Charge Code Description Price 10021 FNA W/O IMAGE 280.00 10060 I&D ABSCESS‐SIMPLE 132.00 10061 I&D COMPLICATED MULTI 223.00 10080 I&D PILONIDAL CYST SIMPLE 200.00 10120 I&D SUBCUTANEOUS SIMPLE 124.00 10121 I&D SUBCUTANEOUS COMP 253.00 10140 DRAINAGE OF HEMATOMA/FLUID 590.00 10160 PUNCTURE DRAINAGE OF LESI 370.00 11042 DEBRIDE SKIN/TISSUE 277.00 11055 PARING OF LESION,SINGLE 167.00 11056 PARING OF LESION,2 TO 4 222.00 11057 TRIM SKIN LESIONS OVER 4 120.00 11100 BIOPSY OF SKIN SUBCT TISSUE, SINGLE LESI 65.00 11101 BIOPSY SKIN SUBCT TISS AD 99.10 11200 Removal of skin tags upto 15 222.00 11201 REMOVE SKIN TAGS add‐on 167.00 11300 SHAVING OF LESION .5CM OR LESS 55.06 11301 SHAVING OF LESION 0.6 TO 1.0CM 156.00 11302 SHAVING OF LES 1.1 TO 2.0 CM TK AR/LG 112.00 11303 shaving of les OVER 2.0CM 222.00 11305 SHAVING OF LES 0.5CM OR LESS SCALP,NECK 112.00 11306 SHAVING OF LES 0.6 TO 1.0 CM 167.00 11307 SHAVING OF LES 1.1 TO 2 C 222.00 11310 SHAV OF EP OR DER SING LES 0.5 CM OR < 112.00 11311 SHAVING OF LES 0.6 TO 1.0 167.00 11312 SHAVING OF LES 1.1 TO 2.0 222.00 11313 SHAVE SKIN LESION >2.0 CM 200.00 11400 EX BE LES TK AR LG 0.5CM OR LESS 112.00 11401 EX BE LE TK AR LG .6 TO 1.0 CM 112.00 11402 LES EXCISION TRUNK,ARM/LEG 1.1 TO 2.0CM 194.00 11403 LES EXCISION OF TRUNK,ARM/LEG 2.1‐3.0CM 165.00 11404 EXC TR‐EXT B9+MARG 3.1‐4 623.00 11406 EXC TR‐EXT B9+MARG > 4.0 564.00 11420 EXC LES OF SC NK HA FT GENT 0.5CM OR LES 100.00 11421 EXC H‐F‐NK‐SP B9+MARG 0.6 172.00 11422 Skin Lesion removal EXC H‐F‐NK‐SP B9+MAR 205.00 11423 EXC H‐F‐NK‐SP B9+MARG 2.1 433.00 11424 EXC H‐F‐NK‐SP B9+MARG 3.1 692.00 11426 EXC H‐F‐NK‐SP B9+MARG >4 CM 360.00 11440 EXC FACE‐MM B9+MARG 0.5 CM/< 480.00 11441 EXC FACE‐MM B9+MARG 0.6‐1 CM 175.00 11442 EXC FACE‐MM B9+MARG 1.1‐2 CM 556.00 11444 EXC FACE‐MM B9+MARG 3.1‐4 CM 1,040.00 11600 EXC TR‐EXT MLG+MARG 0.5 < 285.00 11601 Exc tr‐ext mal+marg 0.6‐1 cm 250.00 11602 EXC OF MAL LES TK AR LG 1.1 TO 2.0CM 381.00 11603 EXC MAL LES TK AR LG 2.1 TO 3.0 CM 431.00 11604 MAL LES REM 3.1 TO 4.0 CM 387.00 11606 EXC TR‐EXT MLG+MARG > 4 C 491.00 11621 EXC H‐F‐NK‐SP MLG+MARG 0. 349.00 Charge Code Description Price 11622 Exc s/n/h/f/g mal+mrg 1.1‐2 275.00 11640 EXC FACE‐MM MALIG+MARG 0. 304.00 11642 EXC FACE‐MM MALIG+MARG 1. 417.00 11643 EXC FACE‐MM MALIG+MARG 2. 491.00 11644 EXC F/E/E/N/L MAL+MRG 3.1‐4 1,514.00 11719 TRIM NAIL(S) ANY NUMBER 31.00 11720 DEBRIDE NAIL 1‐5 121.00 11721 DEBRIDE NAIL 6 OR MORE 100.00 11730 AVULSION NAIL PLATE 172.00 11732 REMOVE NAIL PLATE ADDON 69.00 11740 EVACUATION HEMATOMA NAIL 43.00 11750 REMOVAL OF NAIL BED 334.00 11900 INJECT SKIN LESIONS 850.00 25600 TREAT FRACTURE RADIUS/ULN 1,199.10 25605 TREAT FRACTURE RADIUS/ULNA 985.00 26010 DRAINAGE OF FINGER ABSCES 977.00 27301 DRAIN THIGH/KNEE LESION 715.00 Charge Code Description Price 27323 BIOPSY THIGH SOFT TISSUES 285.00 27613 BIOPSY LOWER LEG SOFT TISSUE 460.00 28470 TX CL FX METATARSAL W/O M 690.00 29075 APPLICATION OF FOREARM CA 240.00 29085 APPLY HAND/WRIST CAST 288.00 29105 APPL SPLINT LONG ARM 117.00 29125 APPL SPLINT SHORT ARM STA 84.00 29130 APPL SPLINT FINGER STATIC 62.00 29515 APPLICATION LOWER LEG SPL 194.00 3000001 SEMI‐PRIVATE ROOM 2,300.00 3000002 PRIVATE ROOM 2,300.00 3020001 BH SEMI‐PRIVATE ROOM 2,000.00 3020002 BH PRIVATE ROOM 2,000.00 3050010 OBS ‐DIRECT ADMIT 400.00 3050011 OBSERVATION PER HOUR 75.00 3100001 SWING BED 2,000.00 3200002 INJECT/IMMUNIZ IN TX RM 60.00 3200003 FB REMOVAL ‐TX RM‐SIMPLE 97.00 3200006 LESION REMOV 2‐TX RM‐CPLX 249.00 3200011 INFUS/HYDRAT T/R SUBSQ HR 33.03 3200013 TX RM ‐INCIDENT TO ANCILL 105.00 3200015 FOLEY CATH PROC ‐TX RM 145.00 3200019 GASTRO TUBE CHANGE ‐TX RM 670.00 3200020 INFUS HYDRAT ER SUBSEQ HR 48.00 3200021 ADMIN OF VACCINE‐ONE 58.50 3200022 RELS DUPUYTREN'S CONTRACT 2,962.00 3200025 TOENAIL REMOVAL ‐TX RM 185.00 3200027 FB REMOVAL ‐ER ‐COMPLEX 222.00 3200028 INFUSION ER SUBSEQ‐HR 48.00 3200033 PNEUMONIA VACCINE ADMIN 55.00 3200036 INFUS SEQUENT up to 1 hr 66.07 3200038 PAC FLUSH 85.00 3200040 INFUS HYDRAT ER 1ST HOUR 234.00 3200041 CYSTOSTOMY TUBE CNGE ‐T/R 235.00 3200044 INFUS HYDRAT T/R 1ST HR 234.00 3200045 INFUS CONCURRENT 66.07 3200046 INJECTION, IV ‐ER ‐SUBSQT 66.07 3200047 INJECTION, IV ‐T/R SUBSQT 40.00 3200048 SUTURE PROC 2‐SIMPLE ‐ER 172.00 3200051 INFUSION T/R SUBSEQ MEDS 33.03 3200052 INJECT, IM SQ ‐T/R ‐FIRST 60.00 3200060 INJECT, IM SQ ‐ER ‐FIRST 55.00 3200062 LESION REMOV 2‐ER‐COMPLEX 249.00 3200063 CRIT CARE‐EA ADD 30 MIN* 469.00 3200064 CYSTOSTOMY TUBE CHANGE‐ER 273.00 3200065 DEBRIDEMENT TX RM SIMPLE 163.00 3200066 DEBRIDEMENT TX RM SIMPLE 163.00 3200069 FLU VACCINE ADMIN 55.00 3200071 INFUSION T/R 1ST HR MEDS 234.00 3200077 TREATMENT RM ‐OUTPATIENT 95.00 Charge Code Description Price 3200080 BIOSPY OF TEMPORAL ARTERY 586.00 3200082 INFUSION ER 1ST HOUR 235.00 3200084 CRIT CARE‐30 TO 74 MIN * 935.00 3200087 TEMP EXTERNAL PACING 352.00 3200088 FOLEY CATH PROCEDURE ‐ER 145.00 3200090 INJECTION, IV ‐ER ‐FIRST 125.00 3200091 INJECTION, IV ‐T/R FIRST 110.00 3200092 STRAPPING KNEE 159.00 3200093 TRACHEOSTOMY TUBE CHANGE 205.00 3200094 CATHETER STRAIGHT TX RM 145.00 3200101 CENTRAL VENOUS CATH ER 802.00 3200103 GASTRO TUBE CHANGE ‐ER 670.00 3200106 AMPUTATION IN TX RM 249.00 3200109 INTRAOSSEOUS INFUSION 209.00 3200111 T&A OVER 12 YEAR OLD 2,000.00 3200112 TB TEST ‐TUBERCULIN 33.03 3200113 CATHETER STRAIGHT ER 145.00 3200114 CHEST TUBE INSERTION 500.00 3200115 EAR IRRIGATION IN ER 70.00 3200121 EAR IRR IN TX ROOM 70.00 3200125 IV START PROCEDURE 20.00 3200127 NOSE BLEED CONTROL 145.00 3200131 LEVEL 2 O/P ER * 168.00 3200134 INTUBATION 352.00 3200135 LEVEL 1 O/P ER * 104.00 3200136 LEVEL 3 O/P ER * 264.00 3200137 LEVEL 4 O/P ER * 421.00 3200139 VAGINAL DELIVERY 2,284.00 3200148 LEVEL 5 O/P ER 626.00 3200150 TUBAL LIGATION 3,144.00 3200151 Cardioversion‐External 799.00 3200159 RESTORATIVE DENTISTRY 172.00 3200161 INFUSION OF THROMBOLYTIC 295.00 3200162 INITIAL BURN TREATMENT 275.00 3200163 FOLLOWUP BURN TREATMENT S 359.00 3200164 FOLLOWUP BURN TREATMENT M 550.00 3200165 STRAPPING ANKLE; ANY A 159.00 3200167 REMOVAL IUD 208.00 3200168 BIOPSY SKIN LESION 117.00 3200170 FB REM; SUBQ TISSUE SIMPL 399.00 3200171 FB REM; SUBQ TISSUE COMPL 2,314.00 3200172 FB REM: MUSCLE/TENDON SIM 652.00 3200173 FB REM: MUSCLE/TENDON DEE 3,178.00 3200174 FB REM: UPPER ARM/ELBOW S 652.00 3200175 FB REM; FOOT SUBCUTANEOUS 1,203.00 3200176 APPL; CAST‐FIGURE EIGHT 159.00 3200177 APPL; CAST‐LONG ARM 355.00 3200178 APPL; CAST‐SHORT ARM 355.00 3200179 APPL; SPLINT LONG ARM 159.00 3200180 APPL; SPLT SHORT ARM‐STAT 159.00 Charge Code Description Price 3200181 APPL; SPLT SHORT ARM‐DYNA 159.00 3200182 APPL; SPLINT FINGER ‐STAT 159.00 3200183 APPL; SPLINT FINGER‐DYNAM 159.00 3200184 STRAPPING SHOULDER; ANY A 159.00 3200185 STRAPPING; ELBOW OR WRIST 159.00 3200186 APPL; CAST‐LONG LEG 355.00 3200187 APPL; CAST‐SHORT LEG 355.00 3200188 APPL; SPLINT LONG LEG 159.00 3200189 APPL; SPLINT SHORT LEG 159.00 3200190 FB REM; INTRANASAL‐SIMPLE 185.00 3200194 PERICARDIOCENTESIS; SUBQ 777.00 3200196 VENIPUNCTURE <3 YRS;FEM O 66.07 3200197 VENIPUNCTURE‐SCALP VEIN 66.07 3200198 VENIPUNCTURE >3 YRS (Phys 33.03 3200200 VENIPUNCTURE CUTDOWN <1 Y 135.00 3200201 VENIPUNCTURE CUTDOWN OVER 135.00 3200202 TRANSFUSION; BLOOD 489.00 3200205 ARTERIAL CATHETER INSERT 220.00 3200206 FB REMOVAL; PHARYNX 233.00 3200207 GASTROSTOMY TUBE REPOSITI 1,261.00 3200208 BLADDER CATH‐COMPLICATED 161.00 3200209 FB REMOVAL EXTERNAL EYE 137.00 3200210 FB REMOVAL CORNEAL W/O SL 137.00 3200211 FB REMOVAL CORNEAL W/ SL‐ 137.00 3200212 FB REMOVAL; EXTER EAR CAN 145.00 3200213 GLUCOSE; ACCUCHECK 41.00 3200214 GASTRIC INTUB‐LAVAGE 220.00 3200215 CARDIOPULMON RESUSCITATIO 673.00 3200217 PULSE OX; SINGLE DETERMIN 57.00 3200218 PULSE OX; MULTI DETERMIN. 110.00 3200219 PULSE OX; CONTIN (OVERNIG 165.00 3200220 ADMIN OF VACCINE‐EA ADD'L 58.50 3200221 INJECTION‐INTRA ARTERIAL 125.00 3200222 Injection, IV ‐ER; ea add 66.07 3200223 IPECAC ADM & OBSERVATION 57.00 3200224 THERAPEUTIC PHLEBOTOMY 88.09 3200225 BLADDER CATH‐FOR URINE SP 96.00 3200226 ER PROCEDURE LEVEL 1 293.00 3200227 ER PROCEDURE LEVEL 2 550.00 3200228 ER PROCEDURE LEVEL 3 1,542.00 3200229 ER PROCEDURE LEVEL 4 2,753.00 3200230 ER PROCEDURE LEVEL 5 3,524.00 3200231 LACERATION REPAIR Level I 271.00 3200232 LACERATION REPAR Level II 341.00 3200233 LACERATION REPAIR Level III 766.00 3200234 LACERATION REPAIR Level IV 1,063.00 3200235 PERIPHERAL IV BY MD 33.03 3200248 TELEHEALTH FACILITY FEE 33.03 3200249 EXPLORE WOUND EXTREMITY 2,022.00 3200250 I&D OF VULVA/PERINEUM 246.00 Charge Code Description Price 3200251 TREAT FRACTURE OF RADIUS 786.00 3200871 TREAT ELBOW DISLOCATION 387.00 3250002 CARPAL TUNNEL RELEASE O/R 2,912.00 3250011 VASCULAR DEVICE PLACEMNT 975.00 3250017 OPERATING ROOM 1 1/2 HR 1,113.00 3250018 OPERATING ROOM 2 1/2 HR 1,560.00 3250021 BONE MARROW BIOP TRY 294.00 3250022 BRUSH BIOPSY STOMACH 1,560.00 3250024 CIRCUMCISION(OVER 3Y 4,455.06 3250026 DISP. SURGICAL LINEN 79.00 3250029 MICRO FOAM PRES/TAPE 15.00 3250030 MULTIPLE PKG SUTURES 84.00 3250031 OPERATING ROOM 1 HR. 895.00 3250032 OPERATING ROOM 2 HR. 1,338.00 3250033 OPERATING ROOM 3 HR. 1,779.00 3250038 POOLE SUCTION TUBING 42.00 3250042 UMBILICAL(OVER 6YRS) 4,008.00 3250048 BOVIE MACH. CAUTERY 68.00 3250052 SIGMOIDOSCOPY WO BIOPSY 1,338.00 3250062 PRECIPITATION TRAY 51.00 3250065 STERILE INSTRUMENT 27.00 3250066 SURG. SUCT. TUBING 13.00 3250077 LIVER BIOPSY TRAY 121.00 3250084 TOURNIQUET, PNUE. 41.00 3250086 GU DRAIN BAG 59.00 3250087 BOVIE PLATE DISP 19.00 3250095 THORACOTOMY TRAY 121.00 3250101 DRAINS, CIGARETTE 13.00 3250102 DRAINS, PENROSE 24.00 3250103 ER TRAY X‐SMALL 35.00 3250106 SUTURE PER PKG. 24.00 3250109 ER TRAY‐MEDIUM 70.00 3250112 MAGNETIC DRAPE 53.00 3250113 SKIN PREP SOL. 37.00 3250116 XYLOCAINE 10CC 29.00 3250117 XYLOCAINE 30CC 62.00 3250120 ER TRAY‐LARGE 84.00 3250121 ER‐TRAY SMALL 51.00 3250125 KERLIX SPONGE 44.00 3250127 SIGMOIDOSCOPY W BIOPSY 1,235.00 3250128 STERILE LINEN 9.00 3250139 KERLIX ROLL 13.00 3250140 MAYO COVERS 35.00 3250152 VAG. PACK 9.00 3250153 VASECTOMY 2,352.00 3250160 4 X 4 19.00 3250163 LAP CHOLE 3,304.00 3250164 COLONOSCOPY 1,246.00 3250165 COLONOSCOPY W/ BIOPSY 1,445.00 3250168 PICC OVER AGE 5 1,532.00 Charge Code Description Price 3250170 COLON CA SCRN‐COLONSCOPY 1,246.00 3250171 COLON CA SCRN‐COLONSCOPY 1,246.00 3250172 DECOMPRESSION OF LEG WITH DEBRIDEMENT 5,205.00 3250801 J PEG KIT 20 FR 332.00 3250819 SALINGO‐OOPHORECTOMY 6,607.00 3250827 LAP CHOLE W/CHOLANGIOGRAM 6,955.00 3250828 I&D SKIN ABSESS 216.00 3250831 HYSTERSCOPY; BIOPSEY 3,353.00 3250833 INCISION OF BREAST LESION 2,886.00 3250835 DRAIN/INJECT JOINT/BURSA 409.00 3250839 PMKR, DUAL, RATE‐RESP 5,397.00 3250856 INSERT NON‐TUNNEL CV CATH 1,710.00 3250857 COLONOSCOPY BY HOT BIOPSY 1,445.00 3250858 COLONOSCOPY‐BIOPSY BY SNA 1,445.00 3250861 APPENDECTOMY 4,223.00 3250862 RMVL DEVITAL TIS 20 CM/< 233.00 3250863 CATHETER FOR HYSTEROGRAPH 167.00 3250864 EGD DIAGNOSTIC 1,303.00 3250868 REMOVAL OF NAIL PLATE 172.00 3250869 REMOVE NAIL PLATE ADD‐ON 137.00 3250872 HYSTEROSCOPY DX SEP PROC 3,549.00 3250873 ABD PARACENTESIS W/IMAGIN 850.00 3250874 RPR S/N/AX/GEN/TRNK 2.5CM 185.00 3250875 REMV+REPLC PM GEN DUAL LE 15,935.00 3250877 I&D OF SKIN ABSCESS MULTI 405.00 3250878 PRP I/HERN INIT REDUC >5 5,082.00 3250880 RPR UMBIL HERN REDUC > 5 5,078.00 3250883 AMPUTATION OF TOE 3,408.00 3250884 EXCISION BENIGN LESION 682.00 3250885 EGD W/BIOPSY 1,542.00 3250886 DEBRIDE GENITALIA & PERIN 3,084.00 3250887 REREPAIR ING HERNIA REDUCE 5,727.00 3250890 DEBRIDE INFECTED SKIN 570.00 3250891 REPAIR INITIAL INCISIONAL VENTRAL HERNIA 6,700.00 3250892 DEBRIDE ABDOM WALL 3,275.00 3250893 GASTRO W/POLYP REMOVAL RM 2,135.00 3300004 RECOVERY ROOM 1/2 183.00 3350010 ENDOTRACHEAL TUBE 59.00 3350020 STR. SUCT. 35.00 3350022 SEVOFLURANE 79.00 3350025 ANES ADMIN PER MIN 29.00 3400001 LHC W/CORONARY ANGIO 9,885.00 3400015 INJECT SUPRVLV AORTOGRAPH 654.00 3400019 LT HRT CATH W/VENTRCLGRPH 7,902.00 3400025 CARDIOVERSION EXTERNAL 1,610.00 3400027 TEE W/COLOR FLOW DOPPLER 1,500.00 3400039 INTRO OF NEEDLE/SHEATH, E 1,432.00 3500004 THYROID STIMULATING IMMUN 282.00 3500012 HERPES SIMP, NON‐SPEC 165.00 3500019 ACETYL RECEP BINDING, AB 240.00 Charge Code Description Price 3500020 ACETYL RECEP MOD AB 240.00 3500024 RENAL FUNCTION PANEL 99.00 3500027 SMEAR‐WND ABC AERO+ANA 59.00 3500028 ACETYL RECEP BLOCKING AB 240.00 3500032 PREG, HCG, QUALT 109.00 3500050 RA FACTOR‐QUANT 88.09 3500053 THYROID PEROX AB ANTI‐TPO 174.00 3500054 TISS TRANSGLUTAM IGG,ISA 112.00 3500061 MICROALB/CREAT RATIO‐OTH 85.00 3500066 CITRIC ACID, CITRATE ‐ UR 260.00 3500069 CULTURE‐HSV 167.00 3500070 IMMUNOELECTROPHOR, SERUM 216.00 3500072 SEX HORMONE BINDING GLOB 249.00 3500073 ANTI‐MAG (MAG DUET AG) 230.00 3500078 ISLET CELL AB SCREEN 213.00 3500079 KEPPRA LEVET LEVEL 269.00 3500088 LYMPHOCYTE SUBSET PANEL 4 480.00 3500089 PHOPHOROUS, 24 HOUR URINE 60.00 3500090 RICKETTSIA ANTIBODY TITER 202.00 3500093 HYDROXY PROGESTERONE ‐17 260.00 3500094 INFLUENZA A VIRUS 73.00 3500095 LIPID PANEL 158.00 3500100 URINE AUTO W/O MICRO 44.04 3500101 CULTURE‐VIBRIO CHOLOREA 103.00 3500102 ALDOSTERONE 24 HR URINE 332.00 3500105 CORTISOL, FREE ‐ 24 HR. 219.00 3500107 GLUCOSE TOLERANCE 3 SPEC 119.00 3500110 PARATHRYOID ‐PTH INTACT 238.00 3500117 PROTEIN ELECTROPHORESIS‐S 153.00 3500119 CULTURE‐WND ABCESS, ANAER 103.00 3500120 CALCIUM‐24 HOUR, URINE 85.00 3500121 DRUG SCREENING‐COC 105.00 3500127 CALCIUM‐TOTAL RANDOM URIN 65.00 3500128 CELIAC DISEASE TEST 1 128.00 3500129 CELIAC DISEASE TEST 2 112.00 3500130 HG A1C LEVEL 7.0‐9.0% 0.01 3500131 ELECTROPHORESIS URINE 85.00 3500134 HEPATITIS BS ANTIBODY 128.00 3500135 HIV RNA,QN,VIRAL LOAD 899.00 3500136 KEPPRA(LEVETIRACETAM) 269.00 3500138 URINE AUTO PLUS MICRO 57.00 3500139 VITAMIN D, 25‐HYDROXY 241.00 3500141 CULTURE‐WND ABCESS, AEROB 128.00 3500145 ALKALINE PHOSPHATASE 48.00 3500147 ALPHA‐1 ANTI‐TRYPSIN‐TOTA 194.00 3500148 AMIKIN PEAK 206.00 3500149 ANTI‐THYROID ANTIBOD 189.00 3500157 CALCIUM,IONIZED/FREE 174.00 3500160 CLOSTRIDIUM DIFF‐CDT 230.00 3500161 COPPER, SERUM/PLASMA 197.00 Charge Code Description Price 3500162 CREATININE CLEARENCE 142.00 3500163 SMEAR‐CRYPTOSPORIDIUM MAF 71.00 3500164 D‐DIMER QUANTITATIVE 123.00 3500165 DRUGS OF ABUSE OUTPT 134.00 3500168 H PYLORI AG, STOOL 167.00 3500169 HEPATITIS A ANTIBODY 142.00 3500170 MONO SPOT 64.00 3500176 LIVER FUNCTION PANEL 156.00 3500180 PROTEIN S, ANTIGENIC 197.00 3500181 RENAL CALCULI ANALYS 71.00 3500182 CLINICAL PATHOLOGY;LIMITE 191.00 3500186 VIRAL C&S FOR HERPES 101.00 3500187 VITAMIN B1,(THIMMINE) 230.00 3500189 ACETAMINOPHEN LEVEL 195.00 3500192 ANTIMICROSOMAL, EA ANTI 174.00 3500199 CAT SCRATCH DISEASE 174.00 3500201 CRYPTOCOCCUS AB,CSF 137.00 3500202 CSF ELECTROPHERESIS 181.00 3500204 DILANTIN/PHENYTOIN‐TOTAL 145.00 3500205 DOUBLE STRANDED DNA 150.00 3500206 DRUG OF ABUSE ER 134.00 3500212 GIARDIA SPECIF ANTI 134.00 3500213 GMI TRIEAD ANTIBODY 230.00 3500214 HEPATITIS A, IGM AB 123.00 3500216 LITHIUM BLOOD LEVEL 108.00 3500217 LUPUS ANTICOAGULANT 131.00 3500218 MICROALB W/O CREAT URINE 119.00 3500219 OCCULT BLOOD (FOBT) 47.00 3500222 PROTEIN C ANTIGENIC 197.00 3500224 CULTURE‐VRE RECTAL SWAB 73.00 3500225 SALMONELLA ANTIBODY 148.00 3500228 TOXOPLASMA ANTIBODY 148.00 3500229 TOXOPLASMA ANTT‐IGM 153.00 3500230 UREA, 24 HOUR URINE 57.00 3500231 PROTEIN‐TOTAL,URINE 77.08 3500233 AFP (TUMOR MARKER) 245.00 3500234 ALPHA FETA P‐TUMOR 246.00 3500238 C‐REACTIVE PROTEIN 68.00 3500239 CHLAMYDIA AB., IGG 134.00 3500241 IMMUNOFIXATION 114.00 3500244 EBSTIEN BARR TITER 192.00 3500247 HEMOGLOBIN ELECTRO 202.00 3500248 HERPES SURVEY, IGG 136.00 3500249 METHYLMOLONIC ACID 400.00 3500251 PARVOVIRUS AB, IGG 161.00 3500252 PARVOVIRUS AB, IGM 161.00 3500254 RAPID STREP SCREEN 55.06 3500255 THEOPHYLLINE LEVEL 194.00 3500256 WEST NILE VIRUS AB 136.00 3500263 CULTURE‐LOWER RESPIRATORY 128.00 Charge Code Description Price 3500264 CYCLOSPORIN LEVEL 249.00 3500265 DEPAKOTE/VALPORIC 95.00 3500267 ELECTROLYTE PANEL 77.08 3500269 FREE TESTOSTERONE 143.00 3500270 FUNGAL ANTIBODIES 150.00 3500271 HOMOCYSTINE LEVEL ‐ QUANT 40.00 3500273 IGG, SUBCLASS 1‐4 222.00 3500274 INFLUENZA B VIRUS 73.00 3500276 LEAD LEVEL, BLOOD 167.00 3500280 MYCOPLASMA TITERS 150.00 3500282 OSMOLALITY, SERUM 172.00 3500285 SERUM ALDOSTERONE 332.00 3500287 URINE MICROSCOPIC 41.00 3500291 C‐PEPTIDE, SERUM 277.00 3500292 COMPLIMENT‐TOTAL 249.00 3500293 CSF CELL CT/DIFF 82.00 3500294 DIRECT BILIRUBIN 42.00 3500295 EBV AB TITER,IGG 192.00 3500296 EBV AB TITER,IGM 192.00 3500304 HIV DNA BY PCR 899.00 3500307 INSULIN ANTIBODY 202.00 3500311 SALICYLATE LEVEL 195.00 3500313 THYROBLOBULIN AB 189.00 3500316 URINE CREATININE 85.00 3500317 URINE OSMOLARITY 131.00 3500319 ANTIBODY SCREEN 304.00 3500320 CARNITINE LEVEL 218.00 3500321 CHLORIDE ‐ URINE 53.00 3500324 ESTRADIOL LEVEL 348.00 3500328 HEMOGLOBIN A1 C 88.09 3500329 HEPATITIS BS AG 121.00 3500330 HEPATITIS PANEL/SURVEY 354.00 3500331 HISTOPLASMA AB, QUANT, DI 150.00 3500332 IGG QUANT, SERUM 128.00 3500334 IONIZED CALCIUM 174.00 3500335 LIPOPROTEIN (A) 172.00 3500339 OVA+PARASITES, DIRECT 101.00 3500342 PROLACTIN LEVEL 211.00 3500344 SIROLIMUS LEVEL 201.00 3500345 TOTAL BILIRUBIN 41.00 3500346 TRILEPTIL LEVEL 269.00 3500348 URINE POTASSIUM 53.00 3500349 URINE URIC ACID, 24HR 69.00 3500350 URINE‐VPEP 24HR 181.00 3500351 VARICELLA TITER 131.00 3500353 AFP (MATERNAL) 245.00 3500355 CATECHOLAMINES 183.00 3500356 CBC, AUTO 65.00 3500357 CCP ANTIBODY'S 121.00 3500360 CORTISOL, FREE 219.00 Charge Code Description Price 3500362 DHEA ‐ SULFATE 262.00 3500363 DILANTIN, FREE 172.00 3500364 ERYTHROPOIETIN 239.00 3500365 CULTURE‐FUNGUS 109.00 3500372 MYSOLINE LEVEL, SERUM 178.00 3500374 OXALATE, URINE 145.00 3500375 PLATELET COUNT‐AUTO 51.00 3500378 CULTURE‐THROAT 128.00 3500380 ALBUMIN‐SERUM 36.00 3500384 BLOOD ALCOHOL 101.00 3500385 CULTURE‐BLOOD 136.00 3500390 CERULOPLASMIN 161.00 3500392 DIGOXIN LEVEL 139.00 3500393 DIRECT COOMBS 77.08 3500397 GASTRIN LEVEL, SERUM 219.00 3500398 INSULIN LEVEL ‐ BLOOD 134.00 3500400 LYME ANTIBODY 239.00 3500401 SMEAR‐MALARIA 95.00 3500402 METANEPHRINES 321.00 3500406 CULTURE‐STOOL 103.00 