EXCISION LESION/FLOOR OF MOUTH 41116 $ 5,815.59 Excision malig lesion,complic D7415 $ 2,184.00 Excision malig lesion<=1.25cm D7413 $ 1,387.00 Excision malig lesion>1.25cm D7414 $ 2,061.00 Excision of salivary gland, B/R D7981 $ 7,392.00 EXCISION OF SUPERNUMERY DIGIT, UNI/BILAT 26951 $ 6,995.52 EXCISION PERICORONAL GINGIVA D7971 $ 232.00 EXCISION, NASAL POLYP, SIMP 30110 $ 3,010.00 EXCISION, NASAL POLYP, SIMPLE 30110 $ 3,010.00 EXCISN, BREST LESION,RADIOLGIC 19126 $ 343.29 EXCISN,BARTHOLIN'S GLAND/CYST 56740 $ 6,010.51 EXCNL BX PALATE W/LOCAL CLOSURE 42106 $ 5,815.59 EXCNL BX PALATE W/LOCAL FLAP 42107 $ 11,474.25 EXCS MAL LES TRUNK; 2.1 TO 3.0 CM 11603 $ 1,514.94 EXENESTABE 25MG TAB Acquisition cost EXERCISE W/HEMODYNAMIC MEAS 93464 $ 192.50 Exfoliative cyt sample collectn D7287 $ 150.00 EXHALED AIR ANALYSIS, O2 94680 $ 360.51 EXHALED AIR ANALYSIS, O2/CO2 94681 $ 658.04 EXHALED NITRIC OXIDE MEASUREMNT 95012 $ 84.11 EXL SILVERHK EXT SM VES EXT LG TIP C1714 $ 5,992.50 EXP BILLARY SD STENT PMTD 5X15X90CM C1876 $ 2,092.50 EXPANDABLE VALVUTOME 1.8MM C1751 $ 5,992.50 Page 115 2018 EXPDIUM 5.50UNIEXT TABULR SCRW C1713 $ 1,496.25 EXPEDITED HIV 87390 $ 52.93 EXPEDIUM 5.50UNI EXT TABULAR SCREW C1713 $ 1,496.25 EXPEDIUM SCREW C1781 $ 1,125.00 EXPEDIUM TI SI POLYAXL SCREW 5MMxVARIOUS C1713 $ 1,125.00 EXPEDIUM TI SI POLYAXL SCREW 7MMxVARIOUS C1713 $ 1,417.50 EXPEDIUM TI SI POLYAXL SCRW 7X C1713 $ 1,417.50 EXPIRED GAS CLCT QUAN SINGLE PROC 94250 $ 147.99 EXPL LAPAROTMY/CELIOTMY;W/WO B 49000 $ 1,646.79 EXPL PEN WND; ABD/FLANK/BK 20102 $ 4,147.84 EXPL PENETR WND; EXT 20103 $ 1,514.94 EXPL PENETRAT WOUND-SEP PROC; NECK 20100 $ 1,216.16 EXPL PENETRATING WND; CHEST 20101 $ 4,147.84 EXPL PENETRATING WND; EXTREM 20103 $ 1,514.94 EXPL POSTOP HEMOR/THROMB/INF; NECK 35800 $ 1,544.55 EXPL W DR/REM FB - MTP FOOT JOINT 28022 $ 6,995.52 EXPL W DRAIN/REM FB; IT/MT FOOT JNT 28020 $ 6,995.52 EXPL W REM DEEP FB; FOREARM/WRIST 25248 $ 3,570.03 EXPL/DRAIN/REM FB CMC JNT 26070 $ 3,570.03 EXPL/DRN/REM FB IPH JNT; EA 26080 $ 3,570.03 EXPLOR/TREAT ANKLE JOINT 27620 $ 6,995.52 EXPLORE FOR UNDESCENDED TESTIS 54550 $ 7,698.79 EXPLORE PENETRAT WND; NECK 20100 $ 1,216.16 EXPO CATH KIT C1887 $ 123.20 EXPRESS BILIARY LD STENT PREMOUNTED C1876 $ 2,063.10 EX-PRESS MINI GLAUCOMA SHUNT C1788 $ 1,342.50 EXPRESS SD STENT C1877 $ 2,092.50 EXPRESS SHUNT PRELOAD ON EDS C1788 $ 1,492.50 EXPRESS SHUNT PRELOADED ON EDS C1783 $ 1,492.50 EXT BRST LES BY N LOC; SINGLE 19125 $ 7,213.98 EXT CANNULA DECLOT (SP); WO BALLOON CATH 36860 $ 1,619.99 EXT CANNULA DECLOT-SP; W/BALLN CATH 36861 $ 11,279.00 EXT CEPHALIC VERSION W/WO TOCOLYSIS 59412 $ 6,010.51 EXT DRAIN PSEUDOCYST PANCREAS; 49405 $ 3,564.97 EXT ECG RECORDING 0296T $ 277.79 EXT ECG SCAN W/REPORT 0297T $ 277.79 EXT MALE CATH-LGE (DISP) A4349 $ 0.69 EXT MALE CATH-MED (DISP) A4349 $ 0.69 EXT MALE CATH-SM (DISP) A4349 $ 0.63 EXT OCULAR PHOTO W/I/R DOC MED PROG 92285 $ 147.99 EXT SET TWIN SITE #4522-58 $ 1.18 EXT SET W/ T-CONNECTOR 4612-04 $ 4.69 EXTEN TEND REP W/O GRAFT 26433 $ 6,995.52 EXTENSIVE ECTROPION REPAIR 67917 $ 4,790.26 EXTENSIVE MIDFOOT CAPSULOTOMY 28262 $ 13,808.82 EXTENSIVE REP ENTROPION 67924 $ 4,790.25 EXTENSOR TENDON REPAIR; EA 26418 $ 3,570.03 EXTERNAL AUDITORY CANAL 69105 $ 3,010.00 EXTERNAL CEPHALIC VERSION 59412 $ 6,010.51 EXTND ASSESMENT-75MIN 90791 $ 290.00 EXTNSR TNDN REP; W FR GRFT; EACH 26420 $ 6,995.52 EXTRA STIFF WIRE GUIDES C1713 $ 140.63 EXTRACAPSULAR CATARACT REMV IO 66984 $ 5,080.46 EXTRACRANIAL ARTERIES COMPL BILAT 93880 $ 614.37 EXTRACRANIAL ARTERIES COMPL UNILAT 93882 $ 302.70 EXTRACRANIAL ARTERIES COMPL UNILAT 93882 $ 302.70 Page 116 2018 EXTRACRANIAL ARTERIES COMPL UNILATERAL 93882 $ 302.70 EXTRACRANIAL ARTERIES COMPLETE BILAT 93880 $ 614.37 EXTRACRANIAL ARTERIES COMPLETE BILATERAL 93880 $ 614.37 EXTRACT NUCLEAR ANTIGEN ANTIBODY 86235 $ 48.71 EXTRACT NUCLR ANTIG ANTIB ANY METHD 86235 $ 48.71 EXTRACTION D7140 $ 210.00 Extraction crnl remnts-decid th D7111 $ 140.00 EXTRACTION DEVICE BALL-CATEG 1 Acquisition cost EXTRACTOR DBL LUMEN ESCORT-CATEG 1 Acquisition cost EXTRAORAL I/D SUBLINGUAL 41015 $ 1,216.16 EXTRAORAL I/D SUBMENTAL 41017 $ 5,815.59 Extraoral-first film D0250 $ 81.00 EXTRAVASATION KIT Acquisition cost EXTREMITY VEINS COMPLETE BILAT 93970 $ 614.37 EXTREMITY VEINS COMPLETE BILATERAL 93970 $ 614.37 EXTREMITY VEINS LIMITED UNILAT 93971 $ 302.70 EXTREMITY VEINS LIMITED UNILATERAL 93971 $ 302.70 EXUDERM-CATEG 1 Acquisition cost EXUDERM-CATEG 2 Acquisition cost EYE CUP-CATEG 1 Acquisition cost EYE CUP-CATEG 2 Acquisition cost EYE EXAM/EVAL W GEN ANESTH; ROM; COMPL 92018 $ 4,790.26 EYE EXAM/EVAL W GEN ANESTH; ROM; LMTD 92019 $ 4,790.26 EYE WASH SOLUTION $ 7.48 EYES CULTURE 87070 $ 23.41 EYLEA 40MG/ML 0.05ML INJ Acquisition cost E-Z DISK 10 GR. TABLET Acquisition cost E-Z PAGUE KIT ENEMA Acquisition cost EZETIMIBE 10MG TAB Acquisition cost E-Z-HD BARIUM SULFATE Acquisition cost F X3 10DEG POLY INSRT 36MM C1776 $ 1,200.00 F.A.N.A. 86038 $ 32.82 F/U OFF/OP VIST E/M 10MIN 99212 $ 315.00 F/U OFF/OP VIST E/M 15 MIN 99213 $ 343.00 F/U OFF/OP VIST E/M 25 MIN 99214 $ 370.00 F/U OFF/OP VIST E/M 40MIN 99215 $ 398.00 F/U OFF/OP VIST E/M 5 MIN 99211 $ 300.00 FA I/D-DP ABSC/HEMATOMA 25028 $ 6,995.52 Fabricate athletic mouthguards D9941 $ 144.00 FACE NRV MUSCLES; CHEMODENRV 64612 $ 647.13 Facial bone-complicated reduct D7680 $ 9,209.00 FACIAL BONES 70140 $ 164.27 FACIAL BONES CT W/W/O CONTRAST 70488 $ 668.38 FACIAL BONES CT WITH CONTRAST 70487 $ 668.38 FACIAL BONES CT WITHOUT CONTRAST 70486 $ 302.70 FACIAL BONES/ZYGOMA 70150 $ 302.70 FACIAL MRI WITH AND WITHOUT CONTRAST 70543 $ 1,206.90 FACIAL MRI WITH CONTRAST 70542 $ 1,206.90 FACIAL MRI WITHOUT CONTRAST 70540 $ 614.37 FACIAL NERVE BLOCK 64402 $ 277.79 FACIAL NERVE FUNCTION STUDY 92516 $ 360.51 FACTOR IX 85250 $ 51.72 FACTOR IX DILUTED 85250 $ 51.72 FACTOR IX,COMPLEX,PER IU J7194 $ 3.14 FACTOR V 85220 $ 47.94 FACTOR VII 85230 $ 48.62 Page 117 2018 FACTOR VIIA 1MCG J7189 $ 4.55 FACTOR VIII 85240 $ 48.62 FACTOR VIII DILUTED 85240 $ 48.62 FACTOR VIII(PORCINE),PER IU J7191 $ 1.87 FACTOR VIII-ANT-HEMO FACT HUMN PER IU J7192 $ 3.85 FACTOR VIII-ANT-HEMO RECOMBINA PER IU J7192 $ 3.85 FACTOR X 85260 $ 48.62 FACTOR XI 85270 $ 48.62 FACTOR XI DILUTED 85270 $ 48.62 FACTOR XII 85280 $ 52.56 FACTOR XIII ASSAY 85290 $ 44.37 FACTOR XIII SCREEN 85291 $ 24.16 FACTOR XIIIQPANEL Acquisition cost FACTREL 100MCG INJ VAIL J1620 Acquisition cost FAM PSYCHOTHERAPY WO PT PRES 90846 $ 290.00 FAM PSYCHTHRPY W/PT PRES 90847 $ 290.00 FAMCICLOVIR 125MG TAB Acquisition cost FAMCICLOVIR 250MG TAB Acquisition cost FAMCICLOVIR 500MG TAB Acquisition cost FAMILY PSY THERAPY W/PT PRES 90847 $ 241.00 FAMILY PSYCHOTHERAPY ADOL ONLY 90849 $ 241.00 FAMILY PSYCHOTHERAPY W/O PT 90846 $ 290.00 FAMILY PSYCHOTHERAPY W/PT PRES 90847 $ 290.00 FAMILY PSYCHOTHERPY WO PT PRES 90846 $ 290.00 FAMILY PSYCHTHRPY W/PT PRES 90847 $ 290.00 FAMILY PSYCHTHRPY WO PT PRES 90846 $ 290.00 FAMODIPINE 29mg/50ml BAG Acquisition cost FAMOTIDINE 20MG S0028 $ 2.70 FAMOTIDINE 20MG TAB Acquisition cost FAMOTIDINE 20MG Tablet J8499 $ 2.13 FAMOTIDINE 20MG/2ML INJ Acquisition cost FANSIDAR PO Acquisition cost FASCIA LATA SZ 2x3CM; HUMAN TISSUE C1762 $ 817.50 FASCIALATA EYELD BIO ELV; HUMAN TIS C1762 $ 727.50 FASCIOTOMY HIP/THIGH; ANY TYPE 27025 $ 1,974.21 FAT 20% 200ML Acquisition cost FATTY ACIDS FREE 82725 $ 41.29 FB REM - RECTUM 45307 $ 6,123.85 FB REMOVAL EAC W/O GA 69200 $ 277.79 FB REMOVAL LARYNGOSCOPY 31511 $ 415.40 FCTN CRTCL/SBCRT MP-BY STM A/O RCD-AD HR 95962 $ 378.69 FDG-18 <= 45 MCI A9552 $ 330.00 FDG-18 CAR <=45 MCI A9552 $ 330.00 FE EXT URIN CLCT DEVICE; POUCH EA A4328 $ 10.92 FECAL FAT 82715 $ 50.53 FECAL FAT QUALITATIVE 82705 $ 13.84 FECAL FAT QUANTITATIVE 82710 $ 45.65 FECAL LEUKOCYTE STAIN 89055 $ 11.59 FECAL PRESERV KIT 87177 $ 24.18 FEED TUB 8FR INFNT $ 0.89 FEED TUBE,5FR,INFANT,PREMIUM C1713 $ 159.51 FELBAMATE 80299 $ 41.01 FELBAMATE 400MG TAB (FELBATOL) Acquisition cost FELBAMATE 600MG TAB Acquisition cost FELBAMATE 600MG/5ML PO SOLN Acquisition cost FELODIPINE 10MG TAB SA Acquisition cost Page 118 2018 FELODIPINE 2.5MG TAB SA Acquisition cost FELODIPINE 5MG TAB SA Acquisition cost FEM COMP POROUS; SZ-D LEFT C1776 $ 7,137.00 FEM COMPONENT POROUS SIZE: E/LEFT C1776 $ 7,137.00 FEM COMPONENT SZ-G; RIGHT C1776 $ 5,211.00 FEM HEAD 11/13 TAPER 32MM C1776 $ 8,580.00 FEM HEAD 12/14 TAPER 3.5x30MM C1776 $ 8,584.95 FEM HIP SIZE-13.5; RIGHT C1776 $ 7,950.00 FEM HIP STEM SZ-12; LEFT C1776 $ 7,950.00 FEM NECK OSTEOTOMY GUIDE-CATEG 1 Acquisition cost FEM STEM 12/14 NECK TAPER SZ-11 C1776 $ 9,624.00 FEM STEM 12/14 NECK TAPER SZ-13 C1776 $ 8,604.00 FEM STEM 12/14 NECK TAPER SZ-14 C1776 $ 8,604.00 FEM STEM INSRTR/EXTRCTR-CATEG 1 C1776 Acquisition cost FEM STM NCK TAPR STD NCK OFFST 12/128MM C1776 $ 7,071.00 FEM/POPL REVASC W/ATHER 37225 $ 27,795.70 FEM/POPL REVASC; W STENT 37226 $ 27,795.70 FEMALE LUER LOCK 303SS ADAPTR C1713 $ 133.98 FEMALE LUER LOCK 303SS THREAD C1713 $ 102.15 FEMALE LUER LOCK ADAPTER C1713 $ 103.50 FEMALE POST 4 HOLE C1713 $ 108.00 FEMALE POST 4 HOLE C1713 $ 108.00 FEMLE PROLPSE REP DEV; SUBFASCL HAMMCK C1771 $ 6,765.00 FEMOR COMP PSN ASF PS 16MM C1776 $ 2,636.25 FEMOR COMPONENT FEMUR TRIATH C1776 $ 2,092.50 FEMOR HEAD 11/13 TAPER 32MM C1776 $ 1,248.00 FEMOR HEAD FROZEN 44MM OR LRGR C1776 $ 2,029.50 FEMOR VASC AXILARY GRFT 8X70CM L8670 $ 3,180.00 FEMORA COMPONENT CEMENT TRIATH C1776 $ 2,092.50 FEMORAL 13.5 LEFT Acquisition cost FEMORAL COMPONENT [RECOAT SIZE E C1776 $ 5,245.50 FEMORAL COMPONENT 14 Acquisition cost FEMORAL COMPONENT OPTION SZ-D LEFT Acquisition cost FEMORAL COMPONENT POROUS SIZE 3/RIGHT C1776 $ 7,137.00 FEMORAL COMPONENT PORUS C1776 $ 7,255.50 FEMORAL COMPONENT RIGHT C1776 $ 4,013.18 FEMORAL COMPONENT SIZE E. LEFT Acquisition cost FEMORAL COMPONENT SZ D C1776 $ 7,137.00 FEMORAL COMPONENT SZ E C1776 $ 7,071.00 FEMORAL COMPONENT SZ E F C1776 $ 2,646.00 FEMORAL COMPONENT SZ#15; STNDRD OFFSET C1776 $ 6,142.50 FEMORAL COMPONENT SZ#5 C1776 $ 1,650.00 FEMORAL COMPONENT SZ.C RIGHT Acquisition cost FEMORAL COMPONENT SZ-G RIGHT C1776 $ 4,013.18 FEMORAL HEAD Acquisition cost FEMORAL HEAD C1776 $ 1,500.00 FEMORAL HEAD +80 32MM C1776 $ 1,102.50 FEMORAL HEAD +80/32MM C1776 $ 1,102.50 FEMORAL HEAD 12/14 TAPER 28MM C1776 $ 781.65 FEMORAL HEAD 12/14 TAPER 28MM HEAD C1776 $ 781.65 FEMORAL HEAD 36MM Acquisition cost FEMORAL HEAD 38MM C1776 $ 1,500.00 FEMORAL HEAD 45 MM C1776 $ 1,586.25 FEMORAL HEAD 6 DEGREE TAPER C1776 $ 1,560.56 FEMORAL HEAD C- TAPER C1776 $ 1,800.15 FEMORAL HEAD LFIT V40 22MM C1776 $ 750.00 Page 119 2018 FEMORAL HIP Acquisition cost FEMORAL HIP CERAMIC-CATEG 1 Acquisition cost FEMORAL HIP SIZE 10.5 RIGHT Acquisition cost FEMORAL HIP SIZE 12 LEFT Acquisition cost FEMORAL HIP SIZE 13.5 LEFT Acquisition cost FEMORAL HIP SIZE 13.5 RIGHT Acquisition cost FEMORAL HIP SIZE 15 HIP Acquisition cost FEMORAL IMPLANTS LEFT UNIT C1776 $ 1,357.50 FEMORAL IMPLANTS RIGHT UNIT C1776 $ 1,357.50 FEMORAL JOINT PATELLA COMPONENT C1776 $ 1,627.50 FEMORAL KNEE COMPONENT Acquisition cost FEMORAL KNEE SIZE 3 Acquisition cost FEMORAL NECK OSTEOTOMY GUIDE Acquisition cost FEMORAL PLATE LCP 6 HOLE C1773 $ 1,872.00 FEMORAL PLATE LCP 6-HOLE C1713 $ 1,872.00 FEMORAL PREP KIT C1713 $ 300.00 FEMORAL PREP KIT SIZE 7 C1776 $ 300.00 FEMORAL PROSTHESIS C1776 $ 7,255.50 FEMORAL SELECTION PLUS-CATEG 1 C1726 Acquisition cost FEMORAL STEAM NECK TAPER Acquisition cost FEMORAL STEM Acquisition cost FEMORAL STEM C1776 $ 9,253.50 FEMORAL STEM 12/14 NECK TAPER C1776 $ 9,624.00 FEMORAL STEM 12/14 NECK TAPER SZ12 125MM C1776 $ 2,851.50 FEMORL COMP,PS CEMNT #1 RIGHT C1776 $ 2,092.50 FEMUR LEFT Acquisition cost FEMUR P/S S2 8 RIGHT Acquisition cost FEMUR PLATE C1713 $ 2,434.62 FEMUR POSTERIOR STAB SZ.10 RT. Acquisition cost FENO DETERMINATION 95012 $ 84.11 FENOFIBRATE 160MG PO Acquisition cost FENOFIBRATE 54 MG. PO Acquisition cost FENOLDOPAM EDES 10MG/ML Acquisition cost FENTANYL 80307 $ 158.03 FENTANYL 100MCG/25ML INFUSION SYRINGE Acquisition cost FENTANYL 100MCG/2ML INJ J3010 $ 4.22 FENTANYL 100MCG/HR PATCH Acquisition cost FENTANYL 12MCG PATCH Acquisition cost FENTANYL 25MCG/HR PATCH Acquisition cost FENTANYL 2MCG/ML/ROPIVACAINE 0.125 Acquisition cost FENTANYL 50MCG/HR PATCH Acquisition cost FENTANYL 75MCG/HR PATCH Acquisition cost FENTANYL CARPUJECT 100MCG/2ML J3010 Acquisition cost FENTANYL CITRATE 0.05MG/ML 20 J3010 Acquisition cost FENTANYL CITRATE 0.05MG/ML 50M J3010 Acquisition cost FENTANYL CITRATE 50MCG/ML, 5ML Acquisition cost FENTANYL DRIP 200MCG/25ML Acquisition cost FENTANYL IVPB J3010 Acquisition cost FENTANYL SCREEN 80354 $ 239.21 FENTANYL W/ BUPIVACAINE J3490 Acquisition cost FEP RINGED GRAFT 8MM 50CM RS X 100CM Acquisition cost FEP RINGED GRAFT T6MM 50CM RS X 100CM C1768 Acquisition cost FERINSOL 75MG/0.6ML DROPS 50ML Acquisition cost FERRIC GLUCONATE INJECTION Acquisition cost FERRIC SUBSULFATE SOLN. $ 219.93 FERRITIN 82728 $ 37.03 Page 120 2018 FERRITIN LAB 82728 $ 37.03 FERRLECIT 12.5 GR J2916 $ 16.79 FERRLECIT 12.5 MG J2916 $ 16.79 FERRLECIT 12.5MG 5 ML J2916 Acquisition cost FERROUS GLUCONATE 300MG TAB Acquisition cost FERROUS SULF 300MG/5ML ORAL LIQ Acquisition cost FERROUS SULFATE 220MG/5ML Acquisition cost FERROUS SULFATE 220MG/5ML CUPS Acquisition cost FERROUS SULFATE 325MG UD TAB Acquisition cost FETAL BIOPHYS PROFILE US 76818 $ 302.70 FETAL BIOPHYSICAL PROFILE US 76818 $ 302.70 FETAL FIBRONECTIN 82731 $ 174.94 FETAL FIBRONECTIN (RAPID) 82731 $ 174.94 FETAL FLUID DRAINAGE W US 59074 $ 709.68 FETAL HEMOGLOBIN 83030 $ 23.63 FETAL INVAS PX W US 59897 $ 424.97 FETAL MID CEREBRL ARTRY ECHO 76821 $ 302.70 FETAL NON-STRESS TEST 59025 $ 424.97 FETAL SCREEN 86880 $ 84.11 FETAL SCREEN. 86941 $ 32.89 FETAL SHUNT PLACEMNT W US 59076 $ 709.68 FETL BIOPHYS PROFILE; W/O NST 76819 $ 302.70 FEVERALL SUPPOSITORY-CATEG 1 Acquisition cost FEXOFENADINE 180MG TAB PO Acquisition cost FFG - FAC NRV PARALYSIS 15840 $ 7,168.06 FG PKG, ANGIOJET PUMP SET C1772 $ 375.00 FIBER LAXATIVE, BULK 4 GM PO Acquisition cost FIBER O TRACHEBRNCHO 31615 $ 1,216.16 FIBER O TRACHEBRONCHO 31615 $ 1,216.16 FIBER STICK #2 FIBERWIRE C1713 $ 75.00 FIBERLINK # BRAIDED PB SUTURE C1713 $ 82.50 FIBEROPTIC ESOPHAGOGASTROSCOPY 43200 $ 1,966.21 FIBERWIRE #5 12/BX C1713 $ 60.00 FIBERWIRE BRAID SUTURE NEEDLE C1713 $ 33.00 FIBERWIRE#2 BRAIDED W/O NEEDLE C2618 $ 4.38 FIBRIN DEGRAD. PROD. 85362 $ 18.72 FIBRIN SEALANT KIT Acquisition cost FIBRIN SPLIT PRODUCTS 85362 $ 18.72 FIBRINOGEN 85384 $ 23.08 FIBRINOGEN: CIEP 86327 $ 65.82 FIBULAR 6 HOLE PLATE C1713 $ 1,067.62 FIBULAR PLATE 3-HOLE C1713 $ 1,029.37 FIBULAR PLATE 6 HOLE C1713 $ 3,000.00 FIBULAR PLATE 6-HOLE C1713 $ 3,000.00 FILGRASTIM 300MCG/ML J1442 Acquisition cost FILGRASTIM 30MCG/0.1ML NICU SY Acquisition cost FILGRASTIM 480MCG/ML INJ J1442 Acquisition cost FILGRASTIM, PER 1MCG J1442 $ 2.93 FILGRASTIM-SNDC 300/0.5ML Acquisition cost FILGRASTIM-SNDC 480MG/0.8ML Acquisition cost FILTER KIDNEY STN $ 4.82 FILTERED SPEECH HEARING TEST 92571 $ 84.11 FINASTERIDE 5MG TAB Acquisition cost FINE NEEDL ASP DEEP TISS W/RAD 10022 $ 1,514.94 FINE NEEDLE ASPIR W/O IMAGE 10021 $ 821.94 FINE NEEDLE ASPIR; DEEP TISS W/RAD GUI 10022 $ 1,514.94 Page 121 2018 FINE NEEDLE ASPIR; DEEP TISS W/RAD GUID 10022 $ 1,514.94 FINE NEEDLE ASPIRAT ORBITAL CONTENTS 67415 $ 4,790.26 FINE NEEDLE ASPIRATE DEEP 88173 $ 118.21 FINE NEEDLE ASPIRATE SUPERFICIAL 88173 $ 118.21 FINE NEEDLE ASPIRATION 10021 $ 821.94 FINE NEEDLE ASPIRATION MAMMO 10021 $ 821.94 FINGER CAST 29086 $ 358.14 FINGER CAST APPLICATION 29086 $ 358.14 FINGER SPLINT 29280 $ 84.11 FINGER SPLINT APPL; DYNAMIC 29131 $ 147.99 FINGER STICK Acquisition cost FINGER/THUMB DISLC INTRPHALNGL 26770 $ 568.33 FINGERS 73140 $ 164.27 FIREHEAD FLAP W/VASC PEDICLE 15731 $ 7,168.06 FIRST LANSOPRAZOLE 3MG/ML 90ML SUSP Acquisition cost FIRST PASS IMAGING 78481 $ 1,198.21 FIRSTPASS ST SGL USE SUTRE PASSR SELF C1713 $ 283.50 FISH OIL 1GM CAP Acquisition cost FISH, CML/ALL, BCR/ABLQPANEL Acquisition cost FISH, PRENATAL SCREENQPANEL Acquisition cost FISH, SUBTELOMERE SCREENQPANEL Acquisition cost FISHMOUTH DRILL TIP C1713 $ 772.50 FISTULA OR SINUS TRACT STUDY 76080 $ 614.37 FISTULIZ SCLER; TRABECULECT AB 66170 $ 5,080.46 FISTULIZAT SCLERA; TRABECULECT 66172 $ 5,080.46 FIT CONTACT LENS; MANAGMNT 92072 $ 343.00 FIT/INSRT /INTRVAGNL SUPPRT DEV 57160 $ 424.97 FIT/INSRT PESSARY-OTH SUPPORT DEVIC 57160 $ 424.97 FITTING OF SPCTCLE MOUTED LOW VISION AID 92354 $ 84.11 FITTING OF TELESCOPIC OR OTHER COMP LENS 92355 $ 84.11 FIX G/COLON TUBE W/DEVICE 49460 $ 1,966.21 FIXATION NAIL 12x235; 130DEGREE STR C1713 $ 1,728.00 FIXED 12X 4.2MM SCRW GOLD/SLVR C1713 $ 300.00 FLAGYL 500MG INJ 100ML BAG Acquisition cost FLAGYL 500MG TAB Acquisition cost FLARED SHELL Acquisition cost FLARED SHELL METAL 50MM Acquisition cost FLARED SHELL W/HOLES 48M Acquisition cost FLECAINIDE 50 MG. PO Acquisition cost FLECAINIDE ACETATE 100MG. PO Acquisition cost FLECANIDE 80299 $ 41.01 FLEET PHOSPHO SODA - ORAL LIQ Acquisition cost FLEX OSTEOTOME GRAY REV SYSTEM C1713 $ 453.60 FLEXIBLE SIGMOID.ABALATION OF 45346 $ 2,476.36 FLEXIBLE SIGMOIDOSCOPY W BIOPS 45331 $ 1,877.59 FLEXIBLE SIGMOIDOSCOPY W POLY 45333 $ 1,877.59 FLEXIFLO BAG W/ QUANTUM PUMP $ 7.00 FLEXIFLO QUNTUM PUMP SET $ 5.24 FLEXIMA URETHRAL CATHETER C1758 $ 290.28 FLEXOR ANSEL GUIDSHEATH ENDTPR C1887 $ 150.00 FLEXOR INTRODUC 10F 40CMX.038 C1729 $ 95.10 FLEXOR INTRODUCER 7F 45CMX.038 C1729 $ 66.15 FLEXOR SHUT 5FR TIB GUIDSHEATH C1887 $ 150.00 FLEXR ANSLHIGH FLX6FR55CM GUID C1887 $ 88.50 FLEXR ANSLHIGH FLX6FR70CM GUID C1887 $ 103.50 FLEXR ANSLHIGH FLX7FR55CM GUID C1887 $ 96.00 Page 122 2018 FLEXR ANSLHIGH FLX7FR70CM GUID C1887 $ 111.00 FLEXR SHUT TIB 110CM GUID SHTH C1887 $ 150.00 FLIPCUTTER II SHORT 7.5MM C1713 $ 487.50 FLIPCUTTER II SHORT 7MM C1713 $ 487.50 FLIPCUTTER II SHORT 8.5MM C1713 $ 487.50 FLIPCUTTER II SHORT 8MM C1713 $ 487.50 FLIPCUTTER II SHORT 9.5MM C1713 $ 487.50 FLIPCUTTER II SHORT 9MM C1713 $ 487.50 FLONASE NASAL SPRAY Acquisition cost FLOURESCEIN 10% INJ $ 110.48 FLOUROGUIDE FOR VEIN DEVICE 77001 $ 40.55 FLOVENT 110MCG INHALER 13GM Acquisition cost FLOVENT 220MCG INHALER 13GM Acquisition cost FLOVENT 44 MCG. INHALER Acquisition cost FLOVENT 44MCG INHALER 13GM Acquisition cost FLOW CYTO DNA/CELL CYCLE 88182 $ 118.21 FLOW CYTO EA CELL 88189 $ 190.32 FLOW CYTOMETRY EACH AB 88189 $ 190.32 FLOW VOLUME LOOP 94375 $ 658.04 FLOWABLE HEMOSTAT C1760 $ 808.50 FLOWCRDIA 142S CRSSR REVAN CATH PERIPH C1714 $ 3,292.50 FLOXIN 0.3% Acquisition cost FLOXIN 200MG IV 50ML BAG Acquisition cost FLOXIN 200MG TAB Acquisition cost FLOXIN 300MG TAB Acquisition cost FLOXIN 400MG IV 100ML BAG Acquisition cost FLOXIN 400MG TAB Acquisition cost FLOXURIDINE, 500MG J9200 $ 314.20 FLU PANEL 6-35 MOS, TRI-VAL, PRES FREE Acquisition cost FLU PANEL 6-35 MOS, TRI-VALENT Acquisition cost FLU PANEL IIV 65YRS+ Acquisition cost FLU PANEL QUAD IIV4 6-35MOS Acquisition cost FLU PANEL3+YR QUAD PRSFRE ADT Acquisition cost FLU PANEL3+YR QUAD PRSFRE PED Acquisition cost FLU PANEL3+YR TRI PRESFRE ADLT Acquisition cost FLU PANEL3+YR TRI PRESFRE PED Acquisition cost FLU VAC INJ, 4 VAL, 3+ YEARS (FLUARIX) 90686 $ 19.03 FLU VAC INTRNSL, 4 VAL, 2+ YRS (FLUMIST) 90672 $ 59.60 FLU VAC; INJ 3+ YRS (FLULAVAL) 90658 $ 17.70 FLU VIR VACC-SPLIT 3 YR / > IM/JET 90658 $ 3.00 FLU VIR VACC-SPLIT 3YR / > IM/JET CLINIC 90658 $ 3.00 FLU VIR VACC-SPLIT 6-35MOS IM/JET CLINIC 90657 $ 3.00 FLU VIRUS VAC QUADIIV4 6-35MOS 90685 $ 21.81 FLU VIRUS VACC LIVE INTRANASL 90660 $ 59.60 FLU VIRUS VACC LIVE INTRANASL P9016 $ 404.29 FLU VIRUS VACC LIVE INTRANASL USE CLINIC 90660 $ 20.70 FLU VIRUS VACC-WHOLE VIRUS IM/JET $ 3.00 FLU VIRUS VACC-WHOLE VIRUS IM/JET CLINIC $ 3.00 FLUARIX ADULT SYRINGE 0.25 ML(SANOFI) Acquisition cost FLUARIX ADULT SYRINGE 0.5 ML Acquisition cost FLUARIX ADULT SYRINGE 0.5 ML(SANOFI) Acquisition cost FLUBLOK 0.5ML INJECTION 90673 Acquisition cost FLUCONAZOLE 100MG. INJECTION Acquisition cost FLUCONAZOLE 400MG/200ML NS INJ J1450 Acquisition cost FLUCONAZOLE 800MG. IVPG J1450 Acquisition cost FLUCONAZOLE/DEX 200MG IV J1450 Acquisition cost Page 123 2018 FLUCONAZOLE/DEX 400MG IV J1450 Acquisition cost FLUCYTOSINE 10MG/ML NICU Acquisition cost FLUCYTOSINE 250MG CAP Acquisition cost FLUCYTOSINE 500MG CAP Acquisition cost FLUDARABINE 50MG VIAL J9185 Acquisition cost FLUDARABINE PHOSPHATE, 50 MG J9185 $ 249.48 FLUDROCORTISONE ACET 0.1MG TAB J3301 Acquisition cost FLUENCY/WALLFLEX COATED/CVRD STNT C1874 $ 4,795.80 FLUIDS 88108 $ 84.11 FLUIDS CULTURE 87070 $ 23.41 FLUMAZENIL 0.1MG/ML INJ 10ML Acquisition cost FLUMAZENIL 0.1MG/ML INJ 5ML Acquisition cost FLUMAZENIL 0.5MG 5ML INJ J3490 $ 29.04 FLUMAZENIL0.5MG/5ML Acquisition cost FLUOCINOLONE 0.025% CRM TOP Acquisition cost TOPICAL SOL SCC) Acquisition cost FLUOCINONIDE CREAM 15GM Acquisition cost FLUOCINONIDE OINT 15GM Acquisition cost FLUOR AB AGAINST VA-INDUCED MEMB ANTIGEN 86256 $ 32.74 FLUOR I - STRIPS $ 0.27 FLUOR-1-STRIP AT PACK 300EA Acquisition cost FLUORASCEIN SOD. 0.25% - 0.4% $ 35.64 FLUORESCEIN ANGIOGRAPHY W/I/R 92235 $ 658.04 FLUORESCEIN ANGIOSCOPY W/I/R 92230 $ 1,175.22 FLUORESCENT AB; SCRN EA AB 86255 $ 32.74 FLUORESCITE 10% INJ 5ML AMP Acquisition cost Fluoride gel carrier D5986 $ 148.00 FLUORO EXAM G/COLON TUBE 49465 $ 614.37 FLUORO GUID NEEDLE-SPINE INJ PROC 77003 $ 65.49 FLUOROMETH FORTE 0.25% EYE DROP Acquisition cost FLUOROMETH FORTE 1% EYE DROP Acquisition cost FLUOROMETHOLONE 0.1% $ 163.11 FLUOROSCOPY > 1HOUR INTRAOPERATIVE 76001 $ 78.85 FLUOROSCOPY UP TO 1HOUR INTRAOPERATIVE 76000 $ 614.37 FLUOROSCOPY UP TO 1HR INTRAOP-OPD 76000 $ 614.37 FLUOROURACIL 500MG/10ML INJ J9190 Acquisition cost FLUOROURACIL CREAM Acquisition cost FLUOROURACIL, 500MG J9190 $ 39.60 FLUOTHANE LIQ 250ML BOT Acquisition cost FLUOXETENE 10MG TAB PO Acquisition cost FLUOXETENE 20MG TAB PO Acquisition cost FLUOXETINE (PROZAC) 80299 $ 41.01 FLUOXETINE 10MG CAP Acquisition cost FLUOXETINE 20MG/5ML ORAL SOL Acquisition cost FLUOXETINE LEVEL 80299 $ 41.01 FLUPHENAZINE 80299 $ 41.01 FLUPHENAZINE 100MG J2680 $ 71.15 FLUPHENAZINE 10MG TAB Acquisition cost FLUPHENAZINE 10MG TAB Acquisition cost FLUPHENAZINE 2.5MG (PROLIXIN) ORAL SYR J2680 Acquisition cost FLUPHENAZINE 2.5MG TAB Acquisition cost FLUPHENAZINE 2.5MG/ML LIQ Acquisition cost FLUPHENAZINE 25MG J2680 $ 71.15 FLUPHENAZINE 50MG J2680 $ 71.15 FLUPHENAZINE 5MG TAB Acquisition cost FLUPHENAZINE 5MG/ML ORAL LIQ Acquisition cost Page 124 2018 FLUPHENAZINE DECANOATE 25MG J2680 $ 71.15 FLUPHENAZINE DECNTE 25MG J2680 $ 71.15 FLUPHENAZINE HCL 2.5MG/ML 10ML Acquisition cost FLURAZEPAM LEVEL 80346 $ 11.00 FLURBUPROFEN EYE DROP Acquisition cost FLURESS OPTH DROPS 5ML Acquisition cost FLUSH SELECT CATH 4FR PIGTAIL C1887 $ 270.00 FLUSHIELD VACCINERIVALENT Acquisition cost FLUTAMIDE 125MG CAP Acquisition cost FLUTCSNE100MC/UMECL/VILNT25MC Acquisition cost FLUTE BALL CUT BURR SPINE TIP C1713 $ 121.50 FLUTE BAR BURR 4.2MM BIT 60DEG C1713 $ 830.13 FLUTE RTER SILVR ATTCH CUT BUR C1713 $ 282.00 FLUTED HDLSS PINS-KNEE INS DISP 3.2x89MM C1713 $ 1,085.70 FLUTED PINS C1713 $ 680.40 FLUTED STEM C1776 $ 1,755.60 FLUTICAS/SALMET 100-50MCG DISC Acquisition cost FLUTICAS/SALMET 250-50MCG DISC Acquisition cost FLUTICAS/SALMET 500-50MCG DISC Acquisition cost FLUTICASONE 100MCG/VILANT 25MC Acquisition cost FLUTICASONE 200MCG/VILANT 25MC Acquisition cost FLUTICASONE HFA 110MCG INH J3535 Acquisition cost FLUTICASONE HFA 220MCG INH J3535 Acquisition cost FLUTICASONE HFA 44MCG INH J3535 Acquisition cost FLUTICASONE NASAL SPRAY Acquisition cost FLUTICASONE PED INH 110MCG HFA Acquisition cost FLUTICASONE PED INH 44MCG HFA Acquisition cost FLUTICASONE/SALMETEROL115-21 (ADVAIR) Acquisition cost FLUTICASONE/SALMETEROL230-21 (ADVAIR) Acquisition cost FLUTICASONE/SALMETEROL45-21 (ADVAIR) Acquisition cost FLUVASTATIN 40MG (LESCOL) CAP Acquisition cost FLUVASTATIN 80MG (LESCOL) XL CAP SA Acquisition cost FLUVOXAMINE 100MG TAB Acquisition cost FLUVOXAMINE 25 MG TABLETS Acquisition cost FLUVOXAMINE 50MG TAB Acquisition cost FLUZONE 0.5 ML ADULT (GSK) Acquisition cost FLUZONE 5 ML. VIAL Acquisition cost FLUZONE PED. 0.25ML SYRINGE Acquisition cost FLUZONE PED. 0.5 ML SYRINGE Acquisition cost FLX ENDOSCOPC EVAL SWALL FUNCT FEE 92612 $ 410.10 FLX ENDOSCPC EVAL SWAL FNCTN-FEEST 92616 $ 444.97 FLX ENDOSCPC EVAL SWALLOW. FNCTN-FEEST 92612 $ 410.10 FLXR TNDN REP, NOT ZONE 2; WO GRAFT; EA 26350 $ 6,995.52 FMP LINER MP NEUTRAL Acquisition cost FNA W/ IMAGE 10022 $ 1,514.94 FNA W/O IMAGE 10021 $ 821.94 FNCTN CRTCL/SBCRT MAP-STM A/O RCD 1ST HR 95961 $ 2,387.99 FO, FINGER KNUCKLE BENDER L3925 $ 45.00 FO, SAFETY PIN, MODIFIED L3925 $ 24.77 FO, SAFETY PIN, SPRING WIRE L3925 $ 24.77 FOCAL LASER 67210 $ 1,290.50 FOGARTY THRU LUMEN CATHETER 4F C1757 $ 135.32 FOGARTY THRU LUMEN EMBLZTION CATH C1757 $ 135.32 FOLATE SERUM 82746 $ 39.93 FOLCATH 2WAY SIL W/STYLET 12CS A4338 $ 54.78 FOLEY CATH 2WAY COUDE TIP LATX A4340 $ 190.80 Page 125 2018 FOLEY CATH 3WAY A4313 $ 238.86 FOLEY CATH SILIC 12/BX RIB BAL A4344 $ 59.40 FOLEY CATHETER 2 WAY A4344 $ 18.83 FOLEY CATHETER TRAY $ 38.50 Foley Catheterization, complicated 51703 $ 360.51 FOLEYCATH 2WAY COUDE TIP LATEX A4340 $ 29.22 FOLIC ACID 1 MG/ 0.2ML SYRINGE J3490 Acquisition cost FOLIC ACID 1MG TAB Acquisition cost FOLIC ACID INJ; PER 1MG J3490 $ 3.21 FOLIC ACID/VITAMIN B W-C 1MG C Acquisition cost FOLIC ACIDE 1MG/ML SOLN Acquisition cost FOLVITE 5MG/ML INJ 10ML VIAL Acquisition cost FOLY 10FR RR/PL A4351 $ 0.72 FOLY 10FR RR/PL 12EA/CS A4338 $ 0.72 FOLY 12FR RR/PL A4351 $ 0.75 FOLY 12FR RR/PL 12EA/CS A4338 $ 0.75 FOLY 14FR RR/PL A4351 $ 1.24 FOLY 14FR RR/PL 12EA/CS A4338 $ 1.24 FOLY 16FR RR/PL A4351 $ 1.24 FOLY 16FR RR/PL 12EA/CS A4338 $ 1.25 FOLY 18FR RR/PL A4351 $ 0.71 FOLY 18FR RR/PL 12EA/CS A4338 $ 0.70 FOLY 20FR RR/PL $ 0.75 FOLY 20FR RR/PL 12EA/CS A4338 $ 0.71 FOLY 2W 30CC 12FR CATH $ 1.31 FOLY 2W 30CC 14FR CATH $ 1.31 FOLY 2W 30CC 16FR CATH $ 1.31 FOLY 2W 30CC 18FR CATH $ 1.57 FOLY 2W 30CC 20FR CATH $ 1.31 FOLY 2W 30CC 22FR CATH $ 1.57 FOLY 2W 30CC 24FR CATH $ 1.31 FOLY 2W 30CC 26FR CATH $ 1.31 FOLY 2W 30CC 28FR CATH $ 1.31 FOLY 2W 5CC 10FR CATH $ 922.95 FOLY 2W 5CC 12FR CATH A4344 $ 950.01 FOLY 2W 5CC 14FR CATH A4344 $ 5.54 FOLY 2W 5CC 16FR CATH A4344 $ 4.62 FOLY 2W 5CC 18FR CATH A4344 $ 5.54 FOLY 2W 5CC 20FR CATH A4338 $ 0.88 FOLY 2W 5CC 22FR CATH $ 1.60 FOLY 2W 5CC 24FR CATH $ 0.88 FOLY 2W 5CC 26FR CATH $ 1.17 FOLY 2W 5CC 28FR CATH $ 1.26 FOLY 2W 5CC 30FR CATH $ 1.09 FOLY 2W 5CC 8FR CATH $ 556.17 FOLY 3W 30CC 18FR $ 0.08 FOLY 3W 30CC 20FR CATH $ 0.08 FOLY 3W 30CC 22FR CATH $ 110.85 FOLY 3W 30CC 24FR CATH $ 267.81 FOLY 3W 30CC 26FR CATH $ 675.09 FOLY 5CC 20FR CATH $ 9.06 FOLY 5CC 22FR CATH $ 9.06 FOLY 5CC 24FR CATH $ 8.84 FOLY 5CC 26FR CATH $ 9.06 FOLY 5CC 8FR RR/CDE $ 6.00 FOLY 8FR RR/PL $ 0.74 Page 126 2018 FOLY 8FR RR/PL 12EA/CS A4338 $ 0.73 FOLY CATH 2WAY 10FR SILICONE A4344 $ 78.03 FOLY CATH 2WAY 24FR BAL 30CC A4344 $ 69.84 FOLY CATH 2WAY BALL COATED C1726 $ 60.84 FOLY CATH 2WAY BALL 12FR 5CC A4344 $ 5.07 FOLY CATH 2WAY BALL 3CC 10FR A4344 $ 9.87 FOLY CATH 2WAY COUDE TIP LATEX A4344 $ 190.80 FOLY CATH 2WAY LATEX COUDE TIP C1725 $ 15.90 FOLY CATH 5CC SILICON RIB BALL A4344 $ 65.34 FOLY CATH SILIC 12FR RIB BALL C1726 $ 4.95 FOLYCATH 2WAY 16FRBALL 5CC LUB A4344 $ 5.07 FOLYCATH 2-WAY 24FR COUDE TIP A4344 $ 190.80 FOMEPIZOLE 1GM/ML INJ J1451 Acquisition cost FONDAPARINUX 7.5MG INJECTION J1652 Acquisition cost FONDAPORINEX 10mg Acquisition cost FONDAPORINEX 2.5 MG. J1652 Acquisition cost FOOT AP / LAT 73620 $ 164.27 FOOT COMPLETE 73630 $ 164.27 FOOTPRNT ANCHR SUTURE W/AWL C1713 $ 78.00 FORCEPS CATHETER-CATEG 1 Acquisition cost FOREARM 73090 $ 164.27 FORESKIN MANIP INCL LYSIS ADHESIONS 54450 $ 607.00 FORMALDEHYDE 10% EXTERNAL SOL Acquisition cost FORMALDEHYDE 37% SOL 4000ML Acquisition cost FORTAZ 1GM VIAL J0713 Acquisition cost FORTAZ 2GM VIAL INJ J0713 Acquisition cost FORTIFIED CEFAZOLIN 50MG/ML DR Acquisition cost FORTIFIED CEFAZOLINE EYE DROP Acquisition cost FORTIFIED 15MG/ML EYE DROP Acquisition cost FORTIFIED TOBRAMY 15MG/ML EYE DROP Acquisition cost FOSAMAX 10MG TAB Acquisition cost FOSAMPRENAVIR 700MG (LEXIVA) TAB Acquisition cost FOSCAVIR 12MG/0.5ML 1ML J1455 Acquisition cost FOSCAVIR 24MG/ML J1455 Acquisition cost FOSFOMYCIN 3 GRAMS $ 0.10 FOSPHENYTOIN 100MG/2ML Q2009 Acquisition cost FOSPHENYTOIN 500MG/10ML Q2009 Acquisition cost FOSPHENYTOIN SODIUM 50MG PE/ML VIAL Q2009 Acquisition cost FOSPHENYTOIN SODIUM 50MG PE/ML VIAL Q2009 Acquisition cost FOSPHENYTOIN, 50 MG Q2009 $ 26.27 FQHC VISIT; EST MH PAT G0470 $ 275.00 FQHC VISIT; EST PATIENT G0467 $ 265.00 FQHC VISIT; IPPE/AWV G0468 $ 300.00 FQHC VISIT; NEW MH PAT G0469 $ 275.00 FQHC VISIT; NEW PATIENT G0466 $ 285.00 FRAGILE X DNA DETPANEL Acquisition cost FRAZIER 18FR SURG SUCT INST A4624 $ 112.50 FRAZIER SUCTION CATH 10FR A4624 $ 112.50 FRAZIER SUCTION CATH 12FR 50CS A4624 $ 112.50 FRAZIER SUCTION TUBE 7 ANG 7FR A4624 $ 23.61 FRE $ 0.10 FREE DILANTIN 80186 $ 37.38 FREE LIGHT CHAIN DET 86331 $ 32.54 FREE PROTEIN S 85306 $ 41.62 FREE PSA 84153 $ 49.96 FREE SKIN FLAP W ANAST 15757 $ 4,885.01 Page 127 2018 FREE T4 84439 $ 24.49 FREE T4 THYROXINE 84439 $ 24.49 FREEZETHAWRBCCHARGE 86931 $ 569.71 FRENECTOMY 41115 $ 3,010.00 FRENOPLASTY 41520 $ 5,815.59 FRENULECTOMY D7960 $ 300.00 Frenuloplasty D7963 $ 514.00 FRENULOTOMY OF PENIS 54164 $ 4,484.35 FRENULOTOMY; PENIS 54164 $ 4,484.35 FRESH FROZEN PLASMA, ONE DONOR, UNIT P9017 $ 159.30 FRESH FROZEN PLASMA, UNIT P9060 $ 106.37 FRONTLIS SUSPEN SET SS NEEDLES C2618 $ 63.82 FROZEN PLASMA, POOLED, SD, UNIT P9023 $ 133.25 FROZEN SECTION (1) 88331 $ 341.62 FROZEN SECTION (2+) 88332 $ 70.53 FRUCTOSAMINE 82985 $ 40.94 FSH SERUM 83001 $ 50.47 FSH URINE 83001 $ 50.47 FT SUTURE ANCHOR 4.5 METAL C1713 $ 345.00 FT SUTURE ANCHOR 5.5 METAL C1713 $ 345.00 FT SUTURE ANCHOR FIX DEVICE C1713 $ 427.50 FT SUTURE ANCHR PEEK CORKSCREW C1713 $ 633.00 FTA-ABS 86780 $ 35.95 FULL GRFT; SCLP/A/L, 20SQ CM OR LESS 15220 $ 4,147.84 FULL HEIGHT BIO CELL TEXTURE&SHAPE C1789 $ 1,200.00 Full mouth debridemnt,eval/diag D4355 $ 175.00 FULL SKIN GRFT E/N/E/LIP; 20/> SQ CM 15260 $ 4,147.84 FULL THICK SKIN GRFT; TRNK EA ADD 20CM 15201 $ 170.02 FULL THICK SKIN GRFT; TRUNK, 20CM> 15200 $ 4,147.84 FULL THICKNESS CORNEA TRANSPLNT TISS V2785 $ 5,700.00 FULL THRD PEG 2.5MM LCK FRAG PLATE SYS C1713 $ 152.64 FULL-DOSE RHIG-IM USE 90384 $ 92.00 FULLER SHIELD $ 20.96 FULVESTRANT 250MG/5ML INJ J9395 Acquisition cost FULVESTRANT 25MG J9395 $ 252.16 FUNCT RESIDUAL CAPACITY/VOL 94726 $ 658.04 FUNCTIONAL STATUS ASSESSED 1170F Acquisition cost FUNCTL ACTIV EA COMP 86161 $ 32.58 FUNDUS PHOTOGRAPHY W/I/R 92250 $ 277.79 FUNGAL ANTIBODY 86612 $ 35.05 FUNGAL ANTIBODY CSF 86612 $ 35.05 FUNGAL SEROLOGY 86671 $ 33.29 FUNGAL SMEAR 87220 $ 11.59 FUNGIZONE 50MG IV J0285 Acquisition cost FUNGL SMEAR - ALL OTHERS 87210 $ 12.80 FUROSEMIDE 10MG/ML ORAL SYR Acquisition cost FUROSEMIDE 1MG/ML Acquisition cost FUROSEMIDE 20MG TAB J8499 $ 0.17 FUROSEMIDE 40MG TAB J8499 $ 2.13 FUROSEMIDE 40MG/4ML INJ J1940 $ 16.41 FUROSEMIDE 80MG TAB PO Acquisition cost FUROSEMIDE DRIP J1940 Acquisition cost FUROSEMIDE INJECTION 40MG/4ML J1940 Acquisition cost FUSION BIG TOE JOINT 28755 $ 14,826.61 FUSION UV DEFENSE SPF 50 Acquisition cost FUSION UV DEFENSE; SPF 50 $ 136.40 Page 128 2018 FUSION WRIST JOINT WO GRAFT 25800 $ 14,826.61 F-V LOOP W/BRONCHOD 94375 $ 658.04 G GLUT TRANSFERASE 82977 $ 19.56 G-6-PHOS DEHYDROGENASE 82960 $ 16.43 G707 PH ELECTRODE Acquisition cost GA-67 CITRATE 6 MC INJECTION PER MCI A9556 $ 52.80 GA-67 GALLIUM CITRATE PER MCI A9556 $ 52.80 GA-67, RADPRM DX GALLIUM / PER MCI A9556 $ 52.80 GABAPENT. OR SOL 250MG/5ML Acquisition cost GABAPENTIN 300MG CAP Acquisition cost GABAPENTIN 300MG TAB Acquisition cost GABAPENTIN 600MG TAB Acquisition cost GABAPENTIN 800MG TAB Acquisition cost GABAPENTIN LEVEL 80299 $ 41.01 GABAPENTIN ORAL SOL-ORAPLUS Acquisition cost GABAPENTIN ORAL SOL-ORASWEET Acquisition cost GABAPENTIN POWDER PAPERS Acquisition cost GABTRIL 16 MG. PO Acquisition cost GADAVIST (GADOBUTROL) 0.10 ML A9585 $ 2.19 GADOBUTROL 1 MMOL/ML 10 ML A9585 Acquisition cost GADOBUTROL 1MMOL/ML 7.5 ML A9585 Acquisition cost GADODIAMIDE (OMNISCAN) 20ML VIAL Acquisition cost GADODIAMIDE (OMNISCAN) SYRINGE Acquisition cost GADOPENTETATE (MAGNEVIST) 20 ML. Acquisition cost GADOPENTETATE 469.01/ML (MAGNEVIST) Acquisition cost GADOTERIDOL (PROHANCE) 10ML VIAL A9576 Acquisition cost GADOXETATE DISODIUM INJ 1ML-EOVIST A9581 $ 36.04 GAIT TRAINING, EA 15 MIN. 97116 $ 65.93 GALACTO SINGLE DUCT 19030 $ 170.65 GALACTOSE-1-PHOSPHATE 84378 $ 31.31 GALLIUM NITR 25MG/ML (GANITE) VIAL IV Acquisition cost GAMIMUNE N 10GM 100ML VIAL J1561 Acquisition cost GAMIMUNE N 5GM 50ML VIAL J1568 Acquisition cost GAMMA 10X170 C1713 $ 2,508.24 GAMMA 3 CLOSED TUBE CLIP C1713 $ 223.77 GAMMA NAIL C1713 $ 3,362.18 GAMMA NAIL DIS SCREW 6.28x35MM C1713 $ 195.00 GAMMA NAIL KIT TI TROCHANTERIC 11x180MM C1713 $ 2,810.25 GAMMA NAIL TI TROCHANTERIC C1713 $ 1,977.52 GAMMA SCREW TI.LAG C1713 $ 807.08 GAMMA SCREW; LONG 90MM C1713 $ 2,145.00 GANCICLOVIR 200MCG/0.01ML INTRAVITlL INJ Acquisition cost GANCICLOVIR 250MG CAP Acquisition cost GANCICLOVIR 2MG/0.1 ML INJ Acquisition cost GANCICLOVIR 4.5MG IMPLANT J7310 Acquisition cost GANCICLOVIR 500MG IV J1570 Acquisition cost GANCICLOVIR OPH. GEL 0.15% Acquisition cost GANCICLOVIR,4.5MG,LON-ACT IMPL J7310 $ 314.04 GARDASIL - 9 90651 $ 510.85 GARDASIL-9 VACCINE 90651 Acquisition cost GAS+DIRECT 02 SAT X17 82805 $ 173.29 GAS+DIRECT 02 SAT X5 82805 $ 173.29 GASES BLD ANY COMBO-PH/PCO2/PO2/CO2/HCO3 82803 $ 57.35 GASES BLOOD ANY COMBO 82803 $ 57.35 GASTRCTMY; PART DIST W GASTRODUODNOSTMY 43631 $ 3,093.84 GASTRIC ANAL.SINGLE 83930 $ 14.78 Page 129 2018 GASTRIC ANAL.STIMUL. 43755 $ 360.51 GASTRIC EMPTYING STUDY 78264 $ 924.11 GASTRIC INTUB/ASP FOR TX 43753 $ 658.04 GASTRIC MOTILITY STUDY 91020 $ 1,175.22 GASTRIC WASHING 88108 $ 84.11 GASTRIN SERUM 82941 $ 47.89 GASTRO FEED TUBE 18FR STER RND C1713 $ 56.07 GASTROESOPH REFLUX W MUCOSAL PH 91035 $ 1,175.22 GASTROESOPH RELFUX W NASAL PH CATH 91034 $ 1,175.22 GASTROESOPHAGEAL REFLUX EXAM 78262 $ 924.11 GASTROGRAFIN SOL 120ML Acquisition cost GASTROSTOMY OP;WO CREATE GASTR 43830 $ 3,774.85 GASTROSTOMY TUBE CHANGE 43760 $ 607.00 GASTROTOMY;W EXPLORE/REM FB 43500 $ 1,677.24 GASTROVIEW 120ML Q9963 $ 183.35 GATIFLOXACIN 0.3% EYE DROP Acquisition cost GC DNA PROBE 87590 $ 59.14 GD1A IGM 83520 $ 37.99 GD1B IGG 83520 $ 37.99 GD1B IGM 83520 $ 37.99 GEBATAMINCIN SULF. OINT. 3MG/1GM OPHTH J1580 $ 94.27 GEBAUER PAIN EASE J3490 Acquisition cost GEL SOFT PLUS Acquisition cost GEL SOFT PLUS 12 X 6 Acquisition cost GEL SOFT PLUS 14 X 7 GRAFT Acquisition cost GEL SOFT PLUS 22 X 11 GRAFT Acquisition cost GEL SOFT PLUS 24 X 12 GRAFT Acquisition cost GEL SOFT PLUS THIN WALL CAROTI Acquisition cost GELFOAM 6 PACK Acquisition cost GELSOFT PLUS 14x7MM C1768 $ 1,207.50 GELSOFT PLUS 16x8MM C1768 $ 1,207.50 GELSOFT PLUS 20x10MM C1768 $ 1,207.50 GEL-SOFT PLUS 20X10MM Acquisition cost GEL-SOFT PLUS THIN WALL CAROTI Acquisition cost GELSOFT VASC 22 X 11MM GRAFT C1768 $ 1,025.33 GELSOFT VASC GRFT 22x11MM C1768 $ 1,025.33 GEMCITABINE 1GM INJ J9201 Acquisition cost GEMCITABINE HCL, 200 MG J9201 $ 31.68 GEMFIBROZIL 600MG TAB Acquisition cost GEMINI UNIVERS LIGHT GUIDE 4MM C1713 $ 661.50 GENERAL HEALTH PANEL 80050 $ 56.10 GENERATOR NEURO RECHG BAT SYS C1820 Acquisition cost GENERATOR, NEURO NON-RECHARGE C1767 Acquisition cost GENESIS STENT 6X18MM Acquisition cost GENET VIRUS ISOLATE HSV 87255 $ 91.98 GENETIC COUNSELING 30 MINUTES 96040 $ 65.00 GENIOPLASTY; AUGMENTATION 21120 $ 11,474.25 GENIOPLASTY; SLID OSTEOTMY; SING PIECE 21121 $ 5,815.59 GENIOPLSTY; 2+ OSTEOTMIES SLIDING 21122 $ 11,474.25 GENIOPLSTY; SLIDING W/ BONE GRAFT 21123 $ 5,815.59 GENITAL CULTURE 87070 $ 23.41 GENOTYPE DNA HIV REVERSE T 87901 $ 699.25 GENTAMICIN 80170 $ 44.48 GENTAMICIN 0.8MG/ML NICU SYR J1580 Acquisition cost GENTAMICIN 100MG/100ML IVPB J1580 Acquisition cost GENTAMICIN 120MG PB PREMIX J1580 Acquisition cost Page 130 2018 GENTAMICIN 20MG/2ML PED INJ J1580 Acquisition cost GENTAMICIN 60MG.50ML NS PRE MIXED J1580 Acquisition cost GENTAMICIN 60MG/100ML IVPB J1580 Acquisition cost GENTAMICIN 80MG PB PREMIX J1580 Acquisition cost GENTAMICIN 80MG/NS 100ML IVPB J1580 Acquisition cost GENTAMICIN SUL. 0.1% OINT. Acquisition cost GENTAMICIN SULF 0.3% EYE DROPS Acquisition cost GENTAMICIN SULF 80MG/2ML INJ. J1580 $ 4.80 GENTAMICIN SULF EYE OINT Acquisition cost GENTAMICIN SULFATE 80MG/2ML J1580 Acquisition cost GENTAMICIN SULFTE 3MG/1ML J1580 $ 4.80 GENTIAN VIOL/BRILIANT GREEN Acquisition cost GENTIAN VIOLET 1% SOLUTION 30 ML Acquisition cost GENTLE CLEANSER 750ML Acquisition cost GENTLE CLEANSER; 750ML $ 88.00 GENVOYA 150/150/200/10MG TABLET Acquisition cost GI BLOOD LOSS IMAGING 78278 $ 924.11 GI DUODENOGRAPHY, HYPOTONIC 74260 $ 302.70 GI TRACT CAPSULE ENDOSCOPY 91110 $ 1,966.21 GI TRACT SCAN 78261 $ 924.11 GI WIRELESS CAPSLE MEASUREMNT 91112 $ 1,966.21 GIA-CATEG 1 Acquisition cost GIA-CATEG 2 Acquisition cost GIARDIA ANTIGEN 87328 $ 32.56 GIARDIA ANTIGEN DETECTION 87328 $ 32.56 GII QUICK ANCHOR PLUS; DEPUY C1713 $ 763.50 Ging flap,root pln, 4+ per quad D4240 $ 560.00 GINGIVAL CURETT EACH D4241 $ 490.00 GINGIVAL CURETTAGE/PER D4241 $ 490.00 GINGIVECTOMY/PER QUADRA D4210 $ 350.00 GINGIVECTOMY;EXC GINGIVA;EA QU 41820 $ 5,815.59 Gingivectomy-1-3 contig th/quad D4211 $ 315.00 GLACIAL ACET ACID IN SW FOR IRR Acquisition cost GLAUCOM VALVE ADULT FLEX PLATE C1713 $ 892.50 GLAUCOMA SCREEN G0117 $ 84.11 GLECAPREVIR100MG/PIBRENTAS40MG Acquisition cost GLIADIN ANTIBODY 86674 $ 39.97 GLIDE CATH 4FR STR 120CMx0.97MM C1887 $ 536.25 GLIDE CATH 4FR STRAIGHT C1769 $ 536.25 GLIDE CATH 4FR X ANGLE 65CM C1713 $ 107.25 GLIDE CATH 4FR X ANGLED, 5/BX C1769 $ 107.25 GLIDE CATH 5FRx65CM COBRA C1887 $ 536.25 GLIDE CATHETER 5FR C1769 $ 536.25 GLIDE WIRE 260 # 5191 Acquisition cost GLIDE WIRE 450 # 5192 Acquisition cost GLIDE WIRE ANGLED $ 475.05 GLIDE WIRE SMALL VESSEL .018/150CM TIP S C1769 $ 492.00 GLIDE WIRE-CATEG 2 Acquisition cost GLIDE WIRE-CATEG 4 Acquisition cost GLIDE WIRE-CATEG 6 Acquisition cost GLIDECATH ANGLE 5FR 5/BX C1769 $ 451.50 GLIDECATH XP 5FR C2-TIP SHAPE C1887 $ 536.25 GLIDESHEATH ACCES SLENDR INTRO C1769 $ 937.50 GLIDEWIRE C1769 $ 330.00 GLIDEWIRE 0.035X180CM STRAIGHT C1713 $ 476.48 GLIDEWIRE 035/260CM STRT 5/BX C1769 $ 395.79 Page 131 2018 GLIDEWIRE ADVANTAGE .014"D C1769 $ 480.00 GLIDEWIRE ADVANTAGE .018"D C1769 $ 472.50 GLIDEWIRE ADVANTAGE 1/BX C1769 $ 367.50 GLIDEWIRE ANGLE STIFF SHFT 5BX C1769 $ 554.85 GLIDEWIRE ANGLE/STIFF SHFT 5BX C1769 $ 100.65 GLIDEWIRE ANGLE/STRAIGHT 5/BX C1769 $ 231.91 GLIDEWIRE ANGLED C1769 $ 475.05 GLIDEWIRE ANGLED TIP 5/BX C1769 $ 503.25 GLIDEWIRE FLEXI ANGLE .038/150 C1887 $ 330.00 GLIDEWIRE GOLD TIP 45DEG ANGL C1769 $ 337.50 GLIDEWIRE SMALL TIP SHAPE 5BX C1769 $ 119.22 GLIDEWIRE STANDARD STRAIGHT C1769 $ 492.98 GLIDEWIRE STIFF ANGLE .035 X 150CM C1769 $ 503.25 GLIDEWIRE STNDRD ANGLRADIOFOCS C1769 $ 441.38 GLIDEWIRE STRAIGHT 5/BX C1769 $ 441.37 GLIMEPRIDE 1MG (AMARYL) TAB PO Acquisition cost GLIMEPRIDE 2MG (AMARYL) TAB PO Acquisition cost GLIMEPRIDE 4MG (AMARYL) TAB PO Acquisition cost GLIPIZIDE 10MG TAB Acquisition cost GLIPIZIDE 5MG TAB Acquisition cost GLIPIZIDE XL 10MG TAB Acquisition cost GLIPIZIED 2.5MG (GLUCOTROL) XL TAB Acquisition cost GLOSSECTOMY;LESS THAN 1/2 OF T 41120 $ 11,474.25 GLU; BLD REAGENT STRIP 82948 $ 11.09 GLUCAGON 82943 $ 38.81 GLUCAGON 1MG INJ J1610 Acquisition cost GLUCAGON EMERGENCY KIT 1MG Acquisition cost GLUCAGON HCL 1 MG IM J1610 $ 453.02 GLUCAGON LEVEL 82943 $ 38.81 GLUCLOSE BLD REAGENT STRIP 82948 $ 11.09 GLUCLOSE BLD REGNT STRIP 82948 $ 11.09 GLUCOL SOL 180ML BOT Acquisition cost GLUCOSE 82947 $ 10.67 GLUCOSE QUAL URINE 81002 $ 7.66 GLUCOSE 2 HR P.P. 82947 $ 10.67 GLUCOSE 4GRAM TABLET PT Acquisition cost GLUCOSE BF 82947 $ 10.67 GLUCOSE BF... 82945 $ 10.67 GLUCOSE BODY FLUID 82945 $ 10.67 GLUCOSE CSF 82947 $ 10.67 GLUCOSE CSF... 82945 $ 10.67 GLUCOSE MONITOR CONT; 72+ HRS 95250 $ 300.65 GLUCOSE QUAL. 81005 $ 5.87 GLUCOSE TABS $ 0.36 GLUCOSE TOLER 3 SAMP 82951 $ 34.96 GLUCOSE TOLER 4 SAMP 82951 $ 34.96 GLUCOSE TOLER 8 SAMP 82952 $ 10.65 GLUCOSE TOLERANCE TEST SOL. BOTTLE $ 22.00 GLUCOSE TOLERANCE(UR) 82951 $ 34.96 GLUCOSE UR RANDOM 82947 $ 10.67 GLUCOSE UR RANDOM... 82945 $ 10.67 GLUCOSE UR T.V. 82947 $ 10.67 GLUCOSE UR T.V.... 82945 $ 10.67 GLUCOSE; BLD BY MONITOR DEVICE 82962 $ 7.22 GLUCOSE; BLOOD, REAGENT STRIP 82948 $ 11.09 GLUCOTROL XL 5MG TAB Acquisition cost Page 132 2018 GLUTAMIC ACID DECABOXYLASE 83519 $ 40.48 GLY IRRG 1.5% 3000 #7974-08 $ 13.93 GLYBURIDE 2.5MG TAB Acquisition cost GLYBURIDE 5MG TAB Acquisition cost GLYBURIDE/METFORMIN 2.5/500 MG. PO Acquisition cost GLYCATED ALBUMIN 82985 $ 40.94 GLYCERINE ADULT SUPPOSITORY Acquisition cost GLYCERINE PED SUPPOSITORY Acquisition cost GLYCOLIC ACID 30% 240 ML Acquisition cost GLYCOLIC ACID 40% 240ML Acquisition cost GLYCOLIC ACID 50% 240 ML Acquisition cost GLYCOLIC ACID 60% 240ML Acquisition cost GLYCOPYROLATE 0.2MG/1ML INJ J7643 $ 34.32 GLYCOPYROLATE 0.2MG/ML 2ML SYRINGE Acquisition cost GLYCOPYROLATE 1MG. PO Acquisition cost GLYCOPYRROLATE 0.02MG/0.1ML INJ J7643 Acquisition cost GLYCOPYRROLATE 0.2MG/ML 1ML VIAL Acquisition cost GLYCOSYLATED HB HOME DEVICE 83037 $ 26.38 GLYCOSYLATED HB HOME DEVICE 83037 $ 26.38 GM1 IGG 83520 $ 37.99 GM1 IGM 83520 $ 37.99 GONADOTROPIN CHORIONIC; QUAL 84703 $ 20.44 GONADOTROPN RLSE HORMONE STIM PAN 80426 $ 403.08 GONIOCOPY 92020 $ 277.79 GONIOSCOPY (SEPART PROC) 92020 $ 277.79 GONIOSOL $ 17.89 GORE 12FR SHEATH C1894 $ 127.50 GORE TEX GRAFT - THIN; 6x50CM C1768 $ 1,078.50 GORE TEX GRAFT THIN 6 X 50CM L8670 $ 1,078.50 GORE VIABAH ENDOPROSTHESES C1874 $ 5,505.00 GORE VIABAH ENDOPROSTHESES C1894 $ 5,505.00 GORETEX MESH 26CMX34CM C1768 Acquisition cost GORE-TEXT 18FR SHEATH C1894 $ 195.00 GOSERELIN ACETATE IMPLT 3.6MG J9202 $ 1,597.20 GRAFT BIO-TISSUE-CATEG 1 Acquisition cost GRAFT FACE, CHINE, EAR AUTO GRAFT 21230 $ 11,474.25 GRAFT FASCIA-CATEG 1 Acquisition cost GRAFT GEL SOFT + - CATEG 1 Acquisition cost GRAFT GEL SOFT + - CATEG 2 Acquisition cost GRAFT GEL SOFT+ THIN WALL CAROT-CATEG 1 Acquisition cost GRAFT GORETEX VASC-CATEG 1 C1894 Acquisition cost GRAFT GORETEX VASC-CATEG 2 C1768 Acquisition cost GRAFT JACKET PER 1 SQ CM Q4107 $ 2,784.00 GRAFT PATCH-CATEG 1 Acquisition cost GRAFT PELVIC-CATEG 1 Acquisition cost GRAFT PUROS BONE-CATEG 1 C1713 Acquisition cost GRAFT SOFT TISSUE-CATEG 1 Acquisition cost GRAFT STRAIGHT GEL SOFT-CATEG 1 Acquisition cost GRAFT STRETCH VASC STANDARD-CATEG 1 C1768 Acquisition cost GRAFT STRETCH-CATEG 1 Acquisition cost GRAFT STRETCH-CATEG 2 Acquisition cost GRAFT STRETCH-CATEG 3 L8670 Acquisition cost GRAFT STRETCH-CATEG 4 Acquisition cost GRAFT THROMBOLECTOMY FOGARTY-CATEG 1 L8670 Acquisition cost GRAFT VASCULAR-CATEG 1 L8670 Acquisition cost GRAFT VASCULAR-CATEG 2 L8670 Acquisition cost Page 133 2018 GRAFT WALL STANDARD-CATEG 1 Acquisition cost GRAFT, BONE; NOSE/MAXIL/MALAR 21210 $ 11,474.25 GRAFT; COMPOSITE 15760 $ 4,147.84 GRAFT; EAR CARTILAGE 21235 $ 11,474.25 GRAFT;COMPOSITE 15760 $ 4,147.84 GRAFTCH 6MM SL LORD CORT SPACR C1768 $ 1,434.38 GRAFTEC LORDOTIC CORTICL SPACR C1768 $ 1,434.38 GRAFTECH 5MM LL CORTICL SPACR C1768 $ 1,434.38 GRAFTECH LORD CORT SPACR YELL C1768 $ 1,434.38 GRAFTECH R 8MM LORD CORT SPACR C1768 $ 1,434.38 GRAFTECH7MM LL LORD CORT SPACR C1768 $ 1,434.38 GRAFTON MATRIX 2.5CM X 10CM Q4117 $ 3,589.12 GRAFTON MATRIX 2.5CM X 5CM Q4117 $ 2,224.87 GRAFTON ORTHOBLEND SMLL DEFCT Q4117 $ 1,912.50 GRAFTON PUTTY 10CC C1713 $ 1,581.00 GRAFTON PUTTY 1CC C1713 $ 255.00 GRAFTON PUTTY 2.5CC BONE DBM C1713 $ 561.00 GRAFTON-DEMINERALIZED BONE MAT Acquisition cost GRAM SMEAR 87205 $ 11.59 GRAMA STAN Acquisition cost GRANISETRON HYDROCHL 1MG ANTEM Q0166 $ 129.82 GRANULEX SPRAY Acquisition cost GRANULOC-PROCESS FEE 86950 $ 341.62 GRANULOC-PROCESSFEE 86950 $ 341.62 GRANULOCYTES, PHERESIS, UNIT P9050 $ 3,340.66 GRAY REV. INST SYS INSERT TIP C1713 $ 546.30 GREATER OCCIPITAL NERVE 64405 $ 647.13 GREENFIELD VENA CAVA FILTER FE Acquisition cost GREENFIELD VENA CAVA FILTER JU Acquisition cost GRFT FACE NRV PARALYSIS; REG MT 15845 $ 7,168.06 GRFT JACKET REGENER TIS MATRIX L8670 $ 4,717.50 GRFT SURG MESH REPAIR SFT RECT C1781 $ 579.00 GRFT SURG VENT HERN LRGE W/HOL C1781 $ 258.75 GRIFULVIN V 125MG/5ML 120ML Acquisition cost GRISEOFULVIN MIC 500MG TAB Acquisition cost GRISEOFULVIN ULTRA MIC 250MG TAB Acquisition cost GROUP ACTIVITY 23 TO 37 MIN. 97150 $ 40.00 GROUP ACTIVITY 38 TO 52 MIN. 97150 $ 40.00 GROUP ACTIVITY 8 TO 22 MIN. 97150 $ 40.00 GROUP AUDIOMETRIC TESTING 92559 $ 120.00 GROUP PSYCHOTHERAPY 90853 $ 290.00 GROUP PSYCHOTHERAPY 60 MIN. 90853 $ 290.00 GROUP PSYCHOTHERAPY 60MIN 90853 $ 290.00 GROUP PSYCHOTHERAPY-7 SESSIONS 90853 $ 290.00 GROUP PSYCHOTHERAPY-FU 90853 $ 290.00 GROUP PSYCHTHRPY 90853 $ 290.00 GROUP SMKING CESS; 10+MIN 99407 $ 67.97 GROUP THERAPY; NOT MULTI-FAM 90853 $ 275.00 GROUP THERAPY; NOT MULTI-FAMILY 90853 $ 275.00 GROUP TX; NOT MULTI-FAMILY 90853 $ 275.00 GROWTH HORMONE 83003 $ 45.28 GROWTH HORMONE AB 86277 $ 42.75 GROWTH HORMONE STIM TEST 80428 $ 181.17 GRP NUTRITION THERAPY; EA 30M 97804 $ 33.07 GRP PSYCHOTHERAPY- 7 SESSIONS 90853 $ 241.00 GRP THERAPY; NOT MULTI-FAMILY 90853 $ 275.00 Page 134 2018 GTT URINE BATTERY 82951 $ 34.96 GUAIFEN/DM Acquisition cost GUAIFEN/DM 100-15/5ML Acquisition cost GUAIFENESIN DM 100/10 5ML UD Acquisition cost GUAIFENESIN PLAIN SYRUP PO Acquisition cost GUAIFENESIN SYRUP 5ML $ 0.64 GUAIFENESIN/DEXTROMETHORPHAN Acquisition cost GUANFACINE 1MG TAB PO Acquisition cost GUANFACINE 2MG TAB PO Acquisition cost GUIDE CATH FLUID DRAIN 10030 $ 1,514.94 GUIDE CATH-CATEGORY1 C1887 $ 76.50 GUIDE CATH-CATEGORY2 C1887 $ 76.50 GUIDE CATH-CATEGORY3 C1887 $ 76.50 GUIDE CATH-CATEGORY4 C1887 $ 76.50 GUIDE CATHET FLUID DRAINAGE 10030 $ 1,514.94 GUIDE DRILL 3+4MM C1713 $ 337.50 GUIDE WIRE Acquisition cost GUIDE WIRE C1713 $ 266.79 GUIDE WIRE *DISCONTINUED* Acquisition cost GUIDE WIRE 2.0MM C1713 $ 129.00 GUIDE WIRE 2.5 C1769 $ 58.87 GUIDE WIRE 2.5x285MM C1769 $ 58.88 GUIDE WIRE ACL-CATEG 1 Acquisition cost GUIDE WIRE AMPLATZ-CATEG 1 C1769 Acquisition cost GUIDE WIRE ANGLED $ 592.50 GUIDE WIRE ANGLED-CATEG 1 C1769 Acquisition cost GUIDE WIRE ANGLED-CATEG 2 Acquisition cost GUIDE WIRE ARGON-CATEG 1 Acquisition cost GUIDE WIRE BALL TIP-CATEG 1 Acquisition cost GUIDE WIRE BENTSON-CATEG 1 Acquisition cost GUIDE WIRE BENTSON-CATEG 2 C1769 Acquisition cost GUIDE WIRE BH-CATEG 1 Acquisition cost GUIDE WIRE BH-CATEG 2 C1769 Acquisition cost GUIDE WIRE COATED-CATEG 1 Acquisition cost GUIDE WIRE COATED-CATEG 2 Acquisition cost GUIDE WIRE COIL-CATEG 1 Acquisition cost GUIDE WIRE CONTROL-CATEG 1 Acquisition cost GUIDE WIRE COPE NITINOL-CATEG 1 Acquisition cost GUIDE WIRE CORDIS-CATEG 1 C1769 Acquisition cost GUIDE WIRE DUOFLEX-CATEG 1 Acquisition cost GUIDE WIRE HYDRONOL-CATEG 1 Acquisition cost GUIDE WIRE J-CATEG 1 C1769 Acquisition cost GUIDE WIRE MAGICTQ 035/180 C1769 $ 88.83 GUIDE WIRE NITINOL-CATEG 1 Acquisition cost GUIDE WIRE PLAT + -CATEG 1 Acquisition cost GUIDE WIRE PTFE-CATEG 1 Acquisition cost GUIDE WIRE ROADRUNNER-CATEG 1 Acquisition cost GUIDE WIRE ROSEN-CATEG 1 Acquisition cost GUIDE WIRE STAINLESS STEEL-CATEG 1 Acquisition cost GUIDE WIRE STIFF-CATEG 1 Acquisition cost GUIDE WIRE STRAIGHT-CATEG 1 C1887 Acquisition cost GUIDE WIRE STRAIGHT-CATEG 2 Acquisition cost GUIDE WIRE SUPER STIFF-CATEG 1 C1769 Acquisition cost GUIDE WIRE TFE COATED CURVED-CATEG 1 Acquisition cost GUIDE WIRE THREADED-CATEG 1 Acquisition cost GUIDE WIRE WALL STENT-CATEG 1 Acquisition cost Page 135 2018 GUIDE WIRE ZEBRA-CATEG 1 C1769 Acquisition cost GUIDE WIRE; BALL TIP 3x800MM C1769 $ 212.03 GUIDE WIRE-CATEG 1 C1769 Acquisition cost GUIDE WIRE-CATEG 1 C1769 Acquisition cost GUIDE WIRE-CATEG 2 Acquisition cost GUIDE WIRE-CATEG 3 C1769 Acquisition cost GUIDE WIRE-CATEG 3 Acquisition cost GUIDE WIRE-CATEG 4 C1769 Acquisition cost GUIDE WIRE-CATEG 5 Acquisition cost GUIDE WIRE-CATEG 6 Acquisition cost GUIDE WIRE-CATEG 7 C1769 Acquisition cost GUIDE WIRE-CATEG 8 Acquisition cost Guided tiss regen-nonresorb-per D4267 $ 455.00 Guided tiss regen-resorb-per D4266 $ 420.00 GUIDEWIRE 0.014X300CM STRAIGHT C1769 $ 313.50 GUIDEWIRE 0.38cm, 145 CM C1769 $ 282.89 GUIDEWIRE 1.5MM C1769 $ 209.00 GUIDEWIRE 180CM 5/BX EACH C1769 $ 277.50 GUIDEWIRE 2.5 C1713 $ 135.00 GUIDEWIRE CATEG 5 C1769 Acquisition cost GUIDEWIRE PACK C1713 $ 1,687.50 GUIDEWIRE PTFE .035 FLOPPY 5BX C1769 $ 196.80 GUIDEWIRE STIF STRGHT TIP150CM C1713 $ 503.25 GUIDEWIRE STRGHT 5/BX C1769 $ 155.68 GUIDEWIRE VASC BENSON 035" C1713 $ 120.77 GUIDEWIRE VASC BENSON 038" C1713 $ 213.05 GUIDEWIRE ZEBRA C1769 $ 376.38 GUIDEWIRE ZIPWIRE ANGLED 5/BX C1769 $ 70.60 GUIDEWIRE; CATEGORY 1 C1769 $ 69.18 GUIDEWIRE; CATEGORY 2 C1769 $ 206.11 GUIDEWIRE; CATEGORY 3 C1769 $ 507.73 GUIDEWIRES STRGHT FLEXIBLE TIP C1713 $ 307.50 GUIDEWIRES ZIPWIRE 035/260 ANGLED C1769 $ 70.61 GURYS DIEGO OTOLOGY TUBE SET A4624 $ 179.79 GUT CHR. $ 88.29 GW 0.035" X 150CM STANDARD STRAIGHT C1769 $ 213.05 GW 0.035" X 180CM STANDARD ANGLE C1769 $ 374.42 GW ADDWIRE EXTENSION WIRE .014/145CM C1769 $ 765.60 GW ASAHI MIRCLEBROS 3 - 180CM C1769 $ 250.25 GW ASAHI PROWATER 180CM C1769 $ 255.75 GW CHOICE FLOPPY .014" X 182CM C1769 $ 742.50 GW CHOICE PT W/ ICE HYDROPHILIC COATING C1769 $ 742.50 GW COUGAR XT STRABLE 190CM (.014")STRGHT C1769 $ 585.75 GW DOC EXTENSION .014/145CM C1769 $ 148.50 GW DX 0.035 FC J3MM 150CM TEF C1769 $ 18.02 GW FILTER WIRES EZ SYSTEM 190CM C1884 $ 2,391.00 GW HI-TORQUE 190CM BAL MID WEIGHT UNIV C1769 $ 412.50 GW HI-TORQUE FLOPPY .014/190CM C1769 $ 412.50 GW HI-TORQUE WHISPER MS 190CM C1769 $ 802.50 GW HI-TORQUE WIGGLE W/ MICROGLD COATING C1769 $ 412.50 GW LUGE W ICE 182CM MODERATE SUPPORT C1769 $ 734.55 GW MAILMAN SUPER SUPPORT - 300CM C1769 $ 675.00 GW PT2 MODERATE SUPPORT 185CM STRAIGHT C1769 $ 622.50 GW RUNTHROUGH .014 EXTRA FLOPPY 180CM C1769 $ 1,031.25 GW SAFE-T-J EXCHANGE HEPARIN COATED C1769 $ 25.53 GW STRAIGHT 145CM C1769 $ 16.80 Page 136 2018 GW STRAIGHT FIXED CORE C1769 $ 23.00 GW TEFLON COATED CURVED C1769 $ 20.00 GW TFE COATED T-J CURVED, FIXED CORE C1769 $ 37.05 GW TFLN .063/160CM PTFE ANGLED C1769 $ 412.50 GW VASCLR FIXED CORE .025"/260CML/3MM C1769 $ 16.80 GW WHOLEY HI-TORQUE FLOPPY C1769 $ 171.09 GYN CYTOLOGY THIN PREP 88142 $ 55.02 GYN MORCELLEX TISS MORCELLATOR C1782 $ 5,884.91 GYNECARE TVT DEVICE MESH C1781 $ 1,192.50 GYNECARE TVT DEVICE MESH SZ 1.1CM X 45CM C1771 $ 1,192.50 GZE SPNG N/STRL 2X2 Acquisition cost GZE SPNG N/STRL 4X4 A6216 $ 7.34 GZE SPNG N/STRL 4X8 $ 13.22 GZE SPNG STRL 2X2 A6402 $ 2.01 GZE SPNG STRL 4X4 A6402 $ 2.63 GZE XRAY 4X4 STRL A6403 $ 0.94 H INFLUENZA B AB TITER 86684 $ 43.03 H. DUCREYI SMEAR 87205 $ 11.59 H. PYLORI AB 86677 $ 39.40 H. PYLORI AG, QL STOOL 87338 $ 39.07 H.I.P. PAP CONSULT 88321 $ 84.11 H.M.W. KININOGEN 85293 $ 51.41 H/A COMPR VST NO PHYS PRES 10M 99212 $ 315.00 H/A COMPR VST NO PHYS PRES 15M 99213 $ 343.00 H/A COMPR VST NO PHYS PRES 25M 99214 $ 370.00 H/A COMPR VST NO PHYS PRES 40M 99215 $ 398.00 H/A COMPR VST NO PHYS PRES 5 M 99211 $ 300.00 H/A COU PREV MED COUNSEL 15M 99401 $ 300.00 H/A COU PREV MED COUNSEL 30M 99402 $ 315.00 H/A COU PREV MED COUNSEL 45M 99403 $ 343.00 H/A COU PREV MED COUNSEL 60M 99404 $ 370.00 H/A NEG PREV MED COUNSEL 15M 99401 $ 300.00 H/A NEG PREV MED COUNSEL 30M 99402 $ 315.00 H/A NEG PREV MED COUNSEL 45M 99403 $ 343.00 H/A NEG PREV MED COUNSEL 60M 99404 $ 370.00 H/A PCR QUANTITATIVE 87536 $ 231.13 H/A POS PREV MED COUNSEL 15M 99401 $ 300.00 H/A POS PREV MED COUNSEL 30M 99402 $ 315.00 H/A POS PREV MED COUNSEL 45M 99403 $ 343.00 H/A POS PREV MED COUNSEL 60M 99404 $ 370.00 H/A T&C PREV MED COUNSEL 15M 99401 $ 300.00 H/A T&C PREV MED COUNSEL 30M 99402 $ 315.00 H/A T&C PREV MED COUNSEL 45M 99403 $ 343.00 H/A T&C PREV MED COUNSEL 60M 99404 $ 370.00 H1N1 (SWINE FLU) 5ML VIAL Acquisition cost H1N1 (SWINE FLU) NASAL SPRAY Acquisition cost H1N1 (SWINE FLU) 0.25 ML SYRINGE Acquisition cost H1N1 (SWINE FLU) 0.5 ML SYRINGE Acquisition cost HABITROL 14MG/24HR PATCH Acquisition cost HABITROL 21MG/HR PATCH Acquisition cost HABITROL 7MG/24HR PATCH Acquisition cost HAEMOPH B OLIGO V-DIPH PRT VACC Acquisition cost HAIR REM; ELECTROLYSIS, per 30 min 17380 $ 1,291.09 HAKIM MEDOS PERITONEAL CATH C1887 $ 289.50 HALDO 5MG/ML INJ 1ML J1630 Acquisition cost HALDOL 0.5MG TAB Acquisition cost Page 137 2018 HALDOL 10MG TAB Acquisition cost HALDOL 1MG TAB Acquisition cost HALDOL 2MG TAB Acquisition cost HALDOL 5MG TAB Acquisition cost HALDOL DECANOATE 100MG/ML 1ML J1631 Acquisition cost HALDOL DECANOATE 50MG/ML 1ML J1631 Acquisition cost HALDOL-ASSAY (HALOPERIDOL) 80299 $ 41.01 HALLUX VALGUS; W/METATARSAL OSTEOT 28296 $ 6,995.52 HALO PROC CERV HALO IN JACKT VEST L0810 $ 5,816.80 HALO PROC CERV HALO INC INTO JACKET VEST L0810 $ 5,816.80 HALOPERIDOL 100MG J1631 $ 74.14 HALOPERIDOL 150MG J1631 $ 74.14 HALOPERIDOL 200MG J1631 $ 74.14 HALOPERIDOL 250MG J1631 $ 74.14 HALOPERIDOL 2MG.ML PO LIQUID J1630 Acquisition cost HALOPERIDOL 2MG/ML (HALDOL) PO CUP Acquisition cost HALOPERIDOL 50MG J1631 $ 74.14 HALOPERIDOL DECNOATE 100MG INJ VIAL J1631 $ 74.14 HALOPERIDOL LACTATE 5MG/ML10ML J1630 Acquisition cost HAM TEST 85475 $ 24.09 HAMMERTOE; CORRECT ONE TOE 28285 $ 6,995.52 HAND 73130 $ 164.27 HAND EVALUATION 95834 $ 117.13 HAND SPLINT 29280 $ 84.11 HAND/FINGER STRAPPING 29280 $ 84.11 HANDL/CONVEY SPECMN-OFFIC TO LAB 99000 $ 27.50 HANDL/CONVEY/OTHER SERV INVOLV DEVICES 99002 $ 56.00 HANDLE W/TRUMPET VALVE CANNULA A4615 $ 645.00 HANDLING AND CONVEYANCE 99000 $ 73.70 HAPTOGLOBIN 83010 $ 34.17 HAPTOGLOBIN; QUANTITATIVE 83010 $ 34.17 HB A2... 