ProcedureID Procedure Description Charge Amount 2500000125 ... fileProcedureID Procedure_Description...

ProcedureID Procedure_Description Charge_Amount2500000125 RELISTOR 12MG VIAL $317.002503000020 ACETAM SUP 120 MG $4.002503000030 ACETAM SUP 650 MG $4.002503000085 ADVAIR DISKUS 250/50 $278.002503000090 ADVAIR DISKUS 500/50 $430.002503000105 ALBUTEROL INHAL KIT 17 GM $163.002503000115 ALBUTEROL SULF AMP 0.083% 3ML $5.002503000140 ALPHAGAN P OPT SOL 0.15% 5 ML $378.002503000240 ANTIPYRINE & BENZ OTIC 15ML $42.002503000260 ASPIRIN SUP 300 MG $5.002503000265 ASPIRIN SUP 600 MG $5.002503000270 ASTELIN NASAL SPRAY 137 MCG $306.002503000290 ATROPINE SULF OPT SOL 1% 5ML $176.002503000305 AZACTAM INJ 1 GM $125.002503000325 BACITRACIN ZINC/POLYMIX B 3.5G $84.002503000335 BACITRACIN‐NEO‐POLY OPT 1/8 OZ $171.002503000370 BISACODYL SUP 10 MG $3.002503000405 BUMETANIDE INJ 0.25MG/ML 4ML $7.002503000425 CALCIUM CHL INJ 1 GM 10ML $30.002503000440 CARBAMIDE PXD 15ML $13.002503000450 CEFEPIME INJ 1 GM 20ML $73.002503000455 CEFEPIME INJ 2 GM 20ML $132.002503000475 CHLORPROMAZINE TAB 25 MG $32.002503000480 CHLORPROMAZINE TAB 50 MG $45.002503000485 CHOLESTYRAME LITE PK 4 GM $11.002503000500 CIPROFLOXACIN OPT SOL 2.5 ML $82.002503000510 CLINDAMYCIN INJ 300MG 2ML $10.002503000520 CLINDAMYCIN INJ 600MG 4ML $12.002503000525 CLINDAMYCIN INJ 600MG ADD $30.002503000540 COCAINE‐ 4% 4ML GLS $636.002503000595 DAKINS SOL 0.5% 473ML $35.002503000625 DETROL LA CAP 2 MG $40.002503000635 DEXTROSE 50% SYRINGE 50ML $27.002503000655 DILTIAZEM INJ 125MG/25ML $30.002503000660 DILTIAZEM INJ 50MG/10ML $15.002503000685 DOXYCYCLINE INJ 100 MG $79.00

2503000690 DUONEB INH/S 3ML $9.002503000700 ENALAPRIL INJ 1.25MG/ML 2ML $17.002503000710 EPINEPHRINE AMP 1:1000 1ML $57.002503000715 EPINEPHRINE INJ 1:1000 30ML $177.002503000740 EYE LUBRICANT OPT OIN 1/8 OZ $39.002503000745 FAMOTIDINE 20MG/2ML 2ML $10.002503000765 FLEET ENEMA W/MERAL OIL $9.002503000775 FLOVENT HFA INHL 110MCG $785.002503000780 FLOVENT HFA INHL 220MCG $1,220.002503000785 FLOVENT HFA INHL 44MCG $453.002503000790 FLUMAZENIL INJ 5 ML $216.002503000805 FLUOROMETHOLONE OPT SUS 5 ML $256.002503000815 FLUTICASONE NASAL 120 DOSE 16G $256.002503000820 FOLIC ACID INJ 50 MG 10ML $72.002503000835 FORTICAL CALCIT‐SALMN SPY 3.7ML $344.002503000840 GDL B‐12 TAB 500 MCG $3.002503000855 GELFOAM SPONGE 12‐7MM $33.002503000865 GENTAMICIN OPT OIN 3.5 GM $64.002503000870 GENTAMICIN OPT SOL 5ML $117.002503000880 GLIMEPIRIDE TAB 1 MG $4.002503000915 HEMORRHOIDAL HC SUP $47.002503000955 HYDROCHLOROTHIAZIDE 12.5MG $3.002503000970 HYDROMORPHONE HCL AMP 1 MG/1ML $11.002503000980 HYOSCYAME SULF 0.125MG 15ML $49.002503001000 INFANRIX SRN W/O NDL 0.5ML $71.002503001030 INVANZ 1GM ADD $392.002503001040 IPRATROPIUM INH 0.02% 2.5ML $674.002503001070 ISOPTO HOMATROPINE 5% 5ML $125.002503001075 ISOPTO TEARS 0.5% 15ML $85.002503001080 KEPPRA O/SOL 100MG/ML 16 OZ $30.002503001090 KETAMINE HCL 50MG/ML 10ML $12.002503001105 LABETALOL INJ 5MG/ML 20ML $23.002503001130 LEXAPRO TAB 10 MG $15.002503001145 LIDOCAINE AMP 1% 2ML $10.002503001160 LIDOCAINE INJ 1% 20ML $5.002503001165 LIDOCAINE INJ 2% 20ML $10.002503001175 LIDOCAINE SRN 1% 5ML $21.00

2503001180 LIDOCAINE/EP INJ 1% 20ML $7.002503001185 LIDOCAINE/EP INJ 1:1 2% 20ML $10.002503001205 M.V.I. ADULT INJ 10ML $66.662503001210 MAG SULF BG 2G 50ML $49.002503001275 METOPROLOL TAR 5MG/5ML $7.002503001280 METRONIDAZOLE BAG 500 MG 100ML $10.002503001285 MIDODRINE HCL TAB 5 MG $18.002503001290 MILK MAGNESIA 30ML UD CUP $8.002503001295 MERAL OIL 30ML $46.002503001310 MIRTAZAPINE TAB 15 MG $12.002503001330 NAFCILLIN SOD INJ 2 GM $92.002503001340 NAPHAZOLINE OPT SOL 0.1% 15ML $29.002503001350 NASONEX NASAL SPRAY 50 MCG 17G $717.002503001360 NEOMYC/POLY‐B/HC EAR SUS 7.5M $252.002503001370 NEOMYCIN‐POLY‐B/DEX SUS 5 ML $65.002503001380 NEO‐SYNEPHRINE SOL/1/2% 15ML $11.002503001390 NEO‐SYNEPHRINE SPY ‐1/2%15ML $22.002503001395 NEO‐SYNEPHRINE SPY 1/4%15ML $15.002503001420 NICOTINE PATCH STEP‐1 21 MG $9.002503001425 NICOTINE PATCH STEP‐2 14 MG $9.002503001430 NICOTINE PATCH STEP‐3 7 MG $9.002503001440 NITRO TRANSDERM 0.1 MG/HR $33.002503001445 NITRO TRANSDERM 0.4 MG/HR $7.002503001450 NITROGL 25 MG/5%DEX 250ML $63.002503001470 NOREPINEPHRINE INJ 1MG/ML 4ML $19.002503001495 OXYCODONE HCL ER TAB 20 MG $39.002503001500 OXYMETAZOLINE SPRAY 15ML $13.002503001570 PILOCARPINE OPT SOL 2% 15ML $293.002503001620 POT CHL BAG 20MEQ 50ML $54.002503001625 POT CHL BAG 40MEQ 100ML $40.002503001640 POT CHL INJ 40MEQ 20ML $23.002503001660 PREDNISOLONE OPT SUS 1% 15ML $166.002503001675 PREDNISOLONE SYRUP 240 ML $8.002503001680 PREDNISOLONE SYRUP 240 ML $5.002503001690 PROCHLORPERAZINE SUP 25 MG $44.002503001695 PROMETHAZINE SUP 12.5MG $58.002503001700 PROMETHAZINE SUP 25 MG $58.00

2503001705 PROMETHAZINE SUP 50 MG $117.002503001710 PROPARACAINE OPT SOL 0.5% 15ML $143.002503001715 PROPOFOL INJ 10MG/ML 20ML $25.002503001720 PROPOFOL INJ 10MG/ML 50ML $99.002503001730 PROTONIX IV 10ML $56.002503001750 PULMICORT RESPULE 0.5MG/2ML $37.002503001795 S2 RACEMIC INHL SOL 0.5ML $5.002503001815 SENSORCAINE INJ 0.5% 50ML $37.002503001835 SILVASORB GEL 1.5 OZ $100.002503001845 SILVERSULFADIAZINE 400 GM JAR $195.002503001850 SILVERSULFADIAZINE 50 GM JAR $51.002503001860 SOD BICARB 8.4 50MEQ/50ML $35.002503001865 SOD BICARB INJ 8.4% 50ML $32.002503001875 SOD CHL 0.9% BAG 250ML $45.002503001920 SOD POLYSTYRENE 30 G/120ML $64.002503001935 SPIRIVA HANDIHALER CAP $237.002503001955 SULFACETAMID OPT SOL 10% 15ML $183.002503001965 SULFAMETHOXAZOLE/TR INJ 10ML $41.002503001995 TETRACAINE HCL 0.5% 15ML $48.002503002025 TIMOLOL MAL OPT G/SOL 0.5% 5ML $50.002503002030 TIMOLOL MAL OPT SOL 0.25% 5 ML $37.002503002045 TOBRADEX OPT SUS 2.5ML $196.002503002085 TRIMETHOPRIM SULF/POLYMXN 10ML $57.002503002100 TRUSOPT IN OCUMETER PLUS 10 ML $212.002503002105 TUBERSOL 5 T.U.‐10 TEST 1ML $38.002503002130 VECURONIUM INJ 10 ML $20.002503002135 VERAPAMIL INJ 2.5 MG 2ML $95.002503002165 WATER INJ STR INJ 20ML $5.002503002170 WATER INJ STR INJ 50ML $8.002503002175 XALATAN 2.5 ML $285.002503002200 XOPENEX INH/S 0.63MG/ 3ML $44.002503002205 XOPENEX INH/S 1.25MG/ 3ML $22.002503002220 XYLOCAINE INJ 1% 5ML $17.002503002225 XYLOCAINE INJ 2% 10ML $10.002503002255 TORSEMIDE 5MG TABLET $12.002503003010 A & D OINTMENT 2 OZ $9.002503003015 ABILIFY TAB 15 MG $101.00

2503003020 ABILIFY TAB 5 MG $315.002503003050 ACETAM COD 5ML $5.002503003075 ACETAM SOL 650 MG 20.3ML/100 $8.002503003080 ACETAM TAB 325 MG $7.502503003085 ACETAZOLAMIDE TAB 250 MG $11.002503003090 ACETYLCYSTEINE INJ 20% 30 ML $41.002503003095 ACETYLCYSTEINE INJ 20% 4 ML $42.002503003125 ACTOS TAB 15 MG $57.002503003130 ACTOS TAB 30 MG $29.002503003145 ACYCLOVIR TAB 800 MG $15.002503003150 AGGRENOX CAP 200MG/25MG $29.002503003155 AKWA TEARS 15 ML $19.002503003180 ALBUTEROL SULF TAB 2 MG $23.002503003190 ALENDRONATE SOD TAB 70MG $50.002503003205 ALLOPURINOL TAB 100 MG $3.002503003210 ALLOPURINOL TAB 300 MG $4.002503003215 ALPRAZOLAM TAB 0.25 MG $5.002503003220 ALPRAZOLAM TAB 0.5 MG $6.002503003225 ALPRAZOLAM TAB 1 MG $5.002503003235 AMANTADINE CAP 100 MG $9.002503003260 AMIODARONE HCL TAB 200 MG $12.002503003270 AMITIZA GELCAP 8 MCG $19.002503003275 AMITRIPTYLINE TAB 10 MG $3.002503003285 AMITRIPTYLINE TAB 25 MG $3.002503003290 AMITRIPTYLINE TAB 50 MG $4.002503003300 AMLODIPINE BESYLATE TB 10MG $8.002503003305 AMLODIPINE BESYLATE TB 2.5MG $7.002503003310 AMLODIPINE BESYLATE TB 5MG $6.002503003325 AMLODIPINE/BENZ CP 5/10MG $10.002503003330 AMLODIPINE/BENZ CP 5/20MG $10.002503003335 AMMONIUM LAC LOT 12% 225G OTC $59.002503003345 AMOXICILLIN CAP 250 MG $3.002503003350 AMOXICILLIN CAP 500 MG $4.002503003355 AMOXICILLIN SUS 125 MG 100ML $20.002503003365 AMOXICILLIN SUS 250 MG 100ML $22.002503003390 AMPICILLIN CAP 250 MG $3.002503003445 ANTACID CHEWABLE TAB $5.00

2503003465 ARICEPT TAB 10 MG $66.002503003475 ARIMIDEX TAB 1 MG $22.002503003480 ARTHRITIS MED CREAM 3 OZ $14.002503003495 ASPIRIN TAB 325 MG $4.002503003500 ASPIRIN TAB 81MG $10.002503003510 ASPIRIN TAB EC 325 MG $3.002503003515 ASPIRIN TAB EC 81 MG $3.132503003535 ATENOLOL TAB 25 MG $4.002503003540 ATENOLOL TAB 50 MG $6.002503003560 AUGMENTIN SUS 250 MG 150ML $98.002503003565 AUGMENTIN TAB 250 MG $12.002503003570 AUGMENTIN TAB 500 MG $17.002503003610 AVODART CAP 0.5 MG $20.002503003630 AZITHROMYCIN OS100MG/5ML 15ML $77.002503003635 AZITHROMYCIN OS200MG/5ML 30ML $114.002503003640 AZITHROMYCIN TAB 250 MG $20.002503003655 BACITRACIN OIN 0.5 OZ W/ZINC $156.002503003660 BACITRACIN POLY OIN 1 OZ $29.002503003665 BACITRACIN‐NEO‐POLY OIN 1 OZ $17.002503003670 BACLOFEN TAB 10 MG $4.002503003680 BACTROBAN CR 15 GM TUBE $208.002503003710 BENAZEPRIL TAB 10MG $4.002503003715 BENAZEPRIL HCL TAB 20 MG $4.002503003725 BENICAR TAB 20 MG $42.002503003730 BENZOIN COMPOUND TIN 2 OZ $19.002503003740 BENZONATATE CAP 100 MG $9.002503003750 BENZTROPINE TAB 1 MG $3.002503003790 BETASEPT SURG SCR 4% 4 OZ $18.002503003805 BETHANECHOL CHL TAB 25 MG $7.002503003815 BIDEX DM TAB $4.002503003820 BISACODYL TAB 5 MG $10.002503003870 BUDEPRION XL TAB 150MG $17.002503003880 BUMETANIDE TAB 1 MG $5.002503003885 BUMETANIDE TAB 2 MG $8.002503003895 BUPROPION HCL SR TAB 150MG $7.002503003900 BUPROPION HCL TAB 100 MG $7.002503003905 BUPROPION HCL TAB 75 MG $6.00

2503003910 BUSPIRONE HCL TAB 10 MG $5.002503003915 BUSPIRONE HCL TAB 15 MG $7.002503003920 BUSPIRONE HCL TAB 5 MG $6.002503003925 BUTALBITAL APAP/CAF TAB $7.002503003945 BYSTOLIC TAB 5MG $10.002503003985 CALCITRIOL CAP 0.25 MCG $6.002503003995 CALCIUM CARB TAB 1250 MG $3.002503004030 CAPTOPRIL TAB 25 MG $6.002503004055 CARBAMAZEPINE TAB 200 MG $12.002503004065 CARBIDOPA/LEVODOPA ER 25/100 $5.002503004070 CARBIDOPA/LEVODOPA 10/100 $5.002503004075 CARBIDOPA/LEVODOPA 25/250 $100.002503004080 CARBIDOPA/LEVODOPA 50/200 $8.002503004100 CARISOPRODOL TAB 350 MG $5.002503004110 CARVEDILOL TAB 12.5 MG $7.002503004115 CARVEDILOL TAB 25 MG $8.002503004120 CARVEDILOL TAB 3.125 MG $14.002503004125 CARVEDILOL TAB 6.25 MG $8.002503004140 CATAPRES‐TTS‐1 $108.002503004145 CATAPRES‐TTS‐2 $168.002503004185 CEFDINIR CAP 300 MG $17.002503004205 CEFPROZIL SUS 125MG/5ML 50 ML $69.002503004210 CEFPROZIL SUS 250MG/5ML 50 ML $128.002503004215 CEFPROZIL TAB 250 MG $16.002503004220 CEFTIN SUS 250 MG/5ML 50ML $317.002503004225 CEFUROXIME AXETIL 250MG $16.002503004230 CELEBREX CAP 100 MG $32.002503004235 CELEBREX CAP 200 MG $15.002503004250 CENTRUM $3.002503004255 CEPACOL THROAT LOZ $3.002503004260 CEPHALEXIN CAP 250 MG $5.002503004265 CEPHALEXIN CAP 500 MG $6.002503004270 CEPHALEXIN SUS 125 MG 100ML $30.002503004275 CEPHALEXIN SUS 250 MG 100ML $94.002503004285 CETIRIZINE 1MG/ML SYR 4OZ $6.002503004305 CHILD SUS 4 OZ $8.002503004320 CHLORDIAZPX 25 MG $4.00

2503004325 CHLORDIAZPX 5 MG $4.002503004330 CHLORDIAZPX W/CLID CAP $14.002503004335 CHLORHEXIDINE GLUC O/R 16 OZ $35.002503004365 CHLORTHALIDONE 25 MG $8.002503004390 CICLOPIROX CR 0.77% 30GM $497.002503004395 CILOSTAZOL TAB 100 MG $12.002503004425 CIPROFLOXACIN TAB 250 MG $18.002503004430 CIPROFLOXACIN TAB 500 MG $20.002503004440 CITALOPRAM TAB 20 MG $9.002503004455 CITRATE/MAG 10OZ $10.002503004475 CLARITIN ALLERGY SYR 4OZ CHILD $5.002503004495 CLINDAMYCIN CAP 150 MG $8.002503004520 CLONAZEPAM TAB 0.5 MG $6.002503004530 CLONIDINE TAB 0.1 MG $5.002503004545 CLORAZEPATE TAB 3.75 MG $6.002503004560 CLOTRIMAZOLE CR 1% 30 GM OTC $35.002503004580 CLOTRIMAZOLE/BETAMET D CR 15GM $112.002503004600 COLCHICINE TAB 0.6 MG $8.002503004615 COLYTE W/FLAVOR PACKS 4‐LITER $130.002503004620 COMBIVIR TAB $49.002503004625 COMTAN TAB 200 MG $23.002503004655 CORTEF TAB 10 MG $4.002503004670 COUMADIN TAB 1 MG $10.502503004675 COUMADIN TAB 10 MG $11.002503004680 COUMADIN TAB 2 MG $7.002503004685 COUMADIN TAB 2.5 MG $8.002503004690 COUMADIN TAB 3 MG $8.002503004700 COUMADIN TAB 5 MG $8.002503004710 COVERA‐HS TAB 180 MG $9.002503004715 COVERA‐HS TAB 240 MG $9.002503004720 COZAAR TAB 25 MG $8.002503004725 COZAAR TAB 50 MG $16.002503004745 CRESTOR TAB 10 MG $36.002503004750 CRESTOR TAB 20 MG $106.002503004775 CYMBALTA CAP 20 MG $27.002503004780 CYMBALTA CAP 30 MG $52.002503004785 CYMBALTA CAP 60 MG $26.00