3500408 PROTEIN‐TOTAL,SERUM 47.00 3500409 TRIGLYCERIDES 51.00 3500411 CULTURE‐URINE 88.09 3500412 CULTURE‐GENITAL 128.00 3500415 B‐6, VITAMIN 251.00 3500419 BLD COUNT W/DIFF 42.00 3500421 FRUCTOSAMINE 121.00 3500423 HCV GENOTYPE 772.00 3500426 PHENOBARITOL 194.00 3500429 PROGESTERONE 201.00 3500430 RENIN LEVELS 286.00 3500433 TESTOSTERONE ‐ TOTAL 71.00 3500435 SODIUM ‐ URINE 57.00 3500436 VENIPUNCTURE 11.01 3500437 WBC STOOL 69.00 3500440 CULTURE‐AFB 68.00 3500441 ANA‐PROFILE 101.00 3500442 ANTIBODY ID 153.00 3500443 ASO TITER O 69.00 3500444 CHOLESTEROL ‐ TOTAL 48.00 3500445 CROSS MATCH ‐ EA UNIT 128.00 3500447 CULTURE‐CSF 128.00 3500448 CSF GLUCOSE 64.00 3500453 HAPTOGLOBIN, QUANT 194.00 3500454 HEPATITIS C 154.00 3500455 LACTIC ACID/LACTATE 189.00 3500456 MEASLES AB IGG 134.00 3500458 PREALBUMIN 172.00 3500460 SICKLE CELL‐SCREEN/REDUCT 71.00 3500464 TRANSFERRIN 172.00 Charge Code Description Price 3500465 B‐12 LEVEL 197.00 3500466 BLOOD TYPE 80.00 3500467 CALCITONIN 250.00 3500469 CREATININE‐BLOOD 51.00 3500471 DIRECT LDL 80.00 3500473 FIBRINOGEN ACTIVITY 101.00 3500474 FOLIC ACID 172.00 3500475 GENTAMYCIN‐PEAK 139.00 3500477 SMEAR‐GRAM STAIN 59.00 3500478 HEMATOCRIT 33.03 3500479 HEMOGLOBIN 32.00 3500481 PHLEBOTOMY 121.00 3500482 PHOSPHORUS 59.00 3500485 TOBRAMYCIN 216.00 3500486 VANCOMYCIN 167.00 3500487 PAP SMEAR 82.00 3500493 FSH LEVEL 219.00 3500494 HCV ‐ RNA 82.00 3500498 MAGNESIUM 92.00 3500499 MYOGLOBIN 181.00 3500500 PH, FECES 41.00 3500501 POTASSIUM‐SERUM,PLASMA,BL 55.06 3500502 PRIMIDONE 178.00 3500504 ROTAVIRUS 145.00 3500506 T3 UPTAKE 85.00 3500507 URIC ACID ‐ BLOOD 57.00 3500508 URINE IEP 201.00 3500509 VITAMIN A 225.00 3500510 VITAMIN C 178.00 3500511 VITAMIN E 162.00 3500512 CYTOLOGY OTH THAN CERV 130.00 3500513 ALDOLASE 148.00 3500516 ANTI‐GMI 230.00 3500519 CA 27‐29 239.00 3500520 CHLORIDE ‐BLOOD 64.00 3500522 CMV, IGG 161.00 3500523 CMV, IGM 172.00 3500524 CPK ‐ MB 134.00 3500525 CRYSTALS 106.00 3500526 ESTROGEN‐TOTAL 241.00 3500527 FERRITIN 112.00 3500529 H‐PLYORI 192.00 3500530 HEP C,QUANT;RNA/DNA PCR W 559.00 3500531 KOH PREP 48.00 3500532 LAMICTOL 269.00 3500533 PROGRAFF 295.00 3500534 PSA FREE 157.00 3500536 SED RATE ‐ NON AUTO 51.00 3500537 SELENIUM 227.00 3500538 SGOT/AST 57.00 Charge Code Description Price 3500539 SGPT/ALT 60.00 3500540 TEGRATOL‐ TOTAL 194.00 3500542 TROPONIN ‐ QUANT 145.00 3500543 T3 TOTAL 192.00 3500544 WET PREP 48.00 3500545 ACETONE SERUM QUAL 41.00 3500546 AMMONIA 213.00 3500547 AMYLASE ‐ BLOOD 80.00 3500549 CA 15‐3 206.00 3500550 CA 19/9 206.00 3500551 CALCIUM ‐ TOTAL 65.00 3500554 ESTRIOL 205.00 3500555 ESTRONE 260.00 3500556 GLUCOSE‐BLOOD 51.00 3500557 HLA‐B27 239.00 3500561 PROTIME 53.00 3500562 RH TYPE 80.00 3500563 RUBELLA 167.00 3500564 T3 FREE 139.00 3500565 T4 FREE 131.00 3500566 CA 125 206.00 3500569 LDH 62.00 3500570 LIPASE 113.00 3500571 SODIUM‐SERUM/BLOOD 42.00 3500572 5‐HIAA 189.00 3500574 IGE ‐ TOTAL 174.00 3500576 MUMPS 35.00 3500577 RETIC 53.00 3500579 G6PD, QUANT 139.00 3500584 VDRL‐QUANT,CSF ONLY 57.00 3500585 ZINC 151.00 3500586 ACE 228.00 3500587 ANA 84.00 3500588 BMP‐CALCIUM TOTAL 101.00 3500589 BNP ‐ QUANT 230.00 3500590 BUN ‐ QUANT 44.04 3500591 CBC, AUTO‐W/AUTO DIFF 74.00 3500592 CEA 234.00 3500593 CMP 128.00 3500594 CO2 47.00 3500595 CPK ‐ TOTAL 80.00 3500596 FTA 137.00 3500597 GGT 59.00 3500598 b‐HCG QUANT 167.00 3500601 HIV 153.00 3500602 IGF 250.00 3500604 PSA‐TOTAL 134.00 3500605 PTT‐ PLASMA OR WHOLE BLD 80.00 3500606 RPR‐QUAL 101.00 3500607 RSV 121.00 Charge Code Description Price 3500608 T‐4 ‐ TOTAL 82.00 3500609 TSH 198.00 3500610 VMA 242.00 3500612 C4 ‐ EA 93.00 3500613 LH 219.00 3500614 GENTAMYCIN TROUGH 139.00 3500615 VANCOMYCIN TROUGH 167.00 3500617 DRUG COLLECTION WALMART 13.00 3500618 EHRLICHIA AB (IgG+M) 113.00 3500624 T3 REVERSE TRIDOTHYRORINE 329.00 3500625 VIT 1,25 DIHYDROXYCHOLECA 492.00 3500627 CULTURE‐YERSINIA 103.00 3500628 ACTH 456.00 3500631 MOLECULAR DIAGNOSTICS 75.00 3500636 ACTIN SMOOTH MUSCLE AB 112.00 3500639 ACCP AB 121.00 3500645 CLOZARIL CLORAPINE 158.00 3500649 TSS TRANSGLUTAMINASE IGA 112.00 3500651 ALLERGEN Ig E, EA SPECIFI 62.00 3500660 OSMOLALITY URINE 26.00 3500661 VITAMIN B2 RIBOFLAVIN 176.00 3500663 FECAL FAT 62.00 3500678 GLUCOSE TOLERANCE EA ADDI 44.04 3500680 SUSCEPTIBILITY, MICRO PER 88.09 3500681 CULTURE AEROBIC IDENTIFY 84.00 3500689 BARTONELLA ANTIBODIES 47.00 3500698 RENAL/LIVER MICROSOMALAB 174.00 3500701 CELL COUNT SYNOVIAL FLUID 82.00 3500702 BK VIRUS, QUANT 502.00 3500703 BONE MARROW ASPIRATION 140.00 3500705 PNEUMOCOCCAL IMMUNOASSAY 134.00 3500707 FREE K L LIGHT CHAINS, QN 163.00 3500709 IGM QUANT, SERUM 128.00 3500710 IGA QUANT, SERUM 128.00 3500711 CHYLMD TRACH, DNA AMP 96.00 3500712 DRUG PROFILE,UR, 9 DRUGS 128.00 3500713 N GONORRHOEAE, DNA, AMP 96.00 3500715 EPSTEIN‐BARR EARLY ANTIGE 161.00 3500716 EPSTEIN‐BARR NUCLEAR ANTI 170.00 3500717 EPSTEIN‐BARR VIRAL ANTIGE 200.00 3500721 OPIATE CONFIRMATION, URIN 209.00 3500725 CORTISOL, TOTAL 44.04 3500729 FERRITIN 112.00 3500730 TIBC‐TOTAL 114.00 3500731 IRON TOTAL SERUM 76.00 3500741 SJOGREN'S 101.00 3500749 THYROID ANTIGLOBULIN ANTI 189.00 3500752 ALLERGEN, SPECIFIC 1GE, D 62.00 3500753 ALLERGEN, SPECIFIC 1GE, D 62.00 3500756 AMIKIN TROUGH 206.00 Charge Code Description Price 3500759 HCV, QUALIT, RNA PCR W/RE 317.00 3500761 SELECT CELL PANEL ‐LIFESH 190.00 3500762 PER ANTIGEN TESTED GRPii‐ 139.00 3500764 DAT ‐LIFESHARE 130.00 3500767 IMMUNOFIX E‐PHORESIS SERU 293.00 3500777 LYME DISEASE, WESTERN BLO 158.00 3500806 CREATINE 24 HR URINE 29.00 3500817 COMPLEMENT C1 ESTERASE IN 93.00 3500818 HIV 1/0/2 ABs 80.00 3500820 BLOOD CLOT FACTOR VIII 272.00 3500821 BLOOD CLOT FACTOR VIII 354.00 3500822 BLOOD CLOT FACTOR VIII 365.00 3500825 VITAMIN A 178.00 3500826 VITAMIN E 209.00 3500835 ASSAY OF CADMIUM 294.00 3500837 JAK 2 MUTATION ANALYSIS, 497.00 3500838 AMPHETAMINE/METHAMPHETAMI 154.00 3500840 QUANTIFERON TB GOLD 510.00 3500843 IAAD EIA HEPATITIS BE ANT 139.00 3500850 CUL BACT XCPT URINE BLOOD 139.00 3500857 IADNA NOS AMPLIFIED PROBE 96.00 3500859 CFTR GENE COM VARIANTS 392.00 3500868 SURGICAL PATH GROSS EXAM 103.00 3500870 TISSUE EXAM BY PATHOLOGIS 272.00 3500871 TISSUE EXAM BY PATHOLOGIS 398.00 3500875 SPECIAL STAINS GROUP i 192.00 3500879 IMMUNOHISTOCHEMISTRY 299.00 3500886 SEROTONIN 513.00 3500889 SPORONOX ITRCONAZOLE LVL 205.00 3500890 CALPROTECTIN FECAL 174.00 3500891 ENTEROVIRUS REALTIME PCR 359.00 3500892 DES‐Y‐CARBOXY PROTHROMBIN 621.00 3500893 MANGANESE 222.00 3500895 IRON 91.00 3500897 DRUG SCREEN COLLECTION 38.00 3500899 IADNA CHLAMYDIA TRACHOMAT 96.00 3500900 IADNA NEISSERIA GONORRHOE 96.00 3500901 IADNA NOS AMPLIFIED PROBE 96.00 3500904 DEOXYRIBONUCLEASE ANTIBOD 36.00 3500909 FLUORESCENT ANTIBODY TITE 161.00 3500911 IMMUNOASSAY ANALYTE QUANT 230.00 3500915 MTHER GENE ANALYSIS COMMO 497.00 3500916 HEPATITIS B VIRUS QUILITA 469.00 3500917 C‐TELOPEPTIDE, SERUM 304.00 3500921 CHLAMYDIA IGM ANTIBODY 165.00 3500928 WHITE CELL CYSTINE 40.00 3500929 PIVKA‐11 230.00 3500931 ACETYLCHOLINE RECEPTOR 240.00 3500933 HISTOPLASMOSIS AG 158.00 3500937 JC VIRUS, PCR 96.00 Charge Code Description Price 3500942 ANITGLOMERULAR BASEMENT MEMBRANE ANTIBOD 112.00 3500945 CELLULAR FUNCTION ASSAY 375.00 3500946 MUSK 1,500.00 3500947 THROMBIN TIME 70.00 3500948 ANTI‐MULLERIAN ANTIBOBY 125.00 3500949 HSV DNA AMP PROBE 340.00 3500950 ASSAY LIPOPROTEIN PLA2 250.00 3500951 BETA 2 GLYCOPROTEIN ANTIBODY 238.00 3500952 ANTICARDIOLIPIN ANTIBODY 246.00 3500953 PHOSPHATIDYLSERINE 186.00 3500954 LUPUS ANTICOAGULANT 123.00 3500955 LUPUS ANTICOAGULANT 83.00 3500956 CMV‐PCR 331.00 3500957 CYTOCHROME P450 2C19 GENOTYPING 835.00 3500958 FACTOR V LEIDEN 650.00 3500959 CRP‐HS 136.00 3500960 ASPIRINWORKS 85.00 3500961 ASPIRINWORKS 146.00 3500962 GROUP B STREP NAA 320.00 3500963 NMR LIPOPROFILE 250.00 3500964 BORDETELLA PERTUSSIS AB IgG 195.00 3500965 GROWTH HORMONE 40.00 3500966 H PYLORI IgG ABS 192.00 3500967 LEPTIN, SERUM 230.00 3500968 ASPERGILLUS FUMIGATUS PRECIP ABS, IGG 152.00 3500969 VITAMIN D 25‐HYDROXY, D2+D3 241.00 3500970 VITAMIN D, 1,25+25‐HYDROXY 492.00 3500971 SCABIES EXAMINATION 53.00 3500972 ANTI‐JO‐1 101.00 3500973 FLECAINIDE (TAMBOCOR), SERUM 269.00 3500974 PHOSPHATASE ALKALINE ISOENZYMES 35.00 3500975 ANDROSTENEDIONE 73.00 3500976 INHIBIN‐A 157.00 3500977 VITAMIN B6 288.00 3500978 ETHYL GLUCURONIDE, URINE 134.00 3500979 TISSUE EXAM BY PATHOLOGIST 210.00 3500980 APOLIPOPROTEIN 178.00 3500981 RNA QUALITATIVE 338.00 3500982 PER ANTIGEN TESTED GRP i 139.00 3500983 PER ANTIGEN TESTED GRP iii 139.00 3500984 PROTEIN, BODY FLUID 47.00 3500985 DESIPRAMINE LEVEL 150.00 3500986 PROINSULIN LEVEL 288.00 3500987 COLD SCREEN‐LIFESHARE 75.00 3500988 ELUTION PREP ‐ LIFESHARE 135.00 3500989 AB ID STD COM PANEL ‐ LIFESHARE 190.00 3500990 PER ANTIGEN TESTED‐GRP IV‐ LIFESHARE 139.00 3500991 THYROXINE BINGIND GLOBULIN 145.00 3500992 FOLATE, RBC 254.00 3500993 AMPHETAMINE CONFIRMATION, URINE 215.00 Charge Code Description Price 3500994 HBV, REAL‐TIME PCR 385.00 3500995 RBC COUNT 35.00 3500996 THRICHOMONAS, NAA 195.00 3500997 CPK ISOENZYMES 145.00 3500998 INFLUENZA A, H1N1 350.00 3500999 BRCA 1 2,480.00 3501000 BRCA 2 650.00 3501001 FUNGUS CULTURE 82.00 3501002 PROCALCITONIN 192.00 3501003 LEGIONELLA PNEUMOPHILIA ANTIBODY 178.00 3501004 FACTOR II, DNA ANALYSI 268.00 3501005 a‐FETOPROTEIN W/ AFP‐L3 458.00 3501006 HEREDITARY HEMOCHROMATOSIS 356.00 3501007 ALPHA‐1 PHENOTYPE 221.00 3501008 BACTERIAL ANTIBODY 118.00 3501009 REDUCING SUBSTANCES, STOOL 40.00 3501010 DIFFERENTIAL , MANUAL 35.00 3501011 INTRINSIC FACTOR 40.00 3501012 MERCURY 50.00 3501013 GI PANEL, STOOL PCR 200.00 3501014 AZATHIOPRINE 198.00 3501015 CHROMOGENIC FACTOR X 75.00 3501016 OSMOLALITY, SERUM 80.00 3501017 THYROGLOBULIN 125.00 3501018 DIHYDROTESTOSTERONE 198.00 3501019 C. difficile, toxogenic 90.00 3501020 VIP, PLASMA 87.00 3501021 MSH 85.00 3501022 HLA DRB1,3,4,5,DQB1 (1R) 623.00 3501023 ADH 90.00 3501024 MMP‐9 230.00 3501025 CRYOGLOBULIN 75.00 3501026 HIV 1 AND 2 150.00 3501027 Herpes simplex type 1 test 90.00 3501028 Herpes simplex type 2 test 90.00 3501029 HG A1C LEVEL LT 7.0% 0.01 3501030 HGB A1C LEVEL 7‐9% 0.01 3501031 HEMOGLOBIN A1C LEVEL >9.0% 0.01 3501032 HNK1 PANEL, 1 60.00 3501033 HNK1 PANEL, 2 105.00 3501034 IODINE 50.00 3501035 BABESIA IGG, IGM 60.00 3501036 CANDIDA, IGG, IGM, IGA 50.00 3501037 ARSENIC 55.00 3501038 ELASTASE, FECAL 250.00 3501039 MYCOPLASMA, PCR 200.00 3501040 ORGANIC ACID ANALYSIS, URINE 185.00 3501041 B‐TYPE NATRIURETIC PEPTIDE 95.00 3501042 HEP B CORE TOTAL AB 31.00 3501043 CMV Quant DNA PCR (Plasma) 95.00 Charge Code Description Price 3501044 HSV CULTURE AND TYPING 95.00 3501045 CD19‐B CELLS 150.00 3501046 CD19‐NK CELLS 250.00 3501047 CYTOPATHOLOGY FNA REPORT 200.00 3501048 CAFFEINE, SERUM 35.00 3501049 VITAMIN B3 65.00 3501050 beta‐HYDROXYBUTYRATE 30.00 3501051 ZARONTIN 80.00 3501052 Rh Phenotype‐LIFESHARE 150.00 3501053 COXSACKIE A IGM AB 125.00 3501054 NICOTINE, URINE 215.00 3501055 FACTOR IX ACTIVITY 80.00 3501056 FACTOR XI ACTIVITY 198.00 3501057 FACTOR XII ACTIVITY 210.00 3501058 PROTEIN S 187.00 3501059 OXCARBAZEPINE, SERUM 200.00 3501060 LYS‐ASPIRIN‐BASOFUNCTIO. HRT 375.00 3501061 FLOW CYTOMETRY PNH 90.00 3501062 ANTINEUTROPHIL CYTOPLASMIC AB 161.00 3501063 FREE VALPROIC ACID 80.00 3501064 IMMUNE COMPLEXES, C1Q 175.00 3501065 TSPOT 90.00 3501066 vWF MULTIMERS 120.00 3501067 GASTRIC OCCULT BLOOD 45.00 3501068 SHIGA TOXIN 80.00 3501069 O AND P SMEAR 125.00 3501070 AFB CULTURE 125.00 3501071 HIPA 80.00 3501072 ADENOVIRUS 60.00 3501073 PARAINFLUENZA 90.00 3501074 RSV 80.00 3501075 ANTIBODY DETECTION NOS 150.00 3501076 VIRAL CULTURE 125.00 3501077 PYRUVIC ACID 50.00 3501078 TOPIRAMATE 167.00 3501079 PEth 215.00 3501080 PROTEIN C FUNCTIONAL 75.00 3501081 CASEIN 65.00 3501082 LEGIONELLA AG URINE 80.00 3501083 5' NUCLEOTIDASE 75.00 3501084 LACOSAMIDE 90.00 3501085 SULFONYLUREA PANEL 150.00 3501086 H PYLORI BREATH TEST 150.00 3501087 PYLORI BREATH TEST COLLECTION 125.00 3501088 HEP B COR AB 125.00 3501089 HHV‐6, DNA PCR 250.00 3501090 B2‐MICROGLOBULIN 90.00 3501091 COBALT, PLASMA 125.00 3501092 CHROMIUM, PLASMA 90.00 3501093 CORTISOL BINDING GLOBULIN 75.00 Charge Code Description Price 3501094 LUPUS ANITICOAGULANT REFLEX 50.00 3501095 PLASMINOGEN 120.00 3501096 ANTITHROMBIN ACTIVITY 50.00 3501097 APO E GENOTYPING: CARDIOVACULAR RISK 125.00 3520001 BLOOD COMPONENTS ADMIN 416.00 3520004 FRESH FROZEN PLASMA 153.00 3520005 PLATELET PHERESIS 1,026.00 3520006 RED BLOOD CELLS 379.00 3520011 VITAMIN K1 160.00 3520012 AB ID STD COM PANEL‐LIFESHARE 150.00 3520013 SELECT CELL SCREEN‐LIFESHARE 95.00 3520014 PHENOTYPE‐LIFESHARE 308.00 3520015 CELL SEPERATION‐LIFESHARE 165.00 3600002 AC JTS BILAT WW/O WEIGHTS 354.00 3600005 KNEE AP BOTH (STANDING) 179.00 3600006 LSPINE W/ OBL MIN 4 VIEWS 242.00 3600007 C SPINE, MIN 4 VIEWS 200.00 3600009 C SPINE, 2 OR 3 VIEWS 183.00 3600011 TOE(S) MIN OF TWO VIEWS 179.00 3600013 L SPINE, 2 OR 3 VIEWS 227.00 3600014 SKULL, MINIMUM OF 4 VIEWS 290.00 3600015 CERVICAL SPINE, COMPLETE 200.00 3600016 CHIN LATERAL SOFT TISSUE 145.00 3600017 STERNO‐CLAVICULAR JOINTS 179.00 3600018 CERVICAL LATERAL 145.00 3600020 SKULL, AP (OR) AP & LAT 145.00 3600026 FINGER, AP LAT & OBL 179.00 3600029 WATERS VIEW OF SINUS 145.00 3600036 JAW, PA & BOTH OBL. 208.00 3600047 COCCYX/SACRUM 2V 227.00 3600054 CHEST, PA & LAT. 179.00 3600055 ABDOMEN, F & E 245.00 3600058 THORACIC SPINE 205.00 3600063 FACIAL BONES 205.00 3600068 CHEST, PA. 161.00 3600069 SOFT TISSUE NCK W/ BARIUM 256.00 3600070 NASAL BONES 205.00 3600072 PELVIS, AP 179.00 3600073 TM JOINTS 205.00 3600078 IVP 371.00 3600083 SINUSES 245.00 3600084 STERNUM 205.00 3600085 ORBITS 205.00 3600086 SACRUM/COCCYX 2V 227.00 3600090 KUB 172.00 3600092 RIBS RT 245.00 3600093 RIBS LT 245.00 3600094 CLAVICLE, AP & ANGLE RT 179.00 3600095 CLAVICLE, AP & ANGLE LT 179.00 3600096 SCAPULA RT 179.00 Charge Code Description Price 3600097 SCAPULA LT 179.00 3600098 SHOULDER RT 179.00 3600099 SHOULDER LT 179.00 3600100 HUMERUS, AP & LAT RT 179.00 3600101 HUMERUS, AP & LAT LT 179.00 3600102 ELBOW, AP LAT & OBL RT 179.00 3600103 ELBOW, AP LAT & OBL LT 179.00 3600104 FOREARM RT XRAY 179.00 3600105 FOREARM LT XRAY 179.00 3600106 WRIST RT 179.00 3600107 WRIST LT 179.00 3600108 HAND, PA, OBL, & LAT RT 179.00 3600109 HAND, PA, OBL, & LAT LT 179.00 3600110 HIP, AP & LAT RT 179.00 3600111 HIP, AP & LAT LT 179.00 3600112 FEMUR 2V RT 179.00 3600113 FEMUR 2V LT 179.00 3600114 KNEE AP&LAT 1OR2 VWS RT 179.00 3600115 KNEE AP&LAT 1OR2 VWS LT 179.00 3600116 KNEE, 3 VIEWS RT 194.00 3600117 KNEE, 3 VIEWS LT 194.00 3600118 TIB FIB AP & LAT RT 179.00 3600119 TIB FIB AP & LAT LT 179.00 3600120 ANKLE, AP, OBL & LAT RT 179.00 3600121 ANKLE, AP, OBL & LAT LT 179.00 3600122 FOOT, AP OBL & LAT RT 179.00 3600123 FOOT, AP OBL & LAT LT 179.00 3600124 CALCANEOUS, 2 VWS RT 179.00 3600125 CALCANEOUS, 2 VWS LT 179.00 3600126 KUB GASTOVIEW 217.00 3600127 KNEE AP STND NOTCH VW BT 179.00 3600128 LUMBAR LATERAL 145.00 3600129 SCOLIOSIS SERIES 150.00 3600130 KNEE RT LAT 1V 179.00 3600131 KNEE LT LAT 1V 179.00 3600132 HIP RT LAT 1V 179.00 3600133 HIP LT LAT 1V 179.00 3600150 INTRAOPERATIVE CHOLANGIOG 442.00 3600151 OMNIPAQUE PER ML 3.00 3600152 SCREENING MAMMO‐ BILATERAL 400.00 3600156 XRAY ACUTE ABD SERIES COM 288.00 3600157 CHOLANGIOGRAPHY THRU E 227.00 3600161 ILIAC ARTERY ANGIO,CARDIA 1,432.00 3600169 INSERT GUIDEANCE FOR PAC 1,055.00 3600171 PELVIS COMPLETE 3V 334.00 3600173 HYSTEROSALPINGOGRAPHY 676.00 3600174 ABDOMEN 1V/AP 218.00 3600175 SHUNTOGRAM 827.00 3600176 SCREENING MAMMO ‐ UNILATERAL 200.00 3600178 LOWER EXTREMITY, INFANT 2V LT 125.00 Charge Code Description Price 3600179 PELVIS & HIPS, INFANT/CHILD, 2V 87.00 3600180 UPPER EXTREMITY, INFANT, 2V LT 125.00 3600181 SOFT TISSUE NECK 1V 200.00 3600182 ANKLE, 2V LT 125.00 3600183 ANKLE, 2V RT 125.00 3600184 LOWER EXTREMITY, INFANT 2V RT 125.00 3600185 UPPER EXTREMITY, INFANT, 2V RT 125.00 3600186 RIBS UNILAT MIN 3V W/PA CHEST, LT 370.00 3600187 CHEST 3V INCULDING APICAL 118.00 3600188 ELBOW 2V LT 250.00 3600189 ELBOW 2V RT 250.00 3600190 RIBS BILAT 3V 335.00 3600191 RIBS UNILAT MIN 3V W/PA CHEST RT 370.00 3600192 RIBS BILAT W/ PA CHEST 461.00 3600193 SI JOINTS 1V OR 2V 257.00 3600194 FLUOROSCOPY UP TO 1 HOUR 395.00 3600195 BONE AGE STUDY 125.00 3600196 HAND 1V‐LT 135.00 3600197 HAND 1V‐RT 135.00 3600198 MASTOIDS LESS THAN 3 VIEWS RT SIDE 85.00 3600199 MASTOIDS LESS THAN 3 VIEWS LT SIDE 85.00 3600200 OSSEOUS SURVEY; LIMITED 165.00 3600201 LSpine Bend Only 2V or 3V 275.00 3603679 BANANA BAG 88.00 3603680 DEXAMETHASONE 10MG INJ 15.00 3603681 LATUDA 40mg 59.00 3603682 Loxapine 5mg 1.00 3603683 Loxapine 10mg 3.00 3603684 Seroquel XR 400mg 33.00 3603685 ISONIAZID 100MG 3.00 3603686 Cleocin 600mg premix 35.00 3603687 NICOTINE 2MG GUM 3.00 3603688 INVEGA SUSTENNA 234 MG 1.00 3603689 INVEGA SUSTENNA 156 MG 1.00 3603690 MEROPENEM 1 GRAM VIAL 31.00 3603691 PAXIL CR 25MG 10.00 3603692 ARIPIPRAZOLE 2mg 39.00 3603693 PROCALAMINE INJ 88.00 3603694 MORPHINE 4MG INJ 19.00 3603695 NALTREXONE HCl 50mg 8.00 3603696 GABAPENTIN 400MG 3.00 3603697 ERYTHROMYCIN 250MG 18.00 3603698 MODAFINIL 100MG 33.00 3603699 ACETAZOLAMIDE 125MG 1.00 3603700 CALCITRIOL 0.25MG 3.00 3603701 TUMS 500MG 1.00 3603702 TIKOSYN 250 MCG 1.00 3603703 KEPPRA 500MG INJ 35.00 3603704 CLONAZEPAM 1MG 1.00 3603705 NARCAN 2MG SYRINGE 1.00 Charge Code Description Price 3603706 PROCAINAMIDE 1000MG/10ML 120.00 3603707 LEVOTHYROXINE 100MCG INJ 148.00 3603708 TIVICAY 50MG 79.00 3603709 DESCOVY 79.00 3603710 BENICAR 20MG 1.00 3610100 US ABDOMEN COMPL 497.00 3610101 US ABDOMEN LIMITED 387.00 3610160 US CAROTID COMPL 602.00 3610190 US EXTR NONVASCULAR 575.00 3610200 US GALLBLADDER 387.00 3610241 US LOW EXTR ART UNI 497.00 3610260 US LOW EXTR VEN BIL 624.00 3610261 US LOW EXTR VEN UNI 403.00 3610280 US OB 2ND/3RD TRI COMPLET 458.00 3610281 US OB 2ND/3RD TRI LIM 491.00 3610310 US PELVIC COMPL 458.00 3610311 US PELVIC LIMITED 387.00 3610320 US RENAL COMPLETE 497.00 3610341 US RETRO LIMITED 387.00 3610360 US SFT TIS HEAD/NECK 464.00 3610400 US TESTICULAR 458.00 3610440 US UPR EXTR ART BIL 744.00 3610441 US UPR EXTR ART UNI 420.00 3610442 US BIOPHYSICAL PROFILE 348.00 3610443 