Pricing Transparency 66 North 6th Street Pomeroy Wa, 99347

Pricing Transparency 66 North 6th Street

Pomeroy Wa, 99347

Charge Master Code Description Price HCPCS Code

417040001 IBUPROFEN 200 MG TABLET 100 mg, 100 eaches $5.00

417040002 ACETAMINOPHEN 160MG/5ML ELIXIR $13.40

417040003 ACETAMINOPHEN 325MG SUPP $6.90

417040004 ACETAMINOPHEN 325MG TAB $5.00



417040007 ACETAMINOPHEN/CODEINE 300/30MG TAB $5.00

417040008 ACETYLCYSTEINE 20% 6GM/30ML VIAL $99.45 J7608

417040009 ACTIVATED CHARCOAL 25GM $94.60

417040010 ADENOSINE 6MG VIAL $16.80 J0150

417040011 ALBUTEROL 2.5MG/3ML NEB SOLN $5.00

417040012 ALBUTEROL INHALER 90MCG $105.30

417040013 ALLOPURINOL 100MG TAB $5.00

417040014 ALPRAZOLAM 0.25MG TAB $5.00

417040015 AMIODARONE 200MG TAB $5.00

417040016 AMITRIPTYLLINE 25MG TAB $5.00

417040017 AMLODIPINE 5MG TAB $5.00

417040018 AMOXICILLIN 250MG CAP $5.00


417040020 AMOXICILLIN 250MG/5ML SUSP 80ML $32.50

417040021 AMOXICILLIN/CLAVULANATE 500/125MG TAB $5.80


417040023 AMOXICILLIN/CLAVULANATE 250MG-62.5MG/5ML SUSP 75ML $153.50

417040024 AMPICILLIN/SULBACTAM 1.5GM VIAL $43.20 J0295

417040025 APIXABAN 2.5MG TAB $44.40

417040026 ARTIFICIAL TEARS $30.50

417040028 ASCORBIC ACID 500MG TAB $5.00

417040029 ASPIRIN 81MG CHEWABLE TAB $5.00

417040030 ASPIRIN ENTERIC COATED 325MG TAB $5.00

417040032 ATENOLOL 25MG TAB $5.00

417040033 ATORVASTATIN 10MG TAB $6.10



417040036 ATROPINE 0.4MG VIAL $46.25 J0461

417040037 ATROPINE 1MG VIAL $71.25 J0461

417040039 AZATHIOPRINE 50MG TAB $10.90

417040040 AZITHROMYCIN 250MG TAB $25.85

417040041 AZITHROMYCIN 500MG VIAL $47.00 J0456

417040042 AZITHROMYCIN 100MG/5ML SUSP 15ML $142.00

417040043 BACLOFEN 10MG TAB $8.00

417040044 BENZONATATE 100MG CAP $8.00

417040045 BETAMETHASONE 6MG VIAL $187.90 J0702

417040046 BISACODYL 10MG SUPPOSITORY $5.00

417040047 BISACODYL 5MG TAB $5.00

417040048 BISOPROLOL FUMARATE 5MG TAB $14.65

417040049 BUDESONIDE 0.5MG/2ML INHALATION SOLUTION $58.30 J7627

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Pomeroy Wa, 99347

417040050 BUPIVACAINE 0.5% 10ML VIAL $20.50

417040051 BUPROPION SR 150MG TAB $9.80

417040052 BUSPIRONE 10MG TAB $10.20

417040053 CALCIUM CARBONATE 500MG CHEWABLE TAB $5.00

417040054 CALCIUM CARBONATE WITH VITAMIN D 600/400MG TAB $5.00

417040055 CALCIUM CHLORIDE 10% SYRINGE $43.20

417040056 CALCIUM GLUCONATE 10% VIAL 10ML $57.30 J0610

417040057 CALCIUM POLYCARBOPHIL 625MG TAB $5.00

417040058 CARBIDOPA/LEVODOPA 25/100MG TAB $8.40

417040059 CARVEDILOL 6.25MG TAB $5.00


417040061 CEFAZOLIN 1G VIAL $12.50 J0690

417040062 CEFDINIR 250MG/5ML SUSP 60ML $212.50

417040063 CEFEPIME 2G VIAL $62.50 J0692

417040064 CEFTRIAXONE 1G VIAL $18.70 J0696

417040066 CEFUROXIME 500MG TAB $42.50

417040067 CEPHALEXIN 500MG CAP $13.50

417040068 CEPHALEXIN 250MG/5ML SUSP 100ML $117.50

417040069 CETIRIZINE 10MG TAB $20.50

417040070 CHOLECALCIFEROL 1000 UNIT TAB $5.00



417040073 CIPROFLOXACIN 400MG/200ML PREMIXED BAG $27.30 J0744

417040074 CIPROFLOXACIN 500MG TAB $26.50

417040075 CIPROFLOXACIN WITH HYDROCORTISONE OTIC DROPS 10ML $538.90

417040076 CITALOPRAM 10MG TAB $7.40


417040078 CLINDAMYCIN 150MG CAP $9.80

417040079 CLINDAMYCIN 600MG/4ML VIAL $30.50 S0077

417040080 CLONAZEPAM 0.5MG TAB $10.50

417040081 CLONIDINE 0.1MG TAB $5.00

417040082 CLOPIDOGREL 75MG TAB $16.90

417040083 CLOTRIMAZOLE CREAM 1% $57.50

417040084 COLCHICINE 0.6MG TAB $36.15

417040085 CYANOCOBALAMIN 1000MCG / ML VIAL $44.00 J3420

417040086 CYANOCOBALAMIN 1000MCG TAB $5.00

417040087 CYCLOBENZAPRINE 10MG TAB $7.80

417040088 CYCLOPENTOLATE OPTHALMIC SOLUTION $76.35

417040091 DANTROLENE 20MG VIAL $212.50

417040092 DAPTOMYCIN 500MG VIAL $326.50 J0878

417040093 DEXAMETHASONE ELIXIR 0.5MG/5ML $-

417040094 DEXAMETHASONE 10MG VIAL $34.00 J1100

417040095 DEXTROSE 50% 25GM SYRINGE $50.50

417040096 DIAZEPAM 5MG TAB $5.70

417040097 DIAZEPAM 5MG/ML 2ML CARPUJECT $133.75 J3360

417040098 DIGOXIN 0.125MG TAB $17.60

417040099 DIGOXIN 0.5MG AMPULE $86.75 J1160

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Pomeroy Wa, 99347

417040100 DILTIAZEM 25MG/5ML VIAL $-

417040101 DILTIAZEM 60MG TAB $5.00

417040102 DILTIAZEM CD 120MG CAP $6.60


417040104 DIPHENHYDRAMINE 25MG CAP $5.00

417040105 DIPHENHYDRAMINE 50MG VIAL $12.50 J1200

417040108 DONEPEZIL 10MG TAB $5.00

417040109 DOPAMINE 400MG/250ML PREMIX BAG $80.20 J1265

417040110 DOXAZOSIN 2MG CAP $12.20

417040111 DOXYCYCLINE 100MG VIAL $97.40

417040112 DOXYCYCLINE HYCLATE 100MG TAB $5.80

417040113 DULOXETINE 30MG CAP $32.50

417040114 ENOXAPARIN SODIUM 100MG/1ML SYRINGE $62.70 J1650

417040115 ENOXAPARIN SODIUM 40MG/0.4ML SYRINGE $50.10 J1650



417040118 EPINEPHRINE 1MG SYRINGE $35.80 J0171

417040119 EPINEPHRINE 1MG VIAL $92.25 J0171

417040120 EPINEPHRINE PEN 0.3MG $550.00 J0171

417040121 EPOETIN ALFA 3,000 UNIT VIAL $212.50 J0885


417040123 ERTAPENEM 1G VIAL $302.50 J1335

417040124 ETOMIDATE 20MG VIAL $39.80

417040125 FAMOTIDINE 20MG TAB $18.00

417040126 FAMOTIDINE 20MG/2ML VIAL $12.50 S0028

417040127 FENTANYL 100MCG/2ML VIAL $19.80 J3010

417040128 FENTANYL 25MCG PATCH $102.50


417040130 FERROUS GLUCONATE 324MG TAB $5.00

417040131 FERROUS SULFATE 325MG TAB $5.00

417040132 FINASTERIDE 5MG TAB $26.50

417040133 FISH OIL 1000MG CAP $5.00

417040134 FLUCONAZOLE 100MG TAB $46.30

417040135 FLUMAZENIL 0.5MG/5ML VIAL $43.10

417040136 FLUOXETINE 20MG CAP $5.00

417040137 FLUTICASONE PROPIONATE 50MCG NASAL SPRAY $212.50

417040138 FOLIC ACID 1MG TAB $5.00

417040139 FUROSEMIDE 20MG TAB $5.00

417040140 FUROSEMIDE 20MG/2ML VAIL $25.40 J1940

417040141 FUROSEMIDE 40MG/4ML VIAL $28.90 J1940


417040143 GABAPENTIN 100MG CAP $5.00



417040146 GENTAMICIN 0.3% OPTHALMIC OINTMENT $144.25

417040147 GLIPIZIDE 5MG TAB $6.50

417040148 GLIPIZIDE XL 5MG TAB $9.70

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Pomeroy Wa, 99347

417040149 GLUCAGON 1MG $491.10

417040150 GLYCERIN SUPPOSITORY $5.00

417040151 GUAIFENESIN 600MG EXTENDED RELEASE TAB $5.00

417040152 GUAIFENESIN AND CODEINE 100MG/10MG PER 5ML $-

417040153 HALOPERIDOL 5MG/ML VIAL $38.30

417040154 HEPARIN SODIUM 25,000 UNITS/500ML PREMIX $40.40 J1644

417040155 HEPARIN SODIUM 5000 UNITS VIAL $26.50 J1644

417040156 HYDROCHLOROTHIAZIDE 25MG TAB $5.00

417040157 HYDROCODONE / APAP 10/325MG TAB $13.40


417040159 HYDROCODONE / APAP 7.5/325MG TAB $11.30

417040160 HYDROMORPHONE 2MG CARPUJECT $26.50 J1170

417040161 HYDROMORPHONE 2MG TAB $5.00

417040162 HYDROXYCHLOROQUINE 200MG TAB $25.15

417040163 HYDROXYUREA 500MG CAP $11.30

417040164 HYDROXYZINE HCL 25MG TAB $5.00

417040165 IBUPROFEN 100MG/5ML ELIXIR $11.20

417040166 IBUPROFEN 200MG TAB $5.00

417040167 INFLIXIMAB 100MG VIAL $2,104.00 J1745

417040168 INSULIN GLARGINE 100U/ML 3ML PEN $212.50

417040169 INSULIN HUMAN R 100U/ML 3ML VIAL $163.10

417040170 INSULIN LISPRO 100U/ML 3ML PEN $256.50

417040171 IPRATROPIUM 0.5MG/2.5ML NEBULIZATION SOLUTION $14.35

417040172 IPRATROPIUM/ALBUTEROL 0.5/2.5MG NEB SOL $20.50

417040173 IRON POLYSACCHARIDE 150MG CAP $5.00

417040174 IRON SUCROSE 100MG/5ML VIAL $182.50 J1756

417040175 KETOROLAC 30MG VIAL $12.50 J1885


417040177 LABETALOL 100MG/20ML VIAL $30.50

417040179 LACTOBACILLUS ACIDOPHILLUS CAP $5.00

417040180 LACTULOSE 10GM/15ML SOLUTION $26.35

417040181 LEVOFLOXACIN 500MG TAB $9.20

417040182 LEVOFLOXACIN 500MG/100ML PREMIX BAG $38.50 J1956



417040185 LEVONORGESTREL 1.5MG TAB $158.50

417040186 LEVOTHYROXINE 100MCG TAB $8.10




417040190 LIDOCAINE 1% 20ML VIAL $27.30

417040191 LIDOCAINE 1% WITH EPINEPHRINE VIAL $15.90

417040192 LIDOCAINE VISCOUS 2% 15ML UDC $12.50



417040196 LIDOCAINE 2GM/500ML PREMIX BAG $47.00 J2001

417040197 LIDOCAINE 5% PATCH $53.80

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Pomeroy Wa, 99347

417040198 LIDOCAINE-PRILOCAINE 2.5%-2% CREAM $42.50

417040199 LINEZOLID 600MG/300ML PREMIX BAG $212.50 J2020

417040200 LISINOPRIL 10MG TAB $13.55


417040202 LOPERAMIDE 2MG CAP $11.20

417040203 LORATADINE 10MG TAB $5.00

417040204 LORAZEPAM 0.5MG TAB $5.00

417040205 LORAZEPAM 1MG TAB $5.00

417040206 LORAZEPAM 2MG/ML CARPUJECT $8.70 J2060

417040207 LOSARTAN 25MG TAB $17.50

417040208 LOSARTAN 50MG TAB $20.50

417040209 MAG-AL-PLUS $24.75

417040211 MAGNESIUM OXIDE 400MG TAB $5.00

417040212 MAGNESIUM SULFATE 1GM/2ML VIAL $19.60 J3475

417040213 MECLIZINE 12.5MG TAB $5.00

417040214 MEGESTROL ACETATE 40MG/ML 10ML SUSP $30.50 S0179

417040215 MELATONIN 5MG TAB $5.00

417040216 METFORMIN 500MG TAB $5.00

417040217 METHADONE 10MG TAB $5.90

417040219 METHOCARBAMOL 1GM/10ML VIAL $140.90 J2800

417040220 METHOCARBAMOL 500MG TAB $6.70


417040222 METHYLPREDNISOLONE 125MG VIAL $60.60 J2930

417040223 METOCLOPRAMIDE 5MG TAB $5.00


417040225 METOCLOPRAMIDE 10MG/2ML VIAL $26.50 J2765

417040226 METOLAZONE 2.5MG TAB $26.50

417040227 METOLAZONE 5MG TAB $28.95

417040228 METOPROLOL TARTRATE 25MG TAB $5.00



417040231 METOPROLOL SUCCINATE 25MG TAB $12.50


417040233 METRONIDAZOLE 250MG TAB $9.20


417040236 METRONIDAZOLE 500MG/100ML PREMIX BAG $21.25 S0030

417040237 MIDAZOLAM 5MG/1ML VIAL $16.00 J2250

417040238 MILK OF MAGNESIA 30ML UDC $21.20

417040239 MINERAL OIL ENEMA $20.50

417040240 MINOCYCLINE 100MG CAP $14.35

417040241 MIRTAZAPINE 15MG TAB $26.50

417040242 MORPHINE SULFATE 15MG EXTENDED RELEASE TABS $19.15


417040244 MORPHINE 4MG/ML CARPUJECT $20.50 J2270

417040246 MULTIVITAMIN W/MINERAL TAB $5.00

417040247 NALOXONE 2MG/2ML SYRINGE $160.00 J2310

417040248 NAPROXEN 500MG TAB $5.00

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Pomeroy Wa, 99347

417040249 NICOTINE 14MG PATCH $20.50


417040251 NITROFURANTOIN 100MG CAP $26.50

417040252 NITROGLYCERIN 0.4MG SL TAB $12.50

417040253 NITROGLYCERIN SUBLINGUAL SPRAY $338.50

417040254 NITROGLYCERIN 50MG/250ML BOTTLE $102.50

417040258 NYSTATIN ORAL SUSP 500,000 UNITS/5ML $13.05

417040259 OLANZAPINE 5MG TAB $19.95

417040260 OMEPRAZOLE 20MG CAP $26.50

417040261 ONDANSETRON ODT 4MG TAB $6.00

417040262 ONDANSETRON 4MG VIAL $8.00 J2405

417040263 OSELTAMIVIR 30MG CAP $38.50



417040266 OXYBUTYNIN ER 5MG TAB $19.15

417040267 OXYCODONE 5MG TAB $6.10

417040268 OXYCODONE-APAP 5/325MG TAB $6.10

417040269 OXYCONTIN 10MG TAB $30.50


417040271 OXYMETAZOLINE 0.05% NASAL SOLN $30.40

417040272 PANTOPRAZOLE 40MG TAB $7.00

417040273 PANTOPRAZOLE 40MG VIAL $32.50 S0164

417040274 PAROXETINE 20MG TAB $24.25

417040275 PENICILLIN VK 250MG TAB $12.85

417040276 PENICILLIN 250MG/5ML SUSP 100ML $53.70

417040277 PHENAZOPYRIDINE 100MG TAB $5.00

417040278 PHENOBARBITAL, HYOSCYAMINE, ATROPINE, SCOPALAMINE $162.50

417040279 PHENYTOIN 100MG CAP $9.80

417040280 PHENYTOIN 100MG/2ML VIAL $16.10 J1165

417040281 PHYTONADIONE 10MG AMPULE $130.50 J3430

417040282 PIPRACILLIN/TAZOBACTAM 3.375GM VIAL $94.80 J2543

417040283 POLYETHYLENE GLYCOL 17GM PACKET $24.75

417040284 POTASSIUM CHLORIDE 10MEQ $11.00


417040286 POTASSIUM CHLORIDE 20MEQ VIAL $27.45 J3480

417040287 PREDNISONE 5MG TAB $5.00 J7506



417040290 PREDNISONE 5MG/5ML ORAL SOLUTION $30.50

417040291 PREDNISOLONE 15MG/5ML SYRUP $16.45 J7510

417040292 PREGABALIN 100MG CAP $47.05


417040294 PROBIOTIC CAP $5.00

417040295 PROMETHAZINE 25MG TAB $5.00

417040296 PROMETHAZINE 25MG SUPP $91.00

417040297 PROMETHAZINE 25MG/ML VIAL $29.45 J2550

417040298 PROPRANOLOL 10MG TAB $5.00

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Pomeroy Wa, 99347

417040299 PSYLLIUM FIBER PACKET $5.50

417040300 QUETIAPINE 25MG TAB $6.00

417040301 RACEMIC EPINEPHRINE 2.25% NEB SOL $12.50

417040302 RIFAMPIN 300MG CAP $14.35

417040303 RIVAROXABAN 10MG TAB $32.50


417040305 RIZATRIPTAN 5MG TAB $20.50

417040306 SALINE ENEMA $5.00

417040307 SCOPALAMINE PATCH 1.5MG $102.50

417040308 SENNA 8.6MG TAB $5.00

417040309 SERTRALINE 50MG TAB $6.50


417040311 SILVER ANTIMICROBIAL WOUND GEL (SILVASORB) $124.75

417040312 SILVER SULFADIAZINE 1% CREAM $47.20

417040313 SIMETHICONE 80MG CHEW TAB $5.00


417040315 SIMVASTATIN 10MG TAB $10.40



417040320 SODIUM CHLORIDE 1GM TAB $5.00

417040321 SODIUM POLYSTYRENE SULFONATE $58.75

417040322 SPIRONOLACTONE 25MG TAB $5.00


417040324 SUCCINYLCHOLINE 200MG/10ML VIAL $102.50 J0330

417040325 SUCRALFATE 1GM TAB $5.80

417040326 SULFACETAMIDE SODIUM 10% OPTH SOL $185.50

417040327 SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160MG TAB $18.95

417040328 SUMATRIPTAN 6MG/0.5ML VIAL $212.50 J3030

417040329 TAMSULOSIN 4MG CAP $7.20

417040330 TENECTEPLASE 50MG VIAL $10,553.85 J3101

417040331 TERAZOSIN 2MG CAP $15.45

417040332 TETANUS, DIPTHERIA, PERTUSSIS (TDAP) $162.50

417040333 TETRACAINE 0.5% 4ML OPTHALMIC DROPS $63.85

417040334 THIAMINE 200MG/2ML VIAL $64.65 J3411

417040335 TIOTROPIUM 18MCG INHALER $212.50

417040336 TRAMADOL 50MG TAB $11.20

417040337 TRAZODONE 50MG TAB $6.80

417040338 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL $58.65 J3301

417040339 VALPROATE SODIUM 500MG/5ML VIAL $102.50

417040340 VANCOMYCIN 500MG VIAL $50.70 J3370

417040341 VANCOMYCIN 1GM VIAL $38.40 J3370

417040342 VERAPAMIL ER 240MG TAB $22.75

417040343 WARFARIN 1MG TAB $8.60


417040345 WARFARIN 2.5MG TAB $8.70


417040347 ZOLPIDEM 5MG TAB $5.00

7 5/3/2019


Pomeroy Wa, 99347

417040086 CYANOCOBALAMIN 1000MCG TAB $5.00


417040124 ETOMIDATE 20MG VIAL $39.80

417040339 VALPROATE SODIUM 500MG/5ML VIAL $102.50

417040177 LABETALOL 100MG/20ML VIAL $30.50


417040114 ENOXAPARIN SODIUM 100MG/1ML SYRINGE $62.70 J1650

417040164 HYDROXYZINE HCL 25MG TAB $5.00

417040120 EPINEPHRINE PEN 0.3MG $550.00 J0171


417040118 EPINEPHRINE 1MG SYRINGE $35.80 J0171

417040251 NITROFURANTOIN 100MG CAP $26.50

417040174 IRON SUCROSE 100MG/5ML VIAL $182.50 J1756

417040211 MAGNESIUM OXIDE 400MG TAB $5.00

417040007 ACETAMINOPHEN/CODEINE 300/30MG TAB $5.00


417040100 DILTIAZEM 25MG/5ML VIAL $-



417040342 VERAPAMIL ER 240MG TAB $22.75



417040091 DANTROLENE 20MG VIAL $212.50

417040209 MAG-AL-PLUS $24.75

417040040 AZITHROMYCIN 250MG TAB $25.85

417040280 PHENYTOIN 100MG/2ML VIAL $16.10 J1165

417040345 WARFARIN 2.5MG TAB $8.70

417040014 ALPRAZOLAM 0.25MG TAB $5.00

417040305 RIZATRIPTAN 5MG TAB $20.50


417040037 ATROPINE 1MG VIAL $71.25 J0461

417040043 BACLOFEN 10MG TAB $8.00


417040149 GLUCAGON 1MG $491.10

417040312 SILVER SULFADIAZINE 1% CREAM $47.20

417040127 FENTANYL 100MCG/2ML VIAL $19.80 J3010


417040084 COLCHICINE 0.6MG TAB $36.15

417040125 FAMOTIDINE 20MG TAB $18.00

417040165 IBUPROFEN 100MG/5ML ELIXIR $11.20

417040268 OXYCODONE-APAP 5/325MG TAB $6.10


417040081 CLONIDINE 0.1MG TAB $5.00

417040082 CLOPIDOGREL 75MG TAB $16.90

417040253 NITROGLYCERIN SUBLINGUAL SPRAY $338.50

417040066 CEFUROXIME 500MG TAB $42.50


8 5/3/2019


Pomeroy Wa, 99347

417040347 ZOLPIDEM 5MG TAB $5.00

417040327 SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160MG TAB $18.95


417040262 ONDANSETRON 4MG VIAL $8.00 J2405

417040279 PHENYTOIN 100MG CAP $9.80


417040061 CEFAZOLIN 1G VIAL $12.50 J0690


417040101 DILTIAZEM 60MG TAB $5.00

417040330 TENECTEPLASE 50MG VIAL $10,553.85 J3101


417040215 MELATONIN 5MG TAB $5.00

417040153 HALOPERIDOL 5MG/ML VIAL $38.30


417040258 NYSTATIN ORAL SUSP 500,000 UNITS/5ML $13.05