83021 $ 49.04 HB CHHROMATOGRAPHY 83021 $ 49.04 HB ELECTROPHORESIS 83020 $ 34.96 HB F 83021 $ 49.04 HBIG FOR IM USE 90371 $ 249.72 HCG QUALITATIVE 84702 $ 40.90 HCG QUANTITATIVE 84702 $ 40.90 HCTZ/TRIAMT 25-37.5MG TAB Acquisition cost HCTZ/TRIAMT 50-75MG TAB Acquisition cost HCV GENOTYPING 87902 $ 699.25 HEAD - 33593503 C1776 $ 1,320.20 HEAD 28MM Acquisition cost HEAD BIOMODULAR-CATEG 1 Acquisition cost HEAD BIPOLAR-CATEG 1 Acquisition cost HEAD COMPONENT 58MM C1713 $ 525.00 HEAD C-TAPER-CATEG 1 Acquisition cost HEAD C-TAPER-CATEG 2 Acquisition cost HEAD EXPANDABLE-CATEG 1 Acquisition cost HEAD FEM DISTAL AUGMENT-CATEG 1 Acquisition cost HEAD FEM MAXIM POSTERIOR-CATEG 1 Acquisition cost HEAD FEM POSTERIOR AUGMENT-CATEG 1 Acquisition cost HEAD FEMORAL-CATEG 1 C1776 Acquisition cost HEAD FEMORAL-CATEG 2 Acquisition cost HEAD FEMORAL-CATEG 3 Acquisition cost HEAD HUMERAL-CATEG 1 C1713 Acquisition cost Page 138 2018 HEAD HUNTER-CATEG 1 Acquisition cost HEAD METAL BALL-CATEG 1 Acquisition cost HEAD MOD.-CATEG 1 Acquisition cost HEAD MOD.-CATEG 2 Acquisition cost HEAD MRA WITH AND WITHOUT CONTRAST 70546 $ 1,206.90 HEAD MRA WITH CONTRAST 70545 $ 668.38 HEAD MRA WITHOUT CONTRAST 70544 $ 614.37 HEAD NEUTRAL-CATEG 1 Acquisition cost HEAD TRIAL +0MM X 36MM INST C1776 $ 240.00 HEAD UHR-CATEG 1 Acquisition cost HEAD UNIPOLAR-CATEG 1 Acquisition cost HEAD UNIVERSAL-CATEG 1 Acquisition cost HEAD ZIRCONIA-CATEG 1 Acquisition cost HEAD/ SOFT TISS ULTRASND 76536 $ 302.70 HEAD/ SOFT TISSUE ULTRASOUND 76536 $ 302.70 HEAD/NECK HIP STEM C1713 $ 3,884.10 HEAD-CATEG 1 C1776 Acquisition cost HEADED NAIL 3/4" PIN C1713 $ 135.00 HEADED NAIL 3/4" PIN C1713 $ 135.00 HEADED PINS NAILS - 1 1/2" C1713 $ 126.90 HEADED SCREW 3.5 C1713 $ 150.00 HEADED SCREW 3.5x32MM DART FIRE C1713 $ 150.00 HEADED SCREW DART FIRE C1713 $ 150.00 HEADLESS COMPRES SCRW THREAD C1713 $ 1,462.50 HEADLESS SCREW 3.0MM X 20MM C1713 $ 630.00 HEADLSS SCRW DARTFIRE COMPRES C1713 $ 552.00 HEALICOI SUTRE ANCH W/ULTRATPE C1713 $ 1,125.00 HEALICOIL PK 4.5MM SUTRE ANCHR C1713 $ 1,125.00 HEALICOIL W/ TAPE COBRAID BLUE C1713 $ 570.00 HEALOS FX DELIV DEV;BONE GRFT C1713 $ 267.75 HEARING AID CHECK- BOTH EARS 92593 $ 178.00 HEARING AID CHECK- ONE EAR 92592 $ 132.00 HEARING AID CHECK, BOTH EARS 92593 $ 178.00 HEARING AID CHECK, ONE EAR 92592 $ 132.00 HEARING AID EXAM BOTH EARS 92591 $ 192.50 HEARING AID EXAM ONE EAR 92590 $ 176.00 HEARING AID EXAM, BOTH EARS 92591 $ 192.50 HEARING AID EXAM, ONE EAR 92590 $ 176.00 HEART CATH TRAY $ 1,262.21 HEART FIRST PASS ADD ON 78496 $ 53.33 HEART IMAGE PET SINGLE 78491 $ 3,642.17 HEART MUSCLE IMAGING PET 78459 $ 3,180.58 HEAVY METAL SCREEN 83655 $ 32.89 HEAVY METAL SCREEN URINE 83655 $ 32.89 HEEL PAD $ 8.27 HEINLICH CHEST DRAIN VALV STRL C1729 $ 45.87 HEINZ BODIES 85441 $ 11.40 HEINZ BODY STAIN $ 3.70 HELICOBACTER PYLORI AB 86677 $ 39.40 HELIOX THERAPY 94644 $ 277.79 HEMADSORPTION 87253 $ 54.87 HEMATOCRIT 85014 $ 6.45 HEMETRIC LG STYLE VENTRIC CATH C1751 $ 217.25 HEMIE-PATELLA TENDON BONE Acquisition cost HEMIN FOR INJECTION 313MG/VIAL J1640 Acquisition cost HEMIS SHELL CUP TRIDENT TRITAN C1713 $ 5,134.50 Page 139 2018 Hemisection, no root can ther D3920 $ 409.00 HEMISPHERCL 56 CUP TRIDENT TRITANIU C1776 $ 1,950.00 HEMODIALYSIS ACC DUPLEX US 93990 $ 302.70 HEMODIALYSIS ACCESS DUPLEX US 93990 $ 302.70 HEMODIALYSIS PROC W/SNGL PHYS EVAL 90935 $ 1,581.54 HEMODIALYSIS-SNGL EVAL 90935 $ 1,581.54 HEMOGLOBIN 83069 $ 10.74 HEMOGLOBIN A1C 83036 $ 26.38 HEMOGLOBIN FREE 85018 $ 6.45 HEMOGLOBIN FREE URINE 83069 $ 10.74 HEMOGLOBIN MANUAL 85018 $ 6.45 HEMOGLOBIN URINARY 83069 $ 10.74 HEMOPHIL FLU B VAC PRP-OMP CONJ CLINIC 90647 $ 76.09 HEMOPHIL FLU B VAC PRP-T CONJ-IM CLINIC 90648 $ 18.00 HEMOPHIL FLU B VACC PRP-OMP CONJ-IM 90647 $ 76.09 HEMOPHIL FLU B VACC PRP-T CONJUG-IM 90648 $ 76.09 HEMORRHAGE KIT #1 Acquisition cost HEMORRHAGE KIT #2 Acquisition cost HEMORRHOIDECTOMY BY SIMPL LIG 46221 $ 1,877.59 HEMORRHOIDECTOMY INT / EXT SIMPL 46255 $ 6,123.85 HEMOSIDERIN 83070 $ 12.89 HEMOSIDERIN STAIN QUAL URINE 83070 $ 12.89 HEMOSIDERIN STAIN QUANT URINE $ 7.74 HEMOSIDERIN; QUALITATIVE 83070 $ 12.89 HEMOSTATIC CLIP FIX W/CLIP DEV C1713 $ 300.00 HEP A VACCINE ADULT-IM USE CLINIC 90632 $ 167.90 HEP A VACCINE PED/ADOLES DOSE-2-IM 90633 $ 167.90 HEP A VACCINE PED/ADOLES DOSE-3-IM 90634 $ 79.24 HEP A VACCINE PED/ADOLES-2DOSE-IM CLINIC 90633 $ 167.90 HEP A VACCINE PED/ADOLES-3DOSE-IM CLINIC 90634 $ 79.24 HEP A VIR VAC 25UNITS//ML (VAQTA) PED Acquisition cost HEP A/B ADULT-IM CLINIC 90636 $ 99.99 HEP B DIAL/IMMUNOSUP PT-4 DOS-IM 90747 $ 129.43 HEP B DIAL/IMMUNOSUP,4 DOSE,IM CLINIC 90747 $ 129.43 HEP B PANEL; ADULT 3 DOSE Acquisition cost HEP B PANEL; PED/ADOL 2 DOSE Acquisition cost HEP B PANEL; PED/ADOL 3 DOSE Acquisition cost HEP B VAC 5MCG/0.5ML Acquisition cost HEP B VAC ADULT-IM CLINIC 90746 $ 42.30 HEP B VAC DIAL/IMMUNOSUP,3DOSE,IM CLINIC 90740 $ 129.43 HEP B VAC PED/ADOLES,2DOSE,IM CLINIC 90743 $ 53.46 HEP B VAC PED/ADOLES,3DOSE,IM CLINIC 90477 $ 62.10 HEP B VACC PED/ADOLES DOSE IM USE 90744 $ 58.80 HEP B VACCINE 0.5ML VFC USE PF 90744 Acquisition cost HEP B VIR VAC 50UNTS//ML (VAQTA) ADULT Acquisition cost HEP B VIR/H-B POLY-MEN P VAC Acquisition cost HEP B/HEMOPHILUS FLU B VACC IM USE 90748 $ 52.27 HEP C GENOTYPING 87522 $ 116.34 HEP LOCK FLUSH 1UNIT/ML NICU J1642 Acquisition cost HEP NA 0.45% 100U/ML I J1644 Acquisition cost HEP WRITTEN 97139 $ 136.00 HEPAGRAM IVIG (HEPATITIS B IVIG) Acquisition cost HEPARIN 1,000 UNITS/ML, 10ML VIAL J1644 $ 11.44 HEPARIN 1000 UNITS/500 ML NS Acquisition cost HEPARIN 1000UNITS/500mL IV BAG J1644 Acquisition cost HEPARIN 1000UNITS/ML 10ML VIAL Acquisition cost Page 140 2018 HEPARIN 5000 UNIT FOR HEMODIALYSIS Acquisition cost HEPARIN 50UNITS/50ML 1/2 NS Acquisition cost HEPARIN 50UNITS/50ML NS J1642 Acquisition cost HEPARIN BEEF 1000U/ML 10ML J1644 Acquisition cost HEPARIN DEPEND. AB 86023 $ 33.84 HEPARIN DEPENDENT PLATELET AB 86022 $ 49.90 HEPARIN FLSH J1644 $ 11.44 HEPARIN FLUSH 10U/ML NICU PR FR Acquisition cost HEPARIN LOCK FLUSH 500UNITS/5mL INJ J1642 Acquisition cost HEPARIN PROCINE 1000U/ML 10ML J1644 Acquisition cost HEPARIN SOD/45%NACL D5W 250ML J1644 Acquisition cost HEPARIN SODIUM 1000U/ML 1ML J1644 Acquisition cost HEPARIN SODIUM 5000U/ML 10ML J1644 Acquisition cost HEPARIN SODIUM 5000U/ML 1ML J1644 Acquisition cost HEPARIN SODIUM/D5W 100U/ML J1642 Acquisition cost HEPARINLOCKFLUSH 100U/ML 250ML J1644 Acquisition cost HEPATIC FUNCTION PANEL W/PRO 80076 $ 22.20 HEPATIC VENOGRAPHY W/EVAL-RAD 75889 $ 6,592.23 HEPATIC VENOGRPHY WO EVAL-RAD 75891 $ 6,592.23 HEPATITIS A ANTIBODY 86708 $ 33.64 HEPATITIS A VACCINE ADULT DOSE-IM USE 90632 $ 167.90 HEPATITIS A VIR VACC 1440 UNIT/1ML Acquisition cost HEPATITIS A VIR VACC 720 UNIT/0.5ML Acquisition cost HEPATITIS B CORE ANTIBODY 86704 $ 32.74 Hepatitis B for NICU/NSY only 90744 Acquisition cost HEPATITIS B IMM GLOB 1ML VIAL 90371 Acquisition cost HEPATITIS B IMM GLOB 5ML VIAL 90371 Acquisition cost HEPATITIS B IMMUNE GLOBULIN HUMAN-IM USE 90371 $ 249.72 HEPATITIS B PCR (QUANTITATIVE) 87517 $ 116.34 HEPATITIS B VACCINE PEDS, DOSE Acquisition cost HEPATITIS B VACCN ADULT-IM USE 90746 $ 42.30 HEPATITIS B VIR VACC 20MCG/ML Acquisition cost HEPATITIS B VIRAL DNA QUAL 87517 $ 116.34 HEPATITIS BE AG EIA 87350 $ 31.31 HEPATITIS C - DNA OR RNA 87902 $ 699.25 HEPATITIS C AB (RIBA) 86804 $ 42.09 HEPATITIS C AB-2 86803 $ 38.74 HEPATITIS C ANTIBODY; CONFIRM TEST 86804 $ 42.09 HEPATITIS C GENOTYPING 87522 $ 116.34 HEPATITIS C PCR (QUANTITATIVE) 87522 $ 116.34 HEPATITIS D ANTIBODY 86692 $ 46.62 HEPATITIS D ANTIBODY IGM 86692 $ 46.62 HEPATITIS D ANTIGEN 87380 $ 44.57 HEPATITIS PANEL 80074 $ 129.38 HEPATOBILIARY SYST IMAGE W/DRUG 78227 $ 1,198.21 HEPATOBILIARY SYSTEM IMAGING 78226 $ 924.11 HEPATOT; OPEN DRAIN ABSC 1/2 S 47010 $ 2,575.85 HEPATOT; PERC DRAIN ABSC 1/2 S 49405 $ 3,564.97 HEP-B AMPLIF NA PROBE 87516 $ 95.33 HEPB VACC 2 DOSE ADULT IM 90739 Acquisition cost HEPB VACC 2 DOSE - ADULT IM 90739 $ 129.44 HEPB-HIB VAC IM CLINIC 90748 $ 52.27 HEPB-HIB VAC IM CLINIC (ADULT) 90748 $ 52.27 HEPB-HIB VAC IM CLINIC (IMMUNOSUPPRESD) 90748 $ 52.27 HEPB-HIB VAC IM CLINIC (PEDIAT/ADOLES) 90748 $ 52.27 HEP-C AMPLIF NA PROBE 87521 $ 95.33 Page 141 2018 HEP-C NA QUAN 87522 $ 116.34 HEP-LOCK FL 100U/ML 1ML VIAL J1642 Acquisition cost HEP-LOCK PF 100U/ML 1ML VIAL J1642 Acquisition cost HEPT B CORE IGM ANTI 86705 $ 31.99 HER-2/NEU 83950 $ 174.94 HEREDITARY HEMOCHROMAT,NYPANEL Acquisition cost HERN MOD KUG LG CIR W/STRP 2CS C1781 $ 913.50 HERN PATCH VENTRALX; MED CRCL 6.4x6.4CM C1781 $ 1,910.10 HERNIA GRFT BIODESIGN 20X20 C1781 $ 12,513.00 HERNIA GRFT SURGISIS 13X15 C1781 $ 6,838.50 HERNIA MOD KUGEL LG CIRCLE W/STRAP C1781 $ 913.50 HERNIA MOD KUGEL MED CIRCLE W/STRAP C1781 $ 919.29 HERNIA MOD KUGEL SM CIRCLE W/STRAP C1781 $ 786.42 HERNIA MOD KUGEL SM/OVAL 8X12CM W/STRAP C1781 $ 411.75 HERNIA PATCH MESH SURG PTCH AB C1781 $ 1,476.00 HERNIA PATCH SM OVAL MESH SURG C1781 $ 1,306.95 HERNIA PATCH VENTRALEX; SM 4.3x4.3" C1781 $ 890.66 HERNIA PROLENE SYS MESH; MEDIUM C1781 $ 1,304.76 HERNIA PROLENE SYSTEM MESH C1781 $ 1,304.76 HERNIA REPAIR GFT 13X15" SURGISIS GOLD C1781 $ 1,080.00 HERNIA REPAIR GRAFT 13X15 C1768 $ 1,323.00 HERNIA REPAIR GRAFT 13X22" C1768 $ 1,638.00 HERNIA REPAIR GRAFT 13X22" C1763 $ 9,166.50 HERNIA REPAIR GRAFT 7X10" GOLD C1781 $ 906.00 HERNIA REPAIR GRAFT 7X10" GOLD L8670 $ 906.00 HERNIA REPAIR W/MESH 49568 $ 571.41 HERPES ANTIBODY NON-SPECIFIC TYPE 86694 $ 39.09 HERPES IGG ANTIBODY 86695 $ 35.82 HERPES S AMPLIF NA PROBE 87529 $ 95.33 HERPES SIMPLEX 1 AG IF 87274 $ 32.56 HERPES SIMPLEX 2 AG BY IF 87273 $ 32.56 HERPES SIMPLEX CF AB 86694 $ 39.09 HERPES SIMPLEX TPNG 87253 $ 54.87 HERPES SIMPLEX TYPG 86695 $ 35.82 HERPES SIMPLEX VIRUS PCR (QUANT) 87530 $ 116.34 HERPES SIMPLEX VIRUS, IgM 86317 $ 40.70 HERPES TYPE I IGG 86695 $ 35.82 HERPES TYPE I IGM 86695 $ 35.82 HERPES TYPE II IGG 86695 $ 35.82 HERPES TYPE II IGM 86695 $ 35.82 HESPAN 500ML BAG Acquisition cost HEWSON SUTURE RETRIEVER BLACK C1713 $ 69.00 HEXABRIX 20ML Q9967 $ 3.70 HEXAVITAMIN LIQUID Acquisition cost HEXAVITAMIN LIQUID 5ML UD CUPS Acquisition cost HFO, COMPOSITE ELASTIC L3929 $ 143.62 HFO, FINGER EXTENSION W/3 L3929 $ 113.04 HFO, FINGER EXTENSION, WITH CLOCK SPRING L3929 $ 113.04 HFO, FLXN GLOVE W LASTIC FINGER CONTROL L3912 $ 153.69 HFO, KNCKL BNDR, TWO SEGMT TO FLEX JNTS L3931 $ 49.50 HFO, KNUCKLE BENDER L3929 $ 49.50 HFO, KNUCKLE BENDER, WITH OUTIGGER L3929 $ 49.50 HFO, REVERSE KNUCKLE BENDER, W OUTRIGGER L3929 $ 49.50 HFO, REVERSE KNUCLE BENDER L3929 $ 49.50 HFO, SPREADING HAND L3923 $ 127.93 HGB AIC 83036 $ 26.38 Page 142 2018 HGB FRACTIONAT / QUANTITAT: ELEC-PHORE 83020 $ 34.96 HGB/RBC FETAL-HEMORR; DIFF LYSIS 85460 $ 21.01 HI FLO INSUFLATTION TUBING A4624 $ 15.48 HI FLOW PIGTAIL CATH 6FR C1887 $ 132.00 HI TORQUE BMW GW C1769 $ 160.50 HIGH DOSE INFLUENZA VACCINE Acquisition cost HIGH PERFORMANCE BONE DRILL C1713 $ 145.35 HIGHFLOW NASAL CANNULA 94799 $ 360.51 HI-LINE XS BUR SURG NEURO III C1713 $ 155.01 HI-LINE XS DISP.BARREL BURR II C1713 $ 197.10 HI-LINE XS DISP.BARREL BURR II C1713 $ 243.12 HI-LINE XS DISP.ROSEN BURR 3.1 C1713 $ 155.01 HI-LINE XS ROSEN BUR III NEURO C1713 $ 146.24 HI-LINE XS ROSEN BUR XLI 6.0MM C1713 $ 273.75 HI-LINE XS ROSEN SURG BUR C1713 $ 146.24 HI-LINE XXS DISP.ROSEN BURRIII C1713 $ 194.67 HIP BALL ARTICULAR-CATEG 1 Acquisition cost HIP IMPLANT SLEEVE C1776 $ 4,215.75 HIP PACK $ 486.96 HIP PROCEDURE CHARGES C1776 $ 750.00 HIP STEM Acquisition cost HIP STEM #8 Acquisition cost HIP STEM #9 Acquisition cost HIP SYST BUILD UP BLOCK W/2SCRWS C1713 $ 755.70 HIPREX 1GM TAB Acquisition cost HIPYLORI CULTURE 87070 $ 23.41 HISTAMINE LEVEL 83088 $ 80.21 HISTAMINE RANDOM URINE 83088 $ 80.21 HISTATROL INDRM MD 0.1MG/ML Acquisition cost HISTOCHEM STAIN W/FROZEN SECT 88314 $ 51.15 HISTOCHEM STAIN+SEC 88314 $ 51.15 HISTOPLASMA AG UR 86698 $ 33.95 HISTOPLASMA ANTIBODY CSF 86698 $ 33.95 HISTOPLASMA ANTIGEN 87385 $ 32.56 HISTOPLASMA ANTIGEN CSF 87278 $ 34.32 HISTOPLASMA ANTIGEN IMMUNOASSAY 87385 $ 32.56 HISTOPLASMA ANTIGEN URINE 87385 $ 32.56 HISTOPLASMA IGG 86698 $ 33.95 HISTOPLASMA IGM 86698 $ 33.95 HISTOPLASMA IMM DIF 86698 $ 33.95 HISTOPLASMA IMMUNO 86698 $ 33.95 HI-TORQ WIGG GWIRE MICROGLDE C1713 $ 412.50 HIV VIRAL LOAD 87536 $ 231.13 HIV WESTERN BLOT 86689 $ 52.58 HIV-1 NA QUAN 87536 $ 231.13 HIV-1 P24 ANTIGEN 87390 $ 52.93 HIV-2 86702 $ 36.72 HLA ABC&DR 86817 $ 233.51 HLA B27 86812 $ 70.09 HLA B27 TYPING; A B OR C SINGLE ANTIGEN 86812 $ 70.09 HLA TESTING FOR PLATELETPHERESIS 86813 $ 157.52 HLA TYPING; A B/C MX ANTIG 86813 $ 157.52 HLA TYPING; DR/DQ MX ANTIG 86817 $ 233.51 HLA-ABC 86813 $ 157.52 HLA-ABC TYPING 86813 $ 157.52 HLA-ABC+DR TYPING 86999 $ 46.20 Page 143 2018 HLA-B5701 TYPINGPANEL Acquisition cost HLA-DR 86817 $ 233.51 HLA-DR TYPING 86817 $ 233.51 HMPAO A4641 $ 192.50 HOLE HEMI RECON PLATE 6X17 C1713 $ 2,062.71 HOMATROPINE HBR 5% $ 38.15 HOME VISIT HIGH COMPLEXITY 60M 99350 $ 430.82 HOME VISIT LOW COMPLEXITY 25MI 99348 $ 209.63 HOME VISIT MOD COMPLEXITY 40MN 99349 $ 318.00 HOME VIST STRT FWD MED DECS15M 99347 $ 142.24 HOMER MAMMALOK-CATEG 1 Acquisition cost HOMOCYSTEINE (BLOOD) 82131 $ 50.56 HOMOCYSTEINE (BLOOD)... 83090 $ 45.83 HOMOCYSTINE (URINE) 82131 $ 50.56 HOMOCYSTINE (URINE)... 83090 $ 45.83 HOMOGENIZ TISS FOR CULTURE 87176 $ 15.97 HOMOGENTISIC ACID 81005 $ 5.87 HOMOGENTISIC ACID RANDOM URINE 83919 $ 44.68 HOMOVANILLIC ACID 83150 $ 52.56 HOMOVANILLIC ACID 83919 $ 44.68 HOMOVANILLIC ACID 83150 $ 52.56 HOOK FOR SCRW HOLES W/O SLAP C1713 $ 269.58 HORMONAL EVAL/MATURATION INDEX 88155 $ 32.23 HOSPICE SEMI PRIVATE ROOM $ 1,150.00 HPV VACCINE QUADRIVALENT 90649 $ 422.51 HPV-Q-VIAL VACC.20-40/0.5ML Acquisition cost HPYLORI STOOL EIA 87338 $ 39.07 HRHK TIBIA ROT COMPONENT XS/SM/MED C1776 $ 5,364.00 HSV 1/2 CSFQPANEL Acquisition cost HSV 1/2 IGG HERPESELECT 86696 $ 52.58 HSV TYPE 1-AB 86695 $ 35.82 HSV TYPE 2-AB 86694 $ 39.09 HT MUSCLE IMAGE SPECT, MULT 78452 $ 3,180.58 HT MUSCLE IMAGE SPECT, SING 78451 $ 3,180.58 HT MUSCLE IMAGE, PLANAR, MULT 78454 $ 3,180.58 HT MUSCLE IMAGE,PLANAR,SING 78453 $ 3,180.58 HTLV CONFIRM (RIPA) 86689 $ 52.58 HTLV I 86687 $ 22.79 HTLV-1 86687 $ 22.79 HTLV-2 86688 $ 38.04 HTLVI ANTIBODY 86790 $ 34.98 HTLVII ANTIBODY 86790 $ 34.98 HUMAN TIG FOR IM USE 90389 $ 1,096.57 HUMATIN 250MG CAP Acquisition cost HUMERAL HEAD Acquisition cost HUMERAL HEAD 22x44 C1776 $ 1,807.50 HUMERAL HEAD 40x12MM SOLAR SHOULDER C1776 $ 1,304.33 HUMERAL NAIL 10MM X 25CM Acquisition cost HUMERAL SOCKET INSERT C1776 $ 1,575.00 HUMERAL SOCKET SHELL C1776 $ 3,112.50 HUMERAL STEM Acquisition cost HUMERAL STEM 6x130MM C1776 $ 4,561.50 HUMERAL STEM 8x145 C1776 $ 4,561.50 HUMERL HEAD 16x38 C1776 $ 1,807.50 HUMERUS 73060 $ 164.27 HUMIBID LA 600 MG TAB Acquisition cost Page 144 2018 HUMMINGBIRD BOLT VENTRICU CATH C1887 $ 1,192.50 HUMMINGBIRD PARENCHYMA CATHETR C1887 $ 1,042.50 HUMPHRY 30-2,24-2,30/60-2 VSUL 92083 $ 343.00 HUMULIN R 5U/ML 10 ML VIAL J1815 Acquisition cost HURRICAIN BILIARY BALLOON CATH C1726 $ 448.50 HURRICAINE 20% SPRAY 60ML Acquisition cost HURRICAINE SPRY EXTEN TUBES200 Acquisition cost HURRICAINE TOPICAL SPRAY $ 20.39 HX AB ID (HISTORICAL ANTIBODY ID)PANEL Acquisition cost HY6ALURONIC ACID (JUVEDERM ULTA) Acquisition cost HYALGAN PER DOSE J7321 $ 501.60 HYALOMATRIX PER 1 SQ CM Q4117 Acquisition cost HYALURONATE SODIUM 23MG SYR Acquisition cost HYALURONATE SODIUM SYRINGE 20mg/2 ml. J7321 Acquisition cost HYALURONIDASE 150 UNIT INJ J3470 Acquisition cost HYDRA BALM Acquisition cost HYDRA BLM $ 33.00 HYDRA WIRE .035 X 450CM 2/BX C1713 $ 558.78 HYDRALAZINE 10MG TABLET Acquisition cost HYDRALAZINE 1MG/ML SUS PO Acquisition cost HYDRALAZINE 20MG INJ J0360 $ 24.75 HYDRALAZINE 20MG/ML INJ J0360 Acquisition cost HYDRALAZINE 25MG TAB Acquisition cost HYDRALAZINE 25MG TABLT J8499 $ 2.13 HYDRALAZINE 50MG TAB Acquisition cost HYDRATE IV INFUSION ADD-ON 96361 $ 979.22 HYDRATED DERMAL ALLOGFT 12x24CM Q4128 $ 15,168.00 HYDRATING B5 MASQUE Acquisition cost HYDRATNG B5 MASQUE $ 154.00 HYDRO INJECT HA BONE SUBST CEM C1713 $ 6,706.80 HYDRO STRAIGHT WIRE C1713 $ 258.00 HYDROCERIN CREAM Acquisition cost HYDROCERIN/EUCERIN CREAM 120GM Acquisition cost HYDROCHLOROTHIAZIDE 1MG/ML Acquisition cost HYDROCHLOROTHIAZIDE 25MG TAB Acquisition cost HYDROCHLOROTHIAZIDE 50MG TAB Acquisition cost HYDROCHLORTHIAZIDE 12.5 MG CAP Acquisition cost HYDROCHLORTHIAZIDE 50MG/5ML Acquisition cost HYDROCOD BIT/HOMATROPINE 480 Acquisition cost HYDROCOD/HOMATROP PO LIQ Acquisition cost HYDROCORTIS 100MG/0.8ML SYR Acquisition cost 0.5% CREAM 30GM Acquisition cost HYDROCORTISONE 1% CREAM 30GM Acquisition cost HYDROCORTISONE 1% LOTION Acquisition cost HYDROCORTISONE 1% OINT 30GM Acquisition cost HYDROCORTISONE 10 mg/ml PEDS $ 0.10 HYDROCORTISONE 1000MG INJ J1720 Acquisition cost HYDROCORTISONE 10MG TAB Acquisition cost HYDROCORTISONE 2.5% (GM) 28.35 Acquisition cost HYDROCORTISONE 20 MG TAB J7507 Acquisition cost HYDROCORTISONE 20MG TAB Acquisition cost HYDROCORTISONE CREAM 1% $ 24.20 HYDROCORTISONE PO LIQ 10MG/5ML Acquisition cost HYDROCORTISONE SUPPOSITORY 25 MG Acquisition cost HYDRODISSECTION CANNULA 25GA A4615 $ 63.30 SOL 480ML Acquisition cost Page 145 2018 HYDROGEN PRXIDE SOLUTION BOTTLE $ 1.05 HYDROMORPHONE 0.5% INJ J1170 Acquisition cost HYDROMORPHONE 0.6MG/0.6ML SYRINGES J1170 Acquisition cost HYDROMORPHONE 10MG/ML 50ML VIAL Acquisition cost HYDROMORPHONE 2 mg/0.2ml SYR $ 0.10 HYDROMORPHONE 20mg/100mL PCA J1170 $ 0.10 HYDROMORPHONE 2MG/ML INJ J1170 Acquisition cost HYDROMORPHONE 3MG RECTAL SUPPOS Acquisition cost HYDROMORPHONE 8mg PO Acquisition cost HYDROMORPHONE HCL 10MG/ML 1ML J1170 Acquisition cost HYDROMORPHONE HCL 2MG UD TAB Acquisition cost HYDROMORPHONE HCL 2MG/ML 20ML J1170 Acquisition cost HYDROMORPHONE HCL 4MG TAB U-D Acquisition cost HYDROMORPHONE HCL 4MG/ML DISP SYRIN J1170 Acquisition cost HYDROMORPHONE HCL 4MG/ML DISP SYRIN J1170 Acquisition cost HYDROMORPHONE INJ 4MG SYRNG J1170 Acquisition cost HYDROMPRPHONE 8MG TABLET Acquisition cost HYDROPH NITINL GUIDEWIRE ANGLE C1773 $ 450.00 HYDROPHILIC OINTMENT Acquisition cost HYDROPMORPHONE 1MG CARPUJECT Acquisition cost HYDROSE INJCT CEMNT H BONE SUB C1713 $ 2,445.13 HYDROSET INJECT CEMNT BONE SUB C1713 $ 4,673.70 HYDROSET INJECTABLE CEMENT 8G BONE SUB C1713 $ 2,445.14 HYDROSET INJECTABLE CEMENT 8GA BONE SUB C1713 $ 2,445.14 HYDROXYAMPH/TROPIC EYE DROP Acquisition cost HYDROXYCHLOROQUINE 200MG TAB Acquisition cost HYDROXYPROLINE FREE 83500 $ 61.51 HYDROXYPROLINE TOTAL 83505 $ 66.02 HYDROXYPROP/METH CELL EYE DROP Acquisition cost HYDROXYPROPYLMETHYLCELL 2.5% DROPS J3490 $ 7.80 HYDROXYUREA 500MG CAP Acquisition cost HYDROXYUREA 50MG/mL SOLUTION Acquisition cost HYDROXYZ HCL TABLET 50MG Q0163 $ 0.55 HYDROXYZINE 25MG VIAL INJ Acquisition cost HYDROXYZINE 25MG ORAL LIQ J8999 $ 1.10 HYDROXYZINE HCL 10MG TAB Acquisition cost HYDROXYZINE HCL 10MG/5ML ORAL SYR Acquisition cost HYDROXYZINE HCL 25MG TAB Acquisition cost HYDROXYZINE HCL 50MG TAB Acquisition cost HYDROXYZINE PAM 25MG CAP Q0177 Acquisition cost HYDROXYZINE PAMOATE 25MG CAP Q0177 Acquisition cost HYDROXYZINE PAMOATE 25MG ORAL Q0177 $ 0.66 HYMENOTOMY 56442 $ 6,010.51 HYOSCYAMINE SULFATE TAB 0.125 MG Acquisition cost HYP-ALLER PAPER TAPE 1" A4450 $ 0.41 HYPERAB 300IU/ML (5ML VIAL) $ 0.10 HYPERFLEXION PLATE Acquisition cost HYPERFLX TRACH TUBE FIXED CUFF A4624 $ 165.15 HYPERGEL 0.17 OZ. (5GM) $ 72.03 HYPERTHERMIA EXT GEN; SUPERF 77600 $ 581.35 HYPERTHERMIA GEN BY INTRACAVITARY PROBE 77620 $ 1,381.29 HYPERTHYROID THERAPY INITIAL 79005 $ 630.67 HYPERTHYROID THERAPY REPEAT 79005 $ 630.67 HYPO-ALLER PAPER TAPE A4450 $ 0.69 HYPO-ALLER PAPER TAPE 3 A4450 $ 1.27 HYPOXIA RESPONSE CURVE 94450 $ 360.51 Page 146 2018 HYPRTHRM GEN INTRSTI PRB<5 APP 77610 $ 1,381.29 HYPRTHRM GEN INTRSTI PRB>5 APP 77615 $ 1,381.29 HYSTCTMY W/COLPO-URTHROCYSTPXY 58152 $ 2,670.47 HYSTER ENDOMAT TUBW/PRESS DOME A4624 $ 152.49 HYSTEROSALPINGOGRAPHY 74740 $ 614.37 HYSTEROSC; W DIV/RESECT INTRAUT SEPT 58560 $ 10,873.98 HYSTEROSCOPY BILAT STERILIZATION 58565 $ 10,873.98 HYSTEROSCOPY DX (SEPART PROC) 58555 $ 6,010.51 HYSTEROSCOPY, DIAG 58561 $ 10,873.98 HYSTEROSCOPY; W BX ENDOM/POLYPECTOMY 58558 $ 6,010.51 HYSTEROSCPY SURG; W/BX // POLYPECT 58558 $ 6,010.51 HYSTEROSCPY; W ENDOMET ALBATION 58563 $ 10,873.98 HYSTEROSCPY; W LYSIS INTRAUT ADHESIONS 58559 $ 10,873.98 HYSTEROSCPY; W REM IMBEDDED FB 58562 $ 6,010.51 HYSTEROSONOGRPHY W/WO COLOR DOPPLER 76831 $ 614.37 HYTONE 2.5 % LOTION Acquisition cost HYTONE 0.5% OINT 30GM Acquisition cost HYTONE 2.5% CREAM 30GM TUBE Acquisition cost HYTRIN (TERAZOSIN) 10 MG TAB Acquisition cost HYTRIN 1MG CAP Acquisition cost HYTRIN 5MG CAP Acquisition cost HYZAAR 100/25 MG. PO Acquisition cost HYZAAR 50-12.5MG TAB Acquisition cost HYZZAR 100/12.5 MG. PO Acquisition cost I / D INFECTED BUR SIMPLE 28001 $ 3,564.97 I & ABSCESS; COMPLEX/MULTI 10061 $ 821.94 I & D ABSC; SIMPLE/SINGLE 10060 $ 446.80 I & D EPIDIDYMIS TESTIS SCRTOAL SP 54700 $ 4,484.35 I & D HEMATOMA/FLUID 10140 $ 3,564.97 I & D PERIRECT ABSCESS 46040 $ 2,476.36 I & D PILONID CYST - COMPLEX 10081 $ 1,514.94 I & D PILONIDAL CYST; SIMPLE 10080 $ 1,514.94 I & D POST-OP WOUND INF; COMPLX 10180 $ 6,148.30 I & D, INFECTED BURSA; FOOT 28001 $ 3,564.97 I / D ABSCESS AURI CMPLE 69005 $ 3,564.97 I / D ABSCESS AURI COMPLE 69005 $ 3,564.97 I / D BREAST ABSCESS 19020 $ 3,564.97 I / D INFECTED BUR COMPLIC 28002 $ 3,570.03 I&D ABSC/CYST, TONGUE, FOM; LINGUAL 41000 $ 1,216.16 I&D ABSC/CYST/HEMA;TONG/FOM;SU 41008 $ 5,815.59 I&D ABSC;RETROPHARYNGEAL;INT A 42720 $ 5,815.59 I&D ABSCESS/SOFT TISSUE; DEEP 20005 $ 3,564.97 I&D ABSCESS; PERITONSILLAR 42700 $ 472.05 I&D ABSCESS; RETROPHARYNGEAL; INTERNAL 42720 $ 5,815.59 I&D APPENDICEAL ABSC; PERCUT 49406 $ 3,564.97 I&D CPLX, POSTOP WD INFECTION 10180 $ 6,148.30 I&D DEEP SUPRALEVATOR ABSCESS 45020 $ 6,123.85 I&D IPIDIDYMIS TESTIS/SCROTAL SP 54700 $ 4,484.35 I&D PENIS, DEEP 54015 $ 3,564.97 I&D PERIANAL ABSCESS 46050 $ 1,877.59 I&D PERIRECTL/ISCHIAL ABSCSS 46040 $ 2,476.36 I&D SHOULDER; DEEP ABSCESS/HEMA 23030 $ 6,148.30 I&D SUBMUC RECT ABSCESS 45005 $ 2,476.36 I&D SUBMUCOSAL ABSCESS,RECTUM 45005 $ 2,476.36 I&D SUPERF ABSC;PERI/ISCHEAL 46045 $ 6,123.85 I&D THYROGLOSSAL DUCT CYST; INFECTED 60000 $ 3,010.00 Page 147 2018 I&D; BARTHOLIN'S GLAND ABSCESS 56420 $ 424.97 I&D; ISCHIORECTAL 46060 $ 6,123.85 I&D; UPPER ARM/EBLOW; BURSA 23931 $ 3,564.97 I&D; VULVA /PERINEAL ABSCESS 56405 $ 709.68 I.V. CATH AUTGRD 18GX1.16 $ 2.43 I.V. CATH AUTGRD 20GX1.16 $ 2.43 I.V. CATH AUTGRD 22GX1.0 $ 2.43 I.V. CATH AUTGRD 24GX.75 $ 2.43 I/D ABSCESS / EXTRAORAL SOFT TISSUE D7520 $ 1,536.00 I/D ABSCESS; COMPLIC/MX 10061 $ 821.94 I/D ABSCESS; SIMPL/SNGL 10060 $ 446.80 I/D BARTHOLIN GLAND ABSC 56420 $ 424.97 I/D BARTHOLIN'S GLAND ABSCESS 56420 $ 424.97 I/D COMPLX POSTOP WOUND INFEC 10180 $ 6,148.30 I/D EAC ABSCESS 69020 $ 1,514.94 I/D HEMATOMA/SEROMA/FL COLLECT 10140 $ 3,564.97 I/D HEMATOMA/SEROMA/FLUID COLLEC 10140 $ 3,564.97 I/D HEMTOMA/SEROMA/FLUID 10140 $ 3,564.97 I/D OF ABSCESS / INTRAORAL SOFT TISSUE D7510 $ 322.00 I/D PELVIS/HIP JOINT, DEEP 26990 $ 6,995.52 I/D PERIANAL ABSCESS SUPERF 46050 $ 1,877.59 I/D PILONIDAL CYST; COMPLIC 10081 $ 1,514.94 I/D PILONIDAL CYST-COMP 10081 $ 1,514.94 I/D PILONIDAL CYST-SIMPLE 10080 $ 1,514.94 I/D PILONIDAL CYST-SMPL 10080 $ 1,514.94 I/D SCROTAL WALL ABSCESS 55100 $ 3,564.97 I/D SKIN ABSCESS-COMP 10061 $ 821.94 I/D SKIN ABSCESS-SIMPLE 10060 $ 446.80 I/D SUPERF PERIANAL ABSC 46050 $ 1,877.59 I/D VULVA/PERINEAL ABSC 56405 $ 709.68 I/D VULVA/PERINEAL ABSCESS 56405 $ 709.68 I/D, DEEP NECK, THORAX, HEMATO 21501 $ 6,148.30 I-123 RADPHRM DX SODIUM IODIDE/100 UCI A9516 $ 103.95 I-123 RADPHRM DX SODIUM IODIDE; 200 UCI A9516 $ 85.80 I-123 RADPHRM DX WHOLE BODY/1 UCI A9509 $ 379.50 I-131 IODINATED SERUM ALBUMIN 5 MCI A9524 Acquisition cost I-131 RADPHRM TX SODIUM IODIDE CAPS/MCI A9517 $ 43.96 I-131 RADPM TX SOD IODN CAP/MCI EA+ 1MCI A9517 $ 43.96 I-131 SODIUM IODIDE SOLUTION, PER UCI A9530 $ 26.14 IA BY EIA - MULTI STEP 87449 $ 32.56 IA INFECTIOUS AGENT AB QUAN 86317 $ 40.70 IADL TRAINING, EA 15 MINS. 97537 $ 72.07 IBANDRONATE (BONIVA) 2.5 MG. Acquisition cost IBANDRONATE 3MG/3ML INJ J1740 Acquisition cost IBUPROFEN 100MG/5ML SUSP Acquisition cost IBUPROFEN 100MG/5ML UD CUP $ 1.92 IBUPROFEN 25MG/1.25ML Acquisition cost IBUPROFEN 400 MG TAB. $ 0.36 IBUPROFEN 400MG TAB Acquisition cost IBUPROFEN 600MG TABLET PO Acquisition cost IBUPROFEN 75 MG. ORAL SYRUP Acquisition cost IBUPROFEN 800MG TAB PO Acquisition cost IBUPROFEN 800MG. PO (FOR SCC ONLY) Acquisition cost IBUPROFEN ORAL SUSP 100MG/5ML Acquisition cost IBUTILIDE FUMARATE 1 MG J1742 Acquisition cost ICAST COVER STNT-7X80CM L-38MM C1874 $ 3,862.50 Page 148 2018 ICAST COVER STNT-7X80CM L-59MM C1874 $ 4,162.50 ICD DEVICE INTERROGATE 93289 $ 99.81 ICD DEVICE PROG EVAL, 1 SNGL 93282 $ 99.81 ICD DEVICE PROGR EVAL, DUAL 93283 $ 99.81 ICD DEVICE PROGR EVAL, MULT 93284 $ 99.81 ICM DEVICE EVAL 93290 $ 99.81 ICM DEVICE INTERROGAT REMOTE 93297 $ 57.64 ICM/ILR REMOTE TECH SERV 93299 $ 99.81 ID VIRAL ISOL-NEUTRALIZATION 87253 $ 54.87 ID/LTRLZTN CRBR SZR FCS,EEG,RCD INTRP24H 95950 $ 1,175.22 IDARUBICIN HCL 1MG/ML VIAL J9211 Acquisition cost IDARUBICIN HYDROCHLORIDE,5 MG J9211 $ 140.18 IDARUCIZUMAB 50MG/ML VIAL Acquisition cost IDL WIRING FOR OTHER THAN FX 21497 $ 3,010.00 IDU OTHER 86999 $ 46.20 ID-VIRAL ISOL HAI 87253 $ 54.87 IFEX 1GM INJ J9208 Acquisition cost IF-VIR AB TEST IGG 86255 $ 32.74 IF-VIR AB TEST IGM 86255 $ 32.74 IGE SERUM 82785 $ 44.70 IGFBP-1 BYRIA 83519 $ 40.48 IGFBP-3 83520 $ 37.99 IGG CSF 82784 $ 25.26 IGG SUBCLASSES 82787 $ 21.78 ILEOSCOPY THRU STOMA 44380 $ 1,966.21 ILEOSCOPY-STOMA; W/BX 1/MX 44382 $ 1,966.21 ILIAC REVASC W STENT 37221 $ 27,795.70 ILIAC REVASC W/ STENT, ADD-ON 37223 $ 460.26 ILIAC REVASC; INIT VES, UNILAT 37220 $ 13,447.68 ILIAC REVASCUL ADD ON 37222 $ 402.34 ILIAC/FEM ART ANGIO CARDIAC CATH G0278 $ 29.39 ILIOINGUINL ILIOHYPOGASTRC NRV 64425 $ 1,437.02 ILLUMINATOR ASPIRAT LASR PROBE C2618 $ 2,517.00 ILR DEVICE EVAL PROGR 93285 $ 99.81 ILR DEVICE INTERROGATE 93291 $ 46.20 IM ADM < 8YR PHYS CSL 1ST VAC ORL INTRNL 90473 $ 153.91 IM ADM < 8YR PHYS CSL EA ADD ORL INTRNL 90474 $ 27.39 IM ADM>18YR PHYS COUNSEL 1VAC 90460 $ 17.85 IM ADM>18YR PHYS COUNSEL EA AD 90461 $ 27.39 IM ANTIBIOTIC 96372 $ 153.91 IM FLU VACC NO PRESERV 3YR / > 90656 $ 19.77 IM INJ ANTIBIOTIC 96372 $ 153.91 IM SPLT VRS FLU VACN, 6-35 MO 90655 $ 15.24 IM TDAP VACCINE AGE 7YR > 90715 $ 52.10 IMADM ANY ROUTE 1ST VAC/TOX 90460 $ 44.02 IMAG SUPERVS I/R-CATH; VENT/ATRIAL 93565 $ 97.75 IMAGE CATH FLUID DRAIN TRANSVAG/RECT 49407 $ 3,564.97 IMAGER 11 CATHETER PIGTAIL C1729 $ 19.65 IMAGER II CATH 5BX UROLOGY TOR C1758 $ 135.30 IMATINAB 400 MG. Acquisition cost IMDS (HEEL STICK) 36416 $ 9.80 IM-GUIDE FLUID CATH DRAIN 10030 $ 1,514.94 IMIPEN/CILAST 5MG/ML NICU SYR Acquisition cost IMIPENEM/CILASTATIN 500MG INJ J0743 Acquisition cost IMIPENUM/CILISTAT 250MG IV Acquisition cost IMIPENUM/CILISTAT 500MG ADD VA J0743 Acquisition cost Page 149 2018 IMIPRAMINE 80335 $ 11.00 IMIPRAMINE HCL Acquisition cost IMIPRAMINE HCL 10MG TABLET Acquisition cost IMIPRAMINE HCL 25MG TAB Acquisition cost IMIPRAMINE HCL 50MG TAB Acquisition cost IMIQUIMOD 5% CREAM Acquisition cost IMIQUIMOD CREAM 5% Acquisition cost IMITREX 25MG TAB Acquisition cost IMITREX 50 MG. PO Acquisition cost IMITREX 6MG /0.5ML INJ J3030 Acquisition cost IMMAGING COIL MR INSRETABLE C1770 Acquisition cost IMMED INS BRST PROSTH S/P M 19340 $ 12,725.37 IMMED. LOWER DENTURE D5140 $ 1,400.00 IMMEDIATE UPPER DENTURE D5130 $ 1,400.00 IMMOBILIZER ECON KNEE-CATEG 1 Acquisition cost IMMOBILIZER KNEE-CATEG 1 Acquisition cost IMMOBILIZER UNIV SHOULDER-CATEG 1 Acquisition cost IMMUNE COMPLEX ASSAY; 86332 $ 66.20 IMMUNE GLOBULIN 1GM NICU IV Acquisition cost IMMUNE GLOBULIN 2.5GM VIAL J1569 Acquisition cost IMMUNE GLOBULIN HUMAN-IM USE 90281 Acquisition cost IMMUNE GLOBULIN IGG 5GM IV Acquisition cost IMMUNFIX E-PHORSIS/URINE/CSF 86335 $ 79.71 IMMUNIZATION ADMIN; 1 VACCINE 90471 $ 153.91 IMMUNIZATION ADMIN; 1 VACCINE CLINIC 90471 $ 153.91 IMMUNIZATION ADMIN; EA ADD VACCINE 90472 $ 70.00 IMMUNIZATION ADMIN; EA ADDL CLINIC 90472 $ 70.00 IMMUNIZATION ADMIN; INTRANASAL CLINIC 90473 $ 153.91 IMMUNIZATION ADMIN;ADDL INTRANASL CLINIC 90474 $ 27.39 IMMUNIZATION-1 VACCINE 90471 $ 153.91 IMMUNIZATION-EA ADDL 90472 $ 70.00 IMMUNOAS ANALYTE QUAN; RADIOPHARM 83519 $ 40.48 IMMUNOASSAY ANALYTE QUAN; NOS 83520 $ 37.99 IMMUNOASSAY NONANTIBDY 83516 $ 31.33 IMMUNOASSAY NONANTIBODY 83516 $ 31.33 IMMUNOASSAY QUANT NOS NONAB 83520 $ 37.99 IMMUNOCHEM PER ANTIB 88342 $ 569.71 IMMUNOCHEMISTRY 88342 $ 569.71 IMMUNOCYTOCHEM TISSUE ESTROGEN 88342 $ 569.71 IMMUNOCYTOCHEM TISSUE PROGESTERONE 88342 $ 569.71 IMMUNOCYTOCHEMISTRY 88342 $ 569.71 IMMUNOELECTROPHORESIS 84155 $ 9.97 IMMUNOFIXATION 86334 $ 60.70 IMMUNOFL.SKIN TEST 88346 $ 569.71 IMMUNOFLUOR; EA ADD ANTB STAIN; PER SPEC 88350 $ 65.25 IMMUNOFLUORESCENCE 88346 $ 569.71 IMMUNOFLUORESCENT STUDY 88346 $ 569.71 IMMUNOGLOBULIN A 82784 $ 25.26 IMMUNOGLOBULIN G 82784 $ 25.26 IMMUNOGLOBULIN LEVEL 86329 $ 38.15 IMMUNOGLOBULIN M 82784 $ 25.26 IMMUNOHISTO/CYTO CHEM 1ST STAIN 88342 $ 569.71 IMMUNOHISTO/CYTO CHEM EA ADDL STAIN 88341 $ 64.39 IMODIUM 1 MG / 5ML SOLN U/D Acquisition cost IMODIUM 1MG-5ML SOLN U/D $ 4.99 IMODIUM 2MG CAP Acquisition cost Page 150 2018 IMOGAM RABIES 150U/ML 10ML SYR Acquisition cost IMOGAM RABIES 150U/ML 2ML SYR Acquisition cost IMOVAX RABIES VACCINE 90675 Acquisition cost IMPACT TOOTH COMP BONY D7240 $ 693.00 IMPACT TOOTH COMP W/ SURG COMP D7241 $ 713.00 IMPACTED CERUMEN REMOVAL 69210 $ 147.99 IMPERVIOUS SPLIT SHEET 60X70" C1781 $ 3.34 IMPL COCHLEAR DEVICE; W/WO MASTDCMY 69930 $ 86,213.12 IMPL EXTENS PACING LEAD/NEUROSTIM C1883 Acquisition cost IMPL MAIN PROC REM PROS CLN / RESRT PROS D6080 $ 98.00 IMPL NEUROELECTRODES 64575 $ 48,577.94 IMPL NEUROELECTRODES; PERIPHERL NRV 64575 $ 48,577.94 IMPL PT-ACTIVATED CARD EVENT RECORDER 33282 $ 19,493.14 IMPL SYSBIO-COMP ARCHIL MIDSUB C1713 $ 2,089.50 IMPL TAPERED SCREW VENT 4.7 C1713 $ 394.80 IMPL,SPONGE,VAISE OVAL SILIC C1784 $ 64.50 IMPL/REPL EM CONDCT HEAR DEV 69710 $ 836.00 IMPL/REVIS/REPOS EPID CATH FOR PUMP 62351 $ 14,826.61 IMPLANON INSERTION 11981 $ 277.79 IMPLANT ALLO MATRIX INJ PUTTY Acquisition cost IMPLANT ARTICULAR SURFACE-CATEG 1 Acquisition cost IMPLANT BREAST SALINE-CATEG 1 C1789 Acquisition cost IMPLANT BREAST SALINE-CATEG 2 Acquisition cost IMPLANT BREAST-CATEG 1 C1789 Acquisition cost IMPLANT BREAST-CATEG 2 C1789 Acquisition cost IMPLANT BREAST-CATEG 3 C1789 Acquisition cost IMPLANT CARDIAC DEFIBRILLATOR 33240 $ 58,472.94 IMPLANT CATHETER 62350 $ 12,238.01 IMPLANT COLLAGEN-CATEG 1 Acquisition cost IMPLANT COLLAGEN-CATEG 2 Acquisition cost IMPLANT CORTICAL CANC BN CHIPS-CATEG 1 Acquisition cost IMPLANT CORTICAL CANC BN TISSUE-CATEG 1 Acquisition cost IMPLANT ENDOSTEAL D6010 $ 1,400.00 IMPLANT EYE POSTERIOR-CATEG 1 Acquisition cost IMPLANT FASCIA-CATEG 1 Acquisition cost IMPLANT GRAFTON DEMINER BONE-CATEG 1 C1713 Acquisition cost IMPLANT LCD PULSE GENERATOR ON 33240 $ 58,472.94 IMPLANT LOOP RECORD PLACEMENT C1713 $ 7,267.50 IMPLANT MEDPOR-CATEG 1 Acquisition cost IMPLANT NONPRO PUMP 62360 $ 43,478.95 IMPLANT ORTHO-CATEG 1 C1713 Acquisition cost IMPLANT OSTEO SET BONE VOID FILL-CATEG 1 C1713 Acquisition cost IMPLANT OSTEO SET BONE VOID FILL-CATEG 2 Acquisition cost IMPLANT PARAGON-CATEG 1 C1713 Acquisition cost IMPLANT PRE-OSTEON-CATEG 1 C1713 Acquisition cost IMPLANT PROGRAM PUMP 62362 $ 43,478.95 IMPLANT PROGRAMABLE PUMP 62362 $ 43,478.95 Implant removal, by report D6100 $ 238.00 IMPLANT SPINAL TRANS 63685 $ 73,761.95 IMPLANT SPINE FUSION PUMP 62361 $ 43,478.95 IMPLANT STEROID ELUDING BIPOL-CATEG 1 Acquisition cost Implant supp porc/cer crown D6065 $ 1,330.00 IMPLANT SUPP PORCELAIN FUSED METAL CROWN D6066 $ 1,330.00 Implant supp ret-cast metal FPD D6077 $ 1,330.00 Implant supp ret-ceramic FPD D6075 $ 1,330.00 Implant supported metal crown D6067 $ 1,330.00 Page 151 2018 IMPLANT TAPER SCRW VENT SBM4.7 C1713 $ 394.80 IMPLANT TUTOPLAST PERICARD-CATEG 1 L8610 Acquisition cost IMPLANTABLE TISSUE MARKER A4648 Acquisition cost IMPLANT-BREAST MAYLOR-CATEG 1 C1713 Acquisition cost IMPLANT-CATEG 1 C1785 Acquisition cost IMPLANT-EYE AHMAD-CATEG 1 V2630 Acquisition cost IMPLANT-EYE BAERVELDT-CATEG 1 Acquisition cost IMPLANT-EYE HALF SCLERAL SHELL-CATEG 1 Acquisition cost IMPLANT-EYE KONTOUR-CATEG 1 Acquisition cost IMPLANT-EYE QTR SCLERAL SHELL-CATEG 1 Acquisition cost IMPLANT-EYE VOLK-CATEG 1 Acquisition cost IMPLANT-EYE WHOLE SCLERAL-CATEG 1 Acquisition cost IMPLANT-EYE, AC-CATEG 1 Acquisition cost IMPLANT-EYE, ACRYLIC FOLDABLE-CATEG 1 Acquisition cost IMPLANT-EYE, BICONVEX-CATEG 1 Acquisition cost IMPLANT-EYE, KK POST SCLRSTMY-CATEG 1 Acquisition cost IMPLANT-EYE, MTA3U0 Acquisition cost IMPLANT-EYE, POSTERIOR-CATEG 1 V2632 Acquisition cost IMPLANT-EYE, SA60AT-CATEG 1 Acquisition cost IMPLANT-EYE, SURGIDEV-CATEG 1 Acquisition cost IMPLANT-EYE-CATEG 1 V2630 Acquisition cost IMPLANT-IOL DIOPTER +20 - CATEG 1 Acquisition cost IMPLANT-IOL VTRCTMY, BICON-CATEG 1 Acquisition cost IMPLANT-IOL VTRCTMY, MACHMR-CATEG 1 Acquisition cost IMPLANT-IOL, ACRYSOF-CATEG 1 V2787 Acquisition cost IMPLANT-IOL, MA30BA-CATEG 1 Acquisition cost IMPLANT-IOL, MA30BH-CATEG 1 Acquisition cost IMPLANT-IOL, MA60BM-CATEG 1 Acquisition cost IMPLANT-IOL, SA60AT-CATEG 1 Acquisition cost IMPLANT-IOL-CATEG 1 V2630 Acquisition cost Implant-mandib/augmentation,B/R D7996 $ 3,150.00 IMPLNT BIOLOGIC IMPLNT; ADD-ON 15777 $ 466.71 IMPLNT PT ACTIVATED CARD EVENT RECORD 33282 $ 19,493.14 IMPLNT SPINAL TRANS 63685 $ 73,761.95 Implnt supp ret-prc fuse mtlFPD D6076 $ 1,330.00 IMRT, W GUIDE/TRCK; CMPLX 77386 $ 1,381.29 IMRT, W GUIDE/TRCK; SIMP 77385 $ 1,381.29 IMS (HEEL STICK) 36416 $ 112.00 IMURAN 50MG TAB J7500 Acquisition cost IN 111RADPHRM DX CAPRMB PNDTE/DSE<=10MCI A9507 $ 4,413.75 IN HOME VISIT H0023 Acquisition cost IN SITU HYBRID (FISH) UR TRT SPEC COMPUT 88121 $ 569.71 IN SITU HYBRID (FISH) UR TRT SPEC MANUAL 88120 $ 341.62 IN SITU HYBRID-QUANTITATIVE, COMPUTER 88367 $ 569.71 IN SITU HYBRID-QUANTITATIVE, MANUAL 88368 $ 569.71 IN SITU, AF CELLS 88269 $ 451.75 IN-111 OCTREASCAN <= 3 MCI A9572 $ 4,776.75 IN-111 OCTREOSCAN UD <= 6 MCI A9572 $ 4,776.75 IN-111 OXYQUINOLINE, PER 0.5 MILLICURIE A9547 $ 854.70 IN-111 PLATELET LABELING STUDY A9571 $ 952.89 IN-111 WHITE BLOOD CELLS A9570 $ 1,897.50 INACTIVATED JE VACC IM 90738 $ 656.17 INADM ANY ROUTE ADDL VAC/TOX <=18 YRS 90461 $ 27.39 INAMRINONE 5MG/ML INJ Acquisition cost INAPSINE 2.5MG/ML INJ 2ML VIAL J1790 Acquisition cost INC & REM FB SQ - COMPLEX 10121 $ 3,564.97 Page 152 2018 INC & REM FB SQ - SIMPLE 10120 $ 821.94 INC ACHILLES TENDON W GEN ANESTH 27606 $ 6,995.52 INC ADHES ANT SEG EYE; NOT GONIOSYN 65870 $ 5,080.46 INC ADHESIONS ANT SEG EYE; POST SYECHIA 65875 $ 5,080.46 INC ANKLE - POST CAPSUL RELEASE 27612 $ 6,995.52 INC FTS WRIST 25001 $ 3,570.03 INC IMPL NEUROELECTRODES 64581 $ 16,014.53 INC IMPL NEUROMUSCULAR ELECTRODES 64580 $ 48,577.94 INC LABIAL FRENUM; MTH VEST 40806 $ 1,216.16 INC LABIAL FRENUM;TONGUE/FOM 41010 $ 3,010.00 INC OF LINGUAL FRENUM 41010 $ 3,010.00 INC THROMBOSED EXT PILE 46083 $ 607.00 INCIS DRAIN ABSCS PERITONSL 42700 $ 472.05 Incis&drain abscs-ext soft comp D7521 $ 1,687.00 Incis&drain abscs-int soft comp D7511 $ 487.00 INCISE FOOT/TOE FASCIA 28008 $ 6,995.52 INCISE THROMBOSED HEMORRHOID;E 46083 $ 607.00 INCISION EXT TENDON SHEATH WRI 25000 $ 3,570.03 INCISION OF CONJUCTIVE 68020 $ 2,137.81 INCISION OF FIBULA 27707 $ 6,995.52 INCISIONAL BIOPSY 19101 $ 7,213.98 INCISN DRAING ABSCS PERITNSL 42700 $ 472.05 INCISN DRAING ABSCS PERITONSL 42700 $ 472.05 INCISN DRAINGE, PILONIDAL CYST 10080 $ 1,514.94 INCOMETHACIN 0.1MG/ML NICU SYR Acquisition cost Incomplt endo ther-inopbl/unres D3332 $ 644.00 INCS / REMOV FB SUBQ TISS; COMPLIC 10121 $ 3,564.97 INCS / REMOV FB SUBQ TISS; SIMPL 10120 $ 821.94 INCS DRAINAGE LACRIMAL SAC 68420 $ 4,790.26 INCS SOFT TISS ABSCESS; DEEP/COMPLIC 20005 $ 3,564.97 INDAPAMIDE 1.25MG TAB PO Acquisition cost INDAPAMIDE 2.5MG TABLET U-D Acquisition cost INDERAL 1MG/ML 1ML AMP J1800 Acquisition cost INDERAL 80 MG TAB Acquisition cost INDIA INK PREP CSF 87210 $ 12.80 INDICAT DILUT STDY; W/CARD OTPUT-SP 93561 $ 27.04 INDIGOTINDISULFONATE NA .8% AM Acquisition cost INDINAVIR SULF 200MG CAP Acquisition cost INDINAVIR SULF 400MG CAP Acquisition cost INDIRECT COOMBS 86885 $ 341.62 INDIV COUNSEL; BRIEF - 25 MIN 90832 $ 290.00 INDIV SMKING CESS; 10+ MIN 99407 $ 67.97 INDIV SMKING CESS; 3-10MIN 99406 $ 67.97 INDOMETHACIN 25MG CAP Acquisition cost INDOMETHACIN ORAL SOL Acquisition cost INDOMETHACIN RECTAL SUPP 50mg Acquisition cost INDOMETHACIN SOD TRIHY 1MG IV Acquisition cost INDUCED AB BY DILAT & EVACUATI 59841 $ 6,010.51 INDUCED AB BY DILAT / CURET 59840 $ 6,010.51 INDUCED ABORTION BY DIL & CUT 59840 $ 6,010.51 INDURA INTRATHECAL CATHETER C1758 $ 1,042.50 INDWELLING SLIT CATHETER SET STRYKER IN A4301 $ 148.25 INF AGT-DNA/RNA NOS; AMP PROBE EA 87798 $ 95.33 INF AGT-DNA/RNA; HEP C-DIRECT PROBE 87520 $ 68.68 INF AGT-DNA/RNA; MYCOBACT-AMP PROB 87551 $ 106.13 INF AGT-DNA/RNA; NEISSR GNRRHEA-DIR 87590 $ 59.14 Page 153 2018 INF AGT-IMMUNOFLUOR; CHLAMYDIA 87270 $ 32.56 INF AGT-IMMUNOFLUOR; HERPES SIMPLX 87274 $ 32.56 INFANT HIPS ULTRASOUND 76885 $ 164.27 INFANT WHOLE BODY X-RAY R/O FOREIGN BODY 76010 $ 164.27 IN-FAST ULTRA INTEGRAFT/SLING SYS Acquisition cost INFEC AG-IMMUNOASSAY; STREP GROUP A 87430 $ 36.98 INFEC AGT-DNA/RNA; HEP C-DIRECT PROBE 87520 $ 68.68 INFECT AGENT DETECT BY DNA/RNA; GI PATH 87505 $ 348.44 INFED 50MG/ML 2ML J1750 Acquisition cost INFERIOR VENA CARVOGRAM 75825 $ 6,592.23 INFINITI CATH 4FR C1887 $ 37.58 INFLATION DEVICE ADVANTAGE-CATEG 1 Acquisition cost INFLATION DEVICE ENCORE-CATEG 1 Acquisition cost INFLATION DEVICE LEVEEN-CATEG 1 Acquisition cost INFLIXIMAB 100MG IV J1745 Acquisition cost INFLIXIMAB 100MG VIAL J1745 Acquisition cost INFLUENZA A ANTIBODY 86710 $ 36.81 INFLUENZA A IGM 86710 $ 36.81 INFLUENZA A LGG 86710 $ 36.81 INFLUENZA ADULT VACCINE 0.5 ML SYRINGE Acquisition cost INFLUENZA ADULT VACCINE 2006/2007 Acquisition cost INFLUENZA ADULT. VACCINE 5ML VIAL 90656 Acquisition cost INFLUENZA B ANTIBODY 86710 $ 36.81 INFLUENZA B IGG 86710 $ 36.81 INFLUENZA B IGM 86710 $ 36.81 INFLUENZA DNA AMP PROB 1+ 87501 $ 139.37 INFLUENZA DNA AMP PROBE 87502 $ 231.13 INFLUENZA PED. VACCINE 0.25 ML (IIV4) 90685 Acquisition cost INFLUENZA PEDS VACCINE 2006/2007 Acquisition cost INFLUENZA VAC 0.5ML FLUZONE 90656 Acquisition cost INFLUENZA VACCINE INTRA DERMAL Acquisition cost INFLUENZA VACCINE QUADRIVALENT 90686 Acquisition cost INFLUENZA VACCINE TRIVALENT Acquisition cost INFLUENZA VIRUS VACC IIV 65YR+ 90662 $ 53.37 INFNT/CHLD APP SKN GFT SUB; T/A/L ADD 15274 $ 98.45 INFUS ALBUMIN (HUMAN) 5% 50 ML P9041 $ 61.63 INFUS ALBUMN (HUMAN) 25% 10 ML P9046 $ 49.48 INFUS NORMAL SALINE SOL 1000 CC J7030 $ 0.22 INFUS NORMAL SALINE SOL 500ML J7040 $ 0.24 INFUS TUB DISP W/O DRAPE CHAMB A4624 $ 22.35 INFUS TX OTH THAN CHEMO RX VISIT 96360 $ 247.61 INFUSE BONE GRAFT XSMALL C1768 $ 2,775.00 INFUSION (CONTINUED) 96370 $ 97.92 INFUSION CANNULA 6.0MM A4615 $ 168.00 INFUSION CANNULA DISP 12/BX A4615 $ 39.00 INFUSION D5W 1000 CC J7070 $ 1.40 INFUSION SUB/DRUG (1 HOUR) 96369 $ 505.36 INFUSOR DISPOSABLE-CATEG 1 Acquisition cost INFUSOR DISPOSABLE-CATEG 2 Acquisition cost INGEST CHALLENGE TEST; ADDL 60 MIN 95079 $ 149.27 INGEST CHALLENGE TEST; INITIAL 120 MIN 95076 $ 1,175.22 INHALA BRONCH CHALLENG; W/HISTAMINE 95070 $ 1,175.22 INHIBIN A 83520 $ 37.99 INHIBIN A. 86336 $ 42.33 INHIBITOR STUDY 85335 $ 34.96 INICIBODY PLATE C1713 $ 835.50 Page 154 2018 INIT NUTRITION THERAPY; EACH 15M 97802 $ 70.75 INIT PREV E/M NEW PT;18-39 99385 $ 343.00 INIT PREV E/M NEW PT;40-64 99386 $ 343.00 INIT PREV EXAM SCREEN ECG TRACING ONLY G0404 $ 46.20 INIT PREV EXAM SCREEN ECG W IN G0403 $ 85.81 INIT PREV MED E&M NEW PT; INFA 99381 $ 343.00 INIT PREV MED E/M NEW PT;12-17 99384 $ 343.00 INIT PREV MED E/M NEW PT;1-4YR 99382 $ 343.00 INIT PREV MED E/M NEW PT;18-39 99385 $ 343.00 INIT PREV MED E/M NEW PT;40-64 99386 $ 343.00 INIT PREV MED E/M NEW PT;5-11Y 99383 $ 343.00 INIT PREV MED E/M NEW PT;65/>Y 99387 $ 343.00 INIT PREVEN E/M NE WPT;65/>YR 99387 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 1 99382 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 1 99384 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 1 99385 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 4 99386 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 5 99383 $ 343.00 INIT PREVEN MEDS E&M NEW PT; 6 99387 $ 343.00 INIT PRV MED E/M NEW PT;12-17Y 99384 $ 343.00 INIT PRV MED E/M NEW PT;1-4YR 99382 $ 343.00 INIT PRV MED E/M NEW PT;18-39Y 99385 $ 343.00 INIT PRV MED E/M NEW PT;5-11YR 99383 $ 343.00 INIT TX 1ST DEGREE BURN 16000 $ 446.80 INJ ACETAZOLAMIDE SODIUM TO 500 MG J1120 $ 109.56 INJ ADENOSINE 30 MG J0153 $ 3.81 INJ ADENOSINE 6 MG J0153 $ 3.81 INJ ADENOSINE, PER 1MG J0153 $ 3.81 INJ ADRENALIN EPINEPH UP 1 ML AMPULE J0171 $ 3.85 INJ ADRENLIN EPINEPH UP 1 ML AMPULE J0171 $ 3.85 INJ AIR/CONTRST IN PERITON CAV-SP 49400 $ 203.65 INJ ALEMTUZUMAD (LEMTRADA) 1 MG J0202 $ 4,796.06 INJ ALTEPLASE RECOMBINANT 1 MG J2997 $ 232.32 INJ AMINOPHYLLIN 250MG J0280 $ 30.01 INJ AMPCLLN SODIM/SULBACTAM-1.5 G J0295 $ 18.94 INJ AMPHOTERICIN B LIPID 10 MG J0287 Acquisition cost INJ AMPHOTERICIN B LIPID 10 MG J0287 $ 59.25 INJ AMPICILLIN 500 MG J0290 $ 9.70 INJ AMPICILLIN SODIUM 500 MG J0290 $ 9.70 INJ ANES AGENT; CELIAC PLEXUS 64530 $ 1,777.62 INJ ANES AGENT; CERV PLEXUS 64413 $ 1,437.02 INJ ANES AGENT; STELLATE GANGL 64510 $ 1,777.62 INJ ANES AGNT; CELIAC PLEXUS 64530 $ 1,777.62 INJ ANES AGNT; STELLATE GANGL 64510 $ 1,777.62 INJ ANES SUP HYPOGASTRIC PLEXUS 64517 $ 1,777.62 INJ ANESTH AGENT; CERV PLEXUS 64413 $ 1,437.02 INJ ANESTH FEMORAL NERVE; SING 64447 $ 1,437.02 INJ ANESTH; BRACHIAL PLEXUS; SINGLE 64415 $ 1,777.62 INJ ANESTH; CATH; BRACHIAL PLEXUS 64416 $ 1,777.62 INJ ANESTH; CATH; FEMORAL NERVE 64448 $ 1,777.62 INJ ANESTH; FACIAL NERVE 64402 $ 277.79 INJ ANESTH; FEMORAL NERVE; SINGLE 64447 $ 1,437.02 INJ ANESTH; GREATER OCCIPITAL NERVE 64405 $ 647.13 INJ ANESTH; HYPOGASTRIC PLEXUS 64517 $ 1,777.62 INJ ANESTH; ILIOING/ILIOHYPOGASTRIC 64425 $ 1,437.02 INJ ANESTH; INTERCOSTAL NERVE; SINGLE 64420 $ 1,437.02 Page 155 2018 INJ ANESTH; LUMB/THOR (SYMPATHETIC) 64520 $ 1,777.62 INJ ANESTH; LUMBAR PLEXUS; CATH 64449 $ 1,777.62 INJ ANESTH; OTHER PERIPHERAL NRV/BRNCH 64450 $ 1,437.02 INJ ANESTH; PARACERVICAL (UTERINE) NERVE 64435 $ 1,437.02 INJ ANESTH; SCIATIC NERVE; SINGLE 64445 $ 1,437.02 INJ ANESTH; TRIGEMINAL NERVE 64400 $ 647.13 INJ ANESTH; TRIGEMINAL NERVE 64400 $ 647.13 INJ ANT CHAMB EYE SEP PROC; AIR/LIQ 66020 $ 5,080.46 INJ ANTERIOR CHAMBER; MEDICATION 66030 $ 5,080.46 INJ ATROPINE SULFATE TO 0.3 MG J0461 $ 2.42 INJ AVASTIN (BEVACIZUMAB) 0.25 C9257 $ 5.13 INJ BENZTROPINE MESYLATE 1MG J0515 $ 82.50 INJ BETAMETHSN ACTAT/SOD PHOSPH-3MG J0702 $ 27.19 INJ BUPIVACAINE 0.25% J3490 $ 11.51 INJ BUSULFAN 1MG J0594 $ 91.08 INJ CALCITRIOL 0.1 MCG AMP J0636 $ 20.62 INJ CEFAZOLIN SODIUM 500 MG J0690 $ 3.26 INJ CEFOXITIN SODIUM 1 GM J0694 $ 27.06 INJ CEFTAZIDIME PER 500 MG J0713 $ 7.08 INJ CEFTRIAXONE SODIUM PER 250 MG J0696 $ 1.98 INJ CHLORDIAZEPOXIDE HCL TO 100 MG J1990 $ 22.38 INJ CILASTATIN SODIUM IMIPENEM 250 MG J0743 $ 25.87 INJ CORPORA CAVERNOSA W/PHARM AGENT 54235 $ 607.00 INJ CORPORA CAVERNOSA WTH PHARM AGENTS 54235 $ 607.00 INJ DESMOPRESSIN ACETATE PER 1 MCG J2597 $ 38.81 INJ DIAZEPAM TO 5 MG J3360 $ 36.10 INJ DIGOXIN TO 0.5 MG J1160 $ 14.52 INJ DIPHENHYDRAMINE HCL TO 50MG J1200 $ 2.16 INJ DIPYRIDAMOLE 10 MG J1245 $ 2.58 INJ DOBUTAMINE HCL PER 250 MG J1250 $ 14.52 INJ DOLASETRON MESYLATE,10 MG J1260 $ 15.47 INJ DRUG; INTRAVITREAL 67028 $ 786.94 INJ DX/TX AGNT PARAVERT W/US; CRV/THR 0213T $ 1,777.62 INJ DX/TX AGNT PARAVERT W/US; LMB/SAC 0216T $ 1,777.62 INJ DX/TX; PARAVERT FAC JNT; C/T; 1LVL 64490 $ 1,777.62 INJ DX/TX; PARAVERT FCT JNT C/T 3RD LVL 64492 $ 133.45 INJ DX/TX; PARAVERT FJNT; C/T; 2ND LVL 64491 $ 131.96 INJ ENOXAPARIN SODIUM 10 MG J1650 $ 21.87 INJ EPIDURAL-BLD/CLOT PATCH 62273 $ 1,437.02 INJ EPIDURAL-BLOOD/CLOT PATCH 62273 $ 1,437.02 INJ FOR CYSTOGRAPHY 51600 $ 98.01 INJ FUROSEMIDE 20MG J1940 $ 16.41 INJ FUROSEMIDE TO 20 MG J1940 $ 16.41 INJ GADAVIST; 0.1ML A9585 $ 2.19 INJ GAMMA GLOBULIN 1CC J1460 $ 84.65 INJ GAMMA GLOBULIN IM OVER 10CC J1560 $ 1,070.00 INJ GANCICLOVIR SODIUM 500 MG J1570 $ 190.08 INJ GARAMYCIN GENTAMICIN TO 80 MG J1580 $ 9.04 INJ HALOPERDL DECANOATE 50MG J1631 $ 74.14 INJ HALOPERDL DECNTE 50MG J1631 $ 74.14 INJ HALOPERIDOL TO 5 MG J1630 $ 3.39 INJ HALOPERIDOL UP TO 5 MG J1630 $ 3.39 INJ HEP B IMMUNE GLOB,PER 1 ML 90371 $ 233.51 INJ HEPARIN SODIUM PER 10 UNT J1642 $ 7.48 INJ HEPARIN SODIUM PER 1000 UNITS J1644 $ 2.64 INJ HYDROCORTISON SOD PHOS TO 50 MG J1710 $ 22.62 Page 156 2018 INJ HYDROCORTISONE ACETATE TO 25 MG J1700 $ 2.66 INJ HYDROCORTISONE SOD SUC 100MG J1720 $ 22.62 INJ HYDROCORTISONE SODIUM SUCC 100 MG J1720 $ 22.62 INJ HYDROXYZINE HCL TO 25 MG J3410 $ 2.12 INJ IMMUNE GLOB IV 500 MG J1561 $ 144.72 INJ IN FACIAL NRV; AGENT 64402 $ 277.79 INJ INSULIN PER 5 UNITS J1815 $ 3.28 INJ INSULIN TO 5 UNITS J1815 $ 3.28 INJ INTERFERON ALFACON-1; 9MCG J9212 $ 17.52 INJ INTERFERON-ALFACON-1 1MCG J9212 $ 17.52 INJ INTRALES; MORE THAN 7 LES 11901 $ 446.80 INJ IRON DEXTRAN 50 MG J1750 $ 35.00 INJ IRON DEXTRAN 50 MG (INFeD) J1750 $ 35.00 INJ IRON SUCROSE 1MG J1756 $ 1.32 INJ ITRACONAZOLE 50 MG J1835 Acquisition cost INJ IV UROKINASE 250000 IU VIAL J3365 $ 578.14 INJ KETOROLAC TROMETHAMINE PER 15 MG J1885 $ 7.59 INJ KINEVAC 5 MCG J2805 $ 267.08 INJ LEUPROLIDE ACET PER 3.75MG J1950 $ 3,232.59 INJ 10ML J2001 $ 1.92 INJ LIDOCAINE HCL 50% J2001 $ 9.00 INJ LINEZOLID 200 MG J2020 $ 80.67 INJ LORAZEPAM 2MG J2060 $ 8.93 INJ MAGNESIUM SULFATE PER 500MG J3475 $ 6.42 INJ MANNITOL 50 ML J2150 $ 7.26 INJ MEDROXYPROGESTERONE ACETATE, 1MG J1050 $ 3.67 INJ MEPERIDINE HCL 100 MG J2175 $ 22.18 INJ METHADONE HCL TO 10 MG J1230 $ 46.20 INJ METHOCARBAMOL TO 10 ML J2800 $ 53.07 INJ METHYLPRDNISOLON SODIM TO 40 MG J2920 $ 15.88 INJ METHYLPREDNISOLONE ACETATE 20 MG J1020 $ 17.45 INJ METHYLPREDNISOLONE ACETATE 40 MG J1030 $ 27.92 INJ METHYLPREDNISOLONE ACETATE 80 MG J1040 $ 48.42 INJ METOCLOPRAMIDE HCL 10MG J2765 $ 8.85 INJ METOCLOPRAMIDE HCL TO 10MG J2765 $ 8.84 INJ MIDAZOLAM HCL 1 MG J2250 $ 1.21 INJ MITOXANTRNE HYDRCHLRDE 5MG J9293 $ 166.94 INJ MORPHINE SULFATE TO 100 MG J2270 $ 17.36 INJ MORPHINE SULFATE, 10 MG J2274 Acquisition cost INJ NALOXONE HCL PER 1 MG J2310 $ 43.56 INJ NALOXONE HCL PER 1 MG (Narcan) J2310 $ 43.56 INJ NANDROLONE DECANOATE TO 200 MG J2320 $ 37.40 INJ NEUROLYTIC; EPIDRL/LUMB/CAUDAL 62282 $ 1,777.62 INJ NEUROLYTIC; EPIDURAL/CERV/THORASIC 62281 $ 1,777.62 INJ ONABOTULINUMTOXIN PER UNIT J0585 $ 15.86 INJ OPRELVEKIN 5MG J2355 $ 1,163.62 INJ PALONOSETRON HCL 25MCG J2469 $ 119.59 INJ PAMIDRONATE DISDM PER30MG J2430 $ 36.45 INJ PANTOPRAZOLE SODIUM, VIAL C9113 $ 18.70 INJ PARAVERT F JNT C/T 1 LEV 64490 $ 1,777.62 INJ PARAVERT F JNT C/T 2 LEV 64491 $ 131.96 INJ PARAVERT F JNT C/T 3 LEV 64492 $ 133.45 INJ PARICALCITOL 1 MCG J2501 $ 27.72 INJ PCN G BENZ/PROCAIN UP 1200000 J0561 $ 39.97 INJ PCN G BENZ/PROCAINE UP 600000 J0561 $ 39.97 INJ PEN G BENZATHINE TO 1200000 UNITS J0561 $ 39.97 Page 157 2018 INJ PEN G BENZATHINE TO 2400000 UNITS J0561 $ 39.97 INJ PEN G BENZATHINE TO 600000 UNITS J0561 $ 39.97 INJ PERQ TX EXTRM PSEUDOANEURYSM 36002 $ 1,619.99 INJ PHENOBARBITAL SODIUM TO 120 MG J2560 $ 131.55 INJ PHENYTOIN SODIUM PER 50 MG J1165 $ 1.52 INJ PHYTONADIONE (VIT K) PER 1 MG J3430 $ 47.52 INJ PHYTONADIONE (VIT K) PER 1 MG J3430 $ 47.52 INJ PIPERACILLIN/TAZOBACTAM 1.125 GM J2543 $ 5.02 INJ POTASSIUM CHLORIDE PER 2 mEq J3480 $ 1.78 INJ ACETATE 1MG J2650 $ 0.23 INJ PROC ANK ARTHROGRAPHY 27648 $ 114.51 INJ PROC ART-OCCLUD AV MALFORM SPINAL 62294 $ 1,777.62 INJ PROC CONTRAST VENOGRAPHY 36005 $ 104.87 INJ PROC CORPORA CAVERNOSOGRAPHY 54230 $ 175.65 INJ PROC DISKOGRAPHY EA LEVEL; 62290 $ 370.99 INJ PROC DISKOGRAPHY; EA LEVEL 62290 $ 370.99 INJ PROC ELBOW ARTHROGRAPHY 24220 $ 149.75 INJ PROC HIP ARTHROGRAPHY; WO ANES 27093 $ 153.19 INJ PROC KNEE ARTHROGRAPHY 27370 $ 110.09 INJ PROC RETROGRADE URETHROCYSTOGRAPHY 51610 $ 140.54 INJ PROC SHOULDER ARTHROGRAPHY 23350 $ 112.02 INJ PROC SIALOGRAPHY 42550 $ 139.26 INJ PROC SPLENOPORTOGRAPHY 38200 $ 292.91 INJ PROC WRIST ARTHROGRAPHY 25246 $ 164.32 INJ PROC; ID SENTINEL NODE 38792 $ 924.11 INJ PROC; LYMPHANGIOGRAPHY 38790 $ 179.78 INJ PROCAINAMIDE HCL TO 1 GM J2690 $ 189.24 INJ PROC-CATH; LT VENT/ATRIAL ANGIO 93565 $ 97.75 INJ PROC-CONTRAST URETHROCYSTOGRAPY 51605 $ 84.83 INJ PROC-DISKOGRAPHY EA LEVEL; CERV/THOR 62291 $ 367.16 INJ PROC-EVAL PERITON-VENOUS SHUNT 49427 $ 99.95 INJ PROCHLORPERAZINE TO 10 MG J0780 $ 48.84 INJ PROC-MYELOGRAPHY //OR CAT-SPINAL 62284 $ 190.83 INJ PROC-URETEROGRAPHY THRU CATH 50684 $ 110.62 INJ PROC-VISUALIZ ILEAL CONDUIT OF RAD 50690 $ 154.24 INJ PROMAZINE HCL TO 25 MG J2950 $ 3.04 INJ PROMETHAZINE HCL TO 50 MG J2550 $ 9.50 INJ PROPRANOLOL HCL TO 1 MG J1800 $ 15.84 INJ PROTAMINE SULFATE PER 10 MG J2720 $ 3.70 INJ PROTONIX IV 40 MG S0164 $ 13.20 INJ PUDENDAL NERVE 64430 $ 1,777.62 INJ RANITIDINE HCL 25 MG J2780 $ 21.78 INJ RISPERIDONE, LG ACTING, 0.5MG J2794 $ 23.94 INJ SCLEROSG SOLU MULTI VEN 36471 $ 821.94 INJ SCLEROSG SOLU;SINGL VEN 36470 $ 821.94 INJ SI JOINT 27096 $ 183.06 INJ SINGL TENDON SHEATH/LIG 20550 $ 647.13 INJ SINUS TRACT; DX 20501 $ 83.05 INJ SINUS TRACT; THERAP (SEPART PROC) 20500 $ 3,010.00 INJ SPHENOPALATINE GANGLION 64505 $ 647.13 INJ STERILE CEFUROXIME SODIUM PER 750 MG J0697 $ 14.08 INJ STREPTOKINASE PER 250000 IU J2995 $ 35.20 INJ SUMATRIPTAN SUCCINATE 6 MG J3030 $ 187.00 INJ SUPRASCAPULAR NERVE 64418 $ 1,437.02 INJ TERBUTALINE SULFATE TO 1 MG J3105 $ 10.56 INJ THERAP AGENT INTO TENON'S CAPSULE 67515 $ 707.85 Page 158 2018 INJ TOBRAMYCIN SULFATE TO 80 MG J3260 $ 9.33 INJ TRIAMCINOLONE ACETATE 10MG J3301 $ 6.38 INJ TRIG PTS; 3 OR MORE MUSCLES 20553 $ 647.13 INJ TRIGGER POINT 1/2 MUSCLES 20552 $ 647.13 INJ TX/DX; PARAVERT F JNT; L/S; 3LVL 64495 $ 115.04 INJ TX/DX; PARAVERT FAC JNT; L/S; 2 LEV 64494 $ 113.54 INJ TX/DX; PARAVERT FAC JNT; L/S; 2 LVL 64494 $ 113.54 INJ TX/DX; PARAVERT FAC JNT; L/S; 3 LEV 64495 $ 115.04 INJ TX/DX; PARAVERT FCT JNT; L/S; 1 LEV 64493 $ 1,777.62 INJ TX/DX; PARAVERT FCT JNT; L/S; 1 LVL 64493 $ 1,777.62 INJ UROKINASE 5000 IU VIAL J3364 $ 11.88 INJ VANCOMYCIN HCL 500 MG J3370 $ 28.23 INJ VELCADE 0.1MG J9041 $ 120.91 INJ VIT B-12 CYNOCOBLMN TO 1000 MCG J3420 $ 19.23 INJ VITAMIN K PHYTONADIONE 1MG J3430 $ 47.52 INJ VITREOUS SUBSTITUTE-SEP PR 67025 $ 5,080.46 INJ, BUPIVACAINE LIPOSOME 1MG C9290 $ 3.12 INJ, DEXAMETHASONE ACETATE, 1MG J1094 Acquisition cost INJ, DIETHYLSTILBESTROL 250MG J9165 $ 33.37 INJ, FENTANYL CITRATE, 0.1 MG J3010 $ 4.22 INJ, GADAVIST, 0.1ML A9585 $ 2.19 INJ, INTRALESIONL UP2 W/7I 11900 $ 446.80 INJ, NIVOLUMAB 1MG, 10ML VIAL J9299 $ 69.21 INJ, NIVOLUMAB 1MG, 4ML VIAL J9299 $ 69.21 INJ, TENDON SHEATH, ORIGIN/INSERT 20551 $ 647.13 INJ,EPTIFIBATIDE,5MG J1327 $ 103.26 INJ,GONADORELIN HCL,100 MCG J1620 $ 105.13 INJ,GRANISETRON HCL,100 MCG J1626 $ 8.44 INJ,IMMUNE GLOBULIN, 500 MG J1561 $ 144.72 INJ,INFLIXIMAB,10MG J1745 $ 308.22 INJ,LEUCOVORIN CALCIUM,50 MG J0640 $ 26.40 INJ,MELPHALAN HYDROCHLRDE 50MG J9245 $ 4,378.00 INJ,OCTREOTIDE, DEPOT, 1 MG J2353 $ 537.79 INJ,RESP VIR IMM GLOB,IV,50 MG 90378 $ 373.45 INJ,RHO D IMM GLOB,HUM,100 I.U J2792 $ 68.20 INJ,RHO IMM GLOB,HUMAN, 300 MCG DOSE J2790 $ 114.52 INJ,RHO IMMUNE GLOBULIN, 300 MCG J2790 $ 211.70 INJ,SARGRAMOSTIM,50 MCG J2820 $ 130.68 INJ,TETANUS IMMUNE GLOBULIN 250 UNITS J1670 $ 1,314.80 INJ,TIROFIBAN HCL,0.25MG J3246 $ 39.17 INJ. DURVALUMAB 10MG C9492 $ 185.06 INJ; TENDON SHEATH LIG GANG CYST 20550 $ 647.13 INJCTN COLLAGN FILL MAT 1.1 11951 $ 1,291.09 INJCTN,COLLAGN FILLING MAT 1.1 11951 $ 1,291.09 INJ-DEFEROXAMINE MESYLATE-500MG J0895 $ 34.19 INJ-DEXAMETHASONE SOD PHOSPHAT J1100 $ 0.62 INJEC C/CATH FR PULM ANGIOGRF 93568 $ 101.97 INJEC,DEXRAZOX HYDROCHLO 250MG J1190 $ 620.09 INJECT ANES AGENT; CERV PLEXUS 64413 $ 1,437.02 INJECT ANES OTH PN 64450 $ 1,437.02 INJECT CONGENITAL CARD CATH 93563 $ 125.93 INJECT DX CHOLANGIOGRM; EXIST ACCESS 47531 $ 7,698.79 INJECT DX CHOLANGIOGRM; NEW ACCESS 47532 $ 7,698.79 INJECT HRT CONGNTL ART/GRFT 93564 $ 131.10 INJECT MAGNESIUM SULFATE PER 500MG J3475 $ 6.42 INJECT PULM ART HRT CATH 93568 $ 101.97 Page 159 2018 INJECT R VENTR/ATRIAL ANGIO 93566 $ 99.64 INJECT SCLEROSG SOLU MULTI VEN 36471 $ 821.94 INJECT SCLEROSG SOLU;SINGL VEN 36470 $ 821.94 INJECT SI JOINT 27096 $ 183.06 INJECT SUPRVLV AORTOGRAPHY 93567 $ 112.77 INJECT, RETEPLASE, 18.1MG J2993 $ 1,400.00 INJECT,MORPHINE SULFATE,10 MG J2274 $ 12.41 INJECT,ONDANSETRON HCL PER 1MG J2405 $ 1.54 INJECTION FOR CHOLANGIOGRAM 47531 $ 7,698.79 INJECTION HEPARIN SODIUM 10 UNITS J1642 $ 0.37 INJECTION IN CARPAL TUNNEL 20526 $ 647.13 INJECTION INTO SKIN LESIONS=<7 11900 $ 446.80 INJECTION PROC TMJ ARTHROGRAPH 21116 $ 103.09 INJECTION, CARPAL TUNNEL 20526 $ 647.13 INJECTION, CLADRIBINE, PER 1MG J9065 $ 92.40 INJECTION, IFOSFAMIDE 1GM J9208 $ 96.99 INJECTION, MESNA, 200MG J9209 $ 15.84 INJECTION, PERTUZUMAB, 1MG J9306 $ 30.58 INJECTION, TENDON SHEATH, ORIGIN/INSERTN 20551 $ 647.13 INJECTION, THERAP IV 96374 $ 505.36 INJECTION,AMIFOSTINE,500MG J0207 $ 1,242.89 INJECTN INTO TURBINTE,THERAPTC 30200 $ 1,216.16 INJECTN INTO TURBINTE,THERPTC 30200 $ 1,216.16 INJECTN, INTRALESIONL UP2 W/7I 11900 $ 446.80 INJ-MILRINONE LACTATE-5 MG J2260 $ 7.47 INLAY PROCELAIN - 1 SURFACE D2610 $ 630.00 INLAY PROCELAIN - 2 SURFACE D2620 $ 665.00 INLAY PROCELAIN - 2 SURFACES D2620 $ 665.00 Inlay-metallic-one surface D2510 $ 630.00 Inlay-porcel/ceramic-1 surface D2610 $ 630.00 INNOMED EXTRACTION C1713 $ 1,200.00 INORGANIC PHOSPHORUS 84100 $ 12.87 INPATIENT OBSERVATION $ 198.00 INPERSOL SET W DRAINAGE-CATEG 1 Acquisition cost INS ANT SEGMNT DFRAIN INTRNL 0191T $ 9,548.90 INS BLADDER CATH COMPLEX; TEMP 51703 $ 360.51 INS CANNULA-HEMODIAL; AV 36815 $ 11,279.00 INS CATH RENAL ART 2ND+ ORDER; BILAT 36254 $ 6,592.23 INS CATH RENAL ART; UNILAT; 2ND ORD 36253 $ 11,279.00 INS CATH RENAL ARTERY; UNILAT; 1ST ORD 36251 $ 6,592.23 INS CATH; RENAL ARTERY; BILATERAL 36252 $ 6,592.23 INS CLONIDINE HYDROCHLORIDE 1 MG J0735 $ 0.24 INS DEV PERQ ABD/PLVC, RAD TX 49411 $ 3,138.26 INS IMPL INTRA-ARTERY 36260 $ 11,279.00 INS MESH REP PELVIC FLOOR DEFCT, VAG APP 57267 $ 551.78 INS MULTI-COMPONENT PENIS PROSTH 54405 $ 41,514.09 INS NASAL SEPTAL PROSTH (BUTTON) 30220 $ 3,010.00 INS NONTUNNL CV CATH; 5+ YRS 36556 $ 2,599.54 INS OR REPL OF TEMP PACEMAKER 33210 $ 19,493.14 INS PENILE PROSTH; INFLATABLE 54401 $ 41,514.09 INS PERIPH CVAD; SUBQ PORT, AGE 5/< 36571 $ 6,592.23 INS PICC, AGE 5 YRS/> 36569 $ 2,599.54 INS PICVAD CATH; <5 YRS 36570 $ 6,592.23 INS PRELOADED IOL INJ SYS C1780 $ 202.50 INS SPINE FIX DEVICE; 2-3 SEGMNTS 22845 $ 1,549.04 INS SQ RSVR/PUMP/INFUS TO VENTR CATH 61215 $ 12,238.01 Page 160 2018 INS SUBQ IMPLNTABL DEFIB ELECTRD 33271 $ 19,493.14 INS TEMP BLADDER CATH; SIMPLE 51702 $ 277.79 INS TUN IP CATH; PERQ 49418 $ 7,698.79 INS TUN IP CATH; W PORT 49419 $ 11,279.00 INS TUNNELD CVAD W SUBQ PORT 36563 $ 11,279.00 INS TUNNELED CV CATH AGE/> 36558 $ 6,592.23 INS TUNNELED CV CATH; AGE 5 & OLDER 36558 $ 6,592.23 INS TUNNELED CVAD W PORT AGE 5YR/> 36561 $ 6,592.23 INS TUNNELED CVAD W SUBQ PORT; AGE 5/< 36561 $ 6,592.23 INS TUNNLD CV CATH W SQ PORT; <5YRS 36560 $ 6,592.23 INS VAG BRACHYTX DEVICE 57156 $ 709.68 INS/REDO PERIPH/GASTRIC NS PG/RCVR 64590 $ 48,577.94 INS/RP PM PCMK W/TRNSVNS ATRIL 33206 $ 25,779.29 INS/RP PM PCMK W/TRNSVNS VNTRI 33207 $ 25,779.29 INS/RP PM PCMK W/TV ATRIL/VNTR 33208 $ 25,779.29 INS/RP/REPOS PERMTRNSV SING CH 33216 $ 19,493.14 INSERT ADULT-CATEG 1 Acquisition cost INSERT ART & VEIN CANNULA 36823 $ 2,973.50 INSERT BLADDER CATH 51701 $ 277.79 INSERT CERVICAL DILATOR 59200 $ 709.68 INSERT DRUG IMPLANT 11981 $ 277.79 INSERT EXT AV CANNULA 36810 $ 6,592.23 INSERT FLOW DIR CATH 93503 $ 2,599.54 INSERT FOLEY CATH 51702 $ 277.79 INSERT FOLEY CATH, TEMP 51702 $ 277.79 INSERT IUD 58300 $ 91.63 INSERT JUNIOR-CATEG 1 Acquisition cost INSERT LEVONORGESTREL RELEAS INTRAUTRN S4981 $ 128.68 INSERT NON-TUNNEL<5 YRS 36555 $ 2,599.54 INSERT OF PERMNT PACEMAKER, DUAL CHAMB 33208 $ 25,779.29 INSERT OF PERMNT PACEMAKER, VENTRICULAR 33207 $ 25,779.29 INSERT OI 2'; AFTER ENUCL WO MUSCL ATT 65135 $ 7,805.64 INSERT PICC CATH 36568 $ 1,619.99 INSERT PLEURAL CATH W CUFF 32550 $ 7,698.79 INSERT POLY-CATEG 1 Acquisition cost INSERT TEMP TV ELECTRODE 33210 $ 19,493.14 INSERT TESTICULAR PROSTHESIS 54660 $ 9,800.87 INSERT TUNNEL CV CATH (2) W SQ PORT 36566 $ 11,279.00 INSERT UTERI TANDEM/OVOIDS 57155 $ 6,010.51 INSERT-CATEG 1 Acquisition cost INSERT-CATEG 2 Acquisition cost INSERTER IN-FAST-CATEG 1 Acquisition cost INSERTER/EXTRACTOR FEM. STEM Acquisition cost INSERTION DRAINAGE CATHETER 49421 $ 7,698.79 INSERTION INTRA-AORTIC BALLOON 33967 $ 556.58 INSERTION OF CENTRAL VENOUS CATHETER 36556 $ 2,599.54 INSERTION OF LCD PULSE GENERAT 33249 $ 81,881.71 INSERTION OF PERIPHERAL VENOUS CATHETER 36569 $ 2,599.54 INSJ BIOMECHANICAL DEVICE 22853 $ 536.93 INSPAN INTERSPINOUS PLATE C1713 $ 5,124.00 INSPAN SLIM 12MM C1713 $ 4,800.00 INSRT / PLCMT FLO DIREC CATH-MONITR 93503 $ 2,599.54 INSRT ANT DRAINAGE DEVICE 66183 $ 9,548.90 INSRT CERV DILAT (SEPART PROC) 59200 $ 709.68 INSRT DEV FOR RAD TX GUIDE; PERQ 32553 $ 3,138.26 INSRT GFT AORTA/GT VES;WO SHNT/BYPS 33330 $ 3,057.91 Page 161 2018 INSRT HEPATIC SHUNT (TIPS) 37182 $ 1,824.09 INSRT IMPLNT CONTRACEPTIVE CAPSULES 11981 $ 277.79 INSRT 58300 $ 91.63 INSRT TUNN CV 2XCATH W SQ PORT 36566 $ 11,279.00 INSRT VEN ACCESS DEV W/WO RESVOIR 36565 $ 6,592.23 INSRT VEN ACCS DEV W/WO RESVOIR 36565 $ 6,592.23 INSRT VENA CAVA FILTR; ENDOVASC 37191 $ 11,279.00 INSRT/ REP PCEMKR SINGL CHAMBR 33212 $ 19,493.14 INSRT/REP PCEMKR DUAL CHAMBER 33213 $ 25,779.29 INSTRUMENT SUCTION FRAZIER-CATEG 1 Acquisition cost INSUFFLATOR TUB HFLOW W/SWIVEL A4624 $ 320.03 INSULIN 83525 $ 31.04 INSULIN 70/30, HUMAN RECOM 100 UNIT J1815 Acquisition cost INSULIN ANTIBODIES 86337 $ 58.15 INSULIN ASPART 100U/ML (NOVOLOG) INS INJ J1815 Acquisition cost INSULIN DETEMIR J1815 Acquisition cost INSULIN DRIP REGULAR IV Acquisition cost INSULIN FOR ADMIN THRU DME 50 UNITS J1817 $ 31.24 INSULIN GLARGINE (SOLOSTAR) 3ML. Acquisition cost INSULIN GLARGINE 100 UNITS INJ J1815 Acquisition cost INSULIN GLULISINE (APIDRA) Acquisition cost INSULIN L, HUMAN RECOM 100 UNIT J1815 Acquisition cost INSULIN LISPRO 100UNIT/ML J1815 Acquisition cost INSULIN NPH (HUMULIN) 5U/ML J1815 Acquisition cost INSULIN NPH, HUMAN RECOM 100 UNIT J1815 Acquisition cost INSULIN NPH/REG 70/30, PER 5 UNITS J1815 Acquisition cost INSULIN REG. RECMB. IV DRIP, PER 5 UNITS J1815 Acquisition cost INSULIN REGULAR 500 UNITS/ML J1815 Acquisition cost INSULIN REGULAR HUMAN INJ J1815 Acquisition cost INSULIN REGULAR PER 5 UNITS J1815 Acquisition cost INSULIN TOLERANCE 83525 $ 31.04 INSULIN U, HUMAN RECOM 100 UNIT J1815 Acquisition cost INSULIN, HUMAN L INJ Acquisition cost INT LIGAT HEMORRHOID(S);W RUB 46221 $ 1,877.59 INT OFF/OP VISIT E/M 10MN 99201 $ 300.00 INT OFF/OP VISIT E/M 20MN 99202 $ 315.00 INT OFF/OP VISIT E/M 30MN 99203 $ 343.00 INT OFF/OP VISIT E/M 45MN 99204 $ 370.00 INT OFF/OP VISIT E/M 60MN 99205 $ 398.00 Int root repair of perf defects D3333 $ 214.00 INT WND REP N/H/F/G; 12.6-20 CM 12045 $ 1,291.09 INTAL INHALER 8.1GM Acquisition cost INTAL NEBU SOL 2ML J7631 Acquisition cost INTEGRILIN 0.75MG/ML J1327 Acquisition cost INTEGRILIN 2MG/ML J1327 Acquisition cost INTENSIVE CARE UNIT (ICU) $ 3,375.00 INTENSIVE OUTPT PSYCH PER DAY 90837 $ 290.00 INTENSTY MODUL RADIOTHRPY-TREATMENT PLAN 77301 $ 3,138.26 Intentional replant, inc splint D3470 $ 1,043.00 INTER HLTH/BEHAV, FAM W/PT 96154 $ 275.00 INTERBODY PLATE 7MM C1713 $ 1,425.00 INTERCARPAL FUSION; W AUTOGRAFT 25825 $ 14,826.61 INTERCEPTIVE ORTHODONTIC TRMT PRMY DENT D8050 $ 5,880.00 INTERCOSTAL NERVE SINGLE BLOCK 64420 $ 1,437.02 INTERCOSTAL NRV MULTI REGN BLK 64421 $ 1,777.62 INTERCOSTAL NRV MULTP REGN BLK 64421 $ 1,777.62 Page 162 2018 INTERF B-1A/ALB 44MCG/0.5ML PFS Acquisition cost INTERFERENCE SCREW 9x23 C1713 $ 346.50 INTERFERON BETA-1B 0.3MG SQ J1830 Acquisition cost INTERFERON ALF-2B REC 3 MILLION UNIT J9214 Acquisition cost INTERFERON ALFA-2B RECOMBINANT J9214 Acquisition cost INTERFERON, GAMMA 1-B, 3 MILL J9216 $ 4,469.52 INTERFERON,ALFA 2-A,RECOM,3MIL J9213 $ 80.78 INTERFERON,ALFA 2-B,RECOM,1MIL J9214 $ 75.63 INTERGT EVAL INPER LEADLS PM 0391T $ 99.81 INTERIM - MANDIBULAR (FLIPPER) D5821 $ 578.00 INTERIM - MAXILLARY (FLIPPER) D5820 $ 545.00 Interim comp denture (mand) D5811 $ 757.00 Interim comp denture (maxil) D5810 $ 704.00 INTERLOCK BOW IM STEM W/SCREW C1713 $ 2,001.00 INTERLOCK BOWED IM STEM W/SCREW C1776 $ 2,001.00 INTERMD REP WND F/E/E/N/L/MM; 12.6-20CM 12055 $ 821.94 INTERMD WND REP FACE/MM; 2.5CM/> 12051 $ 821.94 INTERMD WND REP FACE/MM; 2.6-5.0CM 12052 $ 821.94 INTERMED WND REP; S/A/T/EXTRM; 12.6-20CM 12035 $ 821.94 Internal bleaching-per tooth D9974 $ 242.00 INTERNAL PADDLES $ 125.40 INTERP + RPT OF FNA 88173 $ 118.21 INTERPHALANG TOE JNTEXC; EA 28160 $ 6,995.52 INTERRGTE DEV EVAL; IMPLT SUBQ DEFIB SYS 93261 $ 99.81 INTERST COLLOID RPHARM RX 79300 $ 630.67 INTERSTITIAL RAD SOURCE APPLIC; COMPLX 77778 $ 1,888.52 INTERV FAM W/O PT 15 MIN 96155 Acquisition cost INTERVENE HLTH/BEHAV, GROUP 96153 $ 72.67 INTERVENE HLTH/BEHAV, INDIV 96152 $ 275.00 INTILL TX AGENT; RENAL/PLVS/URETER TUB 50391 $ 607.00 INTMD WND REP F/E/N/E/L/MM 20.1-30CM 12056 $ 821.94 INTMD WND REP FACE/MM; 2.6-5 CM 12052 $ 821.94 INTMD WND REP N/H/F/G; 2.5 CM/> 12041 $ 821.94 INTMD WND REP S/A/TR/EX; 7.6-12.5 CM 12034 $ 821.94 INTMD WND REP; N/H/F/G 12.6-20.0CM 12045 $ 1,291.09 INTMD WND REP; S/A/T/EXT 12036 $ 1,291.09 INTMD WND REPAIR FACE MM 12.6-20.0 CM 12055 $ 821.94 INTMD WOUND REP FACE/MM; 2.5 CM/> 12051 $ 821.94 INTMD WOUND REP N/H/F/G; 7.6-12.5 CM 12044 $ 1,291.09 INTMD WOUND REP S/A/TR/EXT; 2.5 CM/> 12031 $ 821.94 INTR NEEDLE/INTRACATH; EXT ART 36140 $ 195.01 INTR NEEDLE/INTRACATHETER VEIN 36000 $ 44.00 INTRA ABDOMINAL VOIDING PRESSU 51797 $ 88.48 INTRA AORT BALLOON PUMP CATH 7.5FR C1727 $ 1,312.50 INTRA AORTIC BALLOON CATH KIT 8FR/34CC Acquisition cost INTRA AORTIC BALLOON CATH KIT 8FR/40CC Acquisition cost INTRA AORTIC BALLOON CATHETER Acquisition cost INTRA ARTICULAR RPHARM RX 79440 $ 630.67 INTRACAVITARY RAD SOURCE APPLIC; COMPLX 77763 $ 1,888.52 INTRACAVITARY RAD SOURCE APPLIC; SIMPL 77761 $ 1,381.29 INTRACAVITARY RADIOACTIVE COLLOID THERAP 79200 $ 630.67 INTRADERM TEST; ALLERGY TITRATE AIRBORN 95027 $ 46.20 INTRAFIX SCREW C1713 $ 483.00 INTRALESIONAL INJ <=7 11900 $ 446.80 INTRALESIONAL INJECT <=7 11900 $ 446.80 INTRALIPIDS 20% NICU SYR Acquisition cost Page 163 2018 INTRALSIONAL INJ <=7 11900 $ 446.80 INTRALUMINAL DILAT STRICT-RAD S / I 74360 $ 60.92 INTRAMURAL CAUTERY OF TURBINATES 30802 $ 3,010.00 INTRANASAL LIVE FLU VACCINE 90660 $ 56.96 INTRAOP ID SENTNEL LYMPH NODE, ADD-ON 38900 $ 293.52 INTRAOP NEURO MONITOR REMOTE; 1< PAT/HR 95941 Acquisition cost INTRAOPERATIVE ULTRASOUND 76998 $ 134.75 INTRAOPERATIVE MONITORING Acquisition cost INTRAORAL IMAGES D0350 $ 70.00 INTRAQ W/ALLERG EXTRCT-SPEC # TES 95024 $ 147.99 INTRAUTERINE COPPER CONTRACEPTIVE J7300 $ 756.80 INTRAUTERINE CORDOCENTESIS 59012 $ 709.68 INTRAUTERINE TRANSFUSION, FETAL 36460 $ 991.89 INTRAVASCULAR ULTRASOUND, NON- 37252 $ 196.57 INTRAVASCULAR US NON- EACH ADDTNL 37253 $ 158.00 INTRAVEN MOD(CONS) SED/ANAL-EA 15MIN D9243 $ 182.00 INTRAVENOUS INJ 96374 $ 505.36 INTRAVENOUS INJECTION 96374 $ 505.36 INTRAVITREAL INJ PHARMACOLOGIC AGT 67028 $ 786.94 INTRAVITREAL INJECTION OF DRUG 67028 $ 786.94 INTRCAV RAD SOURCE APPLIC; INTERMED 77762 $ 1,381.29 INTRCPT ORTHDONTIC TX TRNSTNL DENTITION D8060 $ 2,100.00 INTRINSIC FACTOR AB 86340 $ 40.94 INTRINSIC FACTOR ABS 86340 $ 40.94 INTRMED TRNSFR PEDICLE FLAP 15650 $ 4,147.84 INTRNL NEURLYSIS W OP MICROSCOPE; ADDON 64727 $ 395.30 INTRO CATH AORTA 36200 $ 299.86 INTRO CATH DIALYSIS CIRCUIT 36901 $ 1,619.99 INTRO CATH DIALYSIS CIRCUIT 36902 $ 13,447.68 INTRO CATH IN VEIN 36000 $ 44.00 INTRO CATH RT HEART/MAIN PULM ART 36013 $ 267.61 INTRO CATH SUPER/INFERIOR VENA 36010 $ 237.78 INTRO INTRACATH-RENAL PELVIS-DRAIN 50432 $ 4,484.35 INTRO LONG GI TUBE (SEPART PRO 44500 $ 1,966.21 INTRO LONG GI TUBE W/MX FILMS-S / I 74340 $ 59.22 INTRO NEEDLE/AORTIC TRANSLUMBAR 36160 $ 271.94 INTRO NEEDLE/INTRACATH CAROTID ART 36100 $ 331.69 INTRO NEEDLE/INTRACATHETER; EXTREM ART 36140 $ 195.01 INTRO NEEDLE/INTRACATHETER-VEIN 36000 $ 44.00 INTROD SHEATH 7FR GWIRE C1887 $ 171.75 INTRODUCER BRITE TIP-CATEG 1 C1713 Acquisition cost INTRODUCER CHECK-FLO-CATEG 1 C1729 Acquisition cost INTRODUCER COAX MICROPNCTR-CATEG 1 Acquisition cost INTRODUCER KIT 7F C1894 $ 75.00 INTRODUCER SET C1894 $ 29.36 INTRODUCER SET-CATEG 1 Acquisition cost INTRODUCER SHEATH PINNACLE-CATEG 1 Acquisition cost INTRODUCER SHEATH W/O WIRE-CATEG 1 Acquisition cost INTRODUCER SHEATH-CATEG 1 Acquisition cost INTRODUCER SHEATH-CATEG 2 Acquisition cost INTRODUCER W/O WIRE-CATEG 1 C1894 Acquisition cost INTRODUCER-CATEG 1 Acquisition cost INTRODUCER-CATEG 2 Acquisition cost INTRO-GUIDE-RENAL PELVIS W/DILAT 50395 $ 7,131.78 INTRON A 5MMU VIAL J9214 Acquisition cost INTROPIN 200MG/5ML INJ 5ML Acquisition cost Page 164 2018 INTUBAT ENDOTRACH EMERG PROC 31500 $ 472.05 INTUBATION ENDOTRACHEAL EMER PROC 31500 $ 472.05 INVANCE MALE COAT SLING SYS C1771 $ 6,150.00 INVANCE MALE COAT SLING SYSTEM C1751 $ 6,150.00 Invanz 1 Gm. Addvantage vials Injection Acquisition cost INVANZ 1 GM. INJECTION Acquisition cost INVEGA 117MG J2426 $ 3,302.44 INVEGA 156MG J2426 $ 4,403.26 INVEGA 234MG J2426 $ 6,604.88 INVEGA 39MG J2426 $ 1,100.81 INVEGA 78MG J2426 $ 2,201.63 INVEGA SUSTENNA 117MG. INJ. J2426 Acquisition cost INVEGA SUSTENNA 156 MG INJ. J2426 Acquisition cost INVEGA SUSTENNA 234MG INJ J2426 Acquisition cost INVEGA SUSTENNA 39MG INJ J2426 Acquisition cost INVEGA SUSTENNA 78MG INJ J2426 Acquisition cost INVEGA SUSTENNA, PER 1MG J2426 $ 28.23 INVENZ INJECTION Acquisition cost IO ANAL GAST N-STIM SUBSQ 95981 $ 277.79 IO GA N-STIM SUBSQ W/REPROG 95982 $ 99.81 IOBAN-CATEG 1 Acquisition cost IOBAN-CATEG 2 Acquisition cost IOBAN-CATEG 3 Acquisition cost IODIXANOL (VISIPAQUE) 320MG/100ML Acquisition cost IODIXANOL 270MG/ML 100ML BOT. Acquisition cost IOHEXOL (Omnipaque) 100ml. 240mg. Acquisition cost IOHEXOL (OMNIPAQUE) 240MG/50ML Q9966 Acquisition cost IOHEXOL (OMNIPAQUE) 350MG/100ML Acquisition cost IOHEXOL (OMNIPAQUE) 350MG/150ML Acquisition cost IOHEXOL (OMNIPAQUE) 350MG/500ML Acquisition cost IOHEXOL 180MG/ML 20ML Acquisition cost IOHEXOL 240MG/ML 10ML SYR Acquisition cost IOHEXOL 240MG/ML 20ML Acquisition cost IOHEXOL 240MG/ML INFUS 50ML Acquisition cost IOHEXOL 300MG/ML 150ML Acquisition cost IOHEXOL 300MG/ML 50ML Acquisition cost IOHEXOL 350MG/ML 50ML Acquisition cost IOL 19.5 DIAMETER V2630 $ 202.50 IOL 6.0MM x 13MM V2632 $ 202.50 IOL 6.5MM BICONVEX 14.0MM C1780 $ 202.50 IOL 6.5MM x 14MM V2632 $ 202.50 IOL 6MMx13MM BICONVEX V2632 $ 202.50 IOL CONVEXPLANO 6MMx13.5MM V2632 $ 202.50 IOL POSTERIOR CHAMBER LENS V2632 $ 202.50 IONIZED CA SERUM 82330 $ 37.14 IONIZED CA++ 82330 $ 37.14 IONIZED CALCIUM 82330 $ 37.14 IONIZED MAGNESIUM 83735 $ 18.19 IONTOPHORESIS, EA 15 MIN. 97033 $ 45.14 IOPIDINE 0.5% OPTH DROPS 5ML Acquisition cost IOPIDINE 1% OPTH DROPS 1ML Acquisition cost IOVERSOL 240MG/ML 50ML IV Acquisition cost IOVERSOL 300MG/ML 100ML IV Acquisition cost IOXAGLATE (HEXABRIX) 20ML VIAL Acquisition cost IP ACOUSTIC REFLEX TESTING 92568 $ 84.11 IP APPLIC MDL 1/> AREA; VASOPNEUM DEV 97016 $ 34.30 Page 165 2018 IP APPLIC MDL 1/> AREAS ELEC STM-UNATTND 97014 $ 34.72 IP APPLIC MDL 1/> AREAS ULTRASOUND-15 MN 97035 $ 29.15 IP APPLIC MDL 1/> AREAS; PARAFFIN BATH 97018 $ 18.77 IP APPLIC MDL 1/> AREAS; TRACTION 97012 $ 32.32 IP APPLIC MDL 1/> AREAS; WHIRLPOOL 97022 $ 41.03 IP APPLIC MDL 1/> AREASELC STM-MAN-15 MN 97032 $ 33.81 IP APPLIC MDL 1/> AREASUNLSTD MDLTY-15MN 97036 $ 76.82 IP APPLICATION SURFACE TENS 64550 $ 38.81 IP AUD EVOKD POTNT // TEST CNS; COMP 92585 $ 658.04 IP COMP AUDIOMETRY THRESHOLD EVAL 92557 $ 360.51 IP EVOKED OTOACOUSTIC EMISSNS; COMP/DX 92588 $ 658.04 IP HAND WO COMPARISON TO NORMAL SIDE 95852 $ 39.27 IP JNT ARTHROPLASTY; EACH 26535 $ 6,995.52 IP MAN THER TECH-1/> MYOFASIAL RELEASE 97140 $ 60.85 IP MANUAL THERAPY TECH-1/> REGIONS 97140 $ 60.85 IP ORTHOT FIT/TRN UP LOW//TRUNK; 15 MN 97760 $ 101.49 IP PHYSICAL THERAPY EVALUATION 97001 $ 186.43 IP PHYSICAL THERAPY RE-EVALUATION 97002 $ 104.02 IP PROSTH TRAIN-UP //LOW EXTREM; 15 MN 97761 $ 87.93 IP ROM. EACH EXTREMITY EXCLUDING HANDS 95851 $ 43.23 IP THERAP 1/> AREA; BLNC/COORD/FLX-15 MN 97112 $ 75.90 IP THERAP 1/> AREAS/; EXERCISE-15 MN 97110 $ 66.68 IP THERAP 1/> AREAS/; GAIT TRNG-15 MN 97116 $ 65.93 IP THERAP PROC 1/> AREAS; MASSAGE-15MN 97124 $ 66.57 IP TOTAL BODY EVALUATION 95834 $ 117.13 IP TYMPANOMETRY 92567 $ 84.11 IPECAC ADMIN-EMESIS&OBS 99175 $ 228.00 IPECAC SYRUP 30ML Acquisition cost IPOL POLIOVIRUS VACCINE INJ 90713 Acquisition cost IPPB TX AIR/02; INIT DEMO/EVAL 94640 $ 492.89 IPPB TX AIR/O2 W/WO NEBULIZ MED; SUBSQT 94640 $ 492.89 IPPB, NEWBORN 94640 $ 492.89 IPPE; NEW BENEFICIARY MCARE ON G0402 $ 300.65 IPRATOPION NASAL Acquisition cost IPRATROPIUM 0.06% NASAL SOLUTION 15 ML Acquisition cost IPRATROPIUM 0.06% NASAL SOLUTION 5 ML Acquisition cost IPRATROPIUM HFA INHALER J3535 Acquisition cost IPRATRPIUM BROMIDE INHALATION SOL 0.02% J7645 $ 1.67 IQ STENT ON OPTA LP 5FR 5MMX5 Acquisition cost IRBESARTAN 150MG TAB Acquisition cost IRBESARTAN 150MG. PO Acquisition cost IRIDECTOMY; SECTOR FOR GLAUCOMA 66630 $ 5,080.46 IRIDOCTOMY/IRIDECTOMY 66761 $ 1,290.50 IRIDOPLASTY 66762 $ 1,290.50 IRIDOPLASTY BY PHOTOCOAGULATION 66762 $ 1,290.50 IRIDOPLASTY W SUTURE 66682 $ 5,080.46 IRIDOTOMY STAB INC; NO TRANSFIX 66500 $ 5,080.46 IRIDOTOMY/IRIDECTOMY BY LASER SURG 66761 $ 1,290.50 IRINOTECAN HCL 20MG/ML 5ML J9206 Acquisition cost IRINOTECAN, 20 MG J9206 $ 33.00 IRON 83540 $ 17.58 IRON BIND. CAPACITY 83550 $ 23.74 IRON BINDING CAPACITY TOTAL 83550 $ 23.74 IRON POLSAC 150MG CAP (FORTE) Acquisition cost IRON STAIN 85536 $ 17.56 IRON SUCROSE 100MG/100ML NS PREMIX J1756 $ 0.10 Page 166 2018 IRON SUCROSE 200MG/100ML NS PREMIX J1756 $ 0.10 IRON SUCROSE 200MG/10ML VIAL J1756 $ 0.10 IRON SUCROSE CMPLX 20MG/ML IV J1756 Acquisition cost IRRAD PLATELET CONCENTRATE 86945 $ 84.11 IRRAD WHL PKD & PHER PRODUCTS 86945 $ 84.11 IRRADIATEBLOODCOMPONENT 86945 $ 84.11 IRRG BULB SYR TRAY A4320 $ 1.44 IRRG PIST SYR TRAY A4320 $ 0.44 IRRIG DEVICE 96523 $ 149.91 IRRIGATE CRPRA CAVRNSA PRIAPISM 54220 $ 607.00 IRRIGATE VAG W MEDS 57150 $ 277.79 IRRIGATION CANNULA 19GA A4615 $ 25.50 IRRIGATION OF VAGINA/MED TREAT 57150 $ 277.79 ISCHMC LMB EXRCS TST W SRL SPCM ACQ MUSC 95875 $ 360.51 ISLAND PEDICLE FLAP 15740 $ 4,147.84 ISOCARBOXAZID 10MG TAB Acquisition cost ISOFLURANE 100ML Acquisition cost ISOKINETIC EXERCISE 97139 $ 136.00 ISONIAZID 100MG TABLET U-D Acquisition cost ISONIAZID 100MG/ML INJ Acquisition cost ISONIAZID 300MG TABLET U-D Acquisition cost ISONIAZID 50MG/5ML SYRUP 480ML Acquisition cost ISOPROPANOL LEVEL 84600 $ 43.67 ISOPROPYL RUBBING ALCOHOL 70% Acquisition cost ISOPROTERENOL 0.2MG/ML INJ 1ML Acquisition cost ISOPROTERENOL 0.2MG/ML INJ 5ML Acquisition cost ISOPROTERENOL INHALER 15ML J7658 Acquisition cost ISOPTO ATROPINE 0.5% OPTH Acquisition cost ISOPTO CARBACHOL 3% OPTH 15ML Acquisition cost ISOPTO HOMATROPINE 2% OPTH 5M Acquisition cost ISOPTO HOMATROPINE 5% OPTH 5ML Acquisition cost ISOPTO HYOSCINE 0.25% OPTH5ML Acquisition cost ISOPTO HYSCINE 0.25% $ 1.91 ISOSORBIDE DINIT 2.5MG SUB LING Acquisition cost ISOSORBIDE DINITR 10MG TAB Acquisition cost ISOSORBIDE DINITR 5MG TAB Acquisition cost ISOSORBIDE DINITRATE 20MG. PO Acquisition cost ISOSORBIDE MONONITRATE 120MG Acquisition cost ISOSORBIDE MONONITRATE 30MG Acquisition cost ISOSORBIDE MONONITRATE 60MG TAB Acquisition cost ISOSORBIDE/HYDRALAZINE 20/37.5 MG. Acquisition cost ISOSULFAN BLUE 1% INJ Q9968 Acquisition cost ISOTRETINOIN 10MG CAP Acquisition cost ISOTRETINOIN 20MG CAP Acquisition cost ISOTRETINOIN 40MG CAP Acquisition cost ISRADIPINE 1MG/ML NICU CH SYR Acquisition cost ISRADIPINE (DYNACIRC ) 5 MG. PO Acquisition cost I-STOP FEMALE SLING C1771 $ 1,042.50 ITRACONAZOLE 100MG CAP Acquisition cost ITRACONAZOLE 10MG/ML KIT Acquisition cost ITRACONAZOLE 10MG/ML ORAL SOL Acquisition cost IUD SUPPLY (MIRENA) J7298 $ 1,959.73 IUD SUPPLY (PARAGARD) J7300 $ 756.80 IV CORONARY THROMBOLYSIS 92977 $ 786.94 IV DOPPLER; EA ADD'L VESSEL 93572 $ 165.33 IV DOPPLER; INITIAL VESSEL 93571 $ 205.70 Page 167 2018 IV INFUS THERAPY/DX-BY PHYS;EA HR-8 96366 $ 82.72 IV INFUS THERAPY/DX-BY PHYS;TO 1 HR 96365 $ 505.36 IV INFUS TX, ONE HR 96365 $ 505.36 IV INFUS TX-1 HOUR 96360 $ 505.36 IV INFUS TX-1 HR 96360 $ 505.36 IV INFUS TX-EA ADDL HR 96361 $ 97.92 IV INFUS TX-ONE HOUR 96365 $ 505.36 IV INFUSION TX-1 HR 96360 $ 505.36 IV INFUSION TX-EA ADDL HOUR 96361 $ 97.92 IV INFUSION TX-EA ADDL HR 96361 $ 97.92 IV INJECT 96374 $ 505.36 IV INJECTION 96374 $ 505.36 IV PUSH (SAME MEDICATION) 96376 $ 144.76 IV PUSH NEW MEDICATION 96375 $ 97.92 IV US CORONARY VES; EA ADDL 92979 $ 165.33 IV US CORONARY VES; INITIAL 92978 $ 205.70 IVERMECTIN 3MG TAB PO Acquisition cost J WIRE .038 150CM 2/BX* C1713 $ 183.12 JAK2 MUTATIONQPANEL Acquisition cost JANUVIA 100 MG. PO Acquisition cost JANUVIA 25 MG. PO Acquisition cost JANUVIA 25MG Acquisition cost JAPANESE ENCEPHALITIS VACCINE 90738 Acquisition cost JC VIRUS BY PCR 87798 $ 95.33 JEJUNOSTOMY CATH 12FR PED C1725 $ 209.33 JETSTREAM G3 SF 1.85 CATH C1724 $ 4,950.00 JETSTREAM NAVITUS L CATH C1724 $ 4,950.00 JOINT MOBILIZATION, 1 UNIT 97140 $ 60.85 JOINT MOBILIZATION, EA 15 MIN. 97140 $ 60.85 Joint reconstruction D7858 $ 15,191.00 JOURNEY BCS ARTICU INSRT RGHT C1713 $ 1,425.00 JOURNEY BCS SIZE 4,FEMORAL C1713 $ 4,425.00 JOURNEY GW 0.014x300CM STRAIGHT C1769 $ 313.50 JT SURVEY SNGL VIEW 1/MORE JT 77077 $ 302.70 JUDKINS LEFT CORONARY-CATEG 1 Acquisition cost JUGGERKNOT SZ2 ANCHR SNGLELOAD C1713 $ 394.50 JUVEDERM ULTRA J3490 $ 211.50 K WIRE C1713 $ 179.78 K WIRE 0.9MM C1713 $ 61.50 K WIRE 1.2MM C1713 $ 15.00 K WIRE 1.6MM C1713 $ 179.78 K WIRE 2.0x228MM C1713 $ 15.00 K WIRE 2.5x270MM C1713 $ 240.00 K WIRE 3.2x450MM C1713 $ 179.78 K- WIRE 4X.062 DOUBLE TROCAR C1713 $ 22.50 K WIRE VARIOUS SIZE C1713 $ 15.00 K WIRES C1713 $ 43.05 K WIRES .028"DX6"L DBLE TROCAR C1713 $ 5.94 K WIRES .035 DOUBLE TROCAR C1713 $ 5.94 K WIRES 6" DOUBLE TROCAR .062 C1713 $ 5.94 K WIRES SMOOTH C1713 $ 6.20 K/L RATIO 82784 $ 25.26 KAFO 1 UPRT SOLID STIRUP CSTM L2000 $ 2,288.00 KAFO FEM FX CAST THERMOPLSTC CSTM F L2126 $ 2,473.90 KANAMYCIN LEVEL $ 60.85 KANAMYCIN SULF 1GM/3ML INJ J1840 Acquisition cost Page 168 2018 KANAMYCIN SULF 500MG/2ML INJ J1840 Acquisition cost KAOLIN-PECTIN SUSPENSION Acquisition cost KAOPECTATE Acquisition cost KAOPECTATE ORAL SUSP 180ML Acquisition cost KAYEXALATE SUSP 15GM/60ML 60ML Acquisition cost KAYPLAST-CATEG 1 Acquisition cost K-B STAIN FOR FETAL HGB 85460 $ 21.01 KCENTRA (PCC) 1000 UNIT VIAL Acquisition cost KCENTRA (PCC) 500 UNIT VIAL Acquisition cost KCL 20 MEQ/ 1000 ML 1/2 NS J3480 Acquisition cost KCL 20MEQ/10ML INJ 10ML VIAL J3480 Acquisition cost KCL 20MEQ/15ML ORAL LIQUID Acquisition cost KCL ORAL SYRINGE Acquisition cost K-DUR/MICRO-K 10MEQ TAB/CAP Acquisition cost KEFLEX 500MG CAP Acquisition cost KELLER/MCBRIDE/MAYO BUNION CORRECT 28292 $ 6,995.52 KENALOG/ARISTOCORT 0.025% 15G Acquisition cost KENALOG/ARISTOCORT 0.025% 15GM Acquisition cost KENALOG/ARISTOCORT 0.5% 15GM Acquisition cost KENALOG/ARISTOCORT 0.5% 15GM Acquisition cost KEOFEED TUB 9FR $ 21.00 KEPPRA 1000 MG PO (SCC ONLY) Acquisition cost KEPPRA 1000mg/100ml IV SOLUTION J1953 Acquisition cost KEPPRA 1500mg/100ML IV SOLUTION Acquisition cost KERATOPROTHESIS 7.2MM LENSE WIDE FIELD C1818 $ 600.00 KERATOPROTHESIS 8.2MM WIDE FIELD LENSE C1818 $ 600.00 KERLIX SPNG STRL 2'S $ 0.59 KETALAR 10MG/ML INJ 20ML Acquisition cost KETAMINE 100MG/10ML INJ. Acquisition cost KETAMINE 500MG/10ML J3490 $ 29.04 KETAMINE 50MG/ML Acquisition cost KETOCONAZOLE 2% CREAM 15GM Acquisition cost KETOCONAZOLE 2% SHAMPOO Acquisition cost KETOCONAZOLE 200MG TB Acquisition cost KETOCONAZOLE LEVEL $ 180.31 KETOCONAZOLE LEVEL PEAK $ 180.31 KETOCONAZOLE LEVEL TROUGH $ 180.31 KETOCONAZOLE ORAL SOL Acquisition cost KETONE (ACETONE) 82009 $ 12.28 KETOROLAC 0.4% OPHTHALMIC DROPS Acquisition cost KETOROLAC 0.5 % J3490 $ 107.21 KETOROLAC 0.5% EYE DROP Acquisition cost KETOROLAC 10MG TAB Acquisition cost KETOROLAC 15MG/ML INJ J1885 Acquisition cost KETOROLAC 30 MG INJ. J1885 $ 7.59 KETOROLAC 30MG/ML INJ J1885 Acquisition cost KETOROLAC INJ 60MG.2ML J1885 Acquisition cost KETROLAC 0.45% EYE DROP Acquisition cost KEYSTONE HIP BODY 16.5MM C1776 $ 7,804.50 KIDNEY FLOW / FUNCTION, MULTIPLE W/ACEI 78709 $ 1,198.21 KIDNEY FLOW / FUNCTION, SINGLE W /DRUG 78708 $ 1,198.21 KIDNEY FLOW / FUNCTION, SINGLE W/O DRUG 78707 $ 1,198.21 KIDNEY FUNT NON-IMAGE RADIOISOTOPIC 78725 $ 924.11 KIDNEY IMAGING, (3D) 78710 $ 1,198.21 KIDNEY IMAGING, STATIC (GHA) 78700 $ 924.11 KIDNEY IMAGING; W/VASCULAR FLOW 78701 $ 924.11 Page 169 2018 KIDNEY IMMUNOFLUORESCENSE 88346 $ 569.71 KIDNEY TRANSPLT FEE 50300 $ 2,035.00 KIT ACL TRANSTIBIA-CATEG 1 Acquisition cost KIT ACL-CATEG 1 Acquisition cost KIT ADULT (RALTEGRAVIR/TRUVADA) Acquisition cost KIT BALLOON UROMAX-CATEG 1 Acquisition cost KIT BOVIE-CATEG 1 Acquisition cost KIT BROVIAC-CATEG 1 C1751 Acquisition cost KIT CATHETER MAHUKAR-CATEG 1 Acquisition cost KIT CATHETER PERI VAC-CATEG 1 Acquisition cost KIT CATHETER-CATEG 1 Acquisition cost KIT CATHETER-CATEG 2 Acquisition cost KIT CHOLANGIO-CATEG 1 Acquisition cost KIT COAGUCHEK-CATEG 1 Acquisition cost KIT DIABETES-CATEG 1 Acquisition cost KIT DISTAL WIRE-CATEG 1 Acquisition cost KIT DTPA-CATEG 1 Acquisition cost KIT EMERG IRRIG-CATEG 1 Acquisition cost KIT FAST TRACKER-CATEG 1 Acquisition cost KIT FETAL BLOOD-CATEG 1 Acquisition cost KIT FINGER SPLINTS-CATEG 1 Acquisition cost KIT GASTRIC LAVAGE-CATEG 1 Acquisition cost KIT GREENFIELD-CATEG 1 Acquisition cost KIT HDP-CATEG 1 Acquisition cost KIT HIP BASE-CATEG 1 Acquisition cost KIT HYGIENIKIT-CATEG 1 Acquisition cost KIT INTRA AORTIC-CATEG 1 Acquisition cost KIT INTRODUCER-CATEG 1 Acquisition cost KIT IRRIGATION SURGICAL-CATEG 1 Acquisition cost KIT IV-CATEG 1 Acquisition cost KIT KITTNER TIP ENDO-CATEG 1 Acquisition cost KIT LAP CHOL-CATEG 1 Acquisition cost KIT LAP-CATEG 1 Acquisition cost KIT LYMWRAP ARM-CATEG 1 Acquisition cost KIT MICRO TIP-CATEG 1 C1724 Acquisition cost KIT MICRO TIP-CATEG 2 Acquisition cost KIT MIX-CATEG 1 Acquisition cost KIT NEBULIZER-CATEG 1 Acquisition cost KIT NEPHRO-CATEG 1 C1729 Acquisition cost KIT NEPHRO-CATEG 2 Acquisition cost KIT NEPHRO-CATEG 3 Acquisition cost KIT OBSTETRICAL-CATEG 1 Acquisition cost KIT P.E.A.-CATEG 1 Acquisition cost KIT P.E.A.-CATEG 2 Acquisition cost KIT PACE COL-CATEG 1 Acquisition cost KIT PACING-CATEG 1 Acquisition cost KIT PEG-CATEG 1 Acquisition cost KIT PEG-CATEG 2 Acquisition cost KIT PERFLURON-CATEG 1 Acquisition cost KIT PERMA CATHETER-CATEG 1 Acquisition cost KIT PESSARY RING W/SUPPORT-CATEG 1 Acquisition cost KIT PHACO-CATEG 1 Acquisition cost KIT PICC-CATEG 1 C1751 Acquisition cost KIT PYP-CATEG 1 Acquisition cost KIT PYR-CATEG 1 Acquisition cost KIT RETRACTOR-CATEG 1 Acquisition cost Page 170 2018 KIT SHEATH INTRODUCER AVANTI-CATEG 1 C1894 Acquisition cost KIT SHEATH INTRODUCER-CATEG 1 Acquisition cost KIT SINGLE LUMEN-CATEG 1 Acquisition cost KIT STENT BILIARY-CATEG 1 C1876 Acquisition cost KIT TECHNESCAN-CATEG 1 Acquisition cost KIT TECHNESCAN-CATEG 2 Acquisition cost KIT TRACH CARE-CATEG 1 Acquisition cost KIT TVT GYNECARE-CATEG 1 Acquisition cost KIT VASCULAR-CATEG 1 Acquisition cost KIT VENOM-CATEG 1 Acquisition cost KIT WOUND MGMT-CATEG 1 Acquisition cost KIT WRENCH-CATEG 1 Acquisition cost KIV- KIT PEDIATRIC Acquisition cost KLEIHAUER BETKE 85460 $ 21.01 KLEIHAUER-BETKE TEST 85460 $ 21.01 KLING BNDGE 2 STRL $ 0.52 KLING BNDGE 3 STRL $ 0.65 KLING BNDGE 4 STRL $ 0.58 KLING BNDGE 6 STRL $ 1.07 KNEE AP / LAT 73560 $ 164.27 KNEE AP, LAT, OBL 73562 $ 164.27 KNEE ARTHRO; REM LB/FB; DIF COMPRT SK G0289 $ 186.56 KNEE ARTHROSC; W LYSIS OF ADHESIONS 29884 $ 6,995.52 KNEE ARTHROSCOPY W LAT RELEASE 29873 $ 6,995.52 KNEE ARTHROSCOPY/SURGERY 29880 $ 6,995.52 KNEE ARTHROSCPY/SRGRY; 2< COMPARTS 29876 $ 6,995.52 KNEE COMPLETE /PATELLA 73564 $ 302.70 KNEE EXPL/DRAIN/ REM FB 27310 $ 6,995.52 KNEE FEM COMP SZ-E C1776 $ 10,539.00 KNEE OPEN PATELLA RND BUTRESS C1776 $ 36.84 KNEE ORTHOSIS WO KNEE JT RIGID/CUST-FAB L1834 $ 1,593.90 KNEE SOLUTION POLY PATELLA SZ 29MM 8.0MM Acquisition cost KNEE STANDING / BOTH 73565 $ 164.27 KNEE STRAPPING 29530 $ 277.79 KNEE TIB STGE 1 CEMNT SPACR C1776 $ 4,200.00 KNEE TIB65X39MM STAGE1 CEMNT C1776 $ 1,798.50 KO IMMOBLIZR CANVAS LNGTUDNL PRFAB L1830 $ 40.52 KUGEL HERNIA PATCH 12"x12" C1781 $ 1,208.19 KUGEL HERNIA PATCH 7.6x7.6 SM CIRCLE C1781 $ 871.38 KUGEL HERNIA PATCH SM OVAL 8X12" C1781 $ 531.48 KUGEL HRNIA MESH MED OVAL 11x14" C1781 $ 1,569.72 KUGEL HRNIA MESH XL OVAL 22.1x27.1CM C1781 $ 3,195.06 KUGL HERN MESH XL OVAL W/EPTFE 9CM C1781 $ 3,992.28 KUGL HERN MSH XL OVL W/EPTFE 19.6x24.6CM C1781 $ 2,694.48 KUGL HERNIA MESH 13.8x17.08" LG OVAL C1781 $ 1,991.51 KWIRE C1713 $ 43.05 K-WIRE C1713 $ 43.05 KWIRE 0.8 FOR 2.0 C1713 $ 56.25 K-WIRE 1.1MM C1713 $ 61.50 KWIRE 1.6 C1713 $ 12.43 KWIRE 1.6MM C1713 $ 32.40 K-WIRE 1.6MM C1713 $ 43.05 K-WIRE 1.6MMx6IN HALF BAY PT C1713 $ 9.45 K-WIRE DIAMOND POINT .035X9" C1713 $ 37.50 KWIRE DOUBLE TROCAR C1713 $ 56.25 KWIRE SMOOTH DBLE TROCAR POINT C1713 $ 56.25 Page 171 2018 KWIRE SMOOTH DUAL TROCAR PT C1713 $ 56.25 KWIRE.07X4" SNGLE TROCR SMOOTH C1713 $ 22.50 K-WIRE-CATEG 1 Acquisition cost K-WIRE-CATEG 2 Acquisition cost K-WIRE-CATEG 3 Acquisition cost KWIRES .028 DBLE TROCAR STERLE C1713 $ 6.30 KWIRES 4X062 DOUBLE TROCAR C1713 $ 56.25 KWIRES 6X.045 DOUBLE TROCAR C1713 $ 56.25 KYPHX HV-R BONE CEMENT & MIXER C1713 $ 262.50 KYTRIL 1MG TABLET Q0166 Acquisition cost KYTRIL 1MG/ML INJ J1626 Acquisition cost L HRT ART/GRFT ANGIO 93459 $ 7,440.77 L HRT ARTERY/VENTRICLE ANGIO 93458 $ 7,440.77 L HRT CATH TRNSPTL PUNCTURE 93462 $ 450.30 L PLATE 4x6 LEFT/RIGHT C1713 $ 564.00 L VENTRIC PACING LEAD ADD-ON 33225 $ 1,008.08 L.A.P. 85540 $ 23.36 L/ D TRAY $ 49.50 L/S RATIO 83661 $ 59.71 L/S RATIO AMNIOTIC FLUID 83661 $ 59.71 LABETALOL - 100MG TAB J8499 $ 8.25 LABETALOL 20MG CARPUJECT J3490 Acquisition cost LABETALOL 20MG INJ J3490 $ 11.51 LABETALOL D45%W premix 500mg/250ml Acquisition cost LABIAL VENEER (LAMINATE) CHAIR D2960 $ 420.00 Labial veneer(laminate)-chairsd D2960 $ 420.00 LABYRINTHECTOMY; TRANSCANAL 69905 $ 11,474.25 LABYRINTHOTOMY; TRANSCANAL 69801 $ 3,010.00 LABYRNTHTMY, W PERF DRUGS; TRNSCNL 69801 $ 3,010.00 LAC AC 10%/W VIT E TOPICAL CR Acquisition cost LAC-HYDRIN 12% LOTION Acquisition cost LAC-HYDRIN CR Acquisition cost LACOSAMIDE (VIMPAT) 50mg Acquisition cost LACOSAMIDE 150MG TABLET Acquisition cost LACOSAMIDE 200MG Acquisition cost LACOSAMIDE 25 MG TAB Acquisition cost LACOSAMIDE 25MG TABLET Acquisition cost LACRI-LUBE EYE OINT 3.5GM Acquisition cost LACRILUBE OINT. Acquisition cost LACT RG INJ 1000 #7953-09 $ 1.53 LACT RG INJ 500 #7953-03 $ 1.34 LACT RG IRRG 3000 #7828-08 $ 12.44 LACTAID CAPLETS Acquisition cost LACTATE 83605 $ 29.02 LACTATE/PYRUVATE 83605 $ 29.02 LACTIC ACID 83605 $ 29.02 LACTIC ACID 10% LOTION TOP Acquisition cost LACTOBACILLUS 10B CAP Acquisition cost LACTOSE LEVEL FASTING 82951 $ 34.96 LACTOSE RINGER #7953-09-CATEG 1 Acquisition cost LACTULOSE 10GM/15ML ORAL SYRUP Acquisition cost LAIX 80MG. PO (FOR SCC ONLY) Acquisition cost LAMICTAL 100MG TAB Acquisition cost LAMINCTMY W EXPL/DCMPRS; 1-2 VRTB, LUMB 63005 $ 14,826.61 LAMINCTMY; EXC INTRASP LES; SACRAL 63268 $ 3,026.54 LAMINECT IMPL NS ELECTRODES; EPIDURAL 63655 $ 48,577.94 Page 172 2018 LAMIVUDINE 10MG/ML AL FR OR SY Acquisition cost LAMIVUDINE/ZIDOVUDINE CAPS Acquisition cost LAMNCTMY/FCTCTMY/FRMNTMY UNI/BI 1 CERV 63045 $ 14,826.61 LAMNCTMY/FCTCTMY/FRMNTMY UNI/BI 1 LUMB 63047 $ 14,826.61 LAMNCTMY/FCTCTMY/FRMNTMY UNI/BI EA ADDL 63048 $ 449.48 LAMOTRIGINE 83516 $ 31.33 LAMOTRIGINE 150MG TAB Acquisition cost LAMOTRIGINE 25MG CHEW TAB Acquisition cost LAMOTRIGINE 25MG TAB Acquisition cost LAMOTRIGINE 300MG TAB Acquisition cost LAMOTRIGINE 5MG CHEW TAB Acquisition cost LAMOTRIGINE LEVEL 80299 $ 41.01 LAMPREN 50MG CAP Acquisition cost LANCET Acquisition cost LANG COMP CURRENT STATUS G9159 Acquisition cost LANG COMP DISCHRG STATUS G9161 Acquisition cost LANG COMP GOAL STATUS G9160 Acquisition cost LANG EXPRESS CURRENT STAT G9162 Acquisition cost LANG EXPRESS DISCHRG STAT G9164 Acquisition cost LANG EXPRESS GOAL STATUS G9163 Acquisition cost LANOXIN 0.05MG/ML ELIXIR 60ML Acquisition cost LANOXIN 0.125MG TAB Acquisition cost LANOXIN 0.1MG/ML PEDIATRIC 1ML Acquisition cost LANOXIN 0.25MG TAB Acquisition cost LANOXIN 0.5MG/2ML INJ AMP J1160 Acquisition cost LANSOPRAZOL 15MG PACKET PO Acquisition cost LANSOPRAZOL 30MG PACKET PO Acquisition cost LANSOPRAZOLE 15MG Acquisition cost LANSOPRAZOLE 15MG. SOLUTAB Acquisition cost LANSOPRAZOLE 30MG Acquisition cost LANSOPRAZOLE 30MG CAPS Acquisition cost LANSOPRAZOLE 30MG. SOLUTAB Acquisition cost LANSOPROZOLE 30MG IV Acquisition cost LAP BILAT TPL&LN BX; SNG/MULTI 38572 $ 20,086.66 LAP ESOPHAGOMYOTOMY; HELLER TYPE 43279 $ 2,752.42 LAP ESOPHOGOGASTRIC FUNDOPLAST 43280 $ 20,086.66 LAP MYOMCTMY EXC; 1-4 W TTL WGHT <250G 58545 $ 11,870.65 LAP MYOMECTOMY, 5+ MYOMAS =250+G 58546 $ 20,086.66 LAP PARAESOPHAGEAL HERN REP 43281 $ 20,086.66 LAP REP RECURRNT INC HERN;INCA 49657 $ 20,086.66 LAP SLEEEVE GASTRECTOMY 43775 $ 2,380.49 LAP SPRCRV HYSTCTMY, 250G< W REM TUB/OV 58544 $ 20,086.66 LAP SUPRACERVCL HYSTRCTMY; UTRS 250 G 58542 $ 20,086.66 LAP; ORCHIOPEXY INTRA-ABD TESTIS 54692 $ 11,870.65 LAP; PARTIAL COLECTOMY 44204 $ 3,303.21 LAP; PROCTOPEXY W SIGMOID RESECTION 45402 $ 3,286.73 LAP; SLING OP STRESS INCONT 51992 $ 11,870.65 LAP; VAG HYST; W REM TUBE/OVRY; 250< G 58554 $ 20,086.66 LAP; VAG HYSTRCTMY; 250/>G 58550 $ 11,870.65 LAP; W DESTRUCTION OVIDUCTS 58670 $ 11,870.65 LAP; W EXC/DEST OVARY/PELVIC/PERIT LES 58662 $ 11,870.65 LAP; W FIMBRIOPLASTY 58672 $ 11,870.65 LAP; W REM ADNEXAL STRUCTURES 58661 $ 11,870.65 LAP; W SALPINGOSCOPY 58673 $ 11,870.65 LAP; WITH LYSIS OF ADHESIONS 58660 $ 11,870.65 LAP;ABD/PERIT/OMENTUM W BX 49321 $ 11,870.65 LAP;CHOLECYSTECTOMY W CHOLANGI 47563 $ 11,870.65 LAP;DX ABD/PERITONEUM/OMENTUM 49320 $ 11,870.65 LAP;INC HERN REP; W MESH;REDUC 49654 $ 20,086.66 LAP;INC HERN REP;COMP 49655 $ 20,086.66 LAP;INIT ING HERNIA REPAIR 49650 $ 11,870.65 LAP;VENT/ABD HERN REP;REDUC 49652 $ 11,870.65 LAP;VENT/ABD HERNIAL REP;COMP 49653 $ 11,870.65 LAPAROSCOPE PROC BLA 51999 $ 11,870.65 LAPAROSCOPE PROC INTESTINE 44238 $ 11,870.65 LAPAROSCOPE PROC URETER 50949 $ 11,870.65 LAPAROSCOPIC 5MM ABC PROBE C2618 $ 1,439.18 LAPAROSCOPY PACK $ 648.27 LAPAROSCOPY; PYELOPLASTY 50544 $ 18,432.28 LAPAROSCP;REP RECUR INGUIN HER 49651 $ 11,870.65 LAPARSCPY SURGICAL; W/FULG OVIDUCTS 58670 $ 11,870.65 LAPARSCPY, SURG; CHOLCTSTCTMY W EXPLR 47564 $ 11,870.65 LAPIDUS 3.5MM LOCKING SCREW C1713 $ 210.20 LAPIDUS PLATE LEFT C1713 $ 2,088.54 LAPIDUS PLATE LEFT C1713 $ 2,088.54 LAPIDUS PLATE RIGHT C1713 $ 2,088.54 LAPIDUS PLATE RIGHT C1713 $ 2,088.54 LAPRO SURG; GASTRO WO CNSTRCT GSTRC TUBE 43653 $ 11,870.65 LAPROSC;ABD/PERIT/OMENTUM W AS 49322 $ 11,870.65 LAPROSCOPIC PROCEDURE LIVER 47379 $ 11,870.65 LAPROSCOPTIC ENTEROLYSIS 44180 $ 11,870.65 LAPROSCOPY; ORCHIECTOMY 54690 $ 11,870.65 LAPROSCOPYL APPENDECTOMY 44970 $ 11,870.65 LARGE COMBINATION CLAMPS C1713 $ 986.70 LARGE MULTICLIP APPLIER 6/BX' C1713 $ 513.42 LARGE VENTRALEX 8CM DIAMETER, 2/CS C1781 $ 1,062.90 LARGETTING SCREW C1713 $ 292.50 LARYNGEAL FUNCTION STUDIES 92520 $ 277.79 LARYNGECTOMY TUBE, SIZE 8 A7520 $ 66.08 LARYNGO FLEX; DX 31575 $ 415.40 LARYNGO W FB REM 31531 $ 6,919.73 Page 174 2018 LARYNGO W FB REMOVAL 31577 $ 992.95 LARYNGOSC W VCL CRD INJ 31571 $ 6,919.73 LARYNGOSCOP BLADE 2-CHILD DISP $ 4.58 LARYNGOSCOPE BLADE 3-MED. DISP $ 3.87 LARYNGOSCOPE BLADE 4-LGE DISP. $ 3.87 LARYNGOSCOPE W/VC INJ 31570 $ 6,919.73 LARYNGOSCOPY DIRECT OR W/BX 31535 $ 6,919.73 LARYNGOSCOPY DIRECT; DX EX NEWORN 31525 $ 3,500.62 LARYNGOSCOPY DX; EXCLD NEWBORN 31525 $ 3,500.62 LARYNGOSCOPY DX; W OPER SCOPE 31526 $ 3,500.62 LARYNGOSCOPY FLEC; W REM FB 31577 $ 992.95 LARYNGOSCOPY FLEX; W BX 31576 $ 3,500.62 LARYNGOSCOPY FLEX; W REM LESION 31578 $ 6,919.73 LARYNGOSCOPY FLEX; WITH BX 31576 $ 3,500.62 LARYNGOSCOPY FLEXIBLE FIBEROPTIC; DX 31575 $ 415.40 LARYNGOSCOPY IND; W FB REM 31511 $ 415.40 LARYNGOSCOPY IND; W REM OF FB 31511 $ 415.40 LARYNGOSCOPY IND; W VC INJ 31513 $ 992.95 LARYNGOSCOPY INDIRECT; DX (SEP PROC) 31505 $ 415.40 LARYNGOSCOPY INDIRECT; W/BX 31510 $ 6,919.73 LARYNGOSCOPY W EXC TUMOR 31540 $ 6,919.73 LARYNGOSCOPY W TUMOR EXC & SCOPE 31541 $ 6,919.73 LARYNGOSCOPY W VOC CORD INJ 31570 $ 6,919.73 LARYNGOSCOPY W/ FB REMOVAL 31530 $ 3,500.62 LARYNGOSCOPY W/BIOPSY 31535 $ 6,919.73 LARYNGOSCOPY W/BX & OPER SCOPE 31536 $ 6,919.73 LARYNGOSCOPY W/BX&OP SCOPE 31536 $ 6,919.73 LARYNGOSCOPY W/FB REMOVAL 31530 $ 3,500.62 LARYNGOSCOPY, FLEX; DIAGNOSTIC 31575 $ 415.40 LARYNGOSCOPY, IND; W/BIOPSY 31510 $ 6,919.73 LARYNGOSCOPY,INDIRECT DIAGNOSTIC 31505 $ 415.40 LARYNGOSCP REM CARTILG; W SCOPE 31561 $ 12,863.66 LARYNGOSCPY ,W/WO TRACHEOSCPY 31515 $ 992.95 LARYNGOSCPY ,W/WO TRACHEOSCPY; 31515 $ 992.95 LARYNGOSCPY; IND; DX 31505 $ 415.40 LARYNGOTOMY; W REM TUMOR/CORDECTOMY 31300 $ 5,815.59 LARYNGSCPY FLEX/RGD, W STRBSCPY 31579 $ 992.95 LARYNGSCPY FLEX/RIG FIBPTC W STROBOSCOPY 31579 $ 992.95 LARYNGSCPY, DIRCT W/WO TRACH; W DILAT 31529 $ 6,919.73 LARYNGSCPY, FLEX FIBEROPTIC W REM LES 31578 $ 6,919.73 LARYNGSCPY, INDIRCT; W BX 31510 $ 6,919.73 LASA 86316 $ 56.54 LASER ALBTN EXTREM; 2ND & SUBSEQNT VEIN 36479 $ 294.10 LASER HAIR REMOVAL, BACK 17999 $ 446.80 LASER HAIR REMOVAL, BEARD 17999 $ 446.80 LASER HAIR REMOVAL, BIKINI 17999 $ 446.80 LASER HAIR REMOVAL, EARS 17999 $ 446.80 LASER HAIR REMOVAL, LEG/CHIN 17999 $ 446.80 LASER HAIR REMOVAL, LIP 17999 $ 446.80 LASER HAIR REMOVAL, UNDERARMS 17999 $ 446.80 LASER PROPHYLAXIS RD 67145 $ 1,290.50 LASER SKIN RESURF, ARMS, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, BACK/SHLDR, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, CHEST, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, HANDS, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, LEGS, 1-14 les 17110 $ 446.80 Page 175 2018 LASER SKIN RESURF, NECK, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, SEGMNT FACE, 1-14 les 17110 $ 446.80 LASER SKIN RESURF, TTL FACE, 1-14 les 17110 $ 446.80 LASER TATTOO REM, 30 sq cm 17999 $ 446.80 LASER TATTOO REM, 30sq cm, EACH SIDE 17999 $ 446.80 LASER TATTOO REM, 31 sq cm SECTION 17999 $ 446.80 LASER TATTOO REM,31 sq cm EA ADDL 17999 $ 446.80 LASER TREATMENT, EA ADDITIONAL LEG VEIN 36479 $ 294.10 LASER TREATMENT, FIRST LEG VEIN 36478 $ 6,592.23 LASER VAPORIZATION OF PROSTATE 52648 $ 9,800.87 LASIX 100MG/10ML INJ VIAL J1940 Acquisition cost LASIX 10MG/ML DROPS 60ML Acquisition cost LASIX 20MG TAB Acquisition cost LASIX 20MG/2ML INJ 2ML J1940 Acquisition cost LASIX 40MG TAB Acquisition cost LASIX 40MG/5ML LIQUID Acquisition cost LASR ANT. SEG. ADHES 65860 $ 1,290.50 LASSO 25 DEGREE CURVE TO LEFT C1713 $ 210.00 LASSO 25 DEGREE CURVE TO RIGHT C1713 $ 210.00 LASSO SUTRE 90DEGRE LFT STRGHT C1713 $ 210.00 LASSO SUTRE 90DEGREE RT STRGHT C1713 $ 210.00 LASSO SUTURE STRGHT 90 DEGREE C1713 $ 210.00 LATANOPROST OPHTH DROPS Acquisition cost LATERAL TIBIA PLATE C1713 $ 1,489.50 LATEX AGGLU CRYPTOCC 86403 $ 27.68 LATEX VIR AB IGG 86403 $ 27.68 LAVAGE BY CANNULATION; MAXIL SINUS 31000 $ 472.05 LAVAGE TUBE 18G LATEX FREE A4616 $ 76.85 LAYER CLOS FACE&/LIPS; 5.17-7. 12053 $ 821.94 LAYER CLOS FACE//LIPS; 7.6-12.5 CM 12054 $ 821.94 LAYER CLOS NECK FT//GENIT; < 2.5CM 12041 $ 821.94 LAYER CLOS NECK//GENIT; > 30.0 CM 12047 $ 4,147.84 LAYER CLOS NECK//GENIT; 2.6-7.5 CM 12042 $ 821.94 LAYER CLOS NECK//GENIT; 7.6-12.5 CM 12044 $ 1,291.09 LAYER CLOS SCLP//TRUNK; < 2.5 CM 12031 $ 821.94 LAYER CLOS SCLP//TRUNK; > 30.0 CM 12037 $ 4,147.84 LAYER CLOS SCLP//TRUNK; 7.6-12.5 CM 12034 $ 821.94 LAYER CLOSURE <2.6 CM 12051 $ 821.94 LAYER CLOSURE >30 CM 12057 $ 821.94 LAYER CLOSURE 2.5-7.5CM 12032 $ 821.94 LAYER CLOSURE 2.6-5 CM 12052 $ 821.94 LAYER CLOSURE 2.6-7.5CM 12042 $ 821.94 LAYER CLOSURE 5-7.5 CM 12053 $ 821.94 L-CARNITINE 250MG. PO Acquisition cost LCCK FEMORAL SZ. F Acquisition cost LCKING SCREW 2.4MM W/14MM STARDRV RECESS C1713 $ 175.50 LCKING SCREW 2.4MM W/18MM STARDRV RECESS C1713 $ 175.50 LCKING SCREW 2.4MM W/STARDIV RECESS 14MM C1713 $ 175.50 LCKING SCREW 3.5MM W/60MM STARDRV RECESS C1713 $ 174.30 LCKING SCRW SELF-TAP W/STRDRV 3.5x12MM C1713 $ 259.50 LCP 1/3 TUB PLATE W/COLLAR 7HOLES 81 MM C1713 $ 408.00 LCP DISTAL RADIUS PLATE C1713 $ 523.50 LCP LATERAL DISTAFIBULA PLATE C1713 $ 1,489.50 LCP POSTEROLATERL DIST HUM PALTE 3.5MM C1713 $ 1,479.00 LCS 3 PEG MB PATELLA TEXT. LAR Acquisition cost LCS 3 PEG MB PATELLA TXT. LAR-CATEG 1 Acquisition cost Page 176 2018 LCS 3 PEG PATELLA STD-COCR/PO Acquisition cost LCS 3 PEG PATELLA P.C STD Acquisition cost LCS 3 PEG PATELLA PC Acquisition cost LCS 3 PEG PATELLA STD-COCR/PO-CATEG 1 Acquisition cost LCS FEMORAL RT. Acquisition cost LCS KNEE FEMUR RT-LG POROCOAT Acquisition cost LCS KNEE ROTATE PLAT POLY LG. Acquisition cost LCS MB 3 PEG PATELLA Acquisition cost LCS PATELLA RT Acquisition cost LCS POLY KNEE ROTAT PLATFORM-CATEG 1 Acquisition cost LCS POLY ROTAT PLATFORM 10MM-S Acquisition cost LCS POLY ROTAT PLATFORM-CATEG 1 Acquisition cost LCS R.P BRIDGING BEARING STD + Acquisition cost LCS R.P. BRIDGING BEARING-CATEG 1 Acquisition cost LCS ROTATE BEARING PLATFORM-CATEG 1 Acquisition cost LCS ROTATE TIBIA Acquisition cost LCS ROTATING TIBIA PC Acquisition cost LCS TEXT FEMUR STD-LEFT Acquisition cost LCS TEXT. TIBIA ROT PLAT LAR Acquisition cost LCS TEXTURE FEMUR RT. LG. Acquisition cost LCS TIBIA PC.RP. LG Acquisition cost LCS TIBIA TEXT STD-LEFT Acquisition cost LDH 83615 $ 16.39 LDH BF 83615 $ 16.39 LDH CSF 83615 $ 16.39 LDH ISOENZYMES 83625 $ 34.76 LDH ISOENZYMES 83625 $ 34.76 LEAD 9770165 SPEC SURESCAN MRI C1713 $ 9,000.00 LEAD AICD ENDO SINGLE COIL C1777 Acquisition cost LEAD ATRIAL-CATEG 1 C1898 Acquisition cost LEAD CHEST-CATEG 1 Acquisition cost LEAD OCTAD 1x8 LZ 4MM SP 60MM ID C1778 $ 3,585.00 LEAD PMKR TRANSVENOUS VDD C1894 Acquisition cost LEAD SERUM 83655 $ 32.89 LEAD UR 83655 $ 32.89 LEAD VENTRICULAR-CATEG 1 Acquisition cost LEAD, NEUROSTIMULATOR C1778 Acquisition cost LEAD, UR 83655 $ 32.89 LEFLUNOMIDE 10MGTAB PO Acquisition cost LEFLUNOMIDE 20MG TAB PO Acquisition cost LeFort II/III-no bone graft D7948 $ 18,106.00 LeFort II/III-with bone graft D7949 $ 25,472.00 LEFORTE 1 RECON 1 PIECE 21141 $ 2,934.84 LEFORTE 1 RECON 2 PIECES 21142 $ 3,017.04 LEFORTE 1 RECON,3ORMORE PIECES 21143 $ 3,166.44 LEFORTE II FX - COMPLEX 21347 $ 2,156.70 LEFT FOSSA COMPONENT Acquisition cost LEFT HRT CATH W/VENTRCLGRPHY 93452 $ 7,440.77 LEFT MANDIBULAR COMPONENT Acquisition cost LEFT MARROW POLAR PLATE C1713 $ 1,134.00 LEG BAG URINE-LARGE A4358 $ 2.23 LEG BAG URINE-MED A4358 $ 2.17 LEG EXTENSIONS WALKER PER SET OF 4 E0158 $ 36.75 LEGACY NEXGEN FEM COMP; SZ-D C1776 $ 10,539.00 LEGACY NEXGEN FEMORAL COMPONENT C1776 $ 5,211.00 LEGIONELLA AB 86713 $ 41.56 Page 177 2018 LEGIONELLA AB TITER 86713 $ 41.56 LEGIONELLA ANTIBODY 86713 $ 41.56 LEGIONELLA ANTIGEN (URINE) 87278 $ 34.32 LEGIONELLA ANTIGEN URINE 87449 $ 32.56 LENGTH/SHORT TENDON LEG/ANKLE; SING 27685 $ 6,995.52 LENGTHEN FLEXOR TENDON 26478 $ 6,995.51 LEPIRUDIN, 50 MG J1945 $ 1,420.96 LEPTOSPIRA 86720 $ 35.82 LEPTOSPIRA ANTIBODY 86720 $ 35.82 LESCOL 20MG CAP Acquisition cost LETROZOLE 2.5MG TAB Acquisition cost LETROZOLE 2.5MG TABS Acquisition cost LEUCINE AMINOPEPTIDASE 83670 $ 24.88 LEUCOVORIN 200MG INJ J0640 Acquisition cost LEUCOVORIN 25MG TABLET Acquisition cost LEUCOVORIN 350 MG. VIAL J0640 Acquisition cost LEUCOVORIN 5MG TAB Acquisition cost LEUCOVORIN CA. 100MG/VIAL INJECTION Acquisition cost LEUKERAN 2MG TABLET Acquisition cost LEUKINE 50 MCG VIAL J2820 Acquisition cost LEUKO CONC 86950 $ 341.62 LEUKOAGGLUTININS 86021 $ 40.90 LEUKOCYTE ALK. PHOS 85540 $ 23.36 LEUKOCYTE PEROXIDASE 88319 $ 1,430.62 LEUKOCYTES IN STOOL 89051 $ 14.96 LEUKOCYTES STOOL 89051 $ 14.96 LEUPROLIDE 22.5MG KIT Acquisition cost LEUPROLIDE ACED DEPOT 3.75MG INJ J1950 Acquisition cost LEUPROLIDE ACET DEPOT 7.5MG INJ J9217 Acquisition cost LEUPROLIDE ACETATE 22.5MG KIT J9217 Acquisition cost LEUPROLIDE ACETATE, 7.5 MG J9217 $ 1,192.46 LEUPROLIDE ACETATE, PER 1 MG J9218 $ 158.99 LEVALBUTEROL HCL 0.31MG INH J7614 Acquisition cost LEVALBUTEROL HCL 0.63MG INH J7614 Acquisition cost LEVALBUTEROL HCL 1.25MG INH J7614 Acquisition cost LEVAMISOL 50MG TAB Acquisition cost LEVEEN INFLATOR-CATEG 1 Acquisition cost LEVEEN/ SHUNT PATENCY EXAM 78291 $ 924.11 LEVETIRACETAM (KEPPRA) 500MG VIAL J1953 Acquisition cost LEVETIRACETAM 100MG/ML Acquisition cost LEVETIRACETAM 100MG/ML (KEPPRA) Acquisition cost LEVETIRACETAM 250MG TABLET Acquisition cost LEVETIRACETAM 500MG TAB Acquisition cost LEVETIRACETAM 500mg/ml J1953 Acquisition cost LEVETIRACETAM PED ORAL SYRINGE J1953 $ 0.10 LEVETIRACETAMA 750MG TAB Acquisition cost LEVOBUNOLOL 0.5% SOLUTION INHALATION Acquisition cost LEVOBUPIVACAINE 0.5% INJ Acquisition cost LEVOCARNITINE (CARNITOR) 100MG/ML Acquisition cost LEVOCARNITINE 1GM/5ML INJ J1955 Acquisition cost LEVOCARNITINE 330MG TAB Acquisition cost LEVOFLOXACIN 0.5% OPH DROPS Acquisition cost LEVOFLOXACIN 250MG IV BAGS J1956 Acquisition cost LEVOFLOXACIN 250MG TAB Acquisition cost LEVOFLOXACIN 500MG INJ BAGS J1956 Acquisition cost LEVOFLOXACIN 500MG TAB Acquisition cost Page 178 2018 LEVOFLOXACIN 750MG (LEVAQUIN) TAB Acquisition cost LEVOFLOXACIN 750MG/150ML (LEVAQUIN) IV J1956 Acquisition cost LEVONORGESTREL (PLAN B) 1.5MG Acquisition cost LEVONORGESTREL 0.75 MG. PO Acquisition cost LEVOTHROID 175MCG TAB PO Acquisition cost LEVOTHYROXINE 100mcg Acquisition cost LEVOTHYROXINE 125MCG TAB Acquisition cost LEVOTHYROXINE 150MCG. PO Acquisition cost LEVOTHYROXINE 25MCG TAB Acquisition cost LEVOTHYROXINE ORAL SUSP Acquisition cost LEVOTHYROXINE SODIUM 125MCG Acquisition cost LEVOTHYROXINE SODIUM 75MCG Acquisition cost LEVOTHYROXINE SODIUM 88MCG TAB Acquisition cost LEVOXYL 0.150 MG TAB Acquisition cost LEVOXYL 0.175 MG TAB Acquisition cost LEVSIN 0.125 MG TAB Acquisition cost LEVSIN 0.125 MG. PO Acquisition cost LEXISCAN 0.1 MG J2785 Acquisition cost LEXISCAN 0.1 MG IV J2785 $ 156.44 LEXISCAN INJ. J2785 Acquisition cost LFIT ANATOMIC V40 36MM FEMORAL HEAD C1776 $ 1,614.53 LFIT V40 FEM HEAD 26MM C1776 $ 750.00 LFIT V40 FEM HEAD 28MMx+4MM C1776 $ 750.00 LFIT V40 FEMORAL HEAD +0 C1713 $ 750.00 LH URINE 83002 $ 50.29 LH SERUM 83002 $ 50.29 LIBRIUM 100MG INJ AMP J0720 Acquisition cost LICODAINE 1% W/ EPI $ 4.65 LIDEX SOLUTION 60ML Acquisition cost LIDOCAINE 80176 $ 39.91 LIDOCAINE PRILOCAINE CREAM 2.5 % $ 17.69 LIDOCAINE (XYLOCAINE) MPF 2% J2001 Acquisition cost LIDOCAINE .5%/EPI 1:200,000 Acquisition cost LIDOCAINE 1% 30 ml Acquisition cost LIDOCAINE 1% STERILE PK 10ML J2001 Acquisition cost LIDOCAINE 1% STRL PACK J2001 $ 6.20 LIDOCAINE 1% W/EPI 0.001% INJ Acquisition cost LIDOCAINE 1%; 10ML VIAL J2001 $ 48.90 LIDOCAINE 1%; 2ML INJ J2001 $ 60.00 LIDOCAINE 2% (5 ML) $ 0.10 LIDOCAINE 2% 10 ML AMPULES Acquisition cost LIDOCAINE 2% 20ML VIAL J2001 $ 2.51 LIDOCAINE 2% STERILE PAK J2001 Acquisition cost LIDOCAINE 2% VISCOUS ORAL SOL CUP Acquisition cost LIDOCAINE 2% W/EPI 0.001% INJ Acquisition cost LIDOCAINE 2% WITH EPI VIAL $ 32.74 LIDOCAINE 20MG ABBJECT J2001 $ 3.08 LIDOCAINE 20MG UROJET J3490 $ 16.82 LIDOCAINE 5% PATCH Acquisition cost LIDOCAINE HCL 10MG/ML 50ML MPF J2001 Acquisition cost LIDOCAINE HCL 10MG/ML AMP 5ML J2001 Acquisition cost LIDOCAINE HCL 2% JELLY 5ML Acquisition cost LIDOCAINE HCL 2% STERILE JELLY Acquisition cost LIDOCAINE HCL 20MG/ML VIAL 5ML J2001 Acquisition cost LIDOCAINE HCL 40MG/ML AMP 5ML J2001 Acquisition cost LIDOCAINE JELLY 2% TUBE $ 171.62 Page 179 2018 LIDOCAINE LEVEL 80176 $ 39.91 LIDOCAINE MPF 4% 40MG/1ML INJ (TOPICAL) $ 13.20 LIDOCAINE MPF 40MG/1ML INJ J2001 $ 0.46 LIDOCAINE STERILE PACK 1% J2001 $ 6.20 LIDOCAINE STERILE PACK 2% J2001 $ 7.23 LIDOCAINE W/ EPI 2% CARTRIDGES 100/BOX $ 6.55 LIDOCAINE/EPI/TETRACAINE Acquisition cost LIDOCAINE/HYDROCORTISONE 3%/0.5% CREAM Acquisition cost LIDOCNE 2% VISCOUS ORAL CUP $ 2.38 LIDODERM PATCH Acquisition cost LIG & DIV LG SAPH VEIN SAPH-FEM JUNCT 37700 $ 6,592.23 LIG COMMON ILIAC VEIN 37660 $ 2,806.87 LIG FALLOP TUBE; POSTPARTUM; VAG/ABD 58605 $ 701.23 LIG FALLOP TUBE; VAG/ABD APPR; UNI/BILAT 58600 $ 6,010.51 LIG FEMORAL VEIN 37650 $ 6,592.23 LIG&DIV SHRT SAPHN VEIN; SAPHPOP JCN 37780 $ 2,599.54 LIG, DIV &/OR EXC VEIN CLUSTR; 1 LEG 37785 $ 6,592.23 LIG/BX TEMPORAL ART 37609 $ 3,564.97 LIGAM AUGMENT KNEE; INTRA-ARTIC 27428 $ 26,770.83 LIGAMAX ENDO 5MM CLIP APPLIER C1713 $ 731.54 LIGAMNT AUGMNT KNEE; EXTRA-ARTIC 27427 $ 14,826.61 LIGASURE 5MM LAPAROSCOPIC ADVANCE A4649 $ 7,704.00 LIGASURE IMPACT VESL SEAL INST FORCETRI A4649 $ 7,440.50 LIGASURE V SEALER/DIVIDER FORCETRIAD A4649 $ 703.10 LIGATE VEIN; RADICAL; W GRF; 1 LEG; OP 37760 $ 6,592.23 LIGATE, DIV & STRIP LONG SAPH VEIN 37722 $ 6,592.23 LIGATION INFERIOR VENA CAVA 37619 $ 11,279.00 LIGATION MAJOR ART; NECK 37615 $ 2,599.54 LIGATION MAJOR ARTERY; EXTREMITY 37618 $ 821.35 LIGATION PERFRT VEIN SUBFASC; W US GUIDE 37761 $ 2,599.54 LIGATION/BAND ANGIOACCESS AV FIST 37607 $ 6,592.23 LIGSURE ATLAS HANDSWST 37CMFORCETRIAD A4649 $ 808.15 Limited ortho treat, adolescent D8030 $ 5,880.00 Limited ortho treat, adult dent D8040 $ 5,880.00 Limited ortho trt, primary dent D8010 $ 5,880.00 Limited ortho trt, transitional D8020 $ 5,880.00 LIMITED PEDIATRIC ECHO 93304 $ 1,287.09 Limited re-evaluation estab pat D0170 $ 70.00 LINDANE 1% SHAMPOO Acquisition cost LINDANE 1% TOPICAL LOTION Acquisition cost LINER 20, 28 ID, XLPE Acquisition cost LINER ACETEB-CATEG 1 Acquisition cost LINER ACETEB-CATEG 2 Acquisition cost LINER ACETEB-CATEG 3 C1776 Acquisition cost LINER BIPOLAR-CATEG 1 Acquisition cost LINER METAL/PE 48/50 Acquisition cost LINER METAL-CATEG 1 C1776 Acquisition cost LINER MP-CATEG 1 Acquisition cost LINER REFLECTION-CATEG 1 Acquisition cost LINER SIZE G-CATEG 1 Acquisition cost LINER SIZE J-CATEG 1 Acquisition cost LINER-CATEG 1 Acquisition cost LINER-CATEG 2 Acquisition cost LINEZOLID 100MG/5ML SUSPEN. Acquisition cost LINEZOLID 200MG/100ML (ZYVOX) Acquisition cost LINEZOLID 600MG INJ. J2020 Acquisition cost Page 180 2018 LINEZOLID 600MG TABLETS Acquisition cost LINK BOTTOM-CATEG 1 Acquisition cost LINK TOP-CATEG 1 Acquisition cost LINVATEC SPHERICAL HS BURS C1713 $ 12.00 LIORESAL 10MG UD TAB Acquisition cost LIOTHYRONINE 25MCG TABLET Acquisition cost LIPASE 83690 $ 18.72 LIPID PANEL 80061 $ 36.37 LIPIODOL ULTRA FLUID 480MG/ML (10ML) Acquisition cost LIPITOR 10MG TAB Acquisition cost LIPITOR 20MG TABLET Acquisition cost LIPITOR 40 MG TAB Acquisition cost LIPOPROT.ELECTROPH. 