US UPR EXTR VEN UNI 403.00 3610444 US ECHO W/DOPPLER COMPL 575.00 3610445 US ANKLE‐BRACHIAL INDICES 321.00 3610446 US LOW EXTR ART BIL 795.00 3610447 US BREAST(s) 348.00 3610448 US CHEST/MEDIASTINUM 299.00 3610449 US OB 1ST TRI 453.00 3610450 US PREGNANT UTERUS LIM 339.00 3610451 US PREGNANT UTERUS FU 445.00 3610452 US UPR EXTR VEN BIL 624.00 3610453 STRESS TTE COMPLETE 1,081.00 3610454 US TRANSVAGINAL NON‐OB 478.00 3610455 US TRANSVAGINAL OBSTETRIC 331.00 3610456 ABDOMINAL PARACENTESIS 600.00 3610457 THORACENTESIS; PLEURAL DRAINAGE W IMAGIN 765.00 3610458 US SCROTUM AND CONTENTS 300.00 3620034 BONE SCAN‐WHOLE BODY 1,237.00 3620042 HEPATOBILIARY (HIDA) 1,088.00 3620044 LUNG PERFUS/VENTILAT 1,385.00 3620045 LUNG SCAN, PERFUSION 828.00 3620047 MYOCARDIAL PERFUSION 1,976.00 3620049 XE REBREATHING SYSTM 92.00 3620053 TC 99M THYROID SCAN 696.00 3620056 BONE SCAN, LIMITED 1,088.00 3620057 BONE SCAN, 3 PHASE 1,285.00 3620061 MYOCARD PERFSN S&R 3,159.00 Charge Code Description Price 3620066 LIVER/SPLEEN SCAN 916.00 3620067 RENAL SCAN MULTIPLE STUDIES 2,065.00 3620068 TC‐99 SULFUR COL. 115.00 3620073 GASTRIC EMPTYING 1,147.00 3620074 PARATHYROID SCAN 841.00 3620075 TC‐99 MEBROFENIN 124.00 3620096 XE 133 DOSE PER 10 MIC 128.00 3620098 CARDIOLITE per SD to 40mc 125.00 3620102 RENAL SCAN 1,281.00 3620103 TC‐99 TC04 115.00 3620104 CAPTIPRIL 11.01 3620108 TC‐99 MAA 115.00 3620109 TC‐99 MDP 115.00 3620113 KINEVAC 135.00 3620116 MAG 3 850.00 3620121 OPTIRAY 1CC 2.00 3620129 BONE DENSITY, AXIAL 326.00 3620132 REGADENOSON INJECTION 112.00 3620153 NON‐HEU TC‐99M ADD‐ON/DOSE 25.00 3630001 Mri orbit/face/neck w/o d 1,213.00 3630003 Mri orbt/fac/nck w/o & w/ 1,433.00 3630004 Mr angiography head w/o d 1,213.00 3630010 Mri brain w/o dye 1,213.00 3630011 Mri brain w/dye 1,433.00 3630012 Mri brain w/o & w/dye 1,433.00 3630020 Mri neck spine w/o dye 1,213.00 3630021 Mri neck spine w/dye 1,433.00 3630022 Mri chest spine w/o dye 1,213.00 3630024 Mri lumbar spine w/o dye 1,213.00 3630025 Mri lumbar spine w/dye 1,433.00 3630026 Mri neck spine w/o & w/dy 1,433.00 3630027 Mri chest spine w/o & w/d 1,433.00 3630028 Mri lumbar spine w/o & w/ 1,433.00 3630030 Mri pelvis w/o dye 1,213.00 3630032 Mri pelvis w/o & w/dye 1,433.00 3630034 Mri upper extremity w/o d 1,213.00 3630036 Mri uppr extremity w/o&w/ 1,433.00 3630037 Mri joint upr extrem w/o 1,213.00 3630038 Mri joint upr extrem w/dy 1,433.00 3630039 Mri joint upr extr w/o&w/ 1,433.00 3630041 Mri lower extremity w/o d 1,213.00 3630042 Mri lower extremity w/dye 1,433.00 3630043 Mri lwr extremity w/o&w/d 1,433.00 3630044 Mri jnt of lwr extre w/o 1,213.00 3630045 Mri joint of lwr extr w/d 1,433.00 3630046 Mri joint lwr extr w/o&w/ 1,433.00 3630048 Mri abdomen w/o dye 1,213.00 3630050 Mri abdomen w/o & w/dye 1,433.00 3630062 MAGNEVIST INJ per ml 5.00 3640001 CPT ‐SUBSEQ DEMO +OR EVAL 128.00 Charge Code Description Price 3640002 CPT ‐INIT DEMO +OR EVAL 175.00 3640010 PULMONARY FUNCTION;SPIROM 211.00 3640012 SPUTUM INDUCTION 170.00 3640023 OXYGEN EA ADD HOUR 13.00 3640027 HOLTER MONITOR‐RECORDING 313.00 3640032 MINI NEB TX‐INITIAL 225.00 3640039 PULSE OX‐SINGLE 62.00 3640043 IPPB TX‐INITIAL 225.00 3640050 STRESS TEST;TRACING ONLY 557.00 3640059 EEG AWAKE+ASLEEP 733.00 3640060 ABG 161.00 3640061 CPR 673.00 3640063 USN TX‐INITIAL 225.00 3640064 EKG‐12 LEAD; TRACING ONLY 161.00 3640065 SPIROMETRY PRE+POST 250.00 3640067 VENT MGMT INITIAL DAY 608.00 3640068 VENT MGMT SUBSEQUENT 442.00 3640069 HOLTER MONITOR‐ANAL/RPT 442.00 3640070 DEMO/EVAL PT USE OF TX DE 170.00 3640071 EKG‐SUBQ 161.00 3640072 STRESS EKG W/PHYS PRESENC 425.00 3640074 PULMONARY STRESS TEST‐6 M 134.00 3640075 MINI NEB TX‐SUBQ 170.00 3640076 IPPB TX‐SUBQ 170.00 3640077 USN TX‐SUBQ 170.00 3640079 PULSE OX‐MULTIPLE 95.00 3640080 PULSE OX‐CONTINOUS 227.00 3640081 O2 W/TENT‐INITIAL 156.00 3640082 O2 W/CROUP CANOPY‐INITIAL 156.00 3640084 O2 W/MASK‐INITIAL HR 84.00 3640086 O2 W/CANNULA‐INITIAL HR 84.00 3640087 O2 TRANSPORT‐INITIAL HR 134.00 3640088 CARDIC EVENT MONITOR‐RECO 84.00 3640089 PM DEVICE PROGR EVAL SNGL 205.00 3640090 PM DEVICE PROGR EVAL DUAL 205.00 3640091 PM DEVICE PROGR EVAL MULTI 205.00 3640092 PRGRMG EVAL IMPLANTABLE DFB 205.00 3640093 PRGRMG EVAL IMPLANTABLE DFB 205.00 3640094 PRGRMG EVAL IMPLANTABLE DFB 205.00 3640095 PM DEVICE EVAL IN PERSON 205.00 3640096 INTERROG DEVICE EVAL HEART 205.00 3640097 PM/ICD REMOTE TECH SERV 205.00 3650001 CT HEAD/BRAIN WO CTRST 630.00 3650002 CT MASTIODS 630.00 3650003 CT HEAD/BRAIN W CTRST 995.00 3650004 CT HEAD/BRAIN WO W CTRST 1,102.00 3650005 CT ORBITS WO CTRST 630.00 3650006 CT SINUSES 630.00 3650007 CT ORBITS W CTRST 995.00 3650008 CT IAC WO W CTRST 1,102.00 Charge Code Description Price 3650009 CT ORBITS WO W CTRST 1,102.00 3650010 CT FACIAL BNS WO CTRST 630.00 3650011 CT FACIAL BNS W CTRST 995.00 3650012 CT FACIAL BNS WO W CTRST 1,102.00 3650013 CT CERV SPINE WO CTRST 630.00 3650014 CT CERV SPINE WO W CTRST 1,102.00 3650015 CT SFT TS NECK WO CTRST 630.00 3650016 CT SFT TS NECK W CTRST 995.00 3650017 CT SFT TS NECK WO W CTRST 1,102.00 3650018 CT UPPER EXT WO CTRST 630.00 3650019 CT UPPER EXT W CTRST 995.00 3650020 CT UPPER EXT WO W CTRST 1,102.00 3650021 CT CHEST WO CTRST 630.00 3650023 CT CHEST W CTRST 995.00 3650025 CT CHEST WO W CTRST 1,102.00 3650027 CT THOR SPINE WO CTRST 630.00 3650028 CT THOR SPINE W CTRST 995.00 3650029 CT THOR SPINE WO W CTRST 1,102.00 3650030 CT ABD WO CTRST 630.00 3650031 CT ABD W CTRST 995.00 3650032 CT ABD WO W CTRST 1,102.00 3650033 CT ABD/PEL WO CTRST 630.00 3650035 CT ABD/PEL W CTRST 995.00 3650037 CT ABD/PEL WO W CTRST 1,102.00 3650039 CT PELVIS WO CTRST 630.00 3650040 CT PELVIS W CTRST 995.00 3650041 CT PELVIS WO W CTRST 1,102.00 3650042 CT LUMBAR SPINE WO CTRST 630.00 3650043 CT LUMBAR SPINE W CTRST 995.00 3650044 CT LUMBAR SPINE WO W CTRS 1,102.00 3650045 CT LOWER EXT WO CTRST 630.00 3650046 CT LOWER EXT W CTRST 995.00 3650047 CT LOWER EXT WO W CTRST 1,102.00 3650048 OPTIRAY PER CC 2.00 3650051 CALCIUM SCORE 530.00 3650053 CT Lung Cancer Screening 250.00 3650153 CTA CHEST W CONTRAST 1,900.00 3650154 CTA ABDOM W/O & W/DYE 2,000.00 3650155 CTA ABDOMINAL ARTERIES 2,050.00 3650156 CTA ABD&PELV W/O&W/DYE 2,975.00 3650157 CTA HEAD 2,465.00 3650158 CTA NECK 2,585.00 3650159 CTA LWR EXTR W/O&W/DYE 1,910.00 3650160 CTA PELV W/O&W/DYE 2,045.00 3650161 CTA UPR EXTRM W/O&W/DYE 1,690.00 3701939 ATROPINE INJ [1MG/10ML] 35.00 3702001 ACARBOSE TAB [50MG] 2.00 3702002 ACEBUTOLOL HCL CAP [200MG 2.00 3702003 ACETAMINOPHEN TAB [325MG] 3.00 3702004 ACETAMINOPHEN SUP [650MG] 3.00 Charge Code Description Price 3702005 ACETAMINOPHEN SUP [120MG] 3.00 3702006 ACETAMINOPHEN TAB [500MG] 3.00 3702007 ACETAMINOPHEN CHILD SYR [ 3.00 3702008 ACETAMINOPHEN INFANT DROP 2.00 3702009 ACETAMINOPHEN/CODEIN TAB 4.00 3702010 ACETAMINOPHEN/CODEIN ELX 4.00 3702011 ACETAZOLAMIDE TAB [250MG] 2.00 3702012 ACETAZOLAMIDE CAP [500MG] 8.00 3702013 ACETAZOLAMIDE SODIUM INJ 53.00 3702014 ACETIC ACID/ALUMINUM PKT 15.00 3702016 ACETYLCYSTEINE SOL 20% 12.00 3702018 ACYCLOVIR CAP [200MG] 3.00 3702019 Zovirax susp 200mg/5mg 30.00 3702020 ACYCLOVIR TAB [800MG] 3.00 3702021 ACYCLOVIR 5% OIN 18.00 3702022 ACYCLOVIR INJ [500MG] 17.00 3702023 ADALIMUMAB INJ [40MG] 3,364.00 3702024 ADENOSINE INJ [6MG/2ML] 15.00 3702025 ANAGRELANIDE CAP [0.5MG] 15.00 3702026 ALBUMIN (HUMAN) SOL 25% 119.00 3702027 MDI ALBUTEROL AER [90MCG 16.00 3702028 MDI ALBUTEROL HFA AER 20.00 3702029 ALBUTEROL NEB 0.083% 3.00 3702030 ALBUTEROL TAB [2MG] 2.00 3702031 ALBUTEROL SYP [2MG/5ML] 3.00 3702033 ALENDRONATE TAB [10MG] 2.00 3702034 ALENDRONATE WEEKLY TAB [7 26.00 3702035 ALFENTANIL INJ [500MCG] 99.00 3702036 ALLOPURINOL TAB [300MG] 3.00 3702037 ALLOPURINOL TAB [100MG] 3.00 3702038 ALOSETRON TAB [1MG] 17.00 3702039 ALPRAZOLAM TAB [0.25MG] 4.00 3702040 ALPRAZOLAM TAB 0.5 mg 4.00 3702041 ALPRAZOLAM TAB [1MG] 4.00 3702042 ALTEPLASE INJ [100MG] 10,563.00 3702043 ALTEPLASE INJ CATHFLO INJ 214.00 3702044 ALUMIN/MAG CARB SUS UP 3.00 3702045 ALUM HYDROX/MAG TR CHW TA 2.00 3702046 ALUMINUM HYDROXIDE GEL 2.00 3702047 AMANTADINE CAP [100MG] 4.00 3702048 IV‐ AMI ACID/DEXT + ELEC 88.00 3702049 AMIKACIN INJ [250MG] 53.00 3702050 IV‐ AMIN ACID/ELECT 3.5% 88.00 3702051 AMINOPHYLLINE INJ [500MG/ 15.00 3702052 AMIODARONE TAB [200MG] 12.00 3702053 AMIODARONE INJ [150MG/3ML 15.00 3702054 AMITRIP/CHLORDIAZEP TAB [ 4.00 3702055 AMITRIPTYLINE TAB [10MG] 3.00 3702056 AMITRIPTYLINE TAB [25MG] 3.00 3702057 AMLODIPINE BESYLATE TAB [ 3.00 Charge Code Description Price 3702058 AMLODIPINE BESYLATE TAB [ 2.00 3702059 AMMONIA AROMATIC INH 16.00 3702060 AMMONIUM LACTATE LOT 12% 21.00 3702061 AMOX./CLAV. TAB [875MG] 9.00 3702062 AMOX/CLAV ES SUS [600MG] 42.00 3702063 AMOXAPINE TAB [25MG] 2.00 3702064 AMOXICILLIN SUS [125MG/5M 3.00 3702066 AMOXICILLIN PEDI DROPS [5 29.00 3702067 AMOXICILLIN CAP [250MG] 3.00 3702068 AMOXICILLIN SUS 250MG/5M 3.00 3702070 AMOXICILLIN/CLAVULAN SUS 49.00 3702071 AMOXICILLIN/CLAVULAN SUS 32.00 3702072 AMOXICILLIN/CLAVULAN CHW 5.00 3702073 AMOXICILLIN/CLAVULAN TAB 14.00 3702074 AMOXICILLIN/CLAVULAN TAB 8.00 3702075 AMOXICILLIN/CLAVULAN XR T 25.00 3702076 AMPHOTERICIN B [50MG] 55.00 3702077 AMPICIL/SULBACT INJ [ 1.5 35.00 3702078 AMPICILLIN CAP [ 250MG] 3.00 3702079 AMPICILLIN SUS [250MG/5ML 16.00 3702080 AMPICILLIN INJ [ 250MG] 17.00 3702081 AMPICILLIN INJ [ 500MG] 30.00 3702082 AMPICILLIN INJ [1GM] 30.00 3702083 AMPICIL/SULBACT INJ [3GM] 35.00 3702084 AMPICILLIN INJ [2GM] 30.00 3702085 ANASTROZOLE TAB [1 MG] 18.00 3702086 ANBESOL LIQ 27.00 3702087 ANTIVENIN‐ CORAL SNAKE 4,999.00 3702088 ANTIVENIN‐ BLACK WIDOW 41.00 3702089 ANUSOL OIN 3.00 3702090 ANUSOL SUP 10.00 3702091 APAP/CAFF/BUTALBITAL TAB 3.00 3702092 HYDROCODONE/APAP TAB [ 5‐ 4.00 3702093 HYDROCODONE/APAP TAB [ 7. 4.00 3702094 ARIPIPRAZOLE TAB [10MG] 34.00 3702095 ARTIFICIAL SALIVA SOL 27.00 3702096 LUBRICANT OPTH OINT 16.00 3702097 ARTIFICIAL TEAR SOL 17.00 3702098 ASA/CAFF/BUTA/COD CAP 3.00 3702100 ASCORBIC ACID TAB [500MG] 3.00 3702101 ASPIRIN TAB [81MG] 3.00 3702102 ASPIRIN SUP [600MG] 3.00 3702103 ASPIRIN EC TAB [325MG] 3.00 3702104 ATENOLOL TAB [50MG] 3.00 3702105 ATENOLOL TAB [25MG] 3.00 3702106 ATOMOXETIN CAP [60MG] 9.00 3702107 ATORVASTATIN TAB [20MG] 15.00 3702108 ATORVASTATIN TAB [10MG] 11.00 3702109 ATROPINE OPTH SOL 1% 41.00 3702110 ATROPINE INJ [0.5MG/5ML] 17.00 Charge Code Description Price 3702111 ATROPINE INJ [0.4MG] 15.00 3702112 AVEENO BAR 18.00 3702113 AZATHIOPRINE TAB [50MG] 4.00 3702114 AZITHROMYCIN TAB [250MG] 11.00 3702115 AZITHROMYCIN SUS 30ML [20 16.00 3702116 AZITHROMYCIN INJ [500MG] 35.00 3702117 AZITHROMYCIN ORAL SUS 15M 17.00 3702118 AZTREONAM INJ [1GM] 48.00 3702119 BACITRACIN OIN [500U] 3.00 3702120 BACITRACIN OPTH OIN 21.00 3702121 BACITRACIN/POLY/NEO/ OPTH 90.00 3702122 BACLOFEN TAB [10MG] 3.00 3702123 BALSALAZIDE CAP [750MG] 3.00 3702125 MDI BECLOMETHASONE INHA 16.00 3702126 BECLOMETHASONE NASAL SPR 18.00 3702127 BENAZEPRIL TAB [10MG] 3.00 3702129 BENZOCAINE/ANTIPYRIN SOL 16.00 3702130 BENZONATATE CAP [100MG] 3.00 3702131 BENZTROPINE MESYLATE INJ 164.00 3702132 BENZTROPINE MESYLATE TAB 3.00 3702133 BETAMETHASONE LOT 0.05% 48.00 3702134 BETAMETHASONE ACET/P INJ 16.00 3702135 BETAMETHASONE DIPROP CR 4.00 3702136 BETAMETHASONE VALERA CRE 45.00 3702137 BETAXOLOL HCL SUS 0.25% 16.00 3702138 BETAXOLOL HCL TAB [10MG] 10.00 3702139 BETAXOLOL HCL SOL 0.5% 73.00 3702140 BETHANICOL TAB [10MG] 4.00 3702141 BICALUTAMIDE TAB [50MG] 3.00 3702142 BIMATOPROST GTT 0.03% 2,066.00 3702143 BISACODYL SUP [1OMG] 3.00 3702144 BISACODYL TAB [5MG] 3.00 3702145 BISMUTH SUBSALICYLAT SUS 3.00 3702146 BISOPROLOL/HCTZ TAB [ 2. 3.00 3702147 BISOPROLOL TAB [5MG] 3.00 3702148 BISOPROLOL/HCTZ TAB [ 5/6 3.00 3702149 BISOPROLOL/HCTZ TAB [10/6 3.00 3702150 BRIMONIDE TARTRATE OPT 0. 131.00 3702151 BRIMONIDINE OPTH SOL 0.2% 17.00 3702152 BRINZOLAMIDE OPTH 1% 318.00 3702153 BUDESONIDE CAP [3MG] 22.00 3702154 MDI BUDESONIDE AER [180 319.00 3702155 BUDESONIDE NEB [0.25MG] 10.00 3702156 BUDESONIDE AQUA SPR [32MC 215.00 3702157 BUMETAMIDE TAB [0.5MG] 3.00 3702158 BUMETANIDE TAB [1MG] 3.00 3702159 BUMETANIDE INJ [0.5MG/2ML 15.00 3702160 BUPIVACAINE INJ 0.5% 56.00 3702161 BUPRENORPHINE INJ [0.3MG/ 21.00 3702162 BUPROPION HCL TAB [100MG] 3.00 Charge Code Description Price 3702163 BUPROPION HCL TAB [ 75MG] 3.00 3702164 BUPROPRION SR (TWICE A DA 4.00 3702165 BUPROPRION XL (ONCE‐A DAY 9.00 3702166 BUSPIRONE HCL TAB [ 5MG] 3.00 3702167 BUSPIRONE HCL TAB [10MG] 2.00 3702169 BUTAMBEN/TETRACAIN/B AER 3.00 3702170 BUTORPHANOL NASAL SPR 57.00 3702171 BUTORPHANOL INJ [2MG/ML] 19.00 3702172 CALAM/PRAMOX/ LOTION LOT 16.00 3702173 CALAMINE LOTION 3.00 3702174 CALCIUM CARB/VIT D TAB [6 3.00 3702175 CALCITONIN (SALMON) INJ [ 1,374.00 3702176 CALCITONIN‐SALMON NASAL S 76.00 3702177 CALCITRIOL CAP [0.25MCG] 2.00 3702178 CALCIUM TAB 3.00 3702179 CALCIUM ACETATE CAP [667M 3.00 3702180 CALCIUM CARBONATE TAB 3.00 3702181 CALCIUM CARB TAB [600MG] 3.00 3702182 CALCIUM CHLORIDE INJ 10% 15.00 3702183 CALCIUM CITRATE TAB [400M 3.00 3702184 CALCIUM GLUCONATE TAB [50 3.00 3702185 CALCIUM GLUC INJ 10% [100 15.00 3702186 CANDESARTAN TAB [16MG] 8.00 3702187 CANDESARTAN TAB [8MG] 8.00 3702188 CAPSAICIN CREAM 3.00 3702189 CAPTOPRIL TAB [12.5MG] 3.00 3702190 CAPTOPRIL TAB [25MG] 2.00 3702191 CAPTOPRIL / HCTZ TAB [25/ 10.00 3702192 CARBAMAZEPINE TAB [200MG] 3.00 3702193 CARBAMAZEPINE SUS [100MG/ 3.00 3702194 CARBAMIDE PEROXIDE GTT 16.00 3702195 CARBENICILLIN INDANY TAB 19.00 3702196 CARBIDOPA TAB [25MG] 7.00 3702197 CARBIDOPA/LEVODOPA TAB 3.00 3702198 CARBIDOPA/LEVODOPA CR TAB 4.00 3702199 CARBIDOPA/LEVODOPA TAB 3.00 3702200 CARBIDOPA/LEVODOPA TAB 3.00 3702201 CARBOXYMETHLYCELLULO OPTH 16.00 3702202 CARBOXYMETHYLCELULOS OPTH 16.00 3702203 CERON DM DROPS 30ML 25.00 3702204 CARISOPRODOL TAB [350MG] 4.00 3702205 CARISOPRODOL/ASA TAB 15.00 3702206 CARVEDILOL TAB [6.25MG] 4.00 3702207 CARVEDILOL TAB [25MG] 4.00 3702208 CARVEDILOL TAB [3.125MG] 4.00 3702209 CASCARA SAGRADA EXT [50MG 5.00 3702210 CASPOFUNGIN ACETATE INJ [ 468.00 3702211 CASTOR OIL LIQ UP TO 30M 2.00 3702212 CEFACLOR SUS [125MG/5ML] 71.00 3702213 CEFACLOR SUS [250MG/5ML] 125.00 Charge Code Description Price 3702214 CEFACLOR CAP [250MG] 4.00 3702215 CEFADROXIL SUS 100ML [25 23.00 3702216 CEFADROXIL CAP [500MG] 8.00 3702217 CEFAZOLIN INJ [1GM] 30.00 3702218 CEFDINIR SUS 60ML [125MG/ 11.00 3702219 CEFDINIR CAP [300MG] 9.00 3702220 CEFIXIME TAB [400MG] 27.00 3702221 CEFIXIME SUS [100MG/5ML] 10.00 3702222 CEFOTAXIME INJ [1GM] 35.00 3702223 CEFPODOXIME SUS [50MG/5ML 3.00 3702224 CEFPROZIL TAB [250MG] 6.00 3702225 CEFPROZIL SUS [125MG/5ML] 22.00 3702226 CEFPROZIL SUS [250MG/5ML] 25.00 3702227 CEFTAZIDIME INJ [2GM] 75.00 3702228 CEFTAZIDIME INJ [1GM] 50.00 3702229 CEFTRIAXONE INJ 250MG 41.00 3702230 CEFTRIAXONE INJ [500MG] 52.00 3702231 CEFTRIAXONE INJ 1GM 69.00 3702232 CEFTRIAXONE INJ [2GM] 39.00 3702233 CEFUROXIME SUS [125MG/5ML 103.00 3702234 CEFUROXIME SUS [250MG/5ML 77.05 3702235 CEFUROXIME INJ [750MG] 17.00 3702236 CELECOXIB CAP [100MG] 13.00 3702237 CEPACOL LIQ 3.00 3702238 CEPACOL LOZ 3.00 3702239 CEPHALEXIN [250MG/5ML] 3.00 3702240 CEPHALEXIN CAP [250MG] 3.00 3702241 CEPHALEXIN SUS [125MG/5ML 3.00 3702242 CETACAINE APPL 19.00 3702243 CETIRIZINE HCL SYR [5MG/5 16.00 3702244 CHARCOAL‐ ACTIVATED SUS [ 35.00 3702245 CHARCOAL‐ ACTIVATED SUS [ 35.00 3702246 CHLORAL HYDRATE SYP [100M 3.00 3702247 CHLORAMBUCIL TAB [2MG] 12.08 3702249 CHLORAMPHENICOL INJ [1GM] 42.00 3702250 SORE THROAT SPRAY CHERRY 16.00 3702251 CHLORDIAZEPOXIDE CAP [25M 4.00 3702252 CHLORDIAZEPOXIDE CAP [10M 4.00 3702253 CHLORDIAZEPOXIDE HCL INJ 49.00 3702254 CHLORHEXIDINE GLUC. LIQ 3.00 3702255 CHLOROPHYLLIN COPPER TAB 5.00 3702256 CHLOROTHIAZIDE TAB [250MG 2.00 3702257 CHLOROX 1:20 SOL 3.00 3702258 CHLORPH/DM/PHENYLEPH SYR 5.00 3702259 CHLORPH/DM/PHENYL DROPS 152.00 3702260 CHLORPHEN/PHENYL DROPS 152.00 3702261 CHLORPHEN/PHENYLEPH SYR 5.00 3702262 CHLORPHENIRAMINE TAB [4MG 2.00 3702263 CHLORPROMAZINE TAB [10MG] 10.00 3702264 CHLORPROMAZINE TAB [25MG] 14.00 Charge Code Description Price 3702265 CHLORPROMAZIN INJ [25MG] 37.00 3702266 CHLORPROPAMIDE TAB [250MG 2.00 3702267 CHLORPROPAMIDE TAB [100MG 2.00 3702268 CHLORTHALIDONE TAB [25MG] 2.00 3702269 CHLORZOXAZONE TAB [500MG] 2.00 3702270 CHOLESTYRAMINE POW [4GM] 7.00 3702271 CILASTATIN/IMIPENEM INJ [ 35.00 3702272 CILASTATIN/IMIPENEM INJ [ 35.00 3702273 CILOSTAZOL TAB [100MG] 4.00 3702274 CIPROFLOXACIN IV SOL [400 255.00 3702275 CIPROFLOXACIN TAB [250MG] 9.00 3702276 CIPROFLOXACIN OPTH SOL 16.00 3702277 CIPROFLOXACIN/HYDROCORT O 44.00 3702278 CITALOPRAM HBR TAB [20MG] 4.00 3702279 CLAR. X 1 APPL IN ER SUS 15.00 3702280 CLARITHROMYCIN SUS [250MG 55.00 3702281 CLARITHROMYCIN SUS [125MG 29.00 3702282 CLARITHROMYCIN TAB [250MG 9.00 3702283 CLINDAMYCIN INJ 300 MG 35.00 3702284 CLINDAMYCIN ADD‐VANT INJ 35.00 3702285 CLINDAMYCIN ADD‐VANT INJ 35.00 3702286 CLINDAMYCIN HCL CAP [150M 3.00 3702287 CLINDAMYCIN HCL SUSP SUS 74.00 3702288 CLINDAMYCIN INJ 150MG 30.00 3702289 CLINDAMYCIN TOP SOL 3.00 3702290 CLINDAMYCIN VAG CRE 2% 29.00 3702291 CLINDINIUM/CHLORDIAZ CAP 3.00 3702292 CLOBETASOL CR 0.05% [1 13.00 3702293 CLOMIPRAMINE HCL CAP [25M 15.00 3702294 CLONAZEPAM TAB [0.5MG] 4.00 3702295 CLONIDINE DIS TTS‐1 35.00 3702296 CLONIDINE DIS TTS‐2 24.00 3702297 CLONIDINE DIS TTS‐3 199.00 3702298 CLONIDINE TAB [0.2MG] 3.00 3702299 CLONIDINE TAB 0.3MG 3.00 3702300 CLONIDINE TAB 0.1MG 3.00 3702301 CLOPIDOGREL TAB 75MG 11.00 3702302 CLORAZEPATE TAB [3.75MG] 3.00 3702303 CLOTRIMAZOLE CRE 1% 15GM 3.00 3702304 CLOTRIMAZOLE TRO [10MG] 2.00 3702305 CLOTRIMAZOLE VAG CREAM 4 33.00 3702306 CLOTRIMAZOLE/BETAMET CRE 3.00 3702307 CLOTRIMAZOLE/BETAMET LOTI 67.00 3702308 CLOTRIMAZOLE/BETAMET CRE 25.00 3702309 COCAINE HCL SOL 4% 65.00 3702310 CODEINE SULFATE TAB [30MG 3.00 3702311 CODEINE/GUAIF SYP [10‐100 4.00 3702312 CO‐ENZYME Q10 TAB [60MG] 2.00 3702313 COLCHICINE TAB [0.6MG] 10.00 3702314 COLD CREAM CRE 3.00 Charge Code Description Price 3702315 COLESELVAM HCL TAB [625MG 8.00 3702316 COLLAGENASE OIN 59.00 3702317 CONJUGAT ESTROGENS TAB [1 10.00 3702318 CORTISONE ACETATE TAB [25 7.00 3702319 CRANBERRY CAP 3.00 3702320 CROMOLYN NA SOL [10MG] 7.00 3702321 CROMOLYN NA AER [800MCG] 159.00 3702322 ANTIVENIN‐ CROTALIDAE POL 3,381.00 3702323 CYANOCOBALAMIN INJ 1000M 15.00 3702324 CYANOCOBALAMIN TAB [100MC 3.00 3702325 CYCLOBENZAPRINE TAB [10MG 3.00 3702327 CYCLOPENTOLATE OPTH SOL 1 16.00 3702328 CYCLOPHOSPHAMIDE TAB [50M 4.03 3702329 CYPROHEPTADINE TAB [4MG] 3.00 3702330 CYPROHEPTADINE SYR 2MG/5M 3.00 3702331 DACRIOSE OPTH SOL 54.05 3702332 DANOCRINE CAP [100MG] 3.00 3702333 DANTROLENE CAP [25MG] 2.00 3702334 DAPSONE TAB [25MG] 2.00 3702335 DARBEPOETIN ALFA INJ [200 5,343.00 3702336 DARBEPOETIN ALFA INJ [300 5,343.00 3702337 DARBEPOETIN ALFA INJ [25 638.00 3702338 DARIFENACIN TAB [7.5MG] 20.00 3702339 DEFEROXAMINE MESYLAT POW 49.00 3702340 DESIPRAMINE TAB [25MG] 4.00 3702341 DESITIN OINT 3.00 3702342 DESMOPRESSIN NAS SPR 237.00 3702343 DESMOPRESSIN ACETATE TAB 11.00 3702344 DESONIDE LOT 0.05% 4OZ 45.00 3702346 DESOXIMETASONE GEL 0.5% 10.00 3702347 DESOXIMETASONE CRE 0.05% 59.00 3702348 DESOXIMETASONE CRE 0.05% 8.00 3702349 NEOMYC/POLY/DEX OPTH SUS 31.00 3702350 DEXAMETHASONE TAB [4MG] 3.00 3702351 DEXAMETHASONE TAB [0.75MG 3.00 3702352 DEXAMETHASONE ELI [0.5MG/ 3.00 3702353 DEXAMETHASONE INH SOL [4M 3.00 3702354 DEXAMETHASONE OPTH SOL 0. 