2503004795 CYPROHEPTADINE TAB 4 MG $4.002503004835 DEPAKOTE ER TAB 250 MG $8.002503004840 DEPAKOTE ER TAB 500 MG $6.002503004845 DEPAKOTE SPRNKL CAP 125MG $20.002503004850 DEPAKOTE TAB 125 MG $5.002503004855 DEPAKOTE TAB 250 MG $8.002503004905 DETROL TAB 2 MG $12.002503004910 DEXAMETHASONE SOL 500ML $24.002503004935 DEXAMETHASONE TAB 4 MG $6.002503004970 DIAZEPAM TAB 2 MG $4.002503004975 DIAZEPAM TAB 5 MG $5.002503005010 DICYCLOME TAB 20 MG $3.002503005030 DIGOXIN TAB 0.125 MG $24.002503005035 DIGOXIN TAB 0.25 MG $34.002503005040 DILANTIN INFATAB 50 MG $3.002503005080 DILTIAZEM HCL ER CAP 180 MG $7.002503005085 DILTIAZEM HCL ER CAP 240 MG $9.002503005095 DILTIAZEM TAB 30 MG $5.002503005140 DIOVAN TAB 320 MG $21.002503005150 DIOVAN TAB 80 MG $25.002503005160 DIPHENHYDRAME 12.5MG/5ML $9.002503005170 DIPHENHYDRAME CAPTB 25MG $5.002503005175 DIPHENHYDRAME CR 2% 1 OZ $14.002503005180 DIPHENHYDRAME ELX 4 OZ $5.002503005225 DOCUSATE SOD 100 MG/10ML $4.002503005230 DOCUSATE SOD CAP 100 MG $3.002503005250 DOXAZOSIN MESYLATE TB 2MG $13.002503005255 DOXAZOSIN MESYLATE TB 4MG $5.002503005265 DOXEPIN CAP 10 MG $3.002503005270 DOXEPIN CAP 25 MG $6.002503005280 DOXYCYCLINE CAP 100 MG $13.002503005295 EFFEXOR TAB 50 MG $14.002503005300 EFFEXOR TAB 75 MG $9.002503005315 EFFEXOR XR ERCAP 75 MG $30.002503005385 ENALAPRIL TAB 5 MG $24.002503005405 EPIVIR TAB 150 MG $23.002503005415 ERYPED 200 SUS 100ML $62.00

2503005420 ERY‐TAB 250 MG $6.002503005450 ESTRACE VAGINAL CR W/AP $752.002503005455 ESTRADIOL TAB 1 MG $10.002503005485 ETHAMBUTOL TAB 400 MG $7.002503005495 ETH‐OXYDOSE 20MG/ML $9.002503005515 EVISTA TAB 60 MG $24.002503005525 EXELON CAP 1.5 MG $16.002503005545 FAMOTIDINE TAB 20MG $8.002503005555 FELODIPINE ER TAB 5 MG $6.002503005575 FENTANYL PATCH 25MCG 10CM $70.002503005580 FENTANYL PATCH 50MCG 20CM $86.002503005635 FERROUS SULF EC 325 MG $3.002503005640 FERROUS SULF LIQ 300MG 5ML $8.002503005655 FEXOFENADINE HCL TAB 180MG $8.002503005670 FIBER‐LAX TAB 500 MG $3.002503005675 FINASTERIDE TAB 5 MG $11.002503005695 FLEET ENEMA 4.5 OZ $5.002503005705 FLOMAX CAP 0.4 MG $8.002503005715 FLUCONAZOLE TAB 100 MG $29.002503005720 FLUCONAZOLE TAB 150 MG $46.002503005730 FLUDROCORTISNE ACETATE 0.1MG $5.002503005770 FLUOCINONIDE SOL 0.05% 20ML $57.002503005775 FLUOXETINE CAP 10 MG $10.002503005780 FLUOXETINE CAP 20 MG $10.002503005815 FOLIC ACID TAB 0.4MG $3.002503005820 FOLIC ACID TAB 1 MG $3.002503005875 FUROSEMIDE TAB 20 MG $5.002503005880 FUROSEMIDE TAB 40 MG $7.502503005885 FUROSEMIDE TAB 80 MG $4.002503005890 GABAPENTIN CAP 100 MG $6.002503005895 GABAPENTIN CAP 300 MG $10.002503005900 GABAPENTIN CAP 400 MG $8.002503005905 GABAPENTIN TAB 600 MG $11.002503005940 GEMFIBROZIL TAB 600 MG $15.002503005950 GENEBS E/S CPL $5.002503005980 GERIVITE LIQ 16 OZ $5.002503005985 GLIMEPIRIDE TAB 2 MG $6.00

2503005990 GLIMEPIRIDE TAB 4 MG $6.002503005995 GLIPIZIDE ER TAB 10 MG $4.002503006000 GLIPIZIDE ER TAB 2.5 MG $3.002503006005 GLIPIZIDE ER TAB 5 MG $4.002503006010 GLIPIZIDE TAB 10 MG $4.002503006015 GLIPIZIDE TAB 5 MG $5.002503006030 GLYBURIDE TAB 2.5 MG $4.002503006035 GLYBURIDE TAB 5 MG $5.002503006045 GLYBURIDE/METFORM 5/500 $5.002503006050 GLYCOLAX 17GM $20.002503006070 GUAIFENESIN SYRUP 16 OZ $7.002503006095 GUIATUSS AC SYR 16 OZ $3.002503006110 GUIATUSS PL SYR 200MG 10ML $9.002503006145 HALOPERIDOL TABS 0.5MG $3.002503006150 HALOPERIDOL TABS 1MG $4.002503006155 HEMORRHOIDAL H OIN 1 OZ $14.002503006175 HUM GLYCERIN USP 16 OZ $5.002503006180 HYDRALAZINE TAB 10 MG $3.002503006185 HYDRALAZINE TAB 25 MG $6.002503006190 HYDRALAZINE TAB 50 MG $4.002503006195 HYDROCHLOROTHIAZIDE 25 MG $3.002503006205 HYDROCODONE W/APAP 10/325 $8.002503006220 HYDROCODONE W/APAP 5/325 $6.002503006225 HYDROCODONE W/APAP 7.5/325 $4.002503006235 HYDROCODONE W/APAP ELX 15ML $16.002503006255 HYDROCORTISON CR 1% 1 OZ $14.002503006265 HYDROCORT CR 2.5% 30 GM $36.002503006310 HYDROMORPHONE TAB 2 MG $6.002503006325 HYDROXYCHLOROQUINE 200 MG $15.002503006340 HYDROXYZINE PAM 25 MG $4.002503006345 HYDROXYZINE PAM 50 MG $6.002503006355 HYDROXYZINE TAB 10 MG $4.002503006360 HYDROXYZINE TAB 25 MG $5.002503006365 HYOSCYAME ODT TAB 0.125MG $5.002503006385 IBUPROFEN SUS 5 ML $12.002503006390 IBUPROFEN TAB 200 MG $3.002503006395 IBUPROFEN TAB 400 MG $3.00

2503006400 IBUPROFEN TAB 600 MG $4.002503006405 IBUPROFEN TAB 800 MG $4.002503006440 IMITREX TAB 100 MG $82.002503006450 IMITREX TAB 50 MG $82.002503006465 INDOMETHACIN CAP 25 MG $4.002503006490 IODOSORB GEL 1.4 OZ $398.002503006500 ISONIAZID TAB 300 MG $5.002503006510 ISOSORBIDE DIN ORL 10 MG $5.002503006530 ISOSORBIDE MON ER 30 MG $7.002503006540 ISOSORBIDE MON TAB 20 MG $5.002503006565 JANUVIA TAB 50 MG $47.002503006600 KEPPRA TAB 500 MG $12.002503006605 KETOCONAZOLE CREAM 2% 15 GM $101.002503006610 KETOCONAZOLE SHAMPOO 2% 4OZ $91.002503006630 KETOROLAC TAB 10 MG $8.002503006640 KLOR‐CON 20 MEQ POW $20.002503006650 LABETALOL TAB 100 MG $4.002503006655 LABETALOL TAB 200 MG $4.002503006670 LACTINEX GRANULE $7.002503006680 LACTULOSE SOL 30ML $8.002503006695 LAMICTAL TAB 100 MG $10.002503006700 LAMICTAL TAB 25 MG $14.002503006705 LAMISIL AT ATH FOOT CR 12 GM $33.002503006750 LEVAQUIN TAB 250 MG $54.002503006755 LEVAQUIN TAB 500 MG $63.002503006760 LEVAQUIN TAB 750 MG $118.002503006765 LEVOTHROID TAB 200 MCG $5.002503006770 LEVOTHROID TAB 50 MCG $4.002503006775 LEVOTHYROXINE SOD 75MCG $8.002503006780 LEXAPRO TAB 20 MG $15.002503006785 LEXAPRO TAB 5 MG $14.002503006795 LIDOCAINE OIN 5% 1.25 OZ $855.002503006800 LIDOCAINE VISCOUS 2% 100ML $20.002503006810 LIDODERM PATCH $31.002503006825 LIPITOR TAB 10 MG $13.002503006830 LIPITOR TAB 20 MG $18.002503006835 LIPITOR TAB 40 MG $16.00

2503006840 LIPITOR TAB 80 MG $18.002503006845 LISINOPRIL TAB 10 MG $5.002503006850 LISINOPRIL TAB 20 MG $8.002503006855 LISINOPRIL TAB 40 MG $6.002503006860 LISINOPRIL TAB 5 MG $5.002503006890 LITHIUM CARB TAB 300 MG $3.002503006900 LOPERAMIDE CAP 2 MG $4.002503006905 LOPERAMIDE ORAL SOL 4 OZ $5.002503006910 LORATADINE TAB 10 MG $5.002503006920 LORAZEPAM TAB 0.5 MG $7.502503006925 LORAZEPAM TAB 1 MG $6.002503006955 LYRICA CAPSULE 100 MG $75.002503006960 LYRICA CAPSULE 25 MG $19.002503006965 LYRICA CAPSULE 50 MG $46.002503006970 LYRICA CAPSULE 75 MG $28.002503006985 MAGNESIUM OXIDE TAB 400MG $3.002503006990 MAG‐SR TAB $3.002503006995 MAXALT‐MLT TAB 10 MG $108.002503007005 MECLIZINE TAB 12.5 MG $3.002503007010 MECLIZINE TAB 25 MG $3.002503007020 MEDROXYPROGESTERONE 2.5MG $3.002503007025 MEDROXYPROGESTERONE 5MG $4.002503007030 MEGESTROL ACETATE 20 MG $6.002503007045 MEGESTROL O/S40MG/ML 10ML $22.002503007050 MELOXICAM TAB 15 MG $17.002503007055 MELOXICAM TAB 7.5 MG $11.002503007105 METAMUCIL PK $4.002503007115 METFORM TAB 500MG $4.002503007120 METFORM ER TAB 500MG $5.002503007130 METFORM HCL TAB 850MG $6.002503007140 METHADONE TAB 10 MG $3.002503007165 METHOCARBAMOL 500 MG $4.002503007170 METHOCARBAMOL 750 MG $4.002503007195 METHYLPREDNIS 4MG DOSEPA $98.002503007200 METHYLPREDNISOLONE TAB 4MG $7.002503007205 METOCLOPRAMIDE SYR 10 ML $22.002503007215 METOCLOPRAMIDE TAB 5 MG $4.00

2503007225 METOLAZONE TAB 2.5 MG $11.002503007230 METOLAZONE TAB 5 MG $13.002503007240 METOPROLOL SUCC ER TAB 25MG $8.002503007245 METOPROLOL TAR TAB 100 MG $5.002503007250 METOPROLOL TAR TAB 25 MG $10.002503007255 METOPROLOL TAR TAB 50 MG $6.002503007270 METRONIDAZOLE TAB 250 MG $20.002503007275 METRONIDAZOLE TAB 500 MG $10.002503007285 MEXILETINE HCL CAP 200 MG $10.002503007310 MICONAZOLE NIT VAG CR 45 GM $45.002503007315 MICRO‐K $4.002503007335 MOXIDIL TAB 10 MG $7.002503007340 MIRAPEX TAB 0.25 MG $10.002503007355 MIRTAZAPINE TAB 30 MG $10.002503007360 MISOPROSTOL TAB 100MCG $6.002503007380 MORPH SULF CR TAB 15 MG $7.002503007385 MORPH SULF CR TAB 30 MG $11.002503007395 MORPH SULF O/CNT 20MG/ML 30ML $8.002503007400 MORPHINE O/SOL 10MG 5ML $5.002503007405 MORPHINE SULF IR TAB 15 MG $3.002503007415 MUCINEX DM TAB 600 MG $4.002503007420 MULTI FERROUS FOLIC $6.002503007435 MUPIROCIN OINT 2% 22GM $83.002503007450 NABUMETONE TAB 500 MG $6.002503007455 NADOLOL TAB 20 MG $24.002503007470 NAMENDA TAB 10 MG $20.002503007475 NAMENDA TAB 5 MG $21.002503007485 NAPROXEN SOD TAB 550 MG $6.002503007495 NAPROXEN TAB 250 MG $5.002503007500 NAPROXEN TAB 375 MG $5.002503007510 NASACORT AQ NASAL SPRAY 16.5G $330.002503007515 NATALCARE PLUS TAB $3.002503007525 NEPHRO‐VITE $3.002503007555 NIASPAN ER COATED TB 500MG $17.002503007570 NICORETTE 2MG $133.002503007575 NIFEDIPINE CAP 10 MG $7.002503007580 NIFEDIPINE ER TAB 30 MG $10.00

2503007585 NIFEDIPINE ER TAB 60 MG $8.002503007590 NIFEDIPINE ER TAB 90 MG $9.002503007600 NITROBID OIN 30 GM $126.002503007605 NITROBID OINTMENT 1GM $18.002503007610 NITROFURANTOIN CAP 50 MG $15.002503007625 NITROGLYCERIN CAP TR 2.5 $3.002503007630 NITROGLYCERIN CAP TR 6.5 $3.002503007650 NITROQUICK SL TAB 0.4MG $78.002503007660 NORTRIPTYLINE CAP 10 MG $4.002503007665 NORTRIPTYLINE CAP 25 MG $5.002503007685 NYSTATIN CR 15 GM $57.002503007720 NYSTATIN‐TRIAM CR 30 GM $455.002503007735 NYSTOP 100M U/GM 15GM $72.002503007740 OCUVITE TAB $5.002503007760 ONDANSETRON ODT TAB 4MG $73.002503007765 ONDANSETRON TAB 4MG $81.002503007790 ORAJEL BABY 0.33 OZ $15.002503007825 OXCARBAZEPINE TAB 150 MG $5.002503007830 OXCARBAZEPINE TAB 300 MG $9.002503007835 OXYBUTYNIN ER TAB 10 MG $11.002503007840 OXYBUTYNIN ER TAB 5 MG $10.002503007850 OXYBUTYNIN TAB 5 MG $4.002503007855 OXYCODONE TAB 5 MG $7.502503007865 OXYCODONE/APAP TAB 10/325 $12.002503007870 OXYCODONE/APAP TAB 7.5/325 $9.002503007875 OXYCONTIN CR TAB 10 MG $13.002503007900 PAIN RELIEVER PLUS TAB $3.002503007930 PAROXETINE HCL TAB 10 MG $10.002503007935 PAROXETINE HCL TAB 20 MG $18.002503007945 PATANOL OPTH SOL 0.1% 5 ML $762.002503007970 PEN V POT OV 500 MG $4.002503007975 PENICILLIN G POT 20MU INJ $457.002503007990 PENTOXIFYLLINE ER 400 MG $7.002503007995 PERMETHRIN CR 5% 60GM $359.002503008000 PERMETHRIN CREME RINSE 2 OZ $28.002503008025 PETROLATUM WHITE 1 OZ TUBE $5.002503008030 PHENASEPTIC CHERRY 6 OZ $11.00

2503008035 PHENAZOPYRIDINE 100 MG $9.002503008040 PHENAZOPYRIDINE 200 MG $13.002503008050 PHENOB 32.4 MG 1/2GR $4.002503008080 PHENYTOIN ER CAP 100 MG $3.002503008085 PHENYTOIN O/SRN 100MG 4ML $29.002503008095 PHENYTOIN SUS 125MG/5ML 8 OZ $9.002503008110 PINK BISMUTH 8 OZ $10.002503008115 PINK BISMUTH TAB $3.002503008135 PLAVIX TAB 75 MG $184.002503008145 POT CHLOR 10% 20MEQ/15ML UD $102.002503008155 POT CHLOR CAP 10 MEQ $14.002503008170 POT CHLOR TAB SR 20 MEQ $6.002503008190 POVIDON IODINE 10% ONT 30 GM $21.002503008200 PRAVASTATIN SOD TAB 10 MG $11.002503008205 PRAVASTATIN SOD TAB 20 MG $22.002503008225 PREDNISONE TAB 1 MG $3.002503008230 PREDNISONE TAB 10 MG $5.002503008235 PREDNISONE TAB 2.5 MG $3.002503008240 PREDNISONE TAB 20 MG $6.002503008245 PREDNISONE TAB 5 MG $10.002503008260 PREMARIN 0.625 MG $17.002503008275 PREMARIN CREAM 1.5 OZ W/APP $1,437.002503008315 PREVACID SOLUTAB 30 MG $20.002503008320 PRILOSEC OTC TAB $16.002503008330 PRIMIDONE TAB 50 MG $3.002503008340 PROBENECID TAB 0.5 GM $4.002503008365 PROCHLORPERAZINE TB 5MG $4.002503008400 PROMETHAZINE SYR 4 OZ $5.002503008405 PROMETHAZINE TAB 25 MG $4.002503008425 PROMETHAZINE W/COD 16 OZ $35.002503008430 PROPAFENONE HCL TAB 150MG $7.002503008465 PROPRANOLOL TAB 10 MG $4.002503008470 PROPRANOLOL TAB 20 MG $4.002503008475 PROPRANOLOL TAB 40 MG $5.002503008485 PROTONIX TR 20 MG TAB $16.002503008490 PROTONIX TR 40 MG TAB $12.002503008520 PYRAZINAMIDE TAB 500 MG $10.00

2503008535 QUINAPRIL HCL TAB 10 MG $16.002503008580 RAMIPRIL CAP 2.5 MG $7.002503008585 RAMIPRIL CAP 5 MG $7.002503008595 RANITIDINE HCL TAB 150 MG $6.002503008605 RAZADYNE TAB 4 MG $9.002503008625 RENAGEL TAB 800 MG $23.002503008635 RETROVIR CAP 100 MG $10.002503008670 RISPERDAL TAB 0.25 MG $13.002503008675 RISPERDAL TAB 0.5 MG $42.002503008680 RISPERDAL TAB 1 MG $15.002503008700 ROPINIROLE HCL TAB 0.5MG $9.002503008705 ROPINIROLE HCL TAB 1MG $6.002503008710 ROPINIROLE HCL TAB 3MG $10.002503008745 SALIVA SUBSTITUTE 120ML $17.002503008770 SENNA PLUS TAB $5.002503008780 SENNA‐GEN TAB $3.002503008795 SEROQUEL TAB 100 MG $26.292503008805 SEROQUEL TAB 25 MG $13.002503008810 SEROQUEL TAB 50 MG $22.002503008820 SERTRALINE TAB 100 MG $10.002503008835 SIMETHICONE DRP 30ML $23.002503008855 SIMETHICONE TAB 80 MG $3.002503008860 SIMVASTATIN TAB 10 MG $20.002503008865 SIMVASTATIN TAB 20 MG $16.002503008870 SIMVASTATIN TAB 40 MG $17.002503008890 SINGULAIR TAB 10 MG $19.002503008935 SODIUM CHLORIDE TAB 1GM $3.002503008950 SORBITOL SOL 30ML $8.002503008970 SOTALOL HCL (AF) TAB 80MG $11.002503009000 SPIRONOLACTONE TAB 50 MG $5.002503009040 SUCRALFATE SUS 1G/10ML $84.002503009045 SUCRALFATE TAB 1 GM $5.002503009075 SULFAMETHOXAZOLE/TR 800‐160 $9.002503009115 SYNTHROID 100MCG $12.002503009120 SYNTHROID 112MCG TABLET $4.002503009125 SYNTHROID 125MCG $4.002503009130 SYNTHROID 137MCG $4.00

