while the file below represents our line item charges for st ...upper gi w small bowel $1,052...

1 of 154 FY2018

DESCRIPTION CHARGESROOM & BEDPRIVATE ROOM $2,476PRIVATE OTHER $2,589SEMI PRIVATE ROOM $1,650INTENSIVE CARE UNIT $5,829INTENSIVE CARE INTERMED $3,800CORONARY CARE UNIT $5,829CORONARY CARE INTERMED $3,819OBSERVATION MED SURG 1 HR $1,355OBSERVATION DOU 1 HR $1,423OBSERVATION SDU 1 HR $1,423OBSERVATION ICC 1 HR $3,583OBSERVATION CSI 1 HR $3,762OBSERVATION MED SURG ADD HR $65OBSERVATION DOU ADD HR $65OBSERVATION ICC ADD HR $169OBSERVATION CSI ADD HR $177

RECOVERY ROOMRECOVERY EA ADDL 15 MIN $594RECOVERY INIT 30 MIN $1,411

RADIOLOGYABD AORTA W BI LWR EXT $5,011ABD AORTOGRPHY BY SERIAL $4,417ABDOMEN 1 VIEW $326ABDOMEN 2 VIEWS $378ABDOMEN 3 VIEWS $485ABDOMEN ACUTE SERIES $485ABDOMEN AP OBLIQUE CONE $378ABDOMEN SINGLE VIEW KUB $326ABDOMEN W DECUB OR ERECT $323ACROMIOCLAVICULAR JTS BI $463ANGIO ADRENAL UNILAT SEL $4,342ANGIO EXIST CATH F U STU $1,092ANGIO EXTREMITY BILAT $4,699ANGIO EXTREMITY UNILAT $3,866

While the file below represents our line item charges for St. Luke's Des PeresHospital, the website link below will provide you with the average out-of-pocketcosts for our most common services together with additional insights into pricingtransparency for our services and frequently asked questions.

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

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

2 of 154 FY2018

DESCRIPTION CHARGES



ANGIO PULM SEL BI $7,511ANGIO SELECT EA ADD VESL $3,200ANGIO VISCERAL SEL SUPSEL $4,000ANKLE 2 VIEWS $750ANKLE 3 VIEWS MINIMUM $861ANTEGRADE NEPHROSTOGRAM $707BILIARY DIL W WO STENT $4,209BONE AGE STUDIES $259BONE LENGTH STUDIES $999BONE SURVEY COMPLETE $1,130CHANGE PERC DRAIN CATH $1,078CHEST 1 VIEW $438CHEST 2 VIEWS $645CHEST 2 VIEWS W FLUORO $802CHEST 3 VIEWS $656CHEST DECUBITUS VIEWS $550CHEST SINGLE VIEW $438CHEST TWO VIEWS $645CHOLANGIOGRPHY OPERATVE $762CISTERNOGRAPHY $990CLAVICLE COMPLETE $726COLON BARIUM ENEMA $853COLON BARIUM ENEMA W AIR $1,072CYSTOGRAPHY 3VW MIN $754DEXA APPENDICULAR SKELTN $401DEXA AXIAL SKELETON $382DISCOGRAPHY CERV THOR $2,237DISCOGRAPHY LUMBAR $2,210DX MAMMO CAD BILAT $434DX MAMMO CAD UNILAT $349ELBOW 2 VIEWS $680ELBOW 3 VIEW MINIMUM $717ELBOW ARTHROGRAPHY $1,686ENDO CATH BILIARY SYSTEM $3,004ENDO CATH PANCREAS DUCT $2,562ENTERCOLYSIS SM BOWEL $1,138ERCP BILIARY PANCREATIC $3,920


3 of 154 FY2018

DESCRIPTION CHARGES



ESOPHAGUS $638EYE DETECTION OF FOR BDY $350FACIAL BONES 2VW MAX $557FACIAL BONES 3VW MIN $719FEMUR 1 VW $315FEMUR 2 VIEWS MIN $808FINGER S 2 VIEWS $512FISTULA SINUS TRCT STDY $766FLUORO BX ASP INJ GUIDE $1,423FLUORO GUIDE SPINE INJ $1,453FLUOROGUID FOR VEIN DVCE $1,684FLUOROSCOPY 1 HOUR $1,042FOOT 2 VIEWS $638FOOT 3 VIEWS MINIMUM $700FOREARM 2 VIEWS $602GI TUBE INTRO W FLUORO $654HAND 2 VIEWS $606HAND 3 VIEWS MINUMUM $674HIP ARTHROGRAPHY $965HIP BI W PEL 2WS $562HIP BI W PEL 5VWS $735HIP UNI SINGLE VIEW $277HIP UNI W PELV 2 3 VWS $381HIP UNI W PELVIS 1VW $277HIP UNILATERAL 2 3VWS $663HUMERUS 2 VIEW MINIMUM $707INFERIOR VENACAVAGRAM $2,981INJ BLADDER RETRO UR $269INJ CM EVAL DTUBE $763INJ CM EVAL GJTUBE $763INJ CM EVAL GTUBE $763INJ CM EVAL JTUBE $763INJ F CYSTO OR VCUG $1,015INJ GALACTO DUCTO PROC $568IVP WITH RENAL TOMOS $1,165KNEE 1 2 VIEWS $313KNEE 3 VIEWS $482


4 of 154 FY2018

DESCRIPTION CHARGES



KNEE ARTHROGRAPHY $1,178KNEE COMP 4 VW MIN $537KNEES BILAT AP STANDING $489LUMB BENDNG 2 OR 3 VWS $131MAMMARY DUCT GALACT SNG $895MANDIBLE 4 VIEWS $447MANDIBLE 4VW MIN $284MASTOIDS 3V SIDE $704MYELOG MULTI REGIONS S I $2,365MYELOGRAM CERV S I $1,681MYELOGRAM LUMBAR S I $1,545MYELOGRAM THORACIC S I $1,627NASAL BONES 3VW MIN $412NECK FOR SOFT TISSUES $475OPTIC FORAMINA $392ORBITS 4VW MIN $418OS CALCIS 2 VIEWS $329PELVIS 1 VIEW $391PELVIS 2 VIEWS $399PELVIS MIN 3 VWS $429PERC CHOLANG EXIST ACCESS $13,692PERC DEVC BRST 1ST MAMMO $1,507PERC DRN ABSC W CATH $987RIBS BI 4V MIN W PA CXR $1,236RIBS BILAT 3VW MIN $798RIBS UNI 3V MIN W PA CXR $1,336RIBS UNILAT 2VW $797SACRO ILIAC JNTS 3 OR VWS $342SACRUM COCCYX 2 VWS $358SCAPULA COMPLETE $730SCRN MAMMO CAD BILAT $382SHOULDER 2VWS MINIMUM $804SHOULDER ARTHROGRAPHY $1,048SHOULDER SINGLE VIEW $488SHUNTOGRAM PREV NONVASC $1,281SINUSES 2VW MAX $282SINUSES 3VW MIN $421


5 of 154 FY2018

DESCRIPTION CHARGES



SKULL 4 VIEWS $342SKULL 4VW MIN $530SMALL BOWEL $758SP LUMBAR MIN 6 VWS $1,353SPINE ANY LEVEL SNGL VW $786SPINE CERV 6 VWS $1,588SPINE CERVICAL 2 VIEWS $887SPINE CERVICAL 3 VIEWS $789SPINE CERVICAL 4 OR 5 VW $1,072SPINE LUMBAR 2 VIEWS $797SPINE LUMBAR 3 VIEWS $888SPINE LUMBAR MIN 4VWS $1,337SPINE THORACIC 2 VIEWS $960SPINE THORACIC 3 VIEWS $994SPINE THORACO LUMBAR JCT $841SPINE THORACOLMBR 1 VW $960SPINE THORACOLMBR 2 3VW $1,586STERNCLAVR JNTS 3VW MIN $380STERNUM 2VW MIN $359SUPERIOR VENACAVAGRAM $3,160SURGICAL SPECIMEN $432SWAL FUNC W CINE VIDEO $606THORACIC W SERL COMPLT $5,569TIBIA FIBULA 2 VIEWS $681TM JOINTS BILATERAL $850TOE S 2 VIEWS $283TOMOGRAPHY SNGL PLANE $1,282TRNSCTH BIOPSY S I $7,070TRNSCTH EMBOLIZATN $10,231UPPER GI AIR KUB $977UPPER GI AIR SMALL BOWEL $1,355UPPER GI W AIR $1,035UPPER GI W KUB $911UPPER GI W O KUB $1,009UPPER GI W SMALL BOWEL $1,052URETHROCYSTOGRAPHY RETR $834URETHROCYSTOGRAPHY VOID $830


6 of 154 FY2018

DESCRIPTION CHARGES



UROG PYELOGRAPHY RETRO $1,491UROGRAPHY EXCRETORY IVP $880US ABD LTD SNGLE QUAD FU $1,424US ABDOMEN COMPLETE $2,830US BREAST UNI COMPLETE $446US BREAST UNI LTD $385US CHEST INCLD MEDIASTNM $713US COMPRESSN REP PSEUDAN $1,427US GUIDE NEEDLE PLACEMNT $1,791US GUIDE VASCULAR ACCESS $737US OB COMP 14WK ADD GEST $1,554US OB COMP 14WK SGL GEST $969US OB COMP 14WKS 1STGEST $942US OB TRANSVAGINAL $1,457US PELVIC COMPLETE $821US PELVIC LTD FU $561US RETROPERITONEAL COMP $865US RETROPERITONEAL LTD $663US SCROTUM CONTENTS $1,758US SOFT TISSUE HEAD NECK $1,018US TRANSRECTAL $992US TRANSVAGINAL NOT OB $862US XTR JOINT COMPLETE $915US XTR JOINT LMTD $802US XTR NON VASC COMPLETE $915US XTR NON VASC LMTD $802US XTR SOFT TISSUE LMTD $802VENOGRAM EXTREMITY BI $1,877VENOGRAM EXTREMITY UNI $1,793WRIST 2 VIEWS $622WRIST 3 VIEWS MINIMUM $690WRIST ARTHROGRAPHY $1,647

LABABG O2 SAT ONLY DIRECT $99ABG W CALC O2 SAT $272


7 of 154 FY2018

DESCRIPTION CHARGES



ABG W CALC O2 SAT DIRECT $262ABID PLT AIA $160ABL1 KINASE VARIANTS $2,240ACETAMINOPHEN $249ACETONE QUALITATIVE $59ACHR BLOCKING ANTIBODY $107ACHR MODULATING ANTIBODY $343ACID FAST STAIN SMEAR $163ACTH $546ACTIN SMOOTH MUSCLE AB $409ACTYCHLN RCPTR BLCKNG AB $224ACTYCHLN RCPTR BNDNG AB $43ACTYCHLN RCPTR BNDNG AB. $89ACTYCHLN RCPTR MDLTNG AB $305ACUTE HEPATITIS PANEL $1,345ADAMTS 13 ACTIVITY $211ADENOVIRUS AB $54AFP TUMOR MARKER $326AGGLUTININS FEBRIL EA QL $38AHG INDIR QL EA ANTISERM $165ALBUMIN CSF $34ALBUMIN SERUM $43ALBUMIN SERUM $13ALCOHOL ETHYL $304ALCOHOL METHYL $43ALDOLASE $209ALDOSTERONE $790ALDOSTERONE URINE $727ALLGN SPEC IGE EA ALLERG $17ALPHA 2 ANTIPLASMIN $183ALPHA FETO PROTEIN SERUM $342AMIKACIN $348AMIKACIN PEAK SERUM $348AMIKACIN TROUGH SERUM $348AMIODARONE QUANT $184AMITRIPTYLLINE QUANT $408AMMONIA $251


8 of 154 FY2018

DESCRIPTION CHARGES



AMYLASE $253AMYLASE BODY FLUID $357AMYLASE ISOENZYMES $59AMYLASE URINE RANDOM $375AMYLASE URINE TIMED $175ANAEROBIC ID $93ANAEROBIC ID CHG 1 $138ANAEROBIC ID CHG 2 $145ANCA C $111ANCA CMPO PR 3 $263ANCA P $111ANCA TITER $58ANGIOTENSIN CONV ENZ CSF $172ANGIOTENSIN CONV ENZYME $262ANTI CARDIOLIPIN AB IGG $189ANTI CARDIOLIPIN AB IGM $189ANTI CENTROMERE AB $229ANTI CENTROMERE AB. $61ANTI GLOMERULAR BSMNT $441ANTI NEUTRPHL CYT AB $211ANTI SCL 70 $37ANTI SMITH AB $118ANTI STREPTOLYSN O TITER $265ANTI STREPTOLYSN SCREEN $215ANTI THROMBINE III AG $455ANTIBDY IDENT RBC EA PNL $597ANTIBODY ID PLATELET $423ANTIBODY INSULIN $408ANTICHROMATIN ANTIBODY $65ANTINUCLEAR AB ANA $358ANTINUCLEAR AB ANA TITER $375ANTIPARIETAL CELL AB $45ANTIPROTEINASE 3 AB $95ANTITHROMBIN III ACTIV $341ANTITHYROID PEROXIDAS AB $205ANTITRYPSIN ALPHA 1 TOTL $161ANTITRYPSIN ALPHA PHENO $92


9 of 154 FY2018

DESCRIPTION CHARGES



APOLIPOPROTEIN A 1 $133ARSENIC 24 HR URINE $362ARSENIC UR RDM $148ASCORBIC ACID VITAMIN C $169ASPERGILLUS FUMIGATUS $105AUTO RBC LEUKOREDUCED $950AUTOLOGOUS BLOOD C P S $387B HENSELAE IGG $24B HENSELAE IGM $24B QUINTANA IGG $24B QUINTANA IGM $24B TYP NATRIURETC PEPTIDE $166BABESIA AB IGG $202BABESIA AB IGM $202BARBITURATE IDENT QUAN $257BASIC METABOLIC PANEL $328BCR ABL 1 MINOR BREAKPNT $605BENZODIAZEPINE QTY $46BETA 2 GLYCOPROT I AB $140BETA 2 MICROGLOBLN $312BETA 2 TRANSFERRIN FLUID $613BETA LACTAMASE $21BILIRUBIN DIRECT $110BILIRUBIN TOTAL $43BILIRUBN NB TOT $191BLASTOMYCES AB $233BLD AUTOSLV INTRA PSOP $2,321BLD DIF WBC BUFFY $140BLD IRRAD RBC $756BLD PLASMA FROZEN $369BLD PLATELET PHERESIS $5,989BLD PLT PHER LEUKO REDUC $2,798BLD RC PACKED $997BLD TYP AG SCR EA UNIT $168BLD TYPE ABO ONLY $175BLD TYPE RHO D ONLY $153BLD UREA NITROGEN QUAN $47


10 of 154 FY2018

DESCRIPTION CHARGES



BLEEDING TIME TEMPLATE $226BLOOD CRYOPRECIPITATE $330BLOOD DIRECTED UNIT $692BLOOD GAS PH ONLY $58BLOOD HEMOGLBN $52BLOOD RC LEUKOCYTE POOR $950BLOOD WHOLE $1,082BORDETELLA AB IGA $141BORDETELLA AB IGG $153BORDETELLA AB IGM $141BRUCELLA IGG AB $190BRUCELLA IGM AB $190C DIFF TOX AB $153C DIFF TOXIN AMP PROBE $117C PEPTIDE $348C REACTIVE PROTEIN QN $261C TELOPEPTIDE $483CA 125 $358CA 19 9 $285CA 27 29 $93CA15 3 $285CALCITONIN $475CALCIUM $43CALCIUM 24HR URINE $141CALCIUM 24HR URINE $18CALCIUM IONIZED $190CALCIUM URINE QUAN TIMED $10CALCULUS QUANT CHEMICAL $247CALPROTECTIN FECAL $500CALR MUTATION ANALY $875CARBAMAZAPINE $218CARBAMAZEPINE FREE $40CARBON DIOXIDE $89CARBON MONOXIDE QUAN $293CARBOXYHEMOGLOBIN QUANT $140CARCINO EMBRYONIC AG $411CARDIOLIPIN AB QNT $189


11 of 154 FY2018

DESCRIPTION CHARGES



CAROTENE $219CATECHOLAMINES FRAC $392CATECHOLAMN FRAC URINE $562CBC PLT AUTO DIFF 5 $256CBC WITHOUT DIFF $157CELL COUNT MISC W DIFF $276CERULOPLASMIN $245CHLAMYDIA DNA AMP PROBE $189CHLAMYDIA DNA PROBE $199CHLAMYDIA PNEUMO IGG $307CHLAMYDIA PNEUMO IGM $307CHLAMYDIA PSIT IGG $295CHLAMYDIA PSIT IGM $283CHLORIDE $57CHLORIDE 24HR URINE $202CHLORIDE URINE $172CHOLESTEROL HDL $139CHOLESTEROL TOTAL $104CHOLINESTERASE PLASMA $219CHOLINESTERASE RBC $322CHROMIUM $117CHROMOGRANIN A $136CI ESTERASE $414CITRIC ACID URINE $79CK MB FRACTION $160CLOPIDOGREL 2C19 GENOTYP $830CLOT FACTOR II PRTHRMBN $327CLOT FACTOR V LABILE $313CLOT FACTOR VII STABLE $324CLOT FCTR IX PTC XMAS $311CLOT FCTR VIII AHG 1 STG $195CLOT FCTR X STUART PRWR $362CLOT FCTR XI PTA $362CLOT FCTR XII HAGEMANN $327CLOT FCTR XIII FBRN STB $354CLOT FCTR XIII SCREEN $136CLOT INHIB CROSS RECALC $476


12 of 154 FY2018

DESCRIPTION CHARGES



CLOT INHIB PTT INHIBITN $156CMV AB IGG $316CMV AB IGM $45CMV AMP PROBE PCR $545CMV ANTIBODY IGG $47CNSLT RPT REFRD MATERIAL $804CNSLT RPT REFRD SLIDES $133COAGULATION TIME ACTIVTD $77COBALT QUANT $88COCAINE OR METABOLITE QN $69COCCIDIODOMYCOSIS AB $52COLD AGGLUTINATN TITER $28COLD AGGLUTINATN TITER $322COMP METABOLIC PANEL $484COMP TST EA UT AHG TECH $213COMP TST EA UT INCUB TCH $262COMP TST EA UT SPIN TECH $185COMPLEMENT C3 $212COMPLEMENT C4 $212COMPLEMENT TOTAL CH50 $469CONCENTRATN OTH BDY FLD $26CONSULT FROZEN ADD $155CONSULT FROZEN SEC $297CONSULT SURGERY $170COOMBS DIRECT $135COPPER $232CORTISOL FREE URINE 24 $146CORTISOL TOTAL $457CORTISOL TOTAL AM $309CORTISOL TOTAL PM $324COTININE $44COXSACKIE B TYPE 1 $40COXSACKIE B TYPE 2 $40COXSACKIE B TYPE 3 $40COXSACKIE B TYPE 4 $40COXSACKIE B TYPE 5 $40COXSACKIE B TYPE 6 $40


13 of 154 FY2018

DESCRIPTION CHARGES



CREATINE KINASE ISONZ $464CREATINE KINASE TOTAL $144CREATINE URINE $26CREATININE 24 HR URINE $26CREATININE 24HR URINE $154CREATININE BLOOD $44CREATININE CLEARANCE $263CREATININE HVY METAL SCR $28CREATININE OTHER SOURCE $215CREATININE RANDOM URINE $26CREATININE URINE $137CRP HI SENSITIVITY $193CRYOGLOBULIN SERUM QUAL $197CRYPTOCOCCAL AG CSF $64CRYPTOCOCCAL ANTIGEN $316CRYPTOCOCCIS AB $155CRYSTAL ID EXCEPT URINE $161CULT BLOOD AERO ANAERO $286CULT E COLI 0157 FECES $39CULT FUNGI ID MOLD EA $54CULT FUNGI ID YEAST EA $90CULT FUNGI SKN HAIR NAIL $185CULT H PYLORI SCREEN $148CULT QNT W AERBC ISOL $268CULT THROAT NOSE $407CULTURE AEROBIC DEF ID $117CULTURE AFB $190CULTURE AFB $43CULTURE AFB IDENT $102CULTURE ANAERO DEF IDWGC $116CULTURE ANAEROBIC ISOL $272CULTURE BIOPSY SURG SPC $491CULTURE BONE MARROW $307CULTURE CAMPYLOBACTER $39CULTURE CATH TIP $468CULTURE CHLAMYDIA $29CULTURE CSF $259


14 of 154 FY2018

DESCRIPTION CHARGES



CULTURE EYE $25CULTURE FLUID EX CSF $509CULTURE FUNGI BLOOD $223CULTURE FUNGI OTHER $204CULTURE GC $192CULTURE GENITAL $484CULTURE LEGIONELLA $255CULTURE MRSA SCREEN $87CULTURE MYCOPLASMA ANY $121CULTURE OTHER SOURCE $491CULTURE SPUTUM $272CULTURE STOOL $348CULTURE STREP SCREENING $183CULTURE TYPING IMMUNOLOG $56CULTURE TYPNG FLUORO EA $29CULTURE URINE COLONY CT $221CULTURE URINE IDENT $84CULTURE VIBRIO $492CULTURE VRE SCREEN $428CULTURE YERSINIA $469CYANIDE $26CYANOCOBLMN VIT B12 $183CYC CITRULLINATED PEP AB $44CYCLOSPORINE $74CYSTATIN C $192CYTO CONSLT INITIAL SITE $118CYTO CONSULT EA ADD SITE $108CYTO SMR 5SLDS MULT ST $152CYTOLOGY SMEAR PREP $172CYTOPATH CONL SMR W INT $368CYTOPATH FILTER W INT $38CYTOPATH WASH BRUSH SM $153DECALCIFICATION $178DEHYDROEPIANDRST SULFATE $464DEHYDROEPIANDRSTRONE $42DESIPRAMINE $492DESOXYCORTICSTRNE 11 $267


15 of 154 FY2018

DESCRIPTION CHARGES



DIAZEPAM $142DIFF MANUAL $167DIGITOXIN $199DIGOXIN TOTAL $209DIHYDROTESTOSTERONE DHT $291DIR RBC LEUKORED IRRAD $1,176DIRECT COOMBS IGG $117DNA ANTIBODY DOUBL STRND $42DNA ANTIBODY SNGL STRAND $82DRUG SCREEN EACH CLASS $120DRUG SCREEN QUAL $113EBV EARLY AG $25EBV EBNA $25EBV PCR $815EBV VCA IGM $31EHRLICHIA CHAFEEN IGG AB $54EHRLICHIA CHAFEEN IGM AB $54EHRLICHIA CHAFF DNA PCR $500EHRLICHIA HGE DNA PCR $500ELECTROLYTE PANEL $167ELECTRON MICROSCPY $1,778ENA ANTIBODY TEST $247ENCEPH AB EQUINE IGM $40ENDOMYSIAL AB $212ENTEROVIRUS AMPL PROBE $392EOSINOPHIL SMEAR BODY FL $87EPSTEIN BARR VIRUS IGG $25EPSTEIN BARR VIRUS IGM $218ERYTHROPOIETIN $77ESTRADIOL $546ESTRIOL $261ESTROGENS FRACTIONATED $398ESTROGENS TOTAL $503ESTRONE $70ETHYL GLUCURONIDE URINE $165ETHYLENE GLYCOL $73F2 GENE ANLS VARIANT $270


16 of 154 FY2018

DESCRIPTION CHARGES



F5 LEIDEN VARIANT $270FACTR VIII RISTO CO FCTR $300FACTR VIII VW AG CO FCTR $201FAT DIFF FECES QUAN $310FAT OR LIPID FECES QUAL $125FAT OR LIPID FECES QUANT $338FCTR VIII VW MLT CO FCTR $372FDP D DIMER QNT $228FDP D DIMER SQNT OR QUAL $217FERRITIN $188FFP QUICK FREEZE 8 24 HR $306FFP THAW EA UNIT $146FIBRINOGEN ACTIVITY $205FIBRNOLTIC PLSMNOGEN ACT $618FIBRNOLYTIC PLASMINOGEN $119FITZGERALD FCTR HIMOL WT $407FLETCHER FACTOR ASSAY $496FLOW CYTO CEL FIRST MRKR $225FLOW EA ADD MARKER $56FLUORESCENT STAIN SMEAR $129FNA INTRP REPRT $276FOLIC ACID $197FOLIC ACID RBC $306FOLLICLE STIMLAT HORMONE $358FRANCISELLA TULARENS AB $269FREE KAPPA LIGHT CHAIN $86FREE LAMBDA LIGHT CHAIN $86FRUCTOSAMINE $25FTA ABS $25G6PD QUANT $278GABAPENTIN $43GAMMAGLOBULIN EACH $11GAMMAGLOBULIN SERUM EACH $30GASTRIN $348GC DNA AMP PROBE $189GENTAMYCIN $172GENTAMYCIN PEAK $258


17 of 154 FY2018

DESCRIPTION CHARGES



GENTAMYCIN TROUGH $258GGT $123GIARDIA AB $169GIARDIA ANTIGEN EIA $41GIARDIA DFA $79GLIADIN ANTIBODY IGA $54GLIADIN ANTIBODY IGG $54GLOMERULAR BASE MEMBRANE $717GLUCOSE BLD BY MONIT DEV $56GLUCOSE BLD RGT ST VISU $52GLUCOSE BODY FLUID $106GLUCOSE CSF $135GLUCOSE POST DOSE $133GLUCOSE QUANT BLOOD $75GLUCOSE TOLERANCE 3SPEC $202GONADTOPN CHORNC HCG QNT $331GONADTOPN CHRONC HCG QL $234GRAM STAIN SMEAR $150GROSS EXAM ONLY $227GROWTH HORMONE HGH $306GTT EA ADD 3SPEC $70H PYLORI BRTH TST $289HAEMOPHILUS INFLUENZA $97HALOPERIDOL $374HAPTOGLOBIN $203HBS ANTIGEN $205HELICOBACTER PYLORI IGA $54HELICOBACTER PYLORI IGG $54HELICOBACTER PYLORI IGM $54HEMATOCRIT AUTOMATED $103HEMOCHROM COMMON VARIANT $337HEMOGLOBIN FRAC QNT $38HEMOGLOBIN GLYCATED $119HEMOGLOBN ELECTRPHORESIS $374HEP B CORE AB TOTAL $312HEP B SURF AB QUANT $205HEP C PCR QUANT $422


18 of 154 FY2018

DESCRIPTION CHARGES



HEP C QUANT $282HEP C RNA AMP PROBE $301HEPARIN ASSAY $444HEPARIN INDUCED PLT AB $588HEPARIN NEUTRALIZATION $94HEPATIC FUNCTION PANEL $467HEPATITIS A AB IGG IGM $199HEPATITIS A AB IGM $409HEPATITIS B CORE AB IGM $408HEPATITIS B SURF AB QUAN $14HEPATITIS BE ANTIBODY $134HEPATITIS BE ANTIGEN $134HEPATITIS C ANTIBODY $345HERPES I AB IGG $197HERPES I II IGG AB $49HERPES I II IGM AB $51HERPES II AB IGG $188HETEROPHILE AB SCREEN $120HGB A2 $690HGB FECAL IA $355HISTO CYTO CHEM ID ENZYM $144HISTOCHEM STN W FRZ SECT $213HISTONE AB $67HISTOPL AG $198HISTOPLASMA ANTIGEN UR $321HISTOPLASMOSIS AB $307HIV 1 AB $81HIV 1 AMP PRB TECH $424HIV 1 HIV 2 SNGL RESULT $281HIV 1 QUANT $666HIV 1 WESTERN BLOT $623HIV 2 AB $81HIV CONFIRM WESTERN BLOT $623HIV I AG HIV I HIV II AB $269HLA B 27 DISEASE ASSOCIATI $98HLA I AG EQUIV EACH LOW $94HOMOCYSTEINE QUANT $324


19 of 154 FY2018

DESCRIPTION CHARGES



HOMOVNLLC ACID HVA $60HSV 1 PCR $182HSV 2 PCR $182HSV TYPE 1 2 PCR $458HUMAN GRAN EHRLIC AB $152HUMAN GRWTH HORMONE AB $155HYDRXINDOL ACD5 HIAA QT $306HYDRXYPRGSTRONE 17 D $63IG A SERUM $282IG D SERUM $40IG E SERUM $276IG G SERUM $282IG M SERUM $282IGF 1 $502IGG CSF $43IGM CSF $38IMIPRAMINE $444IMMCYT MLTIPLEX AB STAIN $550IMMUNCYT 1ST AB PER SPEC $365IMMUNGLB IGG SUBCLASS 1 $59IMMUNGLB IGG SUBCLASS 2 $59IMMUNGLB IGG SUBCLASS 3 $59IMMUNGLB IGG SUBCLASS 4 $59IMMUNOASSAY NON RIA QUAN $58IMMUNOCYTO EA ADD AB STN $185IMMUNOFIX ELECTPHRS $265IMMUNOFIX ELECTRO URINE $326IMMUNOFIXATION ELEC URIN $342IMMUNOFIXATION SERUM $111IMMUNOFLOR 1ST AB PER SPEC $170IN SITU EA PRB PER SPEC $281INDIA INK PREP SMEAR $137INFLUENZA A AB $39INFLUENZA A DIRECT $68INFLUENZA A SUBTYPE $476INFLUENZA B AB $39INFLUENZA B DIRECT $73


20 of 154 FY2018

DESCRIPTION CHARGES



INSULIN $192INTRINSIC FACTOR ANTIBDY $46IODINE $250IRON $182IRON BINDING CAPCTY $126JAK2 VARIANT $815JO 1 ANTIBODY $148KETONES SERUM QUAL $83KOH SKIN HAIR NAILS $135KRAS VARNT CONDONS 12 13 $3,252LACTATE LACTIC ACID $183LACTOFERRIN FECAL QNT $210LAMOTRIGINE QUANT $119LAP LEUCNE AMINO PPTIDSE $193LDH BODY FLUID $196LDH CSF $274LDH ISOENZYMES ELCTROPHR $375LDH LACTIC DEHYDROGENASE $159LDH LACTIC DEHYDROGENASE $17LDL CHOLESTROL $23LEAD QUANT URINE $36LEAD QUANTITATIVE $26LEAD URINE RANDOM $50LEGIONELLA AG UR $395LEGIONELLA PNEUM $486LEGIONELLA PNEUMO AB IGM $74LEGIONELLA PNEUMO DFA $165LEPTIN SERUM $129LEUKOCYTE ALKA PHSPHTASE $278LEVETIRACETAM $77LIDOCAINE $312LIPASE $234LIPID PANEL $255LIPO ULTRCNTRFGTN QUAN $88LITHIUM $247LP PLA2 PLAC $118LUTEINING HORMONE $335