16.00 3702355 DEXAMETHASON INJ 4MG/ML 15.00 3702356 IV‐ DEXTR5% & 0.45%NS 88.00 3702357 IV‐ DEXTR5% & 0.9%NS [ 88.00 3702358 IV‐ DEXTR5% & LR [1000 88.00 3702359 IV‐ DEXTR5%/WATER [500M 88.00 3702360 IV‐ DEXTR5%/WATER [ 50 88.00 3702361 IV‐ DEXTR5% & 0.33NS [ 88.00 3702362 IV‐ DEXTR5%/WATER [250 88.00 3702363 IV‐ DEXTR5% & 0.2%NS [ 88.00 3702364 IV‐ DEXTR5%/WATER [100 88.00 3702365 IV‐ DEXTR5%/WATER [1000M 88.00 3702366 DEXTROMETHORPHAN POL SUS 3.00 Charge Code Description Price 3702367 DEXTROMETHORPHAN/GUAIF SY 3.00 3702369 DEXTROSE INJ 50% 50ML 15.00 3702370 IV‐ DEXTROSE 10% [1000ML] 88.00 3702371 DIATRIZOATE MEGLUMIN SOL 129.00 3702372 DIAZEPAM INJ [10MG/2ML] 19.00 3702373 DIAZEPAM TAB [5MG] 4.00 3702374 DIAZEPAM TAB [2MG] 4.00 3702376 DICLOFENAC OPTH SOL 0.1% 24.00 3702377 DICLOFENAC TAB [50MG] 3.00 3702378 DICLOFENAC TAB [25MG] 2.00 3702379 DICLOFENAC/MISOPROST TAB 14.00 3702380 DICLOXACILLIN NA CAP [250 2.00 3702381 DICYCLOMINE INJ [10MG] 85.00 3702382 DICYCLOMINE SYR [10MG/5ML 3.00 3702383 DICYCLOMINE TAB [20MG] 3.00 3702384 DIFLUNISAL TAB [500MG] 2.00 3702385 DIGESTIVE ENZYME COM CAP 7.00 3702386 DIGOXIN CAP [0.05MG] 6.00 3702387 DIGOXIN CAP [0.1MG] 6.00 3702388 DIGOXIN TAB [0.25MG] 3.00 3702389 DIGOXIN TAB [0.125MG] 19.00 3702390 DIGOXIN INJ [0.5MG/2ML] 15.00 3702391 DIGOXIN ELIXIR DRO [0.05M 5.00 3702392 DIGOXIN IMMUNE FAB I INJ 4,500.00 3702393 DIHYDROERGOTAMINE INJ [1M 174.00 3702394 DILTIAZEM HCL TAB [30MG] 3.00 3702395 DILTIAZEM HCL INJ [25MG/5 15.00 3702396 DILTIAZEM HCL CD CAP [120 37.00 3702397 DILTIAZEM HCL CD CAP [180 7.00 3702398 DILTIAZEM HCL CD CAP [240 4.00 3702399 DILTIAZEM HCL CD CAP [300 5.00 3702400 DILTIAZEM SR CAP [60MG] 3.00 3702401 DILTIAZEM SR CAP [90MG] 9.00 3702402 DIMENHYDRINATE TAB [50MG] 3.00 3702403 DIMENHYDRINATE INJ [50MG] 15.00 3702404 DIPHENHYDRAMINE CAP [25MG 3.00 3702405 DIPHENHYDRAMINE HCL CAP [ 3.00 3702406 DIPHENHYDRAMINE CRE 1OZ 3.00 3702407 DIPHENHYDRAMIN INJ [50MG] 15.00 3702408 DIPHENHYDRAMINE ELX [12.5 3.00 3702409 DIPHENOXYLATE/ATROPI LIQ 3.00 3702410 DIPHENOXYLATE/ATROPI TAB 4.00 3702411 DIPIVEFRIN SOL [0.001] 81.08 3702412 DIPYRIDAMOLE TAB [25MG] 3.00 3702413 DIPYRIDAMOLE/ASA CAP [200 14.00 3702414 DISOPYRAMIDE CAP [100MG] 2.00 3702415 DISOPYRAMIDE CR CAP [150 2.00 3702416 DISOPYRAMIDE CAP [150MG] 2.00 3702417 DISULFIRAM TAB [250MG] 5.00 3702418 DIVALPROEX NA TAB [125MG] 3.00 Charge Code Description Price 3702419 DIVALPROEX NA EC TAB [250 4.00 3702420 DOBUTAMINE INJ [250MG/20M 15.00 3702421 DOCUSATE CALCIUM CAP [240 3.00 3702422 DOCUSATE SYP [100MG/10ML] 3.00 3702423 DOCUSATE NA CAP [100MG] 3.00 3702424 DOCUSATE/SENNA TAB 3.00 3702425 DONEPEZIL HCL TAB [10MG] 12.00 3702426 DONEPEZIL HCL TAB [ 5MG] 12.00 3702428 DOPAMINE INJ [400MG/10ML] 15.00 3702429 DORZOLAMIDE SOL [10ML] 2 64.00 3702430 DORZOLAMIDE HCL/TIMO OPT 45.00 3702431 DOXAPRAM HCL INJ [20MG/ML 79.00 3702432 DOXAZOSIN TAB [ 1MG] 8.00 3702433 DOXAZOSIN TAB [ 4MG] 8.00 3702434 DOXEPIN CAP [50MG] 3.00 3702435 DOXEPIN CAP [10MG] 3.00 3702436 DOXEPIN CAP [25MG] 3.00 3702438 DOXYCYCLINE TAB [100MG] 10.00 3702439 DOXYCYCLINE HYCLATE INJ [ 36.00 3702441 DULOXETINE CAP [20MG] 13.00 3702442 DULOXETINE CAP [60MG] 13.00 3702443 DULOXETINE CAP [30MG] 10.00 3702444 DUTASTERIDE CAP [0.5MG] 12.00 3702445 DYPHYLLINE/GUAIF SYR [10 2.00 3702447 ECHOTHIOPHATE IODIDE SOL 150.08 3702448 ECONAZOLE CRE 1% 15GM 11.00 3702449 EFAVIRENZ TAB [600MG] 52.00 3702450 EMOLLIENTS LOT 32.00 3702451 ENALAPRIL TAB [2.5MG] 3.00 3702452 ENALAPRIL TAB [ 5MG] 4.00 3702453 ENALAPRIL TAB [10MG] 27.00 3702454 ENALAPRILAT INJ [2.5MG/2M 15.00 3702455 ENOXAPARIN SODIUM INJ [3 116.00 3702456 ENOXAPARIN SODIUM INJ [10 117.00 3702457 ENOXAPARIN SODIUM INJ [4 116.00 3702458 ENOXAPARIN SODIUM INJ [6 117.00 3702459 ENOXAPARIN SODIUM INJ [8 117.00 3702460 ENTERIC COATED ASPIR TAB 2.00 3702461 EPHEDRINE INJ [50MG] 48.00 3702462 EPINEPHRINE AUTO INJ [0.1 90.00 3702463 EPINEPHRINE AUTO INJ [0.3 79.00 3702464 EPINEPHRINE SOL [1MG/ML] 52.00 3702465 EPINEPHRINE INJ 1:10,000 34.00 3702466 EPINEPHRINE INJ 1:1000 [ 15.00 3702467 EPOETIN ALPHA 10K INJ [10 357.00 3702468 EPOETIN ALPHA 20K INJ [20 712.00 3702469 EPOETIN ALFA 10K INJ [100 231.00 3702470 EPOETIN ALPHA 3K INJ [ 3 109.00 3702471 EPOETIN ALPHA 4K INJ [ 4 144.00 3702472 EPOETIN ALPHA 40K INJ [40 1,422.00 Charge Code Description Price 3702473 EPTIFIBATIDE INJ [20MG] 500.00 3702474 EPTIFIBATIDE INJ [75MG] 500.00 3702475 ERGOLOID TAB [1MG] 12.00 3702476 ERYTHROCIN LACT INJ [500M 17.00 3702477 ERYTHROMYCIN OPHT OIN 16.00 3702478 ERYTHROMYCIN TAB [333MG] 2.00 3702479 ERYTHROMYCIN TAB [250MG] 17.00 3702480 ERYTHROMYCIN ETHYLSU TAB 2.00 3702481 ERYTHROMYCIN/SULFISO SUS 16.00 3702482 ESCITALOPRAM TAB [10MG] 8.00 3702483 ESMOLOL INJ [100MG] 15.00 3702484 ESTERFIED ESTROGENS TAB 9.00 3702485 ESTRADIOL DIS [0.1MG] 22.00 3702486 ESTRADIOL TAB [1MG] 3.00 3702488 ESTRADIOL/MEDROXY TAB 2.00 3702489 CONJUGAT ESTROGENS TAB [0 10.00 3702490 CONJUGAT ESTROGENS TAB [0 10.00 3702491 CONJUGA ESTROGENS CRE [0. 10.00 3702492 CONJUGAT ESTROGENS TAB [0 10.00 3702494 ESZOPICLONE TAB [2MG] 24.00 3702495 ESZOPICLONE TAB [3MG] 24.00 3702496 ETHACRYNIC ACID TAB [50MG 5.00 3702497 ETIDRONATE DINA TAB [200M 5.00 3702498 ETODOLAC CAP [200MG] 3.00 3702499 ETODOLAC CAP [300MG] 3.00 3702500 ETODOLAC XL TAB [400MG] 5.00 3702501 ETODOLAC XL TAB [600MG] 7.00 3702502 HYDROCERIN CRE 3.00 3702503 EZETIMIBE TAB [10MG] 18.00 3702504 EZETIMIBE/SIMVASTATI TAB 9.00 3702505 EZETIMIBE/SIMVASTATI TAB 9.00 3702506 FAMCICLOVIR TAB [500MG] 17.00 3702507 FE/VIT C/B12 CAP 2.00 3702508 FELODIPINE CR TAB [5MG] 3.00 3702509 FELODIPINE CR TAB [2.5MG] 3.00 3702510 FENOFIBRATE MICRONIZ TAB 9.00 3702511 FENOFIBRATE MICRONIZ TAB 3.00 3702512 FENTANYL CIT INJ [100MCG/ 19.00 3702513 FENTANYL TD PATCH [ 25MCG 19.00 3702514 FENTANYL TD PATCH [100MCG 64.00 3702515 FENTANYL TD PATCH [ 50MCG 33.00 3702516 FERROUS SO4 IRON DROPS 61.00 3702517 FERROUS FUMARATE TAB 3.00 3702518 FERROUS GLUC TAB 5 GRAI 3.00 3702519 FER SULF ELX [220MG/5ML] 3.00 3702520 FERROUS SO4 TAB 5 GRAIN 3.00 3702521 FILGRASTIM INJ [300MCG] 437.00 3702522 FILGRASTIM INJ [480MCG] 500.00 3702523 FINASTERIDE TAB [5MG] 7.00 3702524 FLAVOXATE HCL TAB [100MG] 3.00 Charge Code Description Price 3702525 FLECAINIDE ACET TAB [100M 8.00 3702526 FLEETS PHOS SODA SUS 3.00 3702527 FLUORESCEIN SODIUM OPTH S 16.00 3702528 FLUCON/NACL PM INJ [100MG 35.00 3702529 FLUCON/NACL PM INJ [200MG 35.00 3702530 FLUCON/NACL PM INJ [400MG 35.00 3702531 FLUCONAZOLE TAB [200MG] 18.00 3702532 FLUCONAZOLE TAB [100MG] 13.00 3702533 FLUDROCORTISONE ACET TAB 3.00 3702534 FLUMAZENIL INJ [0.5MG/0.5 15.00 3702535 FLUNISOLIDE AER [250MCG] 215.00 3702536 FLUNISOLIDE SPR 0.025% 77.05 3702537 FLUOCINONIDE CRE 0.05% 1 7.00 3702538 FLUOROMETHOLONE OPTH SUS 61.00 3702539 FLUOROURACIL CRE 5% 40G 330.05 3702540 FLUOXETINE CAP [20MG] 4.00 3702541 FLUOXETINE [10MG] 5.00 3702542 FLUOXETINE CAP [90MG] 38.00 3702543 FLUOXYMESTERONE TAB [10MG 14.00 3702544 FLUPHENAZINE DECAN INJ [2 22.00 3702545 FLUPHENAZINE TAB [10MG] 2.00 3702546 FLUPHENAZINE HCL TAB [ 1M 2.00 3702547 FLUPHENAZINE HCL TAB [2.5 3.00 3702548 FLURBIPROFEN TAB [100MG] 2.00 3702549 FLUTAMIDE CAP [125MG] 2.00 3702550 MDI FLUTICASONE/SALMETR 28.00 3702551 FLUTICASONE NAS SPR 16.00 3702552 MDI FLUTICASONE INH [ 4 27.00 3702553 MDI FLUTICASONE INH [11 31.00 3702554 MDI FLUTICASONE INH [22 46.00 3702555 MDI FLUTICASONE/SALMETR 91.00 3702556 MDI FLUTICASONE/SALMETE 16.00 3702557 FLUVASTATIN SODIUM C CAP 10.00 3702558 FLUVASTATIN SODIUM C TAB 17.00 3702559 FLUVOXAMINE MALEATE TAB [ 2.00 3702560 FOLIC ACID TAB [1MG] 3.00 3702562 FOLTX TAB B12/B6/FOLIC T 3.00 3702563 FORMOTEROL FUM INH [12MCG 56.00 3702564 FOSINOPRIL NA TAB [10MG] 4.00 3702565 FUROSEMIDE INJ [ 20MG/2ML 15.00 3702566 FUROSEMIDE INJ [ 40MG/4ML 15.00 3702567 FUROSEMIDE INJ [100MG/10M 15.00 3702568 FUROSEMIDE TAB [20MG] 3.00 3702569 FUROSEMIDE TAB [40MG] 3.00 3702570 FUROSEMIDE TAB [80MG] 3.00 3702571 GABAPENTIN CAP [100MG] 4.00 3702572 GABAPENTIN CAP [300MG] 3.00 3702573 GALANTAMINE HBR TAB [ 8MG 8.00 3702574 GALANTAMINE HBR TAB [12MG 8.00 3702575 GALANTAMINE HBR TAB [ 4MG 8.00 Charge Code Description Price 3702576 GARLIC CAP CAP [1000MG] 2.00 3702577 GEMFIBROZIL TAB [600MG] 9.00 3702578 GENTAMICI OPTH OINT [3MG/ 16.00 3702579 GENTAMICIN P/MIX [ 60MG] 35.00 3702580 GENTAMICIN P/MIX [ 80MG] 35.00 3702581 GENTAMICIN INJ [40MG/ML] 30.00 3702582 GENTAMICIN CRE 0.1% 15 3.00 3702583 GENTAMICIN OIN 0.1% 15G 3.00 3702584 GENTAMICI OPTH SOL 0.3% 16.00 3702585 GENTAMICIN X1 APPL. OIN 8.05 3702586 GENTIAN VIOLET SOL 3.00 3702587 GLATIRAMER ACETATE INJ [2 171.00 3702588 GLIMEPIRIDE TAB [2MG] 4.00 3702589 GLIPIZIDE TAB [ 5MG] 3.00 3702590 GLIPIZIDE TAB [10MG] 3.00 3702591 GLIPIZIDE XL TAB [5MG] 3.00 3702592 GLIPIZIDE XL TAB [2.5MG] 3.00 3702593 GLUCAGON INJ [1MG] 390.00 3702594 GLUCOSE ORAL SOL [15GM] 3.00 3702596 GLYBURIDE TAB [5MG] 3.00 3702597 GLYBURIDE TAB [2.5MG] 3.00 3702598 GLYCERIN ADULT SUP 3.00 3702599 GLYCERIN PEDIATRIC SUP 3.00 3702600 GLYCOPYRROLATE INJ [0.4MG 21.00 3702601 GLYCOPYRROLATE TAB [1MG] 3.00 3702602 GRISEOFULVIN TAB [125MG] 6.00 3702603 GUAIF/PHENYLEPHRINE TAB [ 5.00 3702604 GUAIF/PHENYLEPHRINE TAB [ 7.00 3702605 GUAIFENESIN SYP [100MG/5M 3.00 3702606 GUAIFENESIN TAB [200MG] 2.00 3702607 GUAIFENSIN LA TAB [600MG] 3.00 3702608 GUANABENZ TAB [4MG] 2.00 3702609 GUANFACINE TAB [1MG] 3.00 3702610 HALOBETASOL PROP CRE 0.0 10.00 3702611 HALCINONIDE CRE 0.1% 60G 225.00 3702612 HALCINONIDE SOL 0.1% 60 205.00 3702613 HALOPERIDOL TAB [2MG] 3.00 3702614 HALOPERIDOL TAB [ 0.5MG] 3.00 3702615 HALOPERIDOL TAB [ 1MG] 3.00 3702616 HALOPERIDOL TAB [5MG] 3.00 3702617 HALOPERIDOL DECON INJ [50 41.00 3702618 HALOPERIDOL LACT INJ [5MG 15.00 3702619 HALOTHANE SOL 201.00 3702620 HEP‐A/HEP‐B VACCINE SUS 137.00 3702621 HEP LOCK‐ HEPARIN FLUSH 1 15.00 3702622 HEPARIN NA (PORCINE) INJ 15.00 3702623 HEPARIN NA (PORCINE) INJ 15.00 3702624 HEPARIN NA (PORCINE) INJ 15.00 3702625 HEPATITIS B VAC INJ PEDI 66.00 3702626 HEXACHLOROPHENE LIQ 76.00 Charge Code Description Price 3702627 HOMATROPINE HBR SOL 5% 5 16.00 3702628 HYDRALAZINE TAB [25MG] 3.00 3702629 HYDRALAZINE HCL INJ [20 M 24.00 3702630 HYDRALAZINE TAB [10MG] 3.00 3702631 HYDRALAZINE/RESERP/H TAB 8.00 3702632 HYDROCHLOROTHIAZIDE TAB [ 3.00 3702633 HYDROCODONE/APAP TAB [10/ 4.00 3702634 HYDROCOD/GUAIF SYR [5/100 4.03 3702635 HYDROCOD/HEMATROP.ME SYR 4.00 3702636 HYDROCOD BIT/APA ELI [2.5 4.00 3702637 HYDROCORT/ACETIC OTIC 141.00 3702638 HYDROCORT/PRAM/CHLOR OTIC 16.00 3702639 HYDROCORTISONE CRE 2.5% 36.00 3702640 HYDROCORTISONE ENEMA 60 16.00 3702641 HYDROCORTISONE TAB [20MG] 3.00 3702642 HYDROCORTISONE CRE 1% 30 3.00 3702643 HYDROCORTISONE ACETA SUP 8.00 3702644 HYDROCORTISONE INJ [250MG 37.00 3702645 HYDROCORTISONE INJ [100MG 22.00 3702646 HYDROCORTISONE/PRAMO AER 83.00 3702648 HYDROMORPHONE TAB [2MG] 4.00 3702649 HYDROMORPHONE HCL I INJ 19.00 3702650 HYDROXY/METHYL OPTH OIN 15.00 3702651 HYDROXYCHLOROQUINE TAB [2 9.00 3702652 HYDROXYUREA CAP [500MG] 3.00 3702653 HYDROXYZINE HCL TAB [25MG 3.00 3702654 HYDROXYZINE HCL INJ [50MG 33.00 3702655 HYDROXYZINE HCL TAB [10MG 3.00 3702656 HYDROXYZINE HCL SYR [10MG 3.00 3702657 HYOSCAMINE DROPS 29.00 3702658 HYOSCAMINE/PB DROPS 16.00 3702659 HYOSCYAMINE ELIXIR 5M 3.00 3702660 HYOSCYAMINE TAB [0.125MG] 3.00 3702661 HYOSCYAMINE ER TAB [0.375 3.00 3702662 IBUPROFEN SUS 100MG/5ML 3.00 3702663 IBUPROFEN TAB [800MG] 3.00 3702664 IBUPROFEN TAB [400MG] 3.00 3702665 IBUPROFEN TAB [600MG] 3.00 3702666 IBUPROFEN TAB [200MG] 3.00 3702667 IMIPRAMINE TAB [25MG] 3.00 3702668 IMIPRAMINE PM CAP [ 75MG 22.00 3702669 IMMUNE GLOBULIN INJ 15.00 3702670 INDAPAMIDE TAB [2.5MG] 3.00 3702671 INDAPAMIDE TAB [1.25MG] 3.00 3702672 INDINAVIR CAP [400MG] 9.00 3702673 INDOMETHACIN SUP [50MG] 14.00 3702674 INDOMETHACIN CAP [25MG] 3.00 3702675 INFLUENZA VIRUS VACC INJ 40.00 3702676 EPLERENONE TAB [25MG] 8.00 3702677 INS‐ INSULIN ASPART 41.00 Charge Code Description Price 3702678 INS‐ INSULIN ASPART.PROT. 42.00 3702679 INS‐ INSULIN GLARGINE INJ 38.00 3702680 INS‐ INSULIN ISOPHANE(HUM 22.00 3702681 INS‐ INSULIN 70/30 REG/IS 22.00 3702682 INS‐ INSULIN ‐ REGULAR 22.00 3702683 INTERFERON ALFA‐2B INJ [3 500.00 3702684 INTERFERON BETA‐1A INJ [3 6,987.00 3702685 INTERFERON BETA‐1A INJ [4 1,377.00 3702686 IOVERSOL 68% 50ML SYR [32 45.00 3702687 IOVERSOL 68% 150ML BTL [ 87.00 3702688 IPRAT BR/ALBUTEROL NEB 3.00 3702689 IPRATROPIUM NAS SPR 0.06% 16.00 3702690 IPRATROPIUM NAS SPR 0.03% 16.00 3702691 IPRATROPIUM/ALBUT INH [18 24.00 3702693 IPRATROPIUM BROMIDE HFA I 41.00 3702694 IPRATROPIUM BROM NEB TREA 3.00 3702695 IRBESARTAN TAB [300MG] 16.00 3702696 IRBESARTAN TAB [150MG] 9.00 3702697 IRON DEXTRAN INJ [50MG] 29.00 3702698 IRON VIT/MIN COMPLEX CAP 3.00 3702699 IRON/VITAMINS TAB 500M 3.00 3702700 ISONIAZID TAB [300MG] 3.00 3702701 ISOPROTERENOL HCL INJ [1M 496.00 3702702 ISOSORBIDE DINITR SL TAB 3.00 3702703 ISOSORBIDE DINITRATE CR T 3.00 3702704 ISOSORBIDE DINITRAT TAB [ 3.00 3702705 ISOSORBIDE DINITRAT TAB [ 3.00 3702706 ISOSORBIDE DINITRAT TAB 3.00 3702707 ISOSORBIDE DINITR SL TAB 3.00 3702708 ISOSORBIDE MONONITRA TAB 3.00 3702709 ISOSORBIDE MONONITRA ER T 4.00 3702710 ISOSORBIDE MONONITRA ER T 8.00 3702711 ISRADIPINE CR TAB [5MG] 7.00 3702712 ISRADIPINE CAP [2.5MG] 3.00 3702713 KCL INJ [20MEQ / 10ML] 15.00 3702714 KCL INJ [30MEQ / 15ML] 15.00 3702715 KCL INJ [40MEQ / 20ML] 15.00 3702716 KETAMINE INJ [50MG/ML] 19.00 3702717 KETOCONAZOLE SHAMPOO 2% 29.00 3702718 KETOCONAZOLE TAB [200MG] 8.00 3702719 KETOCONAZOLE CRE 2% 15G 13.00 3702720 KETOPROFEN CAP [75MG] 5.00 3702721 KETOPROFEN CAP [50MG] 4.00 3702722 KETOPROFEN ER CAP [200MG] 15.00 3702723 KETOPROFEN ER CAP [150MG] 3.00 3702724 KETOROLAC OPTH SOL 0.5% 22.00 3702725 KETOROLAC INJ 30MG 15.00 3702726 KETOROLAC INJ 60MG 15.00 3702727 KETOROLAC TAB [10MG] 4.00 3702728 LABETALOL INJ [100MG/20ML 15.00 Charge Code Description Price 3702729 LABETALOL HCL TAB [100MG] 3.00 3702730 LACTASE ENZYME CAP [3000U 3.00 3702731 IV‐ LACTATED RINGERS [100 88.00 3702732 LACTOBACILLUS GRANULES 4.00 3702733 LACTOBACILLUS TAB 3.00 3702734 LACTULOSE SYP [10GM PER 3.00 3702736 LAMIVUDINE TAB [300MG] 45.00 3702737 LAMOTRAGINE TAB [25MG] 8.00 3702738 LAMOTRIGINE TAB [200MG] 10.00 3702739 LANSOPRAZOLE TAB [15MG] 10.00 3702740 LATANOPROST SOL 0.005% 16.00 3702741 L‐CARNITINE CAP [500MG] 3.00 3702742 LEFLUNOMIDE TAB [20MG] 21.00 3702743 LEUPROLIDE INJ [45MG] 3,405.00 3702744 LEUPROLIDE INJ [ 7.5MG] 569.00 3702745 LEUPROLIDE INJ [7.5MG] 2,016.00 3702746 LEVALBUTEROL NEB [0.31MG/ 8.00 3702747 LEVALBUTEROL NEB [0.63MG/ 14.00 3702748 LEVALBUTEROL NEB [1.25MG/ 14.00 3702749 MDI LEVALBUTEROL HFA IN 16.00 3702750 LEVETIRACETAM LIQ [500MG/ 7.00 3702751 LEVOBUNOLOL OPTH SOL 0.5% 31.00 3702752 LEVOFLOXACIN INJ [500MG/2 270.00 3702753 LEVOFLOXACIN TAB [500MG] 24.00 3702754 LEVOFLOXACIN P/MIX INJ [2 35.00 3702755 LEVOFLOXACIN P/MIX INJ [7 35.00 3702756 LEVOFLOXACIN P/MIX INJ [5 35.00 3702757 LEVOTHYROXINE TAB [ 0.088 3.00 3702758 LEVOTHYROXINE TAB [0.112M 3.00 3702759 LEVOTHYROXINE TAB [ 0.075 3.00 3702760 LEVOTHYROXINE TAB [ 0.1MG 3.00 3702761 LEVOTHYROXINE TAB [0.125M 3.00 3702762 LEVOTHYROXINE TAB [0.2MG] 3.00 3702763 LEVOTHYROXINE TAB [ 0.05M 3.00 3702764 LEVOTHYROXINE TAB [0.15MG 3.00 3702765 LIDOCAINE IV P/MIX [2GM 15.00 3702766 LIDOCAINE CARD INJ [100MG 15.00 3702767 LIDOCAINE OINT 5% 35GM 12.00 3702768 LIDOCAINE VISC SOL 2% 10 48.00 3702769 LIDOCAINE INJ LOCAL 1% 5 15.00 3702770 LIDOCAINE INJ LOCAL 2% 5 15.00 3702771 LIDOCAINE INJ LOCAL 0.5% 15.00 3702772 LIDOCAINE‐MPF GTT 4 15.00 3702773 LIDOCAINE/EPI INJ 1% 20M 15.00 3702774 LIDOCAINE/EPI INJ 2% 20M 15.00 3702775 LIDOCAINE/PRILOCAINE 30GM 11.00 3702776 LIDOCAINE‐MPF 1% 15.00 3702777 LINDANE SHAMPOO 1% 199.00 3702778 LINDANE LOT 1% 199.00 3702779 LINEZOLID TAB [600MG] 237.00 Charge Code Description Price 3702780 LINEZOLID P/MIX INJ [600M 76.00 3702781 LIOTHYRONINE NA TAB [5MCG 3.00 3702782 LIOTHYRONINE TAB [50MCG] 3.00 3702784 LISINOPRIL TAB [ 5MG] 3.00 3702785 LISINOPRIL TAB [10MG] 3.00 3702786 LISINOPRIL TAB [20MG] 3.00 3702787 LITHIUM CARB CAP [150MG] 3.00 3702788 LITHIUM ER TAB [450MG] 3.00 3702789 LITHIUM ER TAB [300MG] 3.00 3702790 LOPERAMIDE LIQ [1MG/5ML[ 3.00 3702791 LOPERAMIDE CAP [2MG] 3.00 3702792 LOPINAVIR/RITONAVIR TAB [ 14.00 3702793 LORATADINE TAB [10MG] 3.00 3702794 LORATADINE ML [5MG/5ML] 3.00 3702795 LORATIDINE/PSE TAB [5/12 3.00 3702796 LORAZEPAM TAB [1MG] 4.00 3702797 LORAZEPAM TAB [0.5MG] 4.00 3702798 LORAZEPAM INJ [2MG] 19.00 3702799 LOSARTAN POTASSIUM TAB [2 3.00 3702800 LOSARTAN POTASSIUM TAB [5 4.00 3702801 LOSARTAN/HCTZ TAB [50‐12. 