2503009135 SYNTHROID 150MCG $4.002503009140 SYNTHROID 25MCG $4.002503009145 SYNTHROID 88MCG $4.002503009150 TAMIFLU CAP 75 MG $51.002503009160 TAMOXIFEN CITR TAB 10 MG $8.002503009180 TEMAZEPAM CAP 15 MG $9.002503009190 TERAZOSIN HCL CAP 1 MG $6.002503009195 TERAZOSIN HCL CAP 2 MG $6.002503009200 TERAZOSIN HCL CAP 5 MG $6.002503009260 THERAGENERIX PLAIN TAB $3.002503009295 THYROID TAB 1 GR $3.002503009365 TOPAMAX TAB 100 MG $21.002503009370 TOPAMAX TAB 25 MG $9.002503009375 TOPAMAX TAB 50 MG $17.002503009380 TOPROL XL TAB 25 MG $4.002503009385 TORSEMIDE TAB 20 MG $4.002503009390 TRAMADOL HCL TAB 50 MG $6.002503009400 TRAVATAN OPTH SOL 2.5 ML $486.002503009405 TRAZODONE TAB 100 MG $5.002503009415 TRAZODONE TAB 50 MG $10.002503009420 TRIAMCINOLONE 0.025% 15 GM $20.002503009425 TRIAMCINOLONE CR 0.1% 15 GM $16.002503009430 TRIAMCINOLONE CR 0.1% 80 GM $38.002503009440 TRIAMCINOLONE OIN 0.1% 15 GM $16.002503009455 TRIAMTERENE/HCTZ 37.5/25 $5.002503009475 TRICOR TAB 145 MG $17.002503009520 TRIMETHOPRIM TAB 100 MG $4.002503009525 TRIPLE ANTIBIO OIN 0.5 OZ $5.002503009560 TUSSIONEX SUS 473 ML $1,776.002503009580 UREA 40 CREAM 3 OZ $138.002503009610 VALPROIC ACID SYR 16 OZ $8.002503009615 VALTREX CPL 500 MG $25.002503009630 VENLAFAXINE HCL TAB 37.5MG $8.002503009640 VERAPAMIL ER TAB 120 MG $8.002503009660 VERAPAMIL TAB 120 MG $5.002503009700 VIGAMOX OPT SOL 0.5% 3 ML $442.002503009725 VIT B‐ 1 TAB 100 MG $3.00

2503009735 VIT B‐ 12 100 MCG $3.002503009740 VIT B‐ 6 TAB 50 MG $3.002503009745 VIT C ASCORBIC TAB 500MG $3.002503009760 VIT E S/GEL 200IU $3.002503009765 VIT E S/GEL 400IU $3.002503009770 VITAM D 50,000 IU SFTGEL $7.002503009825 ZETIA 10 MG TAB $41.002503009840 ZINC SULFATE CAP 220 MG $3.002503009865 ZOLPIDEM TAB 10 MG $18.002503009870 ZOLPIDEM TAB 5 MG $32.002503009895 ZYPREXA TAB 2.5 MG $27.002503009910 MEPERIDINE 25MG INJ $21.002503009945 BICILLINCR 2.4 MU INJ $641.002503009950 BICILLINLA 1,200,000 U INJ $449.002503009985 CEFTAZIDIME PENTAHYD 1GM VIAL $30.002503009995 HEPARIN 5000 UNITS SQ $14.002503010000 AMIDATE VIAL $40.002503010010 MANNITOL 20% 500ML $62.002503010015 NEOSYNEPHRINE 10MG INJ $39.002503010040 SODIUM BICARB INFANT SYRINGE $46.002503010080 ACCUPRIL 40MG TABLET $4.002503010085 ANUSOLHC SUPP $262.002503010125 CORTISPORIN OPTH OINT 3.5GM $291.002503010130 ALBUTEROL 0.5% 2.5MG/0.5ML $5.002503010185 DAKIN'S 1/2 STRENGTH SOL $36.002503010195 NITRODUR PATCH $7.002503010215 SYMBICORT 80MCG/4.5MCG INHALER $491.002503010220 SYMBICORT 160MCG/4.5MCG INHLE $564.002503010235 COMBIGAN OPT SOL 5ML $427.002503010250 EYE‐STREAM SOL 1 OZ $60.002503010290 DEX 10% 500ML/24 BG $46.002503010295 DEX 5% 1/2 500 ML IV SOL $45.002503010305 DEXTROSE 5% 500 ML IV SOLUTION $45.622503010310 DES 5% 250 ML IV.SOLN $42.002503010315 DILITIAZEM SDV 25 MG/5ML $8.002503010325 SEA OMEGA 50 SOFTGEL $5.002503010345 IPRATROPUM INH SOL 0.02% 2.5ML $6.00

2503010390 NORMAL SAL (SOD CH) 100MLIVSLN $43.002503010395 NOR SAL (SOD CH)250ML IVSLN $43.002503010405 SODIUM CHLORIDE 23.4% 30ML $5.002503010415 SPS SUS 60ML $37.002503010435 DEXTROSE 5% 1000 ML IV SOLN $57.002503010445 RINGERS SOL 1000ML IV SOL $51.002503010530 VOLTAREN 1% GEL 100GM $165.002503010590 PROPOFOL 1000MG/100ML VIAL $98.002503010605 MISC NON‐DRUG ORDERS $458,370.002503010650 ACTIVATED CHAR W/SORB 25GM/120 $57.002503010670 ERYTHROMYCIN BASE 3.5GM OINT $62.002503010685 GLYCERIN SUPPOSITORY $12.002503010695 KETAMINE 50MG/1ML SYRINGE $5.002503010750 SILVER NITRATE 1 UNIT STICK $5.002503010770 SCOPOLAMINE 1.5MG/72HR PATCH $70.002503010845 LIDOCAINE JELLY 2% 20ML $31.002503010850 LIDOCAINE 2% JELLY 5ML $26.002503010860 EFFIENT TAB 10MG $50.002503010920 ROBITUSSIN DM 5ML $7.002503010935 MINERAL OIL 30ML $3.002503010940 NOMYCIN‐POLY‐B/GR OPT SOL 10ML $186.002503011000 LABETALOL 5MG/ML 4ML SYR $22.002503011040 XYLOCAINE 2% (100MG) SYRG 5ML $11.002503011045 EPINEPHRINE 1:1OM 10ML $17.002503011055 RIFAXIMIN 550 TABLET $115.002503011080 NORMAL SALINE BAG 500ML $42.002503011110 DABIGATRAN 75MG CAPSULE $42.002503011115 COLCHICINE TAB 0.6 MG $23.002503011155 VITAMIN D 1000 UNIT TABLET $6.002503011165 LITHIUM CARBONATE CAP $2.502503011185 DUREGESIC 12 MCG PATCH $66.002503011190 LATUDA 40 MG PO $121.002503011200 CEFDINIR OS 250MG/5ML $26.002503011270 XARELTO 10MG TAB $92.002503011290 DALIRESP(ROFLUMILAST)500 MG $38.002503011300 BRILINTA 90MG CAP $20.002503011340 LIDOCAINE 1% 2ML VIAL BUFFERED $17.00

2503012000 CRASH CART FOR PHARMACY $100.002504130025 COMBIVENT RESPIMAT INH $984.002506000015 LEVONORGESTREL 1.5MG TABLET $60.002506000040 ELIQUIS 2.5MG TABLET $23.002506000090 TDAP 7 YEARS & OLDER $123.002506000195 CHOLECALCIFEROL(VIT D3)5000 UN $2.502506000390 CERTAVITE MULTIVITAMIN 15ML $2.502506000475 ORAJEL GEL 11.9 GM $17.002580000035 D5 1/2 SALINE 1000CC 7926 $45.002580000080 D5S 500CC 7941 $34.002580000180 NORM SAL 9% 1000CC 7983 $47.002583000015 NORMAL SALINE 100ML MINI BAG $40.002583000025 DEX 5% ADD 50ML $43.002583000030 DEX 5% LR BG 1000ML $57.002583000040 DEX 5%/ 0.9% NACL BG 1000ML $50.002583000055 DEX/SOD 0.9/20MEQ KCL 1000ML $47.002583000065 DEX5/SOD 0.45/KCL.075 1000ML $47.002583000085 POT CHL 20MEQ/ 0.45% SOD CHL $47.002583000105 SOD CHL 0.45% 1000ML $47.002583000125 SOD CHL 0.9% ADD 100ML $40.002583000130 SOD CHL 0.9% ADD 250ML $42.002583000135 SOD CHL 0.9% ADD 50ML $39.002583000140 SOD CHL 0.9% BAG 100ML $40.002583000150 SOD CHL 0.9% BAG 50ML $45.002583000190 SODIUM CHLORIDE 3% 500 ML $45.002583000200 NS W/40 MEQ KCL 1000 ML $47.002583000205 POTASSIUM CHLORIDE 20MEQ D5W $54.002583000220 CARDENE IV 20MG 200 ML $351.002583000245 20 MEQ KCL IN NS 1000ML BAG $47.002583000255 D5W 1/XNS W/20MEQ KCL 1000ML $47.002586000085 LINZESS 145MCG CAPSULE $42.002590000065 ALDACTONE 25MG TAB $5.002590000070 CLARITIND 24HR TAB $5.002590000125 BETAPACE 80MG TAB $11.002590000130 BIAXIN 500 MG TAB $21.002590000135 CALTRATE 600 TABLET $6.002590000140 CARDIZEM CD 120MG CAP $7.00

2590000170 DYAZIDE CAP $4.002590000195 FERROUS GLUCONATE 324MG TAB $3.002590000205 FLEXERIL 10MG TAB $5.002590000210 RANOLAZINE 500MG TAB $38.002590000235 HALDOL 5MG TAB $5.002590000245 LACTINEX TAB $5.002590000250 LOMOTIL TAB $6.002590000265 MACRODANTIN 100MG CAP $17.002590000270 MINIPRES 1MG CAP $6.002590000280 NEURONTIN 100MG CAP $4.002590000290 MIRAPEX 0.5 MG TABLET $9.002590000315 CALCIUM ACETATE667MG CAPSULE $5.002590000320 AMOXICILLIN/CLAVULANATE 875 MG $17.002590000325 SERTRALINE 50MG/2.5ML ORAL SOL $10.002590000340 VITAMIN D 400 IU CAP $3.002590000355 METOCLOPRAMIDE 10MG TAB $6.002590000360 RIFAMPIN 300MG CAP $7.002590000385 TYLENOL #3 TAB $5.002590000395 ZANAFLEX 4MG TAB $7.002590000400 APPIPIPRAZOLE 10MG TABLET $97.002590000410 OLANZAPINE 10MG TABLET $43.002590000450 BENADEYL 5ML ELIXIR $10.002590000455 CHARCOAL W/OUT SORBITOL 25GM $55.002590000460 LACTULOSE 10GM/15ML $7.002590000475 MAGAPLUS 30ML UD $10.002590000490 AMOXICILLIN 250MG/5ML $20.002590000520 MAALOX PLUS 30ML DOSE CUP $10.002590000525 OMNICEF 125/5ML $15.002590000555 BACITRACIN 15GM OINTMENT $13.002590000590 POLYSPORIN OINT 1 OZ $23.002590000675 GI COCKTAIL $18.002590000765 OXYCODONE/ACETAMINO 5‐325MG TA $10.002590000805 ZINC OXIDE OINTMENT 2OZ $10.002590000910 CREAN 12,000 UNITS $9.002590000940 VITAMIN B12 250 MCG $2.502590001010 SANTYL 30GM $644.002590001075 FERROUS SULFATE 220MG/5ML $28.00

2590001105 ZYPREXIA 5MG TABLET $40.002596000005 XARELTO 15MG TABLET $46.002596000035 ELIQUIS 5MG TABLET $23.002596000060 VANCOMYCIN 750MG ADDVANTAGE $84.002596000115 PROMETHAZINE 12.5MG $2.502599999999 MISC PHARMACY $2.502606000010 IV INF THERAPEUTIC CONCURRENT $35.002606000015 IV INF THER EA ADD HOUR $40.002606000025 IV INFUSION UP TO 1 HR ER $205.002607860000 HYDRATION EA ADD HOUR $40.002607860005 HYDRATION INITIAL 31M 1HR $205.002607860010 IV INFUSION CONCURRENT $35.002607860020 IV INFUSION SEQ UP TO 1 HR $65.002607860025 IV INF THERAPEUTIC UP TO 1 HR $205.002608000015 IV INFUSION EA ADD HOUR $40.002608000025 IV INFUSION UP TO 1 HR $205.002700000785 AEROCHAMBER $7.002700000790 AEROCHAMBER W MASK $7.002700000795 AEROSOL MASK $1.002700000845 AIRWAYS ORAL $9.002700000925 AMBU ADULT BAGS $21.002700000930 AMBU BAG $37.002700001935 BIOPSY FORCEPS $38.002700001960 BIPAP CIRCUIT $38.002700002495 BLOOD GAS KIT $9.002700006060 CANNULA $1.002700006225 CANULA 21 FT $1.002700008095 CONNECTING TUBING $1.002700008360 CRE BALLOON DILATION CATHETERS $359.002700008770 DISP CIRCUIT VNT $21.002700008780 DISP. POLYP. SNARE $116.002700009960 ET TUBE HOLDER $11.002700010035 EZ CAP $19.002700010520 FULL FACE CPAP MASK $75.002700010565 GASTRO KIT $395.002700011190 G‐TUBE $95.002700011630 HEAD GEAR $21.00

2700011835 HEMACLIP CLIP DEVICE $152.002700012715 HOT BX FORCEPS $158.002700012775 HUMIDIFIER DISP $2.002700013215 INDIA INK $80.002700013250 IN LINE NEB T WITH VALVE $9.002700014645 MASK NON REBREATH $1.002700014650 MASK SIMPLE $1.002700014655 MASK TRACH $16.002700014660 MASK VENTI $2.002700015530 MISTY OX HIGH FLOW $17.002700016305 NASOPHARYNGEAL AIRWAY $15.002700016330 NCPAP MASK $58.002700016360 NEBULIZER FILLED $16.002700016750 O2 CHRG UP TO 24 HR $140.002700016755 O2 CHRG UP TO 6 HRS ERD $36.002700016765 O2 CHRG UP TO 6 HRS PACU $49.002700017540 PASSYMUIR $114.002700018275 POLYP TRAP $37.002700019115 REPL. BUTTON PEGS (MI) $192.002700019410 ROTH POLYP RETRIEVAL NET $273.002700019500 SCLEROTHERAPY NEEDLE $113.002700020785 SPEED BAND LIGATOR $525.002700021845 STYLET $16.002700022575 TENT SUPPLY $15.002700022775 TOT HUT $37.002700022800 T PIECE W DRN BAG $9.002700023620 TUBING AEROSOL $9.002700023790 UPDRAFT NEB DISP $1.002700024205 VISIPAQUE 320MG/50ML CONTRAST $51.002700024215 VOLDYNE $6.002700024710 YAUNKER $6.002722410000 OMNIPAQUE 350MG/50 ML $170.003000000570 CAPILLARY SPECIMAN $5.003000000577 GLU POCT CR/LM $6.003001000045 URINE DRUG SCR MEDICAL $100.003001000077 NICOTINE SCREEN $45.003001000085 ELECTROLYTES $25.00

3001000090 BASIC METABOLIC PANEL (BMP) $25.003001000095 COMPREHENSIVE MET PANEL (CMP) $32.003001000100 HEPATIC FUNCTION PANEL $25.003001000110 INTACT PTH $123.003001000115 CRP INFLAMMATION $16.003001000120 VOLUME MEASUR URINE $23.003001000135 VANCOMYCIN PEAK $40.003001000140 VANCOMYCIN TROUGH $40.003001000145 UREA NITROGEN, URINE $25.003001000150 ACETONE, SERUM, QUAL $15.003001000155 ALBUMIN $15.003001000165 ETHANOL BLOOD $30.003001000171 AMYLASE $20.003001000175 PHENOBARBITAL $43.003001000180 BILIRUBIN DIRECT $15.003001000185 BILIRUBIN TOTAL $15.003001000190 B‐TYPE NP (BNP) $105.003001000195 CALCIUM TOTAL $19.003001000200 FERRITIN $41.003001000205 CHLORIDE $15.003001000210 CHOLESTEROL $25.003001000215 CK $20.003001000220 CKMB $35.003001000230 TROPONIN I $30.003001000240 CREATININE $15.003001000245 CREATININE URINE $36.003001000250 CREATININE CLEARANCE $43.003001000300 ESTRADIOL $91.003001000305 FOLATE $45.003001000310 CO2 $15.003001000330 GTT 3 SPEC $49.003001000335 GTT EA ADDL $19.003001000345 FSH FOLLICLE STIMUL HORMONE $56.003001000350 LH LUTEINIZING HARMONE $56.003001000355 HEMOGLOBIN A1C $30.003001000360 GAMMA GTP $37.003001000365 T3 UPTAKE $20.00

3001000370 T4 TOTAL $20.003001000375 TSH $51.003001000380 IRON SERUM $20.003001000385 IRON BINDING CAP $26.003001000390 LACTIC ACID $53.003001000396 LD $25.003001000400 LIPASE $21.003001000405 LIPID PROFILE $38.003001000410 MAGNESIUM $20.003001000420 OSMOLALITY SERUM $30.003001000425 OSMOLALITY URINE $30.003001000430 ALK PHOSPHATASE $20.003001000435 PHOSPHORUS $15.003001000440 POTASSIUM $15.003001000450 TOTAL PROTEIN SERUM $15.003001000455 PROTEIN, UR $19.003001000465 SALICYLATES $25.003001000470 SODIUM $15.003001000475 SODIUM URINE $15.003001000485 AST (OT) $15.003001000490 TRANSFERRIN $49.003001000500 BLOOD UREA NITRO (BUN) $15.003001000505 URIC ACID $15.003001000510 VITAMIN B12 $45.003001000520 CARBAMAZEPINE, TOTAL $45.003001000525 BETA HCG QUANT SERUM $33.003001000530 DIGOXIN TOTAL $40.003001000535 LITHIUM $25.003001000545 PHENYTOIN DILANTIN $40.003001000560 ACETAMINOPHEN $60.003001000565 GENTAMICIN PEAK $50.003001000570 GENTAMICINTROUGH $50.003001000580 CRP HIGHLY SENSITI CARDIOCRP $98.003001000585 CEA $58.003001000590 ANA $42.003001000595 RUBELLA, IGG $37.003001000600 PSA SCREENING $55.00

3001000610 PSA TOTAL $55.003001000615 HIV 1 & HIV 2 AB $35.003001000620 VALPROIC ACID TOTAL $49.003001000625 HBSAG $49.003001000631 HEP B CORE ANTIBODY $44.003001000635 HEP B S AB $49.003001000640 HEP A ANTIBODY IGM $56.003001000645 ACUTE HEPATITIS PANEL $256.003001000650 HEP C VIRUS AB $42.003001000655 FREE T4 $126.003001000660 CORTISOL, TOTAL $49.003001000735 ALT (PT) $15.003001000740 TRIGLYCERIDE EXPL $32.003001000820 MYOGLOBIN $33.003001000825 PROCALCITONIN $55.003002000030 CBC DIFF $25.003002000035 HEMOGRAM (CBC NO DIFF) $20.003002000040 WHITE BLOOD COUNT $13.003002000050 HEMATOCRIT $13.003002000060 RETIC AUTOMATED $18.003002000065 RETICULOCYTE, MANUAL $26.003002000070 SED RATE WESTERGREN $15.003002000080 CELL COUNT BODY FLUID $22.003002000090 CRYSTAL ID BODY FLUID $56.003002000095 STOOL WBC $30.003003000010 BLEEDING TIME $19.003003000015 DDIMER QUANT $37.003003000025 FIBRINOGEN QUANT $32.003003000030 PROTHROMBIN TIME + INR $15.003003000035 PTT $20.003004000025 URINALYSIS DIAGNOSTIC $19.003004000030 SCREENING URINALYSIS $10.003004000050 STOOL OCCULT BLD NON CANCER S $10.003004000055 BETA HCG QUAL SERUM $25.003004000060 PREGNANCY TEST URINE $20.003004000065 OCCULT BLOOD CANCER SCREEN $25.003004000070 OCCULT BLOOD GASTRIC $12.00

