Lista Centros De Costo Y Nãºmeros De Artã Culo.Xlsx

Rev. June, 2020

Nota de recordatorio de la Administración CMC revisa sus cargos hospitalarios periódicamente para garantizar que reflejen con precisión la atención de alta calidad que buscamos brindar. En algunos casos, nuestros cargos son diferentes a los de otros proveedores cuando ofrecemos un mayor nivel de atención y una experiencia clínica única. En general, CMC trabaja con pacientes, proveedores y socios para reducir el costo de la atención a través de programas de prevención, salud primaria y cuidado de calidad. Los precios están sujetos a cambio.

Reminder note from Administration CMC reviews the hospital charges periodically to ensure they accurately reflect the high-quality care we seek to provide. In some cases, our charges are different from other providers when we offer a higher level of care and a unique clinical experience. Overall, CMC works with patients, providers, and partners to lower the cost of care through prevention, primary health, and quality care programs. Prices are subject to change.

CodeGroup Description Price 0002 HOSPITALIZATION CESAREAN DELIVERY AFTER FAILED VAGINAL D 1,800.00 0002 HOSPITALIZATION CESAREAN DELIVERY W POSTPARTUM CARE 1,800.00 0002 HOSPITALIZATION EXCISION SKINSUBQ (15833) 1,000.00 0002 HOSPITALIZATION MATERNITY PACKAGE 1,800.00 0002 HOSPITALIZATION PERDIEM REGULAR 800.00 0002 HOSPITALIZATION VAGINAL DELIVERY WPOSPARTUM CARE 1,800.00 0120 HOSPITALIZATION INSOLATION ROOM 800.00 0120 HOSPITALIZATION PER DIEM REGULAR 800.00 0120 HOSPITALIZATION SEMI PRIVADO CUARTO PACIENTE PRIVADO 800.00 0200 HOSPITALIZATION INTESIVE CARE UNIT (ICU) 800.00 0250 PHARMACY 0.45% SALINE SOLUTION 1000 ML 48.00 0250 PHARMACY 0.9% NSS INTRAVENOUS 25ML 12.00 0250 PHARMACY ACEPHEN 325 MG RECTAL SUPPOSITORY ACETAMINOPHEN 1.00 0250 PHARMACY ACETAMINOPHEN 120MG RECTAL SUPPOSITORY 1.00 0250 PHARMACY ACETAMINOPHEN 325MG TAB 1.00 0250 PHARMACY ACETAMINOPHEN CODEINE 3 TABLET 1.00 0250 PHARMACY ACETAMINOPHEN CODEINE ORAL SOLUTION 120 12MG 5ML 1.00 0250 PHARMACY ACETAMINOPHEN CON CODEINA 3 1.50 0250 PHARMACY ACETAMINOPHEN ORAL LIQUID 160 MG 5ML 1.00 0250 PHARMACY ACETAMINOPHEN ORAL TABLET 500 MG 1.00 0250 PHARMACY ACETAMINOPHEN RECTAL SUPPOSITORY 325 MG 1.00 0250 PHARMACY ACETAMINOPHEN SUPPOSITORY 650 MG 1.20 0250 PHARMACY ACETAMINOPHEN SUS 160MG 5ML 1.00 0250 PHARMACY ACETAZOLAMIDE INJECTION 500MG DIAMOX 63.81 0250 PHARMACY ACETAZOLAMIDE ORAL TABLET 250 MG 6.75 0250 PHARMACY ACETYLCYST SOL 20% 14.70 0250 PHARMACY ACETYLCYSTEINE INHALATION 10 % 1.00 0250 PHARMACY ACTIDOSE AQUA ORAL LIQUID 50 GM 240ML 6.78 0250 PHARMACY ACTIVASE 50MG 6,606.22 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY ACTIVASE INJ 100MG (TPA) (FACTURAR 100 UNIDADES 13,212.43 0250 PHARMACY ACYCLOVIR 400MG TAB 3.00 0250 PHARMACY ACYCLOVIR EXTERNAL OINTMENT 5 % 910.02 0250 PHARMACY ACYCLOVIR INTRAVENOUS 50 MG ML 10.90 0250 PHARMACY ADENOSINE INTRAVENOUS SOLUTION 6 MG 2ML 8.85 0250 PHARMACY AFLURIA INJ PF 15 16 37.50 0250 PHARMACY AGGRASTAT 250ML (FACT 50 UNIDADES X C/U) 1,794.00 0250 PHARMACY AGORAL LIQ MAX ST 7.50 0250 PHARMACY AGUA BACTERIOSTATICA INJECTION 3.30 0250 PHARMACY ALBUMIN HUM INJ 25% 50ML 42.50 0250 PHARMACY ALBUMIN INTRAVENOUS 25 % 25 GM100ML 82.50 0250 PHARMACY ALBUTEROL NEB INHALER SOL 1.25MG 3ML 0.042% 4.23 0250 PHARMACY ALBUTEROL SULF INH NEBULIZ 2.5MG 3ML 0.083% 0.33 0250 PHARMACY ALBUTEROL SYP 2MG 5ML 1.00 0250 PHARMACY ALDACTONE 25 MG 2.00 0250 PHARMACY ALLOPURINOL TAB 100MG 1.50 0250 PHARMACY ALPRAZOLAM .25MG ORAL TAB 1.50 0250 PHARMACY ALPRAZOLAM .5MG ORAL TAB 2.20 0250 PHARMACY ALPRAZOLAM 0.25MG TABLET 1.00 0250 PHARMACY ALPRAZOLAM 0.5MG TABLET 1.00 0250 PHARMACY ALPRAZOLAM 1MG TABLET 3.00 0250 PHARMACY AMIDATE INTRAVENOUS 2 MG ML 20.16 0250 PHARMACY AMIKIN INJECTION 500 MG 2ML 12.57 0250 PHARMACY AMINOPHYLLINE INTRAVENOUS 25 MG ML 30.68 0250 PHARMACY AMIODARONE HCI ORAL TABLET 200 MG 1.05 0250 PHARMACY AMIODARONE INTRAVENOUS 150MG 3ML CORDARONE 5.10 0250 PHARMACY AMIODARONE INTRAVENOUS 450 MG 9ML CORDARON 15.80 0250 PHARMACY AMITRIPTYLINE HCI ORAL TABLET 10 MG 1.00 0250 PHARMACY AMITRIPTYLINE HCI ORAL TABLET 25 MG 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY AMLODIPINE BESYLATE ORAL TABLET 10 MG 1.00 0250 PHARMACY AMLODIPINE BESYLATE ORAL TABLET 2.5 MG 1.00 0250 PHARMACY AMLODIPINE BESYLATE ORAL TABLET 5 MG 1.00 0250 PHARMACY AMMONIA AROM INH 1.50 0250 PHARMACY AMP SULBACT INJ 1.5GM UNASYN 9.00 0250 PHARMACY AMP SULBACT INJ 3 GM UNASYN 24.00 0250 PHARMACY AMPICILLIN ORAL CAPSULE 500MG 1.00 0250 PHARMACY AMPICILLIN 125MG INJECTION 9.00 0250 PHARMACY AMPICILLIN 250 MG INJECTABLE 11.90 0250 PHARMACY AMPICILLIN 250MG ORAL CAPS 0.33 0250 PHARMACY AMPICILLIN INJECTION 1 GM 9.75 0250 PHARMACY AMPICILLIN INJECTION 2 GM 14.70 0250 PHARMACY AMPICILLIN INJECTION 500MG 4.65 0250 PHARMACY AMPICILLIN SODIUM PER 1.5 GM 6.00 0250 PHARMACY ANCEF 1 GM CEFAZOLIN SODIUM INJECTION 5.00 0250 PHARMACY ANECTINE INJECTION 20 MG ML 8.61 0250 PHARMACY ANTIPYRINE BENZOCAINE OTIC SOLUTION 5.4 1.4% 78.26 0250 PHARMACY ANUSOL-HC RECTAL SUPPOSITORY 25 MG 53.19 0250 PHARMACY APETIGEN ORAL ELIXIR 55.50 0250 PHARMACY APETIGEN-PLUS ORAL SOLUTION 61.38 0250 PHARMACY APLISOL INJ 5 0.1ML 195.00 0250 PHARMACY AQUACEL AG PAD 10 X 12 36.00 0250 PHARMACY ARTIFICIAL TEARS OPHTHALMIC 1.4 % 5.40 0250 PHARMACY ASCORBIC ACID INJECTION 500 MG ML 190.50 0250 PHARMACY ASPIR LOW ORAL TABLET 81 MG 1.00 0250 PHARMACY ASPIRIN ORAL TABLET 325MG 1.00 0250 PHARMACY ASPIRIN ORAL TABLET CHEWABLE 81 MG 1.00 0250 PHARMACY ATACAND 32MG TABS ORAL 15.75 0250 PHARMACY ATACAND ORAL TABLET 16 MG 11.70 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY ATENOLOL ORAL TABLET 100 MG 1.00 0250 PHARMACY ATENOLOL ORAL TABLET 25 MG 1.00 0250 PHARMACY ATENOLOL ORAL TABLET 50 MG 1.00 0250 PHARMACY ATORVASTATIN 10MG ORAL TAB 3.05 0250 PHARMACY ATORVASTATIN 20MG ORAL TAB 3.05 0250 PHARMACY ATORVASTATIN 40MG ORAL TAB 9.80 0250 PHARMACY ATRACURIUM BESYLATE INTRAVENOUS 50MG 5ML 21.12 0250 PHARMACY ATRACURIUM INJ 100MG 10ML 21.15 0250 PHARMACY ATROPINA 4 ML 4.00 0250 PHARMACY ATROPINE OPHTHALMIC 1 % 50.94 0250 PHARMACY ATROPINE OPHTHALMIC OINTMENT 1% 50.94 0250 PHARMACY ATROPINE SULFATE INJECTION 1MG ML 17.76 0250 PHARMACY AURALGAN SOL. BOX -- CLAY PARK A/B OTIC DROPS 1.00 0250 PHARMACY AVELOX 400 MG IV (FACTURAR 4 UNIDADES) 15.41 0250 PHARMACY AVIVA DEXTROSE INTRAVENOUS 5% 250 ML 5.93 0250 PHARMACY AVIVA SALINE INTRAVENOUS 0.9% 250 ML 5.93 0250 PHARMACY AYR NASAL SOLUTION 0.65 % 10.50 0250 PHARMACY AYR SALINE NASAL DROPS NASAL SOLUTION 0.65% 10.50 0250 PHARMACY AYR SALINE NASAL SPRAY 10.50 0250 PHARMACY AZITHROMYCIN 250MG TAB 15.00 0250 PHARMACY AZITHROMYCIN 500MG TAB 30.00 0250 PHARMACY AZITHROMYCIN INTRAVENOUS 500 MG 12.25 0250 PHARMACY BACITRACIN INTRAMUSCULAR 50000 UNIT 17.31 0250 PHARMACY BENADRYL ORAL CAPSULE 25 MG 1.00 0250 PHARMACY BENADRYL ORAL LIQUID 12.5 MG 5ML 14.55 0250 PHARMACY BENTYL 10 MG LIQ 5.00 0250 PHARMACY BENTYL DICYCLOMINE HCL 20MG 2ML 41.58 0250 PHARMACY BENZONATATE 200MG ORAL 0.45 0250 PHARMACY BENZONATATE ORAL CAPSULE 100 MG 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY BENZTROPIN INJECTION 1MG ML COGENTIN 134.10 0250 PHARMACY BENZTROPINE MESYLATE ORAL TABLET 1 MG 1.00 0250 PHARMACY BETADINE SOL 10% CLAY PARK POVIDONE IODINE 10% 30.72 0250 PHARMACY BETAMETHASONE SODIUM ACET INJECTION 6 3 3 MG ML 24.65 0250 PHARMACY BETAMETHASONE VALERATE EXTERNAL CREAM 0.1% 29.58 0250 PHARMACY BICARSIM ORAL TABLET 80 MG 1.20 0250 PHARMACY BIO T PRESS PEDIATRIC LIQ 1.00 0250 PHARMACY BIONEL PED ORAL LIQ 15 5 50MG ML 1.00 0250 PHARMACY BIONEL PEDIATRIC ORAL LIQUID 15 5 50 MG 5ML 1.80 0250 PHARMACY BISACODYL RECTAL SUPPOSITORY 10 MG 1.00 0250 PHARMACY BRETHINE INJECTION 1MG ML 5.10 0250 PHARMACY BRILINTA ORAL TABLET 90 MG 14.30 0250 PHARMACY BUDESONIDE INH SUSP 0.25MG 2ML 21.00 0250 PHARMACY BUDESONIDE INH SUSP 0.5MG 2ML 24.00 0250 PHARMACY BUDESONIDE INHALATION 0.5 MG 2ML 24.18 0250 PHARMACY BUMETANIDE ORAL TABLET 0.5 MG 1.70 0250 PHARMACY BUMETANIDE ORAL TABLET 1 MG 1.70 0250 PHARMACY BUMEX INJECTION 0.25 MG ML 6.81 0250 PHARMACY BUTALBITAL ACETAMINPHEN ORAL TABLET 1.80 0250 PHARMACY CALAMINE TOPICAL SUSP 5.70 0250 PHARMACY CALCITONIN NASAL SOLUTION 200 UNIT ACT 132.03 0250 PHARMACY CALCITRIOL ORAL CAPSULE 0.25 MCG 1.86 0250 PHARMACY CALCIUM ACETATE 667MG ORAL TAB 2.30 0250 PHARMACY CALCIUM CHLORIDE INTRAVENOUS 10% 39.00 0250 PHARMACY CALCIUM GLUCONATE INTRAVENOUS 10% 30.70 0250 PHARMACY CALCIUM TABS 600 MG PO 0.35 0250 PHARMACY CANCIDAS INJ 50MG (FACT 10 UNIDADES X C/U) 700.00 0250 PHARMACY CANCIDAS IV 70 MG (FACT 14 UNIDADES X C/U) 1,250.00 0250 PHARMACY CAPTOPRIL 100MG PO TABS 3.50 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY CAPTOPRIL ORAL TABLET 25 MG 3.33 0250 PHARMACY CAPTOPRIL ORAL TABLET 50 MG 5.10 0250 PHARMACY CARBIDOPA LEVODOPA 25 100 PO TAB 1.40 0250 PHARMACY CARBON ACTIVADO 15.00 0250 PHARMACY CARDIZEM 120 MG 3.75 0250 PHARMACY CARDIZEM 30MG 1.25 0250 PHARMACY CARDIZEN 60 MG PO 8.00 0250 PHARMACY CARVEDILOL ORAL TABLET 12.5 MG 1.00 0250 PHARMACY CARVEDILOL ORAL TABLET 25 MG 1.00 0250 PHARMACY CARVEDILOL ORAL TABLET 3.125 MG 1.00 0250 PHARMACY CARVEDILOL ORAL TABLET 6.25 MG 1.00 0250 PHARMACY CEFAZOLIN 1 GM INJ 10 ML ANCEF 5.00 0250 PHARMACY CEFAZOLIN INJECTION 500 MG 17.76 0250 PHARMACY CEFAZOLIN INJECTION 500MG 2.70 0250 PHARMACY CEFAZOLIN SODIUM INJECTION 1GM 4.80 0250 PHARMACY CEFEPIME HCI INJECTION 1 GM 16.53 0250 PHARMACY CEFEPIME HCI INJECTION SOLUTION 2 GM 30.00 0250 PHARMACY CEFOTAXIME INJ 500MG 19.50 0250 PHARMACY CEFOTAXINE SODIUM INJECTION 1 GM CLAFORAN 4.98 0250 PHARMACY CEFTAZIDIME 2MG INJ 12.85 0250 PHARMACY CEFTAZIDIME AND AVIBACTAM 800.00 0250 PHARMACY CEFTAZIDIME INJECTION 1 GM FORTAZ 15.54 0250 PHARMACY CEFTAZIDIME INJECTION 2 GM FORTAZ 38.43 0250 PHARMACY CEFTIAXONE SODIUM INJECTION 500MG 4.50 0250 PHARMACY CEFTRIAXONE 250MG INJ 3.00 0250 PHARMACY CEFTRIAXONE INJECTION 1 GM ROCEPHIN 5.61 0250 PHARMACY CEFTRIAXONE INJECTION 2 GM ROCEPHIN 12.60 0250 PHARMACY CEFTRIAXONE INJECTION 500 MG 4.50 0250 PHARMACY CELESTONE SOLUSPAN INJ 25.45 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY CEPHULAC SOLUTION ENULOSE LACTULOSE SYRUP 3.14 0250 PHARMACY CETAPHIL LOT CLEANSER 10.50 0250 PHARMACY CETIRIZINE 10MG TAB 3.80 0250 PHARMACY CHLORDIAZEPOXIDE 10MG CAPSULE 1.00 0250 PHARMACY CHLORPROMAZINE HCL INJECTION 25MG ML 50.28 0250 PHARMACY CHOLESTIRAMINE POW 4GM LITE 7.50 0250 PHARMACY CIPROFLOXACIN 750MG TABS PO 14.30 0250 PHARMACY CIPROFLOXACIN HCI ORAL TABLET 500 MG 1.26 0250 PHARMACY CIPROFLOXACIN IN D5W INTRAVENOUS 200MG 100ML 6.00 0250 PHARMACY CIPROFLOXACIN IN D5W INTRAVENOUS 400MG 200ML 12.00 0250 PHARMACY CITALOPRAM HYDROBROMIDE ORAL TABLET 20 MG 1.00 0250 PHARMACY CLARITIN D 5 120MG TABS PO 3.00 0250 PHARMACY CLARITIN D 24 HOUR ORAL TABLET 10 240 MG 3.51 0250 PHARMACY CLARITIN ORAL TABLET CHEWABLE 5 MG 5.84 0250 PHARMACY CLARITIN RD 10MG ORAL TAB 1.50 0250 PHARMACY CLARITIN RD 10MG TABS PO 1.50 0250 PHARMACY CLEOCIN 600 MG 15.00 0250 PHARMACY CLEOCIN INJECTION 300 MG 2ML 11.31 0250 PHARMACY CLEOCIN INJECTION 600 MG 4ML 10.50 0250 PHARMACY CLEOCIN INJECTION 900MG 6ML 13.95 0250 PHARMACY CLINDAMYCIN 75MG 5ML ORAL SUSP 59.00 0250 PHARMACY CLINIMIX 2.75-D5W (FACT 2 UNIT) 1000ML 114.00 0250 PHARMACY CLINIMIX 4.25-D10W (FACT 2 UNIT) 1000ML 114.00 0250 PHARMACY CLINIMIX 4.25-D5W (FACT 2 UNIT) 1000ML 113.40 0250 PHARMACY CLINIMIX E 2.75-5% (FACT 2 UNIT) 1000ML 168.00 0250 PHARMACY CLINIMIX E 2.75-D10W (FACT 2 UNIT) 1000ML 114.00 0250 PHARMACY CLINIMIX E 4.25-D10W (FACT 2 UNIT) 1000ML 142.50 0250 PHARMACY CLINIMIX E 4.25-D25W (FACT 2 UNIT) 1000ML 114.00 0250 PHARMACY CLINIMIX E 4.25-D5W (FACT 2 UNIT) 1000ML 113.50 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY CLINIMIX E 5% D25W (FACT 4 UNIT) 2000ML 225.00 0250 PHARMACY CLONAZEPAM TAB 0.5MG 0.33 0250 PHARMACY CLONIDINE HCI ORAL TABLET 0.1 MG 1.00 0250 PHARMACY CLONIDINE HCI ORAL TABLET 0.2 MG 1.00 0250 PHARMACY CLONIDINE HCI ORAL TABLET 0.3 MG 1.00 0250 PHARMACY CLOPIDOGREL ORAL TABLET 75 MG 1.00 0250 PHARMACY CLORURO DE POTASIO 4.00 0250 PHARMACY CLOTRIMAZOLE ANTI-FUNGAL EXTERNAL CREAM 1% 6.93 0250 PHARMACY CLOTRIMAZOLE LOZ 10MG PO TABS 3.00 0250 PHARMACY CLOTRIMAZOLE MOUTH THROAT LOZENGE 10 MG 4.13 0250 PHARMACY CLOTRIMAZOLE VAGINAL CREAM 1% 8.85 0250 PHARMACY COLACE 100MG CAP 0.35 0250 PHARMACY COLACE ORAL CAPSULE 100 MG 1.00 0250 PHARMACY COLYTE SOL PACKS 84.00 0250 PHARMACY COUMADIN 2.5 3.75 0250 PHARMACY COUMADIN 3MG 3.75 0250 PHARMACY COUMADIN 4MG 2.50 0250 PHARMACY COUMADIN 5MG 4.00 0250 PHARMACY CROMOLIN SODIUM INH NEB SOLUTION 20MG 2ML 1.00 0250 PHARMACY CYANOCOBOLAMINE INJ 1000MCG 7.50 0250 PHARMACY CYCLOBENZAPRINE HCI ORAL TABLET 10 MG 1.00 0250 PHARMACY CYCLOPENTOLATE HCI OPHTHALMIC 1 % 70.74 0250 PHARMACY CYTRA K ORAL SOLUTION 1100 334 MG 5ML 1.68 0250 PHARMACY DECADRON INJECTION 20MG 5ML 2.70 0250 PHARMACY DECADRON INJECTION 4 MG DEXAMETHASONE 4 MG 2.64 0250 PHARMACY DEMECLOCYCLINE HCI ORAL TABLET 300 MG 34.44 0250 PHARMACY DEMEROL 25 MG IV 10.00 0250 PHARMACY DEMEROL 75 MG MEPERIDINE 1.00 0250 PHARMACY DEMEROL INJECTION 50MG ML 9.60 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY DEMEROL INYECTABLE 25MG 0.5ML 10.50 0250 PHARMACY DEPO MEDROL INJECTION 80 MG ML 51.45 0250 PHARMACY DEPO PROVERA INTRAMUSCULAR 150MG ML 524.46 0250 PHARMACY DEXAMETHASONE INJECTION 4 MG ML 24.42 0250 PHARMACY DEXAMETHASONE ORAL SOLUTION 0.5 MG 5ML 7.95 0250 PHARMACY DEXAMETHASONE PHOSP INJ 10MG ML 4.50 0250 PHARMACY DEXAMETHASONE PHOSP INJ 120MG 30ML 18.90 0250 PHARMACY DEXTROSE 5% SALINE .45% INTRAVENOUS 1000 ML 4.88 0250 PHARMACY DEXTROSE 5% SALINE 0.9% INTRAVENOUS 1000 ML 4.71 0250 PHARMACY DEXTROSE INTRAVENOUS 10 % 500 ML 4.50 0250 PHARMACY DEXTROSE INTRAVENOUS 5% 1000 ML 14.40 0250 PHARMACY DEXTROSE INTRAVENOUS 5% 500ML 3.95 0250 PHARMACY DEXTROSE INTRAVENOUS 50 % 20.37 0250 PHARMACY DIAZEPAM 5MG ML INJECTION X 10ML 6.60 0250 PHARMACY DIAZEPAM 5MG TABLET 1.00 0250 PHARMACY DICYCLOMINE HCI ORAL CAPSULE 10 MG 1.00 0250 PHARMACY DICYCLOMINE HCI ORAL SOLUTION 10 MG 5ML 26.25 0250 PHARMACY DICYCLOMINE HCI ORAL TABLET 20 MG 1.00 0250 PHARMACY DIGOXIN 100MCG ML 4.00 0250 PHARMACY DIGOXIN 250 MCG ORAL TAB 2.61 0250 PHARMACY DIGOXIN INJECTION 0.25 MG ML 18.42 0250 PHARMACY DIGOXIN INJECTION 0.25% ML 14.40 0250 PHARMACY DIGOXIN INJECTION 500MCG/2ML 217.00 0250 PHARMACY DILANTIN CAP 100MG 1.50 0250 PHARMACY DILANTIN ORAL SUSPENSION 125 MG 5ML 32.40 0250 PHARMACY DILTIAZEM 25MG 5ML INJ 6.80 0250 PHARMACY DILTIAZEM CD 180MG CAP 0.50 0250 PHARMACY DILTIAZEM HCI ER ORAL CAPSULE 120 MG 1.20 0250 PHARMACY DILTIAZEM HCI ER ORAL CAPSULE 24 HOUR 300 MG 1.20 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY DILTIAZEM HCI ER ORAL CAPSULE 240 MG 1.80 0250 PHARMACY DILTIAZEM HCI INTRAVENOUS 125MG 25ML 15.66 0250 PHARMACY DILTIAZEM HCI INTRAVENOUS 50MG 10ML 11.16 0250 PHARMACY DILTIAZEM HCI ORAL TABLET 120 MG 1.20 0250 PHARMACY DILTIAZEM HCI ORAL TABLET 30 MG 1.00 0250 PHARMACY DILTIAZEM HCI ORAL TABLET 60 MG 1.00 0250 PHARMACY DILTIAZEM HCI ORAL TABLET 90 MG 1.00 0250 PHARMACY DIPHENHYDRAMINE 50MG ORAL CAP 0.80 0250 PHARMACY DIPHENOXYLATE ATROPINE 2.5MG .025MG TABLET 1.00 0250 PHARMACY DIPYRIDAMOLE ORAL TABLET 25 MG 1.00 0250 PHARMACY DIVALPROEX ORAL TABLET 250 MG 1.00 0250 PHARMACY DIVALPROEX ORAL TABLET 500 MG 1.00 0250 PHARMACY DOBUTAMINE INTRAVENOUS 250MG 20ML 14.31 0250 PHARMACY DOPAMINE INTRAVENOUS SOLUTION 400MG 250ML 42.00 0250 PHARMACY DOXAZOSIN MESYLATE ORAL TABLET 1 MG 1.80 0250 PHARMACY DOXAZOSIN MESYLATE ORAL TABLET 2 MG 2.10 0250 PHARMACY DOXAZOSIN MESYLATE ORAL TABLET 4 MG 2.40 0250 PHARMACY DOXAZOSIN MESYLATE ORAL TABLET 8 MG 2.25 0250 PHARMACY DOXY INTRAVENOUS 100 MG 40.50 0250 PHARMACY DOXYCYCLINE 100MG ORAL CAP 1.02 0250 PHARMACY DOXYXYCLINE 100MG ORAL TAB 1.03 0250 PHARMACY DULCOLAX EC ORAL TABLET DELAYED RELEASE 5 MG 1.00 0250 PHARMACY DYPHENHYDRAMINE 50 MG ML BENADRYL 50MG ML 3.42 0250 PHARMACY ELIQUIS 5MG ORAL TAB 13.25 0250 PHARMACY ELIQUIS ORAL TABLET 2.5 MG 7.81 0250 PHARMACY ENALAPRIL 10 25MG TAB VASERETIC 1.00 0250 PHARMACY ENALAPRIL 10MG ORAL TAB 3.75 0250 PHARMACY ENALAPRIL 2.5MG ORAL TAB 1.50 0250 PHARMACY ENALAPRIL 20MG ORAL TAB 4.50 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY ENALAPRIL 5MG ORAL TAB 1.00 0250 PHARMACY ENALAPRILAT INTRAVENOUS INJECTABLE 1.25 MG ML 12.15 0250 PHARMACY ENALAPRILAT INTRAVENOUS INJECTABLE 1.25MG ML 5.46 0250 PHARMACY ENOXAPARIN SUBCUTANEOUS 30MG 0.3ML 74.43 0250 PHARMACY ENOXAPARIN SUBCUTANEOUS 40MG 0.4ML 99.24 0250 PHARMACY ENOXAPARIN SUBCUTANEOUS 60MG 0.6ML 149.04 0250 PHARMACY EPHEDRINE INJECTION 50 MG ML 102.27 0250 PHARMACY EPINEPHRINE 1MG ML INJ 12.00 0250 PHARMACY EPINEPHRINE HCI INJECTION 0.1 MGML 12.00 0250 PHARMACY EPINEPHRINE HCI INJECTION 1MG ML 12.00 0250 PHARMACY ERYTHROMYCIN OPHTHALMIC OINTMENT 5 MG GM 7.11 0250 PHARMACY ERYTHROMYCIN PH OINT .50% 3.10 0250 PHARMACY EYE IRRIGATING OPHTHALMIC SOLUTION 4.35 0250 PHARMACY FAMOTIDINE INTRAVENOUS 20 MG 2ML 2.07 0250 PHARMACY FAMOTIDINE INTRAVENOUS 200 MG 20ML 23.13 0250 PHARMACY FAMOTIDINE ORAL TABLET 20 MG 1.00 0250 PHARMACY FAMOTIDINE ORAL TABLET 40 MG 1.00 0250 PHARMACY FENTANYL 0.0 5MG ML INJECTION 1.00 0250 PHARMACY FERRLECIT INTRAVENOUS 12.5MG ML 115.17 0250 PHARMACY FERROUS SULFATE ORAL ELIXIR 220 44 FE MG 5ML 9.06 0250 PHARMACY FERROUS SULFATE ORAL SOLTION 75 15 FE MG ML 7.02 0250 PHARMACY FERROUS SULFATE ORAL TABLET 325 65 FE MG 1.00 0250 PHARMACY FINASTERIDE ORAL TABLET 5 MG 1.50 0250 PHARMACY FLAGYL 500 MG 4.00 0250 PHARMACY FLECAINIDE ACETATE ORAL TABLET 100 MG 2.68 0250 PHARMACY FLEET ENEMA ADULTO 5.00 0250 PHARMACY FLEET ENEMA PED 6.00 0250 PHARMACY FLUCONAZOLE 200MG 100ML INTRAVENOUS 22.50 0250 PHARMACY FLUCONAZOLE INTRAVENOUS 200 0.9 MG 100ML % 7.29 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY FLUCONAZOLE ORAL SUSPENSION 40 MG ML 606.72 0250 PHARMACY FLUCONAZOLE ORAL TABLET 100 MG 3.51 0250 PHARMACY FLUCONAZOLE ORAL TABLET 150 MG 10.75 0250 PHARMACY FLUCONAZOLE ORAL TABLET 50 MG 2.10 0250 PHARMACY FLUMAZENIL INTRAVENOUS SOLUTION 1MG 10ML ROMAZICON 42.51 0250 PHARMACY FLUMAZENIL ROMAZICON 30.00 0250 PHARMACY FLUOXETINE 10MG CAP 1.00 0250 PHARMACY FLUOXETINE HCI ORAL CAPSULE 20 MG 1.00 0250 PHARMACY FLUTICASONE PROPIONATE NASAL SUSPENSION 50MCG ACT 14.19 0250 PHARMACY FOLIC ACID 1MG TABS 1.00 0250 PHARMACY FORANE INHALATION SOLUTION 36.21 0250 PHARMACY FUROSEMIDE ORAL SOLUTION 10 MG ML 9.81 0250 PHARMACY FUROSEMIDE ORAL TABLET 20MG 0.44 0250 PHARMACY FUROSEMIDE ORAL TABLET 40 MG 1.00 0250 PHARMACY G PREPROTEIN 20 0.20 0250 PHARMACY GABAPENTIN ORAL CAPSULE 100 MG 1.00 0250 PHARMACY GABAPENTIN ORAL CAPSULE 300 MG 1.00 0250 PHARMACY GABAPENTIN ORAL CAPSULE 400 MG 1.00 0250 PHARMACY GABAPENTIN ORAL TABLET 600 MG 1.20 0250 PHARMACY GABAPENTIN ORAL TABLET 800 MG 1.50 0250 PHARMACY GARAMYCIN INJECTION SOLUTION 10 MG ML 5.80 0250 PHARMACY GARAMYCIN INJECTION SOLUTION 40 MG ML 1.90 0250 PHARMACY GEMFIBROZIL ORAL TABLET 600 MG 1.00 0250 PHARMACY GENTAK OPHTHALMIC OINTMENT 0.3% 30.84 0250 PHARMACY GENTAMICIN CREAM 0.1% 6.50 0250 PHARMACY GENTAMICIN OPHTHALMIC 0.3% 34.50 0250 PHARMACY GENTAMICIN SULFATE EXTERNAL OINRMENT 0.1 % 65.15 0250 PHARMACY GLICERIN SUPP. PEDIATRIC 1.05 0250 PHARMACY GLIMEPIRIDE ORAL TABLET 4 MG 1.32 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY GLIMEPIRIDE TABLET 1MG 1.00 0250 PHARMACY GLIPIZIDE ORAL TABLET 10 MG 1.00 0250 PHARMACY GLIPIZIDE ORAL TABLET 5 MG 1.00 0250 PHARMACY GLIPIZIDE XL 5MG TAB 1.05 0250 PHARMACY GLIPIZIDE XL ORAL TABLET 10 MG 1.00 0250 PHARMACY GLUCAGON KIT 675.00 0250 PHARMACY GLYCERIN ADULT RECTAL SUPPOSITORY 2.1 GM 1.05 0250 PHARMACY GUAIFED ORAL SYRUP 100MG 5ML 1.00 0250 PHARMACY GUAIFENESIN C NR ORAL LIQUID 100 10 MG 5ML 1.00 0250 PHARMACY GUAIFENESIN DM NR ORAL LIQUID 100 10 MG 5ML 1.00 0250 PHARMACY GUAIFENESIN NR ORAL LIQUID 100 MG 5ML 1.00 0250 PHARMACY HALOPERIDOL DECANOATE INTRAMUSCULAR SOL 50MG ML 61.00 0250 PHARMACY HALOPERIDOL INJECTION 5 MG ML HALDOL 2.40 0250 PHARMACY HALOPERIDOL ORAL TABLET 0.5 MG 1.00 0250 PHARMACY HALOPERIDOL ORAL TABLET 1 MG 1.05 0250 PHARMACY HALOPERIDOL ORAL TABLET 5 MG 2.70 0250 PHARMACY HEPARINE INJECTION 1000 UNIT ML 2.69 0250 PHARMACY HEPARINE INJECTION 5000 UNIT ML 3.93 0250 PHARMACY HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM 70.00 0250 PHARMACY HIBICLENS 6.80 0250 PHARMACY HIBICLENS LIQ 4% 25.25 0250 PHARMACY HIDROCORTIZONA CREMA TUBO 3.03 0250 PHARMACY HUMALOG MIX 50 50 PEN INJECTOR 100UNIT ML 1.00 0250 PHARMACY HUMALOG SUBCUTANEOUS 100 UNIT ML 1.00 0250 PHARMACY HUMULIN 70 30 SUBCUTANEOUS 70 30 100 UNIT ML 1.00 0250 PHARMACY HUMULIN N SUBCUTANEOUS 100 UNIT ML 1.00 0250 PHARMACY HUMULIN R INJECTION 100 UNIT ML 1.00 0250 PHARMACY HUMULIN REGULAR 100 UNITS ML 0.30 0250 PHARMACY HYDRALAZINE HCI ORAL TABLET 10 MG 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY HYDRALAZINE HCI ORAL TABLET 25 MG 1.44 0250 PHARMACY HYDRALAZINE HCI ORAL TABLET 50 MG 1.53 0250 PHARMACY HYDRALAZINE HCL INJECTION20MG ML 6.70 0250 PHARMACY HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG 1.00 0250 PHARMACY HYDROCORT CREAM 0.5% 3.75 0250 PHARMACY HYDROCORTISONE EXTERNAL CREAM 1 % 2.13 0250 PHARMACY HYDROXYZ PA CAP 25MG 1.00 0250 PHARMACY HYDROXYZ PA CAP 50MG 1.00 0250 PHARMACY HYOSCYAMINE TABLET 0.125 MG 1.00 0250 PHARMACY HYPRTONIC DEXTROSE INTRAVENOUS 50 % 6.63 0250 PHARMACY IBUPROFEN ORAL 100MG 5ML 1.98 0250 PHARMACY IBUPROFEN ORAL TABLET 400 MG 1.00 0250 PHARMACY IBUPROFEN ORAL TABLET 800 MG 1.00 0250 PHARMACY IMODIUM LIQUIDO 2.00 0250 PHARMACY INDAPAMIDE ORAL TABLET 1.25 MG 1.00 0250 PHARMACY INDERAL HCI INTRAVENOUS 1MG ML 11.70 0250 PHARMACY INDOMETHACIN ORAL CAPSULE 50 MG 1.00 0250 PHARMACY INFANTS GAS RELIEF ORAL SUSPENSION 40 MG 0.6ML 4.90 0250 PHARMACY INFUVITE INTRAVENOUS INJECTABLE ADULT 35.31 0250 PHARMACY INSULINA REGULAR 1.00 0250 PHARMACY INTEGRILIN INTRAVENOUS 0.75 MG ML 932.00 0250 PHARMACY INTEGRILIN INTRAVENOUS 20 MG ML 170.76 0250 PHARMACY INTESTINEX ORAL CAPSULE 600 MG 1.00 0250 PHARMACY INTRALIPID INTRAVENOUS EMULSION 20 % 57.63 0250 PHARMACY INVANZ INJ 1GM 270.00 0250 PHARMACY IPRATROPIUM ALBUTEROL INH SOL 0.5-2.5 3MG 3ML 1.00 0250 PHARMACY IPRATROPIUM ALBUTEROL INHALATION 0.5 2.5 3 MG 3ML 5.85 0250 PHARMACY IPRATROPIUM BROMIDE INHALATION 0.02 % 1.00 0250 PHARMACY IRBESARTAN 75MG ORAL TAB 7.50 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY IRBESARTAN ORAL TABLET 150 MG 1.68 0250 PHARMACY IRBESARTAN ORAL TABLET 300 MG 2.37 0250 PHARMACY ISOFLURANE INHALATION SOLUTION 36.90 0250 PHARMACY ISONIAZID ORAL TABLET 300 MG 1.26 0250 PHARMACY ISOPROPYL ALCOHOL SOLUTION 70% X 16OZ 4.50 0250 PHARMACY ISOSORBIDE DIN 10MG TAB 3.00 0250 PHARMACY ISOSORBIDE DINITRATE ORAL TABLET 20 MG 1.00 0250 PHARMACY ISOSORBIDE DINITRATE ORAL TABLET 30 MG 3.95 0250 PHARMACY ISOSORBIDE MONONITRATE ER ORAL TABLET 30 MG IMDUR 1.00 0250 PHARMACY ISOSORBIDE MONONITRATE ER ORAL TABLET 60 MG 12.20 0250 PHARMACY ISOSORBIDE MONONITRATE ORAL TABLET 10 MG 3.00 0250 PHARMACY KALETRA ORAL TABLET 200 50 MG 21.57 0250 PHARMACY KALTOSTAT PAD 12 X 24 66.00 0250 PHARMACY KAOPECTATE 12.18 0250 PHARMACY KAOPETATE SUSP. --- KAOPECTOLIN NF SUSP 2.90 0250 PHARMACY KCL INTRAVENOUS 2 MEQ/ML X 10ML 9.68 0250 PHARMACY KCL INTRAVENOUS SOLUTION 2MEQ ML X 20ML 13.14 0250 PHARMACY KENALOG 40 INJ 40MG ML TRIAMCINOLONE 45.00 0250 PHARMACY KETAMINE HCL 50MG ML INJECTION X 10ML 1.26 0250 PHARMACY KETOROLAC INJ 15MG ML 2.00 0250 PHARMACY KETOROLAC ORAL TALBET 10 MG 1.00 0250 PHARMACY KIONEX ORAL 15 GM 60ML 22.26 0250 PHARMACY LABETALOL 300MG ORAL TAB 1.00 0250 PHARMACY LABETALOL HCI ORAL TABLET 100 MG 1.14 0250 PHARMACY LABETALOL HCI ORAL TABLET 200 MG 1.62 0250 PHARMACY LACTATED RINGER INTRAVENOUS 1000 ML 4.77 0250 PHARMACY LACTATED RINGER INTRAVENOUS 500 ML 4.06 0250 PHARMACY LACTULOSE SOL 10GM 15ML 0.50 0250 PHARMACY LAMIVUDINE ZIDOVUDINE ORAL TABLET 150 300 MG 45.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY LANOXIN ORAL TABLET 125 MCG 2.19 0250 PHARMACY LANTUSS SUBCUTANEOUS SOLUTION 100 UNIT ML 0.20 0250 PHARMACY LASIX 20 MG 1.00 0250 PHARMACY LASIX INJ 40 MG 4ML 8.43 0250 PHARMACY LASIX INJECTION10MG ML X 2ML 2.71 0250 PHARMACY LEVALBUTEROL HCL 0.65MG 3ML 6.45 0250 PHARMACY LEVALBUTEROL INH NEB SOL 1.25MG 3ML 6.48 0250 PHARMACY LEVALBUTEROL INHALATION NEBULIZATION 0.63MG 3ML 5.22 0250 PHARMACY LEVETIRACETAM 1000MG TAB 0.50 0250 PHARMACY LEVOFLOXACIN IN D5W INTRAVENOUS 500MG 100ML 98.97 0250 PHARMACY LEVOFLOXACION INTRAVENOUS 500MG 100ML 11.25 0250 PHARMACY LEVOFLOXACION INTRAVENOUS 750MG 150ML 12.70 0250 PHARMACY LEVOPHED 1MG ML INJ 52.65 0250 PHARMACY LEVOTHYROXIN 137 MCG TAB 0.33 0250 PHARMACY LEVOTHYROXINE 50 MCG TAB 1.00 0250 PHARMACY LEVOTHYROXINE SODIUM ORAL TABLET 175 MCG 3.42 0250 PHARMACY LIDO EPI 1%INJ 1 100000 2.50 0250 PHARMACY LIDOCAINA CREMA TUBO 14.77 0250 PHARMACY LIDOCAINE HCI INJECTION 1% 7.71 0250 PHARMACY LIDOCAINE HCI INJECTION 2% 10.74 0250 PHARMACY LIDOCAINE HCI INJECTION 2% 20 MG ML 4.26 0250 PHARMACY LIDOCAINE HCI INTRAVENOUS 20 MG ML 5.79 0250 PHARMACY LIDOCAINE HCI PF0 INJECTION SOLUTION 1 % 27.75 0250 PHARMACY LIDOCAINE JELLY 2% 17.50 0250 PHARMACY LIDOCAINE SOL 4% 5.00 0250 PHARMACY LIDOCAINE VISCOUS MOUTH THROAT SOLUTION 2% 35.85 0250 PHARMACY LINEZOLID IV SOLUTION 600MG 300ML 118.39 0250 PHARMACY LISINOPRIL HCTZ 10 12.5MG TAB ZESTORETIC 10.80 0250 PHARMACY LISINOPRIL 10MG TAB 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY LISINOPRIL 20MG TAB 1.00 0250 PHARMACY LISINOPRIL 40MG TAB 3.00 0250 PHARMACY LISINOPRIL 5MG TAB 1.00 0250 PHARMACY LITHIUM ORAL CAPSULE 300 MG 1.00 0250 PHARMACY LOPERAMIDE HCI ORAL CAPSULE 2 MG 1.20 0250 PHARMACY LOPERAMIDE HCI ORAL LIQUID 1 MG 5ML 4.23 0250 PHARMACY LOPERAMIDE SUS 1 MG 7.5 0.75 0250 PHARMACY LOPRESSOR INJECTABLE 1MG 1ML METOPROLOL 14.16 0250 PHARMACY LORATADINE ORAL SYRUP 5 MG 5ML CHILDREN 3.30 0250 PHARMACY LORAZEPAM 1 MG ORAL TABS ATIVAN 2.75 0250 PHARMACY LORAZEPAM 1MG TABLET 1.00 0250 PHARMACY LORAZEPAM 2 MG INJ ATIVAN 2.83 0250 PHARMACY LORAZEPAM 2MG ML INJECTION 1.80 0250 PHARMACY LOSARTAN HCTZ 100 12.5MG ORAL TAB HYZAAR 4.50 0250 PHARMACY LOSARTAN HCTZ ORAL TABLET 100 25 MG 1.00 0250 PHARMACY LOSARTAN HCTZ ORAL TABLET 50 12.5 MG 1.00 0250 PHARMACY LOSARTAN ORAL TABLET 100 MG 1.00 0250 PHARMACY LOSARTAN ORAL TABLET 25 MG 1.00 0250 PHARMACY LOSARTAN ORAL TABLET 50 MG 1.00 0250 PHARMACY LOTRISONE CREAM 187.50 0250 PHARMACY LOVENOX 50 MG 129.25 0250 PHARMACY LOVENOX SUBCUTANEOUS 100MG ML 248.40 0250 PHARMACY LOVENOX SUBCUTANEOUS 80MG 0.8ML 198.72 0250 PHARMACY LUBRIDERM LOT EXT 15.00 0250 PHARMACY LYSIPLEX LIQ PLUS 21.00 0250 PHARMACY MAALOX ORAL SUSPENSION 200 200 20 MG 5ML 1.00 0250 PHARMACY MAALOX PLUS ALAMAG PLUS ANTACID SUSP 4.78 0250 PHARMACY MAGNESIUM SULFATE INJECTION 4GM/100ML 3.84 0250 PHARMACY MAGNESIUM SULFATE INJECTION 50 % 4.52 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY MANITOL 25% 12.5GM 50ML 4.71 0250 PHARMACY MARCAINE INJECTION SOLUTION 0.5 % 13.26 0250 PHARMACY MASTISOL 56.00 0250 PHARMACY MAXIMUM D 3 ORAL CAPSULE 10000 UNIT 1.00 0250 PHARMACY MECLIZINE HCI ORAL TABLET 12.5 MG 1.00 0250 PHARMACY MECLIZINE HCI ORAL TABLET 25 MG 1.16 0250 PHARMACY MEGESTROL ACETATE ORAL SUSPENSION 40 MG ML 5.43 0250 PHARMACY METFORMIN HCI ORAL TABLET 1000 MG 1.00 0250 PHARMACY METFORMIN HCI ORAL TABLET 500 MG 1.00 0250 PHARMACY METFORMIN HCI ORAL TABLET 850 MG 1.00 0250 PHARMACY METHILDOPA ORAL TABLET 500 MG 1.00 0250 PHARMACY METHYLDOPA 250MG ORAL TAB 1.05 0250 PHARMACY METHYLDOPA ORAL TABLET 500 MG 1.00 0250 PHARMACY METHYLENEBLUE INJECTION 1 % 165.57 0250 PHARMACY METHYLERGONOVINE INJECTION 0.2 MG ML 17.70 0250 PHARMACY METHYLPREDNISOLON SODIUM SUCC INJECTION 125 MG 16.42 0250 PHARMACY METHYLPREDNISOLONE SODIUM SUCC INJETION 40 MG 4.04 0250 PHARMACY METOCLOPRAM TAB 10MG 1.00 0250 PHARMACY METOCLOPRAMIDE HCI INJECTION SOLUTION 5 MG ML 3.69 0250 PHARMACY METOLAZONE 2.5MG TAB 1.50 0250 PHARMACY METOPROLOL ORAL TABLET 50 MG 1.00 0250 PHARMACY METRONIDAZOLE IN NACI INTRAVENOUS 5 0.79MG ML % 4.80 0250 PHARMACY METRONIDAZOLE ORAL TABLET 500 MG 1.35 0250 PHARMACY METROPROLOL ORAL TABLET 100 MG 1.00 0250 PHARMACY METROPROLOL ORAL TABLET 25 MG 1.00 0250 PHARMACY MIACALCIN INJECTIO 200 UNIT ML 203.97 0250 PHARMACY MIDAZOLAM 10MG 10ML INJECTION 1.00 0250 PHARMACY MIDAZOLAM 5MG ML INJECTION VERSED 1.00 0250 PHARMACY MIDAZOLAM HCL ORAL SYRUP 2MG ML X 120ML 7.85 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY MILK OF MAG EX LAX MINT 2.30 0250 PHARMACY MILK OF MAGNESIA 5.61 0250 PHARMACY MILK OF MAGNESIA SUS 400 5ML 1.00 0250 PHARMACY MINERAL OIL HEAVY ORAL OIL 1.02 0250 PHARMACY MINOXIDIL ORAL TABLET 10 MG 1.00 0250 PHARMACY MINOXIDIL ORAL TABLET 2.5 MG 1.00 0250 PHARMACY MIOSTAT INTRAOCULAR SOLUTION 0.01% 121.98 0250 PHARMACY MISOPROSTOL 100MCG PO TABS 1.50 0250 PHARMACY MONTELUKAST ORAL TABLET 10 MG 1.00 0250 PHARMACY MORPHINE SU INJ 4MG ML 2.88 0250 PHARMACY MORPHINE SU INJ 5MG ML 1.80 0250 PHARMACY MORPHINE SULFATE 2MG ML INJECTABLE 6.00 0250 PHARMACY MORPHINE SULFATE 8MG ML 4.50 0250 PHARMACY MOTRIN 600 MG TAB IBUPROFEN 600 MG TAB 1.00 0250 PHARMACY MOXIFLOXIN TAB 400MG 1.64 0250 PHARMACY MUCINEX DM ORAL TABLET 30 600 MG 1.89 0250 PHARMACY MUCINEX MAX STRENGTH ORAL TABLET 1200 MG 1.89 0250 PHARMACY MUCINEX ORAL TABLET 600 MG 2.25 0250 PHARMACY MULTIVIT PEDIATRIC INTRAVENOUS INJECTABLE 39.00 0250 PHARMACY MULTIVITAMIN TAB 0.33 0250 PHARMACY MUPIROCIN EXTERNAL OINTMENT 2 % 14.88 0250 PHARMACY MY WAY ORAL TABLET 1.5 MG 73.29 0250 PHARMACY NAPROXEN ORAL TABLET 500 MG 1.00 0250 PHARMACY NAPROXEN SO TAB 550 MG 1.00 0250 PHARMACY NARCAN INJECTION 4 MG ML NALOXONE HCL 4MG ML 50.25 0250 PHARMACY NEOMYCIN POLYMYXIN HC OTIC SOLUTION 3.5 10000 1 133.16 0250 PHARMACY NEOSPORIN OINTMENT TRIPLE ANTIBIOTICO 9.06 0250 PHARMACY NEOSTIGMINE METHYLSUFATE INTRAVENOUS 5 MG 10ML 284.91 0250 PHARMACY NEOSTIGMINE METHYLSULFATE 1MG ML 25.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY NEOSTIGMINE METHYLSULFATE INJ SOL 0.5MG ML 217.95 0250 PHARMACY NEUPOGEN INJECTION 300MCG ML 9.18 0250 PHARMACY NEVIRAPINE ORAL TABLET 200MG 3.33 0250 PHARMACY NICODERM CQ TRANSDEMAL PATCH 24 HOUR 14 MG 24HR 9.00 0250 PHARMACY NIFEDIPINE 60MG ER TAB 1.50 0250 PHARMACY NIFEDIPINE ER ORAL TABLET 30 MG 1.00 0250 PHARMACY NIFEDIPINE ORAL CAPSULE 10 MG 1.83 0250 PHARMACY NIMBEX INJ 2MG ML 35.00 0250 PHARMACY NIMBEX INTRAVENOUS 20 MG 10 ML 46.98 0250 PHARMACY NITROGLYCERIN 50MG 250ML 20.00 0250 PHARMACY NITROGLYCERIN INTRAVENOUS 200 5 MCG ML % 18.38 0250 PHARMACY NITROGLYCERIN TRANSDEMAL PATCH 0.2MG HR 1.38 0250 PHARMACY NITROGLYCERIN TRANSDEMAL PATCH 0.4 MG HR 2.40 0250 PHARMACY NITROSTAT TABLET 0.4 MG 1.80 0250 PHARMACY NORMAL SALINE 0.9% AMPOLLETA 3ML 1.00 0250 PHARMACY NORMAL SALINE 3% AMP 3ML 1.60 0250 PHARMACY NORMAL SALINE 6% AMP 3ML 1.40 0250 PHARMACY NORMODYNE HCI INTRAVENOUS 5 MG ML 9.75 0250 PHARMACY NUBAIN 10 MG 2.50 0250 PHARMACY NYSTATIN EXTERNAL CREAM 15 GM 14.25 0250 PHARMACY NYSTATIN EXTERNAL CREAM 30GM 21.75 0250 PHARMACY NYSTATIN MOUTH THROAT 100000UNIT ML 3.66 0250 PHARMACY OCTREOTIDE INJECTION 100 MCG ML 91.68 0250 PHARMACY OCTREOTIDE INJECTION 50 MCG ML 5.28 0250 PHARMACY OCTREOTIDE INJECTION 500MCG ML 407.64 0250 PHARMACY OFLOXACIN OPHTHALMIC 0.3 % 23.85 0250 PHARMACY OFLOXACION OTIC SOLUTION 0.3% 224.25 0250 PHARMACY OLANZAPINE 10MG TAB 30.00 0250 PHARMACY OLANZAPINE 2.5MG TAB 15.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY OLANZAPINE 5MG TAB 7.00 0250 PHARMACY ONDANSETRON HCI INJECTION 4MG 2ML 3.00 0250 PHARMACY ONDANSETRON ZOFRAN MULT DOSE 2.03 0250 PHARMACY ORA SWEET ORAL SYRUP 3.06 0250 PHARMACY ORAL PLUS ORAL LIQUID 3.06 0250 PHARMACY ORPHENADRINE CITRATE ER ORAL TABLET 100 MG 1.00 0250 PHARMACY ORPHENADRINE INJ 30MG ML 4.50 0250 PHARMACY OSMITROL INTRAVENOUS 20 % 50.85 0250 PHARMACY OXYCODONE ACETAMINOPHEN ORAL TABLET 5 325MG 1.00 0250 PHARMACY OXYTOCIN INJECTION SOLUTION 10 UNIT ML 5.31 0250 PHARMACY PAMIDRONATE INTRAVENOUS 30 MG 114.20 0250 PHARMACY PANTOPRAZOLE ORAL TABLET 20 MG 1.00 0250 PHARMACY PANTOPRAZOLE ORAL TABLET 40 MG 1.00 0250 PHARMACY PAROXETINE 20MG ORAL TAB 0.30 0250 PHARMACY PAROXETINE HCI ORAL TABLET 10 MG 1.50 0250 PHARMACY PEDIA LAX 50MG LIQ 10.00 0250 PHARMACY PEDIA-LAX 1GM SUP 10.00 0250 PHARMACY PEG 3350 ELECTROLYTES ORAL SOLUTION 240GM 40.65 0250 PHARMACY PENTAM INJECTION 300 MG 336.60 0250 PHARMACY PENTOXIFYLINE ER ORAL TABLET 400 MG 1.00 0250 PHARMACY PERMETHRIN EXTERNAL CREAM 5 % 197.94 0250 PHARMACY PHENAZOPYRIDINE HCI ORAL TABLET 100 MG 1.00 0250 PHARMACY PHENERGAN 12.5 MG SUPP 7.88 0250 PHARMACY PHENERGAN INJ 25 MG 1ML PROMETHAZINE 25 MG 1ML 2.64 0250 PHARMACY PHENERGAN INJECTION 50 MG ML 2.73 0250 PHARMACY PHENOBARBITAL 30MG TABLET 1.00 0250 PHARMACY PHENOBARBITAL SODIUM INJECTION 45.00 0250 PHARMACY PHENYTOIN INJECTION 50MG ML DILANTIN 4.89 0250 PHARMACY PHENYTOIN INJECTION 50MG ML 2ML DILANTIN 3.02 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY PHENYTOIN ORAL CAPSULE 100 MG 1.00 0250 PHARMACY PHYSOS SALI INJ 1MG ML 20.50 0250 PHARMACY PILOCARPINE HCI OPHTHALMIC 4 % 271.83 0250 PHARMACY PIOGLITAZONE 15MG TABS 1.00 0250 PHARMACY PIOGLITAZONE 45MG TABS 1.00 0250 PHARMACY PIPERACILLIN TAZOBACTAM 4.5GM INJECTION 21.00 0250 PHARMACY PIPERACILLIN TAZOBACTAM 2.25GM INYECTION 18.00 0250 PHARMACY PIPERACILLIN TAZOBACTAM 3.375GM ZOSYN 14.80 0250 PHARMACY PLAVIX 6.00 0250 PHARMACY POLYMYXIN B INJECTION SOLUTION 500000 UNIT 16.50 0250 PHARMACY POT CHLORID SOL 10% 15.00 0250 PHARMACY POTASSIUM CHLORIDE INTRAVENOUS 20 0.9 MEQ L % 8.61 0250 PHARMACY POTASSIUM CHLORIDE INTRAVENOUS 20 MEQ 100ML 5.60 0250 PHARMACY POTASSIUM CHLORIDE INTRAVENOUS 40 MEQ 100ML 10.65 0250 PHARMACY POTASSIUM CHLORIDE ORAL LIQUID 20 MEQ 15ML 10% 1.00 0250 PHARMACY POTASSIUM PHOSPHATES INTRAVENOUS 15MMOLE 5ML 24.00 0250 PHARMACY PRADAXA ORAL CAPSULE 75 MG 14.16 0250 PHARMACY PREDNISOLONE OPHTALIC SUSP.1% 225.00 0250 PHARMACY PREDNISOLONE OPHTHALMIC 1 % 146.67 0250 PHARMACY PREDNISOLONE ORAL SOLUTION 15MG 5ML 2.70 0250 PHARMACY PREDNISONE 10MG ORAL TAB 0.33 0250 PHARMACY PREDNISONE ORAL TABLET 20 MG 1.00 0250 PHARMACY PREDNISONE ORAL TABLET 5 MG 1.00 0250 PHARMACY PREMARIN INJECTION 25 MG 426.78 0250 PHARMACY PREMARIN ORAL TABLET 0.625 MG 11.49 0250 PHARMACY PRENATALES TAB 0.33 0250 PHARMACY PRIMAXIN INTRAVENOUS 250 MG 14.25 0250 PHARMACY PRIMAXIN INTRAVENOUS 500 MG 20.64 0250 PHARMACY PROAIRHFA INHALATION AEROSOL 108 90 BASE MCG ACT 165.42 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY PROCAINAMIDE HCI INJECTION 500 MG ML 297.00 0250 PHARMACY PROCRIT INJ 10000 UNIT (FACT 10 UNIDADES X C/U) 240.00 0250 PHARMACY PROCRIT INJ 2000 UNIT (FACT 2 UNIDADES) 88.00 0250 PHARMACY PROCRIT INJ 4000 UNIT (FACT 4 UNIDADES) 176.00 0250 PHARMACY PROCRIT INJECTION SOLUTION 40000 UNIT/ML 1,134.00 0250 PHARMACY PROCTOSOL H CREAM 21.50 0250 PHARMACY PROLIXIN ORAL TABLET 10 MG 1.00 0250 PHARMACY PROMETHAZINE CODEINE PHENERGAN CODEINE 1.00 0250 PHARMACY PROMETHAZINE DM ORAL SYRUP 6.25 15 MG 5ML 1.00 0250 PHARMACY PROMETHAZINE HCI ORAL SYRUP 6.25 MG 5ML 1.17 0250 PHARMACY PROMETHAZINE HCI SUPPOSITORY 12.5 MG 23.13 0250 PHARMACY PROMETHAZINE HCL RECTAL SUPP 25MG 22.50 0250 PHARMACY PROPARACAINE HCI OPHTHALMIC SOLUTION 0.5% 73.65 0250 PHARMACY PROPOFOL INJ 10MG ML 7.50 0250 PHARMACY PROPOFOL INTRAVENOUS 10MG ML 19.59 0250 PHARMACY PROPRANOLOL HCI ORAL TABLET 10 MG 1.00 0250 PHARMACY PROPRANOLOL HCI ORAL TABLET 40 MG 1.00 0250 PHARMACY PROPYLTHIOURACIL ORAL TABLET 50 MG 1.00 0250 PHARMACY PROTAMINE SULFATE 10MG ML 21.60 0250 PHARMACY PROTONIX INTAVENOUS SOLUTION 40 MG 12.00 0250 PHARMACY QUESTRAN 4GM POWDER CHOLESTYRAMINE 40.70 0250 PHARMACY QUETIAPINE 400MG TAB 1.00 0250 PHARMACY QUETIAPINE ORAL TABLET 100 MG 1.71 0250 PHARMACY QUETIAPINE ORAL TABLET 25 MG 1.00 0250 PHARMACY QUETIAPINE ORAL TABLET 300 MG 1.00 0250 PHARMACY RACEPINEPHRINE S2 INHALATION 2.25% 6.51 0250 PHARMACY RAMIPRIL 2.5MG ORAL CAPSULE 1.00 0250 PHARMACY RAMIPRIL 5MG ORAL CAP 1.00 0250 PHARMACY RANITIDINE 150MG CAP 0.33 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY RANITIDINE 300MG TAB 1.00 0250 PHARMACY RANITIDINE HCI ORAL SYRUP 75 MG 5ML 9.66 0250 PHARMACY RANITIDINE INJ 50 MG 2ML ZANTAC INJ 50MG 2ML 8.00 0250 PHARMACY RH0 D IMMUNE GLOBULIN INTRAVENOUS HUMAN 300MCG 240.00 0250 PHARMACY RIFAMPIN ORAL CAPSULE 300 MG 7.41 0250 PHARMACY RISPERDAL ORAL TAB 3MG 7.40 0250 PHARMACY RISPERIDONE 1MG TAB 1.50 0250 PHARMACY RISPERIDONE ORAL TABLET 0.5 MG 1.05 0250 PHARMACY ROBAXIN ORAL TABLET 500 MG 4.20 0250 PHARMACY ROBITUSSIN DM SILARX --- SILTUSSIN DM COUGH SYRUP 7.14 0250 PHARMACY ROCEPHIN 1 GM 4.00 0250 PHARMACY ROCURONIUM INTRAVENOUS 50 MG 5 ML 28.70 0250 PHARMACY ROGHAN 125.00 0250 PHARMACY RULOX SUSP 1.00 0250 PHARMACY SALINE INTRAVENOUS .45 % 500 ML 1.20 0250 PHARMACY SALINE INTRAVENOUS 0.9 % 1000 ML 3.75 0250 PHARMACY SALINE INTRAVENOUS 0.9 % 250 ML 2.83 0250 PHARMACY SALINE INTRAVENOUS 0.9 % 500 ML 3.31 0250 PHARMACY SALINE INTRAVENOUS 0.9% MINI BAG 100ML 2.84 0250 PHARMACY SALINE INTRAVENOUS 0.9% MINI BAG 25ML 4.81 0250 PHARMACY SALINE INTRAVENOUS 0.9% MINI BAG 50ML 2.84 0250 PHARMACY SALINE INTRAVENOUS.45 % 1000 ML 1.79 0250 PHARMACY SANI SUPP PEDIATRIC RECTAL SUPPOSITORY 1.2 GM 1.05 0250 PHARMACY SANTYL COLLAGENASE 265.00 0250 PHARMACY SENNA ORAL TABLET 8.6 MG 4.23 0250 PHARMACY SEPTRA 150 MG IV 5.00 0250 PHARMACY SERTRALINE HCL 100MG TAB 5.30 0250 PHARMACY SERTRALINE HCL 50MG TAB 4.50 0250 PHARMACY SERTRALINE HCL ORAL TABLET 25MG 4.50 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY SEVOFLURANE SOL 140.00 0250 PHARMACY SILVADENE CREAM 1 % 24.00 0250 PHARMACY SIMETICONE ORAL TABLET 125 MG 1.00 0250 PHARMACY SIMVASTATIN 10MG TAB 4.50 0250 PHARMACY SIMVASTATIN 20MG TAB 9.80 0250 PHARMACY SIMVASTATIN 40MG TAB 9.80 0250 PHARMACY SINEMET ORAL TABLET 25 250 MG 1.20 0250 PHARMACY SLOK 8 ER ORAL TABLET 8 MEQ 1.00 0250 PHARMACY SOD PHOSPHAT INJ 3MM ML 3.50 0250 PHARMACY SODIUM BICARBONATE 8.4% INJ 25.00 0250 PHARMACY SODIUM BICARBONATE INTRAVENOUS 4.2% 37.60 0250 PHARMACY SODIUM BICARBONATE INTRAVENOUS 8.4 % 28.11 0250 PHARMACY SODIUM BICARBONATE INTRAVENOUS 8.4% 17.81 0250 PHARMACY SODIUM BICARBONATE ORAL TABLET 650 MG 1.00 0250 PHARMACY SODIUM CHLORIDE 0.9% INH SOLUTION 0.33 0250 PHARMACY SODIUM CHLORIDE INH NEB SOL 3% 1.50 0250 PHARMACY SODIUM CHLORIDE INH SOL 3% 3.00 0250 PHARMACY SODIUM CHLORIDE INH SOLUTION 0.9% 3.00 0250 PHARMACY SODIUM CHLORIDE NEB SOL 0.9% 1.00 0250 PHARMACY SODIUM CHLORIDE ORAL TABLET 1 GM 1.00 0250 PHARMACY SOLU CORTEF INJECTION 100 MG 23.40 0250 PHARMACY SOLU CORTEF INJECTION 250 MG 52.12 0250 PHARMACY SOLU MEDROL 1GM INJ 120.00 0250 PHARMACY SOLU MEDROL INJ 125 MG 6.00 0250 PHARMACY SOLU MEDROL INJECTION SOLUTION 40 MG 9.72 0250 PHARMACY SOLU-MEDROL 125 MG 6.00 0250 PHARMACY SPIRONOLACTONE 100MG TABS 2.12 0250 PHARMACY SPIRONOLACTONE 25MG TABS 1.00 0250 PHARMACY SPIRONOLACTONE 50MG TABS 1.05 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY STERILE WATER INJECTION SOLUTION 10 MG 2.00 0250 PHARMACY STERILE WATER INJECTION SOLUTION 20 MG 3.00 0250 PHARMACY SUCRALFATE ORAL TABLET 1 GM 1.00 0250 PHARMACY SUCRALFATE SUSP 1GM 10ML 18.00 0250 PHARMACY SULFAMETH TRIMET DS TAB 800 160MG 0.36 0250 PHARMACY SULFAMETH TRIMETH 400 80MG PO TABS SMZ-TMP 0.36 0250 PHARMACY SULFAMETHOXAZOLE TRIMETHOPRIM IV 400 80MG 5ML 16.80 0250 PHARMACY SULFAMETHOXAZOLE TRIMETHOPRIM ORAL SUSP 200 40MG 5 0.55 0250 PHARMACY SULFATO DE MAGNESIO 2G 0.43 0250 PHARMACY SUPRESS DM PED DROPS 28.75 0250 PHARMACY SUPRESS DX PEDRIATRIC ORAL LIQUID 2.5 5 .50 MG ML 28.74 0250 PHARMACY SUPRESS PE PEDIATRIC DROPS 28.75 0250 PHARMACY SURFAK ORAL CAPSULE 240 MG 1.00 0250 PHARMACY SYNTHROID ORAL TABLET 100 MCG 1.50 0250 PHARMACY SYNTHROID ORAL TABLET 112 MCG 1.80 0250 PHARMACY SYNTHROID ORAL TABLET 125 MCG 3.12 0250 PHARMACY SYNTHROID ORAL TABLET 150 MCG 1.50 0250 PHARMACY SYNTHROID ORAL TABLET 25 MCG 1.41 0250 PHARMACY SYNTHROID ORAL TABLET 75 MCG 1.26 0250 PHARMACY SYNTHROID ORAL TABLET 88 MCG 1.20 0250 PHARMACY TAGAMET 100 MG 4.50 0250 PHARMACY TAMIFLU ORAL CAPSULE 30 MG 34.95 0250 PHARMACY TAMIFLU ORAL CAPSULE 45 MG 34.95 0250 PHARMACY TAMIFLU ORAL CAPSULE 75 MG 38.10 0250 PHARMACY TAMIFLU ORAL SUSPENSION 6MG ML 468.00 0250 PHARMACY TAMSULOSIN HCI ORAL CAPSULE 0.4 MG 1.00 0250 PHARMACY TEARS NATURA SOL FORTE 10.00 0250 PHARMACY TEGRETOL ORAL TABLET 200 MG 2.19 0250 PHARMACY TEMAZEPAM 15MG ORAL CAPSULE 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY TEMAZEPAM 30MG ORAL TABLET 1.00 0250 PHARMACY TETANUS DIPHTERIA TOXOIDS INTRAMUSCULAR 2.2LF 0.5M 25.00 0250 PHARMACY TETRACAINE HCI OPHTHALMIC 0.5% 27.90 0250 PHARMACY THEO-24 CAP 300MG 2.18 0250 PHARMACY THEOPHYLLINE ER ORAL TABLET 100 MG 1.20 0250 PHARMACY THIAMINE HCI INJECTION SOLUTION 100 MG ML 18.12 0250 PHARMACY THIORIDAZINE HCI ORAL TABLET 25 MG 1.26 0250 PHARMACY THIORIDAZINE HCI ORAL TABLET 50 MG 1.92 0250 PHARMACY THORAZINE 4.40 0250 PHARMACY TIGAN INTRAMUSCULAR SOLUTION 100 MG ML 36.15 0250 PHARMACY TNKASE KIT 50MG (FACT 50 UNIDADES X C/U) 6,000.00 0250 PHARMACY TOBRADEX OPHTHALMIC OINTMENT 0.3 0.1 % 709.47 0250 PHARMACY TOBRAMYCIN DEXAMETHASONE OPHTHALMIC 0.3 0.1 % 138.90 0250 PHARMACY TOBRAMYCIN OPHTHALMIC 0.3% 11.94 0250 PHARMACY TOBRAMYCIN SULFATE INJECTION 80 MG 2ML 6.00 0250 PHARMACY TORADOL 10 MG 1.00 0250 PHARMACY TORADOL INJECTION 30 MG ML 8.52 0250 PHARMACY TORADOL INTRAMUSCULAR 60 MG ML KETOROLAC 60 MG 9.00 0250 PHARMACY TRAMADOL ACETAMINOPHEN 3.00 0250 PHARMACY TRAMADOL ORAL TABLET 50MG 1.00 0250 PHARMACY TRAZODONE 50MG TAB 1.00 0250 PHARMACY TRIMETHOBENZAMIDE HCL INJ 100MG ML 84.00 0250 PHARMACY TROPICAMIDE OPHTHALMIC 1 % 17.07 0250 PHARMACY TRUVADA 200MG 300MG 180.00 0250 PHARMACY TUSNEL DIAB LIQ 10 100 5 1.00 0250 PHARMACY TUSNEL DM PEDIATRIC ORAL LIQUID 7.5 2.5 25 MG ML 30.87 0250 PHARMACY TUSNEL LIQ 30.70 0250 PHARMACY TUSNEL PEDIATRIC ORAL LIQUID 7.5 MG ML 30.87 0250 PHARMACY TUSSI ORGANIDIN DM SYRUP 100 10 MG 5 ML 1.00 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY TUSSI PRES PEDIATRIC ORAL LIQUID 2.5 5.75 MG 5 ML 30.90 0250 PHARMACY TUSSI PRESS ORAL LIQ ADULTO 5 10 200MG 5ML 1.00 0250 PHARMACY TUSSI-PRESS PED LIQ 30.90 0250 PHARMACY TYGACIL INTRAVENOUS SOLUTION 50 MG 426.00 0250 PHARMACY TYLENOL 500 MG 1.00 0250 PHARMACY TYLENOL ELIXIR --- CHILDREN SILAPAP LIQ 3.45 0250 PHARMACY UNISERTS 120 MG --- ACEPHEN 120 MG 3.70 0250 PHARMACY VALIUM 10 MG IM 30.00 0250 PHARMACY VALSARTAN 320MG ORAL TAB 1.80 0250 PHARMACY VANCOMYCIN 1GM INJ 10.50 0250 PHARMACY VANCOMYCIN 500MG INJ 15.00 0250 PHARMACY VANCOMYCIN HCL 250MG ORAL TAB 25.00 0250 PHARMACY VAPONEPHRINE RACEPINEPHRINE 2.25% 6.21 0250 PHARMACY VASELINE PUR GEL ULT WHITE 3.00 0250 PHARMACY VERAPAMIL 240MG ER CAP 2.47 0250 PHARMACY VERAPAMIL HCI ER ORAL CAPSULE 120 MG 2.46 0250 PHARMACY VERAPAMIL HCI INTRAVENOUS 2.5 MG ML 85.92 0250 PHARMACY VERAPAMIL HCI ORAL TABLET 40 MG 1.00 0250 PHARMACY VERAPAMIL HCI ORAL TABLET 80 MG 1.00 0250 PHARMACY VERAPAMIL INTRAVENOUS 2.5 MG ML 81.24 0250 PHARMACY VERAPAMIL SR 180 ORAL 1.00 0250 PHARMACY VIGAMOX OPHTHALMIC 0.5% 486.27 0250 PHARMACY VISTARIL 50 MG ML HYDROXYZINE 50 MG ML 3.50 0250 PHARMACY VISTARYL INJ 25 MG/ML 1.00 0250 PHARMACY VITAMIN C 500MG TABS 0.30 0250 PHARMACY VITAMIN K INJECTION 1MG 0.5ML 13.20 0250 PHARMACY VITAMIN K1 INJ 1MG 0.5ML PED 97.00 0250 PHARMACY VITAMIN K1 INJECTION SOLUTION 10MG ML 97.00 0250 PHARMACY VITAMINA B 12 ER ORAL TAB 1000 MCG 0.03 Rev. June, 2020

