website link: ... › pay › documents › cdm.pdf1 of 317 fy2018 description charges room &...

1 of 317 FY2018

DESCRIPTION CHARGESROOM & BEDROOM/BED: CV Stepdown $2,300ROOM/BED: Hospice $1,325ROOM/BED: Intensive Care $3,425ROOM/BED: Med/Surg $1,325ROOM/BED: OB $1,325ROOM/BED: Peds $1,275ROOM/BED: Telemetry $2,100ROOM/BED: Observation $41

RECOVERY ROOMRecovery First Hour $279Recovery Ea Addl Hour $28Phase II Recovery 1/2 Hr $205Phase II Recovery 1 Hr $410Phase II Recovery 9 Hrs $3,691Recovery Room Level III 1/2 Hr $435Recovery Room Level III 1 Hr $739Recovery Room Level III 1.5 Hr $1,043Recovery Room Level III 2.5 Hr $1,650Recovery Room Level III 2hrs $1,346Recovery Room Level III 3 Hrs $1,954Recovery Room Level III 3.5 Hr $2,257Recovery Room Level III 4 Hrs $2,562Recovery Room Level III Ea Add .5hr $304

BEDSIDE NURSING PROCEDURESAmniocentesis Nursing $307Amnioinfusion Bolus Start $257Arthrocentesis Intermediate Joint $371Arthrocentesis Major Joint $424Arthrocentesis Small Joint $352Avulsion Nail Plate 11 $163Biopsy Skin Subcu Ea Addtl Les $184Biopsy Skin Subcu Single Lesio $259Bone Marrow Aspiration $521Bronchoscopy $2,000

While the file below represents our line item charges for St. Luke's Hospital, thewebsite link below will provide you with the average out-of-pocket costs for ourmost common services together with additional insights into pricing transparencyfor our services and frequently asked questions.

Website link: https://www.stlukes-stl.com/pay/average-cost-estimates.html

2 of 317 FY2018

DESCRIPTION CHARGES

Bronchoscopy needle aspiration biopsy $1,591Bronchoscopy through trach $2,000Bronchoscopy with alveolar lavage $1,591Bronchoscopy with biopsy $1,591Bronchoscopy with brushing $1,591Bronchoscopy with foreign body removal $1,591Bronchoscopy with tran Bronchoscopy biopsy $1,591Bronchoscopy with washing $2,515Cardiopulmonary Resuscitation $557Cardioversion Nursing $798Catheterization Umbilical Ar36 $176Catheterization Umbilical VE36 $176Cervical Cerclage $2,859Change Cysto Tube Simple $332Change of Gastrostomy Tube $424Chemical Pleurodesis $690Circumcision Date_NB $292CPR w/Defibrilation $477Cystourethroscopy Nursing $1,256Debr Muscle 1st 20 Sq Cm 11043 $631Debr Muscle Each Addtl 20sq Cm $399Debr Subc 1st 20 Sq Cm 11042 $405Debr Subc Each Addl 20 Sq Cm $30Debridement Nails >6 11 $148Debridement Nails 1 5 $122Discontinued IABP Activity $464Endotracheal Intubation (Emerg) $424Epid Cath Insert Plan'd C Sec $621Epidural Cath Insertion C Sec $621Epidural Placed $621Fetal Scalp Electrode Placed $256Gastric Intubation/Lavage 91 $255I&D of Abscess Simple $265Incision Lingual Frenum $1,359Inj Anesth Other Periph Nerve $584Inj Epid Blood/Clot Patch $902Injection Thrombin Extremity PSA $634

3 of 317 FY2018

DESCRIPTION CHARGES

Insert Arterial Line $145Insert Cervical Dilator $416Insert Chest Tube $928Insert Lumbar Drain $743Insert new site Central IV $1,501Insert new site PA Line $1,688Insert/Repl of Temp Sgl Chamber $7,892Inserted IABP $1,303Insertion of Central Line Non Tunneled $1,501Insertion of Central Line Tunneled $3,614Intercostal Nerve Blk Multiple $1,211Intro of Needle/Intracath Vein $30IUPC Placed $256IVT Insertion of PICC $1,626Laryngoscopy w/wo Trach Diag $2,122Nasal Packing Complex $212Nasal Packing Posterior Initial $212Nasal Packing Posterior Subseq $212Nasal Packing Simple $212Nasopharyngoscopy w/Endoscope $139Nasotrach Suctioning w/Fiber $310Nasotrach Suctioning w/o Fiber $149OB External Version $2,859Operating Room 1 1/2 Hr $2,268Operating Room 1 Hr $1,801Operating Room 1/2 Hr $1,351Operating Room 2 1/2 Hrs $3,177Operating Room 2 Hrs $2,735Operating Room 3 1/2 Hrs $4,100Operating Room 3 Hrs $3,653Operating Room 4 Hrs $4,570Operating Room 45 Min $1,577PA Line Activity - Insert new site $1,688PA Line Activity - Reinsert same site $1,688Peds PICC Insertion < 5 Y/O $1,903Peds PICC Insertion Age 5 & Older $1,626Percutaneous Scoop Insertion $531

4 of 317 FY2018

DESCRIPTION CHARGES

Pericardiocentesis Initial $690Pericardiocentesis Subsequent $690Puncture Aspir Ab/He/Bu/Cyst10 $279Reinsert Same Site Arterial Line $145Reinsert same site Central IV $1,501Reinsert same site PA Line $1,688Removal of Cervical Cerclage $2,859Renal Biopsy Perc $1,087Repair of Wound Dehiscence Sim $424Repositioned Gastric Tube $1,273RT Intubation Assist Endotracheal Tube $421Spinal Punc Therapy Drain Fluid $743Thoracntsis Ndle Asp w/o Guide $690Tracheostomy Emergency Proc $1,281Treatment of Wound Dehiscence $531Tube changed Tracheostomy Tube $332Umbilical Catheterization Type Arterial $176Umbilical Catheterization Type Venous $176Wound Care/Debr Skin Ea Ad 20cm $219Wound Care/Debr Skin(Only) <21cm $219Wound Debridement Extensive Ec $292

RADIOLOGYABD 1 VIEW POST NG TUBE PLACEMENT $231Abd-AP/Oblique/Cone Views $230Abd-Comp w/Decub or Erect Views $409Abd-Compl w/Flat/Upright PA Chest $456Abdomen - (AP View Only) $231ABDOMEN AP (KUB) $255ABDOMEN AP W/OBLIQUES $311Acromioclavicular Jnt-Bilat $196Ankle - (AP & Lat) $174Ankle - (AP & Lat) Bilat $349ANKLE AP AND LAT LEFT $389ANKLE AP AND LAT RIGHT $389Ankle Arthrogram $831Ankle Arthrogram Bilat $1,663

5 of 317 FY2018

DESCRIPTION CHARGES

Ankle Arthrogram Inj $288ANKLE ARTHROGRAM LEFT $831ANKLE ARTHROGRAM RIGHT $831ANKLE COMPLETE LEFT $273ANKLE COMPLETE RIGHT $273Ankle-Complete, Min 3 Views Bilat $483Ankle-Complete, Min Three Views $273ARTHRITIS SERIES $537Asp/Inj Intermediate Joint Wo US $371Asp/Inj Large Joint w/o US $424Asp/Inj Small Joint wo US $352BARIUM ENEMA $707BARIUM ENEMA AIR CONTRAST $945Blood Patch Inj Epidural $902Bone Age Studies $416Bone Length Studies $171Bone Mineralization - (Complete) $537Bone Mineralization - (Limited) $467Brain Imaging, For Alzheimer's $4,389Calcaneus/Heel-Min of 2 Views Bil $472Calcaneus/Heel-Min of Two Views $218C-ARM FLUORO 1 HOUR OR MORE $723C-ARM FLUORO UP TO 1 HOUR $493Cephalogram $63CERVICAL SPINE 1 VIEW $332CERVICAL SPINE 2 OR 3 VIEWS $390CERVICAL SPINE 4 OR 5 VIEWS $450CERVICAL SPINE 6 OR MORE VIEWS $562CERVICAL SPINE FLEX/EXT ONLY $390Chest - (PA & Lat) $270Chest - (Single View) $229CHEST 1 VIEW POST LINE PLACEMENT $229CHEST 2 VIEWS W/APICAL LORDOTIC $297CHEST 2 VIEWS W/FLUOROSCOPY $209CHEST 2 VIEWS W/OBLIQUE $312CHEST 4 OR MORE VIEWS $330CHEST DECUBITUS LEFT $213

6 of 317 FY2018

DESCRIPTION CHARGES

CHEST DECUBITUS RIGHT $213Chest-(Lateral and Decubitus) $213Chest-PA/Lat/oblique Views $312CHOLANGIOGRAM OPERATIVE $559CHOLANGIOGRAM OPERATIVE ADDL SET $171CHOLANGIOGRAM POST OP T TUBE W/INJ $1,339CISTERNOGRAPHY $987Clavicle - (Complete) $218Clavicle - (Complete) Bilat $437CLAVICLE LEFT $218CLAVICLE RIGHT $218COLORECTAL CA SCREEN $613COLORECTAL CA SCREEN HIGH RISK $613CONTRAST INJ FOR EVAL OF GI TUBE $400CORPUS CAVERNOSGRAM $1,135CPC Cinefluoroscopy $197CPC Video Nasoendoscopy $197CT Nerve Block Inj Ilioinguinal $729CYSTOGRAM $428DACRYOCYSTOGRAPHY LEFT $513DACRYOCYSTOGRAPHY RIGHT $513Dexa Scan, Bone Density Study $386Dexa Scan, Bone Density Study, $232Digital Mamm, 3-D Diag Unilat/Bil $70DISCOGRAM CERVICAL $1,765DISCOGRAM LUMBAR $1,765Doppler Fetal Echo Repeat or Follow-Up $217Doppler Fetal Echo, Complete $410Dysphagia/Speech Eval $359Elbow - (AP & Lat) $171Elbow - (AP & Lat) Bilat $343Elbow - (Unilat 3 + Views) Bilat $437Elbow - (Unilat 3+ Views) $274ELBOW AP/LAT LEFT $323ELBOW AP/LAT RIGHT $323ELBOW ARTHROGRAM BILAT $1,566Elbow Arthrogram Injection $288

7 of 317 FY2018

DESCRIPTION CHARGES

ELBOW ARTHROGRAM LEFT $783ELBOW ARTHROGRAM RIGHT $783ELBOW COMPLETE LEFT $274ELBOW COMPLETE RIGHT $274ENTEROCLYSIS TUBE PLACEMENT PERC $1,094Epidural Inj Sgl Cer/Thorac $1,432Epidurography S&I $316ERCP BILIARY AND PANCREATIC DUCT $1,025ERCP BILIARY DUCT $810ERCP PANCREATIC DUCT $415ESOPHAGEAL DILATION PROCEDURE $370ESOPHAGRAM CERVICAL $328Esophagus X-Ray $451ESOPHAGUS/BARIUM SWALLOW $451Exam Per Ultrasound Infertility $400EXTREMITY LOWER INFANT LEFT $230EXTREMITY LOWER INFANT RIGHT $230EXTREMITY UPPER INFANT LEFT $230EXTREMITY UPPER INFANT RIGHT $230Eye Exam-R/O Foreign Body $70Facet Inject Cervical or Thoracic $1,189FACIAL BONES < 3 VIEWS $207Facial Bones-< 3 Views $199Facial Bones-Comp, Min 3 Views $325Femur 1 View $199FEMUR 1 VIEW BILAT $398FEMUR 1 VIEW LT $199FEMUR 1 VIEW RT $199FEMUR 2 OR MORE VIEW BILAT $490FEMUR 2 OR MORE VIEW LT $245FEMUR 2 OR MORE VIEW RT $245Femur Min 2 Views $245Fetal Biophysical Profile w/Nst $508Finger(s)-Min 2 Views $199Finger(S)-Min 2 Views Bilat $398FINGERS LEFT $199FINGERS RIGHT $199

8 of 317 FY2018

DESCRIPTION CHARGES

FL EXAM $581Fluoro < 1 Hour $493FLUORO FOR BRONCHOSCOPY $493Fluoro Guidance Needle Placement $649Fluoro Guidance Spine $400FLUOROSCOPY 1 HOUR OR MORE $723Fluoroscopy for Needle Placement $649Fluoroscopy in OR Room $493FLUOROSCOPY NEEDLE LOC SPINOUS $497Foot - (AP & Lat) $236Foot - (AP & Lat) Bilat $472FOOT AP AND LAT LEFT $348FOOT AP AND LAT RIGHT $348FOOT COMPLETE LEFT $261FOOT COMPLETE RIGHT $261Foot-Complete, Min of 3 Views Bil $472Foot-Complete, Min of Three Views $261Forearm - (AP & Lat) $234Forearm - (AP & Lat) Bilat $468FOREARM LEFT $234FOREARM RIGHT $234FOREIGN BODY REMOVAL ESOPHAGUS $363FOREIGN BODY SURVEY CHILD $186Gallbladder (Oral Contrast) $127Greater Occipital Nerve Blk - CDI RAD $367Hand - (AP & Lat) $400Hand - (AP & Lat) Bilat $372Hand - Complete, Min 3 Views Bilat $545HAND 2 VIEWS LEFT $400HAND 2 VIEWS RIGHT $400HAND COMPLETE LEFT $272HAND COMPLETE RIGHT $272Hand, 2 Views $400Hand-Complete, Min 3 Views $272Hip - (Unilateral, One View) $116Hip Arthrogram Injection $269HIP ARTHROGRAM LEFT $1,082

9 of 317 FY2018

DESCRIPTION CHARGES

HIP ARTHROGRAM RIGHT $1,082Hip Arthrogram S&I $1,082Hip Arthrogram S&I Bilat $2,164HIP BILAT >4 VIEW W/WO PELVIS $420HIP BILAT 2 VIEW W/WO PELVIS $359HIP BILAT 3-4 VIEW W/ PELVIS $513Hip Bilat 3-4 View w/wo Pelvis $390HIP BILATERAL (3-4 VIEW) $479HIP COMP (2-3 VIEW) W/PELVIS LT $359HIP COMP (2-3 VIEW) W/PELVIS RT $359HIP COMPLETE LEFT (2 - 3 views) $274HIP COMPLETE RIGHT (2 - 3 views) $274HIP UNI >3 VIEWS W/WO PELVIS LT $540HIP UNI >3 VIEWS W/WO PELVIS RT $540Hip Uni Min2-3 View w/wo Pelvis $513HIP UNILAT 1 VIEW LT $467HIP UNILAT 1 VIEW RT $467HIP/PELVIS ABSCESS DRAIN $643HUMERUS LEFT $323HUMERUS RIGHT $323Humerus-Min 2 Views $218Humerus-Min 2 Views Bilat $437HYSTEROSALPINGOGRAM $633HYSTEROSALPINGOGRAM INJ $528Inj Anesth Intercostal Nerve, Sgl $367INJ CONTRAST PREV PLACE CATH $261INJECT SINUS TRACT $753Injection for Breast X-Ray $441Injection Trigger Point $392IVP W/ TOMOGRAPHY $924IVT Us Guidance For Needle Placement $753Knee - (AP & Lat) $277Knee - (AP & Lat) Bilat $372Knee - (Bilateral Standing) $349KNEE 2 VIEW AP AND LAT LEFT $277KNEE 2 VIEW AP AND LAT RIGHT $277KNEE 4 VIEWS LEFT $382

10 of 317 FY2018

DESCRIPTION CHARGES

KNEE 4 VIEWS RIGHT $382KNEE AP/LAT/OBL LEFT $327KNEE AP/LAT/OBL RIGHT $327Knee Arthrogram Inj $316KNEE ARTHROGRAM LEFT $628KNEE ARTHROGRAM RIGHT $628Knee Arthrogram S&I $628Knee Arthrogram S&I Bilat $1,256Knee-AP/Lat w/obliq, Min 3 View Bil $507Knee-AP/Lat w/Obliques, Min 3 View $327Knee-Comp, Incl Obliq/Other View Bil $568Knee-Comp, Incl Obliques/Other Views $382LEG TIBIA AND FIBULA LEFT $288LEG TIBIA AND FIBULA RIGHT $288LOOPOGRAM $398LUMBAR AP/LAT/FLEX/EXT STANDING $490Lumbar Epi Steroid Inj $1,432Lumbar Facet Jnt/Nrv Inj 2nd Lvl $1,000Lumbar Facet Jnt/Nrv Inj 3rd+ Lvl $1,000Lumbar Facet Jnt/Nrv Inj-1st Lvl $1,308Lumbar Myelogram Inj Cerv $1,673Lumbar Myelogram Inj Lumbos $1,673Lumbar Myelogram Inj Mult Region $2,002Lumbar Myelogram Inj Thorac $1,673Lumbar Nerve Block Inj-1st Lvl $1,231Lumbar Nerveblock Inj-Ea Addl Lvl $809LUMBAR SPINE 1 VIEW $332LUMBAR SPINE 5 VIEWS $490LUMBAR SPINE AP/LAT 2/3 VIEWS $333LUMBAR SPINE COMPLETE W/BENDING $504LUMBAR SPINE LAT FLEX/EXT/NEUT $333Lumbar-Comp w/oblique Views $490Lumb-Bndg Views Only 2 Or 3 Views $153MAM DIAG/BILAT/DIGITAL 2-D $372MAM DIAG/UNILAT/RT/DIGITAL 2-D $304MAM SCREEN W/ADDL VIEWS DIGITAL $372MAM SCREENING BILAT/DIGITAL $344

11 of 317 FY2018

DESCRIPTION CHARGES

MAM SCREENING UNILAT/DIGITAL $344MAM SCREENING W/IMPLANTS/DIGITAL $372MAMM BREAST SURGERY SPECIMEN LEFT $280MAMM BREAST SURGERY SPECIMEN RIGHT $280MAMM DUCTOGRAM MULTIPLE LEFT IR $415MAMM DUCTOGRAM MULTIPLE RIGHT IR $415MAMM DUCTOGRAM SINGLE LEFT IR $469MAMM DUCTOGRAM SINGLE RIGHT IR $469Mamm Screen Unilateral 2-D $344MAMMO DIAGNOSTIC 3D $70MAMMO DIAGNOSTIC 3D $70MAMMO SCREENING 3D $70Mandible-< 4 Views $326Mandible-Comp, Min 4 Views $284Mastoids-< 3 Views Per Side $107Mastoids-Comp, Min 3 Vws/Side $135MVAN MAMMO SCREENING 3D $70MVAN MAMMO SCREENING DIGITAL $344MVAN MAMMO SCREENING IMPLANTS $372MYELOGRAM INJ CERVICAL $1,673MYELOGRAM INJ LUMBOSACRAL $1,673MYELOGRAM INJ MULT REGION $2,002MYELOGRAM INJ THORACIC $1,673Nasal Bones-Comp, Min 3 Views $196NASO/ORO-GASTRIC TUBE PLACEMENT $700NECK SOFT TISSUE W/FLUOROSCOPY $207NM EXAM $332NM PET BRAIN EVAL OF BRAIN TUMORS $4,780NM PET BRAIN PRESURG EVAL EPILEPSY $4,780NM PET MYOCARDIAL VIABILITY $4,780NM Sentinal Node Injection $411NM Shunt Injection $1,139OB Transvaginal $239OBSTRUCTION SERIES W/CXR $456OBSTRUCTION SERIES W/O CXR $409Orbits-Comp, Min 4 Views $381ORTHOPANTOGRAM PANOREX $287

12 of 317 FY2018

DESCRIPTION CHARGES

OS CALCIS LEFT $218OS CALCIS RIGHT $218OSSEOUS SURVEY INFANT $312Pancreas $259Pelvic Transvaginal (Non-Ob) $707PELVIS AP ONLY $281PELVIS COMPLETE 3 VIEWS $388Pelvis, Limited (Follicular Size) $531PERINEOGRAM/VAGINAGRAM $428PET BRAIN RESEARCH CLINICAL PROF $4,780PET LIMITED AREA INITIAL W/CT $4,780PET LIMITED AREA SUBSEQUENT W/CT $4,780PET LIMITED BRAIN IDEAS AMYVID $4,780PET LIMITED BRAIN IDEAS NEUROSEQ $4,780PET LIMITED BRAIN IDEAS VIZAMYL $4,780PET MYOCARDIAL METABOLIC $3,007PET MYOCARDIAL PERFUSION MULTI $3,443PET MYOCARDIAL PERFUSION SINGLE $3,443PET SB-MT INIT NETSPT GA68 DOTATA $4,780PET SB-MT SUB NETSPT GA68 DOTATAT $4,780PET SKULLBASEMIDTHIGH INITIAL W/CT $4,780PET SKULLBASEMIDTHIGH SUBSEQ W/CT $4,780PET WB INIT AXUMIN F18 FLUCICLOVI $4,780PET WB INIT NETSPOT GA68 DOTATATE $4,780PET WB SUB AXUMIN F18 FLUCICLOVIN $4,780PET WB SUB NETSPOT GA68 DOTATATE $4,780PET WHOLE BODY INITIAL W/CT $4,780PET WHOLE BODY SUBSEQUENT W/CT $4,780Pet, Limited Area $3,318Pet, Skull Base to Mid-Thigh $2,863Pet, Whole Body $2,863Pharynx and/or Esophagus X-Ray $328POST-PROCEDURE MAMMO BILATERAL $334POST-PROCEDURE MAMMO UNILATERAL $266Preg Uterus >14 Weeks Ea Addl Ges $639Preg Uterus >14 Weeks Sngl Ges $778Prostate Volume Study $945

13 of 317 FY2018

DESCRIPTION CHARGES

Radiological Exam, Surg Specimen $280Renal (Kidneys) $259RETROGRADE PYELOGRAM $586Retroperitoneal, Limited $259Ribs - (Bilateral, Three Views) $506RIBS UNILATERAL LEFT $350RIBS UNILATERAL RIGHT $350RIBS UNILATERAL W/CHEST PA LEFT $404RIBS UNILATERAL W/CHEST PA RIGHT $404Ribs-Bilatl, 3 Views w/PA Chest $515Ribs-Inc Chest, Min 3 Views $404Ribs-Unilat, 2 Views $350S&I Abd Aortagram With Runoff $3,029S&I Abdominal Aortagram $3,029S&I ExtremityUnilateral/Art $3,029S&I IVC $2,412S&I Pericardiocentesis $84S&I SVC $2,532S&I Thoracic Aortagram $3,029S&I Transcath Biopsy $1,306S&I Venography Sinus or Jugular $930Sacral Nerve Block Inj Unilat 2l $1,231SACRO ILIAC JOINTS LESS THAN 3 VIEWS $141Sacroiliac Jnts-3 or More Views $283Sacrum & Coccyx-Min 2 Views $218SACRUM/COCCYX $384SALIVARY GLAND LEFT $151SALIVARY GLAND RIGHT $151Scapula - (Complete) Bilat $407Scapula - (Complete) CDI RAD $203SCAPULA LEFT $377SCAPULA RIGHT $377SCOLIOSIS 1 VIEW $143SCOLIOSIS 2 OR 3 VIEWS $237SCOLIOSIS 4 OR 5 VIEWS $451SCOLIOSIS 6 OR MORE VIEWS $451Scrotum & Testicles $916

14 of 317 FY2018

DESCRIPTION CHARGES

Sella Turcica $203Shoulder - (One View) Bilat $278SHOULDER 1 VIEW LEFT $139SHOULDER 1 VIEW RIGHT $139Shoulder Arthrogram Inj $322SHOULDER ARTHROGRAM LEFT $894SHOULDER ARTHROGRAM RIGHT $894SHOULDER COMPLETE LEFT $327SHOULDER COMPLETE RIGHT $327Shoulder- Complete, Min 2 Views Bil $492SI Joint Injection $895SI JOINT INJECTION W/FLUORO $852SIALOGRAM LEFT $613SIALOGRAM RIGHT $613SINUS TRACT STUDY $550Sinuses-<3 Views $239Sinuses-Comp, Min 3 Views $373Skull-< 4 Views $333Skull-Comp, Min 4 Views $409Small Bowel $476SMALL BOWEL SERIES BY ENTEROCLYSIS $694Soft Tissue Head/Neck $673Soft Tissue Neck $199SP ABSCESS DRAIN/SPECIMEN PROCEDURE $1,235SP ANGIOGRAM ADRENAL BILAT SEL $1,973SP ANGIOGRAM ADRENAL SEL LT $3,029SP ANGIOGRAM BRACHIAL RETROGRADE $1,424SP ANGIOGRAM EXTREMITY BILATERAL $3,029SP ANGIOGRAM EXTREMITY UNI LEFT $3,029SP ANGIOGRAM EXTREMITY UNI RIGHT $3,029SP ANGIOGRAM INTERNAL MAMMARY $1,424SP ANGIOGRAM PELVIC SELECT/SUPRA $3,029SP ANGIOGRAM PULMONARY BILAT $3,029SP ANGIOGRAM PULMONARY NONSELECT $1,424SP ANGIOGRAM PULMONARY UNI LEFT $1,581SP ANGIOGRAM PULMONARY UNI RIGHT $1,581SP ANGIOGRAM SELECT EA ADDL VESSEL $1,700

15 of 317 FY2018

DESCRIPTION CHARGES

SP ANGIOGRAM SPINAL SELECTIVE $1,438SP ANGIOGRAM VIA EXISTING CATH $569SP ANGIOGRAM VISC SELECT/SUPRA $3,029SP ANGIOGRM ADRENAL UNI SEL LEFT $3,029SP ANGIOGRM ADRENAL UNI SEL RIGHT $3,029SP ANKLE ARTHROGRAM INJ $288SP AORTOGRAM THORACIC DSA $3,029SP AORTOGRAM W/ BILAT ILEOFEMORAL $3,029SP ARTHROCENTESIS ASP/INJ INT $400SP ARTHROCENTESIS ASP/INJ MAJ $424SP ARTHROCENTESIS ASP/INJ SMALL $352SP BILIARY TRANSHEPATIC DILATION PERC $818SP CATH/TUBE EXCHANGE PROC $417SP CERVICAL DISKOGRAM INJ $186SP CYSTOGRAPHY INJECT $650SP ELBOW ARTHROGRAM INJ $288SP ENDOVAS REPAIR THORACIC AORTA $1,030SP Epidural lumbar or caudal $323SP EPIDUROGRAM $497SP FLUORO GUIDANCE CVA DEVICE $782SP HIP ARTHROGRAM INJ W/O ANESTH $436SP INJ EPI/CERV/THORAC SNGL W/FLUORO $1,432SP INJ EPI/LUMB/CAUDAL SNGL W/FLUORO $1,697SP INJ FACET JNT CERV/THOR SINGLE LEV $1,189SP Inj Facet Jnt Cerv/Thr 3 or more $1,093SP Inj Facet Jnt Cerv/Thr Second Lev $1,093SP INJ FACET JNT LUMB/SAC SINGLE LEV $1,308SP Inj Facet Jnt Lumbar/Scr 2nd Lev $1,000SP Inj Facet Jnt Lumbar/Scr 3 or more $1,000SP Inj Paravrt Lumb/Sacr Ea Add $809SP INJECT DACROCYSTOGRAM $129SP INJECTION TRIGGER POINT $392SP KNEE ARTHROGRAM INJ $500SP LUMBAR DISKOGRAM INJ $202SP LUMBAR PUNCTURE DX $700SP MANOMETRIC STUDY $268SP NEPHROSTOMY URETER DILAT LEFT $2,300

16 of 317 FY2018

DESCRIPTION CHARGES

SP NEPHROSTOMY URETER DILAT RIGHT $2,300SP REMOVAL NEPHROSTOMY W/FLUORO $1,280SP REMOVAL TUNNEL CV CATHETER $640SP RENAL CYST STDY TRANSLUM LEFT $498SP RENAL CYST STDY TRANSLUM RIGHT $498SP REPLACE EXTNL NEPHROUTERL CATH $4,112SP RETRO URETHROCYSTOGRAPHY INJ $1,131SP SALIVARY DUCT DILAT AND CATH $144SP SALIVARY DUCT DILATION $141SP SHOULDER ARTHROGRAM INJ $322SP SHUNTOGRAM $578SP SIALOGRAPHY INJ $354SP SPINAL PUNC THERAPEUTIC DRAIN $395SP SPLENOPORTOGRAM $1,424SP Theraputic Inj Sinus Tract $1,363SP Thrombectomy Arter/Veno Graft $2,612SP TIPS W/ HEMODYN EVAL PERC $3,029SP TIPS W/O HEMODYN EVAL PERC $3,221SP TMJ ARTHROGRAM INJ $208SP TRANSCATH THERAPY EMBOLIZATION $2,731SP TRANSCATHETER BX PROCEDURE $2,400SP TRIGEMINAL ANESTHETIC INJ $62SP URETEROSTOMY INJ $78SP US GUIDE FOR NEEDLE PLACE $753SP VENOGRAM ADRENAL BILAT SELECT $1,713SP VENOGRAM EXTREMITY BILATERAL $2,065SP VENOGRAM EXTREMITY UNILA LEFT $2,169SP VENOGRAM EXTREMITY UNILA RIGHT $2,169SP VENOGRAM HEPATIC W/HEMODYN $3,029SP VENOGRAM HEPATIC W/O HEMODYN $1,515SP VENOGRAM IVC W/SERIAL $2,412SP VENOGRAM ORBITAL $1,319SP VENOGRAM RENAL BILAT SELECT $1,937SP VENOGRAM RENAL SELECT LEFT $1,581SP VENOGRAM RENAL SELECT RIGHT $1,581SP VENOGRAM SINUS/JUGULAR $2,169SP VENOGRAM SUP SAG SINUS $1,424

17 of 317 FY2018

DESCRIPTION CHARGES

SP VENOGRAM SVC W/SERIAL $2,532SP VENOGRAPHY EPIDURAL $1,424SP VENOGRM ADRENAL UNI SELE LEFT $1,581SP VENOGRM ADRENAL UNI SELE RIGHT $1,581SP VENOUS SAMPLE W/O ANGIO $1,655SP WRIST ARTHROGRAM INJ $431Sternoclavicular Joint-Min 3 View $312STERNUM $329Superficial Mass (Unlisted) $436SWALLOWING FUNCTION/COOKIE SWALLOW $516THERAPEUTIC INJ SINUS TRACT $1,363THORACIC SPINE 1 VIEW $332THORACIC SPINE AP/LAT $322THORACIC SPINE W/OBLIQUES $394Thoracic-AP/Lat Inc Swmrs Views $394THORACOLUMBAR SPINE AP/LAT $323Tibia/Fibula - (AP & Lat) $288Tibia/Fibula - (AP & Lat) Bilat $460TMJ - Bilateral $502TMJ ARTHROGRAM UNILATERAL LEFT $1,082TMJ ARTHROGRAM UNILATERAL RIGHT $1,082TMJ UNILATERAL LEFT $263TMJ UNILATERAL RIGHT $263Toe(s) - (Min of Two Views) $164TOES LEFT $164TOES RIGHT $164Tomogram (AP Or Lat) 1 View $366TRANSCERVICAL CATH OF FALLOPIAN TUBE $513Trigger Pnt Inj, 1 Or 2 Muscle(s) $336Trigger Pt Inj Sgl/Mult 3+ Muscle $460UE-Infant, Min 2 Views $230UE-Infant, Min 2 Views Bilat $460Ultrasound Exam AAA Screen $243Ultrasound Fetal Assessment $433UPPER GI AIR CONTRAST W/SM BOWEL SERIES $956Upper GI Tract Air Contrast $643Upper GI Tract with KUB $290

18 of 317 FY2018

DESCRIPTION CHARGES

Upper GI w/Air Contrast $684UPPER GI W/KUB $617Upper GI w/Small Bowel $764URETHROCYSTOGRAM/VOIDING $701Urinary Bladder $715Urography, Infusion with Nephroto $924Urography/Pyelography, IV w/wo UB $624US ABDOMEN APPENDICITIS $732US ABDOMEN COMPLETE $1,064US ABDOMINAL LIMITED $732US ABSCESS DRAIN/SPECIMEN PROCEDURE IR $975US AMNIOCENTESIS GUIDANCE IR $480US ANEURYSM FISTULA GUIDANCE IR $429US AORTA $938US AXILLA BILATERAL LIMITED $623US AXILLA LEFT LIMITED $623US AXILLA RIGHT LIMITED $623US BREAST ASPIRATION $753US BREAST BILATERAL COMPLETE $1,246US BREAST BILATERAL LIMITED $623US BREAST LEFT COMPLETE $815US BREAST LEFT LIMITED $623US BREAST RIGHT COMPLETE $815US BREAST RIGHT LIMITED $623US CHEST $693US ENDOVAGINAL SCAN $707US EXTREMITY NONVAS UNILAT COMPLT $617US EXTREMITY NONVAS UNILAT LIMITD $455US FERTILITY FOLLOW UP $715US FERTILITY INITIAL $715US GALL BLADDER/ BILIARY TRACT $732US GUIDANCE FOR ASPIRATION OVARY $486US GUIDANCE TISSUE ABLATION $486US HIPS W/O MANIPULATION $334US HIPS WITH MANIPULATION $376US HYSTEROSONOGRAPHY $1,273US injection trigger point $392

19 of 317 FY2018

DESCRIPTION CHARGES

US INTRAOPERATIVE $1,332US LIVER $732US NEONATAL HEAD $533US Ob Bio Profile $209US PANCREAS $597US PELVIC $715US PELVIC FOLLOW UP $531US PREGNANCY COMPLETE $778US PREGNANCY FOLLOW UP $645US PREGNANCY LIMITED $455US PREGNANCY MULTIGESTATION $639US PROSTATE $489US PYLORIC STENOSIS $732US RENAL $772US RETROPERITONEUM $938US SPINAL CORD $327US SPLEEN $732US TESTICULAR $916US THYROID PARATHYROID NECK $673US TRANSPLANTED KIDNEY $454US TRANSRECTAL ULTRASOUND $626Uterus w/Detail Fetal Ex Ea Addl $239Uterus w/Detail Fetal Ex Sngl Ges $289VAD Peritoneogram $967VAD Removal Declot CV Device 75902 $236VAD Removal Pericath Fibrin Sheath 75901 $236VASOGRAPHY $428Wrist - (AP & Lat) $208Wrist - (AP & Lat) Bilat $416Wrist - (Complete) $259Wrist - (Complete) Bilat $472WRIST AP AND LAT LEFT $208WRIST AP AND LAT RIGHT $208Wrist Arthrogram Inj $431WRIST ARTHROGRAM LEFT $940WRIST ARTHROGRAM RIGHT $940Wrist Arthrogram S&I $940

20 of 317 FY2018

DESCRIPTION CHARGES

Wrist Arthrogram S&I Bilat $1,880WRIST COMPLETE LEFT $259WRIST COMPLETE RIGHT EXAM $259

LAB10 11 Epoxide $39611 Deoxycortisol $32617 Hydroxyprogesterone $35117 KETOSTEROID 17 KS Add On $9518 Hydroxycorticosterone $39824 HR URINE CREATININE 17 KS Add On $475' Nucleotidase $19082360 Ap Bill Chemical Analysis $14485060 AP Bill Peripheral Smear with Path Interp $8885097 Ap Bill Bone Marrow Interp $18687491 Ap Bill Chlam. Trach. Amplified Probe $6687591 Ap Bill Gc Amplified Probe $6687624 Ap Bill Hpv Dna Low and High Risk $13287625 AP Bill HPV Types 16 and 18 $8587661 AP Bill Trichomonas Vag amplified probe $28088104 AP Bill Non Gyn Cytology $18488108 AP Bill Non Gyn Cytology Concentration Technique $18488112 Ap Bill Cyto Cellular Enhance $18488142 AP Bill Gyn Cytology Liquid Prep $12288150 Ap Bill Cytopath C/V Screen $4188161 Ap Bill Cyto Prep And Interp $18488172 AP Bill FNA Immediate Read $26488173 AP Bill FNA Interp and report $27388300 AP Bill Surgical Pathology Level I Complexity $11088302 AP Bill Surgical Pathology Level II Complexity $20888304 AP Bill Surgical Pathology Level III Complexity $30188305 AP Bill Surgical Pathology Level IV Complexity $35588307 AP Bill Surgical Pathology Level V Complexity $45088309 AP Bill Surgical Pathology Level VI Complexity $61688311 AP Bill Decalcification $9988312 AP Bill Special Stains Group I $14088313 AP Bill Special Stains Group II $142

21 of 317 FY2018

DESCRIPTION CHARGES

88321 AP Bill Consultation Fee Outside slides and report $15088323 AP Bill Consultation Fee Outside slides/report prep $26088329 AP Bill Non Gyn Cytology Intraoperative Consult $8888331 AP Bill Frozen single specimen $26588332 AP Bill Frozen add'l block $19888333 Ap Bill Cyto Exam(Touch Prep Initial) $8988334 Ap Bill Cyto Exam(Touch Prep Addit) $23888341 AP Bill Immunohistochemistry (Additional) $26088342 AP Bill Surg IPX (Each Antibody) $26088360 AP Bill IHC Quant $26088364 Bill Surg In Situ Hybridization (Additional) $39088365 Bill Surg In Situ Hybridization (Initial) $39089060 Ap Bill Crystal Identification Except Urine $152ABS.CD4 CD8 COUNT RATIO Add On $202ABS.CD4 COUNT Add On $132ABY SCREEN PREN T&S PNL Add On $160Acetaminophen Level $237Acetone $65Acetylcholine Receptor AB $407Acetylcholine Receptor Blocking Ab $339Acetylcholine Receptor Modulating Ab $353Acid Fast Bacilli Smear $115Acid Fast Stain Report $115ACT LR $72ACT Plus $72Activated Protein C Resistance $262Activated Protein C Resistance (SLU) $262Addtl Blood Glucose $48Adenovirus Antibody $68ADH (Antidiuretic Hormone) $366Adrenocorticotropic Hormone $430AFB Blood Culture $219AFB Culture $181ALBUMIN Add On $82ALBUMIN CSF MS PANEL Add On $43Albumin Fluid $119Albumin Level $82

22 of 317 FY2018

DESCRIPTION CHARGES

ALBUMIN SERUM MS PANEL Add On $43Aldolase $133Aldosterone $454Alk Phos Isoenzyme (Fract) $202Alkaline Phos. (Bone Specific) $343Alkaline Phosphatase $109Alpha 1 Antitrypsin $195Alpha 1 antitrypsin Genotype $688Alpha 1 antitrypsin Phenotype $242Alpha Fetoprotein Tumor Marker $195ALT (SGPT) $65ALT SGPT Add On $65Aluminum Level $284Amikacin Level $168Amikacin Level Peak $168Amikacin Trough $168Amino Acid Quantitative $837Amino Acid Quantitative Urine $837Amiodarone/Desethylamiodarone $396Amitriptyline Level $199Ammonia Level $171Amylase Level $129ANA PNL Add On $164Anaerobic ID $152ANCA SCREEN ANCA PNL Add On $51Androstenedione $326Angiotensin Converting Enzyme $192ANTI DS DNA ANA PNL Add On $200Anti Histone Antibodies $215Anti Mitochondrial AB $202Anti Mullerian Hormone $225Anti Myocardial AB Screen $202Anti Parietal Cell AB $202ANTI RNP ANA PNL Add On $186Anti SCL 70 Antibody $186ANTI SCL70 ANA PNL Add On $186ANTI SM Add On $200

23 of 317 FY2018

DESCRIPTION CHARGES

ANTI SMITH ANA PNL Add On $186ANTI SSA Add On $186ANTI SSB Add On $186Anti Striated Muscle $202ANTI SULFATIDE AB ADDITIONAL Add On $132ANTI SULFATIDE AB SINGLE Add On $132Anti Thyroglobulin Antibody (Only) $208ANTI THYROGLOBULIN ANTIBODY Add On $208Anti TPO $211ANTI TPO Add On $211Antibody Identification $596Antibody Screen $160Antibody Screen $160Antibody Screen Indirect $160Antibody Screen Tube $160Antibody Titer $210Antibody Titer Prenatal $292Antibody Titer Prenatal Interp $292Antideoxyribonuclease B Titer $148Antigen Type $105Antiglomerular Basement Membrane Antibody $202Antinuclear Antibody Screen $164Antistreptolysin O Screen $125Antithrombin III Activity $201Antithrombin III Assay (SLU) $201Apolipoprotein A1 $173Apolipoprotein B100 $173ARBOVIRUS ABY CALIFORNIA Add On $94ARBOVIRUS ABY EASTERN Add On $94ARBOVIRUS ABY ST LOUIS Add On $210ARBOVIRUS ABY WESTERN Add On $94ARC Antigen Neg 1 per Unit Add On $197ARSENIC BLOOD/URINE Add On $203Arsenic Level $283Aspartate Aminotransferase $91ASPERGILLUS AB ADDITIONAL Add On $199ASPERGILLUS AB SINGLE Add On $199

24 of 317 FY2018

DESCRIPTION CHARGES

Aspergillus Antibody $199Aspergillus Antigen $263ASPERGILLUS HLP Add On $89AST SGOT Add On $91Atypical P ANCA Titer $150B CELLS TOTAL COUNT Add On $225B2 GLYCO IGA Add On $120B2 GLYCO IGG Add On $120B2 GLYCO IGM Add On $120Bacillus anthracis panel (kirby bauer) $141BACTERIUM NOS HLP ADDITIONAL Add On $22BACTERIUM NOS HLP SINGLE Add On $22BARTONELLA HENSELAE IGG Add On $124Bartonella henselae IgG Titer $124BARTONELLA HENSELAE IGM Add On $124Bartonella henselae IgM Titer $124BARTONELLA QUINTANA IGG Add On $124Bartonella quintana IgG Titer $124BARTONELLA QUINTANA IGM Add On $124Bartonella quintana IgM Titer $124BB Splitting Unit Fee $32BCR ABL p190 by PCR $297BCR ABL p210 by PCR $297BCR/ABL Gene Rearrangement PCR $550Benzene Blood $163Beta 2 Microglobulin $242Beta hCG Qualitative Urine $129Beta Human Chorionic Gonadotropin Quantitative $179Beta Lactamase $25BILIRUBIN CONJUGATED NEWBORN Add On $102BILIRUBIN DIRECT Add On $102Bilirubin Total (>14days) $117BILIRUBIN TOTAL Add On $117Bill Only ARC AG Screen (1 10 Units) $26Bill Only ARC AG Screen (11 20 Units) $53Bill Only ARC AG Screen (21 30 Units) $79Bill Only ARC AG Screen (31 40 Units) $106

25 of 317 FY2018

DESCRIPTION CHARGES

Bill Only ARC AG Screen (41 50 Units) $132Bill Only ARC AG Screen (51 60 Units) $158Bill Only ARC AG Screen (61 70 Units) $185Bill Only ARC Antigen Neg (1 per unit) $197Bill Only ARC RBC Antigen (High/Rare/Unit) $456Bill Only CMV Testing $324Bill Only Sickle Cell Testing $99Bill Only SLH AG Screen (1 10 Units) $53Bill Only SLH AG Screen (11 20 Units) $106Bill ONly SLH AG Screen (21 30 Units) $159Bill Only SLH Antigen Neg (1 per Unit) $241BIOTINIDASE Add On $60BLASTOMYCES AB Add On $153Blastomyces Antibody $153Bleeding Time $119BLOOD ABO CORD Add On $69BLOOD ABO NEONATAL Add On $69BLOOD ABO PNL Add On $69BLOOD ABO PREN T&S PNL Add On $69Blood Culture $219Blood Gas (POC ABL) $226Blood Gas Arterial $226Blood Gas Capillary $226Blood Gas Cord Arterial $226Blood Gas Cord Venous $226Blood Gas Venous $226BLOOD GAS W/ O2 SAT POC ABL Add On $226BLOOD RH CORD Add On $62BLOOD RH NEONATAL Add On $62BLOOD SMEAR W/MANUAL DIFF Add On $29Blood Urea Nitrogen $68BMP $155Body Fluid w/ Gram Stain $205BORDETELLA PARAPERTUSSIS Add On $244BORDETELLA PERTUS IGG ADDTL Add On $109BORDETELLA PERTUS IGG SINGLE Add On $109Brucella Antibody Screen $196

26 of 317 FY2018

DESCRIPTION CHARGES

BUN PNL Add On $68C ANCA Titer $49C Gram Stain $75C Peptide $243C Reactive Protein $131C Reactive Protein High Sensitivity $131C Telopeptide (CTx) $139C. DIFFICILE GDH Add On $159C. difficile PCR $173C.DIFF.TOXIN A & B Add On $160C1 Esterase Inhibitor Functional $229C1 Esterase Inhibitor Protein $215C1q Immune Complex Detection $271C3 Complement $215C4 Complement $215CA 27 29 $232Cadmium Level $258Caffeine Level $257Calcitonin Level $330Calcium Level $78Calcium Level 24 Hr Urine $138Calcium Level Ionized $166CALCIUM TOTAL PTH Add On $78Cancer Antigen 125 $256Capillary Stick (CPT 36416) $14Carbamazepine Level $199Carbohydrate Antigen 15 3 $232Carbohydrate Antigen 19 9 $232Carboxyhemoglobin Level $146Carcinoembryonic Antigen $222CARDIOLIPIN AB IGA Add On $283CARDIOLIPIN AB IGG Add On $283CARDIOLIPIN AB IGM Add On $283Cardiolipin Antibody IgA $283Cardiolipin Antibody IgG $283Cardiolipin Antibody IgM $283Carnitine Free and Total $270

27 of 317 FY2018

DESCRIPTION CHARGES

Carotene Level $103Catecholamine Plasma $425Catheter Tip Culture $205Catheterized Urine Culture $91CBCwIndices $100Cell Count Cerebrospinal Fluid w/reflex to Diff $149Ceruloplasmin $125CHLAM.SPEC PNEUMONIAE IGA Add On $132CHLAM.SPEC PNEUMONIAE IGG Add On $132CHLAM.SPEC PNEUMONIAE IGM Add On $141CHLAM.SPEC PSITTACI IGA Add On $132CHLAM.SPEC PSITTACI IGG Add On $132CHLAM.SPEC PSITTACI IGM Add On $141CHLAM.SPEC TRACHOMATIS IGA Add On $133CHLAM.SPEC TRACHOMATIS IGG Add On $133CHLAM.SPEC TRACHOMATIS IGM Add On $141CHLAMYD. PNEUMO AMPL PROBE. Add On $96Chlamydia Culture $218CHLAMYDIA TRACH AMPLIFIED PROBE Add On $245Cholesterol Total $84CHROMATOGRAPHY HGB OPATHY EVAL Add On $153Chromium Level $121Chromogranin A $503CHROMOSOME ANALYSIS BLOOD Add On $428CHROMOSOME ANALYSIS BONE MARROW 1 Add On $676CHROMOSOME ANALYSIS FETAL Add On $716CK MB (Does not include Total CK) $162CLO Test $103Clomipramine (Anafranil) Level $152Clonopin $327CO2 $37COCCIDIODES AB SCREEN Add On $128Coccidioides Antibody $128Cold Agglutinins $117COLLECTION: Venous Draw $20Compatible Crossmatch AHG Interpretation $152Compatible Crossmatch Immediate Spin Interpretation $152

28 of 317 FY2018

DESCRIPTION CHARGES

Compatible Crossmatch PEG Interpretation $152Compatible Crossmatch Pre Warm Interpretation $152Complement Total $251COMPLETE CBC AUTOMATED Add On $100Comprehensive Metabolic Panel $199Computer XM $70Computer XM OK $70CONCENTRATION & PARASITE ID Add On $146Copper Level $204Cortisol Level $230COXIELLA BRUNETTI ADDITIONAL Add On $201COXIELLA BRUNETTI SINGLE Add On $201Coxsackie A Virus Antibody $145Coxsackie B Virus Antibody $145Creatine Kinase $121Creatinine $60Creatinine 24 Hour Urine $91CREATININE CLEARANCE URINE Add On $234Creatinine w/ GFR $93CREATININE WHOLE BLOOD Add On $106CROSSMATCH IMMEDIATE SPIN Add On $152Cryoglobulin $102Cryptococcal Ag Titer $210Cryptococcal Antigen $241Cryptococcal Antigen CSF $209CRYPTOSPORDIUM ANTIGEN DFA Add On $56Crystal Examination Fluid $152CSF Cryptococcal Ag Titer $208CSF Differential $184CSF Glucose $130CSF Lactic Acid $238CSF LDH $134CSF Protein $115Cyanide Level $216Cyclic Citrullinated Peptide $185Cyclosporine Level $376Cystic Fibrosis Panel $452

29 of 317 FY2018

DESCRIPTION CHARGES

Cytomegalovirus Antibody IgG $238Cytomegalovirus Antibody IgM $259D Dimer $165DAT IGG Add On $78Deheparinized PT $170Deheparinized PTT $170Dehydroepiandrosterone Sulfate $309DENGUE FEVER IGG Add On $249DENGUE FEVER IGM Add On $249Desipramine Level $192Differential Automated $104Differential Partial Auto $104Digitoxin Level $257Digoxin Level $164Diphtheria Antibody $115DIPHTHERIA ANTIBODY Add On $115Direct Antiglobulin C3 $195Direct Antiglobulin IgG $78Direct Antiglobulin Poly $78Direct Bilirubin $102DIRECT TIBC Add On $82DNA Antibody (Double stranded) $200Doxepin Level $173Drug Screen Abuse $196Drug Screen Blood $452Drug Screen Urine $201Drug Test Presum(1) W Drug Scr $352Drug Tests Presum(2) W Drug Scr $509Drug Tests Presum(3) W Drug Scr $665Drug Tests Presumptive (2 Drugs) $333Drug Tests Presumptive (3 Drugs) $499Drug Tests Presumptive (4 Drugs) $665dRVVT 1:1 Mixing Study $75dRVVT Confirmation $105Du Test $62DVVRT Add On $34E coli 0157 latex $98

30 of 317 FY2018

DESCRIPTION CHARGES

Ear Culture $205EBV NUCLEAR AG Add On $180EBV VCA IGG Add On $280EBV VCA IGM Add On $280Ehrlichia PCR (Bld) $398ELECTROLYTE PANEL WHOLE BLOOD Add On $145Electrolytes $137Elution $445Endomysial Antibody IgA $230Endomysial Antibody IgA Titer $204Enteric Pathogen PCR Panel $395ENTEROVIRUS AB ADDITIONAL Add On $21ENTEROVIRUS AB SINGLE Add On $21Enterovirus by PCR $390ENZYME ACTIVITY IN CELLS Add On $60Eosinophil Urine $75Epstein Barr Antibody To Early Antigen $264Epstein Barr Antibody To Early Antigen $264Erythropoietin Level $231Estradiol Level $327Estrogen Total $241Ethanol Level $142Ethosuximide Level $53Ethylene Glycol Level $138Eye Culture w/ Gram Stain $205Factor IX Assay $282Factor V Assay $264Factor V Mutation $366Factor VII Assay $264Factor VIII Antigen $383Factor VIII Antigen (SLU) $463Factor VIII Assay $279Factor X Assay $155Factor XI Assay $235Factor XII Assay $330Factor XIII Screen $99Febrile Francisella $97

31 of 317 FY2018

DESCRIPTION CHARGES

Fecal Fat Qualitative $172Fecal Fat Quantitative $383Fecal WBC $75Felbamate Level (Felbatol) $257Ferritin $205Fetal Fibronectin $717Fetal Screen $74Fibrin Degradation Products $62Fibrinogen $118FK 506 (SLU) $381FK 506 (Tacrolimus) $381FLOW CYTO EACH ADD MARKER PNH Add On $73FLOW CYTO FIRST MARKER PNH Add On $438Fluid Amylase $129Fluid ANA $188Fluid Beta 2 Transferrin $423Fluid C3 Complement $134Fluid C4 Complement $134Fluid Cell Count w/reflex to Diff $77Fluid CH50 Total Complement $226Fluid Culture Large Volume $205Fluid Differential $184Fluid LD $89Fluid pH $85Fluid Protein Total $115Fluid Ra Factor $179Fluid Triglycerides $111Fluoxetine Level $201Folate Level $172Follicle Stimulating Hormone Level $264FRAGILE X GENE ANALYSIS Add On $875Free T3 $209Free T3 (Reflex) $209Free T4 (EQ Dialysis) $162Free T4 (Reflex) $162Freeze/Thaw/Emb Biopsy Lab Fees SSD $2,072Fructosamine $45

32 of 317 FY2018

DESCRIPTION CHARGES

FTA ABS $165Fungitell (1 3) beta D Glucan $625Fungus Blood Culture $178Fungus Culture $193Fungus Culture Hair Skin Nail $193G 6 PD $108G0123 Ap Bill Thin Prep Pap Smear Screen $122G0416 AP Bill Prostate Biopsy (10 20) MC $4,254Gabapentin Level $257GAD 65 ABY $341GALACTOSE 1 PHOSPHATE SCREEN Add On $60Gamma Glutamyl Transferase $107GAMMAGLOBULIN ADDITIONAL Add On $43GAMMAGLOBULIN SINGLE Add On $43Gastrin Level $223GEL DIFFUSION HLP Add On $89Genital Comprehensive w/ Gram Stain $205Gentamicin Level Peak $192Gentamicin Level Trough $192Gentamicin Random $192Gestational Screen $82GIARDIA ANTIGEN DFA Add On $134GLIADIN IGA Add On $229GLIADIN IGG Add On $229Glu 2 Hr PP $82Glucose (POC) $48Glucose 1 Hour Post Prandial $82Glucose 1 Hr $82Glucose 2 Hr $177GLUCOSE 3 SPECIMENS Add On $177Glucose Body Fluid $130GLUCOSE C6 PNL Add On $82Glucose Level $82GLUCOSE TOL SPECIMEN Add On $99Glucose Tolerance 2 Hour $177Gram Negative Panel (Microscan Neg/Urine Combo 55) $180Gram Positive Combo Panel (Microscan Pos Combo 33) $180

33 of 317 FY2018

DESCRIPTION CHARGES

Gram Positive Combo Panel (Microscan Pos Combo 43) $180Gram Positive Panel (Microscan Pos MIC 29) $180Gram Positive Panel (Microscan Pos MIC 34) $180Gram Stain Report $75Group B Strep Culture $103Growth Hormone (HGH) $225Growth Hormone Binding Protein $220H pylori Stool Antigen $119H&H (POC ABL) $38Haemophilus Sensitivity Panel(kirby bauer) $141HDL Cholesterol $100HDL Specimen/Processing Fee $25HEMATOCRIT Add On $40HEMATOCRIT HGB OPATHY EVAL Add On $22Hematocrit Spun $47Hemochromatosis DNA Analysis $230Hemoglobin A1c $115HEMOGLOBIN Add On $42HEMOGLOBIN ELECTROPHORESIS Add On $60HEMOGLOBIN HGB OPATHY EVAL Add On $22HEMOGLOBIN POC ABL Add On $38Heparin Anti Xa Activity $264Hepatic Function Panel $280Hepatitis A Antibody IgM $152Hepatitis A Antibody Total $156HEPATITIS B CORE ABY TOTAL Add On $152Hepatitis B Core Antibody $152Hepatitis B Core Antibody IgM Acute Titer $166Hepatitis B E Antibody $192Hepatitis B Surface Antibody $126HEPATITIS B SURFACE ANTIBODY Add On $126Hepatitis B Surface Antigen $147HEPATITIS B SURFACE ANTIGEN Add On $147Hepatitis B Viral DNA Quant $225Hepatitis BE Antigen $231Hepatitis C Antibody $223Hepatitis C RNA Genotype $313

34 of 317 FY2018

DESCRIPTION CHARGES

Hepatitis C RNA PCR Qualitative $532Hepatitis C RNA PCR Quantitative $619Hepatitis Panel Acute $542Hexagonal Phase Confirmation $54Histoplasma Antigen $199Histoplasma Immunodiffusion $199HISTOPLASMA MYCELIAL Add On $199HISTOPLASMA YEAST Add On $199HIT/Heparin PF4 Antibody with Reflex to SRA $318HIV 1 ANTIBODY HIV 1/2 AB DIFF Add On $180HIV 1 RNA Quant (Viral Load) $223HIV 1/2 Ag/Ab Rapid Screen $117HIV 1/2 Ag/Ab Screen 4th gen w/Reflexes $117HIV 2 ANTIBODY HIV 1/2 AB DIFF Add On $180HLA A B C Typing LowRes (Platelet Match) $988HLA B27 $287Homocysteine $240HSV 1 IgM Titer $183HSV 2 IgM Titer $163HSV DNA By PCR CSF $565HSV1 IGG Add On $183HSV1 IGM Add On $183HSV2 IGG Add On $163HSV2 IGM Add On $163HTLV 1&2 Antibody $107HYDROXYPROGESTERONE 17 D Add On $60IGA IG PNL Add On $147IgA Quantitative $147IgE Quantitative $183IGF 1 $285IGF Binding Protein 3 $240IGG IB PNL Add On $147IgG Quantitative $147IGG SUBCLASSES ADDITIONAL Add On $112IGG SUBCLASSES SINGLE Add On $112IGG SUBCLASSES TOTAL Add On $147IgM $147

35 of 317 FY2018

DESCRIPTION CHARGES

IGM PNL Add On $147Imipramine Level $327IMMUNOASSAY NON INFECTIOUS MULTI Add On $60IMMUNOASSAY QUANT. IGG Add On $224IMMUNOASSAY QUANT. IGM Add On $224Import Service Fee ARC $399INFECTIOUS AGENT NOS AMPL PROBE. Add On $96INFLUENZA A RAPID Add On $124INFLUENZA B RAPID Add On $124Inhibin A $60Inhibin B $327INR (CPT 85610QW) $14Insulin Antibody $73Insulin Level Total $185Intrinsic Factor Blocking AB $354Ionized Calcium (POC ABL) $59Iron Level $135Islet Cell Antibody w/Reflex to Titer $251JAK2 Exons 12 and 13 Mutations $813JAK2 V617F w/reflex Exons 12 and 13 $591JO 1 Antibody $200KAPPA LIGHT CHAIN FREE Add On $399Keppra Level $257Kleihauer Betke $194Lacosamide Level $238Lactate (POC ABL) $207Lactate Dehydrogenase $89Lactic Acid $142LAMBDA LIGHT CHAIN FREE Add On $399Lamellar Body Count $172Lamictal (Lamotrigine) $396LDL Direct $112Lead Blood (OSHA) $34LEAD BLOOD/URINE Add On $83Lead Level $135Least Incomp Crossmatch AHG Interpretation $152Least Incomp Crossmatch Immediate Spin Interpretation $152

36 of 317 FY2018

DESCRIPTION CHARGES

Least Incomp Crossmatch PEG Interpretation $152Least Incomp Crossmatch Pre Warm Interpretation $152Legionella Antibody (IgG) $183Legionella Antigen Urine $165Legionella Culture $205Leukocyte Alkaline Phosphatase $106Lidocaine Level $262Lipase Level $129Lipid Panel $196Lipoprotein (A) $276LIS USE ONLY Occult Blood Stool (iFOBT) $73Lithium Level $125Liver Kidney Microsomal AB $211Lupus Anticoagulant (SLU) $200Luteinizing Hormone (LH) $218Lyme AB Western Blot $264Lyme Antibody $264Lyme Disease PCR (CSF) $564Lyrica (Pregablin) $369Magnesium Level $111Malaria Smear $158MASS SPECTROMETRY QUANT NES Add On $60MERCURY BLOOD/URINE Add On $83Metanephrines Fractionated $329Methanol (Wood Alcohol) $179Methemoglobin $86Methotrexate Level $258METHYLMALONIC ACID Add On $211Methylmalonic Acid Quantitative $211MHA TP $165Micro Strep Panel $180Mono Screen $93Mononucleosis Screen $93MTHFR $437Mumps Antibody IgG Convalescent Titer $145Mumps Antibody IgM Acute Titer $145MUMPS IGG ANTIBODY Add On $145

37 of 317 FY2018

DESCRIPTION CHARGES

Mycoplasma Antibody IgG Convalescent Titer $199Mycoplasma Antibody IgM Acute Titer $199MYCOPLASMA PNEUMO AMPL PROBE. Add on $96Mycoplasma/Ureaplasma Culture $427Myelin Basic Protein Cerebrospinal Fluid $202MYELOPEROXIDASE AB ANCA PNL Add on $250Myoglobin $218N. GONORRHOEAE AMPLIFIED PROBE Add On $245Nasal Culture $205Nasal MRSA Screen $103NATURAL KILLER CELLS TOTAL Add On $202Neonatal Indirect $160NH $90NH ID $90Norpace Level $144Nortriptyline Level $187NT proBNP $200O2 Saturation (Mixed Venous) $226O2 SATURATION POC ABL Add On $102Obstetric Panel $255Occult Blood Gastric $40Occult Blood Stool (Guaiac) $37OLIGOCLONAL IMMUNE BANDS Add On $43Omega 3 $572Organism name $115Osmolality Serum $83Osmolality Urine $89Osteocalcin $482P ANCA Titer $49P3000 Ap Bill Cytopath C/V Smear Screen $77Parietal Cell Antibody Screen $202Parietal Cell Antibody Titer $56Partial Thromboplastin Time $101PARVOVIRUS B19 IGG Add On $264PARVOVIRUS B19 IGM Add On $264PBP2A $98Pentobarbital Level $128

38 of 317 FY2018

DESCRIPTION CHARGES

Period & Volume $38Phenobarbital Level $191PHENOBARBITAL MYSO PNL Add On $191Phenytoin (Dilantin) $212Phenytoin Level Free $98Phosphorus Level $89Pinworm Exam $99PLATELET ANTIBODY INDIRECT ADDTL Add On $110PLATELET ANTIBODY INDIRECT SINGLE Add On $110Platelet Count $65PNEUMOCOCCAL AB ADDITIONAL Add On $52PNEUMOCOCCAL AB SINGLE Add On $52Pneumocystis DFA $248POC BASIC MET.PROF (I-STAT) add on $34POC Creatinine w/ eGFR $93POC HEMATOCRIT (I-STAT) add on $36POC Troponin-I (i-STAT) $150POC Urine Pregnancy $129POLIOVIRUS 1 ABY Add On $158POLIOVIRUS 3 ABY Add on $158Pooled Cryo AHF Pool Fee $152Pooling Of Components $152Potassium (POC ABL) $48Potassium (Whole Blood) $61Potassium Level $54Prealbumin $162Prenatal Antibody Screen $160Prewarm Antibody Screen $160PRIMIDONE PANEL Add On $185Procainamide/ NAPA Levels $196Procalcitonin $438Processing Dry Ice $21Procollagen Type I Intact N terminal Propeptide $300Progesterone Level $244Prolactin Level $247Prostatic Acid Phosphatase $158Protein C Activity $390

39 of 317 FY2018

DESCRIPTION CHARGES

Protein C Activity (SLU) $390PROTEIN S FREE Add On $472Protein S Functional Act. (SLU) $321Protein S Functional Activity $321PROTEIN S TOTAL Add On $472Protein Total $103PROTEINASE 3 AB ANCA PNL Add on $250Prothrombin Mutation $714Prothrombin Time $69PSA $215PSA FREE Add On $81PSA Medicare $215PSA TOTAL PNL Add On $81PT Mixing Test $132PTH INTACT PTH. Add On $230PTT LA Add On $34PTT Mixing Test $154Pyruvic Acid $121Quad Screen $241Quantiferon TB Gold $125Quinidine Level $162R.A.S.T. Allergen $183RA QUANT. PNL Add On $68RA Titer $117Rapid NF (IDS) $90Rapid Plasma Reagin Test $77RBC AUTOMATED HGB OPATHY EVAL Add On $22RBC Folate. $172Renin Activity $245Respiratory Culture w/ Gram Stain $205RESPIRATORY VIRUS MULTI 12 25. Add on $1,137Reticulin Aby Iga $134Reticulocyte Count Automated $82RFP $251RH TYPE PREN T&S PNL Add On $62RH TYPE T&S PNL Add On $62Rheumatoid Factor Qualitative $68

40 of 317 FY2018

DESCRIPTION CHARGES

Rheumatoid Factor Quantitative $68Rhogam Workup $74Rickettsial AB Panel $384Ristocetin Cofactor $330ROCKY MTN FEVER IGG Add On $204ROCKY MTN FEVER IGM Add On $204RSV Rapid Screen $134Rubella Antibody IgG Convalescent Titer $160Rubella Antibody IgM Acute Titer $160RUBELLA IGG Add On $160RUBEOLA ANTIBODY Add On $100Rubeola Antibody IgG $100S aureus identification $98Salicylate Level $91SB Specimen Collection $8Sedimentation Rate $67Semen Analysis Complete $219Sendout Phlebotomy $20Serotonin Bld $421Serotonin Release Assay. $650Serum hCG Qualitative $104Serum Immunofixation $261Serum Pregnancy Qualitative $104Serum Protein Electrophoresis $209SEVERE COMBINED IMMUNODEFICIENCY Add On $60SEX BINDING HORMONE GLOBULIN Add On $90Sickle Cell Solubility Test $99Skin Test TB Intradermal $19SLH Antigen Neg 1 per Unit Add On $241Smooth Muscle (Actin) IgG $70Sodium $60Sperm Count $96Staph Latex $98Strep A latex $98Strep B latex $98Strep C latex $98Strep D latex $98

41 of 317 FY2018

DESCRIPTION CHARGES

Strep F latex $98Strep G latex $98Strep Only Culture (Not Throat) $103Strep Screen (Antigen) $67Strep Screen (Cult. Backup) $70Streptococcus pneumoniae Antigen (Bld or CSF) $176Streptococcus pneumoniae Antigen (Urine) $262Striated Muscle Ab Titer $202T CELLS TOTAL COUNT Add On $297T SPOT TB $125T3 Uptake $156Testosterone Level Total $200TESTOSTERONE TOTAL Add On $200Tetanus Antibody $115TETANUS ANTIBODY Add On $115Theophylline Level $177Thiamine (Vitamin B1) $264Thiocyanate Level $181Thiopurine Metabolites (6 TG 6 MMP) $230Thiopurine Methyltransferase Genotype $1,079Throat Culture $205Thrombin Clotting Time $93Thrombin Time $95Thyroglobulin Panel $264Thyroid Stimulating Immunoglobulins $528Thyroxine $134Thyroxine Binding Globulin $165Thyroxine Free $162TISSUE CULTURE BLD Add On $757TISSUE CULTURE BONE MARROW Add On $354TISSUE CULTURE FETAL Add On $484Tissue Transglutaminase Antibody $47Tissue Transglutaminase IgG $400Tobramycin Level Peak $264Tobramycin Level Trough $264Tobramycin Random $264Topiramate Level $178

42 of 317 FY2018

DESCRIPTION CHARGES

TORCH Panel IgG $160Total T3 $184Toxoplasma Antibody IgG Convalescent Titer $185Toxoplasma Antibody IgM Acute Titer $244Transcutaneous Bili $27Transferrin $152Transfusion Reaction Interpretation $184Trichomonas $77TRICHROME STAIN Add On $200Triglycerides $111Trileptal Level (Oxcarbazepine) $257Troponin I $156Tryptase Level $175TSH (Highly Sensitive) $178TSH Add On $60TSH with Reflex $178U24 Electrophoresis $120Urea Nitrogen,Quantitative $25Uric Acid $101Urinalysis (Urisys) $75Urinalysis w/ Reflex to Micro $75Urine 17 Hydroxysteroids (17 OH) $195Urine Aldosterone 24 Hr $454Urine Amylase Random $129Urine Beta 2 Microglobulin $90URINE CALCIUM QUANT Add On $24Urine Calcium Random $78Urine Catecholamines 24 Hr $327Urine Chloride 24 Hr $61Urine Chloride Random $157Urine Citrate 24 Hr $310URINE CITRATE Add On $24Urine Cortisol 24 Hr $259URINE CREATININE Add On $24Urine Creatinine Random $91URINE CREATININE RANDOM Q Add On $91URINE HCG QUALITATIVE $129

43 of 317 FY2018

DESCRIPTION CHARGES

Urine Immunofixation (Random) $343URINE MAGNESIUM Add On $24URINE METANEPHRINE TOTAL 24HR Add On $277Urine Methyl Malonic Acid $238Urine Microalbumin 24 Hour $117URINE MICROALBUMIN RANDOM Add On $91Urine Microscopic $93Urine Multi Dipstick $47Urine Myoglobin Screen Random $218Urine N Telopeptide Cross Links $225Urine Organic Acid Screen $396Urine Oxalate 24 Hr $158URINE OXALATE Add On $24URINE PH Add On $24Urine Phosphorus 24 Hr $93URINE PHOSPHORUS Add On $24Urine Porphobilinogen QT 24 Hr $115Urine Porphyrins Quantative 24 Hr $264Urine Potassium 24 Hr $65URINE POTASSIUM Add On $24Urine Potassium Random $65Urine Protein 24 Hr $119Urine Protein Electrophoresis 24 Hr $120Urine Protein Electrophoresis Random $209Urine Protein Quant Random $119Urine Protein Random (Q) $119Urine Serotonin (5 HIAA) 24 Hr $217Urine Sodium 24 Hr $70URINE SODIUM Add On $24Urine Sodium Random $70Urine Specific Gravity 24 Hr $61URINE SULFATE Add On $24Urine Urea Nitrogen 24 Hr $83Urine Urea Nitrogen Random $83Urine Uric Acid 24 Hr $110URINE URIC ACID Add On $24Urine Uric Acid Random $110

44 of 317 FY2018

DESCRIPTION CHARGES

Urine VMA 24hr $238Urine Void Culture $91Vaginal PAMG 1 (AmniSure ROM) $585Valproic Acid Level $185Vancomycin Level Trough $223Vancomycin Random $223Varicella Zoster Antibody IgG $202Vasoactive Intestinal Polypeptide $396VDRL Screen Cerebrospinal Fluid $77Venous Access/Blood Draw $200Viscosity Serum $150Vitamin A Level $225Vitamin B12 Level $179Vitamin B6 Level $330Vitamin D 1 25 Dihydroxy $429Vitamin D 25 Hydroxy Total $175Vitamin E Level $204von Willebrand Factor Antigen $463Von Willebrand Factor Ristocetin (SLU) $330WAIVED INFLUENZA A RAPID Add On $124WAIVED INFLUENZA B RAPID Add On $124Waived Strep Screen (Antigen) $67WBC $33WEST NILE VIRUS ABY IGG Add On $146WEST NILE VIRUS ABY IGM Add On $146Whole Blood Glucose $48Wound Culture (Aerobic) w/ Gram Stain $205Wound Culture (Ana/Aer) w/ Gram Stain $165XM GEL Add On $152Zinc Level $204Zinc Protoporphyrin (ZPP) $84Zonisamide Level (Zonegran) $257

INFUSION THERAPY2 Nutrition Assessment $2322 Nutrition Assessment w/Procedure $2323 Nutrition Assessment $309

45 of 317 FY2018

DESCRIPTION CHARGES

3 Nutrition Assessment w/Procedure $309Access Flush $120Adenosine Challenge (No FFR) $371Calorie Count $117Cath Placemnt For Spec Collection $159Declot Vascular Access Device $447Fluids Pert Dialys W/Tub 1.5 2000-33948 $98Fluids Pert Dialys W/Tub 1.5 2500-33951 $98Flush Central Catheter $109In & Out Urinary Catheter Activity Type $159Initiated Phototherapy Activity $75Inj/IV Push Initl/Single $230INJECTION INTRA-ARTERIAL $159Injection Intra-Arterial $159INJECTION SQ/IM $111Injection Sq/Im. $111INJECTIONS ANTIBIOTIC > 15 MINUTES $159INJECTIONS SUB Q IM $130Insert Temp Catheter $159Irrigation of Implanted Venous Device $45Irrigation of Vad Cath or Port $109Irrigation Saline 1000cc-1587 $50Irrigation Saline 2000cc-26914 $50Irrigation Saline 500cc-1588 $50Irrigation Sol 0.9% Nacl 3000-1591 $50Irrigation Water 1000cc-1577 $50Irrigation Water 500cc-26892 $50IV Inf/IV Push Each Addl NEW Drug $215IV Inf/IV Push Each Addl SAME Drug $200IV Infusion >8 Hrs Req Pump IFD $130IV Infusion >8 Hrs Req Pump Nursing $290IV Infusion Additional Seq Initial $200IV Infusion Concurrent $210IV Infusion Each Additional Hour $180IV Infusion greater than 8 hr Reg Pump $290IV Infusion Hydrate Each Addtl $180IV Infusion Hydrate Initial $400

46 of 317 FY2018

DESCRIPTION CHARGES

IV Infusion Initial Hour $400IV Inj/IV Push Ea Addtl New Dr $186IV INJ/IV PUSH EA ADDTL NEW DRUG $186IV Inj/IV Push Initial/Single $212IV Injection Initial/Single $212IV Phlebotomy $241Nutrition Cancer Center VisitNutrition monitoring $126Nutrition Support Monitoring w/Procedure $126On Body Injection $150Rapid Desensitization Per Hour $245SOL IRRIG H2O 3000ML BAG-1581 $50SOL IRRIG WATER BOTTLE 500 ML-26892 $50SOL IRRIG WATER STER 1000ML-1577 $50SOL IV GLYCINE 1.5 PERC 3000ML-26915 $50SOL SODIUM CHLORIDE .9 IRRIG 1000CC-1587 $50SOL SODIUM CHLORIDE .9 IRRIG 2000CC-26914 $50SOL SODIUM CHLORIDE .9 IRRIG 500CC-1588 $50SP Refill/Maintenance Pump w/md $350Therapeutic Apheresis-White Cells $1,854Therapeutic Pheresis, Plasma $1,854Therapeutic Platelet Removal $1,854TPN Services Ea Addtl Hour $100TPN Services Initial Hour $170

RADIATION ONCOLOGY & CHEMOTHERAPY30 Min Consult Moderate Level $24240 Min Consult Mod High Level $30960 Min Consult Mod High Level $407Afterload Device Insertion $359Basic Rad Dosimetry Calculation $582Brachytherapy Isodose Plan Complx $1,958Brachytherapy Isodose Plan Interm $1,174Brachytherapy Isodose Plan Simple $1,050Chemo Adm Peritoneal $549Chemo Anti Neopl Sq/Im $265Chemo Hormon Anti Neopl Sq/Im $265

47 of 317 FY2018

DESCRIPTION CHARGES

Chemo IV Addtl Seq Initial Hr $212Chemo IV Each Addtl Hr $206Chemo IV Initial Hr $447Chemo IV Push Each Addtl Subst $285Chemo IV Push Initial/Single $318Continuing Medical Physics Consul $749CT CHEST ABCESS DRN W/IMAGING $3,092Daily External Pump Admin $150Established Pt Low Level E&M $160IMRT Daily Tx Delivery Complex $2,859IMRT Daily Tx Delivery Simple $2,524IMRT Treatment Plan $10,166Init Prolong Inf W/Pump Supplied $400Initiation Prolong Chemo >8hrs $549Interstial Radioel Appl W/S&H/Bdc $3,800Interstitial Radioele Applic $1,180Interstitial Radioelement Applica $797Intracavitary Radioele Applic $972Intracavitary Radioelement Appli $1,011Intracavitary Radioelement Applic $984Intrathecal $549Intrathecal Chemo Admin $549MLC Device(S) For IMRT Design/Con $11,070Naso Pharyngoscopy $555New Op Visit Low Level $155Office Visit/Out Pt (Est) High $309Office Visit/Out Pt (Est) Low $232Office Visit/Out Pt (Est) Mod $258Patient Dosimetry $560Placement Dev/Marker Non Prostate $2,000Rad Tx Delivery Complex $1,124Rad Tx Delivery Intermediate $714Rad Tx Delivery Simple $578Radioactive I 131 Administration $920Radiopharm Radiolabeled Mono Anti $1,350Radiopharmaceutical Therapy $1,200Refill Portable Drug Pump $309

48 of 317 FY2018

DESCRIPTION CHARGES

Remote Afterload 2 12 Chan W/Bdc $5,206Remote Afterload HDR 1 Chan W/Bdc $5,632Removal Of Halo By Rad Onc $214Resp Motion Mgmt Simulation $505SBRT Tx Delivery/1 Fx $23,800SBRT Tx Delivery/Fx No > 5 Fx $13,603Sim Aid Complex W/O Ct $2,293Sim Comp 3 D Recons $5,915Simulation Aided Fld Stg/Complex $3,309Simulation Aided Fld Stg/Intermed $1,866Simulation Aided Fld Stg/Simple $1,282Special Medical Physics Consult $1,530Special Teletherapy $1,247Special Treatment Procedure $2,455Stereoscopic Guide Localization. $413Teletherapy Isodose Plan Complex $5,406Teletherapy Isodose Plan Simple $2,613Therapy Port Film $401Treatment Device/Complex $1,531Treatment Device/Intermediate $801Treatment Device/Simple $535

CT SCANSCT ABD RETROPERITONEAL BX PERC $873CT ABDOMEN LIMITED $983CT ABDOMEN W/CONTRAST $2,067CT ABDOMEN W/O CONTRAST $1,941CT ABDOMEN W/WO CONTRAST $2,661CT ABDOMEN/PELVIS W/CONTRAST $4,128CT ABDOMEN/PELVIS W/O CONTRAST $3,630CT ABDOMEN/PELVIS W/WO CONTRAST $4,998CT ABSCESS DRAIN/SPECIMEN PROCEDURE IR $1,148CT ANGIO ABD/PELVIS W/WO CONTRAST $5,680CT ANGIO ABDOMEN W/WO CONTRAST $3,408CT ANGIO AORTA W/WO CONTRAST $2,873CT ANGIO CHEST W/WO CONTRAST $2,173CT ANGIO EXTREMITY LOWER W/WO CON $1,956

49 of 317 FY2018

DESCRIPTION CHARGES

CT ANGIO EXTREMITY UPPER W/WO CON $1,523CT ANGIO HEAD W/WO CONTRAST $2,146CT ANGIO HEART/CORONARY ARTERIES $2,500CT ANGIO NECK W/WO CONTRAST $2,476CT ANGIO PELVIS W/WO CONTRAST $2,271CT Appendiceal Abscess Drain $1,397CT APPENDICEAL ABSCESS DRAIN IR $2,546CT BONE BX DEEP $650CT BONE BX SUPERFICIAL $1,385CT Bone Density (QCT) $463CT BRAIN ABSCESS DRAIN $3,892CT BRAIN STEREOTACTIC BX $3,979CT BX OF LYMPH NODE $721CT CARDIAC SCORING $125CT CERVICAL SPINE W CONTRAST $2,075CT CERVICAL SPINE W/O CONTRAST $2,044CT CERVICAL SPINE W/WO CONTRAST $2,516CT CHEST LIMITED $983CT CHEST W/CONTRAST $2,143CT CHEST W/O CONTRAST $1,801CT CHEST W/WO CONTRAST $2,559CT COLONOGRAPHY DIAGNOSTIC $1,248CT COLONOGRAPHY DIAGNOSTIC W/WO CON $2,495CT COLONOGRAPHY SCREENING $1,248CT CryoAblation Renal Tumor $10,236CT ENTEROGRAPHY W/CONTRAST $4,128CT EXTREMITY LOWER W/CON BILAT $3,688CT EXTREMITY LOWER W/CON LEFT $1,844CT EXTREMITY LOWER W/CON RIGHT $1,844CT EXTREMITY LOWER W/O CON BILAT $3,160CT EXTREMITY LOWER W/O CON LEFT $1,580CT EXTREMITY LOWER W/O CON RIGHT $1,580CT EXTREMITY LOWER W/WO CON BILAT $3,708CT EXTREMITY LOWER W/WO CON LEFT $1,854CT EXTREMITY LOWER W/WO CON RIGHT $1,854CT EXTREMITY UPPER W/CON BILAT $3,360CT EXTREMITY UPPER W/CON LEFT $1,680