83700 $ 30.58 LIPOPROTEIN DIRECT MEASUR; LDL CHOL 83721 $ 25.92 LIPOPROTEIN DIRECT MEASUR; VLDL CHOL 83719 $ 31.59 LIPOPROTEIN ELECTROPHORESIS 83700 $ 30.58 LIPOSUCT CANN QUICK DISC HANDL A4624 $ 142.50 LIPOSYN 10% 200 ML #9786-01 $ 10.64 LIPOSYN 20% 200 ML #9789-01 $ 19.29 LIPOSYN-CATEG 1 Acquisition cost LIQUI-CHAR 50GM LIQUID 240ML Acquisition cost LIQUID-BASED SLIDE PREP 88112 $ 118.21 LISINOPRIL 10MG TABLET PO Acquisition cost LISINOPRIL 2.5MG TABLET PO Acquisition cost LISINOPRIL 20MG TABLET PO Acquisition cost LISINOPRIL 40MG TABLET PO Acquisition cost LISINOPRIL 5MG TAB J8499 $ 2.13 LISINOPRIL/HCTZ 10-12.5 TB PO Acquisition cost LISINOPRIL/HCTZ 20-12.5 TB PO Acquisition cost LISINOPRIL/HCTZ 20-25 TAB Acquisition cost LITHIUM 80178 $ 17.95 LITHIUM CARBONATE 150 MG CAP Acquisition cost LITHIUM CARBONATE UD CAP Acquisition cost LITHIUM CITRA 8MEQ/5ML SYR CUP Acquisition cost LITHOBID 300 MG TAB Acquisition cost LITHOCRUSH DISP LITHOTRIPTOR-CATEG 1 Acquisition cost LITHOLAPAXY IN BLDR W REM FB; 2.5/CM 52317 $ 7,131.78 LITHONATE 300MG/5ML SYR 500ML Acquisition cost LITHOTRIPTOR DISP-CATEG 1 Acquisition cost LIVER / SPLEEN IMAGE, FLOW 78216 $ 924.11 LIVER / SPLEEN IMAGE, STATIC 78215 $ 924.11 LIVER ELASTOGRAPHY 91200 $ 360.51 LIVER IMAGE STATIC ONLY 78201 $ 3,180.58 LIVER IMAGING (3D) 78205 $ 3,180.58 LIVER IMAGING W FLOW3D (HEMANGIOMA) 78206 $ 1,198.21 LIVER IMAGING WITH FLOW STATIC 78202 $ 3,180.58 LIVER-ELASTOGRAPHY 91200 $ 360.51 LMX (LIDOCAINE 5% CREAM) 15 GM. Acquisition cost LOC ANES NO CONJ WITH OPER OR SURG PROC D9210 $ 35.00 Local anesthesia D9215 $ 42.00 Local deliv antimicrb ag-th B/R D4381 $ 84.00 LOCING SCREW 5.0MM X 46MM C1713 $ 336.00 LOCK SCREW 2.3xVAROPIS C1713 $ 143.45 LOCK SCREW 2.7xVARIOUS C1713 $ 684.68 LOCK SCREWS 2.7 X C1713 $ 163.50 Page 181 2018 LOCKING 5X40MM SCRW FULL THRED C1713 $ 267.75 LOCKING CANNULATED SCREW 5.0 C1713 $ 531.00 LOCKING CAPS C1713 $ 75.00 LOCKING SCREW C1713 $ 267.75 LOCKING SCREW 2.3 X C1713 $ 143.44 LOCKING SCREW 2.4MM/24MM C1713 $ 144.75 LOCKING SCREW 2.4x16MM C1713 $ 340.50 LOCKING SCREW 2.7x24MM C1713 $ 327.00 LOCKING SCREW 3.5MM x VARIOUS C1713 $ 25.88 LOCKING SCREW 4.0x36MM C1713 $ 202.73 LOCKING SCREW 4.0x38MM C1713 $ 190.50 LOCKING SCREW 4.0x70MM C1713 $ 174.30 LOCKING SCREW 4.0x75MM C1713 $ 202.73 LOCKING SCREW 4.0xVARIOUS C1713 $ 202.73 LOCKING SCREW 5.0MMxVARIOUS C1713 $ 247.67 LOCKING SCREW 5.0x34MM C1713 $ 273.00 LOCKING SCREW 5.0x60MM C1713 $ 144.75 LOCKING SCREW 5.5x55MM C1713 $ 157.50 LOCKING SCREW 5x30MM C1713 $ 279.00 LOCKING SCREW 5x36MM C1713 $ 319.50 LOMBARD TEST 92700 $ 46.20 LONG GAMMA NAIL C1713 $ 3,362.17 LONG GAMMA NAIL 11x420MM C1713 $ 2,145.00 LONG GAMMA NAIL LT 11x360/13 C1713 $ 2,145.00 LONG LEG CAST 29345 $ 627.51 LONG LEG CAST-WALKER 29355 $ 627.51 LONG SHANK SCREW 3.5x26MM C1713 $ 1,564.88 LONG SPLINT 29105 $ 358.14 LONG THREAD SCREW 4.5x55MM C1713 $ 412.50 LONG THREAD SCREW 7.5MM X 55MM C1713 $ 412.50 LOOP CUTTING-CATEG 1 Acquisition cost LOOP CUTTING-CATEG 2 Acquisition cost LOPERAMIDE 2MG CAP $ 2.30 LOPRESSOR 100MG UD TAB Acquisition cost LOPRESSOR 1MG/ML 5ML INJ Acquisition cost LORATADINE 10MG TABLET PO Acquisition cost LORATADINE 5MG/5ML SYRP PO Acquisition cost LORATADINE ORAL SYRUP 5MG/5ML Acquisition cost LORATADINE TABLET 10MG J2780 $ 0.60 LORATADINE/PSUE 12HR TB PO Acquisition cost LORATADINE/PSUE 24HR TB PO Acquisition cost LORATIDINE 10MG TAB J8499 $ 2.44 LORAZEPAM 80299 $ 41.01 LORAZEPAM INJECTION 4MG/1ML J2060 Acquisition cost LORAZEPAM 0.1MG/0.05ML INJ J2060 Acquisition cost LORAZEPAM 0.4MG/0.4ML ORAL SOLUTION Acquisition cost LORAZEPAM 0.5MG TAB J8499 $ 2.13 LORAZEPAM 0.5MG TABLET BULK Acquisition cost LORAZEPAM 1 MG/ML IN 100ML D5%W Acquisition cost LORAZEPAM 1MG TABLET Acquisition cost LORAZEPAM 1MG TABLET BULK Acquisition cost LORAZEPAM 2MG TAB Acquisition cost LORAZEPAM 2MG TABLET BULK Acquisition cost LORAZEPAM 2MG/ML INJ J2060 Acquisition cost LORAZEPAM 2MG/ML VIAL 10ML J2060 Acquisition cost LORAZEPAM 4MG/ML INJ J2060 Acquisition cost Page 182 2018 LORAZEPAM 4MG/ML VIAL 1ML J2060 Acquisition cost LORAZEPAM CONC.ORAL SOLUTION 1MG/0.5ML Acquisition cost Lorazepam liquid oral solution Acquisition cost LORCAIN/NORLORCAIN 80299 $ 41.01 LORDOTIC CR SPACER C1713 $ 4,800.00 LOSARTAN 100MG TABS Acquisition cost LOSARTAN 25MG TAB Acquisition cost LOSARTAN 50MG TAB Acquisition cost LOSARTAN POT/HCTZ 100-25MG PO Acquisition cost LOSARTN/HYDROCHLRTHIAZDE 50MG/12.5MG TAB Acquisition cost Lo-So Prep Acquisition cost LOTENSIN 10MG TAB Acquisition cost LOTENSIN 20MG TAB Acquisition cost LOTENSIN 5MG TAB Acquisition cost LOTRIMIN 1% 30 ML Acquisition cost LOUDNESS BALANCE TEST 92562 $ 360.51 LOVASTATIN 20MG TAB Acquisition cost LOVENOX 30MG/0.3ML TUBEX 0. J1650 Acquisition cost LOVENOX 40MG. J1650 Acquisition cost LOW BACK DISC SURGERY 63030 $ 14,826.61 LOW DOSE CT FOR LUNG CANCER SCREEN G0297 $ 164.27 LOW IMPEDANCE EXTENSION KIT C1883 $ 1,042.50 LOWER EXTREM NON-JOINT MRI W/W/O CONTR 73720 $ 1,206.90 LOWER EXTREMITY CT WITH CONTRAST 73701 $ 668.38 LOWER EXTREMITY CT WITH/WITHOUT CONTRAST 73702 $ 668.38 LOWER EXTREMITY CT WITHOUT CONTRAST 73700 $ 302.70 LOWER EXTREMITY INFANT 73592 $ 164.27 LOWER EXTREMITY JOINT WITHOUT CONTRAST 73721 $ 614.37 LOWER EXTREMITY JOINT MRI W/W/O CONTRAST 73723 $ 1,206.90 LOWER EXTREMITY JOINT MRI WITH CONTRAST 73722 $ 1,803.27 LOWER EXTREMITY MRA 73725 $ 197.01 LOWER EXTREMITY NON-JOINT MRI W/O CONTR 73718 $ 614.37 LOWER EXTREMITY NON-JOINT MRI WITH CONTR 73719 $ 668.38 LOWER PARTIAL-ACRYLIC D5212 $ 1,050.00 LOWER PARTIAL-CAST BASE D5214 $ 1,190.00 LOXAPINE 80299 $ 41.01 LOXAPINE 10MG CAP Acquisition cost LOXAPINE 25MG/ML ORAL LIQUID Acquisition cost LOXAPINE 50MG/ML IM Acquisition cost LOXAPINE 5MG CAP Acquisition cost LOZAZA (OMEGA 3 ACID) ETHYL ESTER PO Acquisition cost L-PLATE 2.4MM LCP C1713 $ 645.47 LRE PERFORMER GUID SHEATH C1887 $ 178.55 LRG OVAL HERNIA KUGEL 9.5x13CM C1781 $ 1,005.81 LS SECONDARY SET $ 1.08 LSO FLEXIBLE $ 33.00 LSO FULL CORSET L0976 $ 33.00 LT NARROW VALUR PLATE C1713 $ 1,243.12 LUBIPROSTONE 24 MCG (AMITIZA ) PO Acquisition cost LUBRICANT EYE DROPS (Preservative Free) $ 0.10 LUBRICATH 18FR RIBB BALL CATH C1725 $ 156.06 LUBRICATH FOLY CATH SZ 18/5CC A4344 $ 60.84 LUBRIDERM EMMOLLIENT LOTION Acquisition cost LUBRIFLEX 6FR URETERL STENT C1876 $ 112.94 LUBRIFLEX 6FR, URETERAL STENT C1876 $ 112.94 LUBRIFLEX 8.5FR URETERAL STENT C1876 $ 115.83 Page 183 2018 LUCENTIS 0.3MG/0.05ML OPHTHALMIC DROPS J2778 Acquisition cost LUCENTIS 0.5MG/0.05ML OPHTHALMIC DROPS J2778 Acquisition cost LUGOL'S SOLUTION 14ML J3490 Acquisition cost LUKI ASPR TUBE $ 8.38 LUMBAR DISC ASPIRATIONNJECTION 62287 $ 12,238.01 LUMBAR PNCT, CHILD $ 17.36 LUMBAR SPINE CT WITH/WITHOUT CONTRAST 72133 $ 668.38 LUMBAR SPINE CT WITH CONTRAST 72132 $ 1,206.90 LUMBAR SPINE CT WITHOUT CONTRAST 72131 $ 302.70 LUMBAR SPINE MRI W/W/O CONTRAST 72158 $ 1,206.90 LUMBAR SPINE MRI WITH CONTRAST 72149 $ 1,206.90 LUMBAR SPINE MRI WITHOUT CONTRAST 72148 $ 614.37 LUMBAR SPINE 2/3 VIEWS 72100 $ 302.70 LUMBAR SPINE FLEXION / EXTENSION 72114 $ 302.70 LUMBAR SPINE FUSION 22612 $ 26,770.83 LUMBAR SPINE FUSION ANTERIOR 22558 $ 8,608.88 LUMBAR SPINE FUSION; POSTERIOR 22630 $ 3,321.80 LUMBAR SPINE OBLIQUE COMPLETE 72110 $ 302.70 LUMBAR, THORACIC SYMPATHTC BLK 64520 $ 1,777.62 LUMBR PNCT TRAY INFANT $ 17.20 LUMBR PNCT TRAY-ADULT $ 21.46 LUMEN MECH REM OBSTR CVAD 36596 $ 2,599.54 LUNG PERF & VENT DIFFERENTIAL 78598 $ 1,198.21 LUNG PERFUSION DIFFERENTIAL 78597 $ 924.11 LUNG PERFUSION IMAGING 78580 $ 924.11 LUNG VENT & PERF IMAGING 78582 $ 1,198.21 LUNG VENTILATION IMAGING 78579 $ 924.11 LUPRON DEPOT INJ 22.5MG J9217 $ 3,852.11 LUPUS ANTICOAG EVAL W/RFLQPANEL Acquisition cost LUPUS ANTICOAGULANT 85597 $ 48.82 LURASIDONE (LATUDA) 80 MG Acquisition cost LURASIDONE 20MG TABLET Acquisition cost LURASIDONE 40MG TABLET Acquisition cost LYME AB CSF 86618 $ 46.24 LYME AB SERUM 86618 $ 46.24 LYME DISEASE IGA 86618 $ 46.24 LYME DISEASE IGG 86618 $ 46.24 LYME DISEASE IGM 86617 $ 42.09 LYME IMMUNOBLOT (CONFIRM TEST) 86617 $ 42.09 LYME PCR 87476 $ 95.33 LYMP/ANTITHYMOCYTE GLOB,250 MG J7504 $ 4,633.00 LYMPH SYSTEM IMAGING 78195 $ 1,198.21 LYMPHANGIO EXTRM ONLY BIL RAD S/I 75803 $ 1,619.99 LYMPHANGIOG EXTREM ONLY UNI-S/I 75801 $ 1,619.99 LYMPHANGIOGRAPHY PELVIC/ BILAT 75807 $ 6,592.23 LYMPHANGIOGRAPHY PELVIC/UNILAT 75805 $ 2,599.54 LYMPHANGIOTOMY/OTHER OP LYMPH CHANN 38308 $ 7,213.98 LYMPHOCYTE CD4 COUNTS 86360 $ 127.62 LYMPHOCYTE IMMUNE GLOBULIN (ATGAM) 5 ML Acquisition cost LYMPHOCYTE SUBSET PANEL 3QPANEL Acquisition cost LYMPHOCYTES MITOGEN STUDIES 86353 $ 133.17 LYMPHOZURIN 1% Acquisition cost LYPHOLYTE-II INJ 200ML FOR TPN Acquisition cost LYSE CHEST FIBRIN; INIT DAY 32561 $ 1,619.99 LYSE CHEST FIBRIN; SUBSQNT DAY 32562 $ 1,619.99 LYSIS INTRANASAL SYNECHIA 30560 $ 1,216.16 Page 184 2018 LYSIS INTRANSL SYNECHIA 30560 $ 1,216.16 LYSIS INTRNASAL SYNECHIA 30560 $ 1,216.16 LYSOZYME (URINE) 85549 $ 50.93 LYSOZYME SERUM 85549 $ 50.93 M TUBERCULOSIS BY PCR 87551 $ 106.13 M.R.I. IMPLANT PORT Acquisition cost MAALOX SINGLE DOSE CUP $ 0.48 MACH 1 CATHETER 6FR LIMA C1887 $ 159.00 MACH 1 CATHETER 6FR RDC C1887 $ 159.00 MACRODANTIN 100MG CAP Acquisition cost MACRODANTIN 50MG CAP Acquisition cost MACROSCOPIC EXAM ARTHROPOD 87168 $ 11.59 MAG HYD/ALUM HYD 200/125 SUSP Acquisition cost MAG IGM 83520 $ 37.99 MAG/ALUM SIMETH PLUS SUSP Acquisition cost MAGIC MOUTH WASH Acquisition cost MAGNEBIND 300 MG TAB Acquisition cost MAGNESIUM RBC 83735 $ 18.19 MAGNESIUM (RBC) 83735 $ 18.19 MAGNESIUM (UR) 83735 $ 18.19 MAGNESIUM CITRATE (LO-SO PREP) Acquisition cost MAGNESIUM GLUCNATE 500MG INJ J3475 $ 0.40 MAGNESIUM GLUCONATE 500MG TAB Acquisition cost MAGNESIUM OXIDE 400MG TAB Acquisition cost MAGNESIUM SERUM 83735 $ 18.19 MAGNESIUM SUL 50% 10ML J3475 Acquisition cost MAGNESIUM SUL 50% INJ 10ML J3475 Acquisition cost MAGNESIUM SUL 50% INJ 2ML VIAL J3475 Acquisition cost MAGNESIUM SUL 500 MG J3475 Acquisition cost MAGNESIUM SULF 1%/100ML D5W IV PB J3475 Acquisition cost MAGNESIUM SULFATE 2G IVPB J3475 Acquisition cost MAGNESIUM SULFATE 50%-10ML J3475 Acquisition cost MAGNESIUM SULFATE 50%-20ML J3475 Acquisition cost MAGNESIUM SULFATE/SW IRRIG Acquisition cost MAGNESIUM UR TV 83735 $ 18.19 MAGNETIC RESONANCE SPECTROSCOPY 76390 $ 942.70 MAGNEVIST INJECTION, PER UNIT A9579 $ 5.54 MAGNSEIUM SULFATE20GM/500 PB J3475 Acquisition cost MAHURKAR DUAL-CATEG 1 C1752 Acquisition cost MAHURKAR Q PLUS DUAL LUMEN HIGHFLOW CATH C1751 $ 836.22 MAJ THOR W CARD MASSAGE 32160 $ 1,688.24 MAKENA INJECTION 250MG/ML (5ML VIAL) Acquisition cost MAKENA, INJ 10MG J1726 $ 21.19 MALAR AND/OR ZYGOMATIC ARCH OPEN REDUCTN D7650 $ 3,069.00 MALAR AUGMENTATION W PROSTH MAT 21270 $ 11,474.25 Malar/zygomatic arch-close red D7760 $ 2,108.00 MALARIA THICK SMEAR 87207 $ 16.28 MALE LUER LOCK B/C ADAPTER C1713 $ 396.59 MALE SLING OPERATION 53440 $ 20,088.88 MALE SLING URINARY KIT C1771 $ 5,392.50 MALECOT DRAIN CATH 18FR 6/CS C1729 $ 109.80 MALECOT DRAIN CATHETER 4-WING C1729 $ 109.80 MALECOT DRAIN CATHETER 6/CS C1729 $ 18.30 MALLORY/HEAD SHELL 52.56 Acquisition cost MALLORY/HEAD SHELL SZ. 54 Acquisition cost MAMMALOK-CATEG 1 Acquisition cost Page 185 2018 MAMMAPLASTY AUGMEN; W/PROSTH IMPLNT 19325 $ 19,537.41 MAMMAPLASTY AUGMEN; WO PROSTH 19324 $ 19,537.41 MAMMARY GALACTOGRAM (MULTIPLE DUCTS) 77054 $ 614.37 MAMMARY GALACTOGRAM (SINGLE DUCTS) 77053 $ 614.37 MAMMARY IMPLANT STYLE 163 510 Acquisition cost MAMMARY IMPLANT STYLE 163 685 Acquisition cost MAMMARY IMPLANT STYLE 168 180C C1789 $ 1,575.00 MAMMARY IMPLANT STYLE 2600 SI Acquisition cost MAMMO GUIDED NEEDLE LOCALIZATION 19281 $ 1,514.94 MAMMOGRAM, SCREENING 77057 $ 91.63 MAMMOGRAM, DIAGNOSTIC BILATERAL 77056 $ 120.74 MAMMOGRAM, DIAGNOSTIC UNILATERAL 77055 $ 97.13 MAMMPL; W PROSTHETIC 19325 $ 19,537.41 Mand partial-flex base incl cl D5226 $ 1,120.00 MANDAELAMINE/UREX 500MG TAB Acquisition cost MANDIBLE BONE GRAFT 21215 $ 11,474.25 MANDIBLE COMPLETE 70110 $ 302.70 MANDIBLE PARTIAL 70100 $ 164.27 MANDIBULAR PART DENTURE FLEX D5226 $ 840.00 Mandibular resection w/ flange D5934 $ 7,143.00 Mandibular resection w/o flange D5935 $ 6,215.00 MANIP ANKLE W GEN ANESTH 27860 $ 3,570.03 MANIP CHEST WALL; 1ST DEMO/EVAL 94667 $ 277.79 MANIP ELBOW W ANESTH 24300 $ 3,570.03 MANIP FNGR JNT; W ANESTH; EA JNT 26340 $ 3,570.03 MANIP KNEE JOINT UNDER ANESTH 27570 $ 3,570.03 MANIP SHLDR DIS REQ ANES 23655 $ 3,570.03 MANIP SHLDR DIS-NO ANES 23650 $ 568.33 MANIP SHLDR JNT UNDER ANESTH 23700 $ 3,570.03 MANIP UNDER ANES D7830 $ 507.00 MANIPULATE WRIST W ANESTH 25259 $ 3,570.03 MANIPULATION OF FORESKIN 54450 $ 607.00 MANIPULATOR UTERINE-CATEG 1 Acquisition cost MANIPULATOR UTERINE-CATEG 2 Acquisition cost MANITOL 20% 500ML #7715-03 $ 17.62 MANITOL-CATEG 1 Acquisition cost MANNITOL 20% 500ML IV Acquisition cost MANNITOL 25% INJ 12.5GM 50ML J2150 Acquisition cost MANOMETER CVP $ 6.86 MANUAL PLASMAPHER'S 36514 $ 3,230.99 MANUAL SCREENING BY MD P3001 $ 70.31 MANUAL THERAP TECH-1/> REGIONS-1 UNIT 97140 $ 60.85 MANUAL THERAPY 23 TO 37 MIN. 97140 $ 60.85 MANUAL THERAPY 38 TO 52 MIN. 97140 $ 60.85 MANUAL THERAPY 8 TO 22 MIN. 97140 $ 60.85 MANUAL TUMOR IM HISTOCHEM EA AB 88360 $ 569.71 MARAVIROC 150 MG. TABLET Acquisition cost MARAVIROC 300 MG. TABLET Acquisition cost MARCAINE .25% S0020 Acquisition cost MARCAINE 0.5 % J3490 $ 8.71 MARCAINE 0.5% W/ EPI CARTRIDGE 50/BOX J3490 $ 8.71 MARCAINE SPINAL 0.75MG INJ Acquisition cost MARINOL 2.5MG CAP Q0167 Acquisition cost MARKED SPRING WIRE GUIDE C1769 $ 342.00 MARKED SPRING WIRE GUIDE 25/BX C1713 $ 342.00 MARKER PIGTAIL 5FR CATH 5/BX C1877 $ 712.50 Page 186 2018 MARKER PIGTAIL 6FR CATH/.036 C1887 $ 180.00 MARKER PIGTAIL 6FR CATH/.036 C1887 $ 180.00 MARSUP BARTHOLINS GLAND CYST 56440 $ 6,010.51 MARSUPIALIZATION BARTHOLIN'S GLAND CYST 56440 $ 6,010.51 MARSUPIALIZATION BARTHOLIN'S GLAND-CYST 56440 $ 6,010.51 MARSUPIALIZATION;CYST/LIVER AB 47300 $ 2,416.22 MARSUPIALIZE SUBLING SALIVARY 42409 $ 5,815.59 MASDTOID DIAMOND BURR 1.0X90MM C1713 $ 77.66 MASK INFANT-CATEG 1 Acquisition cost MASK LMA-CATEG 1 Acquisition cost MASK NASAL-CATEG 1 Acquisition cost MASK NEONATAL-CATEG 1 Acquisition cost MASKW/EYESHEILD $ 249.00 MASSAGE, EA 15 MIN. 97124 $ 66.57 MASTEC GYNECOMASTIA 19300 $ 7,213.98 MASTEC SIMPL COMPLT 19303 $ 12,725.37 MASTEC SUBQ 19304 $ 7,213.98 MASTECTOMY RADICAL 19305 $ 2,402.53 MASTOID DIAM BURR 1.50X7.0MM C1713 $ 76.77 MASTOID DIAMOND BURR C1713 $ 76.77 MASTOID DIAMOND BURR 1.5X8.0MM C1713 $ 77.66 MASTOID DIAMOND BURR 2.0X80MM C1713 $ 77.66 MASTOID DIAMOND BURR 2.5X9.0MM C1713 $ 76.77 MASTOID DIAMOND BURR 3.0 C1713 $ 77.66 MASTOID DIAMOND BURR 4.0X70MM C1713 $ 76.77 MASTOID DIAMOND BURR 5.5X70MM C1713 $ 75.05 MASTOID DIAMOND BURR 6.0X7.0MM C1713 $ 74.28 MASTOID DIAMOND BURR 6.5X7.0MM C1713 $ 74.28 MASTOID RND CUT BURR 3.0X70MM C1713 $ 77.66 MASTOID RND CUT BURR 2.5X80MM C1713 $ 76.77 MASTOID RND CUT BURR 6.0X70MM C1713 $ 77.66 MASTOID RND CUT BURR 80X1.0MM C1713 $ 77.66 MASTOID RND CUTT BURR 1.0X90MM C1713 $ 76.77 MASTOID RND CUTTING BURR 70MM C1713 $ 76.77 MASTOIDECTOMY; COMPLETE 69502 $ 11,474.25 MASTOIDS 3 VIEWS 70120 $ 302.70 MASTOIDS COMPLETE 70130 $ 302.70 MASTOPEXY 19316 $ 12,725.37 MASTOTOMY W EXPL, DEEP 19020 $ 3,564.97 MASTOTOMY W/EXPLORATN/DRAINGE 19020 $ 3,564.97 MASTPXY 19316 $ 12,725.37 MATERNAL FETAL HB 88189 $ 190.32 MATERNAL HEMOGLOBIN FLOW CYTOMETRY 88189 $ 190.32 MATRISTEM 500MG MICROMATRIX C1776 $ 2,035.50 MATRISTEM 60MG MICROMATRIX WOUND CARE Q4118 $ 195.33 MATRISTEM MULTILAYER WND SHEET C1781 $ 1,725.00 MATRISTEM PLASTIC SURG MATRIX C1763 $ 3,307.50 MATRISTEM WOUND SHEET 5/BX C1763 $ 2,040.00 MATRIX PER 1 SQ CM Q4110 $ 38.38 MAVRICK MONORAIL PTCA DILAT CATH C1725 $ 262.50 MAXFIRE ZIPLOOP MAXBRAID SUTRE C1713 $ 495.00 Maxil partial-flex base incl cl D5225 $ 1,120.00 Maxilla-closed red(teeth immob) D7620 $ 3,682.00 Maxilla-closed reduction D7720 $ 4,052.00 Maxilla-open red (teeth immob) D7610 $ 4,910.00 MAXILLARY PART DENTURE FLEX D5225 $ 840.00 Page 187 2018 MAXIM FEMRL. POSTERIOR AUGMENT Acquisition cost MAXIM FMRL. DISTAL AUGMENT Acquisition cost MAXIM FMRL. POSTERIOR AUGMENT Acquisition cost MAXIM INTERLOK CONST FEMORAL Acquisition cost MAXIM POROUS TIBIAL TRAY Acquisition cost MAXIM STEM EXT Acquisition cost MAXIM TIBIAL BLOCK Acquisition cost MAXIMUN BREATHING CAPACITY 94200 $ 277.79 MAXIPINE 2GM INJECTION J0692 Acquisition cost MAXITROL OPHTH SUSP Acquisition cost MAXITROL OPTH OINT 3.5GM Acquisition cost MBC 87187 $ 88.37 MCG; DNA PROBE EA 88271 $ 58.17 MCG; IP SITU 100-300 CELLS 88275 $ 112.62 MCG; IP SITU 25-99 CELLS 88274 $ 94.56 MCG; SITU HYBRID 3-5 CELLS 88272 $ 89.54 MCGAHAN 68 SALINE-BREAST IMP 360-390CC C1789 $ 825.00 MCGAHAN 68 SALINE-BREAST IMP 390-420CC C1789 $ 54.00 MCGAHAN 68 SALINE-BREAST IMP 330-360CC C1789 $ 825.00 MCKENZIE DRILL PERFORATING 4 C1713 $ 309.74 MCP ARTHROPL W IMPLANT; EA JNT 26531 $ 14,826.61 MCT OIL Acquisition cost MD QUICK EVAL NEEDLE BX 88172 $ 341.62 MD-76(DIATRZOATE MEGLMNE/DIATRZOATE SOD) Acquisition cost MDMA AND METAB SCREEN,UR 80307 $ 158.03 MEASLES AB IGG 86765 $ 34.98 MEASLES AB IGM 86765 $ 34.98 MEASLES AB IGG 86765 $ 34.98 MEASLES MUMPS RUBELLA&VARCELLA 90710 $ 474.02 MEASLES MUMPS RUBELLA/VARCELLA CLINIC 90710 $ 474.02 MEASLES VACCINE,ATTEN VIAL Acquisition cost MEASLES/MUMPS/RUBELLA VAC LIVE-SUBQ/JET 90707 $ 164.79 MEATOTOMY INFANT 53025 $ 4,484.35 MEATOTOMY NONINFANT 53020 $ 4,484.35 MEBENDAZOLE 100MG CHEW TAB Acquisition cost MECH VENT CPAP, PSV, ADULT 94003 $ 1,218.36 MECH VENT CPAP, PSV, INFANT/PEDS 94660 $ 492.89 MECH VENT OSILLATORY 3100A 94003 $ 1,218.36 MECH VENT PRESSURE, INFNT/PEDS 94003 $ 1,218.36 MECH VENT VOLUME, ADULT 94003 $ 1,218.36 MECH VENT VOLUME, NEONATE 94003 $ 1,218.36 MECHANICAL VENT, VOL; INFANT/PEDS 94003 $ 1,218.36 MECHLORETHAMINE HCL 10MG INJ J9230 Acquisition cost MECHLORETHAMINE HCL,10MG J9230 $ 393.15 MECKEL?S DIVERT EXAM 78290 $ 924.11 MECLIZINE 12.5MG TAB J8597 Acquisition cost MECLIZINE HCL 25MG TAB Acquisition cost MECLIZINE TAB 25MG J8597 $ 1.91 MED LIST DOCMNTED IN MR 1159F Acquisition cost MED NUTRITION THERAPY, INDIV 15 MIN G0270 $ 59.91 MED NUTRTION THERAPY, GRP 30 MIN G0271 $ 33.07 MED SERV, EVE/WKEND/HOLIDAY 99051 $ 275.00 MEDIAL PLATE C1713 $ 6,180.00 MEDIASTINOSCPY W LYMPH NODE BX 39402 $ 11,870.65 MEDIASTINOTMY EXPL/DR/REM FB; CERV APPR 39000 $ 1,062.05 MEDICAL SURGICAL GYN PRIVATE ROOM $ 3,700.00 Page 188 2018 MEDICAL SURGICAL GYN SEMI PRIVATE ROOM $ 1,850.00 MEDICAL SURGICAL OTHER (AIDS) PRIVATE RM $ 3,700.00 MEDICAL SURGICAL OTHER (AIDS)SEMIPRIVATE $ 1,850.00 MEDICARE DEFINITY, 2 ML VIAL Q9957 $ 250.89 MEDICATION TRAINING AND SUPPOR H0034 $ 275.00 MEDIHONEY Acquisition cost MEDIUM GRIP PLATE x 150MM C1713 $ 2,741.55 MEDPOR IMPLANT 38MM X 50 MM Acquisition cost MEDROL 16 MG TAB J7509 Acquisition cost MEDROL 2 MG TAB J7509 Acquisition cost MEDROXYPROG/ESTRADIOL 5MG/25MG INJ Acquisition cost MEDROXYPROGEST 2.5MG TAB Acquisition cost MEDROXYPROGESTER 5MG TAB Acquisition cost MEDROXYPROGESTERONE 10MG TAB Acquisition cost MEDROXYPROGESTERONE 150MG INJ J1050 Acquisition cost MEFILM 4X5 $ 1.52 MEFLOQUINE 250MG TAB Acquisition cost MEGESTROL 40MG/ML ORAL SUSP Acquisition cost MEGESTROL ACET 40MG TAB Acquisition cost MEG-FOR EVKD MGNTC FLDS; EA ADD MODALITY 95967 $ 408.50 MEG-FOR EVKD MGNTC FLDS; SNGL MODALITY 95966 $ 2,387.99 MEG-FOR SPONTANEOUS BRAIN MGNTC ACTIVITY 95965 $ 2,387.99 MELANIN URINE 81005 $ 5.87 MELATONIN 1MG TAB Acquisition cost MELATONIN 5 MG. PO Acquisition cost MELGISORB 4X4 $ 5.61 MELLARIL 80342 $ 47.10 MELLARIL 100MG/ML ORA 120ML Acquisition cost MELLARIL 25MG TAB Acquisition cost MELLARIL 30MG/ML ORAL 120ML Acquisition cost MELLARIL 50 TAB Acquisition cost MELLARIL-S 25MG/5ML SUSP 473ML Acquisition cost MELPHALAM ORAL 2 MG J8600 $ 18.74 MEMANTINE (NAMENDA) 10 MG. Acquisition cost MEMANTINE (NAMENDA) 5 MG. Acquisition cost MEMBRANE AMNIOTIC-CATEG 1 Acquisition cost MEMBRANE DIFFUSION CAPACITY 94729 $ 20.04 MEMMOGRAM; BILATERAL 77066 $ 109.87 MEMMOGRAM; UNILATERAL 77065 $ 89.08 MEMORY CURRENT STATUS G9168 Acquisition cost MEMORY DISCHARGE STATUS G9170 Acquisition cost MEMORY GOAL STATUS G9169 Acquisition cost MENINGOCOCCAL CONJ VACC, IM 90734 $ 297.44 MENINGOCOCCAL GROUP B VAC (BEXSERO) 90733 Acquisition cost MENINGOCOCCAL VACCINE Acquisition cost MENINGOCOCOCCAL POLYSACCH VAC-SUB CLINIC 90733 $ 324.83 MENINGOCOCOCCAL POLYSACCH VAC-SUBQ 90733 $ 324.83 MENISCUS AGGR-CATEG 1 Acquisition cost MENISCUS ARROW IMPLANT SCREWS 1.1x10MM C1713 $ 240.00 MENISCUS MENDER 11 SCREW SET C1713 $ 220.50 MENISCUS MENDER 11 SCREW SET C1713 $ 220.50 MENNIGO VACCINE Acquisition cost MENTAL HEALTH ASSESS NOT MD H0031 $ 275.00 MENTHOL/CAMPHOR LOTION Acquisition cost MENTHOL/CETYLPYRID THROAT LOZ Acquisition cost MENVEO (A/C/Y/W-135) 90734 Acquisition cost Page 189 2018 MEPERIDINE (DEMEROL) 80361 $ 11.00 MEPERIDINE 10MG/ML PCA 30ML J2175 Acquisition cost MEPERIDINE HCL 100MG/ML INJ J2175 Acquisition cost MEPERIDINE HCL 10MG/ML J2175 Acquisition cost MEPERIDINE HCL 25MG/ML INJ J2175 Acquisition cost MEPERIDINE HCL 50MG BULK TAB. J2175 Acquisition cost MEPERIDINE HCL 50MG TAB J2175 Acquisition cost MEPERIDINE HCL 50MG/ML INJ J2175 Acquisition cost MEPERIDINE HCL 50MG/ML INJ AMPS J2175 Acquisition cost MEPERIDINE HCL 75MG/ML INJ J2175 Acquisition cost MEPRON 750MG/5CC 5CC SACHET Acquisition cost MEPRON 750MG/5ML SUSP Acquisition cost MERCAPTOPURINE 50MG TABLET Acquisition cost MERCURY (BLOOD) 83825 $ 44.15 MERCURY URINE 83825 $ 44.15 MEROPENEM 1G BINARY CONNECTOR J2185 Acquisition cost MEROPENEM 1G VIAL J2185 Acquisition cost MEROPENEM 500MG BINARY CONNECTOR J2185 Acquisition cost MEROPENUM 500MG INJ J2185 Acquisition cost MERREM 1 GM. INJECTION Acquisition cost MERSILENE 5-0 WHITE BRAID SUT C1713 $ 215.65 MESALAMINE 1000MG. SUPPOSITORY Acquisition cost MESALAMINE 250MG CAP Acquisition cost MESALAMINE 400MG TABLET EC Acquisition cost MESALAMINE 500MG. PO Acquisition cost MESH BARD-CATEG 1 C1781 Acquisition cost MESH BARD-CATEG 2 Acquisition cost MESH BARD-CATEG 3 Acquisition cost MESH BARD-CATEG 4 C1781 Acquisition cost MESH BARD-CATEG 5 Acquisition cost MESH COMPOSITE C1781 $ 1,743.53 MESH COMPOSIX-CATEG 1 C1781 Acquisition cost MESH DERMABOND-CATEG 1 C1781 Acquisition cost MESH DYNAMIC RIGID-CATEG 1 Acquisition cost MESH ETHIBOND-CATEG 1 Acquisition cost MESH ETHIBOND-CATEG 2 Acquisition cost MESH GORETEX-CATEG 1 C1768 Acquisition cost MESH HERNIA MED PRFIX LGHT PLG C1781 $ 3,008.70 MESH HERNIA PERFIX LGHT PLUG C1781 $ 3,037.50 MESH HERNIA PRT ABS RECON CIRC C1781 $ 2,091.00 MESH HERNIA-CATEG 1 Acquisition cost MESH INTEXEN-CATEG 1 C1763 Acquisition cost MESH KAYPLAST-CATEG 1 Acquisition cost MESH MARLEX POLY FLAT C1781 $ 146.25 MESH MARLEX-CATEG 1 Acquisition cost MESH MARLEX-CATEG 2 Acquisition cost MESH MERSILENE-CATEG 1 Acquisition cost MESH MERSILENE-CATEG 2 Acquisition cost MESH MYCRO-CATEG 1 Acquisition cost MESH PERFIX PLUG C1781 $ 411.00 MESH PERFIX PLUG 1.3X1.55" MEDIUM, C1781 $ 411.00 MESH PERFIX PLUG LARGE C1781 $ 215.25 MESH POLYESTER-CATEG 1 Acquisition cost MESH PROLENE-CATEG 1 Acquisition cost MESH PROLENE-CATEG 2 Acquisition cost MESH PROLENE-CATEG 3 Acquisition cost Page 190 2018 MESH PROLENE-CATEG 4 Acquisition cost MESH PROLENE-CATEG 5 Acquisition cost MESH SEPRAMESH-CATEG 1 C1781 Acquisition cost MESH SEPRAMESH-CATEG 2 C1781 Acquisition cost MESH SEPRAMESH-CATEG 3 C1781 Acquisition cost MESH SEPRAMESH-CATEG 4 C1781 Acquisition cost MESH STRETCH THIN-CATEG 1 Acquisition cost MESH STRETCH VASC-CATEG 1 C1781 Acquisition cost MESH SURG PTCH 1.7"SM W/CIRCLE C1781 $ 931.20 MESH SURG XLARGE OVAL10.8X13.7 C1781 $ 4,766.25 MESH ULTRAPRO PLUG LARGE, 6/BX C1781 $ 287.23 MESH ULTRAPRO PLUG MEDIUM 6/BX C1781 $ 344.20 MESH ULTRAPRO PLUG MEDIUM, C1781 $ 344.21 MESH ULTRAPRO PLUG SMALL, C1781 $ 340.75 MESH ULTRAPRO PLUG SMALL, 6/BX C1781 $ 340.75 MESH VENTRALEX-CATEG 1 Acquisition cost MESH VICRYL WOVEN-CATEG 1 Acquisition cost MESHSURGXLRGEPRFIXPLUGLGHTHERN C1781 $ 3,552.30 MESNA 100MG/ML VIAL 10ML J9209 Acquisition cost MESORIDAZINE BESYLATE 50MG TAB Acquisition cost MET HB. 83045 $ 14.28 METACARPAL CL FX WO MANIP BONE 26600 $ 568.33 METAL ON FEMORAL HEAD 36MM C1776 $ 1,836.00 METALLIC INLAY - 2 SURFACE D2520 $ 700.00 METALLIC INLAY - 3 SURFACE D2530 $ 770.00 METALLIC ONLAY - 2 SURFACE D2542 $ 840.00 METALLIC ONLAY - 3 SURFACE D2543 $ 910.00 METANEPHRINES 83835 $ 46.02 METANEPHRINES (UR) 83835 $ 46.02 METANEPHRINES RANDOM URINE 83835 $ 46.02 METAPROTERENOL 10MG/5ML SYRP Acquisition cost METAPROTERENOL SULF 10MG TAB Acquisition cost METFORMIN 1000MG TAB PO Acquisition cost METFORMIN HCL 500MG TAB Acquisition cost METFORMIN HCL 850MG TAB Acquisition cost METFORMIN HCL ER 50MG TABS Acquisition cost METHACHOLINE 100MG/VIAL INJECTION Acquisition cost METHADONE 80358 $ 11.00 METHADONE SERUM 80358 $ 11.00 METHADONE 10MG/5ML LIQUID PO Acquisition cost METHADONE 40MG DISKETS PO Acquisition cost METHADONE HCL 10MG/ML Acquisition cost METHADONE HCL 40MG TAB DISPER Acquisition cost METHADONE ORAL SOLUTION 0.5MG/0.5ML Acquisition cost METHADONE/SW IRRIGATION Acquisition cost METHAMPHETAMINE SCREEN URINE 80324 $ 11.00 METHANOL 84600 $ 43.67 METHAZOLAMIDE 25MG TAB Acquisition cost METHAZOLAMIDE 50MG TAB Acquisition cost METHAZOLAMIDE25MG TAB Acquisition cost METHEMOGLOBIN 83050 $ 19.91 METHEMOGLOBIN QUAL 83050 $ 19.91 METHERGINE 0.2MG TAB Acquisition cost METHERGINE 0.2MG/ML INJ J2210 Acquisition cost METHIMAZOLE 10MG TAB Acquisition cost METHIMAZOLE 5MG TAB Acquisition cost Page 191 2018 METHOCARBAMOL 500MG TAB Acquisition cost METHOCARBAMOL 750MG TAB Acquisition cost METHOHEXITAL SOD 500MG INJ Acquisition cost METHOTREXATE 80299 $ 41.01 METHOTREXATE 1GM INJ VIAL J9250 Acquisition cost METHOTREXATE 250MG/10ML VIAL J9250 Acquisition cost METHOTREXATE 25MG/ML IM ONLY J9250 Acquisition cost METHOTREXATE 50MG/2ML INJ J9250 Acquisition cost METHOTREXATE ORAL 2.5 MG J8610 $ 13.73 METHOTREXATE SODIUM 5 MG J9250 $ 9.46 METHOTREXATE SODIUM ORAL; 5MG J8610 $ 13.73 METHYL SALIC/MENTHOL OINTMENT Acquisition cost METHYLDOPA 250MG TAB Acquisition cost METHYLDOPA 500MG TAB Acquisition cost METHYLDOPATE 250MG/5ML 10ML J0210 Acquisition cost METHYLENE BLUE 1% INJ Q9968 Acquisition cost METHYLENE BLUE INJ Q9968 $ 44.31 METHYLENEDIOXYAMPHETAMINS; MDA/MDEA/MDMA 80359 $ 11.00 METHYLMALONIC ACID 84999 $ 88.88 METHYLNALTREXONE 12MG/0.6 ML J2212 Acquisition cost METHYLPHENIDATE HCL 10MG TAB Acquisition cost METHYLPHENIDATE HCL 10MG TAB Acquisition cost METHYLPHENIDATE HCL 5MG TAB Acquisition cost METHYLPHENIDATE HCL 5MG TABLET Acquisition cost METHYLPHENIDATE SA 18MG Acquisition cost METHYLPHENIDATE SA 36MG Acquisition cost METHYLPHENIDATE SA 54MG Acquisition cost METHYLPHENIDATE SR 10MG TAB Acquisition cost METHYLPHENINDATE 27MG SA PO Acquisition cost METHYLPRED 62.5MG SYR INJ Acquisition cost METHYLPRED ACETATE 40MG J1030 Acquisition cost METHYLPREDISOLONE 40MG INJ J1030 Acquisition cost METHYLPREDNISLN NA 125MG/ML VIAL J2930 $ 25.59 METHYLPREDNISOLONE 1000MG INJ J2920 Acquisition cost METHYLPREDNISOLONE 40MG/ML INJ J1030 Acquisition cost METHYLPREDNISOLONE 4MG TAB J7509 Acquisition cost Methylprednisolone 62.5mg/10ml syringe Acquisition cost METHYLPREDNISOLONE 80MG/ML INJ J1040 Acquisition cost METHYLPREDNISOLONE NA SUCC 40MG J2920 $ 15.88 METHYLPREDNISOLONE ORAL PER 4 MG J7509 $ 3.62 METHYLPREDNISOLONESODSUCC500MG J2920 Acquisition cost METHYLPREDNISSOD SUCC J2920 Acquisition cost METHYPREDNISOLONE TAPER DOSE J7509 Acquisition cost METOCLOPRAMIDE 10MG TAB Acquisition cost METOCLOPRAMIDE 5MG TAB J8597 Acquisition cost METOCLOPRAMIDE HCL 5MG/ML 10ML J2765 Acquisition cost METOLAZONE 2.5MG TAB Acquisition cost METOLAZONE 5MG TAB Acquisition cost METOPROLOL (TOPROL XL) 100MG Acquisition cost METOPROLOL (TOPROL XL) 200MG Acquisition cost METOPROLOL (TOPROL XL) 25MG Acquisition cost METOPROLOL (TOPROL XL) 50MG Acquisition cost METOPROLOL 1MG/ML Acquisition cost METOPROLOL 1MG/ML IN ORAPLUS Acquisition cost METOPROLOL 1MG/ML INJ Acquisition cost METOPROLOL 25 MG TAB J8499 $ 2.13 Page 192 2018 METOPROLOL 50 MG TAB J8499 $ 2.44 METOPROLOL 5MG/5ML INJ J3490 $ 5.10 METOPROLOL SUCCINATE 12.5MG TABLET J3490 Acquisition cost METOPROLOL TART 100MG TAB Acquisition cost METOPROLOL TART 25MG TAB Acquisition cost METOPROLOL TARTR 50MG TAB Acquisition cost METOPROLOL TARTRATE 12.5MG TABLET J3490 Acquisition cost METROGEL 0.75% CR Acquisition cost METRONIDAZL 250MG TAB J8499 $ 2.13 METRONIDAZOL 500 MG TAB J8499 $ 2.44 METRONIDAZOLE 0.75% GEL Acquisition cost METRONIDAZOLE 0.75% VAGINAL GEL Acquisition cost METRONIDAZOLE 1% TOPICAL GEL Acquisition cost METRONIDAZOLE 250MG TAB Acquisition cost METRONIDAZOLE 500 MG S0030 $ 0.93 METRONIDAZOLE 500MG TAB J8610 Acquisition cost METRONIDAZOLE PO SUSP Acquisition cost METRONIDAZOLE PO SUSP/COLGEN Acquisition cost MEXILERINE HCL 250 MG PO Acquisition cost MEXILETINE 80299 $ 41.01 MEXILETINE 200MG CAPSULE Acquisition cost MEXITIL 150MG CAP Acquisition cost MI PLANAR SPECT 78469 $ 3,180.58 MI PLANAR W EF 1ST PASS 78468 $ 1,198.21 MIACALCIN 200 IU/DOSE NASAL Acquisition cost MIC 87186 $ 23.47 MIC GASTROSTOMY FEEDING TUBE C1713 $ 56.09 MICARDIS 40MG. PO Acquisition cost MICONAZOLE NITRATE 7 VAGINAL CRM Acquisition cost MICRO AT2 DRILL C1713 $ 792.00 MICRO DERMABRASION; SEGMNT FACE 17999 $ 446.80 MICRO DERMABRASION; TOTAL FACE 17999 $ 446.80 MICRO POLISH Acquisition cost MICRO POLSH $ 215.60 MICRO QUICKANCHR PLUS ORTHCORD C1713 $ 841.50 MICRO WET MOUNT 87210 $ 12.80 MICRO XL VERTE SUPP CATH PERIP C1887 $ 22.50 MICROCATHETER $ 717.75 MICRODISSEC NEEDLE 3CM L STER C2618 $ 70.13 MICROFIX QA+ 3-0 ORTHOCORD BRAID C1713 $ 552.00 MICROFIX QA+ 3-0 ORTHOCORD BRAID; QA310 C1713 $ 552.00 MICROFIX QUICK ANCHORS PLUS C1713 $ 750.00 MICROFIX QUICK ANCHORS PLUS #2 C1713 $ 760.50 MICROGLOBULIN BETA-2(CSF) 82232 $ 43.93 MICROMARK TISSUE-CATEG 1 Acquisition cost MICRONASE 1.25 MG TAB Acquisition cost MICROPEEL 20 SOLUTION 120ML Acquisition cost MICROPEEL 20 SOLUTION; 120ML $ 191.40 MICROPEEL 30 SOLUTION 120ML Acquisition cost MICROPEEL 30 SOLUTION; 120ML $ 213.40 MICROPEEL PLUS 20 SOLUTION 120ML Acquisition cost MICROPEEL PLUS 20 SOLUTION; 120ML $ 191.40 MICROPEEL PLUS 30 SOLUTION 120ML Acquisition cost MICROPEEL PLUS 30 SOLUTION; 120ML $ 213.40 MICROPEEL SENSITIVE SKIN SOLUTION 120ML Acquisition cost MICROPEEL SENSITIVE SKIN SOLUTION; 120ML $ 158.40 Page 193 2018 MICROPUNCTURE INTRODUCER SET 4FR C1894 $ 54.90 MICROSHEATH STAND INTROD KIT C1769 $ 720.00 MICROSHEATH XL SUP CATH PERI C1769 $ 412.50 MICROSHEATH XLT TAPP SUPP CATH C1769 $ 412.50 MICROSHTH STRD INTRO KIT GWIRE C1894 $ 720.00 MICROSOMAL AB EACH 86376 $ 39.51 MID EAR EXPL VIA POSTAU/EAR CANAL INC 69440 $ 5,815.59 MIDAS 6MM DIAM BALL DISSECTBUR C1713 $ 246.00 MIDAS REX 10CM3MM DISSECT TOOL C1727 $ 205.80 MIDAS REX 14CM3MM DISSECT TOOL C1727 $ 236.67 MIDAS REX 5MM DIAMOND TIP BUR C1713 $ 234.00 MIDAS REX 7.5CM 4MMBAL DISSECT C1727 $ 246.00 MIDAS REX 7.5CM BALL DISSECT C1727 $ 217.50 MIDAS REX 7.5CMSYMTRI BALL DIS C1727 $ 270.00 MIDAS REX LEG 9CM 6MM DISSECT C1727 $ 233.60 MIDAS REX LEGEND 9CM DISSECT C1727 $ 249.90 MIDAS REX7.5CMBALL DISSCT TOOL C1727 $ 234.00 MIDASREX 14CM4MM LEGND DISSEC C1727 $ 255.78 MIDASREX 14CM5MM LEGND BA DISS C1727 $ 261.66 MIDASREX 14CM6MM LEGND BA DISS C1727 $ 279.30 MIDAZOLAM 100MG/100ML IV J2250 $ 1.21 MIDAZOLAM 10MG/5ML ORAL SOLUTION Acquisition cost MIDAZOLAM 2MG INJ J2250 $ 1.21 MIDAZOLAM 2MG/ML INJ 2ML J2250 Acquisition cost MIDAZOLAM 4MG/50ML IVPB J2250 Acquisition cost MIDAZOLAM 5MG/ML INJ 2ML J2250 Acquisition cost MIDAZOLAM DRIP 2MG/25ML J2250 Acquisition cost MIDAZOLAM HCL 5MG/ML VIAL 10ML J2250 Acquisition cost MIDAZOLAM IVPB J2250 Acquisition cost MIDODRINE (PROAMATINE) 5MG Acquisition cost MIDRNG AIR CUFF ADLT TRACHTUBE A4624 $ 110.30 MIDRNGE AIR CUF ADLT TRACH TUB A4624 $ 110.30 MIDRNGE AIR CUF HYPERFLX TRACH A4624 $ 279.54 MIFEPRISTONE 200MG S0190 $ 8.00 MILARONE LACT 0.2 MG/ML IN 100 ML D5%W J2260 Acquisition cost MILK OF MAGNESIA SUSP 480ML Acquisition cost MILK OF MAGNESIA SUSPENSION Acquisition cost MILK OF MAGNESIUM 30ML $ 1.83 MILLEX SYRINGE FG FILT UN 25MM C2618 $ 5.76 MILRINONE 20MG. 100ML PRE MIXED Acquisition cost MILRINONE LACT 1MG/ML INJ J2260 Acquisition cost MINERAL OIL 480ML BOT Acquisition cost MINERAL OIL ENEMA Acquisition cost MINERAL OIL STERILE 10ML VIAL Acquisition cost MINERAL OIL/PETRO HY-PHIL OINT Acquisition cost MINI BIO-ANCHOR W/NEEDLE 2.4 C1713 $ 435.00 MINI BONE SCREW C1713 $ 792.00 MINI LONG DRILL BIT C1713 $ 415.50 MINI TEG DISTAL-CATEG 1 Acquisition cost MINI-DOSE RHIG-IM USE 90385 $ 92.00 MINILOK QA PLUS W/#2/0 ORTHOCORD, 2MM C1713 $ 1,594.13 MINILOK QUICKANCHOR PLUS #0 C1713 $ 871.50 MINIPRESS 5MG CAP Acquisition cost MINOCIN 100MG CAP Acquisition cost MINOCIN 100mg. INJECTION Acquisition cost MINOXDIL 2.5MG TAB Acquisition cost Page 194 2018 MINOXDIL 5MG TAB Acquisition cost MIOSTAT OPTH VIAL 1.5ML Acquisition cost MIRALAX 17GM (PEG) Acquisition cost MIRTAZAPINE 15MG TAB Acquisition cost MIRTAZAPINE 15MG TABLET Acquisition cost MIRTAZAPINE 30MG TABLET Acquisition cost MIRTAZAPINE 45MG TAB Acquisition cost MIRTAZEPINE 45 MG. PO Acquisition cost MIS CANNULATED X-TAB 6MM TI X C1713 $ 2,781.90 MISC (NOT IN COMPEN - TOPICAL) Acquisition cost MISC (NOT IN COMPEND) Acquisition cost MISC (NOT IN COMPEND-LVP) Acquisition cost MISC DIAGNOSTIC NUC. PROCEDURE 78999 $ 924.11 MISC INJECTALBLE NON FORMULARY Acquisition cost MISC INVESTIGATIONAL DRUG PMFES2 LVL#1 Acquisition cost MISC INVESTIGATIONAL DRUG PMFES2 LVL#2 Acquisition cost MISC INVESTIGATIONAL DRUG PMFES2 LVL#3 Acquisition cost MISC ORAL LIQ NON FORMULARY PO Acquisition cost MISC UNIT DOSE Acquisition cost MISC. INVESTIGATIONAL DRUG (EMTRICITAB) Acquisition cost MISC. INVESTIGATIONAL DRUG (MARAVIROC) Acquisition cost MISC. INVESTIGATIONAL DRUG (TENOFOVIR) Acquisition cost MISC. INVESTIGATIONAL DRUG (TRUVADA) Acquisition cost MISC. NON FORMULARY Acquisition cost MISCELLAN STUDY DRUG PMC-0024 TABLET STD Acquisition cost MISCELLAN STUDY DRUG PML-0024 BLISTER Acquisition cost MISCELLANEOUS INSULIN PUMP ORDER Acquisition cost MISOPROSTOL 100MCG TAB Acquisition cost MISOPROSTOL 200MCG S0191 $ 3.14 MISOPROSTOL 200MCG TAB S0191 Acquisition cost MISOPROSTOL VAGINAL TABLET 5 MG. Acquisition cost MISSED AB TX-1ST TRIMEST 59820 $ 6,010.51 MISSED APPOINTMENT D9986 $ 30.00 MITOMYCIN 0.4MG/ML OPTH DROPS Acquisition cost MITOMYCIN 20 MG J9280 $ 389.31 MITOMYCIN 20MG INJ J9280 Acquisition cost MITOMYCIN 40 MG J9280 $ 389.31 MITOMYCIN 5MG INJ J9280 Acquisition cost MITOMYCIN OPHTH SOL 0.2MG/ML Acquisition cost MITOMYCIN, 5MG J9280 $ 389.31 MITOXANTRONE HCL J9293 Acquisition cost MIVACRON 2MG/ML INJ Acquisition cost MIXER VAC #3 BONE CEMENT C1713 $ 906.00 MIXING CONTACT PROD 85732 $ 17.56 MIXING PTT 85732 $ 17.56 MIXTER VENT NEEDLE 14G C2618 $ 835.50 MLK F/U OFF/OP VIST E/M 10MIN 99212 $ 315.00 MLK F/U OFF/OP VIST E/M 15MIN 99213 $ 343.00 MLK F/U OFF/OP VIST E/M 25MIN 99214 $ 370.00 MLK F/U OFF/OP VIST E/M 40MIN 99215 $ 398.00 MLK F/U OFF/OP VIST E/M 5 MIN 99211 $ 300.00 MLK INT OFF/OP VISIT E/M 10MIN 99201 $ 300.00 MLK INT OFF/OP VIST E/M 20MIN 99202 $ 315.00 MLK INT OFF/OP VIST E/M 30M 99203 $ 343.00 MLK INT OFF/OP VIST E/M 45M 99204 $ 370.00 MLK INT OFF/OP VIST E/M 60M 99205 $ 398.00 Page 195 2018 MLK P/P OFF/OP VIST E/M 10MIN 99212 $ 315.00 MLK P/P OFF/OP VIST E/M 15MIN 99213 $ 343.00 MLK P/P OFF/OP VIST E/M 25MIN 99214 $ 370.00 MLK P/P OFF/OP VIST E/M 40MIN 99215 $ 398.00 MLK P/P OFF/OP VIST E/M 5MIN 99211 $ 300.00 MMR + VARICELLA VACCINE Acquisition cost MMR VAC LIVE,SUBQ/JET CLINIC 90707 $ 164.79 MMR VACCINE 90707 Acquisition cost MMSU RIDL TI 5.5MMxVARIOUS C1713 $ 486.75 MNT GROUP, EA 30 MIN 97804 $ 33.07 MNT REASSESSMENT INDIV, EA 15 MIN 97803 $ 59.91 MNTR F/A SCREW 3.5DIA x; MOUNTAINEER C1713 $ 1,594.13 MNTR F/A SCRW 3.5DIA X;MOUNTAI C1713 $ 1,594.12 MNTRNG LCLZTN CRBRL SZR FCS 16>TLM, EEG 95956 $ 1,175.22 MOBILITY CURRENT STATUS - OT G8978 Acquisition cost MOBILITY CURRENT STATUS - PT G8978 Acquisition cost MOBILITY DISCHARGE STATUS - OT G8980 Acquisition cost MOBILITY DISCHARGE STATUS - PT G8980 Acquisition cost MOBILITY GOAL STATUS - OT G8979 Acquisition cost MOBILITY GOAL STATUS - PT G8979 Acquisition cost MOBILN OF ERUPT MALPOS TOOTH AID ERUPT D7282 $ 343.00 Mod of remvble prosth-post surg D5875 $ 182.00 MOD RAD MASTECTOMY 19307 $ 12,725.37 MOD SED OTH PHYS/QHP <5 YR 99155 $ 33.57 MOD SED OTH PHYS/QHP 5/YRS 99152 $ 33.57 MOD SED SAME PHYS/QHP EA 99153 $ 33.57 MODIFICATION OF VOICE PROSTHETIC 92609 $ 238.52 MODIFIED BARIUM SWALLOW 70371 $ 614.37 MODLR HUMERAL STEM #12 128MM REUNIN TSA C1776 $ 9,081.00 MODULAR FEMORAL HEAD 46MM W/SLEEVE C1776 $ 414.38 MODULAR HEAD COMPONENT 28MM Acquisition cost MODULAR HIP SYSTEM C1713 $ 7,132.65 MODULAR HIP SYSTEM 155X15MM C1713 $ 5,110.35 MODULAR HUMERAL STEM C1776 $ 10,195.50 MODULAR HUMERAL STEM SZ.14 C1776 $ 9,081.00 MODULAR REAMER HEAD C1776 $ 475.26 MOLINDONE 10MG TAB Acquisition cost MOLINDONE 25MG TAB Acquisition cost MOLINDONE 50MG TAB Acquisition cost MOLINDONE 5MG TAB Acquisition cost MOMETASONE 220MCG INH #120 Acquisition cost MOMETASONE 220MCG INH #14 Acquisition cost MOMETASONE 220MCG INH #30 Acquisition cost MOMETASONE 220MCG INH #60 Acquisition cost MOMETASONE 50MCG NASAL SPRAY Acquisition cost MOMETASONE FUR 0.1% CREAM 15GM Acquisition cost MOMETASONE FUR 0.1% OINT 45GM Acquisition cost MON LCLZ CRBRSZRFCS16>EEGRCD/I 95953 $ 1,175.22 MONISTAT 2% CREAM 30GM Acquisition cost MONITORG,LOCALIZTN,CERBRL SEZR 95951 $ 2,387.99 MONO / DIBASIC SOD PHOSPHATE Acquisition cost MONO SPOT TEST 86308 $ 14.06 MONOPOLR INCREMNT STIMULA PRBE C2618 $ 768.00 Page 196 2018 MONOPRIL 10MG TAB Acquisition cost MONOPRIL 20MG TAB Acquisition cost MONOPRIL 40MG TAB Acquisition cost MONORAIL BALLOON CATH 8MMx5MM C1725 $ 396.00 MONOTUBE TRIAX STER WRIST KIT A4624 $ 2,491.88 MONTELUKAST 4MG TAB Acquisition cost MONTELUKAST 5MG TAB Acquisition cost MONTELUKAST SODIUM 10MG Acquisition cost MORCELLATOR C1782 Acquisition cost MORPHINE (DURAMORPH) 1MG/1ML SYRINGE J2270 $ 0.10 MORPHINE 0.15MG/0.075ML SYRINGE Acquisition cost MORPHINE 0.5ML ORAL SYRINGE 0.4MG/ML Acquisition cost MORPHINE 100MG/100ML PCA Acquisition cost MORPHINE 10MG/10ML IV DRIP Acquisition cost MORPHINE 15MG IR TAB 25PAK Acquisition cost MORPHINE 5MG/ML INJECTION J2270 Acquisition cost MORPHINE 8 MG/ML 1 ML. INJECTION J2270 Acquisition cost Morphine concentrated oral solution Acquisition cost MORPHINE ORAL SYRINGE 0.1MG/1ML Acquisition cost MORPHINE SO4 (INFUMORPH) 20ML Acquisition cost MORPHINE SO4 (INFUMORPH) 20ML 25MG/ML Acquisition cost MORPHINE SO4 PCA 30ML J2270 Acquisition cost MORPHINE SUL 10MG/5ML ORAL10 MG J2270 Acquisition cost MORPHINE SULF 25MG/ML 4ML INJ J2270 Acquisition cost MORPHINE SULFATE 100MG TABLET Acquisition cost MORPHINE SULFATE 100MG/100ML D5%W J2270 Acquisition cost MORPHINE SULFATE 10MG/ML 10ML J2270 Acquisition cost MORPHINE SULFATE 15MG SA Acquisition cost MORPHINE SULFATE 2MG/ML J2270 Acquisition cost MORPHINE SULFATE 30MG IR TABLET Acquisition cost MORPHINE SULFATE 30MG RECTAL SUPPOS Acquisition cost MORPHINE SULFATE 4mg INJECTION J2270 Acquisition cost MORPHINE SULFATE 50MG/ML VIAL 50ML J2270 Acquisition cost MORPHINE SULFATE 5MG/ML PCA J2270 Acquisition cost MORPHINE SULFATE IR 15MG Acquisition cost MORPHINE SULFATE UP TO 10MG/ML 10 ML J2270 Acquisition cost MORPHINE SULFATE, 10 MG J2274 Acquisition cost MORPHINE SULFATE; 10 MG J2274 Acquisition cost MORPHINE SULFATE; TUBEX 10MG J2274 Acquisition cost MORPHINE SULFTE 2MG/ML J2270 $ 12.41 MORPHOMET ANA-TUMOR 88358 $ 569.71 MOSQUITO SCREW 6.0 X 40MM C1713 $ 1,350.00 MOSS NASAL TUBE 18FR A4616 $ 307.50 MOTILITY CELLS 81015 $ 8.27 MOTILITY STUDIES; GASTRIC 91020 $ 1,175.22 MOTION ANALYSIS VIDEO/3D 96000 $ 1,175.21 MOTION FLOURO SWAL FUNCT CINE/VIDEO REC 92611 $ 189.64 MOTOR SPEECH CURRENT STAT G8999 Acquisition cost MOTOR SPEECH DISCHRG STAT G9158 Acquisition cost MOTOR SPEECH GOAL STAT G9186 Acquisition cost MOTRIN (IBUPROFEN ) 600 MG TAB Acquisition cost MOXIFLOXACIN 0.5% OPH. DROP (VIGAMOX) Acquisition cost MOXIFLOXACIN 400MG TAB Acquisition cost MOXIFLOXACIN 400MG TAB Acquisition cost MOXIFLOXACIN 400MG/250ML IV J2280 Acquisition cost MOXIFLOXICIN OPHTHALMIC SOLUTION Acquisition cost Page 197 2018 MP + IP FLEXION CONTROL $ 259.29 MP FLEXION CONTROL $ 189.42 MPO-ANTIBODY ID 86021 $ 40.90 MR GUID NEEDLE PLCMT RAD S/I 77021 $ 160.93 MRH FEMUR C1713 $ 9,100.80 MRI ANGIO CHEST W/WO CONTRAST MAT 71555 $ 196.50 MRI BONE MARROW BLD SUPPLY 77084 $ 614.37 MRI BREAST WO //OR W/CONTRAST; BILAT 77059 $ 1,206.90 MRI BREAST WO //OR W/CONTRAST; UNILAT 77058 $ 1,206.90 MRI ELECTRODES A4556 $ 156.60 MRI Ext/Brachial Plexus w Contrast 73219 $ 1,206.90 MRI Ext/Brachial Plexus w/o Contrast 73218 $ 614.37 MRI Ext/Brachial Plexus w/w/o Cont 73220 $ 1,206.90 MRI Head/ Sella Turcica w/w/o Contrast 70546 $ 1,206.90 MRI Head/ Sella Turcica with Contrast 70545 $ 668.38 MRI Head/Posterior Fossa w/w/o Contrast 70546 $ 1,206.90 MRI Head/Posterior Fossa with Contrast 70545 $ 668.38 MRI Head/Posterior Fossa without Cont 70544 $ 614.37 MRI Head/Sella Turcica without Contrast 70544 $ 614.37 MRI Head/Sinuses with / without Contrast 70546 $ 1,206.90 MRI Head/Sinuses with Contrast 70545 $ 668.38 MRI Head/Sinuses without Contrast 70544 $ 614.37 MRI IMPLANT CV CATH 9.5FR W/GROSHONG A4301 $ 480.00 MRI IMPLNT CV CATH 9.5 W/GROSH C1887 $ 480.00 MS CONTIN 15MG TAB Acquisition cost MS CONTIN 30MG TAB Acquisition cost MS CONTIN 60MG TAB Acquisition cost MS PANELQPANEL Acquisition cost MSR POST-VOID URIN//BLADD CAPCTY US 51798 $ 147.99 MTHFR, DNA MUTATION (NY)QPANEL Acquisition cost MTL ACOLDE STM TRIDNT CUP LFIT HD&X3 INS C1776 $ 1,360.16 MTMS BY PHARM; EST PT - 15 MIN 99606 Acquisition cost MTMS BY PHARM; NEW PT - 15MIN 99605 Acquisition cost MTP JNT CAPSULOTOMY; EA SING JNT 28270 $ 6,995.52 MTPCP PLATE RIGHT C1713 $ 4,665.00 MUC SCREW 7.0 X 80MM C1713 $ 1,971.00 MUC SCREW 7.0x16MM C1713 $ 1,971.00 MUCIN CLOT BODY FLUID 83872 $ 15.93 MUGA SPECT W WM AND EF 78494 $ 924.11 MULT EAR/PULSE OXIMETRY 94761 $ 29.70 MULTAQ 400MG. PO Acquisition cost MULTE-PAK-4 INJ 30ML VIAL Acquisition cost MULTI LINK VISION CORONARY STENT C1876 $ 1,005.00 MULTI-FAM GROUP THERAPY 90849 $ 275.00 MULTI-FAMILY GROUP THERAPY 90849 $ 275.00 MULTI-FAMILY GROUP TX 90849 $ 275.00 MULTI-FAMILY GRP THERAPY 90849 $ 275.00 MULTIFETAL PREGNANCY REDUCTION 59866 $ 709.68 MULTIGATED (E.F) SCAN 78472 $ 924.11 MULTIGATED (E.F) SCAN FIRST PASS 78472 $ 924.11 MULTIGATED (E.F) SCAN-OPD 78472 $ 924.11 MULTIPACK INFINITI 4FR DIAGNOSTIC CATHET $ 372.00 MULTIPACK INFINITI 5FR DIAGNOSTIC CATHET $ 372.00 MULTIPIECE LEFORTE 1 D7947 $ 11,627.00 MULTIPIN CLAMP C1713 $ 631.50 MULTIPLE SLEEP LATENCY TEST 95805 $ 2,387.99 Page 198 2018 MULTIPLE WAKEFULNESS TEST 95805 $ 2,387.99 MULTIPOLR BIPLR CUP SHELL 52MM C1776 $ 1,203.00 MULTIVIT.PED. WITH ZINC DROPS Acquisition cost MULTIVITAMIN TAB PO Acquisition cost MULTIVITAMIN W/FE DROPS PO Acquisition cost MULTIVITAMINS CONC INJ 5ML Acquisition cost MULTIVITAMINS FOR TPN USE ONLY Acquisition cost MULTIVITAMINS PEDS INJ FOR TPN Acquisition cost MULTIVITAMINS,THER W-MINERALS Acquisition cost MULTIVITAMINS,THERAP TAB U Acquisition cost MULTIVITAMINS,THERAP 120ML Acquisition cost MULTIVITE/MVI TAB Acquisition cost MUMPS AB IGG 86735 $ 35.44 MUMPS AB IGM 86735 $ 35.44 MUMPS AB IGG 86735 $ 35.44 MUMPS ANTIBODY 86735 $ 35.44 MUMPS IGG 86735 $ 35.44 MUMPS IGM 86735 $ 35.44 MUMPS SKIN TEST ANTIGEN 1ML Acquisition cost MUMPS VACCINE,LIVE VIAL Acquisition cost MUPIROCIN 2% CREAM TOP Acquisition cost MUSC TEST MNL W/RPT; EXTREM/TRNK 95831 $ 70.25 MUSC TSTMAN W/RPT BODY EX HND 95833 $ 88.57 MUSC TSTMAN W/RPT BODY W/HAND 95834 $ 117.13 MUSC TSTNG, MAN WRPT; HND, W/WO CMPRSN 95832 $ 68.97 MUSC TSTNG, MAN WRPT;TOT BDY, EXCLU HNDS 95833 $ 88.57 MUSC TSTNG, MAN WRPT;TOT BDY, INCLU HNDS 95834 $ 117.13 MUSC TSTNG,MAN WRPT;EXTRM(EXCL HND/TRNK) 95831 $ 70.25 MUSCLE BX; PERC NDL 20206 $ 3,564.97 MUSCLE FLAP; LOWER EXTREMITY 15738 $ 7,168.06 MUSCLE FLAP; UPPER EXTREM 15736 $ 4,147.84 MUSCLE TEST; EXTREM OR TNK 95831 $ 70.25 MUSCLE TEST; EXTREM OR TRUNK 95831 $ 70.25 MUSCLE TESTING 95832 $ 68.97 MUSTANG BAL DILATION CATH 75CM C1752 $ 472.50 MUSTANG BALL 5FR DILATION CATH C1752 $ 472.50 MX-FAMILY GROUP PSY THERAPY 90849 $ 241.00 MX-FAMILY GROUP PSYCHOTHERAPY 90849 $ 290.00 MX-FAMILY GROUP PSYCHTHRPY 90849 $ 290.00 MYCELEX VAGINAL CREAM 45GM Acquisition cost MYCO/UREAPL ISOL AGAR PLATES 87109 $ 41.80 MYCOB BLOOD CULT 87015 $ 18.13 MYCOB BLOOD CULTURE 87015 $ 18.13 MYCOB BM CULT 87015 $ 18.13 MYCOB BOWEL MOVEMENT CULT 87015 $ 18.13 MYCOB CSF CULT 87015 $ 18.13 MYCOB CSF CULTURE 87015 $ 18.13 MYCOB FLUID CULT 87015 $ 18.13 MYCOB FLUID CULTURE 87015 $ 18.13 MYCOB MISC CULT 87015 $ 18.13 MYCOB MISC CULTURE 87015 $ 18.13 MYCOB RESPIR CULTURE 87015 $ 18.13 MYCOB SENSITIVITY 87190 $ 16.08 MYCOB STOOL CULTURE 87015 $ 18.13 MYCOB STOOL CULTURE. 87015 $ 18.13 MYCOB TISSUE CULTURE.. 87015 $ 18.13 Page 199 2018 MYCOB URINE CULT 87015 $ 18.13 MYCOB URINE CULTURE.. 87015 $ 18.13 MYCOB WOUND/ABSCESS 87015 $ 18.13 MYCOB WOUND/ABSCESS.. 87015 $ 18.13 MYCOL WND/ABSC CULT 87102 $ 22.84 MYCOLOG (/TRAIM) CR Acquisition cost MYCOLOG (NYSTATIN/TRAIM) OINT Acquisition cost MYCOLOGY B/F CULT 87102 $ 22.84 MYCOLOGY BLOOD CULT 87103 $ 45.01 MYCOLOGY BM CULT 87102 $ 22.84 MYCOLOGY CSF CULT 87102 $ 22.84 MYCOLOGY EYE CULT 87102 $ 22.84 MYCOLOGY HAIR CULT 87102 $ 22.84 MYCOLOGY MOUTH CULT 87102 $ 22.84 MYCOLOGY NAIL CULT 87102 $ 22.84 MYCOLOGY OTHER 87102 $ 22.84 MYCOLOGY OTHER CULT 87102 $ 22.84 MYCOLOGY RESP CULT 87102 $ 22.84 MYCOLOGY SKIN CULT 87101 $ 20.92 MYCOLOGY TISSUE CULT 87102 $ 22.84 MYCOLOGY URINE CULT 87102 $ 22.84 MYCOLOGY VAG CULT 87102 $ 22.84 MYCOPHENOLATE MOFETIL(CELLCEPT) Acquisition cost MYCOPHENOLIC ACID DR 180MG TABLETS J7518 Acquisition cost MYCOPHENOLIC ACID DR 360 MG Acquisition cost MYCOPLASMA ANTIBODY 86738 $ 35.95 MYCOPLASMA IGG 86738 $ 35.95 MYCOPLASMA IGM 86738 $ 35.95 MYCOPLASMA ISOLATION 87109 $ 41.80 MYCOPLASMA PNEU CF 86738 $ 35.95 MYCOSTATIN (NYSTATIN) POWDER Acquisition cost MYELIN ASSOC GLYCOPROTEIN 83520 $ 37.99 MYELIN BASIC PROTEIN 83873 $ 46.73 MYELIN BASIC PROTEIN CEREBROSP FL 83873 $ 46.73 MYELOGRAPHY CERV-RAD S / I 72240 $ 1,803.27 MYELOGRAPHY ENTIRE SP CANAL RAD S/I 72270 $ 1,803.27 MYELOGRAPHY LMBR INJ; 2 + SITES 62305 $ 1,803.27 MYELOGRAPHY LMBR INJ; 2+ SITES 62305 $ 1,803.27 MYELOGRAPHY LUMB INJ 62304 $ 1,803.27 MYELOGRAPHY LUMBAR INJECTION 62304 $ 1,803.27 MYELOGRAPHY LUMBOSACRAL-RAD S / I 72265 $ 1,803.27 MYELOGRAPHY POST FOSSA-RAD S / I 70010 $ 1,206.90 MYELOGRAPHY THORACIC-RAD S / I 72255 $ 1,803.27 MYLERAN 2MG TAB J8510 Acquisition cost MYLICON 80MG TAB Acquisition cost MYOBLOC (TYPE B) 100 UNITS J0587 $ 20.35 MYOCARDIAL IMAG-PET-METABOLIC EVAL 78459 $ 3,180.58 MYOCARDIAL INFARCT IMAGE 78466 $ 924.11 MYOFASCIAL RELEASE, 1 UNIT 97140 $ 60.85 MYOFASCIAL RELEASE, EA 15 MIN. 97140 $ 60.85 MYOGLOBIN 83874 $ 35.09 MYOGLOBIN SERUM 83874 $ 35.09 MYOGLOBIN URINE 83874 $ 35.09 MYOMECTOMY EXCS LEIUM VAGN APP 58145 $ 6,010.51 MYOMECTOMY EXCS OF LEIUMYOMATE 58140 $ 1,957.74 MYOMECTOMY; VAG APPR; 1-4 MYOMAS 58145 $ 6,010.51 Page 200 2018 Myotomy D7856 $ 5,330.00 MYRINGOPLASTY (DRUMHEAD & DONOR AREA) 69620 $ 5,815.59 MYRINGOTOMY INCL ASP &/EUSTACH TUB INFL 69421 $ 5,815.59 MYRINGOTOMY INCL ASPIRAT REQ GEN ANES 69421 $ 5,815.59 MYRINGOTOMY W/ASPIRAT&/EUSTACH 69420 $ 472.05 MYRINGOTOMY W/ASPIRT//EUSTACH TUBE 69420 $ 472.05 MYSOLINE 250 MG. PO Acquisition cost MYSOLINE 250MG TAB Acquisition cost MYSOLINE 250MG/5ML SUSP 240ML Acquisition cost MYSOLINE 50MG TAB Acquisition cost N.S 0.9% WITH 40MEQ. KCL 1000 ML Acquisition cost N.S 100 ML ADDVANTAGE BAG Acquisition cost N.S 15 ML SYRINGE Acquisition cost N.S 250 ML ADDVANTAGE BAG Acquisition cost N.S 50 ML ADDVANTAGE BAG Acquisition cost NA BIPHOS/POTASSIUM PHOSPHATE Acquisition cost NA PHOS,MB/DIB PEDIARTIC ENEMA Acquisition cost NA PHOS,M-B/NA PHOS,DI-BA Acquisition cost NA. PHOSPHATE 15 M.MOL/250ML Acquisition cost NABUMETONE (RELAFEN) 500MG. PO Acquisition cost NABUMETONE (RELAFEN) 750MG. PO Acquisition cost NACI 3% (SODIUM CHLORIDE)-CATEG 1 Acquisition cost NAFCILLIN 1GM ADD VANTAGE Acquisition cost NAFCILLIN 2GM ADD VANTAGE S0032 Acquisition cost NAFCILLIN 40MG/ML NICU 6ML SYR Acquisition cost NAFCILLIN SOD 1GM INJ Acquisition cost NAFCILLIN SOD 2GM INJ Acquisition cost NAFCILLIN SODIUM 500MG VIAL Acquisition cost NAIL C1713 $ 1,350.00 NAIL 011x180MMx125D C1713 $ 1,350.00 NAIL 12x340MM C1713 $ 1,350.00 NAIL BED REPAIR 11760 $ 1,291.09 NAIL DEBRIDEMENT; 1-5 11720 $ 147.99 NAIL END CAP-CATEG 1 Acquisition cost NAIL ENDERS-CATEG 1 Acquisition cost NAIL GAMMA-CATEG 1 Acquisition cost NAIL HUMERAL-CATEG 1 Acquisition cost NAIL LABRAL-CATEG 1 Acquisition cost NAIL RETROGRADE-CATEG 1 Acquisition cost NAIL RETROGRADE-CATEG 2 Acquisition cost NAIL RETROGRADE-CATEG 3 Acquisition cost NAIL TIBIA Acquisition cost NAIL TIBIA-CATEG 1 Acquisition cost NAIL TIBIA-CATEG 2 Acquisition cost NAIL-CATEG 1 C1713 Acquisition cost NALBUPHINE 10MG/ML AMP INJ Acquisition cost NALDOLOL 20 MG. PO Acquisition cost NALOXONE INTRANASAL 2MG/2MG SYRINGE J2310 Acquisition cost NALTREXONE 50MG TABLET J8499 Acquisition cost NAPHAZOLINE 0.012% OPT DROP Acquisition cost NAPHCON-A OPTH DROPS 15ML Acquisition cost NAPROSYN 250MG TAB Acquisition cost NAPROSYN 500MG TAB Acquisition cost NARCAN 0.02MG/ML NEONAT 2ML J2310 Acquisition cost NARCAN 0.4MG/ML INJ 10ML VIAL J2310 Acquisition cost NARCAN 0.4MG/ML INJ 1ML VIAL J2310 Acquisition cost Page 201 2018 NARCOSYNTHESIS FOR PSYCH DX & 90865 $ 290.00 NAROPIN 1 MG/ML 0.2% INJ J2310 Acquisition cost NAROPIN 5MG/ML INJ 0.5% J2795 Acquisition cost NAS/ORO-GAS TUBE PLC-NEED PHYS 43752 $ 872.74 NAS/SINUS ENDO W BALLN DIL 31296 $ 12,863.66 NASAL BONES 70160 $ 164.27 NASAL CANNULA 94799 $ 360.51 NASAL ENDO DX UNILAT/BILAT (SE 31231 $ 415.40 NASAL ENDO DX UNILAT/BILT (SEPART PROC) 31231 $ 415.40 NASAL ENDO DX W MAXIL SINUSOT 31233 $ 992.95 NASAL ENDO ETHMOIDECTOMY; PARTIAL 31254 $ 12,863.66 NASAL ENDO W ETHMOIDECTOMY; TOTAL 31255 $ 12,863.66 NASAL ENDO W MA; W REM TISSUE MAX SIN 31267 $ 12,863.66 NASAL ENDO W MAXILL ANTROSTOMY 31256 $ 6,919.73 NASAL ENDO; W BLOOD CONTROL 31238 $ 3,500.62 NASAL ENDO; W CONCHA BULLA RESECT 31240 $ 3,500.62 NASAL ENDO; W DACRYOCYSTORHINOSTMY 31239 $ 6,919.73 NASAL ENDOSCOPY CONTROL OF NASAL HEMRHGE 31238 $ 3,500.62 NASAL ENDOSCOPY,SURG; W/BX, 31237 $ 3,500.62 NASAL ENDOSCOPYSURGICL; W/BX 31237 $ 3,500.62 NASAL FUNCTION STUDIES 92512 $ 658.04 NASAL MOIST GEL (FOR SCC ONLY) Acquisition cost NASAL/SIN ENDO W REM TIS SPHEN SINUS 31288 $ 12,863.66 NASAL/SINUS ENDO W BLD CNTROL 31238 $ 3,500.62 NASAL/SINUS ENDO W FRONTAL SINUS EXPL 31276 $ 12,863.66 NASAL/SINUS ENDOSC W SPHENOIDOTOMY 31287 $ 12,863.66 NASALCROM NASAL SPRAY 13ML J7631 Acquisition cost NASOLACR DUCT PROBE; REQ GEN ANESTH 68811 $ 4,790.26 NASOPHARYNGEAL AIRWAY-CATEG 1 Acquisition cost NASOPHARYNGOSCOPY 92511 $ 415.40 NASOPHARYNX;BX;VISIBLE LES;SIM 42804 $ 5,815.59 NATRIURETIC PEPTIDE 83880 $ 92.18 N-AUTOM URINALYS WO MICRO 81002 $ 7.66 NAVANE 80299 $ 41.01 NAVIGAT HD URETER ACCES SHEATH C1894 $ 185.88 NAVIGAT HD URETER ACCSS SHEATH C1894 $ 185.88 NAVIGATIONAL BRONCHOSCOPY 31627 $ 213.44 NCPAP (NEONATE/PEDS) 94660 $ 492.89 ND ELCTMYGRP;LMT STD MUSC 1 EXTRM/AX MUS 95870 $ 147.99 ND ELCTMYGRP;THRC PRSPNL MUS-EXCL T1/T12 95869 $ 360.51 NDL 21G X 1 1/2 SHER $ 0.25 NDL ELECTROMYOGRAPHY; LARYNX 95865 $ 277.79 NDLE 25G X 5/8 $ 47.70 NDLE ELCTRMYGRPHY; EA EXTRM; 0-4 MUSC 95885 $ 41.45 NDLE ELCTRMYGRPHY; EA EXTRM; 5< MUSC 95886 $ 101.60 NDLE ELCTRMYGRPHY; NON-EXTRM 95887 $ 83.69 NDSC DCMPRN 1 NTRSPC LUMBAR 62380 $ 14,826.61 NEBCIN 80MG/2ML INJ 2ML J3260 Acquisition cost NEBIVOLOL 5 MG. PO Acquisition cost NEBULIZER WITH COMPRESSOR E0570 $ 109.14 NECK SOFT TISSUE MRI W/W/O CONTRAST 70543 $ 1,206.90 NECK SOFT TISSUE MRI WITH CONTRAST 70542 $ 1,206.90 NECK CONTOUR-CATEG 1 Acquisition cost NECK SOFT TISSUE MRI WITHOUT CONTRAST 70540 $ 614.37 NECK SOFT TISSUE CT W/W/O CONTRAST 70492 $ 668.38 NECK SOFT TISSUE CT WITHOUT CONTRAST 70490 $ 302.70 Page 202 2018 NECK SOFT TISSUE CT WITH CONTRAST 70491 $ 668.38 NECK SOFT TISSUES 70360 $ 164.27 NECK SPINE FUSE/REM; BEL C2 22551 $ 26,770.83 NECK THYROID SHEET 76X120 $ 9.86 NECK/ SOFT TISSUE ULTRASOUND 76536 $ 302.70 NEEDLE #2 TIGER LOOP C2618 $ 75.00 NEEDLE 19G X 1/2 THIN WALL A4215 $ 0.47 NEEDLE ACUFLEX-CATEG 1 Acquisition cost NEEDLE ACUPUNCTURE-CATEG 1 Acquisition cost NEEDLE ASPIRATION BREAST 19000 $ 1,514.94 NEEDLE ASPIRATION-CATEG 1 Acquisition cost NEEDLE BIOPSY QUICK CORE-CATEG 1 Acquisition cost NEEDLE BIOPSY-CATEG 1 Acquisition cost NEEDLE BIOPSY-CATEG 2 Acquisition cost NEEDLE BIOPSY-CATEG 3 Acquisition cost NEEDLE BIOPSY-CATEG 4 Acquisition cost NEEDLE BLUNT-CATEG 1 Acquisition cost NEEDLE CO-AX-CATEG 1 Acquisition cost NEEDLE COLORADO-CATEG 1 Acquisition cost NEEDLE CORE BIOPSY, PERCUTANEOUS 19100 $ 3,564.97 NEEDLE CURVED TIP-CATEG 1 Acquisition cost NEEDLE CV-O-CATEG 1 Acquisition cost NEEDLE DISP ENTRY-CATEG 1 Acquisition cost NEEDLE ELCTRO SURG-CATEG 1 Acquisition cost NEEDLE ELECTROMYOGRAPHY, EYE MUSCLES 92265 $ 147.99 NEEDLE EMG CRAN NERV SUPP MUSC; BIL 95868 $ 360.51 NEEDLE EMG CRAN NERV SUPP MUSC; UNI 95867 $ 360.51 NEEDLE EMG FOR GUIDANCE WITH CHEMOD 95874 $ 43.78 NEEDLE EMG STDY ANAL/URETHRAL SPHIN 51785 $ 607.00 NEEDLE EMG W/QUAN MEAS EA MUSC STDY 95872 $ 360.51 NEEDLE EMG; 1 EXTREM W/WO PARASPNL 95860 $ 277.79 NEEDLE EMG; 2 EXTREM W/WO PARASPNL 95861 $ 277.79 NEEDLE EMG; 3 EXTREM W/WO PARASPNL 95863 $ 360.51 NEEDLE EMG; 4 EXTREM W/WO PARASPNL 95864 $ 360.51 NEEDLE EMG; THORACIC PARASPINAL MUSCLES 95869 $ 360.51 NEEDLE ENDO-CATEG 1 Acquisition cost NEEDLE EPIDURAL-CATEG 1 Acquisition cost NEEDLE EPIDURAL-CATEG 2 Acquisition cost NEEDLE EXTRA FINE-CATEG 1 Acquisition cost NEEDLE FINE-CATEG 1 Acquisition cost NEEDLE FISTULA-CATEG 1 Acquisition cost NEEDLE FISTULA-CATEG 2 Acquisition cost NEEDLE FOR INSULIN PEN Acquisition cost NEEDLE GERTE MARX-CATEG 1 Acquisition cost NEEDLE GERTE MARX-CATEG 2 Acquisition cost NEEDLE GUT-CATEG 1 Acquisition cost NEEDLE HUBER-CATEG 1 Acquisition cost NEEDLE HUBER-CATEG 2 Acquisition cost NEEDLE INSECTION-CATEG 1 Acquisition cost NEEDLE -CATEG 1 Acquisition cost NEEDLE INSUFFLATOR/ACCESS-CATEG 1 Acquisition cost NEEDLE JAMISHIDI-CATEG 1 Acquisition cost NEEDLE JAMISHIDI-CATEG 2 Acquisition cost NEEDLE JAMISHIDI-CATEG 3 Acquisition cost NEEDLE JAMSHIDI BN MARROW-CATEG 1 Acquisition cost NEEDLE KEITH-CATEG 1 Acquisition cost Page 203 2018 NEEDLE KINGLI-CATEG 1 Acquisition cost NEEDLE MERSILENE-CATEG 1 Acquisition cost NEEDLE MONOPOLAR-CATEG 1 Acquisition cost NEEDLE NEUROTRACE-CATEG 1 Acquisition cost NEEDLE PLACEMENT /BIOPSY 77002 $ 61.20 NEEDLE PLCMNT; 36680 $ 872.74 NEEDLE PLEURAL BX-CATEG 1 Acquisition cost NEEDLE PORT-A-CATH-CATEG 1 Acquisition cost NEEDLE PRESS-CATEG 1 Acquisition cost NEEDLE PUNCH BX-CATEG 1 Acquisition cost NEEDLE QINCKE-CATEG 1 Acquisition cost NEEDLE RETROBULBAR-CATEG 1 Acquisition cost NEEDLE ROSENTHAL-CATEG 1 Acquisition cost NEEDLE SAUCER-CATEG 1 Acquisition cost NEEDLE SEIRIN-CATEG 1 Acquisition cost NEEDLE SELDINGER-CATEG 1 Acquisition cost NEEDLE SINGLE WALL-CATEG 1 Acquisition cost NEEDLE SOFT TIP-CATEG 1 Acquisition cost NEEDLE SPECIAL TECHNIQUE-CATEG 1 Acquisition cost NEEDLE SPHINCTERTOME-CATEG 1 Acquisition cost NEEDLE SPINAL 22G1X 1/2 A4215 $ 2.35 NEEDLE SPINAL-CATEG 1 Acquisition cost NEEDLE SPINAL-CATEG 2 Acquisition cost NEEDLE SPINAL-CATEG 3 Acquisition cost NEEDLE SPINAL-CATEG 4 Acquisition cost NEEDLE STRAIGHT KEITH-CATEG 1 Acquisition cost NEEDLE TECHNA-CUT-CATEG 1 Acquisition cost NEEDLE TROCAR-CATEG 1 Acquisition cost NEEDLE TRU-CUT-CATEG 1 Acquisition cost NEEDLE ULTRA-VU-CATEG 1 Acquisition cost NEEDLE VARIJECT-CATEG 1 Acquisition cost NEEDLE VERUS-CATEG 1 Acquisition cost NEEDLE VICRYL-CATEG 1 Acquisition cost NEEDLE YUEH CENTESIS-CATEG 1 Acquisition cost NEEDLE, MAGNUM, DISP 18GX20 C2618 $ 555.00 NEEDLE/INTRACATH INTRO; EXTREM ART 36140 $ 195.01 NEEDLE/STOPCOCK-CATEG 1 Acquisition cost NEEDLE-CATEG 1 Acquisition cost NEEDLES 20G X1-1/2 (BD) A4215 $ 0.04 NEEDLES 25GX1-1/2 (BD) A4215 $ 0.05 NEEDLES 25GX5/8 (BD) A4215 $ 47.70 NEEDLES 26GX1/2 (BD) A4215 $ 0.21 NEEDLES SPINAL 18X2-1/2 (BD) A4215 $ 1.77 NEEDLES SPINAL 18X3 (BD) A4215 $ 1.66 NEEDLES SPINAL 18X3-1/2 (BD) A4215 $ 2.13 NEEDLES SPINAL 19X3-1/2 (BD) A4215 $ 1.61 NEEDLES SPINAL 20X1-1/2 (BD) A4215 $ 2.29 NEEDLES SPINAL 20X2-1/2 (BD) A4215 $ 2.35 NEEDLES SPINAL 20X3 (BD) A4215 $ 219.09 NEEDLES SPINAL 20X3-1/2 (BD) A4215 $ 2.12 NEEDLES SPINAL 22X2-1/2 (BD) A4215 $ 2.34 NEEDLES SPINAL 22X3 (BD) A4215 $ 2.03 NEEDLES SPINAL 22X3-1/2 (BD) A4215 $ 2.08 NEFAZODONE 100MG TAB Acquisition cost NEFAZODONE 