Cedars-Sinai Charge Description Master - Marina Del Rey ...

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02600001 HB IV INFUS HYDRATION 31-60 MIN 96360 1,942.19$ 2,526.14$

02600002 HB IV INFUSION HYDRATION ADDL HR 96361 475.94$ 616.09$

02600003 HB IV INFUSION THERAPY 1ST HR 96365 2,175.25$ 2,829.30$

02600004 HB IV THERAPY ADDL SEQ UP TO 1 HR 96367 475.94$ 616.09$

02600005 HB IV THERAPY-CONCURRENT 96368 636.68$ 825.32$

02600007 HB INFUSION SC INITIAL FIRST HR 96369 893.46$

02600008 HB SC INFUSION ADD'L HOURS 96370 443.82$

02600012 HB IV INFUSION THERAPY EA ADDL HR 96366 475.94$ 616.09$

02600013 HB IV PUSH INITIAL 96374 1,188.35$ 1,544.87$

02600014 HB IV PUSH ADDL SEQ NEW DRUG 96375 847.28$ 1,101.47$

02600015 HB IVP ADDL SEQ SAME DRUG 96376 855.31$ 1,111.91$

02700005 HB CYTOTOXIC SPILL KIT 240.19$

02700007 HB 24 HR PH PROBE 3,042.48$

02700008 HB FEMSTOP 726.11$

02700009 HB PC IPPB KIT 331.50$

02700016 HB PEFR-EQUIPMENT 870.13$

02700018 HB PC AERO KIT 1,779.85$

02700020 HB PC O/P USN EQUIPMENT 1,003.99$

02700021 HB PC MICRO-SPIROMETER 10,942.51$

02700022 HB PC O/P HHN EQUIPMENT 635.86$

02700033 HB STOCKINETTE,2"X25YD/BOX 286.76$

02700034 HB DILATOR, RDS 2,826.81$

02700035 HB NEEDLE, BIOPSY/ASP/LOC/INJ 408.51$

02700036 HB HMII POWER MODULE Q0496 1,877.40$

02700042 HB HMGG, TRAVEL CASE Q0508 722.80$

02700044 HB METANEB RT DEVICE KIT 2,204.87$

02700045 HB PC METANEB KIT 331.50$

02710001 HB SUPPORTER, SCROTAL 836.64$

02710002 HB SPLINT FOREARM - SMALL 482.09$

02710003 HB SPLINT, SUGARTONG 2,653.01$

02710005 HB SPICA - HIP (SINGLE OR DOUBLE) 5,240.06$

02710006 HB COLLAR, CERVICAL 650.75$

02710009 HB CAST, SHORT ARM CAST 1,695.08$

02710012 HB PADS R2 EP STUDY 740.85$

02710013 HB SPLINT FINGER 2 INCHES 344.04$

02710014 HB MUCUS CLEARING DEVICE 345.84$

02710018 HB BILE BAG REG 606.38$

02710019 HB FECAL INCONTINENCE COLLECTOR 494.52$

02710022 HB PC PEP VALVE 391.56$

02710023 HB SPLINT WRIST - LARGE 412.84$

02710024 HB SPLINT WRIST - MEDIUM 412.84$

02710027 HB PENTAMIDINE KIT 490.61$

02710029 HB SPLINT, WRIST 1,157.87$

02710032 HB SUPPORT LUMBO-SACRAL 1,266.15$

02710033 HB KNEE IMMOBILIZER * 1,307.49$

Cedars-Sinai Medical CenterChargemaster

Prices Effective July 1, 2020

Ancillary FY21 1 of 170

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02710035 HB AEROSOL INHAL, PENTAM ADD'L 10 1,408.01$

02710036 HB SPICA - THUMB OR FINGER 1,582.14$

02710037 HB BI-VALVE OR DC CAST 381.03$

02710038 HB KIT, OSTOMY 5PK (1 PIECE) 1,611.78$

02710039 HB SPLINT, MOLDED 1,630.96$

02710041 HB EAR LAVAGE 459.74$

02710044 HB 02 CONNECTION TUBING MASK 462.42$

02710045 HB HEADSET NAVIGATION DEVICE 477.20$

02710047 HB SPLINT FOREARM - MEDIUM 584.28$

02710050 HB SPICA CAST - INFANT 172.96$

02710053 HB PC HELIOX ADMIN. PER HOUR 217.34$

02710054 HB PC NITROGEN ADMIN. PER HOUR 217.34$

02710055 HB ILEOSTOMY POUCH 808.55$

02710056 HB UNIVALVE CAST OR SPLINT 251.50$

02710057 HB PC H.H.N. KIT 414.62$

02710058 HB SPLINT FOREARM - LARGE 694.19$

02710059 HB SPLINT,THUMB 726.82$

02710060 HB PAG-HEART NEB EQUIP 743.68$

02710061 HB PASSY MUIR SPEAKING VALVE 765.40$

02710063 HB STOMAHESIVE WAFER 782.42$

02710064 HB SPLINT, ARM 933.05$

02710067 HB PENTAMIDINE EQUIPMENT OP * 1,126.71$

02710070 HB SPLINT, KNEE VELCRO 4,665.09$

02710073 HB CAST, SHORT LEG WALKING 2,127.61$

02710074 HB CAST, CYLINDER THIGH TO ANKLE 2,415.89$

02710077 HB CAST, PATELLAR TENDON BEARING 3,010.70$

02710078 HB CAST, LONG LEG 3,505.68$

02710080 HB KIT, WOUND CLEASING 294.02$

02710081 HB SPLINT, SHORT/LONG LEG 2,848.09$

02710083 HB PUMP DISCONNECT KIT 130.75$

02710085 HB SPLINT WRIST - SMALL 344.04$

02710087 HB CAST, SHOE 705.36$

02710089 HB CAST SHORT LEG 8,843.15$

02710090 HB CAST, LONG ARM 4,264.87$

02710091 HB CAST, LONG LEG WALKING 2,127.61$

02710101 HB SPLINT, IMMOBILIZER KNEE 1,307.49$

02710104 HB SPLINT,IMMOBILIZER SHOULDER 209.58$

02720001 HB BASKET GEMINI 3FR 1,832.22$

02720003 HB CRYOCATH, FROSTBYTE CLAMP 13,537.31$

02720008 HB MEDIA FOR IUI 215.31$

02720009 HB WIRE, MICRO EXCHANGE 2,520.12$

02720010 HB CATH PERIPHERAL DILITATION C1725 2,599.52$

02720016 HB LASER FIBER, 3 4,011.65$

02720017 HB NEUROPEN WITH NEUROENDOSCOPES 4,196.76$

02720018 HB VALVE, DRAINAGE/FARRELL 291.22$


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02720021 HB CATH DELIVERY SYSTEM 6,425.29$

02720023 HB LASER FIBER, 9 8,279.13$

02720025 HB CATH INTRA-AORTC BALLOON 15,137.08$

02720034 HB CLIP SURGICAL SPRING CLIP 206.57$

02720035 HB KIT, OSTOMY (2 PIECE) 1,095.44$

02720036 HB LEVEL I TUBING D-50 1,114.14$

02720037 HB DRAIN 1 352.79$

02720039 HB ENDOSCOPIC VERSATEP 955.10$

02720040 HB ENDO LLETZ BALL ELCTRODE 303.32$

02720044 HB ENDOSCOPE SHEATH DISPOSABLE 556.85$

02720045 HB COLOSTOMY BAG 557.83$

02720046 HB KYPHON BONE FILLER DEVICE OR 1,155.60$

02720047 HB CATHETER, EPISTAXIS BALLOON 569.28$

02720048 HB ENDO ELECTRODE CUTTING LOOP 929.87$

02720049 HB SHEATH, PERITONEAL/AMPLATZ 577.78$

02720050 HB PC NASAL MASKS BIPAP 1,177.35$

02720051 HB ENDO IRRIG ENDO-FLO 0037970 586.79$

02720053 HB BIOPSY BRUSH COOK 040310 589.79$

02720054 HB NEEDLE, SCLEROSING 1,205.57$

02720055 HB CATH FOLEY W/THERMISTER 504.01$

02720056 HB CANNULA, CORONARY PERFUSION DL 592.17$

02720058 HB ELECTRODE, ACRIM/MENIS/PEN 593.28$

02720059 HB CATHETER, UMBILICAL VES 593.37$

02720064 HB CANNULA AVR CABG KIT 610.73$

02720068 HB TRACH TUBE #14 1,239.50$

02720072 HB CLAMP, DISPOSABLE 397.33$

02720073 HB FILTER, BLOOD TRANSFUSION * 646.59$

02720074 HB PACING WIRE, TEMPORARY 789.30$

02720075 HB LEADWIRE, EKG 149.69$

02720077 HB FRAZIER SUCTION TIPS 317.50$

02720080 HB HANDLE, ENDOSCOPIC GIA 967.42$

02720081 HB TROCAR, ENDOSCOPIC 1 545.54$

02720082 HB CLIP GUN MAGAZINE 317.33$

02720084 HB NEEDLE, SPINAL/DISC 689.25$

02720086 HB KIT, PACEMAKER 1 694.00$

02720088 HB INTRODUCER, OSTEO ONE STEP 7,816.46$

02720089 HB CATHETER, THORACIC MM 709.90$

02720090 HB CATHETER PASSER 917.20$

02720093 HB PIN, DISTRACTION 1 536.76$

02720096 HB ENDO TIP CAUTERY PEDS RT ANGLE 718.51$

02720098 HB LACRIMAL INTUBATION SET 724.53$

02720099 HB ROD, OSTOMY 217.74$

02720101 HB PEN, HEATING LACTOSORB PLATE 800.16$

02720104 HB ENDO BIPOLAR EBF01 747.64$

02720107 HB GRASPER, ENDOSCOPIC 1 1,108.81$


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02720108 HB PIN SKULL PINS MAYFIELD- OMI 215.59$

02720109 HB DRESSING WEBRIL 66.69$

02720110 HB PREP DURA 201.58$

02720111 HB BLADE, TREPHINE 772.43$

02720114 HB TUBING, INSUFFLATION 418.33$

02720115 HB KYPHON BONE ACCESS NEEDLE 11 G 332.30$

02720116 HB ANTENNA,EXTRNL NEUROSTIMALUTOR 1,069.58$

02720121 HB SPLINT DENVER SERIES 251.88$

02720123 HB ADHESIVE, SKIN 1 372.65$

02720124 HB 23G BIPOLAR TAPERED FINE POINT 470.03$

02720125 HB SYRINGE MEDRAD POWER INJECTOR 171.87$

02720126 HB ARTHRO, MENISCAL SYSTEM 1,317.26$

02720132 HB FILTER MILEX 83.18$

02720133 HB SONOHYSTOGRAM CATHETER 244.91$

02720135 HB NET, RETRIEVAL ROTH 1,258.40$

02720137 HB OSTENE BONE HEMOSTASIS 2.5GRMS 832.81$

02720139 HB TUBE, JEJUN FEED/SGL LUMEN 1,336.24$

02720140 HB FORCEPS, BIOPSY 1 511.43$

02720144 HB TUBE,TRACH DCT/DFEN W/DISP CAN 1,473.60$

02720145 HB KIT, NEUROSTIMULATOR 1 998.14$

02720148 HB MEDTRONIC REFILL KIT 1,475.04$

02720153 HB TUNNELING ROD, CATH PASSER 1,262.84$

02720154 HB TUBE, MIC (FEEDING) 2,207.89$

02720159 HB TOOL, DISSECTING 2 1,466.97$

02720161 HB KIT, TRANFIX/BIO-TENODESIS 1,523.84$

02720162 HB NEEDLE, ELECT/BEVEL/TROCAR 1,565.75$

02720165 HB HEMOSTAT, SOF-GRIP 778.39$

02720166 HB BAG DRAINAGE URINARY 257.08$

02720168 HB CUTTER, LOCKING LEAD 1,015.18$

02720169 HB PERF QUICK PRIME LINE 264.43$

02720170 HB ENDO PROBE HANDPIECE 791.04$

02720171 HB PC MICRO BRUSH 1,924.29$

02720172 HB STRIPPER VEIN DISPOSABLE 801.54$

02720174 HB PLEUR-EVAC 2,260.65$

02720175 HB SPENCER DEPTH ELECTRODES 8 CON 2,348.37$

02720176 HB NEEDLE, OSTYCUT 809.79$

02720177 HB T-TUBE, 2 811.35$

02720178 HB ENDO TROCAR 10MM BLNT OMST10BT 820.33$

02720183 HB ILIUMINATOR, LIGHTMAT SURGICAL 830.08$

02720184 HB PC BROCH OCC CATH C2628 1,809.18$

02720185 HB PERF HEMOCONCENTRATOR PEDS 856.22$

02720187 HB TWIST DRILL SURGICAL 1 862.20$

02720189 HB KIT, KYPHOPLASTY INTRO SYSTEM 17,379.17$

02720190 HB TRACH PERCUTANEOUS SET 700.92$

02720191 HB ENDO SUCTION/IRRIG/PROBE 874.20$


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02720193 HB CATHETER, MULTI LUMEN 875.89$

02720195 HB CANNULA, RETROGRADE CARDIOPLEG 886.56$

02720198 HB CANNULA, RETROGRADE 1 898.13$

02720199 HB IV PUMP SET, NITROGLYCERIN 712.68$

02720201 HB ARTHRO WAND 1 1,805.25$

02720202 HB BLADE, ACROM/BLASTER/MIONIZER 849.25$

02720208 HB IRRIGATION SET, CYSTO 738.57$

02720213 HB PERF RESERVOIR CARDIOTOMY 940.03$

02720215 HB RESERVOIR, DRAIN 1 268.24$

02720216 HB DRAIN LUMBAR DRAINAGE SET 947.90$

02720218 HB PACK, AFFINITY VAVD ACCESSORY 500.78$

02720225 HB SHOULDER SUSPENSION KIT 2 974.35$

02720228 HB LP DRAINAGE KIT 987.93$

02720229 HB TUBE, RECTAL 560.75$

02720230 HB RADIAL ARTERY KIT 571.81$

02720231 HB ENDO POLY LOOP 1,315.98$

02720232 HB TUBING, PCA 578.99$

02720233 HB TUBE, GASTROSTOMY 1 590.60$

02720235 HB CABLE, LEAD EKG WIRE 1,004.27$

02720236 HB RESUSCITATION BAG 270.57$

02720243 HB ANESTHESIA BREATHING TRACT 986.51$

02720246 HB NEEDLE SET, BX/ASPIR, ECHO TIP 640.64$

02720247 HB TROCAR, ENDOSCOPIC 2 1,026.85$

02720248 HB INFLATION DEVICE ENDO 1,029.84$

02720251 HB BLADE, INCISOR/ABRADER 1,035.82$

02720253 HB INTRODUCER ACCUSTICK 661.63$

02720254 HB CANNULA ANTERIOR CHAMBER 414.58$

02720257 HB MARKER, SPOT TATOO 347.43$

02720259 HB MICRO PUNCTURE SET 352.37$

02720262 HB CAPSULE, WIRELESS AGILE 1,373.56$

02720263 HB STAPLER, ENDOSCOPIC 5 2,887.62$

02720264 HB TAP, DISPOSABLE 1 1,061.46$

02720265 HB TUBING PENUMBRA STERILE 2,996.51$

02720266 HB PC PNEUMOTHORAX SET 3,240.76$

02720267 HB BASKET, RETRIEVAL II 2,656.10$

02720269 HB BASKET RETRIEVABLE INSERTABLE C1889 1,080.74$

02720271 HB ELECTRODE, ESU 1 1,083.76$

02720272 HB CATH EPID TUN-L XL 16GA X 3.5 1,085.76$

02720276 HB KIT, IRRIGATION OSTOMY 899.23$

02720279 HB SECONDARY PIGGY BACK 831.60$

02720280 HB UNIVER MICROINTRODUCER KIT 7FR 914.55$

02720283 HB ENDO SWITCH BLADE TIPS 526.50$

02720285 HB COLLAGEN, HEMOSTAT INSTAT 1 789.82$

02720286 HB PICC SELDING CONVERSION SET 514.64$

02720287 HB PROBE ESPOHAGEAL RECTAL DISP 526.37$


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02720288 HB DRAIN, VENTRICULAR 1,163.68$

02720289 HB CATHETER, VENTRICULAR 2 1,173.01$

02720290 HB NEEDLE, KYPHON 1,177.35$

02720294 HB 8-CONTACT STRIP ELECTRODE 2,932.58$

02720296 HB KYPHX SYRINGE A08A 1,197.52$

02720297 HB PC YAG LASER FIBER 6,383.49$

02720298 HB INFUSION SET, BUTTERFLY 206.47$

02720299 HB NEEDLE, SCALP VEIN 206.47$

02720303 HB TUBING SET 1,231.12$

02720306 HB SMART NEEDLE 1,844.01$

02720308 HB NEEDLE, FNA 1,867.85$

02720311 HB ORAL APPLIANCE 1,944.61$

02720312 HB GUIDE, DRILL 1 1,215.67$

02720315 HB CEMENT CART.SYS 540198000 1,287.34$

02720318 HB CATHETER, THORACIC 275.50$

02720321 HB ENDO DISSECT, LONG/SHORT 3,024.03$

02720322 HB RETRACTOR, ABDOMINAL MOBIUS 1,311.26$

02720324 HB TUBING CUSA MANIFOLD 1,311.26$

02720325 HB TUBE HARVESTER WITH PINS 3,674.19$

02720326 HB LACRICATH 1 4,369.03$

02720329 HB CANNULA, HYDRODISSECTOR 146.37$

02720331 HB ADHESIVE, INDERMIL 367.39$

02720334 HB APPLICATOR TIP 1 723.96$

02720335 HB BLADE, GENERAL 2 1,328.13$

02720337 HB CATH CHIOU SP 075920 1,329.22$

02720338 HB NEEDLE, BIOPSY/ASP/LOC/INJ MRI 805.57$

02720339 HB PERF RESEVOIR CARDIO 90300018 1,338.23$

02720340 HB ELECTRODES 1,339.64$

02720342 HB GASTROSTOMY GIAS-100 1,343.93$

02720343 HB NEURO BECKER EDMS 1,350.20$

02720345 HB INTRODUCER, NEEDLE 808.55$

02720346 HB ABC DISPOSABLE TIP (NOZZLE) 1,356.41$

02720353 HB POUCH, EAKINS 253.78$

02720355 HB BLOOD CONSERVATION SYSTEM 1,393.49$

02720356 HB INFLATION APPARATUS 1,407.05$

02720357 HB TWIST DRILL, SURGICAL 2 1,407.05$

02720362 HB SEALANT HEMOSTATIC 1 1,940.23$

02720363 HB PERF CDI 500 SHUNT SENSOR 1,437.03$

02720365 HB ENDO SHEARS, LONG/SHORT 2,288.17$

02720366 HB CATHETER, PENUMBRA NEURON GUIDE 1,456.07$

02720367 HB MONITORING KIT, VENTRICULAR 6,690.54$

02720368 HB REAMER, MODULAR SHAFT 1 1,462.91$

02720369 HB CANNULA, CORONARY PERF 1,466.72$

02720374 HB MONITORING KIT, INTRACRANIAL P 8,544.22$

02720378 HB PROBE, SOMN/ULTRSND/ARTHRO 1,505.04$


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02720379 HB NAV-X EP MAP ELECTRODE 9,184.59$

02720380 HB PROBE, ABLATION 12,063.41$

02720381 HB KIT, ENDO MUCOSAL RESECTION 2,371.15$

02720382 HB TUBE, GASTROSTOMY 2 1,529.86$

02720384 HB BONE MILL BM200 1,535.81$

02720387 HB CATHETER, BILIARY DILAT C1726 1,573.23$

02720388 HB SEPARATOR PENUMBRA 13,629.44$

02720389 HB IMPEDANCE PROBE 1,580.71$

02720390 HB CANNULA, ERCP BALL/CONTOUR 799.60$

02720391 HB RETRACTOR, FAN ENDOSCOPIC 1,583.70$

02720392 HB NEEDLE, ENTRY 140.92$

02720394 HB KIT, PENUMBRA 21,979.02$

02720395 HB SPHINCTERTOME DBL LUMEN 1,461.07$

02720398 HB BRUSH, FEMORAL/CYTO 314.36$

02720400 HB IV BAG-O-JET 293.60$

02720401 HB CATHETER, UMBILICAL 321.13$

02720402 HB POSITION COLLAR CERVICAL SOFT 324.57$

02720403 HB CANNULA, ARTHRO/ENDO 329.30$

02720404 HB TUBING TO EVACUATOR MACHINE 329.30$

02720406 HB NEEDLE, ENDO VERESS 1 332.30$

02720407 HB URODYNAMIC PUMP TUBING 332.30$

02720411 HB ENDO CLOSURE PROC/KIT CTI-512N 1,355.75$

02720412 HB ENDO VERSASTEP NEEDLE 14G 341.28$

02720415 HB CLIP, HEMOLOK 350.28$

02720420 HB DRAIN ABRAMSON TRIPLE LUMEN 356.24$

02720422 HB MICROPUNCTURE SET C1894 584.39$

02720423 HB WIRE, TOUHY-BORST Y-VALVE CONN 362.12$

02720425 HB TUBING, IRRIGATION 1 604.81$

02720426 HB COLOSTOMY CLAMP 363.33$

02720428 HB PRESSURE TUBING 445.15$

02720429 HB TUBING, STACKHOUSE/EVACUATOR 371.23$

02720430 HB DRAINAGE SET, CHEST SNGL LINE 372.60$

02720432 HB BALLOON, KYPHON 6,070.38$

02720433 HB CANNULA 8.25MM X 7 CM AR 6530 374.25$

02720435 HB BIOPSY KIT 374.57$

02720438 HB RETAINER, VISCERA SURGIFISH 381.03$

02720442 HB CANNULA, ARTHRO 1 386.17$

02720446 HB DRAIN, PENROSE 327.59$

02720450 HB PC CONCHA WATER 126.57$

02720453 HB ENDO TIP COVER INTUI 400180-0 410.16$

02720454 HB CANNULA, VENOUS 2 STAGE OVAL 410.93$

02720455 HB PERF ARTERIAL FILTER (351) 416.13$

02720459 HB CATHETER, ROBINSON 417.32$

02720461 HB BIOPSY DEVICE KYPHON 418.88$

02720462 HB SCALPEL, SURGICAL 2 423.56$


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02720464 HB TUBING ARTERIAL LINE M/F 414.39$

02720465 HB SET MINI TRIFUSE 132.06$

02720466 HB KNIFE, HANDLE BEV/LARYN 430.01$

02720468 HB STATLOCK 297.12$

02720469 HB BLADE, SAW 1 469.46$

02720472 HB PROBE, FLOW PUMP 449.08$

02720473 HB SURGIFOAM, ABSORBABLE SPONGE 2 449.08$

02720474 HB DRESSING VAC 449.69$

02720475 HB ENDO PROBE ELECTRODE 453.29$

02720477 HB CATHETER, FOLEY 5CC/30CC 1,185.50$

02720478 HB CANNULA, OPS VALVE 464.81$

02720480 HB BALLOON, EXTRACT/BASKET 1,222.26$

02720483 HB CANNULA, INNER DISP 472.59$

02720484 HB BLADE, AORTIC PUNCH 473.57$

02720485 HB KIT, REFILL NEUROSTIMULATION 479.00$

02720486 HB NEEDLE, JAM/INF/CAR/MNS/DURA 479.00$

02720493 HB INSEMI-CATHETER 166.16$

02720496 HB ENDO IRRIGATOR HYDRO-SURG PLUS 768.61$

02720497 HB TUBING, PENROSE DRAIN 163.03$

02720501 HB TUBE, GASTROSTOMY 2 1,279.94$

02720503 HB ABDOMINAL BINDER 1,213.49$

02720508 HB CANNULA , VENOUS RETURN 532.87$

02720509 HB DILATOR 541.85$

02720510 HB PERICARDIOCENTESIS KIT 1,339.90$

02720512 HB SNARE, POLYPECTOMY 789.35$

02720513 HB CONTAINER, PLEURX EVAC 552.98$

02720514 HB BLADE, LARYNGOSCOPE 553.84$

02720515 HB CATHETER, CHOLANGIOGRAM 553.84$

02720522 HB MONITORING TRANSDUCER VENOUS 1,631.53$

02720523 HB MONITORING TRANSDUCER ARTERY 1,439.19$

02720525 HB CATHETER, COUNCIL C1729 1,646.34$

02720526 HB CANNULA, IRRIGATING 2 1,646.58$

02720531 HB BALLOON, PRESSURE DEVICE 1,693.39$

02720532 HB ENDO CLIP APPLIER 5MM 1,694.50$

02720533 HB BLADE, HARMONIC 1,700.47$

02720536 HB PROBE, COAGULATING BEAM 1,275.36$

02720537 HB INJECTOR 1,490.18$

02720538 HB TUBE, BRONCHCATH, RT/LT 802.87$

02720541 HB ANORECTAL CATHETER 1,041.61$

02720545 HB TUBE, ET 367.07$

02720546 HB URINARY DRAIN BAG 380.38$

02720549 HB INFUSION US LYSIS SYSTEM 10,748.12$

02720556 HB SHEATH, BANNANA PEEL 1,427.35$

02720557 HB CATHETER, COUNCIL STIFFNERS 361.70$

02720558 HB GASTROSTOMY PLV-24-.38 644.88$


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02720559 HB HEMOSTASIS PATCH 809.79$

02720560 HB INFLATION DEVICE KYPHON 947.13$

02720562 HB KIT, TIPS 3,557.33$

02720563 HB 2 CONTACT STRIP ELECTRODE 1,329.94$

02720567 HB CATHETER, ARGON COAG PROBE 1,752.79$

02720568 HB NASOGASTRIC TUBE IRRIGATION 542.92$

02720570 HB CATHETER, BILIARY MANOMETRY 1,854.60$

02720572 HB BLADE, DISSECTING DIEGO 1,212.48$

02720575 HB BLADE, PIVOTAL/FIXED HEAD 87.09$

02720582 HB CANNULA SEAL 433.20$

02720583 HB CANNULA AORTIC 1,284.61$

02720586 HB CANNULA, ARTERIAL 2 1,997.64$

02720588 HB CANNULA, IMA 305.84$

02720589 HB CANNULA, OPHTHALMIC 487.97$

02720591 HB CANNULA, VENOUS 5 4,367.94$

02720599 HB CATHETER, VENTRICULAR 1 410.16$

02720600 HB CLIP CORONARY ARTERY RETRACTON 224.55$

02720601 HB CLIP OMNI CLIP GUN 736.46$

02720602 HB CLIP SURGICLIP PREMIUM 2,404.50$

02720604 HB CUTTER, ENDOSCOPIC 4 2,954.85$

02720606 HB DISSECTOR, BLUNT CHERRY 368.23$

02720609 HB ENDO ENDOPOUCH PRO RETRIEVAL 738.39$

02720611 HB ENDO LAP DISC HAND DVICE LD111 4,793.03$

02720612 HB SCISSORS, ENDOSCOPIC 1 1,248.42$

02720613 HB ENDO SURESEAL II 220.37$

02720615 HB HANDPIECE, ENDOSCOPIC 1 975.44$

02720619 HB EXTRACTOR, STONE TIPLESS 2 2,487.84$

02720621 HB GELPORT, SEAL CAP 3,778.12$

02720622 HB HEMOCLIP 403.22$

02720623 HB CATHETER, HYDRAGLIDE 1 337.47$

02720624 HB ISOLATOR, ENDO XCL / XCR 13,044.70$

02720627 HB IV MICRODRIP SET 66.93$

02720631 HB KIT, WIRE STYLET 620.53$

02720632 HB KIT, NEEDLE EYE SNARE WRKSTN 5,145.14$

02720633 HB KIT, PROCEDURAL CARDIOVASCULAR 266.71$

02720634 HB KIT, REPAIR CATHETER 1,230.17$

02720636 HB KYPHON OSTEO INTRODUCER SYSTEM 10,867.43$

02720637 HB LEAD EXTENDER, BULLDOG 1,477.43$

02720638 HB MIDAS REX LUBRICANT/DIFFU 374.25$

02720639 HB NEEDLE KEITH 98.78$

02720645 HB TUBE, GASTROSTOMY 542.92$

02720646 HB PACK, PHACO 1,368.17$

02720649 HB PERFUSION HEMOCONCENTRATOR 1,185.35$

02720652 HB PERF SUCTION CELL SAVER 287.78$

02720654 HB PERFUSION ASSIST PACK 3,062.62$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02720655 HB RASP MICRO RECIPROCATING 758.52$

02720656 HB REAMER, CORING/HEAD 2,047.74$

02720658 HB RELOAD, GIA ENDO 1 1,327.36$

02720659 HB SET SPINAL TRIGEMINAL GANGLION 2,430.93$

02720660 HB SHUNT, CARDIOVASCULAR 1 1,168.24$

02720661 HB KIT, CATHETER 544.00$

02720662 HB ENDO TACKER SYSTEM 5MM 2,586.62$

02720669 HB T-TUBE, 1 314.36$

02720671 HB TUBING LEVEL 1 IR 600 179.65$

02720672 HB TUBING TUR 2 LEAD 272.53$

02720673 HB TUBING, TEFLON 1,733.68$


02720681 HB BIOGLUE, SKNCLSR SYRINGE 3 5,183.67$

02720682 HB BLADE, GENERAL 1 574.26$

02720683 HB CABLE, MICROTARGETING 1,181.16$

02720685 HB CANNULA, ENDO/ERCP/IRRIG 517.12$

02720687 HB CATH THORACIC 36FR 542.26$

02720690 HB CATHETER, DELIVERY SPY SCOPE 5,055.76$

02720692 HB CATHETER, FOLEY 3WAY 5CC/30CC 639.05$

02720693 HB CATHETER, BAKRI TAMPONADE 1,760.75$

02720694 HB CATHETER, PICC DBL LUMEN C1751 954.56$

02720695 HB CATHETER, TEXAS EXTERNAL 163.03$

02720696 HB CATHETER, TROCAR MM 1,447.57$

02720697 HB CATHETER, PENUMBRA DELIVERY 6F 3,989.87$

02720698 HB COLOSTOMY BAG 45MM 506.56$

02720699 HB CORE BIOPSY NEEDLE-EUS 2,236.16$

02720700 HB CANNULA, J HOOK 144.88$

02720702 HB CANNULA, VENOUS 1 781.41$


02720706 HB COOK NEEDLE 645.93$

02720708 HB DRAIN PLEUR-EVAC ADULT/PEDS 517.92$

02720712 HB EYE RETRACTOR FLEXIBLE 1,125.64$

02720714 HB GUN, BIOGLUE APPLICATOR 1 2,141.93$

02720716 HB INTRO BLUE-ON-BLUE 8FR 260-120 541.87$

02720717 HB IV BLOOD PUMP Y-TYPE OR 174.01$

02720718 HB KIT, DEEP BRAIN STIMULATION 351.10$

02720721 HB LIGACLIP 257.01$

02720723 HB BACKGROUND MATERIAL 194.58$

02720727 HB PERI PATCH REPAIR KIT 470.87$

02720736 HB CATHETER, CONNECTOR CTU 194.30$

02720737 HB CVC INSERTION KIT 662.85$

02720738 HB BRUSH, CYTOLOGY RX 1,395.54$

02720739 HB DEPT ELECTRODE PASSING NEEDLE 1,002.23$

02720742 HB DRAIN, URINARY 380.38$

02720744 HB PROBE, EHL 3,205.77$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02720745 HB ELECTRODE, FETAL SCALP 437.91$

02720747 HB ENDO ARTICULATIN LIN CUT ATW35 1,634.94$

02720748 HB EP MAP REFERENCE PATCH 7,510.12$

02720750 HB NEEDLE, GUN SEMI-AUTO DISP 658.64$

02720754 HB INDEFLATOR PTCA 969.10$

02720760 HB CAST PLASTER SPLINT 154.91$

02720763 HB ELC URINARY DRAIN BAG 154002 134.12$

02720765 HB TUBE, TRACHEOSOFT 892.69$

02720766 HB CATHETER, FASTNER PERCU-STAY 138.33$

02720767 HB FLOW CONTRL DEVICE 44-201 149.69$

02720768 HB DISSECTOR, SPONGE PEANUTS 100.79$

02720769 HB BLADE, BEAVER 155.13$

02720770 HB PIN GUIDE 946.04$

02720771 HB IV PCA TUBING 161.67$


02720773 HB MERIT MEDICAL RESPONSE KIT 1,345.00$

02720777 HB CANNULA, BISHOP HARMON 118.47$

02720778 HB TUBE, REPLACMNT Y-PORT 206.95$

02720779 HB LENS GLIDE 173.62$

02720781 HB DILATOR, VESSEL 192.09$

02720783 HB DECUBICARE PAD 277.59$

02720784 HB ADAPTER TUOHY-BORST TBA-6 332.30$

02720787 HB TUNNELER, SURGICAL 1 519.85$

02720789 HB TUBING HOTLINE 621.41$

02720790 HB POUCH/WAFER PEDS 730.28$

02720791 HB NEEDLE, VERTEBROPLASTY 800.22$

02720794 HB MONITORING KIT, INTRAUTERINE P 1,048.64$

02720795 HB ELECTRODE TEMP PACING 6F 1,152.32$

02720799 HB ELECTRODE, ESU 3 1,637.61$

02720800 HB BLADE, OPTHALMOLOGIC 1 413.84$

02720806 HB INTRODUCER SHEATH 237.08$

02720807 HB CLIP, DISPOSABLE 1 997.91$

02720808 HB ENDO ANTI FOG 166.34$

02720809 HB NEEDLE, OSTYCUT BIOPSY 987.93$

02720811 HB PC ENDOTRACHEAL TUBE # 1,003.99$

02720813 HB ESU INSULATED COATED BLADE 124.18$

02720814 HB SMOKE HOUSE FILTER 188.60$

02720817 HB CATHETER, AIRWAY 195.62$

02720818 HB BAG, DRAINAGE 600ML TRU-CLOSE 197.59$

02720819 HB NEEDLE, CHIBA 197.59$

02720822 HB PC CONCHA COLUMN 311.73$

02720823 HB ADHESIVE REPAIR SUPPLY 204.16$

02720825 HB BUTTERFLY, IV INFUSION 205.47$

02720829 HB CHROMOVISION LIGHT HANDLE 206.57$

02720835 HB TUBE STOMACH EVACUATOR 32FR 221.55$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02720842 HB NEEDLE CYSTOME 214.21$

02720843 HB CANNULA, INTRACARDIAC SUMP 251.74$

02720845 HB NEEDLE, LONG, AMNIO, ECHOTIP 437.92$

02720846 HB OT STRAPPING MATERIAL 61.03$

02720847 HB RELOAD, ENDOSTITCH 1 308.97$

02720849 HB THEMOCOOL TUBING SET 314.36$

02720850 HB TUBING, PRESSURE 1 254.46$

02720854 HB TUBING SMOKE EVACUATOR 211.66$

02720858 HB CLIP APPLIER LIGACLIP 855.25$

02720859 HB SCALPEL, SURGICAL 1 37.58$

02720860 HB MASTISOL LIQUID ADHESIVE 74.85$

02720861 HB TOUEY-WEISS NEEDLE 933.05$

02720863 HB SUCTION, RESEVOIR J-P 951.99$

02720864 HB CATHETER, URINARY EXTERNAL 80.86$

02720865 HB OPTHALMIC SURG KIT 80.86$

02720871 HB NEEDLE, INTRODUCER MANAN 177.82$

02720876 HB BAG, DRAINAGE URINARY 105.77$

02720880 HB KIT, UROSTOMY 198.70$

02720883 HB SNARE 1 258.55$

02720884 HB TIP,PULSEVAC FLEX / IRRIGATION 274.88$

02720889 HB NEEDLE, RADIOFREQUENCY 444.53$

02720896 HB CORD, DISPOSABLE 1 293.95$

02720899 HB PERF PMP PCK MEMBRANE 62003-01 1,742.41$

02720902 HB CATHETER, RENAL DILATOR 1,777.93$

02720904 HB SPLINT 1 637.55$

02720905 HB ENDOVASCULAR/RENAL DILATOR SET 1,805.25$

02720911 HB TRANSDUCER, NEONATE 668.28$

02720912 HB BLADE, MYRINGOTOMY 277.19$

02720913 HB CANNULA, ARTERIAL FEMORAL 4 1,852.54$

02720914 HB CATH ROBINSON 635.81$

02720915 HB BLADE, SAW 2 1,008.00$

02720916 HB NEEDLE, BIOPSY 3 1,894.79$

02720919 HB KYPHON BONE BIOSPY DEVICE 1,365.18$

02720921 HB PC CYTOLOGY BRUSH 1,375.86$

02720922 HB PC TOTAL FACE MASK 2,596.39$

02720926 HB PC BRONCHOSCOPY FORCEPS 3,380.14$

02720928 HB CATH PACK -CATH LAB * 1,024.30$

02720929 HB NERVE STIMULATOR 1 1,953.24$

02720931 HB EXTRACTOR, STONE 1,959.47$

02720932 HB PC WANG NEEDLE 2,215.63$

02720933 HB CATHETER, SWAN-GANZ W/THROMBO 1,988.75$

02720934 HB BASKET, LITHOCATCH/PARACHUTE 2,002.85$

02720935 HB FORCEPS, ENDOSCOPIC 3 2,032.78$

02720936 HB ENDO CLIP 2,067.21$



Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02720943 HB FORCEPS, BIOPSY I 433.08$

02720944 HB KIT, CRANIAL ACCESS 2,180.03$

02720949 HB TUBING, IVAC PUMP NICU 1,017.84$

02720950 HB CATH SIZING BALLOON 2,302.40$

02720954 HB TWIST DRILL, SURGICAL 3 1,844.18$

02720957 HB SNARE, GOOSE NECK 3,796.09$

02720958 HB CATHETER, DRAINAGE APDL 1,185.56$

02720962 HB CATHETER, ACHALASIA DILATOR 2,707.01$

02720965 HB BLADE, HARMONIC SCALPEL 1,667.91$

02720966 HB KIT, LEAD ACCSRY INTR/REV 2,565.67$

02720968 HB NEEDLE, SPINAL 305.39$

02720969 HB PERF RESERVOIR OXGYENATOR 2,620.90$

02720972 HB SET LEVEL I DISP 774.59$

02720980 HB INTRODUCER/SHEATH, CV 1 2,653.56$

02720981 HB TIP, CATHETER INTRODUCER 2,653.56$

02720983 HB FORCEPS, ENDOSCOPIC 4 2,676.44$

02720984 HB TUBE, REAMER/IRRIG/ASPIRATOR 2,680.81$

02720986 HB ELECTRODE, VERSA/LOW IMPEDENCE 2,713.47$

02720987 HB PIN, GUARD 362.89$

02720990 HB CATH ARTHERECTOMY C1714 24,412.72$

02720991 HB CATHETER, ATHERECTOMY BALLOON C1714 16,465.75$

02720992 HB ARTHRO WAND 2 2,835.10$

02720994 HB CATHETER, BALLOON PTA C1725 2,793.56$

02720996 HB CATH DUOSTAT PTCA C1725 1,020.63$

02720999 HB CATH DILITATION PTA C1725 2,851.53$

02721000 HB FORCEPS, SPYBITE BIOPSY 3,052.92$

02721001 HB SHEARS, HARMONIC 2 3,092.57$

02721004 HB CAPSULE, ENDOSCOPE DEL SYS 3,227.27$

02721005 HB LIGASURE, ESU 2 3,235.99$

02721008 HB CATH INFUSION PTCA C1725 2,913.13$

02721011 HB FORCEP BX PIRANHA 505-160 3,356.02$

02721014 HB CATHETER, BALLOON SMALL VSL DEV. C1725 6,329.38$


02721016 HB TIB TUNNEL CANN AR-1802D 383.19$

02721019 HB TUBE, TRACHEOSTOMY 1 604.81$

02721020 HB TUBE, TRACHEOSTOMY 2 1,578.52$

02721021 HB CATH DILITATION PTCA C1725 2,832.38$

02721022 HB HEMORRHOID STAPLER 3,541.61$

02721027 HB CANNULA, VENOUS FEMORAL 2 3,682.33$

02721031 HB CATHETER, BALLOON MICROSYS STEALTH C1726 7,123.43$

02721032 HB CATH DILATION VALVULOPLASTY C1726 12,392.41$

02721039 HB CATHETER,BALLOON BIL DILAT C1726 3,288.06$

02721042 HB BLADE, SHAVER 3 4,098.47$

02721044 HB CATH DILATION SEPTOSTOMY C1726 2,301.22$

02721045 HB CATHETER, ABLA ESOPHAGUS C1888 5,336.05$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721047 HB BONE CEMENT REMOVAL SYSTEM 4,232.12$

02721049 HB CATHETER,DISCYPHOR SYS W/GUIDE 4,431.27$

02721050 HB NEEDLE, TRANSJUGULAR LIVER 4,437.24$

02721051 HB CATHETER, CRE BAL DILAT C1726 2,191.26$

02721052 HB ANCHOR, AMPLATZ C1713 1,221.11$

02721053 HB CATHETER, DRAINAGE NEPHROSTOMY C1729 1,063.41$

02721056 HB NEURO MICROTARGETING DEVICE 4,987.63$

02721059 HB PROBE, NIM 2 5,244.55$

02721060 HB CATHETER, DRAINAGE 2 C1729 1,006.67$

02721061 HB CATHETER, DRAINAGE C1729 1,197.90$

02721062 HB CATHETER, DRAINAGE BILIARY C1729 1,057.00$

02721064 HB CATHETER, NASO BIL DRAINAGE C1729 841.24$

02721065 HB CATHETER, EP,19 OR FEW ELEC C1730 6,427.66$

02721067 HB CATHETER, BICAP PROBE 6,245.35$

02721068 HB LASER FIBER, 6 6,605.13$

02721069 HB CATH EP <19 ELECTRODES C1730 7,961.26$

02721073 HB KIT, ENDOVESSEL HARVEST 6,649.18$

02721074 HB CATH EP ABLATION 3D C1732 10,743.94$

02721075 HB CATH EP DIAG/ABLAT 3D MAP C1732 13,096.20$

02721076 HB CATH EP ABLATION NON 3D C1733 10,554.31$

02721079 HB CATHETER, HEMO, LONG TERM C1750 1,135.72$

02721080 HB 64-CONTACT STRIP ELECTRODE 7,397.61$

02721081 HB CATHETER, PENUMBRA REPERFUSION 7,400.10$

02721083 HB CATHETER, MICROSYS INFUSION C1751 3,910.68$

02721084 HB CATHETER, CENTRAL VEN TPL LMN C1751 1,518.25$

02721085 HB CATHETER, CENTRAL VEN SNGL LMN C1751 312.97$

02721088 HB UK INFUSION CATHETER 1,289.91$

02721091 HB CATHETER, SINUS 1 11,956.04$

02721092 HB MICROSYS CATHETER 2-TIP 3,101.69$

02721094 HB MICROSYS CATHETER 1-TIP C2628 2,953.99$

02721095 HB CATHETER, CENTRAL VEN DBL LMN C1751 1,177.50$

02721098 HB CATHETER PERM-A-CATH C1751 2,825.82$

02721099 HB CATH ENDOPROSTHESIS DELVRY C1874 14,222.85$

02721101 HB CATHETER, PORT-A-CATH C1751 151.83$

02721105 HB BIOPTOME 3,479.58$

02721107 HB BLADE, SHAVER 1 1,657.46$

02721109 HB BLOOD ADMIN SET Y TYPE 239.45$

02721110 HB BLOOD PUMP SET W/FILT 7' * 440.27$

02721111 HB BRAVO CAPSULE 2,880.87$

02721112 HB CANISTER, V.A.C. 592.86$

02721113 HB CATH FOLEY 879.05$

02721114 HB CATH ROBINSON 2-EYE 26FR 334.32$

02721115 HB CATH ULTRASOUND INTRAVASC C1753 6,277.74$

02721116 HB CATHETER, EPIDURAL ARROW 19 GA C1754 7,189.35$

02721117 HB CATHETER, THROMBCT/EMBOLECT-120CM C1757 7,945.06$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721118 HB CATH THROMBCT/EMBOLECT-50CM C1757 5,740.86$

02721119 HB CATHETER, DIAGNOSTIC 650.27$

02721121 HB CATHETER, FOGARTY C1757 4,448.18$

02721122 HB CATHETER, THROMBCT/EMBOLECT-50CM C1757 5,646.64$

02721124 HB CATH ULTRASOUND ACUNAV C1759 22,821.13$

02721125 HB CATHETER, TRANS/LU,NONLRS 3 C1725 3,646.97$

02721128 HB INTRO/SHEATH EP FIXED NON-PEEL C1766 1,049.05$

02721129 HB CATHETER, BALLOON DILATION2 C1726 4,255.17$


02721132 HB GUIDEWIRE, 0.18/GOLD C1769 1,228.83$

02721135 HB GUIDE WIRE PTCA C1769 1,324.95$


02721138 HB GUIDEWIRE C1769 392.62$

02721139 HB GUIDEWIRE, TERUMO AMPLATZ C1769 584.39$

02721140 HB GUIDE WIRE ACCESSORY KIT C1769 1,536.68$


02721143 HB GUIDEWIRE, MM C1769 221.32$


02721145 HB GUIDEWIRE, LONG .018-.015 C1769 584.39$

02721146 HB GUIDEWIRE EXCHANGE PTCA C1769 2,691.67$

02721147 HB CATHETER, DRAINAGE 1 C1729 275.46$

02721149 HB CATHETER FLOWIRE C1769 2,592.47$

02721150 HB GUIDE WIRE CATH LAB C1769 1,981.48$

02721151 HB GLIDEWIRE/GUIDEWIRE C1769 1,529.20$

02721152 HB GUIDEWIRE, INTERVENTIONAL COON C1769 217.34$

02721154 HB GUIDE WIRE EP C1769 255.83$

02721155 HB GLIDE WIRE TERUMO C1769 511.89$

02721156 HB GUIDEWIRE J BENTSON COONS C1769 584.39$

02721157 HB GUIDEWIRE, TERUMO C1769 584.39$

02721158 HB STENT, OASIS NON-COAT/COV W/DEL C1876 501.23$

02721159 HB GUIDEWIRE, US 1408/1809/2500 C1769 584.39$

02721160 HB GUIDEWIRE, AMPLATZ SS C1769 584.39$

02721161 HB JAGWIRE I C1769 1,373.56$

02721163 HB COIL, PUSHER 1,628.88$

02721164 HB CATHETER, INFUSION 1 C1751 819.66$

02721166 HB GUIDEWIRE, MICROSYS MICROWIRE C1769 2,693.94$

02721170 HB GUIDE WIRE CATH EP LAB C1769 894.52$

02721171 HB GUIDEWIRE, PLATINUM .018 TIPPED C1769 2,268.16$

02721174 HB CATHETER, GUIDING MICROSYS C1887 3,387.94$

02721175 HB GUIDEWIRE, PMG NITREZ 18-60 C1769 284.57$

02721176 HB GUIDE WIRE-J BENTSON COONS C1769 586.62$

02721177 HB MRI ENDORECTAL INSERTABLE COIL C1770 1,265.20$

02721179 HB RTRVL DVC, COIL C1773 3,910.68$

02721180 HB SNARE RETRIEVER DEVICE C1773 2,018.99$

02721181 HB RTRVL DVC, FILTER IVC C1773 1,165.78$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721182 HB RTRVL DVC, SNARE GNC C1773 3,146.37$

02721185 HB PT/PRGMR, NEUROSTIMULATOR 4 C1787 7,310.26$

02721187 HB EMBOLIC PROTECTION SYSTEM * C1884 12,549.13$

02721190 HB CATHETER, URETERAL 1 C1758 499.98$

02721191 HB EMBOLIC PROTECTION SYSTEM* C1884 17,747.80$

02721192 HB EMBOLIZATION PROTECTIVE SYSTEM C1884 9,787.40$

02721193 HB CATH ANGIOPLASTY LASER C1885 19,114.11$

02721194 HB CATH THERMODILUTION C1887 2,314.11$

02721196 HB CATH DIAGNOSTIC ANGIO C1887 235.39$

02721197 HB CATHETER, GUIDING C1887 1,282.76$

02721200 HB CATHETER, GUIDING 1 C1887 773.79$

02721201 HB CATH GUIDING PEDS C1887 1,335.24$

02721202 HB CATH GUIDING RAPIDO DEL SYS C1887 7,255.73$

02721203 HB GUIDEWIRE 6 C1769 3,195.16$

02721204 HB THROMBOLITIC INFUSION WIRE C1887 2,036.11$

02721205 HB CATHETER, GUIDING 4 C1887 2,311.79$

02721206 HB CATH BERMAN C1887 1,922.66$

02721207 HB CATH DIAGNOSTC ANGIO MULTIPACK C1887 1,786.68$

02721208 HB INTRO/SHEATH, GUIDING C1892 644.10$

02721209 HB INTRO/SHEATH, GUIDING 1 C1892 710.64$

02721211 HB EP INTRO/SHEATH, GUIDING 1 C1892 609.21$

02721212 HB INTRO/SHEATH GUIDE EP TRNSPTL C1893 1,552.68$

02721213 HB INTRO/SHEATH FIXED NON PEEL C1893 1,713.44$

02721215 HB NEEDLE, TRANSEPTAL 2,111.23$

02721216 HB INTRODUCER SHEATH, NON GUIDING C1894 309.80$

02721220 HB INTRO/SHEATH, CONTRALATERA C1894 495.43$

02721222 HB INTRO/SHEATH, BLKN LONG C1894 763.40$

02721224 HB INTRO/SHEATH C1894 385.56$

02721225 HB CATHETER, OCCLUSION BALLOON C2628 1,599.32$

02721230 HB GUIDEWIRE 3 C1769 1,605.73$

02721232 HB EP CATHETER-EZ STEER NAV BI-D C2630 26,307.95$

02721237 HB K-WIRE, SUPPLY 2 1,015.57$

02721238 HB ENDOSCOPIC STRYKEFLOW II 640.06$

02721239 HB TOOL, DISSECTING 1 960.38$

02721241 HB K-WIRE, SUPPLY 3 1,557.37$

02721244 HB PERFUSION BIO PUMP 1 1,652.10$

02721246 HB FILTER, BUFFALO KTP 612.34$



02721254 HB K-WIRE, SUPPLY 1 394.00$

02721255 HB RELOAD, ENDOSCOPIC 2 1,471.52$

02721256 HB EXTENSION, SINUS GUIDE 801.38$

02721258 HB ARTHRO FLOOR SUCTION MAT OR 462.17$

02721259 HB PRESSURIZER, FEMORAL CEMENT 713.15$

02721260 HB CATHETER, GUIDING PERF/INFUS 3 C1887 2,740.67$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721262 HB SUCTION MINI POINT WAND 403.22$

02721264 HB BLADE, FULL RADIUS 977.81$

02721270 HB INTRO/SHEATH, GUIDING 2 C1892 1,048.11$

02721271 HB SPRAY SET, BIO TISSEEL 718.22$

02721272 HB CATHETER, EP COOL-TIP C2630 5,902.54$

02721276 HB INTRODUCER/SHEATH,NONGDNG 3 C1894 2,604.58$

02721284 HB INTRODUCER/SHEATH,NONGDNG 2 C1894 727.04$

02721287 HB PROBE, CRYOABLATION 3 C2618 13,537.31$

02721288 HB CATHETER, SUPRAPUBIC 1 C2627 645.03$

02721291 HB CATHETER, STAMEY SUPRAPUBIC C2627 646.63$

02721293 HB CATHETER, OCCLUSION 1 C2628 3,078.15$

02721294 HB INTRODUCER/SHEATH, LASER 2 C2629 14,933.45$

02721297 HB SLEEVE, INFUSION 1 607.32$

02721298 HB CATHETER,ANORECTAL MANOSHLD AR 580.18$

02721300 HB PINS, HEADLESS DISPOSABLE 1,285.23$

02721301 HB KIT, CATHETER STEER NAVIGATION 7,124.08$

02721303 HB CATHETER, CENTESIS 660.85$

02721304 HB KIT, BONOPTY BONE SYSTEM 765.14$

02721305 HB NEEDLE, TROCAR 350.73$

02721307 HB CATHETER, TROCAR 350.73$

02721309 HB QUADRANT ILLUMINATION 2,240.26$

02721313 HB PROBE, ABLATION RITAS 5,902.54$

02721314 HB PROBE, ABLATION VALLEY LAB 4,274.72$

02721315 HB CATHETER, ESOPHAGEAL MANOSHLD 472.60$

02721316 HB KYPHON BONE FILLER DEVICE 841.46$

02721317 HB NEEDLE, BONOPTY BIOPSY 940.57$

02721320 HB RETRACTOR, WOUND 789.96$

02721321 HB NEEDLE, MAXI-CELL 409.52$

02721322 HB DILATOR 212.85$

02721323 HB KIT, BARD BIOPSY SYSTEM 686.67$

02721324 HB KIT, EASY CORE BIOPSY SYSTEM 667.22$

02721325 HB PROBE, NIM 1 919.80$

02721327 HB VACTHERAPY, CANISTER 300/500ML 597.22$

02721328 HB TUBE, VINYL CONNECTOR 350.73$

02721329 HB WIRE, LOCALIZATION 20G 257.82$

02721330 HB DILATOR, DISPOSABLE 1 982.81$

02721332 HB PUMP, PAIN ON-Q A4306 1,627.94$

02721334 HB CATHETER, INFUSION 2 C1751 1,496.90$

02721339 HB CATHETER, PLEURX WITH KIT C1729 3,394.67$


02721344 HB CATHETER, HEMO, LONG TERM 1 C1750 1,522.48$

02721345 HB CATHETER, INFUSION/NON-HEMO 2 C1751 3,323.09$

02721347 HB CATHETER, GUIDING PERF/INFUS 2 C1887 2,151.56$

02721349 HB VACTHERAPY, DRAPE DRESSING 544.33$

02721350 HB CATHETER, BALLOON RADIOELEMENT C1728 13,329.05$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721351 HB TUBE, FEEDING 2 1,484.28$

02721352 HB VACTHERAPY, ABDOMINAL DRESSING 2,751.86$

02721353 HB PROBE, MONOPOLAR 3 7,124.08$

02721354 HB BLADE, REAMER 1 1,615.34$

02721355 HB BLADE, TRICUT 2 2,915.65$

02721357 HB NEURO MONITORING KIT 4 5,077.82$

02721360 HB SPRAY SET, CSL/TSSL/BIOCUE 718.22$

02721362 HB SIZER, BREAST ALL SIZES 642.60$

02721363 HB PIN, PERCUTANEOUS 1,963.10$

02721364 HB PROBE, MONOPOLAR / ENDO OTO 6,058.11$

02721365 HB ANESTHESIA TUBE 2 1,499.79$

02721366 HB TISSUE LOC/EXCSN DEV (IMPL WIRE) C1819 502.68$



02721381 HB TIP, RUMI 574.60$

02721383 HB TUBING, CUSA / MWA 1,980.73$

02721385 HB PERFUSION, PACK ADAPTER 1 1,073.50$

02721388 HB KIT, INTERNAL TRAJECTORY GUIDE 6,841.81$


02721395 HB LASER FIBER, 4 5,006.24$

02721396 HB LASER FIBER, 1 1,602.73$

02721397 HB CATH BALLOON WEDGE C1887 842.41$

02721399 HB CANNULA, ARTERIAL 1* 665.25$


02721402 HB NEEDLE, MICRODISSECTION 803.87$

02721403 HB CATHETER, SEEKING/EMBOL 1* 478.81$

02721405 HB BLADE, SAW 5 4,732.58$

02721406 HB BALLOON, OCCLUSION NON-NEURO 2,175.14$

02721408 HB BALLOON, OCCLUSION NEURO 7,549.94$

02721409 HB IMMOBILIZER, ALUMI - HAND 418.33$

02721410 HB PUNCH, BIOPSY DISPOSABLE 63.02$

02721412 HB CATHETER,TRANS/LUM,NONLSR 2 C1725 6,027.99$

02721415 HB CATHETER, GUIDING PERF/INFUS C1887 4,082.94$

02721416 HB SPATULA, BRAIN SILICONE DISP 640.06$

02721417 HB LASER FIBER, 2* 965.98$

02721418 HB STRAP, FOOT/ANKLE DISTRACTOR 549.36$

02721422 HB RETRACTOR, WOUND 1 788.77$

02721425 HB PIN, GUIDE 2 1,557.37$

02721427 HB GUIDEWIRE 1 C1769 477.32$

02721428 HB GUIDEWIRE 2 C1769 1,878.64$

02721454 HB BLADE, SAW 3 1,701.58$

02721455 HB CANNULA, ARTERIAL FEMORAL 2 753.41$

02721458 HB DRAIN, EXTERNAL 1 1,200.85$

02721465 HB TUBE NASO-ENTRO FED NG/J OR 2,587.28$

02721467 HB RETRACTOR LP/CHK, ADLT/CHLD 388.41$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721469 HB PADS, ARCTIC SUN ADDL PAD 2,058.40$

02721470 HB PADS, ARCTIC SUN MULTI-PK 5,409.42$

02721471 HB CATHETER-PERIPHERAL CTO 14 9,603.74$

02721475 HB STYLET, PACEMAKR ACCSS LEAD 640.06$

02721478 HB CAGE MAX TITANIUM 11,080.51$

02721479 HB KIT, NAVIGATED PEDCLS ACCSS 4,336.95$

02721481 HB CATHETER, JETSTREAM G2 PV C1724 17,822.43$

02721482 HB CATHETER, RELIANT BALLOON 3,346.42$

02721486 HB SEALANT HEMOSTATIC MM 1,680.78$

02721487 HB COLLAGEN,HEMOSTAT INSTAT MM 741.52$

02721489 HB PLATELET SEPARATION SYSTEM 3,979.18$

02721490 HB T-TUBE 4 1,592.94$

02721491 HB SMALL JOINT CANNULA SET 971.02$

02721496 HB KIT, FRACTURE 4 17,970.70$

02721497 HB KIT, FRACTURE 5 18,248.13$

02721498 HB GUIDEWIRE 4 * 1,983.65$

02721502 HB TUBE, TRACHEOSTOMY 3 1,819.50$

02721503 HB RELOAD, ENDOSCOPIC 1 641.00$

02721507 HB NEEDLE, ELECTRODE MICRO TIP 645.03$

02721508 HB TOOL, TUNNELING LONG 2,020.64$

02721509 HB SPACE PASSING ELEVATOR 744.46$

02721514 HB PROBE, ENDOSCOPIC 2 1,854.17$

02721515 HB ENDOSCOPIC STRYKEFLOW W/TIP 1,306.24$

02721516 HB GUIDEWIRE, .35 X 135CM 1,790.83$

02721519 HB IMPELLA MONITOR SET TUBING 665.27$

02721522 HB PROBE, CHOLANGIOFLEX UHD 6,465.24$

02721527 HB SYSTEM, TITANIUM KNOT 1,431.10$

02721533 HB MANIPULATOR, UTERINE 947.90$

02721535 HB TUBING, DOLPHIN 1 1,061.17$

02721536 HB ESU SEALER DISSECTING 6,528.92$

02721538 HB CATH, IVUS GUIDED CTO/PERI C1887 17,912.82$

02721539 HB CATHETER, PACING BALLOON 854.41$

02721540 HB BIOPSY FORCEP 7F 1,424.24$

02721542 HB ELECTRODE, TEMPORARY PACING 5,424.65$

02721543 HB CATHETER, EXPORT ASPIRATION 3,833.57$

02721544 HB PADS, UNIVERSAL ARCTIC GEL 2,242.49$

02721545 HB PADS, ARCTIC GEL (S,M,L) 7,399.52$

02721546 HB KIT, CRYOABLATION C2618 21,144.26$




02721551 HB BLADE, TRUNCATED 2 5,823.79$

02721554 HB TIP, PHACOEMULSIFICATION 1 799.93$

02721555 HB PUNCH DISPOSABLE 1 547.94$

02721556 HB CATHETER, BALLOON-IN-BALLOON C1726 4,961.42$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721557 HB CATHETER, MULTI-TRACK 654.23$

02721558 HB PERF CELL SAVER BRAT KIT 1,424.14$

02721559 HB PERF UNIV 3 SPIKE 1,338.63$


02721562 HB KIT LEAD LOCKING DEVICE 3,805.47$

02721563 HB RETRACTOR, SCROTAL/TISSUE 2,432.17$

02721564 HB RETRACTOR, VAGINAL 1,502.76$

02721569 HB KIT, ASPIRATION VIZISHOT 1,488.88$

02721570 HB COLLAGEN, HEMOSTAT INSTAT 2 1,618.92$

02721573 HB NEEDLE, BIOPSY 1 628.85$

02721575 HB BIOGLUE, SKNCLSR SYRINGE 2 4,090.17$

02721576 HB NEEDLE, ASPIRATION 1 1,077.37$

02721577 HB CATHETER, ANORECTAL DISP. 714.66$

02721578 HB INTRODUCER/SHEATH,NONGDNG 1 C1894 655.30$

02721580 HB SUCTION VALVE 1 291.31$

02721582 HB CANNULA BLOWER MISTER 746.75$

02721583 HB KIT, TRI/QUAD LPRSCPC SYS 3,098.01$

02721585 HB PERFUSION LINE SPIKE 228.89$

02721586 HB ESU FILTER SMOKE EVACUATOR 1,225.34$

02721587 HB PROBE, PRASS MONOPOLAR STIM 2,653.09$

02721588 HB PROBE, BALL TIP PEDICL STIM 2,653.09$

02721590 HB PACK, PERFUSION PUMP TABLE1 1,204.51$

02721591 HB KIT, OPTIVAC TRIPLE MIX 1,433.40$


02721593 HB KIT, VITRECTOMY INNOVAT PAK 3,028.63$

02721597 HB KIT, PATIENT SPINAL CORD 1,093.54$

02721598 HB ELECTRODE, ESU 2 1,257.70$

02721602 HB HANDPIECE, ENDOSCOPIC 3 2,452.97$

02721604 HB CATHETER, EP<19 ELECTRODES 2 C1730 2,996.29$


02721606 HB PERFUSION, MANOMETER LINE 430.01$

02721607 HB TUBE, ENDOTRACHEAL 3 2,196.34$

02721609 HB CATHETER,TRANS/LUM,NONLSR 1 C1725 4,255.17$


02721611 HB TUBING, PERFUSION 1 383.79$


02721614 HB SPATULA, PLASMA DISPOSABLE 2,448.36$

02721615 HB K-WIRE, SUPPLY 4 2,126.99$






02721622 HB EXTENSION, STAPLER 1 1,174.46$



Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721629 HB MONITORING CATH W LICOX BLT 4,484.19$

02721632 HB VAC THERAPY SYSTEM 1 668.16$

02721634 HB HEAT EXCHANGER 1 2,173.23$

02721636 HB FLANGE, ACETABULAR 1 1,421.84$

02721637 HB CLAMP, BULLDOG 1 198.83$

02721638 HB CANNULA, INTRODUCTION 739.83$

02721639 HB DISPOSABLE PULLBACK SLED 580.30$

02721640 HB DILATOR,VSSL,PERI,HYDRO CTD 229.80$

02721641 HB DILATOR,VSSL, PERIPHERAL IR 158.94$

02721642 HB SHEATH, PINNACLE II RDPAQUE C1894 520.20$

02721643 HB CATHETER, INDWLL SILICONE 1 A4344 171.08$

02721644 HB PROBE, CRYOABLATION 2 C2618 7,645.59$

02721645 HB SLEEVE, TRACTION ARM 876.25$

02721646 HB FILTER, BLOOD 1 351.41$

02721649 HB REAMER SWANSON 1 319.05$

02721650 HB REAMER CRTCLSCRW RMVR DISP2 3,303.75$

02721652 HB ADAPTOR, CELL SAVER 293.61$

02721653 HB CATHETER,BALLOON DILATION9 C1726 6,057.29$

02721654 HB CATHETER, DIAGNOSTIC 1 251.99$

02721655 HB NEEDLE, SPINAL 1 147.96$

02721657 HB EXTRACTOR, STONE TIPLESS 1 978.80$

02721660 HB CATHETER,THRMBCTMYEMBLCTMY1 C1757 237.67$

02721661 HB KIT, MINI STICK DILATOR 654.69$

02721663 HB ELECTRODE, ESU 4 2,223.34$


02721666 HB BOLT EXTRACTION SCREW RMVL 1 1,201.34$

02721670 HB HEMOSTAT ABSORBABLE SURGICE 712.10$

02721673 HB CABLE, PACEMAKER ACCESSORY 864.29$


02721679 HB PLEDGET, CARDIOVASCULAR 1 198.79$

02721680 HB SNARE, W/HOOKS 3,303.69$

02721681 HB SHEATH, CARDIOVASCULAR 1 1,229.42$

02721683 HB ASPIRATOR, ENT 2 974.47$

02721684 HB CATHETER, GLIDECATH HYDRA 1 682.77$

02721685 HB CATHETER,THRMBCTMYEMBLCTMY2 C1757 987.44$

02721686 HB SCISSORS, ENDOSCOPIC 2 2,311.94$





02721692 HB EP INTRO/SHEATH, GUIDING 3 C1892 1,968.62$

02721693 HB EP INTRO/SHEATH, GUIDING 4 C1892 4,812.94$

02721699 HB CANNULA LONG TERM SET 1 1,318.02$

02721703 HB CANNULA, CATH VENT SUMP 1 414.85$

02721704 HB CANNULA AORTIC 404.03$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721706 HB ATRIAL CATH MONITORING SET 514.25$

02721708 HB SUCTION COAGULATOR 1 226.87$

02721709 HB PRESSURE MONITORING SET 1 1,026.33$

02721710 HB SEALANT, HEMOSTATIC 3 5,652.37$

02721711 HB CATHETER, INTRAVAS ULTRSND1 C1753 6,374.06$

02721713 HB CANNULA, GRAFT 1 4,336.51$

02721716 HB PERFUSION OXYGENATOR 5 5,820.89$






02721724 HB PERF FILTER SET 1 1,052.26$


02721727 HB CATHETER, CARDIOPLEGIA 1 1,136.53$

02721728 HB PACK, ACCESSORY VNS 4,041.52$

02721731 HB BAG,DRAINAGE URN MTR 2000ML 178.12$

02721732 HB CATHETER, FOLEY 2 WAY SEC 105.52$

02721740 HB KIT, PICC SELDING 865.12$



02721743 HB TUBING, SUCTION 1 426.63$


02721746 HB CATHETER, EP<19 ELECTRODES 1 C1730 1,121.39$

02721747 HB DRAIN, HEMOVAC 1 224.73$

02721749 HB BLADE, DERMACARRIER 1 481.84$

02721751 HB PERFUSION EXTENTION LINE 529.37$

02721753 HB RET DEV, INSERTABLE 1 C1773 2,063.46$

02721754 HB RET DEV, INSERTABLE 3 C1773 8,290.57$

02721755 HB BLADE, SAW 4 2,564.73$

02721760 HB GUIDE WIRE 2 C1769 1,315.41$

02721761 HB GUIDE WIRE 3 C1769 1,844.66$

02721763 HB CATHETER, ATHERECT ROTATION 2 C1724 8,378.31$

02721764 HB CATH EP 20+ ELECTRODES 1 C1731 6,999.80$




02721768 HB CATHETER, DIAG/ABLATION 1 C1732 12,551.68$

02721769 HB CATHETER, DIAG/ABLATION 2 C1732 14,023.13$

02721771 HB CANNULA ARTERIAL FEMORAL 2,105.61$

02721773 HB SCREW POWER DRIVER 1,037.13$

02721774 HB PLATE, TEMPLATE 1 615.81$

02721776 HB VEIN HOLDER 522.89$

02721777 HB SUCTION KAMVAC CVD MINI 1 466.73$

02721778 HB ADAPTER, LUER 1 75.61$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price




02721781 HB RETRIEVER, ROTH NET 1 1,121.39$

02721782 HB REAMER CRTCLSCRW RMVR DISP1 2,374.59$

02721783 HB DISSECTOR, BALLOON ENDO 1 1,594.60$


02721785 HB CATHETER, GUIDING PERF/INFUS C1887 767.03$

02721786 HB CATHETER, INTRVSC OCT LIGHT 7,125.12$

02721787 HB AMBULATORY CARDIAC ZIO PATCH 1,792.77$

02721789 HB PROBE, ESU 1 3,755.28$

02721790 HB PROBE, ESU 2 4,055.61$

02721791 HB SUCTION IRRIGATION SYSTEM 1 1,646.45$

02721792 HB CATHETER, BALLOON DILATION1 C1726 669.81$

02721793 HB DILATOR, DISPOSABLE 1 1,920.84$

02721794 HB DILATOR, DISPOSABLE 2 3,329.53$

02721798 HB BLADE, BANANA 1 248.48$

02721799 HB BLADE, BANANA 2 1,706.95$

02721801 HB FASTENER CARTRIDGE ESOPHYX 3,338.26$

02721802 HB ADJUSTABLE BAND 2,448.06$

02721803 HB CHISEL, ESU LIGAMENT 3,578.12$

02721805 HB CANNULA, RADIO FREQUENCY 1 499.12$

02721806 HB TUNNELER, SURGICAL 2 3,256.17$

02721807 HB KIT, PLASMA EXCH-SPECTRA/OPTIA 2,242.60$

02721808 HB ANTICOAGULANT 123.88$

02721809 HB TUBING, BLOOD WARMER 214.56$

02721810 HB TUBING, EXTENSION PHERESIS 77.18$

02721812 HB KIT,RED BLOOD CELL EXCHANGE 1,946.91$

02721813 HB TUBING LDL REDUCTION 745.67$

02721814 HB LDL COLUMNS 8,137.39$

02721815 HB LDL BLOOD CELL SEPARATOR 1,283.69$

02721816 HB KIT, PHOTOPHERESIS 9,118.35$

02721817 HB UVADEX 1,229.88$

02721818 HB KIT, STEM CELL COLLECTION 1,765.42$

02721819 HB KIT, WHITE CELL DEPLETION 1,765.42$

02721820 HB TRICITRSOL 50CC 852.85$

02721821 HB KIT, PLATELET DEPLETION 6,717.45$

02721822 HB BASKET, RETRIEVAL I 1,875.25$

02721823 HB BASKET, RETRIEVAL III 4,499.51$

02721825 HB BASKET, LITHO MECHANICAL 5,509.67$

02721826 HB CATHETER, ERCP 1,455.35$

02721827 HB CANNULA, ERCP SWING TIP 1,967.18$

02721828 HB SPHINCTERTOME/PAPILLOTOME I 1,834.39$

02721829 HB SPHINCTERTOME/PAPILLOTOMEII 2,397.02$

02721830 HB BALLOON,RX EXTRACT/MULTI 3V 1,692.93$

02721831 HB STENT, RETRIEVER 1,482.01$

02721834 HB OVERTUBE, DOUBLE BALLOON I 2,278.67$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721836 HB OVERTUBE, GASTRIC GARDIS 1,801.04$

02721837 HB TUBE, JEJUN GW(FEEDING) 2,656.10$

02721838 HB CAPSULE, WIRELESS PILLCAM 3,938.61$

02721839 HB CATHETER, BALLOON BIL RX C1726 2,339.11$

02721840 HB CATHETER,CRE BAL DILAT ROTH C1726 1,085.72$

02721841 HB CATHETER, HALO GUIDE WIRE C1887 1,373.56$

02721842 HB CATHETER,ENDOSCOPY,ABLATION C1888 9,599.17$

02721843 HB GUIDEWIRE PATHFINDER/ACCESS C1769 1,446.84$

02721844 HB GUIDEWIRE/GLIDEWIR/VISIGLID C1769 1,988.80$

02721845 HB JAGWIRE II C1769 1,919.56$

02721846 HB FORCEPS, RESCUE 4,972.23$

02721847 HB FORCEPS, BIOPSY II 2,993.22$

02721849 HB BALLOON, ENDOSCOPY EXTRACTN 2,179.72$

02721850 HB RAPID REFILL CONT. INJ SYS 470.89$

02721851 HB NEEDLE, EUS ECHO-HD 2,912.38$

02721852 HB NEEDLE, HD U/S ACCESS 3,330.37$

02721854 HB SUCTION, ENDO BROVAC 2,839.31$

02721855 HB OTSC SYSTEM SET 100.10 3,491.60$

02721856 HB OTSC TRIPOD ANCHOR ST200.10 3,345.00$

02721858 HB OTSC TWIN GRASPER 200.45 4,432.46$

02721864 HB LASER FIBER, 7 7,352.83$

02721866 HB ELECTRODE, ESU 5 3,759.61$

02721867 HB CAPSULE, ENDOSCOPE DEL SYS 1,594.60$

02721868 HB KIT, ENDO MUCUS RESECTION 2,022.41$

02721872 HB BLADE, TRUNCATED 1 4,837.79$

02721873 HB ENDO CATCH 1 580.30$

02721875 HB COBLATOR, ENT 1 2,106.67$

02721878 HB PT/PRGMR, NEUROSTIMULATOR 1 * C1787 4,494.23$

02721879 HB SHEARS, HARMONIC 1 * 1,985.67$

02721882 HB LASER FIBER, 8 * 7,893.01$

02721883 HB DRIVER AMPLATZER TORQUE 1 4,524.47$

02721885 HB KIT, STANDARD PEG 799.48$

02721887 HB CATHETER,CRYOABLATION ARCTIC C1733 21,221.63$

02721888 HB INTRO/SHEATH EP FLEXCATH C1766 7,602.52$

02721891 HB KIT,TUBE GASTROSTOMY FEEDING 1,251.41$


02721893 HB KIT, TUBE JEJUNAL FEEDING 1,523.40$

02721894 HB NEEDLE,ECHOTIP CELIAC PLEXUS 2,176.98$

02721896 HB CATHETER, URETERAL 2 C1758 1,592.43$

02721897 HB CATHETER,ENSMBL DS BLN18-22 C1887 34,132.66$

02721900 HB TUBE, NASAOGASTRIC 2,070.68$

02721901 HB KIT, COAXIAL TEMNO BX SYSTEM 820.99$

02721903 HB FORCEP,COLON MAXUM RATTOOTH 2,918.37$




Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price




02721915 HB CONNECTOR SMARTSTITCH 1,352.59$

02721917 HB PROBE, RADIO FREQUENCY 1 3,638.94$

02721919 HB DRAIN 2 1,821.48$

02721921 HB GUIDE, DRILL 2 2,037.53$

02721925 HB BLADE, OSTEOTOME 1 1,549.21$

02721929 HB HEAD REAMER 1 2,633.87$

02721930 HB DRILL BIT, DISPOSABLE 1 713.03$

02721931 HB DRILL BIT, DISPOSABLE 2 1,227.04$








02721940 HB TUBING, PCA 118.72$

02721942 HB PREVALON BOOT 813.47$

02721943 HB CATH, CNTRL VENOUS, SINGLE 539.94$

02721944 HB KNIFE, BAYONET 1 1,864.68$

02721948 HB KNIFE, TRIANGLE TIP 4,869.35$

02721953 HB SCALPEL, SURGICAL 10 STER 61.03$

02721958 HB HEMOCLIP MEDIUM 141.21$

02721959 HB LIGACLIP SMALL 87.43$

02721961 HB MASTISOL LIQUID ADHESIVE 61.03$

02721964 HB PACK, PERFUSION PUMP TABLE 1,142.84$

02721966 HB COLLAGEN, HEMOSTAT INSTAT 939.68$

02721969 HB BLADE, PIVOTAL/FIXED 89.15$

02721972 HB DRAIN ,BLAKE 402.12$

02721973 HB DRAIN, RESERVOIR 128.53$

02721974 HB DRAIN, PLEUR ADULT/PEDS 503.91$

02721975 HB FLOSEAL HEMOSTAT 5ML 1,604.23$

02721979 HB CATHETER,BRACHYTHSEEDADMIN1 C1728 1,065.71$

02721980 HB CATHETER, CUTTING BALLOON C1725 7,890.84$

02721981 HB PRP INJECTION KIT 1,739.99$

02721982 HB CATHETER, SOLITARE DEVICE C1757 28,436.71$

02721983 HB KIT, SPINAL CORD STIM 2 11,390.94$

02721984 HB BOLT EXTRACTION SCREW RMVL2 2,633.28$

02721985 HB NEEDLE, MAX FORCE INJECTOR 579.10$

02721987 HB GRASPER, MONOPOLAR HEMOST 2,025.82$

02721988 HB GRASPER, MONOPOLAR 230 CM 2,619.46$

02721989 HB CLIP, QUICK 1,237.23$

02721990 HB ATTACHMENT DISTANT DISPOSBL 834.88$

02721991 HB BLADE, DERMATOME 1 349.10$

02721992 HB GUIDEWIRE 5 C1769 2,714.22$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02721993 HB HEARTMATE, CENTRIMAG PUMP 42,784.75$

02721995 HB KIT, SPARES TAH 11,594.38$

02722000 HB ATHERECTOMY DEVICE 21,650.02$

02722001 HB PROBE, MICROWAVE 9,927.64$

02722009 HB BALLOON, ULTRASOUND LIN/RAD 417.05$

02722012 HB MOUTHPIECE, QFIX 150.05$

02722013 HB CLIP, QFIX NOSE 99.82$

02722014 HB FILTER, QFIX BACTERIAL 237.16$

02722016 HB NANODOTS-SCREENED 274.32$

02722018 HB MICROCATH SUREFIRE INF SYS 15,738.46$

02722020 HB TUBE, FEEDING 1 531.54$

02722021 HB NASOPORE SINUS DRESSING 1,620.52$

02722022 HB PIN, STEINMAN 1 293.87$

02722023 HB PIN, STEINMAN 2 1,104.13$

02722026 HB FIBER LASER R-1 773.54$

02722027 HB FIBER LASER R-2 905.33$

02722028 HB FIBER LASER R-3 1,436.86$

02722030 HB CATHETER, INTRAVAS ULTRSND 1 C1753 5,120.84$

02722031 HB OCCLUDERS, COLPO-PNEUMO 916.14$

02722032 HB TROCAR SITE CLOSURE SYS 496.96$

02722034 HB PERF ANTICOAGULANT LINE 378.11$

02722035 HB INFINITY SAMPLING SYSTEM 422.69$

02722036 HB FORCEPS,RESCUE RAT-T/ALIGTR 1,165.31$

02722037 HB INFLATION SYSTEM BIG60 638.06$

02722038 HB CYSTOTOME 3,075.62$

02722042 HB BASKET BILIARY STONE REMOVAL 2,260.78$

02722043 HB ENDOCATH OCCLUSION BALLOON C2628 4,963.34$

02722045 HB GUIDEWIRE, FINDRWIRZ SYSTEM 7,646.92$

02722047 HB CANNULA, SOFT TIP GUIDE 2,653.56$

02722053 HB NEEDLE, BIOPSY SYSTEM 497.03$

02722056 HB MIC-KEY MEASURING STOMA 163.24$

02722062 HB TISSUE HELIX 1,722.07$

02722063 HB CATHETER, RADIO ENDO 8,193.69$

02722065 HB BIOGLUE, SKNCLSR SYRINGE CL 5,183.67$

02722069 HB PATCH, TACHOSIL 4,729.74$

02722072 HB AEROSIZER STENT SYSTEM C1874 1,797.39$

02722074 HB SEALER, BIPOLAR 1 3,887.08$

02722075 HB CLIP, OCCLUSION 1 7,893.01$

02722076 HB CLIP, OCCLUSION 2 16,965.74$

02722077 HB LIGASURE, ESU 3* 3,843.42$


02722079 HB VAC THERAPY SYSTEM 2 1,374.21$

02722080 HB ROD, REAMING 1 1,335.29$

02722082 HB SEALANT, HEMOSTATIC 2 4,729.74$

02722083 HB TUBE, HOLLOW REAMER* 2,329.23$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722084 HB SEAL SYSTEM PROXIMAL AORTIC 3,852.51$

02722085 HB TUBING HTA PROCEDURE SET 1 7,787.13$

02722088 HB KIT, MENISCAL REPAIR 1,102.31$

02722090 HB TRACKER FUSION ENT 1,488.71$


02722092 HB REAMER, ORTHO 1 3,913.02$

02722094 HB CUP, VACCUUM EXTRACTION 549.32$

02722095 HB SURGICEL 878.11$

02722097 HB CATHETER, ENDO BIL DRAIN 1,201.55$

02722101 HB SURGICAL ELECTR KNIFE DISP 4,532.40$

02722102 HB TUBE, MIC-KEY JEJUNAL STOMA 2,826.76$

02722104 HB TOOL, ULTRA DISK DRIVE* 3,653.04$

02722105 HB INSERTION KIT ART/VEN 697.65$

02722106 HB FORCEPS, ENDOSCOPIC 1* 364.39$

02722107 HB GENERATOR, RADIO FREQUENCY* 4,022.90$

02722109 HB EXTRACTION BALLOON 1 1,692.93$

02722110 HB KIT, LIPIVAGE W/CANNULA 1,571.06$

02722111 HB KNOT PUSHER 1 1,505.16$

02722117 HB CATHETER, FAST CLOSURE 1 5,870.48$

02722119 HB HELIFX APPLIER 31,298.80$

02722120 HB CATHETER, HELIFX GUIDE C1887 12,989.54$

02722127 HB FORCEPS, ENDOSCOPIC 2* 1,408.11$

02722128 HB PT/PRGMR, NEUROSTIMULATOR 3* C1787 6,252.17$

02722129 HB PACK, ACL DISPOSABLE 1,420.94$

02722131 HB BONE COLLECTOR 1,091.34$

02722132 HB PREP CATHETER 1,523.46$

02722134 HB SPECIMEN COLLECTION SYSTEM1 584.12$

02722135 HB ESU SUPRALOOP 1 1,203.03$

02722136 HB DISSECTOR, ARTICULATING 1 8,135.56$

02722137 HB PUSHER COIL NEURO 1,749.24$

02722138 HB EUS BALLOON 639.52$

02722139 HB PROBE COLOFLEX UHD 3,605.14$

02722140 HB MITRAL CLIP DELIVERY SYSTEM 20,739.34$

02722141 HB CATHETER,OCELOT ATHERECTOMY 24,821.12$

02722142 HB PROBE, PEN 1 11,325.33$

02722143 HB PROBE, PEN 2 12,061.41$

02722144 HB PROBE, PEN 3 15,005.80$


02722148 HB LUMBAR CATHETER 1 1,514.32$

02722149 HB TOOL, DISSECTING 3 2,534.23$

02722150 HB TUBING HTA PROCEDURE SET 2 8,626.29$

02722151 HB PERICARDIAL SUMP 1 401.01$

02722153 HB DISPOSABLE INSTRUMENTS 1 5,683.72$

02722156 HB INTRODUCER/SHEATH, LASER 3 C2629 15,791.35$

02722157 HB HANDPIECE, NEURO 1 14,943.57$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722158 HB HANDPIECE BENDING TOOL 584.12$

02722159 HB GUIDE, OUTER TUBE W/STYLET 1,541.79$

02722160 HB DRAINAGE SYSTEM 1 606.10$

02722162 HB SCREW, STEREOTACTIC 1 862.44$

02722163 HB SPACER, TIBIAL/FEMORAL 1 5,191.16$

02722164 HB NEURO MONITORING KIT 5 5,603.16$

02722165 HB HAND DRILL DISPOSABLE 1 908.22$

02722166 HB CATHETER PICC LUMEN 3CG 1,917.26$

02722167 HB NEEDLE, BREAST VACUUM ATEC 2,920.98$

02722168 HB URODYNAMIC PUMP TUBING* 1,558.16$

02722169 HB CATHETER, SINGLE LUMEN CAT895 3,188.06$

02722170 HB CATHETER, DUAL LUMEN CAT880 3,886.59$

02722171 HB CATHETER, RECTAL ABD CAT875 2,811.40$

02722172 HB R.I.A. SYSTEM 1 2,682.55$

02722173 HB R.I.A. SEAL 1 421.16$

02722174 HB TOOL, SIZING 1 1,548.59$

02722178 HB INTRODUCER/SHEATH, GDNG 1 C1893 1,441.07$

02722183 HB GELFILM 3,678.96$

02722184 HB NOZZLE, DISPOSABLE 1 495.92$

02722185 HB FOREIGN BODY HOOD 318.68$

02722186 HB PUSH CATHETER 4/5 FR 315.59$

02722187 HB RX LOCKING/BIOPSY CAP 158.33$

02722189 HB NERVE STIMULATOR 2 3,147.95$

02722192 HB ENDO ANTI-FOG 1 541.70$

02722194 HB PIN, STEINMAN 3 1,980.65$

02722197 HB GRASPER, ENDOSCOPIC 3 3,991.78$

02722198 HB COREVALVE DELIVERY SYSTEM 12,607.39$

02722199 HB COREVALVE LOADING SYSTEM 3,271.70$

02722203 HB CANNULA AND STYLET 1 1,902.81$

02722204 HB SOLOPATH INTRODUCER/BALLOON 4,713.54$

02722205 HB STINGRAY CTO BALLOON 7,890.49$

02722206 HB CROSS BOSS CTO CATHETER 6,371.44$

02722207 HB DRY SEAL SHEATH 2,655.09$

02722208 HB CATHETER, HYSTERO DIAG 5-7F 681.53$

02722209 HB RAPTOR MINI 1,230.95$

02722210 HB OVERTUBE ENDO ACCESS SYSTEM 1,723.31$

02722213 HB BLADE, QUADCUT 1 1,284.82$

02722214 HB BLADE, QUADCUT 2 1,853.97$

02722216 HB CTO NEEDLE HOLDER 1,456.11$

02722217 HB LOCKING BIOPSY CAP 222.68$

02722218 HB CATHETER, ENDO STENT PUSH 1,090.91$

02722219 HB CATHETER, SPRAY 1,922.00$

02722220 HB CATHETER, ABLATION HALO 90 & 60 7,404.07$

02722221 HB PROBE, NEURO SHIELDED 1 1,672.41$

02722222 HB CANNULA, ARTERIAL 2* 1,608.32$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722223 HB STERNAL CABLE SYSTEM 1,123.08$

02722224 HB SUCTION WATER SEAL 700.38$

02722229 HB OBTURATOR 1 477.61$

02722230 HB GUIDEWIRE 7 C1769 4,901.22$

02722233 HB BLADE, ROTATING 1 1,277.18$

02722234 HB ANES PRESSURE BAG DISP 529.49$

02722235 HB CATHETER, ENDOVASCULAR 14,990.41$

02722236 HB CATHETER, TRANS/LU,NONLRS 4 C1725 5,181.99$


02722241 HB RETRACTOR HOOK 1,069.68$

02722245 HB NAVIGATIONAL BRUSH 1,354.13$

02722246 HB BALLOON CATHETER C1726 2,346.78$

02722247 HB INFLATION DEVICE 638.44$

02722248 HB IMPELLA PURGE CASSETTE 1,969.95$

02722255 HB KNIFE, OPHTHALMIC 1 259.41$

02722256 HB BONE CUTTER 1 627.14$

02722257 HB KIT, PORTAL ENTRY 1 1,951.63$

02722258 HB CANNULA W/OBTURATOR 2,223.25$

02722259 HB TAMPONADE BALLOON KIT 2,107.29$


02722261 HB BAG, RETRIEVAL 1 1,412.98$

02722266 HB BALLOON DRUG COATED 3 C2623 10,838.55$

02722267 HB WATCHMAN ACCESS SYSTEM 5,788.62$

02722270 HB TRANSANAL ACCESS PLATFORM 4,879.96$



02722273 HB CATHETER PH IMPEDANCE 1,360.46$


02722277 HB KIT, THERAPEUTIC DOUBLE PHLEBOTOMY 951.10$

02722278 HB CANNULA, ANGIOVAC STAND ALONE 38,638.72$

02722279 HB NEEDLE, BIOPSY 2* 1,142.55$

02722280 HB NEEDLE, BIOPSY 4* 2,824.83$

02722281 HB NEEDLE, BIOPSY 5 3,646.14$

02722282 HB NEEDLE, BIOPSY 6 4,469.39$

02722285 HB BARRIER PROTECTIVE LIQUID 68.35$

02722286 HB BARRIER RING 137.33$

02722287 HB TAH MANAGEMENT SYSTEM Q0508 329.65$

02722288 HB BALLOON, ENDOSCOPY PULM BIOPSY 3,196.32$

02722289 HB ADAPTER, ENDOSCOPY BIOPSY 939.22$

02722290 HB POSITIONER, DISPOSABLE 1 555.55$

02722291 HB POSITIONER, DISPOSABLE 2 1,579.24$

02722295 HB DELIVERY SYSTEM EVOLUTR 15,067.23$

02722296 HB LOADING SYSTEM EVOLUTR 3,269.69$

02722299 HB EP CABLE UMBILICAL 5,773.08$

02722300 HB SENSOR, ANAL/EMG STIMULATION 852.42$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722303 HB KIT, CATHETER EDGE NAVIGATION BR 8,053.29$

02722304 HB BREEZA DRINK /CAN 175.93$

02722305 HB DUCTOGRAM CANNULA 512.08$

02722306 HB KIT, COOLED RADIOFREQUENCY 5,585.54$

02722307 HB MAT, COOLED RADIOFREQUENCY 5,585.54$

02722308 HB PAD, GROUNDING 205.57$

02722309 HB KIT, COOLED RADIOFREQUENCY ACTIVE TIP 9,607.73$

02722310 HB PROBE, COOLED RADIOFREQUENCY 3,338.15$

02722311 HB FLOW RETRIEVER CATHETER 12,558.81$

02722312 HB ASPIRATION GUIDE CATHETER 6,523.31$

02722313 HB RETRACTION ASPIRATOR 2,653.72$

02722314 HB MICRA INTRODUCER SHEATH C1894 4,647.76$

02722316 HB BRAINPATH SHEATH 7,119.35$

02722317 HB BRAINPATH HOOKS 1,070.26$

02722318 HB SCALPEL, BONE 3,371.38$

02722319 HB SCISSOR, ENDOSCOPIC 2,652.80$

02722320 HB PERFUSION CANNULA BLUNT 2,571.12$

02722321 HB INTRODUCER/SHEATH,NONGDNG C1894 2,140.52$

02722322 HB KIT, ANGIO TOUCH 458.29$

02722323 HB PERFUSION SWITCH 592.59$

02722324 HB DV FORCEPS BIPOLAR REPOSABLE 2,407.77$

02722325 HB DV FORCEPS PROGRASP REPOSABLE 2,105.90$

02722326 HB DV DRIVER NEEDLE REPOSABLE 2,105.90$

02722327 HB DV SCISSORS MONO REPOSABLE 2,783.78$

02722329 HB DV DRIVER NEEDLE MEGA REPOSABLE 1,831.75$


02722332 HB INFLOW TUBING SET 826.57$

02722333 HB TISSUE REMOVAL STANDARD 5,824.80$

02722334 HB TISSUE REMOVAL XL 6,493.54$

02722335 HB SEAL SCOPE SET 256.15$


02722337 HB SCALPEL BONE 3,371.38$

02722338 HB BALLOON APPLICATOR 9,607.39$

02722339 HB CLIP, LIGATING 573.20$

02722340 HB KNEE BLOCK 9,607.39$

02722341 HB CATHETER, STRETTA TRANSORAL 8,256.06$

02722342 HB KIT BMAC ANGEL 7,025.19$

02722343 HB SHEARS, HARMONIC 5,810.95$

02722344 HB KIT, ENDOMETRIAL ABLATION 6,211.09$

02722345 HB PLEURX DRAINAGE 843.36$

02722346 HB FOLEY TIP CATHETER PUNCH 867.06$

02722347 HB CARNATION PATCH 2-DAY 1,139.77$

02722348 HB MAX CANISTER 505.38$

02722349 HB MAX PUMP 13,153.22$

02722350 HB CATHETER 5, STRAIGHT TIP 1,610.23$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722351 HB CATHETER 6, STRAIGHT TIP 2,616.80$

02722352 HB CATHETER 8, XTORQ TIP 4,001.35$

02722353 HB SEPARATOR 5 989.96$

02722354 HB SEPARATOR 6 1,495.30$

02722355 HB SEPARATOR 8 2,602.95$

02722356 HB INDIGO ASPIRATION TUBING 606.44$

02722357 HB CATHETER SELECT NERUON BER, 5 FR 173.07$

02722358 HB BLADELESS OBTURATOR 495.67$

02722359 HB DV VESSEL SEALER 4,671.22$

02722360 HB LITHOTRIPTOR CABLE 1,456.54$

02722361 HB DV GRASPER REPOSABLE 2,060.21$

02722362 HB CATHETER INDWELLING FOLEY 3 WAY A4346 265.84$

02722363 HB CATHETER, CORONARY DIAGNOSTIC 4,082.94$

02722364 HB PROBE, PEN 15,997.07$

02722365 HB CATHETER, URINARY STRAIGHT A4351 418.14$

02722366 HB NEEDLE, DEFLUX 879.19$

02722369 HB KIT, VESSEL HARVESTING 6,836.91$

02722370 HB DV CANNULA SEAL 638.28$

02722372 HB FAT GRAFTING HARVEST SYSTEM 2,038.06$

02722373 HB DV SCISSORS REPOSABLE 1,952.22$

02722497 HB DV CANNULA REDUCER 477.68$

02722498 HB DV CLIP APPLIER REPOSABLE 369.67$

02722499 HB CATHETER, BALLOON DILATION C1726 11,126.24$

02722500 HB KIT, CAPTIVATOR 2,637.57$

02722501 HB ANOSCOPE, DISPOSABLE 56.77$

02722502 HB EXTERNAL FIXATOR HOLDER 3,897.51$

02722503 HB GELPORT PLATFORM 2,482.49$

02722504 HB ARTHRO WAND 4,221.49$

02722505 HB SERRATED KNIFE 6,241.55$

02722506 HB UNIVERSAL DRIVER 778.12$

02722507 HB CATHETER SPYGLASS 14,277.46$

02722508 HB PROBE, MEASUREMENT 1,824.84$

02722509 HB FORCEP, ENDOSCOPIC 3,792.28$

02722510 HB INJECTION NEEDLE 1,284.86$

02722511 HB POWERPICK 1,291.78$

02722512 HB PROBE, COAGULATING 2,050.52$

02722513 HB ADJUSTABLE ENDOSCOPIC VALVE 638.28$

02722514 HB PERFUSION CARDIOPLEGIA SET 544.13$

02722515 HB CATHETER, INTUBATION 805.81$

02722516 HB NAIL INSERTION SLEEVE 1,671.15$

02722517 HB KIT, DRILL AND WRENCH 3,829.67$

02722518 HB KIT, DRILL AND WRENCH 6,148.78$

02722519 HB TRUFREEZE ACTIVE VENTING SPRAY KIT 10,565.49$

02722520 HB CARPAL TUNNEL RELEASE SYSTEM 5,581.12$

02722521 HB BALLOON RUMI 1,060.57$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722522 HB PERFUSION PIGTAIL LINE 285.22$

02722523 HB CARDIOHELP HLS SET 27,901.43$

02722524 HB STAPLER, ENDOSCOPIC 5,272.36$

02722525 HB TITANIUM FASTENERS 5,460.66$

02722526 HB TANDEM HEART PUMP KIT 32,055.08$

02722527 HB TISSUE REMOVAL REACH 6,485.51$

02722528 HB TISSUE REMOVAL LITE 4,333.63$

02722533 HB STENT GRAFT BALOON CATHETER 562.04$

02722534 HB DRYSEAL INTRODUCER SHEATH 434.93$

02722535 HB DRYSEAL INTRODUCER SHEATH 719.07$

02722536 HB CHARGER, NEUROSTIMULATOR 8,647.51$

02722538 HB INTRODUCER, OSTEO TOOL 2,659.43$

02722539 HB PULMONARY BALLOON DILATOR 2,617.06$

02722540 HB DV REPOSABLE DISSECTOR 2,445.08$

02722541 HB BLADE, CAPSULOTOMY 1,932.89$

02722542 HB BONE GRAFTING KIT 6,440.46$

02722543 HB HANDPIECE, NEURO 12,917.06$

02722544 HB HANDPIECE, NEURO 14,027.44$

02722545 HB ENDOSCOPIC SEAL 210.61$

02722546 HB OBTURATOR PORT 1,120.35$

02722547 HB FILTERED TUBE SET 1,147.77$

02722548 HB BLADE, SHAVER 1,770.88$

02722549 HB CUSA STANDARD TIP 4,096.32$

02722550 HB DV REPOSABLE HOOKS 1,419.44$

02722551 HB DV REPOSABLE RETRACTOR 2,617.06$

02722552 HB PROTECTION SLEEVE 871.10$


02722554 HB SLEEVE, OUTER PROTECTION 1,319.74$

02722555 HB PROBE EXTENSION CABLE 1,163.97$

02722556 HB KIT, LARYNGECTOMY PULMONARY 2,889.98$

02722557 HB PROBE, BIPOLAR 4,611.01$

02722558 HB TIP, INSERTER 959.59$

02722559 HB XVIVO KIT 38,980.48$

02722560 HB ELECTRODE, HIGH FREQUENCY 1,712.31$

02722561 HB CARTRIDGE CRRT 1,820.39$

02722562 HB EPI-SENSE ABLATION KIT 29,633.83$

02722564 HB CATHETER ABLATION 14,365.16$

02722565 HB GUIDEWIRE C1769 19,938.26$

02722566 HB KIT, DISPOSABLE INSTRUMENTS 1,795.80$

02722567 HB STAPLER, ENDOSCOPIC 4,311.92$

02722568 HB TUBING C02 463.60$

02722569 HB PROBE, DOPPLER 2,780.32$

02722570 HB BRONCHOSCOPE ADAPTOR 958.34$

02722571 HB PROLACT +4 10ML 878.56$

02722572 HB PROLACT +4 20ML 1,453.15$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722573 HB PROLACT +6 30ML 1,880.42$

02722574 HB PROLACT +8 40ML 2,307.70$

02722575 HB PROLACT +10 50ML 2,734.97$

02722576 HB GELPOINT ACCESS PLATFORM 3,711.24$

02722577 HB KIT, BIOPSY TRANSPORT 3,985.41$

02722578 HB FIBER LASER 3,551.72$

02722580 HB AIRFLOW PAD 505.97$


02722582 HB CAROTID SHUNT 4,988.61$

02722583 HB TOOL, LOOPING 2,103.62$

02722584 HB GUIDEWIRE C1769 4,019.05$

02722585 HB ULTRASONIC TIP 3,545.50$

02722586 HB CAROTID SHUNT 4,263.32$

02722604 HB CABLE OR 1MM X 16 61CM IN EXTENSION 43.61$

02722605 HB DRIVER, DISPOSABLE 775.03$

02722608 HB AIMING GUIDES 318.08$

02722619 HB TIP, ASPIRATION 4,004.10$

02722620 HB KIT, CEMENT MIXING 1,556.53$

02722621 HB THREAD LOCKING SLEEVE 2,471.25$

02722622 HB MANIPULATOR, UTERINE 1,453.09$

02722623 HB BLADE, DERMATOME 634.33$

02722624 HB KIT, AUTOMATED MANIFOLD 1,699.85$

02722625 HB CATHETER, QUATTRO COOLING 6,371.94$

02722626 HB CATHETER, ICY COOLING 9,263.72$

02722627 HB KIT, ZOLL START-UP 1,842.29$

02722628 HB ADJUSTABLE ENDOSCOPIC VALVE 636.82$

02722629 HB DISPOSABLES KIT 1,795.80$

02722630 HB SPINAL CORD CABLE 43.61$

02722632 HB BAG, TISSUE RETRIEVAL 1,061.78$

02722633 HB DV BLADELESS OBTURATOR 502.22$

02722634 HB BALLOON DILATOR 1,625.07$

02722635 HB ADAPTOR SPLITTER KIT 23,350.46$

02722636 HB INTRODUCER/SHEATH, GUIDING C1893 3,437.07$

02722637 HB ERCP SAMPLING SYSTEM 1,282.36$

02722638 HB INJECTABLE SUBMUCOSAL COMPOSITION 1,077.98$

02722639 HB PROTEK DUO KIT 34,618.71$

02722642 HB TRANSFILTRATION TUBING HK 347.39$

02722643 HB PROCEDURE PACK FAST CLOSURE 5,977.57$

02722644 HB BAG, TISSUE RETRIEVAL 1,061.78$

02722645 HB DV BLADELESS OBTURATOR 502.22$

02722646 HB BALLOON DILATOR 1,625.07$

02722647 HB CATHETER, FOLEY 22/24 FR 213.05$

02722648 HB KANGAROO BAG 110.22$

02722649 HB BINDER, PELVIC 1,829.76$

02722650 HB ANGI ASSIST C02 KIT 1,228.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722651 HB BALLOON, TRUEPATH CTO DEVICE C1769 11,811.72$

02722653 HB CATHETER, MICROSYS NAVIEN SUPPORT C1887 10,019.54$

02722654 HB CATHETER, TRAILBLAZER 014X150 C1887 1,638.19$

02722655 HB DETACHER SMART COIL 2,226.58$

02722656 HB NEEDLE, BIOPSY IVAS 11G 3,793.34$

02722657 HB BALLOON, CURVED C1726 14,021.27$

02722659 HB DELIVERY GUN 3,848.07$

02722660 HB DETACHER, AZUR 1,740.81$

02722661 HB DETACHER, BARRICADE HANDHELD CABLE 4,613.44$



02722664 HB RTRVL DVC, SNARE GNC 1 3,608.61$

02722665 HB TUBING, ASPIRATION 3,061.27$

02722666 HB MAX CANISTER 1 3,061.27$


02722668 HB VALVE, ROTATING HEMOSTATIC 328.79$

02722669 HB COMPRESSION WRAP 2,035.02$

02722676 HB REAMER, METATARSALPHALANGEAL 2,732.96$

02722677 HB SUCTION TOOL REMOVABLE SHEATH 37.39$

02722678 HB AUDITORY OSSEO, INTERNAL/EXTERNAL COMPONENTS L8690 614.39$

02722679 HB CORD, BIPOLAR HIGH FREQUENCY 2,173.41$

02722680 HB COMPRESSION APPARATUS 560.80$

02722681 HB CANNULA, EXTRACTION 795.09$

02722682 HB UNIVERSAL FILL KIT 254.23$

02722683 HB HANDPIECE, SURGICAL GUIDE 2,309.25$

02722684 HB CATHETER, DRAINAGE C1729 5,495.82$

02722685 HB CATHETER, RESTORATION 12,548.18$

02722686 HB FLIPCUTTER 2,821.44$

02722687 HB TISSUE HARVESTING SYSTEM 3,834.62$

02722688 HB SAFETY PEG KIT 1,171.45$

02722689 HB PROBE, PNEUMATIC 2,167.17$

02722690 HB TRACTION ROPE 67.30$

02722691 HB SEALANT HEMOSTATIC 1,282.36$

02722698 HB TITANIUM FASTENERS 2,993.41$

02722699 HB DV REPOSABLE RETRACTOR 2,240.70$

02722700 HB DV SCISSORS REPOSABLE 4,300.70$

02722701 HB PROBE, ULTRASOUND 4,202.25$

02722702 HB CARTRIDGE NEEDLE INJECTOR 2,112.34$


02722704 HB ENDOSCOPY BRAVO CAPSULE 2,295.53$

02722707 HB CAP, DISTAL ATTACHMENT 362.00$

02722708 HB DV CAUTERY SPATULA 1,965.47$

02722709 HB PRECISION INFLATION INJECTOR 1,350.60$

02722710 HB SPINE BALLOON 14,023.34$

02722711 HB BONEWAX 129.37$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722713 HB FIDUCIAL ECHO TIP NEEDLE 4,114.90$

02722714 HB PRESSURE MONITOR SET 1,293.69$

02722715 HB VOCAL INFUSION NEEDLE 1,965.47$

02722716 HB RET DEV, INSERTABLE C1773 10,146.60$

02722717 HB ABLATION CATHETER 14,367.13$


02722726 HB CHEST TUBE SILICONE CATHETER 238.22$

02722727 HB SILICONE BREAST DELIVERY SLEEVE 1,085.88$

02722728 HB RELOAD, ENDOSCOPIC 3,893.40$

02722729 HB KIT, INSERTION PACK 14,023.34$

02722730 HB KIT, DECOMPRESSION 14,883.23$

02722731 HB BOOT LINER DISPOSABLE 308.71$

02722734 HB PENILE ASSEMBLY SYSTEM 3,196.26$

02722736 HB CATHETER, ABLATION, NON-CARDIAC C1888 8,741.34$

02722737 HB FORCEPS, BIPOLAR 3,996.21$

02722738 HB CATHETER, ELECTROPHYSIOLOGY OTHR THAN COOL-TIPC1733 11,566.10$

02722739 HB VIRTUAL SURGICAL PLANNING SPLINT 6,988.32$

02722740 HB MANIFOLD FOUR PORT 362.00$


02722743 HB CANNULA, LACRIMAL 210.35$

02722745 HB EXTERNAL NEUROSTIMULATOR 3,332.75$

02722746 HB WIRE GUIDE LOCKING TOOL 236.19$

02722747 HB ENDOSCOPIC DOUBLE BALLOON PUMP 471.19$

02722748 HB CATHETER, ESOPHAGEAL 2,957.69$

02722749 HB TISSUE EXTACTION SYSTEM 1,623.65$

02722753 HB REZUM DEVICE KIT 7,223.95$

02722754 HB KIT, ANGEL SYSTEM PRP 2,820.02$

02722755 HB KIT, INTRAPERITONEAL HYPERTHERMIA 19,427.96$

02722756 HB PERFUSION OXYGENATOR 4,567.10$

02722758 HB CLIP, DISPOSABLE 2,497.19$

02722759 HB NEEDLE, INJECTION 744.18$

02722760 HB ASPIRATION TIP 3,825.30$

02722761 HB ILLUMINATOR 2,478.20$

02722762 HB FILTER GRAFT 2,754.74$

02722763 HB DRESSING ANTIMICROBIAL 405.91$

02722764 HB KIT, HAND CONTROLLER 453.39$

02722765 HB ZEPHYR DELIVERY CATHETER 4,016.80$

02722766 HB CHARTIS CATHETER 6,831.47$

02722769 HB FORCEP BIPOLAR TIPS 3,996.29$

02722770 HB PLATELET RECOVERY SYSTEM 2,820.43$

02722771 HB FORCEP BIOPSY INSERTABLE C1889 203.84$

02722772 HB LEAD EXTENDER 2,417.08$

02722773 HB INTRODUCER/SHEATH, LASER C2629 17,168.09$

02722774 HB INTRODUCER SHEATH PERITONEAL 1,725.44$

02722775 HB SEALANT, HEMOSTATIC 2,477.17$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722776 HB HEMOSTAT DELIVERY SYSTEM INSERTABLE C1889 9,429.07$

02722777 HB COIL COMPRESSION INSERTABLE C1889 1,965.88$

02722778 HB CANNULA, DRIVE SHAFT 1,034.65$

02722779 HB ADAPTER, CARIOPLEGIA CANNULAE 458.29$

02722780 HB CATHETER, PERITONEAL 4,116.57$

02722781 HB CANNULA, TRANSSEPTAL TANDEMHEART 22,957.73$

02722782 HB OXYGENATOR, TANDEMLUNG 19,428.37$

02722783 HB TUBING, ASPIRATION 1,724.36$

02722784 HB KNIFE, ELECTROSURGICAL 4,134.08$

02722785 HB SHEARS, THERMAL LIGATING 3,162.25$

02722786 HB KIT, TOTAL KNEE SURGICAL 3,982.61$

02722787 HB TOOL, DISSECTING 3,278.47$

02722788 HB CATHETER, VENTRICULAR 3,702.32$


02722790 HB PROBE, ENDOSCOPIC 3,939.13$

02722791 HB DRILL PIN HEADLESS 2,819.74$

02722792 HB STYLET, NAVIGATION 2,307.70$

02722793 HB RELOAD, ENDOSCOPIC 5,267.76$

02722794 HB CABLES, ELECTRODE STERILE 3,513.64$

02722795 HB ASPIRATOR, UTERINE 593.28$

02722796 HB ENDOSCOPE SHEATH DISPOSABLE A4270 507.16$

02722797 HB TUBE, TRACHEAL LASER 690.17$


02722799 HB CATHETER,THRMBCTMYEMBLCTMY C1757 29,255.70$

02722800 HB CARNATION PATCH 7-DAY 1,965.88$

02722802 HB DISPOSABLE TISSUE RESECTOR 4,007.49$

02722803 HB PACEMAKER SPLITTER KIT 22,382.93$

02722804 HB KIT, ARM SUPPORT 1,010.74$

02722805 HB CATHETER ERCP 612.59$

02722806 HB CABLE, MULTILEAD 3,330.69$

02722807 HB PROSTATE TEMPLATE 1,123.73$

02722808 HB NEEDLE, FLEXIGUIDE 629.80$

02722809 HB TUBING SET 2,819.73$

02722810 HB KIT, CEMENT MIXING 2,202.47$

02722811 HB VIRTUAL SURGICAL PLANNING SPLINT 6,986.00$

02722812 HB TUBING, IRRIGATION 2,209.32$

02722813 HB STONE CATCHER 1,090.37$

02722814 HB CATHETER, EP<19 ELECTRODES C1730 4,796.35$

02722815 HB WOUND RETRACTION SYSTEM SMALL 2,373.59$

02722816 HB WOUND RETRACTION SYSTEM MEDIUM 3,296.51$

02722817 HB BUTTON, TRACHEOSTOMY 103.88$

02722818 HB ADAPTER DRAPE SLEEVE 1,450.68$

02722819 HB EXTENSION CABLE 2,822.60$

02722820 HB PT/PRGMR, NEUROSTIMULATOR C1787 10,819.80$

02722821 HB CARTRIDGE, PUMP 1,353.34$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722822 HB COLLECTION SYSTEM FMS 1,284.90$

