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Transaction Code Description Transaction Code Description Price KIT ACCESSORY BOOT/ANCHOR 0.00 AMPUTATIONS-SUPPL 0.00 PRESSURE MONITOR SWAN KIT 0.00 LVAD DRIVE LINE KIT 0.00 OXYGEN 0.00 NU-GAUZE,IODAFRM 1INCH 0.00 ARTHROTMY-SUPPL 0.00 BONE & OTHER-SUPPL 0.00 DRUG TEST-DEFINITIVE 1-7 0.00 RESTRAINTS,WRST-LMB 0.00 FEM-POPLIT.BYP-SUPPL 0.00 SORENSON MONITOR KIT 0.00 SUPPLEMENTAL NURSING SYS 0.00 BONE ACCESS KIT 0.00 PERFUSION CUSTOM PACK 0.00 PICC DRESSING CHANGE KIT 0.00 FOLLOLWUP 30 0.00 KIT PORTICO DELIVERY SYST 0.00 PACK,NASAL POST W/DRAWSTR 0.00 PLASTIC RECONS-SUPPL 0.00 COOL CATH TUBING KIT 0.00 CARDIAC ANESTHESIA SUPPLY 0.00 PORT-A-CATH-SUPPL 0.00 CARDINAL PAIN INJ KIT 0.00 BIOPSY TRAY 0.00 KIT(LF)ENDOSCOPIC VASVIEW 0.00 MRI CHEST W/CONTRAST 0.00 PCK CARDIAC HEART STERILE 0.00 POWER PULSE KIT 0.00 LEFT HEART CUSTOM KIT 0.00 M & T-SUPPL 0.00 HIP NAILING-SUPPL 0.00 PULSE LAVAGE KIT 0.00 GASTROSTOMY KIT 0.00 LEEP KIT 0.00 DRUG TEST-DEFINITIVE 8-14 0.00 BOTTLE WATER 1.5L 0.00 TEMP WIRE W/INTRODUCERKIT 0.00 SUPPORTER,A3 ADULT-M 0.00 I & D'S-SUPPL 0.00 CRANIOTOMY-SUPPL 0.00 POUCH FLEX MAXI UROSTOMY 0.00 GOOD GRIP SPOON 0.00 OXYHOOD 12- 0.00 SPINAL CARE KIT JACKSON 0.00 BI&UNILAT VEIN-SUPPL 0.00 DRUG TEST-DEFINITIVE15-21 0.00 CUDDLECUP INSERT 0.00 BLANKET (LF) BAIR HUGGER UPPER BODY 0.00 MASTECTOMY-SUPPL 0.00 LOA RMU 0.00 PACK LINQ 0.00 CHOLECYSTECTOM-SUPPL 0.00 RES BWL,SIG,AP-SUPPL 0.00 TRAY BIOPSY GENERAL UTIL 0.00 KIT(LF)CUSTOM SYRINGE ANGIO 0.00 OXISENSOR(LF)PEDI (PINK) 0.00 THORACIC SURG-SUPPL 0.00 NU-GAUZE PLAIN 1/2INCH 0.00 NU-GAUZE,IODAFRM 1/4INCH 0.00 PICC LINE PACK 0.00 LARYNGECTOMY-SUPPL 0.00 CLEAR DRESSING KIT 0.00 SUPPORTER ATHLETIC XL 0.00 D&C,SIG&HEMORR-SUPPL 0.00 TORQUE WRENCH KIT 0.00 PACK CLOSURE PLUS PROCED 0.00 PEDI BROSELOW OXY MODULE 0.00 FLOMATE KITS 0.00 EXTENDER AMS SPECTRA REAR 0.00 CREAT.AV FISTU-SUPPL 0.00 PACK SORIN CUSTOM TUBING 0.00 SPINAL CARE KIT JACKSON T 0.00 NASAL SPO2 SENSOR 0.00 TYMPANO&STAPES-SUPPL 0.00 KIT TOURNIQUET 5 0.00 KIT SORIN VASC DILATOR 0.00 GAUZE GELFOAM 12X7 0.00 NU-GAUZE PLAIN 1/4INCH 0.00 KIT FLUORESCENCE IMAGING 0.00 LEFT WITHOUT BEING SEEN (LWBS) 0.00 SORENSON DBL MON.KIT 0.00 UNNA BOOT SUPPLY 0.00 COOL POINT TUBING KIT 0.00 LAPAROSCOPIES-SUPPL 0.00 LAVAGE KIT 0.00 NERVE&TEND REP-SUPPL 0.00 AORTO FEM.BYPA-SUPPL 0.00 THYROID&DUCTAL-SUPPL 0.00 NASAL ALAR SPO2 0.00 EXPLOR.LAPAROT-SUPPL 0.00 WRIST