3005000010 HETEROPHILE QUAL (MONO) $20.003005000020 RA LATEX QUAL $20.003005000025 RA LATEX QUANT $22.003005000030 STREP SCREEN RAPID $30.003005000035 RPR QUAL $43.003005000040 RSV RESP SYNCYTIAL VIRUS $45.003005000045 RAPID INFLUENZA A $32.003005000050 RAPID INFLUENZA B $32.003005500000 ABG $80.003006000040 CROSSMATCH IS $80.003006000041 CROSSMATCH‐AHG $80.003006000085 INDIRECT ANTIGLOBULIN $15.003006000090 ABO TYPE EXPL $10.003006000095 RH TYPE EXPL $25.003006000110 RBC LEUKO DEPLETED EA UNIT $460.003006000135 RBC LEUKO DEPLIRRADIATED EA U $506.003007000129 ANA ISOLATE DEFIIN ID EA ISO $32.003007000140 STREP SCREEN 2448 HOURS $25.003007000145 ROTAVIRUS $158.003007000175 GRAM STAIN $15.003007000190 AER ISOLATE DEFIN ID EA ISO $32.003007000195 URINE CULTURE $25.003007000200 THROAT CULTURE $30.003007000215 STOOL CULT, SALMON/SHIGELLA $30.003007000220 STOOL CLT, ADDN PATH, EA PLATE $30.003007000230 ROUTINE CULTURE $30.003007000235 BLOOD CULTURE $35.003007000245 FUNG CULT SKIN HAIR NAIL $18.003007000250 FUNG CULT BR SP WD BF $37.003007000265 AFB CULTURE EXPL $54.003007000275 MICROSTREP MIC $37.003007000280 GM POS BPCP $37.003007000285 GM NEG BPCP $37.003007000315 WET PREP $15.003007000320 KOH SLIDE $15.003007000325 CLOSTRIDIUM DIFFICILE $58.003007000330 NASAL CULTURE $30.00

3007000335 FUNGUS SMEAR $15.003007000345 MRSA SCREEN $23.003007000350 VRE SCREEN $32.003007000380 C DIFF AMPLIFIED PROBE $75.003007860000 FOLEY CATH FOR SPEC COLL $86.003007860010 CENTRAL LINE PLACEMENT $454.003008000290 IGG EXPL $18.003008000295 IGA $18.003008000300 IGM $18.003008000340 O & P DIRECT SMEARS CONC & ID EXPL $37.003008000341 SPECIAL STAIN FOR COCCIDIA $20.003008000342 SPECIAL STAIN FOR COCCIDIA #2 $20.003008000345 O & P SM SPECIAL STN EXPL $40.003008000370 ALDOLASE $49.003008000375 ALDOSTERONE $149.003008000385 HOMOCYSTEINE $190.003008000395 AMMONIA $27.003008000405 ARSENIC $50.003008000420 CALCIUM IONIZED $77.003008000430 CALCULI, URINARY $61.003008000435 CATECHOL FRACT EXPL $94.003008000440 CERULOPLASMIN $40.003008000455 COPPER $40.003008000460 C PEPTIDE $77.003008000465 VITAMIN D, 25 HYDROXY $86.003008000490 G6PD $40.003008000515 5 HIAA EXPL $50.003008000520 INSULIN TOTAL $56.003008000530 LEAD $58.003008000545 METANEPHRINES $61.003008000552 MYCOPLASMA ANTIBODY $71.003008000560 MYOGLOBIN, URINE $40.003008000590 POTASSIUM, URINE, RANDOM $19.003008000595 PROGESTERONE $96.003008000600 PROLACTIN $58.003008000605 PROTEIN ELECTROPHORESIS, SERUM $32.003008000610 PROTEIN ELECTROPHERESIS, UR $40.00

3008000615 RENIN $83.003008000620 TESTOSTERONE TOTAL $116.003008000625 TOTAL T3 $46.003008000635 VMA RANDOM URINE EXPL $85.003008000640 VITAMIN B1 (THIAMINE) $69.003008000645 ZINC $35.003008000660 THYROGLOBULIN AUTOAB $74.003008000665 THYROGLOBULIN SERUM $52.003008000670 THYROID PEROXIDASE AB $66.003008000675 FACTOR VIII AHG 1‐STAGE $72.003008000680 ANTI THROMBIN III FUNCTIONAL $44.003008000685 PROTEIN C, FUNCTIONAL $155.003008000690 PROTEIN C, ANTIGENIC $40.003008000700 PROTEIN S, ANTIGENIC $40.003008000705 PROTEIN S, FUNCTIONAL $66.003008000710 ANTI THROMBIN III ANTIGENIC $39.003008000730 ALPHA1 ANTITRP $50.003008000740 ANTI CARDIOLIPIN IGA EXPL $94.003008000745 ANTI CARDIOLIPIN IGG EXPL $94.003008000750 ANTI CARDIOLIPIN IGM EXPL $94.003008000770 COMPLEMENT FUNCT ACTIVE $69.003008000775 C 3 COMPLEMENT $44.003008000780 C 4 COMPLEMENT $44.003008000785 ANTI RNP $60.003008000790 ANTI SMITH $60.003008000795 ANTI DNA DOUBLE STRAND $50.003008000800 ANTI SSA $83.003008000805 ANTI SSB $83.003008000810 ANTI SMOOTH MUSCLE $378.003008000815 ALPHA FETO PROTEIN TUMOR MRKR $61.003008000825 ANTI MITOCHONDRIAL AB $44.003008000830 ASO ANTIBODY $39.003008000835 BARTONELLA CATSCR FEV $33.003008000840 BARTONELLA 2 $33.003008000850 BORRELIA BURGD IGG EXPL $51.003008000855 HEPATITIS BE ANTIGEN (HBEAG) $40.003008000860 HEPATITIS BE AB (ANTI HBE) $40.00

3008000865 CA 125 AG $77.003008000870 CA 19‐9 $77.003008000875 IMMUNOFIXATION, SERUM $103.003008000880 IMMUNOFIXATION URINE $132.003008000890 PREALBUMIN $66.003008000895 CMV IGM $58.003008000900 CMV IGG $52.003008000941 VDRL SERUM $43.003008000955 EHRLICHIA CHAFF IGG EXPL $32.003008000960 EHRLICHIA CHAFF IGM EXPL $32.003008000965 H PYLORI IGG $44.003008000970 H PYLORI IGM $44.003008000975 H PYLORI IGA $44.003008000980 EBV EA $52.003008000985 EBV NA $63.003008000990 EBV CAPSID IGG $58.003008000995 EBV CAPSID IGM TC2211 $58.003008001010 GLIADIN IGG ANTIBODIES EXPL $378.003008001015 GLIADIN IGA EXPL $378.003008001020 HLA B27 $108.003008001025 FREE T3 $51.003008001035 TACROLIMUS (FK506) $42.003008001060 VARICELLA ZOSTER IGG $112.003008001075 VIRUS CULTURE $86.003008001095 MICROALBUMIN URINE $34.003008001115 MYOGLOBIN PLASMA $56.003008001210 HEPATITIS A TOTAL AB $40.003008001265 Herpes 1 PCR, BLD EXPL $115.003008001270 Herpes 2 PCR, BLD EXPL $115.003008001275 HISTOPLASMA AG URINE $60.003008001295 Legionella ag urine TC 9501 $30.003008001335 GIARDIA ANTIGEN $43.003008001345 ANAPLASMA PHAGO IGG $32.003008001350 ANAPLASMA PHAGO IGM $32.003008001415 APOLIPOPROTEIN B TC1903 $40.003008001430 CA 15‐3 $77.003008001445 CHLAMYDIA PRB $105.00

3008001465 CHOLESTEROL LDL DIRCT $30.003008001485 CYCLIC CITRULL PEPTIDE $75.003008001500 DHEA SULFATE $69.003008001515 ESTROGENS TOTAL $86.003008001525 FECAL FAT QUAL $18.003008001526 REDUCING SUBSTANCE,FECAL $15.003008001545 HEPATITIS C RNA ULTRAQUANT $202.003008001550 HEPATITIS C SUBTYP R $507.003008001580 HSV 1 IGG $30.003008001585 HSV 2 IGG $96.003008001590 HSV TYPE 1 IGM EXPLODE $30.003008001595 HSV TYPE 2 IGM EXPLODE $96.003008001600 HYDROXYPROGESTERONE $103.003008001630 JO1 IGG AUTOABS $83.003008001635 LAMOTRIGINE $134.003008001640 LEVETIRACETAM $134.003008001650 MEASLES IGG $33.003008001670 MUMPS IGG EXPL $34.003008001675 MUMPS IGM EXPL $46.003008001685 NEIS PRB $105.003008001695 OXCARBAZEPINE $134.003008001755 PRIMIDONE MYSOLINE $58.003008001795 RICKETTSIA RICKET IGM EXPL $75.003008001800 RICKETTSIA RICKETTSII IGG EXPL $75.003008001835 SCL70 IGG AUTOABS $83.003008001840 TESTOSTERONE, FREE $98.003008001850 TRANSGLUTAMASE IGA $65.003008001855 TRANSGLUTAMASE IGG $65.003008001860 VARICELLA ZOSTER IGM $112.003008001865 VON WILLEBRAND FACTOR AG $75.003008001870 ZARONTIN ETHOSUXIMIDE $58.003008001975 HISTOPLASMA AB SER $70.003008002230 SIROLIMUS $103.003008002325 CARBOXYHEMOGLBOIN $95.003008002330 LUPUS ANTICOAG DVVT $20.003008002350 LEGIONELLA CULTURE $45.003008002355 MURCURY 24HR UR $80.00

3008003060 LIPOPROTEIN A $30.003008003065 VITAMIN D 1,25 DIHYDROXY $100.003008003081 CK ISO $25.003008003082 CK ISO $45.003008003095 BK QT PCR $454.003008003110 TRIIOODOTHYRONINE,REVERSE $62.003008003135 GLUTAMIC ACID DECARBOX AB $360.003008003146 KAPPA FREE CHAIN $45.003008003147 LAMBDA FREE CHAIN $45.003008003150 INSULIN ABS $69.003008003176 PERTUSSIS AB $218.003008003177 PERTUSSIS AB 2 $218.003008003178 PERTUSSIS AS 3 $218.003008003179 PERTUSSIS AB 4 $218.003008003225 METANEPHRINES, FRAC, PLASMA $93.003008003241 BETA 2 GLYCOPROT IGG $94.003008003242 BETA 2 BLYCOPROT IGM $94.003008003243 BETA 2 GLYCOPROT IGA $94.003008003255 TRICHOMONAS VAGIN RNA $170.003008003270 VITAMIN B6 $295.003008003305 DEHYDROEPIANDROSTESULFAT 3146 $80.003008003315 VITAMIN A (RETINOL) $39.003008003396 ALKALINE PHOSPHATASE $20.003008003397 ISOENZYMES $45.003008003401 VIT E ALPHA $46.003008003925 METHYLMALONIC ACID $70.003008003939 PLT ASSOC IMMUNOGLOB $85.003008004011 CHROMATOGRAPHY, HEMOG EVAL $54.003008004025 NICOTINE,SERUM $65.003008004030 NICOTINE,URINE $65.003008004114 IA ANALYTE NONINFECT $50.003008004126 C‐ANCA $50.003008004127 P‐ANCA $50.003008004200 FREE PSA $55.003008004265 ANA TITER $40.003008004301 FRANC TULARENSIS IGG $35.003008004302 FRANC TULARENSIS IGM $35.00

3008004305 NORTRIPTYLINE $45.003008004310 COLLAGEN C‐TELOPEPTIDE $105.003008004325 CLOZAPINE $45.003008004505 PAIN MANAGEMENT UDS $90.003008004520 COBALT $75.003008004535 QUANTIFERON, TB GOLD $135.003008004576 RISTOCETIN COFACTOR $90.003008004580 CENTROMERE AB $40.003008004595 PROTHROMBIN 20210A MUT $660.003008004596 FACTOR V LEIDEN MUTATION $160.003008004600 PERTUSSIS CULTURE $35.003008004606 AMP PRB, EA ORG $138.003008004607 AMP PRB, EA ORG 2 $138.003008004608 AMP PRB, EA ORG 3 $138.003008005015 IGF‐1 $70.003008005020 CMV QUANT $155.003008005070 PHOSPHOLIPIDS $80.003008005110 RPR TITER $15.003008005130 CADMIUM WHOLD BLOOD $75.003008005145 HPYLORI, STOOL $63.003008005310 T SPOT CHARGE $125.003008005320 HISTONE AB IGG $20.003008005330 H PYLORI UREA BREATH TEST $90.003008005380 CALPROTECTIN $135.003200000010 TMJ RAD EXAM OP/CLD MOUTH‐BIL $85.003200000025 SMALL BOWEL MULT IMAGE EXAM $190.003200000035 TMJ RAD EXAM OP/CLD MOUTH‐RT $80.003200000100 MANDIBLE MIN 4V RAD EXAM $140.003200000110 FACIAL BONES MIN 3V RAD EXAM $150.003200000115 NOSE MIN 3V RAD EXAM $80.003200000120 ORBITS, COMP, MIN 4V RAD EXAM $125.003200000130 SINUSES MIN 3V RAD EXAM $125.003200000190 STERNUM MIN 2V RAD EXAM $80.003200000195 STERNOCLAVIC JNT(S) MIN 3V EXM $80.003200000265 LUMBAR SPM MIN 4V $150.003200000280 SACRUM/COCCYX MIN 2V RAD EXAM $80.003200000340 SHOULDER COMP MIN 2V BIL EXAM $250.00

3200000345 SHOULDER COMP MIN 2V LT EXAM $125.003200000355 SHOULDER COMP MIN 2V RT EXAM $125.003200000365 HUMERUS MIN 2V RAD EXAM LT $80.003200000370 HUMERUS MIN 2V RAD EXAM RT $80.003200000380 ELBOW MIN 2V RAD EXAM LT $80.003200000385 ELBOW MIN 2V RAD EXAM RT $80.003200000450 HAND MIN 3V RAD EXAM BIL $160.003200000455 HAND MIN 3V RAD EXAM LT $80.003200000460 HAND MIN 3V RAD EXAM RT $80.003200000500 HIPS 2V MIN RAD EXAM BIL $130.003200000585 KNEE 4V RAD EXAM RT $125.003200000600 LOWER LEG TIB/FIBULA MIN 2V LT $80.003200000605 LOWER LEG TIB/FIBULA MIN 2V RT $80.003200000630 ANKLE MIN 3V RAD EXAM LT $125.003200000635 ANKLE MIN 3V RAD EXAM RT $125.003200000645 FOOT MIN 3V RAD EXAM LT $80.003200000650 FOOT MIN 3V RAD EXAM RT $80.003200000655 HEEL MIN 2V RAD EXAM BIL $160.003200000675 TOES MIN 2V RAD EXAM LT $80.003200000680 TOES MIN 2V RAD EXAM RT $80.003200000700 UGI W/SMALL BOWEL RAD EXAM $305.003200000705 UGI W/AIR W/O KUB RAD EXAM $320.003200000710 UGI W/AIR W/SMALL BOWEL $335.003200000850 CHEST 1V FRONT/PORT RAD EXAM $80.003200000855 CHEST 2V FRONT/LAT RAD EXAM $80.003200000895 AC JOINT BIL $85.003200000905 UGI ESOPHAGUS W/AIR $320.003200000915 UGI STOMACH WO KUB $320.003200000925 FOOT MIN 2V RAD EXAM LT $80.003200000930 FOOT MIN 2V RAD EXAM RT $80.003200000935 FOOT MIN 2V RAD EXAM BILATERAL $160.003200000940 HEEL MIN 2V RAD EXAM RT $80.003200000945 HEEL MIN 2V RAD EXAM LT $80.003201000575 ESOPHAGUS RAD EXAM $320.003201000580 OROPHARYNGEAL SWALLOW $176.003202001430 CERVICAL SPN 5V AP W PLEX EXT $135.003202002000 BARIUM ENEMA W AIR RAD EXAM $325.00

3202002030 LUMBAR SP COMP INC BEND VIEW $150.003202002050 ABDOMEN 2V RAD $80.003202002060 ABDOMEN COMP W 1V VCHEST $150.003202002070 RIBS 3V BIL RAD $275.003202002110 SINUSES WATERS <3V RAD $79.003202002125 SKULL <4V RAD $140.003202002140 SOFT TISSUE FACE NECK RAD $80.003202002155 RIBS 2V LT RAD $80.003202002160 RIBS 2V RT RAD $80.003202002165 RIBS 3V LT RAD $140.003202002170 RIBS 3V RT RAD $140.003202002200 CERVICAL SP 3V OR LESS RAD $125.003202002205 CERVICAL SP 4V OR 5V RAD $150.003202002215 SCOLIOSIS RAD $80.003202002220 THORACIC SP 2V RAD $150.003202002235 THORACOLUMBAR JUNC MIN 2 VIEW $80.003202002245 LUMBAR SP 2V 3V RAD $140.003202002255 PELVIS 1V 2V RAD $150.003202002260 SACROILIAC JNT <3V RAD $150.003202002290 CLAVICLE COMP RAD LT $80.003202002295 CLAVICLE COMP RAD RT $80.003202002305 SCAPULA COMP RAD LT $150.003202002310 SCAPULA COMP RAD RT $150.003202002315 SHOULDER 1V RAD LT $80.003202002320 SHOULDER 1V RAD RT $80.003202002375 ELBOW 3V RAD LT $80.003202002380 ELBOW 3V RAD RT $80.003202002390 FOREARM 2V EA SIDE LT $80.003202002395 FOREARM 2V EA SIDE RT $80.003202002405 WRIST 2V RAD LT $80.003202002410 WRIST 2V RAD RT $80.003202002420 WRIST 3V RAD EXAM LT $80.003202002425 WRIST 3V RAD EXAM RT $80.003202002445 FINGER(S) RAD EXAM LT $80.003202002450 FINGER(S) RAD EXAM RT $80.003202002460 HIP 1V RAD EXAM RT $80.003202002465 HIP 2V COMP RAD EXAM LT $80.00

3202002470 HIP 2V COMP RAD EXAM RT $80.003202002500 KNEE 1V STANDING RAD EXAM BIL $110.003202002510 FEMUR 2V RAD EXAM LT $80.003202002515 FEMUR 2V RAD EXAM RT $80.003202002525 KNEE 1V 2V RAD EXAM LT $80.003202002530 KNEE 1V 2V RAD EXAM RT $80.003202002535 KNEE 3V RAD EXAM BIL $250.003202002540 KNEE 3V RAD EXAM LT $125.003202002545 KNEE 3V RAD EXAM RT $125.003202002555 KNEE 4V RAD EXAM LT $125.003202002610 ANKLE 2V RAD EXAM LT $125.003202002630 ANKLE 2V RAD EXAM RT $125.003206000020 SCOLIOSIS EXAM 1 VIEW $80.003206000040 RT HIP 1V W PELVIS IF PERFORM $60.003206000045 RT HIP 2‐3V W PELVIS IF PERFRM $70.003206000055 LT HIP 1V W/PELVIS IF PERFORM $60.003206000060 LT HIP 2‐3V W/PELVIS IF PERFOR $70.003206000070 BIL 2V HIPS W PELVIS IF NEEDED $150.003206000095 RAD EXAM MIN 2V FEMUR RT $60.003206000100 RAD EXAM MIN 2V FEMUR LT $60.003206000360 ABDOMEN 1 VIEW $125.003206000365 ABDOMEN 2 VIEW $230.003206000445 THORACIC SPINE 3V $150.003209000025 ABDOMEN 1V RAD EXAM $80.003246000000 CHEST 1 VIEW $125.003246000005 CHEST 2 VIEW $125.003500000805 CT ABD WO PELVIS WO $625.003500000810 CT ABD W/WO PELVIS W $560.003500000815 CT ABD W/WO PELVIS WO $560.003500000820 CT ABD WWO PELVIS WWO $560.003500000825 CT ABDOMEN PELVIS W CONTRAST $595.003500000845 CTA ABDOMEN AND PELVIS $680.003501000005 CT ABD CT W CON $460.003501000010 CT ABD CT WO CON $320.003501000015 CT ABD W AND WO CON $630.003501000120 CT CERVICAL SP W CON $640.003501000125 CT CERVICAL SP WO CON $535.00