CodeGroup Description Price 0250 PHARMACY VITAMINA K INJECTION 10MG ML 101.94 0250 PHARMACY WARFARIN 1MG ORAL TAB 1.50 0250 PHARMACY WARFARIN ORAL TABLET 10 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 2 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 2.5 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 3 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 4 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 5 MG 1.00 0250 PHARMACY WARFARIN ORAL TABLET 7.5 MG 1.00 0250 PHARMACY XARELTO ORAL TAB 20MG 30.00 0250 PHARMACY XARELTO 10MG ORAL TAB 30.00 0250 PHARMACY XARELTO 15MG ORAL TAB 30.00 0250 PHARMACY XYLOCAINA JELLY 2% LIDOCAINE JELLY 2% 6.15 0250 PHARMACY ZANTAC INJ. 50 MG/2ML --- RANITIDINE INJ 50 MG/2ML 4.42 0250 PHARMACY ZIDOVUDINE ORAL SYRUP 50 MG 5 ML 9.15 0250 PHARMACY ZIDOVUDINE ORAL SYRUP 50MG 5ML 9.15 0250 PHARMACY ZINC OXIDE EXTERNAL OINTMENT 20% 10.59 0250 PHARMACY ZOLPIDEM 5MG TABLET 1.00 0250 PHARMACY ZYMAXID OPHTHALMIC SOLUTION 0.5% 276.94 0250 PHARMACY ZYRTEC CETIRIZINE HCI ORAL SYRUP 1MG ML 23.61 0250 PHARMACY ZYVOX INTRAVENOUS SOLUTION 2 MG ML 180.00 0260 NUTRITION BOLSA DE ALIMENTACION NUTREN 1.5 3.80 0260 NUTRITION BOOST GLUCOSE CONTROL (FACTURAR 2 UNIDADES) 2.06 0260 NUTRITION DIABETIC SHIELD (FACTURAR 2 UNIDADES) 2.88 0260 NUTRITION DIABETIC SOURCE AC (FACTURAR 3 UNIDADES) 1.80 0260 NUTRITION ENSURE CLEAR (FACTURAR 1 UNIDAD) 2.18 0260 NUTRITION ENSURE ENLIVE (FACTURAR 4 UNIDADES) 2.06 0260 NUTRITION ENSURE ORIGINAL (FACTURAR 3 UNIDADES) 2.06 0260 NUTRITION ENSURE PLUS (FACTURAR 4 UNIDADES) 2.08 Rev. June, 2020

CodeGroup Description Price 0260 NUTRITION GLUCERNA (FACTURAR 3 UNIDADES 1.80 0260 NUTRITION GLUCERNA 1.0 (FACTURAR 3 UNIDADES) 1.52 0260 NUTRITION GLUCERNA 1.5 (FACTURAR 4 UNIDADES 2.28 0260 NUTRITION JEVITY 1.2 (FACTURAR 4 UNIDADES) 1.68 0260 NUTRITION JEVITY 1.5 (FACTURAR 3 UNIDADES) 2.58 0260 NUTRITION JUVEN (FACTURAR 1 UNIDAD) 4.60 0260 NUTRITION NEPRO (FACTURAR 5 UNIDADES) 3.90 0260 NUTRITION NUTREN PULMONARY (FACTURAR 4 UNIDADES) 7.86 0260 NUTRITION OXEPA (FACTURAR 4 UNIDADES) 3.18 0260 NUTRITION PEDIASURE (FACTURAR 3 UNIDADES) 2.20 0260 NUTRITION PEPTAMEN AF (FACTURAR 3 UNIDADES) 5.88 0260 NUTRITION PIVOT 1.5 (FACTURAR 4 UNIDADES) 6.26 0260 NUTRITION PULMOCARE (FACTURAR 4 UNIDADES) 2.00 0260 NUTRITION SUPLENA (FACTURAR 5 UNIDADES) 3.18 0260 NUTRITION TPN 2:1 AA & DEXT 1000ML 345.60 0260 NUTRITION TPN 2:1 AA & DEXTROSE 2500ML 403.92 0260 NUTRITION TPN 2:1 AA 7 DEXT 2000 ML 388.80 0260 NUTRITION TPN 2:1 AA DEXT 1500 ML 380.16 0260 NUTRITION TPN 3:1 W/20% LIPIDS 1000 ML 359.16 0260 NUTRITION TPN 3:1 W/20% LIPIDS 1500 ML 425.14 0260 NUTRITION TPN 3:1 W/20% LIPIDS 2000 ML 479.74 0260 NUTRITION TPN 3:1 W/20% LIPIDS 2500 ML 506.00 0260 NUTRITION TPN 3:1 W/20% LIPIDS 3000 ML 558.16 0260 NUTRITION TPN 3:1 W/30% LIPIDS 1000 ML 359.16 0260 NUTRITION TPN 3:1 W/30% LIPIDS 1500 ML 425.14 0260 NUTRITION TPN 3:1 W/30% LIPIDS 2000 ML 479.74 0260 NUTRITION TPN 3:1 W/30% LIPIDS 2500 ML 506.00 0260 NUTRITION TPN 3:1 W/30% LIPIDS 3000 ML 558.16 0260 NUTRITION VITAL 1.0 (FACTURAR 3 UNIDADES) 5.88 Rev. June, 2020