SUPPORT 0.00 NU-GAUZE,IODAFRM 2INCHES 0.00 CAROTID ENDART-SUPPL 0.00 FEMALE GENITAL-SUPPL 0.00 KIT SPINAL SURGERY TOP 0.00 DENTAL SAVE-A-TOOTH KIT 0.00 LUMBAR LAMINEC-SUPPL 0.00 TUBING PERFUSION PK Y LIN 0.00 HERNIA/HYDROCE-SUPPL 0.00 NU-GAUZE,IODAFRM1/2INCH 0.00 VASELINE STRIP 3 IN. 0.00 ARTHROSCOPY-SUPPL 0.00 SENSURA MIO FLEX DRAINAGE 0.00 NU-GAUZE PLAIN 1INCH 0.00 GNG,LSN,CST,LI-SUPPL 0.00 INSERTION KIT SENSATION 0.00 SKIN GRAFTS-SUPPL 0.00 SPINAL CARE KIT JACKSON 0.00 NEUROSTIM MEDTRONIC RS2 0.00 ARROW PED.JUGULAR KT 0.00 SKIN SAVVY LAVENDER MIST 0.00 RADIAL APPROACH KIT 0.00 KIT BONE MARROW ASPRATION 0.00 T & A-SUPPL 0.00 BURN CARE PACK 0.00 BLOOD WARMER KIT 0.00 PILONIDAL CYST-SUPPL 0.00 EXPANDED MODEL REPORTING 0.00 KIT POWER PULSE 0.00 CERV.LAM W/FUS-SUPPL 0.00 OXYGEN PER DAY 0.00 C-SECTION CUSTOM PACK 0.00 MALE GENITALIA-SUPPL 0.00 NU-GAUZE PLAIN 2INCHES 0.00 KIT ST JUDE WRENCH EPLEAD 0.00 GOOD GRIP FORK 0.00 COMPRESSED AIR 24 0.00 MULT.TEETH EXT-SUPPL 0.00 Y-KIT 0.00 TOT.HIP&KNEE R-SUPPL 0.00 TRACHEOSTOMY-SUPPL 0.00 MULTILAYER COMPRESSION SU 0.00 KIT BARD FLOMATE 0.00 VASCULAR DILATOR KIT 0.00 SUPPORTER,A3 ADULT-L 0.00 COMPRESSED AIR 01 0.00 ABD-VAG HYSTER-SUPPL 0.00 FOREIGN BODIES-SUPPL 0.00 SENSOR PULSEOX TAPE ADULT 0.00 CUDDLE CUP UNIT 0.00 REMOVAL METAL-SUPPL 0.00 PACEMAKER/ICD SUPPLY CART 0.00 BAG-A-JETS 0.00 OXYHOOD SET-UP 0.00 ANGIO PACK 0.00 CVP MONITOR KIT 0.00 GUIDE WIRE 0.00 BREAST BIOPSY-SUPPL 0.00 BARRIER MIO FLEX FLAT 2PC 0.00 OXYGENATOR QUADROX ID 0.00 OXYGENATR SORIN INSPIRE6F 0.00 KIT PATIENTCARE FOR HANNATABLE 0.00 REVEAL LINQ TOOL KIT 0.00 CLSD.REDUC.LMB-SUPPL 0.00 RHYTHMIA PATCH KIT 0.00 PLUG STRYKER SIZE 2 0.00 KIT DRAIN CHEST ATRIUM 0.00 PORT DRESSING CHANGE KIT 0.00 QUICK PRESS. MONITOR PACK 0.00 PF-CIVIL SURGEON CTN VS 0.00 INTRODUCER KIT 0.00 VASCULAR DILATOR KIT 0.00 SUP.-WARMING COVERS 0.00 OPEN REDUC.LMB-SUPPL 0.00 INFANT OXYGEN 0.00 RELOAD LSI COR-KNOT 6PACK 0.00 LIMB HLD LG/XL QK REL/HEE 0.00 FREEDOM WRIST SUPPORT 0.00 KIT TOURNIQUET 6 0.00 KEITH ANTI REFL.VLVE 0.00 DRUG TEST-DEFINITIVE 22+ 0.00 VALVE SAPIEN 23 0.00 OXYHOOD 12+ 0.00 OXISENSOR II ADULT DISP. 0.00 ANESTHESIA SUPPLY 0.00 PACKING FEMORAL CANAL 20CM 0.00 SEPTOPLASTY-SUPPL 0.00 UNI. MICROINTRODUCER KIT 0.00 DRIVER CUTTER HAWKONE 0.00 CPM SOFT GOODS KIT 0.00 NON COVERED HOLD TO ADJUST CLAIM 0.01 CYSTOGRAFIN PER ML 300ML BOTTLE 0.29 TRAVEL ALLOWANCE 34 PATIENTS 0.60 TRAVEL ALLOWANCE 32 PATIENTS 