50 of 317 FY2018

DESCRIPTION CHARGES

CT EXTREMITY UPPER W/CON RIGHT $1,680CT EXTREMITY UPPER W/O CON BILAT $3,155CT EXTREMITY UPPER W/O CON LEFT $1,578CT EXTREMITY UPPER W/O CON RIGHT $1,578CT EXTREMITY UPPER W/WO CON BILAT $3,399CT EXTREMITY UPPER W/WO CON LEFT $1,751CT EXTREMITY UPPER W/WO CON RIGHT $1,751CT GUIDANCE RADIATION TREATMENT PLANNING $1,067CT GUIDANCE STEREOTATIC LOCALIZATION $1,504CT GUIDANCE TISSUE ABLATION IR $1,908CT GUIDE CRYO ABLAT BONE W/IMAGE $10,296CT Guide Cryoablation Renal $10,236CT GUIDE RF ABLATION BONE W/IMAGE $6,875CT GUIDE RF ABLATION LUNG $10,236CT GUIDE RF ABLATION RENAL $10,236CT GUIDED NEEDLE BIOPSY $1,725CT GUIDED VERTEBRAL $1,413CT HEAD W/CONTRAST $1,700CT HEAD W/O CONTRAST $1,523CT HEAD W/WO CONTRAST $2,011CT HEART CARDIAC STRUCTURE $918CT HIP/PELVIS ABSCESS DRAIN $2,964CT HIP/PELVIS BX DEEP $835CT INJ EPI/CERV/THORAC SNGL W/GUID $1,432CT INJ EPI/LUMB/CAUD SNGL W/FLUORO $1,687CT Injection 1 or 2 Muscles $506CT LIMITED OR LOCALIZED FOLLOW-UP $983CT LIVER ABSCESS DRAINAGE IR $2,546CT LIVER BX PERC $960CT LIVER BY W/OTHER PROCEDURE $272CT LUMBAR SPINE W/CONTRAST $2,142CT LUMBAR SPINE W/O CONTRAST $1,850CT LUMBAR SPINE W/WO CONTRAST $2,163CT LUNG OR MEDIASTINUM BX PERC $873CT LUNG RF ABLATION W /IMAGING $12,144CT LUNG SCREENING $1,801CT Lung Screening $1,801

51 of 317 FY2018

DESCRIPTION CHARGES

CT MAXILLOFACIAL AREA W/CONTRAST $1,771CT MAXILLOFACIAL AREA W/O CONTRAST $1,487CT MAXILLOFACIAL AREA W/WO CONTRAST $1,920CT MUSCLE BX PERCUTANEOUS $607CT ORBIT, SELLA, IAC, FOSSA W/CONTRAST $1,685CT ORBIT, SELLA, IAC, FOSSA W/O CONTRAST $1,526CT ORBIT, SELLA, IAC, FOSSA W/WO CON $1,887CT PANCREAS BX PERC $873CT PELVIS W/CONTRAST IR $2,061CT PELVIS W/O CONTRAST IR $1,690CT PELVIS W/WO CONTRAST IR $2,337CT PERITONEAL ABSCESS DRAIN PERC $1,397CT PERITONEAL ABSCESS DRAIN PERC IR $2,546CT PLEURA BX PERCUTANEOUS $1,328CT PLEURAL DRAINAGE TUBE/IMAGING IR $2,825CT RECONSTRUCTION EXAM $2,215CT RENAL ABSCESS DRAINAGE PERC IR $2,546CT RENAL BX PERC $1,087CT RENAL CYST ASP $960CT RETROPERI ABSCESS DRAIN PERC IR $2,546CT RETROPERIT ABSCESS DRAIN PERC $1,476CT RF ABLATION LIVER TUMOR PERC $10,236CT SOFT TISSUE NECK W/CONTRAST IR $1,804CT SOFT TISSUE NECK W/O CONTRAST IR $1,530CT SOFT TISSUE NECK W/WO CONTRAST IR $2,192CT SUBDIAPH ABSCESS DRAIN PERC IR $2,546CT SUBDIAPHRAG ABSCESS DRAIN PERC $1,397CT THORACIC SPINE W/CONTRAST $2,144CT THORACIC SPINE W/O CONTRAST $1,818CT THORACIC SPINE W/WO CONTRAST $2,632Dentascan-Full Arch Mand/Maxilla $1,487Echo Guidance Radiotherapy $279Orbits - Limited (R/O Metal) $1,526

NUCLEAR MEDICINENM ABSCESS LOCALIZATION LIMITED CERETE $1,002NM ABSCESS LOCALIZATION LIMITED GALLIUM $648

52 of 317 FY2018

DESCRIPTION CHARGES

NM ABSCESS LOCALIZATION LIMITED INDIUM $1,002NM ABSCESS LOCALIZATION SPECT $1,159NM ABSCESS LOCALIZATION WHOLE BODY GALLIUM $1,164NM ABSCESS LOCALIZATION WHOLE BODY INDIUM $1,496NM ABSCESS LOCALIZATION WHOLE BODY CERETEC $1,496NM BLOOD PLASMA VOLUME $1,780NM BONE SCAN LIMITED $1,018NM BONE SCAN MULTIPLE $1,306NM BONE SCAN THREE PHASE $1,534NM BONE SCAN WHOLE BODY $1,369NM BONE SPECT SCAN $1,741NM BRAIN SCAN SPECT $1,713NM BRAIN SCAN W/FLOW COMPLETE $1,002NM BRAIN SCAN W/FLOW LIMITED $745NM CISTERNOGRAM $1,323NM CSF LEAKAGE $888NM CSF SHUNT EVALUATION $764NM CYSTOGRAM VOIDING $565NM DACROSCINTIGRAM $526NM DATSCAN BRAIN SPECT $1,713NM ESOPHAGEAL MOTILITY $569NM GASTRIC EMPYTING $1,273NM GASTRIC MUCOSA IMAGING $569NM GASTROESOPHAGEAL REFLUX $569NM GI BLOOD LOSS ACUTE SCAN $1,113NM HEPATOBILIARY SCAN $1,420NM HEPATOBILIARY SCAN W/EJECTION FRACT $1,420NM LIVER AND SPLEEN SCAN $1,385NM LIVER AND SPLEEN SCAN W/FLOW STUDY $831NM LIVER SCAN W/FLOW STUDY $811NM LIVER SPECT SCAN $1,824NM LIVER SPECT SCAN W/FLOW STUDY $2,065NM LUNG PERF QUANTITATIVE $1,753NM LUNG PERF/VENT QUANT $1,753NM LUNG PERFUSION SCAN ONLY $994NM LUNG VENTILATION W/AEROSOL/GAS $496NM LUNG VQ VENT/PERF $1,927

53 of 317 FY2018

DESCRIPTION CHARGES

NM LYMPHATIC BREAST NEXT DAY SURG $1,285NM LYMPHATIC BREAST SAME DAY SURG $1,285NM LYMPHATIC IMAGING MELANOMA $1,285NM MECKELS DIVERTICULUM SCAN $676NM MPI SPECT MULT EFWALL MOT DOBU $3,405NM MPI SPECT MULT EFWALL MOT LEXI $3,405NM MPI SPECT MULT EFWALL MOT TREAD $3,405NM MPI SPECT MULT W/WO EFWALL MOT $3,405NM MPI SPECT SGL STRES DOBUTAMINE $1,963NM MPI SPECT SGL STRESS LEXISCAN $1,963NM MPI SPECT SGL STRESS TREADMILL $1,963NM MPI SPECT SING REST WWO EF MOT $1,963NM MPI SPECT SING W/WO EFWALL MOT $1,963NM MUGA RVG STRESS OR REST SCAN $1,244NM MUGA RVG W/FIRST PASS $809NM MYOCARD PLANAR SGL STRES DOBUT $1,107NM MYOCARD PLANAR SGL STRES TRDML $1,107NM MYOCARD PLANAR SGL STRESS LEXI $1,107NM MYOCARDIAL PLANAR MULT DOBUTAM $1,407NM MYOCARDIAL PLANAR MULT LEXI $1,407NM MYOCARDIAL PLANAR MULT TREADML $1,407NM MYOCARDIAL PLANAR SGL REST $1,107NM MYOCARDIAL SCAN PLANAR SINGLE $1,107NM MYOCARDIAL SCAN TC99M PYP SPECT $809NM PARATHYROID SCAN $848NM PARATHYROID SCAN PLANAR $848NM PARATHYROID SCAN w/SPECT $896NM PARATHYROID w/SPECT and CT $896NM PERITONEAL SHUNT STUDY $1,160NM RED CELL SURVIVAL STUDY $1,217NM RENAL FUNCTION W/PHARM $1,596NM RENAL SCAN SPECT $637NM RENAL SCAN STATIC $525NM RENAL SCAN W/FLOW $565NM RENAL SCAN W/FLOW AND FUNCTION $1,440NM SALIVARY GLAND FUNCTION $874NM SCHILLINGS TEST W/INTRINSIC FACTOR $647

54 of 317 FY2018

DESCRIPTION CHARGES

NM SCHILLINGS TEST W/O INTRINSIC FACTOR $878NM TESTICULAR SCAN W/FLOW $753NM THYROID I-123 UPTAKE/SCAN MULT $1,133NM THYROID I-131 UPTAKE ONLY $430NM THYROID SCAN IMAGING ONLY $750NM THYROID UPTAKE/SCAN SINGLE $1,133NM TUMOR LOCALIZATION LIMITED BREAST $721NM TUMOR LOCALIZATION LIMITED GALLIUM $721NM TUMOR LOCALIZATION LIMITED INDIUM $721NM TUMOR LOCALIZATION LTD $721NM TUMOR LOCALIZATION MULT OCTREOSCAN $613NM TUMOR LOCALIZATION MULTIPLE GALLIUM $613NM TUMOR LOCALIZATION MULTIPLE INDIUM $613NM TUMOR LOCALIZATION SPECT $2,010NM TUMOR WHOLE BODY $1,571NM TUMOR WHOLE BODY 2 OR MORE DAYS $1,857NM TUMOR WHOLE BODY GALLIUM $1,722NM TUMOR WHOLE BODY INDIUM $1,571NM TUMOR WHOLE BODY OCTREOSCAN $1,722NM Whole Body SCAN I-131 HIGH DOSE $1,332NM Whole Body SCAN I-131 LOW DOSE $1,332NM WHOLE BODY SCAN THALLIUM $1,332Wh Myocardial Scan Spect Multiple $3,405Wh Myocardial Scan Spect Single $1,964

MRICardiac MRI w/Stress Img w/o Cont $1,763MR Bone Marrow Blood Supply $1,326MR Breast - Bilateral $1,696MR Breast - Unilateral $1,375MR GUIDE CRYOABLATION LIVER $10,236MR Lower Extremity Any Joint w/Contrast Bilat $5,055MR Lower Extremity Any Joint w/o Contrast Bil $2,527MR Lower Extremity Any Joint w/wo Contrast Bil $6,033MR Lower Extremity Excl Joint w/o Contrast Bil $3,918MR Lower Extremity Excl Joint w/wo Con Bilat $5,355MR Lower Extremity Other than Joint w/Con $4,276

55 of 317 FY2018

DESCRIPTION CHARGES

MR Lumbar Plexus $699MR RF ABLATION LIVER $10,236MR Upper Extremity Exclud Joint w/Contrast Bil $4,532MR Upper Extremity Exclud Joint w/o Con Bilat $3,927MR Upper Extremity Exclud Joint w/wo Con Bilat $5,403MR Upper Extremity Joint w/Contrast Bilat $5,150MR Upper Extremity Joint w/o & w/Contrast Bil $6,001MR Upper Extremity Joint w/o Contrast Bilat $5,036MRA Abdomen w/o or w/Contrast $1,426MRA Chest w/wo Contrast $1,426MRA LE w/o or w/Contrast $2,631MRA Pelvis w/o or w/Contrast $2,197MRA Upper Extremity w/o or w/Contrast $1,389MRI ABDOMEN W/CONTRAST $3,605MRI ABDOMEN W/O CONTRAST $2,559MRI ABDOMEN W/WO CONTRAST $4,034MRI ANGIO ABDOMEN W/CONTRAST $2,294MRI ANGIO ABDOMEN W/O CONTRAST $1,464MRI ANGIO ABDOMEN W/WO CONTRAST $2,445MRI ANGIO CHEST W/CONTRAST $1,660MRI ANGIO CHEST W/O CONTRAST $1,538MRI ANGIO CHEST W/WO CONTRAST $2,375MRI ANGIO EXTREM LOWER W/CON $1,848MRI ANGIO EXTREM LOWER W/O CON $1,714MRI ANGIO EXTREM LOWER W/WO CON $3,138MRI ANGIO HEAD W/CONTRAST $2,402MRI ANGIO HEAD W/O CONTRAST $2,072MRI ANGIO HEAD W/WO CONTRAST $2,588MRI ANGIO NECK W/CONTRAST $2,575MRI ANGIO NECK W/O CONTRAST $2,537MRI ANGIO NECK W/WO CONTRAST $2,696MRI ANGIO PELVIS W/CONTRAST $1,660MRI ANGIO PELVIS W/O CONTRAST $1,538MRI ANGIO PELVIS W/WO CONTRAST $2,375MRI ANGIO SPINAL CANAL W/CONTRAST $1,660MRI ANGIO SPINAL CANAL W/O CONTRAST $1,538MRI ANGIO SPINAL CANAL W/WO CONTRAST $2,375

56 of 317 FY2018

DESCRIPTION CHARGES

MRI ANGIO UP/EXTREM W/CONTRAST $1,660MRI ANGIO UP/EXTREM W/O CONTRAST $1,538MRI ANGIO UP/EXTREM W/WO CONTRAST $2,375MRI ANKLE W CONTRAST $2,527MRI ANKLE W/WO CONTRAST $3,017MRI ANKLE WO CONTRAST $2,361MRI BONE MARROW $1,326MRI BRACHIAL PLEXUS W/O CONTRAST $2,524MRI BRACHIAL PLEXUS W/WO CONTRAST $3,487MRI BRAIN WITH PITUITARY W/WO CON $3,510MRI BRAIN/BRAIN STEM W/ CONTR $2,781MRI BRAIN/BRAIN STEM W/O CONTRAST $2,600MRI BREAST BILAT POST PROCEDURE $225MRI BREAST BILAT W/CONT DIAG $2,575MRI BREAST BILAT W/CONT SCREEN $2,575MRI BREAST BILAT W/O CONT DIAG $1,815MRI BREAST BILAT W/O CONTRAST SCREEN $1,815MRI BREAST BILAT W/WO CONT DIAG $2,881MRI BREAST BILAT W/WO CONT SCREEN $2,881MRI BREAST BIOPSY $3,650MRI Breast CAD $484MRI BREAST NEEDLE LOC EACH ADDL $1,914MRI BREAST NEEDLE LOCALIZATION $2,422MRI BREAST UNI POST PROCEDURE $150MRI BREAST UNI W/CON DIAG LT $1,380MRI BREAST UNI W/CON SCREEN $1,380MRI BREAST UNI W/O CON DIAG $1,124MRI BREAST UNI W/O CON SCREEN $1,124MRI BREAST UNI W/WO CON DIAG $1,739MRI BREAST UNI W/WO CON SCREEN $1,739MRI Breast Unilat w/Con $1,409MRI Breast Unilat w/o Con $1,216MRI Breast Unilat w/wo Con $1,714MRI Breast w/Contrast Bilat $2,575MRI Breast w/o Contrast Bilat $1,815MRI Breast w/wo Contrast Bilat $2,881MRI CARDIAC MORPHOLOGY STRESS W/O $737

57 of 317 FY2018

DESCRIPTION CHARGES

MRI CARDIAC MORPHOLOGY STRESS W/WO $2,850MRI CARDIAC MORPHOLOGY W/O CON $663MRI CARDIAC MORPHOLOGY W/WO CON $1,207MRI CARDIAC VELOCITY FLOW MAPPING $332MRI CERVICAL SPINE W/CONTRAST $3,667MRI CERVICAL SPINE W/O CONTRAST $2,921MRI CERVICAL SPINE W/WO CONTRAST $4,039MRI CHEST W/CONTRAST $2,891MRI CHEST W/O CONTRAST $2,524MRI CHEST W/WO CONTRAST $3,487MRI ELBOW W CONTRAST LEFT $2,599MRI ELBOW W/WO CONTRAST $3,281MRI ELBOW WO CONTRAST $2,472MRI EXTREM LOWER JT W/CONT $2,527MRI EXTREM LOWER JT W/O CON $2,361MRI EXTREM LOWER JT W/WO CON $3,017MRI EXTREM LOWER NON JT W/CON $2,472MRI EXTREM LOWER NON JT W/O $2,365MRI EXTREM LOWER NON JT W/WO $2,991MRI EXTREM UPPER JOINT W/WO $3,281MRI EXTREM UPPER JT W/CON $2,599MRI EXTREM UPPER JT W/O CON $2,472MRI EXTREM UPPER NON JT W/CON $2,369MRI EXTREM UPPER NON JT W/O $2,218MRI EXTREM UPPER NON JT W/WO $2,701MRI FEMUR W CONTRAST $2,527MRI FEMUR W/WO CONTRAST $2,701MRI FEMUR WO CONTRAST $2,218MRI FOOT W CONTRAST $2,369MRI FOOT W/WO CONTRAST $2,991MRI FOOT WO CONTRAST $2,365MRI FOREARM W CONTRAST $2,369MRI FOREARM W/WO CONTRAST $2,701MRI FOREARM WO CONTRAST $2,218MRI GUIDANCE FOR NEEDLE PLACEMENT $1,680MRI GUIDANCE TISSUE $1,521MRI GUIDANCE TISSUE ABLATION $1,521

58 of 317 FY2018

DESCRIPTION CHARGES

MRI HAND W CONTRAST $2,369MRI HAND W/WO CONTRAST $2,701MRI HAND WO CONTRAST $2,218MRI HIP POST ARTHROGRAM $2,527MRI HIP W CONTRAST $2,527MRI HIP W/WO CONTRAST $3,017MRI HIP WO CONTRAST $2,361MRI HUMERUS W CONTRAST $2,369MRI HUMERUS W/WO CONTRAST $2,701MRI HUMERUS WO CONTRAST $2,218MRI KNEE POST ARTHROGRAM $2,527MRI KNEE W CONTRAST $2,527MRI KNEE W/WO CONTRAST $3,017MRI KNEE WO CONTRAST $2,361MRI LUMBAR SPINE W/CONTRAST $3,914MRI LUMBAR SPINE W/O CONTRAST $2,943MRI LUMBAR SPINE W/WO CONTRAST $4,215MRI MRCP w/wo contrast $4,034MRI MRCP wo contrast $2,559MRI MYOCARDIUM W/CONTRAST $2,781MRI MYOCARDIUM W/O CONTRAST $1,851MRI ORBIT/FACE/NECK W/CONTRAST $3,471MRI ORBIT/FACE/NECK W/O CONTRAST $2,838MRI ORBIT/FACE/NECK W/WO CONT $3,790MRI PELVIS W/CONTRAST $2,896MRI PELVIS W/O CONTRAST $2,759MRI PELVIS W/WO CONTRAST $3,957MRI PITUITARY W/WO CONTRAST $2,019MRI SHOULDER POST ARTHROGRAM $2,599MRI SHOULDER W CONTRAST $2,599MRI SHOULDER W/WO CONTRAST $3,281MRI SHOULDER WO CONTRAST $2,472MRI SPECTROSCOPY $1,534MRI THORACIC SPINE W/CONTRAST $3,965MRI THORACIC SPINE W/O CONTRAST $2,870MRI THORACIC SPINE W/WO CONTRAST $4,086MRI TIB/FIBULA W/WO CONTRAST $2,991

59 of 317 FY2018

DESCRIPTION CHARGES

MRI TIBIA/FIBULA W CONTRAST $2,991MRI TIBIA/FIBULA WO CONTRAST $2,365MRI TMJ $2,495MRI VENOGRAM HEAD W/O CONTRAST $2,072MRI WRIST W CONTRAST $2,599MRI WRIST W/WO CONTRAST $3,281MRI WRIST WO CONTRAST $2,472Postprocessing on 3D Workstation $461

CARDIOLOGY3D TEE w/o Anesthesia $3,5003D TEE with Anesthesia $3,500Addl Vessel-DES Intracoronary $10,000Analysis Single Lead ICD/Reprog $226Aortagram-Descending $1,586Arterial Cannulation $29Balloon Aortic Valvuloplasty $7,667BioimpedanceBP Monitior - Scanning add on $516Brachiocep Addl 2nd Or 3rd Order $180Brachiocephalic 1st Order $1,393Brachiocephalic 2nd Order $957Brachiocephalic 3rd Order $1,118Cardiac Resync w/o Reprog PnlCardiac Resync With Reprogram PnlCardiovascular Stress Test $1,068Cardioversion $980Cardioversion Elective External $1,022Cardioversion Elective Internal $1,022Cardioversion via ICD $256Catheter Ablation Of AV Node $7,400Closure of Aortic perivalvul-leak $29,022Closure of Mitral Perivalve-Leak $29,022Color Flow Add On $597Com EP Eval Without Arrhythmia $7,400Common FemoralIpslateral $501Comp EP Eval With Arrhythmia $7,400

60 of 317 FY2018

DESCRIPTION CHARGES

Comp EP Study/Afib Ablation $21,000Comp EP Study/SVT Ablation $21,000Comp EP Study/VT Ablation $21,000Continuous Rhythm Ecg $103Coronary Fistula Embolization $17,900CPR $557CS Or La Recording/Pacing $4,000Debr Muscle ISt 20 Sq Cm 11043 $631Debr Subc ISt 20 Sq Cm 11042 $405DOBUTAMINE STRESS ECHO $1,795Dobutamine Stress Myocardial Perfusion Imaging $1,068DOC BP Monitor - Recording $287DOC Dobutamine Stress Echo Contrast $1,787DOC Echo 2D Limited Study Contrast $802DOC Echo Complete Congen Contrast $2,719DOC Echo Complete w Contrast $2,834Doppler Limited Add On $843Ea Addl Vessel Bmstent/Rotablator $5,832Each Addl 2nd Or 3rd Order Art $155Each Addl Vessel BM Stent $5,832Echo 2D Limited Study $802Echo Complete W/Contrast $2,834Echo Complete W/Contrast - Add On Exam $2,834Echo Doppler $843Echo tee Congen Panel W/DopplerEcho Transesophageal $1,750Echo Transesophageal Congen $1,750Echo Transesophageal O.R. Follow Up $616EKG $270EKG Same Date as Procedure $242Endotrachial Intubation $424First Order Artery $1,649Focused Echocardiogram HCM $45Functional Measure-Ea Addl Vessel $900Functional Measure-Initial Vessel $1,800HIS Bundle Recording $3,054Holter Monitior - Scanning add on $692

61 of 317 FY2018

DESCRIPTION CHARGES

Holter Monitor - Recording $442Holter Monitor 24 Hr $848IABP Insertion $1,303ICD Follow Up(Not Time Of Insert) $1,400ICD Lead Testing-Time Of Insertio $1,400ICD Test Gen/Leads Time Of Insert $1,400Iliac Angio With Cardiac Cath $2,300Implant Cardiac Event Recorder $10,000Implant Internal Loop Cardiac Mon $10,000Implant Loop Recorder $7,149Inj Coronaries-No LHC $6,500Inj CorsGrafts-No LHC $8,000Inject Cors Congenital Cath $1,557Inject Grafts Congenital Cath $2,750Injection Venography $174Ins ICD Gen W/ Exist Mult Leads $12,209Ins ICD Gen W/Exist Dual Leads $12,209Ins Pacer Gen Exist Mult Leads $8,034Ins/Repl Atrial Gen/Leads $8,311Ins/Repl ICD Generator Only Dual $13,124Ins/Repl ICD Generator Only Singl $13,124Ins/Repl ICD Leads/Generator Dual $20,735Ins/Repl ICD Leads/Generator Sing $20,735Ins/Repl ICD W/ LV Lead $19,481Insert Lead Azoygous Vein $9,299Insert Lead Dual Changer Pp Oricd $8,027Insert Lead Sgl Chamber Pp Or ICD $8,314Insert LV Lead Pre Existing Devic $7,363Insert LV Lead Time Of Ins Pp ICD $9,299Insert Pulse Generator Dual Leads $12,209Insert Temp Pacemaker Single Lead $7,892Insert/Repl Leads $8,314Insert/Replace Dual Chamber Gen/Leads $11,968Insert/Replace ICD W/ LV Lead $19,481Insert/Replace Pacer Gen Single Chamber $8,243Insert/Replace Pacer Gen/Dual Chamber $8,781Insert/Replace Subq ICD $61,029

62 of 317 FY2018

DESCRIPTION CHARGES

Insert/Replace Ventricular Lead /Gen $9,856Insertion Perc LV Suport Transptl $1,921Insertion Perc LV Support $1,921Intra Atrial Pacing $3,054Intra Atrial Recording $3,054Intracardiac Echo $4,000Intracoronary Thrombolysis $2,368Intravascular Us-Ea Addnl Vessel $1,551Intravascular Us-Initial Vessel $4,102Intro Intravasc Stent Ea Addl $13,072Intro Of Intravasc Stent W/Angio $16,968Intro Of Needle Aorta Translumbar $439Intro of Needle Brachial/Ax Art $501Intro of Needle Extremity Art $501IV Thrombolysis Coronary $315IVUS-Each Ad-Non Coronary W/S&I $1,684IVUS-Initial-Non Coronary W/S&I $4,462Left Heart Cath/LV $5,989Left HeartCorsLV $9,500Lexiscan Stress MPI $1,068LHCCorsGraftsLV $9,500LV Gram Without LHC $184LV or LA Angio $1,069Major Vessel BM Stent $11,600Major Vessel BM Stent/Rotablator $11,600Major Vessel DES Stent/Rotablator $10,000Major Vessel-DES Intracoronary $10,000Mapping (Non 3d) $3,054Mapping 3 D $4,500Mech Thromb Inj Venous $3,989Mobile Telemetry Monitor $129Non Selective Carotids $3,029Noninvasive Programmed Stim $1,022Noninvasive Programmed Stimulation $200Nonselective Cath-Aorta $1,746Pace Dual Chamber W Reprogram $226Pace Interrogation Wo Reprogram $187

63 of 317 FY2018

DESCRIPTION CHARGES

PCI AMI/DES Single Vessel $10,000PCI CTO/DES Addl Vessel $10,000PCI CTO/DES Single Vessel $10,000PCI Of CTO Addl Vessel $5,832PCI Of CTO Single Vessel $11,600PCI W/AMI Single Vessel $11,600PCI/Bypas Grft Any Method Sng Ves $11,600PCI/Bypass Each Addl Vessel $5,832PCI/DES Bypass Graft Addl Ves $10,000PCI/DES Bypass Graft Single Ves $10,000Perc Closure Of Asd With Implant $29,022Perc Closure Of Interatrial Comm $27,756Pericardiocentesis $1,025PROBE TRANSESOPHAGEAL ECHO $976Pta Iliac Artery $2,785PtaFem-Pop Liteal Art $2,785PTATibioperoneal Art & Branches $930PTCA Ea Addl Vessel $1,803PTCA Single Vessel $6,010Pulmonary Angiogram $1,559Rem/Repl ICD W/ Dual Lead Sys $15,361Rem/Repl ICD W/ Mult Lead Sys $17,421Rem/Repl ICD W/ Single Lead Sys $15,361Rem/Repl Pacer Gen Dual Chmbr $9,888Rem/Repl Pacer Gen Single Chmbr $8,817Rem/Repl Pacer Mult Lead Sys $11,086Remote Interrogation ICM/ILR $91Remote Interrogation PPM/ICD $91Removal Cardiac Event Recorder $2,125Removal ICD Generator $3,847Removal ICD Lead Transvenous $3,247Removal Internal Cardiac Monitor $2,124Removal Loop Recorder $2,063Removal Perm Pacer Generator $3,847Removal Transvenous Lead Dual $3,247Removal Transvenous Lead Single $3,003Removal Tunneled Cv Cath $1,967

64 of 317 FY2018

DESCRIPTION CHARGES

Renal Bilat Selective $2,575Renal Bilat Superselective $2,575Renal Unilat Selective $2,575Renal Unilat Superselective $2,575Repeat Rx On Next Day/Venous $3,989Reposition LV Lead Prev Implant $3,247Reposition Ppm/ICD Lead $3,847Revise/Relocate ICD Pocket $2,584Revise/Relocate Pacer Pocket $2,584RHCCorsGrafts-No LV $9,500RHCLHCCorsGraftsLV $9,500RHCLHCCorsLV $9,500Right & Left Heart Cath $7,530Right Heart Cath $4,272Rota W/PTCA Maj Ves Ea Addl Brnch $7,321Rotationl Athrctmy W/PTCA Maj Ves $14,600Rt Heart Coronaries-No LV $9,500RV or RA Angio $1,316RV Recording $3,054Second Order Artery $1,315Secondary Ablation $9,000Secondary Afib Ablation $9,000SLH Cardiac Event Monitor-Recording $489SLH Echo Complete Congenital $2,719SLH Echo w/Stress Echo & Contrast PanelSLH Echocardiogram Complete $2,719SLH Long Term Holter Monitor $442Stim/Pacing After IV DRug $3,054Stress Echo $1,787Stress Echo with Contrast $2,100Stress Echo with Contrast $2,100Swan Ganz Ins W/O Pressure Monit $1,688TEE- Baseline Pre Ablation $2,600TEE- Intraprocedure WATCHMAN $1,750Third Order Artery $1,669Tilt Table Testing $1,182Trans Septal Heart Cath $6,639

65 of 317 FY2018

DESCRIPTION CHARGES

Transcath Retrieval Fb. $4,722Transcatheter Biopsy $448Transcutaneous Pacing $443Upgrade To Dual Chamber Pacer $10,672Valve Dobutamine Stress Echo PanelValve/HCM Stress EchoVenography Pulmonary Veins $174Watchman Procedure $24,020WOC Definity Contrast W/Doppler $2,834

RESPIRATORY THERAPY6 Minute Walk $250Adult Peak Flow Before Treatment $153Airvo Set Up And Circuit $350Car Seat Test Ea Addl 30 Min $62Car Seat Test First 60 Min $93Carbon Dioxide Monitor $358Chest Physio Pep Therapy Initial $235Chest Physio Pep Therapy Subsequent $75Complex stress Inpatient PFT Charge $1,061CONT END TIDAL MONITORING $186Continuous End Tidal CO2 Monitoring Daily $358Continuous End Tidal CO2 Monitoring Initial $358Continuous Nebulizer Initial $239Continuous Nebulizer Subsequent $127

Continuous Positive Airway Pressure or BIPAP Initial Set Up Charge $500Continuous Pulse Oximetry $186COPD Education $42COPD Education Pulm Rehab COPD Patient Charge $210COPD Initial Visit $354COPD Subsequent Visit $210COPD wih 6 minute walk $167CPAP Daily BiPAP/CPAP Charge $500Disease Management Education Provided Asthma $42Disease Management Education Provided COPD $42Disease Management Education Provided Pneumonia $42

66 of 317 FY2018

DESCRIPTION CHARGES

Done Chest Physio Bed Therapy $76End Tidal CO2 for Tube placement $358High Humidity O2 TherapyNursery $255High Humidity/High Flow Oxygen Therapy $255HIgh Humidity/High Flow Oxygen Therapy Subsequent $168Home Care Evaluation Charge $157Hyperbaric Oxygen Per 1/2 Hour $271Hypertonic Sputum Induction $96Inhaler subsequent Outpatient PFT Charge $156Initial Chest Physiotherapy Charge $185Initial RT Charge MDI $300Initial RT Charge Nebulizer $300Initial RT Charge Ultrasonic Nebulizer $156Level III, w/ monitor $9Maximum Voluntary Ventilation Inpatient PFT Charge $121Maximum Voluntary Ventilation Outpatient PFT Charge $121MDI After Nebulizer Aerosol Delivery Device $156MDI initial Aerosol Delivery Device $300MDI Instruct $156MDI/Medication Education $175Mechanical Vent Infant $950Mechanical Vent Infant Subsequent $775Mechanical Ventilation Adult $950Mechanical Ventilation Adult Subsequent $775

Mechanical ventilation initial (first 24 hours) Daily Vent Charge $950Mechanical ventilation subsequent Daily Vent Charge $775Methacholine challenge Inpatient PFT Charge $743Nasotracheal Suction Method $156Nebulizer initial Aerosol Delivery Device $300Nebulizer subsequent Outpatient PFT Charge $156Nebulizer Treatment $180Nebulizer/Humidity $1Negative Inspiratory Force $153Nitric Oxide Gas Additional Days $9,600Nitric Oxide Gas Per Day Initial $9,600Non-COPD Initial Visit $354

67 of 317 FY2018

DESCRIPTION CHARGES

NonCOPD Subsequent Visit $210OneonOne Fitness Plus Wellness Treatment Charges $25OP ABG $125OP Ambulation Titration Charge $127OP Overnight Oximetry $186OP PFT DLCO NEW Outpatient PFT Charge $196OP PFT F/V LOOP Pre Bronch M&M Outpatient PFT Charge $353OP PFT F/V Loop pre Bronch Outpatient PFT Charge $258OP PFT F/V LOOP PRE/POST M&M Outpatient PFT Charge $552OP PFT Lung Volume Pleth Outpatient PFT Charge $300OP PFT Medication Monitoring Outpatient PFT Charge $258OP Spot Check Only Charge $48Outpatient RT Charge Nebulizer (Outpt) $156Outpatient Respiratory Parameter Peak Flow $153Overnight Oximetry w/ Recording $186Patient Education 15 min Charge $19Patient Education 30 min Charge $38Patient Education 45 min Charge $56Patient Education 60 min Charge $75Pediatric Peak Flow Before Treatment $153Pentamidine Treatment Aerosol Delivery Device $265PFT DLCO NEW Inpatient PFT Charge $196PFT F/V Loop pre Bronch Inpatient PFT Charge $258PFT F/V Loop pre Bronch M&M Inpatient PFT Charge $353PFT F/V pre/post Bronch Inpatient PFT Charge $461PFT Lung Volume Pleth Inpatient PFT Charge $206PFT Medication Monitoring Inpatient PFT Charge $258Pulmonary Rehab Consult Established Patient Charge $232Pulmonary Rehab Consult New Patient Charge $242Pulmonary Rehab Home Care Charge $191Pulmonary Rehab Home Care Evaluation and Setup Established Charge $258Pulmonary Rehab Home Care Evaluation and Setup New Patient Charge $309Pulmonary Rehab Level I Charge $145Pulse Ox Multiple Measurements $127Pulse Oximetry Multiple

68 of 317 FY2018

DESCRIPTION CHARGES

Pulse Oximetry Single $48Pulse Oximetry Spot Check $48Respiratory Therapist Draw Performed By $125RT Charge - MDI Outpatient $156RT Charge Pentamidine $265RT Oxygen Therapy $255RT OXYMETRY/MED MONITORING CONT $186RT Oxymetry/Medication Monitoring Daily Charge $186RT Oxymetry/Medication Monitoring Initial $186RT Surfactant Administration $156Simple stress Inpatient PFT Charge $849Six Minute Walk Initial $200Subsequent Chest Physiotherapy Charge $151Subsequent RT Charge MDI $156Subsequent RT Charge Nebulizer $156Subsequent RT Charge Ultrasonic Nebulizer $156Supervised Exercise Wellness Treatment Charges $9TCOM initial TCOM Daily Charge $409TCOM subsequent TCOM Daily Charge $442Transcutaneous CO2 Monitor Daily $442Ultrasonic Nebulizer initial Aerosol Delivery Device $300Ultrasonic Nebulizer subsequent Aerosol Delivery Device $156VD/VT $177Weaning Vital Capacity $153

EDUCATION1115 mins. RT Charge OP Smoking Cessation $641630 mins. RT Charge OP Smoking Cessation $1273145 mins. RT Charge OP Smoking Cessation $1914660 mins. RT Charge OP Smoking Cessation $254Diabetes Self Management Training $105Diabetes Self-Management Group Ed $55ICR Education Units $274Intake Assessment Intensive Cardiac Rehab Charges $267Intake Assessment Traditional Cardiac Rehab Charges $267Medical Nutrition Therapy Follow-Up $40

69 of 317 FY2018

DESCRIPTION CHARGES

Medical Nutrition Therapy Initial $40Nutrition IBT Obesity - 15 Min $100RT Charge OP Smoking Cessation 310 mins. $42Smoking Cessation Counseling $42Traditional Education Units $274Wellness Assessment Wellness Evaluation Charges $267Wellness Medical Intervention Wellness Evaluation Charges $267

SLEEP MEDICINECPC Cleft Lip Palate Nurser $4CPC Exam By Multidisciplinary Team $192Inpatient Nurse Visit $121Missed Sleep Study Appointment Fee $57MSLT/MWT $1,349Outpatient Visit Level 1 Technical Est $117Outpatient Visit Level 1 Technical New $127Outpatient Visit Level 3 Technical Est $149Outpatient Visit Level 3 Technical New $180Outpatient Visit Level 5 Technical Est $228Outpatient Visit Level 5 Technical New $292Polysonogram W 4/> P W PAP/ASV <6 Yrs Old $3,630Polysonogram W 4/> P W PAP/ASV 6 &Older $4,060Polysonogram W 4/>Param Attended <6 Yrs Old $2,970Polysonogram W 4/>Param Attended 6 & Older $3,529Polysonogram W/4/>Param Attended <2hrs $675Polysonogram W/4/>Param Attended >2hrs <4hrs $1,350Polysonogram W/4/>Param Attended >4hrs <6hrs $2,025Polysonogram W/4/>Param W PAP <2hrs $825Polysonogram W/4/>Param W PAP >2hrs <4hrs $1,650Polysonogram W/4/>Param W PAP >4hrs <6hrs $2,475Sleep Study Unattended $572

DIALYSISBedside Dialysis $2,149CRRT Set Up $1,029Dialysis Treatment $1,687IP Dialysis Part B Only $1,687

70 of 317 FY2018

DESCRIPTION CHARGES

OP Hemodialysis ESRD $1,161OP Hemodialysis Non-ESRD $1,161Z Maintenance Dialysis (Composit) $1,161

BLOOD PRODUCTSAph ARBC ACDA AS1 $463Aph ARBC ACDA AS1 2 $463Aph ARBC ACDA AS1 LR $562Aph ARBC ACDA AS1 LR 2 $562Aph ARBC ACDA AS3 1 $463Aph ARBC ACDA AS3 2 $463Aph ARBC ACDA AS3 LR 1 $562Aph ARBC ACDA AS3 LR 2 $562Aph ARBC CP2D AS3 1 $463Aph ARBC CP2D AS3 2 $463Aph ARBC CP2D AS3 LR 1 $562Aph ARBC CP2D AS3 LR 2 $562Aph DPlt ACDA LR $1,445Aph DPlt ACDA LR <3log 11 1 $1,445Aph DPlt ACDA LR <3log 11 1 Dv $1,445Aph DPlt ACDA LR <3log 11 2 $1,445Aph DPlt ACDA LR <3log 11 2 Dv $1,445Aph DPlt ACDA LR <3log 11 3 $1,445APH DPlt ACDA LR <3log 11 3 Dv $1,445Aph DPlt ACDA LR 1 $1,445Aph DPlt ACDA LR 1 Dv $1,445Aph DPlt ACDA LR 2 $1,445Aph DPlt ACDA LR 2 Dv $1,445Aph DPlt ACDA LR 3 $1,445Aph DPlt ACDA LR 3 Dv $1,445Aph DPlt ACDA LR Irr $1,518Aph DPlt ACDA LR Irr <3log 11 1 $1,518Aph DPlt ACDA LR Irr <3log 11 1 Dv $1,518Aph DPlt ACDA LR Irr <3log 11 1 Dv Open $1,518Aph DPlt ACDA LR Irr <3log 11 2 $1,518Aph DPlt ACDA LR Irr <3log 11 2 Div $1,518Aph DPlt ACDA LR Irr <3log 11 2 Dv Open $1,518

71 of 317 FY2018

DESCRIPTION CHARGES

Aph DPlt ACDA LR Irr <3log 11 3 $1,518Aph DPlt ACDA LR Irr <3log 11 3 Dv $1,518Aph DPlt ACDA LR Irr <3log 11 3 Dv Open $1,518Aph DPlt ACDA LR Irr <3log 11 Dv $1,518Aph DPlt ACDA LR Irr <3log 11 Dv Open $1,518Aph DPlt ACDA LR Irr 1 $1,518Aph DPlt ACDA LR Irr 1 Dv $1,518Aph DPlt ACDA LR Irr 1 Dv Open $1,518Aph DPlt ACDA LR Irr 2 $1,518Aph DPlt ACDA LR Irr 2 Dv $1,518Aph DPlt ACDA LR Irr 2 Dv Open $1,518Aph DPlt ACDA LR Irr 3 $1,518Aph DPlt ACDA LR Irr 3 Dv $1,518Aph DPlt ACDA LR Irr 3 Dv Open $1,518Aph DPlt ACDA LR Irr Dv $1,518Aph DPlt ACDA LR Irr Dv Open $1,518Aph DPlt ACDB LR $1,445Aph DPlt ACDB LR 1 $1,445Aph DPlt ACDB LR 1 Dv $1,445Aph DPlt ACDB LR 2 $1,445Aph DPlt ACDB LR 2 Dv $1,445Aph DPlt ACDB LR 3 $1,445Aph DPlt ACDB LR 3 Dv $1,445Aph DPlt ACDB LR Dv $1,445Aph DPlt ACDB LR Irr $1,518Aph DPlt ACDB LR Irr 1 $1,518Aph DPlt ACDB LR Irr 1 Dv $1,518Aph DPlt ACDB LR Irr 1 Dv Open $1,518Aph DPlt ACDB LR Irr 2 $1,518Aph DPlt ACDB LR Irr 2 Dv $1,518Aph DPlt ACDB LR Irr 2 Dv Open $1,518Aph DPlt ACDB LR Irr 3 $1,518Aph DPlt ACDB LR Irr 3 Dv $1,518Aph DPlt ACDB LR Irr 3 Dv Open $1,518Aph DPlt ACDB LR Irr Dv $1,518Aph DPlt ACDB LR Irr Dv Open $1,518Aph DRBC ACDA AS1 $463

72 of 317 FY2018

DESCRIPTION CHARGES

Aph DRBC ACDA AS1 1 $463Aph DRBC ACDA AS1 1 Dv $463Aph DRBC ACDA AS1 1 Dv Open $463Aph DRBC ACDA AS1 2 $463Aph DRBC ACDA AS1 2 Dv $463Aph DRBC ACDA AS1 2 Dv Open $463Aph DRBC ACDA AS1 Dv $463Aph DRBC ACDA AS1 Irr $417Aph DRBC ACDA AS1 Irr 1 $417Aph DRBC ACDA AS1 Irr 1 Dv $417Aph DRBC ACDA AS1 Irr 1 Dv Open $417Aph DRBC ACDA AS1 Irr 2 $417Aph DRBC ACDA AS1 Irr 2 Dv $417Aph DRBC ACDA AS1 Irr 2 Dv Open $417Aph DRBC ACDA AS1 Irr Div $417Aph DRBC ACDA AS1 Irr Dv Open $417Aph DRBC ACDA AS1 LR $562Aph DRBC ACDA AS1 LR 1 $562Aph DRBC ACDA AS1 LR 1 Dv $562Aph DRBC ACDA AS1 LR 1 Dv Open $562Aph DRBC ACDA AS1 LR 2 $562Aph DRBC ACDA AS1 LR 2 Dv $562Aph DRBC ACDA AS1 LR 2 Dv Open $562Aph DRBC ACDA AS1 LR Dv $562Aph DRBC ACDA AS1 LR Dv Open $562Aph DRBC ACDA AS1 LR Irr $1,348Aph DRBC ACDA AS1 LR Irr 1 $1,348Aph DRBC ACDA AS1 LR Irr 1 Dv $1,348Aph DRBC ACDA AS1 LR Irr 1 Dv Open $1,348Aph DRBC ACDA AS1 LR Irr 2 $1,348Aph DRBC ACDA AS1 LR Irr 2 Dv $1,348Aph DRBC ACDA AS1 LR Irr 2 Dv Open $1,348Aph DRBC ACDA AS1 LR Irr Dv $1,348Aph DRBC ACDA AS1 LR Irr Dv Open $1,348Aph DRBC ACDA AS3 $463Aph DRBC ACDA AS3 1 $463Aph DRBC ACDA AS3 1 Dv $463

73 of 317 FY2018

DESCRIPTION CHARGES

Aph DRBC ACDA AS3 1 Dv Open $463Aph DRBC ACDA AS3 2 $463Aph DRBC ACDA AS3 2 Dv $463Aph DRBC ACDA AS3 2 Dv Open $463Aph DRBC ACDA AS3 Dv $463Aph DRBC ACDA AS3 Dv Open $463Aph DRBC ACDA AS3 Irr $417Aph DRBC ACDA AS3 Irr 1 $417Aph DRBC ACDA AS3 Irr 1 Dv $417Aph DRBC ACDA AS3 Irr 1 Dv Open $417Aph DRBC ACDA AS3 Irr 2 $417Aph DRBC ACDA AS3 Irr 2 Dv $417Aph DRBC ACDA AS3 Irr 2 Dv Open $417Aph DRBC ACDA AS3 Irr Dv $417Aph DRBC ACDA AS3 Irr Dv Open $417Aph DRBC ACDA AS3 LR $562Aph DRBC ACDA AS3 LR 1 $562Aph DRBC ACDA AS3 LR 1 Dv $562Aph DRBC ACDA AS3 LR 1 Dv Open $562Aph DRBC ACDA AS3 LR 2 $562Aph DRBC ACDA AS3 LR 2 Dv $562Aph DRBC ACDA AS3 LR 2 Dv Open $562Aph DRBC ACDA AS3 LR Dv $562Aph DRBC ACDA AS3 LR Dv Open $562Aph DRBC ACDA AS3 LR Irr $1,348Aph DRBC ACDA AS3 LR Irr 1 $1,348Aph DRBC ACDA AS3 LR Irr 1 Dv $1,348Aph DRBC ACDA AS3 LR Irr 1 Dv Open $1,348Aph DRBC ACDA AS3 LR Irr 2 $1,348Aph DRBC ACDA AS3 LR Irr 2 Dv $1,348Aph DRBC ACDA AS3 LR Irr 2 Dv Open $1,348Aph DRBC ACDA AS3 LR Irr Dv $1,348Aph DRBC ACDA AS3 LR Irr Dv Open $1,348Aph DRBC CP2D AS3 $463Aph DRBC CP2D AS3 1 $463Aph DRBC CP2D AS3 2 $463Aph DRBC CP2D AS3 Irr $417

74 of 317 FY2018

DESCRIPTION CHARGES

Aph DRBC CP2D AS3 Irr 1 $417Aph DRBC CP2D AS3 Irr 2 $417Aph DRBC CP2D AS3 LR $562Aph DRBC CP2D AS3 LR 1 $562Aph DRBC CP2D AS3 LR 2 $562Aph DRBC CP2D AS3 LR Irr $1,348Aph DRBC CP2D AS3 LR Irr 1 $1,348Aph DRBC CP2D AS3 LR Irr 2 $1,348Aph FFP Thawed $220Aph FFP Thawed 1 $220Aph FFP Thawed 1 Dv $220Aph FFP Thawed 1 Dv Open $220Aph FFP Thawed 2 $220Aph FFP Thawed 2 Dv $220Aph FFP Thawed 2 Dv Open $220Aph FFP Thawed 3 $220Aph FFP Thawed 3 Dv $220Aph FFP Thawed 3 Dv Open $220Aph FFP Thawed 4 $220Aph FFP Thawed 4 Dv $220Aph FFP Thawed 4 Dv Open $220Aph FFP Thawed 5 $220Aph FFP Thawed 5 Dv $220Aph FFP Thawed 5 Dv Open $220Aph FFP Thawed ACDA $220Aph FFP Thawed ACDA Dv $220Aph FFP Thawed ACDA Dv Open $220Aph FFP Thawed CP2D $220Aph FFP Thawed CP2D Dv $220Aph FFP Thawed CP2D Dv Open $220Aph FFP Thawed Dv $220Aph FFP Thawed Dv Open $220Aph FFP Thawed NaCitrate $220Aph FFP Thawed NaCitrate Dv $220Aph FFP Thawed NaCitrate Dv Open $220Aph Plasma Thawed ACDA $220Aph Plasma Thawed ACDA (24 Hr) $220

75 of 317 FY2018

DESCRIPTION CHARGES

Aph Plasma Thawed ACDA (24 Hr) 1 $220Aph Plasma Thawed ACDA (24 Hr) 2 $220Aph Plasma Thawed ACDA (24 Hr) 3 $220Aph Plasma Thawed ACDA (24 Hr) Dv $220Aph Plasma Thawed ACDA Dv $220Aph Plasma Thawed ACDA Dv Open $220Aph Plasma Thawed ACDB $220Aph Plasma Thawed ACDB Dv $220Aph Plasma Thawed ACDB Dv Open $220Aph Plasma Thawed NaCitrate $220Aph Plasma Thawed NaCitrate Dv $220Aph Plasma thawed NaCitrate Dv Open $220Aph Plt ACDA LR $1,445Aph Plt ACDA LR <3log 11 $1,445Aph Plt ACDA LR <3log 11 1 $1,445Aph Plt ACDA LR <3log 11 1 Dv $1,445Aph Plt ACDA LR <3log 11 2 $1,445Aph Plt ACDA LR <3log 11 2 Dv $1,445Aph Plt ACDA LR <3log 11 3 $1,445Aph Plt ACDA LR <3log 11 3 Dv $1,445Aph Plt ACDA LR <3log 11 Dv $1,445Aph Plt ACDA LR 1 $1,445Aph Plt ACDA LR 1 Dv $1,445Aph Plt ACDA LR 2 $1,445Aph Plt ACDA LR 2 Dv $1,445Aph Plt ACDA LR 3 $1,445Aph Plt ACDA LR 3 Dv $1,445Aph Plt ACDA LR Dv $1,445Aph Plt ACDA LR Irr $1,518Aph Plt ACDA LR Irr <3 log 11 $1,518Aph Plt ACDA LR Irr <3 log 11 1 Dv Open $1,518Aph Plt ACDA LR Irr <3 log 11 2 Dv $1,518Aph Plt ACDA LR Irr <3 log 11 2 Dv Open $1,518Aph Plt ACDA LR Irr <3log 11 1 $1,518Aph Plt ACDA LR Irr <3log 11 1 Dv $1,518Aph Plt ACDA LR Irr <3log 11 2 $1,518Aph Plt ACDA LR Irr <3log 11 3 $1,518

76 of 317 FY2018

DESCRIPTION CHARGES

Aph Plt ACDA LR Irr <3log 11 3 Dv $1,518Aph Plt ACDA LR Irr <3log 11 3 Dv Open $1,518Aph Plt ACDA LR Irr <3log 11 Dv $1,518Aph Plt ACDA LR Irr <3log 11 Dv Open $1,518Aph Plt ACDA LR Irr 1 $1,518Aph Plt ACDA LR Irr 1 Dv $1,518Aph Plt ACDA LR Irr 1 Dv Open $1,518Aph Plt ACDA LR Irr 2 $1,518Aph Plt ACDA LR Irr 2 Dv $1,518Aph Plt ACDA LR Irr 2 Dv Open $1,518Aph Plt ACDA LR Irr 3 $1,518Aph Plt ACDA LR Irr 3 Dv $1,518Aph Plt ACDA LR Irr 3 Dv Open $1,518Aph Plt ACDA LR Irr Dv $1,518Aph Plt ACDA LR Irr Dv Open $1,518Aph Plt ACDA PASC LR $1,445Aph Plt ACDA PASC LR <3log 11 $1,445Aph Plt ACDA PASC LR <3log 11 Dv $1,445Aph Plt ACDA PASC LR 1 $1,445Aph Plt ACDA PASC LR 1 Dv $1,445Aph Plt ACDA PASC LR 2 $1,445Aph Plt ACDA PASC LR 2 Dv $1,445Aph Plt ACDA PASC LR 3 $1,445Aph Plt ACDA PASC LR 3 Dv $1,445Aph Plt ACDA PASC LR Dv $1,445Aph Plt ACDA PASC LR Irr $1,518Aph Plt ACDA PASC LR Irr <3log 11 $1,518Aph Plt ACDA PASC LR Irr <3log 11 Dv $1,518Aph Plt ACDA PASC LR Irr 1 $1,518Aph Plt ACDA PASC LR Irr 1 Dv $1,518Aph Plt ACDA PASC LR Irr 2 $1,518Aph Plt ACDA PASC LR Irr 2 Dv $1,518Aph Plt ACDA PASC LR Irr 3 $1,518Aph Plt ACDA PASC LR Irr 3 Dv $1,518Aph Plt ACDA PASC LR Irr Dv $1,518Aph Plt ACDB LR $1,445Aph Plt ACDB LR 1 $1,445

77 of 317 FY2018

DESCRIPTION CHARGES

Aph Plt ACDB LR 1 Dv $1,445Aph Plt ACDB LR 2 $1,445Aph Plt ACDB LR 2 Dv $1,445Aph Plt ACDB LR 3 $1,445Aph Plt ACDB LR 3 Dv $1,445Aph Plt ACDB LR Dv $1,445Aph Plt ACDB LR Irr $1,518Aph Plt ACDB LR Irr 1 $1,518Aph Plt ACDB LR Irr 1 Dv $1,518Aph Plt ACDB LR Irr 1 Dv Open $1,518Aph Plt ACDB LR Irr 2 $1,518Aph Plt ACDB LR Irr 2 Dv $1,518Aph Plt ACDB LR Irr 2 Dv Open $1,518Aph Plt ACDB LR Irr 3 $1,518Aph Plt ACDB LR Irr 3 Dv $1,518Aph Plt ACDB LR Irr 3 Dv Open $1,518Aph Plt ACDB LR Irr Dv $1,518Aph Plt ACDB LR Irr Dv Open $1,518Aph RBC ACDA AS1 $463Aph RBC ACDA AS1 1 $463Aph RBC ACDA AS1 1 Dv $463Aph RBC ACDA AS1 1 Dv Open $463Aph RBC ACDA AS1 2 $463Aph RBC ACDA AS1 2 Dv $463Aph RBC ACDA AS1 2 Dv Open $463Aph RBC ACDA AS1 DV $463Aph RBC ACDA AS1 Irr $417Aph RBC ACDA AS1 Irr 1 $417Aph RBC ACDA AS1 Irr 1 Dv $417Aph RBC ACDA AS1 Irr 1 Dv Open $417Aph RBC ACDA AS1 Irr 2 $417Aph RBC ACDA AS1 Irr 2 Dv $417Aph RBC ACDA AS1 Irr 2 Dv Open $417Aph RBC ACDA AS1 Irr Dv $417Aph RBC ACDA AS1 LR $562Aph RBC ACDA AS1 LR 1 $562Aph RBC ACDA AS1 LR 1 Dv $562

78 of 317 FY2018

DESCRIPTION CHARGES

Aph RBC ACDA AS1 LR 1 Dv Open $562Aph RBC ACDA AS1 LR 2 $562Aph RBC ACDA AS1 LR 2 Dv $562Aph RBC ACDA AS1 LR 2 Dv Open $562Aph RBC ACDA AS1 LR Dv $562Aph RBC ACDA AS1 LR Dv Open $562Aph RBC ACDA AS1 LR Irr $1,348Aph RBC ACDA AS1 LR Irr 1 $1,348Aph RBC ACDA AS1 LR Irr 1 Dv $1,348Aph RBC ACDA AS1 LR Irr 1 Dv Open $1,348Aph RBC ACDA AS1 LR Irr 2 $1,348Aph RBC ACDA AS1 LR Irr 2 Dv $1,348Aph RBC ACDA AS1 LR Irr 2 Dv Open $1,348Aph RBC ACDA AS1 LR Irr Dv $1,348Aph RBC ACDA AS1 LR Irr Dv Open $1,348Aph RBC ACDA AS3 $463Aph RBC ACDA AS3 1 $463Aph RBC ACDA AS3 1 Dv $463Aph RBC ACDA AS3 1 Dv Open $463Aph RBC ACDA AS3 2 $463Aph RBC ACDA AS3 2 Dv $463Aph RBC ACDA AS3 2 Dv Open $463Aph RBC ACDA AS3 Dv $463Aph RBC ACDA AS3 Dv Open $463Aph RBC ACDA AS3 Irr $417Aph RBC ACDA AS3 Irr 1 $417Aph RBC ACDA AS3 Irr 1 Dv $417Aph RBC ACDA AS3 Irr 1 Dv Open $417Aph RBC ACDA AS3 Irr 2 $417Aph RBC ACDA AS3 Irr 2 Dv $417Aph RBC ACDA AS3 Irr 2 Dv Open $417Aph RBC ACDA AS3 Irr Dv $417Aph RBC ACDA AS3 Irr Dv Open $417Aph RBC ACDA AS3 LR $562Aph RBC ACDA AS3 LR 1 $562Aph RBC ACDA AS3 LR 1 Dv $562Aph RBC ACDA AS3 LR 1 Dv Open $562

79 of 317 FY2018

DESCRIPTION CHARGES

Aph RBC ACDA AS3 LR 2 $562Aph RBC ACDA AS3 LR 2 Dv $562Aph RBC ACDA AS3 LR 2 Dv Open $562Aph RBC ACDA AS3 LR Dv $562Aph RBC ACDA AS3 LR Dv Open $562Aph RBC ACDA AS3 LR Irr $1,348Aph RBC ACDA AS3 LR Irr 1 $1,348Aph RBC ACDA AS3 LR Irr 1 Dv $1,348Aph RBC ACDA AS3 LR Irr 1 Dv Open $1,348Aph RBC ACDA AS3 LR Irr 2 $1,348Aph RBC ACDA AS3 LR Irr 2 Dv $1,348Aph RBC ACDA AS3 LR Irr 2 Dv Open $1,348Aph RBC ACDA AS3 LR Irr Dv $1,348Aph RBC ACDA AS3 LR Irr Dv Open $1,348Aph RBC CP2D AS3 $463Aph RBC CP2D AS3 1 $463Aph RBC CP2D AS3 2 $463Aph RBC CP2D AS3 Irr $417Aph RBC CP2D AS3 Irr 1 $417Aph RBC CP2D AS3 Irr 2 $417Aph RBC CP2D AS3 LR $562Aph RBC CP2D AS3 LR 1 $562Aph RBC CP2D AS3 LR 1 Dv $562Aph RBC CP2D AS3 LR 1 Dv Open $562Aph RBC CP2D AS3 LR 2 $562Aph RBC CP2D AS3 LR 2 Dv $562Aph RBC CP2D AS3 LR 2 Dv Open $562Aph RBC CP2D AS3 LR Dv $562Aph RBC CP2D AS3 LR Dv Open $562Aph RBC CP2D AS3 LR Irr $1,348Aph RBC CP2D AS3 LR Irr 1 $1,348Aph RBC CP2D AS3 LR Irr 1 Dv $1,348Aph RBC CP2D AS3 LR Irr 1 Dv Open $1,348Aph RBC CP2D AS3 LR Irr 2 $1,348Aph RBC CP2D AS3 LR Irr 2 Dv $1,348Aph RBC CP2D AS3 LR Irr 2 Dv Open $1,348Aph RBC CP2D AS3 LR Irr Dv $1,348

80 of 317 FY2018

DESCRIPTION CHARGES

Aph RBC CP2D AS3 LR Irr Dv Open $1,348ARBC CP2D 450 $463ARBC CP2D 450 LR $562ARBC CP2D 500 $463ARBC CP2D 500 LR $562ARBC CP2D AS3 450 $463ARBC CP2D AS3 450 LR $562ARBC CP2D AS3 500 $463ARBC CP2D AS3 500 LR $562ARBC CPD 450 LR $562ARBC CPD 500 $463ARBC CPD 500 LR $562ARBC CPD AS1 450 $463ARBC CPD AS1 450 LR $562ARBC CPD AS1 500 $463ARBC CPD AS1 500 LR $562ARBC CPD AS1 LV $463ARBC CPD AS1 LV Acadj $463ARBC CPD AS5 450 $463ARBC CPD AS5 450 LR $562ARBC CPD AS5 500 $463ARBC CPD AS5 500 LR $562ARBC CPD LV $463ARBC CPD LV Acadj $463ARBC CPDA1 450 $463ARBC CPDA1 450 LR $562ARBC CPDA1 500 $463ARBC CPDA1 500 LR $562ARBC CPDA1 LV $463ARBC CPDA1 LV Acadj $463ARBC Deglyc $571ARBC Deglyc LR $571Auto RBC Adsol $463Auto RBC Adsol LR $562Auto RBC CPD $463Auto RBC CPD LR $562Auto RBC CPDA1 $463

81 of 317 FY2018

DESCRIPTION CHARGES

Auto RBC CPDA1 LR $562Blood Transfusion $1,000Cryo Thawed $296Dir RBC Adsol $463Dir RBC Adsol 1 $463Dir RBC Adsol 1 Dv $463Dir RBC Adsol 2 $463Dir RBC Adsol 2 Dv $463Dir RBC Adsol 2 Irr Dv $417Dir RBC Adsol Dv $463Dir RBC Adsol Irr $417Dir RBC Adsol Irr 1 $417Dir RBC Adsol Irr 1 Dv $417Dir RBC Adsol Irr 2 $417Dir RBC Adsol Irr Dv $417Dir RBC Adsol LR $562Dir RBC Adsol LR 1 $562Dir RBC Adsol LR 1 Dv $562Dir RBC Adsol LR 2 $562Dir RBC Adsol LR 2 Dv $562Dir RBC Adsol LR Dv $562Dir RBC Adsol LR Irr $1,348Dir RBC Adsol LR Irr 1 $1,348Dir RBC Adsol LR Irr 1 Dv $1,348Dir RBC Adsol LR Irr 2 $1,348Dir RBC Adsol LR Irr 2 Dv $1,348Dir RBC Adsol LR Irr Dv $1,348Dir RBC CPD $463Dir RBC CPD Irr $417Dir RBC CPD LR $562Dir RBC CPD LR Irr $1,348Dir RBC CPDA1 $463Dir RBC CPDA1 Irr $417Dir RBC CPDA1 LR $562Dir RBC CPDA1 LR Irr $1,348Dir RBC LR Irr Washed $1,142Dir RBC LR Irr Washed Dv $1,142

82 of 317 FY2018

DESCRIPTION CHARGES

Dir RBC LR Washed $1,142DRBC CP2D 450 $463DRBC CP2D 450 Irr $417DRBC CP2D 450 LR $562DRBC CP2D 450 LR Irr $1,348DRBC CP2D 500 $463DRBC CP2D 500 Irr $417DRBC CP2D 500 LR $562DRBC CP2D 500 LR Irr $1,348DRBC CP2D AS3 450 $463DRBC CP2D AS3 450 Dv $463DRBC CP2D AS3 450 Dv Open $463DRBC CP2D AS3 450 Irr $417DRBC CP2D AS3 450 Irr Dv $417DRBC CP2D AS3 450 Irr Dv Open $417DRBC CP2D AS3 450 LR $562DRBC CP2D AS3 450 LR Dv $562DRBC CP2D AS3 450 LR Dv Open $562DRBC CP2D AS3 450 LR Irr $1,348DRBC CP2D AS3 450 LR Irr Dv $1,348DRBC CP2D AS3 450 LR Irr Dv Open $1,348DRBC CP2D AS3 500 $463DRBC CP2D AS3 500 Dv $463DRBC CP2D AS3 500 Dv Open $463DRBC CP2D AS3 500 Irr $417DRBC CP2D AS3 500 Irr Dv $417DRBC CP2D AS3 500 Irr Dv Open $417DRBC CP2D AS3 500 LR $562DRBC CP2D AS3 500 LR Dv $562DRBC CP2D AS3 500 LR Dv Open $562DRBC CP2D AS3 500 LR Irr $1,348DRBC CP2D AS3 500 LR Irr Dv $1,348DRBC CP2D AS3 500 LR Irr Dv Open $1,348DRBC CPD 450 $463DRBC CPD 450 Irradiated $417DRBC CPD 450 LR $562DRBC CPD 450 LR Irr $1,348

83 of 317 FY2018

DESCRIPTION CHARGES

DRBC CPD 500 $463DRBC CPD 500 Irradiated $417DRBC CPD 500 LR $562DRBC CPD 500 LR Irr $1,348DRBC CPD AS1 450 $463DRBC CPD AS1 450 Dv $463DRBC CPD AS1 450 Dv Open $463DRBC CPD AS1 450 Irr $417DRBC CPD AS1 450 Irr Dv $417DRBC CPD AS1 450 Irr Dv Open $417DRBC CPD AS1 450 LR $562DRBC CPD AS1 450 LR Dv $562DRBC CPD AS1 450 LR Dv Open $562DRBC CPD AS1 450 LR Irr $1,348DRBC CPD AS1 450 LR Irr Dv $1,348DRBC CPD AS1 450 LR Irr Dv Open $1,348DRBC CPD AS1 500 $463DRBC CPD AS1 500 Dv $463DRBC CPD AS1 500 Dv Open $463DRBC CPD AS1 500 Irr $417DRBC CPD AS1 500 Irr Dv $417DRBC CPD AS1 500 Irr Dv Open $417DRBC CPD AS1 500 LR $562DRBC CPD AS1 500 LR Dv $562DRBC CPD AS1 500 LR Dv Open $562DRBC CPD AS1 500 LR Irr $1,348DRBC CPD AS1 500 LR Irr Dv $1,348DRBC CPD AS1 500 LR Irr Dv Open $1,348DRBC CPD AS1 Irr LV $417DRBC CPD AS1 Irr LV Acadj $417DRBC CPD AS1 LV $463DRBC CPD AS1 LV Acadj $463DRBC CPD AS5 450 $463DRBC CPD AS5 450 Dv $463DRBC CPD AS5 450 Dv Open $463DRBC CPD AS5 450 Irr $417DRBC CPD AS5 450 Irr Dv $417

84 of 317 FY2018

DESCRIPTION CHARGES

DRBC CPD AS5 450 Irr Dv Open $417DRBC CPD AS5 450 LR $562DRBC CPD AS5 450 LR Dv $562DRBC CPD AS5 450 LR Dv Open $562DRBC CPD AS5 450 LR Irr $1,348DRBC CPD AS5 450 LR Irr Dv $1,348DRBC CPD AS5 450 LR Irr Dv Open $1,348DRBC CPD AS5 500 $463DRBC CPD AS5 500 Dv $463DRBC CPD AS5 500 Dv Open $463DRBC CPD AS5 500 Irr $417DRBC CPD AS5 500 Irr Dv $417DRBC CPD AS5 500 Irr Dv Open $417DRBC CPD AS5 500 LR $562DRBC CPD AS5 500 LR Dv $562DRBC CPD AS5 500 LR Dv Open $562DRBC CPD AS5 500 LR Irr $1,348DRBC CPD AS5 500 LR Irr Dv $1,348DRBC CPD AS5 500 LR Irr Dv Open $1,348DRBC CPD Irr LV $417DRBC CPD Irr LV Acadj $417DRBC CPD LV $463DRBC CPD LV Acadj $463DRBC CPDA1 450 $463DRBC CPDA1 450 Irr $417DRBC CPDA1 450 LR $562DRBC CPDA1 450 LR Irr $1,348DRBC CPDA1 500 $463DRBC CPDA1 500 Irr $417DRBC CPDA1 500 LR $562DRBC CPDA1 500 LR Irr $1,348DRBC CPDA1 Irr LV $417DRBC CPDA1 Irr LV Acadj $417DRBC CPDA1 LV $463DRBC CPDA1 LV Acadj $463DRBC Deglyc $571DRBC Deglyc Irr $1,434

85 of 317 FY2018

DESCRIPTION CHARGES

DRBC Deglyc LR $571DRBC Deglyc LR Irr $1,434DRBC Irr Washed $723DRBC LR Irr Washed $723DRBC LR Washed $1,142DRBC Washed $1,142FFP Thawed $264FFP Thawed CP2D $264FFP Thawed CP2D Dv $264FFP Thawed CP2D Dv Open $264FFP Thawed CPD $264FFP Thawed CPD Dv $264FFP Thawed CPD Dv Open $264FFP Thawed CPDA1 $264FFP Thawed CPDA1 Dv $264FFP Thawed CPDA1 Dv Open $264FFP Thawed Cryo Red $264FFP Thawed Dv $264FFP Thawed Dv Open $264HLA Matched $1,930Pediatric $612Plasma Thawed 24 hr $316Plasma Thawed 24 hr Dv $316Plasma Thawed 24 hr Dv Open $316Plasma Thawed CP2D $316Plasma Thawed CP2D Dv $316Plasma Thawed CP2D Dv Open $316Plasma Thawed CPD $316Plasma Thawed CPD Cryo Red $316Plasma Thawed CPD Dv $316Plasma Thawed CPD Dv Open $316Plasma Thawed CPDA 1 Cryo Red $316Plasma Thawed CPDA1 $316Plasma Thawed CPDA1 Dv $316Plasma Thawed CPDA1 Dv Open $316Pooled Cryo AHF $296Pooled Cryoprecipitated AHF Thawed $738

86 of 317 FY2018

DESCRIPTION CHARGES

RBC Adsol $463RBC Adsol 1 $463RBC Adsol 1 Dv $463RBC Adsol 2 $463RBC Adsol 2 Dv $463RBC Adsol Dv $463RBC Adsol Irr $417RBC Adsol Irr 1 $417RBC Adsol Irr 1 Dv $417RBC Adsol Irr 2 $417RBC Adsol Irr 2 Dv $417RBC Adsol Irr Dv $417RBC Adsol LR $562RBC Adsol LR 1 $562RBC Adsol LR 1 Dv $562RBC Adsol LR 2 $562RBC Adsol LR 2 Dv $562RBC Adsol LR Dv $562RBC Adsol LR Irr $1,348RBC Adsol LR Irr 1 $1,348RBC Adsol LR Irr 1 Dv $1,348RBC Adsol LR Irr 2 $1,348RBC Adsol LR Irr 2 Div $1,348RBC Adsol LR Irr Dv $1,348RBC CP2D 450 $463RBC CP2D 450 Irr $417RBC CP2D 450 LR $562RBC CP2D 450 LR Irr $1,348RBC CP2D 500 $463RBC CP2D 500 Irr $417RBC CP2D 500 LR $562RBC CP2D 500 LR Irr $1,348RBC CP2D AS3 450 $463RBC CP2D AS3 450 Dv $463RBC CP2D AS3 450 Dv Open $463RBC CP2D AS3 450 Irr $417RBC CP2D AS3 450 Irr Dv $417

87 of 317 FY2018

DESCRIPTION CHARGES

RBC CP2D AS3 450 Irr Dv Open $417RBC CP2D AS3 450 LR $562RBC CP2D AS3 450 LR Dv $562RBC CP2D AS3 450 LR Dv Open $562RBC CP2D AS3 450 LR Irr $1,348RBC CP2D AS3 450 LR Irr Dv $1,348RBC CP2D AS3 450 LR Irr Dv Open $1,348RBC CP2D AS3 500 $463RBC CP2D AS3 500 Dv $463RBC CP2D AS3 500 Dv Open $463RBC CP2D AS3 500 Irr $417RBC CP2D AS3 500 Irr Dv $417RBC CP2D AS3 500 Irr Dv Open $417RBC CP2D AS3 500 LR $562RBC CP2D AS3 500 LR Dv $562RBC CP2D AS3 500 LR Dv Open $562RBC CP2D AS3 500 LR Irr $1,348RBC CP2D AS3 500 LR Irr Dv $1,348RBC CP2D AS3 500 LR Irr Dv Open $1,348RBC CP2D LR $562RBC CP2D LR Irr $1,348RBC CPD $463RBC CPD 450 $463RBC CPD 450 Irradiated $417RBC CPD 450 LR $562RBC CPD 450 LR Irr $1,348RBC CPD 500 $463RBC CPD 500 Irradiated $417RBC CPD 500 LR $562RBC CPD 500 LR Irr $1,348RBC CPD AS1 450 $463RBC CPD AS1 450 Dv $463RBC CPD AS1 450 Dv Open $463RBC CPD AS1 450 Irr $417RBC CPD AS1 450 Irr Dv $417RBC CPD AS1 450 Irr Dv Open $417RBC CPD AS1 450 LR $562

88 of 317 FY2018

DESCRIPTION CHARGES

RBC CPD AS1 450 LR Dv $562RBC CPD AS1 450 LR Dv Open $562RBC CPD AS1 450 LR Irr $1,348RBC CPD AS1 450 LR Irr Dv $1,348RBC CPD AS1 450 LR Irr Dv Open $1,348RBC CPD AS1 500 $463RBC CPD AS1 500 Dv $562RBC CPD AS1 500 Dv Open $562RBC CPD AS1 500 Irr $417RBC CPD AS1 500 Irr Dv $417RBC CPD AS1 500 Irr Dv Open $417RBC CPD AS1 500 LR $562RBC CPD AS1 500 LR Dv $562RBC CPD AS1 500 LR Dv Open $562RBC CPD AS1 500 LR Irr $1,348RBC CPD AS1 500 LR Irr Dv $1,348RBC CPD AS1 500 LR Irr DV Open $1,348RBC CPD AS1 LV $463RBC CPD AS5 450 $463RBC CPD AS5 450 Dv $463RBC CPD AS5 450 Dv Open $463RBC CPD AS5 450 Irr $417RBC CPD AS5 450 Irr Dv $417RBC CPD AS5 450 Irr Dv Open $417RBC CPD AS5 450 LR $562RBC CPD AS5 450 LR Dv $562RBC CPD AS5 450 LR Dv Open $562RBC CPD AS5 450 LR Irr $1,348RBC CPD AS5 450 LR Irr Dv $1,348RBC CPD AS5 450 LR Irr Dv Open $1,348RBC CPD AS5 500 $463RBC CPD AS5 500 Dv $463RBC CPD AS5 500 Dv Open $463RBC CPD AS5 500 Irr $417RBC CPD AS5 500 Irr Dv $417RBC CPD AS5 500 Irr Dv Open $417RBC CPD AS5 500 LR $562

89 of 317 FY2018

DESCRIPTION CHARGES

RBC CPD AS5 500 LR Dv $562RBC CPD AS5 500 LR Dv Open $562RBC CPD AS5 500 LR Irr $1,348RBC CPD AS5 500 LR Irr Dv $1,348RBC CPD AS5 500 LR Irr Dv Open $1,348RBC CPD Irr $417RBC CPD Irr LV $417RBC CPD LR $562RBC CPD LR Irr $1,348RBC CPD LV $463RBC CPDA1 $463RBC CPDA1 450 $463RBC CPDA1 450 Irr $417RBC CPDA1 450 LR $562RBC CPDA1 450 LR Irr $1,348RBC CPDA1 500 $463RBC CPDA1 500 Irr $417RBC CPDA1 500 LR $562RBC CPDA1 500 LR Irr $1,348RBC CPDA1 Irr $417RBC CPDA1 Irr LV $417RBC CPDA1 LR $562RBC CPDA1 LR Irr $1,348RBC CPDA1 LV $463RBC Deglyc $571RBC Deglyc Irr $1,434RBC Deglyc LR $571RBC Deglyc LR Irr $1,434RBC Irr Washed $723RBC LR Irr Washed $723RBC LR Irr Washed Dv $723RBC LR Washed $1,142RBC LR Washed Dv $1,142RBC Washed $1,142RBCs to Ped RBCs $612

OTHER DIAGNOSTIC SERVICES

90 of 317 FY2018

DESCRIPTION CHARGES

24 Hour Video EEG $1,62395928 Upper Extremity TCMEP SSD $30695929 Lower Extremity TCMEP SSD $30695955 EEG Monitoring SSD $449AAA Medicare Screening US $184Ambulatory EEG Monitoring $2,440Ankle/Arm Screen $410Aorta, IVC, & Iliac Vessel Duplex $938Arterial Duplex Bilateral Arms $1,135Arterial Duplex Bilateral Legs $1,135Arterial Duplex Arm $625Arterial Duplex Leg $625Bilateral Cranial Nerve Monitoring SSD $306Bladder Scan Volume $103Brainstem Audio Evoked Response $807Carotid Bilat Duplex Scan $1,200Carotid Duplex, Bilat, Comp $929Carotid Duplex, Unilat, Lmtd $356Complete 4 Ext SSEP SSD $962Complete 4 Ext TCMEP SSD $190Complex Stim Programming First Hr $341DOC ABD Aorta $184DOC Pacemaker TTM $143Doppler Comp Addl to Site Code $942Doppler Limited Addl to Site Code $133EEG Monitoring Video $2,440Electroencephalogram EEG $1,075EMG Complete Add On $600EMG Limited Add On to NCV $350EMG Limited W/Complete Bilat $350EMG Non Extremity Add On $350Eswl Level W/O Addtl Px 0 30 Min SSD $2,036Eswl Level W/O Addtl Px Ea Add 30 SSD $548Extracorporeal Shock Wave Lithotripsy $8,121Extracorporeal Shock Wave Lithotripsy with Stent $8,121Extremity Venous, Bilat, Comp $784Extremity Venous, Unilat or Lmtd $784

91 of 317 FY2018

DESCRIPTION CHARGES

Funct. Cortical Mapp Ea Add Hr SSD $891Functional Cortical Mapping SSD $1,671Hemodialysis AVF Duplex $867Hyperbaric Tcp02 Focused $257Hyperbaric Tcp02 Mapping $743Insert Sphnenoid Electodes EEG $217IOM Testing Per 15 Minutes SSD $181LE Arterial, Bilat, Complete $381LE Arterial, Unilat or Limited $278Limited Carotid Duplex $613Lower Extrem Arterial Doppler W/ Exercise $669Lower Extrem Arterial Doppler W/O Exercise $625MICRO ELECTRODE RECORDING 1ST HOUR $1,671MICRO ELECTRODE RECORDING EACH ADDITIONAL HOUR $891

Miscellaneous Neurodiagnostic Charges 24 Hour EEG Monitor Tech $1,165Miscellaneous Neurodiagnostic Charges Continuous EEG Monitor With Video $1,623