CodeGroup Description Price 0260 NUTRITION VITAL 1.5 (FACTURAR 4 UNIDADES) 7.64 0270 SUPPLIES (A) ENDO CLIP II MED/LRG 402.51 0270 SUPPLIES 0.9 500ML 3.30 0270 SUPPLIES 1.5% GLUCINE IRRIGATION, USP 3000ML 7.95 0270 SUPPLIES 20% IV FAT EMULSION 250ML 44.70 0270 SUPPLIES 3017918 PAMPERS MAINLINE WIPES 9.75 0270 SUPPLIES 60" COILED TUBING 6.00 0270 SUPPLIES A4264 FALLOPY RING 87.00 0270 SUPPLIES ABD PAD STERIL 5 X 9 1.00 0270 SUPPLIES ABD PAD STERIL 8 X 10 1.00 0270 SUPPLIES ABDOMINAL PAD 5X9 ST 0.36 0270 SUPPLIES ABGS KIT NDL 25 5.25 0270 SUPPLIES ACTICOAT FLEX 3 115.00 0270 SUPPLIES ACTICOAT SITE 4MM 18.00 0270 SUPPLIES ADAPTER CAPS 1.29 0270 SUPPLIES ADAPTER TEE 22MM X 22MM 7.41 0270 SUPPLIES ADHESIVE BANDAGE 3/4 X3 0.03 0270 SUPPLIES ADHESIVE BANDAGE 7/8 SPOT 0.03 0270 SUPPLIES ADULT FLOW SENSOR 103.20 0270 SUPPLIES ADULT LUMBAR PUNCTURE TRY 23.46 0270 SUPPLIES ADULT MULTIFUNTION ELECTRODES 90.00 0270 SUPPLIES ADULT PHYSIO CONTROL QUIK COME ELECTRODE 96.00 0270 SUPPLIES AGUA BACTERIOSTATICA 1.32 0270 SUPPLIES AGUA DESTILADA GL 3.84 0270 SUPPLIES AGUJA SAFETY 18 X 1 1.00 0270 SUPPLIES AGUJA SAFETY 20 X 1 1.00 0270 SUPPLIES AGUJA SAFETY 20 X 1 1/2 1.00 0270 SUPPLIES AGUJA SAFETY 21 X 1 1.00 0270 SUPPLIES AGUJA SAFETY 21 X 1 1/2 1.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES AGUJA SAFETY 22 X 1 1/2 1.00 0270 SUPPLIES AGUJA SAFETY 23 X 1 1.00 0270 SUPPLIES AGUJA SAFETY 25 X 1 1.00 0270 SUPPLIES AIRWAY ORAL PHARYNGEAL 80MM 1.65 0270 SUPPLIES AIRWAY ORAL PHARYNGEAL 90 MM 1.40 0270 SUPPLIES ALCOHOL PADS 1.00 0270 SUPPLIES ALCOHOL PREP PAD STERILE 0.03 0270 SUPPLIES ALCON 0.2 METRIC, 30CM CU-1 NYLON BLACK MON 23.20 0270 SUPPLIES ALEXIS WOUND PROTECTOR/RETRACTOR 184.50 0270 SUPPLIES ALGISITE M 5.89 0270 SUPPLIES ALLEVYN ADHESIVE 27.00 0270 SUPPLIES ALLEVYN ADHESIVE 9X9 33.00 0270 SUPPLIES AMBU ADULTO 45.99 0270 SUPPLIES AMBU INFANT 46.74 0270 SUPPLIES AMBU PEDIATRICO 46.50 0270 SUPPLIES AMNIHOOK ST MEMBRANE PERFORATION 4.35 0270 SUPPLIES ANESTHESIA CIRCUITS 35.01 0270 SUPPLIES ANESTHESIA CIRCUITS W/ BRETHIN 17.82 0270 SUPPLIES ANGIO NEONATAL 24 X 56 8.34 0270 SUPPLIES ANGIOS 18 1 1/4 SAFETY 4.68 0270 SUPPLIES ANGIOS 20 X 1 SAFETY 4.68 0270 SUPPLIES ANGIOS 22 X 1 SAFETY 4.68 0270 SUPPLIES ANGIOS 24 3/4 SAFETY 4.68 0270 SUPPLIES ANTI-EMBOLISM STOCKING KNEE L 9.48 0270 SUPPLIES ANTI-EMBOLISM STOCKING KNEE M 9.48 0270 SUPPLIES ANTI-EMBOLISM STOCKING KNEE S 9.48 0270 SUPPLIES ANTI-EMBOLISM STOCKING KNEE XL 9.48 0270 SUPPLIES APLICADORES DE ALGODON STL 1.00 0270 SUPPLIES APPLIER MULTI CLIP MCM 20 294.51 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES APPLIER MULTI CLIP W/SHAF ER 320 178.16 0270 SUPPLIES AQUACEL AG 4 X 4.7 36.03 0270 SUPPLIES AQUAPACK 340 4.44 0270 SUPPLIES AQUAPACK 760 5.31 0270 SUPPLIES ARM SLING LARGE (CABESTRILLO) 8.64 0270 SUPPLIES ARM SLING MEDIUM (CABESTRILLO) 8.64 0270 SUPPLIES ARM SLING SMALL (CABESTRILLO) 8.64 0270 SUPPLIES ARMBOARD REUSABLE INFANT 2' 2.76 0270 SUPPLIES ARROW TWIN CATH 20/22 27.60 0270 SUPPLIES ARTHROSCOPY PUMP TUBING 81.00 0270 SUPPLIES ATRIUM CQUR MESH 10CM X 15CM 975.00 0270 SUPPLIES AVAGARD CHG 16 139.74 0270 SUPPLIES AVIVA 5% DEXTROSE 250ML 5.94 0270 SUPPLIES AVIVA SALINE 0.9% 250 ML 5.94 0270 SUPPLIES B9002 ENTER NUTR INF PUMP ANY TYPE 117.15 0270 SUPPLIES BABY CAP BEANIES 8.31 0270 SUPPLIES BABY LOTION 9OZ 12.00 0270 SUPPLIES BABY RECEIVING BLANKETS 1.59 0270 SUPPLIES BABY SUITS 0.69 0270 SUPPLIES BADCOCKS 5mm 10BB 297.00 0270 SUPPLIES BAG ICE DISPOSABLE LARGE 1.59 0270 SUPPLIES BALL ELECTRODE 3MMD 12 CM 60.00 0270 SUPPLIES BANDAGE ELASTIC LF CLIP 2 X 5 1.32 0270 SUPPLIES BANDAGE ELASTIC LF CLIP 3 1.32 0270 SUPPLIES BANDAGE ELASTIC LF CLIP 4 1.59 0270 SUPPLIES BANDAGE ELASTIC LF CLIP 6 2.37 0270 SUPPLIES BANDEJA DE SUTURA 40.00 0270 SUPPLIES BANDEJA EPIDURAL 18G 60.00 0270 SUPPLIES BANDEJA ESPINAL AGUJA 26 XILOCAINA 39.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES BANDEJA IRRIG w BULD SYR 4.05 0270 SUPPLIES BATAS AMARILLAS/ INSOLATION 1.14 0270 SUPPLIES BATAS DE LABORATORIO LGE 4.59 0270 SUPPLIES BATAS DE LABORATORIO MED 4.65 0270 SUPPLIES BATAS DE PACIENTES (AZUL) 1.00 0270 SUPPLIES BATAS DE PACIENTES (BLANCA) 1.00 0270 SUPPLIES BATAS STERIL DE CIRUJANO 7.50 0270 SUPPLIES BD SPINAL TRAY LIDOCAINE 5% 48.30 0270 SUPPLIES BD VACUTAINER ECLIPSE BLOOD 0.72 0270 SUPPLIES BD VACUTAINER ECLIPSE BLOOD 21G 0.72 0270 SUPPLIES BD VACUTAINER ECLIPSE BLOOD 22G 0.84 0270 SUPPLIES BENDAGE ELASTICO 3 X 5 LATEX 1.44 0270 SUPPLIES BENDAGE ELASTICO 4 X5 LATEX 1.95 0270 SUPPLIES BENDAGE ELASTICO 6 X 5 LATEX 2.94 0270 SUPPLIES BENDAJE ELASTICO 2X5 L 0.44 0270 SUPPLIES BERRY SMOOTHIE READI CAT 3.96 0270 SUPPLIES BIO HAZARD BAG 0.12 0270 SUPPLIES BIOHAZARD TRANSPORT BAG 1.00 0270 SUPPLIES BLADE ELECTRODE 6" 2.39 0270 SUPPLIES BLADE ST #10 2.13 0270 SUPPLIES BLADE ST #11 1.95 0270 SUPPLIES BLADE ST #15 1.29 0270 SUPPLIES BLAKE SILICONE DRAINE 109.98 0270 SUPPLIES BLOOD COLLECTOR SAFETY 2.04 0270 SUPPLIES BLOOD GAS KIT 25G X 5/8 1ML 3.75 0270 SUPPLIES BLUNT FILL NEEDLE 18 X 1 1/2 0.29 0270 SUPPLIES BOLSA DE ALIMENTACION 3.00 0270 SUPPLIES BOLSA DE HIELO 1.50 0270 SUPPLIES BOLSA DE HIELO LGE 2.61 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES BONE CUTTER RESECTOR 4.0 MM 306.00 0270 SUPPLIES BONE WAX 3.91 0270 SUPPLIES BOUFFANT CAP BLUE 21' 0.06 0270 SUPPLIES BRIEF ADULT LARGE 1.20 0270 SUPPLIES BUPI TRAY WHITAKER 25G 98.88 0270 SUPPLIES CANULA NASAL ADULTO 1.26 0270 SUPPLIES CANULA NASAL OXIGENO-ADULTO 1.20 0270 SUPPLIES CANULA NASAL PED 1.50 0270 SUPPLIES CARD-4CHG2-FM SCRUB CAPE 32.49 0270 SUPPLIES CARIBBEAN C SECTION PACK 123.81 0270 SUPPLIES CARIBBEAN LAPAROTOMY PACK 157.08 0270 SUPPLIES CAST PADDING 4 X4 YDS 2.13 0270 SUPPLIES CAST PADING SYNTH 4" X 4 YARD 136.74 0270 SUPPLIES CAST SPCLST PADDING 4X4 2.73 0270 SUPPLIES CATARACT DIAMOND PACK 310.00 0270 SUPPLIES CATHETER SUCTION #12 1.00 0270 SUPPLIES CATHETER SUCTION #14 1.00 0270 SUPPLIES CATHETER SUCTION #16 1.00 0270 SUPPLIES CENTRAL LINE DRESSING CHANGE 4.12 0270 SUPPLIES CERV COLLAR 6 PACK LARGE 9.81 0270 SUPPLIES CERV COLLAR 6 PACK SMALL 9.81 0270 SUPPLIES CERV COLLAR PACK 6 MED 9.81 0270 SUPPLIES CESAREN PACK 41.27 0270 SUPPLIES CHEST DRAINAGE UNIT AQUASEAL 184.80 0270 SUPPLIES CHROMIC 0 CT1 924H 9.06 0270 SUPPLIES CHROMIC 0 L114G 9.48 0270 SUPPLIES CHROMIC 1 925H 9.15 0270 SUPPLIES CHROMIC 1 CT 803 7.74 0270 SUPPLIES CHROMIC 2-0 913H 8.64 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES CHROMIC 4-0 1654G 18.87 0270 SUPPLIES CHROMIC GUT 1 905H 2.91 0270 SUPPLIES CHROMIC GUT 2-0 2.66 0270 SUPPLIES CHROMIC GUT 3-0 GG-122 2.66 0270 SUPPLIES CHROMIC GUT 4-0 U-203 1.84 0270 SUPPLIES CHROMIC GUT 811H 2.66 0270 SUPPLIES CHROMIC GUT CG 1.97 0270 SUPPLIES CIDEX OPA LIQUID DESINFECTANT 101.85 0270 SUPPLIES CIRCUIT VENTILATOR ADULT 7200 20.40 0270 SUPPLIES CLEAR CUT SLIT KNIFE 2.4 DUAL LEVL 84.00 0270 SUPPLIES CLEARTRACE ELECTRODE 0.33 0270 SUPPLIES CO2 DETECTOR ADULT #2K8085 26.40 0270 SUPPLIES COILDED EXTENSION TUBING LINEA ADMINISTRAR CONTRAS 6.75 0270 SUPPLIES COLECTOR DE ORINA 2.00 0270 SUPPLIES COLECTOR URINE PED 1.50 0270 SUPPLIES COLL NEEDLE ECLIPSE 22 X 1 1/4 1.23 0270 SUPPLIES COLL NEEDLE ECLIPSE 21 X 1 1/4 1.00 0270 SUPPLIES CONDOM FOLEY GIZMO COLOPLAST 3.39 0270 SUPPLIES CONECTION SUCTION TUBING 7" 1.68 0270 SUPPLIES CONNECTOR 5IN 1 3/16" X 9/16 1.41 0270 SUPPLIES CONTINOUS FLOW SET 2 INJECT 4.95 0270 SUPPLIES CONTINOUS WAVE MAIN PUMP 24.30 0270 SUPPLIES COOLCUT DISSECTOR 4.0 MM X 13C 61.20 0270 SUPPLIES CORD CLAMP STERILE 1.74 0270 SUPPLIES CORRUGATED W/BAGS ADULT 24.78 0270 SUPPLIES COULED FOLEY 2 WAY 5CC 16FR 17.85 0270 SUPPLIES COULED FOLEY 2 WAY 5CC 18FR 17.85 0270 SUPPLIES CRICOTHYROTOMY KIT 2.0 MM 520.50 0270 SUPPLIES CRICOTHYROTOMY KIT 4.0 MM 520.50 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES CUFF SOFT DESECHABLE 2.95 0270 SUPPLIES CULTURETE SWABS 1.00 0270 SUPPLIES CURITAS REDONDAS 7/8 1.00 0270 SUPPLIES CURITAS REGULARES 3/4 X 3 1.00 0270 SUPPLIES CUSTOM TRAY CENTRAL LINES 12.33 0270 SUPPLIES CVS KIT FR 7 X 16 191.31 0270 SUPPLIES CYSTO / BLADDER IRRI 13.50 0270 SUPPLIES DEFIB PADS 3M 9.30 0270 SUPPLIES DENVER ASCITES SHUNT SINGLE 4,140.00 0270 SUPPLIES DEPRESORES LENGUA 6" STL 1.00 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 6.5 1.71 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 7 1.71 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 7.5 1.71 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 8 1.71 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 8.5 1.71 0270 SUPPLIES DERMA PRENE PF SURG GLOVE 9.0 1.71 0270 SUPPLIES DETERGENTE ENZOL 140.55 0270 SUPPLIES DEXT 5% NS .45 500ML 6.21 0270 SUPPLIES DEXT 5% NS .45% 500ML 4.71 0270 SUPPLIES DEXT 5% WITH .9% SALINE 1000ML 4.74 0270 SUPPLIES DEXT 5% WITH .9% SALINE 500ML 4.65 0270 SUPPLIES DEXTRO 4.00 0270 SUPPLIES DEXTROSE 10% 500 ML 4.50 0270 SUPPLIES DEXTROSE 5% .22% SODIUM CHLOR 4.77 0270 SUPPLIES DEXTROSE 5% 1000ML 4.80 0270 SUPPLIES DEXTROSE 5% 250ML 3.75 0270 SUPPLIES DEXTROSE 5% 500ML 4.05 0270 SUPPLIES DEXTROSE 5% MINI 100ML 2.97 0270 SUPPLIES DIRECT DRIVER CLIP APPLIER 255.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES DISPOSABLE ANESTHESIA MASK SIZE 4 6.99 0270 SUPPLIES DISPOSABLE ANESTHESIA MASK SIZE 5 6.99 0270 SUPPLIES DISPOSABLE ANESTHESIA MASK SIZE 6 6.99 0270 SUPPLIES DISPOSABLE CORE BIOPSY INSTRUMENT 72.00 0270 SUPPLIES DISPOSABLE SCISSOR 114.00 0270 SUPPLIES DRAIN PENROSE STERILE 18 X 25 1.71 0270 SUPPLIES DRAPE SHEET 40 X 48 0.42 0270 SUPPLIES DRAPE SHEET 40X90 0.99 0270 SUPPLIES DRAPE SURGICAL UNDER BUTTOCK PO 9.69 0270 SUPPLIES DURAFIBBER AG 11.63 0270 SUPPLIES DURAPORE 2' X10' 6.75 0270 SUPPLIES DYNACAST (YESO SECO) 3" X 15 FT 234.03 0270 SUPPLIES DYNACAST (YESO SECO) 4" X 15 FT 275.76 0270 SUPPLIES DYNACAST (YESO SECO) 6" X 15FT 429.63 0270 SUPPLIES E.T. INTRODUCER R BOGUEY PR SALES 32.40 0270 SUPPLIES EAR & ULCER SYRINGE DISPOSABLE 3.51 0270 SUPPLIES ECLIPSE NEEDLE 2 1X1 0.66 0270 SUPPLIES ECLIPSE PROVE COVER 2.37/1.75 W 1.38 0270 SUPPLIES EDOBROQUIAL TUBE 37 FH RIGHT 240.18 0270 SUPPLIES ELECTRODOS 0.11 0270 SUPPLIES ELECTRODOS 3M MONITOR 1.00 0270 SUPPLIES ELECTRODOS EKG 3.30 0270 SUPPLIES ELECTROSURGICAL PENCIL 18.30 0270 SUPPLIES ENDO GRASP 302.49 0270 SUPPLIES ENDOCERVICAL CURETTE WITH 12 ML VACU-LOCK SY 10.95 0270 SUPPLIES ENDOCHRATEAL TUBE CUFF 3.0 8.40 0270 SUPPLIES ENDOCROQUIAL TUBE 37 FH LEFT 240.18 0270 SUPPLIES ENDOLOOP COATED VUCRYL SZ 0 1D 141.96 0270 SUPPLIES ENDOLOOP LIG W-PDS II 125.96 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES ENDOPATH ETS FLEX 45 ARTICULATING ENDOSCOPI 391.88 0270 SUPPLIES ENDOTRACHEAL CUFF 4.5 1.53 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 3.5 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 4.0 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 5.5 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 6.0 5.40 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 6.5 4.59 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 7.0 4.59 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 7.5 5.40 0270 SUPPLIES ENDOTRACHEAL TUBE CUFF 8.0 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE STYLET 12 FR 2.50 0270 SUPPLIES ENDOTRACHEAL TUBE UNCUFFEC 4.0 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE UNCUFFED 2.0 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE UNCUFFED 2.5 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE UNCUFFED 3.0 8.40 0270 SUPPLIES ENDOTRACHEAL TUBE UNCUFFED 3.5 8.40 0270 SUPPLIES ENEMA CLEANSING 2.76 0270 SUPPLIES ENTERAL DELIVERY PUMP BAG SET 5.43 0270 SUPPLIES ENTERAL FEDDING BAG 1200ML 5.70 0270 SUPPLIES ENTERAL SYRINGE WITH TIP CAP 35ML 0.87 0270 SUPPLIES EPIX LAPAROSCOPIC DISSECTOR 135.00 0270 SUPPLIES ESPECULO OTOSCOPIO 2.5mm CHD 1.00 0270 SUPPLIES ESPECULOS OTOSCOPIO 4mm ADT 1.00 0270 SUPPLIES ETHIBOND EXCEL X424H 3.09 0270 SUPPLIES ETHILOM BLK MONO 6-0 667G 9.57 0270 SUPPLIES ETHILON 10-0 BLACK 6.27 0270 SUPPLIES ETHILON 10-0 BLACK 9007G 30.24 0270 SUPPLIES ETHILON 2-0 664 H 2.49 0270 SUPPLIES ETHILON 3-0 627H 7.68 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES ETHILON 3-0 663G 17.64 0270 SUPPLIES ETHILON NYL BLK MONO 4-0 662H 7.50 0270 SUPPLIES ETHILONE 4-0 8.00 0270 SUPPLIES ETHILONE 5-0 10.00 0270 SUPPLIES ETHILONE 6-0 14.00 0270 SUPPLIES EXAM GOWN 1.08 0270 SUPPLIES EXAMINATION GLOVE VYNIL LARGE 0.81 0270 SUPPLIES EXAMINATION GLOVE VYNIL MEDIUM 0.81 0270 SUPPLIES EXAMINATION GLOVE VYNIL SMALL 0.81 0270 SUPPLIES EXAMINATION GLOVE VYNIL XLARGE 0.75 0270 SUPPLIES EXCALIBUR SHAVER BLADE 4.0 306.00 0270 SUPPLIES EXT SET W/RATE FLOW REGULATOR 8.37 0270 SUPPLIES E-Z DERM PERDORATED 8X10 CM 156.03 0270 SUPPLIES FAN FOLD DRAPE 44 X 58 5.40 0270 SUPPLIES FENESTRADA 18 X 26 1.00 0270 SUPPLIES FETAL MONITORING BELT TG BB 10.50 0270 SUPPLIES FETAL SPIRAL ELECTRODE 18.48 0270 SUPPLIES FILTER BACTERIA/ VIRUS STANDARD 2.82 0270 SUPPLIES FILTER ELIM IV EXT 6.78 0270 SUPPLIES FILTER HCH/HME BACT/VIRAL 6.72 0270 SUPPLIES FILTRO .22 MICRONES 5.40 0270 SUPPLIES FIRM URETHAL STENT SET 5FR X 26CM 105.00 0270 SUPPLIES FLEX LINER SUCTION 1500 CC 3.51 0270 SUPPLIES FLEXBUMIN 25% SOLUTION 100ML 243.00 0270 SUPPLIES FLEXBUMIN 25% SOLUTION 50ML 159.24 0270 SUPPLIES FOLEY 2 WAY 14 FH 12.78 0270 SUPPLIES FOLEY 2 WAY 18 FH 12.78 0270 SUPPLIES FOLEY 3 WAY 24FR 2.89 0270 SUPPLIES FOLEY CATH SILICONE CODE 16 FR 7.35 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES FOLEY CATH SILICONE CODE 18 FR 7.35 0270 SUPPLIES FOLLEY 22fr 2 WAY 3.90 0270 SUPPLIES FOLLEY 24fr 2 WAY 2.46 0270 SUPPLIES FOLLEY CATH 16FR 14.40 0270 SUPPLIES FOLLEY CATH 18 FR 14.40 0270 SUPPLIES FOLLEY CATHERTER TRAY #16 15.45 0270 SUPPLIES FOLLEY CATHETER TRAY #14 14.28 0270 SUPPLIES FOLLEY CATHETER TRAY #20 14.70 0270 SUPPLIES FRTMAL WOUND CLEANSER 8OZ 12.51 0270 SUPPLIES FS ARTHROSCOPY PK CAT 163.20 0270 SUPPLIES FULL BODY BLANKETS 8.00 0270 SUPPLIES GASAS 2 X 2 N/S N/W 1.00 0270 SUPPLIES GASTRO (CLINIMIX) EXTENSION SET 3.48 0270 SUPPLIES GASTRO FILTER (LIPIDS) ELIM IV EXT 1.2 MICRON 7.20 0270 SUPPLIES GASTROSTOMY FEEDING TUBE 26 FR 150.00 0270 SUPPLIES GASTROSTOMY FEEDING TUBE 28 FR 150.00 0270 SUPPLIES GASTROSTOMY FEEDING TUBE PRH 50.10 0270 SUPPLIES GASTROSTOMY TUBE RIMACO 125.00 0270 SUPPLIES GAUZE 4X4 ESTERILE 12PLY 0.03 0270 SUPPLIES GAUZE N/STERIL 2X2 4PLY N/WOVEN 2.31 0270 SUPPLIES GAUZE STRETCH BAND ROLL ST 4' 0.84 0270 SUPPLIES GAUZE STRETCH BAND ROLL ST. 3" 0.81 0270 SUPPLIES GIGLI SAW BLADE 20" 3.45 0270 SUPPLIES GLIDE SCOPE LARYNGOSCOPES #3 19.50 0270 SUPPLIES GLIDE SCOPE LARYNGOSCOPES #4 19.50 0270 SUPPLIES GLOVE LATEX FREE POWDERED FREE SIZE 6 1.30 0270 SUPPLIES GLOVE LATEX FREE POWDERED FREE SIZE 7.5 1.62 0270 SUPPLIES GLOVE LATEX FREE POWDERED FREE SIZE 8 1.62 0270 SUPPLIES GLOVE LATEX FREE POWDERED FREE SIZE 8.5 1.62 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES GLOVE SURGICAL PROTEXIS LATEX SIZE 6.5 3.90 0270 SUPPLIES GLOVE SURGICAL PROTEXIS LATEX SIZE 7 1.62 0270 SUPPLIES GORRO CIRUJANO 1.00 0270 SUPPLIES GRASPER ENDO CLINCH II 5MM 300.00 0270 SUPPLIES GUANTES N/S P/F LARGE VYNIL 1.00 0270 SUPPLIES GUT CHROMIC 0 802H 8.22 0270 SUPPLIES GUT CHROMIC 1 905H 9.00 0270 SUPPLIES GUT CHROMIC 2-0 1112H 8.22 0270 SUPPLIES GUT CHROMIC 2-0 G 123H 8.25 0270 SUPPLIES GUT CHROMIC 3-0 G 122 8.25 0270 SUPPLIES GUT PLANE 2-0 953H 8.22 0270 SUPPLIES HALF SHEET 1.66 0270 SUPPLIES HEEL AND ELBOW PROTECTOR 15.15 0270 SUPPLIES HEEL/ELBOW PROTECTOR UNIVERSAL 10.65 0270 SUPPLIES HEMODIALISIS KIT 2 LUMEN 330.00 0270 SUPPLIES HEMOSTAT SURGICEL 2X14 89.55 0270 SUPPLIES HEMOSTAT SURGICEL 2X3 121.74 0270 SUPPLIES HEPARIN LOCK 2.67 0270 SUPPLIES HEPARIN LOCK BAX 2N3399 2.25 0270 SUPPLIES HUMID FLOW HME 14.28 0270 SUPPLIES HUMIDIFICADORES 4.26 0270 SUPPLIES HUT 18X18X18 53.73 0270 SUPPLIES HYDROCOLLOID DRESSING 6'X6' 30.00 0270 SUPPLIES HYDRODISSECTION CANNULA 27GA 55.00 0270 SUPPLIES HYDROGEL TUBE 9.00 0270 SUPPLIES HYPAFIX ADHESIVE DRESSING 18.00 0270 SUPPLIES ID BRACELET 3 PARTS OB 2.07 0270 SUPPLIES IMPLANTE DE ORTOPEDIA 313.08 0270 SUPPLIES INCENTIVE SPIROMETYRY 6.12 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES INDICADORES AUTO CLAVE 4" 1.00 0270 SUPPLIES INDICATOR STEAM STRIP LONG 1.44 0270 SUPPLIES INFANT STRAP 6" 7.05 0270 SUPPLIES INFO VAC 1000ML CANNISTER WITH GEL 231.00 0270 SUPPLIES INSOLATION GOWN YELLOW 0.78 0270 SUPPLIES INSULFATION TUBING SET 11.66 0270 SUPPLIES INSULINE SYRINGE 1ML 29G 0.69 0270 SUPPLIES INSYTE AUTO GUARD 16X 1.16" 5.67 0270 SUPPLIES INTRASITE GEL 13.50 0270 SUPPLIES IOBAN 2 ANTIMICROBIAL INCISE D RAPE 2.82 0270 SUPPLIES IRRIGATION TRAY WITH BULB SYRINGE 5.55 0270 SUPPLIES IV CATH PROTECT IV PLUS 20G 4.83 0270 SUPPLIES IV CATHETER PROTECT IV PLUS 22G 4.65 0270 SUPPLIES IV START KIT WITH CHLORAPREP 3.09 0270 SUPPLIES J&J BABY HEAD TO TOE WASH 9OZ 9.06 0270 SUPPLIES J&J BABY OIL 10.47 0270 SUPPLIES JACKSON-PRATT REF 7.63 0270 SUPPLIES JERINGUILLA 30ML 0.17 0270 SUPPLIES JERINGUILLA 3cc 1.65 0270 SUPPLIES JERINGUILLA 60cc 1.26 0270 SUPPLIES JERINGUILLA INSULINA 1.00 0270 SUPPLIES JERINGUILLA TUBERCULINA 1.00 0270 SUPPLIES JERINGUILLAS 5cc 2.19 0270 SUPPLIES J-VAC BILB SUCTION 300 CC 66.39 0270 SUPPLIES J-VAC BULB SUCTION 100 CC 60.84 0270 SUPPLIES KALTOSTAT DRESSING 18.90 0270 SUPPLIES KING HUT 24X24X24 64.11 0270 SUPPLIES KIT ACOMPANANTE OBSTETRICO 20.00 0270 SUPPLIES KIT DE ADMISION 10.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES KIT DE CUIDADO DE TRAQUEOSTOMIA 6.39 0270 SUPPLIES KIT DRAIN WOUND ROUND 20.85 0270 SUPPLIES KLEENSPEC 2.75 MM 1.80 0270 SUPPLIES KLEENSPEC 4.25MM 0.09 0270 SUPPLIES KRONNER MANIPUJECTOR (UTERINE) 4.95 0270 SUPPLIES LAB COAT WHITE LARGE WITH POCK 2.61 0270 SUPPLIES LAB COAT WHITE MEDIUM WITH POCK 2.61 0270 SUPPLIES LAB COAT WHITE SMALL WITH POCK 2.61 0270 SUPPLIES LAB COAT WHITE XLARGE WITH POCK 2.61 0270 SUPPLIES LACTADED RINGER 1000ML 4.77 0270 SUPPLIES LACTADED RINGER 500ML 4.05 0270 SUPPLIES LANCET SAFETY DYNAREX 0.33 0270 SUPPLIES LAPARATOMY PACK 37.80 0270 SUPPLIES LAPAROSCOPIC SCISSORS 39.90 0270 SUPPLIES LAPAROTOMY PACK 46.26 0270 SUPPLIES LAPAROTOMY SPONGE STERILE 0.99 0270 SUPPLIES LAPIZ DE CAUTERIO 9.48 0270 SUPPLIES LARGE RADIUS LOOP ELECTRODE 2.0 CM X 0.8 CM 63.00 0270 SUPPLIES LARGE RADIUS LOOP ELECTRODE 2.0 CM X 1.5 CM 63.00 0270 SUPPLIES LARGE RADIUS LOOP ELECTRODE 2.0 CM X 2.0 CM 63.00 0270 SUPPLIES LARYNGEAL MASK 3.5 REUSABLE 509.40 0270 SUPPLIES LARYNGEAL MASK 4.5 REUSABLE 509.40 0270 SUPPLIES LARYNGEAL MASK AIRWAY SILICON 68.52 0270 SUPPLIES LASER CAMERA DRAPE 9 X 96 8.46 0270 SUPPLIES LEEP BALL ELECTRODE R0312 20.00 0270 SUPPLIES LEGGINGS 4.30 0270 SUPPLIES LEMON GLYCERINE SWAP STICK 4.80 0270 SUPPLIES LEVEL LOCK 1.62 0270 SUPPLIES LEVIN STOMACH 14 fr 2.28 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES LEVIN STOMACH TUBE 10fr 2.01 0270 SUPPLIES LEVIN STOMACH TUBE 12fr 2.01 0270 SUPPLIES LEVIN STOMACH TUBE 16fr 3.15 0270 SUPPLIES LEVIN TUBE 12FR 2.01 0270 SUPPLIES LIGA CLIP MULTI APPLIER MCM 20 378.06 0270 SUPPLIES LIMB HOLDER PAIR 5.85 0270 SUPPLIES LINE FLEX SUCTION 3.51 0270 SUPPLIES LINEA DE OXIGENO 1.14 0270 SUPPLIES LINEAR STAPLER 60MM TL60 156.05 0270 SUPPLIES LINER SUCTION 3000 ML FLEX #65 3.81 0270 SUPPLIES LONE STAR DISPOSABLE RETRACTOR RING 32 60.00 0270 SUPPLIES LONE STAR ELASTIC STAYS 20MM X 20 MM (SPIRA 52.00 0270 SUPPLIES LONE STAR ELASTIC STAYS 6.5 MM X 16 MM (SOLID 47.00 0270 SUPPLIES LONE STAR RETRACTOR SYSTEM GINECOLOGY KIT 105.40 0270 SUPPLIES LOW TEMPERATURE CAUTERY 110.00 0270 SUPPLIES LUBRICATING GEL 3.66 0270 SUPPLIES M1910A FETAL MONITORING RECORD 5.25 0270 SUPPLIES MACINTOSH STANDARD BLADE CHILD 105.00 0270 SUPPLIES MACINTOSH STANDARD BLADE INFANT 97.50 0270 SUPPLIES MACINTOSH STANDARD BLADE SIZE 98.88 0270 SUPPLIES MASCARILLA EAR LOOP 1.00 0270 SUPPLIES MASCARILLA OXIGENO ADT 2.28 0270 SUPPLIES MASCARILLA OXIGENO PED 2.28 0270 SUPPLIES MASCARILLA SIMPLE SALA OPERACIONES 1.98 0270 SUPPLIES MASCARILLA TERAPIA ADULTO 3.69 0270 SUPPLIES MASCARILLA TERAPIA PEDIATRICO 1.94 0270 SUPPLIES MASCARILLAS DE ISOLACION 1.00 0270 SUPPLIES MASK AIR FILTER 3.48 0270 SUPPLIES MASK DISP HOSP FULL FACE LARGE 84.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES MASK DISP HOSP FULL FACE MED 84.00 0270 SUPPLIES MASK OXYGEN MEDIUM CONCENTRADO 1.98 0270 SUPPLIES MASK PARTICULATE FILTER N-95 2.64 0270 SUPPLIES MASK SURGICAL TIE ON 1.00 0270 SUPPLIES MASK VENTURY ADULT 4.50 0270 SUPPLIES MASK VENTURY KIT PED 4.52 0270 SUPPLIES MASK-N-95 3M 3.42 0270 SUPPLIES MAYO COVER STD W/PAD X 54 2.82 0270 SUPPLIES MCGRATH MAC BLADE SIZE 3 27.00 0270 SUPPLIES MCGRATH MAC BLADE SIZE 4 27.00 0270 SUPPLIES MD GASTROVIEW 30ML BOTTLES UNIT 31.50 0270 SUPPLIES MEDIAS ANTIEMBOLICAS 16.00 0270 SUPPLIES MEDICINE CUP 0.03 0270 SUPPLIES MEDICINE CUP 10z 1.00 0270 SUPPLIES MEPILEX BORDER POST OP 10X15 CM 10.38 0270 SUPPLIES MEPILEX BORDER POST OP 10X25 CM 11.14 0270 SUPPLIES MEPILEX BORDER POST OP 10X30CM 10.35 0270 SUPPLIES MERSILEN WITH WOVEN TAPE RS 22 83.52 0270 SUPPLIES MICROTAINER LAVANDER 1.65 0270 SUPPLIES MILEX TIS-U TRAP #10 MM RIGID 68.85 0270 SUPPLIES MILEX TIS-U TRAP #8 MM RIGID 65.85 0270 SUPPLIES MINOR LACERATION TRAY 9.48 0270 SUPPLIES MONOCRYL 3-0 Y 936H 6.86 0270 SUPPLIES MONOCRYL 4-0 Y 496G 21.90 0270 SUPPLIES MONOSOF 5.0 SN-661G 2.46 0270 SUPPLIES MONOSOF CN 3.76 0270 SUPPLIES MORDASA / SHROUND KIT ADT 8.40 0270 SUPPLIES MUCUS SPECIMEN TRAP 40CC 2.34 0270 SUPPLIES MULTIFUNCTION INSTRUMENT SYSTEM 56.50 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES MYSTIC II PUMP 132.99 0270 SUPPLIES N/S 3ml (TERAPIA) 1.00 0270 SUPPLIES NASOFARYNGEAL AIRWAR 26FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 14FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 18FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 20FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 24FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 28FR 25.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 30FR 28.50 0270 SUPPLIES NASOFARYNGEAL AIRWAY 32FR 28.50 0270 SUPPLIES NEEDLE COUNTER 3.63 0270 SUPPLIES NEEDLE ECLIPSE 18X 1-1/2 0.60 0270 SUPPLIES NEEDLE ECLIPSE 22X1 0.57 0270 SUPPLIES NEEDLE ECLIPSE 23 G 0.72 0270 SUPPLIES NEEDLE ECLIPSE 25 G 1.08 0270 SUPPLIES NEEDLE HYPO SAFETY 20G X 1 0.42 0270 SUPPLIES NEONATAL TUBE HOLDER 11.17 0270 SUPPLIES NEWBORN FOOT PRINTER 2.40 0270 SUPPLIES NITRILE GLOVE MEDIUM 0.12 0270 SUPPLIES NITRILE GLOVES LARGE 0.12 0270 SUPPLIES NITRILE GLOVES SMALL 0.12 0270 SUPPLIES NITROGLYCERIN 50MG 250ML 14.49 0270 SUPPLIES NITROGLYCERIN PUMP IV SET 22.50 0270 SUPPLIES NON REABRITHING 25.00 0270 SUPPLIES NON REBREATHING O2 MASK 4.50 0270 SUPPLIES NORMAL SALINA 1000 CC 18.00 0270 SUPPLIES NORMAL SALINA 500ML 10.00 0270 SUPPLIES NORMAL SALINE F/IRRIGA VIA FLEX 16.50 0270 SUPPLIES NUROLON 0 C 541D 58.23 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES NURSE CAP BLUE GLOBAL HEATLH 0.12 0270 SUPPLIES NYL BLK MONO 5-0 661G 7.65 0270 SUPPLIES NYLBLK MONO 2-0 664H 7.71 0270 SUPPLIES OASIS (REF 401) IRRIGATING CYSTOTOME 25G X 7/8 3.50 0270 SUPPLIES OB PACK #SMA 30 FS PRC 57.72 0270 SUPPLIES OBTRETICAL TOWELETTE 0.12 0270 SUPPLIES OPEN END URETHAL CATETER 6FR./70.CM 13.00 0270 SUPPLIES OPEN END URETHAL CATHETER 5 FR/70CM 13.00 0270 SUPPLIES OPSITE OPD RESSING 25CM X 10 3.60 0270 SUPPLIES OPSITE POST OO DRESSING 13 3/4 10.80 0270 SUPPLIES OPSITE POST OP COMPOSITE DRESS 10X4 6.00 0270 SUPPLIES OPSITE POST OP DRESSING 2 1/2 1.80 0270 SUPPLIES OPSITE POST OP DRESSING 3 3/4 2.34 0270 SUPPLIES OPSITE POST OP DRESSING 6 1/8 4.50 0270 SUPPLIES OPSITE POST OP DRESSING 8 X 4 20 5.25 0270 SUPPLIES OPTIRAY 320 X 100 (FACT 100 UNIDADES) 111.75 0270 SUPPLIES OPTIRAY 320 X 125 (FACT 125 UNIDADES) 126.00 0270 SUPPLIES OPTIRAY 320 X 75 (FACT 75 UNIDADES) 97.20 0270 SUPPLIES OPTIRAY 320X50 (FACT 50 UNIDADES) 84.00 0270 SUPPLIES ORAL PHARYNGEAL AIRWAY 100MM 4.20 0270 SUPPLIES ORAL PHARYNGEAL AIRWAY 90MM 4.20 0270 SUPPLIES ORAL PHARYNGEL AIRWAY 80MM 4.20 0270 SUPPLIES OXIGEN TUBE 84" CONNECTOR 1.14 0270 SUPPLIES OXIGENO 1 A 8 HORAS 71.52 0270 SUPPLIES OXIGENO 8 A 24 HORAS (DAILY) 143.04 0270 SUPPLIES OXIMETRY PULSE 45.00 0270 SUPPLIES OXY TENT 30.00 0270 SUPPLIES OXYGEN NON REBREATHER MASK ADULT 2.82 0270 SUPPLIES PAD DE CAUTERIO 8.88 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES PAD MATERNITY 11IN W TAIL STERILE 0.57 0270 SUPPLIES PAMPER NEWBORN 0.99 0270 SUPPLIES PAMPERS ADULTOS L 1.20 0270 SUPPLIES PAMPERS ADULTOS M 0.90 0270 SUPPLIES PAMPERS ADULTOS XL 1.17 0270 SUPPLIES PAMPERS BARIATRIC 1.14 0270 SUPPLIES PANALES ADULTO LARGE 1.32 0270 SUPPLIES PANALES ADULTO MED 1.35 0270 SUPPLIES PAPEL DE CAMILLA 21 X 225 1.00 0270 SUPPLIES PATIENT PACK DISPOSABLE GOWN 3.25 0270 SUPPLIES PATIENT SET UP BAG 0.45 0270 SUPPLIES PATRIOT COLLAR ADULT 26.10 0270 SUPPLIES PATRIOT COLLAR ADULT PROCAR 25.17 0270 SUPPLIES PATRIOT COLLAR PEDIATRIC 26.10 0270 SUPPLIES PDS 0 VL J370H 38.91 0270 SUPPLIES PDS II Z340 3.61 0270 SUPPLIES PDS PLUS 1PDP341 4.14 0270 SUPPLIES PED/INF LUMBAR PUNCT LIDO 22G 21.78 0270 SUPPLIES PEN ROSE 18 X 1/2 0.99 0270 SUPPLIES PEN ROSE 18 X 1/4 2.28 0270 SUPPLIES PERI-GYN PACK #9165 24.45 0270 SUPPLIES PLAIN GUT 853 2.64 0270 SUPPLIES PRECISION H CHRONIC CATHETER KIT 152.50 0270 SUPPLIES PREMIERE CTF POCUH BGE UP 2 1/2 7.92 0270 SUPPLIES PREVAIL PREOP PREP A VIAL 30114 16.23 0270 SUPPLIES PROFORE LF 21.41 0270 SUPPLIES PROLENE 0 BLUE 8424H 10.47 0270 SUPPLIES PROLENE 1 BLUE 8425H 9.84 0270 SUPPLIES PROLENE 2-0 8417H 5.21 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES PROLENE 2-0 BLUE 8685H 10.02 0270 SUPPLIES PROLENE MESH 12X12 ETHICON 682.71 0270 SUPPLIES PROLENE POLYPROPYLENE MESH 3X6 174.99 0270 SUPPLIES PROTECT IV PLUS CATH 18X1 1/4 4.65 0270 SUPPLIES PROTECTIVE GOWN BLUE UNIVERSAL 1.38 0270 SUPPLIES PROTEXIS PI ORTHO 9.0MM 0.75 0270 SUPPLIES PVC FEEDING TUBE 5FR 3.48 0270 SUPPLIES PVC FEEDING TUBE 8FR 28.80 0270 SUPPLIES PVC URETHAL CATHETER 14FR 0.41 0270 SUPPLIES Q4 ORAL CLEANSING SUCTION 99.00 0270 SUPPLIES QUINCKE SPINAL NEEDLE ANESTESIA 14.88 0270 SUPPLIES RELOADS FOR ATW 45 306.24 0270 SUPPLIES REMOVES WIPES 0.51 0270 SUPPLIES REPLICARE 6X6 10.00 0270 SUPPLIES RESUSCITADOR MANUAL DISP ADULT 49.11 0270 SUPPLIES RETRIEVAL BAG 142.11 0270 SUPPLIES SAFETY SMALL VEIN SET 23 11.40 0270 SUPPLIES SALINA IRRIGA STERILE 250ML 6.00 0270 SUPPLIES SALINE .45% WATER 1000ML 5.37 0270 SUPPLIES SALINE .45% WATER 500ML 3.60 0270 SUPPLIES SALINE .9% WATER 1000ML 3.75 0270 SUPPLIES SALINE .9% WATER 100ML 2.85 0270 SUPPLIES SALINE .9% WATER 25 ML 4.80 0270 SUPPLIES SALINE .9% WATER 250ML 2.82 0270 SUPPLIES SALINE .9% WATER 50ML 2.85 0270 SUPPLIES SALINE 0.45% WATER 500ML 3.00 0270 SUPPLIES SALINE IRRIGATION .9% 3000ML 5.49 0270 SUPPLIES SANI-CLOTH PLUS GERMICIDAL LARGE 20.64 0270 SUPPLIES SCRUB BRUSH ST 0.81 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES SECONDARY MEDICATION 2.20 0270 SUPPLIES SENSA TRACK PAD 32.40 0270 SUPPLIES SHARP CONTAINER ROJO 5.4 11.25 0270 SUPPLIES SHOE COVER FLUID RESISTANT 0.30 0270 SUPPLIES SHROUD KIT ADULT 54 X 108 9.18 0270 SUPPLIES SILK 0 BLK BRD K 848H 7.32 0270 SUPPLIES SILK 2-0 423H 2.40 0270 SUPPLIES SILK 2-0 BLK BRD K 833H 7.17 0270 SUPPLIES SILK 3-0 A 304H 15.63 0270 SUPPLIES SILK 3-0 BLK BRD K 832H 7.17 0270 SUPPLIES SILK 7-0 G-6 8.0MM 45.00 0270 SUPPLIES SILK BLK BRD A305H 20.49 0270 SUPPLIES SODIUM CLORIDE PRESILED NORMAL SALINE 0.46 0270 SUPPLIES SPECIMEN COLLECTOR STERILE 0.45 0270 SUPPLIES SPINAL NEEDLE 22 WHITACRE 29.52 0270 SUPPLIES SPINAL NEEDLE 27 GA X 3.50N 4.95 0270 SUPPLIES SPINAL NEEDLE ANESTESIA 22G 8.40 0270 SUPPLIES SPINAL NEEDLE ANESTESIA 26 13.23 0270 SUPPLIES SPONGE X-RAY 4X4 ST 0.27 0270 SUPPLIES STABIL TUBE (HOLDER) 25.89 0270 SUPPLIES STAPLE REMOVER 0.45 0270 SUPPLIES STAPLER SKIN WIDE W35 40.26 0270 SUPPLIES STER WATER F/IRRIG 250ML 6.06 0270 SUPPLIES STERI STRIP 1/2 X4 14.64 0270 SUPPLIES STERI STRIP 1/4 0.84 0270 SUPPLIES STERI-D RAPE LONG U-D RAPE 11.39 0270 SUPPLIES STERI-DRAPE C ARM 16.80 0270 SUPPLIES STERILE HIMA TUR PACK 100.92 0270 SUPPLIES STERILE SALINE IRRIGATION 500ML 4.68 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES STOCKINETTE 3X25 31.50 0270 SUPPLIES STOCKINETTE 4'X25 40.65 0270 SUPPLIES STOCKINETTE 6X25 YDS 57.75 0270 SUPPLIES STOOL CONTAINER 0.33 0270 SUPPLIES STRAIGHT HANDEL H CONTROL 141.00 0270 SUPPLIES STRETCH GAUZE 3' 0.96 0270 SUPPLIES STRETCH GAUZE 3" 0.52 0270 SUPPLIES STRETCH GAUZE 4' 0.99 0270 SUPPLIES STRIPS TEST CIDEX OPA 3.20 0270 SUPPLIES STYLET 14FR 7.89 0270 SUPPLIES SUCTION CATHETER 0.20 0270 SUPPLIES SUCTION CATHETER 10FR 0.60 0270 SUPPLIES SUCTION CATHETER 12 FR 0.60 0270 SUPPLIES SUCTION CATHETER 14 FR 0.60 0270 SUPPLIES SUCTION CATHETER 16 FR 0.60 0270 SUPPLIES SUGICAL CLIPPER BLADE 2.43 0270 SUPPLIES SUPLIDO YESO CORTO 50.00 0270 SUPPLIES SURGEONS CAPS SMS 0.27 0270 SUPPLIES SURGICAL FACE MASK 0.18 0270 SUPPLIES SURGICAL GOWN LARGE 8.79 0270 SUPPLIES SURGICAL GOWN XLARGE 9.39 0270 SUPPLIES SURGILON 0 GS-21 TAPER BRAIDED 7.26 0270 SUPPLIES SUTURE MONOSOF 2 30 G18 14.25 0270 SUPPLIES SUTURE POLYSORB 0 27 GS-21 6.00 0270 SUPPLIES SUTURE POLYSORB 0 36 GS-25 7.83 0270 SUPPLIES SUTURE POLYSORB 1 27 GS-21 6.84 0270 SUPPLIES SUTURE REMOVAL KIT STERILE 1.35 0270 SUPPLIES SUTURE SURGIGUT 0 36 GS-25 5.25 0270 SUPPLIES SUTURE SURGIGUT 2-0 30 GS-24 6.66 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES SWABSTICK PROVIDIONIDE IODINE B 0.27 0270 SUPPLIES SWABTICK PROVIDIONIDE LODINE B 0.10 0270 SUPPLIES SYRINGE 10CC L/ LOCK W/O NEEDLE 0.18 0270 SUPPLIES SYRINGE 20CC L/ LOCK W/O NEEDLE 0.30 0270 SUPPLIES SYRINGE 3CC L/ LOCK W/O NEEDLE 0.18 0270 SUPPLIES SYRINGE 5CC L/ LOCK W/O NEEDLE 0.27 0270 SUPPLIES SYRINGE 60 CC 1.71 0270 SUPPLIES SYRINGE SAFETYLOCK 1ML 29G 1/2 10.65 0270 SUPPLIES TA 90-3.5 SINGLE USE RELOAD 888.00 0270 SUPPLIES TAPE TRANSPORE 1' X 10YDS 2.70 0270 SUPPLIES TAPE TRANSPORE 2' X10YDS 2.70 0270 SUPPLIES TAPER GUARD EVAC SIZE 6.0 ENDO 28.80 0270 SUPPLIES TAPER GUARD EVAC SIZE 6.5 ENDO 28.80 0270 SUPPLIES TAPER GUARD EVAC SIZE 7 ENDO 28.80 0270 SUPPLIES TAPER GUARD EVAC SIZE 7.5 ENDO 28.80 0270 SUPPLIES TAPER GUARD EVAC SIZE 8 ENDO 28.80 0270 SUPPLIES TAPER GUARD EVAC SIZE 8.5 ENDO 28.80 0270 SUPPLIES TC DSE 72H 14 FR WT PACK 41.04 0270 SUPPLIES TERAPIA DE OXIGENO MASCARILLA 60.00 0270 SUPPLIES THERMOMETER ORAL PROBE COVER 0.12 0270 SUPPLIES THORACENTESIS/PARASENTESIS TRA 90.00 0270 SUPPLIES THORACIC CATH 12 FH 10.53 0270 SUPPLIES THORACIC CATH 16 FH 10.53 0270 SUPPLIES THORACIC CATHETER 36 FR 3.40 0270 SUPPLIES THRACHEOSTOMY TUBE CUFFED 7.00MM 8.50 0270 SUPPLIES TONGUE DEPRESSOR STERILE 6' 0.09 0270 SUPPLIES TOPICAL SKIN ADHESIVE PEN 115.47 0270 SUPPLIES TOURNIQUET 1'X18' 0.30 0270 SUPPLIES TRACH TUBE CUFFED SZ 7.0MM 10.50 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES TRACHEOSTOMY CARE KIT 6.39 0270 SUPPLIES TRACHEOSTOMY TUBE CUFF 10MM 34.50 0270 SUPPLIES TRACHEOSTOMY TUBE CUFF 5.5MM 31.50 0270 SUPPLIES TRACHEOSTOMY TUBE CUFF 6.5MM 34.50 0270 SUPPLIES TRANSEPTIC 174.60 0270 SUPPLIES TRAY FOLEY SIL-ELAST 14FR 10M 19.26 0270 SUPPLIES TRIPLE LUMEN (SUBCLAVIA KIT) 240.00 0270 SUPPLIES TROCAR 11MM 99.00 0270 SUPPLIES TROCAR 12MM 108.00 0270 SUPPLIES TROCAR 5MM 63.00 0270 SUPPLIES TUBE LEVIN 14FR VINYL 1.98 0270 SUPPLIES TUBE LEVIN 16FR VINYL 1.98 0270 SUPPLIES TUBE LEVIN 18 FR 1.98 0270 SUPPLIES TUBE VACUTAINER 2.7 LIGHT BLUE 0.30 0270 SUPPLIES TUBE VACUTAINER GREEN 6ML 0.39 0270 SUPPLIES TUBE VACUTAINER HEM 3ML 0.24 0270 SUPPLIES TUBE VACUTAINER RED 4ML 0.21 0270 SUPPLIES TUBING INSUFFLATION MALE 32.25 0270 SUPPLIES U CONNECT IT OXYGEN TUBING 0.96 0270 SUPPLIES ULTIPOR 100 BREATHING SYSTEM 15.00 0270 SUPPLIES ULTRAPO PLUG HERNIA LARGE REF UPP 165.00 0270 SUPPLIES ULTRAPRO PLUG HERNIA MEDIUM REF UPP 165.00 0270 SUPPLIES ULTRAPRO PLUG HERNIA REPAIR SMALL REF UPPS 165.00 0270 SUPPLIES UNDERPADS DISP 23 X 36 0.39 0270 SUPPLIES UNIV ELECTROSURGICAL PAD SPLIT 9.51 0270 SUPPLIES UNIVERSAL PLUS 5MM 61.05 0270 SUPPLIES UNIVERSAL PLUS 5MM SUCTION 61.05 0270 SUPPLIES URETHRAL CATHETER TRAY 14 FR 5.70 0270 SUPPLIES URINARY 5.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES URINARY DRAINAGE 3.78 0270 SUPPLIES URINE KIT COLLECTOR 0.36 0270 SUPPLIES UTERINE EXPLORA 3MM CURETTE WITH VACU LOK 10.95 0270 SUPPLIES UTERINE MANIPULATOR INJECTOR 75.00 0270 SUPPLIES UTERINE SUCTION 8MM 22.95 0270 SUPPLIES V.A.C DRAPE 45.00 0270 SUPPLIES V.A.C GRANUFORM BRIDGE XG DRESSING 228.00 0270 SUPPLIES V.A.C GRANUFORM MEDIUM DRESSING 166.98 0270 SUPPLIES V.A.C. FREEDOM 300ML CANISTER 138.06 0270 SUPPLIES VACUNTAINER HOLDER ONE USE 0.09 0270 SUPPLIES VAGINAL SPECULUM LARGE 0.90 0270 SUPPLIES VAGINAL SPECULUM MED 0.84 0270 SUPPLIES VAGINAL SPECULUM SMALL 0.75 0270 SUPPLIES VENAFLOW ELITE CALF CUFF 66.30 0270 SUPPLIES VICRYL 0 J340 HCT-1 9.03 0270 SUPPLIES VICRYL 0 J370H 3.25 0270 SUPPLIES VICRYL 0 PLUS (ANT) VCP376H 3.80 0270 SUPPLIES VICRYL 1 J 341H CT-1 9.12 0270 SUPPLIES VICRYL 2-0 J 339H 9.18 0270 SUPPLIES VICRYL 2-0 J317H 9.18 0270 SUPPLIES VICRYL 3-0 J316H 2.88 0270 SUPPLIES VICRYL 3-0 J423H 3.05 0270 SUPPLIES VICRYL 4-0 J 422H 9.24 0270 SUPPLIES VICRYL PDS 1 J371H 10.11 0270 SUPPLIES VIVRYL 4-0 J662H 10.05 0270 SUPPLIES VOLTREX VX PORT (QUIMO PORT) 840.00 0270 SUPPLIES WATER IRRIGA STERILE 3000ML 5.28 0270 SUPPLIES WATER IRRIGA STERILE 500ML 6.18 0270 SUPPLIES WOVEN FILIFORM 3FR 60.00 Rev. June, 2020

CodeGroup Description Price 0270 SUPPLIES WOVEN FILIFORM FOLLOWER 90.00 0270 SUPPLIES XEROFORM 2.43 0270 SUPPLIES XRAY DETECTABLE 4X4 STERILE GAUZE (RT) 0.93 0270 SUPPLIES Y TYPE BLOOD SET 112" 24.75 0270 SUPPLIES YANKAUER SUCTION TUBE BULB 14.58 0270 SUPPLIES YESO DYNACAST 2" X 15 FT 162.00 0270 SUPPLIES Y-TYPE TUR/BLADDER IRRIGATION SET 2C4041 6.67 0270 SUPPLIES Y-TYPE TURB/BLADDER IRRIGATION SET 4.50 0270 SUPPLIES ZIP WIRE HYDROPHILIC GUI 35.80 0270 SUPPLIES ZOLL MULTI FUNCTION ELECTRODES 90.00 0272 SUPPLIES 38570 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 38571 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 38572 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 43280 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 43651 LAP, SURGIAL TRANSECTION OF VAGUS NERVES, TRUNCAL 350.00 0272 SUPPLIES 43652 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 43653 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44180 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 44202 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44203 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44204 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44205 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44206 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44207 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44213 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 44970 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 47562 LAPARASCOPIA TRIPLE S 350.00 0272 SUPPLIES 47562 MATERIALES QURURGICOS 350.00 0272 SUPPLIES 49000 MATERIALES QUIRURGICOS 49000 350.00 Rev. June, 2020

CodeGroup Description Price 0272 SUPPLIES 49010 MATERIALES QUIRURJICOS 350.00 0272 SUPPLIES 49320 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49321 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 49322 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49323 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49650 MATERIAL QUIRURGICO 350.00 0272 SUPPLIES 49651 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49652 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49653 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 49654 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 49655 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 49656 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 49657 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 55550 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58545 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58546 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58548 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58550 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58552 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58553 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58554 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58555 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58558 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58570 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58571 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58660 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 58661 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 58662 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES 58670 MATERIALES QUIRURJICOS 350.00 Rev. June, 2020

CodeGroup Description Price 0272 SUPPLIES 58671 MATERIALES QUIRURGICOS 350.00 0272 SUPPLIES 58672 MATERIALES QUIRUGICOS 350.00 0272 SUPPLIES A4649 GIA 6038L SINGLE USE LOADING UNIT 285.00 0272 SUPPLIES A4649 GIA6038S SINGLE USE RELOADABLE STAPLER 500.00 0272 SUPPLIES BANDEJA DE SUTURA 50.00 0272 SUPPLIES CHEST TUBE 25.00 0272 SUPPLIES KNEE REPLACEMENT 4,175.00 0272 SUPPLIES TA9035S SINGLE RELOADABLE STAPLER 888.00 0274 SUPPLIES L8699 PROSTHETIC IMPLANT 5,000.00 0274 SUPPLIES SUPLIDO YESO LARGO 50.00 0275 SUPPLIES C1722 AICD, SINGLE CHAMBER 5,000.00 0275 SUPPLIES C1781 MESH 1,000.00 0275 SUPPLIES C1785- PACEMAKER DUAL CHAMBER 5,000.00 0275 SUPPLIES C1786 PACEMAKER SINGLE CHAMBER 5,000.00 0275 SUPPLIES C1882 AICD, OTHER THAN SING/DUAL 10,000.00 0275 SUPPLIES MESH 1,000.00 0276 SUPPLIES V2630 LENTE INTRAOCULAR 200.00 0276 SUPPLIES V2632 LENTE INTRAOCULAR 200.00 0278 SUPPLIES FEMORAL FEMORAL BYPASS 460.00 0278 SUPPLIES FEMORAL POPLITEAL VEIN BYPASS (35585) 695.00 0278 SUPPLIES MESH 1,372.00 0278 SUPPLIES VASCULAR SHUNT 695.00 0279 SUPPLIES A4301 IMPLANTABLE ACCESS SYST PERC 1,000.00 0279 SUPPLIES A4649 GASTROSTOMY TUBE RIMACO 125.00 0279 SUPPLIES A4740 SHUNT 1,380.00 0279 SUPPLIES B4082 NASOGASTRIC TUBING WITHOUT STYLET 100.00 0279 SUPPLIES BANDEJA ORTOPEDIA 5,000.00 0279 SUPPLIES C1729 CATHETER DRAINAGE 318.84 0279 SUPPLIES C1750 CATH HEMODIALYSIS 550.00 Rev. June, 2020