150MG TAB Acquisition cost NEFAZODONE HCL 200MG TAB Acquisition cost Page 204 2018 NEFAZODONE HCL 50MG TABLET Acquisition cost NEGATIVE PRESSURE VENTILATION, CNP 94662 $ 1,218.36 NEISSERIA AMPLIF NA PROBE 87591 $ 95.33 NELFINAVIR 50MG/ML ORAL SOLN Acquisition cost NELFINAVIR MES 625MG TAB Acquisition cost NELFINAVIR MESYL 250MG TAB Acquisition cost NELFINAVIR MESYLATE 50MG/SCOOP Acquisition cost NEO/POLY B SULF./HC OTIC SUSP 10ML $ 180.95 NEO/POLYMYX B SULF/DEXAMETH Acquisition cost NEO-CALGLUCON 1.8GM/5ML 480ML Acquisition cost NEOMY SULF/PLYMX B HC EYE DROP Acquisition cost NEOMY/BACITR/POLYMIX EYE OINT Acquisition cost NEOMY/PLYMX B HC EAR SOLUTION Acquisition cost NEOMY/PLYMX B HC EAR SUSPENSION Acquisition cost NEOMY/POLYMIX B/HC CREAM TOP Acquisition cost NEOMYC SUL/DEXA SOD PHOS EYE DR Acquisition cost SULFATE 500MG TAB Acquisition cost NEOMYCIN/POLYMIXIN B 40MG/1 LIT. IRRIGAT Acquisition cost NEOMYCIN/POLYMIXIN/BACIT/HYDRO.OPH.OINT. Acquisition cost NEONATAL MANUAL RESUSCITATOR-CATEG 1 Acquisition cost NEONATAL OXYTIP SENSOR-CATEG 1 Acquisition cost NEOPROFEN INJECTION Acquisition cost NEOSPORIN OPHTH. DROP Acquisition cost NEOSPORIN OPTH DROPS 10ML Acquisition cost NEOSPORIN OPTH OINT Acquisition cost NEOSTIGMINE 1:1000 INJ 10ML VIAL Acquisition cost NEOSTIGMINE 5MG/5ML SYRINGE Acquisition cost NEOSTIGMINEMETHYLSULFATE1:2000 J2710 Acquisition cost NEO-SYNEPHRIN 1% INJ 1ML VIAL J2370 Acquisition cost NEO-SYNEPHRINE 0.5% NASAL Acquisition cost NEPHELOMETRY EA ANALYTE NES 83883 $ 36.94 NEPHRO 10FRPERCUT LOOPCATH DRN C1726 $ 116.85 NEPHRO 8FR PERCUTAN CATH DRAIN C1729 $ 123.00 NEPHRO 8FR PERCUTAN LOOP CATH C1726 $ 116.85 NEPHRO CATH 10FR LOCK LOOP C1726 $ 135.30 NEPHRO REENTRY MALECO CATH DRN C1758 $ 110.70 NEPHROURETHRO STENT C2625 $ 9,302.40 NEPHRO-VITE Acquisition cost NEPTAZINE 25 MG TAB Acquisition cost NERV TEASING PREP 88362 $ 1,430.62 NERVE DESTR-PUDENDAL NERVE BLK 64430 $ 1,777.62 NERVE DESTR-TRIGEMINA NERVE 64600 $ 1,777.62 NERVE TEASING 88362 $ 1,430.62 NERVEANA SURGICAL KIT ET TUBE C4324 $ 1,361.25 NESACAINE 2% INJ 30ML VIAL J2400 Acquisition cost NESACAINE 3% INJ 30ML VIAL J2400 Acquisition cost NESIRITIDE 0.5MG VIAL INJ J2325 Acquisition cost NET DISP FIBER OPTIC-CATEG 1 Acquisition cost NET ROTH-CATEG 1 Acquisition cost NEULASTA 6MG INJECT J2505 $ 16,449.99 NEUPOGEN 80MCG./ML Acquisition cost NEURO AGNT DEST SUP HYPOGASTRC PLXS 64681 $ 1,777.62 NEURO BR, LONG 3.0MM C1713 $ 148.50 NEURO BUR, MEDIUM 3.0MM C1713 $ 148.50 NEURO COARSE DIAM BUR/SUPR LNG C1713 $ 178.82 NEURO US 76506 $ 302.70 Page 205 2018 NEUROBEH STATUS EXW/INTER 96116 $ 590.48 NEUROBEHAVRL STATUS EXW/INTER 96116 $ 590.48 NEUROBHVRL STATUS EX,W/INTER 96116 $ 590.48 NEUROMUSC JUNC TST EA NERV 1 METH 95937 $ 360.51 NEUROMUSCULAR IMP NEUROSTIM ELCTRD 64580 $ 48,577.94 NEUROMUSCULAR RE-ED 23 TO 37 MIN. 97112 $ 75.90 NEUROMUSCULAR RE-ED 38 TO 52 MIN. 97112 $ 75.90 NEUROMUSCULAR RE-ED 53 TO 68 MIN. 97112 $ 75.90 NEUROMUSCULAR RE-ED 8 TO 22 MIN. 97112 $ 75.90 NEURONTIN 100MG CAP Acquisition cost NEURONTIN 400MG CAP Acquisition cost NEUROPLASTY MAJ PERIPH NRV; ARM/LEG 64708 $ 4,259.09 NEUROPLASTY; BRACHIAL PLEXUS 64713 $ 4,259.09 NEUROPLASTY; DIGITAL 1/BOTH SAME DIGIT 64702 $ 4,259.09 NEUROPLASTY; MEDIAN @ CARPAL TUNNEL 64721 $ 4,259.09 NEUROPLASTY; ULNAR NRV AT ELBOW 64718 $ 4,259.09 NEUROPLSTY; MEDIAN NERVE AT CARP TUN 64721 $ 4,259.09 NEUROPLSTY; ULNAR NRV AT WRIST 64719 $ 4,259.09 NEUROPSY TESTING BATTERY,W/I 96118 $ 590.48 NEUROPSYCH TESTING BATTERY W/I 96118 $ 590.48 NEUROPSYCH TESTING BATTERYW/I 96118 $ 590.48 NEUROPSYCH TESTING BY TEC 96119 $ 590.48 NEUROPSYCH TST ADMIN W/COMP 96120 $ 373.00 NEUROSTIMULATOR ANALYSIS (PULSE) 95970 $ 277.79 NEUROSTIMULATOR ANALYSIS, EA 30 MIN >1HR 95975 $ 201.89 NEUROSTIMULATOR ANALYSIS, FIRST HR 95974 $ 304.61 NEUTRAPHOS 50MG/3ML Acquisition cost NEUTRAPHOS 50MG/5ML/CHERRYSYRUP Acquisition cost NEVIRAPINE 50MG/5ML 240ML Acquisition cost NEXGEN ALLPLY PAT SZ32MMx8.5MM KNEE SOL C1776 $ 1,702.13 NEXGEN FEM COMP PRECOAT SZ-F; LT C1776 $ 4,181.10 NEXGEN STEM EXT STR 13MM DIA x 100L C1776 $ 2,001.00 NEXIUM 20 MG. Acquisition cost NEXIUM IV INFUSION BAG Acquisition cost NG TUBE PLC W FLUORO 43752 $ 872.74 NIACIN 1000MG (NIASPAN) TAB PO Acquisition cost NIACIN 100MG Acquisition cost NIACIN 250MG TAB Acquisition cost NIACIN 500MG (NIASPAN) TAB PO Acquisition cost NIACIN 750MG (NIASPAN) TAB PO Acquisition cost NIACINAMIDE 500MG TAB Acquisition cost NICARDEPINE 25MG/10ML IV Acquisition cost NICARDIPINE 20 MG CAP Acquisition cost NICARDIPINE 20MG/ 200ML Acquisition cost NICARDIPINE 20mg/ 200ml IN NORMAL SALINE Acquisition cost NICARDIPINE 30 MG CAP Acquisition cost NICARDIPINE IV 20MG/200ML J3490 $ 290.40 NICOTINE GUM 2MG. Acquisition cost NICOTINE LEVEL 80323 $ 11.00 NIFEDIPINE 10MG CAP Acquisition cost NIFEDIPINE 30MG TAB J8499 $ 2.44 NIFEDIPINE 60MG TAB SA OSM U-D Acquisition cost NIFEREX 150 MG CAP Acquisition cost NILANDRON 50 MG TAB Acquisition cost NIMBEX 2MG/ML 10ML INJ Acquisition cost NIMODIPINE 30MG CAP Acquisition cost Page 206 2018 NIMODIPINE 60MG/20ML ORAL SOLUTION Acquisition cost NIMODIPINE 60MG/2ML; PHRM ORAL SOLN Acquisition cost NIPPLE EXPL W/WO EXC DUCT 19110 $ 7,213.98 NIPPLE/AREOLA RECON 19350 $ 7,213.98 NIPRIDE 50MG/2ML INJ 2ML VIAL Acquisition cost NIR BILIARY STENT 7 CELL Acquisition cost NIR BILIARY STENT 9 CELL Acquisition cost NISOLDIPINE 10MG TABLET PO Acquisition cost NISOLDIPINE 20MGTABLET PO Acquisition cost NISOLDIPINE 30MG TABLET PO Acquisition cost NISOLDIPINE 40MG TABLET PO Acquisition cost NITAZOXANIDE (ALINIA) 500MG. PO Acquisition cost NITINOL STENT 7MM X 40MM Acquisition cost NITINOL WIRE 12 X 45CM C1713 $ 81.00 NITRO-DUR/NITROGLYCERIN.6MG/HR Acquisition cost NITROFURANTOIN 25MG/5ML ORAL SUSP Acquisition cost NITROFURANTOIN 25MG/ML ORAL DROPS Acquisition cost NITROFURANTOIN MACRO 100MG Acquisition cost NITROGLY TRANSDRM 0.1MG/HR PATCH Acquisition cost NITROGLY TRANSDRM 0.2MG/HR PATCH Acquisition cost NITROGLY TRANSDRM 0.3MG/HR PATCH Acquisition cost NITROGLY TRANSDRM 0.4MG/HR PATCH Acquisition cost NITROGLYCERIN 2% OINTMENT 30GM Acquisition cost NITROGLYCERIN 50 MCG/ML D5%W 10ML Acquisition cost NITROGLYCERIN 50MG, IN, 10ML VIAL J3490 $ 29.04 NITROGLYCERIN INJ 50MG/10ML Acquisition cost NITROGLYCERIN IV 5% J3490 $ 46.38 NITROGLYCERIN OINT 2% $ 5.52 NITROGLYCERIN OINT 2% 30GMS Acquisition cost NITROGLYCERINE 0.2MG/ML 250ML Acquisition cost NITROGLYCERINE 0.4MG TAB (1/150GR)/BTLE J8499 $ 2.44 NITROPRUSSIDE 50MG/2ML INJ J3490 $ 726.00 NITROSTAT 0.3MG SL TAB 100 BOT Acquisition cost NITROSTAT 0.4MG SL TAB 100BOT Acquisition cost NIVOLUMAB (OPDIVO) Acquisition cost NJX INTERLAMINAR LMBR/SAC 62323 $ 1,437.02 NJX PLATELET PLASMA 0232T $ 872.74 NJX PX NFROSGRM &/URTRGRM 50431 $ 1,495.78 NOCT URETH TUMESCENCE 54250 $ 607.00 NOCTEC 500MG CAP Acquisition cost NON-ARTHROSCOPIC LYSIS AND LAVAGE D7871 $ 690.00 NON-CARDIAC VASCULAR FLOW IMAGING 78445 $ 924.11 NON-DRUG DEPENDENT PLATELET AB 86022 $ 49.90 NON-INTRAVENOUS CONSCIOUS SEDATION D9248 $ 60.00 NONINVAS OXIMETRY;OVERNITE-SEP PROC 94762 $ 360.51 NONINVAS OXIMETRY-O2 SAT; 1 DETERM 94760 $ 3.80 NONINVAS OXIMETRY-O2 SAT; MX DETERM 94761 $ 29.70 NONINVAS STDY XTRACRAN ART BIL STDY 93880 $ 614.37 NONINVAS STDY-UP/LO EXTM ART 1 LEV 93922 $ 277.79 NONINVAS STDY-UP/LO EXTM ART MX LEV 93923 $ 360.51 NONINVASIV PHYSIOL STDY-LO EXTM ART 93924 $ 360.51 NON-LOCKING SCREW 2.3MM X 10 C1713 $ 124.32 NONLOCKING SCREW 22MM C1713 $ 43.04 NONMEDICARE DEFINITY Q9957 $ 250.89 NONPRESS INHALA TX ACUT AIRWAY OBST 94640 $ 492.89 NON-RAD DX ANESTH 106 - 120 MINUTES $ 440.00 Page 207 2018 NON-RAD DX ANESTH 121 - 135 MINUTES $ 495.00 NON-RAD DX ANESTH 136 - 150 MINUTES $ 550.00 NON-RAD DX ANESTH 151 - 165 MINUTES $ 605.00 NON-RAD DX ANESTH 16 - 30 MINUTES $ 110.00 NON-RAD DX ANESTH 166 - 180 MINUTES $ 660.00 NON-RAD DX ANESTH 181 - 195 MINUTES $ 715.00 NON-RAD DX ANESTH 196 - 210 MINUTES $ 770.00 NON-RAD DX ANESTH 211 - 225 MINUTES $ 825.00 NON-RAD DX ANESTH 226 - 240 MINUTES $ 880.00 NON-RAD DX ANESTH 241 - 255 MINUTES $ 935.00 NON-RAD DX ANESTH 256 - 270 MINUTES $ 990.00 NON-RAD DX ANESTH 271 - 285 MINUTES $ 1,045.00 NON-RAD DX ANESTH 286 - 300 MINUTES $ 1,100.00 NON-RAD DX ANESTH 301 - 315 MINUTES $ 1,155.00 NON-RAD DX ANESTH 31 - 45 MINUTES $ 165.00 NON-RAD DX ANESTH 316 - 330 MINUTES $ 1,210.00 NON-RAD DX ANESTH 331 - 345 MINUTES $ 1,265.00 NON-RAD DX ANESTH 346 - 360 MINUTES $ 1,320.00 NON-RAD DX ANESTH 361 - 375 MINUTES $ 1,375.00 NON-RAD DX ANESTH 376 - 390 MINUTES $ 1,430.00 NON-RAD DX ANESTH 391 - 405 MINUTES $ 1,485.00 NON-RAD DX ANESTH 406 - 415 MINUTES $ 1,540.00 NON-RAD DX ANESTH 431 - 445 MINUTES $ 1,650.00 NON-RAD DX ANESTH 446 - 460 MINUTES $ 1,705.00 NON-RAD DX ANESTH 46 - 60 MINUTES $ 220.00 NON-RAD DX ANESTH 461 - 475 MINUTES $ 1,760.00 NON-RAD DX ANESTH 476 - 495 MINUTES $ 1,815.00 NON-RAD DX ANESTH 496 - 510 MINUTES $ 1,870.00 NON-RAD DX ANESTH 511 - 525 MINUTES $ 1,925.00 NON-RAD DX ANESTH 526 - 540 MINUTES $ 1,980.00 NON-RAD DX ANESTH 541 - 555 MINUTES $ 2,035.00 NON-RAD DX ANESTH 556 - 570 MINUTES $ 2,090.00 NON-RAD DX ANESTH 571 - 585 MINUTES $ 2,145.00 NON-RAD DX ANESTH 586 - 600 MINUTES $ 2,200.00 NON-RAD DX ANESTH 61 - 75 MINUTES $ 275.00 NON-RAD DX ANESTH 76 - 90 MINUTES $ 330.00 NON-RAD DX ANESTH 91 - 105 MINUTES $ 385.00 NON-RAD DX ANESTH < 15 MINUTES $ 55.00 NON-REBREATH OXYGN FACE MASK; PEDS 94450 $ 360.51 NON-RENAL EM 88348 $ 1,430.62 NON-ROUTINE BLOOD DRAW; 3+YRS 36410 $ 20.46 NON-SEL WND DEBR-NO ANES 97602 $ 446.80 NONSELECTIVE CATH INTRO - AORTA 36200 $ 299.86 NON-SELECTIVE CATH PLACEMENT IN VEIN 36000 $ 44.00 NOREPINEPHRINE (16 MG/ 250 ML NS) J3490 Acquisition cost NOREPINEPHRINE 4MG/4ML INJ J3490 $ 29.04 NOREPINEPHRINE BIT 1MG/ML INJ 4ML Acquisition cost NOREPINEPHRINE IV 16MG J3490 $ 50.05 NOREPINEPHRINE PREMIXED IV Acquisition cost NORETHINDRONE 5MG. PO Acquisition cost NORG/ETHINYL ESTRADIOL Acquisition cost NORGEST/ETHINYL ESTRADI Acquisition cost NORGEST-ET ESTRA 0.5/0.05 BC TB Acquisition cost NORGESTREL-ETHINYL 0.5-0. Acquisition cost NORIAN DELIVERY NEEDLE C2618 $ 55.50 NORMLGEL 0.17 OZ. (5GM) $ 61.66 Page 208 2018 NORPACE 80299 $ 41.01 NORTRIPTYLINE HCL 10MG CAP Acquisition cost NORTRIPTYLINE HCL 25MG CAP Acquisition cost NORTRIPTYLINE HCL 50MG CAP Acquisition cost NORTRIPTYLINE HCL 75MG CAP Acquisition cost NORTRIPYLINE 80335 $ 11.00 NORVASC 10MG TAB Acquisition cost NORVASC 2.5MG TAB Acquisition cost NORVASC 5MG TAB Acquisition cost NORVIR 100MG CAP Acquisition cost NOT IN USE Acquisition cost NOT USED Acquisition cost NOVOLIN 70/30 INSULIN VIAL J1815 $ 1.96 NOVOLOG 50U/ML J1817 Acquisition cost NRG CEMENTED FEMUR&TIB X3 INS&PATELLA C1776 $ 5,649.98 NRMSL M/DEX 5% 1000 #7965-09 $ 2.58 NRMSL M/DEX 5% 500 #7965-03 $ 1.97 NRV CONDUCT TEST; >13 STUDIES 95913 $ 1,175.22 NRV CONDUCT TEST; 11-12 STUDIES 95912 $ 1,175.22 NRV CONDUCT TEST; 1-2 STUDIES 95907 $ 360.51 NRV CONDUCT TEST; 3-4 STUDIES 95908 $ 658.04 NRV CONDUCT TEST; 5-6 STUDIES 95909 $ 658.04 NRV CONDUCT TEST; 7-8 STUDIES 95910 $ 658.04 NRV CONDUCT TEST; 9-10 STUDIES 95911 $ 1,175.22 NRV GRFT, SING ARM/LEG; UP TO 4CM LONG 64892 $ 12,238.01 NRV REP W ALLOGRAFT; EACH 64910 $ 12,238.01 NRVEGRAFT 2-3MM DIA 50MM LNGTH C1768 $ 3,225.00 NS+KPO4 20MEQ + K.ACETATE 20MEQ. 1000 ML Acquisition cost NSL/SINS NDSC SPHN TISS RMVL 31259 $ 12,863.66 NSL/SINS NDSC TOT W/SPHENDT 31257 $ 12,863.66 NSL/SINS NDSC TOTAL 31253 $ 12,863.66 NSL/SINUS ENDO; W BX, POLYCTMY, DEBRID 31237 $ 3,500.62 NSL/SNUS ENDO W MED&INF ORBTL WALL DCMP 31293 $ 12,863.66 NSL/SNUS ENDO W MED/INF ORBTL WALL DCMP 31292 $ 12,863.66 NSTM ANAL-PLS GN/TRANS W INTROP/SUB RPGM 95971 $ 304.61 NSTM ANL-PLS GN/TRN W INTROP/SUB RPGM 1H 95972 $ 304.61 NTG 0.125 (6 GRAM) OINTMENT $ 0.10 NUMERAL HEAD 16 X 38 Acquisition cost NUMERAL STEM 8 X 145 Acquisition cost NURSERY $ 475.00 NURSERY LEVEL 4 (NICU) $ 3,025.00 NUT LOCK-CATEG 1 Acquisition cost NUT OUTER-CATEG 1 Acquisition cost NUTRISOURCE FIBER $ 0.10 NUTRITION COUNSELING 97802 $ 70.75 NUTRITIONAL COUNSELING D1310 $ 78.00 NYLON BLACK MONO $ 80.03 NYSTATIN 100,000 UNIT/GM OINT 15GM Acquisition cost NYSTATIN 100,000 UNIT/ML ORAL SUSP Acquisition cost NYSTATIN 100,000 UNITS/G. TOPICAL POWDER Acquisition cost NYSTATIN 100,000 UNITS/ML Acquisition cost NYSTATIN 100,000UNIT/GM CREAM 15GM Acquisition cost NYSTATIN 500,000 UNIT PO TABLET Acquisition cost NYSTATIN VAGINAL TABLET Acquisition cost O. R. - TBE THORACOSTMY W/WO WATR SEAL 32551 $ 2,599.54 O/P SURGERY 106 - 120 MINUTES $ 3,960.00 Page 209 2018 O/P SURGERY 121 - 135 MINUTES $ 4,455.00 O/P SURGERY 136 - 150 MINUTES $ 4,950.00 O/P SURGERY 151 - 165 MINUTES $ 5,445.00 O/P SURGERY 16 - 30 MINUTES $ 990.00 O/P SURGERY 166 - 180 MINUTES $ 5,940.00 O/P SURGERY 181 - 195 MINUTES $ 6,435.00 O/P SURGERY 196 - 210 MINUTES $ 6,930.00 O/P SURGERY 211 - 225 MINUTES $ 7,425.00 O/P SURGERY 226 - 240 MINUTES $ 7,920.00 O/P SURGERY 241 - 255 MINUTES $ 8,415.00 O/P SURGERY 256 - 270 MINUTES $ 8,910.00 O/P SURGERY 271 - 285 MINUTES $ 9,405.00 O/P SURGERY 286 - 300 MINUTES $ 9,900.00 O/P SURGERY 301 - 315 MINUTES $ 10,395.00 O/P SURGERY 31 - 45 MINUTES $ 1,485.00 O/P SURGERY 316 - 330 MINUTES $ 10,890.00 O/P SURGERY 331 - 345 MINUTES $ 11,385.00 O/P SURGERY 346 - 360 MINUTES $ 11,880.00 O/P SURGERY 361 - 375 MINUTES $ 12,375.00 O/P SURGERY 376 - 390 MINUTES $ 12,870.00 O/P SURGERY 391 - 405 MINUTES $ 13,365.00 O/P SURGERY 406 - 415 MINUTES $ 13,860.00 O/P SURGERY 416 - 430 MINUTES $ 14,355.00 O/P SURGERY 431 - 445 MINUTES $ 14,850.00 O/P SURGERY 446 - 460 MINUTES $ 15,345.00 O/P SURGERY 46 - 60 MINUTES $ 1,980.00 O/P SURGERY 461 - 475 MINUTES $ 15,840.00 O/P SURGERY 476 - 495 MINUTES $ 16,335.00 O/P SURGERY 496 - 510 MINUTES $ 16,830.00 O/P SURGERY 511 - 525 MINUTES $ 17,325.00 O/P SURGERY 526 - 540 MINUTES $ 17,820.00 O/P SURGERY 541 - 555 MINUTES $ 18,315.00 O/P SURGERY 556 - 570 MINUTES $ 18,810.00 O/P SURGERY 571 - 585 MINUTES $ 19,305.00 O/P SURGERY 586 - 600 MINUTES $ 19,800.00 O/P SURGERY 61 - 75 MINUTES $ 2,475.00 O/P SURGERY 76 - 90 MINUTES $ 2,970.00 O/P SURGERY 91 - 105 MINUTES $ 3,465.00 O/P SURGERY < 15 MINUTES $ 495.00 O2 CONC CAPABL 85%/> O2 @PRSC RATE E1390 $ 1,066.40 O2 UPTAKE EXPIRED GAS; REST-SP 94690 $ 84.11 OB US; NUCHAL MEAS; 1 GEST 76813 $ 302.70 OB US; NUCHAL MEAS; EA ADDL GEST 76814 $ 112.00 OBSERVATION OVER 8 HOURS G0378 $ 225.00 OBSTETRICS PRIVATE ROOM $ 3,900.00 OBSTETRICS SEMI PRIVATE ROOM $ 1,950.00 OBTAIN SCREEN PAP SMEAR Q0091 $ 46.20 OBTURATOR FLEX,CURV DRILL GUID C1713 $ 223.50 Obturator prosthesis, interim D5936 $ 6,980.00 Obturator prosthesis, modificat D5933 Acquisition cost Obturator prosthesis, surgical D5931 $ 4,190.00 Obturator prosthesis,definitive D5932 $ 7,837.00 OCCLUDE FALLOPIAN TUBES BY DEVICE 58615 $ 6,010.51 Occlusal adjustment-complete D9952 $ 644.00 Occlusal adjustment-limited D9951 $ 115.00 Occlusal analysis-mounted case D9950 $ 252.00 Page 210 2018 OCCLUSAL GUARDS D9940 $ 490.00 OCCLUSAL ORTHOTIC APPLIANCE D7880 $ 827.00 OCCULT BLD FECES, 1-3 TESTS 82272 $ 9.31 OCCULT BLOOD STOOL 82270 $ 9.64 OCCULT BLOOD GASTRIC FLUID 82270 $ 9.64 OCCULT BLOOD STOOL 82270 $ 9.64 OCCULT BLOOD STOOL. 82270 $ 9.64 OCCULT BLOOD URINE 82270 $ 9.64 OCCULT BLOOD URINE 82271 $ 11.70 OCCUPATIONAL THERAPY EVALUATION 97003 $ 211.27 OCCUPATIONAL THERAPY RE-EVALUATION 97004 $ 131.63 Ocrelizumab 300 mg/10mL J3590 $ 0.10 OCREVUS 1MG J2350 $ 143.00 OCT/GDX SCAN COMPUTERIZED DIAG IMAGING 92133 $ 147.99 OCTREOTIDE 200MCG/ML INJ J2354 Acquisition cost OCTREOTIDE ACETATE (SANDOSTATIN) 30MG. Acquisition cost OCTREOTIDE ACETATE (SANTODTATIN) 10MG. Acquisition cost OCTREOTIDE ACETATE (SANTODTATIN) 20 MG Acquisition cost OCUL RECONST; LIMBL STEM CELL ALLOGFT 65781 $ 9,548.90 OCUL SURF RECONST; AM TRANSPL 65780 $ 7,805.64 OCULAR LIMBAL CONJ AUTOGRAFT 65782 $ 7,805.64 ODC HIP STEM Acquisition cost ODEFSEY Acquisition cost Odontoplasty 1-2 teeth-rmv enam D9971 $ 62.00 OFC/OUTPT E&M ESTAB 5 MIN 99211 $ 300.00 OFC/OUTPT E&M ESTAB LOW-MOD 15 99213 $ 343.00 OFC/OUTPT E&M ESTAB MINOR 10 M 99212 $ 315.00 OFC/OUTPT E&M ESTAB MOD-HI 25 99214 $ 370.00 OFC/OUTPT E&M ESTAB MOD-HI 40 99215 $ 398.00 OFC/OUTPT E&M NEW LOW-MOD 20 M 99202 $ 315.00 OFC/OUTPT E&M NEW MINOR 10 MIN 99201 $ 300.00 OFC/OUTPT E&M NEW MOD-HI 45 MI 99204 $ 370.00 OFC/OUTPT E&M NEW MOD-HI 60 MI 99205 $ 398.00 OFC/OUTPT E&M NEW MOD-SEVER 30 99203 $ 343.00 OFF HOUR SRV, EVE/WKND/HOLIDAY 99051 $ 290.00 OFF SITE E/M ESTAB LOW-MOD 15M 99213 $ 343.00 OFF SITE E/M ESTAB MINOR 10MIN 99212 $ 315.00 OFF SITE E/M ESTAB MOD-HI 25MI 99214 $ 370.00 OFF SITE E/M ESTAB MOD-HI 40MI 99215 $ 398.00 OFF SITE OUTPT E/M ESTAB 5 MIN 99211 $ 300.00 OFFIC SERV PROVID-EMER BASIS 99058 $ 77.00 OFFSET STEM Acquisition cost 0.3% EYE DROP Acquisition cost OFLOXACIN EYEDROPS 0.3% $ 51.57 OHD SERUM 82306 $ 80.41 OLANZAPINE (ZYPREXA) 10MG TAB Acquisition cost OLANZAPINE 10MG (ZYPREXA) 10MG IM Acquisition cost OLANZAPINE 10MG (ZYPREXA-ZYDIS) 10MG Acquisition cost OLANZAPINE 10MG CAP Acquisition cost OLANZAPINE 15MG (ZYPREXA-ZYDIS) 15MG Acquisition cost OLANZAPINE 15MG TAB (ZYPREXA) Acquisition cost OLANZAPINE 2.5MG TAB Acquisition cost OLANZAPINE 20MG (ZYPREXA-ZYDIS) 20MG Acquisition cost OLANZAPINE 20MG TAB (ZYPREXA) Acquisition cost OLANZAPINE 5MG (ZYPREXA-ZYDIS) 5MG Acquisition cost OLANZAPINE 5MG CAP Acquisition cost Page 211 2018 OLANZAPINE 7.5MG CAP Acquisition cost OLIGOCLONAL BANDS 83916 $ 60.26 OLOPATADINE 0.1% EYE DROP Acquisition cost OLOPATADINE DROPS 0.1% $ 627.00 OMEGA PLUS LAG SCREW C1713 $ 459.00 OMEPRAZOLE 10MG SUSP PO Acquisition cost OMEPRAZOLE 40 MG. PO Acquisition cost OMEPRAZOLE 40 MG/SOD.BICRB. POWER Acquisition cost OMEPRAZOLE 40MG CAPS Acquisition cost OMERPRAZOLE 20MG CAP Acquisition cost OMIFLO SEC SET #1139-48 $ 172.11 OMN MAX ARCH BAR C1713 $ 892.50 OMNI MAX SCREW C1713 $ 292.50 OMNIFIT HIP STEM C-TAPER 25MM C1776 $ 1,265.81 OMNIPAQUE 200-299MG IODINE, 1ML Q9966 $ 2.07 OMNIPAQUE 240MG/50ML Q9966 $ 2.07 Omnipaque 240mg/ml 150ml Acquisition cost OMNIPAQUE 300-399MG IODINE, 1ML Q9967 $ 2.45 OMNIPAQUE 300MG/50ML Q9967 $ 2.45 OMNIPAQUE 300MGL/ML, 500ML PLUS PAK Q9967 $ 2.67 OMNIPAQUE 350MG/100ML Q9967 $ 0.33 OMNIPAQUE 350MG/150ML Q9967 $ 2.45 OMNIPAQUE 350MG/50ML Q9967 $ 2.67 OMNIPAQUE 350MGL/ML, 500ML PLUS PAK Q9967 $ 0.33 OMNIPAQUE PO FOR ER USE ONLY Acquisition cost OMNISCAN 20ML PREFILLED SYRINGES A9579 $ 125.58 OMNISCAN 20ML VIALS A9579 $ 123.53 OMNISCAN INJECTION SOLUTION, PER UNIT A9579 $ 7.27 OMNISCAN INJECTION, PER UNIT A9579 $ 7.27 ONABOTULINUM TOXIN 100UNITS FOR OBGYN J0585 Acquisition cost ONCAGENE EXPRESSION 88342 $ 569.71 ONDANESTRON HYDROLCHL 8MG Q0162 $ 12.72 ONDANSETRON 2MG/ML (20MG VIAL) Acquisition cost ONDANSETRON 4MG TABLET Q0162 Acquisition cost ONDANSETRON ODT 4MG. PO Acquisition cost ONDASETRON 2MG/2.5 ML LIQUID Q0162 Acquisition cost ONE STEP BUTTON-CATEG 1 Acquisition cost ONE STEP BUTTON-CATEG 2 Acquisition cost ONLAY PORCELAIN/CERAMIC 2 SURFACES D2642 $ 735.00 ONLAY PORCELAIN/CERAMIC 3 SURFACES D2643 $ 770.00 Onlay-metallic-four + surfaces D2544 $ 980.00 Onlay-porcel/ceram-4 + surface D2644 $ 840.00 ON-Q CATHETER PUMP C1772 $ 412.50 ON-Q PAIN BUSTER 100ML,2ML/HR C1751 $ 180.00 ON-Q SILVERSOAK 2.5" CATHEEXPANS KIT C1751 $ 76.69 ON-Q SILVERSOAKER 2.5" CATH EXPAN KIT C1751 $ 76.69 ON-Q SILVERSOAKER CATH EXPANS KIT 5.0 C1751 $ 93.00 ON-Q SILVERSOAKR CATH KIT 5" 400MLX4ML A4306 $ 443.70 ON-Q SILVERSOKR CATH KIT 5 270MLX4ML A4306 $ 269.63 ON-Q SILVRSOAKR 400ML CATH KIT C1887 $ 443.70 ON-Q SILVRSOAKR 5 CATH EXP KIT C1887 $ 93.00 ON-Q SOAKER 6.5 PUMP MGMT SYS C1772 $ 220.80 ON-Q SOAKER PUMP 400MLX5ML 10"CATH C1751 $ 517.50 ON-Q SOAKER PUMP MANGMENT SYSTEM C1772 $ 220.80 ON-Q SOAKER PUMP MGMT SYS C1772 $ 517.50 ON-Q SOAKER PUMP MGMT SYSTEM A4306 $ 262.50 Page 212 2018 ON-Q SOAKER PUMP MGMT SYSTEM C1772 $ 330.00 ON-Q SOAKER PUMP MGMT SYSTEM 270ML C1772 $ 255.30 ON-Q SOAKER PUMP MGMT SYSTEM 5/BX C1772 $ 330.00 ON-Q SOAKER PUMP MGMT SYSTMEM 400ML A4306 $ 2,287.50 OOPHORECTOMY; MALIGNANCY 58943 $ 2,511.30 OP AV ANASTOM; UP ARM; CEPHALIC 36818 $ 11,279.00 OP BX/EXC LYMPH NODE(S); DEEP; AXILL NOD 38525 $ 7,213.98 OP EXC ABD TUMOR;DIAM 5CM OR L 49203 $ 2,567.16 OP ILIAC ART-DELIV PROSTH/OCCLU DEV-UNI 34820 $ 755.44 OP INC FINGER FLEXOR 26455 $ 3,570.03 OP INC FOOT/TOE EXTENSOR TENDON 28234 $ 3,570.03 OP REPR AO ANEUR; AORTO-BIFEMORAL PROSTH 34832 $ 4,045.73 OP REVISE AV FIST W THROMBECT 36833 $ 11,279.00 OP REVISE TENDON; ELBOW TO SHLDR 24310 $ 6,995.52 OP TREAT FX RADIAL; 3< FRAGS 25609 $ 14,826.61 OP TREAT ORBIT FLR FX; PERIORBIT W IMP 21390 $ 11,474.25 OP TX ACLAV DISLOC; ACUTE/CHRNIC 23550 $ 14,826.61 OP TX ARTICULAR FRACT MCP/IP JNT; EA 26746 $ 6,995.52 OP TX CARPAL BN FX; NOT SCAPHOID; EA BN 25645 $ 6,995.52 OP TX CARPOMETACARPAL DISLC, NOT THMB 26685 $ 6,995.52 OP TX DISTAL PHALANG FRACT EA 26765 $ 6,995.52 OP TX DISTAL TIBIA & FIBULAR FX 27828 $ 26,770.83 OP TX ELBOW PA FX/DISLOC 24586 $ 26,770.83 OP TX FEMORAL FX; INT FIX 27269 $ 2,670.82 OP TX GRTR HUMERAL TUBROSTY FX; INT FIX 23630 $ 14,826.61 OP TX INTERCONDYL SPIN/TUBRST FX KNEE 27540 $ 1,733.05 OP TX MANDIB FX W MULTI APPRCH/FIXT 21470 $ 11,474.25 OP TX MANDIBULAR FX; W ID FIX 21462 $ 11,474.25 OP TX MTCRPL DISLC; COMPLX 26686 $ 6,995.52 OP TX NAS BONE FX; COMPL W FIX 21330 $ 11,474.25 OP TX NAS FX; W OP TX SEPTUM FX 21335 $ 5,815.59 OP TX NASAL BONE FX; UNCOMPLICATED 21325 $ 5,815.59 OP TX ORBIT FLR FX; TRANSANTRAL 21385 $ 11,474.25 OP TX ORBIT FX; NOT BO; W IMP 21407 $ 11,474.25 OP TX PALATE/MAXIL FX; COMPLICATED 21423 $ 1,694.46 OP TX PAT FX W INT FIX/REM PAT W REP 27524 $ 14,826.61 OP TX PATELLAR DISLOCATION 27566 $ 14,826.61 OP TX PROX TIBIAL FX; UNICONDYLAR 27535 $ 1,924.85 OP TX RAD SHAFT FX; INT FIX 25515 $ 14,826.61 OP TX RADIAL & ULNAR SHFT FX 25574 $ 14,826.61 OP TX RADIAL HEAD/NECK FRACTURE 24665 $ 14,826.61 OP TX TIB/FIB JNT; INT FIX 27829 $ 14,826.61 OP TX TIBIAL FX PROXIM; BICONDYLAR 27536 $ 2,554.16 OP TX TOE FX; NOT GREAT TOE 28525 $ 6,995.52 OP TX TRIMALLEOL ANKL FX W FIX POS LIP 27823 $ 14,826.61 OP TX TRIMALLEOLAR ANKLE FX; WO FIX 27822 $ 14,826.61 OP TX TRSL BN FX, W INTRNL FIX 28465 $ 14,826.61 OP TX ULNAR FX PROXIMAL END 24685 $ 14,826.61 OPAL SPACER 10MM X 24MM C1713 $ 4,875.00 OPEN ANKLE JOINT FUSION 27870 $ 26,770.83 OPEN AV ANAST; FOREARM VEIN 36820 $ 11,279.00 OPEN AV ANASTOM; UP ARM; BASILIC 36819 $ 11,279.00 OPEN AVF REV W/O THROMB 36832 $ 11,279.00 OPEN BREAST CAPSULOTOMY 19370 $ 7,213.98 OPEN BX/EXC DEEP LYMPH NODES 38510 $ 7,213.98 OPEN END URETER CATH 5FR 10/BX C1758 $ 15.09 Page 213 2018 OPEN END URETHRL CATH, 5FR C1758 $ 15.10 OPEN MRI BRAIN W CONTR 70558 $ 668.38 OPEN MRI BRAIN WO AND W CONTR 70559 $ 668.38 Open reduction of dislocation D7810 $ 5,400.00 OPEN REPAIR ROTATOR CUFF 23410 $ 14,826.61 OPEN REPAIR WRIST JOINT 25320 $ 14,826.61 OPEN THOROCOTOMY TRAY $ 71.50 OPEN TIP 5FR URET CATH POLY C1758 $ 169.50 OPEN TREAT PHALANG SHAFT FRACT 26735 $ 6,995.52 OPEN TREAT PHALANG SHAFT FRACTURE 26735 $ 6,995.52 OPEN TX ACLAV DISLOC W GRAFT 23552 $ 14,826.61 OPEN TX ACUTE SHLDR DISLOC 23660 $ 14,826.61 OPEN TX BIMALLEOLAR ANKLE FRACT 27814 $ 14,826.61 OPEN TX CARPAL SCAPHOID NAVILCULAR FX 25628 $ 14,826.61 OPEN TX CMC FX DISLOC THUMB W/MANIP 26665 $ 6,995.52 OPEN TX DEPR ZYGOMATIC ARCH FX 21356 $ 11,474.25 OPEN TX DISTAL FIB FX LAT MALLEOLUS 27792 $ 14,826.61 OPEN TX DISTAL PHALANG FRACT EA 26765 $ 6,995.52 OPEN TX FX DISTAL TIBIA ONLY 27827 $ 26,770.83 OPEN TX KNUCKLE DISLOCATION 26715 $ 6,995.52 OPEN TX MEDIAL ANKLE FRACTURE 27766 $ 14,826.61 OPEN TX NASAL SEPTUM FX 21336 $ 6,995.52 OPEN TX ORBIT FLR FX; PERIORBIT 21386 $ 11,474.25 OPEN TX PROXIMAL HUMERAL FRACTURE 23615 $ 26,770.83 OPEN TX RADIAL & ULNAR SHFT FX; INT FIX 25575 $ 14,826.61 OPEN TX TMJ DISCLOC 21490 $ 5,815.59 OPEN TX ULNAR STYLOID FX 25652 $ 14,826.61 OPEN TX VERT EA ADD VERT/SEG 22328 $ 597.89 OPEN TX VERT -1 SEGMT; CERV 22326 $ 3,152.40 OPEN TX VERT -1 SEGMT; LUMB 22325 $ 3,053.20 OPEN TX VERT -1 SEGMT; THOR 22327 $ 3,180.67 OPEN/PERQ STNT PLACE; EA ADD 37237 $ 460.09 OPEN/PERQ STNT PLACE; INIT ART 37236 $ 27,795.70 OPERATING MICROSCOPE ADD-ON 69990 $ 458.50 OPERATING ROOM 106 - 120 MINUTES $ 2,910.60 OPERATING ROOM 121 - 135 MINUTES $ 3,274.43 OPERATING ROOM 136 - 150 MINUTES $ 3,638.25 OPERATING ROOM 151 - 165 MINUTES $ 4,002.08 OPERATING ROOM 16 - 30 MINUTES $ 727.65 OPERATING ROOM 166 - 180 MINUTES $ 4,365.90 OPERATING ROOM 181 - 195 MINUTES $ 4,729.73 OPERATING ROOM 196 - 210 MINUTES $ 5,093.55 OPERATING ROOM 211 - 225 MINUTES $ 5,457.38 OPERATING ROOM 226 - 240 MINUTES $ 5,821.20 OPERATING ROOM 241 - 255 MINUTES $ 6,185.03 OPERATING ROOM 256 - 270 MINUTES $ 6,548.85 OPERATING ROOM 271 - 285 MINUTES $ 6,912.68 OPERATING ROOM 286 - 300 MINUTES $ 7,276.50 OPERATING ROOM 301 - 315 MINUTES $ 7,640.33 OPERATING ROOM 31 - 45 MINUTES $ 1,091.48 OPERATING ROOM 316 - 330 MINUTES $ 8,004.15 OPERATING ROOM 331 - 345 MINUTES $ 8,367.98 OPERATING ROOM 346 - 360 MINUTES $ 8,731.80 OPERATING ROOM 361 - 375 MINUTES $ 9,095.63 OPERATING ROOM 376 - 390 MINUTES $ 9,459.45 OPERATING ROOM 391 - 405 MINUTES $ 9,823.28 Page 214 2018 OPERATING ROOM 406 - 415 MINUTES $ 13,860.00 OPERATING ROOM 416 - 430 MINUTES $ 14,355.00 OPERATING ROOM 431 - 445 MINUTES $ 10,914.75 OPERATING ROOM 446 - 460 MINUTES $ 11,278.58 OPERATING ROOM 46 - 60 MINUTES $ 1,455.30 OPERATING ROOM 461 - 475 MINUTES $ 11,642.40 OPERATING ROOM 476 - 495 MINUTES $ 16,335.00 OPERATING ROOM 496 - 510 MINUTES $ 12,370.05 OPERATING ROOM 511 - 525 MINUTES $ 12,733.88 OPERATING ROOM 526 - 540 MINUTES $ 13,097.70 OPERATING ROOM 541 - 555 MINUTES $ 18,315.00 OPERATING ROOM 556 - 570 MINUTES $ 13,825.35 OPERATING ROOM 571 - 585 MINUTES $ 19,305.00 OPERATING ROOM 586 - 600 MINUTES $ 14,553.00 OPERATING ROOM 61 - 75 MINUTES $ 1,819.13 OPERATING ROOM 76 - 90 MINUTES $ 2,182.95 OPERATING ROOM 91 - 105 MINUTES $ 2,546.78 OPERATING ROOM < 15 MINUTES $ 363.83 OPERCULECTOMY EXC PERICORONAL 41821 $ 3,010.00 OPHTH BIOMET A-SCAN; W/IO LENS POWR 76519 $ 302.70 OPHTH BIOMETRY BY ULTRASOUND ECHO A-SCAN 76516 $ 302.70 OPHTH EXTEN W/RETINAL DRAW W/I/R; INIT 92225 $ 147.99 OPHTH EXTEN W/RETINAL DRAW W/I/R; SUBSQT 92226 $ 277.79 OPHTH MUCOS MEMBRN TESTS 95060 $ 277.79 OPHTH SERV: EXAM-EVAL; INTERME 92002 $ 300.00 OPHTH SERV: MED EXAM; COMP EST 92014 $ 398.00 OPHTH SERV: MED EXAM; COMP NEW 92004 $ 398.00 OPHTH SERV: MED EXAM; INTERM E 92012 $ 300.00 OPHTH ULTRASOUND ECHO DX; CONTACT B-SCAN 76512 $ 302.70 OPHTHALGAN OPTH DROPS 7.5ML Acquisition cost OPHTHALMIC BIOMETRY 92136 $ 277.79 OPHTHALMIC ENDOSCOPE ADD-ON 66990 $ 196.26 OPHTHALMIC ULTRASOUND, ECHOGR 76513 $ 302.70 OPHTHALMOSXOPY, EXTENDED - INITIAL 92225 $ 147.99 OPHTHALMOSXOPY, EXTENDED - SUBSEQUENT 92226 $ 277.79 OPIATES 80361 $ 11.00 O-PLATE 12MM C1713 $ 697.50 OPN FEM ART-DEL AO PROS-UNI-GROIN 34812 $ 442.86 OPN REPR AO ANEUR/TRAUMA; TUBE PROS 34830 $ 3,762.13 OPN REPR AO ANEUR; AO-BI-ILIAC PROS 34831 $ 4,129.25 OPPONENSPLASTY; OTHER METHODS 26496 $ 6,995.52 OPTEMP DISP CAUTERY-CATEG 1 Acquisition cost OPTIC FORAMINA 70190 $ 164.27 OPTIMARK 10 ML - PREFILLED SYRINGES PER A9579 $ 48.90 OPTIMARK 15 ML - PLASTIC SYRINGE, PER UN A9579 $ 71.40 OPTIMARK 30 ML - PREFILLED SYRINGES, PER A9579 $ 138.60 OPTIMARK 5 ML - GLASS VIALS, PER UNIT A9579 $ 33.72 OPTIMIZED COMPOS MESH RND C1781 $ 1,185.60 OPTION/VENA TECH LOW PROF FILT SYS C1880 $ 1,800.00 OPTISON A4641 $ 192.50 OPTISONE OPHTHALMIC DROPS Acquisition cost OPTOKINETIC NYSTAGMUS TEST 92534 $ 124.00 OPTOKINETIC NYSTAGMUS TEST W/RECORDING 92544 $ 360.51 OR CONSULT W/FROZ SECT 88331 $ 341.62 OR CONSULT-GROSS ONLY 88329 $ 84.11 ORAL ANTRAL FISTULA CLOSURE D7260 $ 3,002.00 Page 215 2018 ORAL EVALUATION D0145 $ 140.00 ORAL HYGIENE INSTRUCTION D1330 Acquisition cost ORAL MED ADMIN W/ OBSRV H0033 $ 225.00 ORBICULARIS OCULI REFLEX ELECDX TST 95933 $ 277.79 ORBITAL EXENTERATION-GROSS & MICRO 88309 $ 1,430.62 ORBITAL IMPLANT INSERTION 67550 $ 7,805.64 ORBITAL IMPLNT; REMOVE/REVISE 67560 $ 7,805.64 ORBITOTOMY WO BONE FLAP; EXPLO 67400 $ 7,805.64 ORBITOTOMY WO BONE FLAP; W/REMOV FB 67413 $ 4,790.26 ORBITOTOMY WO FLAP; W/REMV BONE 67414 $ 7,805.64 ORBITOTOMY; W REMOVAL LESION 67412 $ 4,790.26 ORBITS MRI WITH AND WITHOUT CONTRAST 70543 $ 1,206.90 ORBITS COMPLETE 70200 $ 302.70 ORBITS CT WITH AND WITHOUT CONTRAST 70482 $ 668.38 ORBITS CT WITH CONTRAST 70481 $ 668.38 ORBITS CT WITHOUT CONTRAST 70480 $ 302.70 ORBITS MRI WITHOUT CONTRAST 70540 $ 614.37 ORBITS MRI WITH CONTRAST 70542 $ 1,206.90 ORCHIECTOMY RADICAL -INGUINAL APPR 54530 $ 7,698.79 ORCHIECTOMY, PARTIAL 54522 $ 7,131.78 ORCHIECTOMY; SIMPLE 54520 $ 7,131.78 ORCHIOPEXY ABD APPR; INTRA-ABD TESTIS 54650 $ 7,698.79 ORCHIOPEXY INGUINAL APPROACH 54640 $ 7,698.79 ORCHIOPEXY-ING APPROACH-W/WO HERNIA REPR 54640 $ 7,698.79 ORENCIA INJECTION, 10MG J0129 $ 110.48 ORENCIO 250MG INJ Acquisition cost ORGANIC ACID SINGLE QUANT 83921 $ 46.66 ORGANIC ACIDS BLOOD 83918 $ 51.92 ORGANIC ACIDS URINE 83918 $ 51.92 ORIF MALAR/ZYGOMATIC COMPOUND D7750 $ 5,253.00 ORIF MANDIBLE - COMPOUND D7730 $ 8,348.00 ORIF MANDIBLE - SIMPLE D7630 $ 6,384.00 ORIF MAXILLA - COMPOUND D7710 $ 5,771.00 ORIMUNE ORAL LIVE Acquisition cost OROPHARYNX; BIOPSY 42800 $ 5,815.59 ORTH SHOES-CATEG 1 Acquisition cost ORTHC/PROSTC MGMT SBSQ ENC 97763 $ 124.06 ORTHO MENISCUS-CATEG 1 Acquisition cost ORTHO MENISCUS-CATEG 2 Acquisition cost ORTHO NOVUM 777 Acquisition cost ORTHO-CEPT 28 TABLET PAK Acquisition cost ORTHOGNATHIC WORK UP D7940 $ 4,900.00 ORTHO-NOVUM 777 28 TABLET PAK Acquisition cost ORTHOPANTOGRAM 70355 $ 164.27 ORTHOT FIT/TRN UP LOW//TRNK; 1 UNIT 97760 $ 101.49 ORTHOTIC FABRICATION 23 TO 37 MIN. 29125 $ 277.79 ORTHOTIC FABRICATION 38 TO 52 MIN. 29125 $ 277.79 ORTHOTIC FABRICATION 53 TO 68 MIN. 29125 $ 277.79 ORTHOTIC FABRICATION 8 TO 22 MIN. 29125 $ 277.79 ORTHOTICS TRAINING, EA 15 MIN. 97760 $ 101.49 ORTHO-TRICYCLEN TABLETS 28 PAK Acquisition cost OSCILLATING TRACKING TEST 92545 $ 360.51 OSELTAMIVIR 30MG CAPSULE Acquisition cost OSELTAMIVIR 75MG (TAMIFLU) GELCAP PO G9035 Acquisition cost OSELTAMIVIR PED. SUSPENSION Acquisition cost OSMOGLYN 50% SOLUTION 220ML Acquisition cost Page 216 2018 OSMOLALITY BF 83930 $ 17.95 OSMOLALITY BLOOD 83930 $ 17.95 OSMOLALITY STOOL 84999 $ 15.40 OSMOLALITY UR RANDOM 83935 $ 18.52 OSMOTIC FRAGILITY 85557 $ 36.28 OSS CULTURE (BACTERIAL SCREEN FOR 1 ORG 87081 $ 18.00 OSS OSTE, CART GFT MNDLE FAC BN ATN-ATN D7950 $ 840.00 OSS RESURFACING FEMORAL; VARIOUS SIZE C1776 $ 1,265.55 Osseous surg- 1-3 contg th/quad D4261 $ 735.00 OSSEOUS SURGERY PER QUAD D4260 $ 840.00 OSTECTOMY SCAPULA; PARTIAL 23190 $ 6,995.52 OSTECTOMY, COMPLT EXC; 5TH METATRSL HD 28113 $ 6,995.52 OSTEO 2.3MM CURVE W/ULTRABRAID C1713 $ 622.13 OSTEO SET BONE VOID FILLER PEL Acquisition cost OSTEOCALCIN 86318 $ 39.80 OSTEOCALCIN LAB 83937 $ 81.07 OSTEOCALCIN. 83937 $ 81.07 OSTEOCHONDR ALLGRF KNEE W SCOPE 29867 $ 26,770.83 OSTEOGEN-CATEG 1 Acquisition cost OSTEON RND BUR 6.0MM FLUTE SFT C1713 $ 212.09 OSTEONICS CALCELLOUS BONE SCREW 20MM C1713 $ 162.90 OSTEOPATHIC MANIP, 1-2 BODY REGIONS 98925 $ 70.95 OSTEOPATHIC MANIP, 3-4 BODY REGIONS 98926 $ 70.95 OSTEOPATHIC MANIP, 5-6 BODY REGIONS 98927 $ 70.95 OSTEOPATHIC MANIP, 7-8 BODY REGIONS 98928 $ 70.95 OSTEOPATHIC MANIP, 9-10 BODY REGIONS 98929 $ 70.95 OSTEOPLASTY MANDIBLE D7940 $ 4,900.00 OSTEOPLASTY, FACIAL BONES; AUGMENTATION 21208 $ 11,474.25 OSTEOPLSTY; FACIAL BONES; REDUCTION 21209 $ 11,474.25 OSTEORAPTOR 2.3 W. UB COBRAID C1713 $ 500.85 OSTEORAPTOR 2.3MMCURVW/ULTRABR C1887 $ 647.33 OSTEOTOME STRGHT GRAY C1713 $ 346.50 OSTEOTOMY LEFORTE 1 D7946 $ 13,803.00 OSTEOTOMY MANDIBLE SEGMENTAL 21198 $ 11,474.25 OSTEOTOMY MAXILLA SEGMENTAL 21206 $ 11,474.25 OSTEOTOMY RAMUS EXTRAORAL OPEN D7941 $ 10,839.00 OSTEOTOMY SEGMENTAL D7944 $ 10,066.00 OSTEOTOMY, MANDBLE; SEGMNTAL 21198 $ 11,474.25 OSTEOTOMY, MAXILLA; SEGMNTAL 21206 $ 11,474.25 OSTEOTOMY; CALCANEUS 28300 $ 14,826.61 OSTEOTOMY; METACARPAL, EA 26565 $ 6,995.52 OSTEOTOMY; TIBIA 27705 $ 14,826.61 Osteotomy-body of mandible D7945 $ 11,169.00 Osteotomy-mand rami w/ graft D7943 $ 11,290.00 OSTMY 2PC 1-3/4BARRIER $ 1.48 OSTMY 2PC 2-1/4BARRIER A4414 $ 1.18 OSTMY 2PC 2-3/4BARRIER A4414 $ 1.18 OSTMY 2PC 4BARRIER A4415 $ 2.56 OSTMY BAG 1-3/4 2PC $ 0.94 OSTMY BAG 2-1/4 2PC $ 0.93 OSTMY BAG 2-3/4 2PC $ 0.74 OSTMY BAG 42 PC A5063 $ 1.14 OSTMY BAG CLAMP $ 2.55 OSTMY BAG-CATEG 1 Acquisition cost OSTMY BARRIER-CATEG 1 Acquisition cost OT EVAL HIGH COMPLEX 45 MIN 97167 $ 211.27 Page 217 2018 OT EVAL LOW COMPLEX 20 MIN 97165 $ 211.27 OT EVAL MOD COMPLEX 30 MIN 97166 $ 211.27 OT RE-EVAL EST PLAN CARE 97168 $ 131.63 OTHER O+P 87177 $ 24.18 OTHER PERIPHERAL NERVE BRANCH 64450 $ 1,437.02 OTHER PERIPHERAL NERVE DESTRC 64640 $ 1,777.62 OTHER PRIMARY CURRENT STAT - OT G8990 Acquisition cost OTHER PRIMARY CURRENT STAT - PT G8990 Acquisition cost OTHER PRIMARY DISCHRG STAT - OT G8992 Acquisition cost OTHER PRIMARY DISCHRG STAT - PT G8992 Acquisition cost OTHER PRIMARY GOAL STAT - OT G8991 Acquisition cost OTHER PRIMARY GOAL STAT - PT G8991 Acquisition cost OTHER SPEECH CURRENT STAT G9174 Acquisition cost OTHER SPEECH DISCHRG STAT G9176 Acquisition cost OTHER SPEECH GOAL STATUS G9175 Acquisition cost OTHER SUBSQNT CURRENT STAT - OT G8993 Acquisition cost OTHER SUBSQNT CURRENT STAT - PT G8993 Acquisition cost OTHER SUBSQNT DISCHRG STAT - OT G8995 Acquisition cost OTHER SUBSQNT DISCHRG STAT - PT G8995 Acquisition cost OTHER SUBSQNT GOAL STAT - OT G8994 Acquisition cost OTHER SUBSQNT GOAL STAT - PT G8994 Acquisition cost Other TMJ films, by report D0321 $ 252.00 OTOLARYNGOLOGIC EXAM W/ANESTH 92502 $ 1,216.16 OTOLOGICAL VENT TUBE W/OUTWIRE A4624 $ 67.50 OTPLSTY PROTRUDING EAR W/WO SZ 69300 $ 5,815.59 OTW FEMORAL SYS. GREENFIELD FILTER Acquisition cost OUTPAT E/M ESTAB - 5 MIN 99211 $ 300.00 OUTPAT E/M ESTAB LOW MOD;15MIN 99213 $ 343.00 OUTPAT E/M ESTAB LOW-MOD - 15 99213 $ 343.00 OUTPAT E/M ESTAB MINOR - 10 M 99212 $ 315.00 OUTPAT E/M ESTAB MINOR;10MIN_ 99212 $ 315.00 OUTPAT E/M ESTAB MOD-HI - 25 99214 $ 370.00 OUTPAT E/M ESTAB MOD-HI - 40 99215 $ 398.00 OUTPAT E/M ESTAB MODHI;25MIN 99214 $ 370.00 OUTPAT E/M ESTAB MODHI;40MIN 99215 $ 398.00 OUTPAT E/M ESTAB;5MIN 99211 $ 300.00 OUTPAT E/M NEW LOW MOD 20MIN 99202 $ 315.00 OUTPAT E/M NEW LOW-MOD - 20 M 99202 $ 315.00 OUTPAT E/M NEW MINOR - 10 MIN 99201 $ 300.00 OUTPAT E/M NEW MINOR;10MIN 99201 $ 300.00 OUTPAT E/M NEW MOD SEVER 30MIN 99203 $ 343.00 OUTPAT E/M NEW MOD-HI - 45 MI 99204 $ 370.00 OUTPAT E/M NEW MOD-HI - 60 MI 99205 $ 398.00 OUTPAT E/M NEW MODHI;45MIN 99204 $ 370.00 OUTPAT E/M NEW MODHI;60MIN_ 99205 $ 398.00 OUTPAT E/M NEW MOD-SEVER - 30 99203 $ 343.00 OVAL CARBIDE BUR 4.0MM C1713 $ 48.65 OVAL CARBIDE BURS 4.0MM C1713 $ 51.98 OVARIAN CYSTECTOMY; UNI/BILATERAL 58925 $ 10,873.98 OXACILLIN 1 GM. ADDVANTAGE VIAL J2700 Acquisition cost Oxacillin 2 Gm Addvantage vial Injection Acquisition cost OXACILLIN 2 GM. ADD.VIAL Acquisition cost OXACILLIN 50MG/ML NICU 5ML Acquisition cost OXACILLIN SOD 1GM INJ J2700 Acquisition cost OXALATE (UR) 83945 $ 34.96 OXALIPLANTIN 0.5MG INJECT J9263 $ 1.32 Page 218 2018 OXALIPLATIN 50MG IV Acquisition cost OXANDRIN 2.5 MG TAB Acquisition cost OXCARBAZEPINE 80299 $ 41.01 OXCARBAZEPINE 150MG TAB Acquisition cost OXCARBAZEPINE 300MG TABLET U-D Acquisition cost OXCARBAZEPINE 600MG TAB Acquisition cost OXCARBAZEPINE PO LIQ 300MG/5ML Acquisition cost OXCARBAZEPINE; QUANT. 80183 $ 35.99 OX-CELL HEMOLYSIS TEST 86309 $ 17.56 OXINIUM HEAD 32MM C1776 $ 2,900.63 OXYBUTYNIN 10MG TAB PO SA Acquisition cost OXYBUTYNIN 15MG TAB PO SA Acquisition cost OXYBUTYNIN 5MG TAB PO SA Acquisition cost OXYBUTYNIN 5MG/5ML SYR PO Acquisition cost OXYBUTYNIN CHLORIDE 5MG TAB Acquisition cost OXYCODONE 80307 $ 158.03 OXYCODONE 160MG TB PO Acquisition cost OXYCODONE 5MG/5ML UD Acquisition cost OXYCODONE HCL 10MG TAB.SR Acquisition cost OXYCODONE HCL 20MG BULK SR 12H Acquisition cost OXYCODONE HCL 20MG/ML Acquisition cost OXYCODONE HCL 40MG SR UD Acquisition cost OXYCODONE HCL 80MG SR Acquisition cost OXYCODONE HCL 80MG SR UD 12H Acquisition cost OXYCODONE IR 20MG TABLET Acquisition cost OXYCODONE IR 30MG PO Acquisition cost OXYCODONE IR 5MG C. Acquisition cost OXYCODONE/APAP 3/325MG Acquisition cost OXYCONTIN 10MG SR UD TAB. 12H Acquisition cost OXYCONTIN 20MG TAB UD Acquisition cost OXYCONTIN 30MG TABLET J3490 Acquisition cost OXYCONTIN 40MG SR TAB Acquisition cost OXYGEN VIA VENTURI MASK 94799 $ 360.51 OXYMETAZOLINE NASAL SPRAY Acquisition cost OXYMORPHONE (OPANA) 5MG. PO Acquisition cost OXYMORPHONE 10MG. (OPANA) PO Acquisition cost OXYMORPHONE ER (OPANA ER )5 MG. PO Acquisition cost OXYMORPHONE ER (OPANA ER) 10MG. PO Acquisition cost OXYMORPHONE ER (OPANA-ER) 20MG. PO Acquisition cost OXYMORPHONE ER (OPANA-ER) 40 MG. PO Acquisition cost OXYTOCIN 10 UNIT/500ML IVPB J2590 Acquisition cost OXYTOCIN 10 UNITS/500 ML LACTATED RINGER J2590 $ 0.10 OXYTOCIN 10 UNITS/ML 10ML VIAL J2590 Acquisition cost OXYTOCIN 30 UNIT/1000ML IVPB J2590 Acquisition cost OXYTOCIN 30 UNITS/ML 1000ML LR BAG J2590 Acquisition cost OXYTOCIN CHALLENGE TEST 59020 $ 424.97 P/P OFF/OP VIST E/M 10MIN 99212 $ 315.00 P/P OFF/OP VIST E/M 15 MIN 99213 $ 343.00 P/P OFF/OP VIST E/M 25 MIN 99214 $ 370.00 P/P OFF/OP VIST E/M 40MIN 99215 $ 398.00 P/P OFF/OP VIST E/M 5 MIN 99211 $ 300.00 P24 AG 87390 $ 52.93 P-32 CHROMIC PHOSPHATE 15 MCI A9564 $ 156.51 P-32 SODIUM PHOSPHATE 5 MCI A9563 $ 563.20 P3-ANTIBODY ID 86021 $ 40.90 PAC GUIDEWIRE PAC LATEX FREE C1713 $ 415.80 Page 219 2018 PACEMAKER IMPLANTABLE-CATEG 1 C1785 Acquisition cost PACEMAKR PREPERITON BALL DISEC C1785 $ 2,780.93 PACHYMETRY 76514 $ 46.20 PACK ALGO COLORADO-CATEG 1 Acquisition cost PACK COLD-CATEG 1 Acquisition cost PACK HIP ABDUCTION BRACE-CATEG 1 Acquisition cost PACK HOT-CATEG 1 Acquisition cost PACK PIK-PAK EYE-CATEG 1 Acquisition cost PACK-ORTHO MINOR-CATEG 1 Acquisition cost PACKS COLD-CATEG 1 Acquisition cost PACKS HOT-CATEG 1 Acquisition cost PACKS-CATEG 1 Acquisition cost PACLITAXEL PER 1 MG J9267 $ 1.12 PACLITAXEL SEMI SYNTH 30MG/5ML J9267 Acquisition cost PACLITAXEL SEMI SYNTH PER 1MG J9267 Acquisition cost PAD TELFA-CATEG 1 Acquisition cost PAD-OVAL EYE $ 0.28 PADS BREAST $ 0.11 PAIN SEVERITY QUANTIFIED; NO PAIN 1126F Acquisition cost PAIN SEVERITY QUANTIFIED; PAIN PRESENT 1125F Acquisition cost PAINE MANAGEMENT SCALE Acquisition cost PAK BASIC-CATEG 1 Acquisition cost PAK HIP-CATEG 1 Acquisition cost PAK LAPAROSCOPY-CATEG 1 Acquisition cost PAKS ARTHROSCOPY-CATEG 1 Acquisition cost PAKS BASIC II-CATEG 1 Acquisition cost PAKS C - CATEG 1 Acquisition cost PAKS COULTER RETIC-CATEG 1 Acquisition cost PAKS C-SECTION-CATEG 1 Acquisition cost PAKS CYSTO-CATEG 1 Acquisition cost PAKS EYE BASIC-CATEG 1 Acquisition cost PAKS LITHOTOMY-CATEG 1 Acquisition cost PAKS OB/GYN-CATEG 1 Acquisition cost PAKS PEDIATRIC-CATEG 1 Acquisition cost PAKS VFC INJCTR/EXTRCTN-CATEG 1 Acquisition cost PALATOPHARYNGOPLASTY 42145 $ 11,474.25 PALIPERIDONE (INVEGA ) 3 MG. Acquisition cost PALIPERIDONE (INVEGA ) 6 MG. Acquisition cost PALIPERIDONE (INVEGA) 3 MG. Acquisition cost PALIPERIDONE (INVEGA) 6 MG. Acquisition cost PALIPERIDONE (INVEGA) 9 MG. Acquisition cost PALIPERIDONE (INVEGA) 9 MG. Acquisition cost PALIVIZUMAB 100MG/1ML IM Acquisition cost PALIVIZUMAB 50MG/0.5ML IM Acquisition cost PALIVIZUMAG 100MG VIAL IM Acquisition cost PALIVIZUMAG 50MG VIAL IM Acquisition cost PALM RELEASE W/EA ADDTL DIGIT 26125 $ 590.76 PALM W SGL DIGIT RELEASE 26123 $ 6,995.51 PALMAZ CORINTHIAN STENT 15MM X Acquisition cost PALMAZ CORINTHIAN STENT 5 X 12 Acquisition cost PALMAZ EXPANDABLE STENT Acquisition cost PALMAZ STNT 40MM UNMOUNTED; XL C1877 $ 2,700.00 PALMAZ-SCHATZ STENT 6-10MM C1877 Acquisition cost PALONOSETRON (ALOXI) J2469 Acquisition cost PANCREATCTMY WO PANCREATJEJUNOSTMY 48140 $ 3,337.58 PANCREATIC POLYPEPTIDE 84110 $ 22.92 Page 220 2018 PANCRELIPASE PO Acquisition cost PANCURONIUM 2MG/ML Acquisition cost PANHEMATIN, PER 1MG J1640 $ 56.18 PANTOPRAZOLE 40 MG/50ML Acquisition cost PANTOPRAZOLE 40MG SUSPENSION Acquisition cost PANTOPRAZOLE 40MG TAB PO Acquisition cost PANTOPRAZOLE 80MG/100ML IV BAG Acquisition cost PANTOPRAZOLE IV 40MG C9113 Acquisition cost PAP AUT THIN LAY PREP MAN SCRN & RESCR. 88143 $ 55.02 PAP INTERPRETATION BY MD 88141 $ 70.31 PAP SMEAR 88150 $ 32.23 PAP: REPEAT SCREEN AND RESCREEN 88153 $ 52.87 PAPAIN/UREA OINTMENT Acquisition cost PAPAVERINE 30MG INJ J2440 $ 6.60 PAPAVERINE 30MG/ML 2ML AMP J2440 Acquisition cost PAPAVERINE HCL150 SR CAP Acquisition cost PAPILLOMAVIRUS AMPLIF NA PROBE 87624 $ 95.33 PAR MASTECTOMY W LN REM 19302 $ 12,725.37 PARACENTESIS/REMOV/OF ANT HYA 65810 $ 5,080.46 PARACERVICAL NERVE 64435 $ 1,437.02 PARAFFIN BATH 97018 $ 18.77 PARAGARD-CATEG 1 A4264 Acquisition cost PARASITE IDENT 87177 $ 24.18 PARASITIC SEROLOGY 86317 $ 40.70 PARATHYROID AUTOTRANSPLNTATION 60512 $ 519.71 PARATHYROID IMAGING 78070 $ 924.11 PARATHYROID NUCLEAR IMAGING 78070 $ 924.11 PARATHYROIDECT 60500 $ 11,474.25 PARATHYROIDECTOMY/EXPL; RE-EXPL 60502 $ 11,474.25 PAREGORIC LIQ 2MG/5ML 480ML Acquisition cost PARICALCITOL 1 MCG J2501 $ 31.99 PARICALCITOL 1 MCG/ML VIAL 1 ML J2501 Acquisition cost PARICALCITOL 1 MCG/ML VIAL 2 ML J2501 Acquisition cost PARICALCITOL 1 MCG/ML VIAL IV J2501 Acquisition cost PARICALCITOL 2MCG/ML VIAL IV J2501 Acquisition cost PARIETEX COMPOSITE MESH C1781 $ 875.18 PARIETEX COMPOSITE MESH C1781 $ 905.80 PARIETEX COMPOSITE MESH C1781 $ 905.81 PARIETEX COMPOSITE MESH PTX 20x15CM 8/6 C1781 $ 1,403.93 PARIETEX OPTIMIZED COMPOSITE 15CM ROUND C1781 $ 1,185.60 PARIETEX OPTIMIZED COMPOSITE MESH PCO15X C1781 $ 905.81 PARIETEX OPTIMIZED COMPOSTE 12CM RND 4.8 C1781 $ 905.81 PARIETEX OPTIMIZED COMPOSTE MESH C1781 $ 870.00 PARIETEX OPTIMIZED COMPOSTE MESH 9CM RND C1781 $ 870.00 PARIETEX PROGRIP MESH PRTX 15x15CM 12MM C1781 $ 538.25 PARIETEXOPTIMIZED COMPOSIT MESH 15x10CM C1781 $ 905.81 PARING OR CUT OF BENGN LESN > 4 LESIONS 11057 $ 446.80 PARING OR CUT OF BENIGN LESION 1 LESION 11055 $ 446.80 PARING/CUTTING BEN LES; 1 LES 11055 $ 446.80 PARING/CUTTING BEN LES; 2-4 LES 11056 $ 446.80 PARLODEL 2.5MG TAB Acquisition cost PAROTID COMPLEX 42305 $ 5,815.59 PAROTID SIMPLE 42300 $ 3,010.00 PAROXETINE 10MG/5ML SUSP PO Acquisition cost PAROXETINE HCL 10MG TAB Acquisition cost PAROXETINE HCL 10MG/5ML Acquisition cost Page 221 2018 PAROXETINE HCL 30MG TAB Acquisition cost PAROXETINE LEVEL 80299 $ 41.01 PART EXC 5TH METATARSL HEAD 28110 $ 6,995.52 PART EXC ANKLE/HEEL BONE 28120 $ 6,995.52 PART EXC BN, FEMUR, PROX TIB/FIB 27360 $ 6,995.52 PART EXC BONE; DISTAL PHALANX 26236 $ 3,570.03 PART EXC OLECRANON PROCESS BONE 24147 $ 6,995.52 PART EXC PHALANX TOE BONE 28124 $ 3,570.03 PART THYROID LOBECTOMY; UNILATERAL 60210 $ 11,870.65 PARTIAL EXC - HUMERUS BONE 24140 $ 6,995.52 PARTIAL EXC MCP BONE 26230 $ 6,995.51 PARTIAL HYMENECTOMY/REVISION 56700 $ 6,010.51 PARTIAL MASTECTOMY 19301 $ 7,213.98 PARTIAL REM FOOT - PLANTAR FACIA 28060 $ 6,995.52 PARTIAL THYROID LOBECTOMY; UNILAT; W CLO 60212 $ 11,870.65 PARTICLE AGGULTINATION TITER 86406 $ 28.89 PARTL EXC MDL PHALANX BONE 26235 $ 3,570.03 PARTL EXC TARSL/METATRSL BONE 28122 $ 6,995.52 PARTL REM FT BONE METATRSL HD; 1-5 EA 28288 $ 6,995.52 PARVOVIRUS B19 (EIA) IGG 86747 $ 40.83 PARVOVIRUS B19 (EIA) IGM 86747 $ 40.83 PARVOVIRUS B19 LGG CONFIRM 84181 $ 46.24 PARVOVIRUS B19 LGM CONFIRM 84181 $ 46.24 PASS SUTRE NEEDLE HUTTLE STRL C2618 $ 1,098.53 PASSER CATHETER 38CM DISP C1887 $ 233.28 PASSER CATHETER 60CM DISP C1887 $ 249.12 PASSPORT BUTTON CANNULA A4615 $ 48.00 PASSPORT BUTTON CANNULA 8X3 A4615 $ 48.00 PASSPORT BUTTON CANNULA 8X4 A4615 $ 48.00 PAT. RECORD. SPIROMETRY, RECORDING ONLY 94015 $ 658.04 PATCH HERNIA-CATEG 1 C1781 Acquisition cost PATCH/APPLIC TEST(S) 95044 $ 1,175.22 PATELLA C1776 $ 180.00 PATELLA 30MM C1776 $ 180.00 PATELLA 34MM C1776 $ 180.00 PATELLA 38MM C1776 $ 180.00 PATELLA 42MM C1776 $ 180.00 PATELLA CLAMP C1773 $ 610.20 PATELLA CUTTER C1713 $ 481.50 PATELLA LOW DOME-CATEG 1 Acquisition cost PATELLA MAXIM-CATEG 1 C1776 Acquisition cost PATELLA POLY-CATEG 1 C1776 Acquisition cost PATELLA REAMER BLADE C1713 $ 288.00 PATELLA REAMER BLADE C1713 $ 288.00 PATELLA SIZE 23MM C1776 $ 180.00 PATELLA-ALL POLY SZ.35MM Acquisition cost PATH BILL HIST IMMUNOFOURESCENSE-DIRECT, 88346 $ 569.71 PATIENT OWN MEDICATION Acquisition cost PATIENT OWN MEDICATIONS Acquisition cost PATIENT RECORDED SPIROMETRY, COMPLETE 94014 $ 872.74 PATIENT'S OWN MEDS (CONTROL DRUGS) Acquisition cost PAXIL 20MG TABLET Acquisition cost PC1 PLAIN 13MM 3/8 CIRCL SUTRE C1713 $ 9.58 PCB 82441 $ 16.32 PCCA 86255 $ 32.74 PED TRACH TUBE A4624 $ 47.40 Page 222 2018 PED TRACHEOSTOMY TUBE SIZE 3.5 A4624 $ 47.40 PED TRACHEOSTOMY TUBE, SIZE 3 A4624 $ 47.40 PEDFUSE 7.0 X 35MM C1713 $ 1,200.00 PEDFUSE PEDICLE SCRW 6.0X35MM C1713 $ 1,303.50 PEDFUSE SCREW 6.0 X 40MM C1713 $ 1,449.00 PEDFUSE SCREW 7.0 X 45MM C1713 $ 1,620.00 PEDFUSE SET SCREW 5-7MM X C1713 $ 253.50 PEDIARIX Acquisition cost PEDIATRIC PRIVATE ROOM $ 3,500.00 PEDIATRIC SEMI PRIVATE ROOM $ 1,750.00 PEDIATRIC TRACH TUBE SIZE 5.0 A4624 $ 47.40 PEDIAZOLE SUSP 100ML Acquisition cost PEDICATRIC ICU $ 3,375.00 PEDICLE ACCESS NEEDLEGUIDE TUB C1713 $ 4,171.05 PEDICLE FAP; EL/N/ER/LIP 15576 $ 4,147.84 PEDICLE FLAP; F/N/AXIL/G/H/F 15574 $ 4,147.84 PEDICLE FLAP; SCALP/ARM/LEG 15572 $ 7,168.06 PEDICLE FLAP; W/WO TRNSFR; TRUNK 15570 $ 4,147.84 Pedicle soft tissue graft proc D4270 $ 560.00 PEEK CUST CRANIAL IMPL MEDIUM C1713 $ 11,992.50 PEEK TENODESIS SCREW 5.5x8MM STERILE C1713 $ 933.00 PEEL NEUTRALIZER 473ML Acquisition cost PEEL NEUTRALIZER; 473ML $ 66.00 PEFIER SCREW 25MM C1713 $ 172.50 PEGASPARGASE,SINGLE DOSE VIAL J9266 $ 33,066.37 PEGFIGRASTIM (NEULASTA) 6MG Acquisition cost PEGINTERFERON A 2-A 180MCG VIAL Acquisition cost PEGINTERFERON ALFA 2-A 180MCG Acquisition cost PELIVICOL ORTHO-CATEG 1 Acquisition cost PELVIC ANGIOGRAM 75736 $ 11,279.00 PELVIC EXAM UNDER ANES 57410 $ 6,010.51 PELVIC EXAMINATION 57410 $ 6,010.51 PELVIC EXENTERATION GYN MALIGN 58240 $ 6,230.84 PELVIC GRAFT SOFT 8X12 C1768 $ 1,875.00 PELVIMETRY W/WO PLACENTAL LOCALIZ 74710 $ 164.27 PELVIS 72170 $ 302.70 PELVIS CT WITH CONTRAST 72193 $ 668.38 PELVIS CT WITHOUT CONTRAST 72192 $ 302.70 PELVIS CT WITH AND WITHOUT CONTRAST 72194 $ 668.38 PELVIS MRI WITH AND WITHOUT CONTRAST 72197 $ 1,206.90 PELVIS MRI WITH CONTRAST 72196 $ 1,206.90 PELVIS MRI WITHOUT CONTRAST 72195 $ 614.37 PELVIS COMPLETE ULTRASOUND 76856 $ 302.70 PELVIS MRA 72198 $ 194.68 PEMETREXED 500MG IV Acquisition cost PEN G POT/DEXTR-H2O 1MMU/50ML J2540 Acquisition cost PEN G POT/DEXTR-H2O 2MMU/50ML J2540 Acquisition cost PEN G POT/DEXTR-H2O 3MMU/50ML J2540 Acquisition cost PEN G SKIN TEST DILUTION Acquisition cost PENCLLN G POTSSIUM 5M UNITS INK J2540 $ 80.08 PENETRAT KERATOPLASTY 65730 $ 9,548.90 PENICILL V POTASSIUM 250MG TABLETS J8499 $ 2.13 PENICILLIN G POT 600,000U INJ VIAL J2540 Acquisition cost PENICILLIN G POT 600,000U INJ VIAL J2540 Acquisition cost PENICILLIN G POT 600,000U INJ VIAL J2540 Acquisition cost PENICILLIN G SODIUM 5MU INJ Acquisition cost Page 223 2018 PENICILLIN POT 250MG/5ML PO SUSP Acquisition cost PENICILLIN SYRINGE 200,000UNIT Acquisition cost PENICILLIN V K 500MG TAB Acquisition cost PENICILLIN V POTAS 250MG TAB Acquisition cost PENICILLINAMINE 125MG PO Acquisition cost PENICILLINAMINE 250MG PO Acquisition cost PENILE PLETHYSMOGRAPHY 54240 $ 360.51 PENIS OP STR CHORD/1ST STG HYPOSPAD 54304 $ 4,484.35 PENROSE DRAIN TUBING C1729 $ 138.00 PENTAM 300 MG VIAL Acquisition cost PENTAMIDINE 300MG VIAL J2545 Acquisition cost PENTAMIDINE ORAL SOLN IN SW Acquisition cost PENTAMIDN ISETHIONAT INH SOL-300 MG J2545 $ 440.59 PENTOBARBITAL 80299 $ 41.01 PENTOBARBITAL 50MG/ML IV Acquisition cost PENTOSTATIN, PER 10 MG J9268 $ 5,824.65 PENTOTAL 50 MG SYRINGE J2515 Acquisition cost PERAMIVIR 200MG/20ML INJ J2547 Acquisition cost PERC ARTERIAL CATH 36620 $ 97.26 PERC CVC PLACE-PT >2YRS 36556 $ 2,599.54 PERC D-E COR STENT ATHER S C9602 $ 42,367.13 PERC PLACEMENT OF ENTEROCLYSIS TUBE 44015 $ 303.69 PERC RELEASE- DUPUYTRENS CNTRCTR 26040 $ 3,570.03 PERC RETROPERIT DRAINAGE 49406 $ 3,564.97 PERC SK FIX CMC DISLOC; EA JNT 26676 $ 6,995.52 PERC SK FIX MTP JNT DISLOC; W MANIP 28636 $ 3,570.03 PERC SK FIX UNST PHAL SHFT FX; W MANIP 26727 $ 6,995.52 PERC SKTL FIX DIST PHLANG FX; FNGR/THMB 26756 $ 6,995.52 PERC TX NASOETHMD COMPLX FX W FIX 21340 $ 5,815.59 PERCOCET 5-325MG TAB Acquisition cost PERCU URODIVROPENTIP PERC STNT C1876 $ 291.51 PERCUFLEX + URETER STENTW/WIRE C1876 $ 171.00 PERCUFLEX PLUS 6FR URETER STNT C1876 $ 171.00 PERCUFLEX PLUS URETER STENT C1874 $ 215.56 PERCUFLEX PLUS URETERAL STENT C1874 $ 171.00 PERCUFLEX+7FRX30CM STENT URETE C1876 $ 171.00 PERCUT LYSIS ADHENSION 62263 $ 1,777.62 PERCUT ASPIRAT SPINAL CORD CYST/SYRINX 62268 $ 1,777.62 PERCUT CHOLECYSTOSTOMY 47490 $ 7,698.79 PERCUT PLCMT ENTEROCLYSIS TUBE-RAD S / I 74355 $ 85.32 PERCUT PLCMT GASTROSTOMY TUBE 43246 $ 3,774.85 PERCUT PORTAL VEIN CATH BY ANY 36481 $ 740.08 PERCUTAN TRACH INTROD SET 8FR A4624 $ 570.72 PERCUTANEOUS BILIARY STENT 74363 $ 93.13 PERCUTANEOUS DRAINAGE 75989 $ 127.36 PERCUTANEOUS ENDO GASTROSTMY B4087 $ 132.83 PERCUTANEOUS IMPLANT 63650 $ 16,014.53 PERCUTANEOUS IMPLNT 63650 $ 16,014.53 PERCUTANEOUS TUBE/DRAINAGE CATH REPLACE 75984 $ 76.21 PERDONTL SCAL / RT PLN 1-3 TEETH EA QUAD D4342 $ 210.00 PERF SURGISIS 13X22 GOLD HERN GRFT 8PLY C1763 $ 9,166.50 PERFIT REPLACE PERCUT TRACHTUB A4624 $ 175.07 PER-FIT TRACH KIT W/TRACH TUBE 7.0MM A4625 $ 440.22 PER-FIT TRACH KIT W/TRACH TUBE 8.0MM A4625 $ 440.22 PER-FIT TRACH KIT W/TRACH TUBE 9.0MM A4625 $ 440.22 PERFIT TRACHEA KIT 9.0MM A4625 $ 175.07 Page 224 2018 PERFIX HERNIA PLUG SM2.5X3.4CM C1781 $ 1,237.50 PERFIX PLUG X-LARGE 6/CS* C1781 $ 1,482.75 PERFLURON-CATEG 1 Acquisition cost PERFLUTREN LPD MICROSPHERE Acquisition cost PERGOLIDE (PERMAX) 0.05MG TAB Acquisition cost PERGOLIDE (PERMAX) 0.25MG TAB Acquisition cost PERGOLIDE (PERMAX) 1MG TAB Acquisition cost PERIACTIN 2MG/5ML SYRUP 480ML Acquisition cost PERICARDIOCENTESIS 33010 $ 2,599.54 PERICARDIOCENTESIS; INIT 33010 $ 2,599.54 PERICARDIOCENTESIS; SUBSQT 33011 $ 2,599.54 PERICARDIOCENTESIS-INIT 33010 $ 2,599.54 PERIDEX ORAL RINSE 473ML Acquisition cost PERIGEE W/INTEXEN PROLAPSE REP C1781 $ 3,292.50 PERINEOGRAM 74775 $ 302.70 PERINEOPLASTY - RPR PERINEUM; NON-OB 56810 $ 6,010.51 PERIO MAINTENANCE D4910 $ 182.00 PERIODIC ORAL EXAM D0120 $ 83.00 PERIODIC ORTHODONTIC TREATMENT VISIT D8670 $ 350.00 PERIPHERAL GUIDE WIRE 5/BX C1769 $ 1,350.00 PERIPHERAL IRIDECTOMY 66625 $ 5,080.46 PERIPHERICAL DILATA CATH.035GW C1726 $ 1,467.00 PERIPROSTH CAPSULECT BREAST 19371 $ 7,213.98 PERITONEAL CATH 90CM STNDRD C1887 $ 181.65 PERITONEAL CATH STNDRD NO SLIT C1887 $ 264.96 PERITONEAL CATHETER 110CM C1781 $ 136.50 PERITONEAL INTRO SHEATH 46CM C1769 $ 353.73 PERITONEAL INTRODU SHEATH 61CM C1894 $ 237.00 PERITONEAL INTRODUCER SHEATH C1984 $ 237.00 PERITONEAL LAVAGE 49084 $ 1,966.21 PERITONEAL VENOUS SHUNT PATENCY 78291 $ 924.11 PERITONEOGRAM-RAD S / I 74190 $ 1,287.09 PERM BIRTH CONTROL SYSTEM 5/BX A4264 $ 1,948.50 PERM BRTH CONTRL SYS 1BX 2COIL A4264 $ 2,775.00 PERMA CATHETER Acquisition cost PERMA CATHETER 40CM 5KT A4301 $ 1,386.72 PERMAHAND SLK SUTRE BLCK BRAID C1713 $ 21.27 PERMETHRIN 5% TOPICAL CREAM 60GM Acquisition cost PERPHEN/AMITRIP 2/25 TAB Acquisition cost PERPHENAZINE 2MG TAB Q0175 Acquisition cost PERPHENAZINE 4MG TAB Q0175 Acquisition cost PERPHENAZINE 8MG TAB Q0175 Acquisition cost PERPHENAZINE-ASSAY 80299 $ 41.01 PERPHENZAINE 4MG ANTI-EMETIC Q0175 $ 3.94 PERQ & INTRAQ ALLERGY TEST; VENOMS 95017 $ 84.11 PERQ & INTRAQ ALLERGY TEST;DRUG/BIOL 95018 $ 84.11 PERQ ABLAT 1+ LIVER TUM, RAD FREQ 47382 $ 11,870.65 PERQ CADIAC ANGIOPLAST; 1 ARTERY 92920 $ 13,447.68 PERQ CARD STNT/ANTHRCT/ANGIO; 1ART 92933 $ 42,367.14 PERQ CARDIAC ANTHRCT W/ANGIOPLST; 1ART 92924 $ 27,795.70 PERQ CARP/MTCRPL FX DISLOC, THUMB 26650 $ 6,995.52 PERQ DEV SOFT TISS 1ST IMAG 10035 $ 1,514.94 PERQ DISKECTOMY 62287 $ 12,238.01 PERQ FIX DIST RADIAL FX W/MANIP 25606 $ 6,995.52 PERQ FIX IP JNT DISLOC, SNGL W MANIP 26776 $ 6,995.52 PERQ IMP PERIPH NRV NEUROSTIM ELCTRD 64555 $ 16,014.53 Page 225 2018 PERQ IMPL NEUROELECTRODES 64561 $ 16,014.53 PERQ IMPL NEUROELECTRODES; SACRL NRV 64561 $ 16,014.53 PERQ IMPL NEUROSTIM ELCTRD, PERIPH NRV 64555 $ 16,014.53 PERQ INTRACARD STNT W ANGIOPLST; 1 ART 92928 $ 27,795.70 PERQ LUMBOSACRAL INJECTION 22511 $ 6,995.52 PERQ NEPHROSTOLITHOTOMY; 2+ CM 50081 $ 20,088.88 PERQ NEPHROSTOLITHOTOMY; UP TO 2 CM 50080 $ 20,088.88 PERQ PLACE GASTROSTOMY TUBE 43246 $ 3,774.85 PERQ REVASC BYPASS GRFT; 1 VSL 92937 $ 27,795.70 PERQ REVASC MYOCARD INFARCT; 1 VSL 92941 $ 1,424.39 PERQ SACRPLSTY, BILAT INJ(S) 0201T $ 14,826.61 PERQ SACRPLSTY, UNILAT INJ(S) 0200T $ 14,826.61 PERQ SK FIXATION MC FX; EACH 26608 $ 6,995.52 PERQ SKELTL FIX DISTAL RADIAL FX 25606 $ 6,995.52 PERQ SKELTL FIX METATRSL FX W MANIP 28476 $ 6,995.52 PERQ SKTL FIX DIST PHALNG FX; FING/THMB 26756 $ 6,995.52 PERQ TRACH INTRO SET 8FR C1769 $ 570.72 PERQ TRANSCATH DRUG EL COR STENT C9600 $ 27,795.70 PERQ TRANSHEPAT PORTOG NO EVAL-S/I 75887 $ 2,599.54 PERQ TRANSHEPAT PORTOG W/EVAL-S / I 75885 $ 6,592.23 PERQ W/ALLERG EXTRACT-SPEC # TEST 95004 $ 1,175.22 PERSANTINE 5MG/ML 2ML AMP J1245 Acquisition cost PERTONEAL LAVAGE W IG 49804 $ 1,966.21 PERTUZUMAB 30MG/ML VIAL J9306 Acquisition cost PESSARY: SILICONE,KITS,KNOBS,W/WO SUPPRT A4562 $ 48.66 PETROLATUM OPHTH OINT Acquisition cost PETROLATUM PACKETS Acquisition cost FOIL PACKETS/GROSS/BOX $ 0.58 PF TISSUE SITU HYBRID INTERP+ 88291 $ 72.23 PH 83986 $ 9.72 PH 82800 $ 24.20 PH URINE 81002 $ 7.66 PH GASTRIC FLUID 83986 $ 9.72 PH STOOL 83986 $ 9.72 PH URINE 83986 $ 9.72 PHARMACIST INTERVENTION Acquisition cost PHARMACOLOGIC MGMNT W PSYCHTX 90863 $ 290.00 PHARMACOLOGIC MGMNT W/PSYCHTX 90863 $ 290.00 PHARMACY Acquisition cost PHARMACY MISC Acquisition cost PHARYNGOPLASTY 42950 $ 11,474.25 PHENAZOPYRIDINE 100MG TAB Acquisition cost PHENAZOPYRIDINE 200MG TAB Acquisition cost PHENELZINE 15MG TABLET Acquisition cost PHENERGAN 25MG/ML INJ 1ML AMP J2550 Acquisition cost PHENERGAN 50MG/ML INJ 1ML AMP J2550 Acquisition cost PHENOBARBITAL 80184 $ 33.66 PHENOBARBITAL 10MG/1ML SYRINGE J2560 Acquisition cost PHENOBARBITAL 130MG/ML TUBEX J2560 Acquisition cost PHENOBARBITAL 15MG TAB Acquisition cost PHENOBARBITAL 20MG/5ML 5ML Acquisition cost PHENOBARBITAL 20MG/5ML 480ML Acquisition cost PHENOBARBITAL 30MG BULK TABLET Acquisition cost PHENOBARBITAL 30MG TAB Acquisition cost PHENOBARBITAL 30MG UD TABLET Acquisition cost PHENOBARBITAL 30MG/ML TUBEX J2560 Acquisition cost Page 226 2018 PHENOBARBITAL 60MG/ML TUBEX J2560 Acquisition cost PHENOBARBITAL. 