417040225 METOCLOPRAMIDE 10MG/2ML VIAL $26.50 J2765

417040123 ERTAPENEM 1G VIAL $302.50 J1335

417040150 GLYCERIN SUPPOSITORY $5.00

417040241 MIRTAZAPINE 15MG TAB $26.50


417040260 OMEPRAZOLE 20MG CAP $26.50

417040074 CIPROFLOXACIN 500MG TAB $26.50

417040163 HYDROXYUREA 500MG CAP $11.30

417040208 LOSARTAN 50MG TAB $20.50

417040036 ATROPINE 0.4MG VIAL $46.25 J0461





417040321 SODIUM POLYSTYRENE SULFONATE $58.75


417040094 DEXAMETHASONE 10MG VIAL $34.00 J1100



417040067 CEPHALEXIN 500MG CAP $13.50

417040335 TIOTROPIUM 18MCG INHALER $212.50

417040097 DIAZEPAM 5MG/ML 2ML CARPUJECT $133.75 J3360


417040212 MAGNESIUM SULFATE 1GM/2ML VIAL $19.60 J3475

417040140 FUROSEMIDE 20MG/2ML VAIL $25.40 J1940


417040085 CYANOCOBALAMIN 1000MCG / ML VIAL $44.00 J3420

417040108 DONEPEZIL 10MG TAB $5.00


417040013 ALLOPURINOL 100MG TAB $5.00

417040025 APIXABAN 2.5MG TAB $44.40

417040054 CALCIUM CARBONATE WITH VITAMIN D 600/400MG TAB $5.00

9 5/3/2019


Pomeroy Wa, 99347


417040008 ACETYLCYSTEINE 20% 6GM/30ML VIAL $99.45 J7608

417040080 CLONAZEPAM 0.5MG TAB $10.50


417040130 FERROUS GLUCONATE 324MG TAB $5.00


417040307 SCOPALAMINE PATCH 1.5MG $102.50

417040276 PENICILLIN 250MG/5ML SUSP 100ML $53.70

417040112 DOXYCYCLINE HYCLATE 100MG TAB $5.80

417040266 OXYBUTYNIN ER 5MG TAB $19.15

417040247 NALOXONE 2MG/2ML SYRINGE $160.00 J2310


417040062 CEFDINIR 250MG/5ML SUSP 60ML $212.50



417040202 LOPERAMIDE 2MG CAP $11.20

417040015 AMIODARONE 200MG TAB $5.00

417040326 SULFACETAMIDE SODIUM 10% OPTH SOL $185.50

417040298 PROPRANOLOL 10MG TAB $5.00

417040126 FAMOTIDINE 20MG/2ML VIAL $12.50 S0028

417040302 RIFAMPIN 300MG CAP $14.35

417040286 POTASSIUM CHLORIDE 20MEQ VIAL $27.45 J3480

417040259 OLANZAPINE 5MG TAB $19.95

417040199 LINEZOLID 600MG/300ML PREMIX BAG $212.50 J2020

417040135 FLUMAZENIL 0.5MG/5ML VIAL $43.10


417040282 PIPRACILLIN/TAZOBACTAM 3.375GM VIAL $94.80 J2543

417040296 PROMETHAZINE 25MG SUPP $91.00

417040050 BUPIVACAINE 0.5% 10ML VIAL $20.50

417040131 FERROUS SULFATE 325MG TAB $5.00





417040275 PENICILLIN VK 250MG TAB $12.85


417040239 MINERAL OIL ENEMA $20.50

417040301 RACEMIC EPINEPHRINE 2.25% NEB SOL $12.50

417040111 DOXYCYCLINE 100MG VIAL $97.40

417040016 AMITRIPTYLLINE 25MG TAB $5.00

417040146 GENTAMICIN 0.3% OPTHALMIC OINTMENT $144.25

417040044 BENZONATATE 100MG CAP $8.00

417040046 BISACODYL 10MG SUPPOSITORY $5.00

417040012 ALBUTEROL INHALER 90MCG $105.30

417040147 GLIPIZIDE 5MG TAB $6.50

417040261 ONDANSETRON ODT 4MG TAB $6.00

417040042 AZITHROMYCIN 100MG/5ML SUSP 15ML $142.00

10 5/3/2019


Pomeroy Wa, 99347

417040333 TETRACAINE 0.5% 4ML OPTHALMIC DROPS $63.85

417040026 ARTIFICIAL TEARS $30.50


417040192 LIDOCAINE VISCOUS 2% 15ML UDC $12.50

417040053 CALCIUM CARBONATE 500MG CHEWABLE TAB $5.00



417040088 CYCLOPENTOLATE OPTHALMIC SOLUTION $76.35

417040216 METFORMIN 500MG TAB $5.00

417040141 FUROSEMIDE 40MG/4ML VIAL $28.90 J1940

417040105 DIPHENHYDRAMINE 50MG VIAL $12.50 J1200



417040325 SUCRALFATE 1GM TAB $5.80

417040138 FOLIC ACID 1MG TAB $5.00

417040185 LEVONORGESTREL 1.5MG TAB $158.50

417040134 FLUCONAZOLE 100MG TAB $46.30


417040063 CEFEPIME 2G VIAL $62.50 J0692


417040162 HYDROXYCHLOROQUINE 200MG TAB $25.15

417040340 VANCOMYCIN 500MG VIAL $50.70 J3370


417040051 BUPROPION SR 150MG TAB $9.80

417040246 MULTIVITAMIN W/MINERAL TAB $5.00

417040104 DIPHENHYDRAMINE 25MG CAP $5.00

417040156 HYDROCHLOROTHIAZIDE 25MG TAB $5.00

417040078 CLINDAMYCIN 150MG CAP $9.80



417040068 CEPHALEXIN 250MG/5ML SUSP 100ML $117.50

417040057 CALCIUM POLYCARBOPHIL 625MG TAB $5.00

417040336 TRAMADOL 50MG TAB $11.20

417040113 DULOXETINE 30MG CAP $32.50




417040039 AZATHIOPRINE 50MG TAB $10.90


417040020 AMOXICILLIN 250MG/5ML SUSP 80ML $32.50

417040329 TAMSULOSIN 4MG CAP $7.20


417040110 DOXAZOSIN 2MG CAP $12.20

417040299 PSYLLIUM FIBER PACKET $5.50

417040098 DIGOXIN 0.125MG TAB $17.60


417040092 DAPTOMYCIN 500MG VIAL $326.50 J0878

11 5/3/2019


Pomeroy Wa, 99347

417040334 THIAMINE 200MG/2ML VIAL $64.65 J3411

417040300 QUETIAPINE 25MG TAB $6.00


417040283 POLYETHYLENE GLYCOL 17GM PACKET $24.75

417040308 SENNA 8.6MG TAB $5.00


417040297 PROMETHAZINE 25MG/ML VIAL $29.45 J2550

417040267 OXYCODONE 5MG TAB $6.10


417040032 ATENOLOL 25MG TAB $5.00


417040222 METHYLPREDNISOLONE 125MG VIAL $60.60 J2930

417040009 ACTIVATED CHARCOAL 25GM $94.60

417040132 FINASTERIDE 5MG TAB $26.50


417040159 HYDROCODONE / APAP 7.5/325MG TAB $11.30

417040041 AZITHROMYCIN 500MG VIAL $47.00 J0456

417040095 DEXTROSE 50% 25GM SYRINGE $50.50

417040167 INFLIXIMAB 100MG VIAL $2,104.00 J1745

417040338 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL $58.65 J3301

417040341 VANCOMYCIN 1GM VIAL $38.40 J3370

417040096 DIAZEPAM 5MG TAB $5.70

417040274 PAROXETINE 20MG TAB $24.25




417040273 PANTOPRAZOLE 40MG VIAL $32.50 S0164

417040079 CLINDAMYCIN 600MG/4ML VIAL $30.50 S0077

417040324 SUCCINYLCHOLINE 200MG/10ML VIAL $102.50 J0330

417040047 BISACODYL 5MG TAB $5.00

417040281 PHYTONADIONE 10MG AMPULE $130.50 J3430

417040196 LIDOCAINE 2GM/500ML PREMIX BAG $47.00 J2001

417040311 SILVER ANTIMICROBIAL WOUND GEL (SILVASORB) $124.75

417040002 ACETAMINOPHEN 160MG/5ML ELIXIR $13.40



417040166 IBUPROFEN 200MG TAB $5.00

417040048 BISOPROLOL FUMARATE 5MG TAB $14.65

417040328 SUMATRIPTAN 6MG/0.5ML VIAL $212.50 J3030

417040023 AMOXICILLIN/CLAVULANATE 250MG-62.5MG/5ML SUSP 75ML $153.50

417040119 EPINEPHRINE 1MG VIAL $92.25 J0171


417040238 MILK OF MAGNESIA 30ML UDC $21.20

417040069 CETIRIZINE 10MG TAB $20.50

417040252 NITROGLYCERIN 0.4MG SL TAB $12.50

417040099 DIGOXIN 0.5MG AMPULE $86.75 J1160

417040052 BUSPIRONE 10MG TAB $10.20

12 5/3/2019


Pomeroy Wa, 99347

417040155 HEPARIN SODIUM 5000 UNITS VIAL $26.50 J1644

417040197 LIDOCAINE 5% PATCH $53.80



417040240 MINOCYCLINE 100MG CAP $14.35

417040137 FLUTICASONE PROPIONATE 50MCG NASAL SPRAY $212.50

417040087 CYCLOBENZAPRINE 10MG TAB $7.80

417040207 LOSARTAN 25MG TAB $17.50

417040337 TRAZODONE 50MG TAB $6.80

417040271 OXYMETAZOLINE 0.05% NASAL SOLN $30.40

417040011 ALBUTEROL 2.5MG/3ML NEB SOLN $10.50

417040017 AMLODIPINE 5MG TAB $18.07



417040049 BUDESONIDE 0.5MG/2ML INHALATION SOLUTION $58.30 J7627

417040055 CALCIUM CHLORIDE 10% 1 GM SYRINGE $43.20

417040056 CALCIUM GLUCONATE 10% 1GM VIAL $57.30 J0610

417040083 CLOTRIMAZOLE CREAM 1% 30GM $57.50

417040073 CIPROFLOXACIN 400MG/200ML PREMIXED BAG $27.30 J0744

417040173 IRON POLYSACCHARIDE 150MG CAP $5.20

417040306 SALINE ENEMA $12.95

417040136 FLUOXETINE 20MG CAP $10.20



417040154 HEPARIN SODIUM 25,000 UNITS/500ML PREMIX $40.40 J1644

417040170 INSULIN LISPRO 100U/ML 3ML PEN $256.50

417040161 HYDROMORPHONE 2MG TAB $9.60

417040172 IPRATROPIUM/ALBUTEROL 0.5/2.5MG NEB SOL $20.50

417040171 IPRATROPIUM 0.5MG/2.5ML NEBULIZATION SOLUTION $14.35

417040180 LACTULOSE 10GM/15ML SOLUTION $26.35

417040168 INSULIN GLARGINE 100U/ML 3ML PEN $212.50



417040198 LIDOCAINE-PRILOCAINE 2.5%-2% CREAM $42.50

417040203 LORATADINE 10MG TAB $9.40

417040204 LORAZEPAM 0.5MG TAB $9.40

417040214 MEGESTROL ACETATE 40MG/ML 10ML SUSP $30.50 S0179

417040236 METRONIDAZOLE 500MG/100ML PREMIX BAG $21.25 S0030

417040151 GUAIFENESIN 600MG EXTENDED RELEASE TAB $12.50

417040248 NAPROXEN 500MG TAB $13.50

417040254 NITROGLYCERIN 50MG/250ML BOTTLE $102.50

417040133 FISH OIL 1000MG CAP $27.95

417040272 PANTOPRAZOLE 40MG TAB $30.50

417040277 PHENAZOPYRIDINE 100MG TAB $21.70

417040295 PROMETHAZINE 25MG TAB $12.00

417040219 METHOCARBAMOL 1GM/10ML VIAL $140.90 J2800


13 5/3/2019


Pomeroy Wa, 99347

417040029 ASPIRIN 81MG CHEWABLE TAB $5.00

417040038 ATROPINE 1MG / 10ML SYRINGE $35.20 J0461


417040193 LIDOCAINE 2% 100MG/5ML SYRINGE $29.60


417040318 SODIUM BICARBONATE 650MG TAB $5.00

417040319 SODIUM BICARBONATE 50MEQ SYRINGE $65.85

417040349 VESICARE 10 MG TABLET $75.25

417040348 TERAZOSIN 1 MG CAPSULE $15.45

417040351 CARBIDOPA-LEVO ER 50-200 TAB $16.70

417040352 RESTASIS 0.05% EYE EMULSION 0.05 ea, 30 eaches $460.89

417040106 DIVALPROEX 250MG CAP $14.65

40720396 L-IGM TITER $102.00 86788

40720047 L-LAB SPEC CHEM-LITHIUM $81.00 80178

40720329 L-CRP HIGH SENSITIVITY $119.00 86141

438220153 CL-IV INFUSION THERAP EACH ADD HOUR $76.00 96366

438220214 CL-NEW PATIENT 65 + YEARS $314.00 99387

438220008 CL-TRIM SKIN LESION, SINGLE LESION $186.00 11055

40720210 L-NATRIURETIC PEPTIDE $418.00 83880

438220007 CL-DEBRIDMENT SKIN/SUBCUTANOUS TISSUE $389.00 11042

307010030 A-WOUND VAC < 50 CM $246.00 97605

307010007 A-EXC B9 LES 2.1-3.0CM $710.00 11403

40720446 L-HEPC INFECT AGENT QUANTIF $251.00 87522

40720039 L-VALPROIC TOTAL ACID $163.00 80164

40720031 L-SCREENING FOR METHADONE $163.00 80358

40720434 L-GIARDIA $161.00 87329

40720493 L-IRON DEXTRAN 100MG/2ML $116.00 J1750

40720424 L-GRAM STAIN $74.00 87205

40720462 L-CYOPATHOLOGY $197.00 88112

405120011 CS-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

40720425 L-SMEAR FLORECENT ACID STA $87.00 87206

40720057 L-LAB SPEC CHEM-THEOPHYLINE $154.00 80198

438220146 CL-NEBULIZER TREATMENT $233.00 94640

405120026 CS-WALKING BOOT $141.00 L4361

40720239 L-PREGNANEDIOL $172.00 84135

438220174 CL-NEW PT LEVEL 5 $450.00 99205

40720451 L-MRSA SCREEN-PCR $157.00 87641

40720384 L-HEP B SURFACE ANTIBODY $127.00 86706

438220206 CL-TM CONF. W/O PT NON PHYS. $68.00 99368

40720241 L-PROLACTIN LEVEL $243.00 84146

40720140 L-LAB PROFILE-CARDIAC CKMB- MB FRATION ONLY $226.00 82553

40720337 L-ANIT N DNA $123.00 86225

40720167 L-GLUCOSE REAGENT STRIP $7.00 82948

40720420 L-LAB STOOL-OVA & PARASITES $37.00 87177

40720108 L-DIRECT BILIRUBIN $16.00 82248

438220179 CL-EST PT LEVEL 4 $175.00 99214

40720306 L-BLOOD CLOT FACTOR VIII $248.00 85246

14 5/3/2019


Pomeroy Wa, 99347

40720103 L-SERUM ACE LEVEL $82.00 82164

40720093 L-ALDOLASE $95.00 82085

307010034 A-GROUND MILEAGE PER MILE $16.00 A0425

40720470 L-CYTO/MOLECULAR REPORT $213.00 88291

40720466 L-CD4 EACH ADDL MARKER $108.00 88185

40720310 L-TOTAL PROTIEN S $244.00 85305

40720298 L-HEMOGRAM TEST $87.00 85027

40720249 L-PROTOPORPHYRIN RBC $70.00 84202

40720367 L-LYME ANTIBODY TOTAL $160.00 86618

40720355 L-IMUNOFIXATION STUDY;SERUM $89.00 86334

438220203 CL-HOUSE CALLS 40 MIN. $236.00 99349

40720012 L-ISTAT-IONIZED CALCIUM $22.00 82330

438220142 CL-EKG $252.00 93000

40720220 L-ORGANIC ACID QUANT. $109.00 83921

40720092 L-MICROALBUMIN URINE,QUANT. $40.00 82043

307010025 A-PORT-A-CATH ACCESS $239.00 96522

40720350 L-MONO $103.00 86308

40720189 L-TSH RECEPTOR ANTIBODY $223.00 83519

40720296 L-HGB $39.00 85018

40720236 L-POTASSIUM $36.00 84132

40720055 L-SALICYLATE $147.00 80196

40720187 L-IGF-1 $150.00 83519

438220074 CL-BLOOD OCCULT OTHER SOURCE $54.00 82271

40720377 L-H PYLORI $208.00 86677

40720028 L-RENAL FUNCTION PANEL $99.00 80069

438220033 CL-LACER. BODY 2.5 CM. $230.00 12001

438220156 CL-IV PUSH EA SEQTL. NEW MED $47.00 96375

438220025 CL-EXC LES .5 OR LESS $717.00 11440

40720419 L-PINWORM TEST $40.00 87172

40720119 L-CALCULUS SPECTOSCOPY $123.00 82365

438220067 CL-REM FB FROM EYE, SUPERFIC $341.00 65205

40720322 L-ANTI PARICTAL ANTI $137.00 86000

421190007 ST-ASSESS. OF APHASIA W/RPRT $200.00 96105

40720304 L-CLOTTING, FACTOR VIII STAGE ONE $138.00 85240

40720200 L-LEAD SCREEN $31.00 83655

438220006 CL-DEBRIDMENT, WOUND $611.00 11000

40720275 L-TRANSFERRIN $27.00 84466

40720065 L-DRUG SCREEN URINE $95.00 80307

438220160 CL-WOUND VAC < 50 SQ. CM. $212.00 97605

40720476 L-TISSUE EXAM LEVEL 5 $677.00 88309

40720182 L-HGB GLYCOSYLATED A1C $39.00 83036

438220163 CL-PHONE NON PHY 11-20 MIN $50.00 98967

40720378 L-HTLV I/II $213.00 86689

405120012 CS-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

40720095 L-ANTITRYPSIN LEVEL $183.00 82103

40720074 L-METHADONE CONFIRMATION $103.00 80358

40720043 L-LAB SPEC CHEM-GENTAMICIN $199.00 80170

15 5/3/2019


Pomeroy Wa, 99347

405120018 CS-ANKLE AIR SPLINT 90 $385.00 L1906

40720282 L-TROPONIN QUALITATIVE $150.00 84512

307010014 A-CRYO B9 LESIONS 15+ $251.00 17111

438220211 CL-NEW PATIENT 12-17 YEARS $251.00 99384

40720487 L-CRYSTAL ID ANY BODY FLUID $117.00 89060

40720326 L-LAB (ANA) TITER $51.00 86039

40720068 L-AMPHETAMINES; 1 OR 2 $82.00 80324

405120003 CS-CPAP FACEMASK - LARGE $385.00 A7030

40720251 L-VITAMIN B6 $59.00 84207

438220017 CL-SHAVING OF EPIDERMAL OR DERMAL LESION $278.00 11310

40720109 L-COLORECTAL SCREEN; FECES $14.00 82270

438220010 CL-SKIN BIOSPSY, EA ADD LES. $172.00 11101

438220170 CL-NEW PT LEVEL 1 $65.00 99201

438220176 CL-EST PT LEVEL 1 $55.00 99211

307010042 A-EXC MALIG LES .6-1.0CM $615.00 11601

40720136 L-CHROMA/MASS SPEC, CL QUAN $101.00 82542

40720368 L-CHLAMYDIA TEST $118.00 86631

40720075 L-OPIATES 1 OR MORE $115.00 80361

438220196 CL-PHYS VISIT SNF LEVEL 4 $207.00 99310

40720365 L-BORDETALLA PERTUSSIS $147.00 86615

40720400 L-HEP C ANTIBODY CONFIRMATION $125.00 86804

405120027 CS-WALKING BOOT $141.00 L4361

40720442 L-INFECTIOUS AGENT DETECT $275.00 87449

40720395 L-VARICELLA Z ANTIBODY $16.00 86787

40720253 L-NON-ENDOCRINE $263.00 84238

40720316 L-VIPER VENOM UNDILUTED $185.00 85612

438220093 CL-ADMIN, EA ADDTL VACCINE , VFC $22.00 90472

40720461 L-CYTO CONCENT TECH $104.00 88108

438220061 CL-FINGER SPLINT $153.00 29130

40720414 L-CULTURE, SCREENING $102.00 87081

307010052 A-WOUND VAC > 50 CM $467.00 97606

40720056 L-ASSAY OF TACROLIMUS $448.00 80197

40720201 L-LIPASE $114.00 83690

307010027 A-WOUND CARE SIMPLE-NURSE $361.00 97602

438220002 CL-I&D SIMPLE SINGLE $235.00 10060

40720330 L-PHOSPHOLIPID ANTIBODY, EA $193.00 86147

405120007 CS-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

438220085 CL-INFLUENZA A & B EACH $60.00 87400

405120023 CS-WRIST & THUMB SPLINT $67.00 L3908

405120019 CS-ANKLE WALKER- MED. $326.00 L1930

40720398 L-ANTITHYROID ANTIBODIES $85.00 86800

40720135 L-CORTISOL, SERUM $82.00 82533

438220182 CL-CONSULT MID <30 $160.00 99242

421190003 ST-SPEECH EVALUATION 15 MIN $358.00 92522

40720086 L-HFE GENE ANALYSIS $283.00 81256

40720216 L-MOLECULE NUCLEIC AMPLI $198.00 83898

40720449 L-N.GONORRHOEAE,DNA,PROBE $127.00 87591

16 5/3/2019


Pomeroy Wa, 99347

40720288 L-ASSAY OF VITAMIN K $254.00 84597

40720051 L-DILANTIN LEV. (QUALITATIV $272.00 80186

40720439 L-RSV TEST $190.00 87420

40720217 L-MOLECULE NUCLEIC AMPLI 2 $106.00 83900

40720423 L-SUSPECT, VITEK $13.00 87186

438220043 CL-CRYO PREMALIG LES(1) $212.00 17000

40720010 L-ISTAT-BUN $7.00 84520

40720280 L-T3 REVERSE $161.00 84482

40720037 L-DESIPRAMINE $170.00 80160


40720464 L-PAP $154.00 88175

40720430 L-INFLUENZA B QUICK STEP $94.00 87275

405120008 CS-ENTERAL PUMP KIT $12.00 B4035

41120003 EKG-CARDIAC MONITOR 1-3 LEADS $268.00 93040

40720456 L-RAPID STREP TEST $90.00 87880

40720273 L-AST $76.00 84220

40720234 L-PORPHOBILINOGEN $89.00 84110

405120010 CS-ENTERAL INFUSION PUMP $12.00 B9002

40720244 L-TOTAL PROTEIN, PLASMA $78.00 84155

40720457 L-DAT FOR MENINGITIS $104.00 87899

40720444 L-GARDNERELLA $77.00 87510

40720469 L-CHROMOSOME KARYOTYPE $194.00 88280

438220166 CL-POSTOPERATIVE FOLLOW-UP VISIT $132.00 99024