Miscellaneous Neurodiagnostic Charges Electro Silence (Esc) Tech $884NCV Blink Reflex Left Eye $163NCV Blink Reflex Right Eye $163NCV W/ Fwave Quantity 7 $942NCV W/ Fwave Quantity 8 $1,048NCV W/ Fwave Quantity 9 $1,154NCV W/ Fwave Quantity 10 $1,260NCV W/ Fwave Quantity 11 $1,366NCV W/ Fwave Quantity 12 $1,472NCV W/ Fwave Quantity 13 $1,579NCV W/ Fwave Quantity 14 $1,884NCV W/ Fwave Quantity 15 $1,990NCV W/ Fwave Quantity 16 $2,096NCV W/ Fwave Quantity 17 $2,202NCV W/ Fwave Quantity 18 $2,308NCV W/ Fwave Quantity 19 $2,414NCV W/ Fwave Quantity 20 $2,520NCV W/ Fwave Quantity 21 $2,826

92 of 317 FY2018

DESCRIPTION CHARGES

NCV W/ Fwave Quantity 22 $2,932NCV W/ Fwave Quantity 23 $3,038NCV W/ Fwave Quantity 24 $3,144NCV W/ Fwave Quantity 25 $3,250NCV W/ Fwave Quantity 26 $3,356NCV W/ Fwave Quantity 27 $3,462NCV W/ Fwave Quantity 28 $3,768NCV w/Fwave and H Reflex Quantity 7 $1,048NCV w/Fwave and H Reflex Quantity 8 $1,154NCV w/Fwave and H Reflex Quantity 9 $1,154NCV w/Fwave and H Reflex Quantity 10 $1,260NCV w/Fwave and H Reflex Quantity 11 $1,366NCV w/Fwave and H Reflex Quantity 12 $1,472NCV w/Fwave and H Reflex Quantity 13 $1,579NCV w/Fwave and H Reflex Quantity 14 $2,096NCV w/Fwave and H Reflex Quantity 15 $2,202NCV w/Fwave and H Reflex Quantity 16 $2,308NCV w/Fwave and H Reflex Quantity 17 $2,414NCV w/Fwave and H Reflex Quantity 18 $2,520NCV w/Fwave and H Reflex Quantity 19 $2,627NCV w/Fwave and H Reflex Quantity 20 $2,733NCV w/Fwave and H Reflex Quantity 21 $3,144NCV w/Fwave and H Reflex Quantity 22 $3,250NCV w/Fwave and H Reflex Quantity 23 $3,356NCV w/Fwave and H Reflex Quantity 24 $3,462NCV w/Fwave and H Reflex Quantity 25 $3,568NCV w/Fwave and H Reflex Quantity 26 $3,675NCV w/Fwave and H Reflex Quantity 27 $3,781NCV w/Fwave and H Reflex Quantity 28 $4,192Needle EMG Non Limb Or Sphincter SSD $186Needle EMG w/wo Related Personnel, One extremity $342Needle EMG w/wo Related Personnel, Two Extrem $418Nerve Conduction Study 1 $106Nerve Conduction Study 2 $212Nerve Conduction Study 3 $318Nerve Conduction Study 4 $424Nerve Conduction Study 5 $531

93 of 317 FY2018

DESCRIPTION CHARGES

Nerve Conduction Study 6 $637Nerve Conduction Study 7 $743Nerve Conduction Study 8 $849Nerve Conduction Study 9 $955Nerve Conduction Study 10 $1,061Nerve Conduction Study 11 $1,167Nerve Conduction Study 12 $1,273Nerve Conduction Study 13 $1,379Nerve Conduction Study 14 $1,485Nerve Conduction Study 15 $1,592Nerve Conduction Study 16 $1,698Nerve Conduction Study 17 $1,804Nerve Conduction Study 18 $1,910Nerve Conduction Study 19 $2,016Nerve Conduction Study 20 $2,122Nerve Conduction Study 21 $2,228Nerve Conduction Study 22 $2,334Nerve Conduction Study 24 $2,440Nerve Conduction Study 25 $2,546Nerve Conduction Study 26 $2,653Nerve Conduction Study 26 $2,759Nerve Conduction Study 27 $2,865Nerve Conduction Study 28 $2,971Non Stress Test $262Penile Imaging $385R/O Pseudoaneurysm $625Rapid Desensitization per Hour Nursing $245Repetitive Stimulation Left $219Repetitive Stimulation Right $219Routine EEG $1,075SP ARTERIAL BLOOD WITHDRAW $250SP ARTERIAL PRESSURES MONITOR $152SP Wada Procedure $1,700SSEP Lower Limb $962SSEP Upper and Lower Limb $1,923SSEP Upper Limb $962UE Arterial, Bilat, Complete $381

94 of 317 FY2018

DESCRIPTION CHARGES

UE Arterial, Unilat or Limited $278UEA Bilateral Exam $669Unilateral Cranial Nerve Monitoring SSD $306Unspecified Vascular Study $139US Aorta Ivc Iliac Vas Duplex Ltd $237US DUPLEX PENILE VESSELS $390US DUPLEX SCAN ABD, PEL, SCROTAL ART AND VEIN $942US DUPLEX SCAN LTD ART OR VEIN $385US LIMITED DUPLEX LOWER EXT ART $625VAD Hemodialysis Access Exam $867VASCULAR SCREENING $522Vein Map Bypass Graft Bilat $1,186Vein Map Bypass Graft Uni $700Venous Bilat Extr Duplex $1,186Venous Lower Extremity, $700Venous Upper Extremity, $700Vessel Map Hemodialysis Access $579Video Sleep EEG $1,075Visual Evoked Potential $745Visual Evoked Repsonse (VER) $745

LABOR & DELIVERYAnesthesia Charge OB $201Attendance At Delivery $105Cesarean Section $2,334Circumcision Date $292Delivery Room Resuscitation $879Initial Nursery Assessment $400Labor Home/Transfer Undelivered $1,700Lactation Consult Duration Estab Patient 15 30 minutes $129Lactation Consult Duration Estab Patient 31 90 minutes $232Lactation Consult Duration Estab Patient 91 180 minutes $309Lactation Consultant Duration New Patient 15 30 minutes $155Lactation Consultant Duration New Patient 31 90 minutes $242Lactation Consultant Duration New Patient 91 180 minutes $407Lig/Trans Fallo W/C Delivery $310

95 of 317 FY2018

DESCRIPTION CHARGES

OB Recovery $300OB Recovery Care Ea Addtl Hour $105OB RR Critical Care Over 5hrs/Ea $71OB Surgical Recovery $361Tubal Post Partum $1,124Vaginal Delivery $1,486Vaginal Delivery IUFD <20 weeks $1,454Vaginal Delivery IUFD >20 weeks $1,454

PREVENTIVE CAREImm/Vacc Admin Each Addl $55Optimental/Can $16Rabies Vaccine Outpatient Only $75Vaccination Admin $60Vaccine Admin Hepatitis B $60Vaccine Admin Influenza $60Vaccine Admin Pneumococcal $60

REHABILITATION MEDICINEAttended EStim Units $106Brain Spine Attended E Stim Units $75Brain Spine Eval Level of Complexity I $214Brain Spine Eval Level of Complexity II $266Brain Spine Eval Level of Complexity III $295Brain Spine Exercise Units $115Brain Spine Functl Activity Units $168Brain Spine Gait Training Units $105Brain Spine Hot Cold Pack Units $33Brain Spine Iontophoresis Units $100Brain Spine Manual Therapy Units $95Brain Spine Mechanical Traction Units $122Brain Spine Muscle Testing Units $86Brain Spine Neuromusc Re Ed Units $90Brain Spine Orthotic Mgmt_Train Units $86Brain Spine Range of Motion Units $60Brain Spine SelfCare/Home Mgmt Units $103Brain Spine Ultrasound Units $75

96 of 317 FY2018

DESCRIPTION CHARGES

Brain Spine Unattended Stim Units $42Brain Spine Unlisted Modality $87Brain Spine Unlstd Therapeutic Px $87Canalith Repositioning Units $109Cardiac Rehab Evaluation $274Client No Show IPCS Visit Type (PTA) $45Gait/Mobility Training Units $105I OT Evaluation $255I OT ReEvaluation Level of Complexity $167I PT Evaluation $214I PT Reevaluation $133I Speech Aphasia Eval $75I Speech Cognitive Eval $85I Speech Fluency Eval $243I Speech Sound Eval $197I Speech Voice Eval $206I Speech/Language/Voice/Auditory Units $250I Swallow Evaluation Units $239I Swallow Treatment Units $212I Vestibular Evaluation Units $214I Video Swallow Evaluation Units (FEES) $359I Video Swallow Evaluation Units (MBS) $345II OT Evaluation $265II PT Evaluation $266II Speech Aphasia Eval $100II Speech Cognitive Eval $113II Speech Fluency Eval $286II Speech Sound Eval $232II Speech Voice Eval $242II Speech/Language/Voice/Auditory Units $260II ST Pediatric Treatment Units $246II Swallow Evaluation Units $292II Swallow Treatment Units $265II Vestibular Evaluation Units $266II Video Swallow Evaluation Units (FEES) $432II Video Swallow Evaluation Units (MBS) $418III OT Evaluation $281

97 of 317 FY2018

DESCRIPTION CHARGES

III PT Evaluation $295III Speech Aphasia Eval $125III Speech Cognitive Eval $141III Speech Fluency Eval $328III Speech Sound Eval $267III Speech Voice Eval $278III Speech/Language/Voice/Auditory Units $271III ST Pediatric Treatment Units $271III Swallow Evaluation Units $345III Swallow Treatment Units $292III Vestibular Evaluation Units $295III Video Swallow Evaluation Units (FEES) $485III Video Swallow Evaluation Units (MBS) $458Intensive Behavior Therapy Follow-Up $100Intensive Behavior Therapy Initial $100Intensive Behavior Therapy Visit $100IV Speech Aphasia Eval $150IV Speech Cognitive Eval $169IV Speech Fluency Eval $371IV Speech Sound Eval $302IV Speech Voice Eval $278IV Speech/Language/Voice/Auditory Units $295IV ST Pediatric Treatment Units $295IV Swallow Evaluation Units $398IV Swallow Treatment Units $319IV Video Swallow Evaluation Units (FEES) $525IV Video Swallow Evaluation Units (MBS) $498Massage Therapy - 15 minute session $18Massage Therapy - 30 Minute Session $35Massage Therapy - 60 Minute Session $70Mechanical Traction Units $121Monitored Exercise Intensive Cardiac Rehab $274Monitored Exercise Traditional Cardiac Rehab $274Neuromuscular Reeducation Units $101No show for Return To Work IPCS Visit Type (PTA) $100NonMonitored Exercise Intensive Cardiac Rehab $274NonMonitored Exercise Traditional Cardiac Rehab $274

98 of 317 FY2018

DESCRIPTION CHARGES

Orthotic Training Units $53OT ADL Training Units $103OT Attended EStim Units $106OT Fluidotherapy Units $90OT Functional Activities Units $138OT Hot, Cold Pack Units II $33OT Initial Orthotic Fitting Units $99OT Iontophoresis Units $127OT Manual Therapy Units $101OT Neuromuscular Reeducation Units. $101OT Orthotic Checkout Units $53OT Orthotic Fitting Units $99OT Paraffin Bath Units II $71OT Physical Performance Test $97OT Prosthetic Training Units $88OT Reevaluation Charge $167OT Self Care, Home Management Units $103OT Taping Hand/Fingers Units $159OT Taping Shoulder Units $159OT Therapeutic Activities Units $143OT Therapeutic Exercise Units $143OT Ultrasound Units $106OT Unattended EStim KX Units $66OT Unattended EStim Units II $66OT Vasopneumatic Devices Units II $71OT Wound Care/Debridement < 20 cm $250OT Wound Care/Debridement > 20 cm $301Phase II Medical Intervention Cardiac Rehab Miscellaneous $267PreEmployment Eval IPCS Visit Type (PTA) $60Prosthetic Training Units $53PT Aquatic with Exercise Units $104PT Biofdbk, Peri, Urethral, Rectal Units $111PT Exercise Passive Knee $212PT Initial Orthotic Fitting Units $99PT Orthotic/Prosth Follow Up Units $93PT Paraffin Units $71PT Physical Performance Test $120

99 of 317 FY2018

DESCRIPTION CHARGES

PT Prosthetic Training Units $88PT Taping Ankle Unit $159PT Taping Hip Unit $159PT Taping Knee Unit $159PT Taping Low Back Unit $159PT Taping Shoulder Unit $159PT Taping Toes Unit $159PT Unattended EStim KX Units $66PT Unattended EStim Units $66PT Vasopneumatic Devices Units $71PT Whirlpool, Fluidotherapy Units $90PT Wound Care/Debridement < 20 cm $250PT Wound Care/Debridement > 20 cm $301Return to Work Eval IPCS Visit Type (PTA) $100TENS Initial Application $90Therapeutic Exercise Units $156Ultrasound Units $106Unattended Electrical Therapy Units $66Wheelchair Management Units $77

PHARMACY1 mCi TL201 $9210 mCi GA 67 $40010mCi XE 133 $106200 uCi I 123 $1953 mCi TL 201 $2765 MCI I 123 Ioflupane (DaTscan) $3,2635% Dextrose/Water 250 Ml $72abatacept 250 mg Inj $200abciximab 10 mg/5mL Inj $260Abilify Maintena 1mg $24Abraxane 1mg $53acetaminophen 120 mg Supp $1Acetaminophen 325 Mg PO $5acetaminophen 40 mg/1.25 mL Oral Susp $57Acetaminophen 500mg PO $5

100 of 317 FY2018

DESCRIPTION CHARGES

acetaminophen 650 mg Supp $68acetaminophen 80 mg Chew Tab $39acetaZOLAMIDE 250 mg Tab $21acetaZOLAMIDE 500 mg ER Cap $4acetaZOLAMIDE 500 mg Inj $4acetic acid Otic 2% Sol $9acet-oxyCODONE 325 mg-10 mg Tab $2acet-oxyCODONE 325 mg-5 mg Tab $11acetylcholine ophthalmic 1% $12acetylcysteine 10% Sol 30 mL $11acetylcysteine 20% Sol 30 mL $2acetylcysteine 20% Sol 4 mL $2acetylcysteine 6000 mg/30 mL Inj $10Actemra 1mg $15Acthib .5mL $258acyclovir 200 mg Cap $6acyclovir 5% Oint $6acyclovir 500 mg/10 mL Inj $2adenosine 6 mg/2 mL Inj $6adenosine 60 mg/20 mL Inj $2adenosine 90 mg/30 mL Inj $12Ado-Trastuzumab Emtansine 1 Mg $135Adriamycin 10mg $64afibercept Ophth 2 mg/0.05 mL Inj $3Al/Mg/sim 400mg-400mg-40mg/5mL Oral Susp $12Albumin 50mL $420albumin human 12.5 gm/250 mL Inj $6albumin human 12.5 gm/50 mL Inj $2albumin human 25 gm/100 mL Inj $4albumin human 25 gm/500 mL Inj $17albuterol 0.083% Inh Sol UD $6albuterol 2 mg/5 mL Oral Liq $2albuterol 2.5 mg/0.5 mL (0.5%) for Continuous Neb $2albuterol Inhaler $26albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol UD $27albuterol-ipratropium 20/100 mcg Respimat Inhaler $30alcohol 95% 30 mL Inj $33

101 of 317 FY2018

DESCRIPTION CHARGES

aldesleukin 22,000,000 Units Inj $42alendronate 70 mg Tab $16alginic acid/Al hydroxide/Mg trisilicate (Gaviscon) Chew Tab $30Alimta 10mg $267aliskiren 150 mg Tab $31allopurinol 100 mg Tab $34allopurinol 300 mg Tab $43Aloxi 25mcg $218ALPRAZolam 0.25 mg Tab $30ALPRAZolam 0.5 mg Tab $31alprostadil 0.5 mg/1 mL Inj $35alteplase 1 mg/mL $44alteplase 100 mg/100 mL Inj $4Alteplase 1mg $1,100alteplase 2 mg Inj $3aluminum sulfate-calcium acetate Top Pwdr $5amantadine 100 mg Cap $87amifostine 500 mg Inj $22Amikacin 100mg $14amikacin 250 mg/1 mL Inj $4amikacin 400 mcg/0.1 mL Intravitreal Inj $6aMILoride 5 mg Tab $11Amino Acids 10% (Premasol) 500 mL $1aminocaproic acid 500 mg Tab $12aminocaproic acid 5000 mg/20 mL Inj $9aminophylline 250 mg/10 mL Inj $6aminophylline 500 mg/20 mL Inj $6amiodarone 150 mg/3 mL Inj $11amitriptyline 10 mg Tab $11amLODIPine 10 mg Tab $1amLODIPine 5 mg Tab $3Ammonia Aromatic Inhalation $1ammonium lactate 12% Lotion $11amoxicillin 250 mg Cap $2amoxicillin 400 mg/5 mL Oral Susp $2amoxicillin-clav 200 mg-28.5 mg/5 mL Oral Susp $12amoxicillin-clav 400 mg-57 mg/5 mL Oral Susp $6

102 of 317 FY2018

DESCRIPTION CHARGES

amoxicillin-clavulanate 500 mg-125 mg Tab $6amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Susp $9amoxicillin-clavulanate 875 mg-125 mg Tab $6amphotericin B 50 mg Inj $6amphotericin B liposomal (Ambisome) 50 mg Inj $6ampicillin 1 gm Inj $6ampicillin 2 gm Inj $6ampicillin 500 mg Cap $6ampicillin 500 mg Inj $4ampicillin-sulbactam 1.5 gm Inj $4ampicillin-sulbactam 3 gm Inj $11amyl nitrite 0.3 mL Inh Sol $2anastrozole 1 mg Tab $6angiotensin II 2.5 mg/mL Inj $6antihemophilic factor recombinant (Recombinate) Vial $6antihemophilic factor-von Willebrand factor $6antithrombin III (Thrombate) 500 unit Inj $412antivenin (Crotalidae) polyvalent Inj $14Anzemet 10mg $37APAP/butal/caffeine 325-50-40 mg Tab $74APAP/Caffeine/isometh 325-20-65 mg Cap $9apixaban 2.5 mg Tab $253apixaban 5 mg Tab $47Appligraf Supply $93apraclonidine Opth 0.5% Sol $26apraclonidine Opth 1% Sol $27aprepitant 125 mg-80 mg Kit $170Aquaphor Ointment $323Aranesp 1mcg $28Aredia 30mg IV $384arformoterol 15 mcg/2 mL Inh Sol UD $267arGATROban 250 mg/2.5 mL Inj $14arGATROban 50 mg/50 mL NS $29arginine 10% 300 mL $11ARIPiprazole 2 mg Tab $984ARIPiprazole 5 mg Tab $14arsenic trioxide 12 mg/6 mL Inj $122

103 of 317 FY2018

DESCRIPTION CHARGES

Arsenic Trioxide 1mg $500ASA/butalbital/caffeine 325 mg-50 mg-40 mg Cap $25ascorbic acid 1000 mg/2 mL Inj $23ascorbic acid 250 mg Tab $168ascorbic acid 500 mg Tab $723Aspercreme with 4% Lidocaine $10Aspirin 1 mg/mL Desensitization Susp $124Aspirin 10 mg/mL Desensitization Susp $109aspirin 300 mg Supp $12aspirin 325 mg EC Tab $2aspirin 600 mg Supp $39aspirin 81 mg Chew tab $144aspirin 81 mg Oral EC Tab $165aspirin-dipyridamole 25 mg-200 mg ER Cap $36aspirin-oxyCODONE 325 mg-5 mg Tab $111atenolol 25 mg Tab $119atenolol 50 mg Tab $65atorvastatin 10 mg Tab $972atorvastatin 20 mg Tab $429atorvastatin 40 mg Tab $34atracurium 10 mg/1 mL (1 mL) Inj $12atracurium 100 mg/10 mL Inj $6Atropine 0.01 Mg $28atropine 0.4 mg/1 mL 20 mL Inj $13atropine 0.4 mg/1 mL 3 mL syringe $44atropine 0.4 mg/1 mL Inj $2atropine 1 mg/1 mL Inj $4atropine 1 mg/10 mL Syringe Inj $3atropine Opth 1% Oint $3atropine Opth 1% Sol $6atropine/hyoscy/PB/scop Oral Syringe 5 mL $3atropine-diphenoxylate 0.025 mg-2.5 mg Tab $3atropine-diphenoxylate 0.025 mg-2.5 mg/5 mL Oral Liq $1Avastin 10mg $296Avitene Microfibrillar Collagen Pad $3azacitidine 100 mg Inj $1azaTHIOprine 50 mg Tab $13

104 of 317 FY2018

DESCRIPTION CHARGES

azelastine Nasal 137 mcg Spray $2azithromycin 200 mg/5 mL Oral Susp $4azithromycin 250 mg Tab $2aztreonam 1gm Inj $3aztreonam 2 gm Inj $3bacitracin 50,000 units Inj $3bacitracin topical Oint UD packets $48bacitracin-polymyxin B Opth Oint $2bacitracin-polymyxin B Topical Oint $2baclofen 0.05 mg/1 mL intrathecal Inj $9baclofen 10 mg Tab $89baclofen 2 mg/1 mL 20 mL intrathecal Inj $2Balanced Salt Sol Opth irrigation 15 mL $1Balanced Salt Sol Opth irrigation 250 mL $1Balanced Salt Sol Opth irrigation 500 mL $1Balanced Salt Sol Plus Opth irrigation 500 mL $9balsam Peru-castor oil topical Oint $2basiliximab 20 mg Inj $2belimumab 120 mg/1.5 mL Inj $4belimumab 400 mg/5 mL Inj $566belladonna-opium 16.2 mg-30 mg Supp $2belladonna-opium 16.2 mg-60 mg Supp $2Benadryl $11bendamustine 100 mg Inj $1Bendeka 1mg $123Benlysta 10mg $186benoxinate-fluorescein ophthalmic 0.4%-0.25% Soln $11benzocaine 20% Spray UD 0.5 mL $8benzocaine topical 20% rectal oint $894benzonatate 100 mg Cap $1benzoyl peroxide Top 5% Gel $1benztropine 1 mg Tab $16benztropine 2 mg/2 mL Inj $141betamethasone 30 mg/5 mL Inj $54betamethasone 6 mg/1 mL Syringe Inj $50Betamethasone Acet&Sod Phosp $65betamethasone dipropionate 0.05% Crm $56

105 of 317 FY2018

DESCRIPTION CHARGES

betamethasone dipropionate 0.05% Lotion $63betamethasone dipropionate 0.05% Oint $70betamethasone valerate 0.1% Crm $157betamethasone-clotrimazole topical 0.05%-1% Cre $36betaxolol Opth 0.5% Solution $23bevacizumab 100 mg/4 mL Inj $4Bexsero .5mL $530bicalutamide 50 mg Tab $127bimatoprost 0.01% Opth Sol $8bisacodyl 10 mg Supp $1bisacodyl 5 mg Oral EC Tab $1bismuth subsalicylate 262 mg Chew Tab $21bismuth subsalicylate 262 mg/15 mL Oral Susp $4bivalirudin 250 mg Inj $7Bleomycin 15 U $148bleomycin 15 units Inj $70Boniva 1mg $737bortezomib for IV Injection $2bortezomib for SQ Injection $2botulinum toxin type A 100 units Inj $2Brentuximab 1mg $557brentuximab vedotin 50 mg/10 mL Inj $9briMONIDINE Opth 0.2% Sol $16brinZOLAmide Opth 1% Susp $166budesonide 0.5 mg/2 mL Inh Susp $3budesonide Nasal Spray $10bumetanide 1 mg Tab $19bumetanide 2.5 mg/10 mL Inj $32bupivacaine (Exparel) 1.3% Liposome PF $1bupivacaine 0.125% in NS 750 mL (OnQ) $21bupivacaine 0.25% 10 mL Inj PF $1bupivacaine 0.25% 10 mL Inj PF Syringe $3bupivacaine 0.25% 30 mL Inj PF $1bupivacaine 0.25% 50 mL Inj $14bupivacaine 0.25%-epi 1:200,000 10 mL Inj PF $15bupivacaine 0.25%-epi 1:200,000 30 mL Inj PF $15bupivacaine 0.25%-epi 1:200,000 50 mL Inj $17

106 of 317 FY2018

DESCRIPTION CHARGES

bupivacaine 0.5% 10 mL Inj PF Syringe $3bupivacaine 0.5% 30 mL Inj PF $15bupivacaine 0.5% 50 mL Inj $12bupivacaine 0.5%-epi 1:200,000 10 mL Inj PF $12bupivacaine 0.5%-epi 1:200,000 30 mL Inj PF $2bupivacaine 0.5%-epi 1:200,000 50 mL Inj $2bupivacaine 0.75% 10 mL Inj PF $8bupivacaine 0.75% 2 mL Inj PF $13bupivacaine 0.75% 30 mL Inj PF $110Bupivacaine/fentaNYL 500 mcg 0.125% Epidural Soln $554buPROPion 100 mg ER Tab $162buPROPion 100 mg Tab $55buPROPion 150 mg ER Tab $69buPROPion 75 mg Tab $41busPIRone 5 mg Tab $4busulfan 2 mg Tab $1,097butorphanol 1 mg/1 mL Inj $6CADD Cassette $2caffeine citrate 20 mg/mL Injection $109caffeine citrate 20 mg/mL Oral Syringe $2calamine 8% Lotion $149calamine-pramoxine 8%-1% Lotion $6calamine-zinc oxide (Unna) dressing $976calamine-zinc oxide Top dressing $56calcitonin 400 units/2 mL Inj $20calcitriol 0.25 mcg Oral Cap $1calcitriol 1 mcg/1 mL Inj $3calcium acetate 667 mg Cap $3calcium carbonate 1250 mg/5 mL Oral Susp $5calcium carbonate 500 mg Chew Tab $3calcium chloride 1000 mg/10 mL Inj $68calcium chloride 1000 mg/10 mL Syringe Inj $9calcium glubionate 1.8 gm/5 mL Oral Liq $1calcium gluconate 1000 mg/10 mL Inj $1Calcium Gluconate 10mL $25calcium oyster shell 500 mg Tab $3calcium-vitamin D 500 mg-200 units Tab $5

107 of 317 FY2018

DESCRIPTION CHARGES

camphor-menthol Top 0.5%-0.5% lotion $9Camptosar 20mg $119candida intradermal Inj $21capsaicin Top 0.025% Crm $1capsaicin Top 0.1% Crm $13captopril 12.5 mg Tab $51carbachol Opth 0.01% Sol $97carBAMazepine 100 mg Chew Tab $10carBAMazepine 100 mg ER Tab $105carBAMazepine 200 mg ER Tab $14carBAMazepine 200 mg Tab $1carbamide peroxide Otic 6.5% Sol $1carbidopa-levodopa 10 mg-100 mg Tab $6carbidopa-levodopa 25 mg-100 mg ER Tab $12carbidopa-levodopa 25 mg-100 mg Tab $7carbidopa-levodopa 25 mg-250 mg Tab $18carbidopa-levodopa 50 mg-200 mg ER Tab $17CARBOplatin 150 mg/15 mL Inj $239CARBOplatin 450 mg/45 mL Inj $67Carboplatin 50 Mg $64CARBOplatin 50 mg/5 mL Inj $1,983carboprost 250 mcg/1 mL Inj $13Carfilzomib 1mg $136carfilzomib 60 mg Inj $42carisoprodol 350 mg Tab $87carmustine 100 mg Inj $88carvedilol 25 mg Tab $18carvedilol 3.125 mg Tab $4carvedilol 6.25 mg Tab $4castor oil Oral Liq 60 mL $19ceFAZolin 1 gm/10 mL Inj $2ceFAZolin 1 gm/50 mL D5W $2ceFAZolin 2 gm/100 mL D5W $1ceFAZolin 500 mg Inj $1ceFAZolin opth sol 50 mg/mL 10 mL $16cefdinir 250 mg/5 mL Oral Susp $55cefdinir 300 mg Cap $161

108 of 317 FY2018

DESCRIPTION CHARGES

cefepime 1 gm Inj $385cefepime 2 gm Inj $19Cefepime 500mg $822cefoTEtan 1 gm Inj $289cefoTEtan 2 gm Inj $96cefOXitin 1 gm Inj $21cefOXitin 2 gm Inj $72ceftaroline 400 mg Inj $1ceftaroline 600 mg Inj $23cefTAZidime 1 gm/10 mL Inj $68cefTAZidime 2 gm In $79cefTAZidime 2.25 mg/0.1 mL Intravitreal Inj $213cefTRIAXone 1 gm Inj $103cefTRIAXone 1 gm/50 mL D5W $69cefTRIAXone 2 gm Inj $32cefTRIAXone 250 mg Inj $12Ceftriaxone 250mg $18cefTRIAXone IM Dose $2cefUROXime $17cefUROXime 1.5 gm Inj $1cefUROXime 250 mg Tab $114celecoxib 100 mg Cap $132celecoxib 200 mg Cap $139Cepacol Oral Lozenge (Sugar Free) $46Cephalexin 0.5 mg/mL Desensitization $57cephalexin 250 mg Cap $103cephalexin 250 mg/5 mL Oral Susp $174Cephalexin 5 mg/mL Desensitization $4Cephalexin 50 mg/mL Desensitization $7cephalexin 500 mg Cap $1Certolizumab 1mg $26cetirizine 10 mg Tab $450cetirizine 1mg/1mL Oral Syringe $1cetirizine-pseudoephedrine 5 mg-120 mg ER Tab $7cetuximab 100 mg/50 mL Inj $90charcoal 25 gm Oral Susp 120 mL $660charcoal-sorbitol 25 gm Oral Susp 120 mL $31

109 of 317 FY2018

DESCRIPTION CHARGES

Cherry Syrup $47chlorambucil 2 mg Tab $7chlordiazePOXIDE 10 mg Cap $231chlordiazePOXIDE 25 mg Cap $5chlordiazePOXIDE 5 mg Cap $3chlordiazePOXIDE-clidinium 5-2.5 mg Cap $2chlorhexidine 0.12% Oral Liq $2chloroprocaine 2% 20 mL Inj PF $2chloroprocaine 3% 20 mL Inj PF $18chlorothiazide 500 mg Inj $55chlorphen-HYDROcodone 8 mg-10 mg/5 mL UD Susp. $133chlorpheniramine 4 mg Tab $4chlorproMAZINE 10 mg Tab $12chlorproMAZINE 25 mg Tab $36chlorproMAZINE 25 mg/1 mL Inj $42chlorthalidone 25 mg Tab $326chlorzoxazone 500 mg Tab $3cholecalciferol (Vitamin D-3) 1000 units Tab $3cholecalciferol (Vitamin D-3) 400 units Tab $3cholestyramine 4 g Oral Pwdr $54Cimetidine $4Cimetidine 300mg IV $17cinacalcet 30 mg Tab $21ciprofloxacin 200 mg/100 mL D5W $33ciprofloxacin 250 mg Tab $15ciprofloxacin 400 mg/200 mL D5W $4ciprofloxacin 500 mg Tab $97ciprofloxacin Opth 0.3% Sol $2ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp $3ciprofloxacin-hydrocortisone Otic Susp $3cisatracurium 2 mg/1 mL Inj $4cisatracurium 200 mg/20 mL Inj $5cisatracurium 2mg/1 mL (1 mL) inj $2Cisplatin 10mg IV $14CISplatin 50 mg/50 mL Inj $3citalopram 20 mg Tab $1citalopram 40 mg Tab $2

110 of 317 FY2018

DESCRIPTION CHARGES

citric acid-potassium citrate 30 mEq Packet $5citric acid-sodium citrate 640-490 mg/5 mL Oral Sol 30 mL $5cladribine 10 mg/10 mL Inj $6Cladribine 1mg $170clindamycin 150 mg Cap $6clindamycin 300 mg/2 mL Inj $5clindamycin 600 mg/4 mL Inj $13clindamycin 75 mg/5 mL Oral Susp $274clindamycin 900 mg/6 mL Inj $14clindamycin Top 1% Lotion $11clobetasol 0.05% Cream $13clobetasol 0.05% Oint $21clomiPRAMINE 25 mg Cap $12clonazePAM 0.5 mg Tab $2clonazePAM 1 mg Tab $79cloNIDine 0.1 mg Tab $12cloNIDine 0.1 mg/24 hr Patch $12cloNIDine 0.2 mg Tab $4cloNIDine 0.2 mg/24 hr Patch $7cloNIDine 0.3 mg/24 hr Patch $21cloNIDine 1000 mcg/10 mL intrathecal Inj $7clopidogrel 75 mg Tab $7clopidogrel desensitization $2clorazepate 7.5 mg Tab $44clotrimazole 1% Vag Crm $54clotrimazole 10 mg Oral Lozenge $13,847clotrimazole 200 mg Vag Tab $15clotrimazole Top 1% Crm $14cloZAPine 100 mg Tab $9CO 57 $599coagulation factor IX (Mononine) $9coagulation factor IX recombinant $13coagulation factor VIIa 1000 mcg (1 mg) Inj $3coagulation factor VIIa 2000 mcg (2 mg) Inj $2codeine sulfate 30 mg Tab $14codeine-guaif 10-100 mg/5 mL Oral Liq 5 mL UD $79codeine-prom 10-6.25 mg/5 mL Oral Liq 5 mL $70

111 of 317 FY2018

DESCRIPTION CHARGES

colchicine 0.6 mg Tab $1collagenase (santyl) topical Oint $1conjugated estrogens 0.3 mg Tab $65conjugated estrogens 0.625 mg Tab $552conjugated estrogens 0.625 mg/g Vag Crm $718conjugated estrogens 25 mg Inj $7Conray 60% 50ml $66Conray II Cysto 250ml $91Contrast Ionic $86Contrast Optitray 100cc $265Contrast Optitray 50cc $132copper sulfate 0.4 mg/1 mL Inj $8Cortrosyn 0.25mg $1,042cosyntropin 0.25 mg Inj $5Cottonseed Oil $42CR 51 $2,826CT Gastrografin/Hypaque Liquid $127CT Gastroview 30ml $31CT Omnipaque 240+ 50ml $109CT Omnipaque 350 100ml $78CT Optiray 300 100ml Prefilled $435CT Optiray 320 50ml $264CT Optiray 320 100ml w/IV set $395CT Optiray 320 125ml Prefilled $544CT Sodium Chloride 125ml pref-91837 $54Cubicin 1mg $6cyanocobalamin (Vit B12) 100 mcg Tab $3cyanocobalamin (Vit B12) 1000 mcg Tab $171cyanocobalamin (Vit B12) 1000 mcg/1 mL Inj $330cyclobenzaprine 10 mg Tab $353cyclopentolate Opth 0.5% Sol $427cyclopentolate Opth 1% Sol $2cyclopentolate Opth 2% Solution $1cyclophosphamide 1000 mg Inj $91cyclophosphamide 500 mg Inj $1cycloSPORINE (Neoral) 100 mg/mL Oral Sol $153cycloSPORINE (Neoral) 25 mg Cap $213

112 of 317 FY2018

DESCRIPTION CHARGES

cycloSPORINE ophthalmic 0.05% UD Drops $1cytarabine 100 mg/5 mL Inj $20cytarabine 1000 mg/50 mL Inj $33Cytarabine 100mg $5cytarabine 2000 mg/20 mL Inj $9cytarabine 500 mg Inj $8cytarabine liposomal 50 mg/5 mL intrathecal Inj $15Cytoxan IV 100mg $64D10w 1000mL $65D10w 250mL $65D10w 500mL $71D5ns IV 500mL $67D5W 1000ml $67D5w 500cc-1537 $72D5w In 1/2ns W/Kci 20meq 1L $65D5w In 1/2ns W/Kci 40meq 1L $65dabigatran 150 mg Cap $9dabigatran 75 mg Cap $4Dacarbazine 100mg $53dacarbazine 200 mg Inj $31Dacogen 1mg $155Dactinomycin 0.5mg $3,002DACTINomycin 500 mcg/1 mL Inj $31Dalvance 5mg $77dantrolene 20 mg Inj $644dantrolene 25 mg Cap $11DAPTOmycin 500 mg Inj $11Daratumumab 10mg $239Daratumumab 1mg $24darbepoetin alfa 300 mcg/1 mL Inj $870DAUNOrubicin 20 mg/4 mL Inj $33decitabine 50 mg Inj $1Deferoxamine 500 Mg $83Demerol 100mg $33denosumab 120 mg/1.7 mL Inj $213Depocyte 10mg $1,714Dermabond Topical Skin Adhesive $105

113 of 317 FY2018

DESCRIPTION CHARGES

Dermagraft Supply $106desensitization medication $134desipramine 25 mg Tab $813desmopressin 10 mcg Nasal Spray $4Desmopressin 1mcg $107desmopressin 4 mcg/1 mL Inj $21desonide 0.05% Oint $22desonide Top 0.05% Lotion $22desoximetasone 0.05% Gel $3desoximetasone Top 0.25% Crm $80dex/neo/poly B Opth Oint $12dex/neo/poly B Opth Susp $6Dexamethasone 0.25 Mg PO $5dexamethasone 0.5 mg/5 mL Oral Liq 60 mL $650dexamethasone 1 mg Tab $165dexamethasone 10 mg/1 mL Inj $814Dexamethasone 1mg Inj $1Dexamethasone 1mg IV $18dexamethasone 4 mg Tab $771dexamethasone 4 mg/1 mL Inj $160dexamethasone Opth 0.1% Soln $55dexamethasone Opth 0.7 mg implant $352dexamethasone PF 10 mg/1 mL Inj $8dexamethasone-tobramycin Opth Oint $1dexamethasone-tobramycin Opth Susp $2dex-guaif 20-200 mg/10 mL Oral Liq 10 mL UD $178dexmedetomidine 200 mcg/2 mL Inj $569dexmedetomidine 200 mcg/50 mL NS $179dextran 10%-D5W 500 mL $2dextran 10%-NS 500 mL $103dextroamphetamine 5 mg ER Cap $103dextroamphetamine 5 mg Tab $103Dextrose 10% in Water IV Sol 1000 mL $17Dextrose 10% in Water IV Sol 500 mL $201Dextrose 20% in Water IV Sol 500 mL $2Dextrose 25% 10 mL Syringe Inj $5Dextrose 5% in Lactated Ringers IV Sol 1000 mL $2

114 of 317 FY2018

DESCRIPTION CHARGES

Dextrose 5% in Lactated Ringers IV Sol 500 mL $1Dextrose 5% in Water $2Dextrose 5% in Water IV Sol 100 mL $127Dextrose 5% in Water IV Sol 1000 mL $7Dextrose 5% in Water IV Sol 250 mL $5Dextrose 5% in Water IV Sol 500 mL $138Dextrose 5% with 0.225% NaCl 500 mL $1Dextrose 5% with 0.225% NaCl IV Sol 1000 mL $4

Dextrose 5% with 0.45% NaCl and KCl 10 mEq/L IV Sol 1000 mL $5

Dextrose 5% with 0.45% NaCl and KCl 40 mEq/L IV Sol 1000 mL $7Dextrose 5% with 0.45% NaCl IV Sol 1000 mL $2Dextrose 5% with 0.45% NaCl IV Sol 500 mL $1,178

Dextrose 5% with 0.9% NaCl and KCl 40 mEq/L IV Sol 1000 mL $12Dextrose 5% with 0.9% NaCl IV Sol 500 mL $2Dextrose 50% 50 mL Inj $3Dextrose 50% 50 mL Syringe Inj $2Dextrose 70% in Water IV Sol 2000 mL $4Dialysis 1.5% Solution 2000 mL $5Dialysis 1.5% Solution 2500 mL $4Dialysis 1.5% Solution W/O TUBING 2000 mL $24Dialysis 2.5% Solution 2000 mL $24Dialysis 2.5% Solution 5000 mL $15Dialysis 4.25% Solution 2000 mL $15Dialysis 4.25% Solution 2500 mL $15Dialysis 4.25% Solution 3000 mL $15Dialysis 4.25% Solution 5000 mL $15Dialysis Solution 3 K/3 Ca 5000 mL $15Dialysis Solution 4 K/2.5 Ca 5000 mL $379Dialysis Solution 4 K/3 Ca 5000 mL $278diatrizoate 60% 50 mL Inj $656

115 of 317 FY2018

DESCRIPTION CHARGES

diazePAM 10 mg rectal Gel $3diazePAM 10 mg/2 mL Inj $1diazePAM 2 mg Tab $2diazePAM 5 mg Tab $6dibucaine 1% Oint $26diclofenac Ophth 0.1% Sol $22diclofenac sodium 50 mg EC Tab $19diclofenac sodium 75 mg EC Tab $22dicloxacillin 250 mg Cap $21dicyclomine 10 mg Cap $287dicyclomine 20 mg Tab $122digoxin 0.05 mg/mL Oral Liq $5digoxin 250 mcg (0.25 mg) Tab $12digoxin 250 mcg/mL (0.25 mg/mL) Inj $124digoxin immune FAB 40 mg Inj $516dihydroergotamine 1 mg/1 mL Inj $516Dihydroergotamine 1mg $1,220Dilation Cocktail for Eye $369diltiaZEM 120 mg/24 hours ER Cap $6diltiaZEM 125 mg/25 mL Inj $24diltiaZEM 180 mg/24 hours ER Cap $990diltiaZEM 240 mg/24 hours ER Cap $24diltiaZEM 25 mg/5 mL Inj $51diltiaZEM 30 mg Tab $138diltiaZEM 300 mg/24 hours ER Cap $12diltiaZEM 50 mg/10 mL Inj $12diltiaZEM 60 mg Tab $64dimercaprol 10% 3 mL Inj $64dinoprostone topical 10 mg Vag Insert $2diphenhydrAMINE 12.5 mg/5 mL Oral Liq $4diphenhydrAMINE 12.5 mg/5 mL Oral Liq 480 mL $90diphenhydrAMINE 25 mg Cap $7Diphenhydramine 25mg PO $5diphenhydrAMINE 50 mg Cap $5diphenhydrAMINE 50 mg/1 mL Inj $24Diphenhydramine IV 50 Mg $27dipyridamole 25 mg Tab $441

116 of 317 FY2018

DESCRIPTION CHARGES

dipyridamole 50 mg Tab $14divalproex sodium 125 mg EC Tab $5divalproex sodium 125 mg Sprinkle Cap $40divalproex sodium 250 mg EC Tab $2DOBUTamine 1000 mg/250 mL D5W $726DOBUTamine 250 mg/20 mL Inj $1,815DOBUTamine 250 mg/250 mL D5W $576DOC Definity Echo Contrast $354DOC Optison Contrast Enhance 3 ml-41409 $255Docetaxel 1mg IV $118DOCEtaxel 20 mg/2 mL Inj $9DOCEtaxel 80 mg/4 mL Inj $14docusate sodium 100 mg Cap $6docusate-senna 50 mg-8.6 mg Tab $4dofetilide 125 mcg Cap $5dofetilide 250 mcg Cap $24donepezil 10 mg Tab $2donepezil 5 mg Tab $122DOPamine 200 mg/5 mL Inj $195DOPamine 800 mg/250 mL D5W $125Doripenem 0.005 mg/mL Desensitization $333Doripenem 0.05 mg/mL Desensitization $7Doripenem 0.5 mg/mL Desensitization $7Doripenem 10mg $6Doripenem 5 mg/mL Desensitization $19Doripenem 50 mg/mL Desensitization $24doripenem 500 mg Inj $234dornase alfa 2.5 mg/2.5 mL Inh Sol $231dorzolamide Opth 2% Sol $309dorzolamide-timolol Opth 2%-0.5% Sol $379doxapram 20mg/1 mL inj $379doxapram 400 mg/20 mL Inj $7doxepin 10 mg Cap $1doxepin 25 mg Cap $239Doxil 10mg IV $471DOXOrubicin liposomal (Doxil) 20 mg/10 mL Inj $7doxycycline 100 mg Inj $4

117 of 317 FY2018

DESCRIPTION CHARGES

doxycycline 50 mg Cap $2doxycycline hyclate 100 mg Cap $6dronabinol 2.5 mg Cap $4dronedarone 400 mg Tab $5DULoxetine 20 mg Cap $17DULoxetine 30 mg Cap $13DULoxetine 60 mg Cap $675Durvalumab 10mg $359econazole Top 1% Crm $250eculizumab 300 mg/30 mL Inj $94Edaravone 1mg $93edaravone 30 mg/100 mL NS $6edetate calcium disodium 1000 mg/5 mL Inj $10Electrolyte Solution (Plasma-Lyte A) IV Sol 1000 mL $55Eleview Submucosal Injection-108332 $243Elitek 0.5mg $891Elotuzumab 1mg $31Elotuzumab 300mg $8,226elotuzumab 400 mg/16 mL Inj $24Eloxatin .5mg $56emtricitabine-tenofovir 200 mg-300 mg Tab $17enalapril 1.25 mg/1 mL Inj $3enalapril 10 mg Tab $49enalapril 5 mg Tab $2enoxaparin 100 mg/1 mL Inj $3Enoxaparin 10mg $72enoxaparin 120 mg/0.8 mL Inj $2enoxaparin 150 mg/1 mL Inj $3enoxaparin 30 mg/0.3 mL Inj $1enoxaparin 40 mg/0.4 mL Inj $1enoxaparin 60 mg/0.6 mL Inj $11enoxaparin 80 mg/0.8 mL Inj $1entacapone 200 mg Tab $4Entyvio 1mg $81ePHEDrine 50 mg/1 mL Inj $3Epidural Cassette and Tubing $170Epifix Es 3300 3.5 X 3.5 $2,488

118 of 317 FY2018

DESCRIPTION CHARGES

Epifix Es 4400 4 X 4.5 $2,788Epifix Supply 18mm Disk $1,488Epifix Supply 2cm X 2cm $2,128Epifix Supply 2cm X 3cm $2,288Epifix Supply 2cm X 4cm $2,700EPINEPHrine 0.15 mg Auto-Injector $2Epinephrine 0.1mg $15EPINEPHrine 1 mg/1 mL 30 mL Inj $3EPINEPHrine 1 mg/1 mL Inj $33EPINEPHrine 1 mg/10 mL Inj Syringe $1EPINEPHrine 1mg/mL Topical Solution $10Epirubicin 2mg $27epoetin alfa (Epogen) 10,000 units/mL Inj (ESRD) $3epoetin alfa (Epogen) 20,000 units/1 mL Inj (ESRD) $1epoetin alfa (Epogen) 2000 units/mL Inj (ESRD) $102epoetin alfa (Procrit) 10,000 units/mL Inj $316epoetin alfa (Procrit) 20,000 units/1 mL Inj $76epoetin alfa (Procrit) 2000 units/mL Inj $99Epoetin Alpha 1000 Units $79epoprostenol (Flolan) $5eptifibatide 75 mg/100 mL $2Erbitux 10mg $274eriBULin 1 mg/2 mL Inj $198ertapenem 1 gm Inj $3Ertapenem 500mg $318erythromycin 250 mg Tab $85erythromycin ethyl 200 mg/5 mL Oral Liq $388erythromycin lactobionate 1000 mg Inj $226erythromycin lactobionate 500 mg Inj $186erythromycin Opth 0.5% Oint 1 gm $85erythromycin Opth 0.5% Oint 3.5 gm $45erythromycin Top 2% Sol $11escitalopram 10 mg Tab $269escitalopram 20 mg Tab $2esmolol 100 mg/10 mL Inj $1esmolol 2500 mg/250 mL 0.9% NaCl $1estradiol 0.05 mg/24 hours weekly Patch $1

119 of 317 FY2018

DESCRIPTION CHARGES

estradiol 0.1 mg/24 hours weekly Patch $2estradiol 1 mg Tab $69estradiol cypionate 25 mg/5 mL IM inj $1estradiol valerate 100 mg/5 mL IM Inj $2ethacrynic acid 50 mg Inj $2ethambutol 400 mg Tab $80ethanol 5% in D5W 1000 mL $52ethanol 98% 5 mL Inj $8ethyl chloride Top 100% Spray $1etomidate 20 mg/10 mL Inj $281etoposide 100 mg/5 mL Inj $124etoposide 50 mg Cap $55Evacuated Container $879Extension Set $246ezetimibe 10 mg Tab $33Famotidine 10mg IV $8famotidine 20 mg Tab $252Famotidine 20mg IV $17famotidine 8 mg/mL Oral Suspension $630famotidine Injection $54Fasenra 30mg $24,521Faslodex 25mg $463Fat Emul, 20% IV 500 mL $1felbamate 600 mg/5 mL oral susp $3fenofibrate 145 mg Tab $86fenofibrate 48 mg Tab $17fentaNYL 100 mcg/2 mL Inj $4fentaNYL 100 mcg/hr Patch $858fentaNYL 1000 mcg/20 mL Inj $307fentaNYL 12 mcg/hr Patch $263fentaNYL 200 mcg Oral Lozenge $8fentaNYL 25 mcg/hr Patch $8fentaNYL 250 mcg/5 mL Inj $1fentaNYL 2500 mcg/50 mL Inj $8fentaNYL 400 mcg Oral Lozenge $3fentaNYL 50 mcg/hr Patch $4fentaNYL 75 mcg/hr Patch $2

120 of 317 FY2018

DESCRIPTION CHARGES

Feraheme 1mg $4ferric carboxymaltose 50 mg/mL Inj $3ferric subsulfate (Monsel's)Top Sol 8 mL $6ferrous sulfate 300 mg/5 mL UD Cup $11ferrous sulfate 325 mg Tab $54fibrin sealant Top Sol 2mL $22fibrin sealant Top Sol 5 mL $143fidaxomicin 200 mg Tab $3Filgrastim 1mcg $4filgrastim 300 mcg/1 mL Inj $2filgrastim 480 mcg/1.6 mL Inj $56Filter set $8finasteride 5 mg Tab $100Firmagon 1mg $26Flebogamma 500mg $213flecainide 100 mg Tab $13flecainide 50 mg Tab $1Fleet Pediatric Phospo Rectal Enema 66 mL $46Fleet Phospo Rectal Enema 133 mL $261Flolan diluent 50 mL $16floxuridine 500 mg Inj $6Flu Vaccine $26fluconazole 100 mg Tab $7fluconazole 200 mg/100 mL NS $1fluconazole 400 mg/200 mL NS $19Fludarabine 50 Mg $1,555fludarabine 50 mg Inj $15fludrocortisone 0.1 mg Tab $40flumazenil 0.5 mg/5 mL inj $52fluocinolone Opth 0.59 mg implant $97fluocinolone Top 0.01% Crm $93fluocinonide 0.05% Oint $2fluocinonide Top 0.05% Crm $3fluorescein 10% 5 mL Inj $2fluorescein ophthalmic Test Strip $2fluorometholone Opth 0.1% Susp $2Fluorouracil 500 Mg $64

121 of 317 FY2018

DESCRIPTION CHARGES

fluorouracil 500 mg/10 mL Inj $2FLUoxetine 10 mg Cap $2FLUoxetine 20 mg Cap $1FLUoxetine 20 mg/5 mL Oral Sol $1flurbiprofen Opth 0.03% Sol $2fluticasone (Flonase) NASAL SPRAY $2fluticasone furoate (ARNUITY) 100 mcg Inhaler $73fluticasone furoate (ARNUITY) 200 mcg Inhaler $825fluticasone-vilanterol 100 mcg-25 mcg Inhaler $26fluticasone-vilanterol 200 mcg-25 mcg Inhaler $46fluvoxaMINE 50 mg Tab $21folic acid 0.4 mg Tab $178folic acid 1 mg Tab $21folic acid 50 mg/10 mL Inj $17fomepizole 1500 mg/1.5 mL Inj $9fondaparinux 10 mg/0.8 mL Inj $3fondaparinux 2.5 mg/0.5 mL Inj $36fondaparinux 5 mg/0.4 mL Inj $36fondaparinux 7.5 mg/0.6 mL Inj $42fosaprepitant 150 mg Inj $503Fosaprepitant Inj 1mg $10fosfomycin 3 gm Packet $3fosphenytoin (PE) 100 mg/2 mL Inj $2fosphenytoin (PE) 500 mg/10 mL Inj $3fulvestrant 250 mg/5 mL Inj $3furosemide 100 mg/10 mL Inj $3furosemide 20 mg Tab $1Furosemide 20mg $6furosemide 40 mg Tab $1furosemide 40 mg/4 mL Inj $1furosemide 40 mg/4mL ORAL Solution $2furosemide 80 mg Tab $6gabapentin 100 mg Cap $5gabapentin 250 mg/5 mL Oral Sol $6gabapentin 300 mg Cap $27gabapentin 400 mg Cap $27Gadolinium/Magnevist $17

122 of 317 FY2018

DESCRIPTION CHARGES

gadopentetate dimeglumine 46.9% Inj $5Gadoteridol Inj Per ml $27Gadoxeate Disodium Inj $348galantamine 8 mg oral ER Cap $69Gammagard 500mg $313Gammard POwder 500mg $374Gamunex 500mg $243ganciclovir 4.5 mg intraocular implant $2ganciclovir 500 mg Inj $1Gastrografin/Hypaque Liquid $39Gelfilm Ophth Gel $89Gelfoam 1 gm Powder $190gemcitabine 200 mg/2 mL Inj $1gemfibrozil 600 mg Tab $2Gemzar 200mg IV $768gentamicin 0.1% Oint $12gentamicin 20 mg/2 mL Inj $1gentamicin 80 mg/2 mL Inj $2gentamicin 800 mg/20 mL Inj $3gentamicin Opth 0.3% Oint $12gentamicin Opth 0.3% Sol $10gentamicin Opth 15 mg/mL Sol 10 mL $28Gentamicin Up To 80mg $18gentian violet Top 1% Sol $59GI Cocktail Compound 40 mL $67glimepiride 2 mg Tab $17glimepiride 4 mg Tab $4glipiZIDE 10 mg Tab $2glipiZIDE 5 mg ER Tab $175glipiZIDE 5 mg Tab $28Glucagon $213glucagon 1 mg Inj $2glucose 40% Oral Gel $1glycerin adult Supp $2glycerin Liquid $18glycerin pediatric liquid Supp $1glycopyrrolate 0.2 mg/1 mL 5 mL syringe $615

123 of 317 FY2018

DESCRIPTION CHARGES

glycopyrrolate 0.2 mg/1 mL Inj $185glycopyrrolate 1 mg/5 mL Inj $6gramicidin/neo/poly B Opth Sol $2Granix 1mcg $4Granix 5mcg $17guaiFENesin 100 mg/5 mL Oral Liq 5 mL UD $7guaiFENesin 200 mg Tab $8guaiFENesin 600 mg ER Tab $6Halaven .1 Mg $486haloperidol 1 mg Tab $1haloperidol 10 mg/5 mL Oral Solution $3haloperidol 5 mg Tab $1haloperidol 5 mg/1 mL Inj $4hctz-triamterene 25 mg-37.5 mg Tab $2hemin 313 mg Inj $2hEParin 1 units/1 mL PF Syringe Flush $3hEParin 10 units/1 mL 5 mL Syringe Inj $762hEParin 10,000 units/1 mL 1 mL Inj $7hEParin 100 units/1 mL 1 mL Inj $32hEParin 100 units/1 mL 5 mL Syringe Inj $48hEParin 1000 units/1 mL 10 mL Inj $20hEParin 1000 units/1 mL 2 mL Inj PF $3hEParin 1000 units/500 mL NaCl 0.9% $7hEParin 2000 units/1000 mL NaCl 0.9% $35hEParin 25,000 units/250 mL NaCl 0.45% $3hEParin 5000 units/1 mL 1 mL Inj $5Hepatitis A $80

hepatitis A ped vaccine 25 units/0.5 mL Inj (FOR CLINIC USE ONLY) $4Hepatitis B $189hepatitis B adult vaccine 20 mcg/0.5 mL IM Sol (FOR CLINIC USE ONLY) $2hepatitis B immune globulin IM Sol 1 mL $33hepatitis B immune globulin IM Sol 5 mL $36hepatitis B pediatric vaccine 10 mcg/0.5 mL IM Sol $7

hepatitis B vaccine 5 mcg/0.5 mL IM Sol (FOR CLINIC USE ONLY) $10

124 of 317 FY2018

DESCRIPTION CHARGES

Herceptin 10mg IV $349hetastarch 6%-NaCl 0.9% 500 mL $8Hexabrix 20ml $127High Dose I 131 Per Mci $122histrelin 50 mg SubQ implant $3Hk Theraskin Supply Per 1 Sq Cm $46homatropine Opth 5% Sol $3Human Milk Fortifier Powder Packet $4Hyaluronan 1mg $186hyaluronidase 150 units/1 mL Inj $16hyaluronidase 200 units/mL Inj 1.2 mL $16hydrALAZINE 10 mg Tab $7hydrALAZINE 20 mg/1 mL Inj $47hydrALAZINE 25 mg Tab $11hydrALAZINE 50 mg Tab $13hydroCHLOROthiazide 25 mg Tab $693hydrocortisone 0.5% Oint $327hydrocortisone 1% Oint $430hydrocortisone 1% Oint 454 gm $2hydrocortisone 10 mg Tab $35hydrocortisone 100 mg/2 mL Inj $206hydrocortisone 2.5% Oint $73hydrocortisone 2.5% Rectal Crm $15hydrocortisone 25 mg Supp $2hydrocortisone 250 mg/2 mL Inj $4hydrocortisone 500 mg Inj $5hydrocortisone Top 1% Crm $5hydrocortisone Top 1% Lotion $10hydrocortisone Top 2.5% Crm $10hydrocortisone/neo/poly B (Cortisporin) Otic Susp $10hydrocortisone/neo/poly B Opth Susp $4hydrocortisone/neo/polymyxin B Top Crm $30hydrocortisone-pramoxine Rectal Foam $9HYDROmorphone 10 mg/1 mL Inj $12HYDROmorphone 2 mg/mL PF Inj $6HYDROmorphone 50 mg/5 mL Inj $2HYDROmorphone PCA 6 mg/30 mL Inj $5

125 of 317 FY2018

DESCRIPTION CHARGES

Hydroxocobalamin 100mcg $44hydroxocobalamin 5 gm Inj $6hydroxy methylcellulose (Tears) Opth Sol $3hydroxy methylcellulose Opth 2.5% Sol $4hydroxychloroquine 200 mg Tab $7hydroxypropyl methylcellulose Opth 2% Sol 1 mL $9hydroxyurea 500 mg Cap $6hydrOXYzine 50 mg/1 mL Inj $6hydrOXYzine hydrochloride 10 mg Tab $7hydrOXYzine pamoate 25 mg Cap $7hylan G-F 20 16 mg/2 mL intra-articular Inj $617hyoscyamine 0.125 mg sublingual Tab $3hyoscyamine 0.375 mg ER Tab $5hyoscyamine 0.5 mg/1 mL Inj $9hypromellose 1.7% (ImproVue) ophthalmic drop $1I 123 Capsules $91I 125 HSA $2,019I 131 Diag Capsule 15 uCi $698I 131 Diag Capsule 5 mCi $1,340I 131 Diag Solution 5 mCi $1,041ibandronate 3 mg/3 mL Inj $3ibuprofen 100 mg/5 mL Oral Susp $2ibuprofen 100 mg/mL Inj $4ibuprofen 200 mg Tab $3Ibuprofen 200mg PO $5ibuprofen 400 mg Tab $72ibuprofen 600 mg Tab $48ibutilide 1 mg/10 mL Inj $76IC Nitro / Non Thrombolytic $20IDArubicin 10 mg/10 mL Inj $69IDArubicin 20 mg/20 mL Inj $81IDArubicin 5 mg/5 mL Inj $1idaruCIZUmab 2.5 gm Inj $58ifosfamide 1000 mg Inj $36Ifosfamide 1gm $251imipramine 10 mg Tab $31imipramine 25 mg Tab $36

126 of 317 FY2018

DESCRIPTION CHARGES

immune globulin (Flebogamma) 20 gm/200 mL Inj $61immune globulin (Flebogamma) 5 gm/50 mL Inj $102immune globulin (Gammagard S/D) 5 gm/100 mL $8immune globulin (Gamunex-C) 10 gm/100 mL Inj $34immune globulin (Gamunex-C) 20 gm/200 mL Inj $434immune globulin (Gamunex-C) 40 gm/400 mL Inj $43immune globulin (Gamunex-C) 5 gm/50 mL Inj $4immune globulin (Privigen) 10 gm/100 mL Inj $7immune globulin (Privigen) 20 gm/200 mL Inj $795immune globulin (Privigen) 5 gm/50 mL Inj $140immune globulin 10 mL Inj $8immune globulin intravenous (Carimune) 12 gm Inj $1immune globulin intravenous (Carimune) 6 gm Inj $8IN 111 DTPA $3,628IN 111 Labeled Leukocytes $5,298IN 111 ZEVALIN $13,016IN Proctoscint $12,312indapamide 2.5 mg Tab $186Indermil Topical Skin Adhesive $91india ink 10 mL Top Soln $14indigo carmine 40 mg/5 mL Inj $4indinavir 400 mg Cap $1indocyanine green 25 mg Inj $40indomethacin 25 mg Cap $7indomethacin 50 mg Supp $8inFLIXimab 100 mg Inj $98influenza virus vaccine (High Dose) Inj $3influenza virus vaccine (Quadrivalent) Inj $55Inj Bupivicaine $20Inj Gadobenate Dimeglumine 20ml $88Inj Gadoterate Meglumine Per Ml $9Inj Triamcinolone Acetonide 10mg $75Injectafer, 1mg $5

insulin **500 units/1 mL** regular human (HumuLIN R) 3 mL Pen $12insulin glargine (Lantus) 100 units/1 mL Inj (3 mL Pen) $12insulin isophane human (HumuLIN N) 100 units/1 mL Inj 3 mL $2

127 of 317 FY2018

DESCRIPTION CHARGES

insulin lispro (HumaLOG) 100 units/1 mL Inj (3 mL) $13insulin lispro 75/25 (HumaLOG Mix) 100 units/mL Inj $12

insulin regular human (HumuLIN R) 100 units/1 mL (1 mL COA) $12insulin regular human (HumuLIN R) 100 units/1 mL Inj (3 mL) $326Insulin Syringe with Needle U-100 $4interferon alfa-2b 10,000,000 units Inj $3Interferon-A2b 1mu $68Intestinal Flora Regulator (Flora Q-2) Cap $4iodine Top 2% Tincture $8iohexol 240 mg/mL (Omnipaque) Sol 1 mL $13iohexol 240 mg/mL (Omnipaque) Sol 50 mL $289iopamidol 61% intrathecal Inj 15 mL $1iothalamate 43% 50 mL Inj $10ipratropium 0.02% Inh Sol 2.5 mL $10Ipratropium 1mg $6ipratropium Inhaler $138ipratropium Nasal 0.03% Spray $309ipratropium Nasal 0.06% Spray $1irbesartan 150 mg Tab $4irbesartan 75 mg Tab $1irinotecan 100 mg/5 mL Inj $184iron sucrose 100 mg/5mL Inj $276isavuconazonium 372 mg Inj $277isoniazid 300 mg Tab $291isopropyl alcohol Top 70% Liq $19isoproterenol 1 mg/5 mL Inj $12isosorbide dinitrate 10 mg Tab $12isosorbide dinitrate 20 mg Tab $593isosorbide mononitrate 20 mg Tab $312isosorbide mononitrate 30 mg ER Tab $95Isosulfan Blue 1% 10mg/ml 5ml $429isosulfan blue 50 mg/5 mL Inj $5Isovue 200 $130Isovue M 300 15ml $61itraconazole 100 mg Cap $23IV D 5w 50cc-26904 $72

128 of 317 FY2018

DESCRIPTION CHARGES

IV D5 + 1/4ns 1000cc-1552 $72IV D5 1/2 Ns 500cc-1551 $72IV D5ns 1000cc-1546 $72IV D5w 100cc-26905 $72IV D5w 250cc-1538 $72IV Lr 500cc-26899 $72IV Nacl 50-26896 $72IV Perit Dial 1. 5% Dex 2000cc-26929 $98IV Set/Tubing $68ivabradine 5 mg Tab $1Ixabepilone 1mg $356Jevtanan (Cabazitaxel) 1mg $760ketamine 10 mg/1 mL Inj $1ketamine 10 mg/1 mL inj (1 mL charge) $1ketamine 100 mg/mL Inj $2ketamine 50 mg/mL Inj $28ketoconazole Top 2% Crm $18ketorolac 10 mg Tab $37ketorolac 30 mg/1 mL Inj $8ketorolac 60 mg/2 mL Inj $3Keytruda 1mg $212Kinevac $145Krystexxa 1mg $13,173Kytril 100mcg $44labetalol 200 mg Tab $144labetalol 5 mg/1 mL inj $45labetalol 5 mg/1 mL vial Inj $9lacosamide 100 mg Tab $13lacosamide 200 mg/20 mL Inj $2lacosamide 50 mg Tab $382Lactated Ringers 1000cc $67lactated Ringers IV Sol 1000 mL $63lactated Ringers IV Sol 250 mL $7lactated Ringers IV Sol 500 mL $1Lactose Monohydrate Powder $1lactulose Solution $1lamoTRIgine 100 mg Tab $1

129 of 317 FY2018

DESCRIPTION CHARGES

lamoTRIgine 25 mg Tab $1Lanreotide 1mg $228lansoprazole 30 mg Solutab $3latanoprost ophth 0.005% Sol $1L-cysteine 50 mg/1 mL Inj $4LET (XAP) 3 mL Top Soln $2leucovorin $37leucovorin 100 mg Inj $2leucovorin 5 mg Tab $49Leucovorin 50 Mg $31leuprolide 5000 mcg/1 mL Inj $3Leuprolide 7.5mg Im $3,722levETIRAcetam 250 mg Tab $4levETIRAcetam 500 mg Tab $1levETIRAcetam 500 mg/5 mL Inj $1levETIRAcetam 500 mg/5 mL UD Oral Liquid $6levobunolol Opth 0.5% Sol $7levoFLOXacin 250 mg Tab $5levoFLOXacin 250 mg/50 mL D5W $1levoFLOXacin 500 mg/100 mL D5W $9levoFLOXacin 500 mg/20 mL Inj $1levoFLOXacin 750 mg Tab $3levoFLOXacin 750 mg/150 mL D5W $1Levoleucovorin Calcium Inj 0.5mg $9levothyroxine 100 mcg (0.1 mg) Tab $19levothyroxine 100 mcg/5 mL Inj $11levothyroxine 112 mcg (0.112 mg) Tab $24levothyroxine 125 mcg (0.125 mg) Tab $1levothyroxine 137 mcg (0.137 mg) Tab $3levothyroxine 150 mcg (0.15 mg) Tab $1levothyroxine 175 mcg (0.175 mg) Tab $1,112levothyroxine 200 mcg (0.2 mg) Tab $3levothyroxine 25 mcg (0.025 mg) Tab $2levothyroxine 50 mcg (0.05 mg) Tab $66levothyroxine 500 mcg/5 mL Inj $4levothyroxine 75 mcg (0.075 mg) Tab $6levothyroxine 88 mcg (0.088 mg) Tab $1

130 of 317 FY2018

DESCRIPTION CHARGES

lidocaine 0.5% 50 mL Inj $17lidocaine 0.5% 50 mL Inj PF $385lidocaine 1% 2 mL Inj PF $10lidocaine 1% 20 mL Inj $13lidocaine 1% 30 mL Inj PF $85lidocaine 1% 5 mL Inj PF $5lidocaine 100 mg/5 mL Syringe Inj $155Lidocaine 10mg $10lidocaine 2% 10 mL Inj PF $10lidocaine 2% 20 mL Inj $13lidocaine 2% 5 mL Inj PF $461lidocaine 2% 50 mL Inj $35lidocaine 2000 mg/250 mL D5W $35lidocaine 3.5% ophthalmic Gel $37lidocaine 4% 5 mL Inj PF $12lidocaine 4% 5 mL Inj PF $46lidocaine 5% Oint $46lidocaine 5% Patch $31lidocaine 5%-D7.5% 2 mL Inj $2lidocaine Top 2% Gel 30 mL $7lidocaine Top 2% Gel 5 mL $7lidocaine Top 4% Sol $20lidocaine topical 2% Urojet Gel $20lidocaine topical 4% Cre UD $25lidocaine Viscous 2% Sol 100 mL $25lidocaine Viscous 2% Sol 15 mL $25lidocaine-epi 0.5%-1:200,000 Inj $21lidocaine-epi 1%-1:100,000 Inj $20lidocaine-epi 1%-1:200,000 Inj PF $19lidocaine-epi 2%-1:100,000 Inj $22lidocaine-epi 2%-1:200,000 Inj PF $547Limpsomal Ironotecan 43mg $7,504Limpsomal Ironotecan Per 1mg $198linaclotide 145 mcg Cap $3linaclotide 290 mcg Cap $11linagliptin 5 mg Tab $53linezolid 100 mg/5 mL Oral Susp $36

131 of 317 FY2018

DESCRIPTION CHARGES

linezolid 600 mg/300 mL NS $1liothyronine 25 mcg Tab $1liothyronine 5 mcg Tab $23Lipodox 10mg $2,072lisinopril 10 mg Tab $31lisinopril 20 mg Tab $31lisinopril 5 mg Tab $4lithium 300 mg Cap $180lithium 300 mg ER Tab $84lithium 450 mg ER Tab $83loperamide 2 mg Cap $1loperamide 2 mg/10 mL Oral Liq 10 mL UD Cup $194Loratadine 10mg Tab $4LORazepam 0.5 mg Tab $42LORazepam 1 mg Tab $23LORazepam 2 mg/1 mL Oral Conc UD $32Lorazepam IV $24losartan 50 mg Tab $1Low Dose I 131 Per Mci $122Lupron Depot 3.75mg $4,090lymphocyte immune globulin, anti-thymocyte equine $5Maalox ES/Diph. Elix/Lidoc Visc. $41Maalox ES/Diph. Elix/Nystatin $416magnesium citrate Oral Liq 300 mL $578Magnesium Citrate/Glycerin/Water 160 mL Enema $31magnesium gluconate 500 mg Tab $103magnesium hydroxide (milk of mag) Susp 30 mL $96magnesium oxide 400 mg Tab $5magnesium sulfate 1 gm/2 mL Inj $7magnesium sulfate 20 gm/500 mL $1magnesium sulfate 4 gm/100 mL Water $9magnesium sulfate 5 gm/10 mL Inj $22Magnesium Sulfate IV 500mg $18manganese chloride 1 mg/10 mL Inj $76mannitol 12.5 gm/50 mL Inj $2mannitol 50 gm/250 mL Water $14Mannitol 50mL $18

132 of 317 FY2018

DESCRIPTION CHARGES

Marys Magic Compound 128 mL $1MD 76 $9measles/mumps/rubella vaccine Inj $69mechlorethamine 10 mg Inj $15meclizine 12.5 mg Tab $15meclizine 25 mg Chew Tab $15medroxyPROGESTERone 150 mg/1 mL Inj $2medroxyPROGESTERone 2.5 mg Tab $4megestrol 20 mg Tab $25megestrol 400 mg/10 mL Oral Susp UD $189melatonin 3 mg Tab $2melphalan 2 mg Tab $69memantine 10 mg Tab $74memantine 5 mg Tab $69meningococcal conjugate vaccine Inj $300

meningococcal conjugate vaccine - Sol (FOR CLINIC USE ONLY) $400menthol-zinc oxide topical 0.44%-20.625% Oin $261Menveo .5mL $395meperidine 100 mg/1 mL Inj $28meperidine 50 mg Tab $2,251meperidine 50 mg/1 mL Inj $6meperidine PCA 300 mg/30 mL Inj $413mepivacaine 1% 30 mL Inj PF $5mepivacaine 2% 20 mL Inj PF $12Mepolizumab 1mg $148mercaptopurine 50 mg Tab $17meropenem 1000 mg Inj $4meropenem 500 mg Inj $4mesalamine 1.2 gm Tab $4mesalamine 1000 mg Supp $36mesalamine 4 g/60 mL Rectal Enema $131mesalamine 500 mg ER Cap $79mesna 1000 mg/10 mL Inj $32Mesna 200 Mg IV $25metFORMIN 500 mg ER Tab $48metFORMIN 500 mg Tab $5

133 of 317 FY2018

DESCRIPTION CHARGES

metFORMIN 850 mg Tab $5methacholine 100 mg Inh $8methadone 5 mg Tab $2methazolAMIDE 50 mg Tab $1,047methenamine mandelate 500 mg Tab $284methIMAzole 5 mg Tab $1methocarbamol 750 mg Tab $1methohexital Inj $17methotrexate 1000 mg $16methotrexate 2.5 mg Tab $6methotrexate 25 mg/1 mL Inj PF $41Methotrexate 50mg IV $52methyl salicylate Top Crm $17methyldopa 250 mg Tab $153Methylene Blue 1% 10mg/ml $50methylene blue 5 mg/mL 10 mL Vial $4methylergonovine 0.2 mg Tab $578methylergonovine 0.2 mg/1 mL Inj $38methylphenidate 20 mg ER Tab $22methylphenidate 5 mg Tab $9methylPREDNISolone 1000 mg Inj $26methylPREDNISolone 125 mg/2 mL Inj $1,417methylPREDNISolone 2000 mg Inj $708methylPREDNISolone 4 mg Tab $17methylPREDNISolone 40 mg/1 mL Inj $6Methylprednisolone 40mg Inject $67methylPREDNISolone 500 mg Inj $12

methylPREDNISolone Acet. (DEPO-Medrol) 80 mg/1 mL IM Susp $495metoclopramide 10 mg Tab $2metoclopramide 10 mg/10 mL Oral Liq $1metoclopramide 10 mg/2 mL Inj $83metOLazone 2.5 mg Tab $68metOLazone 5 mg Tab $16metoprolol 100 mg ER Tab $83metoprolol 100 mg Tab $12metoprolol 12.5 mg Tab $48

134 of 317 FY2018

DESCRIPTION CHARGES

metoprolol 25 mg ER Tab $16metoprolol 25 mg Tab $86metoprolol 5 mg/5 mL Inj $2metoprolol 50 mg ER Tab $4metoprolol 50 mg Tab $490metroNIDAZOLE 250 mg Tab $2metroNIDAZOLE 500 mg Tab $6metroNIDAZOLE 500 mg/100 mL 0.9% NaCl $2metroNIDAZOLE Top 1% Gel $29mexiletine 150 mg Cap $220micafungin 100 mg Inj $260Micafungin 1mg $17miconazole 2% Vag Crm $20miconazole 200 mg Vag Supp (Box of 3) $189miconazole Top 2% Crm 30 gm $3midazolam 2 mg/2 mL Inj $2midazolam 5 mg/2.5 mL Oral Solution $14midazolam 50 mg/10 mL Inj $11midodrine 2.5 mg Tab $13midodrine 5 mg Tab $15milrinone 10 mg/10 mL Inj $15milrinone 20 mg/100 mL D5W $21mineral oil (OR only) 10 mL Solution $15mineral oil 100% Liq 30 mL UD Cup $15mineral oil 100% Rectal Enema 133 mL $108minoxidil 10 mg Tab $55minoxidil 2.5 mg Tab $55mirabegron 25 mg Tab $34mirabegron 50 mg Tab $14mirtazapine 15 mg Tab $2mirtazapine 30 mg Tab $10mirtazapine 45 mg Tab $6miSOPROStol 100 mcg Tab $12miSOPROStol 200 mcg Tab $6miSOPROStol 25 mcg tab $6mitoMYcin 0.2 mg/mL Ophth. Inj $4mitoMYcin 20 mg Inj $1

135 of 317 FY2018

DESCRIPTION CHARGES

mitoMYcin 5 mg Inj $1Mitomycin C 5 Mg $319Mitoxantrone 5mg $179modafinil 100 mg Tab $3montelukast 10 mg Tab $1morphine 0.5 mg/mL Inj PF $157morphine 1 mg/mL Inj PF $3morphine 10 mg/0.5 mL Oral Conc UD $6morphine 10 mg/1 mL Inj $3morphine 15 mg ER Tab $6morphine 15 mg Tab $2morphine 2 mg/1 mL Inj $2morphine 2 mg/mL Oral Liquid $6morphine 30 mg ER Tab $6morphine 300 mg/20 mL Inj $3morphine 60 mg ER Tab $6morphine PCA 30 mg/30 mL Inj $23morrhuate sodium 1500 mg/30 mL Inj $93MR Ablavar 10ml $33MR DOTAREM 10ml Prefilled $107MR DOTAREM 10ml-101511 $95MR Dotarem 20ml Vial-104427 $92MR Eovist 10ml $301MR Gadavist 10ml $131MR Magnevist 10mL-29924 $67MR Magnevist 20mL $104MR Optimark 10ml $169MR Optimark 20ml $356MR Optimark 5ml $38MR Sodium Chloride 50ml Prefill-96325 $27Multiple Vitamins Pediatric Inj $138Multiple Vitamins Pediatric Oral Liq 50 mL $169Multiple Vitamins Tab $5Multiple Vitamins w Iron Pediatric Oral Liq 50 mL $3,523Multiple Vitamins with Minerals Tab $6,388multivitamin with minerals (Ocuvite) antioxidants Tab $9,546mupirocin 2% Oint 22 gm $255

136 of 317 FY2018

DESCRIPTION CHARGES

mycophenolate mofetil 250 mg Cap $277mycophenolic acid 180 mg Tab $592Na chondroitin-hyaluronate ophth 40 mg-17 mg/mL Sol $539Na hyaluronate 5.5 mg/0.55 mL Intraocular Liq $4,240Na hyaluronate 8.5 mg/0.85 mL Intraocular Liq $22,044nabumetone 500 mg Tab $44,087nafcillin 1 gm Inj $790nafcillin 2 gm Inj $2,714nalbuphine 10 mg/1 mL Inj $7,740naloxegol 25 mg Tab $7naloxone 0.4 mg/1 mL Inj $6Naloxone 1mg $151naloxone 2 mg/2 mL Inj $10,488naloxone 4 mg/0.1 mL Nasal Spray (Urgent Care Only) $3,478naphazoline Opth 0.012% Sol $4,598naphazoline-pheniramine Opth Sol $2,217naproxen 250 mg Tab $12,683naproxen 500 mg Tab $2,427natalizumab 300 mg/15 mL Inj $8,090nateglinide 120 mg Tab $11,153nateglinide 60 mg Tab $3,119nebivolol 2.5 mg Tab $2,709nebivolol 5 mg Tab $172needle for insulin pen $8,179nelfinavir 250 mg Tab $7,946neomycin 500 mg Tab $2,988neomycin-polymyxin B sulfate Irr Sol $33,927neostigmine 1 mg/1 mL 5 mL syringe $2,466neostigmine 1 mg/1 mL inj $11,783neostigmine 10 mg/10 mL Inj $1,240neostigmine 5 mg/10 mL Inj $581Neulasta 6mg $18,700nevirapine 200 mg Tab $43New Skin Liquid Bandage $7,770New Skin Liquid Bandage Spray $861niacin 100 mg Tab $16,324niacin 500 mg SR Tab $2,537