CodeGroup Description Price 0279 SUPPLIES C1751 CATH CENTRAL VEIN 550.00 0279 SUPPLIES C1788 PORT INDWELLING (IMPLANTABLE) 280.00 0279 SUPPLIES C2621 PACEMAKER, OTHER THAN SINGLE OR DUAL CHAMBER 5,000.00 0279 SUPPLIES CATAPRES 5.00 0279 SUPPLIES ESTRADIOL 35.00 0279 SUPPLIES L8699 PROSTHETIC IMPLANT NOS 5,000.00 0279 SUPPLIES NORMAL SALINA 250 CC 12.00 0279 SUPPLIES NORMAL SALINA 500CC 15.00 0300 LABORATORY % OF SATURATION / TIBC-IRON**DUPLICADO** 32.00 0300 LABORATORY (LAB) ARTERIAL BLOOD GASES 125.00 0300 LABORATORY .. DUPLICADO CULTURE ENVIRONMENT 48.00 0300 LABORATORY .. DUPLICADO CULTURE HD CATHETER 48.00 0300 LABORATORY ..DUPLICADO FIBRINOGEN 30.00 0300 LABORATORY 86985 FRACCIONES DE PRODUCTO 25.00 0300 LABORATORY ACETALDEHYDE BLOOD 36.00 0300 LABORATORY ACETYLCHOLINESTERASE 382.00 0300 LABORATORY ACTINOMYCES AB 18.00 0300 LABORATORY ACYLCARNITINES QUAL EA 270.00 0300 LABORATORY ACYLCARNITINES QUAN EA 36.00 0300 LABORATORY ADAMTS-13 COAGULATION AND FIBRINOLYSIS, FUNCTIONAL ACTIVITY, NOT OTHERWISE SPECIFIED 350.00 0300 LABORATORY ADENOSINE 5 MONOPHOSPHATE CYCLIC 42.00 0300 LABORATORY ADENOVIRUS AB 79.00 0300 LABORATORY ADENOVIRUS AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY ADENOVIRUS AG BY IMMUNOFLUORESCENT 79.00 0300 LABORATORY AGGLUTINATION PARTICLE SCREEN EA AB 72.00 0300 LABORATORY ALBUMIN FLUID/OTHER SOURCE 16.00 0300 LABORATORY ALBUMIN ISCHEMIA MODIFIED 24.00 0300 LABORATORY ALCOHOL ETHANOL BREATH 93.00 0300 LABORATORY ALCOHOL ETHANOL EXCEPT BREATH 93.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY ALKALOIDS URINE QUAN 54.00 0300 LABORATORY ALLERGEN IGE QUAL 192.00 0300 LABORATORY ALLERGEN IGE QUAN 516.00 0300 LABORATORY ALLERGEN IGG QUAN 30.00 0300 LABORATORY ALPHA 1 ANTITRYPSIN PHENOTYPE 88.00 0300 LABORATORY ALPHA FETO PROTEIN MATERNAL 27.00 0300 LABORATORY ALUMINUM 108.00 0300 LABORATORY AMINO ACIDS 2 TO 5 QUAN EA SPEC 36.00 0300 LABORATORY AMINO ACIDS 6 OR MORE QUAN EA 36.00 0300 LABORATORY AMINO ACIDS MULTIP QUAL EA SPEC 96.00 0300 LABORATORY AMINO ACIDS SINGLE QUAL EA SPEC 96.00 0300 LABORATORY AMINO ACIDS SINGLE QUAN EA SPEC 96.00 0300 LABORATORY AMINOLEVULINIC ACID DELTA ALA 148.00 0300 LABORATORY AMITRIPTYLINE (ELAVIL) 144.00 0300 LABORATORY AMNIOTIC FLUID 1,283.00 0300 LABORATORY AMNIOTIC FLUID CELLS NON-NEOPLASTIC DISORDER 64.00 0300 LABORATORY AMNIOTIC FLUID SPECTROPHOTOMETRIC 96.00 0300 LABORATORY AMPHETAMINE METHAMPHETAMINE 84.00 0300 LABORATORY ANCA SCREEN 275.00 0300 LABORATORY ANDROSTANEDIOL GLUCURONIDE 156.00 0300 LABORATORY ANDROSTENEDIONE 289.00 0300 LABORATORY ANDROSTERONE 180.00 0300 LABORATORY ANGIOTENSIN II 72.00 0300 LABORATORY ANIMAL INOCULATION W OBSERV 30.00 0300 LABORATORY ANIMAL INOCULATION W OBSERV & DISSEC 36.00 0300 LABORATORY ANTI CCP 120.00 0300 LABORATORY ANTI DNA DOUBLE STRANDED 80.00 0300 LABORATORY ANTI DNA SINGLE STRANDED 114.00 0300 LABORATORY ANTIBODY CHLAMYDIA 29.20 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY ANTIBODY ELUTION EA ELUTION 84.00 0300 LABORATORY ANTIBODY SCREEN EA TECHNIQUE 18.00 0300 LABORATORY ANTICARDIOLIPIN PANEL 161.00 0300 LABORATORY ANTIDIURETIC HORMONE ADH (VASOPRESSIN) 394.00 0300 LABORATORY ANTIGEN UNLISTED EA 18.00 0300 LABORATORY ANTIMICROBIAL AGENT AGAR DILUTION 19.00 0300 LABORATORY ANTIMICROBIAL AGENT DISK METHOD 6.00 0300 LABORATORY ANTIMICROBIAL AGENT ENZYME DETECTION 12.00 0300 LABORATORY ANTIMICROBIAL AGENT MACROBROTH 12.00 0300 LABORATORY ANTIMICROBIAL AGENT MIC 60.00 0300 LABORATORY ANTIMICROBIAL AGENT MLC 18.00 0300 LABORATORY ANTIMICROBIAL AGENT MYCOBACTERIA 60.00 0300 LABORATORY ANTI-MICROSOMAL ANTIBODIES 58.00 0300 LABORATORY ANTIPLASMIN ALPHA-2 18.00 0300 LABORATORY ANTITHROMBIN III ACTIVITY 96.00 0300 LABORATORY ANTITHROMBIN III AG ASSAY 108.00 0300 LABORATORY APC ACTIVATED PROTEIN C 131.00 0300 LABORATORY APOLIPOPROTEIN 170.00 0300 LABORATORY ARSENIC 170.00 0300 LABORATORY ASPERGILLUS AB 120.00 0300 LABORATORY ATOMIC ABSORPTION SPECTROSCOPY 192.00 0300 LABORATORY AUTOLOGOUS BLOOD COLLECT INTRAOPERATIVE 96.00 0300 LABORATORY B CELLS 180.00 0300 LABORATORY BARBITURATES 48.00 0300 LABORATORY BARTONELLA AB 18.00 0300 LABORATORY BARTONELLA AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY BARTONELLA DIRECT PROBE BY DNA 36.00 0300 LABORATORY BARTONELLA QUANTIFICATION BY DNA 72.00 0300 LABORATORY BETA 2 GLYCOPROTEIN I AB EA 68.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY BETA-2 MICROGLOBULIN 68.00 0300 LABORATORY BILE ACIDS CHOLYLGLYCINE 125.00 0300 LABORATORY BILE ACIDS TOTAL 125.00 0300 LABORATORY BILIRUBIN FECES INDIRECT QUAL 35.00 0300 LABORATORY BILIRUBIN TOTAL/ INDIRECT 115.00 0300 LABORATORY BIOTINIDASE EA SPEC 36.00 0300 LABORATORY BLASTOMYCES AB 30.00 0300 LABORATORY BLEEDING TIME 25.00 0300 LABORATORY BLOOD GRAM STAIN**DUPLICADO 87210*** 48.00 0300 LABORATORY BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 6.00 0300 LABORATORY BLOOD SMEAR PERIPHERAL 25.00 0300 LABORATORY BLOOD TYPING RH PHENOTYPING 18.00 0300 LABORATORY BLOOD TYPING SCREEN RBC ANTIGENS 12.00 0300 LABORATORY BMP 25.00 0300 LABORATORY BONE MARROW SMEAR 24.00 0300 LABORATORY BORDETELLA AB 174.00 0300 LABORATORY BORDETELLA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY BORELIA AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY BORELIA DIRECT PROBE BY DNA 36.00 0300 LABORATORY BORELIA QUANTIFICATION BY DNA 84.00 0300 LABORATORY BORRELIA AB RELAPSING FEVER 144.00 0300 LABORATORY BORRELIA BURGDORFERI AB 160.00 0300 LABORATORY BORRELIA BURGDORFERI AB CONFIRMATORY 36.00 0300 LABORATORY BRADYKININ 30.00 0300 LABORATORY BRUCELLA AB 228.00 0300 LABORATORY BUN SEMIQUAN 16.00 0300 LABORATORY BUN SEMIQUAN. 16.00 0300 LABORATORY C ANCA 275.00 0300 LABORATORY CA 50 CA 72-4 CA 549 EA 189.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CADMIUM 173.00 0300 LABORATORY CALCITONIN 144.00 0300 LABORATORY CALCULUS QUAL 32.00 0300 LABORATORY CALCULUS QUAN 32.00 0300 LABORATORY CALCULUS SPECTROSCOPY 30.00 0300 LABORATORY CALCULUS XRAY DIFFRACTION 30.00 0300 LABORATORY CAMPYLOBACTER AB 48.00 0300 LABORATORY CANDIDA AB 36.00 0300 LABORATORY CANDIDA AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY CANDIDA DIRECT PROBE BY DNA 36.00 0300 LABORATORY CANDIDA QUANTIFICATION BY DNA 72.00 0300 LABORATORY CANDIDA SKIN TEST 18.00 0300 LABORATORY CARBAMAZEPINE FREE (TEGRETOL FREE) 56.00 0300 LABORATORY CARBOHYDRATE DEFICIENT 96.00 0300 LABORATORY CARBON MONOXIDE QUAL 24.00 0300 LABORATORY CARBON MONOXIDE QUAN 112.00 0300 LABORATORY CARDIAC PROFILE 180.00 0300 LABORATORY CAROTENE 48.00 0300 LABORATORY CATECHOLAMINES TOTAL BLOOD 188.00 0300 LABORATORY CATECHOLAMINES TOTAL FRACT 188.00 0300 LABORATORY CATECHOLAMINES TOTAL URINE 188.00 0300 LABORATORY CATHEPSIN-D 36.00 0300 LABORATORY CBC DIFF 12.00 0300 LABORATORY CD34 STEM CELLS TOTAL COUNT 180.00 0300 LABORATORY CD4 COUNT 40.00 0300 LABORATORY CERULOPLASMIN 58.00 0300 LABORATORY CHEMILUMINESCENT ASSAY 30.00 0300 LABORATORY CHEMOTAXIS ASSAY 36.00 0300 LABORATORY CHLAMYDIA AG BY ENZYME IMMUNOASSAY QUAL 30.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CHLAMYDIA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY CHLAMYDIA PNEUM AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY CHLAMYDIA PNEUM DIRECT PROBE BY DNA 108.00 0300 LABORATORY CHLAMYDIA PNEUM QUANTIFICATION BY DNA 84.00 0300 LABORATORY CHLAMYDIA TRACHO BY IMMUNOASSAY 30.00 0300 LABORATORY CHLAMYDIA TRACHO DIRECT PROBE BY DNA 176.00 0300 LABORATORY CHLAMYDIA TRACHO QUANTIFICATION BY DNA 114.00 0300 LABORATORY CHLORAMPHENICOL 30.00 0300 LABORATORY CHLORIDE URINE 32.00 0300 LABORATORY CHLORINATE HYDROCARBONS SCREEN 12.00 0300 LABORATORY CHODROITIN B SULFATE QUAN 36.00 0300 LABORATORY CHOLINESTERASE RBC 119.00 0300 LABORATORY CHOMATOGRAPHY QUAL 18.00 0300 LABORATORY CHOMATOGRAPHY QUAN 84.00 0300 LABORATORY CHROMIUM 72.00 0300 LABORATORY CHROMOGENIC SUBSTRATE ASSAY 30.00 0300 LABORATORY CHROMOSOMAL ANALYSIS ADDITIONAL BANDING TECHNIQUE 660.00 0300 LABORATORY CHROMOSOMAL ANALYSIS ADDITIONAL CELLS COUNT 54.00 0300 LABORATORY CHROMOSOMAL ANALYSIS ADDITIONAL KARYOTYPES 72.00 0300 LABORATORY CHROMOSOME ANALYSIS 15-20 960.00 0300 LABORATORY CHROMOSOME ANALYSIS 20-25 CELLS 132.00 0300 LABORATORY CHROMOSOME ANALYSIS SCORE 100 CELLS 660.00 0300 LABORATORY CHROMOSONE ANALYSIS AMNIOTIC FLUID 6-12 COLONIES 660.00 0300 LABORATORY CHROMOSONE ANALYSIS AMNIOTIC FLUID COUNT 15 CELLS 612.00 0300 LABORATORY CHROMOSONE ANALYSIS ANALYSE 20-25 CELLS 660.00 0300 LABORATORY CHROMOTOGRAPHY ISOTOPE 360.00 0300 LABORATORY CITRATE (CITRIC ACID) URINE 208.00 0300 LABORATORY CLOSTRIDIUM TOXIN A BY IMMUNOASSAY 160.00 0300 LABORATORY CLOT RETRACTION 24.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CLOTTING TIME 12.00 0300 LABORATORY CMP 25.00 0300 LABORATORY COAGULATION TIME ACTIVATED 32.00 0300 LABORATORY COAGULATION TIME LEE AND WHITE 32.00 0300 LABORATORY COAGULATION TIME OTHER METHODS 32.00 0300 LABORATORY COAGULOPATHY SCREEN 12.00 0300 LABORATORY COCCAINE 48.00 0300 LABORATORY COCCIDIOIDES AB 234.00 0300 LABORATORY COCCIDIOIDOMYCOSIS SKIN TEST 18.00 0300 LABORATORY COCKSAKIE,ECHO,POLIO AB ENTEROVIRUS 167.00 0300 LABORATORY COLLAGEN CROSS LINKS ANY METHO 144.00 0300 LABORATORY COMPATIBILITY INCUBATION 36.00 0300 LABORATORY COMPLEMENT ENTERASE INHIBIT-86161 140.00 0300 LABORATORY COOMBS INDIRECT 13.00 0300 LABORATORY COPPER 64.00 0300 LABORATORY CORTICOSTERONE 48.00 0300 LABORATORY CORTISOL FREE 164.00 0300 LABORATORY COXIELLA BURNETII AB 60.00 0300 LABORATORY C-PEPTIDE 205.00 0300 LABORATORY CRYOFIBRINOGEN 36.00 0300 LABORATORY CRYOGLOBULIN QUAL OR SEMIQUAN 32.00 0300 LABORATORY CRYPTOCOCCUS AB 101.00 0300 LABORATORY CRYPTOSPORIDIUM 60.00 0300 LABORATORY CRYPTOSPORIDIUM AG BY IMMUNOFLUORESCENT 80.00 0300 LABORATORY CRYSTALS IDENTIFICATION 18.00 0300 LABORATORY CRYTOCOCCUS AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY CULTURE ABSCESS 48.00 0300 LABORATORY CULTURE ACID FAST BACILLI 16.00 0300 LABORATORY CULTURE AMNIOTIC FLUID 48.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CULTURE ANKLE (TOBILLO) 48.00 0300 LABORATORY CULTURE APPENDIX 48.00 0300 LABORATORY CULTURE ASCITIC FLUID 48.00 0300 LABORATORY CULTURE ASPIRATED SPUTUM 48.00 0300 LABORATORY CULTURE BARTOLINE 48.00 0300 LABORATORY CULTURE BILIS 48.00 0300 LABORATORY CULTURE BODY FLUID 48.00 0300 LABORATORY CULTURE BONE (HUESO) 48.00 0300 LABORATORY CULTURE BRONCHIAL WASH 48.00 0300 LABORATORY CULTURE BUTTOCK (GLUTEO) 48.00 0300 LABORATORY CULTURE CERVIX 48.00 0300 LABORATORY CULTURE CYST (QUISTE) 48.00 0300 LABORATORY CULTURE EAR (OIDO) 48.00 0300 LABORATORY CULTURE ELBOW (CODO) 48.00 0300 LABORATORY CULTURE EXPECTORATED SPUTUM 48.00 0300 LABORATORY CULTURE EYE (OJO)****DUPLICADO 087084** 48.00 0300 LABORATORY CULTURE FEMUR 48.00 0300 LABORATORY CULTURE FINGER (DEDO) 48.00 0300 LABORATORY CULTURE FISTULE 48.00 0300 LABORATORY CULTURE FUNGI BLOOD 61.00 0300 LABORATORY CULTURE FUNGI ID MOLD 61.00 0300 LABORATORY CULTURE FUNGI ID YEAST 61.00 0300 LABORATORY CULTURE FUNGI OTHER 61.00 0300 LABORATORY CULTURE FUNGI SKIN,HAIR OR NAIL 49.00 0300 LABORATORY CULTURE GALLBLADDER (VESICULA) 48.00 0300 LABORATORY CULTURE GASTRIC SECRETIONS 48.00 0300 LABORATORY CULTURE GENITAL 48.00 0300 LABORATORY CULTURE HIP (CADERA) 48.00 0300 LABORATORY CULTURE MILK 48.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CULTURE MYCOBACTERIAL 48.00 0300 LABORATORY CULTURE MYCOPLASMA 69.00 0300 LABORATORY CULTURE NASOPHARYNGEAL 48.00 0300 LABORATORY CULTURE PERITONEAL FLUID 48.00 0300 LABORATORY CULTURE PLACENTA 48.00 0300 LABORATORY CULTURE PLEURAL FLUID 48.00 0300 LABORATORY CULTURE PUSTULE 48.00 0300 LABORATORY CULTURE SACRAL ULCER 48.00 0300 LABORATORY CULTURE SECRETIONS 48.00 0300 LABORATORY CULTURE SEMEN 48.00 0300 LABORATORY CULTURE SKIN (PIEL) 48.00 0300 LABORATORY CULTURE SPINAL FLUID B (CSF) 20.00 0300 LABORATORY CULTURE STOOL ADDITIONAL PATHOGENS 6.00 0300 LABORATORY CULTURE SUB-CLAVIA VIA CATHETER 48.00 0300 LABORATORY CULTURE SYNOVIAL FLUID 48.00 0300 LABORATORY CULTURE THIGH (MUSLO) 48.00 0300 LABORATORY CULTURE THORACENTESIS 48.00 0300 LABORATORY CULTURE THROAT (GARGANTA) 48.00 0300 LABORATORY CULTURE TOE (DEDO PIE) 48.00 0300 LABORATORY CULTURE TYPING CHROMATOGRAPHY 48.00 0300 LABORATORY CULTURE TYPING ID BY NUCLEIC ACID 48.00 0300 LABORATORY CULTURE TYPING ID BY PULSE FIELD 48.00 0300 LABORATORY CULTURE TYPING IMMUNOFLUORESCENT 48.00 0300 LABORATORY CULTURE TYPING OTHER METHODS 48.00 0300 LABORATORY CULTURE ULCER 48.00 0300 LABORATORY CULTURE UMBILICAL 48.00 0300 LABORATORY CULTURE VAGINAL 48.00 0300 LABORATORY CYANIDE 81.00 0300 LABORATORY CYCLOSPORINE 120.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY CYSTATIN C 100.00 0300 LABORATORY CYSTINE HOMOCYSTINE URINE QUAL 200.00 0300 LABORATORY CYTOGENETICS AND MOLECULAR CYTOGENRTICS 495.00 0300 LABORATORY CYTOMEGALOVIRUS AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY CYTOMEGALOVIRUS AG BY IMMUNOFLUORESCENT 40.00 0300 LABORATORY CYTOMEGALOVIRUS AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY CYTOMEGALOVIRUS DIRECT PROBE BY DNA 36.00 0300 LABORATORY CYTOMEGALOVIRUS QUANTIFICATION BY DNA 60.00 0300 LABORATORY DARK FIELD W COLLECTION 32.00 0300 LABORATORY DARK FIELD W/O COLLECTION 32.00 0300 LABORATORY DEHYDROGENASE 6- PHOSPHOGLUCONATE 18.00 0300 LABORATORY DENGUE TITER 141.00 0300 LABORATORY DEOXYCORTISOL 11 150.00 0300 LABORATORY DEOXYRIBONUCLEASE AB 96.00 0300 LABORATORY DESIPRAMINE NORPRAMIN 183.00 0300 LABORATORY DESOXYCORTICOSTERONE 11 126.00 0300 LABORATORY DHEA DEHYDROEPIANDROSTERONE 298.00 0300 LABORATORY DIBUCAINE 60.00 0300 LABORATORY DIFFERENTIAL COUNT 16.00 0300 LABORATORY DIHYDROCODEINONE 36.00 0300 LABORATORY DIHYDROMORPHINONE 36.00 0300 LABORATORY DIHYDROTESTOSTERONE DHT 114.00 0300 LABORATORY DIMETHADIONE 36.00 0300 LABORATORY DIPHTERIA AB 180.00 0300 LABORATORY DOXEPIN (ADAPIN, SINEQUAM) 84.00 0300 LABORATORY DRUG ANALYSIS TISSUE PREPARTION 60.00 0300 LABORATORY DRUG CONFIRMATION EA PROC 60.00 0300 LABORATORY DRUG SCREEN QUANT ALCOHOLS BIOMARKERS 1 OR 2 7.00 0300 LABORATORY DRUG SCREENING BENZODIAZEPINES 1-12 7.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY DRUG SCREENING CANNABINOIDS NATURAL 7.00 0300 LABORATORY DRUG SCREENING COCAINE 7.00 0300 LABORATORY DRUG SCREENING METHADONE 6.30 0300 LABORATORY DRUG SCREENING OPIATES 1 OR MORE 6.30 0300 LABORATORY DRUG SCREENING PROPOXYPHENE 7.00 0300 LABORATORY DRUG TST PRSMV INSTRMINT CHEM ANALYZERS PR DATE 6.30 0300 LABORATORY E COLI AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY EHRLICHIA AB 330.00 0300 LABORATORY ELECTROPHORETIC 42.00 0300 LABORATORY EMBRYO CRYOPRESERVATION 180.00 0300 LABORATORY ENCEPHALITIS CALIFORNIA AB 48.00 0300 LABORATORY ENCEPHALITIS EASTER EQUINE AB 30.00 0300 LABORATORY ENCEPHALITIS ST LOUIS AB 54.00 0300 LABORATORY ENCEPHALITIS WESTERN EQUINE AB 30.00 0300 LABORATORY ENTAMOEBA HIST AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY ENTEROVIRUS AG BY IMMUNOFLUORESCENT 18.00 0300 LABORATORY EOSINOPHIL COUNT (BLOOD) 10.00 0300 LABORATORY EOSINOPHILS URINE 25.00 0300 LABORATORY EPIANDROSTERONE 36.00 0300 LABORATORY EPSTEIN BARR VIRUS EARLY AG 170.00 0300 LABORATORY EPSTEIN BARR VIRUS NUCLEAR AG 170.00 0300 LABORATORY ESTROGEN RECEPTOR ASSAY 222.00 0300 LABORATORY ESTROGENS FRACT 184.00 0300 LABORATORY ESTRONE 260.00 0300 LABORATORY ETHCHLORVYNOL 36.00 0300 LABORATORY ETHOSUXIMIDE ZARONTIN 93.00 0300 LABORATORY ETHYLENE GLYCOL 48.00 0300 LABORATORY ETIOCHOLANOLONE 84.00 0300 LABORATORY EUGLOBIN LYSIS 48.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY FACTOR II PROTHROMBIN 223.00 0300 LABORATORY FACTOR INHIBITOR TEST 138.00 0300 LABORATORY FACTOR VIII VON WILLEBRAND MULT 495.00 0300 LABORATORY FACTOR VIII VON WILLEBRAND RISTO 180.00 0300 LABORATORY FACTOR XIII SCREEN 16.00 0300 LABORATORY FANA / FLUORESCENT ANA 59.00 0300 LABORATORY FAT OR LIPIDS FECES QUAN 60.00 0300 LABORATORY FAT STAIN FECES,URINES OR RESP SECRETIONS 12.00 0300 LABORATORY FATTY ACIDS NONESTERIFIED 64.00 0300 LABORATORY FATTY ACIDS VERY LONG CHAIN 360.00 0300 LABORATORY FC RECEPTOR 36.00 0300 LABORATORY FEBRILE AGGLUTININS EA 55.00 0300 LABORATORY FECAL LEUCOCYTES 8.00 0300 LABORATORY FETAL LUNG FLUORESCENT POLAR 18.00 0300 LABORATORY FETAL LUNG FOAM STABILITY 36.00 0300 LABORATORY FETAL LUNG L/S RATIO 264.00 0300 LABORATORY FETAL LUNG LAMELLAR BODY 12.00 0300 LABORATORY FIBRIN PARACOAGULATION 18.00 0300 LABORATORY FIBRINOGEN AG 40.00 0300 LABORATORY FIBRONECTIN FETAL 36.00 0300 LABORATORY FITZGERALD FACTOR (HMWK) 18.00 0300 LABORATORY FLETCHER FACTOR 36.00 0300 LABORATORY FLOW CYTOMETRY 2 TO 8 MARKERS 802.00 0300 LABORATORY FLOW CYTOMETRY 9 TO 15 MARKERS 802.00 0300 LABORATORY FLOW CYTOMETRY 16 OR MORE MARKERS 802.00 0300 LABORATORY FLUORIDE 174.00 0300 LABORATORY FLURAZEPAM 36.00 0300 LABORATORY FOLIC ACID RBC 72.00 0300 LABORATORY FRANCISELLA TULARENSIS AB 72.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY FROZEN BLOOD FREEZING 18.00 0300 LABORATORY FROZEN BLOOD FREEZING & THAWING 36.00 0300 LABORATORY FROZEN BLOOD THAWING 18.00 0300 LABORATORY FRUCTOSE SEMEN 212.00 0300 LABORATORY FUNGUS AB NOT SPECIFIED 264.00 0300 LABORATORY GALACTOKINASE RBC 30.00 0300 LABORATORY GALACTOSE 40.00 0300 LABORATORY GALACTOSE 1 PHOSPHATE QUAN 40.00 0300 LABORATORY GALACTOSE 1 PHOSPHATE SCREEN 40.00 0300 LABORATORY GARDNERELLA AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY GARDNERELLA DIRECT PROBE BY DNA 36.00 0300 LABORATORY GARDNERELLA QUANTIFICATION BY DNA 72.00 0300 LABORATORY GASTRIC ACID FREE & TOTAL EA 36.00 0300 LABORATORY GASTRIC ACID FREE OR TOTAL EA 36.00 0300 LABORATORY GASTRIN AFTER SECRETIN STIM 36.00 0300 LABORATORY GIARDIA AG BY ENZYME IMMUNOASSAY QUAL 600.00 0300 LABORATORY GIARDIA AG BY IMMUNOFLUORESCENT 600.00 0300 LABORATORY GIARGIA LAMBLIA AB 276.00 0300 LABORATORY GLOBULIN 16.00 0300 LABORATORY GLUCAGON TOLERANCE TEST 221.00 0300 LABORATORY GLUCOSE ( FBS ) 9.00 0300 LABORATORY GLUCOSE 1 HOUR 24.00 0300 LABORATORY GLUCOSE BLOOD DXT 12.00 0300 LABORATORY GLUCOSE C6PD SCREEN.**NO ES PROCEDIMIENTO NO ES CPT 82966** 90.00 0300 LABORATORY GLUCOSE G6PD SCREEN 90.00 0300 LABORATORY GLUCOSE GTT 4 HOURS 24.00 0300 LABORATORY GLUCOSE GTT 5 HOURS 24.00 0300 LABORATORY GLUCOSE POST PANDRIAL 2 HRS 24.00 0300 LABORATORY GLUCOSIDASE BETA 36.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY GLUTAMATE DEHYDROGENASE 18.00 0300 LABORATORY GLUTAMINE 36.00 0300 LABORATORY GLUTATHIONE 36.00 0300 LABORATORY GLUTATHIONE REDUCTASE 36.00 0300 LABORATORY GLUTETHIMIDE 36.00 0300 LABORATORY GLYCATED PROTEIN 36.00 0300 LABORATORY GMP GUANOSINE MONOPHOSPHATE 36.00 0300 LABORATORY GOLD 148.00 0300 LABORATORY GRAM STAIN 24.00 0300 LABORATORY GTT 6 HOURS 24.00 0300 LABORATORY HAI HEMAGGLUTINATION INHIBITION 159.00 0300 LABORATORY HALOPERIDOL (HALDOL) 241.00 0300 LABORATORY HAPTOGLOBIN PHENOTYPES 83.00 0300 LABORATORY HBCAB HEPATITIS B CORE AB IGM 55.00 0300 LABORATORY HBCAB HEPATITIS B CORE AB TOTAL 55.00 0300 LABORATORY HBEAB HEPATITIS BE AB 64.00 0300 LABORATORY HBEAG BY ENZYME IMMUNOASSAY QUAL 64.00 0300 LABORATORY HBSAG NEUTRALIZATION BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY HDL CHOLESTEROL 96.00 0300 LABORATORY HEAVY METAL SCREEN 173.00 0300 LABORATORY HEINZ BODIES ACETYL PHENY 18.00 0300 LABORATORY HEINZ BODIES DIRECT 12.00 0300 LABORATORY HELICOBACTER PYLORI AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY HELICOBACTER PYLORI AG STOOL 100.00 0300 LABORATORY HELICOBACTER PYLORI BLOOD 117.00 0300 LABORATORY HELICOBACTER PYLORI BREATH 117.00 0300 LABORATORY HELMINTH AB NOT SPECIFIED 264.00 0300 LABORATORY HEMOGLOBIN BY COPPER SULFATE 48.00 0300 LABORATORY HEMOGLOBIN CHROMATOGRAPHY 48.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY HEMOGLOBIN ELECTROPHORESIS 77.00 0300 LABORATORY HEMOGLOBIN F FETAL CHEMICAL 48.00 0300 LABORATORY HEMOGLOBIN F FETAL QUAL 48.00 0300 LABORATORY HEMOGLOBIN FETAL DIFF LYSIS 16.00 0300 LABORATORY HEMOGLOBIN FETAL ROSETTE 12.00 0300 LABORATORY HEMOGLOBIN GLYCOHEMOGLOBIN A1C 25.00 0300 LABORATORY HEMOGLOBIN METHEMOGLOBIN QUAL 12.00 0300 LABORATORY HEMOGLOBIN METHEMOGLOBIN QUAN 36.00 0300 LABORATORY HEMOGLOBIN PLASMA 42.00 0300 LABORATORY HEMOGLOBIN SULFHEMOGLOBIN QUAL 12.00 0300 LABORATORY HEMOGLOBIN SULFHEMOGLOBIN QUAN 18.00 0300 LABORATORY HEMOGLOBIN THERMOLABILE 18.00 0300 LABORATORY HEMOGLOBIN UNSTABLE SCREEN 18.00 0300 LABORATORY HEMOGLOBIN URINE 12.00 0300 LABORATORY HEMOLYSIN ACID 18.00 0300 LABORATORY HEMOLYSINS & AGGLUTININS AUTO EA 42.00 0300 LABORATORY HEMOPHILUS INFLUENZA AB 36.00 0300 LABORATORY HEMOSIDERIN QUAL 44.00 0300 LABORATORY HEMOSIDERIN QUAN 44.00 0300 LABORATORY HEPARIN ASSAY 196.00 0300 LABORATORY HEPARIN NEUTRALIZATION 18.00 0300 LABORATORY HEPARIN PROTAMINE TOLERANCE TEST 40.00 0300 LABORATORY HEPATITIS A AB TOTAL (IGG/IGM) 64.00 0300 LABORATORY HEPATITIS B AMPLIFIED DIRECT PROBE BY DNA 312.00 0300 LABORATORY HEPATITIS B DIRECT PROBE BY DNA 36.00 0300 LABORATORY HEPATITIS B QUANTIFICATION BY DNA 84.00 0300 LABORATORY HEPATITIS C AB CONFIRMATORY HCAB 96.00 0300 LABORATORY HEPATITIS C AMPLIFIED DIRECT PROBE BY DNA 357.00 0300 LABORATORY HEPATITIS C DIRECT PROBE BY DNA 36.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY HEPATITIS C GENOTYPE BY DNA 357.00 0300 LABORATORY HEPATITIS C QUANTIFICATION BY DNA 300.00 0300 LABORATORY HEPATITIS DELTA AGENT AB 137.00 0300 LABORATORY HEPATITIS G AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY HEPATITIS G DIRECT PROBE BY DNA 36.00 0300 LABORATORY HEPATITIS G QUANTIFICATION BY DNA 72.00 0300 LABORATORY HERPES SIMPLEX AB NOT SPECIFIC TYPE 136.00 0300 LABORATORY HERPES SIMPLEX AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY HERPES SIMPLEX DIRECT PROBE BY DNA 36.00 0300 LABORATORY HERPES SIMPLEX I AG BY IMMUNOFLUORESCENT 75.00 0300 LABORATORY HERPES SIMPLEX II AB 31.00 0300 LABORATORY HERPES SIMPLEX II AG BY IMMUNOFLUORESCENT 75.00 0300 LABORATORY HERPES SIMPLEX QUANTIFICATION BY DNA 84.00 0300 LABORATORY HERPES VIRUS-6 AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY HERPES VIRUS-6 DIRECT PROBE BY DNA 36.00 0300 LABORATORY HERPES VIRUS-6 QUANTIFICATION BY DNA 72.00 0300 LABORATORY HETEROPHILE ANTIBODIES TITER 40.00 0300 LABORATORY HEXOSAMINIDASE B 36.00 0300 LABORATORY HGH AB 90.00 0300 LABORATORY HGH SOMATOTROPIN 72.00 0300 LABORATORY HISTAMINE 491.00 0300 LABORATORY HISTOPLASMA AG BY ENZYME IMMUNOASSAY QUAL 138.00 0300 LABORATORY HISTOPLASMOSIS SKIN TEST 40.00 0300 LABORATORY HIV 1 AG BY ENZYME IMMUNOASSAY QUAL 144.00 0300 LABORATORY HIV 1 GENOTYPE BY DNA 225.00 0300 LABORATORY HIV 1 PHENOTYPE BY DNA 1 THROUGH 5 DRUGS 48.00 0300 LABORATORY HIV 1 PHENOTYPE BY DNA 1 THROUGH 10 DRUGS 816.00 0300 LABORATORY HIV 2 36.00 0300 LABORATORY HIV 2 AG BY ENZYME IMMUNOASSAY QUAL 36.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY HIV-1 AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY HIV-1 DIRECT PROBE BY DNA 36.00 0300 LABORATORY HIV-2 AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY HIV-2 DIRECT PROBE BY DNA 36.00 0300 LABORATORY HIV-2 QUANTIFICATION BY DNA 84.00 0300 LABORATORY HLA ONE ANTIGEN 253.00 0300 LABORATORY HLA TYPING A,B,OR C MULTIPLE AG 5701 230.00 0300 LABORATORY HLA TYPING A,B,OR C SINGLE AG 86.00 0300 LABORATORY HLA TYPING DR/DQ MULTIPLE ANTIGEN 108.00 0300 LABORATORY HLA TYPING DR/DQ SINGLE ANTIGEN 312.00 0300 LABORATORY HLA TYPING LYMPHOCYTE CULTURE MIXED 96.00 0300 LABORATORY HLA TYPING LYMPHOCYTE CULTURE PRIMED 72.00 0300 LABORATORY HOMOGENIZATION TISSUE FOR CULTURE 12.00 0300 LABORATORY HPL HUMAN PLACENTAL LACTOGEN 114.00 0300 LABORATORY HTLV I AB 42.00 0300 LABORATORY HTLV II AB 42.00 0300 LABORATORY HVA HOMOVANILLIC ACID 224.00 0300 LABORATORY HYDROXYCORTICOSTEROIDS 17-OHCS 56.00 0300 LABORATORY HYDROXYINDOLACETIC 5-HIAA 40.00 0300 LABORATORY HYDROXYPREGNENOLONE 17- 72.00 0300 LABORATORY HYDROXYPROGESTERONE 17-D 321.00 0300 LABORATORY HYDROXYPROGESTERONE 20 237.00 0300 LABORATORY HYDROXYPROLINE FREE 321.00 0300 LABORATORY HYDROXYPROLINE TOTAL 321.00 0300 LABORATORY IAAD IA CLOSTRIDIUM DIFFICILE TOXIN 29.60 0300 LABORATORY IDH ISOCITRIC DEHYDROGENASE 114.00 0300 LABORATORY IFLUENZA A OR B AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY IMIPRAMINE (TOFRANIL) 189.00 0300 LABORATORY IMMUNO. OTHER OR INHIBIN B 210.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY IMMUNOASSAY FOR TUMOR AG QUAL 36.00 0300 LABORATORY IMMUNODIFFUSION GEL DIFFUSION 36.00 0300 LABORATORY IMMUNODIFFUSION NOT SPECIFIED 40.00 0300 LABORATORY IMMUNOFIXATION ELECTROPHORESIS SERUM 150.00 0300 LABORATORY IMMUNOFIXATION ELECTROPHORESIS URINE 72.46 0300 LABORATORY INDIA INK 48.00 0300 LABORATORY INFECTIOUS AGENT AB QUAN OTHER 240.00 0300 LABORATORY INFECTIOUS EA NOT SPEC DIRECT PROBE BY DNA 36.00 0300 LABORATORY INFECTIOUS EA NOT SPEC QUANTIFICATION BY DNA 84.00 0300 LABORATORY INFECTIOUS MULT NOT SPEC DIRECT PROBE BY DNA 36.00 0300 LABORATORY INFECTIOUS NOT SPEC BY IMMUNOASSAY 126.00 0300 LABORATORY INFLUENZA A AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY INFLUENZA A+B ANTIBODY (REFERENCIA) 260.00 0300 LABORATORY INFLUENZA B AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY INHIBIN A 36.00 0300 LABORATORY INMONUELECTROPHORESIS OTHER 536.00 0300 LABORATORY INMONUELECTROPHORESIS SERUM 80.00 0300 LABORATORY INMUNE COMPLEX ASSAY 107.00 0300 LABORATORY INMUNOASSAY QUAN 231.00 0300 LABORATORY INMUNOASSAY SEMIQUANT MULT 123.00 0300 LABORATORY INMUNOASSAY SEMIQUANT SING 100.00 0300 LABORATORY INSULIN ANTIBODIES 120.00 0300 LABORATORY INSULIN FREE 71.00 0300 LABORATORY INTRINSIC FACTOR 36.00 0300 LABORATORY INTRINSIC FACTOR ANTIBODIES 157.00 0300 LABORATORY IRON STAIN PERIPHERAL BLOOD 25.00 0300 LABORATORY ISLET CELL ANTIBODY 180.00 0300 LABORATORY KETOGENIC STEROIDS FRACT 42.00 0300 LABORATORY KETOSTEROIDS 17-KS FRACT 63.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY KETOSTEROIDS 17-KS TOTAL 63.00 0300 LABORATORY KOH 32.00 0300 LABORATORY LACOSAMIDE (VIMPAT) 305.00 0300 LABORATORY LACTOFERRIN FECAL QUAL 60.00 0300 LABORATORY LACTOSE URINE QUAL 36.00 0300 LABORATORY LACTOSE URINE QUAN 36.00 0300 LABORATORY LAP LEUCINE AMINOPEPTIDASE 66.00 0300 LABORATORY LDH / OTHER FLUIDS 24.00 0300 LABORATORY LDH ISOENZYMES 42.00 0300 LABORATORY LDL CHOLESTEROL 96.00 0300 LABORATORY LEGIONELLA MICDADEI AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY LEGIONELLA PNEUM AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY LEGIONELLA PNEUM DIRECT PROBE BY DNA 36.00 0300 LABORATORY LEGIONELLA PNEUM QUANTIFICATION BY DNA 84.00 0300 LABORATORY LEGIONELLA PNEUMOPHILIA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY LEISHMANIA AB 30.00 0300 LABORATORY LEUKOCYTE ALKALINE 55.00 0300 LABORATORY LEUKOCYTE PHAGOCYTOSIS 600.00 0300 LABORATORY LEUKOCYTE TRANSFUSION 150.00 0300 LABORATORY LHR LEUKOCYTE HISTAMINE RELEASE 30.00 0300 LABORATORY LIDOCAINE 135.00 0300 LABORATORY LIPOPROTEIN ELECTROPHORETIC 64.00 0300 LABORATORY LIPOPROTEIN HIGH RESOLUTION 96.00 0300 LABORATORY LISTERIA MONOCYTOGENES AB 30.00 0300 LABORATORY LRH LUTEINIZING RELEASING FACTOR 36.00 0300 LABORATORY LUPUS ANTICOAGULANT EVALUATION 93.00 0300 LABORATORY LYMPHOCYTE NON-NEOPLASTIC DISORDER 696.00 0300 LABORATORY LYMPHOCYTE TRANSFORMATION 246.00 0300 LABORATORY LYMPHOCYTIC CHORIOMENINGITIS AB 72.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY LYMPHOCYTOTOXICITI W TITRATION 96.00 0300 LABORATORY LYMPHOCYTOTOXICITI W/O TITRATION 84.00 0300 LABORATORY LYMPHOGRANULOMA VENEREUM AB 30.00 0300 LABORATORY MACROSCOPIC ARTHROPOD 12.00 0300 LABORATORY MACROSCOPIC PARASITE 12.00 0300 LABORATORY MALARIA PLASMODIUM AB 360.00 0300 LABORATORY MALATE DEHYDROGENASE 24.00 0300 LABORATORY MANGANESE 48.00 0300 LABORATORY MEAT FIBERS FECES 30.00 0300 LABORATORY MEPROBAMATE 36.00 0300 LABORATORY METANEPHRINES 199.00 0300 LABORATORY METHADONE 48.00 0300 LABORATORY METHEMALBUMIN 18.00 0300 LABORATORY METHSUXIMIDE 72.00 0300 LABORATORY METHYLENETITHRAYDROFOLATE(MTHFR) 240.00 0300 LABORATORY MICROALBUMIN 24 HRS URINE 16.00 0300 LABORATORY MICROALBUMIN SPOT URINE 16.00 0300 LABORATORY MIF MIGRATION INHIBITORY FACTOR 36.00 0300 LABORATORY MOLECULAR CYTOGENICS 25-99 CELLS 58.00 0300 LABORATORY MOLECULAR CYTOGENICS DNA PROBE EA 552.00 0300 LABORATORY MUCIN SYNOVIAL FLUID 24.00 0300 LABORATORY MUCOPOLYSACCHARIDES ACID QUAN 38.00 0300 LABORATORY MUCOPOLYSACCHARIDES ACID SCREEN 38.00 0300 LABORATORY MUCORMYCOSIS AB 30.00 0300 LABORATORY MULTISPOT HIV 1/2 RAPID TEST 36.00 0300 LABORATORY MUMPS AB 148.00 0300 LABORATORY MURAMIDASE 108.00 0300 LABORATORY MYCOBACTERIA AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY MYCOBACTERIA AVIUM AMPLIFIED DIRECT PROBE BY DNA 60.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY MYCOBACTERIA AVIUM DIRECT PROBE BY DNA 36.00 0300 LABORATORY MYCOBACTERIA AVIUM QUANTIFICATION BY DNA 84.00 0300 LABORATORY MYCOBACTERIA DIRECT PROBE BY DNA 36.00 0300 LABORATORY MYCOBACTERIA QUANTIFICATION BY DNA 234.00 0300 LABORATORY MYCOBACTERIA TUBERC AMPLIFIED DIRECT PROBE BY DNA 444.00 0300 LABORATORY MYCOBACTERIA TUBERC DIRECT PROBE BY DNA 36.00 0300 LABORATORY MYCOBACTERIA TUBERC QUANTIFICATION BY DNA 84.00 0300 LABORATORY MYCOPLASMA DUPLICADO 135.00 0300 LABORATORY MYCOPLASMA PNEUM AMPLIFIED DIRECT PROBE BY DNA 187.00 0300 LABORATORY MYCOPLASMA PNEUM DIRECT PROBE BY DNA 187.00 0300 LABORATORY MYCOPLASMA PNEUM QUANTIFICATION BY DNA 187.00 0300 LABORATORY MYCOPLASMA PNEUMONIAE IGG 135.00 0300 LABORATORY MYELIN CEREBROSPINAL FLUID 96.00 0300 LABORATORY NASAL SMEAR FOR EOSINOPHILS 5.00 0300 LABORATORY NEISSERIA GONORR BY IMMUNOASSAY 36.00 0300 LABORATORY NEISSERIA MENINGITIS AB 30.00 0300 LABORATORY NEISSERIA QUANTIFICATION BY DNA 84.00 0300 LABORATORY NEPHELOMETRY 224.00 0300 LABORATORY NEUTRALIZATION TEST VIRAL 36.00 0300 LABORATORY NICKEL 144.00 0300 LABORATORY NICOTINE 108.00 0300 LABORATORY NOCARDIA AB 30.00 0300 LABORATORY NORTRIPTYLINE (AVENTYL) 72.00 0300 LABORATORY NTD NITROBLUE TETRAZOLIUM DYE 96.00 0300 LABORATORY NUCLEOTIDASE 5- 55.00 0300 LABORATORY OBSTETRIC PANEL 221.00 0300 LABORATORY OLIGOCLONAL IMMUNE 84.00 0300 LABORATORY ONCOPROTEIN HER-2/NEU 108.00 0300 LABORATORY OPIATES 32.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY ORGANIC ACIDS SINGLE QUAN 289.00 0300 LABORATORY ORGANIC ACIDS TOTAL QUAL 289.00 0300 LABORATORY ORGANIC ACIDS TOTAL QUAN 289.00 0300 LABORATORY OSMOLALITY URINE 48.00 0300 LABORATORY OSTEOCALCIN 40.00 0300 LABORATORY OVULATION TEST 18.00 0300 LABORATORY OXALATE 67.00 0300 LABORATORY OXCARBAZEPINE 69.00 0300 LABORATORY P ANCA 275.00 0300 LABORATORY P9017 PLASMA 1 DONOR FRZ W/IN 8HR 60.00 0300 LABORATORY PAPILLOMAVIRUS AMPLIFIED DIRECT PROBE BY DNA 375.00 0300 LABORATORY PAPILLOMAVIRUS DIRECT PROBE BY DNA 375.00 0300 LABORATORY PAPILLOMAVIRUS QUANTIFICATION BY DNA 375.00 0300 LABORATORY PAPP-A 180.00 0300 LABORATORY PARAINFLUENZA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY PARANEPLSTIC PROFILE 1,500.00 0300 LABORATORY PARVOVIRUS AB 108.00 0300 LABORATORY PCP PHENCYCLIDINE 72.00 0300 LABORATORY PHENOTHIAZINE 72.00 0300 LABORATORY PHENYLKETONES QUAL 36.00 0300 LABORATORY PHENYTOIN FREE (DILANTIN FREE) 78.00 0300 LABORATORY PHLEBOTOMY, THERAPEUTIC 36.00 0300 LABORATORY PHOSPHATASE ACID TOTAL 24.00 0300 LABORATORY PHOSPHATASE ALKALINE HEAT STABLE 35.00 0300 LABORATORY PHOSPHATASE ALKALINE ISOENZYMES 32.00 0300 LABORATORY PHOSPHATESE ACID FORENSIC 24.00 0300 LABORATORY PHOSPHATIDYILGLYCEROL 125.00 0300 LABORATORY PHOSPHOHEXOSE ISOMERASE 18.00 0300 LABORATORY PLASMIN 36.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY PLASMINOGEN ACTIVATOR 36.00 0300 LABORATORY PLASMINOGEN ANTIGENIC 18.00 0300 LABORATORY PLASMINOGEN OTHER 162.00 0300 LABORATORY PLATELET ANTIBODIES 138.00 0300 LABORATORY PLATELET COUNT MANUAL 25.00 0300 LABORATORY PLATELET NEUTRALIZATION 36.00 0300 LABORATORY PNEUMOCYSTIS AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY PORPHOBILLINOGEN URINE QUAL 16.00 0300 LABORATORY PORPHOBILLINOGEN URINE QUAN 16.00 0300 LABORATORY PORPHYRINS FECES QUAL 104.00 0300 LABORATORY PORPHYRINS FECES QUAN 104.00 0300 LABORATORY PORPHYRINS URINE QUAL 93.00 0300 LABORATORY PORPHYRINS URINE QUAN 32.00 0300 LABORATORY POTASIUM SPOT URINE 29.00 0300 LABORATORY POTASSIUM URINE 24 HRS 24.00 0300 LABORATORY PREALBUMIN 108.00 0300 LABORATORY PREGNANCY TEST (LABORATORY) 20.00 0300 LABORATORY PREGNANEDIOL 125.00 0300 LABORATORY PREGNANETRIOL 234.00 0300 LABORATORY PREGNENOLONE 150.00 0300 LABORATORY PRIMIDONE (MYSOLINE) 58.00 0300 LABORATORY PROCAINAMIDE 112.00 0300 LABORATORY PROCAINAMIDE W METABOLITES (NAPA) 114.00 0300 LABORATORY PROCALCITONIN (PCT) 155.00 0300 LABORATORY PROGESTERONE RECEPTOR ASSAY 112.00 0300 LABORATORY PROINSULIN 282.00 0300 LABORATORY PROSTAGLANDIN 120.00 0300 LABORATORY PROTEIN C AG 238.00 0300 LABORATORY PROTEIN ELECTROP FXJQUAN OTH FLUS CONCENTRATI 44.02 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY PROTEIN ELECTROPHORESIS SERUM 30.00 0300 LABORATORY PROTEIN S TOTAL 199.00 0300 LABORATORY PROTEIN TOTAL XCPT REFRACTOMETRY URINE 9.06 0300 LABORATORY PROTOPORPHYRIN RBC QUAN 96.00 0300 LABORATORY PROTOPORPHYRIN RBC SCREEN 18.00 0300 LABORATORY PROTOZOA AB 210.00 0300 LABORATORY PSA COMPLEXED 187.00 0300 LABORATORY PT ( PROTHROMBIN TIME ) INR 10.00 0300 LABORATORY PTT ( PROTHROMBIN TIME ) 10.00 0300 LABORATORY PYRUVATE 98.00 0300 LABORATORY PYRUVATE KINASE 98.00 0300 LABORATORY QUINIDINE 55.00 0300 LABORATORY QUININE 30.00 0300 LABORATORY RBC MECHANICAL FRAGILITY 45.00 0300 LABORATORY RBC OSMOTIC FRAG INCUBATED 30.00 0300 LABORATORY RBC OSMOTIC FRAG UNINCUBATED 36.00 0300 LABORATORY REDUCING SUBSTANCE STOOL 9.00 0300 LABORATORY REDUCING SUBSTANCE URINE 9.00 0300 LABORATORY RENAL FUNCTION PANEL 180.00 0300 LABORATORY RENIN 110.00 0300 LABORATORY REPTILASE TEST 18.00 0300 LABORATORY RESPIRATORY SYNCYTIAL AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY RETICULATED PLATELET ASSAY 60.00 0300 LABORATORY RETICULOCYTE AUTOMATED 12.00 0300 LABORATORY RICKETTSIA AB 30.00 0300 LABORATORY RPR QUAN 27.00 0300 LABORATORY RSV (TERAPIA RESPIRATORIA) 40.00 0300 LABORATORY RSV / SYNCITIAL RESPIRATORY AB SERUM 144.00 0300 LABORATORY RUBEOLA AB 135.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY RUBEOLA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY RUSSELL VIPER DILUTED 90.00 0300 LABORATORY RUSSELL VIPER UNDILUTED 18.00 0300 LABORATORY S3620 NEWBORN METABOLIC SCREENING PANEL 214.00 0300 LABORATORY SALMONELLA AB 36.00 0300 LABORATORY SCHLICTER TEST 36.00 0300 LABORATORY SCOTCH TAPE 12.00 0300 LABORATORY SEMEN ANALYSIS 40.00 0300 LABORATORY SEMEN ANALYSIS COMPLETE 40.00 0300 LABORATORY SEMEN ANALYSIS MOTILITY & COUNT 40.00 0300 LABORATORY SHBG SEX HORMONE BINDING GLOB 100.00 0300 LABORATORY SHIGA-LIKE TOXIN AG BY ENZYME IMMUNOASSAY QUAL 30.00 0300 LABORATORY SHIGELLA AB 36.00 0300 LABORATORY SIALIC ACID 60.00 0300 LABORATORY SILICA 42.00 0300 LABORATORY SKIN BIOPSY NON-NEOPLASTIC DISORDER 72.00 0300 LABORATORY SLELATEX 29.00 0300 LABORATORY SMEAR BLOOD W MANUAL DIFF 16.00 0300 LABORATORY SMEAR FLUORESCENT & ACID FAST STAIN 32.00 0300 LABORATORY SMEAR SPECIAL STAIN 100.00 0300 LABORATORY SODIUM SPOT URINE 29.00 0300 LABORATORY SODIUM URINE 24 HRS 29.00 0300 LABORATORY SOMATOMEDIN 343.00 0300 LABORATORY SOMATOSTATIN 300.00 0300 LABORATORY SPECIFIC GRAVITY EXCEPT URINE 4.00 0300 LABORATORY SPERM ANTIBODY 170.00 0300 LABORATORY SPERM CRYOPRESERVATION 120.00 0300 LABORATORY SPERM IDENTIFICATION 120.00 0300 LABORATORY SPERM IDENTIFICATION FROM TESTIS FRESH 180.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY SPERM ISOLATION COMPLEX PREP 240.00 0300 LABORATORY SPERM ISOLATION SIMPLE PREP 180.00 0300 LABORATORY SPINAL FLUID GLUCOSE 54.00 0300 LABORATORY SPINAL TAP R 12.50 0300 LABORATORY SPLITTING OF BLOOD 120.00 0300 LABORATORY STARCH GRANULES FECES 60.00 0300 LABORATORY STREPTOCOCCUS A AG BY ENZYME IMMUNOASSAY QUAL 18.00 0300 LABORATORY STREPTOCOCCUS A AMPLIFIED DIRECT PROBE BY DNA 60.00 0300 LABORATORY STREPTOCOCCUS A BY IMMUNOASSAY 36.00 0300 LABORATORY STREPTOCOCCUS A DIRECT PROBE BY DNA 36.00 0300 LABORATORY STREPTOCOCCUS A QUANTIFICATION BY DNA 72.00 0300 LABORATORY STREPTOCOCCUS B BY IMMUNOASSAY 36.00 0300 LABORATORY STREPTOKINASE AB 30.00 0300 LABORATORY SUBSTITUTION PLASMA FRACTIONS, EACH 100.00 0300 LABORATORY SUGARS CHROMATOGRAPHIC 19.00 0300 LABORATORY SUGARS MULTIPLE QUAL 12.00 0300 LABORATORY SUGARS MULTIPLE QUAN 30.00 0300 LABORATORY SUGARS SINGLE QUAN 30.00 0300 LABORATORY SULFATE URINE 24.00 0300 LABORATORY T CELLS TOTAL COUNT 144.00 0300 LABORATORY T3 FREE 61.00 0300 LABORATORY T3 REVERSE 138.00 0300 LABORATORY T3 TOTAL 58.00 0300 LABORATORY T3 UPTAKE 29.00 0300 LABORATORY T4 FREE 55.00 0300 LABORATORY T4 TOTAL 29.00 0300 LABORATORY TBG THYROXINE BINDING GLOBULI 96.00 0300 LABORATORY TETANUS AB 36.00 0300 LABORATORY THIOCYANATE 84.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY THROMBIN TIME PLASMA 96.00 0300 LABORATORY THROMBIN TIME TITER 120.00 0300 LABORATORY THROMBOMODULIN 18.00 0300 LABORATORY THYROGLOBULIN 72.00 0300 LABORATORY THYROTROPIN RELEASING HORMONE (TRH) 1HR 452.00 0300 LABORATORY THYROTROPIN RELEASING HORMONE (TRH) 2HR 452.00 0300 LABORATORY THYROXINE NEONATAL 12.50 0300 LABORATORY TOPIRAMATE 150.00 0300 LABORATORY TOXOPLASMA AB IGG 83.00 0300 LABORATORY TRANSCORTIN 36.00 0300 LABORATORY TREPONEMA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY TREPONEMA PALLIDUM AB (FTA) 64.00 0300 LABORATORY TRICHINELLA AB 240.00 0300 LABORATORY TRICHOMONAS DIRECT PROBE BY DNA 600.00 0300 LABORATORY TRIGLYCERIDES OTHER FLUIDS 16.00 0300 LABORATORY TRILEPTAL 143.00 0300 LABORATORY TROPONIN QUAL 35.00 0300 LABORATORY TRYPSIN DUODENAL FLUID 90.00 0300 LABORATORY TRYPSIN FECES QUAL 90.00 0300 LABORATORY TRYPSIN FECES QUAN 90.00 0300 LABORATORY TSI THYROID STIMULATING IMMUN 125.00 0300 LABORATORY TUBERCULOSIS INTRADERMAL SKIN TEST 18.00 0300 LABORATORY TUBERCULOSIS TINE SKIN TEST 12.00 0300 LABORATORY TUMOR SOLID NEOPLASTIC DISORDER 42.00 0300 LABORATORY TYROSINE 18.00 0300 LABORATORY UNLISTED CHEMISTRY PROCEDURE 1,000.00 0300 LABORATORY UNLISTED CYTOGENETIC STUDY 319.00 0300 LABORATORY URINALYSIS COMPLETE 8.00 0300 LABORATORY URINALYSIS NON AUTO 8.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY URINALYSIS SPECIFIC GRAVITY 30.00 0300 LABORATORY URINALYSIS SPECIFIC KETONES 4.00 0300 LABORATORY UROBILINOGEN FECES QUAN 77.00 0300 LABORATORY UROBILINOGEN URINE QUAL 77.00 0300 LABORATORY UROBILINOGEN URINE QUAN 49.00 0300 LABORATORY UROBILINOGEN URINE SEMIQUAN 13.00 0300 LABORATORY VAGINAL FOR GBS 48.00 0300 LABORATORY VARICELLA AG BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY VDRL CSF 27.00 0300 LABORATORY VDRL QUAL 16.00 0300 LABORATORY VDRL QUAN 27.00 0300 LABORATORY VIP VASOPRESSIN INTESTINAL PEP 362.00 0300 LABORATORY VIRUS AB NOT SPECIFIED 144.00 0300 LABORATORY VIRUS AG NOT SPECIFIED BY IMMUNOFLUORESCENT 30.00 0300 LABORATORY VIRUS ISOLATION INCLUDING ID 210.00 0300 LABORATORY VIRUS ISOLATION OF EMBRYONATED EGGS 174.00 0300 LABORATORY VIRUS ISOLATION TISSUE CULTURE 84.00 0300 LABORATORY VIRUS ISOLATION TISSUE CULTURE ADD STUDIES 36.00 0300 LABORATORY VISCOSITY 19.00 0300 LABORATORY VITAMIN A 48.00 0300 LABORATORY VITAMIN B-1 THIAMINE 125.00 0300 LABORATORY VITAMIN B-2 RIBOFLAVIN 270.00 0300 LABORATORY VITAMIN B-6 239.00 0300 LABORATORY VITAMIN C ASCORBIC ACID BLOOD 64.00 0300 LABORATORY VITAMIN D 1 25 45.00 0300 LABORATORY VITAMIN D CALCIFEROL 150.00 0300 LABORATORY VITAMIN E TOCOPHEROL ALPHA 154.00 0300 LABORATORY VITAMIN NOT OTHERWISE SPECIFIED 30.00 0300 LABORATORY VLDL CHOLESTEROL 96.00 Rev. June, 2020