21 of 154 FY2018

DESCRIPTION CHARGES



LYME AB IGM $47LYME AB INDX IGG IGM $374LYME AB WESTERN BLOT CSF $97LYME DISEASE $20LYME DNA PCR BLOOD $638LYME WESTERN BLOT IGG WB $55LYME WESTERN BLOT IGM WB $55M PNEUMONIA AB IGG $188M PNEUMONIA AB IGM $188MAGNESIUM $94MAGNESIUM URINE $94MAGNESIUM URINE 24HR $128MERCURY QUANTATIVE URINE $58MERCURY RANDOM URINE $129MERCURY SERUM $148METANEPHRINES PLASMA $249METANEPHRINES TOT 24HR $293METHOTREXATE QUANT $79METHYLMALONIC SERUM $284MICRO ALBUMIN URINE QNT $95MICROALB UR RANDOM $95MICROSOMAL AB LVR KIDNY $215MITOCHONDRIAL AB $409MITOCHONDRIL AB $15MOLECULAR PATH LEVEL 1 $1,069MOLECULAR PATH LVL 1 $1,069MONONUCLEAR CELL AG QNT $82MORPHOMETRIC TUMOR $128MTB DNA BY PCR $67MTHFR COMMON VARIANTS $270MUMPS AB IGG $454MYCOPLASMA DNA BY PCR $884MYELIN BASIC PROTEIN CSF $442MYELOPEROXIDASE MPO AB $90MYOGLOBIN $212MYOGLOBIN SERUM $95MYOGLOBIN URINE $241


22 of 154 FY2018

DESCRIPTION CHARGES



NASAL SMEAR EOSINOPHILES $196NAT KILLER CELL TOT CNT $82NEISSERIA MENINGITIDIS $449NEISSERIA MENINGITIDIS. $129NEISSERIA MENINGITIDS AG $143NEURON SPECIFIC ENOLASE $136NICOTINE $57NICOTINE METABOLITE $22NUCLEOTIDASE 5 $153OCCULT BLD FECES ONE SPC $45OCCULT BLD STL 1 3 $36OCCULT BLOOD GASTRIC $30OLIGOCLONAL BANDS $454OSMOLALITY BLOOD $163OSMOLALITY STOOL $27OSMOLALITY URINE $179OVA PARASITES SMEARS $18OXCARBAZEPINE TRILEPTAL $33PARVOVIRUS B19 AB IGG $40PARVOVIRUS B19 AB IGM $40PH BODY FLUID EXCEPT BLD $88PH BODY FLUID EXCEPT BLD $85PHENOBARBITAL $192PHENYTOIN TOTAL $202PHOSPHATASE ALKALINE $123PHOSPHATASE ALKALINE $27PHOSPHATASE HEAT STABLE $600PHOSPHATASE ISO ALK $52PHOSPHATIDYL SERINE IGA $36PHOSPHATIDYL SERINE IGG $36PHOSPHATIDYL SERINE IGM $36PHOSPHATSE PROSTATIC $197PHOSPHOLIP NEUT PLATELET $166PHOSPHORUS $70PHOSPHORUS URINE $213PHOSPHORUS URINE $213PHOSPHORUS URINE 24 HR $153


23 of 154 FY2018

DESCRIPTION CHARGES



PLASMAPHERESIS THERAPTC $3,975PLATELET AB SERUM $42PLATELET COUNT AUTO $90PLT AGG EA AGENT $136PLT FUNCTION TST $69PLT PHER LEUKORED IRRAD $3,175PNEUMOCOCCAL ANTIBODY $58POLIO VIRUS 1 ANTIBODY $309POLIOVIRUS AB $309POLIOVIRUS AB 2 $309POOLING CRYO CONC $199PORPHOBILIN UR QN $119PORPHYRINS PLASMA FRACT $174PORPHYRN FRACT URINE $249POTASSIUM 24HR URINE $224POTASSIUM SERUM $62POTASSIUM URINE $160PRE ALBUMIN $84PREGNANCY TEST SLIDE $375PRIMIDONE $145PROCALCITONIN $866PROGESTERONE $408PROLACTIN $427PROTEIN C ACTIVITY $476PROTEIN C AG $455PROTEIN C RESIST $166PROTEIN ELCTRC SERUM QN $247PROTEIN ELCTRO CSF $335PROTEIN ELECTRO URINE $247PROTEIN OTHER SOURCES $39PROTEIN S ACTIVITY $375PROTEIN S ACTIVITY $375PROTEIN S ASSAY FREE $576PROTEIN S FUNCTIONAL $394PROTEIN S TOTAL $236PROTEIN SPINAL FLUID $158PROTEIN TOTAL $63


24 of 154 FY2018

DESCRIPTION CHARGES



PROTEIN TOTAL $34PROTEIN URINE QUAN 24 HR $103PROTEIN URINE RANDOM $68PROTHROMBIN TIME $159PROTHROMBIN TIME SUBST $148PROTOPORPHYRIN RBC QUAN $278PSA FREE $74PSA SCREEN TEST $450PSA TOTAL $473PSA TOTAL $42PTH INTACT $331PTH RELATED PEPTIDE $164PTT $184PTT SUB EA FRACTION $110QUINIDINE $235RBC AG EXCPT ABO RHO EA $188RBC ANTIBODIES SCREEN $264RBC AUTO $50RBC L R CMV IRR $1,166RBC LEUKO RED CMV NEG EA $1,112RBC LEUKORED IRRAD $1,060RENAL FUNCTION PANEL $615RENIN $295RESP VIRUS 12 25 TARGETS $1,616RETICULOCYTE COUNT MAN $102REVERSE T3 $571RH SUBTYPES EA ANTIGEN $221RHEUMATOID FACTOR QUANT $218RNP ANTIBODY TEST $118ROCKY MNTN SPOT FVR IGG $38ROCKY MNTN SPOT FVR IGM $36RSV AB $67RUBELLA VIRUS IGG $50RUBELLA VIRUS IGM $257RUBEOLA IGG $50RUSSL VIPR VEN TIME DIL $154SACCHROMYCES AB IGA $140


25 of 154 FY2018

DESCRIPTION CHARGES



SACCHROMYCES AB IGG $140SALICYLATE $194SEDIMENTN RATE NON AUTO $94SELENIUM $143SEMEN MOTILITY COUNT $222SENSITIVITY ETEST EA AB $80SENSITIVITY ORG 1 MIC $143SENSITV 12 DISKS OR LESS $136SENSITVTY MIC $175SEROTONIN $744SEX HORMONE BIND GLOBULI $104SHIGA TOXIN $91SHIGA TOXIN 1 DIR OBS $87SICKLING OF RBC $26SJOGRENS SSA AB $235SJOGRENS SSB AB $235SMEAR AFB $43SMEAR CRYPTOSPORIDIA $30SMEAR CYCLOSPORA ISOSPOR $43SMEAR FUNGUS $17SMEAR MALARIA $403SMITH ANTIBODY $45SODIUM 24HR URINE $216SODIUM BLOOD $66SODIUM OTHER SOURCE $102SODIUM URINE $167SP GR EXCEPT URINE $62SPEC PROCESSING $43SPEC STAIN CYCLO CRYPT $195SPEC STAIN TRICHROME O P $18SPEC STAINS GROUP I $385SPEC STAINS GROUP II $213STAPH AGGLUTINATION $56STREP A DNA AMP PROBE $201STREP B DIRECT $131STREP B IA DIR $155STREP GRP A LATEX SCRN $144


26 of 154 FY2018

DESCRIPTION CHARGES



STREP PNEUMO ANTIGEN $58STREP PNEUMONIAE $131STRIATED AB SCR $68SURGICAL PATH III $684SURGICAL PATH LEVEL II $445SURGICAL PATH LEVEL IV $824SURGICAL PATH LEVEL V $1,138SURGICAL PATH LEVEL VI $1,695T CELLS ABSOLUTE CD4 CNT $125T CELLS T4/T8 INC RATIO $35T CELLS TOTAL COUNT $247T3 FREE $393TACROLIMUS $78TB CONCENTRATE $59TBG THYROXINE BND GLOBLN $48TESTOSTERONE FREE $373TESTOSTERONE TOTAL $373TETANUS IGG AB $62THEOPHYLLINE $163THIAMINE VITAMIN B1 $34THIOCYANATE $330THROMBIN TIME $40THROMBIN TIME PLASMA $107THROMBOPLSTN INHIB TISS $75THYRD STIM IMMUNGLBN TSI $187THYROGLOBULIN $36THYROGLOBULIN ANTIBODY $205THYROTROPIN RECEPTOR AB $57THYROXINE FREE $192THYROXINE TOTAL $159TISS TRNANSGLUT AB IGA $82TISSUE GRIND FOR CULTURE $51TISSUE TYPING HLA B27 $499TOBRAMYCIN $233TOBRAMYCIN PEAK $330TOBRAMYCIN TROUGH $330TOPIRAMATE LVL $54


27 of 154 FY2018

DESCRIPTION CHARGES



TOXICOLOGY BLOOD EA CLSS $205TOXOPLAS GONDII AB IGG $34TOXOPLASMA AB IGM $48TRANSAMINASE SGPT ALT $95TRANSFERRIN $170TRANSGLUTAMINASE AB IGG $163TRANSTERASE AST SGOT $97TRICHOMONAS AMP PROBE $183TRIGLYCERIDES $145TRIGLYCERIDES FLUID $183TRIIODTHYRN T 3 UPTAKE $123TRIIODTHYRNINE TOTAL T3 $331TROPONIN $113TROPONIN I $222TRYPTASE LEVEL $84TSH $234TUBERCULIN PPD 5TU IJ $17TUBERCULOSIS AG RESPONSE $214TUMOR IMM PER SPEC COMPT $96TYROSINE PHOS PROTEIN AB $202UA AUTO W MICRO $176UREA NITROGEN 24HR URINE $204UREA NITROGEN URINE $153URIC ACID BLOOD $188URIC ACID OTHR SOURCE $221URIC ACID URINE $220URIC ACID URINE 24HR $262URINALYSIS CHEMICAL QUAL $109URINALYSIS MICRO ONLY $121URINE PREG TEST QUAL $248URINE VOL MEASURE TIMED $49URINE W O MICRO AUTO $88VALPROIC ACID TOTAL $185VANCOMYCIN $91VANCOMYCIN PEAK $261VANCOMYCIN TROUGH $290VARICELLA ZOSTER AB IGG $38


28 of 154 FY2018

DESCRIPTION CHARGES



VARICELLA ZOSTER BY PCR $297VARICELLA ZOSTER IGG CSF $54VASOPRESSIN ADH $756VDRL CSF $18VDRL RPR QUAL $224VDRL RPR QUAN $189VENIPUNCTURE $51VERY LOW DENSITY LIPOPRO $480VIRUS ID TISSUE CULT $101VISCOSITY BLOOD $229VIT D 1 25 HIDYDROXY $649VITAMIN A $287VITAMIN B1 WHOLE BLD $375VITAMIN D 25 HYDROXY $765VITAMIN K $310VITAMINE B6 PYRIDOXAL $78VITAMN E TOCOPHRL ALPHA $45VMA 24HR URINE $316WBC AUTO $95WEST NILE VIRUS IGG $154WEST NILE VIRUS IGG CSF $147WEST NILE VIRUS IGM $147WEST NILE VIRUS PCR $335WEST NILE VIRUS SEROLOGY $128WET MOUNT W SMPL STAIN $219WRIGHT S STAIN $210ZINC QUANTITATIVE $36

INFUSION THERAPYBA SURG PROC LVL 1 $2,377DIALYSATE 6000ML OR PD $222E M EST PATIENT LVL I $385E M EST PATIENT LVL II $395E M EST PATIENT LVL III $519E M EST PATIENT LVL IV $791E M EST PATIENT LVL V $916E M NEW PATIENT LVL I $304


29 of 154 FY2018

DESCRIPTION CHARGES



E M NEW PATIENT LVL II $456E M NEW PATIENT LVL III $617E M NEW PATIENT LVL IV $791INJ ADD SEQUENTL IVP $442INJ T/P/D IVP SAME SUBST $443INJ TX PROPH DX SQ IM $161INJ TX/PRPH/DX IVP INT $442IV INF HYD EA ADD HR $81IV INF HYD INIT 31 60MIN $642IV INF SEQUENTL 1 HR $81IV INF TX EA ADD HR $101IV INF TX INIT <= 1 HR $706IV INF TX INIT 1 HR $642

CT SCANS3D IMAG W PP AT INDEP WS $8953D IMAGNG NO POSTPROCESS $895ABD PARACENTESIS W IMAGE $1,541ASPIR BLADDR W/INS CATH $7,975BIOPSY BONE DEEP $2,075BIOPSY BONE SUPERFICIAL $2,091BX ABD RETROPER PERC NDL $2,367BX BACK FLANK SUPRFICIAL $1,190BX LIVER PERC NDL $2,237BX LUNG MEDIAST PERC NDL $2,325BX MUSCLE PERC NDL $1,501BX PANCREAS PERC NDL $2,707BX PLEURA PERC NDL $1,609BX RENAL PERC NDL $2,512BX SOFT TISSUE NECK THOR $1,376CT ABD PELVIS W CM $9,538CT ABD PELVIS W O CM $8,282CT ABD PELVIS WO W CM $11,035CT ABDOMEN W CM $4,591CT ABDOMEN W O CM $4,041CT ABDOMEN WO W CM $5,328CT EYE EAR P FOS WO W CM $5,021


30 of 154 FY2018

DESCRIPTION CHARGES



CT GUIDANCE NDL PLACEMNT $4,015CT HEAD BRAIN W CONTRAST $4,156CT HEAD BRAIN WO CONTRST $3,866CT HEAD BRAIN WO W CONTR $5,251CT LOWER EXTRMTY W CM $4,028CT LOWER EXTRMTY W O CM $3,571CT LOWER EXTRMTY WO W CM $4,022CT LTD OR LOC F U STUDY $1,632CT MAXILLOFACIAL W O CM $4,962CT ORB EAR FOSSA W CM $4,607CT ORB EAR FOSSA W O CM $3,860CT ORB EAR FOSSA WO W CM $5,458CT PELVIS W O CONTRAST $2,024CT PELVIS WITH CONTRAST $2,364CT PELVIS WO W CM $2,863CT SFT TISS NECK WO W CM $5,214CT SINUS W O CM LTD $2,022CT SINUS W O CONTRAST $4,879CT SINUS WITH CONTRAST $4,802CT SINUS WO W CONTRAST $5,316CT SOFT TISS NECK W CM $4,916CT SOFT TISS NECK WO CM $4,476CT SPINE CERVICAL W CM $3,945CT SPINE CERVICAL W O CM $4,112CT SPINE CERVICL WO W CM $4,890CT SPINE LUMBAR W CM $4,185CT SPINE LUMBAR W O CM $4,275CT SPINE LUMBAR WO W CM $5,061CT SPINE THORACIC W CM $4,015CT SPINE THORACIC W O CM $4,232CT THORAX W O CONTRAST $3,997CT THORAX WITH CONTRAST $5,961CT THORAX WO W CONTRAST $6,536CT UPPER EXTRMTY W CM $3,947CT UPPER EXTRMTY W O CM $3,785CT UPPER EXTRMTY WO W CM $4,362CTA ABD LE RO W CONT ONL $2,606


31 of 154 FY2018

DESCRIPTION CHARGES



CTA ABD LE RO WO W CONT $2,736CTA ABD PEL WO W CM $3,235CTA ABDOMEN WO W CM $2,539CTA CHEST NONCOR WO W $4,432CTA HEAD W CONTRAST ONLY $2,631CTA HEAD WO W CONTRAST $3,273CTA LOWR EXTRMTY WO W CM $3,119CTA NECK WO W CONTRAST $2,888CTA PELVIS WO W CONTRAST $4,105CTA UP EXTREMITY WO W CM $3,006FNA W GUIDANCE $564GUIDE CATH FLUID DRAINAG $5,943IMG CATH FLUID COL VISC $5,860IMG CATH FLUID PERI RETR $4,999INSERT THORACOSTMY TUBE. $1,237LDCT LUNG SCREEN $1,960PERC BIOPSY LYMPH NODE $715PERC CHOLECYSTOSTOMY. $2,709PERC DRAIN W CATH PLC $2,108PERC SACRL AUGMENT BILAT. $2,947PERC SACRL AUGMENT UNIL. $3,094PERC VERT 1 BD ADD IMG. $2,785PLEURAL DRAINAGE PERC $822THORACENTSIS W IMAGING $821

NUCLEAR MEDICINEABSCESS LOCALIZE LTD $1,265ABSCESS LOCALIZE WHLBDY $1,968ACUTE GI BLOOD LOSS IMG $852BONE IMAG 3 PHASE STUDY $3,696BONE IMAGING LIMITED $2,150BONE IMAGING MULTIPLE $2,199BONE IMAGING WHOLE BODY $2,795BONE SPECT $5,117BRAIN 4VWS W VASC FLOW $2,918CISTERNOGRAM $1,622GASTRIC EMP SM BOWEL $1,502


32 of 154 FY2018

DESCRIPTION CHARGES



GASTRIC EMPTYING STUDY $1,788GASTRIC SM BOWEL COL $1,502GATED HEART PLANAR SNGL $2,210HEPATOBIL IMAGE W DRUG $2,002HEPATOBILIARY SYSTEM IMG $1,601INJ PROC SENTINEL NODE $462INTESTINE IMAGING $1,363IV RADIOPH LOCALZTN ONLY $377KID IMG FL FUN SNG W RX $1,444KID IMG FL FUN SNG WO RX $1,841KIDNEY IMAG W VASC FLO $1,461KIDNEY IMAGING MORPHOLGY $1,098LIVER IMAG VASCULAR FLOW $717LIVER SPECT W VASC FLOW $1,179LIVER SPLEEN IMAG STATIC $795LUNG PERF PARTICULATE $1,754LUNG PERF VENTILAT DIFF $1,819LUNG PERFUSION DIFFER $1,910LUNG VENT PERF IMAGING $1,972LUNG VENTILATION IMAGING $1,046LYMPHATICS LYMPH NODES $2,956MC PERF SPECT WM EF MULT $3,514MC PERF SPECT WM EF SNGL $3,917PARATHYRD IMG W SPECT $1,180PARATHYROID IMAGING $1,124RADPHARM TX ORAL $1,973THYROID FLOW $822THYROID IMG VSCFI SG MLT $887THYROID UPTK SNG/MULT $822TUMR LOC DIST ISO WE 2 D $2,062

MRIMRA ABDOMEN W O CM $1,456MRA ABDOMEN WCM $1,712MRA ABDOMEN WO W CM $1,797MRA CHEST W CONTRAST $2,072MRA CHEST WO W CONTRAST $2,368


33 of 154 FY2018

DESCRIPTION CHARGES



MRA HEAD W CONTRAST $2,281MRA HEAD W O CONTRAST $3,586MRA HEAD WO W CONTRAST $4,772MRA LOWR EXTRMTY W O CM $4,759MRA LOWR EXTRMTY WCM $5,053MRA LOWR EXTRMTY WO W CM $5,014MRA NECK W CONTRAST $2,233MRA NECK W O CONTRAST $3,592MRA NECK WO W CONTRAST $4,715MRA PELVIS WITH CONTRAST $2,614MRA PELVIS WO W CONTRAST $2,867MRI ABDOMEN W O CM $2,875MRI ABDOMEN WCM $1,907MRI ABDOMEN WO W CM $3,540MRI BRAIN W O CONTRAST $4,660MRI BRAIN WITH CONTRAST $2,437MRI BRAIN WO W CONTRAST $6,459MRI CHEST W CONTRAST $2,183MRI CHEST W O CONTRAST $3,793MRI CHEST WO W CONTRAST $4,674MRI LE JNT WO W CM $5,727MRI LE NONJNT W CM $2,845MRI LE NONJNT W O CM $4,574MRI LE NONJNT WO W CM $5,379MRI LOWR EXT JNT W O CM $4,736MRI LOWR EXT JNT WCM $5,231MRI ORB FACE NECK WO CM $4,696MRI ORB FACE NECK WO W C $6,048MRI PELVIS W O CONTRAST $3,397MRI PELVIS WCONTRAST $2,145MRI PELVIS WO W CONTRAST $3,950MRI SPINE CERV WO W CM $6,595MRI SPINE CERVICAL W CM $3,269MRI SPINE CERVICL W O CM $5,381MRI SPINE LUMBAR W CM $3,468MRI SPINE LUMBAR W O CM $5,751MRI SPINE LUMBAR WO W CM $7,108


34 of 154 FY2018

DESCRIPTION CHARGES



MRI SPINE THOR WO W CM $6,604MRI SPINE THORAC W O CM $5,093MRI SPINE THORACIC W CM $2,872MRI UP EXT JNT W O CM $5,191MRI UP EXT JNT WCM $5,744MRI UP EXT JNT WO W CM $6,293MRI UP EXT NONJNT W O CM $5,439MRI UP EXT NONJNT WCM $4,162MRI UP EXT NONJNT WO WCM $6,740

CARDIOLOGYABLATION AV NODE $6,528ANGIO INTERNAL MAMMARY $5,966ANGIO PELVIC SELECT SUP $2,323ANGIO PULM NON SEL CATH $5,374ARTERIOG EXT CAR SEL $9,879ARTERIOG SUBC INOM $11,648ARTERIOG VERT SEL $11,648ARTERIOGR CAR HD SEL $13,130ARTERIOGR CAR NK SEL $12,505ARTEROGRAM ARCH NON SEL $6,262ATHERCT ILIAC OPEN PERC $18,785CARDIAC DOPPLER FU LTD $295CARDIO STRESS TRACE ONLY $1,283CARDIOVERSION ELECTIVE $1,139CATH ATRIAL PACING $4,501CATH COR ART GRFT S I $7,006CATH CORONARY ARTERY S I $9,354CATH INJ HRT CONG ART GR $17,188CATH INJ SUPRVLV AORTOGR $1,924CATH L HRT ART GRFT $7,193CATH L HRT ARTERY VENTR $8,991CATH L VENTRICAL ATRIAL $3,883CATH POST ERGOTR STDY $2,545CATH R HRT ART GRFT ANGI $4,084CATH R HRT COR ART ANG $9,355CATH R L HRT AR VNT BPGF $8,991


35 of 154 FY2018

DESCRIPTION CHARGES



CATH R L HRT ART VENT $7,193CATH R L HRT W VENTRICLG $14,789CATH RIGHT HEART $5,533CIRC ASSIST INT $2,350COMP EP ABL AFIB $13,157COMP EP ABLAT V TACH 3D $17,952COMP EP EVAL LA FRM CS R $5,312COMP EP EVAL LV RECORD $5,312COMP EP IND ABLA SVT $15,663COMP EP W O INDUC ARRYTH $5,312CONVERSION ARRHYTHMIA $1,355COR ANGPLSTY ADD $10,234COR ANGPLSTY INIT $19,235COR ATHER STNT APLST INI $53,675COR ATHERECT APLAS ADD $26,061COR ATHERECT APLAS INIT $38,464COR STNT ANGIO ADD $25,369COR STNT ANGIO INIT $34,446COR THROMBLYS INTRA COR $4,926CPR $1,569DOPP FLW PR MSMNT ADDL $383DOPP FLW PR MSMNT INIT $768DOPPLER ECHO COLOR FLOW $1,264DOPPLER ECHO PULSE CONT $2,639ECHO 2D COMP W CONTR $4,746ECHO 2D LIMITED W CONTR $959ECHO2D DOP COLFL W CONTR $1,279ECHO2D SPECTR COLOR FLO $4,984ECHOCARD RS ST WCONT EKG $6,256ECHOCARDIO 2D LTD $646ECHOCARDIOGRAM EX STRESS $3,573EKG MNTR > TO 48 HRS $1,331EKG MNTR SCN W RPT 48 HR $138EKG MNTR UP TO 48 HRS $1,331EKG TRACE ONLY $500EP CARDIAC MAPPING $5,695EP COMP STUDY W INDUCTN $5,312


36 of 154 FY2018

DESCRIPTION CHARGES



EP DRUG FOLLOW UP STUDY $5,312EP EVAL AICD LEADS INIT $1,491EP EVAL AICD SUBSEQ $1,491EP POST DRUG INFUSION $5,124EP TEST AICD LEAD GEN $1,420FFR/IVUS ONLY - DHW $2,314HIS BUNDLE RECORDING $5,124ILIAC ART BI W CARD CTH $4,969IMPL PT ACTIV CARD RCDR $6,893INDUCTN ARRHYTHMIA BY EP $5,695INJ VENOGRPHY EXTRMTY $126INJECT PULM ART HRT CATH $9,696INS AICD W DUAL LDS $61,917INS CATH REN ART 1ST BIL $6,251INS CATH REN ART 1ST UNI $8,150INS ENDOVA VENACAVA FILT $6,259INS LV LD W PM OR AICD $2,826INS PM GEN W EXIST LD $21,300INS PMGEN W EXISDUALLDS $21,300INS RPL PM W TRNSV LD AT $25,593INS RPL PM W TRNSV LD VE $24,374INS RPL PMW TRNSV LD A V $28,557INS RPL TEMP LEADS DUAL $5,655INS VAD PERC ART $2,125INSERT SWANGANZ CATHETER $2,618INSRT AICD W EXIS LD $55,650INSRT LD VEN LTVENT PREV $2,197INSRT REPL TEMP PM LEAD $7,225INSRT RPLC AICD LDS $56,940INSRT TRAN ELCTRD DUAL $11,827INSRT TRAN ELCTRD SNGL $9,946INTRA ARTERIAL RECORDING $5,124INTRACARD ABL ARRHY $7,254INTRACARD ECHO $4,463INTRAVENTRICULAR PACING $6,924INTRCRD EP 3DMAP $5,124IVUS CORONARY EA ADD $4,053


37 of 154 FY2018

DESCRIPTION CHARGES



IVUS CORONARY INIT VESSL $3,860IVUS NON CORON ADDL VESL $3,664IVUS NON CORONARY INITL $3,664MECH THRMBCTMY VN RPEAT $6,051OPEN PERC PL ST 1ST AR $4,214OPEN PERC PL ST 1ST VN $4,415OPEN PERC PL ST E ADD AR $9,535OPEN PERC PL ST E ADD VN $9,102P M AICD ELECT REPR LDS $4,121P M AICD ELECTRD RPR $4,241PER COR REVAS CABG ADDL $37,467PER COR REVAS CHRONC SNG $51,258PER COR REVAS D E ADDL $39,340PER COR REVAS D E W AMI $49,487PERC COR ATH D E STNT $48,818PERC COR ATHER STNT ADD $37,467PERC COR DRUG ELUT STNT $34,462PERC COR REVASC D E CABG $48,818PERC CORON THROMBECT $663PERC DRUG ELUT STNT ADDL $23,073PERC INSERT IABP DEV $4,833PERC MECH THROMBECTMY VN $6,051PERICARDIOCENTESIS INIT $2,512PERICARDIOCENTESIS SUBSQ $786PLC CATH AORTA $516PLC CATH ART 1ST ORDR $692PLC CATH ART 2ND ORDR $777PLC CATH ART 3RD ORDR $933PLC CATH ART ABD 1ST $723PLC CATH ART ABD 2ND $792PLC CATH ART ABD 3RD $932PLC CATH ART ADD ORDR $149PLC CATH BRACH ARTERY $334PLC CATH EXTRM ARTERY $354PLC CATH LT RT ARTERY $461PLC CATH VEIN 1ST ORDR $468PLC CATH VEIN 2ND ORDR $566


38 of 154 FY2018

DESCRIPTION CHARGES



PLC CATH VENACAVA $783PLC VASC CLSURE DEVICE $101REM AICD LDS TRANSVEN $2,470REM AICD PULS GEN $2,470REM PCMKR PULS GEN ONLY $8,340REM PCMKR TRAN ELCT DUAL $9,723REM REPL AICD DUAL LD $58,968REM REPL AICD MULT LD $58,968REM REPL AICD SINGL LD $61,917REM REPL PM GEN DUAL LD $19,322REM REPL PM GEN SGL LD $16,027REM REPL PM MULT LDS $17,565REM TRANSV PM ELCTD SNGL $7,943REMV PT ACTIV CARD RCDR $6,065REPS PREV LD VEN LTVENT $2,557REPS TRNSV LD RT ATR VNT $2,435REVAS PERC TRANS OCCL MI $54,411REVAS PERC TRANS SGL VES $53,675REVAS PERC TRANS TOT OCC $56,359REVASC FEMPOP STNT ATHER $21,286REVASC FEMPOP W ATHER $12,083REVASC FEMPOP W STENT $12,083REVASC FEMPOP W TLA $10,347REVASC ILI W STENT ADD O $5,691REVASC ILIAC ADD ON $7,940REVASC ILIAC INITIAL $10,347REVASC ILIAC W STENT $5,692REVASC TIB PER ADD ON $9,486REVASC TIB PER ATH ADD O $15,345REVASC TIBPER STNT ATHER $30,366REVASC TIBPER W ATHER $12,083REVASC TIBPER W STENT $12,687REVASC TIBPER W TLA $10,347REVASC TIBPER WSTENTADD $9,960REVSN RELOC PM SKN POCKT $6,876RHYTHM EKG $335RT VENTRICULAR RECORDING $5,124


39 of 154 FY2018

DESCRIPTION CHARGES



STRESSECHO EX W CONTR $1,563TCATH TX A V NONCOR SUBS $1,523TCATH TX CESSATION $1,523TCATH TX INIT NONCOR ART $1,620TCATH TX INIT NONCOR VEN $1,701TEE CONGTL CARD ANOMALIE $2,385TEMP TRANSCUTNEOUS PACNG $1,099THROMB NONCOR ADD VESSLS $1,946THROMB NONCOR INITL VSL $4,551THROMB NONCOR SECONDARY $1,946TILT TABLE EVAL $655TRANSESOPHAGEAL ECHO $2,676TRNSTHOR 2D ECHO CMPLET $1,169UPGRADE TO DUAL CHAMBER $27,078US GUIDE PERICARDIOCENTS $370USE CONTRAST AGENT ECHO $151VENOGRAPHY RENAL BILAT $5,847

BLOOD PRODUCTSBLOOD ADMINISTRATION 1 2 U $1,520BLOOD ADMINISTRATION 10 UN $11,399BLOOD ADMINISTRATION 3 4 U $3,040BLOOD ADMINISTRATION 5 6 U $4,560BLOOD ADMINISTRATION 7 8 U $6,080BLOOD ADMINISTRATION 9 10 $7,599RBC WASHED AUTO $1,677TRANSFUSION BLD BLD COMP $1,258

RESPIRATORY THERAPYBIPAP INITIAL $1,166BIPAP LESS THAN 12HRS $359BIPAP MANAGEMENT DLY $1,037BLOOD GAS ARTERIAL STICK $46BRONCHOSPASM EVAL PRE PS $676CHST WALL MANIPULATN INI $207CHST WALL MANIPULATN SUB $195CPAP INITIAL $1,166