5.00 3702802 LOTEPREDNOL OPTH SUS 0.5% 126.00 3702803 LOVASTATIN TAB [20MG] 4.00 3702804 LOXAPINE CAP [5MG] 2.00 3702805 LUBIPROSTONE CAP [24MCG] 11.00 3702806 LUBRICANT OPTH SOL 16.00 3702807 LUBRICANT OPTH SOL 16.00 3702808 LUBRIDERM LOT FRAG FREE 3.00 3702809 INS‐ LYSPRO INSULIN [100 41.00 3702810 INS‐ LYSPRO INSULIN 75/25 42.00 3702811 MAAL/DONNATAL/XYL VISC 27.00 3702812 ALUM/MAGN SUSP UP TO 30 3.00 3702813 ALUMI/MAG/SIMETH UP TO 3.00 3702814 MAG SULF 50% VL [4.06MEQ/ 15.00 3702815 MAGNESIUM CHL TAB 3.00 3702816 MAG CITRATE SOL 10OZ 16.00 3702817 MAGNESIUM GLUC TAB [500MG 3.00 3702820 MAGNESIUM OXIDE TAB [400M 3.00 3702821 MAG SULF 50% SYR [4MEQ/ML 15.00 3702822 MANNITOL INJ 25% 50ML 15.00 3702823 MAPROTILINE TAB [50MG] 3.00 3702824 MEBENDAZOLE TAB [100MG] 10.00 3702825 MECLIZINE TAB [12.5MG] 3.00 3702826 MECLIZINE TAB [25MG] 3.00 3702827 ME‐COBAL/LM FOL/PYRI TAB 4.00 3702828 MEDICATED PWD 16.00 3702829 MEDROXYPROGESTERONE TAB [ 3.00 3702830 MEDROXYPROGESTERONE INJ 115.00 3702831 MEGESTROL ACETATE SUS [40 3.00 3702832 MEGESTROL ACETATE TAB [20 3.00 Charge Code Description Price 3702833 MELOXICAM TAB [15MG] 9.00 3702834 MEMANTINE HCL TAB [10MG] 13.00 3702835 MEMANTINE HCL TAB [ 5MG] 13.00 3702836 MENTH/CAMP/PHENOL OIN 3.00 3702837 MEPERIDINE INJ [100 MG] 19.00 3702838 MEPERIDINE INJ [ 75 MG] 17.00 3702839 MEPERIDINE INJ [ 50MG] 19.00 3702840 MEPERIDINE INJ [ 25MG] 19.00 3702841 MEPERIDINE TAB [50MG] 5.00 3702842 MEPERIDINE/PROMETHAZ CAP 8.05 3702843 MERCAPTOPURINE TAB [50MG] 12.00 3702844 MESALAMINE SUS [4GM] 3.00 3702845 MESALAMINE TAB [400MG] 4.00 3702846 MESORIDAZINE BESYL TAB [2 3.00 3702849 METFORMIN TAB [500MG] 3.00 3702850 METFORMIN TAB [850MG] 3.00 3702851 METFORMIN TAB ER [500MG] 3.00 3702852 METHADONE TAB [10MG] 3.00 3702853 METHAZOLAMIDE TAB [50MG] 8.00 3702854 METHENAMINE MANDELAT TAB 3.00 3702855 METHENAMINE/BELL/MB/ TAB 8.00 3702856 METHIMAZOLE TAB [10MG] 3.00 3702857 METHOCARBAMOL INJ [100MG/ 37.00 3702858 METHOCARBAMOL TAB [500MG] 3.00 3702859 METHOTREXATE TAB [2.5MG] 10.00 3702861 METHYLCELLULOSE SCOOP 3.00 3702862 METHYLDOPA TAB [250MG] 3.00 3702863 METHYLDOPA/HCTZ TAB [250/ 4.00 3702864 METHYLDOPATE HCL INJ [250 47.00 3702865 METHYLERGONOVINE MAL TAB 3.00 3702866 METHYLERGONOVINE MAL INJ 15.00 3702867 METHYLPHENIDATE HCL TAB [ 3.00 3702868 METHYLPHENIDATE HCL TAB [ 18.00 3702869 METHYLPREDNISOLONE INJ [ 35.00 3702870 METHYLPREDNISOLONE INJ [2 117.00 3702871 METHYLPREDNISOLONE INJ 43.00 3702872 METHYLPREDNISOLONE A INJ 15.00 3702873 METHYLPREDNISOLONE INJ [ 15.00 3702874 METHYLPREDNISOLONE TAB [4 3.00 3702875 METOCLOPRAMIDE SYP [5MG/5 3.00 3702876 METOCLOPRAMIDE TAB [10MG] 3.00 3702877 METOCLOPRAMIDE INJ [10MG/ 15.00 3702878 METOLAZONE TAB [2.5MG] 7.00 3702879 METOLAZONE TAB [5MG] 8.00 3702880 METOPROLOL SUCC XL TAB [ 3.00 3702881 METOPROLOL SUCC XL TAB [ 3.00 3702882 METOPROLOL TARTRATE INJ [ 15.00 3702883 METOPROLOL TARTRATE TAB [ 3.00 3702884 METOPROLOL TARTRATE TAB [ 3.00 3702885 METOPROLOL TARTRATE TAB [ 3.00 Charge Code Description Price 3702886 METRONIDAZOLE TAB [250MG] 3.00 3702887 METRONIDAZOLE CRM 0.75% 51.00 3702888 METRONIDAZOLE P/MIX INJ [ 35.00 3702889 MEXILETINE HCL CAP [150MG 4.00 3702890 MEXILETINE HCL CAP [200MG 7.00 3702891 MICONAZOLE VAG SUP [200M 43.00 3702892 MICONAZOLE VAG CRE 2% 34.00 3702893 MICONAZOLE VAG SUP [100M 29.00 3702894 GLYBURIDE‐MICRONIZED TAB 3.00 3702895 MIDAZOLAM SDV INJ [5MG/5M 19.00 3702896 MIDODRINE TAB [5MG] 9.00 3702897 MIGLITOL TAB [25MG] 2.00 3702898 MAG HYDROXIDE SUSP UP TO 3.00 3702899 MINERAL OIL UP TO 30ML 16.00 3702900 MINOXIDIL TAB [ 2.5MG] 3.00 3702901 MINOXIDIL TAB [10MG] 3.00 3702902 MIRTAZAPINE TAB [15MG] 5.00 3702903 MIRTAZAPINE TAB [45MG] 4.00 3702904 MISOPROSTOL TAB [100MCG] 3.00 3702905 MIVACURIUM INJ [2MG/ML] 15.00 3702906 MOEXIPRIL HCL TAB [15MG] 3.00 3702907 MOMETASONE FUR OIN 0.1% 17.00 3702908 MOMETASONE FUR CRE 0.1% 1 4.00 3702909 MOMETASONE FUR LOT 0.1% 14.00 3702910 MOMETASONE FUR NAS SPR [5 24.00 3702911 MONTELUKAST TAB [10MG] 10.00 3702912 MONTELUKAST GRAN [4MG] 10.00 3702913 MORPHINE S04 10MG SDV INJ 19.00 3702914 MORPHINE CR TAB [30MG] 5.00 3702915 MORPHINE SUL INJ [100MG/ 19.00 3702917 CENTRUM SILVER TAB 2.00 3702918 MULTIVITAMINS + MINERALS 3.00 3702919 STRESS TAB 600 MULTIVITAM 3.00 3702920 MUP. X 1 APPL. IN ER OIN 6.00 3702921 MUPIROCIN OIN 2% 22GM 17.00 3702922 BACMIN ‐MULTIVITAMINS + 2.00 3702923 MVI VIAL INJ [10ML] 15.00 3702925 SIMETHICONE DROPS 16.00 3702926 NA/K PHOSPHATE POW 3.00 3702927 NABUMETONE TAB [500MG] 3.00 3702928 NADOLOL TAB [80MG] 10.00 3702929 NADOLOL TAB [20MG] 10.00 3702930 NAFCILLIN INJ [2GM] 35.00 3702931 NAFCILLIN INJ [1GM] 30.00 3702932 NALBUPHINE HCL INJ [10MG/ 15.00 3702933 NALOXONE INJ [0.4MG] 44.00 3702934 NAPROXEN TAB [250MG] 3.00 3702935 NAPROXEN TAB [375MG] 3.00 3702936 NAPROXEN NA TAB [275MG] 3.00 3702937 NATEGLINIDE TAB [120] 4.00 Charge Code Description Price 3702938 NEFAZODONE TAB [100MG] 9.00 3702939 NELFINAVIR TAB [250MG] 9.00 3702940 NEOMY/POLYM/GRAM OPTH SOL 16.00 3702941 NEOMY/POLY/BAC OIN UD 16.00 3702942 NEOMY/POLY/BAC OIN 1OZ 16.00 3702943 NEOMYCIN TAB [500MG] 3.00 3702944 NEOMY/POLY/BAC OPTH OIN 3 57.00 3702945 NEOMYC/POLY/DEX OPTH OINT 30.00 3702946 NEOMYCIN/POLYMYX/GRA OPTH 16.00 3702947 NEOMYCIN/POLYMYXIN B SOL 21.00 3702948 NEOMY/POLY/HC OPTH SUS 7. 145.00 3702949 NEOMY/POLY/HC OTIC SOL 10 27.00 3702950 NEOMY/POLY/HC OTIC SUS 10 16.00 3702951 NEOSTIGMINE INJ [1MG] 15.00 3702952 NESIRITIDE [1.5MG] 1,463.00 3702953 NEVIRAPINE SUS [50MG/5ML] 16.00 3702954 NIACIN TAB [50MG] 3.00 3702955 NIACIN TAB [500MG] 3.00 3702956 NIACIN ER TAB [500MG] 8.00 3702957 NICARDIPINE CAP [30MG] 7.00 3702958 NICARDIPINE CAP [20MG] 4.00 3702959 NICARDIPINE SR CAP [30MG] 4.00 3702960 NICARDIPINE SR CAP [45MG] 5.00 3702961 NICOTINE DIS [21MG] 4.00 3702962 NICOTINE DIS [14MG] 4.00 3702963 NICOTINE DIS [ 7MG] 4.00 3702964 NIFEDIPINE CAP [10MG] 3.00 3702965 NIFEDIPINE XL TAB [30MG] 3.00 3702966 FERROUS SULF/FOLIC ACID T 3.00 3702967 NISOLDIPINE TAB [10MG] 3.00 3702968 NITROFURANTOIN SUS [25MG/ 21.00 3702969 NITROFURANTOIN MAC CAP [5 5.00 3702970 NITROFURANTOIN MONO CAP [ 9.00 3702971 NITROGLYCERIN OIN UD 2% 4.00 3702972 NITROGLYCERIN SL AER 80.00 3702973 NITROGLYCERIN SUB [0.4MG] 3.00 3702974 NITROGLYCERIN CAP [6.5MG] 3.00 3702975 NITROGLYCERIN P/MIX IV [5 35.00 3702976 NITROGLYCERIN PATCH PAT [ 4.00 3702977 NITROGLYCERIN PATCH PAT [ 4.00 3702978 NITROGLYCERIN PATCH PAT [ 12.00 3702979 NITROGLYCERIN PATCH PAT [ 10.00 3702980 NITROGLYCERIN PATCH PAT [ 4.00 3702981 NITROGLYCERIN TD CAP [2.5 3.00 3702982 NITROPRUSSIDE NA INJ [50M 36.00 3702983 NIZATIDINE CAP [150MG] 3.00 3702984 NOREPINEPHRINE BIT INJ [4 35.00 3702985 NORTRIPTYLINE HCL CAP [25 3.00 3702986 NORTRIPTYLINE HCL CAP [50 5.00 3702987 IV‐ NS 0.9% ADDVANT INJ 88.00 Charge Code Description Price 3702988 IV‐ NS 0.9% ADDVANT INJ 21.00 3702989 NYST/TRIAMC CRE 60GM 89.00 3702990 NYST/TRIAMC OIN 60GM 89.00 3702991 NYST/TRIAMC OIN 15GM 16.00 3702992 NYST/TRIAMC CRE 15GM 11.00 3702993 NYSTATIN ORAL SUSP 5ML [ 3.00 3702994 NYSTATIN POWDER 15GM 15.00 3702995 NYSTATIN OIN 15GM 3.00 3702997 NYSTATIN CRE 15GM 3.00 3702998 NYSTATIN VAG TAB [100000U 10.00 3702999 OPTH VITAMINS & MINERALS 3.00 3703000 OFLOXACIN OPTH SOL 0.3% 16.00 3703001 OFLOXACIN OTIC SOL 0.3% 23.00 3703002 ESTROPIPATE TAB [0.625MG] 2.00 3703003 OLANZAPINE TAB [ 5MG] 17.00 3703004 OLANZAPINE TAB [10MG] 25.00 3703005 OLMESARTAN TAB [40MG] 12.00 3703006 OLOPATADINE OPTH SOL 154.00 3703007 ONDANSETRON TAB [8MG] 50.00 3703008 ONDANSETRON INJ 4MG/2ML 15.00 3703010 OYST SHELL CALC FORTE TAB 3.00 3703011 OSELTAMIVIR SUS [12MG/ML] 4.00 3703012 OSELTAMIVIR CAP [75MG] 23.00 3703014 OXACILLIN SOL [250MG/5ML] 3.00 3703015 OXACILLIN INJ [1GRAM] 17.00 3703016 OXACILLIN CAP [500MG] 3.00 3703017 OXAPROZIN TAB [600MG] 8.00 3703018 OXCARBAZEPINE TAB [300MG] 5.00 3703019 OXYBUTYNIN TAB [5MG] 3.00 3703020 OXYBUTYNIN XL TAB [5MG] 7.00 3703021 OXYCODONE/APAP TAB [5/325 4.00 3703022 OXYCODONE CR TAB [10MG] 9.00 3703023 OXYCODONE CR TAB [40MG] 19.00 3703024 OXYCODONE CR TAB [80MG] 31.00 3703025 OXYCODONE IMMEDIATE RELEA 4.00 3703026 PHENYLEPHRINE NAS DROPS 1 16.00 3703027 OXYMETAZOLINE 0.05% 15ML 16.00 3703029 OXYTOCIN INJ [10U] 15.00 3703030 OYST SHELL CALC TAB [500M 3.00 3703031 PALIDOXIME CHLORIDE INJ [ 122.00 3703032 PANCRELIPASE E.C CAP 3.00 3703033 PANCRELIPASE TAB 3.00 3703034 PANCURONIUM INJ [1MG/ML] 15.00 3703035 PANTOPRAZOLE TAB [20MG] 8.00 3703036 PANTOPRAZOLE TAB [40MG] 8.00 3703037 PANTOPRAZOLE IV [40MG] 15.00 3703038 PAP/UREA/CHLOROPH/CO OIN 3.00 3703039 PAPAIN‐UREA 830 DEBRIDING 3.00 3703040 PAPAVERINE TR CAP [150MG] 3.00 3703042 PAROXETINE TAB [10MG] 3.00 Charge Code Description Price 3703043 PAROXETINE TAB [20MG] 5.00 3703044 PAROXETINE CR TAB [25MG] 10.00 3703045 PAROXETINE CR TAB [12.5MG 10.00 3703046 GUAIF/PHENYLEPRINE TAB 6.00 3703047 PENICILLAMINE CAP [125MG] 3.00 3703048 PENICILLIN G BENZATH INJ 253.00 3703049 PENICILLIN G BENZATH INJ 200.00 3703051 PENICILLIN G PROC&BE INJ 15.00 3703052 PENICILLIN G PROC/BENZ IN 262.00 3703053 PENICILLIN G PROCAINE INJ 49.00 3703054 PENICILLIN G PROCAINE INJ 41.00 3703055 PEN G SOD INJ [5MU] 69.00 3703056 PENICILLIN V K SUS [250MG 3.00 3703057 PENICILLIN V POT TAB [250 3.00 3703058 PENTAZOCINE/APAP TAB [25/ 3.00 3703059 PENTAZOCINE/NALOXONE TAB 4.00 3703060 PENTOSAN POLYSULFATE CAP 8.00 3703061 PENTOXIFYLLINE TAB [400MG 3.00 3703062 PERGOLIDE MESYLATE T TAB 3.00 3703063 PERINDOPRIL TAB [4MG] 4.00 3703064 PERMETHRIN LIQ RINSE 1% 16.00 3703065 PERPHEN/AMITRIPT TAB [2/2 4.00 3703066 PETROLATUM OIN 3.00 3703067 PHENAZOPYRIDINE TAB [200M 4.00 3703068 NAPHAZ/PHENERAMINE OPTH D 16.00 3703069 PHENO/HYOS/ATR/SCOP TAB 14.00 3703070 PHENOBARB/BELLADONNA ELX 13.00 3703071 PHENOBARBITAL ELX [20MG/5 19.00 3703072 PHENOBARBITAL TAB 1/4GRAI 4.00 3703073 PHENOBARBITAL TAB [60MG] 4.00 3703074 PHENOBARBITAL INJ [130MG] 77.00 3703075 PHENTOLAMINE INJ [5MG] 209.00 3703076 PHENYLEPHRINE NAS SPR 1% 16.00 3703077 PHENYLEPHRINE INJ [10MG/M 15.00 3703078 PHENYLEPHRINE NAS DROPS 0 16.00 3703079 PHENYTOIN SUS [125MG/5ML] 3.00 3703080 PHENYTOIN CHW [50MG] 4.00 3703081 PHENYTOIN INJ [50MG/ML] 15.00 3703082 PHENYTOIN ER CAP [100MG] 3.00 3703083 PHOSPHORATED CARBOHY SUS 3.00 3703084 PHYSOSTIGMINE INJ [1MG] 29.00 3703085 PHYTONADIONE TAB [5MG] 16.00 3703086 PHYTONADIONE INJ [10MG] 69.00 3703087 PILOCARPINE SOL 2% 15ML 16.00 3703088 PILOCARPINE SOL 0.5% 15ML 16.00 3703089 PILOCARPINE SOL 4% 15ML 16.00 3703090 PILOCARPINE HS GEL 4% 97.00 3703091 PILOCARPINE SOL 1% 15ML 16.00 3703092 PILOCARPINE TAB [5MG] 3.00 3703093 PIMECROLIMUS CRE 170.00 Charge Code Description Price 3703094 PIMOZIDE TAB [2MG] 5.00 3703095 PINDOLOL TAB [5MG] 3.00 3703096 PIOGLITAZONE TAB [45MG] 32.00 3703097 PIOGLITAZONE TAB [15MG] 20.00 3703098 PIPERACIL/TAZOB IV [3.375 73.00 3703099 PIPERACIL/TAZOB IV [4.5GM 97.00 3703100 PIPERACIL/TAZOB IV [2.25G 69.00 3703101 PIRBUTEROL AUTOHALER AER 147.00 3703102 PIROXICAM CAP [10MG] 4.00 3703103 PLACEBO INJ 35.00 3703104 PLASMA PLEX SOL 5% 35.00 3703105 PNEUMOCOCCAL VACCINE INJ 263.00 3703107 CALCIUM POLYCARBOPHIL CHW 3.00 3703108 POLYCITRA SYR 16.00 3703109 POLYETHYLENE GLY POW [17G 3.00 3703110 POLYETHYLENE GLY OPTH DRO 16.00 3703111 POLYVINYL PEG SOL 16.00 3703112 POLYETHYLENE GLYCOL/NACHO 21.00 3703113 POLY‐VI‐SOL DROPS 16.00 3703114 POLY‐VI‐SOL W/IRON DROPS 16.00 3703115 POTASSIUM CHL SOL 20% UP 3.00 3703117 POTASSIUM CHL TAB [10MEQ] 3.00 3703118 POTASSIUM CHL TAB [20MEQ] 3.00 3703119 POTASSIUM CHL TAB [ 8MEQ] 3.00 3703120 POTASSIUM EF TAB [25MEQ] 3.00 3703121 POTASSIUM IOD SOL ML [1GM 16.00 3703123 POTASSIUM PO4 DIBASI INJ 15.00 3703124 POVIDONE‐IODINE OIN 3.00 3703125 PRAMIPEXOLE TAB [ 0.125MG 7.00 3703126 PRAMIPEXOLE TAB [1.5MG] 5.00 3703127 PRAMIPEXOLE TAB [ 1MG] 10.00 3703128 PRAVASTATIN TAB [20MG] 7.00 3703129 PRAZOSIN CAP [1MG] 4.00 3703130 PREDNISOLONE LIQ [15MG/5M 16.00 3703131 PREDNISOLONE ACETATE OPTH 29.00 3703132 PREDNISOLONE NA P04 SOL [ 16.00 3703133 PREDNISOLONE NA PO4 LIQ [ 16.00 3703134 PREDNISONE TAB [20MG] 5.00 3703135 PREDNISONE TAB [10MG] 3.00 3703136 PREDNISONE TAB [ 5MG] 3.00 3703137 PREDNISONE TAB [ 1MG] 3.00 3703138 PREGABALIN CAP [25] 13.00 3703139 PREGABALIN CAP [75MG] 13.00 3703140 SHARK LIVER OIR/MIN OIL/P 19.00 3703141 PRIMIDONE TAB [250MG] 3.00 3703142 PRIMIDONE TAB [ 50MG] 3.00 3703143 PROBENECID TAB [500] 3.00 3703144 PROBENECID/COLCH TAB 3.00 3703145 PROCAINAMIDE INJ [100MG] 15.00 3703146 PROCAINAMIDE CAP [250MG] 3.00 Charge Code Description Price 3703147 PROCAINAMIDE SR TAB [250M 3.00 3703148 PROCAINAMIDE SR TAB [500M 3.00 3703149 PROCHLORPERAZINE INJ [5MG 15.00 3703150 PROCHLORPERAZINE SUP [25M 16.00 3703151 PROCHLORPERAZINE TAB [5MG 3.00 3703152 PROGESTERONE INJ [50MG] 15.00 3703153 PROMETH VC/CODEINE SYP 4.00 3703154 PROMETHAZINE SYP [6.25MG/ 16.00 3703155 PROMETHAZINE SUP [25MG] 9.00 3703156 PROMETHAZINE SUP [50MG] 3.00 3703157 PROMETHAZINE TAB [25MG] 3.00 3703158 PROMETHAZINE SUP [12.5MG] 16.00 3703159 INJ PROMETHAZINE PHENERGAN 30.00 3703160 PROMETH W/CODEINE SYP 4.00 3703161 PROPAFENONE TAB [150MG] 3.00 3703163 PROPOFOL INJ 100MG DOSE ( 35.00 3703164 PROPOXYPHENE CAP [65MG] 7.00 3703165 PROPOXYPHENE/APAP TAB [65 7.00 3703166 PROPOXYPHENE/N/APAP TAB [ 8.05 3703167 PROPRANOLOL INJ [1MG] 15.00 3703168 PROPRANOLOL TAB [10MG] 3.00 3703169 PROPRANOLOL TAB [40MG] 3.00 3703170 PROPRANOLOL ER CAP [120MG 3.00 3703171 PROPRANOLOL ER CAP [60MG] 4.00 3703172 PROPRANOLOL TAB [20MG] 3.00 3703173 PROPRANOLOL ER CAP [80MG] 3.00 3703174 PROPYLTHIOURACIL TAB [50M 3.00 3703175 PROTAMINE SO4 INJ [10MG] 15.00 3703176 PRYRIDOXINE INJ [100MG] 24.00 3703177 PSE/CARBINOX/METHSC TAB 7.00 3703178 PSE/DEXTRO/GUAIFE SYR 7.00 3703179 PSE/CARBONOXI SYR 7.00 3703180 PSE/GUAIFENSIN SYR 7.00 3703181 PSE/GUAIFEN TAB [80/800] 8.05 3703182 GUAIF/PSE CAP 10.00 3703183 PSYLLIUM HYDROPHILIC PWD 3.00 3703184 PSYLLIUM/SENNA GRA 3.00 3703185 PUR. H20/GLYC/CETEAR LOT 3.00 3703186 PYRAZINAMIDE TAB [500MG] 10.00 3703187 PYRIDOSTIGMINE TAB [60MG] 3.00 3703188 PYRIDOXINE HCL TAB [100MG 3.00 3703190 QUETIAPINE TAB [25MG] 8.00 3703191 QUETIAPINE TAB [100MG] 11.00 3703192 QUINAPRIL TAB [10MG] 3.00 3703193 QUINAPRIL TAB [20MG] 3.00 3703194 QUINAPRIL TAB [ 5MG] 2.00 3703195 QUINIDINE GLUC TAB [324MG 3.00 3703196 QUINIDINE TAB [200MG] 4.00 3703197 QUINIDINE ER TAB [300MG] 3.00 3703198 QUINUPRISTIN/DALFOPR [50 562.00 Charge Code Description Price 3703199 RABIES IMMUNE GLOBUL INJ 492.00 3703200 RABIES VACCINNE ABSORB 354.00 3703201 RACEMIC EPINEPHRINE SOL 13.00 3703202 RALOXIFENE HCL TAB [60MG] 12.00 3703203 RAMIPRIL CAP [1.25MG] 4.00 3703204 RAMIPRIL CAP [2.5MG] 4.00 3703205 RAMIPRIL CAP [5MG] 4.00 3703206 RANITIDINE SYP [150MG/10M 16.00 3703207 RANITIDINE TAB [150MG] 3.00 3703208 RANITIDINE IV SDV [50MG/2 15.00 3703209 RANITIDINE P/MIX INJ [ 50 15.00 3703210 REFRESH PM OPTH OIN 16.00 3703211 REPAGLINIDE TAB [1MG] 11.00 3703212 RESERP/HYDROFLUMETHI TAB 3.00 3703213 RESERPINE/CHLOROTHIA TAB 6.00 3703214 RIBOFLAVIN TAB [100MG] 3.00 3703215 RIFAMPIN CAP [300MG] 3.00 3703216 RIFAXIMIN TAB [200MG] 28.00 3703217 RIMANTADINE HCL TAB 4.00 3703218 RIMEXOLONE OPTH SUS 1% 73.00 3703219 RISEDRONATE TAB [35MG] 40.00 3703220 RISPERDONE TAB [0.25MG] 8.00 3703221 RISPERIDONE TAB [2MG] 11.00 3703222 RISPERIDONE TAB [1MG] 9.00 3703223 RIVASTIGMINE CAP [1.5MG] 8.00 3703224 ROCURONIUM BROMIDE INJ [1 15.00 3703225 ROPINROLE TAB (2MG) 3.00 3703226 ROPINIROLE TAB [0.5MG] 3.00 3703227 ROSIGLITAZONE TAB [2MG] 7.00 3703228 ROSIGLITAZONE TAB [4MG] 9.00 3703229 ROSIGLITAZONE TAB [8MG] 12.00 3703230 ROSUVASTATIN TAB [10MG] 14.00 3703231 MDI SALMETEROL DISKUS I 16.00 3703232 SALSALATE TAB [500MG] 4.00 3703233 SCOPOLAMINE HBR OPT SOL 0 16.00 3703234 SEBULEX SHAMPOO 4 OZ 16.00 3703235 SEBUTONE SHAMPOO 4OZ 16.00 3703236 SELEGILINE TAB [5MG] 4.00 3703237 SELENIUM INJ [40MCG] 17.00 3703238 SENNA TAB [8.6MG] 3.00 3703239 SENOKOT SYR 2.00 3703240 SERTRALINE TAB [50MG] 17.00 3703241 SEVELAMER TAB [400MG] 8.00 3703242 SILVER NITRATE APPL MIS 3.00 3703243 SILVER SULFADIAZINE CRE 4 60.00 3703244 SILVER SULFADIAZINE CRE 40.00 3703245 SILVER SULFADIAZINE CRE 27.00 3703246 SIMETHICONE TAB [80MG] 3.00 3703247 SIMETHICONE CAP [180MG] 3.00 3703248 SIMVASTATIN TAB [10MG] 10.00 Charge Code Description Price 3703249 SIMVASTATIN TAB [40MG] 9.00 3703250 SKIN TEST INJ 192.00 3703251 SOD BICARB TAB [325MG] 3.00 3703252 IV‐ NS 0.9% [1000ML] 88.00 3703253 IV‐ NS 0.9% MINIBAG [ 50 35.00 3703254 IV‐ NS 0.9% MINIBAG [100 88.00 3703255 IV‐ NS 0.45% [1000ML] 88.00 3703256 IV‐ NS 0.45% [ 500ML] 88.00 3703257 SOD ACETATE INJ [2MEQ] 17.00 3703258 SOD BICARB INJ 7.5% 15.00 3703259 SOD BICARB INJ 4.2% 15.00 3703260 SOD CHLOR NAS SPR 16.00 3703261 SOD CHLOR NEB 0.9% 3.00 3703262 SOD CHLOR 14.6% INJ [2.5M 17.00 3703263 IV‐ NS 0.9% [ 500ML] 88.00 3703264 SOD CHLOR HYPERTONIC OPTH 16.00 3703265 SOD CHLOR HYPERTONIC OPTH 16.00 3703266 IV‐ NS 0.9% [ 100ML] 88.00 3703267 IV‐ NS 0.9% [ 250ML] 88.00 3703268 IV‐ NS 0.9% [50ML] 88.00 3703269 SOD PHOSPHATE INJ [4MEQ] 17.00 3703270 SODIUM POLYSTYRENE SUS [1 20.00 3703271 SOD SULFACETAMIDE OPTH OI 16.00 3703272 SOD SULFACETAMIDE OPTH SO 45.00 3703273 SOTALOL TAB [80MG] 4.00 3703274 SPIRONOLACTONE TAB [50MG] 3.00 3703275 SPIRONOLACTONE TAB [25MG] 3.00 3703276 SPIRONOLACTONE/HCTZ TAB [ 2.00 3703277 STAVUDINE CAP [40MG] 14.00 3703278 STERILE WATER IRR 98.00 3703279 SUCCINYLCHOLINE CHL. INJ 15.00 3703280 SUCRALFATE TAB [1GM] 3.00 3703281 SUCRALFATE SUS [1GM] 3.00 3703283 TMP/SMZ INJ [80MG/ML] 15.00 3703284 SULFANILAMIDE SUP 8.05 3703285 SULFASALAZINE TAB [500MG] 3.00 3703286 SULFISOXAZOLE TAB [500MG 7.00 3703287 SULINDAC TAB [200MG] 2.00 3703288 SUMATRIPTAN TAB [100MG] 29.00 3703289 SUMATRIPTAN INJ [6MG] 211.00 3703290 SUMATRIPTAN TAB [ 25MG] 33.00 3703291 SUSP. X1 APPL. IN ER SUS 17.00 3703292 SUSP.PER DOSE IN ER 42.00 3703293 TACROLIMUS CAP [1MG] 7.00 3703294 TALBOT'S OINT PAS [1 OZ] 3.00 3703295 TALBOT'S OINT PAS [16 OZ] 3.00 3703296 PENTAZOCINE INJ [30MG] 143.00 3703297 TAMOXIFEN TAB [10MG] 3.00 3703298 TAMSULOSIN CAP [0.4MG] 8.00 3703299 TELMISARTAN TAB [80MG] 12.00 Charge Code Description Price 3703300 TEMAZEPAM CAP [15MG] 4.00 3703301 TENOFOVIR DISOPROXIL TAB 46.00 3703302 TERAZOSIN CAP [5MG] 3.00 3703303 TERAZOSIN CAP [1MG] 3.00 3703304 TERAZOSIN CAP [2MG] 3.00 3703305 TERBINAFINE TAB [250MG] 18.00 3703306 TERBINAFINE CRE 1% 15.00 3703307 TERBUTALINE INJ [1MG] 15.00 3703308 TERBUTALINE TAB [2.5MG] 2.00 3703309 TESTOSTERONE CYPIONA INJ 148.00 3703310 TETANUS IMMUNE GLOBU INJ 395.03 3703311 TETANUS TOXOID ADS INJ 113.00 3703312 TET TOX/DIPHTHERIA TOX AD 55.00 3703313 TETRAC/ADREN/COCAINE SOL 15.00 3703314 TETRACAINE SOL 2% 17.00 3703316 TETRACAINE OPHT SOL 0.5% 16.00 3703317 TETRACYCLINE CAP [250MG] 3.00 3703318 TETRAHYDROZOLINE OPTH SOL 16.00 3703320 THEOPHYLLINE P/MIX IV [40 21.00 3703321 THEOPHYLLINE ER TAB [200M 3.00 3703322 THEOPHYLLINE ER TAB [300M 3.00 3703323 MULTIVITAMIN + MINERALS T 3.00 3703324 THIAMINE TAB [100MG] 3.00 3703325 THIAMINE INJ [100MG] 15.00 3703326 THIORIDAZINE TAB [10MG] 2.00 3703327 THIORIDAZINE TAB [15MG] 2.00 3703328 THIORIDAZINE TAB [25MG] 2.00 3703329 THIORIDAZINE TAB [50MG] 2.00 3703331 THIOTHIXENE CAP [1MG] 2.00 3703332 THIOTHIXENE CAP [5MG] 2.00 3703333 THROMBIN SOL [5000UNI] 125.00 3703334 THYMOL/EUCALYPTOL 3.00 3703335 THYROID TAB [ 30MG] 3.00 3703336 THYROID TAB [ 15MG] 2.00 3703337 THYROID TAB [ 60MG] 3.00 3703338 THYROID TAB [3 GR] 2.00 3703339 THYROLAR‐1 TAB 2.00 3703340 TIAGABINE TAB [2MG] 7.00 3703341 TICLOPIDINE TAB [250MG] 2.00 3703342 TIMOLOL TAB [5MG] 2.00 3703343 TIMOLOL MAL OPTH SOL 0.25 16.00 3703344 TIMOLOL MAL OPTH SOL 0.5% 16.00 3703345 TIMOLOL XE OPTH GFS 0.5% 102.00 3703346 MDI TIOTROPIUM BR INH C 20.00 3703347 TIZANIDINE TAB [2MG] 2.00 3703348 TOBRAMYCIN OPTH OIN 0.3 171.00 3703349 TOBRAMYCIN INJ [40MG/ML] 30.00 3703350 TOBRAMYCIN OPTH SOL 0.3% 69.00 3703352 TOBRAMYCIN/DEX OPTH SUS 72.00 3703353 TOBRAMYCIN/DEX OPTH OIN 172.00 Charge Code Description Price 3703354 TOLTERODINE ER CAP [2MG] 19.00 3703355 TOLTERODINE TAB [2MG] 13.00 3703356 TOPIRAMATE [50MG] 9.00 3703357 TOREMIFENE TAB [60MG] 45.00 3703358 TORSEMIDE TAB [20MG] 3.00 3703359 TORSEMIDE TAB [10MG] 2.00 3703360 TORSEMIDE INJ [20MG/2ML] 40.00 3703361 TRACE ELEM (ZN,MG,CU INJ 15.00 3703362 TRIAMTERENE/HCTZ CAP [37 3.00 3703363 TRAMADOL HCL TAB [50MG] 4.00 3703364 TRANDOLAPRIL TAB [4MG] 3.00 3703365 TRAVAPROST OPTH SOLN 0.00 99.00 3703366 TRAZODONE TAB [50MG] 3.00 3703367 TRIAMCINOLONE ACET CRE 0. 