CodeGroup Description Price 0300 LABORATORY VMA VANILYLMANDELIC ACID URINE 84.00 0300 LABORATORY VOLATILES 120.00 0300 LABORATORY WATER LOAD TEST 120.00 0300 LABORATORY WBC COUNT MANUAL 17.00 0300 LABORATORY WESTERN BLOT IMMUNOLOGICAL 225.00 0300 LABORATORY YERSINIA AB 30.00 0300 LABORATORY ZINC 32.00 0301 LABORATORY ALBUMIN ( ALB ) 9.00 0301 LABORATORY ALP ( ALKALINE PHOSPHATASE ) 9.00 0301 LABORATORY ALT (SGPT) 16.00 0301 LABORATORY AMYLASE 12.00 0301 LABORATORY AST (SGOT) 16.00 0301 LABORATORY BILIRUBIN DIRECT 9.00 0301 LABORATORY BILIRUBIN TOTAL 9.00 0301 LABORATORY BILIRUBIN TOTAL, DIRECT AND INDIRECT 18.00 0301 LABORATORY BUN 9.00 0301 LABORATORY CALCIUM ( CA2+ ) 9.00 0301 LABORATORY CHLORIDE (CL-) 5.00 0301 LABORATORY CHLORIDE BODY FLUID 5.00 0301 LABORATORY CHOLESTEROL 9.00 0301 LABORATORY CHOLESTEROL BODY FLUID 9.00 0301 LABORATORY CO2 ( BICARBONATE ) 9.00 0301 LABORATORY CPK ISOFORMS (CREATINE KINASE ISOFORMS) 18.00 0301 LABORATORY CPK MB (CREATINE KINASE MB FRACTION ONLY) 18.00 0301 LABORATORY CPK TOTAL (CREATINE KINASE TOTAL) 10.00 0301 LABORATORY CREATININE 9.00 0301 LABORATORY ELECTROLYTES PANEL 15.00 0301 LABORATORY GENTAMICIN PEAK 28.00 0301 LABORATORY GENTAMICIN TROUGH 28.00 Rev. June, 2020

CodeGroup Description Price 0301 LABORATORY GLUCOSE BODY FLUID 9.00 0301 LABORATORY GLUCOSE TOLERANCE / GTT 5 HRS 45.00 0301 LABORATORY GLUCOSE TOLERANCE TEST / GTT 3 HRS 27.00 0301 LABORATORY GLUCOSE TOLERANCE TEST 2 HRS /GTT 2 HRS 18.00 0301 LABORATORY LDH 50.00 0301 LABORATORY LDH BODY FLUID 9.00 0301 LABORATORY LIPASE 25.00 0301 LABORATORY LIVER PROFILE 30.00 0301 LABORATORY MAGNESIUM ( MG 2+) 15.00 0301 LABORATORY PHENYTOIN ( DILANTIN ) 18.00 0301 LABORATORY PHOSPHATASE ACID PROSTATIC 24.00 0301 LABORATORY PHOSPHORUS ( PO4- ) 9.00 0301 LABORATORY PKU 105.00 0301 LABORATORY POTASSIUM (K+) 5.00 0301 LABORATORY SODIUM (NA+) 5.00 0301 LABORATORY THEOPHYLLINE 18.00 0301 LABORATORY TIBC IRON BINDING CAPACITY TOTAL 15.00 0301 LABORATORY TOTAL PROTEIN ( TP ) 9.00 0301 LABORATORY TOTAL PROTEIN BODY FLUID 9.00 0301 LABORATORY TRIGLYCERIDES 9.00 0301 LABORATORY TRIGLYCERIDES BODY FLUID 9.00 0301 LABORATORY TROPONIN QUAN 15.00 0301 LABORATORY TROPONIN T 25.00 0301 LABORATORY URIC ACID 9.00 0301 LABORATORY URIC ACID BODY FLUID 9.00 0301 LABORATORY VANCOMYCIN PEAK 28.00 0301 LABORATORY VANCOMYCIN TROUGH 28.00 0301 LABORATORY VITAMIN B12 (CYANOCOBALAMIN) 25.95 0305 LABORATORY CELL COUNT BODY FLUID 15.00 Rev. June, 2020

CodeGroup Description Price 0305 LABORATORY CELL COUNT CSF 15.00 0305 LABORATORY HEMATOCRIT (HCT) 3.00 0305 LABORATORY HEMOGLOBIN (HGB) 3.00 0305 LABORATORY SEDIMENTATION RATE (SED RATE) ESR 15.00 0309 LABORATORY ABCESS CULTURE 22.00 0309 LABORATORY ACETAMINOPHEN: SERUM 45.00 0309 LABORATORY ACTH 110.00 0309 LABORATORY AFB CULTURE PLEURAL 19.00 0309 LABORATORY AFB CULTURE SPUTUM 155.00 0309 LABORATORY ALCOHOL 60.00 0309 LABORATORY ALDOLASE 14.00 0309 LABORATORY ALDOSTERONE 80.00 0309 LABORATORY ALPHA FETO PROTEIN TUMOR MARKER 27.00 0309 LABORATORY AMIKACIN PEAK 28.00 0309 LABORATORY AMIKACIN TROUGH 28.00 0309 LABORATORY AMMONIA 20.00 0309 LABORATORY ANA TEST (ANTINUCLEAR ANTIBODIES) 22.12 0309 LABORATORY ANGIOTENSIN 1-CONVERTING ENZYME 60.00 0309 LABORATORY ANTI-MITOCHONDRIAL AB (AMA) 25.00 0309 LABORATORY ANTI-SMITH ANTIBODY 61.00 0309 LABORATORY ANTI-SMOOTH AB (ASMA) 55.00 0309 LABORATORY ASO TITER 15.34 0309 LABORATORY BLOOD CULTURE 12.00 0309 LABORATORY BNP ( B-TYPE NATRIURETIC PEPTIDE ) 50.00 0309 LABORATORY CA 125 43.00 0309 LABORATORY CA 15-3 54.00 0309 LABORATORY CA 19-9 65.00 0309 LABORATORY CA 27-29 20.00 0309 LABORATORY CALCIUM IONIZED ( CA IONIZED) 55.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY CARBAMAZEPINE (TEGRETOL) 22.00 0309 LABORATORY CARDIOLIPIN ANTIBODIES (IGA, IGG, IGM) 185.00 0309 LABORATORY CARNITINE 150.00 0309 LABORATORY CD4 / CD8 80.00 0309 LABORATORY CEA (CARCINOEMBRYONIC ANTIGEN) 31.87 0309 LABORATORY CHLAMYDIA AB IGM 85.00 0309 LABORATORY CHLAMYDIA DNA PROBE 65.00 0309 LABORATORY CHLAMYDIA URINE 65.00 0309 LABORATORY CHOLINESTERASE 41.00 0309 LABORATORY CLONAZEPAM (KLONOPIN) 83.00 0309 LABORATORY CLOSTRIDIUM DIFFICILE TOXIN 75.00 0309 LABORATORY COLD AGGLUTININS 10.00 0309 LABORATORY COLD HEMAGGLUTININS 10.00 0309 LABORATORY COLLECTION OF VENUS BLOOD BY VENOPUNCTURE 8.00 0309 LABORATORY COMPLEMENT C 3 / C 4 31.00 0309 LABORATORY COMPLEMENT CH 50 85.00 0309 LABORATORY CORTISOL TOTAL 25.00 0309 LABORATORY COUMADIN 12.00 0309 LABORATORY CPK ISOENZYMES (CREATINE KINASE ISOENZYMES) 20.00 0309 LABORATORY CREATININE CLEARANCE + TOTAL PROTEIN 24 HRS COLL 23.00 0309 LABORATORY CRP (LABORATORY) 8.00 0309 LABORATORY CRP QUANTITATIVE (REFERENCE) 11.00 0309 LABORATORY CULTURE CATHETER 22.00 0309 LABORATORY CYTOMEGALOVIRUS ANTIBODY IGG 32.00 0309 LABORATORY CYTOMEGALOVIRUS ANTIBODY IGM 32.00 0309 LABORATORY D- DIMER 65.00 0309 LABORATORY DENGUE TITER 125.00 0309 LABORATORY DEPAKENE (DEPAKOTE) VALPROIC ACID 30.00 0309 LABORATORY DHEA-S 65.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY DIGOXIN (LANOXIN) 23.80 0309 LABORATORY EAR CULTURE 22.00 0309 LABORATORY ENVIRONMENTAL CULTURE 22.00 0309 LABORATORY EPSTEIN BARR ANTIBODY IGG 39.00 0309 LABORATORY EPSTEIN BARR ANTIBODY IGM 39.00 0309 LABORATORY ERYTHROPOIETIN 39.00 0309 LABORATORY ESTRIOL 80.00 0309 LABORATORY ESTROGEN 59.00 0309 LABORATORY EYE CULTURE 22.00 0309 LABORATORY FACTOR IX (PTC OR CHRISTMAS FACTOR) 160.00 0309 LABORATORY FACTOR V (LEIDEN) 120.00 0309 LABORATORY FACTOR VII 120.00 0309 LABORATORY FACTOR VIII (VON WILLEBRAND) 135.20 0309 LABORATORY FACTOR X (STUART) 120.00 0309 LABORATORY FACTOR XI (PTA) 130.00 0309 LABORATORY FACTOR XII (HAGEMAN) 145.00 0309 LABORATORY FACTOR XIII 205.00 0309 LABORATORY FERRITIN 25.00 0309 LABORATORY FIBRIN DEGRADATION PRODUCTS (FDPS) 45.00 0309 LABORATORY FIBRINOGEN 14.00 0309 LABORATORY FOLIC ACID ( FOLATE ) 25.00 0309 LABORATORY FSH (FOLLICLE STIMULATING HORMONE) 27.00 0309 LABORATORY FTA- AB (FLUORESCENT TREPONEMA ANTIBODY) 21.00 0309 LABORATORY G6PD QUANTITATIVE 17.75 0309 LABORATORY GASTRIN 65.00 0309 LABORATORY GBS CULTURE 22.00 0309 LABORATORY GC CULTURE 65.00 0309 LABORATORY GGT (GAMMAGLUTAMYL TRANSFERASE) 21.00 0309 LABORATORY GLUCAGON 60.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY GLUCOSE TOLERANCE / GTT 4 HRS 36.00 0309 LABORATORY GLUCOSE TOLERANCE EACH GLUCOSE ADD BEYOND 3 SPECIM 18.00 0309 LABORATORY GRAM STAIN 5.00 0309 LABORATORY HAPTOGLOBIN 28.00 0309 LABORATORY HCG QUANTITATIVE (REFERENCE) 20.00 0309 LABORATORY HELICOBACTER PYLORI IGM 90.00 0309 LABORATORY HEPATITIS A ANTIBODY 25.00 0309 LABORATORY HEPATITIS ACUTE PANEL ( PROFILE ) 41.00 0309 LABORATORY HEPATITIS B SURFACE AB QUANT 70.00 0309 LABORATORY HEPATITIS B SURFACE ANTIGEN (HBsAg) 20.00 0309 LABORATORY HEPATITIS C ANTIBODY 40.00 0309 LABORATORY HERPES SIMPLEX 1 AND 2 IGM 71.00 0309 LABORATORY HISTOPLASMA AB 115.00 0309 LABORATORY HIV BY PCR (VIRAL LOAD) 253.00 0309 LABORATORY HIV TEST 11.00 0309 LABORATORY HOMOCYSTEINE 105.00 0309 LABORATORY IBUPROFEN 87.00 0309 LABORATORY IGA 14.00 0309 LABORATORY IGD 17.00 0309 LABORATORY IGE 20.00 0309 LABORATORY IGG 14.00 0309 LABORATORY IGM 14.00 0309 LABORATORY INFLUENZA A / B RAPID TEST (LABORATORIO) 40.00 0309 LABORATORY INSULIN LEVELS 19.00 0309 LABORATORY IRON 12.00 0309 LABORATORY KETONE 3.00 0309 LABORATORY LE LATEX 14.00 0309 LABORATORY LEAD 16.00 0309 LABORATORY LEGIONELLA AB IGM 87.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY LEGIONELLA ANTIGEN URINE 80.00 0309 LABORATORY LEPTOSPIRA AB 55.00 0309 LABORATORY LH (LUTEINIZING HORMONE) 28.00 0309 LABORATORY LIPID PANEL 34.00 0309 LABORATORY LITHIUM 10.60 0309 LABORATORY LUPUS ANTICOAGULANT 80.00 0309 LABORATORY MERCURY 45.00 0309 LABORATORY MONO TEST 13.00 0309 LABORATORY MYCOPLASMA PNEUMONIAE IGM 75.00 0309 LABORATORY MYOGLOBIN 145.00 0309 LABORATORY MYOGLOBIN URINE 145.00 0309 LABORATORY NEISSERIA GONORRHOEAE AB 120.00 0309 LABORATORY NEISSERIA GONORRHOEAE DIRECT PROBE 125.00 0309 LABORATORY NEISSERIA GONORRHOEAE DNA PROBE 65.00 0309 LABORATORY NEISSERIA GONORRHOEAE URINE 65.00 0309 LABORATORY NOSE CULTURE 22.00 0309 LABORATORY OCCULT BLOOD (OB) (FOBT) 3.00 0309 LABORATORY OVA AND PARASITES 159.00 0309 LABORATORY PERIPHERAL SMEAR 5.00 0309 LABORATORY PERITONEAL FLUID CULTURE: 22.00 0309 LABORATORY PH 3.00 0309 LABORATORY PHENOBARBITAL 20.00 0309 LABORATORY PLEURAL CULTURE: 22.00 0309 LABORATORY PROGESTERONE 27.85 0309 LABORATORY PROLACTIN 41.00 0309 LABORATORY PROTEIN C ACTIVITY 75.00 0309 LABORATORY PROTEIN S ACTIVITY 75.00 0309 LABORATORY PSA 36.00 0309 LABORATORY PTH -C TERMINAL 105.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY PTH INTACT 101.00 0309 LABORATORY RA LATEX 13.00 0309 LABORATORY REDUCING SUBSTANCE 7.80 0309 LABORATORY RETIC COUNT 5.00 0309 LABORATORY ROTAZYME (ROTAVIRUS AG DETECTION) 40.00 0309 LABORATORY RUBELLA ANTIBODY 19.85 0309 LABORATORY SALICYLATE (ASPIRIN) 63.00 0309 LABORATORY SEMEN CULTURE 25.00 0309 LABORATORY SEROTONIN 110.00 0309 LABORATORY SICKLE CELL 9.00 0309 LABORATORY SKIN LESION CULTURE: 22.00 0309 LABORATORY SPINAL FLUID CULTURE: 18.36 0309 LABORATORY SPUTUM CULTURE 12.00 0309 LABORATORY STOOL CULTURE 18.36 0309 LABORATORY SYNOVIAL FLUID CULTURE: 22.00 0309 LABORATORY TACROLIMUS (PROGRAF) 195.00 0309 LABORATORY TESTOSTERONE FREE 55.00 0309 LABORATORY TESTOSTERONE TOTAL 55.00 0309 LABORATORY THROAT CULTURE 22.00 0309 LABORATORY THYROGLOBULIN ANTIBODY 21.00 0309 LABORATORY TOBRAMYCIN 30.00 0309 LABORATORY TOXICOLOGY SERUM 135.00 0309 LABORATORY TOXICOLOGY URINE 30.00 0309 LABORATORY TOXOPLASMA AB IGM 80.00 0309 LABORATORY TRANSFERRIN 35.00 0309 LABORATORY TSH 14.00 0309 LABORATORY TYROID PEROXIDASE (TPO) MICROSOMAL 41.00 0309 LABORATORY ULCER CULTURE 22.00 0309 LABORATORY URINE CULTURE 17.00 Rev. June, 2020

CodeGroup Description Price 0309 LABORATORY VAGINAL CULTURE 22.00 0309 LABORATORY VARICELLA ZOSTER ANTIBODY IGG 71.00 0309 LABORATORY VARICELLA ZOSTER IGM 63.00 0309 LABORATORY VDRL 14.00 0309 LABORATORY VITAMIN D 25 35.00 0309 LABORATORY VITAMIN K 140.00 0309 LABORATORY VON WILLEBRAND FACTOR AG 147.00 0309 LABORATORY WEST NILE VIRUS 185.00 0309 LABORATORY WESTERN BLOT 105.00 0309 LABORATORY WOUND CULTURE 22.00 0309 LABORATORY XYLOSE ABSORPTION TEST 5 HRS 40.00 0320 RADIOLOGY 73520 HIP BIL AP/ FROG 2 VIEW 21.60 0320 RADIOLOGY 73552 INT FEMUR 2 VIEWS 17.40 0320 RADIOLOGY ABDOMEN 1 VIEW 74018 40.55 0320 RADIOLOGY ABDOMEN 2 VIEWS 74019 74.72 0320 RADIOLOGY ABDOMEN 3 VIEWS 74021 74.72 0320 RADIOLOGY ABDOMEN COMPLETE 74022 74.72 0320 RADIOLOGY ABDOMEN SERIES INCLUDING CHEST 74022 74.72 0320 RADIOLOGY ACROCLAVICULAR JOINT BILATERAL 73050 40.55 0320 RADIOLOGY ANKLE (73610) 40.00 0320 RADIOLOGY ANKLE 2 VIEW 73600 40.55 0320 RADIOLOGY ANKLE 3 VIEWS (73610) 40.00 0320 RADIOLOGY ANKLE 3 VIEWS 73610 40.55 0320 RADIOLOGY ANKLE LT COMPLETE APT.LAT, OBLICUA THREE VIEWS 40.00 0320 RADIOLOGY ANKLE RT; AP/LAT TWO VIEWS 30.00 0320 RADIOLOGY BA ENEMA WITH AIR CONTRACT 74280 151.65 0320 RADIOLOGY BA SWALLOW 74220 164.98 0320 RADIOLOGY BARIUM ENEMA SINGLE 74270 74.72 0320 RADIOLOGY BONE AGE 77072 16.80 Rev. June, 2020

CodeGroup Description Price 0320 RADIOLOGY BONE SURVEY (77075) 40.00 0320 RADIOLOGY BONE SURVEY 77074 41.70 0320 RADIOLOGY BREAST NEEDLE (76096) 160.00 0320 RADIOLOGY BREAST PROFILE (MAMOGRAFIA) 250.00 0320 RADIOLOGY CALCANEUS (HEEL) 2 VIEWS 73650 40.55 0320 RADIOLOGY CALCANEUS 2 VIEWS 73650 30.00 0320 RADIOLOGY CERVICAL 2 OR 3 VIEWS 72040 40.55 0320 RADIOLOGY CERVICAL 4 AND 5 VIEWS AP/LAT/OBLIQUE 72050 74.72 0320 RADIOLOGY CERVICAL COMPLETE 6 OR MORE VIEWS 72052 74.72 0320 RADIOLOGY CHEST 4 VIEWS 71048 74.72 0320 RADIOLOGY CHEST COMPLETE DECUBITUS MIN 4 VIEWS 71048 74.72 0320 RADIOLOGY CHOLANGIOGRAPHY/PANCREATOGRAPHY 74300 25.63 0320 RADIOLOGY CLAVICLE COMPLETE 73000 40.55 0320 RADIOLOGY COMPLETE SPINE 72081 40.55 0320 RADIOLOGY COMPONENTE MEDICO HIP BILATERAL FROG 26.00 0320 RADIOLOGY CYSTOGRAM (74430) 151.65 0320 RADIOLOGY DUPLEX CAROTID (93880) 100.00 0320 RADIOLOGY DUPLEX EXTREMITY VEINS 100.00 0320 RADIOLOGY DUPLEX LOWER EXTREMITY (93925) 100.00 0320 RADIOLOGY DUPLEX UPPER EXTREMITY ARTERIAL (93930) 100.00 0320 RADIOLOGY ELBOW 2 VIEWS AP/LAT 73070 40.55 0320 RADIOLOGY ELBOW 2 VIEWS (73070) 20.00 0320 RADIOLOGY ELBOW 3 VIEWS 73080 40.55 0320 RADIOLOGY EXAMINATION SPINE 2 OR 3 VIEWS 72082 74.72 0320 RADIOLOGY FACIAL 3 VIEW 70140 40.55 0320 RADIOLOGY FACIAL BONES 70150 74.72 0320 RADIOLOGY FEMUR 1 VIEW (73551) 35.20 0320 RADIOLOGY FEMUR 1 VIEW 73551 40.55 0320 RADIOLOGY FEMUR 2 VIEWS 73552 40.55 Rev. June, 2020

CodeGroup Description Price 0320 RADIOLOGY FEMUR MINIMUN 2 VIEWS AP / FROG 73552 40.55 0320 RADIOLOGY FINGER (73140) 30.00 0320 RADIOLOGY FINGER 2 VIEWS 73140 40.55 0320 RADIOLOGY FOOT 2 VIEW 73620 40.55 0320 RADIOLOGY FOOT 3 VIEW (73630) 42.00 0320 RADIOLOGY FOOT 3 VIEW 73630 40.55 0320 RADIOLOGY FOOT LT 2 VIEW 40.00 0320 RADIOLOGY FOREARM (73090) 40.00 0320 RADIOLOGY FOREARM 2 VIEWS AP/ LAT 73090 40.55 0320 RADIOLOGY GALLBLADDER (74290) 60.00 0320 RADIOLOGY HAND 2 VIEW 73120 40.00 0320 RADIOLOGY HAND 2 VIEWS AP/OBL 73120 74.72 0320 RADIOLOGY HAND 3 VIEW 73130 40.55 0320 RADIOLOGY HAND RT THREE VIEWS (AP/LAT/OBLIQUE) 50.00 0320 RADIOLOGY HEAD (70350) 40.00 0320 RADIOLOGY HIP (73510) 45.50 0320 RADIOLOGY HIP 2 OR 3 VIEWS 73502 40.55 0320 RADIOLOGY HIP 2 VIEW UNILATERAL 73502 40.55 0320 RADIOLOGY HIP BILATERAL 2 VIEWS 73521 74.72 0320 RADIOLOGY HIP UNILATERAL 1 VIEW 73501 40.55 0320 RADIOLOGY HIP UNILATERAL MIN 4 VIEW 73503 74.72 0320 RADIOLOGY HIPS BILATERAL 3 OR 4 VIEWS 73522 74.72 0320 RADIOLOGY HIPS BILATERAL MIN 5 VIEWS73523 74.72 0320 RADIOLOGY HUMER (73060) 40.00 0320 RADIOLOGY HUMERUS 2 VIEWS 73060 40.55 0320 RADIOLOGY HUMERUS MINIMUN 2 VIEWS 73060 40.55 0320 RADIOLOGY INT FEMUR LT 20.00 0320 RADIOLOGY KNEE 3 VIEWS (73562) 40.00 0320 RADIOLOGY KNEE 3 VIEWS 73562 40.55 Rev. June, 2020

CodeGroup Description Price 0320 RADIOLOGY KNEE 4 VIEW COMLPTE 73564 40.55 0320 RADIOLOGY KNEE AP/ LAT 1 OR 2 VIEWS 73560 40.55 0320 RADIOLOGY KNEE BOTH STANDING 73565 40.55 0320 RADIOLOGY KUB 74020 35.00 0320 RADIOLOGY LEG (73590) 40.00 0320 RADIOLOGY LT COMPLETE, MINIMUN TWO VIEWS HIP/THING 46.00 0320 RADIOLOGY LUMBOSACRAL 2 OR 3 VIEWS 72100 74.72 0320 RADIOLOGY LUMBOSACRAL 4 VIEW AP/LAT/OBL 72110 74.72 0320 RADIOLOGY LUMBOSACRAL ONLY BENDING 2/3 VIEWS 72120 74.72 0320 RADIOLOGY LUMBROSACRAL BENDING 6 VIEWS 72114 74.72 0320 RADIOLOGY MANDIBLE COMPLETE 70110 40.55 0320 RADIOLOGY MANDIBLE LESS 4 VIEWS 70100 42.50 0320 RADIOLOGY MASTOIDS COMPLETE 3 VIEWS PER SIDE 70130 40.55 0320 RADIOLOGY MASTOIDS LESS THAN 3 VIEWS 70120 40.55 0320 RADIOLOGY MASTOIDS LESS THAN 3 VIEWS 70130 40.55 0320 RADIOLOGY NASAL BONES 70160 40.55 0320 RADIOLOGY NECK SOFT TISSUE 70360 40.55 0320 RADIOLOGY ORBITS COMPLETE 70200 40.55 0320 RADIOLOGY PARANASAL (WATERS VIEW) LESS THAN 3 VIEWS 70210 40.55 0320 RADIOLOGY PARANASAL SINUSES 3 VIEWS 70220 40.55 0320 RADIOLOGY PELVIS COMP 3 VIEWS 72190 74.72 0320 RADIOLOGY PELVIS HIPS INFANT 73540 18.00 0320 RADIOLOGY PELVIS MIN 3 VIEW 72190 74.72 0320 RADIOLOGY PELVIS, (1 OR 2 VIEWS) AP/FROG 72170 74.72 0320 RADIOLOGY RIBS 3 VIEWS 71110 74.72 0320 RADIOLOGY RIBS BILATERAL 3 VIEWS 71110 74.72 0320 RADIOLOGY RIBS INCLUDING CHEST MIN 4 VIEWS BILAT 71111 74.72 0320 RADIOLOGY RIBS UNIL 2 VIEW 71100 40.55 0320 RADIOLOGY RIBS UNILATERAL 3 VIEW 71101 60.00 Rev. June, 2020

CodeGroup Description Price 0320 RADIOLOGY SACROILIAC JOINTS 3 VIEWS 72200 74.72 0320 RADIOLOGY SACROLIAC JOINT 72202 74.72 0320 RADIOLOGY SACRUM AND COCCYX 2 VIEWS 72220 40.55 0320 RADIOLOGY SCAPULA 73010 40.55 0320 RADIOLOGY SCOLIOSIS STUDY INCLUDING (72082) 55.00 0320 RADIOLOGY SELLA TURCICA 70240 40.55 0320 RADIOLOGY SHOULDER 1 VIEWS 73020 40.55 0320 RADIOLOGY SHOULDER 2 VIEWS 73030 40.55 0320 RADIOLOGY SHUNT SERIES 75809 74.72 0320 RADIOLOGY SKULL LESS 4 VIEWS 70250 50.00 0320 RADIOLOGY SKULL SERIES COMPLETE 4 VIEWS 70260 74.72 0320 RADIOLOGY SMALL BOWEL 74250 74.72 0320 RADIOLOGY STERNUM MINIMUM 2 VIEWS 71120 40.55 0320 RADIOLOGY TEMPOROMANDIBULAR COMPLETE BILATERAL 70330 40.55 0320 RADIOLOGY TEMPOROMANDIBULAR JOINT UNILATERAL 70328 40.55 0320 RADIOLOGY THORACIC 3 VIEWS 72072 74.72 0320 RADIOLOGY THORACIC MIN 4 VIEWS 72074 74.72 0320 RADIOLOGY THORACIC SNIPE 2 VIEWS 72070 74.72 0320 RADIOLOGY THORACOLUMAR STANDIG FOR SCOLIOSIS 72083 74.72 0320 RADIOLOGY THORACOLUMBAR 2 VIEWS 72080 40.55 0320 RADIOLOGY THORACOLUMBAR FOR SCOLIOSIS 6 VIEW72084 74.72 0320 RADIOLOGY THORACOLUMBAR SPINE, SCOLIOSI 72069 16.80 0320 RADIOLOGY TIBIA AND FIBULA 2 VIEWS 73590 40.55 0320 RADIOLOGY TOE MINIMUM 2 VIEW 73660 40.55 0320 RADIOLOGY UGIS 74241 164.98 0320 RADIOLOGY UPPER EXTREMITY INFANT MIN 2 VIEW 73092 74.72 0320 RADIOLOGY UPPER GI SERIES 74240 164.98 0320 RADIOLOGY WRIST 2 VIEW (73100) 25.00 0320 RADIOLOGY WRIST 3 VIEW 73110 42.00 Rev. June, 2020

CodeGroup Description Price 0320 RADIOLOGY WRIST 3 VIEWS 73110 40.55 0320 RADIOLOGY WRIST AP/ LAT 73100 40.55 0321 RADIOLOGY INT DUPLEX CAROTID 100.00 0324 RADIOLOGY CHEST 3 VIEWS 71047 40.55 0324 RADIOLOGY CHEST PA/ LAT 2 VIEWS 71046 40.55 0324 RADIOLOGY CHEST SINGLE AP 71045 40.55 0324 RADIOLOGY CHEST SPECIAL VIEW 71046 40.55 0329 RADIOLOGY 37225 DSA 5,000.00 0329 RADIOLOGY 77001 FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT 172.26 0341 RADIOLOGY ACUTE GASTRO BLOOD LOSS IMAGING 78278 278.89 0343 RADIOLOGY A9503 TC99M MEDRONATE 20.00 0343 RADIOLOGY A9510 TC99M DISOFENIN 35.70 0343 RADIOLOGY A9512 TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC 33.14 0343 RADIOLOGY A9560 TECHNETIUM TC-99M LABELED RED BLOOD CELLS 65.75 0343 RADIOLOGY J2805 SINCALIDE INJECTION 97.25 0349 RADIOLOGY A9537 TC99M MEBROFENIN (CONTRASTE) 70.00 0350 RADIOLOGY ABDOMINAL (75635) AORTA WITH CONTRAST MATERIAL 175.00 0350 RADIOLOGY (73706) LOWER EXTREMITY LEG ANKLE AND FOOT 175.00 0350 RADIOLOGY 72133 LUMBAR SPINE 172.00 0350 RADIOLOGY 77012 CT GUIDANCE GOR NEEDLE PLACEMENT BIOPSY/A/I 115.00 0350 RADIOLOGY ABDOMEN (74175) WITH CONTRAST 175.00 0350 RADIOLOGY ANGIOGRAPHY (70496) HEAD WITH CONTRAST MATERIAL 175.00 0350 RADIOLOGY ANGIOGRAPHY (70498) /NECT WITH CONTRAST MATERIAL 175.00 0350 RADIOLOGY ANGIOGRAPHY (73206) UPPER EXTREMITY WITH CONTRAST 175.00 0350 RADIOLOGY ANGIOGRAPHY CHEST WITH CONTRAST 71275 175.00 0350 RADIOLOGY ANGIOGRAPHY PEVIS/WITH CONTRAST 72191 175.00 0350 RADIOLOGY BONE MINERAL DENSITY 1 APPENDICULAR SKELETON 37.00 0350 RADIOLOGY BONE MINERAL DENSITY STUDY 1 OR MORE SITE AXIAL SK 50.00 0350 RADIOLOGY CT ABD WITH CONTRAST MATERIAL 74160 360.00 Rev. June, 2020

CodeGroup Description Price 0350 RADIOLOGY CT ABD/PELVIS W/O & W 74178 270.00 0350 RADIOLOGY CT ABDOMEN (74175) WITH CONTRAST ANGIOGRAPHY 175.00 0350 RADIOLOGY CT ABDOMEN WITHOUT CONTRAST MATERIAL74150 360.00 0350 RADIOLOGY CT CERVICAL SPINE WO FOLLOW CONTRAST 72127 660.00 0350 RADIOLOGY CT HEAD WITH CONTRAST 70460 165.00 0350 RADIOLOGY CT HEAD WITH/WITHOUT CONTRAST 70470 165.00 0350 RADIOLOGY CT HEAD WITHOUT CONTRAST 70450 165.00 0350 RADIOLOGY CT LUMBAR WO FOLLOWED CONTRAST 72133 720.00 0350 RADIOLOGY CT ORBIT SELLA AND EAR WO FOLLOWED BY CON 70482 165.00 0350 RADIOLOGY CT PELVIS WO CONTRAST 72192 180.00 0350 RADIOLOGY CT PELVIS WO CONTRAST FOLLOWED 72194 360.00 0350 RADIOLOGY CT SCAN ABD AND PELVIC W/O CONTRAST 74176 270.00 0350 RADIOLOGY CT SCAN ABD AND PELVIC WITH CONTR. 74177 270.00 0350 RADIOLOGY CT SCAN ABD WO FOLLOWED BY CONTRAST 74170 360.00 0350 RADIOLOGY CT SCAN CERVICAL SPINE W CONTRAST 72126 165.00 0350 RADIOLOGY CT SCAN CERVICAL SPINE WO CONTRAST 72125 165.00 0350 RADIOLOGY CT SCAN LOWER EXTREMITY W CONTRAST 73701 320.00 0350 RADIOLOGY CT SCAN LOWER EXTREMITY WO CONTRAST 73700 320.00 0350 RADIOLOGY CT SCAN LUMBAL SPINE W CONTRAST 72132 180.00 0350 RADIOLOGY CT SCAN LUMBAL SPINE WO CONTRAST 72131 312.00 0350 RADIOLOGY CT SCAN MAXILLOFACIAL WITH CONTRAST PNS 70487 165.00 0350 RADIOLOGY CT SCAN MAXILLOFACIAL WO CONTRAST/PNS 70486 165.00 0350 RADIOLOGY CT SCAN MAXILLOFACIAL WO FOLLOWED BY CONTRAST PNS 70488 165.00 0350 RADIOLOGY CT SCAN ORBIT SELLA AND EAR W/O CONTRAST 70480 165.00 0350 RADIOLOGY CT SCAN ORBIT SELLA FOSSA AND EAR W/CONTRAST 70481 165.00 0350 RADIOLOGY CT SCAN PELVIS W CONTRAST 72193 180.00 0350 RADIOLOGY CT SCAN SOFT TISSUE NECK W CONTRAST 70491 165.00 0350 RADIOLOGY CT SCAN SOFT TISSUE NECK WO CONTRAST 70490 165.00 0350 RADIOLOGY CT SCAN SOFT TISSUE NECK WO FOLLOW CONTR 70492 165.00 Rev. June, 2020