40 of 154 FY2018

DESCRIPTION CHARGES



CPAP LESS THAN 12HRS $359CPAP MANAGEMENT DLY $1,037DIFFUSING CAPACITY $416HAND HELD NEB TREATMENT $54HHN TX DEMO AND OR EVAL $88IPPB TX $57IPPB TX DEMO AND OR EVAL $84LUNG VOL GAS DIL WASHOUT $455MDI DEMO AND OR EVAL $80MDI TREATMENT $54PLETHSYMOGRAPHY LUNG VOL $524PULSE OXIM MULT DETRM $251SLEEP APNEA HOURS $147SPIROMETRY $380SPUTUM INDUCTION $57VITAL CAPACITY $21VOLUME VENT SUBSQ DLY $3,720VOLUME VENTILATOR INTL $4,744

EDUCATIONMED NUTRTN TH INIT 15MIN $64MED NUTRTN TH REEVAL 15MN $64MED NUTRTN GRP EA 30 MIN $101

DIALYSISCONT RENAL REPLACE THRPY $1,341IP CCPD $2,692IP HEMODIALYSIS $2,233IP IPD $792PERIT DIALYSIS SNGL EVAL $4,611UNSCHED DIAL ESRD PT $1,710

OTHER DIAGNOSTIC SERVICESART VEN FLOW ABD LTD $1,798ART VEN FLOW PENILE COMP $1,439DOP ART LE W EXER BI $1,593PSYCH DIAG EVAL $456


41 of 154 FY2018

DESCRIPTION CHARGES



DOP ART UE LE COMP 3 LVL $816DOP ART UE LE FLOW 1 2LVL $611DUPLEX ART LE BILAT $1,735DUPLEX ART LE UNI LTD $677DUPLEX ART UE BILAT $2,897DUPLEX ART UE UNI LTD $1,463DUPLEX CAROTID BI COMP $2,003DUPLEX CAROTID UNI LTD $1,026DUPLX AORT IVC ILIAC COM $3,708DUPLX ART VNS FLOW CMPL $2,521DUPLX ART VNS FLOW LTD $1,662DUPLX IVC AO ILI CMPL $3,646DUPLX IVC AO ILI LTD $2,746DUPLX UE LE VNS BI CMPL $2,731DUPLX UE LE VNS UNI LTD $1,486EEG AWAKE/DRWSY $1,064LE ART IMAGING COMP $1,764LITHOTRIPSY OTHER $6,521PRG SPNL GEN CMPLX 1STH $276SPEC PROC W LITHO $6,521

PREVENTIVE CAREHEPATITIS B VACC ADMIN $62INFLUENZA VACC ADMIN $47PNEUMOCOCCAL VACC ADMIN $35

REHABILITATION MEDICINECANALITH REPOS PROCEDURE $185OT COG SKILLS DEV EA15MIN $167OT COG SKL DEV EA 15 $167OT COMM WK REINT TRNG 15 $286OT EVAL HIGH COMP $338OT EVAL LOW COMP $169OT EVAL MOD COMP $278OT GRP 1 THER PROC 2 $276OT NEUROMUSC RE EDUC EA1 $167OT ORTHO MGMT INIT EA 15MIN $167


42 of 154 FY2018

DESCRIPTION CHARGES



OT ORTHO MGMT TRN EA15 2 $167OT ORTHO PROS MGMT EA 15MIN $167OT RE EVAL $169OT SLF CARE HM MGMT 15 2 $176OT SLF CARE HM MGMT EA15 $167OT SPLNT LNG ARM $284OT THERAPTC ACT EA 15 $167OT THERAPTC ACT EA 15 2 $176OT THERAPTC EXER EA 15 $160OT THERAPTC MASSGE EA15 $59PT E STIM COMPLX $268PT E STIM MANUAL 15 BSC $467PT EVAL HIGH COMP $253PT EVAL INTERM $357PT EVAL LOW COMP $111PT EVAL LTD $222PT EVAL MOD COMP $186PT GAIT STR TRN EA 15 $330PT GAIT STR TRN EA 15 2 $347PT GRP 1 THER PROC 2 $272PT IONTOPHORESIS 15 BSC $173PT MANUAL THERAPY EA 15M $174PT MECH TRACTION COMP $297PT NEUROMUSC RE ED EA15 $173PT ORTH MGMT TRN EA 15 2 $173PT PARAFFIN BATH COMPLX $232PT RE EVAL $101PT RE EVAL LTD $161PT SLF CR HM MGMT EA 15 $165PT THER EX EA 15 $111PT THERAPEUTC ACT EA 15 $165PT THERAPEUTC ACT EA15 2 $173PT US EA 15 CMPLX $263PT WHIRLPOOL BSC $391PT WHLCHR TRN EA 15 $117SP EVAL BEH QUAL A V RS $335SP EVAL CINE VIDEO $753


43 of 154 FY2018

DESCRIPTION CHARGES



SP EVAL FIT VOICE PROSTH $490SP EVAL LNG COM W EXP $318SP EVAL SOUND PRODUCTION $153SP STD COG PERF TEST $251SP SWAL EVAL PHARYN COM $753SP SWAL ORAL TX COMPLX $173SPEECH LANG TX BASIC $258SPEECH LANG TX CMPLX $663SPEECH LANG TX GRP BASIC $420

PHARMACYAA 10 1L TPN $1,333AA 2 75 D10 ELEC 2L TPN $2,342AA 4 25 D5 EL CA 1L TPN $254AA 4 25 D5 EL CA 2L TPN $1,152ACAMPROSATE 333MG EC TB $7ACARBOSE 25MG $4ACARBOSE 50MG TB $9ACEBUTOLOL 200MG CAP $17ACETAZOLAMI UPTO 500MGIJ $118ACETAZOLAMID 500MG XR CP $15ACETAZOLAMIDE 125MG TB $5ACETAZOLAMIDE 250MG TB $8ACETYLCHOLINE CL1 2ML OS $338ACETYLCYSTEINE 20 4ML IS $112ACETYLCYSTEINE20 30ML IS $393ACYCLOVIR 200MG CP $8ACYCLOVIR 5 15GM OI $849ACYCLOVIR 5 30GM OI $1,219ACYCLOVIR PER 5MG IJ $3ADENOSINE PER 1MG IJ $10ADHESION BARRIER 5X6 EA $981AL OH 320 5 30ML LQ $5AL OH GEL TB $10AL SULF CA ACET 120GM PW $10ALBUMIN 5 PER 50ML IJ $510ALBUTEROL 083 3ML IS $15


44 of 154 FY2018

DESCRIPTION CHARGES



ALBUTEROL 2MG TB $9ALBUTEROL HFA 8GM IH $124ALBUTEROL HFA 90MCG IH $120ALBUTEROL IPRATR 3ML IS $23ALBUTEROL IPRATR14 7GMIH $816ALBUTEROL2 5MG 5ML UDIS $21ALENDRONATE 10MG TB $23ALENDRONATE 70MG TB $157ALGINATE 3X4 3 4 DG $63ALISKIREN 150MG TB $10ALLODERM 16X20 PER SQ CM $111ALLODERM 2X4CM $110ALLODERM 4X12 PER SQ CM $64ALLODERM 6X16 PER SQ CM $108ALLODERM 8X16 PER SQ CM $119ALLOGRFT DERM COLL HUMAN $7,592ALLOPURINOL 500MG IJ $1,688ALLOPURINOL100MG TB $8ALLOPURINOL150MG TB $4ALLOPURINOL300MG TB $10ALPRAZOLAM 125MG TB $4ALPRAZOLAM 25MG TB $21ALPRAZOLAM 5MG TB $22AMANTADINE 100MG CP $8AMANTADINE 10M/M 10ML LQ $9AMIKACIN PER 100MG IJ $13AMILORIDE 5MG TB $8AMINOCAPROIC ACID500MGTB $18AMINOPHYLLIN UPTO250MGIJ $29AMIODARONE 100MG TB $22AMIODARONE 200MG TB $29AMIODARONE PER 30MG IJ $111AMITRIPTYLINE 10MG TB $8AMITRIPTYLINE 25MG TB $8AMITRIPTYLINE 50MG TB $9AMLODIPINE 10MG TB $20AMLODIPINE 2 5MG TB $9


45 of 154 FY2018

DESCRIPTION CHARGES



AMLODIPINE 5MG TB $14AMMONIA AROMATIC IH $23AMMONIUM LACT12 225ML LT $102AMOX CLAV 200 5 75ML LQ $330AMOXICILLIN 250MG CP $8AMOXICILLIN CLAV 500MGTB $39AMOXICILLIN CLAV 875MGTB $31AMOXICILN 250 5 100ML LQ $45AMPHET DEXAMPHET 10MG TB $5AMPHETAM MIX 10MG XR TB $6AMPHOTERICIN B 50MG IJ $156AMPICIL SUL PER1 5GM IJ $89ANAGRELIDE 0 5MG CP $35ANASTROZOLE 1MG TB $45ANTITHROMBIN 3 PER 1U IJ $7APA ASA CAF ES TB $4APAP 120MG SU $15APAP 160M 5M 20 3ML LQ $5APAP 325MG SU $5APAP 650MG SU $15APAP 80M 8M 15ML LQ $28APAP BUTAL CAF TB $9APAP COD 120 12 10ML LQ $24APAP COD 120 12 12ML LQ $10APAP COD 30MG TB $19APIXABAN 2 5MG TB $18APIXABAN 5MG TB $16APLIGRAF PER SQ CM $91ARFORMOTEROL15MCG 2ML IS $29ARGATROB N ESRD1MG PMXIJ $22ARGATROBAN NONESRD 1MGIJ $10ARGATROBAN PER 5MG IJ $96ARIPIPRAZOLE 15MG TB $49ARIPIPRAZOLE 2MG TB $69ARIPIPRAZOLE 5MG TB $49ARTHROFLEX PER SQ CM $425ASA 300MG SU $15


46 of 154 FY2018

DESCRIPTION CHARGES



ASA 325MG EC TB $5ASA 325MG TB $4ASA 600MG SU $16ASA 81MG CTB $5ASA 81MG EC TB $4ASCORBIC ACID 250MG TB $4ASCORBIC ACID 500MG TB $8ASENAPINE 5MG TB $58ATENOLOL 12 5MG TB $4ATENOLOL 25MG TB $8ATENOLOL 50MG TB $10ATOMOXETINE 40MG CP $27ATORVASTATIN 10MG TB $22ATORVASTATIN 20MG TB $24ATORVASTATIN 40MG TB $31ATORVASTATIN 5MG TB $4ATORVASTATIN 80MG TB $31ATRACURIUM10MG ML 5ML IJ $65ATROPINE 1 15ML OS $133ATROPINE 1 1ML OS $57ATROPINE 1 5ML OS $14ATROPN HYOSC PB SCOP TB $29AZATHIOPRINE 50MG TB $12AZELASTINE 05 6ML OS $304AZELASTINE NASAL 30ML SP $1,227AZITHROMYCIN 250MG TB $68AZITHROMYCIN PER500MG IJ $169AZTREONAM 2GM IJ $338AZTREONAM 2GM PMX IJ $507BACITRA POLYMYX 3 5GM OO $202BACITRACIN 30GM OI $42BACITRACIN POLYB 10GM PW $72BACITRACIN POLYB 30GM OI $17BACITRACIN POLYB 9GM OI $15BACITRACIN500U 1GM OI $15BACITRACIN500U GM3 5GMOO $19BACLOFEN 10MG TB $8


47 of 154 FY2018

DESCRIPTION CHARGES



BACLOFEN 5MG TB $4BALSALAZIDE 750MG CP $9BCG VACC LIVE INTRAVESIJ $746BECAPLERMIN 01 15GM GL $3,640BECLOMETHASN80MCG7 3GMIH $357BELLADONNA OPIUM 30MGSU $27BENAZEPRIL 20MG TB $10BENAZEPRIL 5MG TB $10BENZO BUTA TETR 56ML SP $515BENZOCAIN 10 5GM MMGL $25BENZOCAINE 20 0 5ML TS $51BENZOCAINE 20 30ML TS $41BENZOCAINE ANTIPYR10MLOT $33BENZOCAINE ANTIPYR15MLOT $26BENZOCAINE MENTH 8PK LZ $5BENZOCAINE20 60ML SP $140BENZONATATE 100MG CP $9BENZONATATE 200MG CP $6BENZTROPINE 0 5MG TB $4BENZTROPINE 1MG TB $8BENZTROPINE PER 1MG IJ $126BETAMETHASON D 05 15GOI $74BETAXOLOL 25 5ML OS $329BETAXOLOL 5 5ML OS $347BETHANECHOL 10MG TB $13BETHANECHOL 25MG TB $16BETHANECHOL 5MG TB $4BICALUTAMIDE 50MG TB $118BIMATOPROST 03 2 5ML OS $357BISACODYL 10MG SU $16BISACODYL 5MG EC TB $9BISMUTH SUBSALI 120ML LQ $20BISMUTH SUBSALI 240ML LQ $20BISOPRL HCTZ 2 5 6 25 TB $10BISOPROL HCTZ 10 6 25 TB $13BISOPROL HCTZ 5 6 25 TB $13BISOPROLOL 5MG TB $13


48 of 154 FY2018

DESCRIPTION CHARGES



BIVALIRUDIN PER 1MG IJ $9BLISTEX 9 9GM OI $16BORTEZOMIB PER 1MG IJ $189BOTULIN TOXN B PER100UIJ $45BOWEL EVACUANT $44BRIMO TIMOL 2 5 5ML OS $431BRIMONIDINE 2 5ML OS $316BRINZOLAMIDE 1 10ML OS $711BRINZOLAMIDE 1 5ML OS $290BROMOCRIPTINE 2 5MG TB $25BSS IRR 15ML OS $55BSS IRR 500ML OS $707BUDE FORMOT160 4 5 6GMIH $651BUDES FORMOT80 4 5 6GMIH $566BUDESONIDE 200MCG PW IH $23BUDESONIDE 25MG 2ML IS $27BUDESONIDE 3MG XR CP $55BUDESONIDE 5MG 2ML IS $38BUDESONIDE NAS 7GM IH $888BUDESONIDE180MCG PW IH $645BUMETANIDE 0 5MG TB $8BUMETANIDE 2MG TB $8BUMETANIDE PER 5MG IJ $11BUPIV 125 W PMP 400LIJ $1,195BUPIVAC EPI 25 10ML IJ $17BUPIVAC EPI 5 10ML IJ $30BUPIVAC EPI 5 50ML IJ $63BUPIVACAIN LIPO PER1MGIJ $7BUPIVACAINE 0.5% 10ML IJ $7BUPIVACAINE 25 50ML IJ $66BUPIVACAINE 5 50ML IJ $174BUPIVACAINE 75 10ML IJ $26BUPROPION 100MG TB $8BUPROPION 100MG XR TB $17BUPROPION 150MG XR TB $18BUPROPION 150MG XR24 TB $24BUPROPION 75MG TB $9


49 of 154 FY2018

DESCRIPTION CHARGES



BUSPIRONE 10MG TB $13BUSPIRONE 2 5MG TB $4BUSPIRONE 5MG TB $9BUTORPHANOL PER 1MG IJ $20CA CARB VITD 250 125TB $8CACL 10 10ML IJ $47CADEXOMER IODIN 9 40GMGL $271CALAMINE 120ML LT $16CALAMINE 180ML LT $7CALCITONIN NS200U 2ML SP $486CALCITONIN UPTO 400U IJ $471CALCITONINNS200U 3 7MLSP $381CALCITRIOL 1MCG/ML ORAL SOLUTION $29CALCITRIOL 1MCG/ML ORAL SOLUTION $29CALCITRIOL 25MCG CP $11CALCIUM ACETATE 667MG TB $8CALCIUM CARB 1 25GM TB $9CALCIUM CARB 500MG TB $4CALCIUM CARB 650MG TB $9CALCIUM CARBONATE CTB $8CALCIUM CITRATE 950MG TB $8CAMPHOR MENTHOL240MLLT $44CANAGLIFLOZIN 100MG TB $40CANDESARTAN 8MG TB $12CANDIDA SKIN TEST PER IJ $81CAPSAICIN 025 60GM CR $66CAPTOPRIL 12 5MG TB $8CAPTOPRIL 25MG TB $9CAPTOPRIL 6 25MG TB $5CARBAMAZE 100 5 450ML LQ $87CARBAMAZEPINE 100MG CTB $12CARBAMAZEPINE 100MG XRTB $18CARBAMAZEPINE 200MG TB $6CARBAMAZEPINE 200MG XRTB $19CARBAMIDE PEROXID15ML LQ $9CARBAMIDE PERX6 5 15MLOT $9CARBIDOPA 25MG TB $7


50 of 154 FY2018

DESCRIPTION CHARGES



CARBIDOPA LEVD 10 100 TB $8CARBIDOPA LEVD 12 50 TB $4CARBIDOPA LEVD 25 100 TB $9CARBIDOPA LEVD 25 250 TB $9CARBIDOPA LEVD25 100XRTB $4CARBIDOPA LEVD50 200XRTB $14CARDIOPLEG SOL 1000ML IJ $416CARISOPRODOL 350MG TB $9CARVEDILOL 12 5MG TB $15CARVEDILOL 25MG TB $17CARVEDILOL 3 125MG TB $14CARVEDILOL 6 25MG TB $16CARVEDL1.563 TB $4CASTOR OIL 60ML LQ $16CEFAZOLIN 500MG IJ $77CEFEPIME PER 500MG IJ $58CEFOTAXIME PER 1GM IJ $96CEFOXITIN PER 1GM PMX IJ $68CEFPODOXIME 100MG TB $18CEFPODOXIME 200MG TB $31CEFTAZIDIME PER 500MG IJ $118CEFTRIAX PER250MG IVPBIJ $51CEFUROXIME 250MG TB $41CEFUROXIME PER 750MG IJ $133CELECOXIB 100MG CP $15CELECOXIB 200MG CP $25CELLULOSE OXIDIZ 1X2 EA $311CELLULOSE OXIDIZ 3X4 EA $245CELLULOSE OXIDIZ 4X8 EA $350CEPHALEXIN 250MG CP $18CEPHALEXIN 500MG CP $47CETIRIZINE 10MG $4CETIRIZINE-PSEUDOEPHEDR 5MG/120MG $6CETYLPYRDN BENZ 1 EA LZ $4CETYLPYRIDINIUM LZ $1CHAR SORB50GM 240ML LQ $98CHARCOAL 250MG TB $2


51 of 154 FY2018

DESCRIPTION CHARGES



CHARCOAL 50GM 240ML LQ $157CHLORDIAZEPOXIDE 10MG CP $29CHLORDIAZEPOXIDE 25MG CP $29CHLORDIAZEPOXIDE 5MG CP $19CHLORDIZ CLID 5 2 5MG CP $8CHLORHEXID 12 480ML MMTS $81CHLORHEXIDINE 15ML LQ $6CHLORHEXIDINE4 480ML TS $86CHLORPHENIRAMINE 4MG TB $7CHLORPROMAZ UPTO 50MG IJ $54CHLORPROMAZINE 10MG TB $5CHLORPROMAZINE 25MG TB $8CHLORTHALIDONE 25MG TB $8CHLORZOXAZONE 500MG TB $9CILOSTAZOL 100MG TB $15CILOSTAZOL 50MG TB $15CINACALCET 30MG TB $83CIPROFLOX DEXM 7 5ML OT $454CIPROFLOX PER200MG PMXIJ $42CIPROFLOXACIN 250MG TB $43CIPROFLOXACIN 3 2 5MLOS $377CIPROFLOXACIN 3 3 5GM OO $272CIPROFLOXACIN 3 5ML OS $161CIPROFLOXACIN 500MGTB $50CISATRACURM 2MG ML10MLIJ $408CITALOPRAM 10MG TB $13CITALOPRAM 20MG TB $20CITALOPRAM 40MG TB $22CITRATE MG 300ML LQ $13CLARITHROMYCIN 250MG TB $43CLARITHROMYCIN 500MG TB $43CLINDAMYCIN 1 60ML TS $191CLINDAMYCIN 150MG CP $10CLINDAMYCIN PER 300MG IJ $106CLOBETASOL 05 15GM CR $232CLOBETASOL 05 30GM CR $131CLOMIPRAMINE 25MG CP $8


52 of 154 FY2018

DESCRIPTION CHARGES



CLONAZEPAM 1MG TB $29CLONAZEPAM 25MG DT $4CLONAZEPAM 5MG TB $19CLONIDINE 0 1MG TB $8CLONIDINE 0 2MG TB $8CLONIDINE 1MG XR TD $143CLONIDINE 2MG XR TD $241CLONIDINE 3MG XR TD $368CLOPIDOGREL 300MG TB $77CLOPIDOGREL 75MG TB $19CLORAZEPATE 3 75MG TB $19CLORAZEPATE 7 5MG TB $26CLOTRIMAZ BETAMET 15GMCR $96CLOTRIMAZOLE 1 15GM CR $74CLOTRIMAZOLE 1 45GM VCR $102CLOTRIMAZOLE 10MG LZ $14CLOZAPINE 100MG TB $37CLOZAPINE 25MG TB $15COCAINE 4 4ML TS $204CODEINE 30MG TB $17CODEINE PER 30MG IJ $46COLCHICINE 6MG CP $16COLCHICINE 6MG TB $23COLESEVELAM 625MG TB $7COLESTIPOL 1GM TB $4COLISTIMETHA UPTO150MGIJ $316COLLAGENASE250U GM15GMOI $205COLLAGENASE250U GM30GMOI $369CONJ ESTROG SYN1 25MG TB $7CONJ ESTROGEN 3MG TB $8CONJ ESTROGEN 625MG TB $10CONJUGAT ESTRGN 30GM VCR $1,140CONJUGAT ESTRGN42 5GMVCR $680CONJUGATED ESTR 1 25MG $11CORTISONE 25MG TB $10CORTROSYN PER 25MG IJ $678CROTAMITON 10 60ML LT $56


53 of 154 FY2018

DESCRIPTION CHARGES



CRRT REPL B32 K4 CA2 5L $384CRRT REPL B32/CA0 5L $150CRRT REPL B32/K2/CA3 5L $150CYANIDE HYDROCOBL KT IJ $3,450CYCLOBENZAPRINE 10MG TB $8CYCLOBENZAPRINE 5MG TB $9CYCLOPENTOLATE 1 2ML OS $111CYCLOPENTOLATE 2 2ML OS $144CYCLOPENTOLATE 2 5ML OS $130CYCLOPHOSPH PER 100MG IJ $54CYCLOPHOSPHAMIDE 25MG TB $20CYCLOSPORIN 100MG CP $30CYCLOSPORIN 25MG CP $11CYCLOSPORINE 05 4ML OS $25CYCLOSPORINE 25MG GEL CP $9CYPROHEPTADINE 4MG TB $9D10W 1000ML TPN $283D10W 500ML TPN $109D20W 500ML TPN $94D5 100ML IVF $174D5 250ML IVF $36D5 500ML IVF $181D5 50ML IVF $173D5 L RINGERS 1000ML IVF $36D5 L RINGERS 500ML IVF $268D5 NACL 0 2 1000ML IVF $270D5 NACL 0 2 500ML IVF $239D5 NACL 0 45 1000ML IVF $40D5 NACL 0 45 250ML IVF $36D5 NACL 0 45 500ML IVF $146D5 NACL 0 9 1000ML IVF $38D5 NACL 0 9 500ML IVF $186D5 NACL 2 KCL40 1L IVF $275D5 NACL 45 KCL20 1L IVF $370D5 NACL 45 KCL40 1L IVF $272D5 NACL 9 KCL20 1L IVF $22D5W 1000ML IVF $38


54 of 154 FY2018

DESCRIPTION CHARGES



D70W 1000ML TPN $1,471DABIGATRAN 75MG CP $19DALTEPARIN PER 2500U IJ $105DANTROLENE 25MG CP $9DAPAGLIFLOZIN 5MG TB $45DAPSONE 100MG TB $10DARBEPO ALFA PER 1MCG IJ $18DEMECLOCYCLINE 150MG TB $86DERMAGRAFT PER SQ CM $117DESFLURANE 240ML IA $1,418DESFLURANE PER DOSE IA 58. $676DESIPRAMINE 25MG TB $10DESLORATADINE 5MG TB $19DESMOPRESSIN 01 5ML SP $2,168DESMOPRESSIN 1MG TB $13DESMOPRESSIN PER 1MCG IJ $19DESOXIMETASONE 25 60GMOI $430DESVENLAFAXINE 50MG XRTB $18DEXAMETH NEO POLY 5ML OS $96DEXAMETH NEO POLY3 5GMOO $66DEXAMETHASONE 1 5ML OS $301DEXAMETHASONE 4MG TB $10DEXAMETHASONE 5MG TB $8DEXMEDETM400MCG 100PMXIJ $650DEXMEDETOMIDINE200MCGIJ $391DEXTRAN40NACL 9 500MLIVF $2,601DEXTROSE 50 50ML IJ $91DIATR MEGNASOL66 10 120M $284DIATR MEGNASOL66 10 30ML $112DIAZEPAM 10MG TB $26DIAZEPAM 2MG TB $19DIAZEPAM 5MG TB $24DIAZEPAM UPTO 5MG SG IJ $29DIBUCAINE 1 30GM OI $20DICLOFENAC 1 100GM GL $195DICLOFENAC 1 2 5ML OS $287DICLOFENAC NA 25MG XRTB $8


55 of 154 FY2018

DESCRIPTION CHARGES



DICLOFENAC NA 75MG XRTB $10DICLOXACIL 250MG CP $10DICYCLOMINE 10MG CP $8DICYCLOMINE UPTO 20MG IJ $137DIGOXIN 0 0625MG TB $9DIGOXIN 0 125MG TB $8DIGOXIN 0 25MG TB $9DIGOXIN 05MG ML 5ML LQ $21DIGOXIN 05MG ML 60ML LQ $14DIGOXIN 1MG ML PEDI IJ $148DIGOXIN IMM FB PER VL IJ $13,463DIGOXIN UPTO 5MG IJ $34DIHYDROERGOTAM PER1MGIJ $361DILTIAZEM 120MG XR24 CP $10DILTIAZEM 125 MG IJ $654DILTIAZEM 180MG XR24 CP $13DILTIAZEM 240MG XR24 CP $14DILTIAZEM 25 MG IJ $162DILTIAZEM 300MG XR CP $21DILTIAZEM 300MG XR24 CP $16DILTIAZEM 30MG TB $8DILTIAZEM 60MG TB $9DILTIAZEM 60MG XR CP $9DILTIAZEM 90MG XR CP $10DIMETHYL SULFOX 50 50ML $437DIPHENHYD ZINC 2 30GMCR $16DIPHENHYDR UPTO 50MG IJ $49DIPHENHYDRA 2 30GM CR $23DIPHENHYDRAMINE 25MG CP $8DIPHENHYDRAMINE 50MG CP $9DIPHENOX ATROP 2 5 TB $14DIPHTHER TET 7YR PF IJ $113DIPIVEFRIN 1 5ML OS $116DIPYRDAML ASA200 25 XRCP $18DIPYRIDAMOLE 25MG TB $8DIPYRIDAMOLE 50MG TB $9DISOPYRAMIDE 150MG TB $6


56 of 154 FY2018

DESCRIPTION CHARGES



DIVALPROX NA 125MG EC TB $9DIVALPROX NA 125MG XR CP $9DIVALPROX NA 250MG EC TB $9DIVALPROX NA 250MG XR TB $7DIVALPROX NA 500MG EC TB $13DIVALPROX NA 500MG XR TB $18DOBUTAMINE PER250MG IJ $57DOBUTAMN PER250MG PMX IJ $316DOCETAXEL PER 1MG IJ $92DOCOSANOL 10 2GM CR $130DOCUSATE 100MG 10ML LQ $6DOCUSATE 100MG CP $9DOCUSATE SENNA TB $6DOFETILDE 125MG CP $16DOFETILDE 25MG CP $16DOFETILDE 5MG CP $16DOLASETRON PER 10MG IJ $170DONEPEZIL 5MG TB $42DOPAMINE PER40MG PMX IJ $24DORNASE ALF2 5MG 2 5MLIS $597DORZOLAMIDE 2 10ML OS $191DORZOLAMIDE 2 5ML OS $239DORZOLAMIDE TIMOLO10MLOS $280DORZOLAMIDE TIMOLOL5MLOS $414DOXAPRAM 20MG ML 20ML IJ $733DOXAZOSIN 1MG TB $9DOXAZOSIN 4MG TB $11DOXEPIN 10MG CP $9DOXEPIN 25MG CP $10DOXORUBICIN PER 10MG IJ $69DOXYCYCLINE 100MG CP $10DOXYCYCLINE 100MG IJ $202DOXYCYCLINE 100MG TB $5DOXYCYCLINE 50MG CP $4DRONABINOL 2 5MG CP $36DRONEDARONE 400MG TB $19DROPERIDOL UPTO 5MG IJ $74


57 of 154 FY2018

DESCRIPTION CHARGES



DTAP VACC <7YR IF $114DULOXETINE 20MG XR CP $23DULOXETINE 30MG XR CP $25DULOXETINE 60MG XR CP $29DX I131 SOD CAP PER MCI $521ECONAZOLE 1 15GM CR $86EFAVIRENZ 600MG TB $112ELETRIPTAN 20MG TB $77EMOLLIENT 120GM CR $63EMOLLIENT 180ML LT $23EMOLLIENT 360ML LT $62EMTRICITBINE/TENFOVIR 200/300 TB $131ENALAPRIL 2 5MG 2ML IJ $162ENALAPRIL 2 5MG TB $5ENALAPRIL 20MG TB $14ENALAPRIL 5MG TB $10ENALAPRIL1 25MG 1ML IJ $207ENOXAPARN PER 10MG PFSIJ $40ENTACAPONE 200MG TB $15EPHEDRINE 25MG 1ML IJ $63EPHEDRINE 50MG 1ML IJ $127EPHEDRINE25MGNS 5MLPFSIJ $51EPIFIX INJECT PER 1MG $58EPIFIX PER SQ CM $485EPINEPHRINE 2 25 5ML IS $24EPINEPHRINE PER 0 1MG IJ $6EPINEPHRINE1 1000 30MLTS $265EPLERENONE 25MG TB $23EPOETIN ESRD PER 100U IJ $8EPOETIN NON ESRD1000U IJ $74EPOPROSTENOL DILUE50MLIJ $72EPOPROSTENOL PER 5MG IJ $88EPTIFIBATIDE PER 5MG IJ $165ERGOCALCIFEROL 50000U CP $9ERTAPENEM PER 500MG IJ $260ERYTHROMY200 5 100ML LQ $903ERYTHROMYC BASE 250MG TB $14