02722823 HB CATHWORKS FFR SYSTEM 5,109.15$

02722824 HB KNIFE, COLD WAVEFORM 1,655.30$

02722825 HB CABLE, NEUROSTIMULATOR 827.81$

02722826 HB NEEDLE, ASPIRATION 2,359.92$

02722827 HB DISSECTOR, ARTICULATING 10,092.18$

02722828 HB SEALANT HEMOSTATIC 1,138.16$

02722829 HB WIRE REUNION 580.94$

02722830 HB RETRACTOR, WOUND 1,929.23$

02722831 HB CAUTERY PENCIL 88.22$


02722833 HB CATHETER BILIARY DILATION 870.85$

02722834 HB CONNECTOR KIT 207.29$

02722835 HB KNIFE, COLD WAVEFORM 1,655.30$

02722836 HB CABLE, NEUROSTIMULATOR 827.81$

02722837 HB NEEDLE, ASPIRATION 2,359.92$

02722838 HB DISSECTOR, ARTICULATING 10,092.18$

02722839 HB PROBE, CRYOABLATION C2618 22,874.56$

02722840 HB CATHETER, INFUSION MIDLINE C1751 1,496.90$

02722841 HB PROLACTA READY TO FEED 2,249.17$

02722842 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 13,282.86$

02722843 HB TUBE MEDULLARY 897.75$

02722844 HB DUODENOSCOPE STERILE SINGLE USE 19,088.77$

02722845 HB PIN, FIXATION 1,382.31$

02722846 HB KNEE TRACKING SYSTEM 3,330.69$

02722847 HB CATHETER,THRMBCTMYEMBLCTMY C1757 23,545.49$




02722852 HB ANGIOVAC COMPLETE KIT 27,770.77$

02722853 HB LASER FIBER 9,059.76$

02722854 HB MANTA CLOSURE DEVICE 4,952.75$

02722855 HB TRAPPER EXCHANGE DEVICE 2,305.23$

02722856 HB RF WIRE GUIDE NYKANEN 6,203.98$

02722858 HB CARDIOHELP HLS SET 27,981.77$

02722859 HB COAGULATION GUIDED DEVICE 27,243.27$

02722860 HB BONE PLANER 1,806.17$

02722861 HB DV SUCTION IRRIGATOR 2,407.77$

02722862 HB PULMONARY EMBOLISM REMOVAL SYSTEM 24,605.77$

02722863 HB SCALPEL BONE 4,497.93$

02722864 HB PROTEK DUO KIT 24,078.27$

02722865 HB FAT TRANSFER SYSTEM 3,727.20$

02722866 HB CAUTERY PENCIL 88.22$

02722868 HB ACCESS DISPOSABLE INSTRUMENTS 11,075.44$

02722869 HB PROBE, CRYOABLATION C2618 22,874.56$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02722870 HB 4 CONTACT STRIP ELECTRODES 3,829.74$



02722873 HB 2 CONTACT DISPOSABLE CONNECTOR BLOCK 569.54$







02722880 HB PLACEMENT WRENCH BOLTS 7,196.48$

02722882 HB NEUROPROTECTION TRANSCAROTID SYSTEM 18,695.71$

02722883 HB LIGHT CABLE DISPOSABLE 1,956.57$

02722884 HB DELIVERY GRAFT TOOL 1,331.04$

02722885 HB TIP, STRAIGHT UNIVERSAL 4,275.21$

02722886 HB FLUID CONTROL SYSTEM 2,988.87$

02722887 HB PROBE, BIPOLAR 3,528.94$

02722888 HB KNIFE, DUAL ELECTROSURGICAL 4,131.63$

02722889 HB KNIFE, DUAL ELECTROSURGICAL 5,722.26$


02722891 HB SHOCKWAVE CATHETER 15,745.93$

02722892 HB DESTINO TWIST GUIDING SHEATH 4,101.55$

02740003 HB FLEX THERMOPLASTIC COLLAR MOLD L0130 1,269.53$

02740004 HB CERV COLLAR THERMOPL FOAM 2PC L0172 1,197.51$

02740005 HB CERV COLLAR SEMIRIG THERMO2PC L0174 2,047.74$

02740006 HB TLSO RIGID FRAME HYPEREX PRE L0472 2,757.42$

02740007 HB TLSO RIGID PLASTIC CUSTOM FAB L0484 8,145.86$

02740008 HB TLSO RIGIDLINED CUST FAB TWO L0486 8,653.06$

02740010 HB LO SAGITT RIGID PANEL PREFAB L0627 2,305.61$

02740011 HB SLO POST RIGID PANEL PREFAB L0630 1,238.02$

02740013 HB LSO FLEXION CONTROL PREFAB L0633 1,772.91$

02740015 HB SLO SAGIT RIGID PANEL PREFAB L0635 5,046.02$

02740016 HB LSO SAGITTAL RIGID PANEL CUST. L0636 7,596.00$

02740018 HB CTLSO A-P-L CONTROL MOLDED L0700 9,968.56$

02740019 HB HALO CERVICAL INTO JACKET VEST L0810 12,156.74$

02740021 HB MRI COMPATIBLE SYSTEM L0859 5,382.76$

02740023 HB TENSION BASED SCOLIOSIS ORTHO L1005 11,867.60$

02740026 HB POST-OP HIP ABDUCT CUSTOM FAB L1685 6,703.33$

02740027 HB KNEE ORTHOSES ELAS W STAYS A4466 694.51$

02740028 HB KO ELAS W CONDYLE PADS & JNTS L1820 1,193.42$

02740029 HB KO W ADJ FLEX/EXT ROTAT CUST L1845 3,878.14$

02740030 HB KO W ADJ FLEX/EXT ROTAT MOLD L1846 6,400.90$

02740031 HB AFT ANKLE GAUNTLET L1902 779.46$

02740032 HB AFO SNGL UPRIGHT W/ADJUST STOP L1920 2,040.77$

02740034 HB AFO POS SOLID ANK PLASTIC CUST L1960 3,578.23$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02740035 HB AFT DOUBLE SOLID STIRRUP CALF L1990 2,984.04$

02740036 HB KAFO FEMORAL FX CAST CUSTOM L2128 8,368.57$

02740037 HB VARUS/VALGUS STRAP PADDED L2270 651.40$

02740038 HB PRE-TIBIAL SHELL MOLDED L2340 2,990.59$

02740039 HB KNEE JOINT DROP LOCK EA JOINT L2405 776.42$

02740040 HB ADJ FLEX EXT HIP JNT CNTRL EA L2624 2,356.70$

02740041 HB SOFT INTERFACE ABOVE KNEE MOLD L2830 997.46$

02740042 HB TIB LENGTH SOCK, FX/EQUAL, EA L2840 471.34$

02740044 HB ABDUCT RESTRAINER CANVAS & WEB L3660 957.30$

02740045 HB EO MOTIONDOUBLE UPRIGHT CUSTOM L3720 4,013.43$

02740051 HB WHFO NONTORSION JOINT PREFAB L3931 1,479.23$

02740052 HB UPPER EXT FX ORTHOSIS HUMERAL L3980 2,200.08$

02740053 HB ANKLE CONTROL ORTHOSIS PREFAB L4350 958.15$

02740062 HB HM SYS CONTROLLER BTY Q0508 2,371.70$

02740066 HB STABILIZATION BELT Q0499 474.35$

02740070 HB HEARTMATE, SYS CONTROLLER HM11 Q0481 22,247.24$

02740072 HB HEARTMATE, POCKETPAK POUCH Q0508 1,042.99$

02740077 HB HMGG,UNVRSL BTTRY CHARGR Q0495 27,836.99$

02740078 HB HM GG SHOWER BAG Q0501 2,134.54$

02740079 HB HMGG HOLSTER VEST LARGE Q0498 1,784.42$

02740080 HB HMGG MODULAR BELT Q0499 1,636.48$

02740081 HB HMGG, CONSOLIDATED BAG Q0499 1,541.61$

02740084 HB HMGG, DISPLAY MODULE CABLE Q0486 1,897.35$

02740085 HB HMGG, POWER MODULE CABLE Q0508 4,506.23$

02740087 HB HMGG, SYSTEM DRIVER Q0481 22,247.24$

02740089 HB HM, BATTERY CLIP SET Q0497 5,217.75$

02740090 HB HM, UNVRSL BATTERY CHARGER Q0495 34,152.51$

02740111 HB BATTERY, LITHIUM-ION 14VL Q0506 11,858.52$

02740113 HB DRIVELINE MANAGEMENT SYSTEM Q0508 299.30$

02740114 HB HW, ADAPTER CONTROLLER DC Q0508 10,045.90$

02740115 HB HW, PATIENT PACK Q0498 3,181.46$

02740116 HB HW, BATTERY CHARGER Q0495 24,695.48$

02740117 HB HW, LITHIUM BATTERIES Q0506 5,068.01$

02740118 HB HW, KIT, PUMP IMPLANT Q0508 25,610.35$

02740119 HB HW, CONTROLLER KIT Q0508 25,283.20$

02740120 HB HW, SHOWER BAG Q0501 2,038.72$

02740122 HB HW, ADAPTER CONTROLLER DC* Q0508 10,045.90$

02740126 HB HW, CONTROLLER KIT* Q0508 21,426.44$

02740129 HB HM POCKET CONTROLLER BATTERY Q0506 2,371.70$

02740130 HB HM POCKET CONTROLLER Q0482 26,088.73$

02740131 HB HM PC WEAR ACCESSORY KIT Q0508 806.38$

02740132 HB HW CONTROLLER, AC ADAPTER Q0508 6,486.94$

02740133 HB HW PATIENT PACK Q0499 3,182.34$

02740134 HB HW BATTERY CHARGER Q0495 22,872.46$

02740135 HB HW BATTERY Q0506 5,068.31$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02740136 HB HW SHOWER BAG Q0501 2,406.20$

02740137 HB HW WAIST PACK Q0499 3,182.34$

02740138 HB HW SHOULDER PACK Q0508 3,337.57$

02740140 HB HEARTMATE, PCKT CONT HMII Q0481 26,508.27$

02740143 HB HEARTMATE II MPU Q0479 42,778.10$

02740144 HB HW, CONTROLLER KIT Q0508 19,549.61$

02740145 HB HM MOBILE POWER UNIT Q0479 20,510.03$

02740146 HB HM II BACKUP BATTERY Q0506 3,281.24$

02740147 HB HEARTMATE 3 LVAD MODULAR CABLE Q0508 50,923.20$

02750003 HB PACEMAKER DUAL CHMBR C1785 84,331.20$

02750009 HB PACEMAKER SINGLE CHMBR C1786 71,835.88$

02750011 HB PCMKR OTHER THAN SINGLE/DUAL C2621 122,422.16$

02750013 HB PACEMAKER, SINGLE CHAMBER 1 C1786 34,125.45$

02750014 HB PACEMAKER, DUAL CHAMBER 2 C1785 41,503.94$

02750022 HB PACEMAKER, OTHER THAN SINGLE / DUAL CHAMBER C2621 176,378.17$

02750025 HB PACEMAKER, DUAL CHAMBER C1785 42,173.63$

02760003 HB LENS INTRAOCULAR 2 C1780 1,191.77$

02760004 HB LENS INTRAOCULAR 1 C1780 712.52$



02780004 HB CARDIAC VALVE HUMAN TISSUE 15 78,025.53$


02780007 HB CARDIO VASCULAR ASSIST PUMP 356,892.85$

02780009 HB IMPLANT, CARDIAC PLEDGET 71.57$

02780013 HB ANCHOR BOLTS 307.11$

02780014 HB ORTHO CEMENTRALIZER 332.50$

02780016 HB KIT FRACTURE 361.01$

02780017 HB KIT, VARICEAL BANDING 1,614.03$

02780018 HB VESSEL GUARD 1 4,056.74$

02780025 HB CONNECTOR, CEREBRAL 1 587.61$

02780026 HB EXTERNAL FIXATION 8 C1713 4,898.18$

02780032 HB PEG, ORTHO 1 665.02$

02780033 HB FELT, SURGICAL 1 712.52$


02780037 HB EMBOLIC LIQUID SYSTEM GLUE 24,255.98$

02780039 HB MANDIBLE 4 24,700.63$

02780054 HB GRAFT 9 31,227.32$

02780055 HB LAP BAND SYSTEM 3 32,064.69$

02780056 HB CAGE, SPINE 20 32,405.36$

02780057 HB ANCHOR /SCREW 28 C1713 18,655.03$



02780069 HB CARDIAC GRAFT AORTIC VALVED CO 50,902.32$

02780075 HB CARDIAC BAND 11,400.30$

02780078 HB SPACER, SPINE 14 33,820.88$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780080 HB BMP SMALL 3 38,007.69$

02780081 HB CAGE, SPINE 19 34,647.41$

02780084 HB CAGE, SPINE 26 52,653.58$


02780087 HB DISC, CERVICAL SPINE 2 45,773.81$


02780092 HB SPACER, SPINE 20 49,828.80$

02780099 HB SUPPORT BAR PECTUS 8,084.71$

02780100 HB PLATE 5 8,127.47$

02780107 HB GRAFT 2 8,540.70$

02780117 HB BONE GRAFT 2 9,234.24$

02780118 HB GRIP CABLE 2 9,329.23$

02780121 HB COIL, EMBOLIZATION 1 15,203.08$

02780134 HB CONNECTOR, SPINE 7 11,791.51$

02780135 HB NAIL, ORTHO 2 11,818.33$

02780138 HB CARDIAC RING ANNULOPLASTY 2 12,701.85$




02780154 HB SPACER, SPINE 8 18,620.48$

02780155 HB STRUT, SPINE PSR 2 18,627.89$

02780157 HB VALVE, NEURO 1 20,509.71$

02780160 HB LEAD 4 20,900.54$

02780161 HB VALVE 3 21,126.97$

02780163 HB WASHER, SPINE 1 1,159.05$

02780164 HB EMBOLIC SPHERES 1,761.62$

02780168 HB SHEET, MEDPOR 4 5,690.28$

02780171 HB BAND 4,161.11$

02780172 HB CROSSLINK, SPINE 1 3,027.73$

02780173 HB SHUNT 4 7,780.72$

02780175 HB VALVE 2 8,247.67$


02780183 HB LINER, ORTHO 5 20,900.54$

02780189 HB SEALANT 3 4,212.69$

02780193 HB GRAFT, DURAGEN 3 4,518.79$

02780203 HB SPHERE EYE PLASTIC 2 5,700.12$

02780205 HB BONE FILLER 2 5,941.64$

02780208 HB PLATE 4 5,296.85$

02780215 HB LINER, ORTHO 2 7,495.21$

02780216 HB BLOCK CARVING TESTICULAR IMP 7,552.68$

02780217 HB TESTICULAR PROSTHESIS 1 7,552.68$


02780227 HB COIL, HILAL .018 842.39$

02780228 HB EXTERNAL FIXATION 2 C1713 867.73$

02780233 HB CLIP, LIGATION-RESOLUTION 1,475.68$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780234 HB PLATE 1 958.66$

02780235 HB SHUNT 1 988.00$

02780237 HB EMOBOLIZATION COIL IMPLNT 1,060.38$

02780238 HB BLOCKER 1,073.55$

02780241 HB CEMENT RESTRICTOR 1,187.54$

02780244 HB PLUG, SPINE 1 1,225.52$

02780249 HB RESERVOIR, NEURO 1 1,330.05$


02780254 HB SEAMGUARD BIOAB 1,548.54$

02780255 HB ISOTOPE, MICROSPHERES LC BEADS 15,156.32$

02780256 HB CEMENT, SPINE 1,653.34$


02780265 HB GASTROSTOMY G-J TUBE 2,440.89$

02780266 HB NEEDLE, FIX SYSTEM 1 2,471.81$

02780267 HB KIT, NEPHROSTOMY 23-510-11 2,713.34$

02780269 HB CLIP, LIGATION-QUICK 747.07$

02780270 HB ORTHO CABLE 2 2,865.87$

02780273 HB BONE FILLER 1 3,040.75$

02780275 HB GRIP CABLE 1 3,144.59$

02780276 HB FIBRIN GLUE INJ KIT C9250 3,255.47$

02780278 HB SHEET, MEDPOR 2 3,495.76$

02780279 HB ORTHO BONE GRAFT SUBSTITUTE 1 3,325.11$

02780282 HB PATCH 1 3,510.38$


02780293 HB NEURO CATH KIT 3,750.69$



02780303 HB VENA CAVA FILTER 1 C1880 9,045.81$

02780304 HB VENA CAVA FILTER IMPLANT C1880 10,274.75$

02780310 HB SPACER 3 1,493.94$

02780317 HB HOOK, SPINE 3 6,799.99$

02780322 HB AUDITORY IMPLANT 2 2,724.21$

02780323 HB IMPLANT, ELASTOMERIC TUBING 661.30$

02780326 HB PLATE 2 3,023.79$

02780330 HB PROSTHESIS ENT 2,802.57$

02780335 HB NEURO BAR 228.00$

02780338 HB SPACER 8 9,280.65$

02780339 HB SPACER, SPINE 12 25,184.30$

02780347 HB SPINE SET SCREW 1,164.74$

02780350 HB PC BRONCHIAL STENT C1874 6,242.79$

02780352 HB BEARING, KNEE 1 5,799.68$

02780356 HB IMPLANT, POUCH PAIN PUMP 792.09$

02780357 HB CONNECTOR, SPINE 1 209.00$

02780359 HB CLIP, ANEURYSM 1 2,297.05$

02780363 HB SPACER, SPINE 5 8,540.70$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780366 HB SPINE PEEK 4 25,650.66$

02780370 HB CAP FIXATION PROTECTION PIN 265.99$

02780372 HB SHEET, MEDPOR 1 2,750.92$

02780375 HB LINER, ORTHO 3 9,134.39$

02780380 HB COIL, MWCE 0.35 447.13$

02780381 HB CEMENT, BONE KYPHON 2,148.73$

02780382 HB SPACER , SPINE 1 4,455.61$

02780391 HB TUBE,EAR PRESSURE EQUALIZING 1 105.88$

02780400 HB ROD 1 1,014.03$


02780404 HB COVER, BUR HOLE 1 1,007.05$

02780405 HB CROSSCONNECTOR, 1 4,720.50$

02780409 HB PROSTHESIS, EYELID 1 560.50$

02780415 HB GRAFT, DURAGEN 1 1,248.23$

02780416 HB GRAFT, DURAGEN 2 2,486.79$

02780417 HB GRAFT, DURAGEN 4 8,050.59$

02780430 HB ANCHOR /SCREW 21 C1713 13,775.36$

02780434 HB ANCHOR /SCREW 4 C1713 2,365.84$

02780437 HB ANCHOR /SCREW 20 C1713 13,649.85$

02780440 HB ANCHOR /SCREW 12 C1713 7,848.41$

02780443 HB ANCHOR /SCREW 18 C1713 10,564.28$

02780449 HB ANCHOR /SCREW 22 C1713 16,046.55$

02780454 HB ROD 2 2,289.57$

02780457 HB ANCHOR /SCREW 2 C1713 1,069.77$

02780464 HB ROD, SPINE 2 2,752.34$

02780466 HB ANCHOR /SCREW 9 C1713 5,811.73$

02780473 HB ANCHOR /SCREW 34 C1713 25,691.88$

02780475 HB ANCHOR /SCREW 15 C1713 10,049.67$

02780476 HB ANCHOR /SCREW 29 C1713 19,950.51$

02780477 HB ANCHOR /SCREW 41 C1713 32,576.34$

02780480 HB ANCHOR /SCREW 37 C1713 28,132.45$

02780482 HB ANCHOR /SCREW 25 C1713 15,200.40$

02780494 HB CATHETER, INFUSION/NON-HEMO 2 C1751 1,443.69$

02780498 HB COIL, NESTOR 1,475.40$

02780500 HB ANCHOR /SCREW 33 C1713 22,704.38$

02780501 HB ANCHOR /SCREW 30 C1713 20,372.47$

02780505 HB CATHETER, INTRASPINAL 1 C1755 913.01$

02780510 HB CLOSURE DEVICE, VASC PLUG C1760 2,642.78$

02780511 HB HUMAN TISSUE 1 C1762 1,282.53$

02780513 HB HUMAN TISSUE 43 C1762 91,682.43$

02780514 HB HUMAN TISSUE 5 C1762 9,401.63$

02780515 HB HUMAN TISSUE 6 C1762 9,970.53$

02780516 HB HUMAN TISSUE 15 C1762 23,969.13$

02780517 HB HUMAN TISSUE 11 C1762 16,625.46$

02780519 HB HUMAN TISSUE 13 C1762 20,078.76$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780520 HB HUMAN TISSUE 2 C1762 2,667.99$

02780521 HB HUMAN TISSUE 3 C1762 4,835.62$

02780522 HB HUMAN TISSUE 26 C1762 43,007.62$

02780523 HB BONE CEMENT 4 4,959.14$

02780525 HB ROD 3 5,025.63$

02780527 HB HUMAN TISSUE 20 C1762 34,979.91$

02780529 HB HUMAN TISSUE 4 C1762 7,148.94$

02780530 HB HUMAN TISSUE 18 C1762 29,621.78$

02780532 HB HUMAN TISSUE 7 C1762 11,931.25$

02780533 HB HUMAN TISSUE 14 C1762 28,760.36$

02780535 HB HUMAN TISSUE 14 C1762 19,402.68$

02780536 HB ROD, SPINE 4 5,985.15$

02780538 HB GRAFT SYNTHETIC TISSUE 3 C1763 5,776.15$





02780544 HB CATHETER, MAHURKAR C1752 922.26$

02780548 HB GENERATOR, NEUROSTIMULATOR 3 C1767 85,206.13$

02780550 HB GENERATOR, NEUROSTIMULATOR 5 C1767 107,468.95$

02780552 HB GENERATOR, NEUROSTIMULATOR13 C1767 137,447.25$

02780554 HB GRAFT VASCULAR 8 C1768 14,107.85$




02780559 HB ROD, SPINE 5 7,609.72$








02780572 HB REP DEV URINARY W/SLING 3 C1771 8,550.24$


02780576 HB PUMP INFUSION 1 C1772 85,502.24$

02780581 HB JOINT DEVICE 23 C1776 18,371.24$

02780582 HB JOINT DEVICE 14 C1776 11,026.86$

02780584 HB JOINT DEVICE 40 C1776 33,378.88$

02780585 HB JOINT DEVICE 21 C1776 16,787.16$

02780587 HB JOINT DEVICE 5 C1776 3,524.50$

02780588 HB JOINT DEVICE 8 C1776 6,614.06$

02780589 HB JOINT DEVICE 25 C1776 20,356.49$

02780590 HB JOINT DEVICE 30 C1776 22,088.08$

02780594 HB JOINT DEVICE 9 C1776 7,101.18$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780595 HB JOINT DEVICE 27 C1776 21,621.70$

02780598 HB INSERT, ORTHO 4 C1776 9,999.51$

02780599 HB SPINE ASSEMBLY 1 C1776 2,280.06$

02780600 HB JOINT DEVICE 18 C1776 13,793.86$

02780602 HB JOINT DEVICE 6 C1776 4,577.38$

02780603 HB BONE CEMENT 6 9,201.69$

02780604 HB JOINT DEVICE 16 C1776 12,693.23$

02780606 HB JOINT DEVICE 48 C1776 35,958.44$

02780607 HB JOINT DEVICE 32 C1776 26,487.09$

02780608 HB JOINT DEVICE 74 C1776 64,628.85$

02780609 HB JOINT DEVICE 73 C1776 62,699.15$

02780611 HB JOINT DEVICE 19 C1776 13,296.57$

02780612 HB JOINT DEVICE 80 C1776 73,626.93$

02780615 HB JOINT DEVICE 11 C1776 9,031.33$

02780616 HB JOINT DEVICE 13 C1776 9,699.93$

02780618 HB JOINT DEVICE 22 C1776 14,826.43$

02780620 HB JOINT DEVICE 29 C1776 23,164.64$

02780621 HB JOINT DEVICE 31 C1776 23,199.64$

02780622 HB JOINT DEVICE 7 C1776 4,984.78$

02780623 HB ORTHO FEMORAL 3 C1776 16,102.92$

02780624 HB JOINT DEVICE 1 C1776 942.73$

02780627 HB JOINT DEVICE 81 C1776 76,619.49$

02780628 HB INSERT, ORTHO 2 C1776 6,317.68$

02780629 HB JOINT DEVICE 76 C1776 66,644.88$

02780632 HB CATHETER, DIALYSIS, SHORT TERM C1752 918.60$

02780634 HB CATHETER, MAHURKAR C1752 935.44$

02780635 HB LEAD, NEUROSTIMULATOR 15 C1778 33,862.09$




02780642 HB D STAT FLOWABLE HEMOSTAT C1760 2,353.58$

02780643 HB CLOSURE HEMOSTASIS DEVICE C1760 1,906.50$

02780644 HB CLOSURE DEVICE VASCULAR C1760 3,270.83$

02780647 HB MESH 7 C1781 7,948.53$

02780648 HB MESH 13 C1781 16,119.53$

02780649 HB MESH 9 C1781 10,661.17$

02780653 HB MESH 10 C1781 12,085.88$

02780654 HB MESH 14 C1781 17,470.95$

02780657 HB MESH 4 C1781 2,592.97$

02780658 HB MESH 5 C1781 4,424.41$

02780660 HB MESH 15 C1781 19,185.79$

02780661 HB MESH 1 C1781 828.63$

02780662 HB MESH 6 C1781 6,480.75$


02780675 HB PROSTHESIS BREAST IMP 8 C1789 10,375.29$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price







02780686 HB PROSTHESIS, PENILE INFLATABLE 2 C1813 12,088.45$

02780687 HB BONE CEMENT 10 23,037.49$

02780688 HB PROSTHESIS, URINARY SPHINCTER 2 C1815 27,888.79$

02780689 HB LOOP RECRDR CARDIAC IMPLANT C1764 25,106.67$

02780690 HB NEUROSTIMULATOR, RECHARGEABLE 7 C1820 135,613.59$

02780691 HB NEUROSTIMULATOR, RECHARGEABLE 2 C1820 111,737.94$

02780696 HB JOINT DEVICE 86 C1776 85,581.22$

02780697 HB STENT, COATED/COV W/DEL SYSTEM 14 C1874 32,646.33$

02780698 HB JOINT DEVICE 83 C1776 74,594.55$



02780704 HB STENT, COATED/COV W/DEL SYS 15 C1874 49,724.56$



02780709 HB BONE CEMENT 11 27,353.32$

02780710 HB LEAD PCMKR TRANSVN SNGL PASS C1779 9,555.31$

02780712 HB PORT, INDWELLING (IMPLANTABLE) C1788 2,056.46$


02780714 HB PORT, INDWELLING 2 C1788 2,702.93$

02780715 HB SEPTAL DEFECT CLOSE IMPLANT C1817 109,097.18$

02780716 HB IMPLANT, INTRASPINOUS X-STOP C1821 41,041.06$

02780717 HB STENT, COATED/COV W DEL SYS 3 C1874 17,273.18$

02780718 HB STENT, NON/COATED W/DEL SYS 2 C1876 15,454.56$

02780719 HB STENT, WINGSPAN C1874 27,538.39$

02780723 HB STENT COATED W/ DELIVERY C1874 31,903.53$


02780726 HB STENT, NON/COATED W/DEL SYS 1 C1876 9,815.12$

02780727 HB STENT, NEUROFORM C1876 22,954.00$

02780728 HB STENT, NON/COATED W/O DEL SYS C1877 16,104.28$



02780735 HB ADAPTER/LEAD IMPLANTABLE 6 C1883 7,930.87$


02780742 HB LEAD, AICD, NON SNGL/DUAL 1 C1896 8,861.13$

02780744 HB LEAD, NEUROSTIM KIT 2 C1778 4,478.69$

02780750 HB LEAD, PACEMAKER 1 C1898 5,596.50$

02780753 HB LEAD, PACEMAKER 2 C1898 10,165.28$

02780755 HB CAROTID STENT SYSTEM C1876 18,321.90$

02780757 HB STENT, NON-COR, TEM, W/O DEL 4 C2617 3,040.07$

02780758 HB STENT, NON-COA/NON-COV W/DEL C1876 21,214.00$

02780763 HB STENT, NON-COR, TEM, W/O DEL 2 C2617 627.03$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780765 HB STENT, NON-COR,TEM, W/DEL 1 C2625 8,207.25$

02780767 HB STENT, NON-COATED W DEL SYS 3 C1876 16,409.53$

02780771 HB STENT,ENT DUOD CLN WALLFLX I C1876 23,011.62$




02780775 HB STENT, BIL/PAN NON-METAL C1877 750.73$

02780778 HB VENA CAVA FILTER, IVC C1880 6,486.91$

02780779 HB LEAD ICD ENDOCARD COIL C1895 70,857.15$

02780781 HB LEAD PCMKR OTHER THAN VDD C1898 5,993.59$

02780783 HB LEAD BI-V LEFT VENTRCULAR C1900 38,077.75$

02780784 HB STENT, URETERAL C2617 1,399.07$

02780785 HB STENT, URETERAL 90-3390-91 C2617 2,261.16$

02780788 HB NERVE GUIDE 1 C9352 9,025.24$

02780792 HB CHIN IMPLANT 1 2,470.36$

02780795 HB JOINT DEVICE 60 C1776 45,444.93$

02780796 HB JOINT DEVICE 70 C1776 58,570.33$

02780800 HB AUDITORY, OSSEO DEVICE 1 L8690 27,639.85$

02780805 HB VALVE 4 22,418.58$

02780807 HB HEARTMATE II, IMPLANT KIT 617,093.26$

02780809 HB HEARTMATE, RING APICAL SEWING 5,826.28$



02780819 HB JOINT DEVICE 89 C1776 87,862.33$

02780825 HB CATHETER, IMPELLA 233,471.50$

02780846 HB CONTRALATERAL LIMB 2 37,475.51$

02780847 HB PROSTHESIS, EYELID 2 2,191.13$

02780848 HB STENT, GRAFT BIFURCATED 25 82,230.39$

02780850 HB CEMENT,HYDROSET INJECTABLE 5CC 6,991.55$

02780852 HB EXTNSN, AORTIC/ILIAC/THORACIC3 37,893.63$

02780855 HB CEMENT,HYDROSETINJECTABLE 10CC 13,041.71$

02780856 HB VALVE, NEURO 4 33,647.67$



02780866 HB CATHETER, DIALYSIS, LONG-TERM C1750 4,148.31$

02780869 HB HUMAN TISSUE 8 C1762 12,869.31$

02780874 HB NERVE GUIDE 2 C9352 9,657.90$

02780875 HB RT BRACYTX SOURCE, HDR IR-192 C1717 1,719.57$

02780876 HB ICD DUAL CHAMBER C1721 286,080.65$

02780877 HB ICD SINGLE CHAMBER C1722 243,315.71$

02780878 HB ICD OTHER THAN SINGLE/DUAL C1882 306,071.77$

02780885 HB SPINE COUGAR 22,619.63$

02780886 HB DISC, CERVICAL SPINE 1 C1889 43,274.25$

02780896 HB JOINT DEVICE 72 C1776 61,543.71$

02780900 HB COIL, MICRO DETACHABLE 3,089.84$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02780902 HB BONE CEMENT 1 822.90$

02780905 HB STENT, COATED/COV W/DEL SYS 17 C1874 53,686.56$

02780906 HB TUBE, JONES 1 438.68$


02780916 HB HUMAN TISSUE 9 C1762 14,515.41$



02780920 HB VENA CAVA FILTER 2 C1880 6,178.01$

02780924 HB ANCHOR LEAD 1 391.28$






02780933 HB KIT, PUMP INFUSION 1,282.84$


02780935 HB SHEET, MEDPOR 3 4,448.05$

02780936 HB SUBDURAL ELECTRODE 2 3,565.57$

02780940 HB EYE SPHERE W/CONFORMER 591.13$

02780941 HB VALVE, ENDOBRACHIAL 1 23,518.88$

02780943 HB COVER, BUR HOLE 2 2,993.32$

02780944 HB JOINT DEVICE 75 C1776 60,618.80$

02780945 HB COUPLER 1 1,710.47$

02780948 HB BMP SMALL 3 29,513.91$

02780949 HB BMP MEDIUM 4 41,845.60$

02780950 HB BMP LARGE 5 46,251.72$

02780951 HB BMP X-LARGE 6 46,251.72$


02780960 HB LEAD, AICD ENDO SINGLE COIL 2 C1777 46,115.47$



02780975 HB SPACER, SPINE 13 25,656.96$



02780986 HB INTRAUTERINE DEVICE (IUD) 1 3,615.89$




02780999 HB JOINT DEVICE 69 C1776 60,555.15$




02781003 HB CATHETER,IMPLNTBLTOTALACCSS A4301 2,406.38$

02781004 HB NASAL SEPTAL PROSTHESIS D5922 1,456.84$

02781005 HB BONE CEMENT 3 3,060.40$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781006 HB BONE CEMENT 5 7,774.65$

02781007 HB BONE CEMENT 8 14,941.41$

02781008 HB SHUNT 5 12,266.71$

02781012 HB DEFLUX INJECTION 1ML L8604 16,685.43$

02781014 HB SYNTHETIC IMPLANT URINARY 1 L8606 1,825.74$

02781016 HB SPHERE EYE PLASTIC 1 157.22$

02781020 HB SUBDURAL ELECTRODE 3 6,290.56$

02781021 HB CAGE, SPINE 27 53,041.18$


02781031 HB SPACER, SPINE 2 5,072.71$

02781032 HB CATHETER, MAHURKAR (CL) C1752 1,187.43$

02781033 HB SHEET, SILASTIC 1 238.96$

02781034 HB SHEET, SILASTIC 2 1,087.92$

02781036 HB STENT, SELF RETAINING 607.88$


02781044 HB CATHETER,HMDYLS,SHRT TERM C1752 710.58$

02781045 HB LAP BAND, PORT ONLY 2 7,885.75$



02781059 HB CANNULA, ATRIAL PVAD 18,446.18$

02781060 HB CANNULA, VENTRICULAR PVAD 1 12,912.32$

02781061 HB CARD DEFIB SINGLE CHAMBER 1 C1722 99,322.64$


02781066 HB CROSSLINK, SPINE 2 4,309.86$

02781067 HB PALATE, SOFT TISSUE 1 C9727 5,161.10$


02781069 HB ANCHOR LEAD 2 1,292.97$

02781079 HB PROSTHESIS BREAST IMP 1 C1789 229.50$



02781083 HB CATHETER, BRACHY SEED ADMIN 2 C1728 21,549.29$

02781088 HB ANCHOR /SCREW 42 C1713 34,478.87$

02781089 HB JOINT DEVICE 41 C1776 28,703.66$

02781090 HB JOINT DEVICE 42 C1776 29,471.59$

02781091 HB JOINT DEVICE 43 C1776 30,247.37$

02781092 HB JOINT DEVICE 44 C1776 31,117.15$

02781093 HB JOINT DEVICE 45 C1776 31,806.76$

02781095 HB SEALANT 5 7,481.52$

02781096 HB IMPLANT TISS MARKER CALYPSO BEACON A4648 10,343.64$

02781097 HB MEMBRANE, COLLAGEN 1 861.97$

02781098 HB PROSTHESIS, URINARY SPHINCTER 1 C1815 14,937.57$


02781102 HB PROSTHESIS, PENILE NONINFLATABLE 3 C2622 44,563.94$

02781106 HB FELT, SURGICAL 2 973.63$



Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781110 HB SPACER, SPINE 19 44,665.79$

02781112 HB HUMAN TISSUE ALLODERM 16X20 Q4116 250.77$

02781122 HB HUMAN TISSUE ALLODERM 6 X16 Q4116 252.75$

02781126 HB CANNULA, ARTERIAL PVAD 1 20,687.33$

02781127 HB STENT,NON/COATED W/DELSYS 3 C1876 18,532.40$

02781131 HB JOINT DEVICE 46 C1776 32,435.58$

02781132 HB JOINT DEVICE 47 C1776 33,236.85$

02781133 HB JOINT DEVICE 50 C1776 35,427.03$

02781135 HB SPACER 1 577.91$

02781136 HB SPACER, SPINE 4 6,033.81$

02781137 HB JOINT DEVICE 52 C1776 36,210.65$

02781138 HB JOINT DEVICE 53 C1776 36,727.83$


02781143 HB SPACER, SPINE 11 22,101.73$

02781144 HB SPINE PEEK 5 25,859.16$

02781145 HB GRAFT VASCULAR C1768 20,459.35$

02781146 HB TRANSCONNETOR, SPINE 2 4,309.86$

02781148 HB PLUG, VASCULAR 2 6,895.78$

02781149 HB JOINT DEVICE 87 C1776 82,447.57$

02781150 HB CAGE, SPINE 1 2,758.32$

02781151 HB CAGE, SPINE 3 7,146.54$

02781152 HB CAGE, SPINE 4 7,740.12$

02781154 HB CAGE, SPINE 6 13,127.44$

02781155 HB CAGE, SPINE 7 15,015.94$

02781156 HB CAGE, SPINE 8 16,894.64$

02781157 HB CAGE, SPINE 9 18,093.59$

02781158 HB CAGE, SPINE 11 19,045.47$

02781159 HB CAGE, SPINE 12 21,574.76$

02781160 HB CAGE, SPINE 13 23,255.61$

02781161 HB CAGE, SPINE 15 25,859.16$

02781162 HB CAGE, SPINE 16 28,333.40$

02781163 HB CAGE, SPINE 17 29,410.87$

02781164 HB CAGE, SPINE 18 30,927.14$

02781165 HB CAGE, SPINE 21 35,452.50$

02781166 HB CAGE, SPINE 22 39,650.69$

02781167 HB CAGE, SPINE 23 51,431.25$

02781169 HB CAGE, SPINE 25 54,990.29$

02781170 HB CAGE, SPINE 28 51,046.34$

02781172 HB CAGE, SPINE 30 58,966.69$

02781176 HB KIT, PENILE PROSTHESIS 1 3,861.25$

02781179 HB STENT,NON-COR,TEM,W/O DEL3 C2617 999.10$



02781182 HB JOINT DEVICE 34 C1776 23,704.23$

02781183 HB JOINT DEVICE 35 C1776 24,368.33$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781184 HB JOINT DEVICE 36 C1776 25,402.70$

02781185 HB JOINT DEVICE 37 C1776 25,729.85$

02781186 HB JOINT DEVICE 38 C1776 26,721.12$

02781190 HB HUMAN TISSUE GRFT JCKT 4X7 Q4107 766.54$

02781192 HB HUMAN TISSUE GRFT JCKT 5X10 Q4107 342.72$

02781195 HB SEALANT 1 1,939.44$

02781196 HB SEALANT 2 2,965.95$

02781197 HB SEALANT 4 4,740.84$


02781201 HB MESH 11 C1781 12,222.35$

02781202 HB STENT, NON-COA/COV W/O DEL C1877 11,636.62$

02781203 HB LEAD ICD ENDOCARD DUAL COIL C1777 59,061.48$

02781207 HB LEAD, NEUROSTIMULATOR 1 C1778 991.28$

02781211 HB JOINT DEVICE 55 C1776 38,297.00$

02781212 HB JOINT DEVICE 40 C1776 38,925.85$

02781213 HB JOINT DEVICE 57 C1776 40,142.41$

02781215 HB JOINT DEVICE 58 C1776 41,080.78$

02781216 HB JOINT DEVICE 61 C1776 43,443.38$

02781217 HB JOINT DEVICE 62 C1776 44,168.20$

02781218 HB JOINT DEVICE 63 C1776 54,383.40$

02781219 HB JOINT DEVICE 64 C1776 46,546.45$

02781220 HB JOINT DEVICE 65 C1776 47,271.31$

02781222 HB VALVE, NEURO 4 24,436.90$

02781223 HB VALVE, NEURO 7 33,393.57$

02781224 HB CLIP, ANEURYSM 2 3,181.46$

02781225 HB SPACER, SPINE 7 15,480.22$

02781228 HB RESERVOIR, NEURO 2 2,370.42$


02781233 HB JOINT DEVICE 66 C1776 47,917.77$

02781234 HB JOINT DEVICE 68 C1776 49,520.28$

02781236 HB SPACER, SPINE 10 19,204.32$


02781241 HB MESH 20 C1781 48,701.40$


02781245 HB GRAFT 13 86,154.06$

02781246 HB GRAFT 15 92,256.42$

02781247 HB HUMAN TISSUE 23 C1762 35,340.84$

02781250 HB COLLAGEN IMPLANT 2 5,258.03$

02781255 HB STENT, ESOPH COV/ W/DEL C1874 18,307.84$

02781256 HB STENT,ENT DUOD CLNWALLFLXII C1876 22,089.32$

02781257 HB STENT,BIL WALLFLEX COVERED C1874 22,596.59$

02781258 HB STENT, WALLFLEX N-COV W/DEL C1876 15,218.11$

02781259 HB STENT,WALLFLEX PT/COV W/DEL C1874 21,940.49$

02781260 HB STENT, ENTERAL NG C1876 15,771.48$

02781261 HB STENT, SOLUS C1877 1,370.92$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781262 HB STENT,BILIARY MTL HLS W/DEL C1874 37,679.36$

02781263 HB OTSC FISTULA CLOSURE 200.40 4,233.39$

02781264 HB KIT, CAGE INTERLOCK 1 21,541.45$





02781275 HB SPACER, SPINE 17 40,758.95$

02781277 HB PROSTHESIS, PENILE INFLATABLE 3 12,678.81$

02781278 HB STENT, GRAFT CONVERTER 1 74,776.03$

02781279 HB STENT, GRAFT THORACIC 10 128,547.38$

02781280 HB JOINT DEVICE 71 C1776 55,977.20$


02781283 HB CONNECTOR, CEREBRAL 2 1,861.08$



02781289 HB GENERATOR,NEUROSTIMULATOR12 C1767 124,483.23$

02781290 HB EMBOLIZATION DEVICE, PIPELINE 91,682.43$

02781292 HB JOINT DEVICE 78 C1776 64,052.32$

02781293 HB STENT,NON/COATED W/DELSYS 2 C1876 12,179.27$

02781294 HB MESH 12 C1781 13,188.16$







02781304 HB STENT,COATED/COV W/DELSYS21 C1874 68,724.61$

02781305 HB TRANSCATHETER, PULMONIC VLV 159,856.54$


02781310 HB CATHETER, BRACHY SEED ADMIN 1 C1728 1,065.71$





02781331 HB ANCHOR /SCREW 35 C1713 24,135.19$



02781335 HB ANCHOR /SCREW 39 C1713 30,850.75$

02781336 HB ANCHOR /SCREW 40 C1713 32,116.27$

02781337 HB ANCHOR /SCREW 43 C1713 42,585.08$

02781338 HB CAGE, SPINE 2 5,818.33$

02781341 HB WIRE, SUR TISSUE LOC DEVICE C1819 181.02$

02781342 HB TISSUE MARKER, CLIP/WIRE A4648 646.48$

02781352 HB VASCULAR PLUG AMPLATZ 6,895.78$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781353 HB SAPIEN AORTIC VALVE 23/26MM 354,500.76$




02781363 HB MARKER, VISICOIL / NITINOL FIDUCIAL 1,120.57$

02781364 HB ADHESION BARRIER 1 C1765 2,309.69$

02781365 HB ADHESION BARRIER 2 C1765 5,430.40$

02781367 HB TOTAL ARTIFICIAL HEART 846,906.54$

02781368 HB NEEDLE, FIX SYSTEM 2 4,058.16$

02781376 HB MARKER, FIDUCIAL GOLD IZI 166.01$

02781380 HB ALLOGRAFT FLEXHD 4X12CM 0.8 Q4128 226.28$

02781382 HB ALLOGRAFT FLEXHD 4X7CM Q4128 230.59$





02781390 HB ALLOGRAFT FLEXHD 8X16CM* Q4128 238.09$






02781400 HB STENT, ESOPHAGEAL COVERED C1874 18,963.39$

02781403 HB CATHETER, IMPELLA 5.0 233,471.50$

02781404 HB FLOSEAL MM 1,399.10$

02781407 HB CLIP, HEMOSTASIS 1,388.64$

02781409 HB CARD/DEFI,OTHR THNSIN/DUAL1 C1882 146,535.15$






02781427 HB FIDUCIAL MARKERS CIVCO 1,288.08$

02781428 HB ADHESION BARRIERS SEPRAFILM C1765 2,232.52$

02781429 HB SPACER, SPINE 9 20,687.33$

02781433 HB COIL, EMBOLIZATION 1,405.14$

02781435 HB STENT, DUODENAL EVOLUTION C1876 17,529.10$

02781436 HB LEAD, AICD ENDO SINGLECOIL 1 C1777 34,531.99$

02781437 HB NASAL/FACIAL PROSTHESIS 1 L8048 8,417.17$

02781439 HB CAGE, SPINE 10 18,129.29$


02781441 HB ELECTRODE, NEUROSTIM IMPL1 C1778 25,078.87$

02781442 HB ELECTRODE, NEUROSTIM IMPL2 C1778 25,898.99$

02781443 HB KIT, XLIF 1 27,772.88$

02781444 HB KIT, XLIF 2 44,891.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781445 HB KIT, XLIF 3 65,610.78$

02781446 HB KIT, XLIF 4 86,329.97$


02781453 HB LEAD, CORONARY VENOUS 2 C1900 16,402.69$

02781455 HB CARDIO DEFIB DUAL CHAMBER 1 C1721 129,826.99$

02781458 HB LEAD, AICD ENDO COIL 2 C1895 34,531.99$





02781465 HB KIT, NEURX DIAPHRAGM 1 141,116.30$

02781466 HB G-TUBE REPLACEMNT ENDOVIVE 524.97$

02781467 HB CLIP, ENDO CLOSURE DEVICE 4,135.21$

02781469 HB STENT, COLONIC WALLSTENT C1874 20,676.03$

02781470 HB MITRAL CLIP IMPLANT 290,392.04$

02781473 HB CLIP, LAPAROSCOPIC 1 690.65$

02781476 HB KIT, ALIF LEVEL 2* 68,977.63$

02781477 HB KIT, ALIF LEVEL 3* 83,929.32$


02781485 HB HUMAN TISSUE 17 C1762 25,898.99$

02781486 HB HUMAN TISSUE 19 C1762 28,057.25$

02781487 HB HUMAN TISSUE 21 C1762 32,856.87$

02781488 HB HUMAN TISSUE 24 C1762 36,258.60$

02781490 HB HUMAN TISSUE 30 C1762 47,559.51$

02781491 HB LAP BAND SYSTEM 1* 21,340.10$

02781493 HB SPACER, SPINE 3 5,784.11$

02781494 HB SPACER, SPINE 6 13,537.19$

02781496 HB HUMAN TISSUE 35 C1762 63,668.35$

02781498 HB VALVE 3* 9,504.60$

02781499 HB BONE CEMENT 2* 2,046.40$

02781501 HB CATHETER, INTRASPINAL 4 C1755 8,546.68$

02781502 HB VALVE, NEURO 5 26,287.48$

02781503 HB BONE FILLER 3 10,532.25$

02781504 HB SHEET, MEDPOR 6 7,510.70$

02781505 HB ANCHOR /SCREW 24 C1713 17,075.18$

02781506 HB ANCHOR /SCREW 26 C1713 15,253.85$

02781508 HB MESH 8 C1781 6,683.66$

02781510 HB GENERATOR,NEUROSTIMULATOR15 C1767 121,260.40$


02781513 HB BONE CEMENT 7 10,028.94$

02781514 HB MESH 2* C1781 892.34$

02781515 HB MESH 3* C1781 1,258.97$

02781517 HB OCCLUDER, ABDOMINAL 3 19,244.38$

02781518 HB ANCHOR /SCREW 23 C1713 11,301.75$

02781521 HB COREVALVE AORTIC VALVE 199,223.01$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781522 HB LINQ CARDIAC MONITOR C1764 52,902.15$

02781523 HB IMPLANT TISSUE MARKER I125 SDS A4648 1,942.43$

02781524 HB BONE FILLER 4 23,930.28$

02781525 HB JOINT DEVICE 2* C1776 1,321.25$

02781526 HB JOINT DEVICE 3* C1776 2,072.48$

02781527 HB KIT, ALIF LEVEL 1 32,805.39$

02781529 HB JOINT DEVICE 26 C1776 17,542.69$

02781530 HB JOINT DEVICE 28 C1776 19,061.77$

02781531 HB TESTICULAR PROSTHESIS 3 15,962.75$

02781532 HB JOINT DEVICE 10 C1776 6,698.88$

02781533 HB JOINT DEVICE 12 C1776 9,134.19$

02781534 HB JOINT DEVICE 15 C1776 9,893.36$

02781535 HB JOINT DEVICE 17 C1776 11,145.42$

02781536 HB JOINT DEVICE 24 C1776 19,080.99$

02781537 HB GRAFT SYNTHETIC TISSUE 1* C1763 1,692.01$

02781539 HB GRAFT SYNTHETIC TISSUE 12* C1763 11,395.84$

02781540 HB ANCHOR / SCREW 1* C1713 390.88$

02781541 HB ANCHOR / SCREW 3* C1713 1,728.09$

02781542 HB HEARTWARE, SINGLE PUMP KIT 440,956.60$

02781543 HB JOINT DEVICE 39 C1776 27,721.05$

02781544 HB SPACER 7 7,044.74$

02781545 HB ADAPTER/LEAD IMPLANTABLE 2* C1883 2,926.07$

02781547 HB ALLOGRAFT FLEXHD 8X16CM** Q4128 194.25$

02781548 HB ALLOGRAFT FLEXHD 8X20CM** Q4128 421.63$

02781549 HB JOINT DEVICE 33 C1776 22,757.08$

02781550 HB JOINT DEVICE 54 C1776 37,734.78$

02781552 HB ANCHOR /SCREW 5 C1713 2,632.79$

02781553 HB ANCHOR /SCREW 6 C1713 3,133.61$

02781555 HB JOINT DEVICE 59 C1776 41,499.25$

02781556 HB ICD GENERATOR, SUBCUTANEOUS C1722 145,100.76$

02781557 HB ICD ELECTRODE, SUBCUTANEOUS C1896 30,215.47$

02781558 HB EXTERNAL FIXATION 1* C1713 474.54$

02781559 HB EXTERNAL FIXATION 3* C1713 1,390.41$

02781560 HB JOINT DEVICE 4* C1776 2,581.60$

02781561 HB ANCHOR /SCREW 8 C1713 5,153.41$

02781562 HB ANCHOR /SCREW 10 C1713 6,398.05$

02781563 HB ANCHOR /SCREW 11 C1713 7,282.67$

02781565 HB LAMINARIA 99.04$

02781566 HB DILAPAN (AQUACRYL) 171.31$

02781567 HB ANCHOR /SCREW 7 C1713 3,789.39$

02781568 HB ANCHOR /SCREW 13 C1713 8,712.45$

02781569 HB STENT,COATED/COV W/DEL SYS1 C1874 6,000.22$

02781570 HB ANCHOR /SCREW 14 C1713 7,855.48$

02781571 HB ANCHOR /SCREW 16 C1713 8,944.29$

02781572 HB SENSOR/CARDIO MEMS PULM ART C2624 195,810.00$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781574 HB WATCHMAN LAA DEVICE C1884 225,439.25$

02781575 HB VALVE AORTIC EVOLUTR 332,962.85$

02781576 HB IMPLANT TISSUE MARKER A4648 9,932.94$

02781577 HB PESSARY (SILICONE) A4562 423.61$


02781579 HB HUMAN TISSUE 9 C1762 14,284.90$

02781580 HB HUMAN TISSUE 11 C1762 16,374.93$

02781581 HB HUMAN TISSUE 27 C1762 38,750.59$

02781583 HB BMP XX-SMALL 1 7,755.62$

02781584 HB BMP X-SMALL 2 52,922.76$

02781585 HB BMP MEDIUM 4 52,922.76$

02781586 HB BMP LARGE / XLARGE 5 60,791.74$

02781587 HB MESH 17 C1781 30,228.65$

02781588 HB ANCHOR /SCREW 17 C1713 9,535.35$

02781589 HB ANCHOR /SCREW 19 C1713 10,752.30$

02781590 HB ANCHOR /SCREW 27 C1713 16,133.14$

02781591 HB ANCHOR /SCREW 31 C1713 20,201.69$

02781592 HB ANCHOR /SCREW 32 C1713 21,116.39$

02781593 HB ANCHOR /SCREW 36 C1713 25,867.29$

02781594 HB JOINT DEVICE 20 C1776 13,317.79$

02781595 HB JOINT DEVICE 49 C1776 34,763.29$

02781596 HB CAGE, SPINE 14 24,182.93$





02781606 HB MICRA LEADLESS PACEMAKER C1786 153,577.91$

02781609 HB LAP BAND SYSTEM 19,020.67$

02781610 HB SPACER, SPINE 24,674.66$


02781612 HB CARDIAC VALVE HUMAN TISSUE 41,021.49$

02781613 HB CATHETER VENTRICULAR BIOGLIDE 1,388.39$

02781614 HB UROLIFT SYSTEM L8699 8,739.57$

02781615 HB SHEET, MEDPOR 12,862.06$


02781617 HB COCHLEAR DEVICE L8614 32,848.13$


02781619 HB HUMAN TISSUE C1762 1,747.42$

02781620 HB KIT XLIF 58,396.43$

02781621 HB SPACER, SPINE 42,790.80$

02781622 HB HUMAN TISSUE C1762 25,651.30$

02781623 HB JOINT DEVICE C1776 99,809.59$

02781624 HB EXTERNAL FIXATION C1713 30,843.32$

02781625 HB EXTERNAL FIXATION C1713 27,142.12$

02781627 HB IMPLANT TISSUE MARKER SAVI SCOUT RADAR A4648 8,001.16$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781628 HB SPACER, SPINE 45,064.06$

02781629 HB HEARTWARE, IMPLANT KIT 603,585.10$

02781630 HB STENT, NON/COATED W/DEL SYS C1876 9,221.62$

02781631 HB CATHETER, VENTRICULAR 1,388.39$

02781632 HB PROSTHESIS, URINARY SPHINCTER C1815 19,616.95$


02781684 HB KIT BRIGADE ANTERIOR LUMBAR 1 LEVEL 51,302.60$

02781685 HB GRAFT SYNTHETIC TISSUE C1763 55,775.32$

02781686 HB STENT, NON-COR,TEM, W/DEL C2625 1,192.55$

02781687 HB GENERATOR, NEUROSTIMULATOR C1767 205,304.56$

02781688 HB REP DEV URINARY W/SLING C1771 7,957.51$

02781689 HB PROSTHETIC IMPLANT BONE MATRIX L8699 16,373.20$

02781690 HB AAA EXCLUDER ENDOPROSTHESIS 105,263.73$

02781691 HB AAA EXCLUDER ENDOPROSTHESIS 42,790.80$

02781692 HB EXCLUDER ENDOPROSTHESIS 29,830.13$

02781693 HB SPACE OAR IMPLANT SYSTEM 29,304.09$

02781694 HB LEAD, NEUROSTIMULATOR C1778 70,751.26$



02781697 HB GRAFT ARTHROFLEX 4X4 Q4125 1,429.83$


02781699 HB GRAFT ARTHROFLEX 4X7 Q4125 817.01$




02781703 HB NEUROSTIMULATOR, RECHARGEABLE C1820 186,185.75$

02781704 HB EXCLUDER ENDOPROSTHESIS 42,775.49$

02781705 HB AUDITORY, OSSEO DEVICE L8690 36,028.16$

02781706 HB AUDITORY, OSSEO DEVICE L8690 33,931.05$

02781707 HB VALVE, NEURO 32,769.50$

02781708 HB VALVE, NEURO 33,914.10$




02781712 HB CARDIOVERTER- DEFIBRILLATOR DUAL CHAMBER C1721 145,974.68$

02781717 HB VALVE, ENDOBRONCHIAL 25,191.24$

02781718 HB CARDIOVERTER - DEFIBRILLATOR DUAL CHAMBER C1721 149,407.34$

02781719 HB PROSTHETIC IMPLANT NASAL L8699 10,231.30$

02781720 HB STENT, NON/COATED W/O DEL SYS C1877 10,796.25$

02781732 HB PERMATEMP PPI GENERATOR C1722 7,197.49$

02781744 HB ESSURE COIL IMPLANT A4264 14,394.99$

02781746 HB ENDOPROSTHESIS EXCLUDER 104,420.85$

02781747 HB HUMAN GRAFT TISSUE 10,220.00$

02781748 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 24,626.28$

02781749 HB HUMAN TISSUE ALLODERM 8X16 Q4116 38,594.01$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



02781750 HB IMPLANT, BONE VOID FILLER-STRIP C9362 10,667.43$

02781752 HB STENT, ESOPHAGEAL 23,134.81$

02781753 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 25,705.34$

02781754 HB EMBOLIZATION COIL 13,269.26$

02781755 HB TRACEIT HYDROGEL 9,768.03$

02781760 HB CATHETER,COOLLINE 5,045.24$

02781761 HB CATHETER,ICY 8,041.97$

02781762 HB CATHETER,QUATTTRO 9,008.08$

02781763 HB ER REBOA CATHETER C1760 20,512.86$

02781764 HB CARTRIDGE, CARTOSS 5CC 8,009.79$

02781765 HB CEMENT AUTOPLEX SYS W VERTAPLEX HV 8,739.82$


02781767 HB STENT, BILLIARY 10,796.25$




02781771 HB RE-ENTRY CATHETER SYSTEM 27,761.77$

02781782 HB AUDITORY OSSEO, INTERNAL/EXTERNAL COMPONENTS L8690 30,221.57$

02781783 HB REP DEV URINARY W/SLING C1771 54,166.52$

02781784 HB KIT, URINARY SPHINCTER ACCESSORY 9,881.02$


02781786 HB EVENT RECORDER, CARDIAC IMPLANTABLE C1764 52,902.15$

02781787 HB PROSTHETIC IMPLANT BONE MATRIX L8699 7,017.84$

02781789 HB GENERATOR, NEUROSTIMULATOR W/RECHARGING SYSTEM, HIGH FREQUENCYL8687 194,767.38$

02781790 HB CATHETER, IMPELLA RP 213,936.21$

02781791 HB GENERATOR, NEUROSTIMULATOR W/RECHARGING SYSTEM, HIGH FREQUENCYL8689 10,282.14$

02781805 HB BONE FILLER 14,258.33$

02781806 HB ALLOGRAFT FLEXHD 4X12 Q4128 235.28$

02781807 HB ALLOGRAFT FLEXHD 16X20 Q4128 234.65$

02781808 HB PROSTHETIC IMPLANT SPEEDGRAFT TENDON L8699 23,918.47$


02781812 HB HUMAN TISSUE ALLODERM 10 X 19 Q4116 271.69$


02781814 HB PROSTHESIS ENT 6,429.70$

02781822 HB CARD/DEFI,OTHR THNSIN/DUAL C1882 185,713.34$

02781823 HB CARD/DEFI,OTHR THNSIN/DUAL C1882 189,241.87$

02781824 HB LEAD, PACEMAKER C1898 4,300.10$



02781827 HB ELECTRODE ANCHOR BOLT 3,508.09$

02781828 HB PROSTHESIS, PENILE INFLATABLE C1813 16,460.03$

02781833 HB FLEXHD BREAST 11 X 20 Q4128 280.75$

02781834 HB FLEXHD BREAST 13 X 22 Q4128 268.08$

02781835 HB CARDIO-DEFIB, OTHR THN SING/DUAL C1882 185,713.34$

02781836 HB REFLUX MANAGEMENT SYSTEM 56,581.34$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price




02781838 HB ADAPTER/LEAD IMPLANTABLE C1883 6,790.19$

02781840 HB CARDIO DEFIB DUAL CHAMBER C1721 133,931.41$

02781851 HB TOTAL ARTIFICIAL HEART 70CC 899,095.54$

02781852 HB VALVE PROGRAMMABLE 42,034.62$

02781853 HB PROSTHESIS, PENILE NONINFLATABLE C2622 43,207.57$

02781854 HB PROSTHESIS, PENILE NONINFLATABLE C2622 72,969.26$

02781855 HB BONE FILLER 20,575.03$

02781856 HB KIT, XLIF 2 LEVEL 51,688.41$


02781858 HB AURICAL IMPLANT EAR BASE 8,132.09$

02781859 HB AURICAL IMPLANT HELICAL RIM 3,759.89$


02781861 HB HEARTMATE III MINI APICAL CUFF 5,812.02$

02781862 HB HEARTMATE III IMPLANT KIT 709,857.54$

02781864 HB SPACER, SPINE 43,767.99$


02781866 HB LEAD, PACEMAKER C1898 4,372.19$

02781867 HB HUMAN TISSUE C1762 25,592.19$

02781868 HB ZEPHYR ENDOBRONCHIAL VALVE 22,632.54$





02781875 HB HUMAN TISSUE BILAYER (BMWD) 2X2 Q4104 7,707.20$




02781879 HB KIT, XLIF 3 LEVEL 75,613.24$


02781881 HB STENT, GRAFT THORACIC 194,496.53$


02781883 HB CLIP, OCCLUSION 38,578.19$

02781884 HB SEPTAL DEFECT IMPLANT SYSTEM 81,137.63$

02781885 HB HUMAN TISSUE C1762 4,403.05$



02781891 HB JOINT DEVICE C1776 107,668.36$

02781892 HB VASCULAR PATCH 1,995.78$




02781899 HB COVER, BURR HOLE 8,229.00$

02781900 HB TISSUE MARKER A4648 648.03$

02781901 HB CATHETER, PERITONEAL 5,307.19$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price







02781906 HB TESTICULAR PROSTHESIS 17,589.49$


02781909 HB BONE GRAFT MATRIX 12,343.50$

02781910 HB BONE GRAFT PUTTY 19,543.88$


02781912 HB CLIP, OCCLUSION 56,574.38$

02781913 HB STENT, GRAFT BIFURCATED 62,694.69$

02781914 HB MESH C1781 38,810.02$

02781915 HB MESH C1781 70,357.95$

02781916 HB MESH C1781 88,873.20$



02781919 HB CATHETER, IMPELLA 298,354.00$





02781924 HB JOINT DEVICE C1776 62,441.65$


02781926 HB COCHLEAR IMPLANT EXT PROC/CONTR REPLACEMENT L8619 118,975.26$

02781927 HB DISC, CERVICAL SPINE 41,145.00$

02781928 HB SHEET, MEDPOR 9,678.13$

02781929 HB STENT, COATED/COV W/O DELIVERY SYSTEM C1875 56,008.63$


02781931 HB VALVE, ENDOBRONCHIAL 35,487.56$


02781933 HB 5.5 IMPELLA CATHETER 298,354.00$


02781937 HB STENT, ATLAS NEUROVASCULAR 76,611.99$

02781938 HB SPACER ORTHO 30,776.46$

02781939 HB ADAPTER/LEAD IMPLANTABLE C1883 17,486.63$

02781940 HB CARDIO-DEFIB DUAL CHAMBER C1721 126,620.00$

02781941 HB STENT, NON-COR, TEM, W/O DEL C2617 62,118.66$

02781942 HB INTRAUTERINE TANDEM IMPLANTABLE 848.62$

02781943 HB MESH ABSORBABLE ANTIBACTERIAL 11,777.76$

02781944 HB CARDIO DEFIB DUAL CHAMBER C1721 133,911.91$


03000002 HB NEONATE HEEL STICK 36416 96.12$

03000007 HB BM/PB CRYOPRESVE STEM CELLS 38207 5,499.72$

03000027 HB LYMPHOCYTE BLASTOGENESIS 86353 2,784.41$

03000029 HB PROCESS AUTOLOGUS UNIT 86890 731.12$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03000030 HB AG TYPE /UNIT/AG 86902 980.14$

03000031 HB IRRADIATION OF BLOOD PRODUCT 86945 261.23$

03000033 HB PROCESS OUTSIDE POOL CRYO 86965 731.12$

03000036 HB CRYSTAL ID BY LIGHT MICROSCOPY 89060 599.92$

03000038 HB LAB SWEAT COL, IONTOPHERESIS 89230 664.54$

03000040 HB SEMEN PREP FOR IUI - FRESH SAMPLE 89261 664.54$

03000050 HB LAB POC - FERN TEST Q0114 217.44$

03000084 HB LAB LIPID PANEL 80061 797.52$

03000087 HB LAB RENAL FUNCTION PANEL 80069 1,073.02$

03000107 HB LAB OPIATES UR G0480 1,036.26$

03000109 HB LAB COCAINE UR G0480 1,036.26$

03000136 HB DIGOXIN 80162 915.98$

03000160 HB LAB DILANTN QN SE SC 80185 1,067.00$

03000168 HB LAB SIROLIMUS 80195 224.38$

03000169 HB LAB SALICYL QN SE SC 80329 396.59$

03000250 HB SEMEN ANALYSIS 89320 346.26$

03000264 HB LAB COLLECTION CAPILLARY 36416 96.12$

03000265 HB LAB BLOOD COLLECTION FEE 36416 96.12$

03000266 HB LAB MICRO EOSINOPHILS URN 89050 227.41$

03000267 HB LAB CELL CT TOTAL & DIFF 89051 439.46$

03000268 HB LAB CELL CT TOTAL & DIFF CSF 89051 439.46$

03000269 HB LAB MICRO CRYSTL UNS 89060 227.41$

03000271 HB LAB MICRO EOSINO 89190 227.41$

03000273 HB LAB CELL CT TOT & DF 89051 439.46$

03000274 HB LAB COLLECTION CAPILLARY* 36416 96.12$

03000276 HB FACS T-CELL XM-ADDLSERA/DIL 86826 2,138.00$

03000277 HB FACS B-CELL XM-ADDLSERA/DIL 86826 2,138.00$

03000278 HB FACS AUTO B-CELL ADDLSERA/D 86826 2,138.00$

03000279 HB FACS AUTO T-CELL ADDLSERA/D 86826 2,138.00$

03000280 HB FACS T-CELL XM-1ST SERUM 86825 2,138.00$

03000281 HB FACS B-CELL XM-1ST SERUM 86825 2,138.00$

03000282 HB FACS AUTO B-CELL-1ST SERUM 86825 2,138.00$

03000283 HB FACS AUTO T-CELL-1ST SERUM 86825 2,138.00$

03000285 HB SEMEN ANAL POST VASECTOMY 89321 250.40$

03000286 HB SERUM PRE TREATMENT 86975 209.04$

03000287 HB CELLS PRE TREATMENT W/PRON 86970 209.04$

03000288 HB CELLS PRE TREAT WITH CD20 86977 731.12$

03000289 HB LAB SPLIT BLD PRODUCT EA UN 86985 731.12$

03000290 HB LAB MRSA+MSSA SCREEN 87081 117.93$

03000291 HB SEMEN PREP FOR IUI - CRYO SAMPLE UNWASHED 89261 664.54$

03000292 HB RETROGRADE EJACULATION URINANALYSIS 89331 383.53$

03000293 HB SEMEN PREP FOR IUI - CRYO SAMPLE WASHED 89260 664.54$

03000298 HB WASHING BLOOD PRODUCTS 86999 372.42$

03000299 HB COVID-19 IGG/IGM RAPID TEST 86328 178.16$

03000300 HB RAPID COVID-19 PCR ASSAY 87635 480.00$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03000301 HB COVID-19 SARS-COV-2 IGG 86769 400.00$

03000302 HB COVID-19 SWABBING C9803 261.83$

03010001 HB LAB BASIC METABOLIC PANEL POC 80047 859.64$

03010002 HB LAB ELECTROLYTES 80051 406.49$

03010004 HB LAB BASIC METABOLIC PANEL 80048 826.55$

03010005 HB LAB ACUTE HEPATITIS PANEL 80074 1,556.19$

03010006 HB LAB COMP METABOLIC PANEL 80053 1,422.78$

03010008 HB LAB CANNABINOIDS G0480 1,036.26$

03010013 HB LAB BARBITURATES URN G0480 1,036.26$

03010014 HB LAB BENODIAZEPINES URN G0480 1,036.26$

03010018 HB LAB AMPHETAMIN UR SC G0480 1,036.26$

03010021 HB LAB AMIKACIN 80150 539.53$

03010022 HB LAB CARBAMAZEPINE 80156 807.28$

03010023 HB LAB CYCLOSPORINE, MONOCLONAL 80158 756.95$

03010025 HB LAB VALPROIC ACID 80164 539.53$

03010026 HB LAB GENTAMICIN 80170 771.04$

03010027 HB LAB LITHIUM 80178 269.77$

03010028 HB LAB PHENOB QN SE SC 80184 1,153.54$

03010034 HB LAB FK506 80197 248.01$

03010036 HB LAB TOBRAMYCIN 80200 771.04$

03010037 HB LAB VANCOMYCIN 80202 815.32$

03010038 HB LAB METHOTREXATE 80299 526.52$

03010041 HB LAB ALBUMIN, SERUM - ER 82040 512.99$

03010044 HB LAB URN MICROALBUMIN, TIMED 82043 181.18$

03010045 HB LAB URN MICROALBUMIN, RANDOM 82043 181.18$

03010048 HB LAB ETHANOL QUAN ER 80320 756.95$

03010050 HB LAB ALPHA FETOPROT 82105 448.93$

03010052 HB LAB AMMONIA BL ER 82140 448.93$

03010054 HB LAB AMYLASE SE 82150 526.52$

03010057 HB LAB AMYLASE UR SC 82150 526.52$

03010060 HB LAB BETA-2 MICROGLOBULIN 82232 605.97$

03010061 HB LAB BILIRU TOTAL ER 82247 431.66$

03010063 HB LAB BILIRU TOTAL SC 82247 431.66$

03010067 HB LAB POC OCCULT BLOOD 82272 175.13$

03010069 HB LAB OCCULT BLOOD, GASTRIC 82271 163.07$

03010071 HB LAB OCCULT BLOOD (AB) 82274 289.90$

03010073 HB LAB CALCIUM, FREE 82310 448.93$

03010076 HB LAB CALCIUM SE AU 82310 431.66$

03010081 HB LAB CARBON DIOXIDE BICARBONATE 82374 431.66$

03010082 HB LAB BICARB-CO2 SE AU 82374 431.66$

03010085 HB CARBON DIOXIDE (BICARBONATE) 82374 431.66$

03010086 HB PF CO OXIMETRY 82375 964.30$

03010087 HB LAB CARCINOEMB AN SE 82378 915.98$

03010089 HB LAB CERULOPLASMIN 82390 787.14$

03010093 HB CHLORIDE 82435 431.66$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03010094 HB LAB CHLORIDE UR AU 82436 448.93$

03010098 HB LAB CHOLESTROL SE AU 82465 448.93$

03010103 HB LAB CPK TOTAL SE AU 82550 577.77$

03010106 HB CREATININE 82565 431.66$

03010107 HB LAB CREATININE 82565 431.66$

03010111 HB LAB CREATININ-CLR AU 82575 448.93$

03010113 HB LAB CRYOGLOBULIN SE 82595 382.51$

03010115 HB LAB ERYTHROPOIETIN LEVEL 82668 756.95$

03010116 HB LAB ESTRADIOL 82670 467.10$

03010120 HB LAB FOLATE SE RI 82746 857.61$

03010122 HB LAB IG M, CORD BL 82784 539.53$

03010124 HB LAB IG M SE 82784 539.53$

03010129 HB LAB BLOOD GASES, ART POC 82803 1,765.56$

03010130 HB PF BLD GAS RESTING 82803 1,383.04$

03010133 HB LAB GLUCOSE SF AU 82945 448.93$

03010135 HB LAB GLUCOSE, PRENATAL SCREEN 82947 431.66$

03010137 HB LAB GLUCOSE FAST AU 82947 431.66$

03010143 HB LAB GLUCOSE TOTAL 3H AU 82951 1,425.33$

03010147 HB LAB GLUCOS-G6PD SCRN 82960 547.58$

03010151 HB LAB FOLLICLE STIM HORMONE 83001 310.57$

03010152 HB LAB LUTENIZING HORMONE 83002 309.57$

03010153 HB LAB HAPTOGLOBIN 83010 756.95$

03010154 HB HELIOBACTER PYLORI 83013 1,069.25$

03010156 HB LAB HGB ELECTROPH ACID BL 83020 915.98$

03010158 HB LAB HGB EVAL W/ CONF - HPLC 83021 300.56$

03010159 HB LAB HGB FETAL APT 83033 332.16$

03010163 HB LAB MICRO HEMOSID UR 83070 295.93$

03010164 HB LAB HOMOCYSTEINE 83090 281.77$

03010177 HB LAB LACTIC AC BL SC 83605 577.77$

03010180 HB LAB LDH SE AU 83615 341.05$

03010188 HB LAB LDL CHOLESTEROL 83721 157.66$

03010189 HB LAB MAGNESIUM SE ER 83735 458.76$

03010193 HB LAB MUCIN CLOT 83872 295.93$

03010289 HB DRB1*04 OLIGO 81376 1,601.24$

03010306 HB LUMINEX DNA DRB3, 4, 5 81376 1,601.24$

03010309 HB DPB OLIGO 81376 2,439.98$

03010312 HB DPA OLIGO 86817 2,138.00$

03010313 HB LUMINEX DNA A LOCUS 81373 2,062.38$

03010314 HB DRB4 OLIGO 81376 1,601.24$

03010318 HB LUMINEX DNA B LOCUS 81373 2,062.38$

03010319 HB LUMINEX DNA DQA/B 81376 2,822.51$

03010321 HB LUMINEX DNA DRB1 81376 2,427.91$

03010322 HB DQA OLIGO 81376 2,269.07$

03010323 HB GENERIC DR OLIGO 81375 4,276.06$

03010325 HB DRB5 OLIGO 81376 1,601.24$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03010326 HB DQB OLIGO 81376 2,021.26$

03010329 HB GENERIC ABC OLIGO 81372 6,093.01$

03010342 HB A LOCUS SEQUENCING 81380 14,063.25$

03010343 HB ENGRAFTMENT POST TRANSPLANT 81267 9,354.07$

03010390 HB LAB PROTEIN ELECT SP 83916 1,000.55$

03010393 HB LAB PTH 83970 689.92$

03010398 HB LAB ALK PHOS SE AU 84075 458.76$

03010399 HB LAB ALK PHOS SE ER 84075 428.75$

03010401 HB LAB PHOSPHOR SE AU 84100 431.66$

03010405 HB LAB POTASSIUM * 84132 431.66$

03010407 HB LAB POTASSIUM SE AU 84132 427.81$

03010410 HB LAB POTASSIUM UR AU 84133 448.93$

03010411 HB LAB PREALBUMIN 84134 507.33$

03010413 HB LAB PROLACTIN 84146 323.86$

03010414 HB LAB PROSTATE SPECIFIC ANTGN 84153 372.43$

03010417 HB LAB PROTEN TOT SE AU 84155 394.90$

03010420 HB LAB PROTEN TOT FL SC 84157 410.68$

03010421 HB LAB PROTEN TOT SF SC 84157 410.68$

03010423 HB LAB PROTEIN ELECTROPHORESIS UR 84166 1,000.55$

03010427 HB LAB SODIUM SE AU 84295 431.66$

03010432 HB LAB THYROXINE 84436 341.05$

03010433 HB LAB THYRO TSH SE RI 84443 341.05$

03010434 HB LAB S G O T SE ER 84450 431.66$

03010436 HB LAB SGPT SE ER 84460 431.66$

03010438 HB LAB TRANSFERRIN SE 84466 547.58$

03010439 HB LAB TRIGLYCER SE SC 84478 547.58$

03010442 HB LAB T UPTAKE 84479 341.05$

03010443 HB LAB TROPONIN I 84484 318.92$

03010444 HB LAB UREA NITROGEN 84520 431.66$

03010445 HB UREA NITROGEN 84520 431.66$

03010447 HB LAB UREA NITRO SE AU 84520 431.66$

03010450 HB LAB URIC ACID SE AU 84550 427.81$

03010455 HB LAB BETA HCG, QUAL 84703 539.53$

03010456 HB LAB PSA, SCREEN G0103 372.43$

03010480 HB LAB PROTEIN ELECTROPHORESIS SE 84165 915.98$

03010489 HB LAB SODIUM 84295 431.66$

03010505 HB ACETAMINOPHEN 80329 591.86$

03010527 HB LAB ETHANOL QUAN SC 80320 756.95$

03010538 HB LAB ALPHA ANTI TRYPS 82103 577.77$

03010568 HB LAB AMMONIA BL 82140 448.93$

03010632 HB LAB BILIRUBIN, DIRECT 82248 431.66$

03010635 HB LAB OCCULT BLOOD FE 82272 175.13$

03010655 HB LAB CALCIUM UR AU 82340 448.93$

03010695 HB LAB CHLORIDE SE AU 82435 431.66$

03010700 HB LAB CHLORIDE, SWEAT 82438 1,294.48$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03010771 HB LAB CORTISOL SE RI 82533 915.98$

03010783 HB CKMB FRACTION 82553 259.72$

03010787 HB LAB CREATININE FLD 82570 431.66$

03010789 HB LAB CREATININE UR AU 82570 431.66$

03010798 HB LAB VITAMIN B-12 RI 82607 1,209.90$

03010843 HB LAB FERRITIN 82728 706.61$

03010844 HB FETAL FIBRONECTIN 82731 2,250.58$

03010852 HB LAB IG A, CORD BL 82784 539.53$

03010854 HB LAB IG A SE 82784 539.53$

03010858 HB LAB IG G, CORD BL 82784 539.53$

03010861 HB LAB IG G SE 82784 539.53$

03010877 HB LAB O2 SATURATION 82803 323.42$

03010881 HB LAB GLUCOSE URN 82945 448.93$

03010883 HB LAB GLUCOSE FL AU 82945 448.93$

03010886 HB LAB GLUCOSE 82947 431.66$

03010887 HB LAB GLUCOSE 2H PP 82950 431.66$

03010891 HB LAB GLUC TOL, EA ADNL SPEC 82952 448.93$

03010896 HB LAB GAM GLUT TRAN SC 82977 367.80$

03010911 HB LAB HGB ELECTROPH BL 83020 915.98$

03010925 HB LAB HEMOGLOBIN A1C 83036 231.52$

03010926 HB LAB GLYCATED HEMOGLOBIN 83036 231.52$

03011084 HB LAB PANEL IRON, TOTAL 83540 331.34$

03011085 HB LAB PANEL IRON BIND CAPACITY 83550 331.34$

03011095 HB LAB LDH FL SC 83615 555.56$

03011111 HB LAB LAMELLAR BODY DENSITY 83664 171.10$

03011114 HB LAB LIPASE SE ST 83690 458.94$

03011120 HB LAB HDL CHOLESTEROL 83718 136.73$

03011127 HB LAB MAGNESIUM UR SC 83735 458.76$

03011129 HB LAB MAGNESIUM SE SC 83735 458.76$

03011167 HB LAB NATRIURETIC PEPTIDE ASSY 83880 567.51$

03011168 HB LAB FREE KAPPA LIGHT CHAINS 83883 227.53$

03011169 HB LAB IGG SYNTHETIC RATE, CSF 83883 306.01$

03011171 HB LAB FREE LAMBDA LIGHT CHAINS 83883 227.53$

03011175 HB LAB ANTI-STREPTOLYSIN O ANTIBD 83883 396.59$

03011632 HB LAB OSMOLALITY SE AU 83930 332.16$

03011633 HB OSMOLALITY, URINE 83935 332.16$

03011646 HB LAB PH, URINE 83986 122.81$

03011647 HB LAB POC - PH, BODY FLUIDS 83986 446.92$

03011671 HB LAB PHOSPHOR UR AU 84105 431.66$

03011740 HB LAB SODIUM UR AU 84300 431.66$

03011792 HB ASPARTATE AMINOTRANSFERA 84450 431.66$

03011817 HB LAB UREA NITRO UR 84540 448.93$

03011821 HB LAB URIC ACID UR AU 84560 448.93$

03011860 HB DRB3 OLIGO 81376 1,601.24$

03011861 HB LAB BETA-HCG QUAL 84703 539.53$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03011865 HB LUMINEX DNA MIC 81376 2,355.44$

03011866 HB LUMINEX DNA C LOCUS 81373 2,062.38$

03011867 HB LUMINEX DNA ABC LOCUS 81372 6,093.01$

03011872 HB LAB CREATININE SE AU 82565 431.66$

03011874 HB LAB PROTEIN TOTAL - ER 84155 410.68$

03011877 HB LAB ACETOACETI BL ER 82009 295.93$

03011881 HB LAB HEPATIC FUNCTION PANEL 80076 711.37$

03011883 HB PC BLOOD GAS NEONATE 82803 1,383.04$

03011884 HB PC BLDG GAS ANALYSIS 82803 1,383.04$

03011886 HB PF BLD GAS SHUNT 82803 1,383.04$

03011888 HB LAB AMYLASE FL SC 82150 526.52$

03011889 HB LAB CHLORIDE 82435 431.66$

03011890 HB LAB S G P T SE AU 84460 431.66$

03011891 HB LAB HCG B SUB RI * 84702 821.37$

03011899 HB LAB STOOL K 84999 8.10$

03011900 HB HEPATIC FUNCTION PANEL A 80076 711.37$

03011901 HB LAB CALCIUM, FREE** 82330 431.66$

03011902 HB LAB ALDOLASE 82085 201.33$

03011921 HB LAB URINE PREGNANCY TEST 81025 539.53$

03011961 HB B LOCUS SEQUENCING 81380 15,047.67$

03011962 HB C LOCUS SEWUENCING 81380 15,047.67$

03011963 HB HLA CLASS II DNA HI RES, 1 LOCUS 81382 11,245.79$

03011967 HB LAB TROPONIN I 84484 318.92$

03011970 HB LAB SODIUM* 84295 431.66$

03011974 HB LAB CALCIUM, FREE* 82330 448.93$

03011975 HB LAB CPK TOTAL SE AU* 82550 577.77$

03011977 HB LAB GLUCOSE** 82947 431.66$

03011978 HB LAB NATRIURETIC PEPTIDE ASSY* 83880 567.51$

03011979 HB LAB ALBUMIN, SERUM - ER* 82040 512.99$

03011980 HB LAB ACETOACETI BL ER* 82009 295.93$

03011981 HB LAB ELECTROLYTES* 80051 369.55$

03011982 HB LAB BASIC METABOLIC PANEL* 80048 711.37$

03011985 HB LAB AMYLASE SERUM 82150 526.52$

03012046 HB VIT D:25-HYDROXY 82306 494.79$

03012051 HB CHIMERISM POST TXP W/SEL CEL 81268 2,464.22$

03012052 HB HLA CLASS I & II INITIAL TYPING >4 LOCI 81370 9,402.37$

03012053 HB HLA CLASS I & II VERIFICATION TYPING=4 LOCI 81371 6,160.91$

03012063 HB ENGRAFTMENT PRE TRANSPLANT 81265 7,871.71$

03012064 HB ENGRAFTMENT 1ST DONOR 81265 7,871.71$

03012065 HB ENGRAFTMENT 2ND DONOR-CORD 81266 7,871.71$

03012068 HB LAB MP BCR/ABL1 T922 MAJOR 81206 2,036.87$

03012069 HB LAB MP BCR/ABL1 T922 MINOR 81207 2,036.89$

03012072 HB LAB MP BRAF GEN ANALY V600E 81210 1,374.21$

03012080 HB LAB MP CTFR GEN ANAL COMMON 81220 7,236.52$

03012088 HB LAB MP CYTOGEN CONST MICANL 81228 5,996.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03012090 HB LAB MP F2 GENE ANALYSIS 81240 904.61$

03012091 HB LAB MP F5 GENE ANALYSIS 81241 1,146.20$

03012102 HB LAB MP IGH@ GEN REARR ANAL 81261 4,643.63$

03012105 HB LAB MP IGK@ GEN REARR ANAL 81264 4,326.87$

03012110 HB LAB MP JAK2 GENE ANALYSIS 81270 1,288.27$

03012111 HB LAB MP KRAS GENE ANALYSIS 81275 3,961.65$

03012116 HB LAB MP MTHFR GENE ANALYSIS 81291 936.85$

03012131 HB LAB MP PML/RARALP TRNSL ANL 81315 5,428.30$

03012139 HB LAB MP TRB@ GEN REARR ANAL 81340 1,894.51$

03012141 HB LAB MP TRG@ GENE REARR ANAL 81342 2,017.71$

03012155 HB LAB MP PROC LEVL 1 81400 1,063.01$

03012167 HB LAB TESTOSTERONE, TOTAL 84403 431.45$

03012168 HB IMMUNOASSAY,NOT SPEC QUANTI 83520 380.83$

03012176 HB LAB FREE T4 84439 150.66$

03012182 HB LAB MP F2 GENE ANALY TOMB 81240 1,025.41$

03012185 HB LAB MP F5 GENE ANALY TOMB 81241 1,025.41$


03012187 HB HUM ERYTHR AG GEN ANLYS 81403 17,454.31$


03012191 HB LAB LACTATE - VENOUS POCT 83605 879.97$

03012192 HB LAB LACTATE - ARTERIAL POCT 83605 879.97$

03012196 HB HLA CLASS I & II HI RES. 81378 60,363.36$

03012205 HB CHROM MA CONSTITUTIONAL 81229 6,596.24$

03012206 HB ANGTNSN II TYPE I REC ANTI AT1R 86316 1,244.79$

03012209 HB BRAF V600E MUT DT NETGEN SQ 81210 1,342.89$

03012212 HB EGFR COM VAR NET-GEN SEQ 81235 1,931.52$

03012222 HB KIT NET-GEN SEQ 81402 3,023.63$

03012223 HB KRAS COD 12/13 NETGEN SEQ 81275 1,925.17$

03012228 HB LAB NRAS NET-GEN SEQ 81404 3,068.87$

03012234 HB UNLISTED MOLECULAR CODE 81479 19.59$

03012235 HB EVEROLIMUS 80169 221.41$

03012236 HB SUPAR 83520 1,659.72$

03012237 HB LAB MP EGFR GENE ANALYSIS 81235 1,931.52$

03012238 HB INSULIN 83525 185.76$

03012239 HB KIR GENOTYPING 81403 2,387.54$

03012276 HB PCA3/KLK3 ANTIGEN 81313 3,112.84$

03012277 HB TARGETED GENOMIC SEQ ANALYS 81445 36,756.58$

03012278 HB DRUG SCREEN CLASS LIST A 80307 2,957.35$

03012286 HB ANTI-PHOS A2 RECEP(APLA2R-ELISA) 83520 1,659.72$

03012287 HB LAB PLASMA FREE HEMOGLOBIN 83051 230.13$

03012288 HB LAB T3;FREE 84481 303.83$

03012290 HB KRAS GENE ADDL VARIANTS 81276 2,456.63$

03012292 HB AMNISURE 84112 1,013.33$

03012293 HB INTERLEUKIN - 1BETA - LUMINEX 83520 1,659.72$

03012294 HB INTERLEUKIN - 2 - LUMINEX 83520 1,659.72$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price




03012296 HB INTERLEUKIN - 17A - LUMINEX 83520 1,659.72$


03012298 HB TUMOR NECROSIS FACT ALPH - LUMINEX 83520 1,659.72$

03012299 HB INTERFERON GAMMA - LUMINEX 83520 1,659.72$

03012300 HB RHD GENE ANALYSIS 81403 2,609.81$

03012301 HB RHCE GENE ANALYSIS 81403 2,609.81$

03012302 HB TARGETED GENOMIC SEQ ANALYS LTD 81445 33,748.34$

03012303 HB TARGETED GENOMIC SEQ ANALYS MOD 81445 33,748.34$

03012304 HB TARGETED GENOMIC SEQ ANALYS HEMATO LTD 81450 33,748.34$

03012305 HB TARGETED GENOMIC SEQ ANALYS HEMATO MOD 81450 33,748.34$

03012306 HB TARGETED GENOMIC SEQ ANALYS EXTENDED 81455 33,748.34$

03012307 HB PROCALCITONIN 84145 298.55$

03012308 HB PH, PLEURAL FLUID 83986 61.04$

03012327 HB B-HYDROXYBUTYRATE:QUANT 82010 132.42$

03012328 HB IL-21-LUMINEX 83520 1,659.72$

03012329 HB SIL-6R-LUMINEX 83520 1,659.72$

03012330 HB VEGF-A-LUMINEX 83520 1,659.72$

03012331 HB TGFB1-LUMINEX 83520 1,659.72$


03012335 HB IHC MULTIPLEX STAIN ONLY 2 AB 88344 980.14$

03012336 HB MTHFR 1298C GENE ANALYSIS 81291 711.03$

03012337 HB CALRETICULIN 81219 2,009.45$

03012338 HB RED BLOOD CELL GENOTYPING 81403 2,327.59$

03012339 HB PROTEASE 3 (PR3) IGG ABS 83516 356.28$

03012340 HB MYELOPEROXIDASE (MPO) IGG ABS 83516 356.28$

03012341 HB APIXABAN 80299 187.94$

03012342 HB RIVAROXABAN 80299 187.94$

03012343 HB LUMINEX VIMENTIN ANTIBODY 86832 1,863.61$

03012345 HB TUMOR HCG 84702 185.94$

03012346 HB B-TYPE NATRIURETIC PEP 83880 403.44$

03012347 HB FENTANYL, QUALITATIVE 80354 226.48$

03020001 HB LAB ANCA 86021 406.68$

03020008 HB LAB C-REACT PROT CORD BL 86140 605.97$

03020009 HB LAB C-REACT PROT QT 86141 605.97$

03020011 HB LAB BETA 2 GLYCOPROTEIN1-IGM 86146 425.03$

03020017 HB LAB ANTIBD DNA 1F 86225 740.86$

03020019 HB LAB SS-A ANTIBODIES 86235 254.55$

03020020 HB LAB SCL 70 ANTIBODIES 86235 254.55$

03020028 HB LAB SM ANTIBODIES * 86235 254.55$

03020037 HB LAB CA 19-9 86301 347.60$

03020041 HB LAB PROTEIN IFE, SERUM 86334 1,425.33$

03020042 HB LAB PROTEIN IFE, URINE 86335 1,497.79$

03020050 HB LAB ANTIB RA QUANT 86431 332.16$

03020053 HB LAB ANTIBD SY RPR QL 86592 318.06$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03020057 HB LAB COCCI IGG 86635 194.46$

03020058 HB LAB CSF COCCI IGG 86635 194.46$

03020060 HB LAB CSF COCCI IGM 86635 194.46$

03020067 HB LAB ANTIBODY EBV IGG 86665 624.08$

03020068 HB LAB ANTIBD EBV IGM 86665 624.08$

03020081 HB LAB HERPES SIMPLEX TYP 2 IGG 86696 863.67$

03020091 HB LAB ANTI-HEP B SURF ANTIBD 86706 340.22$

03020092 HB LAB ANTI-HAV TOTAL 86708 200.30$

03020093 HB LAB ANTI-HAV IGM 86709 181.97$

03020096 HB LAB ANTIBD MEASLES IGG 86765 326.12$

03020114 HB HLA T CELL X-MATCH/SERUM 86805 2,156.10$

03020123 HB T-CELL CROSSMATCH WITH DTT 86805 1,604.48$

03020132 HB IVIG B-CELL XM NO DTT 86805 1,604.48$

03020135 HB GLYCINE T-CELL XM NO DTT 86805 1,604.48$

03020140 HB HLA B CELL X-MATCH/SERUM 86805 2,156.10$

03020144 HB GLYCINE B-CELL XM W/DTT 86805 1,604.48$

03020146 HB B-CELL XM W/DTT 86805 1,604.48$

03020150 HB CLASS II QUICK SCREEN W/DTT 86806 702.59$

03020152 HB CLASS II IVIG QS NO DTT 86806 702.59$

03020153 HB CLASS II QUICK SCREEN NO DTT 86806 702.59$

03020155 HB AS & ID W/DTT 86807 897.88$

03020158 HB HLA ANTIBODY SRN & ID/SERUM 86807 1,205.91$

03020186 HB LAB CA125 IA 86304 347.60$

03020251 HB CYTOMEGALOVIRUS (CMV)-PCR, QUAL 87496 2,327.25$

03020252 HB HERPES SIMPLEX VIRUS (HSV)-PCR, QUAL 87529 2,327.25$

03020349 HB LAB POTASSIUM 84132 431.66$

03020350 HB LAB PROGESTERONE 84144 348.72$

03020352 HB LAB PSA, FREE 84154 372.43$

03020353 HB LAB PROTEN TOT UR SC 84156 410.68$

03020356 HB STOOL REDUCING SUBSTANCE 84376 217.44$

03020433 HB LAB CENTROMERE ANTIBODY 86039 756.95$

03020434 HB LAB ANTIBODY ANA, TITER 86039 756.95$

03020445 HB LAB BETA 2 GLYCOPROTEIN1-IGG 86146 425.03$

03020447 HB LAB ANTIBD ANTICARDIOLIPIN 86147 332.16$

03020449 HB LAB COMPLMNT C4 ASSY 86160 771.04$

03020454 HB LAB COMPLMNT C3 ASSY 86160 577.77$

03020462 HB LAB CYCLIC CITRULINATD PEP IGG 86200 211.66$

03020480 HB LAB RNP ANTIBODIES * 86235 254.55$

03020482 HB LAB SS-B ANTIBODIES 86235 254.55$

03020509 HB LAB ANTIBD SM MS TITER 86256 756.95$

03020524 HB LAB ANTIBD ANTIPARIETAL 86256 756.95$

03020526 HB LAB CA 27.29 86300 505.31$

03020527 HB LAB CA 15-3 86300 347.60$

03020545 HB LAB ANTIBD MONO S ER 86308 410.68$

03020591 HB LAB B LYMPH QUANTITATION 86355 616.77$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03020592 HB LAB NK LYMPH QUANTITATION 86357 616.77$

03020593 HB LAB CD34 STEM CELL QUANT 86367 839.49$

03020607 HB LAB TB TEST CELL IMMUN, MEASUR 86480 1,013.33$

03020662 HB LAB COCCI IGM 86635 194.46$

03020668 HB LAB CMV AB, IGG 86644 624.08$

03020672 HB CMV SCREEN 86644 376.47$

03020675 HB LAB CMV AB, IGM 86645 624.08$

03020720 HB LAB H. PYLORI ANTIBODY 86677 248.92$

03020741 HB LAB HERPES SIMPLEX TYP 1 IGG 86695 851.57$

03020742 HB LAB HERPES SIMPLEX TYP 1 IGM 86695 851.57$

03020754 HB AB; HIV-1 & HIV-2 SGL ASSAY 86703 505.31$

03020757 HB LAB HEP ANTI-HBC 86704 295.93$

03020803 HB LAB ANTIBD RUBELLA 86762 410.68$

03020805 HB LAB ANTIBD RUBELLA CORD BL 86762 410.68$

03020818 HB LAB ANTIBD TOX IGG 86777 624.08$

03020819 HB LAB ANTIBD TOXO IGM 86778 624.08$

03020825 HB LAB ANTIBD SY FTA 86780 1,000.55$

03020860 HB LAB HEP C ANTIBD 86803 295.93$

03020866 HB PROCESS PLT HLA MATCHING 86813 1,071.00$

03020868 HB AB SCREEN FICIN (EZ) 86850 664.54$

03020875 HB DAT, POLYSPECIFIC 86880 438.85$

03020880 HB TITRATION EACH 86886 731.12$

03020892 HB LAB HEP B S ANTIG 87340 259.72$

03020893 HB LAB TOXO IGM - EIA 86778 624.08$

03020923 HB LAB HEPATITIS B CORE AB, IGM 86705 190.40$

03020924 HB LAB ANTIBD MITO TITER 86256 742.70$

03020925 HB LAB HERPES SIMPLEX TYP 2 IGM 86696 847.13$

03020926 HB LAB PLT AB - HIT PF4-HEP EIA 86022 527.44$

03020927 HB LAB VARICELLA ZOSTER IGG 86787 394.37$

03020931 HB EPSTEIN-BARR VIRUS (EBV)-PCR, QUAL 87798 2,327.25$

03020932 HB PARVOVIRUS B19 (PARVO B19)-PCR, QUAL 87798 2,327.25$

03020933 HB POLYOMAVIRUS BK (BKV)-PCR, QUAL 87798 2,327.25$

03020934 HB POLYOMAVIRUS JC (JCV)-PCR, QUAL 87798 2,327.25$

03020936 HB THYROGLOBULIN ANTIBODY IGG 86800 265.79$

03020937 HB THYROID PEROXIDASE ANTIBODY 86376 244.76$

03020938 HB LAB BETA 2 GLYCOPROTEIN1-IGA 86146 425.03$

03020939 HB MUMPS IGG EIA 86735 220.45$

03020941 HB LUMINEX DNA DRB1,3,4,5,DQAB 81375 5,914.80$

03020942 HB LUMINEX DNA DPAB 81376 2,355.44$

03020943 HB GENERIC A LOCUS OLIGO 81373 2,062.38$

03020947 HB DQB LOCUS SEQUENCING 81382 11,245.79$

03020950 HB LAB C-REACTIVE PROTEIN 86140 151.46$

03020951 HB ANTBDY SCRN BY FLOW CL I&II 86828 2,486.17$

03020952 HB ANTIBODY SCRN FLOW CL IORII 86829 1,243.00$

03020953 HB ANTBDY ID PHENOTYPE BDS CLI 86830 1,643.14$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03020954 HB ANTBDY ID PHENOTYPE BDS CLII 86831 1,643.14$

03020955 HB ANTBDY ID BY HI DEF BDS CLI 86832 1,865.53$

03020956 HB ANTBDY ID BY HI DEF BDS CLII 86833 1,865.53$

03020957 HB ANTBDY ID HI DEF BDS C1Q CLI 86832 2,881.29$

03020958 HB ANTBDY ID HI DEF BDS C1Q CLII 86833 2,881.29$

03020959 HB ANTBDY TEST WITH TITER CLI 86834 3,888.59$

03020960 HB ANTBDY TEST WITH TITER CLII 86835 3,512.28$

03020962 HB MULTISPOT HIV1 86701 178.74$

03020963 HB MULTISPOT HIV2 86702 229.56$

03020971 HB LUMINEX MICA SINGLE ANTIGEN 86832 1,864.93$

03020972 HB ANTI-HAV IGG 86790 394.37$

03020977 HB AB;HIV1 86701 144.70$

03020978 HB AB;HIV2 86702 223.79$

03020979 HB NON-HLA SOLID PHASE 86808 1,028.48$

03020980 HB CYTOMEGALOVIRUS (CMV)-PCR, QUANT 87497 3,025.43$

03020981 HB EPSTEIN-BARR VIRUS (EBV)-PCR, QUANT 87799 3,025.43$

03020982 HB HERPES SIMPLEX VIRUS (HSV)-PCR, QUANT 87530 3,025.43$

03020983 HB PARVOVIRUS B19 (PARVO B19)-PCR, QUANT 87799 3,025.43$

03020984 HB POLYOMAVIRUS BK (BKV)-PCR, QUANT 87799 3,025.43$

03020985 HB POLYOMAVIRUS JC (JCV)-PCR, QUANT 87799 3,025.43$

03020986 HB VARICELLA-ZOSTER (VZV)-PCR, QUANT 87799 3,025.43$

03020987 HB COVID-19 IGG ELISA 86769 153.84$

03020988 HB COVID-19 IGM ELISA 86769 153.84$

03050002 HB AUTOMATED DIFFERENTIAL* 85004 432.82$

03050003 HB MANUAL DIFFERENTIAL 85007 555.63$

03050012 HB LAB CELL C EOSINO BL 85032 332.16$

03050014 HB RETICULOCYTE; AUTOMATED 85045 410.68$

03050018 HB LAB FACTOR 5 ASSAY 85220 706.61$



03050021 HB LAB RISTOCETIN CO-FACTOR 85245 706.61$


03050030 HB LAB PROTEIN S ASSAY 85306 998.53$

03050034 HB LAB ACTIVATED CLOTTING TIME 85347 394.58$

03050035 HB LAB WHOLE BLOOD ACT 85347 394.58$

03050036 HB LAB HEPARIN DOSE RESPONSE 85348 648.25$

03050038 HB LAB FIBRIN MONOMER 85362 396.59$

03050040 HB LAB D-DIMER QUANT 85379 714.65$

03050046 HB LAB UNFRACTIONATED HEPARIN 85520 185.91$

03050047 HB LAB HEPARIN ASSAY 85520 648.25$

03050048 HB LAB LOW MOL WT HEPARIN 85520 185.91$

03050054 HB LAB ASPIRIN ASSAY 85576 376.47$

03050058 HB LAB PFA - ADP 85576 305.07$

03050059 HB LAB PLAVIX RESISTANCE ASSAY 85576 559.68$

03050062 HB LAB PFA - EPINEPHRINE 85576 305.07$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03050065 HB LAB LUPUS ANTICOAG/ HEXA PL 85598 569.72$

03050066 HB LAB WHOLE BLOOD PROTIME 85610 426.78$

03050067 HB LAB PRO TIME ER 85610 426.78$

03050069 HB LAB PRO TIME ROU PL 85610 320.96$

03050076 HB LAB SICKLE CELL SCRN 85660 295.93$

03050077 HB LAB THROMBIN TIME PL 85670 410.68$

03050079 HB LAB PTT ER 85730 320.96$

03050080 HB LAB PTT DIFF PL 85732 410.68$

03050093 HB LAB HEMATOCRIT* 85014 281.83$

03050094 HB HEMOGLOBIN BY HEMOCUE* 85018 191.25$

03050096 HB CBC WITH AUTO DIFF 85025 673.43$

03050102 HB PLATELET CT AUTOMATED 85049 175.13$

03050108 HB FACTOR II ASSAY 85210 706.61$

03050113 HB LAB CBC WITH AUTO DIFF 85025 673.46$

03050115 HB VON WILLEBRAND FACTOR AG 85246 676.44$

03050116 HB LAB CBC HEMOGRAM W/PLT* 85027 367.80$

03050117 HB PLATELET COUNT, AUTOMATED 85049 175.13$

03050118 HB LAB PROTEIN S TOTAL AG 85305 797.21$

03050119 HB LAB PROTEIN S FREE AG 85306 756.95$

03050120 HB LAB PTT LA 85730 320.96$

03050121 HB FACTOR IX ASSAY 85250 706.61$

03050122 HB FACTOR X ASSAY 85260 706.61$

03050124 HB FACTOR XII ASSAY 85280 706.61$

03050125 HB FACTOR XIII SCREEN 85291 448.93$

03050129 HB ANTI-THROMBIN 3 85301 648.25$

03050132 HB PROTEIN C FUNCTIONAL 85303 1,058.93$

03050138 HB FACTOR INHIBITOR TEST 85335 674.41$

03050142 HB PLASMA D-DIMER 85379 714.65$

03050144 HB D-DIMER ULTRASENS 85379 714.65$

03050146 HB FIBRINOGEN 85384 448.93$

03050157 HB FETAL KLEIHAUER BETKE 85460 756.95$

03050158 HB SCRN FETAL-MATERNAL 85461 287.90$

03050168 HB LEUKOCYTE ALKALINE PHOSP 85540 628.10$

03050192 HB LAB PRO TIME DIFF PL 85611 410.68$

03050196 HB LAB SED RATE WESTEGN 85651 376.47$

03050208 HB LAB VISCOSITY SE SC 85810 332.16$

03050245 HB LAB T CELLS, TOTAL COUNT 86359 631.62$

03050246 HB LAB CD4 AND CD8 T CELL COUNT 86360 839.49$

03050336 HB LAB PTT PL 85730 416.17$

03050338 HB HGBS PER UNIT 85660 154.10$

03050341 HB MANUAL DIFFERENTIAL* 85007 555.63$

03050344 HB LAB CBC HEMOGRAM W/PLT 85027 367.80$

03050345 HB LAB SED RATE WESTEGN* 85651 376.47$

03050346 HB LAB HEMATOCRIT 85014 281.83$

03050348 HB LAB ACTIVATED CLOTTING TIME* 85347 394.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

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Price



03050350 HB LAB HP TEG PLATELET MAPPING 85390 337.30$

03050351 HB LAB HP TEG MA-ACTIVATOR-A 85576 305.07$

03050352 HB LAB HP TEG MA-ADP 85576 305.07$

03050353 HB LAB HP TEG MA-ARACHIDONIC ACID 85576 305.07$

03050354 HB LAB HP TEG BASIC 85390 337.30$

03050355 HB LAB HP TEG HEPARINASE 85390 463.59$

03050356 HB LAB P2Y12 ASSAY 85576 316.77$


03050358 HB LAB DRVV CONFIRM 85613 165.10$

03050359 HB LAB DRVV SCREEN 85613 165.10$

03050360 HB LAB DRVV MIXING 85613 165.10$

03050361 HB LAB COLLAGEN 1UG/ML ATP REL 85576 325.79$

03050362 HB LAB COLLAGEN 5UG/ML AGG 85576 325.79$

03050363 HB LAB COLLAGEN 5UG/ML ATP REL 85576 325.79$

03050364 HB LAB RISTO LOW DOSE AGG 85576 325.79$

03050365 HB LAB RISTO HIGH DOSE AGG 85576 325.79$

03050366 HB LAB THROMBIN PLT ATP REL 85576 325.79$

03050367 HB LAB ARACHODON ACID AGG 85576 325.79$

03050368 HB LAB ARACHODON ACID ATP REL 85576 325.79$

03050369 HB LAB ADP AGG 85576 325.79$

03050370 HB LAB ADP ATP RELEASE 85576 325.79$

03050371 HB LAB COLLAGEN 1UG/ML AGG 85576 325.79$

03050372 HB LAB PBMC ISOLATION 85999 254.16$

03050373 HB LAB RETICULOCYTE AUTO 85046 268.57$

03050374 HB VWF ACTIVITY RISTOCETIN CO-FACTOR 85245 706.61$

03050384 HB HP TEG6S MA-KAOLIN 85576 297.41$

03050385 HB HP TEG6S MA-RAPID TEG 85576 297.41$

03050386 HB HP TEG6S MA-FUNCTIONAL FIBRINOGEN 85576 297.41$

03050387 HB HP TEGS R-KAOLIN 85347 69.34$

03050388 HB HP TEGS R-KAOLIN HEPARINASE 85347 69.34$

03050389 HB SEDIMENTATION RATE, RBC, AUTOMATED 85652 351.84$

03050390 HB HP TEG6S CK-K, ANGLE 85384 108.96$

03060002 HB CONCENTRATION - ANY TYPE 87015 111.64$

03060005 HB CONCENTRATION, CSF FOR GS 87015 111.64$

03060007 HB LAB CULT BLOOD LEGIONELLA 87040 877.76$

03060008 HB LAB CULT BLOOD BRUCELLA ONLY 87040 930.08$

03060012 HB CULTURE, BACT FECAL ROUTINE 87045 362.38$

03060013 HB SRN VRE C. DIFF TOX POS STOOL 87046 183.19$

03060015 HB LAB CULTURE ABSCESS 87070 475.11$

03060016 HB LAB CULT RESPIR CYSTIC FIBRO 87070 352.31$

03060023 HB LAB CULTURE EAR 87070 475.11$

03060024 HB LAB CULTURE GASTRIC 87070 448.93$

03060028 HB LAB CULTURE CSF 87070 475.11$

03060029 HB LAB CULTURE WOUND 87070 475.11$

03060030 HB LAB CULTURE FLUID 87070 475.11$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



03060033 HB LAB CULTURE CATHETER TIP 87070 807.28$

03060036 HB LAB CULTURE SKIN 87070 475.11$

03060039 HB LAB ANAEROBE IDENTIFICATION 87076 210.55$

03060040 HB LAB CHLAMYDIA ADNL WORK 87076 229.53$

03060041 HB LAB CULT ADNL WORKUP 87076 454.97$

03060042 HB LAB ANA DEFIN ID, EACH ORG 87076 210.55$

03060043 HB LAB IDENTIF, BACTERIAL 87076 807.28$

03060048 HB LAB CULT LEGIONELLA 87081 748.90$

03060050 HB LAB BETA STREP SCREEN 87081 410.68$

03060053 HB LAB CULT BAC-PERTUS 87081 410.68$

03060058 HB CULTURE, URINE 87088 915.98$

03060059 HB LAB CULT FUNG UNSPCF 87102 930.08$

03060070 HB CHLAMYDIA PNEUMONIAE 87110 383.53$

03060073 HB LAB CULT AFB BLOOD 87116 930.08$

03060077 HB LAB SEROTYPING, EACH ORG 87147 88.58$

03060084 HB LAB MICRO PINWORMS 87172 314.06$

03060085 HB TISSUE GRINDING 87176 310.01$

03060086 HB LAB O & P DIRECT WET MOUNT 87177 187.21$

03060087 HB LAB O&P CONC/IODN MNT NONSTO 87177 187.21$

03060089 HB LAB O&P CONC/WET MOUNT STOOL 87177 374.44$

03060090 HB WET MOUNT 87210 177.15$

03060095 HB CLIND INDUCED RES.TEST 87184 115.14$

03060096 HB LAB SUSCEPT KB 87184 569.72$

03060101 HB LAB CONFIRM AGAR DIL MIC 87186 144.52$

03060106 HB LAB GRAM STAIN FOR BV SCREEN 87205 332.16$

03060107 HB LAB MICRO WRIGHT ST 87205 231.52$

03060112 HB ZIEHL-NEELSEN STAIN-CONF 87206 181.18$

03060114 HB SMEAR, AFB STOOL 87206 118.79$

03060116 HB LAB MICRO MALARIA BL 87207 332.16$

03060120 HB LAB WETMT FUNG UNSPC 87210 390.55$

03060121 HB LAB (KOH) FUNGAL EXAM 87210 342.25$

03060123 HB LAB INDIA INK CRYPTO 87210 318.06$

03060129 HB LAB VIRUS INOCULATION, SHELL V 87254 157.02$

03060132 HB LAB GENET VIRUS ISOLATE, HSV 87255 565.91$

03060136 HB LAB CRYPTO DFA 87272 217.44$

03060138 HB LAB HERPES TYPE TWO DFA 87273 285.86$

03060139 HB LAB HERPES TYPE ONE DFA 87274 285.86$

03060141 HB LAB INFLUENZA A IFA STAIN 87276 150.23$

03060142 HB LAB RSV IFA STAIN 87280 150.23$

03060144 HB LAB PNEUMOCYSTIS DFA 87281 523.45$

03060145 HB LAB VARICELLA ZOSTER DFA 87290 569.72$

03060152 HB LAB ANTGN CRYPTO SE 87327 505.31$

03060153 HB LAB DIRECT GIARDIA AG 87328 698.57$

03060154 HB LAB H. PYLORI STOOL AG EIA 87338 334.16$

03060155 HB LAB RAPID HELICOBACTER SCRN 87339 155.17$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03060157 HB LAB HBSAG CONFIRMATION 87341 891.83$