0.64 TRAVEL ALLOWANCE 28 PATIENTS 0.73 TRAVEL ALLOWANCE 27 PATIENTS 0.76 TRAVEL ALLOWANCE 25 PATIENTS 0.82 TRAVEL ALLOWANCE 24 PATIENTS 0.85 TRAVEL ALLOWANCE 22 PATIENTS 0.93 TRAVEL ALLOWANCE 21 PATIENTS 0.98 TRAVEL ALLOWANCE-20 PATIENTS 1.03 TRAVEL ALLOWANCE-19 PATIENTS 1.08 TRAVEL ALLOWANCE-18 PATIENTS 1.14 TRAVEL ALLOWANCE-17 PATIENTS 1.21 TRAVEL ALLOWANCE-16 PATIENTS 1.28 TRAVEL ALLOWANCE-15 PATIENTS 1.37 TRAVEL ALLOWANCE-14 PATIENTS 1.47 TRAVEL ALLOWANCE-13 PATIENTS 1.58 TRAVEL ALLOWANCE-12 PATIENTS 1.71 TRAVEL ALLOWANCE-11 PATIENTS 1.87 JEVITY 1.2 2.00 PASTE STRIP OSTOMY 2.00 TRAVEL ALLOWANCE-10 PATIENTS 2.06 TRAVEL ALLOWANCE-9 PATIENTS 2.28 TRAVEL ALLOWANCE-8 PATIENTS 2.57 TRAVEL ALLOWANCE-7 PATIENTS 2.94 DRESSING PRIMAPORE6X3 1/8 3.00 AIRWAY ADULT 80MM 3.00 SENSURA MIO HIGH OUTPUT 3.00 OSMOLITE 1.5 3.00 POUCH MIO SINGLE USE KIT 3.00 OSMOLITE 1 CAL 3.00 PROMOTE WITH FIBER 3.00 TWOCAL HN 3.00 OPTILOCK 6.5X10 3.00 TRAVEL ALLOWANCE-6 PATIENTS 3.43 RECOVERY RM PER MINUTE 4.00 RECOVERY RM PER MIN 4.00 THERABAND 4.00 THERABAND 4.00 CONTRAST ISOVUE 300 PER ML 4.00 LOCM-ISOVUE 300 INJECTION 50ML 4.00 OT-THER IVNTJ COG FUNCJ 1:1 CNTCT-RMU EA ADD'L MIN 4.00 CONTRAST ISOVUE300 PER ML 4.00 WASTE - LOCM-ISOVUE 300 INJECTION 50ML 4.00 LOCM-ISOVUE 300 INJECTION 100 ML 4.00 CONTRAST ISOVUE 370 PER ML 4.00 FACE TENT 4.00 CONTRAST ISOVUE370 PER ML 4.00 WASTE - LOCM-ISOVUE 300 INJECTION 100 ML 4.00 RADIOPHARM TC99M PERTECHNETATE 4.00 RECOVERY RM PER MINUTE 4.00 RECOVERY ROOM CHARGE 4.00 CONTRAST ISOVUE 370 PER ML 4.00 TRAVEL ALLOWANCE-5 PATIENTS 4.12 TRAVEL ALLOWANCE-4 PATIENTS 5.00 CONTRAST ISOVUE300 PER ML 6.00 DECELLULARIZED DERMIS 6.00 CONTRAST ISOVUE M300PERML 6.00 POUCH, OSTOMY 2 3/4INCHES 6.00 TRACH COLLAR 6.00 CONTRAST ISOVUE M300PERML 6.00 POUCH, UROSTOMY 1 3/4INCH 6.00 AZITHROMYCIN 250 MG TAB 6.20 TRAVEL ALLOWANCE-3 PATIENTS 6.66 CATH FOLEYSILICONE5CC12FR 7.00 CATH ULTRAMAR RR 14FR 7.00 POUCH MIO DRAINABLE 7.00 CATH FOLEYSILICONE5CC14FR 7.00 CATH ULTRAMAR RR 18FR 7.00 POUCH MIO UROSTOMY CONVEX 7.00 PROMOTE 8 OZ. 7.00 DRESSING WD PRIM 11 3/4X4 7.00 CATH ULTRAMAR RR 16FR 7.00 CATH FOLEY SILICO30CC16FR 7.00 CATH ULTRAMAR RR 12FR 7.00 CATH ULTRAMAR RR 10FR 7.00 BEHAV CHNG SMOKING > 10 MIN 7.00 CATH FOLEY SILICONE 5CC 16FR 7.00 CATH ULTRAMAR RR 20FR 7.00 SMOKING CESSATION >10 MINUTES 7.00 FLANGE YELLOW STANDARD 7.00 CORRUGATED TUBING 8.00 GLUCERNA 1.2 8.00 CATH FOLEYSILICON30CC18FR 8.00 PT GAIT/MOBILITY