3.00 3703368 TRIAMCINOLONE ACET LOT 0. 3.00 3703369 TRIAMCINOLONE ACET INJ 4 15.00 3703370 TRIAMCINOLONE ACET NAS SP 149.00 3703371 TRIAMCINOLONE ACET AER [7 183.00 3703372 TRIAMCINOLONE ACET DENTAL 76.00 3703373 TRIAMCINOLONE ACET CRE 0. 3.00 3703375 TRIAMTERENE/HCTZ TAB [75‐ 2.00 3703376 TRIAZOLAM TAB [0.25MG] 5.00 3703377 TRIETHANOLAMINE OLEA OTIC 86.00 3703378 TRIFLUOPERAZINE TAB [5MG] 2.00 3703379 TRIFLUOPERAZINE TAB [2MG] 2.00 3703380 TRIFLURIDINE OPTH SOL 1% 173.00 3703381 TRIHEXYPHENIDYL TAB [2MG 3.00 3703382 TRIHEXYPHENIDYL TAB [5MG] 3.00 3703383 TMP/SMZ TAB DS [800/160MG 4.00 3703384 TMP/SMZ SUSP 3.00 3703385 TMP/SMZ TAB [400/80] 3.00 3703386 TROLAMINE SALICYLATE CRE 3.00 3703387 TROLAMINE SALICYLATE CRE 18.00 3703388 TRYP/BALS/CASTOR OIL SPR 25.00 3703389 TRYPSIN/BALSAM/CASTO TOP 3.00 3703390 PURIFIED PROTEIN DERIVATI 85.00 3703391 ANTIP/BENZOC/PHENYL OTIC 17.00 3703392 URSODIOL CAP [300MG] 13.00 3703393 URSODIOL TAB [250MG] 4.03 3703394 VALACYCLOVIR TAB [500MG] 11.00 3703395 VALERIAN ROOT/HOPS TAB [5 2.00 3703396 VALPROIC ACID SYR [250MG/ 16.00 3703397 VALPROIC ACID CAP [250MG] 3.00 3703398 VALSARTAN TAB [160MG] 14.00 3703399 VALSARTAN TAB [ 80MG] 13.00 3703400 VANCOMYCIN INJ [1GM] 71.00 3703401 VANCOMYCIN INJ [ 500MG] 35.00 3703402 VANCOMYCIN ORAL SOLN [25 11.00 3703403 VASOPRESSIN INJ [20U] 212.00 3703404 VECURONIUM BR INJ [20MG] 28.00 Charge Code Description Price 3703405 VENLAFAXINE TAB [75MG] 4.00 3703406 VENLAFAXINE TAB [37.5MG] 4.00 3703407 VENLAFAXINE XR CAP [75MG] 22.00 3703408 VENLAFAXINE XR CAP [37.5M 8.00 3703409 VERAPAMIL SR TAB [240MG] 4.00 3703410 VERAPAMIL CAP [200MG PM] 4.00 3703411 VERAPAMIL CAP [100MG PM] 4.00 3703412 VERAPAMIL TAB [80MG] 3.00 3703413 VERAPAMIL SR TAB [180MG] 4.00 3703414 VERAPAMIL INJ [5MG/2ML] 23.00 3703415 FOLIC ACID/BCOMP/VITAM C 3.00 3703416 VITAMIN A CAP [10K U] 3.00 3703417 VITAMIN A GROUP CAP [25,0 2.00 3703418 VITAMIN E CAP [400IU] 3.00 3703419 VITAMIN E CAP [1000IU] 3.00 3703420 VITAMIN A&D OIN 3.00 3703421 WARFARIN NA TAB [2MG] 4.00 3703422 WARFARIN NA TAB [3MG] 5.00 3703423 WARFARIN NA TAB [2.5MG] 5.00 3703424 WARFARIN TAB (5MG) 5.00 3703425 WARFARIN NA TAB [4MG] 5.00 3703426 WITCH HAZEL PAD 16.00 3703427 ZAFIRLUKAST TAB [20MG] 4.00 3703428 ZIDOVUDINE TAB [300MG] 8.00 3703429 ZIDOVUDINE SYR [50MG/5ML] 2.00 3703430 ZIDOVUDINE/LAMIVUDIN TAB 21.00 3703431 ZN OXIDE UNNAS BOOT 17.00 3703433 ZINC SO4 CAP 220MG [50MG 3.00 3703434 ZIPRASIDONE CAP [60MG] 27.00 3703435 ZIPRASIDONE INJ [20MG] 71.00 3703436 ZIPRASIDONE CAP [20MG] 13.00 3703437 ZINC OXIDE OIN 3.00 3703438 ZOLMITRIPTAN TAB [2.5MG] 36.00 3703439 ZOLPIDEM TAB [5MG] 9.00 3703440 ZOLPIDEM TARTRATE TAB [10 9.00 3703441 DEXAMETHASONE SOLUTION [1 3.00 3703442 DOPAMINE PMIX 400MG 15.00 3703446 VALSARTAN \ HCTZ COMBO SE 6.00 3703447 VALSARTAN \ HCTZ COMBO SE 5.00 3703448 AMLODIPINE/BENAZEPRIL COM 2.00 3703449 DICLOFENAC TAB [75MG] 4.00 3703451 HEP LOCK‐ SALINE FLUSH 0. 15.00 3703453 CEFEPIME [1GM] 49.00 3703454 ACETIC ACID/HC OTIC SOLN 118.00 3703455 NUT‐ PEDIALYTE 1.8OZ GRAP 16.00 3703456 NUT‐ PEDIALYTE 1.8OZ FRUI 16.00 3703457 SOAP SUDS ENEMA 2.00 3703460 CIPROFLOXACIN IV PRE‐MIX 35.00 3703461 METHOCARBAMOL TAB [750MG] 3.00 3703462 COLISTIMETHATE INJ [150MG 41.00 Charge Code Description Price 3703463 HEPATITIS A VACCINE 144 95.00 3703464 ERTAPENEM SODIUM 180.00 3703465 RETAPAMULIN OINT 1% 15GM 162.00 3703466 MIDAZOLAM SYRUP 2MG/ML 4.00 3703467 BUDESONIDE NEB [0.5MG] 10.00 3703468 BUPIVICAINE‐MPF 0.25% 15.00 3703469 HEP LOCK HEPARIN FLUSH FO 15.00 3703470 ALISKIREN/HCTZ TAB [300M 12.08 3703471 GENTAMICIN P/MIX [100MG] 35.00 3703472 GENTAMICIN P/MIX [120MG] 35.00 3703473 GUAIFENESIN/DEXTROMETHORP 3.00 3703474 GUAIFENESIN/PSEUDOEPHEDRI 2.00 3703475 IBANDRONATE INJ [3MG] 608.00 3703476 NUT‐ JEVITY 1.2 CAL RTH ( 16.00 3703477 PROMETH / DM SYRUP 5ML 16.00 3703478 ERYTHROMYCIN ORAL SUSP. 2 16.00 3703479 CIPROFLOXACIN/DEXAMETHASO 193.00 3703480 GUAIFENESIN/PHENYLEPHRINE 2.00 3703481 ER‐ ORAL ANTIBIOTIC ER D 7.00 3703482 ER‐ TOPICAL APPLICATION 7.00 3703483 ER‐ OPTHALMIC DOSE X1 7.00 3703484 ER‐ OTIC DOSE X1 7.00 3703485 NEBIVOLOL TAB [5MG] 10.00 3703486 EPINASTINE HCL OPTH SOL 209.00 3703487 PROMETHAZINE INJ [50MG] 15.00 3703488 SODIUM PHOSPHATE MONOHYDR 8.00 3703489 CLINDAMYCIN VAGINAL OVULE 164.00 3703490 SULFACETAMIDE NA OPTH SOL 16.00 3703491 ZOLEDRONIC ACID INJ [5M 1,274.00 3703492 LEUPROLIDE ACETATE INJ [3 8,057.00 3703493 INS‐ INSULIN DETEMIR [100 41.00 3703494 OSELTAMIVIR COMPOUNDED SU 16.00 3703495 CEFUROXIME AXETIL TAB 250 9.00 3703496 NISOLDIPINE TAB [20MG] 21.00 3703497 NISOLDIPINE TAB [30MG] 23.00 3703498 SCOPOLAMINE HYDROBROMIDE 32.00 3703500 VITAMIN D CAP 1.25MG [50 4.00 3703501 OMEGA‐3 ACID ETHYL ESTERS 3.00 3703502 POT PHOSPHATE MONOBASIC 3.00 3703503 SITAGLIPTIN [50MG] 22.00 3703504 B 52 [PER DR ERICKSON] 97.00 3703505 FOSPROPOFOL DISODIUM 35MG 53.00 3703506 GARLIC CAPSULES 2.00 3703512 ALISKEREN TAB [300MG] 12.00 3703513 SALT WATER GARGLES 2.00 3703514 TICARCILLIN DISOD/K CLAVU 21.00 3703515 CYANOCOBALAMIN TAB [1000M 3.00 3703516 ETODOLAC TABLET [400MG] 3.00 3703517 TYGECYCLINE INJ [50MG] 218.00 3703519 ENOXAPARIN SODIUM INJ [12 174.00 Charge Code Description Price 3703520 CADEXOMER IODINE GEL 40G 152.00 3703521 PREGABALIN CAPSULE [100MG 13.00 3703522 INS‐ NOVOLOG SS MILD 41.00 3703523 INS‐ NOVOLOG SS MODERATE 41.00 3703524 INS‐ NOVOLOG SS AGGRESSIV 41.00 3703525 ONDANSETRON ODT [4MG] 28.00 3703526 MAGIC MOUTHWASH 21.00 3703527 TRIAMCINOLONE NASAL SPRAY 16.00 3703528 COLACE BOMB 3.00 3703529 VITAMIN D3 [1000 I.U.] 3.00 3703530 MUPIROCIN NASAL OINT 2% 26.00 3703531 RIVASTIGMINE TRANSDERMAL 32.00 3703532 DABIGATRAN ETEXILATE 75MG 12.00 3703533 FENTANYL TD PATCH [ 12MCG 26.00 3703535 HEPATITS B VACCINE ADULT 81.00 3703536 ZOSTER VACCINE LIVE 310.00 3703537 CETIRIZINE HCL [10MG] 4.00 3703538 BIVALIRUDIN VL 250MG/VL 1,016.00 3703539 HEPARIN 1M/NACL 500ML PRE 17.00 3703540 NITROGLYCERIN 25MG/250ML 35.00 3703541 IOHEXOL BTL 240MG/ML 50M 98.00 3703542 IOHEXOL BTL 350MG/ML 100 206.00 3703543 IODIXANOL BOT 320MG/ML 156.00 3703544 CLARITHROMYCIN TAB [500MG 10.00 3703545 IOHEXOL BTL 350MG/ML 50 103.00 3703546 TET TOX/PERTUSSIS/DIP TOX 110.00 3703547 N‐ACETYL‐CYSTEINE CAPSULE 3.00 3703548 PURIFIED PROTEIN DERIVATI 15.00 3703549 OSELTAMIVIR SUSP [6MG/ML] 16.00 3703550 RANOLAZINE 500MG TAB 11.00 3703551 PETROLATUM/MIN OIL/LANOLI 3.00 3703552 OXYCODONE/APAP TAB 10/32 4.00 3703553 B.BREVE/B.LONG/B.BIFID/L. 3.00 3703554 ONDANSETRON ODT TAB [8MG] 45.00 3703555 PRAVASTATIN TAB [40MG] 9.00 3703556 PERMETHRIN CREAM 5% 116.00 3703557 HYDROGEN PEROXIDE MOUTH R 16.00 3703558 SEA SALT MOUTH RINSE 2.00 3703559 LORAZEPAM INJ [4MG/ML] 21.00 3703560 DROPERIDOL INJ 2.5MG/ML 15.00 3703561 MOXIFLOXACIN OPHTHALMIC S 153.00 3703562 IV‐ DEXTROSE 10% WITH 0.4 88.00 3703563 MORPHINE SULFATE IR 15MG 4.00 3703564 DOUCHE‐ VINEGAR AND WATER 3.00 3703565 NITROGLYCERIN IN D5W 100M 15.00 3703566 DICLOFENAC SODIUM TOPICAL 16.00 3703567 SODIUM CHLORIDE 1 GRAM 3.00 3703568 MAG SULFATE 2 GRAM PREMIX 35.00 3703569 CONJUGATED ESTROGENS INJ 412.00 3703571 DOBUTAMINE PREMIX 250MG/2 15.00 Charge Code Description Price 3703572 PANTOPRAZOLE GRANULES FOR 22.00 3703573 MIDAZOLAM SDV [2MG/2ML] 19.00 3703574 ACYCLOVIR TABLET (400MG) 4.00 3703575 SOD BICARB INJ 8.4% 50ML 15.00 3703576 MORPHINE S04 2MG CPJ [2 19.00 3703577 DEXAMETHASONE INJ [4MG] S 15.00 3703578 AMOXICILLIN CAP [500MG] 2.00 3703580 PROPOFOL DRIP 10MG/ML [1 88.00 3703581 PHENOBARBITAL TAB 1/2GRAI 4.00 3703582 MUPIROCIN CREAM 2% 11.00 3703583 VACCINE ‐MEASLES‐MUMPS‐RU 100.00 3703584 VACCINE‐ JAPANESE ENCEPHA 599.00 3703585 VACCINE‐ TYPHOID ORAL 77.00 3703586 ETOMIDATE INJ [20MG/10ML] 15.00 3703587 THEOPHYLLINE ELIXIR 80MG/ 6.00 3703588 INFLUENZA VACCINE‐ INTRAN 40.00 3703589 KCL INJ 20 MEQ PRE‐MIX (P 15.00 3703590 SODIUM HYPOCHLORITE TOPIC 3.00 3703591 SODIUM HYPOCHLORITE TOPIC 3.00 3703592 SODIUM HYPOCHLORITE TOPIC 3.00 3703593 NITROGLYCERIN OINTMENT 30 16.00 3703594 METHYLPREDNISOLONE INJ [1 15.00 3703595 AMIODARONE INJ FOR DRIP 57.00 3703596 MEPIVICAINE HCL 1% [10 15.00 3703597 MEGESTROL ACETATE TAB [40 3.00 3703598 VANCOMYCIN INJ [ 750MG] 35.00 3703599 DILTIAZEM HCL INJ POWDER 20.00 3703600 LUBIPROSTONE CAP [ 8MCG] 11.00 3703601 ESTRADIOL CYPIONATE INJ 5 86.00 3703602 FLEETS PEDIA‐LAX ENEMA 3.00 3703603 NUT‐ ENSURE MILK CHOCOLATE 12.50 3703604 KCL20/D5W/0.45%NS PREMIX 88.00 3703605 KCL20/D5W PRE‐MIX 1000ML 88.00 3703606 KCL20/0.9%NS PRE‐MIX 1000 88.00 3703607 KCL40/D5W/0.45%NS PRE‐MIX 88.00 3703608 KCL40/0.9%NS PRE‐MIX 1000 88.00 3703609 KCL20/0.45%NS PRE‐MIX 100 88.00 3703610 GLYCINE 1.5% IRRIGATION 3000ML 105.00 3703611 RHO(D) IMMUNE GLOBULIN‐HUMAN 1500IU 196.00 3703612 INFLIXIMAB 100MG VL INJ 1,614.00 3703613 ZOLEDRONIC ACID INJ 4MG/5ML 235.00 3703614 MIDAZOLAM INJ (10MG/2ML) 19.00 3703616 CEFEPIME INJ 2GM 95.00 3703617 ASACOL HD 800MG TAB 9.00 3703618 PNEUMOCOCCAL 13‐VALENT (PREVNAR 13) 499.00 3703619 GARDASIL HPV 445.00 3703620 ROTOVIRUS VACCINE 164.00 3703621 POLIO VACCINE (IPV) 27.71 3703622 D‐TAP‐IPV 4‐6 YR 141.00 3703623 D‐TAP‐HIB‐IPV 129.00 Charge Code Description Price 3703624 D‐TAP 7 AND UNDER VACCINE 68.00 3703625 VARICELLA CHICKENPOX VACCINE 171.00 3703628 MENACTRA VACCINE MENIINGICOCCAL 323.00 3703629 PedvaxHIB 74.00 3703630 HAVRIX PEDIATRIC 720 EL.U 90.00 3703631 DTAP‐HEP‐B‐IPV PEDIARIX 213.00 3703632 MMR‐VARICELLA VACCINE PROQUAD 281.00 3703633 PEDVAXHIB VACCINE 21.88 3703634 ARIPIPRAZOLE10MG TAB 37.00 3703635 IV‐ STERILE WATER FOR INJECTION 1000ML 15.00 3703636 SODIUM CHLORIDE CONCENTRATE 23.4% 15.00 3703637 OCTREOTIDE INJECTION 15.00 3703638 SAFE‐GEL 27.00 3703639 CARDENE IV 143.00 3703640 SIMVASTATIN 20MG 9.00 3703641 LEUCOVORIN 5MG TAB 9.00 3703642 PHENAZOPYRIDINE TAB 95MG 3.00 3703643 IV‐ D5 1/4NS 1000ML 88.00 3703644 20% MANNITOL INJ 500ML 88.00 3703645 MERROPENEM 1 GRAM VIAL 83.00 3703646 MENVEO VACCINE 172.00 3703647 EXELON PATCH 4.6MG/24Hr 62.00 3703648 VACCINE‐ GARDASIL 9‐VAL HPV 567.00 3703649 0.9% NaCl for IRRIGATION 88.00 3703650 EFFEXOR XR 150MG 14.00 3703651 EFFEXOR XR 150MG 13.00 3703652 EFFEXOR XR 75 10.00 3703653 PERPHENAZINE 2MG TAB 3.00 3703654 PERPHENAZINE 4 MG 4.00 3703655 Latuda 59.00 3703656 TRINTELLIX 20.00 3703657 CHLORPROMAZINE 100MG TAB 53.00 3703658 INVEGA 3 MG 37.00 3703659 HALOPERIDOL DECANOATE 100MG INJ 73.00 3703660 ZYPREXA INJ 10MG 145.00 3703661 SILDENAFILL 20MG 21.00 3703662 MELATONIN 3MG 3.00 3703663 NUEDEXTA 20‐10MG 35.00 3703664 ELIQUIS 5MG 12.00 3703665 CAMPRAL DR TAB 333MG 4.00 3703666 ZOVIRAX INJ 50MG/ML10 ML VIAL 35.00 3703667 CLOZAPINE 25MG TAB 3.00 3703668 CLOZAPINE 100MG TAB 9.00 3703669 Injectafer 750mg 1,388.00 3703670 Aristada 662 mg 1.00 3703671 Aristada 882mg 1.00 3703672 PRISTIQ 50MG TABLET 15.00 3703673 DIASTAT 2.5mg 394.00 3703674 DEPAKOTE 125 MG SPRINKLE 4.00 3703675 SUBUTEX 2MG SL 9.00 Charge Code Description Price 3703676 FOLIC ACID 5MG/ML INJ 15.00 3703677 EXELON 13.3/24HR PATCH 21.00 3703678 AMIODARONE PMIX 360MG 35.00 3720001 IRRIG SET CYSTO/BLADDER 68.00 3720002 INFUS SET 19 G 71.00 3720003 INFUSION SET, 20GA 1 1/2 71.00 3720004 GLUCAGON 1MG, IM, IV, SQ 139.00 3720005 STERILE EVAC FLASK 500ML 44.00 3720006 PRIMARY WITHOUT FILTER 46.00 3720007 IV CATH 14G X 1 1/4 20.00 3720008 IV CATH 18G X 1 1/4 24.00 3720009 IV CATH 20G X 1 1/4 24.00 3720010 IV CATH 24G X 3/4 24.00 3720012 BUTTERFLY INFUS. 25G 20.00 3720013 INFUSION SET 22G 1IN 71.00 3720014 PRIMARY TUBING 59.00 3720015 SOLUSET / BURETROL 53.00 3720016 D5 1/3 NS INJ. 500ML 92.00 3720018 IMPERSOL 1.5% 2000ML 109.01 3720019 LACTATED RINGER 1000 92.00 3720020 50ML NSS MINI BAG 73.00 3720023 BLOOD Y TUBING 125.00 3720024 BUTTERFLY INFUS.21G 20.00 3720025 INJECTION SITE 24.00 3720026 IV CATH, 24 GA 1/2" 24.00 3720027 PRIMARY VENT TUBING 59.00 3720030 D5W 100ML 73.00 3720034 NSS 100ml IV 73.00 3720035 IV‐ RINGERS [1000ML] 88.00 3720036 1/2 NSS INJ. 1000ML 92.00 3720040 THORANCENTESIS SET 91.00 3720043 D109 NS INJ.1000ML 92.00 3720044 D5W 1/2 NS, 1000ML 92.00 3720048 IV CATH 22G X 1" 24.00 3720049 SECONDARY TUBING 24.00 3720050 D5.9 NS INJ. 1000ML 79.00 3720051 E‐VAC BAG 2000 ML 44.00 3720053 GLYCINE 1.5% 3000ML 117.00 3720056 LIPID FILTER SET 37.00 3720058 VENTED NITRO SET 59.00 3720060 IVEX FILTER SET 38.00 3720061 D10W INJ 1000ML 92.00 3720062 D5W INJ. 1000ML 92.00 3720066 D5W INJ. 250ML 84.00 3720067 D5W INJ. 500ML 84.00 3720068 IV‐ INTRALIPID FAT EMULSI 88.00 3720069 NSS INJ. 250ML 84.00 3720070 NSS INJ. 500ML 84.00 3720071 NSS INJ.1000ML 92.00 3720073 1000 NS IRRIG. 84.00 Charge Code Description Price 3720077 EXTENSION SET 24.00 3720080 1/2 NSS 500ML 84.00 3720082 500 DW IRRIG. 84.00 3720083 500 NS IRRIG. 79.00 3720084 MINIDRIP SET 55.06 3720086 INFUSION BAG 170.00 3720087 500CC DEX.40 137.00 3720088 500CC DEX.75 101.00 3720089 DIAL‐A‐FLOW 59.00 3720090 D5LR 1000CC 92.00 3720098 D5 1/4 500 ML 84.00 3720099 500 D‐5‐LR 84.00 3720108 IV LOOP 46.00 3720109 VENEKIT 24.00 3720110 250 ML LACTATED RINGERS 92.00 3720114 INTRAOSS NEEDLE SET PEDI 508.50 3720115 INTRAOSS NEEDLE SET ADULT 508.50 3720116 INTRAOSS NEEDLE SET ADULT YLW 508.50 3720118 TRANSFER SET 24.00 4000001 PT E STIM CONST EA 15MIN 93.00 4000004 PT NEURO REED PER 15MIN 98.00 4000008 PT W/CHAIR MANAGMT 98.00 4000009 PT WORK HARDENING ADD HR 123.00 4000011 PT THERAPEUT ACTS EA15MIN 98.00 4000018 PT ORTHOTIC(S) FITTING 106.00 4000021 PT WORK HARDENING IN 240.00 4000022 PT ACTIVE WOUND CARE 150.00 4000024 PT ACTIVE WOUND CARE 161.00 4000027 PT E STIMULATION UNATT 93.00 4000028 PT IONTOPHORESIS 15 MIN 98.00 4000029 PT MANUAL TX 15 MIN 120.00 4000032 PT CONTRAST BATH 84.00 4000033 PT GAIT TX PER 15 MIN 115.00 4000034 PT RE‐EVALUATION 123.00 4000036 PT MASSAGE 15 MIN 79.00 4000037 PT ULTRASOUND 15 MIN 84.00 4000038 PT GROUP THER EX 79.00 4000041 PT EXERCISE, PER 15 MIN 98.00 4000042 PT TRACTION, MECHANICAL 205.00 4000043 PT PROSTHETIC TRAINING 120.00 4000045 PT HOT OR COLD PACK 24.00 4000046 PT INFRARED THERAPY 98.00 4000049 PT TRAPEZE SET UP 120.00 4000052 PT PHONOPHORESIS 98.00 4000058 PT TENS UNIT 379.00 4000059 PT WHIRLPOOL 102.00 4000060 PT PARAFFIN 66.00 4000062 MOBILITY CURRENT STATUS 0.01 4000063 MOBILITY CURRENT STATUS 0.01 4000064 MOBILITY CURRENT STATUS 0.01 Charge Code Description Price 4000065 MOBILITY CURRENT STATUS 0.01 4000066 MOBILITY CURRENT STATUS 0.01 4000067 MOBILITY CURRENT STATUS 0.01 4000068 MOBILITY CURRENT STATUS 0.01 4000069 MOBILITY GOAL STATUS 0.01 4000070 MOBILITY GOAL STATUS 0.01 4000071 MOBILITY GOAL STATUS 0.01 4000072 MOBILITY GOAL STATUS 0.01 4000073 MOBILITY GOAL STATUS 0.01 4000074 MOBILITY GOAL STATUS 0.01 4000075 MOBILITY GOAL STATUS 0.01 4000076 MOBILITY D/C STATUS 0.01 4000077 MOBILITY D/C STATUS 0.01 4000078 MOBILITY D/C STATUS 0.01 4000079 MOBILITY D/C STATUS 0.01 4000080 MOBILITY D/C STATUS 0.01 4000081 MOBILITY D/C STATUS 0.01 4000082 MOBILITY D/C STATUS 0.01 4000083 BODY POS CURRENT STATUS 0.01 4000084 BODY POS CURRENT STATUS 0.01 4000085 BODY POS CURRENT STATUS 0.01 4000086 BODY POS CURRENT STATUS 0.01 4000087 BODY POS CURRENT STATUS 0.01 4000088 BODY POS CURRENT STATUS 0.01 4000089 BODY POS CURRENT STATUS 0.01 4000090 BODY POS GOAL STATUS 0.01 4000091 BODY POS GOAL STATUS 0.01 4000092 BODY POS GOAL STATUS 0.01 4000093 BODY POS GOAL STATUS 0.01 4000094 BODY POS GOAL STATUS 0.01 4000095 BODY POS GOAL STATUS 0.01 4000096 BODY POS GOAL STATUS 0.01 4000097 BODY POS D/C STATUS 0.01 4000098 BODY POS D/C STATUS 0.01 4000099 BODY POS D/C STATUS 0.01 4000100 BODY POS D/C STATUS 0.01 4000101 BODY POS D/C STATUS 0.01 4000102 BODY POS D/C STATUS 0.01 4000103 BODY POS D/C STATUS 0.01 4000104 CARRY CURRENT STATUS 0.01 4000105 CARRY CURRENT STATUS 0.01 4000106 CARRY CURRENT STATUS 0.01 4000107 CARRY CURRENT STATUS 0.01 4000108 CARRY CURRENT STATUS 0.01 4000109 CARRY CURRENT STATUS 0.01 4000110 CARRY CURRENT STATUS 0.01 4000111 CARRY GOAL STATUS 0.01 4000112 CARRY GOAL STATUS 0.01 4000113 CARRY GOAL STATUS 0.01 4000114 CARRY GOAL STATUS 0.01 Charge Code Description Price 4000115 CARRY GOAL STATUS 0.01 4000116 CARRY GOAL STATUS 0.01 4000117 CARRY GOAL STATUS 0.01 4000118 CARRY D/C STATUS 0.01 4000119 CARRY D/C STATUS 0.01 4000120 CARRY D/C STATUS 0.01 4000121 CARRY D/C STATUS 0.01 4000122 CARRY D/C STATUS 0.01 4000123 CARRY D/C STATUS 0.01 4000124 CARRY D/C STATUS 0.01 4000125 SELF CARE CURRENT STATUS 0.01 4000126 SELF CARE CURRENT STATUS 0.01 4000127 