CodeGroup Description Price 0350 RADIOLOGY CT SCAN THORACIC SPINT W/O CONT PROD & INT (72128) 300.00 0350 RADIOLOGY CT SCAN THORAX (CHEST) W CONTRAST71260 180.00 0350 RADIOLOGY CT SCAN THORAX (CHEST) WO CONTRAST 71250 180.00 0350 RADIOLOGY CT SCAN UPPER EXTREMITY W CONTRAST 73201 320.00 0350 RADIOLOGY CT SCAN UPPER EXTREMITY WO CONTRAST 73200 180.00 0350 RADIOLOGY CT THORACIC SPINE W CONTRAST 72129 180.00 0350 RADIOLOGY CT THORACIC SPINE WO CONTRAST 72128 180.00 0350 RADIOLOGY CT THORACIC W AND WO CONTRAST 72130 175.00 0350 RADIOLOGY CT THORAX CHEST WO CONTRAST FOLLOWED 71270 720.00 0350 RADIOLOGY CT UPPER EXT WO FOLLOWED CONTRAST 73202 720.00 0350 RADIOLOGY CTANGIOGRAPHY ABDOMEN/PELVIS WITH CONTRAST, INCLUDING NON CONTRAST 74174 312.00 0350 RADIOLOGY DUAL-ENERGY ABSORPTIOMETRY B/D AXIAL SKELETON 39.00 0350 RADIOLOGY GUIDANCE (77013) AND MONITORING PARENCHYMAL 225.00 0350 RADIOLOGY GUIDANCE (77014) FOR PLACEMENTOF RADIATION 62.00 0350 RADIOLOGY GUIDANCE FOR STEREOTATIC LOCALIZATION 174.00 0350 RADIOLOGY LIMITED OR LOCLIZED FOLOW-UP STUDY(76380) 175.00 0350 RADIOLOGY LOWER EXTREMITY WITHOUT CONTRAST 73702 175.00 0350 RADIOLOGY PELVIC (72191) WITH CONTRAST 175.00 0360 OPERATING ROOM 10030 IMAGE GUIDED CATHETER FLUID COLLECTION DRAINAGE 867.60 0360 OPERATING ROOM 10040 ACNE SURGERY 67.15 0360 OPERATING ROOM 10060 INCISION AND DRAINAGE OF ABSCESS 867.70 0360 OPERATING ROOM 10121 INCISION REMOVAL FOREIGN BODY SUBQ TISS 867.60 0360 OPERATING ROOM 10140 I & D HEMATOMA SEROMA/FLUID COLLECTION 867.60 0360 OPERATING ROOM 11004 DEBRIDEMENT GENITALIA 867.60 0360 OPERATING ROOM 11005 DEBRIDEMENT ABDOMINAL WALL 867.60 0360 OPERATING ROOM 11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ 867.60 0360 OPERATING ROOM 11043 DEBRIDEMENT 20 SQ 867.60 0360 OPERATING ROOM 11044 DEBRIDEMENT BONE MUSCLE/FASCIA 867.60 0360 OPERATING ROOM 11200 REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 11201 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10 867.60 0360 OPERATING ROOM 11400- EXC LESION MRGN XCP 867.60 0360 OPERATING ROOM 11401 EXC B9 LES MRGN XCP SK TG T/A/L 0.3-1.0 CM 867.60 0360 OPERATING ROOM 11402 EXC B9 LES MRGN XCP SK TG 867.60 0360 OPERATING ROOM 11403 EXC B9 LEX MRGN XCP SK TG T/A/L 2.1-3.0 CM 867.60 0360 OPERATING ROOM 11404 EXCISION EXCISED DIAMETER 3.1 TO 4.0 867.60 0360 OPERATING ROOM 11406 EXCISION (EXCISED DIAMETER OVER 4.0) 867.60 0360 OPERATING ROOM 11420 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.5 CM 867.60 0360 OPERATING ROOM 11420 REMOVER CONDILOMA 867.60 0360 OPERATING ROOM 11421 EXCISION BENIGN LESION 867.60 0360 OPERATING ROOM 11422 EXCISION BENIGN LESION 867.60 0360 OPERATING ROOM 11423 EXCISION LESION EXCISED DIAMETER 2.1 TO 3.0 867.60 0360 OPERATING ROOM 11424 EXCISION EXCISED DIAMETER 3.1 TO 4.0 867.70 0360 OPERATING ROOM 11426 EXC B9 LESION MRGN XCP SK TG 4.0 CM 867.60 0360 OPERATING ROOM 11440 EXC B9 LES MRGN XCP SK 867.60 0360 OPERATING ROOM 11441 EXC B9 LES MRGN XCP SK TG 0.6-1.0CM 867.60 0360 OPERATING ROOM 11443 EXC B9 LES MRGN XCP SX TG F/E/E/N/L/M 2.1-3. 867.60 0360 OPERATING ROOM 11450 EXCISION HIDRADENITIS AXILLARY SMPL 867.60 0360 OPERATING ROOM 11601 EXCISION MAL LESION TRUNK/ARM/LEG (11601) 867.60 0360 OPERATING ROOM 11604 EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM 867.60 0360 OPERATING ROOM 11606 EXCISION MALIGNANT LESSION TRUNK 867.60 0360 OPERATING ROOM 11622 EXCISION MALIGNANT LESION S/NH/F/G 867.60 0360 OPERATING ROOM 11626 EXCISION MALIGNANT LESION S/N/H/F/G >4.0 CM 867.60 0360 OPERATING ROOM 11750 EXCISION NAIL MATRIX PERMANENT REMOVAL 867.60 0360 OPERATING ROOM 11770 EX PILONIDAL CST/SINUS SMPL 867.60 0360 OPERATING ROOM 11770- EXCISION OF PILONIDAL CYST 867.60 0360 OPERATING ROOM 11771 EXCISION PILONIDAL CYST 867.60 0360 OPERATING ROOM 11772 EXCISION PILONIDAL CYST/SINUS COMPLICATED 867.60 0360 OPERATING ROOM 14000 ADJACEMENT TISSUE 10 SQ 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 14001 TIS TRANSFR/REARRANGE TRUNK 867.60 0360 OPERATING ROOM 14020 ADJACENT TISSUE, SCALP, ARMS, LEG 867.60 0360 OPERATING ROOM 14021 ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM 867.60 0360 OPERATING ROOM 14040- ADJAMENT TISSUE TRANFER 10SQ OR LESS 867.60 0360 OPERATING ROOM 14041 ADJT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ 867.60 0360 OPERATING ROOM 14060- ADJECENT TISSUE REARRANGEMENT 867.60 0360 OPERATING ROOM 14060 ATT/REATGMT E/N/E/L DFCT 10 CM/< 867.60 0360 OPERATING ROOM 14061 ADJT TIS REA EYE/NOSE/EAR/LIP10.1-30.0 SQCM 1,300.00 0360 OPERATING ROOM 14301 ADJNT TIS TRNS/REARGMT ANY AREA 30.1-60 SQCM 867.60 0360 OPERATING ROOM 15271 -APP SKIN SUB GRFT 867.60 0360 OPERATING ROOM 15736 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR 867.60 0360 OPERATING ROOM 15931 EXCISION SACRAL PRESSURE 867.60 0360 OPERATING ROOM 15999 UNLISTED PROCEDURE EXCISION PRESSURE ULCER 867.60 0360 OPERATING ROOM 17000 DESTRUCTION PREMALIGNANT LESION 1ST 867.60 0360 OPERATING ROOM 17003 DESTRUCTION PREMALIGNANT LESION 2-14 EA 867.60 0360 OPERATING ROOM 17110- DESTRUCTION BENIGN LESION UP TO 14 867.60 0360 OPERATING ROOM 19020 MASTOTOMY W/EXPL/DRAINAGE ABS 867.60 0360 OPERATING ROOM 19100 EXCISION BIOPSY OF BREAST, PERCUTANEOUS 867.60 0360 OPERATING ROOM 19101 BIOPSY BREAST OPEN INCISIONAL 867.60 0360 OPERATING ROOM 19120 EXC CYST BREAST TISSUE 867.60 0360 OPERATING ROOM 19125 EXCISION OF BREAST AFTER NEEDLE LOCALITION 867.60 0360 OPERATING ROOM 19300 MASTECTOMY GYNECOMASTIA 867.60 0360 OPERATING ROOM 19301 MASTECTOMY PARTIAL LUMPECTOMY 867.60 0360 OPERATING ROOM 19302 MAST PRTL W/AX LMPHADEC 867.70 0360 OPERATING ROOM 19302 MASTECTOMY PARTIAL W/AXILLARY 867.60 0360 OPERATING ROOM 19304 MASTECTOMY SUBCUTANEOUS 867.60 0360 OPERATING ROOM 19499 UNLISTED PROCEDURE BREAST 867.60 0360 OPERATING ROOM 20240 BIOPSY BONE OPEN SUPERFICIAL 867.60 0360 OPERATING ROOM 20525 RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 20610 ARTHROCENTESIS ASPIR/INJ MAJOR 867.60 0360 OPERATING ROOM 20680 REMOVAL IMPLANT DEEP 1,193.00 0360 OPERATING ROOM 21012 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2 867.60 0360 OPERATING ROOM 21014 EXCISION, TUMOR, SOFT TISSUE OF FACE 2 CM 867.60 0360 OPERATING ROOM 21015 RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM 867.60 0360 OPERATING ROOM 21552 EXC TUMOR SOFT TIS NECK/ANT THORAX SUBQ 3 867.60 0360 OPERATING ROOM 21554 EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/> 867.60 0360 OPERATING ROOM 21555 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 867.60 0360 OPERATING ROOM 21556 EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM 867.60 0360 OPERATING ROOM 21930 EXCISION TUMOR SOFT TISSUE 867.60 0360 OPERATING ROOM 21931 EXCISION TUMOR BLACK/FLANK 3CM OR GREATER 867.60 0360 OPERATING ROOM 21932 EXC TUMOR SOFT TISS BACK/FLANCK SUBFASCIAL <5CM 867.60 0360 OPERATING ROOM 21933 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 867.60 0360 OPERATING ROOM 21935 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM 867.60 0360 OPERATING ROOM 22900 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 867.60 0360 OPERATING ROOM 22903 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3 CM 867.60 0360 OPERATING ROOM 22999 UNLISTED PX ABDOMEN MUSCULOSKELETAL 739.00 0360 OPERATING ROOM 23030 ID SHOULDER DEEP ABSCESS/HEMATOMA 867.60 0360 OPERATING ROOM 23071 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 867.60 0360 OPERATING ROOM 23075 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM 867.60 0360 OPERATING ROOM 23076 EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM 867.60 0360 OPERATING ROOM 23130 PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE 867.60 0360 OPERATING ROOM 23410 OPEN REPAIR OF ROTATOR CUFF ACUTE 867.60 0360 OPERATING ROOM 23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC 867.60 0360 OPERATING ROOM 23420 RECONSTRUCTION ROTATOR CUFF 867.60 0360 OPERATING ROOM 23615 OPEN TREATMENT PROXIMAL HUMERAL FRACTURE 867.60 0360 OPERATING ROOM 24071 EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 867.60 0360 OPERATING ROOM 25071 -EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3CM/ 867.60 0360 OPERATING ROOM 25075 EXC TUMOR SOFT TISSUE FOREARM /WRIST SUBQ <3CM 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 25077 RAD RESECT TUMOR SOFT TISS FOREARM & WRIST 867.60 0360 OPERATING ROOM 25105 ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY 867.60 0360 OPERATING ROOM 25111 EXCISION GANGLION WRIST DORSAL/VOLAR 867.60 0360 OPERATING ROOM 25130 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN 867.60 0360 OPERATING ROOM 25248 EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST 867.60 0360 OPERATING ROOM 25515 OPEN TREATMENT OF RADIAL SHAFT FRACTURE 867.70 0360 OPERATING ROOM 25575 OPEN TX RADIALULNAR SHAFT FX W/FIXJ 867.60 0360 OPERATING ROOM 25607-OPEN REDUC WITH INTERNAL FIXATION 867.60 0360 OPERATING ROOM 25608 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRA 867.60 0360 OPERATING ROOM 25609 DISTAL RADIAL W INT FIXATION OF 3 MORE FRAG 867.60 0360 OPERATING ROOM 25628 OPEN TX CARPAL SCAPHOID NAVICULAR FX 867.60 0360 OPERATING ROOM 26111 EX TUM/VASC MALF SFT TISS HAND/FINGR SUBQ 867.60 0360 OPERATING ROOM 26320 REMOVAL OF IMPLANT FROM FINGER OR HAND 867.60 0360 OPERATING ROOM 26476 LENGTHENING TENDON EXTENSON HAND/FING 867.60 0360 OPERATING ROOM 26615 OPEN TX METACARPAL FRACTURE SINGLE EA BONE 867.60 0360 OPERATING ROOM 26700 CLOSED TREATMENT OF METACARPOPHALANGEAL 867.60 0360 OPERATING ROOM 26705 CLTX METACARPOPHALANGEAL 867.60 0360 OPERATING ROOM 26951 AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR 867.60 0360 OPERATING ROOM 27043 EXCISION TUMOR SOFT TISSUE PELVISHIP SUBQ 867.60 0360 OPERATING ROOM 27048 EXC TUMOR SOFT TISSUE PELVIS HIP SUBFAS 867.60 0360 OPERATING ROOM 27065 EXCISION OF BONE CYST OR BENING TUMOR 867.60 0360 OPERATING ROOM 27125 BIPOLAR HEMIARTHROPLASTY HIP PARTIAL 867.60 0360 OPERATING ROOM 27130 ARTHRP ACETBLR/PROX FEM PROSTC 867.60 0360 OPERATING ROOM 27236-HIP BIPOLAR REPLACEMENT 867.60 0360 OPERATING ROOM 27245- TX INTER/SUBTRCHNTRIC FEM FX IMED 867.60 0360 OPERATING ROOM 27248 OPEN TREATMENT GREATER TROCHANTERIC 867.60 0360 OPERATING ROOM 27252 CLTX HIP DISLOCATION TRAUMATIC REQ 867.60 0360 OPERATING ROOM 27269 OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD 867.60 0360 OPERATING ROOM 27299 UNLISTED PROCEDURE PELVIS/HIP JOINT 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 27327 THASH MASS 574.00 0360 OPERATING ROOM 27340 EXCISION PREPATELLAR BURSA 867.60 0360 OPERATING ROOM 27447-ARTHRP KNEE CONDYLEPLATU MEDIALLAT 867.60 0360 OPERATING ROOM 27524 OPTX PATLLR FX W/INT FIXJ/PATLLCSOFT TISS RP 867.60 0360 OPERATING ROOM 27570 MANIPULATION KNEE JOINT UNDER GENERAL 867.60 0360 OPERATING ROOM 27590 AMPUTATION THIGH THR FEMUR 867.60 0360 OPERATING ROOM 27607 INCISION LEG/ANKLE 867.60 0360 OPERATING ROOM 27632 EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3+ 867.60 0360 OPERATING ROOM 27632 LEG MASS 648.00 0360 OPERATING ROOM 27695 RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL 867.60 0360 OPERATING ROOM 27752 CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ 867.60 0360 OPERATING ROOM 27766 OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE 867.60 0360 OPERATING ROOM 27792 OPEN TX DISTAL FIBULAR FRACTURE LAT 867.60 0360 OPERATING ROOM 27814 OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE 867.60 0360 OPERATING ROOM 27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST L 867.60 0360 OPERATING ROOM 27827 OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY 867.60 0360 OPERATING ROOM 27880- AMPUTATION LEG, THROUGH TIBIA AND FIBULA 867.60 0360 OPERATING ROOM 28022 ARTHRT W/EXPL DRG/RMVL FB 867.60 0360 OPERATING ROOM 28039 EXCISION TUMOR SOFT TIS FOOT/TOE SUBQ 1.5 867.60 0360 OPERATING ROOM 28043 ECXCISION TUMOR SOFT TISSUE FOOT/ TOE SUBQ 867.60 0360 OPERATING ROOM 28045-EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 867.60 0360 OPERATING ROOM 28060 FASCIECTOMY PLANTAR PARTIAL SPX 867.60 0360 OPERATING ROOM 28062 FASCIECTOMY PLANTAR FASCIA RADICAL 867.60 0360 OPERATING ROOM 28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH 706.00 0360 OPERATING ROOM 28090 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT 867.60 0360 OPERATING ROOM 28092 EXC LESION TENDON SHEALTH/CAPSULE W/SYNVCT 867.60 0360 OPERATING ROOM 28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT 867.60 0360 OPERATING ROOM 28118 OSTECTOMY CALCANEUS 867.60 0360 OPERATING ROOM 28119 OSTECTOMY CALCANEUS SPUR W/WO PLNTAR 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 28120 FOOT OSCALCIS OF HAGLUNDL'S 867.60 0360 OPERATING ROOM 28122 PRTL EXC B1 TARSAL/METAR 867.60 0360 OPERATING ROOM 28192 REMOVAL FOREIGN BODY FOOT DEEP 867.60 0360 OPERATING ROOM 28285- CORRECTION HAMMERTOE 867.60 0360 OPERATING ROOM 28288 OSTC PRTL EXOSTC/CONDYLC METAR HEAD 867.60 0360 OPERATING ROOM 28289 HALLUX RIGIDUS CORRECTION W CHEILECTOMY 867.60 0360 OPERATING ROOM 28292 CORRJ HALLUX VALGUS W/SESMDC W/RESCJ PROX PHAL 1,800.00 0360 OPERATING ROOM 28293 CORRJ HALLUX VALGUS 587.00 0360 OPERATING ROOM 28296 CORRJ HALLUX VALGUS W/SESMDC W/DIST METAR OSTEOT 1,800.00 0360 OPERATING ROOM 28298 HALLUX VALGUS BY PHALANX OSTEOTOMY 867.60 0360 OPERATING ROOM 28299-HALLUX VALGUS 867.60 0360 OPERATING ROOM 28308 OSTEOT W/WO LNGTH SRT 587.00 0360 OPERATING ROOM 28435 CLOSED TX TALUS FX W/MANIPULATION 867.60 0360 OPERATING ROOM 28585 OPEN TREATMENT TALOTARSAL JOINT DISLOCATION 867.60 0360 OPERATING ROOM 28800 AMPUTATION FOOR MIDTARSAL 867.60 0360 OPERATING ROOM 28805 AMPUTATION FOOR TRANSMETARSAL 867.60 0360 OPERATING ROOM 28810 AMPUTATION METATARSAL WITH TOE SINGLE 867.60 0360 OPERATING ROOM 28820 AMPUTATION TOE 867.60 0360 OPERATING ROOM 29105 APPLICARION LONG ARM SPLINT SHOULDER HAND 867.60 0360 OPERATING ROOM 29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY 867.60 0360 OPERATING ROOM 29826- ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT 867.60 0360 OPERATING ROOM 29827 ARTHROSCOPY WITH ROTATOR CUFF REPAIR 860.67 0360 OPERATING ROOM 29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY 867.60 0360 OPERATING ROOM 29876 ARTHROSCOPY KNEE SYNOVECTOMY 867.60 0360 OPERATING ROOM 29880 ARTHROSCOPY KNEE W/MENISCECTOMY 867.60 0360 OPERATING ROOM 29881 ARTHROSCOPY KNEE SURGERY 867.60 0360 OPERATING ROOM 31502 CHANGE OF WINDPIPE AIRWAY 867.60 0360 OPERATING ROOM 31600TRACHEOSTOMY PLANNED SEPARTE PROC 867.60 0360 OPERATING ROOM 31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 31830 REVISION TRACHEOSTOMY SCAR 867.60 0360 OPERATING ROOM 32556 PLEURAL DRAINGE PERCUTANEOU 867.60 0360 OPERATING ROOM 32607 THORASCOPY WITH DIAGNOSTIC BIOPSY OF LUNG 867.60 0360 OPERATING ROOM 32651 THORACOSCOPY W/PARTIAL PULMONARY 867.60 0360 OPERATING ROOM 32652 THORASCOPY SURGICAL WITH TOTAL PULMONARY 867.60 0360 OPERATING ROOM 33025 CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX 867.60 0360 OPERATING ROOM 33206-PACEMAKER OF NEW OR REPLACEMENT OF PERMANENT 867.60 0360 OPERATING ROOM 33208 INS PERM PACEMAKER DUAL CHAMBER 867.60 0360 OPERATING ROOM 33215 RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE 867.60 0360 OPERATING ROOM 33223 RELOCATE SKIN POCKET IMPLANTABLE DEFIBRILLATOR 867.60 0360 OPERATING ROOM 33227 PERM PM PLSE GEN 867.60 0360 OPERATING ROOM 33228 REMOVAL OF PERMANENT PACEMAKER DUAL LEAD SYS 867.60 0360 OPERATING ROOM 33249 INSJ/RPLCMT PERM DFB W/TRNSVNS LDS 1/DUAL 867.60 0360 OPERATING ROOM 33262 RMVL IMPLTBL DFB PLSE GEN W/REPL PLSE GEN 1 LEAD 867.60 0360 OPERATING ROOM 33264 RMVL IMPLTBL DFB PLS GEN W/RPLCMR PLS GEN 867.60 0360 OPERATING ROOM 35558 BYPASS W/VEIN FEMORAL-FEMORAL 867.60 0360 OPERATING ROOM 35840 WOUND EXPLORATOY 867.60 0360 OPERATING ROOM 36260 INSJ IMPLANTABLE INTRA-ARTERIAL INFUSION 867.60 0360 OPERATING ROOM 36556 INSERTION OF CENTRAL VENOUS ACCESS 867.60 0360 OPERATING ROOM 36558 INSJ TUNNELED CVC W/O SUBQ 867.60 0360 OPERATING ROOM 36561 INSERTION OF TUNNELED CENTRAL VENOUS 867.60 0360 OPERATING ROOM 36571 INSERT PERIPHERALLY INSERTED CENTRALVEIN 5Y 867.60 0360 OPERATING ROOM 36571 INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> 867.60 0360 OPERATING ROOM 36582 RPLCMT COMPL TUN CTR VAD W/SUBP PORT 867.60 0360 OPERATING ROOM 36590 RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ 867.60 0360 OPERATING ROOM 36640 ARTERIAL CATHERIZATION CHEMOTHERAPY 867.60 0360 OPERATING ROOM 37609 LIG/BX TEMPORAL ART 867.60 0360 OPERATING ROOM 37700 LIGDIV LONG SAPH VEIN SAPHFEM 867.60 0360 OPERATING ROOM 37718 LIG DIVSTRIPPING SHORT SAPHENOUS VEIN 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 37722 LIG DIVSTRIP LONG SAPH JUNCT 867.60 0360 OPERATING ROOM 37735 LIGATION AND DIVISION COMPLETE STRIPPING OF 867.60 0360 OPERATING ROOM 38500 BX/EXC LYMPH NODE OPEN SUPERFICIAL 867.60 0360 OPERATING ROOM 38505 BX/EXC LYMPH NODE NEEDLE SUPERFICIAL 867.60 0360 OPERATING ROOM 38510 BX/EXC LYMPH NODE OPEN DEEP CERVICAL NODE 867.60 0360 OPERATING ROOM 38520 BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD 867.60 0360 OPERATING ROOM 38525 BX/EXC LYMPH NODE OPEN DEEP AXILLARY NODE 867.60 0360 OPERATING ROOM 38550 REMOVAL NECK ARMPIT LESION 867.60 0360 OPERATING ROOM 38570 LAP, LYMPH NODE BIOP 1,300.00 0360 OPERATING ROOM 38571 LAPAROSCOPY, LYMPHADENECTOMY 1,300.00 0360 OPERATING ROOM 38572 LAP, LYMPHADENECTOMY AND PERIAORTIC 1,300.00 0360 OPERATING ROOM 38720 CERVICAL LYMPHADENECTOMY 867.60 0360 OPERATING ROOM 38724 CERVICAL LYMPHADEC MODIFIED RADICAL NECK DSJ 867.60 0360 OPERATING ROOM 38745 LT AXILLARY LYMPHADENECTOMY COMPLETE 867.60 0360 OPERATING ROOM 40819 EXC FRENUM LABIAL/BUCCAL 867.60 0360 OPERATING ROOM 43235 ESOPHAGOGASTRODUODENOSCOPY TRANSORAL 867.60 0360 OPERATING ROOM 43255 EGD TRANSORAL CONTROL BLEEDING ANY METHOD 867.60 0360 OPERATING ROOM 43280 LAPS SURG ESOPG/GSTR FUNDOPLASTY 1,300.00 0360 OPERATING ROOM 43631 GASTRECTOMY PARTIAL 867.60 0360 OPERATING ROOM 43631 GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY 867.60 0360 OPERATING ROOM 43651 LAP, SURGICAL TRANSECTION OF VAGUS 1,300.00 0360 OPERATING ROOM 43652 LAP, TRANSECTION OF VAGUS NERVES, 1,300.00 0360 OPERATING ROOM 43653 LAP, CASTROTOMY, WITHOUT GASTRIC TUBE 1,300.00 0360 OPERATING ROOM 43760 CHANGE OF TUBE GASTROSTOMY 867.60 0360 OPERATING ROOM 43830- GASTROSTOMY 867.60 0360 OPERATING ROOM 43832 GASTROSTOMY OPN W/CONSTJ GSTR TUBE 867.60 0360 OPERATING ROOM 44005 ENTEROLSS FRING INTSTINAL ADHESION SPX 867.60 0360 OPERATING ROOM 44050 REDUCTION OF VOLVULUS LAPAROTOMY 867.60 0360 OPERATING ROOM 44120 ENTRC RESCJ SMALL INTESTINE 1 RESCJ ANAST 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 44139 MOBILIZATION WITH PARTIAL COLECTOMY 867.60 0360 OPERATING ROOM 44140 COLECTOMY PARTIAL WITH ANASTOMOSIS 867.60 0360 OPERATING ROOM 44143 COLECTOMY PRTL W/END COLOSTOMY 867.60 0360 OPERATING ROOM 44180 LAPAROSCOPY ENTEROLYSIS 867.60 0360 OPERATING ROOM 44188 LAPARASCOPY COLOSTOMY 867.60 0360 OPERATING ROOM 44202 LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ ANA 1,300.00 0360 OPERATING ROOM 44203 LAPS EA SM INT RESCJANAST 1,300.00 0360 OPERATING ROOM 44204 LAPAROSCOPY COLECTOMY PARTIAL 1,300.00 0360 OPERATING ROOM 44205 LAPS COLECTOMY PRTL W/RMVL TERMINAL ILEUM 1,300.00 0360 OPERATING ROOM 44206 LAPS COLECTOMY PRTL W/END CLST CLSR DSTL SGM 1,300.00 0360 OPERATING ROOM 44207 LAPS COLECTOMY PRTL W/COLOPXTSTMY LW ANAST 1,300.00 0360 OPERATING ROOM 44213 LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLECTOMY 1,300.00 0360 OPERATING ROOM 44373 REVISION OF GASTROSTOMY 867.60 0360 OPERATING ROOM 44950 APPENDECTOMY 800.00 0360 OPERATING ROOM 44970 LAP, SURGICAL, APPENDECTOMY 1,300.00 0360 OPERATING ROOM 44979 UNLISTED LAPARASCOPY PROCEDURE, APPENDIX 1,300.00 0360 OPERATING ROOM 46050 ID PERIANAL ABSCESS SUPERFICIAL 867.60 0360 OPERATING ROOM 46083 INCISION THROMBOSED HEMORRHOID EXTERNAL 867.60 0360 OPERATING ROOM 46250- HEMORRHOIDECTOMY EXTERNAL 867.60 0360 OPERATING ROOM 46260- HEMORRHOIDECTOMY INTERNAL AND EXTERNAL 867.60 0360 OPERATING ROOM 46288 CLSR ANAL FSTL W/RCT ADVMNT FLAP 867.60 0360 OPERATING ROOM 46930 DESTRUCTION INTERNAL HEMORRHOID THERMAL 867.60 0360 OPERATING ROOM 47379 UNLIS LAPAROSCOPIC PROCEDURE LIVER 867.60 0360 OPERATING ROOM 47552 BILIARY NDSC PRQ T-TUBE DX 867.60 0360 OPERATING ROOM 47560 LAP SIRG W/GID TRANSHEPATC CHLNGGRPH 1,300.00 0360 OPERATING ROOM 47561 LAP SIRG W/GID TRANSHEPATC CHOLANGIOGRPH 1,300.00 0360 OPERATING ROOM 47562 LAP, SURGICAL; CHOLECYSTECTOMY 1,300.00 0360 OPERATING ROOM 47562 LAPS SURG CHOLECSTC 867.60 0360 OPERATING ROOM 47563 LAP, CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY 1,300.00 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 47564 LAP, CHOLECYS W EXPLORATION 1,300.00 0360 OPERATING ROOM 47570 LAP CHOLECYSTOENTEROSTOMY 1,300.00 0360 OPERATING ROOM 47579 UNLISTED LAPAROSCOPY PROCEDURE BILIARY TRACT 1,300.00 0360 OPERATING ROOM 47600 OPEN CHOLECYSTECTOMY 867.60 0360 OPERATING ROOM 49000 EXPLORATORY LAPAROTOMY 867.60 0360 OPERATING ROOM 49082 ABDOM PARACENTESIS DX/THER W/O IMAGING 867.60 0360 OPERATING ROOM 49205 EXC/DESTRUCTION OPEN ABDOMINAL TUMORS 867.60 0360 OPERATING ROOM 49250 UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX 867.60 0360 OPERATING ROOM 49255 OMENTECTOMY, RESECTION OF OMENTUM 867.60 0360 OPERATING ROOM 49320 LAPARASCOPY DIAGNOSTIC 867.60 0360 OPERATING ROOM 49321 LAP SURGICAL WITH BIOPSY 1,500.00 0360 OPERATING ROOM 49322 LAP WITH ASPIRATION OF CAVITY OR CYST 1,500.00 0360 OPERATING ROOM 49323 LAP W DRAINAGE OF LYMPHOCELE 1,500.00 0360 OPERATING ROOM 49324 LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER 1,300.00 0360 OPERATING ROOM 49325 LAPS W/REVISION INTRAPERITONEAL CATHETER 1,300.00 0360 OPERATING ROOM 49326 LAPAROSCOPY W/OMENTOPEXY 1,300.00 0360 OPERATING ROOM 49327 LAPS W/INSERTION NTRSTL DEV W/IMG GUID 1/MLT 1,300.00 0360 OPERATING ROOM 49329 LAPAROSCOPY UNLISTED LAP PROC, ADBOMEN, PER 867.60 0360 OPERATING ROOM 49329 UNLIS LAPS PX ABD PRTMOMENTUM 867.60 0360 OPERATING ROOM 49329 UNLISTED LAPAROSCOPIC PX ABD PERTONEUM OMENTUM 1,300.00 0360 OPERATING ROOM 49406 PERITONIAL PERCUTANEOUS 867.60 0360 OPERATING ROOM 49425 INSERTION PERITONEAL VENOUS SHUNT 867.60 0360 OPERATING ROOM 49500RPR 1ST INGUN HRNA AGE 6 MO 5 YRS REDUCIBLE 867.60 0360 OPERATING ROOM 49505 REPAIR INITIAL INGUINAL HERNIA 867.70 0360 OPERATING ROOM 49505 RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE 867.60 0360 OPERATING ROOM 49507 REP IN INGUINAL HERNIA INCARCERATED 867.60 0360 OPERATING ROOM 49520 RPR RECRT INGUINAL HERNIA ANY AGE REDUCIBLE 867.60 0360 OPERATING ROOM 49521 REPAIR REC INGUINAL HERNIA INCARCERATE 867.70 0360 OPERATING ROOM 49525 RPR INGUN HERNIA SLIDING ANY AGE 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 49550 RPR 1ST FEM HRNA ANY AGE REDUCIBLE 867.60 0360 OPERATING ROOM 49553 RPR 1ST FEM HERNIA ANY AGE INCARCERATED 867.60 0360 OPERATING ROOM 49560 REPAIR VENTRAL HERNIA 867.60 0360 OPERATING ROOM 49565 REPAIR RECURRENT INC VENTRAL HERNIA 867.60 0360 OPERATING ROOM 49568 HERNIA REPAIR IMPLANTATION OF MESH 867.60 0360 OPERATING ROOM 49570 RPR EPIGASTRIC HERNIA REDICIBLE SPX 867.60 0360 OPERATING ROOM 49585-REPAIR UMBILICAL HERNIA 867.60 0360 OPERATING ROOM 49587 REPAIR UMBILICAL HERNIA INCAR AGE 5 YRS 867.60 0360 OPERATING ROOM 49587 RPR UMBILICAL HERNIA AGE 5 YRS/> 867.60 0360 OPERATING ROOM 49650 LAP REPAIR INITIAL INGUINAL HERNIA 1,300.00 0360 OPERATING ROOM 49651 LAP REPAIR RECURRENT INGUINAL HERNIA 1,300.00 0360 OPERATING ROOM 49652 LAPS REPAIR HERNIA EXCEPT INCAL 867.60 0360 OPERATING ROOM 49653 LAP RPR HRNA X CPT INCAL/INGUN 1,500.00 0360 OPERATING ROOM 49654 LAPAROSCOPY REPAIR INCISIONAL HERNIA REDICIBLE 1,300.00 0360 OPERATING ROOM 49655 LAPS RPR INCISIONAL HERNIA NCRC8/STRANGULATED 1,300.00 0360 OPERATING ROOM 49656 LAPS RPR RECURRENT INCISIONAL HERNIA REDICIBLE 1,300.00 0360 OPERATING ROOM 49657 LAPS RPR RECURRENT INCAL HRNA NCRC8/STRANGULATED 1,300.00 0360 OPERATING ROOM 49900 SC ABDOMINAL WALL SUTURE 867.60 0360 OPERATING ROOM 50431 NJX PX ANTEGRDE NFROSGRM 867.60 0360 OPERATING ROOM 50435 EXCHANGE NEPHROSTOMY 867.60 0360 OPERATING ROOM 50435 EXCHANGE NEPHROSTOMY CATHETER 867.60 0360 OPERATING ROOM 51840 ANT VESICOURETHROPEXY/URETHROPEXY SMPL 867.60 0360 OPERATING ROOM 52000 CYSTOURETHROSCOPY 867.60 0360 OPERATING ROOM 52276 CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE 867.60 0360 OPERATING ROOM 52310 CYSTO W/SIMPLE REMOVAL STONE STENT 867.60 0360 OPERATING ROOM 52315 CYSTO W/COMPLEX REMOVAL STONE STENT 867.60 0360 OPERATING ROOM 52332 CYSTO W/INSERT URETERAL STENT 867.60 0360 OPERATING ROOM 52601 TRURL ELECTROSURG RESCJ PROSTATE BLEED 867.60 0360 OPERATING ROOM 53270 EXCISION OR FULTURATION SKENES GLANDS 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 54060 DSTRJ LESION PENIS SIMPLE SURG EXCISION 867.60 0360 OPERATING ROOM 54150 CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK 867.60 0360 OPERATING ROOM 54161 CIRCUMCISION AGE 28 DAYS 867.60 0360 OPERATING ROOM 54300 PENIS STRAIGHTENING CHORDEE 867.60 0360 OPERATING ROOM 54500 BIOPSY TESTIS NEEDLE SEPARTE PROCEDURE 867.60 0360 OPERATING ROOM 54505 BIOPSY TESTIS INCISIONAL SEPARATE PROCEDURE 867.60 0360 OPERATING ROOM 54550 EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA 867.60 0360 OPERATING ROOM 55040 EXCISION OF HYDROCELE UNILATERAL 867.60 0360 OPERATING ROOM 55250 VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS 867.60 0360 OPERATING ROOM 55550 LAPS LIGATION SPERMATIC VEINS VARICOCELE 1,300.00 0360 OPERATING ROOM 55700 PROSTATE NEEDLE BIOPSY ANY APPROACH 867.60 0360 OPERATING ROOM 56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL A 867.60 0360 OPERATING ROOM 56440 MARSUPIALIZATION BARTHOLIN'S GLAND CYST 867.60 0360 OPERATING ROOM 56442 HYMENOTOMY SIMPLE INCISION 867.60 0360 OPERATING ROOM 56515 DSTRJ LES VULVA X10SV 867.60 0360 OPERATING ROOM 56515 DESTRUCTION LESION VULVA 867.60 0360 OPERATING ROOM 56605 BIOPSY VULVA/PERINEUM 1 LESION 867.60 0360 OPERATING ROOM 56620 VULVECTOMY SIMPLE PARTIAL 867.60 0360 OPERATING ROOM 56740 EXC BARTHOLINS GLAND/CYST 867.60 0360 OPERATING ROOM 57100 VAGINAL MUCOSA 867.60 0360 OPERATING ROOM 57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY 867.60 0360 OPERATING ROOM 57265 WITH ENTEROCELE REPAIR 867.60 0360 OPERATING ROOM 57270 REPAIR ENTEROCELE ABDOMINAL APPROACH SPX 867.60 0360 OPERATING ROOM 57282 COLPOPEXY VAGINAL EXTRAPERITONEAL 867.60 0360 OPERATING ROOM 57288 SLING OPERATION STRESS INCONTINENCE 867.60 0360 OPERATING ROOM 57410 PELVIC EXAMINATION UNDER ANESTHESIA 867.60 0360 OPERATING ROOM 57455 COLPOSCOPY CERVIX VAGINA 867.60 0360 OPERATING ROOM 57460 COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX 867.60 0360 OPERATING ROOM 57461 COLPOSCOPY CERVIX VAG 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 57505 ENDOCERVICAL CURETTACE W/DILATION & CURETTAG 867.00 0360 OPERATING ROOM 57520 CONIZATION CERVIX +DC RPR 867.60 0360 OPERATING ROOM 57522 CONIZATION CERVIX + D&C 867.60 0360 OPERATING ROOM 57530 TRACHELECTOMY (CERVICECTOMY) AMPUTATION 867.70 0360 OPERATING ROOM 57550 EXCISION CERVICAL STUMP VAGINAL APPROACH 867.50 0360 OPERATING ROOM 58100 ENDOMETRIAL BX W/WO ENDOCERVIX 867.60 0360 OPERATING ROOM 58120 DILATATION & CURETTAGE 867.60 0360 OPERATING ROOM 58145 MYOMECTOMY VAGINAL 867.60 0360 OPERATING ROOM 58150 HYSTERECTOMY TOTAL ABDOMINAL 867.60 0360 OPERATING ROOM 58152 TOT ABD HYST W/WO RMVL TUBE OVARY W/COLPURETHRXY 1,300.00 0360 OPERATING ROOM 58180 SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE 867.60 0360 OPERATING ROOM 58200 TOT ABD HYST W/PARAORTIC PELVIC LYMPH NODE SAM 1,300.00 0360 OPERATING ROOM 58210 RAD ABDL HYST W/BI PEL LMPHADEC 1,300.00 0360 OPERATING ROOM 58240 PEL EXNTJ GYNECOLOGIC MAL 1,300.00 0360 OPERATING ROOM 58260 VAGINAL HYSTERECTOMY UTERUS 250 GM 1,300.00 0360 OPERATING ROOM 58262 VAG HYST 250 GM/ < W/RMVL TUBE/OVARY 1,300.00 0360 OPERATING ROOM 58263 VAG HYST 250 GM/ < W/RMVL TUBE OVARY W/RPR NTRCL 1,300.00 0360 OPERATING ROOM 58267 VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY 1,300.00 0360 OPERATING ROOM 58270 VAGINAL HYSTERETOMY 250 GM/ < W/RPR ENTEROCELE 1,300.00 0360 OPERATING ROOM 58275 VAGINAL HYSTERECTOMY 867.60 0360 OPERATING ROOM 58280 VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE 1,300.00 0360 OPERATING ROOM 58285 VAGINAL HYSTERECTOMY RADICAL SHAUTA OPERATION 1,300.00 0360 OPERATING ROOM 58290 VAGINAL HYSTERECTOMY UTERUS > 250 GM 1,300.00 0360 OPERATING ROOM 58291 VAG HYST > 250 GM RMVL TUBE/OVARY 1,300.00 0360 OPERATING ROOM 58292 VAG HYST > 250 GM RMVL TUBE/OVARY W/RPR ENTRCLE 1,300.00 0360 OPERATING ROOM 58293 VAG HYST > 250GM COLPOURTCSTOPEXY W/WO NDSC CTR 1,300.00 0360 OPERATING ROOM 58294 VAGINAL HYSTERECTOMY> 250 GM RPR ENTEROCELE 1,300.00 0360 OPERATING ROOM 58301 REMOVAL INTRAUTERINE DEVICE IUD 867.60 0360 OPERATING ROOM 58350 CHROMOTUBATION OVIDUCT W/MAT 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 58541 LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM 1,300.00 0360 OPERATING ROOM 58542 LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/ OVAR 1,300.00 0360 OPERATING ROOM 58543 LAPS SUPRACERVICAL HYSTERECTOMY >250 1,300.00 0360 OPERATING ROOM 58544 LAPS SUPRACRV HYSTEREC > 250 G RMVL TUBE/OVARY 1,300.00 0360 OPERATING ROOM 58545 LAPAROSCOPIC MYOMECTOMY 1 TO 4 INTRAMURAL 1,300.00 0360 OPERATING ROOM 58546 LAP MYOMECTOMY; 5 OR MORE INTRAMURAL 1,300.00 0360 OPERATING ROOM 58548 LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY 1,300.00 0360 OPERATING ROOM 58550 LAPAROSCOPY WITH VAGINAL HYSTERECTOMY 1,300.00 0360 OPERATING ROOM 58552 LAPARO-VAG HYST INCL T/O 1,500.00 0360 OPERATING ROOM 58553 LAP WITH VAGINAL HYSTERECTOMY 1,500.00 0360 OPERATING ROOM 58554 LAP HYSTERECTOMY WITH REMOVAL OF TUBE 1,500.00 0360 OPERATING ROOM 58555 HYSTEROSCOPY DIAGNOSTIC SEPARATE PROCEDURE 1,300.00 0360 OPERATING ROOM 58558 HYSTERESCOPY BIOSPY OF ENDOMETRIUM 1,300.00 0360 OPERATING ROOM 58559 HYSTSC LSS INTRAUTERINE ADS 1,300.00 0360 OPERATING ROOM 58560 HYSTEROSCOPY DIV/RESCJ INTRAUTERINE SEPTUM 1,300.00 0360 OPERATING ROOM 58561 HYSTEROSCOPY REMOVAL LEIOMYOMATA 1,300.00 0360 OPERATING ROOM 58562 HYSTEROSCOPY REMOVAL IMPACTED FOREIGH BODY 1,300.00 0360 OPERATING ROOM 58563 HYSTEROSCOPY ENDOMETRIAL ABLATION 1,300.00 0360 OPERATING ROOM 58565 HYSTEROSCOPY BI TUBE OCCLUSION W/PERM IMPLNTS 1,300.00 0360 OPERATING ROOM 58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM 1,300.00 0360 OPERATING ROOM 58571 LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY 1,300.00 0360 OPERATING ROOM 58572 LAPAROSCOPY TOTAL HYSTERECTIMY UTERUS > 250 GM 1,300.00 0360 OPERATING ROOM 58573 LAPAROSCOPY TOT HYSTERECTOMY > 250 G W/TUBE/OVAR 1,300.00 0360 OPERATING ROOM 58575 LAPS TOT HYSTERECTOMY RESJ MALIGNANCY W/OMNTC 1,300.00 0360 OPERATING ROOM 58578 UNLISTED LAPAROSCOPY PROCEDURE UTERUS 867.60 0360 OPERATING ROOM 58579 UNLISTED HYSTEROSCOPY PROCEDURE UTERUS 1,300.00 0360 OPERATING ROOM 58600 LIG/TRNSXJ FLP TUBE 867.60 0360 OPERATING ROOM 58605 LIGATION FALLOPIAN TUBE (EXTERILISATION) 867.60 0360 OPERATING ROOM 58611 FALOPIAN TUBE CESAREAN DEL/ADBML SURG 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 58615- BILATERAL TUBAL OCCUSION 867.60 0360 OPERATING ROOM 58660 LAP LYSUS OF ADHESIONS 1,500.00 0360 OPERATING ROOM 58660 LAPS LSS ADS SPX 1,300.00 0360 OPERATING ROOM 58661 LAP WITH REMOVAL OF ADNEXAL STRUCTURES 1,300.00 0360 OPERATING ROOM 58662 LAPS FULG/EXC OVARY VISCERA/PERITONEAL SURFACE 1,300.00 0360 OPERATING ROOM 58670 LAPAROSCOPY FULGURATION OVIDUCTS 867.60 0360 OPERATING ROOM 58671 LAPARASCOPY FULGURATION OVIDUCTS 867.60 0360 OPERATING ROOM 58671 LAPS OCCLUSION OVIDUXS DEV 1,300.00 0360 OPERATING ROOM 58672 LAPAROSCOPY FIMBRIOPLASTY 1,300.00 0360 OPERATING ROOM 58673 LAPARASCOPIC SALPINGOSTOMY 867.60 0360 OPERATING ROOM 58700 SALPINGECTOMY COMPL/PRTL UNI/BI SPX 867.60 0360 OPERATING ROOM 58720 SALPINGO OOPHORECTOMY COMPL/PRTL UNI/BI 867.60 0360 OPERATING ROOM 58740 LYSIS OF ADHESIONS SALPINX/OVARY 867.60 0360 OPERATING ROOM 58805 DRAINAGE OVARIAN CYST UNI/BI SPX ABDOMINAL 1,300.00 0360 OPERATING ROOM 58900 BIOPSY OVARY UNI/BI SEPARATE PROCEDURE 867.60 0360 OPERATING ROOM 58925 OVARIAN CYSTECTOMY UNI/BI 867.60 0360 OPERATING ROOM 58943 OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN 867.60 0360 OPERATING ROOM 58960 LAPT STG/RESTG OVARIAN 867.60 0360 OPERATING ROOM 59120 TX ECTOPIC PREGNANCY ABD/VAG 867.60 0360 OPERATING ROOM 59320 CERCLAGE CERVIX PREGNANCY VAG 867.60 0360 OPERATING ROOM 59414 DELIVERY PLACENTA SEPARATE PROCEDURE 867.60 0360 OPERATING ROOM 59514 CESAREAN DELIVERY ONLY 867.60 0360 OPERATING ROOM 59812 TX INCOMPL AB ANY TRI COMPLD SURGLY 867.60 0360 OPERATING ROOM 59820 TREATMENT MISSED ABORTION 1ST TRIM 867.60 0360 OPERATING ROOM 59820 TX MISSED AB COMPLD SURGLY 1ST TRI 867.60 0360 OPERATING ROOM 59821 TX MISSED ABORTION SECOND TRIMESTER 867.60 0360 OPERATING ROOM 59870 UTERINE EVACUATION CURETTAGE HYDATIDIFORM MOLE 867.60 0360 OPERATING ROOM 60210 PARTIAL LOBECTOMY ISTHMUSECTOMY 867.60 0360 OPERATING ROOM 60212 PRTL THYROID LOBEC UNI W/CONTRATLAT STOT 867.60 Rev. June, 2020

CodeGroup Description Price 0360 OPERATING ROOM 60240 THYROIDECTOMY TOTAL 867.60 0360 OPERATING ROOM 64704 NEUROPLASTY NERVE HAND/FOOT 867.60 0360 OPERATING ROOM 64721-MEDIAN NERVE AT CARPAL TUNNEL 867.60 0360 OPERATING ROOM 65420-PTERYGIUM EYE EXCISION/TRANSPOSITION 867.60 0360 OPERATING ROOM 66825 REPOSITIONING IO LENS PROSTHESIS 867.60 0360 OPERATING ROOM 66982 CATARACT REMOVAL INSERTION OF LENS 867.60 0360 OPERATING ROOM 66984 CATARACT REMOVAL INSERTION OF LENS 867.60 0360 OPERATING ROOM 88305 LEVEL IV SURG PATHOLOGY GROSSMICROSCOPIC 867.60 0360 OPERATING ROOM 97597 DEBRIDEMENT OPEN WOUND 20 SQ CM 867.60 0360 OPERATING ROOM 97597 RMVL DEVITAL TISS SLCTV DBRDMT W/O ANES 20 867.60 0360 OPERATING ROOM CIR. AMB. POR LAPAROSCOPIA 1,150.00 0360 OPERATING ROOM CIRUGIA GENERAL 867.60 0360 OPERATING ROOM CIRUGIA LAPARASCOPIA 1,300.00 0360 OPERATING ROOM CIRUGIA ORTOPEDICA 1,400.00 0360 OPERATING ROOM EXC B9 LES MRGN XCPS SK (11440) 500.00 0360 OPERATING ROOM EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RSI 867.60 0360 OPERATING ROOM GAUZE SPONGE 4X4 12 P/U ST WAVEN 0.07 0360 OPERATING ROOM INSJ PRPH CTR VAD W/SUBQ PORT (36571) 500.00 0360 OPERATING ROOM INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> 867.60 0360 OPERATING ROOM LAPARASCOPIC CHOLELITIASIS 1,164.00 0360 OPERATING ROOM NJX PX ANTEGRDE NFROSGRM/URTRGRM EXSTNG ACESS 867.60 0360 OPERATING ROOM REPAIR UMBILICAL HERNIA AGE 5 OR OLDER 800.00 0360 OPERATING ROOM USO DE SALA DE OPERACIONES 550.00 0369 OPERATING ROOM 43235 ENDOSCOPY 100.00 0369 OPERATING ROOM 45330 SIGMOIDOSCOPIA 100.00 0369 OPERATING ROOM 45378 COLONOSCOPY 100.00 0369 OPERATING ROOM 47562 LAP. CHOLECYSTECTOMY 789.00 0369 OPERATING ROOM STERILIZATION FOR CESAREAN DELIVERY 500.00 0369 OPERATING ROOM STERILIZATION FOR VAGINAL DELIVERY 700.00 Rev. June, 2020