TRAINING-RMU-M 8.00 PT ULTRASOUND 8.00 OT THERAPEUTIC EXERCISES-RMU-M 8.00 THERAPEUTIC FOAM 8.00 VITAL 1.2 8.00 POUCH URO MULTI-CHAMBER 8.00 PT WHEELCHAIR MGT TRAINING-RMU-M 8.00 OT NEUROMUSCULAR RE-ED/BALAN-RMU-M 8.00 DILATORS SET 8.00 MEDTRONIC LV VENT 16FR 12016 8.00 PT THERAPEUT ACTVITY DIRECT PT CONTACT RMU 8.00 PT PROSTHETIC TRAINING INITIAL -RMU 8.00 DRESSING TEGADERM 4X10 8.00 OT THERAPEUT ACTVITY DIRECT PT CONTACT RMU 8.00 PT NEUROMUSCULAR RE-ED/BALAN-RMU 8.00 PROSOURCE 8.00 PT THER EXERCISE RMU - PER MIN 8.00 LOCM-VISIPAQUE 270 PER ML 9.00 CONTRAST ISOVUE M200 PER ML 9.00 SET ALARIS EXT.W1.2MM FLT 9.00 MECHANICS/NIF VALVE 9.00 SUCTION TRAP 9.00 ADL TRAINING-RMU 9.00 DRESSING, TEGADERM 6X8 9.00 CATH SILASTIC FOLEY 5CC 18F 9.00 CATH SILASTIC FOLEY5CC16F 9.00 BUR DENTAL 558 9.00 POUCH SENSURA W/FILTER 9.00 CONTRASTVISIPAQUE270PERML 9.00 BRKAWAY INTRO.NEEDLE 9.00 CONTRAST ISOVUE M200 PER ML 9.00 PATCH DERMIS 40X40CM 9.00 CLEANER ENDO DEFOGGER 9.00 CATH FOLEY SILASTIC30CC18 9.00 PATCH DERMIS 40X70CM 9.00 BD 25GA 3.5 NEEDLE 9.00 SET ALARIS EXT.W1.2MM FLT 9.00 BLADE MINI BEAVER 65MM 9.00 VENTI-MASK 9.00 CONTRAST ISOVUE M200 PER ML 9.00 OT ORTHOTIC MGMT&TRAIN 1ST ENC EA 15MIN - RMU 10.00 ENDO TBE 10.00 BLADE MINI BEAVER 64MM 10.00 TRAVEL ALLOWANCE-2 PATIENTS 10.30 ORTH/PROSTH MGMT/TRNG SBSQ EA ADD'L MIN-RMU 11.00 OT ORTHTC/PROSTH MGMT SBSQ ENC EA 15MIN - RMU 11.00 ORTH/PROSTH MGMT/TRNG W/FIT-INITIAL MIN-RMU 11.00 T-FOAM 11.00 ESOPHAGEAL STETH 9FR 12.00 STER.SODIUM CHLORIDE 12.00 TEMP PROBE,SKIN 12.00 DRESSING MEPILEX BORDER 3X3 13.00 PLASMA-LYTE 1000 ML 14.00 OPTILOCK 5X5.5 15.00 URINE, MICROALBUMIN 15.00 SENSURA MIO BELT, 40 15.00 SIGMOID SUCTION 16.00 FUROSEMIDE INJECTION, UP TO 20MG 16.00 SENSURA URO 1PC NON-CONV 16.00 TUBING 1 FT-M-F 16.00 DUODERM CGF DRESSING 4X4 17.00 CATH(LF)ULTRAMAR 5CC 18FR 17.00 CATH(LF)ULTRAMAR 5CC 20FR 17.00 SENSURA MIO BELT, 61 17.00 BAG,UROSTOMY NIGHT 2L 17.00 ULTRASOUND PROBE COVER, PE, UNITED MED 6X70IN 18.00 IRR SET CYSTO 6544 18.00 CAUTERY NEEDLE TIP SHORT 18.00 CAUTERY NEEDLE SHORT 18.00 CATH ULTRAMAR 30CC 20FR 18.00 TUBE,SALEM SUMP 10FR 18.00 POWDER OSTOMY NONSTERILE 18.00 VENT CIRCUIT 18.00 CAUTERY NEEDLE SHORT 18.00 18 G NEEDLE 18.00 ANESTHESIA,ADDT'L MIN 18.00 CATH ULTRAMAR2WAY30CC22FR 18.00 ANES-RADIOLOGY PER MIN 18.00 HEMOLOCK CLIP (LF) SMALL 18.00 OUTLET WIDE 1PC SENSURA 18.00 PROTECTOR,HEEL/ELBOW
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