3501000130 CT CHEST W AND WO CON $530.003501000135 CT CHEST W CON $595.003501000140 CT CHEST WO CON $480.003501000250 CT HEAD W AND WO CON $420.003501000255 CT HEAD W CON $355.003501000260 CT HEAD WO CON $430.003501000270 CT LOWER EXTR W CON LT $415.003501000275 CT LOWER EXTR W CON RT $415.003501000285 CT LOWER EXTR W WO CON LT $829.003501000300 CT LOWER EXTR WO CON LT $330.003501000305 CT LOWER EXTR WO CON RT $330.003501000310 CT LUMBAR SP W AND WO CON $530.003501000315 CT LUMBAR SP W CON $860.003501000320 CT LUMBAR SP WO CON $340.003501000325 CT MAXILLOFACIAL W CON $425.003501000330 CT MAXILLOFACIAL W WO $789.003501000335 CT MAXILLOFACIAL WO CON $350.003501000350 CT ORBIT SELLA FOSSA WO CON $425.003501000355 CT PELVIS W AND WO CON $535.003501000360 CT PELVIS W CON $320.003501000365 CT PELVIS WO CON $320.003501000370 CT RECON UNDER CON SUPERVISION $398.003501000375 CT SOFT TISSUE NECK W CON $410.003501000380 CT SOFT TISSUE NECK W WO CON $510.003501000385 CT SOFT TISSUE NECK WO CON $330.003501000400 CT THORACIC SP W CON $505.003501000405 CT THORACIC SP WO CON $340.003501000425 CT UPPER EXTR W AND WO CON RT $545.003501000430 CT UPPER EXTR W CON LT $505.003501000435 CT UPPER EXTR W CON RT $505.003501000445 CT UPPER EXTR WO CON LT $330.003501000450 CT UPPER EXTR WO CON RT $330.003501000460 CTA ABDOMEN $1,328.003501000465 CTA CHEST $645.003501000475 CTA HEAD $855.003501000480 CTA LOWER EXTREMITY $650.003501000485 CTA NECK $875.00

3501000495 CTA RUNOFF $1,747.003603200020 BAND LIGATION VARICES‐EGD $1,575.003603200040 BIOPSY‐COLON $947.003603200050 BIOPSY‐EGD $770.003603200065 BIOPSY‐FLEX SIG $785.003603200075 COLONOSCOPY DIAGNOSTIC $770.003603200080 COLONOSCOPY THROUGH STOMA $770.003603200090 COLONOSCOPY W/SUBMUCOSAL INJ. $1,030.003603200115 CONTROL BLEEDING‐EGD $1,575.003603200150 DIL OVER GUIDEWIRE‐EGD $770.003603200155 DILATION ACHALASIA‐EGD $1,404.003603200160 DILATION BY BALLOON‐EGD $1,575.003603200185 DILATION PYLORIS‐EGD $1,575.003603200190 EGD $770.003603200195 EGD W/ SUBMUCOSAL INJ $770.003603200245 FLEX SIGMOIDOSCOPY $785.003603200260 HEMORRHOIDAL BANDING $750.003603200355 PEG TUBE PLACEMENT‐EGD $1,575.003603200360 REM BY ABLATION TECH‐COLON $947.003603200390 REM BY SNARE TECH‐COLON $947.003603200395 REM BY SNARE TECH‐FLEX SIG $947.003603200425 REM HOT BIOPSY TECH‐EGD $1,497.003603200445 REMOVAL BY HOT BIOPSY‐COLON $947.003603200460 REMOVAL SNARE TECH‐EGD $1,575.003603200465 REPLACEMENT OF G TUBE $360.003603200500 SURGICAL COLONOSCOPY $1,333.003605500070 INTUBATION $117.003605500110 NON‐REBREATHER W/NEB $23.003607840005 LEVEL 1 PROCEDURE $454.003706000000 MOD SEDATION, INITIAL 15 MINS $300.003706000005 MOD SEDATION, EACH ADD 15 MINS $150.003903000000 ALBUM 25% 100ML $640.003917860000 BLOOD ADM $302.004020000615 SCREEN MAMMO DIGIT IMG BIL $185.004021000005 BONE DENSITOMETRY $187.004021000025 US GUIDE BX OR NDL PL $255.004021000505 US SOFT TISSUE HEAD NECK THYR $205.00

4021000515 US BREAST COMPLETE LT $130.004021000520 US BREAST COMPLETE RT $130.004021000550 US ABDOMEN COMPLETE $275.004021000555 US ABDOMEN LIMITED $205.004021000565 US KIDNEY LEFT TRANSPLANTED $159.004021000570 US KIDNEY RIGHT TRANSPLANTED $159.004021000580 US OB <14WKS SING FETUS $205.004021000585 US OB <14WKS ADDL FET $205.004021000590 US OB 14 40 WEEKS SING FETUS $239.004021000595 US OB 14 40 WEEKS ADDL FETUS $126.004021000610 R2 ADD ON FOR SCREEN MAMMO $48.004021000612 US OB LIMITED 1 OR MORE FETUS $159.004021000622 US OB ENDOVAGINAL/TRANSVAGINAL $205.004021000625 DIAGNOSTIC MAMMO LT $120.004021000630 DIAGNOSTIC MAMMO RT $120.004021000635 US PELVIS ENDOVAG (NON OB) $205.004021000637 US PELVIS ENDOVAGINAL (NON‐OB) $205.004021000638 US PELVIS COMPL (W IMNG DOC) $205.004021000647 US PELVIC LIMITED $160.004021000652 US SCROTUM $205.004021000655 US EXTREMITY NON VASCULAR LT $200.004021000660 US EXTREMITY NON VASCULAR RT $199.004021000680 DOP US CAROTID BILATERAL $520.004021000700 DOP AV ABD PLV SCR ORG LIM $454.004021000740 DOP US VENOUS UP LOW EXTR BIL $525.004021000745 DOP US VENOUS UP LOW EXTR RT $345.004021000750 DOP US VENOUS UP LOW EXTR LT $345.004021000800 US KIDNEY RETROPERITANEAL $355.004021000860 US CHEST $100.004021200045 BONE AGE STUDIES $63.004026000005 US BREAST LIMITED LT $125.004026000010 US BREAST LIMITED RT $125.004105500000 BIPAP $70.004105500021 CONT INH TX W AER MED 1ST HR $85.004105500028 CONT INH TX W AER MED ADD HR $33.004105500031 CPT (INITIAL) $40.004105500036 UPDRAFT TX (INITIAL) $200.00

4105500037 CPT (SUBSEQUENT) $35.004105500038 NASAL CPAP $70.004105500041 UPDRAFT TX (SUBSEQUENT) $200.004105500042 MDI ADMISTRATION $200.004105500046 MDI ADMISTRATION SUBS $200.004105500047 VENT TCF INITIAL DAY $332.004105500055 VENTILATOR INITIAL DAY $175.004105500056 PULM CLEARANCE EA 15 M $18.004206000090 EVALUATION PT LOW $120.004206000095 EVALUATION PT MED $120.004206000100 EVALUATION PT HIGH $120.004206000105 RE‐EVALUATION PT $65.004207600005 AQUATPY PTA $59.004207600090 GAIT TRAINING PTA $38.004207600110 GAIT TRAINING PT $38.004207600185 THERAPEUTIC MASSAGE PTA $35.004207600230 THERAPEUTIC MASSAGE $35.004207600405 MANUAL TPY LYMPHADEMA 15 M PTA $40.004207600415 MANUAL TPY TECHNIQUE PTA $40.004207600780 PROSTHETIC TRAINING $45.004207601125 EVALUATION PT $100.004207690005 ACTIVITY OF DAILY LIVING PTA $47.004207690115 WHEELCHAIR MANAGEMENT PTA $41.004207690130 WHEELCHAIR MANAGEMENT $41.004207690410 CHECKOUT ORTHOSIS/PROSTHETIC $66.004207690555 MECHANICAL TRACTION PTA $22.004207690570 MECHANICAL TRACTION $22.004207690665 ELEC MUSC STIM UNATT $21.004207690675 ELEC MUSC STIM UNATT PTA $21.004207690735 VASOPNEUMATIC DEVICE PTA $26.004207690755 VASOPNEUMATIC DEVICE $26.004207690870 PARAFFIN BATH $15.004207690970 ELEC MUSC STIM ATT $26.004207690980 ELEC MUSC STIM ATT PTA $26.004207691045 IONTOPHORESIS PTA $45.004207691060 IONTOPHORESIS $45.004207691190 ULTRASOUND PTA $17.00

4207691235 ULTRASOUND $17.004207691390 NEUROMUSCULAR REED PTA $45.004246500005 MOBILITY:CURRENT 1%‐19% LMTD $0.014246500010 MOBILITY:CURRENT 20‐39% LMTD $0.014246500015 MOBILITY:CURRENT 40%‐59% LMTD $0.014246500020 MOBILITY:CURRENT 60%‐79% LMTD $0.014246500025 MOBILITY:CURRENT 80%‐99% LMTD $0.014246500035 MOBILITY:GOAL 1%‐19% LMTD $0.014246500040 MOBILITY:GOAL 20‐39% LMTD $0.014246500045 MOBILITY:GOAL 40‐59% LMTD $0.014246500050 MOBILITY:GOAL 60‐79% LMTD $0.014246500055 MOBILITY:GOAL 80‐99% LMTD $0.014246500065 MOBILITY:DC 1‐19% LMTD $0.014246500070 MOBILITY:DC 20‐39% LMTD $0.014246500075 MOBILITY:DC 40‐59% LMTD $0.014246500080 MOBILITY:DC 60‐79% LMTD $0.014246500085 MOBILITY:DC 80‐99% LMTD $0.014246500100 POSITIONING:CURRNT 20‐39% LMTD $0.014246500155 POSITIONING:DC 1‐19% LMTD $0.014246500185 CARRYING:CURRENT 1‐19% LMTD $0.014246500190 CARRYING:CURRENT 20‐39% LMTD $0.014246500195 CARRYING:CURRENT 40‐59% LMTD $0.014246500200 CARRYING:CURRENT 60‐79% LMTD $0.014246500205 CARRYING:CURRENT 80‐99% LMTD $0.014246500210 CARRYING:CURRENT 100% LMTD $0.014246500215 CARRYING:GOAL 1‐19% LMTD $0.014246500220 CARRYING:GOAL 20‐39% LMTD $0.014246500245 CARRYING:DC 1‐19% LMTD $0.014246500250 CARRYING:DC 20‐39% LMTD $0.014246500255 CARRYING:DC 40‐59 LMTD $0.014246500260 CARRYING:DC 60‐79% LMTD $0.014246500285 SELF CARE:CURNT 40‐59% LMTD $0.014246500290 SELF CARE:CURNT 60‐79% LMTD $0.014246500295 SELF CARE:CURNT 80‐99% LIMITED $0.014246500305 SELF CARE:GOAL 1‐19 LMTD $0.014246500370 OTHR PT/OT:CURRENT 20‐39% LMTD $0.014246500375 OTHR PT/OT:CURRENT 40‐59% LMTD $0.01

4246500380 OTHR PT/OT:CURRENT 60‐79% LMTD $0.014246500385 OTHR PT/OT:CURRENT 80‐99% LMTD $0.014246500395 OTHR PT/OT:GOAL 1‐19% LMTD $0.014246500425 OTHR PT/OT:DC 1‐19% LMTD $0.014250000010 CARDIAC REHAB MONTHLY CHARGE $40.004250000015 CARDIAC REHAB MONITORED $120.004296000000 MOBILITY:CURRENT 0% LIMITED $0.014296000005 MOBILITY:GOAL 0% LIMITED $0.014296000010 MOBILITY:DC 0% LMTD $0.014296000020 POSITIONING:GOAL 0% LMTD $0.014296000035 CARRYING:GOAL 0% LMTD $0.014296000040 CARRYING:DC 0% LMTD $0.014296000065 OTHR PT/OT:GOAL 0% LMTD $0.014306000000 EVALUATION OT LOW $125.004306000005 EVALUATION OT MED $125.004306000010 EVALUATION OT HIGH $125.004307590130 PARAFFIN BATH $35.004307590545 NEUROMUSCULAR REEDUCATION $45.004307600190 MMT HAND COMPARED W/ REP $55.004307600600 THERAPEUTIC EXERCISE PTA $43.004307600760 MANUAL TPY TECHNIQUE $40.004307600770 MANUAL TPY LYMPHADEMA 15 M $40.004307600960 ORTHOSIS FITTING AND TRAINING $52.004307601085 FUNCTIONAL DYNAMIC ACTIVITIES $47.004307610000 ACTIVITY OF DAILY LIVING $47.004307690065 EVALUATION OT $114.004340000035 MOBILITY:GOAL 0% LMTD $0.014340000315 SELF CARE:CURNT 0% LMTD $0.014340000320 SELF CARE:CURNT 1‐19% LMTD $0.014340000325 SELF CARE:CURNT 20‐39% LMTD $0.014340000350 SELF CARE:GOAL 0% LMTD $0.014340000355 SELF CARE:GOAL 1‐19% LMTD $0.014340000365 SELF CARE:GOAL 40‐59% LMTD $0.014340000385 SELF CARE:DC 0% LMTD $0.014340000395 SELF CARE:DC 20‐39% LMTD $0.014340000400 SELF CARE:DC 40‐59% LMTD $0.014340000540 OTHR SUB PT/OT:CURNT40‐59%LMTD $0.01

4340000575 OTHR SUB PT/OT:GOAL 40‐59% LMT $0.014340000610 OTHR SUB PT/OT:DC 40‐59% LMTD $0.014400010045 SPEECH TPY TREATMENT $129.004400010125 TREATMENT OF SWALL DYSF $177.004400010245 TPY SP‐GEN DEVICE $148.004400010360 THERAPEUTIC EXERCISE $43.004400010515 COGNITIVE SKILLS DEVELOP $35.004400010605 COMMUNITY WORK REINTEGRATION $40.004400010915 EVAL OF SPEECH SOUND PROD $175.004400010920 EVAL OF SPEECH LANGUAGE $360.004407690170 BEDSIDE SWALLOW ASSESSMENT $187.004407690210 MOTION FLUORO EVAL OF SWALLOW $363.004407690255 FEE EVALUATION OF SWALLOW $363.004407690330 ASSESSMENT OF ASPHASIA $256.004446000000 SWALLOW:CURRENT 1‐19% LMTD $0.014446000005 SWALLOW:CURRENT 20‐39% LMTD $0.014446000010 SWALLOW:CURRENT 40‐59% LMTD $0.014446000015 SWALLOW:CURRENT 60‐79% LMTD $0.014446000020 SWALLOW:CURRENT 80‐99% LMTD $0.014446000025 SWALLOW:CURRENT 100% LMTD $0.014446000030 SWALLOW:GOAL 1‐19% LMTD $0.014446000035 SWALLOW:GOAL 20‐39% LMTD $0.014446000040 SWALLOW:GOAL 40‐59% LMTD $0.014446000045 SWALLOW:GOAL 60‐79% LMTD $0.014446000050 SWALLOW:GOAL 80‐99% LMTD $0.014446000055 SWALLOW:GOAL 100% LMTD $0.014446000060 SWALLOW:DC 1‐19% LMTD $0.014446000065 SWALLOW:DC 20‐39% LMTD $0.014446000070 SWALLOW:DC 40‐59% LMTD $0.014446000075 SWALLOW:DC 60‐79% LMTD $0.014446000080 SWALLOW:DC 80‐99% LMTD $0.014446000085 SWALLOW:DC 100% LMTD $0.014446000095 MTR SPEECH:CURNT20‐39% LMTD $0.014446000100 MTR SPEECH:CURNT40‐59% LMTD $0.014446000105 MTR SPEECH:CURNT60‐79% LMTD $0.014446000125 MTR SPEECH:GOAL 1‐19% LMTD $0.014446000130 MTR SPEECH:GOAL 40‐59% LMTD $0.01

4446000135 MTR SPEECH:GOAL 60‐79% LMTD $0.014446000155 MTR SPEECH:DC 20‐39% LTMD $0.014446000160 MTR SPEECH:DC 40‐59% LMTD $0.014446000165 MTR SPEECH:DC 60‐79% LMTD $0.014496000000 SWALLOW:CURRENT 0% LMTD $0.014496000005 SWALLOW:GOAL 0% LMTD $0.014496000010 SWALLOW:DC 0% LMTD $0.014506000000 CARDIOVERSION FAC FEE $575.004506000005 EMERGENCY CC EA ADD'L 30 MIN $525.004506000015 EMERGENCY CC 1ST 30‐74 MINUTES $1,050.004506000025 EMERGENCY LVL 1 $126.004506000035 EMERGENCY LVL 2 $152.004506000045 EMERGENCY LVL 3 $242.004506000055 EMERGENCY LVL 4 $357.004506000065 EMERGENCY LVL 5 $521.004506000100 OP VISIT LEVEL 1 $25.004506000105 EMR BLADDER SCAN $160.004506000160 FOLEY CATH FOR SPEC COLL EMR $86.004506000180 OBSERVATION PER HOUR $25.004506000185 SEXUAL ABUSE EXAM MEDICAID $17.004600000105 PUL FUNCTION BASIC $140.004600000135 PUL FUNCTION PRE AND POST $248.004605500010 PULSE OXIMETRY CONT PER SHIFT $10.004605500015 PULSE OXIMETRY SPOT CHECK $5.004606000000 PULSE OX SPOT CK $5.004801000275 ECHO W/CONTRAST FF $555.004801000295 BUBBLE STUDY ONLY FF $250.004801000595 COMBINED ECHO PEDIATRIC FF $650.004805500000 ADULT CPR $335.004805500005 PEDIATRIC CODE BLUE $335.005101100125 PICC LINE REMOVAL $55.005108000025 EST PT LEVEL 1 $15.005108000040 EST PT LEVEL 4 $115.006102040060 LOWER EXT NON JNT MRI WO LT $1,045.006102040070 LOWER EXT NON JNT MRI WO RT $1,045.006102040100 LOWER EXT NON JNT MRI W WO LT $1,070.006102040110 LOWER EXT NON JNT MRI W WO RT $1,070.00

6102040120 LOWER EXT JOINT MRI WO LT $1,015.006102040130 LOWER EXT JOINT MRI WO RT $1,015.006102040145 LOWER EXT JOINT MRI W WO LT $1,005.006102040150 LOWER EXT JOINT MRI W WO RT $1,005.006102040165 PELVIS MRI WO CONTRAST $1,045.006102040185 PELVIS MRI W AND WO CONTRAST $1,065.006102040235 UPPER EXT NON JNT MRI WO LT $760.006102040245 UPPER EXT NON JNT MRI WO RT $760.006102040275 UPPER EXT NON JNT MRI W WO LT $2,076.006102040280 UPPER EXT NON JNT MRI W WO RT $2,076.006102040285 UPPER EXT JOINT MRI WO LT $710.006102040290 ABDOMEN MRI WO CONTRAST $1,134.006102040295 UPPER EXT JOINT MRI WO RT $710.006102040320 ABDOMEN MRI W AND WO CON $1,070.006102040340 UPPER EXT JOINT MRI W WO LT $2,042.006102040355 UPPER EXT JOINT MRI W WO RT $2,042.006102040395 ORBIT NECK MRI W WO CONTRAST $1,055.006102040400 HEAD MRA WO CONTRAST $825.006102040430 NECK MRA WO CONTRAST $1,282.006102040440 NECK MRA W WO CONTRAST $1,295.006102040450 HEAD MRI WO CONTRAST $1,065.006102040455 HEAD MRI W CONTRAST $1,384.006102040460 HEAD MRI W AND WO CONTRAST $1,025.006102040465 CERVICAL SP MRI WO CONTRAST $950.006102040470 CERVICAL SP MRI W CONTRAST $1,384.006102040475 THORACIC SP MRI WO CONTRAST $935.006102040480 THORACIC SP MRI W CONTRAST $730.006102040485 LUMBAR SP MRI WO CONTRAST $1,309.006102040490 LUMBAR SP MRI W CONTRAST $1,384.006102040495 CERVICAL SP MRI W AND WO CONT $1,010.006102040500 THORACIC SP MRI W AND WO CONT $935.006102040505 LUMBAR SP MRI W AND WO CONT $1,005.006200000010 TRAUMA RESPONSE W CRIT CARE $1,015.006200000450 TELEHEALTH ORIG SITE FEE‐ED $60.006200000530 PRIVATE MONITOR ISOLAT $660.006200000570 PRIVATE TELEMETRY ISOL $610.006200000620 PRIVATE ROOM $410.00