40720383 L-HEPATITIS B CORE ANTIBODY $184.00 86704

438220082 CL-MONO TEST $64.00 86308

40720126 L-ASSAY/ CERULOPLASMIN $108.00 82390

40720225 L-PTH $112.00 83970

438220005 CL-PUNCTURE ASPIRATION OF... $347.00 10160

307010040 A-OBS. ROOM PER HR OVER 4 $126.00 G0378

40720122 L-LAB SPEC. CHEM. - CEA $95.00 82378

405120021 CS-SHOE, POST OP FML - MED $16.00 L3260

40720114 L-VIT-D 250H $87.00 82306

40720072 L-CANNABINOIDS $48.00 80349

40720270 L-TSH $73.00 84443

40720215 L-NUCLEIC ACID PROBE, EACH $35.00 83896

40720048 L-NORTRIPTYLLINE LEVEL $131.00 80182

40720364 L-RPR/VDRL $64.00 86592

438220040CL-REPAIR, INTERMEDIATE, 2.5 CM OR LESS OF HANDS, FEET, NECK, OR

EXTERNAL GENITALIA $389.00 12041

40720004 L-ISTAT-CHLORIDE $8.00 82435

307010032 A-CRASH CART USED $60.00 99211

421190002 ST-LARYNGEAL FUNCTION TEST $158.00 92520

40720307 L-FACTOR X111 $139.00 85291

40720091 L-LAB CHEMISTRY-ALBUMIN $21.00 82040

405120006 CS-NON ELECTRIC SPIROMETER $21.00 A9284

40720121 L-CARBONMONOXIDE QUAN. $105.00 82375

40720020 L-SCOLIOSIS, 1 VIEW $416.00 72081

17 5/3/2019


Pomeroy Wa, 99347

438220004 CL-FB REMOVAL SUB.; SIMPLE $343.00 10120

40720441 L-EHEC EIA $40.00 87427

438220180 CL-EST PT LEVEL 5 $300.00 99215

40720359 L-MICROSOMAL ANTIBODY $94.00 86376

438220226 CL-ELEC. COMM PHYS ONLY $50.00 99444

438220014 CL-SHAVE BIOPSY 1.1 - 2.0 CM $181.00 11302

438220027 CL-DEBRIDEMENT OF NAIL(S) BY ANY METHOD 1 TO 5 $294.00 11720

421190004 ST-SWALOW DYSF/ORAL FUNC. TX $178.00 92526

405120025 CS-ANKLE BRACE $140.00 L4350

40720142 L-CREATININE, URINE $19.00 82570

40720342 L-MYASTHENIA GR PANEL SCREN $75.00 86255

40720436 L-HEPATITIS B SURF.ANTIGEN $44.00 87340

405120014 CS-BIPAP MACHINE $522.00 E0601

40720177 L-H. PYLORI ADULT BREATH TEST $213.00 83013

40720380 L-HERPES SIMPLEX VIRUS I/II, IGG $163.00 86695

438220154 CL-INJECTION, SUBQ/INTRAMSC $67.00 96372

438220222 CL-PREVENTIVE MEDICINE COUNSELING $158.00 99401

438220199 CL-PHYS DC NH > 30 MIN. $163.00 99316

40720063 L-HAIRSTAT 5 REFLEX PANEL $213.00 80302

40720102 L-LAB AMYLASE (AFP) $62.00 82150

40720036 L-CLOZAPINE $213.00 80159

438220094 CL-ADMIN, EA ADDTL VACCINE , VFC $22.00 90472

40720286 L-VMA VANILLYMANDELIC ACID $100.00 84585

40720214 L-MOLECULE GEL ELECTROPHOR $73.00 83894

40720308 L-ANTITHROMBIN ENZYMATIC $229.00 85300

40720422 L-SENSATIVITY URINE $110.00 87184

40720221 L-ASSAY OF OPIATES $133.00 83925

40720391 L-RUBELLA $100.00 86762

40720305 L-BLOOD CLOT FACTOR VIII $248.00 85245

40720150 L-ESTRADIOL LEVEL $86.00 82670

40720116 L-LAB CHEMISTRY-CALCIUM $19.00 82310

40720356 L-OTHER FLUIDS W/CONCENT $177.00 86335

40720258 L-SODIUM; OTHER SOURCE $58.00 84302

40720089 L-ACETONE, QUANT. $89.00 82010

40720248 L-ELECTROPHORETIC FRACT & Q $164.00 84166

438220200 CL-SNF ANNUAL ASSESSMENT $146.00 99318

307010018 A-DRAIN/INJ.JOINT/BURSA INT $287.00 20605

438220208 CL-NEW PATIENT INFANT<1 YR. $207.00 99381

40720346 L-GLUTEN SEN TITER $85.00 86256

40720118 L-CALCIUM - URINE (TIMED) $27.00 82340

40720468 L-CHROMOSOME ANALYSIS $907.00 88262

40720458 L-HEP C GENOTYPE DNA $860.00 87902

438220198 CL-PHYS DC NH < 30 MIN. $124.00 99315

438220064 CL-EPISTAXIS PACK. SIMPLE $157.56 30901

438220167 CL-SPECIAL REPORTS/INS. /L&I $51.00 99080

307010047 A-INJ. TENDON SHEATH/LIGAME $906.00 20550

40720053 L-PROCAINAMIDE (NAPA) $200.00 80192

18 5/3/2019


Pomeroy Wa, 99347

40720386 L-HEP A ANTIBODY $100.00 86709

438220228 CL-ADDITIONAL 30 MIN. ADVANCED CARE PLANNING $75.00 99498

438220092 CL-INJ VACC/TOXOID EACH ADD. $22.00 90472

40720129 L-LAB CHEMISTRY-CHOLESTEROL $19.00 82465

307010013 A-CRYO B9 LESIONS UP TO 14 $198.00 17110

40720478 L-SPECIAL STAINS $127.00 88312

40720267 L-T-4 PROFILE $41.00 84436

438220183 CL-CONSULT 40 MIN FACE TO FA $222.00 99243

40720081 L-UA MICRO ONLY $38.00 81015

40720492 L-L-PSA-YEARLY SCREEN $61.00 G0103

438220035 CL-REPAIR SIMPLE 7.6 TO 12.5 $242.00 12004

438220016 CL-SHAVE BIOPSY - 0.6 - 1.0 CM $209.00 11306

40720218 L-MOLECULAR DIAGNOTIC $158.00 83902

40720030 L-HEPATIC FUNCTON PANEL $36.00 80076

438220001 CL-EXC B9 LES 3.1-4CM $1,554.00 11404

40720405 L-DNA/PATERNITY $41.00 86910

40720176 L-HAPTOGLOBIN $50.00 83010

40720285 L-URIC ACID OTHER SOURCE $27.00 84560

40720071 L-CANNABINOIDS $126.00 80349

40720472 L-TISSUE EXAM PATHOLOGIST $104.00 88302

40720104 L-APOLIPOPROTEIN B ASSAY $98.00 82172

405120002 CS-FOREARM SPLINT, PADDED, MED $31.00 A4570

40720266 L-THYROGLOBULIN $168.00 84432

40720002 L-ED-ISTAT-SODIUM $8.00 84295

40720260 L-URINE INDICANS $215.00 84311

307010041 A-EXC, MALIGN LESION <.5CM $951.00 11600

40720428 L-HERPES CULTUR $108.00 87250

40720073 L-COCAINE CONFIRMATION $103.00 80353

40720125 L-CATECHOLAMINES, BLOOD $225.00 82383

40720084L-BCR-ABL1 QUALITATIVE WITH REFLEX TO BCR-ABL1 QUANTITATIVE $193.00 81206


40720166 L-GLUCOSE; QUANT.BLOOD $19.00 82947


40720138 L-LAB PROFILE-CARDIAC CK $113.00 82550

40720117 L-CALCIUM, IONIZED $129.00 82330

40720052 L-PRIMIDONE LEVEL $11.00 80188

438220205 CL-TM CON PT. PRES. NON PHYS $80.00 99366

40720054 L-ASSAY OF SIROLIMUS $206.00 80195

438220044 CL-CRYO PREMALIG LES (2-14) $54.00 17003

438220050 CL-CARPEL TUNNEL INJECTIONS $334.00 20526

40720169 L-GLUCOSE TOL.TEST 3 SPECIM $150.00 82951

438220070 CL-DRUG SCREEN URINE $39.00 81001

40720090 L-ACETYLCHOLINESTERASE $43.00 82013

40720362 L-TB TEST QUANTIFERON GOLD $264.00 86480

40720015 L-ISTAT-ELECTOLYTE PANEL $11.00 80051

40720153 L-FAT/LIPIDS, FECES;QUALITA $84.00 82705

19 5/3/2019


Pomeroy Wa, 99347

40720160 L-GAMAGLOBULIN;IGA,D,G,M EA $26.00 82784

438220089 CL-ADMIN 1 VACCINE, VFC $69.00 90471

40720050 L-LAB SPEC CHEM-DILANTIN $224.00 80185

40720143 L-LAB URINE-CREATININE CLEA $110.00 82575

40720372 L-EPSTEIN BARR PANEL $92.00 86663

40720399 L-HEPATITIS C ANTIBODY $49.00 86803

307010001 A-SKIN BIOPSY (SINGLE LESION) $389.00 11100

40720007 L-ISTAT-POST GLUCOSE DOSE $8.00 82950

40720426 L-KOH WET MOUNT FUNGAL $66.00 87210

40720376 L-GIRDIA EIA $160.00 86674

40720250 L-ASSAY OF PROINSULIN $163.00 84206

438220149 CL-ALLERGY SHOT 2 + $46.29 95117

40720445 L-HCV RNA QUANT $201.00 87517

40720357 L-INHIBIN A $149.00 86336

40720443 L-CANDIDA $99.00 87480

40720477 L-DECALCIFY TISSUE $28.00 88311


307010029 A-WOUND CARE COMPLEX $536.00 97602

438220024CL-EXC. BEINIGN LESION SCALPL, NECK, HANDS, FEET, GENITALIA 1.1 TO

2.0 CM $1,512.00 11422

40720334 L-C1 INHBTR/COMP.RUNC ACTIV $139.00 86161

307010044 A-EXC MALIG LES 2.1-3CM $2,226.00 11603

40720299 L-RBC AUTOMATED $51.00 85041

405120001 CS-ARM SLING LARGE $54.00 A4565

40720242 L-PSA TOTAL $65.00 84153

438220036 CL-LACER. FACE 2.5 CM. $250.00 12011

40720131 L-CHROMIUM, SERUM $132.00 82495

40720404 L-BLOOD TYPE $132.00 86900

307010017 A-TRIGGER POINT INJECTIONS $794.00 20553


438220066 CL-PESSARY INSERTION $201.00 57160

40720347 L-CA 15-3 (27.29) $108.00 86300

40720038 L-LAB SPEC CHEM-DIGOXIN $207.00 80162

40720014 L-ISTAT-BASIC METABOLIC PANAL (IONIZED CA) $18.00 80047

40720431 L-INFLUENZA A QUICK STEP $89.00 87276

438220185 CL-CONSULT 60 MIN FACE TO FA $351.00 99244

40720024 L-COMP. METABOLIC PANEL $165.00 80053

40720335 L-COMPLEMENT TOTAL (CH50) $144.00 86162

40720292 L-HCG - QUALITATIVE $116.00 84703

40720107 L-TOTAL BILIRUBIN $54.00 82247

438220012 CL-REM. SKINTAGS EA.ADD 10 $36.00 11201

40720455 L-DAT FOR MENINGITIS $99.00 87802

40720344 L-MYASTHENIA GR PANEL TITER $85.00 86256

40720433 L-CRYPTOSPORIDIUM ANTIGEN BY EIA $163.00 87328

40720303 L-PERIPHERAL BLOOD SMEAR $100.00 85060

40720269 L-HYDRA IV ADL, TX IV, IM $131.00 84442

40720069 L-BARBITURATES CONFIRMATION $103.00 80345

20 5/3/2019


Pomeroy Wa, 99347

438220022 CL-EXC. BE.LES..5CM OR LESS $1,554.00 11420

40720058 L-TOBRAMYCIN $205.00 80200

40720197 L-LAB SPEC CHEM-TIBC $33.00 83550

307010048 A-INCISE EXTERNAL HEMORRHOI $320.00 46083

438220223 CL-PHONE CONSULT 5-10 MIN. $28.00 99441

40720165 L-GLUCOSE BODY FLUID OTHER THAN BLOOD $52.00 82945

40720440 L-ROTAVIRUS ANTIGEN $141.00 87425

40720154 L-FATS/LIPIDS/FECES/QUANT. $217.00 82710

307010010 A-TOE NAIL REM.>1 LIST EACH $86.00 11732

438220049 CL-REMOVAL FOREIGN BODY, SIMPLE $1,686.00 20520

438220058 CL-INCN DRNG BLW FACIA FOOT $1,688.00 28002

438220148 CL-ALLERGY SHOT $47.00 95115

438220207 CL-TEAM CONF W/PROVIDER >30 $157.00 99380

40720257 L-URINE SODIUM $22.00 84300

40720295 L-HCT $25.00 85014

40720034 L-LAB MISC.-CYCLOSPORINE $238.00 80158

40720412 L-CULTURE ISOLATE EXC BLOOD $158.00 84075

438220039 CL-INTERM. LAC REPAIR 7.6CM $389.00 12034

307010026 A-IRRIGATION OF FLUSH PICC, CENT LINE, PORT $233.00 96523

40720188 L-MYASTHENIA GR PANEL $223.00 83519

40720459 L-HEP C GENOTYPE $172.00 87902

40720361 L-RA FACTOR QUALITATIVE $37.00 86431

42330051 ED-GLUCOSE REAGENT STRIP $22.00 82948

307010005 A-EXC BEN LES 0.6-1.0 CM $710.00 11401

40720450 L-HPV DNA AMP PROBE $188.00 87621

40720247 L-ELECTROPHORESIS/MICROPROT $104.00 84165

40720278 L-TOTAL TT-3 $34.00 84480

40720045 L-LAMOTOGRINE $65.00 80175

40720360 L-RA FACTOR QUALITATIVE $62.00 86430

40720224 L-OXALATE (URINE) $108.00 83945

40720194 L-AUTOIMMUNE PANEL $157.00 83520

40720144 L-CRYOGLOBULIN $81.00 82595

307010002 A-SKIN BIOPSY EA. AD LESION $74.00 11101

40720044 L-GABAPENTIN $165.60 80171

40720402 L-DIRECT COOMBS $72.00 86880

40720314 L-FIBRINOGEN $35.00 85384

438220157 CL-IV PUSH EA SEQTL SAME MED $47.00 96376

307010036 A-AMB ALS ER TRANSPORT $865.00 A0427

438220165 CL-ELEC. COMM NON PHYS. $50.00 98969

40720435 L-H-PYLORI STOOL $183.00 87338

40720207 L-MERCURY, BLOOD $30.00 83825

438220220 CL-EST. PATIENT 40-64 YEARS $254.00 99396

40720276 L-IV-IM PUSH QNEW MED $19.00 84478

40720338 L-SSDNA $90.00 86226

438220045 CL-CRYO-WARTS < 15 $212.00 17110

40720452 L-TRICHOMONAS $80.00 87660

40720397 L-IGG $127.00 86789

21 5/3/2019


Pomeroy Wa, 99347

438220188 CL-PHYS H&P SNF LEVEL 2 $209.00 99305

40720351 L-ANTICARDIOLIPIN AB $69.00 86318

40720416 L-CULTURE,FUNGUS MOLD/YEAST $101.00 87101

307010022 A-INJ. LMBR SACRAL THERAPEU $1,497.00 62322

438220084 CL-H PYLORI $95.00 86677

40720301 L-LEUKOCYTE AUTOMATED $42.00 85048

40720082 L-HCG URINE TEST $88.00 81025

438220068 CL-REM FB FROM EYE, COMPLEX $210.00 65222

421190005 ST-SWALLOWING FUNCTION EVAL $224.00 92610

307010011 A-CRYO PREMALIG LES(1) $154.00 17000

40720284 L-URIC ACID BLOOD $19.00 84550

40720066 L-LAB CHEMISTRY-ALCOHOL $184.00 80320

40720175 L-HUMAN GROWTH HORMONE(HGH) $163.00 83003


40720336 L-ANTIBODY CCP $140.00 86200

40720226 L-PH BODY FLUID, EXC. BLOOD $89.00 83986

307010008 A-TOENAIL TRIM-HOSPITAL FAC $280.00 11719

307010012 A-CRYO PREMALIG LES(2-14) $15.00 17003


438220021 CL-EXCISION, BENIGN LESION 2.1-3 CM $577.00 11403

40720213 L-MOLECULE ISOLATE NUCLEIC $126.00 83891

41120004 EKG-CARDIAC MONITOR TO 48HR $210.00 93226

40720023 L-ELECTROLYTE $95.00 80051

40720407 L-BLOOD CULTURE $166.00 87040

40720340 L-JO-1 AB $30.00 86235

40720252 L-ASSAY OF PYRUVATE $108.00 84210

40720421 L-SENSITIVITY $44.00 87181

438220079 CL-HCT (SPUN) $23.00 85013

40720417 L-FUNGUS ID $157.00 87106

40720358 L-ANTI INTRINSIC ANTIBODY $129.00 86340

40720352 L-IMUNOELCTROPHORSEIS SERUM $245.00 86320

40720353 L-C3 TEST $156.00 86329

40720488 L-EOSINOPHILS, NASAL SMEAR $65.00 89190


40720185 L-ANTI-MAG AB $80.00 83516

40720283 L-BUN $19.00 84520

438220073 CL-COLORECTAL SCREEN; FECES $25.00 82270

40720373 L-EB AND EBNA $126.00 86664

40720321 L-EOSINOPHIL URINE $50.00 85999

40720192 L-ACHR BLOCKING $223.00 83519

40720016 L-ISTAT-TOTAL B-HCG $24.00 84702

40720406 L-CROSS MATCH $162.00 86920

438220150 CL-IV INFUSION HYDRTION 1 HR $263.00 96360


40720318 L-SEDIMENTATION $58.00 85651

40720484 L-INSITU HYBRIDIZAT,MANUAL $337.00 88368


22 5/3/2019


Pomeroy Wa, 99347

307010024 A-CARDIOVERSION $2,614.00 92960

438220143 CL-CARDIAC MONITOR 1-3 LEADS $157.00 93040

40720229 L-ACID PHOSPHATASE $81.00 84060

307010019 A-DRAIN/INJ.JOINT/BURSA MAJ $339.00 20610

40720059 L-TOPAMEX LEVEL $145.00 80201

40720149 L-ERYTHROPOIETIN $176.00 82668

307010004 A-EX BENIGN LESION < .05 CM $710.00 11400

40720348 L-CA 19 $181.00 86301

40720287 L-ASSAY OF VASOPRESSIN $147.00 84588

40720099 L-AMINOACIDS, 6 OR MORE $216.00 82139

405120022 CS-SHOE, POST OP FML - LG $16.00 L3260

40720211 L-NEPHELOMETRY $64.00 83883

307010035 A-AMB ALS NON ER TRANSPORT $635.00 A0426


438220026 CL-TOE NAIL TRIM $137.00 11719

40720489 L-SEMEN ANALYSIS $99.00 89320

40720205 L-LDL CHOLESTEROL $34.00 83721

438220059 CL-SPLINT LONG ARM $229.00 29105

40720294 L-BLOOD SMEAR WBC DIFF MANUAL $59.00 85007

41120005 EKG-ECHOCARDIOGRAPHY, TRANSTHORACIC $608.36 93306

40720115 L-CALCITONIN $246.00 82308

438220042 CL-LAC REPR COMP. 2.6-7.5 CM $611.00 13121

438220151 CL-HYRATION IV, ADDL BY HR $73.00 96361

40720465 L-CD4 PANEL $270.00 88184

438220030 CL-TOE NAIL REM.>1 LIST EACH $79.00 11732

405120004 CS-CPAP HEADGEAR $164.00 A7035

438220029 CL-TOE NAIL PLATE REM (1) $294.00 11730

40720085 L-FACTOR V LEIDEN $213.00 81241


438220169 CL-THERAPEUTIC PHLABOTOMY $210.00 99195

40720064 L-DRUG SCREEN SERUM $251.00 80307

438220184 CL-PRE-OP CONSULTATION $345.00 99244

40720390 L-SERUM TITRE RICKETTSIA $129.00 86757

40720191 L-ACHR BINDING $223.00 83519

40720394 L-TOXOPLASMA (ANTIBODY) IGM $148.00 86778

40720005 L-ISTAT-TC02 $8.00 82374

40720323 L-ALLERGY PANEL $17.00 86003

40720447 L-HSV DNA AMP PROBE $188.00 87529

40720128 L-LAB CHEMISTRY - CHLORIDE $49.00 82435

438220031 CL-TOENAIL REMV PART./COMPL $389.00 11750

438220056 CL-DRAIN/INJ.JOINT/BURSA MAJ $395.00 20610

438220062 CL-SPLINT LONG LEG $222.00 29505

438220020 CL-EXC BE LESION 1.1-2.0 CM $596.00 11402

438220009 CL-SKIN BIOPSY (SING.LESION) $345.00 11100

40720369 L-COCCIDIODES ANTIBODY $116.00 86635

40720313 L-D-DIMER QUANTITATIVE $170.00 85379

40720291 L-HCG - QUANTITATIVE $162.00 84702

23 5/3/2019


Pomeroy Wa, 99347

40720032 L-AMITRIPTYLINE LEVEL $352.00 80152

40720272 L-VITAMIN E $127.00 84446

40720463 L-CYTO EVAL FNA REPORT $150.00 88173

438220177 CL-EST PT LEVEL 2 $133.00 99212


40720393 L-TOXOPLASMA (TITRE) AB $136.00 86777

40720325 L-LAB (ANA) $51.00 86038

40720158 L-FOLIC ACID, SERUM $57.00 82746

438220057 CL-I&D FINGER COMPLEX $1,685.00 26011

438220186 CL-CONSULT 80 MIN FAC TO FAC $436.00 99245

438220041 CL-REPAIR, INTERMEDIATE 2.6CM TO 7.5CM $395.00 12042

40720232 L-PHOSPHORUS $19.00 84100

307010045 A-EXC MALIG LES 3.1-4CM $1,834.00 11604

438220060 CL-SPLINT SHORT ARM $212.00 29125

307010006 A-EXC BEN LES 1.1-2.0 CM $710.00 11402

40720479 L-SPECIAL STAINS $110.00 88313

307010038 A-AMB BLS ER TRANSPORT $624.00 A0429

40720389 L-ANTIBODY, MUMPS $122.00 86735

438220003 CL-I&D ABSCESS COMPLEX $436.00 10061

438220168 CL-CHS VISION SCREENING $49.00 99172

40720042 L-ETHOSUXIMIDE LEVEL $77.00 80168

40720438 L-INFLUENZA A/B AG, EIA $105.00 87400

438220011 CL-REMOVAL SKIN TAG<15 $216.00 11200

438220083 CL-TB SKIN TEST $22.00 86580

40720264 L-TESTOSTERONE TOTAL $93.00 84403

40720255 L-SEX HORMONE BINDING GLOBU $152.00 84270

40720370 L-CMV ANTIBODY $130.00 86644