80184 $ 33.66 PHENOL APPLICATOR KIT Acquisition cost PHENOSENSE GT TM, NYPANEL Acquisition cost PHENOTYPE DNA HIV W/CLT; EA ADDL DRUG 87904 $ 70.80 PHENOTYPE DNA HIV W/CULTURE; 1-10 DRUGS 87903 $ 1,327.22 PHENOTYPING FLOW CYTOMETRY-LYMPHOMA/LEUK 88346 $ 569.71 PHENOXYBENZAMINE HCL 10MG Acquisition cost PHENYLALANINE 84030 $ 14.94 PHENYLALANINE URINE 82131 $ 50.56 PHENYLEPH/CYCLOPEN 1-0.2% EYE Acquisition cost PHENYLEPH/CYCLOPEN 1-0.2% EYE Acquisition cost PHENYLEPH/HARD FAT HEMORR SUPP Acquisition cost PHENYLEPHRIN 0.5% NASAL SOLUTION $ 6.71 PHENYLEPHRINE 0.25% NASAL DROP Acquisition cost PHENYLEPHRINE 1% NASAL DRIP Acquisition cost PHENYLEPHRINE 100MCG/ML SYRINGE Acquisition cost PHENYLEPHRINE 2.5% EYE DROP $ 29.90 PHENYLEPHRINE 2.5% EYE DROPS Acquisition cost PHENYLEPHRINE PREMIXED IV Acquisition cost PHENYTOIN 100MG/4ML PO SUSP Acquisition cost PHENYTOIN LEVEL FREE 80186 $ 37.38 PHENYTOIN LEVEL FREE + TOTAL 80185 $ 35.99 PHENYTOIN; FREE 80186 $ 37.38 PHERESIS, THERAPEUTIC 36514 $ 3,230.99 PHISODERM CLEANER Acquisition cost PHISOHEX CLEANSER Acquisition cost PHLEB VERICOSE VEINS 1 EXTRM; 20+ INC 37766 $ 6,592.23 PHLEBOTOMY THERAP (SEPART PROC) 99195 $ 204.34 PHLEBOTOMY, THERAP 99195 $ 204.34 PHLEBOTOMY, THERAPEUTIC 99195 $ 204.34 PHLORETIN CF Acquisition cost PHLORETN CF $ 222.20 PHOSPH UR T.V. 84105 $ 14.06 PHOSPH.UR RANDOM 84105 $ 14.06 PHOSPHOLINE IODIDE 0.03% OPTH Acquisition cost PHOSPHOLINE IODIDE 0.06% 5ML Acquisition cost PHOSPHOLINE IODIDE 0.125% 5ML Acquisition cost PHOSPHOLINE IODIDE 0.25% 5ML Acquisition cost PHOSPHORUS LEVEL BODY FLUID 84110 $ 22.92 PHOTOCHEMO;TAR AND UVB 96910 $ 147.99 PHOTODYNAMIC TX EA ADD 15 MIN 96571 $ 64.26 PHOTODYNAMIC TX APPL LGHT 30M 96570 $ 113.45 PHRENIC NERVE BLOCK 64410 $ 1,777.62 PHRM/PHYSCL ACTV RQ MD ATNDNC ACTV PHASE 95954 $ 1,175.22 PHYS PRFRM TEST/MEASUR W/REPORT 97750 $ 81.73 PHYS THERAPY EVALUATION 97001 $ 186.43 PHYS THERAPY RE-EVALUATION 97002 $ 104.02 PHYSICIAN REVIEW / INTERPRETATION ONLY 94016 $ 55.66 PHYSIOMESH 10X15CM OVAL COMP C1781 $ 706.87 PHYSIOMESH 20X25CM, OVAL SHAPE C1781 $ 2,079.03 PHYSIOMESH COMP 15X20CM OVAL C1781 $ 2,023.51 PHYSIOMESH OPEN FLEX COMP MESH C1781 $ 503.27 PHYSOSTIGMINESALICYLATE 1MG/ML Acquisition cost PHYTO PLUS 55ML Acquisition cost PHYTO PLUS; 55ML $ 110.00 Page 227 2018 PHYTONADIONE 10MG/ML INJ 1ML J3430 Acquisition cost PHYTONADIONE 1MG/0.5/ML INJ 1ML J3430 Acquisition cost PHYTONADIONE 5MG TAB J8499 $ 165.00 PHYTONADONE 5MG TAB Acquisition cost PICC CATH INSERT; UNDER 5 YRS AGE 36568 $ 1,619.99 PICC CATH REPLACEMENT 36584 $ 2,599.54 PICC CATHETER-CATEG 1 Acquisition cost PICC LINE KIT 5 FRENCH C1751 $ 660.00 PICC LINE-CATEG 1 Acquisition cost PIGMENT BALANCING PEEL Acquisition cost PIGMNT BALANCING PEEL $ 277.20 PIGS SKIN-CATEG 1 Acquisition cost PILLOW ABDUCTION-CATEG 1 Acquisition cost PILOCARPIN 1% $ 216.83 PILOCARPINE 0.5% OPH. SOLUTION Acquisition cost PILOCARPINE 0.5% OPHTH DROPS Acquisition cost PILOCARPINE 1% EYE DROP Acquisition cost PILOCARPINE 2% EYE DROP Acquisition cost PILOCARPINE 3% EYE DROP Acquisition cost PILOCARPINE 4% EYE DROP Acquisition cost PILOCARPINE 5MG TABLETS J3490 Acquisition cost PILOCARPINE 6% EYE DROP Acquisition cost PILOCARPINE HCL 2% $ 216.83 PILOCARPINE HCL 4% EYE DROPS $ 216.83 PILOCARPINE OPH. SOLUTION 0.5% Acquisition cost PIN ANCHOR-CATEG 1 Acquisition cost PIN FIXATION/BITS-CATEG 1 Acquisition cost PIN FIXATION-CATEG 1 Acquisition cost PIN FIXATION-CATEG 2 Acquisition cost PIN GUIDE-CATEG 1 Acquisition cost PIN ULNAR STYLOID FX 25651 $ 6,995.52 PIN VARIOUS C1713 $ 232.36 PINABALL PRELOADED PINS C1713 $ 680.40 PIN-CATEG 1 C1894 Acquisition cost PINN DESTIN 6FRGUIDESHTH W/DIL C1894 $ 214.50 PINNACLE 7FR W/RO 10/BX C1894 $ 102.75 PINNACLE 8F 10/BX C1894 $ 42.68 PINNACLE ALRX 36 X 56ID X OD C1776 $ 4,743.00 PINNACLE INTRO SHEATH 6FRx10x035 C1894 $ 19.50 PINNACLE INTRO SHEATH GW 7FRx11x0.35 C1894 $ 171.75 PINNACLE INTRODUCE SHEATH 10BX C1894 $ 31.00 PINNACLE INTRODUCER SHEATH 4FR C1894 $ 17.18 PINNACLE INTRODUCER SHEATHS C1729 $ 102.75 PINNACLE MULTIHOLE 54 SZ MM C1713 Acquisition cost PINNACLE SCREW 15MM C1713 $ 202.50 PINNACLE SHEATH 10CM.038D C4894 $ 502.50 PINNACLE SHEATH 6FR CRSSCUT MULTIPRPSE C1887 $ 214.50 PINNDIST 7FR GUIDESHTH W/DILAT C1894 $ 214.50 PINS ORTHOSORB-CATEG 1 Acquisition cost PINWORM EXAM 87172 $ 11.59 PIOCARPINE/EPI BIT-2 EYE DROP Acquisition cost PIOCARPINE/EPI BIT-4 EYE DROP Acquisition cost PIOGLITAZONE (ACTOS) 15MG TAB Acquisition cost PIOGLITAZONE (ACTOS) 30MG TAB Acquisition cost PIOGLITAZONE (ACTOS) 45MG TAB Acquisition cost PIPERAC/TAZO 3.375GM ADD VANT Acquisition cost Page 228 2018 PIPERAC/TAZOB 2.25GM ADD VANT Acquisition cost PIPERAC/TAZOB 4.5GM ADD VANT Acquisition cost PIPERAC/TAZOBAC 2.25GM INJ J2543 Acquisition cost PIPERAC/TAZOBAC 3.375GM INJ J2543 Acquisition cost PIPERACIL/TAZOBACT 4.5GM INJ J2543 Acquisition cost PIPERACILLIN 1GM/ML 3GM VIAL Acquisition cost PIPERACILLIN SOD 2GM INJ Acquisition cost PIPERACILLIN-TAZOBACTAM EMERG STAT DOSE J2543 $ 0.10 PIPERONYL BUTOX/PYRETHRIN SHAMP Acquisition cost PIRBUTEROL 0.2MG AER ADP INH Acquisition cost PIROXICAM 20MG CAP Acquisition cost PISCES-QUAD LEAD KIT Acquisition cost PITOCIN/SYNTOCINON 10U/ML 1ML J2590 Acquisition cost PK STRP IOD 1/2X 5 $ 4.82 PK STRP IOD 1/4X5 $ 4.54 PK STRP IOD 1X5 $ 5.64 PK STRP IODL 2X5 $ 7.70 PK STRP PL 1/2X5 $ 4.06 PK STRP PL 1/4X5 $ 4.13 PK STRP PL 1X5 $ 4.68 PK STRP PL 2X5 $ 7.49 PKD CELL-PROCESS FEE P9021 $ 314.14 PL REP AV ANEUR 36832 $ 11,279.00 PLACE AMNIO MEMBRNE ON CORNEA 65778 $ 2,137.81 PLACE BILIARY DRAIN CATH; EXTRNL 47533 $ 7,698.79 PLACE BILIARY DRAIN CATH; INTRNL-EXTRNL 47534 $ 7,698.79 PLACE CATH; CARTOID ARTERY 36224 $ 11,279.00 PLACE CATH; CARTOID/INNOM EXTRACRANIAL 36222 $ 6,592.23 PLACE CATH; CARTOID/INNOM INTRACRANIAL 36223 $ 11,279.00 PLACE CATH; EXTRN CARTOID ART 36227 $ 248.25 PLACE CATH; SUBCLAV/INNOM ART 36225 $ 6,592.23 PLACE CATH; THORACIC AORTA 36221 $ 6,592.23 PLACE CATH; VERTEBRAL ART 36226 $ 11,279.00 PLACE DEV/MRKR; PROSTATE, RAD TX 55876 $ 3,138.26 PLACE DUOD/JEJ TUBE; PERQ 49441 $ 3,774.85 PLACE GASTROSTMY TUBE;PERQ 49440 $ 3,774.85 PLACE GASTROSTOMY TUBE; PERC W GUIDANCE 49440 $ 3,774.85 PLACE NEEDLE INTRAOSSEOUS INFUSION 36680 $ 872.74 PLACE NEEDLE; INTRAOSSEOUS INFUSION 36680 $ 872.74 PLACE NEEDLES - PELVIC FOR RT 55920 $ 10,873.98 PLACE OF DEVICE FAC ERUPT IMPACT TOOTH D7283 $ 150.00 PLACE PERQ BRST DEV; 1ST LES STEREO GUID 19283 $ 1,514.94 PLACE PERQ BRST DEV; 1ST LES, MR GUIDE 19287 $ 1,514.94 PLACE PERQ BRST DEV; 1ST LES, US 19285 $ 1,514.94 PLACE PERQ BRST DEV; EA ADD LES STRTCTC 19284 $ 112.42 PLACE PERQ BRST DEV; EA ADD LES, MR 19288 $ 142.67 PLACE PERQ BRST DEV; EA ADD LES, US 19286 $ 94.89 PLACE PERQ BRST LOCAL DEV; EA ADDL 19282 $ 111.28 PLACE SETON 46020 $ 6,123.85 PLASMA CONCENTRA W/GPSIII TUBE A4624 $ 751.50 PLASMA CORTISOL 82533 $ 44.26 PLASMA EXCHANGE/PHER 36514 $ 3,230.99 PLASMA HB 83051 $ 19.87 PLASMA HEPARIN LEVEL 85520 $ 35.55 PLASMA PROTEIN FRACT, 5%, 250 ML P9048 $ 103.18 PLASMA PROTEIN FRACT, 5%, 50 ML P9043 $ 33.88 Page 229 2018 PLASMA VOL RADIOPHARM-SEP PROC; MX 78111 $ 3,180.58 PLASMA, FROZEN WITHIN 24 HRS, UNIT P9059 $ 163.33 PLASMINOGEN 85421 $ 27.65 PLASTC REP SALIVARY DUCT;SIMPL 42500 $ 11,474.25 PLASTIC OPERATION OF PENIS FOR INJURY 54440 $ 9,800.87 PLASTIC REP INTROITUS 56800 $ 6,010.51 PLASTIC REPR CANALICULI 68700 $ 4,790.26 PLASTIC SURG TO FIX PENIS ANGLE 54360 $ 7,131.78 PLASTIC SURGERY MATRIX C1763 $ 2,028.60 PLAT AGGREG DILUTED 85576 $ 58.34 PLATE "L"-CATEG 1 Acquisition cost PLATE 16MM ANT CERV PLATE C1713 $ 1,434.37 PLATE 4 HOLE WITH LARGE BAR C1713 $ 418.95 PLATE 4 HOLE WITH SMALL BAR C1713 $ 418.95 PLATE 4-HOLE C1713 $ 418.95 PLATE 6JTCS-CATEG 1 Acquisition cost PLATE 7 HOLE C1713 $ 684.67 PLATE BASE-CATEG 1 C1713 Acquisition cost PLATE BASE-CATEG 2 Acquisition cost PLATE BONE HOLE2 CRANIOMAXILLO C1713 $ 240.23 PLATE CANCANEAL; X-SMALL C1713 $ 865.50 PLATE CERV-CATEG 1 C1713 Acquisition cost PLATE COMP-CATEG 1 C1713 Acquisition cost PLATE HIP SCREW-CATEG 1 Acquisition cost PLATE HIP-CATEG 1 Acquisition cost PLATE HYPERFLEXION-CATEG 1 Acquisition cost PLATE ORBITAL-CATEG 1 C1713 Acquisition cost PLATE RIGHT 16 HOLES-CATEG 1 Acquisition cost PLATE SQUARE-CATEG 1 Acquisition cost PLATE STRAIGHT-CATEG 1 Acquisition cost PLATE THREAD-LOCK-CATEG 1 Acquisition cost PLATE TIBIA-CATEG 1 C1713 Acquisition cost PLATE TITANIUM-CATEG 1 C1713 Acquisition cost PLATE VARIOUS - STRYKER C1713 $ 717.20 PLATE VHS-CATEG 1 Acquisition cost PLATELET P9019 $ 252.89 PLATELET AB SCREEN 86255 $ 32.74 PLATELET AB SCREEN-CHLOROQUINE METHOD 86022 $ 49.90 PLATELET AB SCRN 86022 $ 49.90 PLATELET AGGRE WH BL 85576 $ 58.34 PLATELET AGGREGATION 85576 $ 58.34 PLATELET AGGREGATION 85576 $ 58.34 PLATELET CONC, LR, IRRADIATED, UNIT P9033 $ 368.83 PLATELET CONC, LR, UNIT P9031 $ 256.74 PLATELET COUNT 85049 $ 12.17 PLATELET COUNT CITRATED 85049 $ 12.17 PLATELET COUNT PRP 85049 $ 12.17 PLATELET CROSSMATCH 86922 $ 341.62 PLATELET CROSS-MATCH 86999 $ 46.20 PLATELET DIRECT IF 86023 $ 33.84 PLATELET ESTIMATE $ 3.70 PLATELET INDICES $ 4.18 PLATELET PLA1 TYPING 86999 $ 46.20 PLATELET RICH PLASMA, UNIT P9020 $ 271.72 PLATELET, APH/PHER, LR - UNIT P9035 $ 1,049.40 PLATELET, APH/PHER, LR, UNIT P9035 $ 1,049.40 Page 230 2018 PLATELET; MANUAL CT 85032 $ 11.70 PLATELETS LEUKOREDUCED, IRRADIATED, UNIT P9033 $ 368.83 PLATELETS, HLA-M, L/R, UNIT P9052 $ 1,692.50 PLATELETS, IRRADIATED, UNIT P9032 $ 394.11 PLATELETS, LEUKOCYTES REDUCED, UNIT P9031 $ 256.74 PLATELETS, PHERESIS IRRADIATED, UNIT P9036 $ 1,219.79 PLATELETS, PHERESIS LEUKOREDUCED, UNIT P9035 $ 1,049.40 PLATELETS, PHERESIS, UNIT P9034 $ 926.64 PLATELETS, UNIT P9019 $ 252.89 PLATELTS, PHERESIS LEUKORED, IRRAD, UNIT P9037 $ 1,374.25 PLATFORM ATTACHMENT WALKER EA E0154 $ 134.15 PLAVIX 300MG. PO Acquisition cost PLC EXTEN PROSTH-REPR AO ANEUR-RS/I 75953 $ 175.58 Plcmnt of devc w/o fracture D7998 Acquisition cost Plcmnt: temp anch scrw rtnd plt D7292 Acquisition cost Plcmnt: temp anch w/ surg flap D7293 Acquisition cost Plcmnt: temp anch w/o surg flap D7294 Acquisition cost PLCMT CENT VENOUS CATH; CUTDN <2 YR 36557 $ 11,279.00 PLCMT CENT VENOUS CATH; CUTDWN 36569 $ 2,599.54 PLCMT CHOLEDOCHAL STENT 47801 $ 2,280.65 PLCMT FEM PROS GFT DUR ANEUR REPR 34813 $ 505.98 PLETHYSMOGRAPHY TOT BODY; TRACING ONLY 94726 $ 658.04 PLETHYSMOGRAPHY TOTAL BODY; W/I/R 94726 $ 658.04 PLEURAL DRAIN W CATH INS; NO GUIDE 32556 $ 3,774.85 PLEURAL DRAIN W CATH INS; W GUIDE 32557 $ 2,599.54 PLEURX DRAINAGE CATH C1729 $ 885.00 PLEURX LOCKABLE DRAINAGE LINE C1729 $ 240.00 PLEURX PLEURAL CATHETER KIT C1887 $ 862.50 PLICAMYCIN 2500MCG INJ J9270 Acquisition cost PLMT NEPHROURETERAL CATH 50433 $ 4,484.35 PLMT NEPHROURETERAL CATHETER 50433 $ 4,484.35 PLMT URETERAL STENT PRQ 50693 $ 7,131.78 PLMT URETERAL STENT PRQ 50694 $ 7,131.78 PLSTC REP UTERINE CERVIX; VAGINAL APPR 57720 $ 6,010.51 PLT, APH/PHER, L/R, CMV-NEGATIVE, UNIT P9055 $ 747.89 PLT, PHER, L/R, CMV, IRRADIATED, UNIT P9053 $ 1,187.63 PLT/6 HL STRT W/ BAR MAND LOCK C1713 $ 1,269.33 PLT/STANDARD ANCHOR T-SHP.LNG C1713 $ 230.96 PLUG EAGLE FLEX-CATEG 1 Acquisition cost PLUG PUNCTUM-CATEG 1 Acquisition cost PLUG-CATEG 1 Acquisition cost PLUG-CATEG 2 Acquisition cost PLUG-CATH $ 0.64 PLUM IV NITRO SET #2427-48 $ 18.67 PLUMONARY STRESS TEST/SIMPLE 94620 $ 266.31 PLYSMNGRPHY 4> ADD PRMTRS W/CPAP-BLV VNT 95811 $ 2,387.99 PM DEVICE EVAL IN PERSON 93288 $ 99.81 PM DEVICE PROGR EVAL, DUAL 93280 $ 99.81 PM DEVICE PROGR EVAL, MULTI 93281 $ 99.81 PM DEVICE PROGR EVAL, SNGL 93279 $ 99.81 PM PHONE R-STRIP DEVICE EVAL 93293 $ 99.81 PM/ICD REMOTE TECH SERV 93296 $ 99.81 PMKR, M/N 1270 Acquisition cost PNEUMO PANEL - PNEUMOVAX Acquisition cost PNEUMO PANEL - PREVNAR13 Acquisition cost PNEUMOCOCCAL 86317 $ 40.70 Page 231 2018 PNEUMOCOCCAL AB 86318 $ 39.80 PNEUMOCOCCAL ANTIBODY IGG 86609 $ 34.98 PNEUMOCOCCAL CHILD VAC IM Acquisition cost PNEUMOCOCCAL VACCINE 90732 Acquisition cost PNEUMONOSTOMY; W/PERCUT DRAIN ABSC/CYST 49405 $ 3,564.97 PNEUMOTHORAX THERAP-INTRAPLEURAL INJ AIR 32960 $ 1,619.99 PNEUMOVAX VACCINE 90732 $ 96.33 PNEUMOVAX VACCNE 90732 $ 96.33 POC TO ADDRESS PAIN DOCUMENTED 0521F Acquisition cost PODOFILOX 0.05% Acquisition cost PODOFILOX 0.5% GEL TOPICAL Acquisition cost PODOPHYLLM 25% TOPICAL LIQUID $ 269.50 PODOPHYLLUM 25% COMPOUND Acquisition cost PODOPHYLLUM IN BENZOIN TINCT Acquisition cost PODOPHYLLUM RESIN POWDER 25GM Acquisition cost POLARCATH .035 5X80X120 C1725 $ 1,080.00 POLARCATH BALL DILAT 5X40X120M C1725 $ 900.00 POLARCATH BALLON 4.0 6FR 120CM C1725 $ 900.00 POLARCATH BALLOON .014 6X60X135 6FR C1725 $ 1,296.00 POLARCATH BALLOON 2.5X60X150 C1725 $ 1,296.00 POLARCATH BALLOON 3.5x40x150 C1725 $ 1,296.00 POLARCATH BALLOON 3x60x150CM C1725 $ 1,296.00 POLARCATH BALLOON 4.0X6FRX120CM C1725 $ 900.00 POLARCATH BALLOON 5.0 6FR C1725 $ 900.00 POLARCATH BALLOON 6.0 7FR 120CM C1725 $ 900.00 POLARCATH BALLOON 6X40X120 C1725 $ 900.00 POLARCATH BALLOON 7.0 7FR 80CM C1725 $ 900.00 POLARCATH BALLOON 7FR/7.0/80CM C1725 $ 900.00 POLARCATH BALLOON 8.0 8FR 80CM C1725 $ 900.00 POLARCATH BALLOON 8FR/8.0/80CM C1725 $ 900.00 POLARCATH DILATATION BALL CATH C1726 $ 1,296.00 POLARCATH PERIPHER DILATA CATH C1714 $ 930.00 POLIDOCANOL 0.5% INJ J3490 $ 44.88 POLIDOCANOL 1% INJ J3490 $ 29.04 POLIOVIRUS TITER 86658 $ 35.38 POLIOVIRUS VACCINE INACT,IPV,SUBQ CLINIC 90713 $ 79.66 POLRCATH 5FR 40x135 DILATRION BALL CATH C1725 $ 1,296.00 POLRCATH BALL DILAT 5.0MMX40MMX120MM C1725 $ 900.00 POLY INSERT 57 10/11MM Acquisition cost POLY INSERT SIZE 6/9MM Acquisition cost POLY PATELLA KNEE SOLUTION C1776 $ 1,702.12 POLY SCREW 6 X 35 Acquisition cost POLYAXIAL SCREW 6.0 X 40 Acquisition cost POLYBRENE PANEL 86886 $ 341.62 POLYCITRA SYRUP Acquisition cost POLYETHYLENE GLYCOL 4000ML Acquisition cost POLYMIXIN B 500KU INJECTION Acquisition cost POLYMIXIN B/TMP EYE DROP Acquisition cost POLYMYXIN B SULFATE/TMP 10ML $ 28.38 POLYSCREW 6 X 45 Acquisition cost POLYSOMNOGRAPHY, 1-3 ADDL PRMTRS 95808 $ 2,387.99 POLYSOMNOGRAPHY, 4 OR MORE ADDL PRMTRS 95810 $ 2,387.99 POLYSOMNOGRAPHY; W/4-MORE ADD PARAMETERS 95810 $ 2,387.99 POLYSPORIN OPH. OINT. Acquisition cost POLYSPORIN POWDER Acquisition cost POLYTRIM EYE DROPS Acquisition cost Page 232 2018 POLYVINYL ALCHOL EYE DROPS Acquisition cost POLYVINYL ALCOHOL 1.4% 15M Acquisition cost POLY-VITAMIN DROPS 50ML Acquisition cost PONTIC TITANIUM D6214 $ 644.00 Pontic-cast high noble metal D6210 $ 840.00 PONTIC-PFM D6240 $ 840.00 PONTOCAINE 2% SPRAY 30ML TOPICAL USE $ 13.73 POOLBLOODCOMPONENT 86965 $ 341.62 PORCELAIN INLAY - 3 SURFACE D2630 $ 700.00 PORCELAIN VENEER-LAB D2962 $ 770.00 PORPHOBILINOGEN 84110 $ 22.92 PORPHOBILINOGEN UR 84110 $ 22.92 PORPHOBILINOGEN DEAMINASE RBC $ 76.44 PORPHOBILINOGEN QUAL URINE 84110 $ 22.92 PORPHOBLINOGEN 84106 $ 12.80 PORPHOBLINOGEN UR 84106 $ 12.80 PORPHYRIN QUANT (UR) 84120 $ 39.95 PORPHYRINES QUANT 84120 $ 39.95 PORPHYRINS 24 HOUR URINE 84120 $ 39.95 PORT ACCESS INFUSION SET; KAWASUMI C1788 $ 344.10 PORT DUAL DISP TOURNIQUET-CATEG 1 Acquisition cost PORT MBS-CATEG 1 Acquisition cost PORT MRI IMPLANT-CATEG 1 Acquisition cost PORT PLASTIC-CATEG 1 Acquisition cost PORT SAMPLE-CATEG 1 Acquisition cost PORT SURGIPORT-CATEG 1 Acquisition cost PORT THORACOPORT-CATEG 1 Acquisition cost PORT VASC ACCESS TI-CATEG 1 Acquisition cost PORTA CATH 5FR ST305P C1752 $ 255.00 PORTA CATH 5FR ST305P C1714 $ 255.00 PORTABLE PEAK FLOW METER S8096 $ 10.30 PORT-A-CULT TUBE $ 6.09 PORTCATH INTRO SNGL LUMEN TITN C1752 $ 427.50 PORTER GUIDEWIRES .014" C1713 $ 1,657.50 POSACONAZOLE 200MG/5ML SUSPENSION Acquisition cost POSITIONAL NYSTAGMUS TEST 92532 $ 240.00 POSITIONAL NYSTAGMUS TEST WO/RECORDING 92542 $ 277.79 POST CAPSULAR RELEASE; KNEE 27435 $ 6,995.52 POST COLPORRHAPHY; RPR RECTOCELE 57250 $ 10,873.98 POST OP FOLLOW-UP VISIT 99024 $ 398.00 POST PARTUM VISIT - SUPP 59430 $ 293.77 Post removal (not with endo) D2955 $ 280.00 POST TIB NEUROSTIM, PERQ NDLE ELCTRODE 64566 $ 647.13 POST, EXTENSION ARMS OUTRIGGER C1713 $ 242.55 POSTER STABILIZE FEMRL #7RTFEM C1776 $ 2,092.50 POSTERIOR COMPOSITE RESIN - 1 SURFACE D2391 $ 175.00 POSTERIOR COMPOSITE RESIN - 2 SURFACE D2392 $ 210.00 POSTERIOR COMPOSITE RESIN - 3 SURFACE D2393 $ 252.00 POSTERIOR COMPOSITE RESIN - 4 SURFACE D2394 $ 280.00 POSTERIOR CONTROL SUB 30906 $ 472.05 POSTERIOR CONTROL SUBS 30906 $ 472.05 POSTERIOR FOSS CT WITH CONTRAST 70481 $ 668.38 POSTERIOR FOSSA CT W/W/O CONTRAST 70482 $ 668.38 POSTERIOR FOSSA CT WITHOUT CONTRAST 70480 $ 302.70 POSTOP F/U VISIT INCLD GLOBAL 99024 $ 318.00 POSTOP F/U VISIT INCLD GLOBAL 85097 $ 1,430.62 Page 233 2018 POSTOPERATIVE EYE KIT Acquisition cost POSTUROGRAPHY 92548 $ 277.79 POT CL 10MEQ/1L D5-0.225 NACL IV Acquisition cost POT CL/NA CHLOR .9% per 2 mEq/L J3480 Acquisition cost POTAS PHOS DIBASIC TAB Acquisition cost POTASS CHLORIDE 20MEQ TAB/CAP Acquisition cost POTASSIUM 84132 $ 12.50 POTASSIUM STOOL 84133 $ 11.70 POTASSIUM 20mEQ/00mL 1/2 NaCl $ 0.10 POTASSIUM ACETATE 2MEQ/ML 20ML Acquisition cost POTASSIUM BF 84132 $ 12.50 POTASSIUM CHLOR PER MEQ/NS 1L IV J3480 Acquisition cost POTASSIUM CHLOR 20MEQ/1L D5/ 0.33NS Acquisition cost POTASSIUM CHLORDE 0.1. mcg/ml Acquisition cost POTASSIUM CHLORIDE 10MEQ/0.1L J3480 Acquisition cost POTASSIUM CHLORIDE 2 MEQ/ML 20ML J3480 Acquisition cost POTASSIUM CHLORIDE 20MEQ/0.1L J3480 Acquisition cost POTASSIUM CHLORIDE 40MEQ/15ML ORAL SOLN Acquisition cost POTASSIUM CHLORIDE/D5NS20MEQ/L J3480 Acquisition cost POTASSIUM CL 0.5MEQ SYRINGE J3480 Acquisition cost POTASSIUM CL 20MEQ D5W 1L IV J3480 Acquisition cost POTASSIUM CL 40MEQ/1L NS IV J3480 Acquisition cost POTASSIUM CL/D5-.25NACL 20ME J3480 Acquisition cost POTASSIUM CL/D5-.45NACL 20ME J3480 Acquisition cost POTASSIUM HYDROXIDE 20% Acquisition cost POTASSIUM HYDROXIDE 20% W/ D50% Q0112 $ 31.57 POTASSIUM LEVEL BODY FLUID 84999 $ 14.30 POTASSIUM PHOS 15MMOL/250 IV Acquisition cost POTASSIUM PHOS 45mmol/15mL vial Acquisition cost POTASSIUM PHOSPHATE 3MM/ML Acquisition cost POTASSIUM UR RANDOM 84133 $ 11.70 POTASSIUM UR T.V. 84133 $ 11.70 POUCH-CATEG 1 C1781 Acquisition cost POVIDINE - IODINE SOLUTION $ 4.19 POVIDONE IODINE 5% OPH SOL Acquisition cost POVIDONE-IODINE FOIL PACK Acquisition cost POVIDONE-IODINE SOLUTION 473ML Acquisition cost POVIDONE-IODINE SURG SCRB 473ML Acquisition cost PPPS INITIAL VISIT; MCARE ONLY G0438 $ 371.54 PRA-FULL 86807 $ 173.03 PRA-SHORT 86808 $ 80.61 PRASUGREL HCL 10MG TAB J8499 $ 34.47 PRASUGREL TABLET 10 MG. Acquisition cost PRASURGEL 10MG. PO Acquisition cost PRATT SILIC DRAIN 15FR TROCAR C1729 $ 110.33 PRAVASTATIN 10MG TAB Acquisition cost PRAVASTATIN 20MG TAB Acquisition cost PRAVASTATIN 40MG TAB Acquisition cost PRAVASTATIN 80MG TABS Acquisition cost PRAZIQUANTEL 600MG. PO Acquisition cost PRCTCTMY; CMPLT ABDMNPERINEAL W COLOSTMY 45110 $ 3,979.91 PREALBUMIN 84134 $ 39.62 PRE-ALBUMIN 84134 $ 39.62 PREC PIN 10BX THREAD STERILE C1713 $ 1,125.00 PRECEDEX 100mL VIALS Acquisition cost PRECEED SURGICAL MESH OVAL 8X10" C1781 $ 2,073.09 Page 234 2018 PRECISION GLIDE NEEDL 30GX1/2 C2618 $ 10.47 PRECISON ATTACHMENT D6950 $ 680.00 PRED FORTE 1% OPTH DROPS 5ML Acquisition cost PREDATOR CATH .014 PLATFRM DBX SLD CRWN C1724 $ 4,942.50 PREDISONLONE 15MG/5ML SYR J7510 Acquisition cost PREDNISNE 10MG TAB, PER 1MG J7512 $ 1.76 PREDNISNE 20MG TAB, PER 1MG J7512 $ 1.76 PREDNISNE 5 MG TAB, PER 1MG J7512 $ 1.10 PREDNISNE ORAL PER 5MG J7510 $ 1.41 PREDNISNE SYRUP 15MG/5ML J7510 $ 1.41 PREDNISOLON 1% $ 121.70 PREDNISOLONE 1% EYE DROP Acquisition cost PREDNISOLONE 15MG ORAL LIQ J7510 $ 0.18 PREDNISOLONE 5MG/1.7ML PO Acquisition cost PREDNISOLONE MILD 0.12% EYE DROP Acquisition cost PREDNISOLONE NA PHOS 15MG/5ML J7510 Acquisition cost PREDNISONE 1 MG TAB, PER 1MG J7512 Acquisition cost PREDNISONE 10 MG TAB, PER 1MG J7512 Acquisition cost PREDNISONE 20MG TAB, PER 1MG J7512 Acquisition cost PREDNISONE 5MG TAB, PER 1MG J7512 Acquisition cost PREDNISONE TAPER DOSE, PER 1MG J7512 Acquisition cost PREDNISONE, ORAL, PER 1 MG J7512 $ 1.63 PREFAB ABUTMENT INCLUDES PLACEMENT D6056 $ 560.00 PREFAB POST / CORE D2954 $ 364.00 PREFAB RESIN CROWN D2932 $ 231.00 Prefab stain steel crown-perm D2931 $ 630.00 Prefb esth ctd stnl stl crn-prm D2934 $ 405.00 PREG UTERUS / TRANSVAGINAL US 76817 $ 302.70 PREG UTERUS > 1ST TRIM US 76801 $ 302.70 PREG UTERUS FETAL ANATOMIC EXAM US 76811 $ 302.70 PREG UTERUS FETAL EXAM ADD GEST US 76812 $ 199.96 PREG UTERUS US-COMPLETE 76805 $ 302.70 PREGABALIN 100MG CAPSULE Acquisition cost PREGABALIN 150MG CAPSULE Acquisition cost PREGABALIN 200MG CAPSULE Acquisition cost PREGABALIN 225MG CAPSULE Acquisition cost PREGABALIN 25MG CAPSULE Acquisition cost PREGABALIN 300MG CAPSULE Acquisition cost PREGABALIN 50MG CAPSULE Acquisition cost PREGABALIN 75MG CAPSULE Acquisition cost PREGNANCY (URINE) 81025 $ 18.94 PREGNANCY (URINE) VISUAL COLR COMPAR 81025 $ 18.94 PREGNANCY TEST URINE 81025 $ 18.94 PREGNANEDIOL (UR) 84135 $ 51.99 PREGNANETRIOL (UR) 84138 $ 51.41 PREGNANT UTERUS / TRANSVAGINAL US 76817 $ 302.70 PREGNANT UTERUS /FOLLOW UP US 76816 $ 302.70 PREGNANT UTERUS > 1ST TRIMESTER US 76801 $ 302.70 PREGNANT UTERUS >14 WEEKS / COMPLETE US 76805 $ 302.70 PREGNANT UTERUS >14 WEEKS / COMPLETE-OPD 76805 $ 302.70 PREGNANT UTERUS >14 WEEKS ADD GESTATION 76810 $ 109.49 PREGNANT UTERUS >14 WEEKS ADD GEST-OPD 76810 $ 109.49 PREGNANT UTERUS FETAL ANATOMIC EXAM US 76811 $ 302.70 PREGNANT UTERUS FETAL EXAM ADD GEST US 76812 $ 199.96 PREGNANT UTERUS/ADD GESTATION>1ST TRIMUS 76802 $ 92.64 PREGNANT UTERUS/LIMITED/EVAL ORGAN-OPD 76815 $ 302.70 Page 235 2018 PREGNANT UTERUS/LIMITED/EVALUATE ORGAN 76815 $ 302.70 PREKALLIKREIN 85292 $ 51.41 PREMARIN 0.625MG TAB Acquisition cost PREMARIN 2.5 MG TAB Acquisition cost PREMARIN 25MG INJ VIAL J1410 Acquisition cost PREMARIN VAGINAL CREAM 43GM Acquisition cost PRENATAL VIT/W-CA,FE,FA 1+1 TAB Acquisition cost PRE-NATAL WITH IRON VITAMIN (STARTER D Acquisition cost PRE-OP ICD DEVICE EVAL 93287 $ 50.89 PRE-OP PM DEVICE EVAL 93286 $ 33.26 PRE-ORTHODONTIC VISIT D8660 $ 427.00 PREP CORNEAL ENDOTHL ALLOGRAFT; ADDON 65757 Acquisition cost PREP REPRT PT PSYCH STS/HX/TX/ 90889 $ 290.00 PREP SET GEN SURG $ 8.27 PREPEN Acquisition cost PRE-PEN 0.25MG AMPULE Acquisition cost PREV COUNS/RISK RED 45MIN 99403 $ 263.00 PREV MED CNSL GRP PROC;60 99412 $ 235.50 PREV MED CNSL GRP-SEP PROC; 60 99412 $ 235.50 PREV MED COUN GRP;30MIN 99411 $ 224.50 PREV MED COUNS/RISK RED 45 MIN 99403 $ 263.00 PREV MED COUNS/RISK RED 60 MIN 99404 $ 290.50 PREV MED COUNSEL GRP ; 30 MIN 99411 $ 224.50 PREV MED E/M ESTAB PT;12-17YR 99394 $ 343.00 PREV MED E/M ESTAB PT;1-4YR 99392 $ 343.00 PREV MED E/M ESTAB PT;18-39YR 99395 $ 343.00 PREV MED E/M ESTAB PT;40-64YR 99396 $ 343.00 PREV MED E/M ESTAB PT;5-11YR 99393 $ 343.00 PREV MED E/M ESTAB PT;65/>YR 99397 $ 343.00 PREVEN E/M ESTAB PT:40-64 YR 99396 $ 343.00 PREVEN E/M ESTAB PT;18-39 YR 99395 $ 343.00 PREVEN E/M ESTAB PT;65/> YR 99397 $ 343.00 PREVEN MEDS E&M ESTAB PT; 12-1 99394 $ 343.00 PREVEN MEDS E&M ESTAB PT; 1-4 99392 $ 343.00 PREVEN MEDS E&M ESTAB PT; 18-3 99395 $ 343.00 PREVEN MEDS E&M ESTAB PT; 40-6 99396 $ 343.00 PREVEN MEDS E&M ESTAB PT; 5-11 99393 $ 343.00 PREVEN MEDS E&M ESTAB PT; 65/> 99397 $ 343.00 PREVEN MEDS E&M ESTAB PT; INFA 99391 $ 343.00 PREVENT MED CNSL PROC;30 99402 $ 235.50 PREVENT MED CNSL-SEP PROC; 15 99401 $ 224.50 PREVENT MED CNSL-SEP PROC; 30 99402 $ 235.50 PREVENT MED CNSL-SEP PROC; 45 99403 $ 263.00 PREVNAR VACCINE Acquisition cost PREVNAR-13 Acquisition cost PREVNAR13 VACCINE 90670 $ 180.04 PREVPAC PO Acquisition cost PREZCOBIX 800MG/150MG TABLET Acquisition cost PREZISTA (DARUNAVIR) 800MG TAB Acquisition cost PRIM ART MRCH THROMBECTOMY, INIT VES 37184 $ 13,447.68 PRIM ART MRCH THROMBECTOMY; ADD ON 37185 $ 362.25 PRIM TIBIAL BASEPLATEûCEMENT C1776 $ 2,212.50 PRIMAQUINE 15MG BASE TAB Acquisition cost PRIMAQUINE 1MG/ML SUSP Acquisition cost PRIMARY TIBIAL BASEPLATE C1776 $ 1,237.50 PRIMARY CLOSURE OF A SINUS PERFORATION D7261 $ 825.00 Page 236 2018 PRIMARY REPAIR RUPT ACHILLES TENDON 27650 $ 6,995.52 PRIMARY TIBIAL BASEPLATE - CEMENTED #3 C1776 $ 2,212.50 PRIMARY TIBIAL BASEPLATE - CEMENTED #5 C1776 $ 2,212.50 PRIMAXIN 250 MG VIAL J0743 Acquisition cost PRIMIDONE 80188 $ 45.06 PRIMIDONE + PHENOBARBITALPANEL Acquisition cost PRIMIDONE.C231 80188 $ 45.06 PRIMOPAC CATHETER INF. 4FR W/CSI $ 68.34 PRINIVIL 10 MG TAB Acquisition cost PRINIVIL/ZESTRIL 5MG TAB Acquisition cost PRISCOLINE 25MG/ML INJ 4ML Acquisition cost PRISTIQ 50 MG. PO Acquisition cost PRO VASCULAR135CM STENT SYSTEM C2625 $ 2,175.00 PROB NASLCRML DCT, W/WO IRRG; W TUB/STNT 68815 $ 4,790.26 PROBE APC-CATEG 1 Acquisition cost PROBE BLACK N2 DE, AEGLE C2618 $ 35.55 PROBE ENDOOCULAR-CATEG 1 Acquisition cost PROBE ESOPH TEMP-CATEG 1 Acquisition cost PROBE GOLD-CATEG 1 Acquisition cost PROBE GUIDES-CATEG 1 Acquisition cost PROBE HEMOSTASIS-CATEG 1 Acquisition cost PROBE LAP-CATEG 1 Acquisition cost PROBE MANNOTOME-CATEG 1 Acquisition cost PROBE NLD 68810 $ 707.85 PROBE RECTAL TEMP-CATEG 1 Acquisition cost PROBE VITRECTOMY-CATEG 1 C1781 Acquisition cost PROBING LACRIMAL CANALICULI W/WO IRRIGA 68840 $ 707.85 PROBING NASOLACRIMAL DUCT W/WO 68810 $ 707.85 PROBING OF LACRIM CANALCULI W W/O IRRIG 68840 $ 707.85 PRO-BNP 83880 $ 92.18 PROC SURG MESH SQRE15X15CM 1BX C1781 $ 755.13 PROC VENT PTCH 1.7 PVP DEV 2BX C1781 $ 556.86 PROC VENT PTCH 2.5 PVP DEV2BX C1781 $ 666.01 PROCAINAMIDE 100MG CH SYR Acquisition cost PROCAINAMIDE 375MG CAP Acquisition cost PROCAINAMIDE 500MG CAP Acquisition cost Procainamide 500mg/vial 2ml injection Acquisition cost PROCAINAMIDE HCL 1G/10ml J2690 Acquisition cost PROCAINAMIDE HCL 250MG CAP Acquisition cost PROCAINAMIDE LEVEL 80192 $ 45.50 PROCAINAMIDE W METABOLITES 80192 $ 45.50 PROCAINAMIDE/NAPA 80192 $ 45.50 PROCALCITONIN 84145 $ 72.78 PROCARBAZINE 50MG (MANULANE) PO Acquisition cost PROCARDIA XL 30MG TAB Acquisition cost PROCARDIA XL 90MG TAB Acquisition cost PROCEED MESH 8X2" (20X30CM) 1/BX; ETHICO C1781 $ 2,369.45 PROCEED MESH ORVAL 6X8 C1781 $ 1,281.66 PROCEED SURG MESH 10X13" OVAL C1781 $ 3,356.14 PROCEED SURG MESH 4"X6" OVAL C1781 $ 741.70 PROCEED SURG MESH OVAL 10X15CM 4X6 C1781 $ 741.71 PROCEED SURG MESH OVAL 15X20CM 6X8" C1781 $ 1,342.47 PROCEED SURG MESH RECTANGLE C1781 $ 374.06 PROCEED SURG MESH RECTANGLE C1781 $ 470.91 PROCEED SURGIC MESH 10X14 1/BX C1781 $ 3,315.88 PROCEED SURGIC MESH 12X12 1/BX C1781 $ 3,205.12 Page 237 2018 PROCEED SURGIC MESH 8X12 1BX C1781 $ 2,369.44 PROCEED SURGICAL MESH 10"X14" 1/BX; ETHI C1781 $ 3,315.89 PROCEED SURGICAL MESH 12X12 1/BX; ETHICO C1781 $ 3,205.13 PROCEED SURGICAL MESH 6X8 OVAL C1781 $ 1,281.66 PROCEED SURGICAL MESH OVAL 10X13" C1781 $ 3,356.15 PROCEED SURGICAL MESH RECTANGL C1781 $ 719.90 PROCEED SURGICAL MESH SQUARE 15X15CM C1781 $ 755.13 PROCEED VENTRAL PATCH 1.7" PVP DEVICE C1781 $ 556.87 PROCEED VENTRAL PATCH 2.5" PVP DEVICE C1781 $ 666.02 PROCHLOR MALEATE 5MG ANT-EMETC Q0164 $ 1.08 PROCHLORPER MALEATE 10MG TAB Q0164 $ 1.08 PROCHLORPERAZINE 10MG TAB Q0164 Acquisition cost PROCHLORPERAZINE 2.5MG SUPPOS Q0164 Acquisition cost PROCHLORPERAZINE 25MG SUPPOS J8498 Acquisition cost Prochlorperazine 50mg/10ml 10 ml vial Acquisition cost PROCHLORPERAZINE 5MG SUPPOS Q0164 Acquisition cost PROCHLORPERAZINE 5MG TABLET Q0164 Acquisition cost PROCHLORPERAZINE 5MG/ML INJ 2ML J0780 Acquisition cost PROCHLORPERAZINE 5MG/ML ORAL Q0164 Acquisition cost PROCHLORPERAZINE MALEATE 10 MG ORL Q0164 $ 1.08 PROCHLORPERZ 10MG INJ. J0780 $ 48.84 PROCRIT/EPOGEN 2000U/ML 1ML J0885 Acquisition cost PROCRIT/EPOGEN 3000U/ML 1ML J0885 Acquisition cost PROCRIT/EPOGEN 4000U/ML 1ML J0885 Acquisition cost PROCSIGMOSCOPY RIGID; DX-SEP PROC 45300 $ 1,877.59 PROCTOPLASTY;PROLAPSE MUC MEM 45505 $ 6,123.85 PROCTOSIG/POLYP REMOVAL 45309 $ 2,476.36 PROCTOSIG;RIGID;W ALBT TUM/POL 45320 $ 6,123.85 PROCTOSIGMOIDOSCOPY RIGID; W/B 45305 $ 2,476.36 PROCTSIGMDSCPY; RIGID W REM MULTI T/P/L 45315 $ 2,476.36 PROF SRVC IMMUNOTX INCL EXT; 2/>INJ 95125 $ 40.06 PROF SRVC IMMUNOTX W/O EXT; 1 INJ 95115 $ 97.92 PROF SRVC IMMUNOTX W/O EXT; 2/> INJ 95117 $ 97.92 PROFILE SILICONE IMPLANTS C1789 $ 1,350.00 PROFSRVC IMMUNOTX INCL EXT; 1 INJ 95120 $ 40.06 PROG DEV EVAL; IMPLNTBLE SUBQ LEAD SYS 93260 $ 99.81 PROG EVAL INPER LEADLS PM 0389T $ 99.81 PROG VALVE HAKIM W/SPHNGD C1713 $ 8,094.00 PROG/MOD OF VOICE PROSTHETIC 92609 $ 238.52 PROGESTERONE 200 MG CAPSULES Acquisition cost PROGESTERONE 50 MG/ML INJ J2675 Acquisition cost PROGESTERONE 8% (PROCHIEVE) VAG GEL Acquisition cost PROGESTERONE PROMETRIUM 100MG Acquisition cost PROGESTERONE RECEPTOR 84234 $ 176.22 PROGESTERONE SERUM 84144 $ 56.67 PROGRAM INTAKE ASSESSMENT 99366 $ 290.00 PROGREAT COAXIAL MICROCATH C1887 $ 957.00 PROGRIP MESH PRTX 15X15CM 12MM C1781 $ 538.24 PROGUAD Acquisition cost PROHANCE (GADOTERIDOL) PER 1ML A9576 $ 15.36 PROINSULIN 84206 $ 58.72 PROKERA AMNIOTIC MEMBRNE 15MM V2790 $ 1,492.50 PROLACTIN SERUM 84146 $ 52.62 PROLAPSE REP; PERIGEE W/INTEXEN C1763 $ 3,292.50 PROLENE MESH 3" X 6" 6/BX C1781 $ 79.00 PROLENE SUTRE BL MON RB2 NEEDL C1713 $ 239.00 Page 238 2018 PROLENE SUTURE 18"(45CM) 5-0 B C1713 $ 427.82 PROLENE SUTURE 36"(90CM) 3-0 B C1713 $ 232.29 PROLIXIN 80299 $ 41.01 PROLIXIN 2.5MG/ML INJ 10ML Acquisition cost PROLIXIN DECANOATE 25MG/ML 5ML J2680 Acquisition cost PROLONG EVAL-BRONCHOSPASM MX DETERM 94070 $ 658.04 PROLOPRIM/TRIMPEX 200 MG TAB Acquisition cost PROMACTA 25MG Acquisition cost PROMETHAZINE 80299 $ 41.01 PROMETHAZINE HCL 25MG TAB Q0169 Acquisition cost PROMETHAZINE HYDROCHL 12.5MG Q0169 $ 0.55 PRONESTYL 100MG/ML INJ 10ML J2690 Acquisition cost PROPANTHELINE BROM 15MG TAB Acquisition cost PROPARACAINE EYE DROP Acquisition cost PROPARACNE 0.5% (REFRIG) $ 96.51 PROPHYLAXIS / ADULT D1110 $ 181.00 PROPHYLAXIS / CHILD D1120 $ 125.00 PROPHYLAXIS RET DETACH; PHOTOC 67145 $ 1,290.50 PROPHYLAXIS RETINAL DETACH; CRYOTX 67141 $ 707.85 PROPINE 0.1% OPHTH SOL Acquisition cost PROPOFOL 10MG/ML 20ML J2704 Acquisition cost PROPOFOL 10MG/ML 50ML VIAL Acquisition cost PROPOFOL 10MG/ML INJ J2704 $ 0.31 PROPOFOL 10MG/ML VIAL 100ML J2704 Acquisition cost PROPOFOL 200MG/20ML VIAL INJ J2704 $ 0.62 PROPOXY NAP/APAP (N 100) PO Acquisition cost PROPOXYPHENE 65MG CAP PO Acquisition cost PROPOXYPHENE NAP 100MGPO Acquisition cost PROPOXYPHENE SCREEN 80299 $ 41.01 PROPOXYPHENE SCREEN URINE 80299 $ 41.01 PROPRANOLOL 80299 $ 41.01 PROPRANOLOL 1MG/ML ORA SWT Acquisition cost PROPRANOLOL HCL 10MG TAB Acquisition cost PROPRANOLOL HCL 40MG TAB Acquisition cost PROPRANOLOL HCL20MG TAB Acquisition cost PROPULSID 10MG TABLET Acquisition cost PROPULSID 20MG TAB Acquisition cost PROPYLTHIOURACIL 1MG/ML CH SYR Acquisition cost PROPYLTHIOURACIL 1MG/ML SUSP Acquisition cost PROPYLTHIOURACIL 50MG TABLET Acquisition cost PROPYLTHIOURACIL ORAL SUSP Acquisition cost PROS SMART DELACRUZ PISTON.6MM C1725 $ 433.95 PROSTATE / FOR BRACHYTHERAPY US 76873 $ 302.70 PROSTATE CA SCRN DIG RECTAL EXAM G0102 $ 19.21 PROSTATE LASER ENUCLEATION 52649 $ 9,800.87 PROSTATE NEEDLE PUNCH; BX 55700 $ 4,484.35 PROSTATE SPEC ANTIGEN 84153 $ 49.96 PROSTH REPL TRAPEZIUM BONE 25445 $ 14,826.61 PROSTH TRAIN-UP //LOW EXTREM; 1 UNIT 97761 $ 87.93 PROSTHETIC TRAINING, EA 15 MIN. 97761 $ 87.93 PROSTIN E2 VAGINAL SUPPOSITORY Acquisition cost PROSTIN VR PEDS 500MCG/ML 1ML J0270 Acquisition cost PROTAMINE SULFATE 50MG/5ML J2720 Acquisition cost PROTECTOR-CATEG 1 Acquisition cost PROTEIN BODY FLUID 84157 $ 9.97 PROTEIN C ACTIVITY 85303 $ 37.58 Page 239 2018 PROTEIN C ANTIGEN 85302 $ 32.63 PROTEIN C ANTIGEN 85302 $ 32.63 PROTEIN C TOTAL 85303 $ 37.58 PROTEIN CSF 84157 $ 9.97 PROTEIN ELECTROPHORESIS 84165 $ 29.17 PROTEIN ELECTROPHORESIS CSF 84166 $ 48.42 PROTEIN ELECTROPHORESIS URINE 84166 $ 48.42 PROTEIN S ANTIGEN 85305 $ 31.53 PROTEIN S TOTAL 85306 $ 41.62 PROTHROMB TIME 85610 $ 10.67 PROTHROMBIN GENE, NYQPANEL Acquisition cost PROTHROMBIN TIME 85610 $ 10.67 PROTHROMBIN-FACTOR 11 85210 $ 35.27 PROTOPAM 1GM INJ J2730 Acquisition cost PROTOPOROHYRIN-EP 84202 $ 38.96 PROTOPORPHYRIN RBC; QUAN 84202 $ 38.96 PROUS HA SYNERGY STEM 15HO C1776 $ 8,775.00 Provisional crown D2799 $ 630.00 PROVISIONAL SPLINTING EXTRAORAL D4321 $ 294.00 Provisional splinting-intracor D4320 $ 336.00 PROVOX 2 VOICE PROSTHESIS 8MM L8509 $ 396.00 PROVOX 2VOICE PROSTHESIS SIZE 10MM L8509 $ 385.50 PROVOX GUIDE WIRE C1713 $ 85.50 PROX TIB PLATE C1713 $ 1,992.82 PROXIMAL HUMERAL BASE PLATE C1713 $ 1,840.65 PROXIMAL HUMERUS PLATE C1713 $ 1,840.65 PROXIMAL RELEASE ESOPHAGEAL ST Acquisition cost PROXIMAL TIB PLATE (4HOLE/RIGHT LCP) C1713 $ 1,948.50 PROXIMAL TIB PLATE 3.5MM LCP C1713 $ 1,770.00 PROXIMARL TIB PLATE; 2-HOLE C1713 $ 1,992.83 PROZAC 20MG CAP Acquisition cost PROZOSIN 1MG CAP Acquisition cost PRP 67228 $ 1,290.50 PRQ CARD STENT W/ANGIO 1 VSL 92928 $ 27,795.70 PRQ CARD STENT W/ANGIO ADDL 92929 $ 150.00 PRQ REVASC CHRONIC TOT OCC; 1 VSL 92943 $ 27,795.70 PRSC / FIT CONTACT LENS;NOT APHAKIA 92310 $ 330.00 PRSC / FIT CONTACT; APHAKIA-1 EYE 92311 $ 872.74 PRSC RX ORAL NONCHEMOTHAPEUTIC NOS J8499 $ 99.99 PRUITT INAHARA CAROTID SHUNT 8FR W/T-POR C1875 $ 955.50 PRUITT INAHARA CAROTID SHUNT 9FR W/T-POR C1875 $ 982.50 PRV MED CNSL GRP-SEP PROC;60MI 99412 $ 235.50 PRV MED COUNS 60MIN 99404 $ 290.50 PRV MED COUNS/RISK RED 45 MIN 99403 $ 263.00 PRV MED COUNS/RISK RED 60MIN 99404 $ 290.50 PRV MED COUNSEL GRP;30 MIN 99411 $ 224.50 PRV MED E/M ESTAB PT;12-17YR 99394 $ 343.00 PRV MED E/M ESTAB PT;1-4 YR 99392 $ 343.00 PRV MED E/M ESTAB PT;18-39YR 99395 $ 343.00 PRV MED E/M ESTAB PT;5-11YR 99393 $ 343.00 PRVENT MED CNSL PROC; 15 MIN 99401 $ 224.50 PRVENT MED CNSL-SEP PROC;15MIN 99401 $ 224.50 PRVENT MED CNSL-SEP PROC;30MIN 99402 $ 235.50 PS FEMORAL COMPONENT - CEMENTED #2 RIGHT C1776 $ 2,092.50 PS FEMORAL COMPONENT - CEMENTED #3 LEFT C1776 $ 2,092.50 PS FEMORAL COMPONENT - CEMENTED #5 LEFT C1776 $ 2,092.50 Page 240 2018 PS FEMORAL COMPONENT CEMENTED #5 RIGHT C1776 $ 2,092.50 PS TIBIAL INSERT - X3 #3 - 9MM C1776 $ 1,378.50 PS TIBIAL INSERT; X3 #1 - 11MM C1776 $ 1,378.50 PS TIBIAL INSERT; X3 #6 - 19MM C1776 $ 2,567.40 PS/7FR/10/038 W/O WIRE INTRO C1894 $ 277.50 PS7FR.10038W/OWIRE INTROSHEATH C1894 $ 277.50 PSA FREE 84154 $ 49.96 PSA FREE/TOTALPANEL Acquisition cost PSA; FREE 84154 $ 49.96 PSA; TOTAL 84153 $ 49.96 PSEUDOCHOLINESTERASE 82480 $ 21.38 PSEUDOEPHDE 30MG TAB $ 0.15 PSEUDOEPHEDRINE 9.4MG DROPS PO Acquisition cost PSEUDOEPHEDRINE LIQUID 30MG/5ML Acquisition cost PSITACOSIS CF 86171 $ 27.19 PSY PT&/OR FAM; 45 MINSRVCS 90834 $ 290.00 PSY PT/ FAM; 45 MIN 90834 $ 290.00 PSY TESTING W/I/R PER HR 96101 $ 590.48 PSY THERAPY PT/FAMILY; 45 MINS 90834 $ 275.00 PSY TX PAT/FAM W/E&M; 45 MINS 90836 $ 275.00 PSY TX PAT/FAMILY - 45 MINS 90834 $ 275.00 PSY TX PT/FAM W/E&M; 45 MINS 90836 $ 275.00 PSYCH ACTIVITY THERAPY - 1 HR G0177 $ 275.00 PSYCH DIAG EVAL W MED SRVCS 90792 $ 290.00 PSYCH DIAG EVAL W/MED SRVCS 90792 $ 290.00 PSYCH DIAG EVALUATION 90791 $ 290.00 PSYCH DIAGNOSTIC EVAL 90791 $ 290.00 PSYCH DIAGNOSTIC EVALUATION 90791 $ 290.00 PSYCH DX EVAL W/MED SRVCS 90792 $ 290.00 PSYCH PT&/OR FAM 45 MIN 30 MIN 90834 $ 290.00 PSYCH PT/OR FAM; 45 MINSS 90792 $ 290.00 PSYCH TEST W/I&R PER HR 96101 $ 590.48 PSYCH TESTING W/I&R PER HR 96101 $ 590.48 PSYCH TX CRISIS; EA ADD'L 30 MIN 90840 $ 555.00 PSYCH TX CRISIS; EA ADD'L 30MIN 90840 $ 555.00 PSYCH TX CRISIS;INT'L 60 MIN 90839 $ 1,175.00 PSYCH TX CRISIS;INT'L 60 MIN 90839 $ 1,175.00 PSYCH TX; PT/FAM; 30M 90832 $ 290.00 PSYCH TX; PT/FAM; 45M 90834 $ 290.00 PSYCH WARD $ 1,350.00 PSYCH; DX EVALUATION 90791 $ 290.00 PSYCHIATRIC PRIVATE ROOM $ 2,700.00 PSYCHIATRIC SEMI PRIVATE ROOM $ 1,350.00 PSYCHO TX PAT/FAM; 45 MINS 90834 $ 275.00 PSYCHOTHERAPY W/O PATIENT 90846 $ 290.00 PSYCHT PT FAM; 45 MINS0 MINS 90834 $ 290.00 PSYCHTX CRISIS- EA ADDL 30 MIN 90840 $ 290.00 PSYCHTX CRISIS EA ADDL 30 MINS 90840 $ 290.00 PSYCHTX CRISIS- INITIAL 60 MIN 90839 $ 290.00 PSYCHTX PT FAM; 45 MINSNS 90834 $ 290.00 PSYCHTX PT/OR FAM 45 MINS 90834 $ 290.00 PSYCHTX PT/OR FAM; 45 MINS 90791 $ 290.00 PSYCHTX W E&M PAT AND/OR FAM;6 90838 $ 290.00 PSYCHTX W E/M; PT&/OR FAM,30MI 90833 $ 290.00 PSYCHTX W E/M; PT&/OR FAM,30MI 90833 $ 290.00 PSYCHTX W E/M; PT&/OR FAM,45MI 90836 $ 290.00 Page 241 2018 PSYCHTX W E/M; PT&/OR FAM,60MI 90838 $ 290.00 PSYCHTX;PAT &/OR FAM;60 MINS 90837 $ 290.00 PSYCHTX;PAT&/0R FAM-30MINS 90832 $ 290.00 PSYCHTX;PAT&/0R FAM-30MINS 90832 $ 290.00 PSYCHTX;PAT&/0R FAM-45MINS 90834 $ 290.00 PSYCHTX;PAT&/0R FAM-45MINS 90834 $ 290.00 PSYCHTX;PT &/OR FAM;30 MINS 90832 $ 290.00 PSYCHTX;PT &/OR FAM;45 MINS 90834 $ 290.00 PSYCHTX;PT&/0R FAM-30MINS 90832 $ 290.00 PSYCHTX;PT&/0R FAM-45MINS 90834 $ 290.00 PSYCHTX;W EM;PT&/OR FAM;30 MIN 90833 $ 290.00 PSYCHTX;W EM;PT&/OR FAM;45 MIN 90836 $ 290.00 PSYCHTX;W EM;PT&/OR FAM;60 MIN 90838 $ 290.00 PSYLLIUM/HYDROCIL/METAMUCIL Acquisition cost PSYTHERAPY PAT/FAMILY; 45 MINS 90834 $ 275.00 PSYTX INTERACTIVE COMPLEX;ADD 90785 $ 290.00 PSYTX INTERACTIVE COMPLEXITY A 90785 $ 290.00 PSYTX PAT/FAM W/E&M; 45 MINS 90836 $ 275.00 PSYTX PT/FAM W/E&M; 45 MINS 90836 $ 275.00 PSYTX-CRISIS INITIAL 60-MIN 90839 $ 290.00 PT ADPT/TRAINING USE SPCH GEN DEVC 92609 $ 238.52 PT DEMND REC;TRNSMS PHYS REV/INTEPR 93268 $ 132.00 PT EVAL - SCRIPT SPEECH GEN DEVICES 92607 $ 284.50 PT EVAL HIGH COMPLEX 45 MIN 97163 $ 186.43 PT EVAL LOW COMPLEX 20 MIN 97161 $ 186.43 PT EVAL MOD COMPLEX 30 MIN 97162 $ 186.43 PT PROGR NEUROSTIM C1787 Acquisition cost PT RE-EVAL EST PLAN CARE 97164 $ 104.02 PT/PTT 85610 $ 10.67 PTA 4FR BALLON DILATATION CATH C1726 $ 618.75 PTA BALL CATH OTW 0.035 VASC C1725 $ 202.50 PTCA DILATION CATH 2.5MMx12MM C1725 $ 262.50 PTERYGIUM EXCISION 65420 $ 4,790.26 PTERYGIUM EXCISION W/GRAFT 65426 $ 4,790.26 PTFE COAT GUIDEWIRE 3CM FIXCOR C1769 $ 16.47 PTFE COATED GUIDEWIRE 15CM C1769 $ 22.76 PTFE NITINOL GWIRE ANGLED C1713 $ 313.65 PTFE NITINOL GWIRE STRGHT C1713 $ 390.11 PTFE WIRE .035/150 5/BX; ACMI C1713 $ 94.11 PTFE/HPRN COATED GW JFC/.035/150/3/3MM C1769 $ 16.47 PTH 83970 $ 112.11 PTH 83970 $ 112.11 PTH (INTACT) 83970 $ 112.11 PTH C TERMINAL 83970 $ 112.11 PTH N TERMINAL $ 46.20 PTH SERUM 83970 $ 112.11 PTT; PLASMA OR WHOLE BLOOD 85730 $ 16.32 PULM COMPLIANCE STUDY ANY METHD 94750 $ 360.51 PULM. COMPLIANCE STUDY 94750 $ 360.51 PULMO STRESS TEST/6MIN WLK TST 94618 $ 277.79 PULMONARY STRESS TEST/SIMPLE 94620 $ 266.31 PULMONARY STRESS TESTING 94620 $ 266.31 PULMOZYME (DORNASE) INHALATION SOLU. J7639 Acquisition cost PULP CAP-DIRECT D3110 $ 70.00 PULP CAP-INDIRECT D3120 $ 56.00 PULPAL DEBRIDEMENT PRIMARY OR PERM TEETH D3221 $ 140.00 Page 242 2018 PULPAL THERAPY RESOR FILL PRMY TOOTH ANT D3230 $ 186.00 PULPAL THERAPY RESOR FILL PRMY TOOTH PST D3240 $ 200.00 PULPOTOMY D3220 $ 140.00 PULSE OXIMETRY 94760 $ 3.80 PULSE OXIMETRY CONTINUOUS 94762 $ 360.51 PULSE OXIMETRY, ROOM AIR 94760 $ 3.80 PULSE OXIMETRY-02 SAT 94760 $ 3.80 PUNCH GRAFT HAIR TRNSPLANT; 1-15 PUNCHES 15775 $ 821.94 PUNCH GRAFT HAIR TRNSPLANT; 15< PUNCHES 15776 $ 821.94 PUNCH STRGHT W/CENTR SUCT CHAN A4624 $ 889.14 PUNCT ASP - ABSC/HEMAT/CYST 10160 $ 821.94 PUNCT ASP BRST CYST - EA ADDTL 19001 $ 46.90 PUNCT ASP BRST CYST - INITIAL 19000 $ 1,514.94 PUNCT ASPIR ABSC HEMAT BULLA/CYST 10160 $ 821.94 PUNCT ASPIRAT CYST BREAST; EA ADD CYST 19001 $ 46.90 PUNCT SHUNT TUBE/RESERVOIR-ASPIRAT 61070 $ 1,437.02 PUNCTAL CAUTERY 68760 $ 707.85 PUNCTAL DILATIO, W OR W/O IRRIGATION 68801 $ 872.74 PUNCTAL PLUG PROCEDURE 68761 $ 707.85 PUNCTURE ASP CYST BREAST 19000 $ 1,514.94 PUNCTURE ASP SKIN LESION 10160 $ 821.94 PUNCTURE ASPIRATION CYST BREAST; ADD'L 19001 $ 46.90 PUNCTURE SUTURE CLOSURE DEVICE C1713 $ 16.80 PURE TONE AUDIOMETRY AIR 92552 $ 277.79 PURE TONE AUDIOMETRY, AIR 92552 $ 277.79 PURE TONE HEARING TEST 92551 $ 11.68 PURGED STOOL 87177 $ 24.18 PUROS, BONE GRAFT L8699 $ 105.00 PUSHLOCK 3.5 PEEK C1713 $ 540.00 PVC DRAIN 10FR RESERVOIR KIT C1729 $ 148.08 PYLORIC DILATION 43245 $ 3,774.85 PYRDOXINE IN STERILE WATER Acquisition cost PYRIDINOLINE $ 37.16 PYRIDOSTIGMINE 60MG TAB Acquisition cost PYRIDOXINE 100 MG TAB Acquisition cost PYRIDOXINE 5MG/ML ORAL SOL. FOR NICU Acquisition cost PYRIDOXINE HCL 100MG/ML 30ML Acquisition cost PYRIDOXINE SUSP IN COLGEL Acquisition cost PYRIMETHAMINE-LEUCOVORIN 50/20mg CAP J0640 Acquisition cost PYRUVATE 84210 $ 31.86 PYRUVATE KINASE 84220 $ 25.65 PYRUVIC ACID 84210 $ 31.86 PZA/PYRAZINAMIDE 500MG TAB Acquisition cost Q FEVER 86638 $ 32.93 Q FEVER ANTIBODY 86638 $ 32.93 Q.I. IGA-NEPH 82784 $ 25.26 Q.I. IGD-RID 82784 $ 25.26 Q.I. IGE-NEPH 82785 $ 44.70 Q.I. IGG-NEPH 82784 $ 25.26 Q.I. IGM-NEPH 82784 $ 25.26 QCKANCH PLS 3-0 ORTHCORBRAID C1713 $ 672.00 QUAD CORTICAN SCREW C1713 $ 2,025.00 QUADRICEPSPLASTY 27430 $ 14,826.61 QUAN MASS SPECT EA SPECIM 83789 $ 53.04 QUANTIT ORGANIC ACIDS EA SPECIM 83918 $ 51.92 QUANTITATIVE BLOOD CULTURE 87040 $ 28.03 Page 243 2018 QUANTUM MAVRCK 2.0x8MM PTCA DILAT CATH C1725 $ 360.00 QUELICIN/ANECTINE 20MG/ML 10ML J0330 Acquisition cost QUETIAPINE 300MG TAB PO Acquisition cost QUETIAPINE 400MG TABLET Acquisition cost QUETIAPINE 50MG. PO Acquisition cost QUETIAPINE FUMARATE 100MG TAB Acquisition cost QUETIAPINE FUMARATE 200MG TAB Acquisition cost QUETIAPINE FUMARATE 25MG TAB Acquisition cost QUICK CAT EXTRACTION CATH 6FR C1757 $ 675.00 QUICK CAT EXTRACTION CATHETER** C1757 $ 675.00 QUICK CONN TUB 10FT SMRT PUMP C1772 $ 66.26 QUICK CROSS CATH .014X135CM, C1887 $ 250.50 QUICK CROSS CATH .014X150CM, C1887 $ 250.50 QUICK CROSS CATH .018X135CM C1887 $ 250.50 QUICK CROSS CATH .035X135CM C1887 $ 250.50 QUICK CROSS CATH .035X150CM C1887 $ 250.50 QUICK CROSS CATH .035x65CM C1887 $ 1,252.50 QUICK CROSS CATH .035X65CM C1887 $ 1,252.50 QUICK CROSS CATH .035X90CM C1887 $ 250.50 QUICK CROSS CATH .18 X 90CM C1887 $ 250.50 QUICK CROSS CATH 5/BX C1887 $ 250.50 QUICK CROSS CATH.018X150CM C1887 $ 250.50 QUICK CROSS EXT ANGLED CATH 035X135CM C1887 $ 250.50 QUICK CROSS EXTREME ANGLE CATH C1887 $ 1,522.50 QUICKANCHR ORTHOCORD 2MM DRILL C1713 $ 873.00 QUICKCROSS EXTREME STRGHT CATH C1887 $ 1,477.50 QUICKCRS EXTREME ANGL CATH 5BX C1714 $ 304.50 QUINAPRIL (ACCUPRIL) 40MG TAB Acquisition cost QUINAPRIL (ACCUPRIL) 5MG TAB Acquisition cost QUINAPRIL/HCTZ 10-12.5MG TABPO Acquisition cost QUINAPRIL/HCTZ 20-12.5MG TABPO Acquisition cost QUINAPRIL/HCTZ 20-25MG TAB PO Acquisition cost QUINDINE GLUCONATE 324MG TAB Acquisition cost QUINIDINE 80194 $ 39.67 QUINIDINE GLUCONATE 80MG/ML10M Acquisition cost QUINIDINE SULFATE 200MG TAB Acquisition cost QUININE SULFATE 260MG TAB Acquisition cost QUININE SULFATE 324MG CAP Acquisition cost QUINUPRISTIN/DALFOPRISTIN 500 MG J2770 $ 1,071.00 R & B EOB $ 1,350.00 R HRT ART/GRFT ANGIO 93457 $ 7,440.77 R HRT CORONARY ARTERY ANGIO 93456 $ 7,440.77 R X 90 15 X250 MM LONG STEM Acquisition cost R&B DETOX - ALC LEVEL 1 $ 950.00 R&B DETOX ALC LEVEL 2 $ 950.00 R&B MATERNITY - ALC LEVEL 1 $ 1,950.00 R&B MATERNITY ALC LEVEL 2 $ 1,950.00 R&B MED/SURG ALC LEVEL 1 $ 1,850.00 R&B MED/SURG ALC LEVEL 2 $ 1,850.00 R&B NEONATAL ICU (BORDER BABY) $ 3,025.00 R&B PEDIATRICS ALC LEVEL 1 $ 1,750.00 R&B PEDIATRICS ALC LEVEL 2 $ 1,750.00 R&B PSYCHIATRY - ALC LEVEL 1 $ 1,350.00 R&B PSYCHIATRY - ALC LEVEL 2 $ 1,350.00 R&B REHABILITATION ALC LEVEL 1 $ 800.00 R&B REHABILITATION ALC LEVEL 2 $ 800.00 Page 244 2018 R&L HRT ART/GRAFT/VENTRICLE ANGIO 93461 $ 7,440.77 R&L HRT ART/VENTRICLE ANGIO 93460 $ 7,440.77 R&L HRT CATH W/VENTRICLGRPHY 93453 $ 7,440.77 R/B I/D MONITORING ALC LEVEL 1 $ 1,850.00 R/B I/D MONITORING ALC LEVEL 2 $ 1,850.00 R/O GRP A BETA STREP 87081 $ 18.00 R/O N. GONORRHOEAE 87081 $ 18.00 R00M & BOARD - BORDER BABY $ 475.00 RA TRACER ID OF SENTINL NODE 38792 $ 924.11 RABEPRAZOLE 20MG TAB PO Acquisition cost RABIES IG INJECTION 90375 $ 693.18 RABIES IMMUNE GLOBULIN 10ML VI 90375 Acquisition cost RABIES IMMUNE GLOBULIN 2 ML VIAL 90375 Acquisition cost RABIES IMMUNE GLOBULIN-IM //SUBQ 90375 $ 693.18 RABIES VACCINE-IM USE 90675 $ 850.87 RABIES VACCINE-IM USE CLINIC 90675 $ 850.87 RABIES VACCINE-INTRADERMAL USE CLINIC 90676 $ 99.99 RAD 2 TX AREAS-3/> PORTS 5 MEV 77407 $ 329.87 RAD EX SM INTESTINE; VIA ENTEROCLYS 74251 $ 302.70 RAD EX TEETH; PART EX < FULL MOUTH 70310 $ 614.37 RAD EXAM 1 PLNE BOD SECT-NOT W/UROG 76100 $ 302.70 RAD EXAM ANK ARTHROGRAPHY-RAD S / I 73615 $ 1,206.90 RAD EXAM CHEST CMPL; W/FLOUROSCPY 71034 $ 300.17 RAD EXAM CHEST FRONT / LAT; W/FLUOR 71023 $ 159.39 RAD EXAM COMPLX MOTION BODY; BIL 76102 $ 302.70 RAD EXAM COMPLX MOTION BODY; UNI 76101 $ 302.70 RAD EXAM ELBOW ARTHROGRAPHY-RAD S / I 73085 $ 1,206.90 RAD EXAM EYE DETECTION FB 70030 $ 164.27 RAD EXAM HAND; 2 VIEWS 73120 $ 302.70 RAD EXAM HIP ARTHROGRAPHY-RAD S / I 73525 $ 1,206.90 RAD EXAM INT AUDITORY MEATI COMPLT 70134 $ 614.37 RAD EXAM KNEE ARTHROGRAPHY-RAD S / I 73580 $ 1,206.90 RAD EXAM PELVIS; COMPLT MINI 3 VIEWS 72190 $ 302.70 RAD EXAM S I JT ARTHROGRAPHY RAD S/I 27096 $ 183.06 RAD EXAM SALIVARY GLAND CALCU 70380 $ 164.27 RAD EXAM SHOULDER ARTHROGRAPHY-RAD S / I 73040 $ 1,206.90 RAD EXAM SPINE LUMBOSACRAL MINI 4 72120 $ 302.70 RAD EXAM SPINE; THOR 3 VIEWS 72072 $ 302.70 RAD EXAM STRESS VIEW ANY JT 77071 $ 164.27 RAD EXAM TEETH; COMPLT FULL MOUTH 70320 $ 614.37 RAD EXAM TEETH; SNGL VIEW 70300 $ 164.27 RAD EXAM WRIST ARTHROGRAPHY-RAD S / I 73115 $ 668.38 RAD EXAM; PHARYNX INCL FLUORO 70370 $ 164.27 RAD EXAM-RENAL CYST-TRNSLUMB-S / I 74470 $ 614.37 RAD EXC WRIST/FOREARM EXTENSORS 25116 $ 6,995.52 Rad resectn-maxilla or mandible D7490 $ 8,995.00 RAD TX DEL-1 TX AREA 1 PRT;TO 5 MEV 77402 $ 329.87 RAD TX DELIV SUP /OR ORTHO VOLTAGE 77401 $ 329.87 RAD TX DELIV-3/MORE AREAS; TO 5 MEV 77412 $ 581.35 RADCL EXCISN BENIGN TUMOR>1.25 D7461 $ 1,732.00 RADIAL HD ARTHROPLSTY W IMPLANT 24366 $ 26,770.83 RADIAL HEAD PROSTHESIS C1776 $ 5,659.50 RADIAL KERATOTOMY 65771 $ 907.76 RADIAL STYLOIDECTOMY 25230 $ 6,995.52 RADICAL ABDOMINAL HYSTRECTOMY 58210 $ 3,949.70 RADICAL EXC EXTRN AUDTRY CANAL LES 69150 $ 11,474.25 Page 245 2018 RADICAL EXCISION <1.25 D7410 $ 1,075.00 RADICAL EXCISION BENIGN TUMOR <1.25 D7460 $ 1,075.00 RADICAL REMOV FOOT PLANTAR FASCIA 28062 $ 6,995.52 RADIESSE VOICE GEL Acquisition cost RADIESSE VOICE GEL Acquisition cost RADIO BONE CEMNT W/GENTA STRL C1776 $ 477.37 RADIO EXAM- ABDOM;3ORMORE VIEW 74021 $ 302.70 RADIO EXAM-CHST;4 OR MORE VIEW 71048 $ 302.70 RADIO PHARM I-131 IODIDE CAP, 1 MCI A9517 $ 43.96 Radiograph/surg impl index B/R D6190 $ 232.00 RADIOLOGIC EXAM- CHEST; 1 VIEW 71045 $ 164.27 RADIOLOGIC EXAM- CHEST;2 VIEWS 71046 $ 164.27 RADIOLOGIC EXAM- CHEST;3 VIEWS 71047 $ 164.27 RADIOLOGIC EXAM-ABDOM; 1 VIEWS 74018 $ 164.27 RADIOLOGIC EXAM-ABDOM; 2 VIEWS 74019 $ 302.70 RADIOPHARM DACRYOCYSTOGRAPHY 78660 $ 924.11 RADIOPHARM LOCALIZ TUMOR; LTD AREA 78800 $ 924.11 RADIOPHARM THERAP CHRONIC LEUKEMIA EA-TX 79005 $ 630.67 RADIOPHARM TX; INTRA-ART 79445 $ 630.67 RADIOPHARMACENTICAL THERAPY(NON THYROID) 79101 $ 630.67 RADIOULNAR JNT FUSION W ULNA RESECTION 25830 $ 14,826.61 RADIUS ROD RT 3.2 Acquisition cost RAIL COMPRESSION-CATEG 1 Acquisition cost RAIL-CATEG 1 Acquisition cost RAIL-CATEG 2 Acquisition cost RAJI CELL TITER 86332 $ 66.20 RALTEGRAVIR 100MG CHEWABLE TABLETS J3490 Acquisition cost RALTEGRAVIR 25MG CHEWABLE TABLETS J3490 Acquisition cost RALTEGRAVIR K 400MG. TABLET Acquisition cost RAMELTEON 8MG TAB (ROZEREM) Acquisition cost RAMIPRIL 1.25MG CAPSULE PO Acquisition cost RAMIPRIL 10MG CAPSULE PO Acquisition cost RAMIPRIL 2.5MG CAPSULE PO Acquisition cost RAMIPRIL 5MGCAPSULE PO Acquisition cost RAMUCIRUMAB (CYRAMZA) 10MG/ML Acquisition cost RANEXA 500MG. PO Acquisition cost RANEY CLIP GUN KIT 1/PK* C1713 $ 109.73 RANITIDINE 15MG/ML ORAL SYR Acquisition cost RANITIDINE 50MG IVPB PREMIX Acquisition cost RANITIDINE PED SYRINGE IN 1/2 N>S.IV Acquisition cost RANITIDINE SYRUP 15MG/ML Acquisition cost RAPAMUNE 2 MG. PO Acquisition cost RAPAMYCIN 80299 $ 41.01 RAPID AG DET-RSV (EIA) 87420 $ 32.56 RAPID TEST EIA-HIV-1/HIV-2 AB 86703 $ 37.22 RAPIDVAC SMOKE TUB 1X3CM 38X10 A4624 $ 16.72 RASBURICASE 1.5MG AMPS Acquisition cost RASBURICASE 1.5MG VIAL J2783 Acquisition cost RAST TEST (QUANTITATIVE) 86003 $ 14.17 RBC DEGLYCEROLIZED, UNIT P9039 $ 925.83 RBC FOLATE 82747 $ 47.04 RBC IRRADIATED, UNIT P9038 $ 470.34 RBC LEUKO REDUCED IRRADIATED, UNIT P9040 $ 572.44 RBC LEUKOCYTES REDUCED, UNIT P9016 $ 404.29 RBC WASHING 86999 $ 46.20 RBC, FRZ/DEG/WSH, L/R, IRRADIATED, UNIT P9057 $ 619.85 Page 246 2018 RBC, L/R, CMV NEG, IRRADIATED, UNIT P9058 $ 523.71 RCI 7X25 SCREW METAL STERILE C1713 $ 301.31 RCI 8X25 SCREW METAL C1713 $ 301.31 RCI 8X35 SCREW METAL C1713 $ 307.31 RCI SCREW 10 X25 MM C1713 $ 240.00 RCI SCREW 7X35MM WITH 8MM HEAD C1713 $ 267.77 RCI SCREW 9X25 TITANIUM STERLE C1713 $ 270.00 RCI SCRW FIX CANNULAT 9X35X2MM C1713 $ 275.81 RCNSTRCTN MAND,W/INTRNL RIGID 21196 $ 3,194.99 RCNSTRCTN MANDIBLE, WO INTRNL RIGID FIX 21195 $ 11,474.25 READI-CAT 2, 250ML (BANANA SMOOTHIE) Q9966 $ 5.60 READI-CAT 2, 450ML (BANANA SMOOTHIE) Q9951 $ 5.76 REALIGNMENT EXTENSOR TENDON 26437 $ 3,570.03 REAMER PLOTTED HEAD 6.5MM C1713 $ 439.50 REAMER SHAFT C1713 $ 432.22 RE-ASSESS NUTRITION THER; EA 15M 97803 $ 59.91 REBETRON Acquisition cost REBLD OUTER EAR CANAL 69310 $ 11,474.25 RECEMENT CROWN / INLAY D2920 $ 126.00 Recement impl/abt supt crown D6092 $ 63.00 Recement impl/abt supt fxd dent D6093 Acquisition cost RECEMENT PARTIAL BRIDGE D6930 $ 154.00 RECLAST; per 1MG J3489 $ 528.00 RECNSTR MANDIBULAR RAMUS W/O BN GRFT 21193 $ 11,474.25 RECON / IMPLANT 21248 $ 11,474.25 RECON EXT AUDITORY CANAL (SEPART PROC) 69310 $ 11,474.25 RECON LID; TOT LID LOWER 1 STAGE 67973 $ 4,790.26 RECON PLATE 4-HOLE C1713 $ 418.95 RECON PLATE 4-HOLE C1713 $ 418.95 RECON POLYDACTYLUS DIGT SFT TI 26587 $ 6,995.52 RECON ZYG ARCH/AUTO GRAFT 21255 $ 3,070.19 RECONS COMPLT SHLDR CUFF AVULS 23420 $ 14,826.61 RECONST DISLOC PATELLA W MSCL ADV 27422 $ 14,826.61 RECONST INFRAPATELLAR TENDON 27381 $ 14,826.61 RECONST MANDIMAXILLA; COMPL 21249 $ 11,474.25 RECONST NAIL BED W GRAFT 11762 $ 4,147.84 RECONSTR IP JNT COLLAT LIG; EACH 26545 $ 6,995.52 RECONSTR MAND/MAXILLA; PARTIAL 21248 $ 11,474.25 RECONSTR MCP JNT COLLAT LIG; W GFT 26541 $ 6,995.52 RECONSTR POST TIB TNDN W EXC NAVIC BN 28238 $ 14,826.61 RECONSTR TOE(S); POLYDACTYLY 28344 $ 6,995.52 RECONSTRCT MIDFACT; LEFORTE, 2 PCS 21142 $ 3,017.04 RECONSTRCT ULNA/RADIOULNR JNT 25337 $ 14,826.61 RECONSTRUCT DISLOCATING PATELLA 27420 $ 14,826.61 RECONSTRUCT EYELID; SECOND STAGE 67975 $ 4,790.26 RECONSTRUCT NIPPLE/AREOLA 19350 $ 7,213.98 RECONSTRUCT ORBIT W OSTEO; W BN GFT 21256 $ 11,474.25 RECOVERY ROOM 106 - 120 MINUTES $ 364.32 RECOVERY ROOM 121 - 135 MINUTES $ 409.86 RECOVERY ROOM 136 - 150 MINUTES $ 455.40 RECOVERY ROOM 151 - 165 MINUTES $ 500.94 RECOVERY ROOM 16 - 30 MINUTES $ 91.08 RECOVERY ROOM 166 - 180 MINUTES $ 546.48 RECOVERY ROOM 181 - 195 MINUTES $ 592.02 RECOVERY ROOM 196 - 210 MINUTES $ 637.56 RECOVERY ROOM 211 - 225 MINUTES $ 683.10 Page 247 2018 RECOVERY ROOM 226 - 240 MINUTES $ 728.64 RECOVERY ROOM 241 - 255 MINUTES $ 774.18 RECOVERY ROOM 256 - 270 MINUTES $ 819.72 RECOVERY ROOM 271 - 285 MINUTES $ 865.26 RECOVERY ROOM 286 - 300 MINUTES $ 910.80 RECOVERY ROOM 301 - 315 MINUTES $ 956.34 RECOVERY ROOM 31 - 45 MINUTES $ 136.62 RECOVERY ROOM 316 - 330 MINUTES $ 1,001.88 RECOVERY ROOM 331 - 345 MINUTES $ 1,047.42 RECOVERY ROOM 346 - 360 MINUTES $ 1,092.96 RECOVERY ROOM 361 - 375 MINUTES $ 1,138.50 RECOVERY ROOM 376 - 390 MINUTES $ 1,184.04 RECOVERY ROOM 391 - 405 MINUTES $ 1,229.58 RECOVERY ROOM 406 - 415 MINUTES $ 1,275.12 RECOVERY ROOM 416 - 430 MINUTES $ 1,320.66 RECOVERY ROOM 431 - 445 MINUTES $ 1,366.20 RECOVERY ROOM 446 - 460 MINUTES $ 1,411.74 RECOVERY ROOM 46 - 60 MINUTES $ 182.16 RECOVERY ROOM 461 - 475 MINUTES $ 1,457.28 RECOVERY ROOM 476 - 495 MINUTES $ 1,502.82 RECOVERY ROOM 496 - 510 MINUTES $ 1,548.36 RECOVERY ROOM 511 - 525 MINUTES $ 1,593.90 RECOVERY ROOM 526 - 540 MINUTES $ 1,639.44 RECOVERY ROOM 541 - 555 MINUTES $ 1,684.98 RECOVERY ROOM 556 - 570 MINUTES $ 1,730.52 RECOVERY ROOM 571 - 585 MINUTES $ 1,776.06 RECOVERY ROOM 586 - 600 MINUTES $ 1,821.60 RECOVERY ROOM 61 - 75 MINUTES $ 227.70 RECOVERY ROOM 76 - 90 MINUTES $ 273.24 RECOVERY ROOM 91 - 105 MINUTES $ 318.78 RECOVERY ROOM < 15 MINUTES $ 45.54 RECTAL BIOPSY 45100 $ 6,123.85 RECTAL FOREIGN BODY REMOVAL 46608 $ 1,877.59 RECTAL SUCT BX 45100 $ 6,123.85 RED BLOOD CELL COUNT 85041 $ 8.21 RED BLOOD CELLS, LR AS-1 P9016 $ 404.29 RED BLOOD CELLS, LR AS-3 P9016 $ 404.29 RED BLOOD CELLS, UNIT P9021 $ 314.14 RED CELL