6200000621 SEMI PRIVATE ROOM $400.006200000630 PRIVATE MONITOR BED $610.006200000650 SWING BED PRIVATE $465.006200000655 SWING BED ISOLATION $515.006200000670 PRIVATE TELEMETRY BED $560.006200000680 PRIVATE ISOLATION ROOM $460.006200003660 ARTERIAL BLOOD GASES ‐ PROF FEES $35.006200012153 VENIPUNCTURE ADDITIONAL $12.006200012383 THERAPEUTIC PHLEBOTOMY $138.006200016801 ER PF WOUND CLOS UTL T ‐ PROF FEES $66.006200016802 ER WOUND CLOS UTL TISS $103.006200021055 THORACIC SPINE 3 VIEW $150.006200022311 HAND 2 VIEWS $150.006200026182 ARTERIAL DOPPLER UPPER EXT BIL $573.006200026189 ARTERIAL DOPPLER LOW EXT BIL $675.006200031500 ENDOTRACHEAL INTUB ‐ PROF FEES $280.006200032257 NASAL CANNULA PEDS $1.006200032349 AEROSOL COOL MIST $200.006200032540 INCENTIVE SPIROMETRY $43.006200033042 OXYGEN ER OP $24.006200035063 STEPDOWN RECOVERY $200.006200036430 BLOOD TRANSFUSION ‐ PROF FEES $69.006200036513 OBSERV TELEMETRY EA HR $38.006200036514 OBSERV ISOLATION BED EA HR $38.006200036515 OBSERV ISOL/TELM EA HR $50.006200040219 SALINE VIALS 3CC RT $8.006200042322 POTASSIUM CHL 10MEQ TAB $8.006200042562 CALCIUM CARBONATE/VITAMINE D3 $5.006200043000 EZ IO $160.006200043246 EGD WITH PEG TUBE PLACEMENT $1,575.006200045271 DIP TET ADULT $64.006200045350 COLONOSCOPY SCREEN HIGH RISK $770.006200045352 COLONOSCOPY SCREEN LOW RISK $770.006200045385 COLONOSCOPY REMOVE T P $947.006200045675 OMNIPAQUE (IOHEXOL) $300.006200045685 NORMAL SALINE 10ML DISP SYR $6.006200045690 FLOURI‐STRIP $5.00

6200045797 LIDOCAINE HCL 1% 10ML VIAL $7.006200045885 WATER FOR INJECT STERILE 10ML $7.006200045921 ESTRADIOL 0.5MG TAB $6.006200046752 BRIMONIDINE 0.2% 5ML $107.006200047754 CYCLOPENTOLATE HCL $147.006200047884 VISIPAQUE 320MG/100ML CONTRAST $369.006200047965 LIDOCAINE VISC 20ML $6.006200048234 EMLA CREAM $160.006200048258 ZOVIRAX 5% 2GM OINT $361.006200048368 METHENAMINE HIPP TAB $7.006200048490 MORPHINE SULFATE 4MG/1ML $7.006200051702 INSERT BLADDER CATH $300.006200051703 INSERT FOLEY COMPLICAT $300.006200054063 SULFAMETH/TRIME 20ML SUSP $13.006200055555 VALACYCLOVIR 1000 MG TABLET $42.006200057385 BENICAR 40MG TAB $32.006200059410 VAGINAL DELIVERY ‐ PROF FEES $1,825.006200070177 BANDAGE ELASTIC 3 INCH $4.006200070185 BANDAGE ELASTIC 4 INCH $4.006200070193 BANDAGE ELASTIC 6 INCH $6.006200070284 SET INJECTION SITE $6.006200070287 BANDAGE COBAN 4 INCH $4.006200070466 STOPCOCK 3 WAY 20 INCH $6.006200070490 CATH COUDE 16 FRENCH $35.006200070672 COLLAR CERVICAL LARGE $27.006200070680 URINE PEDIATRIC COLLECTOR $3.006200070763 DRESSING 4X4 STERILE $3.006200070789 DRESS ADAPTIC 3X3 $3.006200070847 DRESS TELFA 3X8 $4.006200070860 OPTILOCK NON‐ADH WOUND DRESSNG $14.006200070862 XEROFORM DRESSING 5X9 $4.006200071035 NUGAUZE IDOFORM 1 2 X 5 $14.006200071043 NUGAUZE IDOFORM 1X5 $16.006200071050 NUGAUZE IDOFORM 2X5 $17.006200071076 VASELINE GAUZE 1X36 $2.006200071217 BANDAGE KERLIX $4.006200071324 BAG URINARY DRAIN $11.00

6200071365 SUCTION CANNISTER 1400 $8.006200071480 PACK ICE DISPOSABLE $6.006200071522 PAD OB PER 12 $7.006200071647 RESTRAINT WRIST $15.006200071654 TRAY IRRIG WITH DISPO BULB $6.006200071681 CONNECTOR 5 IN 1 $3.006200071693 TRACHEOTOMY CARE KIT $10.006200071853 BAG LEG DRAIN 32 OUNCE $10.006200071893 CATH STRAP VELCRO $11.006200072009 AIRCAST FOOT ANKLE $100.006200072066 ADULT/PED EVAC CHEST DRAIN SET $162.006200072082 SPLINT LEG TIBULA HALF $32.006200072157 TUBE SALEM SUMP 16 FRENCH $8.006200072165 Kidney Stone Filter $4.006200072272 SYRINGE EAR 2 OUNCE $6.006200072385 PORT A CATH GRIPPER $19.006200072702 TUBE SALEM SUMP 18 FRENCH $7.006200072710 TUBE STOMACH 12 FRENCH $4.006200072716 EXTERNAL PACE MAKER $729.006200072744 ARMBOARD INFANT $3.006200072868 OB PACK $37.006200072975 NUGAUZE IDOFORM 1 4X5 $14.006200073031 MID STREAM KIT $3.006200073239 SPECULUM VAGINAL DISPOSABLE $4.006200073247 PAD EYE OVAL $3.006200073281 KIT DRESS CHANGE V CAT $24.006200073297 CATH INF CTRL BARD 16 FR 5CC $28.006200073298 CATH INF CTRL BARD 18 FR 5CC $28.006200073445 ARMBOARD 3 18 INCH $3.006200073452 ARMBOARD 3 9 INCH $3.006200073486 BANDAGE KLING 3 INCH $3.006200073635 IV START KIT $7.006200073643 IV CATH 24 5 8 GAUGE $6.006200073672 VAC ATS MEDIUM DRESSING $61.006200073676 IV CATH 22 GAUGE $6.006200073684 IV CATH 20 GAUGE $6.006200073692 IV CATH 18 GAUGE $6.00

6200073932 CAST BOOT OPEN TOE LARGE $25.006200074005 CATH FOLEY 16 FRENCH 5CC $20.006200074013 CATH FOLEY 18 FRENCH 5CC $10.006200074021 CATH FOLEY 20 FRENCH 5CC $10.006200074161 BRACE CLAVICLE LARGE $60.006200074179 BRACE CLAVICLE MEDIUM $60.006200074195 COLLAR CERVICAL MEDIUM $27.006200074203 COLLAR CERVICAL SMALL $27.006200074576 VAC ATS INFO CANISTER $91.006200074612 OPSITE 5 1 2 X 4 $4.006200074625 YANKUAER SUCTION REGULAR $4.006200074971 SPLINT FINGER 4 PRONG SMALL $8.006200075127 NUGAUZE PLAIN 1 4X5 $20.006200075135 NUGAUZE PLAIN 1X5 $27.006200075184 CATH COUDE 20 FRENCH $39.006200075192 CATH COUDE 18 FRENCH $39.006200075321 KIT MULTI LUMEN CATH $138.006200075440 SLING ARM UNIVERSAL $10.006200075457 SLING ARM SMALL $10.006200075663 STOCKING KNEE LG REG PAIR $13.006200075671 STOCKING KNEE MED REG PAIR $13.006200075689 STOCKING KNEE SM REG PAIR $13.006200075826 TRAY SUCTION CATH 14 FR $6.006200075853 KNEE IMMOBILIZER MEDIUM $107.006200075861 KNEE IMMOBILIZER LARGE $107.006200075882 DRESS ALLEVYN TRACHEOSTOMY $8.006200075952 KNEE IMMOBILIZER EXTRA LARGE $107.006200075964 KNEE IMMOBILIZER SMALL $107.006200075982 LOW AIR LOSS MATTRESS $40.006200076054 DRESS TEGADERM 2 3 8 X 2 3 4 $4.006200076075 SKIN STAPLE REMOVER $8.006200076577 SET MACROBORE EXTENSION $7.006200076695 TRAY URETHERAL CATH $16.006200076705 NGTUBE GUARD 18 $4.006200076733 TRAY LACERATION $28.006200076737 TUBE STOMACH 16 FRENCH $4.006200076745 TUBE STOMACH 18 FRENCH $4.00

6200076775 US RETROPERTIONEAL LIM $199.006200076844 CATH FOLEY PED 10 FR 3CC $4.006200077057 CATH COUDE 14 FRENCH $39.006200077099 CATH FOLEY PED 8 FR 3CC $7.006200077523 CERVICAL COLLAR RIGID $145.006200077560 SLING ARM CHILD $15.006200077586 SPLINT COLLIES LEFT LARGE $11.006200077594 SPLINT COLLIES RIGHT LARGE $11.006200077602 SPLINT COLLIES LEFT SMALL $11.006200077610 SPLINT COLLIES RIGHT SMALL $11.006200077628 SPLINT COLLIES LEFT MEDIUM $11.006200077636 SPLINT COLLIES RIGHT MEDIUM $11.006200077750 SPLINT W/F LEFT LARGE $60.006200077768 SPLINT W/F LEFT MEDIUM $60.006200077776 SPLINT W/F LEFT PEDI $60.006200077784 SPLINT W/F LEFT SMALL $60.006200077800 SPLINT W/F RIGHT LARGE $60.006200077818 SPLINT W/F RIGHT MEDIUM $60.006200077834 SPLINT W/F RIGHT SMALL $60.006200077842 SPLINT W/F RIGHT XL $60.006200078014 WRAP ANKLE ELASTIC MEDIUM $26.006200078022 WRAP ANKLE ELASTIC LARGE $26.006200078220 TUBE ENDOTRACH 6.0 $18.006200078246 TUBE ENDOTRACH 7.0 $18.006200078254 BED KENAIR MED SURG $159.006200078255 BED CLINITRON $245.006200078261 TUBE ENDOTRACH 8.0 $18.006200078279 TUBE ENDOTRACH 8.5 $18.006200078341 LOW PRESSURE WALKER ALL SZ $175.006200078445 TRAY PARACENTESIS $59.006200078625 KIT FEMALE CATH $8.006200078726 SHOULDER IMMOBILIZER $65.006200079799 SUTURE REMOVAL KIT $6.006200080069 RENAL FUNCTION PANEL $26.006200080100 UDS COC COLL ONLY $25.006200080101 UDS COC COLLECTION AND TEST $100.006200090471 VACCINE ADMINISTRATION $40.00

6200090761 IV INF HYDRATION EA ADD HR $40.006200090767 ADD SEQ INFUS UP TO 1 HOUR $65.006200090774 IV PUSH SNGLE/INITIAL SUBSTANC $205.006200090775 IV PUSH EA ADD'L NEW DRUG $47.006200090776 IV PUSH EA ADD'L SAME DRUG $40.006200090780 IV HYDRATION 1ST 31 TO 60 MIN $205.006200090785 IV INF THERAPEUTIC 1ST HOUR $205.006200093010 EKG 12 LEAD PHYSICIAN INTERP ‐ PROF FEES $20.006200093041 EKG TRACING ONLY FF $60.006200093042 EKG RHYTHM STRIP ‐ PROF FEES $22.006200093926 ARTERIAL DOPPLER LOW EXT UNI $445.006200093931 ARTERIAL DOPPLER UPPER EXT UNI $380.006200099208 EMERGENCY ASSESSMENT $75.006200099280 PRO FEE ASSESSMENT ‐ PROF FEES $35.006200099281 PRO FEE MINIMAL ‐ PROF FEES $35.006200099282 PRO FEE LOW COMPLEXITY ‐ PROF FEES $65.006200099283 PRO FEE LOW MODERATE C ‐ PROF FEES $110.006200099284 PRO FEE MODERATE COMPL ‐ PROF FEES $185.006200099285 PRO FEE HIGH COMPLEXIT ‐ PROF FEES $275.006200099291 PRO FEE CRITICAL 30 74 ‐ PROF FEES $350.006200099292 PRO FEE CRITICAL EA AD ‐ PROF FEES $175.006200099309 EMERGENCY NON EMERGENC $75.006200099506 TRIAGE $75.006200099507 NURSE ASSIGN PCP ‐ PROF FEES $5.006200149080 PARACENTESIS W/O IMAGING $820.006200160201 DRESS THICK SM IN SUB $123.006200160251 DRESSING OR DEBRIDEMENT MED $246.006200160252 DRESSING OR DEBRIDEMENT MED ‐ PROF FEES $225.006200160301 DRESS DEBR >10% BODY PF ‐ PROF FEES $265.006200205521 INJ SGLE MULT TRIGGER 1/2 MUSC ‐ PROF FEES $70.006200205522 INJ SIN MULT TRIG 1/2 MUSCLES $350.006200366801 PLACEMENT OF INTRAOSSEOUS PF ‐ PROF FEES $120.006200366802 PLACEMENT OF INTRAOSSEOUS FF $350.006200437602 CHANGE GASTRO TUBE PF ‐ PROF FEES $95.006200437603 CHANGE GASTRO TUBE FF $455.006200929601 CARDIOVERSION PRO FEE ‐ PROF FEES $225.006201000615 SCREEN MAMMO DIGIT IMG BIL $110.00

6201000620 DIAGNOSTIC MAMMO BIL $155.006201002101 NEEDLE ASPIRATION W/O IMAGE PF ‐ PROF FEES $135.006201002102 NEEDLE ASPIRATION W/O IMAGE FF $300.006201006001 I & D ABCESS ‐ PROF FEES $190.006201006002 I & D ABCESS $300.006201006101 MULTIPLE I & D ABCESS PF ‐ PROF FEES $350.006201006102 MULTIPLE I & D ABCESS $350.006201008001 I & D PILONIDAL CYST ‐ PROF FEES $200.006201008002 I & D PILONIDAL CYST $550.006201012001 F BODY S TISS SIMPLE ‐ PROF FEES $200.006201012002 F BODY S TISS SIMPLE $350.006201012101 F BODY S TISS COMPLEX ‐ PROF FEES $370.006201012102 F BODY S TISS COMPLEX $1,421.006201014001 I & D HEMATOMA SIMPLE ‐ PROF FEES $235.006201014002 I & D HEMATOMA SIMPLE $1,350.006201016001 PUNCTURE ASPIRATION OF ‐ PROF FEES $190.006201016002 PUNCTURE ASPIRATION OF $350.006201104201 DEBRIDE SKIN P THICK PF ‐ PROF FEES $125.006201104202 DEBRIDE SKIN P THICK FF $350.006201173001 NAIL AVULSION ‐ PROF FEES $110.006201173002 NAIL AVULSION $300.006201200101 SIMPLE REPAIR 2.5CM ‐ PROF FEES $100.006201200102 SIMPLE REPAIR 2.5CM $300.006201200201 SIMPLE REPAIR 7.5CM ‐ PROF FEES $130.006201200202 SIMPLE REPAIR 7.5CM $300.006201200401 SIMPLE REPAIR 12.5CM ‐ PROF FEES $155.006201200402 SIMPLE REPAIR 12.5CM $300.006201200701 SIMPLE REPAIR +30CM ‐ PROF FEES $310.006201200702 SIMPLE REPAIR +30CM $357.006201201101 FACIAL REPAIR 2.5CM ‐ PROF FEES $120.006201201102 FACIAL REPAIR 2.5CM $300.006201201301 FACIAL REPAIR 5.0CM ‐ PROF FEES $135.006201201302 FACIAL REPAIR 5.0CM $300.006201201401 FACIAL REPAIR 7.5CM ‐ PROF FEES $170.006201201402 FACIAL REPAIR 7.5CM $300.006201201501 FACIAL REPAIR 12.5CM ‐ PROF FEES $210.006201201502 FACIAL REPAIR 12.5CM $300.00

6201203101 SCALP AX TR EXT 2.5CM ‐ PROF FEES $305.006201203102 SCALP AX TR EXT 2.5CM $360.006201203201 SCALP AX TR 2.6 5C ‐ PROF FEES $380.006201203202 SCALP AX TR 2.6 5C $350.006201203401 SCALP AX TR EXT 7.6 1 ‐ PROF FEES $410.006201203402 SCALP AX TR EXT 7.6 1 $350.006201203501 SCALP AX TR EXT 12.6 ‐ PROF FEES $475.006201203502 SCALP AX TR EXT 12.6 $385.006201204101 NCK HND FT GT2.5CM OR ‐ PROF FEES $300.006201204102 NCK HND FT GT2.5CM OR $350.006201204201 NCK HND FT GTRPR 2.6 ‐ PROF FEES $400.006201204202 NCK HND FT GTRPR 2.6 $350.006201204401 NCK HND FT GT 7.6 12.5 ‐ PROF FEES $430.006201204402 NCK HND FT GT 7.6 12.5 $530.006201204501 NCK HND FT GTRPR 12.6 ‐ PROF FEES $535.006201204502 NCK HND FT GTRPF 12.6 $530.006201205101 FC EAR EYE 2.5 CM OR LESS ‐ PROF FEES $340.006201205102 FC EAR EYE 2.5 CM OR LESS $350.006201205201 FC ER EYE NO LI MM 2.6 ‐ PROF FEES $405.006201205202 FC ER EYE NO LI MM 2.6 $360.006201205301 FC ER EYE NO LI MM 5.1 ‐ PROF FEES $435.006201205302 FC ER EYE NO LI MM 5.1 $350.006201205411 FC ER EYE NO LI MM 7.6 TO 12.5 ‐ PROF FEES $445.006201205412 FC ER EYE NO LI MM 7.6 TO 12.5 $528.006201312001 COMPLEX REPAIR 2.5CM ‐ PROF FEES $470.006201312002 COMPLEX REPAIR 2.5CM $530.006201312101 COMPLEX REPAIR 7.5CM ‐ PROF FEES $625.006201312201 COMPLEX EA ADD ‐ PROF FEES $170.006201312202 COMPLEX EA ADD $300.006201313101 COMPLEX REPAIR 2.5CM ‐ PROF FEES $525.006201313102 COMPLEX REPAIR 2.5CM $360.006201313201 COMPLEX REPAIR 7.5CM ‐ PROF FEES $895.006201315201 COMPLEX REPAIR 7.5CM ‐ PROF FEES $700.006201315202 COMPLEX REPAIR 7.5CM $530.006201600101 INITIAL TX 1ST DEGREE ‐ PROF FEES $95.006201600102 INITIAL TX 1ST DEGREE $300.006202000101 ECHO COMPLETE OR W/BUBBLE PF ‐ PROF FEES $170.00