307010028 A-WOUND CARE INTERMED-NURSE $472.00 97602

40720019 L-BLOOD DRAW (PORTA CATH) $158.00 36591

40720331 L-COLD AGGLUTININ $274.00 86156

40720228 L-CALPROTECTIN, FECAL $303.00 83993

40720013 L-ISTAT-HEMATOCRIT $4.00 85014

438220071 CL-DIPSTICK UA (NOT MICRO) $15.00 81002

40720164 L-ASSAY OF GASTRIN $154.00 82941

40720486 L-LEUKOCYTE ASSESMENT,FECAL $76.00 89055

40720162 L-IGG SUBCLASSES $159.00 82787

40720168 L-POST GLUCOSE DOSE $64.00 82950

40720245 L-URINE TOTAL PROTEIN $58.00 84156

40720040 L-VALPROIC FREE ACID $141.00 80165

40720172 L-GGT $23.00 82977

307010033 A-DRESSING CHANGE $66.00 99211

40720467 L-TISSUE CULTURE LYMP $508.00 88230

438220054 CL-DRAIN/INJ. SMALL JOINT OR BURSA $306.00 20600

40720202 L-LIPOPROTEIN A $152.00 83695

40720083 L-LAB URINE-VOLUME MEASURE $13.00 81050

405120009 CS-NUTRITION PUMP KIT $53.00 B4035

40720302 L-PLATELETS AUTOMATED $72.00 85049

24 5/3/2019


Pomeroy Wa, 99347

40720080 L-UA DIP W/MICRO $35.00 81001

40720345 L-CMV TEST $85.00 86256

438220069 CL-EAR IRRIGATION $70.00 69210

40720077 L-CLINICAL PATHOLOGY CONSUL $89.00 80500

40720111 L-NON COLORECTAL; FECES $16.00 82272

438220152 CL-IV INFUSION THERAPEUTIC UP TO 1 HOUR $287.00 96365

40720409 L-STOOL CULTURE PRESUMPTIVE $22.00 87046

40720067 L-ALCOHOL BIOMARKERS $32.00 80321

40720341 L-ACENTROMERE B ABS $30.00 86235

438220018 CL-EXC. BE.LES..5CM OR LESS $593.00 11400

40720332 L-COLD AGGLUTININ TITER $98.00 86157

405120028 CS-WALKING BOOT NON PNEUMATIC $141.00 L4387

40720088 L-LAB-ACETAMINOPHEN LEVEL $220.00 82003

40720098 L-URINE ALA $79.00 82135

40720418 L-MYCOBACTERIA CULTURE $31.00 87116

40720132 L-CITRATE (URINE) $207.00 82507

438220086CL-DECTECTION INFECTIOUS AGENT BY IMMUNOASSY WITH DIRECT

OPTICAL OBSERVATION INFLUENZA $60.00 87804

438220034 CL-LACER. BODY^2.5 CM. $242.00 12002

40720170 L-GLUCOSE TOLR.TEST EA.ADD. $127.00 82952

40720178 L-H. PYLORI, BLOOD $48.00 87338

40720401 L-HLA TYPING; A,B,OR C $306.00 86812

40720453 L-BK VIRUS, QUANTITATIVE BY PCR $173.00 87799

41120002 EKG $112.00 93005

40720061 L-QUANTITATION THERAPUTIC DRUG $177.00 80299

40720311 L-PROTEIN S, FREE $287.00 85306

438220159 CL-WOUND CARE $252.00 97602

40720289 L-ASSAY OF ZINC $95.00 84630

40720046 L-LEVETIRACETAM $213.00 80177

438220063 CL-SPLINT SHORT LEG $222.00 29515

40720454 L-DETECT AGENT NOS,DNA,QUAN $710.00 87799


40720382 L-HIV1/HIV2 ANTBDY, SGL ASY $154.00 86703

40720186 L-GLUTEN SEN ANTIBODY $80.00 83516

40720374 L-EPSTEIN-BARR ANTIBODY $144.00 86665

438220015CL-SHAVE BIOPSY 0.5CM OR LESS OF SCALP, NECK, HANDS, FEET,

GENITALIA $209.00 11305

438220158 CL-ACTIVE WOUND CARE/20 CM< $365.00 97597

40720480 L-IMMUNOHISTOCHEMISTRY $270.00 88342

40720141 L-CREATININE, SERUM $19.00 82565

40720163 L-BLODD GASES, ANY COMBO $264.00 82803

40720195 L-INSULIN; TOTAL $73.00 83525

40720490 L-LAB MISC/HANDLING FEE $25.00 99001

405120029 CS-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

40720112 L-BLOOD OCCULT BY FECAL HEMAGLOBIN DETERMINATION $16.00 82274

438220075 CL-NON COLORECTAL; FECES $25.00 82272

40720049 L-LAB SPEC CHEM PHENOBARBIT $112.00 80184

25 5/3/2019


Pomeroy Wa, 99347

307010051 A-FITTING INSERT OF PESSARY $201.00 57160

438220181 CL-CONSULT LIMITED ,<15 MIN $76.00 99241

40720388 L-LEGIONELLA ANTIBODY $111.00 86713

40720320 L-VISCOSITY $81.00 85810

40720437 L-HIV ANTIGEN $154.00 87390

40720035 L-CYCLOSPORINE A $289.00 80158

438220161 CL-WOUND VAC > 50 SQ. CM. $467.00 97606

307010021 A-CENTRAL LINE DRAW $56.00 36592

438220048 CL-FACE LESION .6-1 CM $389.00 17281

40720315 L-PRO-TIME $68.00 85610

40720079 L-UA W/O MICRO (DIPSTICK) $9.00 81002

40720481 L-IMMUNOFLOR STDY,EA ANTIBO $139.00 88347

307010016 A-TRIGGER POINT INJECTIONS $220.00 20552

40720094 L-ALDOSTERONE $116.00 82088

405120013 CS-BIAP HEATED HUMIDIFIER $163.00 E0562

438220232 CL-H1N1 PANDEMIC ADMIN $0.10 G9141

40720148 L-ASSAY DIHDROXYVITAMIN D $246.00 82652

40720339 L-E.N.A. $30.00 86235

307010046 A-EXC MALIG LES >4.0CM $2,753.00 11606

40720379 L-HERPES SIMPLEX ANTIBODIES $108.00 86694

40720277 L-THYROXINE UPTAKE $86.00 84479

40720025 L-LAB-OB PANEL $362.00 80055

40720203 L-ASSAY LIPOPROTEIN PLA2 $186.00 83698

40720262 L-SUGARS, SINGLE, QUAL $274.00 84376

40720375 L-ANTIBODY - FUNGUS UNSPEC $100.00 86671

438220145 CL-NEBULIZER TREATMENT $233.00 94640

40720003 L-ISTAT-POTASSIUM $8.00 84132

40720219 L-GENETIC INTERP. & REPORT $85.00 83912


40720151 L-ESTROGEN $163.00 82672


40720392 L-RUBEOLA IGG $120.00 86765

438220178 CL-EST PT LEVEL 3 $158.00 99213


307010009 A-AVULSON NAIL PLATE SMPL 1 $388.00 11730

40720127 L-CHEMILUMINESCENT ASSAY $196.00 82397


40720011 L-ISTAT-CREATININE $8.00 82565

40720100 L-LAB AMMONIA LEVEL $199.00 82140

438220013 CL-SHAVE SKIN LESION 0.6 TO 1.0 CM $181.00 11301

40720124 L-CATECHOLAMINES; TOT.URINE $200.00 82382

40720385 L-HEPATITIS A SURFACE ANTI $215.00 86708

40720145 L-MEGALOBLASTIC PANEL $163.00 82607

40720110 L-BLOOD OCCULT OTHER SOURCE $16.00 82271

40720087 L-MTHFR MUTATION $170.00 81291

40720256 L-SODIUM; SERUM $63.00 84295

40720482 L-TUMOR IMMUNOHISTO/MANUAL $270.00 88360

26 5/3/2019


Pomeroy Wa, 99347

438220046 CL-CRYO-WARTS > 15 $212.00 17111

40720235 L-PORPHYRIA SCREEN $152.00 84120

438220023 CL-EXC. BEN.LESION .6 - 1 $717.00 11421

405120024 CS-WRIST IMMOBILIZER $104.00 L3980

438220141 CL-HEARING TEST $132.00 92552

438220216 CL-EST.PATIENT 1-4 YEARS $176.00 99392

438220077 CL-GLUCOSE / REAGENT STRIP $22.00 82948

438220032 CL-WEDGE EXCISION FO THE SKIN OF THE NAIL FOLD $389.00 11765

40720193 L-IMMUNOASSAY,NOT SPECIFIED $157.00 83520

438220076 CL-BLOOD, OCCULT, BY FECAL $54.00 82274

40720184 L-IMMUNOASSAY, MULTI-STEP $80.00 83516

438220155 CL-IV PUSH MED INJECTION $195.00 96374

438220052 CL-TRIGG PTS 1+/1-2 MUS GRP $306.00 20552

307010015 A-CARPEL TUNNEL INJECTION $334.00 20526

40720147 L-DHEA SULFATE $27.00 82627

438220173 CL-NEW PT LEVEL 4 $317.00 99204

438220065 CL-PESSARY IRRIGATION $132.00 57150

40720243 L-PSA FREE $137.00 84154

40720179 L-HEAVY METAL SCREEN $32.00 83015

40720403 L-INDIRECT COOMBS $162.00 86885

438220037 CL-LACER. FACE ^2.5 CM. $317.00 12013

307010020 A-FINGER SPLINT-HOSP $153.00 29130

40720174 L-LH (LUTEINIZING HORMONE) $67.00 83002

40720230 L-PHOSPHATASE, ALKALINE $36.00 84075

40720198 L-LACTIC ACID $128.00 83605

438220080 CL-HEMATOCRIT; FINGERSTICK $34.00 85014

40720246 L-PROTEIN BODY FLUID $73.00 84157

40720106 L-ASSAY OF BETA 2 PROTEIN $141.00 82232

40720343 L-GLUTEN SEN SCREEN $75.00 86255

40720460 L-CYTO FLUIDS NONGYN SMEAR $85.00 88104

40720204 L-LAB CHEMISTRY-HDL CHOLEST $33.00 83718

40720181 L-HEMOGLOBIN EVALUATION $77.00 83021

40720133 L-COPPER SERUM $20.00 82525

40720324 L-ANCA $182.00 86021

40720333 L-COMPLEMENT; ANTIGEN $83.00 86160

40720123 L-CAROTENE $120.00 82380

40720274 L-ALT / ALANINE AMINOTRANSFERASE $59.00 84460

40720137 L-ESSENTIAL FATTY ACID PANE $389.00 82544

40720183 L-HOMOCYSTEINE $48.00 83090

40720171 L-G6PD QUALITATIVE $102.00 82955

40720222 L-OSMOLALITY SERUM $52.00 83930

40720300 L-RETICULOCYTES AUTO $25.00 85045

438220227 CL-FIRST 30 MIN. OF ADVANCED CARE PLANNING $90.00 99497

40720261 L-SPECIFIC GRAV NOT URINE $33.00 84315

40720097 L-CYSTINE (URINE) $314.00 82131

438220171 CL-NEW PT LEVEL 2 $150.00 99202

40720265 L-VIT B-1 $83.00 84425

27 5/3/2019


Pomeroy Wa, 99347

40720076 L-ACTH $261.00 80400

438220051 CL-INJECT TENDON SHEATH/LIGAMENT $306.00 20550

405120020 CS-SHOE, POST OP MENS-LG $16.00 L3260

438220221 CL-EST. PATIENT 65 + YEARS $264.00 99397

40720009L-ISTAT-GLUCOSE TOLLERANCE TEST, EACH ADDITIONAL BEYOND 3

SPECIMENS $7.00 82952

40720254 L-ASSAY OF RENIN $129.00 84244

40720155 L-FATTY ACIDS / PLASMA $265.00 82725

40720101 L-AFP $82.00 82150

438220028 CL-DEBRIDEMENT OF NAIL(S) 6 OR MORE $294.00 11721

438220078 CL-TROPONIN QUANTITATIVE $177.00 84484

40720159 L-RBC FOLIC $22.00 82747

40720022 L-GENERAL HEALTH PANEL $552.00 80050

438220047 CL-DES. OF BEIGN LESION 1-14 $212.00 17111

438220144 CL-UP TO 48 HRHOLTER MONITOR $205.00 93225

438220038 CL-CLOSURE OF SPLIT WOUND $611.00 12020

438220091 CL-ADMIN 1 VACCINE, VFC $69.00 90471

40720366 L-LYME DISEASE ANTIBODY $226.00 86617

438220090 CL-VACCINE/TOXOID 1ST INJ $69.00 90471

40720483 L-INSITU,HYBRIDIZ,(FISH) $230.00 88365

40720017 L-ISTAT-PROTHROMBIN TIME $7.00 85610

40720240 L-PROGESTERONE $82.00 84144

40720408 L-STOOL CULTURE PRELIMINARY $95.00 87045

40720206 L-LAB CHEMISTRY-MAGNESIUM $36.00 83735

40720161 L-GAMMAGLOBULIN IGE $45.00 82785

40720371 L-CMV ANITBODY IGM $145.00 86645

438220055 CL-DRAIN/INJ.JOINT/BURSA INT $338.00 20605

307010023 A-HEART LUNG RESUSITATION CPT $2,117.00 92950

307010037 A-AMB BLS NON ER TRANSPORT $414.00 A0428

40720139 L-CARDIAC ISOENZYMES $251.00 82552

40720387 L-INFLUENZA VIRUS; ANTIBODY $124.00 86710

40720327 L-ASO $99.00 86060

40720293 L-BLEEDING TIME $112.00 85002

40720237 L-POTASSIUM, URINE $56.00 84133

40720208 L-METANEPHRINE $104.00 83835

40720152 L-ASSAY OF ESTRIOL $128.00 82677

40720196 L-LAB SPEC CHEM-IRON $33.00 83540

438220229 CL-TOENAIL TRIM (DYSTROPHIC) $105.00 G0127


405120015 CS-ADULT CERVICAL COLLAR $33.00 L0172

40720312 L-APC RESISTANCE $214.00 85307

40720309 L-TOTAL PROTEIN C $223.00 85302

40720134 L-URINARY FREE CORTISOL $66.00 82530

307010050 A-US URINECAP MEASURE $247.00 51798

40720233 L-PHOSPHATE (URINE) $27.00 84105


40720173 L-FSH $67.00 83001

28 5/3/2019


Pomeroy Wa, 99347

40720223 L-OSMOLALITY URINE $52.00 83935

438220053 CL-TRIGG PTS 1+/3+ MUSCLE GP $525.00 20553

40720199 L-LAB PROFILE-CARDIAC LDH $22.00 83615

421190006 ST-MOTION FLUORO SWALLOW $320.00 92611

40720130 L-CHROMATOGRAPHY, GL COLUMN $172.00 82491

421190001 ST-NASOPHARYNGOSCOPY $315.00 92511

40720096 L-URINE AMINO ACIDS $61.00 82128

40720146 L-LAB SPEC. CHEM B12 $57.00 82607

438220215 CL-EST. PATIENT INFANT< 1 YR $157.00 99391

438220147 CL-PULSE OXIMETER $29.00 94760

40720212 L-MOLECULE ISOLATE $210.00 83890

40720041 L-DOXEPIN LEVEL $74.00 80166

40720491 L-MILLENIUM LAB MISC/HANDLING FEE $25.00 99001

40720319 L-PTT, WHOLE BLOOD $74.00 85730

40720281 L-TROPONIN QUANTITATIVE $222.00 84484

40720026 L-LAB OB PANEL(INCLUDES HIV TESTING) $128.00 80081

40720427 L-TISSUE EXAM, KOH TEST $65.00 87220

40720429 L-VIRAL CULTURE $147.00 87252

40720259 L-SOMATOMEDIN $150.00 84305

438220087 CL-QUICK STREP TEST CLINIC $69.00 87880

307010003 A-REMOVAL OF SKIN TAGS $547.00 11200


438220172 CL-NEW PT LEVEL 3 $206.00 99203

40720448 L-HIV-1, RNA QUANTIFICATION $293.00 87536

40720190 L-ANTI-MUSK ANTIBODY $223.00 83519

307010049 A-FOLY CATH INSERTION INIT $211.00 51702

40720473 L-HISTOPATHOLOGY $108.00 88304


40720113 L-CADMIUM, BLOOD $43.00 82300

40720432 L-C.DIFFICLE TOXIN A & B $120.00 87324

438220245 CL-SUTURE REMOVAL $78.00 S0630

40720231 L-ALP ISOENZYMES $170.00 84080

40720415 L-URINE CULTURE $78.00 87088

40720209 L-MYOGLOBIN $203.00 83874

405120005 CS-CPAP TUBING $168.00 A7037

307010043 A-EXC MALG LES 1.1-2.0CM $1,010.00 11602


40720381 L-HIV AB $157.00 86701

438220072 CL-DIP PREG TEST $61.00 81025

438220019 CL-EXC. BE. LES. 0.6-1.0 CM $480.00 11401



40720485 L-CELL COUNT ANY BODY FLUID $74.00 89051

40720363 L-TB TEST $38.00 86580

40720120 L-CARBON DIOXIDE TEST $54.00 82374

40720070 L-BENZODIAZEPINES 13+ $103.00 80347

40720105 L-ARSENIC, BLOOD $138.00 82175

29 5/3/2019


Pomeroy Wa, 99347

40720180 L-HEMOGLOBIN ELECTROPHORESI $166.00 83020

40720290 L-C PEPTIDE $142.00 84681

40720078 L-UA W/MICRO $10.00 81000

40720029 L-ACUTE HEPATITIS PANEL $172.00 80074

40720227 L-PHENCYCLIDINE CONFIRMATION $103.00 80365

40720354 L-CITRULINATED PTIDE AB IGG $170.00 86332

40720062 L-OXYCODONE, URINE CONFIRMATION $103.00 80365

405120016 CS-ANKLE BRACE-LACER-L $134.00 L1902

40720349 L-CA 125 TEST $194.00 86304

40720238 L-PRE-ALBUMIN $93.00 84134

40720279 L-FT-3 $29.00 84481

40720317 L-VIPER VENOM DILUTED $145.00 85613

40720006 L-ISTAT-GLUCOSE $7.00 82947

40720263 L-FREE TESTOSTERONE $102.00 84402

417040399 methIMAzole 10 MG TABLET 10 mcg, 100 eaches $-

417040400 TOTAL B WITH VIT C CAPLET $5.00

417040401 amiodarone 150 MG/3 ML VIAL 150 mg, 3 mL $-

417040107 DOCUSATE SODIUM 100MG CAP $5.00

417040404 Protonix 40 MG SUSPENSION 40 mcg, 30 eaches $25.80

417040405 POTASSIUM CL 20 MEQ PACKET 20 mcg, 30 eaches $16.00

417040406 MOMETASONE FUROATE 50 MCG SPRY 50 mcg, 17 g $386.88

417040407 DESONIDE 0.05% OINTMENT 15 g $102.50

417040408 tiZANidine HCL 4 MG TABLET $18.30

417040179 LACTOBACILLUS ACIDOPHILLUS CAP $5.00

417040410 Advair 250-50 DISKUS 250 mcg $302.50

417040354 SODIUM CHLORIDE 0.45% SOLN 1000 mL $50.00

417040256 SODIUM CHLORIDE 0.9% SOLUTION 250 mcg, 250 mL $50.00



417040356 DEXTROSE 5%-0.45% NACL IV SOLN 1000 mL $62.00

417040358 DEXTROSE 5%-0.9% NACL IV SOLN 500 mL $62.00

417040089 DEXTROSE 5%-0.9% NACL IV SOLN 1000 mcg, 1000 mL $62.00

417040357 DEXTROSE 5%-LR IV SOLUTION 1000 mL $62.00

417040355 DEXTROSE 5%-WATER IV SOLN 250 mL $50.00

417040090 DEXTROSE 5%-WATER IV SOLN 1000 ML $62.00

417040178 LACTATED RINGERS 1000ML BAG $62.00

417040411 ARMOUR THYROID 30 MG TABLET $10.80

417040412 levETIRAcetam 250 MG TABLET $23.15

417040413 levETIRAcetam 500 MG/5 ML VIAL $49.80 J1953

417040414 DOPamine 400 MG-D5W 500 ML $96.00 J1265

417040415 dilTIAZem 125 MG/25 ML VIAL $70.75

417040416 DOCU LIQUID 50 MG/5 ML $5.00

307010031 A-NEGATIVE PRESSURE WOUND THERAPY <50 SQ CM $257.00 97607

307010031 A-WOUND VAC >50 CM $265.00 97606

417040417 HYDROmorphone 1 MG/ML CARPUJCT $26.40

41420101 X-ELBOW RIGHT COMPLETE $241.00 73080

41420134 X-KNEE LEFT 3 VIEW $241.00 73562

30 5/3/2019


Pomeroy Wa, 99347

41420165 X-ABODMEN-SINGLE VIEW $186.00 74018

41420128 X-FEMUR LEFT 2 VIEWS $226.00 73552

41420001 X-EYE FOREIGN BODY XRAY-LEFT $276.00 70030

41420078 X-SACRUM/COCCYX $297.00 72220

41420054 X-CERVICAL SPINE 4 OR 5 VIEWS $406.00 72050

41420024 X-SKULL 2 VIEWS $373.00 70250

41420018 X-ORBITS 4 VIEW $373.00 70200

41420076 X-SI JOINTS 3 VIEWS $311.00 72202

41420151 X-ANKLE RIGHT COMPLETE $235.00 73610

41420022 X-SINUS MIN 3 VIEW $377.00 70220

41420084 X-SCAPULA-RIGHT $233.00 73010

41420038 X-RIBS - UNILATERAL LEFT $228.00 71100

41420030 X-BILATERAL TMJS $377.00 70330

41420116 X-HAND RIGHT COMPLETE $225.00 73130

41420087 X-SHOULDER-RIGHT 1 VIEW $196.00 73020

41420154 X-FOOT RIGHT 2 VIEWS $215.00 73620

41420160 X-HEEL - RIGHT $215.00 73650

41420048 X-STERNUM XRAY $276.00 71120

41420106 X-WRIST LEFT 2 VIEWS $184.00 73100

41420050 X-SPINE 1 VIEW SPECIFIC $205.00 72020

41420118 X-FINGER LEFT $178.00 73140

41420147 X- ANKLE LEFT 2 VIEWS $197.00 73600

41420002 X-EYE FOREIGN BODY XRAY-RIGHT $276.00 70030

41420008 X-MASTOID $354.00 70120

41420163 X-TOES X-RAY-RIGHT $176.00 73660

41420010 X-MASTOIDS 3 VIEWS $354.00 70130

41420068 X-SPINE LUMBOSACRAL COMPLETE $412.00 72110

41420092 X-AC JOINTS 2 VIEWS $307.00 73050

41420113 X-HAND RIGHT 2 VIEWS $214.00 73120

41420086 X-SHOULDER-LEFT 1 VIEW $196.00 73020

41420169 X-ABDOMEN, COMPLETE VIEW $248.00 74021

41420097 X-ELBOW LEFT 2 VIEWS $198.00 73070