58 of 154 FY2018

DESCRIPTION CHARGES



ERYTHROMYCIN 2 30GM GL $109ERYTHROMYCIN 5 3 5GM OO $55ERYTHROMYCIN LA500MG IJ $46ESCITALOPRAM 10MG TB $21ESCITALOPRAM 20MG TB $25ESCITALOPRAM 5MG TB $22ESMOLOL 10MG ML 10ML IJ $448ESMOLOL NACL 250ML PMXIJ $850ESMOLOL250MG ML 10ML IJ $1,506ESOMEPRAZOL40MGXR PWLQ $31ESOMEPRAZOLE 40MG IJ $172ESTRADIOL 0 5MG TB $4ESTRADIOL 05BIWK EA TD $35ESTRADIOL 1MG GM42 5GMCR $338ESTRADIOL 1MG TB $12ESTROG METH 625 1 25MGTB $11ESTROGEN CONJ PER25MG IJ $1,383ESTROPIPATE 0 625MG TB $19ESTROPIPATE 0 75MG TB $4ETHACRYNIC ACID 25MG TB $6ETHAMBUTOL 100MG TB $6ETHAMBUTOL 400MG TB $4ETHYL CHLORIDE 105ML SP $89ETHYL CL 100ML SP $156ETIDRONATE 200MG TB $20ETODOLAC 200MG CP $17ETODOLAC 400MG TB $31ETOMIDATE20MG 10ML IJ $487ETOPOSIDE 50MG CP $213ETOPOSIDE PER 10MG IJ $9EXEMESTANE 25MG TB $41EXENATIDE 5MCG 60 DS IJ $950EYEWASH SOLUTION 4OZ $10EZETIMIBE 10MG TB $15EZETIMIBE 5MG TB $14FAC 8 VWF CMPL PER 1U IJ $6FACTOR VIIA PER 1MCG IJ $5


59 of 154 FY2018

DESCRIPTION CHARGES



FAMCICLOVIR 125MG TB $29FAMCICLOVIR 250MG TB $30FAMOTIDINE 20MG TB $15FAMOTIDINE PER 20MG IJ $217FAT EMULS 10 500ML TPN $507FAT EMULS 20 250ML TPN $215FAT EMULS 20 500ML TPN $581FE DEXTRAN PER 50MG IJ $181FE POLY ASC AC 150 50 CP $9FE POLYSACCHAR 150MG CP $6FEBUXOSTAT 40MG TB $24FELBAMATE 400MG TB $14FELODIPINE 2 5MG XR TB $12FELODIPINE 5MG XR TB $11FENOFIBRATE 145MG TB $13FENOFIBRATE 160MG TB $29FENOFIBRATE 48MG TB $7FENOFIBRATE 54MG TB $9FENOLDOPAM 10MG 1ML IJ $2,183FENTANYL 100MCG HR TD $206FENTANYL 12MCG HR TD $91FENTANYL 25MCG HR TD $56FENTANYL 50MCG HR TD $102FENTANYL 75MCG HR TD $155FENTANYL PER 0 1MG IJ $44FERRIC SUBSULFATE 8ML TS $54FERROUS SULFATE 325MG TB $8FEXOFENADINE 180MG TB $21FEXOFENADINE 60MG TB $10FILGRASTIM G CSF 1MCG IJ $5FINASTERIDE 5MG TB $23FLAVOXATE 100MG TB $7FLECAINIDE 100MG TB $28FLECAINIDE 50MG TB $6FLU VAC ?6MONTH 4 VAL PF IJ $92FLU VAC 3 YRS IM PF IJ $84FLU VAC 3Y AFLURIA IM IJ $51


60 of 154 FY2018

DESCRIPTION CHARGES



FLU VAC 3Y FLUVIRN IM IJ $62FLU VAC CELL CULT PF IJ $111FLU VACC NOS IJ $62FLUCONAZ PER200MG PMX IJ $457FLUCONAZOLE 100MG PMX IJ $44FLUCONAZOLE 100MG TB $80FLUCONAZOLE 150MG TB $43FLUCYTOSINE 250MG CP $23FLUCYTOSINE 500MG CP $153FLUDROCORTISONE 1MG TB $8FLUMAZENIL 1MG ML 5MLIJ $285FLUMAZENIL 1MG ML10MLIJ $1,678FLUNISOLIDE 250MCG7GM IH $957FLUNISOLIDE 25MCG25ML SP $650FLUOCINOLONE 025 15GMCR $46FLUOCINONIDE 05 15GM CR $78FLUORESCEIN STRIP 1 EACH $55FLUOROMETHALONE 1 5MLOS $117FLUOXETINE 10MG CP $29FLUOXETINE 20MG CP $33FLUOXETINE20MG 5ML LQ $48FLUPHENAZ 2 5MG ML10MLIJ $1,440FLUPHENAZ DC UPTO25MG IJ $155FLUPHENAZINE 1MG TB $9FLUPHENAZINE 5MG TB $11FLURBIPROFEN 03 2 5ML OS $72FLUT SALM 100 50 14DS IH $406FLUT SALM 100 50 28DS IH $37FLUT SALM 250 50 14DS IH $406FLUT SALM 250 50 28DS IH $45FLUT SALM 500 50 14DS IH $661FLUT SALM 500 50 28DS IH $64FLUTICASONE 05MG16GM SP $224FLUTICASONE 110MCG 7 9GM $736FLUTICASONE110MCG12GM IH $531FLUTICASONE220MCG12GM IH $825FLUTICASONE220MCG7 9GMIH $1,164


61 of 154 FY2018

DESCRIPTION CHARGES



FLUTICASONE44MCG10 6GMIH $397FLUTICASONE44MCG7 9GM IH $593FLUVOXAMINE 50MG TB $28FOLIC ACID 1MG TB $9FOLIC ACID 400MCG TB $6FOLIC ACID 50MG 10ML IJ $51FONDAPARINUX PER 5MG IJ $44FORMOTER12MCG 12BX IH CP $313FOSAPREPITANT PER 1MG IJ $10FOSINOPRIL 10MG TB $12FOSINOPRIL 40MG TB $12FOSPHENYTOIN PER 50MG IJ $89FUROSEMIDE 20MG TB $8FUROSEMIDE 40MG 5ML LQ $15FUROSEMIDE 40MG TB $8FUROSEMIDE 80MG TB $8FUROSEMIDE UPTO 20MG IJ $16GA67 CITRATE 1MCI $108GABAPENTIN 100MG CP $8GABAPENTIN 300MG CP $14GABAPENTIN 400MG CP $15GADOBUTROL PER 0 1ML IJ $6GALANTAMINE 4MG TB $22GANCICLOVIR 500MG IJ $213GELATIN ABS OPTH FILM $471GELATIN ABS STER 1GM PK $396GELATIN FILM OPHTHALM EA $448GELATIN SPONG ABS100SZEA $426GELATIN SPONGE ABS12X7EA $84GELATIN SPONGE ABS1GM PW $678GEMCITABINE PER 200MG IJ $360GEMFIBROZIL 600MG TB $8GENTAMICIN 1 15GM CR $28GENTAMICIN 1 15GM OI $37GENTAMICIN 3 3 5GM OO $119GENTAMICIN 3 5ML OS $64GENTAMICIN UPTO 80 PMXIJ $44


62 of 154 FY2018

DESCRIPTION CHARGES



GENTAMICIN UPTO 80MG IJ $57GF CODEINE10 100 5 10LQ $7GLATIRAMR ACET PER20MGIJ $397GLIMEPIRIDE .5 TB $4GLIMEPIRIDE 1MG TB $5GLIMEPIRIDE 2MG TB $9GLIMEPIRIDE 4MG TB $9GLIPIZIDE 10MG TB $11GLIPIZIDE 10MG XR TB $14GLIPIZIDE 2 5MG TB $4GLIPIZIDE 2 5MG XR TB $6GLIPIZIDE 5MG TB $9GLIPIZIDE 5MG TB. $10GLUCAGON PER 1MG IJ $320GLYBURIDE 1 25MG TB $4GLYBURIDE 2 5MG TB $8GLYBURIDE 5MG TB $9GLYBURIDE MIC 3MG TB $9GLYCERIN ADULT SU $10GLYCOPYRROL 2MG 1ML IJ $97GLYCOPYRROL 2MG ML 2MLIJ $122GLYCOPYRROL 2MG ML 5MLIJ $152GLYCOPYRROLATE 1MG TB $9GRAFTJACKET PER SQ CM $252GRFT ALLODERM PER SQ CM $74GUAF 100MG 5ML 10ML LQ $4GUAIFENESIN 600MG XR TB $26GUAIFENESIN DM 600 30 TB $6GUANFACINE 1MG TB $18HAEMOPH B PRP T VAC IJ $109HALOPERID DEC PER 50MGIJ $149HALOPERIDOL 1MG TB $8HALOPERIDOL 2MG TB $9HALOPERIDOL 5MG TB $4HALOPERIDOL 5MG TB. $13HALOPERIDOL UP TO 5MG IJ $80HALOPERIDOL2MG ML120MLLQ $427


63 of 154 FY2018

DESCRIPTION CHARGES



HCTS 1 30GM CR $38HCTS 100MG 60ML RE $120HCTS 2 5 30GM CR $84HCTS 2 5 60ML LT $204HCTS 25MG SU $85HCTS 30MG SU $150HCTS 5 30GM CR $11HCTS 5 30GM OI $20HCTS PRAMOX 10GM R FOAM $187HCTS SS PER 100MG IJ $28HCTZ 12 5MG CP $8HCTZ 12 5MG TB $13HCTZ 25MG TB $9HCTZ 6 25MG TB $7HEP B VAC ADULT IJ $146HEP B VAC PED ADOL3DS IJ $103HEPARIN PER 1000U IJ $5HEPARIN PER 1000U PMX IJ $8HEPATITIS B IMMUNE GLOBULIN 1ML $490HETASTARCH 6 500ML IJ $951HOCM 149MG ML ID 1ML $1HOMATROPINE 2 5ML OS $171HOMATROPINE 5 5ML OS $196HUMAN ALBUMIN MICRO 1ML $218HYALURON CHONDR 5ML IJ $1,015HYALURON HYLGN PER DS IJ $701HYALURON10MG ML 55MLSGIJ $789HYALURON10MG ML 85MLSGIJ $1,198HYALURONIDASE RECOMB 1U $2HYDRALAZINE 10MG TB $8HYDRALAZINE 25MG TB $9HYDRALAZINE 50MG TB $10HYDRALAZINE 5MG TB $4HYDRALAZINE UPTO 20MG IJ $143HYDROCOD APAP 10 325 TB $11HYDROCOD APAP 10ML LQ $32HYDROCOD APAP 15ML LQ $28


64 of 154 FY2018

DESCRIPTION CHARGES



HYDROCOD APAP 5 325 TB $21HYDROCOD APAP 5 500 TB $7HYDROCOD APAP 7 5 325TB $8HYDROCOD APAP 7 5 500TB $29HYDROCOD CPM 10ML XR LQ $20HYDROCOD CPM 5ML XR LQ $20HYDROCORTISONE 10MG TB $8HYDROCORTISONE 5MG TB $4HYDROMORPH PER4MG PCA IJ $48HYDROMORPHONE 1MG TB $4HYDROMORPHONE 2MG TB $4HYDROMORPHONE 4MG TB $4HYDROMORPHONE UPTO4MG IJ $77HYDROXYCHLOROQUN200MG TB $10HYDROXYUREA 500MG CP $10HYDROXYZINE 10MG TB $8HYDROXYZINE 25MG TB $10HYDROXYZINE UPTO25MGIJ $45HYOSCYAMINE 125MG 5MLLQ $4HYOSCYAMINE 125MG TB $8HYOSCYAMINE 375MG XR CP $8I 123 SOD CAP PER 100UCI $562IBUPROFEN 100 5 120ML LQ $53IBUPROFEN 200MG TB $8IBUPROFEN 400MG TB $8IBUPROFEN 600MG TB $9IBUPROFEN 800MG TB $16IBUTILIDE PER 1MG IJ $927IDARUCIZUMAB 5GM IJ $11,025IMATINIB 100MG TB $123IMIPENEM CIL PER250MG IJ $89IMIPRAMINE 10MG TB $8IMIPRAMINE 25MG TB $9IMP ALLODERM PER SQ CM $123IN111 DTPA 5MCI $936IN111 OXINE 5MCI $4,600IND 111 PENTTREOTDE DOSE $8,845


65 of 154 FY2018

DESCRIPTION CHARGES



INDAPAMIDE 1 25MG TB $4INDAPAMIDE 2 5MG TB $9INDIGO CARMIN8MG ML5MLIJ $199INDOCYANINE GRN 25MG IJ $492INDOMETHACIN 25MG CP $18INDOMETHACIN 75MG XR CP $16INFLIXIMAB BIOSIM 10MGIJ $477INS ANALG LISP75 25 10ML $631INS ANALOG ASP 70 30DOSE $32INS ANALOG ASPAR 10ML $374INS ANALOG ASPAR 3ML $199INS ANALOG ASPAR DOSE $32INS ANALOG ASPR70 30 3ML $199INS ANALOG LISPRO 10ML $631INS ANALOG LISPRO DOSE $30INS ASPART PER 5U IJ $7INS DETEMIR 1 UNIT IJ $4INS DETEMIR DOSE IJ $41INS DETEMIR PEN 3ML $190INS DETEMR PER 5U IJ $7INS GLARG PER 5U IJ $7INS GLARGINE 10ML $573INS GLARGINE DOSE $28INS GLULISINE 3ML PEN IJ $212INS HUM 70 30 10ML $287INS HUM 70 30 DOSE $28INS HUM NPH 10ML $287INS HUM NPH DOSE $28INS HUM REG 10ML $287INS HUM REG DOSE $28INS HUM ULTRALENTE 10ML $287INS LISP 75 25 PER 5U IJ $7INS LISPRO PER 5U IJ $7INS N R 50 50 PER 5U IJ $7INS N R 70 30 PER 5U IJ $6INS NPH HUM PER 5U IJ $6INS REG HUM PER 5U IJ $6


66 of 154 FY2018

DESCRIPTION CHARGES



INTEGRA 2LAY 5X5 SQ CM $354INTEGRA 2LAYR MTRX SQ CM $377INTEGRA 2X2 PER SQ CM $932INTEGRA 4X5 PER SQ CM $6,215INTERFER B 1A 1MCG SQ IJ $63IPRATROPIUM 02 2 5ML IS $22IPRATROPIUM PER DOSE IH $20IPRATROPIUM17MCG12 9GMIH $307IPRATROPIUM18MCG14GM IH $742IPRATROPIUMNAS 03 30MLSP $202IPRATROPIUMNAS 06 15MLSP $308IRBESARTAN 150MG TB $21IRBESARTAN 75 MG TB $16IRON SUCROSE PER 1MG IJ $4IRRIGANT OPHTH 15ML OS $57IRRIGANT OPHTH 30ML OS $50ISOFLURANE 100ML IA $1,708ISOFLURANE PER DOSE IA $34ISOLYTE S 1000ML IVF $546ISONIAZID 100MGTB $9ISOPROTERENOL 1MG 5ML IJ $1,345ISOSORBIDE DN 10MG TB $9ISOSORBIDE DN 20MG TB $9ISOSORBIDE DN 40MG XR TB $10ISOSORBIDE DN 5MG TB $4ISOSORBIDE MN 10MG TB $4ISOSORBIDE MN 15MG XR TB $4ISOSORBIDE MN 20MG TB $10ISOSORBIDE MN 30MG XR TB $17ISOSORBIDE MN 60MG XR TB $18ISOSULFAN BLUE PER1MG IJ $60ISRADIPINE 2 5MG CP $11IVIG LYOP PWD PER500MGIJ $154IVIG OCTAGAM PER 500MGIJ $240IVIG PRIVIGEN PER500MGIJ $149K ACET 40MEQ 20ML IJ $47K IODIDE 1GM ML 30ML LQ $68


67 of 154 FY2018

DESCRIPTION CHARGES



K PHOS 3MM ML 15ML IJ $47KAOLIN PECTIN 30ML LQ $6KCL 20MEQ PK PWLQ $18KCL PER 2MEQ IJ $2KCL PER 2MEQ PMX IJ $11KETAMINE 50MG ML 10ML IJ $191KETAMINE 50MG/5ML SYRINGE $20KETOCONAZL SHMP2 120MLSH $85KETOCONAZOLE 2 15GM CR $198KETOCONAZOLE 200MG TB $26KETOROLAC 0 5 3ML OS $228KETOROLAC 0 5 5ML OS $549KETOROLAC 10MG TB $39KETOROLAC PER 15MG IJ $62KETOTIFEN 025 5ML OS $64L RINGERS 1000ML IVF $38L RINGERS 500ML IVF $24LABETALOL 100MG TB $23LABETALOL 200MG TB $54LABETALOL 5MG ML4MLSGIJ $38LABETALOL5MG ML 20ML IJ $380LACOSAMIDE 50MG TB $20LACTASE 3000U TB $4LACTASE ENZYME $9LACTOBACILLUS TB CP $2LAMIVUDINE 150MG TB $45LAMOTRIGINE 100MG TB $25LAMOTRIGINE 25MG TB $15LANSOPRAZOLE 30MG XR CP $38LANTHANUM CARB 500MG CTB $29LATANOPROST 005 2 5MLOS $457LEFLUNOMIDE 10MG TB $74LEPIRUDIN PER 50MG IJ $408LETROZOLE 2 5MG TB $48LEUCOVORIN 5MG TB $16LEUCOVORIN PER 50MG IJ $254LEVALBUTERL1 25MG 5MLIS $29


68 of 154 FY2018

DESCRIPTION CHARGES



LEVALBUTEROL 63MG 3ML IS $30LEVALBUTEROL1 25MG 3MLIS $5LEVETIRACET PER10MGPMXIJ $3LEVETIRACETAM 250MG TB $4LEVETIRACETAM 500MG TB $19LEVETIRACETAM PER10MG IJ $5LEVETIRACETAM500MG 5MLLQ $39LEVOBUNOLOL 5 5ML OS $130LEVOCARNITINE PER 1GM IJ $236LEVOFLOXAC PER250MGPMXIJ $231LEVOFLOXACIN 250MG TB $69LEVOFLOXACIN 500MG TB $79LEVOFLOXACIN 750MG TB $89LEVOMILNACIPRAN 40MGXRCP $27LEVOTHYROXIN 025MG TB $8LEVOTHYROXIN 05MG TB $8LEVOTHYROXIN 075MG TB $9LEVOTHYROXIN 088MG TB $10LEVOTHYROXIN 112MG TB $9LEVOTHYROXIN 125MG TB $9LEVOTHYROXIN 137MG TB $6LEVOTHYROXIN 15MG TB $10LEVOTHYROXIN 175MG TB $6LEVOTHYROXIN 1MG TB $9LEVOTHYROXIN 2MG TB $9LEVOTHYROXINE 1MG IJ $299LEVOTHYROXINE 5MG IJ $97LIDO PRILOC 2 5 5GM CR $88LIDOCAIN IV PER10MGPMXIJ $1LIDOCAINE 1 20ML PF IJ $144LIDOCAINE 1 2ML PF IJ $31LIDOCAINE 1 30ML PF IJ $98LIDOCAINE 1 BUFF CMD IJ $16LIDOCAINE 1 EPI 20ML IJ $109LIDOCAINE 1 EPI 30ML IJ $163LIDOCAINE 1 EPI 50ML IJ $17LIDOCAINE 1 PER DS IJ $14


69 of 154 FY2018

DESCRIPTION CHARGES



LIDOCAINE 1% 10ML PFS $22LIDOCAINE 1% 5ML PFS $20LIDOCAINE 2 10ML GL $183LIDOCAINE 2 10ML PF IJ $137LIDOCAINE 2 15ML TS $5LIDOCAINE 2 20ML IJ $101LIDOCAINE 2 20ML TS $8LIDOCAINE 2 2ML PF IJ $82LIDOCAINE 2 30GM GL $251LIDOCAINE 2 5ML GL $58LIDOCAINE 2 5ML PF IJ $20LIDOCAINE 2 6ML GL $24LIDOCAINE 2 EPI 20ML IJ $124LIDOCAINE 4 10ML TS $189LIDOCAINE 4 4ML TS $156LIDOCAINE 4 50ML TS $118LIDOCAINE 4 5ML PF IJ $78LIDOCAINE 5 30GM CR $77LIDOCAINE 5 35GM OI $151LIDOCAINE 5 50ML PF IJ $102LIDOCAINE 5 EPI 50ML IJ $140LIDOCAINE 5 TD $47LIDOCAINE DEXTR 5 2MLIJ $159LIDOCAINE VISC 2 15MLLQ $5LIDOCAINE VISC 2 20 LQ $10LIDOCAINE100MG 5ML SG IJ $190LIDOCAINE2 UROJET 10MLGL $51LIDOCAINE2 UROJET 5MLGL $23LINACLOTIDE 145MCG CP $32LINAGLIPTIN 5MG TB $35LINEZOLID 600MG TB $343LINEZOLID PER 200MG IJ $764LIOTHYRONINE 25MCG TB $14LIOTHYRONINE 5MCG TB $9LIRAGLUTIDE 18MG 3ML IJ $564LISINOPRIL 10MG TB $11LISINOPRIL 2 5MG TB $5


70 of 154 FY2018

DESCRIPTION CHARGES



LISINOPRIL 20MG TB $12LISINOPRIL 40MG TB $14LISINOPRIL 5MG TB $10LISINOPRL HCTZ10 12 5 TB $4LISINOPRL HCTZ20 12 5 TB $4LITHIUM 150MG CP $9LITHIUM 300MG CP $9LITHIUM 450MG XR TB $9LITHIUM CARB 300MG XR TB $9LOCM 200 299MG ML ID 1ML $21LOCM 300 399MG ML ID 1ML $5LOPERAMIDE 2MG CP $9LOPINAV RITONA 200 50 TB $36LORATADINE 10MG TB $30LORATADINE 5MG 5ML LQ $4LORATADINE 5MG CTB $4LORAZEPAM 1MG TB $26LORAZEPAM 2MG TB $30LORAZEPAM 5MG TB $21LORAZEPAM PER 2MG IJ $61LORAZEPAM2MG 1ML LQ $6LOSARTAN 12 5MG TB $4LOSARTAN 25MG TB $14LOSARTAN 50MG TB $14LOSARTAN HCTZ50 12 5 TB $7LOTEPREDNOL 5 5ML OS $266LOVASTATIN 10MG TB $4LOVASTATIN 20MG TB $11LOXAPINE 25MG CP $18LOXAPINE 5MG CP $6LUBIPROSTONE 24MCG CP $13LUBIPROSTONE 8MCG CP $18LURASIDONE 20MG TB $89LURASIDONE 80MG TB $81MAG SULF PER 500MG IJ $4MAG SULF PER 500MG PMXIJ $20MAGNESIUM OXIDE 250MG TB $6


71 of 154 FY2018

DESCRIPTION CHARGES



MAGNESIUM OXIDE 400MG TB $9MANNITOL 20 500ML IVF $1,092MANNITOL 25 50ML IJ $48MATRIX HD PER SQ CM $275MATRX ACEL MICRONZ PRTCL $4,584MECLIZINE 12 5MG TB $9MECLIZINE TAB 25MG TB $9MEDROXYPROGEST 10MG TB $18MEDROXYPROGEST 2 5MG TB $22MEDROXYPROGEST PER 1MGIJ $2MEGESTROL 40MG TB $24MELATONIN 5MG TABLET $2MELOXICAM 7 5MG TB $17MEMANTINE 10MG TB $17MEMANTINE 14MG XR CP $38MEMANTINE 28MG XR CP $36MEMANTINE 5MG TB $10MEMANTINE ER 7MG $15MENINGOCOCCAL VAC IM IJ $606MENINGOCOCCAL VAC SQ IJ $475MENTHOL PHENOL LZ $9MEPERIDINE 50MG IJ $111MEPERIDINE 50MG TB $21MEPERIDINE PER 100MG IJ $123MEPERIDINE PER 100MG PCA $83MEPIVACAIN 1 PER10ML IJ $6MEPIVACAIN 2 PER10ML IJ $22MERCAPTOPURINE 50MG TB $18MEROPENEM PER 100MG IJ $34MESALAMINE 1 2GM EC TB $25MESALAMINE 1000MG SU $41MESALAMINE 250MG XR CP $8MESALAMINE 375MG XR CP $10MESALAMINE 400MG EC TB $10MESALAMINE 400MG XR CP $8MESALAMINE 4G 60ML RE $151MESALAMINE 500MG SU $29


72 of 154 FY2018

DESCRIPTION CHARGES



MESALAMINE 800MG XR TB $27METAXOLONE 400MG TB $24METAXOLONE 800MG TB $17METFORMIN 250MG TB $4METFORMIN 500MG TB $16METFORMIN 500MG XR TB $27METFORMIN 750MG XR TB $4METFORMIN 850MG TB $16METHADONE 5MG TB $16METHAZOLAMIDE 50MG TB $8METHIMAZOLE 10MG TB $19METHIMAZOLE 5MG TB $4METHOCARBAMOL 500MG TB $19METHOCARBAMOL 750MG TB $22METHOCARBAMOL UPTO10MLIJ $204METHOHEXITAL 500MG IJ $306METHOTREXATE 2 5MG TB $43METHOTREXATE PER 50MG IJ $28METHYL SAL MENTH 30GM OI $21METHYL SALICY 90GM CR $9METHYLDOPA 250MG TB $9METHYLEN BLUE PER 1MG IJ $18METHYLERGONOV UPTO 2MGIJ $62METHYLERGONOVIN 2MG TB $8METHYLNALTREXONE 0 1MGIJ $2METHYLPHENIDATE 5MG TB $19METHYLPRE SS UPTO125MGIJ $66METHYLPRED 2MG TB $5METHYLPRED 4MG TB $9METHYLPRED A PER40MG IJ $61METHYLPRED A PER80MG IJ $102METHYLPRED SS UPTO40MGIJ $47METIPRANOLOL 3 5ML OS $180METOCLOPRAM UPTO10MG IJ $80METOCLOPRAM5 5 10ML LQ $13METOCLOPRAMIDE 10MG TB $9METOCLOPRAMIDE 5MG TB $6


73 of 154 FY2018

DESCRIPTION CHARGES



METOLAZONE 2 5MG TB $10METOLAZONE 5MG TB $11METOPROLOL 12 5MG TB $5METOPROLOL 12 5MG XR TB $6METOPROLOL 1MG ML5ML IJ $73METOPROLOL 25MG TB $8METOPROLOL 25MG XR TB $9METOPROLOL 50MG TB $8METOPROLOL 50MG XR TB $10METOPROLOL 6 25MG TB $4METRONIDAZ PER500MGPMXIJ $146METRONIDAZOL PER500MG IJ $466METRONIDAZOLE 250MG TB $4METRONIDAZOLE 500MG TB $4METRONIDAZOLE 75 28GM GL $292METRONIDAZOLE 75 45GM GL $241METRONIDAZOLE 75 70GMVGL $228MEXILETINE 150MG CP $9MEXILETINE 200MG CP $9MG GLUCONATE 500MG TB $9MG OH 24 10ML LQ $4MICAFUNGIN PER 1MG IJ $13MICONAZOLE 100MG 7PK VSU $16MICONAZOLE 100MG EA VSU $52MICONAZOLE 2 15GM CR $23MICONAZOLE 2 45GM VCR $50MIDAZOLAM 2MG 1ML LQ $177MIDAZOLAM 5MG 2 5ML LQ $21MIDAZOLAM PER 1MG IJ $40MIDAZOLAM PER 1MG INF IJ $6MIDODRINE 2 5MG TB $10MIDODRINE 5MG TB $18MILNACIPRAN 25MG TB $13MILNACIPRAN 50MG TB $9MILRINONE PER 5MG IJ $338MINERAL OIL 133ML RE $10MINERAL OIL STER 10ML LQ $75


74 of 154 FY2018

DESCRIPTION CHARGES



MINOCYCLINE 100MG CP $12MINOXIDIL 10MG TB $16MINOXIDIL 2 5MG TB $10MIRABEGRON 25MG XR24 TB $29MIRABEGRON 50MG XR24 TB $29MIRTAZAPINE 15MG TB $23MIRTAZAPINE 30MG DT $12MIRTAZAPINE 30MG TB $42MIRTAZAPINE 7 5MG TB $4MISOPROSTOL 100MCG TB $8MITOMYCIN PER 5MG IJ $300MIVACURIUM 2MG ML 10MLIJ $412MODAFINIL 100MG TB $32MOMETASONE 110MCG IH $589MOMETASONE NASAL 17GM SP $965MOMETASONE220MCG 24GM IH $361MONTELUKAST 10MG TB $26MORPH PF EPI INTR 10MGIJ $65MORPHINE 100MG XR TB $49MORPHINE 10MG 0 5ML LQ $8MORPHINE 10MG 5ML LQ $101MORPHINE 15MG TB $19MORPHINE 15MG XR TB $21MORPHINE 20MG 1ML LQ $25MORPHINE 30MG XR TB $22MORPHINE 60MG XR TB $35MORPHINE PER 10MG PCA $27MORPHINE UPTO 10MG IJ $145MORRHUATE 50MG ML 30MLIJ $1,382MOXIFLOXACIN 5 3ML OS $352MR CONTRAST GAD BASE 1ML $29MUPIROCIN 2 15GM CR $253MUPIROCIN 2 1GM OI $46MUPIROCIN 2 22GM OI $326MUPIROCIN 2 9GM OI $8MVI 10ML IJ $69MVI 5ML LQ $3


75 of 154 FY2018

DESCRIPTION CHARGES



MVI CP $7MVI MIN TB $2MVI RENAL FORMULA TB $9MVI TB $7MVI THERAP TB $6MVI VIT B C FA CP $3MVI VIT B COMPLEX FA CP $2MVI VIT B COMPLEX TB $4MVI VIT B FE INTR FAC CP $8MVI VIT B VIT C FA FE TB $6MYCOPHENOLATE 250MG CP $16N ACETYLCYSTEINE600MG CP $6NA ACETATE2MEQ ML 20MLIJ $50NA BICARB 8 4 10ML PFSIJ $120NA BICARB 8 4 50ML IJ $47NA BICARB 8 4 50ML PFSIJ $76NA BICARB PED4 2 IJ $53NA BICARBONATE 325MG TB $9NA BIPHOPH NA PHOS90MLLQ $15NA BIPHOSPHATE ADULT RE $7NA CITRA CITRC AC30ML LQ $4NA CL 1GM TB $8NA FERR GLUC PER12 5MGIJ $48NA HYPOCHL 125 480ML TS $41NA HYPOCHL 25 480ML TS $54NA HYPOCHL 5 480ML TS $40NA K PHOS 250 280 160 PK $6NA PHOSPHATE3MM ML15MLIJ $47NA POT PHOS NEUT TB $8NABUMETONE 500MG TB $23NACL 0 45 1000ML IVF $36NACL 0 9 1000ML IVF $40NACL 0 9 100ML IVF $7NACL 0 9 250ML IVF $38NACL 0 9 500ML IVF $24NACL 0 9 50ML IVF $7NACL 23 4 30ML IJ $13