03060160 HB LAB INFLUENZA B MEMBRANE EIA 87400 356.35$

03060161 HB LAB INFLUENZA A MEMBRANE EIA 87400 356.35$

03060164 HB LAB ROTAVIRUS BY EIA 87425 748.90$

03060165 HB LAB CAMPYLOBACTER DR AG IN STL 87427 370.45$

03060167 HB LAB RAPID STREP GROUP A 87430 195.28$

03060170 HB LAB DNA PROBE CANDIDA SP 87480 324.32$

03060173 HB CHLAMYDIA BY AMPLIFICATION 87491 781.11$

03060183 HB LAB LEGIONELLA DIRECT 87540 505.31$

03060201 HB LAB STREP A RPD SCN 87880 340.22$

03060207 HB LAB SPECIMEN CONCENTRATION 87015 111.64$

03060210 HB CONCENTRATION - STOOL 87015 118.79$

03060212 HB LAB CONCENTRATION(BROTH ENRICH 87015 111.64$

03060215 HB LAB CULT BAC BLOOD 87040 930.08$

03060218 HB LAB BLOOD STEM CELL CULTURE 87040 172.52$

03060223 HB ADDITIONAL WORKUP 87046 169.11$

03060227 HB LAB CULTURE RESPIRATORY 87070 807.28$

03060237 HB LAB CULTURE TISSUE 87070 475.11$

03060238 HB LAB CULTURE GENITAL 87070 143.82$

03060239 HB LAB CULT RESPIRATORY QUANT 87070 807.28$

03060240 HB LAB CULTURE BONE 87070 475.11$

03060241 HB CULTURE ANY SOURCE 87070 620.07$

03060243 HB LAB CULTURE ENVIRONMENTAL 87070 807.28$

03060244 HB LAB CULTURE BONE MARROW 87070 475.11$

03060246 HB LAB CULTURE UMBILICUS 87070 448.93$

03060247 HB LAB CULTURE EYE 87070 475.11$

03060248 HB LAB CULTURE ACTINOMYCES 87075 1,397.15$

03060249 HB LAB CULT BAC-ANAROB 87075 1,397.15$

03060267 HB LAB BACTI ADDNL. ID, EACH 87077 173.14$

03060271 HB LAB URINE DEFIN ORG ID, EACH 87077 134.93$

03060292 HB LAB IDENTIF, FUNGAL 87106 930.08$

03060293 HB LAB FUNG DEFIN. ID, 1ST ORG 87106 172.52$

03060294 HB LAB FUNG DEFIN. ID, 4TH ORG 87106 172.52$

03060295 HB LAB FUNG DEFIN. ID, 3RD ORG 87106 172.52$

03060296 HB LAB FUNG DEFIN. ID, 2ND ORG 87106 172.52$

03060298 HB LAB CULT BLOOD MYCOPLASMA 87109 930.08$

03060299 HB LAB CULTURE STERILE GENITAL 87070 475.11$

03060301 HB LAB CHLAMYDIA CULTURE 87110 383.53$

03060303 HB CULTURE, AFB UNSPECIFIED 87116 930.08$

03060306 HB LAB CULT URINE STERILE 87088 915.98$

03060308 HB LAB AFB ID 87118 986.43$

03060309 HB LAB CULT FUNG BLOOD 87103 930.08$

03060314 HB BACT ID BY FLUOR - STAPH 87149 461.02$

03060315 HB BACT ID BY FLUOR - YST 87149 461.02$

03060326 HB LAB ETEST MIC, EACH DRUG 87181 96.62$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03060335 HB BETA LAC ENZ DETECT 87185 96.62$

03060337 HB LAB WETMT FUNG 87210 273.81$

03060339 HB LAB SUSCEPT MIC 87186 807.28$

03060343 HB LAB HEP C VIR QUANT NUC ACID 87522 1,071.00$

03060388 HB LAB MICRO WBC FE 87205 273.81$

03060400 HB LAB MICROSPORIDIUM STAIN 87207 161.05$

03060401 HB LAB O&P TRICHROME STAIN 87209 374.44$

03060422 HB LAB VIRUS INOCULATION, TISSUE 87252 435.70$

03060438 HB LAB VIR RAP INFLU A & B CULT 87254 463.00$

03060441 HB LAB GIARDIA DFA 87269 217.44$

03060454 HB LAB VIR RESP IFA STAIN, NOS 87299 301.97$

03060481 HB LAB RSVMEMBRANE EIA 87420 583.82$

03060485 HB LAB MRSA RAPID LATEX 87450 223.48$

03060493 HB LAB ENTEROVIRUS AMP PROBE 87498 1,107.24$

03060494 HB LAB DNA PROBE GARD VAGINALIS 87510 324.32$

03060519 HB LAB HIV QUANTITATION BY PCR 87536 879.76$

03060521 HB LAB AFB DNA PROBE, 1ST ID 87550 324.32$

03060522 HB LAB AFB DNA PROBE, 4TH ID 87550 324.32$

03060523 HB LAB AFB DNA PROBE, 2ND ID 87550 324.32$

03060524 HB LAB AFB DNA PROBE, 3RD ID 87550 324.32$

03060528 HB GC BY AMPLIFICATION 87591 781.11$

03060533 HB LAB DNA PROBE TRICH VAGINALIS 87660 336.35$

03060551 HB LAB E COLI TOXIN AG DETCT OTHR 87899 179.18$

03060552 HB E COLI TOXIN AG DETECT 87899 150.23$

03060567 HB LAB UPPER RESP CULTURE 87070 495.25$

03060570 HB LAB GENITAL MYCOPLASMA CULT 87109 871.71$

03060571 HB CORD BLOOD/STEM CELL CX 87040 172.52$

03060573 HB HCV GENOTYPING 87902 4,300.32$

03060575 HB LAB HEP B RT PCR QUANT 87517 1,095.15$

03060597 HB LAB FUNGAL BLD CULTURE PEDS 87103 930.08$

03060598 HB LAB CULTURE STERILE RESPIRTY 87070 761.00$

03060603 HB LAB MICRO WRIGHT ST 87205 231.52$

03060606 HB LAB ANTGN CRYPTO SF 87327 495.86$

03060607 HB LAB UPPER RESP CULT MRSA SCRN 87081 304.79$

03060608 HB LAB YERSINIA CULTURE 87081 109.92$

03060609 HB LAB GRAM ST UNSPCFD 87205 325.53$

03060610 HB AFB TB SUSCEPT, EACH DRU 87190 116.65$

03060611 HB LAB CULT BAC-GC 87081 402.66$

03060612 HB LAB HISTOPLASMA BLD CULT 87103 911.65$

03060613 HB LAB SURVEILLANCE CULTURE 87081 402.66$

03060614 HB SMEAR, AFB UNSPECIFIED 87206 112.13$

03060615 HB LAB CULT BAC-STREP A 87081 402.66$

03060616 HB LAB SENST BAC ANAERO 87186 1,369.63$

03060617 HB MRSA SCREEN ONLY 87081 109.92$

03060618 HB LAB CULT STOOL-VIBRIO 87081 855.26$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03060619 HB LAB RHODAMINE AUROMN 88312 664.54$

03060621 HB C.DIFFICILE TOXIN B PCR 87798 567.60$

03060623 HB LAB ADENOVIRUS AG, DFA 87260 140.61$

03060624 HB LAB CYTOMEGALOVIRUS AG,DFA 87271 151.89$

03060627 HB LAB VARICELA ZOSTER AG, DF 87290 150.23$

03060640 HB RSV BY AMPL PCR 87798 567.60$

03060660 HB LAB HIV AG/AB COMBO 87389 335.54$

03060680 HB LAB INFLUENZA A/H1 87503 280.97$

03060681 HB LAB INFLUENZA A/H3* 87503 280.97$

03060682 HB LAB INFLUENZA A/2009H1N1 87503 280.97$

03060683 HB LAB INFLUENZA A UNSUBTYPEABLE 87502 1,151.81$

03060684 HB LAB INFLUENZA B* 87502 1,151.81$

03060685 HB LAB RSVA 87798 567.60$

03060686 HB LAB RSVB 87798 567.60$

03060687 HB VIRAL RESP PNL - 16 TARGETS 87633 5,710.99$

03060688 HB CHLAMYDIA PNEUMONIAE* 87486 567.60$

03060689 HB MYCOPLASMA PNEUMONIAE 87581 567.60$

03060690 HB BORDETELLA PERTUSSIS 87798 567.60$

03060692 HB MALDI MYCOBACTERIA ID ORGS 1 87118 986.43$

03060695 HB MALDI BACTI ANAEROB ID ORGS 1 87076 210.55$






03060701 HB MALDI BACTI ANAEROB ID CONTAM 87076 196.78$

03060702 HB MALDI YEAST ID ORGS 1 87106 172.52$



03060706 HB MALDI BACTI AEROB ID ORGS 1 87077 134.93$






03060712 HB MALDI BACTI AEROB ID CONTAM 87077 134.93$

03060713 HB MALDI MOLD ID ORGS 1 87107 172.52$

03060718 HB GRAM-POS BLD CULT NUCL ACID 87149 334.88$

03060719 HB MTB CMPLX RIFAMPIN PCR RESP 87556 567.60$

03060720 HB RIF MARKER 87500 548.23$

03060722 HB LAB HSV PCR 1+2 87529 551.02$

03060724 HB LAB GRAM NEG BLD CULT NA 87149 334.88$

03060726 HB HPV HIGH-RISK TYPES 87624 702.59$

03060727 HB HPV TYPES 16 & 18 ONLY 87625 1,118.45$

03060728 HB LAB ENTERIC BACTERIA PCR 87505 1,597.13$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03060729 HB VARICELLA-ZOSTER (VZV)-PCR, QUAL 87798 2,327.25$

03060730 HB LAB BINAXNOW MALARIA ANTIGN 87899 457.66$

03060734 HB BORDETELLA DNA FLEX 87798 438.26$

03060735 HB FLUA+B+RSV DNA FLEX 87632 3,810.74$

03060736 HB ENTERIC PARASITE PCR 87505 1,597.13$

03060737 HB RESP VIRUS DNA, 12-15 TARGETS 87633 5,710.99$

03060738 HB INFECTIOUS AGENT DNA, EA ORG 87798 807.28$

03060739 HB RESP VIRUS DNA FLEX 87633 5,710.99$

03060748 HB PHENO SUSCEPTIBILITY ID FISH 87149 326.49$

03060749 HB PHENO SUSCEPTIBILITY MIC WITH INTERP 87186 140.86$

03060750 HB MENINGITIS ENCEPHALITIS PCR PANEL 87483 5,449.93$

03060751 HB MRSA CONFIRMATION 87147 84.54$

03060752 HB CRYPTO AG LF CSF 87899 146.46$

03060753 HB CRYPTO AG TITER LF BLD 87899 146.46$

03060754 HB CRYPTO AG LF BLD 87899 146.46$

03060755 HB CRYPTO AG TITER LF CSF 87899 146.46$

03060756 HB VRE SCREEN 87081 402.66$

03060759 HB EXT ENTERIC BACT PCR 8 TARGET 87506 2,490.30$

03060760 HB RECTAL MDRO SCREEN 87081 384.48$

03060761 HB SUPPLEMENTAL RESPIRATORY VIRUS FLEX PNL 87631 1,597.13$

03060765 HB RANDOM VIRUSES OF RESPIRATORY TRACT PANEL FLEX87631 1,338.51$

03060766 HB INFLUENZA WITH H1/H3 TYPING PANEL FLEX 87631 1,338.51$

03060767 HB PRIMARY SEASONAL INFLUENZA PANEL FLEX 87631 1,338.51$

03060768 HB INFLUENZA A RAPID SCREEN, RESPIRATORY 87804 116.00$

03060769 HB INFLUENZA B RAPID SCREEN, RESPIRATORY 87804 116.00$

03060770 HB PARAINFLUENZA PANEL FLEX 87631 1,597.13$

03060771 HB INFLUENZA A RAPID ANTIGEN, RESPIRATORY 87804 406.68$

03060772 HB INFLUENZA B RAPID ANTIGEN, RESPIRATORY 87804 406.68$

03060773 HB SARS-COVID-19 DETECTION BY NUCLEIC ACID 87635 480.00$

03060774 HB SARS-COV-S PCR ROUTINE RESP (COVID-19) 87635 480.00$

03060776 HB COVID-19 SARS-COV-2 PCR RAPID RESP 87635 480.00$

03060777 HB VIRAL RESPIRATORY PANEL WITH COVID19 - 22 TARGETS0202U 6,826.05$

03070002 HB LAB URINALYSIS W/ MICROSCOPY 81001 328.30$

03070003 HB LAB URINALYSIS 81002 271.79$

03070004 HB LAB SPECIFIC GRAV UR 81003 122.81$

03070008 HB LAB PREGNANCY TEST URINE 81025 539.53$

03070014 HB URINALYSIS AUTO W/O MICRO 81003 273.81$

03070025 HB LAB POC URINE CHEMISTRY 81003 273.81$

03070026 HB LAB URINALYSIS W/ MICRO 81001 328.31$

03070027 HB LAB PREGNANCY TEST URINE* 81025 539.53$

03090018 HB LAB HGH SE 83003 12.06$

03090019 HB MYELIN BASIC PROTEIN 83873 18.34$

03090020 HB PROPAFENONE (RHYTHMOL) 80299 30.40$

03090021 HB PROZAC (FLUOXETINE) 80299 18.82$

03090024 HB URN METHYLMALONIC ACID 83921 21.53$


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HCPCS

Code

OP/ Default

Price

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Price



03090025 HB PHENYLALANINE 84030 19.30$

03090028 HB INFLUENZA VIRUS TYPES A & B 86710 10.71$

03090031 HB LAB ESTRADIOL SE 82670 17.85$

03090032 HB RIBOSOMAL P PROTEIN 83520 9.99$

03090046 HB ESTRIOL, UNCONJUGATED 82677 19.30$

03090048 HB HEPATITIS BE ANTIBODY 86707 7.72$

03090055 HB LAB TBG RIA SE 84442 17.61$

03090056 HB TRIGLYCERIDES 84478 6.03$

03090057 HB CHOLESTEROL 82465 6.03$

03090060 HB SOMATOSTATIN 84307 86.24$

03090063 HB XYLOSE, BLOOD 84620 63.32$

03090067 HB PARAINFLUENZA AB 86790 23.16$

03090071 HB MYELOPEROXIDASE AB 86021 10.62$

03090072 HB PROTEIN C ANTIGEN 85302 21.23$

03090073 HB PROTEINASE-3 AB 86021 14.48$

03090076 HB ASPERGILLUS AB 86606 12.30$

03090079 HB LAB ESTROGEN TOTAL 82672 14.48$

03090083 HB LAB VIP 84586 107.90$

03090087 HB LAB ANTIBD PM-1 86235 31.85$

03090091 HB ANTI CHROMATIN AB IGG 86235 19.30$

03090092 HB BORRELIA BURGDORFERI DNA 87476 226.78$

03090103 HB LAB TESTOSTERONE TOTAL 84403 8.00$

03090107 HB LAB SEX HORM BINDING GLOB 84270 11.42$

03090110 HB LAB FREE T4 BY DIALYSIS 84439 10.62$

03090132 HB LAB BONE SPECIFIC ALK PHOSPH# 84080 12.55$

03090136 HB LAB CREATINE, 24 HR URINE 82540 62.20$

03090137 HB LAB ALPHA SUBUNIT BLOOD # 83519 55.97$

03090141 HB LAB TRANSGLUTAMIN IGG/IGA 83516 9.91$

03090142 HB LAB DEOXYCORTICOSTERONE # 82633 47.29$

03090144 HB LAB INHIBIN B 83520 125.00$

03090149 HB LAB 17-HYDROXYPREGNENOLONE 84143 32.09$

03090173 HB LAB CLOZAPINE 80159 25.09$

03090174 HB LAB SEROTONIN 84260 47.29$

03090178 HB LAB 17-OH-CORTICOSTEROIDS 83491 24.13$

03090182 HB LAB FECAL FAT, TIMED 82710 43.23$

03090184 HB LAB CLONAZEPAM 80346 13.51$

03090185 HB TRYPTOPHAN 82131 41.90$

03090188 HB LAB BILE ACIDS, FRAC 83789 57.90$

03090192 HB LAB MUMPS IGM 86735 16.65$

03090194 HB LAB B. PERTUSSIS PCR 87801 28.95$

03090199 HB LAB IG GAMAGLOB 82784 7.85$

03090204 HB LAB HIV-1 DIRECT AG 87390 106.80$

03090205 HB LAB EPIDERMAL AB, IFA 86255 28.95$

03090207 HB LAB TULAREMIA AGGLUTININ 86000 51.15$

03090208 HB LAB ANTIBD CYSTICER 86682 54.04$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03090217 HB LAB TWAR PNL AB CHLAMYDIA IGM 86632 13.45$

03090222 HB LAB ANTIBD SCHISTOSOM 86682 40.53$

03090223 HB TOXOCARA AB 86682 35.46$

03090224 HB LAB ANTIBD CA EQ ENCP 86651 17.37$

03090226 HB LAB ANTIBD LCM 86727 15.00$

03090230 HB LAB CHLAMYDIA GROUP AB 86631 41.44$

03090231 HB VARICELLA ZOSTER ACIF 86787 6.87$

03090236 HB LAB ANTIBD TETANUS ANTITOXID# 86774 19.30$

03090252 HB LAB BLASTOMYCOSIS - CF # 86612 28.95$

03090253 HB BORDETELLA IGG (FHA) 86615 18.76$

03090254 HB BORDETELLA IGG (PT) 86615 18.76$

03090257 HB LAB LYME WESTERN BLOT IGG # 86617 10.61$

03090258 HB LAB LYME WESTERN BLOT IGM # 86617 10.62$

03090261 HB LAB VARICELLA ZOSTER IGM AB # 86787 9.89$

03090277 HB LAB MYCOPLASMA IGM ANTIBODY 86738 14.48$

03090278 HB CALIFORNIA ENCEPH AB, IGG 86651 15.92$

03090282 HB ST. LOUIS ENCEPH AB, IGG 86653 15.93$

03090286 HB C. PNEUMONIAE IGG 86631 8.96$

03090287 HB C. PNEUMONIAE IGA 86631 8.96$

03090288 HB C. PNEUMONIAE IGM 86632 8.97$

03090289 HB C. TRACHOMATIS IGG 86631 8.96$

03090290 HB C. TRACHOMATIS IGA 86631 8.96$

03090291 HB C. TRACHOMATIS IGM 86632 8.97$

03090292 HB C. PSITTACI IGG 86631 8.96$

03090293 HB C. PSITTACI IGA 86631 8.96$

03090294 HB C. PSITTACI IGM 86632 8.97$

03090301 HB ECHOVIRUS TYPE 4 86682 5.79$




03090315 HB STRONGYLOIDES IGG AB 86682 45.11$

03090316 HB WESTERN EQ ENCEPH IGG 86654 3.95$

03090319 HB GIARDIA IGG AB 86674 14.71$

03090320 HB GIARDIA IGA AB 86674 17.71$

03090321 HB GIARDIA IGM AB 86674 14.73$

03090326 HB STREPTOZYME 86063 14.48$

03090327 HB VARICELLA ZOSTER IGM 86787 6.88$

03090328 HB CSF CMV IGG 86644 14.48$

03090348 HB WEST NILE VIRUS IGM AB 86317 16.89$

03090352 HB HERPESVIRUS 7 IGM AB 86790 27.02$

03090353 HB HERPESVIRUS 6 DNA, PCR 87532 175.44$

03090370 HB CON A MITOGEN 86353 31.67$

03090371 HB PHA MITOGEN 86353 31.67$

03090372 HB POKEWEED MITOGEN 86353 31.67$

03090373 HB SPOTTED FEVER IGG AB 86757 9.65$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



03090374 HB SPOTTED FEVER IGM AB 86757 9.65$

03090376 HB SOLUBLE LIVER ANTIGEN AB 83520 28.95$

03090388 HB LAB URN FREE LIGHT CHAINS NEPH 83883 30.88$

03090389 HB LAB CHRONIC GRANULO DIS 82657 19.30$

03090394 HB LAB CANDIDA ANTIBODY PANEL 86628 13.51$

03090396 HB LAB HEPATITIS E IGM 86790 45.36$

03090398 HB LAB W NILE ANTIBODY PNL, CSF 86317 29.44$

03090401 HB LAB PAN ANCA EVAL ANA 86038 9.08$

03090409 HB LAB URN CITRATE 82507 13.70$

03090411 HB LAB THYROGLOBULIN ANTIB 86800 28.00$

03090412 HB LAB FITZGERALD FACTOR 85293 125.00$

03090415 HB LAB IGF-II 83519 85.00$

03090493 HB LAB CARNITINE, FREE # 83789 24.30$

03090501 HB LAB COPPER, URINE # 82525 15.75$

03090525 HB PANCREATIC AMYLASE 82150 14.00$

03090551 HB FLURAZEPAM 80346 36.05$

03090558 HB NEURONAL CELL AB, SERUM 83520 74.77$

03090560 HB INSULIN, TOTAL 83525 10.40$

03090562 HB INSULIN, FREE 83527 13.20$

03090593 HB ZINC,URINE 84630 11.20$

03090607 HB ASPERGILLUS AB BY ID 86606 10.85$

03090621 HB H. PYLORI IGA AB 86677 12.80$

03090624 HB HEMOGLOBIN, PLASMA 83051 14.65$

03090626 HB LEPTOSPIRA AB 86720 30.40$

03090629 HB MEASLES IGG 86765 11.03$

03090653 HB VIT B2, RIBOFLAVIN 84252 53.08$

03090663 HB LAB CSF MENINGO PNL RUBELLA 86765 18.25$

03090668 HB LAB INSULIN, FASTING 83525 9.60$

03090670 HB LAB INSULIN, 60 MINUTES 83525 9.60$


03090675 HB LAB SULFONAMIDES 80299 31.50$

03090683 HB LAB N-TELOPEPTIDE SE GC/MS 82523 105.00$

03090685 HB LAB MYCOPHENOLIC ACID 80180 14.62$

03090699 HB LAB PANCREATIC ELASTASE 83520 100.00$

03090706 HB LAB ALPHA-1-ANTITRYPSIN TOTAL 82103 19.27$

03090707 HB LAB ALPHA-1-ANTITRYPSIN PHNTYP 82104 20.73$

03090731 HB ALPHA 1 ANTITRYPSIN, STOOL 82103 19.30$

03090732 HB CARBOHYDRATE DEF TRNSFRN 82373 82.80$

03090738 HB VITAMIN K 84597 57.90$

03090770 HB LAB ANTI-GLIADIN ELISA, IGG 82397 23.45$

03090774 HB LAB TTG IGA 82397 30.15$

03090793 HB LAB FIBR IA NOT INFCT AGNT NOS 83520 73.70$

03090796 HB LAB TPMT ENZ NON-RADIO SUBSTRA 82657 73.70$

03090800 HB LAB GENOTYPE DNA HIV REVERSE T 87901 398.44$

03090802 HB LAB PHENOTYPE DNA HIV W/CLT AD 87904 40.56$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03090806 HB LAB COCCI ID IGG & IGM 86331 16.25$

03090820 HB OPIATE CONFIRMATION 80362 15.00$

03090824 HB PROPOXYPHENE CONFIRMATION 80362 9.73$

03090830 HB BARBITURATES, IDENTIFICATION 80345 122.41$

03090839 HB METHAQUALONE 80102 9.73$

03090849 HB SERTRALINE (ZOLOFT) 82542 66.77$

03090856 HB LAB MEXILETENE 82542 50.08$

03090864 HB LAB METHOTREXATE * 80299 24.13$

03090871 HB LAB PRIMIDONE 80188 10.40$

03090875 HB CALCITONIN 82308 26.54$

03090876 HB PARAINFLUENZA AB * 86790 11.58$

03090878 HB PROSTATIC ACID PHOSPHATASE 84066 9.41$

03090879 HB ALDOSTERONE 82088 11.58$

03090909 HB LAB CSF CA 19-9 86301 34.66$

03090914 HB LAB FLD CEA PERICARDIAL 82378 11.70$

03090916 HB LAB FLD CEA PLEURAL 82378 8.69$

03090920 HB LAB CSF HCG 84702 11.58$

03090922 HB LAB TUMOR NECROSIS FACTOR 83520 48.25$

03090934 HB LAB BIOTINIDASE 82261 18.25$

03090935 HB LAB IMMUNOREACTIVE TRYPSINOGEN 83516 18.25$

03090941 HB CHROMAGRANIN A 86316 22.68$

03090943 HB LAB NB TSH 84443 18.25$

03090947 HB LAB PLASMINOGEN # 85421 72.69$

03090955 HB LAB N-TELOPEPTIDE 82523 16.88$

03090956 HB CAFFEINE 80155 19.30$

03090959 HB LAB GONADOTROPIN RELEAS HRM 83727 225.00$

03090960 HB LAB GROWTH HORMONE AB 86277 104.22$

03090961 HB LAB SERUM FREE CORTISOL 82530 24.13$

03090964 HB LAB SOUTH CA ALLERGY PANE 86003 6.19$

03090969 HB LAB PROTHROMBIN ABS 83520 38.34$

03090970 HB LAB PLASMA RENIN ACTIVITY 84244 11.58$

03090977 HB LAB ANTITHROMBIN III ANTIGEN 85301 25.09$

03090987 HB LAB ANLZR - IMMUNOASSAY, RIA 83520 9.66$

03090988 HB LAB ANLZR - ANTINUCLEAR ABS 86038 9.02$

03090990 HB LAB ANLZR - DNA ANTIBODY 86225 10.24$

03090991 HB LAB ANLZR - NUCLEAR ANTIGEN AB 86235 66.85$

03090995 HB LAB PH, BODY FLUID 83986 5.44$

03091007 HB LAB COBALT SERUM 83018 21.40$

03091011 HB LAB PHENOBARBITAL 80184 7.20$

03091012 HB VIT D: 1,25-DIHYDROXY 82652 26.00$

03091014 HB URN VMA 84585 17.92$

03091016 HB LAB URN OXALATE 83945 22.08$

03091017 HB LAB URN METANEPHRINE 83835 23.15$

03091034 HB LAB CYSTATIN C 82610 52.11$

03091035 HB FOOD ALLERGY PROFILE 86003 5.78$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03091043 HB LAB CALPROTECTIN, STOOL 83993 62.73$

03091045 HB LAB HIV GENOTYPING 87901 241.25$

03091083 HB CHOLINESTERASE, PSEUDO 82480 11.94$

03091084 HB CHOLINESTERASE, PSEUDO 82480 9.55$

03091085 HB DIBUCAINE NUMBER 82638 14.33$

03091086 HB CK TOTAL 82550 8.88$

03091087 HB CK ISOENZYMES 82552 22.83$

03091089 HB LAB GASTRIN SE 82941 11.58$

03091090 HB HEPATITIS BE ANTIGEN 87350 7.72$

03091092 HB INTRINSIC FACTOR ANTIBODY 86340 12.06$

03091095 HB LIPOPROTEIN ELECTR SEP 82664 12.07$

03091100 HB TYROSINE 84510 24.13$

03091101 HB COMPLEMENT COMPONENT C2 86160 18.34$



03091106 HB CARDIOLIPIN IGA AB 86147 5.11$

03091107 HB AB BY GEL DIFFUSION 86331 1.96$

03091108 HB NOCARDIA AB 86744 20.55$

03091110 HB IGF-I BINDING PROTEIN 3 83519 27.99$

03091111 HB INHIBIN A 83520 19.30$

03091113 HB METHYLMALONIC ACID, SERUM 83921 13.51$

03091116 HB FOLATE, RBC 82747 6.27$

03091117 HB URN ALDOSTERONE 82088 24.30$

03091124 HB LAB SOMATOMEDIN-C, RIA 84305 18.34$

03091125 HB LAB MAGNESIOUM, RBC 83735 34.42$

03091126 HB LAB TESTOSTERONE TOT (FE/CH) 84403 8.69$

03091127 HB LAB TESTOSTERONE FREE 84402 8.00$

03091129 HB LAB SEX HORMONE BIND GLOB 84270 14.96$

03091130 HB LAB TESTOSTERONE BIOAV TOT 84403 14.20$

03091132 HB LAB ALBUMIN 82040 2.85$

03091136 HB FACTOR 8 MULTIMERIC 85247 25.00$

03091156 HB HCV RNA (TMA), QUAL 87521 56.94$

03091159 HB LAB ADINOPECTIN 83520 172.25$

03091160 HB LAB INTERLEUKIN 2 83520 91.68$

03091161 HB LAB HEP B PCR, QUAL 87516 91.68$

03091165 HB LAB AMNIO FLD AFP W/REF 82106 12.10$

03091166 HB LAB CKIE-CK 82550 13.00$

03091167 HB LAB ISLET CELL AB W/REFLEX 86341 24.13$

03091169 HB LAB OSTEOCALCIN # 83937 28.95$

03091172 HB LAB CREATININE, NOT BLOOD 82570 4.25$

03091174 HB LAB PEDIATRIC ALLERGY PNL 86003 5.58$

03091175 HB THYROTROPIN RELEASE HORM 83519 205.00$

03091181 HB LAB CITRATE # 82507 35.80$

03091185 HB GABAPENTIN 80171 24.13$

03091186 HB LAB PORPHOBILINOGEN, URINE 84110 32.96$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



03091187 HB LAB FATTY ACIDS, FREE 82725 14.48$

03091191 HB LAB LEUCINE AMINOPEPTIDASE 83670 32.00$

03091193 HB LAB CREATINE 82540 5.00$

03091195 HB LAB RESP MYCOPLASMA CULT 87109 19.65$

03091196 HB HEPATITIS D IGM AB 86692 64.75$

03091198 HB LAB WEST NILE VIRUS, PCR 87798 231.60$

03091203 HB LAB IGG SUBCLASSES 82787 7.86$

03091204 HB LAB FTA-ABS (IGM) 86780 5.79$

03091207 HB LUK ADH DF FLW CYT 1STMRK 88184 158.25$

03091208 HB LAB LUK ADH DF FLW CYT ADL MKR 88185 79.50$

03091210 HB LAB HEPATITIS D PCR 87798 37.44$

03091211 HB LAB ASPERGILLUS PPT, ID 86606 17.86$

03091213 HB LAB TYSABRI ABS 83516 243.75$

03091214 HB LAB FREE LIGHT CHAINS, 24H URN 83883 30.88$

03091215 HB LAB ANTIBD COXSACK A 86658 6.60$

03091216 HB LAB TWAR PNL ID GEL QUAL EA 86331 13.44$

03091218 HB ST. LOUIS EQ ENCEPH AB 86653 15.00$

03091219 HB LAB ANTIBD CRYPTO 86641 14.40$

03091225 HB LAB ANTIBD RESP SYN 86756 18.34$

03091226 HB TRICHINELLA AB 86784 36.91$

03091227 HB LYME IGG AB 86618 11.23$

03091229 HB LAB ANTIBD MYCOPLASMA CF 86738 33.78$

03091230 HB PARVOVIRUS (B19) AB 86747 14.48$

03091231 HB LAB DIPHTHERIA ANTITOXOID # 86648 19.30$

03091247 HB BORDETELLA IGA (FHA) 86615 18.76$

03091248 HB BORDETELLA IGA (PT) 86615 14.58$

03091251 HB LAB CSF LYME AB IGG # 86618 11.36$

03091252 HB LAB CSF LYME AB IGM # 86618 11.36$

03091256 HB LAB HISTO YEAST AB - CF # 86171 9.00$

03091257 HB LAB HISTO MYCELIAL AB-CF # 86171 9.00$

03091258 HB CALIFORNIA ENCEPH AB, IGM 86651 15.92$

03091259 HB EASTERN EQUINE AB, IGG 86652 15.93$

03091260 HB EASTERN EQUINE AB, IGM 86652 15.92$

03091262 HB ST. LOUIS ENCEPH AB, IGM 86653 15.92$

03091264 HB WESTERN EQUINE AB, IGM 86654 15.92$

03091277 HB MUMPS IGG AB 86735 12.53$

03091278 HB MUMPS IGM AB 86735 12.54$


03091285 HB MYOCARDIAL AB 86255 11.82$

03091288 HB WESTERN EQ ENCEPH IGM 86654 1.67$

03091296 HB CSF EBV IGG 86665 35.00$

03091297 HB CSF TOXO IGG 86777 41.50$

03091305 HB S. PNEUMO IGG AB 86609 9.65$

03091306 HB TOXOPLASMA DNA, PCR QUAL 87798 82.03$

03091309 HB WEST NILE VIRUS IGG AB 86317 16.89$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03091310 HB HANTAVIRUS IGG AB 86790 24.12$

03091311 HB HANTAVIRUS IGM AB 86790 24.13$

03091312 HB HERPESVIRUS 7 IGG AB 86790 27.02$

03091313 HB MYCOPLASMA DNA, PCR 87581 91.68$

03091315 HB A1 ACID GLYCOPROTEIN 83883 17.90$

03091316 HB HIV-1 PROVIRAL DNA, PCR 87535 120.63$

03091317 HB HERPESVIRUS 8 DNA, PCR 87798 249.45$

03091318 HB HERPESVIRUS 8 IGG AB 86790 43.91$

03091319 HB MITOCHONDRIAL M2 AB 83520 14.48$

03091320 HB LYME IGM AB 86618 11.23$

03091321 HB MAG AB-WESTERN BLOT 84181 73.50$

03091324 HB TOPHERYMYA WHIPPELLI DNA, PCR 87798 91.68$

03091325 HB POLIOVIRUS INNOC STUDY 87253 11.23$

03091326 HB POLIOVIRUS ISOL - INNOC 87252 32.10$

03091327 HB PLATELET CIRCULATING AB PNL 86022 12.87$

03091328 HB LAB SUBSTANCE P 83520 141.40$

03091329 HB LAB NEISSERIA GONORRHOEAE AB 86171 29.05$

03091332 HB LAB HEPATITIS E IGG 86790 13.99$

03091333 HB LAB HEPATITIS E IGG AND IGM 86790 29.68$

03091334 HB LAB COCCI CF 86635 11.34$

03091335 HB LAB ANTIBD DNA-FARR 86225 68.00$

03091336 HB LAB PAN ANCA EVAL LEUK AB 86021 15.00$

03091342 HB LAB PHOSPHATIDYLGLYCEROL ABS 84081 25.08$

03091345 HB LAB ANLZR - COMPLEMENT, AG 86160 17.90$

03091346 HB LAB ANLZR - MICROSOMAL AB 86376 10.84$

03091347 HB LAB ANLZR - RHEUM FAC, QUANT 86431 4.25$

03091350 HB LAB THYROGLOBULIN 84432 29.00$

03091352 HB LAB CORTICOSTERONE 82528 69.00$

03091353 HB PREGNENOLONE 84140 110.00$

03091403 HB LAB VITAMIN A # 84590 11.58$

03091405 HB LAB VITAMIN B6 # 84207 13.51$

03091409 HB LAB NICKEL, SERUM # 83885 16.70$

03091416 HB LAB PORPHYRINS, URINE 84120 29.12$

03091422 HB LAB TRYPSINOGEN 83519 22.40$

03091428 HB RUBELLA IGM ANTIBODY 86762 9.60$

03091435 HB TRICYCLIC ANTIDEPRESS SCR G0480 16.60$

03091438 HB SALIVARY AMYLASE 82150 13.99$

03091442 HB ARSENIC,URINE 82175 22.05$

03091445 HB URN B-2-MICROGLOBULIN 82232 15.50$

03091447 HB URN CADMIUM 82300 16.00$

03091448 HB VIT D: 25, HIDROXY 82306 15.00$

03091449 HB CALCIUM, IONIZED 82330 6.00$

03091450 HB LAB CARBOXYHEMOGLOBIN 82375 68.15$

03091455 HB ESTRONE 82679 32.00$

03091457 HB T3 FREE 84481 6.80$


Charge

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03091461 HB URN HISTAMINE 83088 29.20$

03091462 HB URN HOMOCYSTINE 83090 36.80$

03091464 HB LAB NEURONAL CELL AB, CSF 86316 74.77$

03091465 HB INSULIN, SERUM 83525 9.60$

03091473 HB LAB URN MERCURY 83825 14.98$

03091476 HB MYOGLOBIN 83874 14.70$

03091481 HB TOTAL ALKALINE PHOSPHATASE 84075 4.50$

03091482 HB ALK PHOS ISOENZYMES 84080 12.75$

03091496 HB INSULIN ANTIBODIES 86337 43.40$

03091499 HB ASPERGILLUS AB BY CF 86606 10.85$

03091501 HB B. HENSELAE IGG 86611 12.13$

03091514 HB H. PYLORI IGM AB 86677 12.80$

03091516 HB E. HISTOLYTICA IGG AB 86753 12.80$

03091517 HB LAB PANCREASTATIN 83519 255.00$

03091518 HB MEASLES IGM 86765 11.03$

03091522 HB VARICELLA ZOSTER VIRUS PCR 87798 100.00$

03091525 HB CIC RAJI CELL 86332 156.00$

03091526 HB SOLUBLE TRANSFERRIN RECPT 84238 18.00$

03091528 HB LAB TRYPTASE 83520 47.29$

03091529 HB LAB URN LEAD 83655 8.00$

03091530 HB LAB FLD LIPASE 83690 8.00$

03091532 HB LAB PLASMINOGEN ACTIVTR INHIB 85415 68.00$

03091533 HB LAB PYRUVATE KINASE 84220 58.00$

03091534 HB LAB FECAL FAT, QUAL 82705 14.33$


03091544 HB LAB ADENOSINE DEAMINASE,FLD 84311 32.00$

03091554 HB LAB ACETYLCHOL RECEPT AB PNL 83519 48.89$

03091556 HB LAB HER 2 / NEU 83950 64.59$

03091563 HB LAB B PERTUSSIS AB 86615 17.00$

03091566 HB LAB PORPHYRINS 84311 19.80$

03091567 HB HEINZ BODIES, DIRECT 85441 45.05$

03091568 HB HEINZ BODIES, INDUCED 85445 72.95$

03091574 HB LAB URN CATECHOLAMINES, FRAC 82384 26.46$

03091580 HB PLASMINOGEN ACTIVITY 85420 100.00$

03091597 HB LAB QUANTITATIVE IRON # 83540 48.52$

03091598 HB LAB QUANTITATIVE COPPER # 82525 57.90$

03091601 HB PTH RELATED PROTEIN 82397 24.55$

03091602 HB PANCREATIC POLYPEPTIDE 83519 65.74$

03091604 HB LAB MUCOPOLYSACCH, ACID QUANT 83864 59.95$

03091607 HB LAB PYRUVIC ACID 84210 22.80$

03091610 HB PROTEIN S AG, TOTAL 85305 23.00$

03091613 HB SPOROTHRIX AB 86671 97.08$

03091615 HB LAB METANEPHRINES, FRAC 83835 68.45$

03091616 HB LAB STOOL CL 82438 16.20$

03091617 HB LAB STOOL MG 83735 16.20$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03091619 HB LAB STOOL NA 84302 16.20$

03091623 HB LAB TUMOR HCG 84702 20.00$

03091624 HB LAB BETA 2 TRANSFERRIN 86335 253.60$

03091626 HB LAB 6MP METABOLITES 82542 90.45$

03091630 HB LAB ANTI-GLIADIN ELISA, IGA 82397 23.45$

03091631 HB LAB ANTI-HU-TTG ELISA IGA REC 82397 30.15$

03091633 HB LAB TOT SE IGA BY NEPHELOMETRY 82784 16.75$

03091644 HB LAB FIBRO NEPH, EA ANALYTE NES 83883 87.10$

03091646 HB LAB TPMT ENZ COLMN SGL ANALYTE 82542 73.70$

03091648 HB LAB HIV PHENOTYPE, COMPREHEN 87903 777.82$

03091649 HB LAB HIV PHENOTYPING, ADDL DRGS 87904 41.72$

03091650 HB LAB PHENOTYPE DNA HIV W/CULT 87903 756.26$

03091651 HB LAB TROFILE 87999 1,960.00$

03091661 HB COCAINE CONFIRMATION 80353 15.00$

03091663 HB AMPHETAMINE CONFIRMATION 80324 25.00$

03091664 HB BARBITURATE CONFIRMATION 80345 89.02$

03091665 HB METHADONE CONFIRMATION 80358 13.91$

03091666 HB BENZODIAZEPINE CONFIRMATION 80346 89.02$

03091669 HB PHENCYCLIDINE CONFIRMATION 83992 38.95$

03091671 HB AMOBARBITAL 80345 44.51$

03091679 HB METHADONE 80358 77.90$

03091682 HB NICOTINE 80323 35.00$

03091688 HB CITALOPRAM (CELEXA) 82542 83.46$

03091691 HB LAB KEPPRA (CHROMATOGRAPHY) 80177 14.72$

03091699 HB LAB STELAZINE 80342 37.50$

03091716 HB LAB NB GAL1PO4 URD TRANS SCN# 82776 18.25$

03091717 HB LAB NB HGB ELECTROPHORESIS # 83021 18.25$

03091718 HB LAB NB TANDEM MS.MS QUANT 83789 19.75$

03091719 HB LAB NB 17-OHP 83498 18.25$

03091723 HB LAB CA125 86304 49.00$

03091728 HB LAB FLD CA 125, PERITONEAL 86304 15.25$

03091729 HB LAB FLD CA 19-9 PERITONEAL 86301 34.66$

03091730 HB LAB FLD CA 19-9 PLEURAL 86301 34.66$

03091731 HB LAB CSF CEA 82378 51.75$

03091732 HB LAB FLD CEA PERITONEAL 82378 29.29$

03091744 HB RAST ANTIBODY 86003 5.58$

03091745 HB LAB HEPATITIS DELTA ANTIBODY 86692 24.13$

03091754 HB COMPLIMENT C1Q 86160 12.81$

03091756 HB LIVER-KIDNEY MICROSOMAL AB 86376 14.67$

03091766 HB LAB NEUTROPHIL ANTIBODY 86021 72.38$

03091769 HB VITAMIN B3 84591 58.87$

03091773 HB LAB URN ORGANIC ACIDS,QUANT 83918 135.00$

03091781 HB URN TELPEP 24H COL CX LNK 82523 16.98$

03091782 HB LAB URN TELPEP 24H CRT OTH SRC 82570 4.25$

03091784 HB LAB RA, IGG 86431 13.51$


Charge

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03091785 HB LAB RA, IGA 86431 13.51$

03091786 HB LAB RA, IGG, IGA, IGM 86431 13.51$

03091791 HB LAB WESTERN EQUINE AB, IGG 86654 15.92$

03091793 HB LAB MACROAMYLASE 84999 99.86$

03091807 HB URINE CYSTINE 82131 69.40$

03091808 HB ALLERGY PROF ASSY GAMMA IGE 82785 73.75$

03091812 HB C3 ACTIVATOR 83883 44.40$

03091813 HB ALPHA2 MACCROGLOBULIN 83883 27.99$

03091841 HB ALLERGY PRF ALLERG SPEC IGE 86003 1.55$

03091846 HB HISTOPLASMA ANTIGEN * 87385 103.00$

03091847 HB SULFONYLUREA HYPOGLYCEMICS G0480 88.10$

03091849 HB URINE HISTOPLASMA ANTIGEN 87385 103.00$

03091850 HB LAB CSF MENIN PNL WNV AB 86789 20.30$

03091851 HB LAB CSF MENN PL WNV AB, IGM 86788 23.80$

03091852 HB LAB CSF MENINGO PL AB MUMPS 86735 18.30$

03091853 HB LAB CSF MENINGO PL AB VZ 86787 18.10$

03091854 HB LAB CSF MENIN PNL AB HSV NS 86694 20.25$

03091857 HB CSF HSV 1 IGG 86695 20.00$

03091858 HB CSF HSV 2 IGG 86696 20.00$

03091859 HB MANGANESE, BLOOD 83785 16.70$

03091863 HB NEUROKININ A 83519 255.00$

03091871 HB C-TELOPEPTIDE, SERUM 82523 28.95$

03091872 HB HIAA, URINE 83497 17.92$

03091875 HB EUGLOBULIN CLOT LYSIS 85360 28.95$

03091877 HB TB COMPLEX PCR STERILE FLDS 87556 82.03$

03091878 HB HE4 OVARIAN CANCER MONITOR 86305 96.50$

03091882 HB VORICONAZOLE LEVEL 80299 72.38$

03091883 HB ITRACONAZOLE AND METABOLITE 80335 55.64$

03091884 HB RICKETTSIA IGG TITER 86757 24.61$

03091885 HB RICKETTSIA IGM TITER 86757 5.25$

03091886 HB BRUCELLA IGG/IGM 86622 9.42$

03091887 HB CRYOFIBRINOGEN 82585 23.28$

03091888 HB CRYOGLOB - QUAL/SEMI QUAN 82595 11.71$

03091890 HB Y ENTEROCOLITICA IGG/IGA 86793 14.48$

03091892 HB AB; TOXOPLASMA 86777 19.30$

03091893 HB AB; TOXOPLASMA, IGM 86778 19.30$

03091897 HB TSH RECEPTOR ANTIBODY 83520 35.80$

03091898 HB PROCALCITONIN 84145 180.00$

03091900 HB MYCOPLASMA IGG/IGM, IFA 86738 14.48$

03091901 HB OVARIAN AB, RFLX TTR (IFA) 86255 71.22$

03091902 HB RESP REGN XIII GAM GLOB IGE 82785 21.00$

03091903 HB RESP REGN XIII EA ALLERGEN 86003 5.26$

03091904 HB HISTAMINE RELEASE 86343 96.50$

03091911 HB THYROID STIMULAT IGG 84445 33.78$

03091915 HB IGF BIND PROTEIN-1 83519 44.39$


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03091919 HB EASTERN EQ ENCEPH AB 86652 17.37$

03091924 HB LAB COCCI PPTN (LATEX)# 86635 28.12$

03091926 HB LAB FLD CA 19-9 PERICARDIAL 86301 34.66$

03091942 HB LAB RETICULIN AB IGG 86255 57.90$

03091946 HB LAB WHOLE BLOOD VISCOSITY 85810 19.10$

03091947 HB TRNSF GRWTH FAC BETA, PL 83520 150.00$

03091948 HB INTERFERON GAMMA 83520 85.00$

03091956 HB LACOSAMIDE LEVEL 80299 82.03$

03091958 HB CONCT TIS DIS PRF ENA EA AB 86235 19.78$

03091959 HB CONCT TIS DIS PRF IMM ASSY 83516 10.25$

03091960 HB CORTISOL BINDING GLOBULIN 84449 75.00$

03091961 HB ESTROGENS, FRACT ESTRADIOL 82670 19.87$

03091962 HB ESTROGENS, FRACT ESTRIOL 82677 19.87$

03091963 HB ESTROGENS, FRACT ESTRONE 82679 19.88$

03091964 HB SEROTONIN, SERUM/PLASMA 84260 47.29$

03091965 HB ALPHA 2 ANTIPLASMIN 85410 48.73$

03091966 HB CSF CYSTERCERCUS ANTIBODY 86682 16.41$

03091967 HB NOROVIRUS PCR 87798 86.85$

03091969 HB ENTEROVIRUS PCR 87498 86.85$

03091970 HB HERPESVIRUS 8 PCR, QUANT 87799 173.70$

03091971 HB ADAMTS-13 ACTIVITY 85397 142.00$

03091972 HB AMD13X FAC INHIBITOR TST 85335 151.00$

03091973 HB AMD13Y IMM ASY INF AGNT 83520 175.00$

03091974 HB DRUG DEPENDENT PLATELET AB 86022 225.00$

03091990 HB THYROGLOB PNL THYROGLOBULIN 84432 48.00$

03091991 HB THYROGLOB PNL THYROGLOB AB 86800 27.00$

03091998 HB OCTREOTIDE 80299 175.00$

03092002 HB ADRENAL AB W RFLX 86255 21.23$

03092003 HB VW COLLAGEN BINDING 83520 57.90$

03092004 HB FLD MUCIN CLOT TEST 83872 21.58$

03092005 HB LAB COCCI COMP FIX TEST 86171 16.25$

03092008 HB LAB HIV PHENO INFECT AG DRG 87900 201.72$

03092011 HB LAB PROCOLLAGEN TYPE I 83519 77.20$

03092021 HB LAB NUT ALLERGEN PANEL 86003 8.89$

03092023 HB LAB CMV IGG AVIDITY 86644 41.43$

03092024 HB LAB STREP PNEU AG 86403 43.43$

03092025 HB LAB CAROTENES, FRACTIONATED 82380 48.00$

03092027 HB LAB CSF NMO 86255 300.00$

03092028 HB LAB URN OROTIC ACID 83921 107.00$

03092029 HB LAB URN FAT STAIN 89125 24.40$

03092030 HB LAB BARTONELLA PCR 87471 120.63$

03092032 HB LAB PROSTAGLANDIN D2 84150 275.00$

03092033 HB LAB PROSTAGLANDIN E2 84150 275.00$


03092035 HB LAB CSF PROT WB; IM ID BNDS 84182 24.65$


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03092036 HB LAB CSF IA INF AGNT AB QUAN 86317 16.65$

03092037 HB LAB PEPTIDE YY 83519 225.00$

03092039 HB LAB B PERTUSSIS IGG BY IB 86615 31.30$

03092040 HB LAB B PERTUSSIS IGM BY IB 86615 29.40$

03092041 HB LAB B PERTUSSIS IGA BY IB 86615 31.30$

03092042 HB LAB TROFILE DNA 87999 1,960.00$

03092045 HB LAB CHOLINESTERASE, SERUM 82480 11.94$

03092046 HB LAB CHOLINESTERASE, RBC 82482 11.94$

03092047 HB URN FREE CORTISOL 82530 17.60$

03092054 HB URN ETHANOL 80320 19.30$

03092060 HB GENTAMICIN LEVEL 80170 86.58$

03092061 HB VANCOMYCIN LEVEL 80202 18.02$

03092063 HB DIGOXIN LEVEL 80162 15.00$

03092065 HB BETA-HCG, QUANT 84702 6.80$

03092066 HB AMIKACIN LVL 80150 11.00$

03092067 HB CYCLOSPORINE LVL 80158 40.00$

03092068 HB AFB SLOW GROWER MIC 87186 97.95$

03092069 HB AFB ID, HPLC, CONVEN METHOD 87143 52.21$

03092070 HB H PYL CULTURE P PATHO SCRN 87081 13.89$

03092071 HB H PYL CUL SMEAR GRAM/GIEMSA 87205 13.89$

03092072 HB H PYLORI MIC PANEL 87181 35.78$

03092073 HB NOCARDIA/ACTINO MIC PNL 87186 82.03$

03092075 HB BACTERIAL ID, AEROBIC 87077 2.90$

03092076 HB COCCI IMMITIS DNA PROBE 87149 144.75$

03092079 HB FUNGAL IDENTIFICATION 87106 25.00$

03092090 HB HTLV-1/HTLV-2 DNA PCR 87798 75.76$

03092091 HB URN NICOTINE/COTININE SCRN 80323 35.00$

03092092 HB GHRELIN 83519 305.00$

03092093 HB GASTRIN RELEASING PEPTIDE 83519 200.00$

03092094 HB GROWTH HORMONE RELEAS HORM 83519 225.00$

03092095 HB INTERLEUKIN 1A 83519 225.00$

03092096 HB INTERLEUKIN 10 83519 325.00$

03092098 HB NMO ANTIBODY 83516 392.95$

03092099 HB RISPERIDONE 83789 38.60$

03092100 HB INTERLEUKIN 1 BETA 83519 225.00$

03092101 HB TESTOSTERONE, FR (MALE) 84402 13.50$

03092102 HB TESTOSTERONE, FR (FEM/CHLD) 84402 47.90$

03092103 HB LAB T CRUZI ANTIBODY, RIPA 86753 360.00$

03092104 HB LAB B PERTUSSIS IGG 86615 14.07$

03092105 HB LAB BABESIA MICROTI PCR 87798 245.30$

03092106 HB HERPESVIRUS 7 (HHV-7) PCR 87799 140.89$

03092108 HB LAB ANNA FLUOR AB; TIT EA 86256 89.19$



03092114 HB LAB URN SALICYLATE 80329 65.00$


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03092117 HB LAB URN CYCLIC AMP 82030 25.60$

03092122 HB LAB STOOL LACTOFERRIN 83630 60.31$

03092127 HB LAB FACTOR H 86160 55.00$

03092128 HB LAB BIOTIN 84591 90.00$

03092129 HB LAB STOOL CHYMOTRYPSIN 84311 14.48$

03092130 HB LAB THROMBOPOIETIN 83520 86.85$

03092131 HB LAB INF A H1N1 (2009) PCR 87502 91.68$

03092132 HB LAB HMPV PCR 87798 276.71$

03092134 HB LAB ADENOVIRUS PCR 87798 79.13$

03092136 HB LAB INFLUENZA A-B PCR 87502 72.38$

03092140 HB LAB LEGIONELLA PCR AMP PRB 87541 39.58$

03092141 HB LAB LEGION PCR AMP PRB NOS 87798 39.55$

03092147 HB LAB IBDSGI IMM ASS QU NOS 83520 18.74$

03092148 HB LAB IBDSGI CHEM LUM ASSAY 82397 20.45$

03092149 HB LAB IBDSGI CRP 86140 7.49$

03092156 HB LAB METHEMOGLOB REDUCTASE 82657 250.46$

03092157 HB LAB FLUCYTOSINE,SERUM 82542 125.14$

03092158 HB LAB MP ASPA GENE ANALYSIS* 81200 75.00$

03092163 HB LAB MP BLM GENE ANALYSIS* 81209 75.00$

03092184 HB LAB MP FANCC GENE ANALYSIS* 81242 75.00$

03092185 HB LAB MP FMR1 GEN ANAL EVAL* 81243 228.00$

03092187 HB LAB MP FLT3 GENE ANALYSIS* 81245 150.00$

03092190 HB LAB MP HEXA GENE ANALYSIS* 81255 75.00$

03092193 HB LAB MP IKBKAP GENE ANALYSIS* 81260 75.00$

03092207 HB LAB MP MCOLN1 GENE ANALYSIS* 81290 75.00$

03092222 HB LAB MP NPM1 GENE ANALYSIS* 81310 300.00$

03092228 HB LAB MP SMPD1 GENE ANALYSIS* 81330 75.00$

03092248 HB LAB MP PROC LEVL 2* 81401 166.67$


03092269 HB LAB NMRLP LIPOPROT BLD NMR 83704 38.50$

03092270 HB LAB NMRLP LIPID PANEL 80061 16.50$

03092282 HB LAB PFRBC ASY RBC PRTPRPH 84202 63.50$

03092285 HB LAB BHRM BORRELIA AB 86619 69.58$

03092286 HB LAB LGVF CHLAMYDIA AB 86631 6.72$

03092287 HB LAB LGVF CHLAMYDIA IGM AB 86632 6.73$

03092288 HB LAB HGEGM EHRLICHIA AB 86666 15.68$

03092289 HB LAB MI2Q NUCLEAR AG AB 86235 84.92$

03092290 HB LAB NMPQ IMASY QT NS NONAB 83520 67.06$

03092292 HB LAB LPTN CHEMILUM ASSAY 82397 70.88$

03092293 HB LAB RNP3R IMSY QT NS NONAB 83520 56.94$

03092294 HB LAB AGAL ENZYME CELL ACTV 82657 200.00$

03092298 HB LAB TPA FIBRNLYTIC PLASMIN 85415 119.00$

03092308 HB MALARIA IGG 86750 88.00$

03092336 HB T-CELL LYMPH SUBSETS BAL 86356 12.33$

03092340 HB HEPATITIS DELTA ANTIGEN* 87380 125.00$


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03092341 HB PORPHOBILIN DEAMINASE, RBC 82657 77.00$

03092349 HB COCAINE/BENZOYLECGONINE 80353 54.88$

03092350 HB PHOSPHATIDYLSERINE AB 86148 11.58$

03092351 HB ASPERGILLUS AB, EIA 86606 6.17$

03092352 HB PHOSPHATIDYLETHANOLAMINE AB 83520 14.48$

03092353 HB MULLERIAN INHIBITORY SUBS 83520 36.67$

03092354 HB PHOSPHATIDYLINOSITOL AB 83520 11.58$

03092355 HB PHOSPHATIDYLCHOLINE AB 83520 14.48$

03092356 HB FIP1L1-PDGFRA CYG DNA PRB 88271 22.52$

03092357 HB FIP1L1 CYG 100-300 88275 135.10$

03092358 HB FIP1L1 CYG INTERP & RPT 88291 67.55$

03092359 HB HERPES SIMPLEX WESTERN BLOT 86695 60.79$

03092360 HB HERPES SIMPLEX TYPE 2 86696 140.00$

03092367 HB CTCB CIRCULATING TUM BREAST 86152 503.73$

03092369 HB CTCC CIRCULATING TUM COLON 86152 503.73$

03092371 HB CRTCP CIRCULATING TUM PROST 86152 503.73$

03092373 HB VWF QUANTITATIVE MULTIMERS 85247 147.00$

03092374 HB SEROTONIN RLS ASSAY 86022 166.00$

03092376 HB JCV ANTIBODY NEUTRALIZATION 86790 563.56$

03092377 HB FACTOR V BLD CLOT TEST 85220 93.13$

03092378 HB FACTOR INHIBITOR TEST 85335 93.12$

03092379 HB FACTOR VIII BLD CLT TEST 85240 78.50$

03092381 HB FACTOR IX BLD CLT TEST 85250 142.81$

03092382 HB FACTOR IX INHIBITOR TEST 85335 84.91$

03092383 HB FACTOR XI BLD CLT TEST 85270 89.60$

03092384 HB FACTOR XI INHIBITOR TEST 85335 64.40$

03092386 HB INTERLEUKIN 6* 83520 95.54$

03092388 HB FACTOR 13 ACTIVITY 85290 38.60$

03092389 HB INTERLEUIN 2 RECEPTOR 84238 123.62$

03092390 HB HU, YO, RI RFLX TO TITER/WB 86255 51.71$

03092391 HB HU WESTERN BLOT 84181 96.50$

03092393 HB YO WESTERN BLOT 84181 100.00$

03092395 HB RI WESTERN BLOT 84181 96.50$

03092397 HB HU AB RFLX TO WB/TITER 86255 28.95$

03092398 HB HU, YO, RI RFLX WB/TIT, CSF 86255 93.55$

03092399 HB YO AB REFLEX TO WB/TITER 86255 40.28$

03092400 HB MOT SEN NEUR WEST BLOT 84181 16.67$

03092401 HB MOT SEN NEUR FLUOR AB SCRN 86255 16.67$

03092402 HB MOT SEN NEUR IMMASSY NO AB 83520 16.67$

03092403 HB RI ANTIBODY RFLX WB/TITER 86255 85.89$

03092404 HB HU WESTERN BLOT, CSF 84181 269.24$

03092406 HB YO WESTERN BLOT, CSF 84181 135.10$

03092408 HB RI WESTERN BLOT, CSF 84181 96.50$

03092410 HB MAG WB RFLX SGPG/MAG EIA 84181 43.43$

03092411 HB MAG-SGPG IGM EIA 83520 44.41$


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03092412 HB MAG IGM EIA 83520 47.29$

03092413 HB SENP FLUOR AB SCRN 86255 37.56$

03092414 HB SENP WESTERN BLOT 84181 37.55$

03092415 HB GANGLIOSIDE PANEL 83520 69.18$

03092416 HB MNP WESTERN BLOT 84181 90.70$

03092417 HB MNP IMMASSY QU NOS NONAB 83520 82.20$

03092418 HB C PSITTACI ANTIBODY 86631 8.80$

03092419 HB C PSITTACI ANTIBODY IGM AB 86632 9.30$

03092420 HB ARBOVIRUS AB, CA, IFA (CSF) 86651 45.56$

03092421 HB ARBOVIRUS AB, EA EQ 86652 45.56$

03092422 HB ARBOVIRUS AB, ST LO 86653 41.56$

03092423 HB ARBOVIRUS AB, WE EQ 86654 41.56$

03092424 HB BLADDER TUMOR AG 86294 156.00$

03092425 HB FACTOR II PT 85730 54.98$

03092426 HB FACTOR II PT 85610 35.96$

03092427 HB FACTOR II PROTHROMBIN 85611 36.09$

03092428 HB FACTOR II BLD CLT FAC 85210 118.95$

03092429 HB FACTOR II FAC INHIB TEST 85335 117.92$

03092430 HB FACTOR X THROMB TIM PART 85730 49.41$

03092431 HB FACTOR X PT 85610 32.32$

03092432 HB FACTOR X PROTHROMBIN 85611 32.44$

03092433 HB FACTOR X BLD CLT FAC 85260 147.42$

03092434 HB FACTOR X FAC INHIB TEST 85335 105.97$

03092436 HB SENSORY NEUROPATH XP AB 83516 143.19$

03092437 HB SENSORY NEUROPATH IMM ASSY 83520 143.19$

03092438 HB GALOP AB 83520 145.04$

03092439 HB SULFATIDE AB 83520 129.50$

03092440 HB NEOCOMPLETE IMMASSY NONAB 83516 158.40$

03092441 HB NEOCOMPLETE RIA NONAB 83519 158.40$

03092442 HB NEOCOMPLETE WEST BLT 84181 158.45$

03092443 HB NEOCOMPLETE PROT WB 84182 158.40$

03092444 HB NEOCOMPLETE FLUOR AB SC 86255 158.40$

03092445 HB NEOENCEPHALITIS IMMASSY NAB 83516 154.95$

03092446 HB NEOENCEPHALITIS RIA NONAB 83519 154.91$

03092447 HB NEOENCEPHALITIS WEST BLT 84181 154.95$

03092448 HB NEOENCEPHALITIS PROT WB 84182 154.95$

03092449 HB NEOENCEPHALITIS FLUOR AB SC 86255 154.95$

03092450 HB LEMS ANTIBODY 83519 149.63$

03092459 HB MUSK RIA NON-AB 83519 702.00$

03092481 HB ENDOMYSIAL ANTIBODY, IGG 86256 47.50$

03092483 HB ADEN DEAMINASE, PERIT FL 84311 39.20$

03092489 HB COMPLEMENT C7 86160 41.98$

03092490 HB COMPLEMENT C8 86160 78.73$

03092491 HB COMPLEMENT C9 86160 57.90$

03092492 HB HOUST DUST GREER (H1) IGE 86003 5.58$


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03092493 HB HSE DST HOLL-STR (H2) IGE 86003 5.58$

03092494 HB SUNFLOWER SEED (K84) IGE 86003 5.58$

03092495 HB A FUMIGATUS (M3) IGE 86003 5.58$

03092497 HB BRUCELLA IGM AGGLUTINATION 86622 11.58$

03092498 HB CSF GAD 86341 120.00$

03092499 HB ADEN DEAM, PERICARD FL 84311 109.24$

03092500 HB 5 HIAA PLASMA 82542 305.00$

03092501 HB FEB AGLUT AB; RICKETTSIA 86757 9.28$

03092502 HB FEB AGLUT AB; BRUCELLA 86622 9.28$

03092503 HB FEB AGLUT AB; SALMONELLA 86768 9.28$

03092504 HB PT.SERA DIFF ABSORPTION-ARC 86978 60.00$

03092505 HB PRETREAT RBC'S ENZM EA-ARC 86971 20.00$

03092507 HB PLATELET ANTIBODY SCREEN* 86022 252.00$

03092508 HB LAB PLATELET XROSSMATCH 86022 160.00$

03092510 HB ANTIBODY ELUTION (RBC)-ARC 86860 75.00$

03092514 HB LAB HLA MATCHING LARC 86813 383.00$

03092515 HB LAB AJWQ F5 GENE 81241 75.00$

03092516 HB LAB CELG HLA II TYP1 LOC HR 81382 217.75$

03092517 HB LAB CELPL HLA II TYP LOC HR 81382 232.83$

03092518 HB LAB CX26 GJB2 GENE FULL SEQ 81252 495.00$

03092519 HB LAB CYP2D6 GENE COM VAR 81226 199.76$

03092520 HB LAB FLT3R UNLISTED MOL PATH 81479 150.00$

03092521 HB LAB HB5GQ GENOTYPE DNA HEPB 87912 125.00$

03092522 HB LAB IBDSGI UNLISTD MOL PATH 81479 42.13$

03092525 HB LAB LACTP MOPATH PROC LEV 1 81400 198.32$

03092526 HB LAB MEN1 MOPATH PROC LEV 6 81405 543.75$

03092527 HB LAB MEN1 MOPATH PROC LEV 5 81404 543.75$

03092528 HB LAB PANCR CFTR GENE FUL SEQ 81223 786.67$

03092529 HB LAB PANCR MOPATH PROC LEV 5 81404 786.67$

03092531 HB LAB PCDQ UNLISTED MOLPAT 81479 668.75$

03092534 HB LAB SMAQ MOPATH PRO LEVEL 4 81401 607.95$

03092536 HB MOL SPINK1 POLYMORPHISM 81404 490.00$

03092537 HB LAB TPMT MOPATH PROC LEV 2 81335 264.65$

03092540 HB LAB ATHALI HBA1/HBA2 GENE 81257 378.00$

03092541 HB LAB ATHAL MOPATH PROC LEV 6 81405 600.00$

03092542 HB LAB APOEA MOPATH PROC LEV 2 81401 383.50$

03092543 HB LAB ATAX UNLISTED MOL PATH 81479 277.35$

03092544 HB LAB ATAX MOPATH PROC LEV 6 81405 277.35$




03092548 HB LAB CMTA MOPATH PROC LEV 6 81405 319.76$

03092549 HB LAB CMTA UNLISTED MOL PATH 81479 319.78$




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03092552 HB LAB CMTA PMP22 GEN FULL SEQ 81325 319.78$

03092553 HB LAB CMTA PMP22 GEN DUP/DEL 81324 319.78$


03092555 HB LAB DM1 MOPATH PROC LEV 2 81401 570.50$

03092556 HB LAB MP ASPA GENE ANALYSIS* 81200 137.51$

03092557 HB LAB MP FLT3 GENE ANALYSIS* 81245 166.67$

03092558 HB LAB MP HEXA GENE ANALYSIS* 81255 114.59$

03092560 HB LAB MP NPM1 GENE ANALYSIS* 81310 166.67$


03092562 HB LAB GROWTH HORMONE, 5 SPEC 83003 12.06$

03092563 HB LAB GROWTH HORMONE, 9 SPEC 83003 12.06$

03092564 HB LAB MYG PANEL RIA NONAB 83519 26.38$

03092565 HB LAB MYG PNL FL AB; SC EA AB 86255 79.13$

03092566 HB LAB MOLD ALLERGY ASY OF IGE 82785 26.72$

03092567 HB LAB MOLD ALRGN SP IGE Q/SQ 86003 1.78$

03092568 HB LAB PLATELET AB INDIRECT 86022 79.61$

03092569 HB LAB PLATELET AB DIRECT 86023 33.78$

03092570 HB LAB 1,5-ANHYDROGLUCITOL 84378 26.06$

03092571 HB LAB ANSER/INFLIXIMAB LEVEL 84999 400.00$

03092572 HB PT ABO TYPE (ARC) 86900 24.00$

03092573 HB PT RH TYPE (ARC) 86901 15.00$

03092575 HB PT RBC PHENOTYPE EACH (ARC) 86905 22.00$

03092576 HB ANTIBODY SCR EA TECH (ARC) 86850 38.00$

03092577 HB ANTIBODY ID EACH TECH (ARC) 86870 50.00$

03092578 HB DAT EACH ANTISERA (ARC) 86880 17.00$

03092579 HB ABID EA SELECTED CELL (ARC) 86885 10.00$

03092580 HB TITRATION EACH (ARC) 86886 76.00$

03092581 HB RH PHENOTYPE (ARC) 86906 42.00$

03092582 HB COLD AGGLUT. SCREEN (ARC) 86156 32.00$

03092585 HB INCUB. OF SER W DRUGS (ARC) 86975 138.00$

03092586 HB 17-KETOSTEROIDS, FRAC. 83586 19.30$

03092587 HB ALPHA-1-ANTITRYPSIN 82103 21.23$

03092588 HB AMINO ACID, LC/MS, PLASMA 82139 72.38$

03092589 HB ACETYLCHOLINE REC BLOC AB 83519 46.32$

03092590 HB ACE, SERUM 82164 8.69$

03092591 HB ACETYLCHOLINE REC MOD AB 83519 38.00$

03092593 HB ACYLCARNITINE, PLASMA 82017 82.99$

03092594 HB ACETYLCHOLINE REC BINDING 83519 43.43$

03092595 HB ACTH, PLASMA 82024 9.65$

03092596 HB ARGININE VASOPRESSIN 84588 24.13$

03092597 HB ADENOVIRUS ANTIBODY,SERUM 86603 10.62$

03092598 HB GBM AB 83520 24.13$

03092599 HB ALUMINUM 82108 21.23$

03092602 HB AMIODARONE & METABOLITE 80299 27.99$

03092603 HB AMITRIPTYLINE 80335 11.58$


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03092607 HB ANDROSTENEDIONE, LS/MS/MS 82157 20.27$

03092609 HB ALK. PHOSPHATASE ISO 1 84080 7.40$

03092610 HB ALK. PHOSPHATASE ISO 2 84075 2.60$

03092611 HB ALDOSTERONE 82088 15.05$

03092612 HB PRA,LC/MS/MS 84244 8.11$

03092614 HB ARYLSULFATASE A 84311 60.80$

03092617 HB VITAMIN B12 BIND CAPACITY 82608 30.38$

03092619 HB B MICROTI AB (IGG, IGM) 86753 16.89$

03092620 HB ASPERGILLUS ANTIGEN 87305 100.66$

03092621 HB BETA-HYDROXYBUTYRATE 82010 40.14$

03092622 HB BENZODIAZEPINES, SERUM 80346 68.52$

03092624 HB BETA-GLOBIN GENE DOSAGE 81404 437.82$

03092625 HB BUPROPION AND METAB,S/P 80299 95.54$

03092626 HB ANGIOTENSIN CONV ENZ 82164 12.00$

03092628 HB CANDIDA ANTIBODY, ID 86628 52.06$

03092629 HB CARNITINE, LC/MS/MS 82379 29.92$

03092630 HB CAROTENE, SERUM 82380 14.48$

03092631 HB CATECHOLAMINES, PLASMA 82384 72.38$

03092632 HB COBALT, BLOOD 83018 24.13$

03092633 HB CADMIUM, 24-HOUR URINE 82300 15.44$

03092634 HB CADMIUM,RANDOM URINE 82300 15.44$

03092635 HB CADMIUM, BLOOD 82300 24.61$

03092636 HB IMMUNOGLOBULINS(G,A,M)CSF 82784 10.62$

03092637 HB HIV-1 RNA, QN PCR, CSF 87536 72.38$

03092638 HB CHROMIUM, SERUM 82495 21.47$

03092639 HB HSV 1/2 (IGG) 86694 99.40$

03092640 HB IMMUNE COMPLEX, C1Q 86332 15.68$

03092642 HB C1 INHIBITOR, FUNCTIONAL 86161 16.41$

03092643 HB C1 INHIBITOR, PROTEIN 86160 16.41$

03092644 HB LACTIC ACID, CSF 83605 33.78$

03092657 HB 11-DEOXYCORTISOL,LC/MS/MS 82634 26.21$

03092658 HB NSE, CSF 86316 48.25$

03092659 HB COLD HEMAGGLUTININS 86157 21.04$

03092660 HB COENZYME Q10 82542 54.04$

03092661 HB C-PEPTIDE 84681 10.62$

03092662 HB COMPLEMENT, TOTAL (CH50) 86162 8.44$

03092663 HB TREPONEMA PALLIDUM AB 86780 5.79$

03092664 HB COPPER 82525 9.65$

03092665 HB VDRL, CSF 86592 4.83$

03092666 HB COXSACKIE B (1-6) AB,S 86658 11.21$

03092667 HB CYANIDE, BLOOD 82600 14.48$

03092668 HB CYSTINE, 24-HOUR URINE 82131 47.29$

03092670 HB DNASE-B ANTIBODY 86215 15.44$

03092671 HB DEXAMETHASONE 80299 61.08$

03092672 HB DENGUE FEVER AB (IGG,M) 86790 36.19$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092673 HB DIGITOXIN, S/P 80299 53.00$

03092674 HB DHEA,UNCONJUGATD,LC/MS/MS 82626 14.48$

03092675 HB DIHYDROTESTOSTERON,LCMSMS 80327 99.07$

03092676 HB DESIPRAMINE 80335 17.61$

03092677 HB DISOPYRAMIDE, SERUM 80299 14.48$

03092680 HB DOXEPIN 80335 21.23$

03092681 HB DIPHENHYDRAMINE, S/P 82542 56.00$

03092683 HB DRUG SCREEN PANEL 1 G0480 12.59$

03092685 HB DHEA SULFATE 82627 7.00$

03092686 HB EBV EA-D AB (IGG) 86663 6.76$

03092687 HB EBV EBNA AB (IGG) 86664 9.36$

03092688 HB E. CHAFFEENSIS AB (M) 86666 12.07$

03092689 HB E. CHAFFEENSIS AB (IGG) 86666 12.06$

03092690 HB ECHINOCOCCUS AB (IGG) 86682 65.14$

03092691 HB ENTAMOEBA HIST. IGG, ELIS 86753 18.34$

03092692 HB ESTRONE, LC/MS/MS 82679 22.47$

03092693 HB ETHOSUXIMIDE, SERUM 80168 16.50$

03092694 HB ETHYLENE GLYCOL 82693 11.58$

03092695 HB FECAL FAT, QUALITATIVE 82705 22.20$

03092696 HB FELBAMATE, SERUM 80299 24.13$

03092697 HB FENTANYL AND NORFENTANYL, 80361 58.87$

03092698 HB FUNGITELL(R) (1-3) 87449 110.00$

03092699 HB FIBRINOGEN AG,NEPHLOMETRY 85385 14.48$

03092700 HB FLECAINIDE, SERUM 80299 19.40$

03092701 HB LIPASE, PLEURAL FLUID 83690 19.30$

03092702 HB FAMIL. MEDITERRANEAN FEVE 88299 241.25$

03092704 HB COPPER, FREE 82525 63.00$

03092705 HB FRUCTOSAMINE 82985 5.79$

03092706 HB G-6-PD, QN 82955 13.51$

03092707 HB GAD-65 ANTIBODY 83519 24.13$

03092708 HB ASPERGILLUS ANTIGEN* 87305 38.60$

03092709 HB GLUCAGON 82943 15.44$

03092710 HB GLYCATED ALBUMIN 82985 37.50$

03092711 HB HCV FIBROSURE APOLIPOPROT 82172 73.65$

03092712 HB HCV FIBROSURE BILI TOT 82247 24.72$

03092713 HB HCV FIBROSURE GGT 82977 35.47$

03092714 HB HCV FIBROSURE HAPTOGLOB QU 83010 61.94$

03092715 HB HCV FIBROSURE NEPH N SPEC 83883 66.96$

03092716 HB HCV FIBROSURE 84460 26.04$

03092717 HB HEREDITARY HEMOCHROMATOS 81256 72.38$

03092718 HB H.INFLUENZAE TYPE B IGG 86317 11.10$

03092719 HB HISTAMINE, PLASMA 83088 64.17$

03092720 HB HISTONE ANTIBODIES 83516 19.30$

03092721 HB ARSENIC, BLOOD 82175 14.09$

03092722 HB LEAD, BLOOD 83655 8.49$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092723 HB MERCURY, BLOOD 83825 11.11$

03092724 HB ARSENIC, 24-HOUR URINE* 82175 14.70$

03092725 HB LEAD, 24-HOUR URINE 83655 9.55$

03092726 HB MERCURY, 24-HOUR URINE 83825 12.48$

03092727 HB 17-HYDROXYPROGESTERONE 83498 13.99$

03092728 HB HTLV-I/II AB W/RFL CONF 86790 13.80$

03092729 HB HTLV-I/II, CONFIRM ASSAY 86689 22.73$

03092730 HB HOMOVANILLIC ACID, 24 HR 83150 21.23$

03092731 HB IA-2 ANTIBODY 86341 48.25$

03092732 HB IGA SUBCLASSES IGA/IGD/IGG/IGM EA 82784 17.05$

03092733 HB IGA SUBCLASSES IGG 1, 2, 3 OR 4, EA 82787 7.27$

03092735 HB ACCUTYPE(R) IL28B 81400 57.90$

03092736 HB IMIPRAMINE 80335 21.23$

03092738 HB IODINE, SERUM/PLASMA 82542 24.13$

03092739 HB JAK2 EXONS 12, 13,QL,LEUM 81403 168.88$

03092740 HB JO-1 ANTIBODY 86235 15.50$

03092745 HB LAMOTRIGINE 80175 9.17$

03092746 HB LEAD, BLOOD* 83655 4.83$

03092747 HB LEGIONELLA AB 86713 23.74$

03092748 HB LIDOCAINE 80176 18.58$

03092749 HB LD ISOENZYME PNL - LACTATE 83615 11.11$

03092750 HB LD ISOENZYME PNL - LDH ENZ 83625 23.60$

03092751 HB LORAZEPAM 80346 31.85$

03092752 HB LIPOPROTEIN (A) 83695 21.00$

03092753 HB LP-PLA2 83698 50.00$

03092754 HB LEPTOSPIRA AB SCR W/RFL 86720 32.00$

03092755 HB PREGABALIN 82542 108.08$

03092761 HB MERCURY, BLOOD* 83825 13.75$

03092763 HB MANGANESE 83785 27.02$

03092765 HB PROLACTIN,TOTAL,MONOMERIC 84146 9.65$

03092766 HB METANEPHRINES, 24HR URINE 83835 16.41$

03092767 HB MYOGLOBIN, URINE 83874 14.48$

03092769 HB NEURON SPECIFIC ENOLASE 86316 40.05$

03092770 HB NORTRIPTYLINE* 80335 15.83$

03092771 HB 5' NUCLEOTIDASE 83915 52.45$

03092772 HB VDRL, SERUM 86592 8.70$

03092773 HB OLANZAPINE 80299 71.41$

03092774 HB OXYCODONE SCRN/CONFIRM 80361 64.66$

03092775 HB PENTOBARBITAL 80345 17.37$

03092776 HB B-TYPE NATRIURETIC PEP 83880 38.60$

03092777 HB ADA, PLEURAL FLUID 84311 94.09$

03092778 HB PAI-1 ANTIGEN 85415 53.08$

03092780 HB PORPHYRINS, FRACT, PLASMA 84311 88.78$

03092782 HB PROINSULIN 84206 38.60$

03092783 HB PROCAINAMIDE 80192 17.37$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092784 HB PORPHYRINS,FRACT,RAND UR 84120 16.41$

03092787 HB QUINIDINE 80194 13.27$

03092788 HB RETINOL BINDING PROTEIN 83883 17.37$

03092789 HB RETT SYNDROME MUTATION 83898 13.27$

03092790 HB B HENSELAE IGG,M W/RFL 86611 6.03$

03092791 HB RUBELLA AB IGM 86762 8.30$

03092792 HB RUFINAMIDE, SERUM/PLASMA 80299 62.76$

03092793 HB T3, REVERSE 84482 14.23$

03092794 HB S CEREVISIAE AB (IGG,IGA) 86671 51.30$

03092795 HB E. HISTOLYTICA AG 87337 32.81$

03092796 HB SELENIUM 84255 24.61$

03092799 HB LYSOZYME, SERUM 85549 17.37$

03092800 HB CLARISURE OLIGO-SNP,POST 81229 910.00$

03092803 HB STONE ANALYSIS 82365 11.58$

03092804 HB STRIATED MUSCLE AB 86255 11.58$

03092806 HB T3, TOTAL 84480 8.44$

03092808 HB THIOCYANATE, SERUM 84430 27.74$

03092811 HB TOPIRAMATE 80201 33.78$

03092813 HB TRAZODONE 80299 23.16$

03092814 HB OXCARBAZEPINE METABOLITE 80183 35.71$

03092815 HB TROPONIN T 84484 16.16$

03092816 HB TRYPSIN 83519 33.78$

03092817 HB T.PALLIDUM IGG & IGM AB 86780 5.79$

03092818 HB AMINO ACID, LC/MS, URINE 82139 72.38$

03092819 HB ACYLGLYCINES QUANT.,URINE 82542 370.15$

03092820 HB DELTA ALA, 24 HR URINE 82135 26.54$

03092821 HB ALDOSTERONE, URINE 82088 30.88$

03092824 HB CATECHOLAMINES, 24-HR UR 82384 26.54$

03092826 HB CHROMIUM 82495 119.49$

03092827 HB COPPER, 24-HOUR URINE 82525 17.37$

03092828 HB CORTISOL, FREE, URINE 82530 11.58$

03092829 HB DIURETICS PANEL, URINE 80307 83.00$

03092831 HB LEAD, 24-HOUR URINE* 83655 8.20$

03092832 HB MURAMIDASE, URINE 85549 80.34$

03092833 HB MERCURY, 24-HOUR URINE* 83825 15.44$

03092834 HB MANGANESE, 24-HOUR URINE 83785 36.19$

03092837 HB UREA NITROGEN, 24 HR UR 82397 215.35$

03092838 HB OXALIC ACID 24U W/O CREAT 83945 11.58$

03092839 HB PORPHOBILINOGEN, 24 HR UR 84110 24.13$

03092840 HB FLUNITRAZEPAM AND METAB,U G0480 160.19$

03092841 HB VMA, 24 HR URINE 84585 11.58$

03092842 HB DIAZEPAM AND METABOLITE 80346 97.74$

03092843 HB VAP TM CHOLESTEROL TRIG 84478 11.59$

03092844 HB VAP TM CHOL LIPO BL HR FR 83701 49.41$

03092845 HB VITAMIN B1 (THIAMINE),(B)* 84425 11.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092846 HB VITAMIN B1,LCMSMS 84425 11.58$

03092847 HB VITAMIN B5 84591 75.00$

03092848 HB VITAMIN D, 25-HYDROXY 82306 9.00$

03092849 HB VITAMIN D(1,25OHD),LCMSMS 82652 15.44$

03092850 HB VITAMIN C, SERUM 82180 14.00$

03092851 HB VERY LONGCHAIN FATTY ACID 82726 210.64$

03092853 HB VITAMIN E (TOCOPHEROL) 84446 13.51$

03092854 HB COUMADIN 82542 17.37$

03092855 HB ALPRAZOLAM, QN, SERUM 80346 100.00$

03092858 HB COCAINE CONFIRMATION GCMS 80353 56.87$

03092863 HB CANNABINOIDS 82542 55.00$

03092864 HB BENZODIAZEPINES, CONFIRM 80346 42.90$

03092865 HB ZINC 84630 8.93$

03092867 HB ZONISAMIDE 80203 47.77$

03092868 HB ZINC PROTOPORPHYRIN (ZPP) 84202 6.50$

03092869 HB OVA1 84999 585.00$

03092870 HB CYP2C19 GENOTYPE 81225 168.88$

03092871 HB UGT1A1 GEN PLYMRPH (TA RP) 81350 287.09$

03092872 HB VKORC1 GENOTYPING 81227 241.25$

03092873 HB CYP2C9 GENOTYPING 81355 241.25$

03092877 HB PRTRT RBC W/CHEM OR DRG ARC 86970 42.00$

03092881 HB RICKETTSIA IGM TITER RICKM 86757 22.20$

03092886 HB LAB HMEUR ASSAY ARSENIC 82175 15.31$

03092887 HB LAB HMEUR ASSAY URN CREAT 82570 4.25$

03092888 HB LAB HMEUR ASSAY LEAD 83655 9.78$

03092889 HB LAB HMEUR ASSAY MERCURY 83825 13.18$

03092890 HB LAB MTFRR ASSAY URN CREAT 82570 8.44$

03092891 HB LAB MTFRR METANEPHRINES 83835 25.34$

03092892 HB LAB PRPRQ URINE PORPHYRINS 84120 16.41$

03092893 HB LAB UALAR AMINOLEVULINIC AC 82135 26.54$

03092894 HB LAB UCATR 3 CATECHOLAMINES 82384 25.85$

03092895 HB LAB UCATR ASSAY URN CREAT 82570 6.48$

03092896 HB LAB UCBLTR QUNT SCN METALS 83018 62.06$

03092901 HB LAB UCRTFR CORTISOL FREE 82530 8.68$

03092902 HB LAB UCRTFR ASSAY URN CREAT 82570 2.90$

03092903 HB LAB UHVAR HOMOVANILLIC ACID 83150 16.98$

03092904 HB LAB UHVAR ASSAY URN CREAT 82570 4.25$

03092905 HB LAB ULEDR ASSAY LEAD 83655 5.74$

03092906 HB LAB ULEDR ASSAY URN CREAT 82570 2.46$

03092907 HB LAB UMERR ASSAY MERCURY 83825 11.58$

03092908 HB LAB UMERR ASSAY URN CREAT 82570 3.86$

03092909 HB LAB UMNGR ASSAY MANGANESE 83785 29.89$

03092910 HB LAB UMNGR ASSAY URN CREAT 82570 6.30$

03092911 HB LAB UNIKR ASSAY NICKEL 83885 38.65$

03092912 HB LAB UNIKR ASSAY URN CREAT 82570 8.15$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092913 HB LAB UOXR ASSAY OXALATE 83945 9.68$

03092914 HB LAB UOXR ASSAY URN CREAT 82570 4.80$

03092915 HB LAB UPBGR PORPHOBILINOGEN 84110 24.13$

03092916 HB LAB UVMAR ASSAY URINE VMA 84585 21.77$

03092917 HB LAB UVMAR ASSAY URN CREAT 82570 7.26$

03092918 HB LAB UZNR ASSAY ZINC 84630 27.11$

03092919 HB LAB UZNR ASSAY URN CREAT 82570 12.30$

03092920 HB LAB HAEQ COMPLEMENT ANTIGEN 86160 9.89$

03092921 HB LAB HAEQ COMP/FUNC ACTIVITY 86161 19.79$

03092922 HB LAB FRPN PHENYTOIN FREE 80186 21.71$

03092923 HB LAB UARSQ ASSAY ARSENIC 82175 13.09$

03092924 HB LAB UARSR ASSAY ARSENIC 82175 10.28$

03092925 HB LAB UARSR ASSAY URN CREAT 82570 2.81$

03092926 HB LAB HV6 VIRUS ANTIBODY NOS 86790 16.89$

03092927 HB LAB MYOSQ IMMUNOASSAY NONAB 83516 11.46$

03092928 HB LAB MYOSQ NUC AGEN ANTIBODY 86235 33.98$

03092929 HB LAB UCOPR ASSAY COPPER* 82525 17.37$

03092930 HB LAB UHISQ ASSAY HISTAMINE 83088 28.09$

03092931 HB LAB AVIAN COMPLEX MIC PNL 87186 144.48$

03092932 HB FLUID CREATININE 82570 8.70$

03092933 HB FLUID AMYLASE 82150 11.60$

03092934 HB FLUID LACTATE DEHYDROGENASE 83615 7.00$

03092935 HB FLUID GLUCOSE 82945 6.00$

03092936 HB FLUID PROTEIN 84157 6.00$

03092937 HB FLUID ALBUMIN 82042 6.00$

03092938 HB FLUID CHOLESTEROL 84311 10.60$

03092939 HB FLUID BILIRUBIN 82247 8.80$

03092940 HB FLUID CHLORIDE 82438 9.80$

03092941 HB FLUID TRIGLYCERIDES 84478 9.60$

03092942 HB FLUID URIC ACID 84560 7.80$

03092943 HB FLUID UREA NITROGEN 84520 8.70$

03092944 HB FLUID SODIUM 84302 9.70$

03092945 HB FLUID POTASSIUM 84999 10.70$

03092946 HB BORON LEVEL 83018 51.00$

03092947 HB FLUID RHEUMATOID FACTOR 86431 11.50$

03092948 HB ANSER ADA 84999 400.00$

03092949 HB ANSERI FX SUBSEQUENT SAMPLE 84999 251.25$

03092950 HB ANSWER ADA SUBSEQUENT SMPLE 84999 251.25$

03092953 HB OPIATES, SERUM 80361 77.20$

03092954 HB THYROTROPIN-BIND INHB IMGLB 83519 19.30$

03092955 HB ENDOMYSIAL IGA, RFLX TITER 86255 9.91$

03092956 HB JO-1 ANTIBODY IGG 86235 14.96$

03092957 HB PHOSPHOLIPIDS 84311 9.65$

03092958 HB ASIALO-GM1 IGM 83520 68.00$

03092959 HB ASIALO-GM1 IGG 83520 115.00$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03092960 HB URINE FENTANYL 80361 78.17$

03092961 HB URINE OXYCODONE 80362 64.66$

03092963 HB CMV GENOTYPE 87910 343.93$

03092964 HB DPD GENE MUTATION 81400 303.98$

03092965 HB HIAA, 24 HOUR URINE 83497 6.95$

03092966 HB ESTRONE SULFATE 82679 154.59$

03092968 HB RETICULIN IGG SCREEN 86255 11.82$

03092969 HB DEAMIDATED GLIADIN IGA 83516 9.91$

03092970 HB DEAMIDATED GLIADIN IGG 83516 10.27$

03092971 HB DEAMIDATED GLIADIN IGA/IGG 83516 9.91$

03092972 HB TISSUE TRANSGLUTAMINASE IGA 83516 9.91$

03092973 HB TISSUE TRANSGLUTAMINASE IGG 83516 9.60$

03092974 HB SINGLE STRANDED DNA 86226 62.84$

03092975 HB IMMUNOGLOBULIN IGD 82784 20.27$

03092976 HB 17OHP, ACTH STIMULATION 83498 14.50$

03092977 HB CORTISOL, ACTH STIMULATION 82533 2.11$

03092979 HB CSF HU 86255 95.54$

03092980 HB CSF YO 86255 82.03$

03092981 HB CSF RI 86255 103.07$

03092982 HB TAYEQ B HEXOSAMINIDASE 83080 168.00$

03092983 HB MFANQ UNLISTD MOL PATH PROC 81479 620.00$

03092984 HB FLCHMQ CHROMIUM 82495 19.00$

03092985 HB FLCBQ QUANT SCREEN METALS 83018 21.40$

03092986 HB FLCCQ CHROMIUM 82495 19.00$

03092987 HB FLCCQ QUANT SCREEN METALS 83018 21.40$

03092988 HB SEAFQ ALLERGEN SPECIFIC IGE 86003 6.70$

03092989 HB DHCQ COL CHROMTGRPHY QUANT 82542 175.00$

03092990 HB 18HC MASS SPECTROMETRY QUNT 83789 185.00$

03092991 HB DLACT LACTIC ACID 83605 300.56$

03092992 HB KITQ MOPATH PROCEDURE LEV 5 81273 334.86$

03092993 HB SNPOCQ CYTG M ARY CPY N&SNP 81229 1,061.50$

03092996 HB PLCHL ASSAY SERUM CHOLINEST 82480 11.94$

03092997 HB FANQ FANCC GENE 81242 148.37$

03092998 HB FMDQ IKBKAP GENE 81260 144.75$

03092999 HB GSDQ1 G6PC GENE 81250 308.80$

03093000 HB YDELQ MOPATH PROC LEVEL 4 81403 282.61$

03093014 HB RCKGQ RICKETTSIA ANTIBODY 86757 12.06$

03093015 HB QFEVR Q FEVER ANTIBODY 86638 11.83$

03093016 HB Q1GT Q FEVER ANTIBODY 86638 28.23$

03093017 HB Q2GT Q FEVER ANTIBODY 86638 28.23$

03093018 HB Q1MT Q FEVER ANTIBODY 86638 32.62$

03093019 HB Q2MT Q FEVER ANTIBODY 86638 32.62$

03093020 HB BART BARTONELLA ANTIBODY 86611 6.03$

03093021 HB BLASQ BLASTOMYCES ANTIBODY 86612 23.81$

03093022 HB AIGA IMMASY QUANT NOS NONAB 83520 138.60$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03093025 HB ACRTQ ALDOSTERONE 82088 14.86$

03093026 HB ACRTQ TOTAL CORTISOL 82533 6.37$

03093027 HB CEAPN CARCINOEMBRYONIC AG 82378 125.00$

03093031 HB SHELLFISH ALLERGY PANEL 86003 5.58$

03093032 HB ESTRADIOL, FREE 82670 75.13$

03093033 HB HIAA, CREAT RANDOM URINE 82570 4.25$

03093034 HB HIAA, 5-HIAA RANDOM URINE 83497 8.49$

03093035 HB MOPATH PROC LVL 5 MEN2 MUT 81404 206.51$

03093036 HB MOPATH PROC LVL 6 FMTC MUT 81405 206.51$

03093037 HB LOEDQ MOPATH PROC LEV 6 81405 311.65$

03093038 HB LOEDQ UNLISTED MOL PATH 81479 311.70$

03093039 HB DRGQ ASSAY OF VOLATILES 84600 13.58$

03093040 HB DRGQ DRUG SCREEN MULT CLASS G0480 61.42$

03093041 HB THEOQ ASSAY OF THEOPHYLLINE 80198 13.51$

03093043 HB LPFIMQ LIPOPROT BLD BY NMR 83704 22.61$

03093044 HB IGG4 IGG 1, 2, 3 OR 4, EACH 82787 8.62$

03093045 HB AJ4Q ASPA GENE 81200 159.63$

03093047 HB AJ4Q HEXA GENE 81255 159.63$

03093048 HB AJ4Q IKBKAP GENE 81260 159.62$

03093049 HB NEOP RIA NONANTIBODY 83519 68.89$

03093050 HB HISTD HISTOPLASMA 86698 21.71$

03093053 HB HV6PQ HHV-6, DNA, QUANT 87533 265.38$

03093054 HB MEAPQ RUBEOLA ANTIBODY 86765 8.45$

03093055 HB SLYT ASSAY OF PHOSPHORUS 84100 16.20$

03093070 HB OXL OXALATE 83945 82.00$

03093071 HB CRTSNQ CORTISONE LEVEL 83789 110.98$

03093072 HB CYCSQ CYCLOSERINE LEVEL 80299 57.33$

03093073 HB OSMUQ RBC FRAGILITY 85557 25.81$

03093074 HB SNPPCQ CHROM MICROARRAY POC 81229 1,590.00$

03093075 HB HTLVC HTLV CONFIRMATION 86689 21.93$

03093077 HB GAL3Q GALECTIN-3 82777 103.10$

03093078 HB VOLSQ VOLATILES 84600 45.40$

03093079 HB RISQ RISTOCETIN CO-FACTOR 85245 27.02$

03093080 HB RABVQ VAC RESP END PNT TTR 86382 90.00$

03093081 HB LYMR LYME DIS AB W/RFLX IB 86618 8.69$

03093082 HB SALMAB SALMONELLA AB PANEL 86768 7.00$

03093083 HB RTCAQ RETICULIN IGA 86255 11.77$

03093084 HB BHGT B HENSELAE IGG TITER 86611 14.48$

03093086 HB BQGT B QUINTANA IGG TITER 86611 37.00$

03093087 HB BQMT B QUINTANA IGM TITER 86611 6.03$

03093088 HB ATAX MOPATH PROCEDURE LEV 4 81403 277.35$

03093090 HB IMMUNOHISTOCHEMICAL STAIN 88342 55.00$

03093091 HB LAB N-METHYL-D-ASP REC AB CSF 86255 126.00$

03093093 HB LAB URINE CREATINE, 24 HR 82540 6.00$

03093094 HB LAB MSUD MUTATIONAL ANALYSYS 81205 340.65$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03093095 HB LAB CSF RIBOSOMAL P ANTIBODY 83516 62.06$

03093096 HB LAB URN FREE LIGHT CHAINS 83883 30.88$

03093097 HB LAB URN BETA-2-MICROGLOB RAND 82232 13.52$

03093098 HB LAB UB2MR, CREATININE 82570 6.75$

03093099 HB LAB PSA, POST-PROSTATECTOMY 84153 20.00$

03093100 HB LAB PORPHYRINS,PLASMA 82542 48.25$

03093101 HB LAB METHEMGLOBIN 83050 15.90$

03093102 HB LAB MEASLES IGM 86765 13.75$

03093103 HB LAB LYMPHOCYTE MITOGEN SCREEN 86353 115.80$

03093104 HB LAB COCCI TP AND F 86635 22.68$

03093105 HB LAB POSACONAZOLE LEVEL 80299 176.60$

03093107 HB LAB HIV-2 DNA/RNA PCR QL 87538 84.92$

03093108 HB LAB ADENOVIRUS PCR QUANT 87799 265.38$

03093109 HB LAB FILARIA IGG4 86682 55.97$

03093110 HB LAB HEAT SHCK PRT(HSP) 70KD AB 83520 125.00$

03093111 HB LAB HT SHK PROT(HSP) 70KD WB 86804 125.00$

03093112 HB LAB INNER EAR 68KD ANTIBODY 83520 125.00$

03093113 HB N-METHYL-D-ASPARTATE REC AB 86255 143.50$

03093114 HB BRCA,GENE ANALYSIS COMP 81162 2,074.75$

03093120 HB HEP C VIR RNA NS3 GENO 87902 607.95$

03093121 HB MYCOPLASMA/UREAPLASMA PCR 87798 80.72$

03093122 HB MICROARRAY, ONC. MOL LV 7 81406 1,621.80$

03093125 HB INF AGNT DRG SUS PH GN BI 87900 232.05$

03093126 HB INF AGNT GEN NUC ACD RV TR 87901 468.24$

03093127 HB INF AGNT GEN NUC ACID HIV-1 87906 189.71$

03093128 HB LAB CALR MUTATION ANALYSIS 81219 445.55$

03093129 HB LAB C4 BINDING PROTEIN 86329 19.30$

03093130 HB LAB H PYLORI BREATH TEST 83013 50.00$

03093131 HB LAB MYD88 MUTATION 81479 442.94$

03093132 HB LAB URODSK CAL,URN QN TMDSP 82340 3.60$

03093133 HB LAB URODISK CITRATE* 82507 3.50$

03093134 HB LAB URODSK CREATININE;URINE 82570 3.50$

03093135 HB LAB URODSK MG BLD;CHEMICAL 83735 3.50$

03093136 HB LAB URODISK OXALATE, URINE 83945 3.50$

03093137 HB LAB URODISK PH BDY FLD, NOS* 83986 3.50$

03093138 HB LAB URODISK PHOS URINE* 84105 3.50$

03093139 HB LAB URODISK POTASSIUM;URINE 84133 3.50$

03093140 HB LAB URODISK SODIUM; URINE* 84300 3.50$

03093141 HB LAB URODISK SULFATE, URINE* 84392 3.50$

03093142 HB LAB URODSK URIC ACID,URINE 84560 3.50$

03093143 HB LAB T CELL IMMUNE FUNCTION 86352 150.41$

03093144 HB LAB CEBPA MUTATION ANALYSIS 81218 280.82$

03093145 HB LAB OMEGA-3&6 FAT ACIDS, PL 82542 48.25$

03093146 HB LAB IMMUNOGLOBULIN IGE 82785 7.72$

03093147 HB LAB CELIAC PANEL 82784 2.21$


Charge

CodeDescription

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HCPCS

Code

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Price



03093148 HB LAB CELIAC PANEL* 83516 12.53$

03093149 HB LAB IBD DIF PANEL, LEUK ID 86021 25.76$

03093150 HB LAB IBD DIF PANEL, FUNGUS NOS 86671 32.93$

03093152 HB LAB TPMT ENZYME ACTIVITY 83789 275.05$

03093153 HB LAB LIV FIBROS SCRE BIL TOT 82247 17.21$

03093154 HB LAB LIVER FIBROS SCORE GGT 82977 24.88$

03093155 HB LAB LIV IB SCR IMS INFNS QU 83520 44.55$

03093156 HB LAB LIVER FIBR SCR NEPF NES 83883 46.85$

03093157 HB LAB HIV-1TROPISM,PROVIR DNA 87906 650.00$

03093158 HB LAB MANNOSE BINDING LECTIN 83520 24.13$

03093161 HB LAB APOLIPOPROTEIN A1 82172 10.62$

03093162 HB LAB APOLIPOPROTEIN B 82172 8.38$

03093163 HB LAB APOLIPOPROTEIN A1/B 82172 9.50$

03093164 HB LAB ACQRD ANGIOEDEMA AG EA 86160 11.41$

03093165 HB LAB ACQRD ANGIOEDEMA FUNC 86161 22.81$

03093166 HB LAB CARBO DEFIC TRANSF-ADLT 82373 82.80$

03093167 HB LAB CARNITINE PALMTRNS II D 81404 1,223.60$

03093168 HB LAB STOOL PORPHYRINS 84126 284.40$

03093169 HB LAB STREP PNEUMO 23 SEROTYP 86317 9.65$

03093170 HB LAB ACT PROT C RESISTANCE 85307 43.43$

03093172 HB LAB N MENINGITIDIS IGG 86317 12.18$

03093173 HB LAB CHIKUNGUNYA IGG/IGM 86790 45.84$

03093174 HB LAB THYROGLUBULIN-BILL ONLY 84432 40.00$

03093175 HB LAB THYROGLBLN AB-BILL ONLY 86800 27.00$

03093176 HB LAB ABL T315I MUTATION 81401 500.00$

03093177 HB LAB HYDROXYPROGESTERONE 83498 14.50$

03093178 HB LAB ALZHEIMER EVAL BLD CSFA 81401 330.13$

03093179 HB LAB ALZHEIMER EVAL BLD CSFB 83520 330.14$

03093180 HB LAB IGG KAPPA LAMBDA RATIOA 82784 188.98$

03093181 HB LAB IGG KAPPA LAMBDA RATIOB 83883 138.26$

03093182 HB LAB BWS/RSS MOLECULAR ANAL 81401 148.85$

03093183 HB LAB BILIARY TRACT MAL, FISH 88368 328.80$

03093184 HB LAB C TRACH/GC, TMA A 87491 21.45$

03093185 HB LAB C TRACH/GC, TMA B 87591 21.45$

03093186 HB LAB LYME IGG IMMUNOBLOT 86617 19.30$

03093187 HB LAB LEISHMANIA IGG 86717 44.25$

03093188 HB DRUG TEST, GEN TOXICOLOGY, BLOOD 80320 72.38$

03093189 HB DRUG TEST, GEN TOXICOLOGY, URINE 80320 75.00$

03093190 HB DRUG TEST, GEN TOXICOLOGY, SERUM 80320 72.38$

03093191 HB KIT 816V MUTATION ANALYSIS 81402 442.94$

03093192 HB PRADER/WILLI ANGELMAN 81331 343.06$

03093194 HB HLA B27 ANTIGEN 86812 15.44$

03093195 HB L/S RATIO 83661 50.00$

03093197 HB ADV LIP PNL CARDIO IQR CHOL 82465 6.30$

03093198 HB ADV LIP PNL CARDIO IQR LIPD 83718 6.30$


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CodeDescription

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HCPCS

Code

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Price



03093199 HB ADV LIP PNL CARDIO IQR TRIG 84478 6.30$

03093200 HB ADV LIP PNL CARDIO IQR LIPO 83704 12.62$

03093201 HB ADV LIP PNL CARDIO APO PROT 82172 6.30$

03093202 HB ADV LIP PNL ASSAY LIPOPROT 83695 6.30$

03093203 HB HIV 1 RNA QUAL, TMA 87535 77.20$

03093204 HB NAT PROCLEIX W/RFLX 87801 345.03$

03093205 HB CORTISOL, SALIVARY 82530 24.13$

03093206 HB IGA KAPPA LAMBDA RATIO A 82784 188.98$

03093207 HB IGA KAPPA LAMBDA RATIO B 83883 138.26$

03093212 HB IMMUNOHISTOCHEMICAL STAIN ADDL' 88341 69.80$

03093228 HB DRUG SCREENING COCAINE 80353 1.97$

03093248 HB IMMUNOFLUOR ANTIBODY INITIAL STAIN 88346 100.50$

03093250 HB LAB IBDSGI IF DNASE SEN 88350 37.52$

03093251 HB LAB IBDSGI IF PANCA 88346 37.52$

03093252 HB LAB ENTCY DIR IFA 88346 182.49$

03093253 HB LAB ENTCY IND IFA 88350 182.49$

03093256 HB RBC SNP HEA ARRAY RUO-RC 81403 275.00$

03093257 HB RHD ZYGOSITY RHZ-RC 81403 250.00$

03093258 HB RHD GENE ANALYSIS-RC 81403 450.00$

03093259 HB RHCE GENE ANALYSIS-RC 81403 450.00$

03093260 HB LICENSED RBC PANEL IVD-RC 81403 325.00$

03093261 HB GENOTYPING FOR WEAK D WKD-RC 81403 250.00$

03093262 HB VSOACTV INTST PLYPEP 84586 50.00$

03093263 HB 14-3-3 PROTEIN, CSF 83520 145.30$

03093264 HB VITAMIN C 82180 27.52$

03093265 HB LEPTOSPIRA AB, IGM 86720 44.80$

03093266 HB HISTOPLASMA AG, EIA 87385 103.00$

03093267 HB URN COCAINE/METAB 80353 21.23$

03093268 HB URN CANNABINOID 80349 21.23$

03093269 HB URN BENZODIAZEPINE 80346 38.60$

03093270 HB URN AMPHETAMINE 80359 10.61$

03093271 HB URN AMPHETAMINE 80324 10.62$

03093272 HB URN OPIATES 80361 13.00$

03093273 HB URN OPIATES 80365 12.80$

03093274 HB URN OPIATES 80367 12.80$

03093275 HB URN PROPOXYPHENE 80367 95.00$

03093276 HB URN PHENCYCLIDINE 83992 21.23$

03093277 HB URN METHADONE 80358 10.61$

03093278 HB URN METHADONE 80367 10.62$

03093279 HB URN BARBITURATES 80345 16.41$

03093280 HB LUTEINIZING HORM,PEDS 83002 15.92$

03093281 HB FOLLICLE STIM HORM,PEDS 83001 11.58$

03093282 HB T.CRUZI AB, TOTAL 86753 43.45$

03093283 HB DONOR WEST NILE, NAT 87798 313.63$

03093284 HB LEPTOSPIRA DNA, PCR 87798 313.63$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03093285 HB OVA1 81503 650.00$