41420156 X-FOOT LEFT COMPLETE $230.00 73630

41420046 X-RIB BILATERAL 4 VIEW $324.00 71111

41420042 X-UNI RIB 3 VIEW W/PA CHEST-RIGHT $263.00 71101

41420175 X-SEGMENTAL PNEUMATIC PUMP $1,558.00 E0667

41420131 X-KNEE LEFT 1 OR 2 VIEW $228.00 73560

41420006 X-MANDIBLE 4 VIEW $354.00 70110

41420150 X-ANKLE LEFT COMPLETE $235.00 73610

41420100 X-ELBOW LEFT COMPLETE $241.00 73080

41420052 X-SPINE CERVICAL 2 VIEW $238.00 72040

41420028 X-UNILATERAL TMJS $377.00 70328

41420034 X-CHEST 1 VIEW $171.00 71045

41420121 X-HIP UNILATERAL WITH PELVIS WHEN PERFORMED $190.00 73501

41420036 X-CHEST 2 VIEWS $219.00 71046

41420115 X-HAND LEFT COMPLETE $225.00 73130

41420016 X-NASAL BONES $279.00 70160

31 5/3/2019


Pomeroy Wa, 99347

41420142 X-KNEES BILATERAL VIEWS $269.00 73565

41420173 X-DOPPLER STUDY $378.00 93922

41420004 X-MANDIBLE LESS THAN 4 VIEW $268.00 70100

41420064 X-SPINE L BENDING VIEWS $386.00 72120

41420140 X-KNEE RIGHT 4 OR MORE VIEWS $260.00 73564

41420044 X-RIBS BILATERAL $261.00 71110

41420090 X-SHOULDER RIGHT COMPLETE $242.00 73030

41420162 X-TOES X-RAY-LEFT $176.00 73660

41420081 X-CLAVICLE - RIGHT $208.00 73000

41420139 X-KNEE LEFT 4 OR MORE VIEWS $260.00 73564

41420119 X-FINGER RIGHT $178.00 73140

41420074 X-SI JOINT $248.00 72200

41420107 X- WRIST RIGHT 2 VIEWS $184.00 73100

41420124 X-HIP RIGHT 2 VIEWS $252.00 73502

41420148 X-ANKLE RIGHT 2 VIEWS $197.00 73600

41420072 X-PELVIS COMPLETE $186.00 72190

41420145 X-TIBIA/FIBULA RIGHT $209.00 73590

41420056 X-CERVICAL SPINE COMPLETE $479.00 72052

41420094 X-HUMERUS LEFT 2 VIEWS $209.00 73060

41420026 X-SKULL 4 VIEW $413.00 70260

41420032 X-NECK SOFT TISSUE $195.00 70360

41420109 X-WRIST LEFT COMPLETE $241.00 73110

41420135 X-KNEE RIGHT 3 VIEW $241.00 73562

41420014 X-FACIAL BONES MIN 3 VIEWS (COMPLETE) $373.00 70150

41420157 X-FOOT RIGHT COMPLETE $230.00 73630

41420144 X- TIBIA/FIBULA LEFT $209.00 73590

41420110 X-WRIST RIGHT COMPLETE $241.00 73110

41420153 X-FOOT LEFT 2 VIEWS $215.00 73620

41420095 X-HUMERUS RIGHT 2 VIEWS $209.00 73060

41420020 X-SINUS LESS THAN 3 VIEWS $248.00 70210

41420039 X-RIBS - UNILATERAL RIGHT $228.00 71100

41420132 X-KNEE RIGHT 1 OR 2 VIEW $228.00 73560

41420080 X-CLAVICLE - LEFT $208.00 73000

41420058 X-THORACIC DORSAL 3 VIEWS $268.00 72072

41420089 X-SHOULDER LEFT COMPLETE $242.00 73030

41420083 X-SCAPULA - LEFT $233.00 73010

41420112 X-HAND LEFT 2 VIEWS $214.00 73120

41420129 X-FEMUR RIGHT 2 VIEWS $226.00 73552

41420123 X-HIP LEFT 2 VIEWS $252.00 73502

41420167 X-ABDOMEN, 2 VIEWS $255.00 74019

41420062 X-THORACIC/LUMBAR $262.00 72080

41420137 X-AP BILATERAL STANDING KNEES $593.00 73565

41420012 X-FACIAL BONES LESS THAN 3 $268.00 70140

41420171 X-ACUTE ABDOMEN $396.00 74022

41420066 X-SPINE LUMBOSACRAL AP/LAT $262.00 72100

41420070 X-PELVIS AP $209.00 72170

41420098 X-ELBOW RIGHT 2 VIEWS $198.00 73070

32 5/3/2019


Pomeroy Wa, 99347

41420104 X-FOREARM RIGHT $203.00 73090

41420159 X-HEEL - LEFT $215.00 73650

41420126 X-HIP BILATERAL W/AP PELVIS $374.00 73521

41420103 X-FOREARM LEFT $203.00 73090

41420041 X-UNI RIB 3 VIEW W/PA CHEST-LEFT $276.00 71101

41420060 X-THORACIC 4 VIEWS $455.00 72074

438220230 CL-ANNUAL WELLNESS VISIT 1ST $200.00 G0402

438220231 CL-ANNUAL WELLNESS VISIT SUB $200.00 G0439

306100005 N-WOUND CARE COMPLEX $536.00 97602

306100006 N-DRESSING CHANGE $66.00 99211

306100008 N-WOUND VAC > 50 CM $467.00 97606

306100009 N-WOUND VAC < 50 CM $246.00 97605

306100011 N-HYDRATION IV INFUSION: EACH ADD HR $79.00 96361

306100012 N-TREATMENT IV INFUSION: #1 UP TO 1 HR $344.00 96365

306100007 N-WOUND CARE $252.00 97602

306100010 N-HYDRATION IV INFUSION:INT 31 MIN-1HR $229.01 96360

306100013 N-TREATMENT IV INFUSION:#1 EACH ADD HR $76.00 96366

306100014 N-TREATMENT IV INFUSION:#2 UP TO 1 HR $344.00 96365






306100020 N-IV PUSH MEDICATION INJ-INITIAL #1 $149.00 96374

306100021 N-IV PUSH MEDICATION INJ-SEQ PUSH; EACH $88.00 96375

306100022 N-IV PUSH MEDICATION INJ-INITIAL #2 $149.00 96374

306100023 N-IV PUSH MEDICATION INJ-SEQ PUSH; EACH $88.00 96375

306100024 N-INJECTION(SUBQ,INTRMS) $75.50 96372

306100025 N-GLUCOMETRY READING $7.00 82943

306100027 N-PICC LINE FLUSH (W/O INJ OR INFUS) $233.00 96523

306100028 N-PICC LINE REMOVAL $233.00 36589

306100029 N-BATH $30.00

306100058 N-FRENCH FOLEY CATH 22" 2 WAY $27.00 A4344

306100059 N-FRENCH FOLEY CATH 18" 2 WAY $27.00 A4344

306100060 N-ENEMA KIT $48.00

417040418 MEXILETINE 150 MG CAPSULE $22.75

417040419 NITRO-BID 2% OINTMENT $24.50

417040420 DOXEPIN 75 MG CAPSULE $18.80

417040421 THP Cefdinir 250mg/5ml 60ml susp $162.00

417040331 TERAZOSIN 2MG CAP $15.45



417040423 MECLIZINE 25 MG TABLET $10.90

417040424 SODIUM CHLORIDE 1,000 MG TAB $14.11

417040425 TIMOLOL MALEATE 0.5% EYE DROPS 15 mL $50.45

417040426 heparin 50 UNITS/5 ML (10u/ML) $6.20

417040427 protamine 10 MG/ML VIAL 25 mL $162.50 J2720

33 5/3/2019


Pomeroy Wa, 99347

307010039 A-OBS. ROOM PER HOUR 1-4 $126.00 G0378

417040169 INSULIN HUMAN R 100U/ML 3ML VIAL $20.00

417040210 MAGNESIUM CITRATE 10OZ BOTTLE $13.55

307010101 *************** $233.00 96523

10000000 NO CHARGE $-

41800001 I-BREATHING CAPACITY TEST $175.00 94010

53200007 D-DIABETES GROUP TRAIN UNIT $76.00 G0109

53200005 D-NUTRITION SUPPLEMENT-1500ML FEEDING BAGS $17.00 B4150

53200004 D-DIETARY CONSULT $92.00 99411

53200003 D-NUTRITION THER. GROUP $35.00 97804

53200002 D-NUTRITION RE-EVAL EA. 15 $43.00 97803

42330073 ED-ARM SLING LARGE $54.00 A4565

42330074 ED-FOREARM SPLINT, PADDED, MED $31.00 A4570

42330075 ED-CPAP FACEMASK - LARGE $385.00 A7030

42330076 ED-CPAP HEADGEAR $164.00 A7035

42330077 ED-CPAP TUBING $168.00 A7037

42330078 ED-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

42330079 ED-ENTERAL PUMP KIT $12.00 B4035

42330080 ED-NUTRITION PUMP KIT $53.00 B4035

42330081 ED-ENTERAL INFUSION PUMP $12.00 B9002

42330082 ED-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

42330083 ED-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

42330084 ED-BIAP HEATED HUMIDIFIER $163.00 E0562

42330085 ED-BIPAP MACHINE $522.00 E0601

42330086 ED-ADULT CERVICAL COLLAR $33.00 L0172

42330087 ED-ANKLE BRACE-LACER-L $134.00 L1902

42330088 ED-ANLKE BRACE-LACER-M $134.00 L1902

42330089 ED-ANKLE AIR SPLINT 90 $385.00 L1906

42330090 ED-ANKLE WALKER- MED. $326.00 L1930

42330091 ED-SHOE, POST OP MENS-LG $16.00 L3260

42330092 ED-SHOE, POST OP FML - MED $16.00 L3260

42330093 ED-SHOE, POST OP FML - LG $16.00 L3260

42330094 ED-WRIST & THUMB SPLINT $67.00 L3908

42330095 ED-WRIST IMMOBILIZER $104.00 L3980

42330096 ED-ANKLE BRACE $140.00 L4350

42330097 ED-WALKING BOOT $141.00 L4361

42330098 ED-WALKING BOOT $141.00 L4361

42330099 ED-WALKING BOOT NON PNEUMATIC $141.00 L4387

42330100 ED-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

306100030 N-ARM SLING LARGE $54.00 A4565

306100032 N-CPAP FACEMASK - LARGE $385.00 A7030

306100033 N-CPAP HEADGEAR $164.00 A7035

306100034 N-CPAP TUBING $168.00 A7037

306100035 N-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

306100036 N-ENTERAL PUMP KIT $12.00 B4035

306100037 N-NUTRITION PUMP KIT $53.00 B4035

306100038 N-ENTERAL INFUSION PUMP $12.00 B9002

34 5/3/2019


Pomeroy Wa, 99347

306100039 N-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

306100040 N-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

306100041 N-BIAP HEATED HUMIDIFIER $163.00 E0562

306100042 N-BIPAP MACHINE $522.00 E0601

306100043 N-ADULT CERVICAL COLLAR $33.00 L0172

306100044 N-ANKLE BRACE-LACER-L $134.00 L1902

306100045 N-ANLKE BRACE-LACER-M $134.00 L1902

306100046 N-ANKLE AIR SPLINT 90 $385.00 L1906

306100047 N-ANKLE WALKER- MED. $326.00 L1930

306100048 N-SHOE, POST OP MENS-LG $16.00 L3260

306100049 N-SHOE, POST OP FML - MED $16.00 L3260

306100050 N-SHOE, POST OP FML - LG $16.00 L3260

306100051 N-WRIST & THUMB SPLINT $67.00 L3908

306100052 N-WRIST IMMOBILIZER $104.00 L3980

306100053 N-ANKLE BRACE $140.00 L4350

306100054 N-WALKING BOOT $141.00 L4361

306100055 N-WALKING BOOT $141.00 L4361

306100056 N-WALKING BOOT NON PNEUMATIC $141.00 L4387

306100057 N-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

307010056 A-ARM SLING LARGE $54.00 A4565

307010057 A-FOREARM SPLINT, PADDED, MED $31.00 A4570

307010058 A-CPAP FACEMASK - LARGE $385.00 A7030

307010059 A-CPAP HEADGEAR $164.00 A7035

307010060 A-CPAP TUBING $168.00 A7037

307010061 A-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

307010062 A-ENTERAL PUMP KIT $12.00 B4035

307010063 A-NUTRITION PUMP KIT $53.00 B4035

307010064 A-ENTERAL INFUSION PUMP $12.00 B9002

307010065 A-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

307010066 A-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

307010067 A-BIAP HEATED HUMIDIFIER $163.00 E0562

307010068 A-BIPAP MACHINE $522.00 E0601

307010069 A-ADULT CERVICAL COLLAR $33.00 L0172

307010070 A-ANKLE BRACE-LACER-L $134.00 L1902

307010071 A-ANLKE BRACE-LACER-M $134.00 L1902

307010072 A-ANKLE AIR SPLINT 90 $385.00 L1906

307010073 A-ANKLE WALKER- MED. $326.00 L1930

307010074 A-SHOE, POST OP MENS-LG $16.00 L3260

307010075 A-SHOE, POST OP FML - MED $16.00 L3260

307010076 A-SHOE, POST OP FML - LG $16.00 L3260

307010077 A-WRIST & THUMB SPLINT $67.00 L3908

307010078 A-WRIST IMMOBILIZER $104.00 L3980

307010079 A-ANKLE BRACE $140.00 L4350

307010080 A-WALKING BOOT $141.00 L4361

307010081 A-WALKING BOOT $141.00 L4361

307010082 A-WALKING BOOT NON PNEUMATIC $141.00 L4387

307010083 A-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

35 5/3/2019


Pomeroy Wa, 99347

405120017 CS-ANL;E BRACE-LACER-M $134.00 L1902

405120027 CS-WALKING BOOT $141.00 L4361

53200001 D-NUTRITION THERAPY 15 MIN. $54.00 97802

417040429 gentamicin 3 MG/ML EYE DROP 5 mL $32.50

42330001 ED-I&D ABSCESS SIMPLE $253.43 10060

42280008 OT-OCC. ADL. TRAINING 15"" $61.00 97535

42280007 OT-OCCU. THERAPY 15 MIN $61.00 97530

42280005 OT-MANUAL THERAPY 15 MIN"" $71.99 97140

42280004 OT-MASSAGE $17.00 97124

42280003 OT-NEUROMUSCULAR REDUCTION $58.00 97112


42400001 PR-LAC N/H/F 12.6-20 CM $611.00 12045

42280002 OT-OCC. THERAPUTIC EXERC $78.00 97110


42280001 OT-OCC. THERAPY EVALUATION $175.00 97003

42400002 PR-LAC N/H/F 20.1-30 CM $611.00 12046




42280006 OT-OCC. THERAPY RE-EVAL. $133.00 97168



422180004 OT-MASSAGE $17.00 97124

424210001 PR-LAC N/H/F 12.6-20 CM $611.00 12045

424210002 PR-LAC N/H/F 20.1-30 CM $611.00 12046

42400003 PR-LAC N/H/F > 30 CM INTM $1,961.00 12047

424210003 PR-LAC N/H/F > 30 CM INTM $1,961.00 12051

42400004PR-WOUND INTERMEDIATE REPAIR OF F,E,E,N,L, AND OR MUCOUS

MEMBRANES 2.5 CM OR LESS $467.00 12051



42400005 PR-WOUNDS INTERMEDIATE REPAIR-LAC FACE 2.6-5.0 CM $467.00 12052


42400006 PR-WOUND INTERMEDIATE REPAIR LAC FACE 5.1-7.5 CM $611.00 12053


42400007 PR-WOUND INTERMEDIATE REPAIR LAC FACE 7.6-12.5 CM INTM $611.00 12054


42400008 PR-WOUND INTERMEDIATE REPAIR LAC FACE 12.6-20 CM INTM $611.00 12055


42400009 PR-WOUND INTERMEDIATE REPAIR LAC FACE 20.1-30 $611.00 12056


42400010 PR-WOUND INTERMEDIATE REPAIR LAC FACE > 30 CM $1,961.00 12057


42400011 PR-WOUND COMPLEX REPAIR TRNK 1.1-2.5 CM $611.00 13100


42400012 PR-WOUND COMPLEX REPAIR LAC TRNK 2.6-7.5 CM $611.00 13101


36 5/3/2019


Pomeroy Wa, 99347

42400013 PR-WOUND COMPLEX REPAIR LAC S/A/L 1.1-2.5CM $611.00 13120



42400015 PR-WOUND COMPLEX REPAIR LAC N/H/F 1.1-2.5CM $467.00 13131




42400017 PR-WOUND COMPLEX REPAIR FACE,EAR,LIP,EYE 1.0 CM TO 2.5 CM $611.00 13151


42400018 PR-WOUND COMPLEX REPAIR LAC FACE 1.1-2.5 CM $611.00 13151




42400020 PR-PR-BURN INITIAL TX 1ST DEGR. $221.00 16000


42400021 PR-BURN DBRD/DRSS SM<5% $300.00 16020


42400022 PR-BURN DBRD/DRSS MED 5-10% $370.00 16025

42400023 PR-BURN DBRD/DRSS LG > 10% $467.00 16030


42400024 PR-DESTROY B9 LESION 1ST ONE $212.00 17000


42400025 PR-WOUND EXPLORATION EXTREM $717.00 20103


42400026 PR-RMV FRN BDY MSCL/TNDN SMP $1,686.00 20520


42400027 PR-CARPEL TUNNEL INJECTION $334.00 20526


42400028 PR-TRIGGER POINT INJECTIONS $334.00 20552




42400030 PR-DRAIN/INJ SM JOINT/BURSA $334.00 20600

42400031 PR-DRAIN/INJ MAJR JOINT/BURS $334.00 20610

42400032 PR-SHOULDER TX W/O ANESTHESA $323.00 23650


42400033 PR-SHOULDER TX WITH ANESTHES $1,688.00 23655


42400034 PR-ELBOW TX WITH ANESTHESIA $1,688.00 24605


42400035 PR-I&D FINGER COMPLEX $1,686.00 26011


42400036 PR-EXCISION OF CYST HAND/FIN $1,688.00 26160


42400037 PR-KNUCKLE TX W/OUT ANESTHES $358.00 26700


42400038 PR-FINGER TX W/OUT ANESTHESA $1,688.00 26742

37 5/3/2019


Pomeroy Wa, 99347


42400039 PR-INCISION OF ABSCESS $2,907.00 27301


42400040 PR-KNEE TX WITH ANESTHESIA $1,688.00 27552


42400041 PR-KNEECAP TX W/OUT ANESTHES $370.00 27560


42400042 PR-SPLINT LONG ARM $229.00 29105


42400043 PR-SPLINT SHORT ARM $212.00 29125


42400044 PR-SPLINT LONG LEG $232.00 29505


42400045 PR-SPLINT SHORT LEG $222.00 29515


42060164PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS DISCHARGE-

100% IMPAIRED $- G8995



42060163PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS DISCHARGE-80-








42060161PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS DISCHARGE-40

-59% IMPAIRED $- G8995















42060157PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS GOAL-100%

IMPAIRED $- G8994


IMPAIRED $- G8994

38 5/3/2019


Pomeroy Wa, 99347

42060156PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS GOAL-80-99%

IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994

42060154PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS GOAL-40 -59%

IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994

42060150PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS CURRENT-




42060149PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS CURRENT-80-








42060147PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS CURRENT-40 -










39 5/3/2019


Pomeroy Wa, 99347



42060144PT-OTHER PT/OT SUBSEQUENT FUNCTIONAL LIMITATIONS CURRENT-0%

IMPAIRED $- G8993


IMPAIRED $- G8993

42060143PT-OTHER PT/OT PRIMARY FUNCTIONAL LIMITATION DISCHARGE-100%

IMPAIRED $- G8992


IMPAIRED $- G8992

42060142PT-OTHER PT/OT PRIMARY FUNCTIONAL LIMITATION DISCHARGE-80%-
















42060138PT-OTHER PT/OT PRIMARY FUNCTIONAL LIMITATION DISCHARGE-1%-19%

IMPAIRED $- G8992


IMPAIRED $- G8992


IMPAIRED $- G8992


IMPAIRED $- G8992

42060136PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS GOAL-100% IMPAIRED $- G8991


42060135PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS GOAL-80%-99%

IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991

40 5/3/2019


Pomeroy Wa, 99347


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991

42060131PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS GOAL-1%-19% IMPAIRED $- G8991




42060129PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS CURRENT-100%

IMPAIRED $- G8990


IMPAIRED $- G8990

42060128PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS CURRENT-80%-99%

IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990

42060126PT-PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS CURRENT-40%-59%

IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990

42060123PT-OTHER PT/OT PRIMARY FUNCT LIMITATIONS CURRENT-0% IMPAIRED $- G8990


42060122 PT-SELF CARE DISCHARGE-100% IMPAIRED $- G8989


42060121 PT-SELF CARE DISCHARGE-80%-99% IMPAIRED $- G8989

41 5/3/2019


Pomeroy Wa, 99347












42060115 PT-SELF CARE GOAL-100% IMPAIRED $- G8988



420170114 PT-SELF CARE GOAL-80%-99% IMPAIRED $- G8988












42060108 PT--SPT-ELF CARE CURRENT-100%IMPAIRED $- G8987


42060107 PT--SPT-ELF CARE CURRENT-80-99% IMPAIRED $- G8987


42060106 PT-SPT-ELF CARE CURRENT-60%-79% IMPAIRED $- G8987


42060105 PT-SELF CARE CURRENT-40-59% IMPAIRED $- G8987






42060102 PT-SELF CARE CURRENT-0% IMPAIRED $- G8987


42060101PT-CARRYING, MOVING AND HADLING OBJECTS DISCHARGE-100%

IMPAIRED $- G8986


IMPAIRED $- G8986

42060100PT-CARRYING, MOVING AND HADLING OBJECTS DISCHARGE-80%-99%

IMPAIRED $- G8986

42 5/3/2019


Pomeroy Wa, 99347


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986

42060094PT-CARRYING, MOVING, AND HANDLING OBJECTS GOAL-100% IMPAIRED $- G8985


42060093PT-CARRYING, MOVING, AND HANDLING OBJECTS GOAL-80%-99%

IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985

43 5/3/2019


Pomeroy Wa, 99347



42060087PT-CARRYING, MOVING, AND HANDLING OBJECTS CURRENT-100%

IMPAIRED $- G8984


IMPAIRED $- G8984

42060086PT-CARRYING, MOVING, AND HANDLING OBJECTS CURRENT-80%-99%

IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984

42060080PT-CHANGING AND MAINTAINING BODY POSITION DISCHARGE-100%

IMPAIRED $- G8983


IMPAIRED $- G8983

42060079PT-CHANGING AND MAINTAINING BODY POSITION DISCHARGE- 80%-99%

IMPAIRED $- G8983


IMPAIRED $- G8983

42060078PT-CHANGING AND MAINTAINING BODY POSITION DISCHARGE-60% -79%

IMPAIRED $- G8983


IMPAIRED $- G8983

42060077PT-CHANGING AND MAINTAINING BODY POSITION DISCHARGE-40%-59%

IMPAIRED $- G8983

44 5/3/2019


Pomeroy Wa, 99347


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983

42060073PT-CHANGING AND MAINTAINING BODY POSITION GOAL-100% IMPAIRED $- G8982


42060072PT-CHANGING AND MAINTAINING BODY POSITION GOAL-80-99%

IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982



42060066PT-CHANGING AND MAINTAINING BODY POSITION CURRENT-100%

IMPAIRED $- G8981


IMPAIRED $- G8981

45 5/3/2019


Pomeroy Wa, 99347

42060065PT-CHANGING AND MAINTAINING BODY POSITION CURRENT-80-99

IMPAIRED $- G8981


IMPAIRED $- G8981

42060064PT-CHANGING AND MAINTAINING BODY POSITION CURRENT-60-79%

IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981

42060059 PT-MOBILITY DISCHARGE-100% IMPAIRED $- G8980


42060058 PT-MOBILITY DISCHARGE-80-99% IMPAIRED $- G8980












42060052 PT-MOBILITY GOAL STATUS-100% IMPAIRED $- G8979


42060051 PT-MOBILITY GOAL STATUS-80-99% IMPAIRED $- G8979









46 5/3/2019


Pomeroy Wa, 99347



42060045 PT-MOBILITY CURRENT STATUS-100% IMPAIRED $- G8978


42060044 PT-MOBILITY CURRENT STATUS-80-99% IMPAIRED $- G8978











420170038 PT-ELEC.STIM.UNATT/ MEDICARE $39.00 G0283

42060037 PT-UNLIST.PT/REHAB/BY RPT $81.00 97799



42060036 PT-ORTHOTIC MNGMT. 15 MIN $84.00 97760


42060035 PT-P.T.PRFRM TEST/REPORT 15 $81.00 97750


42060034 PT-WHEELCHAIR MNGT EA.15 MIN $135.00 97542


42060033 PT-COMMUNITY INTERGRATION $74.00 97537

420170033 PT-COMMUNITY INTEGRATION $74.00 97537

42060032 PT-SELF CARE/ADL $61.00 97535

420170032 PT-SELF CARE/ADL $61.00 97535

42060031 PT-PT SELF CARE/HOME ASSMT. $74.00 97535


42060030 PT-THERAPEUTIC ACT. 15 MIN. $66.00 97530

42060029 PT-SCHOOL THERAPY 15 MIN. $66.00 97530

42060028 PT-PT. RE-EVAL PERIODIC $124.00 97164

42060027 PT-SCHOOL RE-EVALUATION $124.00 97164


42060026 PT-PHYSICAL THERAPY RE-EVALUATION $124.00 97164

42060025 PT-PHYSICAL THERAPY EVALUATION HIGH COMPLEXITY $230.00 97163

42060024 PT-PHYSICAL THERAPY EVALUATION MODERATE COMPLEXITY $199.00 97162

42060023 PT-PHYSICAL THERAPY EVALUATION LOW COMPLEXITY $188.00 97161

42060021 PT-ULISTED THERAP PROC SPECI $81.00 97139


42060020 PT-MASSAGE THERAPY 15 MIN $87.00 97124


42060019 PT-GAIT TRAINING $88.00 97116

42060018 PT-SCHOOL GAIT TRAINING $88.00 97116


47 5/3/2019


Pomeroy Wa, 99347

42060017 PT-NEUROMUSCULAR REEDUCATION $80.00 97112

42060016 PT-SCHOOL NEUROMUSCULAR REDU $80.00 97112


42060015 PT-THERAPEUTIC EXERC. 15 MIN $93.00 97110

42060014 PT-SCHOOL THERAPEUTIC EXER. $65.00 97110


42060013 PT-ULTRASOUND,EACH 15" $52.00 97035


42060012 PT-CONTRAST BATH,EACH 15" $38.00 97034


42060011 PT-IONTOPHORESIS 15 MIN. EA. $56.00 97033


42060010 PT-ELECTRICAL STM ATTENDED $72.00 97032


42060009 PT-WHIRLPOOL $40.00 97022

420170009 PT-WHIRLPOOL $40.00 97022

42060008 PT-PARAFIN BATH $18.00 97018

420170008 PT-PARAFIN BATH $18.00 97018





42060004 PT-PT. EVAL INITIAL $195.00 97001



42060007 PT-APP MOD VASOPNEUMATIC DEV $44.00 97016


42060006 PT-ELECTRICAL STIM(UNATTENDE $60.00 97014


42060005 PT-TRACTION MECHANICAL $40.00 97012


42060003 PT-SCHOOL THERAPY EVAL. $195.00 97001


42060002 PT-CANALITH REPOSITIONING $100.00 95992


42060001 PT-DYNAMIC FINGER SPLINTING $153.00 29131


42330002 ED-I&D ABSCESS, COMPLEX $389.00 10061

42330003 ED-REMOVE-FB SKIN $389.00 10120

42330004 ED-PUNCTURE ASPIRATE ABSCESS $389.00 10160

42330005 ED-DEBRID, SKIN-SUB Q TISSUE $389.00 11042

42330006 ED-SIMPLE-EXTREMITY H/N/T $212.00 12001

42330007 ED-SIMP REP H/N/T 2.6-7.5CM $212.00 12002

42330008 ED-WOUND, SUPERFICIAL, SIMPLE-FACE,L/E/E, FEET $212.00 12011

42330009 ED-LAC FACE 5.1CM-7.5CM $254.00 12014

42330010 ED-LAC FACE 7.6-12.5CM $254.00 12015

42330011 ED-LAC FACE 12.6 - 20. CM $467.00 12016

48 5/3/2019


Pomeroy Wa, 99347

42330012 ED-INTERMED-ARM,LEG,TRUNK,SC $467.00 12031

42330013 ED-INTERMED-NECK,HAND,FEET,G $467.00 12041

42330014 ED-INTERMED-FACE,EAR,LIP,EYE $467.00 12051

42330015 ED-COMPLEX-ARM,LEG,TRUN,SCAL $610.00 13100

42330016 ED-COMPLEX-NECK,HAND,FEET,G $467.00 13131

42330017 ED-COMPLEX-FACE,EAR,LIP,EYE 1.0 CM TO 2.5 CM $610.00 13151

42330018 ED-INITIAL BURN TX LOCAL $254.00 16000

42330019 ED-BURN DRESS/DEBRIDE P <5% $254.00 16020

42330020 ED-BURN DRESSY INTERMEDIATE 5-10% $254.00 16025

42330021 ED-BURN DRESSING COMPLEX $467.00 16030

42330022 ED-INJ.TENDON/LIGAMENT $368.00 20550

42330023 ED-TRMT SHOULDER DISLOCATION $323.00 23650

42330024 ED-ELBOW DISLOCATION W/CL RE $1,688.00 24605

42330025 ED-METACARPAL CLOSED W/REDUC $323.00 26700

42330026 ED-KNEE DISLOCATION W/CL RED $1,688.00 27552

42330027 ED-SPLINT ARM, LONG $229.00 29105

42330028 ED-SPLINT ARM, SHORT $212.00 29125

42330029 ED-SPLINT LEG, LONG $232.00 29505

42330030 ED-SPLINT LEG, SHORT $222.00 29515

42330031 ED-REMOVE-FB NASAL $158.00 30300

42330032 ED-EENT CONTROL NOSE BLEED $158.00 30901

42330033 ED-EENT CONT NOSE BLEED BILA $158.00 30901

42330034 ED-NOSE BLEED WITH PACKING $211.00 30905

42330035 ED-ENDOTRACHEAL INTUBATION $268.00 31500

42330036 ED-THORANCENTESIS-ASPIRATION $330.00 32554

42330037 ED-LAW ENFORCEMENT BLOOD DRA $25.00 36415

42330038 ED-CENTRAL LINE INSERTION $1,475.00 36556

42330039 ED-INSERT NEEDLE BONE CAVITY $429.00 36680

42330040 ED-GASTRIC INTUBATION $341.00 43753

42330041 ED-STRAIGHT CATHETERIZATION $158.00 51701

42330042 ED-CATHETERIZATION $210.00 51702

42330043 ED-INJ. SPINE L/S ER FAC. $1,497.00 62322

42330044 ED-REMOVE-FB EYE EXTERNAL $281.00 65205

42330045 ED-REMOVE-FB EYE COMPLEX $313.00 65222

42330046 ED-REMOVE-FB EAR $281.00 69200

42330047 ED-REMOVE IMPACTED CERUMEN $70.00 69210

42330048 ED-DRUG SCREEN URINE $251.00 80100

42330049 ED-HEMMOCULT BY RN $54.00 82270


42330050 ED-CBG $22.00 82948

423030050 ED-CBG $22.00 82948



42330052 ED-QUICK STEP STREP TEST $69.00 87880


42330053 ED-INJECTION VACCINE/TOXOID $73.00 90471


49 5/3/2019


Pomeroy Wa, 99347

42330054 ED-HEART-LING RESUSCIT CPR $2,532.00 92950

42330055 ED-CARDIOVERSION $2,614.00 92960

42330056 ED-HYDRATION IV INF, INITIAL $239.00 96360

42330057 ED-HYDRA IV ADL, TX IV, IM $79.00 96361

42330058 ED-TREATMENT-IV INF, INITIAL $344.00 96365


42330059 ED-TREATMENT IV INF, ADD-ON $76.00 96366


42330060 ED-TREATMENT IV INF SEQ $151.00 96367


42330061 ED-TX CONCUR INF >1HR $151.00 96368


42330062 ED-INJECT TX -IM OR SQ $73.00 96372


42330063 ED-IV PUSH, SINGLE/INIT. $239.00 96374


42330064 ED-IV-IM PUSH QNEW MED $56.00 96375


42330065 ED-IV PUSH SEQTL SAME MED $49.00 96376

42330066 ED-DEBRIDE SKIN PARTIAL<20CM $338.00 97597


42330067 ED-EMERGENCY ROOM LEVEL 1 $175.00 99281


42330069 ED-ED-EMERGENCY ROOM LEVEL 3 $663.00 99283


42330071 ED-EMERGENCY ROOM LEVEL 5 $1,474.00 99285

42330072 ED-ER ROOM CRITICAL CARE $1,964.00 99291


42400046 PR-CAST REMOVAL $297.00 29705

424210046 PR-CAST REMOVAL $297.00 29705

42400047 PR-REMOVAL FB FROM NOSE $158.00 30300


42400048 PR-NASAL HEMORRHAGE CONTROL $158.00 30901


42400049 PR-NASAL HEMORRHAGE PAK/CAUT $212.00 30905


42400050 PR-THORACENTESIS PROC. $297.00 32554


42400051 PR-CENTRAL LINE INSERTION $1,229.00 36556


42400052 PR-REMOVAL TUNNELED CV CATH $766.00 36590


42400053 PR-INSRT NEEDLE BONE - PROFE $413.00 36680


42400054 PR-NG INSERTION $413.00 43752

424210054 PR-NG INSERTION $413.00 43752

42400055 PR-GASTRIC INTUBATION/ASPIRATION $413.00 43753

50 5/3/2019


Pomeroy Wa, 99347



42400057 PR-FOLEY CATH INSERTION $211.00 51702


42400058 PR-FITTING INSERT OF PESSARY $201.00 57160


42400059 PR-SPINAL PUNCTURE, LUMBAR $680.00 62270


42400060 PR-INJ.SPINE L/S ER PROFEE $125.00 62322


42400061 PR-REMOVAL FB EXTERNAL EYE $281.00 65205


42400062 PR-REMOVAL FB FROM EAR $281.00 69200


42400063 PR-EAR IRRIGATION $70.00 69210


42400064 PR-PELVIS XRAY READING $144.00 72170


42400065 PR-PULSE OXIMETRY $12.00 94760


42400066 PR-DEBRIDEMENT SKIN PART<20C $338.00 97597


42400067 PR-CONSCIOUS SEDATION 1ST 30 $198.00 99144


42400068 PR-CONSCIOUS SEDATION +15 MN $209.00 99145

42400069 PR-THERAPEUTIC PHLABOTOMY $210.00 99195


42400070 PR-OBS D/C $157.00 99217

424210070 PR-OBS D/C $157.00 99217

42400071 PR-OBS H&P LEVEL 1 $150.00 99218

424210071 PR-OBS H&P LEVEL 1 $150.00 99218

42400072 PR-OBS H&P LEVEL 2 $208.00 99219

42400073 PR-OBS H&P LEVEL 3 $348.00 99220

424210073 PR-OBS H&P LEVEL 3 $348.00 99220

42400074 PR-PHYS. H&P LEVEL 1 $184.00 99221

424210074 PR-PHYS. H&P LEVEL 1 $184.00 99221

42400075 PR-PHYS H&P LEVEL 2 $243.00 99222

424210075 PR-PHYS H&P LEVEL 2 $243.00 99222

42400076 PR-PHYS H&P LEVEL 3 $313.00 99223

424210076 PR-PHYS H&P LEVEL 3 $313.00 99223

42400077 PR-SUBSQNT OBS CARE $66.00 99224


42400078 PR-SUBSQNT OBS CARE- MODERAT $117.00 99225


42400079 PR-SUBSQNT OBS CARE-HIGH $116.00 99226


42400080 PR-PHYS HOSP VISIT LEVEL 1 $103.00 99231

51 5/3/2019


Pomeroy Wa, 99347






42400083 PR-OBS/IP SAME DAY ADM/DC #1 $265.00 99234






42400086 PR-PHYS D/C SUMM. < 30 MIN. $146.00 99238


42400087 PR-PHYS D/C SUMM > 30 MIN. $205.00 99239


42400088 PR-ER VISIT BRIEF $138.00 99281

424210088 PR-ER VISIT BRIEF $138.00 99281

42400089 PR-ER VISIT LIMITED $250.00 99282


42400090 PR-ER VISIT INTERMEDIATE $439.00 99283


42400091 PR-ER VISIT EXTENDED $712.00 99284


42400092 PR-ER VISIT COMPREHENSIVE $1,042.00 99285


42400093 PR-CRITICAL CARE 1 HOUR $1,964.00 99291


42400094 PR-CRITCAL CARE EA AD 30 MIN $227.00 99292


42400095 PR-INITIAL NURSING FACILITY CARE - LOW (25MIN) $162.00 99304


42400096 PR-INITIAL NURSING FACILITY CARE - MODERATE (35 MIN) $189.00 99305


42400097 PR-INITIAL NURSING FACILITY CARE - HIGH (45 MIN) $243.00 99306


42400098PR-SUBSEQUENT NURSING FACILITY CARE- STRAIGHT FORWARD (10 MIN) $103.00 99307


42400099 PR-SUBSEQUENT NURSING FACILITY CARE - LOW (15 MIN) $124.00 99308


42400100 PR-SUBSEQUENT NURSING FACILITY CARE - MODERATE 25 MIN) $162.00 99309


42400101 PR-SUBSEQUENT NURSING FACILITY CARE - HIGH (35 MIN) $211.00 99310


42400102 PR-NURSING FACILITY DISCHARGE ( < 30 MIN ) $123.00 99315


52 5/3/2019


Pomeroy Wa, 99347

42400103 PR-NURSING FACILITY DISCHARGE (> 30 MIN) $163.00 99316

42400104 PR-ANNUAL NURSING FACILITY ASSESSMENT $146.00 99318


42400105PR-MEDICAL TEAM CONFERENCE WITH PATIENT OR FAMILY PRESENT (30

MIN) $80.00 99366


MIN) $80.00 99366

42400106PR-MEDICAL TEAM CONFERENCE WITHOUT PATIENT OR FAMILY PRESENT $157.00 99367


42400107 PR-PROVIDER CALL < 10MIN $23.00 99441


42400108 PR-PROVIDER CALL 11-20MIN $46.00 99442




42400110 PR-SUTURE REMOVAL $78.00 S0630


423037000 ED-ARM SLING LARGE $54.00 A4565

423037001 ED-FOREARM SPLINT, PADDED, MED $31.00 A4570

423037002 ED-CPAP FACEMASK - LARGE $385.00 A7030

423037003 ED-CPAP HEADGEAR $164.00 A7035

423037004 ED-CPAP TUBING $168.00 A7037

423037006 ED-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

423037007 ED-ENTERAL PUMP KIT $12.00 B4035

423037008 ED-NUTRITION PUMP KIT $53.00 B4035

423037010 ED-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

423037011 ED-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

423037012 ED-BIAP HEATED HUMIDIFIER $163.00 E0562

423037013 ED-BIPAP MACHINE $522.00 E0601