76 of 154 FY2018

DESCRIPTION CHARGES



NACL 3 500ML IVF $276NACL 65 45ML NASL IS $23NACL 9 10ML IJ $14NACL 9 10ML PFS IJ $17NACL 9 15ML IH $23NACL 9 2 5ML PFS IJ $7NACL 9 20ML IJ $9NACL 9 3ML IS $14NACL 9 3ML PFS IJ $6NACL 9 KCL20 1000ML IVF $23NACL 9 KCL40 1000ML IVF $248NACL BACT 9 10ML IJ $4NACL BACT 9 30ML IJ $4NACL HYPERTONIC2 15ML OS $85NACL HYPERTONIC5 15ML OS $103NACL HYPERTONIC5 3 5MLOO $50NACL100MEQ 40ML IJ $49NADOLOL 20MG TB $10NADOLOL 40MG TB $10NAFCILLIN 1GM IJ $84NAFCILLIN PER 2GM IJ $132NAFCILLIN PER 2GM PMX IJ $142NALBUPHINE PER 10MG IJ $29NALOXEGOL 12 5MG TB $31NALOXONE PER 1MG IJ $56NALTREXONE 50MG TB $33NAPHAZOLINE 1 15ML OS $57NAPHAZOLINE PHENIR15MLOS $28NAPROXEN 250MG TB $24NATEGLINIDE120MG TB $11NEBIVOLOL 2 5MG TB $7NEBIVOLOL 5MG TB $7NEFAZODONE 100MG TB $14NEO BAC POLYB 30GM OI $19NEO BAC POLYB 9GM OI $7NEO POLY BAC HCTS3 5GMOO $128NEOMY POLY BACIT3 5GM OO $78


77 of 154 FY2018

DESCRIPTION CHARGES



NEOMY POLY GRAMICD10MLOS $245NEOMY POLY HCTS 7 5ML OS $494NEOMYCIN 500MG TB $11NEOMYCIN POLYMB IR 1MLTS $190NEOSTIGMINE 15MG TB $11NEOSTIGMINE UPTO 5MG IJ $9NEPAFENAC 1 3ML OS $629NESIRITIDE PER 1MG IJ $349NEVIRAPINE 200MG TB $53NIACIN 100MG TB $8NIACIN 250MG XR CP $7NIACIN 500MG TB $4NIACIN 500MG XR TB $6NICARDIPINE 20MG 200MLIJ $854NICARDIPINE 20MG CP $6NICARDIPINE 25MG 10ML IJ $1,711NICARDIPINE 40MG 200MLIJ $1,686NICOTINE 14MG TD $37NICOTINE 21MG TD $41NICOTINE 2MG LZ $14NICOTINE 7MG TD $36NICOTINE GUM 2MG EA $8NIFEDIPINE 10MG CP $19NIFEDIPINE 30MG XR TB $8NIFEDIPINE 60MG XR TB $19NIFEDIPINE 90MG XR TB $20NIMODIPINE 30MG CP $106NITROFURANTOIN 50MG CP $7NITROGLY50MG 250MLPMXIJ $43NITROGLYCERIN 1MG 10MLIJ $7NITROGLYCERIN 1MG HR TD $15NITROGLYCERIN 2 5MGXR CP $9NITROGLYCERIN 2MG HR TD $16NITROGLYCERIN 3MG HR TD $23NITROGLYCERIN 4MG HR TD $18NITROGLYCERIN 4MG SL TB $8NITROGLYCERIN 4MG4 9GMSP $271


78 of 154 FY2018

DESCRIPTION CHARGES



NITROGLYCERIN 4MGSL 25TB $2NITROGLYCERIN 6 5MGXR CP $9NITROGLYCERIN 6MG HR TD $19NITROGLYCERIN2 1GM OI $15NITROGLYCERIN50MG 10MLIJ $41NITROPRUSSIDE 10MG/50ML PMX $192NITROPRUSSIDE 50MG 2MLIJ $1,260NITROPRUSSIDE 50MG/100ML IJ $720NOREPINEPHRINE 4MG 4MLIJ $275NORETHINDRONE 5MG TB $7NORTRIPTYLINE 10MG CP $11NORTRIPTYLINE 25MG CP $22NYSTATIN 15GM CR $19NYSTATIN 15GM OI $20NYSTATIN 15GM PW $259NYSTATIN 30GM CR $39NYSTATIN 5ML LQ $7NYSTATIN TRIAMCIN 15GMCR $41OCTAFLUOROPROP MIC 1MLIJ $225OCTREOTIDE PER 25MCG IJ $46OCULAR LUB 3 5GM OO $68OCULAR LUB PF 15ML OS $57OCULAR LUB PRSRV 15ML OS $16OFLOXACIN 3 10ML OS $137OFLOXACIN 3 25ML OT $21OFLOXACIN 3 5ML OS $366OFLOXACIN 3 5ML OT $363OLANZAPINE 10MG 10ML IJ $199OLANZAPINE 10MG 2ML IJ $101OLANZAPINE 10MG TB $80OLANZAPINE 2 5MG TB $42OLANZAPINE 5MG DT $60OLANZAPINE 5MG TB $50OLMESARTAN 20MG TB $9OLOPATADINE 1 5ML OS $603OMEGA3 FISH OIL 1000MGCP $2OMEPRAZOL BICARB40MGPWLQ $19


79 of 154 FY2018

DESCRIPTION CHARGES



OMEPRAZOLE 20MG XR CP $21ONDANSETRON 4MG DT $85ONDANSETRON 4MG TB $275ONDANSETRON PER 1MG IJ $37ONDONSETRON ODT 8MG TAB $93ORPHENADRINE 100MG XR TB $19OSELTAMIVIR 30MG CP $39OSELTAMIVIR 75MG CP $43OXANDROLONE 2 5MG TB $37OXAPROZIN 600MG TB $18OXCARBAZEPINE 150MG TB $9OXCARBAZEPINE 300MG TB $15OXCARBAZEPINE 5ML LQ $21OXYBUTYNIN 2 5MG TB $4OXYBUTYNIN 5MG TB $9OXYBUTYNIN 5MG XR TB $22OXYCOD APAP 10 325 TB $27OXYCOD APAP 5 325 TB $61OXYCOD APAP 7 5 325 TB $21OXYCODONE 10MG XR TB $40OXYCODONE 15MG TB $6OXYCODONE 20MG ML LQ $8OXYCODONE 20MG XR TB $62OXYCODONE 40MG XR TB $71OXYCODONE 5MG 5ML LQ $19OXYCODONE 5MG TB $21OXYMETAZOLN NS 05 15MLSP $55OXYMETAZOLN NS 05 3ML SP $49OXYTOCIN UPTO 10U IJ $31PACLITAXEL PER 1MG IJ $2PALIPERIDONE 3MG XR TB $45PALIPERIDONE 6MG XR TB $60PALONOSETRON PER25MCGIJ $241PAMIDRONATE PER 30MG IJ $187PANCRELIP 30 8 30 TB $11PANCRELIP 5 17 27 XRCP $6PANCURONIUM 10MG 10ML IJ $265


80 of 154 FY2018

DESCRIPTION CHARGES



PANTOPRAZOLE 40MG EC TB $28PANTOPRAZOLE 40MG LQ $32PANTOPRAZOLE PER40MGIJ $152PAPAIN UREA 30GM OI $540PAPAIN UREA CHLOR30GM OI $47PAPAVERINE UPTO 60MG IJ $36PARICALCITOL 1MCG CP $40PARICALCITOL PER 1MCG IJ $39PAROXETINE 10MG TB $23PAROXETINE 12 5MG XR TB $24PAROXETINE 20MG TB $23PE 10 1ML OS $247PE 10 5ML OS $37PE NASAL 1 15ML DR IS $49PE NASAL 1 15ML SP $47PE NASAL 25 15ML DR IS $44PE NASAL 25 15ML SP $12PE NASAL 5 15ML DR IS $44PE NASAL 5 15ML SP $41PEN G BENZ PER 100KU IJ $42PEN G K UPTO 600KU IJ $8PENICILLIN 250MG TB $16PENICILLIN G NA 5MU IJ $146PENTAMIDINE PER 300MG IJ $725PENTAZOCINE PER30MGPFSIJ $86PENTOXIFYLLN 400MG XR TB $8PERFLUTREN LIP MICRO 1ML $268PERMETHRIN 1 60ML TS $35PERMETHRIN 5 60GM CR $300PERPHENAZINE 2MG TB $8PETROLATUM 30GM OI $9PETROLATUM 5GM UD OI $1PHENAZOPYRIDINE 100MG TB $9PHENELZINE 15MG TB $9PHENOBARB UPTO 120MG IJ $13PHENOBARBITAL 100MG TB $24PHENOBARBITAL 16 2MG TB $4


81 of 154 FY2018

DESCRIPTION CHARGES



PHENOBARBITAL 30MG TB $21PHENOBARBITAL 32 4MG TB $5PHENOL 1 4 20ML SP $7PHENOL 89 SWAB EA $21PHENOL NA 32 5MG LZ $2PHENOXYBENZAMINE 10MGCP $372PHENTOLAMINE UPTO 5MG IJ $269PHENYLEPH PER 1ML PFS IJ $5PHENYLEPHRINE HEMOR R OI $50PHENYLEPHRINE HEMOR SU $4PHENYLEPHRINE UPTO 1MLIJ $43PHENYTOIN 100MG XR CP $9PHENYTOIN 30MG XR CP $8PHENYTOIN 50MG CTB $9PHENYTOIN PER 50MG IJ $7PHENYTOIN PER50MG SG IJ $7PHYSOSTIGM 1MG ML 2ML IJ $145PHYTONADIONE 5MG TB $128PHYTONADIONE PER 1MG IJ $9PHYTONADN PED PER 1MG IJ $20PILOCARPINE 1 15ML OS $50PILOCARPINE 1 2ML OS $57PILOCARPINE 2 15ML OS $51PILOCARPINE 2 2ML OS $97PILOCARPINE 3 15ML OS $110PILOCARPINE 4 15ML OS $92PILOCARPINE 5MG TB $9PINDOLOL 5MG TB $10PIOGLITAZONE 15MG TB $27PIOGLITAZONE 45MG TB $38PIPER TAZ PER1 125GM IJ $71PIPER TAZPER1 125GMPMXIJ $75PIRBUTEROL 2MG 14GM IH $162PIROXICAM 10MG CP $22PNEUMOCOC 13 VAL VACC IJ $870PNEUMOCOC23 VAL VACC IJ $205POLY NEO HCTS 10ML OT $290


82 of 154 FY2018

DESCRIPTION CHARGES



POLYCARBOPHIL 500MG TB $9POLYCARBOPHIL 625MG TB $6POLYETHYLE GLYCOL 17GMPW $14POLYMYXIN B 500MU IJ $123POT PHOS 1 45GM PWLQ $11POTASSIUM 20MEQ EFF TB $4POTASSIUM CIT 10MEQ XRTB $6POTASSIUM CL 10MEQ XR CP $9POTASSIUM CL 20MEQ XR TB $10POTASSIUM CL 8MEQ XR CP $9POVIDONE IODINE10 30GMOI $17PRAMIPEXOLE 125MG TB $9PRAMIPEXOLE 1MG TB $17PRAMIPEXOLE 25MG TB $12PRAMLINTIDE1MG ML1 5MLIJ $688PRAMOXINE 1 15GM R FM $121PRAMOXINE ZINC 30GM R OI $36PRASUGREL 10MG TB $23PRASUGREL 5MG TB $41PRAVASTATIN 10MG TB $16PRAVASTATIN 20MG TB $11PRAVASTATIN 40MG TB $23PRAZOSIN 1MG CP $8PRAZOSIN 5MG CP $5PREDNISOLONE 1 5ML OS $98PREDNISOLONE 12 5ML OS $204PREDNISONE 10MG TB $20PREDNISONE 2 5MG TB $6PREDNISONE 20MG TB $24PREDNISONE 50MG TB $4PREDNISONE PER 5MG TB $1PREGABALIN 100MG CP $8PREGABALIN 25MG CP $8PREGABALIN 50MG CP $9PREGABALIN 75MG CP $16PRIMATRIX 4X4 PER SQ CM $106PRIMATRIX 6X6 PER SQ CM $118


83 of 154 FY2018

DESCRIPTION CHARGES



PRIMATRIX 8X12 PER SQ CM $105PRIMATRIX 8X8 PER SQ CM $106PRIMIDONE 250MG TB $7PRIMIDONE 25MG TB $4PRIMIDONE 50MG TB $8PROBENECID 500MG TB $18PROCAINAMIDE 500MG XR TB $9PROCAINAMIDE UPTO 1GM IJ $94PROCHLORPERAZ 10MG PFSIJ $40PROCHLORPERAZINE 10MG IJ $124PROCHLORPERAZINE 10MG TB $23PROCHLORPERAZINE 25MG SU $61PROCHLORPERAZINE 5MG SU $31PROCHLORPERAZINE 5MG TB $31PROGESTERONE 100MG CP $13PROMETHAZ 6 25 5 120MLLQ $28PROMETHAZINE 25MG SU $46PROMETHAZINE 25MG TB $14PROMETHAZINE UPTO50MG IJ $36PROPAFENONE 150MG TB $16PROPAFENONE 225MG XR CP $21PROPARACAINE 5 15ML OS $193PROPOFOL PER 10MG IJ $2PROPRANOLOL 20MG TB $9PROPRANOLOL 60MG XR CP $10PROPRANOLOL UPTO 1MG IJ $142PROPYLTHIOURACIL 50MG TB $8PROTAMINE PER 10MG IJ $14PSEUDOEPHED 30MG TB $8PURAPLY AM PER SQ CM $329PYRIDOSTIGMINE 60MG TB $15PYRIDOSTIGMINE10MG 2MLIJ $128PYRIDOXINE 50MG TB $12PYRIDOXINE PER 100MG IJ $24QUETIAPINE 100MG TB $24QUETIAPINE 12 5MG TB $6QUETIAPINE 200MG XR TB $43


84 of 154 FY2018

DESCRIPTION CHARGES



QUINAPRIL 20MG TB $12QUINAPRIL 5MG TB $9QUINIDIN GLUC324MG XR TB $11RABEPRAZOLE 20MG XR TB $40RABIES IG IM SC 150U IJ $5,253RABIES VACCINE IM IJ $1,007RAMIPRIL 1 25MG CP $9RAMIPRIL 5MG CP $18RANITIDINE 150MG TB $6RASAGILINE 0 5MG TB $55RASBURICASE PER 5MG IJ $1,234REGADENOSON PER 0 1MG IJ $325REMIFENTANIL 2MG 5ML IJ $459REPAGLINIDE 1MG TB $11RETEPLASE 1U SG IJ $1,197RETEPLASE PER18 1MG IJ $13,998RHOPHYLAC IV IMPER100UIJ $35RIFAMPIN 600MG IJ $600RISEDRONATE 35MG TB $102RISPERIDONE 0 25MG TB $24RISPERIDONE 1M M 1ML LQ $19RISPERIDONE PER 5MG IJ $35RITONAVIR 100 MG CP $19RITUXIMAB PER 100MG IJ $2,571RIVAROXABAN 10MG TB $40RIVAROXABAN 15MG TB $33RIVASTIGMINE 1 5MG CP $19RIVASTIGMINE 4 6MG TD $34RIVASTIGMINE 9 5MG TD $32ROCURONIUM10MG 1ML 5MLIJ $296ROCURONIUM10MG 1ML10MLIJ $707ROPINIROLE 1MG TB $9ROSIGLITAZONE 2MG TB $16ROSUVASTATIN 20MG TB $19ROSUVASTATIN 5MG TB $19ROTIGOTINE 2MG 24HR TD $85ROTIGOTINE 4MG 24HR TD $65


85 of 154 FY2018

DESCRIPTION CHARGES



SACUBIT/VALS 97-103MG TB $23SACUBIT/VALSAR 24-26MGTB $23SACUBIT/VALSAR 49-51MGTB $23SALIVA SUBST 120ML LQ $38SALMETEROL 21MCG 13GM IH $25SALMETEROL DK 50MCG PW $463SALSALATE 500MG TB $9SCOPOLAMINE 25 5ML OS $171SCOPOLAMINE 4MG 1ML IJ $49SCOPOLAMINE1 5MG72HR TD $52SELEGILINE 5MG CAPSULES $4SELEGILINE 5MG TB $17SELENIUM SUL2 5 120ML LT $113SELENUM SU SHMP1 210MLLT $45SERTRALINE 50MG TB $24SEVELAMER 400MG TB $7SEVELAMER CARB 800MG TB $15SEVOFLURANE 250ML IA $1,651SEVOFLURANE PER DOSE IA $485SILDENAFIL 25MG TB $52SILVER NITRAT 1 STICK EA $2SILVER NITRATE APPL 10PK $18SILVER SALINE WND45GM GL $131SILVER SULFADIA 1 50GMCR $78SILVER SULFADIA1 400GMCR $347SIMETHICONE 80MG TB $8SIMETHICONE40 6 30ML LQ $27SIMVASTATIN 10MG TB $22SIMVASTATIN 40MG TB $45SINCALIDE 5MCG $182SITAGLIPTIN 100MG TB $26SKIN CLEAN MED 480ML TS $58SMX TMP 200 40 5 20MLLQ $19SODIUM TETRADECYL3 2MLIJ $424SOTALOL 40MG TB $4SOTALOL 80MG TB $20SPIRONOLACTONE 25MG TB $8


86 of 154 FY2018

DESCRIPTION CHARGES



STARCH 51 SU $6STRATTICE TM PER SQ CM $101STREPTOMYCIN UPTO 1GM IJ $89SUCCINYLCHOL UPTO 20MGIJ $11SUCRALFATE 1G 10ML LQ $23SUCRALFATE 1GM TB $9SUFENTANIL 50UG ML1ML IJ $327SUGAMMADEX 200MG 2ML IJ $527SUGAMMADEX 500MG 5ML IJ $921SULFACET PRED 25 5ML OS $317SULFACETAMID NA10 15MLOS $27SULFACETAMIDE10 5ML OS $57SULFASALAZINE 500MG TB $9SULINDAC 200MG TB $9SUMATRIPTAN 50MG TB $140SUMATRIPTAN PER 6MG IJ $411SUMATRIPTAN PER6MG KT IJ $497SURGICAL ADHESIVE 67MLTS $68TALC STERILE 4GM PW SP $913TALC STERILE 5GM PW SP $723TAMOXIFEN 10MG TB $11TAPENTADOL 50MG TB $9TAPENTADOL 75MG TB $11TBO FILGRASTIM PER1MCGIJ $5TC99 ALBUMIN MAA DOSE $753TC99 EXAMETAZIME DOSE $6,611TC99 EXAMETAZME WBC DOSE $3,311TC99 MEBROFENIN DOSE $569TC99 MEDRONAT UPTO 30MCI $311TC99 MERTIATIDE DOSE $948TC99 PENTET AEROSL DOS $284TC99 PENTETATE DOSE $645TC99 PERTECHN PER MCI $37TC99 RBC DOSE $919TC99 SESTAMIBI DOSE $1,142TC99 SUCCIMER DOSE $1,547TC99 SULFUR COLLOID DOSE $360


87 of 154 FY2018

DESCRIPTION CHARGES



TDAP 7YR VAC IJ $139TELMISARTAN 80MG TB $11TEMAZEPAM 7 5MG CP $21TENECTEPLASE PER 1MG IJ $352TERAZOSIN 1MG CP $18TERAZOSIN 5MG CP $18TERBINAFINE 1 12GM CR $84TERBINAFINE 1 15GM CR $29TERBUTALINE UPTO 1MG IJ $238TESTOSTERONE 1 2 5GMPKGL $46TESTOSTERONE CYP 1MG IJ $1TETANUS IG UPTO 250U IJ $585TETRACAINE 1 2ML IJ $181TETRACAINE 2 30ML TS $326TETRACAINE 5 2ML OS $55TETRACAINE 5 4ML OS $41TETRACYCLINE 250MG CP $9TETRAHYDRAZOL 05 15ML OS $14THEOPHYLLINE 100MG CP $9THEOPHYLLINE 200MG XR TB $5THEOPHYLLINE 300MG XR CP $9THEOPHYLLINE80 15 30MLLQ $47THERASKIN PER SQ CM $213THIAMINE 50MG TB $4THIAMINE PER 100MG IJ $6THIOPENTAL 500MG SG IJ $149THIORIDAZINE 10MG TB $9THIOTHIXENE 1MG CP $4THROMBIN 10000U PW $582THROMBIN 20000U PW $2,176THROMBIN 20000U SP KT $1,978THROMBIN 5000U BOV SP KT $255THROMBIN 5000U PW $632THYROID DESICTED 30MG TB $8TIAGABINE 2MG TB $21TIAGABINE 4MG TB $18TICAGRELOR 60MG TB $16


88 of 154 FY2018

DESCRIPTION CHARGES



TICAR CLAV PER 3 1GM IJ $195TIGECYCLINE PER 1MG IJ $8TIMOLOL 0 5 5ML OS $74TIMOLOL 25 2 5ML GL $137TIMOLOL 25 45ML OS $140TIMOLOL 25 5ML GL $243TIMOLOL 25 5ML OS $117TIMOLOL 5 2 5ML GL $162TIMOLOL 5 5ML GL $291TIOTROPIUM CP18MCG6DS IH $206TIROFIBAN PER 25MG IJ $72TIZANIDINE 4MG TB $14TL201 CHLORIDE 1MCI $334TOBRAMYC DEXAMETH 5ML OS $117TOBRAMYC DEXAMETH3 5GMOO $513TOBRAMYCIN 1 2GM PW $3,082TOBRAMYCIN 3 3 5GM OO $400TOBRAMYCIN 3 5ML OS $117TOBRAMYCIN UPTO 80MG IJ $148TOLNAFTATE 1 15GM CR $16TOLTERODINE 1MG TB $13TOLTERODINE 2MG XR CP $24TOLVAPTAN 15MG TB $807TOPIRAMATE 25MG TB $14TORSEMIDE 10MG ML 2ML IJ $86TORSEMIDE 10MG ML 5ML IJ $120TORSEMIDE 5MG TB $5TRACE METAL 1ML IJ $11TRACE METAL 5ML IJ $275TRAMADOL 25MG TB $5TRAMADOL 50MG TB $21TRANDOLAPRIL 1MG TB $8TRANEXAMIC ACID1G 10MLIJ $448TRAVOPROST 004 2 5ML OS $287TRAZODONE 50MG TB $10TRIAMCIN A 1 5GM PASTE $97TRIAMCINOL A 1 15GM CR $19


89 of 154 FY2018

DESCRIPTION CHARGES



TRIAMCINOLON A PER10MGIJ $19TRIAMCINOLONE 025 15GMCR $28TRIAMCINOLONE 1 15GM CR $33TRIAMCINOLONE 1 15GM OI $35TRIAMCINOLONE 1 454GM OI $228TRIAMCINOLONE 1 60GM OI $49TRIAMCINOLONE 1 80GM CR $33TRIAMCINOLONE 1 80GM OI $65TRIAMCINOLONE 16 5GM SP $744TRIAMCINOLONE 20GM IH $573TRIAMCINOLONE 5 15GM CR $47TRIAMCINOLONE 5 20GM CR $997TRIAMTER HCTZ 75 50 TB $10TRIAMTERENE 50MG CP $9TRIETHANOLAMINE 6ML OT $287TRIFLUOPERAZINE 1MG TB $8TRIFLURIDINE 1 7 5ML OS $862TRIGLYCERIDES MED 30 ML $8TRIMETHOBENZ TO 200MG IJ $80TRIMETHOPRIM 100MG TB $8TRIMETHPRM POLYMYX10MLOS $180TROLAMINE SALIC10 90GMCR $28TROPICAMIDE 1 15ML OS $103TROPICAMIDE 5 15ML OS $265TRYPS BALS CASTOIL60GMOI $287TX I131 SOD CAP PER MCI $429UBIQUINONE 100MG CP $4UREA 20 90GM CR $43UREA 40 30GM CR $234URSODIOL 250MG TB $7VALPROATE 500MG 5ML IJ $294VALSARTAN 40MG TB $7VALSARTAN 80MG TB $15VANCOMYCIN 125MG CP $82VANCOMYCIN 125MG LQ $8VANCOMYCIN PER 500MG IJ $64VANCOMYCIN PER500MGPMXIJ $230


90 of 154 FY2018

DESCRIPTION CHARGES



VANCOMYCIN250MG 10ML LQ $10VARENICLINE 0 5MG TB $8VASOPRESSIN 20U 1ML IJ $276VENLAFAXINE 37 5MG TB $6VENLAFAXINE 75MG XR CP $22VERAPAMIL 120MG TB $9VERAPAMIL 180MG XR TB $10VERAPAMIL 40MG TB $4VERAPAMIL2 5MG ML 2ML IJ $17VERAPAMIL2 5MG ML 4ML IJ $49VILAZODONE 10MG TB $21VINCRISTINE PER 1MG IJ $175VINORELBINE PER 10MG IJ $2,912VITAMIN A 10MU CP $7VITAMIN A D 60GM OI $28VITAMIN B 12 100MCG TB $8VITAMIN B 12 250MCG TB $4VITAMIN D 1000U TB $6VITAMIN D3 400U TB $5VITAMIN D3 5000U CP $5VON WILLEBRANDFC PER1UIJ $13VORTIOXETINE 20MG TB $32VORTIOXETINE 5MG TB $32WARFARIN 2 5MG TB $9WARFARIN 2MG TB $9WATER INJ STERL 10ML IJ $4WATER INJ STERL 20ML IJ $6WATER STERL INJ 1L IVF $36WATER STERL INJ 5L IVF $245WOUND DRESSING GEL GL $58WOUND DRESSING15ML PASTE $17ZAFIRLUKAST 20MG TB $10ZIDOV LAMI300MG 150MG TB $98ZIDOVUDINE 100MG CP $18ZINC CL 1MG ML 10ML IJ $55ZINC COD LIV 40 28GM OI $20ZINC OX CALAMINE4X360 EA $79


91 of 154 FY2018

DESCRIPTION CHARGES



ZINC OX MENTHOL 113GM OI $47ZINC OXIDE 20 30GM OI $15ZINC SULF 1MG ML 10ML IJ $16ZIPRASIDONE 20MG CP $33ZOLEDRONIC ACID PER1MGIJ $1,123ZOLMITRIPTAN 2 5 MG TB $136ZONISAMIDE 100MG CP $13

ORTHOTICSAFO ANKLE GAUNTLET $344BG FECAL COLLECTION $58ORTH AFO SPRNG DRSFLX CA $1,092ORTH BOOT NONPNEU PREFAB $163ORTH ELBOW ADJ LCK JNT $1,400ORTH HO AB CNTRL STC PLS $690ORTH KAFO SNG SLD STRUP $2,516ORTH LSO SAG COR CUST $4,108ORTH LSO SAG CTRL SAC T9 $2,127ORTH TLSO FLX THOR CUSTF $1,432ORTH TSLO TRNK SUPP PREF $707ORTH TSLO TRPL CTRL 2PC $5,270SLING SHOULDER $222UE FX HUMERAL $1,162VLV TRACH SPEAK $365WHFO PALMER $98

PACEMAKERS & IMPLANTABLESADPTR MOLD HIP SPCR NECK $930ALLOGRAFT CARTILAGE $2,331ALLOGRFT CARTLG MSH VIAB $37,485ALLOGRFT TISS MATRX FLOW $4,186ANASTOMIC DEV $453ANCH BIO SWIVELOCK $1,176ANCH CORKSCREW $886ANCH ENDOBUTTON CL BTB $839ANCH GRFT DELIVERY SYS $5,550ANCH PEEK PUSH LCK $1,111


92 of 154 FY2018

DESCRIPTION CHARGES



ANCH SCRW BN BN TISS BN $295ANCH SCRW BN BN TISS BN2 $548ANCH SCRW BN BN TISS BN3 $649ANCH SCRW BN BN TISS BN4 $819ANCH SCRW BN BN TISS BN5 $878ANCH SCRW BN BN TISS BN6 $1,050ANCH SCRW BN BN TISS BN7 $1,441ANCH SUT BIO FAST ARTHRX $1,035ANCH SUT MINI BIOCOMPSTE $1,367ANCH SUT SHORT SFT W NDL $868ANCH VERSALOK $1,227ARTICULAR COMPONENT $18,302BARRIER ADH SEPRA GEL $815BARRIER ADHESION $857BIOINDUCTIVE IMPLANT $10,281BLD CUTTR TURBOHAWK SUPR $8,319BLN DIL ESOPH QUANTUM $1,856BLN DISSECT SPACEMAKER $1,167BN BLOCKS $11,921BN CADAVAR $963BN CMT PLFL DS DPY CAP $443BN FILLER $2,331BN FILLER 2 $4,661BN FIXATOR MAJ $13,580BN GEL $3,082BN GEL PUTTY 10CC $4,195BN GEL PUTTY 1CC $852BN GEL PUTTY 2 5CC $1,134BN GEL PUTTY 5CC $2,859BN GRANUELS 15CC $3,897BN GRFT $544BN GRFT INFS LG $17,192BN GRFT INFS MED 4SPNG $15,205BN GRFT INFS SM 4SPNG $11,079BN GRFT INFS XSM $5,541BN GRFT INFS XXS $2,641BN GRFT INJECT INDUCTIVE $28,131


93 of 154 FY2018

DESCRIPTION CHARGES



BN PASTE 1 $1,455BN PASTE 2 $2,194BN PASTE 3 $2,993BN PLUGS $401BN STRIP $3,457BOLT LOCKING 1 $1,532BONE PUTTY $463BUTTON ARTHRO $207BUTTON CBL HEX LCK PLT $821BUTTON CERCLAGE HEX $577CAGE PROXIMAL HUMERUS $10,795CAP LOCKING SCREW NCB $716CARPEL HEAD $3,713CATH ANG QUICK CROSS $728CATH ANG TRANSLUM NLSR2 $2,383CATH ANG TRANSLUM NLSR3 $2,735CATH ANG TRANSLUM NLSR4 $4,810CATH ANG TRANSLUMNL NLSR $949CATH ANGIOJET RHEO THROM $7,987CATH ASH SPLIT MEDCOMP $2,035CATH ATHER SILVERHAWK $6,721CATH ATHR TRANSLUM DIREC $13,367CATH ATTAIN COMND SURVLV $840CATH BAL DIL SINUS $2,526CATH BLN CUT INTERVENTNL $4,913CATH BLN DIL DIA ULT THN $2,034CATH BLN DIL HURRICANERX $812CATH BLN DIL MINI TREK $545CATH BLN DIL NONVASC 2 $1,905CATH BLN DIL NONVASCULAR $2,834CATH BLN DIL RX NC TREK $599CATH BLN DIL ULTRATHIN $2,719CATH BLN DIL UROMAX UHP $673CATH BLN DIL XXL LARGE $697CATH BLN PTA POWERFLX P3 $854CATH DRAINAGE $428CATH DRAINAGE 2 $966