03093286 HB ZIKA VIRUS, PCR 87799 125.00$

03093287 HB ZIKA VIRUS, IGM 86790 65.00$

03093479 HB T. CRUZI AB, IGG 86753 41.93$

03093480 HB CARBAMAZEPINE, FREE 80157 33.78$

03093481 HB ALDOLASE 82085 5.79$

03093495 HB ARBOVIRUS, CALIFORNIA 86651 42.12$

03093496 HB ARBOVIRUS, EASTERN EQUINE 86652 42.12$

03093497 HB ARBOVIRUS, ST.LOUIS 86653 42.12$

03093498 HB ARBOVIRUS, WESTERN EQUINE 86654 42.12$

03093539 HB FDA PANEL 89398 625.00$

03093542 HB LEISHMANIA IGG 86717 94.69$

03093543 HB LEGIONELLA AB, IGG 86713 10.13$

03093544 HB LEGIONELLA AB, IGM 86713 80.10$

03093545 HB NICOTINE/COT, SERUM 80323 56.94$

03093546 HB URN NICOTINE/COT 80323 56.94$

03093573 HB MYELOID MALIGNANCIES MUTATION PANEL NEXT GEN SEQ81455 1,995.00$

03093574 HB NEXT GEN SEQ (NGS), MULTIPLE MYELOMA 81455 3,014.10$

03093575 HB FLT3 ITD MUT ANALYSIS 81245 216.45$

03093576 HB FLT3 D835 MUT ANALYSIS 81246 108.55$

03093622 HB NEWBORN METABOLIC SCREENING PANEL S3620 141.25$

03093625 HB MANUAL DIFFERENTIAL 85007 4.24$

03093626 HB LAB CBC HEMOGRAM W/PLT* 85027 7.98$

03093627 HB CBC WITH AUTO DIFF 85025 9.59$

03093628 HB LAB BASIC METABOLIC PANEL 80048 10.44$

03093629 HB LAB MAGNESIUM SE ER 83735 8.27$

03093630 HB LAB SED RATE WESTEGN 85651 4.38$

03093631 HB LAB HEPATIC FUNCTION PANEL 80076 10.09$

03093632 HB LAB LIPASE SE ST 83690 8.51$

03093633 HB LAB URINALYSIS W/ MICROSCOPY 81001 3.92$

03093635 HB LAB URINALYSIS 81002 3.48$

03093636 HB LAB WHOLE BLOOD PROTIME 85610 4.85$

03093637 HB LAB COMP METABOLIC PANEL 80053 13.04$

03093638 HB LAB THYRO TSH SE RI 84443 20.75$

03093639 HB LAB POC OCCULT BLOOD 82272 4.23$

03093640 HB LAB LDH SE AU 83615 7.45$

03093641 HB LAB GLUCOSE, PRENATAL SCREEN 82947 4.85$

03093642 HB LAB PHOSPHOR SE AU 84100 5.85$

03093643 HB LAB BILIRU TOTAL ER 82247 6.19$

03093644 HB LAB BILIRUBIN, DIRECT 82248 6.19$

03093645 HB LAB PTT ER 85730 7.42$

03093646 HB LAB LIPID PANEL 80061 16.53$

03093647 HB LAB AMYLASE SE 82150 8.00$

03093648 HB VIT D:25-HYDROXY 82306 36.55$

03093649 HB CREATININE 82565 6.33$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



03093650 HB LAB FREE T4 84439 11.13$

03093651 HB LAB CALCIUM, FREE 82310 6.37$

03093652 HB LAB SGPT SE ER 84460 6.54$

03093653 HB LAB CA 27.29 86300 25.70$

03093654 HB LAB CARCINOEMB AN SE 82378 23.41$

03093655 HB LAB URIC ACID SE AU 84550 5.58$

03093656 HB LAB CA125 IA 86304 25.70$

03093657 HB LAB CA 19-9 86301 25.70$

03093658 HB LAB VITAMIN B-12 RI 82607 18.61$

03093659 HB LAB PROSTATE SPECIFIC ANTGN 84153 22.71$

03093660 HB LAB FOLLICLE STIM HORMONE 83001 22.94$

03093661 HB LAB LUTENIZING HORMONE 83002 22.86$

03093662 HB LAB TRIGLYCER SE SC 84478 7.09$

03093663 HB LAB FERRITIN 82728 16.83$

03093664 HB LAB POTASSIUM * 84132 5.68$

03093665 HB LAB SODIUM SE AU 84295 5.94$

03093666 HB LAB IG M, CORD BL 82784 11.48$

03093667 HB LAB PANEL IRON, TOTAL 83540 7.99$

03093668 HB LAB PANEL IRON BIND CAPACITY 83550 10.79$

03093669 HB LAB ALPHA FETOPROT 82105 20.71$

03093670 HB LAB GAM GLUT TRAN SC 82977 8.89$

03093671 HB URINALYSIS, NONAUTO, W/SCOPE 81000 4.02$

03093672 HB LAB C-REACT PROT QT 86141 15.98$

03093673 HB LAB UREA NITROGEN 84520 4.88$

03093674 HB LAB CHOLESTROL SE AU 82465 5.37$

03093675 HB LAB ALK PHOS SE AU 84075 6.39$

03093676 HB LAB S G O T SE ER 84450 6.39$

03093677 HB LAB LDL CHOLESTEROL 83721 11.78$

03093678 HB LAB TESTOSTERONE, TOTAL 84403 31.87$


03093680 HB RETICULOCYTE; AUTOMATED 85045 4.93$

03093681 HB LAB FOLATE SE RI 82746 18.15$

03093682 HB GENERAL HEALTH PANEL 80050 61.50$

03093683 HB PHOSPHATIDYLSERINE AB 86148 19.84$

03093684 HB FIBRINOGEN TEST,QUANTITATIVE 85370 14.02$

03093685 HB RETICULATED PLATELET ASSAY 85055 35.74$

03093686 HB ASSAY FREE HYDROXYPROLINE 83500 27.96$

03093687 HB ALDOSTERONE SUPPRESSION EVAL 80408 154.94$

03093688 HB LAB URN CATECHOLAMINES, FRAC 82384 31.18$

03093691 HB MULLERIAN HORM, FEM 82397 36.67$

03093692 HB MULLERIAN HORM, MALE 82397 36.67$

03093695 HB LAB GLUCOSE TOTAL 3H AU 82951 15.89$

03093696 HB LAB ALBUMIN 82040 6.11$

03093697 HB LAB CSF HCG 84702 18.59$

03093698 HB LAB ELECTROLYTES 80051 8.66$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03093699 HB LAB PROTEN TOT SE AU 84155 4.53$

03093700 HB MLH1 HYPERMETHYLATION MLH1 GENE 81288 508.30$

03093701 HB SLIDE REVIEW 88381 75.00$

03093702 HB AMYLOID PROTEIN ID, MICRODISSECTION LASER 88380 940.71$

03093703 HB AMYLOID PROTEIN ID, MASS SPECTROMETRY QUA 82542 157.89$

03093704 HB AMYLOID PROTEIN ID, CONGO RED, STAIN 88313 159.10$

03093705 HB COPPER, LIVER TISSUE 82525 57.90$

03093706 HB MICROSATELLITE INSTABILITY, TUMOR 81301 435.70$

03093707 HB MAML2 CYTO/MOLECULAR REPORT 88291 239.47$

03093708 HB MAML2 CYTOGENETICS DNA PROBE X2 88271 436.73$

03093709 HB INTERPHASES, 100-300 88275 30.00$

03093710 HB PDGFB CYTO/MOLECULAR REPORT 88291 277.93$

03093711 HB PDGFB CYTOGENETICS DNA PROBE X2 88271 506.87$

03093712 HB MGMT PROMOTER METHYLATION, TUMOR 81287 560.00$

03093713 HB AMYLOID PROTEIN MICRODISSECTION LASER 88380 940.71$

03093714 HB AMYLOID PROTEIN MASS SPECTROMETRY QUA 82542 157.89$

03093715 HB TFE3 CYTO/MOLECULAR REPORT 88291 329.25$

03093716 HB TFE3 CYTOGENETICS DNA PROBE X2 88271 620.45$

03093717 HB PROBE, +1 88271 30.00$

03093718 HB MYC CYTO/MOLECULAR REPORT 88291 320.71$

03093719 HB MYC CYTOGENETICS DNA PROBE X2 88271 584.89$

03093720 HB INTERPHASES, 25-99 88274 30.00$

03093721 HB COCCIDIOIDES PCR, PARAF 87798 225.50$

03093722 HB FUS, FISH CYTO/MOLECULAR REPORT 88291 279.81$

03093723 HB FUS, FISH CYTOGENETICS DNA PROBE X2 88271 510.29$

03093724 HB MELANOMA, FISH CYTO/MOLECULAR REPORT 88291 517.58$

03093726 HB IHC-TC ONLY INITIAL ANTIBODY 88342 105.00$

03093727 HB IHC-TC ONLY ADDITIONAL ANTIBODY 88341 92.00$

03093750 HB TRIIODOTHYRONINE TOTAL ASSAY, TT-3 84480 15.75$

03093785 HB ANSER VDZ 84999 400.00$

03093786 HB CYSTATIN C W/EGFR 82610 52.11$

03093787 HB COPEPTIN 86255 151.46$

03093788 HB VISCOSITY SERUM 85810 11.58$

03093789 HB CA27.29 86300 9.65$

03093790 HB VITAMIN C 82180 27.52$

03093791 HB MYELOID MUT PNL, NGS 81455 1,995.00$

03093792 HB LEUKOCYTE ALK PHOS 85540 64.00$

03093888 HB COVID 19, QUAL NAAT 87635 100.00$

03100016 HB LAB FLOW CYTOM-ADDL MARKERS 88185 418.75$

03100023 HB LAB GCSOF-TIS CULT SOLID TIS 88233 1,996.83$

03100036 HB LAB CAK-IN SITU ANL 15 CL/1K 88269 2,779.83$

03100042 HB LAB IISH1-ANALYZE 25-99 CELLS 88274 3,275.79$

03100043 HB LAB IISH2-ANALYZE100-300 CELLS 88275 4,094.73$

03100044 HB LAB ADDITIONAL KARYOTYPE 88280 419.51$

03100049 HB PATH INTROP TCH PRP, INITIAL 88333 2,739.16$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03100050 HB PATH INTROP TCH PRP, ADDL 88334 167.77$

03100052 HB LAB IMMUNOHISTOCHEMISTRY EA AB 88342 731.12$

03100058 HB LAB ESTROGEN RECEPTOR 88361 980.14$

03100059 HB LAB PROGESTERONE RRECEPTOR 88361 980.14$

03100070 HB LAB MORPHO ANALY, FISH, MYC 88368 980.14$

03100072 HB LAB MORPHO ANALY, FISH 13Q DEL 88368 980.14$

03100076 HB LAB TUMOR IHC QUANT MAN 88360 731.12$

03100089 HB LAB IISH2-FISH PROBE, EACH 88271 2,654.00$

03100091 HB LAB IISH2-ADDITIONAL PROBE 88271 2,480.38$

03100095 HB LAB IISH1-FISH PROBE, EACH 88271 2,654.00$

03100316 HB LAB CFKS-TISSUE CULTURE LYMPH 88230 1,653.19$

03100328 HB LAB ANALYZE 20-25 CELLS 88264 2,074.03$

03100329 HB LAB CBK-CYT BL 15-20 CLS 2K 88262 2,083.26$

03100352 HB LAB IHC MISC-SLIDE ONLY* 88342 731.12$

03100353 HB BM/PB STEM CELL PLAS DEPLETE 38214 5,499.72$

03100355 HB LAB MDS FISH PROBES * 88368 980.14$

03100356 HB LAB MORPHO ANALY, FISH, 14;18 * 88368 980.14$


03100358 HB LAB EGFR FISH ASSAY * 88368 980.14$

03100359 HB LAB MORPHO ANALY, FISH, 1P * 88368 980.14$

03100360 HB LAB MORPHO ANALY, FISH, 19Q * 88368 980.14$

03100361 HB LAB MORPHO ANALY, FISH, 11;14* 88368 980.14$

03100362 HB LAB HER-2/NEU FISH PROBE * 88368 980.14$

03100363 HB LAB MORPHO ANALY, FISH 13Q DEL * 88368 980.14$

03100364 HB LAB UROVYSION * 88121 980.14$


03100366 HB LAB CLL FISH PROBES * 88368 980.14$

03100368 HB PATH CON INTRAOP FZS, 1 BLOC 88331 731.12$

03100370 HB BRAF, MICRODISECT, MANL 88381 2,021.36$

03100371 HB KRAS MICRODISECTION MAN 88381 2,021.36$

03100372 HB NERVE TEASING PREPARATION 88362 2,739.16$

03100373 HB MYELOPEROXIDASE STAIN 88319 2,739.16$

03100374 HB LAB ALK FISH ASSAY 88368 980.14$

03100375 HB EGFR MICRODISECTION MAN 88381 2,021.36$

03100378 HB IMMUNO CYTOCHEM, EA ADDTL 88344 980.14$

03100380 HB IMMUNOHISTO ANTIBODY SLIDE ADDL 88341 775.69$

03100381 HB INSITU HYBRIDIZATION (FISH) 88364 1,189.54$

03100382 HB MORPHO ANAL ADDTL PROBE FISH ALK 88369 1,216.74$

03100384 HB LAB ISH SLIDE ONLY 88365 731.12$

03100385 HB LAB IHC MISC-SLIDE ONLY ADDL' 88341 874.12$

03100387 HB MORPHO ANALYSIS FISH MULTIPLEX PROBE 88377 731.12$

03100388 HB MICRODISSECTION, LASER CAPTURE 88380 553.65$

03100389 HB MICROSATELLITE INSTABILITY ANALYSIS 81301 2,178.98$

03100390 HB TARGETED GEMONIC SEQ ANALYS CSCOMP 81479 33,748.34$

03100391 HB TARGETED GENOMIC SEQ ANALYS MYELOID 81479 33,748.34$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03100392 HB TARGETED GENOMIC SEQ ANALYS MYELOID NGS 81455 33,748.34$

03110002 HB PATHOLOGY FLUID, SMEAR 88104 416.12$

03110003 HB PATHOLOGY FLUID, CONCENTRATE 88108 512.27$

03110004 HB PATHOLOGY FLUID, SUREPATH 88112 664.54$

03110009 HB PATHOLOGY SMEAR PREP/SCR/INT 88161 372.42$

03110012 HB PATHOLOGY GYN (BETHESDA) MAN 88164 259.72$

03110015 HB PATHOLOGY FNA INTERP & RPT 88173 664.54$

03110016 HB LAB DNA ANAL, TISSUE 88182 664.54$

03110017 HB LAB DNA ANAL, BONE MARROW 88182 664.54$

03110020 HB FLOW CYTOMETRY, FIRST MARKER 88184 980.14$

03110025 HB FACS, ADDL MARKER 3 88185 320.38$




03110033 HB FACS, INTERP 2-8 MARKERS (4X) 88187 830.38$

03110035 HB PATHOLOGY FNA CYTOTECH ASST 88199 664.54$

03110042 HB CELL CRYOPRESERVE/STORE 88240 243.12$

03110050 HB FROZEN CELL/THAW 88241 353.65$

03110164 HB PATHOLOGY GYN LIQUID/MAN SCR 88142 236.31$

03110174 HB FLOW CYTOM- 1ST MARKER 88184 980.14$

03110192 HB LAB ANEU-FISH PROBE, EACH 88271 2,654.00$

03110193 HB LAB MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL88275 4,094.73$

03110198 HB CYTO QUICK STAIN 88172 731.12$

03110199 HB LAB ADNL CELLS COUNT/KARYOTYPE 88285 269.73$

03110200 HB LAB CBK-BLOOD TISSUE CULTURE 88230 1,653.19$

03110209 HB CYTOPATH FNA - ADQC 2 SM ST 88177 131.95$

03110213 HB CELL CULTURE 88230 1,653.19$

03110216 HB LUMINX C1Q INTERP 88187 830.38$

03110219 HB LUMINX SINGLE AG INTERP 88188 1,036.04$

03110222 HB FLOW SCREEN INTERPRETATION 88189 1,364.77$

03110223 HB FACS, ADD'L MARKER 5 88185 320.38$

03110224 HB FACS, INTERP 2-8 MARKERS (5X) 88187 1,037.95$





03110252 HB FACS, INTERP 9-15 MARKERS 88188 1,036.04$

03120001 HB PATHOLOGY LEVEL I SURGICAL 88300 276.23$

03120003 HB PATHOLOGY LEVEL II SURGICAL 88302 482.54$

03120004 HB PATHOLOGY LEVEL III SURGICAL 88304 664.54$

03120006 HB LAB TISSUE GR M 7 88305 664.54$

03120007 HB CYTOLOGY CELL BLOCK 88305 664.54$

03120008 HB LAB TISSUE GR M 7 - BM 88305 664.54$

03120009 HB PATHOLOGY LEVEL V SURGICAL 88307 980.14$

03120010 HB PATHOLOGY LEVEL VI SURGICAL 88309 2,739.16$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03120011 HB PATHOLOGY DECALICIFICATION 88311 122.81$

03120012 HB PATHOLOGY DECAL - BM 88311 122.81$

03120013 HB PATHOLOGY TISSUE STAIN GR I 88312 664.54$

03120015 HB PATHOLOGY TISS STN GR II - BM 88313 237.79$

03120016 HB LAB IRON STAIN - BM 88313 257.01$

03120017 HB LAB IRON STAIN 88313 257.01$

03120018 HB PATHOLOGY TISSUE STAIN GR II 88313 237.79$

03120019 HB PATHOLOGY TISSUE STAIN, FROZ 88314 915.98$

03120022 HB PATHOLOGY TISSUE STAIN, ENZ 88319 2,739.16$

03120025 HB PATHOLOGY INTRAOPERATIVE CON 88329 420.13$

03120027 HB PATH CON INTRAOP FZS, ADDL 88332 146.95$

03120028 HB IMMUNOFLUOR ANTB INITIAL STAIN 88346 980.14$

03120032 HB PATHOLOGY EM, DIAGNOSTIC 88348 2,739.16$

03120040 HB LAB CTK-TIS CULT SOLID TISSUE 88233 1,996.83$

03120042 HB LAB CAK-TISSUE CULTURE AMNIO 88235 1,845.50$

03120043 HB LAB CCCK-TISSUE CULTURE CVS 88235 1,845.50$

03120044 HB LAB CCBK-TIS CULT CANCER/HEM 88237 1,792.26$

03120045 HB LAB CMS-BLOOD TISSUE CULTURE 88239 2,386.07$

03120046 HB LAB GCSOF-FRZ & STRG OF CELLS 88240 360.35$

03120048 HB LAB ANALYSIS 5 CELLS/1 KARYT 88261 2,507.72$

03120049 HB LAB CFKS-CHROM ANL 5 CELLS/1K 88261 2,507.72$

03120054 HB LAB CTK-TIS CHROM AN 20 CELLS 88262 2,083.26$

03120055 HB LAB CCBK-ANALYZE 20-25 CELLS 88264 2,074.03$

03120057 HB LAB CKST-ANALYZE 20-25 CELLS 88264 2,074.03$

03120058 HB LAB CCCK-ANALYSIS 15 CELLS/1K 88267 3,004.77$

03120062 HB LAB CCBK-1 CHROM ADD KARYOTYPE 88280 419.51$

03120063 HB LAB CAK-1 CHROMO ADD KARYOTYPE 88280 419.51$

03120065 HB LAB CKST-ADDITIONAL KARYTYPE 88280 419.51$

03120066 HB LAB CCCK-1 CHROM ADD KARYOTYPE 88280 419.51$

03120069 HB LAB CCCK-AD CELLS CNT/KARY 88285 269.73$

03120078 HB LAB HER2/NEU RECEPTOR 88361 980.14$

03120079 HB LAB KI67 (MIB-1) 88361 980.14$

03120082 HB LAB CAK-ADNL CELLS CNT/KARYO 88285 269.73$

03120084 HB LAB CHRK-CHRM ANL 15-20 CLS/1K 88262 2,083.26$

03120085 HB LAB CMS-CHRM AN 15-20 CELLS/1K 88262 2,083.26$

03120088 HB LAB HPV HIGH RISK IN SITU 88365 731.12$

03120089 HB LAB HPV LOW RISK IN SITU 88365 731.12$

03120090 HB LAB TISSUE INSITU INTRP, RPT 88365 731.12$

03120091 HB OUTSIDE CONSULT, WITH PREP 88323 664.54$

03120098 HB IMMUNOFLUOR ANTB ADDL STAIN 88350 907.10$

03200002 HB XR C-SPINE 1 VW 72020 1,028.69$ 1,337.30$

03200003 HB XR L-SPINE 1VW 72020 1,028.69$ 1,337.30$

03200004 HB XR T-SPINE 1VW 72020 1,028.69$ 1,337.30$

03200011 HB XR KNEE 1-2VW UNILATERAL 73560 1,028.69$ 1,337.30$

03200013 HB XR COLON POUCH-O-GRAM 74270 2,825.94$ 3,675.13$


Charge

CodeDescription

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HCPCS

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Price

IP/ER

Price



03200014 HB XR COLON ENEMA W CONT 74270 2,825.94$ 3,675.13$

03200019 HB IMG ABSCESS/FISTULA S&I 76080 2,123.60$ 2,760.67$

03200021 HB PATHOLOGY TISSUE XRAY 76098 2,123.60$

03200024 HB PLCMT VEIN DEVICE 77001 1,326.56$ 1,724.32$

03200027 HB XR GUIDANCE S&I 77002 1,944.22$ 2,527.49$

03200030 HB XR MANDIBLE 1-3VW 70100 1,028.69$ 1,337.30$

03200031 HB XR MANDIBLE 4VW/MORE 70110 1,347.16$ 1,751.30$

03200032 HB XR MASTOIDS 1-3VW 70120 1,028.69$ 1,337.30$

03200033 HB XR FACIAL BONES 1-2VW 70140 1,174.22$ 1,526.48$

03200034 HB XR FACIAL BONES 3VW/MORE 70150 1,347.16$ 1,751.30$

03200035 HB XR NASAL BONES 3VW/MORE 70160 1,028.69$ 1,337.30$

03200037 HB XR ORBITS 4VW/MORE 70200 1,347.16$ 1,751.30$

03200038 HB XR SINUSES 1-2VW 70210 1,028.69$ 1,337.30$

03200039 HB XR SINUSES 3VW/MORE 70220 1,347.16$ 1,751.30$

03200040 HB XR SKULL 1-3VW 70250 1,347.16$ 1,751.30$

03200041 HB XR SKULL 4VW/MORE 70260 1,616.59$ 2,101.57$

03200042 HB XR TMJ UNILATERAL 70328 961.83$ 1,250.39$

03200043 HB XR TMJ BILAT 70330 1,028.69$ 1,337.30$

03200044 HB XR NECK SOFT TISSUE 70360 1,028.69$ 1,337.30$

03200045 HB SIALOGRAM S&I 70390 2,123.60$ 2,760.67$

03200048 HB XR PLACEMENT NEEDLE SPINE 77003 1,630.71$ 2,119.68$

03200052 HB XR RIBS 2-3VW UNILAT 71100 1,028.69$ 1,337.30$

03200053 HB XR RIBS 2-3VW UNI & CHEST 71101 1,121.47$ 1,457.90$

03200054 HB XR RIBS 3VW BILAT 71110 1,347.16$ 1,751.30$

03200055 HB XR STERNUM 2VW/MORE 71120 1,028.69$ 1,337.30$

03200056 HB XR STERNOCLAV JNT 3VW/MORE 71130 1,028.69$ 1,337.30$

03200060 HB XR C-SPINE 2-3VW 72040 1,347.16$ 1,751.30$

03200061 HB XR C-SPINE 4-5VW 72050 1,616.59$ 2,101.57$

03200062 HB XR C-SPINE 6VW/MORE 72052 1,939.91$ 2,521.89$

03200063 HB XR T-SPINE 2VW 72070 1,347.16$ 1,751.30$

03200064 HB XR T-SPINE 3VW 72072 1,616.59$ 2,101.57$

03200065 HB XR T-SPINE 4VW/MORE 72074 1,939.91$ 2,521.89$

03200066 HB XR T/L-SPINE MIN 2VW 72080 1,028.69$ 1,337.30$

03200068 HB XR L-SPINE 2-3VW 72100 1,347.16$ 1,751.30$

03200069 HB XR L-SPINE 4-5VW 72110 1,616.59$ 2,101.57$

03200070 HB XR L-SPINE 6VW W BENDING 72114 1,939.91$ 2,521.89$

03200071 HB XR L-SPINE 2-3VW BEND ONLY 72120 1,347.16$ 1,751.30$

03200072 HB XR PELVIS 1-2VW 72170 1,347.16$ 1,751.30$

03200073 HB XR PELVIS 3VW/MORE 72190 1,616.59$ 2,101.57$

03200074 HB XR SACROILIAC JNT 2VW/LESS 72200 1,028.69$ 1,337.30$

03200075 HB XR SACROILIAC JNT 3VW/MORE 72202 1,347.16$ 1,751.30$

03200076 HB XR SACRUM/COCCYX 2VW/MORE 72220 1,028.69$ 1,337.30$

03200077 HB MYELOGRAM C-SPINE 72240 7,692.59$

03200078 HB MYELOGRAM T-SPINE 72255 7,692.59$

03200079 HB MYELOGRAM L-SPINE 72265 7,692.59$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03200080 HB MYELOGRAM 2/MORE REGION S&I 72270 7,692.59$

03200081 HB DISCOGRAM LUMBAR S&I 72295 10,499.62$

03200082 HB XR CLAVICLE UNILATERAL 73000 1,028.69$ 1,337.30$

03200083 HB XR SCAPULA UNILATERAL 73010 1,028.69$ 1,337.30$

03200084 HB XR SHOULDER 1VW UNILATERAL 73020 1,028.69$ 1,337.30$

03200085 HB XR SHOULDER 2VW/MORE UNILT 73030 1,347.16$ 1,751.30$

03200086 HB XR AC JNTS WO/W WEIGHTS BIL 73050 1,347.16$ 1,751.30$

03200087 HB XR HUMERUS 2VW/MORE UNILAT 73060 1,028.69$ 1,337.30$

03200088 HB XR ELBOW 2VW UNILATERAL 73070 1,028.69$ 1,337.30$

03200089 HB XR ELBOW 3VW/MORE UNILAT 73080 1,347.16$ 1,751.30$

03200090 HB XR FOREARM 2VW UNILATERAL 73090 1,028.69$ 1,337.30$

03200091 HB XR EXT UPP INFANT 2VW UNI 73092 1,347.16$ 1,751.30$

03200092 HB MAMMO DUCTOGRAM SINGLE S&I 77053 1,863.78$

03200093 HB XR WRIST 2VW UNILATERAL 73100 1,028.69$ 1,337.30$

03200094 HB XR WRIST 3VW/MORE UNILAT 73110 1,347.16$ 1,751.30$

03200095 HB ARTHROGRAM WRIST S&I UNILAT 73115 2,933.97$ 3,814.18$

03200096 HB XR HAND 2VW UNILATERAL 73120 1,028.69$ 1,337.30$

03200097 HB XR HAND 3VW/MORE UNILATERAL 73130 1,121.47$ 1,457.90$

03200098 HB XR FINGERS 2VW UNILATERAL 73140 1,028.69$ 1,337.30$

03200106 HB XR BONE SURVEY AGE 77072 1,347.16$ 1,751.30$

03200107 HB XR BONE SURVEY LENGTH 77073 1,347.16$ 1,751.30$

03200109 HB XR KNEE 4VW/MORE UNILATERAL 73564 1,616.59$ 2,101.57$

03200110 HB XR KNEE 1VW STANDING BILAT 73565 1,028.69$ 1,337.30$

03200111 HB XR TIBIA/FIBULA 2VW UNILAT 73590 1,028.69$ 1,337.30$

03200112 HB XR EXT LOW 2VW UNILAT INFNT 73592 1,347.16$ 1,751.30$

03200113 HB XR ANKLE 2VW UNILATERAL 73600 1,347.16$ 1,751.30$

03200114 HB XR ANKLE 3VW/MORE UNILAT 73610 1,616.59$ 2,101.57$

03200115 HB XR FOOT 2VW UNILATERAL 73620 1,028.69$ 1,337.30$

03200116 HB XR FOOT 3VW/MORE UNILAT 73630 1,347.16$ 1,751.30$

03200118 HB XR TOES 2VWS/MORE UNILAT 73660 1,028.69$ 1,337.30$

03200119 HB XR ABDOMEN 1VW FRONTAL 74018 1,028.69$ 1,337.30$

03200121 HB XR ABDOMEN+CHEST 2+ VIEWS 74022 1,347.16$ 1,751.30$

03200122 HB XR ESOPHAGRAM SINGLE CONT STUDY 74220 2,002.34$ 2,603.04$

03200123 HB XR SWALLOW CINE VIDEO CONT STUDY 74230 2,002.34$ 2,603.04$

03200128 HB XR SMALL INTESTINE SINGLE CONT 74250 2,002.34$ 2,603.04$

03200129 HB XR SMALL BOWEL ENTEROCLYSIS 74251 2,314.22$ 3,009.39$

03200130 HB XR BONE SURVEY OSSEOUS LTD 77074 1,347.16$ 1,751.30$

03200132 HB XR COLON ENEMA W CONT & AIR 74280 3,376.22$ 4,390.67$

03200136 HB ENDO CATH- BILE DUCT S & I 74328 1,476.30$

03200137 HB ENDO CATH- PANCR DUCT S & I 74329 1,476.30$

03200138 HB ENDO CATH-BIL- PANCR DUCT S& I 74330 1,890.42$

03200139 HB XR PLCMT LONG GI TUBE S&I 74340 1,988.40$ 2,584.92$

03200140 HB DILATE BILIARY DUCT S&I 74363 9,639.25$

03200141 HB UROGRAM IVP 74400 3,892.49$ 5,060.25$

03200143 HB UROGRAM INFUSION W TOMO 74415 3,281.11$ 4,266.15$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03200144 HB UROGRAM RETROGRADE 74420 2,377.60$ 3,090.92$

03200145 HB UROGRAM ANTEGRADE S&I 74425 1,006.93$ 1,309.01$

03200146 HB CYSTOGRAM 3VW/MORE S&I 74430 1,999.47$ 2,599.53$

03200147 HB VESICULOGRAM S&I 74440 2,266.67$

03200148 HB CORPORA CAVERNOSOGRAM S&I 74445 1,562.43$

03200149 HB URETHROCYSTOGRAM RETRO S&I 74450 2,556.51$

03200150 HB URETHROCYSTOGRAM VOID S&I 74455 3,469.06$ 4,508.41$

03200153 HB NEPHROS TRACT DILATION 74485 9,835.81$

03200154 HB HYSTEROSALPINGOGRAM S&I 74740 2,123.60$ 2,760.67$

03200155 HB VAGINOGRAM/PERINEOGRAM 74775 1,843.23$ 2,395.75$

03200157 HB SPLENOPORTOGRAPHY 75810 6,247.55$

03200158 HB VENOGRAM EXTREMITY UNI S&I 75820 4,021.50$

03200159 HB VENOGRAPHY EXTREMITY BILAT 75822 6,247.55$

03200160 HB VENOGRAM VENA CAVA INF S&I 75825 11,407.72$

03200161 HB VENOGRAPHY SUPERIOR CAVAL 75827 4,421.85$

03200162 HB VENOGRAPHY RENAL UNILAT 75831 10,149.06$

03200163 HB VENOGRAPHY RENAL BILAT 75833 11,802.07$

03200164 HB VENOGRAM JUGULAR S&I 75860 11,407.72$

03200165 HB PERC TRANSHEP PORT W HDM 75885 11,407.72$

03200166 HB VENOGRAQM HEPATIC W HDM 75889 15,248.48$

03200167 HB VENOUS SAMPLE W/WO ANGIO 75893 19,109.22$

03200168 HB TRANSCATH EMBOLIZATION S&I 75894 15,914.13$

03200171 HB XR BONE SURVEY CHILD 77076 1,347.16$ 1,751.30$

03200172 HB DXA BONE DEN PERIPH SKEL 77081 1,028.69$

03200173 HB CATH REMOVAL OBS MAT S&I 75901 1,890.42$

03200174 HB CATH REMOVAL OBS MAT CV S&I 75902 1,619.04$

03200179 HB REPAIR DEC AORTA W SUB S&I 75956 6,536.91$

03200180 HB REPAIR DEC AORTA WO SUB S&I 75957 5,601.08$

03200182 HB DXA BONE DEN AXIAL SKEL WO VFA 77080 1,347.16$ 1,751.30$

03200188 HB BIOPSY TRANSCATHERTER S&I 75970 8,244.86$

03200192 HB XCHANGE DRAINAGE CATH S&I 75984 3,312.89$

03200193 HB XR DRAINAGE S&I 75989 3,609.09$ 4,690.09$

03200194 HB XR CALCANEUS 2VW/MORE UNI 73650 1,028.69$ 1,337.30$

03200200 HB ARTHROGRAM ELBOW S&I UNILAT 73085 2,933.97$ 3,814.18$

03200202 HB IMG SURGICAL SPECIMEN 76098 2,123.60$ 2,760.67$

03200204 HB XR TOMOGRAPHY SINGLE PLANE 76100 1,347.16$ 1,751.30$

03200206 HB XR UL PROC DEFECOGRAPHY 74280 3,376.22$ 4,390.67$

03200208 HB SHUNTOGRAM NON-VAS SHUNT SI 75809 1,347.16$

03200211 HB XR BONE SURVEY COMPLETE 77075 3,561.90$ 4,630.72$

03200212 HB XR KNEE 3VW UNILATERAL 73562 1,347.16$ 1,751.30$

03200215 HB DISCOGRAM CERV/THOR S&I 72285 10,499.62$

03200218 HB PRC TRNHEP ANG WO HDM S&I 75887 6,247.55$ 8,121.82$

03200220 HB PLCMT PROX EXT THOR AORTA 75958 3,535.24$

03200242 HB UL PROC DXA FAT COMP ASSMT 76499 1,028.69$ 1,337.30$

03200244 HB PLCMT EXT DEV PST ARTA RPS&I 75959 8,061.05$ 8,061.05$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03200246 HB MAMMO DUCTOGRAM MULT S&I 77054 2,123.60$ 2,760.67$

03200249 HB CHOLANGIOGRAM INTRAOP 74300 2,379.38$ 3,095.34$

03200255 HB XR NOSE TO RECTUM FB CHILD 76010 952.50$ 1,238.24$

03200258 HB VENOGRAPHY ADRENAL UNILAT 75840 11,407.72$

03200259 HB VENOGRAM SUP SAG SINUS S&I 75870 6,247.55$

03200261 HB UL PROC ART/VEN STRUCTURE 76496 644.20$ 831.67$

03200263 HB XR COLON ENEMA THERAPEUTIC 74283 1,992.68$ 2,592.75$

03200274 HB DILATE FOR STRICTURE/OBSTR 74360 1,476.30$

03200275 HB X-RAY EXAM ENTIRE SPI 1 VW 72081 775.47$ 1,008.11$

03200276 HB X-RAY EXAM ENTIRE SPI 2/3 VW 72082 1,284.23$ 1,669.51$

03200277 HB X-RAY EXAM ENTIRE SPI 4/5 VW 72083 2,179.84$ 2,833.78$

03200278 HB X-RAY EXAM ENTIRE SPI 6/> VW 72084 2,627.66$ 3,415.94$

03200279 HB X-RAY EXAM HIP UNI 1 VIEW 73501 2,586.86$ 3,362.92$

03200280 HB X-RAY EXAM HIP UNI 2-3 VIEWS 73502 4,876.34$ 6,339.24$

03200281 HB X-RAY EXAM HIP UNI 4/> VIEWS 73503 11,853.56$ 15,409.63$

03200282 HB X-RAY EXAM HIPS BI 2 VIEWS 73521 1,284.23$ 1,669.51$

03200283 HB X-RAY EXAM HIPS BI 3-4 VIEWS 73522 1,732.04$ 2,251.63$

03200284 HB X-RAY EXAM HIPS BI 5/> VIEWS 73523 2,179.84$ 2,833.78$

03200285 HB X-RAY EXAM OF FEMUR 1 73551 925.82$ 1,203.57$

03200286 HB X-RAY EXAM OF FEMUR 2/> 73552 1,028.69$ 1,337.30$

03200287 HB XR RENAL CYST TRANSLUMBAR S&I 74470 2,123.39$ 2,123.39$

03200288 HB LYMPHANGIOGRAM PELVIC/ABD; BILAT 75807 11,407.72$ 14,830.03$

03200289 HB LYMPHANGIOGRAM PELVIC/ABD; UNILAT 75805 6,247.55$ 8,121.82$

03200290 HB XR EXAM ABDOMEN 2 VIEWS 74019 1,121.47$ 1,457.90$

03200291 HB XR EXAM ABDOMEN 3+ VIEWS 74021 1,347.16$ 1,751.30$

03200292 HB INSERTION PICC RS&I <5 YR 36572 5,513.73$ 7,168.55$

03200293 HB INSERTION PICC RS&I 5 YR+ 36573 6,247.55$ 8,121.82$

03200294 HB REPLACE PICC CATH W IMG GUID 36584 6,247.55$ 8,121.82$

03200295 HB DILAT XST TRC NEW ACCESS RCS 50437 11,094.38$

03200296 HB DILAT XST TRC NDURLGC PX 50436 9,835.81$

03200297 HB ENDOVENOUS FEM-POP ARTL REVASC 0505T 78,294.72$

03200298 HB XR ESOPHAGRAM DOUBLE CONT STUDY 74221 2,377.60$ 3,090.92$

03200299 HB XR UPPER GI SINGLE CONT STUDY 74240 2,244.01$ 2,913.23$

03200300 HB XR UPPER GI DOUBLE CONT 74246 1,992.68$ 2,592.75$

03200301 HB XR SMALL INTESTINE F-THRU STUDY 74248 3,663.65$ 4,926.57$

03220003 HB ARTHROGRAM SHOULDER S&I UNI 73040 2,933.97$ 3,814.18$

03220004 HB ARTHROGRAM KNEE S&I UNILAT 73580 2,933.97$ 3,814.18$

03220005 HB ARTHROGRAM ANKLE S&I UNILAT 73615 2,933.97$ 3,814.18$

03220007 HB ARTHROGRAM HIP S&I UNILAT 73525 2,933.97$ 3,814.18$

03230001 HB ANGIOGRAM AORTA THORACIC SI 75605 19,109.22$

03230002 HB ANGIOGRAM AORTA ABDOMEN S&I 75625 10,581.56$

03230003 HB AORTOGRAPHY ABD+ILIOFEM BILAT 75630 12,336.47$

03230012 HB ANGIOGRAPHY THRU EXIST CATH, OTHER THAN FOR THROMBOLYSIS75898 6,247.55$

03230019 HB ANGIO SPINAL 75705 19,109.22$

03230020 HB ANGIO EXTREMITY UNI S&I 75710 13,853.61$


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Price



03230021 HB ANGIO EXTREMITY BILAT 75716 15,248.48$

03230025 HB ANGIOGRAM VISCERAL S&I 75726 19,109.22$

03230028 HB ANGIOGRAM PELVIC S&I 75736 19,109.22$

03230029 HB ANGIO PULMONARY UNILAT 75741 7,866.52$

03230030 HB ANGIO PULMONRY BILAT 75743 15,248.48$

03230032 HB ANGIO PULM NON SELECT CATH 75746 6,247.55$

03230033 HB ANGIO INTERNAL MAMMARY 75756 11,407.72$

03230034 HB ANGIOGRAM EA ADDL VESSEL SI 75774 13,658.72$

03230039 HB ANGIOGRAM ADRENAL ARTERY, UNI 75731 6,247.55$ 8,121.82$

03240005 HB XR RIBS 3VW BILAT & CHEST 71111 1,347.16$ 1,751.30$

03240008 HB XR CHEST 1VW FRONTAL 71045 1,028.69$ 1,337.30$

03240014 HB XR UL XVIVO LUNG TRANSPLANT 76499 1,028.69$ 1,337.30$

03240015 HB XR EXAM CHEST 2 VIEWS 71046 1,058.17$ 1,375.61$

03240016 HB XR EXAM CHEST 3 VIEWS 71047 1,121.47$ 1,457.90$

03240017 HB XR EXAM CHEST 4+ VIEWS 71048 1,347.16$ 1,751.30$

03310002 HB CHEMO ANTI-NEOPL, SC/IM 96401 922.68$

03310003 HB CHEMO HORMNL ANTI-NEOPL, SC/IM 96402 847.28$

03310004 HB CHEMO ADMIN, NON HORMONAL 96402 847.28$

03310005 HB CHEMO IVP/INF 0-15 MIN ADD/SEQ 96411 1,188.35$

03310006 HB CHEMO INF>8HRS VIA AMB PUMP 96416 1,862.85$

03310007 HB CHEMOTHERAPY INTRA-ART PUSH 96420 1,465.74$

03310008 HB CHEMO INF,INTRACAV PERITONEAL 96446 1,862.85$

03310009 HB CHEMOTHERAPY, INTO CNS 96450 1,570.88$

03310010 HB CHEMOTHERAPY SPINE PUNCTURE 96450 1,570.88$ 2,042.12$

03310011 HB CHEMO HORMONAL INTINEOPL, SC/I 96402 847.28$

03310012 HB CHEMO IVP/INF 0-15 MIN INITIAL 96409 1,906.65$

03310013 HB CHEMO PUSH 96409 1,906.65$

03310014 HB CHEMOTHERAPY INJECTION 96542 1,862.85$

03310015 HB NON-CHEMO INF >8HRS VIA AMB PU 96379 1,862.85$

03310019 HB CHEMO INTRALESIONAL UP TO 7 96405 844.64$ 1,098.02$

03310020 HB CHEMO INTRALESIONAL OVER 7 96406 1,900.11$ 2,470.16$

03330003 HB RT SIMULATION SIMPLE 77280 7,687.67$

03330004 HB RT SIMULATION COMPLEX 77290 11,199.72$

03330005 HB RT 3-D SIMULATION 77295 13,412.64$

03330010 HB RT DOSIMETRY BASIC 77300 2,126.26$

03330011 HB RT IMRT TX PLANNING 77301 13,412.64$

03330020 HB RT INVIVO DOSIMTRY DIODE/TLD 77331 2,119.48$

03330021 HB RT TX DEVICE SIMPLE 77332 4,075.92$

03330024 HB RT TX DEVICE COMPLEX - MASKS 77334 4,075.92$

03330026 HB RT TX DEVICE COMPLEX - BLOCKS 77334 4,075.92$

03330028 HB RT CONTINUING PHYSICS CNSLT 77336 1,896.07$

03330032 HB RT SUPERFICIAL 77401 1,261.83$

03330046 HB RT PORT IMAGES 77417 477.30$

03330074 HB RT SPECIAL TX PROCEDURE HD 77470 7,572.16$

03330077 HB DESIGN MLC FOR IMRT 77338 4,101.56$


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Price



03330079 HB RT PHYSICS CONSL-IMG FUSION 77370 7,187.46$

03330080 HB RESPIRATOR MOTION MGMT SIM 77293 5,331.54$

03330081 HB TELETHX ISODOSE PLAN SIMPLE 77306 2,133.58$

03330082 HB TELETHX ISODOSE PLAN CPLX 77307 9,981.53$

03330083 HB BRACHYTX ISODOSE PLAN SIMPLE 77316 11,180.08$

03330084 HB BRACHYTX ISODOSE INTERMED 77317 12,636.09$

03330085 HB BRACHYTX ISODOSE COMPLEX 77318 14,092.13$

03330086 HB NTSTY MODUL RAD TX DLVR SMPL 77385 7,572.16$

03330087 HB NTSTY MODUL RAD TX DLVR CPLX 77386 7,572.16$

03330088 HB GUIDANCE FOR RADIAJ TX DLVR 77387 7,025.70$

03330089 HB RAD TREATMNT DELVRY SIMPLE 77402 1,261.83$

03330090 HB RAD TREATMNT DELVRY INT 77407 1,514.20$

03330091 HB RAD TREATMNT DELVRY COMPLX 77412 2,590.85$

03330092 HB HDR ELCTRNC SKN SURF BRCHYTX 0394T 2,590.85$

03330093 HB HDR ELCTR NTRST/NTRCV BRCHTX 0395T 15,516.93$

03330094 HB HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHNL 77770 15,516.93$

03330095 HB HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHNLS 77771 15,516.93$

03330096 HB HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHNLS 77772 15,516.93$

03330099 HB SRS LINEAR BASED 1 SESSION 77372 78,482.16$

03330100 HB SBRT DELIVERY PER FRACTION 77373 20,985.90$

03330104 HB IO RAD TX DELIVERY BY X-RAY 77424 78,482.16$

03330105 HB IO RAD TX DELIVER BY ELCTRNS 77425 78,482.16$

03350001 HB CHEMO INFUSION FIRST HOUR 96413 2,989.91$

03350002 HB CHEMO INFUSION ADDL HOUR 96415 954.76$

03350004 HB CHEMO INF ADD/SEQ 1ST HOUR 96417 954.76$

03400004 HB NM LIVER SCAN STATIC ONLY 78201 7,725.36$ 10,042.97$

03400006 HB NM CARDIAC 1ST PASS SINGLE 78481 6,027.22$ 7,835.38$

03400011 HB NM CSF LEAK SCAN 78650 7,725.36$ 10,042.97$

03410004 HB NM THYROID METS SCAN LTD 78015 4,804.93$ 6,246.41$

03410005 HB NM THYRD METS SCAN WHO BODY 78018 6,027.22$ 7,835.38$

03410007 HB NM BONE MARROW SCAN MULT 78103 4,804.93$ 6,246.41$

03410009 HB NM LYMPHATICS/NODES SCAN 78195 6,027.22$ 7,835.38$

03410010 HB NM UL BONE MARROW SPECT 78199 4,804.93$ 6,246.41$

03410015 HB NM LIVER/SPLEEN SCAN VAS/FL 78216 4,804.93$ 6,246.41$

03410017 HB NM GASTRIC EMPTYING STUDY 78264 4,804.93$ 6,246.41$

03410018 HB NM ACUTE GI BLEED STUDY 78278 4,804.93$ 6,246.41$

03410021 HB NM PERITONEAL SHUNT PATENCY 78291 4,804.93$ 6,246.41$

03410023 HB NM BONE/JNT SCAN MULT AREAS 78305 4,804.93$ 6,246.41$

03410024 HB NM BONE/JNT SCAN WHOLE BODY 78306 4,804.93$ 6,246.41$

03410025 HB NM BONE/JNT SCAN 3-PHASE 78315 4,804.93$ 6,246.41$

03410031 HB NM CARDIAC INFARCT SPECT 78469 7,725.36$ 10,042.97$

03410034 HB NM CARDIAC MUGA WM/EF SPECT 78494 4,804.93$ 6,246.41$

03410035 HB NM LUNG PERFUSION SCAN 78580 4,804.93$ 6,246.41$

03410044 HB NM CSF FLOW/CISTERNOGRAM 78630 6,027.22$ 7,835.38$

03410045 HB NM CSF FLOW/SHUNT EVAL 78645 6,027.22$ 7,835.38$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03410048 HB NM KIDNEY SCAN FLOW/FUNCT 78707 6,027.22$ 7,835.38$

03410050 HB NM KIDNEY FUNCTION STUDY 78725 4,804.93$ 6,246.41$

03410052 HB NM TESTICULAR SCAN W VAS FL 78761 4,804.93$ 6,246.41$

03410053 HB NM TUMOR SCAN PLANAR SINGLE 78800 4,804.93$ 6,246.41$

03410055 HB NM TUMOR SCAN WHOLE BODY 78802 7,725.36$ 10,042.97$

03410056 HB NM TUMOR SPECT SINGLE AREA 78803 7,725.36$ 10,042.97$

03410057 HB NM TUMOR SCAN 2DAYS/MORE 78804 7,725.36$ 10,042.97$

03410061 HB NM INTESTINE SCAN 78290 4,804.93$ 6,246.41$

03410063 HB NM CARDIAC MUGA WM/EF SINGL 78472 4,804.93$ 6,246.41$

03410069 HB NM HEART SPECT SNGL RST/STR 78451 7,725.36$ 10,042.97$

03410070 HB NM HEART SPECT MULT RST/STR 78452 7,725.36$ 10,042.97$

03410071 HB NM HEART PLANR SNGL RST/STR 78453 7,725.36$ 10,042.97$

03410072 HB NM HEART PLANR MULT RST/STR 78454 7,725.36$ 10,042.97$

03410074 HB NM HEPATOBILIARY WO PHARM 78226 4,804.93$ 6,246.41$

03410075 HB NM HEPATOBILIARY W PHARM 78227 6,027.22$ 7,835.38$

03410076 HB NM LUNG VENT WO PERFUSION 78579 4,804.93$ 6,246.41$

03410077 HB NM LUNG VENT W PERFUSION 78582 6,027.22$ 7,835.38$

03410078 HB NM LUNG VENT W DIFFERENTIAL 78597 4,804.93$ 6,246.41$

03410080 HB NM THYROID UPTAKE SINGLE/MULT 78012 4,804.93$ 6,246.41$

03410081 HB NM THYROID IMG W VAS FL ONLY 78013 4,804.93$ 6,246.41$

03410082 HB NM THYROID IMG W VAS & UPTKE 78014 4,804.93$ 6,246.41$

03410084 HB NM PARATHYRD SCAN W SPECT 78071 4,804.93$ 6,246.41$

03410085 HB NM PARATHYRD SCAN W SPECT/CT 78072 6,027.22$ 7,835.38$

03410086 HB NM CARDIAC SHUNT DETECT 78428 4,804.93$ 6,246.41$

03410089 HB NM CARDIAC SYMP PLANAR ONLY 0331T 7,725.36$ 10,042.97$

03410090 HB NM CARDIAC SYMP PLANAR & SPECT 0332T 7,725.36$ 10,042.97$

03410092 HB UNLINSTED NM PET/MR ATTENUATION 78999 4,804.93$ 6,246.41$

03410093 HB NM UL MUSCULOSKELETAL PROC 78399 4,804.93$ 6,246.41$

03410094 HB NM GASTRIC EMPTYNG IMG W/SM BWL 78265 4,804.93$ 6,246.41$

03410095 HB NM KIDNEY SCAN FLOW/FUNCT PHARM 78708 6,027.22$ 7,835.38$

03410096 HB RADIOACTIVE TRACER ID SENTINEL NODE 38792 4,804.93$ 6,246.41$

03410097 HB TUMOR SPECT CNCRNT CT SINGLE AREA 78830 7,725.36$ 10,042.97$

03410098 HB TUMOR SPECT MIN 2 AREAS 78831 7,725.36$ 10,042.97$

03410099 HB TUMOR SPECT CNCRNT CT MIN 2 AREAS 78832 14,900.85$ 19,371.27$

03410100 HB RADIOPHARM QUANT MEASURE 1 AREA 78835 5,237.61$ 6,808.89$

03420007 HB NM RAD DOSE HANDLING/LOADING 77790 3,415.86$

03420010 HB NM RADIOPHARM TX ORAL 79005 3,118.06$ 4,053.49$

03420011 HB NM RADIOPHARM THERAPY, IV 79101 3,118.06$ 4,053.49$

03420013 HB RADIOPHARM TX INTRAARTERIAL 79445 3,118.06$

03420014 HB PHARM MONOCLONAL THERAPY 79403 3,118.06$ 4,053.49$

03500014 HB CT DRAINAGE S&I 75989 3,609.09$ 4,690.09$

03500016 HB CT LIMITED/FOLLOW-UP SCAN 76380 3,528.84$ 4,587.49$

03500027 HB CT GUIDANCE S&I 77012 4,738.25$ 6,159.72$

03500033 HB CT ANGIO ABDOMINAL RUNOFF W 3D 75635 3,452.57$ 4,488.34$

03500037 HB CT GUIDANCE FOR ABLATION 77013 4,069.01$ 5,289.87$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03500038 HB CT BONE SURVEY SCANOGRAM 77073 1,347.16$ 1,751.30$

03500039 HB CT UL PROC 76497 1,028.69$ 1,337.30$

03500046 HB CT ANGIO ABDOMEN WO/W CONT W 3D 74175 6,858.74$ 8,915.73$

03500047 HB CT NECK SFT TISS WO CONT 70490 5,104.69$ 6,636.08$

03500048 HB CT NECK SFT TISS W CONT 70491 6,160.31$ 8,008.43$

03500049 HB CT NECK SFT TISS WO/W CONT 70492 6,451.63$ 8,387.13$

03500051 HB RECON CTA SURGICAL PLANNING G0288 4,353.19$ 5,659.16$

03500053 HB CT HEART W CONT 75572 6,890.90$ 8,958.18$

03500054 HB CT HEART W CONT, CONGEN DZ 75573 6,160.31$ 8,008.43$

03510001 HB CT PERFUSION BRAIN 0042T 4,101.73$ 5,332.24$

03510002 HB CT HEAD/BRAIN W CONT 70460 6,160.31$ 8,008.43$

03510003 HB CT HEAD/BRAIN WO/W CONT 70470 6,451.63$ 8,387.13$

03510012 HB CT ORBITS/SELLA/EAR W CONT 70481 6,451.63$ 8,387.13$

03510019 HB CT ANGIO HEAD W 3D 70496 5,702.25$ 7,412.76$

03510020 HB CT ANGIO NECK W 3D 70498 5,702.25$ 7,412.76$

03510022 HB CT ORBIT/SELLA/EAR WO/W CON 70482 7,741.96$ 10,064.54$

03510026 HB CT MAXILLOFACIAL WO CONT 70486 5,104.69$ 6,636.08$

03510032 HB CT MAXILLOFACIAL WO/W CONT 70488 6,451.63$ 8,387.13$

03510036 HB CT ORBITS/SELLA/EAR WO CONT 70480 5,104.69$ 6,636.08$

03510039 HB CT HEAD/BRAIN WO CONT 70450 5,104.69$ 6,636.08$

03510044 HB CT MAXILLOFACIAL W CONT 70487 6,160.31$ 8,008.43$

03520002 HB CT COLONOGRAPHY SCREENING 74263 6,787.74$ 8,824.09$

03520003 HB CT HEART WO CONTRAST 75571 5,742.42$ 7,465.16$

03520004 HB CT COLONOGRAPHY DIAG WO CNT 74261 12,677.18$ 16,479.88$

03520007 HB CT CHEST WO/W CONTRAST 71270 6,451.63$ 8,387.13$

03520008 HB CT ANGIO HEART W 3D 75574 4,424.31$ 5,751.59$

03520011 HB CT ANGIO CHEST W 3D 71275 5,702.25$ 7,412.76$

03520013 HB CT C-SPINE WO/W CONTRAST 72127 6,451.63$ 8,387.13$

03520014 HB CT T-SPINE WO/W CONTRAST 72130 6,451.63$ 8,387.13$

03520015 HB CT L-SPINE WO CONTRAST 72131 5,104.69$ 6,636.08$

03520016 HB CT L-SPINE W CONTRAST 72132 6,160.31$ 8,008.43$

03520017 HB CT L-SPINE WO/W CONTRAST 72133 6,451.63$ 8,387.13$

03520018 HB CT ANGIO PELVIS W 3D 72191 4,386.75$ 5,702.25$

03520020 HB CT PELVIS W CONTRAST 72193 6,160.31$ 8,008.43$

03520022 HB CT EXT UPP WO CONTRAST UNI 73200 5,104.69$ 6,636.08$

03520023 HB CT EXT UPP W CONTRAST UNI 73201 6,160.31$ 8,008.43$

03520024 HB CT ANGIO EXT UPPER UNILAT W 3D 73206 3,335.68$ 4,336.52$

03520028 HB CT LOW EXT WO/W CONT UNILAT 73702 6,451.63$ 8,387.13$

03520029 HB CT ANGIO EXT LOW WO/W CN UN 3D 73706 3,543.20$ 4,606.15$

03520030 HB CT PELVIS WO CONTRAST 72192 5,104.69$ 6,636.08$

03520040 HB CT CHEST W CONTRAST 71260 6,160.31$ 8,008.43$

03520041 HB CT C-SPINE WO CONTRAST 72125 5,104.69$ 6,636.08$

03520042 HB CT C-SPINE W CONTRAST 72126 6,160.31$ 8,008.43$

03520043 HB CT T-SPINE WO CONTRAST 72128 5,104.69$ 6,636.08$

03520044 HB CT T-SPINE W CONTRAST 72129 6,160.31$ 8,008.43$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03520045 HB CT PELVIS WO/W CONTRAST 72194 6,451.63$ 8,387.13$

03520046 HB CT LOW EXT WO CONT UNILAT 73700 5,104.69$ 6,636.08$

03520048 HB CT EXT LOW W CONT UNILAT 73701 6,160.31$ 8,008.43$

03520049 HB CT ABDOMEN WO CONTRAST 74150 5,104.69$ 6,636.08$

03520050 HB CT ABDOMEN W CONTRAST 74160 6,160.31$ 8,008.43$

03520051 HB CT ABDOMEN WO/W CONTRAST 74170 6,451.63$ 8,387.13$

03520052 HB CT CHEST WO CONTRAST 71250 5,104.69$ 6,636.08$

03520054 HB CT COLONOGRAPHY DIAG W CONT 74262 13,282.78$ 17,267.61$

03520056 HB CT ABD & PELVIS WO CONTRAST 74176 10,073.74$ 13,095.86$

03520057 HB CT ABD & PELVIS W CONTRAST 74177 13,051.58$ 16,967.09$

03520058 HB CT ABD & PELVIS WO/W CONT 74178 15,693.01$ 20,400.91$

03520059 HB CT ANGIO ABD & PEL WO/W CON 74174 13,015.27$ 16,919.85$

03520061 HB CT EXT UPP WO/W CONT UNILAT 73202 6,451.63$ 8,387.13$

03520062 HB CT UL FRACTIONAL FLOW RESERVE 76497 1,803.10$ 2,344.03$

03520063 HB UL PROC CT BONE SURVEY SKULL-THIGH 76497 1,049.27$ 1,364.05$

03520064 HB PLACEMENT, CATH RADIOELEMENT HEAD SOFT TISS 41019 17,596.07$ 22,874.89$

03520065 HB PLACEMENT, CATH RADIOELEMENT PELVIC ORG 55920 23,256.66$

03520066 HB PLACEMENT, CATH RADIOELEMENT PROSTATE 55875 12,965.96$

03520067 HB LOC BREAST DEV W IMG GD PRIM 10035 4,554.44$ 5,920.77$

03520068 HB LOC BREAST DEV W IMG GD EA ADDL 10036 3,096.53$ 4,025.50$

03520069 HB UL PROC PLACEMENT, CATH RADIOELEMENT LYMPH NODES38999 5,499.72$ 7,149.63$

03520070 HB UL PROC PLACEMENT, CATH RADIOELEMENT LUNG 38999 5,499.72$ 7,149.63$

03520071 HB UL PROC PLACEMENT, CATH RADIOELEMENT LIVER 38999 5,499.72$ 7,149.63$

03520072 HB UL PROC PLACEMENT, CATH RADIOELEMENT KIDNEY 38999 5,499.72$ 7,149.63$

03600002 HB OR LEVEL 5 - EA ADDL MINUTE 137.71$





03600007 HB BEDSIDE PROCEDURE - MINOR 5,831.03$

03600008 HB OR LEVEL 1 - 1ST HOUR 38,214.99$

03600010 HB BEDSIDE PROCEDURE - MAJOR 14,127.05$





03600016 HB OR LEVEL 1 - 1ST HOUR CANCELED 10,563.22$





03600022 HB WHOLE LUNG LAVAGE 32997 9,745.14$

03610002 HB LIVER BIOPSY OR 47000 8,779.14$ 11,412.90$

03610004 HB EXC, BENIGN DIA 0.5 CM- LESS 11400 4,554.44$ 5,920.77$

03610008 HB BIOPSY NECK/THORAX SFT TISS 21550 8,779.14$ 11,412.90$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03610009 HB RMVL IMPACTED CERUMEN, REQ. INSTRMNT, UNILATERAL69210 793.59$ 1,031.66$

03610011 HB SP VIDEOSTROBOSCOPY - (4) EXT 31579 1,856.26$

03610012 HB INDWL TUNN PLEU CATH W/CUFF 32550 7,830.14$ 10,179.17$

03610013 HB CHEST TUBE PLMT,WTR SL OPN 32551 6,247.55$ 8,121.82$

03610019 HB THR APHER, PLASMA PHERESIS 36514 7,596.40$

03610021 HB THR APHER SEL ADS/FIL PL REINF 36516 15,101.85$

03610022 HB CATH INSRT NON-TUN 5YR/M 36556 6,247.55$ 8,121.82$

03610024 HB BLOOD DRAW VIA IMPL. DEVICE 36591 821.97$ 1,068.56$

03610026 HB DECLOT VASCULAR DEVICE 36593 1,723.70$ 2,240.80$

03610027 HB CATH REPOSITIONING 36597 6,247.55$ 8,121.82$

03610028 HB ARTERIAL CATH INSERT PERC 36620 1,343.09$ 1,744.53$

03610030 HB FINE NEEDLE ASP W/O IMG GUID FIRST LESION 10021 1,578.81$ 2,052.44$

03610033 HB EXCISION 2.1 TO 3.0 CM 11403 4,554.44$ 5,920.77$

03610034 HB INCISION & DRAINAGE, ABSCESS 10060 1,195.75$ 1,554.47$

03610035 HB PUNCTURE ASPIRATION CYST 10160 1,578.81$ 2,052.44$

03610036 HB EXC LES SCLP/NECK/EXT <.5 11420 8,779.14$ 11,412.90$

03610037 HB DEBRIDE SURGICAL WOUND 11000 3,088.06$ 4,014.46$

03610039 HB ASPIRATION BREAST CYST 19000 4,554.44$

03610042 HB AUTO PB STEM CELL APHERESIS BD 38206 7,596.40$

03610043 HB EXC,BENIGN DIA 0.6 TO 1.0 11401 1,578.81$

03610044 HB ASPIRATION BREAST CYST ADDL 19001 559.08$

03610045 HB BIOPSY NEEDLE CORE WO GDNCE 19100 8,779.14$

03610052 HB BIOPSY MUSCLE PERC NEEDLE 20206 8,779.14$ 11,412.90$

03610054 HB BIOPSY BONE DEEP 20225 8,779.14$ 11,412.90$

03610055 HB INJ SING TENDON SHEATH/LIG 20550 1,607.17$ 2,089.31$

03610060 HB ABLATION R/F BONE 20982 29,655.60$ 38,552.27$

03610067 HB UNLISTED SPINE PROCEDURE 22899 1,702.35$

03610068 HB ARTHROGRAM SHOULDER INJ UNI 23350 4,584.85$

03610069 HB ARTHROGRAM ELBOW INJ UNILAT 24220 1,122.38$

03610070 HB ARTHROGRAM WRIST INJ UNILAT 25246 2,181.74$

03610071 HB DIST RAD/COLLES FX W MANIP 25605 4,667.13$ 6,067.25$

03610072 HB BIOPSY PELVIS/HIP ST SUPF 27040 8,779.14$ 11,412.90$

03610073 HB BIOPSY PELVIS/HIP ST DEEP 27041 8,779.14$ 11,412.90$

03610074 HB ARTHROGRAM HIP INJ WO ANES 27093 1,367.12$

03610076 HB ARTHROGRAM KNEE INJ UNILAT 27369 829.60$ 1,078.49$

03610078 HB CAST APP - LONG ARM 29065 1,943.32$ 2,526.33$

03610079 HB CAST APP - THUMB/FINGER 29086 1,028.69$ 1,337.29$

03610080 HB SPLINT APP - SHORT ARM 29125 821.97$ 1,068.56$

03610081 HB CAST APP - LONG LEG 29345 1,943.32$

03610082 HB CAST APP - LONG LEG WALK CAST 29355 1,943.32$

03610083 HB CAST LONG LEG/THIGH TO ANKLE 29365 1,943.32$ 2,526.33$

03610084 HB CAST APP - SHORT LEG 29405 1,943.32$ 2,526.33$

03610085 HB CAST APP - SHORT LEG WALK CAST 29425 1,943.32$ 2,526.33$

03610086 HB CAST APP - PTB 29435 1,943.32$

03610087 HB CAST APP - CLUBFOOT W/ MANI 29450 1,028.69$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03610088 HB REM/BIVALVE - SHOULDER/HIP 29710 1,943.32$

03610089 HB CAST - REPAIR 29720 1,028.69$

03610090 HB CAST - WINDOWING 29730 1,028.69$ 1,337.29$

03610091 HB TRACH TUBE CHANGE 31502 1,584.08$ 2,059.31$

03610093 HB ENT-LARYNGO, FLEXE, DX 31575 1,224.72$ 1,592.12$

03610097 HB TRACHEOSTOMY 31600 9,259.02$ 12,036.73$

03610098 HB DX BRONCHOSCOPE/WASH 31622 9,194.88$ 11,953.35$

03610099 HB PC BRONCH:BRUSHING 31623 9,194.88$

03610100 HB PC BRONCH:ALEVOLAR LAVAGE 31624 9,194.88$

03610101 HB PC BRONCH W/BIOPSY 31625 9,194.88$

03610102 HB BRONCH W TB SGL LOBE LUNG BX 31628 13,790.38$

03610103 HB ASPIR NDL BIOPSY(S) TRNSBRONCH 31629 13,790.38$

03610104 HB PC BRONCH: TRACH STENT 31631 19,526.29$

03610105 HB TB LUNG BIOPSY, EA ADDTL LOBE 31632 10,309.57$

03610106 HB BRONCHOSCOPY; W REMOVAL FB 31635 9,194.88$ 11,953.35$

03610107 HB PC BRONCH: BRONCH STENT 31636 19,526.29$

03610108 HB PC BRONCH: ADDL BRONCH STENT 31637 17,245.65$

03610109 HB PC BRONCH: STENT REVISION 31638 19,526.29$

03610110 HB BRONCHOSCOPY,TREAT BLOCKAGE 31641 13,790.38$

03610113 HB BIOPSY LUNG 32400 8,779.14$ 11,412.90$

03610114 HB BIOPSY LUNG/MEDIASTINUM 32405 8,779.14$ 11,412.90$

03610117 HB REPAIR DECEND AORT W SUBCLAV 33880 14,553.19$

03610118 HB REPAIR DECEND AORT WO SUBCLAV 33881 12,514.41$

03610119 HB REMOV INTRA-AORT BALLOON 33968 1,126.61$

03610125 HB INSERT ILIAC OCCL DEVICE 34808 2,423.43$

03610138 HB PSEUDOANEURYSM INJ EXT UNI 36002 4,021.50$ 5,227.96$

03610139 HB VENOGRAM INJ EXT UNILATERAL 36005 1,553.27$

03610140 HB CATH INTRO SVC/IVC 36010 5,794.82$

03610141 HB CATH PLCMT VENOUS 1ST ORD 36011 7,232.45$

03610142 HB CATH PLCMT VENOUS2ND ORD IR 36012 7,397.31$ 7,397.31$

03610143 HB CATH INTRO RT HEART/PULM AR 36013 5,569.89$

03610144 HB CATH PLCMT RT/LT PULM ART 36014 6,870.93$

03610145 HB CATH PLCMT SEGMENTAL ARTERY 36015 5,307.18$

03610149 HB CATH INTRO AORTIC TRANSLUMN 36160 5,847.33$

03610150 HB CATH AORTA 36200 5,124.32$

03610151 HB CATH PLCMT THORACIC 1ST ORD 36215 10,624.83$

03610152 HB CATH PLCMT THORACIC 2ND ORD 36216 11,967.90$

03610153 HB CATH PLCMT THORACIC 3RD ORD 36217 14,441.81$

03610154 HB CATH PLCMT THORACIC EA ADDL 36218 2,299.41$

03610155 HB CATH PLCMT ABD-EXT 1ST ORD 36245 5,124.32$

03610156 HB CATH PLCMT ABD-EXT 2ND ORD 36246 7,102.16$

03610157 HB CATH PLCMT ABD-EXT 3RD ORD 36247 10,805.59$

03610158 HB CATH PLCMT ABD-EXT EA ADDL 36248 2,145.99$

03610159 HB VENIPUNCTURE INFNT 3YR/OLDER 36410 68.48$ 90.59$

03610161 HB VENIPUNCTURE CUTDOWN > 1 YR 36425 1,272.58$ 1,654.37$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03610164 HB CATH PLCMT PERC PORTAL VEIN 36481 5,361.80$

03610165 HB VENOUS SAMPLING 36500 2,522.22$

03610166 HB TUBE CHANGE G-TUBE TO GJ 49446 5,709.74$

03610167 HB TUBE REPLACE DUOD/JEJ 49451 3,477.64$ 4,520.92$

03610168 HB TUBE REPLACE GJ 49452 3,477.64$

03610169 HB TUBE FIX G-GOLON 49460 3,477.64$ 4,520.92$

03610170 HB G-COLON CONTRAST INJECTION 49465 823.03$

03610174 HB CATH INSRT TUNNLED 5YR/MORE 36558 11,407.72$ 14,830.03$

03610175 HB INSRT TUNN CVC W/PORT >5YRS 36561 11,407.72$ 14,830.03$

03610177 HB CATH INSRT PICC 5YR/LESS W/O IMG GUID 36568 4,021.50$ 5,227.96$

03610178 HB CATH INSRT PICC 5YR/MORE W/O IMG GUID 36569 6,247.55$ 8,121.82$

03610180 HB PAS PORT INSERTION >5 YRS 36571 11,407.72$ 14,830.03$

03610181 HB CATH REPAIR CV OR PICC 36575 4,021.50$ 5,227.96$

03610183 HB CATH REPLCMT NON-TUN CV 36580 6,247.55$ 8,121.82$

03610184 HB CATH REPLCMT TUNNLED CV 36581 11,407.72$ 14,830.03$

03610185 HB REPL CHEST PORT VIA CATH EX 36582 11,407.72$ 14,830.03$

03610186 HB REPL PAS PORT VIA CATH EXCH 36585 11,407.72$ 14,830.03$

03610187 HB COMPLEX CMG (CYSTOMETROGRAM) 51726 3,215.10$

03610188 HB CATH REMOVE TUNNLED VAD 36590 4,021.50$ 5,227.96$

03610189 HB REMOVE PERICATH OBST CVC 36595 11,407.72$

03610190 HB REMOVE INTRACATH OBST MAT 36596 6,247.55$ 8,121.82$

03610191 HB I & D VULVA/PERINEUM 56405 1,416.09$ 1,840.91$

03610192 HB HYSTEROSALPINGOGRAM INJECT 58340 613.67$

03610193 HB CONTRAST INJ INTO CV CATH 36598 1,081.39$

03610195 HB AMNIOCENTESIS, THERAPEUTIC 59001 1,416.09$

03610196 HB ASPIR/INJECT THYROID CYST 60300 4,554.44$

03610197 HB SHUNT INSERT HEPATIC TIPS 37182 9,563.39$

03610198 HB SHUNT REVISION HEPATIC TIPS 37183 36,647.54$

03610199 HB THROMBECTOMY PRIM MECH 37184 78,294.72$

03610200 HB THROMBECTOMY SECNDRY MCH 37186 6,439.83$ 8,372.37$

03610201 HB THROMBECTOMY VENOUS MECH 37187 36,647.54$

03610202 HB THROMBECTOMY VENOUS MECH ADD ON 37188 11,407.72$

03610203 HB BIOPSY TRANSCATHETER 37200 19,109.22$

03610212 HB STENT PLCMT W DIST PROTECT 37215 22,439.29$

03610213 HB STENT PLCMT WO DIST PROTECT 37216 22,439.29$

03610215 HB EPIDURAL INJ CATH CERV/THOR 62324 5,260.12$ 6,838.17$

03610218 HB DIAG BONE MARROW ASPIRATION ONLY 38220 8,779.14$ 11,412.90$

03610219 HB DIAG BONE MARROW BIOPSY 38221 8,779.14$ 11,412.90$

03610220 HB THER/PROPH/DIAG INJ, SC/IM 96372 315.42$ 409.30$

03610222 HB BIOPSY LYMPH NODE 38505 8,779.14$ 11,412.90$

03610228 HB SIALOGRAM INJECTION 42550 975.26$ 1,267.83$

03610230 HB REPOSIT NG/OG TUBE 43761 3,215.10$ 4,179.64$

03610233 HB BIOPSY LIVER 47000 8,779.14$ 11,412.90$

03610235 HB ABLATION R/F LIVER 47382 19,856.63$ 25,813.77$

03610236 HB CHOLECYTOSTOMY S&I 47490 7,830.14$


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OP/ Default

Price

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Price



03610237 HB ANTRODUODENAL MANOMETRY 91020 4,631.23$

03610246 HB BIOPSY PANCREAS 48102 8,779.14$ 11,412.90$

03610251 HB BIOPSY RETROPERITONEAL MASS 49180 8,779.14$ 11,412.90$

03610252 HB INJ PREVIOUS DRAINAGE CATH 49424 1,771.87$

03610253 HB BX RENAL/KIDNEY,PERC 50200 8,779.14$ 11,412.90$

03610254 HB REMOVE TUBE NEPHROSTOMY 50389 3,120.54$

03610255 HB ASPIR/INJECT RENAL CYST 50390 4,554.44$ 5,920.77$

03610261 HB ABLATION R/F KIDNEY UNILAT 50592 19,856.63$ 25,813.77$

03610262 HB URETEROPYELOGRAM/LOOP INJ 50690 1,721.42$

03610264 HB BLADDER INSTILLATION/IRRGTN 51700 3,215.10$ 4,179.64$

03610265 HB CATHERIZATION, STRAIGHT 51701 821.97$ 1,068.56$

03610266 HB CYSTOSTOMY TUBE CHANGE 51705 3,215.10$ 4,179.64$

03610270 HB 24 HR ESOPHAGEAL PH STUDY 91034 4,631.23$

03610271 HB UROFLOWMETRY (SIMPLE) 51736 821.97$

03610272 HB UROFLOWMETRY (COMPLEX) 51741 2,512.10$

03610276 HB POST-VOID RESIDUAL MEASUREMENT 51798 793.59$

03610277 HB CYSTOSCOPY 52000 3,120.54$ 4,056.70$

03610278 HB CYTOURETHROSCOPY 52005 9,835.81$ 12,786.55$

03610280 HB CYSTO W/ DILATION URETHRA STRT 52281 9,835.81$

03610281 HB CYSTO W/ STENT REMOVE (SIMPLE) 52310 9,835.81$

03610282 HB IMPEDANCE PH REFLUX 91038 4,631.23$

03610283 HB CYSTOURETHROSCOPY 52351 11,094.38$

03610284 HB DILITATION URETHRAL STRICTURE 53600 3,215.10$

03610286 HB CIRCUM., BY CLAMP OR DEVICE 54150 9,835.81$

03610288 HB BIOPSY PROSTATE 55700 9,835.81$ 12,786.55$

03610291 HB BIOPSY, VULVA 1ST LESION 56605 2,288.21$

03610294 HB PESSARY FITTING 57160 1,343.98$

03610295 HB HEMOSTATIC AGENT, INTRODUCTION 57180 1,343.98$ 1,747.17$

03610296 HB ECC 57505 2,288.21$

03610297 HB BIOPSY, ENDOMETRIAL 58100 1,343.98$ 1,747.17$

03610301 HB CATH INSRT TUNNLED 5YR/LESS 36557 19,109.22$ 24,841.98$

03610302 HB PLCMT NG TUBE BY W FLUORO 43752 1,272.58$ 1,654.37$

03610306 HB CHORIONIC VILLUS SAMPLING 59015 2,288.21$

03610308 HB CELIAC PLEXUS INJ WO/W IMAGE 64530 5,260.12$

03610309 HB INSERT CERVICAL DILATOR 59200 1,416.09$

03610310 HB BIOPSY THYROID PERC NDL 60100 4,554.44$ 5,920.77$

03610311 HB PUNCTURE C-SPINE W MEDS 61055 1,607.17$

03610312 HB PUNCTURE OF SHUNT TUBING 61070 3,494.61$ 4,543.00$

03610313 HB ENDOVSC TEMP BALLN ART OCCLUSN 61623 78,294.72$

03610314 HB EMBOLIZATION CNS 61624 16,545.74$

03610315 HB EMBOLIZATION EXTRACRANIAL 61626 78,294.72$

03610316 HB ANGIOPLASTY CRANIAL 61630 22,439.29$

03610317 HB ANGIOPLASTY CRANIAL W STENT 61635 28,049.15$

03610318 HB DIL CRANIAL VASOSPASM INIT 61640 28,049.15$

03610319 HB DIL CRANIAL VASOSPASM ADDL 61641 11,219.65$


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Price



03610320 HB DIL CRANIAL VASOSPASM ADDON 61642 22,439.29$

03610323 HB INJ EPIDURAL OR BLOOD PATCH 62273 5,260.12$ 6,838.17$

03610324 HB MYELOGRAM INJ 62284 4,146.93$

03610326 HB INJ DISCOGRAM L-SPINE 62290 5,038.14$

03610328 HB INJ EPIDURAL CERV/THOR 62320 5,048.10$

03610329 HB INJ EPIDURAL L/S-SPINE 62322 5,048.10$

03610333 HB INJ ANESTH/STEROID PUDENDAL NERVE 64430 5,260.12$ 6,838.15$

03610339 HB INJ C/T-SPINE TRNSFORAM INI- IMG GUIDE INCL 64479 5,260.12$ 6,838.15$

03610340 HB INJ C/T-SPINE TRNSFORAM ADL-IMG GUIDE INCL 64480 3,335.63$

03610341 HB INJ L/S-SPINE TRNSFORAM INI-IMG GUIDE INCL 64483 5,260.12$ 6,838.15$

03610342 HB INJ L/S-SPINE TRNSFORAM ADL-IMG GUIDE INCL 64484 3,226.34$

03610343 HB BOTOX, CERVICAL SPINAL MUSCLES 64616 1,607.17$ 2,089.31$

03610344 HB ARG/KRYP TRABECULOPLASTY * 65855 4,166.72$

03610345 HB YAG IRIDOTOMY 1 OR MORE 66761 4,166.72$ 5,416.74$

03610346 HB YAG DISCISSION A-CATARACT MEM* 66821 4,166.72$

03610347 HB ARG/KRYP ANTERIOR SMGNT EYE * 66999 7,483.86$

03610349 HB ARG/KRYP DESTRUCTION RETINA * 67210 4,166.72$

03610350 HB ARG/KRYP DESTRUCT RETINOPATHY* 67228 4,166.72$

03610354 HB VENOGRAM HEPATIC WO HEMO SI 75891 17,100.76$

03610356 HB ARTHROGRAM INJ SI JOINT UNI G0259 1,914.96$

03610357 HB ESOPHAGEAL MANOMTRY W/INTER RPT 2D 91010 7,718.70$

03610358 HB ESOPHGEAL MOTILITY W/STIM/PERFUS 2D 91013 6,622.91$

03610360 HB ARTHROGRAM ANKLE INJ UNILAT 27648 4,584.85$

03610361 HB PLCMT PROX EXTENSION PROS 33883 8,737.38$

03610362 HB THROMBECTOMY PRIM MECH ADON 37185 6,515.75$

03610366 HB FIBERLAYER PHO OPTHAL NERVE 92499 372.42$

03610371 HB C MOTOR EVOKED, UPPR LIMBS 95928 12,594.42$ 16,372.77$

03610372 HB C MOTOR EVOKED, LWR LIMBS 95929 12,594.42$ 16,372.77$

03610373 HB CYSTOGRAM/VCUG INJ 51600 276.53$ 358.89$

03610376 HB URETHROCYSTOGRAM RETRO INJ 51610 485.55$ 631.20$

03610377 HB IR INJ EPIDURAL LS SPINE 62326 5,260.12$

03610380 HB PLCMT PERC GASTROSTOMY TUBE 49440 5,709.74$

03610383 HB GASTRIC LAP BAND ADJUSTMENT S2083 4,794.35$ 6,232.65$

03610384 HB INTRODUCTION LONG GI TUBE 44500 3,477.64$ 4,520.92$

03610385 HB BX VULVA/PERINEUM EA ADDL LES 56606 1,307.36$

03610386 HB IUD INSERTION 58300 416.17$

03610387 HB IUD REMOVAL 58301 1,416.09$ 1,840.91$

03610388 HB HYSTEROSCOPY 58555 16,582.00$

03610392 HB DEBRIDEMENT SQ TISSUE 11042 1,578.81$ 2,052.44$

03610393 HB PARING OR CURETTEMENT 1 LESION 11055 1,195.75$

03610395 HB RMVL SKIN TAGS UP TO 15 11200 1,195.75$ 1,554.47$

03610396 HB SIMPLE LAC REPAIR UP TO 2.5 CM 12001 1,195.75$ 1,554.47$

03610397 HB CAST APP - SHORT ARM 29075 1,943.32$ 2,526.33$

03610398 HB SPLINT APP - LONG ARM 29105 1,028.69$ 1,337.29$

03610399 HB STRAPPING CHEST 29200 1,028.69$ 1,337.29$


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Code

OP/ Default

Price

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Price



03610400 HB STRAPPING, SHOULDER 29240 821.97$ 1,068.56$

03610401 HB STRAPPING, ELBOW/WRIST 29260 307.05$ 399.16$

03610402 HB SPLINT APP - LONG LEG 29505 1,028.69$ 1,337.29$

03610403 HB SPLINT APP - SHORT LEG 29515 1,028.69$ 1,337.29$

03610404 HB STRAPPING, KNEE 29530 821.97$ 1,068.56$

03610405 HB STRAPPING ANKLE &/OR FOOT 29540 1,028.69$ 1,337.29$

03610406 HB STRAPPING TOES 29550 793.59$ 1,031.66$

03610407 HB REM/BIVALVE - FULL ARM/LEG 29705 1,943.32$ 2,526.33$

03610408 HB ANT. EPISTAXIS COMPLEX 30903 1,574.80$ 2,047.24$

03610409 HB POSTERIOR EPISTAXIS INITIAL 30905 821.97$ 1,068.56$

03610410 HB LARYNGOSCOPY, DIRECT ASPIRATIO 31515 1,856.26$ 2,413.12$

03610411 HB INJ ANES/STEROID PERIPHERAL NERVE 64450 1,608.65$ 2,091.26$

03610413 HB BIOPSY BONE SUPERFICIAL 20220 7,023.31$ 9,130.31$

03610418 HB THORACENTESIS WO IMG GUIDE 32554 4,021.50$ 5,227.96$

03610422 HB CATH PLCMT NON-SELECTIVE 36000 296.35$

03610423 HB CATH INSRT NON-TUN 5YR/LESS 36555 6,247.55$ 8,121.82$

03610424 HB CATH REMOVE TUNNLED CV 36589 4,021.50$ 5,227.96$

03610425 HB BLOOD DRAW PICC 36592 821.97$ 1,068.56$

03610426 HB ARTERIAL PUNCTURE 36600 821.97$ 1,068.56$

03610428 HB CATHETERIZATION, INDWELLING 51702 821.97$ 1,068.56$

03610429 HB TRANS ABD AMNIOINFUSION W/US 59070 1,416.09$

03610430 HB PUNCTURE L-SPINE DIAG 62270 4,206.87$ 5,468.94$

03610431 HB DRAINAGE CSF FLUID 62272 2,917.58$ 3,792.84$

03610432 HB PEDS ENT-REMOVE-FB-EXTAUDITCAN 69200 821.97$ 1,068.56$

03610433 HB PLACEMENT, CATH RADIOELEMENT 19296 23,293.18$

03610435 HB CHEMODENERVATION;FACIAL NERVE 64612 1,607.17$ 2,089.31$

03610436 HB DESTRC, NEUROLYTIC AGENT, OTHR 64640 5,260.12$ 6,838.17$

03610438 HB SP VIDEOSTROBOSCOPY - (3) MOD 31579 1,392.20$

03610439 HB SP VIDEOSTROBOSCOPY - (2) INT 31579 928.13$

03610441 HB TRIGGER PT INJ >3 MUSCLES 20553 1,607.17$ 2,089.31$

03610442 HB ASPIR/INJECT JOINT MAJOR* 20610 1,607.17$ 2,089.31$

03610443 HB ASPIR/INJECT GANGLION CYST(S) 20612 1,607.17$ 2,089.31$

03610445 HB SPLENOPORTOGRAPHY INJECTION 38200 296.35$

03610446 HB DEPLOY HEMOSTASIS DEVICE 37799 4,021.50$

03610449 HB MUSCLE TRIGGER PT INJ 1-2 20552 1,607.17$ 2,089.31$

03610457 HB SI JOINT ANES/STEROID INJ W IMG 27096 3,635.77$

03610459 HB INJ ANES/STEROID INTRCSTL NRVE SGLE LVL 64420 2,917.58$ 3,792.85$

03610460 HB INJ ANES/STEROID INTECSTL NRVE EACH ADDL LVL 64421 5,260.12$

03610466 HB CL TX PROX HUM FX; WO MANIP 23600 1,702.35$ 2,213.06$

03610467 HB CL TX HUMERUS FX WO MANIP 24500 1,702.35$ 2,213.06$

03610468 HB CL TX SC/TC HUM FX WO MANIP 24530 1,702.35$ 2,213.06$

03610469 HB CL TX EC HUM FX WO MANIP 24560 1,702.35$ 2,213.06$

03610471 HB CL TX C HUMERUS FX W MANIP 24577 4,667.13$ 6,067.25$

03610472 HB CL TX MONTGG ELB FX W MANIP 24620 4,667.13$ 6,067.25$

03610473 HB CL TX ULNAR FX; PROX END WO MANIP 24670 1,702.35$ 2,213.06$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

IP/ER

Price



03610474 HB CL TX RAD SHFT FX; WO MANIP 25500 1,702.35$ 2,213.06$

03610475 HB GALEAZZI FX/DISLOC 25520 4,667.13$ 6,067.25$

03610476 HB CL TX ULNAR SHFT FX WOMANIP 25530 1,621.29$ 2,107.68$

03610477 HB CL TX ULNAR SHFT FX W MANIP 25535 1,702.35$ 2,213.06$

03610478 HB CL TX DSTL RADIAL FX/EPIPHYSL SEP WO MANIP 25600 1,702.35$ 2,213.06$

03610479 HB CL TX MC FX,SGLWO MNP EA BN 26600 1,702.35$ 2,213.06$

03610480 HB CL TX MC FX, SGL; W MANIP 26605 1,702.35$ 2,213.06$

03610482 HB CL TX FEM SHAFT FX, W MANIP 27502 4,667.13$ 6,067.25$

03610483 HB CL TX SC/TC FEM FX, W MANIP 27503 4,667.13$ 6,067.25$

03610484 HB CL TX D FEM FX WO MANIP 27508 1,702.35$ 2,213.06$

03610485 HB CL TX DIST FEM EPIPHYS SEP; WO MANIP 27516 1,702.35$ 2,213.06$

03610487 HB CLOSED TX PTLLR FX,WO MANIP 27520 1,702.35$ 2,213.06$

03610488 HB CL TX PROX TIB FX, WO MANIP 27530 1,702.35$ 2,213.06$

03610490 HB CL TX IC SP ORTUBEROSITY W OR W/O MANIP 27538 1,702.35$ 2,213.06$

03610491 HB CL TX PRX FIB/SHFT FX WOMNP 27780 1,702.35$ 2,213.06$

03610492 HB CL TX DSTL FIB FX WO MANIP 27786 1,702.35$ 2,213.06$

03610493 HB CL TX WB DSTL TIB WO MANIP 27824 1,702.35$ 2,213.06$

03610494 HB CL TX CALCANEAL FX;WO MANIP 28400 1,702.35$ 2,213.06$

03610495 HB CL TX TALUS FX; WO MANIP 28430 1,702.35$ 2,213.06$

03610496 HB TX TARSAL BONE FX;WO MANIPU 28450 1,702.35$ 2,213.06$

03610498 HB CL TX METATARSAL FX;WOMANIP 28470 1,702.35$ 2,213.06$

03610499 HB CL TX METATARSAL FX;W MANIP 28475 1,702.35$ 2,213.06$

03610500 HB CL TX RADIAL SHFT FX WMANIP 25505 4,667.13$ 6,067.25$

03610501 HB SINUS TRACT INJ THERAPEUTIC 20500 5,161.10$

03610503 HB CHANGE URETER STENT, PERCUT 50382 9,835.81$

03610504 HB INSTILATN OF ANTICARCINOGNC 51720 3,215.10$

03610505 HB INSERT ABD. PLEURX CATH 49418 7,830.14$ 10,179.17$

03610507 HB EXC, BENIGN DIA 1.1-2.0 CM 11402 4,554.44$

03610508 HB REMOVE URETER STENT PERCUT 50384 9,835.81$ 12,786.55$

03610509 HB PHOTOPHERESIS, EXTRACORP 36522 15,101.85$

03610511 HB ABLATION CRYO RENAL UNILAT 50593 17,681.09$ 22,985.42$

03610513 HB UL VASCULAR INJECTION 36299 5,217.45$ 6,782.67$

03610516 HB REMOVAL OF NAIL BED 11750 1,578.81$ 2,052.44$

03610518 HB CL TX SHLDR DISL,MANIP;ANES 23655 4,667.13$ 6,067.25$

03610519 HB LARYNGOSCOPY, IND; DIAGNOSTIC 31505 1,224.72$ 1,592.12$

03610522 HB TX CL ELBOW DISLOC W ANESTH 24605 4,667.13$ 6,067.25$

03610523 HB CL LAC, MTH VESTIB; >2.5 CM 40831 2,262.47$ 2,941.21$

03610530 HB REM FB,EXTEYE;CRNL,SLT LAMP 65220 1,272.58$ 1,654.37$

03610531 HB REPLACE CATH ONLY OF VAD 36578 11,407.72$ 14,830.03$

03610534 HB PLACE DUOD/JEJ TUBE PERC 49441 5,709.74$

03610535 HB INJ ANES/STEROID SCIATIC NERVE 64445 4,206.87$ 5,468.94$

03610541 HB BIOPSY MUSCLE SUPERFICIAL 20200 8,779.14$ 11,412.88$

03610542 HB BIOPSY MUSCLE; DEEP 20205 9,572.41$ 12,444.15$

03610543 HB STENT PLCMT INTERNAL CAROT 93799 2,512.10$

03610545 HB PLCMT RT DEV/MARKER PROSTATE 55876 13,412.64$


Charge

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Code

OP/ Default

Price

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Price



03610546 HB EXC FACE-MM B9+MARG 0.5< CM 11440 4,554.44$ 5,920.77$

03610547 HB BRONCH W FLUORO COMPTR ASST 31627 9,164.04$

03610550 HB REMOVAL OF PLEURX CATHETER 32552 4,021.50$ 5,227.96$

03610565 HB EXC NECK LES SC = 3 CM 21552 9,572.41$

03610576 HB EXC THIGH/KNEE LES SC> 3 CM 27337 9,572.41$

03610580 HB ABLATION CRYO FIBROADENOMA 19105 14,148.37$ 18,392.86$

03610582 HB ABLATION CRYO LIVER 47383 19,856.63$ 25,813.77$

03610587 HB SINUS INJECTION, DIAGNOSTIC 20501 1,553.96$ 2,020.17$

03610594 HB DEEP I & D, THIGH/KNEE 27301 9,572.41$ 12,444.15$

03610595 HB ILIAC ENDARTERECTOMY 35351 15,967.28$

03610596 HB THROMBOENDARTARECTOMY OF RF 35371 15,967.28$

03610600 HB CL TX DISTL FIB FX W MANIP 27788 2,042.82$ 2,655.67$

03610603 HB DRAIN BL W/CATH INSERTION 51102 9,835.81$ 12,786.55$

03610604 HB NASOPHARYNGOSCOPY W ENDOSCP 92511 1,224.72$ 1,592.12$

03610605 HB UGI W BX. SGL/MULTIPLE 43239 3,477.64$ 4,520.92$

03610606 HB UGI W REMOVAL OF FB 43247 3,477.64$ 4,520.92$

03610608 HB EXC,BLES,S/N/EX,G;1.1-2.0CM 11422 8,779.14$ 11,412.90$

03610609 HB REM FB, UP ARM OR ELBOW; SQ 24200 8,779.14$ 11,412.88$

03610613 HB UNLISTED VASC PROCEDURE 37799 4,021.50$ 5,227.96$

03610615 HB REMOVE FECAL IMPACTION OR FB 45915 9,345.56$ 12,149.22$

03610616 HB CNTRL OROPHRYNGEAL HEMORRH;SIMPL 42960 2,262.47$ 2,941.21$

03610620 HB DX LARYNGOSCOPY EXCL NB 31525 9,194.88$ 11,953.35$

03610621 HB SKIN TEST; TB, ID 86580 372.42$ 484.14$

03610622 HB BRONCHOSCOPY DILATE/FX REPR 31630 13,790.38$ 17,927.50$

03610625 HB ATT F/C/M/N/A/G/H/F; 10 SQ CM 14040 6,081.70$ 7,906.19$

03610627 HB REM GAUNTLET,BOOT - BDY CST 29700 1,943.32$ 2,526.33$

03610628 HB DEEP REM FB FROM UA/ELBOW 24201 9,572.41$ 12,444.15$

03610630 HB ENDOVASC PROSTH TAA ADD-ON 33884 5,124.32$

03610631 HB EXPOSE FEM ART PROSTH UNI 34812 5,124.32$

03610632 HB BIOPSY SALIVARY GLAND NDL 42400 4,554.44$ 5,920.77$

03610633 HB CERV COLP W EC CURETT 57456 1,416.09$

03610634 HB COLPOSCOPY OF VULVA 56820 1,343.98$

03610635 HB EXAM/BIOPSY OF VAG W/SCOPE 57421 2,288.21$

03610639 HB HYSTEROSCOPY BX ENDM-PLYPT 58558 16,582.00$

03610644 HB ANGIO ILIAC, INITIAL VESSEL 37220 36,647.54$

03610645 HB STENT, ILIAC INITIAL VESSEL 37221 78,294.72$

03610646 HB ANGIO ILIAC, ADDL VESSEL 37222 34,741.56$

03610647 HB STENT ILIAC, ADDL VESSEL 37223 37,425.90$

03610648 HB ANGIO FEM/POP SYSTEM 37224 36,647.54$

03610649 HB ATHERECTOMY FEM/POP SYSTEM 37225 78,294.72$

03610650 HB STENT PLACEMENT FEM/POP 37226 78,294.72$

03610651 HB STENT PLCMNT W/ATHRCTMY FEM 37227 87,688.44$

03610652 HB ANGIO PTA TIB/PERON INI VSL 37228 78,294.72$

03610653 HB ATHERECTOMY TIB/PERON INI 37229 87,688.44$

03610654 HB STENT PLCMNT TIB/PERON, INI VSL 37230 87,688.44$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



03610655 HB STENT PLCMNT W/ATH TIB, INITIAL VESSEL 37231 87,688.44$

03610656 HB ANGIO TIB/PERONEAL,EA ADDL 37232 29,785.43$

03610657 HB ATHERECTOMY TIB/PERON EA 37233 32,579.93$

03610658 HB STENT PLCMNT TIB/PERON,EA 37234 32,469.72$

03610659 HB STENT PLCMNT TIB/PER W/ATH, EA ADDL 37235 60,923.66$

03610661 HB STENT PLACEMENT INTRACRANIAL 37799 4,021.50$

03610663 HB PARTNER TRANSFEMORAL 33361 58,165.50$

03610664 HB PARTNER TRANSAPICAL 33366 22,592.64$

03610668 HB DEBRIDE MUSC/FASCIA ADD-ON 11046 1,234.40$ 1,604.72$

03610669 HB DEBRIDE BONE ADD-ON 11047 838.22$ 1,089.68$

03610671 HB BIOPSY BACK/FLANK; SUPERF 21920 8,779.14$ 11,412.90$

03610674 HB CHNGE CYSTO TUBE COMPLICATD 51710 3,120.54$ 4,056.70$

03610675 HB INJ ANES/STEROID BRACH PLEX CONT INF 64416 5,260.12$ 6,838.17$

03610677 HB THROMECTOMY PRIM MECH ADDON 37185 6,515.75$

03610679 HB AVULSION NAIL PLATE; SGL 11730 1,195.75$

03610680 HB AVULSION NP; SGL EA ADDL 11732 746.17$ 970.03$

03610682 HB EXC INTRDG MRTN NERM EA SGL 28080 4,667.13$

03610684 HB INJ TENDON ORIGIN/INSERT 20551 1,607.17$

03610685 HB CARPAL TUNNEL TX INJ 20526 1,607.17$ 2,089.31$

03610686 HB CHEMODENRV EXTRCLR MUSCLE 67345 1,219.90$ 1,585.89$

03610687 HB CHEMODENRV ECRN GLNDS 2AXIL 64650 1,607.17$ 2,089.31$

03610688 HB CHEMODENRV ECRN GLNDS OTHR 64653 1,607.17$ 2,089.31$

03610691 HB CHEMODENERV SALIV GLANDS 64611 1,607.17$ 2,089.31$

03610696 HB CL TX NSL BN FX; W STABILIZ 21320 9,259.02$ 12,036.73$

03610699 HB CATHETERIZATION,NON-INDWELLNG 51701 821.97$

03610712 HB INSERT TEMP PACELEAD SGL CL 33210 34,183.78$ 44,438.91$

03610731 HB INTERDISCAL PERQ ASPIR, DX 62267 4,554.44$

03610747 HB ASPIRATION/INJ RNL CYST IR 50390 4,554.44$

03610753 HB REPLACE G/C TUBE PERC 49450 3,477.64$

03610754 HB INJ C/T-SPINE FACET FRST 64490 2,489.18$

03610755 HB INJ C/T-SPINE FACET SECOND 64491 2,995.14$

03610756 HB INJ C/T-SPINE FACET ADDL 64492 2,995.14$

03610757 HB INJ L/S-SPINE FACET FIRST 64493 5,260.12$

03610758 HB INJ L/S-SPINE FACET SECOND 64494 2,995.14$

03610759 HB INJ L/S-SPINE FACET ADDL 64495 2,995.14$

03610761 HB EXCHANGE PREVIOUS DRAINAGE CATH 49423 5,709.74$ 7,422.66$

03610762 HB NERVE INJ GANGLN IMPR BLCK 64999 1,607.17$

03610768 HB REMOVAL FB SQ SIMPLE* 10120 1,578.81$

03610769 HB I&D HEMATOMA 10140 8,779.14$ 11,412.88$

03610776 HB EXC,BEN LES,T/A/L;3.1-4.0CM 11404 8,779.14$

03610777 HB EXC BEN LESS T/A/L; >4.0CM 11406 8,779.14$

03610778 HB EXC MLES T/A/L; 0.6-1.0CM* 11601 4,554.44$

03610779 HB EXC MLES T/A/L; 1.1-2.0CM* 11602 1,578.81$

03610780 HB EXC MLES T/A/L; 2.1-3.0CM* 11603 4,554.44$

03610781 HB EXC MLES T/A/L; 3.1-4.0CM* 11604 4,554.44$


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Price



03610782 HB EXC MLES T/A/L; >4.0CM* 11606 8,779.14$

03610794 HB ARTERIAL CATH INSERT PERC 36620 1,300.82$

03610797 HB SGL/MLT INJ SPDR VN;LMB/TRK 36468 1,195.75$

03610799 HB INJ SCLRSNG SOLN - SGL VEIN 36470 1,578.81$

03610800 HB INJ SCLRSNG SOLN;MLT SM LG 36471 1,578.81$

03610802 HB DEBRIDEMENT MUSCLE/FASCIA 11043 3,088.06$ 4,014.46$

03610803 HB DEB BONE 20 SQ CM/< 11044 8,779.14$ 11,412.90$

03610804 HB EXC BLES S/N/EX G; > 4.0CM 11426 9,572.41$

03610806 HB EXC MLS F/E/E/N/L;0.6-1.0CM 11641 4,554.44$

03610807 HB EXC MLS F/E/E/N/L;1.1-2.0CM 11642 4,554.44$

03610812 HB TX S WND DEHISC; SMPL - 12020 3,088.06$ 4,014.46$

03610813 HB WOUND DEHISCENCE PACKING - 12021 1,578.81$

03610828 HB INJ ANES/STEROID ILING/ILHYPGSTRC 64425 2,917.58$ 3,792.85$

03610829 HB PLCMT EXT DEV PST ARTA REP 33886 7,014.72$

03610830 HB DEBRIDE SKIN MUSC AT FX STE 11011 4,554.44$ 5,920.77$

03610831 HB INJ SUP HYPOGASTRIC PLXUS 64517 5,260.12$

03610832 HB INJ ANES/STEROID FEMORAL NRV 64447 4,206.87$ 5,468.94$

03610833 HB INJ AIR PERITONEUM 49400 672.59$

03610834 HB INJ MAMMARY DUCT(S) 19030 1,948.42$ 2,532.96$

03610835 HB UL PROC ABLATION LIVER ALCOHOL 47399 4,554.44$ 5,920.77$

03610836 HB UL PROC ABLATION LIVER MICROWAVE 47382 19,856.63$ 25,813.77$

03610841 HB UL PROC ABLATION SPINE RADFREQ 20982 29,655.60$ 38,552.27$

03610842 HB UL PROC ABLATION BONE MICROWAVE 20982 29,655.60$ 38,552.27$

03610844 HB INS CATH REN ART 1ST UNILAT 36251 58,028.05$

03610845 HB INS CATH REN ART 1ST BILAT 36252 63,340.60$

03610846 HB INS CATH REN ART 2ND+ UNILAT 36253 43,094.13$

03610847 HB INS CATH REN ART 2ND+ BILAT 36254 53,978.56$

03610848 HB INS VENA CAVA FILTER 37191 19,109.22$ 24,841.98$

03610849 HB REPOSITION VENA CAVA FILTER 37192 11,407.72$

03610850 HB REMOVAL VENA CAVA FILTER 37193 11,407.72$

03610851 HB PARACENTESIS W IMG 49083 3,999.28$ 5,199.07$

03610852 HB ESOPH IMPED FUNCTION TEST 91037 2,690.19$

03610853 HB DESTR W NEURLYTC CELC PLEXS 64680 5,260.12$

03610854 HB INJ ANES/STEROID BRACH PLEXUS 64415 5,260.12$ 6,838.17$

03610855 HB BM/PB WASH HARVST STM CELLS 38209 5,499.72$

03610856 HB BM/PB WASH HARVST STM CELLS 38208 5,499.72$

03610857 HB REP TENDN/MSCL - FARM.WRIST 25260 12,463.59$ 16,202.66$

03610858 HB CYSTO W MULTI OBSTR CLOT REM 52001 11,094.38$ 14,422.69$

03610860 HB ABLATION RENAL MICROWAVE UN 50592 19,856.63$ 25,813.77$

03610861 HB ABLATION RENAL ALCOHOL UNI 53899 3,215.10$ 4,179.64$

03610862 HB INJ PLATELET PLASMA & IMG 0232T 1,272.58$

03610863 HB INJ ANESTH/STEROID GRTR OCCPTL NRV 64405 1,607.17$ 2,089.31$

03610865 HB INJ ANES SPHENOPALATE GANG 64505 1,607.17$ 2,089.31$

03610868 HB UNLIST PROC HEMIC/LYMPH 38999 5,499.72$ 7,149.63$

03610874 HB UL PROC URETEROPLASTY 53899 3,215.10$ 4,179.64$


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Price



03610880 HB CSF SHUNT REPROGRAM 62252 955.87$

03610881 HB BRONCHIAL VALVE INIT INSERT 31647 19,526.29$

03610882 HB BRONCHIAL VALVE REMOV INIT 31648 13,790.38$

03610883 HB BRONCHIAL VALVE REMOV ADDL 31649 9,194.88$

03610884 HB BRONCHIAL VALVE INSETN ADDL 31651 17,245.65$

03610887 HB THORACENTESIS W IMG 32555 4,825.81$ 6,273.56$

03610888 HB DRAINAGE PLEURA W CATH W IMG 32557 6,247.55$ 8,121.82$

03610889 HB AORTIC VLV RPLMT;OPEN FEMOL 33362 58,165.50$

03610890 HB AORTIC VLV RPLMT;OPEN AXLRY 33363 58,165.50$

03610892 HB AORTIC VLV RPLMT;TRANSRTC 33365 22,592.64$

03610893 HB AORTIC VLV W/BYP;FEMORAL 33367 58,165.50$

03610896 HB PLACE CATH THORACIC AORTA 36221 11,407.72$

03610897 HB PLACE CATH CAR/INOM ART,UNI 36222 33,868.11$

03610898 HB PLACE CATH CAR/INOM ART,BIL 36222 34,970.04$

03610899 HB PLACE CATH CAR/INOM ART,UNI * 36223 45,782.70$

03610900 HB PLACE CATH CAR/INOM ART,BIL * 36223 50,002.54$

03610901 HB PLACE CATH CAROTD ART,UNI 36224 46,884.66$

03610902 HB PLACE CATH CAROTD ART,BIL 36224 52,032.28$

03610903 HB PLACE CATH SUBCLAV ART,UNI 36225 35,067.76$

03610904 HB PLACE CATH SUBCLAV ART, BIL 36225 36,169.71$

03610905 HB PLACE CATH VERTEBRL ART,UNI 36226 36,169.71$

03610906 HB PLACE CATH VERTEBRL ART,BIL 36226 38,199.43$

03610907 HB PLACE CATH XTRNL CAR,UNI 36227 11,832.44$

03610908 HB PLACE CATH XTRNL CAR, BIL 36227 16,626.59$

03610909 HB PLACE CATH INTRCRNL ART,UNI 36228 14,049.16$

03610910 HB PLACE CATH INTRCRNL ART,BIL 36228 28,098.35$

03610911 HB REMOVE INTRAVS FOREIGN BODY 37197 11,407.72$

03610912 HB THROMBOLYTIC ART THERAPY 37211 19,109.22$

03610913 HB THROMBOLYTIC VENOUS THERAPY 37212 11,407.72$

03610914 HB THROMBLYTIC ART/VEN THERAPY 37213 6,247.55$

03610915 HB CESS THERAPY CATH REMOVAL 37214 6,247.55$

03610917 HB CYSTOSCOPY CHEMODENERVATION 52287 9,835.81$ 12,786.55$

03610918 HB GI WIRELESS CAPSULE MEASURE 91112 3,477.64$

03610920 HB DUODENAL MOTILITY STUDY 91022 12,594.42$

03610922 HB REMOVAL TUN ABD PLEURX CATH 49422 11,407.72$ 14,830.03$

03610923 HB CHEMODENERV MUSC MIGRAINE 64615 1,607.17$

03610926 HB EXC TR-EXT MAL+MARG 0.5 < CM 11600 4,554.44$

03610927 HB INJECTION INTO SKIN LESIONS =<7 11900 1,195.75$

03610930 HB ATT TRUNK; D 10 SQ CM/< 14000 6,081.70$ 7,906.19$

03610931 HB ATT S/A/L; D 10 SQ CM/< 14020 6,081.70$

03610942 HB CYSTOMETROGRAM W/VP 51728 3,120.54$

03610944 HB DESTRUCT PREMALIG LES 2-14 17003 1,294.92$

03610947 HB CYSTO REM FB/ST URE/BLD;COM 52315 9,835.81$ 12,786.55$

03610948 HB VULVA COLPOSC W BX 56821 1,416.09$

03610951 HB SHAVE LES T/A/L; 0.6-1.0CM 11301 1,195.75$


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03610954 HB SHAVE LES S/N/H/F/G; 0.6-1.0CM 11306 1,195.75$ 1,554.47$

03610964 HB BIOPSY THIGH/KNEE ST DEEP 27324 9,572.41$ 12,444.15$

03610966 HB EXC S/N/H/F/G MAL+MRG 2.1-3 11623 8,779.14$

03610968 HB EXC S/N/H/F/G MAL+MRG 0.6-1 11621 4,554.44$

03610969 HB EXC H-F-NK-SP MAL+MARG 0.5 < 11620 8,779.14$

03610970 HB EXC F/E/E/N/L MAL+MRG > 4 CM 11646 9,572.41$

03610972 HB EXC F/E/E/N/L MAL+MRG 0.5CM< 11640 4,554.44$

03610974 HB EXC BLES S/N/EX G; 0.6-1.0CM 11421 4,554.44$

03610975 HB COLPOSCOPY OF VAGINA 57420 1,416.09$

03610976 HB CERVIC COLP W CERVIX BX 57455 1,416.09$

03610978 HB ABD PARACENTESIS 49082 3,477.64$ 4,520.92$

03610986 HB PERITONEAL VENOUS SHUNT INJ 49427 1,540.76$ 2,002.97$

03610992 HB EXC THIGH/KNEE LES SC <3 CM 27327 8,779.14$

03610995 HB ARTIFI INSEMINTN; INTRA-CER 58321 1,416.09$

03610997 HB INSERT DRUG IMPLANT 11981 821.97$

03610998 HB REMOVE DRUG IMPLANT 11982 1,272.58$

03610999 HB REMOVE W INS DRUG IMPLANT 11983 1,272.58$

03611002 HB APPLY SHORT ARM SPLNT;DYNAM 29126 821.97$ 1,068.56$

03611003 HB CL TX ULN FRC PROX END WMNP 24675 4,667.13$ 6,067.25$

03611005 HB CL TX CLAVICULAR FX; WO MANIP 23500 1,702.35$ 2,213.06$

03611006 HB INTMD WND REPAIR S/A/T/EXT 12036 3,088.06$ 4,014.46$

03611010 HB CL TX PROX FIB/SHFT FX WMAN 27781 4,667.13$ 6,067.25$

03611012 HB INC & REM FB SQ; COMPL 10121 8,779.14$ 11,412.88$

03611013 HB REMOVAL OF SUPPORT IMPLANT 20670 8,779.14$

03611014 HB TENOTOMY TOE MULT PERQ 28011 5,600.55$

03611015 HB TENOTOMY TOE SNGL PERQ 28010 4,667.13$

03611019 HB EXC FACE-MM B9+MARG 0.6-1 CM 11441 4,554.44$

03611021 HB TRIM NONDYSTROPHIC NAILS 11719 793.59$ 1,031.66$

03611022 HB UL PROC TRANSFORAM GLUE INJ 64999 1,607.17$

03611027 HB SURG TX INCOMPL ABORTION 59812 16,582.00$ 21,556.60$

03611028 HB SURG TX MSD ABORT;1ST TRIM 59820 16,582.00$ 21,556.60$

03611030 HB APPLY R & L PULM ART BANDS 33620 22,592.64$

03611031 HB TRANSTHOR CATH FOR STENT 33621 21,516.81$

03611034 HB BX DONE W/COLPOSCOPY ADD-ON 58110 940.83$

03611036 HB TRNSCTH RNL SYMP DNRV BIL 0339T 36,647.54$

03611040 HB TRNSCTH MTRAL VLVE RPR 0345T 58,165.50$ 58,165.50$

03611057 HB TRNSCTH STNT PLMNT RTR CRTD,UNI 37217 73,634.59$

03611058 HB TRNSCTH STNT PLMNT RTR CRTD,BIL 37217 124,829.86$

03611059 HB TRNSCTH PLMNT OPN/PRQ STNT 1ST 37236 78,294.72$

03611060 HB TRNSCTH PLMNT OPN/PRQ STNT EA 37237 60,319.86$

03611061 HB TRNSCTH PLMNT OPN/PRQ STNT SAME 37238 78,294.72$

03611062 HB TRNSCTH PLMNT OPN/PRQ STNT EA 37239 66,125.73$

03611063 HB VASC EMBOLIZE/OCCLUDE VEN 37241 78,294.72$

03611064 HB VASC EMBOLIZE/OCCLUDE ARTRY 37242 78,294.72$

03611065 HB VASC EMBOLIZE/OCCLUDE ORGAN 37243 78,294.72$


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03611066 HB VASC EMBOLIZE/OCCLUDE BLEED 37244 78,294.72$