423037014 ED-ADULT CERVICAL COLLAR $33.00 L0172

423037015 ED-ANKLE BRACE-LACER-L $134.00 L1902

423037016 ED-ANKLE AIR SPLINT 90 $385.00 L1906

423037017 ED-ANKLE WALKER- MED. $326.00 L1930

423037018 ED-SHOE, POST OP MENS-LG $16.00 L3260

423037019 ED-SHOE, POST OP FML - MED $16.00 L3260

423037020 ED-SHOE, POST OP FML - LG $16.00 L3260

423037021 ED-WRIST & THUMB SPLINT $67.00 L3908

423037022 ED-WRIST IMMOBILIZER $104.00 L3980

423037023 ED-ANKLE BRACE $140.00 L4350

423037024 ED-WALKING BOOT $141.00 L4361

423037025 ED-WALKING BOOT NON PNEUMATIC $141.00 L4387

423037026 ED-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

306107000 N-ARM SLING LARGE $54.00 A4565

306107002 N-CPAP FACEMASK - LARGE $385.00 A7030

306107003 N-CPAP HEADGEAR $164.00 A7035

53 5/3/2019


Pomeroy Wa, 99347

306107004 N-CPAP TUBING $168.00 A7037

306107006 N-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

306107007 N-ENTERAL PUMP KIT $12.00 B4035

306107008 N-NUTRITION PUMP KIT $53.00 B4035

306107010 N-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

306107011 N-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

306107012 N-BIAP HEATED HUMIDIFIER $163.00 E0562

306107013 N-BIPAP MACHINE $522.00 E0601

306107015 N-ANKLE BRACE-LACER-L $134.00 L1902

306107016 N-ANKLE AIR SPLINT 90 $385.00 L1906

306107017 N-ANKLE WALKER- MED. $326.00 L1930

306107018 N-SHOE, POST OP MENS-LG $16.00 L3260

306107019 N-SHOE, POST OP FML - MED $16.00 L3260

306107020 N-SHOE, POST OP FML - LG $16.00 L3260

306107021 N-WRIST & THUMB SPLINT $67.00 L3908

306107022 N-WRIST IMMOBILIZER $104.00 L3980

306107023 N-ANKLE BRACE $140.00 L4350

306107024 N-WALKING BOOT $141.00 L4361

306107025 N-WALKING BOOT NON PNEUMATIC $141.00 L4387

306107026 N-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

306107027 N-FRENCH FOLEY CATH 22 2 WAY $27.00 A4344

306107028 N-FRENCH FOLEY CATH 18 2 WAY $27.00 A4344

306107029 N-ENEMA KIT $48.00 A4458

423037005 ED-NON ELECTRIC SPIROMETER $21.00 A9284

423037027 ED-FRENCH FOLEY CATH 22 2 WAY $27.00 A4344

423037028 ED-FRENCH FOLEY CATH 18 2 WAY $27.00 A4344

307017000 A-ARM SLING LARGE $54.00 A4565

307017001 A-FOREARM SPLINT, PADDED, MED $31.00 A4570

307017002 A-CPAP FACEMASK - LARGE $385.00 A7030

307017003 A-CPAP HEADGEAR $164.00 A7035

307017004 A-CPAP TUBING $168.00 A7037

307017005 A-NON ELECTRIC SPIROMETER $21.00 A9284

307017006 A-ENTERNAL FEEDING SUPPLY KIT $7.00 B4034

307017007 A-ENTERAL PUMP KIT $12.00 B4035

307017008 A-NUTRITION PUMP KIT $53.00 B4035

307017009 A-ENTERAL INFUSION PUMP $12.00 B9002

307017010 A-CATHETER, INFUSION, OTHER THAN HEMODIALYSIS $348.00 C1751

307017011 A-CATHETER INFUSION, NON-HEMODIALYSIS $348.00 C1751

307017012 A-BIAP HEATED HUMIDIFIER $163.00 E0562

307017013 A-BIPAP MACHINE $522.00 E0601

307017014 A-ADULT CERVICAL COLLAR $33.00 L0172

307017015 A-ANKLE BRACE-LACER-L $134.00 L1902

307017016 A-ANKLE AIR SPLINT 90 $385.00 L1906

307017017 A-ANKLE WALKER- MED. $326.00 L1930

307017018 A-SHOE, POST OP MENS-LG $16.00 L3260

307017019 A-SHOE, POST OP FML - MED $16.00 L3260

307017020 A-SHOE, POST OP FML - LG $16.00 L3260

54 5/3/2019


Pomeroy Wa, 99347

307017021 A-WRIST & THUMB SPLINT $67.00 L3908

307017022 A-WRIST IMMOBILIZER $104.00 L3980

307017023 A-ANKLE BRACE $140.00 L4350

307017024 A-WALKING BOOT $141.00 L4361

307017025 A-WALKING BOOT NON PNEUMATIC $141.00 L4387

307017026 A-MEDE KAST ULTRA CASTING SYSTEM TCC2ULTR $213.00 Q4038

307017027 A-FRENCH FOLEY CATH 22 2 WAY $27.00 A4344

307017028 A-FRENCH FOLEY CATH 18 2 WAY $27.00 A4344

307017029 A-ENEMA KIT $48.00 A4458

307010084 A-HYDRATION IV INFUSION:INT 31 MIN-1HR $229.01 96360


307010058 A-TREATMENT IV INFUSION: #1 UP TO 1 HR $344.00 96365

307010057 A-HYDRATION IV INFUSION: EACH ADD HR $79.00 96361


307010059 A-TREATMENT IV INFUSION:#1 EACH ADD HR $76.00 96366

307010060 A-TREATMENT IV INFUSION:#2 UP TO 1 HR $344.00 96365






307010066 A-IV PUSH MEDICATION INJ-INITIAL #1 $149.00 96374

307010067 A-IV PUSH MEDICATION INJ-SEQ PUSH; EACH $88.00 96375



307010070 A-INJECTION(SUBQ,INTRMS) $75.50 96372

307010073 A-PICC LINE FLUSH (W/O INJ OR INFUS) $233.00 96523

307010075 A-PICC LINE REMOVAL $233.00 36589

306107001 N-FOREARM SPLINT, PADDED, MED $31.00 A4570

306107005 N-NON ELECTRIC SPIROMETER $21.00 A9284

417040109 DOPAMINE 400MG/250ML PREMIX BAG $80.20 J1265

417040430 Cathflo Activase 2 MG VIAL $302.50 J2997

101150008 SWING BED-SEMI PVT $230.00

101130008 SWING BED-SEMI PVT $230.00

101150020 SWING BED-PRIVATE $260.00

307010071 A-GLUCOMETRY READING $7.00 82943

306107014 N-ADULT CERVICAL COLLAR $33.00 L0172






532160006 D-DIABETES TRAINING (UNIT) $106.00 G0108





55 5/3/2019


Pomeroy Wa, 99347







325250006 D-DIABETES TRAINING (UNIT) $106.00


325250004 D-DIETARY CONSULT $92.00

325250005 D-NUTRITION SUPPLEMENT-1500ML FEEDING BAGS $17.00




41420003 X-EYE FOREIGN BODY XRAY-READING $25.00 70030

41420005 X-MANDIBLE LESS THAN 4 VIEW-READING $25.00 70100

41420007 X-MANDIBLE 4 VIEW-READING $25.00 70110

41420009 X-MASTOID-READING $25.00 70120

41420011 X-MASTOIDS 3 VIEWS-READING $25.00 70130

41420013 X-FACIAL BONES LESS THAN 3-READING $25.00 70140

41420015 X-FACIAL BONES MIN 3 VIEWS-READING $25.00 70150

41420017 X-NASAL BONES-READING $25.00 70160

41420019 X-ORBITS 4 VIEW-READING $25.00 70200

41420021 X-SINUS LESS THAN 3 VIEWS-READING $78.00 70210

41420023 X-SINUS MIN 3 VIEW-READING $78.00 70220

41420025 X-SKULL 2 VIEWS-READING $144.00 70250

41420027 X-SKULL 4 VIEW-READING $25.00 70260

41420029 X-UNILATERAL TMJS-READING $25.00 70328

41420031 X-BILATERAL TMJS-READING $25.00 70330

41420033 X-NECK SOFT TISSUE-READING $78.00 70360

41420035 X-CHEST 1 VIEW-READING $25.00 71045

41420037 X-CHEST 2 VIEWS READING $25.00 71046

41420040 X-RIBS-READING $25.00 71100

41420043 X-RIB UNI-READING $25.00 71101

41420045 X-RIB BILATERAL READING $25.00 71101

41420047 X-BILATERAL RIB 4 VIEW READING $25.00 71111

41420049 X-STERNUM READING $25.00 71120

41420051 X-SPINE 1 VIEW READING $25.00 72020

41420053 X-SPINE CERVICAL READING $25.00 72040

41420055 X-CERVICAL SPINE 4 OR 5 VIEWS-READING $25.00 72050

41420057 X-CERVICAL SPINE COMPLETE-READING $25.00 72052

41420059 X-THORACIC 3 VIEWS -READING $25.00 72072

41420061 X-THORACIC 4 VIEW-READING $25.00 72074

41420063 X-THORACIC/LUMBAR READING $25.00 72080

41420065 X-SPINE L BENDING VIEWS-READING $25.00 72120

41420067 X-SPINE LUMBOSACRAL AP/LAT-READING $25.00 72100

41420069 X-SPINE LUMBOSACRAL COMPLETE-READING $25.00 72110

41420071 X-PELVIS AP-READING $25.00 72170

56 5/3/2019


Pomeroy Wa, 99347

41420073 X-PELVIS COMPLETE-READING $25.00 72190

41420075 X-SI JOINT-READING $25.00 72200

41420077 X-SI JOINTS 3 VIEWS-READING $25.00 72202

41420079 X-SACRUM/COCCYX-READING $25.00 72220

41420082 X-CLAVICLE-READING $25.00 73000

41420085 X-SCAPULA-READING $25.00 73010

41420088 X-SHOULDER 1 VIEW-READING $25.00 73020

41420091 X-SHOULDER COMPLETE-READING $25.00 73030

41420093 X-AC JOINTS 2 VIEWS-READING $25.00 73050

41420096 X-HUMERUS 2 VIEWS-READING $25.00 73060

41420099 X-ELBOW 2 VIEWS-READING $25.00 73070

41420102 X-ELBOW COMPLETE-READING $25.00 73080

41420105 X-FOREARM-READING $25.00 73090

41420108 X-WRIST 2 VIEWS-READING $25.00 73100

41420111 X-WRIST COMPLETE-READING $25.00 73110

41420114 X-HAND 2 VIEWS-READING $25.00 73120

41420117 X-HAND COMPLETE-READING $25.00 73130

41420120 X-FINGER-READING $25.00 73140

41420122 X-HIP UNILATERAL WITH PELVIS -READING $25.00 73501

41420127 X-HIP BILATERAL W/AP PELVIS READING $25.00 73521

41420130 X-FEMUR 2 VIEWS-READING $25.00 73552

41420133 X-KNEE 1 OR 2 VIEW-READING $25.00 73560

41420136 X-KNEE 3 VIEW-READING $25.00 73562

41420138 X-KNEE AP BILATERAL STANDING SINGLE VIEW-READING $25.00 73565

41420141 X-KNEE 4 OR MORE VIEWS-READING $25.00 73564

41420143 X-KNEES BILATERAL VIEWS READING $25.00 73565

41420146 X-TIBIA/FIBULA READING $25.00 73590

41420149 X-ANKLE 2 VIEW READING $25.00 73600

41420152 X-ANKLE COMPLETE-READING $25.00 73610

41420155 X-FOOT 2 VIEWS-READING $25.00 73620

41420158 X-FOOT COMPLETE-READING $25.00 73630

41420161 X-HEEL READING $25.00 73650

41420164 X-TOES X-RAY- READING $25.00 73660

41420166 X-ABDOMEN , SINGLE VIEW READING $25.00 74018

41420168 X-ABDOMEN, 2 VIEWS READING $25.00 74019

41420170 X-ABDOMEN, COMPLETE VIEW- READING $25.00 74021

41420172 X-ACUTE ABDOMEN-READING $25.00 74022

423037029 ED-ENEMA KIT $48.00 A4458

438220234 CL-WELCOME TO MEDICARE $200.00 G0402

405127027 CS-FRENCH FOLEY CATH 22 2 WAY $27.00 A4344

405127028 CS-FRENCH FOLEY CATH 18 2 WAY $27.00 A4344

405127029 CS-ENEMA KIT $48.00 A4458

100010001 NSF CHECK FEE $25.00





57 5/3/2019


Pomeroy Wa, 99347


42330050 ED-CBG $22.00 82948







42330069 ED-ED-EMERGENCY ROOM LEVEL 3 $663.00 99283






























42330011 ED-LAC FACE 12.6 - 20. CM $467.00 12016

42330009 ED-LAC FACE 5.1CM-7.5CM $254.00 12014

42330010 ED-LAC FACE 7.6-12.5CM $254.00 12015







58 5/3/2019


Pomeroy Wa, 99347

42330046 ED-REMOVE-FB EAR $281.00 69200




42330003 ED-REMOVE-FB SKIN $389.00 10120

42330007 ED-SIMP REP H/N/T 2.6-7.5CM $212.00 12002

















IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986


IMPAIRED $- G8986






424210072 PR-OBS H&P LEVEL 2 $208.00 99219







42400046 PR-CAST REMOVAL $297.00 29705


59 5/3/2019


Pomeroy Wa, 99347









40720328 L-CRP TEST $84.00 86140

40720060 L-VANCOMYCIN $215.00 80202


42400088 PR-ER VISIT BRIEF $138.00 99281





















42400003 PR-LAC N/H/F > 30 CM INTM $1,961.00 12047

42400001 PR-LAC N/H/F 12.6-20 CM $611.00 12045

42400002 PR-LAC N/H/F 20.1-30 CM $611.00 12046


MIN) $80.00 99366




42400054 PR-NG INSERTION $413.00 43752



42400070 PR-OBS D/C $157.00 99217

42400071 PR-OBS H&P LEVEL 1 $150.00 99218

42400072 PR-OBS H&P LEVEL 2 $208.00 99219

60 5/3/2019


Pomeroy Wa, 99347

42400073 PR-OBS H&P LEVEL 3 $348.00 99220







42400075 PR-PHYS H&P LEVEL 2 $243.00 99222

42400076 PR-PHYS H&P LEVEL 3 $313.00 99223




42400074 PR-PHYS. H&P LEVEL 1 $184.00 99221


































61 5/3/2019


Pomeroy Wa, 99347














417040432 MUPIROCIN 2% OINTMENT 22 g $102.50


42280004 OT-MASSAGE $17.00 97124






OT-OCC. THERAPY RE-EVAL.OT-OCC. THERAPY RE-EVAL. $133.00 97168



IMPAIRED $- G8986


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984


IMPAIRED $- G8984



IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8985

62 5/3/2019


Pomeroy Wa, 99347


IMPAIRED $- G8985


IMPAIRED $- G8985


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8981


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983


IMPAIRED $- G8983




IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982


IMPAIRED $- G8982

42060033 PT-COMMUNITY INTERGRATION $74.00 97537



63 5/3/2019


Pomeroy Wa, 99347




42060019 PT-GAIT TRAINING $88.00 97116




























IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990


IMPAIRED $- G8990




64 5/3/2019


Pomeroy Wa, 99347


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8991


IMPAIRED $- G8992


IMPAIRED $- G8992


IMPAIRED $- G8992










IMPAIRED $- G8993























65 5/3/2019


Pomeroy Wa, 99347






IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


IMPAIRED $- G8994


42060008 PT-PARAFIN BATH $18.00 97018









IMPAIRED $- G8990



















66 5/3/2019


Pomeroy Wa, 99347






42060032 PT-SELF CARE/ADL $61.00 97535











42060009 PT-WHIRLPOOL $40.00 97022

41420125 X-HIP UNILATERAL WITH PELVIS WHEN PERFORMED - READING $25.00 73502

42119 ST-SPEECH THERAPY GROUP $80.00 92508

421190008 ST-SPEECH THERAPY GROUP $80.00 92508

421190009 ST-FLEXIBLE ENDOSCOPIC EVAL OF SWALLOWING-BY VIDEO $479.00 92612

421190010 ST-SWALLOW CURRENT STATUS $- G8996

421190011 ST-SWALLOW GOAL STATUS $- G8997

421190012 ST-SWALLOW D/C STATUS $- G8998

421190013 ST-SPEECH THERAPY 15 MIN $149.00 92507

307010053 A-HEART-LING RESUSCIT CPR $2,532.00 92950

307010054 A-FRENCH FOLEY CATH 22" 2 WAY $27.00 A4344

307010055 A-FRENCH FOLEY CATH 18" 2 WAY $27.00 A4344

307010085 A-HYDRATION IV INFUSION: EACH ADD HR $79.00 96361

307010086 A-TREATMENT IV INFUSION: #1 UP TO 1 HR $344.00 96365












307010098 A-INJECTION(SUBQ,INTRMS) $75.50 96372

307010099 A-GLUCOMETRY READING $7.00 82943

307010102 A-PICC LINE REMOVAL $233.00 36589

101150029 HOSPITAL RESPITE-PRIVATE $295.00

307010101 A-PICC LINE FLUSH (W/O INJ OR INFUS) $233.00 96523

100010000 NO CHARGE $-

67 5/3/2019


Pomeroy Wa, 99347

306100001 N-CENTRAL LINE DRAW $56.00 36592

306100002 N-PORT-A-CATH ACCESS $239.00 96522

306100003 N-WOUND CARE SIMPLE-NURSE $361.00 97602

306100004 N-WOUND CARE INTERMED-NURSE $742.00 97602


417040402 VANCOMYCIN HCL 750 MG VIAL $60.60 J3370

40720018 L-BLOOD DRAW $25.00 36415

417040409 CULTURELLE HEALTH-WELLNESS CAP/lactobacillus $8.60