94 of 154 FY2018

DESCRIPTION CHARGES



CATH ECHO INTRACARDIAC $9,479CATH EMBOLECTOMY $369CATH GD ATTAIN SELII SUR $732CATH GD BREAKAWAY OUTER $1,655CATH GUIDING $1,261CATH GUIDING 2 $1,836CATH GUIDING 4 $384CATH GUIDING LAUNCHER $213CATH HEMODIAL LONG TERM $650CATH HEMODIAL LONG TERM2 $186CATH HEMODIAL SHORT TERM $749CATH IMPELLA VENT ASSIST $45,800CATH INF CV DL ARROW $392CATH INF PERPH CNTRL ML3 $940CATH INF PERPH CNTRL ML4 $1,181CATH INF PERPH CNTRL ML5 $1,561CATH INF PICC DL PWR $444CATH INF PICC SL PWR $434CATH INF PULSESPRY ANGIO $1,480CATH INF SGL LMN $43CATH INTRASPINAL $1,756CATH IVUS GD PIONEER PLS $12,512CATH MULT LUM AR $1,293CATH MULT LUM CV $1,029CATH MUSHROOM MALECOT $174CATH NEPHROSTOMY $239CATH OCCLUSION $511CATH OCCLUSION 2 $3,148CATH PORTACATH $1,886CATH PTA ARMADA 18 BLLN $902CATH PTA ARMADA 35 BLLN $493CATH PTA ARMADA14 BLN $1,177CATH PTA BLN PWRFLX $584CATH PTA CORDIS MAXI LID $1,610CATH PTA DIL ULTRAVERSE $439CATH PTA DRUG COATED BLN $4,384CATH PTA MUSTANG BLLN $669


95 of 154 FY2018

DESCRIPTION CHARGES



CATH PTA NANOCROSS 014 $1,289CATH PTA POWERCROSS 018 $921CATH PTCA SCORING RX BLN $3,925CATH SINUS GUIDE $1,224CATH STENT GRAFT BLLN $1,572CATH SUPPORT USHER $919CATH SUPRAPUBC CYSTOSCOP $425CATH SUPRAPUBIC $442CATH THORACIC $254CATH THORACIC ANGLED $118CATH THROMB EMBOLECTMY 2 $5,970CATH THROMB EMBOLECTMY 3 $2,273CATH THROMB EMBOLECTOMY $6,448CATH THROMBECTOMY $5,720CATH TRNSLMN ATHRCTMY DR $12,374CATH URETER U30 BLN DILT $601CBL ORTHO W CRIMP $877CBLE FIX BN SLEVE $929CEMT BN 2 $1,044CEMT BN PL FUL STRYK CAP $420CEMT OPACIFIER $386CHONDRAL DART $808COIL EMBOLIC $144COIL EMBOLIC DETACH $3,087COIL PV PLATINUM $393CONTROL CLIP RESOLUTION ROTATION $1,051COUPLER ANASTOMOTIC $1,156DEFIB MAXIMO II D284TRK $52,516DEFIB MAXIO II D284VRC $36,979DEFIB VIRTUOSO II DR $40,086DEV CLOSR VASC IMP INSRT $1,004DEV REP URINARY W SLING $1,290DEV VAG TP TENSN FR SNGL $2,055DFB AMPLIA MRI DTMB1QQ $60,746DFB ELLIPS DR DF1 231136 $46,612DFB ELLIPSE DR CD231136Q $46,146DFB ELLIPSE DR CD241136C $43,551


96 of 154 FY2018

DESCRIPTION CHARGES



DFB ELLIPSE VR CD131136Q $40,647DFB ELLIPSE VR CD141136C $40,647DFB ENERGN CRTD DF1 N141 $51,828DFB EVERA MRI XT DDMB1D4 $45,688DFB FORTFY AS VR 135740Q $40,647DFB FORTFY ASR DR235740C $43,606DFB FORTFY ASR DR235740Q $43,551DFB ILESTO HFT HE 383549 $45,030DFB ILESTO HFTDF4 405577 $45,030DFB ILESTO VRTDF4 383580 $30,791DFB INCEPTA CRTD DF1N161 $55,673DFB INCEPTA CRTD DF4N160 $59,819DFB INCEPTA CRTD LV1N164 $55,603DFB INCEPTA DR DF1 E163 $44,651DFB INCEPTA VR DF1 E161 $42,146DFB INOGEN X4 CRT D G146 $48,704DFB INVENTR HFT QP393012 $46,746DFB INVENTR PROMR 399436 $42,354DFB IPERIA DRTDF1 392409 $44,762DFB IPERIA PROMRI 392423 $44,762DFB IPERIA PROMRI 393009 $49,083DFB ITREVA VRTDF4 393041 $34,868DFB ITREVIA DR T 392412 $38,007DFB ITREVIA DR T 392426 $38,007DFB ITREVIA HF T 393014 $46,574DFB ITREVIA HF T 393016 $46,574DFB ITREVIA HFTQP 401662 $43,110DFB ITREVIA VRTDX 393037 $38,007DFB LUMAX 740DR T MOBL $39,620DFB LUMAX 740HFT BIV MOB $48,942DFB LUMAX 740HFT HM MNTR $66,587DFB LUMAX SC 740 VRT MOB $36,202DFB QUADRA ASSUR 336540C $50,809DFB QUADRA ASSUR 336540Q $50,809DFB UNIFY ASSURA 335740C $50,809DFB UNIFY ASSURA DF1 IS1 $50,809DFB VISIA AF MRI DVFB1D4 $60,160


97 of 154 FY2018

DESCRIPTION CHARGES



DFB VISIA AF VR DVAB 1D1 $45,637DFB VIVA QUAD XT DTBA1QQ $56,609DFB VIVA XT CRTD DTBA1D1 $56,680DFB VIVA XT CRTD DTBA1D4 $55,650DFIB COGNIS HE N119 $54,965DFIB CONCERTO II CRT D $52,516DFIB CURRENT DR RF 2207 $46,550DFIB CURRENT VR RF120736 $47,599DFIB DC ATLAS II HFV365 $82,348DFIB DC ATLAS II V268 $42,401DFIB DC ENTRUST $49,409DFIB DC LEXOS DRT $40,708DFIB DC LUMOS DR T $33,005DFIB DC MAXIMO DR 7278AA $40,086DFIB DC PROTECTA XT DR $49,409DFIB DC VITALITY 2 T165 $60,595DFIB DC XELOS DR T $40,708DFIB ENERGEN DR DF1 E143 $41,637DFIB ENERGEN DR DF4 E142 $42,389DFIB ENERGEN VR DF1 E141 $39,132DFIB EVERA S DR DDBC3D1 $47,926DFIB EVERA XT DR DDBB1D1 $39,690DFIB EVERA XT DR DDBB1D4 $46,687DFIB EVERA XT VR DVBB1D1 $42,786DFIB FORTIFY DR SJ4 CONN $46,612DFIB ILESTO 7 DRT 383562 $32,364DFIB ILESTO 7 HFT 383547 $35,295DFIB ILESTO 7 HFT 400450 $45,086DFIB ILESTO 7 VRT 383578 $33,324DFIB ILESTO 7 VRT 400453 $33,324DFIB ILESTO DR T 383564 $36,464DFIB INOGEN EL VR D141 $37,732DFIB INSYNC MAXIMO 7304 $65,257DFIB INSYNC SENTRY 7297 $69,296DFIB KRONOS LVT 347406 $62,149DFIB LUMAX 300 DR T $51,273DFIB LUMAX 300 VR T $48,166


98 of 154 FY2018

DESCRIPTION CHARGES



DFIB LUMAX 340 359654 $35,270DFIB LUMAX 340 DR T $52,827DFIB LUMAX 340 HF T $68,364DFIB LUMAX 340 VR T $37,199DFIB LUMAX 540 DR T $38,843DFIB LUMAX 540 HF T $48,166DFIB LUMAX 540 VR T $35,114DFIB MAXIMO II D284DRG $41,822DFIB PROMOTE CRT D 3211 $60,595DFIB PROTECTA CRT D $61,838DFIB PROTECTA XT CRT D $63,902DFIB RENEWAL 3 H170 $59,042DFIB RENEWAL HEART FAIL $59,042DFIB SC LEXOS VR $35,736DFIB SC LUMOS VR T $37,289DFIB SC MAXIMO VR7232CX $49,879DFIB SC PRELIFE W UPGRD $44,940DFIB SC PROTECTA XT VR $43,194DFIB SC VITALTY VR T135 $48,166DFIB TELIGEN DR HE E110 $41,637DFIB TELIGEN VR HE E102 $40,341DFIB UNIFY CRT D DF1 IS1 $50,809DFIB UNIFY CRT D SJ4 CON $54,380DFIB VIRTUOSO II VR ICD $36,979DFIB VIVA S CRTD DTBB1D1 $50,781DIL BLN ESOPH PYLORIC $965DRS INTERCEED 3X4 $775DVC ENDOBUTTON CL ULTRA $694DVC FIX FASTNER ZIPTIGHT $1,650DVC FIX TOGGLELOC PE ZIP $1,235DVC MENISCAL CINCH $1,907DVC MENISCAL CINCH. $5,720DVC SUT CAPTR CAPIO SLIM $1,355ENDOPROSTH BLN VIABAHN V $15,971ENDOPROSTH PERIPH VIABAH $8,674ENDOPROSTH THORACIC TAG $39,620EXTERNAL FIXATION MODULE $217


99 of 154 FY2018

DESCRIPTION CHARGES



FALLOPIAN RING $325FEM NAIL $4,136FILTER VENA CAVA $1,842FLTR VC GREENFIELD 12INT $2,740FLTR VC TRAPEASE CORDIS $3,285GCATH CRDS VISTABRT TP 6 $217GCATH SA VISTABRITE TIP8 $656GCATH WISEGUIDE $219GEL VOICE INJ $684GEN NSTIM VAGUS NRV $57,970GRAFT TENDON $3,048GRFT AAA STENT $10,016GRFT ALLOMAX 10X15 $10,197GRFT ALLOMAX 16 X 20CM $21,747GRFT ALLOMAX 5X8CM $3,070GRFT ALLOMAX 7X10CM $7,327GRFT AORTIC EXTENDER $8,710GRFT CNTRLTRL LEG $12,010GRFT CV FELT 6IN $278GRFT DVF WOVN HEMASHIELD $1,648GRFT IPSLTRL LEG $26,786GRFT MESH COMPOSIX 6X8 $1,759GRFT NERVE AVANCE $7,130GRFT OCULAR AMNIO MEMBRN $3,120GRFT STNT TRNK IPSIL LEG $28,797GRFT V IMPRA VNFL C ST50 $1,574GRFT V IMPRACRBOFLO ST50 $1,574GRFT VASC CAROTID $315GRFT VASC ILIAC LEG EXT $8,670GRFT VASCULAR $3,104GRFT VASCULAR 2 $3,446GRFT VASCULAR 3 $3,664GRFT VASCULAR 4 $5,075GRFT VASCULAR 5 $2,212HIP HEMI BIPLR BIOMT CAP $3,979HIP HEMI BIPLR DEPUY CAP $3,979HIP HEMI BIPLR SNN CAP $3,979


100 of 154 FY2018

DESCRIPTION CHARGES



HIP HEMI BPLR STRYKR CAP $3,979HIP HEMI UNIPL DEPUY CAP $3,979HIP PREM MDM STRYKR CAP $3,979HIP PREMIUM BIOMET CAP $3,979HIP PRIM TTL DEPUY CAP $3,979HIP PRIM TTL SNN CAP $3,979HIP PRIM TTL STRYKER CAP $3,979HIP PRMRY TOTL MCRPT CAP $3,979HIP REV BIOMT OF LST PRC $3,979HIP REV ZIM OFF LST PRC $3,979HIP REVISION DEPUY OLP $3,979HIP REVN STRY OF LST PRC $3,979IMP ACL TIGHTROPE RT $1,890IMP ADAP EXT LD NSTM $1,266IMP ADAP EXT LD PM NSTIM $2,579IMP ANCH INNOVAS ROC EZ $465IMP ANCH MITEK KNOTLESS $921IMP ANCH MITEK PANALOK $939IMP ANCHOR PITON KNOTLSS $1,414IMP ANKLE TOTAL $3,979IMP BLN PRES REG $5,497IMP BN CORTICAL $1,176IMP BN FEMORAL HEAD $6,143IMP BN GRFT SUB OSTEO 10 $1,494IMP BN GRFT SUB OSTEO 20 $3,156IMP BN MATRIX 1 $1,134IMP BN MATRIX 2 $1,989IMP BN MATRIX 3 $1,709IMP BN MATRIX 4 $2,967IMP BN MATRIX 5 $2,719IMP BN SPACER $3,185IMP BN SUBST FOAM 10CC $8,637IMP CERV FUSION PRIMARY $1,572IMP CERV FUSION REFUSION $1,572IMP CLAMP TITANIUM $393IMP CLIP TUBE $514IMP COLLAGEN A S $1,507


101 of 154 FY2018

DESCRIPTION CHARGES



IMP CUFF URIN SPHINCTER $11,516IMP DEV JOINT $3,185IMP GEN NSTIM N RECHG $26,481IMP GEN NSTM RESTORESNSR $51,102IMP HIP BIPOLAR $3,979IMP HIP BIPOLAR 2 $3,979IMP HIP HIGH DEMAND $3,979IMP HIP HYBRID $3,979IMP HIP LOW DEMAND $3,979IMP HIP MED DEMAND $3,979IMP HIP NON DEMND MATCH $3,979IMP HIP REVISION $3,979IMP HIP UNIPOLAR $3,979IMP JOINT FINGER $3,557IMP JOINT TOE $2,408IMP KNEE HIGH DEMAND $3,979IMP KNEE HYBRID $3,979IMP KNEE LOW DEMAND $3,979IMP KNEE MED DEMAND $3,979IMP KNEE NON DEMND MATCH $3,979IMP KNEE REVISION $3,979IMP KNEE UNI $3,979IMP LD CARDV DFIB EC DC $6,836IMP LD CARDV DFIB EC SC $1,243IMP LD NSTIM $1,524IMP LOAD EYELID GOLD $761IMP MARKER TISSUE $249IMP MENISCAL SYS $350IMP MESH $678IMP MESH RESORBABLE $2,734IMP MONITOR CARD CONFIRM RX $21,729IMP MONITR CARD BIOMNTR2 $12,965IMP NASAL $865IMP PEG SMOOTH $306IMP PEG THREAD $306IMP PMP CNTRL UR SPHINE $11,909IMP PMP INF PERM N PRGRM $22,007


102 of 154 FY2018

DESCRIPTION CHARGES



IMP PMP INF SYNCHROMED $22,389IMP PMP INF TEMP N PRGM $1,179IMP PMP INF TEMP N PRGRM $521IMP PORT INDWELLING $725IMP POUCH DEFIB $2,925IMP PROSTHESIS BREAST $1,709IMP RADIAL BODY $6,307IMP RCRD CRD REVEAL LINQ $15,005IMP RD STABLZTN PHALANGE $1,864IMP RECRDR CARD CONFIRM $12,333IMP RECVR TRANSMIT NSTIM $1,006IMP SAPH VEIN CRYO PRES $24,549IMP SCAFFLD ACELL $3,045IMP SCRW BIOTENODESIS $1,398IMP SFT TISS FIX BROW $1,268IMP SHOULDER PRIMARY $3,979IMP SHOULDER REVERSE $3,979IMP SHOULDER REVISION $3,979IMP SHTH TIBIAL $912IMP SINUS STEROID RELEAS $4,171IMP SINUS TARSI $3,928IMP SLV FEMORAL $455IMP SMRTNAIL PLLA BIONX $331IMP SPACER TENDON $3,134IMP STIM BN GRWTH $27,571IMP SUBTALAR $6,709IMP SUBTALAR 2 $4,024IMP TENDON ACHILLES $6,384IMP TENDON GRACILIS $4,862IMP TENDON SEMI TENDNSIS $4,032IMP URINARY SYN 1ML $935IMP WEDGE $2,715IMPL ACCESS ANCHOR KT $1,057IMPL SCRW BIOABSORB I $164IMPL SCRW BIOABSORB II $654IMPL SLEEVE TYPE $572IMPL SUTURE ANCHOR $1,044


103 of 154 FY2018

DESCRIPTION CHARGES



IMPLANT SPACER $12,399INJ BULK AGNT 1ML DEXTRN $5,863INJ BULK AGNT URIN 2 5ML $2,004INJECTABLE BULK AGENT $941INTERPORE $1,787INTRPHLNGEAL JOINT SPACR $2,551KNEE BI ONLAY MAKO CAP $3,979KNEE CONSUM PF MAKO CAP $2,439KNEE CONSUMBL MAKO CAP $2,315KNEE PFG MAKO CAP $3,979KNEE PREMIUM BIOMET CAP $3,979KNEE PRIM TTL BIOMET CAP $3,979KNEE PRIM TTL CORIN CAP $3,979KNEE PRIM TTL DEPUY CAP $3,979KNEE PRIM TTL DJO CAP $3,979KNEE PRIM TTL EXACT CAP $3,979KNEE PRIM TTL SNN CAP $3,979KNEE PRIM TTL STRYKR CAP $3,979KNEE PRIM TTL ZIMMER CAP $3,979KNEE PRM TL CMLS STY CAP $3,979KNEE PRMY TOTL MCRPT CAP $3,979KNEE REV BMT OFF LST PRC $3,979KNEE REV MCRPT OF LST PR $3,979KNEE REV STRY OF LST PRC $3,979KNEE REV ZIM OFF LST PRC $3,979KNEE REVISION CORIN OLP $3,979KNEE REVISION DEPUY OLP $3,979KNEE REVISION EXACT OLP $3,979KNEE REVISION SNN CAP $3,979KNEE UNI ONLY MAKO CAP $3,979KNEE UNICND MB BIOMT CAP $3,979KNEE UNICND ZIMMER CAP $3,979KNEE UNICOND BIOMET CAP $3,979KNEE UNICONDYL CORIN CAP $3,979KT AC REPAIR ACUTE $4,980KT BN CEMT W MIXER $695KT BN RESORB BEAD 25CC $3,900


104 of 154 FY2018

DESCRIPTION CHARGES



KT BN RESORB BEAD 5CC $1,749KT BN TO BN BUTTN W DRLL $2,593KT BONE SUBST INJECT HA $4,321KT CATH CENT VEN DBL LUM $1,081KT CATH PLEURAL $1,544KT CATH THERMODILUTION $1,393KT CORE DECMPRSS W GRFT $11,655KT DFIB INSERTION $2,384KT DRN CATH $843KT DRN NRO EXT $1,128KT LD NSTIM OCTRODE 60CM $8,479KT LIGAMENT AUGMNT REPR $4,742KT MENISCAL ROOT REPAIR $6,977KT PASTA BRIDGE REPAIR $5,233KT PEC BUTTON IMPL REPR $7,279KT PIN PLUG DFIB PM $265KT PROX TENODES IMP SYS $3,312KT REPAIR AC TIGHTROPE $1,998KT REPAIR MINI TIGHTROPE $1,630KT REPAIR SYNDESMOSIS $3,244KT REPR MED PATL FEM LIG $6,122KT SPINAL CEMENT NDLSS $8,891KT STAPLE BN FIXATION $5,593LD ACUITY X4 SPRL S 4674 $6,924LD ATTAIN ABILITY 4196 $5,171LD ATTAIN BIPLR 4194 $5,623LD ATTAIN PERFORMA 4298 $7,187LD ATTAIN PERFORMA 4598 $6,887LD COROX OTW 354807 $3,729LD COROX OTW 355148 $3,729LD COROX OTW 355149 $4,853LD COROX OTW L85 368346 $4,167LD DEFB LINOX S65 369818 $9,993LD DEFB LINOX SDX 365501 $8,232LD DEFIB LINOX SD 350054 $7,147LD DEFIB LINOX SD 359067 $7,147LD DFB LINOX SGL 375012 $9,993


105 of 154 FY2018

DESCRIPTION CHARGES



LD DFB PLEXA PROMRI SD 40226 $13,084LD DFB PLEXA S 65 402266 $13,084LD DFB PLEXA S DX 65 15 4140 $13,084LD DFB PROTEGO SD 399410 $9,261LD DFB RELIANC 4STE 0296 $12,215LD DFB SPRINT SECR 6935M $9,878LD DFIB ACUITY 4555 $5,553LD DFIB DURATA 7120Q SJ4 $12,024LD DFIB LINOX SD 359065 $10,005LD DFIB LINOX SD 359066 $7,147LD DFIB LINOX SD 363303 $10,372LD DFIB LINOX TD 351337 $11,450LD DFIB LINOX TD 351338 $7,147LD DFIB PROTEGO S 379969 $8,644LD DFIB PROTEGO S 379970 $9,993LD DFIB QUICKFLEX 1258T $7,258LD DFIB RELIANC SG 0180 $11,106LD DFIB RELIANCE END0184 $12,215LD DFIB SPRINT 6944 $12,119LD DFIB SPRINT 6947 $11,452LD LFT VENT COR VEN SYS $5,283LD NSTIM VAGUS NRV $17,610LD PM ADAPTOR $684LD PM CAPSUREFIX 5086MRI $2,020LD PM CAPSURFX NOVUS4076 $1,398LD PM CAPSURFX NOVUS5076 $1,235LD PM DEXTRUS 4135 $1,660LD PM DEXTRUS 4136 $1,660LD PM DEXTRUS 4137 $1,660LD PM FLEXTEND 4087 $1,759LD PM MYOPORE EPI 511212 $2,284LD PM NOT TRNSVEN VDD SP $1,554LD PM OPTISENSE 1999 $1,179LD PM SELOX JT45 $311LD PM SELOX JT53 $311LD PM SELOX ST53 $311LD PM SELOX ST60 $311


106 of 154 FY2018

DESCRIPTION CHARGES



LD PM SETROX S 350973 $1,355LD PM SETROX S45 $311LD PM SETROX S53 $1,235LD PM SETROX S60 $1,235LD PM SOLIA S $1,235LD PM TENDRIL ST 1888TC $2,020LD PM TENDRIL STS 2088TC $1,689LD PM TENDRL DX 1388T 46 $2,020LD QUARTET QUADPLR 1458Q $7,258LD QUICKSITE XL 1058T $9,322LD SENTUS PROMRI OTW 408719 $9,346MATRX CARTILAG EXTRACELL $4,579MATRX COLLAGEN XENMATRIX $2,547MATRX COLLGN PELV ACEL48 $2,517MATRX DURAL GRFT DURAGEN $792MATRX TISS PLST XSTRNGTH $4,475MATRX TISS XENFORM $5,231MCATH FFR RX NAVVUS $1,871MCATH FINECROSS $1,581MESH BARD 3DMAX LG $472MESH BARD 3DMAX MED $460MESH COMPOSIX E X 10X13 $4,873MESH COMPOSIX E X 4X6 $1,103MESH COMPOSIX E X 7X9 $3,089MESH COMPOSIX L P 6X8 $3,139MESH GRTX DUAL 150CM1OVL $1,455MESH H BARD COMPOSIX E X $2,733MESH HERNIA COMPOSITE $2,067MESH HERNIA COMPOSIX 48 $1,759MESH HERNIA VENT $2,464MESH HERNIA VENT 2 $1,360MESH MARLEX PERFIX PLUG $523MESH PELVISOFT $1,632MESH PLUG PERFIX BARD $409MESH POLYPRO 10X14 $274MESH POLYPRO FLAT 6X6 $166MESH POLYPRO PRESHAPE $115


107 of 154 FY2018

DESCRIPTION CHARGES



MESH SURGIWRAP LG RESRB $696MESH UPSYLON $5,291MOLD CEMENT SPACER HIP $3,706MSH COMPOSIX E X 8X10 $3,854MSH CONTAINMENT BONE $15,435MSH MACROPOR PARIETENE $493MSH POLYPRO PLUG EXL $556MSH PROLENE SM $219MSH VENTRALEX W STRP $1,096NAIL ANKLE ARTHRODESIS $7,856NAIL CEPHALOMEDULLARY $17,173NAIL HUMERAL $10,377NAIL INTRAMEDULLARY TYP1 $2,923NAIL INTRAMEDULLARY TYP2 $4,376NAIL TIBIA $6,180NEURAWRAP PER CM $1,502NEUROFLEX PER 0 5CM $820OH RING ANNULOPLASTY $8,654OH VALVE MITRAL $13,965PERMACOL 10X15 PER SQ CM $36PERMACOL 15X20 PER SQ CM $108PIN CERCLAGE POSITION $577PIN DISTRACTION $427PIN FIXATION PROVISIONAL $293PIN HALF THREAD $483PLT CARPAL TAPERED $4,924PLT CLAW FT ANKL $6,830PLT DISTAL LATERAL FEMUR $4,071PLT DORSAL DR $3,646PLT FIBULA DISTL LATERL $2,287PLT FOOT FIRST RAY $4,077PLT HUMERUS MEDIAL $5,336PLT L STERNAL $1,834PLT LC CLAVICLE TIT $3,201PLT LC MEDIAL DISTAL TIB $6,539PLT LC PROX TIBIAL $4,783PLT LCK STERNAL $3,016


108 of 154 FY2018

DESCRIPTION CHARGES



PLT LCP CLAVICLE $3,444PLT MAX FACL $184PLT POSTERIOR $4,748PLT POSTERLAT DISTL HUM $4,128PLT RADIAL $3,713PLT SUBCONDYLAR $3,803PLT VOLAR DISTAL RADIUS $3,837PLT VOLAR RADIUS $1,849PLT X STERNAL $3,325PLUG VASCULAR AMPLATZER $2,486PM ACCOLADE DR L301 $10,753PM ACCOLADE EL DR L321 $10,400PM ADVANTIO DR K063 $11,094PM ADVANTIO SR K062 $9,425PM ADVISA DR MRI A2DR01 $12,425PM ADVISA SR MRI A3SR01 $10,264PM ALTRUA DDDR S603 $11,094PM ALTRUA SSIR SC S601 $9,425PM ASSURITY DR RF PM2240 $14,672PM ASSURITY SR RF PM1240 $12,595PM CONSULTA CRT P C4TR01 $25,792PM CONTAK RENEWAL H120 $22,588PM DC ACCENT DR PM2210 $12,548PM DC ACCOLADE L311 $18,692PM DC ALTRUA 60 S602 $11,094PM DC ALTRUA 60 S606 $11,094PM DC EVIA DR T 359529 $14,585PM DC RHAPSODY 2510 $12,430PM DC RR ADAPTA 0101ID $13,673PM DC RR ADAPTA ADDR01 $8,335PM DC RR ADAPTA ADDRL101 $11,900PM DC RR ADAPTA ADDRS1 $13,263PM DC RR CYLOS DR $14,294PM DC RR CYLOS DRT $14,586PM DC RR ENPULSE 2 $18,955PM DC RR ENRYTHM P1501 $14,620PM DC RR IDENTITY $18,909


109 of 154 FY2018

DESCRIPTION CHARGES



PM DC RR IDENTITY ADX $20,799PM DC RR INSIGN ULTR DR $16,780PM DC RR INSIGNA ENTR $17,868PM DC RR INSIGNA ENTR DR $13,673PM DC RR INSIGNA PLUS $21,441PM DC RR INSIGNA SR $23,291PM DC RR INSIGNA ULTRA $14,916PM DC RR INTEGRITY ADXXL $20,799PM DC RR INTEGRTY ADX DR $20,799PM DC RR KAPPA 900 $17,868PM DC RR KAPPA KDR701 $14,139PM DC RR KAPPA KDR901 $18,179PM DC RR PHILOS II DR $12,430PM DC RR PHILOS II DR T $14,011PM DC RR PROTOS DR $18,955PM DC RR RHAPSODY DR2530 $19,266PM DC RR SENSIA SEDR01 $8,820PM DC RR SIGMA 300DR $12,430PM DC RR VERITY ADX XL $17,381PM DC RR VERSA VEDR01ID $12,209PM DC RR VICTORY XLDR $12,489PM DC RR ZEPHYR 5820 $13,148PM DC RR ZEPHYR 5826 $13,148PM EDORA PROMRI 407145 $15,421PM ELUNA PROMRI 394969 $11,496PM ELUNA PROMRI 394971 $10,805PM ENTOVIS PROMRI 371992 $11,946PM ENTOVIS PROMRI 404722 $12,621PM ENTOVIS PROMRI 404723 $11,087PM ESSENTIO DR IS1 L101 $9,832PM ETRINSA DR T 394931 $10,286PM ETRINSA HF T 394919 $21,636PM ETRINSA SR T 394936 $9,378PM EVIA DR T CLS HM GSM $10,864PM EVIA HF T CLS 395421 $21,752PM EVIA SR T CLS HM MOB $10,876PM INGENIO DR IS 1 K173 $10,740


110 of 154 FY2018

DESCRIPTION CHARGES



PM INGENIO DR K174 $11,047PM INGENIO SR IS 1 K172 $9,180PM INSYNC III 8042 $24,626PM REPLY DR ICV1258 $14,605PM REVO MRI SRSCN RVDR01 $13,175PM SC ACCENT SR PM1210 $10,668PM SC AZURE W1SR01 $14,402PM SC EVIA SR T 359533 $10,005PM SC PRELIFE W UPGRD $9,700PM SC RR ADAPTA ADSR01 $10,277PM SC RR ADAPTA SR01ID $11,680PM SC RR ATR VNT BI $13,207PM SC RR CYLOS VR $13,984PM SC RR ENPULSE $16,454PM SC RR IDENTITY ADX $15,329PM SC RR KAPPA KSR901 $16,517PM SC RR PHILOS II SR $9,146PM SC RR PHILOS SR $9,633PM SC RR PROTOS VR $15,848PM SC RR SENSIA SESR01 $6,094PM SC RR SIGMA 300 $11,171PM SC RR VICTORY $10,516PM SC RR ZEPHYR SR 5620 $11,174PM STRATOS LV 338200 $18,645PM SYNCRA CRT P C2TR01 $23,210PM VALITUDE X4 CRTP U128 $20,374PM VIVA CRT P C6TR01 $21,208PROS ANKLE $1,075PROS AUGMENTATION $787PROS CARPAL STEM $3,713PROS DURA SUBST $1,010PROS ELBOW $3,979PROS FEMORAL HEAD $2,010PROS FEMORAL MODULE $4,602PROS HUMERAL HD $2,595PROS HUMERAL STEM $8,869PROS KNE PATELA $18,938


111 of 154 FY2018

DESCRIPTION CHARGES



PROS KNE PATELA. $1,765PROS METACARPOPHALANGEAL $9,114PROS PENILE INFLATABLE $5,065PROS RADIAL HEA $6,946PROS RADIAL STEM $3,328PROS SHOULDER $3,415PROS TESTICULAR $5,127PROS TIB BEARING $8,005PROS TOE HAMMER $1,911PROS ULNAR ASSEMBLY $10,225PROS ULNAR HEAD $5,560PROS ULNAR STEM $12,851PST TEF VCL CHD $1,122PTCH H VENTRIO LG OVAL $2,867PTCH H VENTRIO MED OVAL $2,265PTCH H VENTRIO SM OVAL $1,534RCRDR LOOP REVEAL $12,119RD TYPE I $432SCAFFLD SURG SLK BIORSRB $9,262SCREW BIOABSORBABLE $280SCREW SPECIALITY TYPEI $1,100SCREW SPECIALITY TYPEII $671SCRW ANTI ROTATION $1,300SCRW BIOINTERFER ARTHREX $517SCRW BIOINTERFER ARTHRX $845SCRW BN $52SCRW BN MULCH BIOMET $2,900SCRW BN. $304SCRW CANN $380SCRW COMPRESS $92SCRW COMPRS LAG $1,978SCRW CORTICAL $156SCRW CORTX. $109SCRW DISTRACTION $926SCRW HI TORQUE $288SCRW LOCKING CANN $383SCRW MANDIBULAR $639