03611067 HB DRAINAGE SUBQ SFT TISS W IMG 10030 4,554.44$ 5,920.77$

03611068 HB BIOPSY BREAST W MAM PRIM 19081 8,779.14$ 11,412.90$

03611069 HB BIOPSY BREAST W MAM EA ADDL 19082 8,240.85$ 10,713.11$

03611070 HB BIOPSY BREAST CORE WUS PRIM 19083 8,779.14$ 11,412.90$

03611071 HB BIOPSY BREAST W US PRIM 19083 8,779.14$ 11,412.90$

03611072 HB BIOPSY BREAST W US EA ADDL 19084 6,394.89$ 8,313.34$

03611073 HB BIOPSY BREAST W MRI PRIM 19085 8,779.14$ 11,412.90$

03611074 HB BIOPSY BREAST W MRI EA ADDL 19086 8,356.25$ 10,863.12$

03611075 HB LOC BREAST DEV W MAM PRIM 19281 4,554.44$ 5,920.77$

03611076 HB LOC BREAST DEV W MAM EA ADL 19282 3,096.53$ 4,025.50$

03611077 HB LOC BREAST DEV W US PRIM 19285 4,554.44$ 5,920.77$

03611078 HB LOC BREAST DEV W US EA ADDL 19286 3,096.53$ 4,025.50$

03611079 HB LOC BREAST DEV W MRI PRIM 19287 4,554.44$ 5,920.77$

03611080 HB LOC BREAST DEV W MRI EA ADL 19288 3,096.53$ 4,025.50$

03611081 HB DRAINAGE VISCERA W IMG 49405 8,779.14$ 11,412.90$

03611082 HB DRAINAGE RETRO/PERITON W IMG 49406 8,779.14$ 11,412.90$

03611084 HB CHEMODENER MUSCLE LARYNX EMG 64617 1,607.17$ 2,089.31$

03611085 HB CHEMODENERV 1 EXTRM 1-4 MUS 64642 2,917.58$ 3,792.84$

03611086 HB CHEMODENERV 1 EXTRM 1-4 EA 64643 992.07$ 1,289.69$

03611087 HB CHEMODENERV 1 EXTRM 5/>MUS 64644 2,917.58$ 3,792.84$

03611088 HB CHEMODENERV 1 EXTRM 5/> EA 64645 992.07$ 1,289.69$

03611089 HB CHEMODENERV TRUNK MUSC 1-5 64646 2,917.58$ 3,792.84$

03611090 HB CHEMODENERV TRUNK MUSC 6/> 64647 2,917.58$ 3,792.84$

03611091 HB IMPLT SUBQ DEFB INTEROGAT 93261 1,102.53$

03611092 HB IMPLT SUBQ DEFB SYS DEV EVL 93260 1,102.53$

03611098 HB PLCMT RT DEV/MARKER ABD/PEL 49411 13,412.64$ 17,436.43$

03611099 HB PLCMT RT DEV/MARKER CHEST 32553 13,412.64$ 17,436.43$

03611100 HB BRONCHOSCOPY CLEAR AIRWAY 31645 9,194.88$

03611101 HB BRONCHOSCOPY RECLEAR AIRWAY 31646 1,856.26$

03611103 HB RPR LIP FT;UP HLF VRT HGHT 40652 2,262.47$ 2,941.21$

03611107 HB ATT TRUNK; D 10.1-30 SQ 14001 6,081.70$

03611108 HB ATT S/A/L; D 10.1-30 SQ CM 14021 6,081.70$

03611109 HB ATT F/C/M/N/A/G/H/F;10.1-30 14041 6,081.70$

03611112 HB SKN TIS RERNG 30.1-60.0SQCM 14301 8,023.23$

03611113 HB SKN TIS RERNG ADDL 30.0SQCM 14302 6,683.59$

03611124 HB REP LIP FT;>1/2 V HT / COMP 40654 5,161.10$ 6,709.44$

03611125 HB RECTAL SENSATION TEST 91120 5,294.70$

03611126 HB DRAIN/INJECT SM JNT/BURSA WO US 20600 1,607.17$ 2,089.31$

03611127 HB DRAIN/INJ SM JNT/BURSA W/US 20604 1,607.17$ 2,089.31$

03611128 HB DRAIN/INJ INTERM JNT/BURSA WO US 20605 1,607.17$ 2,089.31$

03611129 HB DRAIN/INJ IN JNT/BURSA W/US 20606 1,608.65$ 2,091.26$

03611130 HB DRAIN/INJ MAJOR JNT/BURSA WO US 20610 1,607.17$ 2,089.31$

03611131 HB DRAIN/INJ MJ JNT/BURSA W/US 20611 1,607.17$ 2,089.31$

03611132 HB ABLATION CRYO BONE 20983 29,655.60$


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03611133 HB VERTEBROPLASTY C/T SPINE W IMG 22510 12,463.59$

03611134 HB VERTEBROPLASTY L/S SPINE W IMG 22511 12,463.59$

03611135 HB VERTEBROPLASTY ADDL SPINE W IMG 22512 13,209.44$

03611136 HB KYPHOPLASTY T-SPINE W IMG 22513 29,655.60$

03611137 HB KYPHOPLASTY L-SPINE W IMG 22514 29,655.60$

03611138 HB KYPHOPLASTY ADDL SPINE W IMG 22515 23,385.10$

03611139 HB INS/REP SUBQ DEFIBRILLATOR 33270 200,427.98$

03611140 HB REPR TCAT MITRAL VALV INTL 33418 58,165.50$

03611141 HB REPR TCAT MITRAL VALV ADDL 33419 58,165.50$

03611142 HB ECMO/ECLS INITIATION VENOUS 33946 13,771.31$

03611143 HB ECMO/ECLS INITIATION ARTERY 33947 13,771.31$

03611144 HB ECMO/ECLS DAILY MGMT-VENOUS 33948 6,885.64$

03611145 HB ECMO/ECLS DAILY MGMT ARTERY 33949 6,885.64$

03611146 HB ECMO/ECLS INSJ PRPH CAN PERC<5 33951 14,547.26$

03611147 HB ECMO/ECLS INSJ PRPH CAN PERC>5 33952 14,547.26$

03611148 HB ECMO/ECLS INSJ PRPH CAN OPEN<5 33953 14,547.26$

03611149 HB ECMO/ECLS INSJ PRPH CAN OPEN>5 33954 14,547.26$

03611150 HB ECMO/ECLS INSJ CTR CAN <5YR 33955 14,547.26$

03611151 HB ECMO/ECLS INSJ CTR CAN >5YR 33956 14,547.26$

03611153 HB ECMO/ECLS REPOS PRPH CAN PERC>5 33958 10,396.84$

03611155 HB ECMO/ECLS REPOS PRPH CAN OPEN>5 33962 10,396.84$

03611157 HB ECMO/ECLS REPOS CTR CAN>5YR 33964 10,396.84$

03611158 HB ECMO/ECLS RMVL PRPH CAN PERC<5 33965 5,941.05$

03611159 HB ECMO/ECLS RMVL PRPH CAN PERC>5 33966 5,941.05$

03611160 HB ECMO/ECLS RMVL PRPH CAN OPEN<5 33969 5,941.05$

03611161 HB ECMO/ECLS RMVL PRPH CAN OPEN>5 33984 5,941.05$

03611162 HB ECMO/ECLS RMVL CTR CAN <5YR 33985 5,941.05$

03611163 HB ECMO/ECLS RMVL CTR CAN >5YR 33986 5,941.05$

03611164 HB ARTERY EXPOS/GRAFT ARTERY 33987 10,396.84$

03611165 HB INSERTION OF LEFT HEART VENT 33988 13,367.35$

03611166 HB REMOVAL OF LEFT HEART VENT 33989 10,396.84$

03611167 HB STENT PLACEMT ANTE CAROTID 37218 22,439.29$

03611168 HB PERQ STENT/CHEST VERT ART 0075T 22,439.29$

03611170 HB MYELOGRAM C-SPINE VIA LP W S&I 62302 7,692.59$

03611171 HB MYELOGRAM T-SPINE VIA LP W S&I 62303 7,692.59$

03611172 HB MYELOGRAM L-SPINE VIA LP W S&I 62304 7,692.59$

03611173 HB MYELOGRAM 2/MORE REGN VIA LP W S&I 62305 7,692.59$

03611175 HB TRACHEOBRONCH THRU OLD INC 31615 2,262.47$ 2,941.21$

03611176 HB BRONCHOSCOPY W/MARKERS 31626 19,526.29$

03611177 HB BRONCH W/BALLOON OCCLUSION 31634 19,526.29$

03611178 HB ABLATION R/F BONE TUMOR(S) 20982 29,655.60$ 38,552.27$

03611180 HB PERQ SACRAL AUGMT BILAT INJ 0201T 29,655.60$

03611181 HB BIOPSY LUNG/PLEURA 32400 8,779.14$ 11,412.90$

03611182 HB UL PROC LOCALIZATION LUNG 32999 4,021.50$ 5,227.96$

03611183 HB BIOPSY, NERVE 64795 10,499.62$ 13,649.51$


Charge

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Price



03611185 HB INS VAG BRACHYTX DEVICE 57156 1,416.09$

03611188 HB BX OF ANORECTAL WALL ANAL APPROACH 45100 9,114.06$

03611189 HB TENOTOMY HIP ADDUCTOR PERQ 27000 4,667.13$ 6,067.25$

03611190 HB TENOTOMY HAM/ADCTR SNGL PERQ 27306 12,463.59$ 16,202.66$

03611191 HB TENOTOMY ELBOW PERQ 24357 12,463.59$ 16,202.66$

03611192 HB TENOTOMY HAM/ADCTR MULT PERQ 27307 14,045.22$ 18,258.78$

03611193 HB TENOTOMY FINGER PERQ 26060 4,667.13$ 6,067.25$

03611194 HB TENOTOMY ACHILLES PERQ 27605 4,667.13$ 6,067.25$

03611195 HB UNLISTED TENOTOMY SHOULDER PERQ 23929 1,702.35$ 2,213.06$

03611197 HB UNLISTED TENOTOMY FOOT PERQ 28899 1,702.35$ 2,213.06$

03611199 HB BRONCHOSCOPY/NEEDLE BX ADDL 31633 9,802.82$

03611201 HB UL PROC SPINAL HARDWARE INJ 64999 1,607.17$

03611202 HB BIOPSY UPPER ARM SFT TISS SUPERF 24065 8,779.14$

03611203 HB EXC NECK LES SC < 3 CM 21555 8,779.14$ 11,412.90$

03611205 HB BIOPSY LEG/ANKLE SOFT TISSUE SUPERFICIAL 27613 8,779.14$ 11,412.90$

03611207 HB NEPHROSTOLITHOTOMY PERQ <2CM 50080 14,622.61$ 19,009.38$

03611208 HB NEPHROSTOLITHOTOMY PERQ >2CM 50081 14,622.61$ 19,009.38$

03611210 HB DX NASAL ENDOSCOPY 31231 1,224.72$ 1,592.12$

03611211 HB REM EMBEDDED FB MOUTH VESTIB; SIMPLE 40804 3,477.64$ 4,520.92$

03611212 HB THROMBECTOMY VC ILIAC FEM LEG INCS 34421 11,407.72$

03611213 HB EVASC PRLNG ADMN RX AGNT 1ST 61650 113,939.75$ 113,939.75$

03611214 HB EVASC PRLNG ADMN RX AGNT ADD 61651 108,329.93$ 108,329.93$

03611215 HB INJECTION FOR CHOLANGIOGRAM EXISTING ACCESS 47531 7,830.14$

03611216 HB INJECTION FOR CHOLANGIOGRAM NEW ACCESS 47532 7,830.14$

03611217 HB PLMT BILIARY DRAINAGE CATH EXTERNAL 47533 7,830.14$

03611218 HB PLMT BILI DRAINAGE CATH INTERNAL-EXTERNAL 47534 7,830.14$

03611219 HB CONVERSION EXT BIL DRG CATH 47535 7,830.14$

03611220 HB EXCHANGE BILIARY DRG CATH 47536 7,830.14$

03611221 HB REMOVAL BILIARY DRG CATH 47537 3,477.64$

03611222 HB PERQ PLMT BILE DUCT STENT EXISTING ACCESS 47538 19,856.63$

03611223 HB PERQ PLMT BILE DUCT STENT NEW ACCESS 47539 19,856.63$

03611224 HB PERQ PLMT BILE DUCT STENT 47540 19,856.63$

03611225 HB PLMT ACCESS BIL TREE SM BWL 47541 7,830.14$

03611226 HB DILATE BILIARY DUCT/AMPULLA 47542 17,806.55$

03611227 HB ENDOLUMINAL BX BILIARY TREE 47543 10,116.20$

03611228 HB NJX PX NFROSGRM &/URTRGRM NEW ACCESS 50430 3,120.54$

03611229 HB NJX PX NFROSGRM &/URTRGRM EXISTING ACCESS 50431 3,120.54$

03611230 HB PLMT NEPHROSTOMY CATHETER 50432 9,835.81$

03611231 HB PLMT NEPHROURETERAL CATHETER 50433 11,094.38$

03611232 HB CONVERT NEPHROSTOMY CATHETER 50434 9,835.81$

03611233 HB CHANGE NEPHROSTOMY CATH 50435 9,835.81$

03611235 HB PLMT URETERAL STENT PRQ PRE-EXISTING TRACT 50693 11,094.38$

03611236 HB PLMT URETERAL STENT PRQ NEW ACCESS 50694 11,094.38$

03611237 HB PLMT URETERAL STENT PRQ NEW ACCESS W/NEPH CATH50695 11,094.38$

03611238 HB PERQ ART M-THROMBECT &/NFS UNI 61645 64,266.62$ 64,266.62$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611239 HB PVB THORACIC SINGLE INJ SITE 64461 2,917.58$

03611240 HB PVB THORACIC 2ND+ INJ SITE 64462 3,092.18$

03611241 HB PVB THORACIC CONT INFUSION 64463 2,917.58$

03611242 HB BIOPSY PENIS DEEP 54105 9,572.41$

03611243 HB BRONCH EBUS SAMPLNG 1/2 NODE 31652 13,790.38$

03611244 HB BRONCH EBUS SAMPLNG 3/> NODE 31653 13,790.38$

03611245 HB BRONCH EBUS IVNTJ PERPH LES 31654 8,487.21$

03611246 HB REMOVE IMPACTED EAR WAX UNI 69209 793.59$ 1,031.66$

03611247 HB CONZ OF CERVIX W/SCOPE LEEP 57461 16,582.00$

03611249 HB BLEPHAROTOMY DRAIN ABSC EYELID 67700 1,219.90$ 1,585.89$

03611253 HB NEPHROURETHRAL CATH CHANGE 50387 9,835.81$ 12,786.55$

03611254 HB URETERAL EMBO W IMG GUIDANCE 50705 13,114.51$

03611255 HB URETERAL BALLOON DIL W IMG GUIDANCE 50706 13,114.51$

03611256 HB PIERCE SKULL IMPLANT DEVICE 61210 6,065.98$

03611257 HB DRAINAGE OF SCROTAL WALL ABSCESS 55100 8,779.14$ 11,412.90$

03611258 HB DR EXT EAR ABSCESS/HEMATOMA; COMPLIC 69005 8,779.14$ 11,412.90$

03611259 HB CL TX IP JOINT DISL; W ANESTH 28665 1,943.32$ 2,526.33$

03611260 HB CL TX ACLAV DISLOC; WO MANIP 23540 1,702.35$ 2,213.06$

03611261 HB CL TX TARSAL BONE DISLO; WO ANESTH 28540 1,702.35$ 2,213.06$

03611262 HB CL TX TALOTARSAL JOINT DIS; WO ANEST 28570 1,702.35$ 2,213.06$

03611263 HB CL TX TMT JNT DISL; W ANESTHESIA 28605 2,042.83$ 2,655.67$

03611264 HB CL TX TMT JNT DISL; WO ANESTHESIA 28600 1,702.35$ 2,213.06$

03611265 HB CL TX DSTL RADIOULNAR DISLOC W MANIP 25675 1,702.35$ 2,213.06$

03611266 HB CL TX CMC DISLOC THUMB W MANIP 26641 1,702.35$ 2,213.06$

03611267 HB CL TX CMC DISL W M EA 26670 1,702.35$ 2,213.06$

03611268 HB CL TX TALOTARSAL JOINT DISL; W ANESTH 28575 12,463.59$ 16,202.66$

03611269 HB CL TX MTP JNT DISLOC; W ANESTH 28635 4,667.13$ 6,067.25$

03611270 HB CL TX LUNATE DISLOC W MANIP 25690 4,667.13$ 6,067.25$

03611271 HB CL TX CMC DISLOC W MANIP & ANESTH 26675 4,667.13$ 6,067.25$

03611272 HB CL TX MCP DISLOC W MANIP & ANESTH 26705 4,667.13$ 6,067.25$

03611273 HB CL TX TARSAL BONE DISLOC; W ANESTH 28545 12,463.59$ 16,202.66$

03611274 HB DR ABSC/HEMATOMA NASAL INT 30000 1,584.08$ 2,059.31$

03611275 HB DR ABSC/HEMATOMA NASAL SEPTUM 30020 2,262.47$ 2,941.21$

03611276 HB I&D ABSC/CYST TONGUE FOM; SUPERF 41005 1,584.08$ 2,059.31$

03611277 HB I&D ABSC/CYS FOM; MASTIC SPACE 41009 2,262.47$ 2,941.21$

03611278 HB DRAINAGE OF ABSCESS OF PALATE UVULA 42000 1,584.08$ 2,059.31$

03611279 HB DR ABSC CYST HEMAT-MOUTH; COMPLICATED 40801 2,262.47$ 2,941.21$

03611280 HB I&D ABSC/CYST TONGUE FOM; LINGUAL 41000 2,262.47$ 2,941.21$

03611281 HB I&D ABSC/CYST FOM; SUBMENTAL 41007 5,161.10$ 6,709.44$

03611282 HB CL TX TMJ DISLOCATION; COMPLIC 21485 5,161.10$ 6,709.44$

03611283 HB I&D ABSC/CYS FOM; SUBMANDIB 41008 9,259.02$ 12,036.73$

03611284 HB MARSUPIALIZATION BARTHOLIN'S GLAND CYST 56440 16,582.00$ 21,556.60$

03611285 HB CANTHOTOMY 67715 7,238.24$ 9,409.71$

03611286 HB CL TX ACLAV DISLOC; W MANIP 23545 2,042.83$ 2,451.40$

03611287 HB CL TX SCAPULAR FX; WO MANIP 23570 1,702.35$ 2,213.06$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611288 HB CL TX CARPAL SCAPHOID FX; WO MANIP 25622 1,702.35$ 2,213.06$

03611289 HB CLTX CARPL BONE FX WO MANIP EA BONE 25630 1,702.35$ 2,213.06$

03611290 HB CL TX PROX FEM FX WO MANIP 27230 1,702.35$ 2,213.06$

03611291 HB CL TX PROX TIB-FIB JNT DISL; WO ANESTH 27830 1,702.35$ 2,213.06$

03611292 HB CL TX OF ULNAR STYLOID FX 25650 1,702.35$ 2,213.06$

03611293 HB CL TX TRANS-SPL FX DISL; W MANIP 25680 1,702.35$ 2,213.06$

03611294 HB CL TX ART FX MCP/IP JNT; WO MANIP 26740 1,702.35$ 2,213.06$

03611295 HB CL TX PELV RNG FX WO MANIP 27197 1,702.35$ 2,213.06$

03611296 HB CL TX PELV RNG FX W MANIP 27198 2,042.83$ 2,451.40$

03611297 HB CL TX OF ACETABULUM X(S); WO MANIP 27220 1,702.35$ 2,213.06$

03611298 HB CL TX GTR TROCHNTRC FX WO MANIP 27246 1,702.35$ 2,213.06$

03611299 HB CL TX FEMORAL SHAFT FX WO MANIP 27500 1,702.35$ 2,213.06$

03611300 HB CL TX SC/TC FEMUR FX WO MANIP 27501 1,702.35$ 2,213.06$

03611301 HB CL TX POST ANKLE FX W/O MANIP 27767 1,702.35$ 2,213.06$

03611302 HB CL TX SCLAV DISLOC WO MANIP 23520 4,667.13$ 6,067.25$

03611303 HB CL TX SCAPULAR FX; W MANIP 23575 4,667.13$ 6,067.25$

03611304 HB CL TX GR TUBEROSITY FX; W MANIP 23625 4,667.13$ 6,067.25$

03611305 HB CL TX SHLDR DISLOC & FX GT; W MANIP 23665 4,667.13$ 6,067.25$

03611306 HB CL TX CARPL SCAPHOID FX W MANIP 25624 4,667.13$ 6,067.25$

03611307 HB CLTX CARPL BONE FX W MANIP EA BONE 25635 4,667.13$ 6,067.25$

03611308 HB CL TX MC FX W M+F EA 26607 12,463.59$ 16,202.66$

03611309 HB CL TX CMC FX DISLOC THUMB W MANIP 26645 4,667.13$ 6,067.25$

03611310 HB CL TX INTER/PERI/SBTRCHNTC FEM FX WO MANIP 27238 4,667.13$ 6,067.25$

03611311 HB CLTX THIGH FX W/O MANIP 27267 12,463.59$ 16,202.66$

03611312 HB CL TX FEMUR FX OR EPIPHYS SEP W MANIP 27510 4,667.13$ 6,067.25$

03611313 HB CL TX POST ANKLE FX W/MANIP 27768 4,667.13$ 6,067.25$

03611314 HB OPEN TX TOE FRACTURE 28525 12,463.59$ 16,202.66$

03611315 HB CL TX SCCLAV DISLOC W MANIP 23525 1,702.35$ 2,213.06$

03611316 HB THORACOTOMY W/ EXPLORATION 32100 6,931.90$

03611317 HB CL TX LEFORT I FX; W ID W FIX 21421 9,259.02$ 12,036.73$

03611318 HB CL TX OF MAND FX W ID FIX 21453 17,596.07$ 22,874.89$

03611319 HB APPLY FINGER SPLINT; DYNAMIC 29131 793.59$ 1,031.66$

03611321 HB CL TX STERNUM FX 21820 1,702.35$ 2,213.06$

03611326 HB CL TX SESAMOID FRACTURE 28530 1,702.35$ 2,213.06$

03611327 HB CL TX VERTEBRAL BODY FX WO MANIP 22310 1,702.35$ 2,213.06$

03611338 HB CRANIAL TONGS/ST FRAME 20660 4,667.13$ 6,067.25$

03611339 HB CL TX VERTEBR FX/DISLOC W CAST/BRACE 22315 12,463.59$ 16,202.66$

03611347 HB CL TX ORBIT FX NOT "BOT"; WO MANIP 21400 2,262.47$ 2,941.21$

03611348 HB CL TX ORBIT FX NOT "BOT"; W MANIP 21401 5,161.10$ 6,709.44$

03611349 HB CL TX LEFORT II FX; W FIXATION 21345 5,161.10$ 6,709.44$

03611350 HB CL TX NASAL SEPTAL FX 21337 9,259.02$ 12,036.73$

03611351 HB CL TX MAND/MAXILL ALVEOLAR RIDGE FX 21440 9,259.02$ 12,036.73$

03611352 HB LARYNGOSCOPY FLEX; W REM FB 31577 1,856.26$ 2,413.12$

03611353 HB REPAIR FOOT EXTENSOR TENDON EACH 28208 12,463.59$ 16,202.66$

03611354 HB THER APHER RED CELL DEPLETION 36512 7,596.40$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611355 HB ACCESS AV DIALYSIS GRAFT EVAL 36901 6,247.55$

03611356 HB ACCESS AV DIALYSIS GRAFT W PTA 36902 36,647.54$

03611357 HB ACCESS AV DIALYSIS GRAFT W STENT 36903 78,294.72$

03611358 HB THROMBECTOMY/LYSIS DIALYSIS CIRCT 36904 36,647.54$

03611359 HB THROMBECTOMY/LYSIS W/ PTA DIALYSIS CIRCT 36905 78,294.72$

03611360 HB THROMBECTOMY/LYSIS W/ STENT DIALYSIS CIRCT 36906 87,688.44$

03611361 HB PTA CENTRAL DIALYSIS SEGMENT 36907 44,023.90$

03611362 HB DIALYSIS CIRCUIT EMBOL 36909 88,676.43$

03611363 HB PTA UE/VISCERAL ARTERY INITIAL 37246 36,647.54$

03611364 HB PTA UE/VISCERAL ARTERY EA ADDL 37247 33,295.88$

03611365 HB PTA VEIN INITIAL 37248 36,647.54$

03611366 HB PTA VEIN EA ADDL 37249 33,295.88$

03611367 HB INJ INTERLAMINAR CERV/THOR 62321 9,621.95$

03611368 HB INJ INTERLAMINAR LUMBAR/SACRAL 62323 9,621.95$

03611369 HB INJ INTERLAMINAR CERV/THOR W/ INDWELL CATH 62325 5,260.12$

03611370 HB INJ INTERLAMINAR LUMBAR/SACRAL W/ INDWELL CATH 62327 5,260.12$

03611371 HB SCLEROTX FLUID COLLECTION 49185 4,554.44$ 5,920.77$

03611372 HB DIAPHRAGM OR CERVIAL CAP FITTING 57170 1,343.98$ 1,747.17$

03611373 HB AMPUTATE FING/TH SGL; W LOC ADV FLAP 26952 12,463.59$ 16,202.66$

03611374 HB STENT PLMT CTR DIALYSIS SEG 36908 66,125.73$

03611375 HB CATHETER ASPIRATION FIBERSCOPE BEDSIDE 31725 12,743.66$

03611376 HB I & D SHLDR ABSC/HEMA,DEEP 23030 12,444.15$

03611377 HB I & D ARM,DEEP ABSC/HEMATOMA 23930 12,444.15$

03611378 HB I & D FOREARM DEEP ABSCESS 25028 16,202.66$

03611379 HB I & D FOREARM INFECTED BURSA 25031 6,067.25$

03611380 HB DRAIN LOWER LEG DEEP ABSC/HEMATOMA 27603 9,572.41$ 12,444.15$

03611381 HB I & D BURSA OF FOOT 28001 11,412.88$

03611382 HB I & D RECTAL SUBMUCOSAL ABSCESS 45005 12,149.22$

03611383 HB INCISE/DRAIN CONJUNCTIVA 68020 3,162.27$ 4,110.96$

03611384 HB SUTURE EYELID WOUND,PARTIAL THICK 67930 9,409.71$

03611385 HB SUTURE EYELID WOUND,FULL THICK 67935 9,409.71$

03611386 HB REPR FOREARM TEND/MUSC,EXTEN,PRIM,EA 25270 16,202.66$

03611387 HB MUSC/TENDON REPAIR EACH; ARM/ELBOW 24341 38,552.27$

03611388 HB CLOSED RX PROX TIB/FIB DISLOC+ANESTH 27831 16,202.66$

03611389 HB INSERT AND REMOVE BONE PIN 20650 16,202.66$

03611390 HB LARYNGOSCOPY,DIRCT,OP,F.B. REMVL 31530 11,953.35$

03611391 HB LARYNGOSCOPY,INDIRECT+REMV FOR.BODY 31511 1,592.12$

03611392 HB DILATE ESOPHAGUS 43450 4,520.92$

03611393 HB SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY 45332 12,149.22$

03611394 HB ASPIRATION BLADDER NEEDLE 51100 4,179.64$

03611395 HB ASPIRATION BLADDER TROCAR/INTRACATHETER 51101 15,712.83$

03611396 HB INJECT NERV BLCK,TRIGEMINAL EACH BRANCH 64400 1,607.17$ 2,089.31$

03611398 HB BIOPSY, URETHRA 53200 9,835.81$ 12,786.55$

03611399 HB REMOVAL OF BREAST IMPLANT 19328 14,148.37$ 18,392.86$

03611400 HB REMOVAL OF EXTERNAL PENILE RING 55899 3,215.10$ 4,179.64$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611401 HB REPAIR CARDIAC WOUND; WO CPB 33300 6,652.49$

03611402 HB OP TX OF NASAL FX; UNCOMPLICATED 21325 9,259.02$ 12,036.73$

03611403 HB TRANSPERINEAL PLCMT BIODEGRADEABLE MATRL 55874 12,965.96$

03611404 HB INJECTION FOR LYMPHANGIOGRAPHY 38790 3,650.92$

03611405 HB REPAIR BLOOD VESSEL DIRECT; UPPER EXTREMITY 35206 11,407.72$ 14,830.03$

03611406 HB SUTURE OF DGTL NERVE, HAND/FOOT; 1 NERVE 64831 10,499.62$ 13,649.52$

03611408 HB ENDOVENOUS ABLATION THERAPY RF, 1ST VEIN 36475 13,725.59$ 17,843.27$

03611410 HB EXCISION AND REPAIR OF EYELID TO 1/4 LID MARG 67961 7,238.24$ 9,409.71$

03611411 HB NASAL ENDO W BLD CNTRL 31238 9,194.88$ 11,953.35$

03611413 HB INJ ANES/STEROID FEMORAL NRV CONT INF W/ CATH PLCMNT64448 5,260.12$ 6,838.15$

03611414 HB TMVI PERCUTANEOUS APPROACH 0483T 58,165.50$

03611415 HB TMVI TRANSTHORACIC EXPOSURE 0484T 22,592.64$

03611416 HB COR FFR DATA PREP & TRANS 0502T 1,250.05$ 1,625.07$

03611417 HB ABLAT THER PULM TUMOR PERQ CRYOABL 32994 19,856.63$ 25,813.77$

03611418 HB EVASC RPR A-AO NDGFT 34701 25,406.63$

03611419 HB EVASC RPR A-AO NDGFT 34702 25,406.63$

03611420 HB EVASC RPR A-UNILAC NDGFT 34703 24,542.36$

03611421 HB EVASC RPR A-UNILAC NDGFT RPT 34704 24,542.36$

03611422 HB EVAC RPR A-BIILIAC NDGFT 34705 21,787.24$

03611423 HB EVASC RPR A-BIILIAC RPT 34706 21,787.24$

03611424 HB EVASC RPR ILIO-ILIAC NDGFT 34707 17,065.03$

03611425 HB EVASC RPR ILIO-ILIAC NDGFT 34708 17,065.03$

03611426 HB PLCMT EXTN PROSTH EVASC RPR 34709 9,926.68$

03611427 HB PLCMT EXTN PROSTH EVASC RPR 34710 14,682.64$

03611428 HB DLYD PLCMT EXTN PROSTH EA ADDL 34711 8,211.04$

03611429 HB TRANSCATH DLVRY ENHNCD FIX DEV AND S&I 34712 5,124.32$

03611430 HB PERQ ACCESS & CLSR FEM ART 34713 3,948.15$

03611432 HB OPN AX/SUBCLA ART EXPOS 34715 5,124.32$

03611433 HB OPEN AX/SUBCLA ART EXPOS W CONDUIT 34716 5,124.32$

03611434 HB INJ NONCMPND SCLRSNT SNGL VEIN 36465 6,081.70$

03611435 HB INJ NONCMPND SCLRSNT MULT VEINS 36466 6,081.70$

03611436 HB ENDOVEN THER CHEM ADHES 1ST VEIN 36482 19,109.22$

03611437 HB ENDOVEN THER CHEM ADHES SUB VEIN 36483 1,673.28$

03611439 HB ABLATION R/F CHEST/LUNG UNI 32998 19,856.63$ 25,813.77$

03611440 HB CATH INTRO ARTERY UPPER/LOWER EXT 36140 2,766.34$

03611441 HB DIAG BONE MARROW BX & ASPIR 38222 9,572.41$ 12,444.15$

03611442 HB ATT E/N/E/L; D 10.1 - 30 SQ CM 14061 6,081.70$ 7,906.19$

03611443 HB, LATERAL CANTHOPEXY 21282 9,259.02$ 12,036.73$

03611444 HB CORPUS SPONGIOSUM SHUNT – PRIAPISM 54430 9,500.70$ 12,350.92$

03611445 HB REPAIR, SECONDAY,SINGLE EACH TENDON OR MUSCLE 25263 29,655.60$ 38,552.27$

03611446 HB INJ ANESTH/STEROID VAGUS NERVE 64408 1,607.17$ 2,089.31$

03611452 HB CL TX SHDR DISLOC W NK FX W MANIP 23675 4,667.13$

03611453 HB INJ ANESTH/STEROID AXILLARY NERVE 64417 5,260.12$ 6,838.16$

03611454 HB INJ ANESTH/STEROID SUPRASCAPULAR NERVE 64418 4,206.87$ 5,468.94$

03611455 HB WEDGING OF CLUBFOOT CAST 29750 1,943.32$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611456 HB HYSTEROSCOPY W RMVL IMPCTD FOREIGN BODY 58562 16,582.00$

03611457 HB HYSTEROSCOPY W LYSIS INTRAUT ADHESIONS 58559 23,256.66$

03611458 HB HYSTEROSCOPY W RMVL LEIOMYOMATA 58561 23,256.66$

03611459 HB HYSTEROSCOPY BILAT STERILIZATION 58565 23,256.66$

03611460 HB MULTILAYER COMPRESSION LOWER LEG 29581 1,028.69$

03611461 HB MULTILAYER COMPRESSION ARM/HAND 29584 1,028.69$

03611462 HB CAST APP - HIP CAST 1 LEG 29305 1,943.32$

03611463 HB CAST APP - HIP CASTS 1.5 SPICA/2 LEGS 29325 1,943.32$

03611464 HB CAST APP - RIGID TOTAL CONTACT LEG CAST 29445 1,943.32$

03611465 HB RECONSTRUCTION, NIPPLE/AREOLA 19350 14,148.37$

03611466 HB ENDOVENOUS ABLATION THERAPY RF SUB VEIN 36476 1,673.28$ 2,175.26$

03611467 HB BIOPSY, INTERVERTEBRAL DISC, CORE 64999 1,607.17$ 2,089.31$

03611468 HB ENDOVENOUS ABLATION THERAPY MCHNCHEM, 1ST VEIN36478 13,725.59$ 17,843.27$

03611469 HB ENDOVENOUS ABLATION THERAPY LASER SUB VEIN 36479 1,673.28$

03611470 HB ENDOVENOUS ABLATION THERAPY LASER, 1ST VEIN 36473 13,725.59$ 17,843.27$

03611471 HB ENDOVENOUS ABLATION THERAPY MCHNCHEM SUB VEIN36474 1,673.28$

03611472 HB EMBOLIZATION BONE TUMOR 20999 1,702.35$ 2,213.06$

03611473 HB DEBRIDE ASSOC OPEN FX/DISLOC SKIN/SUBQ 11010 4,554.44$ 5,920.77$

03611474 HB STAB PHLEBECTOMY, LESS THAN 10 37799 4,021.50$ 5,227.96$

03611475 HB STAB PHLEBECTOMY, 1 EXTREMITY 20+ 37766 11,407.72$ 14,830.03$

03611476 HB STAB PHLEBECTOMY, 1 EXTREMITY 10-20 37765 11,407.72$ 14,830.03$

03611477 HB INJ ANES/STEROID SCIATIC CONT INF 64446 5,260.12$

03611478 HB INJ ANES/STEROID LUMBAR PLEXUS 64449 5,260.12$

03611479 HB INJ TFRML EPRL W/US LUMB/SAC FIRST 0230T 5,260.12$

03611480 HB INJ TFRML EPRL W/US LUMB/SAC ADDL 0231T 3,226.34$

03611481 HB INJ TFRML EPRL W/US CER/THOR FIRST 0228T 5,260.12$

03611482 HB INJ TFRML EPRL W/US CER/THOR ADDL 0229T 3,226.34$

03611483 HB TAP BLOCK BY INJECTION UNILATERAL 64486 4,458.62$

03611484 HB TAP BLOCK BY CONTINUOUS INFUSION UNILATERAL 64487 4,458.62$

03611485 HB TAP BLOCK BY INJECTION BILATERAL 64488 4,458.62$

03611486 HB TAP BLOCK BY CONTINUOUS INFUSION BILATERAL 64489 4,458.62$

03611487 HB LIGATION OR BIOPSY, TEMPORAL ARTERY 37609 8,779.14$ 11,412.90$

03611488 HB LENSTAR 92136 821.97$

03611489 HB SPECULAR MICROSCOPYE 92286 821.97$

03611490 HB MYOMECTOMY VAG METHOD 1-4 MYOMAS 58145 16,582.00$ 21,556.60$

03611491 HB PHOTODYNAMIC THERAPY ENDOSCOPIC INITIAL 30 MIN 96570 1,209.08$

03611492 HB PHOTODYNAMIC THERAPY ENDOSCOPIC ADDL 15 MIN 96571 255.77$

03611493 HB DIR THROMBIN INJ ABLATN NON EXTR PSEUDOANEURYSM37799 3,494.61$ 4,543.00$

03611494 HB HPC PLATELET DEPLETION 38213 5,499.72$

03611495 HB NASOLACR DUCT PROBING W/WO IRRIGATION 68810 1,219.90$

03611496 HB LACRIMAL CANALICULI PROBING 68840 1,219.90$

03611497 HB EXC OF CHALAZION; SINGLE 67800 1,219.90$

03611498 HB BIOPSY EYELID & LID MARGIN 67810 1,219.90$

03611499 HB EYELASH PILATION BY ELECTROSURGERY 67825 1,219.90$

03611500 HB EXC OF CHALAZION; MULTI SAME LID 67801 3,162.27$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611501 HB EXC EYELID LESION WO CLOSE/SIMP REPAIR 67840 3,162.27$

03611502 HB EPILATION BY FORCEPS 67820 821.97$

03611504 HB CLOSURE LAC PUNCTUM; BY PLUG (EACH) 68761 1,216.48$

03611505 HB REPAIR CORNEA LAC,APPLY GLUE 65286 7,483.86$

03611506 HB EXCIS PTERYGIUM,W GRAFT 65426 7,238.24$

03611507 HB EXCIS PTERYGIUM 65420 7,238.24$

03611508 HB CORNEAL SMEAR 65430 1,272.58$

03611509 HB PLACE AMNIOTIC MEMBRA OCULAR SURFACE W/O SUTURES65778 3,162.27$

03611510 HB INJECT ANTER CHMBR EYE,MEDICATN 66030 7,483.86$

03611511 HB INJECTION,ANT CHAMBER,EYE,AIR/LIQUID 66020 7,483.86$

03611512 HB TEMP CLOSURE EYELID BY SUTURE 67875 3,162.27$

03611513 HB EXPRESS CONJUNC FOLLICLES 68040 1,216.48$

03611514 HB BIOPSY OF CONJUNCTIVA 68100 7,238.24$

03611515 HB REPAIR CORNEA LAC,NONPERFORATING 65275 8,048.76$

03611516 HB PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED65779 8,048.76$

03611517 HB REPAIR CORNEA LAC,PERF,NO UVEAL 65280 9,846.30$

03611518 PRHB REPAIR CORNEA LAC,PERF,RESEC UVEAL 65285 9,846.30$

03611519 HB REPAIR FLEX TENDON,ZONE 2,HAND 26356 12,463.59$ 16,202.66$

03611520 HB PERC SKTL FIX D PHLNG FX FINGR 26756 12,463.59$ 16,202.66$

03611521 HB BIOPSY OF BREAST; OPEN, INCISIONAL 19101 14,148.37$

03611522 HB SLITTING OF PREFUCE, DORSAL OR LATERAL 54001 9,835.81$ 12,786.55$

03611523 HB FINE NEEDLE ASP W/O IMG GUID EA ADDL LESION 10004 1,171.30$ 1,522.69$

03611524 HB FINE NEEDLE ASP W/ US GUID FIRST LESION 10005 4,554.44$ 5,920.77$

03611525 HB FINE NEEDLE ASP W/ US GUID EA ADDL LESION 10006 3,096.53$ 4,025.50$

03611526 HB FINE NEEDLE ASP W/ FLUORO GUID FIRST LESION 10007 4,554.44$ 5,920.77$

03611527 HB FINE NEEDLE ASP W/ FLUORO GUID EA ADDL LESION 10008 3,096.53$ 4,025.50$

03611528 HB FINE NEEDLE ASP W/ CT GUID FIRST LESION 10009 4,554.44$ 5,920.77$

03611529 HB FINE NEEDLE ASP W/ CT GUID EA ADDL LESION 10010 3,096.53$ 4,025.50$

03611530 HB FINE NEEDLE ASP W/ MRI GUID FIRST LESION 10011 4,554.44$ 5,920.77$

03611531 HB FINE NEEDLE ASP W/ MRI GUID EA ADDL LESION 10012 3,164.02$ 4,113.22$

03611532 HB BX SKIN TANGENTIAL SIMP CLS SNGL LESION 11102 1,195.75$ 1,554.47$

03611533 HB BX SKIN TANGENTIAL SIMP CLS ADDL LESION 11103 342.30$ 444.41$

03611534 HB BX SKIN PUNCH SIMP CLS SNGL LESION 11104 1,195.75$ 1,554.47$

03611535 HB BX SKIN PUNCH SIMP CLS ADDL LESION 11105 342.30$ 444.41$

03611536 HB BX SKIN INCISIONAL SIMP CLS SNGL LESION 11106 1,578.81$ 2,052.44$

03611537 HB BX SKIN INCISIONAL SIMP CLS ADDL LESION 11107 342.30$ 444.41$

03611538 HB REPLACE GTUBE NO REVJ TRC 43762 3,215.10$ 4,179.64$

03611539 HB REPLACE GTUBE REVJ GSTRST TRC 43763 3,215.10$ 4,179.64$

03611540 HB ERECTOR SPINAE 64999 1,607.19$ 2,089.31$

03611541 HB STENT PLACEMENT (CCA) CERV CAROTID ART 37799 16,286.13$ 21,171.96$

03611542 HB INJECTION PAROTID GLAND 42699 1,584.08$ 2,059.31$

03611543 HB PROSTATIC RF THERMOTHERAPY 53852 11,094.38$

03611544 HB EXCIS CHALAZION,MULT,BOTH LIDS 67805 1,219.90$

03611545 HB CLOSE TEAR DUCT OPENING 68760 1,219.90$

03611546 HB INJECT PROC PENILE PLAQUE 54200 3,215.10$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03611547 HB UL PROC LOCALIZATION BREAST 19499 14,148.37$ 18,392.86$

03611548 HB UL PROC ABLATION NERVE MICROWAVE 64999 1,607.17$ 2,089.31$

03611549 HB PLACE ANGEL FILTER/CATHETER 37799 41,110.70$ 53,443.91$

03611550 HB RF MAGNETIC-GUIDE AV FISTULA G2171 87,688.44$ 113,994.97$

03611552 HB CREATION OF ACCESS,RPLCMNT WIRE,SHEATH,ANGIO CATH53899 3,215.10$

03611553 HB DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST 53060 9,835.81$ 12,786.55$

03611554 HB BRONCHOSCOPY W/ EXCISION OF TUMOR 31640 13,790.38$ 17,927.50$

03611555 HB CRTJ SUBQ INSJ IMPLTBL GLUCOSE SENSOR SYS TRAIN0446T 3,088.06$

03611556 HB RMVL IMLTBL GLUCOSE SENSOR 0447T 1,195.75$

03611557 HB RMVL INSJ IMPLTBL GLUC SENSOR DIF ANATOMIC SITE 0448T 3,088.06$

03611558 HB INTRAOSS DES LUMB/SAC W/FLUORO GDN, 1ST 2 C9752 75,356.09$

03611559 HB INTRAOSS DES LUMB/SAC W/FLUORO GDN, EA ADDL C9753 37,425.90$

03611561 HB TRANSCATH TRI PERQ APPR INITIAL PROSTH 0569T 58,165.50$

03611562 HB TRANSCATH TRI PERQ APPR EACH ADDL PROSTH 0570T 58,165.50$

03611563 HB PERICARDIOCENTESIS W W/O IMG 33016 6,247.55$

03611564 HB EVASC RPR ILIAC ART ENDOGRAFT UNI 34717 28,400.76$

03611565 HB EVASC RPR ILIAC ART N/A A-ILIAC ENDOGRAFT UNI 34718 28,400.76$

03611566 HB DIAG LUMB SPINAL PUNCT W/ FLUORO/CT 62328 5,702.87$ 7,065.40$

03611567 HB THERA LUMB SPINAL PUNCT DRN CSF W/ FLUORO/CT 62329 4,413.58$

03611568 HB INJ ANESTHETIC/STEROID SI JOINT W/ IMG 64451 4,206.87$ 5,468.94$

03611569 HB INJ ANESTHETIC/STEROID GENICULAR NERV 64454 4,206.87$ 5,468.94$

03611570 HB DESTRUCT NEURO AGNT GENIC NERV W/ IMG 64624 10,499.62$ 13,649.52$

03611571 HB RADIOFREQ ABLTN SI JOINT W/ IMG 64625 10,499.62$ 13,649.52$

03611572 HB ANGIOPLASTY CCA, DOTTER CATH 37799 40,024.63$

03611578 HB DESTRUCT PREMALIG LESION 15/> 17004 1,578.81$ 2,052.44$

03611579 HB INJ ANES FACIAL, PHRENIC OR C-SPINE NERVE 64999 1,607.17$ 2,089.31$

03611580 HB ABLTN MALIG BRST TUMOR PERC CRYO UNI 0581T 15,321.82$ 19,918.33$

03611581 HB THROMBOLYSIS CEREBRAL IV INFUSION 37195 2,989.91$

03611582 HB PERC ARTERIOVENOUS FISTULA, DIRECT G2170 87,688.44$

03611583 HB LIGATION OF A-V FISTULA 37607 11,407.72$ 14,830.03$

03611584 HB FIBRIN SHEATH DISRUPTION 37799 12,971.93$

03700001 HB ANES-CAT 2-BASIC+A LINE-1ST HR 13,254.91$

03700002 HB ANES-CAT 2 - EA ADDL MIN 130.50$

03700003 HB ANES-CAT 1-BASIC - 1ST HOUR 9,507.79$

03700004 HB ANES-CAT 2+ALINE OUTLYING AREA 10,101.20$


03700006 HB ANES-CAT 1-BASIC OUTLYING AREA 5,759.98$


03700008 HB ANES-CAT 3+CVP,SWAN-1ST HOUR 20,899.06$

03700010 HB MODERATE SEDATION <5YRS 15 MIN 99151 782.90$ 1,017.40$

03700011 HB MODERATE SEDATION >5YRS 15 MIN 99152 782.90$ 1,017.40$

03700014 HB MODERATE SEDATION EA ADDL 15 MIN 99153 323.27$ 420.25$

03700015 HB CX ANES-CAT 1-BASIC -1ST HR 2,174.55$

03700018 HB ANES-CAT 3+ALINE OUTLYING AREA 15,899.37$

03700019 HB MOD SED OTH PHYS/QHP <5 YRS 99155 782.90$ 1,017.40$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03700020 HB MOD SED OTH PHYS/QHP 5/>YRS 99156 782.90$ 1,017.40$

03700021 HB MOD SED OTHER PHYS/QHP EA 99157 305.82$ 399.60$

03820001 HB WHOLE BLOOD, LEUKOREDUCED, IRRADIATED, EACH UNITP9056 2,429.75$

03830001 HB PROCESS PLAS, FRZ 8-24HR CS P9059 366.17$

03900001 HB AB SCREEN LISS 86850 664.54$

03900003 HB AB SCREEN, GEL 86850 664.54$

03900005 HB ANTIBODY ELUTION (RBC) 86860 731.12$

03900007 HB ANTIBODY RBC IDENTIFICATION 86870 980.14$

03900008 HB ANTIBODY I.D. LISS 86870 980.14$

03900009 HB ANTIBODY I.D. GEL EZ 86870 980.14$

03900011 HB ANTIBODY I.D. GEL 86870 980.14$

03900012 HB ANTIBODY I.D. PEG 86870 980.14$

03900013 HB CORD BLOOD SCREEN 86880 655.23$

03900014 HB DAT C3D 86880 127.44$

03900016 HB DAT C3 86880 112.74$

03900017 HB DAT (COOMBS) IGG 86880 98.04$

03900020 HB PATIENT ABO TYPE 86900 821.97$

03900021 HB ALLO BM/PBSC DONOR ABO * 86900 821.97$

03900022 HB ALLO BM/PBSC DONOR RH (D) 86901 138.11$

03900023 HB PATIENT RH TYPE 86901 439.53$

03900028 HB RBC PHENO PT/BLD GRP AG 86905 980.14$

03900034 HB PLASMA THAW FFP 86927 731.12$

03900035 HB HLA LYMPHOCYTE PREP 86930 980.14$

03900036 HB HEMOL/AGGLUTININ INCUBA 86941 551.68$

03900037 HB DONATH LANDSTEINER, BLOOD 86941 639.38$

03900039 HB PRETREAT RBC'S ENZM EA 86971 980.14$

03900045 HB PT. SERA DIFF ABSORPTION 86978 490.98$

03900053 HB PROCESS CRYOPRECIPITATE P9012 117.00$

03900058 HB PROCESS PACKED RBC-OS P9038 846.50$

03900062 HB PROCESS PCK RBC WASHED P9022 2,206.37$

03900064 HB PROCESS PLATELETPHERESIS P9036 1,615.88$

03900066 HB PROCESS PLT PHERS LEUKO RED-OS P9037 1,808.47$

03900068 HB PROCESS PCK RBC DEGLYCEROLIZE-OS P9057 3,127.21$

03900071 HB PROCESS PLASMA FFP P9059 366.17$

03900073 HB PROCESS GRANULOCYTE PHER P9050 1,933.00$

03900074 HB PROCESS PLASMA, FRZ BET 8-24HR P9059 366.17$

03900075 HB TRANSFUSION REACT WORKUP 86078 731.12$

03900081 HB PRE SC UNIT PT 86904 128.96$

03900084 HB RH PHENOTYPE 86906 178.35$

03900090 HB PROCESS POOLING CRYO 86965 731.12$

03900092 HB PRETREAT RBC'S/DRUGS - ARC 86975 1,567.38$

03900094 HB ANTIBODY RBC TITRE 86886 731.12$

03900108 HB PROCESS PCK RBC WASHED* P9022 2,202.60$

03900109 HB PROCESS PLASMA FFP-OS P9059 366.17$

03900110 HB PROCESS CRYOPRECIPITATE* P9012 117.00$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



03900111 HB PROCESS PLT PHERESIS LEUKO RED* P9037 1,808.47$

03900112 HB PROCESS PACKED RBC* P9038 846.50$

03900114 HB PROCESS PCK RBC LEUKOREDUCED-OS P9040 992.22$

03900115 HB PROCESS PCK RBC LEUKOREDUCED* P9040 992.22$

03900119 HB PLATELETS, PHERESIS, PATHOGEN REDUCED EACH UNITP9073 2,348.70$

03910001 HB TRANSFUSION, BLOOD COMPLEX 36430 4,160.89$ 5,409.14$

03910002 HB TRANSFUSION, BLOOD INTERM 36430 3,509.73$ 4,562.66$

03910003 HB TRANSFUSION, BLOOD COMPONENT 36430 2,207.46$ 2,869.72$

03910004 HB TRANSFUSION, BLOOD SIMPLE 36430 3,166.93$ 4,116.48$

04010004 HB MAMMO DIAG DIGITAL BILAT INCL CAD 77066 1,427.55$

04010005 HB MAMMO DIAG DIGITAL UNILAT INCL CAD 77065 1,115.12$

04010006 HB MAMMO TOMOSYNTHESIS UNILAT 77061 728.95$ 947.65$

04010007 HB MAMMO TOMOSYNTHESIS BILAT 77062 960.83$ 1,249.08$

04020001 HB US DRAINAGE S&I 75989 3,609.09$ 4,690.09$

04020002 HB US HEAD/NECK SOFT TISSUE 76536 2,336.60$ 3,037.58$

04020005 HB US RETROPERITONEUM LIMITED 76775 1,486.94$ 1,933.01$

04020006 HB US TRANSPLANTED KIDNEY 76776 2,336.60$ 3,037.58$

04020007 HB CHD RISK IMT STUDY 0126T 372.42$

04020008 HB AMNIOCENTESIS 59000 2,288.21$

04020009 HB U/S OB W/ DETAIL FETAL EXAM 76811 3,584.35$

04020010 HB US BRAIN W DOPPLER 76506 1,486.94$ 1,933.01$

04020011 HB U/S OB, ADDL GESTATION 76812 2,917.52$

04020012 HB OB U/S NUCHAL MEAS, 1 GEST 76813 1,486.94$

04020013 HB U/S OB NUCHAL, ADDL GESTATION 76814 612.97$

04020014 HB US CHEST 76604 2,336.60$ 3,037.58$

04020020 HB US ABDOMEN COMPLETE 76700 2,761.44$ 3,589.85$

04020021 HB US OB FU/EVAL PER FETUS 76816 1,083.24$ 1,408.22$

04020022 HB US ABDOMEN LIMITED 76705 2,336.60$ 3,037.58$

04020023 HB US RETROPERITONEUM COMPLETE 76770 2,336.60$ 3,037.58$

04020025 HB FETAL BIOPH PROFILE W/O NST 76819 2,336.60$ 3,037.59$

04020026 HB US SPINAL CANAL 76800 1,083.24$ 1,408.22$

04020027 HB US OB < 14 WKS SINGLE FETUS 76801 1,486.94$ 1,933.02$

04020028 HB OB US < 14 WKS, ADD'L FETUS 76802 584.89$

04020029 HB ULTRASOUND OB >14 WEEKS 76805 2,229.22$ 2,897.98$

04020030 HB US OB > 14 WKS ADD'L GEST 76810 1,382.73$

04020031 HB US PELVIS TRANSVAGINAL 76830 1,486.94$ 1,933.01$

04020033 HB US PELVIS NON-OB COM 76856 2,336.60$ 3,037.59$

04020034 HB US PELVIS LIMITED 76857 1,083.24$ 1,408.22$

04020035 HB US PREG UTERUS LMTD 76815 1,486.94$ 1,933.02$

04020037 HB US PELVIS TRANSABDOMEN COM 76856 2,336.60$ 3,037.58$

04020039 HB U/S GUID VASCULAR ACCESS 76937 1,541.79$ 2,005.06$

04020040 HB US GUIDE IUT/CORDOCENTESIS 76941 1,062.21$

04020041 HB US PLACEMENT NEEDLE S&I 76942 2,601.67$ 3,383.09$

04020042 HB UMBILICAL ARTERY DOPPLER 76820 1,083.24$

04020043 HB FETAL MID CEREBRAL ARTERY DPLR 76821 1,083.24$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04020044 HB FETAL ECHO COMPLETE 76825 2,191.77$

04020045 HB FETAL ECHO FOLLOW UP 76826 1,369.97$

04020046 HB FETAL ECHO COMPLETE DOPPLER 76827 1,083.24$

04020047 HB FETAL ECHO FOLLOW UP DOPPLER 76828 1,083.24$

04020050 HB US PELVIS HYSTEROSONOGRAM 76831 3,584.35$

04020055 HB US EXAM PELVIC/FOLLICLE LIMITED 76857 1,279.72$ 1,663.63$

04020056 HB US SCROTUM & TESTICLE(S) 76870 2,336.60$ 3,037.58$

04020057 HB US TRANSRECTAL 76872 2,336.60$ 3,037.58$

04020058 HB US COMPLETE JOINT 76881 2,336.60$ 3,037.58$

04020059 HB U/S GUID PSEUDOANEURYSM REPR 76936 2,690.19$

04020061 HB VASCULAR ACCESS GUIDANCE 76937 1,541.79$ 2,005.06$

04020062 HB US GUIDE FOR AMNIOCENTESIS 76946 1,275.11$

04020063 HB US INTRAOPERATIVE GUIDANCE 76998 1,484.75$ 1,930.21$

04020064 HB US UL PROC 76999 1,083.24$ 1,408.21$

04020066 HB VAS SCREENING ABDOMEN 76706 1,083.24$ 1,408.21$

04020067 HB US GUIDANCE FOR ABLATION 76940 1,414.02$ 1,838.94$

04020069 HB US PELVIS OB TRANSVAGINAL 76817 1,486.94$ 1,933.01$

04020070 HB PRENATAL CVS GUIDANCE 76945 774.42$

04020074 HB FETAL BIOPHYS PROF W NONSTRESS 76818 2,761.44$

04020079 HB US LTD JOINT/NON-VASC EXT 76882 1,083.24$ 1,408.22$

04020085 HB US INFANT HIPS; LIMITED/STATIC 76886 1,083.24$ 1,408.22$

04020087 HB US EXAM CHEST 76604 2,336.60$ 3,037.58$

04020088 HB US BREAST COMPLETE UNILATERAL 76641 1,486.94$ 1,933.02$

04020089 HB US BREAST LIMITED UNILATERAL 76642 1,083.24$ 1,408.21$

04020091 HB OPHTH US B & QUANT A 76510 821.97$

04020092 HB DX OPHTHAL B-SCAN US 76512 891.80$

04020093 HB CORNEAL US 76514 372.42$

04020094 HB A-SCAN EYE US W IOL MEASR 76519 891.80$

04020095 HB US TRGT DYN MBUBB 1ST LES 76978 6,160.31$ 8,008.43$

04020096 HB US TRGT DYN MBUBB EA ADDL 76979 2,665.36$ 3,352.62$

04020097 HB US PARENCHYMA 76981 5,104.69$ 6,636.08$

04020098 HB US 1ST TARGET LESION 76982 5,104.69$ 6,636.08$

04020100 HB ULTRASOUND EXAM FOLLOW-UP 76970 1,343.26$ 1,746.23$

04030002 HB MAMMO SCREENING BILATERAL INCL CAD 77067 1,296.83$

04030005 HB MAMMO TOMOSYNTHESIS SCREEN BILAT 77063 523.53$ 680.58$

04030006 HB MAMMO SCREENING UNILATERAL INCL CAD 77067 1,178.93$

04040001 HB NM PET CARDIAC METABOLIC 78459 8,134.05$ 10,574.27$

04040002 HB NM PET CARDIAC PERF SINGLE 78491 10,886.09$ 13,011.66$

04040003 HB NM PET CARDIAC PERF MULT 78492 26,648.88$ 33,504.65$

04040004 HB NM PET BRAIN METABOLIC EVAL 78608 13,451.43$ 17,486.87$

04040005 HB NM PET LIMITED AREA 78811 7,725.36$ 10,042.97$

04040006 HB NM PET SKULL-THIGH 78812 9,690.65$ 12,597.84$

04040007 HB NM PET/CT LIMITED AREA 78814 14,821.92$ 19,396.58$

04040008 HB NM PET/CT SKULL-THIGH 78815 14,900.85$ 19,371.27$

04040009 HB NM PET/CT WHOLE BODY 78816 12,477.35$ 16,220.55$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04040010 HB NM PET WHOLE BODY 78813 11,224.69$ 14,592.10$

04040012 HB PET CARDIAC META SNGL CNCRNT CT 78429 14,900.85$ 19,371.27$

04040013 HB PET CARDIAC PERF SNGL CNCRNT CT 78430 14,900.85$ 19,371.27$

04040014 HB PET CARDIAC PERF MULT CNCRNT CT 78431 7,725.36$ 10,042.97$

04040015 HB PET CARDIAC PERF/META DUAL RADTRCR 78432 7,725.36$ 10,042.97$

04040016 HB PET CARD PERF/META DUAL RAD CNCRNT CT 78433 7,725.36$ 10,042.97$

04040017 HB PET AQMBF REST AND PHARM STRESS 78434 8,421.01$ 10,947.31$

04100009 HB AEROSOL INHAL, HHN TRT,SUBS 94640 491.23$

04100012 HB PC IPPB TRT SUBSEQUENT 94640 491.23$

04100013 HB PC PENTAMIDINE TREATMENT 94642 1,247.31$

04100014 HB AEROSOL INHAL, PENTAMIDINE 94642 1,247.31$

04100015 HB PENTAMIDINE TREATMENT ADDL 10* 94642 1,247.31$

04100016 HB PC AEROSOL TREATMENT INIT HR 94644 821.97$

04100017 HB PC AEROSOL TRMNT EA ADDL HOUR 94645 348.36$

04100026 HB SURFACTANT TREATMENT-NICU 94664 940.53$

04100027 HB PC SPUTUM INDUCTION 94640 491.23$

04100029 HB AEROSOL INHAL, INITIAL HHN 94640 491.23$

04100030 HB PAG-HEART NEB INITIAL 94644 821.97$

04100031 HB BRONCHODILATOR ADMIN 94640 491.23$

04100033 HB PC HEATED AERO. TRT. 94640 491.23$

04100034 HB BRONCHODILATOR ADMINISTATION 94640 491.23$

04100036 HB PC MDI INITIAL 94640 491.23$

04100037 HB PC INITIAL IPPB TRT 94640 491.23$

04100038 HB PC INITIAL HAND NEBULIZER TRT 94640 491.23$

04100039 HB PC O/P SPUTUM INDUCT 94640 491.23$

04100041 HB PC INITIAL CHEST PHYSIOTHERAP 94667 821.97$

04100042 HB PC POST.DRAINAGE TRT 94667 821.97$

04100044 HB PC CHEST PHYSIO THER SUBS 94668 821.97$

04100045 HB PR THER PROCEDURE 15 MIN 94799 2,512.10$

04100046 HB PR SELF CARE/HOME MGT G0238 372.42$

04100047 HB PULMONARY INSTRUCTIONS G0238 372.42$

04100049 HB PR THER GROUP 2 OR G0239 1,140.35$

04100051 HB IPPB TRT, INITIAL 94664 940.53$

04100053 HB AIRWAY INHALATION TREATMENT 94640 491.23$

04100054 HB PAG-HEART NEB EACH ADDL HR 94645 348.36$

04100055 HB PC BIPAP, INITIAL 94660 5,628.85$

04100056 HB PC BIPAP, SUBSEQUENT 94660 5,117.13$

04100057 HB PC CPAP, INITIAL 94660 5,645.84$

04100058 HB PC CPAP, SUBSEQUENT 94660 5,132.43$

04100059 HB PC VENT, INITIAL 94002 9,287.32$

04100060 HB PC VENT, SUBSEQUENT 94003 8,444.13$

04100061 HB PC VENT JET, INITIAL 94002 15,706.69$

04100062 HB PC VENT JET, SUBSEQUENT 94003 14,327.98$

04100064 HB MECHN CHST WALL OSCIL,PR SN 94669 645.42$

04100065 HB PC INITIAL CHFO/CPAP/NEBULIZER (METANEB) TRT 94640 491.23$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04100066 HB PC CHFO/CPAP/NEBULIZER (METANEB) SUBSEQUENT 94640 491.23$

04120001 HB PC HAND NEB. TRT SUBS 94640 491.23$

04120002 HB PEDS PULM -INHAL. TREAT, MLTP 94640 537.90$

04120003 HB AEROSOL INHAL, TREATMENT 94640 491.23$

04200002 HB M CAL PT EXRCSE EA ADDL 15M 391.90$ 508.00$

04200003 HB M CAL PT EVALUATION 1,666.67$ 2,167.42$

04200004 HB M CAL PT EXRCSE 1ST 30M 781.36$ 1,015.96$

04200005 HB M CAL PT MOD/EXER 1ST 30M 781.36$ 1,015.96$

04200008 HB M CAL PT MOD/EXER EA ADDL 15M 391.90$ 508.00$

04200010 HB PT TAPE/STRAP LOW BACK 29799 1,028.69$

04200013 HB PT TAPE/STRAP HIP 29520 793.59$ 1,031.66$

04200022 HB PT HOT OR COLD PACK 97010 307.21$ 399.14$

04200023 HB PT TRACTION, MECHANICAL 97012 338.65$ 440.23$

04200024 HB PT ELEC STIM, UNATTEND EA 15M 97014 440.23$

04200026 HB WHIRLPOOL/FLUIDTHERAPY 97022 834.56$ 1,083.74$

04200027 HB ELEC STIM, ATTENDED EA 15M 97032 416.06$ 541.85$

04200028 HB IONTOPHORESIS 15 MIN 97033 416.06$ 540.90$

04200029 HB PT ULTRASOUND EA 15M 97035 401.56$ 522.51$

04200030 HB THER EXERCISE EA 15M 97110 391.90$ 508.00$

04200031 HB NEUROMUSC REED EA 15M 97112 406.05$ 526.99$

04200032 HB PT GAIT TRAINING EA 15M 97116 416.06$ 541.85$

04200033 HB PT MASSAGE THERAPY EA 15M 97124 457.19$

04200034 HB MANUAL THERAPY EA 15M 97140 371.50$ 483.81$

04200035 HB EXERCISE GRP OF 2 OR MORE 97150 537.03$ 696.67$

04200038 HB THER ACTVTIES, DIR EA 15M 97530 406.05$ 529.15$

04200039 HB COMM TRN/REINT 15M 97537 418.51$ 544.26$

04200040 HB PT W/C MAN/PROPLSN TRN EA 15M 97542 362.84$ 471.72$

04200041 HB PT WND CARE SELECT DEBRDMNT 97597 1,195.75$ 1,554.47$

04200042 HB PT WND CARE NONSELECT DEBRDMNT 97602 1,195.75$ 1,554.47$

04200046 HB PT PHYS PERFRM TEST EA 15M 97750 416.06$

04200047 HB ORTHTC ASSESS/TRN EA 15M 97760 403.88$ 524.84$

04200049 HB PT PROSTHETIC TRAIN EA 15M 97761 430.58$ 558.77$

04200051 HB ORTH/PROS CHECK EA 15M 97763 537.03$ 699.10$

04200052 HB PATIENT/FAM CONF INTERM 97799 632.66$ 822.47$

04200053 HB PATIENT/FAM CONF BRIEF 97799 500.58$ 650.73$

04200054 HB ELEC STIM, UNATTENDED 97014 338.65$

04200055 HB M CAL PT SNGL MODAL, INIT 30M 984.30$

04200085 HB CANALITH REPOSITIONING PROC 95992 415.51$

04200086 HB M-CAL PT EVVAL ADDL 15 MIN 833.35$ 1,083.36$

04200087 HB NEG PRESS WND TX <=50 SQ CM 97607 1,578.81$ 2,052.44$

04240002 HB PT EVAL MOD COMPLEXITY 97162 1,250.63$ 1,625.58$

04240004 HB PT EVAL LOW COMPLEXITY 97161 834.56$ 1,081.03$

04240006 HB PT RE-EVALUATION - (2) INT 97164 834.56$ 1,083.74$

04240009 HB PT EVAL HIGH COMPLEXITY 97163 1,666.67$ 2,167.42$

04240011 HB PT REEVALUATION (3) MOD 97164 1,250.63$ 1,625.58$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04240012 HB PT REEVALUATION (4) EXT 97164 2,167.42$

04240013 HB PT REEVALUATION (1) BRF 97164 541.85$

04300002 HB OT NEUROMUSC RE-ED 15M 97112 526.99$

04300003 HB M CAL OT TRTMNT EA ADDL 15M 430.58$ 558.77$

04300004 HB M CAL OT TRTMNT INIT 30 MIN 861.15$ 1,117.57$

04300005 HB SWALLOW THERAPY - (2) INT 92526 986.98$ 1,284.49$

04300006 HB SWALLOW THERAPY - (4) EXT 92526 1,973.92$ 2,566.55$

04300007 HB SWALLOW THERAPY - (3) MOD 92526 1,480.43$ 1,925.54$

04300008 HB SWALLOW THERAPY - (1) BRF 92526 493.47$ 641.04$

04300009 HB VIDEO SWALLOW EVAL 92611 2,155.35$ 2,801.20$

04300011 HB OT ELEC STIM, UNATTEND EA 15M 97014 440.23$

04300014 HB OT ELEC STIM, ATTENDED EA 15M 97032 416.06$ 541.85$

04300015 HB OT CONTRAST BATH EA 15M 97034 181.42$ 237.08$

04300016 HB OTM ULTRASOUND EA 15M 97035 401.56$

04300017 HB OT UPPER EXT EXERCISE EA 15M 97110 391.90$

04300021 HB OT ADL THERAPY EA 15M 97535 412.53$ 535.64$

04300022 HB OT JOB SITE EVAL EA 15M 97750 416.06$

04300023 HB PT ASSIST TECH ASSESS EA 15M 97755 633.77$

04300024 HB ORTHOTIC SPLINT/TRN 15M 97760 524.84$

04300025 HB OT PARAFFIN BATH EA 15M 97018 355.59$ 464.45$

04300027 HB OT MASSAGE EA 15M 97124 457.19$

04300028 HB M CAL SINGLE MODAL, INIT 30M 757.13$ 984.30$

04300029 HB SENSORY INTEGRATION, 15 MIN 97533 2,167.42$

04300031 HB THER INTERVENTION W FOCUS COG FUNC, 1ST 15MIN 97129 320.91$ 366.40$

04300032 HB THER INTERVENTION W FOCUS COG FUNC,EA ADDL 15MIN97130 320.91$ 366.40$

04340001 HB M CAL OT EVAL ADD'L 15M 379.79$ 493.47$

04340002 HB M CAL OT EVAL INIT 30 MIN 757.13$ 984.50$

04340010 HB OT EVAL HIGH COMPLEXITY 97167 1,516.70$ 1,971.72$

04340011 HB OT EVAL LOW COMPLEXITY 97165 757.13$ 970.68$

04340012 HB OT EVAL MOD COMPLEXITY 97166 1,136.92$ 1,477.98$

04340018 HB M CAL OT EVAL EA ADDL 15M 379.79$

04340019 HB OT REEVALUATION (2) INT 97168 834.56$ 1,083.74$

04340020 HB OT DRIVING EVAL EA 15M 97750 416.06$

04340023 HB SWALLOW EVAL (2) INT 92610 834.56$ 1,083.74$

04340027 HB OT REEVALUATION (1) BRF 97168 541.85$

04340028 HB OT REEVALUATION (4) EXT 97168 2,167.42$

04340029 HB OT REEVALUATION (3) MOD 97168 1,250.63$ 1,625.58$

04400001 HB M CAL LANG SWALL IND TX 30M 1,284.49$

04400002 HB M CAL SLP IND TX 30 MIN 897.44$ 1,166.66$

04400003 HB M CAL SWALLOW EVAL 60 MIN 1,666.67$ 2,167.42$

04400004 HB M CAL VIDEO SWALLOW 2,155.35$

04400005 HB M CAL SP SWALLOW THERAPY INIT 60 MIN 2,566.10$

04400007 HB M CAL SPEECH EVAL 2,167.42$

04400008 HB M CAL LANG SWALL IND TX 60M 2,566.10$

04400009 HB M CAL SP SWALLOW THER 30 MIN 1,165.94$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04400010 HB M CAL LANG SWALL IND TX 60 MIN 1,973.92$

04400011 HB SP BIOFEEDBACK 90901 379.79$

04400017 HB SP VOICE LANG THER - (1) BRF 92507 493.47$

04400018 HB SP VOICE LANG THER - (4) EXT 92507 1,973.92$

04400020 HB SP LNG VC SPCH IND TRT (4) EXT 92507 2,566.55$

04400021 HB SP LNG VC SPCH IND TRT (3) MOD 92507 1,925.54$

04400022 HB SP VOICE LANG THER - (3) MOD 92507 1,480.43$

04400023 HB SP VOICE LANG THER - (2) INT 92507 986.98$ 1,284.49$

04400024 HB SP LNG VC SPCH IND TRT (1) BRF 92507 641.04$

04400025 HB SP LNG VC SPCH IND TRT (2) INT 92507 1,284.49$

04400026 HB SP LANGUAGE/SWALLOW GROUP 92508 537.03$ 696.67$

04400028 HB SP LARYN FUNC STUDY - (3) MOD 92520 991.00$

04400029 HB SP LARYN FUNC STUDY - (1) BRF 92520 331.00$

04400030 HB SP LARYN FUNC STUDY - (2) INT 92520 659.98$

04400032 HB HEARING SCREENING 92551 437.85$ 568.47$

04400034 HB SP VOICE PROSTHETIC TRAINING 92597 2,167.42$

04400035 HB SP AUG DEV TRAINING EXTEND 92609 1,667.24$ 2,167.42$

04400042 HB SP PATIENT/FAM CONF INTERM * 97799 822.47$

04400043 HB SP PATIENT/FAM CONF INTERM 97799 822.47$

04400059 HB VOICE RESN BEH QLT ANL(1)BRF 92524 541.86$ 704.42$

04400060 HB VOICE RESN BEH QLT ANL(3)MOD 92524 1,625.58$ 2,113.27$

04400061 HB VOICE RESN BEH QLT ANL(4)EXT 92524 2,167.42$ 2,817.65$

04400062 HB VOICE RESN BEH QLT ANL(2)INT 92524 1,083.71$ 1,408.82$

04400063 HB COGNITIVE TEST BY HC PRO 96125 1,117.08$

04440001 HB M CAL LANGUAGE EVAL 2,167.42$

04440002 HB SP LANG/COGNITIVE EVALUATION 2,167.42$

04440003 HB M CAL LANG COG EVAL 60 MIN 1,666.67$

04440004 HB M CAL SPEECH VOICE EVALUATION 1,666.67$

04440013 HB SP VC PRSTH DEV EVAL - (4) EXT 92597 1,666.67$ 2,167.42$

04440016 HB SP ENDOSCOPIC SWALLOW EVAL 92612 2,167.42$

04440018 HB SP ENDO SWALLOW EVAL - (3) MOD 92612 1,250.63$

04440019 HB SP ENDO SWALLOW EVAL - (4) EXT 92612 1,666.67$

04440020 HB SP END/SWALLW EVAL W/SENS 92616 1,940.03$

04440022 HB SWALLOW EVAL - (3) MOD 92610 1,250.63$ 1,625.58$

04440023 HB SWALLOW EVAL (1) BRF 92610 416.06$ 541.85$

04440024 HB SWALLOW EVALUATION- (4) EXT 92610 1,666.67$ 2,167.42$

04440027 HB EVAL SGD 1HR 92607 1,666.67$

04440028 HB EVAL SGD EACH ADD 30 MIN. 92608 833.35$

04440033 HB SP FLUENCY EVAL (1) BRF 92521 416.06$ 540.88$

04440034 HB SP SOUND PROD EVAL(1) BRF 92522 416.06$ 540.88$

04440035 HB SP SOUND PROD W/LAN EVAL(1)BRF 92523 416.06$ 540.88$

04440036 HB SP FLUENCY EVAL (2) INT 92521 834.56$ 1,084.91$

04440037 HB SP FLUENCY EVAL (3) MOD 92521 1,250.63$ 1,625.81$

04440038 HB SP FLUENCY EVAL (4) EXT 92521 1,666.67$ 2,166.68$

04440039 HB SP SOUND PROD EVAL(2) INT 92522 834.56$ 1,084.91$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04440040 HB SP SOUND PROD EVAL(3) MOD 92522 1,250.63$ 1,625.81$

04440041 HB SP SOUND PROD EVAL(4) EXT 92522 1,666.67$ 2,166.68$

04440042 HB SP SOUND PROD W/LAN EVAL(2)INT 92523 834.56$ 1,084.91$

04440043 HB SP SOUND PROD W/LAN EVAL(3)MOD 92523 1,250.63$ 1,625.81$

04440044 HB SP SOUND PROD W/LAN EVAL(4)EXT 92523 1,666.67$ 2,166.68$

04440045 HB EVAL APHASIA PER HOUR 96105 1,666.67$ 2,166.68$

04500003 HB I&D BARTHOLIN ABSCESS 56420 1,343.98$ 1,747.17$

04500004 HB VAGINAL DELIVERY ED 59409 16,582.00$ 21,556.60$

04500005 HB PLACENTAL DELIVERY 59414 16,582.00$ 21,556.60$

04500007 HB I & D ABSCESS COMPL/MULTI 10061 1,578.81$ 2,052.44$

04500008 HB I&D PILONIDAL CYST 10080 1,641.05$ 2,133.37$

04500009 HB PILONIDAL CYST COMPLEX 10081 4,146.48$ 5,390.42$

04500010 HB REMOVAL FB SQ SIMPLE 10120 1,578.81$ 2,052.44$

04500013 HB SUBUNGUAL HEMATOMA EVAC 11740 821.97$ 1,068.56$

04500014 HB REPAIR NAIL BED 11760 3,088.06$ 4,014.45$

04500016 HB WEDGE EXCISON SKIN NAIL FOLD 11765 1,578.81$ 2,052.44$

04500018 HB SIMPLE LAC REPAIR 2.6-7.5 CM 12002 1,195.75$ 1,554.47$


04500020 HB SIMPLE LAC REPAIR 12.6-20.0 CM SCALP 12005 1,578.81$ 2,052.44$


04500022 HB SIMPLE LAC REPAIR OVER 30.0 CM 12007 1,195.75$ 1,554.47$

04500023 HB SIMPLE LAC REPAIR UP TO 2.5 CM FACE 12011 1,195.75$ 1,554.47$

04500024 HB SIMPLE LAC REPAIR 2.6 - 5.0 CM 12013 1,195.75$ 1,554.47$

04500025 HB SIMPLE LAC REPAIR 5.1 - 7.5 CM 12014 1,195.75$ 1,554.47$

04500026 HB SIMPLE LAC REPAIR 7.6-12.5 CM FACE 12015 1,195.75$ 1,554.47$

04500027 HB SIMPLE LAC REPAIR 12.6-20.0 CM FACE 12016 1,578.81$ 2,052.44$

04500029 HB INTERM LAC REPAIR UP TO 2.5 CM 12031 1,578.81$ 2,052.44$

04500030 HB INTERM LAC REPAIR 2.6-7.5 CM SCALP 12032 1,578.81$ 2,052.44$

04500031 HB INTERM LAC REPAIR 7.6-12.5 CM 12034 1,578.81$ 2,052.44$


04500033 HB INTERM LAC REPAIR UP TO 2.5 CM 12041 1,578.81$ 2,052.44$



04500036 HB INTERM LAC REPAIR UP TO 2.5 CM FACE 12051 1,578.81$ 2,052.44$




04500040 HB INTERM LAC REPAIR 12.6-20.0 CM FACE 12055 1,578.81$ 2,052.44$

04500042 HB COMPLEX REPAIR 2.6 TO 7.5 CM TRUNK 13101 3,088.06$ 4,014.45$

04500043 HB CMPLX REPAIR TRUNK@ADD 5CM- 13102 3,211.17$

04500044 HB COMPLEX REPAIR 1.1 TO 2.5 CM 13120 3,088.06$ 4,014.45$

04500045 HB COMPLEX REPAIR 2.6 TO 7.5 CM 13121 3,088.06$ 4,014.45$

04500046 HB CMPLX RPR HEAD/EXTR @ADD 5CM 13122 3,211.17$

04500047 HB COMPLEX REPAIR 1.1 TO 2.5 CM FOREHEAD 13131 1,578.81$ 2,052.44$

04500048 HB COMPLEX REPAIR 2.6 TO 7.5 CM FOREHEAD 13132 3,088.06$ 4,014.45$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04500049 HB CMPLX RPR FACE/HANDS @ADD 5CM 13133 3,211.17$

04500051 HB COMPLEX REPAIR 1.1 TO 2.5 CM EYE 13151 3,088.06$ 4,014.45$

04500052 HB COMPLEX REPAIR 2.6 TO 7.5 CM EYELID 13152 3,088.06$ 4,014.45$

04500053 HB CMPLX RPR EYELID @ADD 5CM 13153 3,211.17$

04500055 HB BURN DRESSING SMALL 16020 1,195.75$ 1,554.47$

04500056 HB BURN DRESSING MEDIUM 16025 1,195.75$ 1,554.47$

04500057 HB BURN DRESSION LARGE 16030 1,578.81$ 2,052.44$

04500060 HB EXPLORE PENE WOUND EXTREMITY 20103 4,554.44$ 5,920.77$

04500061 HB REMOVE FB MUSCLE SIMPLE 20520 8,779.14$ 11,412.88$

04500064 HB NASAL FX W/O MANIPULATION 21310 1,702.35$ 2,213.06$

04500065 HB NASAL FX W/O STABILIZATION 21315 5,161.10$ 6,709.44$

04500066 HB CLOSED TX MANDIBLAR FX WO MANI 21450 2,262.47$ 2,941.21$

04500067 HB CLOSED TX MANDIBLAR FX W MANIP 21451 5,161.10$ 6,709.44$

04500068 HB TM JOINT DISLOCATION 21480 1,702.35$ 2,213.06$

04500069 HB UNLIST PROC ABD/MUSK SYS 22999 1,702.35$ 2,213.06$

04500071 HB HUMERAL NECK FX W/MANIP 23605 4,667.13$ 6,067.25$

04500072 HB HUMERAL FX WO MANIPULATE CLOSE 23620 1,702.35$ 2,213.06$

04500073 HB CL TX SHLDR DISL W MANIP; WO ANESTH 23650 1,702.35$ 2,213.06$

04500074 HB I&D UPPER ARM/ELBOW BURSA 23931 8,779.14$ 11,412.90$

04500075 HB HUMERAL SHAFT FX W/ MANIP 24505 4,667.13$ 6,067.25$

04500076 HB FX HUMERAL W MANIPULATION 24535 4,667.13$ 6,067.25$

04500077 HB ELBOW DISLOCATION 24600 1,702.35$ 2,213.06$

04500078 HB CL TX "NURSEMAID ELBOW" W MANIP 24640 1,702.35$ 2,213.06$

04500079 HB CL TX RADIAL HD/NECK FX; WO MANIP 24650 1,702.35$ 2,213.06$

04500080 HB RAD/ULNAR SHAFT FX WO MANIP 25560 1,702.35$ 2,213.06$

04500081 HB CLTX RDCRPL/INTERCARPL DISLC 1+ BONES W MANIP 25660 1,702.35$ 2,213.06$

04500082 HB I&D ABSCESS FINGER SIMPLE 26010 1,195.75$ 1,554.47$

04500083 HB I&D ABSCESS FINGER COMPLICATED 26011 8,779.14$ 11,412.90$

04500084 HB REV/REP EXTEN TENDON FINGER 26418 4,667.13$ 6,067.25$

04500085 HB CLOSED TX METACARPAL FX W/MA @ 26605 1,702.35$ 2,213.06$

04500086 HB CL TX MCP DISLOC SGL W MANIP 26700 1,702.35$ 2,213.06$

04500087 HB FINGER SHAFT PROX FX 26720 1,702.35$ 2,213.06$

04500088 HB CL TX PHALANG SHFT FX; W MANIP 26725 1,702.35$ 2,213.06$

04500089 HB CLOSED TX ARTICULAR FX W MANIP 26742 4,667.13$ 6,067.25$

04500090 HB CL TX D PHAL FX FGR/THMB; WO MANIP 26750 1,702.35$ 2,213.06$

04500091 HB DIST PHALANGEAL FX W/MANIP 26755 1,702.35$ 2,213.06$

04500092 HB CL TX IP JNT D W MANIP ; WO ANESTH 26770 1,702.35$ 2,213.06$

04500094 HB COCCYGEAL FRACTURE 27200 1,702.35$ 2,213.06$

04500095 HB HIP DISLOCATION 27250 1,702.35$ 2,213.06$

04500096 HB FB KNEE/THIGH DEEP 27372 9,572.41$ 12,444.15$

04500097 HB KNEE DISLOCATION 27550 1,702.35$ 2,213.06$

04500098 HB PATELLAR DISLOCATION 27560 1,702.35$ 2,213.06$

04500099 HB CL TX TIB SHFT FX W/O MANIP 27750 1,702.35$ 2,213.06$

04500100 HB FX TIBIAL SHAFT W MANIPULATION 27752 4,667.13$ 6,067.25$

04500101 HB CLTX MEDIAL ANKLE FX; W/O MANIP 27760 1,702.35$ 2,213.06$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04500102 HB FX MEDIAL MALLEOLUS W MANIPUL 27762 4,667.13$ 6,067.25$

04500103 HB CL TX BIMALLEOLAR ANKLE FX W/O MANIP 27808 1,702.35$ 2,213.06$

04500104 HB BIMALLEOLAR ANKLE FX CLD W/MAN 27810 4,667.13$ 6,067.25$

04500105 HB TRIMALLEOLAR ANK FX W/O MAN 27816 1,702.35$ 2,213.06$

04500106 HB TRIMALLEOLAR ANK FX W/MAN 27818 4,667.13$ 6,067.25$

04500107 HB ANKLE DISLOCATION 27840 1,702.35$ 2,213.06$

04500108 HB FB REMOVE FOOT SQ 28190 4,554.44$ 5,920.77$

04500109 HB FX TALUS W MANIPULATION 28435 4,667.13$ 6,067.25$

04500110 HB CL TX FX GT PHALANX(S); W/O MANIP 28490 1,702.35$ 2,213.06$

04500111 HB FX TOE W MANIPULATION 28495 1,702.35$ 2,213.06$

04500112 HB TOES 2-5 FX W/O MAINIP 28510 1,621.29$ 2,107.68$

04500113 HB TOES 2-5 FX W/MAINIP 28515 1,702.35$ 2,213.06$

04500114 HB METATARSAL-PHALANGEAL DISLOC 28630 1,702.35$ 2,213.06$

04500115 HB INTERPHALANGEAL DISLOCATION 28660 1,702.35$ 2,213.06$

04500117 HB CAST GAUNTLET 29085 1,028.69$ 1,337.29$

04500119 HB APPLICATION, FINGER SPLINT 29130 793.59$ 1,031.66$

04500121 HB ED FACILITY LEVEL 1 99281 2,612.48$ 2,612.48$

04500122 HB ED FACILITY LEVEL 1 W/PROC 99281 2,612.48$ 2,612.48$

04500123 HB STRAPPING HAND/FINGER 29280 307.05$ 399.16$




04500130 HB CAST WEDGING 29740 1,943.32$ 2,526.33$

04500131 HB REMOVE INTRANASAL FB 30300 821.97$ 1,068.56$

04500132 HB ANT. EPISTAXIS SIMPLE 30901 786.62$ 1,022.61$

04500135 HB ENDOTRACHEAL INTUBATION 31500 1,584.08$ 2,059.31$

04500137 HB TRACHEOSTOMY (CRICO) 31605 1,584.08$ 2,059.31$

04500138 HB THORACOTOMY W/ CARDIAC MASSAGE 32160 6,931.90$

04500140 HB VENIPUN/IV <3YRS CENTRAL 36400 519.38$




04500148 HB INTRAOSSEOUS NEEDLE INSERTION 36680 1,272.58$ 1,654.37$

04500149 HB RPR LIP THRU&THRU/VERM BORDER 40650 2,262.47$ 2,941.21$

04500150 HB DRAIN ABSCESS VEST MOUTH SIMP 40800 4,554.44$ 5,920.77$

04500151 HB REPAIR VEST MOUTH <2.5 CM 40830 1,584.08$ 2,059.31$

04500152 HB TONGUE LAC REPAIR UNDER 2.6 CM 41250 821.97$ 1,068.56$

04500153 HB RPR TONGUE >2.5/COMPLEX 41252 1,584.08$ 2,059.31$

04500154 HB I&D ABCESS/CYST DENTOALVEOLAR 41800 821.97$ 1,068.56$

04500155 HB I&D ABSCESS PERITONSILAR 42700 1,584.08$ 2,059.31$

04500156 HB FB THROAT REMOVAL 42809 1,272.58$ 1,654.37$

04500160 HB RECTAL PROLAPSE MAN REDUC 45999 4,248.40$ 5,522.91$

04500161 HB ABSCESS ISCHOIO/PERIANAL 46040 9,345.56$ 12,149.22$

04500162 HB I&D PERIANAL ABSCESS 46050 4,248.40$ 5,522.91$

04500163 HB INC THROMBOSED HEMORRHOID EXT 46083 3,215.10$ 4,179.64$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04500164 HB HEMORRHOID ENUC/EXC 46320 9,345.56$ 12,149.22$

04500165 HB ANOSCOPY DIAGNOSTIC 46600 821.97$ 1,068.56$

04500166 HB ANOSCOPY FB REMOVAL 46608 4,630.65$ 6,019.84$

04500168 HB INSERT FOLEY CATH COMPLICATED 51703 2,512.10$ 3,265.73$

04500169 HB I&D TEST/SCROTUM EPIDIDYMIS 54700 9,835.81$ 12,786.55$



04500172 HB EPISIOTOMY REPAIR 59300 16,582.00$ 21,556.60$

04500173 HB CRITICAL CARE 30-74 MIN 99291 11,915.43$ 11,915.43$

04500174 HB CRITICAL CARE 30-74 MIN W/PROC 99291 11,915.43$ 11,915.43$

04500177 HB CRITICAL CARE EACH ADD 30 MIN 99292 4,766.18$ 4,766.18$

04500178 HB REMOVE FB CONJUNCT SUPERFIC 65205 821.97$ 1,068.56$

04500179 HB REMOVAL CORNEAL FB W/SLIT LAMP 65222 821.97$ 1,068.56$

04500181 HB I&D ABSCESS AURICLE SIMPLE 69000 4,554.44$ 5,920.77$

04500185 HB UNSCHEDULED/EMERGENCY DIALYSIS G0257 5,607.23$ 7,289.40$

04500186 HB TX HIP DISLOCATION SPLNT/TRAC 27256 1,702.35$ 2,213.06$

04500190 HB INTEST TUBE PLACE/MONITOR 44500 3,477.64$ 4,520.92$

04500191 HB GASTRIC LAVAGE/INTUB OD 43753 2,690.19$ 3,497.24$

04500192 HB EYE EXAM INTERMEDIATE NEW PATIENT 92002 839.07$ 1,090.79$

04500194 HB TRANSCUTANEOUS PACE TEMP 92953 3,595.35$ 4,673.96$

04500200 HB ARTHROPLASTY, HIP DISL W/ ANES 27266 4,667.13$ 6,067.25$

04500201 HB ARTHROPLASTY, HIP DISL W/O ANES 27265 1,702.35$ 2,213.06$

04500203 HB N BLOCK INJ, PLANTAR DIGIT 64455 1,607.17$ 2,089.31$

04500204 HB MASTOTOMY W EXPL, DEEP 19020 8,779.14$ 11,412.90$

04500205 HB TREAT FINGER DISLOCATION 26785 12,463.59$ 16,202.66$

04500208 HB CL TX TRAUMA HIPDISLC WANES 27252 4,667.13$ 6,067.25$

04500209 HB IRRIG CRPR CVERNSA PRIAPISM 54220 3,215.10$ 4,179.64$

04500210 HB DEBR O FX; SKIN - TO BONE 11012 9,572.41$ 12,444.15$

04500211 HB TREAT FINGER FRACTURE, EACH 26765 12,463.59$ 16,202.66$

04500214 HB CL TX RADIAL&ULNA FX WMANIP 25565 4,667.13$ 6,067.25$

04500216 HB REPAIR,INTRINSIC MSCLS HAND 26591 12,463.59$ 16,202.66$

04500229 HB COMPLIC REM FB FROM FOOT 28193 7,512.04$ 9,765.66$

04500232 HB REM EMBEDDED FB MOUTH VESTIB; COMPLICATED 40805 2,262.47$ 2,941.21$

04500233 HB REM EMB FB FROM DENTOALV; SFT TISSUE 41805 5,161.10$ 6,709.44$

04500234 HB REMOVE VAGINAL FOREIGN BODY 57415 16,582.00$ 21,556.60$

04500235 HB REMOVE EMBEDDED FB EYELID 67938 1,219.90$ 1,585.89$

04500236 HB REM FB CONJUNCTIVA; EMBEDDED 65210 1,272.58$ 1,654.37$

04500239 HB REPAIR PALATE LACERATION; OVER 2 CM 42182 17,596.07$ 22,874.89$

04500240 HB COLPORRHAPHY 57200 16,582.00$ 21,556.60$

04500241 HB VASC EMBOLIZE/OCCLUDE BLEED (ED ONLY) 37244 101,783.13$

04600005 HB METHACHOLINE CHALLENGE 94070 2,690.19$

04600007 HB PF MIPS/MEPS-PIMAX PEMAX 94200 793.59$

04600010 HB THORACIC GAS VOLUME 94726 2,690.19$

04600014 HB PF ALTITUDE 02 STUDY 94452 821.97$

04600015 HB PF ALTITUDE 02 STUDY W/ O2 94453 821.97$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04600017 HB EXERC INDUCED BROCHO SPASM 94060 2,690.19$

04600018 HB O2 PRESCRIPTION 94680 2,512.10$

04600019 HB DIFFUSING CAPACITY 94729 1,052.27$

04600021 HB PRE/POST SPIROMETRY 94060 2,690.19$

04600022 HB SLOW VITAL CAPACITY 94150 2,512.10$

04600023 HB VITAL CAPACITY PER MEASUREMENT 94150 2,512.10$

04600026 HB PULMONARY STRESS; COMPLEX 94621 2,690.19$

04600028 HB PULSE OXIMETRY SNGL 94760 321.72$

04600030 HB INITIAL TRANSCUTANEOUS * 94761 602.32$

04600032 HB 6 MIN WALK/ PULSE OXIMETRY 94618 821.97$

04600034 HB TRANSCUTANEOUS PER HOUR * 94761 602.32$

04600036 HB CO, EXPIRED GAS BY IR 94770 2,512.10$

04600040 HB PC MDI TX 94799 2,512.10$

04600044 HB LUNG VOLUME-HELIUM 94727 2,512.10$

04600045 HB SCREENING SPIROMETRY 94375 2,690.19$

04600046 HB SPIROMETRY 94010 2,512.10$

04600047 HB O2 UPTAKE,EXP GAS, CO2/VO2 EXT 94680 2,512.10$

04600049 HB OXYGEN UPTAKE REST INDIRECT 94690 527.31$

04600050 HB FLOW VOLUME LOOP 94375 2,690.19$

04600051 HB EXERCISE TEST BRONCOSPASM 94617 821.97$ 1,068.56$

04600052 HB INH BRONCH CHALLENGE; W HISTAMINE 95070 10,623.32$ 13,810.34$

04700001 HB INT NEWBORN HEARING SCREEN TST 788.61$

04700002 HB RPT NEWBORN HEARING SCREEN TST 788.61$

04710001 HB BAER COMPREH-W/LATENCY 92585 2,690.19$ 3,497.24$

04710002 HB BAER LTD - W/OUT LATENCY 92586 2,512.10$ 3,265.73$

04800001 HB CARDIOVERSION, INTERNAL 92961 3,595.35$ 4,673.96$

04800005 HB TILT TABLE TEST 93660 3,619.91$ 4,705.88$

04800008 HB CARDIOPULMONARY RESUSCITAT 92950 2,690.19$ 3,497.24$

04800011 HB ECG CARDIOVERSION 92960 3,595.35$ 4,673.96$

04800012 HB PERI-PROC PRG DEV EVAL LEAD OR LEADLS 93286 527.36$ 687.00$

04800013 HB INTERRO REM 90DAYS PPM/ICD 93296 1,102.53$ 1,433.29$

04800014 HB PROGRAMMING DUAL LEAD ICD 93283 1,102.53$ 1,433.29$

04800018 HB TRANSTELEPHONIC 90 DAYS PPM 93293 1,102.53$ 1,433.29$

04800020 HB PROGRAMMING SNG LEAD ICD 93282 1,102.53$ 1,433.29$

04800023 HB PROGRAMMING MULT LEAD PPM 93281 1,102.53$ 1,433.29$

04800026 HB INTERROGATION IN PERSON ICM 93290 1,102.53$ 1,433.29$

04800027 HB INTERROGATION IN PERSON ICD 93289 1,102.53$ 1,433.29$

04800029 HB INTERROGATION IN PERSON LEAD OR LEADLS 93288 1,102.53$ 1,433.29$

04800031 HB PROGRAMMING MULT LEAD ICD 93284 1,102.53$ 1,433.29$

04800032 HB PROG SQ CARD RHYTH PACEMAKER SYSTEM 93285 1,102.53$ 1,433.29$

04800035 HB 2D ECHO W/SPEC,COLR FLW DOP 93306 4,042.65$ 5,255.65$

04800036 HB STRESS ECHO W ECG,MD SUPRV 93351 4,042.65$ 5,255.65$

04800038 HB PROG SNG LEAD OR LEADLESS ONE CHAMBR 93279 1,102.53$ 1,433.29$

04800041 HB PROGRAMMING DUAL LEAD PPM 93280 1,102.53$ 1,433.29$

04800042 HB PERI-PROC PRG DEV EVAL ICD 93287 1,224.00$ 1,589.28$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04800043 HB INTER IN PERSON SQ CARD RHYTH PACE SYS 93291 372.42$ 484.14$

04800046 HB INTERROGATION VAD,IN PERSON 93750 1,005.45$

04800052 HB WCD DEVICE INTERROGATE 93292 1,102.53$

04800056 HB EECP PER TREATMENT G0166 821.97$

04800057 HB LEADLESS C PM INS/RPL VENTR 33274 87,688.44$

04800058 HB LEADLESS C PM REMOVE VENTR 33275 11,407.72$

04800059 HB PROG EVAL INPER LEADLS PM 93279 1,102.53$

04800061 HB INTERGT EVAL INPER LEADLS PM 93288 1,102.53$

04800063 HB COR FFR CTA DATA ALYS & GNRJ 0503T 6,187.43$ 8,043.66$

04800064 HB REM INTERROG ICPMS <30 D PHYS/QHP 93297 1,201.81$ 1,562.36$

04800065 HB REM INTERROG SCRMS <30 D PHYS/QHP 93298 1,201.81$ 1,562.36$

04810002 HB INSRT NEW OR REPL PERM PCMKR+ATRIAL LEAD 33206 59,443.28$

04810003 HB INSRT NEW OR REPL PERM PCMKR+VNTRC LEAD 33207 59,443.28$

04810004 HB INSRT NEW OR REPL PERM PCMKR+VNTRC/ATRIAL 33208 59,443.28$

04810006 HB INSERT PCMKR GEN ONLY-SNGL; EXISTING LEAD 33212 34,183.78$

04810007 HB INSERT PCMKR GEN ONLY;EXISTING DUAL LEADS 33213 59,443.28$

04810008 HB UPGRADE PCMKR SNGL TO DUAL 33214 59,443.28$

04810009 HB REPOSITION TRNSVN LEAD-RA/RV 33215 11,407.72$

04810010 HB INSERT LEAD SINGLE CHAMBER 33216 34,183.78$

04810011 HB INSERT LEAD DUAL CHAMBER 33217 34,183.78$

04810012 HB REPAIR LEAD SINGLE CHAMBER 33218 11,022.94$

04810013 HB REPAIR LEAD DUAL CHAMBER 33220 11,022.94$

04810014 HB RELOCATION PCMKR POCKET 33222 6,081.70$

04810015 HB RELOCATION ICD POCKET 33223 6,081.70$

04810016 HB INSRT BI-V LEAD PREV PCMKR/ICD 33224 59,443.28$

04810017 HB INSRT BI-V LEAD NEW PCMKR/ICD W/O POCKET REVISION33225 54,773.43$

04810018 HB REPOSITN LV LEAD+GEN REPLACE 33226 11,407.72$

04810019 HB REMOVE PACEMAKER GEN 33233 34,183.78$

04810020 HB REMOVE PCMKR LEAD SINGLE 33234 11,022.94$

04810021 HB REMOVE PCMKR LEAD DUAL 33235 11,022.94$

04810022 HB INSERT ICD SC/DC GEN. ONLY 33240 179,365.45$

04810023 HB REMOVE ICD GEN SINGLE/DUAL 33241 11,022.94$

04810024 HB REMOVE ICD LEAD SINGLE/DUAL 33244 11,022.94$

04810025 HB INS/REP ICD SNGL/DUAL W LEADS 33249 200,427.98$

04810026 HB IMPLANT CARDIAC LOOP RECRDER 33285 34,183.78$

04810027 HB REMOVE CARDIAC LOOP RECRDR 33286 4,554.44$

04810029 HB INSERT INTRA-AORT BALLOON 33967 8,731.08$

04810031 HB EXTRN CIRCULATORY&CARDIOASSIST 92971 3,432.57$

04810032 HB THROMBECTOMY, CORONARY MECHANICAL 92973 21,681.10$

04810033 HB THRMOBOLYSIS INTRACOR INFUSN 92975 14,080.97$

04810034 HB IVUS/OCT CORONARY GRAFT/VESSEL INITIAL 92978 19,043.68$

04810035 HB IVUS/OCT CORONARY GRAFT/VESSEL EA ADDL 92979 18,985.66$

04810038 HB PTCA RC ARTERY 92920 36,647.54$

04810039 HB PTCA LD ARTERY 92920 36,647.54$

04810040 HB AORTIC VALVUOPLASTY 92986 36,647.54$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04810041 HB VALVULOPLASTY MITRAL 92987 78,294.72$

04810042 HB VALVULOPLASTY PULM VALVE 92990 78,294.72$

04810043 HB ATRIAL SEPTECTOMY SEPTOSTOMY 92992 63,380.09$

04810044 HB PTCA LC ARTERY 92920 36,647.54$

04810045 HB PTCA SINGLE VESSEL 92920 36,647.54$

04810046 HB PTCA EA ADDL VESSL-LD 92921 34,125.97$

04810047 HB PULM ART ANGIOPLASTY 92997 78,294.72$

04810048 HB PULM ART ANGIOPLSTY ADDL VESSL 92998 20,123.62$

04810049 HB ERGONOVINE PROVOCATION TEST 93024 1,272.58$

04810050 HB RIGHT HEART CATH 93451 28,280.97$

04810051 HB INSERT SWAN GANZ CATH 93503 6,247.55$ 8,121.82$

04810052 HB ENDOMYOCARDIAL BIOPSY 93505 11,407.72$

04810058 HB RHC CONGENITAL ANOMALY 93530 28,280.97$

04810059 HB RHC&TRNSPT LHC INTCT SEPT CNGN 93532 28,280.97$

04810060 HB RHC&TRNSPT LHC OPEN SEPT CNGN 93533 28,280.97$

04810070 HB DOPPLER FLOW WIRE INITL VESSL 93571 18,140.03$

04810071 HB DOPPLER FLOW WIRE ADDL VESSL 93572 10,375.08$

04810072 HB CLOSURE ATRIAL DEFECT 93580 87,688.44$

04810073 HB CLOSURE VENTRICULR DEFECT 93581 87,688.44$

04810074 HB BUNDLE OF HIS RECORDING 93600 29,074.71$

04810075 HB INTRA ATRIAL RECORDING 93602 29,074.71$

04810076 HB RT VENTRICULAR RECORDING 93603 5,477.68$

04810077 HB INTRAVENTR OR ATR MAPPING 93609 27,445.90$

04810078 HB INTRA ATRIAL PACING 93610 29,074.71$

04810079 HB INTRAVENTRC PACING 93612 29,074.71$

04810080 HB INTRACARDIAC EP 3D MAPPING 93613 22,905.47$

04810081 HB INDUCT ARRHYTH BY ELECTR PACE 93618 5,477.68$

04810082 HB COMP EP EVAL W/O ARRHYT INDUCT 93619 29,074.71$

04810083 HB COMP EP EVAL W/ARRHYT INDUCT 93620 29,074.71$

04810084 HB COMP EP EVAL LFT ATRIAL PACE 93621 24,410.10$

04810085 HB COMP EP EVAL LFT VNTRC PACE 93622 24,410.10$

04810086 HB EP STIM+PACE POST DRUG INFUSN 93623 27,445.90$

04810087 HB EP F/U STUDY THERAPY TEST 93624 29,074.71$

04810088 HB EP EVAL ICD LEAD W/INSERT 93640 7,252.15$

04810089 HB EP EVAL ICD GEN & LEADS 93641 11,441.86$

04810090 HB EP EVAL ICD W/PROGRAMMING 93642 5,477.68$

04810091 HB ABLATION ATRIOVENTRC NODE 93650 29,074.71$

04810094 HB INTRACARDIAC ECHO 93662 18,921.38$

04810095 HB PTCA EA ADDL VESSL-RC 92921 34,125.97$

04810096 HB PTCA EA ADDL VESSL-LC 92921 34,125.97$

04810097 HB ATHERECTOMY LAD 92924 78,294.72$

04810098 HB ARTHERECTOMY MECHANICAL 92924 78,294.72$

04810099 HB ATHERECTOMY CIRCUMFLEX 92924 78,294.72$

04810100 HB ATHERECTOMY RCA 92924 78,294.72$

04810101 HB ARTHERECTOMY EA ADDL VESSL 92925 80,505.22$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04810103 HB ATHERECTOMY ADD'L LAD 92925 80,505.22$

04810104 HB ATHERECTOMY ADD'L RC 92925 80,505.22$

04810106 HB DEPLOY HEMOSTASIS DEVICE 37799 4,021.50$

04810108 HB ILIAC ANGIO W/HEART CATH 93799 2,512.10$

04810109 HB STENT, PLACE LC RX-ELUT 92928 78,294.72$

04810110 HB STENT, PLACE LD RX-ELUT 92928 78,294.72$

04810111 HB STENT, PLACE RC RX-ELUT 92928 78,294.72$

04810112 HB STENT, PLACE LC RX ADDL VSL 92929 73,520.74$

04810113 HB STENT, PLACE RC RX ADDL VSL 92929 73,520.74$

04810114 HB STENT, PLACE LD RX ADDL VSL 92929 73,520.74$

04810117 HB INSERT CARD ASSIST IMPELLA 33990 31,126.66$

04810120 HB STENT, PLACEMENT 92928 78,294.72$

04810121 HB STENT, PLACEMENT LC 92928 78,294.72$

04810122 HB STENT, PLACEMENT LD 92928 78,294.72$

04810123 HB STENT, PLACEMENT RC 92928 78,294.72$

04810125 HB STENT, PLACEMENT LC ADDL VSL 92929 73,520.74$

04810126 HB STENT, PLACEMENT RC ADDL VSL 92929 73,520.74$

04810127 HB STENT, PLACEMENT LD ADDL VSL 92929 73,520.74$

04810128 HB PTCA EA ADDL VESSL 92921 34,125.97$

04810129 HB PROCAINAMIDE CHALLENGE STUDY 93799 25,178.63$

04810130 HB EMBO SHIELD DEP CORONARY 93799 2,512.10$

04810131 HB LHC +/- LV GRAM 93452 28,280.97$

04810132 HB R/LHC +/- LV GRAM 93453 28,280.97$

04810133 HB COR ANGIO W/INJ S & I 93454 28,280.97$

04810134 HB COR ANGIO W/GRFT INJ S & I 93455 28,280.97$

04810135 HB RHC W/COR INJ S & I 93456 28,280.97$

04810136 HB RHC W/COR + GRFT INJ S & I 93457 28,280.97$

04810137 HB LHC W/COR +/- LV GRAM 93458 28,280.97$

04810138 HB LHC W/COR +/- LV GRM W/GRFT 93459 28,280.97$

04810139 HB R/LHC+/-LV GRAM W/COR 93460 28,280.97$

04810140 HB R/LHC +/- LV GRM W/COR+GRFT 93461 28,280.97$

04810141 HB TRNSPTL TRNSAP PUNCTURE 93462 20,687.24$

04810142 HB NITRIC OXIDE/HEMO MEAS 93463 2,203.00$

04810144 HB RHC & RETROGR LHC, CONGENITAL 93531 28,280.97$

04810145 HB INJ CNGNTL COR ANGIO W/S&I 93563 1,163.50$

04810146 HB INJ CNGNTL ART/GRFT WS&I 93564 1,245.78$

04810147 HB INJ CNGNTL LV/LA W/S&I 93565 834.56$

04810148 HB INJ RV/RA W/S&I 93566 834.56$

04810149 HB INJ AORTO W/S&I 93567 732.96$

04810150 HB INJ PULM ART W/S&I 93568 691.84$

04810152 HB CATH-LAA OCCLUSION 93799 15,538.49$

04810156 HB ATHERECTOMY ILIAC,EA VESSEL 0238T 87,688.44$

04810157 HB INTRAVSC IMG COR VSL(S) OCT 93799 2,512.10$

04810162 HB INSERT SWAN GANZ CATH CL 93503 6,247.55$

04810163 HB IMPLT PULM VLV EVASC APPR 33477 58,165.50$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04810164 HB INS PPI GEN ONLY-BI-V 33221 59,539.46$