137 of 317 FY2018

DESCRIPTION CHARGES

niCARdipine 1 mg/10 mL Syringe $3,818niCARdipine 25 mg/10 mL Inj $95nicotine 14 mg/24 hr Patch $2,069nicotine 2 mg Oral Gum $6nicotine 21 mg/24 hr Patch $6nicotine 7 mg/24 hr Patch $7,512NIFEdipine 10 mg Cap $14,977NIFEdipine 30 mg ER Tab $37,509NIFEdipine 60 mg ER Tab $3,780niMODipine 30 mg Cap $1,890nitrofurantoin 50 mg Cap $35nitrofurantoin monomacrocrystals 100 mg Cap $103nitroglycerin 0.1 mg/hr Patch $108nitroglycerin 0.2 mg/hr Patch $148nitroglycerin 0.4 mg Spray $14,418nitroglycerin 0.4 mg sublingual Tab $57nitroglycerin 0.4 mg/hr Patch $72nitroglycerin 0.6 mg/hr Patch $7,647nitroglycerin 2 mg/10 mL Syringe $407nitroglycerin 2% Oint Packet $5,934nitroglycerin 50 mg/10 mL Inj $3,484nitroglycerin 50 mg/250 mL D5W $11,441nitroglycerin 6.5 mg ER Cap $5,569nitroprusside 50 mg/2 mL Inj $11,718nivolumab 100 mg/10 mL Inj $954Nivolumab 1mg $126nivolumab 40 mg/4 mL Inj $3,819NM Choletec Kit $232NM DTPA Kit $527NM F18 AXUMIN PER DOSE $6,805NM F18 Florbetaben $5,600NM F18 FLORBETAPIR-109431 $5,270NM I 123 MIBG 10 MCI $4,119NM Lymphoseek $1,078NM MAA Kit $1,199norepinephrine 4 mg/4 mL Inj $49Normal Saline IV 1000mL-1565 $72

138 of 317 FY2018

DESCRIPTION CHARGES

Normal Saline IV 250mL $72Normal Saline IV 500mL $72nortriptyline 10 mg Cap $57nortriptyline 25 mg Cap $4,950NS IRRIGATION 2000CC $50Nulojix 1mg $19nystatin 100,000 units/1 mL Oral Susp $1,122nystatin Top 100,000 units/g Crm $2,802nystatin Top 100,000 units/g Oint $12,402nystatin Top 100,000 units/g Pwdr $1,257nystatin-triamcinolone Top Crm $2,530nystatin-triamcinolone Top Oint $253Obinutuzumab 10mg $271Ocrelizumab 1mg $280ocrelizumab 300 mg/10 mL Inj $1,257Octreoscan $5,865octreotide 100 mcg/1 mL Inj $2,530octreotide 20 mg depot Inj $253octreotide 30 mg depot inj $968octreotide 500 mcg/1 mL Inj $2,807ocular lubricant (Systane) Ophth. Solution $4,549ofloxacin 0.3% Ophth Sol $48OLANZapine 10 mg Inj $205OLANZapine 10 mg Tab $4,403OLANZapine 2.5 mg Tab $1,555OLANZapine 5 mg Tab $2,514Olaratumab 10mg $248omega-3 (Fish Oil) 1000 mg Cap $645Omnipaque 180 20ml $100Omnipaque 300 10ml $97ondansetron 4 mg OD Tab $1,578ondansetron 4 mg/2 mL Inj $98,169ondansetron 40 mg/20 mL Inj $15ondansetron 8 mg OD Tab $3,897ophthalmic irrigation, extraocular - Sol $4,880Opium Tincture $21,500Optiray 240 50 ml $219

139 of 317 FY2018

DESCRIPTION CHARGES

Optiray 300 100ml Prefilled $259Optiray 320 50ml $229Optiray 320 50ml Prefilled $256Optiray 320 100ml w/ IV sets $343Optiray 320 125ml Prefilled $532Optiray 320 150ml $746Optiray 350 100ml Prefilled $377Optiray 350 200ml $187Optiray 350 50ml $51Optiray 50cc $29Orbactiv 10mg $122Orencia 10mg $110oseltamivir 30 mg Cap $426oseltamivir 6 mg/1 mL Oral Susp $227oseltamivir 75 mg Cap $2,348oxacillin 1 gm Inj $25,787oxaliplatin 100 mg/20 mL Inj $790oxaliplatin 50 mg/10 mL Inj $3,459oxazepam 15 mg Cap $15,011OXcarbazepine 150 mg Tab $3,351OXcarbazepine 300 mg Tab $2,266oxidized cellulose (Interceed) pad $2,334oxidized cellulose (Oxycel) Pad $850oxybutynin 5 mg ER Tab $1,700oxybutynin 5 mg Tab $425oxyCODONE 10 mg ER Tab $8,063oxyCODONE 20 mg ER Tab $300oxyCODONE 40 mg ER Tab $3,674oxyCODONE 5 mg Tab $7,347oxymetazoline Nasal 0.05% Spray $1,837Oxymetazoline/Lidocaine 2% Nasal Spray $3,810oxytocin 10 units/1 mL Inj $4,988oxytocin 30 units/500 mL NS $9,975PACLitaxel 100 mg/16.7 mL Inj $20,923PACLitaxel 30 mg/5 mL Inj $2,494Pain Ease Spray $5,728palivizumab 50 mg/0.5 mL Inj $11,455

140 of 317 FY2018

DESCRIPTION CHARGES

palonosetron 0.25 mg/5 mL Inj $2,864pamidronate 30 mg Inj $551pamidronate 90 mg Inj $5,212pancrelipase 120,000 units-24,000 units-76,000 units Cap $2,606pancrelipase 30,000 units-6000 units-19,000 units Cap $6,026pancuronium 1 mg/1 mL inj $1,040pancuronium 10 mg/10 mL Inj $155Panhematene 1mg $65pantoprazole 40 mg Inj $6,708pantoprazole 40 mg Tab $2,838papain-urea 10%-10% Oint $4,114papaverine 60 mg/2 mL Inj $8,590paricalcitol 5 mcg/1 mL Inj $733PARoxetine 10 mg Tab $24PARoxetine 20 mg Tab $142patiromer 8.4 gm Powder $206PED-acyclovir 5 mg/mL Inj $27PED-adenosine 0.3 mg/mL Inj $47PED-alprostadil 200 mcg/20 mL Inj $1,722PED-aminophylline 5 mg/mL Inj $3,044PED-ampicillin 30 mg/mL Inj $1,172PED-ampicillin-sulbactam 30 mg/mL Inj $2,104PED-atracurium 0.5 mg/mL PF Inj $28,488PED-cefTRIAXone 100 mg/mL Inj $124PED-clindamycin 6 mg/mL Inj $124PED-digoxin 10 mcg/mL Inj $8,385PED-DOBUTamine 40 mg/20 mL Inj $15,932PED-DOPamine 400 mg/250 mL D5W $23,857PED-EPINEPHrine 2 mg/20 mL Inj $1,825PED-famotidine 2 mg/mL Inj $912PED-fentaNYL 10 mcg/1 mL Inj $294PED-gentamicin 5 mg/mL Inj $88PED-glucose 40% Oral Gel 15 mL UD Cup $6,090PED-hydrocortisone 1 mg/ml Inj $1,461PED-influenza virus vaccine (For age 6-35 months) $32,152PED-levetiracetam 15 mg/mL Inj $22,944PED-midazolam 50 mcg/1 mL Inj $13,432

141 of 317 FY2018

DESCRIPTION CHARGES

PED-morphine 0.4 mg/mL Oral Liquid $25,111PED-morphine 1 mg/10 mL Inj $1,381PED-oxacillin 50mg/mL Inj $98PED-penicillin GK 50,000 units/mL Inj $16,725PED-PHENobarbital 10 mg/mL Inj $3,664PED-tobramycin 5 mg/mL Inj $10,481PED-vancomycin 5 mg/mL Inj $3,889pegfilgrastim 6 mg/0.6 mL Inj $1,733pembrolizumab 100 mg/4 mL Inj $5,829PEMEtrexed 500 mg Inj $3,398penicillin desensitization $6,012penicillin G benz 1,200,000 units/2 mL IM Susp $1,591penicillin G benz 2,400,000 units/4 mL IM Susp $44penicillin GK 1,000,000 units Inj $6,849penicillin GK 20,000,000 units Inj $16,546penicillin GK 5,000,000 units Inj $3,070Penicillin VK 0.5 mg/mL Desensitization $7,737penicillin VK 250 mg Tab $5,616penicillin VK 250 mg/5 mL Oral Susp $520Penicillin VK 5 mg/mL Desensitization $171Penicillin VK 50 mg/mL Desensitization $35pentamidine 300 mg Inj $404pentamidine 300 mg/6 mL Inhalation solution $910Pentostatin 10mg $8,708pentoxifylline 400 mg ER Tab $4,128Perflutren Lipid Mic Inj-Definity $354perphenazine 2 mg Tab $5,084Pertuzumab 1mg $54pertuzumab 420 mg/14 mL Inj $393PET Cardiogen RB82 Per Dose $667PET FDG Unit Dose $1,381PET Prov of Isotope NAFL UnitDose $1,381phenazopyridine 100 mg Tab $391phenazopyridine 200 mg Tab $1,839PHENobarbital 130 mg/1 mL Inj $130PHENobarbital 16.2 mg Tab $61PHENobarbital 20 mg/5 mL Oral Liq $1,271

142 of 317 FY2018

DESCRIPTION CHARGES

PHENobarbital 32.4 mg Tab $1,917phenol (Phenaseptic) Spray $79phenoxybenzamine 10 mg Cap $978phentolamine 5 mg Inj $228phenylephrine 0.25% Supp $14phenylephrine 10 mg/1 mL Inj $58phenylephrine 100 mcg/1 mL 10 mL syringe $110phenylephrine Nasal 0.25% Spray $8phenylephrine Nasal 0.5% Spray $34phenylephrine Oint $372phenylephrine Opth 10% Sol $1,693phenylephrine Opth 2.5% Sol $70phenytoin 100 mg ER Cap $137phenytoin 100 mg/2 mL Inj $36phenytoin 100 mg/4 mL Oral Susp $74phenytoin 250 mg/5 mL Inj $59phenytoin 50 mg Chew Tab $2,241physostigmine 2 mg/2 mL Inj $337phytonadione 1 mg/0.5 mL Inj $5phytonadione 10 mg/1 mL Inj $25phytonadione 5 mg Tab $156pilocarpine Opth 1% Sol $343pilocarpine Opth 2% Sol $37pilocarpine Opth 4% Sol $36pioglitazone 15 mg Tab $16piperacillin-tazobactam $52piperacillin-tazobactam 3.375 gm Inj $73piperacillin-tazobactam 3.375 gm/50 mL D5W $322piperacillin-tazobactam 4.5 gm Inj $567Plavix 0.5 mg/mL Desensitization $108Plavix 5 mg/mL Desensitization $636pneumococcal 13-valent conjugate vaccine 0.5 mL Inj $5,705pneumococcal 23-valent vaccine 0.5 mL Inj $486Pneumococcal Vaccine $47Pneumovax 0.5mL $176

poliovirus vaccine, inactivated SubQ Susp (FOR CLINIC USE ONLY) $366

143 of 317 FY2018

DESCRIPTION CHARGES

polycarbophil 625 mg Tab $56polyethylene glycol 3350 Oral Pwdr 17 gm Packet $24polyethylene glycol 3350 Oral Pwdr Bottle $2,934polyethylene glycol electrolytes 4000 mL $16polymyxin B sulfate 500000 units Inj $50poractant 240 mg/3 mL intratracheal Susp $47pot phosphate-sod phosphate (Phos-Nak) powder pkt $51pot phosphate-sod posphate 250 mg-45 mg-298 mg Tab $32potassium acetate 40 mEq/20 mL Inj $65potassium bicarbonate 25 mEq Eff Tab $121potassium chloride 10 mEq ER Tab $18potassium chloride 10 mEq/100 mL IV Sol $57potassium chloride 20 mEq Oral Pwdr $18potassium chloride 20 mEq/10 mL Inj $28potassium chloride 20 mEq/100 mL IV Sol $35potassium chloride 20 mEq/50 mL IV Sol $81potassium chloride 40 mEq/20 mL Inj $129potassium phosphate 45 mmol/15 mL Inj $18povidone iodine 10% Oint $24povidone iodine Opth 5% Sol $64PPD 5 TU/0.1 mL Intradermal Inj $36pralidoxime 1000 mg Inj $235pramipexole 0.25 mg Tab $61pramipexole 1 mg Tab $33pramoxine Top 1% Rectal Foam $46prasugrel 10 mg Tab $89pravastatin 20 mg Tab $188pravastatin 40 mg Tab $1,924prazosin 1 mg Cap $26prednisoLONE Opth acetate 0.12% Susp $57prednisoLONE Opth acetate 1% Susp $90prednisoLONE sod phos 3 mg/mL Oral Syringe $79predniSONE 1 mg Tab $23predniSONE 10 mg Tab $57Prednisone 1mg PO $2predniSONE 2.5 mg Tab $96predniSONE 20 mg Tab $145

144 of 317 FY2018

DESCRIPTION CHARGES

predniSONE 5 mg Tab $289predniSONE 50 mg Tab $62pregabalin 25 mg Cap $125pregabalin 50 mg Cap $1,358pregabalin 75 mg Cap $1,358Prenatal Multivitamins with Folic Acid 1 mg Tab $116Primatrix Graft Per Sq Cm $68primidone 250 mg Tab $105primidone 50 mg Tab $47Privigen 500mg $279probenecid 500 mg Tab $38prochlorperazine 10 mg Tab $139prochlorperazine 10 mg/2 mL Inj $59prochlorperazine 25 mg Supp $41prochlorperazine 5 mg Tab $38Prochlorperazine 5mg PO $2progesterone 50 mg/1 mL Inj $52progesterone 500 mg/10 mL Inj $110PROLASTIN C 10MG $19Prolia 1mg $59promethazine 25 mg Supp $208promethazine 25 mg Tab $219promethazine 25 mg/1 Inj $2,027propafenone 150 mg Tab $156propofol 1000 mg/100 mL Inj $36propofol 200 mg/20 mL Inj $25propofol 500 mg/50 mL Inj $68propranolol 1 mg/1 mL Inj $258propranolol 10 mg Tab $2,548propranolol 20 mg Tab $7propranolol 60 mg ER Cap $30propranolol 80 mg ER Cap $33propylthiouracil 50 mg Tab $50protamine 250 mg/25 mL Inj $609protamine 50 mg/5 mL Inj $1,795prothrombin complex (Kcentra) Vial $36Provenge 1 Unit $88,782

145 of 317 FY2018

DESCRIPTION CHARGES

pseudoephedrine 120 mg ER Tab $862pseudoephedrine 30 mg Tab $68pseudoephedrine 30 mg/5 mL Oral Liq 118 mL $867psyllium Oral Pwdr Packet $9pyridostigmine 60 mg Tab $86pyridOXINE (Vit B6) 100 mg Tab $60pyridOXINE (Vit B6) 100 mg/1 mL Inj $13pyridOXINE (Vit B6) 50 mg Tab $12QUEtiapine 100 mg Tab $40QUEtiapine 25 mg Tab $628QUEtiapine 50 mg ER Tab $1,550quiNIDine 200 mg Tab $252quiNIDine 300 mg ER Tab $252quiNIDine 300 mg Tab $66quiNIDine 800 mg/10 mL Inj $22rabies imm glob 1500 units/5 mL Inj $72rabies imm glob 300 units/1 mL Inj $141rabies vaccine 2.5 units/1 mL Inj $54racepinephrine 2.25% Inh Sol $1,462Rad Bill Only $5,270Radium 223 Therapeutic Infusion $54,962raloxifene 60 mg Tab $102raltegravir 400 mg Tab $21ramipril 1.25 mg Cap $43ramipril 10 mg Cap $897ramipril 5 mg Cap $27Ramucirumab 5mg $268ranibizumab Opth 0.5 mg/0.05 mL Inj $221Ranitidine 25mg $18ranolazine 500 mg ER Tab $49rasburicase 1.5 mg Inj $405Recombinant zoster (shingles) vaccine $17regadenoson 0.4 mg/5 mL Inj $352Relistor 0.1mg $4Remicade 10mg $334remifentanil 2 mg Inj $341repaglinide 1 mg Tab $38

146 of 317 FY2018

DESCRIPTION CHARGES

RHIG $335RHo (D) immune globulin 1500 units/1.3 mL Inj $538RHo (D) immune globulin 5000 units/4.4 mL Inj $236Rhogam 300mcg $122rifAMPin 300 mg Cap $757rifAMPin 600 mg Inj $29rifAXIMin 550 mg Tab $538riMANTAdine 100 mg Tab $233riMANTAdine 50 mg/5 mL Oral Liq $807ringers IV Sol 1000 mL $243risperiDONE 0.25 mg Tab $265risperiDONE 1 mg Tab $323risperiDONE 1 mg/mL Oral Sol $531Rituxan 100mg IV $3,418riTUXimab 100 mg/10 mL Inj $462rivaroxaban 10 mg Tab $978rivaroxaban 15 mg Tab $143rivaroxaban 20 mg Tab $59rivastigmine 1.5 mg Cap $231rivastigmine 4.6 mg/24 hr Patch $501rivastigmine 9.5 mg/24 hr Patch $1,145ROCuronium 10 mg/1 mL inj $62ROCuronium 50 mg/5 mL Inj $487roflumilast 500 mcg Tab $72Romiplostim 10mcg $237romiPLOStim 250 mcg Inj $1,916rOPINIRole 0.25 mg Tab $896rOPINIRole 1 mg Tab $972rOPINIRole 2 mg Tab $37,154ropivacaine 0.2% 100 mL Inj $107ropivacaine 0.5% 30 mL Inj $792rosuvastatin 10 mg Tab $78rosuvastatin 20 mg Tab $9rosuvastatin 5 mg Tab $210sacubitril-valsartan 24 mg-26 mg Tab $88sacubitril-valsartan 49 mg-51 mg Tab $97sacubitril-valsartan 97 mg-103 mg Tab $64

147 of 317 FY2018

DESCRIPTION CHARGES

salicylic acid Top 17% Liq $206salicylic acid-sulfur Shampoo $26saliva substitutes Spray $1,107salmeterol Inhaler $445Salt Substitutes Crystals $1,107Sandostatin Lar 1mg $633saquinavir mesylate 200 mg Cap $1,144sargramostim 500 mcg/1 mL Inj $2,513scopolamine 0.4 mg/1 mL Inj $258scopolamine 1 mg/3 day Patch $469selenium 400 mcg/10 mL Inj $48selenium sulfide Top 2.5% Lotion/Shampoo $28senna 8.6 mg Tab $421sertraline 100 mg Tab $933sertraline 50 mg Tab $39sevelamer 800 mg Tab $12sevelamer carbonate 0.8 gm Powder $10sevelamer carbonate 2.4 gm Powder $1,584Shingles Vaccine $200sildenafil 20 mg Tab $67sildenafil 50 mg Tab $127Silvasorb Gel $86Silver Lactate 0.5% Solution $12silver nitrate Top Stick $31silver sulfADIAZINE Top 1% Crm 400 gm $29silver sulfADIAZINE Top 1% Crm 50 gm $53simethicone 40 mg/0.6 mL Liq 30 mL $27simethicone 80 mg Chew Tab $30Simponi Aria 1mg $157sincalide 5 mcg Inj $26Sm 153 Thera Per Tx Dose Up to 150 $80,866sod hypochlorite (Dakin's Half Strength) top 0.25% Sol $134sodium acetate 40 mEq/20 mL Inj $32sodium bicarbonate (Neut) 4.2% 5 mL Inj $56sodium bicarbonate 4.2% 10 mL Syringe Inj $83sodium bicarbonate 50 mEq/50 mL Syringe $25sodium bicarbonate 650 mg Tab $224

148 of 317 FY2018

DESCRIPTION CHARGES

Sodium Chloride 0.45% IV Sol 500 mL $260sodium chloride 0.45% IV Sol 1000 mL $546Sodium Chloride 0.45% with KCl 20 mEq/L $744Sodium Chloride 0.9% $43sodium chloride 0.9% 10 mL Flush Inj $110sodium chloride 0.9% 10 mL Inj PF $204sodium chloride 0.9% 20 mL Inj PF $407sodium chloride 0.9% Inh Sol 3 mL $218sodium chloride 0.9% Irr Sol 1000 mL Bottle $3,173sodium chloride 0.9% Irr Sol 2000 mL Bag $171sodium chloride 0.9% Irr Sol 500 mL Bottle $134Sodium Chloride 0.9% IV Sol 100 mL $68Sodium Chloride 0.9% IV Sol 1000 mL $864Sodium Chloride 0.9% IV Sol 150 mL $8Sodium Chloride 0.9% IV Sol 250 mL $53Sodium Chloride 0.9% IV Sol 500 mL $114Sodium Chloride 0.9% with KCl 20 mEq/L IV Sol 1000 mL $489Sodium Chloride 0.9% with KCl 40 mEq/L IV Sol 1000 mL $2,670sodium chloride 1 gm Tab $8,650sodium chloride 120 mEq/30 mL Inj $9sodium chloride 3% Inh Sol 4 mL $10Sodium Chloride 3% IV Sol 500 mL $13sodium chloride bact. 0.9% 30 mL Inj $112sodium chloride nasal 0.65% Sol 45 mL $123sodium chloride, hypertonic, Opth 5% Sol $64sodium chondroitin-hyaluronate Opth Sol 0.5 mL $85sodium hyaluronate 20 mg/2 mL intra-articular Inj $38sodium hyaluronate ophth (Duovisc) Kit $72sodium phosphate 45 mmol/15 mL Inj $59sodium polystyrene sulfonate 15 gm/60 mL Oral Susp $357sodium sulfacetamide Opth 10% Sol $59sodium tetradecyl sulfate 60 mg/2 mL Inj $1,033sodium thiosulfate 12.5 gm/50 mL Inj $1,019Softshield 12 Hour $45SOL IRRIG LR 3000ML-1584 $50Sol IV .9 Sod Chl 150CC $72SOL IV 5 PERC DEX 45 PERC NACL 1000ML-1550 $72

149 of 317 FY2018

DESCRIPTION CHARGES

SOL IV LACT RINGER 1000ML-1557 $72Soliris 10mg $1,086Solucortef 100mg $43Solu-Medrol Up To 125 Mg $48sorbitol 70% Oral Liq UD 30 mL $123sotalol 80 mg Tab $17spironolactone 25 mg Tab $14Spray Kit $24stavudine 30 mg Cap $24Stelara IV 1 mg $64Stelara Sub-Q 1mg $1,094streptomycin 1 gm Inj $39Strong iodine Solution 14 mL UD $59sinylcholine 20 mg/1 mL 10 mL syringe $20sinylcholine 20 mg/1 mL Inj $22sinylcholine 200 mg/10 mL Inj $36sucralfate 1 gm Tab $132sucralfate 1 gm/10 mL Oral Susp $73sucrose 24% PF oral solution $42SUFentanil 50 mcg/1 mL Inj $22sugammadex 100 mg/mL Inj $50sulfacetamide 10%-prednisolone 0.23% Opth Sol $37sulfameth-trimeth 4 mg-0.8 mg/1 mL Desensitization Susp $101sulfameth-trimeth 40 mcg-8 mcg/1 mL Desensitization Susp $37

sulfameth-trimeth 400 mcg-80 mcg/1 mL Desensitization Susp $125sulfameth-trimeth 400 mg-80 mg Tab $611sulfameth-trimeth 80 mg-16 mg/mL Inj $11sulfameth-trimeth 800 mg-160 mg Tab $60sulfameth-trimeth 800 mg-160 mg/20 mL UD Oral Susp $78sulfanilamide 15% Vag Crm $17sulfaSALAzine 500 mg Tab $11SUMAtriptan 100 mg Tab $36SUMAtriptan 25 mg Tab $386SUMAtriptan 50 mg Tab $1,299SUMAtriptan 6 mg/0.5 mL Inj $1,205Supplies- Fluorine F-18 (Fdg) $1,033

150 of 317 FY2018

DESCRIPTION CHARGES

Surgicel 2x14 Oxidized Cellulose Pad $1,237Surgicel Nu-Knit Cellulose Pad $44Surgicel Snow 4x4 Oxidized Cellulose Pad $74surgifoam/gelfoam sponge size 12-7 $196SYRINGE PREFILLED SODIUM CHLORIDE 0.9 PERCENT POSIFLUSH 10 ML $23Tachosil Patch $58tacrolimus 0.5 mg Cap $137talc 4 gm $242tamoxifen 10 mg Tab $48tamsulosin 0.4 mg Cap $717tapentadol 50 mg Tab $52Taxol 1mg IV $3TC 99m $156TC 99m CEA $13,016TC 99M CERETEC $2,071TC 99m Choletec 5mci $185TC 99m DTPA $258TC 99m HDP $68TC 99m MAA $366TC 99m MAG $726TC 99m MDP $45TC 99m Myoview $536TC 99m PYP $89TC 99m RBC $444TC 99m RBC Ultra Tag $444TC 99m Sestamibi $1,266TC 99m Sulfur Colloid $361Tdap $75Tears Oint $128Tecentriq 10mg $371Telavancin 10mg $28telavancin 250 mg Inj $87telavancin 750 mg Inj $152temazepam 15 mg Cap $9temazepam 30 mg Cap $10temazepam 7.5 mg Cap $18

151 of 317 FY2018

DESCRIPTION CHARGES

Temozolomide 1mg $22temsirolimus 25 mg/1 mL Inj $1,829tenecteplase 50 mg Inj $61terazosin 1 mg Cap $154terazosin 2 mg Cap $685terazosin 5 mg Cap $112terbinafine 250 mg Tab $620terbutaline 1 mg/1 mL Inj $119testosterone cypionate 200 mg/1 mL Inj $231Tetanus And Diptheria $48tetanus immune globulin 250 units/1 mL Inj $32tetanus/diphtheria/pertussis, acel (Tdap) Vaccine Inj $152tetanus-diphtheria toxoids 0.5 mL Inj $166tetracaine 20 mg/2 mL Inj $130tetracaine Opth 0.5% Sol $86tetracaine Top 2% Sol $96tetrahydrozoline Opth 0.05% Sol $62theophylline 100 mg/24 hours Cap $14theophylline 200 mg/24 hours Cap $46thiamine (Vit B1) 100 mg Tab $197thiamine (Vit B1) 200 mg/2 mL Inj $16thiotepa 15 mg Inj $71thiothixene 1 mg Cap $171thrombin bovine 5 mL (Floseal) Kit $813thrombin topical 20,000 units $86thrombin topical 5000 units $97Thyrogen $5,948thyroid 30 mg Tab $342thyroid 60 mg Tab $295ticagrelor 60 mg Tab $9ticagrelor 90 mg Tab $204ticlopidine 250 mg Tab $118tigecycline 50 mg Inj $7timolol Opth 0.25% Sol $285timolol Opth 0.5% Sol $196tiotropium 2.5 mcg/inh Respimat Inhaler $1,174TISSEEL FROZEN RTU 4ML-91860 $546

152 of 317 FY2018

DESCRIPTION CHARGES

TISSUE STRAVIX VIABLE CRYOPRESERVED PLACENTAL UMBILICAL 3X6 CM-110053 $6,365TISSUE STRAVIX VIABLE CRYOPRESERVED PLACENTAL UMBILICAL 5X5CM-110056 $5,700TISSUE STRAVIX/VIABLE CRYPORESERVED PLACENTIAL UMBILICAL 2 X 4CM-107654 $3,800tiZANidine 4 mg Tab $2tobramycin 1.2 gm Powder for Inj $23tobramycin 1200 mg/30 mL Inj $64tobramycin 80 mg/2 mL Inj $115tobramycin Opth 0.3% Oint $494tobramycin Opth 0.3% Sol $44tocilizumab 400 mg/20 mL Inj $61tolterodine 2 mg ER Cap $538tolterodine 4 mg ER Cap $73tolvaptan 15 mg Tab $7tolvaptan 7.5 mg Tab $155topiramate 100 mg Tab $374topiramate 25 mg Tab $2Topotecan .1mg $155topotecan 4 mg Inj $269Torisel 1mg $279TPN 2:1 $712TPN Adult 3:1 $107TPN Filter 0.22 Micron $349trace elements Inj 2 mL $193trace elements Inj 3 mL $444trace elements with selenium 10 mL Inj $411traMADol 50 mg Tab $4tranexamic acid 1000 mg/10 mL Inj $110trastuzumab 150 mg Inj $432travoprost 0.004% Opth Sol $275traZODone 100 mg Tab $45traZODone 50 mg Tab $1,285Treanda 1mg $103tretinoin 10 mg Cap $2,633Triad Wound Dressing Paste $22

153 of 317 FY2018

DESCRIPTION CHARGES

triamcinolone 0.1% Oint 15 gm $495triamcinolone 0.1% Oint 454 gm $108triamcinolone acetonide 200 mg/5 mL Inj $966triamcinolone acetonide 40 mg/1 mL Inj $4,157triamcinolone Top 0.025% Crm 15 gm $38triamcinolone Top 0.025% Crm 454 gm $5triamcinolone Top 0.1% Crm 15 gm $11triamcinolone Top 0.1% Crm 454 gm $16trifluoperazine 1 mg Tab $100trifluoperazine 5 mg Tab $46trifluridine Opth 1% Sol $425trihexyphenidyl 2 mg Tab $113trimethobenzamide 200 mg/2 mL Inj $136trimethobenzamide 300 mg Cap $224trimethoprim 100 mg Tab $225tropicamide Opth 1% Sol $110trypan blue Opth 0.06% Sol $53Tysabri 1mg $58umeclidinium-vilanterol 62.5 mcg-25 mcg Inhaler $31Urine Pregnancy $141VAD Contrast Omnipaque 50ml-103466 $36VAD OPTIRAY 240 50ML $173VAD OPTIRAY 320 50ML $195VAD SOL IV NS 100ML $3VAD Visipaque 320 50ml-82601 $243valACYclovir 500 mg Tab $29valGANciclovir 450 mg Tab $31valproic acid 250 mg Cap $35valproic acid 250 mg/5 mL Oral Liq $32valproic acid 500 mg/5 mL Inj $182valsartan 160 mg Tab $72valsartan 40 mg Tab $848valsartan 80 mg Tab $181Vancomycin 0.02 mg Desensitization $32Vancomycin 0.2 mg Desensitization $317vancomycin 1 mg/0.1 mL Intravitreal Inj $8vancomycin 1000 mg $117

154 of 317 FY2018

DESCRIPTION CHARGES

vancomycin 1000 mg/200 mL NS $3vancomycin 125 mg/2.5 mL Oral Syringe $153Vancomycin 2 mg Desensitization $82Vancomycin 20 mg Desensitization $18vancomycin 50 mg/1 mL Opth Sol 15 mL $18vancomycin 500 mg $92vancomycin 5000 mg Inj $176Vancomycin 500mg $27vancomycin 750 mg $2,196vancomycin 750 mg/150 mL NS $1,199Vancomycin Enema $7Vancomycin Enema $1,746Vancomycin/Gentamicin/Aquaphor Oint $44varenicline 1 mg Tab $221vasopressin 20 units/1 mL Inj $308Vectibix 10mg $389VECuronium 10 mg Inj $3,064Vedolizumab 1mg $90Velcade .1mg $222venlafaxine 150 mg ER Cap $78venlafaxine 37.5 mg ER Cap $41venlafaxine 50 mg Tab $816venlafaxine 75 mg ER Cap $29venlafaxine 75 mg Tab $184Venofer 1mg $7Vepesid 10mg IV $64verapamil 180 mg ER Tab $84verapamil 240 mg ER Tab $77verapamil 5 mg/2 mL Inj $18verapamil 80 mg Tab $182Vidaza 1mg $24vinBLAStine (Velban) 10 mg/10 mL Inj $764Vinblastine 1 Mg $15vinCRIStine (Oncovin) 1 mg/1 mL Inj $753Vincristine 1mg IV $64vinorelbine 10 mg/1 mL Inj $33Vinorelbine 10mg $448

155 of 317 FY2018

DESCRIPTION CHARGES

Visipaque 100ml $187Visipaque 320 100ml $302Visipaque 320 150ml $654VISIPAQUE 50 ML-102667 $57Visipaque 50cc $141vitamin A & D Oint $2Vitamin B Complex (Foltx) Tab $187Vitamin B Complex with C (Stresstab) Tab $44Vitamin B Complex with C and FA (Nephrocap)Cap $929Vitamin B-12 Inj 1,000mg $31vitamin E 200 units Cap $9vitamin E 400 units Cap $693voriconazole 200 mg Inj $614voriconazole 200 mg Tab $1,831warfarin 0.5 mg Tab $17warfarin 1 mg Tab $4,871warfarin 10 mg Tab $152warfarin 2 mg Tab $88warfarin 2.5 mg Tab $1,630warfarin 3 mg Tab $1,399warfarin 4 mg Tab $817warfarin 5 mg Tab $235warfarin 7.5 mg Tab $20water bact. 30 mL Inj $34water, sterile 10 mL Inj PF $64water, sterile 1000 mL Inj Bag $122water, sterile 20 mL Inj PF $300water, sterile 2000 mL Inj Bag $386water, sterile Irr Sol 1000 mL Bottle $83water, sterile Irr Sol 500 mL Bottle $260X Contrast Low Osmolar 100cc $300X Contrast Low Osmolar 50cc $163Xgeva 1mg $83Xolair 5mg $102Y 90 Zevalin Per Dose $161,062Yervoy 1mg $547Zaltrap 1mg $62

156 of 317 FY2018

DESCRIPTION CHARGES

ziconotide 25 mcg/mL Inj $169zidovudine 100 mg Cap $68zidovudine 200 mg/20 mL Inj $73zidovudine 300 mg Tab $233zidovudine 50 mg/5 mL Oral Liq $37zinc chloride 10 mg/10 mL Inj $699zinc sulfate 220 mg Cap $54ziprasidone 20 mg Inj $126Zithromax 500mg $148Zofran 1mg $18Zoladex 3.6 $1,955Zoldronic Acid 1mg $1,067zoledronic acid 4 mg/5 mL Inj $1,066zoledronic acid 5 mg/100 mL IV Sol $83ZOLMitriptan 2.5 mg Tab $314ZOLMitriptan 5 mg Tab $1,459zolpidem 10 mg Tab $248zolpidem 5 mg Tab $221zonisamide 100 mg Cap $406

QUICKCARE FOR KIDS26460 QCK Reduction Nursemaid Elbow $19996372 QCK Injection SQ/IM $11199201 QCK OP Visit Level 1 (New Patient) $10099202 QCK OP Visit Level 2 (New Patient) $12599203 QCK OP Visit Level 3 (New Patient) $15099204 QCK OP Visit Level 4 (New Patient) $17599211 QCK OP Visit Level 1 (Established Patient) $10099212 QCK OP Visit Level 2 (Established Patient) $12599213 QCK OP Visit Level 3 (Established Patient) $15099214 QCK OP Visit Level 4 (Established Patient) $175

ORTHOTICSBoot Ortho Ambulating Large-85489 $454Boot Ortho Ambulating Med-85488 $454Boot Stabilizer Pediatric Ped Lg-110117 $120

157 of 317 FY2018

DESCRIPTION CHARGES

Boot Stabilizer Pediatric Sm/Med-110116 $120Boot Stabilizer Pediatric Xlarge-110118 $120Boot Stabilizer Walker Large-110114 $84Boot Stabilizer Walker Medium-110113 $84Boot Stabilizer Walker Small $84Boot Stabilizer Walker X Large-110115 $84Boot Stabilizer Walker X Small-110111 $84Brace Ankle Surround W/ Gel $371Brace Clavicle Extra Small $154CAST AQUAPLAST WHITE 3X3IN-25982 $14Cast Supplies Max $327Cast Supplies Max $327Cast Supplies Min $171Cast Supplies Mod $213Cast Supplies Short Leg Adult-108141 $206Clavical Brace Adult (Large)-27120 $81Clavicle Brace (Med)-27119 $81Clavicle Brace All $154Clavicle Brace Small-27118 $22COLLAR CERV SM LNG-59197 $91COLLAR CERV ASPEN EXTA TALL ADULT-31482 $162COLLAR CERV ASPEN REG ADULT 983130-31482 $162COLLAR CERV ASPEN REG CHILD-31493 $162COLLAR CERV ASPEN SHORT ADULT 983128-31491 $162COLLAR CERV ASPEN TALL ADULT 983131-31482 $162COLLAR CERV LG-59200 $91COLLAR CERV MED LNG-59199 $91COLLAR CERV MED-59198 $91COLLAR CERV MIAMI JAY WPAD MED-25971 $217COLLAR CERV MIAMI JAY WPAD SHORT-58172 $217COLLAR CERV MIAMI JAY WPAD STD-25970 $217COLLAR CERV MIAMI JAY WPAD TALL-31482 $162COLLAR CERV SM-59196 $91COLLAR CERV XLNG NARROW-59201 $91Collar Cervical Aspen Adult Reg-31482 $175Collar Cervical Aspen Adult Short-31491 $175Collar Cervical Aspen Child Reg-31493 $175

158 of 317 FY2018

DESCRIPTION CHARGES

Collar Cervical Large X Long $91Collar Cervical Large-59200 $91Collar Cervical Med X-Long-59199 $91Collar Cervical Medium-59198 $91Collar Cervical Miami Jay Med-25971 $163Collar Cervical Miami Jay Short-25972 $163Collar Cervical Miami Standard-25970 $163Collar Cervical Small X-Long-59197 $91Collar Cervical Small-59196 $91Collar Cervical Vista Adult-110769 $99Collar Neck Patriot Adult-110143 $18Collar Neck Patriot Peds-110136 $18Custom TlSO Back Brace $4,538I CPM Sling $47IMMOBILIZER KNEE TRI PANEL CONTOURED 19IN-33390 $288IMMOBILIZER KNEE TRI PANEL CONTOURED 24IN-33390 $288Lg Boot $162Orthotics AFO $2,668Orthotics AFO Brace $1,378Orthotics Brace Cervical Thoracic $912Orthotics Brace Hip Spica $2,612Orthotics Brace Humeral $1,000Orthotics Brace M Type $3,169Orthotics Collar(Miami/Aspen) $718Orthotics Corset Dorsosacral $359Orthotics Corset Lumbar $322Orthotics Corset Lumbar Sacral $289Orthotics Corset Lumbar Thoracic $817Orthotics Halo $4,847Orthotics Halo Addition $2,347Orthotics LSO Corset $291Orthotics LSO Corset Back $1,582Orthotics LSO Corset Front $152Orthotics LSO Corset Soft $419Orthotics LSO Former $821Orthotics LSO Molded $2,500Orthotics Tl Body Mold $5,559

159 of 317 FY2018

DESCRIPTION CHARGES

Orthotics Tlso Corset $359Orthotics Tlso Full Clam $3,352Philadelphia Collar $140Regular Boot-108143 $136Shoulder Immobilizer $318Shoulder Immobilizer Mens Lg-36475 $27Shoulder Immobilizer Mens Med-59631 $27Shoulder Immobilizer Mens Small-92063 $27Shoulder Immobilizer Mens XLG-59633 $27Shoulder Immobilizer Nursing $318Shoulder Immobilizer Women XL-92064 $27Shoulder Immobilizer Women XXL-92065 $27Sling _ Comfort $36Sling Arm Fashion Navy Ped SPD $16Sling Arm Muslin SPD-27134 $18SLING ARM PADDED STRAP LG LF-1796 $42Sling Arm Padded Strap Med Lf SPD $15SLING ARM PADDED STRAP MED LF-1795 $15Sling Arm Padded Strap Sm Lf SPD $15SLING ARM PADDED STRAP SM LF-1794 $15SLING ARM PADDED STRAP XLG LF-1797 $15Sling Pediatric Child $28Sling Shoulder Immobilizer Lg SSD $19Sling Shoulder Immobilizer Med Lf $19Sling Shoulder Immobilizer Sm Lf $19Sling Shoulder Immobilizer XLG Lf $19SLING ULTRA LG 11-0138-413130-7906 $158SLING ULTRA MED-10347 $80Sling-31159 $19Soft Cervical Collar $93Splint Ankle Universal-84359 $49Splint Baseball 4in $10Splint Baseball 5in $6Splint Baseball Foam Med 2.75in $8Splint Baseball Large-1851 $45Splint Baseball Small-1852 $43Splint Baseball-43216 $10

160 of 317 FY2018

DESCRIPTION CHARGES

Splint Colles All $75Splint Finger 1/2 X 18-34620 $33SPLINT FINGER FOAM 3/4IN X 18IN LF-1845 $5Splint Finger Protector-27121 $39Splint Finger Strt 1x18-1847 $33Splint Finger Strt 3/4 X 18-1845 $33Splint Frog $10Splint Maxi Light $56SPLINT NASAL DOYLE SEPTICAL $126SPLINT NASAL REUTER .25MM $126SPLINT PLASTER FAST SET 3X15IN-1164 $208SPLINT PLASTER FAST SET 5X45IN-27133 $2SPLINT PLASTER ORTHOGLASS 3INX15FT-30304 $194SPLINT PLASTER ORTHOGLASS 4INX15FT-30305 $233SPLINT PLASTER ORTHOGLASS 5INX15FT-30306 $210Splint Post Op Knee Ex-Large-33851 $298Splint Post Op Knee Small-33390 $290SPLINT ROM ORIGINAL LNG-24677 $536SPLINT ROM ORIGINAL SHORT-24669 $296Splint Stack Finger #1 $33Splint Stack Finger #2-32668 $33Splint Stack Finger #3-27138 $33Splint Stack Finger #4 $34Splint Stack Finger #5-27141 $33Splint Stack Finger #6 $28SPLINT THERMA LG $54SPLINT THERMA MED $54SPLINT THERMA SM $54Splint Wrist Lt Ped 6in $19Splint Wrist Ped-59395 $19Splint Wrist Universal-103453 $38Splint Zinfoam $35Splint/Brace Air Ankle/Leg $255Splints Stack $36Split Thumb Spica $26Stiffneck Cervical Collar $46Support Wrist U2 Left 10 Inch SPD $38

161 of 317 FY2018

DESCRIPTION CHARGES

Support Wrist U2 Right 10 Inch SSD $38Universal Knee Immobilizer $212XL Boot-108142 $170

PACEMAKERS & IMPLANTABLES.018x270cm Guidewire $189_ SCREW LEVEL 1 $125_SCREW LEVEL 2 $400_SCREW LEVEL 3 $850_SCREW LEVEL 4 $2,226_SCREW LEVEL 5 $1_SCREW LEVEL 6 $3,182_SCREW LEVEL 7 $4,686014x180 guidewire $172014x300 guidewire $189018 Picc guidewire $851.5MM-100963 $70010.2 FR CORE LOOP NEPH TUBE $224100cm MPA Catheter $7710684 CATHETER C1750 Add on $191109308 ABS TIGHTROPE IMPLANT 278 Add on $1,458110312 SUTURE TAK Add on $1,288110312 SWIVELCK 4.75X19.1 CL EYE Add on $1,28812F Navarre Drainage Tube $11514F Flexi Drain Tube $17418MM X 50CM-103584 $1,95021653 INTRODUCER C1894 Add on $2363403 INTRODUCER C1894 Add on $1673403 PORT C1788 Add on $1673586 CATHETER C1752 Add on $643586 GUIDWIRE C1769 Add on $643587 CATHETER C1750 Add on $1683587 GUIDEWIRE C1769 Add on $1773587 PORT C1788 Add on $1683588 GUIDEWIRE C1769 Add on $2353588 INTRODUCER C1894 Add on $235

162 of 317 FY2018

DESCRIPTION CHARGES

3588 PORT C1788 Add on $2353589 CATHETER C1750 Add on $3683589 INTRODUCER C1766 Add on $3683704 CATHETER C1752 Add on $733704 GUIDEWIRE C1769 Add on $733705 CATHETER C1752 Add on $1143705 GUIDEWIRE C1769 Add on $1143706 CATHETER Add on $1903706 GUIDWIRE C1769 Add on $2153706 INTRODUCER C1894 Add on $1903708 CATHETER C1752 Add on $2713708 GUIDEWIRE C1769 Add on $2713708 PORT C1788 Add on $2713709 CATHETER C1769 Add on $2503709 INTRODUCER C1894 Add on $2503709 PORT C1788 Add on $2503767 CATHETER C1750 Add on $1123767 GUIDEWIRE C1769 Add on $1123767 INTRODUCER C1894 Add on $1124026 35 CM CATH Add on $3084029 710FR STENT Add on $6174029 ACUCISE DEVICE Add on $6174029 GUIDEWIRE Add on $6174029 URETERAL ACCESS SHEATH Add on $6174034 CONNECTOR Add on $1,8294037 SLING Add on $7,08240cm Kumpe Catheter $224mm Bidirectional Abl Cath-94101 $1,1455.5Fr Peel Away Sheath $28501 5F 5 Introducer $665Fr Dual Lumen Solo Picc $2355Fr RCFN 5 18 MPIS NT $6865cm Angio Cath 4Fr Omniflush $228mm Dual Therapy Abl Cath-87236 $1,7609236 ASCENDA ANCHOR Add on $285Ablation Cath-Scorpion 4mm-98365 $1,410Accolade MRI DR IS-1 (EL)-109464 $6,100

163 of 317 FY2018

DESCRIPTION CHARGES

Acrobat Wire 260x4cm-108093 $445ADAPTER OFFSET BMT 360 2.5MM-102639 $1,992ADAPTER OSS SEGMENTAL STACKING REVISION-101792 $295ADAPTER SIGMA FEMORAL NEUTRAL BOLT-105910 $500ADAPTER TIBIAL OFFSET 5.0 BMT 360-102387 $1,804ADAPTOR REV SHOULDER VERSA DIAL STD-98626 $200ADHESIVE MEDICAL-94549 $52AES 035 180 $45AES 38 80 $38Agilis Introducer-88575 $1,760ALLODERM 6CM X 12CM THICK-96987 $3,353

ALLODERM REFRIGERATE 3CMX7CM IMPLANT MEDIUM-32071 $1,680ALLODERM TISSUE 16 X 20CM THICK-95066 $20,958ALLODERM TISSUE 4CM X 16CM-89664 $2,981ALLODERM TISSUE 6CM X 16CM THICK-96742 $4,728ALLOGRAFT BONE CANC CROUTON CUBES 30CC-25044 $1,265ALLOGRAFT BONE CHIPS CANC 15CC-9504 $580ALLOGRAFT CANCELLOUS BONE FREEZE DRIED 1 TO 8MM CHIPS 15CC-110949 $528ALLOGRAFT CANCELLOUS CUBES 15CC-20754 $789ALLOGRAFT CORNEA-25795 $5,180ALLOGRAFT FEMOEAL HEAD W/O CARTHLAGE-92724 $2,504

ALLOGRAFT FEMORAL HEAD WITHOUT CARTILAGE 4.7CM-102278 $1,606ALLOGRAFT FIBULA SHAFT 10CM-98788 $814ALLOGRAFT GRACILIS DOUBLE STRAND GREATER THAN 32 CM-103968 $3,700ALLOGRAFT PRO OSTEON BLOCK 500 12X25X24-80530 $3,694ALLOGRAFT PRO OSTEON BLOCK IP200 50X15X10MM-21780 $2,708ALLOGRAFT SCLERAL WHOLE-35906 $749ALLOGRAFT SEMITENDONOSIS HAM STRING-96408 $3,946ALLOGRAFT SKIN ALLODERM 6/12 1000 THICK 2X4CM GRAFTABLE-69535 $500ALLOGRAFT SPACER BONE PLIF $5,014ALLOGRAFT TENDON ACHILLES-13908 $3,113ALLOGRAFT TENDON ANTERIOR TIBIALIS-96409 $3,300

164 of 317 FY2018

DESCRIPTION CHARGES

ALLOGRAFT TRINITY EVOLUTION 10C-97010 $6,898ALP Balloon $318Altas 12x4x75cm Balloon-87948 $562Altas 14x4x75cm Balloon $1,120AMNION MATRIX 2CM X 3CM $4,858Amplatz Embolization Plug $1,381Amplatzer PFO Occluder-107628 $19,990Amplatzer Plug $1,600ANCHOR 4.75 SWIVELOCK ASBJST Add on $1,069ANCHOR 4.75MM W/FIBERWIRES ASBJST Add on $1,069

ANCHOR BONE WITH ARTHROSCOPIC DELIVERY SYSTEM PKG OF 3 $2,000ANCHOR BUMPY COMPONENT Add on $6,310ANCHOR CINCHLOCK FLEX WITH INSERTER-106137 $1,100ANCHOR FAST FIX AB CURVED-89738 $528ANCHOR FAST FIX AB STRAIGHT-89739 $527ANCHOR GRYPHON P BR DS WITH ORTHOCORD-97570 $822ANCHOR GRYPHON P BR WITH ORTHOCORD-97576 $634

ANCHOR HEALIX ADVANCE BR 4.5 MM WITH ORTHOCORD-105000 $966ANCHOR HEALIX ADVANCE BR 5.5 W/ORTHOCORD-102151 $928ANCHOR HEALIX ADVANCE KNOTLESS 5.5MM-101956 $910ANCHOR HEALIX ADVANCE KNOTLESS BR 5.5MM-102561 $1,010

ANCHOR HEALIX ADVANCE PEEK 4.5MM W/ORTHOCORD-102758 $817ANCHOR HEALIX ADVANCE PEEK 5.5MM WITH ORTHOCORD-101601 $860ANCHOR HEALIX ADVANCE WITH PERMATAPE SUTURE WHITE/BLUE $1,112ANCHOR HEALIX W/ORTHOCORD $725ANCHOR INTERBRACE BIOCOMPOSITE Add on $1,281ANCHOR KNOTLESS CINCHLOCK-104271 $972ANCHOR LEAD CLIK $790ANCHOR LUPINE BR-91745 $739ANCHOR QUICK GII MITEK-91745 $739ANCHOR QUICK MINI S $858ANCHOR QUICK MINI SUT 0 MITEK-7339 $856

165 of 317 FY2018

DESCRIPTION CHARGES

ANCHOR ROTATOR CUFF W/ETHIBOND-14330 $1,060

ANCHOR SCREW SYSTEM BI WING NEUROSTIMULATOR-110224 $550ANCHOR SUTURE 6.5MM V LOXTI-95876 $308ANCHOR SUTURE BIO COMPOSITE 3 X 14.5MM-97976 $650ANCHOR SUTURE BIO COMPOSITE 5.5 X 15MM-97574 $698ANCHOR SUTURE BIO COMPOSITE PUCHLOCK $1,144

ANCHOR SUTURE BIO CORKSCREW 5MM W/TIGERTAIL-88113 $567ANCHOR SUTURE BIOCOMPOSITE FT VENTED W/2 FIBERWIRES 6.5 X 14.7MM-100532 $519ANCHOR SUTURE BIOCOMPOSITE SUTURE TAK-104778 $930ANCHOR SUTURE CORKSCREW FULLY THREADED 5.5 X 16.3MM-103576 $466ANCHOR SUTURE CORKSCREW FULLY THREADED 6.5X16MM-101233 $490ANCHOR SUTURE CORKSCREW WITH 0 FIBERWIRE-102693 $399

ANCHOR SUTURE HELICOIL WITH 3 ULTRABRAID SUTURES-103978 $760

ANCHOR SUTURE HELICOIL WITH ULTRABRAID SUTURES-103807 $764ANCHOR SUTURE MINILOK 1.3MM 2-0 ABSORBABLE $1,162ANCHOR SUTURE PEEK MINI PUSHLOCK-105692 $1,030ANCHOR SUTURE PUSHLOCK HIP PEEK 2.4MM-110697 $1,086ANCHOR SUTURE QUICKANCHOR 2-0 CORD V-5-110002 $1,164ANCHOR SUTURE SPARTAN 5.5MM-100481 $440ANCHOR SUTURE VLOX W/NEEDLES SUTURE 6.5MM-99549 $364ANCHOR SWIFTLOCK-97882 $344

ANCHOR SWIVEL LOC W CLOSED EYELET 4.75 X 19.1MM-97181 $800ANCHOR SWIVELOCK BIOCOMPOSITE 5.5X19.1MM W/CLOSED EYELET C VENTED-100138 $800

ANCHOR SWIVELOCK TENODESIS BIO COMPOSITE 7 X 19.5-103688 $827ANCHOR SWIVELOCK TENODESIS BIO COMPOSITE 8 X 19.5 MM-102590 $870

166 of 317 FY2018

DESCRIPTION CHARGES

ANCHOR SWIVELOCK TENODESIS BIO COMPOSITE 9 X 19.5MM-102643 $770ANCHOR SWIVELOCK TENODESIS BIO CPMPOSITE $1,244ANCHOR TENDON PKG OF 8 $800ANCHOR VERSALOK W/ORTHOCORD-92043 $783ANGIO SEAL 6 FR $470ANGIO SEAL 8 FR BY BOX ONLY-92050 $530Angiodynamic Benston $23Angioseal $524Angioseal Closure Device $386ANNULOPLASTY SYSTEM MC3 TRICUSPID 28-30MM $5,786Ansel Sheath $171Ansil Flexor Introducer 7Fx45cm $109AP2 7 38 90 $23APPLIER HELI-FX WITH ANCHOR CASSETTE-102966 $9,500Argon Micro V Stick 4FR stiff $40Argon Micropuncture V stick 4FR $38ARGON OPTION FILTER-100740 $1,628Argon Thrombectomy Cleaner $1,379Arrow 6x11cm Sheath $435Arrow Super Arrow Flex 9F 24cm Shearth-12076 $85ARTICULAR SURFACE FIXED SZ G/H RIGHT 10MM-102987 $1,330ATB Balloon 10x4x80cm $259Atlas Balloon $590Attain Delivery System-83632 $352AUGMENT BLOCK DIST SZ G 15MM NEXGEN-104634 $2,275AUGMENT BLOCK POST SZ G 10MM NEXGEN-104632 $1,750AUGMENT FEM DIST 62.5 X 5/15 LL /RM-102388 $2,447AUGMENT FEM DIST VG 360 75 X 10 -104521 $2,704AUGMENT FEM UNIV PST FM 75 X 5-104523 $2,704AUGMENT FEM UNIV PST VG 360 62.5 X 5-102385 $1,996

AUGMENT FEMORAL 72.5 RIGHT VANGUARD SSK 360-106702 $10,758AUGMENT FEMORAL DISTAL VANGUARD $1,804AUGMENT FEMORAL SZ4 10MM-102134 $2,342AUGMENT FEMORAL UNIV PST FM $2,233AUGMENT TIBIA BMT 71 X 10MM-102638 $2,231

167 of 317 FY2018

DESCRIPTION CHARGES

AUGMENT TIBIAL BLOCK SZ 5 10MM-109143 $2,342AUGMENT TIBIAL BMT 360 $1,644

AUGMENT TIBIAL BMT 360 DEG 63MM X 10MM REVISION-110587 $2,079AUGMENT TIBILA BLOCK SZ 7 10MM-102711 $1,790

AUGUMENT DISTAL FEMORAL VANGUARD 360 UNIVERSAL PST $1,804AUMENT TIB WITH BOLTS-105675 $2,590Australian Wire $53AVAULTA POSTERIOR-90362 $2,894AWL SLOTTED 1.6MM SBF BIOMET Add on $71AXIAL PIN FEM RESURF SZ 2-102994 $3,762AXLE OSS-104039 $1,066BAHA SYSTEM UNILATERIAL $32,375BALL GREEN .062X3/8IN-6248 $20BALL YELLOW .045X3/8IN-6247 $20BALLN ANGIO UT SDS 10/4/90-20324 $450BALLN CATH UT SDS $334BALLN CATH UT SDS 6X8X135-96483 $271BALLN CRE PULMONARY 3CM 10-12MM OD 75CM-30528 $648BALLN CRE PULMONARY 3CM 8-10MM OD 75CM-82619 $681BALLN CRYOPLASTY 4X4X120CM-85197 $1,102BALLOON PERIPHERAL CUTTING $1,752BALLOON ATLAS ANGIO PLASTY 12 X 4 X 75-87948 $692BALLOON DILATATION 22/23MMX6CM Z MED X $1,465BALLOON ENDO $1,096BALLOON TIGHTRAIL BRIDGE OCCLUSION- $1,700Balloon- Trek $814BALLOON URETHRAL ATALA SHEPARD COAXIAL 16FR-95886 $231Balloon-Empirarx PTCA & Empira NC $814Balloon-Mozec PTCA & Mozec NC $814Balloon-Sprinter $814BAND DURAN ANCORE ANNULOPLASTY 27MM $4,000

BAND TENSION PREBENT MANDIBLE LEFT 1 MM THICK-104834 $916Bare Metal Stent-Veriflex $2,487BARS ARCH OMF ERICH-24604 $140

168 of 317 FY2018

DESCRIPTION CHARGES

BASE GLENOID HYBRID LG 4MM-98190 $4,351BASE GLENOID SMALL HYBRID 4MM-107781 $1,600BASE PLATE REVERSE TM 15MM POS-102728 $4,768BASE PLATE REVERSE TM 25MM-102729 $8,694BASE PLATE TIBIAL SZ 5-101771 $4,948BASE TIB NON-POROUS SZ 4-76326 $3,891BASE TIBIA NP SZ 5 LT JRNY II-105426 $2,995BASE TIBIAL $2,500BASE TIBIAL MOD SZ 1 PLUS-102058 $4,017BASE TIBIAL NON POROUS SZ 5-103676 $2,375BASE TIBIAL NP SZ 4 LT-103900 $4,218BASEPLATE GLENOID UNIVERSAL MEDIUM $1,678BASEPLATE KNEE TIBIAL OSS SHORT 67MM $8,246BASEPLATE TIBIAL ADVANCE TITANIUM KNEE; TIBIAL 5 MODULAR REVISION II 20 MM-109140 $5,634BASEPLATE TIBIAL COLUMBUS NON 70MM X 45MM-109179 $9,000BASEPLATE TIBIAL GENESIS II SZ 4 LEFT-108074 $2,268BASEPLATE TIBIAL MODULAR OSS 71MM REVISION-110399 $8,722BASEPLATE TIBIAL MODULAR OSS 75MM-105925 $8,554

BASEPLATE TIBIAL OSS CO-CR LONG 63MM REVISION-109298 $3,465BASEPLATE TIBIAL OSS MOD 67MM REVISION $4,361BEARING ACROM XL 28MM X 50MM-110611 $1,500BEARING ANATOMIC OXFORD $1,500BEARING ANATOMIC OXFORD MEDIUM 102326 $1,163BEARING ANATOMIC OXFORD SM REVISION-102037 $1,703BEARING TIB MAX 10 X 79/83 DCM PS-104972 $2,302BEARING TIBIAL 14 X 63/67 MM NON CONSTRAINED PS VANGUARD SSK REVISION-108518 $3,518BEARING TIBIAL KNEE POLY 22MM REVISION-110268 $2,258BEARING TIBIAL MAXIM 16 X 71 X 175MM-102422 $2,607BEARING TIBIAL OSS AVL 14MM-107970 $2,986BEARING TIBIAL OSS POLY 16MM-110398 $2,786BEARING TIBIAL POLY 12 MM-104041 $2,608BEARING TIBIAL PSC 20 X 63/67-102381 $4,775BEARING TIBIAL VANGUARD E1 10MM X 75MM-110591 $1,600

169 of 317 FY2018

DESCRIPTION CHARGES

BEARING TIBIAL VANGUARD SSK 14-16MM X 71MM-75MM-83-108426 $3,518BENDING TOOL 1.6MM SBF BIOMET Add on $71BENDPLATE WRIST FUSION LCP SHORT-102696 $4,077Bentson Wire 180cm $22BERVERA BIOPSY NEEDLE 13CM 9GA $460Biliary Catheter PU 10.2 38 40 32S $190Biliary Catheter PU 8.5/12 38 40 P 32S $139Biliary Evolutionstent $3,098BIOCOMPOSITE SWIVEL LOCK ANCHOR Add on $2,304BIPOLAR 48 OD 28 ID-104537 $560BLADE 20MM FOR 11MM INST-25234 $86BLADE DHHS HELIX STERILE 90MM-102686 $757BLADE HELICAL FENESTRATED TFNA STERILE $1,661BLADE HELICAL FIX STERILE TITANIUM-105730 $1,428BLADE HELIX 100MM-102028 $548BLADE HELIX DHHS STERILE 75MM-103084 $757BLADE SPIRAL 75MM STER F/TI RETRO FEM NAIL-95360 $1,134BLADE SPIRAL TI FOR TI RETROGRADE FEMORAL NAIL 70-90MM-102580 $1,214BLADE TFNA HELICAL STERILE 110MM-109303 $1,661BLADE TFNA HELICAL STERILE 90MM-107454 $1,740BLADE TI HELICAL 5 X 11MM-103309 $1,356BLOCK OSS TIBIAL MR II 20 X 71/75-107083 $2,842

BLOCK TIBIAL OSS RIGHT MEDIAL/ LEFT LATERAL 20X63-67-110404 $2,758BM Stent 107495 $2,487BMI 1530 Micro Mark Clip 11G $370BODY PROX ARCOS CON SZ C 60 MM-105558 $18,106BOLT FASTENING INTRAMADULLARY NAILING SYSTEM $1,519

BOLT FIXATION FOR SEGMENT NECK MP HIP REVISION-109188 $682

BONE CANC GRANUALS EQUIMATRIX 2 GR SZ.2 TO 1MM-99008 $550BONE ILIAC CREST WEDGE 10-12MM FREEZE-DRIED-95776 $1,395BONE ILIAC CREST WEDGE 7/8/9MM FREEZE-DRIED-95774 $1,708BONE SPACER PLIF 9MM-55128 $5,014

170 of 317 FY2018

DESCRIPTION CHARGES

Brachseed I 125 Rx Loaded $125Brachy Source HDR IR 192 $1,528Brachyseed I 125 Loose $58Brachyseed I 125 Stranded $154Brachyseed Pd 103 Loose $178Brachyseed Pd 103 Rx Loaded $198Brachyseed Pd 103 Strand $227BRANCH ILIAC ENDOPROSTHESIS EXCLUDER AAA 14.5MMX10CM-107980 $22,038Braun 11F 30cm Sheath-89819 $75Braun 13F 30cm Sheath $246Braun Venatech IVC Filter $1,990Breast Clip $194BRIDGE ANATOMIC OXFORD LEFT MED SZ4-98194 $2,165BRIDGE TIBIAL PS 16MM X 63MM-67MM REVISION-110585 $4,356BRIDGE TIBIAL PS 24 X 63/67-103376 $4,290BSC Accolade DR 1s-1-106395 $12,133BSC Accolade MRI DR Generator-106603 $12,133BSC Accolade SR Generator-106398 $8,030BSC Accolade SR Pacemaker-106398 $8,030BSC Acuity Break Away Guide-99611 $830BSC Acuity Break Away Inner-99610 $495BSC Advantio DR IS-1 $12,133BSC Advantio SR-99904 $8,833BSC Altrua 60 DR $12,133BSC Altrua Dr-92796 $12,133BSC Altura 60 SR-98064 $8,833BSC Brady Lead Flextend $1,940BSC Cognis He Crt D $59,024BSC Dextrus Lead $1,940BSC Dextrus Lead EP Lab $1,940BSC Dynagen CRT D IS 1 ICD $59,024BSC Dynagen EL ICD VR, CCL $39,842BSC Dynagen EL ICD VR-106408 $39,842BSC Dynagen Mini ICD Df4-DR-103710 $45,868BSC Dynagen X4 Crt-D-106418 $59,024BSC Emblem MRI S-ICD-107613 $39,842

171 of 317 FY2018

DESCRIPTION CHARGES

BSC Endotak ICD Lead-98684 $7,708BSC Energen Crt-D-99609 $59,024BSC Energen DR ICD $45,868BSC Energen DR ICD IS 1/Df4 $45,868BSC Essentio MRI Dr-106978 $12,133BSC Flextend Bipolar Lead-89474 $881BSC ICD Lead Endotak Reliance $7,184BSC Incepta Crt D IS 1/Df 1/IS 1 $59,024BSC Incepta Crt-D IS-1/Df-1/Lv-1-103446 $59,024BSC Incepta ICD IS-1/Df-1 DR-101835 $45,868BSC Incepta ICD IS-1/Df-1 VR-101809 $39,842BSC Ingenio DR IS-1 $12,133BSC Ingenio SR IS-1 $8,030BSC Ingevity MRI Lead - EP Lab-106604 $1,940BSC Ingevity MRI Lead-106604 $1,940BSC Inogen El ICD DR-106404 $45,868BSC Inogen X4 Crt D $59,024BSC Invive IS 1 Dual Lead System $17,500BSC Lead Fineline Bipolar-82276 $1,940BSC Teligen IS DR $45,868BSC Teligen RF He-VR-97798 $39,842BTK Biomonitor 2 AF Loop Monitor-108918 $9,600BTK Cylos DR Generator $12,133BTK Cylos Vr-96372 $8,030BTK Edora 8 DR-T Generator-108865 $9,250BTK Edora 8 SR-T-108756 $10,200BTK Eluna 8 DR-T Promri $12,133BTK Eluna 8 SR-T-105550 $8,030BTK Entovis DR-T Promri-104177 $14,200BTK Entovis SR-T-14080 $10,220BTK Etrinsa 8 SR-T-105553 $8,030BTK Evia DR Generator-97036 $12,133BTK Evia HF-T-103483 $12,133BTK Evia SR Generator-97042 $8,833BTK ICD Lead - Protego S 65-106000 $7,184BTK Itrevia 7 HF-T Crt-D-106001 $59,024BTK Pacer Lead $1,940

172 of 317 FY2018

DESCRIPTION CHARGES

BTK Pacer Lead EP Lab $1,940BTK Philos II DR Generator $12,133BTK Philos II SR Generator $8,833BTK Solia S Lead $875BTK-Evia DR-T Generator-97011 $12,133BTK-Evia SR-T Generator-97038 $10,220BUCKLE SCLERAL STYLE 112 12 MM-104787 $43BURR CUTTING GENDER SOLUTIONS STANDARD SHAFT MILLING PATELLO $274BUSHING FEMORAL POLY-104040 $964BUSHING TIBIAL POLY-104037 $688BUTTON DISTAL CLAVICLE PLATE-103091 $1,000BUTTON DOG BONE-104854 $1,000BUTTON NASAL SEPTAL 3.2 CM DIA 6MM POST-103518 $160BUTTON NASAL SEPTAL 5CM DIA 8MM POST-103519 $212BUTTON NASAL SEPTAL SILICONE 3CM X 4MM-106209 $182Button Pectoral LG Add On $3,537BUTTON SUTURE 3.5MM 2 HOLE Add on $2,134BUTTON TIGHTROPE ABS 12MM-103355 $286BUTTON TIGHTROPE ABS 14MM-102690 $581BWI Decanav Multielectrod Mapping-110152 $2,216BWI Navistar Nonirrigate Abl Cath-110154 $4,200BWI Soundstar Sensor Ice Catheter-110151 $5,180BWI STS Ablation Catheter-110149 $6,880CABLE AND EXTENSION PRESISION SPECTRA 1 X 6-100658 $912CABLE ASSEM CABLE READY 1.8X559MM-65231 $856CABLE COBALT CHROME W/TITANIUM CRIMP STERILE 1.7X750MM-100450 $1,053CABLE DBL W/INTEGRAL CLAMP TI-26304 $1,600CABLE STERNAL CUTTING EDGE NEEDLE WITH SS CABLE $186CABLE STERNAL CUTTING EDGE NEEDLE WITH SS CABLE 4 $412CABLE W/CRIMP 1- 1.7X750MM STERILE-90933 $1,067CAGE 16 X 14 X 6 MM 6 DEGREE-104097 $7,200CAGE 16 X 14X 9MM 6 DEGREE-102547 $7,899CAGE 16X14X7MM 6 DEGREE-100182 $8,315CAGE 6 DEGREE 13 X 22MM-103683 $9,876CAGE 6 DEGREE 13 X 27MM-104010 $7,600

173 of 317 FY2018

DESCRIPTION CHARGES

CAGE BULLET TIP 10 X 22MM-97519 $7,082CAGE BULLET TIP 10 X 26MM-100721 $7,000CAGE BULLET TIP 11-14 X 26MM-102039 $6,400CAGE BULLET TIP 14-15 X 22MM-103004 $7,000CAGE BULLET TIP 15MM X 22MM-110644 $4,560CAGE BULLET TIP 22 X 12-13MM-102311 $6,400CAGE BULLET TIP 8-12 X 26MM-103878 $6,650CAGE BULLET TIP 8-16 X 22MM-103059 $6,650CAGE C LUS 12 X 14 X 8 MM-104671 $2,333CAGE C PLUS 12 X 14 X 10 MM-109146 $2,000CAGE C PLUS WEBBED 12 X 14 X 8 MM-105557 $2,000CAGE CAPSTONE 10 X 22MM 2991022-93838 $4,600CAGE CAPSTONE 10 X 26MM-101421 $5,056CAGE CAPSTONE 11 X 22MM-101615 $4,263CAGE CAPSTONE 12 X 26MM-101420 $5,200CAGE CAPSTONE 13 X 22MM-103895 $5,225CAGE CAPSTONE 6 DEGREES 15 X 27 MM-104134 $8,000CAGE CERVICAL 0 DEGREE 5MM-108433 $2,000CAGE CERVICAL 0 DEGREE 9-10MM-103047 $2,280CAGE CERVICAL 10 DEGREE 10MM-90MM-103056 $2,280CAGE CERVICAL 6 DEGREE 14MM X 16MM-108090 $2,000CAGE CERVICAL 6 DEGREE 5-8MM-103633 $2,333CAGE CERVICAL 6 DEGREE 7MM-103048 $2,400CAGE CERVICAL CRYSTAL 7MM-104539 $2,000CAGE CERVICAL FOUNDATION PARALLEL 7MM-101901 $1,860CAGE CONCORDE BUL LORDOTIC 9 X 10 X 23MM-102558 $9,674CAGE CONCORDE BUL PAR 11 BY 13 BY 27-97937 $9,674CAGE CONCORDE BUL PAR 9 BY 9 BY 27-97936 $9,306CAGE CONCORDE BUL PAR 9 X 10 X 23-27-94988 $8,261CAGE CONCORDE BUL PAR 9 X 9 X 23-94987 $7,497CAGE CONCORDE BULL LOR 9 X 10 X 27-105477 $12,160CAGE CONCORDE BULL LOR 9 X 9 X 27 MM-103935 $9,190CAGE CONCORDE BULLET PARALLEL 9 X 11 23-92081 $8,261CAGE CONCORDE LORDOTIC 9 X 11 X 23-94360 $9,674CAGE CONTACT 36 X 14MM 8 DEGREE-103085 $7,980CAGE CORPECTOMY ZVBR 12X14MM EXPANDABLE 30-49MM X 0 DEGREE $16,000

174 of 317 FY2018

DESCRIPTION CHARGES

CAGE C-PLUS 12 X 14 X 5-7 MM-104585 $2,333CAGE FOUNDATION LORDOTIC 6MM-101113 $1,860CAGE FOUNDATION LUMBAR 100017 $4,015CAGE FOUNDATION LUMBAR 10X10X22MM-100016 $5,241CAGE FOUNDATION LUMBAR 8-15X10X30MM-100036 $5,580CAGE FOUNDATION LUMBAR 9X10X22MM-100015 $5,180CAGE GLENOID EQUINOXE SMALL ALPHA-105723 $3,450CAGE JAGUAR EDGD 7 X 11 X 9 X 21-97927 $6,753CAGE LORDOTIC BULLET 105033 $4,800CAGE LORDOTIC ROI-C H 7 MM 12 X 15.5 MM-105577 $7,200CAGE LORDOTIC ROIC H9 12X14MM-108222 $7,200CAGE LUMBAR WDGD I/F 7 X 9 X 9 X 21-94356 $6,734

CAGE PEEK IBF VBR 4 & 8 DEGREE 30MM X 12-14MM-110930 $7,600CAGE PLIF SHORT 12` X 10 X 22MM-98966 $5,241CAGE PYRAMESH 16 X 60 MM-105694 $16,500

CAGE SMALL VBR 6 DEGREE ANGLED 12 X 16 TO 25MM-101633 $15,824CAGE SMALL VBR 6 DEGREE ANGLED 12 X 24-40MM-103996 $18,000

CAGE SMALL VBR TI ANGLED 6 DEGREE 14 X 24 TO 40MM-101366 $21,538CAGE SPINAL COUGAR MED 14MM 10DEG $7,473CAGE SPINE BULLET TIP 9 X 26MM-97340 $7,144CAGE SYNFIX LR 26X32X13.5MM12-98184 $14,857CAGE T2 ALTITUDE 13 X 22MM-102985 $13,775CAGE VBR BULLET TIP 13X26MM-101895 $6,400CAGE VBR BULLET TIP 9 X 22MM-101593 $6,650CAGE VERTEBRAL SPACER 10 X 28 X 10MM-95431 $9,846CAGE VERTEBRAL SPACER OPAL 10 X 28 X 9- 11MM-93691 $8,157CAGE VERTIBRAL SPACER 7X28X10MM-97915 $8,115CAGES CAPSTONE 12 X 22 MM-103982 $4,370

CAP FEMORAL NAIL RETROGRADE SHORT 5MM HEIGHT-98762 $503CAP LOCKING SCREW NCB-97845 $322CAP LOCKING SYNAPSE 3.5X8MM-91644 $344CAP LOCKING TI MATRIX-97557 $482

175 of 317 FY2018

DESCRIPTION CHARGES

CAP PROTECTIVE XTRAFIX YELLOW FIXATION PIN 4 MM-108511 $13CAP TI CLICK X LOCKING TI FOR 3D HEAD-64489 $440Capsule Kit $851CARH SOFT VU RIM 4F X 65CM.035 BRAIDED-94218 $36CATCH CROSSER OVER THE WIRE 140CM-96756 $4,442CATCHER STONE FOR PERC NEPH-88186 $146CATH 120CM PERITONEAL STANDARD-86657 $376CATH 23CM VENTRICULAR STANDARD-86656 $320CATH 60CM DISP PASSER-86655 $324CATH 6CM VENTRICULAR SNAP SHUNT-86662 $514Cath Ablation 4mm Celcius-87413 $1,158Cath Ablation 4mm Ez Steer Bw-92202 $1,366Cath Ablation 8mm Ez Steer Bw-92203 $1,938CATH ANCEL O 4FR X 90-92674 $344

CATH ANG 5FR 38-65 ANGIOGRAPHIC SOLD IN QTY OF 5-73154 $59CATH ANG 5FR ANGIOGRAPHIC SELECTIVE-55005 $26

CATH ANGIO 5F 100CM NS MINIMUM OF 5 IN A GROUP-55006 $74

CATH ANGIO HNBR5.0-38-65-P-NS-SIM1 MULTIPLES OF 5-35011 $59CATH ANGIOGRAPHIC 5.0 KUMPE 65CM-89813 $27CATH ANGIOGRAPHIC PIGTAIL 100CM SOLD IN MULTIPLES OF 5-86706 $358CATH ANGROGRAPHIC KUMPC 5FR X 65CM-94219 $36CATH ARES IMPREG ANTIBIOTIC Add on $1,078CATH BALLN BIL FOGARTY 5FR-23835 $168CATH BALLN DIL $648CATH BALLN DIL UDT 8MMX4CMX75CMX5.8FR-20324 $450CATH BALLN HYDRO PLUS-25511 $528CATH BALLN OCCLUSION-23692 $379CATH BALLN ORIGIN TACKER SYST CUF-32358 $384CATH BALLN RUMI-29177 $138CATH BALLN UROMAX 6 X 4MM-25362 $543

CATH BALLN 6FR CONQUEST ANGIO 75CM 8MMX4CM-86445 $469

176 of 317 FY2018

DESCRIPTION CHARGES

CATH BALLN 6FR CONQUEST ANGIO 75CM 7MMX4CM-86447 $390CATH BALLN ADVANCE $336CATH BALLN ADVANCE $480CATH BALLN ADVANCE $514CATH BALLN ADVANCE 14LP 2.5MM X 14CM-96712 $1,060CATH BALLN COYOTE $700CATH BALLN INTRA AORTIC 8FR 34CC $1,603CATH BALLN INTRA AORTIC 8FR 40CC $1,660Cath Balln Intra Aortic 8fr-85243 $1,950CATH BALLN POLARCATH $1,513CATH BALLN POLARCATH 4X40MMX135CM-98010 $1,943CATH BALLN POLARCATH 5X40MMX135CM-98011 $1,862CATH BALLN RX TREK $300CATH BALLN RX TREK MINI $300CATH BALLN STERLING ANGIO PLASTY $700CATH BALLN STERLING ANGIO PLASTY 3 X 3-95663 $536CATH BALLN STERLING ANGIO PLASTY 6 X 2-89186 $463CATH BALLN VALVULPLTY 13FRX26X110 $2,400CATH BALLOON ADVANCE $597CATH BALLOON ADVANCE $700CATH BALLOON ADVANCE LP 4X8CM X 150CM-110384 $360CATH BALLOON ADVANCE PTA LP $290CATH BALLOON ADVANCE PTA LP 3 X 12-95722 $633CATH BALLOON ANGIOPLASTY 2MM X 4CM-91608 $411CATH BALLOON ANGIOPLASTY 2MM X 80CM X 150-91607 $576CATH BALLOON CHARGER ANGIOPLASTY $300CATH BALLOON COYOTE OTW $747CATH BALLOON DORADO $605CATH BEACON TIP ADVANTAGE 4-5FR-99772 $36CATH CM SIZING 5FR PIGTAIL RADIOPAQUE BAND-69235 $253CATH COBRA 2 $36CATH CROSSER CTO OVER THE WIRE 140CM-96754 $4,442CATH CROSSER RAPID EXCHANGE 146CM-96755 $3,609CATH CROSSER S6 CTO 154CM-98578 $5,858CATH CUTTING BALLN 3 X 2 X 140 CM-94265 $1,407CATH CX1 CROSSING 2.6 STR-95682 $360

177 of 317 FY2018

DESCRIPTION CHARGES

CATH CXI PERIPHERAL SUPPORT 4FR ANG 135CM-99773 $360CATH DIAG $17Cath Dialysis Vaccess Plus $346CATH DIL ULTRABALL $516