SURVIVAL STUDY; DIFF ORGAN 78135 $ 924.11 RED CELL VOLUME DETERM; MX SAMP 78121 $ 1,198.21 RED MASSETER M&B; EXTRAORAL 21295 $ 3,010.00 RED TORSION TESTIS, SURG W/WO FIX TESTIS 54600 $ 7,131.78 REDO ENDOVAS VENA CAVA FILTR 37192 $ 6,592.23 REDUC PROCIDENTIA UNDER ANESTH 45900 $ 1,877.59 REDUCER CAP ONE SEAL 6/BX A4649 $ 7.39 REDUCING SUBSTANCE 84376 $ 14.94 REDUCING SUBSTANCE STOOL 84376 $ 14.94 REDUCING SUBSTANCE URINE 81005 $ 5.87 REDUCING SUBSTANCES URINE 81002 $ 7.66 REDUCTION MAMMAPLASTY 19318 $ 12,725.37 REDUCTION OVERCORRECTION PTOSIS 67909 $ 4,790.26 REDUCTION SCREW 6.0 X 45 Acquisition cost RE-EVAL OF SPEECH DEVICE 92607 $ 284.50 RE-EVAL POST-OP VISIT D0171 $ 101.00 REFIL&MAINT IMPL PUMP/RESERVOIR 96522 $ 505.36 REFILL IMPL PUMP, SPINL/BRN; PHYSN REQ 95991 $ 464.07 Page 248 2018 REFILL IMPL PUMP, SPINL/BRN; W ANALYSIS 95990 $ 751.04 REFLECTION CUP/POROUS Acquisition cost REFLUDAN 50MG INJECTION J1945 Acquisition cost REGITIN 5MG INJ J2760 Acquisition cost REGITINE 5MG INJ J2760 Acquisition cost REGLAN 10 MG 2ML J2765 $ 8.84 REGLAN 10 MG/ML INJ 2 ML VIAL J2765 Acquisition cost REGLAN 5MG/5ML SOL J8597 Acquisition cost REGONOL/MESTINON 5MG/ML 2ML Acquisition cost REGRANEX GEL Acquisition cost REGULAR STEMED TIBIAL Acquisition cost REHAB FOR COCHLEAR IMPLANT 92633 $ 570.00 REHABILITATION PRIVATE ROOM $ 1,600.00 REHABILITATION SEMI PRIVATE ROOM $ 800.00 REINFORCE RELD W/TRISTAPLE 6BX C1713 $ 5,161.05 REINSERT OCUL IMP; W/WO CONJ GRFT 65150 $ 7,805.64 REINSERT RUPT BI/TRICEPS TENDON, DISTL 24342 $ 14,826.61 REINSRT OCLR IMPL; W REINFRC/ATTCH MUSC 65155 $ 7,805.64 REL EXT SCAR TIS WO DET EO MUSCLE 67343 $ 4,790.26 RELANZA INHALATION Acquisition cost RELATIVE VISCOSITY 85810 $ 31.70 RELEASE EXTNSR TENDON; HAND/FNGR 26445 $ 6,995.52 RELEASE FLXSOR TENDON; PALM/FING 26440 $ 3,570.03 RELEASE INTRINSIC MUSCLES-HAND 26593 $ 6,995.51 RELEASE MCP JOINT; EACH 26520 $ 6,995.52 RELEASE THENAR MUSCLE; THMB CONTRCTR 26508 $ 6,995.52 RELEASE TRSL TNNL (POST TIB NRV DECOMP) 28035 $ 4,259.09 RELENZA 5 MG. PO Acquisition cost Reline complete mand (lab) D5751 $ 420.00 Reline complete maxillary (lab) D5750 $ 420.00 Reline mandibular partial (lab) D5761 $ 350.00 Reline maxillary partial (lab) D5760 $ 350.00 RELINES-CHRSD MAXIL, CMPLT DENTURE D5730 $ 280.00 RELINES-CHRSD MNDBLR, CMPLT DENTURE D5731 $ 280.00 RELINES-CHRSDE MAXILLARY PARTIAL DENTURE D5740 $ 210.00 RELINES-CHRSE MANDIB PARTIAL DENTURE D5741 $ 210.00 RELOAD HEAVY WIRE 90MM C1769 $ 1,030.46 REM ADENOIDS;PRIMARY; UNDER 12 42830 $ 5,815.59 REM ANAL FISSURE 46200 $ 6,123.85 REM ANAL FISTULA; COMPLEX 46280 $ 6,123.85 REM ANAL FISTULA;INTERSPHINCTE 46275 $ 6,123.85 REM ANAL SETON,OTHER MARKER 46030 $ 2,476.36 REM BREAST LESION; 1 OR MORE 19120 $ 7,213.98 REM CORNEAL EPITHEL; W/WO CHEMOCAUT 65435 $ 2,137.81 REM CVD LUMEN OBSTR 75902 $ 41.34 REM DEEP FB FOOT 28192 $ 3,564.97 REM DIGIT NERV LES 1-2SAME DIG 64776 $ 4,259.09 REM EMB FB FROM DENTOALV; SFT TISSUE 41805 $ 3,010.00 REM EMB FB;DENTOALVEOLAR;BONE 41806 $ 3,010.00 REM EMB FB;DENTOALVEOLAR;SFT 41805 $ 3,010.00 REM EMBEDDED FB MOUTH VEST; SIMP 40804 $ 1,966.21 REM EMBEDDED FB MOUTH VESTIB; COMPLEX 40805 $ 1,216.16 REM EMBEDDED FB, MOUTH VESTIB; SIMPLE 40804 $ 1,966.21 REM ENDOVAS VENA CAVA FILTR 37193 $ 6,592.23 REM EXT FIX SYS W ANESTH 20694 $ 3,570.03 REM EXT HEMRRH; GROUPS 2/< 46250 $ 6,123.85 Page 249 2018 REM FB EMBEDDED - EYELID 67938 $ 707.85 REM FB EMBEDDED MOUTH VESTIB;S 40804 $ 1,966.21 REM FB EXT AUDITRY CANAL; W ANESTH 69205 $ 3,564.97 REM FB EXT AUDITRY CANAL; WO ANESTH 69200 $ 277.79 REM FB EXTRN AUD CANAL; W GEN ANESTH 69205 $ 3,564.97 REM FB FOOT SQ 28190 $ 1,514.94 REM FB FROM DEEP PENILE TISSUE 54115 $ 6,148.30 REM FB INTRANASAL; BY LAT RHINECTOMY 30320 $ 3,010.00 REM FB INTRANASAL; OFFICE 30300 $ 277.79 REM FB INTRANASAL; W ANESTH 30310 $ 5,815.59 REM FB INTRAOCULAR; ANT CHAMBR/LENS 65235 $ 5,080.46 REM FB MUSCLE' SIMPLE 20520 $ 3,564.97 REM FB MUSCLE/TNDN; SIMPLE 20520 $ 3,564.97 REM FB MUSCLE; DEEP 20525 $ 6,148.30 REM FB PELVIS/HIP; SUBQ 27086 $ 3,564.97 REM FB PHARYNX 42809 $ 872.74 REM FB SHOULDER SQ 23330 $ 1,514.94 REM FB UP ARM OR ELBOW; SQ 24200 $ 3,564.97 REM FB UPPER ARM/ELBOW; SUBQ 24200 $ 3,564.97 REM FB, CONJUNCTIVA; SUPERFICIAL 65205 $ 277.79 REM FB/DACRYOLITH LACRIMAL PASSAGES 68530 $ 707.85 REM FB; CORNEAL; WO SLIT LAMP 65220 $ 872.74 REM FB; DEEP THIGH/KNEE 27372 $ 6,148.30 REM FB; DEEP UPPER ARM/ELBOW 24201 $ 6,148.30 REM FB; EXT EYE - CORNEA W/ SLIT LAMP 65222 $ 277.79 REM FECAL IMPACT/FB, W ANESTH 45915 $ 2,476.36 REM FINGER TENDON; EACH 26180 $ 3,570.03 REM FOREIGN BODY SOFT TISSUE 41805 $ 3,010.00 REM FOREIGN BODY, PHARYNX 42809 $ 872.74 REM FULL ARM/LEG CAST 29705 $ 627.51 REM HEMORRHOID CLOT 46320 $ 2,476.36 REM HEMRRHOID INT/EXT W FISTUL 46258 $ 6,123.85 REM HEPATIC SHUNT (TIPS) 37183 $ 13,447.68 REM IMP FRM FINGER/HAND 26320 $ 3,564.97 REM IMP MATRL; POST SEGM; INTRAOCUL 67121 $ 5,080.46 REM IMPACTED EAR WAX; 1-2 EARS 69210 $ 147.99 REM IMPL INTRA-ARTERIAL INFUS PUMP 36262 $ 7,584.52 REM IMPLANT; DEEP 20680 $ 6,148.30 REM IMPLANTED CATHETER 62355 $ 4,259.09 REM IMPLANTED PUMP 62365 $ 12,238.01 REM IMPLNT INFUSION PUMP 36590 $ 1,619.99 REM INT HEMRRHD BY LIGATION 46945 $ 6,123.85 REM INT&EXT HEM;GRP 2/<;W FIST 46262 $ 6,123.85 REM INT&EXT HEMORRHOID;GRP 2/< 46260 $ 6,123.85 REM INT&EXT HEMORRHOID;SING 46255 $ 6,123.85 REM INT/EXT HEMORRH;2+GRPS & F 46261 $ 6,123.85 REM INTRA-NAS LES; INT APPR 30117 $ 5,815.59 REM INTRAVASC FB; W IMAG GUID 37197 $ 6,592.23 REM IOL 65920 $ 5,080.46 REM LENS FRAGMENT 66840 $ 5,080.46 REM LENS MATERIAL; EXTRACAPSULAR 1+ STGS 66940 $ 5,080.46 REM LENS MATERIAL; INTRACAPSULAR 66920 $ 5,080.46 REM LUNG CATH 32552 $ 1,619.99 REM MAMMARY IMP MATERIAL 19330 $ 7,213.98 REM MAMMARY IMPLANT 19328 $ 7,213.98 REM OBSTRUCTN FROM CVD 75901 $ 51.50 Page 250 2018 REM PROSTATE REGROWTH 52630 $ 9,800.87 REM RENAL TUBE W FLUORO GUIDANCE 50389 $ 1,495.78 REM REPLC INTERN DWELL URETRL STENT 50385 $ 4,484.35 REM SKIN TAGS; 15 LES OR LESS 11200 $ 446.80 REM SPINE ELECTRODE PLATE 63662 $ 7,614.73 REM STENT VIA TRANSURETHRAL APPR 50386 $ 4,484.35 REM SUTURES W ANESTH; OTH SURG 15851 $ 4,147.84 REM TIS EXPAN WO PROSTH INSERT 11971 $ 6,148.30 REM TONSILS&ADENOIDS; UNDER 12 42820 $ 11,474.25 REM TUNNLD IP CATH 49422 $ 6,592.23 REM URETER STENT; PERQ 50384 $ 4,484.35 REM VAGINAL IMPACTED FB; W ANESTH 57415 $ 6,010.51 REM WRIST BONE; 1 BONE 25210 $ 6,995.52 REM&REPLC PERM PACE MAKER; DUAL LEAD 33228 $ 25,779.29 REMI FENTANYL 5 MG. Acquisition cost REMIFENTANYL 2MG INJ Acquisition cost REMINYL 12MG TAB Acquisition cost REMINYL 4MG TAB Acquisition cost REMINYL 4MG/ML PO SOL Acquisition cost REMINYL 8MG TAB Acquisition cost REML OF FORGN BODY, DEEP 25248 $ 3,570.03 REML OF FORGN BODY, DEEP THIGH OR KNEE 27372 $ 6,148.30 REMOTE AFTERLOAD BRACHYTHERAP; >12 77772 $ 1,888.52 REMOTE AFTERLOAD BRACHYTHERAP; 1 CHANNL 77770 $ 1,888.52 REMOTE AFTERLOAD BRACHYTHERAP; 2-12 77771 $ 1,888.52 REMOTE DX RETINAL IMAGING 92227 $ 84.11 REMOTE PT 30 DAY ECG REV/REPORT 93270 $ 99.81 REMOV CORNEAL EPITHEL; W/WO CHEMOCA 65435 $ 2,137.81 REMOV FB EXT EYE; CONJUNC SUPERF 65205 $ 277.79 REMOV FB EXT EYE; CORNEAL W/SLIT LAMP 65222 $ 277.79 REMOV FB FT; SUBQ 28190 $ 1,514.94 REMOV FB INTRANASAL; OFFIC TYPE PROC 30300 $ 277.79 REMOV FB INTRANASAL; OFIC TYPE PROC 30300 $ 277.79 REMOV FB INTRANASAL; W ANESTH 30310 $ 5,815.59 REMOV FB INTRNASL; OFFIC TYPE PROC 30300 $ 277.79 REMOV FB MUSCL/TENDON SHEATH; SIMPL 20520 $ 3,564.97 REMOV FB; CONJUNCT SUPERFICIAL 65205 $ 277.79 REMOV FB-EXT AUDITORY CANAL; WO GEN ANES 69200 $ 277.79 REMOV IMPLNT CONTRACEPTIVE CAPSULES 11976 $ 1,514.94 REMOV IMPLNT IV INFUSION PUMP 36590 $ 1,619.99 REMOV IMPLNT MAT POST SEGMT; EXTRAOCULAR 67120 $ 5,080.46 REMOV IMPLNT; DEEP 20680 $ 6,148.30 REMOV IMPLNT; SUPERF (SEPART P 20670 $ 3,564.97 REMOV INT HEMRRHD LIGATION;2/< 46946 $ 6,123.85 REMOV INTRAUTERINE DEVICE 58301 $ 424.97 REMOV LENS MATRL; INTRACAPS; DISL LENS 66930 $ 9,548.90 REMOV POST SEGMT INSTRUM 22852 $ 1,477.81 REMOV SKIN TAGS ANY AREA; EA ADD 10 LES 11201 $ 36.89 REMOV SUTURES UNDER ANES OTHER SURG 15851 $ 4,147.84 REMOV SUTURES UNDER ANES SAME SURG 15850 $ 1,291.09 REMOV TONSILS&ADENOIDS:12/= 20 SQ CM 97598 $ 24.75 REMV FB ESOPH W/BALLN CATH-RAD S/I 74235 $ 134.60 REMV FB EXT EYE; CONJUNC EMBEDDED 65210 $ 872.74 REMV LENS MAT; PARS PLANA APPR 66852 $ 9,548.90 REMV LENS MAT; PHACOFRAGMENTAT 66850 $ 5,080.46 REMV SKIN TAGS; TO / INCL 15 LES 11200 $ 446.80 Page 252 2018 REMV SKIN TAGS; TO / INCL 15 LESION 11200 $ 446.80 REMV VITREOUS ANT; SUBTL REMOV 67010 $ 5,080.46 REMV/BIVALV; SHOULDR/HIP SPICA 29710 $ 627.51 REMVL FB INTRAOCULAR POST MANG 65260 $ 5,080.46 REMVL FB INTRAOCULAR POSTERIOR 65265 $ 5,080.46 RENAL BX; PERCUT BY TROCAR/NEE 50200 $ 3,564.97 RENAL ENDO NEPHROS W REMOV. FB 50561 $ 9,800.87 RENAL FUNCTION PANEL 80069 $ 23.58 RENAL LITHOTRIPSY-ESWL 50590 $ 9,800.87 RENIN ACTIVITY 84244 $ 59.73 REOPRO 10MG/5ML J0130 Acquisition cost REP 2NDARY RUPT ACHILLES TNDN 27654 $ 14,826.61 REP ANORECTAL FIST W PLUG 46707 $ 6,123.85 REP BLD VES W GRFT, NOT VEIN; UP EXTREM 35266 $ 11,279.00 REP BLEPHAROPT; SUP RECTUS TECHNQ 67906 $ 7,805.64 REP BLEPHAROPT; TLR/ADV; EXTERNAL 67904 $ 4,790.26 REP BLEPHAROPTOSIS; TLR/ADV; INTERNAL 67903 $ 4,790.26 REP BLOCKED UMBIL HERN; LESS THAN 5 YRS 49582 $ 7,698.79 REP BLOOD VESSEL DIR;HAND FING 35207 $ 6,592.23 REP BLOOD VESSEL DIRECT; NECK 35201 $ 11,279.00 REP CMPLX E/N/E/L 2.6-7.5CM 13152 $ 1,291.09 REP CMPLX E/N/E/L; 1.1-2.5CM 13151 $ 1,291.09 REP COLLAT LIG, MCP/IP JNT 26540 $ 6,995.52 REP COMP F/A/G/H/F; 1.1-2.5 CM 13131 $ 821.94 REP COMP S/A/L, EA ADD 5CM OR LESS 13122 $ 185.55 REP CONGENITAL AVFIST; HEAD&NCK 35180 $ 1,619.99 REP CVA CATH 36575 $ 1,619.99 REP DEV URINARY W/SLING C1771 Acquisition cost REP DISLOCATING PERONEAL TENDONS 27675 $ 6,995.52 REP DUOD/JEJ TUBE; PERQ W GUIDE 49451 $ 1,966.21 REP ELBOW W DEBRIDE; OPEN 24358 $ 6,995.52 REP ENTEROCELE; VAGINAL APPROACH 57268 $ 6,010.51 REP ENTROPION ; EXC TARSAL WEDGE 67923 $ 4,790.26 REP EPIGASTRIC HERN;INCARCERAT 49572 $ 7,698.79 REP EXT TNDN HND PR/SEC WO GFT 26410 $ 3,570.03 REP EXTNSR TENDN, DISTL INSERT; WO GRFT 26433 $ 6,995.52 REP EXTNSR TENDN; LEG; PRIM WO GRFT; EA 27664 $ 14,826.61 REP EXTROPIAN; EXC TARSAL WEDGE 67916 $ 4,790.26 REP EYELID DFCT W AUTOLOGOUS FASC SLING 67902 $ 7,805.64 REP FIBULA NONUNION; W INT FIX 27726 $ 14,826.61 REP FIST; OROMAXILLARY 30580 $ 11,474.25 REP FLX TEND ZONE 2 DIGTL; W/O GFT 26356 $ 6,995.52 REP FLXR TNDN, NOT ZONE 2; W GFT; EA 26352 $ 6,995.52 REP FLXR TNDN, ZONE 2, 2NDRY, W GRFT; EA 26358 $ 6,995.52 REP FLXR TNDN; LEG WO GFT; EA 27658 $ 6,995.52 REP FLXR TNDN; NOT ZONE 2; WO GRFT; EA 26350 $ 6,995.52 REP FLXR TNDN; ZONE 2 WO GFT; EA 26357 $ 6,995.52 REP FLXR TNDN; ZONE 2; WO GRFT; EACH 26356 $ 6,995.52 REP FOOT EXTENSOR TENDON EA 28208 $ 6,995.52 REP HUMERUS MALUNION W AUTOGRFT 24435 $ 26,770.83 REP HYPOSP COMPLICATIONS; SIMPLE 54340 $ 7,131.78 REP INCOMPLETE CIRCUMCISION 54163 $ 4,484.35 REP ING HERN BLCKD;PRE 50 FLR MOUTH/ANT 2/3 TNG 41250 $ 277.79 REP LAC ANT TONG-<2.6 CM 41250 $ 277.79 REP LAC POST TONG-<2.6CM 41251 $ 472.05 REP LAC TONGUE >2.6 CM 41252 $ 1,216.16 REP LAC; CORNEA NONPERFOR; W/WO REM FB 65275 $ 7,805.64 REP LACERATION FACE <2.5CM 12011 $ 446.80 REP LACERATION FACE >2.5-5.0CM 12013 $ 446.80 REP LACRTION; CONJUNCT FLAP, DIRCT CL 65270 $ 4,790.26 REP LIP, FULL THICKNESS; VERMILION ONLY 40650 $ 1,216.16 Rep maxillofacial sft/hrd tis D7955 Acquisition cost REP NONUNION RADIUS/ULNA W AUTOGRFT 25405 $ 14,826.61 REP NU/MU METATARSAL; W/WO BN GFT 28322 $ 14,826.61 REP OVAL WINDOW FISTULA 69666 $ 5,815.59 REP PENIS PROSTH; MULTI-COMPONENT 54408 $ 9,800.87 REP PRIM DISRPT LIG ANKL; BOTH COLL LIG 27696 $ 14,826.61 REP PROFUNDUS TENDON; PRIMARY; EA 26370 $ 6,995.52 REP RECNSTCT, FNGR, VOLAR PLT IP JNT 26548 $ 6,995.52 REP RECTOCELE 45560 $ 6,123.85 REP RECURRENT FEM HERN;REDUCIB 49555 $ 7,698.79 REP RECURRENT HERN BLCKD;ANY A 49521 $ 7,698.79 REP RECURRENT INC HERN; BLCKD 49566 $ 11,870.65 REP ROTATOR CUFF; CHRONIC 23412 $ 14,826.61 REP RUPT ACHILLES TNDN W GRFT 27652 $ 14,826.61 REP S/A/L; COMPLEX 1.1-2.5CM 13120 $ 1,291.09 REP SCLERAL STAPHYLOMA; W GRAFT 66225 $ 9,548.90 REP SHOULDER SLAP LESION 29807 $ 14,826.61 REP TEN/MUSC; EXTNSR; FA/W; EACH 25270 $ 6,995.52 REP TENDN/MSCL - FARM.WRIST 25260 $ 6,995.52 REP TMT JNT DISLOC; W INT FIX 28615 $ 14,826.61 REP TNDN/MUSC, FLXR, FOREARM/WRST, EACH 25260 $ 6,995.52 REP TORN COLLAT ANKLE LIG 27698 $ 14,826.61 REP TORN CRUCIATE LIGAMNT 27407 $ 14,826.61 REP TS FA/WR W FREE GRAFT 25275 $ 6,995.52 REP TUNICA VAGINALIS HYDROCELE 55060 $ 4,484.35 REP UMBILICAL BLCKD HERN; 5+YRS 49587 $ 7,698.79 REP WND E/F/E/N/L/MM; SIMP; 12.6-20CM 12016 $ 821.94 REPAGLINIDE 0.5 MG TAB PO Acquisition cost REPAGLINIDE 1MG TAB PO Acquisition cost REPAGLINIDE 2 MG TAB PO Acquisition cost REPAIR - PARTIAL RESIN DENTURE BASE D5610 $ 172.00 REPAIR - PARTIAL CAST FRAMEWORK D5620 $ 252.00 REPAIR ANT PALATE INCL VOMR FL 42235 $ 11,474.25 REPAIR BLEPHAROPTOSIS; W RESECTION 67908 $ 4,790.26 REPAIR BROKEN COMPLETE DENTURE BASE D5510 $ 112.00 REPAIR CHOANAL ATRESIA; INTRANASAL 30540 $ 11,474.25 REPAIR COLLAT LIGAMENT MCP/IP JOINT 26540 $ 6,995.52 REPAIR DETACHED RETINA PC 67105 $ 1,290.49 REPAIR DEV, URIN, INCONT, W SLING GRAFT L8699 Acquisition cost REPAIR DUAL CHAMBER ELECTRODES 33220 $ 7,584.52 REPAIR ECTROPION; SUTURE 67914 $ 4,790.26 REPAIR ELBOW; DEBRID/REATTACH; OPEN 24359 $ 6,995.52 REPAIR ENTROPION; SUTURE 67921 $ 4,790.26 REPAIR EPIGASTRIC HERNIA;REDUC 49570 $ 7,698.79 Page 254 2018 REPAIR FOOT FLXSR TENDON; EA 28200 $ 6,995.52 REPAIR HALLUX RIGIDUS 28289 $ 6,995.52 Repair implant abutment, B/R D6095 $ 210.00 Repair implant sup prosth, B/R D6090 $ 140.00 REPAIR ING HERN BLCKD; 5+ YR 49507 $ 7,698.79 REPAIR KNEECAP TENDON 27380 $ 14,826.61 REPAIR LUMBAR HERNIA 49540 $ 11,870.65 REPAIR NAIL BED 11760 $ 1,291.09 REPAIR NASAL SEPTAL PERFORATIONS 30630 $ 5,815.59 REPAIR NASAL STENOSIS 30465 $ 11,474.25 REPAIR NONUNION CARPAL NAVICULAR BN 25440 $ 14,826.61 REPAIR NONUNION HAND 26546 $ 14,826.61 REPAIR NONUNION OF RADIUS/ULNA 25400 $ 14,826.61 REPAIR NU/MU TIBIA; WO GRAFT 27720 $ 14,826.61 REPAIR OF NAILBED 11760 $ 1,291.09 Repair of orthodontic appliance D8691 $ 252.00 Repair or replace broken clasp D5630 $ 224.00 REPAIR RETINAL DETACHMENT; COMPLEX 67113 $ 9,548.90 REPAIR ROUND WINDOW FISTULA 69667 $ 5,815.59 REPAIR TOE DISLOCATION 28645 $ 6,995.52 REPAIR TORN COLLATERAL KNEE LIGAMNT 27405 $ 14,826.61 REPAIR UA/ELBOW TENDON/MUSCLE 24341 $ 14,826.61 REPAIR UA/ELBOW; TENDON/MUSCLE 24341 $ 14,826.61 REPAIR WRIST JOINT CARTILAGE 25107 $ 6,995.52 REPAIR WRIST JOINTS 25447 $ 6,995.52 Repair/Reline of occlusal guard D9942 $ 116.00 REPL D TIP TO ST 20822 $ 3,570.03 REPL MCP TO FLXR SUB TENDON 20816 $ 4,436.59 REPL PERIPH VAD W PORT 36585 $ 6,592.23 REPL TEMP BN WO MASTOIDECTOMY 69717 $ 14,826.61 REPL TIS EXPAND W PERM PROSTH 11970 $ 14,826.61 REPLAC GTUB STRGHT ENTERL FEED C1713 $ 51.65 REPLAC GTUBE 20FR CURV RT ANGL C1725 $ 51.65 REPLACE - MISSING / BROKEN TEETH D5520 $ 112.00 Replace broken teeth-per tooth D5640 $ 105.00 REPLACE CATH ONLY OF CVAD 36578 $ 6,592.23 REPLACE CATH; VAD 36578 $ 6,592.23 REPLACE G/C TUBE PERC 49450 $ 1,966.21 REPLACE NONTUNNL CV CATH 36580 $ 2,599.54 REPLACE PICC CATH 36584 $ 2,599.54 REPLACE TUNNELED CV CATH 36581 $ 6,592.23 REPLACE TUNNELED CVAD W PUMP 36583 $ 11,279.00 REPLACEMENT COIL SHEATH C1894 $ 93.36 REPLACEMENT OF BILIARY CATHETER 75984 $ 76.21 REPLACEMENT RETAINTER - LOWER D8692 $ 490.00 REPLACMNT G/C TUBE;PERQ 49450 $ 1,966.21 REPLANT DIGIT, NOT THUMB; TOTAL AMP 20822 $ 3,570.03 REPLC DUOD/JEJ TUBE; PERQ 49451 $ 1,966.21 REPLC NON-TUNNELED CATH 36580 $ 2,599.54 REPLC TUNNELED CVAD W PORT 36582 $ 6,592.23 Replcmt prec attachmt-part/full D5867 $ 175.00 REPLICA HIP STEM 13.5 LG. LEFT Acquisition cost REPOSIT GASTRIC FEED TUBE THRU DUOD 43761 $ 607.00 REPOSITION GASTROSTOMY TUBE 43761 $ 607.00 REPOSITION IOL PROSTH W INCISION 66825 $ 5,080.46 REPOSITION L VENTRIC LEAD 33226 $ 6,592.23 Page 255 2018 REPR 1 ELEC 1 CHAMB PACERMKR/DEFIB 33218 $ 7,584.52 REPR BLD VESSEL DIRECT; LOWER 35226 $ 1,514.94 REPR BLD VESSEL W/VEIN GFT; LOWER EXTREM 35256 $ 11,279.00 REPR BROW PTOSIS 67900 $ 4,790.26 REPR EPIGASTRIC HERN; RDUC-SEP PROC 49570 $ 7,698.79 REPR EXT TEND HAND PRIM/SEC; W 26410 $ 3,570.03 REPR EXTEN TENDON FINGER 26418 $ 3,570.03 REPR FOOT FLEXOR TENDON EA 28200 $ 6,995.52 REPR INIT INCS/VENTRAL HERNIA; 49560 $ 7,698.79 REPR INIT ING HERNIA 5YR/MORE; 49505 $ 7,698.79 REPR INIT ING HERNIA 6MO-<5YR; 49500 $ 7,698.79 REPR LACERAT; APPLIC TISS GLUE 65286 $ 5,080.46 REPR LACERAT; CORNEA PERFORATING 65280 $ 9,548.90 REPR RECUR ING HERN ANY AGE; 49520 $ 7,698.79 REPR RET DETACH; INJ AIR/OTH G 67110 $ 5,080.46 REPR RETINAL DETACH; PHOTOCOAG 67105 $ 1,290.50 REPR RETINAL DETACH; W/VITRECT 67108 $ 9,548.90 REPR THORACOABD AORTIC ANEURY W/GFT 33877 $ 7,731.57 REPR UMBIL HERNIA 5YR/OVER; RD 49585 $ 7,698.79 REPR UMBILICAL HERNIA < 5 YR; 49580 $ 7,698.79 REPTILASE TIME 85635 $ 26.75 RESCRIPTOR 200 MG Acquisition cost RESECT NECK TUMOR; 5CM OR MORE 21558 $ 6,148.30 RESECT CONFYL; DISTL PHALNX; EA TOE 28153 $ 3,570.03 RESECT FOOT/TOE TUMOR; 3CM/> 28046 $ 6,148.30 RESECT INFERIOR TURBINATE 30140 $ 5,815.59 RESECT LIP;WO RECONSTRCT;1/4< 40530 $ 5,815.59 RESECT NECK THORAX TUMOR<5CM 21557 $ 6,148.30 RESECT PALATE/EXTEN RESECT LES 42120 $ 11,474.25 RESECT SCROTUM 55150 $ 7,131.78 RESECT TALUS/CALCANEUS TUM 27647 $ 6,995.52 RESECT TUM; FOREARM/WRST; 3> CM 25077 $ 3,564.97 RESECTOR CUTTER-CATEG 1 Acquisition cost RESECTOR-CATEG 1 Acquisition cost RESECTSCOPE TUB SET W/CON-STRL A4624 $ 302.18 RESERPINE 0.1MG TAB PO Acquisition cost RESERVOIR SUCT SILIC BULB EVAC A4624 $ 63.51 RESIDUAL VOLUME 94726 $ 658.04 RESIN-BASED COMPOSITE CROWN ANTERIOR D2390 $ 294.00 RESPIRATOR SILICONE FULL FACE-CATEG 1 Acquisition cost RESPIRATORY FLOW VOLUM LOOP 94375 $ 658.04 RESTORATION MOD STEM CONICAL C1776 $ 5,110.35 RESTORE PLUS 4 X 4 A6234 $ 22.50 RESTORE PLUS 6X8 A6235 $ 49.50 RESTORE PLUS HCD WOUND CARE-CATEG 1 Acquisition cost RESTORE PRIME ADVANC NEUROSTIM C1713 $ 1,650.00 RESTORIL 15MG CAP Acquisition cost RESTRICTOR CEMENT-CATEG 1 Acquisition cost RESULTS EXPL TO FAMILY 90887 $ 275.00 RESULTS EXPLAINED TO FAM 90887 $ 275.00 RESULTS EXPLAINED TO FAMILY 90887 $ 275.00 RESULTS EXPLNED TO FAM 90887 $ 275.00 RET DEV INSERTABLE C1773 Acquisition cost Retainer crn-full cast nob met D6792 $ 980.00 RETAINER SCREW 3.5 X 14MM C1713 $ 368.28 RETAINER SCREW 3.5X12M STERILE C1713 $ 750.00 Page 256 2018 RETAINER SCREW 3.5X14MM STERIL C1713 $ 750.00 RETAINER VISCERA-CATEG 1 Acquisition cost RETENTION D8680 $ 420.00 RETENTIONS DENTAL D8680 $ 420.00 RETEXTURING ACTIVATOR 55ML Acquisition cost RETEXTURING ACTIVATOR; 55ML $ 103.40 RETICULOCYTE COUNT 85044 $ 11.70 RETICULOCYTE CT AUTO 85045 $ 10.85 RETIN-A 0.025% CREAM 20GM Acquisition cost RETIN-A 0.05% CREAM 20GM Acquisition cost RETIN-A 0.1% CREAM 45GM Acquisition cost RETINOL 1.0 BOOSTER Acquisition cost RETINOL 1.0 BOOSTR $ 99.00 RETINOL BINDING PROTEIN 86329 $ 38.15 RETRACTOR C1713 $ 900.00 RETRIEVAL BALLOON-CATEG 1 Acquisition cost RETRIEVED ARCHIVAL 88363 $ 46.20 RETROBULBAR INJ; ALCOHOL 67505 $ 707.85 RETROBULBAR INJ; MEDS 67500 $ 707.85 RETROBULBAR INJECTION; ALCOHOL 67505 $ 707.85 RETROBULBAR INJECTION; MEDICATION 67500 $ 707.85 RETROBUTTON DRILL PIN C1713 $ 172.50 RETROGRADE FILLING PER D3430 $ 140.00 RETROGRADE NAIL Acquisition cost REUNION HE FRACTURE STEM HUMERAL COMP C1776 $ 5,389.43 REV AQUEOUS SHUNT XTRAOCULR RESRVOR 66185 $ 5,080.46 REV COLOSTOMY;W REP PC HERNIA 44346 $ 2,541.20 REV OPN AV FIST; W/O THROMB-GF 36832 $ 11,279.00 REV SKIN POCKET CARDIOVERT-DEFIB 33223 $ 4,147.84 REV/REP OP WND ANT SEG EARLY/LATE 66250 $ 4,790.26 REV/REP STRESS INCONT SLING 57287 $ 6,010.51 REVASC FEM/POPL STENT & ANTHER 37227 $ 42,367.14 REVASC FEM/POPL W/TLA 37224 $ 13,447.68 REVASC OP/PRQ TIB/PERN ART; W STENT 37234 $ 615.34 REVASC TIB PERNL ART W STENT 37230 $ 42,367.14 REVASC TIB PERNL ART; ADD-ON 37232 $ 435.95 REVASC TIB/PER ART W/TRNSLUM STNT; ADD 37235 $ 861.89 REVASC TIB/PERNEAL ART W/ATHER; ADD 37233 $ 710.07 REVASC, ENDOVASC; OP/PERQ, TIB ART UNI 37228 $ 27,795.70 REVATIO 20MG TABLET Acquisition cost REVIEW MEDS BY PHARM/MD IN MR 1160F Acquisition cost REVIS IMPLNT IV INFUSION PUMP 36576 $ 2,599.54 REVIS VEN ACCESS DEVIC//RESERVOIR 36576 $ 2,599.54 REVIS/REM SPINAL TRANS 63688 $ 7,614.73 REVIS/REPR OPERATIVE WOUND ANT 66250 $ 4,790.26 REVIS/RMV SPINAL TRANS 63688 $ 7,614.73 REVISE ARTIFICIAL DISC; LUMBAR 22862 $ 4,859.03 REVISE GASTROPLASTY 43848 $ 4,111.71 REVISE RECONSTRUCTED BREAST 19380 $ 12,725.37 REVISE SPINE ELCTRD PLATE 63664 $ 48,577.94 REVISE SPINE ELECTRDE PERQ ARRAY 63663 $ 16,014.53 REVISE SPINE ELECTRODE PERQ ARRAY 63663 $ 16,014.53 REVISE/REM CRANIAL NS PLS GEN/RCVR 61888 $ 16,014.53 REVISE/REMOVE NEUROELECTRODES 64585 $ 7,614.73 REVISE/RMV NEUROELECTRODES 64585 $ 7,614.73 REVISION MASTOIDECTOMY; COMPLETE 69601 $ 11,474.25 Page 257 2018 REVISION MODULAR FEMUR- RIGHT Acquisition cost REVISION MODULAR TIBIA-RIGHT Acquisition cost REVISION OF TRACHEOSTOMY SCAR 31830 $ 5,815.59 REWIND SCREW 5.0 X 35MM C1713 $ 2,025.00 REZULIN 200MG TAB Acquisition cost REZULIN 300MG TAB Acquisition cost REZULIN 400MG TAB Acquisition cost RF HEDGEHOG PROBE C2618 $ 291.00 RF J HOOK PROBE 30 DEGRESS C2618 $ 282.27 RH TYPE 86901 $ 84.11 RHC & RETROGR LHC CONGENITAL 93531 $ 7,440.77 RHC & TS LHC CONG - INTACT SEPTM 93532 $ 7,440.77 RHC & TS LHC CONG - OPEN SEPTUM 93533 $ 7,440.77 RHC FOR CONG ANOMALY 93530 $ 7,440.77 RHEUMATOID FACTOR QUAL 86431 $ 15.40 RHEUMATOID FACTOR QUANT 86431 $ 15.40 RHEUMATOID FACTOR QUANT 86431 $ 15.40 RHEUMATOID FACTOR; QUAL 86430 $ 15.40 RHIGIV 90386 $ 92.00 RHINO PRIM; LAT&ALAR CART&/ELE 30400 $ 11,474.25 RHINOPL 2NDRY TO CCL/CCP; TIP/SEPTUM 30462 $ 11,474.25 RHINOPLASTY; COMPLETE; EXT PARTS 30410 $ 11,474.25 RHINOPLASTY; MAJOR REVIS; 2NDRY 30450 $ 11,474.25 RHINOPLASTY; PRIMARY; W MAJ SEPTL REP 30420 $ 11,474.25 RHINOPLSTY; INTERMED REVISION, SECONDARY 30435 $ 11,474.25 RHINOPLSTY; MINOR REVISION, SECONDARY 30430 $ 11,474.25 RHOGAM HUMAN FULL-DOSE IM USE_ 90384 $ 92.00 RHOGAM HUMAN FULL-DOSE IM USE_ 78608 $ 3,642.17 RHYTHM ECG 1-3 LEADS TRACING 93041 $ 147.99 RHYTHM ECG 1-3 LEADS; W/INTERPT / REPORT 93040 $ 11.00 RHYTHM ECG W I/R 93040 $ 11.00 RHYTIDECT; CK/CN/NK 15828 $ 7,168.06 RHYTIDECTOMY; FOREHEAD 15824 $ 4,147.84 RHYTIDECTOMY; FROWN LINES 15826 $ 7,168.06 RHYTIDECTOMY; NECK W TIGHTENING 15825 $ 7,168.06 RHYTIDECTOMY; SMAS FLAP 15829 $ 7,168.06 RIA NONANTIBODY 83519 $ 40.48 RIBA-PAK 400/400 TABLET Acquisition cost RIBA-PAK 600/400 TABLET Acquisition cost RIBA-PAK 600/600 TABLET Acquisition cost RIBAVIRIN 200MG CAPSULE PO Acquisition cost RIBBED BALL-CATEG 1 Acquisition cost RIBOSOMAL-P ANTIBODY 86235 $ 48.71 RIBS BILATERAL 71110 $ 302.70 RIBS UNILATERAL 71100 $ 164.27 RIFABUTIN 150MG CAP Acquisition cost RIFADIN 600MG INJ Acquisition cost RIFADIN/RIMACTANE 150MG CAP Acquisition cost RIFADIN/RIMACTANE 300MG CAP Acquisition cost RIFAMPIN 10MG/ML SUSPENSION Acquisition cost RIFAXIMIN 200MG. PO Acquisition cost RIFAXIMIN 200MG. PO. Acquisition cost RIFAXIMIN 550 MG. PO Acquisition cost RIGHT 15 HOLE C1713 $ 1,520.44 RIGHT DISTAL RADIUS PLATE C1713 $ 1,437.00 RIG-HT FOR IM/SUBCU USE 90376 $ 761.86 Page 258 2018 RIGHT FOSSA COMPONENT Acquisition cost RIGHT HEART CATH 93451 $ 7,440.77 RIGHT STANDARD POLAR PLATE C1713 $ 1,134.00 RIGHT VENTRICLE/ATRIAL ANGIOGRAM 93566 $ 99.64 RILPIVIRINE (EDURANT) 25 MG. PO Acquisition cost RILUTEK 50 MG TAB Acquisition cost RIMSO-50 (DIETHYL SULFOXIDE) 50 ML. Acquisition cost RING 165MM, 3/4" C1713 $ 534.00 RING SILICONE PESSARY-CATEG 1 Acquisition cost RING-CATEG 1 Acquisition cost RINGED GFT T8MM 50CMx100CM C1768 $ 2,661.00 RINGED GRAFT T8MM 50CMRSX100CM C1768 $ 2,661.00 RINGERS SOLN LACTATED 500ML J7120 Acquisition cost RINGLOC BI-POLAR 28 X 49MM Acquisition cost RINGLOC BI-POLAR-CATEG 1 Acquisition cost RISEDRONATE SOD 30MG TAB Acquisition cost RISEDRONATE SOD 5MG TAB Acquisition cost RISPERDAL 0.5MG UD TABLETS Acquisition cost RISPERDAL CONSTA - 12.5MG J2794 $ 299.20 RISPERDAL CONSTA - 25MG J2794 $ 598.40 RISPERDAL CONSTA - 37.5MG J2794 $ 897.60 RISPERDAL CONSTA - 50MG J2794 $ 1,196.80 RISPERDAL CONSTA 12.5MG INJ J2794 Acquisition cost RISPERDAL CONSTA 12.5MG INJ VIAL J2794 $ 299.20 RISPERDAL CONSTA 25MG INJ VIAL J2794 $ 598.40 RISPERDAL CONSTA 37.5MG INJ VIAL J2794 $ 897.60 RISPERDAL CONSTA 50MG INJ VIAL J2794 $ 1,196.80 RISPERDAL CSNTA 0.5MG INJ VIAL J2794 $ 23.94 RISPERIDONE 80299 $ 41.01 RISPERIDONE 0.25MG TABLET Acquisition cost RISPERIDONE 1MG (RISPERDAL) ORAL SYR Acquisition cost RISPERIDONE 1MG TAB Acquisition cost RISPERIDONE 1MG/ML SOLN Acquisition cost RISPERIDONE 2MG TAB Acquisition cost RISPERIDONE 3MG TAB Acquisition cost RISPERIDONE 4MG TAB Acquisition cost RISPERIDONE CONC 1MG/ML-30ML Acquisition cost RISPERIDONE CONSTA 25MCG/2 ML J2794 Acquisition cost RISPERIDONE CONSTA 37.5MCG/2 ML J2794 Acquisition cost RISPERIDONE CONSTA 50MCG/2ML J2794 Acquisition cost RISPERIDONE PO Acquisition cost RISPERIDONE-M 0.5MG TAB PO Acquisition cost RISPERIDONE-M 1MG TAB PO Acquisition cost RISPERIDONE-M 2MG TAB PO Acquisition cost RITALIN 80299 $ 41.01 RITALIN LEVEL 80299 $ 41.01 RITONAV/LOPINAV 400/100 PO LIQ Acquisition cost RITONAVIR 100MG TABLET ORAL Acquisition cost RITONAVIR 80MG/ML ORAL SOLN Acquisition cost RITONAVIR/LOPINAVIR 33.3-133.3 Acquisition cost RITONAVIR/LPINAVIR 50/200 MG Acquisition cost RITUXIMAB 100MG J9310 $ 2,384.93 RITUXIMAB 100MG/10ML VIAL J9310 Acquisition cost RITUXIMAB 10MG/ML VIAL 10ML Acquisition cost RIVASTIGMINE 1.5MG CAP Acquisition cost RIVASTIGMINE 2MG/ML PO SOL Acquisition cost Page 259 2018 RIVASTIGMINE (EXELON) 3MG CAP Acquisition cost RIVASTIGMINE (EXELON) 6MG CAP Acquisition cost RIVASTIGMINE 4.5MG CAP Acquisition cost RMSF/TYPHYUS IgG/IgM 86757 $ 52.58 RMV BILIARY DRAIN CATH; W RAD 47537 $ 1,966.21 RMV BY CONTOUR OF B9 TUM FACE BONE 21029 $ 5,815.59 RMV FB; UPPER ARM/ELBOW, SUBQ 24200 $ 3,564.97 RMV FECAL IMPACT/FB; UNDER ANESTH 45915 $ 2,476.36 RMV IMPACTD EAR WAX; UNILAT; IRRGT/LAVAG 69209 $ 147.99 RMV IMPLANTED CATHETER 62355 $ 4,259.09 RMV IMPLANTED PUMP 62365 $ 12,238.01 RMV NON-BIODEGRD DRUG DELIVERY IMPLANT 11982 $ 872.74 RMV SPINE ELECTRODE PERQ ARRAY 63661 $ 4,259.09 RMVL & REPLC PULSE GEN 1 LEAD 33262 $ 58,472.94 RMVL & RPLCMT DFB GEN 2 LEAD 33263 $ 58,472.94 RMVL & RPLCMT DFB GEN MLT LD 33264 $ 81,881.71 RMVL BENIGN ODONTOGENIC CYST/LSN <1.25 D7451 $ 1,688.00 RMVL BENIGN ODONTOGENIC CYST/LSN >1.25 D7461 $ 1,732.00 RMVL EMBED FB CONJUNCT 65210 $ 872.74 RMVL PERM PERITON CATH 49422 $ 6,592.23 RO B PERTUSSIS (DFA) 87260 $ 32.56 RO C DIFFICILE 87230 $ 53.61 RO CRYPTOSPORIDIUM 87207 $ 16.28 RO L PNEUMOPHILA-DFA 87278 $ 34.32 RO PNEUMO CARINII 87299 $ 35.42 ROADRUNNER WIREGUIDE C1713 $ 217.50 ROBAXIN 100MG/ML VIAL 10ML J2800 Acquisition cost ROBINUL 0.2MG/ML VIAL 1ML Acquisition cost ROBITUSSIN-DM 200-30 SYRUP PO Acquisition cost ROBOTIC ASSISTED SURGERY ADD-ON S2900 Acquisition cost ROCCURONIUM 10MG/ML 5 ML SYRINGE Acquisition cost ROCHALIMAEA HENSELAE ANTIBODY 86611 $ 27.63 ROCKY MT SP FEV IGG 86609 $ 34.98 ROCKY MT SP FEV IGM 86609 $ 34.98 ROCKY MTN SPOT FEVER 86317 $ 40.70 ROCKY MTN SPOTTED FEVER ANTIBODY 86757 $ 52.58 ROCURONIUM 50MG/5ML SYRNG J3490 $ 15.05 ROD 3.5x120MM MOUNTAINEER C1713 $ 487.50 ROD CARBON FIBER-CATEG 1 Acquisition cost ROD RADIUS-CATEG 1 Acquisition cost ROD REAMING-CATEG 1 Acquisition cost ROD-CATEG 1 Acquisition cost ROD-CATEG 2 Acquisition cost ROD-CATEG 3 Acquisition cost ROFECOXIB (VIOXX) 25MG TAB Acquisition cost ROFECOXIB (VIOXX) 50MG TAB Acquisition cost ROFLUMILAST 500MCG TABLET Acquisition cost ROI-A ANCHORING PLATE S ORIG C1713 $ 2,250.00 ROI-A ANCHORING PLATE S ORIG C1713 $ 2,250.00 ROI-C IMPLANT 8MM ANCHOR PLATE C1713 $ 3,000.00 ROM / RPT-SEP PROC; EA EXTREM/TRNK SEC 95851 $ 43.23 ROM HAND 95852 $ 39.27 ROM MSMTS/RPT, HAND, W/WO CMPRSN 95852 $ 39.27 ROM MSMTS/RPT,EA EXTR(EXCL HND)OR EA TRK 95851 $ 43.23 ROM-HAND (PVT ONLY) 95852 $ 39.27 ROMIPLOSTIM 250MCG INJ Acquisition cost Page 260 2018 ROOT AMPUTATION D3450 $ 140.00 ROOT CANAL THERAPY - ANTERIOR D3310 $ 560.00 ROOT CANAL THERAPY - BICUSPID D3320 $ 700.00 ROOT CANAL THERAPY - MOLAR D3330 $ 910.00 ROOT FORM IMPLANT - PER TOOTH D7272 $ 885.00 ROPINIROLE 0.25MG TABLET PO Acquisition cost ROPINIROLE 0.5MG TABLET PO Acquisition cost ROPINIROLE 1MG TABLET PO Acquisition cost ROPINIROLE 2MG TABLET PO Acquisition cost ROPINIROLE 3MG TABLET PO Acquisition cost ROPINIROLE 4MG TABLET PO Acquisition cost ROPINIROLE 5MG TABLET PO Acquisition cost ROPIVACAINE 0.2% 200ml P.F. J2795 Acquisition cost ROSIGLITAZONE ( 2MG) TAB PO Acquisition cost ROSIGLITAZONE (8MG) TAB PO Acquisition cost ROSIGLITAZONE4MG TAB Acquisition cost ROTARIX Acquisition cost ROTATOR CUFF REP ARTHROSCOPY 29827 $ 14,826.61 ROTAVIRUS 90680 $ 206.07 ROTAVIRUS RAPID TST 87425 $ 32.56 ROTAVIRUS VACC 2 DOSE ORAL 90681 $ 206.07 ROTAVIRUS VACCNE,TETRAVLNT,LVE CLINIC 90680 $ 206.07 ROTAVIRUS VACCNETETRAVLNTLVEVE 90680 $ 206.07 ROTH MAXI POLYP RETRIEVAL NET-CATEG 1 Acquisition cost ROTIGOTINE SYSTEM Acquisition cost ROTOVIRUS Acquisition cost ROUND BUR 1.8MM C1713 $ 12.42 ROUND CARBIDE BUR 3.0MM^ C1713 $ 55.88 ROUND FLUTED BUR, LONG 3.0MM C1713 $ 138.41 ROUTINE CHROM ANALYSIS 88262 $ 338.54 ROUTINE ECG W I/R 93000 $ 33.00 ROUTINE HIV SCEROLOGY 86701 $ 24.13 ROUTINE VENIPUNCT-COLLEC SPECMN 36415 $ 6.60 ROUTINE VENIPUNCTURE 36415 $ 6.60 ROWASA 4GM ENEMA 60ML Acquisition cost ROWASA 500 MG SUPP Acquisition cost RPHARM MONOCLONIAL AB THERAPY 79403 $ 630.67 Rpl: atchmt: imp/abt sup pros D6091 Acquisition cost RPLACE G-J TUBE; PERCU 49452 $ 1,966.21 RPR BLD VESSEL DIRECT; LWR EXTRM 35226 $ 1,514.94 RPR DTCHD RETINA CRYOTX/DIATHRMY 1+ STGS 67101 $ 5,080.46 RPR EYELID DEFECT W SUTURE/OTHER 67901 $ 4,790.26 RPR ING HERN BLCKD;0.5 < 5 YR 49501 $ 7,698.79 RPR LAC; APP TISS GLUE; WND SCL/CRN 65286 $ 5,080.46 RPR LIP FULL THICK; UP TO HALF VERT HGHT 40652 $ 1,216.16 RPR OF IRIS; CILIARY BODY 66680 $ 5,080.46 RPR PARAVAGINAL DEFECT; VAG APPR 57285 $ 16,627.40 RPR RECURRENT INC HERN; REDUC 49565 $ 11,870.65 RPR RETINAL DETCHMNT; SCLERAL BUCKLING 67107 $ 9,548.90 RPR UMBILICAL HERN; BLCKD;5+YR 49587 $ 7,698.79 RSA LOWER EXTREMITY 0350T $ 164.27 RSA SPINE EXAM 0348T $ 302.70 RSA UPPER EXTREMITY 0349T $ 302.70 RSV ANTIBODY $ 53.09 RSV ANTIGEN 87420 $ 32.56 RSV IGG $ 53.09 Page 261 2018 RSV IGM $ 53.09 RT TROCHANTERIC FIX NAIL 11MM/130x360 C1713 $ 1,959.00 RUBBER DAM CLAMP #14 SS C1713 $ 17.40 RUBBER DAM CLAMP SATIN FINISH C1713 $ 15.00 RUBBER DAM CLAMP SATIN FNSH 2 C1713 $ 16.43 RUBBER DAM CLMP SATIN FNSH 12A C1713 $ 16.43 RUBBER DAM CLMP SATN FINSH 13A C1713 $ 16.43 RUBBING ALCOHOL Acquisition cost RUBBING ALCOHOL 70%480M Acquisition cost RUBBING ALCOHOL ETHYL 480ML Acquisition cost RUBELLA AB IGG 86762 $ 39.09 RUBELLA AB (RUBASCAN) IGG 86762 $ 39.09 RUBELLA AB IGMEIA 86280 $ 22.26 RUBELLA AB PR (HAI) 86762 $ 39.09 RUBELLA AB SGL (HAI) 86762 $ 39.09 RUBELLA ANTIBODY 86762 $ 39.09 RUBELLA VACCINE Acquisition cost RUBELLA/MUMPS VIRUS VAC LIVE SUBQ 90707 Acquisition cost RUBEOLA ANTIBODY 86765 $ 34.98 RUBIDIUM RB-82 DIAG <= 60 MCI A9555 Acquisition cost RUGGLES DRILL PERFOR D'ERRICO C1713 $ 416.96 RUGGLES GIGLI SAW GUIDE 12" C1769 $ 105.09 RUSCH SUPRAFOLEY SP INTROD16FR A4340 $ 27.45 RUSSELL VIPER VENOM TIME; DILUTED 85613 $ 26.03 RVVT; DILUTED 85613 $ 26.03 RX 90 ACETABULAR LINER SIZE 44 Acquisition cost RX 90 CONNECTED FEMUR STEM Acquisition cost RX CONTACT; CORNEAL BOTH EYES 92310 $ 330.00 RYTHMOL 150MG UD TAB Acquisition cost RYTHMOL 225 MG PO Acquisition cost RYTHMOL 325 MG. PO Acquisition cost S.T. SCREW 14MM TI; SKYLINE ANT PLATE C1713 $ 370.50 S-2/RACEPINEPHRINE NEB 15ML Acquisition cost SACROILIAC JOINT BIOPSY 27050 $ 3,570.03 SACROILIAC JOINTS 72200 $ 302.70 SACROILIAC JOINTS COMPLETE 72202 $ 302.70 SACROSPINOUS LIGAM FIX FOR PROLAPSE 57282 $ 16,627.40 SACRUM / COCCYX 72220 $ 164.27 SACUBITRIL-VALSARTAN24-26mg(Entresto) Acquisition cost SACUBITRIL-VALSARTAN49-51mg(Entresto) Acquisition cost SACUBITRIL-VALSARTAN97-103mg(Entresto) Acquisition cost SAFESHEATH INTRODUCER 7FR C1892 $ 438.75 SAFESHEATH INTRODUCER 9FR C1892 $ 438.75 SAFESHEATH TEAR AWAY W/SIDE PORT C1892 $ 112.50 SALIC ACID/ALC/PROP GLY 6% GEL Acquisition cost SALICYLATE 80329 $ 21.45 SALICYLIC ACID 17% Acquisition cost SALINE 0.65% NOSE DROPS 50ML Acquisition cost SALINE BREAST IMP 163/440CC STYLE C1789 $ 1,200.00 SALINE BREAST IMP 163/530CC STYLE C1789 $ 1,200.00 SALINE BREAST IMP 168/150CC C1789 $ 712.50 SALINE BREAST IMP 168/210CC C1789 $ 712.50 SALINE BREAST IMP 168/240CC C1789 $ 712.50 SALINE BREAST IMP 168/270CC C1789 $ 712.50 SALINE BREAST IMP 168/300CC C1789 $ 772.50 SALINE BREAST IMP 168/360CC C1789 $ 712.50 Page 262 2018 SALINE BREAST IMP 168/450CC C1789 $ 712.50 SALINE BREAST IMP 168/510CC C1789 $ 733.88 SALINE BREAST IMP 20/325CC C1789 $ 1,390.50 SALINE BREAST IMP 363LF/330-350 C1789 $ 1,236.00 SALINE BREAST IMP 363LF/410-430 C1789 $ 1,200.00 SALINE BREAST IMP 363LF/450-475 C1789 $ 1,200.00 SALINE BREAST IMP 68HP/500-540CC C1789 $ 825.00 SALINE BREAST IMP 68HP/550-590CC C1789 $ 1,236.00 SALINE BREAST IMP 68MP/300CC C1789 $ 67.50 SALINE BREAST IMP 68MP/330CC C1789 $ 862.50 SALINE BREAST IMP 68MP/390CC C1789 $ 862.50 SALINE BREAST IMP 68MP/450CC C1789 $ 888.00 SALINE BREAST IMPL 168 STYLE C1789 $ 733.87 SALINE BREAST IMPL 20/325CC C1789 $ 1,390.50 SALINE BREAST IMPL 68/150-420 C1789 $ 577.50 SALINE BREAST IMPL 68/450CC C1789 $ 888.00 SALINE BREAST IMPLANT C1789 $ 712.50 SALINE BREAST IMPLANT 163 C1789 $ 1,200.00 SALINE BREAST IMPLANT 168/180CC C1789 $ 577.50 SALINE BREAST IMPLANT 168/390CC C1789 $ 712.50 SALINE BREAST IMPLANT 168/420CC C1789 $ 712.50 SALINE BREAST IMPLANT 168/480CC C1789 $ 712.50 SALINE BREAST IMPLANT 168/510CC C1789 $ 712.50 SALINE BREAST IMPLANT 168/550 C1789 $ 712.50 SALINE BREAST IMPLANT 168/600 C1789 $ 733.88 SALINE BREAST IMPLANT 260CC C1789 $ 1,200.00 SALINE BREAST IMPLANT 300CC C1789 $ 1,236.00 SALINE BREAST IMPLANT 363LF C1789 $ 1,200.00 SALINE BREAST IMPLANT 68 STYLE C1789 $ 862.50 SALINE BREAST IMPLANT 68HP C1789 $ 825.00 SALINE BREAST IMPLANT 68MP C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 363LF/450 C1789 $ 1,200.00 SALINE BREAST IMPLANT STYLE 363LF/510 C1789 $ 1,200.00 SALINE BREAST IMPLANT STYLE 363LF/560 C1789 $ 1,200.00 SALINE BREAST IMPLANT STYLE 68/120CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68/150CC C1789 $ 825.00 SALINE BREAST IMPLANT STYLE 68MP/180CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68MP/210CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68MP/240CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68MP/270CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68MP/360CC C1789 $ 862.50 SALINE BREAST IMPLANT STYLE 68MP/420CC C1789 $ 888.00 SALINE BREAST IMPLANT W/BIOCEL C1789 $ 1,236.00 SALINE BREAST IMPLNT 168 STYLE C1789 $ 712.50 SALINE BRST IMP 363LF/450CC STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMP 370CC/363LF STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMP 410CC/363LF STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMP 510CC/363LF STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMP 620CC/363LF STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMP 690CC/363LF STY W/BIOCEL C1789 $ 1,236.00 SALINE BRST IMPT SIZER STYLE 68 510CC C1789 $ 67.50 SALINE IMPLANT STYLE 163 655C Acquisition cost SALINE IMPLANT STYLE 163 780C Acquisition cost SALINE IMPLANT STYLE 363 SIZE Acquisition cost SALINE NOSE SPRAY Acquisition cost SALINE-FILL BREAST IMPLNT C1789 $ 825.00 Page 263 2018 Saliography D0310 $ 252.00 SALIVARY GLAND FUNCTION 78232 $ 924.11 SALIVARY GLAND IMAGING 78230 $ 924.11 SALIVARY GLAND, NEEDLE BIOPSY 42400 $ 1,514.94 SALIVARY GLAND/SERIAL IMAGING 78231 $ 924.11 SALIVRY GLAND, NEEDLE BIOPSY 42400 $ 1,514.94 SALMETEROL XIN 50MCG DISK Acquisition cost SALMONELLA AGGLUTININS 86768 $ 35.82 SALPINGECTOMY; COMPL/PART; UNI/BILAT 58700 $ 1,659.53 SALPINGO-OOPHOR; COMPL/PART/ UNI/BILAT 58720 $ 1,572.14 SANDIMMUNE 100MG/ML SOL J7502 Acquisition cost SANDOSTATIN 100MCG INJ J2354 Acquisition cost SANDOSTATIN 1MG J2353 $ 537.79 SANDOSTATIN 500MCG INJ J2354 Acquisition cost SANDOSTATIN 50MCG INJ J2354 Acquisition cost SANDOSTATIN KIT LAR 30MG J2353 $ 537.79 SANQUINAVIR 200MG CAP Acquisition cost SANTYL COLLAGENASE OINT 30GM Acquisition cost SAQUINAVIR 200MG CAP Acquisition cost SAQUINAVIR 500MG TAB Acquisition cost SBSQ PSYC COLLAB CARE MGMT 99493 $ 275.00 SBSQ PSYC COLLAB CARE MGMT YR2 99493 $ 275.00 SC THER INFUSION ADDL HR 96370 $ 97.92 SC THER INFUSION RESET PUMP 96371 $ 153.91 SC THER INFUSION UP TO 1HR 96369 $ 505.36 SC THER INFUSION, RESET PUMP 96371 $ 153.91 SCALP CLIP APPLICATOR DISP C1713 $ 662.16 SCAN PROC; CRANIAL/INTRADURAL 61781 $ 496.14 SCAN PROC; SPINAL 61783 $ 490.69 SCAN PROCEDURE; CRANIAL/EXTRADURAL 61782 $ 375.76 SCANNG COMPTZD OPHTHLMC DX IMG 92134 $ 147.99 SCAPULA 73010 $ 302.70 SCARRING OF EOM 67332 $ 723.29 SCC (CARCINOMA AG) 86316 $ 56.54 64445 $ 1,437.02 SCLERAL REINFRCMNT; W GRAFT 67255 $ 5,080.46 SCLEROSING SOLN INJ; 2+ VEIN SAME LEG 36471 $ 821.94 SCLEROSING SOLN INJ; SING VEIN 36470 $ 821.94 SCLEROSOL INTRAPLEURAL AEROSOL Acquisition cost SCLEROTHER OF VEINS, LIMB, OR TRUNK 36468 $ 446.80 SCOPE KNEE SURG; ABRASION ARTH 29879 $ 6,995.52 SCOPE KNEE SURG; DEBRID/SHAVE 29877 $ 6,995.52 SCOPE KNEE SURG;W/MENISCECT MED/LAT 29880 $ 6,995.52 SCOPE KNEE SURG;W/MENISCECT MED/LAT 29881 $ 6,995.52 SCOPE KNEE; SYNOVECT LTD SEP PROC 29875 $ 6,995.52 SCOPE SHOULDER; DECOMP SUBACROM 29826 $ 378.53 SCOPOLAMINE 1.5MG/72H PATCH Acquisition cost SCOPOLMNE HYDROBROMIDE 0.25% $ 9.54 SCORPIO TOTAL STABILIZER FEMORAL C1776 $ 7,100.10 SCORPION NEEDLE C2618 $ 360.00 SCOTT DISP VENTRI CANNULA 8FR A4615 $ 773.39 SCR 1.7MM EMERGENCYS C1713 $ 108.17 SCRAPING CORNEA DX SMEAR //OR CULTURE 65430 $ 872.74 SCRAPING OF CORNEA, DIAGNOSTIC 65430 $ 872.74 SCREEN CERV/VAG THIN LAYER G0123 $ 55.02 SCREEN COLONOSCOPY; NOT HIGH RISK G0121 $ 1,877.59 Page 264 2018 SCREENING PAP BETHESDA BY CT P3000 $ 32.23 SCREENING PAP BETHESDA BY MD 88141 $ 70.31 SCREENING TEST VISUAL ACUITY-QUAN-BILAT 99173 $ 50.00 SCREW 16MM C1713 $ 467.28 SCREW 3.5x22MM C1713 $ 627.00 SCREW 4.0 X 50MM C1713 $ 237.60 SCREW 6.5x110MM C1713 $ 386.33 SCREW 7.5MM X 35MM C1713 $ 1,312.50 SCREW ACETEB-CATEG 1 Acquisition cost SCREW AUTOPILOT-CATEG 1 Acquisition cost SCREW BIO INTERFER-CATEG 1 Acquisition cost SCREW BONE SELF TAP-CATEG 1 Acquisition cost SCREW BONE-CATEG 1 Acquisition cost SCREW BONE-CATEG 2 C1713 Acquisition cost SCREW BONE-CATEG 3 C1713 Acquisition cost SCREW BREAK OFF-CATEG 1 Acquisition cost SCREW CANCELL BONE-CANC 1 Acquisition cost SCREW CANCELL-CATEG 1 Acquisition cost SCREW CANCELL-CATEG 2 C1713 Acquisition cost SCREW CANN. CANC-CATEG 1 Acquisition cost SCREW CANNUL SHEATH-CATEG 1 C1713 Acquisition cost SCREW CENTRE DRIVE-CATEG 1 Acquisition cost SCREW COMPRESS-CATEG 1 Acquisition cost SCREW CORTEX SELF TAP-CATEG 1 C1713 Acquisition cost SCREW CORTEX-CATEG 1 C1713 Acquisition cost SCREW CORTICAL BONE-CATEG 1 Acquisition cost SCREW CORTICAL BONE-CATEG 2 C1713 Acquisition cost SCREW CORTICAL-CATEG 1 C1713 Acquisition cost SCREW CORTICAL-CATEG 2 Acquisition cost SCREW COVER-CATEG 1 Acquisition cost SCREW CROSS-CATEG 1 C1713 Acquisition cost SCREW DISTAL-CATEG 1 C1713 Acquisition cost SCREW FIX CANNULATED STERILE C1713 $ 275.81 SCREW GAMMA 10.5X 90MM TI.LAG C1713 $ 807.07 SCREW HEX-CATEG 1 Acquisition cost SCREW IMPLANT; VARIOUS SIZES C1713 $ 531.00 SCREW INFAST-CATEG 1 Acquisition cost SCREW INNER-CATEG 1 Acquisition cost SCREW LAG-CATEG 1 Acquisition cost SCREW LAG-CATEG 2 Acquisition cost SCREW LOCKING-CATEG 1 C1713 Acquisition cost SCREW MINI-CATEG 1 Acquisition cost SCREW MULTI AXIAL-CATEG 1 Acquisition cost SCREW PEFIER-CATEG 1 Acquisition cost SCREW PHANTOM-CATEG 1 Acquisition cost SCREW POLY-CATEG 1 C1713 Acquisition cost SCREW SELF DRLL-CATEG 1 C1713 Acquisition cost SCREW SELF-TAPPING 1.3MM X C1713 $ 171.00 SCREW SET-CATEG 1 Acquisition cost SCREW SLEEVE C1713 $ 235.12 SCREW SLEEVE C1713 $ 235.13 SCREW SMART-CATEG 1 Acquisition cost SCREW T WRENCH BONE-CATEG 1-CATEG 1 Acquisition cost SCREW TAPERSCREW-CATEG 1 Acquisition cost SCREW TI HEX-CATEG 1 Acquisition cost SCREW TI HEX-CATEG 2 Acquisition cost Page 265 2018 SCREW TI SELF-TAPPING 1.0MM X C1713 $ 151.50 SCREW TI SELF-TAPPING 2.0MM X C1713 $ 71.62 SCREW TI WHOLE-CATEG 1 Acquisition cost SCREW TI-CATEG 1 Acquisition cost SCREW TRANSVERSE-CATEG 1 Acquisition cost SCREW VARIOUS-CATEG 1 C1713 Acquisition cost SCREW-CATEG 1 C1713 Acquisition cost SCREW-CATEG 2 C1713 Acquisition cost SCREW-CATEG 3 C1713 Acquisition cost SCREWS DFFERENT SIZES C1713 $ 217.50 SCREWS NUTS, ETC-CATEG 1 Acquisition cost SCRIPT W/FIT BY TECH; LENS-APHAKIA-1 EYE 92315 $ 277.79 SCRN CERV VAG THIN LYR G0123 $ 55.02 SCRN COLONOSCOPY PT NOT HI RISK G0121 $ 1,877.59 SCRN COLONOSCOPY; HIGH RISK PT G0105 $ 1,877.59 SCROTAL EXPLORATION 55110 $ 4,484.35 SCROTOPLASTY; SIMPLE 55175 $ 7,131.78 SCROTUM US 76870 $ 302.70 SCRW BONE NONLOCKING 2.7MM DIA C1713 $ 106.87 SCRW,NUT,BOLT,PLATE,DRLL,SUPPL C1713 $ 1.50 SD SCR 1.55X4MM CROSS PIN C1713 $ 147.00 SD SCR 1.5X5MM W/ NEW HEAD C1713 $ 110.31 SEALANT-TOOTH D1351 $ 146.00 SECND ART MRCH THROMBECTOMY; ADD ON 37186 $ 529.98 SECND CL SURG WND/DEH; EXTNSIVE 13160 $ 4,147.84 SECOBARBITAL LEVEL 80345 $ 11.00 SECONDARY IMPLANT 66985 $ 5,080.46 SEDATION-IV/IM/INHAL $ 275.00 SEDATIVE FILLING D2940 $ 120.00 SEDIMENTATION RATE 85651 $ 9.64 SED-SCHISTOSOMIASIS 87177 $ 24.18 SEL CATH PLCMT ART; EA 1ST ABD 36245 $ 517.88 SEL CATH PLCMT SEG PLUM ART 36015 $ 377.34 SEL CATH PLCMT VENOUS; 1ST ODR 36011 $ 342.32 SEL CATH PLCMT VENOUS; 1ST ORD 36011 $ 342.32 SEL CATH PLCMT VENOUS; 2ND ORD 36012 $ 378.20 SEL CATH PLMT ART 1ST ORD THOR 36215 $ 464.33 SEL CATH PLMT ART 2ND ORD THOR 36216 $ 591.76 SEL CATH PLMT ART 2ND ORDR ABD 36246 $ 550.42 SEL CATH PLMT ART 3RD ORD THOR 36217 $ 705.76 SEL CATH PLMT ART 3RD ORDR ABD 36247 $ 657.82 SEL CATH PLMT ARTADD 2/3D BEYD 36218 $ 112.55 SEL CATH PLMT ARTADD 2/3RD ABD 36248 $ 107.76 SELECT CATH PLCMT LT/RT PULM ART 36014 $ 329.23 SELECT PICTURE AUDIOMETRY 92583 $ 84.11 SELEGELINE 5 MG. PO Acquisition cost SELENIUM (BLOOD) 84255 $ 69.34 SELENIUM (URINE) 84255 $ 69.34 SELENIUM 40MCG/ML IV Acquisition cost SELENIUM SULF 2.5% LOTION TOP Acquisition cost SELENIUM SULFIDE 120ML SHAMPOO Acquisition cost SELENIUM SULFIDE 2.5% LOT TOP Acquisition cost SELF CARE TRAIN-ONE-ON-ONE; 1 UNIT 97535 $ 74.95 SELF CENTERING HIP 43/28 Acquisition cost SELF PRESSURIZ GLENOID SIZE 44 C1713 $ 5,904.00 SELF TAPPING LOCKING SCREW 3.5x16MM C1713 $ 259.50 Page 266 2018 SELFCARE CURRENT STATUS - OT G8987 Acquisition cost SELFCARE CURRENT STATUS - PT G8987 Acquisition cost SELFCARE DISCHARGE STATUS - OT G8989 Acquisition cost SELFCARE DISCHARGE STATUS - PT G8989 Acquisition cost SELFCARE GOAL STATUS - OT G8988 Acquisition cost SELFCARE GOAL STATUS - PT G8988 Acquisition cost SELF-CARE MGMT TRAINING 23 TO 37 MIN. 97535 $ 74.95 SELF-CARE MGMT TRAINING 38 TO 52 MIN. 97535 $ 74.95 SELF-CARE MGMT TRAINING 53 TO 68 MIN. 97535 $ 74.95 SELF-CARE MGMT TRAINING 8 TO 22 MIN. 97535 $ 74.95 SELFDRILL SCRW BONE 1.5X4MM C1713 $ 147.00 SELF-DRILLING PIN 4x90x10MM C1713 $ 450.00 SELF-HELP/PEER SVC PER 30MIN H0038 $ 275.00 SELF-TAPPING LOCKING SCREW 3.5x16MM C1713 $ 259.50 SELLA CT WITH CONTRAST 70481 $ 668.38 SELLA CT WITH AND WITHOUT CONTRAST 70482 $ 668.38 SELLA CT WITHOUT CONTRAST 70480 $ 302.70 SELLA TURCICA 70240 $ 164.27 SEMEN ANALYSIS 89320 $ 32.74 SEMEN COUNT 89320 $ 32.74 SEMEN COUNT. 89320 $ 32.74 SENNA 187MG (8.6MG SENNOSID) TAB Acquisition cost SENNA TABLETS Acquisition cost SENNA/SUCROSE PREP LIQUID 74ML PO Acquisition cost SENSOR TIP-CATEG 1 Acquisition cost SENSORCAINE/MARCAINE 0.75% Acquisition cost SENSOR-CATEG 1 Acquisition cost SENSOR-CATEG 2 Acquisition cost SENSORIMOTOR EXAM 92060 $ 147.99 SENSORIMOTOR EXM W/INTERPRETN 92060 $ 147.99 SENSORINEURAL ACUITY TEST 92575 $ 84.11 SENSORY INTEGRATION 97533 $ 74.32 SENSRY INTEGRAT TECH-1:1-EA 15 MIN 97533 $ 74.32 SENTINAL NODE ID; RAD TRACER 38792 $ 924.11 SEO MB A 1SP A/H SP OHD LB 4A/H SL SP E2630 $ 990.00 SEP ACC MECH REM OBSTR CVAD 36595 $ 6,592.23 SEPART LAB ADHES 56441 $ 6,010.51 SEPRAFILM ADHESION BARRIER 5"X6" C1765 $ 436.39 SEPTOCAINE W/ EPINEPHRINE AMP 1:100,000 Acquisition cost SEPTOPLASTY OR SUBMUCOUS RESECT 30520 $ 5,815.59 SEPTOPLASTY/SUBMUCOS RES W/GFT 30520 $ 5,815.59 SEPTRA DESENSITIZATION 8 DAYS Acquisition cost SEPTRA RAPID DESENSITIZATION Acquisition cost SEPTRA/BACTRIM 400-80MG/5ML5ML Acquisition cost SEQUESTRECTOMY FOR OSTECTOMY D7550 $ 1,960.00 SERENTIL 10MG TAB Acquisition cost SERENTIL 25MG TAB Acquisition cost SEREVENT INHALER 13GM Acquisition cost SERIAL TONOMETRY 92100 $ 74.84 SERIAL TONOMETRY-SEP PROC W/I/R 92100 $ 74.84 SEROMYCIN 250 MG. PO Acquisition cost SEROMYCIN 250MG CAP Acquisition cost SEROPHENE/CLOMED 50MG TAB Acquisition cost SEROQUEL 50mg (SCC ONLY) Acquisition cost SEROQUEL XR 150MG. PO Acquisition cost SEROQUEL XR 200 MG. PO Acquisition cost Page 267 2018 SEROQUEL XR 300MG. PO Acquisition cost SEROQUEL XR 50 MG. PO Acquisition cost SEROQUEL; XR 400MG. PO Acquisition cost SEROTONIN LEVEL 84260 $ 84.15 SERUM BACT SCHLICHTER 87197 $ 40.81 SERUM IMMUNOELECTRO. 86320 $ 65.82 SERUM IMMUNOFIXATION ELECTROPHORES 86334 $ 60.70 SERUM LEVEL (FUNGAL) 80299 $ 41.01 SERUM LOG-IN 86999 $ 46.20 SERUM PROTEIN ELECTROPHORESIS 84165 $ 29.17 SESAMOIDECTOMY; FIRST TOE 28315 $ 6,995.52 SET BLOOD-CATEG 1 Acquisition cost SET BLOOD-CATEG 2 Acquisition cost SET CALCIUM SULFATE TAB-CATEG 1 Acquisition cost SET CATH SNGL LUMEN-CATEG 1 Acquisition cost SET CATHETER ARROW-CATEG 1 Acquisition cost SET CATHETER EPIDURAL-CATEG 1 Acquisition cost SET CATHETER-CATEG 1 Acquisition cost SET CLIP FIXING DEVICE-CATEG 1 Acquisition cost SET C-SECTION-CATEG 1 Acquisition cost SET FILTER/EXT-CATEG 1 Acquisition cost SET 'H' FILTERLINE-CATEG 1 Acquisition cost SET I.V. ADMIN-CATEG 1 Acquisition cost SET INFUSION TURBO TRACKER-CATEG 1 Acquisition cost SET INFUSION-CATEG 1 Acquisition cost SET INTRODUCER-CATEG 1 Acquisition cost SET LATEX FREE C-SCTN-CATEG 1 Acquisition cost SET LATEX FREE L/D-CATEG 1 Acquisition cost SET OMNIFLOW PRIMARY-CATEG 1 Acquisition cost SET PANCREATIC STENT-CATEG 1 Acquisition cost SET PICC-CATEG 1 C1751 Acquisition cost SET PLUM IV NITRO-CATEG 1 Acquisition cost SET SCREW C1713 $ 112.50 SET SPINAL-CATEG 1 C1820 Acquisition cost SET SURGERY-CATEG 1 Acquisition cost SET TUBE ARTHRO-CATEG 1 Acquisition cost SET VAGINAL-CATEG 1 Acquisition cost SETINS/RP/REPOS PERMTRNSV DUAL CH 33217 $ 19,493.14 SET-TUR Y - CATEG 1 Acquisition cost SEVELAMER (RENAGEL) 400MG TAB Acquisition cost SEVELAMER (RENAGEL) 800MG TAB Acquisition cost SEVELAMER 403MG GELCAP PO Acquisition cost SEVELAMER CARBONATE 800 MG Acquisition cost SEVERING ADHES ANT SEG LASR TE 65860 $ 1,290.50 SEVERING VITREOUS STRANDS-LASER 67031 $ 1,290.50 SEVOFLURANE ANESTHETIC SOL Acquisition cost SEWHO ABDUCT POSITION, AIRPLANE DSIGN L3960 $ 1,221.62 SEWHO ABDUCT POSITION, ERBS PALSY DSIGN L3962 $ 1,162.72 SEWHO MLD SHLD,ARM,4ARM,WRST W ART LB JT L3978 $ 2,950.99 SEX DETERMINATION SCREENING 88130 $ 48.82 SEX HORMONE BINDING GLOBULIN 84270 $ 59.03 SEXA BONE DENSITY, PERIPH G0130 $ 302.70 SGL/MULTI INJ SPIDER VEIN; LIMB/TRNK 36468 $ 446.80 SGMDSC W/BAND LIGATION 45350 $ 2,476.36 SGOT 84450 $ 14.06 SGPG IGM 83520 $ 37.99 Page 268 2018 SGPT 84460 $ 14.39 SHAFT ANGLED STIFF-CATEG 1 Acquisition cost SHAFT ANGLED STIFF-CATEG 2 Acquisition cost SHAFT DIAMOND-CATEG 1 C1725 Acquisition cost SHAV 1 LES FACE EAR LIP; 1.1-2.0 CM 11312 $ 821.94 SHAV 1 LES FACE EAR LIP;0.5 CM/LESS 11310 $ 446.80 SHAV 1 LES FCE EAR LIP; 1.1-2.0 CM 11312 $ 821.94 SHAV 1 LES FCE EAR LIP;0.5 CM/LESS 11310 $ 446.80 SHAV 1 LES TRNK ARM/LEG; 0.6-1.0 CM 11301 $ 446.80 SHAV EPID/DER SCLP NECK HND>2. 11308 $ 821.94 SHAV EPID/DER TRNK ARM LEG >2. 