6202000102 ECHO COMPLETE OR W/BUBBLE FF $555.006202000103 ECHO W/CONTRAST PF ‐ PROF FEES $170.006202010301 WOUND EXPLORATION EXTREMITY PF ‐ PROF FEES $690.006202010302 WOUND EXPLORATION EXTREMITY FF $555.006202060501 ARTHROCENTESIS MED JOI ‐ PROF FEES $80.006202060502 ARTHROCENTESIS MED JOI $350.006202061001 ASPIR MAJ JOINT KNEE S ‐ PROF FEES $95.006202061002 ASPIR MAJ JOINT KNEE S $350.006202148001 T‐M JOINT REDUCTION PF ‐ PROF FEES $190.006202148002 T‐M JOINT REDUCTION FF $360.006202365001 SHOULDER REDUCTION W/O ANESTH ‐ PROF FEES $545.006202365002 SHOULDER REDUCTION W/O ANESTH $300.006202405701 MAMMO SCREENING $110.006202601001 I & D FINGER SIMPLE ‐ PROF FEES $265.006202601002 I & D FINGER SIMPLE $300.006202819001 F BODY FOOT SUBCUT ‐ PROF FEES $270.006202819002 F BODY FOOT SUBCUT $915.006202866001 FINGER/TOE REDUCTION PF ‐ PROF FEES $180.006202866002 FINGERS/TOE REDUCTION FF $300.006202912501 SPLINT SHORT ARM ‐ PROF FEES $80.006202912502 SPLINT SHORT ARM $300.006202924001 SPLINT SHOULDER ‐ PROF FEES $90.006202924002 SPLINT SHOULDER $300.006202951501 SPLINT SHORT LEG ‐ PROF FEES $100.006202951502 SPLINT SHORT LEG $300.006203030001 F BODY INTRANASAL ‐ PROF FEES $240.006203030002 F BODY INTRANASAL $300.006203090301 EPISTAXIS CONTR ANT PA ‐ PROF FEES $160.006203090302 EPISTAXIS CONTR ANT PA $300.006203090501 EPISTAXIS CONTR POSTER ‐ PROF FEES $210.006203090502 EPISTAXIS CONTR POSTER $300.006203151101 F BODY THROAT ‐ PROF FEES $265.006203151102 F BODY THROAT $300.006203202001 CHEST TUBE PLACEMENT ‐ PROF FEES $355.006203202002 CHEST TUBE PLACEMENT $1,010.006203656101 ER PRO FEE CENT LINE C ‐ PROF FEES $660.006203656102 CENT LINE CENTRAL INSE $2,580.00

6205642001 I & D BARTHOLIAN ABCESS ‐ PROF FEES $185.006205642002 I & D BARTHOLIAN ABCESS $300.006206522001 F BODY CORNEAL ‐ PROF FEES $85.006206522002 F BODY CORNEAL $350.006206522201 F BODY CORNEAL SLIT ‐ PROF FEES $115.006206522202 F BODY CORNEAL SLIT $350.006206920001 REMOVAL FOREIGN BODY EAR PF ‐ PROF FEES $100.006206920002 REMOVAL FOREIGN BODY EAR FF $300.006207200501 SIMPLE REPAIR 12.6CM‐20.0CM ‐ PROF FEES $210.006207200502 SIMPLE REPAIR 12.6CM‐20.0CM $350.006209295001 CARDIOPULMONARY RES PF ‐ PROF FEES $365.006209917001 GASTRIC LAVAGE ‐ PROF FEES $170.006209917002 GASTRIC LAVAGE $350.006209930901 PRO FEE NON‐EMERGENCY ‐ PROF FEES $40.006360000205 PROLIA 60MG/ML (DENOSUMAB) $3,720.006363000095 AMIODARONE INJ 150MG/3ML $42.006363000130 AMPICILLIN SOD INJ 1 GM $30.006363000175 ARANESP INJ 200MCG/1ML $4,412.006363000205 ATROPINE SULF INJ .4MG 1ML $15.006363000210 ATROPINE SULF OPT SOL 1% 5ML $59.006363000235 AZITHROMYCIN INJ 500MG $56.006363000240 B‐12 INJ 1000 MCG 1ML $29.006363000245 BICILLIN LA .6MU 1ML $273.006363000260 BROVANA INH SOL 15MCG/2ML $53.006363000265 BUTORPHANOL INJ 1MG 1ML $13.006363000270 BUTORPHANOL INJ 2MG 1ML $30.006363000280 CALCIUM GLUC INJ 10% 100ML $30.006363000315 CEFAZOLIN INJ 1 GM 10ML $21.006363000340 CEFOXITIN INJ 1GM 10ML $78.006363000360 CEFTRIAXONE INJ 1GM $149.006363000365 CEFTRIAXONE INJ 1GM ADD $46.006363000370 CEFTRIAXONE INJ 250MG $26.006363000375 CEFTRIAXONE INJ 2GM ADD $71.006363000380 CEFTRIAXONE INJ 500MG $23.006363000420 CHLORPROMAZINE AMP 50MG 2ML $94.006363000425 CIPROFLOXACIN IV BG 400M FLEX $96.006363000465 CORTROSYN INJ 0.25MG 1ML $310.00

6363000480 CUBICIN INJ 500MG 10ML $1,270.006363000590 DEXAMETHASONE INJ 4 MG 1ML $10.006363000595 DEXAMETHASONE INJ 4 MG 5ML $9.006363000605 DIAZEPAM SRN 5MG/ML 2ML $89.006363000610 DICYCLOME INJ 10MG/ML 2ML $47.006363000620 DIGOXIN AMP 0.5 MG 2ML $18.006363000625 DIHYDROERGOTAME AMP 1ML $450.006363000630 DIPHENHYDRAME 50 MG/ML $10.006363000735 ERYTHROCIN LACT P/F INJ 500MG $205.006363000745 FENTANYL AMP 2ML $7.006363000760 FENTANYL PATCH 100MCG 40CM $237.006363000765 FLUCONAZOLE BAG 200MG 100ML $224.006363000790 FLUZONE INFLUENZA VACCINE $52.006363000795 FORTAZ INJ 1 GM ADD $44.006363000810 FOSPHENYTOIN INJ 50MG/ML 10ML $299.006363000815 FOSPHENYTOIN INJ 50MG/ML 2ML $103.006363000830 FUROSEMIDE INJ 100 MG 10ML $19.006363000835 FUROSEMIDE INJ 20 MG 2ML $28.006363000840 FUROSEMIDE INJ 40 MG 4ML $17.006363000895 GENTAMICIN 40MG/ML 2ML $7.006363000910 GEODON CAP 20 MG $28.006363000920 GLUCAGON 1MG $490.006363000935 HALOPERIDOL INJ 5MG/ML 1ML $25.006363000955 HEPARIN SOD INJ 1000U 1ML $24.006363000970 HEPARIN W/D5W 25M 500ML $44.006363000990 HYDRALAZINE INJ 20MG 1ML $371.006363000995 HYDROMORPHONE HCL INJ 2 MG $18.006363001005 HYDROXYZINE INJ 25 MG 1ML $79.006363001010 HYDROXYZINE INJ 50 MG 1ML $27.006363001020 HYPERTET 1ML PRE‐FIL SRN W/SAF $1,420.006363001035 IMITREX INJ 6MG $310.006363001055 INS HUMULIN 70/30 $8.006363001060 INS HUMULIN N U‐100 $45.006363001065 INS HUMULIN R U‐100 $8.006363001090 INVANZ 1GRAM VIAL $374.006363001115 KEPPRA INJ 5ML $119.006363001125 KETOROLAC INJ 30MG 1ML $17.00

6363001130 KETOROLAC INJ 60MG 2ML $21.006363001155 LEVAQUIN INJ BG 250MG 50ML $51.006363001160 LEVAQUIN INJ BG 500MG 100ML $144.006363001165 LEVAQUIN INJ BG 750MG 150ML $173.006363001175 LORAZEPAM INJ 2MG/ML 1ML $25.006363001180 LOVENOX SRN 100MG/ 1ML $262.006363001190 LOVENOX SRN 30MG/0.3ML $79.006363001195 LOVENOX SRN 40MG/0.4ML $105.006363001200 LOVENOX SRN 60MG/0.6ML $157.006363001205 LOVENOX SRN 80MG/0.8ML $210.006363001230 MAG SULF INJ 1G 2ML $7.006363001250 MARINOL CAP 2.5 MG $36.006363001255 MARINOL CAP 5MG $40.006363001280 MERREM IV 1 GM 30 ML $219.006363001290 METHADONE TAB 5 MG $4.006363001315 METHOTREXATE TAB 2.5 MG $21.006363001325 METHYLPRED ACETATE 40MG/1ML $35.006363001330 METHYLPRED ACETATE INJ 80MG 1ML $60.006363001335 METHYLPRED SOD SUC 125MG/3ML $32.006363001345 METOCLOPRAMIDE INJ 10MG 2ML $5.006363001350 MIACALCIN INJ 200I.U./ML 2ML $9,245.006363001355 MIDAZOLAM INJ 2 MG/ML 2ML $23.006363001365 MIDAZOLAM INJ 5MG/ML 1ML $7.006363001370 MIDAZOLAM INJ 5MG/ML 5ML $7.006363001400 MORPHINE CPJ 2MG/ML $16.006363001420 MORPHINE SULF PCA 30MG/30ML $35.006363001445 NALOXONE INJ 0.4 MG 1ML $52.006363001450 NALOXONE L‐J 2 MG 2ML $108.006363001500 OCTREOTIDE AMP 500MCG $214.006363001510 ONDANSETRON INJ 2ML $5.006363001515 ORPHENADRINE AMP 2ML $74.006363001555 PENICILLIN G POT 5MU INJ $42.006363001575 PHENYTOIN INJ 250 MG 5ML $7.006363001580 PITOCIN INJ 10U/ML 1ML $7.006363001585 PNEUMOVAX 23 INJ $11,850.006363001620 POT CHL BAG 20MEQ 100ML $80.006363001635 PRIMAXIN INJ 250 MG 10ML $38.00

6363001640 PRIMAXIN INJ 250 MG ADD $74.006363001645 PRIMAXIN INJ 500 MG 10ML $133.006363001650 PRIMAXIN INJ 500 MG ADD $111.006363001660 PROCHLORPERAZINE 5MG/ML 2ML $61.006363001665 PROCRIT 10000U/ML 1ML $473.006363001680 PROMETHAZINE INJ 25MG 1ML $8.006363001710 QUELICIN INJ 20MG/ML 10ML $87.006363001720 RANITIDINE INJ 25MG 2ML $51.006363001810 SOLU‐CORTEF ACT‐O‐INJ 100 MG $31.006363001815 SOLU‐CORTEF ACT‐O‐INJ 250 MG $81.006363001825 SOLU‐MEDROL INJ 500 MG $76.006363001880 TETANUS DIPHT ABSR ADULT 7.5ML $103.006363001885 THIAME INJ 100 MG 2ML $33.006363001915 TOBRAMYCIN SUL INJ 80MG/2ML $15.006363001935 VANCOMYCIN INJ 1 GM $63.006363001940 VANCOMYCIN INJ 1 GM ADD $67.006363001945 VANCOMYCIN INJ 500MG $32.006363001950 VANCOMYCIN INJ 500MG ADD $35.006363002005 VIT K1 AMP 10 MG $157.006363002015 XOLAIR 150MG P/F LYPOH INJ $2,457.006363002045 ZOSYN INJ 2.25 GM $48.006363002055 ZOSYN INJ 3.375 GM $71.006363002065 ZOSYN INJ 4.5 GM $77.006363002070 ZYVOX IV BAG 600MG/300ML $435.006363002125 DEMEROL 50 MG INJ $8.006363002190 KENALOG 40MG/1ML INJ $31.006363002210 ANCEF 1GM ADDVANTAGE $10.006363002220 AMPICILLIN 500MG VIAL $13.006363002225 AMPICILLIN 1GM VIAL $59.006363002230 AMPICILLIN 2GRM VIAL $102.006363002250 ZYVOX 600MG TABLET $524.006363002310 ACTIVASE 100MG $25,082.006363002320 MORPHINE 10MG /1ML SYRINGE $7.006363002500 INFED IN 100MG 2ML/10VL $87.006363002520 VENOFER 100MG/5ML $180.006363002540 ZITHROMAX 500MG ADD W/250ML NS $84.006363002565 EPOGEN 20KU/2ML 10,000UNITS/ML $946.00

6363002575 CEFTRIAXONE 2GM VIAL $272.006363002670 ADENOSINE 6MG VIAL $85.006363002700 PREVNAR 13 SYRINGE $512.006363002745 FERAHEME 510MG INJ $2,533.006363002820 NPLATE 250 MCG SDV 0.5ML $6,020.006363025432 PIPERACILLIN/TAZO 2.25GM ADV $48.006363025433 PIPERACILLIN/TAZO 3.375GM ADV $60.006366000045 ARANESP 500MCG/ML SYRINGE $11,030.006366000560 ZARXIO 300MCG 0.5ML PFS $786.006366000565 ZARXIO 480 MCG/0.8ML SYRINGE $1,252.006366000910 MORPHINE 4MG\1ML VIAL $7.006366100045 MULTIHANCE 15 ML $256.006366100125 OMNISCAN 15 ML $237.006370000005 LITTLE NOSES NASAL SPRAY $8.006370000010 HUMALOG MIX 75/25 10ML VIAL $170.006370000020 INSULIN REG, HUMILIN 100UN/ML $49.006370000025 INSULIN GLARGINE (LANTUS) INJ $164.906370000030 INSULIN DETEMIR 100UN/ML $111.007300010055 EKG $90.007300010060 HOLTER MONITOR W REPORT WO INTER $140.007401000000 POLYSOMNOGRAPHY $1,230.007401000005 POLYSOMNOGRAPHY‐CPAP $1,350.007615500000 ARTERIAL PUNCTURE $183.007617300000 INJECTION IM ANTIBIOTICS $60.007617300005 INJECTION IV $195.007617300015 INJECTION SUBQ IM $60.007617860000 IM OR SUBQ INJECTION $60.007617860005 FOLEY CATH I&O $300.007617860020 INJECTION IV $195.007617860025 INJECTION IV EA ADDL $47.007617860040 IV INJECTION SAME DRUG $40.007617870010 FOLEY CATH INDWELLING $300.007618000125 IV INJECTION SAME DRUG $40.007627860005 DIRECT ADMIT TO OBSERVATION $193.007714110005 ADM FEE PNEUMO VACCINE $40.007716000000 ADM FEE TETANUS VACCINE $40.007717840010 PNEMOVAX ADM $40.00

7717860000 ADM FEE FLU VACCINE $40.008000000010 PULMONARY REHAB PHASE 3 $40.008000036591 COLLECTION OF BLOOD SPEC PORT $15.008000045393 COLONOSCOPY W/ENDO MUCOSAL RES $947.008000049083 PARACENTESIS W/IMAGING $820.008000070000 ADM & REPORTING FEE $45.008000080008 ADM FEE FLU VACCINE $45.008000080009 ADM FEE PNEUMONIA VACCINE $45.008000085060 BLOOD SMEAR, PERIPHERIAL $45.008000085378 D DIMER QUALITATIVE OR SEMI‐QU $25.008000088112 CYTOPATHOLOGY, SELECTIVE CELL $90.008000088302 SURGICAL PATHOLOGY LEVEL II $105.008000088305 SURGICAL PATHOLOGY LEVEL IV $145.008000088312 SURG PATH LEVEL VI SPEC STAIN $120.008000088313 SURGICAL PATHOLOGY GROUP II $80.008000088341 IMMUNO STAIN EA ADDL ANTIBODY $66.008000088342 IMMUNOCYTOCHEMISTRY, INT ANTIB $240.008000088360 TUMOR IMMUNOHISTOCHEMISTRY $85.008000090471 IMMUNIZATION ADMIN 1ST VACCINE $45.008000099211 OP VISIT LEVEL 1 $15.008000099460 NEWBORN EVAL ‐ PROF FEES $155.008000100168 CYTOPATHOLOGY, CERVICAL OR VAG $30.008000190633 VFC ADM FEE HEP A 2 DOSE $19.008000190647 VFC ADM FEE HIB PRP‐OM 3 DOSE $19.008000190649 VFC ADM FEE HPV QUAD 3 DOSE $19.008000190651 VFC ADM FEE HPV 9 3DOSE $19.008000190657 VFC ADM FEE INF VIR 6‐35MONTHS $19.008000190658 VFC ADM FEE INF VIR 3YRS & UP $19.008000190660 VFC ADM FEE INF VIR INTRANASAL $19.008000190669 VFC ADM FEE PNEUMOCOCCAL 7 VAL $19.008000190670 VFC ADMIN FEE PCV13 $19.008000190681 VFC ADM FEE ROTAVIRUS 2 DOSE $19.008000190696 VFC ADM FEE DTAP‐IPV 4‐6YEARS $19.008000190700 VFC ADM FEE DTAP UNDER 7 YEARS $19.008000190707 VFC ADM FEE MMR $19.008000190713 VFC ADM FEE POLIOVIRUS $19.008000190715 VFC ADM FEE TDAP 7 YEARS & UP $19.00

8000190716 VFC ADM FEE VARICELLA VIRUS $19.008000190723 VFC ADM FEE DTAP‐HEPB‐IPV $19.008000190734 VFC ADM FEE MENINGOCCAL VACCIN $19.008000190744 VFC ADM FEE HEP B PEDIATRIC $19.008000205501 BICEPS TENDON SHEATH INJ PF ‐ PROF FEES $85.008000205502 BICEPS TENDON SHEATH INJ FF $350.008000300014 AMPICILLIN 500 MG CAPSULE $2.508000300051 IRBESARTAN 150MG TABLET $10.008000300136 DEXAMETHASONE 0.5 MG TABLET $2.508000300247 INSTA GLUCOSE 31 GM TUBE $13.008000300249 VENLAFAXINE 25 MG TABLET $10.508000300301 HYOSCYAMINE 0.125 MG $2.508000300337 MELATONIN 3 MG TABLET $5.008000300558 TAMIFLU 30 MG CAPSULE $47.008000300602 Z‐BEC TABLET $2.508000300652 CATAFLAM (DICLOFENAC) 50 MG $6.008000300654 GUAIFENESIN 400 MG TABLET $2.508000300664 JANUVIA 100MG TABLET $47.008000300675 SLOW IRON 50 MG TABLET $2.508000300696 CRANBERRY 425MG CAPSULE $2.508000300713 GLUCOSAMINE 500 MG TABLET $2.508000300743 METHIMAZOLE 5MG TABLET $2.508000300756 CALCIUM/VIT D 600MG/800MG $2.508000300770 JANUVIA 25 MG TABLET $88.008000300777 CREON DR 6000 UNITS CAP $5.008000300811 PROPYLTHIOURACIL 50 MG TABLET $3.008000301083 CYANOCOBLAMIN 1000MCG/1ML VIAL $29.008000301091 AMIODARONE 150MG/3ML VIAL $7.708000301097 DEXAMETHASONE 10MG/1ML VIAL $18.008000301117 DOPAMINE 800MG/500ML (PREMIX) $65.008000301147 FOLIC ACID 5MG/ML 10ML MDV $147.008000301158 NOVOLOG 70/30 MIX $50.008000301214 HUMALOG 100UN/1ML $9.008000301222 KETALAR INJ 12.5 TO 75MG $12.008000301237 LEVOPHED 4MG/4ML VIAL $132.008000301277 NARCAN 1MG/ML $50.008000301294 NEUPOGEN 300MCG/0.5ML $925.00