CATH DILATATION 7FR CONQUEST 10MMX4CMX75MM-90488 $473CATH DILATATION NEPHROMAX 10-12/7/55-90006 $543CATH EMBOL 4FR FOGARTY OTW 80CM-89727 $275CATH EMBOLECTOMY DIST IRRIG DUAL LUM 6FR-23831 $199CATH EMBOLECTOMY DIST IRRIG DUAL LUM 9FR-23832 $403CATH EPIDURAL MULTIPORT W/CONN 21G-96679 $112CATH FITTING SIDEARM 5.8FRX35X70CM PLASTIC-24026 $45CATH FLEXIMA URETERAL CONE TIP-97141 $21CATH FOGARTY ART EMBOL $79CATH HYDROPHILIC KUMPE 4FR X 65-90CM-96469 $90CATH HYDROPHILIC STR 4FR X 65 CM-96471 $73CATH HYDROPHILICVERTEBRAL 4FRX 100CM-96685 $73CATH MALECOT $84CATH MALECOT $27CATH MUSTANG PTA BALLOON DILITATION OTW 10 X 20MM X 75CM-102572 $388CATH MUSTANG PTA BLLN DILITATION OTW 10X40MMX75CM-100383 $467CATH MUSTANG PTA BLLN DILITATION OTW 5X40MMX75CM-100388 $327CATH MUSTANG PTA BLLN DILITATION OTW 8X80MMX135CM-100389 $1,000CATH NB ADVANTAGE BEACON TIP 100CM-86684 $33CATH OPEN TIP U5FR-87087 $21CATH PD STR W/DOUBLE CUFF 42CM-87166 $300CATH PERIPHRAL SIKVERHAWK 110CM TIP 6CM-85700 $3,938Cath PICC Solo 2 Dual 5Fr $172Cath PICC Solo 2 Sgl 4Fr $149Cath PICC Solo 2 Triple 5Fr $226CATH PRUITT OCCLUSION 5FR 11MMM X 27CM-98970 $362Cath Reflexion Spiral $2,819CATH RESERVOIR RICKMAN-30756 $642

178 of 317 FY2018

DESCRIPTION CHARGES

CATH SIZING OMNI FLUSH 4FR X 100CM-96462 $1,451CATH SIZING OMNIFLUSH 4-5 FR X 70CM-94220 $300Cath SJM Halo-96882 $1,586Cath SJM Therapy Coolpath-95740 $1,760CATH SLIP BEACON 4FR .038X100CM STRAIGHT-86161 $98CATH SLIPBEACON TIP 4FR .038 X 100CM-93137 $112CATH SNARE 9- 12 15-20 MM-96848 $700CATH SOFT VU BRAIDED MPA 4F X 65CM-96003 $27CATH SOFT VU HNY 4FR X 100CM-96468 $73CATH SOFT VU OMNIFLESH 4FR X 65CM-94221 $27CATH SOFT VU PIGTAIL 4FR X 100CM-96463 $27CATH SOFT VUE HEADHUNTER 4FR X 100CM-96461 $145CATH SOFT-VU MPA 4FR X 65CM NON BRAIDED-95701 $27Cath Swan Ganz Cco 8 Fr-85179 $954CATH THERMA CHOICE IIC VERSION 2.0-58392 $2,684CATH THORACIC FR RIGHT ANGLE SILICONE $66CATH THORACIC SILICONE 28FR R ANG 10/CS $21CATH URETERAL CONETIP 8FR-11060 $33CATH URETERAL WEDGE RUTNER 5FR 70CM-803 $25CATH URETHERAL WHISTLE TIP $33CATH UROL Y URETERAL-24906 $37CATH VENTRICULAR HAKIM STR-61344 $378CATH VENTRICULAR SNAP SHUNT- $467CATH VERTBRAL MPA 4F X 100-95732 $90CATH XRAY H/S LF 5FR-17796 $50Cath-Ablation 8mm Celcius-87415 $1,674Cath-Damato Quad-87563 $173Cath-Dynamic Deca-87359 $1,258CATHETER 45-190 DEGREE Add on $1,776Catheter 5F DBLL PICC $244CATHETER 8FR 1878001 Add on $263CATHETER ANGIOGRAPHIC ACCU-VU PIGTAIL 5 FR X 100 CM-109348 $1,500CATHETER ANGIOGRAPHIC CONTRA FLUSH $22CATHETER ANGIOGRAPHIC GLIDECATH HYDROPHILIC-COATED TAPERED ANGLED 5FR 100CM-106182 $110

179 of 317 FY2018

DESCRIPTION CHARGES

CATHETER ANGIOGRAPHIC SOFT-VU NON-BRAIDED OMNI FLUSH 4FR 65CM 6 SIDE HOLES-105902 $36CATHETER ANGIOGRAPHIC TORCON NB ADVANTAGE ANGLED VAN SCHIE $36

CATHETER ANGIOGRAPHY DIAGNOSTIC MARINER NON-BRAIDED MPA SELECTIVE HYDROPHILIC COATED 4FR X 100CM-105894 $130CATHETER ANGIOJET XMI 2MM X 135CM 4FR-97506 $3,309CATHETER ARTERIAL LEADER 18G 10CM-102665 $41CATHETER ASPIRATION EXPORTAP 140CM-94095 $1,140CATHETER BALLOON ARMADA $320CATHETER BALLOON ARMADA $590Catheter Balloon Array $6,648CATHETER BALLOON DIALATION TRI LOBE 26-42MM ANGIOPLASTY 108CM 12FR-110618 $1,356CATHETER BALLOON DIALATION VIATRAC ANGIOPLASTY 4-5MM X 20MM X $480CATHETER BALLOON DILATATION $582CATHETER BALLOON DILATATION HERCULES 55MM 10-12 MM 240CM-110652 $388CATHETER BALLOON DILATATION HERCULES 55MM 8-9-10MM 300CM-110258 $388CATHETER BALLOON DILATATION LUTONIX $3,400CATHETER BALLOON DILATION LOW PROFILE PTA 5.0FR X 20CM-106780 $490CATHETER BALLOON DILATION TYSHAK II COAXIAL 100CM 9FR 25MM X 40MM 0.035IN-106366 $1,022CATHETER BALLOON LUTONIX DRUG COATED $2,800CATHETER BALLOON TRUE DILATATION VALVULOPLASTY 11FR 20MM 110CM-107001 $2,100CATHETER BALLOON VALVUOPLASTY Add on $12,188CATHETER BIPOLAR VENTRICULAR PACING 60 DEGREE CRV 6 FR 110 CM $120Catheter- Celcius Thermocool-88272 $2,291CATHETER CLASSIC CROWN 1.25MM-95759 $5,254CATHETER COBRA 2 4FR X 100CM-96472 $130CATHETER CODA BALLOON $660

180 of 317 FY2018

DESCRIPTION CHARGES

CATHETER CORECATH 2.7 S-110030 $2,750CATHETER CP STANDARD COATED $2,190Catheter CRD 2 $335CATHETER DELIVERY MARKER Add on $35CATHETER DIAGNOSTIC COBRA 2 5FR 65CM-106565 $61CATHETER DRAINAGE MALECOT $29CATHETER DVX 3MM X90CM 6FR-97504 $2,534CATHETER ELLIPTOSPHERE 5 FR WITH 5CC SYRINGE-100686 $43CATHETER ENDOBRONCHIAL BLOCKER ARNDT 7FR-106733 $362CATHETER FOGARTY OCCLUSION 8FR 28/45 MM X 80 CM $413CATHETER GLIDECATH ANGLED 5FR 65CM-90965 $112

CATHETER GUIDING NAVICROSS 4FR STRAIGHT 135CM ANGLED TIP $433CATHETER HI TORQUE SHAFT 5FR X 65CM X 0.038-107081 $130Catheter Impress MPA1 5F 65 cm-106963 $26

CATHETER INDIGO D WITH LARGE LUMEN ASPIRATIONTUBING $5,380CATHETER INTRA AORTIC BALLOON MEGA WITH INTRODUCERS AND STATLOCK DEVICES 8FR 50C $1,878CATHETER INTRATHECAL ASCENDA 114CM-102655 $2,200CATHETER LEFT HEART VENTRICULAR 16FR WITH MALLEABLE INTRODUCER $45CATHETER LUMBAR EDM 80CM-46697 $472CATHETER NB ADVANTAGE KMP 5FR X 40CM .038-108033 $231CATHETER OMNI 2 5FR 80CM-106566 $61CATHETER OMNI FLUSH SOFT RADIOPAQUE TIP 5FR 65CM .038IN-106663 $36CATHETER OPEN ENDED WITH ADAPTER $2,500CATHETER PASSER-90855 $215Catheter PICC Groshong 5F $377CATHETER PTA BALLOON LUTONIX 035 DRUG COATED 5MM X 40MM 5FR 130CM-105913 $3,300CATHETER QUICK CROSS .014-0.18X135-87317 $334Catheter Quick Female $17CATHETER SILICONE THORACIC $17CATHETER SOFT VU BRAIDED $36

181 of 317 FY2018

DESCRIPTION CHARGES

CATHETER SOFT-VU NON-BRAIDED BERENSTEIN 5FR X 40CM X 3CM TIP-106557 $36CATHETER SOLENT OMNI ANGIOJET THROMBECTOM 3MM X 120-99214 $3,420CATHETER SPYSCOPE DS ACCESS AND DELIVERY-106046 $5,500Catheter Swan Ganz 7fr-974 $162Catheter Swan Ganz Bipolar-989 $280Catheter Trifusion $1,075Catheter Viewflex Ice- $5,600Catheter-Duo Deca(20 Pole)-89074 $1,938Catheter-Lasso-107656 $3,876Catheter-Quad 2MM-94100 $203Cath-Halo (20 Pole)-87411 $1,750Cath-Josephson 5mm Quad-53310 $453Cath-Josephson Quad 2mm(Bw)-87562 $173Cath-Octapolar(Bw)-87412 $719Cath-Optima(Sjm)-88020 $2,995CEMENT 40G PALACOS-86535 $227CEMENT BONE COBALT HV 40 G-104333 $225CEMENT BONE OSTEOSET 3.0MM 10CC-44255 $1,183CEMENT BONE PALACOS RX 40 GR $195CEMENT BONE REFOBACIN $500CEMENT BONE SIMPLEX P FULL DOSE-92832 $215CEMENT BONE SMARTMIX GHV 40G-91046 $884CEMENT BONE W/GENTAMICIN GMV 40GR-87177 $874CEMENT COBALT GENT 40G-102382 $820CEMENT DEPUY 2 BONE 20GR-80280 $103

CEMENT PALACOS LV 1 X 40 SINGLE LV LOW VISCOSITY-101426 $116CEMENT PALACOS W/GENT PLUS G $850CEMENT QUIKSET 16CC-101923 $5,985CEMENT SMARTSET MV-94922 $152CEMENT SYRINGEABLE BONE 40GR-71573 $268CENTRALIZER DIST SZ 11 MM-104551 $100CENTRALIZER STEM INVIS FEMORAL DISTAL 10MM-106525 $228CENTRALIZER VERSYS DISTAL 10/11MM-20423 $96CENTRALIZER VERSYS DISTAL 9MM-51242 $190

182 of 317 FY2018

DESCRIPTION CHARGES

CERVICAL MOBI-C 13-15X17 H5-109254 $12,000Charger Balloon $330CHARGING SYSTEM FOR ANS IPG-95254 $2,459CHARGING SYSTEM FOR EON MINI-101602 $2,430CHARGING SYSTEM FOR RESTORE SENSOR-98773 $2,631CLAMP COMBINATION LARGE MR SAFE-89151 $1,572CLAMP COMBINATION MEDIUM-108509 $1,218CLAMP CONNECTING MINI-EXTERNAL FIXATOR 3MM-108081 $1,510CLAMP CRANIOFIX $246CLAMP HOLDING MINI-EXTERNAL FIXATOR 1.6MM-108080 $1,625CLAMP LARGE MULTI PIN 6 POSITION-101563 $1,393CLAMP OPEN ADJUSTABLE MEDIUM-108510 $1,013CLEARVIEW ISP PORT $780Closure Wire (Boomerang Catalyst) $396Coil embol .035-3cm-4mm-99714 $140COIL FIBERED INTERLOCKING 12 MM X 30 CM-104816 $1,990COIL FIBERED INTERLOCKING 14MM X 30CM-103583 $1,235COIL INTERLOCK 2D .035 $2,234COIL INTERLOCK 2D .035 10MM X 25CM-98140 $1,690COIL INTERLOCK 2D .035 15MM X 20CM-98138 $1,763COIL INTERLOCK 2D .035 20MM X 40CM-98136 $2,208COIL INTERLOCK 2D .035 8MM X 20CM-98141 $1,322

COIL NESTER EMBOLIZATION PLATINUM STERILE DISPOSABLE $183Coil Pusher-16-20365 $244Coilemboltornado .035-7cm-3mm-99855 $167Cola Pinto Transjugular Bx Set $722COLLAGEN VERITAS 10CM X 16CM-92547 $7,316COLLAR LOCKING BOLT OSS 0 DEG REVISION $8,750COLLAR SEG TM 9-16MM 35MM-103422 $5,153COMP SEG NECK 135CCDNO C35MM $10,594COMPONENT ACETABULAR REGENERIX $7,018COMPONENT ARTICULAR SURFACE ACTIVE ARTICULATION HIP E1 28MM X 46MM-108774 $3,440COMPONENT ARTICULAR SURFACE ACTIVE ARTICULATION HIP E1 28MM X 54MM-108844 $3,439

183 of 317 FY2018

DESCRIPTION CHARGES

COMPONENT ARTICULAR SURFACE ACTIVE ARTICULATIONHIP E1 28MM X 42MM-110597 $2,500COMPONENT ARTICULAR SURFACE SIGMA ROTATING PLATFORM SIZE 3 25MM-105912 $4,540COMPONENT ARTICULAR SURFACE TIBIAL FIXED BEARING 10MM RIGHT $1,600COMPONENT ARTICULAR SURGACE VANGAURD KNEE TIBIAL 18MM RIGHT $3,289COMPONENT CRUTIATE RT 71MM X 65MM SZ 4-110273 $8,320COMPONENT FEMORAL COCR POSTERIOR STABILIZED LEFT 67.5MM-110400 $3,670

COMPONENT FEMORAL ECHO FX STANDARD 7/9MM-108429 $2,662COMPONENT FEMORAL INSERT LG LCS 17.5MM-108062 $2,604COMPONENT FEMORAL LEFT 5 73MM CRUTIATE SUBSTITUTING 69MM-110369 $9,641COMPONENT FEMORAL OXINIUM CR SZ 5N LEFT-108077 $5,296

COMPONENT FEMORAL PERSONA CRUCIATE RETAINING LEFT STANDARD CEMENTED COBALT CHROME SIZE 7-106144 $3,260COMPONENT FIXED BEARING LEFT 6-9 13MM $1,000COMPONENT GENDER SOLUTIONS PATELLO FEMORAL JOINT IMPLANT $7,600COMPONENT HIP AUGMENT FEMORAL ACETABULAR 10MM X 50MM-110234 $4,444COMPONENT HIP FEMORAL PROXIMAL LEFT 7CM-110348 $18,200COMPONENT ILIAC EXCLUDER AAA 10MMX7CM-107983 $6,150COMPONENT KNEE ARTICULAR SURFACE NEXGEN CR FLEX C-H 5 6 10MM-110267 $1,400COMPONENT KNEE AUGMENTATION DISTAL FEMUR $1,413COMPONENT KNEE AUGMENTATION MBT FEMORAL WEDGE SIZE 3 5MM RE $2,723

COMPONENT KNEE DISTAL FEMORAL OSS LEFT 70MM-110269 $15,694COMPONENT KNEE LEFT COBALT CHROMIUM RESURFACING OSS 3CM-105923 $17,308COMPONENT KNEE TIBIAL REMEDY MEDIUM 70MM-110227 $5,954

184 of 317 FY2018

DESCRIPTION CHARGES

COMPONENT LOWER EXTREMEITY ARCOS-109222 $10,726COMPONENT LOWER EXTREMITY IBALANCE DOME 34 MM 9 MM-108794 $1,750COMPONENT LOWER EXTREMITY VANGUARD CO-CR FEMORAL KNEE $13,310COMPONENT PATELLA PERSONA ALL-POLY CEMENTED CONVENTIONAL 26MM X 7.5MM-106147 $600COMPONENT PATELLAR GENESIS II 29MM-108075 $955

COMPONENT RESTORATION CONE BODY 21MM PLUS 30-110662 $15,618COMPONENT SEGMENT DIAPHYSEAL OSS 300MM-110349 $15,148COMPONENT TIBIAL AUGMENT 10MM X 71/75MM REVISION-109299 $2,232COMPONENT TIBIAL BEARING 10MM STANDARD 63/67MM-110401 $1,000COMPONENT TIBIAL INSERT S4 17.5MM-110276 $3,994COMPONENT TIBIAL ROTATING PLATFORM TC3 SZ3 15MM $3,994CONE PROX BODY SZ A STD 60MM-103299 $14,556CONE PROX BODY SZ C HI 70MM-102583 $14,556CONE PROXIMAL BODY 50MM SZ A ARCOS MODULAR FEMORAL-105735 $12,872

CONE PROXIMAL BODY ARCOS SIZE B STANDARD 70MM-107023 $17,572CONE PROXIMAL BODY SZ C STD 70 MM-104027 $15,286CONE TIBIAL AUGMENT 51/59X15/34MM-99541 $7,390Confirm RX Cardiac Monitor $5,580CONNECTOR AXIAL 3.5X3.5MM-105711 $1,844CONNECTOR AXIAL-102662 $2,470CONNECTOR DIAPHYSEAL OSS 1CM REVISION $7,560CONNECTOR DOMINIO-102661 $2,470CONNECTOR EXPEDIUM TOP NOTCH TI 5.5X5.5MM-107973 $2,921CONNECTOR ILIAC OPEN 5.5 X 20/60 MM-104017 $2,706CONNECTOR ILIAC TI OPEN 5.5 X 40MM-103665 $2,571CONNECTOR LATERAL STREAMLINE OFFSET $1,710CONNECTOR LATERAL TI FIXED 20MM-103666 $2,284CONNECTOR LATERAL-105698 $1,358CONNECTOR MONARCH SIDE BY SIDE 5.5X5.50MM-101802 $1,809

185 of 317 FY2018

DESCRIPTION CHARGES

CONNECTOR OFF SET 12MM-103322 $998CONNECTOR OFFSET ANGLED TI 5.5-6.35X5.5-103372 $3,500CONNECTOR OPEN PARALLEL 5.5MM-102977 $1,710

CONNECTOR OPEN ROD TO ROD OFFSET 5.5 TO 5.5MM 12MM $1,615CONNECTOR PARALLEL ROD END BEND-105684 $1,900CONNECTOR PARALLEL ROD TO ROD-103861 $2,052CONNECTOR PUDENZ NYLON $133CONNECTOR ROD TO ROD CLOSED 3.2-3.2-109316 $2,000CONNECTOR STREAMLINE OCT LARGE-109283 $1,600CONNECTOR STREAMLINE OCT LATERAL OFFSET $2,000CONNECTOR TRANS TI LO PRO 42-55MM-61597 $2,775CONNECTOR UNIVERSAL SIDE LOADING-103684 $2,964Conquest 10x4x75-90488 $499Conquest Balloon $363Contour Emboli $316CONTROLLER THERAPY KINETRA NEUROSTIMULATOR-87808 $1,389Cook Check Flow 8F 80cm Sheath-93853 $35Coolpath Bidirectional Abl-98239 $2,643Cordis .038 AES 180cm Guidewire-89865 $16Cordis 5.0 C2(Glide) 65cm Catheter $137Cordis Brite Tip Sheath-89868 $23Cordis Catheter $33Cordis Extreme Balloon $199Cordis Extreme Balloon $416Cordis Genesis Stent 10 12x27 25mm $2,923Cordis Genesis Stent 8 29mm $2,605Cordis MR-A1 Guide Cath 55cm 7F-89839 $197Cordis Palmaz Stent 8 12mm $1,839Cordis Smart Stent $2,614Cordis Smart Stent 8x8cm $2,241Cordis SmartControl Stent $3,090Cordis SmartControl Stent $2,923Cordis Straight Guide Cath 55cm 7F-89840 $195CORKSCREW 5MM W/FIBERWIRE-91745 $739Corpak GT 20F 32 2020 $56COVER BURR HOLE $366

186 of 317 FY2018

DESCRIPTION CHARGES

COVER BURR HOLE LARGE LOW PROFILE 6 HOLE-103143 $713COVER BURR HOLE MATRIX $283COVER BURR HOLE MATRIX 15MM-95381 $383COVER BURR HOLE MATRIX 17MM-95382 $319COVER BURR HOLE MEDIUM LOW PROFILE 5 HOLE-103137 $728COVER BURR HOLE SMALL LOW PROFILE 5 HOLE-103142 $682COVER HOLE THREADED 6.5MM-106544 $236CROSS CONNECTOR 37 TO 50MM-99924 $1,395CROSSLINK 36MM X 10-84871 $2,000CROSSLINK 45-58MMX10-85010 $3,220CROSSLINK CD HORIZON SOLERA 4.75 X 36-38 MM-103983 $1,900CROSSLINK DVR NARROW MINI RIGHT-108902 $2,330CROSSLINK DVR NARROW RIGHT-102731 $2,044CROSSLINK MULTI 39-45MMX10-88207 $2,647CROSSLINK ROD CONNECTOR LARGE-103081 $2,690CROSSLINK STREAMLINE TI VARIABLE $1,700CRUCIATE WING TIB SM BMT 360-102393 $1,576CRYO ABLATION EQUIPMENT W/PROBES-87322 $11,000Cryo Probe Kit Renal/Prostate $1,705Cs Balloon Venography Catheter-89513 $194CUFF OCCLUSIVE 4.0CM IZ AMS-94789 $9,608CUFF OCCLUSIVE 4.5CM IZ AMS-94790 $12,236CUP ACETABULAR WITH GRIPTION 54 MM-104062 $6,059CUP FREEDOM ALL POLY 52 MM-105511 $4,586CUP HUMERAL STD $2,827CUP HUMERAL STD PE 38 X 6-101559 $3,523CUP SZ 60MM STD ARCOS CON-103939 $20,379Cutting Balloon $1,495Cutting Balloon V18 Wire-30498 $187Dawson Mueller $128Decapolar Catheter-90203 $793DELIVERY EVOLUT CATH 16FR SHEATH $4,220Denali IVC Filter $1,705DERMACLOSE RC-94027 $1,393DEVICE ADIANA STERILIZATION-94501 $1,038DEVICE FEMORAL TOGGLEOC W/ZIPLOOP-97000 $8,502DEVICE FLEXTOME CUTTING BALLOON-86880 $1,316

187 of 317 FY2018

DESCRIPTION CHARGES

Device Inflation BasicCompak-81622 $47DEVICE LEAD LOCKING LLD 2 65CM $1,735DEVICE REATTACHMENT TI TROCHANTRIC W/CABLE LONG STERILE-100452 $4,654DEVICE REATTACHMENT TI TROCHANTRIC W/CABLESTANDARD STERILE-100451 $4,168Dfine Stabili T 1st Device $4,424Dfine Stability 2nd FX Device $2,586Diag. Guidewire / Exchange-70854 $27Diagnostic Guidewire 50603 $11Direx Steerable Sheath $1,163DISC CERVICAL MOBI-C 13-15 X 15/17MM-102952 $12,000DISC PRESTIGE 7 X 16MM REPLACEMENT-95341 $822DISC PRESTIGE ARTIFICIAL CERVICAL REPLACEMENT 6 X 14MM-103515 $8,455DOME PATELLA 3 PEG ROUND SMALL 35MM-100919 $1,504DOME PATELLA INSET ALL POLY 29MM-22366 $600Double Lumen Catheter HD $120Double Lumen Hohn Catheter $681DRAIN 19FR FLUTED RD W/3/16 TROCAR-84921 $38DRAIN 19FR SILIC RD HUBLESS $31DRAIN BLAKE HUBLESS- $37DRAIN CONSTAVAC 3/16IN-24470 $248DRAIN HUBLESS 24FR FULL FLUTES $180DRAIN MALECOT 20FR-3827 $84DRAIN SUMP $95DRAIN WOUND PVC ROUND $19DRAIN WOUND SILIC END PERF $15DRAIN WOUND SILICONE 19FR 1/4 ROUND-86299 $10DRESSING BARRIER ADHES 5INX6IN-18692 $575DRESSING BIOSYNTHETIC 10X15 $8,280DRESSING WOUND MATRIX MATRISTEM 2 LAYER 7CM X 10CM-110350 $2,300DRESSING WOUND MESHED BILAYER 4IN X 5IN-107093 $12,230DRILL BIT ACUSINCH Add on $180DRILL BIT W STOP 3X14MM-13640 $667DRIVER ASSEMBLY Add on $180

188 of 317 FY2018

DESCRIPTION CHARGES

DRUG ELUTING STENTS $5,624DUAL LUMEN POWER LINE 6FR-109044 $510DURAGEN 3X3 LF-81857 $2,031DURAGEN MATRIX 1 X 1-89887 $672DURAGEN MATRIX 1X3-81247 $1,089DURAGEN MATRIX 4X5-87029 $3,412Eagle Eye Catheter-94045 $1,469ECHO POR FMRL RED NC 12 X 140-109184 $8,004Ed Life Fogarty Fortis Balloon $105Edwards Fogarty Balloon- $60Ekos Mach 4 Endovas 40x106cm $4,462ELECTRODE GRID 32 CONTACT PLATINUM-84733 $1,811ELECTRODE STRIP 4 CONTACT PLATINUM-84734 $1,265ELECTRODE STRIP 6 CONTACT PLATINUM-84737 $1,356Embolic Protection System $2,776END CAP TI FOR HINDFOOT ARTHRODESIS NAIL EX $325

END CAP TI FOR RETROTOGRADE FEMORAL NAIL BLADE-103987 $363

END CAP TI WITH T40 STARDRIVE FOR TI NAILS 15MM-108513 $543END CAP-91334 $335ENDO RELOAD ECHELON BLUE 60MM-110698 $2,205ENDOBUTTON CL ULTRA 10MM-108483 $832ENDOBUTTON CL ULTRA 15MM-95251 $510ENDOBUTTON CL ULTRA 16MM-95250 $684Enteral Stent $3,304Enteral Stent-92944 $9,036Envelope Antibacterial $1,434ENVELOPE TYRX ABSORBABLE ANTIBACTERIAL LG & MED $1,790Epidural Tray Portex $237EPIFILM OTOLOGIC LAMINA 2.5 X 25.CM-102259 $324Esophageal Stent $2,923ESSURE PERMANENT BIRTH CONTROL SYS-81971 $2,713EV3 2x8 Amperion Balloon $658EV3 6Fr Snare $452EV3 Amplatz GooseNeck Snare 10/35mm $976EV3 Infusion Cath $138

189 of 317 FY2018

DESCRIPTION CHARGES

EV3 Infusion Cath $155EV3 Infusion Cath $228EV3 Ultra Select Guidewire .018 $86Eviva Biopsy Site Identifier $253EXPANDER TISSUE BREAST WITH SUTURE TABS $2,700EXPANDER TISSUE MAMMARY 133SV-15-94193 $1,876EXPANDER TISSUE MAMMARY 250CC 133SV-12-94190 $2,378EXPANDER TISSUE MAMMARY 300CC 133MX II-94195 $2,350EXPANDER TISSUE MAMMARY FH -97169 $1,932

EXPANDER TISSUE MAMMARY WITH SUTURE TABS 550CC-97733 $2,623EXPANDER TISSUE MANNARY FH 550CC-97168 $2,378EXTENSION 2X4 BIFURCATED STRETCH COIL 40CM-95109 $2,800EXTENSION STEM NEXGEN STR 11 X 100 MM-104031 $2,136EXTENSION STEM PROFEMUR PLASMA Z $4,077EXTENSION STEM STR 20X100MM-99544 $1,655EXTENSION STRECH COIL DBS 60CM-101364 $1,478EXTENSION STRETCH COIL DBS 40CM-100067 $1,495

EXTENSION STRETCH COIL SINGLE QUADRIPOLAR 20CM-107871 $1,478EXTENSION VELA ENDOGRAFT 28X28X75X75MM-103570 $5,700Extension Wire / Exch Device $107Extractor Rx $259Eye Plaque I 125 CLS1 $163Eye Plaque I 125 CLS2 $171Eye Plaque I 125 DLS1 $178Eye Plaque I 125 DLS2 $186Eye Plaque I 125 ELS1 $194Eye Plaque I 125 ELS2 $202Eye Plaque I 125 FLS1 $209Eye Plaque I 125 FLS2 $217Fast Cath-Ep Sheath 60cm-20208 $278FAST FIX ULTRA CURVED-92536 $563Fathom Renegade $1,069FEM AGMT BLOCK PRECOAT SZ F 5MM $2,189FEM CR NARROW F6N CEM F6N R-105475 $3,550FEM KNEE SYS LEFT WITH SCREW REVISION L 67.5-108519 $10,759

190 of 317 FY2018

DESCRIPTION CHARGES

FEM KNEE SYS LEFT WITH SCREW-105581 $16,946FEM RESURF LT-105463 $17,872FEMORAL ADAPTER 5D-92211 $3,566FEMORAL AUGMENT SZ 5 10MM-104392 $1,800FEMORAL COMPONENT $2,457FEMORAL COMPONENT SZ 7 RIGHT-101772 $10,328FEMORAL COMPONENT SZ3 LEFT-98173 $2,796FEMORAL CR FLEX COMPONENT SZ G MINUS RIGHT-104368 $3,100FEMORAL HEAD $2,000FEMORAL HEAD METAL 3.5 NECK 38MM-98430 $2,302FEMORAL HEAD SUPER FINISH BFH 42MM MINUS 3.5-92582 $2,000FEMORAL HINGE ROTATING SZ F LEFT-102415 $14,942FEMORAL KNEE LPS PRECOAT SZ F LEFT-99503 $2,403FEMORAL LOCK SZ D LEFT 57.5X64MM-98992 $11,556FEMORAL NEXGEN CR FLEX POROUS SZ F RT MINUS-89516 $3,900FEMORAL OXIN SZ 4 LT-103902 $9,108FEMORAL RESURF 5CM OSS REVISION $232FEMORAL RESURF RT 3CM OSS-104788 $19,778FEMORAL RIGHT WITH SCREW-102383 $14,602FEMORAL STEM DISTAL 12 X 150-103300 $7,501FEMORAL STEM Z SZ 3-92576 $2,800FEMORAL UNI OXFORD MEDIUM-98195 $6,951FEMORAL VANGUARD SSK 360 $13,310FEMORAL VNGD SSK 360 75MM RIGHT-104526 $16,138FEMUR DISTAL SEGMENTAL SZ B&C 103419 $17,693FEMUR ELLIPTICAL SEGMENTAL RIGHT 8.5 CM-104034 $18,328FEMUR EVOLUTION CS/CR COMPONENT $2,300FEMUR EVOLUTION CS/CR NONPOROUS $2,300FEMUR EVOLUTION NON PRE $2,327FEMUR EVOLUTION PS NONPOROUS $1,783FEMUR HINGE KIT SZ B-103421 $4,150FEMUR NATURAL-KNEE II NP GENDER FLEX NONPOROUS CEMENTED FEMORAL COMPONENT LEFT SZ 2-105890 $2,900FEMUR OXFORD TWIN PEGGED CEMENTED $4,800FEMUR REV SZ 5 LEFT-104394 $9,666FEMUR VANGUARD SSK 360 RIGHT 70MM REVISION-108214 $10,759FILLER BONE VOID NORIAN DRILLABLE 5CC-104326 $2,972

191 of 317 FY2018

DESCRIPTION CHARGES

FILTER FEMORAL CELECT 30X48MMX65CM-98983 $2,621FILTER OPTEASE RETRIEVAL-96984 $3,440FILTER VENA CAVA CELECT 30 X 48MM X 65CM-96862 $3,050FILTERWIRE EZ SYS 300CM-85568 $2,621FINN FEMORAL PROX RIGHT OSS-101789 $12,576FITTING SIDE BY SIDE WIDE 5.5MM X 6.0MM-108882 $1,700Flexibility Cath Bi $3,572Flexibility Cath Uni $3,230Flexura Guidewire $47Fluency Stent $6,145Fluency Stent Graft $4,400FOLLOWER URETHERAL WOVEN $215FOOTPLATE MODULIFT VBR M 0 DEGREE-110199 $2,000FORCEP PINNACLE 23G MICROSERRATED TEWARI OMNICEP-105853 $1,600FOREFOOT IB 3X8 SCREW Add on $1,495FOREFOOT TIGHTROPE OBLNG BUTTON Add on $1,495Fox SV Balloon 2x8-91607 $682Freeman Pancreatic Stent 4fx3cm-87869 $149Gdt Teligen DR He Generator $45,868Gelmark Ultra Clip Senorx $291GENERATOR 104 DEMIPULSE DUO VNS-93884 $41,994GENERATOR BIOTRONIK SR $4,604GENERATOR DEMIPULSE VNS-93885 $31,597GENERATOR EON RECHARGEABLE SCS 16 CHANNEL-101383 $20,639

GENERATOR IMPLANTABLE PULSE SPECTRA WAVEWRITER-110040 $40,976GENERATOR INTER STIM INS II MODEL 3058-90721 $22,450GENERATOR INTERSTIM IPG-82738 $19,800GENERATOR IPG ANS RECHARGEABLE-95255 $35,171GENERATOR PRECISION PLUS-97208 $35,171GENERATOR PROCLAIM Add on $30,281GENERATOR PROTEGE MRI-106841 $38,139GENERATOR SPINAL CORD RESTORE INS-95100 $35,171

GENERATOR SPINAL CORD SPECTRA IMPLANTABLE PULSE-100655 $40,976GENERATOR STIMULATOR DUO VNS 102R-93546 $35,148

192 of 317 FY2018

DESCRIPTION CHARGES

GENERATOR STIMULATOR VNS 102-82478 $23,975GENERATOR SURESCAN SENSOR MRI SAFE-101550 $33,800GENERATOR VNS THERAPY ASPIRE HC-100378 $46,192GLADIATOR BIPOLAR $600GLADIATOR BIPOLAR 33X49MM-97859 $2,537GLADIATOR BIPOLAR 48MM-98619 $1,042GLADIATOR BIPOLAR 51MM-98931 $800GLENOID 46MM W 52MM SURFACE PEGGED $2,000GLENOID EQUINOXE PEGGED MEDIUM-97388 $3,181GLENOID PEGGED $1,520GLENOSPHERE 36 MM TM REVERSE-104626 $2,060GLENOSPHERE EQUINOXE REVERSE 38MM-97625 $5,550Glide Catheter $167Glidewire Angled .025x145 $141

GLIDEWIRE HYDROPHILIC COATED GUIDEWIRE STIFF SHAFT ANGLED FLEXIBLE TIP 0.035IN DIAMETER 260CM TOTAL-106189 $120GLIDEWIRE STANDARD ANGLE TIP .035 DIA X 260CM-94216 $104

GLIDEWIRE STANDARD ANGLE TIP .035DIAX X 180CM LONG-88662 $93Gordon Drainage $112Gore PFO Closure Device-109027 $14,350Gore Viabohn 7x15 Graft $6,145GRAFT VASC ALBOGRAFT 14MM X 8MM X 50CM-96989 $1,201GRAFT AAA BIFU MAIN BD 16FR 14X90-96963 $4,927GRAFT AAA BIFU MAIN BD 20FR 32X82-96964 $16,617GRAFT AAA BIFUR MAIN BODY 36-95-96965 $13,364GRAFT AAA BIFURCATED MAIN BODY 36-94-90449 $15,423GRAFT AAA EXCLUDER CONTRALATERAL LEG $9,078GRAFT AAA EXCLUDER CONTRALATERAL LEG $9,246GRAFT ADVANTA VXT PTFE 4 TO 7MM X 45CM-103866 $1,006GRAFT ADVANTA VXT STD WALL PTFE 6MM X 10CM-107094 $218GRAFT ADVANTA VXT THIN WALL RINGED W/SLIDER GDS PFTE 6MMX80CM-105720 $2,034GRAFT ALYTE Y MESH-101610 $1,423GRAFT ARTHROFLEX FLEXGRAFT 70 MM X 40 MM-109999 $7,894

193 of 317 FY2018

DESCRIPTION CHARGES

GRAFT ARTHROFLEX FLEXIGRAFT 0.76 TO 1.24MM THICKNESS 70MM X $4,080GRAFT ARTHROFLEX FLEXIGRAFT 1.26 TO 1.75MM THICK 35X35MM-110311 $4,660GRAFT BIF HEMASHIELD $1,568GRAFT BIFUR 32 X 10 X 50 HEMASHEILD PLATINUM-94153 $2,420GRAFT BONE ALLOGRAFT MTP DISC 19X5MM-110673 $3,899GRAFT BONE ALLOGRAFT PHALANX METATARSUS 10MM X 19MM-110179 $4,080GRAFT BONE ALLOSYNC PURE 2.5CC-110193 $1,200GRAFT BONE BIOCARTLAGE 1CC-110280 $2,800GRAFT BONE LATERAL COLUMN LENGTHENING EVANS WEDGE 20MMX6MM 1 $5,550

GRAFT BONE NANOSS DEMINERALIZED BONE MATRIX 1ML-106212 $540

GRAFT BONE SUBSTITUTE NANOSS 3D ADVANCED 10CC-108045 $3,200

GRAFT BONE SUBSTITUTE NANOSS 3D ADVANCED 5CC-106792 $1,800GRAFT BONE VOID FILLER PRO OSTEON 500 CORALLINE HYDROXYAPATITE BLOCK 50MM X 20MM X 10MM-106143 $3,962GRAFT CARTIFORM 12MM X 19MM-110429 $12,500GRAFT DBL VELOUR WOVEN 14MM/50CM-73251 $1,035GRAFT DBL VELOUR WOVEN 18MM/50CM-73253 $804GRAFT DBL VELOUR WOVEN 20MM/50CM-73254 $804GRAFT DBL VELOUR WOVEN 22MM/50CM-73255 $623GRAFT DURAGEN DURAL XS 2IN X 2IN-98787 $1,448GRAFT DURAGEN DURALS XS 1IN X 3 IN-97329 $1,500GRAFT DURAGEN PLUS DURAL 2 INCH X 2 INCH-101199 $1,208GRAFT DURAL BOVINE PERICARDIUM SUTURABLE 8 X 12CM $1,836GRAFT DUREPAIR 1X2-88971 $759GRAFT ENDO ZENITH FLEX W/Z TRAK AAA CONVERTER $2,799GRAFT ENDO ZENITH RENU AAA CONVERTER 32 X 113MM 20FR-103660 $9,777GRAFT ENDO ZENITH RENU AAA CONVERTER 59 X 54 X 113MM 20FR-102714 $10,292

194 of 317 FY2018

DESCRIPTION CHARGES

GRAFT ENDOVASCULAR ZENITH FLEX AAA MAIN BODY BIFURCATED 18FR 24MM X 111MM-106132 $13,364GRAFT ENDOVASCULAR ZENITH RENU AAA ANCILLARY MAIN BODY EXTENSION 28MM X 62MM 20FR-106193 $8,478GRAFT EXCLUDER AAA $22,000GRAFT EXCLUDER AAA 12MM X 26MM X 180MM-110962 $22,186GRAFT EXCLUDER AAA 14.5 X 35 X 160MM-110375 $23,114GRAFT EXCLUDER AAA 23MM X 12MM X 18CM-108839 $22,500GRAFT EXCLUDER AAA 26MM X 14.5 MM X 160CM-110608 $22,186GRAFT EXCLUDER AAA CONTRALATERAL LIMB 23MM X 120MM-110376 $9,478

GRAFT EXCLUDER AAA ILIAC EXTENDER 12MM X 7MM-110964 $6,342Graft Exxcel Soft $1,138Graft Exxcel Soft 5x40 $815GRAFT EXXCEL SOFT 6/50/50-91237 $719GRAFT EXXCEL SOFT SHORT TAPER 4-7MM X 45CM-105719 $1,536GRAFT FLEXIGRAFT ANTERIOR TIBIALS TENDON FROZEN 230MM X 7.5M $3,746GRAFT FLEXIGRAFTACHILLES TENDON WITH BONE BLOCK FROZEN 160MM $3,510GRAFT FLUENCY PLUS ENDOVASCULAR STENT 10MM X 40MM X 80 CM 9FR-108590 $4,400GRAFT GELWEAVE VALSALVA 34 MM $4,900GRAFT HEMASHIELD 10X20X40CM $1,350GRAFT HEMASHIELD 34MM SINGLE ARM $2,668GRAFT HEMASHIELD DOUBLE WOVEN 38 X 60-36015 $1,568GRAFT HEMASHIELD PLATINUM 28MMX30CM $1,055GRAFT HEMASHIELD PLATINUM PATCH 8X76IN-42725 $212GRAFT HEMASHIELD STR TUBE PLATINUM $1,055GRAFT HEMASHIELD WOVEN PLATINUM 10MMX30CM $883GRAFT HEMASHIELD WOVEN PLATINUM 30MMX60CM $1,423

GRAFT HEMASHIELD WOVEN PLATINUM 32MMX60CM-36011 $1,568GRAFT HEMASHIELD WOVEN PLATINUM 8MMX30CM-30848 $987GRAFT HIATAL HERNIA SURGISIS PRESHAPED 7X10CM-92485 $1,773GRAFT ILIAC LEG EXTENSION AAA 16 X 16 X 55MM-101748 $2,799

195 of 317 FY2018

DESCRIPTION CHARGES

GRAFT ILIAC ZENITH SPIRAL Z $4,846GRAFT ILIAC ZENITH SPIRAL-Z $4,903GRAFT ILIAC ZENTIH SPIRAL Z 16 X 74MM 14 FR-104989 $6,170GRAFT INTERINGS STR 4-7MM X 45CM-94439 $1,568GRAFT INTERINGS STR 6MM 40CM RS X 40CM-94440 $1,015GRAFT JACKET MAX FORCE 5 X 5-98645 $4,335GRAFT JACKET REGENERATIVE MEMBRANE 5X5CM-90297 $4,510GRAFT MAIN BODY 22 X 90 X30MM-101553 $21,000GRAFT MAIN BODY 22X13X80X40MM-103571 $20,930GRAFT MAIN BODY 25X13X80X40MM-103568 $19,884GRAFT MATRIGRAFT FEMORAL HEAD WITH NECK FROZEN ALLOGRAFT 43MM 10-12MM-110194 $2,815GRAFT MTP LENGTH RESTORING 19 X 8MM-108765 $4,080GRAFT ONE BRANCH $1,814GRAFT ONE BRANCH 30/50 $2,257GRAFT PATCH CAROTID HEMA COATED KNIT 8X75MM $222GRAFT PATCH EPTFE EXPAND 20X90MM-9548 $631GRAFT PATCH HEMASHIELD VASC 2X2-35948 $244GRAFT PATCH MESH 4.6X607IN 3D MAX XLARG RT-98174 $645GRAFT PATCH MESH 4X6 3 MAX LG -72708 $479GRAFT PATCH MESH KNITTED 6X6-37032 $147GRAFT PATCH MESH MARLEX 10X14-23840 $260GRAFT PATCH MESH MARLEX 1X4IN-23840 $260GRAFT PATCH MESH MARLEX 2X4IN-30477 $115GRAFT PATCH MESH MARLEX 3X6IN-25413 $107GRAFT PATCH MESH MARLEX KEYHL 2X4IN-37033 $132GRAFT PATCH MESH MARLEX PLUG SZ LG-26438 $482

GRAFT PATCH MESH MARLEX PRESHAPED LG KEYHOLE-30416 $143GRAFT PATCH MESH MARLEX PRESHAPED LRG-30417 $232GRAFT PATCH MESH MAX 3D XLRG LEFT-89520 $491GRAFT PATCH MESH MAX 3D XLRG RIGHT 4.8X6.7-100914 $466GRAFT PATCH MESH MAX 3D XLRG RIGHT-89521 $374GRAFT PERIGUARD 4X4CM $500GRAFT PROPATEN 6MM X 50CM W/RINGS-95485 $3,726GRAFT PROPATEN 6MM X 80CM W/RINGS-94479 $5,730GRAFT PROPATEN 6MM X 90CM $5,826

196 of 317 FY2018

DESCRIPTION CHARGES

GRAFT PROPATEN 8MM X 80CM TW W/RINGS-95486 $5,902GRAFT SKIN DERMASPAN DERMAL MATRIX 4 X 7CM 0.9 1.99 MM STERI $3,400GRAFT SOFT TISSUE AMNION THICK 3CM X 8CM $8,800GRAFT SOFT TISSUE BIODESIGN OTOLOGIC 0.9CM X 0.6CM $380GRAFT SOFT TISSUE BIODESIGN OTOLOGIC 2.5CM X 2.5CM $460GRAFT STENT EXCLUDER EPTFE AMDOMINAL AORTIC ANEURYSM 120MM X 14.5MM-109230 $9,246

GRAFT STENT GORE EXCLUDER 140MM X 14MM X 35MM-109320 $22,550GRAFT STENT MAIN BODY 24 X 82-91970 $13,504GRAFT STENT MAIN BODY 32X96MM-93653 $13,521GRAFT STENT OVATION IX PTFE ABDOMINAL AORTA MAIN BODY 35MM X $22,798GRAFT STENT OVATION IX PTFE ILIAC LIMB 22MM X 140MM $9,498GRAFT STENT VIABAHN VBX 8FR 39MM X 80CM $6,672GRAFT STENT ZENITH ILIAC SEG TFLE- $4,783GRAFT STENT ZENITH ILIAC SPIRAL Z 11 X 90MM-102970 $4,604GRAFT STENT ZENITH MAIN BODY 30MM X 96MM-92992 $16,617GRAFT STENT ZENITH MB EXT 28 X 58-98398 $3,102GRAFT STR 6MM 40CM RS RG X 50CM-94443 $2,250GRAFT STR 6MM 60CM RS RG X 100CM-93445 $1,990GRAFT STR 6MM 60CM RS RG X 80CM-94444 $3,102GRAFT STR 8MM 30CM RS RG X 40CM $1,626GRAFT STR 8MM 70CM RS RG X 100CM-94448 $3,418GRAFT STR 8MM 70CM RS RG X 80CM-94447 $2,856GRAFT STRETCH 6MM X 10CM-94441 $290GRAFT STRETCH 7MM X 10CM-94441 $290GRAFT SURGICAL ALLOMAX 7CM X 10CM-95860 $3,477GRAFT THORACIC TAG COMFORMABLE 40 X 40MM X 20CM-108494 $33,312GRAFT THORACIC TAG CONFORMABLE 37MMX 37MM X 15CM-110616 $32,896GRAFT THORACIC TAG CONFORMABLE 45MM X 45MM X 15CM-110619 $30,896GRAFT VASC BIFUR 14MMX7CM-35109 $977GRAFT VASC BIFUR 16MM X 8CM-23923 $1,202

197 of 317 FY2018

DESCRIPTION CHARGES

GRAFT VASC BIFUR 20X10MMX48CM-97868 $1,568GRAFT VASC DURAGUARD $977GRAFT VASC DURAGUARD 8X14CM-18555 $1,136GRAFT VASC PATCH 2X6IN $790GRAFT VASC PERIGUARD 6CMX8CM $653GRAFT VASC WOVEN DBL PLATINUM 24MM-36014 $1,423GRAFT VASC WOVEN DV DBL PLATINUM- $1,568GRAFT VASCU GUARD .08CM X 8CM-92362 $339GRAFT VASCULAR ADVANTA SLIDER GDS 4 TO 7MM X 45CM-103071 $742

GRAFT VASCULAR ADVANTA VS STD WALL 6MM X 40CM-100456 $473GRAFT VASCULAR ADVANTA VS THIN WALL RINGED 6MM X 40CM-100457 $1,373GRAFT VASCULAR AORTIC ARCH 4 BRANCH HEMASHIELD PLATINUM DOUBLE VELOUR $2,828GRAFT WOVEN DBL VELOUR BIF 24 X 12MM X 48CM-34043 $1,026GRAFT ZENITH FLEX W/Z TRAK AAA MAIN BODY $2,379GRAFT ZENITH ILIAC SEGMENT-93688 $13,504GRAFT ZENITH ILIAC SPIRAL Z $4,604GRAFT ZENITH MAIN BODY 18 FR 22 X 96MM-97496 $13,908GRAFT ZENITH RENU 22FR $10,712GRAFT ZENITH TX2 36 X 152MM 22FR-96459 $18,746GRAFT ZENTH MAIN BODY $13,364GROMMET ARMSTRONG BEVELED FLUOROPLASTIC-23637 $54GUIDE CATH 6FR RUNWAY AL.75 $100Guide Catheter-85523 $86GUIDE NEEDLE TRAJECTORY-90711 $1,922GUIDE SHEATH W/BIOPSY FORCEP Add on $70Guide Wire 50602-62713 $14GUIDE WIRE BEADED TIP 3.0 X 98CM-102585 $270GUIDEDWIRE PLATINUM PLUS .018 X 300-96676 $235Guideliner Catheter-96251 $835GUIDEROD WITH STOP TROCAR TIP 2.5X230MM-108276 $43GUIDEWIRE (INTERVENTION) $165GUIDEWIRE .014X260-101235 $360Guidewire .025 X 145cm SSD $53

198 of 317 FY2018

DESCRIPTION CHARGES

GUIDEWIRE .059 X 5 MM-105526 $32GUIDEWIRE .062 X 6 INCHES-103641 $76GUIDEWIRE .062 X 6-101572 $23GUIDEWIRE .062 X 7 INCHES-103642 $76GUIDEWIRE .35 X 6 INCH-90348 $30GUIDEWIRE .8 X 100 MM-104087 $334GUIDEWIRE 1.1MMX15INCH NITINOL-89613 $137

GUIDEWIRE 1.6 MM THREADED TROCAR POINT 220 MM-150496 $81GUIDEWIRE 1878001 Add on $263GUIDEWIRE 2.0-91336 $72GUIDEWIRE 3.2MM X 14-31431 $73GUIDEWIRE 3.2MM-91347 $215GUIDEWIRE 3.2X400MM-85994 $223Guidewire 35cm $19Guidewire AES .025x145-90572 $41GUIDEWIRE AMPLATZ EXTRA STIFF 3 MM J CURVED .035 INCHES X 260 CM NO MIN ORDER-104820 $47GUIDEWIRE AMPLATZ EXTRA STIFF 3MM J CURVED .035 INCHES X 180 CM NO MIN ORDER-104819 $33GUIDEWIRE AMPLATZ STIFF STR 0.035 X 180CM-106787 $54

GUIDEWIRE AMPLATZ SUPER STIFF .038 X 6CM X 180CM-89973 $97GUIDEWIRE AMPLATZ SUPER STIFF .35X260CM-96477 $105GUIDEWIRE ANGLED .035X260CM-91868 $100GUIDEWIRE APPROACH 25 GRAM TIP-94243 $334GUIDEWIRE AUSTRALIAN-57460 $78GUIDEWIRE BALL NOSE-90452 $304GUIDEWIRE BALL TIP 1000MM-99500 $577GUIDEWIRE BALL TIP 207MM X 810MM $779GUIDEWIRE BEAD TIP 2.6 MM X 80 CM-104795 $242GUIDEWIRE BENTSON .035X150CM-82026 $33GUIDEWIRE BENTSON 260CM-83016 $45GUIDEWIRE BENTSON STR .035 IN X 150CM-80755 $27GUIDEWIRE BENTSON-82715 $43GUIDEWIRE CHOICE PT FLOPPY $160GUIDEWIRE CONFIDA CRVD .035X260MM $390

199 of 317 FY2018

DESCRIPTION CHARGES

GUIDEWIRE CONTROL V-18 .018INX8CMX200CM-30498 $219GUIDEWIRE CONTROL V-18 .018INX8CMX300CM-96677 $229GUIDEWIRE CVD ROSEN HEAVY DUTY W BH-55009 $34GUIDEWIRE DELIVERY MARKER Add on $38GUIDEWIRE DEPUY-31035 $238GUIDEWIRE DRILL TIP 1.6 X 200 MM-104325 $83GUIDEWIRE DRILL TIP 2.5 X 300MM-97919 $152GUIDEWIRE DRILL TIP 2.5X200MM-86183 $145GUIDEWIRE DVR .054 X 6IN ACCUMED-94609 $32GUIDEWIRE FIX .035 150CM PTFE CTD BENTSON BX10-70855 $21GUIDEWIRE FIX .035 260CM EXCNG TFLN COAT 3 CRV BX10 $24GUIDEWIRE GLIDE ANG .035 150CM-9136 $75GUIDEWIRE HI TORQUE COMMAND 300CM-107269 $300GUIDEWIRE HI TORQUE PILOT 200 $150GUIDEWIRE J TIP FIXED CORE .035 3MM 150CM SOLD BX OF 5-62689 $12

GUIDEWIRE J TIP FIXED CORE .035 3MM 180CM SOLD BY BOX OF 5 $13GUIDEWIRE JOURNEY .014 300CM-97654 $253GUIDEWIRE LUGE 182CM $160GUIDEWIRE OLIVE TIP 1.4MM-110178 $288GUIDEWIRE PERIPHERAL FATHOM 180 X 35CM-103585 $741GUIDEWIRE PERIPHERAL HI-TORQUE SUPRA CORE 0.035IN X 300CM-107270 $220GUIDEWIRE PERIPHERAL SPARTACORE 14 HI TORQUE .014 5X300CM-108208 $150GUIDEWIRE PLATINUM PLUS .018 X180CM-96675 $202Guidewire PTCA Reg & Exch $232GUIDEWIRE PULMONARY JAGWIRE-82617 $289GUIDEWIRE QUICKFIX .045 W LASER LINE-110638 $43Guidewire Radiopaque 70cm $17GUIDEWIRE ROADRUNNER 180CM-91983 $215GUIDEWIRE ROADRUNNER 300CM-85778 $222

GUIDEWIRE ROADRUNNER TM XTRA SUPPORT 18 X 270-90974 $245GUIDEWIRE ROADRUNNER UNIGLIDE .035 X 260CM-103080 $78

200 of 317 FY2018

DESCRIPTION CHARGES

GUIDEWIRE ROADRUNNER UNIGLIDE .035INCH 180CM-103104 $74GUIDEWIRE SAFARI 2 PRE SHAPED TAVR EXTRA SMALL CURVE STAINLESS STEEL LUBRIGREEN $398GUIDEWIRE SAFETY .025 X 145CM $53GUIDEWIRE SINGLE TROCAR 2.4MM 9.25 INCHES-102622 $36GUIDEWIRE SPRING J ARROW .025X13.75X35CM-13439 $37GUIDEWIRE STANDARD STR TIP .035DIA 180CM LONG-88661 $76GUIDEWIRE STIFF ANG TIP .035DIA 180CM LONG-88835 $108GUIDEWIRE STORQ STD STR 180 CM-94400 $132GUIDEWIRE STORQ STD STR 300CM-94399 $177GUIDEWIRE STR AMPLATZ EXTRA STIFF .035X260CM $54GUIDEWIRE STR AMPLATZ EXTRA STIFF W/HEPARIN COATING-24092 $76GUIDEWIRE STR AMPLATZ STIFF .035X260CM $69GUIDEWIRE SUPER STIFF .035INX6CMX145CM-33440 $62GUIDEWIRE SUPER STIFF .035INX6CMX260CM-8240 $90GUIDEWIRE THREADED 1.1/1.25X150MM-34643 $65GUIDEWIRE THREADED 1.6X150MM-7110 $74GUIDEWIRE THREADED 2.8X300MM-21006 $106GUIDEWIRE THREADED SPADE POINT 2.5X230MM-85204 $103GUIDEWIRE THREADED TIP SMOOTH 2.0MM $711GUIDEWIRE THREADED WITH TROCAR TIP 1.35MM-103020 $58GUIDEWIRE THRUWAY .014-85611 $256GUIDEWIRE THRUWAY .018-82699 $173

GUIDEWIRE THRUWAY SHORT TAPER STR .014X300CM-85734 $216GUIDEWIRE TROCAR 3.2 22.9CM-23749 $51GUIDEWIRE TROCAR TIP 0.86MM $63

GUIDEWIRE TROCAR TIP ORTHOPEDIC 1.35 MM 150 MM-109136 $58GUIDEWIRE TROCAR TIP STERILE .045IN-110431 $20GUIDEWIRE VASCULAR GUIDERIGHT STRAIGHT TIP PTFE COATED FLEXIBLE 0.035IN X 150CM $63GUIDEWIRE W/TROCAR TIP 1.35MM-104380 $45GUIDEWIRE WHOLEY 260CM J TIP .035 $226GUIDEWIRE WITH TROCAR TIP .094IN X 8IN-110417 $42

201 of 317 FY2018

DESCRIPTION CHARGES

GUIDEWIRE WITH TROCAR TIP 1.6 X 150MM-97367 $43

GUIDEWIRE X-STIFF DBL CURVED (LUNDERQUIST) MIN 5 EA-91983 $215

GUIDEWIRE ZIPWIRE ANGLED TIP STD .035IN X 150CM-100369 $76GUIDEWIRE ZIPWIRE STR TIP .035X260CM-104852 $88GUIDEWIRE ZIPWIRE STRAIGHT 0.025IN 150CM-103602 $75GUIDEWIRE ZIPWIRE STRAIGHT STIFF .035INX150CM-100370 $110

GUIDEWIRE ZIPWIRE STRAIGHT TIP STD .035IN X 150CM-100368 $76Guidewire-87408 $64GUIDEWIRES 3.2 X 230MM-103840 $65Guidewire-Whisper Crm-87718 $137Guidewire-Whisper-87718 $950Gw-Terumo / Wholey / Amplatz $167H PLATE LEFT LRG LOW PRO 36 X 16MM-104365 $1,200H PLATE LOCKING STRUT OBLIQUE ANGLED 8 HOLE $673HEAD ANATOMIC RADIAL LEFT 24MM-102562 $5,005HEAD BIPOLAR UHR 28 X 50-103256 $3,116HEAD CONSERVE FEMORAL ONECK 40-42MM-98791 $2,302HEAD CONSTRAINED STD-104029 $3,834HEAD DVR-A STANDARD TI LEFT-87536 $2,090HEAD FEM 0X28MM-20424 $450HEAD FEM 12 14 TAPER 26MM PLUS 8MM-18971 $1,235HEAD FEM 12X14 TAPER 26MM PLUS 3.5M-7781 $450HEAD FEM ARTIC METAL ON METAL 36MM-98943 $2,473HEAD FEM COCR 12/14 36MM PLUS 12-105405 $4,680HEAD FEM COCR 28MM MINUS 3.5-61813 $450HEAD FEM CONST FREEDOM 36MM T1 PLUS 6MM-105010 $2,808HEAD FEM MOD COCR 28MM STD REVISION-18132 $1,428HEAD FEM SHORT MINUS 3.5 NECKX28MM-61844 $600HEAD FEMOAL BIOLOX DELTA 32MM-98748 $4,077HEAD FEMORAL $2,000HEAD FEMORAL $3,756HEAD FEMORAL 12/14 + 5.0 36MM-103131 $4,942HEAD FEMORAL 22.25-103063 $600HEAD FEMORAL 28MM FED NECK-101727 $570

202 of 317 FY2018

DESCRIPTION CHARGES

HEAD FEMORAL 32 MM 12/14-104553 $788HEAD FEMORAL 44 MM-104530 $1,200

HEAD FEMORAL BIOLOX CERAMIC 12/14 28 MM +0 MM-108843 $1,250HEAD FEMORAL BIOLOX CERAMIC 12-14MM 28MM PLUS 5-110326 $4,054HEAD FEMORAL BIOLOX CERAMIC TAPERED 28 MM-108772 $3,240HEAD FEMORAL BIOLOX DELTA $1,800HEAD FEMORAL BIOLOX DELTA 40MM PLUS 0MM-104360 $2,032HEAD FEMORAL BIOLOX DELTA CERAMIC $1,800HEAD FEMORAL BIOLOX DELTA CERAMIC 6MM TAPERED TYPE 1 ADAPTOR FEMORAL ADAPTER-105733 $452HEAD FEMORAL BIOLOX DELTA CERAMIC OD 40MM TAPERED ADAPTOR-105732 $4,472HEAD FEMORAL BIOLOX DELTA SHORT 40MM-109289 $1,800HEAD FEMORAL BIOLOX-109223 $3,727HEAD FEMORAL C TAPER 28MM-103255 $2,307HEAD FEMORAL CERAMIC .857 40MM PLUS 5MM-110890 $4,957HEAD FEMORAL CERAMIC BIOLOX DELTA TAPER REVISION 12/14 36MM + 8.5-108443 $5,191HEAD FEMORAL CERAMIC DELTA $4,706HEAD FEMORAL CONSERVE 3.5 NECK 40MM-98936 $1,597HEAD FEMORAL CONSERVE 38 MM-104078 $2,000HEAD FEMORAL CONST 12/14 36MM MINUS 3MM-110402 $800HEAD FEMORAL CONST 12/14 36MM STD-105460 $3,510HEAD FEMORAL FREEDOM HIP TAPERED COMP MODULAR IMPLANT CONSTRAINED OD 36 MM OFFSET 9MM-105887 $3,686HEAD FEMORAL G7 COCR 12/40MM +12 REVISION $600HEAD FEMORAL G7 COCR 36MM -6MM-109339 $1,586

HEAD FEMORAL G7 COCR 40MM TAPERED TYPE 1 +6MM REVISION $600HEAD FEMORAL LINEAGE TRASCEND 26MM X -3.5MM SHORT-101408 $2,000HEAD FEMORAL METAL ON METAL 36MM-98170 $2,463HEAD FEMORAL MOD CONST +9 12/14-104487 $3,510HEAD FEMORAL OXINIUM $4,488HEAD FEMORAL OXINIUM MODULAR 40MM-105921 $5,058

203 of 317 FY2018

DESCRIPTION CHARGES

HEAD FEMORAL SZ 32MM STD NECK-103940 $2,713

HEAD FEMORAL TOTAL CONSERVE BCH CERAMIC 42MM-108524 $1,800HEAD FEMORAL TRANSCEND XL NECK 36MM-110318 $2,732HEAD FEMORAL V40 TAPER 36MM PLUS 0-110663 $5,732HEAD FREEDOM CONST $2,808HEAD GLENOID ECCENTRIC 38MM-97874 $5,193HEAD GLENOID STD 42MM-97379 $4,619HEAD HEMI TAPERED 3.5 MM NECK-104256 $1,200HEAD HIP FEMORAL BIOLOX CERAMIC DELTA 40MM PLUS 7MM-110241 $1,450HEAD HUMERAL 18MM X 52MM-109325 $2,000HEAD HUMERAL 27MM X 52MM-102725 $2,480HEAD HUMERAL 44 X 15-80307 $3,238HEAD HUMERAL 46 X 18 X 53 VERSA DIAL-102405 $2,280HEAD HUMERAL EQUINOXE 47MM-97572 $2,723HEAD HUMERAL EQUINOXE SHORT 44MM-97385 $2,973HEAD HUMERAL OFFSET 23 X 46MM-98127 $3,799HEAD HUMERAL OFFSET 23X52MM-84265 $3,688HEAD HUMERAL OFFSET 54X22X4MM-98191 $3,244HEAD HUMERAL VERSA DIAL 50X21X57MM-98625 $2,232HEAD MEDIUM NECK 48 MM-104049 $1,200HEAD MOD 32MM PLUS 6 NO SKIRT-101793 $2,800HEAD MODULAR 32MM - 3MM NK-102584 $2,660HEAD MODULAR COCR 28MM DIA 6MM NK-107022 $3,120HEAD OFFSET HUMERAL $2,400HEAD OFFSET HUMERAL $2,000HEAD OFFSET HUMERAL 19X52MM-98172 $3,688HEAD RINGLOC BIPOLAR 28MM X 45MM-108440 $1,969HEAD SCREW FOR MATRIX 5.5-98021 $1,170HEAD TANDEM BIPOLAR 44 /46X 28MM-106526 $2,436HEAD TANDEM UNIPOLAR CO-CR OUTER DIAMETER 47MM-106503 $1,130HEAD TAPER FEMORAL CO-CR $2,232HEAD TAPER FEMORAL CO-CR $2,808HEAD TAPER FEMORAL CO-CR 28MM -3-106504 $2,034HELIMEND 30 X 40 MM MEMBR CLGN-104837 $356

204 of 317 FY2018

DESCRIPTION CHARGES

Hemodialysis Catheter-96885 $337Hemosplit Cath- $724Hi Wire $78Hickman Dual Lumen Catheter $321Hickman Triple Lumen Catheter $407HINGE PIN LPS XX-XM-103531 $1,387HINGE TIB BASE WITH ROT STOP PIN-102998 $3,950HIP ACTIS STEM UPCHARGE-110064 $400

HIP ACTIVE ARTICULATION G7 DUAL MOBILITY ARCOM XL-105904 $5,278HIP ALTRX LINER UPCHARGE-110065 $300HIP ARCOS CON $10,726HIP ARCOS CON SZ B HI 70MM REVISION $13,277HIP BALL TOTAL 32MM PLUS 0-110342 $1,919HIP BI CEMENTED UNI W/FX STEM $2,874HIP BIPOLAR CEMENTED FRACTURE SYSTEM-110250 $4,600HIP BIPOLAR FRACTURE OR PRIMARY SYSTEM STEM-110254 $4,600HIP BIPOLAR FRACTURE STEM CEMENTED BP2B-104664 $8,000HIP BIPOLAR HIP-POR ST MLTPLR CP \T\ LN STD HD-110506 $5,600

HIP BIPOLAR HP-AVRN-FIT ST MLTPL CP \T\ LN ST HD-110509 $5,600HIP BIPOLAR LOW DEMAND PRESS FIT-101910 $3,460HIP BIPOLAR PRESSFIT FRACTURE SYSTEM-110251 $4,600HIP BIPOLAR PRESSFIT W/FX STM-96429 $4,311HIP BIPOLAR PRIMARY STEM CEMENTED BP1B-104663 $8,000HIP BIPOLAR W/PRIM STEM-96433 $6,226HIP BIPOLAR-103615 $5,842HIP CEM FX BIPOLAR STD HD-110504 $3,400HIP CEM PRIMARY BIPOLAR STD HD-110510 $5,600HIP CEM ST OSS CP XL LN CER HD-110469 $9,000HIP CEM ST OSS CP XL LN STD HD-110468 $8,200HIP CEMENTED FX UNIPOLAR-110513 $3,200HIP COC POROUS CERAMAX ON CERAMIC STANDARD HEAD H9-110062 $11,000HIP COP MARATHON TOTAL CONSTRUCT-110061 $7,400HIP GRIPTION POROUS CUP UPCHARGE-110063 $600

205 of 317 FY2018

DESCRIPTION CHARGES

HIP H1 POROUS ALTRX POLY COP W GRIPTION STANDARD HEAD-104650 $15,000HIP H1 POROUS MARATHON POLY COP W GRIPTION STANDARD HEAD-104648 $15,000HIP H2 POROUS STEM/CUP <36MM-96451 $7,025

HIP H3A POROUS CERAMAX COC W 28MM CERAMIC HEAD-104656 $15,000HIP H6 CEMENTED MARATHON POLY MOP W GRIPTION LARGE HEAD-104660 $15,000HIP HYB HIP-CEM ST HIP POR CUP XLPE LN STD HD-110464 $7,400HIP HYB HIP-CEM ST TM CUP XLPE LN CER HD-110467 $9,000HIP HYB HIP-CEM ST TM CUP XLPE LN STD HD-110465 $7,400HIP HYBRID HIP W CEMENTED FEMUR AND STD METAL HEAD-98942 $7,453HIP HYBRID OVER 36MM-96427 $9,100HIP HYBRID W LG HEAD ADND XLPE LINER-93623 $8,442HIP HYBRID WITH CONTINUUM-97561 $9,226HIP HYBRIO WITH CONTINUUM AND LARGE HEAD-100523 $6,851HIP KINECTIV POROUS W STANDARD LINER-92491 $10,890HIP LOW DEMAND CEMENTED BIPOLAR-96334 $5,474HIP OSS CP/XL LN-110334 $4,800HIP POR FX BIPOLAR STD HD-110505 $3,400HIP POR PRIMARY BIPOLAR STD HD-110511 $5,600

HIP POR ST G7 CP E1 AA DM LN CER VITAMIN E POLY-110489 $13,250

HIP POR ST G7 CP E1 AA DM LN STD VITAMIN E POLY-110485 $12,450

HIP POR ST G7 CP E1 DM LN CER HD VITAMIN E POLY-110491 $13,250HIP POR ST G7 CP E1 LN CER HD VITAMIN E POLY-110456 $9,600HIP POR ST G7 CP E1 LN STD HD VITAMIN E POLY-110444 $8,800HIP POR ST G7 CP XL AA DM LN CER-110487 $12,250HIP POR ST G7 CP XL AA DM LN STD-110481 $11,450

HIP POR ST OSS CP E1 AA DM LN CER VITAMIN E POLY-110501 $14,050

HIP POR ST OSS CP E1 AA DM LN STD VITAMIN E POLY-110496 $13,250

206 of 317 FY2018

DESCRIPTION CHARGES

HIP POR ST OSS CP E1 LN CER HD VITAMIN E POLY-110478 $10,000HIP POR ST OSS CP LG XL LG HD-110472 $8,600HIP POR ST OSS CP XL AA DM LN CER-110497 $13,050HIP POR ST OSS CP XL LN CER HD-110474 $9,000HIP POR ST OSS CP XL LN STD HD-110470 $8,600HIP POR ST TM CUP XLPE LN STD HD-110441 $7,800HIP POROUS CERAMIC UNDER 36MM-96421 $7,663

HIP POROUS FEM WITH COCR HEAD AND REG REF LINER-104842 $7,000HIP POROUS SYS LG HD AND XLPE LN LG CUP-91744 $9,084HIP POROUS SYSTEM-95862 $8,594HIP POROUS W HA CUP LG HEAD XLPE LINER-93839 $6,979HIP POROUS W/DUROM CUP METASUL LD HEAD-91787 $9,253HIP POROUS WITH CONTINUUM AND CERAMIC HEAD-97382 $10,678HIP POROUS WITH CONTINUUM AND LRG HEAD-97547 $9,585

HIP PREM ST G7 CP E1 AA DM LN CER VITAMIN E POLY-110490 $13,250

HIP PREM ST G7 CP E1 AA DM LN STD VITAMIN E POLY-110486 $12,450

HIP PREM ST G7 CP E1 DM LN CER HD VITAMIN E POLY-110492 $13,250HIP PREM ST G7 CP E1 LN CER HD VITAMIN E POLY-110457 $9,600HIP PREM ST G7 CP E1 LN STD HD VITAMIN E POLY-110445 $8,800HIP PREM ST G7 CP XL AA DM LN CER-110488 $12,250HIP PREM ST G7 CP XL AA DM LN STD-110482 $11,450

HIP PREM ST OSS CP E1 AA DM LN CER VITAMIN E POLY-110499 $14,050

HIP PREM ST OSS CP E1 AA DM LN STD VITAMIN E POLY-110495 $13,250HIP PREM ST OSS CP E1 LN CER HD VITAMIN E POLY-110479 $10,000

HIP PREM ST OSS CP LG E1 LN CER HD VITAMIN E POLY-110500 $14,050HIP PREM ST OSS CP LG XL CER HD-110477 $9,000HIP PREM ST OSS CP XL AA DM LN CER-110498 $13,050

HIP STEM PROSTALAC SZ 3 150MM LEFT BOWED REVISIO)-110923 $14,932

207 of 317 FY2018

DESCRIPTION CHARGES

HIP SUPERPATH HYBRID CEMENTED STEM W/ BIOFOAM SHELL COCR HEAD-110249 $7,200HIP SUPERPATH POROUS PRESSFIT W/ BIOFOAM SHELL CERAMIC HEAD AND VIT E LINER-110246 $9,200HIP SUPERPATH POROUS PRESSFIT W/ BIOFOAM SHELL CERAMIC HEAD-110247 $8,800HIP SUPERPATH POROUS PRESSFIT W/ BIOFOAM SHELL COCR HEAD-110248 $7,600HIP SYSTEM CEMENTED BIPOLAR-91561 $5,842HIP SYSTEM POR FEM WITH OXINIUM HEAD AND R3 X LINER-105423 $9,600HIP SYSTEM POROUS BIPOLAR-42904 $5,911

HIP SYSTEM POROUS FEM W COCR HEAD AND XLPE LINER-104589 $6,250HIP SYSTEM POROUS FEM WITH COCR HEAD AND -104587 $7,000HIP SYSTEM POROUS STEM CP LG XL/LG HD-109331 $8,800HIP SYSTEM POROUS W/XLPE LINER POR COP-91562 $6,739

HIP SYSTEM TANDEM BIPOLAR CEM FEM WITH COCR HD-105517 $4,077

HIP SYSTEM TM POR ST/TM CUP/XLPE LINER STD HEAD-104375 $8,594HIP SYSTEM TM ST/TM CUP/LNR/LG CERAMIC HEAD-104377 $9,900HIP TANDEM BIPOLAR POROUS FEM WITH CO-104536 $4,346

HIP TM POR ST TM CUP VIT E LN CER HD VITAMIN E POLY-110455 $9,600HIP TM POROUS BIPOLAR-103619 $5,550HIP TM ST TM CUP LG XLPE LN CER HD-110451 $8,600HIP TOTAL POROUS FEMORAL WITH OXINIUM HEAD AND XLPE-106135 $9,600HIP UNIPOLAR FRACTURE OR PRIMARY SYSTEM $4,600HIP UNIPOLAR FRACTURE STEM CEMENTED UP2B-104662 $8,000HIP UNIPOLAR HIP-LD FX HIP CEM ST ENDO HD-110512 $3,200HIP UNIPOLAR HIP-POROUS ST ENDO HD- $5,400HIP UNIPOLAR LD/FX ST ENDO HEAD LOW DEMAND-99538 $2,823HIP UNIPOLAR NP FEM W/UNIPOLAR HEAD-105376 $3,410HIP UNIPOLAR PRESSFIT FRACTURE SYSTEM-110252 $4,200HIP UNIPOLAR PRIMARY STEM CEMENTED UP1B-104661 $8,000

208 of 317 FY2018

DESCRIPTION CHARGES

HIP UNIPOLAR TM POROUS ST ENDO HEAD-104376 $5,842Hohn $231Hologic Atec Introducer-104148 $105

HOOPLATE FEMUR LCP PROXIMAL 12 HOLES 4.5 X 313MM-109304 $3,957

HOOPLATE FEMUR LCP PROXIMAL 6 HOLES 4.5 X 205 MM-104075 $3,686HUMERAL STEM 48 D 13MM X 130MM-92336 $6,000

HYBRID GENDER FLEX CEM KNEE WITH TB TIB SURF PAT-103001 $7,400HYBRID GENDER FLEX KNEE W/PROLONG-95592 $9,547HYBRID HIP W CEMENTED FEMUR AND LG METAL HEAD AND GRIPTION-98937 $7,141

HYBRID KNEE SYSTEM POROUS FEM AND PRECOAT TIBIAL-102394 $7,600Hydra Jagwire .035 Ss Ang-85873 $258Hydra Jagwire .035-85874 $258I PLATE STERNALOCK 4 HOLE 100 DEGREE $1,298ICD Gen Fortify Assura VR-105162 $45,868Ice Catheter-Accuson-87197 $4,405IMP DELTA EXTEND METAGLENE CEMENTLESS-97375 $3,641IMP HUMERAL CEMENTED MONOBLOC STD SZ 1 12MM DIA-101648 $7,467IMP HUMERAL MOROBLOC $8,980IMP MAMMARY BIODIMENSIONAL 230--87610 $1,316IMP MAMMARY CLASSIC BASE MOD PROJ 240 CC $2,190IMP MAMMARY GEL SMOOTH ROUND HIGH PROFILE 750CC $2,043IMP MAMMARY HIGH PROJECTION 320CC $2,043IMP MAMMARY SISI GEL MIDRANGE $1,500IMP MAMMARY SMOOTH ROUND HP $1,990IMP MAMMARY STYLE 410FX SILICONE FULL HEIGHT EXTRA FULL PROJ 410CC $2,190IMP MAMMARY STYLE 410MX SILICONE MOD HEIGHT EXTRA PROJ 255 CC-102323 $610IMP MAMMARY TEXTURED OVAL BASE LOW & MOD PROJ $1,990IMP MAMMARY TEXTURED SILICONE CLASSIC BASE MOD PROJ 450CC-103068 $1,891

209 of 317 FY2018

DESCRIPTION CHARGES

IMP MAMMARY TEXTURED SILICONE OVAL BASE HIGH PROJ 480CC-103064 $2,043IMP MONITOR CONFIRM CARDIAC-97567 $7,400IMP SPEED SCREW BIO COMPOSITE-97565 $4,800Impella 2.5 Heart Pump $42,823IMPELLA CATH/CABLE Add on $42,000IMPELLA GUIDEWIRE Add on $5,600IMPELLA INTRODUCER Add on $5,600IMPL CHIN EXTENDED SILIC EXTRA SM-32117 $248IMPL CHIN EXTENDED SILIC SM-32114 $255IMPL MAMMARY GEL 222CC STYLE 115-90433 $1,197IMPL MAMMARY SALINE 300-330CC STYLE 68 MP-94775 $658IMPL MAMMARY SALINE 450-475CC STYLE 363LF-94773 $1,619IMPL MAMMARY SALINE 510-535CC-22362 $1,316IMPL MAMMARY SALINE STYLE 68MP 150 180 210CC-32557 $658IMPL MAMMARY SALINE STYLE 68MP 150 180CC-22679 $809IMPL MAMMARY SIL SM STYLE 20 HP $1,500IMPL MAMMARY SIL TEX STYLE 115 $1,500IMPL MAMMARY SIL TEX 167CC STYLE 115-94756 $1,197IMPL MAMMARY SIL TEX 650CC STYLE 120-94760 $1,518IMPL MAMMARY SIL TEX STYLE 115-89389 $1,233IMPL MAMMARY SILC GEL HP 220CC-95929 $1,197IMPL MAMMARY SILI GEL MIDRANGE $1,233IMPL MAMMARY SILI GEL MIDRANGE -89388 $1,500IMPL MAMMARY SILIC GEL $1,518IMPL MAMMARY SILIC GEL 440CC-60076 $1,531IMPL MAMMARY SILICONE STYLE 20HP $1,500IMPL MAMMARY SILITEX HI PRO 750CC-103988 $1,957IMPL MAMMARY SILITEX HI PRO 800CC-103989 $2,060IMPL MAMMARY SILL GEL MIDRANGE 272CC-90435 $1,197IMPL MAMMARY SILLC GEL HP 260CC-94022 $1,197IMPL MAMMARY SLSI GEL MIDRANGE 290CC-90436 $1,518IMPL MAMMARY SMOOTH HI PROFILE $1,500IMPL MAMMARY STYLE 168 SALINE 270-300CC-88372 $1,000IMPL MAMMARY STYLE 168 SALINE 330-360CC-35998 $699IMPL MAMMARY STYLE 168 SALINE 420-450CC-85686 $860IMPL MAMMARY STYLE 20 HP SILICONE $1,500