417040359 THP Acetaminophen 160mg/5ml #118ml bottle $15.00

417040361 THP Amox/clav 250-62.5mg #75ml Susp $141.60

417040364 THP Amoxi/clav 500-125mg tab #6 $102.50

417040365 THP Amox/clav 875-125mg tab #6 $123.70

417040366 THP Azithromycin 100mg/5ml #15ml susp $142.00

417040367 THP Azithromycin 250mg tab #6 $32.50

417040368 THP Benzonatate 100mg cap #6 $30.50

417040369 THP Cephalexin 250mg/5ml #100ml Susp $117.50

417040371 THP Ciprofloxacin 500mg tab #6 $20.50

417040374 THP Diphenhydramine 12.5mg/5ml sol #60ml $20.00

417040376 THP Doxycycline 100mg tab #6 $20.00

417040428 THP Gentamicin 0.3% Opth Sol $35.50

417040375 THP Diphenhydramine 25mg cap #6 $20.00

417040372 THP Cyclobenzaprine 10mg tab #6 $20.00

417040370 THP Cephalexin 500mg cap #6 $20.00

417040362 THP Amoxicillin 250mg cap #6 $20.00

417040360 THP acetaminophen/Codeine 300/30mg #6 $20.00

417040377 THP Guaifenesin/codeine #60ml $20.00

417040378 THP Hydrocodone/APAP 5/325mg tab #6 $20.00

417040380 THP Ibuprofen 200mg tab #24 $20.00

417040381 THP Levofloxacin 750mg tab #2 $20.00

417040382 THP Lorazepam 0.5mg tab #6 $20.00

417040383 THP MECLIZINE 25MG TAB #6 $20.00

417040384 THP Metronidazole 500mg tab #6 $20.00

417040385 THP Omeprazole 20mg cap #6 $20.00

417040386 THP Ondansetron ODT #6 $25.00

417040387 THP oxycodone/APAP 5/325mg tab #6 $20.00

417040388 THP Penicillin 250mg/5ml susp #100ml $53.70

417040389 THP Penicillin 250mg tab #6 $20.00

417040390 THP Phenazopyridine 100mg tab #6 $20.00

417040392 THP Prednisone 20mg tab #6 $20.00

417040393 THP Prednisone 5mg tab #6 $20.00

417040395 THP Promethazine 25mg tab #6 $20.00

417040396 THP Sulfa/TMP 800/160mg tab #6 $20.00

417040394 THP Prednisone 5mg/5ml liq #60ml $162.00

417040397 THP Sulfacetamide 10% opth sol 15ml $132.00

417040398 THP Tramadol 50mg tab #6 $25.00


405120017 CS-ANKLE BRACE-LACER-M $134.00 L1902

68 5/3/2019


Pomeroy Wa, 99347

424210112PR-SIMPLE SUPERFICIAL REPAIR WOUND S,N,A,EG,T, EX 2.6CM TO 7.5 CM $396.00 12002

424210111PR-SIMPLE SUPERFICIAL REPAIR WOUND S,N,A,EG,T, EX 2.5CM OR LESS $373.00 12001

424210113PR-SIMPLE SUPERFICIAL REPAIR WOUND S,N,A,EG,T, EX 7.6 CM TO 12.5

CM $464.00 12004


CM $579.00 12005


CM $719.00 12006

424210116PR-SIMPLE SUPERFICIAL REPAIR WOUND S,N,A,EG,T, EX OVER 30.0 CM $815.00 12007

424210117PR-SIMPLE REPAIR OF SUPERFICIAL FACE E,E,N,L,MM 2.5 CM OR LESS $394.00 12011

424210118PR-SIMPLE REPAIR OF SUPERFICIAL FACE E,E,N,L,MM 2.6 CM TO 5.0 CM $432.00 12013



424210121PR-SIMPLE REPAIR OF SUPERFICIAL FACE E,E,N,L,MM 12.6 CM TO 20.0

CM $218.00 12016

424210122 PR-INTERMEDIATE REPAIR WOUNDS S,A,T,EX 2.5 CM OR LESS $448.00 12031

424210123 PR-INTERMEDIATE REPAIR WOUNDS S,A,T,EX 2.6 CM TO 7.5 CM $629.00 12032




424210127 PR-INTERMEDIATE REPAIR WOUNDS S,A,T,EX OVER 30.0 CM $1,140.00 12037

424210128 PR-INTERMEDIATE REPAIR WOUNDS N,H,F,EX 2.5 CM OR LESS $496.00 12041


423030003 ED-REMOVE-FB SKIN $389.00 10120




423030007 ED-SIMP REP H/N/T 2.6-7.5CM $212.00 12002

423030009 ED-LAC FACE 5.1CM-7.5CM $254.00 12014

423030010 ED-LAC FACE 7.6-12.5CM $254.00 12015

423030011 ED-LAC FACE 12.6 - 20. CM $467.00 12016










69 5/3/2019


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423030046 ED-REMOVE-FB EAR $281.00 69200





438220249 CL-SPORTS PHYSICAL EXAM $53.00

417040431 APLISOL 5T UNITS/0.1 ML VIAL 1 unit, 1 mL $15.00


IMPAIRED $- G8981


IMPAIRED $- G8981


420170167 PT-MANUAL THERAPY 1 OR MORE REGIONS, EACH 15 MINS $103.00 97140

420170166 PT-THERAPEUTIC ACTIVITIES,DIRECT,EACH 15 MIN $90.00 97530









70 5/3/2019


Pomeroy Wa, 99347


306107009 N-ENTERAL INFUSION PUMP $12.00 B9002





417040433 MIDAZOLAM HCL 1 MG/ML VIAL 5 mL $12.85 J2250

417040237 MIDAZOLAM 5MG/1ML VIAL $16.00 J2250

420170019 PT-GAIT TRAINING $88.00 97116


423037031ED-MEASUREMENT OF POST VOIDING RESIDUAL URINE AND/OR

BLADDER CAP BY US, NON-IMAGING $662.00 51798


40720495L-CULTURE, FUNGI ISOLATION, WITH PRES IDENTIFICATION OF ISOLATES-

OTHER SOURCE(EXCEPT BLOOD) $110.00 87102

417040434 TENIVAC SYRINGE 0.5 mL $158.90 90714

417040332 TETANUS, DIPTHERIA, PERTUSSIS (TDAP) $162.50 90715

41120001 EKG $252.00 93000




417040439 FluZONE QUAD 2018-2019 SYRINGE 0.5 mL $25.00 90686

417040440 FluZONE HIGH-DOSE 2018-19 SYR , 0.5 mL $52.00 90662





438220246 CL-POLIOVIRUS VACCINE (STATE SUPPLY) $0.01 90713,SL

438220247 CL-HEPATITS A VACCINE (STATE SUPPLY) $0.01 90633,SL

438220248 CL-VARICELLA VIRUS VACCINE (STATE SUPPLY) $0.01 90716,SL

438220250 CL-HEPATITS A VACCINE (ADULT) $101.00 90632

438220252 CL-TDAP GREATER THAN 7 YEARS OF AGE $163.00 90715

438220253 CL-MMRV (STATE SUPPLY) $0.01 90710,SL

438220254 CL-HEPATITIS B (ADULT) $86.00 90746

438220255 CL- INFLUENZA VIRUS VACCINE $25.00 90686

438220256 CL- INFLUENZA VIRUS VACCINE(HIGH DOSE) $62.00 90662

417040438 INFANRIX DTAP SYRINGE 0.5 mL $35.50 90700

417040435 HAVRIX 1,440 UNITS/ML SYRINGE 1 mL $101.00 90632

417040437 PROQUAD VIAL 1 each $302.50 90710

417040436 Engerix-B 20 MCG/ML SYRINGE $85.70 90746


405127030 CS-UNNA BOOT $88.00

306107030 N-UNNA BOOT $88.00

307017030 A-ACUTE CARE LEVEL 1 $1,055.00




71 5/3/2019


Pomeroy Wa, 99347



307017033 A-ACUTE CARE LEVEL 4 $-




405127034 CS-LINERS-SMALL $14.00

405127035 CS-LINERS-MED $14.00

405127036 CS-LINERS-LARGE $14.00

405127037 CS-PULL ONS-SM/MED $43.00

405127038 CS-PULL ONS-LARGE $38.00

405127039 CS-PULL ONS-XLARGE $38.00

405127040 CS-PULL ONS-XXL $25.00

405127041 CS-BRIEFS-MED $18.00

405127042 CS-BRIEFS-LARGE $24.00

405127043 CS-BRIEFS-XLARGE $25.00

405127044 CS-BRIEFS-XXL $35.00

40720496 L-CHAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH $163.00 87491

438220257 CL-PNEUMOCOCCAL 23 $110.00 90732

438220258 CL-INFLUENZA (PEDIATRIC 6-30 MONTHS) $0.01 90685,SL



438220259 CL-INFULENZA (36 MONTHS+) $0.01 90686,SL

438220251 CL-DTAP (STATE SUPPLY) $0.01 90700,SL


438220081 CL-PROTHROMBIN TIME; FINGERSTICK $- 85610

438220175 CL-SUTURE/STAPLE REMOVAL $78.00 99211

40720497 L-PROCALCITONIN (SEND OUT) $171.00 84145

596729 morphine SULFATE 10 MG/ML VIAL 10 mg, 1 mL $2.87

417040441 glipiZIDE ER 10 MG TABLET $11.25

417040442 ISOSORBIDE MONONIT 10 MG TAB $10.90

596730 glipiZIDE ER 10 MG TABLET 10 mcg, 100 eaches $0.24

596731 ISOSORBIDE MONONIT 10 MG TAB 10 mcg, 100 eaches $0.08

417040148 GLIPIZIDE ER 5MG TAB $29.50

417040443 morphine SULFATE 10 MG/ML VIAL 10 1 mL $20.90

417040444 PIPERACIL-TAZOBACT 2.25 GM VL $64.00 J2543

417040075 CIPROFLOXACIN WITH HYDROCORTISONE OTIC DROPS 10ML $538.90

417040363 THP Amoxicillin 250mg/5ml #80ml Susp $32.50

417040373 THP Dexamethasone 0.5mg/5ml elixir #60ml $83.50


417040445 lithium carbonate 300 MG CAP $5.00

417040226 METOLAZONE 2.5MG TAB $26.50

417040447 FLUCAINE EYE DROPS 5 mL $70.00

417040448 levoFLOXacin 250 MG/50 ML-D5W $44.50 J1956


417040227 METOLAZONE 5MG TAB $28.95

417040093 DEXAMETHASONE ELIXIR 0.5MG/5ML $-

72 5/3/2019


Pomeroy Wa, 99347

417040152 GUAIFENESIN AND CODEINE 100MG/10MG PER 5ML $-

417040452 NYAMYC 100,000 UNITS/GM POWDER 15 g $31.65

417040453 I-VITE PROTECT TABLET 1 ea $5.00

417040290 PREDNISONE 5MG/5ML ORAL SOLUTION $30.50

417040451 SOLU-Medrol 1 GRAM VIAL $162.50 J2930

417040449 IBUPROFEN 400 MG TABLET $5.00

417040454 DEEP SEA 0.65% NOSE SPRAY 1 ea, 44 mL $20.00



417040455 HYDROmorphone 2 MG/ML VIAL mL $26.50

417040456 HYDROCORTISONE 1% CREAM 1 g, 28 g $26.85

417040450 INSTA-GLUCOSE GEL 31g $30.50

417040457 TRIAMCINOLONE 0.1% OINTMENT 15 g $32.50

417040459 SINUS RELIEF 1% NASAL SPRAY 30 mL $30.00


417040217 METHADONE 10MG TAB $5.90

417040422 MAGNESIUM SULF 1 G/100 ML-D5W $46.90 J3475

417040460 VITAMIN D2 1.25MG(50,000 UNIT) 5,0000 unit cap $20.50

438220262

CL-DIPHTHERIA,TETNUS TOXOIDS,ACELLUAR PERTUSSIS VACCINE,

HAEMOPHILUS INFLUENZA TYPE B, AND INACTIVEATED

POLIOVIRUS(DTAP-IPV/HIB) FOR INTRAMUSCULAR USE $0.01 90698,SL

438220260 CL-HEPATITIS B VACC, PEDI/ADOL DOSAGE 3 DOSE SCHEDULE $0.01 90744,SL

438220261CL-PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR

INTRAMUSCULAR USE $0.01 90670,SL

417040462 CHOLESTYRAMINE PACKET 4 g, 1 each $26.50



417040278 PHENOBARBITAL, HYOSCYAMINE, ATROPINE, SCOPALAMINE $114.00

417040464 LISINOPRIL 2.5 MG TABLET $7.60

40720500L-AEROBIC ISOLATE, ADD METHODS REQ FOR DEFIN IDENT, EACH

ISOLATE $9.00 87077

40720498 L-URINALYSIS AUTOMATED W/O MICROSCOPY $21.00 81003

40720503 L-CARBAMAZEPINE:TOTAL $13.00 80156

40720502 L-TRANSFERASE:ASPARTATE AMINO (AST)(SGOT) $10.00 84450

40720505L-HIV-1 ANTIGEN(S),WITH HIV-1 AND HIV-2 ANTIBODIES,SINGLE RESULT $40.00 87389

40720506 L-ALPHA-FETOPROTEIN (AFP);SERUM $44.00 82105

40720507 L-ALKALOIDS, NOT OTHERWISE SPECIFIED $84.00 80323

40720504 L-CLOTTING,FACTOR V(ACG OR PROACCELERIN),LABILE FACTOR $133.00 85220

40720499 L-TREPONEMA PALLIDUM $4.00 86780

40720501 L-CULTURE, BACTERIAL, QUANTITATIVE COLONY COUNT, URINE $15.00 87086

417040465 lidocaine 4% patch (salonpas) $16.00

417040379 THP Hydrocodone/APAP 7.5/325mg tab #6 $20.00

417040466 PREVNAR 13 SYRINGE 0.5 mL $302.50

417040467 PNEUMOVAX 23 SYRINGE 0.5 mL $212.50

417040468 ketorolac 0.5% OPHTH SOLUTION 10 mL $56.50

417040469 ABILIFY 10 MG TABLET $113.65

73 5/3/2019


Pomeroy Wa, 99347

417040470 GEMFIBROZIL 600 MG tablet $12.94

417040471 ESTRACE 0.01% CREAM 1 ea, 42.5 g $443.00

417040472 PIOGLITAZONE HCL 30 MG TABLET $-

417040473 QUEtiapine FUMARATE 100 MG TAB $21.60

417040474 raNITIdine 150 MG TABLET $5.00

417040475 THP Metoprolol 50mg #6 $15.00

417040477 THP Oseltamivir 75mg capsule #4 $102.00

417040723 THP Oseltamivir 6mg/ml Susp 60ml $203.50



417040291 PREDNISOLONE 15MG/5ML SYRUP $16.45 J7510

417040461 Cortrosyn 0.25 MG VIAL 0.25 mg, 1 each $1,496.00

417040725 PROCRIT 10,000 UNITS/ML VIAL 10000 unit, 1 mL $275.00 J0885

417040724 OSELTAMIVIR PHOS 30 MG CAPSULE $32.50

438220263 CL-DOT/CDL PHYSICAL $110.00


438220264 CL-NO CHARGE $-

306100026 N-IMMUNIZATION ADMINISTRATION $52.00 90471

307010100 A-IMMUNIZATION ADMINISTRATION $52.00 90471

438220088 CL-IMMUNIZATION INJECTION $30.00 90471

307010072 A-IMMUNIZATION ADMINISTRATION $52.00 90471

417040726 Farxiga 5 MG TABLET $79.20

417040727 CHLORTHALIDONE 25 MG TABLET $15.55

417040160 HYDROMORPHONE 2MG CARPUJECT $26.50 J1170

417040728 PREPARATION H CREAM 27 g $15.00

101150007 PERM SWING-SEMI PRIVATE $230.00

101150017 PERM SWING -PRIVATE $260.00

101130020 SWING BED-PRIVATE $260.00

417040729 LINEZOLID 600 MG TABLET $16.75

417040730 XYLOCAINE-MPF 1% VIAL 5 mL $21.45

417040731 VERAPAMIL 2.5 MG/ML VIAL 10 mg, 4 mL $162.50

417040732 THP Albuterol Inhaler $102.20

417040733 diphenhydrAMINE 25 MG/10 ML $5.00


417040045 BETAMETHASONE 6MG VIAL $187.90 J0702

417040734 WARFARIN SODIUM 3 MG TABLET $9.00


438220266 CL-CLONIDINE HCL 1 MG $0.28 J0735

438220267 CL-DIPHENHYDRAMINE HCL, UP TO 50MG $1.54 J1200

438220268 CL-KETOROLAC TROMETHAMINE, 15MG $7.20 J1885

438220269 CL-METOCLOPRAMIDE HCL, UP TO 10MG $1.60 J2765

438220271 CL-ALBUTEROL MIX $1.20 J7620

438220272CL-PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALLENT(PCV13, FOR

INTRAMUSCULAR USE) $280.50 90670

438220273 CL-VACCINE/TOXOID 1ST INJ $30.00 G0008

438220274 CL-HOME VISIT NEW PATIENT $91.00 99341

74 5/3/2019


Pomeroy Wa, 99347

438220275CL-SPIROMETRY, INCLUDING GRAPHIC RECORD,TOTAL AND TIMED VITAL

CAPACITY, EXPIRATORY FLOW RATE $129.00 94010

40720508L-CLOSTRIDIUM DIFFICILE, TOXIN GENE(S), AMPLIFIED PROBE TECHNIQUE $31.00 87493

40720509 L-CYTOMEGALOVIRUS, QUANTIFICATION $84.00 87497

438220265 CL-CEFTRIAXONE SODIUM, PER 250 MG $26.50 J0696

417040058 CARBIDOPA/LEVODOPA 25/100MG TAB $8.40

417040735 THP Ofloxacin 0.3% otic solution $63.55

438220270 CL-TRIAMCINOLONE ACETONIDE 10MG (KENALOG) $13.48 J3301

438220276 CL-TRIAMCINOLONE ACETONIDE 40MG VIAL (KENALOG) $49.95 J3301

417040403 metoprolol tart 5 MG/5 ML VIAL $20.50

417040213 MECLIZINE 12.5MG TAB $9.50

40720033 L-CARBAMAZEPINE; TOTAL $185.00 80156

40720471 L-SURGICAL PATH GROSS $50.00 88300

417040206 LORAZEPAM 2MG/ML VIAL $26.50 J2060

417040244 MORPHINE 4MG/ML VIAL $20.50 J2270




417040218 METHENAMINE HIPPURATE 1GM TAB $20.50

417040205 LORAZEPAM 1MG TAB $5.00


417040024 AMPICILLIN/SULBACTAM 1.5GM VIAL $43.20 J0295

417040391 THP Potassium 20mEq tab #6 $20.00

417040463 labetalol HCL 20 MG/4 ML CRPJ 20 mcg, 4 mL $43.05

40720021 L-BASIC METABOLIC PANEL-BMP $144.00 80048

40720297 L-COMPLETE BLOOD COUNT-CBC $137.00 85025

40720268 L-THYROXINE FREE-T4 $74.00 84439

40720156 L-FERRITIN $125.00 82728

40720494L-CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE-THROAT

CULTURE $171.00 87070

40720027 L-LIPID PANEL $68.00 80061

417040736 cranberry concentrate 500mg $5.00

417040257 SODIUM CHLORIDE 0.9% SOLUTION 500 mL $50.00

417040446 glipiZIDE ER 2.5 MG TABLET $13.20

417040458 XYLOCAINE-MPF 1% VIAL 2 mL $15.00

417040010 ADENOSINE 6MG VIAL $16.80 J0153

75 5/3/2019

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