8000301348 ROMAZICON 5ML $22.008000301382 CHLORPROMAZINE 25 MG/1 ML AMP $82.008000301405 MARCAINE 0.5% 10ML VIAL $56.008000301417 ENALAPRILAT 1.25M/1ML VIAL $7.708000301441 XYLOCAINE/EPI 1% 10ML VIAL $10.008000301562 MARCAINE 0.25% 10ML VIAL $12.008000301573 MEROPENEM 500 MG VIAL $33.008000301577 HEPARIN SRN 200 UNITS/2ML $6.008000301580 NUBAIN 20 MG/1ML INJ $19.008000301581 NEUPOGEN 480MCG 0.8ML SRN $1,515.008000301582 DEFINITY 2ML VIAL $668.008000301583 FLU VACCINE FLUARIX QUAD $40.008000301584 VENOFER 200MG/10ML $348.008000301585 PROHANCE 15 ML VIAL $297.008000303071 FENTANYL INJ 0.2MG $8.008000303211 MIDAZOLAM PER 1 MG $2.008000303249 GUAIFENESIN/CODEINE 10ML CUP $3.008000305023 AMOX/CLAV 250MG/62.5MG PER 5ML $225.008000305147 SEPTRA 30ML LIQUID $20.008000305194 ROBITUSSUN DM 5ML $6.008000305207 TYLENOL SUSP 160MG/5ML LIQ30ML $9.008000305211 VANCOMYCIN 50MG/ML 150 ML ORAL $363.008000306037 CORTISPORIN OPTH 7.5ML $206.008000306087 HUMIST NASAL SPRAY $7.008000306205 ADVAIR 100/50 $278.008000306212 TETRACAINE 0.5% OPTHALMIC 4ML $34.008000306290 VISINE‐A 15ML $16.008000307120 SILVADENE CREAM 1% 25GM $51.008000307122 SWEEN CREAM JAR $40.008000307165 DAKIN'S SOLUTION 0.125% $35.008000307167 BENZ‐PROTECT SWABS $2.508000307170 AQUAPHOR OINTMENT 1.75OZ $18.008000307175 LIDOCAINE 5% RECTAL CREAM 15GM $78.008000411500 WOUND VAC RENTAL $100.008000411522 SLEEVE DVT FOOT $28.008000411523 SLEEVE DVT CALF $43.008000497772 MEPILEX BORDER 4X4 $7.00

8000500016 DUODERM 4X4 $11.008000500036 GAUZE SPONGE BOAT $3.008000500067 DERMAL GEL DRESSING $29.008000500099 STRATASORB COMPOSITE DRESSING $5.008000500138 ENEMA SODIUM PHOSHATE $4.008000500141 ENEMA KIT CLEAN $4.008000500150 TELEMETRY POUCH $11.008000500254 ABD PADS 8X10 $3.008000500908 TUBE SALEM SUMP 12 FR $8.008000500911 TUBE SALEM SUMP 14FR $7.008000500950 RECTAL TUBE $18.008000501248 MAXORB DRESSING $5.008000501399 CATH SILICONE 22FR/5CC $11.008000501409 DRESSING SACRUM $15.008000501567 GASTRO TUBE ALL SIZES $95.008000501792 TED HOSE KNEE SM/LONG $13.008000501801 TED HOSE KNEE MED/LONG $13.008000501810 TED HOSE KNEE LRG/LONG $13.008000501816 TED HOSE KNEE XLG/LONG $14.008000502008 BLOOD SET $28.008000503562 GAUZE DRESSING 6X6 $8.008000503567 BORDER GAUZE 4X10 $2.008000503598 MORGAN LENSES $31.008000510000 OP CLINIC VISIT LEVEL 1 $15.008000510054 PLAIN PACKING GAUZE 1/2" $9.008000542201 IRRIGATION OF CORPORA CAVER PF ‐ PROF FEES $265.008000542202 IRRIGATION OF CORPORA CAVER FF $300.008000702025 SUTURE REMOVAL PRO FEE NO CHRG ‐ PROF FEES $0.018000710060 I&D ABSCESS ‐ SIMPLE OR SINGLE $220.008000711200 REMOVAL OF SKIN TAGS,MULTPLE $165.008000711201 SKIN TAG REMOVAL EA ADD'L 10 $40.008000711400 EXC BEN LESION‐ 0.5CM OR LESS $230.008000717000 LESION DESTRUCTION‐ 1ST LESION $150.008000717003 LESION DESTRUCTION‐ 2ND TO 14 $13.008000717004 LESION DESTRUCTION‐ 15 OR MORE $280.008000717110 DESTRUCTION WARTS ‐ UP TO 14 $205.008000717250 UMBILICAL GRANULOMA $125.00

8000720552 TRIGGER POINT INJ‐ 1 OR 2 MUSC $100.008000730005 SUB Q OR IM INJECTION $65.008000730006 INSERTION FOLEY CATH $300.008000730011 INSERTION NON‐INDWELLING CATH $300.008000751701 CATHERIZATION SIMPLE $90.008000751798 BLADDER SCAN $35.008000753060 I&D OF CYST OR SKENE'S ABSESS $360.008000770010 ADMIN OF HEP B VACCINE $45.008000770438 INITIAL ANNUAL WELLNESS VISIT $246.008000770561 BICILLIN INJ 600,000 UNITS $75.008000770595 STADOL PER 1MG $5.008000770696 ROCEPHIN INJ PER 250MG $5.008000771020 DEPO MEDROL INJ 20MG $6.008000771030 DEPO MEDROL ING 40MG $8.008000771040 DEPO MEDROL INJ 80MG $12.008000771050 DEPO PROVERA INJ 150MG $72.008000771094 DECADRON LA INJ 1MG $2.008000771100 DECADRON INJ 1MG $2.008000771170 DILAUDID INJ UP TO 4 MG $5.008000771200 BENADRYL INJ UP TO 50MG $2.008000771319 SUPRAPUBIC CATH INSERTION $1,615.008000772025 SUTURE REMOVAL NO CHARGE $0.018000772175 DEMEROL INJ PER 100MG $7.008000772550 PHENERGAN INJ UP TO 50MG $5.008000773030 SUMATRIPTAN 6MG $65.008000773420 VITAMIN B‐12 INJ UP TO 1000MCG $6.008000773430 VITAMIN K 1MG $5.008000777080 BONE DENSITY PRO FEE ‐ PROF FEES $30.008000777614 XOPENEX 1.25MG $5.008000781002 DIPSTICK UA $10.008000781025 URINE PREGNANCY TEST $20.008000782270 FECAL OCCULT BLOOD‐ CARD $10.008000782962 GLUCOSE $6.008000783026 HEMOGLOBIN $10.008000785610 PROTHROMBIN TIME $15.008000787420 RESPIRATORY SYNCYTIAL VIRUS $30.008000790633 HEPATITIS A VACCINE 3 DOSE $45.00

8000790647 HIB VACCINE 3 DOSE $35.008000790649 HPV 3 DOSE VACCINE $245.008000790657 INFLUENZA VIRUS VACCINE 6M‐35M $20.008000790681 ROTAVIRUS VACCIN, 2 DOSE, ORAL $130.008000790686 FLUARIX INFLUENZA VIRUS VACC $25.008000790696 DTAP IPV VACCINE $65.008000790700 DTaP ‐ UNDER 7 YEARS OF AGE $32.008000790707 MEASLES‐MUMPS‐RUBELLA VACCINE $85.008000790714 TD TETANUS & DIPTHERIA 7 & UP $30.008000790715 TDAP‐ 7YRS OR OLDER $45.008000790716 VARICELLA VIRUS VACCINE $145.008000790723 DTAP‐HERP‐IPV VACCINE $85.008000790732 PNEUMOCOCCAL VACCINE 23 VALENT $135.008000790734 MENINGOCOCCAL VACCINE $148.008000790744 HEP B PEDIATRIC/ADOLESCENT $32.008000790746 HEPATITIS B VACCINE 3 DOSE $75.008000792551 AUDIO SCREENING TEST PURE TONE $20.008000792552 HEARING TEST‐ PURE TONE AUDIO $50.008000793005 ECG W/O INTERP & REPORT $30.008000793010 EKG INTERP & REPORT ONLY ‐ PROF FEES $20.008000793227 HOLTER INTERPRETATION ‐ PROF FEES $70.008000795115 ALLERGY INJ SINGLE INJECTION $20.008000795117 ALLERGY INJ 2 OR MOR INJECTION $20.008000795810 INTERPRETATION SLEEP STUDY ‐ PROF FEES $380.008000795811 INTERPRET SLEEP STUDY W/CAP ‐ PROF FEES $380.008000796374 IV PUSH SINGLE OR INITIAL DRUG $95.008000799173 VISION SCREENING TEST BIL $6.008000799174 PHOTOSCREEN $12.008000799205 OFFICE VISIT NEW PATIENT LEV 5 $310.008000799215 OFFICE VISIT EST PAT LEV 5 $215.008000799217 OBSERVATION CARE DISCHARGE PF ‐ PROF FEES $110.008000799218 INTIAL OBS CARE LOW PF ‐ PROF FEES $155.008000799219 INTIAL OBS CARE MODERATE PF ‐ PROF FEES $210.008000799220 INITIAL OBS CARE HIGH COMPL PF ‐ PROF FEES $285.008000799221 INITIAL HOSPITAL CARE LOW PF ‐ PROF FEES $155.008000799222 INITIAL HOSPITAL CARE MOD PF ‐ PROF FEES $210.008000799223 INTIAL HOSP CARE HIGH PF ‐ PROF FEES $310.00

8000799224 SUBSEQUENT OBS CARE LOW PF ‐ PROF FEES $65.008000799225 SUBSEQUENT OBS CARE MOD PF ‐ PROF FEES $115.008000799231 SUBSEQUENT HOSP CARE LOW PF ‐ PROF FEES $60.008000799232 SUBSEQUENT HOSP CARE MOD PF ‐ PROF FEES $110.008000799233 SUBSEQUENT HOSP CARE HIGH PF ‐ PROF FEES $160.008000799234 OBS/IP ADM/DIS SAME DOS LOW PF ‐ PROF FEES $205.008000799235 OBS/IP ADM/DIS SAME DOS MOD PF ‐ PROF FEES $260.008000799236 OBS/IP ADM/DIS SAME DOS HI PF ‐ PROF FEES $335.008000799238 HOSP DISCH 30 MIN OR LESS PF ‐ PROF FEES $110.008000799239 HOSP DISH MORE THAN 30 MIN PF ‐ PROF FEES $165.008000799243 OFFICE/OP CONSULT LEVEL 3 PF ‐ PROF FEES $190.008000799305 INITIAL NH CARE MODERATE PF $200.008000799306 INITIAL NH CARE HIGH PF $255.008000799307 SUBSEQUENT NH VISIT STRFRWD PF $70.008000799308 SUBSEQUENT NH VISIT LOW PF $105.008000799309 SUBSEQUENT NH VISIT MOD PF $140.008000799310 SUBSEQUENT NH VISIT HIGH PF $205.008000799315 NH DISCHARGE 30 MIN OR LESS PF $110.008000799381 WELLNESS EXAM NEW PAT <1YR $165.008000799384 WELLNESS EXAM NEW PAT 12‐17YRS $200.008000799406 TOBACCO CESSATION 3‐10 MIN $25.008000799407 TOBACCO CESSATION OVER 10 MIN $45.008000799464 ATTENDENCE AT DELIVERY ‐ PROF FEES $115.008000802069 CHEST TUBE TRAY $32.008000810025 PHLEBOTOMY THERAPEUTIC $138.008000991521 MOD SED 1ST 15 MIN >5YRS PF ‐ PROF FEES $78.008000991522 MOD SED 1ST 15 MIN >5YRS FF $300.008000999304 INITIAL SW BED CARE LOW PF $140.008000999305 INITIAL SW BED CARE MOD PF $200.008000999306 INITIAL SW BED CARE HIGH PF $255.008000999307 SUBSEQUENT SW VISIT STRFRWD PF $70.008000999308 SUBSEQUENT SW VISIT LOW PF $105.008000999309 SUBSEQUENT SW VISIT MODERAT PF $140.008000999310 SUBSEQUENT SW VISIT HIGH PF $205.008000999315 SW DISCHARGE 30 MIN OR LESS PF $110.008000999316 SW DISCHARGE MORE THAN 30 MIN $160.008001000295 BUBBLE STUDY ONLY PF ‐ PROF FEES $60.00

8003401122 DEPO PROVERA 150MG $72.008003410060 I & D OF ABSCESS SIMPLE/SINGLE $220.008003411200 REMOVAL OF SKIN TAGS UP TO 15 $165.008003411401 EXC BEN SKN LES 0.6CM TO 1.0CM $280.008003411602 EXC MALIG LESN 0.6 TO 1.0 CM $460.008003417000 DESTRUCTION FIRST LESION $140.008003417003 DESTRUCTION LESION 2ND‐14 $20.008003417110 DESTRUCTION WARTS UP TO 14 $205.008003420552 TRIGGER POINT INJ 1‐2 MUSCLES $100.008003420610 JOINT INJ MAJOR JOINT/BURSA BI $135.008003436415 VENIPUNCTURE $12.008003440008 ADMIN INFLUENZA VIRUS VACCINE $45.008003440009 ADMIN PNEUMOCOCCAL VACCINE $45.008003440180 INITIAL CERT FOR HOME HEALTH ‐ PROF FEES $80.008003440561 BICILLIN LA 1.2 MILLION $145.008003440696 ROCEPHIN PER 250MG $5.008003441030 DEPO MEDROL 40 MG $8.008003441040 DEPO MEDROL 80 MG $12.008003441094 DECADRON LA PER 1MG $2.008003441580 GENTAMICIN 80MG INJ $5.008003441885 TORADOL INJ PER 15MG $2.008003441940 FUROSEMIDE (LASIX) 40MG/4ML $5.008003442405 ZOFRAN INJ PER 1MG $2.008003442550 PHENERGRAN INJ UP TO 50 MG $5.008003443301 KENALOG INJ PER 10 MG $6.008003443420 B‐12 INJ UP TO 1000 MCG $6.008003444110 DECADRON 1 MG $2.008003447613 ALBUTEROL $2.008003447614 XOPENEX 1.26MG $5.008003447644 ATROVENT $2.008003469209 CERUMEN REMOVAL IRRIG/LAVAGE $95.008003469210 CERUMEN REMOVAL REQ/INSTRUMENT $100.008003480100 URINE SPECIMEN COLLECTION ONLY $25.008003480300 URINE DRUG SCREEN $37.008003481000 URINALYSIS, BY DIPSTICK W/MICR $10.008003481002 URINALYSIS $10.008003481025 URINE PREGNANCE TEST $20.00

8003482270 STOOL GUAIAC $10.008003482272 FECAL OCCULT BLOOD DIG $10.008003482962 GLUCOSE $15.008003485610 PROTIME $15.008003486580 TB SKIN TEST $15.008003487880 STREP SCREEN $30.008003490471 IMMUN ADMINISTRATN 1ST VACCINE $45.008003490472 IMMUN ADMIN EA ADD'L VACCINE $25.008003490658 FLUZONE INFLUENZA VIRUS VACCIN $20.008003490670 PNEUMOCOCCAL VACCINE 13 VALENT $220.008003490686 FLUARIX INFLUEZA VIRUS VACC $25.008003490702 DT DIPHTHERIA & TETANUS TOXOID $45.008003490703 TETANUS TOXIOD VACCINE $55.008003490714 TD TETANUS & DIPHTHERIA 7 & UP $30.008003490715 TDAP $45.008003490732 PNEUMOCOCCAL VACCINE 2YRS & UP $135.008003493005 EKG W/O INTERP & REPORT $30.008003494640 UPDRAFT $30.008003495115 ALLERGY INJECTION‐ SINGLE PF $20.008003496372 ADM INJECTION SUB Q OR IM $45.008003499000 DOT PHYSICAL $66.008003499201 OFFICE VISIT NEW PATIENT LEV 1 $65.008003499202 OFFICE VISIT NEW PATIENT LEV 2 $110.008003499203 OFFICE VISIT NEW PATIENT LEV 3 $160.008003499204 OFFICE VISIT NEW PATIENT LEV 4 $245.008003499211 OFFICE VISIT EST PAT LEVEL 1 $30.008003499212 OFFICE VISIT EST PAT LEVEL 2 $65.008003499213 OFFICE VISIT EST PAT LEVEL 3 $110.008003499214 OFFICE VISIT EST PAT LEVEL 4 $160.008003499381 WELLNESS EXAM NEW PAT UNDER 1 $165.008003499382 WELLNESS EXAM NEW PAT 1‐4 YRS $170.008003499383 WELLNESS EXAM NEW PAT 5‐11 YRS $180.008003499385 WELLNESS EXAM NEW PAT 18‐39YRS $195.008003499386 WELLNESS EXAM NEW PAT 40‐64YRS $230.008003499387 WELLNESS EXAM NEW PAT 65&OVER $250.008003499391 WELLNESS EXAM EST PAT <1YEAR $150.008003499392 WELLNESS EXAM EST PAT 1‐4YEARS $160.00

8003499393 WELLNESS EXAM EST PAT 5‐11YRS $160.008003499394 WELLNESS EXAM EST PAT 12‐17YRS $175.008003499395 WELLNESS EXAM EST PAT 18‐39YRS $175.008003499396 WELLNESS EXAM EST PAT 40‐64YRS $190.008003499397 WELLNESS EXAM EST PAT 65YRS&UP $200.008003499406 TOBACCO CESSATION 3‐10 MINUTES $25.008003499457 SCHOOL PHYSICAL $15.008006440001 INJ ANES TRIGEMINAL NERVE PF ‐ PROF FEES $140.008006440002 INJ ANES TRIGEMINAL NERVE FF $350.008034206051 JOINT INJ INTERMEDIATE RT $110.008034206052 JOINT INJ INTERMEDIATE LT $110.008034206101 JOINT INJ MAJOR JOINT/BURSA RT $135.008034206102 JOINT INJ MAJOR JOINT/BURSA LT $135.008034878041 INFLUENZA A $25.008034878042 INFLUENZA B $25.008079920225 OFFICE VISIT NEW PAT LEV 2 25 $110.008079921525 OFFICE VISIT EST PAT LEV 5 25 $215.008079938125 WELLNESS EXAM NEW PAT <1YR 25 $165.008079938225 WELL EXAM NEW PAT 1‐4 YRS 25 $170.008079938425 WELL EXAM NEW PAT 5‐11 YRS 25 $200.008079938625 WELL EXAM NEW PAT 40‐65 YRS 25 $230.008079938725 WELL EXAM NEW PAT 64&UP YRS 25 $250.008079939125 WELLNESS EXAM EST PAT <1 YR 25 $150.008079939225 WELL EXAM EST PAT 1‐4 YRS 25 $160.008079939325 WELL EXAM EST PAT 5‐11 YRS 25 $160.008079939425 WELL EXAM EST PAT 12‐17 YRS 25 $175.008079939525 WELL EXAM EST PAT 18‐39 YRS 25 $175.008079939725 WELL EXAM EST PAT 65&UP YRS 25 $200.008346920950 CERUMEN REMOVAL IRRIG/LAV BIL $140.008346921050 CERUMEN REMOVAL REQ INST BIL $150.008349920125 OFFICE VISIT NEW PAT LEV 1 25 $65.008349920225 OFFICE VISIT NEW PAT LEV 1 25 $110.008349920325 OFFICE VISIT NEW PAT LEV 3 25 $160.008349920425 OFFICE VISIT NEW PAT LEV 4 25 $245.008349921125 OFFICE VISIT EST PAT LEV 1 25 $30.008349921225 OFFICE VISIT EST PAT LEV 2 25 $65.008349921325 OFFICE VISIT EST PAT LEV 3 25 $110.00

8349921425 OFFICE VISIT EST PAT LEV 4 25 $160.008349938525 WELL EXAM NEW PAT 18‐39 YRS 25 $195.008349939625 WELL EXAM EST PAT 40‐64 YRS 25 $190.009201000035 U/S ABI SERIES $265.009498000000 PORT FLUSH ONLY $65.00

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