04810165 HB INS PPI GEN ONLY SINGLE 33227 34,183.78$

04810166 HB INS PPI GEN ONLY DUAL 33228 59,443.28$

04810167 HB REMOVE/REPLACE PPI GEN,BI-V 33229 59,539.46$

04810168 HB INS ICD GEN ONLY-DUAL 33230 179,365.45$

04810169 HB INS ICD GEN ONLY-BI-V 33231 200,427.98$

04810170 HB REMOVE/REPLACE ICD, SINGLE 33262 150,865.00$

04810171 HB REMOVE/REPLACE ICD, DUAL 33263 179,365.45$

04810172 HB REMOVE/REPLACE ICD/BI-V 33264 200,427.98$

04810173 HB LAA CLOSURE W/IMPLANT 33340 17,847.16$ 17,847.16$

04810179 HB REMOVE VAD DIFFERENT SESSN 33992 22,592.64$

04810180 HB REPOSITION VAD DIFF SESSION 33993 21,516.81$

04810181 HB PTCA RI ARTERY 92920 36,647.54$

04810182 HB PTCA LM ARTERY 92920 36,647.54$

04810183 HB PTCA EA ADDL VESSL-RI 92921 34,125.97$

04810185 HB STENT,PLACE RI RX-ELUT 92928 78,294.72$

04810186 HB STENT,PLACE LM RX-ELUT 92928 78,294.72$

04810187 HB STENT,PLACEMENT RI 92928 78,294.72$

04810189 HB STENT,PLACE RI RX ADDL VSL 92929 73,520.74$

04810190 HB STENT,PLACE RX ADDL VSL 92929 73,520.74$

04810193 HB STENT/ATH/ANGIO 92933 87,688.44$

04810194 HB STENT/ATH/ANGIO;EA ADDL 92934 80,658.09$

04810195 HB REVASC BYP GRAFT 1 VSL 92937 78,294.72$

04810196 HB REVASC BYP GRAFT ADDL 92938 80,505.22$

04810197 HB CARD REVASC MI 1 VSL 92941 139,519.99$

04810198 HB REVSC CTO INI VSL 92943 78,294.72$

04810199 HB REVSC CTO ADDL 92944 72,644.17$

04810200 HB EP & SVT ABALATION 93653 90,089.68$

04810201 HB EP & VT ABLATION 93654 90,089.68$

04810202 HB ABLATE ARRHYTHMIA ADD ON 93655 30,977.64$

04810203 HB TX ATRIAL FIB PULM VEIN ISL 93656 90,089.68$

04810204 HB TX L/R ATRIAL FIB ADDL 93657 30,977.64$

04810205 HB INSERT SUBQ DEFIB ELECTRODE 33271 34,183.78$

04810209 HB RMVL SUBQ DEFIB ELECTRODE 33272 11,022.94$

04810210 HB REPOS SUBQ DEF ELTRD &/GEN 33273 11,022.94$

04810211 HB EPHYS EVAL SUBQ IMPLT DEFIB 93644 11,467.77$

04810213 HB IMPLT SUBQ DEFIB SYS DEV EV 93260 1,102.53$

04810214 HB PERQ TRANSCATH CLOSURE PDA 93582 87,688.44$

04810215 HB PERQ TRANSCATH SEPTL REDUXN 93583 98,966.16$

04810216 HB IMPL PRESSURE SENSR W/ANGIO 33289 67,013.93$

04810217 HB EXERCISE W/HEMODYNAMIC MEAS 93464 3,306.47$

04810218 HB INTRVASC US NONCORONARY 1ST 37252 19,536.89$

04810219 HB INTRVASC US NONCORONARY ADDL 37253 10,340.85$

04810221 HB PERQ TRANSCATH CLOSURE MITRAL 93590 87,688.44$

04810222 HB PERQ TRANSCATH CLOSURE AORTIC 93591 87,688.44$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



04810223 HB PERQ TRANSCATH CLOSURE EA ADDL 93592 42,071.32$

04810226 HB INTRA-PROC CORONARY FFR W/3D FUNC MAP 0523T 18,140.03$

04810227 HB PERICARD DRAIN 6YR+ W/O CONG CAR ANOM 33017 3,965.27$

04810228 HB PERICARD DRAIN 0-5YR/ANY AGE W/ CONG CAR ANOM 33018 3,965.27$

04810229 HB PERICARD DRAIN INSERT INDWELL CATH CT GUID 33019 8,153.28$

04810230 HB TRANSCATH IMPL INTERATRIAL SHUNT IDE STUDY C9758 58,144.34$

04820001 HB CARDIAC STRESS TEST CL 93017 2,690.19$ 3,497.24$

04830001 HB 2D ECHO W/O SPEC/COLOR DOP 93307 4,603.72$ 5,984.23$

04830002 HB 2D ECHO, LIMITED 93308 3,568.31$ 4,638.81$

04830003 HB PULSE WAVE DOPPLER 93320 1,468.32$ 1,908.80$

04830004 HB PULSE WAVE DOPPLER/SPEC,LTD 93321 2,099.72$ 2,728.61$

04830005 HB DOPPLER COLOR FLOW 93325 2,099.72$ 2,728.61$

04830008 HB STRESS ECHO 93350 4,042.65$ 5,255.65$

04830009 HB TEE WITHOUT CONTRAST 93312 7,623.26$ 9,910.26$

04830010 HB TEE WITH CONTRAST 93312 8,383.98$ 10,900.81$

04830011 HB 2D ECHO, LIMITED WITH CONTRAST 93308 9,229.78$ 11,998.75$

04830012 HB STRESS ECHO WITH CONTRAST, ECG 93351 8,383.98$ 10,900.81$

04830013 HB TTE/2D ECHO - WITH CONTRAST 93306 8,383.98$ 10,900.81$

04830014 HB TTE CONG ABN;COMPLETE W/O CONT 93303 3,263.41$

04830015 HB TTE CONG ABN;LIM F-UP W/O CONT 93304 2,211.72$

04830016 HB TEE CONGENITAL;GLOBAL W/O CONT 93315 2,211.72$

04830018 HB TTE CONG HRT ANOM W -W/CON 93303 3,263.41$

04830019 HB TTE CONG ANOMALIES W/CONT 93304 2,211.72$

04830020 HB TEE CONG W/CONT 93315 2,211.72$

04830023 HB TEE CONGENITAL; INT & REP 93317 1,921.54$

04830024 HB ECHO TRANSESOPHAGEAL (TEE) 93355 13,336.14$

04830025 HB MYOCRD STRAIN IMG SPECKLE TRCK ASSMT 93356 2,410.88$

04900006 HB ALLOGENEIC LYMPHOCYTE INFUSIONS 38242 7,596.40$

04900009 HB BIOPSY OF VAGINA 57100 2,288.21$ 2,974.68$

04900010 HB COLPOSCOPY 57452 1,343.98$

04900011 HB COLPOSCOPY W/CERVICAL BIO 57454 1,416.09$

04900012 HB BIOPSY OF CERVIX 57500 2,288.21$

04900013 HB LOOP ELECTRODE EXCISION PROC 57522 12,574.03$

05100006 HB I&D OF POSTOP WOUND COMPLEX 10180 9,572.41$ 12,444.15$

05100015 HB DEBRIDEMENT/NAILS ANY METH > 6 11721 793.59$

05100017 HB DESTRUCT BENIGN NONFACE 1ST LE 17000 1,195.75$

05100019 HB CHEMICAL CAUTERIZATION/TISSUE 17250 1,195.75$

05100023 HB STRAPPING UNNA BOOT 29580 1,028.69$ 1,337.29$

05100028 HB THERAPEUTIC PHLEBOTOMY CC 99195 821.97$

05100029 HB ARTIFICAL INSEM/INTRA- UT 58322 1,343.98$

05100030 HB INJ ANES/STEROID PARACERVICAL BLOCK 64435 2,917.58$ 3,792.85$

05100038 HB NEW PATIENT, LEVEL 5 W/PROC 99205 883.04$

05100042 HB EST PATIENT, LEVEL 1 99211 268.59$

05100045 HB EST. PATIENT, LEVEL 3 99213 386.71$

05100046 HB ANALYZE NEUROSTIM, NO PROG 95970 821.97$ 1,068.56$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



05100047 HB GENETIC COUNSELING 16-30MINS 1 UNIT 96040 488.94$

05100049 HB FLUSH IMPLANTABLE PORTS 96523 793.59$

05100051 HB GENETIC COUNSELING 31-60MINS 2 UNITS 96040 559.61$

05100053 HB GENETIC COUNSELING 61-90MINS 3 UNITS 96040 628.33$

05100055 HB NEW PATIENT, LEVEL 4 99204 630.75$


05100058 HB GENETIC COUNSELING 91-120MIN 4 UNITS 96040 699.04$

05100059 HB GENETIC COUNSELING 121+ MINS 5 UNITS 96040 767.76$








05100073 HB EST PATIENT, LEVEL 3 W/PROC 99213 386.71$








05100095 HB INJ TX/DX/PROPHYLACTIC 96373 607.33$

05100145 HB RETINAL FUNDUS 92250 821.97$

05100147 HB SLCTV WND DEBRID ADDL20CM/< 97598 843.72$ 843.72$

05100149 HB CMPTR OPHTH IMG OPTIC NERVE 92133 793.59$

05100150 HB CPTR OPHTH DX IMG POST SEG 92134 793.59$

05100152 HB SPIN/BRAIN PMP RFL-PHY SKLL 95991 1,607.17$ 2,089.31$

05100158 HB PREV COUNSEL INDIV; 15 MIN 99401 295.44$

05100159 HB PREVEN COUNSEL INDIV;30 MIN 99402 322.08$



05100164 HB SLIT LAMP PHOTOGRAPHY (EXT) 92285 793.59$

05100165 HB EYE EXAM NEW PATIENT 1+ VISITS 92004 885.79$

05100166 HB EYE EXAM & TREATMENT EST PATIENT 1+VISITS 92014 885.79$

05100167 HB EYE EXAM INTERMEDIATE EST PATIENT 92012 885.79$

05100168 HB GONIOSCOPY 92020 821.97$

05100169 HB DETERMINE REFRACTION 92015 891.86$

05100170 HB CORNEAL TOPOGRAPHY 92025 793.59$

05100171 HB COMPUTERIZED OPHTHALMIC IMAGING ANTERIOR SEGMENT92132 793.59$

05100172 HB COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 92133 793.59$

05100173 HB COMPUTERIZED OPHTHALMIC IMAGING RETINA 92134 793.59$

05100174 HB ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY92286 821.97$

05100175 HB ANT SGM IMAGING W/FLUOROSCEIN ANGIO & I&R 92287 882.79$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



05100176 HB OPHTHAL BIOMETRY,INTRAOC LENS POW CALC 92136 821.97$

05100177 HB TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES99406 140.54$

05100178 HB TOBACCO USE CESSATION INTENSIVE >10 MINUTES 99407 140.54$

05100179 HB HEALTH & WELL-BEING COACHING F2F INDIV 1ST ASSMT0591T 225.66$

05100180 HB HEALTH & WELL-BEING COACHING F2F INDIV F-UP SESS 0592T 451.33$

05100181 HB HEALTH & WELL-BEING COACHING FACE TO FACE GROUP0593T 236.30$

05100182 HB BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT 90912 2,738.31$

05100183 HB BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT90913 2,738.31$

05100184 HB SELF-MEAS BP PT EDUC/TRAINING DEV 99473 372.42$

05100185 HB TELEHEALTH ORIGINATING SITE FACILITY FEE Q3014 319.50$

05120006 HB XR DENTAL INTRAOR COMP D0210 2,912.69$ 3,786.48$

05120007 HB XR DENTAL INTRAOR PERI 1ST D0220 2,912.69$ 3,786.48$

05120008 HB XR DENTAL INTRAOR PERI ADL D0230 2,912.69$ 3,786.48$

06100007 HB MRI PELVIS W CONTRAST 72196 5,605.69$ 7,287.40$

06100015 HB MRI TMJ BILATERAL 70336 5,039.48$ 6,551.33$

06100016 HB MRI ORBITS/FACE/NECK WO CONT 70540 6,401.88$ 8,321.57$

06100017 HB MRI ORBITS/FACE/NECK W CONT 70542 10,047.17$ 13,061.31$

06100025 HB MRI CHEST WO/W CONTRAST 71552 10,004.20$ 13,005.45$

06100031 HB MRI PELVIS WO CONTRAST 72195 5,017.72$ 6,522.36$

06100033 HB MRI PELVIS WO/W CONT 72197 10,065.53$ 13,085.19$

06100037 HB MRI EXT UPP JT WO CONT UNI 73221 5,042.82$ 6,555.81$

06100054 HB MRI ABDOMEN WO/W CONT MRCP 74183 10,507.41$ 13,658.97$

06100055 HB MRI ABDOMEN WO/W CONTRAST 74183 10,065.53$ 13,085.19$

06100058 HB MRI EXT UPP JT WO/W CNT UNI 73223 10,047.17$ 13,061.31$

06100062 HB MRI UL PROC MYELOMA BNE SVY 76498 4,549.09$ 5,914.82$

06100068 HB MRI EXT LOW JT W CONT UNI 73722 7,692.59$ 10,000.37$

06100072 HB MRI EXT LOW JT WO/W CNT UNI 73723 10,047.17$ 13,061.31$

06100079 HB MRI ABDOMEN WO CONT MRCP 74181 8,490.63$ 11,037.97$

06100080 HB MRI ABDOMEN WO CONTRAST 74181 6,054.16$ 7,870.38$

06100081 HB MRI HEART WO CONTRAST 75557 8,967.61$ 11,658.90$

06100083 HB MRI HEART WO/W CONTRAST 75561 9,560.10$ 12,428.80$

06100088 HB MRI GUIDANCE S&I 77021 4,893.25$ 6,361.21$

06100089 HB MRI BREAST WO/W CONT UNILAT 77048 5,902.41$ 8,083.97$

06100094 HB MRI BREAST CA, W & W/O BILAT 77049 6,367.77$ 7,885.18$

06100095 HB MR ANGIO PELVIS WO CONT W 3D 72198 4,608.69$ 5,991.29$

06100099 HB MRI EXT LOW WO CONT UNI 73718 5,042.82$ 6,555.81$

06100101 HB MRI EXT LOW WO/W CONT UNILAT 73720 9,054.65$ 11,771.06$

06100102 HB MRI EXT LOW JT WO CONT UNI 73721 5,867.94$ 7,628.66$

06100103 HB MRI ORBITS/FCE/NCK WO/W CON 70543 10,553.17$ 13,719.11$

06100106 HB MR ANGIO NECK WO/W CONT W 3D 70549 9,003.82$ 11,704.97$

06100109 HB MR ANGIO EXT LOW WO CONT W 3D 73725 4,625.86$ 6,013.61$

06100112 HB MRI EXT UPP WO CONT UNI 73218 4,526.95$ 5,885.03$

06100113 HB MRI EXT UPP WO/W CONT UNI 73220 7,073.00$ 9,193.58$

06100115 HB MRI EXT UPP JT W CONT UNI 73222 7,692.59$ 10,000.37$

06100116 HB MRI CHEST WO CONTRAST 71550 4,454.82$ 5,791.29$


Charge

CodeDescription

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HCPCS

Code

OP/ Default

Price

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Price



06100121 HB MRI HEART WO/W CONT W STRES 75563 7,692.59$ 10,000.37$

06100122 HB MRI HEART FLOW/VELOCITY 75565 4,138.19$ 5,376.34$

06100133 HB MRI BREAST WO CONT UNILAT 77046 3,652.88$ 4,748.76$

06100144 HB MRI BREAST WO CONT BILAT 77047 4,755.90$ 6,182.67$

06100148 HB MRI EXT UPP W CONT 73219 5,605.69$ 7,287.40$

06100153 HB MRI FETAL SNGL/1ST GESTATION 74712 8,333.88$ 10,834.04$

06100154 HB MRI FETAL EA ADDL GESTATION 74713 9,084.32$ 11,809.61$

06100155 HB UNLISTED MRI ELASTOGRAPHY 76498 1,028.69$ 1,337.30$

06100156 HB MRI ABDOMEN WO CONT ELASTOGRAPHY 74181 5,867.94$ 7,628.66$

06100157 HB MRI GUIDANCE FOR TISSUE ABLATION 77022 36,563.24$ 47,536.31$

06100158 HB MR ELASTOGRAPHY 76391 10,030.94$ 12,943.14$

06100159 HB MRI BREAST W CAD WO/W CONT UNILAT 77048 2,405.12$ 3,024.17$

06100160 HB MRI BREAST W CAD, W & W/O BILAT 77049 2,393.14$ 3,009.10$

06100161 HB MRI UL PROC TBI 76498 7,779.30$ 10,114.10$

06110003 HB MRI HEAD/BRAIN WO CONT 70551 7,779.30$ 10,114.10$

06110004 HB MRI HEAD/BRAIN W CONT 70552 9,787.72$ 12,724.04$

06110010 HB MRI HEAD/PITUITARY WO/W CNT 70553 11,796.13$ 15,336.01$

06110012 HB MRI HEAD/BRAIN WO/W CONT 70553 11,796.13$ 15,336.01$

06110015 HB MRI BRAIN FUNCT W MD ASST 70555 7,779.30$ 10,113.11$

06110017 HB MRI HEAD/BRAIN DURING OPEN INTRACRANIAL PROC 70557 4,042.65$ 5,255.65$

06120001 HB MRI C-SPINE WO CONTRAST 72141 6,054.16$ 7,870.38$

06120003 HB MRI T-SPINE WO CONTRAST 72146 4,941.05$ 6,423.37$

06120005 HB MRI L-SPINE WO CONTRAST 72148 6,054.16$ 7,870.38$

06120006 HB MRI L-SPINE WO/W CONT 72158 9,680.64$ 12,584.45$

06120012 HB MRI C-SPINE W CONTRAST 72142 7,695.62$ 10,003.62$

06120013 HB MRI T-SPINE W CONTRAST 72147 6,054.16$ 7,870.38$

06120014 HB MRI L-SPINE W CONTRAST 72149 8,201.08$ 10,661.40$

06120015 HB MRI C-SPINE WO/W CONT 72156 11,368.65$ 14,779.22$

06120016 HB MRI T-SPINE WO/W CONT 72157 11,368.65$ 14,779.22$

06150001 HB MR ANGIO NECK WO CONT W 3D 70547 5,437.81$ 7,069.67$

06150002 HB MR ANGIO NECK W CONT W 3D 70548 6,054.16$ 7,870.38$

06150003 HB MR ANGIO HEAD WO CONT W 3D 70544 5,854.55$ 7,611.92$

06150004 HB MR ANGIO HEAD WO/W CONT W 3D 70546 9,003.82$ 11,704.97$

06180001 HB MR ANGIO PELVIS WO/W CONT W 3D 72198 7,686.69$ 9,991.83$

06180003 HB MR ANGIO ABDOMEN WO CONT W 3D 74185 4,608.69$ 5,991.29$

06180004 HB MR ANGIO ABDOMEN WO/W CONT W 3D 74185 6,244.45$ 8,117.29$

06180005 HB MR ANGIO CHEST W CONT W 3D 71555 6,460.62$ 8,397.42$

06180006 HB MR ANGIO CHEST WO CONT W 3D 71555 4,607.61$ 5,989.88$

06180008 HB MR ANGIO CHEST WO/W CONT W 3D 71555 6,692.33$ 8,700.06$

06180011 HB MR ANGIO EXT LOW WO/W CONT W 3D 73725 8,331.70$ 10,832.28$

06180024 HB MR ANGIO SPINE WO/W CONT 72159 6,625.21$ 8,611.84$

06180027 HB MR ANGIO EXT UPP WO/W CN UN 73225 6,341.16$ 8,241.94$

06180028 HB MR ANGIO EXT UPP WO CONT UN 73225 5,751.60$ 7,475.71$

06210002 HB NEEDLE, MAMMOTOME MULTI-PROBE 1,872.27$

06810001 HB TRAUMA, LOW LEVEL RESPONSE G0390 13,190.76$ 13,190.76$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



06820001 HB TRAUMA, MID LEVEL RESPONSE G0390 30,775.36$ 30,775.36$

06830001 HB TRAUMA, HIGH LEVEL RESPONSE G0390 39,568.33$ 39,568.33$

07100005 HB HOURLY EXT RECOVERY 421.00$

07100044 HB PACU - 1ST HOUR 5,498.85$

07100047 HB PACU - EA ADDL MINUTE 88.09$

07100050 HB PHASE I PACU 1ST HOUR 5,498.85$

07100051 HB PHASE I PACU EA ADDL MIN 88.09$

07100052 HB PHASE II PACU 1ST HOUR 1,355.21$

07100053 HB PHASE II PACU EA ADDL MIN 22.03$

07100054 HB RECOVERY LABOR & DELIVERY 4,578.19$

07200001 HB VAGINAL DELVRY-W/VBAC SUCCESS 19,442.79$

07200002 HB C-SECTION W/FAILED VBAC 19,563.03$

07200003 HB C-SECTION W/TUBAL LIGATION 19,294.28$

07200004 HB BREECH VERSION ATTEMPT 59412 16,582.00$

07200005 HB L & D MINOR PROCEDURE 5,274.45$

07200006 HB VAGINAL BIRTH W/HYSTERECTOMY 19,181.10$

07200007 HB VAGINAL DELIVERY W/TUBAL LIGA 18,916.59$

07200008 HB C-SECTION MULTIPLE BIRTHS 19,824.72$

07200009 HB C-SECTION 19,032.58$

07200010 HB VAGINAL MULTIPLE BIRTHS 19,704.49$

07200011 HB ADDL PROC OR RETURN TO THE OR/MINOR 9,366.37$

07200012 HB C-SECTION W/HYSTERECTOMY 21,218.03$

07200013 HB ADDL PROC OR RETURN TO THE OR/MAJOR 12,445.01$

07200015 HB VAGINAL DELIVERY 59409 16,582.00$

07200016 HB REMOVAL OF RETAINED PLACENTA 59414 16,582.00$ 21,556.60$

07200019 HB VBAC/MULTIPLE BIRTHS 21,218.03$

07200020 HB C-SEC-MULT BRTHS/W HYSTRCTMY 28,785.80$

07200021 HB C-SEC MULT BRTHS W/TBL LIG 28,007.79$

07200022 HB VAG DEL/MULT BRTH W/TBL LIG 25,461.64$

07300002 HB ROUTINE ECG 93005 793.59$ 1,031.66$

07300005 HB ECG RHYTHM STRIP 93041 793.59$ 1,031.66$

07300006 HB PATIENT DEMAND EVENT RECOR 93270 1,102.53$ 1,433.29$

07300007 HB PATIENT DEMAND ANALY & RPT 93271 2,815.30$ 3,659.87$

07300008 HB ECG SIGNAL AVR HIGH GAIN TE 93278 837.65$ 1,088.94$

07310001 HB ECG UP TO 48HRS RECORDING 93225 821.97$ 1,068.56$

07310002 HB ECG UP TO 48HRS SCAN ANLYS RPT 93226 974.86$ 1,267.32$

07310005 HB EXT ECG RECORDING >48 HRS 0296T 793.59$ 1,031.66$

07310006 HB EXT ECG SCAN W/REPORT>48 HR 0297T 821.97$ 1,068.56$

07320001 HB REMOTE 30 DAY ECG TECH SUPP 93229 2,512.10$

07400002 HB EEG EXT- MON ( 41-60 MIN) 95812 2,690.19$ 3,497.24$

07400003 HB EEG EXTENDED MON > 61-119 MINUTES 95813 2,690.19$ 3,497.24$

07400004 HB EEG AWAKE/DROWSY 95816 2,690.19$ 3,497.24$

07400005 HB EEG (AWAKE & SLEEP) 95819 2,690.19$ 3,497.24$

07400006 HB EEG IN COMA OR SLEEP ONLY 95822 2,690.19$ 3,497.24$

07400007 HB ECI (BRAIN DEATH) STUDY 95824 10,997.66$ 14,297.55$


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CPT/

HCPCS

Code

OP/ Default

Price

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Price



07400012 HB EEG W/MED &/OR ACTIVTN W/MD 95954 3,487.66$ 4,533.95$

07400013 HB WADA ( MEMORY DOMINANCE TEST) 95958 13,425.36$ 17,452.98$

07400014 HB EEG DURING CEA SURGERY 95955 4,167.95$ 5,418.56$

07400016 HB DIG/ANALYS/EPILEP/SPIKE/ANALYS 95957 3,751.60$ 4,877.05$

07400017 HB WADA ACT HEMISPHERIC FUNCT 95958 13,425.36$ 17,452.98$

07400019 HB FUNCT/MOTOR/LANGUAG MAP/1ST HR 95961 13,425.36$ 17,452.98$

07400020 HB FUNCT/MOTOR/LANG MAP ADD'L HR 95962 4,298.54$ 5,587.86$

07400021 HB ECOG (ELECTROCORTICOGRAPHY) 95829 25,225.94$ 32,793.73$

07400022 HB EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS 95700 3,294.29$

07400023 HB EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED 95705 14,660.74$

07400024 HB EEG W/O VIDEO BY TECH 2-12 HR INTERMITTENT MNTR 95706 14,660.74$

07400025 HB EEG WO VIDEO 2-12HR,CONTINUOUS R-T MNTR 95707 14,660.74$

07400026 HB EEG WO VIDEO EA INCR 12-26HR UNMONITORED 95708 14,660.74$

07400027 HB EEG WO VIDEO EA INCR 12-26HR INTMT MNTR 95709 14,660.74$

07400028 HB EEG WO VIDEO EA INCR 12-26HR CONT R-T MNTR 95710 14,660.74$

07400029 HB VEEG 2-12HR UNMONITORED 95711 24,865.08$ 32,324.61$

07400030 HB VEEG 2-12 HR INTERMITTENT MONITORING 95712 13,425.36$ 17,452.98$

07400031 HB VEEG 2-12HR CONTINUOUS R-T MONITORING 95713 24,865.08$ 32,324.61$

07400032 HB VEEG EA INCR 12-26HR UNMONITORED 95714 24,865.08$ 32,324.61$

07400033 HB VEEG EA INCR 12-26HR INTERMITTENT MNTR 95715 13,425.36$ 17,452.98$

07400034 HB VEEG EA INCR 12-26HR CONT R-T MNTR 95716 24,865.08$ 32,324.61$

07500004 HB GI PROCEDURE-EACH ADDL MINUTE 34.05$

07500015 HB GI BEDSIDE PROC UP TO 1 HR 6,705.88$

07500020 HB GI PROC LEVEL I- 1ST HR 8,665.22$

07500021 HB GI PROC LEVEL II - 1ST HR 23,027.96$

07500025 HB CANCELED PROC GI LEVEL 1 2,512.91$

07500026 HB CANCELED PROC GI LEVEL 2 5,807.05$

07500028 HB GI BEDSIDE PROC - MINOR 3,352.94$

07610002 HB PC SUCTIONING 31720 475.97$

07610003 HB INJ C-SPINE STELLATE GANGLN 64510 5,260.12$

07610004 HB INJ T/L-SPINE SYMPATHETIC 64520 5,260.12$

07610005 HB CHRONIC PAIN CNTR PROCEDURES 1 1,512.01$





07610011 HB CANCELED PROCEDURE PAIN CENTER 1,339.20$

07620003 HB OBSERVATION, PER HOUR G0378 421.00$

07700001 HB SCREENING PAP CERV/VAG Q0091 372.42$

07710001 HB IMMUNIZATION ADM;1 VACCINE 90471 303.10$

07710002 HB ADMIN INFLUENZA VACCINE 90471 303.10$

07710003 HB ADMIN PNEUMOCOCCAL VACCINE 90471 303.10$

07710006 HB VACCINE ADMIN, EA ADD'L 90472 305.97$

07710007 HB VACCINE/IMMUNIZATION ADMIN ADD 90472 305.97$

07710009 HB IMMUNIZATION ADM ANY ROUTE 1ST VAC/TOX 90460 298.72$


Charge

CodeDescription

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HCPCS

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OP/ Default

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Price



07710010 HB ADMIN IMMUN ADDL VAC/TOX(PEDS) 90461 133.40$

07710011 HB ADMIN HEPATITIS B VACCINE 90472 303.10$

08010001 HB ACUTE HEMODIALYSIS G0257 8,177.98$

08010002 HB CRRT VENOUS HEMODIALYSIS G0257 24,869.64$

08020001 HB PERITONEAL DIALYSIS G0257 8,177.98$

08110002 HB ORGAN ACQ KIDNEY LIVE DONOR 221,571.58$

08120002 HB ORGAN ACQ LIVER DEC DONOR 214,212.10$

08120003 HB ORGAN ACQ HEART DEC DONOR 255,013.58$

08120004 HB ORGAN ACQ LUNG BILA DEC DNR 326,359.96$

08120005 HB ORGAN ACQ SNGL LUNG DEC DNR 221,052.70$

08120006 HB ORGAN ACQ KIDNEY DEC DONOR 221,147.83$

08120007 HB ORGAN ACQ PANCREAS 227,417.66$

08120008 HB SYSTEM, OCS LUNG PERFUSION SINGLE 473,742.85$

08120009 HB SYSTEM, OCS LUNG PERFUSION DOUBLE 551,889.85$

08150001 HB T-CELL DEPLETION 38210 5,499.72$

08190002 HB ALLO PB STEM CELL APHERESIS BD 38205 6,577.89$

08190004 HB NMDP CT BLOOD SAMPLE 2,177.48$

08190005 HB NMDP IDM TESTING AT CT 1,737.59$

08190006 HB NMDP CUSTMZD(HR)HLA TS DNR 19,962.39$

08190007 HB NMDP CNFIMTRY(CT)HLA TS DNR 19,962.39$

08190008 HB NMDP HR C,HRDQ HLA CLS I,II 4,179.00$

08190009 HB NMDP HR A,B,C,HR DP HLA CLS I,II 7,038.31$

08190010 HB NMDP HR A,C, HR DQ HLA CLS I, II 6,577.86$

08190011 HB NMDP PRECOLLECT BLD SAMPLE 2,177.48$

08190012 HB NMDP PHYSICAL EXAM 9,985.60$

08190013 HB NMDP MARROW COLLECTION 171,628.68$

08190014 HB NMDP PBSC COLLECTION 260,689.79$

08190018 HB NMDP CORD BLOOD COLLECTION 184,852.76$

08190019 HB NMDP FORMAL SEARCH 6,872.73$

08190020 HB NMDP WORK UP CANCELLATION 10,057.88$

08190022 HB NMDP DONOR INFO SESSION 99205 3,225.35$

08190023 HB NMDP MNC APHERESIS COLLECTION 38205 76,835.98$

08210001 HB OUTPATIENT HEMODIALYSIS G0257 8,177.98$

08710001 HB LYMPHS CAR-T CELL HARVEST 0537T 6,061.25$

08720001 HB LYMPHS PREP/TRNSPRT 0538T 5,017.50$

08720002 HB LYMPHS PREP/TRNSPRT - FRESH 0538T 1,527.69$

08730001 HB CAR-T CELL PREP/ADMINISTRATION 0539T 2,808.11$

09000003 HB DIAG INTERVIEW EXAM 60 MINUTES 90791 995.97$

09000004 HB DIAGNOSTIC INTERVIEW EXAM 90 90791 995.97$

09000009 HB PSYTX COMPLEX INTERACTIVE 90785 439.90$

09000010 HB PSYCH DIAGNOSTIC EVALUATION 90791 995.97$

09000011 HB PSYCH DIAG EVAL W/MED SRVCS 90792 995.97$

09000012 HB PSYCHOTHERAPY 30 MINUTES 90832 995.97$

09000013 HB PSYCHOTHERAPY W/E&M 30 MIN 90833 1,005.41$



Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

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Price






09000018 HB PSYTX CRISIS INITIAL 60 MIN 90839 995.97$

09000019 HB PSYTX CRISIS EA ADDL 30 MIN 90840 1,005.41$

09000020 HB PHARMACOLOGIC MGMT W/PSYTX 90863 824.80$

09140017 HB ADAPT BEHAV TX TECH 1 PT EA 15 MIN 97153 140.54$

09140018 HB ADAPT BEHAV TX 1 PT EA 15 MIN 97155 140.54$

09140019 HB HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT 96156 304.85$

09140020 HB HEALTH BEHAVIOR INTERVENTION , 1ST 30 MIN 96158 447.09$

09140021 HB HEALTH BEHAVIOR INTERVENTION, EA ADDL 15 MIN 96159 225.66$

09150011 HB ADAPT BEHAV TX TECH MULT PTS EA 15 MIN 97154 140.54$

09150012 HB GRP ADAPT BEHAV TX GUID EA 15 MINS 97158 140.54$

09150013 HB GROUP THERAPY 90853 223.54$

09150014 HB HEALTH BEHAVIOR INTERVENTION, GROUP 1ST 30MIN 96164 234.08$

09150015 HB HEALTH BEHAVIOR INTERVENTION, GROUP EA ADDL 15MIN96165 118.15$

09160007 HB FAM ADAPT BEHAV TX GUID EA 15 MIN 97156 140.54$

09160008 HB MULT FAM GRP ADAPT BEHAV TX EA 15 97157 140.54$

09160009 HB HEALTH BEHAVIOR INTERVENTION, FAMILY INITIAL 30MIN96167 447.09$

09160010 HB HEALTH BEHAVIOR INTERVENTION, FAMILY EA ADDL 15MIN96168 225.66$

09160011 HB HEALTH BEHAVIOR INTERVENTION, FAMILY WO PT, IST 30MIN96170 451.01$

09160012 HB HEALTH BEHAVIOR INTERVENTION,FAMILY WO PT,EA ADDL 15MIN96171 225.50$

09180004 HB NEUROBHV STATUS EXAM W INT/RPT 96116 2,690.19$

09180010 HB DEVELOPEMENTAL TEST 1ST HR 96112 2,512.10$

09180011 HB DEVELOPEMENTAL TEST EA ADDL 30 MIN 96113 1,179.92$

09180012 HB NEUROBEHAVIORAL EXAM EA ADDL HR 96121 58.92$

09180013 HB PSYCHOLOGICAL TEST EVAL 1ST HR 96130 2,512.10$

09180014 HB PSYCHOLOGICAL TEST EVAL EA ADDL HR 96131 1,179.92$

09180015 HB NEUROPSYCH TEST EVAL 1ST HR 96132 2,512.10$

09180016 HB NEUROPSYCH TEST EVAL EA ADDL HR 96133 1,179.92$

09180017 HB PSYCH/NEUROPSYCH TEST 1ST 30 MIN 96136 372.42$

09180018 HB PSYCH/NEUROPSYCH TEST EA ADDL 30 MIN 96137 122.51$

09180019 HB PSYCH/NEUROPSYCH TECH 1ST 30 MIN 96138 372.42$

09180020 HB PSYCH/NEUROPSYCH TECH EA ADDL 30 MIN 96139 122.51$

09180021 HB PSYCH/NEUROPSYCH TEST AUTO RESULT 96146 372.42$

09180022 HB BEHAV ID ASSMT EA 15 MIN 97151 140.54$

09180023 HB BEHAV ID ASSMT TECH EA 15 MIN 97152 140.54$

09200001 HB FETAL NON-STRESS TEST 59025 1,343.98$

09200002 HB BRAVO 48 HR PH STUDY 91035 7,732.47$

09200003 HB LACT/GLUC/FRUC HYDROGEN OR METHANE BREATH TEST91065 2,512.10$

09200004 HB ANORECTAL MANOMETRY 91122 3,215.10$

09200005 HB PERIMETRY VFS LTD 92081 793.59$

09200006 HB PERIMETRY VFS INTMD 92082 793.59$

09200007 HB PERIMETRY VFS COMPR 92083 821.97$

09200008 HB BPM 24HR OR >,RECORD 93786 821.97$ 1,068.56$


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HCPCS

Code

OP/ Default

Price

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Price



09200009 HB BPM 24HR OR >, SCAN ANAL W 93788 821.97$ 1,068.56$

09200011 HB VNS - SIMPLE PROGRAMMING 95971 1,005.45$ 1,307.10$

09200013 HB ANALYZE NEUROSTIM, SIMPLE 95971 1,005.45$ 1,307.10$

09200014 HB GLUCOSE MONITORING CONT 95250 881.03$ 1,145.33$

09200017 HB SCS ANALYSIS, COMPLEX 95972 3,026.44$ 3,934.38$

09200020 HB NEEDLE EMG ANL/URTHRL SPHNCT 51785 3,215.10$ 4,179.64$

09200021 HB UPR/LWR SSEPS 95938 9,230.25$ 11,999.30$

09200022 HB C MOTOR EVOKED UPR&LWR LIMB 95939 13,425.36$ 17,452.98$

09200023 HB AUTONOMIC NERV FUNC SUDOM 95923 821.97$ 1,068.56$

09200028 HB FIBROSCAN 91200 2,512.10$

09200029 HB BIS XTRACELL FLUID ANALYSIS (L-DEX) 93702 2,512.10$

09200031 HB BIOELECTRICAL IMP ANALYSIS WHOLE BODY 0358T 372.42$

09200032 HB CONT GLUC MONTR PAT PRVD EQUIP 95249 793.59$ 1,031.66$

09200033 HB AUTONOMIC NERV FUNCTION TEST VASOMOTOR 95922 821.97$ 1,068.56$

09200037 HB CRANIAL NEUROSTIM ANALYSIS SIMPLE 95976 1,102.53$

09200038 HB CRANIAL NEUROSTIM ANALYSIS COMPLEX 95977 2,722.71$ 3,653.35$

09200039 HB NEUROSTIM ANALYSIS BRAIN 1ST 15 MIN 95983 1,021.76$ 1,328.29$

09200040 HB NEUROSTIM ANALYSIS BRAIN EA ADDL 15 MIN 95984 1,058.61$ 1,376.32$

09200041 HB OPSCPY EXTND RTA DRAWING & SCL DEPRSN I&R UNI/BI92201 793.59$

09200042 HB OPSCPY EXTND OPTIC NRV/MACULA DRAWING I&R UNI/BI92202 793.59$

09210011 HB VAS DUPLEX CAROTIDS BILAT 93880 3,568.31$ 4,638.81$

09210012 HB VAS DUPLEX CAROTID LTD UNI 93882 3,568.31$ 4,638.81$

09210013 HB VAS DUPLEX TRANSCRANIAL COM 93886 3,568.31$ 4,638.81$

09210014 HB VAS DUPLEX TRANSCRANIAL LTD 93888 1,480.27$ 1,924.36$

09210015 HB VAS DUPLEX ABI WO EX BILAT 93922 821.97$ 1,068.56$

09210016 HB VAS DUPLEX THORACIC OUTLET 93923 2,512.10$ 3,265.73$

09210017 HB VAS DUPLEX DIG FINGERS MULT 93923 2,512.10$ 3,265.73$

09210018 HB VAS DUPLEX TCP02 MULT 93923 2,512.10$ 3,265.73$

09210019 HB VAS DUPLEX ABI W EX BILAT 93923 2,512.10$ 3,265.73$

09210020 HB VAS DUPLEX ARM SEGMENTAL 93923 2,512.10$ 3,265.73$

09210021 HB VAS DUPLEX DIG TOES MULT 93923 2,512.10$ 3,265.73$

09210022 HB VAS DUPLEX LEG GRAFT BILAT 93925 3,568.31$ 4,638.81$

09210023 HB VAS DUPLEX LEG ART BILAT 93925 3,568.31$ 4,638.81$

09210024 HB VAS DUPLEX POPLITEAL ASM UN 93926 2,749.08$ 3,573.80$

09210025 HB VAS DUPLEX LEG GRAFT UNILAT 93926 2,749.08$ 3,573.80$

09210026 HB VAS DUPLEX LEG ART UNILAT 93926 2,749.08$ 3,573.80$

09210027 HB VAS DUPLEX FEMORAL ANSM UNI 93926 2,749.08$ 3,573.80$

09210028 HB VAS DUPLEX ARM ARTERY BILAT 93930 3,568.31$ 4,638.81$

09210029 HB VAS DUPLEX ARM GRAFT BILAT 93930 3,568.31$ 4,638.81$

09210031 HB VAS DUPLEX ARM ARTERY UNI 93931 2,326.15$ 3,023.98$

09210032 HB VAS DUPLEX ARM GRAFT UNILAT 93931 2,326.15$ 3,023.98$

09210033 HB VAS DUPLEX LEG VN SP/DP BIL 93970 3,568.31$ 4,638.81$

09210034 HB VAS DUPLEX ARM VEIN BILAT 93970 3,568.31$ 4,638.81$

09210035 HB VAS DUPLEX ARM VN SP/DP BIL 93970 3,568.31$ 4,638.81$

09210036 HB VAS DUPLEX LEG VEIN DVT BIL 93970 3,568.31$ 4,638.81$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



09210037 HB VAS DUPLEX ARM VN SP/DP UNI 93971 2,749.08$ 3,573.80$

09210038 HB VAS DUPLEX LEG VEIN DVT UNI 93971 2,749.08$ 3,573.80$

09210039 HB VAS DUPLEX LEG VN SP/DP UNI 93971 2,749.08$ 3,573.80$

09210040 HB VAS DUPLEX ARM VEIN UNILAT 93971 2,749.08$ 3,573.80$

09210042 HB VAS DUPLEX RENAL/VISC ART 93975 3,568.31$ 4,638.81$

09210043 HB US DUPLEX ABDOMEN 93975 3,568.31$ 4,638.81$

09210044 HB VAS DUPLEX SMA/CELIAC ART 93975 3,568.31$ 4,638.81$

09210046 HB DOPPLER, UTERINE ARTERY 93976 3,258.73$ 4,236.35$

09210047 HB VAS DUPLEX REN/VISC ART LTD 93976 3,568.31$ 4,638.81$

09210048 HB VAS DUPLEX RENAL TRANSPLANT 93976 3,568.31$ 4,638.81$

09210049 HB VAS DUPLEX IVC/ILI VEIN COM 93978 3,568.31$ 4,638.81$

09210050 HB VAS DUPLEX AOR/ILI ANSM COM 93978 3,568.31$ 4,638.81$

09210051 HB VAS DUPLEX AOR/ILI ART COM 93978 3,568.31$ 4,638.81$

09210054 HB VAS DUPLEX IVC/ILI VEIN LTD 93979 2,326.15$ 3,023.98$

09210055 HB VAS DUPLEX AOR/ILI ANSM LTD 93979 2,326.15$ 3,023.98$

09210056 HB VAS DUPLEX DIALYSIS ACCESS 93990 2,749.08$ 3,573.80$

09210057 HB VAS DUPLEX EXT UPP/LOW BIL 93970 3,258.73$ 4,236.35$

09210059 HB VAS LEG VARICOS VEIN UNI 93971 2,749.08$ 3,573.80$

09210062 HB TCD, VASOREACTIVITY STUDY 93890 2,749.08$ 3,573.80$

09210063 HB TCD, EMBOLI DETECT W/O INJ 93892 2,749.08$ 3,573.80$

09210064 HB TCD, EMBOLI DETECT W/INJ 93893 2,749.08$ 3,573.80$

09210067 HB DUPLEX SCAN ART IN & VEN OUT COMPL+J12 BIL 93985 3,568.31$ 4,638.81$

09210068 HB DUPLEX SCAN ART IN & VEN OUT COMPL UNI 93986 2,336.60$ 3,037.58$

09220001 HB EMG URETHA / ANUS 51784 2,512.10$ 3,265.73$

09220002 HB EMG-3 EXTREMITIES 95863 2,512.10$ 3,265.73$

09220003 HB EMG-4 EXTREMITIES 95864 2,512.10$ 3,265.73$

09220004 HB NEEDLE EMG; CRANIAL NERVE (ONE 95867 2,512.10$ 3,265.73$

09220005 HB NEEDLE EMG; CRANIAL NERVE (BOT 95868 2,512.10$ 3,265.73$

09220006 HB NEEDLE EMG/THORACIC PARASPINAL 95869 2,512.10$ 3,265.73$

09220010 HB SSEP - UPPER EXTREMITIES 95925 2,690.19$ 3,497.24$

09220011 HB SSEP - LOWER EXTREMITIES 95926 2,690.19$ 3,497.24$

09220012 HB VEP - CHECKBOARD OR FLASH 95930 2,512.10$ 3,265.73$

09220013 HB NCS - (BLINK) REFLEX 95933 793.59$ 1,031.66$

09220015 HB NCS - REPET STIM 95937 2,512.10$ 3,265.73$

09220016 HB EMG - 1 EXTREMITY 95860 821.97$ 1,068.56$

09220017 HB EMG - 2 EXTREMITIES 95861 821.97$ 1,068.56$

09220018 HB NEEDLE EMG; SINGLE FIBER 95872 2,512.10$ 3,265.73$

09220020 HB GUIDE NERV DESTR,NEEDLE EMG 95874 437.98$ 569.40$

09220021 HB GUIDE NERV DESTR, ELEC STIM 95873 437.98$ 569.40$

09220022 HB MUSCLE TEST LARYNX 95865 821.97$ 1,068.56$

09220024 HB MUSCLE TST NONPRSPNL 1 EXTR 95870 793.59$ 1,031.66$

09220027 HB MUSCLE TEST HEMIDIAPHRAGM 95866 2,512.10$ 3,265.73$

09220028 HB MUSC TST DN W/NERV TST LIM 95885 3,006.58$ 3,908.59$

09220029 HB MUSC TEST DN W/N TEST COMP 95886 3,006.58$ 3,908.59$

09220030 HB MUSC TST DN W/N TST NONEXT 95887 2,250.65$ 2,925.88$


Charge

CodeDescription

CPT/

HCPCS

Code

OP/ Default

Price

IP/ER

Price



09220031 HB NERVE CND TST 1-2 STUDIES 95907 2,512.10$ 3,265.73$



09220034 HB NERVE CND TEST 7-8 STUDIES 95910 2,690.19$ 3,497.24$



09220037 HB NERVE CND TEST 13/> STUDIES 95913 14,907.93$ 19,380.33$

09220038 HB IONM IN OPERATNG ROOM 15 MIN 95940 503.09$ 654.01$

09220039 HB IONM REMOTE/>1 PT OR PER HR 95941 1,916.52$ 2,491.49$

09240001 HB PEDS - PERCUTAN.SKIN TESTS 95004 1,272.58$

09240002 HB SKIN TEST ID IMMED, PER TST 95018 334.58$

09240005 HB SKIN TEST ID IMED,NON-CHEMO 95018 351.32$

09240006 HB SKIN TEST ID IMMED, CHEMO 95018 351.32$

09240014 HB INGEST CHALLENGE ADDL 60 MN 95079 1,259.98$

09400001 HB THERAPEUTIC APHER WBC 36511 7,596.40$

09400002 HB THER APHER FOR RBC'S 36512 7,596.40$

09400003 HB THER APHER FOR PLTS 36513 5,499.72$

09400005 HB AMBUL PUMP REFILL /MAINT-CHEMO 96521 1,376.71$

09400006 HB AMBUL PUMP REFIL/MAINT-NONCHEM 96521 1,351.69$

09400007 HB THERAPEUTIC PHLEBOTOMY 99195 821.97$

09400012 HB NEG PRESS WND TX DME <=50 SQ CM 97605 1,195.75$ 1,554.47$

09400015 HB HALO FH STUDY - THER APHERESIS W/HDL DELIP 0342T 15,101.85$

09410001 HB RC THER RECREATION EVAL 97139 1,791.40$

09420001 HB MED NUTR THPY 60 MIN 97802 814.91$

09420002 HB NUTRITION THERAPY (IND) EA 15 97802 329.75$

09420003 HB NUTRITION REASSES (IND) EA 15 97803 280.78$

09420004 HB NUTRITION THER (GRP V1) EA 30M 97804 491.83$

09420005 HB DIABETES TEACH, IND PER 30 MIN G0108 700.47$

09420006 HB DIABETES TEACH, GRP PER 30 MIN G0109 637.88$

09420009 HB GROUP MNT -30 MIN 97804 491.83$

09420012 HB CONT GLUC MNTR ANALYSIS I&R 95251 904.36$ 1,175.66$

09420014 HB LACTATION CLASS S9443 197.79$

09420015 HB PT EDUCATION NOC GRP S9446 477.50$

09430001 HB CONT CARD EXERC # 93798 1,190.38$

09430002 HB CARD REHAB INIT EVAL # 93798 1,190.38$

09430003 HB CARDIAC REHAB; WO CONT ECG 93797 1,190.38$

09480001 HB PULM REHAB WEXER 1 HR P/SES G0424 793.59$

09900501 HB STD GUEST TRAY 32.00$

09900503 HB ADD-ON FOR DELUXE ROOM 8-NE 3,002.00$

09900505 HB ADD-ON FOR DELUXE ROOM 8-SE 3,002.00$

09900506 HB ADD-ON FOR DELUXE ROOM 8-SW 3,002.00$

09900509 HB ADD-ON FOR DELUXE ROOM 8-NW 3,002.00$


Charge

CodeDescription Price

01200001 HB ROOM CHARGE 1:5 SEMI PRIV $10,081.00

01200002 HB ROOM CHG 1:5 OB PRIV DELX $10,081.00

01200003 HB ROOM CHG 1:5 OB DELX 1 ROOM $10,081.00

01200004 HB ROOM CHG 1:5 OB DELX 2 ROOMS $10,081.00

01200005 HB ROOM CHG 1:5 OB DELX 3 ROOMS $10,081.00

01200006 HB ROOM CHARGE 1:5 SEMI PRIV ** $10,081.00

01270001 HB ROOM CHARGE 1:1 ONC $44,568.00




01280001 HB ROOM CHARGE 1:5 REHAB $9,513.00

01290001 HB ROOM CHARGE TRAUMA 1:5 MED/SURG $14,331.00

01530001 HB ROOM CHARGE TRAUMA 1:5 PEDS $14,980.00

01710001 HB ROOM CHARGE 1:8 NSY $4,071.00

01720001 HB ROOM CHARGE 1:4 NSY $5,285.00

01720003 HB ROOM CHARGE 1:4 NICU/PICU $20,921.00





02000001 HB ROOM CHARGE 2:1 ICU $51,146.00



02030001 HB ROOM CHARGE 1:3 STP DWN PED $12,514.00

02030002 HB ROOM CHARGE 1:4 STP DWN PED $10,772.00

02060001 HB ROOM CHARGE 1:3 STP DWN $12,514.00

02060003 HB ROOM CHARGE TRAUMA 1:3 & 1:4 $29,884.00

02060006 HB ROOM CHARGE 1:4 STP DWN $11,305.00

02060007 HB ROOM CHARGE 1:3 STP DWN ** $12,514.00

02060008 HB ROOM CHARGE 1:4 STP DWN ** $11,305.00

02080001 HB ROOM CHARGE TRAUMA 2:1 TO 1:2 $59,602.00

09900052 HB ROOM PRIVATE DELUX $3,002.00

09900053 HB ROOM OB DELUX 1 RM $5,359.00





Room and Board FY21 1 of 1

Charge Code Description

CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price

16 PHENYLEPHRINE HCL 10 % OP DROP 17478020605 5 mL $546.24 $546.24

45 AMANTADINE HCL 50 MG/5 ML PO SOLN 00121064610 10 mL $153.00 $153.00

76 AMANTADINE HCL 100 MG PO TABS 00832011100 100 Each $2,384.00 $2,384.00

96 LOSARTAN 50 MG PO TABS 68084034701 100 Each $902.40 $902.40

107 LORAZEPAM 4 MG/ML IJ SOLN J2060 00641604710 10 mL $153.00 $153.00

111 ZIDOVUDINE 10 MG/ML PO SYRP 65862004824 240 mL $537.60 $537.60

123 QUETIAPINE 25 MG PO TABS 16714045201 100 Each $153.00 $153.00

154 TOLTERODINE 2 MG PO CP24 00009519002 90 Each $7,895.52 $7,895.52

155 CYCLOSERINE 250 MG PO CAPS 13845120202 30 Each $31,169.28 $31,169.28

157 PENICILLIN V POTASSIUM 250 MG PO TABS 67253020010 100 Each $153.00 $153.00

175 HYDROCORTISONE 5 MG PO TABS 00603389919 50 Each $153.00 $153.00

188 CEFUROXIME SODIUM 750 MG IJ SOLR J0697 00143997922 1 Each $153.00 $153.00

198 NAFCILLIN 1 GRAM IJ SOLR 00781312485 1 Each $153.00 $153.00

220 ZANAMIVIR 5 MG/ACTUATION IN DSDV 00173068101 20 Each $435.52 $435.52

256 PHENOBARBITAL 97.2 MG PO TABS 00603516821 100 Each $1,420.80 $1,420.80

267 MITOMYCIN 20 MG IV SOLR J9280 55390025201 1 Each $2,074.24 $2,074.24

311 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN J2354 63323037601 1 mL $153.00 $153.00

348 AMOXICILLIN 500 MG PO CAPS 16714029903 100 Each $153.00 $153.00

355 PRAMIPEXOLE 1 MG PO TABS 00597019061 100 Each $153.00 $153.00

360 SODIUM CHLORIDE 5 % OP DROP 17478062312 15 mL $153.00 $153.00

371 BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 IJ SOLN 00409175250 50 mL $153.00 $153.00

405 CEFAZOLIN 1 GRAM IJ SOLR J0690 63323023710 1 Each $153.00 $153.00

407 NEOMYCIN-COLIST-HC-THONZONIUM 3.3-3-10-0.5 MG/ML OT DRPS 63481042105 10 mL $3,385.60 $3,385.60


428 NEVIRAPINE 50 MG/5 ML PO SUSP 00597004724 240 mL $2,926.08 $2,926.08

432 METHOHEXITAL 500 MG IJ SOLR 42023010501 1 Each $1,001.76 $1,001.76

439 AMINOCAPROIC ACID 500 MG PO TABS 49411005030 30 Each $9,610.08 $9,610.08

445 RIVASTIGMINE TARTRATE 1.5 MG PO CAPS 63739057610 100 Each $3,569.60 $3,569.60

450 LATANOPROST 0.005 % OP DROP 17478062512 2.5 mL $231.84 $231.84

451 PEGASPARGASE 750 UNITS/ML IJ SOLN J9266 00944381001 5 mL $167,412.60 $167,412.60

461 GANCICLOVIR SODIUM 500 MG IV SOLR J1570 00004694003 1 Each $719.84 $719.84

482 PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN J2560 00641047625 1 mL $288.88 $288.88

486 CLINDAMYCIN PHOSPHATE 150 MG/ML IJ SOLN J3490 00009087026 300 mg $153.00 $153.00



515 CHLORAMPHENICOL SOD SUCCINATE 1 GRAM IV SOLR J0720 63323001115 1 Each $386.88 $386.88

535 DEXTROAMPHETAMINE-AMPHETAMINE 7.5 MG PO TABS 00555077502 100 Each $1,280.00 $1,280.00

561 MANNITOL 25 % 25 % IV SOLN J2150 00409403101 50 mL $153.00 $153.00

605 MONTELUKAST 5 MG PO CHEW 00781555592 90 Each $1,006.56 $1,006.56

608 TROPICAMIDE 0.5 % OP DROP 17478010112 15 mL $153.00 $153.00

614 PIOGLITAZONE 15 MG PO TABS 57237021930 30 Each $153.00 $153.00

615 FUROSEMIDE 10 MG/ML IJ SOLN J1940 36000028225 2 mL $153.00 $153.00

615 FUROSEMIDE 10 MG/ML IJ SOLN J1940 00409610210 10 mL $153.00 $153.00

630 EPOETIN ALFA 2000 UNITS IJ SOLN J0885 55513012610 1 mL $305.99 $489.58

631 FLUCONAZOLE 100 MG PO TABS 00904650061 100 Each $1,808.00 $1,808.00

656 METHOCARBAMOL 500 MG PO TABS 63739016610 100 Each $160.00 $160.00

667 MESALAMINE 4 GRAM/60 ML PR ENEM 45802009851 60 mL $153.00 $153.00

681 POTASSIUM CHLORIDE IN 5 % DEX 20 MEQ/L IV SOLP J3480 00409790509 1000 mL $153.00 $153.00

684 MITOMYCIN 40 MG IV SOLR J9280 55390025301 1 Each $4,147.52 $4,147.52

697 CLOTRIMAZOLE 10 MG MM TROC 00574010777 70 Each $954.24 $954.24

715 PENTOSAN POLYSULFATE SODIUM 100 MG PO CAPS 50458009801 100 Each $14,012.80 $14,012.80

726 DEFEROXAMINE 2 GRAM IJ SOLR J0895 00078034751 4 Each $1,409.92 $1,409.92

726 DEFEROXAMINE 2 GRAM IJ SOLR J0895 00409233725 1 Each $440.69 $440.69

728 SILVER SULFADIAZINE 1 % TP CREA 61570013120 20 gram $153.00 $153.00

728 SILVER SULFADIAZINE 1 % TP CREA 43598021055 50 gram $153.00 $153.00


755 DOXYCYCLINE MONOHYDRATE 25 MG/5 ML PO SUSR 00069097065 60 mL $613.44 $613.44

762 PHENOBARBITAL 16.2 MG PO TABS 63739020010 100 Each $523.20 $523.20

764 FENTANYL 50 MCG/HR TD PT72 00378912298 5 Each $919.68 $919.68

791 DOXORUBICIN, PEG-LIPOSOMAL 2 MG/ML IV SUSP Q2050 47335005040 25 mL $12,714.53 $12,714.53

791 DOXORUBICIN, PEG-LIPOSOMAL 2 MG/ML IV SUSP Q2050 47335004940 10 mL $9,041.44 $9,041.44

794 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN J3490 00187433005 5 mL $2,087.84 $2,087.84

866 THALIDOMIDE 50 MG PO CAPS 59572020514 28 Each $76,563.20 $76,563.20

870 EPTIFIBATIDE 2 MG/ML IV SOLN J1327 00085117702 100 mL $3,411.20 $3,411.20

870 EPTIFIBATIDE 2 MG/ML IV SOLN J1327 00085117701 10 mL $313.12 $313.12

872 TERCONAZOLE 0.4 % VA CREA 51672130406 45 gram $418.32 $418.32

888 PEGINTERFERON ALFA-2B 50 MCG/0.5 ML SC KIT 00085435301 1 Each $12,034.72 $12,034.72

909 ACYCLOVIR 200 MG/5 ML PO SUSP 50383081016 473 mL $3,912.66 $3,912.66

909 ACYCLOVIR 200 MG/5 ML PO SUSP 99999900302 10 mL $153.00 $153.00

916 IVERMECTIN 3 MG PO TABS 00006003220 20 Each $1,066.24 $1,066.24

926 DILTIAZEM HCL 5 MG/ML IV SOLN J3490 00409117101 5 mL $153.00 $153.00

926 DILTIAZEM HCL 5 MG/ML IV SOLN J3490 55390056505 5 mL $153.00 $153.00

930 CYCLOPHOSPHAMIDE 2 GRAM IV SOLR J9070 10019095701 1 Each $5,890.50 $5,890.50

939 ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN J7608 00409330803 30 mL $153.00 $153.00



949 LIDOCAINE HCL 10 MG/ML (1 %) IJ SOLN J2001 63323020102 2 mL $153.00 $153.00


959 TUBERCULIN PPD 5 TUB. UNIT /0.1 ML ID SOLN 49281075222 5 mL $4,597.92 $4,597.92



Pharmacy FY21 MED IDs 1 of 37


CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



959 TUBERCULIN PPD 5 TUB. UNIT /0.1 ML ID SOLN 49281075221 1 mL $1,180.32 $1,180.32

964 VALGANCICLOVIR 450 MG PO TABS 00004003822 60 Each $37,977.60 $37,977.60

967 ANASTROZOLE 1 MG PO TABS 00310020130 30 Each $225.60 $225.60

1007 HYDROXYUREA 500 MG PO CAPS 00555088202 100 Each $1,758.40 $1,758.40

1010 NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OT SOLN 24208063110 10 mL $1,164.96 $1,164.96

1014 METHOXSALEN 20 MCG/ML IJ SOLN 64067021601 10 mL $30,039.60 $30,039.60

1036 BICALUTAMIDE 50 MG PO TABS 16714057102 100 Each $304.00 $304.00

1052 FLUTICASONE PROPION-SALMETEROL 250-50 MCG/DOSE IN DSDV 00173069600 60 Each $2,908.32 $2,908.32

1052 FLUTICASONE PROPION-SALMETEROL 250-50 MCG/DOSE IN DSDV 00173069604 14 Each $866.54 $866.54

1069 ASPIRIN-DIPYRIDAMOLE 25-200 MG PO CM12 00597000160 60 Each $8,409.60 $8,409.60

1084 ATORVASTATIN 80 MG PO TABS 00071015823 90 Each $404.64 $404.64

1120 LEVONORGESTREL 20 MCG/24 HOURS (5 YRS) 52 MG IU IUD J7298 50419042101 1 Each $15,256.16 $15,256.16

1155 ACETIC ACID 2 % OT SOLN 60432074115 15 mL $286.32 $286.32

1167 AZELASTINE 0.05 % OP DROP 60505057804 6 mL $286.27 $286.27

1172 NYSTATIN 100000 UNITS/ML PO SUSP 66689003750 5 mL $153.00 $153.00

1202 VENLAFAXINE 37.5 MG PO CP24 00008083703 100 Each $496.00 $496.00

1221 RIFAMPIN 600 MG IV SOLR J3490 00068059701 1 Each $2,663.04 $2,663.04

1226 EPINEPHRINE HCL 1 MG/ML NA SOLN 42023010301 30 mL $1,861.20 $1,861.20

1237 ALPHA-1 PROTEINASE INHIB.(HUM) 500 MG IV SOLR J0256 00944280201 1 Each $1,750.00 $2,800.00

1258 DICYCLOMINE 10 MG/ML IM SOLN J0500 58914008052 2 mL $1,253.60 $1,253.60

1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 69918090110 10 mL $5,904.00 $5,904.00

1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 00409226501 1 mL $582.88 $582.88

1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 00703505401 10 mL $5,816.32 $5,816.32

1320 VENLAFAXINE 75 MG PO CP24 00904646961 100 Each $513.60 $513.60

1343 BETAXOLOL 0.25 % OP DRPS 00065024610 10 mL $4,608.00 $4,608.00

1387 COLISTIN (COLISTIMETHATE NA) 150 MG IJ SOLR J0770 00574085801 1 Each $162.08 $162.08

1405 LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 IJ SOLN 63323048731 30 mL $153.00 $153.00

1431 INTERFERON ALFA-2B 50 MILLION UNIT (1 ML) IJ SOLR J9214 00085435201 1 Each $12,889.53 $12,889.53

1434 REPAGLINIDE 2 MG PO TABS 68084096725 30 Each $153.00 $153.00

1460 NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS 51079058420 100 Each $1,504.00 $1,504.00

1473 INTERFERON ALFA-2B 10 MILLION UNIT (1 ML) IJ SOLR J9214 00085435001 1 Each $4,582.88 $4,582.88

1524 MITOTANE 500 MG PO TABS 00015308060 100 Each $7,152.00 $7,152.00

1539 IODINE STRONG (LUGOLS) 5 % PO SOLN 00395277516 473 mL $1,210.88 $1,210.88

1539 IODINE STRONG (LUGOLS) 5 % PO SOLN 48433023015 14 mL $428.74 $428.74

1545 DOXYCYCLINE HYCLATE 100 MG PO CAPS 00143314250 50 Each $895.20 $895.20

1546 ATOVAQUONE-PROGUANIL 62.5-25 MG PO TABS 68462040201 100 Each $2,006.40 $2,006.40

1558 NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TP OINT 00713026831 28.4 gram $153.00 $153.00

1567 ALPROSTADIL 500 MCG/ML IJ SOLN J0270 00703150102 1 mL $1,581.57 $1,581.57

1576 TOBRAMYCIN SULFATE 10 MG/ML IJ SOLN J3260 63323030502 2 mL $153.00 $153.00

1586 IMIGLUCERASE 400 UNITS IV SOLR J1786 58468466301 10 mL $13,396.00 $15,070.50

1606 CEFUROXIME AXETIL 250 MG PO TABS 16714040002 60 Each $764.16 $764.16

1610 PIPERACILLIN-TAZOBACTAM 40.5 GRAM IV SOLR J2543 00206885910 1 Each $891.04 $891.04

1616 AMINO ACID (TROPHAMINE) INFUSION 10 % 10 % IV SOLP 00264934155 500 mL $432.00 $432.00

1651 DEXRAZOXANE HCL 250 MG IV SOLR J1190 00013871762 1 Each $1,836.32 $1,836.32

1665 ARGATROBAN 100 MG/ML IV SOLN J0883 00007440701 2.5 mL $3,072.00 $3,072.00

1667 MICONAZOLE NITRATE 100 MG VA SUPP 49348083361 7 Each $153.00 $153.00



1677 METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN J2765 00409341401 2 mL $153.00 $153.00

1697 LAMOTRIGINE 200 MG PO TABS 00173064460 60 Each $15,882.24 $15,882.24

1714 SOMATROPIN 2 MG/0.25 ML SC SYRG J2941 00013265802 7 Each $16,804.81 $16,804.81

1726 VENLAFAXINE 75 MG PO TABS 16714065801 100 Each $182.40 $182.40

1733 POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN 00409729501 15 mL $203.28 $203.28

1733 POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN 63323008605 5 mL $167.60 $167.60

1734 ATROPINE 1 % OP OINT 24208082555 3.5 gram $212.02 $212.02

1736 LEUPROLIDE (3 MONTH) 11.25 MG IM SYKT J1950 00074366303 1 Each $35,148.15 $35,148.15

1749 IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML IN NEBU J7620 00487020101 3 mL $153.00 $153.00

1764 LEUPROLIDE 3.75 MG IM SYKT J1950 00074364103 1 Each $11,715.93 $11,715.93

1834 INSULIN GLARGINE 100 UNITS/ML SC SOLN J1815 00088222033 10 mL $1,336.16 $1,336.16

1843 POTASSIUM CHLORID-D5-0.45%NACL 30 MEQ/L IV SOLP J3480 00409790309 1000 mL $153.00 $153.00

1861 PILOCARPINE HCL 1 % OP DROP 61314020315 15 mL $1,130.16 $1,130.16

1865 LORATADINE 5 MG/5 ML PO SOLN 99999900320 10 mL $153.00 $153.00

1884 NIACIN 1000 MG PO TB24 00074308090 90 Each $2,462.40 $2,462.40

1945 FLUCYTOSINE 500 MG PO CAPS 00187355510 100 Each $94,032.00 $94,032.00

1956 PENTOSTATIN 10 MG IV SOLR J9268 00409080101 1 Each $17,627.22 $17,627.22

1961 CEFEPIME 1 GRAM IJ SOLR J0692 60505083404 1 Each $153.00 $153.00



1966 SULFASALAZINE 500 MG PO TABS 00591079601 100 Each $278.40 $278.40

1974 FLUDARABINE 50 MG IV SOLR J9185 00703585401 1 Each $984.32 $984.32

1977 CLONIDINE 0.1 MG/24 HR TD PTWK 00597003134 4 Each $943.04 $943.04



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price




2035 LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 IJ SOLN 00409318301 20 mL $153.00 $153.00

2036 TOBRAMYCIN IN 0.225 % NACL 300 MG/5 ML IN NEBU J7682 00078049471 5 mL $1,954.16 $1,954.16

2039 ERYTHROMYCIN 500 MG PO TABS 24338010413 100 Each $18,262.40 $18,262.40

2052 CROMOLYN 5.2 MG/SPRAY (4 %) NA SPRY 57782039726 26 mL $153.00 $153.00

2057 LOPINAVIR-RITONAVIR 400-100 MG/5 ML PO SOLN 00074395646 160 mL $7,636.48 $7,636.48

2057 LOPINAVIR-RITONAVIR 400-100 MG/5 ML PO SOLN 99999777700 5 mL $238.40 $238.40

2072 FAT EMULSION 20 % IV EMUL 00338051909 250 mL $188.00 $188.00

2072 FAT EMULSION 20 % IV EMUL 00338051913 500 mL $224.00 $224.00

2086 RIBAVIRIN 200 MG PO CAPS 68382026012 84 Each $1,671.94 $1,671.94

2091 DEXTROAMPHETAMINE 15 MG PO CPSR 51862034690 90 Each $6,235.20 $6,235.20

2112 LIDOCAINE 4 % TP PTMD 45611000938 6 Each $153.00 $153.00

2125 LEUCOVORIN CALCIUM 25 MG PO TABS 51079058205 20 Each $3,280.96 $3,280.96

2133 ENALAPRIL MALEATE 10 MG PO TABS 51079095220 100 Each $544.00 $544.00

2164 ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) IN NEBU J7613 00487950103 3 mL $153.00 $153.00

2180 PROTAMINE 10 MG/ML IV SOLN J2720 63323022905 5 mL $153.00 $153.00

2180 PROTAMINE 10 MG/ML IV SOLN J2720 63323022930 25 mL $380.80 $380.80

2193 SUCCIMER 100 MG PO CAPS 55292020111 100 Each $30,528.00 $30,528.00

2204 HYLAN G-F 20 16 MG/2 ML IX SYRG J7325 58468009001 2 mL $916.30 $916.30

2266 AMMONIUM LACTATE 12 % TP LOTN 00904598426 226 gram $153.00 $153.00

2286 EPOPROSTENOL (GLYCINE) 0.5 MG IV SOLR J1325 00173051700 1 Each $373.76 $373.76

2324 CARBAMIDE PEROXIDE 10 % MM SOLN 42037010476 60 mL $153.00 $153.00


2348 DIVALPROEX 250 MG PO TBEC 62756079713 500 Each $904.00 $904.00

2398 TRIAZOLAM 0.25 MG PO TABS 59762371809 100 Each $4,374.40 $4,374.40

2406 APRACLONIDINE 0.5 % OP DROP 00065066505 5 mL $825.60 $825.60

2412 LEVORPHANOL TARTRATE 2 MG PO TABS 42358010210 100 Each $66,366.40 $66,366.40

2421 DEXTROAMPHETAMINE 5 MG PO TABS 00555095202 100 Each $2,236.80 $2,236.80

2444 PHYTONADIONE (VITAMIN K1) 10 MG/ML IJ SOLN J3430 00409915801 1 mL $553.81 $553.81

2446 LAMIVUDINE 100 MG PO TABS 00173066200 60 Each $14,549.76 $14,549.76

2451 DIAZEPAM 5 MG/ML IJ SOLN J3360 00409321312 10 mL $558.56 $558.56


2523 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN J7643 00517460125 1 mL $193.87 $193.87

2523 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN J7643 00143968225 1 mL $153.00 $153.00

2525 PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML IJ SOLN J3430 00409915701 .5 mL $153.00 $153.00

2618 GOSERELIN 3.6 MG SC IMPL J9202 00310095036 1 Each $10,164.00 $10,164.00

2629 INDOMETHACIN 50 MG PR SUPP 42211010243 30 Each $83,587.20 $83,587.20

2659 CLARITHROMYCIN 250 MG PO TABS 00054003621 60 Each $835.20 $835.20

2709 AMINO ACID (HEPATAMINE) INFUSION 8 % 8 % IV SOLP 00264937155 500 mL $1,504.00 $1,504.00

2716 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) PO ELIX 99999000980 5 mL $153.00 $153.00

2720 MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) PO SOLN 99999900409 1 mL $153.00 $153.00

2721 IOHEXOL 180 MG IODINE/ML IT SOLN Q9965 00407141120 20 mL $625.60 $625.60

2729 VINBLASTINE 1 MG/ML IV SOLN J9360 63323027810 10 mL $559.52 $559.52

2767 DANTROLENE 20 MG IV SOLR J3490 27505000367 1 Each $1,302.08 $1,302.08

2791 OXYBUTYNIN CHLORIDE 10 MG PO TR24 00378661005 500 Each $3,360.00 $3,360.00

2793 AZITHROMYCIN 250 MG PO TABS 59762306003 50 Each $752.00 $752.00

2795 CLONIDINE 0.2 MG/24 HR TD PTWK 00597003234 4 Each $1,383.68 $1,383.68

2808 FOSFOMYCIN TROMETHAMINE 3 GRAM PO PACK 00456430001 1 Each $1,361.12 $1,361.12

2812 ALLOPURINOL SODIUM 500 MG IV SOLR J3490 67457018750 1 Each $20,972.25 $20,972.25

2817 BENZOCAINE-MENTHOL 20-0.5 % TP AERO 16864068002 56 gram $153.00 $153.00

2823 NITROGLYCERIN 0.3 MG SL SUBL 00071041724 100 Each $884.80 $884.80

2834 LEVALBUTEROL HCL 0.63 MG IN NEBU J7614 00378968144 3 mL $153.00 $153.00

2931 PRAVASTATIN 40 MG PO TABS 51079078220 100 Each $1,222.40 $1,222.40

2941 FLOXURIDINE 0.5 GRAM IJ SOLR J9200 63323014507 1 Each $1,149.76 $1,149.76

2956 DILTIAZEM HCL 180 MG PO CP24 62037059890 90 Each $354.24 $354.24

2961 CHONDROITIN SULF-SOD HYALURON 3 %-4 %(0.5 ML) 1 % (0.55 ML) IO SYRG 08065183150 1.05 mL $1,414.07 $1,414.07

3006 HEMIN 313 MG IV SOLR J1640 55292070155 1 Each $71,119.08 $71,119.08

3010 CITALOPRAM 10 MG/5 ML PO SOLN 65862007424 240 mL $960.00 $960.00

3026 OFLOXACIN 0.3 % OP DROP 17478071310 5 mL $153.00 $153.00

3029 ESTRADIOL CYPIONATE 5 MG/ML IM OIL J1000 00009027101 5 mL $1,714.24 $1,714.24

3049 CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS 00378003001 100 Each $1,483.20 $1,483.20

3097 NYSTATIN 100000 UNIT/GRAM TP OINT 00168000730 30 gram $312.96 $312.96

3103 CYCLOSPORINE MODIFIED 25 MG PO CAPS J7515 00093574065 30 Each $369.12 $369.12

3122 ESTRAMUSTINE 140 MG PO CAPS 00013013202 100 Each $23,912.00 $23,912.00

3142 ACETAZOLAMIDE 125 MG PO TABS 51672402201 100 Each $2,347.20 $2,347.20

3146 METHADONE 10 MG/ML IJ SOLN J1230 99999900655 2 mL $578.56 $578.56

3146 METHADONE 10 MG/ML IJ SOLN J1230 67457021720 20 mL $5,786.24 $5,786.24

3186 LIOTHYRONINE 10 MCG/ML IV SOLN 39822015101 1 mL $4,011.68 $4,011.68

3190 CHLOROPROCAINE 20 MG/ML (2 %) IJ SOLN J2400 63323047637 30 mL $259.20 $259.20

3210 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS 53489014501 100 Each $336.00 $336.00

3235 AMPICILLIN 500 MG PO CAPS 00781214501 100 Each $564.80 $564.80



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



3250 DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN Q9963 00270044540 120 mL $153.00 $153.00

3250 DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN Q9963 00270044535 30 mL $3,898.05 $3,898.05

3304 POTASSIUM ACETATE 2 MEQ/ML IV SOLN 00409818301 20 mL $153.00 $153.00

3321 SODIUM ACETATE 2 MEQ/ML IV SOLN 00409729973 20 mL $153.00 $153.00

3345 VALACYCLOVIR 1 GRAM PO TABS 59746032530 30 Each $520.80 $520.80

3347 RITONAVIR 80 MG/ML PO SOLN 00074194063 240 mL $21,477.12 $21,477.12

3372 ONABOTULINUMTOXINA 100 UNITS IJ SOLR J0585 00023114501 1 Each $6,010.00 $9,616.00

3378 AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML PO SUSR 00781613957 75 mL $336.00 $336.00

3404 CLARITHROMYCIN 500 MG PO TABS 65862022660 60 Each $745.92 $745.92

3435 AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5 ML PO SUSR 60432006575 75 mL $777.60 $777.60

3443 ETHACRYNATE SODIUM 50 MG IV SOLR 25010021027 1 Each $12,900.32 $12,900.32

3445 UREA 20 % TP CREA 58980061030 85 gram $153.00 $153.00

3449 MICROFIBRIL. COLLAGEN HEMOSTAT TP POWD 53276101002 1 gram $2,089.39 $2,089.39

3466 TOLTERODINE 4 MG PO CP24 00009519103 500 Each $45,888.00 $45,888.00

3470 CEPHALEXIN 250 MG PO CAPS 00093314501 100 Each $196.80 $196.80

3475 CHLORAMBUCIL 2 MG PO TABS 76388063550 50 Each $17,960.00 $17,960.00

3493 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS 00406012362 100 Each $534.40 $534.40

3504 SEVELAMER HCL 800 MG PO TABS 58468002101 180 Each $19,863.36 $19,863.36

3509 CHLORPROMAZINE 100 MG PO TABS Q0161 51079051620 100 Each $11,475.20 $11,475.20

3511 RIFAPENTINE 150 MG PO TABS 00088210224 24 Each $1,433.09 $1,433.09

3566 MELPHALAN 2 MG PO TABS J8600 52609000105 50 Each $8,441.60 $8,441.60

3571 MYCOPHENOLATE MOFETIL 250 MG PO CAPS J7517 00004025943 500 Each $3,384.00 $3,384.00

3593 DAUNORUBICIN 5 MG/ML IV SOLN J9150 00703523313 4 mL $1,307.20 $1,307.20

3596 DEFEROXAMINE 500 MG IJ SOLR J0895 00409233610 1 Each $153.00 $153.00

3598 IMIPENEM-CILASTATIN 500 MG IV SOLR J0743 00409350701 1 Each $153.00 $153.00


3600 FLUCONAZOLE IN NACL (ISO-OSM) 400 MG/200 ML IV PGBK J1450 55390004601 200 mL $153.00 $153.00

3605 HYDROCORTISONE 1 % TP OINT 00168002031 28.35 gram $153.00 $153.00


3629 PENICILLIN G POTASSIUM 5 MILLION UNIT IJ SOLR J2540 00049052083 1 Each $153.00 $153.00

3689 ALUM, AMMONIUM (BULK) MISC POWD 00395004996 170 gram $153.00 $153.00

3697 NALOXONE 0.4 MG/ML IJ SOLN J2310 00409121501 1 mL $153.00 $153.00

3708 BACITRACIN 50000 UNITS IM SOLR 63323032930 1 Each $153.00 $153.00

3723 SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) IV SOLN 60267070550 12.5 gram $1,424.00 $1,424.00

3757 TOLTERODINE 1 MG PO TABS 00093001006 60 Each $1,236.48 $1,236.48

3764 EPINEPHRINE 0.15 MG/0.3 ML IJ ATIN J0171 49502050102 2 Each $8,985.76 $8,985.76

3796 ERGOTAMINE-CAFFEINE 1-100 MG PO TABS 00781540501 100 Each $18,417.60 $18,417.60

3798 PROMETHAZINE 25 MG PR SUPP J8498 00713052612 12 Each $1,744.51 $1,744.51

3821 MAGNESIUM SULFATE 4 MEQ/ML (50 %) IJ SOLN J3475 51754100001 10 mL $153.00 $153.00

3821 MAGNESIUM SULFATE 4 MEQ/ML (50 %) IJ SOLN J3475 63323064250 50 mL $200.80 $200.80

3823 SODIUM BICARBONATE 325 MG PO TABS 00536104610 1000 Each $224.00 $224.00

3850 HYDROCORTISONE 1 % TP LOTN 00394085932 114 gram $153.00 $153.00

3861 ONDANSETRON HCL 8 MG PO TABS S0119 51079052520 100 Each $1,041.60 $1,041.60

3865 ONDANSETRON HCL 2 MG/ML IV SOLN J2405 55390012101 20 mL $153.00 $153.00

3873 METHACHOLINE CHLORIDE 100 MG IN SOLR 64281010006 1 Each $1,118.53 $1,118.53

3881 AMIFOSTINE CRYSTALLINE 500 MG IV SOLR J0207 66220001703 3 Each $47,935.54 $47,935.54

3901 METHADONE 10 MG PO TABS 00054855424 100 Each $521.60 $521.60

3903 ERGOTAMINE-CAFFEINE 2-100 MG PR SUPP 75987009011 12 Each $25,136.64 $25,136.64





3928 MINOCYCLINE 100 MG PO CAPS 65862021150 50 Each $358.40 $358.40

3930 ALDESLEUKIN 22 MILLION UNIT IV SOLR J9015 65483011607 1 Each $39,290.22 $39,290.22

3936 FLUCYTOSINE 250 MG PO CAPS 00187355410 100 Each $44,736.00 $44,736.00

3939 SODIUM CHLORIDE 3 % IN NEBU 00378699789 15 mL $153.00 $153.00



3956 FLUCONAZOLE 200 MG PO TABS 16714069302 100 Each $2,232.00 $2,232.00

4002 ETHANOLAMINE OLEATE 5 % IV SOLN J1430 67871479006 2 mL $6,375.74 $6,375.74




4092 IODIXANOL 320 MG IODINE/ML IV SOLN Q9967 00407222306 50 mL $1,718.50 $1,718.50

4097 RISEDRONATE 5 MG PO TABS 00430047115 30 Each $5,451.84 $5,451.84

4100 ATOVAQUONE-PROGUANIL 250-100 MG PO TABS 00173067502 24 Each $2,457.60 $2,457.60

4129 HALOPERIDOL DECANOATE 100 MG/ML IM SOLN J1631 50458025414 1 mL $2,475.55 $2,475.55

4187 ONDANSETRON HCL 4 MG PO TABS S0119 51079052420 100 Each $736.00 $736.00

4191 LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 IJ SOLN 00409317701 50 mL $153.00 $153.00

4210 HYDROMORPHONE 8 MG PO TABS 00406324901 100 Each $430.40 $430.40

4220 THIOTEPA 15 MG IJ SOLR J9340 00143956501 1 Each $5,809.60 $5,809.60



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



4232 METHYLPHENIDATE HCL 5 MG PO TABS 00406114201 100 Each $558.40 $558.40

4262 DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NA SPRP 69918050105 5 mL $1,468.96 $1,468.96

4271 DEXTROAMPHETAMINE-AMPHETAMINE 10 MG PO TABS 00555097202 100 Each $1,265.60 $1,265.60

4299 CLONAZEPAM 0.5 MG PO TABS 51079088120 100 Each $153.00 $153.00

4315 CEFTRIAXONE 250 MG IJ SOLR J0696 00143985925 1 Each $153.00 $153.00

4317 CIPROFLOXACIN 250 MG/5 ML PO SUMC 50419077701 100 mL $1,945.60 $1,945.60

4327 ESTRADIOL 0.05 MG/24 HR TD PTWK 00378335099 4 Each $999.36 $999.36

4386 CEFTAZIDIME 2 GRAM IJ SOLR J0713 00409508411 1 Each $153.00 $153.00


4402 NITROGLYCERIN 0.3 MG/HR TD PT24 00085331530 30 Each $9,364.80 $9,364.80

4412 TACROLIMUS 5 MG PO CAPS J7507 00469065711 100 Each $19,392.00 $19,392.00


4482 POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP J3480 00409710709 1000 mL $153.00 $153.00

4490 GENTIAN VIOLET 1 % TP SOLN 00395100392 59 mL $153.00 $153.00

4497 DOXYCYCLINE HYCLATE 50 MG PO CAPS 53489011802 50 Each $302.40 $302.40

4503 ENALAPRIL MALEATE 2.5 MG PO TABS 51079095020 100 Each $384.00 $384.00

4507 BERACTANT IN 0.9 %SOD.CHLORIDE 25 MG/ML ITL SUSP 00074104004 4 mL $3,998.40 $3,998.40

4517 FLUOROURACIL 5 % TP CREA 66530024940 40 gram $894.72 $894.72

4533 BENZOYL PEROXIDE 5 % TP GEL 45802021601 90 gram $236.16 $236.16

4533 BENZOYL PEROXIDE 5 % TP GEL 00536105556 42.5 gram $153.00 $153.00

4544 CIPROFLOXACIN IN 5 % DEXTROSE 400 MG/200 ML IV PGBK J0744 00409477702 200 mL $153.00 $153.00

4599 CEFOXITIN 1 GRAM IV SOLR J0694 60505075905 1 Each $153.00 $153.00


4648 ETHACRYNIC ACID 25 MG PO TABS 25010021515 100 Each $13,320.00 $13,320.00

4699 TRIAZOLAM 0.125 MG PO TABS 59762371709 100 Each $4,374.40 $4,374.40

4714 PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2-0.1037 -0.0194 MG/5 ML PO ELIX 99999900145 5 mL $153.00 $153.00

4758 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN J3490 00703950303 5 mL $153.00 $153.00




4810 TERCONAZOLE 0.8 % VA CREA 51672130200 20 gram $368.00 $368.00

4828 LIDOCAINE 4 % TP CREA 00496088230 30 gram $491.52 $491.52

4835 SULFASALAZINE 500 MG PO TBEC 59762010401 100 Each $334.40 $334.40

4842 GOSERELIN 10.8 MG SC IMPL J9202 70720095130 1 Each $17,151.75 $17,151.75

4886 EDROPHONIUM CHLORIDE 10 MG/ML IJ SOLN 67457019015 15 mL $1,193.04 $1,193.04

4888 METRONIDAZOLE 250 MG PO TABS 00904145361 100 Each $483.20 $483.20

4891 MICONAZOLE NITRATE 2 % VA CREA 00713025237 45 gram $153.00 $153.00

4901 NIMODIPINE 30 MG PO CAPS 57664013564 30 Each $633.60 $633.60

4939 CLONAZEPAM 1 MG PO TABS 51079088220 100 Each $153.00 $153.00


5006 NEVIRAPINE 200 MG PO TABS 00597004660 60 Each $153.00 $153.00

5053 DOFETILIDE 250 MCG PO CAPS 00069581060 60 Each $277.44 $277.44

5083 DOXORUBICIN 50 MG IV SOLR J9000 67457043650 1 Each $3,922.72 $3,922.72

5148 PENTAMIDINE 300 MG IJ SOLR J7676 63323011310 1 Each $1,685.23 $1,685.23

5157 ERYTHROMYCIN 500 MG PO TBEC 24338012613 100 Each $9,968.00 $9,968.00

5159 FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN 00065009265 5 mL $694.72 $694.72

5171 PIMECROLIMUS 1 % TP CREA 00187510001 30 gram $2,601.12 $2,601.12

5177 ASCORBIC ACID (VITAMIN C) 500 MG/ML IJ SOLN 67457011850 50 mL $1,352.00 $1,352.00

5192 TRETINOIN (ANTINEOPLASTIC) 10 MG PO CAPS 00555080802 100 Each $36,334.40 $36,334.40

5208 MOXIFLOXACIN 400 MG PO TABS 65862060330 30 Each $1,316.16 $1,316.16

5311 CROMOLYN 20 MG/2 ML IN NEBU J7631 00172640649 2 mL $209.92 $209.92

5312 PANTOPRAZOLE 40 MG IV SOLR C9113 00008092355 40 mg $153.00 $153.00

5318 PERMETHRIN 5 % TP CREA 00472024260 60 gram $317.76 $317.76

5332 ACETAZOLAMIDE 250 MG PO TABS 51672402301 100 Each $2,700.80 $2,700.80

5335 PENICILLIN V POTASSIUM 250 MG/5 ML PO SOLR 00093412774 200 mL $153.00 $153.00

5336 RIFABUTIN 150 MG PO CAPS 00013530117 100 Each $18,784.00 $18,784.00

5368 CLINDAMYCIN HCL 150 MG PO CAPS 63304069201 100 Each $214.40 $214.40

5380 VENLAFAXINE 150 MG PO CP24 00008083603 100 Each $560.00 $560.00

5398 INSULIN NPH AND REGULAR HUMAN 100 UNIT/ML (70-30) SC SUSP J1815 00002871517 3 mL $153.00 $153.00

5406 MONTELUKAST 4 MG PO CHEW 31722072790 90 Each $446.40 $446.40

5443 TEMOZOLOMIDE 100 MG PO CAPS J8700 00093760141 14 Each $7,073.47 $7,073.47

5455 ITRACONAZOLE 10 MG/ML PO SOLN 50458029515 150 mL $5,112.00 $5,112.00

5464 DOFETILIDE 125 MCG PO CAPS 00069580060 60 Each $3,701.76 $3,701.76

5468 TRAVOPROST 0.004 % OP DROP 00065026025 2.5 mL $2,892.96 $2,892.96

5477 NYSTATIN 500000 UNITS PO TABS 53489040001 100 Each $1,566.40 $1,566.40

5489 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN J0153 00469087130 30 mL $696.00 $696.00

5491 LEUCOVORIN CALCIUM 350 MG IJ SOLR J0640 00703514501 1 Each $200.96 $200.96

5493 CARDIOPLEGIC SOLN 16 MEQ/L (= K+) PF SOLN 00409796905 1000 mL $656.00 $656.00

5559 DILTIAZEM HCL 100 MG IV SOLR 00409435003 1 Each $185.07 $185.07

5573 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML PO SYRP 99999900466 5 mL $153.00 $153.00




CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



5612 OXYCODONE 5 MG/5 ML PO SOLN 66689040150 5 mL $153.00 $153.00

5614 METRONIDAZOLE IN NACL (ISO-OS) 500 MG/100 ML IV PGBK 00264553532 100 mL $153.00 $153.00

5620 METHYLERGONOVINE 0.2 MG PO TABS 43386014028 28 Each $22,446.14 $22,446.14

5628 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS 00378041501 100 Each $1,044.80 $1,044.80

5652 VALSARTAN 80 MG PO TABS 60687012801 100 Each $1,504.00 $1,504.00

5668 PARICALCITOL 5 MCG/ML IV SOLN J2501 00074165801 1 mL $153.00 $153.00


5706 ETANERCEPT 25 MG (1 ML) SC SOLR J1438 58406042534 4 Each $41,436.99 $41,436.99

5715 KIT IN-111-CAPROMAB PENDETIDE 0.5 MG/ML IV SOLN A9507 57902081701 3 mL $55,476.18 $55,476.18

5738 MIDAZOLAM 5 MG/ML IJ SOLN J2250 55390012605 5 mL $153.00 $153.00




5770 AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS 00781187431 30 Each $2,123.04 $2,123.04

5780 TETRAHYDROZOLINE 0.05 % OP DROP 00904633435 15 mL $153.00 $153.00

5798 CLOTRIMAZOLE 1 % VA CREA 49348079376 45 gram $153.00 $153.00

5817 CODEINE SULFATE 15 MG PO TABS 00054024324 100 Each $1,048.00 $1,048.00

5888 TOPIRAMATE 25 MG PO TABS 69097012215 1000 Each $512.00 $512.00

5933 DIMERCAPROL 100 MG/ML IM SOLN J0470 17478052603 3 mL $2,230.80 $2,230.80

5934 COSYNTROPIN 0.25 MG IJ SOLR J0834 00548590000 1 Each $1,192.13 $1,192.13

5952 ROCURONIUM 10 MG/ML IV SOLN 00409955849 5 mL $153.00 $153.00

5983 METHYLPHENIDATE HCL 54 MG PO TR24 00591271830 30 Each $1,651.20 $1,651.20

6010 VANCOMYCIN 5 GRAM IV SOLR J3370 00409650949 1 Each $262.72 $262.72

6046 RISPERIDONE 0.25 MG PO TABS 50458030101 100 Each $192.00 $192.00


6070 BIMATOPROST 0.03 % OP DROP 68180042901 2.5 mL $1,606.40 $1,606.40

6070 BIMATOPROST 0.03 % OP DROP 68180042902 5 mL $2,230.40 $2,230.40


6094 DILTIAZEM HCL 360 MG PO CP24 00187079942 90 Each $10,990.08 $10,990.08

6101 SULFACETAMIDE-PREDNISOLONE 10-0.2 % OP DRPS 11980002205 5 mL $2,278.24 $2,278.24

6120 METRONIDAZOLE 500 MG PO TABS 42292000120 100 Each $720.00 $720.00

6128 LIDOCAINE HCL 2 % MM JELL 17478071110 5 mL $153.00 $153.00

6128 LIDOCAINE HCL 2 % MM JELL 17478071130 30 mL $1,139.52 $1,139.52

6143 TROPICAMIDE 1 % OP DROP 17478010212 15 mL $153.00 $153.00

6143 TROPICAMIDE 1 % OP DROP 24208058559 2 mL $153.00 $153.00

6162 AZATHIOPRINE 50 MG PO TABS J7500 51079062006 50 Each $384.00 $384.00

6170 FILGRASTIM 300 MCG IJ SOLN J1442 55513053010 1 mL $4,690.59 $4,690.59

6198 HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN 00264196510 500 mL $272.00 $272.00

6230 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN J0330 00409662902 10 mL $285.92 $285.92

6253 FLUOCINONIDE 0.05 % TP OINT 00093026415 15 gram $844.08 $844.08

6262 ACETAMINOPHEN-CODEINE 300-30 MG PO TABS 00406048462 100 Each $190.40 $190.40

6279 CLOPIDOGREL 75 MG PO TABS 63653117103 100 Each $260.80 $260.80

6329 CIPROFLOXACIN HCL 250 MG PO TABS 16714065102 100 Each $179.20 $179.20

6349 BACLOFEN 500 MCG/ML IT SOLN J0476 58281056001 20 mL $2,960.00 $2,960.00

6389 DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRP 00121063810 10 mL $153.00 $153.00

6389 DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRP 00121063805 5 mL $153.00 $153.00

6431 MINERAL OIL-HYDROPHIL PETROLAT TP OINT 54868587000 396 gram $190.08 $190.08

6431 MINERAL OIL-HYDROPHIL PETROLAT TP OINT 61924018416 454 gram $217.92 $217.92

6446 LEVOFLOXACIN 250 MG PO TABS 65862053650 50 Each $283.20 $283.20

6512 BACITRACIN ZINC 500 UNIT/GRAM TP OINT 49348015472 28.4 gram $153.00 $153.00

6554 CAPECITABINE 500 MG PO TABS J8521 00004110150 120 Each $1,288.32 $1,288.32

6569 EPOPROSTENOL (GLYCINE) 1.5 MG IV SOLR J1325 00173051900 1 Each $902.88 $902.88

6571 ALBUMIN, HUMAN 5 % 5 % IV SOLP P9041 13533069020 50 mL $472.00 $472.00


6571 ALBUMIN, HUMAN 5 % 5 % IV SOLP P9041 68516521402 500 mL $1,200.00 $1,200.00

6574 TRIMETHOPRIM 100 MG PO TABS 00591557101 100 Each $464.00 $464.00

6620 FONDAPARINUX 2.5 MG/0.5 ML SC SYRG J1652 67457058210 .5 mL $153.00 $153.00

6635 STREPTOMYCIN 1 GRAM IM SOLR J3000 39822070602 1 Each $1,118.53 $1,118.53

6661 DIVALPROEX 500 MG PO TBEC 62756079813 500 Each $1,816.00 $1,816.00

6680 GALANTAMINE 4 MG/ML PO SOLN 00054013749 100 mL $2,620.80 $2,620.80

6695 NICARDIPINE 25 MG/10 ML IV SOLN 67286081201 10 mL $233.60 $233.60

6713 ENALAPRILAT 1.25 MG/ML IV SOLN 55390001010 1 mL $153.00 $153.00

6714 VALACYCLOVIR 500 MG PO TABS 63739052510 100 Each $2,176.00 $2,176.00

6725 METHOTREXATE SODIUM 25 MG/ML IJ SOLN J9250 63323012310 10 mL $385.28 $385.28

6740 SULFADIAZINE 500 MG PO TABS 00185075701 100 Each $5,425.60 $5,425.60

6747 CIPROFLOXACIN HCL 500 MG PO TABS 68084007001 100 Each $299.20 $299.20

6776 CEFTRIAXONE 1 GRAM IV SOLR J0696 00409733304 1 Each $153.00 $153.00

6778 MORPHINE 30 MG PO TBSR 00406833062 100 Each $1,761.60 $1,761.60

6785 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS 00904272561 100 Each $230.40 $230.40

6799 HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS 00406012562 100 Each $592.00 $592.00

6824 PROCAINAMIDE 100 MG/ML IJ SOLN J2690 00409190201 10 mL $881.44 $881.44



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



6848 IOHEXOL 300 MG IODINE/ML IV SOLN Q9967 00407141361 50 mL $153.00 $153.00

6862 INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IJ SOLN 00517037505 5 mL $2,132.64 $2,132.64

6869 GRANISETRON HCL 1 MG PO TABS Q0166 00093748520 20 Each $1,062.40 $1,062.40

6891 DIHYDROERGOTAMINE 1 MG/ML IJ SOLN J1110 00574085010 1 mL $987.07 $987.07

6928 PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP Q9957 11994001101 1.5 mL $1,020.60 $1,020.60

6969 VANCOMYCIN 1000 MG IV SOLR J3370 67457034001 1 Each $153.00 $153.00

6983 CYCLOPHOSPHAMIDE 1 GRAM IV SOLR J9070 10019095601 1 Each $5,236.00 $5,236.00

6990 DIGOXIN 250 MCG/ML (0.25 MG/ML) IJ SOLN J1160 00781305995 2 mL $153.00 $153.00


7002 METHOCARBAMOL 100 MG/ML IJ SOLN J2800 00641610325 10 mL $153.00 $153.00

7005 TESTOSTERONE 4 MG/24 HR TD PT24 52544007754 1 Each $306.24 $306.24

7011 DEXAMETHASONE 1 MG/ML PO DROP 00054317644 30 mL $355.20 $355.20

7029 AMANTADINE HCL 100 MG PO CAPS 68084061101 100 Each $2,160.00 $2,160.00

7048 MORPHINE (PF) 1 MG/ML IJ SOLN J2274 00641601910 10 mL $268.32 $268.32

7050 PRAZIQUANTEL 600 MG PO TABS 50419074701 6 Each $7,430.40 $7,430.40

7052 RISPERIDONE 3 MG PO TABS 50458033001 100 Each $233.60 $233.60

7084 COAGULATION FACTOR IX 1,000 (+/-) UNIT IV SOLR J7193 68516360202 1 Each $13,920.00 $13,920.00

7122 TRIAMCINOLONE ACETONIDE 0.1 % TP CREA 00168000415 15 gram $153.00 $153.00

7151 ANTHRALIN 1 % TP CREA 11086003701 50 gram $5,220.00 $5,220.00

7204 MAFENIDE ACETATE 85 MG/G TP CREA 51079062383 453.6 gram $4,644.86 $4,644.86

7208 SINCALIDE 5 MCG IJ SOLR J2805 00270055615 1 Each $1,631.79 $1,631.79

7228 PHYSOSTIGMINE SALICYLATE 1 MG/ML IJ SOLN 17478051002 2 mL $1,167.52 $1,167.52

7236 KETOROLAC 30 MG/ML (1 ML) IJ SOLN J1885 00409379501 1 mL $153.00 $153.00

7266 HYDRALAZINE 20 MG/ML IJ SOLN J0360 67457029101 1 mL $153.00 $153.00

7276 BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG PO TABS 00591336901 100 Each $995.20 $995.20

7291 TRIMETHOBENZAMIDE 100 MG/ML IM SOLN J3250 42023011925 2 mL $528.19 $528.19

7329 TEMAZEPAM 7.5 MG PO CAPS 00406991501 100 Each $5,224.00 $5,224.00

7340 DIAZOXIDE 50 MG/ML PO SUSP 00575620030 30 mL $5,136.48 $5,136.48

7359 ACYCLOVIR 800 MG PO TABS 31722077805 500 Each $1,216.00 $1,216.00

7392 FERRIC SUBSULFATE 259 MG/G TP SOLN 59365606500 8 gram $215.94 $215.94


7427 LIDOCAINE-PRILOCAINE 2.5-2.5 % TP CREA 50383066730 30 gram $369.60 $369.60



7429 THYROTROPIN ALFA 1.1 MG (0.9 MG/ ML FINAL CONC.) IM SOLR J3240 58468003002 1 Each $30,429.00 $30,429.00

7571 SELENIUM 200 MCG PO TABS 74312003201 100 Each $153.00 $153.00

7583 MORPHINE 25 MG/ML IV SOLN J2270 00409113502 10 mL $153.00 $153.00

7587 AZATHIOPRINE SODIUM 100 MG IJ SOLR J7501 00143956601 1 Each $3,288.48 $3,288.48

7594 LAMOTRIGINE 25 MG PO TABS 00173063302 100 Each $19,422.40 $19,422.40

7633 ROPIVACAINE (PF) 2 MG/ML (0.2 %) IJ SOLN J2795 63323028564 200 mL $720.00 $720.00


7669 OXYCODONE 15 MG PO TABS 00406851501 100 Each $737.60 $737.60

7682 PARICALCITOL 2 MCG/ML IV SOLN J2501 00074463701 1 mL $153.00 $153.00

7705 ACYCLOVIR SODIUM 500 MG IV SOLR J0133 55390061210 1 Each $153.00 $153.00

7713 ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR J1364 00409648201 1 Each $1,139.25 $1,139.25

7725 POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML IJ SUSP 90713 49281086010 5 mL $4,987.68 $4,987.68

7734 HYDROCORTISONE ACETATE 25 MG PR SUPP 00574709012 12 Each $2,065.34 $2,065.34

7734 HYDROCORTISONE ACETATE 25 MG PR SUPP 00713050324 24 Each $3,910.27 $3,910.27

7743 POTASSIUM CHLORIDE 20 MEQ/15 ML PO LIQD 00121146515 15 mL $194.40 $194.40

7743 POTASSIUM CHLORIDE 20 MEQ/15 ML PO LIQD 66689004850 30 mL $292.80 $292.80

7769 NITROFURANTOIN 25 MG/5 ML PO SUSP 99999900327 20 mL $2,121.60 $2,121.60

7804 IFOSFAMIDE 1 GRAM IV SOLR J9208 63323014210 1 Each $383.68 $383.68

7823 DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP DROP 24208072002 5 mL $759.20 $759.20

7826 PANTOPRAZOLE 20 MG PO TBEC 00093001198 90 Each $153.00 $153.00

7852 PHENOXYBENZAMINE 10 MG PO CAPS 49884003801 100 Each $115,558.40 $115,558.40

7854 SODIUM BICARBONATE 8.4 % IV SOLN 00409662502 50 mL $153.00 $153.00

7854 SODIUM BICARBONATE 8.4 % IV SOLN 00409662525 50 mL $153.00 $153.00

7855 PREDNISOLONE ACETATE 0.12 % OP DRPS 11980017405 5 mL $2,278.24 $2,278.24

7855 PREDNISOLONE ACETATE 0.12 % OP DRPS 11980017410 10 mL $4,556.48 $4,556.48

7861 KETOROLAC 0.5 % OP DROP 17478020919 3 mL $218.06 $218.06

7861 KETOROLAC 0.5 % OP DROP 60505100301 5 mL $478.08 $478.08

7868 BISOPROLOL FUMARATE 5 MG PO TABS 00185077130 1 tablet $153.00 $153.00

7917 CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) IJ SOLN J9100 63323012020 20 mL $222.72 $222.72

7935 MYCOPHENOLATE MOFETIL 500 MG PO TABS J7517 00004026001 100 Each $1,097.60 $1,097.60


8028 CYCLOPENTOLATE 1 % OP DROP 24208073501 2 mL $178.24 $178.24

8068 VECURONIUM BROMIDE 10 MG IV SOLR 41616093140 1 Each $153.00 $153.00

8068 VECURONIUM BROMIDE 10 MG IV SOLR 55390003710 1 Each $153.00 $153.00

8070 PRAMIPEXOLE 0.5 MG PO TABS 00597018561 100 Each $153.00 $153.00

8080 RABIES IMMUNE GLOBULIN (PF) 150 UNITS/ML IM SOLN 90375 13533061810 10 mL $20,979.90 $20,979.90

8090 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TP OINT 51672127201 15 gram $744.24 $744.24



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



8098 ALFENTANIL 500 MCG/ML IJ SOLN J3490 00409226605 5 mL $153.00 $153.00

8114 DRONABINOL 2.5 MG PO CAPS Q0167 00051002121 60 Each $9,769.92 $9,769.92

8117 AMINOCAPROIC ACID 250 MG/ML IV SOLN J3490 00409434673 20 mL $153.00 $153.00

8121 METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP J1040 00009347503 1 mL $211.33 $211.33

8143 LEUPROLIDE 11.25 MG IM KIT J1950 00074228203 1 Each $25,587.99 $25,587.99

8154 DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP 90700 58160081011 .5 mL $296.19 $296.19

8178 PAROXETINE HCL 10 MG/5 ML PO SUSP 99999900345 5 mL $153.00 $153.00

8180 CEFADROXIL 500 MG PO CAPS 57237009650 50 Each $444.00 $444.00

8181 FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV PGBK J1450 00409468823 100 mL $153.00 $153.00

8191 METHYLPREDNISOLONE 2 MG PO TABS J7509 00009002001 100 Each $2,411.20 $2,411.20

8203 CARMUSTINE 100 MG IV SOLR J9050 00015301260 1 Each $12,623.58 $12,623.58


8235 POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML IV PGBK J3480 00409707514 50 mL $153.00 $153.00

8244 TRIFLURIDINE 1 % OP DROP 61570003775 7.5 mL $2,648.04 $2,648.04

8250 NITROGLYCERIN IN D5W 50 MG/250 ML (0.2 MG/ML) IV SOLN 00409148202 250 mL $160.00 $160.00

8321 TACROLIMUS 5 MG/ML IV SOLN J7525 00469301601 1 mL $1,240.27 $1,240.27

8352 CAFFEINE-SODIUM BENZOATE 250 MG/ML (125 MG/ML CAFFEINE) IJ SOLN 00517250210 2 mL $291.49 $291.49

8360 FOLIC ACID 5 MG/ML IJ SOLN J3490 63323018410 10 mL $340.00 $340.00

8366 MELPHALAN HCL 50 MG IV SOLR J9245 52609300100 1 Each $24,504.48 $24,504.48

8387 METHYLERGONOVINE 0.2 MG/ML (1 ML) IJ SOLN J2210 00517074020 1 mL $262.96 $262.96

8449 BETAMETHASONE ACET,SOD PHOS 6 MG/ML IJ SUSP J0702 00085056605 5 mL $506.40 $506.40

8495 BENZOCAINE 20 % TP AERO 63736037882 57 gram $424.99 $424.99

8500 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS 00406051262 100 Each $331.20 $331.20

8529 HYDROCORTISONE 2.5 % TP CRPE 65649040130 30 gram $1,044.00 $1,044.00

8531 DIBUCAINE 1 % TP OINT 54162001101 28 gram $153.00 $153.00

8575 LIDOCAINE-EPINEPHRINE 1 %-1:100,000 IJ SOLN 00409317801 20 mL $153.00 $153.00




8631 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN J2515 76478050120 20 mL $12,267.84 $12,267.84

8631 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN J2515 76478050150 50 mL $12,574.80 $12,574.80

8632 CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML IV SOLN J0850 44206053211 50 mL $12,384.00 $12,384.00

8639 TERBINAFINE HCL 250 MG PO TABS 00078017915 30 Each $153.00 $153.00

8654 ALPRAZOLAM 0.5 MG PO TABS 00904585961 100 Each $153.00 $153.00

8668 DEXTRAN 40 10 % IN 0.9 % NACL 10 % IV SOLP J7100 00409741903 500 mL $360.00 $360.00

8669 RIFAMPIN 300 MG PO CAPS 51079089020 100 Each $1,552.00 $1,552.00

8672 RIBAVIRIN 6 GRAM IN SOLR 00187000714 4 Each $249,984.00 $249,984.00

8702 FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN 63323028110 10 mL $1,341.44 $1,341.44

8725 ENTACAPONE 200 MG PO TABS 00078032705 100 Each $11,500.80 $11,500.80

8740 CEFTRIAXONE 1 GRAM IJ SOLR J0696 63323034610 1 Each $153.00 $153.00

8740 CEFTRIAXONE 1 GRAM IJ SOLR J0696 00781320895 1 Each $153.00 $153.00

8767 FENOLDOPAM 10 MG/ML IV SOLN 00409230402 2 mL $9,450.40 $9,450.40

8791 THIAMINE HCL (VITAMIN B1) 100 MG/ML IJ SOLN J3411 63323001302 2 mL $153.00 $153.00

8824 SODIUM CHLORIDE 5 % OP OINT 17478062235 3.5 gram $238.00 $238.00

8857 SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SC SOLN J3030 00781317414 .5 mL $153.00 $153.00

8862 PROGESTERONE 50 MG/ML IM OIL J2675 00591312879 10 mL $462.40 $462.40

8908 STREPTOZOCIN 1 GRAM IV SOLR J9320 00703463601 1000 mg $4,960.00 $4,960.00


8929 ALPRAZOLAM 0.25 MG PO TABS 67253090010 100 Each $153.00 $153.00

8932 TRIPTORELIN PAMOATE 3.75 MG IM SUSR 00023590204 1 Each $9,702.56 $9,702.56

8944 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML PO SOLR 00009076004 100 mL $454.40 $454.40

8953 AMOBARBITAL 500 MG IJ SOLR J0300 00187430305 1 Each $10,932.48 $10,932.48

8991 ALTEPLASE 100 MG IV SOLR J2997 50242008527 1 Each $73,825.38 $73,825.38

8998 ZIPRASIDONE HCL 20 MG PO CAPS 68180033107 60 Each $1,193.28 $1,193.28

9050 DOBUTAMINE IN D5W 500 MG/250 ML (2,000 MCG/ML) IV SOLP J1250 00409234732 250 mL $156.00 $156.00

9067 ESMOLOL 100 MG/10 ML (10 MG/ML) IV SOLN 67457018210 10 mL $153.00 $153.00

9085 ESTRADIOL 0.025 MG/24 HR TD PTWK 00378334999 4 Each $1,001.92 $1,001.92

9087 PRAVASTATIN 80 MG PO TABS 60505132309 90 Each $381.60 $381.60

9114 TOLTERODINE 2 MG PO TABS 00009454402 60 Each $6,575.04 $6,575.04


9137 PREDNISOLONE ACETATE 1 % OP DRPS 11980018001 1 mL $153.00 $153.00

9137 PREDNISOLONE ACETATE 1 % OP DRPS 61314063705 5 mL $545.76 $545.76

9146 DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN J1200 00641037625 50 mg $153.00 $153.00

9179 SUFENTANIL CITRATE 50 MCG/ML IV SOLN 17478005002 2 mL $153.00 $153.00

9179 SUFENTANIL CITRATE 50 MCG/ML IV SOLN 00409338049 1 mL $153.00 $153.00

9202 SIROLIMUS 1 MG/ML PO SOLN J7520 00008103006 60 mL $26,949.12 $26,949.12

9231 ONDANSETRON HCL 4 MG/5 ML PO SOLN 68094076362 5 mL $190.40 $190.40

9231 ONDANSETRON HCL 4 MG/5 ML PO SOLN 99999999996 5 mL $153.00 $153.00

9245 LORAZEPAM 0.5 MG PO TABS 63739049910 100 Each $153.00 $153.00





CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price




9301 CALCIUM CHLORIDE 100 MG/ML (10 %) IV SOLN 00517271025 10 mL $153.00 $153.00

9325 TEMAZEPAM 15 MG PO CAPS 51079041820 100 Each $153.00 $153.00

9336 SODIUM NITRITE 30 MG/ML IV SOLN 60267031110 10 mL $1,424.00 $1,424.00

9347 TOPOTECAN 4 MG IV SOLR J9351 16729015131 1 Each $644.64 $644.64

9354 TRIAMCINOLONE ACETONIDE 0.1 % DT PSTE 51672126705 5 gram $556.80 $556.80

9359 CEFAZOLIN IN DEXTROSE (ISO-OS) 1 GRAM/50 ML IV PGBK J0690 00264310311 1 Each $153.00 $153.00

9360 ETOMIDATE 2 MG/ML IV SOLN 55390076210 10 mL $153.00 $153.00





9418 MORPHINE 20 MG/5 ML (4 MG/ML) PO SOLN 00054023849 100 mL $193.60 $193.60

9418 MORPHINE 20 MG/5 ML (4 MG/ML) PO SOLN 00054023863 500 mL $520.00 $520.00


9469 PROMETHAZINE 12.5 MG PR SUPP J8498 00713053612 12 Each $1,744.51 $1,744.51

9484 EXEMESTANE 25 MG PO TABS 00009766304 30 Each $788.64 $788.64

9499 FAMCICLOVIR 500 MG PO TABS 00093811956 30 Each $494.40 $494.40

9503 LEVOTHYROXINE 200 MCG IV SOLR 63323064710 1 Each $2,432.96 $2,432.96


9526 LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV SOLN J7504 00009722402 5 mL $18,297.90 $18,297.90

9541 SIROLIMUS 1 MG PO TABS J7520 00008104110 100 Each $47,160.00 $47,160.00

9547 MORPHINE 10 MG/ML IJ SOLN J2270 63323045101 1 mL $153.00 $153.00

9554 HYDROMORPHONE 2 MG/ML IJ SOLN J1170 00641012125 1 mL $153.00 $153.00

9573 DACARBAZINE 200 MG IV SOLR J9130 63323012820 1 Each $153.00 $153.00

9573 DACARBAZINE 200 MG IV SOLR J9130 00703507501 1 Each $244.80 $244.80

9583 METHOTREXATE SODIUM 2.5 MG PO TABS J8610 00054855025 100 Each $3,268.80 $3,268.80

9620 LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN 00054350547 50 mL $438.40 $438.40

9682 HOMATROPINE HBR 5 % OP DROP 54799043105 5 mL $551.20 $551.20

9696 THIOGUANINE 40 MG PO TABS 76388088025 25 Each $9,330.00 $9,330.00


9728 GENTAMICIN 0.3 % OP DROP 61314063305 5 mL $231.20 $231.20

9766 OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS 00406052362 100 Each $2,825.60 $2,825.60

9771 RIFAMPIN 150 MG PO CAPS 00185080101 100 Each $3,867.20 $3,867.20

9784 AMPHOTERICIN B LIPID COMPLEX 5 MG/ML IV SUSP J0287 57665010141 20 mL $1,331.20 $1,331.20

9785 REPAGLINIDE 0.5 MG PO TABS 65862067001 100 Each $462.40 $462.40

9794 TAMSULOSIN 0.4 MG PO CAPS 00597005801 100 Each $640.00 $640.00

9811 LINEZOLID 600 MG PO TABS 00009513503 30 Each $1,545.60 $1,545.60

9866 LEVOTHYROXINE 500 MCG IV SOLR J3490 63323064810 1 Each $5,889.92 $5,889.92

9879 HYDROCORTISONE-ACETIC ACID 1-2 % OT DROP 50383090110 10 mL $2,402.88 $2,402.88

9894 BECLOMETHASONE DIPROP (AQ) 42 MCG (0.042 %) NA SPRY 00173038879 25 gram $2,187.60 $2,187.60

9977 DOXYCYCLINE HYCLATE 100 MG IV SOLR J3490 63323013011 1 Each $300.66 $300.66

9978 AMPICILLIN-SULBACTAM 3 GRAM IJ SOLR J0295 00641611701 1 Each $153.00 $153.00

10013 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN J2680 63323027205 5 mL $2,311.04 $2,311.04