210 of 317 FY2018

DESCRIPTION CHARGES

IMPL MAMMERY LOW BLEED GEL 600CC-97171 $1,521IMPL PENILE 18CM CXMS INFRAPUBIC-89753 $11,683IMPL PENILE BALLN 61-70CM-11156 $5,596IMPLANT 4MM WITH 10MM BIA400 ABUTMENT-100373 $5,878IMPLANT 4MM WITH 12MM BIA400 ABUTMENT-100374 $5,623IMPLANT 4MM WITH 6MM BIA400 ABUTMENT-100371 $4,358IMPLANT 4MM WITH 8MM BIA400 ABUTMENT-100372 $5,623IMPLANT ARTHROSCOPIC BIOINDUCIVE MEDIUM $4,400IMPLANT ARTHROSCOPIC FIXATION TIGHTROPE ABS STERILE TITANIUM-105725 $900IMPLANT AUTOLOGOUS CULTURED CHONDROCYTES $84,580IMPLANT BAHA 4 ATTRACT BI300 4MM-102972 $2,728IMPLANT BIA 300 SERIES 4MM W 9MM ABUTMENT-96975 $5,200IMPLANT BIA400 ABUTMENT 4MM X 14MM-107085 $5,878IMPLANT BREAST INSPIRA STYLE $1,660IMPLANT BREAST STYLE FX 185CC $2,190IMPLANT BREAST STYLE LF 125270CC $2,190IMPLANT BREAST STYLE LM 190CC $2,190IMPLANT BREAST STYLE MF 195CC $2,190IMPLANT BREAST STYLE SCF 295CC $2,190IMPLANT BREAST STYLE SCL $2,190IMPLANT BREAST STYLE SCM 140CC $2,190IMPLANT BREAST STYLE SCX 470CC $2,190IMPLANT BREAST STYLE TCF 415CC $2,190IMPLANT BREAST STYLE TCLP 125CC $2,190IMPLANT BREAST STYLE TCX 560CC $2,190IMPLANT COAPTITE INJ 1ML SYRINGE-98929 $756IMPLANT COLLAMEND 6CM X 12CM-89284 $3,793IMPLANT EAR NUCLEUS 5 CI512-97303 $64,076IMPLANT EAR NUCLEUS PROFILE WITH SLIM MODIOLAR CI532-106705 $64,000IMPLANT EAR NUCLUES C1422 SLIM-86204 $63,246IMPLANT FINGER PIP SIZE 3-90527 $6,934IMPLANT FINGER SR MCP SIZE MD-90528 $5,682IMPLANT GREAT TOE PRIMUS FLEXIBLE WITH GROMMETS SIZE 30-108444 $3,046IMPLANT INTERPHALANGEAL SZ 4-104359 $8,626

211 of 317 FY2018

DESCRIPTION CHARGES

IMPLANT LOWER EXTREMITY CARTIVA 10MM-108911 $7,600IMPLANT LOWER EXTREMITY IBALANCE 3 PFJ PATELLOFEMORAL LEFT POROUS-108793 $9,520IMPLANT LOWER EXTREMITY IBALANCE PATELLOFEMORAL LEFT SIZE 2-110645 $3,570IMPLANT MACROPLASTIQUE 2.5ML-98119 $990IMPLANT MAGNET BIM400-102973 $3,846IMPLANT MAMMARY NATRELLE INSPIRA SMOOTH ROUND GEL -105854 $1,600IMPLANT MAMMARY SALINE 380-400CC-96747 $1,000IMPLANT MAMMARY SALINE 410-430CC-87063 $1,440IMPLANT MAMMARY SHAPED GEL MODERATE HEIGHT EXTRA FULL PROJECTION 560 CC $2,190IMPLANT MAMMARY SHAPED GEL MODERATE HEIGHT FULL PROJECTION $2,380IMPLANT MAMMARY SHAPED GEL MODERATE HEIGHT MODERATE PROJECTION $2,380IMPLANT MAMMARY SHAPED SILICONE FULL HEIGHT MODERATE PROJECTION $1,845IMPLANT MAMMARY SHAPED SILICONE FULL HEIGHT MODERATE PROJECTION 255CC $2,190IMPLANT MAMMARY STYLE 110 -90008 $1,233IMPLANT MAMMARY STYLE 15 MP SILICONE $1,500IMPLANT MAMMARY STYLE 20 HP SILICONE $1,500

IMPLANT MAMMARY STYLE 68HP SALINE 425CC-455CC-88060 $800

IMPLANT MAMMARY STYLE 68HP SALINE 465CC-505CC-88061 $658

IMPLANT MAMMARY STYLE 68HP SALINE 550CC 590CC-88063 $904IMPLANT MERIDIONAL STYLE 106 10.5MM-103857 $63IMPLANT NAIL CAP 1.6MM SBF BIOMET Add on $3IMPLANT NUCLEUS HYBRID L24-103954 $64,657IMPLANT OPTEASE FILTER FEMORAL Add on $1,598IMPLANT OPTEASE FILTER JUGULAR Add on $1,598IMPLANT PRODISC C MEDIUM STERILE 5MM-102303 $9,143

212 of 317 FY2018

DESCRIPTION CHARGES

IMPLANT PROPEL MINI STEROID RELEASING MOMETASOME FUROATE $1,590IMPLANT RADIESSE VOICE 1CC SYRINGE-103654 $1,093IMPLANT TIBIAL TRAY CEMENTLESS-97373 $2,342IMPLANT VOCOM 5MM DISPLACEMENT-95026 $451IMPLANT VOCOM SHIM 3MM OFFSET-102408 $305INJ CEMENT HYDROSET 10CC-89106 $7,490INJECTION NORIAN DRILLABLE BONE FILLER 10CC-103288 $5,549Inrad Bead Local Wire 5-9cm-92937 $72Inrad Clip Tissue Mark 17G 10cm $167INSER KNEE EVOLUTION $1,085INSERT ACET DURASUL STD 32 X 53MM-97843 $1,217INSERT ARTRICULAR GENESIS II SZ 3-4 18MM-108076 $1,745INSERT CROSS LINKED STABALIZED S24 15MM-97548 $2,271INSERT DUAL TAPER REVERSE TM-102730 $1,459INSERT KNEE EVOLUTION $1,330INSERT KNEE EVOLUTION CR $1,400INSERT KNEE EVOLUTION CS $1,417INSERT KNEE EVOLUTION STD SZ 4 17MM LEFT-98933 $1,151INSERT KNEE EVOLUTION SZ 5 17MM LEFT-104777 $3,916INSERT RESTORATION ADM MDM 28MM X 54MM-110637 $3,286

INSERT RESTORATION ADM/MDM X3 28MM X 28/52MM-107844 $3,190INSERT STANDARD SZ 5 10MM RT-98803 $1,400INSERT TIB LT SZ4 12MM-73006 $1,442INSERT TIB NON POROUS SZ 4 PLUS-63744 $1,472INSERT TIB RT SZ4 10MM-73210 $1,186INSERT TIBIA RIGHT SZ 1 25MM-100494 $1,085INSERT TIBIA RT SZ 5 12MM-98183 $1,151INSERT TIBIAL LT SZ 5 14MM-109141 $1,600INSERT TIBIAL SIGMA CURVED XLK 5X10MM-107996 $2,943INSERT TIBIAL SZ 1 LEFT-102059 $3,112INSERT TIBIAL SZ 2 10MM RIGHT-103653 $1,400INSERT TIBIAL SZ 2 14MM RIGHT-103313 $1,330INSERT TIBIAL SZ 3-4 LT-103898 $4,606INSERT TIBIAL SZ 5-6 11MM-101770 $5,160Internal Loop Recorder $9,208

213 of 317 FY2018

DESCRIPTION CHARGES

INTODUCER STR. BRITE TP 7FRX11-96969 $145Intra-Aortic Balloon Catheter $1,290Introducer 10cm $17Introducer 11F x 10cm-88255 $13INTRODUCER ANGLED BRITE TIP 5-8FR X 11CM-90410 $81INTRODUCER BRITE TIP 4FRX11CM-96758 $81INTRODUCER CHECK FLO 7FR X45CM-88644 $132INTRODUCER ESSURE-105490 $47INTRODUCER PACEMAKER LEAD SET 11FR $90INTRODUCER PEEL AWAY 9FR NOT TAPER $97Introducer Safety Periph IV Cath $47INTRODUCER SET CHECKFLO 16FR 35CM-89931 $267INTRODUCER SHEATH 13 CM SPLITTABLE BLUE HUB DILATOR PRELUDESNAP 8FR $90INTRODUCER SHEATH MICRO NITINOL GUIDEWIRE MATERIAL GOLD TIP STIFF 5FR X 7CM $99Introducer Valved 16.5Fr x 13cm $72INTRODUCER VALVED AIRGUARD 13CM 16.5 FR $72IVT Trpl Lumen Pwr PICC Fullt $675J J Mammo Clip Marker $217Jag Hini 025/260 Ss-86949 $199Jagtome 39 W/Guidewire-97409 $475Jagwire Str.025/0.35-32821 $207Jostent Graft $6,987JURGAN BALL SET-6247 $20K- WIRE .062 X 3 INCH DIA-103092 $58K WIRE 1.6MM DIAMETER X 15CM LENGTH-101925 $36K WIRE 228MM-102959 $67K WIRE STANDARD TIP 1.5 X 100MM-103912 $47K WIRE WITH TROCAR 3.2 X 320 MM-104793 $256KIT ART LINE 20GAX5IN SAFETY LF $46KIT BONE MARROW ASPIRATION-110281 $416KIT CATH QUAD 8.5FR 16CM ANTIMICRO SAFETY-93543 $324KIT CATH QUAD 8.5FR 20CM ANTIMICRO SAFETY-93544 $251KIT CATH TRIPLE 7FR 16CM ANTIMICRO SAFETY-93541 $281KIT CATH TRIPLE 7FR 20CM ANTIMICRO SAFETY-93542 $218KIT CATHETER PASSER 38CM-110655 $98

214 of 317 FY2018

DESCRIPTION CHARGES

KIT CEMENT PREP QUICK USE FEMORAL BONE-100167 $115KIT CHARGING SYSTEM PRECISION PLUS-97209 $5,488KIT EQUINOX TORQUE SCREW $2,226KIT GRAFT OVATION PRIME POLYMER $1,500KIT HINGE SEGMENTAL FEMORAL SZ C-103966 $4,150KIT INFUSE BMP LG-84787 $10,943KIT INFUSE BMP MED-84788 $9,901KIT INFUSE BMP SM-84789 $6,983KIT INFUSE BMP XX SMALL-98643 $1,796KIT INJEX BUMPY ANCHORING SYSTEM-100670 $634KIT LACRICATH BILATERAL $555KIT LEAD EXTENSION 35 CM 8 CONTACT-108790 $1,616KIT LEAD EXTENSION 51CM-87949 $1,143KIT LEAD VECTRIS COMPACT 1 X 8 60CM-101549 $4,946KIT LEAD VECTRIS SUBCOMPACT 1 X 8 60CM-102769 $4,946KIT NAVIGUS PASSIVE INTERNAL-90711 $1,922KIT NEUROSTIMULATOR LEAD EXTENSION SENZA BLUE 35CM-109114 $2,400KIT NEUROSTIMULATOR LEAD SENZA BLUE DISPOSABLE 50CM X 5MM-109110 $1,000KIT PADDLE LEAD 16 CONTACT 50/70CM-108041 $4,000KIT PATIENT PROGRAMMER PRECISION PLUS-97210 $2,500Kit Power PICC SL 5F $476KIT QUICKSET INJECTABLE MACROPOROUS CALCIUM PHOSPHATE 8CC-105704 $1,995KIT REPAIR PECTORAL BUTTON LARGE-111039 $4,716KIT REVISION SUTURELESS PUMP CONNECTOR-102982 $300KIT SNARE AMPLATZ GOOSENECK 20MM X 120CM $560KIT STERILE DILATING CATHETER AND FUNNEL-104831 $376KIT STILULAN RAPID CURE 5CC $4,872KIT STIMULAN RAPID CURE 10CC-110920 $2,900KIT STIMULAN RAPID CURE 20CC-110921 $5,400KIT SURGICAL LEAD COVER EDGE $11,560KIT TENODESIS ATHREX-92984 $634KNEE ART SURF RT SZ 1-2-104998 $2,995KNEE ARTICULAR SURFACE FIXED EF 5-6 17MM-103296 $1,330KNEE ATTUNE CEMENTED FIXED BEARING K3AFB-110069 $6,840

215 of 317 FY2018

DESCRIPTION CHARGES

KNEE ATTUNE CEMENTED ROTATING PLATFORM K3ARP-110070 $7,140KNEE ATUNE K3A CEMENTED FIXED PLATFORM-104641 $7,500KNEE ATUNE K4A CEMENTED ROTATING PLATFORM MOBILE BEARING-104643 $7,500KNEE AUG BLOCK PRECOAT SZ F 5MM-104847 $1,750KNEE AUG UNIV 360 75 X 10-104830 $2,164KNEE CEM FLX FEM CEM TIB FLX SURF STD PAT-110529 $6,600KNEE CEMENT FEM CEM TIBIA STD SURF STD PAT-110527 $6,000KNEE CEMENTED FLEX W PROLONG-92845 $7,386KNEE CEMENTED FLEX WITH PROLONG PATELLA-101691 $6,935KNEE CEMENTED PERSONA STANDARD-103999 $7,400KNEE CEMENTED W PROLONG-95875 $6,800KNEE CEMENTED WITH PqROLONG PATELLA-101753 $6,935KNEE DISTAL PRECOAT AUGMENT BLOCK SZ D 5 MM-104032 $1,884KNEE FEM OXIN RT SZ 4-104996 $10,000KNEE FEM SURFACE LCCK SZ F LEFT-103634 $10,978KNEE FEMORAL LCCK NEXGEN SZ F LEFT-104846 $10,626KNEE FLEX CEMENTED SYSTEM-91611 $8,695KNEE FLEX HYBRID GENDER CEMENTED-98401 $7,369KNEE GENDER FLEX CEMENTED STANDARD PATELLA-106730 $6,800KNEE GENDER FLEX CEMENTED W/PROLONG-92321 $8,901KNEE GENDER FLEX POROUS-93707 $7,947

KNEE GSF FLX CEM FEM CEM TIB PRLG SURF STD PAT-110532 $6,600KNEE GSF FLX POR FM POR TIB PRLG SUR XLPE PAT- $7,700KNEE HP UNI COMPARTMENTAL-110066 $4,531KNEE HYB FLX GSF POR FM CM TB PRLG SF ST PAT-110538 $7,100KNEE HYBRID FLEX 98-0002-015-61-93382 $9,422KNEE HYBRID FLEX 98-0002-015-80-93890 $7,423KNEE HYBRID FLEX-94506 $9,028KNEE HYBRID SYSTEM-92117 $6,584KNEE K1A POROUS ROTATING PLATFORM-96436 $7,886KNEE K2A HYBRID ROTATING PLATFORM-96439 $7,184KNEE K3A CEMENTED ROTATING PLATFORM-96440 $6,818KNEE KS HYBRID WITH TRABECULAR-99760 $7,689KNEE NEXGEN FLEX METAL W/TM TIBIA-101908 $7,400

216 of 317 FY2018

DESCRIPTION CHARGES

KNEE OXF CEM FEM CEM TIB STD AS-110556 $8,400KNEE OXF CEM FEM MON TIB-110557 $8,400KNEE PATELLA ALL POLY 29MM-104848 $600KNEE PERSONA CEM FEM CEM TIB VE SURF STD PAT VITAMIN E POLY-110541 $7,700

KNEE PERSONA CEM FEM /CEM TIB/CPS VE SUR/STD PAT-105534 $8,000KNEE PERSONA TM FEM TM TB STD SURF STD PAT-110543 $10,000KNEE PERSONA TM FEM-TM TIB-VE SURF-STD PAT $9,500KNEE PERSONA UNI KNEE W INSTRU-110555 $7,400KNEE POR FEM MIS TM TIB PRLG SURF STD PAT-110520 $7,700KNEE POR FLX FM MIS TM TIB FLX SURF STD PAT-110521 $7,700KNEE POROUS SYSTEM 98-0002-000-02-93624 $8,661KNEE POROUS FIXED BEARING-99222 $7,229KNEE POROUS FLEX TRIBECULAR METAL TIBIA-99505 $8,661KNEE POROUS GENDER FLEX WITH PROLONG-103517 $8,560KNEE POROUS SYSTEM 98-0002-000-00-42905 $6,739KNEE POROUS TRIBECULAR METAL TIBIA-98995 $8,661KNEE POROUS TRIBECULAR TIBIA PROLONG-99537 $6,634KNEE POROUS W PROLONGAND XLPE PATELLA-92013 $7,109KNEE POROUS WITH TRABECULAR METAL MONOBLOCK TIBIA-100531 $6,634KNEE SIGMA FIXED BEARING-110068 $5,980KNEE SIGMA K1 POROUS FIXED BEARING ALL POLY- $6,300KNEE SIGMA K2 POROUS MOBILE BEARING ROTATING PLATFORM-104637 $6,300KNEE SIGMA K3 CEMENTED FIXED BEARING ALL POLY- $6,300KNEE SIGMA K4 CEMENTED ROTATING PLATFORM MOBILE BEARING-104642 $6,300KNEE SIGMA K5 HYBRID FIXED FLATFORM-104644 $6,300KNEE SIGMA K6 HYBRID ROTATING PLATFORM MOBILE BEARING-104645 $6,300KNEE SIGMA ROTATING PLATFORM-110067 $6,206KNEE STEM SPLINED BMT VC 18 X 20-104520 $3,392KNEE STEM SPLINED V2 21 X 80-104829 $2,714KNEE STEM SPLINED VC 18 X 80-104524 $3,392KNEE SURFACE FLEX FIXED SZ EF/567 14MM-104849 $1,400

217 of 317 FY2018

DESCRIPTION CHARGES

KNEE SURFACE LPS FIXED ARTIC SZ 12MM-103635 $1,330KNEE SYSTEM CEMENTED-91566 $7,663KNEE SYSTEM HYBRID FLEX-98004 $7,207KNEE SYSTEM LEGION VERILAST WITH NON-POROUS TIBIA OXINIUM AND XLPE-105927 $10,264KNEE SYSTEM POROUS FLEX-91565 $7,716KNEE TIBIAL BASE NP RT SZ 2-104997 $5,364KNEE TIVANIUM FLEX STANDARD-103967 $7,885KNEE UNI COMPARTMENTAL UK2A ALL POLY- $4,600

KNEE UNICOMPARTMENTAL OXFORD MOBILE BEARING-108868 $10,840KNEE VANGUARD TITANIUM $10,000KNEE VANGUARD TITANIUM E1 $10,600KNEE VG CEM CEM FEM POR TIB ARC PAT- $7,400KNEE VG CEM POR FEM RGX TIB ARC PAT-110553 $7,800KNEE VG CEM CEM CR FEM CEM TIB ARC PAT-110548 $7,000KNOTLESS FIXATION DEVICE MULTIFIX P 4.5MM-101784 $758K-WIRE .062 x 6 IN SBI-95241 $32K-WIRE 2.5MM W/TROCAR POINT-95307 $244KWIRE GAMMA 3 3.2MM X 450MM-97523 $372KWIRE TI 1.6 X 127MM-87544 $56K-WIRE TROCAR POINT 1.6MM X 150MM-95580 $152KYPHON CEMENT / MIXER $390KYPHON KIT LUMBAR $7,613L PLATE LCP 2 HOLE HEAD 3 HOLE SHAFT 2.7-101186 $675

L PLATE LCP OBLIQUE 2 HOLE HEAD 3 HOLE SHAFT 2.7-101184 $675

L PLATE OBLIQUE TI 3MM X 3MM HOLE 0.5MM THICK-110327 $790L PLATE OBLIQUE TI MATRIX 3HL SHORT .7MM-104279 $636L PLATE TI MATRIX 90 DEGREE 2HL LONG .7MM-190287 $762L PLATE TI MATRIX 90 DEGREE 2HL SHORT .7MM-102323 $610LACE SILIC SB .60X2.5 STYLE 240-85420 $48LACE SILIC SB .75X2.0 STYLE 40-103857 $63LEAD 1 X 8 COMPACT 60CM-97335 $3,446LEAD 303 PERENNIADURA 2MM VNS-93886 $11,133LEAD ARTISAN SCS PRECISION PLUS 2 X 8MM 50CM-97211 $11,696

218 of 317 FY2018

DESCRIPTION CHARGES

LEAD ARTSAN SCS PRECISION PLUS 2X8MM 70CM-97948 $11,696LEAD ATRIAL TEMPORARY PACING $42LEAD CAPSURE BIPOLAR EPICARDIAL 60CM $1,456LEAD EPICARDIAL BIPOLAR 35CM $1,352LEAD EXTENDER ENDOPATH 14 CM $650LEAD EXTENSION DBS 60CM-94557 $1,406LEAD INFINION 16 CONTACT 50/70CM-100660 $5,580LEAD INGEVITY MRI IS 1 BI POSITIVE FIX RA/RV 52CM $680LEAD INTERSTIM TINED 28MM-104542 $7,500LEAD INTRODUCER INTERSTIM-82737 $567Lead Introducer Peel Away $91LEAD KIT RESTORE 20CM-94541 $4,249LEAD LAMITRODE 2 COLUMN PADDLE 60CM-102410 $5,301LEAD LAMITRODE TRIPOLE 16 LEAD 60 CM-106828 $11,576LEAD MYOCARDIAL TEMPORARY PACING $42LEAD NEUROSTIM 3MM 60 CM-96980 $12,293LEAD PACEMACKER SELOX JT 53 $900LEAD PACEMAKER 46CM $1,352LEAD PACEMAKER CAPSURE FIX NOVUS 5076 MRI SURESCAN BIPOLAR STRAIGHT SCREW IN 6.1 $1,456LEAD PACEMAKER FIX NOVUS CAPSURE $1,163LEAD PACEMAKER ISOFLEX OPTIM 52CM $1,428LEAD PACEMAKER ISOFLEX OPTIM 58CM $2,458

LEAD PACEMAKER ISOFLEX OPTION BIPOLAR STRAIGHT 46CM $1,400LEAD PACEMAKER OPTISENSE OPTIM 46CM $1,428LEAD PACEMAKER SELOX $900LEAD PACEMAKER SETROX S 53 $900LEAD PACEMAKER SETROX S 60 $900LEAD PACEMAKER TENDRIL BIPOLAR 100CM $760LEAD PACEMAKER TENDRIL BIPOLAR 58CM $760LEAD PACEMAKER TENDRIL BIPOLAR 85CM $1,428LEAD PACEMAKER TENDRIL MRI OPTIMA IS 1 BIPOLAR STRAIGHT ACTIVE 46CM $760LEAD PACEMAKER TENDRIL MRI OPTIMA IS 1 BIPOLAR STRAIGHT ACTIVE 52CM $760

219 of 317 FY2018

DESCRIPTION CHARGES

LEAD PACEMAKER TENDRIL MRI OPTIMA IS 1 BIPOLAR STRAIGHT ACTIVE 58CM $760LEAD PACEMAKER UNI MYOCARDIAL SCREW $850LEAD PACEMARKER SELOX ST 60 $900LEAD PERCUTANEOUS 1 X 4 PISCES QUAD 56MM-103373 $2,790LEAD PERCUTANEOUS SUB COMPACT OCTAD 60CM-103621 $4,224LEAD QUAD EXTENDER INTERSTIM-82736 $990LEAD QUAD PLUS RESTORE 33/45CM-95111 $2,823LEAD REDUCED SPACING DBS 0.5MM 40CM $7,500LEAD RESPIRATORY SENSING ELECTRTHERAPY $6,100LEAD SOLIA S PRO MRI $1,400LEAD SPECIFY SURESCAN MRI 65CM-110612 $13,552LEAD STIMULATION 45CM $3,900LEAD STIMULATOR RESTORE 565 KIT-95113 $11,668LEAD VECTRIS MRI COMPONENT Add on $6,310LEAD VNS THERAPY PERENNIA FLEX 2.0-100379 $13,228LEAD VNS THERAPY PERENNIA FLEX 3.0-100380 $9,953LEADS SURESCAN MRI COMPONET Add on $3,155Leiberman VSSW 6.5 38 37 $56LENS EYE ARCYSOF TORIC SN6AT7 19.5 $600LENS EYE MTA4U0 13.5 $325LENS EYE RESTOR SN6AD1 18.5 $1,000LENS EYE RESTOR SN6AD1 22.5 $1,000LENS EYE RESTOR SN6AD1 24.5 $1,000LENS EYE RESTOR SN6AD1 6.0 $1,000LENS EYE RESTOR SN6AD1 8.0 $1,000LENS EYE TECHNIS 17.5 $325LENS EYE TORIC SN6AT8 15.0 $600LENS IMPLANT $325Lens Implant Crystalens SSD $1,200Lens Implant Premium Restor SSD $1,000Lens Implant Premium Toric SSD $600LINER 36MM POLY REV TM +3-104624 $1,640LINER ACET BIPOLAR 28X46MM REVISION-21001 $1,969LINER ACETAB 0 DEG 32 X 54-104550 $1,225LINER ACETABULAR $4,077LINER ACETABULAR +4 10D 36 X 54-103868 $2,901

220 of 317 FY2018

DESCRIPTION CHARGES

LINER ACETABULAR +4 10D 36 X 58-103869 $4,048LINER ACETABULAR 36 X 60 NUET PLUS 4-101773 $8,573LINER ACETABULAR 36MM X 52MM PLUS 4-110667 $3,769LINER ACETABULAR 40 X 56-105427 $4,975

LINER ACETABULAR ALTRX 32X48MM 10 DEG LIPPED-105721 $3,337LINER ACETABULAR ALTRX PINNACLE NEUTRAL OD 48MM ID 32MM-106142 $3,021LINER ACETABULAR ALTRX; PINNACLE UHMWPE 58 MM 36 MM-108889 $4,111LINER ACETABULAR CONST 50 MM X 36 MM-104486 $5,732LINER ACETABULAR DURALOC 56-68MM-98171 $3,279

LINER ACETABULAR DYNASTY 40X40MM 15 DEG GROUP F-105724 $800LINER ACETABULAR DYNASTY A-CLASS GROUP B 15 DEGREE POLY 28MM-107958 $1,000LINER ACETABULAR DYNASTY A-CLASS POLYETHYLENE ID 42 MM 15 DEG GROUP G HIP-105875 $800LINER ACETABULAR G7 DUAL MOBILITY NEUTRAL 36MM SIZE B-105905 $5,026LINER ACETABULAR G7 HIGH WALL 40MM REVISION $1,500LINER ACETABULAR G7 NEUTRAL 36MM REVISION $7,020LINER ACETABULAR G7 NEUTRAL 36MM-110432 $7,020LINER ACETABULAR MDM-110636 $4,170LINER ACETABULAR NEUTRAL 36 X 600-104022 $3,868LINER ACETABULAR PINNACLE CONSTRAINED NEUTRAL 10 DEGREE PLUS 4 OD 48MM ID 28MM-106141 $8,346LINER ACETABULAR PINNACLE CONSTRAINED NEUTRAL PLUS 4 OD 48MM ID 28MM-106140 $9,005LINER ACETABULAR R3 20 DEG 40 X 55MM-109993 $4,128LINER ACETABULAR R3 32 x 52/56MM-106546 $3,486

LINER ACETABULAR R3 XLPE 0 DEG 40MM X 56/62MM-105920 $4,128

LINER ACETABULAR RINGLOC BIPOLAR 28MM X 44MM-108428 $1,969LINER ACETABULAR SZ 32 X 57-101752 $5,894LINER ACETABULAR SZ 32MM GROUP C-103369 $800

221 of 317 FY2018

DESCRIPTION CHARGES

LINER ACETABULAR XLPE $3,384LINER ACETABULAR XLPE ANTIVERTED GROUP F 36MM X 54-56MM-106537 $4,692

LINER ACETABULAR XLPE GROUP F 36MM X 54-56MM-106536 $4,944LINER ACETABULAR-103291 $1,389LINER ALTRIX NEUTRAL 36 X 54 MM PLUS 4-104063 $4,261

LINER ALTRX ACETABULAR 40MM X 56MM +4 NEUTRAL-107956 $4,975LINER ARCOMXL 40MM PLUS 3 HW SZ 24-104355 $3,610LINER ASSY 44 45 46MM OD X 28MM ID-81939 $296LINER BIPOLAR ASSY $450LINER CEMENTLESS MDM 46MM F-107843 $4,049LINER CONST FREEDOM SZ PLUS 5 23-105009 $4,586LINER CONSTRAINED STD SZ 25-104028 $5,732LINER CONTINUUM LONGEVITY CONST 32 X 56-105518 $6,127LINER CONTINUUM LONGEVITY CONSTRAINED 28 X 50 MM-104070 $6,826LINER CONTINUUM LONGEVITY CONSTRAINED 28MM X 54MM-110347 $6,699

LINER CONTINUUM LONGEVITY CONSTRAINED 32 X 58 LL-109154 $6,127LINER CONTINUUM LONGEVITY CONSTRAINED 36 X 64 MM-104004 $6,485LINER CONTRAINED 12/14 PLUS 3 MM-104089 $3,510LINER DUR MAR 10DEG 32MM X 56MM-110343 $3,648LINER DUR MAR 28 ID X 48 OD-103303 $3,362LINER DUR MAR 32 ID X 58 0D-101569 $3,398LINER DYNASTY A CLASS SZ 38MM STANDARD-102532 $800LINER DYNASTY A CLASS POLY GRPD 36MM-98631 $2,076LINER DYNASTY ACE GROUP E 38MM-98427 $800LINER DYNASTY POLY GROUP F 40MM-98790 $2,678LINER E1 FREEDOM CONSTR G7 36MM-110403 $7,020LINER G7 HI-WALL ACROMXL 40mm-110891 $1,500LINER HIP ACETABULAR G7 DUAL MOBILITY $4,308LINER HIP ACETABULAR G7 HIGH WALL E1 40MM-110242 $580

222 of 317 FY2018

DESCRIPTION CHARGES

LINER HIP DURALOC MARATHON XLPE 48MM X 28MM-107783 $3,448LINER HIP G7 E1 NEUTRAL 36MM-110320 $7,020LINER HIP G7 E1 NEUTRAL 40MM-110271 $3,082LINER HUMERAL 42MM PLUS O MM EQUINOXE REVERSE SHOULDER-102759 $1,506LINER LONGEVITY CONT GG 32 X 48 MM-105027 $1,050LINER LONGEVITY CONTINUUM CONST 36MM-101913 $6,488LINER LONGEVITY CONTINUUM LL 32 X 58MM-103617 $1,389LINER LONGEVITY MOD CUP 36MM 10 DEG-103938 $1,389LINER LOWER EXTREMITY FREEDOM HIP ACETABULAR CONSTRAINED STANDARD FACE 27MM-105886 $6,020LINER STD POLY APR HOODED 32MM X 55MM $1,826LINER STD SZ 24 FREEDOM-105459 $4,586LINER SZ 42-102950 $800Linq Internal Loop Recorder-102875 $9,708LOCKING BAR TIBIAL-102953 $418LOCKING DEVICE 1.6MM SBF BIOMET Add on $71L-PLATE LONG 2X2 HOLE-108267 $562Magnet Exchange Device-30697 $195MAINTAINER ANT CHAMBER SELF RETAINING $90Mallink Feeding Tube Kit $290Mammotome Clip 8G-85408 $217MARKER FEDUCIAL SUPERLOCK NITINOL COIL-106765 $348MDT Achieve Mapping Catheter $1,900MDT Adapta DR Generator-94551 $12,133MDT Adapta SR-100762 $8,030MDT Advisa DR MRI Generator-101045 $12,133MDT Advisa SR MRI System Peem-105296 $8,833MDT Amplia MRI Quad Crt-D-106435 $59,024MDT Arctic Front Balloon Cath $9,000MDT Attain Lead (Cs/Lv) $7,441MDT Attain Starfix Lead $7,441MDT Azure S DR MRI-109395 $6,200MDT Azure S SR MRI $10,200MDT Azure XT DR MRI Generator, CCL $12,500MDT Azure XT DR MRI Generator-110082 $12,500

223 of 317 FY2018

DESCRIPTION CHARGES

MDT Azure XT SR MRI Generator-110083 $11,000MDT Capsure Fix MRI Lead $1,940MDT Claria Crt D $59,024MDT Consulta Crt D $59,024MDT Consulta Crt-P-99123 $21,037MDT Evera MRI Xt System-105978 $45,868MDT Evera Xt DR-102459 $45,868MDT Evera Xt Generator W Df4 - EP Lab-101044 $45,868MDT Evera Xt Generator W Df4-101044 $45,868MDT Evera Xt VR-102826 $39,842MDT Export Aspiration Catheter $1,298MDT ICD Viva Xt CRT-D IS1/DF1 $59,024MDT ICD VR System Visia AF-109008 $23,600MDT Lead Capsure Sp Novus $1,940MDT Lead Capsurefix Novus $1,940MDT Maximo Ii Crt D Generator $59,024MDT Maximo Ii DR Generator EP Lab $45,868MDT Maximo II DR Generator-94432 $45,868MDT Maximo Ii VR Generator $39,842MDT Pacemaker Percepta Crt-P-108353 $21,688MDT Pacer Lead $1,940MDT Protecta Crt D $59,024MDT Protecta DR ICD $45,868MDT Protecta VR ICD $39,842MDT Protecta Xt Crt D $59,024MDT Revo MRI DR Generator $12,133MDT Secura DR ICD $45,868MDT Secura DR ICD EP Lab $45,868MDT Secura VR ICD $39,842MDT Secura VR ICD EP Lab $39,842MDT Sensia DR Generator $12,133MDT Sensia SR-91260 $8,030MDT Syncra P Bivent Pacer $21,668MDT Versa DR (Vedr01)-91522 $12,133MDT Versa DR(Vedr01)-91522 $13,517MDT Visia Af MRI - Single Chamber-107123 $39,842MDT Visia Af MRI.-107123 $39,842

224 of 317 FY2018

DESCRIPTION CHARGES

MDT Viva Quad Xt Crt-D Generator-103737 $59,024MDT Viva Xt Crt D $59,024Medcomp Cath Split 16Fx55cm $682Medcomp Symetrex Cath $350MEDCOMP SYMETREX EXCH $263Medcomp Titan Cath $286Meditech 014x190 thruway $205Meditech 014x300 thruway $213Meditech 32 136 AT Glidecath 5 65 38 22 $103Meditech 46 852 Platinum Plus V 018 $187Meditech 49 147 Benston 180cm $19Meditech 49 148 Benston 260cm $38Meditech 49 279 Thru Way Wire $177Meditech Platinum Plus 018 $159Meditech Vortex Emboliz Coils $155Medtronic Sensia SR Generator $8,513Medtronic Sprint Quattro Sec Lead $11,731Merit 1 Step Centises Catheter $40Merit 12Fr Resolve Drain Tube-93844 $92Merit 4Fr 11cm Sheath $50Merit 5Fr 11cm Sheath $33Merit 7Fr 11cm Sheath $32Merit 7Fr 23cm Sheath $38Merit Declot Sheath $31Merit Embosphere $399MERIT MAK INTRODUCER $30MESH COLLAGEN VERITAS 4 X 7-95284 $1,131MESH COLLAGEN VERITAS 8CM X 14XM-97355 $3,989MESH PARIETEX 10 INCH X 8 INCH-93233 $3,249MESH PARIETEX 14.5 INCH X 11 INCH-93232 $3,124MESH PARIETEX 15 X 15-95480 $759MESH PARIETEX 4.8 INCH ROUND-93234 $1,551MESH PARIETEX 6 INCH X 4 INCH-93236 $2,030MESH PARIETEX 8 INCH X 6 INCH-93235 $2,488MESH PARIETEX COMPOSITE U SHAPED 9CM X 8CM-93170 $839MESH PARIETEX COMPOSITE 12X8-93168 $4,200MESH PARIETEX COMPOSITE 15CM X 10CM-95928 $1,353

225 of 317 FY2018

DESCRIPTION CHARGES

MESH PARIETEX COMPOSITE 3.6CM ROUND-93167 $1,131MESH PARIETEX PLUG & PATCH 8CM-98566 $411MESH PARIETEX PROGRIP RECTANGULAR 15 X 9 CM-96736 $739MESH PARIETEX ROUND 6.5CM-98589 $257MESH PERMACOOL 5X10CMX1MM-96682 $1,727MESH PLUG LRG ULTRAPRO-92715 $402MESH PLUG MED ULTRAPRO $165MESH PLUG SM ULTRAPRO $165MESH RAPID RESORB CONTOURABLE $2,812MESH RAPID RESORBABLE 50 X 50 X 0.8 MM-103997 $2,729MESH RESTORELLE L FLAT 24 X 8 CM-105504 $1,850MESH RESTORELLE Y SHAPED 24 X 4CM-102704 $1,576MESH RESTORELLE Y SHAPED 27 X 4 CM-96405 $1,592MESH ROUND TITANIUM PYRAMESH 13 X 50 MM-104860 $14,740MESH TI MICRO $1,609MESH TI MICRO 125 X 203 X 0.6MM-103125 $4,236MESH TI MICRO 131 X 200 X 0.2MM-103123 $4,024MESH TI MICRO BOWTIE 61 X 61 X 0.6MM-103129 $2,183MESH TI MICRO BOWTIE 90 X 90 X 0.4MM-103126 $3,268MESH TI MICRO BOWTIE 90 X 90 X 0.6MM-103127 $3,105MESH TI MICRO CUSTOM $1,609MESH TI MICRO CUSTOM 89 X 120 X 0.6MM-103116 $2,975MESH UPSYLON Y-101376 $2,015MESH Y INTEPRO-92114 $1,500MESH Y UPSYLON-106693 $2,220

MICROCATHETER HI FLO RENEGADE ANGLES 105 X 20MM-103582 $1,026MICROCATHETER RENEGADE STC -18 STR 105 CM-104818 $1,070Microez Microintroducer $47Microintroducer 5cm $19MICROMATRIX MICRONIZED PARTICLES 1000MG-108502 $4,968MICROSCOPE LEICA NEURO-80347 $12MICROSTIC MEDICOMP INTRODUCER $33MicroVena Ultra Select Guidewire $449MODULIFT VBR M MOD 50-74MM-110198 $14,000

MODULIFT VBR S 12/14 X 14 19 & 16 34-74MM 5 DEGREE-109203 $16,000

226 of 317 FY2018

DESCRIPTION CHARGES

MODULIFT VBR S 14 X 16 19-45MM 0 DEGREE-109210 $16,000

MOLD CEMENT REINFORCED HIP STEM 15MM X 200MM-105898 $4,016MOLD HIP STEM WITH REINF 9 X 125-105512 $2,294MONITOR SYSTEM REVEAL LINQ INSERTABLE CARDIAC MONITOR MRI COMPATIBLE (INCLUDES L $10,290MR ATEC Clip $194MR Bard Breast Local Wire-93497 $726MR Devices Localization Wire $126MR SenoMark UltraCor 14GSS Clip-91470 $318MR Suros Eviva 9Ga-96384 $147Multi purpose 14F $135Multi purpose 16F $112Mynx Grip Closure Device, CCL $410Mynx Grip Closure Device-110090 $410MYOWIRE INTRAMYOCARDIAL 26MM $23NAIL HUMERAL TITANIUM CANNULATED BLUE 240 MM 9 MM-109243 $3,898NAIL ANKLE LOCKING 12 X 150 MM-104796 $6,358NAIL EX HUMERAL 7 X 270MM TI CANN STERILE-101130 $4,088NAIL FEMORAL RETRO ANTE EX $3,511NAIL FEMORAL RETRO ANTEGRADE TI CANN STERILE $3,498NAIL FEMORAL RETRO ANTEGRADE TI CANN STERILE 12 X 300MM-105020 $3,683NAIL FEMORAL RETROGRADE SHORT 13MM X 24CM-98760 $3,994NAIL FEMORAL TI LATERAL ENTRY 11m X 360MM-109296 $3,406NAIL GAMMA 3 TROCHANTERIC 11X180MM 130 DEG-99010 $3,912

NAIL GAMMA 3 TRONCHANTERIC 11 X 180MM 125DEG-97174 $3,414NAIL HUMERAL TI MULTILOC PROXIMAL LEFT STERILE 8 X 160 MM-109250 $3,679NAIL HUMERAL TI MULTILOC PROXIMAL LEFT STERILE 9.5MM X 160MM $3,853NAIL HUMERAL TI MULTILOC PROXIMAL RIGHT STERILE 8 X 160 MM-104555 $4,040NAIL HUMERAL TI MULTILOC PROXIMAL RIGHT STERILE 9.5 X 160MM-102682 $3,064

227 of 317 FY2018

DESCRIPTION CHARGES

NAIL INTRAMEDULARRY PEDINAIL 8/9MM X 36/38CM $6,631NAIL INTRAMEDULARY.045-1.1MM SBF BIOMET Add on $320

NAIL INTRAMEDULLARY ORTHOPEDIC LONG 12X340MM STERILE TITANIUM 130 DEG CANNULATED FIXATION TROCHANTER-105731 $3,942NAIL INTRAMEDULLARY PEDIAFLEX 205MM X 300MM $1,034NAIL INTRAMEDULLARY TI $3,511

NAIL LOWER EXTREMITY TI-6AL-7NB 380MM X 10MM-109180 $3,874NAIL TFN $3,942NAIL TFN 10MM/130 DEG X 170MM TI CANN -STER-95371 $2,996NAIL TI CANN TFNA $4,873NAIL TI CANN TFNA 125 DEGREE STERILE $3,477

NAIL TI CANN TFNA 130 DEGREE RIGHT 10MM X 400MM-110372 $4,875

NAIL TI CANN TFNA 130 DEGREE STERILE 10MM X 360MM-110032 $4,872NAIL TI CANN TROCANTERIC $3,759NAIL TI CANN TROCH FIXATION $2,857

NAIL TI CANN TROCH FIXATION STERILE LEFT 10 X 340MM-101914 $3,149NAIL TI CANN TROCHANTERIC $3,942NAIL TI CANN TROCHANTERIC 10 X 400 MM 130 DEGREE RIGHT-104310 $4,065

NAIL TI CANN TROCHANTERIC 12X360MM 130 DEG RT-98149 $4,171

NAIL TI CANN TROCHANTERIC 12X380MM 130 DEG RIGHT-98814 $4,452NAIL TI CANN TROCHANTERIC LEFT 125 DEGREE STERILE 10MM X 320MM-107969 $3,874NAIL TI CANNULATED $2,996NAIL TI TIBIAL CANN $2,656NAIL TI TIBIAL CANN 11MM X 390MM $3,075NAIL TI TIBIAL CANN 8 X 135MM-97127 $2,499NAIL TI TROCHANTERIC $2,996NAIL TI TROCHANTERIC $3,745NAIL TI TROCHHANTERIC $3,942

228 of 317 FY2018

DESCRIPTION CHARGES

NAIL TIBIAL EXPERT PROXIMAL BEND CANNULATED STERILE $3,225NAIL TIBIAL EXPERT PROXIMAL BEND CANNULATED STERILE 10 X 345MM-103864 $3,064NAIL TIBIAL EXPERT TIBIAL BEND CANNULATED STERILE 10MM X 360 $3,075NAIL TIBIAL TI CANN PROXIMAL BEND STERILE $3,075NAIL TIL INTRAMEDULLARY RIGHT CANNULATED 150MM $2,918NECK COLLARLESS LINK REVISION 126DEG 35MM-98632 $6,836NECK FEMORAL PROFEMUR LONG STRAIAGHT-102531 $775NECK FEMORAL PROFEMUR NEUTRAL SHORT-98620 $834NECK FEMORAL PROFEMUR SZ 2 SHORT-98182 $775NECK FEMORAL PROFEMUR VAR VAL-98792 $1,000NEEDLE SET MICROPUNC 4FR NITINOL-41479 $84Nephrostomy Catheter ULT 8.5 $160NEPHROURETEROST 8FRX30CM-104730 $224NEUROSTIMULATER SPINAL CORD RESTORE SENSOR-98775 $34,197NEUROSTIMULATOR ACTIVA PC-94556 $35,870NEUROSTIMULATOR ACTIVA RC RECHARGEABLE MULTI PROGRAM DBS-107078 $44,000NEUROSTIMULATOR ACTIVA SC SINGLE CHANNEL QUADRAPOLAR-99497 $18,450NEUROSTIMULATOR GENERATOR COMPNT Add on $37,862NEUROSTIMULATOR MRI SURESCAN-103632 $29,863NEUROSTIMULATOR PROGRAMABLE ITREL 4-107870 $14,498NEUROSTIMULATOR PROTEGE 16 CHANNEL RECHARGEABLE UPGRADEABLE-103646 $35,549NEUROSTIMULATOR SPINAL CORD RESTORE ULTRA-94540 $32,376NEUROSTINULATOR PRIME ADVANCE-97363 $21,777Newton Wire 35 x 145 $41Niagara Slim Acute Cath $137Niagra Dialysis Cath 15/20cm $295Oasis Biliary Plastic Stent-34320 $354Octapolar Catheter $1,089OCTRODE LEAD KIT 90CM-103672 $5,045OCTRODE LEAD KIT-95253 $5,671OIL SILIKON 1000 VIAL 8.5ML $900OIL SILIKON 1000-33058 $990

229 of 317 FY2018

DESCRIPTION CHARGES

OPTEASE GUIDEWIRE FEMORAL Add on $178OPTEASE GUIDEWIRE JUGULAR Add on $178PACEMACKER EVIA SR T CLS HM MOBILE $11,134PACEMACKER VERSA DR NO LEADS $5,968PACEMAKER ACCENT DR $10,002PACEMAKER ACCENT DR 1 $8,482PACEMAKER ACCENT SR $7,526PACEMAKER ACCOLADE EXTENDED LIFE MRI DR IS 1 $6,100PACEMAKER ADAPTA DUAL CHAMBER $9,880PACEMAKER ADVISA DR MRI GENERATOR $10,868PACEMAKER ALLURE RF $17,480PACEMAKER ASSURITY DEVICE $11,068PACEMAKER DR MRI SYSTEM ADVISA MEEE WITHOUT MRI COMPATIBLE LEAD $9,700PACEMAKER DR MRI SYSTEM ADVISA MEEM WITHOUT MRI COMPATIBLE LEAD $9,700PACEMAKER DR MRI SYSTEM ADVISA PEEE WITH MRI COMPATIBLE LEAD $8,000PACEMAKER DR SYSTEM ADVISA MEEE DUAL CHAMBER WITHOUT MRI COMPATIBLE LEAD $9,700PACEMAKER DR SYSTEM ADVISA MEEM DUAL CHAMBER WITHOUT MRI COMPATIBLE LEAD $9,700PACEMAKER EDORA 8 DR T PROMRI WITH CLS (R) WITH HOME MONITORING $8,800PACEMAKER EDORA 8 SR-T $6,250PACEMAKER ELUNA 8 DR T GENERATOR W/CLS W/HM MOBILE MRI COMPATIBLE $14,200PACEMAKER ELUNA 8 SR T GENERATOR W/CLS W/HM MOBILE MRI COMPATIBLE $12,134PACEMAKER ENDURITY DR $9,650PACEMAKER ENDURITY SR $7,410PACEMAKER ENTOVIS DR T $14,200PACEMAKER ENTOVIS DR T GENERATOR W/HM MOBILE MRI COMPATIBLE $13,490PACEMAKER ENTOVIS SR T GENERATOR W/HM MOBILE MRI COMPATIBLE $11,527PACEMAKER ENTOVIS SR T MRI COMPATIBLE $12,134

230 of 317 FY2018

DESCRIPTION CHARGES

PACEMAKER ETRINSA 8 DR T GEMERATOR W/CLS W/HM MOBILE $14,440PACEMAKER ETRINSA 8 HF T CRT P GENERATOR WITH CLS HM MOBILE $14,440

PACEMAKER ETRINSA 8 SR T GENERATOR W/CLS W/HM MOBILE $11,134PACEMAKER EVIA DR CLS AUTO RESP $9,730PACEMAKER EVIA DR T CLS HM $10,600PACEMAKER EVIA DR T CLS HM MOBILE $12,200PACEMAKER EVIA SR CLS AUTO RESP $8,833PACEMAKER EVIA SR T CLS HM LANDLINE $9,535PACEMAKER EVIA SR T CLS HM MOBILE $9,534PACEMAKER GEN ADVISA SR SINGLE CHAMBER MRI SAFE $8,420PACEMAKER GEN ASSURITY MRI DR RF IS 1 $6,220PACEMAKER GEN ASSURITY MRI DR RF IS 1 W MERLIN PKG $6,220PACEMAKER GEN ASSURITY MRI SR RF IS 1 $5,020PACEMAKER GEN ASSURITY SR RF $7,800PACEMAKER GEN ASSURITY SR RF W MERLIN PKG $8,200PACEMAKER GEN CONSULTA-P CRT P BIVENTRICULAR-99123 $17,460PACEMAKER GEN ZEPHYR SR $6,400PACEMAKER GENERATOR AZURE S DR MRI SURESCAN $8,000PACEMAKER GENERATOR AZURE S SR MRI SURESCAN $6,800PACEMAKER GENERATOR AZURE XT DR MRI SURESCAN $8,800PACEMAKER GENERATOR AZURE XT SR MRI SURESCAN $7,600PACEMAKER GENERATOR ESSENTIO SR RA/RV:IS1 SIZE 4.45CM X 4.81 $3,168PACEMAKER IDENTITY THIN PROFILE DR NO LEADS $6,791PACEMAKER SR GEN ADAPTA SINGLE CHAMBER UNIPOLAR 5MM OR 6MM $5,000PACEMAKER SR MRI SYSTEM ADVISA PEEE SINGLE CHAMBER WITH MRI COMPATIBLE LEAD $5,950PACEMAKER SYSTEM ADVISA SR SINGLE CHAMBER MRI SAFE WITH LEADS $8,420PACEMAKER SYSTEM ELUNA 8 DR T W/SOLIA W/CLS W/HOME MONITORING MRI COMPATIBLE $16,200PACEMAKER VICTORY DR NO LEADS $8,438PACEMAKER VICTORY SR NO LEADS $6,586

231 of 317 FY2018

DESCRIPTION CHARGES

PACEMAKER ZEPHYR DR $6,697PACEMAKER ZEPHYR XL DR $6,898PACEMAKR ACCOLADE MRI STD VR $5,344PACEMKR ACCOLADE DR L321 $4,228PACEMKR ACCOLADE MRI DR L311 $6,100PACEMKR ACCOLADE SR L300 $3,344PACK PHACO FMS 30 DEGREE $1,055Pancreatic Stent $414PASTE DBM ALLOSYNC 1CC-110430 $600PASTE STIMUBLAST WITH CANCELLOUS BONE 3CC-106202 $1,430PASTE STIMUBLAST WITH CANNCELLOUS BONE 8 CC-105681 $2,333

PATCH KNITTED HEMAGARD NON TAPERED 25X150MM-99807 $269PATCH VASC PERIPATCH .8CM W X 8CM L-94285 $350PATELLA 3 PEG DOME OVAL 41MM-19326 $1,940PATELLA ASSYMETRIC 8.5 X 34MM REVISION-110590 $600PATELLA COLUMBUS SZ 3-105474 $800PATELLA NATURAL KNEE FLEX PROLONG $600PATELLA RD 29MM STD-103899 $1,739PATELLA RESURFASING GENESIS 2 32MM-101769 $2,192PATELLA SINGLE PEG STD 31 X 8 MM-101600 $1,742Pathfinder Guidewire-26840 $428PATIENT CONTROLLER ELITE 5 STJM Add on $4,625Patient Programmer Neurostim $2,586Peds PICC LCath 1.9Fr $245Peds PICC LCath 3Fr $248PEEK 7X10MM SCREW Add on $1,275PEEK KNOTLESS SUTURETAK OPEN REPAIR $1,100PEG PARTIAL THREAD $222PEG SMOOTH TI 2.0 X 14MM-87554 $184PEG THREADED $222PEG THREADED 2.5MMX24MM TI $238PEG THREADED LOCKING $168PEG THREADED MULTIDIR $426PEG THREADED MULTIDIR 2.5 X 16 MM-104610 $352PEG THREADED NON LOCKING $177Pentaray Nav Multielectr Mapping-110148 $3,840

232 of 317 FY2018

DESCRIPTION CHARGES

PENUMBRA POD $2,775PENUMBRA RUBY COIL $1,580PENUMBRA RUBY COIL $1,980PENUMBRA RUBY COIL RBY $2,000Perc Local Needle/Wire 20Gx10cm-57515 $72

PERCLOSE PROGLIDE 6FR SUTURE MEDICATED CLOSURE SYS-98063 $530Perclose Proglide Closure Device-98063 $411Percutaneous Neff Set NPAS104 $111Pericardiocentesis Tray $291Periph Balloon-Fox Cross $612Periph Balloon-Viatrac 14 Plus $529Periph Guidewire-Spartacore $116Periph Guidewire-Supracore $171Periph Stent-Omnilink Elite $1,589PERISTRIP DRY W/ERIT AS FOR ECHELON 60 $289Peritenial Aspira Catheter $1,748PIN 2MMX100MM add on $225PIN BIO-TRANSFIX 5X40MM-97179 $640PIN CRIMP POSITIONING STERILE $634PIN FIXATION SPINAL ELEMENTS $200PIN FIXATION THREADED-100136 $155PIN FIXATION-91329 $388PIN GUIDE THRD ZIMMER-4852 $65PIN LOCKING SHORT $128PIN LOCKING STD $128PIN META 1.9MM PRE DRILL add on $225PIN POLY LOCK-104038 $510PIN POSITIONING CERCLAGE THREADED 4.5MM-90934 $391PIN SHOULDER REVERSE TM 2.5 STERILE-103304 $634

PIN SHOULDER REVERSE TRABELULAR METAL 2.5MM-100169 $434PIN STEIMANN THREADED $22PIN STEINMAN SMOOTH $9PIN STEINMANN 3.2 X 9 INCH-102403 $358PIN TEMPORARY FIXATION SKY-104517 $217PIN TEMPORARY FIXATION-103088 $600

233 of 317 FY2018

DESCRIPTION CHARGES

PIN TRANSFIXATION 5 X 225 MM-104804 $320PIN VERSITOMIC STAINLESS STEEL STERILE-109281 $918PINN GRIP TF REV AUGM 20 X 58/60-108872 $5,178PINN GRIP TF REV BUTTRESS 56L-108871 $9,322PINN GRIP TF REV SHIM 15 DEG-108870 $3,366PISTON ECLIPSE FLAT RIBBON $599PLATE I 16MM-65364 $326PLATE STERNALOCK TI L SHAPED 8 HOLE 2.4/2.7MM 1.6MM $812PLATE 2 X 10MM DOUBLE BEND-102991 $1,590PLATE 2 X 6MM SINGLE BEND-102993 $1,506PLATE 23MM LEFT L OSTEOMED-95222 $450PLATE 23MM RIGHT L OSTEOMED-95221 $512PLATE 36MM TI SKY 2-LEVEL-95000 $3,244PLATE 3X3 HOLE L SHAPED $598PLATE 4 HOLE LONG BSSO 2MM SCREW 2MM X 1.5MM $846PLATE 4 HOLE RECTANGLE $700PLATE 4.5MM LCP CONDYLAR 6HL 170MM -86191 $3,413PLATE 4.5MM LCP CONDYLAR 8 HL 206MM LT-87754 $2,667PLATE 4.5MM LCP CONDYLAR 8 HL 206MM RT-87741 $2,849PLATE 41MM LUMBAR-91338 $11,550PLATE 6-HL REG STR-80329 $148PLATE 8 HOLE ACULOC LATERAL DORSAL RADIAL 3.5MM SCREW 3.5X100MM-110674 $1,934PLATE 8 HOLE VOLAR MID SHAFT RADIUS 8 HOLE-109393 $1,934PLATE ACU LOC 2 VDR NARROW LEFT-100931 $2,610PLATE ACU LOC 2 VDR NARROW RIGHT-107875 $1,305PLATE ACU LOC 2 VDR STANDARD LEFT-109327 $26,100PLATE ACU LOC 2 VDR STD RIGHT-104580 $2,534PLATE ACU LOCK 2 VDR NARROW LONG RIGHT-108376 $2,610PLATE ACULOC TI LEFT DISTAL CLAVICULAR 12 HOLE 3.5MM SCREW 3 $2,722PLATE ACU-LOC2 VDR NARROW RIGHT-99515 $2,610PLATE ADAPTION LCP STR 12 HOLE 1.5X59MM-100962 $667PLATE ADAPTION LCP STR 4 HOLE 1.5MMX23MM-100959 $363PLATE ADAPTION LCP STR 6 HOLE 1.5X29MM-100960 $667PLATE ADAPTION LCP STR 6 HOLE 1.5X36MM-100961 $363

234 of 317 FY2018

DESCRIPTION CHARGES

PLATE ADAPTION LOCKING COMPRESSION 12 HOLE 2X81MM-100831 $712PLATE ADAPTION MATRIX 5HL-95386 $562PLATE ANCHORING ROI-C LONG H8-105001 $1,200PLATE ANCHORING ROI-C STANDARD 5 TO 7 MM-104245 $1,200PLATE ANKLE ANTERIOR TIBIOTALAR LEFT-110419 $5,930PLATE ANTERIOR 25MM-84990 $2,034

PLATE ANTERIOR CERVICAL 1 LEVEL ANODYNE 14MM-108815 $2,000

PLATE ANTERIOR CERVICAL 3 LEVEL ANODYNE 56MM-108838 $2,300PLATE ANTERIOR CERVICAL 45MM-86569 $2,271PLATE ANTERIOR CERVICAL SKYLINE 1 LEVEL 14MM-99498 $2,979

PLATE ANTERIOR CLAVICLE LCP 6HL RIGHT 3.5 X 94 MM-104776 $2,004PLATE ANTERIOR CLAVICLE LCP 8HL 3.5X102MM-103567 $2,005PLATE ANTERIOR CLAVICLE W/LATERAL EXTENSION 4HL LEFT 3.5X81MM-103566 $1,851PLATE ANTERIOR LUMBAR 36MM $5,348PLATE ANTERIOR LUMBAR CONTACT ALP 42- 46MM-109157 $8,000PLATE ANTERIOR SACRAL CONTACT ALP 38- 44MM-108072 $8,000

PLATE ATERIOR CLERCICAL LOW PROFILE ANODYNE 16MM-101116 $1,888PLATE ATLANTIS ELITE 23MM-97656 $2,333PLATE ATLANTIS ELITE 25MM-102624 $3,631PLATE ATLANTIS ELITE 45MM-102984 $3,924PLATE ATLANTIS ELITE 55 MM-105695 $2,200PLATE ATLANTIS ELITE 70MM-102543 $4,361PLATE ATLANTIS TRANLATIONAL 25MM 1 LEVEL-100885 $2,400PLATE ATLANTIS TRANSLATIONAL 27.5 MM 1 LEVEL-103643 $2,613PLATE ATLANTIS TRANSLATIONAL 3 LEVEL 52.5MM-102742 $3,274

235 of 317 FY2018

DESCRIPTION CHARGES

PLATE ATLANTIS TRANSLATIONAL 37.5MM 2 LEVEL-102647 $2,812PLATE ATLANTIS TRANSLATIONAL 57.5 MM-104861 $2,800PLATE BOX TI MATRIX LOW PROFILE 10 X 16MM-101666 $499PLATE BROAD LAP 12HL 4.5 X 224MM-92414 $1,226PLATE BROAD LCP 11HL 4.5X206MM-90932 $1,149

PLATE CD HORIZON SOLERA CROSSLINK 4.75X41 TO 48MM-100899 $3,381PLATE CERVICAL 1 LEVEL 12-18MM-103026 $2,333PLATE CERVICAL 1 LEVEL 14MM-103024 $2,436PLATE CERVICAL 1 LEVEL ANODYNE 16-18MM-109324 $1,900PLATE CERVICAL 2 LEVEL 26 MM-105510 $2,150PLATE CERVICAL 2 LEVEL 28-37MM-103029 $2,489PLATE CERVICAL 2 LEVEL 40MM-108437 $2,150PLATE CERVICAL 3 LEVEL 39MM-109284 $2,300PLATE CERVICAL 3 LEVEL 42- 57MM-103035 $2,753PLATE CERVICAL 3 LEVEL 60MM-108101 $2,185PLATE CERVICAL 4 LEVEL 72MM-109273 $2,450PLATE CERVICAL ANTERIOR 23MM-86571 $2,034PLATE CERVICLE 1 LEVEL 20 MM-103932 $2,314PLATE CHIN 6MM-71962 $642PLATE CHIN 8MM-49211 $508PLATE CLAVICAL LCP SUPERIOR LATERAL EXT 6HL LEFT 3.5 X 105MM-103818 $2,333PLATE CLAVICAL LCP SUPERIOR LATERAL EXT 6HL LEFT 3.5 X 108MM-103817 $1,904PLATE CLAVICLE 6 HOLE LEFT-109290 $2,474PLATE CLAVICLE DOG BONE BUTTON Add on $2,412PLATE CLAVICLE FRACTURE CENTRAL THIRD RIGHT-108459 $1,572

PLATE CLAVICLE LCP SUPERIOR 5H LEFT 3.5MM X 94MM-110374 $1,889

PLATE CLAVICLE LCP SUPERIOR 6HL RIGHT 3.5 X 85MM-102603 $1,904PLATE CLAVICLE LCP SUPERIOR LATERAL EXT 8HL RIGHT 3.5 X 130 MM-104836 $2,110PLATE CLAVICLE LOW PROFILE 10 HOLE LEFT-103879 $2,282PLATE CLAVICLE LOW PROFILE STR 8 HOLE LEFT-105523 $2,402PLATE CLAVICLE NARROW PROFILE 6 HOLE RIGHT-103580 $2,402

236 of 317 FY2018

DESCRIPTION CHARGES

PLATE CLAVICLE NARROW PROVILE 8 HOLE STR RIGHT-101132 $1,792

PLATE CLAVICULAR LCP 7 HOLE RIGHT 3.5MM X 100MM-110592 $1,961

PLATE CLAW POLYAXIAL COMPRESSION 2 HOLE 15MM-101407 $4,398PLATE CLOVERLEAF 3HL 88MM THIN BLADE-2779 $641

PLATE CODYLAR VA LCP CURVED 6 HOLE 4.5 X 159MM-102674 $3,400PLATE COLLES FRACTURE-80808 $1,091PLATE COMPRESSION 4 HL-72908 $496PLATE COMPRESSION CLAW 2 POLY 2HL 20MM-103872 $4,270PLATE COMPRESSION CLAW 2 POLY 4HL 20MM-103873 $5,208PLATE CONDYLAR 2.0 LCP 7HOLE-91350 $1,710PLATE CONDYLAR LOCKING 6 HOLE SHAFT 2 HOLE HEAD 1.5MM-100968 $673PLATE CONDYLAR VA LCP CURVED 10 HOLE RIGHT 4.5 X 230MM-103395 $3,818PLATE CONDYLAR VA LCP CURVED 14 HOLE LEFT 4.5X301MM-108272 $3,967PLATE CONDYLAR VA LCP CURVED 14 HOLE RIGHT 4.5 X 301MM-105541 $4,161PLATE CONDYLAR VA LCP CURVED 16 HOLE LEFT 4.5 X 336 MM-105575 $4,242PLATE CONDYLAR VA LCP CURVED 6 HOLE RIGHT 4.5 X 159 MM-104992 $3,579

PLATE CONDYLAR VA LCP CURVED 8 HOLE 4.5 X 195MM-103276 $3,648PLATE CONTACT ANTERIOR LUMBAR 40MM-107837 $8,000PLATE CRANIAL 4 HOLE STRAIGHT 12MM-97352 $149PLATE CRANIOMAXILLOFACIAL TITANIUM 2 MM STRAIGHT 2 MM SCREW 16 HOLE-110261 $1,102PLATE CROSSLINK SOLERA MULTISPAN 47-60MM-103317 $3,212PLATE CSLP VARIABLE ANGLE 76MM 4 LEVEL-97932 $2,674PLATE CURVED BROAD LC-LCP 13 HOLE 4.5MM X 247MM $1,599PLATE CVD 4.5 LCP 12 HOLE 278 MM LT-92368 $3,706PLATE CVD 4.5 LCP 12 HOLE 278 MM RT-92367 $3,544

237 of 317 FY2018

DESCRIPTION CHARGES

PLATE DCP 6HL 3.5X73MM-24335 $272PLATE DCP 7HL 3.5X85MM-24343 $283PLATE DCP 8HL 3.5X97MM-24336 $295

PLATE DCP TI MATRIX MANDIBLE 3 X 3HL 1.25 MM THICK-104583 $974PLATE DHHS LCP 130 DEGREE STD 4HL-97521 $1,039PLATE DHS 130 DEG 4 HOLE 78MM SHRT BARREL-92886 $1,134

PLATE DHS SHORT BARREL 2HL 38 X 46 MM 135 DEG-104775 $1,192PLATE DHS SHORT BARREL 4HL 25X78MM 135 DEG-88677 $1,296

PLATE DHS STANDARD BARREL 4HL 38X78MM 135 DEG-85205 $925PLATE DISTAL CLAVICLE SHORT LEFT-103090 $1,493PLATE DISTAL CLAVICLE SHORT RIGHT-104855 $1,572PLATE DISTAL FIBULA LATERAL 9HL 2.7 TO 3.5 X 151MM RIGHT-102546 $1,459PLATE DISTAL FIBULA LCP 2.7 TO 3.5-97361 $1,378

PLATE DISTAL FIBULA LCP LATERAL 3H 2.7X3.5X73MM -109323 $1,292PLATE DISTAL FIBULA LCP LATERAL 4HL 2.7 TO 3.5 X 86MM LEFT-101637 $1,314PLATE DISTAL FIBULA LCP LATERAL 4HL RIGHT 2.7 TO 3.5 X 86MM-102615 $1,309PLATE DISTAL FIBULA LCP LATERAL 5HL 2.7 TO 3.5 X 99MM LEFT-103971 $1,397PLATE DISTAL FIBULA LCP LATERAL 5HL 2.7 TO 3.5 X 99MM RIGHT-102313 $1,396PLATE DISTAL FIBULA LCP LATERAL 6HL LEFT 2.7 TO 3.5 X 112MM-103275 $1,419PLATE DISTAL FIBULA LCP LATERAL 9HL 2.7 TO 3.5 X 151MM LEFT-101664 $1,130PLATE DISTAL FIBULA LCP LATERAL RIGHT 3H 2.7MM X 3.5MM X 125 $1,371PLATE DISTAL FIBULA LCP VARIABLE ANGLE LATERAL 4HL LEFT 2.7 X 92MM-102548 $1,716PLATE DISTAL FIBULA LCP VARIABLE ANGLE LATERAL 5HL RIGHT 2.7MM-102553 $1,791

238 of 317 FY2018

DESCRIPTION CHARGES

PLATE DISTAL FIBULA LCP VARIABLE ANGLE LATERAL 6HL LEFT 2.7 MM-104805 $1,992PLATE DISTAL FIBULA LCP VARIABLE ANGLE LATERAL 6HL RIGHT 2.7MM-102551 $2,333

PLATE DISTAL FIBULA VARIABLE ANGLE 3 HL LEFT 2.7 MM-104327 $1,727

PLATE DISTAL FIBULAR LCP LATERAL RIGHT 4HOLE 90MM-110278 $1,640PLATE DISTAL HUMERUS LCP EXTRA ARTICULAR 6 HL LEFT 3.5 X 158-103529 $2,848PLATE DISTAL HUMERUS LCP EXTRA ARTICULAR 8HL RIGHT 3.5 X 194 MM-104966 $3,182PLATE DISTAL POSTEROLATERAL FIBULAR RIGHT 11 HOLE 181MM-109294 $1,412PLATE DISTAL RADIUS 2 COLUMN 2 HL SHAFT 6 HL HEAD RIGHT-104541 $1,964

PLATE DISTAL RADIUS 2 COLUMN 3HL SHAFT 6HL HEAD NRW $2,042PLATE DISTAL RADIUS 2 COLUMN 3HL SHAFT 7HL HEAD 2.4MM-102424 $2,333PLATE DISTAL RADIUS 2 COLUMN 4 HOLE SHAFT 6 HOLE HEAD LEFT 2.4MM-110946 $4,031PLATE DISTAL RADIUS 2 COLUMN 5H SHAFT 6 HOLE HEAD RIGHT 2.4MM-110230 $2,090PLATE DISTAL RADIUS 2 COLUMN 6HL HEAD 3HL SHAFT NRW LEFT-105574 $2,042PLATE DISTAL RADIUS COLUMN 3HL SHAFT 7HL HEAD LEFT 2.4 X 55MM-103871 $1,940PLATE DISTAL RADIUS STD RIGHT-87535 $1,926PLATE DISTAL TIBIA VARIABLE ANGEL LCP MEDIAL 6HL RIGHT 2.7 TO 3.5MM-102549 $3,038PLATE DISTAL TIBIA VARIABLE ANGLE LCP MEDIAL 6 HL LEFT 2.7 TO 3.5MM-101581 $2,478PLATE DISTAL TIBIA VARIABLE ANGLE LCP MEDIAL 8HL LEFT 2.7-3.5 x 172MM-103816 $3,069PLATE DISTAL TIBIAL VARIABLE ANGLE LCP MEDIAL 4HL LEFT 2.7 TO 3.5MM X 112MM-103274 $3,005

239 of 317 FY2018

DESCRIPTION CHARGES

PLATE DISTAL VOLAR NARROW SHORT RIGHT-87538 $2,092PLATE DISTAL VOLAR SHORT LEFT-87076 $1,926PLATE DORSOLATERAL MIDSHAFT RADIUS 6 HOLE-108891 $1,934PLATE DOVAR WIDE HEAD TI LEFT-87539 $2,090PLATE DVR ANATOMIC EXTRA EXTENDED -102083 $3,732PLATE DVR ANATOMIC NARROW LEFT-102080 $1,834PLATE DVR ANATOMIC WIDE HEAD RIGHT-102081 $1,926PLATE DVR CROSSLOCK MEDIUM LEFT-104800 $2,190PLATE DVR NARROW LEFT 51MM X 22MM-109392 $2,330PLATE DVRA NARROW SHORT TI LEFT-87537 $2,090PLATE DVR-A SHORT TI RIGHT-87534 $2,024PLATE FEMUR PROXIMAL RT NCB 285MM-97853 $2,968

PLATE FEMUR TI TOMOFIX LATERAL DISTAL 4HL LEFT-108021 $2,667PLATE FIBULAR DISTAL LATERAL 6H LEFT-97856 $831PLATE FOOT 3 HOLE T SHAPED 3MM LOW PROFILE $2,286PLATE FOOT TITANIUM 2 HOLE STRAIGHT COMPRESSION 30MM-110299 $2,558

PLATE FRACTURE COMMINUTE ANGLED LOCKING 2.4MM-108463 $2,756PLATE GLENOID REVERSE EQUINOXE-97621 $5,990PLATE HOOK LCP 3HL STERILE 3.5MM-103972 $1,204

PLATE HUMERAL LAT DISTAL VA LCP 1 HOLE SHORT 69MM-105483 $2,444PLATE HUMERAL MEDI DISTAL VA LCP EXT 2 HOLE LEFT MEDIUM 85MM-105482 $2,520PLATE HUMERUS PROXIMAL LONG 6HL SHAFT 3.5 X 160MM-102646 $3,474PLATE IT VOLAR DISTAL RADIUS RIGHT 3H-110702 $2,272PLATE L 15MM 2.0 SCREW-55124 $326PLATE L 3HL 2.7X34MM OBLIQUE RIGHT-2795 $105PLATE L LT 15MM-62956 $341PLATE L RIGID LT 18MM-44991 $472PLATE L RT 15MM RIGID 2.0 SCREW-54927 $472PLATE L SHAPE 0.5MM 90 DEG THICK 2MM X 2MM-110434 $686PLATE L TI OBLIQUE 2.0MM 2X2HL LNG LT-81541 $350PLATE LARGE STRAIGHT 2 HOLE-104120 $152

240 of 317 FY2018

DESCRIPTION CHARGES

PLATE LATERAL DISTAL FIBULA LCP 7HL LEFT 2.7 X 125MM-102534 $1,438PLATE LATERAL LOCKING 10HL RIGHT-108378 $2,370PLATE LC DCP 10HL 3.5X129MM $358PLATE LC-DCP 10HL 3.5X137MM $772PLATE LC-DCP 14HL 3.5X189MM $1,278PLATE LC-DCP 6HL 3.5X85MM-88601 $690PLATE LC-DCP 7HL 3.5X98MM-88602 $570PLATE LC-DCP 8HL 3.5X111MM-87762 $598PLATE LCP ADAPTION 10 HOLE 2.7X94MM-101176 $710PLATE LCP ADAPTION 12 HOLE 2.7X97MM-101174 $784PLATE LCP ADAPTION 4 HOLE 2.7X40-58MM-101177 $710PLATE LCP ADAPTION 7 HOLE 2.7X67MM-101180 $917PLATE LCP ADAPTION 8 HOLE 2.7X76MM-101175 $710PLATE LCP CONDYLAR 7 HOLE SHAFT 2.7-101181 $1,102PLATE LCP PROXIMAL HUMERUS 6/3HL 3.5X90MM-89015 $3,427PLATE LCP PROXIMAL HUMERUS 6/5HL 3.5X114MM-90506 $3,485

PLATE LCP PROXIMAL HUMERUS LONG 8 HOLE 196MM-109285 $3,621PLATE LCP TIBIA PROXIMAL 4HL 4.5X82MM -86360 $3,151PLATE LEFT DISTAL RADIUS STANDARD-92156 $1,545PLATE LOCKING CALCANEAL MINI RIGHT-98163 $1,090PLATE LOCKING CALCANEAL SHORT 69MM RT-89546 $1,182PLATE LOCKING COMPRESSION 4 HOLES $420PLATE LOCKING COMPRESSION 8 HOLE 2X59MM-100861 $542

PLATE LOCKING LATERAL EPICONDYLAR 14 HOLE 142MM-110044 $2,956PLATE LOCKING LCP 8HL SHAFT 3HL HEAD-97356 $826PLATE LOCKING MEDIAL RIGHT 12 HOLE-110045 $2,606PLATE LOCKING PROX METATARSAL WEDGE LARGE-100881 $1,574PLATE LOCKING PROX METATARSAL WEDGE RIGHT-100930 $1,510PLATE LOCKING TUBULAR 5HL 57MM W/COLLAR-86187 $387PLATE LOCKING TUBULAR 10HL 117MM W/COLLAR-82152 $453PLATE LOCKING TUBULAR 7HL 81MM W/COLLAR-85993 $394PLATE LOCKING TUBULAR 8HL 93MM W/COLLAR-85063 $414PLATE LOCKING-109228 $1,840PLATE LOW PRO MTP CONTOURED SHORT LEFT-103018 $2,333

241 of 317 FY2018

DESCRIPTION CHARGES

PLATE LOW PRO MTP CONTOURED SHORT RIGHT-103849 $2,172PLATE LOW PRO MTP CONTOURED STD LEFT-104384 $1,600

PLATE LOW PROFILE STRAIGHT WITH 14.5MM GAP 2 HOLE-103134 $434

PLATE LOW PROFILE STRAIGHT WITH 9MM GAP 2 HOLE-103133 $396PLATE LOWER EXTREMITY A.L.P.S.-108487 $1,616PLATE LOWER EXTREMITY LCP STAINLESS STEEL 2.7/3.5 MM 129 MM-109137 $1,371PLATE LOWER EXTREMITY LCP STAINLESS STEEL RIGHT 3.5 MM 106 MM-109138 $3,150PLATE LOWER EXTREMITY TITANIUM RIGHT ANTERIOR TIBIOTALAR-109172 $5,930PLATE LUMBAR 45MM-95398 $10,857PLATE MANDIBLE TI 12HL 1.25MM THICK-103096 $1,562PLATE MANDIBLE TI 2 X 2 HOLE DCP 1.5MM THICK-103097 $1,400PLATE MEDIUM STRAIGHT 2 HOLE-104119 $137PLATE MESH 14X14 HOLE-105705 $2,955PLATE MESH CONTOURABLE EXTRA RIGID 100 X 100-95392 $2,967

PLATE MESH COUNTOURABLE 200 X 200MM STERILE-102969 $21,487PLATE MESH VA LOCKING 5 X 12HL 2.4MM TO 2.7MM STERILE-102625 $3,325

PLATE METAPHYSEAL LCP 11HL 4.5 TO 3.5 X 172 MM-104806 $2,078PLATE MINI OSTEOMED 18MM-32527 $472PLATE MINI TENSION BAND 2 X 2HL 1MM THICK-104582 $1,068PLATE MTP GRAFT SPANNING RIGHT SZ5-108763 $3,474PLATE MTP REVISION LOCKING 4 DEGREE RIGHT-107780 $1,554PLATE MTP REVISION LOCKING RIGHT-104302 $1,510PLATE NARROW DCP 8HL 4.5X135MM-24766 $276PLATE NARROW LCP 6HL 4.5X116MM-90492 $715PLATE NARROW LCP 8HL 4.5X152MM-90916 $824PLATE NARROW LCP 9HL 4.5X170MM-90917 $857PLATE OLECRANON STANDARD 3HL 108375 $2,500PLATE OLECRANON STANDARD 5HL RIGHT-108796 $2,500

242 of 317 FY2018

DESCRIPTION CHARGES

PLATE OLECRANON VA LCP 2HL LEFT 2.7 TO 3.5 X 73MM-103268 $2,333

PLATE OLECRANON VA LCP 2HL LEFT 2.7 TO 3.5 X 90MM-104367 $2,224

PLATE OLECRANON VA LCP 2HL RIGHT 2.7 TO 3.5 X 90MM-102544 $2,224PLATE OLECRANON VA LCP 2HL RIGHT 2.7MM TO 3.5MM X 73MM-108082 $1,886PLATE POST LAT MEDIAL DISTAL HUMERUS LEFT 3 HOLE 3.5MM-110232 $1,952

PLATE POST LAT MEDIAL HUMERUS LEFT 3 HOLE 3.5MM-110231 $1,950PLATE POSTERIOR DISTAL TIBIA 3 HOLE $2,844PLATE PREMIER 40MM-84877 $2,271PLATE PREMIER CERV 50MM-90214 $2,271PLATE PROXIMAL HUMERUS LCP PERARTICULAR 2HL LEFT 3.5 X 91MM-103336 $3,378

PLATE PROXIMAL TIBIA VA LCP SMALL BEND 8HL RIGHT-104317 $3,776PLATE PROXIMAL TIBIAL VA LCP SMALL BEND 8HL LEFT 147MM-107966 $3,601PLATE REPLICATOR EQUINOXE 1.5MM-97386 $1,427

PLATE REVISION MTP RIGHT MED & LONG 5 DEGREE-110672 $5,790PLATE RIGHT 18MM L-88387 $450PLATE RIGID 10HL STR-59738 $419PLATE RIGID CUSTOM 2 HOLE-104121 $348PLATE RIGID L 23MM-82689 $506PLATE SACRAL 39MM-92131 $10,858PLATE SACRAL 45MM-91327 $10,587PLATE SACRAL CONTOURED 42MM-103086 $9,500