CodeGroup Description Price 0370 OPERATING ROOM BILATERAL ECX BENING LESS FACE EAR NOSEEYELID LIP 50.00 0379 OPERATING ROOM APPPENDECTOMY DONE PURPOSE TIME OR MAJOR PROCEDU 500.00 0379 OPERATING ROOM LAP RPR HRNA X CPT INCAL/INGUN (49653) 500.00 0379 OPERATING ROOM 01951 BURN LESS 4 PERCENT 500.00 0379 OPERATING ROOM 28060 PARTIAL REMOVAL FOOT FASCIA 500.00 0379 OPERATING ROOM ADHESIOLYSIS TUBE, OVARY 500.00 0379 OPERATING ROOM AMPUTATION BELOW KNEE 300.00 0379 OPERATING ROOM AMPUTATION OF FINGER/THUMB (26951) 500.00 0379 OPERATING ROOM AMPUTATION OF HAND 300.00 0379 OPERATING ROOM AMPUTATION OF LOWER LEG (27880) 400.00 0379 OPERATING ROOM AMPUTATION THIGH FEMUR ANY LEVEL 300.00 0379 OPERATING ROOM AMPUTATION THRY METATARSAL 500.00 0379 OPERATING ROOM AMPUTATION TOE FOOT 500.00 0379 OPERATING ROOM AMPUTATION TOE METATARSAL 500.00 0379 OPERATING ROOM ANES OPEN PROC UPPER ENDS TIBIA/FIB/PAT (01392) 500.00 0379 OPERATING ROOM ANEST INTEG (00300) 500.00 0379 OPERATING ROOM ANEST ESOPH, THYROID, LARYNX, TRACHEA (00320) 500.00 0379 OPERATING ROOM ANEST FOR CS HYSTERECTOMY W/O ANY LABOR ANALGESIA 500.00 0379 OPERATING ROOM ANEST FOR ELECTROCONVULSIVE THERAPY 500.00 0379 OPERATING ROOM ANEST FOR INCOMPLETE OR MISSED ABORTION PROC 500.00 0379 OPERATING ROOM ANEST FOR INDUCED ABORTION PROC 500.00 0379 OPERATING ROOM ANEST FOR PROC EXTERNAL, MIDDLE AND INNER EAR 500.00 0379 OPERATING ROOM ANEST FOR PROC ON EYE, NOT OTHERWISE SPECIFIED 500.00 0379 OPERATING ROOM ANEST FOR PROC ON NOSE AND ACCESSORY SINUSES 500.00 0379 OPERATING ROOM ANEST FOR PROD IN EYE, BLEPHAROPLASTY 500.00 0379 OPERATING ROOM ANEST FOR URGENT HYSTERECTOMY FOLLOWING DELIVERY 500.00 0379 OPERATING ROOM ANEST FOR VAGINAL DELIVERY ONLY 500.00 0379 OPERATING ROOM ANEST RADICAL SURGERY 500.00 0379 OPERATING ROOM ANEST SURGERY OF SHOULDER 300.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM ANEST, ELECTROCOAGULATION OF INTRACRANIAL NERVE 500.00 0379 OPERATING ROOM ANEST, FOR EXTERNAL CEPHALIC VERSION PROC 500.00 0379 OPERATING ROOM ANEST, HEAD/NECK/PTRUNK 500.00 0379 OPERATING ROOM ANEST, PROCEDURES IN SITTING POSITION 500.00 0379 OPERATING ROOM ANESTESIA FOREARM 300.00 0379 OPERATING ROOM ANESTESIA SKIN, EXTREMITY, TRUNK 500.00 0379 OPERATING ROOM ANESTESIA VULVA 300.00 0379 OPERATING ROOM ANESTH , LUMBAR AND VENTRAL HERNIAS AND/OR WOUND 500.00 0379 OPERATING ROOM ANESTH FOR CS DELIVERY FOLLOWING NEURAXIAL LABOR 500.00 0379 OPERATING ROOM ANESTH FOR CS HYSTERECTOMY FOLLOWING NEURAXIAL 500.00 0379 OPERATING ROOM ANESTH FOR HERNIA REPAIRS IN UPPER ABDOMINAL 500.00 0379 OPERATING ROOM ANESTH FOR HERNIA REPAIRS LOWER ABD < 1 YEAR 500.00 0379 OPERATING ROOM ANESTH FOR LOWER INTESTINAL ENDOSCOPIC 500.00 0379 OPERATING ROOM ANESTH FOR PROC ON LOWER ANTERIOR ABD WALL 500.00 0379 OPERATING ROOM ANESTH FOR PROC ON LOWER POSTERIOR ABD WALL 500.00 0379 OPERATING ROOM ANESTH FOR PROC ON UPPER ANTERIOR ABD WALL 500.00 0379 OPERATING ROOM ANESTH FOR PROC ON UPPER POSTERIOR ABD WALL 500.00 0379 OPERATING ROOM ANESTH FOR PROC PERCUTANEOUS LIVER BIOPSY 500.00 0379 OPERATING ROOM ANESTH FOR UPPER GASTROINTESTINAL ENDOSCOPIC 500.00 0379 OPERATING ROOM ANESTH HERNIA REPAIRS IN LOWER ABDOMEN 500.00 0379 OPERATING ROOM ANESTH HERNIA REPAIRS PREEMIE 500.00 0379 OPERATING ROOM ANESTH HYSTEROSCOPY 500.00 0379 OPERATING ROOM ANESTH LOWER ANTERIOR ABD VENTRAL AND INCISIONAL H 500.00 0379 OPERATING ROOM ANESTH NOSE BIOPSY, SOFT TISSUE 500.00 0379 OPERATING ROOM ANESTH PROCEDURE ON MOUTH 500.00 0379 OPERATING ROOM ANESTH RADIACAL HYSTERECTOMY 500.00 0379 OPERATING ROOM ANESTH RADICAL RESECTION (INCLUDING BELOW KNEE AMP 500.00 0379 OPERATING ROOM ANESTH, BURR HOLES, INCLUDING VENTRICULOGRAPHY 500.00 0379 OPERATING ROOM ANESTH, CEREBROSPINAL FLUID SHUNTING PROCEDURES 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM ANESTH, CRANIAL SURGERY NOS 500.00 0379 OPERATING ROOM ANESTH, CRANIOPLASTY OR ELEVATION OF DEPRESSED SKU 500.00 0379 OPERATING ROOM ANESTH, EXCISION OF RETHOPHARYNGEAL TUMOR 500.00 0379 OPERATING ROOM ANESTH, FACIAL BONE SURGERY 500.00 0379 OPERATING ROOM ANESTH, FOR ALL PROC ON MAJOR ABD BLOOD VESSELS 500.00 0379 OPERATING ROOM ANESTH, HEMORR/EXCISE LIVER 500.00 0379 OPERATING ROOM ANESTH, LOWER ARM SURGERY 500.00 0379 OPERATING ROOM ANESTH, LOWER LEG PROCEDURE 500.00 0379 OPERATING ROOM ANESTH, OMPLALOCELE 500.00 0379 OPERATING ROOM ANESTH, PANCREATECTOMY, PARCIAL OR TOTAL 500.00 0379 OPERATING ROOM ANESTH, PROC ON FACIAL BONES OR SKULL 500.00 0379 OPERATING ROOM ANESTH, REPAIR OF CLEFT PALATE 500.00 0379 OPERATING ROOM ANESTH, SKULL DRAINAGE 500.00 0379 OPERATING ROOM ANESTH, TRANSABDOMINAL REPAIR OF DIAPHRAGMATIC 500.00 0379 OPERATING ROOM ANESTH, VASCULAR PROCEDURES 500.00 0379 OPERATING ROOM ANESTH/ANALG, VAGINAL DELIVERY 500.00 0379 OPERATING ROOM ANESTHESIA CLAVICLE AND SCAPULA (00450) 500.00 0379 OPERATING ROOM ANESTHESIA FOR CESAREAN DELIVERY ONLY 500.00 0379 OPERATING ROOM ANESTHESIA LOWER LEG SURGERY 300.00 0379 OPERATING ROOM ANESTHESIA, SALIVARY GLAND 500.00 0379 OPERATING ROOM APPENDECTOMY 500.00 0379 OPERATING ROOM APPENDECTOMY FOR RUPTURED APPENDIX WITH ABSCESS 500.00 0379 OPERATING ROOM ARTERIAL CATHETERIZATION FOR CHEMOTHERAPY (36640) 500.00 0379 OPERATING ROOM ARTHROCENTESIS ASPIR/INJ MAJOR (20610) 500.00 0379 OPERATING ROOM ARTHROSCOPY KNEE (29876) COMPARTMENTS 300.00 0379 OPERATING ROOM ARTHROSCOPY KNEE DXW/O SYNOVIAL BIOPSY SEP PROCED 500.00 0379 OPERATING ROOM ARTHROTOMY SHOWDER INCLUDING EXPLORATION 500.00 0379 OPERATING ROOM ARTHRT W/EXPL DRG/RMVL FB (28022) 500.00 0379 OPERATING ROOM ARTRT EXPL DRG/RMVL LOOSE/FBCARP/MTCRP/JT (26070) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM BILIARY NDSC PRQ T-TUBE DX (47552) 500.00 0379 OPERATING ROOM BILR ENDSCP PRQ VIA T-TUBE W RMVL CALCULUS (47554) 500.00 0379 OPERATING ROOM BIOPSY BREAST 500.00 0379 OPERATING ROOM BIOPSY BREAST NEEDLE CORE W/IMG GDNC (19102) 500.00 0379 OPERATING ROOM BIOPSY CAUTERY OF CERVIX, ELECTRO (57510) 300.00 0379 OPERATING ROOM BIOPSY CERVIX 1/MLT OR EXC OF LESION (57500) 500.00 0379 OPERATING ROOM BIOPSY LIVER NEEDLE PERCUTANEOUS (47000) 500.00 0379 OPERATING ROOM BIOPSY OF ANORECTAL WALL, ANAL APPROACH (45100) 500.00 0379 OPERATING ROOM BIOPSY SOFT TISSUE BACK OR FLANK MASS SUPERFICIAL 500.00 0379 OPERATING ROOM BIOPSY SOFT TISSUE SHOULDER (23065) 500.00 0379 OPERATING ROOM BIOPSY VULVA/PERINEUM 1 LESION (56605) 500.00 0379 OPERATING ROOM BIOPSY, SOFT TISSUE OF NECK OR THORAX (21550) 300.00 0379 OPERATING ROOM BIOPSY/REMOVAL HYMPH NODES (38525) 500.00 0379 OPERATING ROOM BONE BIOPSY EXCISIONAL 20245 500.00 0379 OPERATING ROOM BREAST MASS BIOPSY (19101) 500.00 0379 OPERATING ROOM BREAST MASTECTOMY (19306) 500.00 0379 OPERATING ROOM BX BREAST NDL CORE W/IMG GDN (19102) 500.00 0379 OPERATING ROOM BX OF CERVIX W/SCOPE,LEEP 500.00 0379 OPERATING ROOM BX SKIN SUBCUTANEOUS & MUCOUS MEMBRANE (11100) 500.00 0379 OPERATING ROOM BX/EXC LYMPH NODE OPEN SUPERFICIAL (38500) 500.00 0379 OPERATING ROOM BYPASS W/VEIN FEMORAL-FEMORAL (35558) 800.00 0379 OPERATING ROOM CARPAL TUNNEL SURGERY 64721 500.00 0379 OPERATING ROOM CERCLAGE OF CERVIX DURING PREGNANCY 500.00 0379 OPERATING ROOM CERVICAL (00948) 500.00 0379 OPERATING ROOM CESAREAN DELIVERY 500.00 0379 OPERATING ROOM CESAREAN DELIVERY ONLY (59515) W/POSTP CARE 500.00 0379 OPERATING ROOM CHANGE GASTROSTOMY TUBE 500.00 0379 OPERATING ROOM CHOLECYSTECTOMY OPEN (47600) 500.00 0379 OPERATING ROOM CHROMOTUBATION OVIDUCT W/MATERIALS (58350) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM CIRCUM 28 DAYS OR LESS 500.00 0379 OPERATING ROOM CIRCUM SEGUNDO PROCEDIMIENTO 500.00 0379 OPERATING ROOM CLOSED TX TALUS FX W/MANIPULATION (28435) 500.00 0379 OPERATING ROOM CLOSURE ENTEROSTOMY LG/SMALL INTESTINE (44620) 500.00 0379 OPERATING ROOM COLECTOMY PRTL W/END COLOSTOMY (44143) 500.00 0379 OPERATING ROOM COLLECT BLOOD IMPLANT VENOUS (36591) 500.00 0379 OPERATING ROOM COLPOCLEISIS LE FORT TYPE (57120) 500.00 0379 OPERATING ROOM COLPOPERINEORRHAPHY SUTURE INJ VAG/PER (57210) 500.00 0379 OPERATING ROOM COLPOSCOPY CERVIX BX (57454) 500.00 0379 OPERATING ROOM COLPOSCOPY CERVIX UPPER (57452) 500.00 0379 OPERATING ROOM COLPOSCOPY CERVIX VAGINA (57455) 500.00 0379 OPERATING ROOM COLPOSCOPY ENTIRE VAGINA W/VAGINAL CERVIX (57421) 500.00 0379 OPERATING ROOM COMBINED ANTEROPOSTERIOR COLPORRHAPHY 500.00 0379 OPERATING ROOM COMMON BITE DUCT EXPL (43260) 500.00 0379 OPERATING ROOM COMPLEX DRAINAGE,WOUND 300.00 0379 OPERATING ROOM CONIZATION OF CERVIX (57520) 500.00 0379 OPERATING ROOM CONIZATION OF CERVIX (57522) 500.00 0379 OPERATING ROOM CONSULTA ANESTESIA OPD (99241) 30.00 0379 OPERATING ROOM CONZ OF CERVIX W/WCOPE LEEP 300.00 0379 OPERATING ROOM CORNEAL TRANSPLANT 500.00 0379 OPERATING ROOM CYSTOCECTOCELE REPAIR (57250) 500.00 0379 OPERATING ROOM CYTOPATH C/V, THIN LAYER 500.00 0379 OPERATING ROOM D&C AFTER DELIVERY 300.00 0379 OPERATING ROOM DBRDMT SKIN SUBQ NECRO INFCTJ ABDL WALL 500.00 0379 OPERATING ROOM DBRMT (11000) 500.00 0379 OPERATING ROOM DEBRIDE GENITALIA (11004) 500.00 0379 OPERATING ROOM DEBRIDE SKIN SUBCUTANEOS TISSUE 500.00 0379 OPERATING ROOM DEBRIDE SKIN/ TISSUE 500.00 0379 OPERATING ROOM DEBRIDE TISSUE/MUSCLE 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM DEBRIDEMENT BONE (11044) 500.00 0379 OPERATING ROOM DEBRIDEMENT OF SKIN 100.00 0379 OPERATING ROOM DEST.BENING LESIOS THAN SKIN 500.00 0379 OPERATING ROOM DESTROY VULVA LESION 300.00 0379 OPERATING ROOM DESTRUCTIO VABINAL LESIONS EXTENSIVE (57065) 500.00 0379 OPERATING ROOM DESTRUCTION PREMALIGNANT LESION 1ST (17000) 500.00 0379 OPERATING ROOM DESTRUCTION PREMALIGNANT LESION 2-14 EA (17003) 500.00 0379 OPERATING ROOM DIAG LAPARO SEPARATE PROC (49320) 500.00 0379 OPERATING ROOM DILATION AND CURETTAGE 500.00 0379 OPERATING ROOM DISSECTION DEEP JUGULAR NODE 38542 500.00 0379 OPERATING ROOM DRAIN NECK/CHEST LESION (21501) 500.00 0379 OPERATING ROOM DRAIN, OPEN, ABDOM ABCESS 300.00 0379 OPERATING ROOM DRAINAGE OF GLAND ABSCESS 500.00 0379 OPERATING ROOM DRAINAGE OF SKIN ABCESS 300.00 0379 OPERATING ROOM DRAINAGE OF SKIN OBSCESS (10061) 500.00 0379 OPERATING ROOM DRAINAGE OVARIAN CYST UNI/BI SPX VGNL APRR 58800 500.00 0379 OPERATING ROOM DRG XTRNL CANAL (69020) 500.00 0379 OPERATING ROOM DSTRJ LESION ANUS SIMPLE CHIMICAL (46900) 500.00 0379 OPERATING ROOM DSTRJ LESION ANUS SIMPLE SURG EXCISION (46922) 500.00 0379 OPERATING ROOM DYC OF CERVICAL STUMP (57558) 300.00 0379 OPERATING ROOM ENDOMETRIAL BX W/WO ENDOCERVIX BX (58100) 500.00 0379 OPERATING ROOM ENDOMETRIAL UTERINE CURETTAGE 500.00 0379 OPERATING ROOM ENDOVEN ABLT (36475) 500.00 0379 OPERATING ROOM ENTEROLSS FRING INTSTINAL ADHESION SPX (44005) 500.00 0379 OPERATING ROOM EXAM OF VAGINA W/SCOPE (57420) 500.00 0379 OPERATING ROOM EXC 2.0 BACK CYST 300.00 0379 OPERATING ROOM EXC B9 (11421) 500.00 0379 OPERATING ROOM EXC B9 (11441) 500.00 0379 OPERATING ROOM EXC B9 LES MARG 4.0 CM (11406) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM EXC B9 LES MRGN XCP SK TG S/N/H/F/G> 4.0CM (11426) 500.00 0379 OPERATING ROOM EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0CM (11404) 500.00 0379 OPERATING ROOM EXC B9 MARG 6-1.0 (11401) 500.00 0379 OPERATING ROOM EXC EXOSTOSIS (69140) 500.00 0379 OPERATING ROOM EXC F/E/E/N/L MAL + MRG 0.6-1 (11641) 500.00 0379 OPERATING ROOM EXC FACE-MM B9+MARG 1. 1-2 CM 300.00 0379 OPERATING ROOM EXC FACEMMB9+MARG 2-1-3CM (11443) 500.00 0379 OPERATING ROOM EXC FOOT/TOE TUM DEEP 350.00 0379 OPERATING ROOM EXC FOOT/TOE TURN DEP 1.5CM (28041) 500.00 0379 OPERATING ROOM EXC FRENUN LABIAL/BUCCAL (40819) 500.00 0379 OPERATING ROOM EXC GANGLION WIRST(DORSAL OR VOLAR) PRIMARY 500.00 0379 OPERATING ROOM EXC ISION HYDROCELE UNILATERAL (55040) 500.00 0379 OPERATING ROOM EXC LESION HAND/FINGER 300.00 0379 OPERATING ROOM EXC NECK MASS 300.00 0379 OPERATING ROOM EXC OF HEMORROIDS INTERNAL (46262) 500.00 0379 OPERATING ROOM EXC OF LESION CONJUCTIVA OVER 1CM 500.00 0379 OPERATING ROOM EXC OTHER BENING LESS FACE,EAR,NOSE,EYELID,LIP 500.00 0379 OPERATING ROOM EXC PILONIDAL CYST 500.00 0379 OPERATING ROOM EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ 42410) 500.00 0379 OPERATING ROOM EXC SKIN TRUNK, ARM. LEG, 0.5CM OR LESS 500.00 0379 OPERATING ROOM EXC THIGH/KNEE TURN DEEP <5CM (27328) 500.00 0379 OPERATING ROOM EXC TISSUE BACK OR FLANK DEEP 500.00 0379 OPERATING ROOM EXC TUMOR (21556) 500.00 0379 OPERATING ROOM EXC TUMOR SOFT TISSUE BACK OR FLANK 500.00 0379 OPERATING ROOM EXC TUMOR SOFT TISSUE PELVIS HIP SUBFAS (27048) 500.00 0379 OPERATING ROOM EXC TUMOR SOFTTISS FOREARM & WIRST (25071) 500.00 0379 OPERATING ROOM EXC WRIST LESION 300.00 0379 OPERATING ROOM EXC. TUMOR OR MALFORMATION SOFT TISS HAND OR FINGE 500.00 0379 OPERATING ROOM EXC/TRPOS PTERYGIUM W/O GRF (65420) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM EXC-H-NK-SP B9+MARG 0.5 500.00 0379 OPERATING ROOM EXCION DERMOID CYST (30124) 500.00 0379 OPERATING ROOM EXCION RECTAL (45130) 500.00 0379 OPERATING ROOM EXCISE EXCESSIVE SKIN THINGH (15832) 500.00 0379 OPERATING ROOM EXCISION BACK MASS 500.00 0379 OPERATING ROOM EXCISION BENIGN LESION (11421) 500.00 0379 OPERATING ROOM EXCISION BENIGN LESION 11422 500.00 0379 OPERATING ROOM EXCISION BENING LESION SKIN EXT DIAM 2.1 A 3.0 CM 500.00 0379 OPERATING ROOM EXCISION EAR MASS (69110) 500.00 0379 OPERATING ROOM EXCISION FOOT GANGLION CYST 500.00 0379 OPERATING ROOM EXCISION HIDRADENITIS AXILLARY SMPL (11450) 500.00 0379 OPERATING ROOM EXCISION MAL LESION TRUNK/ARM/LEG (11601) 500.00 0379 OPERATING ROOM EXCISION MALIGNALNT TUMOS MAX ZYGOMA (21034) 500.00 0379 OPERATING ROOM EXCISION MALIGNANT LESION S/N/H/F/G (11622) 500.00 0379 OPERATING ROOM EXCISION MASS 2.1 A 3 500.00 0379 OPERATING ROOM EXCISION OF CHEST WALL LESION (19260) 500.00 0379 OPERATING ROOM EXCISION OF PILONIDAL CYST 300.00 0379 OPERATING ROOM EXCISION OF SCALP MASS 500.00 0379 OPERATING ROOM EXCISION OR FULGURATION SKENES GLANDS (53270) 500.00 0379 OPERATING ROOM EXCISION PILONIDAL CYST (11771) 500.00 0379 OPERATING ROOM EXCISION SCALP CYST 500.00 0379 OPERATING ROOM EXCISION SKINSUBQ (15833) 500.00 0379 OPERATING ROOM EXCISION SYNOVIAL CYST POPLITEAL BAKER'S 500.00 0379 OPERATING ROOM EXCISION TUMOR (23071) 500.00 0379 OPERATING ROOM EXCISION TUMOR SOFT 500.00 0379 OPERATING ROOM EXCISION, BREAST LESION 500.00 0379 OPERATING ROOM EXCSN MALLESION TRNK/ARM/LG 2.1-3.0CM/< (11603) 500.00 0379 OPERATING ROOM EXCSN/DSTRCTN INTRANASAL LESION XTRNL (30118) 500.00 0379 OPERATING ROOM EXPLORATION OF ABDOMEN 200.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM EXPLORATORY LAPARATOMY 200.00 0379 OPERATING ROOM EXTRA CAPSULAR EXTRATION IOL IMPLANT 500.00 0379 OPERATING ROOM FIXATION OF KNEE JOINT 500.00 0379 OPERATING ROOM GASTRECTOMY PARTIAL (43631) 300.00 0379 OPERATING ROOM GASTROSTOMY 300.00 0379 OPERATING ROOM HEMORRHOIDECTOMY, EXTERNAL, COMPLETE 500.00 0379 OPERATING ROOM HEMORROIDECTOMY 500.00 0379 OPERATING ROOM HERNIA VENTRAL INCARCERATED (49561) 500.00 0379 OPERATING ROOM HIP JOINT SURGERY (01210) 500.00 0379 OPERATING ROOM HYSTERECTOMY LAP 500.00 0379 OPERATING ROOM HYSTEROSCOPY BIOSPY 500.00 0379 OPERATING ROOM HYSTEROSCOPY DX SEP PROC 300.00 0379 OPERATING ROOM HYSTEROSCOPY RMVL IMPACTED FRGH BODY (58562) 500.00 0379 OPERATING ROOM I & D HEMATOMA SEROMA/FLUID (10140) 500.00 0379 OPERATING ROOM I&D OF VULVA 300.00 0379 OPERATING ROOM ID ABSCESS SUBFASCIAL (20005) 500.00 0379 OPERATING ROOM IN SITU FEM ANT TIBL PST (35585) 800.00 0379 OPERATING ROOM INCISION AND DRAINAGE OF APPENDICEAL 44900 500.00 0379 OPERATING ROOM INCISION AND DRINAGE BARTHOLIN'S GLAND 500.00 0379 OPERATING ROOM INCISION AND DRINAGE VULVA OR PERINEAL 500.00 0379 OPERATING ROOM INCISION OF ANAL ABCESS 300.00 0379 OPERATING ROOM INCOMPLETE ABORTION ANY TRIMESTER MISCARRIAGE 500.00 0379 OPERATING ROOM INDUCED ABORTION DILATION AND CURETAGE (59840) 500.00 0379 OPERATING ROOM INGINAL HERNIA REPAIR >5 YR 500.00 0379 OPERATING ROOM INICIAL HOSPITAL CARE 500.00 0379 OPERATING ROOM INITIAL HOSPITAL CARE 25.00 0379 OPERATING ROOM INJECTION (20550) TENDON 500.00 0379 OPERATING ROOM INJX/INFUS NEUROLYT SBST EPIDURAL LSS (62282) 500.00 0379 OPERATING ROOM INS/REP PER PAC CVDFB TRNSVEN LEADS 1/2 CHM -33249 300.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM INSERT EMERGENCY AIRWAY 500.00 0379 OPERATING ROOM INSERT HEART PM VENT (33207) 300.00 0379 OPERATING ROOM INSERTION OF CHEST TUBE 300.00 0379 OPERATING ROOM INSERTION OF INTRAOCULAR LENS PROSTHESIS 500.00 0379 OPERATING ROOM INSERTION OF TUNNELED CENTRAL VENOUS (36561) 500.00 0379 OPERATING ROOM INSERTION TUNNELED SUBCUTA PUMP (VENOPORT) 500.00 0379 OPERATING ROOM INSICION & DRAINAGE LEG LESION 300.00 0379 OPERATING ROOM INSJ IMPLANTABLE INTRA-ARTERIAL INFUSION (36260) 500.00 0379 OPERATING ROOM INSRT HEART PM ATRIAL AND VENT 33208 300.00 0379 OPERATING ROOM IRIDECTOMY 500.00 0379 OPERATING ROOM KNEE ARTHROSCOPY 500.00 0379 OPERATING ROOM KNEE ARTHROSCOPY (29880) 500.00 0379 OPERATING ROOM KNEE ARTHROSCOPY/DRAINAGE (29871) 500.00 0379 OPERATING ROOM KNEE ARTHROSCOPY/SURGERY 300.00 0379 OPERATING ROOM KNEE ARTHROSCOPY/SURGERY (29881) 500.00 0379 OPERATING ROOM KNEE REPLACEMENT (27447) 500.00 0379 OPERATING ROOM LAP COLOSTOMY 300.00 0379 OPERATING ROOM LAP ENTRC RESECTION SMALL INTESTINE (44202) 800.00 0379 OPERATING ROOM LAP FULG/EXC (58662) 500.00 0379 OPERATING ROOM LAP ING HERNIA REPAIR INIT (49650) 500.00 0379 OPERATING ROOM LAP ING HERNIA REPAIR RECUR (499651) 500.00 0379 OPERATING ROOM LAP SURGICAL ENTEROLYSIS INTEST ADHESION SEP PROC 500.00 0379 OPERATING ROOM LAP SURGICALWITH OCCLUSION OF OVIDUCTS BY DEVICE 500.00 0379 OPERATING ROOM LAP TREATMENT EPTOPIC PREG WITH SALPINGECTOMY 400.00 0379 OPERATING ROOM LAP UPPER ABDOMEN 500.00 0379 OPERATING ROOM LAP VENT/ABD HERNIA REPAIR W OR WO MESH 500.00 0379 OPERATING ROOM LAP WITH OCC OVIDUCTS (58671) 500.00 0379 OPERATING ROOM LAPAROSCOPY APPENDECTOMY 500.00 0379 OPERATING ROOM LAPAROSCOPY FULGURATION OVIDUCTS (58670) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM LAPAROSCOPY LOWER ABDOMEN 500.00 0379 OPERATING ROOM LAPAROSCOPY OF ADHESIONS 500.00 0379 OPERATING ROOM LAPAROSCOPY STERILIZATION 500.00 0379 OPERATING ROOM LAPAROSCOPY, CHOLECYSTECTOMY 500.00 0379 OPERATING ROOM LAPS SURG W/ASPIR CAVITY/CYST SINGLE (49322) 500.00 0379 OPERATING ROOM LAPS SURG W/DRAINAGE LYMPHOCELE PERITONEAL (49323) 500.00 0379 OPERATING ROOM LENGTHENING OF TENDON, EXTENSOR, HAND, FIN (26476) 500.00 0379 OPERATING ROOM LENS SURGERY (00142) 500.00 0379 OPERATING ROOM LGTN OF PERFORATOR VEINS, SUBFASCIAL, RADICAL 500.00 0379 OPERATING ROOM LIG/BX TEMPORAL ART (37609) 500.00 0379 OPERATING ROOM LIGATE LEG VEINS OPEN (37761) 500.00 0379 OPERATING ROOM LIGATE/STRIP SHORT LEG VEIN (37718) 300.00 0379 OPERATING ROOM LIGATION OF HEMORRHOID(S) 500.00 0379 OPERATING ROOM LIGATION OR TRANSECTION OF FALLOPIAN TUBES (58600) 500.00 0379 OPERATING ROOM LIGATION, DIVISION & STRIPPING LONG VEINS (37722) 500.00 0379 OPERATING ROOM LOWER LEG/ANKLE/FOOT (01480) 300.00 0379 OPERATING ROOM LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY MASTECTOMY 500.00 0379 OPERATING ROOM LYSIS/MASS LABIAL VULVA ADHESIONS 500.00 0379 OPERATING ROOM MARSUPIALIZATION BARTHOLIN'S GLAND 500.00 0379 OPERATING ROOM MAST MOD RAD 19307 500.00 0379 OPERATING ROOM MASTECTOMY GYNECOMASTIA (19300) 500.00 0379 OPERATING ROOM MASTECTOMY PARTIAL W/AXILLARY (19302) 500.00 0379 OPERATING ROOM MASTECTOMY SUBCUTONEOUS (19304) 300.00 0379 OPERATING ROOM MASTECTOMY SYMPLE COMPLETE (19303) 500.00 0379 OPERATING ROOM MASTECTOMY/PARTIAL/LUMPECTOMY/QUADRANTECTOMY 500.00 0379 OPERATING ROOM MASTOTOMY (19020) 300.00 0379 OPERATING ROOM METATARSAL INCISION 500.00 0379 OPERATING ROOM MNPJ SPINE/CLSD (00640) 650.00 0379 OPERATING ROOM NEUROPLASTY NERVE HAND/FOOT (64704) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM OCCLUDE FLP TUBE DEV VAGL SUPRAPUBIC APPR 58615 500.00 0379 OPERATING ROOM OFFICE/OUTPATIENT VISIT NEW 25.00 0379 OPERATING ROOM OOPHORECTOMY 300.00 0379 OPERATING ROOM OPEN TX CARPAL SCAPHOID NAVICULAR FX (25628) 500.00 0379 OPERATING ROOM OPHTHALMMOSCOPY 500.00 0379 OPERATING ROOM OPTX DSTLRADL I-ARTIC FX/EPIPHYSL SEP3 FRAG-25609 500.00 0379 OPERATING ROOM OPTX POST ANKLE FX (27769) 500.00 0379 OPERATING ROOM OSTECTOMY CALCANEUS SPUR W/WO PLANTAR FASCIAL RELE 500.00 0379 OPERATING ROOM OTOSCOPY 500.00 0379 OPERATING ROOM OVARIAN CYSTECTOMY UNI/BI (58925) 500.00 0379 OPERATING ROOM PARATHYROIDECTOMY/EXPL PARATHYROIDS (60500) 500.00 0379 OPERATING ROOM PARTIAL REMOVAL OF COLON 500.00 0379 OPERATING ROOM PARTIAL REMOVAL OF THYROID (60220) 500.00 0379 OPERATING ROOM PARTIAL THYROID LOBECTOMY UNILATERAL W/WOUT 500.00 0379 OPERATING ROOM PERITO ABD PARACENTESIS (49080) 500.00 0379 OPERATING ROOM PLACE GASTROSTOMY TUBE 500.00 0379 OPERATING ROOM PLASTIC REPAIR OF CLEFT LIP 500.00 0379 OPERATING ROOM PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ (15004) 500.00 0379 OPERATING ROOM PRINEOPLASTY RPR PERINEUM NON OB (56810) 500.00 0379 OPERATING ROOM PRP IHERN INIT BLOCK 5 YRS 500.00 0379 OPERATING ROOM RADICAL RESE TUMOR MALIG/NEOP SOFT TISSUE FACE/SCA 500.00 0379 OPERATING ROOM RADICAL RESECTION TUMOR MALIGNANT FOREAM/WIRST 500.00 0379 OPERATING ROOM RECURENT VENTRAL HERNIA REPAIR 300.00 0379 OPERATING ROOM REMOVAL FOREIGN BODY FOOF DEEP (28192) 500.00 0379 OPERATING ROOM REMOVAL FOREIGN BODY UPPER ARM/ELBOW (24201) 500.00 0379 OPERATING ROOM REMOVAL INTRAUTERINE DEVICE IUD (58301) 500.00 0379 OPERATING ROOM REMOVAL NAIL 500.00 0379 OPERATING ROOM REMOVAL NECK/ARMPIT LESION (38550) 500.00 0379 OPERATING ROOM REMOVAL OF BREAST LESION 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM REMOVAL OF LEG VEINS/LESION 500.00 0379 OPERATING ROOM REMOVAL OF SKIN TAGS

CodeGroup Description Price 0379 OPERATING ROOM RPR UMBIL HERN REDUC<5YR (49580) 500.00 0379 OPERATING ROOM RPR UMBILICAL HERNIA AGE 5 YRS/>INC (49587) 500.00 0379 OPERATING ROOM RPR WND EXTRAOCLR MSCL TNDN P/TNN CPSL (65290) 500.00 0379 OPERATING ROOM SCALP, ARM, LEG EXCISION AND TISSUE REARRANGEMENT 500.00 0379 OPERATING ROOM SHOULDER JOINT SURGERY (23101) 300.00 0379 OPERATING ROOM SHOWLDER RECONST COMP ROTATOR INC ACROMIOPLASTIC 500.00 0379 OPERATING ROOM SIPINAL PUNCUTURE,LUMBAR,DX(SPINAL BLOCK)TAP 24.00 0379 OPERATING ROOM SKIN TISSUE REARRANGEMENT 500.00 0379 OPERATING ROOM SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 12002 500.00 0379 OPERATING ROOM SPECIAL SUPPLIES 25.00 0379 OPERATING ROOM SPINAL BLOCK LUMBAR, SACRAL (62311) 500.00 0379 OPERATING ROOM SPINE BLOCK (62310) 500.00 0379 OPERATING ROOM STAB PHLEBT VRCS VNS 1 XTR 10-20 STAB INES 37765 500.00 0379 OPERATING ROOM STERILIZATION AFTER NORMAL DELIVERY 500.00 0379 OPERATING ROOM STERILIZATION DURING CESAREAN 500.00 0379 OPERATING ROOM STERILIZATION REGULAR (58700) 500.00 0379 OPERATING ROOM SUBTOTAL LUBECTOMY (THYROIDECTOMY) 500.00 0379 OPERATING ROOM SURGERY OF BREAST 500.00 0379 OPERATING ROOM THORACOSCOPY W/PARTIAL PULMONARY (32651) 500.00 0379 OPERATING ROOM THORACOSCOPY WITH BIOPSYIES OF PLEURA (32609) 500.00 0379 OPERATING ROOM THYROIDECTOMY TOTAL (60240) 500.00 0379 OPERATING ROOM TISSUE REARRANGEMENT, EYELID, NOSE, EAR, LIPS 500.00 0379 OPERATING ROOM TOTAL HIP ARTHROPLASTY (01214) 300.00 0379 OPERATING ROOM TOTAL HIP REPLACENENT 27130 500.00 0379 OPERATING ROOM TOTAL HYSTERECTOMY 500.00 0379 OPERATING ROOM TRACHEOSTOMY PLANNED SEPARATE PROC (31600) 500.00 0379 OPERATING ROOM TREAT EPTOPIC PREGNANCY TUBAL/SALPINGECTOMY 300.00 0379 OPERATING ROOM TREAT FRACTURE OF RADIUS (25515) 500.00 0379 OPERATING ROOM TREAT FRACTURE RADIUS/ULNA (25575) 500.00 Rev. June, 2020

CodeGroup Description Price 0379 OPERATING ROOM TREAT FX RAD EXTRA-ARTICUL (25607) 500.00 0379 OPERATING ROOM TREATMENT OF ANKLE FRACTURE (27814) 500.00 0379 OPERATING ROOM TREATMENT OF MISSED ABORTION 1ST TRIM (59820) 500.00 0379 OPERATING ROOM TUBE THORACOSTOMY INCLUDES WATER SEAL (32551) 500.00 0379 OPERATING ROOM TYMPANOTOMY 500.00 0379 OPERATING ROOM UMBILICAL HERNIA (49600) 500.00 0379 OPERATING ROOM URETHROPLASTY RECONSTRUCTION ANTERIOR URETHRA 500.00 0379 OPERATING ROOM URETTROPLASTY RECONSTRUCTION FEMELE URETHRA 500.00 0379 OPERATING ROOM VAG HYST 250 GMKW/RMVL TUBE&/OVARY (58262) 500.00 0379 OPERATING ROOM VAGINAL HYSTERECTOMY FOR UTERUS G OR LESS (58260) 300.00 0379 OPERATING ROOM VAGINAL HYSTERECTOMY UTERUS 250 GM (58260) 500.00 0379 OPERATING ROOM VAGINAL MUCOSA (57100) 500.00 0379 OPERATING ROOM VAGINAL PROCEDURES 500.00 0379 OPERATING ROOM VENO PORT (36561) 500.00 0379 OPERATING ROOM VENTRIAL HERNIA REPAIR/INCISIONA IMPLANTATION MESH 500.00 0379 OPERATING ROOM VITREORETINAL SURGERY 500.00 0379 OPERATING ROOM VULVECTOMY SIMPLE PARTIAL (56620) 500.00 0380 BLOOD AND BLOOD PRODUCTS 36514 PLASMAPHERESIS 1,000.00 0380 BLOOD AND BLOOD PRODUCTSABO GROUP 7.50 0380 BLOOD AND BLOOD PRODUCTS ANTIBODY PANEL 60.00 0380 BLOOD AND BLOOD PRODUCTSBLOOD TYPING ANTIGEN 25.00 0380 BLOOD AND BLOOD PRODUCTS COMPATIBILITY TEST 50.00 0380 BLOOD AND BLOOD PRODUCTSCOOMBS DIRECT TEST 20.00 0380 BLOOD AND BLOOD PRODUCTS P9016 LR RED BLOOD CELLS 235.00 0380 BLOOD AND BLOOD PRODUCTS P9021 RED BLOOD CELLS UNITS 205.00 0380 BLOOD AND BLOOD PRODUCTS P9023 FRESH FROZEN PLASMA, POOLED 480.00 0380 BLOOD AND BLOOD PRODUCTS P9031PLATELETS LEUKOCYTES REDUCED RANDOM 100.45 0380 BLOOD AND BLOOD PRODUCTS RH TYPE 7.50 0380 BLOOD AND BLOOD PRODUCTS WARM AUTOANTIBODY ABSORCION 200.00 Rev. June, 2020

CodeGroup Description Price 0384 BLOOD AND BLOOD PRODUCTS P9019 PLATELETS, EACH UNIT 70.00 0384 BLOOD AND BLOOD PRODUCTS P9031 PLATELETS LEUKOCYTES REDUCED SINGLE 100.00 0384 BLOOD AND BLOOD PRODUCTS P9035 PLATELET PHERESIS LEUKOREDUCED 480.00 0387 BLOOD AND BLOOD PRODUCTS P9012 CRYOPRECIPITATE 40.00 0389 BLOOD AND BLOOD PRODUCTS COMPATIBILITY EACH UNIT ANTIGLOBLIN 65.00 0401 RADIOLOGY 77063 SCREENING DIGITAL BREAST ROMOSYNTHESIS BI 60.00 0401 RADIOLOGY 77065 DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ UNI 90.00 0401 RADIOLOGY 77066 DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETCJ BI 120.00 0401 RADIOLOGY 77067 SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD 99.60 0402 RADIOLOGY ULTRASOUND (76870) ESCROTAL COM. PROF 47.50 0402 RADIOLOGY ULTRASOUND( 76870) 60.00 0402 RADIOLOGY 76810 US PG UTER FMAT AFTER 1ST TRI ABDL EA 78.00 0402 RADIOLOGY 76872 TRANSRECTAL SONOGRAHY 74.72 0402 RADIOLOGY 76937 US VASC ACCESS SITS VSL PATENCY NDL ENTRY 64.30 0402 RADIOLOGY 77001 FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT 172.26 0402 RADIOLOGY 93882 DUP SCAN OF EXTRACRANIAL ARTERIES UNILATERAL 74.72 0402 RADIOLOGY 93976 ABD/PELV DUPLEX SCAN ART/VEIN LIMITED STUDY 151.65 0402 RADIOLOGY 93978 DUP SCAN AO/IVC/ COMPLETE STUDY 151.65 0402 RADIOLOGY 93979 DUP SCAN A/O/IVC/ILIAC LIMITED STUDY 74.72 0402 RADIOLOGY ABDOMINAL (76700) SONO COMPONENTE PROFESIONAL 74.72 0402 RADIOLOGY ABDOMINAL (76700) SONOGRAM 74.72 0402 RADIOLOGY ABDOMINAL PRODUCTION & INT (76700) 110.00 0402 RADIOLOGY BREAST US UNILATERAL REAL TIME WITH IMAGE COMPLETE 76641 74.72 0402 RADIOLOGY BREAST US UNILATERAL REAL TIME WITH IMAGE LIMITED 76642 40.55 0402 RADIOLOGY CHEST (766040 SONOGRAM 70.00 0402 RADIOLOGY CHEST (76604) SONOGRAM COMPONONTE PROFESIONAL 70.00 0402 RADIOLOGY DOPPLER BILATERAL NONINV (93923TC) 50.00 0402 RADIOLOGY DOPPLER BILATERAL NONINV COMP PROF (9392326) 50.00 0402 RADIOLOGY DUP SCAN UXTR ART/ARTL (93930) COMP PROFESIONAL 100.00 Rev. June, 2020

CodeGroup Description Price 0402 RADIOLOGY DUPLEX ARTERIAL LOWER COMP (93926) 45.00 0402 RADIOLOGY DUPLEX CAROTID COMP PROFESIONAL (93880) 100.00 0402 RADIOLOGY DUPLEX EXTR. VEIN COMP PROF (93970) 100.00 0402 RADIOLOGY DUPLEX LOWER EXTREMITY COMP PROF (93925) 100.00 0402 RADIOLOGY DUPLEX SCAN UP EXT ART UNILATERAL 93931 90.00 0402 RADIOLOGY DUPLEX VEINS UNIL COMP PROF (93971) 45.00 0402 RADIOLOGY EXTREMITY (76880) NON VASCULAR COMP PROF 75.00 0402 RADIOLOGY EXTREMITY (76881) SONOGRAM 74.72 0402 RADIOLOGY EXTREMITY (76880) NON VASCULAR 75.00 0402 RADIOLOGY FETAL BIOPHYSICAL PROFILE NST (76818) 74.72 0402 RADIOLOGY FETAL BIOPHYSICAL PROFILE NST PROFESIONAL (76818) 40.00 0402 RADIOLOGY GALL BLADDER (76705) SONOGRAM 74.72 0402 RADIOLOGY GALLBLADDER (767050 SONOGRAM 50.00 0402 RADIOLOGY HEAD OF SONOGRAM (76506) FONTANELLE 74.72 0402 RADIOLOGY INT. SONOGRAM OF HEAD ( 76506) FONTANELLE 60.00 0402 RADIOLOGY NECK (76536) SONOGRAM 42.50 0402 RADIOLOGY NON INVAS PHYSIOLOGIC STD EXT ART 2 LEVEL (93922) 35.00 0402 RADIOLOGY NON INVAS PHYSIOLOGIC STD EXT COMP (93922) 35.00 0402 RADIOLOGY OB FIRST TRIMESTER (76801) 180.00 0402 RADIOLOGY OB REGULAR (76805) SONOGRAM 78.00 0402 RADIOLOGY OB TRASVAGINAL (76817) 120.00 0402 RADIOLOGY OBSTETRIC (76805) SONOGRAM COMP. PROFESIONAL 62.50 0402 RADIOLOGY OFFSET UTERUS (76801) COMP PROF 40.00 0402 RADIOLOGY PELVIC (76856) SONO COMPONENTE PROFESIONAL 42.50 0402 RADIOLOGY PELVIC (76856) SONOGRAM 90.00 0402 RADIOLOGY PELVIC MALE COMPONENTE (76857) 50.00 0402 RADIOLOGY PREGNAT UTER R-T LMTD (76815) 180.00 0402 RADIOLOGY RENAL (76770) SONO COMPONENTE PROFESIONAL 42.50 0402 RADIOLOGY RENAL (76770) SONOGRAM 120.00 Rev. June, 2020

CodeGroup Description Price 0402 RADIOLOGY RETROPRTNEAL REALTM W/IMAGE LMTD (76775) 74.72 0402 RADIOLOGY TESTICULAR/SCROTUM (76870) COMPONENTE MEDICO 47.50 0402 RADIOLOGY TESTICULAR/SCROTUM (76870) SONOGRAM 98.40 0402 RADIOLOGY THYROID (76536) SONOGRAM COMP. PROFESIONAL 42.50 0402 RADIOLOGY THYROID (76536) SONOGRAM 74.72 0402 RADIOLOGY TRANSVAGINAL (76830) SONOGRAM 120.00 0402 RADIOLOGY TRANSVAGINAL OB (76817) COMPONENTE 62.50 0402 RADIOLOGY TVS (76830) SONO COMPONENTE PROFESIONAL 80.00 0402 RADIOLOGY ULTRASOUND (76880) SCROTUM AND CONTENTS LT 50.00 0402 RADIOLOGY ULTRASOUND (76870) SCROTUM AND CONTENTS RT 47.50 0402 RADIOLOGY US FETAL NUCHAL FIRST TRIM COMP PROF (76813) 30.00 0402 RADIOLOGY US FETAL NUCHAL FIRST TRIMESTER (76813) 30.00 0402 RADIOLOGY US GUIDANCE NEEDLE PLACEMENT IMG SI 76942 97.20 0402 RADIOLOGY US PELVIC MALE (76857) 120.00 0402 RADIOLOGY US PG UTER R-T IMG (76816) 74.72 0402 RADIOLOGY US PG UTER R-T IMG LMTD (76815) COMP PROF 25.00 0402 RADIOLOGY US PG UTER R-T IMG PROFESIONAL (76816) 40.00 0402 RADIOLOGY VENOUS DOPPLER OF EXT VEINS BILAT COMP PROF -93965 75.00 0402 RADIOLOGY VENOUS DOPPLER OF EXT VEINS BILATERAL (93965) 75.00 0410 RESP THERAPY 94640 AEROSOL (POWER NEB) LESS THAN 1 HOUR 19.00 0410 RESP THERAPY 94644 AEROSOL (POWER NEB) INICIAL FIRST HOUR 19.00 0410 RESP THERAPY 94645 EACH ADDITIONAL HOUR 19.00 0410 RESP THERAPY 94664 DEMO/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/I 19.00 0410 RESP THERAPY 95012 NITRIC OXIDE THERAPY 257.50 0410 RESP THERAPY ARTERIAL BLOOD GASES 125.00 0410 RESP THERAPY BOLSA PARA MASCARILLA DE TERAPIA 0.45 0410 RESP THERAPY CARDIOPULMONARY RESUSCITATION (CPR) 250.00 0410 RESP THERAPY CATETER DE SUCCION 14 FR(72HR) 41.03 0410 RESP THERAPY CHEST TAPPING 30.00 Rev. June, 2020

CodeGroup Description Price 0410 RESP THERAPY CIRCUITO DE CROSVENT ADULTO 42.15 0410 RESP THERAPY CIRCUITO DE CROSVENT INFANTE 42.15 0410 RESP THERAPY CIRCUITO DE CROSVENT PED 42.15 0410 RESP THERAPY CIRCUITO DE VENTILADOR 20.40 0410 RESP THERAPY COMPLETE PFT 35.00 0410 RESP THERAPY CUIDADO DE TRAQUEOSTOMIA 80.00 0410 RESP THERAPY ESPIROMETRIA INCENTIVA 6.12 0410 RESP THERAPY EXTUBACION 20.00 0410 RESP THERAPY FILTRO BACTERIA DE FUNCION PULMONAR 4.80 0410 RESP THERAPY FILTRO BACTERIA DE VENTILADOR 2.83 0410 RESP THERAPY HOLDER ENDOTRAQUEAL 25.88 0410 RESP THERAPY HUMIDIFICADOR DE NARIZ (HME) 4.44 0410 RESP THERAPY INCENTIVE SPIROMETRY 40.00 0410 RESP THERAPY INTUBATION 100.00 0410 RESP THERAPY MASCARILLA AEROSOLPEDIATRICO 4.14 0410 RESP THERAPY MASCARILLA DE TRAQUEOSTOMIA ADULTO 3.96 0410 RESP THERAPY MASCARILLA TRAQUEOSTOMIA PEDIATRICO 3.96 0410 RESP THERAPY MASCARILLAS CPAP-BIPAP LARGE 84.00 0410 RESP THERAPY MASCARILLAS DE CPAP-BIPAP MEDIUM 84.00 0410 RESP THERAPY MASCARILLAS DE CPAP-BIPAP SMALL 84.00 0410 RESP THERAPY MASCARRILLA AEROSOL ADULTO 4.82 0410 RESP THERAPY MECHANICAL VENTILATION INITIAL 250.00 0410 RESP THERAPY MECHANICAL VENTILATION SUBSEQUENT 250.00 0410 RESP THERAPY MISTY FINITY LARGE VOLUMEN (NEBULIZADOR X 8 HR) 21.00 0410 RESP THERAPY MISTY FINITY MEDIUM VOLUMEN(NEBULIZADOR 1HR) 15.86 0410 RESP THERAPY MUCUS TRAP 2.34 0410 RESP THERAPY NASAL CANULA ADULTO 1.21 0410 RESP THERAPY NEBULIZADOR 760 ML 15.93 0410 RESP THERAPY NON INVASIVE VENTILATION (CPAP/BIPAP) 150.00 Rev. June, 2020

CodeGroup Description Price 0410 RESP THERAPY NON INVASIVE VENTILATION (CPAP/BIPAP) SUBSEQUENT 150.00 0410 RESP THERAPY NON-INVASIVE VENTILATION INITAL(CPAP-BIPAP) 200.00 0410 RESP THERAPY NON-REABREATHING MASK ADULTO 2.82 0410 RESP THERAPY NON-REABREATHING MASK PEDIATRICO 4.03 0410 RESP THERAPY OXIGEN INSTALLATION DAILY 60.00 0410 RESP THERAPY OXYTENT 12X12 44.47 0410 RESP THERAPY OXYTENT 18X18 53.70 0410 RESP THERAPY OXYTENT 24 X24 64.12 0410 RESP THERAPY SATURATION O2 20.00 0410 RESP THERAPY SENSOR FLOW 79.50 0410 RESP THERAPY SPIROMETRY (PFT) 35.00 0410 RESP THERAPY SPIROMETRY (PFT) PRE AND POST 35.00 0410 RESP THERAPY SUCTION 80.00 0410 RESP THERAPY TEE ADAPTER WITH VALVE 7.40 0410 RESP THERAPY TERAPIA RESPIRATORIA VAPONEFRINA 15.00 0410 RESP THERAPY TRACHEOSTOMY MASK 3.96 0410 RESP THERAPY TRAQUEAL TOILETTE 80.00 0410 RESP THERAPY TUBO CORRUGADO 1.91 0410 RESP THERAPY VENTURY MASK ADULTO 4.80 0410 RESP THERAPY VENTURY MASK PEDIATRICO 4.72 0450 EMERGENCY 10 MINUTES FACE TO FACE 25.00 0450 EMERGENCY 20 MINUTES FACE TO FACE 45.00 0450 EMERGENCY 30 MINUTES FACE TO FACE 60.00 0450 EMERGENCY 45 MINUTES FACE TO FACE 110.00 0450 EMERGENCY 60 MINUTES FACE TO FACE 140.00 0450 EMERGENCY 90471 IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE 75.98 0450 EMERGENCY 96360 IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR 249.48 0450 EMERGENCY 96361 IV INFUSION HYDRATION EACH ADDITIONAL HOUR 48.34 0450 EMERGENCY 96365 IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR 249.48 Rev. June, 2020

CodeGroup Description Price 0450 EMERGENCY 96366 IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR 48.34 0450 EMERGENCY 96367 IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR 75.98 0450 EMERGENCY 96372 THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM 75.98 0450 EMERGENCY 96374 THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG 249.48 0450 EMERGENCY 96375 THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG 75.98 0450 EMERGENCY 99281 URGENCY ROOM 183.60 0450 EMERGENCY 99282 URGENCY ROOM 183.60 0450 EMERGENCY 99283 URGENCY ROOM 183.60 0450 EMERGENCY 99284 URGENCY ROOM 183.60 0450 EMERGENCY 99285 URGENCY ROOM 183.60 0450 EMERGENCY 99291-CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN 942.48 0450 EMERGENCY EKG SALA DE EMERGENCIA 20.00 0450 EMERGENCY EVALUACION MEDICA NIVEL 1 20.00 0450 EMERGENCY EVALUACION MEDICA NIVEL 2 35.00 0450 EMERGENCY EVALUACION MEDICA NIVEL 3 60.00 0450 EMERGENCY EVALUACION MEDICA NIVEL 4 85.00 0450 EMERGENCY EVALUACION MEDICA NIVEL 5 110.00 0450 EMERGENCY PROLONG SERVICE 150.00 0450 EMERGENCY TRACING ONLY WITHOUT INTERPRETATION 15.00 0450 EMERGENCY USO DE SALA DE EMERGENCIA MODERATE SEVERITY 150.00 0450 EMERGENCY USO SALA DE EMERGENCIA 183.60 0459 EMERGENCY ACNE SURGERY 67.15 0459 EMERGENCY AVULSION OF NAIL, PARTIAL, COMPLETE, EACH ADDITIONAL 25.44 0459 EMERGENCY AVULSION OF NAIL, PARTIAL, COMPLETE, SIMPLE 48.95 0459 EMERGENCY BIOPSY OF SKIN PRIMARY PROCEDURE 20.22 0459 EMERGENCY BIOPSY OF SKIN SINGLE LESION 39.50 0459 EMERGENCY CLOSURE OF SPLIT WOUND 203.57 0459 EMERGENCY DEBRIDE INFECTED SKIN 38.77 0459 EMERGENCY DEBRIDE SKIN, FX 347.58 Rev. June, 2020

CodeGroup Description Price 0459 EMERGENCY DEBRIDEMENT MUSCLE FASCIA 20 SQ 183.04 0459 EMERGENCY DEBRIDEMENT SKIN/TISSUE 69.39 0459 EMERGENCY DRAINAGE OF SKIN ABSCESS 77.53 0459 EMERGENCY EMERGENCIA TRAUMATICA 92281 183.60 0459 EMERGENCY EMERGENCIA TRAUMATICA 99282 183.60 0459 EMERGENCY EMERGENCIA TRAUMATICA 99283 183.60 0459 EMERGENCY EMERGENCIA TRAUMATICA 99284 183.60 0459 EMERGENCY EMERGENCIA TRAUMATICA 99285 183.60 0459 EMERGENCY EVACUATION OF SUBUNGUAL HEMATOMA 23.72 0459 EMERGENCY EXCISION DIAMETER 0.5 CM OR LESS 61.97 0459 EMERGENCY EXCISION DIAMETER 0.6 TO 1.0 CM 83.49 0459 EMERGENCY EXCISION DIAMETER 1.1 TO 2.0 CM 95.39 0459 EMERGENCY EXCISION DIAMETER 2.1 TO 3.0 AND 3.1 TO 4.0CM 115.57 0459 EMERGENCY EXCISION DIAMETER 2.1 TO 3.0 CM 118.36 0459 EMERGENCY EXCISION DIAMETER 3.1 TO 4.0 CM 144.10 0459 EMERGENCY EXCISION DIAMETER OVER 4.0 CM 193.18 0459 EMERGENCY EXCISION MALIGNANT, PARTS OF THE FACE 2.1 TO 3.0 CM 177.20 0459 EMERGENCY EXCISION MALIGNANT, PARTS OF THE FACE 3.1 TO 4.0 CM 221.39 0459 EMERGENCY EXCISION MALIGNANT, TRUNK, ARMS, LEGS 0.6 TO 1.0 CM 110.73 0459 EMERGENCY EXCISION MALIGNANT, TRUNK, ARMS, LEGS 1.1 TO 2.0 CM 121.95 0459 EMERGENCY EXCISION MALIGNANT, TRUNK, ARMS, LEGS 2.1 TO 3.0 CM 146.15 0459 EMERGENCY EXCISON MALIGNANT, TRUNK, ARMS, LEGS 0.5 CM OR LESS 85.67 0459 EMERGENCY HEMATOMA SEROMA/FLUID COLLECTION 106.95 0459 EMERGENCY INCISION DRAINAGE ABSCESS COMPLICATED/MULTIPLE 70.03 0459 EMERGENCY INCISION DRAINAGE COMPLEX PO WOUND INFECTION 95.77 0459 EMERGENCY INCISION DRAINAGE PILONIDAL CYST SIMPLE 71.44 0459 EMERGENCY INCISION REMOVAL FOREIGN BODY SUBQ TISS SIMPLE 105.09 0459 EMERGENCY LAYER CLOSURE OF WOUND 198.79 0459 EMERGENCY LAYER CLOSURE OF WOUND 12.6-20.0 CM 271.28 Rev. June, 2020

CodeGroup Description Price 0459 EMERGENCY LAYER CLOSURE OF WOUND 2.5 CM 170.75 0459 EMERGENCY LAYER CLOSURE OF WOUND 2.6-7.5 CM 194.53 0459 EMERGENCY LAYER CLOSURE OF WOUND 7.6-12.5 CM 228.15 0459 EMERGENCY PARING OR CUTTING ABD LESION SINGLE 23.18 0459 EMERGENCY PARING OR CUTTING OF MORE THAN FOUR LESIONS 35.15 0459 EMERGENCY PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST 72.05 0459 EMERGENCY REMOVAL OF NAIL BED 130.07 0459 EMERGENCY REMOVAL OF SKIN TAGS 31.66 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 202.29 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 12.6-20.0 CM 185.92 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 2.5 CM 124.89 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 2.5CM 118.55 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 2.6-7.5 CM 126.40 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 20.1-30.0 CM 232.57 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 30.0 CM 275.31 0459 EMERGENCY REPAIR SUPERFICIAL WOUND 7.6-12.5 CM 177.71 0459 EMERGENCY REPAIR WOUND, NECK, HAND, FEET, GENITALIA 12.6-20.0 CM 189.41 0459 EMERGENCY REPAIR WOUND, NECK, HAND, FEET, GENITALIA 7.6-12.5 CM 163.96 0459 EMERGENCY REPAIR WOUNDS, SCALP, TRUNK, EXTREMITIES 2.5 OR LESS 120.10 0459 EMERGENCY SHAVING OF EPIDERMAL, DERMAL LESION 0.5 CM OR LESS 34.95 0459 EMERGENCY SHAVING OF EPIDERMAL, DERMAL LESION 0.6 TO 1.0 CM 46.16 0459 EMERGENCY SHAVING OF EPIDERMAL, DERMAL LESION 1.1 TO 2.0 CM 54.65 0459 EMERGENCY SHAVING OF EPIDERMAL, DERMAL LESION OVER 2.0 CM 67.84 0459 EMERGENCY SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM 30.55 0459 EMERGENCY TREATMENT OF SUPERFICIAL WOUND DEHISCENCE, PACKING 103.04 0471 HEARING SCREEN 92585 AUDITORY EVOKED (PRUEBA AUDITIVA) 80.75 0479 HEARING SCREEN HEARING SCREENING 25.00 0480 CARDIO 75710 ANGIOGRAPHY EXTREMITY UNILATERAL RSI 175.44 0480 CARDIO 75716 ANGIOGRAPHY EXTREMITY BILATERAL RSI 202.28 Rev. June, 2020