10046 AMOXICILLIN 250 MG/5 ML PO SUSR 00781604155 150 mL $153.00 $153.00

10071 ETOPOSIDE 20 MG/ML IV SOLN J9181 00703565301 5 mL $153.00 $153.00



10079 RISPERIDONE 1 MG/ML PO SOLN 50458059601 30 mL $228.96 $228.96

10098 ESTRADIOL VALERATE 20 MG/ML IM OIL J1380 42023011101 5 mL $2,789.92 $2,789.92

10115 CISPLATIN 1 MG/ML IV SOLN J9060 63323010364 200 mL $518.40 $518.40




10155 CIPROFLOXACIN HCL 0.3 % OP DROP 61314065605 5 mL $153.00 $153.00

10155 CIPROFLOXACIN HCL 0.3 % OP DROP 61314065625 2.5 mL $153.00 $153.00

10156 CALCITONIN (SALMON) 200 UNIT/ACTUATION NA SPRY 60505082306 3.7 mL $235.68 $235.68

10163 TAMOXIFEN 10 MG PO TABS 63739026910 100 Each $585.60 $585.60

10180 GEMCITABINE 200 MG IV SOLR J9201 47335015340 1 Each $153.00 $153.00

10188 FLUCONAZOLE 10 MG/ML PO SUSR 59762502901 35 mL $159.04 $159.04

10222 IMIQUIMOD 5 % TP CRPK 00168043224 24 Each $2,238.72 $2,238.72

10254 BLEOMYCIN 15 UNITS IJ SOLR J9040 00703315401 1 Each $429.12 $429.12



10301 SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) IV SOLN J3490 67457016302 2 mL $1,165.15 $1,165.15

10304 SODIUM BICARBONATE 650 MG PO TABS 64980029410 1000 Each $153.00 $153.00

10308 FOMEPIZOLE 1 G/ML IV SOLN J1451 00781318284 1.5 mL $9,074.88 $9,074.88

10318 LORAZEPAM 2 MG PO TABS 00603424821 100 Each $153.00 $153.00


10346 DIAZEPAM 2 MG PO TABS 51079028420 100 Each $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



10355 PHENYTOIN SODIUM 50 MG/ML IV SOLN J1165 00641255545 5 mL $153.00 $153.00

10355 PHENYTOIN SODIUM 50 MG/ML IV SOLN J1165 00641049325 2 mL $153.00 $153.00

10372 SULFACETAMIDE SODIUM 10 % OP DROP 60758001805 5 mL $212.32 $212.32

10372 SULFACETAMIDE SODIUM 10 % OP DROP 61314070101 15 mL $560.88 $560.88

10387 DILTIAZEM HCL 300 MG PO CP24 00187079842 90 Each $73,919.52 $73,919.52

10417 CLINDAMYCIN IN 5 % DEXTROSE 900 MG/50 ML IV PGBK J3490 00781329009 50 mL $153.00 $153.00

10420 ETHAMBUTOL 400 MG PO TABS 68850001202 100 Each $1,163.20 $1,163.20

10447 DIATRIZOATE MEGLUMINE 30 % UR SOLN Q9958 00270014957 300 mL $16,785.00 $16,785.00

10466 SODIUM ACETATE 4 MEQ/ML IV SOLN J3490 63323003200 100 mL $153.00 $153.00

10471 SODIUM HYALURONATE 10 MG/ML IO SYRG 05047450858 .55 mL $462.44 $462.44

10481 OXACILLIN 2 GRAM IJ SOLR J2700 55150012824 1 Each $153.70 $153.70

10484 ACARBOSE 100 MG PO TABS 00054014225 100 Each $902.40 $902.40

10528 BIVALIRUDIN 250 MG IV SOLR J0583 65293000101 1 Each $1,490.02 $1,490.02

10535 TIMOLOL MALEATE 0.25 % OP DROP 61314022605 5 mL $153.00 $153.00

10574 HOMEOPATHIC PRODUCTS TP OINT 8764710176 100 gram $272.00 $272.00



10578 NALBUPHINE 10 MG/ML IJ SOLN J2300 00409146401 10 mL $449.12 $449.12

10578 NALBUPHINE 10 MG/ML IJ SOLN J2300 00409146301 1 mL $153.00 $153.00

10585 HYDROCORTISONE 1 % TP CREA 00168001516 453.6 gram $870.91 $870.91

10585 HYDROCORTISONE 1 % TP CREA 00573283010 26 gram $153.00 $153.00



10606 BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG PR SUPP 00574704512 12 Each $3,931.39 $3,931.39

10625 IFOSFAMIDE 3 GRAM IV SOLR J9208 10019092616 1 Each $1,267.68 $1,267.68

10670 DOXORUBICIN 2 MG/ML IV SOLN J9000 00703504001 100 mL $2,100.80 $2,100.80

10685 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP J3301 00003029320 5 mL $708.48 $708.48

10714 PHENYLEPHRINE HCL 1 % NA SPRY 00024135202 15 mL $153.00 $153.00

10728 DORNASE ALFA 1 MG/ML IN SOLN J7639 50242010040 2.5 mL $1,713.88 $1,713.88

10745 GRANISETRON HCL 1 MG/ML IV SOLN J1626 00143974501 4 mL $153.00 $153.00

10745 GRANISETRON HCL 1 MG/ML IV SOLN J1626 00143974505 4 mL $153.00 $153.00

10751 MIFEPRISTONE 200 MG PO TABS S0190 64875000101 1 Each $896.00 $896.00

10760 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS 00406012462 100 Each $460.80 $460.80



10790 DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NA SPRY 24208034205 5 mL $1,302.88 $1,302.88

10791 CHORIONIC GONADOTROPIN, HUMAN 10000 UNITS IM SOLR J0725 55566150101 1 Each $4,303.68 $4,303.68

10806 GELATIN ABSORBABLE IL FILM 00009028301 1 Each $3,374.94 $3,374.94

10814 CEPHALEXIN 500 MG PO CAPS 00143989701 100 Each $153.00 $153.00

10851 COCAINE 4 % TP SOLN C9046 00527172874 4 mL $2,661.76 $2,661.76

10876 PANTOPRAZOLE 40 MG PO TBEC 65862056090 90 Each $223.20 $223.20

10877 METHYLPREDNISOLONE SODIUM SUCC 1000 MG IV SOLR J2930 00009069801 1 Each $624.00 $624.00

10885 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OP OINT 00574402439 3.5 gram $223.27 $223.27

10885 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OP OINT 24208091019 1 gram $153.00 $153.00

10891 VENLAFAXINE 37.5 MG PO TABS 00093738001 100 Each $478.40 $478.40

10901 OXYTOCIN 10 UNITS/ML IJ SOLN J2590 63323001201 1 mL $153.00 $153.00

10901 OXYTOCIN 10 UNITS/ML IJ SOLN J2590 63323001210 10 mL $153.00 $153.00

10923 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR J1120 00143950301 1 Each $649.12 $649.12

10938 METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP J1030 00009307303 1 mL $153.00 $153.00

10941 ACYCLOVIR 5 % TP OINT 00378870049 30 gram $4,474.08 $4,474.08

10947 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML IJ SOLN J3420 00517003125 1 mL $153.00 $153.00

10947 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML IJ SOLN J3420 00517003225 10 mL $648.80 $648.80

11009 OSELTAMIVIR 75 MG PO CAPS 00004080085 10 Each $975.36 $975.36

11016 PYRIDOXINE (VITAMIN B6) 100 MG/ML IJ SOLN J3415 63323018001 1 mL $153.00 $153.00

11037 TELMISARTAN 40 MG PO TABS 00591329345 1 Each $153.00 $153.00

11042 FOSCARNET 24 MG/ML IV SOLN J1455 76310002425 250 mL $6,716.00 $6,716.00

11042 FOSCARNET 24 MG/ML IV SOLN J1455 00409386305 500 mL $13,232.00 $13,232.00

11075 FLUCONAZOLE 50 MG PO TABS 68462010130 30 Each $298.08 $298.08

11099 ETHAMBUTOL 100 MG PO TABS 54879000101 100 Each $528.00 $528.00

11112 CEPHALEXIN 250 MG/5 ML PO SUSR 00093417774 200 mL $611.20 $611.20

11112 CEPHALEXIN 250 MG/5 ML PO SUSR 00093417773 100 mL $342.40 $342.40

11121 TETRACAINE HCL (PF) 1 % (10 MG/ML) IJ SOLN J3490 17478004532 2 mL $1,132.54 $1,132.54

11154 CONJUGATED ESTROGENS 0.625 MG/GRAM VA CREA 00046087221 30 gram $5,849.76 $5,849.76

11186 LIDOCAINE HCL 5 MG/ML (0.5 %) IJ SOLN J2001 00409427501 50 mL $153.00 $153.00

11212 LEUPROLIDE (3 MONTH) 22.5 MG IM SYKT J9217 00074334603 1 Each $41,884.02 $41,884.02

11233 GEMCITABINE 1 GRAM IV SOLR J9201 00002750201 1 Each $280.96 $280.96

11241 CROTALIDAE POLYVAL IMMUNE FAB IJ SOLR J0840 50633011012 1 Each $26,827.70 $26,827.70

11281 FACTOR IX CPLX(PCC)NO4,3FACTOR 1,000 (+/-) UNIT IV SOLR J7194 68516320202 1 Each $18,720.00 $18,720.00

11304 NEOMYCIN-POLYMYXIN B-DEXAMETH 3.5MG/ML-10,000 UNIT/ML-0.1 % OP DRPS 24208083060 5 mL $211.84 $211.84

11331 AZTREONAM 2 GRAM IJ SOLR 63323040220 1 Each $806.38 $806.38

11346 TOBRAMYCIN 0.3 % OP DROP 61314064305 5 mL $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



11352 TRIAMCINOLONE ACETONIDE 0.1 % TP OINT 00168000615 15 gram $153.00 $153.00


11352 TRIAMCINOLONE ACETONIDE 0.1 % TP OINT 00168000616 453.6 gram $370.14 $370.14

11354 CISATRACURIUM 2 MG/ML IV SOLN 00074438010 10 mL $153.00 $153.00

11354 CISATRACURIUM 2 MG/ML IV SOLN 00781315095 5 mL $153.00 $153.00

11364 MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR J7517 00004026129 160 mL $16,064.00 $16,064.00

11384 MINOCYCLINE 100 MG IV SOLR J2265 65293001410 1 Each $2,880.00 $2,880.00

11390 NYSTATIN 100000 UNIT/GRAM TP CREA 00168005415 15 gram $153.00 $153.00

11402 DIPYRIDAMOLE 5 MG/ML IV SOLN J1245 00641256941 10 mL $275.20 $275.20

11435 HYDROCORTISONE-PRAMOXINE 1-1 % PR FOAM 00037682210 10 gram $2,096.96 $2,096.96

11462 MITOMYCIN 5 MG IV SOLR J9280 16729011505 1 Each $894.72 $894.72

11479 MITOXANTRONE 2 MG/ML IV CONC J9293 63323013210 10 mL $1,526.56 $1,526.56

11489 CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TP CREA 51672404801 15 gram $251.52 $251.52

11536 ADENOSINE 3 MG/ML IV SOLN J0153 67457085502 2 mL $153.00 $153.00

11546 ISONIAZID 100 MG/ML IJ SOLN 00781305670 10 mL $4,148.32 $4,148.32

11549 DEPACON 500 MG/5 ML (100 MG/ML) IV SOLN 00074156410 5 mL $473.04 $473.04

11576 BOSENTAN 62.5 MG PO TABS 66215010106 60 Each $223,326.72 $223,326.72

11655 CYCLOPENTOLATE 2 % OP DROP 00065039702 2 mL $519.52 $519.52

11677 ATROPINE 0.1 MG/ML IJ SYRG J0461 00409491134 10 mL $153.00 $153.00

11691 MEROPENEM 1 GRAM IV SOLR J2185 00310032130 1 Each $153.00 $153.00

11704 INSULIN REGULAR HUMAN 100 UNITS/ML IJ SOLN J1815 00002821517 3 mL $153.00 $153.00

11716 ALBENDAZOLE 200 MG PO TABS 69097023772 2 Each $5,416.00 $5,416.00

11730 INFLIXIMAB 100 MG IV SOLR J1745 57894003001 1 Each $8,703.84 $9,791.82

11761 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML PO SUSR 24338013402 100 mL $3,646.40 $3,646.40



11789 FLUOROMETHOLONE 0.1 % OP DRPS 60758088005 5 mL $1,059.68 $1,059.68

11807 CEFAZOLIN 500 MG IJ SOLR J0690 63323023610 1 Each $153.00 $153.00

11807 CEFAZOLIN 500 MG IJ SOLR J0690 00781345095 1 Each $153.00 $153.00

11814 FENTANYL CITRATE (PF)-0.9%NACL 10 MCG/ML IV SOLN 66647217133 250 mL $824.00 $824.00

11847 CLONAZEPAM 2 MG PO TABS 51079088320 100 Each $153.00 $153.00

11888 CHLOROPROCAINE (PF) 30 MG/ML (3 %) IJ SOLN J2400 63323047827 20 mL $313.92 $313.92

11900 POVIDONE-IODINE 5 % OP SOLN 00065041130 30 mL $153.00 $153.00

11907 ISOSULFAN BLUE 1 % SC SOLN Q9968 63261025021 5 mL $14,207.20 $14,207.20

11938 POLYMYXIN B SULF-TRIMETHOPRIM 10,000 UNIT- 1 MG/ML OP DROP 24208031510 10 mL $153.00 $153.00

11983 CARBACHOL 0.01 % IO SOLN 00065002315 1.5 mL $190.30 $190.30

11987 DIGOXIN 100 MCG/ML (0.1 MG/ML) IJ SOLN J1160 24987026210 1 mL $1,959.68 $1,959.68


12002 CABERGOLINE 0.5 MG PO TABS 49884067314 8 Each $372.74 $372.74

12009 METHYLPHENIDATE HCL 20 MG PO TBSR 00406147301 100 Each $4,568.00 $4,568.00

12015 TRACE ELEMENTS CR-CU-MN-SE-ZN 4-400-100-20 -1000 MCG/ML IV SOLN 00517851025 10 mL $192.00 $192.00

12053 AMPICILLIN SODIUM 500 MG IJ SOLR J0290 63323038810 1 Each $153.00 $153.00

12060 IDARUBICIN 1 MG/ML IV SOLN J9211 00013257691 5 mL $688.64 $688.64

12060 IDARUBICIN 1 MG/ML IV SOLN J9211 00013258691 10 mL $1,376.96 $1,376.96

12061 METHOTREXATE SODIUM (PF) 1 GRAM IJ SOLR J9260 63323012250 1 Each $939.04 $939.04

12070 DEXMEDETOMIDINE 100 MCG/ML IV SOLN J3490 00409163802 200 mcg $608.00 $608.00

12070 DEXMEDETOMIDINE 100 MCG/ML IV SOLN J3490 44567060004 4 mL $298.11 $298.11

12078 MESNA 100 MG/ML IV SOLN J9209 25021020111 10 mL $219.20 $219.20

12100 IRON SUCROSE 100 MG IRON/5 ML IV SOLN J1756 00517234010 5 mL $307.60 $492.16

12138 FLUTICASONE PROPIONATE 44 MCG/ACTUATION IN HFAA 00173071820 10.6 gram $1,297.53 $1,297.53


12174 CAPREOMYCIN 1 GRAM IJ SOLR 17478008050 1 Each $3,211.04 $3,211.04

12195 URSODIOL 250 MG PO TABS 58914078510 100 Each $992.00 $992.00

12200 HYDROCORTISONE 100 MG/60 ML PR ENEM 00574202007 60 mL $316.80 $316.80

12206 LOSARTAN 25 MG PO TABS 65862020190 90 Each $153.00 $153.00

12239 BRIMONIDINE 0.2 % OP DROP 61314014305 5 mL $223.68 $223.68

12255 DIGOXIN IMMUNE FAB 40 MG IV SOLR J1162 50633012011 1 Each $32,053.95 $32,053.95

12268 EDETATE CALCIUM DISODIUM 200 MG/ML IJ SOLN J0600 99207024005 5 mL $86,167.20 $86,167.20

12273 DIVALPROEX 125 MG PO TBEC 62756079688 100 Each $153.00 $153.00

12275 OXYCODONE 5 MG PO CAPS 68462020401 100 Each $2,206.40 $2,206.40

12301 EPINEPHRINE 0.1 MG/ML IJ SYRG J0171 00409492134 10 mL $153.00 $153.00

12325 VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN 55390000710 5 mL $153.00 $153.00

12352 POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLP J3480 00338081104 1000 mL $153.00 $153.00

12446 INTERFERON ALFA-2B 10 MILLION UNIT/ML IJ SOLN J9214 00085113301 3.2 mL $14,749.59 $14,749.59

12458 TOBRAMYCIN SULFATE 1.2 GRAM IJ SOLR J3260 39822041206 1 Each $2,485.60 $2,485.60


12484 INSULIN NPH ISOPH U-100 HUMAN 100 UNITS/ML SC SUSP J1815 00002831517 3 mL $153.00 $153.00

12503 CAPECITABINE 150 MG PO TABS J8520 00004110020 60 Each $12,131.52 $12,131.52

12523 CLOTRIMAZOLE 1 % TP SOLN 51672203701 10 mL $456.80 $456.80

12542 CASPOFUNGIN 70 MG IV SOLR J0637 00006382310 1 Each $5,232.96 $5,232.96

12578 CHLORPROMAZINE 25 MG/ML IJ SOLN J3230 00641139735 1 mL $347.92 $347.92



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



12578 CHLORPROMAZINE 25 MG/ML IJ SOLN J3230 00641139835 2 mL $398.66 $398.66

12586 MECHLORETHAMINE 10 MG IJ SOLR J9230 55292091151 4 Each $19,821.44 $19,821.44

12639 SALMETEROL 50 MCG/DOSE IN DSDV 00173052000 28 Each $1,739.58 $1,739.58

12639 SALMETEROL 50 MCG/DOSE IN DSDV 00173052100 60 Each $2,946.72 $2,946.72

12678 POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLP J3480 00409711509 1000 mL $153.00 $153.00

12686 OLANZAPINE 10 MG PO TBDL 00002445485 30 Each $562.08 $562.08

12694 DINOPROSTONE 10 MG VA INSR 55566280001 1 Each $6,123.36 $6,123.36

12729 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TP CREA 00168008115 15 gram $283.20 $283.20

12729 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TP CREA 00168008130 30 gram $436.80 $436.80

12768 PRALIDOXIME 1 GRAM IJ SOLR J2730 60977014101 6 Each $7,758.05 $7,758.05

12801 ZIDOVUDINE 300 MG PO TABS 65862002460 60 Each $352.32 $352.32

12824 NITROGLYCERIN 400 MCG/SPRAY TL SPRY 45802021002 12 gram $3,146.11 $3,146.11

12824 NITROGLYCERIN 400 MCG/SPRAY TL SPRY 45802021001 4.9 gram $1,465.45 $1,465.45

12831 AMPICILLIN-SULBACTAM 1.5 GRAM IJ SOLR J0295 25021014220 1 Each $153.00 $153.00


12863 CLADRIBINE 10 MG/10 ML IV SOLN J9065 63323014010 10 mL $3,154.72 $3,154.72

12876 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN J3010 00409909335 5 mL $153.00 $153.00







13030 CEFDINIR 125 MG/5 ML PO SUSR 16714039201 60 mL $384.96 $384.96


13136 AMPICILLIN SODIUM 2 GRAM IJ SOLR J0290 67457035210 1 Each $153.00 $153.00


13150 CLARITHROMYCIN 250 MG/5 ML PO SUSR 00781602352 50 mL $1,018.40 $1,018.40

13178 POTASSIUM CHLORIDE-D5-0.2%NACL 20 MEQ/L IV SOLP J3480 00409790109 1000 mL $153.00 $153.00

13181 MUPIROCIN CALCIUM 2 % TP CREA 00029152722 15 gram $2,272.80 $2,272.80

13181 MUPIROCIN CALCIUM 2 % TP CREA 00029152725 30 gram $3,652.80 $3,652.80

13189 LEUPROLIDE (4 MONTH) 30 MG IM SYKT J9217 00074368303 1 Each $55,845.45 $55,845.45

13207 MILRINONE 1 MG/ML IV SOLN J2260 00143971010 10 mL $153.00 $153.00



13209 RILUZOLE 50 MG PO TABS 60505328506 60 Each $2,362.56 $2,362.56

13212 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP 99999900380 20 mL $153.00 $153.00

13212 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP 99999900393 10 mL $153.00 $153.00

13213 CALCITRIOL 1 MCG/ML IV SOLN J0636 17478093101 1 mL $153.00 $153.00

13235 ACETIC ACID 0.25 % IR SOLN 00409614309 1000 mL $153.00 $153.00

13240 AMPHOTERICIN B 50 MG IJ SOLR J0285 39822105505 1 Each $565.92 $565.92

13248 MORPHINE 10 MG/5 ML PO SOLN 00054023749 100 mL $153.00 $153.00



13271 ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) IO KIT 24208053920 1 Each $973.44 $973.44

13276 KETAMINE 10 MG/ML IJ SOLN J3490 42023011310 20 mL $295.04 $295.04

13290 VINCRISTINE 1 MG/ML IV SOLN J9370 61703030906 1 mL $153.00 $153.00

13324 OXYBUTYNIN CHLORIDE 5 MG PO TR24 51079072220 100 Each $1,102.40 $1,102.40

13327 DIAZEPAM 5 MG/ML PO CONC 00054318544 30 mL $448.32 $448.32


13351 MERCAPTOPURINE 50 MG PO TABS 00054458111 25 Each $590.80 $590.80

13404 MOMETASONE 50 MCG/ACTUATION NA SPRY 00085128801 17 gram $700.26 $700.26

13421 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR J1205 63323065820 1 Each $633.76 $633.76

13423 SELENIUM 40 MCG/ML IV SOLN 00517651025 10 mL $264.00 $264.00

13426 BUDESONIDE 0.25 MG IN NBSP J7626 00186198804 2 mL $153.00 $153.00

13443 CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) IV SOLN J0706 55150018703 3 mL $153.00 $153.00

13446 TOBRAMYCIN 0.3 % OP OINT 00065064435 3.5 gram $3,180.97 $3,180.97

13466 LIDOCAINE HCL 2 % MM SOLN 50383077517 15 mL $153.00 $153.00

13568 ZINC CHLORIDE 1 MG/ML IV SOLN 00409409001 10 mL $199.84 $199.84

13582 BUDESONIDE 0.5 MG IN NBSP J7626 00186198904 2 mL $153.00 $153.00

13621 GENTAMICIN 0.1 % TP CREA 45802005635 15 gram $589.20 $589.20

13631 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP DROP 00065035902 2 mL $415.04 $415.04

13631 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP DROP 00065035905 5 mL $728.80 $728.80

13633 CORTICORELIN OVINE TRIFLUTATE 100 MCG IV SOLR J0795 55566030201 1 Each $13,609.60 $13,609.60

13642 BACLOFEN 2000 MCG/ML IT SOLN J0476 58281056302 40 mL $13,320.00 $13,320.00

13700 VANCOMYCIN 500 MG IV SOLR J3370 00409433201 500 mg $153.00 $153.00

13701 CHLORDIAZEPOXIDE-CLIDINIUM 5-2.5 MG PO CAPS 00187410010 100 Each $68,340.80 $68,340.80

13709 TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN J3260 63323030602 80 mg $153.00 $153.00



13741 RALOXIFENE 60 MG PO TABS 60687026621 30 Each $753.60 $753.60



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price




13816 STRONTIUM-89 CHLORIDE 1 MCI/ML IV SOLN A9600 17156052401 4 mL $75,841.35 $75,841.35

13819 BENZTROPINE 1 MG/ML IJ SOLN J0515 17478001202 2 mL $684.16 $684.16

13830 HALOPERIDOL DECANOATE 50 MG/ML IM SOLN J1631 10147092103 1 mL $293.28 $293.28

13830 HALOPERIDOL DECANOATE 50 MG/ML IM SOLN J1631 50458025303 1 mL $1,298.56 $1,298.56

13899 BUSULFAN 60 MG/10 ML IV SOLN J0594 59148007091 10 mL $749.70 $749.70

13932 VERAPAMIL 2.5 MG/ML IV SOLN 00409114401 2 mL $153.00 $153.00




14038 FLUORESCEIN-PROPARACAINE 0.25-0.5 % OP DROP 54799050721 5 mL $549.60 $549.60

14053 PRAMOXINE-CALAMINE 1-8 % TP LOTN 49348033736 177 mL $153.00 $153.00

14083 PYRIDOSTIGMINE BROMIDE 180 MG PO TBSR 00187301330 30 Each $6,632.64 $6,632.64

14113 LEUCOVORIN CALCIUM 5 MG PO TABS 00054449625 100 Each $880.00 $880.00

14144 CIPROFLOXACIN HCL 0.3 % OP OINT 00065065435 3.5 gram $3,180.97 $3,180.97

14172 HYDROCORTISONE 2.5 % TP CREA 00168008031 30 gram $153.00 $153.00

14172 HYDROCORTISONE 2.5 % TP CREA 00168008016 453.6 gram $892.69 $892.69

14183 AMOXICILLIN 250 MG PO CAPS 16714029801 100 Each $153.00 $153.00

14186 ENOXAPARIN 150 MG/ML SC SYRG J1650 00703851023 1 mL $261.98 $261.98


14195 CIDOFOVIR 75 MG/ML IV SOLN J0740 23155021631 5 mL $7,956.48 $7,956.48

14243 MONTELUKAST 10 MG PO TABS 31722072690 90 Each $197.28 $197.28

14266 CLINDAMYCIN PHOSPHATE 2 % VA CREA 59762500901 40 gram $1,296.00 $1,296.00

14281 MORPHINE 15 MG PO TBSR 00406831562 100 Each $848.00 $848.00

14309 CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN J7502 00078027422 50 mL $7,317.60 $7,317.60

14315 CODEINE-GUAIFENESIN 10-100 MG/5 ML PO LIQD 00121177505 5 mL $153.00 $153.00

14315 CODEINE-GUAIFENESIN 10-100 MG/5 ML PO LIQD 00121177510 10 mL $153.00 $153.00

14338 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN J1630 63323047401 1 mL $153.00 $153.00

14341 COAL TAR 1 % TP SHAM 54162020006 177 mL $153.00 $153.00

14345 EFAVIRENZ 50 MG PO CAPS 00056047030 30 Each $1,219.68 $1,219.68

14355 LAMIVUDINE 10 MG/ML PO SOLN 49702020548 240 mL $1,655.04 $1,655.04

14359 ACETAMINOPHEN-CODEINE 300-60 MG PO TABS 00093035001 100 Each $417.60 $417.60

14381 OXYCODONE-ACETAMINOPHEN 2.5-325 MG PO TABS 00603497821 100 Each $2,036.80 $2,036.80

14447 AMPICILLIN SODIUM 1 GRAM IJ SOLR J0290 00781340495 1 Each $153.00 $153.00

14460 KETAMINE 50 MG/ML IJ SOLN 99999001752 1 mL $153.00 $153.00

14460 KETAMINE 50 MG/ML IJ SOLN 00143950810 10 mL $153.00 $153.00

14524 FLUTICASONE PROPIONATE 220 MCG/ACTUATION IN HFAA 00173072020 12 gram $2,697.98 $2,697.98

14572 LEUCOVORIN CALCIUM 500 MG IJ SOLR 63323071100 1 Each $671.04 $671.04


14595 CLONIDINE 0.3 MG/24 HR TD PTWK 00597003334 4 Each $1,295.04 $1,295.04

14600 PENICILLIN G SODIUM 5 MILLION UNIT IJ SOLR J3490 00781615395 1 Each $584.80 $584.80


14615 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS 61958040101 30 Each $18,694.08 $18,694.08

14633 PYRIDOSTIGMINE BROMIDE 5 MG/ML IJ SOLN 00781304095 2 mL $448.99 $448.99

14642 QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR J2770 61570026010 1 Each $6,618.54 $6,618.54

14701 ACYCLOVIR 200 MG PO CAPS 00904578961 100 Each $174.40 $174.40

14713 MUPIROCIN 2 % TP OINT 00168035222 22 gram $153.00 $153.00

14718 SODIUM NITROPRUSSIDE 25 MG/ML IV SOLN 00409302401 50 mg $352.00 $352.00

14737 PENICILLIN G BENZATHINE 600000 UNITS/ML IM SYRG J0561 60793070010 1 mL $1,482.05 $1,482.05


14785 ZOLPIDEM 5 MG PO TABS 51079072420 100 Each $192.00 $192.00


14805 DACTINOMYCIN 0.5 MG IV SOLR J9120 55292081155 1 Each $13,014.88 $13,014.88


14835 BUMETANIDE 0.25 MG/ML IJ SOLN J3490 55390050010 10 mL $153.00 $153.00





14838 METHYLPREDNISOLONE SODIUM SUCC 500 MG IV SOLR J2930 00009075801 500 mg $336.00 $336.00

14853 DEXRAZOXANE HCL 500 MG IV SOLR J1190 67457020850 1 Each $4,413.92 $4,413.92

14857 ZIPRASIDONE HCL 40 MG PO CAPS 65862070360 60 Each $372.48 $372.48

14862 PHENYLEPHRINE HCL 10 MG/ML IJ SOLN J2370 00641614225 1 mL $153.00 $153.00

14862 PHENYLEPHRINE HCL 10 MG/ML IJ SOLN J2370 76014000410 5 mL $265.76 $265.76

14881 ZINC SULFATE 5 MG/ML IV SOLN 00517810525 5 mL $596.80 $596.80

14934 METHADONE 10 MG/ML PO CONC 9999995600 2 mL $153.00 $153.00

14935 BASILIXIMAB 20 MG IV SOLR J0480 00078033184 1 Each $32,991.39 $32,991.39


15037 GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TP SPGE 00009031508 12 Each $982.80 $982.80

15064 PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN J2560 00641047725 1 mL $749.55 $749.55

15082 LOTEPREDNOL ETABONATE 0.5 % OP DRPS 24208029905 5 mL $3,156.64 $3,156.64



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



15106 CEFUROXIME SODIUM 1.5 GRAM IV SOLR J0697 00143997722 1 Each $153.00 $153.00

15117 LEVOFLOXACIN 25 MG/ML IV SOLN J1956 17478010720 500 mg $240.00 $240.00

15122 BETAXOLOL 0.5 % OP DROP 61314024503 10 mL $1,413.76 $1,413.76


15135 FAMOTIDINE 40 MG/5 ML (8 MG/ML) PO SUSP 68180015001 50 mL $1,380.00 $1,380.00

15140 CYCLOSPORINE MODIFIED 100 MG PO CAPS J7502 00093574265 30 Each $705.60 $705.60

15143 NYSTATIN 100000 UNIT/GRAM TP POWD 00574200815 15 gram $289.20 $289.20


15190 CODEINE SULFATE 30 MG PO TABS 00054024424 100 Each $1,281.60 $1,281.60

15202 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN J1100 63323016505 5 mL $153.00 $153.00


15231 VANCOMYCIN 10 GRAM IV SOLR J3370 63323031461 1 Each $417.76 $417.76

15232 LORAZEPAM 1 MG PO TABS 63739050010 100 Each $153.00 $153.00

15272 AZTREONAM 1 GRAM IJ SOLR 63323040120 1 Each $403.12 $403.12

15284 AZELASTINE 137 MCG (0.1 %) NA SPRA 60505083305 30 mL $153.00 $153.00

15284 AZELASTINE 137 MCG (0.1 %) NA SPRA 42291015330 30 mL $153.00 $153.00

15289 BECAPLERMIN 0.01 % TP GEL 50484081015 15 gram $17,517.36 $17,517.36

15344 BUDESONIDE 3 MG PO CECX 00378715501 100 Each $6,636.80 $6,636.80

15346 INSULIN LISPRO 100 UNITS/ML SC SOLN J1815 00002751001 10 mL $839.68 $839.68

15395 EPINEPHRINE 0.3 MG/0.3 ML IJ ATIN J0171 49502050002 2 Each $8,985.76 $8,985.76

15404 TRIAMCINOLONE ACETONIDE 0.1 % TP LOTN 60432056161 60 mL $258.24 $258.24

15412 PHENYLEPHRINE HCL 2.5 % OP DROP 17478020102 2 mL $455.52 $455.52

15412 PHENYLEPHRINE HCL 2.5 % OP DROP 42702010215 15 mL $1,342.32 $1,342.32



15452 TESTOSTERONE CYPIONATE 200 MG/ML IM OIL J1071 00009041701 1 mL $153.00 $153.00

15455 MANNITOL 20 % 20 % IV SOLP 00409771503 500 mL $153.00 $153.00

15464 HEPARIN (PORCINE) 20000 UNITS/ML IJ SOLN J1644 63323091501 1 mL $153.00 $153.00


15550 CYSTEINE (L-CYSTEINE) 50 MG/ML IV SOLN 00781894095 10 mL $270.40 $270.40

15551 TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP J3301 00003049420 5 mL $180.32 $180.32

15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312001 1 mL $153.00 $153.00

15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312047 .25 mL $153.00 $153.00

15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312055 .5 mL $153.00 $153.00

15570 CALCITRIOL 1 MCG/ML PO SOLN 6330424101 1 mL $153.00 $153.00

15572 PROPOFOL 10 MG/ML IV EMUL J2704 63323026965 100 mL $166.40 $166.40



15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 99999002391 6.25 mL $153.00 $153.00

15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 99999900750 5 mL $153.00 $153.00



15630 CEFUROXIME AXETIL 500 MG PO TABS 64679092202 60 Each $2,054.40 $2,054.40


15665 PACLITAXEL 6 MG/ML IV CONC J9267 61703034222 16.7 mL $369.00 $369.00

15665 PACLITAXEL 6 MG/ML IV CONC J9267 61703034209 5 mL $153.00 $153.00

15665 PACLITAXEL 6 MG/ML IV CONC J9267 00703476601 16.7 mL $368.74 $368.74


15699 OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS 00406052262 100 Each $2,390.40 $2,390.40

15712 ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT IV SOLR J7197 13533060320 1 Each $25,120.00 $25,120.00

15728 SODIUM FERRIC GLUCONAT-SUCROSE 62.5 MG/5 ML IV SOLN J2916 00024279210 5 mL $474.24 $474.24

15743 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR 51991093917 1 Each $153.00 $153.00


15757 AMIODARONE 50 MG/ML IV SOLN J0282 63323061603 3 mL $153.00 $153.00

15757 AMIODARONE 50 MG/ML IV SOLN J0282 67457015309 9 mL $153.00 $153.00

15760 CEFACLOR 250 MG/5 ML PO SUSR 16571007112 150 mL $8,616.00 $8,616.00


15785 LETROZOLE 2.5 MG PO TABS 00078024915 30 Each $153.00 $153.00

15803 ZOLPIDEM 10 MG PO TABS 16714062201 100 Each $153.00 $153.00

15809 DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG PO TB12 63824005632 20 Each $153.00 $153.00

15810 TOPIRAMATE 15 MG PO CPSP 00093733506 60 Each $969.60 $969.60

15813 SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 00378647099 4 Each $731.84 $731.84

15833 SODIUM PHOSPHATE 3 MMOL/ML IV SOLN 00409739172 15 mL $217.20 $217.20

15860 NEOMYCIN 500 MG PO TABS 39822031005 100 Each $2,024.00 $2,024.00

15893 ALBUTEROL SULFATE 90 MCG/ACTUATION IN HFAA J3535 00173068224 8 gram $156.35 $156.35

15893 ALBUTEROL SULFATE 90 MCG/ACTUATION IN HFAA J3535 00173068220 18 gram $156.38 $156.38

15939 ABACAVIR 20 MG/ML PO SOLN 49702022248 240 mL $2,188.80 $2,188.80

15966 MOXIFLOXACIN-SOD.CHLORIDE(ISO) 400 MG/250 ML IV PGBK J2280 67457032325 250 mL $640.00 $640.00



15977 IPRATROPIUM BROMIDE 42 MCG (0.06 %) NA SPRY 24208039915 15 mL $272.16 $272.16



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price




15994 COLCHICINE 0.6 MG PO TABS 66993016502 100 Each $8,064.00 $8,064.00

15996 KETOROLAC 60 MG/2 ML IM SOLN J1885 00409379601 2 mL $153.00 $153.00

16057 BUTORPHANOL TARTRATE 1 MG/ML IJ SOLN J0595 00409162301 1 mL $153.00 $153.00

16060 INDOMETHACIN SODIUM 1 MG IV SOLR 63323065903 1 Each $4,324.80 $4,324.80

16066 MYCOPHENOLATE MOFETIL (HCL) 500 MG IV SOLR 00004029809 1 Each $1,030.61 $1,030.61

16098 IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN J1742 00009379401 10 mL $1,094.24 $1,094.24


16165 OXANDROLONE 2.5 MG PO TABS 54396011111 100 Each $4,144.00 $4,144.00

16221 OXACILLIN 1 GRAM IJ SOLR J2700 25021014610 1 Each $153.00 $153.00

16239 KETOCONAZOLE 2 % TP CREA 00168009930 30 gram $621.60 $621.60


16303 LABETALOL 5 MG/ML IV SOLN 17478042020 20 mL $372.80 $372.80



16308 MORPHINE 15 MG PO TABS 00054023524 100 Each $1,102.40 $1,102.40

16323 ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG IV SOLR J0256 00053720102 1 Each $4,315.70 $6,905.12

16347 EFAVIRENZ 200 MG PO CAPS 00056047492 90 Each $10,186.56 $10,186.56

16366 ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR J7511 58468008001 1 Each $9,100.80 $9,100.80

16371 DICLOXACILLIN 250 MG PO CAPS 00093312301 100 Each $731.20 $731.20

16382 DEXTRAN 40 10 % IN 5% DEXTROSE 10 % IV SOLP J7100 00409741803 500 mL $304.00 $304.00

16419 PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2-0.1037 -0.0194 MG PO TABS 59212042510 100 Each $15,510.40 $15,510.40


16430 AMPHOTERICIN B LIPOSOME 50 MG IV SUSR J0289 00469305130 1 Each $1,294.24 $1,294.24

16455 METHADONE 5 MG PO TABS 00054855324 100 Each $312.00 $312.00

16461 PROPARACAINE 0.5 % OP DROP 17478026312 15 mL $523.44 $523.44


16480 SARGRAMOSTIM 250 MCG IJ SOLR J2820 00024584305 1 Each $4,026.14 $4,026.14

16506 ZIPRASIDONE HCL 60 MG PO CAPS 60505253006 60 Each $1,342.08 $1,342.08


16562 ATROPINE 1 % OP DROP 17478021505 5 mL $765.44 $765.44

16573 ONDANSETRON 4 MG PO TBDL S0119 00781523864 30 Each $153.00 $153.00

16595 CEFDINIR 300 MG PO CAPS 16714039101 30 Each $482.40 $482.40

16601 APRACLONIDINE 1 % OP DPET 00065066010 24 Each $9,874.94 $9,874.94

16609 SODIUM CHLORIDE 0.9 % IN NEBU 00378698601 5 mL $153.00 $153.00

16609 SODIUM CHLORIDE 0.9 % IN NEBU 00487930133 3 mL $153.00 $153.00


16638 OXYCODONE 20 MG/ML PO CONC 99999900408 1 mL $153.00 $153.00




16714 ALBUTEROL SULFATE 5 MG/ML IN NEBU J7611 50383074120 20 mL $720.32 $720.32

16773 CEFOTETAN 2 GRAM IJ SOLR 63323038620 1 Each $272.03 $272.03

16785 BENZOCAINE 20 % MM GEL 54162092629 29 gram $194.88 $194.88

16785 BENZOCAINE 20 % MM GEL 10310028313 11.9 gram $153.00 $153.00

16824 FLUTICASONE PROPIONATE 50 MCG/ACTUATION NA SPSN 60505084703 16 gram $153.00 $153.00

16844 EPOETIN ALFA 10000 UNITS IJ SOLN J0885 59676031002 1 mL $1,345.11 $2,152.18

16869 CLOTRIMAZOLE 1 % TP CREA 51672127506 45 gram $463.68 $463.68

16869 CLOTRIMAZOLE 1 % TP CREA 00904782236 14.17 gram $153.00 $153.00

16884 DIVALPROEX 125 MG PO CDRS 00074611411 100 Each $1,056.00 $1,056.00

16899 CASPOFUNGIN 50 MG IV SOLR J0637 00006382210 1 Each $5,036.48 $5,036.48

16904 SEVELAMER HCL 400 MG PO TABS 58468002001 360 Each $12,384.00 $12,384.00

16919 HEPARIN (PORCINE) 5000 UNITS/ML IJ SOLN J1644 63323026201 1 mL $153.00 $153.00

16931 ANAKINRA 100 MG/0.67 ML SC SYRG 66658023428 .67 mL $2,480.18 $2,480.18

16947 LAMIVUDINE 150 MG PO TABS 60505325106 60 Each $3,355.20 $3,355.20

16948 RITUXIMAB 10 MG/ML IV CONC J9312 50242005121 10 mL $9,395.00 $15,032.00

16948 RITUXIMAB 10 MG/ML IV CONC J9312 50242005306 50 mL $37,580.00 $42,277.50


16971 INDOCYANINE GREEN 25 MG IJ SOLR 17478070102 1 Each $1,699.12 $1,699.12

16978 AZTREONAM IN DEXTROSE(ISO-OSM) 2 GRAM/50 ML IV PGBK 00003224011 50 mL $1,064.00 $1,064.00

16979 ALTEPLASE 2 MG CATH SOLR J2997 99999900374 1 Each $2,282.72 $2,282.72

16979 ALTEPLASE 2 MG CATH SOLR J2997 50242004164 1 Each $2,282.72 $2,282.72

16980 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP DROP 00065008515 15 mL $153.00 $153.00

16996 ITRACONAZOLE 100 MG PO CAPS 10147170003 30 Each $3,320.64 $3,320.64

17023 TACROLIMUS 1 MG PO CAPS J7507 00469061711 100 Each $1,808.00 $1,808.00

17032 DOFETILIDE 500 MCG PO CAPS 00069582043 40 Each $953.60 $953.60

17037 INSULIN LISPRO PROTAMIN-LISPRO 100 UNIT/ML (75-25) SC SUSP J1815 00002751101 10 mL $839.68 $839.68

17041 CORTICOTROPIN 80 UNITS/ML IJ GEL J0800 63004871001 5 mL $358,776.00 $358,776.00

17117 MEDROXYPROGESTERONE 150 MG/ML IM SUSP J1050 00703680101 1 mL $1,216.00 $1,216.00

17144 HYDROXYZINE HCL 50 MG/ML IM SOLN J3410 00517561025 10 mL $2,115.20 $2,115.20

17144 HYDROXYZINE HCL 50 MG/ML IM SOLN J3410 00517560225 2 mL $227.52 $227.52



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



17144 HYDROXYZINE HCL 50 MG/ML IM SOLN J3410 00517560125 1 mL $211.47 $211.47

17168 METRONIDAZOLE 0.75 % TP GEL 00168027545 45 gram $2,038.32 $2,038.32

17181 PAPAVERINE 30 MG/ML IJ SOLN J2440 00517400225 2 mL $448.16 $448.16

17206 CYCLOPHOSPHAMIDE 500 MG IV SOLR J9070 10019095501 1 Each $2,618.08 $2,618.08

17250 BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG PR SUPP 00574704012 12 Each $4,703.81 $4,703.81



17294 LAMOTRIGINE 100 MG PO TABS 00093046301 100 Each $344.00 $344.00

17308 AZITHROMYCIN 600 MG PO TABS 00781149731 30 Each $1,082.40 $1,082.40

17327 ESTRADIOL 0.1 MG/24 HR TD PTWK 00378335299 4 Each $1,006.40 $1,006.40

17342 BLEOMYCIN 30 UNITS IJ SOLR J9040 61703032322 1 Each $603.68 $603.68

17412 IRBESARTAN 300 MG PO TABS 00054025213 30 Each $153.00 $153.00

17435 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN 55390000210 4 mL $153.00 $153.00

17448 NEOMYCIN-POLYMYXIN B GU 40 MG-200,000 UNIT/ML IR SOLN 61570004710 1 mL $153.00 $153.00

17448 NEOMYCIN-POLYMYXIN B GU 40 MG-200,000 UNIT/ML IR SOLN 61570004820 20 mL $1,132.80 $1,132.80

17510 DEXTROAMPHETAMINE-AMPHETAMINE 5 MG PO TABS 13107006801 100 Each $556.80 $556.80

17511 RIVASTIGMINE TARTRATE 3 MG PO CAPS 63739057710 100 Each $4,377.60 $4,377.60

17527 PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML IJ SOLN 90732 00006494300 .5 mL $1,521.76 $1,521.76

17540 ELECTROLYTE-A IV SOLP 00338022104 1000 mL $153.00 $153.00

17566 ETOPOSIDE 50 MG PO CAPS J8560 00378326694 20 Each $22,468.48 $22,468.48

17578 RISPERIDONE 0.5 MG PO TABS 50458030201 100 Each $228.80 $228.80

17580 ROPIVACAINE (PF) 7.5 MG/ML (0.75 %) IJ SOLN J2795 00409930221 20 mL $153.00 $153.00

17582 IPRATROPIUM BROMIDE 0.02 % IN SOLN J7644 00487980125 2.5 mL $153.00 $153.00

17621 GENTAMICIN 0.1 % TP OINT 45802004635 15 gram $523.92 $523.92

17637 FLUTICASONE PROPIONATE 110 MCG/ACTUATION IN HFAA 00173071920 12 gram $1,736.93 $1,736.93

17640 MORPHINE (PF) 0.5 MG/ML IJ SOLN J2274 00409381412 10 mL $153.00 $153.00

17640 MORPHINE (PF) 0.5 MG/ML IJ SOLN J2274 00641602010 10 mL $389.12 $389.12

17675 PREDNISOLONE 5 MG PO TABS J7510 23594050550 50 Each $11,520.00 $11,520.00

17702 BISMUTH SUBGALLATE (BULK) MISC POWD 00406030402 500 gram $1,280.00 $1,280.00

17731 ATOVAQUONE 750 MG/5 ML PO SUSP 00173054700 5 mL $445.04 $445.04

17732 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5 ML PO LIQD 99999900270 5 mL $153.00 $153.00


17782 ZIDOVUDINE 100 MG PO CAPS 65862010701 100 Each $2,259.20 $2,259.20

17819 ZIDOVUDINE 10 MG/ML IV SOLN J3485 49702021326 20 mL $435.20 $435.20

17839 HYDROMORPHONE 1 MG/ML PO LIQD 99999900407 1 mL $153.00 $153.00

17852 DOBUTAMINE IN D5W 1,000 MG/250 ML (4,000 MCG/ML) IV SOLP J1250 00409372432 250 mL $200.00 $200.00

17881 DIAZEPAM 5 MG PO TABS 51079028520 100 Each $153.00 $153.00

17891 SODIUM CHLORIDE 3 % 3 % IV SOLP J7131 00338005403 500 mL $153.00 $153.00

17972 REPAGLINIDE 1 MG PO TABS 68084095425 30 Each $153.00 $153.00

17976 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS 66685100101 100 Each $2,417.60 $2,417.60

18012 TRIPTORELIN PAMOATE 11.25 MG IM SUSR 00023590412 1 Each $16,373.25 $16,373.25

18021 PHENOBARBITAL 32.4 MG PO TABS 63739020110 100 Each $384.00 $384.00

18049 CONJUGATED ESTROGENS 25 MG IJ SOLR J1410 00046074905 1 Each $4,647.68 $4,647.68

18055 ARSENIC TRIOXIDE 1 MG/ML IV SOLN J9017 63459060010 10 mL $1,536.00 $1,536.00


18060 METHADONE 5 MG/5 ML PO SOLN 99999900321 1 mL $153.00 $153.00

18063 DORZOLAMIDE 2 % OP DROP 00006351936 10 mL $171.20 $171.20

18087 SODIUM CHLORIDE 4 MEQ/ML IV SOLP 63323018730 30 mL $153.00 $153.00

18087 SODIUM CHLORIDE 4 MEQ/ML IV SOLP 00409114102 100 mL $153.00 $153.00

18113 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS 00093227434 20 Each $420.80 $420.80

18132 ARGININE HCL (L-ARGININE) 10 % IV SOLP 00009043601 300 mL $571.20 $571.20

18156 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OP OINT 17478023835 3.5 gram $153.00 $153.00

18171 ARTIFICIAL TEARS(HYPROMELLOSE) 0.5 % OP DROP 00998040815 15 mL $385.44 $385.44

18172 PROPRANOLOL 1 MG/ML IV SOLN J1800 63323060401 1 mL $153.00 $153.00

18173 TACROLIMUS 0.5 MG PO CAPS J7507 00469060773 100 Each $1,800.00 $1,800.00

18176 TESTOSTERONE 1 % (50 MG/5 GRAM) TD GLPK 00051845030 5 gram $318.32 $318.32

18188 METOPROLOL TARTRATE 5 MG/5 ML IV SOLN 55390007310 5 mg $153.00 $153.00

18193 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN J3490 00009085608 1 mL $3,830.10 $3,830.10

18193 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN J3490 43598069858 1 mL $3,830.10 $3,830.10

18205 PORFIMER 75 MG IV SOLR J9600 76128015575 1 Each $183,843.00 $183,843.00

18210 LEVOCARNITINE 200 MG/ML IV SOLN J1955 54482014701 5 mL $268.80 $268.80

18211 KETAMINE 100 MG/ML IJ SOLN J3490 42023011510 5 mL $198.88 $198.88

18219 MUPIROCIN CALCIUM 2 % NA OINT 00029152611 1 gram $153.00 $153.00

18231 CLINDAMYCIN PHOSPHATE 1 % TP SOLN 59762372801 30 mL $225.60 $225.60

18245 CLINDAMYCIN IN 5 % DEXTROSE 600 MG/50 ML IV PGBK J3490 00781328909 50 mL $153.00 $153.00

18251 CYCLOPENTOLATE 0.5 % OP DROP 00065039515 15 mL $1,134.48 $1,134.48

18253 BUSULFAN 2 MG PO TABS J8510 76388071325 25 Each $8,644.00 $8,644.00

18259 PHYTONADIONE (VITAMIN K1) 5 MG PO TABS 00187170405 100 Each $43,816.00 $43,816.00

18297 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP DRPS 00065064725 2.5 mL $1,174.88 $1,174.88


18309 OLANZAPINE 5 MG PO TBDL 00002445385 30 Each $339.84 $339.84



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



18313 MODAFINIL 100 MG PO TABS 68084062121 30 Each $4,675.20 $4,675.20

18328 HYDROMORPHONE 3 MG PR SUPP 00574722406 6 Each $869.28 $869.28

18342 VALSARTAN 160 MG PO TABS 00378581477 90 Each $596.16 $596.16

18343 MIDAZOLAM 1 MG/ML IJ SOLN (PF) J2250 00641605701 2 mL $153.00 $153.00

18343 MIDAZOLAM 1 MG/ML IJ SOLN (PF) J2250 00641605901 5 mL $153.00 $153.00

18356 FLUMAZENIL 0.1 MG/ML IV SOLN J3490 00143978410 5 mL $153.00 $153.00

18356 FLUMAZENIL 0.1 MG/ML IV SOLN J3490 63323042405 5 mL $153.00 $153.00

18367 ABACAVIR 300 MG PO TABS 65862007360 60 Each $2,236.80 $2,236.80

18415 NEOMYCIN-POLYMYXIN B-DEXAMETH 3.5 MG/G-10,000 UNIT/G-0.1 % OP OINT 24208079535 3.5 gram $236.94 $236.94

18425 CALCITONIN (SALMON) 200 UNITS/ML IJ SOLN J0630 67457067502 2 mL $24,149.70 $24,149.70

18429 NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OT DRPS 24208063562 10 mL $1,133.44 $1,133.44


18438 PEGFILGRASTIM 6 MG/0.6 ML SC SYRG J2505 55513019001 .6 mL $37,750.05 $37,750.05

18442 CLINDAMYCIN PHOSPHATE 1 % TP LOTN 00168020360 60 mL $1,721.28 $1,721.28

18492 CIPROFLOXACIN IN 5 % DEXTROSE 200 MG/100 ML IV PGBK J0744 00409477723 100 mL $153.00 $153.00

18500 ERTAPENEM 1 GRAM IJ SOLR J1335 00006384371 1 Each $842.78 $842.78

18851 INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SC SYRG Q3028 44087004403 .5 mL $9,908.62 $9,908.62

18928 SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SC PNIJ J3030 00781317207 1 mL $1,728.16 $1,728.16

18959 RETEPLASE 10 UNITS IV KIT J2993 24477004001 1 Each $25,300.35 $25,300.35

18963 PIPERACILLIN-TAZOBACTAM-DEXTRS 3.375 GRAM/50 ML IV PGBK J2543 00206886102 50 mL $160.00 $160.00

19008 SODIUM HYPOCHLORITE 0.25 % MISC SOLN 00436093616 473 mL $158.93 $158.93


19048 PAMIDRONATE 30 MG/10 ML (3 MG/ML) IV SOLN J2430 67457043010 10 mL $153.00 $153.00

19049 PAMIDRONATE 90 MG/10 ML (9 MG/ML) IV SOLN J2430 67457044610 10 mL $418.40 $418.40

19052 HYPROMELLOSE 2.5 % OP DROP 17478006412 15 mL $262.80 $262.80

19263 ORAL WOUND CARE PRODUCTS MM GLPK 89141045602 15 mL $675.36 $675.36

20265 ETHANOL (ETHYL ALCOHOL) 98 % IJ SOLN 00517857510 5 mL $1,306.40 $1,306.40

20265 ETHANOL (ETHYL ALCOHOL) 98 % IJ SOLN 17478050305 5 mL $6,662.72 $6,662.72

20400 SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) OP DROP 24208031705 5 mL $170.72 $170.72

21183 OLMESARTAN 20 MG PO TABS 65597010330 30 Each $3,444.96 $3,444.96

21200 FULVESTRANT 250 MG/5 ML IM SYRG J9395 00310072010 5 mL $14,459.12 $14,459.12

21259 LEUPROLIDE 7.5 MG (1 MONTH) SC SYRG J9217 62935075375 1 Each $1,476.48 $1,476.48

21264 RISEDRONATE 35 MG PO TABS 00430047207 12 Each $15,255.36 $15,255.36

21294 HYDROMORPHONE 2 MG/ML IJ SYRG J1170 00409131230 1 mL $153.00 $153.00

21301 TREPROSTINIL SODIUM 1 MG/ML IJ SOLN J3285 66302010101 20 mL $13,896.00 $13,896.00

21302 TREPROSTINIL SODIUM 2.5 MG/ML IJ SOLN J3285 66302010201 20 mL $17,983.80 $17,983.80



21308 ENOXAPARIN 30 MG/0.3 ML SC SYRG J1650 00075062430 .3 mL $153.00 $153.00



21311 ENOXAPARIN 100 MG/ML SC SYRG J1650 00075062300 1 mL $178.35 $178.35


21432 DEXTROAMPHETAMINE-AMPHETAMINE 5 MG PO CP24 54092038101 100 Each $894.40 $894.40

21560 VORICONAZOLE 50 MG PO TABS 00049317030 30 Each $2,902.56 $2,902.56

21561 VORICONAZOLE 200 MG PO TABS 00049318030 30 Each $10,364.16 $10,364.16

21562 VORICONAZOLE 200 MG IV SOLR J3465 00049319028 1 Each $440.64 $440.64

22090 CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRG 00409492834 10 mL $153.00 $153.00

22122 RABIES VACCINE, PCEC (PF) 2.5 UNITS IM SUSR 90675 58160096412 1 Each $4,424.00 $4,424.00

22637 ZIPRASIDONE MESYLATE 20 MG/ML (FINAL CONC.) IM SOLR J3486 00049392020 1 Each $776.80 $776.80

22680 DEXTROSE 50 % IN WATER (D50W) IV SYRG 00409490234 50 mL $153.00 $153.00

22717 LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK J2020 00009514001 300 mL $336.00 $336.00

22821 DIAZEPAM 5 MG/ML IJ SYRG J3360 00409127332 2 mL $354.94 $354.94

22905 SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG 00409553434 10 mL $153.00 $153.00

22906 SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG 00409663734 50 mL $153.00 $153.00

22953 MORPHINE 10 MG/ML IJ SYRG J2270 76045000810 1 mL $153.00 $153.00

22977 HYDROMORPHONE 1 MG/ML IJ SYRG J1170 00409128303 1 mL $153.00 $153.00

22985 FILGRASTIM 300 MCG IJ SYRG J1442 55513092410 .5 mL $4,971.76 $4,971.76


22989 PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG J0561 60793070210 4 mL $5,260.86 $5,260.86

22990 PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG J0561 60793070110 2 mL $2,567.14 $2,567.14

23025 NALOXONE 0.4 MG/ML IJ SYRG J2310 00409178269 1 mL $215.95 $215.95

23026 NALOXONE 1 MG/ML IJ SYRG J2310 76329336901 2 mL $442.94 $442.94

23235 ESCITALOPRAM OXALATE 20 MG PO TABS 00456202001 100 Each $18,748.80 $18,748.80

23248 VALSARTAN 40 MG PO TABS 00378580793 30 Each $153.00 $153.00

23263 RASBURICASE 1.5 MG IV SOLR J2783 00024515010 1 Each $13,358.77 $13,358.77

23319 LEUPROLIDE (3 MONTH) 22.5 MG SC SYRG J9217 62935022305 1 Each $4,429.28 $4,429.28

23485 EPLERENONE 25 MG PO TABS 59762171001 100 Each $4,622.40 $4,622.40

23528 METAXALONE 800 MG PO TABS 60793013601 100 Each $7,361.60 $7,361.60

23576 PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN J3490 00004035009 1 mL $15,234.08 $15,234.08

23664 EZETIMIBE 10 MG PO TABS 66582041428 100 Each $464.00 $464.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



23725 KIT FOR YTTRIUM-90-IBRITUMOMAB 3.2 MG/2 ML IV KIT A9543 68152010303 1 Each $202,310.17 $202,310.17

23757 BENZOCAINE 20 % MM SPRA 00283067902 57 gram $424.99 $424.99

23797 ARIPIPRAZOLE 10 MG PO TABS 13668021830 30 Each $665.28 $665.28


23850 ATOMOXETINE 10 MG PO CAPS 00002322730 30 Each $5,896.80 $5,896.80

23853 ATOMOXETINE 40 MG PO CAPS 00002322930 30 Each $6,407.04 $6,407.04

24410 ADALIMUMAB 40 MG/0.8 ML SC SYKT J0135 00074379902 2 Each $46,616.85 $46,616.85

24442 ELETRIPTAN 40 MG PO TABS 00049234045 6 Each $837.89 $837.89

24455 BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL 65162041603 30 Each $828.48 $828.48

24456 BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL 65162041503 30 Each $994.08 $994.08

24467 BUPRENORPHINE HCL 2 MG SL SUBL J0571 00054017613 30 Each $1,111.20 $1,111.20

24468 BUPRENORPHINE HCL 8 MG SL SUBL J0574 00054017713 30 Each $631.68 $631.68

24567 ESCITALOPRAM OXALATE 5 MG/5 ML PO SOLN 54838055170 240 mL $1,612.80 $1,612.80

24567 ESCITALOPRAM OXALATE 5 MG/5 ML PO SOLN 99999900343 5 mL $153.00 $153.00

24592 FILGRASTIM 480 MCG IJ SOLN J1442 55513054610 1.6 mL $7,469.16 $7,469.16

24664 METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN J9250 00703367501 10 mL $153.00 $153.00



24719 CYCLOSPORINE 0.05 % OP DPET 00023916330 30 Each $4,364.16 $4,364.16

24719 CYCLOSPORINE 0.05 % OP DPET 99999900428 .4 mL $153.00 $153.00

24764 LEUPROLIDE (4 MONTH) 30 MG SC SYRG J9217 62935030330 1 Each $5,905.76 $5,905.76


24803 SIROLIMUS 2 MG PO TABS J7520 00008104205 100 Each $30,782.40 $30,782.40


24892 APREPITANT 80 MG PO CAPS J8501 00006046106 6 Each $10,362.24 $10,362.24


25010 CLONAZEPAM 0.25 MG PO TBDL 49884030702 60 Each $614.40 $614.40

25020 ZOLEDRONIC ACID 4 MG/5 ML IV SOLN J3489 55111068507 4 mg $180.80 $289.28

25092 RISPERIDONE 0.5 MG PO TBDL 50458039530 30 Each $1,564.80 $1,564.80

25093 RISPERIDONE 1 MG PO TBDL 50458031528 28 Each $331.52 $331.52

25094 RISPERIDONE 2 MG PO TBDL 50458032528 28 Each $438.14 $438.14

25100 MOXIFLOXACIN 0.5 % OP DROP 00065401303 3 mL $2,583.84 $2,583.84

25114 MINOCYCLINE 100 MG PO TABS 49884051303 50 Each $2,384.00 $2,384.00

25153 AGALSIDASE BETA 35 MG IV SOLR J0180 58468004001 1 Each $50,016.80 $56,268.90

25217 BORTEZOMIB 3.5 MG IJ SOLR J9041 63020004901 1 Each $14,427.00 $14,427.00

25307 LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK J1956 25021013282 100 mL $153.00 $153.00



25321 BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 IJ SOLN 00409904517 30 mL $153.00 $153.00





25324 BUPIVACAINE (PF) 0.25 % IJ SOLN J3490 99999001846 10 mL $153.00 $153.00







25331 BUPIVACAINE-DEXTROSE-WATER(PF) 0.75 % (7.5 MG/ML) IJ SOLN 00409176102 2 mL $153.00 $153.00

25384 MORPHINE (PF) 25 MG/ML IJ SOLN J2274 00641604001 20 mL $5,221.44 $5,221.44

25390 POTASSIUM CHLORIDE-0.45 % NACL 20 MEQ/L IV SOLP J3480 00338070434 1000 mL $153.00 $153.00

25404 POVIDONE-IODINE 10 % TP SOLN 52380190504 118 mL $153.00 $153.00

25441 IMATINIB 100 MG PO TABS J8999 00078040134 90 Each $4,574.88 $4,574.88

25463 PHENYLEPHRINE HCL 0.25 % NA SPRY 00024134803 15 mL $153.00 $153.00

25468 PHENYLEPHRINE HCL 0.5 % NA SPRY 00024135301 15 mL $153.00 $153.00

25469 PHENYLEPHRINE HCL 1 % NA DROP 49348019727 30 mL $153.00 $153.00

25540 SODIUM CHLORIDE 0.65 % NA SPRA 49348035984 88 mL $153.00 $153.00

25540 SODIUM CHLORIDE 0.65 % NA SPRA 00904386575 44 mL $153.00 $153.00

25564 ATAZANAVIR 150 MG PO CAPS 00003362412 60 Each $6,643.20 $6,643.20


25578 PHENYLEPHRINE HCL 0.125 % NA DROP 56184012105 15 mL $153.00 $153.00

25681 OMALIZUMAB 150 MG SC SOLR J2357 50242004062 1 Each $9,027.84 $10,156.32

25758 LANSOPRAZOLE 30 MG PO TBLD 64764054411 100 Each $20,635.20 $20,635.20

25819 EMTRICITABINE 200 MG PO CAPS 61958060101 30 Each $8,001.60 $8,001.60

25827 BACITRACIN ZINC 500 UNIT/GRAM TP PACK 00168011109 144 Each $299.52 $299.52

25847 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM TP PACK 69968006009 144 Each $426.24 $426.24

25851 INHALATIONAL SPACING DEVICE MISC SPCR 00456315467 1 Each $542.40 $542.40

26040 INTERFERON BETA-1A 30 MCG/0.5 ML IM SYKT Q3027 59627022205 1 Each $14,815.35 $14,815.35

26051 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN J3480 63323096730 30 mL $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price







26184 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT DRPS 00065853302 7.5 mL $3,696.12 $3,696.12

26260 RIMABOTULINUMTOXINB 2500 UNIT/0.5 ML IM SOLN J0587 10454071010 .5 mL $2,656.50 $4,250.40

26261 RIMABOTULINUMTOXINB 5000 UNITS/ML IM SOLN J0587 10454071110 1 mL $5,313.00 $8,500.80

26267 PALONOSETRON 0.25 MG/5 ML IV SOLN J2469 62856079701 5 mL $1,864.20 $2,982.72

26267 PALONOSETRON 0.25 MG/5 ML IV SOLN J2469 69097092735 5 mL $216.00 $216.00

26268 ROSUVASTATIN 5 MG PO TABS 00310075590 90 Each $1,313.28 $1,313.28



26271 ROSUVASTATIN 40 MG PO TABS 57237017190 90 Each $253.44 $253.44

26317 AMINOPHYLLINE 250 MG/10 ML IV SOLN J0280 00409592101 10 mL $174.08 $174.08

26318 AMINOPHYLLINE 500 MG/20 ML IV SOLN J0280 00409592201 20 mL $153.00 $153.00

26359 EPINEPHRINE 1 MG/ML IJ SOLN 42023016801 30 mL $3,724.80 $3,724.80

26362 VARDENAFIL 2.5 MG PO TABS 00173082813 30 Each $7,471.20 $7,471.20

26366 VARDENAFIL 20 MG PO TABS 00173083113 30 Each $7,471.20 $7,471.20

26409 CARBOPLATIN 10 MG/ML IV SOLN J9045 61703033950 45 mL $642.96 $642.96

26485 BUPROPION HCL 300 MG PO TB24 51079010903 30 Each $926.40 $926.40

26486 BUPROPION HCL 150 MG PO TB24 00378200877 90 Each $1,123.20 $1,123.20

27590 DAPTOMYCIN 500 MG IV SOLR J0878 67919001101 1 Each $945.60 $945.60

27637 RISPERIDONE MICROSPHERES 25 MG/2 ML IM SSRR J2794 50458030611 1 Each $7,431.84 $7,431.84

27638 RISPERIDONE MICROSPHERES 37.5 MG/2 ML IM SSRR J2794 50458030711 1 Each $11,148.32 $11,148.32

27639 RISPERIDONE MICROSPHERES 50 MG/2 ML IM SSRR J2794 50458030811 1 Each $14,864.80 $14,864.80

27683 GENTAMICIN IN NACL (ISO-OSM) 120 MG/100 ML IV PGBK J1580 00338050748 100 mL $153.00 $153.00

27808 TADALAFIL 5 MG PO TABS 00002446230 30 Each $158.88 $158.88

27810 TADALAFIL 20 MG PO TABS 00002446430 30 Each $31,094.88 $31,094.88

27852 MEMANTINE 10 MG PO TABS 00456321063 100 Each $11,054.40 $11,054.40

27855 MEMANTINE 5 MG PO TABS 00456320563 100 Each $608.00 $608.00

27947 TETANUS-DIPHTHERIA TOXOIDS-TD 2-2 LF UNIT/0.5 ML IM SUSP 90714 13533013101 .5 mL $325.95 $325.95

28051 ESCITALOPRAM OXALATE 5 MG PO TABS 00456200501 100 Each $17,184.00 $17,184.00

28058 RIBAVIRIN 40 MG/ML PO SOLN 99999002247 100 mL $400.00 $400.00

28284 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN 00121477210 10 mL $153.00 $153.00

28284 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN 99999900653 10 mL $153.00 $153.00

28290 PEMETREXED 500 MG IV SOLR J9305 00002762301 1 Each $30,570.39 $30,570.39

28300 BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TP OINT 00810079888 14.2 gram $153.00 $153.00

28409 BEVACIZUMAB 25 MG/ML IV SOLN J9035 50242006101 16 mL $28,690.56 $28,690.56

28409 BEVACIZUMAB 25 MG/ML IV SOLN J9035 50242006001 4 mL $12,751.36 $12,751.36

28431 MYCOPHENOLATE SODIUM 180 MG PO TBEC J7518 00078038566 120 Each $6,147.84 $6,147.84

28432 MYCOPHENOLATE SODIUM 360 MG PO TBEC J7518 00078038666 120 Each $7,848.96 $7,848.96

28443 SODIUM HYALURONATE (VISCOSUP) 30 MG/2 ML IX SYRG J7324 59676036001 2 mL $1,884.00 $1,884.00

30717 CINACALCET 30 MG PO TABS 55513007330 30 Each $5,661.12 $5,661.12



30732 VORICONAZOLE 200 MG/5 ML (40 MG/ML) PO SUSR 00049316044 75 mL $12,590.40 $12,590.40

30817 OLANZAPINE 10 MG IM SOLR J3490 00002759701 1 Each $686.08 $686.08

31058 CLOZAPINE 100 MG PO TBDL 18860010401 48 Each $11,457.02 $11,457.02

31059 CLOZAPINE 25 MG PO TBDL 18860010201 48 Each $2,863.87 $2,863.87

31084 TERBUTALINE 1 MG/ML SC SOLN J3105 55390010110 1 mL $153.00 $153.00

31177 ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN J0132 66220020730 30 mL $3,086.88 $3,086.88

31245 FLUOCINONIDE-EMOLLIENT 0.05 % TP CREA 00093026315 15 gram $574.56 $574.56

31276 AGALSIDASE BETA 5 MG IV SOLR J0180 58468004101 1 Each $8,930.10 $14,288.16

31386 CHEMO DILUENT 1 (PF) 73-19-8-3 MG/10 ML IT SOLN J9175 55792000710 10 mL $15,024.00 $15,024.00

31411 AZACITIDINE 100 MG IJ SOLR J9025 59572010201 1 Each $9,363.84 $9,363.84

31575 METHYLPHENIDATE HCL 5 MG/5 ML PO SOLN 99999900347 5 mL $153.00 $153.00

31606 RACEPINEPHRINE 2.25 % IN NEBU 00487590199 1 Each $153.00 $153.00

31607 ALBUTEROL SULFATE 2.5 MG/0.5 ML IN NEBU J7611 00487990130 1 Each $153.00 $153.00

31855 RIFAXIMIN 200 MG PO TABS 65649030103 30 Each $7,997.76 $7,997.76

31954 NITROFURANTOIN 100 MG PO CAPS 51079034801 1 Each $153.00 $153.00

31954 NITROFURANTOIN 100 MG PO CAPS 51079034820 100 Each $3,696.00 $3,696.00

31954 NITROFURANTOIN 100 MG PO CAPS 68084044601 100 Each $3,691.20 $3,691.20

32038 DOXERCALCIFEROL 0.5 MCG PO CAPS 58468012001 50 Each $3,280.00 $3,280.00

32060 NITAZOXANIDE 500 MG PO TABS 67546011112 30 Each $60,236.16 $60,236.16

32112 EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG PO TABS 61958070101 30 Each $27,475.20 $27,475.20

32120 DULOXETINE 20 MG PO CPDR 00002323560 60 Each $256.32 $256.32

32121 DULOXETINE 30 MG PO CPDR 00904645361 100 Each $1,873.60 $1,873.60

32122 DULOXETINE 60 MG PO CPDR 60505299703 30 Each $219.84 $219.84

32142 TRIMETHOPRIM 10 MG/ML PO SOLN 99999900346 10 mL $225.60 $225.60

32429 CAPSAICIN 0.1 % TP CREA 41167075142 42.5 gram $153.00 $153.00

32482 FLUDARABINE 50 MG/2 ML IV SOLN J9185 00703485211 2 mL $744.00 $744.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



32633 MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT- 200 MCG/5 ML IV SOLN 54643564601 5 mL $192.56 $192.56

32635 VANCOMYCIN IN DEXTROSE 5 % 1 GRAM/200 ML IV PGBK J3370 00338355248 200 mL $460.80 $460.80

32666 ETANERCEPT 50 MG/ML (1 ML) SC SYRG J1438 58406043504 .98 mL $10,851.17 $10,851.17

32711 NORFLURANE-PENTAFLUOROPROPANE TP SPRA 00386000803 103.5 mL $374.26 $374.26

32711 NORFLURANE-PENTAFLUOROPROPANE TP SPRA 00386000404 103.5 mL $410.69 $410.69

32773 LEVOFLOXACIN 250 MG/10 ML PO SOLN 50383028616 480 mL $7,856.64 $7,856.64

32832 FONDAPARINUX 5 MG/0.4 ML SC SYRG J1652 67457058304 .4 mL $477.57 $477.57

32833 FONDAPARINUX 10 MG/0.8 ML SC SYRG J1652 55111068110 .8 mL $470.14 $470.14

32838 FONDAPARINUX 7.5 MG/0.6 ML SC SYRG J1652 55150023210 .6 mL $424.35 $424.35

32851 ERLOTINIB 150 MG PO TABS 50242006401 30 Each $126,040.80 $126,040.80

32853 ERLOTINIB 25 MG PO TABS J8999 50242006201 30 Each $40,571.04 $40,571.04

32872 NATALIZUMAB 300 MG/15 ML IV SOLN J2323 64406000801 15 mL $54,814.80 $61,666.65

32889 LANTHANUM 500 MG PO CHEW 54092025290 90 Each $16,116.48 $16,116.48

32964 SOLIFENACIN 10 MG PO TABS 51248015101 30 Each $5,749.44 $5,749.44

33033 PALIFERMIN 6.25 MG IV SOLR J2425 66658011206 1 Each $24,280.47 $24,280.47

33050 ESZOPICLONE 2 MG PO TABS 63402019110 100 Each $275.20 $275.20

33133 CLOFARABINE 20 MG/20 ML IV SOLN J9027 00024586001 20 mL $25,948.80 $25,948.80

33171 OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN 99999000985 500 mL $153.00 $153.00

33184 DARIFENACIN 7.5 MG PO TB24 00430017015 30 Each $5,682.72 $5,682.72

33224 ZICONOTIDE 100 MCG/ML IT SOLN J2278 18860072010 1 mL $13,280.00 $13,280.00

33225 ZICONOTIDE 25 MCG/ML IT SOLN J2278 18860072310 20 mL $37,350.00 $37,350.00

33229 HYALURONIDASE (OVINE) 200 UNITS/ML IJ SOLN 24208000202 1.2 mL $1,541.91 $1,541.91

33242 TOBRAMYCIN-LOTEPRED 0.3-0.5 % OP DRPS 24208035805 5 mL $3,597.92 $3,597.92

33253 MESALAMINE 1000 MG PR SUPP 58914050156 30 Each $17,326.56 $17,326.56

33266 PACLITAXEL-PROTEIN BOUND 100 MG IV SUSR J9264 68817013450 1 Each $12,137.94 $12,137.94

33486 LEUPROLIDE (6 MONTH) 45 MG SC SYRG J9217 62935045345 1 Each $8,858.72 $8,858.72

33571 BACLOFEN 50 MCG/ML IT SOLN J0476 58281056201 1 mL $480.00 $480.00

33700 LEVALBUTEROL TARTRATE 45 MCG/ACTUATION IN HFAA J3535 63402051001 15 gram $508.92 $508.92

33739 IBANDRONATE 150 MG PO TABS 00004018682 3 Each $153.00 $153.00

33770 ENTECAVIR 0.05 MG/ML PO SOLN 00003161412 210 mL $14,327.04 $14,327.04

33771 ENTECAVIR 0.5 MG PO TABS 00003161112 30 Each $954.24 $954.24

33809 ESOMEPRAZOLE SODIUM 40 MG INJECTION 00186604001 1 Each $665.87 $665.87

33997 EXENATIDE 5 MCG/DOSE (250 MCG/ML) 1.2 ML SC PNIJ 00310651201 1.2 mL $10,554.87 $10,554.87

33998 EXENATIDE 10 MCG/DOSE(250 MCG/ML) 2.4 ML SC PNIJ 00310652401 2.4 mL $10,554.89 $10,554.89

34005 IPRATROPIUM BROMIDE 17 MCG/ACTUATION IN HFAA J3535 00597008717 12.9 gram $3,067.72 $3,067.72


34103 OXALIPLATIN 50 MG/10 ML (5 MG/ML) IV SOLN J9263 61703036318 10 mL $481.60 $481.60

34104 OXALIPLATIN 100 MG/20 ML IV SOLN J9263 25021023320 20 mL $715.84 $715.84

34149 PARICALCITOL 1 MCG PO CAPS 00074431730 30 Each $648.00 $648.00

34209 BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN J0592 42023017905 1 mL $192.80 $192.80

34214 SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABS 00591378019 90 Each $201.60 $201.60

34232 PALIVIZUMAB 50 MG/0.5 ML IM SOLN 90378 60574411401 .5 mL $13,197.60 $13,197.60

34233 PALIVIZUMAB 100 MG/ML IM SOLN 90378 60574411301 1 mL $24,920.73 $24,920.73

34244 TIGECYCLINE 50 MG IV SOLR J3243 00008499002 1 Each $776.32 $776.32

34312 SECRETIN (HUMAN) 16 MCG IV SOLR J2850 67066000501 1 Each $8,400.00 $8,400.00

34331 METRONIDAZOLE 1 % TP GEL 00299382060 60 gram $5,614.08 $5,614.08

34332 MOMETASONE 220 MCG/ ACTUATION (14) IN AEPB 00085134106 1 Each $358.48 $358.48

34352 MEGESTROL 625 MG/5 ML (125 MG/ML) PO SUSP 24979004113 150 mL $10,548.00 $10,548.00

34375 LIDOCAINE-TETRACAINE 70-70 MG TP PTMH C9285 10885000210 10 Each $2,264.32 $2,264.32

34572 PREGABALIN 25 MG PO CAPS 00071101268 90 Each $1,769.76 $1,769.76




34585 OPIUM TINCTURE 10 MG/ML (MORPHINE) PO TINC 99999900181 .6 mL $153.00 $153.00

34653 INSULIN DETEMIR U-100 100 UNITS/ML SC SOLN J1815 00169368712 10 mL $3,422.08 $3,422.08

34848 MEDROXYPROGESTERONE 400 MG/ML IM SUSP J1050 00009062601 2.5 mL $8,032.80 $8,032.80

34936 MEPERIDINE (PF) 50 MG/ML IJ SOLN J2175 00409125301 1 mL $153.00 $153.00




34971 PANCURONIUM 1 MG/ML IV SOLN J3490 00409464601 10 mL $153.00 $153.00

35153 LOPINAVIR-RITONAVIR 200-50 MG PO TABS 00074679922 120 Each $15,273.60 $15,273.60

35164 NELARABINE 250 MG/50 ML IV SOLN J9261 00078068306 50 mL $10,967.20 $10,967.20

35188 BCG LIVE 50 MG IS SUSR J9030 00052060202 1 Each $2,341.76 $2,341.76

35244 PORACTANT ALFA 240 MG/3 ML ITL SUSP 10122051003 3 mL $12,372.34 $12,372.34

35245 PORACTANT ALFA 120 MG/1.5 ML ITL SUSP 10122051001 1.5 mL $6,359.69 $6,359.69

35270 DEFERASIROX 125 MG PO TBDP 00078046815 30 Each $373.44 $373.44







CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



35500 SORAFENIB 200 MG PO TABS J8999 50419048858 120 Each $319,699.20 $319,699.20

35507 EMOLLIENT COMBINATION NO.10 TP EMUL 58980096012 45 gram $234.72 $234.72

35507 EMOLLIENT COMBINATION NO.10 TP EMUL 00187511090 90 gram $745.92 $745.92


35539 ABATACEPT (WITH MALTOSE) 250 MG IV SOLR J0129 00003218710 1 Each $10,957.50 $17,532.00

35558 LENALIDOMIDE 5 MG PO CAPS 59572040528 28 Each $341,828.48 $341,828.48


35590 ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR J7198 64193042502 1 Each $69,200.00 $69,200.00

35592 INSULIN GLULISINE U-100 100 UNITS/ML SC SOLN J1815 00088250033 10 mL $1,693.92 $1,693.92

35688 IBANDRONATE 3 MG/3 ML IV SYRG J1740 25021082761 3 mL $1,073.76 $1,073.76


35707 ILOPROST 10 MCG/ML IN NEBU Q4074 66215030200 1 mL $2,586.24 $2,586.24

35715 ANTIHEMOPHILIC FACTOR-VWF 250-600 UNIT IV SOLR J7187 63833061502 1 Each $8,832.00 $8,832.00

35716 ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV SOLR J7187 63833061702 1 Each $35,328.00 $35,328.00

35717 ANTIHEMOPHILIC FACTOR-VWF 500-1,200 UNIT IV SOLR J7187 63833061602 1 Each $17,664.00 $17,664.00

35720 HEPARIN (PORCINE) IN 5 % DEX 25,000 UNIT/250 ML(100 UNIT/ML) IV SOLP J1644 00409779362 250 mL $153.00 $153.00

35721 HEPARIN, PORCINE (PF) 100 UNITS/ML IV SYRG J1642 08290306513 5 mL $153.00 $153.00


35729 SUNITINIB 12.5 MG PO CAPS 00069055038 28 Each $86,226.56 $86,226.56

35730 SUNITINIB 25 MG PO CAPS 00069077038 28 Each $172,453.12 $172,453.12

35731 SUNITINIB 50 MG PO CAPS 00069098038 28 Each $300,218.24 $300,218.24

35739 HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML IJ SYRG J1644 00409131632 .5 mL $153.00 $153.00

35749 RANOLAZINE 500 MG PO TB12 61958100301 60 Each $5,851.20 $5,851.20

35772 LUBIPROSTONE 24 MCG PO CAPS 64764024060 60 Each $5,478.72 $5,478.72

35944 OMEPRAZOLE-SODIUM BICARBONATE 40-1.1 MG-GRAM PO CAPS 68012010430 30 Each $49,316.64 $49,316.64

35951 SELEGILINE 6 MG/24 HR TD PT24 49502090030 30 Each $26,200.32 $26,200.32

35986 HYALURONIDASE, HUMAN RECOMB. 150 UNITS/ML IJ SOLN 18657011704 1 mL $595.09 $595.09

36260 ALGLUCOSIDASE ALFA 50 MG IV SOLR J0221 58468016001 1 Each $8,241.60 $13,186.56

36297 LIDOCAINE (PF) 40 MG/ML (4 %) IJ SOLN J2001 00409428301 5 mL $153.00 $153.00







36302 LIDOCAINE (PF) 5 MG/ML (0.5 %) IJ SOLN J2001 00409427801 50 mL $153.00 $153.00

36303 LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN J2001 63323020805 5 mL $153.00 $153.00

36304 LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG J2001 00409490334 5 mL $153.00 $153.00

36311 LIDOCAINE IN 5 % DEXTROSE (PF) 4 MG/ML (0.4 %) IV SOLP J2001 00338040903 500 mL $153.00 $153.00

36385 DECITABINE 50 MG IV SOLR J0894 62856060001 1 Each $2,848.48 $2,848.48

36429 ZOSTER VACCINE LIVE (PF) 19400 UNIT/0.65 ML SC SUSR 90736 00006496341 1 Each $3,334.56 $3,334.56

36433 RASAGILINE 0.5 MG PO TABS 68546014256 30 Each $3,561.12 $3,561.12

36435 RASAGILINE 1 MG PO TABS 47781013930 30 Each $5,073.60 $5,073.60

36472 VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SC SUSR 90716 00006482700 1 Each $2,063.62 $2,063.62

36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516412 5 mL $153.00 $153.00

36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516413 10 mL $548.24 $548.24

36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516414 15 mL $1,212.60 $1,212.60

36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516415 20 mL $2,155.68 $2,155.68

36560 IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN 39822103002 2 mL $2,833.60 $2,833.60

36580 DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML IJ SYRG J0881 55513003201 1 mL $31,166.46 $31,166.46

36721 DASATINIB 20 MG PO TABS 00003052711 60 Each $120,048.00 $120,048.00






36829 EFAVIRENZ-EMTRICITABIN-TENOFOV 600-200-300 MG PO TABS 15584010101 30 Each $44,662.08 $44,662.08

36856 LIDOCAINE HCL 4 % LATR SOLN 00409469801 4 mL $340.48 $340.48

36861 FENOFIBRATE NANOCRYSTALLIZED 48 MG PO TABS 16714073701 90 Each $256.32 $256.32

36862 FENOFIBRATE NANOCRYSTALLIZED 145 MG PO TABS 16714073801 90 Each $900.00 $900.00

36869 ADALIMUMAB 40 MG/0.8 ML SC PNKT J0135 00074433902 2 Each $46,616.85 $46,616.85

36900 ETONOGESTREL 68 MG SD IMPL J7307 00052433001 1 Each $14,957.12 $14,957.12

36914 IDURSULFASE 6 MG/3 ML IV SOLN J1743 54092070001 3 mL $25,086.72 $28,222.56

36940 DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML IJ SYRG J0881 55513002801 .4 mL $12,466.62 $12,466.62



37078 LEVETIRACETAM 500 MG/5 ML IV SOLN J1953 50474000263 5 mL $153.00 $153.00

37078 LEVETIRACETAM 500 MG/5 ML IV SOLN J1953 00409188602 500 mg $153.00 $153.00

37107 DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/ML IJ SOLN J0881 55513000601 1 mL $12,466.62 $12,466.62


37273 POSACONAZOLE 200 MG/5 ML (40 MG/ML) PO SUSP 00085132801 105 mL $21,468.72 $21,468.72



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



37284 PEG3350-SOD SUL-NACL-KCL-ASB-C 100-7.5-2.691 GRAM PO PWPK 65649020175 1 Each $743.52 $743.52

37377 PERITON.DIALYSIS 8-4.25 % DEXT CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045908 2000 mL $153.00 $153.00

37377 PERITON.DIALYSIS 8-4.25 % DEXT CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045905 5000 mL $153.00 $153.00

37399 PERITON.DIALYSIS 7-2.5 % DEXTR CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045705 5000 mL $153.00 $153.00

37399 PERITON.DIALYSIS 7-2.5 % DEXTR CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045708 2000 mL $153.00 $153.00

37422 SITAGLIPTIN 25 MG PO TABS 00006022128 100 Each $23,532.80 $23,532.80




37480 PERIT.DIALYSIS 6-1.5 % DEXTROS CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941040907 5000 mL $153.00 $153.00

37480 PERIT.DIALYSIS 6-1.5 % DEXTROS CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941040906 2000 mL $153.00 $153.00

37499 MICAFUNGIN 100 MG IV SOLR J2248 00469321110 1 Each $976.16 $976.16

37523 ONDANSETRON HCL (PF) 4 MG/2 ML IJ SOLN J2405 00409475518 2 mL $153.00 $153.00



37635 MORPHINE 20 MG PO CSRP 52544021160 60 Each $9,568.32 $9,568.32

37726 PALIPERIDONE 3 MG PO TR24 50458055010 100 Each $16,144.00 $16,144.00



37766 EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) IJ SOLN J0171 54288010310 1 mL $153.00 $153.00




37815 PRAMOXINE 1 % TP FOAM 00037682315 15 gram $1,092.24 $1,092.24

37831 DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML IJ SOLN J1100 63323050601 1 mL $153.00 $153.00

37860 OLOPATADINE 0.2 % OP DROP 00065027225 2.5 mL $1,707.68 $1,707.68

37860 OLOPATADINE 0.2 % OP DROP 60505058604 2.5 mL $153.00 $153.00

38060 HEPATITIS B IMMUNE GLOBULIN GREATR THAN 312 UNIT/ML IM SOLN 90371 59730420201 1 mL $2,191.52 $2,191.52

38074 HEPATITIS B IMMUNE GLOBULIN GREATER THAN 1,560 UNIT/5 ML IM SOLN 90371 59730420301 5 mL $7,908.00 $7,908.00

38081 LISDEXAMFETAMINE 30 MG PO CAPS 59417010310 100 Each $15,859.20 $15,859.20

38083 LISDEXAMFETAMINE 70 MG PO CAPS 59417010710 100 Each $15,859.20 $15,859.20

38088 ALISKIREN 300 MG PO TABS 70839030030 30 Each $3,909.60 $3,909.60

38089 ALISKIREN 150 MG PO TABS 70839015030 30 Each $3,098.88 $3,098.88


38312 ECULIZUMAB 300 MG/30 ML IV SOLN J1300 25682000101 30 mL $58,706.10 $58,706.10



38551 ZOLEDRONIC ACID-MANNITOL-WATER 5 MG/100 ML IV PGBK J3489 00078043561 100 mL $286.00 $457.60

38595 PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO SOLR 52268010001 4000 mL $153.00 $153.00

38613 RISPERIDONE MICROSPHERES 12.5 MG/2 ML IM SSRR J2794 50458030911 1 Each $3,716.16 $3,716.16

38677 HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG 90744 58160082043 .5 mL $231.52 $231.52

38693 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75 MG-10,000 UNIT-0.025MG/ML OP DROP 24208079062 10 mL $555.68 $555.68

38804 BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION IN HFAA 00186037028 6 gram $439.92 $439.92

38811 VIT B1-B2-B3-B5-B6 100-2-100-2-2 MG/ML IJ SOLN 67457014630 30 mL $2,726.88 $2,726.88

38826 HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRG 58160081152 .5 mL $915.06 $915.06

38863 HEPATITIS A VIRUS VACCINE (PF) 1440 UNITS IM SYRG 90632 58160082652 1 mL $936.77 $936.77

39122 AMBRISENTAN 5 MG PO TABS 00378427093 30 Each $186,393.60 $186,393.60

39123 AMBRISENTAN 10 MG PO TABS 00378427193 30 Each $186,393.60 $186,393.60

39167 SAMARIUM SM 153 LEXIDRONAM 5550 MBQ/3 ML IV SOLN A9604 11994001601 3 mL $253,144.84 $253,144.84

39283 HYDROMORPHONE (PF) 10 MG/ML IJ SOLN J1170 00703011003 1 mL $153.00 $153.00



39284 TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST) IV SOLR J9330 00008117901 2.5 mL $14,844.87 $14,844.87

39409 RIVASTIGMINE 4.6 MG/24 HR TD PT24 00078050115 30 Each $6,047.52 $6,047.52

39410 RIVASTIGMINE 9.5 MG/24 HR TD PT24 00078050261 1 Each $201.58 $201.58

39902 MARAVIROC 150 MG PO TABS 49702022318 60 Each $23,208.96 $23,208.96

39907 MARAVIROC 300 MG PO TABS 49702022418 60 Each $23,208.96 $23,208.96

39952 GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML IJ SOLN J1580 63323017302 2 mL $153.00 $153.00

40154 HEPATITIS A VIRUS VACCINE (PF) 1440 UNITS IM SUSP 90632 58160082601 1 mL $936.80 $936.80

40175 ANTIHEMOPHIL FVIII,FULL LENGTH 500 (+/-) UNIT IV SOLR 00026378335 1 Each $8,080.00 $8,080.00

40176 ANTIHEMOPHIL FVIII,FULL LENGTH 1,000 (+/-) UNIT IV SOLR 00026378555 1 Each $15,040.00 $15,040.00

40258 CARISOPRODOL 250 MG PO TABS 42543043401 100 Each $3,944.00 $3,944.00

40298 THROMBIN (BOVINE) 5000 UNITS TP SPSY 60793070505 1 Each $676.96 $676.96

40314 THROMBIN (BOVINE) 5000 UNITS TP SOLR 60793021505 1 Each $663.68 $663.68

40435 LANREOTIDE 60 MG/0.2 ML SC SYRG J1930 15054106003 .2 mL $50,175.00 $50,175.00




40480 OSELTAMIVIR 30 MG PO CAPS 00004080285 10 Each $1,026.24 $1,026.24

40481 OSELTAMIVIR 45 MG PO CAPS 00004080185 10 Each $1,024.48 $1,024.48

40498 RALTEGRAVIR 400 MG PO TABS 00006022761 60 Each $24,653.76 $24,653.76



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



40529 IXABEPILONE 15 MG IV SOLR J9207 00015191012 1 Each $13,009.05 $13,009.05

40530 IXABEPILONE 45 MG IV SOLR J9207 00015191113 1 Each $39,297.15 $39,297.15

40536 FAMOTIDINE (PF) 20 MG/2 ML IV SOLN 55390002910 2 mL $153.00 $153.00

40724 MAGNESIUM SULFATE IN WATER 4 GRAM/100 ML (4 %) IV PGBK J3475 00409672923 100 mL $153.00 $153.00

40747 CEFOTETAN IN DEXTROSE, ISO-OSM 1 GRAM/50 ML IV PGBK 00264317311 1 Each $270.53 $270.53

40748 CEFOTETAN IN DEXTROSE, ISO-OSM 2 GRAM/50 ML IV PGBK 00264317511 1 Each $386.86 $386.86

40854 AMINO ACID (AMINOSYN NO.2) 10% 00409717217 2000 mL $512.00 $512.00

40996 SEVELAMER CARBONATE 800 MG PO TABS 58468013001 270 Each $23,837.76 $23,837.76

41003 DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG 90700 58160081052 .5 mL $296.19 $296.19

41017 INDIUM 111-PENTETREOTIDE 3-10 MCI/ML-MCG IV KIT A9572 00019905040 1 Each $22,225.97 $22,225.97

41043 MAGNESIUM SULFATE IN D5W 1 G/100 ML IV PGBK J3475 00409672723 100 mL $153.00 $153.00

41044 MAGNESIUM SULFATE IN WATER 20 GRAM/500 ML (4 %) IV SOLP J3475 00409672903 500 mL $153.00 $153.00

41060 NEBIVOLOL 5 MG PO TABS 00456140563 100 Each $7,614.40 $7,614.40

41061 NEBIVOLOL 2.5 MG PO TABS 00456140230 30 Each $2,243.04 $2,243.04

41122 CLOPIDOGREL 300 MG PO TABS 55111067131 30 Each $3,883.68 $3,883.68

41124 GRANISETRON HCL 1 MG/ML (1 ML) IV SOLN J1626 00703797103 1 mL $153.00 $153.00

41126 PEMETREXED 100 MG IV SOLR J9305 00002764001 1 Each $10,869.44 $10,869.44

41148 PARENTERAL AMINO ACID 10% NO.2 10 % IV SOLP 00409419103 500 mL $240.00 $240.00

41158 HAEMOPH B POLY CONJ-TET TOX-PF 10 MCG/0.5 ML IM SOLR 90648 49281054503 1 Each $164.64 $164.64



41195 BARIUM SULFATE 0.1 % PO SUSP 32909094503 450 mL $5,832.00 $5,832.00

41197 ETRAVIRINE 100 MG PO TABS 59676057001 120 Each $20,638.08 $20,638.08

41290 IRINOTECAN 100 MG/5 ML IV SOLN J9206 00703443411 5 mL $182.40 $182.40



41323 FOSPHENYTOIN 100 MG PE/2 ML IJ SOLN Q2009 00143978825 2 mL $153.00 $153.00

41324 FOSPHENYTOIN 500 MG PE/10 ML IJ SOLN Q2009 00143978210 10 mL $222.40 $222.40

41359 PARENT. AMINO ACID 8.5 % NO.2 8.5 % IV SOLP 00409418703 500 mL $160.00 $160.00

41364 DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP 90700 49281028610 .5 mL $433.17 $433.17

41386 TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG 90714 49281021515 .5 mL $454.96 $454.96

41387 TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP 90714 49281021510 .5 mL $454.96 $454.96

41388 DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP 90715 49281040010 .5 mL $563.82 $563.82

41424 DARUNAVIR ETHANOLATE 600 MG PO TABS 59676056201 60 Each $26,333.76 $26,333.76

41578 EPIRUBICIN 50 MG/25 ML IV SOLN J9178 61703035993 25 mL $720.00 $720.00

41592 BENDAMUSTINE 100 MG IV SOLR J9033 63459039120 1 Each $14,734.26 $14,734.26

41623 MENING VAC A,C,Y,W135 DIP (PF) 4 MCG/0.5 ML IM SOLN 90734 49281058905 .5 mL $1,768.83 $1,768.83

41635 AMINO ACID (PREMASOL) 10% NO.7 IV SOLP 00338113003 500 mL $336.00 $336.00

41635 AMINO ACID (PREMASOL) 10% NO.7 IV SOLP 00338113004 1000 mL $512.00 $512.00

41670 MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SC SOLR 90707 00006468100 10 Each $11,163.84 $11,163.84

41749 DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG 90715 49281040015 .5 mL $538.56 $538.56

41754 CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SC KIT J0717 50474070062 1 Each $24,785.19 $24,785.19

41764 HEPATITIS B VIRUS VACC.REC(PF) 40 MCG/ML IM SUSP 90740 00006499200 1 mL $1,502.56 $1,502.56

41766 HEPATITIS B VIRUS VACC.REC(PF) 5 MCG/0.5 ML IM SUSP 90744 00006498100 .5 mL $193.04 $193.04

41843 TETANUS IMMUNE GLOBULIN (PF) 250 UNITS IM SYRG J1670 13533063402 1 Each $7,186.40 $7,186.40

41938 METHYLNALTREXONE 12 MG/0.6 ML SC SOLN 65649055102 .6 mL $1,723.04 $1,723.04

41976 REGADENOSON 0.4 MG/5 ML IV SYRG J2785 00469650189 5 mL $3,369.76 $3,369.76

73589 NOREPINEPHRINE (LEVOPHED)(0.032MG/ML) 8 MG IN D5W 250 ML 99999900217 250 mL $200.00 $200.00

73592 METHYLPREDNISOLONE SODIUM SUCC 2 MG IJ SOLR J2920 99999900220 2 Each $153.00 $153.00

73642 HEPARIN INJECTION FOR DIALYSIS J1644 99999900254 10 mL $153.00 $153.00

73652 LABETALOL 250 MG/50 ML (5 MG/ML) STRAIGHT DRUG IV SOLN 99999900668 50 mL $153.00 $153.00

73654 MIDAZOLAM 125MG IN D5W 250ML (0.5 MG/ML) J2250 99999900260 250 mL $153.00 $153.00

73656 CYTARABINE INJECTION 100 MG/ML J9100 99999900263 1 mL $153.00 $153.00

73769 ONABOTULINUMTOXINA 200 UNITS IJ SOLR J0585 00023392102 1 Each $9,616.00 $10,818.00

73838 TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN J3262 50242013501 4 mL $6,877.63 $6,877.63



73852 METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML IJ SOLR J2920 00009003928 40 mg $153.00 $153.00

73853 METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML IJ SOLR J2930 00009004722 125 mg $153.00 $153.00

73854 METHYLPREDNISOLONE SOD SUC(PF) 500 MG/4 ML IV SOLR J2930 00009000302 1 Each $569.76 $569.76

73855 METHYLPREDNISOLONE SOD SUC(PF) 1000 MG/8 ML IV SOLR J2930 00009001820 1 Each $720.32 $720.32

73887 USTEKINUMAB 45 MG/0.5 ML SC SYRG J3357 57894006003 .5 mL $96,819.84 $96,819.84

73888 USTEKINUMAB 90 MG/ML SC SYRG J3357 57894006103 1 mL $193,639.68 $193,639.68

73896 VALGANCICLOVIR 50 MG/ML PO SOLR 00591257920 88 mL $11,528.70 $11,528.70

74090 MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT 90734 58160095509 5 Each $7,444.80 $7,444.80

74092 SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN J3490 55150016613 12.5 mL $1,953.00 $1,953.00

74134 VELAGLUCERASE ALFA 400 UNITS IV SOLR J3385 54092070104 1 Each $11,016.00 $12,393.00

74136 PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG 90670 00005197101 .5 mL $3,012.59 $3,012.59

74264 ROMIDEPSIN 10 MG/2 ML IV SOLR J9315 00703312508 1 Each $24,149.88 $24,149.88

74371 MORPHINE 1 MG/ML PCA CSMC J2270 66647204073 30 mL $153.00 $153.00

74371 MORPHINE 1 MG/ML PCA CSMC J2270 99999900242 30 mL $302.40 $302.40



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



74394 KIT PREP OF TC-99M-MEBROFENIN 45 MG IV SOLR A9537 45567045502 30 Each $8,677.50 $8,677.50

74417 KIT PREP OF TC-99M-SOD PYROPH 12 MG IV SOLR A9538 45567006001 5 Each $1,157.00 $1,157.00

74454 SIROLIMUS 0.5 MG PO TABS J7520 00008104010 100 Each $23,580.80 $23,580.80

74461 TRIPTORELIN PAMOATE 22.5 MG IM SUSR J3315 00023590623 1 Each $32,746.50 $32,746.50

74481 HYDROCORTISONE SOD SUCC (PF) 500 MG/4 ML IJ SOLR J1720 00009001612 1 Each $807.04 $807.04



74528 RIFAXIMIN 550 MG PO TABS 65649030303 60 Each $30,490.56 $30,490.56

74562 EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG PO TABS J7527 00078041420 60 Each $16,595.52 $16,595.52

74563 EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG PO TABS J7527 00078041720 60 Each $8,298.24 $8,298.24

74619 SIPULEUCEL-T-LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSP Q2043 30237890006 250 mL $532,032.75 $532,032.75

74739 LACOSAMIDE 10 MG/ML PO SOLN 99999900342 10 mL $236.80 $236.80

74773 DENOSUMAB 60 MG/ML SC SYRG J0897 55513071001 1 mL $9,535.68 $10,727.64

74877 AMIKACIN 500 MG/2 ML IJ SOLN J0278 63323081502 2 mL $173.60 $173.60

74933 CABAZITAXEL 10 MG/ML (FIRST DILUTION) IV SOLN J9043 00024582411 60 mg $95,108.58 $95,108.58

74971 EVEROLIMUS (ANTINEOPLASTIC) 2.5 MG PO TABS J7527 00078059451 28 Each $133,203.84 $133,203.84

75011 GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML IJ SOLR J1610 00597026010 1 Each $2,559.20 $2,559.20

75158 CALCIUM GLUCONATE IN 0.9% NACL 2 G/100 ML IV SOLN J0610 99999001123 100 mL $272.00 $272.00

75276 INCOBOTULINUMTOXINA 100 UNITS IM SOLR J0588 00259161001 1 Each $4,820.00 $7,712.00


75287 BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM J0572 12496120201 1 Each $153.00 $153.00

75535 DOCETAXEL 20 MG/ML (1 ML) IV SOLN J9171 16729026763 1 mL $222.88 $222.88

75536 DOCETAXEL 80 MG/4 ML (20 MG/ML) IV SOLN J9171 00075800404 4 mL $891.52 $891.52

75580 KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR A9541 45567003001 5 Each $10,346.25 $10,346.25

75596 DABIGATRAN ETEXILATE 150 MG PO CAPS 00597013560 60 Each $5,337.60 $5,337.60


75600 KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR A9500 00019-9092-D0 10 mL $440.55 $440.55

76251 LEVOLEUCOVORIN CALCIUM 50 MG IV SOLR J0641 68152010100 1 Each $1,267.68 $1,267.68

76256 COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) IV SOLR J7189 00169720101 1 Each $17,570.70 $17,570.70



76259 MEPIVACAINE (PF) 20 MG/ML (2 %) IJ SOLN J0670 00409106720 20 mL $153.00 $153.00



76347 DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP 90696 58160081211 .5 mL $641.20 $641.20

76425 MILRINONE IN 5 % DEXTROSE 20 MG/100 ML (200 MCG/ML) IV PGBK J2260 00409277623 100 mL $235.20 $235.20

76443 GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) IV SOLN A9579 00407069010 10 mL $1,060.20 $1,060.20

76459 FLUOROURACIL 500 MG/10 ML IV SOLN J9190 63323011710 10 mL $153.00 $153.00

76460 FLUOROURACIL 1 GRAM/20 ML IV SOLN J9190 63323011720 20 mL $153.00 $153.00

76461 FLUOROURACIL 2.5 GRAM/50 ML IV SOLN J9190 63323011751 50 mL $153.00 $153.00

76462 FLUOROURACIL 5 G/100 ML IV SOLN J9190 63323011761 100 mL $232.00 $232.00

76561 HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP J1644 00409762003 500 mL $153.00 $153.00

76691 CYCLOSPORINE 250 MG/5 ML IV SOLN J7516 00078010901 5 mL $897.68 $897.68

76828 ALVIMOPAN 12 MG PO CAPS 67919002010 30 Each $83,126.40 $83,126.40

76830 VINORELBINE 50 MG/5 ML IV SOLN J9390 00703418301 5 mL $1,342.40 $1,342.40

76832 GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) IV SOLN A9581 50419032005 10 mL $2,647.08 $2,647.08

76835 ROMIPLOSTIM 500 MCG SC SOLR J2796 55513022201 1 Each $32,731.02 $32,731.02

76836 ROMIPLOSTIM 250 MCG SC SOLR J2796 55513022101 1 Each $16,365.51 $16,365.51

76857 DIMETHYL SULFOXIDE 50 % IS SOLN J1212 67457017750 50 mL $9,225.60 $9,225.60

76877 LIDOCAINE HCL 2 % MM JELP 76329301305 10 mL $153.00 $153.00

76889 VINCRISTINE 2 MG/2 ML IV SOLN J9370 61703030916 2 mL $153.00 $153.00

76889 VINCRISTINE 2 MG/2 ML IV SOLN J9370 00703441211 2 mL $153.00 $153.00

76890 PANITUMUMAB 100 MG/5 ML (20 MG/ML) IV SOLN J9303 55513095401 5 mL $10,761.75 $10,761.75

76895 CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EP SOLN J0735 67457021810 10 mL $212.48 $212.48

76896 CLONIDINE (PF) 5000 MCG/10 ML EP SOLN J0735 00517073101 10 mL $729.60 $729.60

77052 DOXORUBICIN 50 MG/25 ML IV SOLN J9000 00069303220 25 mL $314.00 $314.00



77119 BICARBONATE DIALYSIS SOLN NO.9 K (4 MEQ/L)-CA (2.5)-MG (1.5) HD SOLN 24571010506 5000 mL $400.00 $400.00

77121 BICARB DIALY SOLN 11 WITHOUT K CA (2.5 MEQ/L) -MG (1.5 MEQ/L) HD SOLN 24571010806 5000 mL $400.00 $400.00

77150 TERIPARATIDE 20 MCG/DOSE - 600 MCG/2.4 ML SC PNIJ 00002840001 2.4 mL $30,181.85 $30,181.85

77204 PERFLUTREN PROTEIN-A MICROSPHR 0.22 MG/ML IV SUSP Q9956 00407270703 3 mL $1,458.00 $1,458.00

77278 INTERFERON BETA-1B 0.3 MG SC KIT J1830 00078056999 1 Each $6,643.84 $6,643.84

77397 NICARDIPINE IN NACL (ISO-OS) 40 MG/200 ML IV PGBK 10122032501 200 mL $2,976.00 $2,976.00

78467 DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV SOLN J1250 00409234401 20 mL $153.00 $153.00

78470 DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP J1250 00409234632 250 mL $153.00 $153.00

78473 DOPAMINE 200 MG/5 ML (40 MG/ML) IV SOLN J1265 00409582001 5 mL $153.00 $153.00



78477 DOPAMINE IN 5 % DEXTROSE 800 MG/250 ML (3,200 MCG/ML) IV SOLN J1265 00409781022 250 mL $153.00 $153.00

78478 DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN J1265 00409780922 250 mL $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