11303 $ 821.94 SHAV EPID/DER TRNK ARM LEG 1.1 11302 $ 446.80 SHAV SKIN LESION, 0.6-1.0CM 11311 $ 446.80 SHAVE S/N/H/F/G; SING LES, 0.5cm or less 11305 $ 446.80 SHAVE S/N/H/F/G; SING LES, 0.6-1.0cm 11306 $ 446.80 SHAVE S/N/H/F/G; SING LES, over 2.0cm 11308 $ 821.94 SHAVE S/N/H/F/G; SINGLE LES, 1.1-2.0cm 11307 $ 446.80 SHAVE T/A/L; SING LES, 0.5cm or less 11300 $ 446.80 SHAVE T/A/L; SINGLE LESION, 0.6-1.0cm 11301 $ 446.80 SHAVE T/A/L; SINGLE LESION, 1.1 - 2.0cm 11302 $ 446.80 SHAVE T/A/L; SINGLE LESION, over 2.0cm 11303 $ 821.94 SHAVG SKIN LESION, >2.0CM 11313 $ 821.94 SHAVING SKIN LES .6-1CM 11306 $ 446.80 SHAVING SKIN LES <.6CM 11305 $ 446.80 SHAVING SKIN LES 1.1-2CM 11307 $ 446.80 SHAVING SKIN LESION, >2.0CM 11313 $ 821.94 SHAVING SKIN LESION, 0.6-1.0CM 11311 $ 446.80 SHEATH BALKIN-CATEG 1 Acquisition cost SHEATH BRITE TIP-CATEG 2 Acquisition cost SHEATH CHECK FLO-CATEG 1 Acquisition cost SHEATH INTRO FLX BALKIN-CATEG 1 C1885 Acquisition cost SHEATH INTRO FLX-CATEG 1 Acquisition cost SHEATH INTRO-CATEG 1 Acquisition cost SHEATH INTRODUCER-CATEG 1 Acquisition cost SHEATH OPTA-CATEG 1 Acquisition cost SHEATH PEEL AWAY-CATEG 1 Acquisition cost SHEATH PINNACLE-CATEG 1 Acquisition cost SHEATH RENAL-CATEG 1 Acquisition cost SHEATH SHORT-CATEG 1 Acquisition cost SHEATH/DIL LOCK-CATEG 1 Acquisition cost SHEATH/DIL SNAP / PEEL AWAY-CATEG 1 Acquisition cost SHEATH-CATEG 1 Acquisition cost SHEETING SILICONE REINFORCED-CATEG 1 Acquisition cost SHELL 44MM C1776 $ 1,149.00 SHELL 44MM C1776 $ 1,149.00 SHELL ACET 38MM C1776 Acquisition cost SHELL ACETAB-CATEG 1 C1776 Acquisition cost SHELL BIPOLAR-CATEG 1 C1813 Acquisition cost SHELL BIPOLAR-CATEG 2 C1813 Acquisition cost SHELL FLARED-CATEG 1 C1813 Acquisition cost SHELL UNI-CATEG 1 Acquisition cost SHELL VIAL TECHNIQUE 87252 $ 70.80 SHELL W/CLUSTER HOLES Acquisition cost SHELL W/CLUSTER HOLES 54MM C1776 $ 1,200.00 SHELL W/CLUSTER HOLES 58MM C1776 $ 3,801.00 SHELL W/CLUSTER HOLES 66MM C1776 $ 2,971.50 Page 269 2018 SHELL WITH CLUSTER HOLES 58MM C1776 $ 3,801.00 SHERPA NX ACTIVE CATH C1887 $ 67.50 SHIGA-LIKE TOXIN DETECTION 87427 $ 32.56 SHILEY 4.0 NEONATAL TRACH TUBE A4624 $ 47.40 SHINGRIX (ZOSTER VAC RECOMB) $ 0.10 SHLDR CAPSULOR ARTHROSCOPY 29806 $ 14,826.61 SHORT ARM DYNAMIC SPLINT 29126 $ 277.79 SHORT LEG CAST 29405 $ 627.51 SHORT NEEDLE ELECTRODE 40/BX C2618 $ 66.95 SHORT SCREW 5.5 MMxVARIOUS C1713 $ 425.25 SHORT SCREW 5.5MM X C1713 $ 425.25 SHORT SCREW 5.5MMxVARIOUS C1713 $ 425.25 SHORT SCREW 7MM X C1713 $ 513.45 SHORT SCREW 7MMxVARIOUS C1713 $ 513.45 SHORT THREAD SCREW 7.5MMX65MM C1713 $ 412.50 SHORT THREAD SCREW 7.5x65MM C1713 $ 412.50 SHORTEN METATRSAL; NOT 1ST MT 28308 $ 6,995.52 SHORTENING OF RADIUS OR ULNA 25390 $ 14,826.61 SHORT-LATENCY SOMATOSENSRY 95925 $ 658.04 SHOULDER 1 VIEW 73020 $ 164.27 SHOULDER ANCHORS C1713 $ 592.50 SHOULDER ARTHROSCOPY DX 29805 $ 6,995.52 SHOULDER ARTHRSCPY/SURGERY 29826 $ 378.53 SHOULDER COMP. 73030 $ 164.27 SHOULDER HUMERAL COMP 11MMx7 STEM C1776 $ 6,885.00 SHOULDER HUMERAL HEAD C1776 $ 1,475.10 SHOULDER MUMFORD PROCEDURE 29824 $ 6,995.52 SHOULDER PEGGED #5 GLENOID COMPONENT C1776 $ 1,356.30 SHOULDER STRAPPING 29240 $ 277.79 SHOULDR HUMERL COMP 11MMX7STEM C1776 $ 6,885.00 SHRTEN FLEXR TENDON HAND/FING; EA TENDON 26479 $ 3,570.03 SHTLTNCY SOMT EPS,STMNRV/SKN SITES;LW LB 95926 $ 658.04 SHTLTNCY SOMT EPS,STMNRV/SKN SITES;UP LB 95925 $ 658.04 SHTLTNCY SOMT EPS,STMNV/SKN SITES;TRK/HD 95927 $ 360.51 SHUNT-CATEG 1 C1788 Acquisition cost SHUNTOGM-PREV PLCED NONVASC-RS/I 75809 $ 302.70 SI ENDO W ABALATION TUM/POLYP/ 44369 $ 3,774.85 SI JNT INJ; ANESTH/STEROID G0260 $ 1,437.02 SI POLYAXL EXT TAB SCREW 6MM X C1713 $ 1,575.00 SI POLYAXL SCREW 6MM EXPEDIUM TI C1713 $ 1,582.50 Sialodochoplasty D7982 $ 2,804.00 SIALOGRAPHY-RAD S / I 70390 $ 614.37 SIALOLITHOTMY; SUBMANDIB; COMP 42335 $ 5,815.59 SIALOLITHOTOMY D7980 $ 1,042.00 SIALOLITHOTOMY; SUBMANDIB; UNC 42330 $ 5,815.59 SICKLE CELL TEST 85660 $ 14.96 SICKLING OF RBC REDUCTION 85660 $ 14.96 SIDEROCYTES PERIPH-B 85536 $ 17.56 SIG W/BALLOON DIL;1+STRICTURES 45340 $ 2,476.36 SIGMOID ABLATION OF TUMOR/LASE 45346 $ 2,476.36 SIGMOID CONTROL OF BLEED 45334 $ 2,476.36 SIGMOID FB REMOVE 45332 $ 2,476.36 SIGMOID W REM PLYP SNARE 45338 $ 2,476.36 SIGMOIDOSCOPY FLEX; DX-SEP PRO 45330 $ 1,877.59 SIGMOIDOSCOPY W/ RESECTION 45349 $ 2,476.36 SIGMOIDOSCOPY W/US GUIDE BX 45342 $ 2,476.36 Page 270 2018 SIGMOIDOSCOPY; W SUBMUC INJ 45335 $ 1,877.59 SIGMOIDOSCPY W FB REMOV 45332 $ 2,476.36 SIGMOIDOSCPY; W ULTRASOUND ENDO 45341 $ 2,476.36 SIGN LANG/INTERPRETER/15 MIN T1013 $ 275.00 SIGNAL AVERAGE EKG 93278 $ 147.99 SILFAMYLON CREAM 60GM Acquisition cost SILIC KNEE 70 FEM STAGE 1CEMNT C1776 $ 3,790.50 SILICONE FLAT DRAIN 7MM 15FR C1729 $ 110.33 SILICONE IMPLANTS SIZE 40 C1789 $ 1,350.00 SILICONE IMPLANTS SIZE 40 C1789 $ 1,350.00 SILICONE SHEET 0.25MM, 10/BX* C1781 $ 31.20 SILICONE SHEETING C1781 $ 303.00 SILITHMY SBMNDR (SBMAX SBLGL PRTD UNCMP) 42330 $ 5,815.59 SILK, BLACK BRAIDED C1713 $ 11.34 SILKNEETIB STGE1 CEM SPACR MLD C1776 $ 3,192.00 SILVER NITR STICKS 100/TUBE $ 1.46 SILVER NITRATE STICKS Acquisition cost SILVER SULFADIAZ 1% CREAM 50 GM Acquisition cost SILVER SULFADIZE CREAM 1% $ 21.96 SILVERHAWK PERIPH CATH LS6CM TIP P-ART C1714 $ 5,992.50 SILVERHAWK PERIPH CATH MS 6CM P-ARTERIES C1714 $ 5,992.50 SILVERHK PERIPH CATH SS 2.6 CM P-ART C1714 $ 5,992.50 SILVERHK PERIRAL CATH SX 4.3CM FOR P-ART C1714 $ 5,992.50 SIMETHICONE 333mg/5ml Acquisition cost SIMETHICONE 40MG/0.6ML PO DROPS Acquisition cost SIMP REP WND F/E/N/E/L/MM; 2.6-5.0 CM 12013 $ 446.80 SIMP RPR WND F/E/N/E/L/MM; 2.5 CM/< 12011 $ 446.80 SIMP RPR WND S/N/A/G/T/EXT; 7.6-12.5 CM 12004 $ 446.80 SIMPL CYSTOMETROGRAM 51725 $ 607.00 SIMPL REPR FACE//MUCOUS; < 2.5 CM 12011 $ 446.80 SIMPL REPR FACE//MUCOUS; > 30.0 CM 12018 $ 446.80 SIMPL REPR SCLP&/TRUNK; < 2.5 12001 $ 446.80 SIMPL REPR SCLP//TRUNK; > 30.0 CM 12007 $ 446.80 SIMPL REPR SCLP//TRUNK; 2.6-7.5 CM 12002 $ 446.80 SIMPL RPR F/E/E/N/L/MM; 7.6-12.5CM 12015 $ 446.80 SIMPL UROFLOWMETRY 51736 $ 277.79 SIMPLE BLADDER IRRIGATE LAVAGE/INSTILL 51700 $ 607.00 SIMPLE I&D EAR ABSC/HEMA 69000 $ 1,514.94 SIMPLE I/D EAR ABSC HEMA 69000 $ 1,514.94 SIMPLE I/D EAR ABSC/HEMA 69000 $ 1,514.94 SIMPLE INC/RMVL SUBCU FB 10120 $ 821.94 SIMPLE UFR 51736 $ 277.79 SIMPLE URETHRAL CATH 51701 $ 277.79 SIMPLE WND REP 12.6-20CM 12005 $ 821.94 SIMPLE WND REP 2.5-7.5CM 12002 $ 446.80 SIMPLE WND REP 2.6-5 CM 12013 $ 446.80 SIMPLE WND REP 20-30 CM 12006 $ 821.94 SIMPLE WND REP 5-7.5 CM 12014 $ 446.80 SIMPLEX P WITH TOBRAMYCIN STRYKER J3260 $ 0.62 SIMVASTATIN (ZOCOR) 10MG TAB Acquisition cost SIMVASTATIN (ZOCOR) 20MG TAB Acquisition cost SIMVASTATIN (ZOCOR) 40MG TAB Acquisition cost SINCALIDE 5 MCG INJ. (KINEVAC) INJ J2805 $ 267.08 SINCALIDE 5MCG INJ Acquisition cost SINEMET CR 25/100 MG TAB Acquisition cost SINEMET CR 50/200MG TAB Acquisition cost Page 271 2018 SINEQUAN/ADAPIN 50MG CAP Acquisition cost SING/DUAL LUMEN PICC C1751 $ 216.30 SINGL SITE LAPAROS SEAL CAP A4649 $ 1,080.00 SINGLE LUMEN 4FR CT PICC 80CM GW 5/BX C1751 $ 210.00 SINGLE LUMEN CATH PERC KIT C1729 $ 411.82 SINGLE RADIUS HUMERAL HEAD C1776 $ 4,384.50 SINOGRAFIN INJ 10ML VIAL Acquisition cost Sinus augmentation w/bone D7951 $ 1,400.00 SINUS ENDO W/BALLOON DIL FRONTAL SINUS 31296 $ 12,863.66 SINUS ENDO W/BALLOON DIL MAX SINUS 31295 $ 12,863.66 SINUS ENDO W/BALLOON DIL SPHENOID SINUS 31297 $ 12,863.66 Sinuses CT with and without Contrast 70488 $ 668.38 Sinuses CT with Contrast 70487 $ 668.38 Sinuses CT without Contrast 70486 $ 302.70 SINUSES PARANASAL COMPLETE 70220 $ 164.27 SINUSES PARANASAL PARTIAL 70210 $ 164.27 SINUSOIDAL ROTATIONAL TEST 92546 $ 360.51 SINUSOTOMY FRONT; OBLIT WO BROW INC 31080 $ 11,474.25 SINUSOTOMY FRONTAL; EXTERN; SIMP 31070 $ 11,474.25 SINUSOTOMY MAXILLARY; INTRANASAL 31020 $ 5,815.59 SINUSOTOMY, SPHENOID; W/WO BX 31050 $ 11,474.25 SINUSTMY; SPENOID; W/WO BX; W POLYP REM 31051 $ 11,474.25 SIROLIMUS 1 MG. PO Acquisition cost SISI HEARING TEST 92564 $ 46.20 SITAGLIPTAN 100MG. PO Acquisition cost SITAGLIPTIN (JANUVIA) 100MG. Acquisition cost SITAGLIPTIN (JANUVIA) 25 MG. Acquisition cost SITAGLIPTIN (JANUVIA) 50MG. Acquisition cost SITAGLIPTIN 50MG TABLET J3490 Acquisition cost SITAGLIPTIN 50MG TABS Acquisition cost SITAGLIPTIN/METFORMIN 50/1000MG Acquisition cost SITAGLIPTIN/METFORMIN 50/500MG Acquisition cost SIZE 11 STEM Acquisition cost SIZE 16 STEM Acquisition cost SIZE 2 10MM MEDIAL PIVOT TIBIA Acquisition cost SIZE 2 LEFT FEMORAL IMPLANT Acquisition cost SIZE 2 TIBIAL BASE Acquisition cost SIZE G LINER #57779400 Acquisition cost SIZE GxLPE 20 DEGREE LINER C1776 $ 1,725.00 SIZE J LINER #59950900 Acquisition cost SJOGREN'S ANTIBODY 86235 $ 48.71 SKIN FULL GRFT F/G/HF/A; 20 SQ CM/> 15240 $ 4,147.84 Skin grafts, by report D7920 $ 3,620.00 SKIN SPLT GRFT TRNK/ARM/LEG 00SQ CM/1%BA 15100 $ 4,147.84 SKIN SUB GRFT F/N/HF/G; ADDL 15276 $ 55.22 SKIN SUB GRFT F/N/HF/G; UP TO 100 SQ CM 15275 $ 4,147.84 SKIN SUB GRFT TRNK/A/L; UP TO 100 SQ CM 15271 $ 4,147.84 SKIN TEST INTRADERMAL TB 86580 $ 46.20 SKIN TEST INTRADML TB 86580 $ 46.20 SKIN TEST; CANDIDA 86485 $ 84.11 SKIN TEST; TB INTRADERMAL 86580 $ 46.20 SKIN TEST; TUBERCULOSIS INTRADERMAL 86580 $ 46.20 SKIN TEST; TUBERCULOSIS TINE TEST 86580 $ 46.20 SKIN TEST; UNLISTED ANTIGEN EA 86486 $ 46.20 SKIN TIS REARRANG/TRNSFR; ADDL 30.0SQ CM 14302 $ 476.52 SKIN TONER CONDITIONING SLTN $ 59.40 Page 272 2018 SKIN TONER CONDITIONING SOLUTION Acquisition cost SKINTEGRITY-CATEG 1 Acquisition cost SKN SUB GRFT TRNK/A/L; ADD-ON 15272 $ 38.28 SKULL PARTIAL 70250 $ 302.70 SKULL COMPLETE 70260 $ 302.70 SKY 2 LEVEL ANTER CERV PLATE C1713 $ 1,911.00 SKY 3 LEVEL ANTER CERV PLATE C1713 $ 2,076.75 SKY 3 LEVEL TI SKYLINE; ANT CERV PLATE C1713 $ 2,076.75 SKY CNSTRND S-D SCRW14MM TI; ANT CRV PLT C1713 $ 394.88 SKY VARI CSD SCRW TI; ANT CERV PLATE C1713 $ 58.50 SKY VARIABLE SCRW TI ANT PLATE C1713 $ 394.87 SKY VARIB S-D SCRW 16MM TI; ANT CERV PLT C1713 $ 394.88 SKY1 LVL PLT 12MM TI SKYLINE ANT CRV PLT C1713 $ 394.88 SKY1 LVL PLT 16MM TI SKYLINE ANT CRV PLT C1713 $ 1,755.00 SKY1 LVL PLT 20MM TI SKYLINE ANT CRV PLT C1713 $ 1,755.00 SKY2 LVL TI SKYLINE ANT CERV PLATE C1713 $ 1,911.00 SL GRAFTCH R5MM LORD CORT SPCR C1768 $ 1,434.38 SLCTV WIND DEBRIDMEN 20 CM OR < 97597 $ 446.80 SLEEP STUDY, ATTENDED 95807 $ 1,175.22 SLEEP STUDY, UNATTENDED 95806 $ 360.51 SLEEVE CENTRALIZE-CATEG 1 Acquisition cost SLEEVE COMPRESSION-CATEG 1 Acquisition cost SLEEVE NEOPRENE-CATEG 1 Acquisition cost SLEEVE NEOPRENE-CATEG 2 Acquisition cost SLEEVE SHOULD TRACT ADD ROT6CS C1713 $ 150.00 SLEEVE SMIT-CATEG 1 Acquisition cost SLEEVE TAPER-CATEG 1 Acquisition cost SLEEVE UNIPOLAR-CATEG 1 Acquisition cost SLGRAFTEC R 6MMLORD CORT SPACR C1768 $ 1,434.38 SLIDE REV W/SL PREP 88323 $ 118.21 SLIDE REV+RPT REF SLIDES 88321 $ 84.11 SLIDE REVIEW W/RECORDS 88325 $ 118.21 SLIDE TEST CHLAMYDIA 87206 $ 14.63 S-LIFT IMPLANT 10X 38 C1713 $ 1,291.50 SLING ARM-CATEG 1 Acquisition cost SLING ARM-CATEG 2 Acquisition cost SLING CANVAS-CATEG 1 Acquisition cost SLING OP - STRESS INCONTINENCE (FEMALE) 57288 $ 10,873.98 SLING ULTRA-CATEG 1 Acquisition cost SLING ULTRA-CATEG 2 Acquisition cost SLING ULTRA-CATEG 3 Acquisition cost SLING/MESH FGS C1781 $ 750.00 SLING/MESH FGS C1781 $ 750.00 SLING-CATEG 1 C1813 Acquisition cost SLINGS A4565 $ 6.89 SLIT PREPUCE DORSAL OR LAT; NOT NEWBORN 54001 $ 4,484.35 SLITTING PREPUCE DORS/LAT; NEWBORN 54000 $ 4,484.35 SLO-BID 100MG CAP Acquisition cost SLO-BID 200MG CAP Acquisition cost SLO-BID 300MG CAP Acquisition cost SLO-BID 50MG CAP Acquisition cost SLO-NIACIN 250 MG TAB Acquisition cost SLOTTED WIRE FIXATION BOLT* C1713 $ 363.00 SM INT ENDOSC W ILEUM W BX; SNGL/MULTI 44377 $ 3,774.85 SM INTEST ENDO W BLEED CONTROL 44366 $ 3,774.85 SM INTEST ENDO; W/GASTRO TO JEJUNO 44373 $ 3,774.85 Page 273 2018 SM INTESTINAL ENDO NOT ILEUM; 44361 $ 3,774.85 SM INTESTINE ENDO W REM T/P/L BY SNARE 44364 $ 3,774.85 SM INTST ENDO; DX W/WO SPEC COLL 44376 $ 3,774.85 SM JNT/BRSA; DRAIN/INJECT 20600 $ 647.13 SM-153 RADPHRM TX LEXIDRONAM / 50 MCI A9604 $ 29,405.93 SMALL ARTICULAR SURFACE Acquisition cost SMALL BOWEL/MULTIPLE FILMS 74250 $ 302.70 SMALL FEMUR C1776 $ 2,092.50 SMART BILIARY STENT 6x120MM; CORDIS C1876 $ 2,900.25 SMART CONTROL ELIAC STENT 6x40ML; CORDIS C1876 $ 2,097.75 SMART CTRL ELIAC STENT 6x100ML; CORDIS C1876 $ 2,645.25 SMART PORT LOW PROFILE C1788 $ 556.20 SMART STENT 10x40MM CONTROL ELIAC VASC C1876 $ 2,097.75 SMART STENT 7FR 12X30MM VASC C1876 $ 2,617.50 SMART STENT 7x40 CORDIS C1876 $ 2,097.75 SMOKE EVACUATR TUBING ST STRL A4624 $ 310.65 SMOKING CESSATION 3-10 MIN 99406 $ 67.97 SMOKING CESSATION,>10MIN GROUP 99407 $ 67.97 SMOKING CESSATION,MORE THAN10M 99407 $ 67.97 SMPL CHANGE CYSTOST TUBE 51705 $ 607.00 SMPL DRAIN FING ABSCESS 26010 $ 446.80 SMPL REP WND S/A/N/G/T/E; 20.1-30 CM 12006 $ 821.94 SMPL RPR WND E/F/E/N/L/MM; 5.1-7.5CM 12014 $ 446.80 SMPL WND REP 7.5-12.5 CM 12004 $ 446.80 SMPL WND REP 7.6-12.5 CM 12015 $ 446.80 SNARE DISP-CATEG 1 Acquisition cost SNARE POLYPECTOMY-CATEG 1 C1887 Acquisition cost SNGL EAR/PULSE OXIMETRY 94760 $ 3.80 SNIP INCS LACRIMAL PUNCTUM 68440 $ 707.85 SNS LEAD KIT INSTERSTIM C1778 $ 4,740.00 SNSRY TSTNG W FLX/ENDO SWLW FNCTN-FEEST 92614 $ 310.51 SOD BICARBNATE 8.4% INJ J3490 $ 555.72 SOD CHL 9% 100ML ADV#7101-23 $ 2.50 SOD CHL 9% 250ML ADV#7101-02 $ 2.93 SOD CHL 9% 50ML ADV#7101-13 $ 2.12 SOD CL .9% INJ. $ 9.57 SOD CL 5% 500 $ 7.77 SOD CL 9% POR 250 #6138-02 $ 1.37 SOD CL 9% POR 500 #6138-03 $ 1.50 SOD CL NEBULIZING SOL 0.9% 3ML Acquisition cost SOD CL NEBULIZING SOL 3% 15ML Acquisition cost SOD CL.45%INJ 1000 #7985-09 $ 1.52 SOD CL.45%INJ 500 #7985-03 $ 1.35 SOD CL.9%INJ 100 #7984-23 $ 1.99 SOD CL.9%INJ 1000 #7983-09 $ 2.99 SOD CL.9%INJ 250 $ 1.12 SOD CL.9%INJ 3000 $ 9.33 SOD CL.9%INJ 50 #7984-13 $ 1.99 SOD CL.9%INJ 500 #7983-03 $ 1.22 SOD HYALURONATE 10MG/ML 0.85ML Acquisition cost SOD POLYST SULF ENEMA Acquisition cost SOD POLYSTYRENE ENEMA Acquisition cost SOD THIOSULF/SOD NIT/AMYL NIT Acquisition cost SODIUM 84295 $ 13.07 SODIUM STOOL 84300 $ 13.20 SODIUM ACETATE 150 mEq/1000 mL $ 0.10 Page 274 2018 SODIUM ACETATE 2MEQ/ML Acquisition cost SODIUM BF 84295 $ 13.07 SODIUM BICAR 4.2% 10ML Acquisition cost SODIUM BICAR 650MG TAB Acquisition cost SODIUM BICAR 7.5% 50ML Acquisition cost SODIUM BICAR 8.4% INJ 50ML Acquisition cost SODIUM BICARBONATE 2.1% 500ML Acquisition cost SODIUM BICARBONATE 5% 500ML Acquisition cost SODIUM BICARBONATE 8.4% 10ml Acquisition cost SODIUM BICARBONATE 8.4% 50ML Acquisition cost SODIUM BICARBONATE INJ 8.4% 100 ML $ 0.10 SODIUM BICARBONATE PERIFERAL IV Acquisition cost SODIUM BICARBONATE VIAL Acquisition cost SODIUM CHLOR 0.9% 1000ML J7040 $ 1.50 SODIUM CHLORD 0.9% INJ. 10ML $ 1.80 SODIUM CHLORIDE #798-309-CATEG 1 Acquisition cost SODIUM CHLORIDE (NACL) 0.9% 3ML SYR Acquisition cost SODIUM CHLORIDE 0.45% 500ML IV Acquisition cost SODIUM CHLORIDE 0.45% 1000 ML Acquisition cost SODIUM CHLORIDE 0.45% INJ Acquisition cost Sodium Chloride 0.45%. 1000 ml Bag Acquisition cost SODIUM CHLORIDE 0.9% (NACL) 50ML IV J7040 Acquisition cost Sodium Chloride 0.9% + 40meq. KCL J3480 Acquisition cost SODIUM CHLORIDE 0.9% 1000 ML J7030 Acquisition cost SODIUM CHLORIDE 0.9% 100ML IV Acquisition cost SODIUM CHLORIDE 0.9% 500ML IV J7040 Acquisition cost SODIUM CHLORIDE 0.9% INJ J7030 Acquisition cost SODIUM CHLORIDE 0.9% INJ 10ML Acquisition cost SODIUM CHLORIDE 0.9%250ML IV J7050 Acquisition cost SODIUM CHLORIDE 100ml IV BAG Acquisition cost SODIUM CHLORIDE 10ML-CATEG 1 Acquisition cost SODIUM CHLORIDE 1GM TAB Acquisition cost SODIUM CHLORIDE 2% EYE DROPS Acquisition cost SODIUM CHLORIDE 23.4% INJ 30ML Acquisition cost SODIUM CHLORIDE 3% J7131 Acquisition cost SODIUM CHLORIDE 3%-CATEG 1 Acquisition cost SODIUM CHLORIDE 45% 1000 Acquisition cost SODIUM CHLORIDE 45%-CATEG 1 Acquisition cost SODIUM CHLORIDE 5% EYE DROPS Acquisition cost SODIUM CHLORIDE 5%-CATEG 1 Acquisition cost SODIUM CHLORIDE 9%-CATEG 1 Acquisition cost SODIUM CHLORIDE FLUSH Acquisition cost SODIUM CITRATE + CITRIC ACID-ORAL PEDS Acquisition cost SODIUM CL IRRIG 0.9% 1000ML Acquisition cost SODIUM FLUORIDE F-18 <= 30 MCI A9580 Acquisition cost SODIUM HYPOCHLORITE 0.25% (HALF STR) Acquisition cost SODIUM HYPOCHLORITE 0.5% (FULL STR) Acquisition cost Sodium Iodide 100mcg/ml 10ml vial Acquisition cost SODIUM IODIDE 100MCG/ML 10ML VIAL Acquisition cost SODIUM MORRHUATE 50MG/ML 30ML Acquisition cost SODIUM NITRITE 30MG/ML 10 ML VIAL Acquisition cost Sodium Nitrite 30mg/ml Injection Acquisition cost SODIUM PHOSPHATE 3MM/ML 15ML Acquisition cost SODIUM POLYSTENEMA 30GM Acquisition cost SODIUM TETRADECYL 1% IV Acquisition cost SODIUM TETRADECYL 3% IV Acquisition cost Page 275 2018 SODIUM THIOSULFATE 10% 10ML Acquisition cost SODIUM THIOSULFATE 25% 50 ML INECTION J3490 Acquisition cost SODIUM UR RANDOM 84300 $ 13.20 SODIUM UR T.V. 84300 $ 13.20 SODIUM/POTAS/SOD CHLOR EYE DROP Acquisition cost SODIUM/POTASSIUM 84132 $ 12.50 SODIUM/POTASSIUM/CAL/MAGNESIUM Acquisition cost SOF-FLEX 10FRDBLE PIGTAIL STNT C1876 $ 191.40 SOFOSBUVIR 400MG TAB Acquisition cost SOFT 14X12 POLY MESH 3/BX C1781 $ 2,049.12 SOFT TIPS 23 GUAGE NEEDLE DISP C2618 $ 372.60 SOFT TIS BX; BCK/FLANK; DEEP 21925 $ 3,564.97 Soft tissue allograft D4275 $ 840.00 SOFT TISSUE NECK MRA W/W/O CONTRAST 70549 $ 1,206.90 SOFT TISSUE NECK MRA WITH CONTRAST 70548 $ 668.38 SOFT TISSUE NECK MRA WITHOUT CONTRAST 70547 $ 614.37 SOFT TISSUE PATCH 10X15X2MM Acquisition cost SOFT URETER STENT W/WIR GUIDE C1876 $ 155.10 SOFT URETER STNT 8FR WIREGUIDE C1713 $ 167.10 SOLGANAL 50MG/ML INJ 10ML VIAL J2910 Acquisition cost SOLIFENACIN 10MG TABS Acquisition cost SOLIRIS 300MG INJ J1300 Acquisition cost SOLU-CORTEF 100MG INJ J1720 Acquisition cost Solu-Cortef 500mg. 4ml vial Acquisition cost SOLU-MEDROL 125MG INJ J2920 Acquisition cost SOLU-MEDROL 125MG INJECT J2930 $ 25.59 SOMATOMEDIN-C 84305 $ 57.75 SOMOPHYLLIN 105MG/5ML 240ML Acquisition cost SONES-CATEG 1 Acquisition cost SORBITOL SOLUTION 70% Acquisition cost SOTALOL (BETAPACE) 160MG TAB Acquisition cost SOTALOL (BETAPACE) 80MG TAB Acquisition cost SOTRADECOL 3% INJECTION Acquisition cost SP PUNCT TX DRAIN CEREBROSP FL 62272 $ 1,437.02 SP3 REFLECTION L8699 $ 2,625.00 SPACE MAINTAINER BILAT FIXED D1515 $ 665.00 SPACE MAINTAINER FIXED UNILATE D1510 $ 434.00 SPACE MAINTAINER REMOVABLE BIL D1525 $ 812.00 SPACE MAINTAINR RECEMENT D1550 $ 94.00 SPACE MAINTAINR UNILAT REMOVBL D1520 $ 630.00 SPACER ACF-CATEG 1 Acquisition cost SPACR BAG/RESRVOR METRD DOSE INHAL A4627 $ 118.10 SPEC ANT SEGMT PHOTO; W/MICRO/CNT 92286 $ 277.79 SPEC DOSIMETRY-PRESCRIB BY TX PHYS 77331 $ 331.50 SPEC ENZYME HISTOCHEMISTRY 88319 $ 1,430.62 SPEC STAINS-GROUP I 88312 $ 118.21 SPEC STAINS-GROUP II 88313 $ 84.11 SPEC TELETHERAP PORT PLAN PARTICLES 77321 $ 854.44 SPECIAL MED RADIATION PHYSICS CONS 77370 $ 331.50 SPECIAL STAINS-MICROORGANISMS (EACH) 88312 $ 118.21 SPECIAL STAINS-OTHERS 88313 $ 84.11 SPECIAL TX PROC 77470 $ 1,381.29 SPECIAL VIROLOGY FOLLOW UP 86689 $ 52.58 SPECIAL VIROLOGY SCREEN 86701 $ 24.13 SPECIF GRAVITY EX UR 84315 $ 7.22 SPECIFIC GRAVITY 84315 $ 7.22 Page 276 2018 SPECIFIC GRAVITY URINE 81005 $ 5.87 SPECIFIC GRAVITY BODY FLUID 84315 $ 7.22 SPECIFIC GRAVITY URINE AUTOMATED $ 4.90 SPECIFIC GRAVITY URINE DIPSTICK $ 4.90 SPECIMEN TRANSPORT 99001 $ 22.00 SPECTAZOLE 1% CR Acquisition cost SPECTINOMYCIN HCL 2GM INJ J3320 Acquisition cost SPEECH AUDIOMETRY, COMPLETE 92556 $ 84.11 SPEECH EVAL, COMPLEX 92611 $ 189.64 SPEECH LANG EVAL CINERADIOGRAPHY VIDEO 70371 $ 614.37 SPEECH THRESHOLD - AUDIOMETRY 92555 $ 84.11 SPEECH THRESHOLD AUDIOMETRY 92555 $ 84.11 SPEED LYSER CATHETER 15FR X 20CM C1881 $ 240.00 SPEEDBRG IMP SYS BIOCOM SWVLK C1713 $ 2,610.00 SPERM; CERV MUCOS PENETRAT 89330 $ 26.86 SPHENOPALATINE GANGLION 64505 $ 647.13 SPHERICAL HEAD SCREW 15MM C1713 $ 192.00 SPHERICAL SCREW 25MM C1713 $ 192.00 SPHINCTERTOME-CATEG 1 Acquisition cost SPHINCTERTOME-CATEG 2 Acquisition cost SPIN/FILTER PC P9016 $ 404.29 SPINAL CANAL MRA 72159 $ 196.17 SPINAL CANAL ULTRASOUND 76800 $ 302.70 SPINAL DISK SURG DISCECTOMY; NECK 63075 $ 14,826.61 SPINAL DISK SURGRY DISCECTMY; NCK ADDL 63076 $ 523.60 SPINAL PUNCT LUMBAR DX 62270 $ 1,437.02 SPINE 1VIEW SPECIAL LEVEL 72020 $ 164.27 SPINE BONE ALLOGRFT, MORSEL; ADD-ON 20930 $ 150.00 SPINE BONE AUTOGRFT, LOCAL; ADD-ON 20936 $ 150.00 SPINE DISK SURG ADD ON; EA ADD CERV/LUMB 63035 $ 406.45 SPINE FUSE&REMV CERV BELW C2, EA ADDL 22552 $ 844.16 SPINE FUSION WO DECOMPR; CERV BELOW C2 22554 $ 26,770.83 SPINEWAVE 6.5MM PED SCREW X C1713 $ 1,342.50 SPIRAL TAP CANNULATED 6.0 A4615 $ 693.00 SPIROMETRY 94010 $ 360.51 SPIROMETRY W/BRONCHO 94060 $ 658.04 SPIROMTRY W/RECRD-VC-EXPIR FLO RATE 94010 $ 360.51 SPIRONALACTONE 50MG. PO Acquisition cost SPIRONOLACTONE 100MG TAB PO Acquisition cost SPIRONOLACTONE 12.5MG TABLET J3490 Acquisition cost SPIRONOLACTONE 1MG/ML ORAL SYNGE Acquisition cost SPIRONOLACTONE 25MG TAB Acquisition cost SPIRONOLACTONE PO SUSP-1MG/ML Acquisition cost SPL AVULSE NP; EA ADDTL 11732 $ 39.03 SPLEEN IMAGING ONLY 78185 $ 924.11 SPLENOPORTOGRAPHY-RAD S / I 75810 $ 2,599.54 SPLINT A4570 Acquisition cost SPLINT ANKLE-CATEG 1 Acquisition cost SPLINT ARM-CATEG 1 Acquisition cost SPLINT ELBOW-CATEG 1 Acquisition cost SPLINT ELBOW-CATEG 2 Acquisition cost SPLINT FINGER ALUM-CATEG 1 Acquisition cost SPLINT FINGER-CATEG 1 Acquisition cost SPLINT FOAM-CATEG 1 Acquisition cost SPLINT HAND-CATEG 1 Acquisition cost SPLINT NASAL-CATEG 1 Acquisition cost Page 277 2018 SPLINT WRIST/FOREARM-CATEG 1 Acquisition cost SPLINT WRIST/THUMB-CATEG 1 Acquisition cost SPLINT WRIST-CATEG 1 Acquisition cost SPLIT CATH III-IMPL DIALSYS SYS C1750 $ 492.75 SPLIT POLYSOMONOGRAPHY 95811 $ 2,387.99 SPLT GRFT; NOT TRUNK, 100 SQCM OR LESS 15120 $ 7,168.06 SPNE/BRAIN PUMP REFIL/MAINTENANCE 95991 $ 647.13 SPNG LAP PAK 18X18 W/RING $ 2.35 SPNL PUNCT, TX; DRAIN CSF (NDDL/CATH) 62272 $ 1,437.02 SPONTANEOUS NYSTAGMUS TEST 92531 $ 120.00 SPONTANEOUS NYSTAGMUS TEST W/RECORDING 92541 $ 277.79 SPR STIFF GUIDEWIRE STRGHT 5BX C1769 $ 40.75 SPUTUM CULTURE 87070 $ 23.41 SPUTUM CYTOLOGY 88108 $ 84.11 SPUTUM FOR O & P 87177 $ 24.18 SPUTUM OBST SPEC AROSL INDUCD TECH 89220 $ 341.62 SQ COLLAGEN; 1 CC OR LESS 11950 $ 446.80 SQ MASTECTOMY 19304 $ 7,213.98 SR-89 RADPHRM DX CHLORIDE / MCI A9600 $ 3,341.16 SREP F E N L MM 12.6-20.0CM 12016 $ 821.94 SREP F E N L MM 20.1 1-30.0 CM 12017 $ 821.94 SREP S/N/EX/G/T/A; 2.6-7.5 CM 12002 $ 446.80 SRG TX ECT PREG TUB/OVAR REQ SALP/OOPH 59120 $ 1,677.06 S-ROM TOTAL HIP SYS FEMOR STEM C1776 $ 5,820.00 SSKI 1GM/ML SOLUTION 30ML Acquisition cost SST SILVERHAWK PERIPHERAL CATH SET C1714 $ 5,992.50 ST 4X6 MESH SURGICAL PATCH C1781 $ 1,422.15 ST STIM SP CORD; PERC; WO OTHER OP 63610 $ 4,259.09 ST. LOUIS ENCEPHALITIS ANTIBODY 86653 $ 35.82 STAB PHLEB VEINS; 1 EXTREM; 10-20 INC 37765 $ 6,592.23 STABILIZE FEMOR TRIATH POSTER C1713 $ 2,092.50 STABILIZED #3 FEM RT TRIATHLON POSTERIOR C1776 $ 2,092.50 STABILIZER SGW-CATEG 1 Acquisition cost STABILIZER WIRE-CATEG 1 Acquisition cost STAGE 1 CEMNT KNEE FEM SPACER C1776 $ 3,555.00 STAGGERED SPONDIAC WORD TEST 92572 $ 360.51 STAINLESS STEEL CONNECT STRGHT C1751 $ 138.24 STAINLESS STEEL CROWN D2930 $ 238.00 STALEVO 25/100/200MG TABLET Acquisition cost STAMARIL (YELLOW FEVER VACCINE) 90717 $ 0.10 STANDARD COG PERFORM TEST HOUR 96125 $ 292.29 STANDARD GLIDEWIRE 3CM STRGHT C1769 $ 282.89 STANDARD LOCKED PLATE LEFT C1713 $ 1,665.00 STANDARD RIGHT PLATE C1713 $ 1,437.00 STANDARD WALL GRAFT Acquisition cost STAPDCTMY/OTMY W OSSCLR W/WO MTRL W DRLL 69661 $ 11,474.25 STAPDCTMY/STAPDTMY W OSSCLR; W/WO MATRL 69660 $ 11,474.25 STAPE RND CUT BURR 1.3MM DIA C1713 $ 164.43 STAPES DIAM BURR SYNERGY 2.3MM C1713 $ 164.43 STAPES DIAMOND BURR 1.3MM DIA C1713 $ 162.81 STAPES RND CUT BURR 2.0MM DIA C1713 $ 164.43 STARTER PTFE/HPRN COAT GWIRE C1769 $ 183.12 STAT FLO BRISTLE TIPS 19G C1713 $ 66.75 STAT-1 LYTES 80051 $ 19.05 STAT-1 LYTES 82803 $ 57.35 STAT-2 LYTES 80051 $ 19.05 Page 278 2018 STAT-2 LYTES 82803 $ 57.35 STAVUDINE 1/ML ORAL LIQUID Acquisition cost STAVUDINE 15MG CAP Acquisition cost STAVUDINE 20MG CAP Acquisition cost STAVUDINE 30MG CAP Acquisition cost STAVUDINE 40MG CAP Acquisition cost STEINMANN PINS W/CENTRAL THREAD 5x225MM C1713 $ 26.78 STEM C1713 $ 3,600.00 STEM BIPOLAR-CATEG 1 Acquisition cost STEM EXT-CATEG 1 C1776 Acquisition cost STEM EXTENSION REPLACEMENT SCREW C1713 $ 151.50 STEM HIP-CATEG 1 C1776 Acquisition cost STEM OFFSET-CATEG 1 Acquisition cost STEM-CATEG 1 L8670 Acquisition cost STEMMED TIB COMP SZ-3 C1776 $ 3,607.50 STEMMED TIBIAL COMPONENT Acquisition cost STEMMED TIBIAL COMPONENT SZ-3 Acquisition cost STENGER TEST - PURE TONE 92565 $ 84.11 STENGER TEST, PURE TONE 92565 $ 84.11 STENGER TEST, SPEECH 92577 $ 1,175.22 STENT AA-CATEG 1 C1874 Acquisition cost STENT BALLOON Acquisition cost STENT BALLOON-CATEG 1 C1725 Acquisition cost STENT BILIARY-CATEG 1 C1877 Acquisition cost STENT BILIARY-CATEG 2 C1876 Acquisition cost STENT BILIARY-CATEG 3 Acquisition cost STENT CORINTHIAN 12MM IQ STENT Acquisition cost STENT CORINTHIAN 15MM IQ Acquisition cost STENT CORINTHIAN 18MM IQ Acquisition cost STENT CORINTHIAN-CATEG 1 Acquisition cost STENT ESOPHAG-CATEG 1 Acquisition cost STENT FLUORO-CATEG 1 Acquisition cost STENT METAL BALLOON-CATEG 1 C2625 Acquisition cost STENT NEPHROURETERAL-CATEG 1 Acquisition cost STENT NITINOL-CATEG 1 Acquisition cost STENT PIGTAIL W/INTROD-CATEG 1 Acquisition cost STENT PIGTAIL-CATEG 1 Acquisition cost STENT POLARIS-CATEG 1 C1725 Acquisition cost STENT REPHROURETERAL-CATEG 1 C2617 Acquisition cost STENT SYMPHONY-CATEG 1 C2617 Acquisition cost STENT URETERAL-CATEG 1 C2617 Acquisition cost STENT URETERAL-CATEG 2 Acquisition cost STENT WALL-CATEG 1 C1874 Acquisition cost STER COLLECTEVAC,CONN TUB/END A4624 $ 14.38 STERIJECT 33GX13MM PREM NEEDLE C2618 $ 56.93 STERILE GLYCEROL FOR INJ Acquisition cost STERILE MINERAL OIL 25ML Acquisition cost STERILE TALC POWDER AEROSOL J3490 Acquisition cost Sterile Water 1000 ml Bag Acquisition cost STERIOD STUDY-OTHER 83582 $ 38.50 STERIPAK SHRT FIX,PINS,HEX&PIN C1713 $ 5,934.00 STERI-STRP 1/2 X 4 $ 0.73 STERI-STRP 1/4 X 3 $ 0.73 STERL BALL CATH OTW ES 1.5X20X142 C1725 $ 262.50 STERL BALL CATH OTW ES 4FR 2.5X20X143 C1725 $ 667.50 STERL BALL CATH OTW ES 4FR 2.5X40X145 C1725 $ 667.50 Page 279 2018 STERL BALL CATH OTW ES 4FR 2X20X142 C1725 $ 567.38 STERL BALL CATH OTW ES 4FR 2X40X144 C1725 $ 567.38 STERL BALLOON CATH DILATATION C1726 $ 592.87 STERLING 3X20X135 BALLOON DILATA CATH C1725 $ 592.88 STERLING 4X60X135 BALLOON DILATAT CATH C1725 $ 567.38 STERLING 5X40X135 BALLOON DILATAT CATH C1725 $ 567.38 STERLING BALL 3.5X40X135 CATH DILATAT C1725 $ 592.88 STERLING BALLOON 3.5X20X135 CATH DILAT C1725 $ 592.88 STERLING BALLOON 3X60X135 CATH DILAT C1725 $ 592.88 STERLING BALLOON 4X20X135 CATH DILATAT C1725 $ 735.00 STERLING BALLOON 4X40X135 CATH DILATAT C1725 $ 711.00 STERLING BALLOON DILAT CATH 4X10X135 C1725 $ 567.38 STERLING BALLOON DILAT CATH 4X10X80 C1725 $ 567.38 STERLING BALLOON DILATAT CATH 5X10X135 C1725 $ 567.38 STERLING BALLOON DILATATI CATH 5X10X80 C1725 $ 711.00 STERLING SL 2.5x80x150 L/P BALL CATH OTW C1725 $ 567.38 STERNOCLAVICULAR JOINT 71130 $ 164.27 STERNUM 71120 $ 164.27 STEROID ELUTING BIPOLAR IMPLAN Acquisition cost STIFF MICRO INTRO GW KIT C1769 $ 900.00 STIFF MICRO INTRO KIT 10BX GUI C1769 $ 900.00 STIFF SHAFT GLIDEWIRE ANGLED C1769 $ 412.05 STIM EVOKED RESPONSE 51792 $ 147.99 STIVARGA (Regorafenib 40 mg ) $ 0.10 STNT PLACMT RETROGRD TX; CAROTID 37217 $ 2,327.03 STOCKINETTE 2 $ 12.36 STOCKINETTE 3 N/STRL $ 10.25 STOCKINETTE 4 N/STRL $ 13.25 STOCKINETTE-CATEG 1 Acquisition cost STOCKINETTE-CATEG 2 Acquisition cost STOCKINETTE-CATEG 3 Acquisition cost STOCKINETTE-CATEG 4 Acquisition cost STOCKING-CATEG 1 Acquisition cost STOMACH TUB 16FR $ 1.10 STOMACH TUB 18FR $ 1.10 STOMAHESIVE-CATEG 1 Acquisition cost STONE ANALYSIS 82360 $ 34.96 STOOL CULTURE 87045 $ 25.65 STOOL, ADDITIONAL PATHOGENS 87046 $ 25.65 STOP PINS 50MM 10/BX OPERATIVE C1713 $ 1,575.00 STOPCOCK 3-WAY $ 0.70 STOPCOCK 4 WAY $ 0.72 STOPCOCK SS303 EXT MALE THREAD C1713 $ 119.48 STRABISMUS SURG; 1 HORIZONTAL 67311 $ 4,790.26 STRABISMUS SURG; 2 HORIZONTAL 67312 $ 7,805.64 STRABISMUS SURG; 2/MORE VERTIC 67316 $ 4,790.26 STRABISMUS SURG; SUPER OBLQUE MUSCL 67318 $ 4,790.26 STRABISMUS SURGRY BY POST FIXATION 67334 $ 657.69 STRABISMUS W EXPLR/REP EXTRAOCLR MUSC 67340 $ 781.84 STRAIGH PLATE 2.0 Acquisition cost STRAIGHT CLAW PLATE C1713 $ 3,204.00 STRAIGHT PLATE C1713 $ 2,484.00 STRAPPING OF TOES 29550 $ 147.99 STRAPPING; ANK 29540 $ 358.14 STRAPPING; LOW BACK 29799 $ 358.14 STRAPPING; SHOULDER 29240 $ 277.79 Page 280 2018 STRAPPING; THORAX 29200 $ 358.14 STRAPPING; UNNA BOOT 29580 $ 358.14 STRAPPING-ANKLE 29540 $ 358.14 STRAPPING-ELBOW/WRIST 29260 $ 84.11 STRAPPING-HAND/FINGER 29280 $ 84.11 STRAPPING-KNEE 29530 $ 277.79 STRAPPING-SHOULDER 29240 $ 277.79 STRAPPING-TOES 29550 $ 147.99 STRAPPING-UNNA BOOT 29580 $ 358.14 STREP A AG EIA 87430 $ 36.98 STREP A, IA W DOO 87880 $ 36.37 STREPTOKINASE 250,000 UNIT INJ Acquisition cost STREPTOKINASE 250MU VIAL J2995 Acquisition cost STREPTOKINASE 750,000 UNIT INJ J2995 Acquisition cost STREPTOKINASE 750MU VIAL J2995 Acquisition cost STREPTOMYCIN 1 GM INJECTION J3000 Acquisition cost STREPTOMYCIN 1GM INJ J3000 Acquisition cost STREPTOMYCIN INJ TO 1GM J3000 $ 206.25 STREPTOMYCIN SULFATE 1G VIAL J3000 Acquisition cost STREPTOZOCIN, 1GM J9320 $ 921.97 STREPTOZYME 86063 $ 15.66 STREPTOZYME SCREEN 86063 $ 15.66 STRESS BREAKER D6940 $ 349.00 STRESS TTE COMPLETE 93351 $ 1,287.09 STRETCH GRAFT 6MM X 50CM Acquisition cost STRETCH THIN GRAFT 6MM X 50CM Acquisition cost STRETCH VASCULAR GRAFT STANDAR Acquisition cost STRGHT GUIDEWIRE .035 15X150CM C1713 $ 21.31 STRGHT-IN DEV WI/ INTEPRO LITE FEM; AMS C1781 $ 1,726.69 STRIBILD 150MG/150MG/200MG/300MG TAB Acquisition cost STRL WTR IRR 500ML #6139-02 $ 1.44 STROMECTOL 6MG TAB Acquisition cost STRONG IODINE/LUGOLS 480ML Acquisition cost STRPPING UNNA BOOT 29580 $ 358.14 STRTCH AXIL BIFEMOR VASC GRFT C1768 $ 4,032.00 STRYKEFLOW SUCT IRRIGATOR DISP A4624 $ 569.96 STRYKER ACETABULAR SHELL C1776 $ 1,200.00 STRYKER BONE LOCKING SCREW C1713 $ 265.50 STRYKER BONE SCREW LOCKING C1713 $ 265.50 STRYKER CAP BIPOLAR HIP C1776 $ 717.20 STRYKER CLIP C1713 $ 265.50 STRYKER END 16MM DRLL 5MM STOP C1713 $ 178.98 STRYKER END 16MM DRLL 7MM STOP C1713 $ 189.09 STRYKER END 16X115MM DRLL 35MM C1713 $ 390.68 STRYKER END DRILL 26MM C1713 $ 202.08 STRYKER GAP PLATE BONE 25SCREW C1713 $ 216.30 STRYKER HEAD C1776 $ 717.20 STRYKER K WIRE; ORTHO C1713 $ 55.13 STRYKER PIN C1713 $ 191.25 STRYKER SCREW C1713 $ 157.58 STRYKER WASHER C1713 $ 52.59 STYLE 468 SALINE IMPLANT SIZE Acquisition cost STYLET-CATEG 1 Acquisition cost STYLETTES - ADULT (DISP) A4212 $ 3.98 SUB SKIN GRFT; T/A/L; 100SQ CM 15273 $ 7,168.06 SUB SKN GRFT F/N/H/F/G; 100SQCM/1% BA 15277 $ 4,147.84 Page 281 2018 SUBARACHNOID NERVE DESTRUCTION 62280 $ 1,777.62 SUBCONJUNCTIVAL INJ 68200 $ 277.79 SUBCONJUNCTIVAL INJECTION; MEDICATION 68200 $ 277.79 SUBCU/IM INJECT 96372 $ 153.91 SUBCU/IM INJECTION 96372 $ 153.91 SUBCU-IM INJECT 96372 $ 153.91 SUBDURAL PUNCT ININ 61000 $ 1,437.02 SUBDURAL PUNCT SUBSEQ 61001 $ 1,437.02 SUBEPITHELIAL CONN. TISSUE GRAFT D4273 $ 770.00 SUBLIMAZE 0.1 MG/ML 2 ML AMP J3010 Acquisition cost SUBMANDIBULAR SPACE 41008 $ 5,815.59 SUBMAX INTRAORAL 42310 $ 1,216.16 SUBOXONE 2MG/0.5MG FILMTAB J0572 Acquisition cost SUBOXONE 8MG/2MG FILMTAB Acquisition cost SUBQ HORMONE PELLET IMPLNT 11980 $ 872.74 SUBQ INJ FILLING MAT; 5.1 - 10.0 cc 11952 $ 1,291.09 SUBQ INJ FILLING MAT; over 10.0 cc 11954 $ 821.94 SUBTALAR ARTHRO W/EXC 29905 $ 6,995.52 SUBTALAR ARTHRODESIS 28725 $ 26,770.83 SUBTALAR MBA IMPLANT 10MM C1713 Acquisition cost SUBTALAR MBA IMPLANT 10MM C1713 $ 1,342.50 SUBTTL HYSTERECTMY; W/WO TUBE/OVRY REM 58180 $ 2,057.53 SUC CATH TRAY W/SAL 14 FR $ 1.98 SUCCINYL CHOLINE 20MG/ML SYRINGE Acquisition cost SUCCINYLCHOLINE CHLORIDE 20MG J0330 $ 5.27 SUCRALFATE 1GM/10ML SUSP Acquisition cost SUCT CATH 14FR $ 0.48 SUCT CONNECTING TUBE 72" STRL A4624 $ 0.83 SUCT IRRIG CYLIND TUBE A4624 $ 144.00 SUCT PUNCH UPT W/CENTRAL CHNL A4624 $ 984.38 SUCT TUBE 6.3", BARON 7 FRENCH A4624 $ 79.26 SUCT TUBE 6.3, BARON 9 FRENCH A4624 $ 46.20 SUCT TUBE BUBB NON-STRL $ 16.16 SUCTION ASSISTED LIPECTOMY; HE 15876 $ 7,168.06 SUCTION ASSISTED LIPECTOMY; LO 15879 $ 7,168.06 SUCTION ASSISTED LIPECTOMY; TR 15877 $ 7,168.06 SUCTION ASSISTED LIPECTOMY; UPPER EXTREM 15878 $ 4,147.84 SUCTION CATH 8FR 50/CS A4624 $ 112.50 SUCTION DEVICES/AESCULAP C1713 $ 49.50 SUCTION LIPECTOMY; UPPER EXTREM 15878 $ 4,147.84 SUCTION TUBE 7FR MED ANGLED A4624 $ 20.93 SUCTION TUBE-BARON, 5" 3FRENCH A4624 $ 30.75 SUCTION TUBING STRL FUNNEL CO C1713 $ 1.80 SUCTTUBE 7FR W/FINGER CUTOFF A4624 $ 49.50 SUCTTUBFRAZ SEMIRIG STRGHT10FR A4624 $ 144.00 SUCTTUBFRAZ SEMIRIG STRGHT12FR A4624 $ 132.75 SUDAFED 60 MG TAB Acquisition cost SUDAFED 30MG TABLET Acquisition cost SUDAN BLACK STAIN 82705 $ 13.84 SUFENTA 50MCG/ML INJ 1ML AMP Acquisition cost SUGAMMADEX (Bridion) 200mg/2mL $ 0.10 SUGAMMADEX (Bridion) 500mg/5mL $ 0.10 SUGAR WATER TEST 85555 $ 18.15 SUGAR+ACETONE 81002 $ 7.66 SULFACET/PRED 10-0.2% EYE DROP Acquisition cost SULFACET/PREDNISOL 0.2% EYE DROP Acquisition cost Page 282 2018 SULFACETAMIDE 10% EYE DROP Acquisition cost SULFACETAMIDE EYE OINT Acquisition cost SULFACETAMIDE SODIUM 10% J3490 $ 128.70 SULFACETMD PREDNISOLONE SOLN 10/0.2% J3490 $ 128.70 SULFADIAZINE 500MG TABLET U-D Acquisition cost SULFADIAZINE IN STERILE WATER Acquisition cost SULFADIAZINE SUSP IN CHERRY Acquisition cost SULFAMETHOX/TRIMETH DS TAB Acquisition cost SULFAMETHOX/TRIMETHOPR 10ML VIAL IV S0039 Acquisition cost SULFAMETHOXAZOLE LEVEL 80299 $ 41.01 SULFAMETHOXAZOLE/TMP IN S.W. Acquisition cost SULFASALAZINE 500MG TAB Acquisition cost SULFATIDE AUTOANTIBODY 83520 $ 37.99 SULFHEMOGLOBIN 83060 $ 22.46 SULINDAC 150MG TAB Acquisition cost SULINDAC 200MG TAB Acquisition cost SUMATRIPTAN 0.5ML/INJ J3030 $ 187.00 SUMMER'S EVE Acquisition cost SUMP SUCT NASL GASTR TUBE A4624 $ 149.51 SUNSCREEN 30SPF TOPICAL Acquisition cost SUPER ANCHOR QA+ C1713 $ 402.00 SUPER SHEATH 6FR C1894 $ 277.50 SUPER SHEATH 9FR C1894 $ 171.75 SUPER SHEATH INTRODUCER C1894 $ 171.75 SUPER STIFF GUIDE WIRE 5/BX C1769 $ 354.00 SUPER STIFF GUIDEWIRE 5/BX C1769 $ 310.65 SUPER STIFF GW .035/180 PTFE C1769 $ 354.00 SUPEREN PLATE MED 6DEGREE STRL C1713 $ 8,662.50 SUPERIOR VENA CARVOGRAM 75827 $ 1,619.99 SUPERVS/HANDLING/LOADING RAD SOURCE 77790 $ 130.11 SUPPLEMENTAL ELECTRICAL TEST 92547 $ 286.00 SUPPLY Acquisition cost SUPPLY CONTACT LENSES EX PROSTH APHAKIA Acquisition cost SUPPLY LOW VISION AIDS $ 321.20 SUPPLY RADIOPHARM DX IMAGING AGENT NOS A4641 Acquisition cost SUPPORT ABDOM-CATEG 1 Acquisition cost SUPPORT ANKLE-CATEG 1 Acquisition cost SUPPORT ARM-CATEG 1 Acquisition cost SUPPORT ELBOW-CATEG 1 Acquisition cost SUPPORT KNEE-CATEG 1 Acquisition cost SUPPORT PATELLA-CATEG 1 Acquisition cost SUPPORT WRIST-CATEG 1 Acquisition cost SUPRACERVICAL ABDOM HYSTRCTOMY 58180 $ 2,057.53 SUPRASCAPULAR NERVE 64418 $ 1,437.02 SUPRAX 100MG/5ML SUSP Acquisition cost SUR CATHWIRE BASK 2.2FR NO TIP C1713 $ 244.71 SURFACE ARTICULAR-CATEG 1 Acquisition cost SURG ANEURY; INTRA-ART EMBOLIZATION 61710 $ 4,491.67 SURG ANEURY; INTRACRAN ELECTROTHROMBOSIS 61708 $ 5,340.39 SURG BUR 3MM DIA HD RND FLUTEX C1713 $ 212.09 SURG BUR 6.0MM PRECISION ACORN C1713 $ 204.75 SURG BUR 7.5MM PRECISION ACORN C1713 $ 204.75 SURG BUR DIA HD RND DIAMON C1713 $ 212.09 SURG BUR DIA HEAD ROUND DIAMON C1713 $ 212.09 SURG CL TRACHEOST/FISTULA WO PLAS REP 31820 $ 5,815.59 SURG CLO TRACHEOST/FISTULA W PLAS REP 31825 $ 5,815.59 Page 283 2018 SURG COMPL INCOMPLETE AB 59812 $ 6,010.51 SURG DX EXAM; ANORECTAL 45990 $ 6,123.85 SURG EXP IMPCTD TOOTH W/O ORTH D7280 $ 595.00 SURG EXPOSURE IMPACTED TOOTH ORTHO D7280 $ 595.00 SURG FR0Z SECT ADDL 88332 $ 70.53 SURG GRAFT 10X15 RECTANGULAR C1768 $ 7,291.50 SURG GRAFT 13X15 RECTANGULAR C1768 $ 7,770.00 Surg isolation of th w/rub dam D3910 $ 168.00 SURG MESH LRGE 3.2 HERN PATCH C1781 $ 1,193.70 SURG PATH GROSS EXAM ONLY 88300 $ 46.20 SURG PATH LEVEL I 88300 $ 46.20 SURG PATH LEVEL II 88302 $ 84.11 SURG PATH LEVEL III 88304 $ 118.21 SURG PATH LEVEL IV 88305 $ 118.21 SURG PATH LEVEL V 88307 $ 569.71 SURG PATH LEVEL VI 88309 $ 1,430.62 Surg place: transosteal implant D6050 $ 6,950.00 Surg revision proc, per tooth D4268 $ 350.00 SURG RND BUR ELITE FLUTED SFT C1713 $ 212.09 SURG SIMP P FULL DSE BONE CEM C1713 $ 226.35 SURG SUCT CON TUBE W/MALECLAMP A4624 $ 121.13 SURG TX ANAL FISTULA; SUBQ 46270 $ 6,123.85 SURG TX INCOMPL ABORTION 59812 $ 6,010.51 SURG TX MISSED ABORTION; 2ND TRIMESTER 59821 $ 6,010.51 SURG.REMOVAL TOOTH D7210 $ 385.00 SURGGRFT RECTANG HUMAN COLLAG C1768 $ 2,790.00 SURGGRFT SQUARE HUMAN COLLAG C1768 $ 3,975.00 Surgic place: eposteal implant D6040 $ 11,197.00 Surgical discect:w/ w/o implant D7850 $ 6,357.00 SURGICAL MESH 8X10" OVAL, 1/BX C1781 $ 2,073.09 SURGICAL RDCTN OF OSSESOUS TUBEROSITY D7485 $ 1,114.00 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS D7250 $ 305.00 Surgical reposition of teeth D7290 $ 563.00 SURGICAL SIMPLEX BONE CEMENT C1713 $ 156.83 SURGICAL SPECIMEN MAMMOGRAPHY 76098 $ 1,287.09 SURGICAL SPLINT D5988 Acquisition cost Surgical stent D5982 $ 725.00 SURGICAL SUPPLY MISC A4649 Acquisition cost SURGICAL TRAYS A4550 $ 3,979.50 SURGICEL 2X14" ABSORBABLE HEMOSTAT A5126 $ 2,290.80 SURGILUBE FOILPAC 5GM Acquisition cost SURGISEAL .35ML SKIN ADHESIVE Q4106 $ 135.00 SURGISIS ANL FISTULA PLUG KIT C1781 $ 1,387.50 SURGISIS FISTULA PLUG RECTL C1781 $ 1,612.50 SURGISIS GOLD HERNIA GRFT 13X22CM G13572 C1763 $ 9,166.50 SURGISIS GOLD HERNIA REPAIR GRAFT C1781 $ 1,080.00 SURGISIS GOLD HERNIA REPAIR GRAFT L8670 $ 1,080.00 SURVANTA 25MG/ML INJ 8ML VIAL Acquisition cost SUSTIVA 50MG CAPSULE Acquisition cost SUTRE FACIAL NRV; EXTRACRANIAL 64864 $ 12,238.01 SUTRE MAJ PERIPH NRV; ARM/LEG WO TRNSPOS 64857 $ 12,238.01 SUTRE PASSER 45DEG UPBEND ANG1 C1713 $ 190.50 SUTURE 1 NERVE; MEDIAN MOTOR THENAR 64835 $ 12,238.01 SUTURE 1 NERVE; ULNAR MOTOR 64836 $ 12,238.01 SUTURE 1 NERVE;HAND/FOOT COMMON SENSORY 64834 $ 12,238.01 SUTURE 12"( 30CM) 5-0 WHT 5MM C1713 $ 270.98 Page 284 2018 SUTURE ANCHOR 6.5MM FP PK C1713 $ 527.81 SUTURE ANCHOR PUSHLOCK C1713 $ 540.00 SUTURE CHROMIC-CATEG 1 Acquisition cost SUTURE CLEAR-CATEG 1 Acquisition cost SUTURE CV-CATEG 1 Acquisition cost SUTURE CV-CATEG 2 Acquisition cost SUTURE DERMALON Acquisition cost SUTURE DIG NRV; HND/FT; EA ADDL NRV 64832 $ 730.09 SUTURE DIGITAL NRV; HND/FT; I NRV 64831 $ 12,238.01 SUTURE ENDOPOUCH-CATEG 1 Acquisition cost SUTURE ENDOPOUCH-CATEG 2 Acquisition cost SUTURE ENDOPOUCH-CATEG 3 Acquisition cost SUTURE ENDOSCOPIC-CATEG 1 Acquisition cost SUTURE ETHIBOND-CATEG 1 Acquisition cost SUTURE ETHIBOND-CATEG 2 Acquisition cost SUTURE ETHIBOND-CATEG 3 Acquisition cost SUTURE ETHICON-CATEG 1 Acquisition cost SUTURE ETHILON-CATEG 1 Acquisition cost SUTURE ETHILON-CATEG 2 Acquisition cost SUTURE GUT-CATEG 1 Acquisition cost SUTURE GUT-CATEG 2 Acquisition cost SUTURE GUT-CATEG 3 Acquisition cost SUTURE LDS-CATEG 1 Acquisition cost SUTURE LIGAMENT ANKLE; COLLATERAL 27695 $ 14,826.61 SUTURE MERSILENE-CATEG 1 Acquisition cost SUTURE MONCRYL-CATEG 1 Acquisition cost SUTURE NEURALON-CATEG 1 Acquisition cost SUTURE NYLON-CATEG 1 Acquisition cost SUTURE NYLON-CATEG 2 Acquisition cost SUTURE OF URETHRAL WOUND; FEMALE 53502 $ 7,131.78 SUTURE PANAPCRYL-CATEG 1 Acquisition cost SUTURE PDS-CATEG 1 Acquisition cost SUTURE PROLENE-CATEG 1 Acquisition cost SUTURE PROLENE-CATEG 2 Acquisition cost SUTURE QUAD/HAMSTRNG MSCL RUPT 27385 $ 14,826.61 SUTURE RAPIDE-CATEG 1 Acquisition cost SUTURE RECENT WOUND LID; FULL THICK 67935 $ 4,790.26 SUTURE RECENT WOUND LID; PART THICK 67930 $ 4,790.26 SUTURE REMOVAL D7999 Acquisition cost SUTURE REMVL TRAY $ 0.67 SUTURE SILK-CATEG 1 Acquisition cost SUTURE SILK-CATEG 2 Acquisition cost SUTURE SM INT;ULCER/WND/INJRY; 44602 $ 3,018.00 SUTURE TRACH WND/INJRY; INTRATHORASIC 31805 $ 1,735.14 SUTURE VICRYL-CATEG 1 Acquisition cost SUTURE VICRYL-CATEG 2 Acquisition cost SUTURE WOUND > 5CM D7912 $ 700.00 SUTURE WOUND UP TO 5CM D7910 $ 315.00 SUTURE, ETHILON, MONO, BLK C1713 $ 152.99 SUTURE;2NDARY;ABD WALL EVISC/D 49900 $ 1,744.93 SUTURE-CATEG 1 Acquisition cost SUTUREFIX 1.7 C1713 $ 505.74 SUTUREFIX 1.7 ANCHOR C1713 $ 742.50 SUTUREFIX 1.9 DRILL BIT C1713 $ 472.50 SUTURE-LENS-CATEG 1 Acquisition cost SUTURETAK 2.4 PEEK; 5/BX C1713 $ 412.50 Page 285 2018 SUTURETAK 2.4MM C1713 $ 937.50 SUTURETAK 3.0 C1713 $ 1,095.00 SUTURETAK 3.0 DBLE LOADED PEEK C1713 $ 360.00 SUTURETAK 3.0 DISP KIT C1713 $ 240.00 SUTURETAK 3.0 DISPOSABLES KIT C1713 $ 240.00 SUTURETAK GUIDE 2.4MM C1769 $ 333.00 SUTURETAPE 1.3MMW/TAIL 12BX EA C1713 $ 52.50 SUTURING FORCE-CATEG 1 Acquisition cost SWALLOW CURRENT STATUS G8996 Acquisition cost SWALLOW DISCHARGE STATUS G8998 Acquisition cost SWALLOW GOAL STATUS G8997 Acquisition cost SWAN-GANZ (BIPOLAR PACING WIRE) $ 280.39 SWEAT CHLORIDE 89230 $ 118.21 SWIVELCK ANCHR 4.75 BIO COMP C1725 $ 705.00 SXL SILVERHAWK¢ PERIPHERAL CATHETER C1714 $ 5,992.50 SYMBICORT 160/4.5 MCG. 6 GM. J3535 Acquisition cost SYMBICORT 80/4.5 MCG. 6 GM. J3535 Acquisition cost SYMETRY BALLOON CATH 2X4X90 C1725 $ 520.50 SYMETRY BALLOON CATH 4X10X90 C1725 $ 520.50 SYMMETRY 2x10x90 C1725 $ 520.50 SYMMETRY 3x4x135 C1725 $ 546.00 SYMMETRY 4x4x153 C1725 $ 546.00 SYMMETRY 5x4x135 C1725 $ 546.00 SYMMETRY 6FR C1725 $ 1,027.50 SYMMETRY BALLOON CATH 3X10X90 C1727 $ 570.00 SYMMETRY SM VES BALL CATHR 2X10X135/ C1725 $ 546.00 SYMMETRY W/ SHAFT 1.5X10X135 C1725 $ 546.00 SYMMTRY VES BAL CATH 4FR 90x4x4 C1725 $ 520.50 SYMPHONY 10X40 STENT Acquisition cost SYMPHONY 6X22 STENT Acquisition cost SYMPHONY 8X23 STENT Acquisition cost SYMPHONY RO BILIARY 8-60/7/75 C1729 $ 1,818.00 SYMPHONY STENT 10MM X 40CM 75 Acquisition cost SYMPHONY STENT 10MM X 60CM / 7 Acquisition cost SYMPHONY STENT 12MM X 40CM/ 75 Acquisition cost SYMPHONY STENT 12MM X 60CM/ 75 Acquisition cost SYMPHONY STENT 7MM X 40CM/75 S Acquisition cost SYMPHONY STENT 7MM X40MM Acquisition cost SYMPHONY STENT 8MM X 44CM/ 75 Acquisition cost SYMPHONY STENT 8MM X 60CM/ 75 Acquisition cost SYMPHONY STNT 8MMx44CM,7FR C1876 $ 1,818.00 SYMPHONY STNT 8MMx60CM,7FR C1876 $ 1,818.00 SYMTRY SM VES BALL CATH 3X10X135/6FR C1725 $ 546.00 SYMTRY SM VES BALL CATH 4X10X135/7FR C1725 $ 546.00 SYMTRY SM VESSEL BALL CATH 2X4X90/6FR C1725 $ 588.00 SYMTRY VES BALLOON CATH 90CM 3.0X4 C1725 $ 607.50 SYN MESH 12MM C1781 $ 4,306.50 SYN MESH 12MM X 5MM DIAMETER C1781 $ 2,071.50 SYNAGYS PALIVIZUMAB 100MG/VIAL Acquisition cost SYNCHROMED II PUMP C1772 $ 16,800.00 SYNECHROLYSIS 65865 $ 5,080.46 SYNERCID J2770 Acquisition cost SYNERGY 10 CEMENTED STEM Acquisition cost SYNERGY 17H C1776 $ 5,852.25 SYNERGY IPG C1820 $ 5,852.25 SYNERGY POROUS SIZE 12 C1776 $ 5,852.25 Page 286 2018 SYNEX IMPLANT C1713 $ 10,666.50 SYNGERY HIGH OFF. STEM Acquisition cost SYNOVATOR BLADE 4.5 5/BX EP-1 C1713 $ 491.40 SYNOVECTMY PIP JNT; EA IP JNT 26140 $ 3,570.03 Synovectomy D7854 $ 7,511.00 SYNOVECTOMY CMC JOINT 26130 $ 6,995.51 SYNOVECTOMY MCP JNT; EA DIGIT 26135 $ 6,995.52 SYNOVECTOMY WRIST JOINT 25105 $ 6,995.52 SYNOVECTOY TENDON SHTH RADICAL 26145 $ 3,570.03 SYNOVIAL BIOPSY; IP JOINT 26110 $ 3,570.03 SYNOVIAL BX TARSAL JOINT 28050 $ 6,995.52 SYNOVIAL MTP JOINT BX 28052 $ 6,995.52 SYNRGY - POROUS HIP PLUS HA STEM C1776 $ 6,142.50 SYNRGY POROUS-COATED STM; SZ-16 C1776 $ 5,535.00 SYNTHES REAMER ATTACHMENT Acquisition cost Synthetic graft-mand/facial,B/R D7995 $ 4,550.00 SYNTHETIC SENTENCE TEST 92576 $ 84.11 SYNTHOCAST HP CASTING-CATEG 1 Acquisition cost SYNTHROID 0.05MG TAB Acquisition cost SYNTHROID 0.1MG UD TAB Acquisition cost SYNTHROID 112MG TAB Acquisition cost SYNTHROID 200MCG INJ VIAL Acquisition cost SYNVISC J7325 $ 25.72 SYPHILIS QUANT 86593 $ 11.97 SYPHILLIS SCREEN 86592 $ 11.59 SYRINGE ANGIOGRAPHIC-CATEG 1 Acquisition cost SYRINGE INFLATION-CATEG 1 Acquisition cost SYRINGE MEDRAD-CATEG 1 Acquisition cost SYST BP >=140 MM HG 3077F $ 0.10 SYST BP GE 130 - 139MM HG 3075F $ 0.10 SYST BP LT 130 MM HG 3074F $ 0.10 SYSTEM CLOSED DRAIN-CATEG 1 Acquisition cost SYSTEM DELIV-CATEG 1 Acquisition cost SYSTEM LAVAGE-CATEG 1 Acquisition cost SYSTEM MANDELKORN-CATEG 1 Acquisition cost SYSTEM SLING-CATEG 1 C1771 Acquisition cost SYSTEM SUCTION-CATEG 1 Acquisition cost SYSTEM SUCTION-CATEG 2 Acquisition cost SYSTEM TENDERWET CAVITY-CATEG 1 Acquisition cost SYSTEM THROMBOLECTOMY OASIS-CATEG 1 Acquisition cost SYSTEM TISSUE RETRIEVING-CATEG 1 Acquisition cost SYSTEM VENA CAVA DUAL FILTER-CATEG 1 C1880 Acquisition cost T CELL SUBSET 86360 $ 127.62 T CELL SUBSET 86360 $ 127.62 T CELL SUBSET ABS CD4-CD8 CNT-RATIO 86360 $ 127.62 T CELL SUBSET. 88189 $ 190.32 T CELLS; ABSOL CD4 AND CD8 86360 $ 127.62 T CELLS; ABSOLUTE CD4 COUNT 86361 $ 72.73 T CELLS; TOT CT 86359 $ 102.48 T CELLS; TOTAL COUNT 86359 $ 102.48 T PLATE C1713 $ 645.46 T UMOR IMAGE PET/CT SKUL-THIGH 78815 $ 3,642.17 T WRENCH FIXATOR-CATEG 1 Acquisition cost T&B CELL EVAL-FLOW CYTOMETRY 88189 $ 190.32 T/A; AGE 12 OR OVER 42821 $ 5,815.59 T/A; UNDER AGE 12 42820 $ 11,474.25 Page 287 2018 T-3 FREE 84481 $ 46.02 T-3 (REVERSE) 84482 $ 42.81 T3 THYROXINE; FREE 84439 $ 24.49 T3 TRIIODOTHYRONINE T3; TOTAL 84480 $ 38.52 T3 UPTAKE 84479 $ 17.56 TAB VENT TUBE TITANIUM.76ID A4624 $ 54.90 TAC-C-CATEG 1 Acquisition cost TACROLIMUS 80197 $ 37.31 TACROLIMUS 0.1% OINT Acquisition cost TACROLIMUS (PROGRAF) 1MG TAB J7507 Acquisition cost TACROLIMUS ANDYR 1MG (PROGRAF) CAP J7507 Acquisition cost TACROLIMUS ANDYR 5MG (PROGRAF) CAP J7507 Acquisition cost TACROLIMUS ANHY 0.5MG CAP PO J7507 Acquisition cost TACROLIMUS ORAL PER 1 MG J7507 $ 9.81 TAC-S-CATEG 1 Acquisition cost TADALAFIL 20MG TABLET Acquisition cost TAGAMET 300MG/2ML INJ 2ML Acquisition cost TAMIFLU 45MG $ 0.10 TAMOXIFEN 20MG TAB Acquisition cost TAMOXIFEN CITR 10MG TAB Acquisition cost TAMSULOSIN (FLOMAX) 0.4MG CAP Acquisition cost TAP SCREW C1713 $ 500.94 TAP SCREW 4.5 C1713 $ 500.94 TAPE OBTURATOR-CATEG 1 Acquisition cost TAPE TEST (PINWORM) 87177 $ 24.18 TAPER BONE SCREW 6.0x5.0; 130/30 C1713 $ 280.50 TAPER POINT-CATEG 1 Acquisition cost TAPER SCRW VENT IMPLNT 4.7X16 C1713 $ 374.85 TAPER SCRW VENT IMPLNT SBM4.7 C1713 $ 383.25 TAPER STEM PLUG C1776 $ 1,342.50 TAPERD SCREW VENT IMPL SBM 3.7MM C1713 $ 330.03 TAPERED SCREW VENT 3.7MMx10 C1713 $ 330.03 TAPERED SCREW VENT 3.7MMx16 C1713 $ 330.03 TAPERED SCREW VENT 4.7MMx10 C1713 $ 383.25 TAPERED SCREW VENT 4.7MMx13MM C1713 $ 374.85 TAPERED SCREW VENT IMPLANT SBM C1713 $ 330.03 TARCEVA 150MG TAB Acquisition cost TARCOLIMUS 1 ML. INJECTION Acquisition cost TATTOOING; 6.0SQ CM OR LESS 11920 $ 1,291.09 TB AG RESPONSE T-CELL SUSP 86481 $ 220.00 TB ANGIOPLASTY RENAL/ VISCERAL 75966 $ 162.49 TB ANGIOPLASTY REPAIR ARTERIAL BLOCKAGE 75962 $ 67.80 TB PURIFIED PROTEIN DERIV 50 TEST VIAL Acquisition cost TB TEST CELL IMMUN MEASURE 86480 $ 168.34 TBA/TRANSLUMINAL BALLOON ANGIOPLASTY 75978 $ 6,022.15 TC 99M EXAMETAZINE / DOSE <=25 MCI A9521 $ 805.20 TC 99M MAA / PER MCI A9540 $ 30.53 TC 99M RADPHRM DX DEPREOTIDE <=35MCI A9536 $ 1,016.40 TC 99M RADPHRM DX DISOFENIN/VIAL<=15MCI A9510 $ 137.50 TC 99M RADPHRM DX MEBROFENIN/<= 15 MCI A9537 $ 56.10 TC 99M RADPHRM DX MEDRONATE / TO 30 MCI A9503 $ 30.53 TC 99M RADPHRM DX PENTETATE /<= 25 MCI A9539 $ 57.75 TC 99M RADPHRM DX PERTECHN/PER MCI CAR A9512 $ 1.58 TC 99M RADPHRM DX PERTECHNETATE 1 MCI A9512 $ 1.58 TC 99M RADPHRM DX SESTAMIBI / DOSE A9500 $ 108.90 TC 99M RADPHRM DX SESTAMIBI / DOSE CAR A9500 $ 108.90 Page 288 2018 TC 99M RADPHRM PYROPHOSPHATE / <=25 MCI A9538 $ 137.50 TC-99 SUCCIMER (DMSA) UD <= 10 MCI A9551 $ 176.10 TC-99M CERETEC WBC LABELING A9569 $ 871.99 TC-99M CHOLETEC UD <=15 MCI A9537 $ 56.10 TC-99M DTPA AEROSOL VENT STUDY 1UD A9567 $ 57.75 TC-99M MACROAGGREGATED ALBUMIN A9540 $ 30.53 TC-99M MACROAGGREGATED ALBUMIN 1 UD A9540 $ 30.53 TC-99M PENETETATE (DTPA) UD <= 75 MCI A9567 $ 57.75 TC-99M PYROPHOSPHATE (PYP) UD <= 25 MCI A9538 $ 20.97 TC-99M RADPHRM DX LABELED RBC <=30 MCI A9560 $ 173.25 TC-99M RADPHRM DX MERTIATIDE <= 15 MCI A9562 $ 453.75 TC-99M RADPHRM DX OXIDRONATE / MCI $ 33.00 TC99M RADPM DX SULFUR COLLOID/MCI<=20MCI A9541 $ 62.70 TC-99M SULFUR COLLOID UD <= 20 MCI A9541 $ 62.70 TCD EMBOLI DETECT W INJ 93893 $ 302.70 TCD EMBOLI DETECT W/O INJ 93892 $ 302.70 TCD VASOREACTIVITY STUDY 93890 $ 614.37 TCM W/IN 14 DAYS OF DISCHARGE 99495 $ 290.50 TCM W/IN 7 DAYS OF DISCHARGE 99496 $ 318.00 TD PRESERVATIVE FREE 7YR OR OL 90714 $ 68.68 Tdap VACCINE LESS THAN 7 YRS, IM 90715 $ 52.10 TE FISTULA W INS SPEECH PROSTH 31611 $ 5,815.59 TECH QUICK EVAL BX 88172 $ 341.62 TECHNESCAN PYP KIT <=25 MCI A3538 $ 51.98 TEE FOR MONITORING 93318 $ 1,287.09 TEGRETOL 100MG TAB Acquisition cost TEGRETOL 100MG/5ML SUSP Acquisition cost TEGRETOL 200MG TAB Acquisition cost TELMISARTAN 80MG TAB Acquisition cost TEMAZEPAM 15MG BULK CAP. Acquisition cost TEMAZEPAM 30MG CAP Acquisition cost TEMAZEPAM 7.5MG CAPSULE Acquisition cost TEMOZOLMIDE, ORAL 5MG J8700 $ 30.95 TEMOZOLOMIDE 140MG. PO (FOR ONCOLOGY ) J8700 Acquisition cost TEMP CLOSURE EYELID BY SUTURE 67875 $ 2,137.81 TEMP TRANSC PACING 92953 $ 1,355.77 TEMPORARY CLO EYELIDS BY SUTURE 67875 $ 2,137.81 TEMPORARY PACEMAKER DUAL CHAMB 33211 $ 19,493.14 TEMPORARY TRANSCUTANEOUS PACING 92953 $ 1,355.77 TEMPOROMANDIBULAR JOINT BILATERAL 70330 $ 164.27 TEMPOROMANDIBULAR JOINT UNILATERAL 70328 $ 164.27 TEMPOROMANDIBULAR JOINTS MRI 70336 $ 614.37 TEMSIROLIMUS 25MG VIAL J9330 Acquisition cost TENDODESIS BICEPS TENDON AT ELBOW 24340 $ 14,826.61 TENDON GRFT FROM DISTANCE 20924 $ 14,826.61 TENDON PULLE RECONSTR; W GRAFT 26502 $ 6,995.52 TENDON PULLEY RECONSTRUCTION 26500 $ 14,826.61 TENDON SHEATH INCISION 26055 $ 3,570.03 TENDON SHEATH INCS 26055 $ 3,570.03 TENECTEPLASE (TNKASE) 50MG KIT J3101 Acquisition cost TENECTEPLASE 50 MG/VIAL J3101 $ 154.75 TENODESIS LONG TENDON BICEPS 23430 $ 14,826.61 TENODESIS SCREW BIOCOMPOSITE C1713 $ 879.00 TENODESIS SCREW BIOCOMPOSITE C1713 $ 879.00 TENODESIS SCRW 7X19.1MM STER C1713 $ 612.00 TENOFOVIR 300MG RERSEARCH TB PACTG394 Acquisition cost Page 289 2018 TENOFOVIR 40MG/SCOOP ORAL POWDER J3490 Acquisition cost TENOFOVIR DISOPR. 300MG TAB Acquisition cost TENOLYSIS FL/EX TEND FA/W EA TEND 25295 $ 6,995.52 TENOLYSIS, FLXOR TNDN; PALM/FING;EA 26442 $ 6,995.52 TENONS CAPSULE INJECTION 67515 $ 707.85 TENORMIN 0.5MG/ML-10ML Acquisition cost TENOTMY, OP TNDN FLEXR; TOE SING 28232 $ 3,570.03 TENOTOMY HIP FLEXOR(S) OPEN 27005 $ 1,552.56 TENOTOMY, SHLDR AREA; SING TENDON 23405 $ 14,826.61 TENS-CATEG 1 Acquisition cost TENSILON TEST MYASTHENIA GRAVIS 95857 $ 658.04 TENT-CATEG 1 Acquisition cost TENT-CATEG 2 Acquisition cost TERAZOSIN 2 MG CAP PO Acquisition cost TERBINAFINE 250MG TABLET Acquisition cost TERBINAFINE CREAM 1% (LAMISIL) Acquisition cost TERBUTALINE SULF 2.5MG TAB Acquisition cost TERIDENT PSL ACETABULAR SHELL 50MM E CUP C1776 $ 1,200.00 TERSION BAND 2.0 L8699 $ 291.00 TEST FREE/TOTALPANEL Acquisition cost TESTICULAR IMAGING / FLOW 78761 $ 924.11 TESTOSTERONE 5MG/HR PATCH Acquisition cost TESTOSTERONE CYPIONATE-1MG J1071 Acquisition cost TESTOSTERONE FREE 84402 $ 69.19 TESTOSTERONE GEL PAK 1% Acquisition cost TESTOSTERONE PATCH 2.5 MG (SCC) Acquisition cost TESTOSTERONE PATCH 2mg/24hr Acquisition cost TESTOSTERONE PATCH 4mg/24hr Acquisition cost TESTOSTERONE TOTAL 84403 $ 70.11 TESTOSTERONE; FREE 84402 $ 69.19 TESTOSTERONE; TOTAL 84403 $ 70.11 TETANUS AB 86774 $ 40.19 TETANUS IMMUNE GLOB 250 UNIT INJ J1670 Acquisition cost TETANUS IMMUNE GLOBULIN 90389 $ 1,096.57 TETANUS TOXOID 1:10 DILUTION Acquisition cost TETANUS TOXOID 1:5 DILUTION Acquisition cost TETANUS TOXOID TUBEX 0.5ML SYR Acquisition cost TETANUS TOXOID/REDUCED DIPHTH VACC IM 90715 Acquisition cost TETANUS, DIPHTHERIA (TD) ADULT SYR 90714 Acquisition cost TETANUS,DIPHTHER TOXOID ADULT Acquisition cost TETANUS,DIPHTHERIA TOXOID PED < 7 YRS 90702 Acquisition cost TETANUS,DIPTHERIA PED 0.5ML Acquisition cost TETRA/BIS.SC/METRO.125/140/125 (PYLERA) Acquisition cost TETRACAINE 0.5% EYE DROPS 2ML Acquisition cost TETRACAINE 0.5% OPTH 15ML Acquisition cost TETRACAINE HCL 0.5%/15ML EYE DROPS $ 23.10 250MG CAP Acquisition cost TETRACYCLINE 3% TOPICAL OINT Acquisition cost TETRACYCLINE 500MG. PO Acquisition cost TETRACYCLINE 500MG. PO. Acquisition cost TETRACYCLINE INJ TO 250MG J0120 $ 4.38 TETRAMUNE VACCINE 5ML INJ Acquisition cost THALLIUM 82190 $ 40.50 THAM SOL 500 #1593-04 6/CS $ 212.07 THAW & EXPAND FROZEN CELLS EACH ALIQUOT 88241 $ 27.43 THAWFROZENPLASMA 86927 $ 569.71 Page 290 2018 THEOPHYLLIN ANHY 600MG PO Acquisition cost THEOPHYLLINE 80198 $ 38.41 THEOPHYLLINE 200MG GYROCAP Acquisition cost THEOPHYLLINE ANHY 200MG TAB Acquisition cost THEOPHYLLINE ANHYD 100MG TAB Acquisition cost THEOPHYLLINE ANHYD 300MG TAB Acquisition cost THEOPHYLLINE ANHYDROUS 100 MG ER/24HR $ 0.10 THEOPHYLLINE ANHYDROUS 125MG Acquisition cost THEOPHYLLINE ANHYDROUS 200 MG ER/24HR $ 0.10 THER DIAG CONCURRENT INF 96368 $ 23.54 THER IVNTJ W/FOCUS COG FUNCJ 97427 $ 65.69 THER SP PUNCT FOR DRAIN 62272 $ 1,437.02 THER/DIAG CONCURRENT INF 96368 $ 23.54 THER/PROPH/DG IV INF, ADD-ON 96366 $ 97.92 THER/PROPH/DIAG INJ, IA 96373 $ 505.36 THER/PROPH/DIAG INJ, SC/IM 96372 $ 153.91 THER/PROPH/DIAG IV INF ADDON 96366 $ 97.92 THER/PROPH/DIAG IV INF, INIT 96365 $ 505.36 THERAP 1/> AREA/1 UNIT; BALNC/COORD 97112 $ 75.90 THERAP 1/> AREAS/1 UNIT; AQUATIC 97113 $ 84.85 THERAP 1/> AREAS/1 UNIT; EXERCISES 97110 $ 66.68 THERAP 1/> AREAS/1 UNIT; GAIT TRAIN 97116 $ 65.93 THERAP 1/>AREAS/;UNLISTED PROC 97139 $ 136.00 THERAP FX; NASAL INF TURBINATE 30930 $ 5,815.59 THERAP GASTRIC INTUB W ASP 43753 $ 658.04 THERAP PROC 1/> AREAS 1 UNIT; MASSAGE 97124 $ 66.57 THERAP PROC(S)-GROUP 97150 $ 40.00 THERAP RAD PORT FILM 77417 $ 47.52 THERAP RAD SIMULAT-AID FLD; COMPLX 77290 $ 854.44 THERAP RAD SIMULAT-AID FLD; INTERMD 77285 $ 854.44 THERAP/PROPHYLACTIC DX INJ SC/IM RSV-IG 96372 $ 153.91 THERAP/PROPHYLACTIC/DX INJ; SUBQ/IM 96372 $ 153.91 THERAPEUTIC ACTIVITIES 8 TO 22 MIN. 97530 $ 87.71 THERAPEUTIC APHERESIS 36514 $ 3,230.99 THERAPEUTIC DRUG INJECTION BY REPORT D9610 $ 140.00 THERAPEUTIC EXERCISE 23 TO 37 MIN. 97110 $ 66.68 THERAPEUTIC EXERCISE 38 TO 52 MIN. 97110 $ 66.68 THERAPEUTIC EXERCISE 53 TO 68 MIN. 97110 $ 66.68 THERAPEUTIC EXERCISE 8 TO 22 MIN. 97110 $ 66.68 THERAPY PUTTY BLUE, 5LB C1713 $ 69.27 THERMAL ENDOMETRIAL TUM ALBATION 58353 $ 10,873.98 THIABENDAZOLE 500MG CHEW TAB Acquisition cost THIAMINE HCL Acquisition cost THIAMINE LEVEL 84425 $ 57.66 THIOCYANATE 84430 $ 31.59 THIORIDAZINE 10MG TAB Acquisition cost THIORIDAZINE 200MG TAB Acquisition cost THIORIDAZINE 25MG TAB Acquisition cost THIORIDAZINE HCL Acquisition cost THIORIDAZINE HCL 100MG TAB Acquisition cost THIORTHIXENE 10MG CAP Acquisition cost THIORTHIXENE 1MG CAP Acquisition cost THIORTHIXENE 2MG CAP Acquisition cost THIORTHIXENE 5MG CAP Acquisition cost THIOTEPA, 15MG J9340 $ 1,980.00 THIOTHIXENE HCL Acquisition cost Page 291 2018 THIOTHIXINE 5MG/ML ORAL LIQ Acquisition cost THORACENTSIS TRAY C1729 $ 37.56 THORACIC 18FR $ 8.00 THORACIC 20FR $ 8.00 THORACIC 24FR $ 8.70 THORACIC 28FR $ 9.75 THORACIC 32FR $ 9.75 THORACIC 32FR 10/BX C1887 $ 10.52 THORACIC 36FR $ 9.75 THORACIC 40FR $ 9.91 THORACIC CATHETER STERILE 24FR C1887 $ 117.68 THORACIC GAS VOLUM 94727 $ 360.51 THORACIC GAS VOLUME 94727 $ 360.51 THORACIC SPINE CT WITH CONTRAST 72129 $ 668.38 THORACIC SPINE CT WITH/WITHOUT CONTRAST 72130 $ 668.38 THORACIC SPINE MRI W/W/O CONTRAST 72157 $ 1,206.90 THORACIC SPINE MRI WITHOUT CONTRAST 72146 $ 614.37 THORACIC SPINE AP / LAT 72070 $ 302.70 THORACIC SPINE COMPLETE 72074 $ 302.70 THORACIC SPINE CT WITHOUT CONTRAST 72128 $ 302.70 THORACIC SPINE MRI WITH CONTRAST 72147 $ 1,206.90 THORACOLUMBAR 2 VIEWS 72080 $ 164.27 THORACOTOMY; W CNTRL/REP LUNG TEAR 32110 $ 3,122.57 THORAZINE 80299 $ 41.01 THORAZINE 100MG/ML CON 240ML Acquisition cost THORAZINE 25MG/ML 2ML INJ J3230 Acquisition cost THORAZINE 30MG/ML LIQ 120ML Acquisition cost THORAZINE 50MG J3230 $ 132.30 THREAD-LOCK RECON PLATE ANGLE Acquisition cost THROAT/NOSE CULT 87070 $ 23.41 THROAT/NOSE CULTURE 87070 $ 23.41 THROMB ART/VEN TX; W CESS/CATH REM 37214 $ 2,599.54 THROMBECTOMY ART/VENOUS GFT; 35875 $ 11,279.00 THROMBECTOMY CATHETER C1757 Acquisition cost THROMBECTOMY, DIRECT OR WITH C 34451 $ 3,064.56 THROMBIN 5000 UNITS TOPICAL $ 189.46 THROMBIN TIME 85670 $ 15.66 THROMBIN TIME; PLASMA 85670 $ 15.66 THROMBOLYSIS ART/VEN TX; W F/U 37213 $ 2,599.54 THROMBOLYSIS ATERIAL THERAPY 37211 $ 11,279.00 THROMBOLYSIS CEREBRAL BY IV INFUSION 37195 $ 786.94 THROMBOLYSIS VENOUS INFUSION 37212 $ 6,592.23 THROMBOLYSIS; IC INFUSION 92975 $ 808.43 THROMBOLYTIC VENOUS THERAPY 37212 $ 6,592.23 THROMBOSTAT 20,000UNITS/VIAL Acquisition cost THROMBOSTAT 5,OOOUNITS/VIAL Acquisition cost THRUWAY GWIRE SHRT TAPE STRGHT C1713 $ 185.25 THYRDCTOMY MALIG; W NCK DISSECT 60252 $ 11,474.25 THYROGLOB ANTIBODY 86800 $ 43.21 THYROGLOBULIN 84432 $ 43.63 THYROID 60MG TAB Acquisition cost THYROID ABLATION, CARCINOMA 79005 $ 630.67 THYROID ANTI-MICROSOMAL 86376 $ 39.51 THYROID BINDING GLOB 84442 $ 40.15 THYROID CANCER, METS TREATMENT 79005 $ 630.67 THYROID HORMONE UPTAKE/BINDNG RATIO 84479 $ 17.56 Page 292 2018 THYROID IMAG W BLD FLOW; SING/MULTI 78014 $ 924.11 THYROID IMAGING W BLOOD FLOW 78013 $ 924.11 THYROID MET IMAGING, WHOLE BODY 78018 $ 1,198.21 THYROID MET THERAPY 77080 $ 302.70 THYROID MET UPTAKE 78020 $ 61.25 THYROID METASTASTES IMAGING 78015 $ 924.11 THYROID METS W ADDTL STUDIES 78016 $ 924.11 THYROID STIM IMMUNO 84445 $ 138.12 THYROID STIM IMMUNOGLOBULINS 84445 $ 138.12 THYROID STIM LG 84445 $ 138.12 THYROID STIMULATING IMMUNOGLOBULINS 84445 $ 138.12 THYROID SUPPRESSION TX FOR CARDIAC 79005 $ 630.67 THYROID UPTAKE MEASURE; SING/MULTI 78012 $ 924.11 THYROIDECTOMY AFTER PREV PART REM THYR 60260 $ 11,474.25 THYROIDECTOMY TRANSTHOR APPR 60270 $ 2,918.67 THYROIDECTOMY; CERVICAL 60271 $ 11,474.25 THYROIDECTOMY; TOTAL OR COMPLETE 60240 $ 11,870.65 THYROTROPIN BINDING INHIB IG 83519 $ 40.48 THYROXINE (T4) 84436 $ 18.66 THYROXINE BINDING GLOBULIN 84442 $ 40.15 TI END CAP STRDRV 5MM C1713 $ 27.30 TI END CAP W/T40 STRDV 0MM EXT TIB NAILS C1713 $ 282.00 TI LOCKING SCREW 4.0x28MM C1713 $ 301.50 TI-201 RADPHRM DX THAL CHLOR 1 MCI CAR A9505 $ 29.70 TI-201 RADPHRM DX THALLOUS CHLOR/PER MCI A9505 $ 29.70 TIAGABINE 2MG TAB (GABITRIL) Acquisition cost TIAGABINE HCL 12MG TAB Acquisition cost TIAGABINE HCL 16MG TAB Acquisition cost TIAGABINE HCL 20MG TAB Acquisition cost TIAGABINE HCL 4MG TAB Acquisition cost TIB BASEPLATE SZ#5 C1713 $ 1,237.50 TIB BEAR INSERT B RED 10MM RT C1713 $ 187.50 TIB BEAR INSERT B YELLOW LEFT C1713 $ 187.50 TIB BEAR INSERT BLUE D LFT 14M C1713 $ 187.50

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