PLATE SAPPHIRE ANTERIOR CERVICAL FOUR LEVEL 60MM-100102 $2,450

PLATE SAPPHIRE ANTERIOR CERVICAL FOUR LEVEL 68MM-100104 $3,140PLATE SAPPHIRE ANTERIOR CERVICAL FOUR LEVEL 72-84MM-100105 $2,434

243 of 317 FY2018

DESCRIPTION CHARGES

PLATE SAPPHIRE ANTERIOR CERVICAL ONE LEVEL 11MM-100076 $2,000

PLATE SAPPHIRE ANTERIOR CERVICAL ONE LEVEL 13MM-99742 $2,333

PLATE SAPPHIRE ANTERIOR CERVICAL ONE LEVEL 15-19MM-99741 $2,465PLATE SAPPHIRE ANTERIOR CERVICAL ONE LEVEL 21MM-25MM-100078 $1,888

PLATE SAPPHIRE ANTERIOR CERVICAL THREE LEVEL 42MM-103528 $2,753PLATE SAPPHIRE ANTERIOR CERVICAL THREE LEVEL 45-60MM-100086 $2,333

PLATE SAPPHIRE ANTERIOR CERVICAL THREE LEVEL 54MM-100089 $2,932PLATE SAPPHIRE ANTERIOR CERVICAL THREE LEVEL 57/68MM-100090 $2,246PLATE SAPPHIRE ANTERIOR CERVICAL TWO LEVEL 29-35MM-100082 $2,651

PLATE SAPPHIRE ANTERIOR CERVICAL TWO LEVEL 38MM-100083 $2,620

PLATE SAPPHIRE ANTERIOR CERVICAL TWO LEVEL 44MM-100085 $2,031PLATE SCP TUBE 10HL 135DEG-23971 $878PLATE SCP TUBE 4-6HL 135DEG $611PLATE SCP TUBE 4HL 130DEG-81697 $875PLATE SCP TUBE 4HL 140DEG-24078 $810PLATE SCP TUBE 4HL 145DEG-24065 $670PLATE SCP TUBE 5HL 130DEG-81696 $670PLATE SCP TUBE 8HL 135DEG-23970 $784PLATE SHUNT LARGE 5 HOLE-103139 $714PLATE SHUNT MODIFIED 6 X 7MM CUTOUT-103132 $1,408PLATE SHUNT SMALL 5 HOLE-103140 $714PLATE SKY 1 LEVEL TI 16MM-103594 $2,830PLATE SKY 1 LEVEL TI 18MM-97564 $2,979PLATE SKY 2 LEVEL TI 30 MM-104679 $4,070PLATE SKY 2 LEVEL TI 32-34MM-96954 $3,244PLATE SKY 3 LEVEL TI 57MM-97999 $2,732

244 of 317 FY2018

DESCRIPTION CHARGES

PLATE SMALL STRAIGHT 2 HOLE-104118 $134PLATE SPINAL ANODYNE ANTERIOR CERVICAL LOW PROFILE 30MM-109262 $2,042PLATE SQUARE LARGE 9 X 9MM 4 HOLE-103111 $348PLATE SQUARE MULTI GRID 9 X 9MM 1 LEVEL-103135 $547PLATE SQUARE MULTI GRID-103136 $426PLATE SQUARE SMALL 6 X 6MM 4 HOLE-103112 $346PLATE STANDARD DVR CROSSLINK RIGHT-103627 $1,847PLATE STANDARD DVR CROSSLOCK LEFT-102981 $2,333PLATE STANDARD LOCKING 15HL 2.4 MM-104047 $1,852PLATE STANDARD RELEASE 6MM $2,000PLATE STERNALOC BLU 4 HOLE-110594 $642PLATE STERNALOC BLUE 4 HOLE STRAIGHT $642PLATE STERNALOCK BLUE 16 HOLE STRAIGHT-110934 $1,198PLATE STERNALOCK BLUE 6 HOLE STRAIGHT-110933 $820PLATE STERNALOCK BLUE 8 HOLE STRAIGHT-110932 $1,070PLATE STERNALOCK HEX 6 HOLE $924PLATE STERNALOCK RECON GRID SMALL-110931 $3,000PLATE STRAIGHT 4 HOLE-104122 $166PLATE STRAIGHT LOW PROFILE 12 HOLE-103141 $705PLATE STRAIGHT REGULAR 8HL 1MM-108270 $918PLATE STRAIGHT RIGID 4HL 24MM-108432 $566PLATE STRAIGHT SHORT 6 HOLE-104125 $182PLATE STRAIGHT SHSORT 16 HOLE-104126 $222PLATE STRAIGHT WITH 7.5/9MM GAP 4 HOLE-104123 $158PLATE SYNPOR TI ORBITAL FLOOR 1.5MM SCREW 1.5MM X 0.8MM-110395 $3,606PLATE T 2HL 2.0X18MM-2802 $116PLATE T LCP 4HL 4.5X83MM-90925 $1,343PLATE T LCP OBLIQUE LEFT 3/7HL SHAFT 3.5X90MM-90084 $733PLATE T TI 2/8HL 2.0X53MM-90686 $407PLATE TACK-92423 $104PLATE TENSION BAND PREBENT 2 X 2 HOLE RIGHT 1MM THICK-103095 $916PLATE TI MATRIX MANDIBLE 6HL 2MM THICK-104969 $1,606PLATE TI ADAPTION 20 HOLE 1.3MM X 0.5MM-110435 $1,739PLATE TI ANKLE 4 HOLE T SHAPE LOW PROFILE 3MM-110188 $1,600

245 of 317 FY2018

DESCRIPTION CHARGES

PLATE TI ANTEGRA ONE LEVEL SACRAL 41MM-99551 $10,985PLATE TI ANTEGRA ONE LEVEL SACRAL 43-47MM-92566 $10,857PLATE TI ANTEGRAM 1 LEVEL 43MM-96999 $11,550PLATE TI ANTREGRA 1 LEVEL LUMBAR 39MM-98130 $10,985PLATE TI CERV SPINE LOCKING 20X12MM LEVEL 1-33562 $1,496PLATE TI CERV SPINE LOCKING 22X14MM LEVEL 1-66537 $1,841PLATE TI CERV SPINE LOCKING 25X16MM LEVEL 1-87929 $2,577PLATE TI CERV SPINE LOCKING 28X20MM LEVEL 1-42887 $1,934PLATE TI CERV SPINE LOCKING 29X20MM LEVEL 1-71002 $2,094PLATE TI CERV SPINE LOCKING 34X26MM LEVEL 2-81409 $2,032PLATE TI CERV SPINE LOCKING 40X31MM LEVEL 2-87781 $2,256PLATE TI CERV SPINE LOCKING 42X34MM LEVEL 2-33476 $1,934PLATE TI CERV SPINE LOCKING 45X37MM LEVEL 2-55862 $2,333PLATE TI CERV SPINE LOCKING 46X37MM LEVEL 2-71003 $2,776PLATE TI CERV SPINE LOCKING 48X40MM LEVEL 2-61351 $2,008PLATE TI CERV SPINE LOCKING 54X45MM LEVEL 3-89674 $2,464PLATE TI CERV SPINE LOCKING LEVEL 1-33356 $1,911PLATE TI CERV SPINE LOCKING LEVEL 1-65889 $1,761PLATE TI CERV SPINE LOCKING LEVEL 2-61021 $1,572PLATE TI CERV SPINE LOCKING LEVEL 3-65251 $1,628PLATE TI LC-DCP 6HL 2.4X47MM-80272 $618PLATE TI LC-DCP 8HL 2.0X48MM-82057 $601PLATE TI MICRO GAP LARGE-103254 $323PLATE TI MICRO GAP MEDIUM-103253 $304PLATE TI MICRO GAP SMALL-103252 $334PLATE TI MICRO MULTI GRID 6 HOLE 2 LEVEL-103113 $346PLATE TI MICRO MULTI GRID 8 HOLE 3 LEVEL-104114 $366PLATE TI STRAIGHT 12HL 1.5X59MM-82305 $418PLATE TI STRAIGHT 6HL 2.0X35MM-81732 $370PLATE TI VECTRA 1 LEVEL 16MM-97867 $2,779PLATE TI VOLAR DISTAL RADIAL LEFT 3 HOLE-110379 $1,590PLATE TIBIA LCP 6H/LT 4.5MM X 142MM-110341 $3,139PLATE TIBIA LCP LOW BEND 8HL RT 35 X 161MM-97538 $2,591PLATE TIBIA MEDIAL PROXIMAL LCP 6HL RIGHT STERILE 4.5 X 142MM $3,127PLATE TIBIA MEDIAL PROXIMAL LCP 8HL RT STERILE 4.5X142MM-103287 $3,162

246 of 317 FY2018

DESCRIPTION CHARGES

PLATE TIBIA TI TOMOFIX MEDIAL HIGH 4HL SMALL-108020 $2,667PLATE TIBIAL A P WEDGED PRCT SZ6-99504 $4,212

PLATE TIBIAL NON MODULAR LONG 71 MM REVISION-109300 $6,869PLATE TIBIAL NON MODULAR LONG 75 MM-104035 $7,996PLATE TUBULAR .3 9HL 105MM W COLLAR-41573 $131PLATE TUBULAR 1/3 10HL 121MM W/COLLAR-20157 $162PLATE TUBULAR 1/3 2HL 25MM W/COLLAR-25198 $132PLATE TUBULAR 1/3 4HL 49MM W/COLLAR-2783 $483PLATE TUBULAR 1/3 5HL 61MM W/COLLAR-2784 $148PLATE TUBULAR 1/3 6HL 73MM W/COLLAR-2785 $151PLATE TUBULAR 1/3 7HL 85MM W/COLLAR-2786 $156PLATE TUBULAR 1/3 8HL 97MM W/COLLAR-2787 $131PLATE TUBULAR 1/4 3HL 23MM W/COLLAR-2788 $133PLATE ULNA MIDSHAFT 6 HOLE-105396 $1,878PLATE UNI 2 LEVEL 36MM-90372 $2,097PLATE UNIPLATE 2 LEVEL 32MM-93466 $2,097PLATE UNIPLATE 2 LEVEL 34MM-92569 $2,658PLATE UPPER EXTREMITY TITANIUM RIGHT DISTAL VOLAR RADIAL 3 HOLE-109134 $2,272PLATE VARIABLE ANGLE LCP DISTAL RADIUS NRW 6HL HEAD 2HL SHAFT LEFT-104676 $2,333PLATE VARIABLE ANGLE LCP FIRST METATARSOPHALANGEAL 2.4-2.7 MM LEFT 48 MM-110665 $2,022PLATE VARIABLE ANGLE LCP FIRST MTP FUSION SMALL 5 DEGREES LEFT 2.4 TO 2.7MM-101585 $2,015PLATE VARIABLE ANGLE LCP FIRST MTP FUSION SMALL 5 DEGREES RIGHT 2.4 TO 2.7 MM-104083 $2,333PLATE VARIABLE ANGLE LCP T-FUSION 2HL HEAD SHORT 53MM-107968 $1,748PLATE VOLAR DISTAL RADIUS GEMINUS NARROW 3HL RIGHT-103911 $1,510PLATE WRIST LCP 2.4 X 170MM STRAIGHT-101936 $2,392Pleural Aspira Catheter $1,676PLIF LUMINARY 9MM-89500 $5,484PLT STERNALOC LADDER 12 HL $949PLT STERNALOCK 12 HL SP 3215 $1,244

247 of 317 FY2018

DESCRIPTION CHARGES

PLUG ALLEN 16/24MM DIA $207Plug Amplatzer $1,381PLUG HOLE APICAL 3/8-24 1/CUP-104356 $302

POROUS GENDER FLEX KNEE W/PROLONG/XLPE PATELLA-93625 $9,986POROUS HIP PLUS W LG HEAD AND GRIPTION-98939 $10,210POROUS HIP W LG CERAMIC HEAD-98941 $10,694POROUS HIP W STD CERAMIC HEAD-98940 $9,342POROUS HIP W STD METAL HEAD-98938 $8,423POROUS HIP WITH CERAMIC HEAD-103811 $9,600PORP ALTO PART ADJ OFFSET-91478 $656Port Dialysis Catheter $724

PORT POWER MRI WITH 8 FR CHRONOFLEX CATHETER-104066 $840PORT SINGLE LUMEN XPORT TI LOW PROFILE WITH 6FR CATHETER-102779 $504POST GLENOID HYBRID REGENEREX-98189 $1,253Power Port $580Powerport $1,195Preface Guiding Sheath-98513 $354Prime Wire-94044 $1,340PROCESSOR SOUND CP950 KANSO BLACK $25,710PRODENSE 10 CC -INJECTABLE-95515 $6,172

PROSTHESES STAPES ECLIPSE PISTON NITINOL 4.50MM-106724 $599PROSTHESES STAPES ROBINSON BUCKET HANDLE TITANIUM 4.00MM-106721 $418PROSTHESES STAPES ROBINSON BUCKET HANDLE TITANIUM 4.25MM-106722 $418PROSTHESIS FOOT PLATE SHOE DORNHOFFER-91479 $205PROSTHESIS INCUDOSTAPEDEAL APPLEBAUM $820PROSTHESIS PENILE INFLATABLE WITH MS PUMP PRECONNECTED WITH INHIBIZONE-105702 $19,050PROSTHESIS PORP ALTO CENTERED $646PROSTHESIS STAPES 4.5MM RW/NS-30940 $385PROSTHESIS STAPES 4.5MM SMITH AND NEPHEW-32876 $360PROSTHESIS STAPES 4MM RW/RS-26158 $397

248 of 317 FY2018

DESCRIPTION CHARGES

PROSTHESIS TI OSSICULAR CENTERED ALTO CONSICE PARTIAL $790PROSTHESIS TORP CAPCEL 90D 11 12084 $646PROSTHESIS TORP HAPEX MALLEABLE $646PROSTHESIS TORP MICRON ADJ TI CTR 2MM 10MM $646PROTECTOR TISSUE TENOGLIDE COLLAGEN MATRIX 2 IN X 2IN-109991 $4,942

PROTECTOR TISSUE TENOGLIDE COLLAGEN MATRIX 4 IN X 5 IN $7,728PSC Lead Acuity Spiral-99613 $7,441PTCA Balloon OTW $814PTCA Balloon Rx $814PTCA Guide Catheter-85523 $107PUMP CYLINDER 18CM LGX INFRAPUBLIC-91305 $12,126PUMP CYLINDER 18CM LGX PENOSCROTAL-92869 $19,782PUMP CYLINDRICAL 15CM LGX MS-PS-91910 $17,792PUMP IZ CONTROL-92341 $11,782PUMP SYNCHROMED 20ML-95104 $20,600PUMP SYNCHROMED II 40ML-95116 $26,077PUSHLOCK BIO COMPOSITE 3.5 X 19.5-95884 $656PUTTY DBX 0.5CC-94109 $262PUTTY DBX 1 CC-104678 $479PUTTY HEALOS STRIP SINGLE 5CC-94992 $1,692PUTTY IGNITE INJECTABLE 20CC-103459 $6,850Quadra Assura Mp_ICD Dual Chamber-107174 $32,460Quadra Assura MP_ICD Dual Chamber-107174 $32,460Quickcross Catheter $275RBYPODJ30 $2,000RCFW 6.0 38 40 RB BLKN $169RCLW 7 35 40 BLKN $97REAMER 1 BASE PLATE CANNULATED-108091 $1,120RECORDER REVEAL XT ICM-95093 $9,703RESERVOIR 100ML IZ PC-91304 $2,897RESERVOIR 65ML PC-IZ-89752 $4,858

RESERVOIR CONCEAL PRECONNECTED INHIBIZONE 100ML-103588 $4,952RESERVOIR CSF OMMAYA $795

249 of 317 FY2018

DESCRIPTION CHARGES

RESERVOIR CSF OMMAYO $795RESERVOIR RICKHAM VENTRICULOSTOMY 17MM CAP 15CM VENTRICULAR CATHETER-108059 $926RESTRICTOR CEMENT 13.25MM SIZE 3-101646 $273RESTRICTOR CEMENT BIOSTOP G-44100 $224RETRIEVAL SET GUNTHER TULIP-88382 $630RING ANNULOPASTY CG FUTURE 24-38MM $3,255RING ANNULOPLASTY MC3 SLH TRICUSPID $4,782RING ANNULOPLASTY MC3 TRICUSPID 32MM $5,737RING ANNULOPLASTY MC3 TRICUSPID 34MM $4,925RING ANNULOPLASTY MC3 TRICUSPID 36MM $4,782RING ANNULOPLASTY PHYSIO MITRAL 24-36MM $4,761RING ANNULOPLASTY PHYSIO MITRAL 28-30-32MM $5,592RING ANNULOPLASTY PHYSIO MITRAL 32M $4,782RING ANNULOPLASTY PHYSIO2 24MM $4,622RING ANNULOPLASTY PHYSIO2 26MM $5,587RING ANNULOPLASTY PHYSIO2 28-40MM $5,790RING CATARACT CAPSULAR TENSION 28MM-94257 $340RING CATARACT CAPSULAR TENSION SZ 10 TYPE 14-94256 $358RING CATARACT PARTIAL CAPSULAR TENSION SZ 9.5 TYPE 6D-103280 $371RING DURAN ANCORE 27MM $3,398RING LOCK RPLCMNT MOD CUP 60MM-103937 $215RING LOCKING DURALOC 48MM-107782 $677RING LOCKING DURALOC 50MM-110653 $714RING LOCKING DURALOC 56MM-10618 $1,252RING MALYUGIN-93609 $253Rival Balloon $268RoadRunner Angle Glide $49ROD 10CM TI CP 5.5X100-85015 $521ROD 480MM-90369 $1,481ROD 4CM TI CP 5.5X40-85013 $641ROD 5.5 X 60 PREBENT-84872 $633ROD ATTACHMENT FOR LG MULTI PIN CLAMP-101562 $780ROD CARBON FIBER 11X350MM STRAIGHT-46066 $578ROD CARBON FIBER 3MM X 45MM-108079 $93ROD CARBON FIBER 8.0X160MM-108512 $349

250 of 317 FY2018

DESCRIPTION CHARGES

ROD CD HORIZON 500 MM-103981 $1,195ROD CD HORIZON CHROMALOY PREBENT 70MM-99767 $835ROD CD HORIZON SOLERA 100 MM-104005 $665ROD CD HORIZON SOLERA 120MM-104253 $700ROD CD HORIZON SOLERA 50 MM-101736 $825ROD CD HORIZON SOLERA 60MM-102604 $784ROD CD HORIZON SOLERA 90MM-101240 $640ROD CD HORIZON SOLERA PRE BENT 110MM-102530 $784ROD CD HORIZON SOLERA STR 4.75X500MM-100900 $812ROD COCR 3.5 X 100MM-110226 $1,670ROD CURVED 90MM-103685 $784ROD EXPEDIUM PEEK LRD BA 5.5/6.35 X 35/40MM-97600 $1,289ROD EXPEDIUM PRE-LOR DOSED 5.5 X 40MM-89124 $959ROD EXPEDIUM TI 5.5X300MM-104280 $1,821ROD FORTRESS 100 MM-104786 $400ROD GIBRALT CURVED $380ROD GIBRALT CURVED 120MM-102765 $400ROD GIBRALT CURVED 240 MM-104561 $320ROD GIBRALT CURVED 3.5 X 30/50MM-102560 $310ROD IT SOFT 6 X 500MM-97138 $526ROD LINED HEX END STAINLESS STELL 5.5 X 500MM-102660 $681ROD PEEK 6.35 X 40MM-91976 $1,450ROD PRE BENT 130MM-103323 $523ROD PRE BENT TIGER 5.5X55MM-98968 $450ROD PRE BENT WITH LINE 5500 SERIES $349ROD PREBENT 25MM-103991 $570ROD PREBENT 50 MM-104677 $600ROD PREBENT COBALT CHROME 5.5 X 75/85MM-101917 $896

ROD PRE-BENT COCR STREAMLINE OCT 3.2MM X 60MM-107845 $320ROD PREBENT TI 5.5 X 3.0 LEGACY-87502 $521ROD PREBENT TI 5.5X70-88209 $641ROD PREBENT TI 5.5X80-88210 $521ROD PREBENT TI EXPEDIUM 5.5X35MM-87933 $977ROD PREBENT WITH LINE 5500 SERIES $426ROD PREBENT WITH LINE 5500 SERIES $455ROD PRECUT BENT 3.5 X 60MM-102588 $1,200

251 of 317 FY2018

DESCRIPTION CHARGES

ROD PRECUT BENT 90 MM-104072 $1,670ROD PRELORDDOSED WITH LINE 95MM-97918 $993ROD PRELORDOSED WITH LINE 120 MM-103934 $665ROD PRELORDOSED WITH LINE 85MM-102630 $700ROD QUANTIUM PREBENT $450ROD QUANTIUM PREBENT 5.5 X 50MM-102053 $349ROD QUANTUM COMPLEX HEX END STRAIGHT 5.5 X 400MM-102555 $550ROD QUANTUM PRE BENT $428ROD QUANTUM PREBENT $400ROD QUANTUM PREBENT $523ROD QUANTUM STRAIGHT 5.5MM X 90MM-110314 $400ROD QUANTUM STRAIGHT 80MM-103860 $428ROD SILASTIC 1.5 -5MM $194ROD SILASTIC NS 1-2MM X 30MM $194ROD SINGLR INCLINE CONN 5.5 X 5.5MM-98115 $2,867ROD SPINAL EXPEDIUM PRE LORDOSED 5.5MM X 115MM $636ROD SPINAL MOSS MIAMI TI 5.5MM X 40MM $1,754ROD SPINAL TI CURVED 3.5MM X 45MM $4,600ROD SPINAL TIGER PRE-BENT 5.5MM X 70MM $400ROD STRAIGHT HEX END 5.5 X 200 MM-104591 $450

ROD STRAIGHT QUANTUM COCR HEX END 5.5X50MM-107998 $400

ROD STRAIGHT QUANTUM COCR HEX HEAD 5.5X150MM-107976 $450ROD STRAIGHT WITH LINE 5500 SERIES 5.5X450MM-100014 $557ROD STREAMLINE OTC COCR 60/120/240MM-110392 $320ROD T14 HARD 5.5MM X 300MM STRAIGHT-99487 $415ROD TI 3.5X120MM-46075 $519ROD TI 3.5X80MM-61609 $354ROD TI CRVD $336ROD TI CURVED 3.5 X 75/85 MM-104403 $1,154ROD TI CURVED 5.5 X 45MM-98577 $342ROD TI CURVED 5.5X125MM-98576 $428ROD TI CURVED 55MM-97657 $413ROD TI EXPEDIUM PREBENT 5.5X45MM-89399 $1,230ROD TI EXPEDIUM PREBENT 5.5X55MM-89400 $977

252 of 317 FY2018

DESCRIPTION CHARGES

ROD VERTEX 3.5 X 240MM-101755 $698RODS CURVED 80 MM-104132 $1,386Rosen 035 180 $26Rotalink Burr $2,947Rotalink Plus Exchange System $2,731Rotalink System Advancer $475ROTATING PLATFORM INSERT 12.5MM-110370 $4,540Rotawire-Floppy Or Ex Support $366RX Hurricane Dil Balloon $395RX Stent $414Safe Sheath-Long-87339 $130Safe Sheath-Short-87341 $138Safire 8 Mm Ablation Catheter $2,678Safire Ablation Catheter-88908 $1,445Safire Blu Irrig Ablation $2,643SAPHENOUS VEIN 4MM X 6MM X75CM-94912 $18,009SCAFFOLD CARTIFORM 20 MM DISC-105560 $17,000SCAFFOLD SERI SURGICAL 10 X 25 CM-104850 $7,490SCAFFOLD SERI SURGICAL 20 X 30 CM-105023 $19,990Schlueter Tube $135SCOUT Reflector $1,071SCREW 5.5 X 45MM LEGACY PEEK HA-95146 $4,168SCREW CANNULATED FT 3.75 X 30MM $850SCREW CDH LEGACY 7.5X45MM-84878 $2,302SCREW CORTICAL LOCKING 3.5 X 10MM-97877 $262SCREW CORTICAL LOCKING LOW PROFILE FULL THREAD $125SCREW CORTICAL LOCKING THREADED 2.3MM X 10MM $400SCREW EMERG HT X DRIVE 2.7X8MM $400SCREW EXPEDIUM 6.35 TI POLY 6 X 45MM-97492 $2,424SCREW EXPEDIUM POLYAXAIL 5.0 X 45MM-89117 $3,233SCREW EXPEDIUM POLYAXAIL 6.0 45 MM-89118 $3,073SCREW LAG GAMMA 3 10.5X95MM-98147 $1,392SCREW LOW PROFILE FULL THREAD $399SCREW MATRIX POLYAXIAL 5.5X35MM-98586 $1,771SCREW MNTR F/A 3.5 X 14MM-92504 $2,796SCREW MNTR M/L 4.35 X 30-95006 $2,880SCREW MNTR ML 4.35 X 35MM-97916 $2,814

253 of 317 FY2018

DESCRIPTION CHARGES

SCREW NON TOGGLING 2.3 X 2.0MM-97876 $166SCREW NON-LOCKING HEXALOBE 3.0MM X 14MM $276SCREW OCT RELEASE 2.1MM X 8MM $399SCREW PEDICLE 5500 SERIES 7.5 X 45MM 99922-99922 $2,160SCREW QUICKFIX Add on $1,019SCREW SI POLYAXL 4.35 X 30MM-98116 $2,424SCREW SI POLYAXL 6 X 35MM-98114 $3,165SCREW TI MATRIX POLYAXIAL 4-5X35MM-98585 $1,771SCREW TI MATRIX POLYAXIAL 7X40MM-98575 $2,202SEALANT EVICEL 5ML-91593 $1,392SEALANT SPINAL DURASEAL EXACT 5ML-106484 $2,363SEGMENT DIPHYSEAL ELLIP 3CM OSS-101791 $12,644SEGMENT INTERCALARY LPS 55MM-105871 $4,310SEGMENT KNEE FEMORAL DIAPHYSEAL OSS 130MM-110239 $12,093SEGMENT KNEE TIBIAL BEARING OSS ELLIPTICAL DIAPH 30MM-110240 $11,506

SEGMENT NECK MP HIP REVISION XXL 126 DEGREE 65 MM-109187 $10,594SEGMENT STEM HIP REVISION 210 X 22.5 MM-104051 $12,390SEGMENT STEM MP HIP REVISION $8,444Select Filter $2,159SELF CENTERING BIPOLAR CUP $1,100Senomark Clip $291Set Central Venous Turbo Flo 5F $187SET DILATOR S CURVE URETHRAL 8 TO 20FR-106759 $401SET DISPOSABLE TENODESIS DRIVER WITH SCREW BIOCOMPOSITE 6.25 $1,100SET INTUBATION C LINE CANALICULUS $215Set Ministick 5F MISC SUPPLY Add on $38SET PIN TRANS FIX ARTHREX-94802 $455SET SCEW-91194 $328SET SCREW PEEK-90713 $634SET SHUNT PERITONEAL LUMB-9892 $1,229SETSCREW ROD TO ROD CONNECTOR-110316 $240SETSCREW STREAMLINE-101589 $240SFX 5.5 TI MED SZ A6-90365 $3,101SFX 5.52 TO MED SIZE A5-95009 $3,771

254 of 317 FY2018

DESCRIPTION CHARGES

SFX MEDIUM 5.5MM SZ F7-98113 $2,482SGL J URINARY DIVERSION-11099 $580SHAFT RENAL W CHECK FLO VALVE-72357 $101SHEATH PEEL AWAY 9.5FR 14CM-30533 $70SHEATH 10FR CHECK FLO-89931 $267SHEATH 11FR BRITE TIP 11CM-96968 $81SHEATH 12FR CHECK FLO-89932 $160SHEATH 14FR CHECK FLO $254SHEATH 6FR BRITE TIP 23 CM-96967 $91SHEATH ANSEL 4FR X 45CM-94099 $156SHEATH ANSEL FLEXOR 4FR X 110CM-96067 $344SHEATH ANSEL FLEXOR 5FR X 45CM-95601 $104SHEATH ANSEL FLEXOR 6FR X 45CM-91049 $150SHEATH ASCENDRA INTRODUCER Add on $12,188SHEATH AWAY 16FR 14CM-98972 $124SHEATH BIOINTRAFIX-90190 $634SHEATH CAROTID GUIDING STRADE 6FR X 90CM-96560 $271SHEATH DELIVERY SYSTEM AMPLATZER TORQVUE 9 F 45 DEGREE CURVE $1,208SHEATH FLEXOR ANSEL WITH CHECK FLO VALVE AND HIGH FLEX DILATOR 6FR 55CM-100677 $160SHEATH FLEXOR ANSEL WITH CHECK FLO VALVE AND HIGH FLEX DILATOR 7FR 55CM-100678 $91SHEATH FLEXOR CHECK FLO RAABE MODIFICATION 7FR 90CM-101579 $143SHEATH FLEXOR WITH HEMOSTASIS VALVE AND HI FLEX DILATOR 12FR 45CM-103675 $160SHEATH GUIDING FLEXOR ANSEL 6FR 90CM-92815 $195

SHEATH GUIDING FLEXOR RAABE 70 CM 6 FR 2.2 MM-109239 $165SHEATH GUIDING PINNACLE DESTINATION PTFE 65CM 8FR $232SHEATH GUIDING PINNACLE DISTINATION PTFE 45CM 6-8FR $209SHEATH INTRO 11FR 10CM W/O GUIDEWIRE-88255 $35SHEATH INTRODUCER 7FR 24CM $132SHEATH INTRODUCER DRY SEAL 33CM 18FR-108818 $1,178SHEATH INTRODUCER DRY SEAL 4.3MMX28CM 12FR-97886 $658

255 of 317 FY2018

DESCRIPTION CHARGES

SHEATH INTRODUCER DRYSEAL FLEX 24FR 8MM X 33CM-110617 $1,208SHEATH INTRODUCER DRYSEAL FLEX 4X4.7MMX45CM 12FR-107981 $1,282SHEATH INTRODUCER DRYSEAL FLEX 5.3X6.1MMX33CM 16FR-107982 $872Sheath Long - Arrow-99902 $994

SHEATH NAVIGATOR URETERAL ACCESS 11-13FRX36CM-88034 $248

SHEATH NAVIGATOR URETERAL ACCESS 12 TO 14 FR 36CM-100511 $282

SHEATH NAVIGATOR URETERAL ACCESS 13 TO 15FR X 36CM-97502 $209SHEATH PEEL AWAY 10.0FR 14CM MIN OF 5-85977 $71Sheath Peel Away Long $118SHEATH PEEL AWAY STRAIGHT INTRODUCER SET 7FR X 15.5CM-106598 $124SHEATH PINNACLE 8FR 10CM W/GUIDEWIRE-88266 $18SHEATH PRELUDE 4FR 11CM-94189 $49SHEATH PRELUDE SHORT 6FR X 4CM GREEN HUB-98853 $54

SHEATH PRELUDE SHORT 7FR 4CM ORANGE HUB 5/BX-93443 $38SHEATH RAABE INTRO FLEX/CHECK FLO 7X70-96374 $112SHEATH RAABE INTRO FLEXOR CHECK FLO 6X90-95990 $110SHEATH SPLITTABLE HEMOSTATIC INTRODUCER CLASSIC STANDARD SINGLE CHAMBER 7FR 13CM-106190 $110SHEATH TIGHTRAIL ROTATING DILATOR 13FR-106690 $3,790SHEATH VASCULAR STANDARD ENGAGE 6F $16SHEATH W MARKER TIP 7FR X 23CM-93666 $47Sheath, Long $146Sheath, Short Diagnostic $44Sheath-Check Flo-106903 $195Sheath-Flex Cath Advance-107146 $2,400Sheath-Peel Away-Short-30533 $61SHEATHS 5F 10CM GUIDE WIRE INCLUDED $18SHEATHS 6F WITH GUIDEWIRE-88269 $19SHEATHS PINNACLE 5F 25CM W/O GUIDEWIRE 10/PK $50

256 of 317 FY2018

DESCRIPTION CHARGES

SHEET SILICONE 5CM X 5CM X .13MM $44SHEETING SILICONE 5CM X 5CM X 1MM-109322 $44SHELL ACETABULAR 62 MM GOUP G-104990 $2,800SHELL ACETABULAR BIOFOAM 58/60MM GROUP G-102951 $2,600SHELL ACETABULAR R3 3 HOLE $4,284SHELL ACETABULAR TI CLUSTER 62MM-110634 $4,734SHELL BIOFOAM 50MM GROUP C-103370 $2,800SHELL BIOFOAM DYNASTY 48MM GROUP B-107959 $2,800SHELL BIOFOAM REVISION GROUP E 54MM-98428 $2,600SHELL BIOFOAM REVISION GROUP F 56MM-98789 $4,523SHELL BIOFOAM REVISION GRPD 52MM-98627 $4,391SHELL BIPOLAR 52MM OD-110944 $325SHELL BIPOLAR GLADIATOR 28X43-103539 $570SHELL BIPOLAR METAL 47MM OD-86524 $650SHELL CONSERVE POROUS ACE 6MM SZ 48-98179 $6,665SHELL CONTINUUM MULTI HOLE 54MM-110346 $5,510SHELL CONTINUUM MULTI HOLE 58LL-109153 $4,881

SHELL CONTINUUM MULTI HOLE TM POROUS 60/64MM-101912 $6,354SHELL FEMORAL $2,800SHELL FEMORAL 3 HOLE 54MM-104549 $1,506SHELL GRIPTION 52MM-110666 $5,359

SHELL HIP ACETABULAR CONTINUUM MULTI HOLE 56MM-110238 $4,881

SHELL HIP ACETABULAR G7 TITANIUM 4 HOLE 58/62MM REVISION $7,596

SHELL HIP ACETABULAR G7 TITANIUM 4 HOLE 62MM-110609 $4,288

SHELL HIP ACETABULAR G7 TITANIUM MULTI HOLE 60MM-110236 $6,496SHELL HIP ACETABULAR G7 TITANIUM MULTI HOLE E 52MM-110595 $7,596SHELL HIP G7 3 HOLE 52MM REVISION $6,288SHELL HIP GLADIATOR BIPOLAR 46MM-102672 $800

SHELL LOWER EXTREMITY FREEDOM STANDARD ALL POLY ACETABULAR HIP CONSTRAINED OD 58MM ID 36MM-105899 $6,020

257 of 317 FY2018

DESCRIPTION CHARGES

SHELL SPIKED ACETABULAR 54/56MM-106542 $4,392SHELL TRIDENT TI HEMISPHERICAL 60MM F-107841 $6,539

SHOULD TOTAL POROUS SHOULDER TM GLENOID +TM-110577 $9,600SHOULDER ANATOMICAL PED GLENOID MED-93858 $3,400SHOULDER CEMENTED HEMI-98961 $8,400SHOULDER COMP SHRT ST TI SHOULDER COMP RVS GLN XL-110580 $16,600SHOULDER COMP ST COMP RVS GLN XLPE-110573 $16,000SHOULDER COMP ST POLY GLD VRSDL HD-110567 $9,000SHOULDER COMP ST RGX GLD STD HD-110569 $9,000SHOULDER COMP ST STD HD-110560 $7,000SHOULDER FRAC ST COMP RVS GLN XLPE-110575 $16,000SHOULDER FRAC ST STD HD-110564 $7,000SHOULDER HEMI-99916 $8,200SHOULDER NON- POROUS TM REVERSE SHOULDER SYSTEM-110571 $16,000SHOULDER POR HUM ST STD HD-110562 $7,000SHOULDER POROUS HEMI-103616 $7,980

SHOULDER REVERSE TM WITH LONG TM BASE PLATE-105565 $18,500SHOULDER REVERSE-99915 $16,000SHOULDER TM HEMI SHOULDER STD HEAD + TM-110576 $7,600SHOULDER TM REVERSE SHOULDER W TM LONG BASE PLATE-110584 $18,100SHOULDER TM REVERSE-110583 $16,600SHOULDER TOTAL POROUS W/TRABECULAR METAL GLENOID-100170 $10,400SHOULDER TOTAL POROUS-110565 $9,000SHOULDER TOTAL PRESS FIT-103297 $9,500SHOULDER TOTAL-99917 $9,200SHOULDER TRABECULAR METEL-98956 $10,000SHUNT CAROTID 6FR-46477 $73SHUNT CAROTID PRUITT F3 WITH PORT 9FR 31CM-101952 $1,238SHUNT CLEARVIEW INTRACORONARY $129SHUNT EXPRESS MINI GLAUCOMA 200UM-102666 $1,990SHUNT EXPRESS MINI GLAUCOMA VALVE 50 200UM 2.64MM $1,609

258 of 317 FY2018

DESCRIPTION CHARGES

SHUNT LUMB OPERITONEAL T TUBE $1,006SHUNT STRATA 2 SNAP W/DISTAL 120CM CATH-88260 $11,942SHUNT STRATA II W/PERITONEAL CATHETER-88629 $8,768SHUNT SUNDT 3.0X5.0-3.5X4X30MM-33468 $796Shuttle Sheath-104430 $302SIDEPLATE STD BARREL 135 DEGREE LCP DHHS STERILE 5HL-102009 $1,220SIDEPLATE STD BARREL 135 DEGREE LCP DHHS STERILE 6HL-102010 $1,284

SIDEPLATE STD BARREL LCP DHHS 135 DEGREE 5 HOLES-101971 $1,126

SIDEPLATE STD BARRELL 4 HOLE STERILE 135 DEGREE LCP-101084 $1,284SIDEPLATE STD BARRELL LCP DHHS 140 DEGREE 4 HOLE STERILE-104518 $1,284SIGMA PFC POROCOAT FEMUR RT SZ3-93057 $9,103SIGMA XLKCVD PLUS INS 2.5 8MM $6,478SILIC OIL ESCALON ADATOSIL5-33058 $905SilverHawk Peripheral Catheter LS $5,342Single Lumen Catheter $102SIZER BREAST STYLE TRLP $1,660SIZER BREAST STYLE TRX $1,660SIZER MAMMARY SILICONE STYLE 15 MODERATE PLUS PROFILE 575CC-101550 $33,800

SIZER MAMMARY SILICONE STYLE 45 EXTRA HIGH PROFILE 800CC $11,068SJM Accent DR Rf Generator $12,133SJM Accent VR RF Generator $8,833SJM Acuity Steerable Lva Dual-105060 $7,184SJM Anthem Biv Pacemaker $21,668SJM Assurity Pm1240 $8,833SJM Assurity Pm1272-107349 $8,030SJM Assurity Pm2240-103488 $12,133SJM Durata ICD Lead $11,731SJM Durata Sj4 Lead $11,731SJM Ellipse DR 36 Df4 ICD $45,868SJM Ellipse DR 36 ICD $45,868

259 of 317 FY2018

DESCRIPTION CHARGES

SJM Ellipse VR 36 Df4 ICD $39,842SJM Ellipse VR 36 ICD $39,842SJM Fortify Assura DR 40 Df4 ICD $45,867SJM Fortify Assura DR 40 ICD $45,867SJM Fortify Assura VR 40 Df4 ICD $39,842SJM Fortify Assura VR 40 ICD $39,842SJM Fortify DR ICD-96262 $45,868SJM Fortify DR-Q ICD-96263 $45,868SJM Fortify SR ICD-96264 $39,842SJM Fortify SR-Q ICD-96265 $39,842SJM Pacer Lead $1,940SJM Pm2272 Assurity MRI-107443 $12,133SJM Quadra Allure RF-103231 $21,668SJM Quadra Allure Rg-103231 $21,668SJM Quadra Assura Crt D $59,024SJM Quadra Assura Crt D Df4 $59,024SJM Quartet Quadripolar Lead $7,441SJM Quicksite LV Lead $7,441SJM Quicksite Micro Lead-96266 $7,441SJM Unify Assura Crt D 40 $59,024SJM Unify Crt-D Q-96261 $59,024SJM Unify Crt-D-96260 $59,024SJM Unity Assura Crt D Df4 $59,024SJM Verity Adx DR Generator $8,030SJM Zephyr XL DR Generator $12,133SLEEVE CABLE COBALT 2X8.5MM STERILE-25864 $704SLEEVE CABLE OSTEOCLAGE 2.0X850MM-25442 $670SLEEVE ORTHOPEDIC-LOWER EXTREMITY BIOLOX CERAMIC TAPERED TYPE 1-108773 $377SLEEVE POROUS MBT REVISION 45MM-108064 $4,561SLEEVE SILICONE ROUND STYLE 72-103854 $17SLEEVE SILICONE STYLE 270-103855 $40SLEEVE SILICONE STYLE 70-103853 $17SLEEVE TANDEM UNIPOLAR 12/14 TAPERED +0MM-106528 $302SLEEVE TIBIAL SZ 2 WITH PLUGS-103000 $6,772SLEEVE TITANIUM MODULAR 12/14 TAPER +4-105922 $444SLING ADVANTAGE FIT-96419 $2,600

260 of 317 FY2018

DESCRIPTION CHARGES

SLING ALTIS SINGLE INCISION-100871 $2,791SLING MESH ABBREVO 12CM-97626 $2,725SLING MID URETHRAL OBTRYX 2 HALO-106697 $1,960SLING OBTRYX II CURVED-109268 $1,848SLING OBTRYX TRANSOBUTATOR HALO-97176 $1,882

SLING PROLAPSE REPAIR TRANSVAGINAL ELEVATE SYSTEM WITH INTEPRO LITE ANTERIOR AND APICAL PORCINE ACEL-106188 $3,900SLING TRANS OBTURATOR MINI ARC-94795 $3,330SLING TVT GYNECARE EXACT RETROPUBIC SYSTEM-100524 $2,339SLING TVT MINIARC PRECISE-103523 $2,300SLING TVT SPARC SYSTEM FGS-82212 $2,100Slitable Lead Delivery System-89075 $872Small J Wire $21Smartablate Irr Tube Set-110155 $237SNARE ENDOSCOPIC CAPTIVATOR II SINGLE-USE ROUNDED-STIFF LOOP 20MM OD 2.4MM 240CM X 2.8MM-106268 $34SNARE GOOSENECK 6F RX120-57866 $640SNARE GOOSENECK 6FX15X120-57866 $640Soehendra Stent Retriever 10 Fr-98553 $181Soehendra Stent Retriever 8.5 Fr-98552 $194SP Bard Filter Retrievel Device $650SPACER 15MM ALIF-92033 $7,262SPACER ACF LORDOTIC 7MM-94510 $2,258SPACER ALIF 13MM-92130 $7,262SPACER BONE 13MM LUMINARY PLIF FD-95200 $5,485SPACER BONE 6MM STRAIGHT ODL $2,062SPACER BONE ACF PARALLEL $1,729SPACER BONE ACF PARALLEL $2,087SPACER BONE ACF PARALLEL 9MM-95205 $1,729SPACER BONE ADVANCED ACF FREEZE DRIED $1,827SPACER BONE ADVANCED ACF FREEZE DRIED $2,358SPACER BONE ALIF 11MM-95192 $7,262SPACER BONE ALIF 17MM $6,817SPACER BONE ALIF 19MM-95194 $6,618SPACER BONE LUMINARY PLIF $4,327SPACER BONE LUMINARY PLIF 15MM-93391 $5,223

261 of 317 FY2018

DESCRIPTION CHARGES

SPACER BONE PLIF 17MM FREEZE DRIED-94016 $4,195SPACER BONE PLIF FREEZE DRIED $4,195SPACER CERVICAL CORTICO CANN 10MM-98785 $2,350SPACER CERVICAL CORTICO CANN 6MM-98784 $2,119SPACER CERVICAL CORTICO CANN 7MM-98780 $2,333SPACER CERVICAL CORTICO CANN 9MM-98779 $2,140SPACER CERVICAL SERIES CI CORTICAL LORDOTIC $2,226

SPACER CERVICAL SERIES CI CORTICAL LORDOTIC 6MM-100038 $2,000SPACER CERVICAL SERIES CII CORT CANC $2,200SPACER CERVICAL SERIES CII CORT CANC $1,705SPACER FALCON SERIES PLIF $4,108SPACER FALCON SERIES PLIF 9MM-100041 $5,300SPACER HIP METAL 10 MM-104052 $946SPACER KNEE TEMPORARY-100883 $7,980SPACER LORDOTIC $2,140SPACER LORDOTIC $2,389SPACER LORDOTIC ACF $2,007SPACER LORDOTIC ROI-C 6 X 12 X 14 MM-104246 $7,200SPACER LUMINARY ALIF $9,826SPACER LUMINARY ALIF 11MM-98580 $10,220SPACER LUMINARY ALIF 17MM-100070 $8,915SPACER LUMINARY ALIF 19MM-106799 $7,931SPACER LUMINARY PLIF $5,223SPACER SPINAL PLIF 15MM-63059 $4,195SPACER SPINAL PLIF 17MM-110623 $4,257SPACER SPINAL PLIF 7MM-110622 $4,257SPACER TIBIAL POLY-102999 $2,884SPACER VERTEBRAL 8X22X11MM $4,921SPACER VERTEBRAL 8X22X17MM-108792 $6,712SPACER VERTEBRAL LORDOTIC 7MM-97559 $2,203SPACER ZERO-P LORDOTIC $6,578SPEEDSCREW KNOTLESS 6.5MM-98133 $809SPEEDSCREW KNOTLESS WITH HANDLE-97351 $1,026Spire Dialysis Cath All Sizes- $724SPLINED KNEE STEM BMT V2 13MM X 40MM REVISION $3,289SPONGE COLLAGEN-23702 $189

262 of 317 FY2018

DESCRIPTION CHARGES

SPONGE DURAFORM 1X1 IN-85724 $258SPONGE DURAFORM 1X3 IN-85725 $471St Jude Guidewire $139STAPES PISTON 0.5MM X 5.00ML $558STAPES PISTON ECLIPSE 5MM X 6.-97132 $1,034

STAPLE BONE EASYCLIP SI SUPERELASTIC FIXATION LOW PROFILE BICORTICAL WIDTH 10MM LEG LENGTH 15 AND 13-106196 $1,825Starclose Vascular Closure Device $655STEM 10MM X 170MM REV TM-104625 $9,700STEM AML LARGE STATURE SZ 15.0-103870 $11,005STEM ARCOS 13 X 150 MM SPL-105559 $8,708STEM CALCAR CEMENTED REVISION 13X170MM-107984 $8,446STEM CEMENTED 14MM X 50MM-110661 $1,440STEM CEMENTED IM 12 X 150 OSS-104789 $4,986STEM CEMENTED WITH HEAD-110333 $3,400STEM COMP SHOULDER STD 14MM-98192 $8,062STEM DIST 17 X 3000-103941 $14,203

STEM DISTAL 12X150MM ARCOS MODULAR FEMORAL-105734 $6,634STEM DISTAL BOWED TIP ARCOS 14MM X 150MM-107024 $9,058STEM DISTAL FEMORAL STRAIGHT TAPERED 16 X 150 MM REVISION-109182 $5,528

STEM DISTAL FEMORAL STRAIGHT TAPERED 16 X 150 MM-104026 $7,877STEM ECH POR STD 260MM BOW SZ 15 L-105404 $26,020STEM EXT $1,706STEM EXT CANAL FILLING $1,621STEM EXT ST NEXGEN 17MM X 145MM-104535 $1,964STEM EXT STR 12MM X 100MM-102395 $2,029

STEM EXTENSION ADVANCE KNEE 100/140 MM 15/19 MM-109139 $2,326STEM EXTENSION COMPONENT STRAIGHT LPS CEMENTED COCR ALLOY 12MM DIAMETER X 125MM LENGTH-105872 $9,526STEM EXTENSION COMPONENT STRAIGHT LPS CEMENTED COCR ALLOY 13MM DIAMETER X 125MM LENGTH-105873 $9,526STEM EXTENSION TIBIAL 30MM X 14MM-110172 $2,000

263 of 317 FY2018

DESCRIPTION CHARGES

STEM FEM AUG DISTAL 4-8MM -110274 $1,413STEM FEM LT SZ 6 JRNY II OXIN-105424 $10,000STEM FEM NONPOROUS LT 60MM-19380 $7,787STEM FEM NONPOROUS RT SZ 4-65296 $2,457STEM FEM NONPOROUS SZ 4 LT-63743 $3,050STEM FEMORAL $2,660STEM FEMORAL 12/14 SMALL STATURE SOL SYST-102606 $16,250STEM FEMORAL COMPONENT POROUS SZ 5 LT-109142 $12,572STEM FEMORAL GLADIATOR SZ 7-101726 $4,077STEM FEMORAL LEFT BOWED 240MM-101775 $7,133STEM FEMORAL OSS POROUS IM 18MM X 150MM REVISION $4,452STEM FEMORAL OSS POROUS IM 20.5MM X 150MM-110397 $5,250STEM FEMORAL PROFEMUR PLASMA $3,900STEM FEMORAL PROFEMUR PLASMA-104991 $4,077STEM FEMORAL PROFEMUR SZ 4-97560 $10,897STEM FEMORAL PROSTALAC RT SZ 3 240MM-110607 $8,511STEM FEMORAL REV CEM SZ 15 NECK-101788 $8,446STEM FEMORAL SZ 13 STD PRIMARY FULLCOAT-104538 $2,915STEM FEMORAL SZ 4-104547 $4,077STEM FEMORAL TAPERED 22 X 185MM-103609 $5,415STEM FEMORAL VERSYS COCR $9,955STEM FEMORAL WITH BULLET 16 X 250MM-102582 $7,501STEM FEMORAL-104532 $2,400STEM HIP BIPOLAR 26 X 52MM-103356 $1,233STEM HIP BIPOLAR 26X47MM-18958 $890STEM HIP CALCAR A BODY 46 X 55MM-103612 $7,114STEM HIP PROFEMUR PRESERVE CLASSIC SIZE 10 VARUS 8 DEGREES-108066 $3,400STEM HIP UNIPOLAR HIGH DEMAND UNIVERSAL CAPIT POROUS SLEEVE-106181 $4,046STEM HUMERAL 48 DEG 14MM X 130MM-92592 $8,158STEM HUMERAL 48 DEG 15/16MM X 130MM-109152 $6,000STEM HUMERAL 48 DG 11MM X 130MM-95556 $6,390STEM HUMERAL COMPREHENSIVE 14MM-98623 $5,035STEM HUMERAL EQUINOXE PRIMARY 13MM-97387 $7,280STEM HUMERAL METAL 10 X 130MM-98126 $8,403STEM HUMERAL REVERSE 12MM X 170MM-102727 $12,950

264 of 317 FY2018

DESCRIPTION CHARGES

STEM HUMERAL UNIVERSAL APEX 10MM $5,348STEM IM 17 X 225 CEMENTED OSS-101794 $4,005STEM IM CEM 13MM X 90MM-105461 $4,010STEM IM CEM 17MM X 150MM-105462 $4,364STEM IM CEMENTED 13 X 150 MM-104033 $4,156STEM IM POROUS 13.5 X 150 MM-104071 $4,512STEM KNEE BMT SPLINED V2 $2,261STEM KNEE POROUS OSS 11.5MM X 90MM-105924 $4,438STEM KNEE SPLINED BMT 12 X 200-102390 $3,821STEM KNEE SPLINED BMT V2 $2,261STEM KNEE SPLINED BMT V2 10-15MM X 40MM REVISION $3,289STEM KNEE SPLINED BMT V2 12/16 X 80-102640 $3,069STEM LOWER EXTREMITY UNIVERSAL FLUTED $2,560STEM MOLD STAGE ONE HIP COBALT G-HV CEMENT SPACER REINFORCED CORE ORTHOPEDIC FEMORAL 135MM X 11MM-105885 $4,218STEM OFFSET NON POROUS COCR NATURAL HIP SZ 3-99540 $3,622STEM OSS CEMENTED 9-11MM X 90MM REVISION $4,088STEM OSS POROUS IM 12.5MM X 225MM REVISION $5,250STEM OSS POROUS IM 14.5MM X 225MM-107082 $5,410STEM OSS POROUS IM 16.5MM X 150MM REVISION-109297 $3,910STEM POROUS SUMMIT POROCOAT AML $3,500STEM POROUS SYNERGY HI OFFSET $10,326STEM POROUS SYNERGY HI OFFSET SIZE 12 150MM-106512 $2,808STEM POROUS SYNERGY STD $10,326STEM PRI FINNED 40MM X 10MM REVISION-110391 $3,000STEM PRIMARY 10MM MINI COMP-102406 $3,941STEM PROFEMUR GLADIATOR SZ 6-104048 $2,800STEM PROFEMUR PLASMA STD SZ 6-104349 $2,800STEM PROFEMUR PLASMA STD SZ 8-104361 $4,077STEM PROFEMUR PLASMA Z CLASSIC $3,400STEM PROFEMUR PLASMA Z FEMORAL CLASSIC STANDARD SZ 4 REVISION $8,742STEM PROFEMUR Z SIZE 5&7-98618 $2,467STEM RADIAL 8 X 2MM-108824 $4,168STEM RADIAL 8 X 4MM-102563 $3,735STEM REVERSE TM $9,700

265 of 317 FY2018

DESCRIPTION CHARGES

STEM REVISION PROFEMUR Z SIZE 5-107785 $9,774STEM ROT HINGE PLATE-103514 $9,090STEM SEG FLUTED STR 12 X 130MM-103513 $8,208STEM SPLINED KNEE BMT VC 20MM X 120MM-110405 $3,288

STEM SPLINED TAPER DISTAL 17MM X 2 50MM REVISION-110428 $8,052STEM SPLINED TAPERED DISTAL 15 X 250MM-107876 $10,980STEM STR EXT 15MM DIA X 75MM $2,452STEM SUMMIT SZ 5 HI OFFSET-103923 $15,108STEM TIBIAL PERSONA 5 DEGREE LEFT CEMENTED TIVANIUM ALLOY SIZE E-106146 $2,140STEM UNIVERSAL FLUTED 115MM X 12MM-108061 $2,560STEM UNIVERSAL FLUTED 75 MM X 16MM-110004 $2,560STEM UNIVERSAL FLUTED 75MM X 14MM-110424 $2,231STEM UNIVERSAL-103527 $3,673STEM UPPER EXTREMITY HUMERAL TRABECULAR METAL STERILE TANTALUM TIVANIUM 12MM X 130MM-105901 $6,000STEM VERSYS 6 INCH 11 X 160 MM-105026 $4,460STEM VERSYS ADVOCATE CEMENTED 16X145 $2,800STEM VERSYS BEADED 13MM X 160MM STD BODY STD NECK-104623 $4,460STENT ABSOLUTE PRO SELF EXPANDING 6MM X 100MM X 135CM-107271 $2,500STENT 6MMX15CMX120 VIABAHN W/HEPARIN-87172 $6,991STENT 7MMX10CMX120 VIABAHN W/HEPARIN BIOACTIVE SURFACE-87198 $5,102STENT 8MMX5MMX120 VIABAHN W/HEPARIN-98470 $1,400Stent Advanix Bil Addl-97410 $86Stent Advanix Bil W/Del System $220Stent Advntix Pancreatic Strt-105985 $285STENT ASPIRE OPEN-87848 $3,725STENT BILIARY LIFESTENT XL $2,200STENT BILIARY LIFESTENT XL 5 X 100MM X 130CM-106673 $3,600STENT BILIARY LIFESTENT XL 5 X 20MM X 130CM-106669 $2,600Stent Biliary Lifestent XL periph-106676 $2,200STENT BILIARY XPERT 3X40MMX135CM-97984 $2,790Stent Biliary Zilver 8cm 8mm-110688 $2,010

266 of 317 FY2018

DESCRIPTION CHARGES

STENT CAROTID WALLSTENT 8X13 5FR 135CM-96711 $4,226Stent Cl50 7 10 $180STENT COVERED ICAST 10MM X 38MM X 80CM-110332 $5,150STENT DBL PIGTAIL URETERAL 6/30-33413 $298STENT DES RESOLUTE $2,550STENT DRUG ELUTING ZILVER PTX 6 X 100MM-106788 $3,590STENT DRUG ELUTING ZILVER PTX 6.0FR X 120MM-106801 $3,990Stent Esophageal 8-12.5cm 13-25mm-110691 $2,908Stent Esophageal 8-12cm 22-30mm-110681 $3,978STENT EVOLUTION ESAPHAGEAL CONTROLLED RELEASE 18 X 23 MM 8CM-109185 $3,045

STENT EXPRESS BILLARY LD PREMOUNTED 7 X 60 X 75CM-91876 $1,671STENT EXPRESS LD $1,997STENT EXPRESS LD $2,499STENT EXPRESS LD 8X37X75-82009 $2,458STENT EXPRESS MONORAIL BILIARY 6.0X14X90CM-85619 $2,499STENT EXPRESS MONORAIL BILIARY 6.0X18X90CM-85621 $1,939STENT GRAFT BALLOON CATHETER Q50 10MM-50MM ANGIOPLASTY 65CM-110377 $1,018STENT GRAFT EXCLUDER CONTRA SEG 12 X 12-95489 $9,036STENT GRAFT EXCLUDER CONTRA SEG 20 X 12-95490 $7,540STENT GRAFT GORE EXCLUDER ABDOMINAL AORTA 100 MM-109191 $9,246STENT GRAFT ZENITH ILIAC SEG TFLE- $4,927STENT ILIAC ENTENDER EDNOPROSTHESIS 12FR 12 TO 13.5 X 14.5 X 7CM-101902 $4,573STENT LUMINEX VASC $2,550STENT LUMINEXX VASC 10MMX60MM-96947 $3,308STENT LUMINEXX VASC 10MMX80MM-96948 $3,515STENT LUMINEXX VASCULAR 10 MM X 40MM-101580 $1,589STENT LUMINEXX VASCULAR 8MMX40MM-94392 $1,973STENT OMNILINK ELITE $2,050STENT OMNILINK ELITE $2,392STENT OMNILINK ELITE 8MM X 39MM X 135CM-107272 $2,050STENT OMNILINK ELITE 9MM X 29MM X 80CM-107404 $2,700STENT PALMAZ BILIARY XL-96950 $3,642

267 of 317 FY2018

DESCRIPTION CHARGES

STENT PANCREATIC GREEN POLY 4 FR-110649 $138STENT PERCUFLEX PLUS $237STENT PERCUFLEX PLUS 6X22-26235 $299STENT PERCUFLEX PLUS 6X30-96748 $306STENT PERCUFLEX PLUS 7FR 20CM-33496 $273STENT PERCUFLEX PLUS W/O WIRE $280STENT PERCUFLEX PLUS W/O WIRE 7X30-33490 $228STENT PERCUFLEX URINARY DIVERSION 8FR X 80CM-98175 $468STENT PERCULFEX PUP 6FR X 80-94844 $426STENT PERIPHERAL VASCULAR SUPERA NITINOL 5.5 X 40MM X 120CM-108847 $4,390STENT PIGTAIL URETERAL DBL 7FRX30CM-33414 $261STENT POLARIS PERCUFLEX $315STENT POLARIS PERCUFLEX 5FR X 26MM-81353 $320STENT PULMONARY ICAST BALLOON EXPANDING 8 X 59MM PTFE 120CM DELIVERY SYSTEM 7FR INTRODUCER-105892 $130STENT SILIC BLACK W/POSTIONER $261STENT SINUSPACER TURBINATE-60121 $43Stent Smart 14x40x80-89854 $3,090STENT SMART BILIARY $1,950STENT TRUNK ENDOPROSTHESIS EXCLUDER AAA 26 X 14.5MM X 18CM-101905 $15,880STENT URETERAL INFRAVISION 6FR X 70CM-89573 $400STENT VASCULAR LIFESTENT $2,631STENT VASCULAR LIFESTENT $2,762STENT VASCULAR LIFESTENT $3,570STENT VASCULAR LIFESTENT 6 X 12 X130-94377 $3,612STENT VASCULAR LIFESTENT 6 X 15 X 130-94379 $4,000STENT VASCULAR LIFESTENT 6 X 6 X 130-94376 $2,730STENT VASCULAR LIFESTENT 7 X 15 X 130-94396 $4,095STENT VASCULAR LIFESTENT 7 X 17 X 130-94395 $4,993STENT VASCULAR LIFESTENT 7 X 6 X 130-94382 $2,600

STENT VASCULAR XACT NITINOL SELF EXPANDING 40MM 8-10MM $3,300STENT VIABAHN $5,634STENT VIABAHN 10MM X 15CM-103804 $6,831STENT VIABAHN 10MM X CM X 12CM-91238 $5,190

268 of 317 FY2018

DESCRIPTION CHARGES

STENT VIABAHN 120CM-87171 $6,113STENT VIABAHN 5MM X 10CM-97611 $6,263STENT VIABAHN 5MM X 15CM-97615 $7,275STENT VIABAHN 5MM X 5CM-97604 $5,393STENT VIABAHN 6MM X 10CM-97612 $6,518STENT VIABAHN 6MM X 5CM-103791 $5,756Stent Viabahn 6x10x75 W/O Hep-96575 $4,753Stent Viabahn 6x5x75 W/O Hep-96567 $4,037STENT VIABAHN 7MM X 10CM-97613 $6,314STENT VIABAHN 7MM X 2.5CM-97607 $5,814STENT VIABAHN 8MM X 2.5CM-97609 $4,382Stent Viabahn 8x10x75 W/O Hep-96246 $4,610Stent Viabahn 8X2.5X75-100621 $4,040Stent Viabahn 8x5x75 W/O Hep-96244 $4,040Stent Viabahn 9x10 $4,753STENT VIABAHN W/HEPARIN-87173 $5,190STENT ZILVER 8X6-88881 $2,529STENT ZILVER BILIARY 6FR 10X40MM-84822 $2,499STENT ZILVER BILIARY 6FR 7X60MM-84819 $2,850STENT ZILVER BILIARY SELF EXPANDING $3,000

STENT ZILVER BILIARY SELF EXPANDING 12X40MM 125CM-100174 $2,850STENT ZILVER PTX DRUG ELUTING 6-7MM X 40MM-106781 $2,350STENT ZILVER PTX DRUG ELUTING 6MM X 120MM-106783 $3,990STENT ZILVER PTX DRUG ELUTING 7MM X 80MM-107243 $3,590STENT ZILVER VASCULAR 6FR $2,558STENT ZILVER VASCULAR 6X60X125-94035 $2,850Stent-Herculink Biliary $2,923STIMULATOR ELITE Add on $27,750STIMULATOR NEURO DBS KINETRA-87809 $36,221STIMULATOR NEURO SOLETRA DBS-87951 $17,450STRAIGHTPLATE LCP WRIST FUSION-104260 $3,597STRIP GRAFTON DBM 8MMX1CMX20CM-103318 $5,712STRIP GRAFTON DBM SCOLIOSIS-102654 $3,000STRIP SILICONE STYLE 41 3.5 MM-103851 $41STRIP TCP CHRONOS 10 X 25 X 3MM-100507 $3,266STRIP TCP CHRONOS 10X25X6MM-95426 $5,576

269 of 317 FY2018

DESCRIPTION CHARGES

STRIP TCP CHRONOS 50X25X3MM-95425 $1,860STRUT CORTICAL 11.0 24.9CM FREEZE DRY-88503 $782

SUCTION OASIS PLEUR EVAC SINGLE COLLECTION DRY ATS READY $55SUMMIT CEMENTED C STEM AMT TOTAL CONSTRUCT $3,500SURFACE AC ART 7-10 BLUE 12MM-102378 $1,400SURFACE AC ARTICULAR YELLOW 14MM-101144 $1,085SURFACE ART FLEX FIXED 7-10 12MM NEXGEN PRO-104630 $1,400SURFACE ART SZ 5-6 LT JRNY II-105425 $5,364SURFACE ARTICULAR CONST SZ 3-4 13MM-104838 $6,160SURFACE ARTICULAR PERSONA CRUCIATE RETAINING LEFT FIXED CONVENTIONAL 11MM-106145 $1,400SURFACE ARTICULAR SEGMENTAL SZ 0 12MM-103965 $4,013SURFACE CR FLEX ART C-H/7-10 BLUE 12MM-98470 $1,400SURFACE HINGE ROTATING ARTICULAR SZ F 17MM-102416 $4,013

SURFACE KNEE GENDER FLEX PROLONG SZ 00/0 13MM RT-98756 $2,537

SURFACE KNEE GENDER FLEX PROLONG SZ 1/2 11MM RT-98754 $1,400

SURFACE KNEE GENDER FLEX PROLONG SZ 3/4/5 9MM LT-98758 $2,537SURFACE KNEE LPS FEMORAL $1,085SURFACE KNEE LPS FLEX FIXED SZ 5-6 12MM-99502 $1,417SURFACE KNEE LPS SZ 3-4 14 MM FEMORAL C-D-104030 $1,400

SURFACE NATURAL KNEE CONGRUENT SZ 1/2 9MM LT-99519 $1,417SURFACE NATURAL KNEE ULTRACONGRUENT SZ 3 4 5 9MM RIGHT REVISION-110703 $1,000

SURFACE NK FLEX PROLONG CONGRUENT SZ1-2 13MM-99204 $1,118SUT ANCHOR CORKSCREW 3.5MM-34132 $287SUTURE ANCHOR 1.3 MICRO C1 NEEDLE-54840 $854SUTURE FLEXBRAID #5X28 INCH Add on $180SUTURE RETAINER Add on $180SUTURE VICRYL MESH KNIT VIOLET-12835 $2,770SUTUREPLATE HUMERAL TI 5 HOLE-103409 $4,558

270 of 317 FY2018

DESCRIPTION CHARGES

SWIVELOCK BIOCOMPOSITE C VENTED 4.75MM X 19.1MM WITH CLOSED EYELET-105737 $834SWIVELOCK C VENTD 4.75X19.1MM ALR Add on $1,179SYSTEM IMPLANT DELIVERY ACL TIGHTROPE RT-100893 $900SYSTEM IMPLANT DELIVERY BIOCOMPOSITE DISTAL BICEPS REPAIR-108266 $3,144

SYSTEM IMPLANT TIGHTROPE RT WITH 8MM FLIP CUTTER-103962 $1,834SYSTEM IMPLANT TIGHTROPE RT WITH FLIPCUTTER II 9.0MM-106167 $1,350SYSTEM INPLANT UROLIFT-108438 $1,850SYSTEM NEUROSTIMULATOR CHARGING FOR MODEL 37612 ACTIVA RC-107079 $4,000SYSTEM NEUROSTIMULATOR IMPLANT-109183 $40,976SYSTEM NEUROSTIMULATOR RESTORE ADVANCED MRI 15MM X 65MM-107096 $28,000SYSTEM PERFECT CALCAR 17.5 X 145MM SZ12-98426 $2,474SYSTEM PROXIMAL TENODESIS IMPLANT-105693 $1,350SYSTEM SLING TOT OBTRYX CVD-92545 $2,600T PLATE LCP 2 HOLE HEAD 3 HOLE SHAFT 2.7MM-101182 $1,237T PLATE LOCKING COMPRESSION 3 HOLE HEAD 7 HOLE SHAFT 2MM-100862 $744TACK PLATE CLAW 2-103874 $346TACKER SORBAFIX FIXATION 30 COUNT-94462 $980Tacticath Irr Ablation-104213 $7,750TAK BB TEMPORARY FIXATION-103019 $100TAK BIO SUTURE W/2 TIGER 3X14MM-88114 $634TAPE SUTURE CORKSCREW-109177 $900TAPE TVT VAG LF-34867 $1,912Tenotomy tray-105942 $1,530Terumo .035 TerumoStiff 180cm Guidew-88835 $93Terumo 0.35in 180cm Angle Guidewire-88662 $79Terumo 0.35in 260cm Str Guidewire $182TERUMO ADVANTAGE GLIDEWIRE 260 $460Terumo Glidewire Standard 180cm $75Terumo Glidewire Stiff $89Terumo Glidewire Straight 260cm $85

271 of 317 FY2018

DESCRIPTION CHARGES

Terumo Progreat Microcath $559TESTICULAR IMPLANT SZ 4-90717 $1,398TFE Coated Torq Cable-96539 $60Therapy Dual Ablation Cath-95740 $1,744TIB BASE AUGMENT SZ 5-104395 $1,800TIB BASE SZ 5 LEFT-104396 $4,228TIB BEARING 12MM OSS-150464 $2,738TIB BUSHING SET POLY OSS-105465 $868TIB II BEARING DCM 10 X 83-103931 $3,403TIB INSER LT 13MM SZ .5-80214 $2,613TIB INSERT REV SZ 5 14MM-104397 $2,906TIB LOCKING RING AVL OSS-105467 $1,012TIB PLATE MOD 71 AVL OSS-105468 $9,078TIB TRAY WITH LCKNG BAR AND SCREW-105676 $6,482TIBIA BRG VANGRD PS+ 16 X 71/75-102641 $4,564TIBIA EVOLUTION KEELED NONPOROUS $2,500TIBIA KNEE EVOLUTION KEELED NONPOROUS $2,529TIBIA PLAT CEM COLUMBUS T3 PLUS-105472 $3,500TIBIA UNI OXFORD LM PMA-101757 $2,700TIBIA UNI OXFORD SZ B LM-98193 $4,630TIBIAL ART SURFACE PERSONA $1,400TIBIAL ART SURFACE SZ B 14MM-103420 $4,013TIBIAL AUG BLK 10 X 63/67 UNIV OSS-104791 $3,090TIBIAL BEARING POLY 14 MM OSS-104792 $3,128TIBIAL BEARING VANGUARD 10MM X 71/75MM-110406 $4,356TIBIAL BRG SSK VNGD 12 X 79/83-104527 $5,278TIBIAL HINGE UNIV LPS XXSM 23M-103526 $6,775TIBIAL INSERT SZ T3/T3 PLUS 19MM COLUMBUS DD-105473 $1,150TIBIAL OXF UNI SZ B4 LM/RL-103858 $2,090TIBIAL OXFORD UNI SZ D RIGHT-102418 $2,565TIBIAL PLATE NON MOD LONG 63 OSS-104790 $9,594TIBIAL STM ROT HINGE PL SZ 5-102414 $7,415TIBIAL TRAY 360 79MM-104828 $4,938TIGHTROPE ABS IMPLANT OPEN-101743 $528TIGHTROPE BTB-101742 $581TIRE 7.0 SB STYLE 277-85418 $33TIRE ASYMMETRICAL STYLE 276 7 X 2.5 MM-103856 $35

272 of 317 FY2018

DESCRIPTION CHARGES

TIRE SCLERAL BUCKLE SILICONE STYLE 278-24683 $85TIRE SCLERAL BUCKLE STYLE 275-88180 $81TISSEEL FROZEN RTU 10ML-91861 $1,168TISSEEL FROZEN RTU 2ML-91859 $562TISSUE ALLODERM 3CM X 7CM MEDIUM-97123 $1,682TISSUE ALLODERM 8X20CM THICK-98808 $10,482

TISSUE ALLODERM CONTOUR PERFORATED RTU SMALL-109275 $6,888TISSUE ALLODERM CONTOURED RTU THICK 10.7 X 21.5 CM-104054 $10,736

TISSUE ALLODERM CONTOURED RTU THICK 9.6X19.36CM-100898 $10,642TISSUE ALLODERM PERFORATED RTU MEDIUM THICKNESS 7.3 X 14.7 CM-107421 $5,194

TISSUE ALLODERM PERFORATED RTU THICK 10.7X21.5CM-104298 $11,058

TISSUE ALLODERM PERFORATED RTU THICK 9.6X19.3CM-104299 $8,900TISSUE ALLODERM RTU $8,382TISSUE ALLODERM RTU 16 X 20CM THICK-103384 $20,966TISSUE ALLODERM RTU 6X16CM THICK-98807 $6,290TISSUE ALLODERM RTU THICK- $4,462TISSUE ALLODERM THICK 2 X 4CM-22490 $1,058TISSUE ALLODERM THIN 2X4CM-98161 $5,200

TISSUE ALLOGRAFT BONE CANCELLOUS CRUSHED 15CC-102757 $790TISSUE ALLOMEND RTU 8X16CM-104374 $6,994TISSUE AMNIOGRAFT 2.5X2.0-82732 $1,406Tissue Marker (Implantable). $550Tissue Marker Seeds Each $20TISSUE PROKERA 16MM-96760 $1,472TISSUE REPAIR SOFT XENFORM 6 X 10-92544 $2,700TISSUE STRATTICE 7.65X21.4CM-97566 $4,662TISSUE STRATTICE 8CM X 16CM-110422 $5,888TISSUE STRATTICE PLIABLE 6CM X 8CM-110704 $2,208TISSUE STRATTICE PLIABLE 8 X 8CM-101417 $2,874TISSUE TUTOPLAST PERICARDIUM-85415 $581

273 of 317 FY2018

DESCRIPTION CHARGES

TISSUE TUTOPLAST SUSPEND FASCIA LATA-101243 $1,008TISSUE WOUND MESHED BILAYER MATRIX 2 X INCH-100662 $6,098TISSUE XCM BIOLOC THICK 20X30CM-99546 $35,632TISSUE XCM BIOLOGIC 16 X 20CM-97978 $19,004TISSUE XCM BIOLOGIC THICK 10X16CM-100061 $7,364Toray Wire-Transeptal-98514 $309TORP ALTO TOTAL ADJ OFF SET $646TOTAL SHOULDER WITH REGENEREX $2,000T-PLATE CLAW II 4 HOLE 20MM-108025 $5,692TRANSCONNECTOR 38 TO 47MM-97554 $2,224TRANSCONNECTOR 47 TO 62MM-98587 $2,179TRANSCONNECTOR SYNAPSE 50 MM-104020 $1,154Transseptal Guidewire $308Trapper Exchange Device6-8FR-108316 $500Tray Cath Percut 8 Fr-85178 $150TRAY CHEST TUBE THAL QUICK 16FRX41CM $310Tray Chest Tube Thal Quick 28 Fr-95966 $408Tray Insertion Trialysis Str-96885 $428TRAY PRIMARY POROUS TIB SZ 2.5 KNEE-82162 $3,527TRAY PRIMARY TIB COMPONENTS $3,700TRAY SLEEVE POR M/L 29MM $4,167TRAY THORACENTESIS 7IN CATH NDL 14GA X 2IN LF-383 $82TRAY TIB 360 BMT 83MM-104525 $12,172TRAY TIB MBT CEM KEEL SZ5-71899 $3,511TRAY TIBIA BMT 360 $5,192TRAY TIBIAL BMT 360 67MM-102386 $6,808TRAY TIBIAL ILOK 63MM-103374 $5,698TRAY TIBIAL ILOK 67MM-110390 $7,040TRAY TIBIAL MBT KNEE CEMENTED 3-90334 $2,287TRAY TIBIAL MBT REVISION CEMENTED SIZE 3 OR 4 70-75MM M/L X 46MM A/P-105911 $7,982Trial Octrode Lead $5,682TUBE COLLAR BUTTON VENT FLUOROPLASTIC-23637 $54TUBE DONALDSON VENT SILIC 1.14MM-23637 $54TUBE REUTER TEFLON-23637 $54TUBE SHEEHY COLLAR BUTTON 1.27MM-103905 $13TUBE T SILIC RICHARDS-23637 $54

274 of 317 FY2018

DESCRIPTION CHARGES

TUBE THORACIC 24FR $10TUBE THORACIC SILIC 28FR $17TUBE VENT ARMSTRONG 1.14 MM-103976 $31TUBE VENT ARMSTRONG SILIC-23637 $54Tulip Retrieval Set $478Tunneler Plastic-89947 $60Turnpike Catheter-106998 $1,190TVT OBTURATOR SYSTEM-86469 $2,760Ultraverse Balloon $268UPLATE CLAW COMPRESSION SMALL-104274 $5,926Uresil 6FR Drainage Catheter $134US BARD ULTRA CORE TWIRL MARKER $210US HYDROMARK 15 G CLIP-97266 $228US SMARK SiteMarker $253VACCESS Balloon $164VALVE AHMED MAINT GLAUCOMA S-1-85030 $1,195VALVE AHMED PED S-2-85030 $1,195VALVE ASCENDING AORTIC WITH GELWEAVE VALSALVA 19 TO 29MM $15,590VALVE EVOLUT R AORTIC TAVR 23/29MM $60,000VALVE GLAUCOMA BAERVELDT-85030 $1,195VALVE HEART AORTIC 23-33MM MOSAIC MODEL 305 $11,740VALVE HEART AORTIC 27MM MOSAIC $11,339VALVE HEART AORTIC CONFORM X 19-29MM $9,990VALVE HEART AORTIC INTUITY ELITE 23MM $24,000VALVE HEART AORTIC MECHANICAL 21-23MM $9,990VALVE HEART AORTIC MECHANICAL OPEN PIVOT 18-26MM $7,500VALVE HEART AORTIC MECHANICAL WITH STANDARD SEWING RING 25/27/29MM $9,990VALVE HEART AORTIC PERIMOUNT PERICARDIAL THERMAFIX 21-29MM $10,100VALVE HEART AORTIC THERMAFIX 19-33MM $12,980VALVE HEART EPIC MITRAL 27/29MM $12,522VALVE HEART EPIC MITRAL 33MM $12,040VALVE HEART EPIC SUPRA TISSUE 23MM $12,492VALVE HEART EPIC TISSUE 25MM $9,331VALVE HEART INSPIRIS PERICARDIAL 19/21/27/29MM $15,000

275 of 317 FY2018

DESCRIPTION CHARGES

VALVE HEART MECHANICAL 19 MM $9,990VALVE HEART MECHANICAL 25-29MM $7,800VALVE HEART MITRAL 21- 25MM MOSAIC $12,142VALVE HEART MITRAL CONFORM $9,990VALVE HEART MITRAL MAGNA EASE 25-33MM $12,331VALVE HEART MITRAL MECHANICAL 25-33MM $7,500VALVE HEART MITRAL MECHANICAL WITH STANDARD SEWING RING 25/27/29/31/33MM $9,990VALVE HEART MOSAIC ULTRA AORTIC 21/29MM $12,200VALVE HEART MOSAIC ULTRA AORTIC 23-27MM $10,980VALVE HEART TAVR EVOLUTE PRO AORTIC TRANSCATHETER PORCINE 23-34MM $60,000VALVE HEART TRANSCATH W/ASCEN Add on $24,375VALVE HEART TRANSCATH W/NOVA Add on $24,375VALVE HEART WITH ANATOMIC SEWING RING 19-29MM $9,990VALVE REG STRATA II $10,522Valvuloplasty Balloon $1,355Vascade Arterial Closure Device- $390Venture Deflectable Catheter $1,406Vertebropasty Cement/Mix $784Vertebropasty Cement/Mix $784VIABAHN STENT 6x2.5x120-97749 $3,875Vidacare 11G Bone Bx Needle $208Wallflex Biliary Stent 10x40 $3,680Wallflex Biliary Stent 10x60 $3,279Wallflex Covered Bil Stent 10x60 $4,230Wallflex Covered Bil Stent 10x80-96536 $5,669WASHER 10MM FOR 4.5MM CANN SCREW-7109 $59WASHER 6.5MM DEPUY-31505 $16WASHER SCREW SM 7.0MM-2831 $56WASHER SPIKED 13.5/5.5MM LG SCREW-2975 $241WASHER TI 16 X 6MM-103579 $78Watchman Device $28,100Webster Quad Cath $937