78487 CETUXIMAB 100 MG/50 ML IV SOLN J9055 66733094823 50 mL $9,792.80 $9,792.80

78488 CETUXIMAB 200 MG/100 ML IV SOLN J9055 66733095823 100 mL $11,016.90 $11,016.90

78615 PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SC SOLN J2562 00024586201 1.2 mL $75,831.88 $75,831.88

78881 FEBUXOSTAT 40 MG PO TABS 64764091830 30 Each $4,921.92 $4,921.92

78883 FEBUXOSTAT 80 MG PO TABS 64764067730 30 Each $4,921.92 $4,921.92

78912 SILODOSIN 4 MG PO CAPS 59651009530 30 Each $509.76 $509.76

78913 SILODOSIN 8 MG PO CAPS 59651009630 30 Each $522.24 $522.24

79343 ARMODAFINIL 150 MG PO TABS 63459021530 30 Each $12,628.80 $12,628.80



79352 TIROFIBAN-0.9% SODIUM CHLORIDE 12.5 MG/250 ML (50 MCG/ML) IV SOLN J3246 25208000202 250 mL $2,444.00 $2,444.00

79353 NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN 00517481025 10 mL $174.72 $174.72

79374 DEGARELIX 80 MG SC SOLR J9155 55566830301 1 Each $7,284.48 $7,284.48

79382 DEGARELIX 120 MG SC SOLR J9155 55566840301 2 Each $22,731.04 $22,731.04

79392 HYLAN G-F 20 48 MG/6 ML IX SYRG J7325 58468009003 6 mL $2,748.00 $2,748.00

79426 LACOSAMIDE 50 MG PO TABS 00131247735 60 Each $8,492.16 $8,492.16

79430 LACOSAMIDE 200 MG PO TABS 00131248060 60 Each $15,473.28 $15,473.28

79488 TEMOZOLOMIDE 100 MG IV SOLR J9328 00085138101 1 Each $14,960.00 $14,960.00

79537 CONIVAPTAN IN 5 % DEXTROSE 20 MG/100 ML IV SOLN 66220016010 100 mL $8,915.20 $8,915.20

79622 EVEROLIMUS (ANTINEOPLASTIC) 5 MG PO TABS J7527 00078056651 28 Each $133,082.88 $133,082.88

79623 EVEROLIMUS (ANTINEOPLASTIC) 10 MG PO TABS J7527 00078056751 28 Each $251,305.60 $251,305.60

79804 LACOSAMIDE 200 MG/20 ML IV SOLN C9254 00131181067 20 mL $813.12 $813.12

79860 GOLIMUMAB 50 MG/0.5 ML SC PNIJ J1602 57894007002 .5 mL $40,049.91 $40,049.91

79862 GOLIMUMAB 100 MG/ML SC SYRG J1602 57894007001 .5 mL $40,049.91 $40,049.91

80021 CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SC SYKT J0717 50474071079 1 Each $38,260.89 $38,260.89

80085 TOLVAPTAN 15 MG PO TABS 59148002050 10 Each $78,872.00 $78,872.00

80086 TOLVAPTAN 30 MG PO TABS 59148002150 10 Each $81,820.80 $81,820.80

81014 CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) IJ SOLN J9100 61703030538 5 mL $153.00 $153.00

81046 VANCOMYCIN 750 MG IV SOLR J3370 00143935510 1 Each $153.00 $153.00

81091 TAPENTADOL 50 MG PO TABS 69865021002 100 Each $10,432.00 $10,432.00

81093 TAPENTADOL 100 MG PO TABS 69865023002 100 Each $16,240.00 $16,240.00

81166 FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN Q0138 59338077501 17 mL $9,324.50 $14,919.20

81205 DRONEDARONE 400 MG PO TABS 00024414210 100 Each $16,038.40 $16,038.40

81234 PRASUGREL 5 MG PO TABS 00002512152 24 Each $5,476.22 $5,476.22

81236 PRASUGREL 10 MG PO TABS 00002512377 90 Each $20,535.84 $20,535.84

81294 LEVONORGESTREL 1.5 MG PO TABS 51285016288 1 Each $153.00 $153.00

81462 SEVELAMER CARBONATE 0.8 GRAM PO PWPK 58468013202 90 Each $23,955.84 $23,955.84

81463 SEVELAMER CARBONATE 2.4 GRAM PO PWPK 58468013102 90 Each $23,955.84 $23,955.84

81533 ASENAPINE MALEATE 5 MG SL SUBL 00456240563 100 Each $29,832.00 $29,832.00

81534 ASENAPINE MALEATE 10 MG SL SUBL 00456241060 60 Each $17,899.20 $17,899.20

82920 ULIPRISTAL 30 MG PO TABS 50102091101 1 Each $533.12 $533.12

82922 CEFTAROLINE FOSAMIL 400 MG IV SOLR J0712 00456040010 1 Each $2,632.42 $2,632.42

82923 CEFTAROLINE FOSAMIL 600 MG IV SOLR J0712 00456060010 1 Each $2,632.42 $2,632.42


82976 ABOBOTULINUMTOXINA 300 UNITS IM SOLR 00299596230 1 Each $5,155.00 $8,248.00

82995 ERIBULIN 1 MG/2 ML (0.5 MG/ML) IV SOLN J9179 62856038901 2 mL $10,620.00 $10,620.00

83015 GEMCITABINE 2 GRAM IV SOLR J9201 67457046302 1 Each $499.36 $499.36

83036 DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SC SOLN J0897 55513073001 1.7 mL $17,540.25 $19,732.78

83125 IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) IJ SOLN J1561 13533080020 50 mL $4,310.00 $6,896.00



83558 ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN J0131 43825010201 100 mL $494.40 $494.40

83651 TETRACAINE HCL (PF) 0.5 % OP DROP 00065074114 4 mL $153.00 $153.00

83739 CYTARABINE (PF) 20 MG/ML IJ SOLN J9100 61703030346 50 mL $277.60 $277.60

83904 PRALATREXATE 20 MG/ML (1 ML) IV SOLN J9307 48818000101 1 mL $51,937.83 $51,937.83

83905 PRALATREXATE 40 MG/2 ML (20 MG/ML) IV SOLN J9307 48818000102 2 mL $103,875.66 $103,875.66

84090 PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) IV SOLN J2547 61364018101 20 mL $15,200.00 $15,200.00

84428 BENDAMUSTINE 25 MG IV SOLR J9033 63459039008 1 Each $8,088.32 $8,088.32

84434 COLESEVELAM 3.75 GRAM PO PWPK 65597090230 30 Each $9,798.24 $9,798.24

103469 HEPARIN, PORCINE (PF) 1000 UNIT/ML IJ SOLN (ADULT FLUSH) J1644 63323027602 2 mL $153.00 $153.00

103574 BELIMUMAB 120 MG IV SOLR J0490 49401010101 1 Each $8,541.92 $8,541.92

103575 BELIMUMAB 400 MG IV SOLR J0490 49401010201 1 Each $16,015.68 $16,015.68

103730 IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN J9228 00003232711 10 mL $67,512.60 $67,512.60

103731 IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN J9228 00003232822 40 mL $270,050.40 $270,050.40

103822 GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) IV SOLN A9585 50419032511 7.5 mL $356.69 $356.69

103823 GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) IV SOLN A9585 50419032512 10 mL $634.10 $634.10

103824 GADOBUTROL 15 MMOL/15 ML (1 MMOL/ML) IV SOLN A9585 50419032513 15 mL $464.06 $464.06

103849 PEGINTERFERON ALFA-2B 200 MCG SC KIT 00085434701 1 Each $16,611.66 $16,611.66

103963 ROFLUMILAST 500 MCG PO TABS 00310009539 20 Each $4,310.40 $4,310.40

103972 LINAGLIPTIN 5 MG PO TABS 00597014030 30 Each $5,378.40 $5,378.40

103988 IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN A9584 17156021001 2.5 mL $27,456.50 $27,456.50



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



104222 RITONAVIR 100 MG PO TABS 00074333330 30 Each $3,835.20 $3,835.20

104223 QUETIAPINE 25MG HALF-TAB = 12.5MG 99999900355 1 Each $153.00 $153.00

104612 IRON SUCROSE 200 MG IRON/10 ML IV SOLN J1756 00517231005 200 mg $596.00 $953.60

104614 LEUPROLIDE 7.5 MG IM SYKT J9217 00074364203 1 Each $13,961.43 $13,961.43

104621 EPINEPHRINE 1 MG/ML (1 ML) IJ SOLN J0171 00409724101 1 mL $153.00 $153.00

104677 RILPIVIRINE 25 MG PO TABS 59676027801 30 Each $17,378.88 $17,378.88

104764 FIDAXOMICIN 200 MG PO TABS 52015008001 20 Each $60,536.64 $60,536.64

104871 BELATACEPT 250 MG IV SOLR J0485 00003037113 250 mg $14,400.00 $14,400.00

104927 RIVAROXABAN 10 MG PO TABS 50458058010 100 Each $153.00 $153.00

104948 OFATUMUMAB 1000 MG/50 ML IV SOLN J9302 00078069061 50 mL $50,616.00 $50,616.00

104974 OSELTAMIVIR 6 MG/ML PO SUSR 00004082205 60 mL $2,265.60 $2,265.60

105071 CEFTAZIDIME IN D5W 2 GRAM/50 ML IV PGBK J0713 00264314511 1 Each $259.04 $259.04

105072 TICAGRELOR 90 MG PO TABS 00186077739 100 Each $9,529.60 $9,529.60

105162 KIT FOR OF PREP TC-99M-ALBUMIN 2.5 MG IV SOLR A9540 65174027030 30 Each $78,042.78 $78,042.78




105271 LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT J1950 00074969403 1 Each $84,548.07 $84,548.07

105273 LEUPROLIDE (PEDIATRIC 3 MONTH) 11.25 MG IM SYKT J1950 00074377903 1 Each $76,764.24 $76,764.24

105290 KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR A9539 65174028830 30 Each $44,145.78 $44,145.78

105320 BRENTUXIMAB VEDOTIN 50 MG IV SOLR J9042 51144005001 1 Each $74,430.00 $74,430.00

106214 KIT FOR PREP TC-99M-SUCCIMER 1 MG IV SOLR A9551 17156052501 1 Each $1,780.00 $1,780.00

106243 EPOPROSTENOL (ARGININE) 1.5 MG IV SOLR J1325 66215040201 1 Each $936.80 $936.80

106245 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) IJ SOLN J0780 55390007710 2 mL $153.00 $153.00

106246 PEGINTERFERON ALFA-2A 180 MCG/0.5 ML SC SYRG 00004035230 1 Each $8,569.17 $8,569.17

106252 HYDROXOCOBALAMIN 5 GRAM IV SOLR 11704037001 1 Each $350.72 $350.72

106348 FENTANYL CITRATE IN D5W (PF) 10 MCG/ML IV SOLN 99999900194 250 mL $160.00 $160.00

106623 BUPIVACAINE LIPOSOME (PF) 1.3 % (13.3 MG/ML) LINF SUSP C9290 65250013310 10 mL $2,886.40 $2,886.40

106626 GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN J9201 00409018101 26.3 mL $281.10 $281.10

106648 TESTOSTERONE 2 MG/24 HOUR TD PT24 52544007654 1 Each $153.12 $153.12



106772 TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN 00013111410 10 mL $153.00 $153.00

106783 ASPARAGINASE (ERWINIA CHRYSAN) 10000 UNITS IJ SOLR J9019 57902024901 1 Each $36,277.56 $36,277.56

106856 CLOBAZAM 10 MG PO TABS 67386031401 100 Each $32,852.80 $32,852.80

106962 KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT A9521 17156002305 1 Each $5,139.75 $5,139.75

106995 SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) PO CAPS A9516 48815100101 1 Each $162.16 $162.16

107001 IOBENGUANE SULFATE I-123 10 MCI/5 ML (370 MBQ/5 ML) IV SOLN A9582 17156023501 5 mL $22,121.15 $22,121.15

107877 LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK J1953 70860060282 100 mL $179.20 $179.20

108003 PENTETATE INDIUM DISOD. IN-111 1.5 MCI/1.5 ML IT SOLN A9548 17156025108 1.5 mL $11,344.16 $11,344.16

108012 METHYLNALTREXONE 12 MG/0.6 ML SC SYRG J2212 65649055103 .6 mL $1,723.07 $1,723.07

108016 METHYLNALTREXONE 8 MG/0.4 ML SC SYRG J2212 65649055204 .4 mL $1,859.17 $1,859.17

108126 EVEROLIMUS (ANTINEOPLASTIC) 7.5 MG PO TABS J7527 00078062051 28 Each $187,393.92 $187,393.92

108169 CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/50 ML IV PGBK J0690 00264310511 1 Each $170.61 $170.61

108192 ENFUVIRTIDE 90 MG SC SOLR J1324 00004038140 60 Each $53,473.92 $53,473.92

108263 DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) PO SOLN 68094075062 5 mL $153.00 $153.00

108862 C1 ESTERASE INHIBITOR 500 UNIT (10 ML) IV KIT J0597 63833082502 1 Each $21,571.11 $21,571.11

109350 TALIGLUCERASE ALFA 200 UNITS IV SOLR J3060 00069010601 1 Each $8,028.30 $12,845.28

109480 FLORBETAPIR F-18 10 MCI (370 MBQ) IV SOLN A9586 00002120001 1 Each $13,479.05 $13,479.05

109607 PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN J9306 50242014501 14 mL $47,628.00 $47,628.00

110536 SODIUM IODIDE I-131 CAPSULE A9517 99999900479 1 Each $153.00 $153.00

110542 RUBIDIUM CHLORIDE RB-82 A9555 00270009101 1 Each $1,007.39 $1,007.39

110577 MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN 54643564901 10 mL $153.00 $153.00

110766 CARFILZOMIB 60 MG IV SOLR J9047 76075010101 1 Each $21,916.62 $21,916.62

110849 TETANUS,DIPHTHERIA TOX PED(PF) 5-25 LF UNIT/0.5 ML IM SUSP 49281022558 .5 mL $853.76 $853.76

110946 ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) IV SOLN J9400 00024584001 4 mL $12,800.00 $12,800.00

111054 ELVITEG-COB-EMTRI-TENOFO DISOP 150-150-200-300 MG PO TABS 61958120101 30 Each $50,661.12 $50,661.12

111103 LINACLOTIDE 145 MCG PO CAPS 00456120130 30 Each $6,633.60 $6,633.60

111104 LINACLOTIDE 290 MCG PO CAPS 00456120230 30 Each $6,633.60 $6,633.60

111144 RIVASTIGMINE 13.3 MG/24 HOUR TD PT24 00781731358 1 Each $201.60 $201.60

111144 RIVASTIGMINE 13.3 MG/24 HOUR TD PT24 00781731331 30 Each $6,048.00 $6,048.00

111324 HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) PO SYRP 00121481105 5 mL $153.00 $153.00

111324 HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) PO SYRP 99999900135 5 mL $153.00 $153.00

111550 MEGESTROL 400 MG/10 ML (10 ML) PO SUSP 66689002050 10 mL $153.00 $153.00

111602 ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN 00121050405 5 mL $153.00 $153.00

111602 ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN 99999900386 5 mL $153.00 $153.00

111657 DARUNAVIR ETHANOLATE 800 MG PO TABS 59676056630 30 Each $26,333.28 $26,333.28

112770 FLUORODEOXYGLUCOSE (F-18) ISOTOPE (NUC MED) A9552 65857010010 5 mL $467.25 $467.25

112771 SODIUM FLOURIDE (F-18) ISOTOPE (NUC MED) A9580 40028512300 1 Each $911.27 $911.27

112772 GALLIUM (GA-67) CITRATE ISOTOPE (NUC MED) A9556 11994012109 9.9 mL $65,740.74 $65,740.74

112772 GALLIUM (GA-67) CITRATE ISOTOPE (NUC MED) A9556 11994012106 1 Each $4,382.58 $4,382.58



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



112774 BICISATE DIHYDROCHLORIDE (TC-99M) (NEUROLITE) ISOTOPE (NUC ME) A9557 11994000602 1 Each $6,219.14 $6,219.14

112777 MEDRONATE (TC-99M MDP) ISOTOPE (NUC MED) A9503 00270387680 1 Each $570.40 $570.40

112778 SODIUM PERTECHNETATE (TC-99M O4) ISOTOPE (NUC MED) A9512 99999900480 1 Each $153.00 $153.00

112780 MICROSPHERES (Y-90 GLASS) (THERA-SPHERES) ISOTOPE (NUC MED) C2616 99999900481 1 Each $84,500.00 $84,500.00

112781 MICROSPHERES (Y-90 RESIN) (SIR-SPHERES) ISOPTOPE (NUC MED) C2616 99999900482 1 Each $84,500.00 $84,500.00

112909 APIXABAN 2.5 MG PO TABS 00003089331 100 Each $2,236.80 $2,236.80

112998 HONEY 80 % TP GEL 09958003461 15 mL $153.00 $153.00

113023 APIXABAN 5 MG PO TABS 00003089431 100 Each $2,236.80 $2,236.80

113111 LEVONORGESTREL 14 MCG/24 HRS (3 YRS) 13.5 MG IU IUD J7301 50419042201 1 Each $12,703.36 $12,703.36

113840 LABELED RED BLOOD CELLS (TC-99M RBC) (ULTRATAG) ISOTOPE (NUC MED) A9560 00019N068B0 1 kit $775.01 $775.01

113955 ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR J9354 50242008801 1 Each $28,390.41 $28,390.41

113956 ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR J9354 50242008701 1 Each $45,424.62 $45,424.62

114065 HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IX SYRG J7326 87541030091 3 mL $2,910.00 $2,910.00

114142 SOD BORATE-BORIC AC-NACL-WATER OP IRSL 00536122497 118 mL $153.00 $153.00

114352 DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN 00409166050 50 mL $435.20 $435.20

114407 LIPASE-PROTEASE-AMYLASE 36,000-114,000- 180,000 UNIT PO CPDR 00032301613 100 Each $14,992.00 $14,992.00

115116 ADENOSINE IN 0.9% NACL 90 MG/90 ML INFUSION (CATH LAB USE) J0153 99999900544 90 mL $691.20 $691.20

115120 HYDROMORPHONE 1 MG/ML PO LIQUID (DOSE >= 4 MG) 99999001194 4 mL $153.00 $153.00

115127 TECHNETIUM (LYMPHOSEEK) TC 99M TILMANOCEPT A9520 52579160005 1 kit $2,211.65 $2,211.65

115140 DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP 90715 58160084211 .5 mL $522.45 $522.45

115146 SODIUM GLYCEROPHOSPHATE 1 MMOL/ML IV SOLN 63323024120 20 mL $171.20 $171.20

115242 RADIUM RA 223 DICHLORIDE 1,100 KBQ/ML(30 MICROCURIE/ML) IV SOLN A9606 50419020801 1 Each $98,988.69 $98,988.69

115276 HYDROMORPHONE 0.5 MG/0.5 ML IJ SYRG J1170 00409128304 .5 mL $153.00 $153.00

115363 NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN J2710 63323041510 10 mL $153.00 $153.00

115413 NIMODIPINE 60 MG/20 ML PO SOLN 99999001225 10 mL $627.20 $627.20

115413 NIMODIPINE 60 MG/20 ML PO SOLN 24338020020 20 mL $1,254.40 $1,254.40

115541 DEXTROSE-SOD CITRATE-CITRIC AC 2.45-2.2 GRAM- 730 MG/100 ML MISC SOLN 99999002271 750 mL $153.00 $153.00

115596 BUTALBITAL-ACETAMINOP-CAF-COD 50-300-40-30 MG PO CAPS 00591264101 100 Each $7,968.00 $7,968.00

116015 BECLOMETHASONE DIPROPIONATE ORAL EMULSION 99999900600 120 mL $153.00 $153.00

116028 INFLUENZA VACCINE (FLUMIST) INTRANASAL J3530 66019030001 .2 mL $354.56 $354.56

116040 VINCRISTINE SULFATE LIPOSOMAL 5 MG/31 ML(0.16 MG/ML) FINAL IV KIT J9371 20536032201 1 Each $135,670.14 $135,670.14

116056 COPPER 380 SQUARE MM IU IUD J7300 51285020401 1 Each $14,152.00 $14,152.00

116063 GOLIMUMAB 12.5 MG/ML IV SOLN J1602 57894035001 4 mL $15,994.91 $15,994.91

116071 TACROLIMUS 0.5 MG PO CP24 J7508 00469064773 30 Each $1,053.60 $1,053.60

116072 TACROLIMUS 1 MG PO CP24 J7508 00469067773 30 Each $2,107.20 $2,107.20

116092 GOLIMUMAB 100 MG/ML SC PNIJ J3490 57894007102 1 mL $48,481.65 $48,481.65

116111 FERRIC CARBOXYMALTOSE 50 IRON MG/ML IV SOLN J1439 00517065001 15 mL $8,534.55 $13,655.28

116118 CLOBAZAM 2.5 MG/ML PO SUSP 99999900624 2 mL $287.68 $287.68

116187 DOLUTEGRAVIR 50 MG PO TABS 49702022813 30 Each $27,239.04 $27,239.04

116691 ASPIRIN ORAL SUSPENSION 1 MG/ML PEDIATRIC 99999900636 81 mL $153.00 $153.00

116706 MIDAZOLAM (PF) 5 MG/ML IJ SOLN J2250 00409230801 1 mL $153.00 $153.00

116707 MIDAZOLAM (PF) 1 MG/ML IJ SOLN J2250 00409230517 2 mL $153.00 $153.00

116780 VORTIOXETINE 5 MG PO TABS 64764072030 30 Each $5,665.92 $5,665.92

116781 VORTIOXETINE 10 MG PO TABS 64764073030 30 Each $5,665.92 $5,665.92

116808 RIOCIGUAT 0.5 MG PO TABS 50419025091 9 Each $17,533.44 $17,533.44

116809 RIOCIGUAT 1 MG PO TABS 50419025191 9 Each $16,539.84 $16,539.84

116812 RIOCIGUAT 2.5 MG PO TABS 50419025401 90 Each $165,404.16 $165,404.16

116883 MACITENTAN 10 MG PO TABS 66215050115 15 Each $87,264.00 $87,264.00

116902 TOCILIZUMAB 162 MG/0.9 ML SC SYRG 50242013801 .9 mL $15,580.17 $15,580.17

116926 OBINUTUZUMAB 1000 MG/40 ML IV SOLN J9301 50242007001 40 mL $59,842.80 $59,842.80

116976 TBO-FILGRASTIM 300 MCG SC SYRG J1447 63459091011 .5 mL $2,235.84 $2,235.84

116977 TBO-FILGRASTIM 480 MCG SC SYRG J1447 63459091211 .8 mL $3,578.24 $3,578.24

117038 POSACONAZOLE 100 MG PO TBEC J8499 00085432402 60 Each $28,999.68 $28,999.68

117397 METHOTREXATE (PF) 10 MG/0.4 ML SC ATIN 54436001004 .4 mL $2,422.64 $2,422.64

117459 PERAMPANEL 2 MG PO TABS 62856027230 30 Each $7,606.08 $7,606.08

117460 PERAMPANEL 4 MG PO TABS 62856027430 30 Each $15,033.12 $15,033.12

117913 RAMUCIRUMAB 10 MG/ML IV SOLN J9308 00002767801 50 mL $53,536.50 $53,536.50

117913 RAMUCIRUMAB 10 MG/ML IV SOLN J9308 00002766901 10 mL $10,707.30 $10,707.30

117921 ETHIODIZED OIL 480 MG IODINE/ML IJ OIL A9698 67684190101 10 mL $22,280.00 $22,280.00

117924 VEDOLIZUMAB 300 MG IV SOLR J3380 64764030020 1 Each $60,548.85 $60,548.85

117930 CYCLOPHOSPHAMIDE 25 MG PO CAPS J8530 00054038225 100 Each $11,169.60 $11,169.60

117931 CYCLOPHOSPHAMIDE 50 MG PO CAPS J8530 00054038325 100 Each $20,499.20 $20,499.20

117933 POLIDOCANOL 1 % IV FOAM 60635011801 45 mL $28,755.00 $28,755.00

117944 UMECLIDINIUM-VILANTEROL 62.5-25 MCG/ACTUATION IN DSDV 00173086906 14 Each $430.08 $430.08

118080 MORPHINE 2 MG/ML IV SYRG J2270 00409189001 1 mL $153.00 $153.00

118081 MORPHINE 4 MG/ML IV SYRG J2270 00409189101 1 mL $153.00 $153.00

118427 HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT (400-620 UNIT) IV SOLR 63833038602 1 Each $13,840.00 $13,840.00

118616 HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1240 UNIT) IV SOLR C9132 63833038702 1 Each $27,680.00 $27,680.00

118876 EMPAGLIFLOZIN 25 MG PO TABS 00597015337 30 Each $6,077.28 $6,077.28

118877 EMPAGLIFLOZIN 10 MG PO TABS 00597015237 30 Each $6,077.28 $6,077.28

119944 GLATIRAMER 20 MG/ML SC SYRG J1595 68546031730 1 mL $3,536.51 $3,536.51



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



119952 METHOTREXATE (PF) 15 MG/0.3 ML SC ATIN 59137052000 .3 mL $1,838.11 $1,838.11

120220 COBICISTAT 150 MG PO TABS Z7610 61958140101 30 Each $3,605.28 $3,605.28

120661 FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN (RADIANT USE) Q9953 99999001534 17 mL $7,097.76 $7,097.76

120702 TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION IN MIST J3535 00597010051 4 gram $279.62 $279.62

120847 VASOPRESSIN 20 UNITS/ML IV SOLN J3490 42023016425 1 Each $2,937.98 $2,937.98

120857 BUDESONIDE 2 MG/ACTUATION PR FOAM 65649065103 33.4 gram $4,960.08 $4,960.08

120887 ALEMTUZUMAB 12 MG/1.2 ML IV SOLN (NON-ONCOLOGICAL USE) J0202 58468020001 1.2 mL $201,107.97 $201,107.97

120946 BLINATUMOMAB 35 MCG IV KIT J9039 55513016001 1 Each $36,048.24 $36,048.24

120962 HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SUSP 90651 00006411903 .5 mL $3,297.63 $3,297.63

120963 HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG 90651 00006412102 .5 mL $3,297.63 $3,297.63

121230 MENINGOCOCCAL B VACCINE,4-COMP 50-50-50-25 MCG/0.5 ML IM SYRG 90620 58160097606 .5 mL $2,269.28 $2,269.28

121236 OXYCODONE 10 MG PO TR12 43063035402 2 Each $153.00 $153.00

121236 OXYCODONE 10 MG PO TR12 43063035410 10 Each $531.20 $531.20

121236 OXYCODONE 10 MG PO TR12 59011041010 100 Each $5,168.00 $5,168.00



















121327 CEFTOLOZANE-TAZOBACTAM 1.5 GRAM IV SOLR J0695 67919003001 1 Each $1,867.41 $1,867.41

121347 NIVOLUMAB 40 MG/4 ML IV SOLN J9299 00003377211 4 mL $9,870.84 $9,870.84


121439 PEGFILGRASTIM 6 MG/0.6 ML SC OBISYRINGE J2505 55513019201 .6 mL $37,750.05 $37,750.05

121472 PEMBROLIZUMAB 25 MG/ML IV SOLN J9271 00006302602 4 mL $43,758.36 $43,758.36

121508 SECUKINUMAB 150 MG/ML SC PNIJ C9399 00078063968 1 mL $49,872.87 $49,872.87

121532 PALBOCICLIB 125 MG PO CAPS 00069018921 21 Each $199,190.88 $199,190.88

121945 IVABRADINE 5 MG PO TABS 55513080060 60 Each $6,852.48 $6,852.48

121946 IVABRADINE 7.5 MG PO TABS 55513081060 60 Each $6,852.48 $6,852.48

121950 OCTREOTIDE,MICROSPHERES 20 MG IM SSRR J2353 00078081881 1 Each $31,483.28 $35,418.69



122035 CEFTAZIDIME-AVIBACTAM 2.5 GRAM IV SOLR J0714 00456270001 1 Each $5,348.48 $5,348.48

122080 ISAVUCONAZONIUM SULFATE 372 MG IV SOLR J1833 00469042099 1 Each $4,696.16 $4,696.16

122083 ISAVUCONAZONIUM SULFATE 186 MG PO CAPS 00469052014 14 Each $19,319.10 $19,319.10

122566 IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN 13533063504 2 mL $895.00 $1,432.00

122566 IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN 13533063512 10 mL $4,089.00 $6,542.40

122590 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IV SOLN 59730650201 50 mL $6,650.00 $10,640.00

122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270002 10 mL $869.00 $1,390.40

122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270004 50 mL $4,345.00 $6,952.00



122593 IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN J1459 44206043710 10 gram $6,718.00 $10,748.80

122602 IMMUN GLOB G-GLY-GLUC-IGA 0-50 5 GRAM IV SOLR 00944265707 5 gram $6,199.50 $9,919.20

122603 IMMUN GLOB G-GLY-GLUC-IGA 0-50 10 GRAM IV SOLR J1569 00944265804 1 Each $9,919.12 $11,159.01

122923 CANGRELOR 50 MG IV SOLR C9460 65293000301 1 Each $10,053.28 $10,053.28

122998 SACUBITRIL-VALSARTAN 24-26 MG PO TABS 00078065935 100 Each $13,408.00 $13,408.00



123564 FILGRASTIM-SNDZ 480 MCG IJ SYRG Q5101 61314031201 .8 mL $2,876.42 $2,876.42

123565 FILGRASTIM-SNDZ 300 MCG IJ SYRG Q5101 61314030401 .5 mL $1,797.60 $1,797.60

123745 SULFUR HEXAFLUORIDE MICROSPHR 25 MG IV SUSR Q9950 00270709916 1 Each $253.18 $253.18

123826 TICAGRELOR 60 MG PO TABS 00186077660 60 Each $5,717.76 $5,717.76

124171 TRABECTEDIN 1 MG IV SOLR J9352 59676061001 1 Each $27,328.95 $27,328.95

124173 INSULIN DEGLUDEC 100 UNIT/ML (3 ML) SC INPN 00169266015 3 mL $1,443.70 $1,443.70

124174 INSULIN DEGLUDEC 200 UNIT/ML (3 ML) SC INPN 00169255013 3 mL $2,887.39 $2,887.39

124331 MORPHINE 4 MG/ML IV SOLN J2270 00641612501 1 mL $153.00 $153.00

124446 IDARUCIZUMAB 2.5 GRAM/50 ML IV SOLN J3590 00597019705 50 mL $17,941.50 $17,941.50

124464 IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP J9205 69171039801 10 mL $21,294.00 $21,294.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



124485 TALIMOGENE LAHERPAREPVEC 10EXP6 (1 MILLION) PFU/ML IJ SUSP J9325 55513007801 1 mL $828.64 $828.64

124486 TALIMOGENE LAHERPAREPVEC 10EXP8 (100 MILLION) PFU/ML IJ SUSP J9325 55513007901 1 mL $46,613.34 $46,613.34

124522 MEPOLIZUMAB 100 MG SC SOLR J2182 00173088101 1 Each $25,015.59 $25,015.59

124529 ELVITEG-COB-EMTRI-TENOF ALAFEN 150-150-200-10 MG PO TABS 61958190101 30 Each $48,294.72 $48,294.72

124585 DARATUMUMAB 20 MG/ML IV SOLN J9145 57894050220 20 mL $19,904.40 $19,904.40

125030 SUGAMMADEX 100 MG/ML IV SOLN J3490 00006542312 2 mL $1,561.70 $1,561.70


125039 HYDROXYPROGESTERONE CAP(PPRES) 250 MG/ML IM OIL 64011024301 5 mL $26,937.00 $26,937.00

125129 ELOTUZUMAB 300 MG IV SOLR J9176 00003229111 1 Each $17,477.64 $17,477.64

125130 ELOTUZUMAB 400 MG IV SOLR J9176 00003452211 1 Each $23,303.43 $23,303.43

125167 BENDAMUSTINE 25 MG/ML IV SOLN J9034 63459034804 4 mL $15,564.35 $15,564.35

125227 SELEXIPAG 200 MCG PO TABS 66215060206 60 Each $198,028.80 $198,028.80





125904 HYALURONATE,MOD.,NON-CROSSLINK 24 MG/3 ML IX SYRG J7322 89122049663 3 mL $4,200.00 $4,200.00


126722 BRIVARACETAM 10 MG/ML PO SOLN 99999002174 2.5 mL $153.00 $153.00

126724 BRIVARACETAM 25 MG PO TABS Z7610 50474047066 60 Each $17,588.16 $17,588.16

126780 RESLIZUMAB 10 MG/ML IV SOLN J2786 59310061031 10 mL $14,912.00 $14,912.00

126839 EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG PO TABS 61958200201 30 Each $27,475.20 $27,475.20

127054 ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN J9022 50242091701 20 mL $82,746.00 $82,746.00

127441 AZATHIOPRINE ORAL SUSPENSION 50 MG/ML J7500 99999001272 30 mL $230.40 $230.40

127442 DILTIAZEM ORAL SUSPENSION 12 MG/ML 99999001276 100 mL $153.00 $153.00

127475 TADALAFIL (PULM. HYPERTENSION) 20 MG PO TABS 00378697693 30 Each $672.00 $672.00

127510 EPHEDRINE SULFATE 50 MG/ML IV SOLN 76014000530 1 mL $164.00 $164.00

127526 VANCOMYCIN IN 0.9 % SODIUM CHL 750 MG/150 ML IV PGBK J3370 00338358201 150 mL $1,224.00 $1,224.00

127562 MESALAMINE 400 MG PO CDTI 00023585318 180 Each $10,414.08 $10,414.08

128085 SOD,POT CHLOR-MAG-SOD,POT PHOS 800-40-20-8.75- 6.25 MG/100 ML IR IRSL 00338019004 1000 mL $153.00 $153.00

128096 FAT EMULSION 20% (SMOFLIPID) ADULT 63323082074 250 mL $320.00 $320.00

128102 METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN Q9968 00517037401 10 mL $3,081.60 $3,081.60

128205 THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLN A9505 11994042726 1 Each $153.00 $153.00

128651 USTEKINUMAB 130 MG/26 ML IV SOLN J3358 57894005427 26 mL $13,038.48 $13,038.48

128668 HYDROMORPHONE 1 MG/ML IJ SOLN J1170 00409255201 1 mL $153.00 $153.00

128671 INFLIXIMAB-DYYB 100 MG IV SOLR Q5103 00069080901 1 Each $7,800.00 $7,800.00

128700 LEVONORGESTREL 17.5 MCG/24 HRS (5 YRS) 19.5 MG IU IUD J7296 50419042401 1 Each $15,256.16 $15,256.16

128837 OLARATUMAB 10 MG/ML IV SOLN J9285 00002892601 50 mL $22,380.30 $22,380.30

129158 SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IX SYRG J7323 55566410001 2 mL $1,008.00 $1,008.00

129165 MELPHALAN HCL-BETADEX SBES 50 MG IV SOLR J9246 68152010900 1 Each $9,647.28 $9,647.28

129166 IMM GLOB G (IGG)-SORB-IGA 0-50 10 % IV SOLN 61953000501 50 mL $4,180.00 $6,688.00

129189 TENOFOVIR ALAFENAMIDE 25 MG PO TABS 61958230101 30 Each $17,487.36 $17,487.36

129316 NUSINERSEN (PF) 12 MG/5 ML IT SOLN J2326 64406005801 5 mL $500,000.00 $500,000.00

130591 OCRELIZUMAB 30 MG/ML IV SOLN J2350 50242015001 10 mL $146,250.00 $146,250.00

131258 LETERMOVIR 240 MG PO TABS 00006307502 28 Each $89,771.58 $89,771.58

131412 LU-177 DOTATATE (LUTATHERA) ISOTOPE (NUC MED) A9513 99999911111 25 mL $165,045.16 $165,045.16

131493 SARILUMAB 200 MG/1.14 ML SC SYRG J3590 00024591001 1.14 mL $14,594.40 $14,594.40

131569 RITUXIMAB-HYALURONIDASE,HUMAN 1400 MG/11.7 ML (120 MG/ML) SC SOLN J9311 50242010801 11.7 mL $52,612.56 $59,189.13

131584 DURVALUMAB 50 MG/ML IV SOLN J9173 00310450012 2.4 mL $14,073.60 $14,073.60

131584 DURVALUMAB 50 MG/ML IV SOLN J9173 00310461150 10 mL $32,985.00 $32,985.00

131629 EDARAVONE 30 MG/100 ML IV PGBK J1301 70510217101 100 mL $9,040.00 $9,040.00

131760 RITUXIMAB-HYALURONIDASE,HUMAN 1600 MG/13.4 ML (120 MG/ML) SC SOLN J9311 50242010901 13.4 mL $60,128.48 $67,644.54


132800 SPIRONOLACTONE 25 MG/5 ML PO SUSP 46287002004 118 mL $3,864.74 $3,864.74

132827 DAUNORUBICIN-CYTARABINE LIPOS 44-100 MG IV SOLR J9153 68727074501 1 Each $71,842.50 $71,842.50

132843 INOTUZUMAB OZOGAMICIN 0.9 MG (0.25 MG/ML INITIAL) IV SOLR J9229 00008010001 .9 mg $178,549.43 $178,549.43

132886 GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONC) IV SOLR J9203 00008451001 1 Each $78,294.42 $78,294.42

133065 BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION IN HFAB J3535 59310030240 10.6 gram $1,375.80 $1,375.80

133081 COPANLISIB 60 MG IV SOLR J9057 50419038501 1 Each $41,987.52 $41,987.52

133185 TRIAMCINOLONE ACETONIDE 32 MG IX SSRR J3304 70801000301 1 Each $9,120.00 $9,120.00

133245 VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR 90750 58160081912 1 Each $2,212.96 $2,212.96


133641 ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN J0256 13533070501 1 Each $3,821.60 $6,114.56

133859 ANGIOTENSIN II 2.5 MG/ML IV SOLN C9399 68547050102 1 mL $13,500.00 $13,500.00

133949 BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG PO TABS 61958250101 30 Each $48,294.72 $48,294.72

134118 ESMOLOL IN STERILE WATER 2,500 MG/250 ML (10 MG/ML) IV SOLP 44567081110 250 mL $2,312.00 $2,312.00

134119 ESMOLOL IN STERILE WATER 2,000 MG/100 ML (20 MG/ML) IV SOLP 44567081210 100 mL $2,699.20 $2,699.20

134253 STERILE TALC 4 GRAM PL SUSR 62327044404 1 Each $2,240.00 $2,240.00

134510 IRON DEXTRAN 50 MG/ML IJ SOLN J1750 52544093102 2 mL $435.52 $435.52





CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



134676 FACTOR XA,INACTIVATED-ZHZO 100 MG IV SOLR J7169 69853010101 1 Each $48,227.85 $48,227.85

134878 DAPTOMYCIN 350 MG IV SOLR J0878 70594005301 1 Each $783.04 $783.04

134885 SARILUMAB 150 MG/1.14 ML SC PNIJ J3590 00024592001 1.14 mL $14,594.40 $14,594.40

134886 SARILUMAB 200 MG/1.14 ML SC PNIJ J3590 00024592201 1.14 mL $14,594.40 $14,594.40

134907 EPOETIN ALFA-EPBX 2000 UNITS/ML IJ SOLN Q5106 00069130510 1 mL $183.25 $293.20

134908 EPOETIN ALFA-EPBX 3000 UNITS IJ SOLN Q5106 00069130610 1 mL $274.88 $439.81

134909 EPOETIN ALFA-EPBX 4000 UNITS IJ SOLN Q5105 00069130710 1 mL $366.50 $586.40

134910 EPOETIN ALFA-EPBX 10000 UNITS IJ SOLN Q5105 00069130810 1 mL $916.27 $1,466.03

135244 SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM PO PWPK 00310110539 11 Each $627.09 $627.09

135246 SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM PO PWPK 00310111039 11 Each $627.09 $627.09

135306 DARUNAVIR-COBI-EMTRI-TENOF ALA 800-150-200-10 MG PO TABS 59676080030 30 Each $58,010.40 $58,010.40

135562 AMINO ACID 15% NO.5 15 % IV SOLP 00338050206 2000 mL $768.00 $768.00

135681 IOHEXOL 12 MG IODINE/ML PO SOLN A9698 00407141612 500 mL $153.00 $153.00

135879 EVEROLIMUS (IMMUNOSUPPRESSIVE) 1 MG PO TABS J7527 00078042220 60 Each $33,191.04 $33,191.04

135886 AMINOLEVULINIC ACID HCL 30 MG/ML PO SOLR 71469023101 1 Each $25,101.00 $25,101.00

135895 RIVAROXABAN 2.5 MG PO TABS 50458057710 100 Each $4,492.80 $4,492.80

135932 ANTIVENIN CROTALIDAE (EQUINE) IJ SOLR 66621079002 1 Each $10,233.63 $10,233.63

135933 DORAVIRINE 100 MG PO TABS 00006306901 30 Each $20,584.80 $20,584.80

136003 CEMIPLIMAB-RWLC 50 MG/ML IV SOLN J9119 61755000801 7 mL $81,900.00 $81,900.00

136071 BALSAM PERU-CASTOR OIL TP OINT 58980078021 60 gram $443.52 $443.52

136931 DEXTROSE-SOD CITRATE-CITRIC AC 2.45-2.2 GRAM- 800 MG/100 ML MISC SOLN 14537096775 750 mL $153.00 $153.00

136994 ARGININE-LYSINE IN 0.9 % NACL 25-25 MG/ML IV SOLN 69374098810 1000 mL $720.00 $720.00

137088 PRUCALOPRIDE 1 MG PO TABS 54092054601 30 Each $6,511.68 $6,511.68

137091 PRUCALOPRIDE 2 MG PO TABS 54092054701 30 Each $6,511.68 $6,511.68

137338 ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) IV SOLN J9022 50242091801 14 mL $57,922.20 $57,922.20

137514 TRASTUZUMAB-HYALURONIDASE-OYSK 600 MG-10,000 UNIT/5 ML SC SOLN J9356 50242007701 5 mL $42,077.25 $42,077.25

137554 ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SC SYRG J3111 55513088002 1.17 mL $8,212.45 $8,212.45

137819 SELENIUM 60 MCG/ML IV SOLN 00517656025 10 mL $3,041.60 $3,041.60

138215 BEVACIZUMAB-AWWB 25 MG/ML IV SOLN Q5107 55513020701 16 mL $23,538.96 $23,538.96

138215 BEVACIZUMAB-AWWB 25 MG/ML IV SOLN Q5107 55513020601 4 mL $10,461.76 $10,461.76

138219 CALCIUM GLUC IN NACL, ISO-OSM 2 G/100 ML IV SOLN J0610 44567062124 100 mL $268.80 $268.80

138220 FLU VAC QS 2019-20(6-35MO)(PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRG 90685 33332021920 .25 mL $956.42 $956.42

138220 FLU VAC QS 2019-20(6-35MO)(PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRG 90685 33332021921 .25 mL $239.10 $239.10

138221 FLU VAC QS2019-20 36MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 33332031901 .5 mL $478.21 $478.21

138221 FLU VAC QS2019-20 36MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 33332031902 .5 mL $239.10 $239.10

138222 FLU VACC QS2019-20 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 58160089641 .5 mL $204.32 $204.32

138222 FLU VACC QS2019-20 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 58160089652 .5 mL $408.64 $408.64

138229 FLU VAC QV 2019(18YR UP)RC(PF) 180 MCG (45 MCG X 4)/0.5 ML IM SYRG 90682 49281071910 .5 mL $1,339.42 $1,339.42

138229 FLU VAC QV 2019(18YR UP)RC(PF) 180 MCG (45 MCG X 4)/0.5 ML IM SYRG 90682 49281071988 .5 mL $1,339.36 $1,339.36

138233 FLU VACC TS2019-20(65YR UP)PF 180 MCG/0.5 ML IM SYRG 90662 49281040588 .5 mL $1,339.36 $1,339.36

138233 FLU VACC TS2019-20(65YR UP)PF 180 MCG/0.5 ML IM SYRG 90662 49281040565 .5 mL $1,339.42 $1,339.42

138242 TRASTUZUMAB-ANNS 420 MG IV SOLR Q5117 55513013201 1 Each $32,119.02 $32,119.02

138287 AMLODIPINE BENZOATE 1 MG/ML PO SUSP 52652500101 150 mL $7,392.00 $7,392.00

138755 ANTI-INHIBITOR COAGULANT CMPLX 700-1,300 UNIT IV SOLR J7198 64193042402 1 Each $22,880.00 $22,880.00

139145 TRASTUZUMAB-ANNS 150 MG IV SOLR Q5117 55513014101 1 Each $11,471.13 $11,471.13

140183 CEFIDEROCOL 1 GRAM IV SOLR 59630026601 1 Each $2,734.16 $2,734.16

140925 NIMODIPINE 30 MG/5 ML PO SYRG 24338023012 5 mL $653.92 $653.92

140935 DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SC SOLN C9399 57894050301 15 mL $67,825.22 $67,825.22

200001 AMIODARONE IV INFUSION (1 MG/ML) J0282 99999900423 500 mL $153.00 $153.00

200005 PROCAINAMIDE 2500MG IN D5W 250ML 99999900514 250 mL $2,200.00 $2,200.00

400009 AZITHROMYCIN 500 MG IV J0290 63323039810 1 Each $153.00 $153.00

400022 CARDIOPLEGIC SOLUTION WITH GLUTAMATE/ASPARTATE IRRIGATION 99999900396 1000 mL $2,144.00 $2,144.00

400026 HYDROMORPHONE 1MG/ML PCA CSMC J1170 99999900382 30 mL $211.20 $211.20

400061 CALCIUM GLUCONATE IVPB 1 G J0610 99999900162 50 mL $153.00 $153.00

400093 VANILLA TPN PICU/NICU 250 ML 99999900406 250 mL $420.00 $420.00

400279 HEPARIN, PORCINE (PF) 1000 UNIT/ML IJ SOLN FOR INTRACATHETER J1644 99999900420 10 mL $153.00 $153.00

400282 CEFAZOLIN IVPB 2 G J0690 99999900109 1 Each $153.00 $153.00

400290 SODIUM CHLORIDE 3% IV PEDIATRIC 99999900203 1 mL $153.00 $153.00

400309 HYDROMORPHONE PCA HIGH DOSE 99999900383 30 mL $153.00 $153.00

400311 PHENOBARBITAL ORAL SOLUTION 4 MG/ML FOR NICU 99999900140 1 mL $153.00 $153.00

400312 CHLORAL HYDRATE ORAL SOLUTION 100 MG/ML FOR NICU 99999900141 1 mL $153.00 $153.00

400318 OXYTOCIN CONTINUOUS INFUSION (0.06 UNITS/ML) J2590 99999900362 250 mL $153.00 $153.00

400338 LOSARTAN 25 MG HALF-TAB = 12.5 MG 99999900426 1 Each $153.00 $153.00

400350 METHACHOLINE 50 MG IN 0.9% NACL WITH 0.4% PHENOL 2 ML (25 MG/ML) (TEST SOLUTION A) 999990020654 1 Each $559.20 $559.20

400351 METHACHOLINE 25 MG IN 0.9% NACL WITH 0.4% PHENOL 2.5 ML (10 MG/ML) (TEST SOLUTION B) 999990020655 1 Each $279.68 $279.68

400352 METHACHOLINE 22.5 MG IN 0.9% NACL WITH 0.4% PHENOL 9 ML (2.5 MG/ML ) (TEST SOLUTION C) 999990020656 1 Each $251.68 $251.68

400353 METHACHOLINE 2.5 MG IN 0.9% NACL WITH 0.4% PHENOL 10 ML (0.25 MG/ML ) (TEST SOLUTION D) 999990020657 1 Each $153.00 $153.00

400449 LEVOTHYROXINE 100 MCG IV SOLR 6332364907 1 Each $1,252.00 $1,252.00

400457 DEXTROSE 25% - PEDIATRIC 99999900474 1 Each $153.00 $153.00

400473 INSULIN REGULAR 1 UNIT/ML BOLUS PEDIATRIC 99999-9002-04 1 mL $153.00 $153.00

400474 PENICILLIN 0.5MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900443 50 mL $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



400475 PENICILLIN 5 MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900444 50 mL $153.00 $153.00

400476 PENICILLIN 50 MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900445 50 mL $153.00 $153.00

400480 METOPROLOL (LOPRESSOR) ORAL SOLUTION 10MG/ML 99999900440 100 mL $448.00 $448.00

400493 DIETHYLENE TRIAMINE PENTAACETIC ACID (TC-99M DTPA) ISOTOPE (NUC MED) N A9567 99999900478 30 Each $1,471.53 $1,471.53

400500 AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO HALF-TAB = 2.5 MG CS0040050001 1 Each $153.00 $153.00

400502 ALPRAZOLAM 0.25 MG HALF-TAB = 0.125 MG CS0040050201 1 Each $153.00 $153.00

400505 AZATHIOPRINE 50 MG HALF-TAB = 25 MG CS0040050501 1 Each $153.00 $153.00

400509 CAPECITABINE 150 MG HALF-TAB = 75 MG J8520 CS0040050901 1 Each $153.00 $153.00

400527 LORAZEPAM 0.5 HALF-TAB = 0.25 MG 99999900353 1 Each $153.00 $153.00

400529 MERCAPTOPURINE 50 MG HALF-TAB = 25 MG CS0040052901 1 Each $153.00 $153.00

400530 METHOTREXATE SODIUM 2.5 MG HALF-TAB = 1.25 MG J8610 CS0040053001 1 Each $153.00 $153.00

400531 METHYLPHENIDATE 5 MG HALF-TAB = 2.5 MG CS0040053101 1 Each $153.00 $153.00

400533 MODAFINIL 100 MG HALF-TAB = 50 MG CS0040053301 1 Each $153.00 $153.00

400534 PHYTONADIONE 5 MG HALF-TAB = 2.5 MG CS0040053401 1 Each $473.92 $473.92

400545 ZOLPIDEM 5 MG HALF-TAB = 2.5 MG CS0040054501 1 Each $153.00 $153.00

400551 ALBUTEROL 90 MCG/ACTUATION IN AERO - PEDIATRIC 00085113201 6.7 gram $156.30 $156.30

400554 PANTOPRAZOLE ORAL SUSPENSION 2 MG/ML 99999900434 10 mL $153.00 $153.00

400554 PANTOPRAZOLE ORAL SUSPENSION 2 MG/ML 99999900436 20 mL $153.00 $153.00

400560 CARVEDILOL (COREG) ORAL SUSPENSION 99999900437 100 mL $160.00 $160.00

400563 IOHEXOL 300 MG IODINE/ML IV SOLN (RADIANT USE) Q9967 00407141351 50 mL $435.60 $435.60

400563 IOHEXOL 300 MG IODINE/ML IV SOLN (RADIANT USE) Q9967 00407141360 100 mL $1,581.60 $1,581.60

400565 PENICILLIN G POTASSIUM 3 MILLION UNITS IN 0.9% NACL 50ML J2540 99999900483 50 mL $352.00 $352.00

400568 TRANEXAMIC ACID (CYCLOKAPRON) (100MG/ML) 5000MG IN 50ML (STRAIGHT DRU) 99999900670 50 mL $584.00 $584.00

400588 PEMBROLIZUMAB (STUDY DRUG) - CHEMO VIAL (PRL: BPT-201) 99999001801 4 mL $150.00 $150.00

400641 TECHNETIUM TETROFOSMIN (TC-99M) (MYOVIEW) ISOTOPE (NUC MED) A9502 17156002630 5 Each $1,227.31 $1,227.31

400642 TECHNETIUM MERTIATIDE (TC-99M) (MAG3) ISOTOPE (NUC MED) A9562 00019N096BO 10 mL $2,459.87 $2,459.87

400645 FOSAPREPITANT (EMEND) VIAL-TO-BAG VIAL J1453 00006394132 1 Each $451.30 $722.08

400646 POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (BMT PROTOCOL) J3480 00409707426 100 mL $153.00 $153.00

400650 LIDOCAINE (PF) 10 MG/ML (1 %) IJ SOLN (30 CC-OB USE) J2001 00409427902 30 mL $153.00 $153.00

400652 PHENOL 5% IN OLIVE OIL 99999900554 30 mL $153.00 $153.00

400653 BACLOFEN (LIORESAL) ORAL SUSPENSION 10 MG/ML PEDIATRIC 99999900563 30 mL $830.40 $830.40

400654 DAPSONE ORAL SUSPENSION 2 MG/ML PEDIATRIC 99999900564 30 mL $153.00 $153.00

400655 HYDRALAZINE ORAL SUSPENSION 4 MG/ML PEDIATRIC 99999900565 30 mL $153.00 $153.00

400656 LAMOTRIGINE (LAMICTAL) ORAL SUSPENSION 1 MG/ML PEDIATRIC 99999900566 30 mL $153.00 $153.00

400657 RIFABUTIN (MYCOBUTIN) ORAL SUSPENSION 20 MG/ML PEDIATRIC 99999900567 30 mL $753.60 $753.60

400658 ZONISAMIDE (ZONEGRAN) ORAL SUSPENSION 10 MG/ML PEDIATRIC (IP ORDERING ONLY) 99999900568 30 mL $153.00 $153.00

400659 FINASTERIDE (PROSCAR) ORAL SUSPENSION 99999900569 30 mL $153.00 $153.00

400664 CLOPIDOGREL ORAL SUSPENSION 5 MG/ML PEDIATRIC (IP ORDERING ONLY) 99999900579 90 mL $153.00 $153.00

400665 ANTITHYMOCYTE GLOBULIN (EQUINE) (ATGAM) SKIN TEST J7504 99999900578 .1 mL $153.00 $153.00

400717 HIV POST EXPOSURE PROPHYLAXIS KIT 99999900169 1 Each $3,492.48 $3,492.48

400723 CLONAZEPAM 0.1 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900306 10 mL $153.00 $153.00

400723 CLONAZEPAM 0.1 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900173 1 mL $153.00 $153.00

400724 LORAZEPAM 1 MG/ML ORAL SUSPENSION 99999900174 1 mL $153.00 $153.00

400732 DAKINS SOLUTION FULL STRENGTH 99999900186 1000 mL $320.00 $320.00

400733 DAKINS SOLUTION 1/2 STRENGTH 99999-9001-83 1000 mL $320.00 $320.00

400740 FENTANYL 10 MCG/ML NS 250 ML PYXIS J3010 99999900195 250 mL $160.00 $160.00

400742 FENTANYL (SUBLIMAZE) CONTINUOUS INFUSION (STRAIGHT DRUG) J3010 99999900671 50 mL $153.00 $153.00

400744 TOBRAMYCIN IN D5 100 MG/50 ML IV PGBK CSHS J3260 99999900210 50 mL $153.00 $153.00

400745 TOBRAMYCIN IN D5 120 MG/50 ML IV PGBK CSHS J3260 99999900211 50 mL $153.00 $153.00

400783 LEVOTHYROXINE (SYNTHROID) ORAL SUSPENSION 25 MCG/ML 99999900350 60 mL $624.00 $624.00

400784 TOPIRAMATE (TOPAMAX) ORAL SUSPENSION PEDIATRIC 6 MG/ML (IP ORDERING ONLY) 99999900351 100 mL $153.00 $153.00

400801 METHOCARBAMOL 500 MG PO HALF-TAB = 250 MG 99999900613 1 Each $153.00 $153.00

400814 THYROTROPIN ALFA 1.1 MG IM SOLR FOR IMAGING J3240 99999900697 1 Each $1,326.00 $1,326.00

400815 RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML IJ SYRG FOR OB J2790 99999900696 2 mL $1,502.64 $1,502.64

400827 MAGNESIUM SULFATE L&D LOADING DOSE 6 GRAM/100 ML 99999000881 100 mL $153.00 $153.00

400846 HEPARIN IN 0.45% NACL 25000 UNITS/250ML FOR CRRT NX STAGE PUMP J1644 00409765062 250 mL $153.00 $153.00

400852 VANILLA TPN WITH HEPARIN NICU 99999001466 250 mL $420.54 $420.54

400876 PHENOBARBITAL ORAL SOLUTION 8 MG/2 ML FOR NICU 99999001809 2 mL $153.00 $153.00

400966 BACLOFEN (LIORESAL) ORAL SUSPENSION 5 MG/ML 65628010102 60 mL $892.80 $892.80

401003 KETAMINE 10 MG/ML PO SOLN 99999002113 5 mL $153.00 $153.00

409195 OLAPARIB (STUDY DRUG) 50MG CHEMO CAPSULE - (PRL: D0810C00042) 99999900491 1 capsule $10.00 $10.00

409286 PASIREOTIDE (STUDY DRUG) INJECTION - (PRL: SOM230B2412) 99999900588 40 mg $75.00 $75.00

409286 PASIREOTIDE (STUDY DRUG) INJECTION - (PRL: SOM230B2412) 99999001161 60 mg $75.00 $75.00

409379 SGN-LIV1A (STUDY DRUG) CHEMO VIAL - (PRL: SGNLVA-001) 99999900676 40 mg $150.00 $150.00

409410 BRENTUXIMAB (STUDY DRUG) VIAL - (PRL: COG ANHL12P1) 99999900767 50 mg $150.00 $150.00

409543 PT2385 (STUDY DRUG) 200 MG CHEMO TABLET - (PRL: PT2385-101) 99999000876 1 tablet $30.00 $30.00

409563 BLINATUMOMAB (STUDY DRUG) PEDS 24 CHEMO VIAL-(PRL:AALL1331) 99999000895 38.5 mcg $30.00 $30.00

409609 LUPRON DEPOT (LEUPROLIDE ACETATE, 3 MONTH)(STUDY DRUG) 22.5 MG SYRINGE - (PRL: MDV3100-13)99999001058 1 kit $30.00 $30.00

409612 ENZALUTAMIDE OR PLACEBO (STUDY DRUG) 40 MG CAPSULE - (PRL: MDV3100-13) 99999001060 120 capsule $30.00 $30.00

409613 ENZALUTAMIDE (OPEN-LABEL) (STUDY DRUG) 40 MG CAPSULE - (PRL: MDV3100-13) 99999001061 120 capsule $30.00 $30.00

409646 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE - (PRL: PR-30-5020-C) 99999001103 93 capsule $50.00 $50.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



409660 HEPARIN (PORCINE) IN NACL (PF) 1000 UNITS/500ML FOR ECMO FLUSH IV SOLP 99999001111 500 mL $153.00 $153.00

409667 MERCAPTOPURINE (PURINETHOL) ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999001122 1 mL $153.00 $153.00

409701 PEMBROLIZUMAB (STUDY DRUG) VIAL - (PRL: IIT2015-13-WALSH-PEMCIGEM) 99999001154 50 mg $150.00 $150.00

409701 PEMBROLIZUMAB (STUDY DRUG) VIAL - (PRL: IIT2015-13-WALSH-PEMCIGEM) 99999001155 100 mg $150.00 $150.00

409726 LEUPROLIDE DEPOT (ELIGARD) (STUDY DRUG) INJECTION - (IRB# 40227) 99999001184 1 Syringe $30.00 $30.00

409744 PEMBROLIZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: MK3475-158) 99999001202 4 mL $150.00 $150.00

409755 ASTX660 (STUDY DRUG) 30 MG CAPSULE - (PRL: ASTX660-01) 99999001208 14 Each $50.00 $50.00

409756 ASTX660 (STUDY DRUG) 180 MG CAPSULE - (PRL: ASTX660-01) 99999001209 14 Each $50.00 $50.00

409759 AZD9291 OR PLACEBO (STUDY DRUG) 80 MG TABLET - (PRL: D5164C00001) 99999001212 80 mg $50.00 $50.00

409760 AZD9291 OR PLACEBO (STUDY DRUG) 40 MG TABLET - (PRL: D5164C00001) 99999001213 40 mg $50.00 $50.00

409771 SDX-7320 (STUDY DRUG) - (PRL: SDX-101 ) SYRINGE #1 99999001227 1 mL $30.00 $30.00

409774 BICALUTAMIDE OR PLACEBO (STUDY DRUG) 50 MG CAPSULE (PRL: 56021927PCR3003) 99999001231 30 capsule $30.00 $30.00

409890 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE (PRL: 3000-PN162-01-001) 99999001263 72 capsule $30.00 $30.00

409915 AVELUMAB (STUDY DRUG) VIAL - (PRL: B9991003) 99999001273 200 mg $150.00 $150.00

409917 NIVOLUMAB OR PLACEBO (STUDY DRUG) VIAL (PRL: CA209-548) 99999001275 100 mg $150.00 $150.00

410042 FUROSEMIDE (LASIX) 1000MG IN 100ML (STRAIGHT DRUG) INFUSION J1940 99999900669 100 mL $160.00 $160.00

410043 BUMETANIDE (BUMEX) 25MG IN 100ML (STRAIGHT DRUG) INFUSION 99999900561 100 mL $304.00 $304.00

410068 EPINEPHRINE IN D5W 4MG/250ML IV PREMIX 99999900258 250 mL $480.00 $480.00

410104 RGX-104 (STUDY DRUG) 40 MG CAPSULE (PRL: RGX-104) 99999001477 30 capsule $30.00 $30.00

410130 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2015-18-MITA-MK3475) 99999001484 100 mg $150.00 $150.00

410133 HYDROXYCHLOROQUINE 200 MG/8 ML ORAL SUSPENSION 99999002386 8 mL $153.00 $153.00

410135 HYDROMORPHONE IN D5W 50 MG/250 ML (0.2 MG/ML) PREMIX IV PGBK 99999002399 250 mL $153.00 $153.00

411068 EPINEPHRINE IN D5W 8 MG/250ML (0.032 MG/ML)IV PREMIX 99999900395 250 mL $920.00 $920.00

411069 EPINEPHRINE IN D5W 3 MG/100 ML (0.03 MG/ML) IV PREMIX 99999001971 100 mL $372.80 $372.80

411072 SUFENTANIL CITRATE IN 0.9% NACL 100 MCG/250 ML IV SOLP 99999002411 250 mL $153.00 $153.00

500037 METHOTREXATE INTRAMUSCULAR 99999900274 2 mL $153.00 $153.00

500047 THIOTEPA CHEMO IV PUSH J9340 99999900196 15 mg $5,810.40 $5,810.40

500060 HEPARIN FOR NICU ARTERIAL LINE INFUSION 99999900401 100 mL $153.00 $153.00

500068 LIDOCAINE 1% (BUFFERED) INJ. SOLUTION J2001 99999900197 1 mL $153.00 $153.00

500073 MMX ORAL SUSPENSION (IP ORDERING ONLY) 99999900375 120 mL $153.00 $153.00

500092 VANCOMYCIN ORAL SOLUTION 25 MG/ML 99999900335 5 mL $153.00 $153.00

500092 VANCOMYCIN ORAL SOLUTION 25 MG/ML 99999900390 10 mL $153.00 $153.00

500125 CAFFEINE CITRATE 20 MG/ML ORAL SOLUTION PEDIATRIC 99999900133 1 mL $153.00 $153.00

500133 AMIKACIN 25 % FOR INHALATION 99999900469 4 mL $153.00 $153.00

500137 GENTAMICIN 4 % NEBULIZER SOLUTION 99999900152 1 mL $153.00 $153.00

500138 PENTAMIDINE NEBULIZER SOLUTION J2545 99999900153 1 mL $153.00 $153.00

500140 MEDICINAL LEECH 99999900155 1 Each $274.40 $274.40

500142 VANCOMYCIN ENEMA 99999900370 1 enema $262.72 $262.72

500143 HEPARIN 500 UNITS PICU PRESSURE LINE INFUSION (PT WT 10KG OR GREATER) 99999900402 500 mL $153.00 $153.00

500149 MORPHINE INJECTION - PEDS < 1 YEAR J2250 99999900161 2 mL $153.00 $153.00

500151 HEPARIN 20,000 UNITS/20 ML SYRINGE FOR CRRT DIALYSIS J1644 99999900394 20 mL $153.00 $153.00

500152 FLUCONAZOLE 2 MG/ML IN NS IV PEDIATRIC 99999900163 1 mL $153.00 $153.00

500153 METRONIDAZOLE 5 MG/ML IV PEDIATRIC 99999900164 1 mL $153.00 $153.00

500154 LINEZOLID 2 MG/ML IV PEDIATRIC 99999900165 1 mL $153.00 $153.00

500155 LEVOFLOXACIN 5 MG/ML IV PEDIATRIC J1956 99999900166 1 mL $153.00 $153.00

500165 FENTANYL 10 MCG/ML IV PEDIATRIC J3010 99999900253 1 mL $153.00 $153.00

500167 ENOXAPARIN 100 MG/ML IV PEDIATRIC J1650 99999900167 1 mL $178.24 $178.24

500177 CEFTRIAXONE IVPB VIAL 1 GRAM/50 ML VIAL-TO-BAG IVPB J0696 00781320885 1 Each $153.00 $153.00

500181 MEROPENEM 500 MG/50 ML VIAL-TO-BAG IVPB J2185 00310032520 1 Each $153.00 $153.00

500183 OXACILLIN IVPB VIAL 1 G VIAL-TO-BAG J2700 00781309985 1 Each $153.00 $153.00

500184 OXACILLIN IVPB VIAL 2 G VIAL-TO-BAG J2700 00781310180 1 Each $153.00 $153.00

500188 PIPERACILLIN-TAZOBACTAM VIAL 4.5 G VIAL-TO-BAG IVPB J2543 00206885516 1 Each $153.00 $153.00

500193 CEFOTETAN 1 G/50 ML VIAL-TO-BAG IVPB 63323038510 1 Each $153.00 $153.00

500195 FAT EMULSION 20 % IV PEDS 99999900172 25 mL $153.00 $153.00

500203 METRONIDAZOLE IN NACL (ISO-OS) 250 MG/50 ML IVPB 99999900206 50 mL $153.00 $153.00

500222 HEPARIN FLUSH INFUSION FOR THROMBOLYSIS (5 UNITS/ML) IV SOLN J1644 99999900577 1000 mL $153.00 $153.00

500329 CEFTRIAXONE 2 GRAM/50 ML VIAL-TO-BAG IVPB J0696 00409733503 1 Each $153.00 $153.00

500356 DEXAMETHASONE (DECADRON) 10MG/50ML VIAL-TO-BAG J1100 99999001479 1 Each $153.00 $153.00

500363 IRON SUCROSE 100 MG/100 ML VIAL-TO-BAG IVPB J1756 99999001650 1 Each $307.60 $492.16

500364 IRON SUCROSE 200 MG/100 ML VIAL-TO-BAG IVPB J1756 99999001651 1 Each $596.70 $954.72

500365 MIDAZOLAM 250 MG/50 ML (5 MG/ML) ADULT STRAIGHT DRUG IV SOLUTION 99999001701 50 mL $153.00 $153.00

500500 FERRIC CARBOXYMALTOSE 750MG/250ML VIAL-TO-BAG IVPB J1439 99999002225 1 Each $8,534.50 $13,655.20

500670 HEPARIN 20,000 UNITS/20 ML SYRINGE FOR BM HARVEST (INTRAPROCEDURE) J1644 99999002185 20 mL $153.00 $153.00

501143 POTASSIUM CHLORIDE 10 MEQ/100ML IN 0.9% NACL PGBK J3480 99999001764 100 mL $153.00 $153.00

501144 POTASSIUM CHLORIDE 10 MEQ/100ML IN D5W PGBK J3480 99999001765 100 mL $153.00 $153.00

501151 CEFAZOLIN IN 0.9% NACL 2 GRAM/50 ML IV PGBK J0690 99999001811 1 Each $153.00 $153.00

501152 GENTAMICIN 80 MG/50ML VIAL-TO-BAG IVPB J1580 99999001812 1 Each $153.00 $153.00

509012 SODIUM BICARBONATE (STRAIGHT DRUG) IV INFUSION 99999900433 50 mL $153.00 $153.00

509015 MMX ORAL SUSPENSION (CC) 99999-900438 10 mL $153.00 $153.00

509029 HEPARIN 1000UNIT/ML 1ML VIAL FOR PORT FLUSH J1644 63323054001 1 mL $153.00 $153.00

509031 CARFILZOMIB CHEMO VIAL J9047 99999900439 30 mL $16,757.55 $16,757.55



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



509034 LIDOCAINE 10 MG/ML (1 %) IJ SOLN (CC) J2001 63323048527 20 mL $153.00 $153.00

509034 LIDOCAINE 10 MG/ML (1 %) IJ SOLN (CC) J2001 00409427602 50 mL $153.00 $153.00

509035 PACLITAXEL 6 MG/ML INTRAPERITONEAL VIAL CC J9267 00703476401 5 mL $153.00 $153.00

509043 LIDOCAINE 4 % TP CREA CC 00496088206 5 gram $153.00 $153.00

510005 MAGIC MOUTHWASH (IP ORDERING ONLY) 99999900376 120 mL $153.00 $153.00

520001 FORTIFIED TOBRAMYCIN 14 MG/ML OP DROPS 99999900036 7 mL $153.00 $153.00

520002 FORTIFIED GENTAMICIN 14 MG/ML OP DROPS 99999900037 7 mL $278.88 $278.88

520003 FORTIFIED VANCOMYCIN 50 MG/ML OP DROPS 99999900038 10 mL $153.00 $153.00

520004 FORTIFIED CEFAZOLIN 33 MG/ML OP DROPS 99999900039 15 mL $153.00 $153.00

520009 AMPHOTERICIN SWISH & SWALLOW 0.1 MG/ML 99999900044 120 mL $307.20 $307.20

520012 MODIFIED STANFORD'S STOMATITIS ORAL SUSPENSION (IP ORDERING ONLY) 99999900050 100 mL $252.80 $252.80

520014 ATENOLOL ORAL SOLUTION 2 MG/ML 99999900052 100 mL $153.00 $153.00

520015 CAPTOPRIL ORAL SUSPENSION 1 MG/ML 99999900053 1 mL $153.00 $153.00

520017 ENALAPRIL ORAL SUSPENSION 1 MG/ML (IP ORDERING ONLY) 99999900056 1 mL $153.00 $153.00

520018 HYDROCORTISONE ORAL SUSPENSION 2 MG/ML (IP ORDERING ONLY) 99999900055 1 mL $153.00 $153.00

520019 METOLAZONE ORAL SUSPENSION 1 MG/ML 99999900057 1 mL $153.00 $153.00

520020 METRONIDAZOLE ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999900058 1 mL $153.00 $153.00

520021 NIFEDIPINE ORAL SUSPENSION 4 MG/ML (IP ORDERING ONLY) 99999900326 30 mL $153.00 $153.00

520022 URSODIOL ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999001192 5 mL $153.00 $153.00

520023 HYDROXYUREA ORAL SUSPENSION 50 MG/ML 99999900309 30 mL $153.00 $153.00

520024 POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION 99999900065 1 mL $153.00 $153.00

520024 POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION 99999900066 3 mL $153.00 $153.00

520025 SPIRONOLACTONE 5 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900336 5 mL $153.00 $153.00

520026 ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION 99999900301 50 mL $168.00 $168.00

520027 SILDENAFIL 2.5 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900334 4 mL $153.00 $153.00

520028 RIFAMPIN ORAL SUSPENSION 25 MG/ML 99999900079 1 mL $153.00 $153.00

520029 SODIUM CHLORIDE ORAL SOLUTION 4 MEQ/ML 99999900082 .5 mL $153.00 $153.00

520029 SODIUM CHLORIDE ORAL SOLUTION 4 MEQ/ML 99999900083 1 mL $153.00 $153.00

520034 MODIFIED DANIELS SOLUTION 99999900089 240 mL $1,958.40 $1,958.40

520035 ARGININE ORAL SOLUTION 10 % (0.475 MEQ/ML) 99999900090 1 mL $153.00 $153.00

520036 CALCIUM GLUCONATE ORAL SOLUTION 100 MG/ML 99999900091 1 mL $153.00 $153.00

520037 DEXAMETHASONE 4 MG/ML ORAL SOLUTION 99999900092 1 mL $153.00 $153.00

520039 KANAMYCIN ORAL SOLUTION 333 MG/ML 99999900094 1 mL $153.00 $153.00

520042 SODIUM PHOSPHATE ORAL SOLUTION 4 MEQ/ML (3 MMOL/ML) 99999900097 1 mL $153.00 $153.00

520043 ZINC SULFATE ORAL SOLUTION 1 MG ELEMENTAL ZINC/ML 99999900098 1 mL $153.00 $153.00

520044 GENTAMICIN NEBULIZER SOLUTION 40 MG/ML 99999900099 2 mL $153.00 $153.00

520045 TOBRAMYCIN NEBULIZER SOLUTION 40 MG/ML J3260 99999900100 2 mL $153.00 $153.00

520046 HYDROXYUREA ORAL SUSPENSION 100 MG/ML (IP ORDERING ONLY) 99999900308 240 mL $230.40 $230.40

520047 MORPHINE ORAL SOLUTION 1 MG/ML PEDIATRIC 99999900102 1 mL $153.00 $153.00

520050 LEVOFLOXACIN ORAL SUSPENSION 50 MG/ML 99999900105 1 mL $153.00 $153.00

520052 AMIODARONE ORAL SUSPENSION 5 MG/ML 99999900107 120 mL $153.00 $153.00

520053 LABETALOL ORAL SUSPENSION 10 MG/ML 99999900108 1 mL $153.00 $153.00

520057 RIFAMPIN (RIFADIN) ORAL SUSPENSION 10MG/ML PEDIATRIC 99999900419 1 mL $153.00 $153.00

520061 TACROLIMUS ORAL SUSPENSION 1 MG/ML (IP ORDERING ONLY) 99999900611 60 mL $1,084.80 $1,084.80

520062 MESNA 100 MG/ML ORAL SOLN 99999001095 10 mL $153.00 $153.00

520064 CLONIDINE ORAL SUSPENSION 10 MCG/ML 99999001340 200 mL $153.00 $153.00

520101 F-18 FLUCICLOVINE A9588 69932001030 10 millicurie $18,899.15 $18,899.15

522058 HEPARIN INJECTION FOR APHERESIS 1000 UNIT/ML J1644 63323054011 10 mL $153.00 $153.00

530011 KETOROLAC 30 MG/ML IV PEDIATRIC J1885 99999900201 1 mL $153.00 $153.00

530018 CLINDAMYCIN IVPB PEDIATRIC 99999900215 1 mL $153.00 $153.00

530036 METOCLOPRAMIDE 5 MG/ML IV PEDIATRIC 99999900113 1 mL $153.00 $153.00

530037 HYDROCORTISONE 50 MG/ML IV PUSH PEDIATRIC J1720 99999900114 1 mL $153.00 $153.00

531014 MIDAZOLAM 2 MG/ML PO SYRP < 1 ML 99999900324 5 mL $153.00 $153.00

531032 PENTOXIFYLLINE 20 MG/ML ORAL SUSPENSION 99999002269 200 mL $153.00 $153.00

800037 AMINOCAPROIC ACID 5G/20 ML (0.25 G/ML) STRAIGHT DRUG IV SOLN 99999900548 20 mL $153.00 $153.00

800040 ACETIC ACID 4% TOPICAL SOLN INTRAPROCEDURE 99999900549 120 mL $307.20 $307.20

800071 GENTAMICIN (MIX WITH GELFOAM) FOR INTRAPROCEDURE J1580 00409120703 2 mL $153.00 $153.00

800087 BUPIVACAINE 0.25% INFUSION (ANES-INTRAPROCEDURE) J3490 55150016710 10 mL $153.00 $153.00



800088 BUPIVACAINE 0.5% INFUSION (ANES-INTRAPROCEDURE) 00409116202 30 mL $153.00 $153.00

800093 LIDOCAINE OINTMENT 5% (MIX WITH GELFOAM) INTRAPROCEDURE 00168020437 35.44 gram $3,579.16 $3,579.16

800093 LIDOCAINE OINTMENT 5% (MIX WITH GELFOAM) INTRAPROCEDURE 51672300803 50 gram $1,133.60 $1,133.60

800111 SUFENTANIL - BUPIVACAINE PF 0.25% EPI EPIDURAL (L&D ANES-INTRAPROCEDURE) 99999001607 1 Each $330.00 $330.00

800116 NITROGLYCERIN 100 MCG/ML INJECTION FOR INTRAPROCEDURE 99999001687 10 mL $153.00 $153.00

800117 HEPARIN 1000 UNITS IN 1000 ML OF 0.9% NACL THERMOCOOL INFUSION FOR INTRAPROCEDUREJ1644 99999001253 1000 mL $153.00 $153.00

800121 ADENOSINE (ADENOCARD) 100 MCG/ML INJECTION FOR INTRAPROCEDURE J0153 99999001217 50 mL $153.00 $153.00

800122 VERAPAMIL (ISOPTIN) 100 MCG/ML INJECTION FOR INTRAPROCEDURE 99999001218 10 mL $153.00 $153.00

800126 VANCOMYCIN 500 MG IN 200 ML 0.9% NACL POCKET IRRIGATION FOR INTRAPROCEDURE J3370 99999001254 200 mL $153.00 $153.00

800127 GENTAMICIN 80 MG IN 200 ML 0.9% NACL POCKET IRRIGATION FOR INTRAPROCEDURE J1580 99999001255 200 mL $416.00 $416.00

800132 ACETYLCHOLINE 0.182 MCG/ML (ACH 10-6) INJECTION FOR INTRAPROCEDURE 99999001306 1 Each $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



800160 HEPARIN SOLUTION 5 UNITS/ML FOR INSTRUMENT WASH/RINSE FOR INTRAPROCEDURE (IR ONLY)J1644 99999001999 1000 mL $153.00 $153.00

802321 ALTEPLASE 25 MG/25 ML (1 MG/ML) STRAIGHT DRUG IV INFUSION J2997 99999900673 25 mL $18,456.75 $18,456.75

802781 ARGATROBAN IN NACL (ISO-OS) 50 MG/50 ML (1 MG/ML) IV SOLN J0883 42367020307 50 mL $1,424.00 $1,424.00

802787 LORAZEPAM 100 MG/50 ML (2 MG/ML) IV SOLN STRAIGHT DRUG 99999900430 50 mL $360.00 $360.00

802796 LORAZEPAM 120 MG/30 ML (4 MG/ML) IV SOLN STRAIGHT DRUG J2060 99999900429 30 mL $753.60 $753.60

802810 MIDAZOLAM PF 10 MG/10 ML (1 MG/ML) STRAIGHT DRUG IV SOLN 99999900470 10 mL $153.00 $153.00


802812 MIDAZOLAM PF 50 MG/50 ML (1MG/ML) STRAIGHT DRUG IV SOLN 99999900472 50 mL $240.00 $240.00

802815 FENTANYL 2500 MCG/50 ML (50 MCG/ML) STRAIGHT DRUG IV SOLN 99999900473 50 mL $153.00 $153.00

802832 MIDAZOLAM 250 MG/50 ML (5 MG/ML) PEDS STRAIGHT DRUG IV SOLUTION 99999900847 50 mL $153.00 $153.00

802848 MORPHINE (PF) 1 MG/ML IJ SOLN J2274 99999000898 50 mL $504.00 $504.00

803835 FUROSEMIDE (LASIX) 500 MG IN 50 ML (STRAIGHT DRUG) IV INFUSION J1940 99999900848 50 mL $153.00 $153.00

803847 FENTANYL 150 MCG/3 ML (50 MCG/ML) STRAIGHT DRUG IV SOLN 99999002262 3 mL $153.00 $153.00

803852 FUROSEMIDE (LASIX) 30 MG IN 3 ML (STRAIGHT DRUG) IV INFUSION J1940 99999002264 3 mL $153.00 $153.00


803869 MIDAZOLAM 15 MG/3 ML (5 MG/ML) PEDS STRAIGHT DRUG IV SOLUTION 99999002267 3 mL $153.00 $153.00

803879 SILDENAFIL (ANTIHYPERTENSIVE) 2.4 MG/3 ML (0.8 MG/ML) STRAIGHT DRUG IV SOLN J3490 99999002268 3 mL $468.48 $468.48

909005 ETHIODIZED OIL 48% IJ OIL 99999900513 10 mL $17,504.00 $17,504.00

1000020 CEDIRANIB (STUDY DRUG) 15 MG TABLET- (PRL: D8488C00001) 99999001509 30 tablet $30.00 $30.00

1000021 OLAPARIB (STUDY DRUG) 100 MG TABLET- (PRL: D8488C00001) 99999001511 32 tablet $30.00 $30.00

1000022 CEDIRANIB (STUDY DRUG) 20 MG TABLET- (PRL: D8488C00001) 99999001510 30 tablet $30.00 $30.00

1000023 OLAPARIB (STUDY DRUG) 150 MG TABLET- (PRL: D8488C00001) 99999001512 32 tablet $30.00 $30.00

1000053 PALBOCICLIB (STUDY DRUG) 75 MG CAPSULE- (PRL: AFT-05 PALLAS) 99999001584 21 capsule $30.00 $30.00



1000096 ALXN1210 (STUDY DRUG) IN 0.9% NACL VIAL (PRL: ALXN1210-PNH-301) J1300 99999001644 300 mg $75.00 $75.00

1000099 XILONIX (STUDY DRUG) IN 0.9% NACL VIAL (PRL: IIT2016-07-HENDIFAR-ONFX) 99999001646 800 mg $150.00 $150.00

1000125 DURVALUMAB (STUDY DRUG) VIAL (PRL: IIT2016-01-TULI-DURVARAD) 99999001684 500 mg $150.00 $150.00

1000141 EDO-S101 (STUDY DRUG) VIAL (PRL: EDO-S101-1002) 99999001695 100 mL $150.00 $150.00

1000143 P-32 ONCOSIL (ONCOPA-1 STUDY DRUG) ISOTOPE NUC MED - (IRB #49148) 99999001678 1 Each $1.00 $1.00

1000161 MINNELIDE (STUDY DRUG) 0.25 MG CAPSULE (PRL: MINNELIDE 101) 99999001702 25 capsule $30.00 $30.00

1000162 MINNELIDE (STUDY DRUG) 0.5 MG CAPSULE (PRL: MINNELIDE 101) 99999001703 25 capsule $30.00 $30.00

1000172 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2017-07-HO-PEMBRORT) 99999001717 4 mL $150.00 $150.00

1000187 TRC105 (STUDY DRUG) VIAL (PRL: IIT2016-16-POSADAS-TRC105) 99999001730 100 mg $150.00 $150.00

1000187 TRC105 (STUDY DRUG) VIAL (PRL: IIT2016-16-POSADAS-TRC105) 99999001731 400 mg $150.00 $150.00

1000191 PF-06804103 (STUDY DRUG) VIAL (PRL: C0541001) 99999001732 40 mg $150.00 $150.00

1000193 DSP-7888 (STUDY DRUG) INTRADERMAL SYRINGE (PRL: BBI-DSP7888-201G) 99999001740 3 mL $200.00 $200.00

1000196 PALBOCICLIB (STUDY DRUG) 125 MG CAPSULE - (PRL: TAPUR) 99999001734 21 capsule $75.00 $75.00



1000202 SUNITINIB MALATE (STUDY DRUG) 50 MG CAPSULE - (PRL: TAPUR) 99999001741 28 capsule $75.00 $75.00

1000203 SUNITINIB MALATE (STUDY DRUG) 37.5 MG CAPSULE - (PRL: TAPUR) 99999001742 28 capsule $75.00 $75.00

1000204 SUNITINIB MALATE (STUDY DRUG) 25 MG CAPSULE - (PRL: TAPUR) 99999001743 28 capsule $75.00 $75.00

1000205 SUNITINIB MALATE (STUDY DRUG) 12.5 MG CAPSULE - (PRL: TAPUR) 99999001744 28 capsule $75.00 $75.00

1000218 TISLELIZUMAB BGB-A317 (STUDY DRUG) VIAL (PRL: BGB-A317/BGB-290) 99999900477 100 mg $150.00 $150.00

1000236 TRASTUZUMAB (STUDY DRUG) VIAL - (PRL: TAPUR) 99999001759 150 mg $75.00 $75.00

1000238 PERTUZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999001760 420 mg $75.00 $75.00

1000245 COBIMETINIB (STUDY DRUG) 20 MG TABLET (PRL: CO39611) 99999001771 63 tablet $30.00 $30.00

1000246 IPATASERTIB (STUDY DRUG) 100 MG TABLET (PRL: CO39611) 99999001772 7 tablet $30.00 $30.00

1000251 SGN-LIV1A (STUDY DRUG) VIAL (PRL: SGNLVA-002) 99999001776 40 mg $150.00 $150.00

1000253 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: SGNLVA-002) 99999001778 100 mg $150.00 $150.00

1000255 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: UCDCC258) 99999001777 1200 mg $150.00 $150.00

1000257 MCLA-128 (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001779 100 mg $150.00 $150.00

1000259 TRASTUZUMAB (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001780 150 mL $150.00 $150.00

1000261 VINORELBINE (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001781 50 mg $150.00 $150.00

1000264 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: CO39611) 99999001782 1200 mg $150.00 $150.00

1000266 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: CO39611) 99999001783 400 mg $150.00 $150.00

1000276 ABEMACICLIB (STUDY DRUG) 50 MG CAPSULE (PRL: I3Y-MC-JPCF) 99999001820 60 capsule $30.00 $30.00

1000277 RX108 (STUDY DRUG) 0.1 MG/ML VIAL (PRL: NP-102) 99999001821 5 mL $150.00 $150.00

1000300 MELPHALAN/HDS (STUDY DRUG) VIAL (PRL: PHP-ICC-203) 99999001835 50 mg $150.00 $150.00

1000307 CALCIUM CHLORIDE 300 MG IN 0.9% NACL 100 ML FOR THERA APHERESIS 99999001849 100 mL $153.00 $153.00

1000318 BENDAMUSTINE (STUDY DRUG) VIAL (PRL: IIT2017-03-MERIN-HA) 99999001859 100 mg $150.00 $150.00

1000325 DURVALUMAB (STUDY DRUG) VIAL (PRL: D419CC00002) 99999001862 500 mg $150.00 $150.00

1000327 TREMELIMUMAB (STUDY DRUG) VIAL - (PRL: D419CC00002) 99999001865 400 mg $150.00 $150.00

1000329 XMAB20717 (STUDY DRUG) VIAL (PRL: XMAB20717-01) 99999001870 100 mg $150.00 $150.00

1000331 CB-839 OR PLACEBO (STUDY DRUG) 200 MG TABLET (PRL: CX-839-008) 99999001869 250 tablet $30.00 $30.00

1000332 SELINEXOR OR PLACEBO (STUDY DRUG) 20 MG TABLET (PRL: KCP-330-020) 99999001867 12 tablet $30.00 $30.00

1000333 SELINEXOR (OPEN-LABEL) (STUDY DRUG) 20 MG TABLET (PRL: KCP-330-020) 99999001868 12 tablet $30.00 $30.00

1000338 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: BIG16-05/AFT-27/WO39391) 99999001871 1200 mg $150.00 $150.00

1000343 XMAB18087 (STUDY DRUG) VIAL (PRL: XMAB18087-01) 99999001876 1000 mcg $150.00 $150.00

1000344 SORAFENIB (STUDY DRUG) 200 MG TABLET (PRL: D419CC00002) 99999001875 120 tablet $75.00 $75.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



1000353 FPA150-001 (STUDY DRUG) IN 0.9% NACL VIAL (PRL: FPA150-001) 99999001877 100 mg $150.00 $150.00

1000400 ENTINOSTAT (STUDY DRUG) 5 MG TABLET (PRL: CO39611) 99999001907 3 tablet $30.00 $30.00

1000401 ENTINOSTAT (STUDY DRUG) 1 MG TABLET (PRL: CO39611) 99999001908 9 tablet $30.00 $30.00

1000409 F-18 CP-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES 99999001933 1 Each $150.00 $150.00

1000529 BOSUTINIB (STUDY DRUG) 500 MG TABLET - (PRL: TAPUR) 99999001993 30 tablet $75.00 $75.00

1000530 AXITINIB (STUDY DRUG) 5 MG TABLET - (PRL: TAPUR) 99999001995 60 tablet $75.00 $75.00

1000532 CRIZOTINIB (STUDY DRUG) 200 MG CAPSULE - (PRL: TAPUR) 99999001997 60 capsule $75.00 $75.00

1000533 CRIZOTINIB (STUDY DRUG) 250 MG CAPSULE - (PRL: TAPUR) 99999001998 60 capsule $75.00 $75.00

1000534 DASATINIB (STUDY DRUG) 50 MG TABLET - (PRL: TAPUR) 99999002000 60 tablet $75.00 $75.00

1000536 ERLOTINIB (STUDY DRUG) 100 MG TABLET - (PRL: TAPUR) 99999002002 30 tablet $75.00 $75.00

1000537 ERLOTINIB (STUDY DRUG) 150 MG TABLET - (PRL: TAPUR) 99999002003 30 tablet $75.00 $75.00

1000538 VISMODEGIB (STUDY DRUG) 150 MG CAPSULE - (PRL: TAPUR) 99999002004 28 capsule $75.00 $75.00

1000539 CETUXIMAB (STUDY DRUG) CHEMO IVPB - (PRL: TAPUR) 99999002014 200 mg $75.00 $75.00

1000539 CETUXIMAB (STUDY DRUG) CHEMO IVPB - (PRL: TAPUR) 99999002013 100 mg $75.00 $75.00

1000540 PEMBROLIZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999002006 100 mg $75.00 $75.00

1000542 REGORAFENIB (STUDY DRUG) 40 MG TABLET - (PRL: TAPUR) 99999002007 84 tablet $75.00 $75.00

1000543 NIVOLUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999002010 100 mg $75.00 $75.00

1000577 PAMIPARIB BGB-290 (STUDY DRUG) 20 MG CAPSULE (PRL: BGB-A317/BGB-290) 99999900605 30 capsule $30.00 $30.00

1000595 PT2977 (STUDY DRUG) 40 MG TABLET (IRB# 54237) 99999002033 90 tablet $30.00 $30.00

1000597 RGX-104 (STUDY DRUG) 80 MG CAPSULE (PRL: RGX-104-001) 99999001792 30 capsule $30.00 $30.00

1000611 SELICRELUMAB (RO7009789) SYRINGE #1 (STUDY DRUG) (PRL: BP29889) 99999002036 20 mg $150.00 $150.00

1000615 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: BP29889) 99999002040 400 mg $150.00 $150.00

1000615 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: BP29889) 99999002041 100 mg $150.00 $150.00

1000669 TEMSIROLIMUS (STUDY DRUG) VIAL - (PRL:TAPUR) 99999002072 25 mg $75.00 $75.00

1000670 PEMBROLIZUMAB OR PLACEBO (STUDY DRUG) CHEMO VIAL (PRL: MK3475-789) 99999002067 100 mg $150.00 $150.00

1000672 PEMBROLIZUMAB (OPEN-LABEL) (STUDY DRUG) CHEMO VIAL (PRL: MK3475-789) 99999002071 100 mg $150.00 $150.00

1000674 JNJ-61186372 (STUDY DRUG) CHEMO VIAL (PRL: 61186372EDI1001) 99999002074 150 mg $150.00 $150.00

1000676 NIVOLUMAB (STUDY DRUG) VIAL (PRL: IIT2018-01-MCARTHUR-IPI) 99999002077 100 mg $150.00 $150.00

1000678 IPILIMUMAB (STUDY DRUG) VIAL (PRL: IIT2018-01-MCARTHUR-IPI) 99999002078 200 mg $150.00 $150.00

1000680 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: ACT15377) 99999002075 20 mL $150.00 $150.00

1000685 RGX-202-01 (STUDY DRUG) 200 MG CAPSULE (IRB# 55176) 99999002080 60 capsule $75.00 $75.00

1000686 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2018-04-MCARTHUR-NEOHP) 99999002079 100 mg $150.00 $150.00

1000698 SULOPENEM/PLACEBO (IT001-303 STUDY DRUG) VIAL (IRB# 55070) 99999002092 1 Each $150.00 $150.00

1000700 ERTAPENEM/PLACEBO (IT001-303 STUDY DRUG) VIAL (IRB# 55070) 99999002093 1 Each $150.00 $150.00

1000706 TSR-042 OR PLACEBO (STUDY DRUG) VIAL (PRL: 3000-03-005) 99999002098 500 mg $150.00 $150.00

1000708 NIRAPARIB OR PLACEBO (STUDY DRUG) 100 MG CAPSULE (PRL: 3000-03-005) 99999002099 72 capsule $30.00 $30.00

1000730 IPILIMUMAB (STUDY DRUG) 200 MG VIAL (PRL: RGX-104-001) 99999002117 200 mg $150.00 $150.00

1000733 GZ17-6.02 (STUDY DRUG) 300 MG CAPSULE (PRL: GZ17-6.02-CT-101) 99999002119 100 capsule $75.00 $75.00

1000736 BI 754091 (STUDY DRUG) VIAL (PRL: 1381-1) 99999002122 300 mg $150.00 $150.00

1000761 RGX-202-01 (STUDY DRUG) 400 MG TABLET (PRL: RGX-202-001) 99999002138 60 tablet $75.00 $75.00

1000768 ASTX029 (STUDY DRUG) 40 MG TABLET (PRL: ASTX029-01) 99999002143 21 tablet $50.00 $50.00


1000782 PALONOSETRON (STUDY DRUG) INJECTION (PRL: EDO-S101-1002) 99999002150 .25 mg $30.00 $30.00

1000806 IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE A9570 99999002164 1 kit $8,066.52 $8,066.52

1000808 CYCLOPHOSPHAMIDE (STUDY DRUG) 50 MG CAPSULE (PRL: P1719-SUR-Z11) 99999002166 14 capsule $75.00 $75.00

1000820 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: P1719-SUR-Z11) 99999002181 4 mL $150.00 $150.00

1000822 DPX-SURVIVAC (STUDY DRUG) SYRINGE (PRL: P1719-SUR-Z11) 99999002182 1 Each $150.00 $150.00

1000826 AB154 (STUDY DRUG) VIAL (PRL: AB154CSP0001) 99999002187 80 mg $150.00 $150.00

1000828 AB122 (STUDY DRUG) VIAL (PRL: AB154CSP0001) 99999002188 120 mg $150.00 $150.00

1000830 RO6958688 (CIBISATAMAB) (STUDY DRUG) VIAL (PRL: CO40939) 99999002189 2 mL $150.00 $150.00

1000832 TOCILIZUMAB (STUDY DRUG) 200 MG/10 ML VIAL (PRL: CO40939) 99999002190 10 mL $75.00 $75.00

1000834 ATEZOLIZUMAB (STUDY DRUG) 1,200 MG/20 ML VIAL (PRL: CO40939) 99999002191 20 mL $150.00 $150.00

1000836 OBINUTUZUMAB (STUDY DRUG) 1000 MG/40 ML VIAL (PRL: CO40939) 99999002192 40 mL $150.00 $150.00

1000838 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: FPA150-001) 99999002196 100 mg $150.00 $150.00

1000846 OLAPARIB (STUDY DRUG) 150 MG TABLET (PRL: MK-7339-002) 99999002200 32 tablet $30.00 $30.00

1000847 OLAPARIB (STUDY DRUG) 100 MG TABLET (PRL: MK-7339-002) 99999002201 32 tablet $30.00 $30.00

1000861 ATEZOLIZUMAB (STUDY DRUG) 60 MG/ML VIAL (PRL: XL184-021) 999990021111 14 mL $150.00 $150.00

1000861 ATEZOLIZUMAB (STUDY DRUG) 60 MG/ML VIAL (PRL: XL184-021) 999990021110 20 mL $150.00 $150.00

1000863 CABOZANTINIB (STUDY DRUG) 20 MG TABLET (PRL: XL 184-021) 999990021112 30 tablet $30.00 $30.00

1000864 CABOZANTINIB (STUDY DRUG) 60 MG TABLET (PRL: XL 184-021) 999990021113 30 tablet $30.00 $30.00

1000879 RX108 (STUDY DRUG) 0.5 MG/ML VIAL (PRL: NP-102) 99999002230 4 mL $150.00 $150.00

1000882 PEMBROLIZUMAB OR PLACEBO (STUDY DRUG) VIAL (PRL: MK3475-756) 99999002232 100 mg $150.00 $150.00

1000884 NKTR-214 (STUDY DRUG) VIAL (PRL: 17-214-09) 99999002233 1 mg $150.00 $150.00

1000886 NIVOLUMAB (STUDY DRUG) VIAL (PRL: 17-214-09) 99999002234 100 mg $150.00 $150.00

1000905 COPANLISIB (STUDY DRUG) 60 MG/4 ML VIAL (PRL: 19769) 99999002252 4 mL $150.00 $150.00

1000916 LENVATINIB (STUDY DRUG) 4 MG CAPSULE (IRB# 55738) 99999002259 25 capsule $50.00 $50.00

1000917 LENVATINIB (STUDY DRUG) 10 MG CAPSULE (IRB# 55738) 99999002260 25 capsule $50.00 $50.00

1000918 PEMBROLIZUMAB (STUDY DRUG) VIAL (IRB# 55738) 99999002261 4 mL $150.00 $150.00

1000923 CART-TNMUC1 (STUDY DRUG) IV IN CRYOBAG (PRL: CART-TNMUC1-01) 99999002270 10 mL $150.00 $150.00





CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



1000926 GRN-1201 + GM-CSF (STUDY DRUG) INTRADERMAL INJECTION (PRL: GRN-1201-002) - SYRINGE #1 99999002274 10 mg $150.00 $150.00

1000931 OBT076 (STUDY DRUG) 50 MG/10 ML VIAL (PRL: OBT076-001) 99999002279 10 mL $150.00 $150.00

1000934 HSPPC-96 OR PLACEBO (STUDY DRUG) INTRADERMAL INJECTION (PRL - 17C0034-BTTC) 99999002282 .4 mL $200.00 $200.00

1000935 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL - 17C0034-BTTC) 99999002283 100 mg $150.00 $150.00

1000937 MT-5111 (STUDY DRUG) 5 MCG/ML SYRINGE (PRL: MT-5111-001) 99999002284 1 Each $200.00 $200.00

1000938 MT-5111 (STUDY DRUG) 10 MCG/ML SYRINGE (PRL: MT-5111-001) 99999002285 1 Each $200.00 $200.00

1000939 MT-5111 (STUDY DRUG) 1 MG/ML VIAL (PRL: MT-5111-001) 99999002286 1 mL $150.00 $150.00

1000942 CDX-301 (STUDY DRUG) 2,500 MCG/ML SC SOLN (PRL: PICI0033 COHORT C) 99999002288 1 mL $75.00 $75.00

1000945 ABBV-155 (STUDY DRUG) VIAL (PRL: M16-573) 99999002400 100 mg $150.00 $150.00

1000947 INO-5151 (STUDY DRUG) 3 MG/ML IM SOLN (PRL: PICI0033 COHORT C) 99999002290 3.3 mg $75.00 $75.00

1000948 NIVOLUMAB (STUDY DRUG) 100 MG/10 ML IV SOLN (PRL: PICI0033 COHORT C) 99999002291 10 mL $150.00 $150.00

1000950 PACLITAXEL (STUDY DRUG) VIAL (PRL: M16-573) 99999002401 100 mg $150.00 $150.00

1000952 DOCETAXEL (STUDY DRUG) VIAL (PRL: M16-573) 999999002402 80 mg $150.00 $150.00

1000988 ASTX660 (STUDY DRUG) 90 MG CAPSULE - (PRL: ASTX660-01) 99999002324 14 capsule $50.00 $50.00

1001001 CEMIPLIMAB-RWLC (STUDY DRUG) 50 MG/ML VIAL (PRL: ATI001-204) 99999002335 7 mL $150.00 $150.00

1001010 BALIXAFORTIDE (STUDY DRUG) VIAL (PRL: POL6326-009) 99999002344 385 mg $150.00 $150.00

1001012 ERIBULIN (STUDY DRUG) IVP (PRL: POL6326-009) 99999002345 1 mg $150.00 $150.00

1001014 ENZASTAURIN OR PLACEBO (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002349 9 tablet $50.00 $50.00

1001014 ENZASTAURIN OR PLACEBO (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002348 96 tablet $50.00 $50.00

1001015 ENZASTAURIN (OPEN-LABEL) (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002350 96 tablet $50.00 $50.00

1001034 RGX-202-01 (STUDY DRUG) 600 MG TABLET (PRL: RGX-202-001) 99999002367 60 tablet $75.00 $75.00

1001037 VE800 (STUDY DRUG) 400 MG CAPSULE (PRL: VE800-001) 99999002368 5 capsule $75.00 $75.00

1001038 NIVOLUMAB (STUDY DRUG) VIAL (PRL: VE800-001) 99999002369 240 mg $150.00 $150.00

1001040 GEFITINIB (STUDY DRUG) 250 MG TABLET (PRL: D6186C00001) 99999002372 30 tablet $50.00 $50.00

1001041 SAVOLITINIB (STUDY DRUG) 100 MG TABLET (PRL: D6186C00001) 99999002373 24 tablet $50.00 $50.00

1001042 SAVOLITINIB (STUDY DRUG) 200 MG TABLET (PRL: D6186C00001) 99999002374 24 tablet $50.00 $50.00

1001043 OSIMERTINIB (STUDY DRUG) 40 MG TABLET (PRL: D6186C00001) 99999002375 35 tablet $50.00 $50.00

1001044 OSIMERTINIB (STUDY DRUG) 80 MG TABLET (PRL: D6186C00001) 99999002376 35 tablet $50.00 $50.00

1001047 DURVALUMAB (STUDY DRUG) 500 MG/10 ML VIAL (PRL - D6186C00001) 99999002377 10 mL $150.00 $150.00

1001049 NECITUMUMAB (STUDY DRUG) 800 MG/50 ML VIAL (PRL - D6186C00001) 99999002378 50 mL $150.00 $150.00

1001051 CARBOPLATIN (STUDY DRUG) 10 MG/ML IV SOLN (PRL - D6186C00001) J9045 99999002379 60 mL $150.00 $150.00

1001053 PEMETREXED (STUDY DRUG) 500 MG IV SOLR (PRL - D6186C00001) J9305 99999002380 20 mL $150.00 $150.00

1001055 NIVOLUMAB OR PLACEBO (STUDY DRUG) 10 MG/ML IV SOLN (PRL: CA209-914) 99999002381 24 mL $150.00 $150.00

1001057 IPILIMUMAB OR PLACEBO (STUDY DRUG) 5 MG/ML IV SOLN (PRL: CA209-914) 99999002382 40 mL $150.00 $150.00

1001059 NGM120 (OPEN-LABEL) (STUDY DRUG) SYRINGE (PRL: 18-0402) 99999002383 100 mg $75.00 $75.00

1001060 NGM120 OR PLACEBO (STUDY DRUG) SYRINGE (PRL: 18-0402) 99999002384 100 mg $75.00 $75.00

1001062 JNJ-73841937 (LAZERTINIB) (STUDY DRUG) 80 MG TABLET (PRL: 61186372EDI1001) 99999002385 98 tablet $50.00 $50.00

1001067 SB 11285 (STUDY DRUG) 2 MG VIAL (PRL: GTI-4419-301) 99999002390 2 mg $200.00 $200.00

1001079 AVASOPASEM MANGANESE (GC4419) OR PLACEBO (STUDY DRUG) 9 MG/ML IV SOLN (PRL: GTI-4419-301) 99999002395 90 mL $75.00 $75.00

1001100 LNS8801 (STUDY DRUG) 125 MG TABLET (PRL: LNS-101) 99999002419 30 tablet $50.00 $50.00

1001117 BA3021 (STUDY DRUG) VIAL (PRL: BA3021-001) 99999002430 5 mL $150.00 $150.00

1001119 PEGFILGRASTIM (STUDY DRUG) INJECTION (PRL: BA3021-001) 99999002431 .6 mL $50.00 $50.00

1001120 BA3011 (STUDY DRUG) VIAL (PRL: BA3011-001) 99999002432 5 mL $150.00 $150.00

1001122 PEGFILGRASTIM (STUDY DRUG) INJECTION (PRL: BA3011-001) 99999002433 .6 mL $50.00 $50.00

1001123 MELPHALAN (STUDY DRUG) 5 MG/ML IV SOLN (PRL: PHP-OCM-301A) 99999002436 10 mL $150.00 $150.00

1001126 PEGFILGRASTIM (STUDY DRUG) INJECTION SYRINGE (PRL: PHP-OCM-301A) 99999002437 .6 mL $50.00 $50.00

1001127 ENZALUTAMIDE (STUDY DRUG) 40 MG CAPSULE (PRL: RTOG 3506) 99999002435 124 capsule $50.00 $50.00

1001137 GSK3359609 OR PLACEBO (STUDY DRUG) VIAL (PRL: 209229) 99999002446 8 mL $150.00 $150.00

1001139 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: 209229) 99999002447 4 mL $150.00 $150.00

1001146 ALKS4230 (STUDY DRUG) 5 MG/ML SUBQ SOLN (PRL: ALKS4230-001) 99999002450 10 mg $75.00 $75.00

1001147 ALKS4230 (STUDY DRUG) 15 MG/ML SUBQ SOLN (PRL: ALKS4230-001) 99999002451 30 mg $75.00 $75.00

1001148 PEMBROLIZUMAB (STUDY DRUG) 25 MG/ML IV SOLN (PRL: ALKS4230-001) 99999002452 4 mL $150.00 $150.00

1001160 PALBOCICLIB (STUDY DRUG) 125 MG CAPSULE (PRL: C0541001) 99999002458 23 capsule $50.00 $50.00



1001163 TUCATINIB (STUDY DRUG) 150 MG TABLET (PRL: ACCRU-GI-1617-SGNTUC017) 99999002461 50 tablet $50.00 $50.00

1001164 TUCATINIB (STUDY DRUG) 50 MG TABLET (PRL: ACCRU-GI-1617-SGNTUC017) 99999002462 50 tablet $50.00 $50.00

1001165 TRASTUZUMAB (STUDY DRUG) 150 MG IV SOLN (PRL: ACCRU-GI-1617-SGNTUC017) 99999002463 150 mg $150.00 $150.00

1001167 PANCRELIPASE (STUDY DRUG) 21,000 UNIT CAPSULE (PRL: IIT2018-29-HENDIFAR-PNCX3) 99999002464 100 capsule $50.00 $50.00

4088577 SODIUM BICARBONATE 4.2% NEBULIZER SOLUTION J3490 00409555502 5 mL $153.00 $153.00

4089713 PHENTOLAMINE SUBCUT INJ PEDIATRIC (RN TO PREP) J2760 00143956410 1 Each $5,626.90 $5,626.90

40838681 HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SUSP (RESTRICTED) 90740 58160082101 1 mL $728.32 $728.32

40895160 CALCIUM GLUCONATE 1G VIAL-TO-BAG IVPB J0610 63323031110 1000 mg $160.00 $160.00

408200000 AMIODARONE 150MG-D5W 150ML CSHS J0282 99999900424 150 mL $153.00 $153.00

408400007 MODIFIED HOPP'S STOMATITIS ORAL SUSPENSION 99999900425 100 mL $153.00 $153.00

408400077 ALTEPLASE IV INFUSION J2997 50242004406 1 Each $36,912.69 $36,912.69

408909015 IOHEXOL 350 MG IODINE/ML PO SOLN **FOR INPATIENT USE** Q9967 00407141489 50 mL $153.00 $153.00

408909027 PENICILLIN G POTASSIUM INJ FOR DESENSITIZATION J2540 99999002296 1 Each $153.00 $153.00

408999001 LEUPROLIDE 1 MG/0.2ML FOR PEDS STIM TEST J9218 00781400332 2.8 mL $8,248.80 $8,248.80

408999002 GALLIUM DOTATATE (GA-68)(NETSPOT) ISOTOPE (NUC MED) A9587 69488000140 5.4 millicurie $84,105.00 $84,105.00

4080000012 VANCOMYCIN 750 MG/250 ML IVPB J3370 99999900366 1 Each $153.00 $153.00



CPT/

HCPCS

Code

NDCERx Charge

Quantity

OP/Default

Price IP/ED Price



4080000110 MAGNESIUM SULFATE 50 % (4 MEQ/ML) IJ SOLN J3475 63323006402 2 mL $153.00 $153.00

4080100012 VANCOMYCIN 1250 MG/250 ML PREMIX IVPB J3370 99999900367 250 mL $153.00 $153.00

4080200012 VANCOMYCIN 1500 MG/300 ML IVPB J3370 99999900368 1 Each $153.00 $153.00

4080210007 CEFTRIAXONE IVPB VIAL 250 MG/50 ML VIAL-TO-BAG IVPB J0696 00781320685 1 Each $153.00 $153.00

4084040008 HEPARIN BOLUS FOR APHERESIS 10000 UNITS/10 ML 99999001144 10 mL $153.00 $153.00

4084040010 CEFOXITIN 2 GRAM/50 ML VIAL-TO-BAG IVPB J0694 63323034225 1 Each $190.00 $190.00

4084040023 HEPARIN (PORCINE) IN NACL 500 UNITS/500ML NS FOR CONGENITAL HEART ECMO FLUSH IV SOLP 99999001207 500 mL $153.00 $153.00

4084040025 SILDENAFIL 2.5 MG/ML ORAL SUSPENSION (DOSE > 10 MG) (IP ORDERING ONLY) 99999900078 8 mL $153.00 $153.00

4084040027 METHADONE 5 MG/5 ML PO SOLN (2.5MG<DOSE<=10MG) 99999001239 5 mL $153.00 $153.00

4084040029 SULFAMETHOXAZOLE-TRIMETHOPRIM 0.2-0.04 MG/ML PO SUSP 99999001467 100 mL $272.00 $272.00

4084040030 HEPARIN (PORCINE) IN NACL 500 UNITS/500ML NS FOR CONGENITAL HEART ECMO FLUSH FROM BAG 99999001468 500 mL $153.00 $153.00

4084040031 HEPARIN (PORCINE) IN NACL (PF) 1000 UNITS/500ML FOR ECMO FLUSH IV SOLP BOLUS FROM BAG 99999001469 500 mL $153.00 $153.00

4084040035 FLORBETABEN F18 (NEURACEQ), INJECTION, PER STUDY DOSE, UP TO 8.1 MILLICURIES Q9983 54828000130 30 mL $12,460.00 $12,460.00

4087770001 GLUTARALDEHYDE (GLUTARALD) SOLUTION 3% 99999000048 5 mL $990.00 $990.00

4087770012 SODIUM CHLORIDE 5% FOR APHERESIS ONLY J7131 00338005603 500 mL $153.00 $153.00

4087770016 HYDROMORPHONE 1MG/ML PED 20-50KG CONTIN PCA 99999001238 1 mL $153.00 $153.00

4087771292 TRASTUZUMAB 150 MG IV SOLR J9355 50242013201 1 Each $14,025.78 $14,025.78


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