SELF CARE CURRENT STATUS 0.01 4000128 SELF CARE CURRENT STATUS 0.01 4000129 SELF CARE CURRENT STATUS 0.01 4000130 SELF CARE CURRENT STATUS 0.01 4000131 SELF CARE CURRENT STATUS 0.01 4000132 SELF CARE GOAL STATUS 0.01 4000133 SELF CARE GOAL STATUS 0.01 4000134 SELF CARE GOAL STATUS 0.01 4000135 SELF CARE GOAL STATUS 0.01 4000136 SELF CARE GOAL STATUS 0.01 4000137 SELF CARE GOAL STATUS 0.01 4000138 SELF CARE GOAL STATUS 0.01 4000139 SELF CARE D/C STATUS 0.01 4000140 SELF CARE D/C STATUS 0.01 4000141 SELF CARE D/C STATUS 0.01 4000142 SELF CARE D/C STATUS 0.01 4000143 SELF CARE D/C STATUS 0.01 4000144 SELF CARE D/C STATUS 0.01 4000145 SELF CARE D/C STATUS 0.01 4000146 OTHER PT/OT CURRENT STATU 0.01 4000147 OTHER PT/OT CURRENT STATU 0.01 4000148 OTHER PT/OT CURRENT STATU 0.01 4000149 OTHER PT/OT CURRENT STATU 0.01 4000150 OTHER PT/OT CURRENT STATU 0.01 4000151 OTHER PT/OT CURRENT STATU 0.01 4000152 OTHER PT/OT CURRENT STATU 0.01 4000153 OTHER PT/OT GOAL STATUS 0.01 4000154 OTHER PT/OT GOAL STATUS 0.01 4000155 OTHER PT/OT GOAL STATUS 0.01 4000156 OTHER PT/OT GOAL STATUS 0.01 4000157 OTHER PT/OT GOAL STATUS 0.01 4000158 OTHER PT/OT GOAL STATUS 0.01 4000159 OTHER PT/OT GOAL STATUS 0.01 4000160 OTHER PT/OT D/C STATUS 0.01 4000161 OTHER PT/OT D/C STATUS 0.01 4000162 OTHER PT/OT D/C STATUS 0.01 4000163 OTHER PT/OT D/C STATUS 0.01 4000164 OTHER PT/OT D/C STATUS 0.01 Charge Code Description Price 4000165 OTHER PT/OT D/C STATUS 0.01 4000166 OTHER PT/OT D/C STATUS 0.01 4000167 SUB PT/OT CURRENT STATUS 0.01 4000168 SUB PT/OT CURRENT STATUS 0.01 4000169 SUB PT/OT CURRENT STATUS 0.01 4000170 SUB PT/OT CURRENT STATUS 0.01 4000171 SUB PT/OT CURRENT STATUS 0.01 4000172 SUB PT/OT CURRENT STATUS 0.01 4000173 SUB PT/OT CURRENT STATUS 0.01 4000174 SUB PT/OT GOAL STATUS 0.01 4000175 SUB PT/OT GOAL STATUS 0.01 4000176 SUB PT/OT GOAL STATUS 0.01 4000177 SUB PT/OT GOAL STATUS 0.01 4000178 SUB PT/OT GOAL STATUS 0.01 4000179 SUB PT/OT GOAL STATUS 0.01 4000180 SUB PT/OT GOAL STATUS 0.01 4000181 SUB PT/OT D/C STATUS 0.01 4000182 SUB PT/OT D/C STATUS 0.01 4000183 SUB PT/OT D/C STATUS 0.01 4000184 SUB PT/OT D/C STATUS 0.01 4000185 SUB PT/OT D/C STATUS 0.01 4000186 SUB PT/OT D/C STATUS 0.01 4000187 SUB PT/OT D/C STATUS 0.01 4000188 PT Evaluation: Low Complex 150.00 4000189 PT Evaluation: Moderate Co 150.00 4000190 PT Evaluation: High Comple 150.00 4000191 PT Re‐evaluation of Est Plan Care 123.00 4000192 C/o for orthotic/prosth use 150.00 4050001 OT COGNITIVE SKILL DEV 80.00 4050003 OT NEURO RE‐ED EA 15 MIN 140.00 4050004 OT SELFCARE MGMT TRAIN 108.00 4050005 OT W/CMANGMT TRAIN 15 MIN 98.00 4050006 OT SPLINT APP‐FOREARM 117.00 4050008 OT THER ACT 15 MIN 98.00 4050009 OT THER EX 15 MIN 108.00 4050012 OT E STIM THERAPY 93.00 4050013 OT ULTRASOUND TX 15 MIN 84.00 4050014 OT ORTHOTIC TRAIN 15 MIN 106.00 4050016 OT MSG THERAPY 15 MIN 79.00 4050017 OT IONTOPHORESIS 15 MIN 98.00 4050019 OT HOT OR COLD PACKS 24.00 4050020 OT CONTRAST BATHS 84.00 4050022 OT FLUIDOTHERAPY 102.00 4050023 OT PARAFFIN BATH 66.00 4050024 OT RE‐EVALUATION 137.00 4050027 OT MANUAL TX 15 MIN 120.00 4050029 OT PULLEYS 15.00 4050033 WORK HARDENING INIT 2 HR 145.00 4050034 WORK HARDENING EA ADD HR 105.00 4050037 MOBILITY CURRENT STATUS 0.01 Charge Code Description Price 4050038 MOBILITY CURRENT STATUS 0.01 4050039 MOBILITY CURRENT STATUS 0.01 4050040 MOBILITY CURRENT STATUS 0.01 4050041 MOBILITY CURRENT STATUS 0.01 4050042 MOBILITY CURRENT STATUS 0.01 4050043 MOBILITY CURRENT STATUS 0.01 4050044 MOBILITY GOAL STATUS 0.01 4050045 MOBILITY GOAL STATUS 0.01 4050046 MOBILITY GOAL STATUS 0.01 4050047 MOBILITY GOAL STATUS 0.01 4050048 MOBILITY GOAL STATUS 0.01 4050049 MOBILITY GOAL STATUS 0.01 4050050 MOBILITY GOAL STATUS 0.01 4050051 MOBILITY D/C STATUS 0.01 4050052 MOBILITY D/C STATUS 0.01 4050053 MOBILITY D/C STATUS 0.01 4050054 MOBILITY D/C STATUS 0.01 4050055 MOBILITY D/C STATUS 0.01 4050056 MOBILITY D/C STATUS 0.01 4050057 MOBILITY D/C STATUS 0.01 4050058 BODY POS CURRENT STATUS 0.01 4050059 BODY POS CURRENT STATUS 0.01 4050060 BODY POS CURRENT STATUS 0.01 4050061 BODY POS CURRENT STATUS 0.01 4050062 BODY POS CURRENT STATUS 0.01 4050063 BODY POS CURRENT STATUS 0.01 4050064 BODY POS CURRENT STATUS 0.01 4050065 BODY POS GOAL STATUS 0.01 4050066 BODY POS GOAL STATUS 0.01 4050067 BODY POS GOAL STATUS 0.01 4050068 BODY POS GOAL STATUS 0.01 4050069 BODY POS GOAL STATUS 0.01 4050070 BODY POS GOAL STATUS 0.01 4050071 BODY POS GOAL STATUS 0.01 4050072 BODY POS D/C STATUS 0.01 4050073 BODY POS D/C STATUS 0.01 4050074 BODY POS D/C STATUS 0.01 4050075 BODY POS D/C STATUS 0.01 4050076 BODY POS D/C STATUS 0.01 4050077 BODY POS D/C STATUS 0.01 4050078 BODY POS D/C STATUS 0.01 4050079 CARRY CURRENT STATUS 0.01 4050080 CARRY CURRENT STATUS 0.01 4050081 CARRY CURRENT STATUS 0.01 4050082 CARRY CURRENT STATUS 0.01 4050083 CARRY CURRENT STATUS 0.01 4050084 CARRY CURRENT STATUS 0.01 4050085 CARRY CURRENT STATUS 0.01 4050086 CARRY GOAL STATUS 0.01 4050087 CARRY GOAL STATUS 0.01 Charge Code Description Price 4050088 CARRY GOAL STATUS 0.01 4050089 CARRY GOAL STATUS 0.01 4050090 CARRY GOAL STATUS 0.01 4050091 CARRY GOAL STATUS 0.01 4050092 CARRY GOAL STATUS 0.01 4050093 CARRY D/C STATUS 0.01 4050094 CARRY D/C STATUS 0.01 4050095 CARRY D/C STATUS 0.01 4050096 CARRY D/C STATUS 0.01 4050097 CARRY D/C STATUS 0.01 4050098 CARRY D/C STATUS 0.01 4050099 CARRY D/C STATUS 0.01 4050100 SELF CARE CURRENT STATUS 0.01 4050101 SELF CARE CURRENT STATUS 0.01 4050102 SELF CARE CURRENT STATUS 0.01 4050103 SELF CARE CURRENT STATUS 0.01 4050104 SELF CARE CURRENT STATUS 0.01 4050105 SELF CARE CURRENT STATUS 0.01 4050106 SELF CARE CURRENT STATUS 0.01 4050107 SELF CARE GOAL STATUS 0.01 4050108 SELF CARE GOAL STATUS 0.01 4050109 SELF CARE GOAL STATUS 0.01 4050110 SELF CARE GOAL STATUS 0.01 4050111 SELF CARE GOAL STATUS 0.01 4050112 SELF CARE GOAL STATUS 0.01 4050113 SELF CARE GOAL STATUS 0.01 4050114 SELF CARE D/C STATUS 0.01 4050115 SELF CARE D/C STATUS 0.01 4050116 SELF CARE D/C STATUS 0.01 4050117 SELF CARE D/C STATUS 0.01 4050118 SELF CARE D/C STATUS 0.01 4050119 SELF CARE D/C STATUS 0.01 4050120 SELF CARE D/C STATUS 0.01 4050121 OTHER PT/OT CURRENT STATU 0.01 4050122 OTHER PT/OT CURRENT STATU 0.01 4050123 OTHER PT/OT CURRENT STATU 0.01 4050124 OTHER PT/OT CURRENT STATU 0.01 4050125 OTHER PT/OT CURRENT STATU 0.01 4050126 OTHER PT/OT CURRENT STATU 0.01 4050127 OTHER PT/OT CURRENT STATU 0.01 4050128 OTHER PT/OT GOAL STATUS 0.01 4050129 OTHER PT/OT GOAL STATUS 0.01 4050130 OTHER PT/OT GOAL STATUS 0.01 4050131 OTHER PT/OT GOAL STATUS 0.01 4050132 OTHER PT/OT GOAL STATUS 0.01 4050133 OTHER PT/OT GOAL STATUS 0.01 4050134 OTHER PT/OT GOAL STATUS 0.01 4050135 OTHER PT/OT D/C STATUS 0.01 4050136 OTHER PT/OT D/C STATUS 0.01 4050137 OTHER PT/OT D/C STATUS 0.01 Charge Code Description Price 4050138 OTHER PT/OT D/C STATUS 0.01 4050139 OTHER PT/OT D/C STATUS 0.01 4050140 OTHER PT/OT D/C STATUS 0.01 4050141 OTHER PT/OT D/C STATUS 0.01 4050142 SUB PT/OT CURRENT STATUS 0.01 4050143 SUB PT/OT CURRENT STATUS 0.01 4050144 SUB PT/OT CURRENT STATUS 0.01 4050145 SUB PT/OT CURRENT STATUS 0.01 4050146 SUB PT/OT CURRENT STATUS 0.01 4050147 SUB PT/OT CURRENT STATUS 0.01 4050148 SUB PT/OT CURRENT STATUS 0.01 4050149 SUB PT/OT GOAL STATUS 0.01 4050150 SUB PT/OT GOAL STATUS 0.01 4050151 SUB PT/OT GOAL STATUS 0.01 4050152 SUB PT/OT GOAL STATUS 0.01 4050153 SUB PT/OT GOAL STATUS 0.01 4050154 SUB PT/OT GOAL STATUS 0.01 4050155 SUB PT/OT GOAL STATUS 0.01 4050156 SUB PT/OT D/C STATUS 0.01 4050157 SUB PT/OT D/C STATUS 0.01 4050158 SUB PT/OT D/C STATUS 0.01 4050159 SUB PT/OT D/C STATUS 0.01 4050160 SUB PT/OT D/C STATUS 0.01 4050161 SUB PT/OT D/C STATUS 0.01 4050162 SUB PT/OT D/C STATUS 0.01 4050163 OT Evaluation: Low Com 168.00 4050164 OT Evaluation: Moderat 168.00 4050165 OT Evaluation: High Co 168.00 4050166 OT Re‐evaluation Established Plan of Car 137.00 4050167 OT C/o for orthotic/prosth use 150.00 4100001 SLP SWALLOW FXN EVAL 189.00 4100002 SLP THER ACT EA 15 MIN 90.00 4100003 SLP COGN DEV EA 15 MIN 80.00 4100004 SLP E STIM EA 15MIN 59.00 4100005 SLP NEURO REED EA 15MIN 98.00 4100007 SLP THER EX EA 15 MIN 95.00 4100008 SLP SP/LANG TX GROUP 196.00 4100009 SLP SENSORY INT EA 15 M 87.00 4100010 SLP SWALLOWING FXN TX 130.00 4100011 SLP ASSESS OF APHASIA 284.00 4100012 SLP S/P/LANG TX INDIV 238.00 4100014 SLP ENDOSCOPY SWALLOW TST 260.00 4100015 SWALLOW CURRENT STATUS 0.01 4100016 SWALLOW CURRENT STATUS 0.01 4100017 SWALLOW CURRENT STATUS 0.01 4100018 SWALLOW CURRENT STATUS 0.01 4100019 SWALLOW CURRENT STATUS 0.01 4100020 SWALLOW CURRENT STATUS 0.01 4100021 SWALLOW CURRENT STATUS 0.01 4100022 SWALLOW GOAL STATUS 0.01 Charge Code Description Price 4100023 SWALLOW GOAL STATUS 0.01 4100024 SWALLOW GOAL STATUS 0.01 4100025 SWALLOW GOAL STATUS 0.01 4100026 SWALLOW GOAL STATUS 0.01 4100027 SWALLOW GOAL STATUS 0.01 4100028 SWALLOW GOAL STATUS 0.01 4100029 SWALLOW D/C STATUS 0.01 4100030 SWALLOW D/C STATUS 0.01 4100031 SWALLOW D/C STATUS 0.01 4100032 SWALLOW D/C STATUS 0.01 4100033 SWALLOW D/C STATUS 0.01 4100034 SWALLOW D/C STATUS 0.01 4100035 SWALLOW D/C STATUS 0.01 4100036 MOTOR SPEECH CURRENT STAT 0.01 4100037 MOTOR SPEECH CURRENT STAT 0.01 4100038 MOTOR SPEECH CURRENT STAT 0.01 4100039 MOTOR SPEECH CURRENT STAT 0.01 4100040 MOTOR SPEECH CURRENT STAT 0.01 4100041 MOTOR SPEECH CURRENT STAT 0.01 4100042 MOTOR SPEECH CURRENT STAT 0.01 4100043 MOTOR SPEECH GOAL STATUS 0.01 4100044 MOTOR SPEECH GOAL STATUS 0.01 4100045 MOTOR SPEECH GOAL STATUS 0.01 4100046 MOTOR SPEECH GOAL STATUS 0.01 4100047 MOTOR SPEECH GOAL STATUS 0.01 4100048 MOTOR SPEECH GOAL STATUS 0.01 4100049 MOTOR SPEECH GOAL STATUS 0.01 4100050 MOTOR SPEECH D/C STATUS 0.01 4100051 MOTOR SPEECH D/C STATUS 0.01 4100052 MOTOR SPEECH D/C STATUS 0.01 4100053 MOTOR SPEECH D/C STATUS 0.01 4100054 MOTOR SPEECH D/C STATUS 0.01 4100055 MOTOR SPEECH D/C STATUS 0.01 4100056 MOTOR SPEECH D/C STATUS 0.01 4100057 LANG COMP CURRENT STATUS 0.01 4100058 LANG COMP CURRENT STATUS 0.01 4100059 LANG COMP CURRENT STATUS 0.01 4100060 LANG COMP CURRENT STATUS 0.01 4100061 LANG COMP CURRENT STATUS 0.01 4100062 LANG COMP CURRENT STATUS 0.01 4100063 LANG COMP CURRENT STATUS 0.01 4100064 LANG COMP GOAL STATUS 0.01 4100065 LANG COMP GOAL STATUS 0.01 4100066 LANG COMP GOAL STATUS 0.01 4100067 LANG COMP GOAL STATUS 0.01 4100068 LANG COMP GOAL STATUS 0.01 4100069 LANG COMP GOAL STATUS 0.01 4100070 LANG COMP GOAL STATUS 0.01 4100071 LANG COMP D/C STATUS 0.01 4100072 LANG COMP D/C STATUS 0.01 Charge Code Description Price 4100073 LANG COMP D/C STATUS 0.01 4100074 LANG COMP D/C STATUS 0.01 4100075 LANG COMP D/C STATUS 0.01 4100076 LANG COMP D/C STATUS 0.01 4100077 LANG COMP D/C STATUS 0.01 4100078 LANG EXPRESS CURRENT STAT 0.01 4100079 LANG EXPRESS CURRENT STAT 0.01 4100080 LANG EXPRESS CURRENT STAT 0.01 4100081 LANG EXPRESS CURRENT STAT 0.01 4100082 LANG EXPRESS CURRENT STAT 0.01 4100083 LANG EXPRESS CURRENT STAT 0.01 4100084 LANG EXPRESS CURRENT STAT 0.01 4100085 LANG EXPRESS GOAL STATUS 0.01 4100086 LANG EXPRESS GOAL STATUS 0.01 4100087 LANG EXPRESS GOAL STATUS 0.01 4100088 LANG EXPRESS GOAL STATUS 0.01 4100089 LANG EXPRESS GOAL STATUS 0.01 4100090 LANG EXPRESS GOAL STATUS 0.01 4100091 LANG EXPRESS GOAL STATUS 0.01 4100092 LANG EXPRESS D/C STATUS 0.01 4100093 LANG EXPRESS D/C STATUS 0.01 4100094 LANG EXPRESS D/C STATUS 0.01 4100095 LANG EXPRESS D/C STATUS 0.01 4100096 LANG EXPRESS D/C STATUS 0.01 4100097 LANG EXPRESS D/C STATUS 0.01 4100098 LANG EXPRESS D/C STATUS 0.01 4100099 SPEECH LANG CURRENT STATU 0.01 4100100 SPEECH LANG CURRENT STATU 0.01 4100101 SPEECH LANG CURRENT STATU 0.01 4100102 SPEECH LANG CURRENT STATU 0.01 4100103 SPEECH LANG CURRENT STATU 0.01 4100104 SPEECH LANG CURRENT STATU 0.01 4100105 SPEECH LANG CURRENT STATU 0.01 4100106 SPEECH LANG GOAL STATUS 0.01 4100107 SPEECH LANG GOAL STATUS 0.01 4100108 SPEECH LANG GOAL STATUS 0.01 4100109 SPEECH LANG GOAL STATUS 0.01 4100110 SPEECH LANG GOAL STATUS 0.01 4100111 SPEECH LANG GOAL STATUS 0.01 4100112 SPEECH LANG GOAL STATUS 0.01 4100113 SPEECH LANG D/C STATUS 0.01 4100114 SPEECH LANG D/C STATUS 0.01 4100115 SPEECH LANG D/C STATUS 0.01 4100116 SPEECH LANG D/C STATUS 0.01 4100117 SPEECH LANG D/C STATUS 0.01 4100118 SPEECH LANG D/C STATUS 0.01 4100119 SPEECH LANG D/C STATUS 0.01 4100120 ATTEN CURRENT STATUS 0.01 4100121 ATTEN CURRENT STATUS 0.01 4100122 ATTEN CURRENT STATUS 0.01 Charge Code Description Price 4100123 ATTEN CURRENT STATUS 0.01 4100124 ATTEN CURRENT STATUS 0.01 4100125 ATTEN CURRENT STATUS 0.01 4100126 ATTEN CURRENT STATUS 0.01 4100127 ATTEN GOAL STATUS 0.01 4100128 ATTEN GOAL STATUS 0.01 4100129 ATTEN GOAL STATUS 0.01 4100130 ATTEN GOAL STATUS 0.01 4100131 ATTEN GOAL STATUS 0.01 4100132 ATTEN GOAL STATUS 0.01 4100133 ATTEN GOAL STATUS 0.01 4100134 ATTEN D/C STATUS 0.01 4100135 ATTEN D/C STATUS 0.01 4100136 ATTEN D/C STATUS 0.01 4100137 ATTEN D/C STATUS 0.01 4100138 ATTEN D/C STATUS 0.01 4100139 ATTEN D/C STATUS 0.01 4100140 ATTEN D/C STATUS 0.01 4100141 MEMORY CURRENT STATUS 0.01 4100142 MEMORY CURRENT STATUS 0.01 4100143 MEMORY CURRENT STATUS 0.01 4100144 MEMORY CURRENT STATUS 0.01 4100145 MEMORY CURRENT STATUS 0.01 4100146 MEMORY CURRENT STATUS 0.01 4100147 MEMORY CURRENT STATUS 0.01 4100148 MEMORY GOAL STATUS 0.01 4100149 MEMORY GOAL STATUS 0.01 4100150 MEMORY GOAL STATUS 0.01 4100151 MEMORY GOAL STATUS 0.01 4100152 MEMORY GOAL STATUS 0.01 4100153 MEMORY GOAL STATUS 0.01 4100154 MEMORY GOAL STATUS 0.01 4100155 MEMORY D/C STATUS 0.01 4100156 MEMORY D/C STATUS 0.01 4100157 MEMORY D/C STATUS 0.01 4100158 MEMORY D/C STATUS 0.01 4100159 MEMORY D/C STATUS 0.01 4100160 MEMORY D/C STATUS 0.01 4100161 MEMORY D/C STATUS 0.01 4100162 VOICE CURRENT STATUS 0.01 4100163 VOICE CURRENT STATUS 0.01 4100164 VOICE CURRENT STATUS 0.01 4100165 VOICE CURRENT STATUS 0.01 4100166 VOICE CURRENT STATUS 0.01 4100167 VOICE CURRENT STATUS 0.01 4100168 VOICE CURRENT STATUS 0.01 4100169 VOICE GOAL STATUS 0.01 4100170 VOICE GOAL STATUS 0.01 4100171 VOICE GOAL STATUS 0.01 4100172 VOICE GOAL STATUS 0.01 Charge Code Description Price 4100173 VOICE GOAL STATUS 0.01 4100174 VOICE GOAL STATUS 0.01 4100175 VOICE GOAL STATUS 0.01 4100176 VOICE D/C STATUS 0.01 4100177 VOICE D/C STATUS 0.01 4100178 VOICE D/C STATUS 0.01 4100179 VOICE D/C STATUS 0.01 4100180 VOICE D/C STATUS 0.01 4100181 VOICE D/C STATUS 0.01 4100182 VOICE D/C STATUS 0.01 4100183 SLP EVAL OF FLUENCY 213.00 4100184 SLP EVAL SOUND PRODUCTION 183.00 4100185 SLP EVAL SOUND PROD+LANG 365.00 4100186 SPL EVAL BEHAVIORAL+QUALI 183.00 41115 EXCISION OF TONGUE FOLD 595.00 43760 CHANGE GASTROSTOMY TUBE 1,716.00 4500010 AMB ALS LEVEL 1 NON‐EMERG 675.00 4500015 AMB‐SPECIAL CARE TRANSPRT 1,826.00 4500020 AMB ALS‐LEVEL 1 EMERGENCY 1,069.00 4500021 AMB ALS‐LEVEL 2 EMERGENCY 1,547.00 4500038 AMB BLS ‐NON EMERGENCY 564.00 4500084 AMB BLS ‐EMERGENCY 899.00 4500112 AMB ALS MILEAGE 19.00 4500113 AMB BLS MILEAGE 19.00 4500164 AMB ALS MILEAGE 3.00 4500165 AMB BLS MILEAGE 3.00 4500166 AMB‐Response & Treatment‐no transport 100.00 4550006 URETHRAL DILATAT W/CYSTO 1,095.00 4550008 STRILE H2O FOR INJ 1000ML 18.00 4550009 SPECI CONTAIN 16OZ PATH 9.00 4550010 SPECI CONTAIN UNSTRL 8OZ 9.00 4550011 TUBE DECLOGGER 66.00 4550012 BP UNIT DISP. ADULT 31.00 4550014 INTRAOSS NEEDLE SET‐ADULT 293.00 4550015 LARYNGEAL AIRWAY 4mm 87.00 4550017 SPECI CONTAIN STRILE 4OZ 9.00 4550018 AIR PRO ELITE FLOAT SYS 19.00 4550019 DSG, MEPITEL 38.00 4550020 INTRAOSS NEEDLE SET‐PED 293.00 4550021 LARYNGEAL AIRWAY 1.5 87.00 4550022 STERILE H2O IRRIG 1000 20.00 4550023 DSG, AQUA CELL PLAIN 4X4 44.00 4550025 SIGMIODOSCOPY ‐PROC RM 162.00 4550028 STERILE H2O IRRIG 4OZ 9.00 4550031 TRACHEOST TUBE CUFFED 5.0 59.00 4550032 COLOSTO POUCH DRAIN 2‐3/4 136.00 4550033 DSG, ADAPTIC 3 X 8 BOX 198.00 4550035 IMMOBIL, SHOULDER ADULT 200.00 4550036 COLLAR, STIFF CERV ADULT 161.00 4550037 DSG, AQUA CELL AG 4X4 75.00 Charge Code Description Price 4550038 GLOVES, STERILE SZ 6 1/2 26.00 4550039 GLOVES, STERILE SZ 7 1/2 26.00 4550042 STERILE WTR IRR 500 ML 3.00 4550043 AMBU BAG, INFANT 218.00 4550046 RHINO NASAL PACKING LARGE 128.00 4550049 WRIST SUPPORT 130.00 4550050 QTIP STERILE 9.00 4550051 TRACHEOSTOMY QUICK 2.0 MM 557.00 4550052 BRACE, ANKLE GELCAST 190.00 4550053 CATH, TRAY, CENTRAL VEIN 264.00 4550054 DIC #8 44.00 4550055 DRESSING OIL EMUL 3X8 20.00 4550056 DRESSING, TEGASORB XTHIN 73.00 4550057 SPECIMEN CONTAINER N/S 9.00 4550060 SPONGE, 4X4 STERILE 2PKG 9.00 4550061 TRACHEOSTOMY QUICK 4.0MM 557.00 4550062 TUBE, ENDOTRACHEAL 2.5MM 13.00 4550063 TUBE, ENDOTRACHEAL 6.5MM 55.06 4550064 TUBE, ENDOTRACHEAL 7.5MM 59.00 4550067 TUBE, TRACH 4 DCT 315.00 4550068 TUBE, TRACH 6 DCT 315.00 4550069 POVIDONE IODINE SOLUTION 3.00 4550070 COLLAR, STIFF CERV PEDI 146.00 4550071 SKIN ADHESIVE 118.00 4550072 DRESSING OIL EMIL 3X3 9.00 4550073 DRESSING, COMBIDERM ACD 53.00 4550074 DRESSING, HYDRASORB FEN 24.00 4550076 DRESSING, PANOGAUZE 4X4 29.00 4550078 SPONGE, 4X4 STERILE 10S 20.00 4550080 WRIST SUPPORT IV, ADULT 73.00 4550081 WRIST SUPPORT IV, CHILD 68.00 4550082 CATH, TRAY, MULTILUMEN 447.00 4550083 CIRCUMCISION PROCEDURE 92.00 4550085 GASTROSCOPY W/O BIOPSY 1,306.00 4550087 GLOVES, STERILE EXAM 7 26.00 4550088 GLOVES, ST EXAM 8 26.00 4550089 IMMOBILIZER, KNEE 20" 240.00 4550090 SPLINT, WRIST ‐FOREARM 178.00 4550091 SPONGE, KERLIX STERILE 44.00 4550094 TUBE, ENDOTRACHEAL 3MM 59.00 4550095 TUBE, ENDOTRACHEAL 4MM 59.00 4550097 TUBE, ENDOTRACHEAL 6MM 59.00 4550098 TUBE, ENDOTRACHEAL 7MM 59.00 4550099 TUBE, ENDOTRACHEAL 8MM 59.00 4550102 BRACE, PRO 8 ANKLE LL 92.00 4550105 CATH, FOLEY 22FR 30CC 124.00 4550108 CATH, FOLEY 30FR 30CC 124.00 4550109 CATH, 3 WAY 16FR 30CC 124.00 4550110 CATH, 3 WAY 18FR 30CC 124.00 4550111 CATH, 3 WAY 20FR 30CC 124.00 Charge Code Description Price 4550113 CATH, 3 WAY 24FR 30CC 124.00 4550114 OSTOMY POUCH 1‐3/4 10.00 4550115 OSTOMY POUCH 2‐3/4 16.00 4550116 OSTOMY WAFER 1‐3/4 13.00 4550117 OSTOMY WAFER 2‐3/4 16.00 4550120 DRESSING, CONFORM 4 " 9.00 4550122 FLEETS ENEMA ‐ MINERAL OI 3.00 4550123 GAUZE, VASELINE 3X18" 9.00 4550124 IMMOBLIZIER, KNEE 12" 227.00 4550125 IMMOBLIZIER, KNEE 16" 231.00 4550126 NEEDLE, SPINAL 18X3.5 24.00 4550131 NEEDLE, SPINAL 25X3.5 24.00 4550132 