WEDGE CHRONOS BETA TCP 10 DEGREES RECTANGULAR-108022 $1,438

276 of 317 FY2018

DESCRIPTION CHARGES

WEDGE CHRONOS BETA TCP 22 DEGREES RECTANGULAR-108023 $1,697WEDGE TRI CORT ILIUM 1.7-1.9CM-82441 $1,696WEDGE TRI CORT ILIUM 2.0-2.2CM-82442 $1,821WEDGE TRI CORT ILIUM 2.3CM OR GREATER-88864 $2,115WEIGHT GOLD SERIES 3000 1.2MM-15488 $521WIRE C TROCAR TIP $24WIRE C TROCAR TIP BLACK .062INX1.57MM-25094 $27WIRE CARDIAC T5 $71

WIRE CERCLAGE STAINLESS STEEL ORTHOPEDIC 0.5MM X 175MM $268WIRE COMPRESSION 20 MM THREAD 1.6 X 50 MM-104578 $98WIRE FIXATION STAINLESS STEEL TROCAR TIP SMOOTH 150MMX 2.3M $120WIRE FIXATION TITANIUM 6IN X 1.6MM-97585 $46WIRE K 2.0MM X 9 INCH-32060 $268WIRE K SMOOTH $6WIRE K SMOOTH .028X4IN-56354 $28WIRE K STR PIN HALF BANNETT POINT 9IN-7707 $71WIRE K THRD 4.72MMX3/16-24957 $40WIRE KIRSCHNER 0.6X70MM-56354 $28WIRE KIRSCHNER 1.25X150MM-2827 $82WIRE KIRSCHNER 1.6X150MM 5MM THRD LGTH-90507 $37WIRE KIRSCHNER 1.6X150MM-2828 $215WIRE KIRSCHNER 2.0X150MM-2829 $20WIRE KIRSCHNER 2MM-97846 $57

WIRE KIRSCHNER WITH THREADED TIP 1.6MM X 100MM-108078 $97WIRE KIRSCHNER WITH TROCAR POINT 2X285MM-108005 $233

WIRE KIRSCHNER WITH TROCAR POINTS 1.6 X 150 MM-104086 $230WIRE NITINOL 45CM WITH TUNGSTON TIP 7CM-98612 $96WIRE TEMPORARY CARDIAC PACING 2 0 ORANGE 24IN $46WL Gore Viabahn Stent Graft $5,174WOUND MATRIX CYTAL 6 LAYER 10X15CM $9,568WOUND MATRIX CYTAL 6 LAYER 5X5CM $2,484WRAP AXOGUARD PERIPHERAL NERVE PROTECTION $1,938

277 of 317 FY2018

DESCRIPTION CHARGES

WRAP AXOGUARD PERIPHERAL NERVE PROTECTION 2X20MM-99762 $2,500X PLATE CUSTOM 4 HOLE-103114 $348X PLATE STERNALOCK 8 HOLE $1,754XENFORM SOFT REPAIR MATRIX 4X7CM-100181 $1,786Y PLATE 3HL HEAD 7 HL SHAFT LCP 2MM-101915 $1,384Y PLATE DOUBLE LONG LOW PROFILE 7 HOLE-103144 $570Y PLATE DOUBLE SHORT LOW PROFILE 6 HOLE-103138 $534Y PLATE LARGE DOUBLE LARGE 7 HOLE-104130 $247

Y PLATE LOCKING 8 HOLE SHAFT 3 HOLE HEAD 1.5MM-100967 $673Y PLATE SMALL DOUBLE SMALL 6 HOLE-104129 $247Y PLATE SMALL OR MEDIUM 4 HOLE-104128 $228YCFW 7 35 6 CW 12 Introducer $43YOKE 12MM AVL OSS-105466 $2,356YOKE REINFORCED-104036 $2,436Zimmon Double Pigtail Stent 10x10-101065 $144Zimmon Double Pigtail Stent 10x7-101066 $93ZIPWIRE ANG 035X180MM $88ZV Sheath Prelude 6F Short-98853 $56

OTHER SUPPLIES_MISCELLANIOUS OR SUPPLY CHARGE $102 Concentrator/Day $52.0 Prolene SH 8833-100331 $8Adapter Oxygen Nipple/Nut $2Advance Adapters $4Aerosol Drainage Unit $2Air Compressor/Pulmoaide $6Applicator Chloraprep 3ml LF $4BATH SITZ-27398 $6BD 3.5 Spinal Needle 18-27G-37055 $3BD Catheter Adapters $3Beneprotein Scoop $1BLADE BEAVER MINI #61 1.31 INCH-108452 $4BLADE SURG CARBON # 20-3904 $6BLADE SURG CARBON NO 10-15 STERILE-740 $6

278 of 317 FY2018

DESCRIPTION CHARGES

BLADE SURG MINI RND TIP-24865 $6BLADE SURG SS PLASTIC DISP SZ 15C-3906 $6Bovie Grounding Pad $6BOWL STER DISP-26626 $6BRIEF STRETCH MESH XL LF-95742 $6Cann Crvd Nonflair Tip w/7'TU $3CANNULA CRVD NON FLAIR TIP W/7 TUBING DISP LF $6Cannula Nasal Oxygen $5Cardioversion via ICD $7CATH FOLEY CTD 2WAY 18FR 5CC-32805 $6CATH FOLEY SILIC 20FR-32805 $6Cath IV Safety 18-22G x 1.16in $6Cavilon Barrier Film Wand $4ChloraPrep One-Step-85354 $3Conformant $2Connector Oxygen $2CONNECTOR Y KCI WOUND VAC LF-84030 $6Cook 20Gx7 Perc Needle $8Cook Low Pressure Stopcock $7Cook PFLLA VTA L Multi light house Adapter $7Cook PMLLA LHA Male Adapter $7Corregated Tubing $4COVER KWIRE AND PIN GREEN 1.6MM-108453 $6COVER STANDARD MAYO STAND-95817 $3COVER TABLE 44X89-95821 $4COVER XL MAYO STAND-95818 $6CT Coeur Y Line w/2 chk valves $7Drainage Unit Aerosol $4DRAPE 3/4 SHEET 53X77 AURORA-95823 $5DRAPE BAR HEAD PROXIMA-95826 $5Drape Brachial $6DRAPE MEDIUM 40X70 AURORA-95838 $4DRAPE MINOR PROCEDURE-95839 $5DRAPE UTILITY W/TAPE 15 X 26 PR-95847 $2Dressing Gauze Sponge Ster 16 PLY $3Dressing Skin Closure Steri 1/2x4 $4DRESSING WRAP SELF ADH TAN COBAN 3INX5YD-16148 $5

279 of 317 FY2018

DESCRIPTION CHARGES

Electrode Bio Tac Foam $2ENDO STAPLE LIGACLIP TI SM LT100 $8Ensure Enlive 8 Oz $5Extension Tubing $4Forcep Mosquito 4 3/4 Sterile DI'' $6Glucerna 8 oz $2Glucerna 8 oz $5GOWN POLY REINFORCED GOWN L SIRUS-95866 $8GOWN SIRUS NON-REINFORCED LARGE-95865 $8Hi Humidity Adapt $6High Protein Ensure 8 Oz $5Humidifier Adapter $5IV Set Secondary $3Jevity 1.2/Can $5Kit Cath Suction Rigid Wet 14 Fr $4Kit IV Start with Chg.67ml LF $3Loop Vascular Blue or Red $5Loop Vascular Red Mini $3Lukens Sputum Trap $4Marker Pen Fine Point $3Mask Face Adult (Resusitator) $7MASK FACE TENT DISP $4Mask High O2 3in1 w/7Ft Tubing AD $3Mask Non Rebreather Ped $5MASK NONREBREATHER 3IN1 ADULT LF $4Mask Oxygen Adult $3Mask Simple 02 $5Meditech Namic 2way Stopcock $6MR ATEC Tissue Filter $8MR Coeur Y Line w/2 chk valves-98735 $7Nasal Pharyngeal Airway $6NEBULIZER (FOR TREATMENT) $4Nebulizer 1/2 Nacl For Hi Humid $5Nebulizer Aerosol $6Nebulizer Misty Neb $4Nebulizer Surrey $3NEEDLE MAYO TAPER-27092 $5

280 of 317 FY2018

DESCRIPTION CHARGES

Nepro 8 oz $5Nepron 8 oz $5NG MORMAC TUBE GUARD-26955 $6Non Rebreather Mask #1203 $2Ointment Antibiotic DBL Bacitraci $3Optichamber $8Osmolite 1.2/Can $5OT Theraband (per foot) $3Oto Clear Irrigation Tip $3Oxygen Adult Mask $7Oxygen Cannula Support $6Oxygen Cont Therapy Per Hr. $8Oxygen Hourly $8Oxygen Mask #1201 $2Oxylite Oxygen Admin $3Pad Electrode Polyhesive $8Pharmaceal K 50 Tubing $6Promote W/Fiber/Can $5Promote Without Fiber/Can $5Prosource Tf Pkt $3Pumping Details Bottle Brushes $4Scissor Iris 4.5 Inch $6Set IV Extension W/Clave 7in $7Set IV Micro w/Clave 7in LL $8Shield Size 16-24 $8SLEEVE STER DISP-43837 $4SLEEVE STERILE AURORA-95858 $3SPIROMETER DISP ADULT LF-88027 $8SPONGE PEANUT 1/4X9/16-27084 $1SPONGE TONSIL LG-72277 $4Sterile Handle Covers $4Stopcock 3 way w/male LL LF $3Suction Canister $2Suction Machine Daily Chg $3Suction Tubing $2SUT ETHIBOND 0 30INCH X306H-91373 $6SUT ETHIBOND 4-0 X303H-37067 $8

281 of 317 FY2018

DESCRIPTION CHARGES

SUT ETHIBOND 5-0 30INCH RB-1 X870H-91371 $7SUT VICRYL 0 UR-6 27 INCH DYED-89108 $7SUT VICRYL CT-1 36INCH VIOLET-96027 $6SUTURE 2 SILK 30IN MH K846H-18166 $6SUTURE 2-0 ETHILON BLACK MONO SA FS-103536 $5SUTURE 2-0 VICRYL COATED NONBRAIDED SA CT-1-103535 $5SUTURE 2-0 VICRYL COATED NONBRAIDED SA FSL-103534 $6SUTURE 3-0 PROLENE BLUE MONO SA FS-1-103537 $7SUTURE BUTTON PEARL POLYESTER 2 HOLES 5/8 IN X 16 MM-109258 $3

SUTURE BUTTON PEARL POLYESTER 2HOLE 9/16 X 14MM-109257 $8SUTURE BUTTON POLY 520G-2644 $7SUTURE CHROMIC 3-0 FS-2 636H-1482 $8SUTURE ETHIBOND 2-0/4 X833H SH-2553 $6SUTURE ETHIBOND EXCEL TAPER POINT CT 2 30 INCH $5SUTURE ETHILON 3-0 KS 627H-2521 $5SUTURE MERSILENE 2-0 R665H-24315 $7SUTURE MERSILENE 3-0 R647H-24316 $6SUTURE MONOCRYL 0-5-0 UNDYED TF 27 INCH-102291 $7SUTURE MONOCRYL 2-0/4-0CT-1 Y339H 27 INCH-26369 $6SUTURE MONOCRYL VIOLET 2-0 SH V-20 36 INCHES-105489 $6SUTURE PDS 0 CT Z352H-24280 $7SUTURE PROLENE 0/2/4 30IN 8412H-19277 $7SUTURE PROLENE 2 0 30IN FSLX 8689H $8SUTURE PROLENE SZ 1 8455H $6SUTURE RETENTION BOLSTER 450G-2680 $6SUTURE SHARPOINT NYLON 9-0 AA1825-89700 $6SUTURE SILK 0-4 30IN SA86G-1467 $6Suture Silk 18 Precut Blk'' $4SUTURE SILK 18IN PRECUT BLK 124Q-87328 $8Suture Silk 2 0 12 18 Braided'' $4SUTURE SILK 2-0 12-30 INCH BRAIDED-87383 $7SUTURE SILK 3-0/4-0 684H-23846 $5SUTURE TAPE UMBILICAL U11T-2431 $5SUTURE VICRYL 0 27 INCH UNDYED CT-2-100506 $5SUTURE VICRYL 0 CT-1 DYED J340H-23852 $5

282 of 317 FY2018

DESCRIPTION CHARGES

SUTURE VICRYL 0/2/3/4 UR-5 DYED J376H-11428 $7

SUTURE VICRYL 0-5 27-54 INCH DYED & UNDYED J616H-24207 $6Suture Vicryl 3 0 27 SH J416H'' $5SUTURE VICRYL 4-0 FS-2 UNDYED J422H-15909 $8Sx Can/Lid $5Sx Machine/Day $4Syringe Pulsator Abg's $2Syringe Saline Prefill 12cc 10ml $3Towel Huck Disp Blue-1270 $7Tubagrip Size B Per Ft $1Tubagrip Size C-F Per Ft $2Tubagrip Size G/K Per Ft $4Tubing O2 Ext Disp 21 ft $3Tubing O2 Hudson RCI LF $3Tubing Oxygen $4Two Cal HN 8 oz $5VAD Dressing Gauze Roll-1220 $2VAD Dressing Sponge Raytec Ster 4x4 $2Vaseline Gauze (Each Pkg) $4Welch Allen Speculum $4Wrap Non Conductive Foam Large $5WRAP SELF ADH COBAN 2 IN X 5 YD-5513 $6YANKAUER SUCTION $8Yankaver $8Yankeur Suction Tip $6

EMERGENCY ROOM13121 Wound Repair Complx2.6-7.5 - ED $42423665 Shld Dis Fxgrtub W/Man - ED $47725675 Rad/Uln Disl W/Man $26526770 Ip Jt Disl With Man Ea $34730901 Con Nsl Hem Ant Smp - ED $28251798 Bladder Scan ED $115Abd Paracentesis W/O Img $540AC Jt Disl W/O Man 23540 $255Acetablr Fx W/Man 27222 $174

283 of 317 FY2018

DESCRIPTION CHARGES

Acetablr Fx W/O Man 27220 ED $255Adjacent Tiss Transf 10.1 30sqcm $2,109Adjacent Tissue TransfER <10sqcm $1,886Amp /FingER W/Closure $2,217Ankle Dislocation 27840 $265Anoscopy Diagnstic 46600 $91Anoscopy Rfb 46608 $1,180Art Catheterizatn 36620 $145Arterial Punct Diag 36600 $172Arthrocentesis Int Jt 20605 $424Arthrocentesis Mjr Jt 20610 $424Arthrocentesis Sm Jt 20600 $352Aspiration Nasal Sinus $177Aspiration Peritons Abscess $244Aspiration.Drng Gang Cyst Any Loc $406Avul Nail Plate Ea Add11732 $126Avulnail Plate 11730 $163Bimall Fx W/Man 27810 $371Bimall Fx W/O Man 27808 ED $318Biopsy Single Skin/Sq/Muc Memb $266Bladder Cath Suprpbc 51102 $2,449Bladder Irr/Lav/Instil 51700 $378Bleph/Drain/Abcess/Eyelid $528Blood Transfusion 36430 $700Bone Marrow Biopsy Needle/Trocar $544Bronchoscopy Diag W/Cell Wash $1,888Bronchoscopy W/ Lavage $1,743Bronchoscopy W/Aspiration $1,918Burn Tx Init Local 16000 ED $126Burn Tx Large 16030 ED $318Burn Tx Med 16025 ED $265Burn Tx Small 16020 ED $326Calcaneal Fx W/Man 28405 $255Calcaneal Fx W/O Man 28400 ED $255Capsulrphy Sutr/Lgmt Upr Xtmty $255Cardioversion Ext 92960 $798Carpal Fx W/Man 25635 $255

284 of 317 FY2018

DESCRIPTION CHARGES

Carpal Fx W/O Man 25630 ED $255Cast Hip Spica 29305 $328Cast Hnd/Forarm/Gtlt 29085 $292Cast Long Arm 29065 $424Cast Long Leg 29345 Mlp $424Cast Rem Full Leg/Arm 29705 $292Cast Shld Spica 29055 $328Cast Short Arm 29075 $345Cast Short Leg 29405 $345Cast Wedging 29740 $160Cast Windowing 29730 $160Catheterization Umbilical Ve $176Central VenoUS Cath<2 36555 $1,219Cerumen Removal Flexible $117Chem Cautery Granulation Tissue $274Chest Tube Insertion 32551 $928Clavicle Fx W/Man 23505 ED $2,122Clavicle Fx W/O Man 23500 ED $255Closd Tx Nasal Fx W/Stabilization $1,838Cmc Disloc W/Man 26670 ED $255Coccyx Fx 27200 $255Collect Blood W/Estab Cath Venous $105Colonscpy Rfb 45379 $1,268Con Hem S/P T&A Reqadm42961 $84Con Hem S/P T&A Smp 42960 $212Con Np Hem S/P T&A Adm42971 $91Con Nsl Hem Ant Com 30903 $212Con Nsl Hem Post Init 30905 $313Cor Trichiasis Epilation Forceps $166Cpr Management 92950 $642Critcare Facility Lvl 99291 $1,900Cystourethroscopy $1,221Cyststmy Tube Change 51705 $367Debr Muscle 1st 20 Sq Cm 11043 ED $631Debr Subc 1st 20 Sq Cm 11042 ED $405Debridement Skin/Muscle/Bone $739Declot W/Thromb Agent Imp Dvc $376

285 of 317 FY2018

DESCRIPTION CHARGES

Decompressive Fasciotomy Hand $2,738Drainage Of Arm Bursa $1,982Drn Abscess/Cyst Mouth Vestibule $1,281Elbow Dislocation 24600 $265Elbow Fx/Disl W/Man 24620 ED $255ER Visit Level 1 99281 ED $230ER Visit Level 2 99282 $450ER Visit Level 3 99283 $750ER Visit Level 4 99284 $900ER Visit Level 5 99285 $1,219EvAC Subung Hem 11740 $111Fast Exam Echo Exam Of Abdomen $255Fast Exam Tte F Up Or Limited $770Fem Fx Distal W/Man 27510 $255Fin/Th Dist Fx Open Tx26765 $5,613Fin/Th Fx Prxmid W 26725 ED $265Flapzplas Head<1014040 $2,122G Tube Change/Replace 43760 ED $524Gastr Lav/Int/Asp/Ng 91105 ED $255Hip Disl S/P Arthplsty27265 ED $700Hip Disl Spont W/O Man27256 ED $255Hip Disl Traumatic 27250 $276Hip Reduction Traumatic W/Anes $1,543Hum Fx Neck W/Man 23605 $2,122I&D Abs Bartholins 56420 $353I&D Abs Dentoalvelar 41800 $308I&D Abs Mouth Smple 40800 ED $308I&D Abscess Comp 10061 $535I&D Abscess Smp 10060 ED $339I&D Ext Ear Abs Smp 69000 ED $241I&D Fing Abs Deep Smp 26010 ED $241I&D Hematoma 10140 $1,781I&D Per/Ischrect Abs 46040 $2,680I&D Perianal Abs 46050 $519I&D Pilonid Cyst Cmp 10081 $1,781I&D Pilonid Cyst Smp 10080 ED $241I&D Scrotal Wall Abs 55100 $2,414

286 of 317 FY2018

DESCRIPTION CHARGES

I&D Vul/Perineal Abs 56405 ED $353Imm/Vacc Admin Ea Add 90472 ED $58Imm/Vacc Admin X 1 90471 ED $70Inc Thromb Hemrrd 46083 $616Inj Anesth Facial Nerve $368Inj Anesthetic Mult Ic Nerves $1,211Inj Anesthetic Trigeminal Nerve $336Inj Epidural/Blood Or Patch 62273 $777Inj Sgl/Mult Trigger 1 2 Muscles $460Inject Trigger Pts =/> 3 Muscles $460Injection Sq/Im ED $114Insert Non Indwel Blad Cath 51701 $254Intubate Endotrach 31500 $500Ip Joint Dislocation 28660 $265Irrig Corp Cavernosa For Priapsm $341Iv Infusion Addtl Seq Initial Hr ED $186Iv Infusion Concurrent ED $191IV Infusion Ea Addtl Hr X ED $159Iv Infusion Hydrate Ea Addtl Hr ED $159Iv Infusion Hydrate Initial Hr ED $345IV Infusion Initial Hour X ED $376Iv Inj/Iv Push Ea Addtl New Drug ED $186Iv Inj/Iv Push Initial/Single ED $212Laryngoscopy Direct Diagnostic $268Lavage Para/Peri/Abd 49080 $637Lavage Peri/Abd Sbsq 49081 $321Lumbar Puncture 62270 $624Mcp Disl W/Man 26700 ED $276Mcp/Ip Jt Fx W/Man 26742 ED $276Med Mall Fx W/Man 27762 $255Mod Sed <5 Yrs 1st 15 Min Same Md $100Mod Sed <5 Yrs 1st Min Diff Md $100Mod Sed >5 Yrs 1st 15 Min Diff Md $100Mod Sed >5yrs 1st 15 Min Same Md $100Mod Sed Each Add 15 Min Same Md $80Naso/Oro Gastric Tube 43752 $197Nasopharyngoscopy W/Endoscope $139

287 of 317 FY2018

DESCRIPTION CHARGES

Nerve Block Peripheral $584Non Tunneled VenoUS Cath 36556 $1,501Nursemaid Elbow W/Man 24640 ED $276Open Tx Artic Fx Mcp/IP Jt 26746 $4,976Open Tx Nasal Septal Fx $2,766PacER Tem Ext Trnscut 92953 $443Patellar Dislocation 27560 $265Place Needle IntraosseoUS Inf $267Punct Asp Abs/Hem 10160 ED $353Rad Hd/Neck Fx W/Man 24655 $255Rd/Ul Dist Fx W/O Man 25600 ED $265Rd/Ul Distal Fx W/Man 25605 $651Rd/Ul Shft Fx W/Man 25565 $371Reduction S/P Hip Arthroplasty $1,543Removal Of Iud $441Rep Ext Tendon Hand $2,317Rep Ext Tendon/Finger $2,652Rep Flexor Tdn Prim/Sec Wo Graft $2,986Rep Tongue/Mth Fl<2.5 41250 ED $308Rep/Reconst Finger Volar Plate Ip $2,782Repair Lip Vermilion 40650 $1,201Repair Mouth Vest<2.5 $436Repair Of Nail Bed 11760 $386Repos G Feedngtube 43761 $1,273Rfb Conj Superficl 65205 $265Rfb Cornea W/O Sl Lamp65220 ED $212Rfb Cornea W/Sl Lamp 65222 ED $265Rfb Ear Ext Canal 69200 $117Rfb Intranasal 30300 $117Rfb Sq Comp 10121 $2,222Rfb Sq Smp 10120 ED $402Rpr Coltrl Ligm Mtcarphlngl/Iphal $4,507Safe Exam $723Shld Dis W/Man 23650 ED $500Skin Tissue Rearrange $1,890Splt FingER 29130 $217Splt Long Arm 29105 $292

288 of 317 FY2018

DESCRIPTION CHARGES

Splt Long Leg 29505 $524Splt Short Arm 29125 $239Splt Short Leg 29515 $239Strap Ankle 29540 $202Strap Elbow/ Wrist 29260 $158Strap Hand/ Fing 29280 $158Strap Knee 29530 $279Strap Should/Clav 29240 $159Suture Dentoaveolar Structure $182Thoracntsis Ndle Asp W Guide $984Thrombolysis Cerebral By Iv Infus $655Tib(Fib) Fx Shft W/Man27752 $2,122TMJ Dislocation 21480 ED $308Toe OthER Fx W/Man 28515 ED $276Trimall Fx W/Man 27818 ED $750Tx Of Fracture LowER Leg $2,118Tx/Pro/Dx Inj Same Drug Add On $152Uln Shaft Fx W/Man 25535 $255Ulnar Styloid Fx 25650 $255Urethral Cath Comp 51703 $212Urethral Cath Smp 51702 ED $219US Fine Needle Asp 10021 ED $269wound repair Complx Ea Ad 5 13133 $318wound repair Complx Ea Ad 5 13153 $318wound repair Complx1.1 2.5 13120 ED $230wound repair Complx1.1 2.5 13131 ED $371wound repair Complx1.1 2.5 13151 ED $371wound repair Complx2.6 7.5 13132 ED $572wound repair Complx2.6 7.5 13152 ED $796wound repair Intrmd<2.5 12031 ED $265wound repair Intrmd<2.5 12041 ED $265wound repair Intrmd<2.5 12051 ED $521wound repair Intrmd2.6 5 12052 ED $341wound repair Intrmd2.6 7.5 12032 ED $292wound repair Intrmd2.6 7.5 12042 ED $292wound repair Intrmd5.1 7.5 12053 ED $254wound repair Intrmd7.6 12.5 12034 ED $318

289 of 317 FY2018

DESCRIPTION CHARGES

wound repair Intrmd7.6 12.5 12044 ED $230wound repair Intrmd7.6 12.5 12054 ED $318wound repair Smp<2.5 12001 ED $328wound repair Smp<2.5 12011 ED $364wound repair Smp>30 12007 ED $230wound repair Smp12.6 20 12005 ED $346wound repair Smp12.6 20 12016 ED $230wound repair Smp2.6 5 12013 ED $348wound repair Smp2.6 7.5 12002 ED $344wound repair Smp20.1 30 12006 ED $371wound repair Smp5.1 7.5 12014 ED $372wound repair Smp7.6 12.5 12004 ED $395wound repair Smp7.6 12.5 12015 ED $318Wound Care/Debr Skin(Only) <21cm ED $399Wound Dehis Simple 12020 $254

URGENT CARE CENTERSAc Jt Disl w/o Man 23540 $265Acetablr Fx w/o Man 27220 $265Administrative Physical $60Ankle Dislocation 27840 $265Arthrocentesis Int Jt 20605 $371Arthrocentesis Mjr Jt 20610 $424Avul Nail Plate Ea Add11732 $108Avulnail Plate 11730 $300Bimall Fx w/o Man 27808 $318Burn Tx Init Local 16000 $108Burn Tx Large 16030 $318Burn Tx Med 16025 $265Burn Tx Small 16020 $212Calcaneal Fx w/o Man 28400 $265Cardioversion External $798Cardioversion Int 92961 $801Carpal Fx w/o Man 25630 $265Cerumen Removal Unilat 69210 $127Chemical Cauterization $155

290 of 317 FY2018

DESCRIPTION CHARGES

Clavicle Fx W/Man 23505 $265Clavicle Fx w/o Man 23500 $265Close Tx Of Pha Joint Dislow/Anes $265Cmc Disloc W/Man 26670 $265Coccyx Fx 27200 $265Complex Wound Repair $777Con Nsl Hem Ant Com 30903 $212Con Nsl Hem Ant Smp 30901 $310Con Nsl Hem Post Init 30905 $340Con Nsl Hem Post Subsq30906 $212Cpr Management 92950 $477Crichothyrotomy Ndle 31605 $932Debr Bone 1st 20 Sq Cm 11044 $1,222Debr Bone Each Addtl 20 Sq Cm $1,241Debr Muscle 1st 20 Sq Cm 11043 $631Debr Muscle Each Addl 20 Sq Cm $399Debr Nails 1 5 11720 $97Debr Nails 6> 11721 $97Debr Open Fx/Disl Bon 11012 $900Debr Open Fx/Disl Mus 11011 $596Debr Open Fx/Disl Sq 11010 $710Debr Subc 1st 20 Sq Cm 11042 $405Debr Subc Each Addtl 20 Sq Cm $399Decomp Fing/Hand Inj 26035 $1,738Digital Nerve Block $584Ecg Tracing Without Interp $103Elbow Dislocation 24600 $265Elbow Fx/Disl W/Man 24620 $265Evac Subung Hem 11740 $150Exc Benign Lesion .6 1cm 11421 $212Exc Benign Lesion 0.5cm Or Less $771Exc Benign Lesion 1.1 2.0cm 11422 $771Exc.Ben.Les.Trunk Arm Leg06 1.0 $596Expl. Pentr Wd Extrem 20103 $550Fem Fx Distal w/o Man27508 $265Fem Fx Gtrtroc W/Oman27246 $265Fem Fx Int/Per/Sub W 27240 $174

291 of 317 FY2018

DESCRIPTION CHARGES

Fem Fx Int/Per/Sub W/O27238 $265Fem Fx Neck w/o Man 27230 $265Fem Fx Shaft w/o Man 27500 $265Fem Fx Supcond w/o Man27501 $265Fib Fx Prxshft w/o Man27780 $265Fin/Th Distal Fx W 26755 $265Fin/Th Distal Fx w/o 26750 $265Fin/Th Fx Prxmid W 26725 $265Fin/Th Fx Prxmid w/o 26720 $265Hip Disl S/P Arthplsty27265 $276Hip Disl Spont w/o Man27256 $265Hip Disl Traumatic 27250 $276Hum Cond Fx w/o Man 24576 $265Hum Epi Fx w/o Man 24560 $265Hum Fx Gtrtub W/Man 23625 $265Hum Fx Gtrtub w/o Man 23620 $265Hum Fx Neck w/o Man 23600 $265Hum Shaft Fx w/o Man 24500 $265I&D Abs Bartholins 56420 $336I&D Abs Dentoalvelar 41800 $293I&D Abs Mouth Smple 40800 $293I&D Abs Sublingual 41005 $276I&D Abs Submand 41008 $1,786I&D Abs Subment 41007 $1,786I&D Abscess Comp 10061 $475I&D Abscess Smp 10060 $300I&D Abscess Tongue 41000 $1,786I&D Conj Cyst 68020 $2,002I&D Ext Ear Abs Cmp 69005 $1,781I&D Ext Ear Abs Smp 69000 $500I&D Eyelid Abscess $550I&D Fing Abs Deep Cmp 26011 $1,297I&D Fing Abs Deep Smp 26010 $241I&D Hematoma Seroma Fluid Coll. $1,781I&D Perianal Abs 46050 $650I&D Pilonid Cyst Cmp 10081 $500I&D Pilonid Cyst Smp 10080 $241

292 of 317 FY2018

DESCRIPTION CHARGES

I&D Postop Wd Infec 10180 $1,781I&D Vul/Perineal Abs 56405 $336Imm/Vacc Admin Ea Add 90472 $55Imm/Vacc Admin X 1 90471 $60Inc Thromb Hemrrd 46083 $587Inj Anes Trigi Nerve $336Injection Im/Sq $111Injection Trigger Point 20552 $312Inser Non Indwelling Bladder Cath $230Intubate Endotrach 31500 $424Ip Joint Dislocation 28660 $265Ip Jt Disl W/Man Ea 26770 $308IV Infusion Addtl Seq Initial Hr $186IV Infusion Concurrent $191IV Infusion Hydrate Ea Addtl Hr $159IV Infusion Hydrate Initial Hr $345IV Infusion Of A Medication $371IV Inj/IV Push Ea Addtl New Drug $186IV Inj/IV Push Initial/Single $212Knee Dislocation 27550 $265Lat Mall Fx w/o Man 27786 $265Mand/Max Fx w/o Man 21440 $2,590Mandibula Fx w/o Man 21450 $276Mc Fx Ea W/Man 26605 $302Mc Fx Ea w/o Man 26600 $265Mcp Disl W/Man 26700 $276Mcp/Ip Jt Fx W/Man 26742 $276Mcp/Ip Jt Fx w/o Man 26740 $265Med Mall Fx w/o Man 27760 $265Mt Fx w/o Man 28470 $265Mtp Jt Dislocation 28630 $276Nasal Septal Fx 21337 $1,786Nasl Fx W/Man w/o Stb 21315 $276Nasl Fx W/Man W/Stab 21320 $932Nasl Fx w/o Man 21310 $276Nasomaxllry Fx W/Fix 21345 $2,590Nursemaid Elbow W/Man 24640 $276

293 of 317 FY2018

DESCRIPTION CHARGES

Orbit Fx w/o Man 21400 $932Paring/Cutting Lesion 11055 $108Patellar Dislocation 27560 $265Patellar Fx w/o Man 27520 $265Pelv Rng Fx/Dis w/o Man27193 $265Punct Asp Abs/Hem 10160 $279Rad Hd/Neck Fx w/o Man24650 $265Rad Shaft Fx W/Man 25505 $371Rad Shaft Fx w/o Man 25500 $265Rad Shaft Fx/Disl 25520 $265Rd/Ul Dist Fx w/o Man 25600 $265Rd/Ul Shft Fx w/o Man 25560 $265Rem Impac Cerum/Irrig/Lav/Uni $106Removal Of Skin Tags 11200 $300Remove Fb Subq Foot Simple $615Rep Mouth Vest <2.5 40830 $276Rep Mouth Vest >2.5 40831 $932Rep Tongue Post<2.5 41251 $276Rep Tongue/Mth Fl<2.5 41250 $350Rep Tongue/Mth Fl>2.6 41252 $932Repair Lip Vermilion 40650 $1,143Repair Of Nail Bed 11760 $254Rfb Conj Embedded 65210 $210Rfb Conj Superficl 65205 $265Rfb Cornea w/o Sl Lamp65220 $250Rfb Cornea W/Sl Lamp 65222 $265Rfb Ear Ext Canal 69200 $175Rfb Embedded Mouth 40804 $91Rfb Eyelid Embedded 67938 $210Rfb Intranasal 30300 $150Rfb Pharynx 42809 $117Rfb Sq Comp 10121 $1,667Rfb Sq Smp 10120 $318Scaphoid Fx w/o Man 25622 $265Scapular Fx w/o Man 23570 $265Sequential Intravenous Push $152Sesamoid Fx 28530 $265

294 of 317 FY2018

DESCRIPTION CHARGES

Shaving Of Epidermal 0.5 11305 $163Shld Dis Fxgrtub W/Man23665 $265Shld Dis Fxneck W/Man 23675 $265Shld Dis W/Man 23650 $424Splt Finger 29130 $186Splt Long Arm 29105 $292Splt Long Leg 29505 $292Splt Short Arm 29125 $239Splt Short Leg 29515 $239Sports Physical $45Sternclv Disl w/o Man 23520 $265Sternum Fx 21820 $265Strap Ankle 29540 $158Strap Elbow/Wrist 29260 $158Strap Hand/Fing 29280 $158Strap Knee 29530 $158Strap Toes 29550 $158Strapping Thorax $224Supracond Fx W/Man 24535 $265Supracond Fx w/o Man 24530 $265Sut Eyelid Wd Ful Thck67935 $2,002Sut Eyelid Wd Par Thck67930 $2,002Talotarsal Disl 28570 $265Talus Fx w/o Man 28430 $265Tarsal Disl 28540 $265Tarsal Fx w/o Man 28450 $265Thum/Cmc Disl W/Man 26641 $265Thum/Cmc Fx/Dis W/Man 26645 $265Tib Fx Prox w/o Man 27530 $265Tib(Fib) Fx Shft w/o 27750 $265Tib/Fib Prox Disl 27830 $265Tissue Adhesive Repair G0168 $49Tmj Dislocation 21480 $293Tmt Joint Dislocation 28600 $265Toe Great Fx W/Man 28495 $265Toe Great Fx w/o Man 28490 $265Toe Other Fx W/Man 28515 $276

295 of 317 FY2018

DESCRIPTION CHARGES

Toe Other Fx w/o Man 28510 $265Treat Fracture Radius $2,859Trimall Fx W/Man 27818 $265Trimall Fx w/o Man 27816 $265 Visit Level 1 Type B $190 Visit Level 2 Type B $270 Visit Level 3 Type B $320 Visit Level 4 Type B $400 Visit Level 5 Type B $450Uln Fx Prox w/o Man 24670 $265Uln Shaft Fx w/o Man 25530 $265Ulnar Styloid Fx 25650 $265Urethral Cath Comp 51703 $212Urethral Cath Smp 51702 $230Vertebral Body Fx 22310 $265Vertebral Process Fx 22305 $265wound repair Complx<1.0 13150 $345wound repair Complx1.1 2.5 13100 $213wound repair Complx1.1 2.5 13120 $254wound repair Complx1.1 2.5 13131 $371wound repair Complx1.1 2.5 13151 $371wound repair Complx2.6 7.5 13101 $677wound repair Complx2.6 7.5 13121 $424wound repair Complx2.6 7.5 13132 $424wound repair Intrmd<2.5 12031 $265wound repair Intrmd<2.5 12041 $325wound repair Intrmd<2.5 12051 $325wound repair Intrmd>30 12037 $677wound repair Intrmd>30 12047 $677wound repair Intrmd>30 12057 $677wound repair Intrmd12.6 20 12035 $371wound repair Intrmd12.6 20 12045 $254wound repair Intrmd12.6 20 12055 $254wound repair Intrmd2.6 5 12052 $350wound repair Intrmd2.6 7.5 12032 $350wound repair Intrmd2.6 7.5 12042 $350wound repair Intrmd20.1 30 12036 $254

296 of 317 FY2018

DESCRIPTION CHARGES

wound repair Intrmd20.1 30 12046 $254wound repair Intrmd20.1 30 12056 $254wound repair Intrmd5.1 7.5 12053 $280wound repair Intrmd7.6 12.5 12034 $318wound repair Intrmd7.6 12.5 12044 $254wound repair Intrmd7.6 12.5 12054 $318wound repair Smp<2.5 12001 $270wound repair Smp<2.5 12011 $270wound repair Smp>30 12007 $254wound repair Smp>30 12018 $254wound repair Smp12.6 20 12005 $340wound repair Smp12.6 20 12016 $254wound repair Smp2.6 5 12013 $325wound repair Smp2.6 7.5 12002 $325wound repair Smp20.1 30 12006 $371wound repair Smp20.1 30 12017 $280wound repair Smp5.1 7.5 12014 $350wound repair Smp7.6 12.5 12004 $340wound repair Smp7.6 12.5 12015 $318Wdg Exc Skn Nailfld 11765 $300Wnd Dehis Sim W/Pack 12021 $424Wound Care/Debr Skin (Only) <21cm $219Wound Care/Debr Skin Ea Adtl 20cm $219Wound Dehis Simple 12020 $254

GI LAB24 Hour Ph Study $613Agile Patency Procedure $248Anoscopy $900Biliary Dilation $845Biopsy $280Bravo Ph Study $912Capsule Endoscopy $1,992Cauterization Chemical GI Lab $155Colon Decompression $928Colonic Wall Stent Placement $990Colonoscopy Limited $361

297 of 317 FY2018

DESCRIPTION CHARGES

Colonoscopy Pediatric $2,000Colonoscopy W/EUS $2,000Colonoscopy W/EUS W/FNA $2,500Colonoscopy. $2,000Contrl of Bleeding EGD $2,000Contrl of Bleedng Colon $2,000CPR Management 92950 $557Dilation Maloney $147Dilation Rigiflex $250Dilation Savary $250DISE $865Duodenal Wall Stent Placement $598EGD W/EUS $2,300EGD W/EUS of Esophagus $2,300EGD W/EUS of Esophagus W/FNA $2,500EGD W/EUS W/FNA $2,500Enteral Stent Placement $990ERCP $2,854Esophageal Motility $1,000Esophageal Wall Stent Placement $598Esophagoscopy $569Esophagoscopy W/EUS Exam $2,300Esophagoscopy W/EUS FNA $2,500Fecal Disimpaction $760Fecal Transplant $1,002Flexible Sigmoidoscopy. $500Foreign Body Removal $700Ileoscopy $600Ligation of Varices $636Limited Esophageal Motility $400Lithotripsy of Calclus $845Needle Bone Marrow Aspiration $1,385P.E.J. $832Panendoscopy ( Upper Endoscopy). $1,700Panendoscopy Pediatric $1,700Peg $832Peg Replacement $300

298 of 317 FY2018

DESCRIPTION CHARGES

Polypectomy $386Rectal Suction Biopsy $1,600Small Bowel Endoscope $1,700Small Intesting Stent Placement $990Sphincterotomy $353Spyglass Direct Visual of Cbd $1,200Stent Placement $845Stone Extraction $845Upper GI Stent Placement $598

ANESTHESIAAnes Expense 15 Min $172Anes Expense 30 Min $230Anes Expense 45 Min $287Anes Expense 1 Hr $327Anes Expense 1 Hr 15 Min $402Anes Expense 1 Hr 30 Min $425Anes Expense 1 Hr 45 Min $470Anes Expense 2 Hrs $528Moderate Sedation First 15 Minute $100Moderate Sedation Ea Addl 15 Min $80

HYPERBARIC MEDICINEAmputation Of Toe $2,073Arthrocentesis Sm Jnt (Fngr/Toe) $352Arthrocntsis Int Jnt Wrst Ankl El $419Arthrocntsis Mjr Jnt Knee Hip Shl $419Biospy Bone Open Deep $3,285Burn Debridement Lg >10% $318Burn Debridement Med 5 10% $265Burn Debridement Sm <5% $212Cauterization Chemical $155Cmplx Repair Arms Legs 1.1 2.5cm $230Cmplx Repair Arms Legs 2.6 7.5cm $424Debr Bone 1st 20 Sq Cm 11044 $1,379Debr Bone Each Addtl 20 Sq Cm $1,241Debr Muscle 1st 20 Sq Cm 11043 $631

299 of 317 FY2018

DESCRIPTION CHARGES

Debr Muscle Each Addtl 20 Sq Cm $399Debr Subc 1st 20 Sq Cm 11042 $372Debr Subc Each Addtl 20 Sq Cm $399Debridement Of Nails 6 Or More $148Ea Additional 5cm Or Less $318Exc Lesion Tendon/Capsule Foot $3,200Exc Of Nail/Matrix Part Or Compl $637Excision Lesion 0.6 1.0cm $596Hyperbaric Oxygen Established Patient Level 1 $129Hyperbaric Oxygen Established Patient Level 2 $180Hyperbaric Oxygen Established Patient Level 3 $232Hyperbaric Oxygen Established Patient Level 4 $270Hyperbaric Oxygen Established Patient Level 5 $309Hyperbaric Oxygen New Patient High Level $407Hyperbaric Oxygen New Patient Level 1 $155Hyperbaric Oxygen New Patient Level 2 $198Hyperbaric Oxygen New Patient Level 3 $242Hyperbaric Oxygen New Patient Level 4 $324Incision & Drainage Of Abscess $241Incison & Drainage Of Hematoma $1,781Inj Nerve Block Other Periph $584Multi Layer Comp Arm/Hand/Fingers $203Multi Layer Comp Leg Below Knee $203Nail Debridement Any Method 1 5 $149Neg Pressure Wound Therapy >50cm $299Neg Pressure Wound Therapy 50 Cm $149NPWT Disposable <=50cm $550NPWT Disposable >50cm $550Par/Cut Hyperkerat Lesion > 4 Les $232Par/Cut Hyperkerat Lesion 2 4 Les $199Par/Cut Hyperkerat Lesion Single $166Prep Ft/Dgt/Face Ea Addl 100sqcm $777Prep Ft/Digit/Face/Scalp <101sqcm $777Prep Trk/Arm/Leg Ea Addl 100 Sqcm $777Prep Trunk/Arm/Leg<101 Sq Cm $777Puncture Abscess Hematoma Bulla $279Removal Of Nail Plate Ea Add'l $143

300 of 317 FY2018

DESCRIPTION CHARGES

Removal Of Nail Plate Sngl Nail $149Repair Suprfcl Wnds 12.6cmto20cm $254Skin Graft All Other <100/25cm $583Skin Graft All Other <100/Add25cm $2,149Skin Graft All Other>100/100cm $888Skin Graft All Other>100/Add100cm $583Skin Graft Tk/Arm/Leg <100/25cm $583Skin Graft Tk/Arm/Leg <100/Add 25 $215Skin Graft Tk/Arm/Leg >100/100cm $888Skin Graft Tk/Arm/Leg >100/Add100 $583Smpl Repair Superficial Wnd >30cm $254Smpl Repair Suprfcl Wnd 2.6 7.5cm $254Smpl Repair Suprfcl Wnd 20.1 30cm $254Smpl Repair Suprfclwnd 7.6 12.5cm $254Smpl Repair Suprficial Wnd <2.5cm $254Smpl Repr Suprfcl Wnd 12.6 To 20c $241Tenotomy Perc Toe Mult Tendons $1,715Tenotomy Perc Toe Single Tendon $1,695Total Contact Casting $351Trim Dystophic Nails Any Number $143Trim Nondystophic Nails Any Nmbr $111Unaboot Application Per Leg $157Wound Care/Debr Skin Ea Adtl 20cm $301Wound Care/Debr Skin(Only) <21cm $250

ADULT DOWN SYNDROME CLINICNew Patient, Age 18-39 (99385) $341New Patient, Age 40-64 (99386) $341New Patient, Low Complexity (99203) $242New Patient, Moderate Complexity (99204) $199Established Patient, Age 18-39 (99395) $231Established Patient, Age 40-64 (99395) $231Established Patient, Low Complexity(99213) $232Established Patient, Moderate Complexity (99214) $188

ANTI COAGULATION CLINIC

301 of 317 FY2018

DESCRIPTION CHARGES

Low Level (CPT 99201) $150Low Level (CPT 99211) $155Mid Level (CPT 99203) $235Mid Level (CPT 99213) $225High Level (CPT 99205) $420High Level (CPT 99215) $300

VASCULAR ACCESSDeclot Vascular Access $448VAD Angioplasty Cntrl Via AV Accs $7,960VAD AV Fistula Autogen Graft $6,990VAD AV Fistula NonAutogen Graft $6,990VAD Central Line Placement 36556 $1,501VAD Contrast Injection of CVA Device $509VAD CVA Injection Lytic Injection $448VAD Decloting Implant Vasc Access 36550 $448VAD Embolization $11,470VAD ESTABLISHED PT HIGH LEVEL E/M $309VAD Established Pt Low Level E/M $116VAD Established Pt Mid Level E/M $232VAD Exchange Non Tunnel Cath $1,967VAD Fine Needle Asp w/Imaging $651VAD Incision and Drainage Abcess Simple $265VAD Insert CV Device w/Port 36571 $3,614VAD Insert NonTunnel CV w/o Port 36558 $3,614VAD Insert Peritoneal Drain Cath 49421 $4,112VAD Insert Tun CV 2Cath w/oPort 36565 $4,217VAD Insert Tunnel CV Dev w/Port 36561 $3,967VAD Intro Cath SVC or IVC 36010 $1,015VAD Intro Ndl Angioplasty $10,354VAD Intro Ndl AV Shunt $2,394VAD Intro Ndl Stent Placement $19,346VAD Intro Ndl Thromb Angioplasty $15,158VAD Intro Ndl Thromb Stenting $24,149VAD Intro Ndl Thrombectomy $7,198VAD Intro Needle Extremity Art 36140 $501VAD Intro Needle into Vein $30

302 of 317 FY2018

DESCRIPTION CHARGES

VAD Laparoscopy w/wo Specimen 49320 $4,472VAD New Patient Low Level E/M $155VAD New Patient Mid Level E/M $242VAD NEW PT HIGH LEVEL E/M $407VAD Non AV Arterial Angioplasty $9,672VAD Non AV Venous Angioplasty $10,158VAD Open Thrombectomy w/o Revision $6,990VAD Peritoneal Cavity Injection $422VAD PICC Line Placement 36569 $1,626VAD Port Repair $1,967VAD Puncture Aspiration of Abcess/Hematoma $279VAD Removal CV Access Device 36590 $1,967VAD Removal Declot CV Catheter 36596 $1,343VAD Removal Pericath Fibrin Sheath 36595 $3,156VAD Removal Port $1,967VAD Removal Tunnel CV Cath w/o Rad Exam $1,280VAD Removal Tunnel CV Cath w/RadExam $1,280VAD Remove Peritoneal Drain Cath 49422 $3,566VAD Renal Bx Perc 50200 $1,087VAD Repair Blood Vessel 35206 $5,166VAD Repair Tunnel Cath w/o Rad Exam $1,021VAD Repair Tunnel Catheter w/Rad Exam $1,021VAD Replace CV Device w/Port 36578 $3,156VAD Replace NonTunnel CV w/o Port 36580 $1,967VAD Replace Tunnel CV w/o Port 36581 $3,414VAD Replace Tunnel CV w/Port 36582 $4,291VAD Reposition Central Line. $1,967VAD Rev AV Fistula w/o Thrombectomy $6,990VAD Rev Open w/ Thrombectomy $6,990VAD SECONDARY PERC TRANSL THROMB ART $3,989VAD Sel Cath Venous 1st Order 36011 $557VAD Sel Cath Venous 2nd Order 36012 $622VAD Stent Central Via AV Access $16,952VAD SUTURE REPLACEMENT $70VAD Venography Inj 36005 $569

SURGERY

303 of 317 FY2018

DESCRIPTION CHARGES

Abdominoplasty $2,514AFFIRM 3D BREAST BIOPSY $3,754AFFIRM 3D BREAST NEEDLE LOC $1,496AFFIRM 3D BREAST NEEDLE LOC ADDL $987AFFIRM STEREOTACTIC BREAST BIOPSY $3,754Aspiration Known Donor SSD $1,500Aspiration Multiple Ovarian Cysts $6,050Aspiration Multiple Ovarian Cysts Infertility $6,050Aspiration Of Eggs And Freezing SSD $4,400Aspiration Of Ovarian Cyst SSD $1,545Axillary Nerve SSD $367Blepharoplasty Four Lid $1,544Blepharoplasty Two Lid $1,047BONE BIOPSY BX SUPERFICIAL $2,500BONE MARROW BIOPSY WO IMAGING $1,800Brachial Plexus SSD $367BREAST AUGMENTATION $1,714Breast Biopsy MR $1,397Bronchscopy C Arm Linear NPR SSD $7,418Bronchscopy C Arm W/Bx NPR SSD $7,418Bronchscopy C Arm W/Navigation NPR SSD $7,418Bronchscopy W/Perc Trach NPR SSD $7,418Browlift Endoscopic ENT $1,323Browlift Endoscopic PLS $1,323Capsulotomy Eye SDS-29950 $1,870Cataract Extraction by Phacoemulsification $4,356Cataract Extraction by Phacoemulsification Intraocular Lens Implant $4,356Cataract Extraction Pediatric $4,356Cerv Thor Facet Jnt 2nd-Fl $1,093Cervical Or Thoracic Epidural SSD $891Cervical/Thoracic Epidural W/Cath SSD $891Choroidal Biopsy Vitreal Approch $6,927Cosmetic Mult Proc Ea Adtl 30 Min SSD $375Cosmetic Multiple Proc 0 30 Min SSD $500CT GUIDE RF ABLATION LUNG $1,854Diagnostic Testicular Biopsy SSD $2,000

304 of 317 FY2018

DESCRIPTION CHARGES

DIGITAL BRST NEEDLE LOC EACH ADDL $687DIGITAL BRST NEEDLE LOCALIZATION $1,462Drain Hematoma/seroma/or fluid $674Drainage of Breast Lesion ea Addl $245ECMO/LVAD Daily Management SSD $4,015ECMO/LVAD Initiation SSD $5,446Egg Maintenance Fee Annually SSD $250Embryo Freeze/Thaw SSD $4,400Embryo Maintenance Fee SSD $250EMERGENCY SURGERY Add on $756Endometrial Scratch Procedure $150Exam Under Anesthesia INF $400Femoral Nerve Single SSD $703Femoral Nerve With Catheter SSD $367FIDUCIAL MARKER PLACEMENT $2,967Fine Needle Asp w/Imag Guid $651FLUORO IN OR RM 0-30 MINUTES $493FLUORO IN OR RM 31-60 MINUTES $493FLUORO IN OR RM 61-120 MINUTES $723FLUORO IN OR RM OVER 120 MINUTES $962Freezing Sperm SSD $115Frozen Eggs (ICSI/ICU) SSD $4,400Frozen Eggs ICSI/No Transfer SSD $1,200Frozen Embryo Iuc SSD $2,000Frozen Embryo Zift SSD $4,400Inj Therapeutic Substance $146Insert Urinary Catheter $159Interdiscal Perq Aspir Dx $1,013Intrauterine Cannulization $2,000Intrauterine Cannulization with Embryo Transfer $2,000Iridectomy Eye-29950 $1,870Iridotomy SDS-29950 $1,870Liver Biopsy $960Lumbar Epidural W/Cath SSD $891Lumbar EpiduralSSD $1,873Lumbar Plexus W/Catheter SSD $367Lung Aspiration $535

305 of 317 FY2018

DESCRIPTION CHARGES

Lung Biopsy $873Mamm Breast Wire Placement $916Micro Vasectomy Reversal SSD $6,050Microsurgical Epididymal Sperm Aspiration $3,000Microsurgical Epididymal Vasal Reconstruction $2,000Microsurgical Vasovasotomy $6,050Min Simulation W/Freezing (Zift) SSD $4,000Min Stim W/Freezing (ICSI ICU) SSD $6,050Min Stimulation W/Freezing (ICSI) SSD $4,000Min Stimulation W/Freezing (ICU) SSD $2,050Mini Denmark IVF SSD $6,050Mini Laparotomy Aspiration Multiple Ovarian Cysts Oocyte And Sperm Transfer $6,050Mini Laparotomy Diagnostic $2,300Mini Laparotomy Ovarian Tissue Freeze $2,060Mini Laparotomy Ovarian Tissue Transplant Donor $2,700Mini Laparotomy Ovarian Tissue Transplant Recipient $2,700MOD PORP MICRON OCTR $1,873MOHS Procedure SDS $877Muscle Biopsy, Percu Needle $732Oper Microscope Use Of Neuro SSD $880Operarting Room Level III Ea Adtl 30min SSD $1,415Operarting Room Level IV 0 30 Min SSD $2,701Operating Room Level I 0 30 Min SSD $1,582Operating Room Level I Each Adtl 30min SSD $1,107Operating Room Level II 0 30 Min SSD $2,036Operating Room Level II Ea Adtl 30 Min SSD $1,206Operating Room Level III 0 30 Min SSD $2,424Operating Room Level IV Ea Adtl 30 Min SSD $1,507Other Periph Nerve/Branch Block SSD $336Ovarian Tissue Freeze Minilap SSD $2,060Ovarian Tissue Maintenance Fee SSD $250Parotid Gland Aspiration $1,681PERFUSIONIST TIME 2 1/2 HRS $1,246PERFUSIONIST TIME 2 HRS $1,031PERFUSIONIST TIME 3 1/2 HRS $1,676PERFUSIONIST TIME 3 HRS $1,461

306 of 317 FY2018

DESCRIPTION CHARGES

PERFUSIONIST TIME 4 1/2 HRS $2,423PERFUSIONIST TIME 4 HRS $2,175PERFUSIONIST TIME 5 1/2 HRS $2,917PERFUSIONIST TIME 5 HRS $2,670PERFUSIONIST TIME 6 1/2 HRS $3,412PERFUSIONIST TIME 6 HRS $3,165PERFUSIONIST TIME 7 1/2 HRS $3,907PERFUSIONIST TIME 7 HRS $3,660PERFUSIONIST TIME 8 1/2 HRS $4,402PERFUSIONIST TIME 8 HRS $4,155PERFUSIONIST TIME ADD 1/2 HRS $247Procedure Done Outside Or SSD $796Punc/Asp Abs/Hema/Bulla/Cyst $279Puncture Aspiration Cyst Breast $445Recp Anonymous/Known Donor SSD $1,800Renal Aspiration $960Renal Biopsy $1,087Rhinoplasty ENT $1,323Rhinoplasty PLS $1,323Sciatic Nerve SSD $367Soft Tissue Neck Biopsy $895SP Abcess/Cyst Cath Exchange $2,500SP ABD PARACENTESIS W/O IMAGING $536SP ABD PARACENTESIS WITH IMAGING $1,289SP ABD RETROPERITONEAL BX PERC $518SP Abdominal Seroma Cath Place $2,642SP Abscess Drain Ovarian Perc $1,476SP ABSCESS DRAIN OVARIAN PERC $2,546SP ANGIO CEREB CAROTID LT-1ST ORD $4,422SP ANGIO CEREB CAROTID LT-2ND ORD $10,000SP ANGIO CEREB CAROTID RT-2ND ORD $4,476SP ANGIO CEREB CAROTID RT-3RD ORD $10,000SP ANGIO CERV CAROTID LT-1ST ORD $4,422SP ANGIO CERV CAROTID RT-2ND ORD $4,476SP ANGIO CERVICOCEREBRAL/ARCH $4,775SP ANGIO EXTER CAROTID LEFT $4,754SP ANGIO EXTER CAROTID RIGHT $4,754

307 of 317 FY2018

DESCRIPTION CHARGES

SP ANGIO RENAL BILAT $6,327SP ANGIO RENAL BILAT SUPERSEL $4,703SP ANGIO RENAL UNI SUPERSEL $4,703SP ANGIO VERT UNI-1ST ORD $4,422SP ANGIO VERT UNI-2ND ORD $4,476SP ANGIOGRAM RENAL UNI $4,678SP ANGIOPLASTY CENTRAL VIA AV ACCESS $7,960SP Appendiceal Abscess Drain $505SP APPENDICEAL ABSCESS DRAIN $2,546SP BALLOON DILIT URETRAL STRICT $2,394SP BILIARY DRN TO STENT W/WO CHOL $5,200SP Biliary Endo W/WO Bx Brush $476SP BILIARY ENDOSCOPY W/ BX $606SP BILIARY ENDOSCOPY W/ DUCT DILAT $1,094SP BILIARY ENDOSCOPY W/ STENT DIL $1,714SP BILIARY ENDOSCOPY W/ STONE REMVL $1,076SP BILIARY INTRO DRN WWO CHOLANG $4,397SP BILIARY INTRO STENT W/WO CHOLA $7,168SP BILIARY REMV DRN/STNT WWO CHOL $2,400SP BILIARY STENT PLACEMENT $4,445SP BILIARY STENT TO DRN W/WO CHOL $3,672SP BILIARY STONE REMOV PERC W/IMG $2,515SP BILIARY XCHG DRN/STNT WWO CHOL $4,121SP Bone Ablation $2,562SP BONE BX DEEP $2,500SP Bone Bx Superficial $646SP BONE CYST ASPIRATION/INJECTION $186SP Bone Marro Asp w Bone Mar Bx $117SP Bone Marrow Aspiration $641SP BRACHEOCEPHALIC ATHERECTOMY $1,209SP BREAST ABSCESS DRAINAGE $1,885SP Bx Back/Flank Superficial $496SP BX BACK/FLANK SUPERFICIAL $496SP Cannula Declot W/ Balloon $693SP Cannula Declot W/O Balloon $559SP CATH VENOUS BLOOD SAMPLING $340SP Celiac Plexus Neurolysis $873

308 of 317 FY2018

DESCRIPTION CHARGES

SP CENTRAL LINE PLACEMENT $1,219SP CHEMICAL PLEURODESIS $964SP CHOLANGIOGRAM PTC W/INJ $1,468SP CIST/LAT CERV PUNCTURE W/INJ $570SP CONTRAST INJ EVAL OF GI TUBE $400SP CORPORA CAVERNOSA INJ $246SP CORPORA CAVERNOSA INJ PHARM $145SP CORPORA CAVERNOSA IRRIGATION $385SP CVA INJECT/CHECK $448SP CVP CATH PLACEMENT REPOSITION $1,967SP CYSTOSTOMY TUBE CHANGE SIMP $574SP Decloting Implant Vasc Acces $448SP DRAIN PELVIC ABSCESS PERCUTAN $2,000SP EMBOLIZATION - AV SHUNT $11,470SP Embolization AVM Spinal $1,476SP Epidural Blood Patch $792SP FALLOPIAN TUBE CATH $3,500SP FASCIOTOMY FOOT/TOE $437SP FEEDING TUBE REPOSITION $1,273SP FEM-POP ANGIOPLASTY $6,441SP FEM-POP ATHERECTOMY $14,976SP FEM-POP STENT AND ATHERECTOMY $23,967SP FEM-POP STENT PLACEMENT $15,433SP FOREIGN BODY RETRIEVAL - PERC $4,200SP GASTRO J TUBE CHANGE $1,000SP GASTROSTOMY TUBE CHANGE $372SP GASTROSTOMY TUBE PLACEMNT PERC $2,300SP GI TUBE INTRO $223SP Gift SSD $6,050SP HIP/PELVIS ABSCESS DRAIN $643SP HYBRID >120 MINUTES $962SP HYBRID 31 - 60 MINUTES $493SP HYBRID 61 - 120 MINUTES $723SP HYBRID ANGIOPLASTY EACH ADD $1,671SP HYBRID ANGIOPLASTY PERIPH $3,656SP HYBRID ATHERECT EA ADD ARTERY $1,323SP HYBRID ATHERECTOMY 1ST ARTERY $2,390

309 of 317 FY2018

DESCRIPTION CHARGES

SP HYBRID TRANSCATH STENT $2,968SP HYBRID UP TO 30 MINUTES $280SP HYSTEROSALPINGOGRAM INJ $528SP ICSI Ebx ICU SSD $6,050SP ICSI ICU Day 1 SSD $4,840SP ICSI ICU Day 2 SSD $1,210SP ICSI Zift SSD $6,050SP ILIAC ANGIOPLASTY EACH ADDL $4,456SP ILIAC ANGIOPLASTY INITIAL $6,441SP ILIAC ARTERY ATHERECTOMY EACH $3,380SP ILIAC STENT PLACEMENT EACH ADD $11,038SP ILIAC STENT PLACEMENT INITIAL $15,433SP INCISION & DRAINAGE ABSCESS $333SP INJ CONTRAST PREV PLACE CATH $261SP INJ TRANSFOR EPI CERV/THO SING $1,463SP INJ TRANSFOR EPI LUM/SAC SING $1,463SP Inject for Mammory Ductogram $441SP INJECT OF SINUS TRACT $450SP Injection one or two muscles $528SP INSERT CANNULA VEIN TO VEIN $350SP INSERT GASTROSTOMY TUBE PERC $2,284SP INSERT TUN IP CATH FLUORO GUID $4,000SP INSERT TUN IP W/ US GUIDE $3,914SP INSERT TUNNEL CV DEV W/PORT W/IMAGING $3,967SP Insert Tunnel CV W/O Port $3,156SP INSERT TUNNEL CV W/O PORT $3,614SP INSERT TUNNELED PLEURAL CATH $3,000SP Insertion of Suprapubic Cath $2,449SP INTRA INFUS PUMP INSERTION $836SP INTRA INFUS PUMP REMOVAL $1,967SP INTRA INFUS PUMP REVISION $1,021SP INTRO CATH AORTA $1,746SP INTRO CATH PULMONARY ARTERY $340SP INTRO CATH SVC OR IVC $1,015SP INTRO NEEDLE AORTA TRANSLUMBAR $439SP INTRO NEEDLE AV SHUNT $2,394SP INTRO NEEDLE BRACHIO ART RETRO $501

310 of 317 FY2018

DESCRIPTION CHARGES

SP INTRO NEEDLE CAROTID/VERT ART $169SP INTRO NEEDLE EXTREMITY ART $580SP INTRO NEEDLE W/ANGIOPLASTY $10,354SP INTRO NEEDLE W/STENT PLACEMENT $19,346SP INTRO NEEDLE W/THROMB AND ANGIOPLASTY $15,158SP INTRO NEEDLE W/THROMB AND STENTING $24,149SP INTRO NEEDLE W/THROMB/STNT/PTA $32,109SP INTRO NEEDLE W/THROMBECTOMY $7,198SP IVC FILTER PLACEMENT PERC $5,929SP IVC FILTER REMOVAL W/FLUORO $7,000SP IVF ICU SSD $6,050SP JEJUNOSTOMY TUBE $1,416SP Jejunostomy Tube Change $1,886SP KYPHO EA ADTL LEV THOR/LUMB $7,371SP KYPHOPLASTY LUMBAR $13,525SP KYPHOPLASTY THORACIC $13,525SP LIVER ABSCESS DRAINAGE $2,546SP LIVER BX W/ OTHER PROCEDURE $272SP LIVER BX PERC $2,000SP LOOPOGRAM INJ $138SP LOWER EXT VESSEL W/ GRAFT $1,441SP LUMBAR DISC ASPIRATION $1,041SP LUNG OR MEDIASTINUM BX PERC $1,000SP LYMPHANGIOGRAM INJ $543SP Mech Thromb Vein w/Pharm $3,989SP MECHANICAL RMVL OBST MATERIAL $900SP MUSCLE BX PERCUTANEOUS $179SP NASO/ORO-GASTRIC TUBE PLACE $700SP NEPH STENT BASKET EXT PERC <2 $2,041SP NEPH STENT BASKET EXT PERC >2 $2,674SP NEPHROSTOGRAM IN OR $398SP NEPHROSTOGRAM VIA EXIST CATH $2,113SP NEPHROSTOGRAM VIA NEW ACCESS $5,864SP NEPHROSTOMY DILATION PERC $2,000SP NEPHROSTOMY EXCH WWO NEPHROSTO $4,930SP NON-AV ACCESS ARTERIAL ANGIOPLASTY $10,171SP Occlusion Femoral Vein Perc $1,078

311 of 317 FY2018

DESCRIPTION CHARGES

SP Occlusion Iliac Vein Perc $1,078SP PANCREAS BX PERC $2,000SP PANCREAS DRAINAGE PERC $2,546SP PANCREATIC ANASTOMOSIS $1,496SP Perc Asp. Spinal Cord/syrinx $1,305SP PERC TRANS MECH THROMB VEIN $3,989SP PERCUTANEOUS CHOLECYSTOSOMY $3,800SP PERCUTANEOUS REPLACEMENT JTUBE $2,304SP PERICARDIOSTOMY TUBE $1,650SP PERITONEAL ABSCESS DRAIN PER $2,546SP PERITONEAL CAVITY INJ $422SP PERITONEAL LAVAGE $1,289SP PERITONEAL VENOUS SHUNT INJ $117SP PICC PLACEMENT $1,626SP PICC REPLACMNT SAME VAIN $1,937SP PLEURA BX PERCUTANEOS W/IMAGING $338SP PLEURA BX PERCUTANEOUS $338SP PLEURAL DRAINAGE TUBE/IMAGING $1,854SP PLEURODESIS $964SP PORTAL VEIN CATH PERC $1,013SP PORTOCAVAL VENOUS ANASTOMOSIS $3,349SP PRIMARY PERC TRANS MECH THROMB $3,989SP PUNCTURE ASP AB $279SP PUNCTURE ASP AB/HE/BU/CYST W/IMAGING $279SP REMOVAL CV ACCESS DEVICE $1,967SP REMOVAL CV ACCESS DEVICE W/IMAGING $1,967SP Removal Tunnel CV Catheter $1,280SP REMOVAL TUNNEL PLEURAL CATH $1,031SP RENAL ARTERY ATHERECTOMY $17,390SP RENAL BX PERC W/IMAGING $1,087SP RENAL CATH INTR W/WO NEPHROSTO $5,864SP RENAL CYST ASP/INJ/ PERC $2,000SP Replace CV Device W/Port $3,156SP REPLACE G TUBE PERC W/FLUORO $1,084SP REPLACE J TUBE PERC W/FLUORO $1,084SP REPLACE NONTUNNEL CV W/O PORT $1,967SP REPLACE TUNNEL CV W/O PORT $3,414

312 of 317 FY2018

DESCRIPTION CHARGES

SP RETROPERI ABSCESS DRAIN PERC $2,546SP SACROPLASTY BILATERAL W/GUIDE $5,000SP SACROPLASTY UNILATERAL W/GUIDE $4,989SP SCLEROSING SOLUTION MULT INJ $915SP SCLEROSING SOLUTION SINGLE INJ $69SP SCLEROTHERAPY CYST W/IMAGING $1,884SP Second and all Subse Vessels $3,989SP Secondary Perc Trans Thromb $3,989SP SEL CATH ABD/PEL EXT ART 1ST $2,500SP SEL CATH ABD/PEL EXT ART 2ND $1,561SP SEL CATH ABD/PEL EXT ART 3RD $1,788SP SEL CATH ABD/PEL EXT ART ADDL $313SP SEL CATH BRACH ART 1ST ORDER $1,393SP SEL CATH BRACH ART 2ND ORDER $1,447SP SEL CATH BRACH ART 3RD ORDER $1,724SP SEL CATH BRACH ART ADD 2ND/3RD $315SP SEL CATH PULMONARY ARTERY $518SP SEL CATH PULMONARY SEGMENTAL $615SP SEL CATH VENOUS 1ST ORDER $882SP SEL CATH VENOUS 2ND ORDER $976SP SHOULDER BX DEEP $66SP Spinal Cord Needle Bx $583SP STENT CENTRAL VIA AV ACCESS $16,952SP SUBDIAPH ABSCESS DRAIN PERC $2,546SP SUBDIAPHRAG ABSCESS DRAIN PERC $1,375SP THORACENTESIS W IMAGING IR $1,701SP Thrombectomy Vein Leg Incis $3,119SP THROMBOLYSIS DC $4,000SP THROMBOLYSIS F/U $4,000SP THROMBOLYSIS INIT-ART $5,685SP THROMBOLYSIS INIT-VENOUS $2,000SP TIB PERO STENT ATHER EACH ADDL $14,829SP TIB PERO STENT EACH ADDL $10,609SP TIB PERONEAL ANGIOPLASTY EACH $4,027SP TIB/PER REVASC STENT AND ATHER $20,290SP TIBIOPERONEAL ANGIOPLASTY INT $6,012SP TIBIOPERONEAL ATHER EACH ADDL $8,246

313 of 317 FY2018

DESCRIPTION CHARGES

SP TIBIOPERONEAL ATHERECTOMY INT $11,298SP TIBIOPERONEAL STENT PLACEMENT $15,004SP TRANSCATH EMBL NON CNS PERC $2,014SP TRANSCATH EMBOL CNS PERC $2,050SP TRANSCATH EMBOL NON CNS PERC $2,014SP Transcath Place Carotid Stent $3,989SP TRANSCATH STENT ADDL ARTERY $14,768SP TRANSCATH STENT ADDL VEIN $14,542SP TRANSCATH STENT INITIAL ARTERY $19,162SP TRANSCATH STENT INITIAL VEIN $16,952SP TRANSCATH THERAPY INF EA ADDTL $1,727SP TRANSCATH THERPY INF 1ST W/IMG $5,880SP TRANSCATHETER BIOPSY $4,000SP Transluminal Mech Thrombectomy $3,989SP TRIGEMINAL DESTRUC BY AGENT $133SP TRIGEMINAL MEDULLARY INJ $1,821SP T-TUBE CHOLE POSTOP W/INJECT $1,339SP URET STEN PLC WWO NEPH NEW/CTH $9,500SP URETERAL CATH PLACE WWO NEPHRO $5,350SP URETERAL STEN PLC WWO NEPH NEW $9,101

SP URETERAL STENT PLACE W/WO NEPHRO VIA EXIST NEPHRO $3,550SP URETEROSTOMY TUBE CHANGE $2,400SP URETHRAL CATH COMPLEX $123SP URETHRAL CATH SIMPLE $92SP US LIVER BX PERC $960SP US PERC DRAIN SOFT TISSUE $1,152SP US PLEURAL DRAIN TUBE/IMAGING $1,854SP US RENAL ABSCESS DRAIN PERC $2,546SP US RF ABLATION LIVER PERC $10,236SP UTERINE FIBROID EMBOLIZATION $15,626SP VASC EMBOL BLEED/LYMPH EXTRAVA $8,739SP VASC EMBOL TUMORS $8,739SP VASC EMBOL VENOUS $18,000SP VASC EMBOL VENOUS ARTERIAL $18,000SP VASOGRAPHY CATH $466SP VASOTOMY $508

314 of 317 FY2018

DESCRIPTION CHARGES

SP VENOGRAPHY INJ $2,000SP VENOS ACCESS PORT REMOVAL $1,967SP VENOUS ACCESS PORT INSERTION $4,217SP VENOUS ACCESS PORT REVISION $1,967SP VENOUS ANGIOPLASTY OTHER $1,687SP VERTEBROPLASTY LUMBAR PERC $4,695SP VERTEBROPLASTY PERC EA ADD $2,928SP VERTEBROPLASTY THORACIC PERC $4,235SP VISCERAL ARTERY ATHERECTOMY $17,390SP Wound Repair SMP<2.5 $239Sperm Freeze Recipient SSD $115Sperm Maintenance Fee SSD $250STEREOTAC BRST NEEDLE LOC ADDL $987STEREOTACTIC BREAST BIOPSY $3,754STEREOTACTIC BREAST NEEDLE LOC $1,762Strtc Breast Bx Vac Asst w/C $3,474TAVR Perfusion Standby Per 30 Min SSD $215Testicular Biopsy Infertility $2,000Testicular Biopsy with Vasograms $2,000Testicular Sperm Extraction Scrotal Exploration $3,000Thoracentesis $948Thyroid Aspiration $445Thyroid Biopsy $468Trabeculoplasty SDS $2,065Trans Cer/Thoracic Epid (Adl Lvl) $952Trans Cer/Thoracic Epid (Sgl Lev) $1,020Tubalplasty $6,050Tuboplasty - Outpatient SSD $360Unlisted Procedure Hands/Finger $255US RETROPERITONEAL BX PERC $960US ABD PARACENTESIS W/O IMAGING IR $536US AMNIOCENTESIS $307US APPENDICEAL ABSCESS DRAIN IR $2,546US ARTHROCENTESIS ASP/INJ INT $1,125US ARTHROCENTESIS ASP/INJ MAJ $1,178US ARTHROCENTESIS ASP/INJ SMALL $1,106US ASP AND/OR INJ THYROID CYST $445

315 of 317 FY2018

DESCRIPTION CHARGES

US AXILLA BIOPSY $2,723US Biopsy Salivary Gland $1,772US BREAST ASPIRATION CYST PUNCT $445US Breast Bx $2,151US Breast Bx w/Clip $2,723US Breast Needle Loc/Wire Placement $916US BREAST PUNCTURE ADDL $245US Bx of Lymph Node by Needle $732US Bx of Lymph Node by Needle $732US Bx soft tissue neck/thorax $1,772US FINE NEEDLE ASP W/IMAGING $651US FINE NEEDLE ASP W/O IMAGING $269US GUIDE CRYO ABLATION LIVER $10,236US GUIDED BREAST BIOPSY $2,723US GUIDED BREAST NEEDLE LOC $1,496US GUIDED BREAST NEEDLE LOC ADDL $987US Guided Needle BX/ASP/N Add on $753US Guided Vascular Access $753US HIP/PELVIS ABSCESS DRAIN $2,189US HIP/PELVIS ABSCESS DRAIN W/IMAGING $2,189US Hysterosonography Inject $528US Incis Sft/Tissue Abcess Deep $445US INJECT PSEUDOANEURYSM PERC $634US LIVER ABSCESS DRAINAGE $2,000US LIVER ABSCESS DRAINAGE IR $2,546US LIVER BX PERC $960US MUSCLE BX PERCUTANEOUS $732US MUSCLE BX PERCUTANEOUS W/IMAGING $960US PERC DRAINAGE SOFT TISSUE IR $1,152US PERITONEAL ABSCESS DRAIN PER IR $2,546US PERITONEAL ABSCESS DRAIN PERC $1,495US PERITONEAL LAVAGE $1,289US PROSTATE NEEDLE BX $1,136US PRP INJECTION $375US RENAL ABSCESS DRAINAGE PERC IR $2,546US RENAL BX PERC $1,087US RF ABLATION LIVER TUMOR PERC $10,236

316 of 317 FY2018

DESCRIPTION CHARGES

US STEM CELL INJECTION $2,500US TENOTOY, ACHILLES $2,911US TENOTOY, ELBOW $2,911US TENOTOY, HAMSTRING $2,911US TENOTOY, HIP $2,911US TENTOMY, SHOULDER $4,791US THYROID BX PERC $468Uterine Biopsy $732Vitrectomy SSD $6,927Vitreolysis SDS-29950 $1,870Vitreous Biopsy $6,927

PAIN MANAGEMENTArthrocent/Asp Major Joint Wo Us $500Arthrocent/Asp Small Joint Wo Us $500Cer/Tho Epi/Inj W or W/O Con $1,073Cerv/Thor Facet Joint Sgl Fl $1,700Cerv/Thor Facet Joint 2nd Fl $1,093Cerv/Thor Facet Joint 3rd Fl $1,093Cervical/Thoracic Facet Rf Addtl $1,014Cervical/Thoracic Facet Rf Single $3,000Inj Single Tendon Sheath or Liga $500Lum/Cau Epid/Inj W or W/O Con $1,073Lum/Sacral Inj or Cath Placement $1,933Lumbar Facet Joint 2nd Fl $1,500Lumbar Facet Joint 3rd Fl $1,500Lumbar Facet Joint Sgl Fl $1,500Lumbar Facet Phenol/RfAdtl # $1,500Lumbar Facet Phenol/RfSingle $3,000Other Peripheral Nerve $1,022Other Peripheral Nerve. $1,265Perc Implant Stim Electrode Epi $11,393Percut VertebroplastyLumbar $5,757Punct Shunt Tubing For Asp or Inj $1,139Removal of Spinal Neurostim Fl $3,000Si Joint Injection $930

317 of 317 FY2018

DESCRIPTION CHARGES

Stellate Ganglion Blk $1,265Trans Cerv/Thoracic Epid(Sgl Lev) $1,265Transfor Cerv/Thor Epid(Adtl Lev) $952Transfor Lumb/Sacr Epid(Adtl Lev) $952Transforam Lumb/Sac Epid(Sgl Lev) $1,413Trigger Point 1 or 2 Muscle Group $500

website link: ... › pay › documents › cdm.pdf1 of 317 fy2018 description charges room &...

Documents

bed room furniture

river cottage - crabapple · twin bed single bunk single...

voltage and current stepdown pwm controller

magicbricks · block 3 1 flat d room bed room beo 10-9. x...

new cons c ion housing 5chome e-—3 280 ts aya 3,280 bed...

suvashsika furniture, madurai, bed room set

2 bed room - standard, 28m2, inboard ensuite - room layout

property junction · living/dining e.foye kitch m.bed room...

· type - bed room bed room b acc. wash kitchen living...

pramukmeridian.com · room '15 4.8512.wm toilet toilet...

flat no: b - 015 - sbioacc.com photos b-015.pdfmaster bed...

indianrealtybytes-344c.kxcdn.com · 2018. 4. 10. · bed...

powerpoint presentation · 2020-01-14 ·...

a13 stepdown controller with dal 2.1hz stepdown dcdc...

bed & breakfast - cley windmill · bed & breakfast rates...

kitchen bed room living room entrance guest room swimming...

stepup stepdown

untitled-1 [teja9.kuikr.com] · 03/03/2017 · apartment...

magicbricks · exquisite sanitary standard company fixtures...

cape may bed & breakfast room choices