112 of 154 FY2018

DESCRIPTION CHARGES



SCRW MAX FACIAL $207SCRW POLYAXIAL $306SCRW TENDONESIS $886SCRW TITAN $404SCRW TOTAL HIP $243SCRW WASHERLOC BIOMET $379SHLDR PRIM TTL DEPUY CAP $3,979SHLDR PRM PART STRYK CAP $3,979SHLDR PRM PRT DEPUY CAP $3,979SHLDR PRM PRT EXACT CAP $3,979SHLDR PRM REV BIOMET CAP $3,979SHLDR PRM REV EXACT CAP $3,979SHLDR PRM TTL BIOMET CAP $3,979SHLDR PRM TTL EXACT CAP $3,979SHLDR PRM TTL STRYKR CAP $3,979SHLDR RESRF ARTHRSRF CAP $3,979SHLDR REV BMT OF LST PRC $3,979SHLDR REV ZIM OF LST PRC $3,979SHLDR REVISION DEPUY OLP $3,979SP ANT CERVICAL PLT L1 $4,199SP ANT CERVICAL PLT L2 $4,489SP ANT CERVICAL PLT L3 $4,770SP ANT CERVICAL PLT L4 $5,043SP ANTERIOR SCREW $668SP ARTIFICIAL DISC CERV $21,271SP BN EXTN ALLOGRAFT $1,957SP BN GRAFT ALLOGRAFT $3,042SP BN GRFT EXT SYNTHETIC $4,202SP BN MORPHOGNIC PROTEIN $10,521SP CELLULAR BN MATRIX $2,999SP CERV INTERBODY DEV $4,006SP CERV STANDLNE INT DEV $13,511SP CERV STNLN INT DV SCR $1,441SP CLAMP $1,461SP COMP SCRW WASHER $6,418SP CROSSLINK ASSEMBLY $4,397SP DYNC STABILIZ SPACER $15,790


113 of 154 FY2018

DESCRIPTION CHARGES



SP EXPAND STACK DEVICES $20,280SP IBF BN ALLOGRAFT CERV $3,871SP IBF BN ALLOGRAFT LUMB $9,805SP INTRSPN PROC DCMP DVC $6,219SP LAMINAL HOOKS BLADE $1,544SP LUM INTBDY DV LAT OTR $13,232SP LUMB INTBODY DEV ALIF $11,766SP LUMB INTBODY DEV PLIF $11,876SP LUMB INTBODY DEV TLIF $10,898SP LUMB STANDLNE INT DEV $27,748SP LUMB STNLN INT DV SCR $1,757SP PEDICLE SCREW ADV $3,545SP PEDICLE SCREW STND $2,929SP ROD ADVANCED $2,241SP ROD STANDARD $709SP SET SCRW BOLT CAP NUT $580SP SPINOUS PROCESS DEV $15,133SP THORACOLUMB SP PLT $19,778SP THORCOLUMB SP PLT SCR $420SPOOL HUMERAL $7,049ST DIL RENAL AMPLATZ $1,486ST PUMP IMPELLA CP CATH $11,683STENT BILIARY PRELOADED $654STNT B DS PARAMNT INTRA $3,045STNT B EXPRESS LD $2,763STNT B FLEXIMA SYS SNGL $311STNT B PALMAZ XL 40 $2,735STNT B PROTEGE EVERFLEX $4,229STNT B PROTEGE GPS $3,403STNT B RX PLASTIC $370STNT B SMART CORDS NITNL $3,987STNT B TRNSHEPTIC SE OTW $4,927STNT B VISIPRO $2,983STNT B WALLFLEX RX CVR $7,853STNT B ZILVER $4,195STNT C ACS MULTILNK ULT $1,864STNT C GRAFTMASTER RX $7,393


114 of 154 FY2018

DESCRIPTION CHARGES



STNT C INTEGRITY BMS RX $2,020STNT C NIRXCELL $2,208STNT C PACLITAXEL $4,801STNT C PROMUS RX $5,920STNT C RESOLUT INTEG DES $4,428STNT C TAXUS LIBERTE $6,666STNT C XIENCE $4,428STNT COAT COV W DEL SYS7 $9,306STNT COR RESOLUTE ONYX DES RX $3,855STNT DUODENAL BEND PLSTC $224STNT ENDOPROSTH FEM ART $9,795STNT ESOPH ENDOMAXX FCVR $6,791STNT ILIAC SMART CONTROL $2,099STNT MULTLINK VISION RX $1,864STNT MULTLNK MINI VISION $1,864STNT PERIPHERAL SUPERA $4,785STNT U DIVERSN PERCUFLEX $556STNT U INLAY DBL PIGTAIL $394STNT U PERCUFLX PLUS $497STNT U VL MARDIS SOFT H $663STNT URET MULTLNG W O GW $285STNT URET SILHOUETTE $353STNT URETERAL CONTOUR VL $473STNT VAS ABSOLUTE PRO SE $3,010STNT VASC BLN EXPND OTW $2,701STNT VASC EPIC SLF EXPND $4,832STPL LINE REINFORCEMENT $594SYS ACHILLES SPEEDBRIDGE $7,674SYS ACL TIGHTROPE BTB $1,877SYS ANCH TRANSFIX BN W D $1,378SYS ANCHOR KNOTLESS $1,103SYS BICEP DSTL REPR IMPL $3,776SYS BRTH CNTRL $4,273SYS COMPL PLNTAR PLT RPR $4,220SYS ELBOW IMPLANT FIXATN $5,486SYS FIXATION SM BN $1,476SYS FRONTAL SINUS BLN $5,076


115 of 154 FY2018

DESCRIPTION CHARGES



SYS IMPL SPEEDBRGD SWVLK $5,389SYS LD DLV COR SINUS $1,298SYS LIGAMENT RECON CMC $2,633SYS MCATH PROGREAT COAX $1,363SYS MEN SEQUENT REPR CRV $1,875SYS MENISCAL FAST FIX $803SYS MENISCL FAST FIX CRV $1,451SYS REP TRANSVAG W SLNG $5,058SYS SACROILC JOINT FUSN $7,930SYS SEALANT DURAL $1,680SYS SLNG FIX M ADVNC W S $18,695SYS SLNG MIDURETH TRNOBT $3,125TENOGLIDE PER SQ CM $94TIGHTROPE ABS NO BUTTON $812TIGHTROPE ABS W BUTTON $633TISS CONNECTIVE HUMAN $901TISSUE EXPANDER $1,631VAS CLS ANGSL 6FR 610130 $752VENA CAVA KT $2,308VLV CERB SPINAL $3,800WASHER NUT $261WSTNT B ENDPR UNISTEP DS $4,559

OTHER SUPPLIESACCESSORY SPRAY AIRLESS $90ACETIC ACID 25 1L IRR $168ADHES TOPICAL SKN $276ADHES TOPICAL SKN 2 $81ADHES TOPICAL SKN 3 $346ADPT CATH $45ADPT SEALING $119ADPT SWIVEL $41ADPT Y CATH $64ADPT Y CORON $92AID SHOE HORN $61AID SOCK $80AID SOCK STOCKING $120


116 of 154 FY2018

DESCRIPTION CHARGES



AID TOILET TONGS $95ANCH NEUROSTIM LD SWFT $566ANS ESPH STH $250ANS VENT CIRC $245ANTICOAG SL $266ANVIL STPLR TRNSORL CIRC $1,035AORTIC ARCH CANNULA $155APPL HEMOSTAT FLXTP $108APPL SLVR NITR $61APPL TIP $88AQUAPLAST PERF $69ART FEM CANNULA $147AS EEA XX A T $870AS ENDOCLIP $1,009AS ENDOSTITCH $966AS ENDOSTITCH RELOAD $182AS GIA REFILL $842AS HERNIA STPL $1,658AS LDSXX A T $1,158AS STPL END $1,002AS STPL FACA $251AS STPL ILS $1,247AS STPL SKN $140AS STPL TA30 90 $1,022AW ADPT STR $71AW FASTRACH DISP $340AW NASL $210AW NASO PHARYNGL $23AW ORAL $41AW OROPHARTNGL W CUFF $238BACKGROUND MICRO YEL $99BAND FACIAL UNIVERSAL $65BATRY PAK QUAD $73BG AMBU $334BG BILE 19 OZ $36BG FEEDING $70BG PRESS INFU $55


117 of 154 FY2018

DESCRIPTION CHARGES



BG URINE DRN $154BG URINE METER $142BITEBLOCK TONGUE $105BLD AORTIC PUNCH $374BLD ARTHRO CUT $3,550BLD ARTHROSCPY $494BLD ARTHROSCPY. $256BLD BASIC GEN $2BLD BONE MILL $849BLD CLIPPER DISP $52BLD DERMAT HEAD DISP $280BLD DISP $54BLD ELECTR EXT $77BLD EYE $114BLD INCISOR ELITE CURVED $409BLD LARYNGEAL $1,142BLD OSCILLATOR $827BLD OSTEOTOME $363BLD OTOLARYNGOLOY DISP $633BLD PATEL REAM $505BLD PLASMA $908BLD RADNOID DISP $854BLD RASP ANY $364BLD RASP TEAR CROSS CUT $1,827BLD REAMER PERCUT EXPND $1,644BLD SAW GIGLE $224BLD SAW GIGLI $113BLD SCALPL HARMONIC $1,424BLD SCREWDRIVER $587BLD SHAVER $1,163BLD SINUS RADICAL DISP $609BLD STERNAL $68BLD TRICUT DISP $729BLD TURBINATE INFERIOR $850BLLN VERTEBRAL BODY $1,342BLN DISSCT SPCMKR HERNIA $2,221BLN DISTENTION $838


118 of 154 FY2018

DESCRIPTION CHARGES



BLNKT AIR WARM $253BLNKT BAIR HUGG $29BLNKT WARM CARDIAC $112BLOOD INFU ST $66BLOOD REPL BAG $646BLT GAIT TRNSFR $26BN MILL $278BND BIND ABD $36BND BIND ABD. $190BND COBAN A S $57BND COMP MULTILAYER $107BND COMPRESSION $102BND ELST A S $23BND ELST DBL LNTH4 $197BND ELST DBL LNTH6 $245BND ESMARK ANY $48BND GZ ELASTIC $16BND KLING A S $39BND LIGATOR $1,647BND STKNG KNEE $51BND STKNG THGH $89BND STKNG WAIST $48BND TBGZ A S $57BOARD TRANSFER $304BOOT HEEL W TOE PAD $61BOOT SUTURE $47BRCE FOOTDROP $1,136BRD TRANSFER BARI $584BRSH CYTOLOGY $238BRSH ENDO $219BRSH FOOT $143BRSH SUCT ECON $71BSK RETRV $709BSK RETRVL TRAPEZOID $1,102BSK SEGURA $2,076BSK STONE $377BSK WALKER $222


119 of 154 FY2018

DESCRIPTION CHARGES



BULB ESOPH DETECTOR $57BURR BN DIAMOND $400BURR DIAMOND $483BURR ROTABLADER $2,627BURR TYPE I $206BURR WIRE PASS $85BX FORCEPS $1,502BX THERMA JAW HT $1,812CABLE NSTIM PT $306CABLE PACING $247CABLE SCRN NSTIM $342CANISTER SUCT $54CANISTER WOUND VAC $118CANN $31CANN ARTERL LNG STRAIGHT $591CANN ATRIAL LNG $1,129CANN BUTTON PASSPORT $124CANN CORONARY PERFUS $317CANN CRD AST PMP $747CANN DISP INER $40CANN EMBOLIZTN PROTECT $4,370CANN ERCP $706CANN FEMORAL VENOUS $833CANN IMA $51CANN LAP W SEAL N THRD $70CANN NASAL O2 CO2 $99CANN NDL LS $48CANN PROBE $289CANN RETROPLEGIA $370CANN SHOULDER $243CANN THREADED $79CARD SUCKER $198CARTRIDGE CRYO $402CARTRIDGE IV FLUID SYS $53CARTRIDGE SUTURE $630CAST BOOT $365CAST BOOT BRACE SHORT $912


120 of 154 FY2018

DESCRIPTION CHARGES



CATCHER STONE LITHOCLAST $281CATH ABL BLAZER II HTORQ $3,554CATH ABL BLAZER II XP $6,137CATH ABL CELSIUS BRAID T $4,839CATH ABL NAVISTAR THERMO $9,257CATH ABL NAVISTR DEFL TI $6,015CATH ABL POLARIS DX $1,885CATH ABL THERMOCPL BIDIR $8,205CATH ANG TEMPO AQUA STRT $283CATH ANGIO $80CATH ANGIO IMAGER II $81CATH ANGIOGRAM $611CATH ATHER STEALTH 360 $9,020CATH ATHR TRANSLUM ROTAT $1,805CATH BALOON SV $2,595CATH BILI DIL $2,284CATH BLN DIL URETRL COOK $1,467CATH BLN TIS DISSCT NVAS $3,803CATH BLN VENOGRAM $356CATH BRACHYTHER SEED ADM $11,719CATH CARD ASH SPLIT $3,684CATH CARD INFUSN $1,626CATH CEREBRAL BP I $414CATH CHOLANG A S $313CATH COUDE ALL $70CATH DIAG ELECT TORQR $1,017CATH DIAG ENSITE 3000 $13,560CATH DIAMONDBACK 360 $11,353CATH EP CORDIS FIX QUAD $563CATH EP DFLECT TP BS WEB $2,979CATH EP DIAG NOT3D 19OR $573CATH EP DIAG NOT3D 20OR $326CATH EP DIAG O T3D MPNG $3,333CATH EP DX ABL 3D VECTR $11,847CATH EP FC BS WEBSTER $1,352CATH EP FIX BRDVKNG QUAD $369CATH EP LASSO DEFL CIRC $6,094


121 of 154 FY2018

DESCRIPTION CHARGES



CATH EP OTH THN COOL TIP $2,843CATH EPIDURAL $380CATH EXT $39CATH EXTENDER $2,370CATH FEMORAL $57CATH FGRTY IRR $263CATH FOLEY 3CC $253CATH FOLEY 5CC $209CATH FOLY 2W ALL $250CATH FOLY 30C SY $219CATH FOLY 3W ALL $310CATH FOLY COUNCIL TIP $59CATH FOLY IC 2W $62CATH FOLY SILI $187CATH GOLD PRB DISP $1,958CATH GUIDE SLIT OUTR CPS $776CATH HEART RIGHT $591CATH IV 16X1 1 4 $76CATH IV 18X1 1 4 $76CATH IV 20X1 1 4 $76CATH IV 22X1 $76CATH IV 24X3 4 $39CATH JEJUNOS BKR $1,061CATH LSR ATHER CORON RX $6,492CATH LSR SPECTRANTC EXTR $7,144CATH NASL BALLON $370CATH PASSER $398CATH PERCUTANEOUS $637CATH PLXS NRV BLCK CONT $763CATH RADIAL ART $47CATH RADIAL ART $95CATH REENTRY $8,880CATH ROB NEL $95CATH SINUS CORONRY OCCLS $5,239CATH SINUS LAVAGE $609CATH SNARE $2,443CATH SPEC $199


122 of 154 FY2018

DESCRIPTION CHARGES



CATH SPNL STEER TARGET $1,571CATH STRP LEG $78CATH SUCT GL A S $5CATH SW GZ $866CATH SW GZ THERM $696CATH TROCAR ANY $492CATH URETERAL $43CATH URETERAL DL $135CATH URETH $770CATH URTRL FLEXIMA $39CATH US INTRAVASCULAR $3,240CATH VESSEL SIZING $825CATHETER IVUS $3,546CAUT BIPOLAR DISP $447CAUT COAG SUCT $246CAUT ELCTRD $135CAUT EYESTAT $519CAUT HOOK $606CAUT OPHTH LOTEMP $91CAUT PEN TIP $504CAUT SHTH DISSECTION $2,426CAUT TIP BAL NED $106CAUT TIP CLEANER $4CAUT TIP EXTEND $94CAUT ULTRASONIC HNDPC $1,857CELLSAVER TUBING $143CEMENT CURRETTE $1,492CEMT FEMORAL PRESSURZR $109CEMT INTRO NDL $385CEMT NOZZLE $340CEMT RESTRC RG $1,099CEMT SYR $555CHAMBER VLV HLDING $114CINCH SUTURE OVERSTITCH $284CIRT HHN $225CLIP APPLIER DISP $633CLIP LIGATING POLYMER $127


123 of 154 FY2018

DESCRIPTION CHARGES



CLIP OH HORIZON MULT $813CLIPPER LEAD $473CLMP ARTERIAL $204CLMP INSRT SOFT $87CLMP POUCH $25COIL PUSHER $994COLL FLEXISEAL FECAL $1,970COLLAR CERV A S $335COLLAR HARD CERV $118COLLAR PHIL $577COMPRESN FT GARMNT $260COMPRESS EYE GEL $349CON URET CATH $96CONEC TB $80CONEC TUBE $48CONEC Y $48CONN SUT DEV $855CONTROLER DETACH EMBCOIL $570CORD BI POLAR $154CORD MONOPOLAR DISP $87CORNEAL PROTECT $41COTTON ROLL 1LB $149COUNTERSINK CANNULATED $608COUNTERSINK DISP $993CRRT DIALY G110 K2 C0 5L $396CRRT DIALY G110K4C2.5 5L $150CST ARM LNG A $751CST ARM LNG C $424CST ARM SHRT A $542CST ARM SHRT C $222CST LEG LNG A $1,061CST LEG LNG A FG $1,839CST LEG SHRT A $1,061CST LEG SHRT C $326CST LEG SHT A FG $1,044CST PLASTER A S $561CST PROTCTR $140


124 of 154 FY2018

DESCRIPTION CHARGES



CUFF TOURNIQUET $302CUP NOSE $43CUTTER RETROGRADE DUAL $982CYSTITOME IRRIGATING $232DAM SILICONE PUSHLOCK $84DECANTER BAG $45DERMACARRIER $135DETR CP CO2 $38DEV BN FILLER $840DEV BN TAMP INFLATABLE $5,685DEV CUTTING $888DEV HAND ACCESS LAP $2,522DEV INFLATION $259DEV LAP SEAL DIV $2,029DEV LAP VES SEAL $2,833DEV LDLOCK SPECTRA518018 $2,155DEV LDLOCK SPECTRA518019 $2,155DEV LDLOCK SPECTRA518039 $1,816DEV LDLOCK SPECTRA518062 $1,816DEV QCK LOAD TI KNOT $162DEV RETRIEVAL INSERTABLE $1,959DEV SEALER DIVIDER $2,281DEV TITANM KNOT TK5 $214DEV TUNNELER $338DIALYSATE 2000 2999ML PD $343DIALYSATE 3000 3999ML PD $208DIL VESSEL $105DRAINAGE SYSTEM $126DRILL BITS 1 $1,014DRILL BITS 2 $694DRILL HAND IVAS $386DRILL SLEEVE DISP $1,626DRIVER DISP SCREW $878DRL WIRE PASS $168DRN BLAKE $386DRN CHEST $1,556DRN CHST HEIMLICH VALVE $174


125 of 154 FY2018

DESCRIPTION CHARGES



DRN JACKPRAT $237DRN PENROSE $77DRN RESER $173DRN SUMP SALEM $128DRP BARRIER $209DRP LAP PEDI $301DRP LAP T SHET $181DRP STRI POUCH $126DRP TUR $149DRS ABD PD $19DRS ALGINATE $57DRS ANTIMICROBIAL I $388DRS DUO DERM 8X8 $114DRS EYE PD $19DRS EYE SHIELD $4DRS FLUFF KER10 $57DRS GEL PAD $52DRS HYDROFIBER AG $70DRS KERLIX $79DRS OPSITE IV $69DRS OPSITE LG $30DRS OPSITE MD $65DRS PCKNG NASAL $964DRS PET AD 3X3 $37DRS PET AD 3X8 $26DRS PET VS 1X8 $48DRS PET VS 3X18 $48DRS PK IODO 1 2 $114DRS PK IODO 1 4 $114DRS PK IODO 1IN $114DRS PK IODO 2IN $114DRS PK NU GZ A S $147DRS SPNG 4X4 2P $2DRS STERI STRIP 1IN $16DRS STICK $22DRS TUBIGRIP 9 $51DRS WND ANY $54


126 of 154 FY2018

DESCRIPTION CHARGES



DRS WND OPEN ABD ABTHERA $995DRS WND VAC LG $331DRS WND VAC MED $288DRS WOUND ANY II $24DRS WRAP COLD $450DRS XEROFORM A S $10DRSG FM 16 48SQ IN WO BR $47DRSG FM 16SQ IN WO BRD $21DRSG HYDRO 16 48SQ WO BR $105DRSG SILICONE GEL SHT $130DRSG TRANSP FLM 16 48SQ $57DRSG TRANSP FLM 16SQ $75DVC ABL SURG BPLR $7,814DVC BX CORE AUTO $365DVC CRYO UNIT DISP $5,148DVC DISSECTN US CORDLESS $477DVC FIX ARTIC RELD TACK $663DVC INFLAT SINUS BLLN $434DVC LAP FIX HERNIA $1,395DVC LAP PRT ACCESS $2,043DVC PUNCT CLOSURE DIS 2 $315DVC RADIAL COMPRESSION $218DVC RETRIEVAL ENDOHELIX $1,218DVC SECURE FOLEY $28DVC SECURE P C ML $38DVC SUT KNOT TYING DISP $237DVC TACKER DELIV $1,198DVC TISS REMVL HYSTERSCP $2,044DVC TISSUE FIXATION $1,454DVCE BN BX $994DVCE INFL $523DVCE LAPR MESH TCKR DISP $1,357DVCE PINCH ON TOOL $156DVCE SIZING $266DVCE TORQUE $187DYCEM $2EAR WICK $42


127 of 154 FY2018

DESCRIPTION CHARGES



ELCT COAG ANGLD PNT $344ELCTRD EKGSUB $697ELCTRD FLAT BLD $118ELCTRD FULGURATING $352ELCTRD KNF $698ELCTRD LOOP $286ELCTRD NDL 2 CHANEL PR $478ELCTRD NDL EEG $100ELCTRD PACING $415ELCTRD RESECT RLLR BALL $384ELCTRD VAPOR $1,508ELECTRODES ROLLERBALL 24 $379ENDO BABCOCK $944ENDO CATCH SAC $1,183ENDO DISSECTOR $2,191ENDO GRASPER $363ENDO IRRIGATOR $641ENDO ONSEAL REDUCER CAP $114ENDO OVERTUBE $483ENDO SHEARS $790ENDO STAPLER $267ENDOCLIP APPLIER DISP $1,221ENDOPATH $288ENDOSCRUB $283ENEMA BA PREP KT $23ENEMA BOWEL EVAC $16ENEMA OIL RETNT $5ENEMA PHOS $2EVC BLADDER $298EXERCISER BALL $160EXFX CLAMP I $1,927EXFX DIGIT WIDGET $4,126EXT DRN BG $102EXT MIRROR $138EXTR BALN STONE $1,904FEED ENTRL ST $23FEM CANAL BRUSH $162


128 of 154 FY2018

DESCRIPTION CHARGES



FEM COMP ARCH $899FETHER WGHT REACHR $96FILTER PALL I $353FILTER TPN IV $94FLOW CONT VLV CF $2,924FLTR BLD PALL $306FLTR CIRCUIT $40FORK BLT UP HNDL $51FORK WGHTD $115FRCP DISP 1 $1,718FRCP GRSP $1,290FRCP GRSPNG $1,322FUNNEL $175GARMENT COMPRESSION $609GASTROSTOMY TUBE $104GCATH MYLOTEC VIDEO $2,861GDE DRILL $360GDE NDL BX COMP $118GDE SINUS CORON WORLEY $954GEL INTRASITE $65GEL ULTRASONIC $37GINTRO AGILIS STRB NPEEL $3,476GINTRO EP IC FC PEELAWAY $1,481GLUE FIBRIN DRL $4,626GLV ISOTONER $130GRASPER ALLIG MINI LAP $665GRASPER SUTURE $1,194GRSPR TISS HELIX TIP $635GUIDE CUSTOM KNEE $1,591GUIDEWIRE $181GUIDEWIRE II $364GUIDEWIRE III $498GUIDEWIRE IV $1,225GUIDEWIRE V $1,572GUIDEWIRE VI $651GW DRILL TIP $425GW EXCHNG ZEBRA SNGL USE $3,033


129 of 154 FY2018

DESCRIPTION CHARGES



GW FLOWIRE DOPPLER $3,253GW GLIDEWIRE GOLD $643GW HITORQ STD $430GW HP JAGWIRE SNGL USE $347GW PRESSR AERIS AGILE TP $1,748GW PTCA IT TRACKWIRE $1,471GW TRACER WILSONCOOK $1,561GZ PACKING VAG $44HAND EXER SOFT $43HANDHELPER $136HEEL ELBOW PROTECTOR $80HEMOSTAT ABSORB SNOW $218HEMOSTAT FLOWABLE $360HEMOSTAT VALVE $365HL LIMB EA $124HNDBPC COAG ARGO $853HNDL SINUS GD CATH $336HOOK BUTTON $34ILLUMINATOR SURG DISP $399IMBL ANKLE AIR $231IMBL HAND ALUM DISP $632IMBL KNEE $38IMBL SHLDR $31IMP SPACER SINUS TEMP $3,120INCENTIVE SPIRO $245INCNT FECAL $69INFL SYR MT $126INFL SYR W GAUGE $107INFLATOR $116INJCTR HAND DISP $207INJECTR BONE GRFT SUBST $2,287INK TATTOO $179INSERTR BUTTN DSTL BICEP $606INST BB TAK FOR SML JNTS $276INST TUNNELER IVS DISP $1,800INTR ACCUSTICK II ROMRKR $547INTRO CATH SHTH STD $213


130 of 154 FY2018

DESCRIPTION CHARGES



INTRO EP IC N LSR N GD 2 $543INTRO EP IC N LSR N GD 3 $339INTRO PM LEAD $1,223INTRO TRANSFEMORAL BLN $1,537INTRODUCER $642INTRODUCER GUIDEWIRE $365IRG MALIS BPLR $353IV INFUSION SET 21 X 3 4 $43KIT ACL $1,087KIT PENILE PROSTH PREP $2,387KITTNER ENDO $940KNF ANGLED SLIT $249KNF ARTHRO $204KNF BLT UP HNDL $64KNF CARPEL TNL $833KNF COLD $697KNF ENT JPLASMA $931KNF GRAF $556KNF LIGHT $580KNF MYRINGOTOMY $187KNF ROCKER SOLID $55KNF ROCKR $119KNF SURG EYE $139KT ABG $19KT ABLATION $15,687KT ABLATION RF $3,973KT ACCESS $2,117KT ACCESS BAND $3,328KT ACCESS LD LOCK RMVL $512KT ACCESS VERTEBRAL BODY $386KT ACCESSORY AMS 800 $2,790KT ACCESSORY PIP $1,313KT ACL TRNSTIBIAL DISP $484KT ACROHPLSTY ELECT DISP $2,635KT ANCHOR SOFT DISP $757KT APPLICTR ENT HEMOSTAT $552KT ARTERY RADIL $52


131 of 154 FY2018

DESCRIPTION CHARGES



KT ARTHROSCOPY HIP $638KT AUTOTRANS WOUND DRAIN $309KT BIOTENODES DISP SCREW $636KT BN PREP $913KT BX BN $4,594KT CARPAL TNNL RELR $1,010KT CARTLG BX TRNSPRT $1,654KT CATH DIALYSH $291KT CATH EXPANSION $252KT CATH VENOUS ACCESS $628KT CHARGER NSTIM $5,149KT CHOLANGIOGRAPHY $575KT CLIP GUN $522KT CLOSE TROCAR WND $342KT COLLAGEN INCNT INTROD $361KT COMPARTMENT SYNDROM $364KT CONTRAST ADMIN WORLEY $120KT CRICOTHYROTOMY $447KT CYTO $1,541KT DILATOR SPINAL $3,280KT DISP ZIPTIGHT FIX DVC $1,408KT DRAPE RIO W POCKETS $113KT DRILL BIT $1,470KT DRN VAC SYS $341KT EAR DRS $255KT ELECTRD SURFACE $1,157KT ENDO VEIN HARVEST $4,119KT ENDOSCOPIC SUT $1,179KT EPI SPINAL ANES $45KT EPID W MED $142KT EYE CR $810KT FEM FIX TOGGLELC DISP $1,563KT GASTRC LAVAG $599KT HEMOCONC $1,880KT HYSTERO FLUID COLLECT $1,375KT IABP INSERT $1,731KT INFLATOR SINUS BLN $492


132 of 154 FY2018

DESCRIPTION CHARGES



KT INSERT PERC 2 9 PSHLK $1,052KT INSTR DSP MINI SUTRTK $557KT INSTR HAMMERTOE FIX $1,045KT INSTRUMENT CLAVICLE $1,466KT INTUBATION $828KT IRR WND $3,200KT JACKSON TBL PT CR $140KT KNEE PAD $127KT KNEE PROCEDR TRACKING $415KT LAP CHOLECY $746KT LD END CAP $96KT LIPO $895KT MICRO ACCESS $193KT MOUTH CR W SUCT $67KT NASO EPISTAX $454KT NEDL BX $205KT OSTEOCHRONDAL $2,428KT PAC BLN ELCTRD $1,906KT PACE ELECTRO $206KT PAD ARCTICGEL LRG $2,272KT PAIN MGMT 100ML 2ML H $776KT PAIN MGMT 270ML 4ML H $1,403KT PAIN MGMT 270ML 8ML H $1,100KT PAIN MGMT 400ML 2 14H $2,566KT PAIN MGMT 400ML 4ML H $987KT PAIN MGMT 65ML 5ML HR $775KT PEG A S $530KT PERCU NEPHRO $1,477KT PLATELET SEPARATION $3,915KT PORTAL ENTRY $1,157KT POSITION $299KT PRESSURE MONITOR $246KT RADIAL ART $474KT RETRACT ENDO $612KT SCRW TST W PRB $205KT SHEATH CATH $387KT SHLDR SUSPN $467