PACKING, AQUA CELL AG 75.00 4550134 SWAB, LEMON GLYCERINE 9.00 4550136 TONGUE BLADE, STERILE 9.00 4550138 TRACHEOSTOMY TUBE TIE 9.00 4550139 TROCAR THORACIC 32 FR 51.00 4550140 TUBE, SALEM SUMP 10FR 62.00 4550141 TUBE, SALEM SUMP 12FR 62.00 4550142 TUBE, SALEM SUMP 14FR 62.00 4550143 TUBE, SALEM SUMP 16FR 62.00 4550144 TUBE, SALEM SUMP 18FR 62.00 4550150 CATH, COUDE 14FR 5CC 130.00 4550151 CATH, COUDE 16FR 5CC 130.00 4550152 CATH, COUDE 18FR 5CC 130.00 4550153 CATH, FOLEY 12FR 5CC 68.00 4550154 CATH, FOLEY 14FR 5CC 68.00 4550155 CATH, FOLEY 16FR 30C 124.00 4550156 CATH, FOLEY 16FR 5CC 68.00 4550157 CATH, FOLEY 18FR 30C 124.00 4550158 CATH, FOLEY 18FR 5CC 68.00 4550159 CATH, FOLEY 20FR 30C 124.00 4550160 CATH, FOLEY 20FR 5CC 68.00 4550166 CATH, TRAY, URETHRAL 62.00 4550167 CATH, TRAY, W/O CATH 73.00 4550168 CATH, 3 WAY 16FR 5CC 124.00 4550169 CATH, 3 WAY 18FR 5CC 124.00 4550170 CATH, 3 WAY 20FR 5CC 124.00 4550173 DRESSING, CONFORM 2" 9.00 4550174 DRESSING, CONFORM 3" 9.00 4550175 DRESSING, CONFORM 6" 19.00 4550176 NUT‐ ENSURE PUDDING CHOCO 16.00 4550177 FRAZIER SUCTION PEDI 35.00 4550178 FRAZIER SUCTION 10FR 85.00 4550180 GAUZE, VASELINE 1X8" 9.00 4550181 GAUZE, VASELINE 3X9" 9.00 4550185 ISOLATION GOWN DISP. 9.00 4550186 K‐10 MOD HEATING PAD 101.00 4550187 LAPIDUS DAILY RENTAL 42.00 4550189 LUMBAR PUNCTURE TRAY 130.00 Charge Code Description Price 4550190 NASOPHARYNGEAL 28 FR 42.00 4550191 NASOPHARYNGEAL 34 FR 42.00 4550192 NEEDLE, JAMSHIDI BIO 242.00 4550193 NSS IRR 500ML 16.00 4550195 PACK STRIP ½in IOD 53.00 4550196 PACK STRIP 1/4in IOD 46.00 4550199 PENROSE DRAIN 1/2X18 24.00 4550200 PRESSURE RELIEF RING 108.00 4550203 SHEEPSKIN IMMITATION 172.00 4550204 SOX, SAFETY ‐ MEDIUM 8.00 4550206 STRAP, CLAVICLE XLG 106.00 4550209 STERI‐STRIP 1/2 X 3" 20.00 4550210 STERI‐STRIP 1/4 X 3" 19.00 4550214 SYRINGE 2OZ CATH TIP 9.00 4550217 TED HOSE MED‐REGULAR 97.00 4550222 TROCAR THORACIC 28FR 161.00 4550225 URINE COLLECTION KIT 19.00 4550229 ACCESS PORT ‐SINGLE 1,273.00 4550231 AMBU BAG DISP,ADULT 213.00 4550232 AMBU BAG DISP,CHILD 205.00 4550235 BRACE, ANKLE PRO SL 92.00 4550236 BURN ROLL KERLIX 20.00 4550237 CATH, FOLEY 6FR 1.5CC 117.00 4550238 CATH, FOLEY 8FR 3CC 92.00 4550240 ICE COLLAR 9.00 4550241 COLLAR, FOAM LG 121.00 4550242 COLLAR, FOAM MEDIUM 121.00 4550244 CRUTCH ACESSORY KIT 121.00 4550245 CRUTCHES TALL ADULT 184.00 4550246 BRIEFS, ADULT LARGE 59.00 4550252 NUT‐ ENSURE PUDDING VANIL 16.00 4550253 ENTERAL Y EXTENSION 26.00 4550255 GEL SKIN SCRUB PACK 53.00 4550256 INCONTINENT DIAPERS 59.00 4550260 NEEDLE, SPINAL 18X3 24.00 4550261 NSS IRR 1000ML 97.00 4550262 PACK STRIP 1IN IOD 59.00 4550264 SOX, SAFETY ‐ LARGE 8.00 4550265 SPLINT HAND ALUM LG/LF 91.00 4550266 SPLINT HAND ALUM LG/RT 91.00 4550267 SPLINT HAND ALUM MD/LFT 91.00 4550268 SPLINT HAND ALUM MD/RT 91.00 4550269 SPLINT HAND ALUM SM/LFT 91.00 4550270 SPLINT HAND ALUM SM/RT 91.00 4550271 STRAP, CLAVICLE LG 106.00 4550272 STRAP, CLAVICLE XS 106.00 4550274 SPLINT, FINGER 1/2" 24.00 4550276 SPLINT, ARM LT UNIVERSAL 178.00 4550277 SPLINT, FOREARM L S 178.00 4550279 SPLINT, ARM RT UNIVERSAL 178.00 Charge Code Description Price 4550282 STOPCOCK/ EXT. TUBE 53.00 4550285 TED HOSE LG REGULAR 97.00 4550286 TED HOSE SM‐REGULAR 97.00 4550287 TELFA STERILE SMALL 9.00 4550288 TELFA‐STERILE LARGE 9.00 4550289 THORACENTHESIS TRAY 231.00 4550290 TUBE FEED BAG 62.00 4550297 AIRWAY 100MM LG AD 9.00 4550302 CAST, BOOT LARGE 137.00 4550303 CAST, BOOT SMALL 137.00 4550304 CATH, SUCTION 10FR 29.00 4550305 CATH, SUCTION 14FR 29.00 4550306 CATH, SUCTION TUBING 18fr 29.00 4550307 CATHETER LEG STRAP 41.00 4550308 COLLAR, FOAM SMALL 106.00 4550309 CO2 DETECTOR ADULT 81.00 4550310 CRUTCHES REG ADULT 184.00 4550313 BRIEFS, ADULT MED. 47.00 4550315 TEGADERM HYDROCOLLOID 47.00 4550316 FLEETS ENEMA ‐ PLAIN 3.00 4550318 FOGARTY CATH. TRAY 213.00 4550321 CANNULA LEVER LOCK 19.00 4550322 NSS IRRIGATION 4 OZ 9.00 4550325 NUT‐ BENEPROTEIN SCOOP 3.00 4550327 RINO NASAL PACK XL 128.00 4550330 STRAP, CLAVICLE M 106.00 4550331 STRAP, CLAVICLE S 106.00 4550335 STOMA SKIN BARRIER 124.00 4550339 SUSPENSORY X‐LARGE 79.00 4550340 SUTURE REMOVAL SET 26.00 4550343 TED HOSE MED‐SHORT 97.00 4550344 TEGADERM 4 X 4 3/4 20.00 4550346 THOROCENTESIS TRAY 139.00 4550347 TUBE, STOMACH 12FR 24.00 4550349 TUBE, STOMACH 16FR 24.00 4550350 TUBE, STOMACH 18FR 24.00 4550351 VAGINAL SPEC MED 20.00 4550352 VAGINAL SPECULUM SM 20.00 4550353 VAGINAL SPECULUM LARGE 20.00 4550356 AIRWAY 80MM CHILD 9.00 4550357 AIRWAY 90MM ADULT 9.00 4550359 CAST, BOOT MED 137.00 4550360 CATH, SUCTION 5/6 29.00 4550365 CONNECTOR, 5 IN 1 19.00 4550366 CO2 DETECTOR PEDI 81.00 4550367 DERMABOND PRO‐PEN 147.00 4550373 ENEMA, FLEET PEDI 15.00 4550374 NUT‐ ENSURE PLUS VANILLA 16.00 4550381 ICE PACK COLPRESS 9.00 4550389 PACKING STRIP PLAIN 1/2 44.00 Charge Code Description Price 4550390 PACKING STRIP PLAIN 1/4 42.00 4550395 PEDI FINGER PROBE 129.00 4550400 PUMP DAILY RENTAL 79.00 4550403 SLING, ARM MEDIUM 68.00 4550405 SPLINT, FINGER 1" 24.00 4550406 SPLINT LEG LARGE 258.00 4550407 SPLINT LEG SMALL 231.00 4550408 SPLINT LEG MED 231.00 4550410 SKIN STAPLER 35s 84.00 4550413 SUCTION CANNISTER 42.00 4550414 SUSPENSORY MEDIUM 79.00 4550415 SYRINGE BULB 2 OZ 20.00 4550416 TED HOSE LG SHORT 97.00 4550417 TED HOSE MED‐LONG 97.00 4550418 TED HOSE SM‐SHORT 97.00 4550422 TUBE, FEEDING 5FR 15.00 4550423 TUBE, FEEDING 8FR 15.00 4550424 TUBE, GASTRO 14FR 282.00 4550425 TUBE, GASTRO 16FR 282.00 4550426 TUBE, GASTRO 18FR 282.00 4550427 TUBE, GASTRO 20FR 282.00 4550428 TUBE, GASTRO 22FR 282.00 4550429 TUBE, GASTRO 24FR 282.00 4550430 TUBE, GASTRO 26FR 282.00 4550431 URINAL DISPOSABLE 12.00 4550432 URINARY DRAIN BAG 59.00 4550433 VAGINAL IRRIG SET 26.00 4550437 BARD PORT‐A‐CATH 2,352.00 4550438 BED PAN FRACTURE 29.00 4550441 CAST, WALKERS LARGE 192.00 4550442 CAST, WALKERS SMALL 192.00 4550443 CATH, TRAY, 16FR 131.00 4550444 CATH, TRAY, 18FR 131.00 4550445 BRIEFS, ADULT XL 43.00 4550448 FOLEY (SILASTIC) 88.00 4550449 FURACIN ROLL, L. 42.00 4550453 NUT‐ JEVITY 1CAL RTH [100 52.00 4550455 KLING GUAZE BDG. 20.00 4550456 LEVELER MATTRESS 124.00 4550459 MEDIC‐AIR REFILL 51.00 4550461 PACKING STRIP PLAIN 1" 47.00 4550462 NUT‐ OSMOLITE 1.5 RTH [10 16.00 4550464 PNEUMOTHORAX KIT 444.00 4550465 RAZOR DISPOSABLE 7.00 4550466 SLING, ARM LARGE 68.00 4550467 SLING, ARM SMALL 68.00 4550471 SUSPENSORY LARGE 79.00 4550472 SUSPENSORY SMALL 79.00 4550473 SYRINGE 60CC LL 9.00 4550477 TED HOSE LG LONG 97.00 Charge Code Description Price 4550478 TED HOSE SM‐LONG 97.00 4550479 THERMOMETER ORAL 19.00 4550484 ADAPTER, FEMALE 8.00 4550485 ARM BOARD LARGE 9.00 4550486 ARM BOARD MED 9.00 4550487 ARM BOARD SMALL 9.00 4550488 BED PAN REGULAR 29.00 4550495 CONNECTER, SIMS 13.00 4550496 DIAPER, BABY #1 4.00 4550497 DIAPER, BABY #3 4.00 4550498 DIAPER, BABY #4 4.00 4550499 DIAPER, BABY #5 4.00 4550500 DIAPER, BABY #6 4.00 4550503 MINI ISLAND DRESSING 9.00 4550509 GAYMAR TEMP PAD 59.00 4550510 INSTRUMENT TRAY 59.00 4550512 IRRIGATION TRAY 42.00 4550513 LUMBAR PUNCTURE 400.00 4550515 OB PADS STERILE 20.00 4550518 RAPID RHINO 4.5 132.00 4550520 RAPID RHINO 7.5 132.00 4550521 RIB BELT FEMALE 146.00 4550525 STYLETTE, ADULT 37.00 4550526 STYLETTE, YOUTH 37.00 4550532 SYRINGE 30CC LL 9.00 4550537 TURN Q MATTRESS 70.00 4550539 ACE BANDAGE 2" 19.00 4550540 ACE BANDAGE 3" 20.00 4550541 ACE BANDAGE 4" 20.00 4550542 ACE BANDAGE 6" 24.00 4550544 CAST, WALKERS MED 192.00 4550547 CATH, URETHRAL 9.00 4550549 CAUTERIZER PIN 92.00 4550554 CRUTCHES CHILD 165.00 4550555 CRUTCHES YOUTH 172.00 4550557 DERMILITE TAPE 19.00 4550562 FOLEY (BARDEX) 68.00 4550566 NUT‐ JEVITY 1.5CAL RTH [1 3.00 4550574 STYLETTE, PEDI 37.00 4550579 TEGADERM 6 X 8 26.00 4550582 TOOTHETTE SWAB 9.00 4550585 TUBE FEED PUMP 42.00 4550587 CALCULLI STRAINER 9.00 4550588 UROSTOMY POUCH 16.00 4550590 XYLOCAINE 10CC 29.00 4550602 DOVER LEG BAG 35.00 4550605 EYE PAD, OVAL 9.00 4550606 FINGER COT SM 20.00 4550607 FINGER COT MED 20.00 4550608 FOLEY (3 WAY) 121.00 Charge Code Description Price 4550609 FURACIN STRIP 9.00 4550610 NUT‐ GLUCERNA 240ML 16.00 4550615 PRELL SHAMPOO 20.00 4550616 PUDENDAL TRAY 115.00 4550617 NUT‐ PULMOCARE RTH [1000M 53.00 4550618 Q TIP STERILE 9.00 4550620 SPONGE, TRACH 10.00 4550626 TRACTION BOOT 62.00 4550627 TUM E‐VAC KIT 179.00 4550628 WATER PITCHER 19.00 4550629 YANKAUER TIP 9.00 4550633 DE LEE SUCT. 24.00 4550634 DENTURE CUPS 9.00 4550635 DRESSING, IV 9.00 4550636 DRI‐FLO PADS 101.00 4550638 EMISIS BASIN 12.00 4550639 FACEMASK BOX 79.00 4550640 GASTRIC GAV. 46.00 4550641 GASTRIC LAV. 46.00 4550644 IV START PAK 24.00 4550645 KARA SEAL 3' 9.00 4550654 SPLINT, FROG 9.00 4550655 STOMA BAG 2" 302.00 4550657 SURGIPAD ABD 9.00 4550663 TROCAR THORACIC 36 FR 59.65 4550668 BOVIE MACH. 68.00 4550670 CATH EXTERNAL MALE 9.00 4550672 DENTURE CUP 9.00 4550673 BULB SYRINGE 20.00 4550674 EKG MONITOR 381.00 4550675 NUT‐ ENSURE VANILLA [240 16.00 4550678 LIMB HOLDER 104.00 4550679 LUMBER TRAY 146.00 4550681 MORGAN LENS 101.00 4550684 PERI BOTTLE 9.00 4550687 SHAMPOO CAP 20.00 4550688 SHAVE GEL 7.00 4550690 TELFA SMALL 9.00 4550691 THERMOMETER 19.00 4550695 PERSONAL WIPES 20.00 4550699 CATH, PLUG 9.00 4550702 FLATUS BAG 24.00 4550704 NUT‐ JEVITY 1 16.00 4550707 PLEUR EVAC 476.00 4550709 SCAPEL #11 42.00 4550710 SCAPEL #15 42.00 4550713 STABILTUBE 41.00 4550717 SUTURE, M. 71.00 4550720 TUBE SPEC COLLECT TRAP 53.00 4550721 WASH BASIN 10.00 Charge Code Description Price 4550725 CHEMSTRIP 227.00 4550726 DEODORANT 9.00 4550727 ENEMA BAG 24.00 4550728 GROOM KIT 9.00 4550729 I & O CUP 9.00 4550731 ISOLATION 264.00 4550733 MANOMETER 85.00 4550734 PREP TRAY 20.00 4550735 NUT‐ PULMOCARE CAN 16.00 4550736 SHEEPSKIN 145.00 4550743 BILE BAG 59.00 4550745 EAR WICK 24.00 4550746 EYE TRAY 20.00 4550748 HYDROGEN PEROXIDE 3.00 4550749 POLIDENT 9.00 4550751 NUTRITIONAL PIERCE PIN 24.00 4550752 RIB BELT 145.00 4550753 SAFE‐GEL 131.00 4550754 SPECIPAN 20.00 4550755 STOPCOCK 42.00 4550757 DIC # 4 44.00 4550760 GELFOAM 121.00 4550761 HEMOVAC 205.00 4550762 ICE BAG 26.00 4550763 KLEENEX 9.00 4550765 STOMACH 9.00 4550766 SUPLENA 18.00 4550767 WEE BAG 9.00 4550771 DIC #6 44.00 4550775 LOTION 7.00 4550776 POWDER 7.00 4550778 TEXAS 9.00 4550779 BELT 200.00 4550781 LACERATION TRAY 33.00 4550783 TUBE TRACH 8 SHILEY 315.00 4550787 STOMA BARRIER 8X8 90.00 4550793 DIAPER ADULT SMALL 30.00 4550802 TUBE ENDO 4.5 UNCUFF 59.00 4550809 LARYNGEAL AIRWAY 2.5 14.00 4550818 FOOT HEEL PROTECTOR 22.02 4550833 TUBE ENDO 5.5 CUFFED 55.06 4550840 SOX SAFETY 2XL 10.00 4550841 NUT‐ ARGININE/GLUTAMINE 16.00 4550844 TUBE‐ENDO 6.5MM CUFFED 9.00 4550845 FINGER SPLINT, BASEBALL 20.00 4550846 FINGER SPLINT GUTTER 11.00 4550847 FINGER SPLINT TOAD 18.00 4550848 SPLINT FINGER #3 10.00 4550849 SPLINT FINGER #4 10.00 4550850 SPLINT FINGER #5 10.00 Charge Code Description Price 4559008 6.5 ST EXAM GLOVE 26.00 4559010 ENSURE CHOCOLATE 16.00 4559012 DRESSING FOAM LARGE 36.00 4559013 DRESSING FOAM SMALL 29.00 4559035 NUT‐ GLUCERNA 1.5 CAN VA 16.00 4559050 NUT‐ SUPLENA CAN 240ML 16.00 4559051 #2 BABY DIAPER 4.00 4559052 TED KNEEHIGH HOSE REG/SM 22.02 4559053 TED KNEEHIGH HOSE REG/M 22.02 4559054 TED KNEEHIGH HOSE REG/L 22.02 4559055 TED KNEEHIGH HOSE REG/XL 22.02 4559056 TEGADERM W/PAD 11.01 4559059 BOUGIE INTRODUCER 20.00 4559060 NASOPHARYNGEAL 7mm 28 FR 42.00 4559061 D5 1/4 1000ML 7.75 4559062 FEED BAG‐DUAL 31.00 4559063 BRIEFS, ADULT XXL 13.00 4559064 VALVE LOPEZ NG 10.50 4559065 CATH 24 FR 30 CC 37.00 4559066 Cannula DIC #4 16.00 4559067 Cath‐Indwelling Suction 46.50 46040 INCISION OF RECTAL ABSCESS 1,490.50 46083 INCISE EXTERNAL HEMORRHOI 414.00 49060 DRAIN OPEN RETROPERI ABSCESS 2,150.00 51701 INSERT BLADDER CATHETER 55.06 54150 CIRCUMCISION W/REGIONL BLOCK 200.00 54700 DRAINAGE OF SCROTUM 400.00 55100 DRAINAGE OF SCROTUM ABSCESS 230.00 56405 I&D OF VULUA‐PERINEAL ABS 190.00 56420 DRAINAGE OF GLAND ABSCESS 135.00 57420 COLPOSCOPY OF VAGINA W/CE 183.00 57454 COLPOSCOPY CERVIX W‐BIOPSY 553.00 57455 BIOPSY OF CERVIX W/SCOPE 385.00 57500 CERVIX BIOPSY 304.00 57522 CONIZATION OF CERVIX 961.00 58100 ENDOMETRIAL BIOPSY 359.00 58150 TOTAL ABDOMINAL HYSTERECT 1,650.00 58563 HYSTEROSCOPY ABLATION 700.00 58565 HYSTEROSCOPY STERILIZATIO 2,848.00 58720 SALPINGO‐OOPHORECTOMY 1,488.00 58999 GENITAL SURGERY PROCEDURE 260.00 59200 INSERT CERVICAL DILATOR 846.00 59899 MATERNITY CARE PROCEDURE 112.00 65205 EXT EYE CONJ SUPERFICIAL 65.00 65235 REMOVE FOREIGN BODY FROM 1,356.00 69000 Drain external ear lesion 200.00 69100 BIOPSY EXTERNAL EAR 196.00 69110 REMOVE EXTERNAL EAR PARTI 425.00 69145 REMOVE EAR CANAL LESION 415.00 69200 EXT AUDITORY CANAL 76.00 Charge Code Description Price 69210 CERUMEN‐REMOVAL 70.00 75630 X‐RAY AORTA LEG ARTERIES 350.00 81003 LAB DIP STICK URINE 14.00 82607 VITAMIN B‐12 25.00 82962 DEXTOSTIX 36.00 86580 TUBERCULOSIS INTRADERMAL 29.00 88147 CYTOPATH C/V AUTOMATED 86.00 90378 SYNAGIS 0.01 90471 IMMUN ADMIN‐SINGLE INJECT 36.00 90472 IMMUN ADMIN‐EACH ADDL INJ 36.00 90473 IMMUN ADMIN‐NASAL‐ORAL VA 36.00 90474 IMMUN ADMIN‐NASAL‐ORAL VA 36.00 90632 VACCINE‐HEPATITIS A 105.00 90633 HEP A PED/ADOL (2‐DOSE) 40.00 90636 HEP A/HEP B VACC ADULT IM 194.00 90648 HIB 4 DOSE SCHEDULE 30.00 90649 HPV VACCINE 172.00 90657 INFLUENZA 6‐35 MONTHS 24.00 90658 INFLUENZA 3 YRS & UP 24.00 90660 INFLUENZA VACCINE;NASAL 51.00 90670 PNEUMOCOCCAL VACCINE 202.00 90680 ROTOVIRUS VACCINE 125.00 90681 ROTAVIRUS VACCINE‐2 DOSE 238.00 90691 TYPHOID VACCINE IM 100.00 90696 DTAP‐IPV 4 TO 6 YRS 55.06 90698 DTAP‐HIB‐IPV 96.00 90700 DTAP 7 YRS & UNDER 33.03 90703 TETANUS TOXOID ADULT 50.00 90707 MMR VACCINE 167.00 90710 MMRV (MMR/VARICELLA) 182.00 90713 POLIO (IPV) VACCINE 35.00 90715 TDAP‐7 YRS AND OLDER 51.00 90716 CHICKEN POX / VARICELLA 134.00 90723 DTAP‐HEPB‐IPV 84.00 90732 PNEUMONIA 2 YRS AND OLDER 95.00 90734 MCV4‐MENINGOCOCCAL CON 139.00 90736 ZOSTER VACC SC 359.00 90744 HEP B‐PED/ADOL (3 DOSE) 62.00 90746 HEPATITIS B ADULT 267.00 92551 AUDIOLOGIC SCREENING TEST 17.00 93294 PM DEVICE INTERROGATE REMOTE 65.00 93459 L HRT ART/GRFT ANGIO 698.00 94640 INHALATION TREATMENT 225.00 94760 PULSE OX 27.00 95115 ADMIN ALLERGY INJECT 1 58.50 95117 ADMIN ALLERGY INJECT 2+ 58.50 95144 ANTIGEN TX SINGLE INJ SUP 38.00 96372 THERAPEUTIC DIAGNOSTIC INJECTION 29.00 96374 THER/PROPH/DIAG INJ IV PU 62.00 96375 INFUSION SUBSEQ 40.00 Charge Code Description Price 97597 RMVL DEVITAL TIS 20 CM/< 178.00 99173 VISUAL ACUITY SCREENING 3.00 99201 OFF VST‐NEW‐BRIEF‐(10MIN) 79.00 99202 OFF VST‐NEW‐LTD(20MIN) 99.10 99203 OFF VST‐NEW‐INTER(30MIN) 134.00 99204 OFF VST‐NEW‐EXTEND(45MIN) 203.00 99205 OFF VST‐NEW‐COMP(60MIN) 251.00 99211 OFF VST‐EST‐BRIEF(5MIN) 51.00 99212 OFF VST‐EST‐LTD(10MIN) 70.00 99213 OFF VST‐EST‐INTER(15MIN) 97.00 99214 OFF VST‐EST‐EXTEND(25MIN) 194.00 99215 OFF VST‐EST‐COMP(40MIN) 222.00 99217 OBSERVATION CARE DISCHARG 110.00 99218 INITIAL OBSER CARE‐ LOW 102.00 99219 INITIAL OBSER CARE‐MODERA 172.00 99220 INITIAL OBSER CARE‐HIGH 238.00 99221 INPT‐INIT‐NEW/EST(30MIN) 99.10 99222 INPT‐INIT NEW/EST(50MIN) 196.00 99223 INPT‐INIT NEW/EST(70MIN) 251.00 99224 SUBST OBSERV CARE LOW 44.04 99225 SUBST OBSERV CARE MODERAT 79.00 99226 SUBST OBSERV CARE HIGH 118.00 99231 INPT‐SUBSEQ‐EST (15MIN) 70.00 99232 INPT‐SUBSEQ‐EST(25MIN) 99.10 99233 INPT‐SUBSEQ‐EST(35MIN) 140.00 99234 HOSPITAL OBSERV ‐ LOW 208.00 99235 HOSPITAL OBSERV ‐ MOD 280.00 99236 HOSPITAL OBSERV ‐ HIGH 349.00 99238 INPT‐DSCHG‐(UNDER 30MIN) 140.00 99239 INPT‐DSCHG‐(OVER 30MIN) 175.00 99242 OFFICE CONSULTATION‐EXPAN 150.00 99243 OFFICE CONSULTATION 202.00 99244 OFFICE CONSULTATION 230.00 99245 OFFICE CONSULTATION 275.00 99251 INPT‐INIT CONSULT‐20MIN 113.00 99252 INPT‐INIT CONSULT‐40 MIN 126.00 99254 INPT‐INIT CONSULT‐80 MIN 212.00 99304 INITIAL NURSING FC PER DA 150.00 99305 NURSING FACILITY CARE INI 253.00 99306 NURSING FACILITY CARE INI 322.00 99307 NURSG FAC CARE‐SUBSEQ 74.00 99308 NURSG FAC CARE‐SUBSEQ 107.00 99309 NURSG FAC CARE‐SUBSEQ 148.00 99310 NURSING FAC CARE SUBSEQ 257.00 99315 NURSING FAC DISCHG 30 MIN OR < 175.00 99316 NURSING FAC DISCHG<30 MIN 201.00 99342 HOME VISIT NEW PT EXPANDE 175.00 99347 HOME VISIT EST PT SIMPLE 123.00 99348 HOME VISIT EST PT EXPANDE 183.00 99381 PM‐INITIAL/NEW (< 1 YR) 123.00 Charge Code Description Price 99382 PM‐INITIAL/NEW(AGE 1‐4) 134.00 99383 PM INITAL/NEW (AGE 5‐11) 134.00 99384 PM INIT/NEW (AGE 12‐17) 145.00 99385 PM‐INIT/NEW (AGE 18‐39) 145.00 99386 PM INIT/NEW PT AGES 40 TO 64 YRS 167.00 99387 PM INIT/NEW PT AGES 65 AND OLDER 178.00 99391 PM‐PERIOD/EST (< 1 YR) 95.00 99392 PM‐PERIOD/EST(1‐4YR) 105.00 99393 PM‐PERIOD/EST(5‐11YR) 105.00 99394 PM‐PERIOD/EST(12‐17YR) 117.00 99395 PM‐PERIOD/EST(18‐39YR) 117.00 99396 PM REEVAL OF EST PT AGES 40 TO 64 YEARS 134.00 99397 PM REEVAL OF EST PT AGES 65 AND OLDER 145.00 99980 AI‐LFMC MEDICAID RURAL ENCOUNTER VISIT 162.79 99981 AI‐LPHC MEDICAID RURAL ENCOUNTER VISIT 195.46 G0008 ADMINISTRATION FLU INJECT 58.50 G0009 ADMINISTRATION PNEU INJ 58.50 G0101 SCREENING PELVIC EXAM 62.00 G0179 HH ‐ RECERT 140.00 G0180 HH ‐ CERTIFICATION 105.00 G0260 INJ TRIGGER POINT 1/2 MUSCL 1,200.00 G0402 Preventive Exam‐ Initial 145.00 G0438 PPPS, INITIAL VISIT 327.00 G0439 PPPS, SUBSEQ VISIT 218.00 J0171 EPINEPHRINE 1ML 3.00 J0561 PENICILLIN G BENZATHINE 8.00 J0696 ROCEPHIN 8.00 J0702 CELESTONE 7.00 J1020 DEPO MEDROL 20MG 37.00 J1030 DEPO MEDROL 40MG 37.00 J1040 DEPO MEDROL 80MG 73.00 J1050 DEPO‐PROVERA INJ 0.35 J1100 DECADRON 1MG 10.00 J1200 BENADRYL 25MG 36.00 J1631 HALOPERIDOL DECON INJ 32.00 J1815 NOVOLOG 4.00 J1885 TORDOL 30MG 36.00 J1940 FUROSEMIDE/LASIX INJ 20 M 15.00 J2405 ZOFRAN PER 1 MG INJ 27.00 J2550 INJ,PROMETHAZINE(PHENERGAN) 38.00 J2920 SOLU‐MEDR IN 40MG METHY 42.00 J2930 SOLUMEDROL 125MG 71.00 J3301 KENALOG‐10 10.00 J3420 VITAMIN B‐12 INJ (1000MCG 37.00 J7510 PREDNISOLONE, ORAL PER 5M 3.00 J7609 ALBUTEROL 8.00 J7613 ALBUTEROL NEB 0.083% 4.00 J7614 XOPENEX 7.00 J7620 DEO NEB 5.00 J7626 BUDESONIDE NON‐COMP UNIT 18.00 Charge Code Description Price J7644 ATROVENT 13.00 LAB0532 CHRONIC URTICARIA 125.00 Q2036 INFLUENZA 3 YRS & UP 24.00 Q2038 INFLUENZA 3 YRS & UP 24.00 S0077 CLINDAMYCIN INJ 300 MG 26.00 S0119 ONDANSETRON 4 MG 27.00 S0630 REMOVAL OF SUTURES 84.00 T1015 MEDICAID‐RURAL VISIT 158.64