CodeGroup Description Price 0480 CARDIO 93224 EXTERNAL ELECTROCARDIOGRAPHIC 48 HOURS 182.81 0480 CARDIO 93228 XTRNL MOBILE CV TELEMETRY 182.81 0480 CARDIO DUPLEX SCAN 200.00 0483 CARDIO ECHO (93306) 317.70 0490 OPERATING ROOM 10121-INCISION AND REMOVAL FOREIGH BODY 867.60 0490 OPERATING ROOM 11043 SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE 800.00 0490 OPERATING ROOM 11044 -DEBRIDE TISSUE MUSCLE BONE 867.60 0490 OPERATING ROOM 11403 EXCISION BENING LESION SKIN EXC DIA 2.1 TO 3 800.00 0490 OPERATING ROOM 11404 EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0CM 867.60 0490 OPERATING ROOM 11406 EXC B9 LESION 4.0 CM 867.60 0490 OPERATING ROOM 11424 EXC B9 LES MRGN XCP 867.60 0490 OPERATING ROOM 11606EXCISION MALIGNANT LESSIONTRUNK/ARM/LEG<4.0CM 867.60 0490 OPERATING ROOM 11641 EXCISION MALIGNANT LESION 867.60 0490 OPERATING ROOM 12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 867.60 0490 OPERATING ROOM 14000 -ADJ TRANS RE ARRANG TRUNK DEF 10 SQ CM 530.00 0490 OPERATING ROOM 14001 REARRANGE TRUNK 867.60 0490 OPERATING ROOM 14020 -Skin tissue rearrangement 867.60 0490 OPERATING ROOM 14040 -Skin tissue rearrangement 867.60 0490 OPERATING ROOM 14060 ADJT TIS TRNSFR/REARRGMT 867.60 0490 OPERATING ROOM 19100 -BIOPSY OF BREAST 867.60 0490 OPERATING ROOM 19101 -BX BREST OPEN INCAL 530.00 0490 OPERATING ROOM 19120 - Removal of breast lesion 867.60 0490 OPERATING ROOM 19125 EXC BREAST LEASION IDENT BY OPERATIVE OPEN 867.60 0490 OPERATING ROOM 19300 MASTECTOMY GYNECOMASTIA 867.60 0490 OPERATING ROOM 19300-50 MASTECTOMY GYNECOMASTIA 867.60 0490 OPERATING ROOM 19301 MASTECTOMY, PARTIAL 867.60 0490 OPERATING ROOM 19304 -MASTECTOMY SUBCUTONEOUS 800.00 0490 OPERATING ROOM 21555 Remove lesion, neck/chest 867.60 0490 OPERATING ROOM 21556 -REMOVAL LESION NECK CHEST 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM 21933 BACK MASS 867.60 0490 OPERATING ROOM 22900 EXC ABDL WALL TUM SUBFSCAL 530.00 0490 OPERATING ROOM 23101 SHOULDER JOINT SURGERY 867.60 0490 OPERATING ROOM 23145 SHOULDER REPAIR /REVSION/RECONST 549.00 0490 OPERATING ROOM 23420- RECONSTRUCTION OF SHOULDER ROTATOR CUFF 867.60 0490 OPERATING ROOM 24071 AXILAR MASS 574.00 0490 OPERATING ROOM 25105 REMOVA WRIST JOINT LINING 867.60 0490 OPERATING ROOM 25515 TREAT FRACTURE RADIUS 867.60 0490 OPERATING ROOM 25575 TREAT FRACTURE RADIUSL ULNA 867.60 0490 OPERATING ROOM 25607 TREAT FX RAD EXTRA-ARTICUL 867.60 0490 OPERATING ROOM 27125 HIP BIPOLAR REPLACEMENT 867.60 0490 OPERATING ROOM 27245- HIP INTRAMEDULARY NAILING 867.60 0490 OPERATING ROOM 27327- REMOVAL OF THIGH LESION 867.60 0490 OPERATING ROOM 27607 INCISION LEG/ANKLE 867.60 0490 OPERATING ROOM 27632 LEG MASS 867.60 0490 OPERATING ROOM 27814 TREATMENT OF ANKLE FRACTURE 867.60 0490 OPERATING ROOM 27880-AMPUTATION LEG 867.60 0490 OPERATING ROOM 28060 PARTIAL REMOVAL FOOT FASCIA (28060) 867.60 0490 OPERATING ROOM 28192 Removal of foot foreign body 867.60 0490 OPERATING ROOM 28285 HAMMER CORRELATION 867.60 0490 OPERATING ROOM 28298-HALLUX VALGUS W/WO SESMDS PHALANX 867.60 0490 OPERATING ROOM 28299 CRRJ HALLUX VALGUS W/WO SESMDC 2 OSTEOT 867.60 0490 OPERATING ROOM 29807 SHOULDER SCOPE, REPAIR CARTILAGE TEAR 551.00 0490 OPERATING ROOM 29826-ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT 867.60 0490 OPERATING ROOM 29876 ARTHR KNEE COMPARTMENT 867.60 0490 OPERATING ROOM 29879 KNEE ARTHROSCOPY 867.60 0490 OPERATING ROOM 29880 ARTHRS KNEE SURG W/MENISC 867.60 0490 OPERATING ROOM 29881 ARTHRS KNEE SURG W/MENISC MED/LAT 867.60 0490 OPERATING ROOM 29882 ARTHROSCOPY KNEE 564.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM 33206-PACEMAKER INSERTION OR REPLAMENT PERMANENT 867.60 0490 OPERATING ROOM 36561 VENO PORT 5 YEARS OLDER 551.00 0490 OPERATING ROOM 36590 REMOVAL OF TUMNELED CENTRAL VENOUS ACCESS 867.60 0490 OPERATING ROOM 37765 STAB PHLEBT VRCS VNS 1 XTR 10-20 STAB INES 867.60 0490 OPERATING ROOM 41510 SUTURE TONGUE LACERATION 549.00 0490 OPERATING ROOM 43832 PLACE GASTROSTOMY TUBE 800.00 0490 OPERATING ROOM 44180 Lap, enterolysis 1,300.00 0490 OPERATING ROOM 44950 -APPENDECTOMY 549.00 0490 OPERATING ROOM 46270 0urgical treatment of anal fistula (fistulec 650.00 0490 OPERATING ROOM 47562 CHOLECYSTECTOMY LAP 1,300.00 0490 OPERATING ROOM 47562 Laparoscopic cholecystectomy 1,300.00 0490 OPERATING ROOM 49000 -Exploration of abdomen 867.60 0490 OPERATING ROOM 49321 -LAPAROSCOPY BIOPSY 1,300.00 0490 OPERATING ROOM 49505 -PRP HERN INIT REDUC 5 YR 867.60 0490 OPERATING ROOM 49505 -Prp i/hern init reduc >5 yr 867.60 0490 OPERATING ROOM 49520 -Rerepair ing hernia, reduce 867.60 0490 OPERATING ROOM 49560 -Rpr ventral hern init, reduc 867.60 0490 OPERATING ROOM 49585 -Rpr umbil hern, reduc > 5 yr 867.60 0490 OPERATING ROOM 49587 RPR UMBILICAL HERNIA 867.60 0490 OPERATING ROOM 52500 SURGERY ON BLADDER NECK THROUGH URETHRA 530.00 0490 OPERATING ROOM 54161 Circumcision 867.60 0490 OPERATING ROOM 56440 -MARSUPIALIZATION BARTHOLINS GLAND CYST 530.00 0490 OPERATING ROOM 56620-VULVECTOMY SIMPLE PARTIAL 867.60 0490 OPERATING ROOM 56740 -Excision of Bartholin's gland or cyst 650.00 0490 OPERATING ROOM 57100 VAGINAL MUCOSA 800.00 0490 OPERATING ROOM 57461 -CONZ OF CERVIX W/SCOPE LEEP 867.60 0490 OPERATING ROOM 57520 -Conization of cervix 867.60 0490 OPERATING ROOM 57522 -CONIZATION OF CERVIX, LOOP OF CERVIX 867.60 0490 OPERATING ROOM 58120 D & C 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM 58120- Dilation and curettage 867.60 0490 OPERATING ROOM 58260 VAGINAL HYSTERECTOMY FOR UTERUS G OR LESS 800.00 0490 OPERATING ROOM 58262 VAG HYST 250 GMKW/RMVL TUBE&/OVARY 867.60 0490 OPERATING ROOM 58301- Remove intrauterine device 867.60 0490 OPERATING ROOM 58550 -LAP. HISTERECTOMY 1,300.00 0490 OPERATING ROOM 58555 -HYSTEROSCOPY FOR DIAGNOSIS WITHOUT BIOPSY 549.00 0490 OPERATING ROOM 58558 -Hysteroscopy, biopsy 1,300.00 0490 OPERATING ROOM 58615 -OCCLUSION FLP TUBE DEV VAGL SUPRAPUBIC APPR 867.60 0490 OPERATING ROOM 58661- Laparoscopy, remove adnexa 1,300.00 0490 OPERATING ROOM 58700 - REMOVAL OF FALLOPIAN TUBE 867.60 0490 OPERATING ROOM 58700 -Removal of fallopian tube 867.60 0490 OPERATING ROOM 58920 WEDGE RESCJ/BISCTJ OVARY UNI*BI 530.00 0490 OPERATING ROOM 59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY 800.00 0490 OPERATING ROOM 59151 TREATMENT OF ECTOPIC PREGNANCY LAP 800.00 0490 OPERATING ROOM 59320 -CERCLAGE OF CERVIX, DURING PREGNANCY; 650.00 0490 OPERATING ROOM 59812 -TREATMENT OF MISCARRIAGE 867.60 0490 OPERATING ROOM 59812 -TX INCOMPLETE ABORTION ANY TRI 867.60 0490 OPERATING ROOM 59820 -TX MISSED ABORTION FIRST TRIMESTER 867.60 0490 OPERATING ROOM 59821 TREATMENT OF INCOMPLETE ABORTION, SECONDTRIM 800.00 0490 OPERATING ROOM 60225 SUBTOTAL LOBECTOMY (THYROIDECTOMY) 800.00 0490 OPERATING ROOM 62270 SPINAL PUNCTURE, LUMBAR (SPINAL BLOCK) TAP 62.00 0490 OPERATING ROOM 62310 SPINE BLOCK 800.00 0490 OPERATING ROOM 62311 SPINAL BLOCK LUMBAR, SACRAL 800.00 0490 OPERATING ROOM 64721 NEURP/TRPOS MEDIAN NRV CARPAL TUNNEL 867.60 0490 OPERATING ROOM 65420 EXCISION OR TRANSP. OF PTERYGIUM W/O GRAFT 867.60 0490 OPERATING ROOM 66982 EXTRACAPSULAR CATARACT REMOVAL WITH INSERTIO 867.60 0490 OPERATING ROOM 66984- CATARACT REMOVAL, INSERTION OF LENS 867.60 0490 OPERATING ROOM 88142 CYTOPATH, C/V, THIN LAYER 800.00 0490 OPERATING ROOM 88305 LEVEL IV SURG PATHOLOGY GROSSMICROSCOPIC 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM ABSC COMP/MLT (10061) 653.00 0490 OPERATING ROOM ADHESIOLYSIS TUBE OVARY (58740) 867.60 0490 OPERATING ROOM AMP METAR W/TOE 1 (28810) 530.00 0490 OPERATING ROOM AMPUTACION PENE (54130) 530.00 0490 OPERATING ROOM AMPUTATION FINGER OR THUMB PRIMARY OR SECON(26951 800.00 0490 OPERATING ROOM AMPUTATION TOE METARSALPHALANGEAL 800.00 0490 OPERATING ROOM APPENDECTOMY 800.00 0490 OPERATING ROOM ARTERIAL CATHETERIZATION FOR CHEMOTHERAPY (36640) 800.00 0490 OPERATING ROOM ARTHROSCOPY KNEE DIAG W/O SYNOVIAL BIOP SEP (29870 800.00 0490 OPERATING ROOM ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTO29880 551.00 0490 OPERATING ROOM ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/R29888 551.00 0490 OPERATING ROOM ARTHRS KNEE DRLG OSTEO DISS GRFG (29885) 549.00 0490 OPERATING ROOM ARTHRS KNEE OSTEO DISS LESS INT FIXJ(29887) 551.00 0490 OPERATING ROOM ARTHRS KNEE SURG W/MENISC. RPR MED&LAT (29883) 549.00 0490 OPERATING ROOM ARTHRS KNEE SURG W/MENISC. RPR MED&LAT(29882) 549.00 0490 OPERATING ROOM ARTHRS SHOULDER SURG. CAPSULORRHAPHY (29806) 551.00 0490 OPERATING ROOM ARTHRS SHOULDER SURG. DBRDMNT LMTD(29822) 551.00 0490 OPERATING ROOM ARTHRT ACROMCLAV STRNCLAV JT W/ EXPL (23044) 867.60 0490 OPERATING ROOM ARTRT EXPL DRG/RMVL LOOSE/FBCARP/MTCRP/JT (26070) 800.00 0490 OPERATING ROOM ASPIRATION & CURETTAGE POST ABORTION(59870) 549.00 0490 OPERATING ROOM ATT/REARGMT TRNK DFCT 10 CM/< (14000) 867.60 0490 OPERATING ROOM BIG TOE SPAILOR RIGHT (59092) 530.00 0490 OPERATING ROOM Biopsy arm/elbow soft tissue (24066) 867.60 0490 OPERATING ROOM BIOPSY OF ANORECTAL WALL, ANAL APPROACH (45100) 800.00 0490 OPERATING ROOM BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQUIRI57105 650.00 0490 OPERATING ROOM Biopsy of vulva or perineum (separate proce56605 650.00 0490 OPERATING ROOM BIOPSY OR EXCISION OF LYMPH (38510) 549.00 0490 OPERATING ROOM Biopsy soft tissue of back (21925) 867.60 0490 OPERATING ROOM BIOPSY SOFT TISSUE SHOULDER (23065) 800.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM Biopsy, nail unit (11755) 867.60 0490 OPERATING ROOM BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION57500 549.00 0490 OPERATING ROOM BIOPSY, SOFT TISSUE OF BACK OR FLANK; SUPE21920 650.00 0490 OPERATING ROOM BIOPSY, SOFT TISSUE OF NECK OR THORAX (21550) 800.00 0490 OPERATING ROOM BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; 27323 650.00 0490 OPERATING ROOM Biopsy, thigh soft tissues (27324) 867.60 0490 OPERATING ROOM BIOPSY/REMOVAL HYMPH NODES (38525) 867.60 0490 OPERATING ROOM BIOSPY CAUTERY OF CERVIX, ELECTRO OR THERMA (57510 800.00 0490 OPERATING ROOM BONE BIOPSY EXCISIONAL (20245) 867.60 0490 OPERATING ROOM BREAST MASS BIOPSY 800.00 0490 OPERATING ROOM BX BRST PRQ NDL CORE W/IMG GDN (19102) 867.60 0490 OPERATING ROOM BX SKIN SUBCUTANEOUS & MUCOUS (11100) 867.60 0490 OPERATING ROOM BX SOFT TISS PELVISHIP AREA DP SUBFCAL/IM 530.00 0490 OPERATING ROOM BX SOFT TISS PELVISHIP AREA DP SUBFSCAL/IM 530.00 0490 OPERATING ROOM BX SOFT TISS PLEVISHIP AREA DP SUBFSCAL/IM (27041) 530.00 0490 OPERATING ROOM BX SOFT TISS SHO AREA DP (23066) 530.00 0490 OPERATING ROOM BX/EXC LYMPH NODE OPN DP AX NODE (38525) 530.00 0490 OPERATING ROOM CATARACT REMOVAL INSERTION OF LENS (66984) 867.60 0490 OPERATING ROOM CATARACT REMOVAL, INSERTION OF LENS(66984) 867.60 0490 OPERATING ROOM CHOLECYSTECTOMY (47600) 1,300.00 0490 OPERATING ROOM CISTOLITOTOMIA (51050) 530.00 0490 OPERATING ROOM CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FR25565 551.00 0490 OPERATING ROOM Colectomy, partial; with end colostomy and 44143 650.00 0490 OPERATING ROOM COLLECT BLOOD FROM VENOUS (36591) 800.00 0490 OPERATING ROOM COLPOSCOPY CERVIX BX (57454) 800.00 0490 OPERATING ROOM COLPOSCOPY CERVIX UPPER (57452) 867.60 0490 OPERATING ROOM COLPOSCOPY ENTIRE VGN W/VGNL CERVIX (57421) 867.60 0490 OPERATING ROOM COMBINED ANTEROPOSTERIOR COLPORRHAPHY(57260) 530.00 0490 OPERATING ROOM CRIOCIRUGIA PROSTATA (54065) 600.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM CROSTOTOMIA (51040) 530.00 0490 OPERATING ROOM CYSTOCECTOCELE REPAIR (57250) 800.00 0490 OPERATING ROOM Cystourethroscopy (separate procedure)52000 650.00 0490 OPERATING ROOM DBRDMT (11000) 867.60 0490 OPERATING ROOM DEBRIDE SKIN PARTIAL (11040) 800.00 0490 OPERATING ROOM DEBRIDE SKIN SUBCUTANEOS TISSUES (11010) 650.00 0490 OPERATING ROOM DEBRIDEMENT SKIN TISSUE (11042) 800.00 0490 OPERATING ROOM DEBRITMENT OF ARTICULAR CARTILAGE CHONDROPL29877 800.00 0490 OPERATING ROOM DESTROY VULVA LESION (56501) 800.00 0490 OPERATING ROOM Destruction of lesion(s), penis (eg, condylo54055 650.00 0490 OPERATING ROOM DESTRUCTION VAGINAL LESIONS EXT (57065) 867.60 0490 OPERATING ROOM Diag laparo separate proc (45320) 1,300.00 0490 OPERATING ROOM DILATION AND CURETTEGE, DIAGNOSTIC 800.00 0490 OPERATING ROOM DISSECTION DEEP JUGULAR NODE (38542) 867.60 0490 OPERATING ROOM Division of fallopian tube (58600) 867.60 0490 OPERATING ROOM DRAIN NECK/CHEST LESION (21501) 867.60 0490 OPERATING ROOM DRAINAGE OF SKIN OBSCESS (10061) 867.60 0490 OPERATING ROOM DRAINAGE OVARIAN CYST UNI/BI SPX VGNL APRR (58800) 867.60 0490 OPERATING ROOM DS TRJ TGS/CUTAN VASC UP 14< (17110) 530.00 0490 OPERATING ROOM DSTRJ LESION ANUS SIMP[LE CHEMICAL (46900) 867.60 0490 OPERATING ROOM DSTRJ LESION ANUS SIMPLE SURG EXC (46922) 867.60 0490 OPERATING ROOM ENDOMETRIAL CURETTAGE 800.00 0490 OPERATING ROOM ENDOMETRIAL UTERINE CURETTAGE (58356) 800.00 0490 OPERATING ROOM ENDOSCOPY ANTHROSCOPY SYNOVECTOMY COMPLE (29821) 800.00 0490 OPERATING ROOM ENDOVEN ABLT (36475) 800.00 0490 OPERATING ROOM ENTEROLYSIS SEPARATE PROCEDURE 44005 549.00 0490 OPERATING ROOM Enucleation or excision of external thromboti46320 650.00 0490 OPERATING ROOM ERCP ENDSCPY RTRGD CHLNGIOPNCREATGRPHY (43260) 867.60 0490 OPERATING ROOM EXAM OF VAGINA W/SCOPE (57420) 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM EXC FRONTAL /FACIAL TUMOR (11443) 530.00 0490 OPERATING ROOM EXC 2.0 BACK CYST (11402) 800.00 0490 OPERATING ROOM EXC B1 CST/B9 TUM DP+SGRFT (27066) 530.00 0490 OPERATING ROOM EXC B9 (11421) 800.00 0490 OPERATING ROOM EXC B9 (11441) 800.00 0490 OPERATING ROOM EXC B9 LES MRGN XCP SK TG F/E/E/IN/L/M 21.3.(11443 653.00 0490 OPERATING ROOM EXC B9 LES MRGN XCP SK TG S/N/H/F/G> 4.0CM (11426) 867.60 0490 OPERATING ROOM EXC B9 LES MRGN XCP SK TG T/AL/4.0 CM (11406) 530.00 0490 OPERATING ROOM EXC B9 MARG 6-1. (11401) 800.00 0490 OPERATING ROOM EXC EXOSTOSIS (69140) 800.00 0490 OPERATING ROOM EXC F/E/E/N/L MAL + MRG 0.6-1 (11641) 867.60 0490 OPERATING ROOM Exc face-mm b9+marg 1.1-2 cm (11442) 550.00 0490 OPERATING ROOM Exc face-mm b9+marg 3.1-4 cm (11444) 867.60 0490 OPERATING ROOM EXC FOOT/TOE TURN DEP 1.5CM (28041) 867.60 0490 OPERATING ROOM EXC FRENUM LABIAL/BUCCAL (40819) 867.60 0490 OPERATING ROOM EXC LES TDN SHTH/JT CAPSL HAND/FINGR (26160) 698.80 0490 OPERATING ROOM EXC OF LESION, CONJUCTIVA; OVER 1 CM (68115) 800.00 0490 OPERATING ROOM EXC PILONIDIAL CST/SINUS COMP (11772) 867.60 0490 OPERATING ROOM EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ (42410 867.60 0490 OPERATING ROOM EXC RECTAL (45130) 800.00 0490 OPERATING ROOM EXC SOFT TISS TUM SHO AREA DP SUBFSCAL (23076) 653.00 0490 OPERATING ROOM EXC SOFT TISS TUM SHO AREA SUBFSCAL/IM (23076) 530.00 0490 OPERATING ROOM EXC TUM SOFT TISS UPR ARM/ ELBW AREA DP (24076) 530.00 0490 OPERATING ROOM EXC TUMOR SOFT TISS FOREARM &WRIST SUB (25071) 867.60 0490 OPERATING ROOM EXC WRIST LESION (25110) 800.00 0490 OPERATING ROOM EXC, FOOT MASS, ARTHROTOMY, SINOVECTOMY (23105) 549.00 0490 OPERATING ROOM EXC/DSTRJ INTRANSL LES XTRNL APR LAT (30118) 530.00 0490 OPERATING ROOM EXCISE EXCESSIVE SKIN THINGH (15832) 867.60 0490 OPERATING ROOM EXCISION ABDOMINAL WALL TUMOR, SUBFACIAL(22900) 530.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM EXCISION DERMOID CYST (30124) 800.00 0490 OPERATING ROOM EXCISION MASS (11423) 530.00 0490 OPERATING ROOM Excision of bone cyst or benign tumor; 27065 650.00 0490 OPERATING ROOM EXCISION OF CYST OR ADENOMA OF THYROID (60200) 700.00 0490 OPERATING ROOM EXCISION OF FACE LESSION WITH REAR. OF TISS (14060 549.00 0490 OPERATING ROOM Excision of foot lesion (28043) 867.60 0490 OPERATING ROOM Excision of foot lesion (28045) 867.60 0490 OPERATING ROOM EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR)25111 800.00 0490 OPERATING ROOM EXCISION OF LESSION OF EYELID WITHOUT CLOS67840 551.00 0490 OPERATING ROOM EXCISION OF RECTAL TUMOR, TRANSANAL APPRO45170 551.00 0490 OPERATING ROOM EXCISION PILONIDAL CYST SIMPLE (11770) 549.00 0490 OPERATING ROOM EXCISION TUMOR (23071) 800.00 0490 OPERATING ROOM EXCISION, BENIGN LESION INCLUDING MARGINS, 11422 800.00 0490 OPERATING ROOM EXCISION, BENIGN LESION INCLUDING MARGINS, E11400 549.00 0490 OPERATING ROOM EXCISION, BENIGN LESION INCLUDING MARGINS,11420 551.00 0490 OPERATING ROOM Excision, soft tissue tumor, shoulder area; 23075 650.00 0490 OPERATING ROOM EXCITION ON FACE, EAR NOSELIP 0.5 OR LESS (11440) 800.00 0490 OPERATING ROOM EXCITION TUMOR OF NOSE (30110) 800.00 0490 OPERATING ROOM EXCSN MAL LESION TRNK/ARM/LG 20.1-3.0CM/< (11603) 867.60 0490 OPERATING ROOM EXCSN MALIGNANT TUMOR MAX ZYGOMA (21034) 867.60 0490 OPERATING ROOM EXCSN OF PILONIDAL CYST OR SINUS EXTENSIVE (11771) 867.60 0490 OPERATING ROOM EXCSN SYNOVIAL CYST POPITL SPACE BAKER'S (27345) 800.00 0490 OPERATING ROOM EXPL W/RMVL DP F/ARM /WRST (25248) 530.00 0490 OPERATING ROOM Exploration of abdomen (49000) 1,300.00 0490 OPERATING ROOM G0342 USO DE SALA DE OPERACIONES 530.00 0490 OPERATING ROOM GASTROSCOPIA (43510) 530.00 0490 OPERATING ROOM GASTROSCOPIA POR LAPAROSCOPIA (43653) 1,100.00 0490 OPERATING ROOM HEMORRHOIDECTOMY (46260) 867.60 0490 OPERATING ROOM HEMORROHIDECTOMY EXTERNAL COMPLETE (46250) 800.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM Hernia repair w/mesh (59568) 867.60 0490 OPERATING ROOM HISTERECTOMIA (58150) 1,135.00 0490 OPERATING ROOM HYSTEROSCOPY RMVL IMPACTED FRGH BODY (58562) 867.60 0490 OPERATING ROOM ID ABSCESS SUBFASCIAL (20005) 867.60 0490 OPERATING ROOM ID VULVA / PRNL ABSC (56405) 530.00 0490 OPERATING ROOM INCISION & DRAINAGE ABSCESS SIMPLE (10060) 800.00 0490 OPERATING ROOM INCISION AND DRAINAGE OF BARTHOLIN'S GLAND A56420 549.00 0490 OPERATING ROOM Incision of knee joint (27435) 867.60 0490 OPERATING ROOM INCISION, DRAINAGE OF LACRIMAL GLAND68400 650.00 0490 OPERATING ROOM INCRML FB SUBQ TISS SMPL (10120) 530.00 0490 OPERATING ROOM INCSN & DRAINAGE OF APPENDICEAL ABS; OPN (44900) 800.00 0490 OPERATING ROOM INDUCED ABORTION DILATION AND CURETAGE (59840) 867.60 0490 OPERATING ROOM INJECTION (20550) 800.00 0490 OPERATING ROOM INJX/INFUS NEUROLYT SBST EPIDURAL LSS (62282) 800.00 0490 OPERATING ROOM INS/REP PER PAC CVDFB TRNSVEN LEADS 1/2 CHM -33249 800.00 0490 OPERATING ROOM INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS,(49440 800.00 0490 OPERATING ROOM INSETION OF INTRAOCULAR LENS (66985) 500.00 0490 OPERATING ROOM INSJ PRPH CTR VAD W/SUBQ PORT (36571) 800.00 0490 OPERATING ROOM INSJ T6UN CTR VAD W/ SUBQ PMP (36563) 530.00 0490 OPERATING ROOM INTRODUCTION OF URETERAL CATHETER OR STENT 50393 650.00 0490 OPERATING ROOM KNEE ARTHROSCOPY/DRAINAGE (29871) 867.60 0490 OPERATING ROOM KNEE ARTHROSCOPY/SURGERY (29877) 800.00 0490 OPERATING ROOM LAP SALPINGOSTOMY (48673) 1,100.00 0490 OPERATING ROOM LAP VENT/ABD HERNIA REPAIR W OR WO MESH (49652) 800.00 0490 OPERATING ROOM LAP. APENDECTOMY (44970) 1,300.00 0490 OPERATING ROOM LAP. REDUCTION HERNIA (49650) 1,125.00 0490 OPERATING ROOM LAPAROSCOPY BIOPSY (49321) 1,300.00 0490 OPERATING ROOM LAPAROSCOPY TUBAL BLOCK (58671) 1,300.00 0490 OPERATING ROOM Laparoscopy, lysis (58660) 1,300.00 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM LAPAROSCOPY, SURGICAL; WITH FULGURATION OR 58662 1,300.00 0490 OPERATING ROOM Laparoscopy, surgical; with retroperitoneal 38570 1,164.00 0490 OPERATING ROOM Laparoscopy, tubal block (58671) 1,300.00 0490 OPERATING ROOM LAPS SURG W/DRG LYMPHOCELE PERITON CAVITY (49323) 500.00 0490 OPERATING ROOM LEEP OF CERVIX (57460) 867.60 0490 OPERATING ROOM LEG/ANKLE DP ABSC/HMTMA (27503) 867.60 0490 OPERATING ROOM LENGTHENING TENDON EXTENSOR HAND/FING (26476) 800.00 0490 OPERATING ROOM LGT/TRNSXJ FALOPIAN TUBE CESATEAN DEL (58611) 867.60 0490 OPERATING ROOM LGTN OF PERFORATOR VEINS, SUBFASCIAL,RADICAL(37760 800.00 0490 OPERATING ROOM LIGATE LEG VEINS OPEN (37761) 867.60 0490 OPERATING ROOM LIGATE/STRIP SHORT LEG VEIN (37718) 800.00 0490 OPERATING ROOM LIGATION OR TRANS OF FALLOPIAN TUBE (S) UNI (58605 530.00 0490 OPERATING ROOM LIGATION, DIVISION & STRIPPING, LONG VEINS (37722) 550.00 0490 OPERATING ROOM LT, OR, RT,BREAST LUMPECTOMY WITH AXILLARY D19302 650.00 0490 OPERATING ROOM LYSIS/MASS OF LABIAL ADHESIONS (56441) 800.00 0490 OPERATING ROOM MANIPULATION KNEE UNDER ANESTASIA (27570) 600.00 0490 OPERATING ROOM MARSUPIALIZATION BARTHOLIN`S GLAND CYST (56440) 530.00 0490 OPERATING ROOM MAST GYNECOMASTIA (19300) 867.60 0490 OPERATING ROOM MAST MOD RAD (19307) 867.60 0490 OPERATING ROOM MAST SMP COMPL (19303) 530.00 0490 OPERATING ROOM MASTOTOMY WITH EXPLO. OR DRAINAGE (19020) 530.00 0490 OPERATING ROOM MYOMECTOMY 1-4 250 GM/< VAG (58145) 530.00 0490 OPERATING ROOM OOPHORECTOMY UNILATERAL OR BILATERAL, TOTAL58940 549.00 0490 OPERATING ROOM OPTX DSTLRADL I-ARTIC FX/EPIPHYSL SEP3 FRAG-25609 800.00 0490 OPERATING ROOM OPTX POST ANKLE FX (27769) 867.60 0490 OPERATING ROOM OSTECTOMY CALCANEUS SPUR W/WO PLANTAR FAS (28119) 800.00 0490 OPERATING ROOM Partial mastectomy (19160) 867.60 0490 OPERATING ROOM Partial removal of vulva (56620) 867.60 0490 OPERATING ROOM PARTIAL REMOVAL OR THYROID (60220) 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM Partial thyroid lobectomy, unilateral; with 60210 650.00 0490 OPERATING ROOM PELVIS/ HIP JT AREA DP ABSC/ HMTMA (26990) 867.60 0490 OPERATING ROOM PREV IMPLTED PM/CVDFB R ATR/R VENT ELTRD (33215 867.60 0490 OPERATING ROOM PRINEOPLASTY RPR PR NONBAL SPX (56810) 530.00 0490 OPERATING ROOM PRINEOPLASTY RPR PR NONOBAL SPX (56810) 530.00 0490 OPERATING ROOM Prostatectomy (TURP) (52601) 867.60 0490 OPERATING ROOM PRP IHERN INIT BLOCK 5 YRS (49507) 867.60 0490 OPERATING ROOM RADICAL RECEPTION OF TUMOR BONE,FEMUR O KNEE(27365 650.00 0490 OPERATING ROOM RADICAL RESECT TUMOR MALIGNANT FOREAM/WIRST 25077 800.00 0490 OPERATING ROOM Radical resection of tumor, bone; tibia 27645 650.00 0490 OPERATING ROOM RADICAL RESECTION STERNUM (21630) 800.00 0490 OPERATING ROOM RAPAIR INIT FEMORAL HERNIA ANY AGE RDCIBL (49550) 800.00 0490 OPERATING ROOM Reconstruction of complete shoulder (rotator)23420 650.00 0490 OPERATING ROOM Reconstruction of urethra (53430) 867.60 0490 OPERATING ROOM RECONSTRUCTION URETHRA FEMELE (53430) 867.60 0490 OPERATING ROOM Reconstruction, tongue fold (41520) 867.60 0490 OPERATING ROOM RECONSTRUTION OF URETHRA MALE (53410) 867.60 0490 OPERATING ROOM RECTOCELE (45560) 800.00 0490 OPERATING ROOM Removal forearm lesion subcu (25075) 867.60 0490 OPERATING ROOM REMOVAL FOREING BODY OF EXTREMITY (20103) 650.00 0490 OPERATING ROOM Removal hand lesion subcut (26115) 867.60 0490 OPERATING ROOM REMOVAL NAIL (11750) 650.00 0490 OPERATING ROOM REMOVAL NECK/ARMPIT LESION (38550) 867.60 0490 OPERATING ROOM Removal of breast tissue (19140) 867.60 0490 OPERATING ROOM Removal of foot lesion (28090) 867.60 0490 OPERATING ROOM REMOVAL OF FOREING BODY, DEEP, THIGHREGIONKNE27372 800.00 0490 OPERATING ROOM REMOVAL OF GALLBLADDER (47600) 867.60 0490 OPERATING ROOM Removal of leg veins/lesion (37735) 867.60 0490 OPERATING ROOM REMOVAL OF OVARIA CYST (58925) 867.60 Rev. June, 2020

CodeGroup Description Price 0490 OPERATING ROOM REMOVAL OF SKIN TAGS

CodeGroup Description Price 0490 OPERATING ROOM RMVL IMPLNTD INTRA-ARTERIALS INFSN PUMP (36262) 800.00 0490 OPERATING ROOM RPR 1ST INCAL/VNT HERNIA INCARCERATED (49561) 800.00 0490 OPERATING ROOM RPR UMBIL HERN REDUC<5YR (49580) 867.60 0490 OPERATING ROOM Rpr ventral hern init, reduc (59560) 867.60 0490 OPERATING ROOM RPR WND EXTRAOCLR MSCL TNDN P/TNN CPSL (65290) 867.60 0490 OPERATING ROOM SCOPE BLADDER, REMOVAL OF TUMORS,SMALL (52234) 867.60 0490 OPERATING ROOM SCOPE BLADDER, RMVL OF TUMORS,MDM (52235) 530.00 0490 OPERATING ROOM Secondary closure of surgical wound or deh13160, 650.00 0490 OPERATING ROOM SHOULDER DISLOCATION WITH CORAID PROCESS (23462) 800.00 0490 OPERATING ROOM V2630 -SUPLIDO LENTE CATARATA SURG 200.00 0490 OPERATING ROOM V2631 SUPLIDO LENTE CATARATA IRIS SUPORTED 200.00 0490 OPERATING ROOM V2632 -SUPLIDO LENTE CATARATA SURG 200.00 0490 OPERATING ROOM VENTRAL HERN INIT REDUC 650.00 0540 AMB TRANSPORT AMBULANCE 180.00 0540 AMB TRANSPORT AMBULANCIA ESTUDIO 400.00 0540 AMB TRANSPORT AMBULANCIA TRASLADO 400.00 0555 OPERATING ROOM BIOPSY NASOPHARYNX, VISIBLE LESION, SIMPLE (42804) 800.00 0555 OPERATING ROOM INSJ IMPLANTABLE INTRA-ARTERIAL INFSN PUMP (36260) 800.00 0555 OPERATING ROOM METATARSAL INCISION (28308) 800.00 0555 OPERATING ROOM USO SALA LAPAROSCOPIA 1,200.00 0610 RADIOLOGY 70336 MRI TMJ W/O CONTRAST 493.72 0610 RADIOLOGY 70540 MRI ORBIT,FACE,NECK W/O CONTRAST 417.60 0610 RADIOLOGY 70542 MRI SOFT TISSUE NECK, ORBIT WITH CONTRAST 493.00 0610 RADIOLOGY 70543 MRI ORBIT,FACE,NECK, W W/O CONTRAST 609.00 0610 RADIOLOGY 70551 MRI BRAIN W/O CONTRAST 321.18 0610 RADIOLOGY 70552 MRI BRAIN WITHOUT CONTRAST 474.14 0610 RADIOLOGY 70553 MRI BRAIN W W/O CONTRAST 540.84 0610 RADIOLOGY 71550 MRI CHEST W/O CONTRAST 493.74 0610 RADIOLOGY 71551 MRI CHEST WITH CONTRAST 760.54 Rev. June, 2020

CodeGroup Description Price 0610 RADIOLOGY 71552 MRI CHEST W W/O CONTRAST 919.30 0610 RADIOLOGY 72141 MRI SPINE CERVICAL W/O CONTRAST 308.12 0610 RADIOLOGY 72142 MRI CERV SPINE WITHWOUT CONTRAST 485.74 0610 RADIOLOGY 72146 MRI SPINE THORACIC W/O CONTRAST 308.86 0610 RADIOLOGY 72147 MRI THORACIC WITH CONTRAST 481.40 0610 RADIOLOGY 72148 MRI SPINE LUMBAR W/O CONTRAST 308.12 0610 RADIOLOGY 72149 MRI LUMBAR SPINE WITH CONTRAST 477.04 0610 RADIOLOGY 72156 MRI SPINE CERVICAL W W/O CONTRAST 545.20 0610 RADIOLOGY 72157 MRI SPINE THORACIC W W/O CONTRAST 546.64 0610 RADIOLOGY 72158 MRI SPINE LUMBAR W W/O CONTRAST 543.02 0610 RADIOLOGY 72159 MRI SPINE ANGIOGRAPHY 508.94 0610 RADIOLOGY 72195 MRI PELVIS W/O CONTRAST 493.74 0610 RADIOLOGY 72196 MRI PELVIS WITH CONTRAST 535.04 0610 RADIOLOGY 72197 MRI PELVIS W W/O CONTRAST 648.16 0610 RADIOLOGY 73218 MRI UPPER EXTREMITY W/O CONTRAST 494.44 0610 RADIOLOGY 73219 INT MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL 166.32 0610 RADIOLOGY 73219 MRI UPPER EXT. NON JOINT WITH CONTRAST 660.48 0610 RADIOLOGY 73220 MRI UPPER EXTREMITY W W/O CONTRAST 804.76 0610 RADIOLOGY 73221 MRI UPPER EXTREMITY JOINT W/O CONTRAST 347.26 0610 RADIOLOGY 73222 MRI UPPER EXT JOINT WITH CONTRAST 611.18 0610 RADIOLOGY 73223 MRI UPPER EXTREMITY JOINT W W/O CONTRAST 744.58 0610 RADIOLOGY 73718 MRI LOWER EXTREMITIES W/O CONTRAST 490.84 0610 RADIOLOGY 73719 MRI LOWER EXT WITH CONTRAST 508.94 0610 RADIOLOGY 73720 MRI LOWER EXTREMITY W W/O CONTRAST 652.50 0610 RADIOLOGY 73722 INT MRI LOWER EXT JOINT WITH CONTRAST 167.04 0610 RADIOLOGY 73722 MRI LOWER EXT JOINT WITH CONTRAST 616.26 0610 RADIOLOGY 73725 MRA ANGIO LOWER EXTREMITY 638.00 0610 RADIOLOGY 74181 MRI ABDOMINAL ABDW/O CONTRAST 429.20 0610 RADIOLOGY 74182 MRI ABDOMINAL WITH CONTRAST 607.56 Rev. June, 2020

CodeGroup Description Price 0610 RADIOLOGY 74183 MRI ABD W W/O CONTRAST 650.32 0610 RADIOLOGY 77058 MRI BREAST UNILATERAL 919.30 0610 RADIOLOGY 77059 BREAST W W/O CONTRAST 919.30 0619 RADIOLOGY 70544 MRA HEAD WITHOUT CONTRAST 493.72 0619 RADIOLOGY 70545 MRA HEAD WITH CONTRAST 508.94 0619 RADIOLOGY 70546 MRA HEAD W/O & WITH CONTRAST 841.00 0619 RADIOLOGY 70547 MRA NECK WITHOUT CONTRAST 493.72 0619 RADIOLOGY 70548 MRA NECK/CAROTID WITH CONTRAST 508.94 0619 RADIOLOGY 70549 MRA NECK W/O & WITH CONTRAST 846.80 0619 RADIOLOGY 71555 MRA CHEST 635.82 0619 RADIOLOGY 72198 MRA PELVIS 639.46 0619 RADIOLOGY 73225 MRA UPPER EXTREMITY 508.94 0619 RADIOLOGY 74185 MRA ABD C+MATRL 643.80 0710 RECOVERY RECOVERY ROOM 100.00 0722 LABOR ROOM CHARGES FETAL NON STRESS TEST (59025) 90.00 0730 EKG DUPLEX CAROTID 200.00 0730 EKG DUPLEX EXTREMITY VEINS 200.00 0730 EKG DUPLEX LOWER EXTREMITY (93925) 200.00 0730 EKG DUPLEX UPPER EXTREMITY ARTERIAL (93930) 200.00 0730 EKG ECHO 2D M-MODE 100.00 0730 EKG ECHOCARDIOGRAM 200.00 0730 EKG EKG (PRODUCCION E INTERPRETACION) 30.00 0730 EKG EKG MONITOR 25.00 0730 EKG EKG PROD OPD 15.00 0730 EKG EKG PRODUCCION 93005 15.00 0730 EKG ELECTROCARDIOGRAM REPORT 25.00 0730 EKG INTERPRETACION EKG 30.00 0730 EKG ROUTINE INTERPRETATION AND REPORT 30.00 0732 TELEMETRY TELEMETRIA 650.00 Rev. June, 2020

CodeGroup Description Price 0740 ENCEPHALOGRAM 95812 ELECTROENCEPHALOGRAM 663.34 0750 ENDOSCOPY 43235 ENDOSCOPY 485.34 0750 ENDOSCOPY 43260 ERCP DX COLLECTION SPECIMEN BRUSHING/WASHING 683.36 0750 ENDOSCOPY 43261 ERCP W/BIOPSY SINGLE/MULTIPLE 717.92 0750 ENDOSCOPY 43262 ERCP W/SPHINCTEROTOMY/PAPILLOTOMY 756.08 0750 ENDOSCOPY 43263 ERCP W/PRESSURE MEASUREMENT SPHINCTER OF ODDI 756.08 0750 ENDOSCOPY 43264 ERCP REMOVE CALCULI/DEBRIS BILIARY/PANCREAS DUCT 771.20 0750 ENDOSCOPY 43265 ERCP DESTRUCTION/LITHOTRIPSY CALCULI ANY METHOD 916.62 0750 ENDOSCOPY 43266 EGD ENDOSCOPIC STENT PLACEMENT W/WIRE DILATION 461.54 0750 ENDOSCOPY 43270 EGD ABLATE TUMOR POLYP/LESION W/DILATION WIRE 475.30 0750 ENDOSCOPY 43273 ENDOSCOPIC PAPILLA CANNULATION BILE/PANCREATIC 252.68 0750 ENDOSCOPY 43274 ERCP STENT PLACEMENT BILIARY/PANCREATIC DUCT 979.96 0750 ENDOSCOPY 43275 ERCP REMOVE FOREIGN BODY/STENT BILIARY/PANC DUCT 797.82 0750 ENDOSCOPY 43276 ERCP BILIARY/PANC DUCT STENT EXCHANGE W/DILWIRE 1,020.28 0750 ENDOSCOPY 43277 ERCP BALLOON DILATE BILIARY/PANC DUCT/AMPULLA EA 802.14 0750 ENDOSCOPY 43278 ERCP TUMOOR/POLYP/LESION ABLATION W/DILATIONWIRE 917.32 0750 ENDOSCOPY 45330 SIGMOID COLON 100.00 0750 ENDOSCOPY 45378 COLONOSCOPY 100.00 0800 IPD HEMODIALISIS HEMODIALISIS 150.00 0921 SUPPLIES 93880 DUPLEX CAROTID BI/ COMPLETE STUDY 162.00 0921 SUPPLIES 93975 DUP SCAN ABDOMEN, PELVIS, SCROTUM OR RETROPE 190.00 0921 SUPPLIES ART DUPLEX UPPER EXT UNILATERAL 93931 257.40 0921 SUPPLIES ARTERIAL DUPLEX BILATERAL LOWER EXTREMITY (93925) 321.60 0921 SUPPLIES ARTERIAL DUPLEX BILATERAL UPPER EXTR (93930) 240.00 0921 SUPPLIES ARTERIAL DUPLEX UNILATERAL LOWER EXT (93926) 72.36 0921 SUPPLIES DUPLEX CAROTID 162.00 0921 SUPPLIES INT ART DUPLEX UPPER EXT UNILATERAL 93931 257.40 0921 SUPPLIES INT ARTERIAL DUPLEX BILATERAL LOWER EXTREMITY (93 321.60 0921 SUPPLIES INT ARTERIAL DUPLEX BILATERAL UPPER EXTR (93930) 240.00 Rev. June, 2020

CodeGroup Description Price 0921 SUPPLIES INT ARTERIAL DUPLEX UNILATERAL LOWER EXT (93926) 70.00 0921 SUPPLIES INT DUPLEX CAROTID 130.20 0921 SUPPLIES INT VENOUS DUPLEX BILATERAL LOWER / UPPER EXT (93 140.40 0921 SUPPLIES INT VENOUS DUPLEX UNILATERAL LOWER/UPPER E (93971) 86.40 0921 SUPPLIES INT VENOUS DUPLEX UNILATERAL LOWER/UPPER EXTR (93 86.40 0921 SUPPLIES VENOUS DUPLEX BILATERAL LOWER / UPPER EXT (93970) 146.03 0921 SUPPLIES VENOUS DUPLEX UNILATERAL LOWER/UPPER EXTR (93971) 86.40 0999 SUPPLIES CARGO AGENCIA DE COBRO 20.00 0999 SUPPLIES CARGO ANESTESIOLOGO 15.00 15.00 0999 SUPPLIES FACIAL AROMATICO 50 MIN 60.00 0999 SUPPLIES FRISA 20.00 0999 SUPPLIES JABON 2.00 0999 SUPPLIES KIT ADMISIONES 25.00 0999 SUPPLIES KIT PACIENTE BANO 10.00 0999 SUPPLIES MASAJE DRENAJE LINFATICO 50MIN 55.00 0999 SUPPLIES MASAJE LINFATICO 80 MIN 80.00 0999 SUPPLIES MASAJE ORTOPEDICO 25 MIN 30.00 0999 SUPPLIES MASAJE ORTOPEDICO 50 MIN 55.00 0999 SUPPLIES MASAJE PRENATAL 25 MIN 30.00 0999 SUPPLIES MASAJE PRENATAL 50 MIN 55.00 0999 SUPPLIES MASAJE TERAPEUTICO 25 MIN 30.00 0999 SUPPLIES MASAJE TERAPEUTICO 50MIN 55.00 0999 SUPPLIES PASTA DENTAL 2.00 0999 SUPPLIES PRUEBAS ENFERMEDADES HERIDITARIAS 32.00 0999 SUPPLIES REFLEXOLIGIA 25 MIN 30.00 0999 SUPPLIES REFLEXOLOGIA 50MIN 55.00 0999 SUPPLIES TELEFONO 25.00 0999 SUPPLIES TELEVISOR 10.00 0999 SUPPLIES TERAPIA CRANIOSACRAL 50 MIN 55.00 Rev. June, 2020

CodeGroup Description Price

PARA TODOS LOS SERVICIOS (FOR ALL SERVICES)

1. Suplidos, medicamentos y materiales se facturan aparte y de modo individual. (Supplies, pharmacy and materials are billed separately and per unit)

2. Para evitar la facturación privada deberá presentar evidencia de cubierta de plan médico. (To avoid private billing, you must present evidence of medical plan coverage.)