133 of 154 FY2018

DESCRIPTION CHARGES



KT SHROUD MORGU $88KT SHTH INTRO W GW DIL $63KT SHTH LASER GLIDELIGHT $7,082KT SPINAL MAX ACCESS $5,955KT SPINAL MAX ACCESS 2 $6,434KT SPRAY APPLICATOR $310KT SURGICAL SEALANT $663KT SUTURE PASSING UCL $2,507KT SYR VERTECEM V $445KT TBG BAND ACCESS $615KT TOOL ASP INJ EXTRACTN $363KT TOTAL BN PREP $335KT TRACH PERC DIL $2,285KT TRANSURTH DEL $178KT TRNSDU $197KT VEN ACCESS $198KT VERTEBRO KYPHOPLASTY $9,340KT VERTEBRO KYPHOPLSTY2 $12,282KT VERTEBRO KYPHOPLSTY3 $15,761KT WRENCH DISP $147LAPRSONIC COAG SHEARS $2,365LASSO SUTURE ARTHREX $640LAVAGE PULSE DV $414LENS MORGAN $358LIFT LEG $113LINE CAPNO SMART $109LINE SAMPLE CO2 MAC LINE $64LOOP RESECTOSCOPE DISP $279LOOP VESSEL 320 $71LUBRICANT ROTOBLADER $371LUMBAR ROLL $138LZ HOLMIUM $3,937LZ TUBING $181MALE LL CAPS $2MANIFOLD DISP $136MANIPULATR UTER ELEV CUP $321MASK NAVIGATION $1,289


134 of 154 FY2018

DESCRIPTION CHARGES



MASTISOL $94METER PEK FLO $35MIDS RX CUT TOOL $720MIDS RX DIFFUSE $192MIRR INSPECT $181MISC SUPPLIES NON STRL $50MITT HND CNTRL $227MNFLD PRESS $87MOLD CEMENT SPACER KNEE $3,021MOLD CEMENT SPACER TIBIA $1,884MORCELLATOR $1,863MOUTHGUARD DISP $2MSK FACE TNT $298MSK LARYNGL AIRWAY ADLT $63MSK NOREBRET $71MSK O2 ADLT $70MSK O2 PED $65MSK O2 TUBE ADL $24MUG INSULATED $31MUG T HNDL $16MULT BAND LIGATOR $77NASAL STATS $454NDL ACCESS PORT HUBER TP $46NDL ARTERIAL $175NDL ASPIRATION $101NDL BX $271NDL BX $365NDL BX B MAR $430NDL BX B MAR 2 $905NDL BX CHIBA $285NDL BX T CUT $103NDL COAPTITE RGD W CANN $219NDL CYSTOTOM $70NDL DISP EMG $415NDL DISP RETRO $83NDL ELECTRD INSULATED $868NDL EPIDURAL $40


135 of 154 FY2018

DESCRIPTION CHARGES



NDL EYE IRR $21NDL FASCIAL INCISING $143NDL GRICE $373NDL INTRAOSS $403NDL JAMSHIDI $488NDL LOCALIZER $109NDL MENISCAL $620NDL MICRODISSECTION $226NDL MICROPIGMENTATION $445NDL MYELOGRAM $42NDL NRVE BLK $73NDL PERCUTAN $271NDL SCLERO $973NDL SMART $1,035NDL SPINAL $121NDL SPINAL A S $44NDL SPINAL SPC $211NDL STIMULAT $63NDL SUT PASSER $758NDL TRANBRON $564NDL TRANSORAL INJECTION $372NET DISP RETRIEVAL $357OBTURATOR BLADELESS $164OCCLUDER VES FLO RESTOR $274OH ADAPTR PRFUSN $27OH BALN INT AORTIC $6,699OH BLOWER MISTER $614OH CATH VENOUS RETURN $343OH HEMOSTATIC FIBRILLAR $200OH OBTURATOR $73OH PERFUSION KIT $36OH TUBING PUMP $6,333OH VALV SUCT CNTRL DISP $204OR KIT NEURO $1,742ORTHO PACK $1,313OST ADHSV SPRAY $48OST PASTE STMA $69


136 of 154 FY2018

DESCRIPTION CHARGES



OST PCH DRNBLE $17OST PCH WFR $42OST SKIN PREP $130OST WAFR W FLANGE $45OST WAFR W O FLANGE $43OXISENSOR $71OXISENSOR CEREBRL $505P M CABLE $261PACE ELECTR TEMP $244PACE LEAD SUTWIR $71PACKING STNT SINUS TURB $122PACKING SURGICEL $397PACKING SURGICEL. $214PAD BOOT INSERT $315PAPILLOTOME $2,608PAPILLOTOME W GW $2,960PASSER SUT NANOPASS RCH $828PATCH DEFIB FAST $502PD CAUTERY GRO $11PD DEFIB $80PD DUOTHERM $33PD FLUID CIRCULATING $291PD GROUND RF $280PD HIP PEHR $348PD PACEMAKER EXTERNAL $337PD TBL OR $299PEEP FLO VALVE $102PEN ABL SURG $7,369PEN MARKER SURG $91PERCUT NEPHROS $636PILLOW ABDUCT $420PILLOW ABDUCT LG $314PILLOW ABDUCT MD $299PILLOW ABDUCTION $376PIN BONE THREADED MAKO $142PIN CAP A S $2PIN SKULL MAYFLD $206


137 of 154 FY2018

DESCRIPTION CHARGES



PIN TEMPORARY TYPE 1 $964PK ACESS VEIN HARVEST $353PK ARTHROSCOPY $433PK BREAST $1,228PK CELL SAVER $1,091PK CUSTM MINOR $836PK CUSTOM HEART $2,916PK HAND SPEC $780PK HEAD NECK $244PK HIP $1,636PK INSTRU MOD ULNAR HEAD $1,308PK INTRAOSSEUS MODULE $174PK INTUBATION MODULE $145PK IV DEL MODULE $139PK LAP $263PK LAPSCP CHOLE $4,171PK NASAL $117PK O2 DEL MODULE $71PK SINUS ENDO $750PK SURGICAL CUSTOM 4 $1,182PK TOTAL KNEE $1,617PK TUBAL LIGATION $321PK TURP $716PKNG NASAL MEROGEL $306PLATFORM ADVANCED ACCESS $1,623PLEDGET TEFLON $21PLEUR EVAC $1,367PLUG PULLER DISP $2,370PLUNGER CORE $1,066POSITIONER HEART $1,209POST OP SHOE A S $20POSTN BODY $291POUCH DISP $75PRB ARGON PLASMA $650PRB CANNULA RF $848PRB DEPTH MEASURING $1,084PRB ELECTROSURGICAL $404


138 of 154 FY2018

DESCRIPTION CHARGES



PRB LIGAMENT $2,064PRB LITHO PNEUMATIC $651PRB LITHO ULTRASONIC $1,439PRB LITHOTRIP $1,290PRB NEURO MONITORING $1,292PRB TEMP $230PRB THERMAL ELECTRO $222PRB TIP NRV MAP $352PREM 25 W35 $87PRESS TB $41PROGRAMMER PT NEUROSTIM $5,576PROS SIZER BRST IMP $738PROTECTOR ORTHOPAEDIC $650PRT ACCESS OPTICL BLDLSS $377PUNCH BIOCORKSCREW $304PURSE STRING $664PUSHER KNOT $890PWDR HEMOSTAT ABS ARISTA $945RAZOR DISP STERL $2RD REAMING W BALL TIP $555REAMER PILOTED HEADED $932RESERVOIR BL COLLECTION $342RESTRCTR INJ CMN $569RESUSITATE MANL $280RETAINER VISCERA $522RETR STONE $1,447RETRAC STABLZR VAC $5,440RETRACTOR ABD DISP MINI $189RETRACTOR DISP $696RETRACTOR DISP 2 $215RETRACTOR SYSTEM $162RETRIEVER $1,780ROBOTIC SYS ACCESSORIES $6,643ROTICULATOR $1,603SCALPEL HARMONIC $3,144SCISSORS DISP $155SEALANT DURA PEG $2,356


139 of 154 FY2018

DESCRIPTION CHARGES



SEALANT HEMOSTAT MATRIX $886SEALANT HEMOSTAT MATRIX2 $1,578SEEKER BLLN EM FRONTAL $1,813SEEKER BLLN EM SPHENOID $1,133SEEKER BLN EM MAXILLARY $1,171SENSOR DISP BIS $88SET ENDOTRACH CPAP $100SHEET SILASTIC $195SHFT REAMER MODULAR $1,319SHIELD CATH CONT $52SHIELD COLLAGEN $310SHIELD FACE DISP $101SHOE CST A S $238SHOE HORN $57SHOE LACES ELST $15SHTH DILATR MECHAN ROTAT $4,784SHTH ENDO $236SHTH INTRO $33SHTH INTRODUCER DRYSEAL $1,321SHTH LSR SPECT 500 001 $8,073SHTH LSR SPECT 500 012 $8,073SHTH LSR SPECT 500 013 $8,073SHTH PEELAWAY OVR DIL $1,900SHTH VASCULAR $506SHUTTLE SUTURE ACCU PASS $361SKIN CLOS 1 2 $80SKIN CLOS 1 4 $73SLED PULLBACK $589SLEEVE CATH $154SLEEVE GLIDESCOPE $83SLEEVE TROCAR LAP $48SLEEVE W O TROCAR $75SLEVE KNEE COMP $103SLEVE TH PR COM $1,275SLING ARM DELUX $146SLING ARM HEMI $202SLING IMOBL A S $631


140 of 154 FY2018

DESCRIPTION CHARGES



SLING SWATH $35SLNG CRADLE A S $170SNARE MINI BARD $589SNARE POLYPECTOMY $71SNARE STERILE $770SNARE TONSIL $75SP DISP PORTS ACCESS $5,057SP DRILL BIT $1,167SP GUIDEWR FOR MIS PRO $240SP TEMP FIXATION PIN $244SP VPLASTY SUPP ACCES $253SPHINCTRTOME HYDRATOME $1,241SPLINT SOFT $250SPLNT BUCK TRCT A S $175SPLNT FINGER $146SPLNT FORARM A S $282SPLNT IMOBL SHLD $436SPLNT NASAL ALUM $317SPLNT NASL DOYLE $298SPLNT OCL PER FOOT $116SPLNT REST HAND $417SPLNT WRIST DLX $129SPNG FEMORAL CANAL $87SPNG GELATIN SURGIFOAM $28SPNG LONG $24SPOON BLT UP HNDL $48SPOON WGHTD $98SPPRT FACIAL $295SPPRT HEAD FOAM $139SPPRT KNEE HINGD $802SPPRT SCROTAL $180SPPRT WRIST $40ST ASPIRATN $40ST BASIN DBL S $318ST CARDIOPLEGIC $141ST CATH STNT NPH TMP BLN $660ST CONTRAST DELIVERY $115


141 of 154 FY2018

DESCRIPTION CHARGES



ST DIAL A FLOW $154ST ESOPH DILATOR $298ST EXT DRN $428ST FLUD BL WARMER $287ST INFUSN CRD PLEG $344ST INTRO PEELAWAY W GW $341ST INTUBATION $102ST INTUBT $27ST IRG CYS TUR $151ST IRR $24ST IV ADM CLYSIS $84ST IV EXT PCA $149ST IV INF 25X3 4 $41ST IV Y PCA $75ST JURGEN BALL $73ST NDL ACCESS $103ST NDL CATH ECHOLONG $124ST NDL INTRAOSS ADLT $379ST NEPHROSTOMY $672ST NEPHROSTOMY $959ST O2 $15ST PERCU NEPHRO $874ST PNEUMOTHORAX $1,457ST PRIMARY N VN $37ST SHTH DILATOR $140ST SPRAY FIBRIN SEALANT $353ST STYLET LOCKING $2,159ST SUTURE DISP $5ST THROMB EMB PMP $1,720ST TRANSDCR COV US $71ST TUBING INSUFLATN DISP $795ST URET ACCESS $334STAY RETRCTR ELST PKG $48STIM LOC NERVE W $225STONE EXTRACTOR $1,205STOPCOCK 4W $60STOPCOCK 4WAY $22


142 of 154 FY2018

DESCRIPTION CHARGES



STOPCOCK A S $40STPL FASCIA $1,377STPL GIA 30 $1,974STPL LINEAR CUTTR $907STPL LINEAR CUTTR TH GRN $1,200STPL LINR RL30 60 90 V30 $672STPL RELD ENDO UNIT $547STPL RELOAD 3 $1,416STPL RELOAD 4 $412STPLR INT ENDO CIRCULAR $1,460STPLR MENISCAL B10 ABSRB $356STPLR TACKER DEVICE $2,274STRIPPER VEIN $431STRP FT ANKLE DISTRCT $404STRP LEG $151STRP MONTGOMERY $69STRYKER HOOD SWEAT BANDS $245STYLET $76STYLET PACEMAKER $131STYLET TB FEED $39STYLETTE WIRE $464SUCT HAND FRZR $44SUCT HAND YANK $80SUCT HANDLE POOL $100SUCT IRR HDL TUB $171SUCT IRRIG $747SUCT TUBNG $204SUCT TUBNG VAC $161SUMP DRN $149SUPPORT STERNAL WOUND $617SURGINEEDLE $325SUT ARTHRO APPLIER $843SUT BASIC GEN $54SUT BLSTR RETEN $47SUT BUTTON $294SUT CARD ETHIBN $66SUT CARD VICRYL $56


143 of 154 FY2018

DESCRIPTION CHARGES



SUT CARDIOVASCULAR $100SUT CATG I $71SUT CATG III $125SUT CATG IV $142SUT CATG IX $253SUT CATG V $173SUT CATG VI $194SUT CATG VII $208SUT CATG VIII $241SUT CATG X $336SUT CLIP HEMO $185SUT CLIP HEMO $52SUT CLIP LIGA 6 $154SUT CLOS STEEL $71SUT CLP LIGA AS $393SUT CV PROLENE MULTI $25SUT CV VALVE $972SUT ENDOLOOP $246SUT FIBERSTICK 2 $268SUT GDE $134SUT NEEDLE $71SUT OBGYN MERLN $119SUT PASSER $263SUT PASSER. $1,201SUT PDS $101SUT PLAST VIC $87SUT POLYBLEND $106SUT RETREIVER $355SUT RETREIVER. $418SUT STAPLE REM $95SUT STAY $45SUT SURGICLIP $759SUT SURGICLIP II PREMIUM $609SUT SURGIGRIP $127SUT VASCLR DERM $400SW GZ INTRODUCR $1,621SWAB BENSOIN $21


144 of 154 FY2018

DESCRIPTION CHARGES



SYR COLLAGEN TREATMNT $2,825SYRINGE MEDRAD $224SYS ATHERECTOMY PHOENIX $6,527SYS AUTOGRAFT TRANSFER $3,200SYS BLLN BLUNT TIP KII $104SYS CAPSULE GASTRIC PH $744SYS CEMT MIX VAC $158SYS CLSD FLSH $67SYS COLD THERAPY DISP $1,575SYS COLD THERAPY DISP 2 $929SYS COR ROTLNK CATH BURR $3,155SYS DEL DC VERTBROPLSTY $4,442SYS DEL LP VERTBROPLASTY $3,198SYS DERMACLOSE $2,656SYS EMBOLIZATN PROTECT $11,071SYS EMBOLIZTN PROTECT2 $3,914SYS GASTRIC POSITIONING $703SYS ILLUM SINUS $1,856SYS INCISION MANAGEMENT $1,170SYS INTRAGASTRIC BLLN $4,915SYS LOCK DVC BX CAP $104SYS MIXING AND DELIVERY $573SYS NAVIFLEX RX DELIVERY $341SYS PORT CLOSURE $339SYS RETRAC STBLZR OPCAB $5,936SYS SEALER BIPLR $1,340SYS SUTURE ENDOSCOPIC $2,209SYS TISSUE REMOVAL TX1 $1,831SYS TISSUE RETRIEVAL $297SYS TUNNELER W SHTH $169SYS WND DEBRDMNT CLNS $257TAMPON NASAL $192TB CALIBRATION LAP BND $379TB CHST $142TB CPAP $187TB DECOMP FED $947TB EMG ENDOTRACH $999


145 of 154 FY2018

DESCRIPTION CHARGES



TB ENDO LZ $3,236TB ENDO LZ CUFFED $159TB ENDOBRON $187TB ENDOTRACH $26TB ENDOTRACH W BLOCKER $1,065TB ENDTRACH $59TB ENTRL FEED $172TB ET RAE $26TB FD JEJUNAL $626TB FEED $190TB GASTRIC MINNESOTA $1,439TB GASTROS $460TB GASTROSTOMY $852TB INFLOW GYN $357TB INTUBATION LMA $80TB IRRIGAT $202TB LSR SMOKE EVAC DISP $356TB MICROLARYNGEAL ET $29TB PRESS $19TB RECTAL PLAS $5TB T DISP $214TB TRACH $469TB TRACH FN $372TB TRACH LP CUFF $123TB TRACH REIN $81TB TRACH SHILY $28TB TRACH W CUF $410TB UTRN ASPIRN $576TB VASC TUNNLER $423TELFA A S $22TEMPLT MPFL $1,257TENDON SMOOTHER $961TEXTILE INTERDRY AG $264THERABAND $22THERAPUTTY $65TIP CAUTERY ENT $24TIP HEX DRIVER $351


146 of 154 FY2018

DESCRIPTION CHARGES



TIP INSERTER ARTFCL DISC $565TIP IRRG FEM $154TIP IRRIGATNG ASPIRATING $3,016TIP RETENT ENEMA $71TIP SCISSOR DISP $112TIP SPRAY DUAL $301TIPS IRRIGATOR $438TISS DERML HUM ORIGN W $4,208TOOL GDWR $302TOOL SMOOTHER CRUCIATE $1,129TOURN INFL DIS $296TOURNIQUET VASC $61TP GLOW TELL $208TP ZONAS A S $41TRACH BUTTON $1,035TRACH TB HOLDER $19TRACH TUBE FLEX $320TRACKER ENT INSTRUMENT $700TRANMTR ANS RENEW NROSTM $33,954TRNSDU SNGL $189TRNSDU TRIPLE $618TROCAR BLUNT $1,344TROCAR LAPSCOPE $1,208TROCAR W CANN $793TRP FINGER $377TRY ANGIOGRAPHY $1,018TRY ANGIOGRPHIC $93TRY ANS CONEPI $651TRY ANS EPIDRL $209TRY ANS REG NR $271TRY ANS SPINAL $468TRY ARTHOGRAM $401TRY BN MARROW $108TRY BX BASIC $504TRY CATH 6 INTR $245TRY CATH FO URIMETER $253TRY CATH FOLY $303


147 of 154 FY2018

DESCRIPTION CHARGES



TRY CATH ST $121TRY CRANIOTOMY $1,454TRY DRS CVPTPN $47TRY EYE $1,491TRY FACIAL $842TRY I D $5TRY INST BIOTENODES DISP $620TRY LUMB PUNCT $639TRY MYELOGRAM $492TRY PEG $949TRY PENILE PROS $1,413TRY PERC INTRO $282TRY PLS $373TRY SHLDR RECON $556TRY SOFT TISSUE $351TRY SUT MAJ $315TRY THORACENTES $429TRY TRACH CLEAN $24TUBING ARTHRO IR $237TUBING CONEC $65TUBING INSUFLTR $84UNIV SLITTER $232URO SHTH $470UTENSIL FLEXIBLE $70UTENSIL WEIGHTED $108VALVUTOME DISP $3,318VELFOAM $2VENOUS CANNULA $119VEST COMPRESSION $259VISIPORT DISP AS $367VLV ANTIREFLUX $29WAND ARTHRO BIPOLAR CAPX $1,523WAND ARTHRO BIPOLAR DISP $1,492WAND ARTHRO VAPOR $827WAND SPINAL $6,338WAX BONE 2 5GMS $435WEDGES ORTHO $184


148 of 154 FY2018

DESCRIPTION CHARGES



WIRE EXCH $1,573WIRE SUTURE PASSING $304WND CLEANERS ANY TYPE SZ $43WR GDE SPHINCTER PRELOAD $951WRAP ARM TRACTION $135WRENCH DISP $131

EMERGENCY ROOMCARDIOVERSION ELEC SCHED $1,139CPR CARDIOPULM RESUSC $1,069CRIT CARE E M 30 74 MIN $3,313CRITICAL CR E M ADDL 30 $595E M NEW PATIENT LVL I $374ER VISIT LVL I $1,095ER VISIT LVL II $1,288ER VISIT LVL III $1,736ER VISIT LVL IV $2,059ER VISIT LVL V $2,318IMM ADM EA ADDL VACCINE $286IMM ADMIN SNGL COMBO VAC $114INJ ADD SEQUENTL IVP $442INJ ANTIBIOTIC IM $422INJ T P D IVP SAME SUBST $443INJ TX PROPH DX SQ IM $211INJ TX PRPH DX IVP INT $442IV INF CONCURRENT $81IV INF HYD EA ADD HR $101IV INF HYD INIT 31 60MIN $642IV INF SEQUENTL 1 HR $89IV INF TX EA ADD HR $101IV INF TX INIT 1 HR $706OSTEOPATHIC MANIPULATION $70RIGHT CARE RIGHT PLACE $116SURG PROC LEVEL I $406SURG PROC LEVEL II $1,776SURG PROC LEVEL III $3,548


149 of 154 FY2018

DESCRIPTION CHARGES



GI LABAMB PROC 1ST 1 2HR $845AMB PROC EA ADDL MIN $23ESOPH MOTILITY STUDY $1,087MAJOR GI LAB 1 2HR $1,602MAJOR GI LAB ADDL MIN $47MAJOR GI LAB II 1 2 HR $2,466MAJOR GI LAB II EA ADD $61MINOR GI LAB 1 2HR $700MINOR GI LAB ADDL MIN $26REPOS GI TUBE THRU DUODN $680

ANESTHESIAANESTHESIA EA ADD 15 MIN $601ANESTHSIA INIT 30 MIN $1,332MOD SED OTH 5YRS INIT15 $66MOD SED OTH EA ADD15 $66MOD SED SAME 5YRS INIT15 $129MOD SED SAME EA ADD15 $70

SURGERYABD PARACENTESIS W IMAGE $2,111ARTERIOG CAR NKHD SEL $11,257ARTERIOG SUBC INOM $13,960ARTERIOGR CAR HD SEL $10,517ARTERIOGR CAR NK SEL $4,367ARTEROGRAM ARCH NON SEL $9,752ASP ABS HEMAT CYST $356ASP INJ INTERM JT WO US $249ASPIR BLADDR W/INS CATH $7,975ASPIR BREAST CYST $312ASPIR INJ MAJ JT WO US $411ASPIR INJ MAJOR JT W US $2,407ASPIR INJ SM JNT WO US $248ASPIR INJ THYROID CYST $436ATHERCT ILIAC OPEN PERC $11,931BALOON DILATE URETER $5,090


150 of 154 FY2018

DESCRIPTION CHARGES



BILIARY ENDO DIL W STENT $3,088BIOPSY BONE DEEP $1,785BIOPSY BONE SUPERFICIAL $1,256BX ABD RETROPER PERC NDL $1,716BX BRST 1ST LESION US $3,098BX BRST ADD LESION US $237BX LIVER PERC NDL $2,237BX MUSCLE PERC NDL $940BX PROSTATE NEEDLE PUNCH $931BX RENAL PERC NDL $2,638BX SOFT TISSUE NECK THOR $1,170BX THYROID PERC NDL $928C T FACET INJ IMAGE LV3 $1,393C T FACET INJ IMAGE LVL1 $2,700C T FACET INJ IMAGE LVL2 $1,393C T L MYELO LUMB INJ $2,138CERVICAL MYELO LUMB INJ $1,520CHANGE BILIARY DRAIN CTH $3,401CHANGE NEPHROSTOMY TUBE $962CONTRST EVAL EXISTNG CVD $742CONVRT NEPHOST TO URETER $4,631DES L S FACET JNT ADDL $1,385DES LUMB SAC FACET JNT $7,575DEST CERV THO FACET JNT $7,575DEST NRLTC PERIPH NRV $3,161DESTY C TH FACT JNT ADDL $1,393DILAT BILE DUCT EA $4,209DRAIN PERITONEAL ABSCESS $2,376EST NEPH TRACT TO KIDNEY $1,493EXCH ABSC CYST DRN CATH $2,053EXT CANNULA DECLOTTING $936FASCIOTOMY FOOT OR TOE $3,649FNA W GUIDANCE $564GUIDE CATH FLUID DRAINAG $3,040GUIDE CATH FLUID DRAINAG $3,192IMG CATH FLUID PERI RETR $3,192IMG CATH FLUID PERI RETR $3,679


151 of 154 FY2018

DESCRIPTION CHARGES



IMP TUNLD CATHETER $9,500INJ ABSC CYST PREV CATH $193INJ ANES PERIPH NERVE $880INJ ANESTH CERV THOR SGL $654INJ ANESTH LUMB CAUD SGL $838INJ ANKLE ARTHROGRAM $426INJ CERV THOR EA ADD LVL $686INJ CM EVAL DTUBE $763INJ CM EVAL GJTUBE $763INJ CM EVAL GTUBE $763INJ CM EVAL JTUBE $727INJ ELBOW ARTHROGRAM $495INJ EPID BLD PATCH $886INJ EPID CERV THORC $2,641INJ EPID LUMB CAUD $2,422INJ HIP ARTHRO W O ANES $551INJ INF NEURO C T SP EPI $1,013INJ KNEE ARTHROGRAM $551INJ LUMB CAUD EA ADD LVL $838INJ MYELOGRAM LUMBAR $747INJ NEPHROGRM EXIS ACC $915INJ NEURO EPID LUMB CAUD $1,013INJ PERC EXT PSEUDANYSM $544INJ SHOULDER ARTHROGRAM $387INJ SINUS TRACT DIAGNSTC $294INJ SPINE DISK CERV THOR $1,056INJ TRIGGER PTS 1 2 MUSC $1,096INJ TRIGGER PTS 3 MUSCL $1,149INJ URETER ILEAL CONDUIT $391INJ VENOGRPHY EXTRMTY $276INJ WRIST ARTHROGRAM $845INJECT PLT RICH PLASMA $749INJECT PROC SACRO JNT $661INJECT SPINE DISK LMBR $729INJECT TENDON LIGAMENT $1,302INS ENDOVA VENACAVA FILT $6,430INSERT THORACOSTMY TUBE $722


152 of 154 FY2018

DESCRIPTION CHARGES



INSRT BILI DRAIN EXT $6,122INSRT BILI DRAIN INT EXT $6,306INSRT CVAD W PRT 5YRS $1,450INSRT NONTUNNL CV CTH 5 $2,068INSRT PICC NO PRT PMP 5 $2,166INSRT TNL CV CTH5 WO PMP $1,969INSRT TUNLD PLEURAL CATH $1,969INSRT TUNNL VAD 5 W PORT $4,397L S MYELO W INJ $1,536L SP FACET INJ IMAG LV3 $686L SP FACET INJ IMAG LVL1 $1,412L SP FACET INJ IMAG LVL2 $654OH SURG EA ADD 15MIN $1,610OH SURG INT 30 MIN $5,233OPEN PERC PL ST 1ST AR $19,578PERC AUG 1 BD LUMB IMG $5,590PERC AUG 1 BD THOR IMG $5,456PERC AUG ADD T L IMG $6,149PERC BIOPSY LYMPH NODE $1,448PERC CHOLECYSTOSTOMY $2,709PERC DISC REMOVAL W IMAG $5,696PERC SACRL AUGMENT BILAT $6,358PERC VERT 1 BD ADD IMG $2,652PERC VERT 1 BD LSAC IMG $2,652PERC VERT 1BD CTHOR IMG $2,652PL STNT BIL EXIS ACCESS $14,594PL STNT BIL W O DRN $18,403PL STNT INT EXT BILE DRN $22,150PLC CATH AORTA $990PLC CATH ART 1ST ORDR $1,271PLC CATH ART 2ND ORDR $1,269PLC CATH ART 3RD ORDR $1,506PLC CATH ART ABD 1ST $1,102PLC CATH ART ABD 2ND $1,193PLC CATH ART ABD 3RD $1,344PLC CATH ART ABD ADD $348PLC CATH ART ADD ORDR $327


153 of 154 FY2018

DESCRIPTION CHARGES



PLC CATH EXTRM ARTERY $676PLC CATH LT RT ARTERY $1,042PLC CATH VEIN 1ST ORDR $938PLC CATH VEIN 2ND ORDR $1,167PLC CATH VENACAVA $843PLC NEPHROSTOMY CATH $1,780PLC NEPHROURETERAL CATH $5,686PLC STNT NEW DX W CATH $11,242PLC STNT NEW DX WO CATH $6,757PLC STNT W DX NEPHRO $3,222PUNCT SHUNT TB RESERV $925RBTCS DAVN LVL II EA 15 $1,382RBTCS DAVN LVL II INT 30 $4,591RBTCS DAVN LVL III EA 15 $1,579RBTCS DAVN LVL III INT 30 $5,184RBTCS DAVN LVL IV EA 15 $1,778RBTCS DAVN LVL IV INT 30 $5,776RBTCS MAKO LVL II EA 15 $1,382RBTCS MAKO LVL II INT 30 $4,591RBTCS MAKO LVL III EA 15 $1,579RBTCS MAKO LVL III INT 30 $5,184RBTCS MAKO LVL IV EA 15 $1,778RBTCS MAKO LVL IV INT 30 $5,776REM ENDO VENA CAVA FILTR $6,752REM INTRLMNL OBST CV CTH $1,046REMOVE BILI DRAIN CATH $2,032REMV TUNL CVC WO PMP PRT $759REPL GASTRO TUBE W FLUOR $1,111REPLCE CATH ONLY CVAD $558REPOSITN CV CATH W FLURO $797REVASC FEMPOP W TLA $8,947REVASC ILIAC INITIAL $6,132RMV TUNLD CVAD W SQ PORT $1,280RPLC PICC NO PRT PMP $1,969RPLC TUNNL CVAD W PORT $3,165SPINAL PUNCTR LUMB DIAG $353SPINAL PUNCTURE THERAPTC $479


154 of 154 FY2018

DESCRIPTION CHARGES



SURG LEVEL I EA ADD 15M $1,128SURG LEVEL I INT 30 MIN $3,616SURG LEVEL II EA ADD 15M $1,382SURG LEVEL II INT 30 MIN $4,591SURG LEVEL III EA ADD 15 $1,579SURG LEVEL III INT 30 MIN $5,184SURG LEVEL IV EA ADD 15 $1,778SURG LEVEL IV INT 30 MIN $5,776SURG PROC II $620TCATH TX INIT NONCOR VEN $12,879TENOTOMY ADDUCTOR HIP $3,649TENOTOMY ELBOW PERC $5,445TENOTOMY PERC ABDUCTOR $3,476TENOTOMY PERC MULT TENDO $5,718TENOTOMY PERC TENDON $3,649TENOTOMY SHOULDER $5,718THORACENTSIS W IMAGING $604THORACIC MYELO LUMB INJ $1,545TRNSCTH BIOPSY $3,051


while the file below represents our line item charges for st ...upper gi w small bowel $1,052...

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